[Digital imaging system are rapidly introduced in Swedish departments of radiography. This calls for new strategic planning]. / Digitala bildsystem införs nu snabbt på röntgenavdelningarna i Sverige. Detta ställer nya krav på beredskapsplaneringen.

Diagnostic radiology in Sweden is changing rapidly to digital (filmless) technique. The advantages are more rapid delivery of radiologic service, better working conditions and less negative effects on the environment. Teleradiology is also facilitated. The Swedish Board of Health and Welfare has investigated the speed with which this change is taking place. In 1998, 26 of the 118 departments of diagnostic radiology had already turned digital; it is estimated that in the near future at least five departments will become fully digital each year. For planning purposes, less emphasis should be put on the supply of radiographic film, and more on telecommunications, computer hardware and digital storage.

Cost of a saved life following out-of-hospital cardiac arrest resuscitated by specially trained ambulance personnel.

During a 1-year-study period three emergency ambulances manned by specially trained emergency medical technicians (EMTs) were successful in the resuscitation of 28 out-of-hospital cardiac arrest patients, who were admitted to hospital for further treatment. Nineteen patients died in hospital while nine were discharged to their homes, a survival rate corresponding to 3.5 saved lives per 100,000 inhabitants per year. The extra pre-hospital costs and the estimated costs for hospital treatment of the admitted patients amounted to 929,600 Swedish kronor (SEK). The program cost of the early defibrillation by trained EMTs accounted for only 12% of this amount, or 113,600 SEK. The cost of hospital treatment accounted for the remaining 88%, or 816,000 SEK. Intensive care accounted for 53% of the hospital costs, coronary care 4%, treatment in a general ward 33% and in a ward for rehabilitation or long-term care 10%. Non-survivors accounted for 58% of the hospital expenditure. The marginal prehospital cost (program cost) for each survivor was 12,622 SEK or approximately 1800 US dollars. The total cost per life saved was 103,000 SEK or approximately 14,700 US dollars. The estimated cost to each taxpayer of providing this extra emergency resource would be approximately 0.5 SEK a year.

Intensive care of the elderly--a retrospective study.

Access to intensive care is to a large extent a prerequisite of the treatment of increasingly old patients for more and more complicated diseases. The ultimate outcome of such treatment is little known, however. In this study we have followed up 143 patients (91 males and 52 females), aged 70 years or more, who were treated in the intensive care unit (ICU) of Danderyd Hospital for 48 h or more during the years 1979-1982. As a comparison, another group of 143 patients in all age groups treated in the ICU for 48 h or more were studied during 1 year (1980). The main diagnostic groups were infectious diseases, trauma, acute abdominal diseases, malignancy, cardiovascular diseases, and other diseases. The mean mortality within 12 months at age 70 years and above was 52%, highest for cardiovascular diseases (73%) and malignant diseases (60%). Within this age group, the main part of the occupancy in our ICU was held by patients who died within 18 months (58%). The results show that the ICU-cost per patient per year saved was not much higher for patients in diagnostic groups with higher mortality or longer duration of stay in the ICU than in other groups. Calculations of ICU-cost seem to be a relevant parameter for the evaluation of the results of ICU care. Fifty per cent of all patients were able to return home some time after intensive care. The humanitarian end result is thus encouraging, but better criteria for selection of patients are needed.

Solute equilibrium over the extracellular fluid space in haemorrhagic hypotension: a study in a cannulated thoracic duct model.

Haemorrhagic hypotension, 50 mm Hg, has been inflicted on non-starved rats. Osmolar and solute developments have been followed in lymph and arterial plasma to assess diffusion and equilibration characteristics of the initial stages of haemorrhage. Lymph flow changes have reflected an intracellular fluid mobilization to the interstitium, caused by an osmotic gradient due to the elevated levels of glucose. A fluid homeostatic effect of pseudodiabetes associated with stress and haemorrhage is postulated.

Induced hyperosmolality effects on extracellular fluid volume, lymph flow and osmolar equilibrium: studies in the rat.

The effects of experimentally induced hyperosmolality has been studied in rats. Renal vascular pedicle ligation was performed on all animals to prevent renal clearance of the infused solute, xylose, and allow accurate ECF space determinations with 51Cr EDTA. Small volume hyperosmolar xylose infusions caused parallel elevation of the osmolality of thoracic duct lymph and arterial plasma. A positive correlation was obtained between lymph osmolality and flow alterations. The maximal osmolality elevation of 22 mosm X kg-1 H2O was associated with an intracellular fluid mobilisation which was equal to 7.1% of the ECF space. The infused and mobilised fluid volumes were distributed unequally between the intra and extra vascular compartments of the ECF.

51Cr EDTA determinations of the extracellular fluid volume in hemorrhage: a study with fed and starved rats.

Extracellular fluid volumes have been determined in fed and 24-30 h starved rats, before and after 60 min of hemorrhagic hypotension at 70 mmHg. Bilateral renal vascular ligation was carried out to prevent clearance of the isotope tracer used, 51Cr EDTA. The time taken for a bolus of the tracer to distribute itself in its space, was determined in fed and starved animals after the standard period of hypotension. This was found to be 37 min for fed animals, and 50 min for those which had been starved. When the isotope ECF space was compared before and after hemorrhage in fed animals, it was unchanged, despite an estimated blood volume loss of 39%. The isotope ECF space was reduced 5.5% after hemorrhage in animals which had been starved. It is concluded that fed rats mobilised intracellular fluid to the interstitium in hemorrhage, whereas, starved animals did not. This finding of variable fluid homeostasis is ascribed to the different nutritional status of the animals investigated, and has considerable implications.

Glucose, insulin and osmolality changes in rats sustaining different hemorrhage volumes.

Plasma glucose, osmolality and insulin have been investigated during hemorrhage in non-starved rats. The rate of blood loss leading to hemorrhages of 44% and 55% of the estimated original blood volume determined the patterns of response. Substantial hyperglycemic hyperosmolality and insulin values appropriate for the raised levels of glucose were observed in the animals bleeding more rapidly. The slower rate of hemorrhage was associated with only moderate hyperglycemia and hyperosmolality, while the insulin values rose to very high levels, 45 times basal. It is postulated that altered glucose-insulin metabolism in haemorrhage may have important consequences for fluid homeostasis, and the rate of bleeding is the fundamental factor steering this effect.

Osmolar changes in haemorrhage: the effects of an altered nutritional status.

Fed and 24-30 hour starved rats were submitted to haemorrhagic hypotension, 70 mmHg, with a modified Wigger's system. Neuroleptanalgesia was used to ensure a normal degree of stress reactivity. Despite fed animals losing 53% of their original blood volume (BV) and starved animals 47% (BV = 6% prestarved body weight), blood gas data and creatinine levels confirmed a well intact and compensated status in both groups. Fed animals compensated for the greater haemorrhage with a haematocrit reduction which was double that in starved animals. When the alterations in osmole skeletons were compared, evidence for an intracellular fluid (ICF) shift to the interstitium was obtained in fed rats. Their NaCl space increased by 5.5%. Glucose increased its osmolar effect by 224% among fed animals and was reduced in those which had been starved. Glucose was identified as the solute causing an acute mobilisation of ICF to the interstitium.

Primary tumors of the small intestine.

In our department of surgery 28 patients with malignant and 10 with benign tumors of the small intestine were treated from 1940 to 1974. Fifteen patients with malignant and 7 with benign tumors underwent surgery with the intention to cure. Palliative operations or explorations were carried out on 13 patients with malignant tumors. Three patients with benign tumors were not operated on. The initial symptoms were vague: abdominal pain, nausea, anemia or bleeding in 75 and 80 percent of patients with malignant and benign tumors, respectively. The indication for operation in the malignant cases was, however, stenosis of the intestine or biliary tract or a palpable mass in 60 percent of the cases. At operation the tumors were thus in an advanced stage. Because the initial symptoms are vague, early diagnosis is difficult. The overall 5 year survival rate was 21 percent after surgery for malignant tumors. Among the patients considered by the surgeons to have had radical operations excluding cancer patients, 40 percent survived 5 years. The surgeon's opinion regarding "radical" operation as well as the presence or absence of metastases at microscopy were of limited prognostic value.

Sympathetic innervation and noradrenaline content of normal human thyroid tissue from fetal, young, and elderly subjects.

In man, as well as in the mouse, there is morphologic and functional evidence for a direct, stimulatory influence of the sympathetic nervous system on the secretion of thyroid hormone by noradrenaline (NA), released from interfollicular adrenergic nerve terminals. In mice and rats, an age-related reduction of the sympathetic innervation of the thyoid has recently been observed. In the present study, possible age-related variations of the sympathetic innervation and the concentration of NA in human thyroid tissue were examined. Interfollicular adrenergic nerve terminals were studied by fluorescence histochemistry, and the tissue concentration of NA was measured by fluorometry. In apparently normal thyroid tissue, obtained from fetuses, young (20-45), and elderly (greater than 60) euthyroid people with thyroid cancer or hyperparathyroidism, the number of interfollicular adrenergic nerve terminals appeared to be reduced with increasing age, and the thyroid tissue concentration of NA was significantly lower in elderly than in young people. These findings may have functional importance.

Fluorescence-microscopical demonstration of a population of gastro-intestinal nerve fibres with a selective affinity for quinacrine.

A population of nerve fibres in the gastro-intestinal tract of mice showing a high affinity for quinacrine was revealed by fluorescence microscopy. Similar results were obtained in rats and guinea pigs. Whole-mounts of sheets of the smooth muscle layer following incubation in 10(-6)-10(-7) M quinacrine for 15-60 min revealed fine fluorescent varicose nerve fibers in the myenteric plexus of Auerbach both around nerve cell bodies and in the interconnecting strands. Many fibers were also present between the strands of the plexus, especially running parallel to the circular muscle layer. Such fibers were not seen in similarly quinacrine-incubated irides. A proportion of the cell bodies in Auerbach's plexus also showed quinacrine accumulation. These cells were apparently smaller neurons, sometimes with fluorescent processes. Intraperitoneal injections of quinacrine failed to demonstrate nerve fibers, but some cell bodies in Auerbach's plexus were positive. Subsequent paraformaldehyde treatment for monoamine visualization showed persistent adrenergic nerve terminals in the intestine and iris. These nerves seemed to be fewer and had a more yellow fluorescence than normally. The identity of the quinacrine-positive fibers is discussed with respect to recent suggestions that "purinergic", substance P, enkephalin, and somatosin-containing nerves, in addition to adrenergic and cholinergic nerves, are present in the gut wall.

Free autogenous grafts into the penile cavernous tissue. An experimental study in dogs.

The behaviour of free autogenous fat, dermofat, and dermo grafts in the penile cavernous tissue was studied experimentally in dogs. Dermo-fat grafts were those most easily maipulated during surgery and allowed perfect haemostasis. All the grafts were gradually replaced by fibrous tissue causing subsequent scarring and contraction. This reaction was least noticeable with dermis grafts. Cavernous transformation of the adipose tissue was not observed. For the surgical correction of Peyronie's disease the use of a dermo-fat graft is suggested. The grafts should be slightly larger than necessary to allow for the subsequent fibrosis, and the layer of fat should be kept very thin.