Sustained reduction of antibiotic use and low bacterial resistance: 10-year follow-up of the Swedish Strama programme.

Increasing use of antibiotics and the spread of resistant pneumococcal clones in the early 1990s alarmed the medical profession and medical authorities in Sweden. Strama (Swedish Strategic Programme for the Rational Use of Antimicrobial Agents and Surveillance of Resistance) was therefore started in 1994 to provide surveillance of antibiotic use and resistance, and to implement the rational use of antibiotics and development of new knowledge. Between 1995 and 2004, antibiotic use for outpatients decreased from 15.7 to 12.6 defined daily doses per 1000 inhabitants per day and from 536 to 410 prescriptions per 1000 inhabitants per year. The reduction was most prominent in children aged 5-14 years (52%) and for macrolides (65%). During this period, the number of hospital admissions for acute mastoiditis, rhinosinusitis, and quinsy (peritonsillar abscess) was stable or declining. Although the epidemic spread in southern Sweden of penicillin-resistant Streptococcus pneumoniae was curbed, the national frequency increased from 4% to 6%. Resistance remained low in most other bacterial species during this period. This multidisciplinary, coordinated programme has contributed to the reduction of antibiotic use without measurable negative consequences. However, antibiotic resistance in several bacterial species is slowly increasing, which has led to calls for continued sustained efforts to preserve the effectiveness of available antibiotics.

A 40-year follow-up of patients with obsessive-compulsive disorder [see commetns].

BACKGROUND: The long-term course of obsessive-compulsive disorder is insufficiently known. We studied the course of this disorder in patients who were followed up for 40 years. METHODS: Patients admitted with a diagnosis of obsessive-compulsive disorder to the Department of Psychiatry, Sahlgrenska University Hospital, Göteborg, Sweden, between 1947 and 1953 were examined by an experienced psychiatrist using a semistructured interview between 1954 and 1956 (n=251). The diagnosis was made according to the criteria of Schneider. A reexamination was performed by the same psychiatrist between 1989 and 1993 (n=122). In another 22 patients, the necessary information was obtained from close informants and medical records. The response rate in surviving patients was 82%. The mean length of follow-up from onset was 47 years. RESULTS: Improvement was observed in 83%, including recovery in 48% (complete recovery, 20%; recovery with subclinical symptoms, 28%). Among those who recovered, 38% had done so already in the 1950s. Forty-eight percent had obsessive-compulsive disorder for more than 30 years. Early age of onset, having both obsessive and compulsive symptoms, low social functioning at baseline, and a chronic course at the examination between 1954 and 1956 were correlated with a worse outcome. Magical obsessions and compulsive rituals were correlated with a worse course. Qualitative symptom changes within the obsessive-compulsive disorder occurred in 58% of the patients. CONCLUSION: After several decades, most individuals with obsessive-compulsive disorder improve, although most patients continue to have clinical or subclinical symptoms.

Relations between mixed venous oxygen saturation and hemodynamic variables in patients subjected to abdominal aortic aneurysm surgery and in patients with septic shock.

In order to study if oxygen saturation in mixed venous blood (SvO2) could be used as a marker for heart performance, oxygen delivery (DO2) or consumption (VO2) in critically ill patients 134 hemodynamic measurements were performed by a thermodilution pulmonary catheter in 23 patients after abdominal aortic aneurysm surgery. These data were compared to 200 measurements performed in 30 patients with septic shock. When analysed on an individual basis SvO2 was only closely related to DO2 or VO2 in a minority of the patients. Neither could SvO2 be used as a reliable marker for heart rate, hemoglobin concentration, stroke volume or cardiac index. On the other hand SvO2 was found to be an excellent marker for oxygen extraction (OER) in both groups of patients (median r = 0.98. p < 0.0001). In conclusion, the present study shows that SvO2 could not be used as a reliable marker for the important hemodynamic variables CI, DO2 or VO2 in critically ill patients. However, SvO2 was found to be an excellent marker for OER.

Clinical buffering of metabolic acidosis: problems and a solution.

Traditionally sodium bicarbonate has been the buffer of first choice in the treatment of metabolic acidosis. This treatment, however, involves risks of developing a hyperosmolar state, a high sodium concentration in the blood, increased arterial carbon dioxide tension and, as a result of the latter, intracellular and intracerebral acidosis and also cerebral oedema. The buffering effect occurs slowly and as a consequence of this, and of the titration curve of sodium bicarbonate, overcorrection of metabolic acidosis is often seen. Tris buffer was introduced as an alternative and has been claimed to solve most of these problems, but on the other hand it entails a very high risk of peripheral venous thrombosis and thrombophlebitic lesions owing to its local irritative effect. In order to overcome these disadvantages a new mixture of Tris, acetate, bicarbonate and phosphate has been designed. In the studies described it was shown to have an adequate buffering effect and to provide a solution to most of the problems connected with buffering of metabolic acidosis. The new Tris buffer mixture has a buffering effect in blood equivalent to 0.5 mol/l sodium bicarbonate, although its sodium content has been decreased to one-third of pure sodium bicarbonate. Its administration also results in predictable buffering in cerebrospinal fluid and skeletal muscle. In a clinical study it was demonstrated that the new Tris buffer mixture results in sufficient and adequate buffering without significant side-effects.