[The radiotherapy satellite in Kristiansand--a model for Norwegian regional hospitals?]. / Stråleterapisatellitten i Kristiansand--en modell for norske regionsykehus?

BACKGROUND: During the first decade of 2000, significant increase of radiotherapy capacity in Norway will take place, as the number of linear accelerators will increase from 24 to 36. In Norway, radiotherapy departments are traditionally located only in university hospitals. However, six of the new accelerators will not be installed in existing radiotherapy centres, but in small, new radiotherapy units, set up in selected county hospitals and organized as satellites of the university hospitals, in order to secure the treatment quality. The university hospital is responsible for both medical and technical standards in the satellite, while the county hospitals have the financial responsibility. RESULTS: The satellite model combines two important aspects of hospital management; treatment is geographically decentralized, while treatment quality is centralized. The first radiotherapy satellite was established in the town of Kristiansand in January 2001. We report our experience with this new concept in radiotherapy. INTERPRETATION: The satellite model should be evaluated also for other medical specialties within the university hospitals.

Evaluation of indicators of cobalamin deficiency defined as cobalamin-induced reduction in increased serum methylmalonic acid.

BACKGROUND: Early detection of cobalamin deficiency is clinically important, and there is evidence that such deficiency occurs more frequently than previously anticipated. However, serum cobalamin and other commonly used tests have limited ability to diagnose a deficiency state. METHODS: We investigated the ability of hematological variables, serum cobalamin, plasma total homocysteine (tHcy), serum and erythrocyte folate, gastroscopy, age, and gender to predict cobalamin deficiency. Patients (n = 196; age range, 17-87 years) who had been referred from general practice for determination of serum cobalamin were studied. Cobalamin deficiency was defined as serum methylmalonic acid (MMA) >0.26 micromol/L with at least 50% reduction after cobalamin supplementation. ROC and logistic regression analyses were used. RESULTS: Serum cobalamin and tHcy were the best predictors, with areas under the ROC curve (SE) of 0. 810 (0.034) and 0.768 (0.037), respectively, but age, intrinsic factor antibodies, and gastroscopy gave additional information. CONCLUSIONS: When cobalamin deficiency is suspected in general practice, serum cobalamin should be the first diagnostic test, and the result should be interpreted in relation to the age of the patient. When a definite diagnosis cannot be reached, MMA and tHcy determination will provide additional discriminative information, but MMA, being more specific, is preferable for assessment of cobalamin status.

[Future requirements for hematologists]. / Fremtidig behov for spesialister i blodsykdommer.

Today there are not enough specialists in haematology in Norway. During the period 1990-1995 2.5 specialists in haematology qualified per year. In order to meet future requirements for haematologists at Norwegian municipal and university hospitals, it has been estimated by the Norwegian Society for Haematology that the number of specialists qualifying per year should be increased to ten for the next ten years.

[Chronic lymphatic leukemia. A population-based study of symptoms, findings, complications and choice of treatment]. / Kronisk lymfatisk leukemi. En populasjonsbasert undersøkelse av symptomer, funn, komplikasjoner og behandlingsvalg.

224 patients with a recent diagnosis of chronic lymphocytic leukemia, confirmed by immune phenotype, were studied with a mean follow-up of 16 months. The median age was 72 years and the ratio of men to women was 1.51. An incidental diagnosis because of leukocytosis was made in 75% of the patients; in only 22% was the diagnosis related to symptoms. 80% were in stage A, 7.5% in stage B, and 12.5% in stage C. A relation was found between advanced stage and the number of lymphocytes in the blood, the percentage of lymphocytes in the bone marrow, WHO performance status, bacterial infection and disease-related mortality. Thus, six patients in stage C (21%) died because of infection (septicaemia or pneumonia), as opposed to only one out of 196 patients in stages A and B. The incidence of bacterial infection was 64% in stage C, as compared to 8.3% in stage A. Treatment with chlorambucil, started in 59 patients, was in accordance with the guidelines of the national programme for 52 of them. In contrast, a strict indication for prednisone (autoimmune cytopenia) was found in only 42% of 42 patients given this treatment.

[Chronic lymphatic leukemia. Immunophenotyping as an aid to correct diagnosis]. / Kronisk lymfatisk leukemi. Immunfenotyping som hjelpemiddel for riktig diagnose.

The purpose of the study was to examine the validity of the primary diagnosis in chronic lymphocytic leukemia based on clinical and morphological criteria, and to examine the role of immune phenotyping for correct diagnosis in an unselected population-based group of patients. Over a 2-year period leukemic cells from 222 of 235 patients in Norway with a recent clinical diagnosis of chronic lymphocytic leukemia (CLL) were immune phenotyped in order to find cases erroneously diagnosed as CLL. Median age was 72.5 years, and the ratio of men to women was 1.47. At the time of diagnosis, 77% of the patients were in Binet stage A and 23% in stage B or C. Immune phenotyping, in some patients followed by lymph node or bone marrow biopsy, showed a different diagnosis in 11 (5%) of 222 patients: prolymphocytic leukemia, four patients (three B-cell and one T-cell); morbus Waldenstrøm, one patient; T-cell CLL, one patient; hairy cell leukemia, one patient; mycosis fungoides, one patient; mantle cell lymphoma, one patient; monocytoid B-cell lymphoma, one patient and immunoblastic lymphoma one patient. In eight of these 11 patients, the clinical features or morphology, or both, were atypical for CLL, but this was not recognized at the time of diagnosis. Thus, immune phenotyping is valuable for correct diagnosis in a small subgroup of patients with chronic B- or T-cell leukemia, and it is essential in patients with modest lymphocytosis (lymphocytes < 10. 10(9)/1).

[Consequences of reduced working hours for continuing education of physicians]. / Arbeidstidsforkortningens konsekvenser for spesialistutdanningen for leger.

Since 1960 the working hours for hospital doctors in training have been reduced by 12.5 hours per week. A questionnaire was sent to all departments in Norway involved in the education of specialists, asking them about the consequences of this reduction. The survey showed that the working time actually paid for today is not so short (42-46 hours per week). It showed indirectly, however, that the time available for education must have been reduced. About 50% stated that the reduction in working hours has had a negative effect on the extent and quality of the education. Nearly all confirmed a conflict of priorities between clinical routines and education. There were seldom opportunities to read medical literature or do research during working hours. There has been no reduction in routine work nor any increase in staff, in spite of a considerable increase in duties connected with the education of specialists.

[Quality assurance in clinical medicine--from theory to practice]. / Kvalitetssikring i klinisk medisin--fra teori til handling.

So far, in Norway, quality assurance methodology has been applied mainly within medical technology, and it is now high time to involve clinical medicine. In order to develop quality assurance as a continuous process in clinical departments there is a need for clinical data programmes. Moreover, leaders of health institutions and departments must make available the necessary funds. Greater efforts must be made to develop quality standards and indicators. Clinicians need to improve their knowledge of quality assurance methods, and develop guidelines for practice, different methods of consensus, medical audits and quality circles. It is proposed that education in quality assurance be included in postgraduate training programmes.

Prognostic factors in multiple myeloma in a population-based trial.

Prognostic factors have been tested in patients with multiple myeloma treated according to a randomized trial of standard therapy versus 5-drug combination therapy. The following population-based study included 92 patients with a median age of 70 yr. The median survival was 31 months. The Cox regression model was used to search for predictors of survival. The cut-off levels for blood analyses derived in earlier studies tended to select few patients in the high-risk groups, for example only 8% of the patients had hemoglobin (Hb) less than or equal to 7.5 g/dl. Lytic bone lesions in the pelvis or in the long bones, or spontaneous fractures and age greater than 70 yr gave prognostic information in addition to anemia and impaired renal function. The MRC staging system was a better prognostic tool than the Durie & Salmon stages. Palliative treatment regimens which take quality of life into account should be considered carefully in multiple myeloma patients greater than 70 yr.

Erythrocyte sedimentation rate as a prognostic factor in renal cell carcinoma.

In a follow-up study of 193 adult patients with renal cell carcinoma diagnosed in northern Norway 1974-1980, ESR as a prognostic factor was studied with the Cox regression model. In 71 patients (37%) metastatic disease was known at diagnosis. In patients without metastatic disease an elevated ESR greater than 15 mm/h and renal vein involvement were significant prognostic factors indicating short survival. Multivariate survival analyses of all patients showed the presence of metastatic disease and elevated ESR (greater than 15 and greater than 30 mm/h) as significant prognostic factors indicating high-risk patients. This study concludes that ESR deserves attention as a prognostic discriminator in renal cell carcinoma.

Erythrocyte sedimentation rate as a prognostic factor in chronic lymphocytic leukaemia.

In a follow-up study, survival data for 62 patients with chronic lymphocytic leukaemia (CLL), diagnosed in northern Norway from 1974 to 1982, were analysed. 10 patients not reported to the Cancer Registry had a significantly (p less than 0.05) better prognosis. In a multivariate survival analysis (Cox's model) anaemia, elevated erythrocyte sedimentation rate (ESR) and 4 or more regions involved at diagnosis were significant prognostic factors indicating high risk patients with short survival. ESR was also a significant prognostic factor in a multivariate survival analysis, together with the classifications of Rai (1) or Binet (2).

Testicular neoplasms occurring in four brothers. A search for a genetic predisposition.

Four brothers who developed testicular neoplasms, one bilaterally, are described. Histologic examination showed four of the tumors to be seminomas and one to be a mixed germ cell tumor. Three of the brothers are alive. Apart from a late-onset bladder carcinoma in their father and a pulmonary cancer in a maternal uncle, cancers were not recorded in the extended kindred. One patient, a sister, and the parents had normal frequency of sister chromatid exchange (SCE) and chromosome aberrations, whereas the two patients sampled after radiation showed increase in one or both. The father was found heterozygous in 12 and the mother in 8 genetic marker systems among 25 tested. For the blood group gene loci JK and MNSs, and the erythrocyte enzyme locus GPT the father had given the same allele to all three affected sons examined. The mother had given different alleles to the sons in all of her informative markers. On the model of a recessively acting susceptibility gene, only JK and GPT remained consistent with linkage without recombination. These investigations did not add support to a genetic etiology for the unusual family occurrence of testicular cancer. An apparent birth-order effect on time at onset/diagnosis in this and published families suggests time-limited environmental factors. Nevertheless, JK, MNSs, and GPT should be included in future testis cancer families to test the model of a "dominant" genetic predisposition.