Medical education in Sweden

Undergraduate medical education in Sweden has moved from nationally regulated, subject-based courses to programmes integrated either around organ systems or physiological and patho-physiological processes, or organised around basic medical science in conjunction with clinical specialities, with individual profiles at the seven medical schools. The national regulations are restricted to overall academic and professional outcomes. The 5? year long university undergraduate curriculum is followed by a mandatory 18 months internship, delivered by the County Councils. While quality control and accreditation for the university curriculum is provided by the Swedish National Agency for Higher Education, no such formal control exists for the internship; undergraduate medical education is therefore in conflict with EU directives from 2005. The Government is expected to move towards 6 years long university undergraduate programmes, leading to licence, which will facilitate international mobility of both Swedish and foreign medical students and doctors. Ongoing academic development of undergraduate education is strengthened by the Bologna process. It includes outcome (competence)-based curricula, university Masters level complying with international standards, progression of competence throughout the curriculum, student directed learning, active participation and roles in practical clinical education and a national assessment model to assure professional competence. In the near future, the dimensioning of Swedish undergraduate education is likely to be decided more by international demands and aspects of quality than by national demands for doctors.     

Vocal dysfunction following cricothyroidotomy: a prospective study

Voice dysfunction is a known consequence of cricothyroidotomy, but few detailed analyses have been published. This study reports an investigation of voice function in 19 patients who underwent cricothyroidotomy during a 12-month period (54 were patients operated on, 29 survived the primary disease or injury, and 19 agreed to participate in the investigation). The patients were interviewed regarding signs of dysfunction of the cricothyroid muscles, or a diminished external tensor effect on the vocal folds. Laryngoscopy with a magnifying-angled endoscope, stroboscopy, phonetography, determination of mean speaking fundamental frequency, perceptual analysis of the voice, and electromyogram of the cricothyroid muscle were all performed. Four patients had signs of diminished external tensor effect on the vocal folds (mild or moderate voice dysfunction), 5 patients had other voice disorders, and 10 were classified as having normal voice. Elective cricothyroidotomy should be avoided in patients with professional or other activities that place heavy demands on the voice.     

The hospital experience of seat belt legislation in the county of Skaraborg, Sweden

The effect of legislation for the compulsory wearing of seat belts by car drivers and front seat passengers was prospectively analysed in the county of Skaraborg, Sweden. After legislation fewer vehicle occupants were admitted to the hospitals, despite a 40 per cent increase in crashes reported to insurance companies in the country. The frequency of seat belt wearing among injured victims was considerably lower than that recorded in regular traffic surveys. Significantly fewer head and neck injuries were suffered by restrained drivers than by unrestrained. Restrained front seat passengers had more thoracic injuries than unrestrained, but the degree of severity was less. The frequency of seat belt wearing by rear seat passengers was low, but they were injured as severely as front seat occupants. It seems important to insist on an increase in seat belt wearing for this category.     

The identity of enzymes reducing a thiamine disulfide derivative and cystine derivatives via thiol-disulfide exchange

In earlier work¹, we have studied a labile enzyme activity catalyzing an exchange between thiol and acceptor. Glutathione (GSH) was used as the thiol and a number of low molecular weight substances such as cystine and GSH-disulfide derivatives, S-sulfocysteine (CySSO₃H), S-sulfoglutathione and 5,5′-dithiobis(2-nitrobenzoa (DTNB) were used as acceptor substrates in the thiol transfer reaction. This broad substrate specificity led us to the tentative suggestion that thiamine disulfide derivatives also were acceptor substrates to the thioltransferase² activity, which is confirmed in this study. The methods used for the resolution of enzymes and substrate specificity were: (1) isoelectric focusing, (2) CM-cellulose chromatography, (3) labelling of the thioltransferase with [³⁵S]GSH, (4) gel filtration on Bio-Gel P-150, and (5) investigation of ratios of the specific activities of GSH-linked enzymes in different tissues. Generally it was found that bovine tissue had higher specific thioltransferase activity than rat tissue. GSH S-aryltransferase (EC 2.5.1.13) had quite different activity ratios from those obtained with the enzyme involved in cystine and thiamine disulfide reduction. This result, and dissimilar Chromatographic behavior, indicate that GSH S-aryltransferase is not involved in disulfide reduction.     

Two cases of gastric carcinoids: Diagnostic and therapeutic aspects

Two cases of gastric carcinoid tumors with the foregut carcinoid syndrome are presented. Due to elevated urinary levels of 5-hydroxyindoleacetic acid (5-HIAA), primary tumors of midgut origin were suspected. Provocation with pentagastrin (PG) elicited atypical flushing and severe bronchoconstriction, most probably caused by the release of histamine. Excessive excretion of the main histamine metabolite, tele-methylimidazole acetic acid (MeImAA), in urine of both patients was demonstrated. Both patients had good symptomatic relief with prednisolone and blockade of histamine receptors. One of the patients had excessive secretion of serotonin (5-HT) as well as of histamine. Peripheral blockade of 5-HT₂receptors was therefore added to the medical treatment. This patient had a subjective and biochemical response to cytotoxic treatment with streptozotocin and later responded well to a somatostatin analogue.On clinical suspicion of a foregut carcinoid tumor, or in patients with carcinoid tumors without anatomical localization, PG provocation should not be used until the excretion of MeImAA has been determined.

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Resumen Se presentan 2 casos de tumores carcinoides gástricos con el síndrome carcinoide del intestino anterior. Los altos niveles urinarios de ácido 5-hidroxiindolacético (5-HIAA) hicieron sospechar la presencia de tumores primarios de origen en el intestino medio. El estímulo con pentagastrina (PG) provocó un flush atípico y broncoconstricción severa, muy probablemente causada por liberación de histamina. La excreción excesiva del metabolito principal de la histamina, el ácido tele-metilimidazolacético (MeImAA) fue demostrada en ambos pacientes, y ambos obtuvieron mejoría sintomática con prednisolona y bloqueo de los receptores de histamina. Uno de los pacientes presentó secreción excesiva de serotonina (5-HT) así como de histamina. Por ello se decidió añadir el bloqueo periférico de los receptores 5-HT₂ al regimen terapéutico. Este paciente mostró respuesta subjetiva y bioquímica al tratamiento citotóxico con estreptozotocina y ulteriormente respondió bien a un análogo de la somatostatina.Cuando se sospeche de un tumor carcinoide del intestino anterior, o en presencia de pacientes con tumores carcinoides sin ubicación anatómica, la prueba de estímulo con PG no debe ser utilizada hasta cuando se haya determinado la excreción de MeImAA.

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Résumé Deux cas de tumeurs carcinoïdes de l'estomac s'accompagnant d'un syndrome carcinoïde sont rapportés par les auteurs. En raison de l'élévation des taux du 5-HIAA (acide 5 hydroxyindolacétique) le diagnostic de tumeurs carcinoïdes d'origine digestive fut envisagé. L'emploi de la pentagastrine (PG) provoqua un flushing atypique et une broncho-constriction intense plus que probablement provoqués par la libération d'histamine. Une excrétion anormalement élevée du métabolite principal de l'histamine, l'acide acétique téléméthylimidazole (MeImAA) dans l'urine des 2 malades fut mise en évidence. Ils bénéficièrent d'une nette amélioration des symptômes qu'ils présentaient grâce à la prednisolone et au blocage des récépteurs histaminiques. Un des 2 malades accusait une sécrétion excessive de sérotonine (5-HT) et d'histamine; le blocage périphérique des récepteurs 5-HT₂ fut de ce fait adjoint au traitement. Ce malade répondit favorablement sur le plan clinique et biochimique à un traitement cystotoxique par la streptozotocine et plus tard par un analogue de la somatostatine. Chez les malades qui sont suspects d'être porteurs d'une tumeur carcinoïde de siège indéterminée l'emploi de la pentagastrine doit être écarté jusqu'à ce que l'excrétion de la MeImAA ait été mise en évidence.

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This work supported by the Swedish Medical Research Council (grant nos. 2235, 2207, 5520, 6534) and the Swedish Life Insurance Company.     

What have we learned about laryngeal physiology from high-speed digital videoendoscopy?

PURPOSE OF REVIEW: The purpose of this review is to describe recent developments in high-speed videoendoscopy. The applications of this technique are highlighted and important findings regarding vocal fold physiology and voice pathology are discussed. RECENT FINDINGS: The number of applications for digital high-speed imaging has increased during recent years because of the development of camera image sensor systems with increased image resolution of video and television quality. Other improvements are related to computer processing speed and storage capacity and the development of automatic algorithms for quantification and measurements both in time and room dimensions. This is enhanced by combining high-speed videoendoscopy with laser-based measurement systems, acoustic analyses or other glottographic methods, such as flow glottography or electroglottography. High-speed videoendoscopy is currently used in studies of voice mechanisms of phonation (e.g., the voice source can be examined with a high sampling rate, from 1000 to over 8000 frames per second), and in phonation onset or offset. High-speed imaging is also useful in linguistic studies and in the examination of different artistic singing styles, such as extremely high-pitched singing, throat singing, or different pop and rock styles. High-speed videoendoscopy is also used in the examination of patients with voice disorders, particularly with irregular vocal fold vibrations, ventricular phonation, or the phonation of individuals who have had a laryngectomy. SUMMARY: Findings from studies of normal voice physiology and of voice disorders using high-speed imaging are presented and their relevance is discussed.