[Spotted fever imported into Norway in 1997]. / Flekkfeber importert til Norge i 1997.

Tick-borne rickettsioses are important zoonoses in many tropical and subtropical areas. There has recently been an increase in the number of reported cases among tourists returning to Scandinavia. In this article we present all five serologically confirmed cases of tick-borne rickettsioses imported into Norway in 1997. The patients were Norwegian tourists who had visited South Africa (three cases), Zimbabwe, and Italy. Four cases had typical eschar and three had maculopapular exanthema. The patients were treated with either doxycycline or ciprofloxacin. No complications were reported. The diagnosis of tick-borne rickettsiosis was confirmed by the detection of specific IgM antibodies to Rickettsia conorii using micro-immunofluorescence in serum samples.

[Meningococcal project Telemark. Experiences after 5 years with contact tracing and eradication of the pathogenic bacteria in near contacts of the patients with meningococcal disease]. / Meningokokkprosjekt Telemark. Erfaringer etter fem år med smitteoppsporing og sanering av den sykdomsfremkallende bakterien hos naerkontakter av pasienter med meningokokksykdom.

Since 1987 we have analysed throat samples from 1,086 healthy contacts of 32 patients with meningococcal disease. The disease-causing strain was found in contacts of 17 out of the 32 patients. 161 (18%) of the contacts carried meningococci, and 30 (3%) of them were carriers of the disease-causing strain as determined by DNA fingerprinting. The carrier strain was eradicated in 29 of these 30 contacts by treatment with rifampicin. No secondary case of meningococcal disease was observed. During the four-year period 1984-87, there were 39 confirmed cases of meningococcal disease, including 12 verified and four suspected secondary cases of meningococcal disease. Therefore identification and eradication of the disease-causing strain seems to prevent secondary cases. A change in the Norwegian recommendations for preventing secondary cases of meningococcal disease should be discussed.

[Medical and nursing leadership in hospitals. Tasks and experiences]. / Medisinsk og sykepleiefaglig ledelse i sykehus. Oppgaver og opplevelser.

During winter 1991, 60% of medical and nursing administrators in Telemark county made an extensive evaluation of their own jobs. Head of Department physicians spent 60% of their working time on medical tasks, 10% on budgets and accounting, and 30% on care of the staff. Direct work in connection with patients took 48% of time. 19% of the working time was spent on secretarial functions which could preferably be delegated to others. Head of Department doctors have too little education in budgeting and accounting. Head of Section doctors spent 77% of their working time on medical tasks. This is a group of contented and productive physicians. Head of Department nurses spent 74% of their time on administrative tasks and 11% on work directly connected to patients. 25% of the time was spent on individual care of colleagues in addition to professional instruction, and the group would like to have even more time for this task. Head of Ward nurses spent 38% of their working time on patients and 58% on tasks connected to the staff. 26% of their time is mere secretarial work. Individual care of colleagues required 21% of their time, and they would like to have even more time for this purpose. All groups of administrators would like to receive more feedback from the top management of their hospital.

Ciprofloxacin versus a tobramycin/cefuroxime combination in the treatment of serious systemic infections: a prospective, randomized and controlled study of efficacy and safety.

Sequential intravenous and oral ciprofloxacin (CF) was compared with a combination of tobramycin and cefuroxime (T/C) in the treatment of serious systemic infections. Altogether 310 patients were randomized, 160 receiving CF and 150 T/C, the 2 groups being reasonably well balanced. 29 patients without infection were excluded from the analysis. Complete clinical resolution was obtained in 75% (107/143) patients receiving CF and in 78% (107/138) receiving T/C; the difference was not statistically significant. The rate of bacterial eradication in septicaemia was 72% (95% confidence interval (95% c.i.): 58-86%) for patients treated with CF and 87% (95% c.i.: 77-96%) when T/C was given, while the eradication rates in urinary tract infection were 72% (95% c.i.: 54-90%) and 45% (95% c.i.: 23-67%) for CF and T/C, respectively. Significant differences in bacteriological response for other diagnoses were not detected. Also for lower respiratory tract infections (LTRI) the clinical and bacteriological responses were quite similar, although relatively more failures occurred in CF treated patients with LRTI caused by pneumococci. The frequencies of adverse reactions were comparable, but the reactions were less serious following CF treatment. Our results indicate that CF may be used for empirical treatment of serious infections. However, if pneumococcal etiology is likely, alternative antibiotics should be used, and if necessary, coverage against anaerobic bacteria should be added.

Preventing secondary cases of meningococcal disease by identifying and eradicating disease-causing strains in close contacts of patients.

In Norway, the use of chemoprophylaxis after cases of meningococcal disease is not recommended. Instead, household members less than 15 years are treated with penicillin for 7 days. Failures of this treatment have been reported. We therefore used DNA fingerprinting to identify the disease-causing strain in healthy contacts combined with selective rifampicin prophylaxis to these carriers to prevent secondary cases. During a 2-year period (1987-89) there were 13 cases of meningococcal disease in the County of Telemark (165000 inhabitants). 65 (14.7%) out of 441 contacts to these 13 patients harbored meningococci in their throat; 16 (3.6%) carried the disease-causing strain. Only 1 carrier fulfilled the criteria for being treated with penicillin; 8 were adults and the remaining 7 were not household members. No secondary cases of meningococcal disease occurred during the study period or the following 12 months. During the 4-year period (1984-87) preceding the study period there were 39 cases of meningococcal disease in Telemark; 7 of them were index cases for 12 bacteriologically verified and 4 clinically suspected secondary cases of meningococcal disease. We conclude that selective prophylaxis with rifampicin seems to be more efficient that penicillin treatment of household members less than 15 to prevent secondary cases of meningococcal disease.

[Refractory Clostridium difficile infection. Untraditional treatment of antibiotic-induced colitis]. / Refraktaer Clostridium difficile-infeksjon. Utradisjonell behandling av antibiotikaindusert kolitt.

Intestinal Clostridium difficile infections are treated successfully with antibiotics. Relapses can be a problem. We describe a patient who suffered seven relapses after treatment with all the medicaments reported to be efficacious. She was cured only after treatment with faeces administered by duodenal tube.

[Examination of the environment in meningococcal disease. Identification and clearing of the virulent microorganism from the environment of patients with meningococcal disease]. / Miljøundersøkelse ved meningokokksykdom. Oppsporing og sanering av den sykdomsfremkallende mikrobe i miljøet til pasienter med meningokokksykdom.

During the period from January 1987 to June 1988 DNA fingerprinting was used to identify carriers of the disease-causing strain of Neisseria meningitidis among the patients contacts. A total of 432 persons were screened during nine episodes. The overall carrier-rate was 16.2%, and the causative strain was found in 3.4% of the contacts. Eleven carriers were successfully treated with rifampicin, whereas two of three carriers treated with penicillin remained carriers. We conclude that DNA fingerprinting is a valuable tool for rapid identification of carriers of the causative organism in order to eradicate the epidemic strain of N. meningitidis.

A novel pathway for biosynthesis of cholestanol with 7 alpha-hydroxylated C27-steroids as intermediates, and its importance for the accumulation of cholestanol in cerebrotendinous xanthomatosis.

A mixture of 7 alpha-3H- and 4-14C-labeled cholesterol was administered intravenously to rats. Cholestanol with 20-30% lower ratio between 3H and 14C than in cholesterol could be isolated from different organs. In a healthy human control, cholestanol isolated from feces had a 3H/14C ratio which was 28% lower than in administered cholesterol. Cholesterol and coprostanol reisolated in these experiments had the same ratio between 3H and 14C as in the precursor. A previously unknown pathway for formation of cholestanol, involving 7 alpha-hydroxylated intermediates, may explain these results. Under normal conditions, this pathway is responsible for at most 30% of the cholestanol synthesized from cholesterol. Intravenous administration of the 7 alpha-3H- and 4-14C-labeled cholesterol to a patient with cerebrotendinous xanthomatosis (CTX) resulted in formation of cholestanol which had 70-75% lower 3H/14C ratio. It is concluded that the novel pathway involving 7 alpha-hydroxylated intermediates is accelerated in patients with CTX. This acceleration may contribute essentially to the accumulation of cholestanol, which is a predominant feature of this disease. 7 alpha-Hydroxycholesterol and 7 alpha-hydroxy-4-cholesten-3-one might be intermediates in the novel pathway to cholestanol. After intravenous administration of 7 beta-3H-labeled 7 alpha-hydroxycholesterol in a patient with CTX, significant amounts of 3H were incorporated into plasma and fecal cholestanol. Only small amounts of 7 alpha-hydroxycholesterol and 7 alpha-hydroxy-4-cholesten-3-one are excreted into the intestine, and we therefore conclude that the 7 alpha-dehydroxylation step mainly occurs in the liver. In CTX, the synthesis of cholestanol may be accelerated because the concentrations of 7 alpha-hydroxylated bile acid intermediates in the liver are increased. A possible mechanism for the conversion of a minor fraction of 7 alpha-hydroxycholesterol into cholestanol is suggested.

Leber's idiopathic stellate neuroretinitis.

Twenty-nine eyes of 27 patients demonstrated the typical features of neuroretinitis with a mascular star. Historical and fluorescein angiographic features of this condition implicate a bloodborne infectious agent. It is likely that multiple agents can produce this condition, including the agent of cat-scratch fever and leptospirosis. A small subgroup may exist in whom this condition resembles anterior ischemic optic neuropathy and has a less favorable clinical course than is usual. There is evidence that this condition is not related to demyelinating disease. It is emphasized that this condition is not a maculopathy since vascular leakage in the optic nerve causes the star. Therefore, we suggest that this condition be renamed Leber's idiopathic stellate neuroretinitis.

Decrease of Fc gamma and C3b receptor-bearing granulocytes and of T lymphocytes in myelomatosis.

18 patients with myelomatosis had lower percentages of granulocytes bearing receptors for Fc gamma (47.6%) and C3b (43.0%) than controls (80.4% and 75.0%). The percentage of T lymphocytes was decreased in patients when untreated sheep erythrocytes were used as indicator cells. Patients with high serum IgG levels had lower percentages of T lymphocytes. There was no significant difference in receptor profile between treated and untreated patients. The decrease in Fc gamma and C3b receptor-bearing granulocytes in myelomatosis is probably not due to serum or plasma factors since (a) the distribution of receptor-bearing lymphocytes was not different from that of the controls; (b) extra washings of cells or overnight incubation did not enhance the percentage of receptor positive cells; and (c) incubation of normal granulocytes in sera or plasma from myelomatosis patients did not cause a more pronounced reduction in the proportions of Fc gamma of C3b receptor-bearing cells than incubation in normal sera or plasma.

Influence of tetracyclines on human polymorphonuclear leukocyte function.

Low concentrations of oxytetracycline, doxycycline, or minocycline (less than 10 micrograms/ml) did not influence in vitro polymorphonuclear leukocyte random migration, chemiluminescence, or glucose oxidation. At high concentrations of doxycycline or minocycline (greater than 10 micrograms/ml), chemiluminescence and glucose oxidation were impaired. High concentrations of doxycycline also reduced random migration. Oxytetracycline did not influence these functions in concentrations up to 100 micrograms/ml. The inhibiting effect of doxycycline and minocycline was abolished when 4 mM Mg2+ was added to the reaction mixture, and 4 mM Ca2+ partly restored minocycline-inhibited polymorphonuclear leukocyte functions. This indicates that the major effect of tetracyclines on in vitro polymorphonuclear leukocyte functions is mediated by their divalent cation chelating effect and that the results of in vitro experiments are highly dependent on the concentration of divalent cations in the reaction mixtures. The difference between the tetracyclines may be due to differences in lipid solubility, with solubility being highest for minocycline and lowest for oxytetracycline, or to different divalent cation chelating ability.

Mechanisms of decreased leucocyte adhesiveness and migration in plasma from patients with IgG myelomatosis.

The adhesiveness of leucocytes in human plasma was decreased by the addition of IgG M-protein, commercial IgG, F(ab)2-fragments, or bovine serum albumin (BSA). Leucocyte migration was inhibited by IgG M-protein and commercial IgG, but not by reduced and alkylated IgG, F(ab)2-fragments or BSA. Guinea pig serum (GPS) strongly enhanced leucocyte migration in Hanks' balanced salt solution. This effect was abolished by hydrazine treatment or heating, and reduced, but not abolished, by zymosan treatment. C4-deficient guinea pig serum (C4-def-GPS), but not zymosan treated C4-def-GPS stimulated migration. In IgG myeloma sera migration was enhanced by the addition of C4-def-GPS and by untreated or heated, but not hydrazine treated GPS, and inhibited by zymosan treated GPS. IgG M-protein inhibits leucocyte adhesiveness and migration. Migration is specifically inhibited by the intact IgG, probably through complement activation with consumption of heat stable chemokinetic factor(s) and production of migration inhibitors.

Simultaneous measurement of phagocytosis and phagosomal pH by flow cytometry: role of polymorphonuclear neutrophilic leukocyte granules in phagosome acidification.

Human polymorphonuclear neutrophilic leukocytes (PMNLs) phagocytosed fluorescein-isothiocyanate (FITC)-labelled Staphylococcus aureus. Free bacteria, phagocytes, and nonphagocytes were discriminated and quantified by flow cytometry (FCM). The relative fluorescence of phagocyte-associated and free bacteria (Nf:N) was calculated by dividing the mean phagocyte fluorescence by that of the free bacteria and the number of phagocytosed bacteria. Bactericidal capacity and chemiluminescence were measured by standard methods. The red-to-green fluorescence ratio of acridine orange-stained PMNLs (R/G) was measured by FCM. Degradation of bacteria was monitored by the reduction in FITC and ethidiumbromide fluorescence of bacteria liberated from the phagocytes. Bacterial FITC fluorescence was pH dependent. Nf:N was 0.5 to 0.7. Using a standard curve for the interrelationship between bacterial fluorescence and pH, phagosomal pH was 5.0-5.5. Phagocytes, kept at 4 degrees C for 24 h had Nf:N approximately 1, did not degrade bacteria, but killed them and emitted chemiluminescence. NH4Cl increased phagocyte fluorescence by 27% and decreased R/G by 50%. Cyanide and azide did not affect Nf:N. Nf:N of phagocytes from a patient with chronic granulomatous disease was 32% below, and R/G was 32% higher than the controls. Acidification of the phagosomes seems to be related to discharge of PMNL granule contents and independent of the respiratory burst.

The pupil in congenital third nerve misdirection syndrome.

The involved pupil in the syndrome of aberrant regeneration of the oculomotor nerve usually remains larger than the uninvolved side, or approaches equality in size. A 4-year-old child was seen with congenital aberrant regeneration of the right third nerve. The right pupil was consistently smaller than the left, but particularly so in dim illumination. The question can be raised as to whether relative pupillary miosis more commonly follows third nerve misdirection in children than adults.

Granulocyte function in malignant monoclonal gammopathy.

Granulocyte function was studied in 22 patients with untreated myelomatosis or macroglobulinaemia. Granulocyte adhesiveness (GA) and migration in capillary tubes (Tm) were, except for light chain disease, significantly decreased in patients of all gammopathy classes especially IgG myelomatosis. A plasma factor inhibited GA. The impairment of Tm was due to an inhibiting factor as well as lack of a stimulating plasma factor. Migration of granulocytes to skin chambers was decreased in patients with IgG myelomatosis. Chemiluminescence production during phagocytosis of opsonized zymosan was decreased. Compared to control sera, the opsonic activity of patient sera was strongly decreased. The impaired granulocyte functions in patients with malignant monoclonal gammopathy may contribute to the enhanced susceptibility to infections in these patients.

The Wyburn-Mason syndrome. Concomitant chiasmal and fundus vascular malformations.

We report a 56-year-old female with a 50-year history of a progressive chiasmal syndrome who was found to have a suprasellar arteriovenous malformation involving the chiasm and both optic nerves associated with an unusual fundus picture consistent with the Wyburn-Mason syndrome. A review of the literature of this rare syndrome is also presented.

Role of the 26-hydroxylase in the biosynthesis of bile acids in the normal state and in cerebrotendinous xanthomatosis. An in vivo study.

On the basis of different in vitro studies, we have previously suggested that the basic metabolic defect in the rare inherited disease cerebrotendinous xanthomatosis (CTX) is a lack of a hepatic mitochondrial C27-steroid 26-hydroxylase, involved in the normal biosynthesis of bile acids (1980. J. Clin. Invest. 65: 1418-1430; 1981. J. Lipid Res. 22: 191-200; 22: 632-640). In the present work, this hypothesis was tested in vivo. One patient with CTX and two control subjects received intravenously a mixture of [4-14C]7 alpha-hydroxy-4-cholesten-3-one and [6 beta-3H]7 alpha,26-dihydroxy-4-cholesten-3-one, steroids believed to be important precursors of chenodeoxycholic acid. The ratio between 14C and 3H in cholic acid and chenodeoxycholic acid isolated from bile of the CTX-patient was approximately 1/40 and 1/60 of those of the control subjects, respectively. Another patient with CTX and one control subject received a mixture of [4-14C]5 beta-cholestane-3 alpha,7 alpha-diol and [1,2-3H]5 beta-cholestane-3 alpha,7 alpha,26-triol, both possible precursors to chenodeoxycholic acid. In this case the 14C/3H ratio in cholic acid and chenodeoxycholic acid from the patient with CTX was 1/10 and 1/15, respectively, compared with that of the control subject. The most likely explanation for these findings is that very little of the 14C-precursors, i.e. without a 26-hydroxyl group, can be converted into cholic acid and chenodeoxycholic acid because of a defect of the 26-hydroxylase step. The results obtained are in accord with our previous findings in vitro. The results further underline the importance of the 26-hydroxylase pathway in the normal biosynthesis of cholic acid and chenodeoxycholic acid in man.

Intraocular lenses and experimental bacterial endophthalmitis.

To determine if an intraocular lens renders bacterial endophthalmitis more resistant to therapy, an animal model was developed. Nine rabbits underwent bilateral extracapsular lens extraction with placement of a Simcoe posterior chamber IOL in one eye. Approximately 170 organisms of Staphylococcus aureus were inoculated into both eyes. The eyes of seen animals were treated with intravitreal and subconjunctival gentamicin after 24 and 48 hours. Vitreous cultures remained sterile in all treated eyes for one week after antibiotic therapy. Two animals that did not receive antibiotics showed persistent infection. There was no difference between aphakic and pseudophakic eyes in terms of clinical response or onset of negative cultures.