Comparable biocompatibility of Phisio- and Bioline-coated cardiopulmonary bypass circuits indicated by the inflammatory response.

BACKGROUND: The biocompatibility of cardiopulmonary bypass surfaces has been improved by heparin and polymer surface modifications. The present study compared the effect of two such coatings on the inflammatory reactions after open heart surgery. METHODS: Thirty patients undergoing elective heart surgery were randomly assigned to receive one of two types of coated circuits: Bioline (n=15) or phosphorylcholine (Phisio, n=15). The platelet and leukocyte counts, neutrophil activation (myeloperoxidase), complement activation (C3a and TCC), concentrations of lactate dehydrogenase, 27 cytokines (including interleukins, chemokines and growth factors), thrombin-antithrombin complexes, and the endothelial cell marker syndecan-1 were analyzed at five predetermined time points until 24 hrs post operatively. RESULTS: Most measurements were comparable in both groups. However, myeloperoxidase was significantly higher in the Bioline group (p < 0.001). Postoperative lactate dehydrogenase concentrations were significantly higher in the Phisio group (p<0.01) and the maximal concentration of thrombin-antithrombin complexes 2 hours postoperatively tended to be higher in the Phisio group (p=0.08), consistent with a longer aortic cross-clamp and cardiopulmonary bypass time. CONCLUSIONS: The two circuits exhibited a comparable degree of in vivo biocompatibility.

Evaluation of oxygenators and centrifugal pumps for long-term pediatric extracorporeal membrane oxygenation.

OBJECTIVE: Two extracorporeal membrane oxygenation (ECMO) circuits for children under 10 kg were evaluated and compared for plasma leakage, hemolysis, blood transfusions, and durability. METHODS: Group A (n=20) was supported by ECMO circuits with the Minimax oxygenator and the Biomedicus centrifugal pump. Group B (n=10) was supported by ECMO circuits with the Lilliput 2 ECMO oxygenator and the Rotaflow centrifugal pump. RESULTS: ECMO circuit durability, as measured by oxygenator lifespan, was significantly better in Group B than in Group A (p = 0.04). There was significantly lower hemolysis, measured by plasma free hemoglobin, in Group B (p = 0.019), and patients in Group B had significantly less need for antithrombin III transfusion (p = 0.004). No plasma leakage was observed in Group B oxygenators, but plasma leakage was observed in all Group A oxygenators. CONCLUSION: The combination of a Rotaflow centrifugal pump and Lilliput 2 ECMO oxygenator in pediatric ECMO circuits improved durability and reduced circuit-induced hemolysis. This improvement may be due to the low priming volume, the oxygenator's plasma leakage resistance, the suspended rotor of the centrifugal pump, or a combination of these factors.

An outbreak of hepatitis A among homosexuals linked to a family outbreak.

Several outbreaks of hepatitis A occurred in Norway in 1995-8. Molecular epidemiology was used to follow the spread of hepatitis A virus in the population. Distinct strains of hepatitis A virus (HAV) were detected by reverse transcriptase-polymerase chain reaction (RT-PCR) and subsequent sequencing in serum from patients in different communities at risk of infection. Two HAV strains were detected in an outbreak among 26 men having sexual contact with other men. One of these strains was also detected in a geographically limited family outbreak. The family outbreak was first believed to be acquired abroad. The sequence information linked the two outbreaks, and epidemiological and serological analyses revealed the transmission route. This study demonstrates the importance of molecular epidemiology in outbreak investigation, surveillance and monitoring of hepatitis A in the population.

[Surgical treatment of ulcerative colitis]. / Kirurgisk behandling ved ulcerøs kolitt.

Continence-preserving coloproctectomy for ulcerative colitis is technically demanding and is relatively often afflicted with complications. We have retrospectively reviewed the files of all patients being operated for ulcerative colitis at Ullevål Hospital from 1992 to 1997 (n = 53). Most of the patients (n = 50) were examined clinically; 12 patients had anal manometry before and after operation. 44 patients were operated with continence-preserving coloproctectomy with J-pouch and handsewn anastomosis; of these, 42 were followed more than six months. Eight had pouchitis, four perianal abscess/fistula, three septicaemia and three were operated for ileus. Two had anastomotic leakage and pelvic abscess that required transanal drainage. One had the pouch removed six years after operation due to chronic pouchitis and pouch-vaginal fistula. There was no deterioration of anal maximal resting and squeezing pressures on pre- and post-operative anal manometry. Mean number of stools from the reservoir per 24 hours were 6.2 (range 3-11); 11 patients had leakage of air and loose stool, three at day-time and eight at night. Two patients (4%) died from colorectal cancer and three (7%) had Crohn's disease. Nine patients were unfit for pouch surgery and underwent coloproctectomy (n = 7) or subtotal colectomy (n = 2). Our results indicate that pouch surgery for ulcerative colitis is a good option for most patients.

[Tularemia after tick bite in Vestfold]. / Tularemi etter flåttbitt i Vestfold.

Direct contact with rodents or their faeces is a well-known risk factor for contracting tularaemia in Norway. Both insects and ticks can act as vectors of tularaemia, but transmission by this route has not previously been described in this country. We report three cases of serologically confirmed ulceroglandular tularaemia on a small island in Southern Norway, an area in which tularaemia has not previously been known to occur. Tick bites preceded infection in two of the patients. The third patient may also have become infected through a tick or insect bite. Diagnosis was made late in all cases, causing a delay in appropriate treatment. Two of the patients were successfully treated with ciprofloxacin. Our experience and previous reports suggest that quinolones should be considered as the first choice of drugs in the treatment of tularaemia in Norway.

Characterisation of an epidemic of hepatitis A virus involving intravenous drug abusers--infection by needle sharing?

An epidemic of hepatitis A virus (HAV) among intravenous drug abusers in Oslo involved 144 serologically confirmed cases. Another 26 patients (non-drug abusers), of whom 14 were derived from a single nosocomial outbreak, were associated with the epidemic. Sequencing of the VP1/P2A junction revealed that viruses associated with the epidemic were completely identical, whereas other HAV samples collected during the same period differed by up to 10%. HAV was detected in the serum of 48 of 100 patients by a nested PCR. Viremia was observed as early as 25 days before the onset of clinical hepatitis, and up to 30 days after. The large number of patients within the drug abuser group, and the few secondary cases, raised the question of whether the virus could be transmitted by the use of needles. To establish whether viral contamination of drugs did contribute appreciably to maintaining the epidemic, we examined heroin and amphetamine confiscated during the period, using immunomagnetic separation coupled to nested PCR, but failed to detect any virus. Antibodies against hepatitis B virus and hepatitis C virus were common among the HAV infected drug abusers (43% and 81%, respectively), suggesting widespread sharing of needles. This observation and the large number of patients with a demonstrable viremia suggest that needle sharing may contribute to the dissemination of HAV.

[An outbreak of hepatitis A among intravenous drug addicts in Oslo 1995-96]. / Hepatitt A-epidemi blant intravenøse stoffmisbrukere i Oslo 1995-96.

Intravenous drug abuse is a well-known risk factor for acquiring hepatitis A infection. Among drug abusers most cases are sporadic, but epidemic outbreaks may occur occasionally. In this article we describe an epidemic outbreak including 144 serologically proved cases of hepatitis A among intravenous heroin and amphetamine abusers in Oslo. The outbreak lasted for 11 months. 59 (41%) of the patients were admitted to hospital. One of them died and seven developed severe but reversible acute hepatitis. We also registered 26 cases of hepatitis A among close contacts, 14 of whom were associated with a nosocomial outbreak that affected nurses, fellow patients and relatives. We do not know how the hepatitis A virus was introduced into the abuser population, but the further spread was probably dominated by a combination of faecal-oral transmission and parenteral transmission secondary to sharing needles. Although we were unable to detect hepatitis A virus in confiscated drug samples by means of polymerase chain reaction we cannot exclude that some abusers were infected by injection of contaminated amphetamine.

[Utilization of a unit of ambulatory surgery]. / Utnyttelse av en dagkirurgisk operasjonsenhet.

The productivity in an operating theatre can be defined as surgical time divided by the total work hours of the operating room staff. This productivity factor is normally reduced in the case of operations that take only a short time to perform, since the time interval between operations is usually not reduced correspondingly. In the unit for outpatient surgery at Akershus Central Hospital, 4.6 operations were performed daily in 206 days in 1993, with a productivity factor of 42% and an operating theatre utilization of 66% (operating theatre time spent on specific patients/total operating theatre time). The mean interval from the time the surgeons finished one operation until they could start the next was 33 minutes (confidence interval 32-34), with a mean operating time of 44 minutes (42-46). The productivity seemed good compared with the central operating theatre suite at the same hospital, and with US standard.

[Productivity in a Norwegian department of surgery]. / Produktivitet i en norsk operasjonsavdeling.

There are few good methods of evaluating efficiency in the operating theatres. Data from four operating theatres (gynaecology, gastroenterology, thoracic/vascular-surgery and orthopaedics) during regular working hours (0730-1530) were evaluated for a period of 37 weeks in 1993. A record was made of duration of surgery and the time that elapsed from when the nurses received the patient until he or she was delivered to the postoperative ward. We also registered the time elapsing from the end of one operation to the start of the next. On average 2.2 (thoracic/vascular) to 3.2 (gynaecology) patients were operated on each day. The surgeons spent about 40% of their normal working hours actually operating. Preparations before start of anaesthesia took about 30 minutes, and before surgery 30-40 minutes. Another 30 minutes elapsed from the end of the operation until the patient was delivered to the postoperative ward. We conclude that there may still be a potential for increasing productivity in these operating theatres.

[Yersinia enterocolitica septicemia after blood transfusion]. / Yersinia enterocolitica-septikemi etter blodtransfusjon.

Transfusion-associated transmission of Yersinia enterocolitica was first described in 1982. Since then more than 40 cases have been reported world-wide. The blood units are contaminated from apparently healthy donors who may, however, recently have had an episode of diarrhoea. Y enterocolitica is able to grow in packed red cells at refrigerator temperature. The mortality rate among recipients of contaminated blood is more than 50%. We describe a non-fatal case of a 80 year-old male who received one unit of packed red blood cells contaminated with Y enterocolitica (serogroup O:3, biotype 4). The blood had been collected 14 days before from a Norwegian donor with transient and slight abdominal discomfort. The microbe was isolated both from the patient's blood and from the donor blood bag. The patient was treated with ofloxacin and recovered without sequelae.

Asymptomatic carriage of Neisseria meningitidis in a randomly sampled population.

To estimate the extent of meningococcal carriage in the Norwegian population and to investigate the relationship of several characteristics of the population to the carrier state, 1,500 individuals living in rural and small-town areas near Oslo were selected at random from the Norwegian National Population Registry. These persons were asked to complete a questionnaire and to volunteer for a bacteriological tonsillopharyngeal swab sampling. Sixty-three percent of the selected persons participated in the survey. Ninety-one (9.6%) of the volunteers harbored Neisseria meningitidis. The isolates were serogrouped, serotyped, tested for antibiotic resistance, and analyzed by multilocus enzyme electrophoresis. Eight (8.8%) of the 91 isolates represented clones of the two clone complexes that have been responsible for most of the systemic meningococal disease in Norway in the 1980s. Age between 15 and 24, male sex, and active and passive smoking were found to be independently associated with meningococcal carriage in logistic regression analyses. Working outside the home and having an occupation in transportation or industry also increased the risk for meningococcal carriage in individuals older than 17, when corrections for gender and smoking were made. Assuming that our sample is representative of the Norwegian population, we estimated that about 40,000 individuals in Norway are asymptomatic carriers of isolates with epidemic potential. Thus, carriage eradication among close contacts of persons with systemic disease is unlikely to have a significant impact on the overall epidemiological situation.

[Outbreak of typhoid fever in a family]. / Et familieutbrudd av tyfoidfeber.

We describe a small epidemic of typhoid fever in a family who came originally from Pakistan. In 1992 six members (mother and five children) of a family of ten were admitted to our department with typhoid fever within a nine-day period. The index case was an 18 months old girl who had been hospitalized and treated elsewhere for typhoid fever. Two weeks after completing antibiotic treatment she was admitted to our hospital with a relapse. The source of her first infection is unknown. The rapid spread of typhoid fever in the family was most likely due to insufficient hygienic precautions and inadequate antibiotic treatment of the index case. Several coexisting factors such as poor housing conditions and cultural barriers may also have influenced the outcome. There is obviously a need for strict guidelines and proper coordination of treatment and follow-up of this and other similar contagious diseases.

[Pneumococcal vaccine recommended for HIV-infected individuals]. / Pneumokokkvaksine til HIV-smittede.

The Epidemic Section at the Oslo City Department of Health and Environment, is responsible for monitoring communicable diseases in Oslo. We have registered an increase in the number of severe cases of pneumococcal disease with bacteremia, sepsis and meningitis. Fifty-two cases of invasive pneumococcal disease occurred in Oslo in 1992. There are no available data on the HIV-status of these patients. Streptococcus pneumoniae is frequently found as part of the normal flora of the upper respiratory tract, and is an important pathogen for patients infected with HIV. We discuss indications for use of pneumococcal vaccine, and recommend earlier and more extensive use of this vaccine in HIV-infected persons in Norway.

Tularemia: a differential diagnosis in oto-rhino-laryngology.

Tularemia can present as an oto-rhino-laryngological disease. The clinical and radiological (CT) manifestations, diagnosis and treatment are discussed based on a case report where a patient with tonsillitis and enlarged cervical lymph nodes was admitted to the department of oto-rhino-laryngology of a hospital in Northern Norway. Francisella tularensis was isolated from the blood and there was a high titre of agglutinating serum antibodies to F. tularensis. The patient's contaminated drinking water well is the suspect source of infection.