[X-ray of small bowel with a probe--indications and diagnostic yield in a 10-year material]. / Røntgen tynntarm med sonde--indikasjoner og diagnostisk utbytte i et tiårsmateriale.

BACKGROUND: We wanted to evaluate the indications for ordering small bowel enema, and whether specific clinical symptoms and signs are associated with the diagnostic yield. MATERIAL AND METHODS: Medical charts and requisition slips for 241 patients examined with small bowel enema at Harstad Hospital from 1986 to 1995 were reviewed. RESULTS: The most common symptom leading to small bowel radiography was pain, registered in almost three fourths of the patients; about one half reported diarrhoea. Elevated sedimentation rate and occult blood in the faeces were reported in one fourth of the patients. For a large proportion of the patients, there was no information about adequate preliminary tests in the medical charts. Normal radiography was reported in three fourths of the patients. Lesions consistent with Crohn's disease were found in one of eight patients. No symptoms or signs, except for elevated sedimentation rate, clearly indicate a positive diagnostic finding. Many requisition slips did not contain available information. INTERPRETATION: Small bowel radiography is performed on wide indications. It is difficult to make a careful selection of patients based on reported symptoms and signs. However, some preliminary tests are helpful and should be done.

[Infrared tympanic thermometry compared to mercury thermometers]. / Infrarød tympanisk termometri sammenliknet med bruk av kvikksølvtermometer.

Because of conflicting reports we examined the accuracy of infrared tympanic thermometry compared with mercury rectal thermometer and a digital rectal thermometer in a medical ward. We studied prospectively the accuracy of parallel measurements with infrared tympanic thermometer and the correlation between this method and the rectal mercury thermometer. Measurements with digital rectal thermometry are also compared with mercury thermometry. 191 adult inpatients were included. The median difference between infrared tympanic and rectal mercury thermometry in the whole material was -0.5 degree C, but increased to -1.4 degrees C in a selected group with rectal temperature 38 degrees C or more. The median difference between parallel measurements with infrared tympanic thermometer was 0.4 degree C. Digital rectal thermometry, however, was in strict accordance with the rectal mercury method. We found an unacceptable difference in body temperature between measurements with infrared tympanic thermometer and rectal mercury thermometer. In a clinical setting the infrared ear thermometer has a very low sensitivity for detecting fever. Digital rectal thermometry seems to be a good alternative to the rectal mercury thermometer.

[Improved routines for thrombolytic treatment of acute myocardial infarction]. / Forbedrede rutiner for trombolytisk behandling ved akutt hjerteinfarkt.

A study in 1995 at Harstad District Hospital concluded that too few patients with acute myocardial infarction had received thrombolytic treatment and that the in-hospital delay before administration of thrombolytics had been too long. To evaluate the effect of improvements in medical and nursing routines, data on all patients with acute myocardial infarction treated between October 1996 and October 1997 (n = 122) were analysed prospectively and compared with data from the 1995 study. The proportion of patients who received thrombolytic treatment increased from 24% in 1995 to 37% (p = 0.02). All patients received thrombolytics when indicated. The proportion of patients who died in hospital decreased from 25% in 1995 to 16% (p = 0.06). The proportion of patients who were treated within 60 minutes after arrival at the hospital increased from 20% to 67% (p < 0.001). For patients with typical ECG changes at arrival the mean door-to-needle time was 37 minutes. Mean delay from onset of symptoms to treatment was 4.5 hours. The results indicate that improved routines may have increased the proportion of patients receiving thrombolytic treatment and reduced the in-hospital delay. It is possible that a further reduction of delay may be achieved by reducing the pre-hospital delay, or by starting thrombolytic treatment before arrival to hospital.

A comparative study of infrared tympanic thermometry and rectal mercury thermometry.

In this study we compared infrared tympanic thermometry with rectal mercury thermometry and digital rectal thermometry in patients admitted to a medical department. We found that infrared tympanic thermometry has a low sensitivity for detecting fever. Digital rectal thermometry is a good alternative to rectal mercury thermometry.

[Myelomatosis and low level of vitamin B12]. / Myelomatose og lavt serum-vitamin B12-nivå.

Many patients with multiple myeloma tend to have low serum cobalamin. The cause of this remains unclear. The important issue is whether cobalamin therapy should be used or not. We describe one case of megaloblastic erythropoiesis and multiple myeloma, and refer to some of the few studies describing the subject. Most of the patients with multiple myeloma are elderly, and the frequency of hypo- and achlorhydria is therefore increased. It has been demonstrated that cobalamin uptake and consumption is higher in myeloma cells than in normal bone marrow cells, and that cobalamin may be required for paraprotein synthesis. These facts may suggest that patients with multiple myeloma are more vulnerable to developing megaloblastic anemia than others. Our patient received cobalamin therapy in addition to cytostatic therapy for multiple myeloma without complications. However, we cannot exclude that cobalamin therapy may accelerate multiple myeloma; this should be considered when such therapy is given. However, accurate guidelines require more studies.

Primary sclerosing cholangitis with autoimmune hemolytic anemia and pulmonary infiltrations.

A 39-year-old man presenting with pulmonary infiltrations and hemolytic anemia was diagnosed as having primary sclerosing cholangitis (PSC) without evidence of ulcerative colitis. This constellation of associations is unique to the best of our knowledge. Autoimmune hemolytic anemia has been reported to be associated with PSC on only a few occasions, and pulmonary infiltrations in association with PSC are also quite unusual. Genetic and immunologic mechanisms are major factors in the pathogenesis of these disorders.

[Thrombolytic therapy in acute myocardial infarctions]. / Trombolytisk behandling ved akutt hjerteinfarkt.

Data on all patients with acute myocardial infarction who were treated in Harstad District Hospital in 1995 were analysed. Of the 170 patients, 24% received thrombolytic treatment. Thrombolytics were withheld from 15% of the patients, although there were no contraindications present. Thrombolytics were administered two hours and 18 minutes (mean) after admission to hospital and seven hours after the onset of symptoms. 54% of the patients were admitted to hospital within six hours and 73% within 12 hours. In-hospital delay before the administration of thrombolytics is too long. In Norwegian hospitals this factor has only been analysed to a minor degree. Despite a fairly standardized treatment regimen for thrombolytics, how frequently it is used probably varies from hospital to hospital. There is great potential for improving thrombolytic treatment. The results of our analyses have resulted in an extensive change in routine in our hospital.

[Congenital dyserythropoietic anemia type III. A case report]. / Kongenitt dyserytropoetisk anemi type III. En kasuistikk.

Congenital dyserythropoietic anaemia type III is a rare disorder characterized by mild to moderate anaemia, ineffective erythropoiesis, and morphologic abnormalities of mature red blood cells and their precursors. The most extraordinary feature of this condition is the large number of multinuclear erythroblasts found in the bone marrow, some containing up to 12 nuclei. This type of anaemia is an autosomal dominant inherited disorder, though sporadic cases have been described. Little conclusive is known about the pathogenesis of congenital dyserthropoietic anaemia type III. At present the management of patients consists of observation and supportive care. We describe a 20 year old man who was admitted to a county hospital, showing the typical features of this rare illness. He had a Hb value of 10.2 g/100 ml.

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.

Multiple myeloma in central and northern Norway 1981-1982: a follow-up study of a randomized clinical trial of 5-drug combination therapy versus standard therapy.

In a randomized study of 92 previously untreated patients with multiple myeloma, the intention was to document the possible beneficial effect of combination chemotherapy including vincristine, carmustine, alkylating agents and prednisone, as compared to conventional therapy with melphalan and prednisone. Major prognostic factors did not differ significantly between the treatment groups. With the 2-drug therapy and 5-drug combination therapy, 48 and 54% of the patients achieved remission, respectively. Median survival for patients treated with the 2-drug regimen and 5-drug regimen was 29 and 33.5 months, respectively. No significant difference was found between the survival curves for stage III patients treated with the two regimens. After 12 months, patients who had achieved remission were randomized to have treatment discontinued or to have maintenance treatment. The numbers of relapses, remission duration and survival of the two groups were similar.

Effect of free fatty acids on the cytolytic activity of tumour necrosis factor/monocyte-derived cytotoxic factor.

The effect of different fatty acids on tumour necrosis factor (TNF)-induced cytolysis of TNF-sensitive WEHI 164 murine fibrosarcoma cells has been determined. The saturated fatty acids palmitic (16:0) and stearic (18:0) acid strongly potentiated the cytolytic activity of TNF. They also had a slight cytotoxic effect in the absence of TNF. Contrary to this, the unsaturated fatty acids oleic (18:1), linoleic (18:2), alpha-linolenic (18:3), arachidonic (20:4), and eicosapentaenoic (20:5) acid were neither cytotoxic by themselves, nor did they have any significant effect on the cytolytic activity of TNF. Addition of either of the unsaturated fatty acids 18:2 or 20:5 together with 18:0 eliminated the potentiating effect 18:0 by itself had on TNF-induced cytolysis. A mixture of fatty acids resembling that found in cell phospholipids had no cytotoxic effect by itself, nor any effect on the cytolytic activity of TNF. The potentiating effect of saturated fatty acids on TNF thus seems to depend on their relative amount compared to the amount of unsaturated acids. The results indicate that TNF does not exert its cytotoxic effect simply by suppressing hydrolysis of triglyceride, thereby inducing an insufficient cellular supply of fatty acids.

Multiple myeloma in central Norway 1981-1982: a randomized clinical trial of 5-drug combination therapy versus standard therapy.

67 previously untreated patients with multiple myeloma were entered on a randomized clinical trial to determine whether the use of combination chemotherapy including vincristine, carmustine, alkylating agents, and prednisone was more effective than conventional therapy with melphalan and prednisone. The treatment groups did not show significant differences with respect to major prognostic factors. With the 2-drug combination therapy and 5-drug combination therapy, 67 and 74% of the patients achieved remission, respectively. Moreover, no significant difference was found between the two treatment schedules in terms of median survival (30+ months). The survival curves for stage III patients treated with the two regimens did not differ significantly. After 12 months, patients who had achieved remission were randomized to have treatment discontinued or to have maintenance treatment. 7 of 15 patients on maintenance therapy relapsed, whereas 9 of 14 patients who had their therapy discontinued relapsed, and the survival of the two groups was similar.

Human monocyte-released cytotoxic factor: effect on various cellular functions, and dependency of cytolysis on various metabolic processes.

The ability of the human monocyte-released cytotoxic protein factor(s) (CF) to mediate cytolysis when various metabolic processes in target cells were inhibited, and its effect on various cell functions have been studied. Cytolysis was reduced when target cells were exposed to either chloroquine or colchicine, indicating that lysosome function and the formation of microtubule are of importance with respect to the interaction between CF and target cells, possibly by effecting internalization and processing CF and its receptor. A decrease in the energy charge of the target cells did not affect the ability of CF to mediate cytolysis, since the 60-70% reduction of the cellular ATP content by uncoupling oxidative phosphorylation had little effect on CF-induced lysis. It was unnecessary for target cells to be actively growing and dividing for CF to induce lysis because inhibition of cellular protein, RNA, and DNA synthesis potentiated the cytolytic effect of CF. CF-induced cell lysis of Walter and Eliza Hall Institute (WEHI) 164 target cells was first detected between 3.0 and 4.5 hr after addition of CF. Target cell DNA synthesis nearly terminated within 3-4 hr, about the time of first cell lysis detection. Compared to the effect on DNA synthesis, the CF effect on protein synthesis was negligible and only a slight reduction was detected in the RNA synthesis and in the cellular ATP content. The results indicated that the DNA-synthesizing machinery may either be a primary target site of CF or a rapid influence of CF action on its primary target site; however, neither the protein- or RNA-synthesizing machinery nor the cellular ATP generating systems are likely to be primary target sites.

The role of monocyte cytotoxic factor in monocyte-mediated lysis of tumour cells.

The role of a monocyte cytotoxic factor (CF) in monocyte-mediated lysis of leukaemia cells (K562) has been investigated using a polyclonal rabbit antiserum raised against purified CF. The CF antiserum inhibited K562 cell lysis mediated by interferon gamma (IFN-gamma)-activated monocytes. CF antiserum also inhibited monocyte-mediated lysis of antibody-coated K562 cells (AbK562). Preimmune serum at the same concentration as CF antiserum did not affect monocyte-mediated lysis, and the CF antiserum did not inhibit binding between effector and target cells, indicating that inhibition of monocyte-mediated lysis by CF antiserum was not merely a result of toxic components present in the rabbit serum, or a result of a decrease in monocyte-target cell binding. Taken together, the data suggest that CF is involved in monocyte-mediated lysis of uncoated as well as antibody-coated K562 cells.

WEHI 164 sarcoma cells rendered resistant to monocyte-released cytotoxin are also resistant to monocyte-induced cytolysis.

WEHI 164 sarcoma cells cultured with monocyte-released cytotoxin (CF) for 4 weeks became resistant to CF-induced cytolysis and were concomitantly rendered resistant to monocyte-induced cytolysis. The resistant cell line (R-WEHI 164) has been stable with respect to resistance to monocyte- and CF-induced lysis for more than 7 months. WEHI 164 and R-WEHI 164 cells adsorbed CF and no significant difference in CF adsorption was observed. The results indicate that CF may be an effector molecule in monocyte-mediated cytolysis.

Monocyte-mediated drug-dependent cellular cytotoxicity: effects on different WEHI 164 target cell lines.

The contribution of monocyte cytotoxic protein factor (CF) to monocyte-mediated drug-dependent cellular cytotoxicity (DDCC) has been investigated. Cell lines which have been derived from murine WEHI 164 cells (termed WEHI 164 parental) by selecting for high (WEHI 164 clone 3) and low (R-WEHI 164) sensitivity to CF-mediated cytotoxicity were used as target cells in DDCC. By comparing the CF doses which produced 50% dead cells (LD 50) we found that WEHI 164 clone 3 was approximately 30 times more sensitive than WEHI 164 parental which in turn was 70 times more sensitive than R-WEHI 164. Actinomycin D (Act D) treatment of WEHI 164 parental and R-WEHI 164 greatly increase susceptibility to CF-mediated cytotoxicity. The susceptibility of WEHI 164 clone 3 was apparently somewhat increased at low dilutions of CF, whereas no significant increase was observed at high dilutions. The susceptibility to DDCC of the three target cell lines (WEHI 164 parental, WEHI 164 clone 3, and R-WEHI 164) correlated with the sensitivity pattern obtained in CF-mediated cytotoxicity of Act D-treated target cells. Monocyte- and CF-mediated cytotoxicity against Act D-treated WEHI 164 clone 3 and R-WEHI 164 was inhibited by neutralizing CF antiserum. These data indicate that CF is an effector molecule in monocyte-mediated DDCC.