Abstracts kull 98

					Book of Abstracts

Student theses Class 98


The University of Bergen Faculty of Medicine

Preface The Student Thesis A full 6 (or 6 ½) years medical curriculum at The University of Bergen includes the thesis work. At the end of the 5th year, 4 weeks are exclusively reserved for this purpose. Apart from this period, the thesis work must be done parallel to the full-time study. The thesis must be completed and accepted within the last but one semester. The students must start to prepare their research work early. They are encouraged to develop ideas for their own research from the very start, and in addition they can choose subjects from a catalogue on the intranet. At the end of the 3rd year, they must have decided a subject and made contact with a supervisor. They must hand in a project review which has to be approved by the Committee of Theses (appointed by The Faculty of Medicine). Most students do their research work within the university area, but they may also do this outside the Bergen area. Some students even go to distant locations like Africa and SouthAmerica and do their fieldwork there in their elective period. A condition is nevertheless that one of our faculty academic must take responsibility as a local mentor in addition to any supervisor at their chosen study site. The aim of the project work is for the students to achieve competence in all aspects of medical research conduct, including ethical and legal considerations, literature search strategies, definition and hypothesis formulation, choice of methods, data collection and analysis, and interpretation and dissemination of results. The objectives of the student thesis are training in critical thinking, scientific methods and search for information, and the research subjects must be relevant for medical theory or practice in a wide sense. The student thesis may, thus, build on scientific literature, existing (patient) data, or own original observations within the area of medicine. One of the aims is to further written communication skills. It is therefore recommended that the format, extent and level of the thesis must comply with the requirements of a scientific journal paper in the field of their chosen subject or method. Each thesis may have one, two or at most three student authors. This Book of Abstracts presents the English summaries of all the student theses of class 98. These demonstrate the wide aspects of subjects, and the academic ability of our students. For most of the students this is their first publication, and it hopefully will encourage further research activity, including those choosing a clinical career. Every year, five theses from students at the beginning of the 6th year are selected to be presented to fellow students and staff. There is a reward of NOK 2000 for each thesis presented.

Head of Committee Are Næss Professor

Bestkytter kirurgiske hansker operatøren ved bruk av diatermi?
Abrahamsen, Håkon

Supervisor: Svein Landsvik, siv.ing. og Ståle Freyer, avd.ing. Høgskolen i Stavanger, linje for medisinsk teknikk

Most doctors have been convinced that the sudden electrical shocks and burns that we focused on in this experiment, are caused by pinholes in the gloves. While there has been no doubt that gloves do develop holes during use, it has not been possible to develop effective solutions without a clear understanding of the cause. This study made clear that destruction of surgical gloves occurs readily in the ordinary use of electric knives for coagulation. During actual surgery, forceps are used in conjunction with the knives, reducing the impedance. Because of this, high frequency current will pass through gloves even if there are no pinholes. In much the same way, if blood or cleaning fluid gets on the gloves. The conductivity of most NRL gloves decrease significantly over time, once the gloves is wetted. Burns due to this type of insulation destruction will occur more readily. A number of measures, to improve the situation, are possible. First is to ensure that doctors have a proper understanding of the coagulation functions of electric knives. Also, for surgery that requires wide use of coagulation, there is need to develop forceps that are partially insulated. In addition, the oscillation frequency and the output power of electric knivew should be standardized below set values.

Efficiency of light treatment on SAD/sub-SAD Effekt av lysbehandling ved SAD/sub-SAD
Amundsen, Ola

Supervisor: Bjørn Bjorvatn, professor dr.med. Seksjon for allmennmedisin, Institutt for samfunnsmedisinske fag, UiB

This is probably the first study to evaluate the efficiency of bright light treatment on winter depression (SAD/sub-SAD) using treatment in the patient’s home. 138 patient journals given from two doctors at the Bergen Center of Sleep (Bergen Søvnsenter) were examined. The patients approached the clinic either at their own initiative or through referral from a primary care physician. 34 patients were included in the study-group. The patients in the study group had completed a questionnaire on seasonal changes (SPAQ), and in the light of this they had a suspected or confirmed SAD/sub-SAD diagnose. They were all evaluated with a depression score (MADRS) before and after treatment. Mean depression score before treatment was 13,8 (range: 5 to 23) and after treatment 5,2 (range: 0 to 16). The change was –8,65 (range –1 to – 16). Improvement in depression score was calculated to be statistically significant, p-value <0,001. There was no placebo-controlled group. Some other characteristics in the studygroup, data from the SPAQ and CGI-change for one group of patients are further discussed in the paper .

Ikke-medikamentell behandling av primær insomnia – en klinisk beskrivelse
Archer, Sunniva Evensen, Birte Veslemøy (class 99)

Supervisor: Fred Holsten, professor dr.med. Seksjon for psykiatri, Institutt for klinisk medisin, UiB

In this project we have investigated non-pharmacological treatment of primary insomnia by observing five and interviewing three patients who underwent treatment. Our aim was to look into an alternative to the traditional pharmacological treatment often rendered inefficient or unsuitable in chronic insomnia. Non-pharmacological treatment of insomnia includes sleep restriction and sleep hygiene called stimulus control. The effects are monitored by use of sleep diaries. These contain patient-registered data as time in bed, total wake time, total sleep time, sleep efficiency and daytime functioning. Long-term efficacy was also recorded. Four of our patients achieve higher sleep efficiency and longer total sleep time during treatment. They also record better daytime functioning. The interviewed patients report long term effect, three to twelve months after final consultation. The patients in this project are not randomized, and are not compared with a control-group. However, the results are in conjunction with the majority of the published material on this subject. Non-pharmacological therapy seems to be a useful alternative to patients suffering from long-term insomnia.

Can children learn basic life support? Kan barn lære gjenoppliving?
Asbjørnsen, Helge Supervisor: Ivar Austlid, universitetslektor Medisinsk ferdighetssenter, Det medisinske fakultet, UiB

Introduction: Survival after prehospital cardiac arrest is more than doubled if cardiopulmonary resuscitation (CPR) is started before ambulance arrival1. Large efforts are put into increasing the knowledge of CPR in the general population, unfortunately with poor results2. In this study we evaluated children’s ability to learn and retain CPR-skills. Materials and methods: A total of 42 pupils in 3rd, 5th and 7th grade were studied. We presented an illustrated story where children performed CPR. Then two and two pupils were told to act like the children in the story using a junior resuscitation doll (Laerdal Medical) for 10-15 minutes. Brennan’s skills checklist and overall CPR rating scale was used for evaluation3. The overall CPR rating scale ranges from 1 (not competent) to 5 (outstanding). The children were re-tested for retention of skills after three months. Eighty-two adults, with a standard three hours CPR course, were controls. Results: The mean score of the 3rd, 5th and 7th grade pupils was 4.3, 4.1 and 4.3, respectively. Three months later the results were still satisfactorily with 2.8, 3.3 and 3.7, respectively. The adults scored 2.4 after three months. The 95% confidence interval of the mean was 2.9-3.5 for the children and 2.2-2.7 for the adults (p<0,001, student-t test). In all the eight items studied (airway, breathing, compressions etc.), children scored equal or better than adults. Conclusions: Children can learn and retain skills in CPR. Therefore, regular CPR training should be a part of the curriculum in the elementary school. This may be an effective mean to disseminate CPR knowledge in the general population.

Opprette og utvikle http://www.akuttmedisin.uib.no Create and develop http://www.akuttmedisin.uib.no
Aurstad, Håvar Østerås, Øyvind (class 99)

Supervisor: Ivar Austlid, universitetslektor Medisinsk ferdighetssenter, Det medisinske fakultet, UiB

Intention: To develop an emergency care internet-resource for both teaching and updating of knowledge and skills among medical students, physicians, ambulance workers, and other persons who work with emergency care. The main target is medical students at the University of Bergen. Method: Literature study. www.akuttmedisin.uib.no is based on international acknowledged guidelines in cardiopulmonary resuscitation and treatment of trauma. The resuscitation-section is based on international guidelines from the European Resuscitation Council. The trauma-section is based on guidelines described in the PreHospital Trauma LifeSupport - manual. Fieldwork and practical experience. Developing the internet-resource has required procedure training, emergency care fieldwork through working with ambulance-units and participating at ambulance training sessions. We have also used feed-back from doctors and ambulance-personnel during the process of creating the web site. Programming, photographing and video-capturing. http://www.akuttmedisin.uib.no is programmed in a simple HTML-code. Our goal has been pages that appear fast and correctly. The photos and the videos are captured digitally and are optimised for internet using picture- and videoprograms on a computer. The resources are located at the student server at the University of Bergen. Publication: The resource is published on the Internet address http://www.akuttmedisin.uib.no. The resource is integrated in emergency care teaching of health professions from ambulance workers to physicians. The main target is medical students and http://www.akuttmedisin.uib.no is already in use in the education of medical students at the University of Bergen.

Fremmedlegemer i Orbita
Bakke, Magnus B. Supervisor: Eyvind Rødahl, professor dr. med./overlege Seksjon for oftalmologi, Institutt for klinisk medisin, UiB/Øyeavdelingen, Haukeland Universitetssykehus

Purpose: To identify mechanisms of injury causing intraorbital foreign bodies (IOFBs), the type of foreign bodies and their location within the orbit. Further to examine the association of these factors to the outcome after treatment. Design: Retrospective record-based case series. Patients and Method: The medical records of 35 patients with IOFB admitted to the Department of Ophtalmology at Haukeland University Hospital between 1971 and 2002 were reviewed. Results: Thirtyfour out of 35 patients were men and 46% were younger than 20 years. There were four occupational injuries. Fourtysix percent of the cases were caused by gunshots. There were 28 metallic, three non-metallic inorganic and six organic IOFBs. The IOFB was removed in 68% of the patients. Information on visual acuity on admission and after treatment was obtained from 33 patients. Thirteen eyes retained normal visual acuity, 15 suffered from reduced vision and six ended up blind after treatment. In 21 cases (62 %), the treatment did not change the visual acuity, in eight patients (24 %) visual acuity was reduced, while in four patients (12 %), the visual acuity improved. The prognosis of IOFBs located in the middle part of the orbit was worse than that of IOFBs located laterally or medially. Likewise, organic and non-metallic inorganic IOFBs were more often associated with reduced visual acuity than metallic IOFBs. In twelve patients the injury caused other forms of visual impairment like reduced motility, diplopia and visual field defects. IOFBs located in the medial part of the orbit were most frequently associated with this type of impairment (46 % of the cases). Conclusions: Injuries caused by IOFB are rare. The patients are most often men, and most IOFBs occur after high-velocity injuries such as gunshots. In most cases, removal of the IOFB does not improve the patient’s visual acuity. Several factors influence outcome, like the mecanism of injury, the composition and the location of the IOFB in the orbit.

Maternity Care in Botswana-from home deliveries to health facilities.

Bakkegard, Mari E Iden, Marianne Supervisor: Torvid Kiserud, professor Seksjon for obstetrikk og gynekologi, Institutt for klinisk medisin, UiB

Objectives: 1. To study traditional and institutional maternity care in Botswana. 2. To study practical aspects of the process of birth, and the women’s personal birth experience. Methods: The study of traditional and institutional birth care was primarily based on national literature studies, and, additionally, on observations made during our 3 weeks stay at Deborah Retief Memorial Hospital, which included interviews of 20 women. Results and discussion: The history of modern maternity care in Botswana is short. Available information indicates that institutional maternity services have been steadily increasing and was 77 % in 1994. Botswana has from 1990 adopted the strategies of the Safe Motherhood Programme. Although institutional maternity care is very different from the traditional care, traditional attitudes and beliefs are still present among the women giving birth. One of the main differences between traditional and institutional maternity care is the relationship between the woman in labour and the birth attendant/midwife. Whereas the traditional birth attendant usually knows the woman as a relative or village member, such relationship is rare with the hospital staff. In addition to inaccessibility to health facilities and lack of awareness this may contribute towards choosing home delivery. Where to deliver: 15/20 women stated that they got the opportunity to choose where to deliver, and 19/20 stated that they would prefer to deliver at the hospital. They mentioned very similar reasons for their choice, safety being the most prominent, which reflected confidence in the services provided at the hospital. Satisfaction with services: 20/20 agreed that they appreciated the way they were professionally attended, conveying safety. However, looking at their stated reasons for satisfaction, we find that their expectations and requirements are basic. Compared to the traditional delivery attended by female relatives who themselves had previously given birth, the hospital delivery seemed to offer appropriate practical support but less emotional and mental reassurance. Communication: 5/20 respondents disagreed when asked if they received the information they wanted during the delivery, a pattern known from a previous study in Botswana. Lack of communication between the modern midwives and their patients seems to be a problem. Who attended: There were many other patients present during first stage of labour (mean 2.16, median 2, range 0-7) while in second stage the woman in most cases was alone with the midwife. Males, other than health personnel, were never present. Birth positions: Position during second stage seemed to differ from what used to be the traditional way. 20/20 gave birth mainly lying on their back or side, although 14 felt free to choose. HIV/AIDS has become an urgent problem in Botswana with an estimated 39% of the adult population infected. 3/7 of our women tested positive during pregnancy. Conclusion: In a short time Botswana has achieved to bring an impressive high percentage of the deliveries into health institutions. However, based on our small study, we got the impression that some of the valuable traditional support had not been brought into the modern delivery room at the same scale and left the mothers with some unattended needs.

Antivaskulær behandling av BT4An gliomer ved bruk av hypertermi og metalloproteinasehemmeren batimastat
Bjørkhaug, Steinar T

Supervisor: Olav Dahl, professor dr.med. og Hans Petter Eikesdal, stipendiat Seksjon for onkologi, Institutt for indremedisin, UiB

Jeg undersøkte de antivaskulære effektene av lokal hypertermi (44oC, 60 min) på s.c. BT4An gliomer på rotte, samt effekten på tumor-vekst av hypertermi og angiogenesehemmeren batimastat (30 mg/kg i.p.). Varme-indusert karskade ble vurdert i små og store svulster ved hjelp av fluorscensmikroskop og immunfarging for von Willebrand faktor. Effekten av hypertermi på svulsters blodgjennomstrømning ble målt ved hjelp av 86RbCl-ekstraksjonsmetode. Jeg undersøkte anti-tumor aktiviteten av hypertermi (en eller to fraksjoner med en ukes mellomrom) og batimastat (7 eller 14 daglige injeksjoner), samt ulike kombinasjoner av de ulike behandlingsmodalitetene. Begge tumorgruppene (små og store) fikk moderat karskade etter hypertermi, men størst skade ble observert sentralt i de store svulstene. De hypertermibehandlede svulstene hadde en nedgang i blodgjennomstrømning på 40-60%, noe som vedvarte inntil den siste målingen 24t etter behandling. Den første fraksjonen hypertermi førte til signifikant forsinket tumorvekst, derimot gav den andre fraksjonen ingen ytterligere forsinkelse. Batimastat hadde ingen innflytelse på tumorvekst, noe heller ikke kombinasjonen av hypertermi og batimastat hadde, sammenlignet med hypertermi alene. Jeg konkluderer med at hypertermi ved 44oC i 60 min gir antivaskulære effekter og hemmer tumorvekst i tumor-modellen BT4An . Batimastat gav ingen økt effekt av hypertermibehandlingen.

Effect of ischemia on glomerular charge selectivity in the rat kidney
Bjånes, Tormod K

Supervisor: Olav Tenstad, førsteamanuensis Seksjon for fysiologi, Institutt for biomedisin, UiB

Background: Normal human kidneys produce 180 liters of primary urine daily. Most of this is reabsorbed, resulting in 1,5-2 liters daily urine excretion. During resting conditions the kidneys are perfused with 20-25% of cardiac output, ie 1-1,5 l/min. Blood constains 50-70 grams of protein per liter. Proteinuria is a hallmark of renal diseased/injuries. This article focuses on some of the pathophysiological mechanisms causing proteinuria, the central issue being whether proteinuria is a result og leaky glomerular capillaries or a tubular dysfunction. At present there are to widely different views on glomerular filtration of plasma-proteins. The classical hypothesis states that albumine is poorly filtered, resulting in a filtrate; plasma ratio (θ) close to 1:1000, which is far below that of neutral and cationic proteins of similar size and shape. This phenomenon is referred to as charge-selectivity. The alternative hypothesis postulates that albumine is filtered without charge-restriction, and that its θ is exclusively dependent upon sixe and shape. This hypothesis operates with a θ for albumin which is 100 times greater than formerly thought. The low urine excretion of albumin is explained by the presence of a massive transtubular transport of filtered albumin in proximal tubular cells. These findings are based upon experiments performed in isolated perfused kidneys. Hypoxic injury to the “charge-barrier” during the experimental procedures in the isolated perfused kidneys may explain the controversy. We have therefore studied the effect of ischemia on glomerular filtration, with anionic (pI ~ 4) and cationic (pI ~ 9). Chymotrypsinogen, MW 25kD, stokes radius 21Å, as test macromolecules in intact rat kidneys. Methods: 1. Native Chymotrypsinogen (Chym+) and acetylated Chymotrypsinogen (Chym-) were iodinated with 131I and 125I respectively, using av IODOGEN-method. Molecular charge and size then evaluated by size-exclution and ionic exchange chromatography and isoelectric focusing. 2. The left kidneys of anaesthetized rats were exposed to 15 minutes of complete ischemia following reperfusion (n=12) while the right kidneys served as controls. 3. In another series of rats (n=18) glomerular filtration rate (GFR) was lowered to mimic that of the post-ischemic kidney by increasing left ureteral hydrostatic pressure by 50 cmH2O (n=9) or by reducing the left kidney perfusion pressure to 50-80 mmHg (n=9). The right kidneys served as controls. 4. In 6 of the 12 rats exposed to ischemia 131I-Chym+ was injected together with 125I-Chym- to obtain paired data on the effect of ischemia on glomerular charge selectivity, i.e. the θChym-/θChym+ ratio in the post ischemic kidney versus that of the undisturbed right kidney. 5. In the remaining rats 125I-Chym- was iinjected together with 51 Cr-EDTA to measure GFR and to test if the GFR reduction per se could explain the increase in glomerular filterability of anionic Chymotrypsinogen observed after ischemia. 6. The total kidney tracer clearances (tissue content + urine) were measured after a period of 7 minutes duration, i.e. when the filtered protein probes were quantitatively retained in renal tissue and urine. Glomerular sieving was calculated as probe clearance divided by GFR measured as 51 Cr-EDTA clearance.

Results: 1. Acute ischemia and reduced perfusion pressure decreased GFR similarly by about 55%, whereas elevated ureteral pressure decreased GFR by about 35%. 2. The total plasma clearance of Chym- was lower than that of Chym+ indicating a general charge selectivity in the capillary wall. 3. The glomerular charge selectivity, assessed by the ratio between glomerular sieving of anionic and cationic Chymotrypsinogen, decreased by about 10% in the post ischemic kidney (p<0,01). 4. GFR per se had a marked effect on glomerular filtration of Chymotrypsinogen : increasing θ with decreasing GFR. Conclusions: 1. There is a marked glomerular charge selectivity for anionic and cationic Chymotrypsinogen (25kD, 21Å) that is slightly reduced in the post ischemic kidney. 2. The observed dependency of GFR on Chymotrypsinogen filtration can be explained by an increasing contribution of diffusive transport across the glomerular membrane as GFR approaches 0. All molecules that are able to pass through the glomerular capillary wall to some extent will at equilibrium show a filtrate: plasma ratio (θ) of 1,0 and no convective transport if GFR = 0.

Vitamin D3-mangel hos pasienter i dialyse
Bostad, Anders D

Supervisor: Ole Langeland Myking, professor dr.med. Seksjon for endokrinologi, Institutt for indremedisin, UiB

Background Vitamin D plays an important role in the regulation of calsium homeostasis. In patients with chonic renal failure suboptimal serum levels of vitamin D contributes to disturbances in scalsium, and development of secondary hyperparathyroidism. Dysregulation of calsium metabolism is associated with serious complications, and frequently seen in patients receiving dislysis treatment. Objective This publication is primarily divided into two main parts. Initially we present up to date information about vitamin D and mineral metabolism, with emphasis on calsium, magnesium and phosphorus. Then present knowledge about PTH and chronic renal failure follows. Important complications related to disturbances in calsium metabolism (especially renal osteodystrophia and cardiovascular disease) are given much attention. In part two, we present a study where bloodsamples from 39 patients receiving dialysis treatment have been analysed, and the relationship between vitamin D, calcium and PTH is described. Materials and method We have analysed data collected from 39 dialysis patients that received treatment at Haukeland University Hospital during the autumn og 2002. Blood samples taken just before and after dialysis were analysed for vitamin D (calcidiol and calcitriol), PTH and calcium. Results and conclusion A majority of the patients had sufficient levels of calcidiol, but the opposite was true for calcitriol. Dialysis did not affect the serum consentrations of the two different metabolites significantly. In addition to this, most of the patients had elevated levels of PTH (both before and after treatment). Among selected patients (where changes in s-calsium consentration exceeded +/- 10% after dialysis), an inverse relationship existed between s-calsium and PTH. These findings suggested that secondary hyperparathyroidism was present, and that negative changes in s-calsium after dialysis made the condition worse. Based on our results possible therapeutic implications include a more “radical” administration of vitamin D analogs and use of higher dialysate calsium concentration to prevent low levels of s-calsium after dialysis.

In vitro fremstilling av 3-dimensjonal hastighetsfordeling bak kunstige hjerteklaffer med farge-Doppler
Braute, Marit

Supervisor: Knut Matre, professor, dr.philos. Institutt for indremedisin, HUS

This report opens with a presentation of why measurements of velocity distribution are carried out and how the colour-Doppler method can be used for this purpose. This is followed by an introduction to the applied ultrasound method. The flowrig is described with regards to the function of the pump, the fluid and the different heart valve prostheses tested. Colour Doppler recordings were made for three mechanical and one biological valve. The results of the experiments are presented as a number of three dimensional dolour-Doppler pictures compiled in Echopac, as well as some graphical representations of velocity distribution made using Matlab. The distribution of velocities after passing through the different heart valve prostheses were very different and reflected the different design of the valve prostheses. This study shows that three dimensional colour-Doppler can give us useful data on the velocity distribution behind valve prostheses. This is important information for the possible clinical use of 3D colour Doppler, in particular the diagnosis of dysfunction of the prosteses.

Variant Creutzfeldt-Jakob sykdom: Utbredelse og årsak. Risiko for epidemi?
Brevik, Einar André

Supervisor: Ole-Bjørn Tysnes, professor dr.med. Seksjon for nevrologi, Institutt for klinisk medisin, UiB

Since 1995 there has been a general public concern about the new prion disease that had crossed the species barrier from cattle to man. Unlike the sporadic Creutzfeldt-Jakob disease (CJD), this disease primarily affected young people (median age 26-27 years on onset). This variant Creutzfeldt-Jakob disease (vCJD) seemed to develop into an epidemic with future numbers in the millions the first couple of years. As the years have passed more optimistic studies has revealed that the first estimates of the future epidemic most probably was wrong, and that the new estimates suggest a much smaller amount of cases. The numbers vary from at couple of hundred cases to a few thousand cases. There are currently planned several studies that will look into the problems and uncertainties surrounding vCJD. One of these uncertainties is the incuabation period for the asymptomatic carriers and to try to give an estimate of the incubation period of vCJD. This paper looks into many of the different aspects of bovine spongiform encephalopathy (BSE) and vCJD, and it will give the readers a general comprehension of how vCJD emerged, the future course of the epidemic as we see it now and general measures taken to control the disease.

Depresjon ved Parkinsons sykdom Et litteraturstudium
Christiansen, Line Cecilie Johnsen, Åse Katrine Wold

Supervisors: Dag Årsland, seksjonsoverlege og Uwe Ehrt, overlege/stipendiat Senter for nevro- og alderspsyk. forskning, Psykiatrisk klinikk, Helse Stavanger

Objective: The purpose of this paper is to focus on different aspects of depression in Parkinson’s disease, with special attention to its prevalence, etiology, diagnosis and treatment options. Method: We have used a computerbased search of the litterature in Medline concerning Depression in Parkinson’s disease. Of 125 articles found relevant for the review, a varied selection is presented here as references. Findings: Parkinson’s disease (PD) is a common neurodegenerative disorder in the population and is often accompanied by neuropsychiatric disturbances. Depression is the most frequent disturbance with a prevalence ranging from 4%-70% in different studies. Most of these patients reveal symptoms of mild to moderate Depression, whereas major Depression is more unusual. Questions still remain regarding the etiology of Depression in PD-patients, but it is probably a result of both psychosocial and biological events. Among screening and diagnostic tools used for Depression in PD the international classification systems DSM-IV and ICD-10 has proved to be the best altenatives. There is still no consensus regarding the preferred treatment of Depression in PD, although recommended alternatives based on clinical experience exists. Conclusion: Depression in PD has a high prevalence and a major impact on patient quality of life. This define the need for further evidence-based studies to evaluate proper diagnosis and efficient treatment .

Urininkontinens hos 40-årige kvinner i Hordaland
Eikaas, Ragnhild Nyseter, Silje

Supervisor: Steinar Hunskår, professor dr.med. Seksjon for allmennmedisin, Institutt for samfunnsmedisinske fag, UiB

The aim was to assess the prevalence of urinary incontinence amongst 40-year-old wimen in Hordaland county of Norway. Also type of incontinence, severity, the women’s experience and relation to health, activity, enuresis, nocturia and incomplete emptying of the bladder were assessed. Methods: “The Women Cohort for Prospective Studies of Urinary Incontinence, Urinary Tract Infections and Medicine Epidemiology” is a part of HUSK (the Health Survey of Hordaland ’97-’98), in which 9.983 women participated. Every fifth was invited to take part in the Women Cohord. 96% agreed to participate and 2087 filled-in questionnaires were returned. A Severity Index was used to assess the degree of urinary incontinence. Results: 39% had urinary incontinence. Of these, 43% had stress incontinence, 16% had urge incontinence and 32% mixed incontinence. Mild incontinence dominated with 62%. 32% of the incontinent women had moderate leakage and 6 % had severe leakage. Women with mixed incontinence had significantly more of both moderate and severe leakage. They also reported to be more bothered by the incontinence than the rest of the women. Only 10% had sought medical help for their incontinence problems. Enuresis during childhood and nocturia were reported almost 4 times more often amongst women with urge or mixed incontinence. Conclusion: Urinary incontinence is common. Very few of the incontinent women seek medical help for the problem. However, the mild forms of incontinence are predominating.

Vitamin D mengde i serum hos blodgivere, pasienter med coxarthrose og pasienter med lårhalsbrudd år 2000
Engan, Britt Moksnes, Maria

Supervisor: Ole Langeland Myking, professor dr.med. Seksjon for endokrinologi, Institutt for indremedisin, UiB

Background: Hypovitaminosis D leads to reduced calcium absorption and increased parathyroid function. This can be a contributor to the development of osteoporosis and/or osteomalacia, conditions connected with Fractura Colli Femoris (FCF) in elderly, which is a great problem in Norway. We have studied the serum levels of Vitamine D in blood donors and in groups of patients with coxarthrosis and FCF i Bergen (Norway). Methods: Blood was taken from 217 blood donors at Haukeland Hospital, 45 patients with coxarthrosis at Hagavik Hospital and 60 patients with FCF at Haukeland Hospital. These bloodsamples were analysed using Gamma-B 25(OH)D3 RIA kit and Gamma-B 1,25(OH)2D3 RIA kit. Results: The normale range of 25(OH)D3 in serum is between 50-110 nmol/l and for 1,25(OH)2D3 the normale range is between 50-145 pmol/l. Onehoundredandthree of the bloodsamples from the blood donors (20- 69 years old) were taken in April 2000 and 114 were taken in October 2000. 23,5 % of the males and 23,1 % of the females showed decreased levels of 25(OH)D3 in the april-samples. 19,6% of the males and 7,5% of the females showed values of 1,25(OH)2D3 under the lower recommended limit. In the October-samples 37,9 % of the males and 16,1 % of the females showed too low levels of 25(OH)D3. 29,8% of the males and 21,4% of the females showed values of 1,25(OH)2D3 below the lower recommended limit. Fourtyfive bloodsamples were taken from patients with coxarthrosis (average age 68 years old) in a periode from May to October 2000. The results showed too low values of 25(OH)D3 in 17,8% of the patients and too low values of 1,25(OH)2D3 in 24,4 % of the patients. 30 bloodsamples were taken from the FCF patients (average age 83 years old) in May/June and 30 bloodsamples were taken in November/December. 46,7% of the summer-samples and 86,7% of the winter-samples showed values of 25(OH)D3 below 50 nmol/L. 40% of the summer-samples and 60% of the winter-samples showed values of 1,25(OH)2D3 below 50 pmol/l. Conclusions: Many blood donors showed low vitamine D values in serum. 25,3% of the blood donors showed serum levels of 25(OH)D3 below 50 nmol/l and 19,8 % showed 1,25(OH)2D3 levels below 50 pmol/l. The patients with coxarthrosis had vitamin D levels quite similar to the blood donors. 17,8 % showed serum levels of 25(OH)D3 below 50 nmol/l and 24,5 % of them had serum levels of 1,25(OH)2D3 below 50 pmol/l. The members of patients with hypovitaminosis D is even greater in patients with FCF, and we belive that hypovitaminosis D is related to FCF. 66,7 % of the patients with FCF showed serum levels of 25(OH)D3 below 50 nmol/l and 50 % had 1,25(OH)2D3 levels in serum below 50 pmol/l . 12 out of 30 patients with FCF in May/June showed levels of both 25(OH)D3 and 1,25(OH)2D3 within the normale range. This was the case for only one patient with FCF in November/December.

Smoking habits, weight and body mass index in a group of 40-42 years old men and women followed over a six-year period
Engan, Mette Hagen, Kristin Gjerde

Supervisor: Stein Emil Vollset, professor Seksjon for medisinsk statistikk, Institutt for samfunnsmedisinske fag, UiB

Background: Tobacco use is a major risk factor and cause of cardiovascular diseases, respiratory diseases and cancer. Despite this knowledge, currently about 33% of the Norwegian population between 16-74 years old smoke daily. There are many reasons why people smoke. One is the belief that smoking can help control body weight. The purpose of this study was to evaluate the association between smoking habits, weight and body mass index, particularly assess differences between men and women. We followed the participants in two studies with a five-year interval in between, and investigated changes and associations between weight, body mass index and smoking habits. Method/Materials: Smoking and weight characteristics of 2039 women and 1625 men born in 1950-51 from the Hordaland County of Western Norway were collected twice by the National Health Screening Service (NHSS). The first data collection took place in 1992-93 and the second in 1997-99. Results: Women who smoked 1-9 cigarettes a day had a lower mean BMI compared to never-smokers and ex-smokers, and women smoking 10-19 cigarettes pr day were on average leaner than heavy smoking women. Women who had quit smoking gained weight and achieved similar mean BMI as never-smokers. Men who quit smoking had a higher mean BMI than the rest of the men, but we found no significant difference in mean BMI between male smokers and never-smokers. For both men and women we found a significant difference in mean weight gain between quitters, about 7 kg, and the others, about 3 kg. Male and female quitters gained more than twice as much as never-smokers and current-smokers in the period between the two data collections. The quitters gained weight depending on the amount of cigarettes smoked prior to cessation, heavy smokers gained significantly more weight than light smokers. Those who smoked more than 20 cigarettes pr day before cessation had an average weight gain of about 9,5 kg. Conclusion: The average middle-aged men and women who quit smoking gained about 7 kg within the next few years after cessation compared with an average weight gain of 3 kg for the whole group, men to achieve a higher BMI than other men, women to achieve a similar BMI as never-smokers. Weight gain after cessation is positively related to the amount of cigarettes smoked prior to cessation.

Restitusjon av maksimal muskelstyrke etter et løpsarbeid
Enoksen, Cathrine Harstad

Supervisor: Jostein Hallén, førsteamanuensis Norges Idrettshøgskole

Isokinetisk dynamometer brukes i testing og rehabilitering innenfor fysioterapi. Denne oppgaven er basert på gjennomføringen av et forsøk for å finne ut om isokinetisk muskelstyrke målt på Cybex 6000 forandrer seg ved en definert intervensjon. Det ble foretatt en registrering av muskeltretthet og restitusjon. Seks forsøkspersoner gjennomførte et hvileforsøk (kontroll) og et arbeidsforsøk (intervensjon; sykkelarbeid til utmattelse). Arbeidsforsøket viste at det var en nedgang i isokinetisk muskelstyrke etter sykkelarbeidet, og at denne muskelstyrken gradvis nærmet seg utgangsnivået før sykkelarbeidet igjen, i løpet av tester hver ½ time.

Effekt av fysisk trening på fibromyalgi
Espe, Synnøve

Supervisor: Roald Bahr, professor dr.med. Senter for idrettsskadeforskning, Norges Idrettshøgskole

Oppgåva er eit litteraturstudium med fokus på nyare forsking om fysisk trening og fibromyalgi. Problemstillinga for oppgåva er å finne eventuelle rehabiliterande effektar av fysisk trening på pasientar med fibromyalgi. Forskinga viser til ein viss grad positive resultat med tanke på rehabilitering av fibromyalgi. Ein kan utifrå dagens litteratur konkludere med at fysisk trening har noko rehabiliterande effekt på pasientar med fibromyalgi, men at mykje framleis er uprøvd. Treninga ser først og fremst ut til å gje ein verknad i form av hormonelle effektar og ved å hindre negative konsekvensar av inaktivitet. Det er derimot behov for mykje meir forsking på området.

Akupunktur og dens virkning på ANS
Fang, Pei

Supervisors: Anders Bærheim, professor og Terje Alræk, stipendiat Seksjon for allmennmedisin, Institutt for samfunnsmedisinske fag, UiB

Accupuncture is one of many different treatment practices in traditional Chinese medicine (TCM). Thousands of years of experience have been put down into TCM. In TCM, the body is viewed upon in its totality, composed of several organs and energy paths that have to be in state of inner balance and harmony. This inner balance is a condition for good health. In TCM, a disease or illness is an inbalacnce in the body`s energy system. The goal of acupuncture treatment is to normalize this inbalance in the body`s energy system. Our modern Western medical research shows that acupuncture most likely has its main treatment mechanisms via neuropeptides and their pain treating systems. In addition to the pain relieving effect, acupuncture also has a significant effect on the autonomous nervous system (ANS), like cardiovascular diseases, airways, stomach and bowl system and the urinary tracts. The effect of acupuncture in the ANS, seems to be sympathicolytic. There is still necessary with more research and studies to map the exact effect that acupuncture has on the ANS.

Hørselens fysiologi – spesielt med henblikk på det indre øre
Flakstad, Merete K.

Supervisor: Asgaut Warland, førsteamanuensis Seksjon for øre-nese-hals, Institutt for kirurgiske fag, UiB

Two sensory modalities, hearing and equilibrium, are housed in the ear. The aim of this study has been to give an updated presentation of the physiology of hearing, with special focus on the inner ear. The macroscopical structure of the ear has been known for relatively long. Knowledge about the ears inherent mecanisms of signal amplification is rapidly growing. It is in the nature of the matter that even the newest textbooks will lack the latest research findings concerning specific details in this area. In order to consider new research results and incorporate these in the understanding of the physiology of hearing, it is necessary with insight in the fundamentals of the different anatomical components of the ear along with their structural as well as functional relationship with each other. It is also necessary to be familiar with a few facts about the physics of sound and its analysis. Knowledge is of most importance where it can be of practical use. Pathological conditions are therefore mentioned where relevant, and the most commom causes of hearing loss and diagnostical approaches are given a short comment at the end of this paper. This has been a literary study. To gain knowledge about the physiology of hearing, I have studied relevant chapters of different textbooks written for medical students, general practitioners and others needing a basis for a range of more advanced studies. I have studied both the macroscopical and microscopical anatomy of the ear, as well as neurological, physiological and pure biochemical aspects of the organ. Doing this I have come across some minor divergencies concerning the explanations of the physiology of the ear. Where this has been the case, I have attempted to supplement the text with new, commonly accepted research results. This applies to amplifying mecanisms in the inner ear on a cellular level. The ear and its nerve fibers represent a complex and fascinating repertory of different components and connections. New research findings are constantly released. Nevertheless, for patients suffering from hearing loss, the most important issue is that the practitioner has adequate insight into and understanding of the most common pathological concerns related with hearing problems. Such knowledge and a good diagnostical approach are necessary for the pasient to benefit from the consultation. My aim has been to present the physiology of hearing mainly within the frame of its practical use.

Flåtten, Per A.

Supervisor: Erik Florvåg, førsteamanuensis dr.med./overlege Seksjon for medisinsk biokjemi, Institutt for indremedisin, UiB/Laboratorium for klinisk biokjemi, Haukeland Universitetssykehus

Background: In recent years a correlation of studies have shown an increasing prevalence of allergic illnesses, and there is a higher occurrence rate in countries with a western lifestyle, rather than eastern. Based on these studies, several different hypotheses have evolved, to explain this prevalence increase. Amongst others, factors like air pollution, new allergens and diet, have been taken into view. The hygiene hypothesis occurred in 1989, and was presented by David P. Strachan. He claimed that manifestation of allergic illness was negatively correlated to a high number of siblings. He also said that this could be explained by allergic illnesses being prevented by infections in early childhood. Since then, a lot more studies have been made, with results that can be supportive of this hypothesis. Objectives: Make an outline over the differing models of explanations, with emphasis on the hygiene hypothesis. Method: Study of literature. Results: The allergic illnesses are a multifactorial illness group, as such the increase in prevalence probably has many reasons. In this paper, some of the factors that can be of importance for the development of allergic illnesses, will be discussed. It seems probable that microbiological influence can be of importance, even though the final connection is yet to be found. Possible alternatives for treatment will also be discussed, though today, the documentation is not strong enough for these treatments to be recommended.

Kunnskap om HIV-smitte og haldningar vedkomande HIV-smitta og AIDSsjuke pasientar melklom medisinske studentar i Bergen
Folkestad, Trude

Supervisor: Kåre-Steinar Tveit, overlege Hudavdelingen, Haukeland Universitetssykehus

Background: We studied the student’s knowledge of modes of HIV transmission and their attitude towards risk groups of catching HIV (i.v. addicts) and persons with HIV or AIDS. Earlier studies have shown that knowledge is correlated with multiple factors, for instance the level of education, gender and religious conviction. We expected to find a higher level of knowledge among students who already finished the courses at Section of Dermatovenereology. We also studied in what degree different attitudes affected each person’s knowledge of HIV transmission, and we wanted to see if attitude to use force against risk groups of catching HIV and persons with HIV or AIDS changes along the study progression. Material and methods: First year through forth year students answered a self-administered questionnaire. We included 589 medical students at the University of Bergen. The rate of response was 70 %. Results: Each person’s knowledge of modes of HIV transmission was positively correlated with the numbers of years the person had been studying medicine. Regarding ways in which HIV is transmitted, ignorance was first and foremost related to whether the HIV virus could be passed on by oral kissing and anal sex. There was statistically significant higher level of knowledge of how HIV is transmitted/not transmitted, among the forth year students compared to first year students. Knowledge of other venereal diseases was positively correlated with knowledge of modes of HIV transmission. Knowledge of HIV transmission was negatively correlated with the acceptance to use force towards risk groups and compulsory AIDS-screening of the population. There was statistically significant higher level of knowledge among students who already had their sexual debut, compared to the students who had not. Numbers of years the person had been studying medicine was negatively correlated with the acceptance to use force on risk groups of catching HIV and compulsory AIDS-screening of the population. Interpretation: In this study we have shown that the student’s level of knowledge on the subject increases along with the study progression. As we expected, the level of knowledge among students who already finished the course in Dermatovenreology, was higher compared to first year students. This study indicates that the acceptance to use force on risk groups of catching HIV and compulsory AIDS-screening of the population decreases along with the study progression. There are however, ignorance among the students concerning modes of HIV transmission, and that level of knowledge affects the attitude towards risk groups of catching HIV and persons with HIV or AIDS. It is therefore important to educate the students in ethics and attitude, as well as theory of HIV and AIDS. The theory on how HIV is not transmitted must be emphasized during lectures to reasure that the students know this. This is important to the students qualifications to guide pasients on the issue of HIV transmission.

Barn av psykisk syke foreldre
Fosse, Inger Marie

Supervisor: Ole Bernt Fasmer, førsteamanuensis Seksjon for psykiatri, Institutt for klinisk medisin, UiB

Background. This article deals with children of parents with mental diseases. Method. It is based on newer Norwegian literature about the subject. Result. 15 000 children have a parent who is treated for a mental disease. Often this group lack help and support from the surroundings. Both the school and the healthcare system often take no responsibility for these children. This is a paradox since all experience says that children of parents with mental diseases more often get a mental disease than people in general. Still there is a lack of knowledge and people often have prejudices when it comes to mental diseases. This makes it more difficult for the children involved. It is important that people working in the health-care system clearly see their responsibility in helping these children. Hopefully this area will become a priority amongst doctors and nurses in the future. Because there is not much to be proud of in this field for the time being.

Abruptio placentae - grader, fordeling og risikofaktorer sett i forhold til de ulike gradene
Gammelsæter, Mariann Hagerup

Supervisor: Svein Rasmussen, professor Seksjon for obstetrikk og gynekologi, Institutt for klinisk medisin, UiB

This was a retrospective study in which 50 women who had abruptio placentae (AP) were compared with 50 controls with respect to possible risk factors and sociodemographic variables. The aim of the study was to assess the occurrence of different clinical grades of AP (grades 1-3) and whether possible risk factors were different in different grades. Among the 50 cases 21, 27 and 2 women had grades 1, 2, and 3, respectively. Significantly more cases had prepartum vaginal bleeding, delivered preterm, and / or were delivered by caesarean section than among controls. We found no significant differences between cases and controls in smoking habits and preeclampsia. Newborns whose mothers had AP were lighter, shorter, leaner, and had shorter head circumference than controls, even after adjusting for gestational age. The occurrence of possible risk factors were not significantly different in different grades of AP.

Metadon. En prosjektanalyse To which extend does the length of opiate abuse influence the success of the methadone rehabilitation program?
Greve-Isdahl, Finn

Supervisor: Kristin B. Lazaridis, overlege Aust-Agder klinikken

Background: In Norway there has been, and still is, discussion among politicians concerning the carrying out of the methadone treatment program. The program at The Aust-Agder clinic is under evaluation and the Parliament is expected to deal with the national grant in the spring of 2002. In addition to this evaluation, one wishes to see if one of the criteria, a documented ten year abuse, is essential for the outcome of the methadone treatment. This is now under current interest since the nation is seeing an increase of older abusers. Method/Materials: This is a prospective cohort-study including the first 44 clients to enter the treatment program. The journals of the clients have been analyzed and over checked. The clinics annual reports have been under examination. In addition the superior staff members have been interviewed, along with the Police Drug Department. Results: The results show that 87% of the patients need additional treatment for psychopathological problems. PD was often found among the clients. The program itself is not a direct factor for success, but only serves to neutralize the neuro-biochemical complications caused by longterm abuse. Rehabilitation has shown to be most effective only when complications have been neutralized with methadone. Conclusion: It is shown that the entry requirement for the treatment program, a documented long-term opiate abuse, is not very good. The level of PD and psychopathology serves as a far better indicator for success in the treatment program. The individually force of confidence and will to struggle is a more accurate than the total number of years as an addict.

Infeksjon og prematur fødsel
Grimstad, Anne Karine Johannesen, Edle M. (class 99)

Supervisor: Svein Rasmussen, professor Seksjon for obstetrikk og gynekologi, Institutt for klinisk medisin, UiB

This study was undertaken to determine the association between infection and spontaneous preterm birth. We wanted to find out how to identify the various infections through inexpensive and easily available methods at an early stage in pregnancy, and to see whether antibiotic therapy can reduce the frequency of preterm birth or not. We have collected a sample of articles describing the relationship between infection and prematurity, and summarized the various results. It has been estimated that at least 40% of all preterm births occur to mothers with intrauterine infection. This type of infection has a well known molecular pathophysiology. Uterine contractions may be induced by cytokines and prostaglandins, which are lelkeased by microorganisms. Of all genitourinary infections asymptomatic bacteriuria, gonococcal cervicitis and bacterial vaginosis are strongly associated with preterm delivery. Screening of asymptomatic bacteriuria is standard procedure in every consultation during pregnancy, and treatment seems to reduce the prevalence of pyelonephritis and preterm birth. Screening of gonococcal cervicitis and bacterial vaginosis is not recommended, but treatment of both infections will decrease the risk of preterm delivery. The role of Chlamydia trachomatis, Trichomonas vaginalis and Ureaplasma urealyticum is less clear.

Bestemmelse av blodplateaktivering ved trykkendringer under hypobare forhold
Grønnevet, Ellen Qvindesland Ivars, Stefan Ytre-Hauge, Sigmund

Supervisor: Holm Holmsen, professor dr.philos. og Eirik Søfteland, 1.amanuensis dr.med Seksjon for biokjemi og molekylærbiologi, Institutt for biomedisin, UiB

Background: Trekking in high mountain areas all over the world has become a more common activity the last decades. The associated exposure to hypobaric environment has the potential to affect many processes in the human body. However, a lot of details on hypobaric physiology and biochemistry are not yet assessed. In hyperbaric medicine experiments on divers have demonstrated that blood platelets are affected by pressure. The possibility of a corresponding mechanism during pressure changes in hypobaric environment has not been studied, and constitutes the background for our experiment. Methods: During trekking in Nepali mountains in November 2000, blood samples were collected from a group of seven people. Blood samples were collected directly into a fixative agent at different altitudes during ascent (1300 m, 3600 m, 4400 m, 4900 m) and descent (4100 m, 3600 m, 1300 m). In addition one blood sample had been collected before the expedition (in Bergen, 100 m). In January 2001 blood samples were prepared for scanning electron microscopy, and activation of blood platelets was determined by manually counting activated and non-activated platelets in each sample. From these countings we have been able to compare the different blood samples with regards to activation of blood platelets. Results: The reference blood samples (collected in Bergen 100 m) showed an average platelet activation of 32%. Compared to this reference our investigation showed a significant increase in platelet activation in samples collected at 3600 m during ascent (58% activation, p=0,0466), in samples collected at 4900 m during ascent (52% activation, p=0,0424), and in samples collected at 4100 m during descent (46% activation, p=0,0178). There was no significant difference between females and males. In general there seemed to be a correlation between the altitude curve and the curve showing development in platelet activation. A curve representing overall ascent and descent for the last five days before each blood sample revealed an even better correlation with the curve of blood platelet activation. Discussion/conclusion: An increase in blood platelet activation seems to occur during changes in air pressure in an hypobaric environment, which is consistent with findings in hyperbaric medicine – the fact that an association between air pressure and blood platelet activation exists. However, our findings have strong elements of uncertainty. The group studied consisted of only 7 people, and sources of errors are likely to be present. Confounding is also a possibility. Thus final conclusions should not be drawn until more thorough research has been done, but if the association between blood platelet activation and changes in air pressure in hypobaric environment is confirmed, it would be an important contribution to understanding high altitude medicine as well as aviation medicine.

Meslingevirus: Nevrologiske komplikasjoner og vaksinering
Gundersen, Trude

Supervisor: Johan A. Aarli, professor Seksjon for nevrologi, Institutt for klinisk medisin, UiB

After a discussion in the media autumn 2001, there have been articles in the newspapers where it is recommended to not give children the MMR vaccine. Some has concluded that measles is a harmless children’s disease. I have on this background gone through some literature on the subject measles to shed some light on the acute disease, but I have concentrated on the neurological complications, such as acute post-infectious encephalitis, inclusion-body encephalitis and subacute sclerosing panencephalitis. These conditions have no medical cure, so the mortality is near to 100%. The only way to prevent these serious complications is to prevent epidemics of measles infections. This can be done with the MMR vaccine if the coverage is 90-95% of all children.

Poliklinisk behandling av etevanskar
Halleraker, Brita Nybø, Tore

Supervisor: Annicken Ulvik, overlege/med. rådgjevar Barne- og ungdomspsykiatrisk avdeling, Haukeland universitetssjukehus

Eating disorders is a psychiatric illness that includes Anorexia Nervosa, Bulimia Nervosa and “binge eating disorder”. Common to them all is a morbid way of looking at themselves and food. These are serious conditions with a much higher risk of premature death than the rest of the population. It's believed only a small part of these patients get into treatment. Because of this, it's important to discover these patients at an early stage. Before making a diagnosis, it's important to exclude other psychiatric illnesses, drug abuse and especially somatic conditions, such as metabolic diseases, malabsorbation and cancer. Once an eating disorder has been discovered and diagnosed, the patient must get into treatment. When a therapeutic alliance with the patient is to be established, some short-term and long-term goals are important: In a short term perspective, the patient needs to gain reasonable weight and establish constructive eating habits. In a long term perspective, the patient needs to gain control over food and weight, and work on underlying problems and get out of the disease. Important key words are making accurate agreements and carrying them through and the ability to give good reasons for the therapeutic interventions. Motivation is here of great importance. Co-morbidity needs to be treated simultaneously. It's believed that the paranoid image of their own bodies mainly is a result of the low weight, so that an increase in weight in it self will improve the psychic condition. To give the patient time to get used to the increasing weight, the increase shouldn't be more than 0,5 kg a week. Psychotherapeutic treatment often starts with cognitive behavioral therapy, focusing on eating, weight, reasonable exercise and registration of results. As the somatic condition improves, focus will be shifted towards the emotional problems the patient often denies in the beginning. Even though the physical symptoms are the most prominent ones, it's essential to focus on treatment of the psychic symptoms and to increase the persons self-reliance. These persons must learn to accept their own bodies and themselves as persons. The choice of therapeutic strategy depends on the patient's age, presentation of the illness and the problems the patient is coping with. One can use a single kind of therapy or a combination of therapeutic approaches. The patient is not the only one suffering because of the disease, so the people close to him/her shouldn't be forgotten. Finally, it's important to be aware that the prognosis is good for those who get treatment in time. With good treatment most patients get better or well.

Resultater etter 25 år med Medtronic Hall mekanisk klaffeprotese i aortaposisjon
Hansen, Hans Jørgen

Supervisor: Leidulf Segadal, professor Thoraxkirurgisk seksjon, Institutt for kirurgiske fag, UiB

Objective: We wanted to investigate the survival after implantation of mechanical aortic valve prosthesis. At the same we wanted identify risk factors for death with this sort of operation. Metode: From 22.03.1979 – 01.01.2004 a number of 1154 patients received a primary mechanical Medtronic-Hall aortic valve prosthesis at Haukeland University Hospital (649 with isolated aortic valve prosthesis (AVR), 321 with concomitant coronary artery bypass grafting (AVR+CABG), 56 with concomitant implantation of a mechanical mitral/tricuspid valve prosthesis (AVR+MVR/TVR) and 88 with concomitant aortic surgery (AVR+AO)). The patients were observed for 23,9 years. Observed survival was related to the general survival expected in the general norwegian population. Survival in the AVR-group was compared to the other groups. The risk of reoperastion from different prosthesis size was also examined. Results: Operation mortality (until 30 days after operation) was in total 2,1%. For AVR 1,2%. Cumulative survival (including operation mortality) was for AVR at 5, 10, 15 and 20 years respectively 91, 78, 67 and 54 percent. Relative survival was 94, 83, 77 and 61 percent. Relative survival for patients older than 70 year at the operationdate was for 10 years similar to that of the norwegian population at large in this agesegment. Cox regressionanalysis showed significant increased risk of early death for AVR+CABG (p=0,00) and AVR+MVR/TVR (p=0,20), bordersignificant increased risk (p=0,100) with increasing prosthesis size and no increased risk (p=0,325) for AVR+AO. We found signigificant increased risk (p=0,0026) for reoperation in those who received a large prosthesis by subdividing the total population in small (up to 25mm) and large (equal to or larger than 25mm) prosthesis. Conclusion: Implantation of Medtronic-Hall mechanical valve prosthesis in the aortic position produces very low operation mortality and very good longtime survival, Compared to the norwegion population at large however it demonstrates increased risk for death. Patients above the age of 70 years at the time of operation displayed for many years the same survival as the norwegian population at large in that agesegment. Independent riskfactors for implantation of mechanical valve prosthesis in the aortic position are concomitant arteriocoronary bypass-grafting or implantation of a mechanical valve prosthesis in the mitral-/tricuspid position. It was increased risk of reoperation in the group that received prosthetic valves with a diameter of 25 mm or larger.

Psykiske ettervirkninger etter selvbestemt svangerskapsavbrudd innen utgangen av 12. uke
Hardang, Ingrid M Husa, Mariann Amsrud Supervisor: Torvid Kiserud, professor Seksjon for obstetrikk og gynekologi, Institutt for klinisk medisin, UiB

Background: Every year about 14000 Norwegian women have an abortion. We have heard and read about individual women who face mental health problems after having had an abortion and some of them relate their problems to this experience. In order to get an impression of the extent of this problem, we wanted to review systematically the literature on psychiatric problems following pregnancy termination before 12 weeks of gestation. Method: Literature review. We got access to relevant literature through people and organisations we assumed would know about this problem. Internet and the articles’ lists of reference were also useful. The articles were chosen according to criteria such as accessibility, relevant title, design and language. We noted patterns and the extent of psychological sequelae. In addition, we tried to assess whether the studies’ had the design and power to draw a conclusion concerning the number of women affected by post abortion mental health problems. Result: Our review is based on 13 cohort studies, 10 historical cohort studies, 3 qualitative studies and some other literature that addresses abortion and psychology. The women included in the studies were followed from years to hours before the abortion to weeks and years after the abortion. The follow-up percentage varies from 33 to 93 %. Depression affects 3-35 %. 2 studies find an increased risk of admission to psychiatric ward within 3 months post abortion (10,2/10.000 and 18,4/10.000), compared to women having given birth ( 3,8/10000 and 12,0/10000) and women in general (7,5/1000). Suicide is more common within the first year after abortion, OR 3,68 (1,92-7,04), compared to women having not been pregnant for the last year. The increased risk of suicide is found to persist up to 8 years post abortion, RR 2,54 (1,14-5,67), when compared to women having given birth. There is also an increased risk of death from all causes the first year after abortion, OR 1,76 (1,27-2,42), compared to women having not been pregnant for the last year. Compared to women having given birth, this risk persists for 8 years, RR 1,62 (1,34-1,94). Sense of guilt occurs in 13-55 % of the women. Post traumatic stress disorder affects 1-18 % of the women 2 years after the abortion. The studies find that 50 % of the women either do not relate to the abortion or deny having had an abortion when asked. Within 2 years after the abortion 10 % of the women give birth. Women prone to post abortion mental health problems are characterized by ambivalence, earlier psychiatric problems, pressure to choose abortion and lack of social support. Discussion: The present study was limited by time constraints and economical support in a field of extensive publishing. It has been difficult to compare the different studies as they examine different parameters at different times after the abortion, and often the same parameter does not imply the same thing in different studies. Most of the studies have used design and methods that are insufficient to draw a conclusion concerning the number of aborting women affected by post abortion mental health problems. Conclusion: The literature finds that some women face post abortion mental health problems. However, no one really knows how many of the 14000 aborting women per year in Norway are affected. It is of concern that the studies done so far have used design and methods with substantial limitations and most probably are underestimating the women affected.

Amming som prevensjonsmiddel
Hassellund, Skjalg

Veileder: Roar Sandvei, professor Seksjon for obstetrikk og gynekologi, Institutt for klinisk medisin, UiB

Objectives The aim of this article is to decide to what extent breast-feeding can be used as a contraceptive method. Factors that have an impact on the effect of this method will be stated. Comparisons to other contraceptives and thoughts about use will be given. Methods General medical litteratur databases such as Medline, Cochrane library, Web of science, and Embase have been searched. Key words like latational amenorrhoea, LAM, birth spacing, fertility, contraception, and breast-feeding were used. The evidence of the effects of breastfeedings as a contraceptive method were summarised and the articles were critically analysed. Results Women who remain amenorrrhoeic, who are fully or nearly fully breast-feeding (little or no supplements) have a less than 2% risk of pregnancy during the first six months after the delivery. Suckling activity is the key factor determining the contraceptive effect. Giving supplements or extending the method in time, decreases this effekt. Not any well-designed study comparing contraceptive effects postpartum has been identified. Conclusion There should be given information about LAM postpartum as an alternative to other contraceptive methods. Where there are limited supplies of other contraceptive methods, breast-feeding is an important resource. In spite of declining effects by giving /supplements/ and extending LAM in /time/, breast-feeding still results in increased birth intervals at a population level and positively influence child health.

Tuberculosis at Haydom Hospital 1998
Haug, Elisabeth Tangen Nygard, Maren

Supervisor: Rune Nilsen, professor Senter for internasjonal helse, UiB

Tuberculosis is a global health threat. It is estimated that from 1990 the incidence and mortality was 30 and 80 millions, respectively, with most cases occurring in developing countries. Tanzania is one of the high-incidence countries. The aim for the present work, was to study the incidence of tuberculosis (TB), both in general and extra-pulmonary tuberculosis (EPTB) in particular, at a rural hospital in Tanzania. Our study is based on evaluation of all TB patients registered at Haydom Lutheran Hospital in 1998, a total of 527 patients. The patients were categorised according to age, gender, home village and anatomical localisation of TB-infection. We also studied the system and performances of the hospital’s work on case finding, follow-up on AFB positive cases and outcome of treatment. Results: We found that EPTB is an evident problem in the area and that the indicence is particularly high in some villages. This is probably related to living close to the cattle and drinking unboiled cow mild. We found a higher indicence of TB among men than women. TB adenitis, in particular cervica, had the highest incidence among EPTB, with highest age group. TB meningitis has the highest incidence among children age 0-9. Abdominal TB equally affects men and women. According to case finding and lab work, all AFB positive registered at the lab, received TB treatment at Haydom or was transferred to another health unit. The workload on the lab showed some variations from month to month. We have not been able to axplain this, but we ask it there may have been any changes in the way the lab is organised. The outcome of TB treatment at Haydom gave 51% cured, 6% dead and 43% transferred. The high number of transferred cases, however, makes it difficult to evaluate the treatment.

Interferens mellom mental aktivitet og balansekontroll hos vertigopasienter og friske kontroller
Hegelstad, Elling Christer Olsen, Geir Erik

Supervisor: Torbjørn Aasen, sjefingeniør Balanselaboratoriet, ØNH-avdelingen, Haukeland Universitetssykehus

Background: Recent studies have been discussing whether balance is more than just an action controlled by reflexes, and to what extend the consciousness contributes in this process. The purpose of the present study was to investigate whether there is interference between the control of balance and other cognitive activity. Previous studies have illustrated this by investigating elderly compared to adolescents. In this study we investigated the balance of 25 vertigo patients and 15 healthy controls. Hypothesises: 1. The patient-group will have an impaired balance compared to the controlgroup in all tests. 2. Interference between control of balance and other cognitive activity will be apparent in both groups. 3. The patients will sway relatively more compared to the controls during the mental task, given they need more attention keeping normal balance. Methods: The subjects were tested on a static balance platform, that recorded the shift of the body`s centre of pressure. They were balancing in standing position with eyes open and eyes closed, and with and without a mental task. The mental task was backward subtraction. Results: The patients performed better than the controls in every test. The control-group and half of the patient-group performed worse when they had a mental task compared to only balancing. This reflects interference. The other half of the patient-group surprisingly performed better. We did not manage to categorise the patient-group from a joint diagnosis. Thus, there is no factual evidence in support that vertigopatients, narrowly speaking, perform worse when at the same time doing a mental task. Conclusion: The study shows that cognitive activity can interfere with the control of balance. It also shows that it is not precise enough to include all dizzy patients. It would be of interest for future research to find out if vertigopatients can be categorised from the way that they balance.

Gutter er ikke som jenter…. En studie av navleveneforsnevringens påvirkning på placentavekt
Heggheim, Silje Seglem Svanæs, Ragnhild Åreskjold, Hanne M

Supervisor: Torvid Kiserud, professor Seksjon for obstetrikk og gynekologi, Institutt for klinisk medisin, UiB

Objective: Based on the knowledge that a narrow unbilical ring may cause obstruction and increased venous blood velocity at the abdominal wall, we wanted to test the hypothesis that hemodynamic forces influence the human placental development. We determined the effect of umbilical venous constriction on placental weight. Design: Cross sectional study Setting: Hospital antenatal clinic Population: 283 low risk singleton pregnancies specifically recruited for the study. Complete data were obtained from 191 participants. Methods: Ultrasound Doppler measurements at 20-40 weeks of gestation to determine velocity in the umbilical vein at the fetal end of the cord and at the inlet through the abdominal wall. Determination of placentaeweight at delivery. Outcome measures: 10th, 50th and 90th percentiles were estimated for the ratio birthweight/placentaeweight, velocity and velocity increment at the umbilical ring. Velocity increment as the blood entered the abdominal wall was calculated in percent of the velocity in the cord. Separate regression analysis were made for both sexes, using birthweight/placentaeweight and velocity increment as parameters. Results: Time-averaged maximum venous blood velocity in the cord was low (mean 13-19 cm/s) during 20-40 weeks of gestation. In contrast, the mean of the venous blood velocity at the umbilical ring was 34-41 cm/s during the same period. Of 191 pair of observations 41 (21%) had a velocity increment of ≥ 300%. Median placentaweight was 3720 gram (range 1220-5060). We found that birthweight/placentaeweight-ratio dropped significantly with increasing velocity increment in boys (r = 1,15 · 10-3, 95% CI: (-2,26 · 10-3; (-2,69 · 10-5)), but not in girls (r = 1,6 · 10-5, 95% KI: (-9,52 · 10-4; 9,84 · 10-4)). Conclusion: This study shows that physical forces has an impact on placental development through constriction of the umbilical vein in male fetuses. However, further studies are needed to confirm the relationship.

Hvorfor lever kvinner lengre enn menn?
Hegna, Tuva M Knudsen, Kristel

Supervisor: Kjell Haug, professor dr.med. Seksjon for sosialmedisin, Institutt for samfunnsmedisinske fag, UiB

Since the beginning of the 20th century, morality rates for both men and women have decreased in the Western industrial countries, but the reduction has been greater for women compared to men. In 1900 women could expect to live approximately 3 years longer than men, while the difference in longevity had increased to 7 years in 1990. Why do women live longer than men, and what is the reason for the gradual increase in the gender gap? Many different hypotheses exist today, but there are no clear answers. We have looked at different theories, including genetics, hormons, different metabolism and socioeconomic factors. X inactivation and X linked genetics factors may lead to better survival for women. Oestrogen in women has a great impact on lipidmetabolismen and favours and protects women against coronary heart diseases. Men are more likely than women to adopt beliefs and behaviours that increase their risks, and are less likely to engage in behaviours that are linked with health and longevity. Women report poorer health, but more men that women die from diseases. Women tend to cope better with social changes like family conflicts and workrelated problems. Overall, 7 years cannot be divided between the risk factors. Further research is necessary to give us more exact knowledge about why women live longer than men.

Kawasaki syndrom. Risikofaktorer for utvikling av koronare aneurismer
Helle, Rebecca

Supervisor: Gunnar Norgård, Seksjon for pediatri, Institutt for klinisk medisin, UiB

Background: Few patients with Kawasaki syndrome have been described in Norway. Different aspects of diagnosis and treatment are assessed. Material/methods: We retrospectively reviewed 26 cases of Kawasaki syndrome at the childrens hospital in Bergen 1985 – 1999. Results: 85% of the patients fulfilled all criterias for diagnosis and were treated as recommended. Yet, we found a high occurrence of coronary aneurysms (22%). Children who developed aneurysms, had delayed treatment compared to patients without complications. Infants were treated later and had a higher incidence of aneurysms. Laboratory findings differed among infants and older children, and in patients with and without aneurysms. Interpretation: Kawasaki syndrome is still a clinical diagnosis. Laboratory tests may, however, help to identify patients with high risk of complications. Infants should be followed carefully in the acute phase of febrile illness and be treated early, even when atypical presentation. Early adequate treatment is of vital importance to avoid complications and reduce short and longterm morbidity.

Føtomaternell blødning ved induksjon og elektivt keisersnitt En flowcytometrisk studie
Hellebust, Henriette Høie, Mina Øydis

Supervisors: Torvid Kiserud, professor dr.med. og Einar K. Kristoffersen, førsteamanuensis dr.med. Seksjon for obstetrikk og gynekologi, Institutt for klinisk medisin, UiB og Seksjon for mikrobiologi og immunologi, Gades institutt, UiB

Background: Transplacental bleeding from the fetus to the mother can cause complications, e.g. the mother can produce anti-D or anemia can occur in the fetus. Studies have shown higher incidence of fetal-maternal hemorrhage (FMH) associated with induction of labor with oxcytocin and in cases of acute cesarean section Our intention was to test the hypothesis: Is there an increase in FMH in induced labors with Prostin E and in elective cesarean section? This will give us the opportunity to learn more about a new method used at Haukeland University Hospital and provide us with numbers for power calculation for future studies. Material and method: The study aimed to include 20 women in two groups, elective cesarean section and induction with Prostin E. However, we achieved 19 women delivered by elective cesarean section and 12 induced with prostin-E. For each woman one blood sample was drawn one hour before the cesarean section/start of induction (0-sample) and another sample one hour after delivery (1-sample). We analyzed the amount of HbF in the blood sample. The women included in the group of elective cesarean section had the following indication: mechanical disproportion, abnormal presentation, previous difficulty with vaginal delivery and mother`s own wish. To be included in the induction group, it had to be postdate pregnancy, uncomplicated pregnancy and induction with prosin-E. Flowcytometry and Kleihauer-Bethke test were used to quantify HbF in the blood of the mother. To analyze the results we used paired t-test and 5% significanse level. The power calculation was based on 90%. Results: Our results, show that 4/18 (22.0%) in the induction group and 8/19 (42.0%) in the cesarean section group had had FMH > 1,0 ml at the time of 0 sample. In the interval from 0 sample to 1 sample in the inductian- and cesarean section group, our data indicate FMH respectiveley 1/12 (8.3%) and 4/19 (21.0%). Discussion and conclution: Our hypothesis that there was no significant bleeding during labour or cesaerean section was confirmed. We were able to arrive at this conclution regarding the group of patients who undertook cesarean section, since we had a suffisient numbers of patients according to the calculation of strength. We found out however that in many cases there were signs of FMH prior to the start of induction of cesarean section. Our data showed a small differences from the ones found earlier, this make us awarl of the importance of studying procsedures before they are applied in science and practis.

Drug Dispensing in Bhaktapur, Nepal
Hembre, Berit Sofie H

Supervisor: Tor A. Strand, Senter for internasjonal helse, UiB

Rational use of antibiotics is of major importance both to protect the individual patients from unnecessary and sometimes harmful side effects, and to avoid development of resistant stains. Objectives: To assess drug dispensers’ reported practices when treating children < 7 years old with diarrhoea, in Bhaktapur, Nepal. Furthermore, to assess the doctor’s prescription practice when working with the same group of patients, and compare the findings with the WHO’s guidelines for treatment of diarrhoea. Methods: Standardised interview of drug dispensers in 23 pharmacies, where they reported what kind of drugs they would give or actions they would take when treating patients presenting with acute, persistent or prolonged diarrhoe, or who had diarrhoa and feber, or had seen blood in the stool. Doctor’s prescriptions were collected from 5 of the pharmacies. 46 patients with diarrhoea were counted into the analysis. The information written on the prescriptions were copied and the caretakers were asked some additional questions. Results: Doctors and drug dispensers in this sample from Bhaktapur are in general not following the WHO-guidelines for the treatment of diarrhoea. Antibiotics are being given when this is not indicated. Drugs with possible harmful side effects like Chloramphenicol are also being used, but only by the doctors. According to the WHO-guidelines ORS (Oral Rehydration Solution) should be given to all patients with diarrhoea, if they are capable of drinking the solution. This recommendation is not being followed. Conclusion: This survey suggests that there might be a need to emphasise the WHO guidelines for diarrhoea treatment and for monitoring the practices of health personnel in Nepal.

Rehabilitering etter hjertesykdom – en kvalitativ undersøkelse
Hitland, Eva Camilla L

Supervisor: Eivind Meland, førsteamanuensis Seksjon for allmennmedisin, Institutt for samfunnsmedisinske fag, UiB

Background: The treatment aims concerning rehabilitation after heart disease may seem self evident, although these aims, as expressed by individuals, are rarely scutinised. Therefore this study set out to examine objectives and treatment goals as well as motivational factors as expressed by patients after heart disease. Material and method: The study was performed using focus group interviews in two groups. Seventeen patients 38 to 70 years of age, who participated in a heart rehabilitation program at Krokeidesenteret after myocardial infarction or coronary surgery, were interviewed. Results: We identified three dimensions as concerned personally defined rehabilitation goals. The first dimension was to regain the physical health as it was before heart disease. We called the second dimension: learn to live with a new body. This dimension contained elements as not violating the boundaries of what the body tolerates, change life style to prevent disease, and learn to know and respect personal limits anew. The last dimension was the relational one: to live and spend more time together with the family, improve dialogue with ones nearest and return to work. Pessimistic stories turned optimistic during the rehabilitation process. Such a process was enabled by family, by eye opening experiences, peer support and negotiation of new self demands. Interpretation: Arenas where the individual cognition and insights are discussed and negotiated are important. New role expectations and limits should be discussed where the point of departure preferably is the patients altered self demands. Physical training is not only a remedy to achieve better aerobic capacity, but important occasions for new mastering experiences and opportunities to interpret physical symptoms anew. Peer work seems important during the rehabilitation process.

Health Care Workers, occupational environment and occupational health service - a study among employees at Haraldsplass Deaconal Hospital, Bergen, Norway Helsepersonell, arbeidsmiljø og bedriftshelsetjeneste – en studie blant ansatte på Haraldsplass Diakonale Sykehus, Bergen
Hjellestad, Iren Drange

Supervisor: Bente E. Moen, professor Seksjon for arbeidsmedisin, Institutt for samfunnsmedisinske fag, UiB

Background Most reports and studies regarding health care workers reveals a higher rate of musculoskeletal injuries, stress-related symptoms, hand dermatitis and occupational injuries than observed in the general population. It is not statutory today for employers in Norway to have occupational health service for health care workers. The Ministry of Labour and Gouvernment Administration appointed recently a committee to evaluate the occupational health service in Norway, and if necessary propose an extension of the regulations. The committee recommends all companies in Norway to have occupational health service, this includes health care workers. The object of this study is to enlighten the need for occupational health service in hospitals, and comment the economical consequences of this service. Material and methods A cross-sectional study was performed. During autumn 2001, data was collected among 176 pre-nurses, nurses and medical doctors at Haraldsplass Deaconal Hospital, using a specially designed questionnaire. The questionnaire was divided into two parts, where the first part dealed with the work situation and health related to this, and the second part included questions about health-, environment- and safety actions as well as the need for occupational health service. Data was compared to information from relevant litterature. Results 121 questionnaires were returned by 22 pre-nurses, 68 nurses and 31 medical doctors. The percentage of returned questionnaires was 69. PART 1 Occupational situation The study showed that 80% of the employees work overtime weekly or monthly. The majority (65,3%) quoted low manning as main reason for the overtime work. 21,5% quoted that they had suffered from occupational health problems which lead to short time absence from work, and 13,2% quoted long time absence from work for the same reason. The absence from work was mainly due to musculoskeletal injuries, and secondly due to strain-related symptoms. The number of hand dermatitis/latexallergy was low, causing only 2 persons' absence from work, and just short time. Nobody had long term absence from work due to hand dermatitis/latexallergy. PART 2 Health-, Environment- and Safety actions/ Occupational health service

In 96,7% out of 121 returned questionnaires it was stated that the employees had safety equipment available and the opportunity to make use of the equipment, but 26,4% need access to additional safety equipment. The employees evaluated their own use of safety equipment as satisfactory. 71,1% of the employees found other conditions in their ward unsatisfactory, and gave the following specifications: Lack of space in patients' rooms, dressing rooms, preparation rooms and lunch rooms, unsatisfactory working conditions in the office and preparation area such as noise, frequent interruptions and lack of ergonomical adjusted equipment, unsatisfactory ventilation, lack of lavatories for the employees, lack of technical equipment. The majority of the employees (69,4%) quoted that they were unfamiliar with the contents of the regulation of internal control, and barely one third had experienced a visit from a safety officer or a survey of the occupational environment in their engagement period at the ward. 90,1% of the participants in the study thought that there is need for an occupational health service at their workplace. Interpretation The study reveals that the employees at Haraldsplass Deaconal Hospital experience occupational problems similar to those described in the litterature. The preventive work concidering health related problems at Haraldsplass Deaconal Hospital is not satisfactory and should be improved. It is difficult to evaluate the economical consequences of occupational health service. Decreased numbers of health,- environment- and safety problems reduces the costs for the employers, which again indicates that help from an occupational health service is profitable.

Diagnostisering av albinisme
Hoff, Thorleif Søreide

Supervisor: Eyvind Rødahl, professor dr.med./overlege Seksjon for oftalmologi, Institutt for klinisk medisin, UiB/Øyeavdelingen, Haukeland Universitetssykehus

Background: Albinism is a condition characterized by a lack of pigment in the eye and skin. The disease presents with many different patterns of symptoms and can therefore be difficult to diagnose, especially in infancy. Objective: To establish the munber of patients with albinism admitted to the Department of Ophtalmology at Haukeland University Hospital between 1988 and February of 2003, and thereby get an impression of the incidence of the condition. Furthermore to determine which symptoms and signs the patients usually present with, and which diagnostic methods were most often used. Lastly, to establish a suggested standard program for the examination of patients with suspected albinism based on the findings of the survey. Methods: Patients were identified by searching the hospital’s database utilizing ICD diagnosis codes. In a retrospective case study, data was collected from the medical records of these patients. Results: 15 patients were admitted to the Department of Ophtalmology between 1988 and February 2003. All patients had congenital nystagmus, and 8 out of 15 had strabism. Mean visual acuity was identical in the group of patients with strabism compared to the group of patients who did not have stratism. Electrophysiological testing was carried out with an increasing frequency in later years, and was in many cases the deciding factor for the diagnosis. Conclusion: Electrophysiological testing is a valuable aid in the examination and diagnosis of albinism, especially in the evaluation of infants with congenital impaired vision of unknown cause. VEP tests should ideally be performed utioizing pattern stimuli when investigating a possible case of albinism. Standardized test procedures and quantitative analysis of the VEP curves is desirable in order to make as objective an evaluation as possible. Mothers of male subjects with suspected albinism should be investigated for a possible carrier state. Siblings of a subject should also be compared with the findings in the subject. Genetic counseling is useful both in investigation of the case and for distributing information to the patient’s family. Genetic testing and tissue sampling is only needed in special cases.

Seksuell debutalder og prevensjonsbruk ved 1. samleie blant medisinstudenter i Bergen
Hope, Kirsten Øvergaard

Supervisor: Kåre-Steinar Tveit, overlege Hudavdelingen, Haukeland Universitetssykehus

Background: Our intention was to examine age of sexual debut and use of contraception at first intercourse among medical students in Bergen. Several studies have shown that the ambition of higher education is highly predictive of a late sexual debut. We expected a higher age of sexual debut in this population than found in national surveys of a general population. In addition we wanted to map which factors predicted use of contraception at time of first intercourse. Material and methods: 589 medical students answered a questionaire. The survey was conducted between autumn –00 until autumn –01. Seventy percent of the students asked replied. Results: We found that 78.4 % of the cohort were sexually experienced. The theoretically lowest average age of sexual debut for the entire cohort was calculated to be 18.7 years, with a median of 19.0 years. Average age of sexual debut among those who were sexually experienced was 17.6 years for females and 18.2 years for males. These numbers can be compared to figures presented in national surveys, which is 16.7 years for females and 18.0 years for males. A large propotion had used contraception at first time of intercourse, and relatively few were under influence of alcohol. Factors strongly associated with use of contraception were a close relationship with the partner, and whether or not contraception had been discussed previously. For females, there was a correlation between being under influence of alcohol and non- use of condom, and for boys early sexual debut was correlated with non- use of condom. Interpretation: Our study showed a significant difference in age of sexual debut between males and females. Our results strengthen previous findings that higher education is assosiated with late sexual debut. Close relationships and good communication are important factors regarding use of contraception at first time of intercourse. It is therefore of high importance that the youths achieve knowledge and attitudes both in school and elsewhere in the society.

Hypercortisolemia and Cognitive Dysfunction in Major Depression Hyperkortisolemi og kognitiv svikt ved alvorlig depresjon
Husa, Roger Toppe, Bjarte .

Supervisor: Anders Lund, professor Seksjon for psykiatri, Institutt for klinisk medisin, UiB

Background Many patients with major depression have impaired cognitive function compared to healthy subjects. Major depression is also associated with high levels of cortisol and resistance against the dexamethasone suppression test. Neuroimaging studies on patients with major depression have found evidence for structural brain changes in areas such as the hippocampus, amygdala, nucleus caudatus, putamen and frontal cortex. These are all structures known to be involved with cognitive and executive tasks. One possible mechanism for this volume loss is the toxic effects of cortisol on neural tissue. If cognitive dysfunction in patients with major depression is due to hypercortisolemiainduced neural tissue loss, then lowering the plasma levels of cortisol in these patients could be of benefit. The objective of this study was to examine the status of current knowledge on this field and to evaluate how well documented the studies are. According to this we would see if there is an association between hypercortisolemia and cognitive dysfunction in major depression. Method A search for the words “major depression”, “depression”, “cognitive function”, “cognition”, “executive function”, “cortisol”, “hypercortisolemia” and “antiglucocorticoid treatment” and combinations of these words was made on Medline. Priority was given to articles printed in well recognized journals. Results Of patients with major depression, less than fifty percent are showing cognitive dysfunction. The degree of cognitive dysfunction is varying and may be associated with the degree of depression. Cognitive dysfunction seems to increase with increasing number of depressive episodes. After remission of the depressive episode, cognitive function improves but does not equal the level of normal healthy subjects. About half of the patients with major depression are having hypercortisolemia and disturbances in the regulation of the hypothalamus-pitiutary-adrenal gland axis (hyperactivity). The median volume of the adrenal glands in patients with major depression is significantly increased but returns to normal when remission of the depressive episode occurs. Repeated hypercortisolemic episodes of depression give rise to irreversible atrophy of the hippocampus and higher cortisol levels correlate longitudinally with greater hippocampal volume loss. The mechanisms underlying these observations remain unclear and hypercortisolemia is only one of several possible explanations. Conclusion In the studies evaluated the number of patients are few and the study designs are often far from the randomized double-blind gold standard. Few studies on cognitive dysfunction in major depression have focused on the possible association with hypercortisolemia. There are still many aspects of this field that needs to be studied before a conclusion can be made that there is an association between ypercortisolemia and cognitive dysfunction in major depression. Antiglucocorticoid therapy is an interesting and promising area and may have a role in future treatment of major depression. More research is needed on this as well.

Faktorer som regulerer mitose. Interaksjon mellom tertiære responser og tidlige signaloverføringsreaksjoner
Husebø, Gunnar Reksten

Supervisors: Holm Holmsen, professor dr.philos. og Flemming S. Vassbotn, 1.aman. dr.med. Seksjon for biokjemi og molekylærbiologi, Institutt for biomedisin, UiB

The cell division is under regulation by a number of factors, extra- and intra-cellular. Activation by growth factors is a main contributor to the mitosis in normal cells. The growth factor effect is mediated by tyrosine kinase growth factor receptors. The intracellular signalling follows several different pathways to the cell nucleus, where mitogenic transcription occurs. These pathways are changed in cancer cells, due to mutations in protooncogenes and tumor supressor genes, with unintended cell division as a result. Modern, targeting cancer therapy can take advantage of this by attacking the changes in these signalling proteins, as they are different from the originals. New medical therapy is being developed, some medications are already in use.

Læreres og lærerskolestudenters kunnskap om tidlige tegn ved psykiske lidelser
Jacobsen, Cathrine Johannessen, Lene Sunniva

Supervisor: Kjetil Hustoft, seksjonsoverlege Akutt Mottakspost, Rogaland Psykiatriske sjukehus

What do teachers and students at teacher colleges know about early signs on mental illness? Is there a difference in the level of knowledge among the teachers in Stavanger, which have been given information about the TIPS project, and the teachers in Bergen, where the project has not yet been started? Those are the main questions in this article. Using questionnaires, we have performed a survey among teachers and students at the teacher colleges in Stavanger and Bergen, from September 03 until January 04. In the first part of the article we take a closer look at the most significant mental illnesses. We describe the symptoms, treatment and to a certain degree, some of the etiology. We think this is important due to the fact that this article focuses on the level of knowledge in this field. In this part we also describe the TIPS project. Through this project one seeks to educate the public so that they recognize the early signs of a psychosis. In the second part of the article we get into which methods we have used. We describe the research method, the population and how we performed the survey. The third and last part of the article is an account of the results we found. The survey uncovers several similarities when it comes to the general knowledge on mental illnesses. But there are big differences between Stavanger and Bergen when it comes to recognizing the early signs of a mental illness. This shows that it is possible to use systematic information on the early signs of mental illness, like the TIPS project, to increase the level of awareness among teachers. We think this is very important considering that the teachers often are the first to realize that “something is wrong” with one of their students.

Slanking: Energibalanse vs. næringsstoff
Jassal, Bhupinder

Supervisor: Miriam Fukami, professor Seksjon for biokjemi og molekylærbiologi, Institutt for biomedisin, UiB

Rates of obesity and overweight in most western countries have risen sharply over the past 30-40 years. Epidemiologic studies have revealed a clear association between obesity and the risks of hypertension, cardiovascular disease, non-insulin dependent diabetes mellitus, certain forms of cancer, gallstones, some respiratory disorders, osteoarthritis and an increase in overall mortality. The increase in obesity has been attributed to high fat content of western diets. However, weight gain is increasing even though we are consuming less fat now than 100 years ago. Too much sugar and refined carbohydrates in the diet has been suggested as another reason for the weight gain. The theory that a high-carbohydrate diet induces high insulin levels, which promote fat-storage has been the inspiration for some special diets. A high fat/ low carbohydrate -diet is claimed to result in a hormone profile that lowers insulin levels and thereby less fat storage and more fat oxidation. But long-term studies which can prove the claims have not been carried out and those who have lost weight by following such diets, have lost it because of reduction in calories consumed and not because of the changes in the macronutrient. It is correct that the population's total calorie-consumption has been reduced over the past 25 years. But it is also correct that the daily level of physical activity has been reduced even more. Weight gain is not particularly affected by the proportion of calories obtained from fat or carbohydrate, but it is the total amount of calories that is absorbed and available for metabolism, compared to the amount one burns that matters. An overweight person will have more difficulties loosing weight permanently just by eating less, because the body's energy requirements will fall in parallel with the reduction in weight and musclemass. Permanently weight reduction must include proper eating and adequate levels of exercise, both of which involve permanent changes in lifestyle.

Vektauke i svangerskapet. Eit mål for helse hos mor og barn?
Jensen, Guro Furset

Supervisor: Steinar Hunskår, professor dr.med. Seksjon for allmennmedisin, Institutt for samfunnsmedisinske fag, UiB

Objective: To investigate if routine weighing of pregnant women is useful as a part of perinatal care. Does measuring of weight gain give information about risk pregnancies? This is a review of available knowledge on the connection between maternal weight gain and risk of adverse outcome of pregnancy. Methods: Literature review Results: There are different opinions on maternal weight gains impact on the pregnant and the fetus. Research on the subject does not lead to one conclusion. The risk of getting SGA infant increases with low maternal weight gain, and the risk of high birth weight increases with high weight gain. Preterm birth could be connected to low maternal weight gain, and caesarean delivery linked to high weight gain. There are no collectively conclusions from the research on these items. The risk of postpartum weight retention increases with high weight gain, but other factors could be of important influence. Conclusion: Limits for normal weight gain and intervention if the pregnant has a gain outside this recommendations, are necessary if routine weighing should be of any use. Weighing is no good as a screening tool. Executing randomised controlled trails on weight gain probably attains better user of the resources and more reliable knowledge. Still it is important to give pregnant women advice on recommended weight gain and follow up those with very high or low weight gain.

Jensen, Synnøve Magnhild

Supervisor: Asgaut Warland, førsteamanuensis Seksjon for øre-nese-hals, Institutt for kirurgiske fag, UiB

Tinnitus is an iindividual’s perception of sound in the absence of any physical source. Objective tinnitus is produced mechanically often caused by vascular and muscular abnormalities. Subjective (“real”) tinnitus is more common and does usually reflect an abnormality of the auditory system. This one is difficult to treat because of the auditory system is difficult to reach, because of the variability from individual to individual, and because of unaffected biological parameters. It is undetectable to the excaminer. This might be the explanation of the mystification of the tinnitus phenomenon in medical remedies since the Egyptian papyruses. Today we know more about tinnitus and we take it more seriously. It is found that 10-15% of adult population has tinnitus and that it makes 18 000 Norwegians invalids. Considering working population with tinnitus 35% get disablement benefit or retire on a pension at ean earlier age. Tinnitus causes interference with their getting to sleep and causes consentration difficulties, headache and psychosocial problems making the tinnitus worse. Modern treatment methods are based on breaking this evil circle. Patients are supposed to learn to accept and get used to their tinnitus. It is always possible to relieve the tinnitus problems, even when tinnitus itself cannot be cured. Tinnitus Retraining Therapy (TRT) seems to be the best method of treatment. It includes psychological and physica treatment and sound stimulation, a method developed from the masking therapy. The external sound is meant to divert the attention from the tinnitus and make is less annoying. Tinnitus is often associated with hearing loss. Ear diseases, ear trauma or chonical ear infections, noise exposure and aging are connected to tinnitus. By preventing hearing loss, tinnitus is also prevented. Because tinnitus might be the first symptom of abnormalities of the auditory system, important pathology, eg. an acoustical neuroma has to be excluded or treated. Often, however, we do not find the underlying pathology.

The value of open-ended question in the consultation in general practice Verdien av åpne spørsmål i konsultasjonen i allmennpraksis
Johansen, Marie C. (senere Stjärne) Stuedal, Kristine

Supervisor: Anders Bærheim, professor Seksjon for allmennmedisin, Institutt for samfunnsmedisinske fag, UiB

In this paper we have studied the information given by patients as a consequence of the doctor’s use of open-ended questions in consultations in general practice. Open-ended questions are an important part of patient-centered method. Methods and materials: The third year medical students in Bergen (class 98A) had a day in general practice in the autumn 2000. During that day, the students had to answer some questions in a journal. One of these questions was as follows: “May you give an example where the doctor used an open-ended question, which led to useful, new or surprising information?” Our paper is based upon the answers from this question. The analysis is based on Giorgi’s fenomenological analysing method, as referred in Malterud’s book “Kvalitative metoder I medisinsk forskning – en innføring”. First we got an overview of the material, we found the categories which seemed useful for further work. We have found some common points in each category, and we have summarized and described the material. Results: The material spanned broadly, from hurting knees to threats of murder. It was divided into three categories. Category 1 gives examples of different types of open-ended questions. Category 2 shows that open-ended questions can lead to information about new problems, where “life and relations” is one subcategory and “physical and psychological disease/illness” is another. In category 3 the new information elucidates the patient’s initial problem. Conclusion: We have seen that the doctor actually can get a lot of new information by using open-ended questions. Part of this new information would probably not have been revealed without the open-ended questions. Open-ended questions are an important and effective tool for the doctor, which also gives the patient an opportunity to tell the doctor what’s really on his mind. Yes to open-ended questions!

Minimal change in the occurrence of HSV-2 antibody in sera in Sweden
Jonsson, Maria Karolina

Supervisor: Britta Wahren, MD, PhD. Mikrobiologiskt och Tumörbiologiskt Centrum, Karolinska Institutet, Stockholm

The prevalence of antibodies to herpes simplex virus type 2 (HSV-2) was determined in sera collected from two Swedish cross-section populations during 1990/91 and 1996/97. A glycoprotein G2 (gG-2) peptide ELISA was used to analyse 2899 sera from adults. We found a prevalence of 13.0% in 18-70 year-olds in 1990/91 and 16.4% in 31-55 year-olds in 1996/97. Seropositivity to HSV-2 was somewhat higher in women than in men; 14.4% compared to 11.6% in 1990/91 and 18.9% compared to 13.6% in 1996/97. Overall there was a significant difference in female prevalence of HSV-2 compared to prevalence in males of the same age groups (p=0.013). A total antibody prevalence to HSV-1 of approximately 80% in HSV-2 negative individuals was found. HSV-2 positive individuals were found seropositive to HSV-1 in approximately 95% of the cases. Twelve percent of the samples were negative for both HSV-1 and HSV-2 antibodies. In addition, there was no sign that the reported increase of HSV-1 as an early sexual disease had reduced the frequency of HSV-2 seropositivity in the sexually most active age-groups. In conclusion our investigation has shown no significant increase of HSV-2 seroprevalence.

Miller Fisher Syndrome
Jørgensen, Lisa

Supervisor: Christian A. Vedeler, professor/overlege Seksjon for nevrologi, Institutt for klinisk medisin, UiB/Nevrologisk avdeling, Haukeland Universitetssykehus

Background. Miller Fisher syndrome (MFS) is characterized by the clinical triad of ophtalmoplegia, ataxia and areflexia, and is considered a variant form of Guillain-Barre syndrome (GBS). The incidence of MFS is reported to be approximately 1-5% that of GBS in Western countries. Approximately 90% of patients with MFS have antibodies against the ganglioside GQ1b which is of diagnostic and pathogenic importance. Material and methods. We present two patients with MFS and describe clinical features and possible mechanisms of GQ1b antibodies. Results and interpretation: Both patients presented with the classical triad of symptoms and GQ1b antibodies after upper respiratory tract infection. One of the patients had a more severe form of MFS with additional bulbar signs and was treated with plasma exchange. Both patients made almost complete recovery within a few months.

Røyking i postpartum-perioden
Kjellevold, Stein-Harald

Supervisor: Kjell Haug, professor dr.med. Seksjon for sosialmedisin, Institutt for samfunnsmedisinske fag, UiB

Smoking in the postpartum period is associated with a number of hazardous side-effects for the baby. Children exposed to ETS (environmental tobacco smoke) are at increased risk of SIDS, several infections including respiratory and middle ear, childhood asthma and a prolonged reduced lung capacity. Smoking mothers are also more likelly to stop breastfeeding their babies, with the possible consequence of reduced immunization in the child. While trends in smoking during pregnancy are thought to be well known, and are continuously registered by the Norwegian Medical Birth Registry, the prevalence of passive smoking in infants is not so obvious. In this paper the Medline search engine is used to map Norwegian and international knowledge on the prevalence of smoking women in the postpartum period. The search words “smoking, postpartum, pregnancy, prevalence, relapse” were used in different combinations. Out of an impressive number of hits nine studies were identified, two were Norwegian and the rest American. Ths scope of smoking mothers was measured either as relapse of previously smoking mothers or as a general prevalence. The postpartum relapse in this period varied from 15,2 to 79 percent. At 2 to 6 month postpartum relapse varied from 47,8 to 65 percent at 2 to 6 months to 28 percent at 12 month postpartum. The different measuring methods complicate direct comparison of the studies. This was further made difficult by the studies using different study populations. The studies were also published evenly from 1986 to 2003 and knowing that, at least in Norway, the prevalence of smoking in the general population has decreased in the past decade, older studies may not be valid for the current situation. This paper concludes that the current knowledge on the scope of smoking in the postpartum period is limited and more research is needed.

En klinisk og histomorfologisk studie på reversibilitet av kroniske snusinduserte lesjoner i munnslimhinnen
Kjelsberg, Magnus

Supervisor: Anne Christine Johannessen, professor dr.odont, cand.med. Odontologisk institutt – oral patologi og rettsodontologi, Det odontologiske fakultet, UiB

There is a close relationship between general health/disease and oral mucosal reactions. Many diseases show unspecific or specific changes which may evolve throughout the course of the disease, but the mucosal reaction may also constitute the initial sign of the disease. Oral cancer is amongst one of the most potentially malignant forms of cancer. The use and adverse effects of smokeless tobacco (ST) has been linked to the development of precancerous and malignant oral lesions. An attempt has been made to describe the current situation in Scandinavia regarding consumption of ST, development of oral cancer and possible measures for intervention, and also to select pertinent review articles from among the huge amount of literature published in recent years. This project is a combined article review and part of a Swedish smokeless tobacco intervention study.

Leddbruskskader i kne
Lande, Inger Vatne, Maria

Supervisor: Eirik Solheim, førsteamanuensis Institutt for kirurgiske fag, UiB

Purpose: New surgical methods have improved treatment of focal chondral defects. With this new optimism, diagnosing and following up this group of patients has gained importance. The established knee evaluation forms (Cincinnati, IKCD, Tegner, and Lysholm), have been distributed to review the effects of surgery. However, no single evaluation form has been developed specifically for patients with chondral defects. Our study is an attempt to describe ethiology and symptoms of patients with focal chondral defects, in order to develop a new knee score system. Methods: 224 former patients were included in the study. The patients had all gone through articular reconstructive surgery at the Deaconess Hospital Haraldsplass during the period 06.02.97-24.02.03. A detailed questionnaire was sent them, focusing on the situation where the damage first appeared, which symptoms were experienced as the most devastating, and how the impaired joint influenced their daily life (before surgery). Results: 52% of the patients were damaged by acute trauma to the knee, 48% experienced gradual worsening. The most common mechanism was direct trauma to the knee (53%), followed by twisting (20%). Most of the traumas occurred during work (28%) or athletic workouts (58%). Pain was a major symptom. Many also reported the knee was unstable and felt weak. Pain and dysfunction made daily activities like walking and climbing stairs difficult. The damaged knee greatly influenced the patients’ mood, sleep and social life, making many feel that their general health was worse after the knee damage. Conclusion: Patients with focal chondral defects in their knees are a group of formerly very active people. Most have been traumatized during work or athletics. Damage can be a result of both direct and indirect trauma. Manifestations of the defect are pain, even at rest and loss of function. In addition the impaired knee reduces general well being, sleep and mood.

CRP i allmennpraksis
Larsson, Marthe Lene Johnsen, Marit (class 99)

Supervisor: Sverre Sandberg, professor dr.med./avd.overlege NOKLUS, Institutt for samfunnsmedisinske fag, UiB/Nasjonals kompetansesenter for porfyrisykdommer, Lab for kinisk biokjemi, Haukeland Universitetssykehus
Background CRP is an acute phase protein. Due to its rapid increase in serum and thereafter rapid normalisation after ended stimuli, it is beneficial as a diagnostic marker for certain infections and monitoring of infectious and inflammatory processes.1 We would like through this essay first to briefly describe the acute phase reaction and CRPs biokinetic qualities. Further more will we examine studies which deals with the use of CRP in clinical practice. First and foremost are we going to focus on infections in general practice. The last part of the essay are based on a survey made by NOKLUS-Norwegian center for quality improvement of primary care laboratories. General practitioners all over the country received a case story (a woman with pneumonia-like symptoms) together with a blood sample. The doctors were to measure CRP with their own equipment, and decide whether to treat the woman with antibiotics or not. The “true” value measured by NOKLUS was 50 mg/L. Material and method Part 1-3 is a literature study, where we searched for literature in Medline and PubMed. We preferred literature published after 1996. Initially we tried words such as “C-reactive protein” and “acute phase protein”. When we added “general practice”, we only found 3-4 usable articles. We also used literature recommended by our tutor. In part 4 we base our material on response from 1719, of which 1698 were useable, general practitioners all over the country. We have processed and tried to describe, discuss and analyse the coarse material from the survey. We used Microsoft Excel to facilitate the graphic products. Results and concluding remarks It turned out that it is well-studied how CRP can discriminate between viral and bacterial infections, and most studies conclude that the marker can be used for this purpose. In general practice the research is mainly done on CRP in relation to pneumonia in adults, tonsillitis and maxillary sinusitis.1 Main conclusions are that it is recommended that CRP is measured when bacterial pneumonia is suspected. 6 When maxillary sinusitis is suspected, a combined applications of SR and CRP is useful, but not optimal 11. Streptococcus-antigen quick-test give better diagnostic information than CRP in situations where bacterial tonsillitis are suspected.1,9 According to NOKLUS the uncertainty of a result of 50 mg/L is +/- 30% with NycoCard. 1196, or 70, 4%, of the doctors measured a value within these limits. 357 doctors changed their action if they had known the correct result. 4 / 61 doctors that measured values above 100 mg/L chose to treat. 340, or 68%, of the doctors who measured 50 mg/L decided to treat. 21 / 230 who measure < 25 mg/L chose to treat. In the range 25-75 mg/L we found that the percentage who chose to treat, increased with increasing CRP value, while the percentage who did not treat decreased with decreasing CRP values. Our conclusion is that the measured CRP-value is of importance when the doctors decide wether to treat the patient with antibiotics or not. Therefore, the analytical quality is also of great importance.

AD/HD og bilkjøring – en pilotstudie
Laudal, Espen Spildo Malmo, Thomas

Supervisor: Pål Zeiner, overlege/dr.med. Sogn senter for barne- og ungdomspsykiatri, Psykiatrisk divisjon, Ullevål Universitetssykehus

Children and young adults with Attention Deficit Hyperactivity Disorder (AD/HD) are characterized with high levels of activity, agitation, restlessness, low perseverance, frequently change of activities, and they are easily distracted from external and internal impulses. Studies show that about 50% have a persisting AD/HD in their adult age, and this is a large population which is not been researched a lot. One focused area are driving skills among adults with AD/HD. There have been several selfreporting-studies with comparison between persons with AD/HD and a control group on traffic skills. Only one study has researched the effect of central stimulating medication among persons with AD/HD and driving skills. The results showed a significant improvement when people with AD/HD used an adequate dose of metylphenidat (Ritalin®). Norwegian health government are now giving allowance for testing central stimulating medication on adults with AD/HD that are diagnosed after the age of 18. Today, people with AD/HD need a health certificate from their general practitioner. There are few (no) standards in giving this driving allowance, and there are not much research supporting them. In corporation with Sør-Trøndelag Psychiatric center (STPS) department Brøset, and SINTEF in Trondheim, we made a study with 5 males between the age 20 and 40 with AD/HD, and 5 controls in the same age group. Two types of simulators were used in this study. Driving behavior and hazard perception was primarily studied in a full scale dynamic car simulator, driver awareness and response time was studied in a fixed based, video image simulator. The controls conducted one test, whild those with AD/HD were tested once without prior intake of prescription drugs and once after taking an ordinary morning dose of methylphenidate. All the participants had to answer questions from different diagnose schemes, and give self-report status on their previous record on driving behavior. The results from our study show that there were statistically differences between controls and persont with AD/HD, which had not taken prescription drugs, both in number of indicators on bad driving skills, and on global driving ability. When persons with AD/HD were doing the tests on medication, their performance improved, and there were no significant difference between the controls and persons with AD/HD. In the fixed based video-simulator, where the reaction times to stimuli, variance in reaction time, and failed/missed response were compared, we found no significant differences between the controls and the persons with AD/HD, with or without medication. The persons gave themselves 5.6 (on a scale from 0-10, where 0=very bad driver, 5=average driver and 10=very good driver) on driving skills before the test, controls gave themselves 5.9. After the tests the persons with AD/HD rated themselves to 5.0 without medication, and 6.8 with medication. The controls gave themselves 5.4. This is a pilot study and is in no means conclusive. The selection was too small, the analysing of the material from the dynamic simulator was not optimal, and ideally the controls should have driven the program a second time, like the people with AD/HD. In any case, under the given circumstances, the persons with AD/HD made a significant improvement when they were on medication, and showed no significant differences sompared to the controls. These results were found so interesting that there is a new large scale study going on at SINTEF in Trondheim.

Forekomst av øycelleantistoffer hos barn med nyoppdaget type 1 Diabetes Mellitus
Lauritzen, Peter Mæhre

Supervisors: Njølstad, Pål R., professor og Oddmund Søvik Seksjon for pediatri, Institutt for klinisk medisin, UiB

Introduction: The majority of children presenting with type 1 diabetes test positive for one or more islet specific autoantibodies. Several studies have investigated the possible relationship between such antibodies and the clinical manifestation and progression of type 1 diabetes with somewhat conflicting results. Objective: The objective of this study was to determine the frequency of autoantibodies to islet cell components in the serum of children presenting with type 1 diabetes. Further more we wanted to investigate whether these autoantibodies, or other information known at presentation are related to the mode of presentation or short term progression represented by routine biochemical screening of such children. Subjects And Methods: 154 patients aged 0-15 years were recruited at presentation with type 1 diabetes mellitus at The Childrens Hospital, Haukeland University Hospital, Bergen, Norway between 1st January 1986 and 31st December 2000. Blood samples were obtained at diagnosis, before the first injection of insulin and tested for insulin autoantibodies (IAA), autoantibodies to protein tyrosine phosphatase (IA-2A) and glutamic acid decarboxylase autoantibodies (GADA). The following additional information was recorded: Presence of diabetic ketoacidosis (DKA), a pH < 7,3 combined with bicarbonate level below 15 mmolL-1 constituting DKA. To measure remaining endogenous insulin secretion, C-peptide levels were recorded before and five minutes after i.v. injection of 1 mg of glucagon. Levels below 0,18 nmolL-1 before glucagon were considered abnormal. Metabolic control was assessed by blood HbA1c analysis at the time of diagnosis and after four weeks. Levels below eight percent were one of the goals of treatment. A positive family history was defined as type 1 diabetes among first degree relatives of the patients at the time of diagnosis to the knowledge of the patient or next of kind. Requirement of exogenous insulin at four weeks below 0,5 IU kg-1day-1 constituted partial remission. Results: Only 6,5% tested negative for all three autoantibodies. Combinations of two autoantibody assays identified between 78,6 and 90,2% of the patients, depending on which two assays being combined. The presence or levels of autoantibodies were not related to any of the other parameters, with the exception of IAA which showed a weak but significant negative correlation to age at presentation. Female patients showed slightly higher residual capacity for endogenous insulin secretion. Insulin requirement, levels of HbA1c and c-peptide showed a weak but significant positive correlation to age at presentation. Patients with a positive family history showed significantly lower levels of HbA1c and a lower insulin requirement. Patients presenting with diabetic ketoacidosis showed significantly higher levels of HbA1c at presentation, but at four weeks this difference was no longer significant although their insulin requirement was significantly higher. HbA1c-levels at presentation showed a significant negative correlation to c-peptide levels at presentation and a significant positive correlation to insulin requirement at four weeks. Conclusion: There is a high frequency of autoantibodies to islet cell components in the serum of children presenting with type 1 diabetes. These assays may help to confirm the diagnosis, but cannot reliably exclude it. The presence or level of antibodies give no indication of short term prognosis. The described results may contribute to our understanding of the pathogenesis of type 1 diabetes and to identify areas for further research, but are of minor clinical importance.

”Bare en kontakt…” Sjelesorg for gamle på sjukeheim. Ein kvalitativ studie.
Lillestøl, Kristine

Supervisor: Stein Husebø, overlege Bergen Røde Kors sykehjem

Bakgrunn: Føremålet med studien var å få auka innsikt i kva som er viktig for gamle på sjukeheim med omsyn til omsorg i siste fasen av livet. Vi fokuserte mest på kva sjelesorg, også kalla åndeleg omsorg, kan vere for desse pasientane, og kor viktig det er for dei. I den samanhengen var vi særleg interesserte i å høyre om tankar kring døden og religiøse spørsmål var noko som opptok dei. Materiale og metode: Vi nytta ei semi-strukturert intervjuform, og intervjua 14 pasientar på ei utvald sjukeheimsavdeling i Bergen, hausten 2001. Deltakarane var mellom 73 og 94 år gamle, og hadde ein gjennomsnittsalder på 83,7 år. Resultat: Pasientane var generelt nøgde med den delen av pleien som dekkjer daglege behov knytt til hygiene og ernæring. Fleire av dei sa at dei ofte kjenner seg einsame, og noko av det dei sakna mest, var meir tid til samtale med personalet. ”Dei store spørsmåla” knytte til religion og tankar om døden såg ikkje ut til å oppta dei i særleg grad. Tolking: Utvalet er for lite til at konklusjonar kan trekkjast, men funna tyder på at sjelesorg er noko av det viktigaste for gamle pasientar på sjukeheim. Det kan òg sjå ut til at sjelesorg er ei omsorgsform med låg prioritet i eldreomsorga i dag.

Hjemmekontor – helsemessige konsekvenser?
Lyster, Idunn

Supervisor: Bente E. Moen, professor Seksjon for arbeidsmedisin, Institutt for samfunnsvitenskapelige fag, UiB

Background: During the past years alternative work arrangements such as telecommuting have been introduced in order to meet the increasing demand for flexibility in the workforce. The aim of this study was to focus on different aspect of health among employees with homebased offices. Methods: Ten qualitative interviews were carried out. Questions ask from a semistructural questionnaire. The informants were five employees with homebased offices, a firmmanager and a firm physician in companies with employees who uses a homebase working model. Finally, representatives for the Labour Organisation (LO), Norwegian Employers Association (NHO) and Norwegian Labour Inspectorate (Arbeidstilsynet) were asked the same set of questions. Special notice was made to factors such as social support, stress, isolation and sickleave. One also sought to clarify it there seemed to be any gender difference in the perception of this way of organising work, and whether or not there was a difference between those who used telecommuting full time contra part-time. The interviews were written down and analysed. Result: Part-time telecommuting seems to have a beneficial effect on stressreduction, sickleave, job satisfaction, effectiveness and in combining professional life with family. The last in particular for women. Social support was not compromised and isolation was not a huge object to the part-time telecommuters in the group. This way of organising work seemed to have a positive effect on the employees health. When it came to fulltime telecommuting these effects were not so evident. There was a higher risk of isolation and stress reduction was not as clearly evident. Conclusion: Since the material is based on ten interviews, there is need for more extensive surveys in order to conclude fully. Nevertheless, it seems apparent from the experience made from the group that part-time telecommuting have positive effects on health related matters, whereas for fulltime telework this is more uncertain.

Autoimmunt polyendokrint syndrom type II
Løitegård, Terje

Supervisor: Eystein Husebye, professor dr.med. Institutt for indremedisin, UiB

In autoimmune polyendocrine syndromes (APS) several endocrine glands are affected by an autoimmune-mediated destruction. APS is divided into 4 subgroups of whom 3 has autoimmune primary adrenal failure (Addison’s disease) as one of the obligatory components. This paper focuses on APS II since this is the most common APS with Addison’s disease. APS II is characterized by autoimmune Addison’s disease (100%), and at least one of the following; diabetes mellitus type 1 and autoimmune thyroid disease (either Hashimoto’s thyroiditis or Graves’ disease or both). In a large study among 263 patients with autoimmune Addison’s disease, 107 (41%) of the patients had APS II. The most common combination was Addison’s disease with autoimmune thyroid disease (59-82%). Many of the patients also had autoimmune manifestations from other organs, i.e. vitiligo, pernicious anaemia, and coeliac disease. The syndrome most often commences in the young adult, and of reasons that are not yet clear, women are affected more than three times as often as men. The reason why som patients develop APS, is most likely a complex interaction between inheritance and environment. There is a strong relationship between the HLA class II haplotypes DR3 and DR4 and the different components of the syndrome. The different disease components of APS II constitute a considerable morbidity and mortality risk, and it is of vital importance to diagnose and treat at an early stage of the disease. It is also important that this group of patients receive regular follow-up with clinical evaluation and laboratory tests in order to diagnose new components. There is no curative treatment for APS II, and the diseases are therefore treated separately. The endocrinipathies are treated with replacement of the missing hormones.

Overlevelse etter prehospitale hjertestans i Bergen og Hordaland 2000 - 2002
Magnesen, Geir Johannesen, Egil H (class 99)

Supervisor: Ivar Austlid, universitetslektor Medisinsk ferdighetssenter, Det medisinske fakultet, UiB

Survival was studied. Resuscitations in Hordaland, Norway were identified in the local air ambulance registry. Additional data was collected from hospital journals. A total of 328 resuscitations in Bergen were identified. 490 resuscitations were identified in Hordaland. In the group of cardiac arrest presenting with ventricular fibrillation in Bergen there were 24% survivors discharged from hospital. This is the highest proportion ever seen in a study in Bergen. Survival rate for patients in Hordaland as a whole was 25%. 1-year survival was excellent as well, 54 of a total of 55 patients discharged alive in Hordaland survived one year. Survival rate was best among patients who experienced cardiac arrest outside of their homes compared to patients who were at home. Witnessed arrests had a much better survival rate than unwitnessed arrests. Conclusion: CPR education of the public, especially relatives of elderly and sick, should be emphasized. The effect of early CPR must not be underestimated. Compressions alone may be a good alternative to compression and ventilation when guiding untrained personell over the phone.

”My job is to keep his alive, but what about his brother and sister?” Indian doctors’ experience of ethical dilemmas in neonatal medicine
Miljeteig, Ingrid

Supervisor: Ole Frithjof Norheim, professor Fagområdet medisinsk etikk og vitenskapsteori, Seksjon for allmennmedisin, Institutt for samfunnsmedisinske fag, UiB

Background: Studies from Western countries show that doctors working in neonatal intensive care units (NICU) find withdrawal of treatment as their most difficult ethical dilemma. There is less knowledge of how this is experienced in different economical, cultural, religious and educational contexts. Objectives: To explore and describe Indian Doctors’ experience of ethical dilemmas concerning withdrawing of treatment in extremely sick and/or premature neonates. Method: Design: Qualitative data from interviews analysed according to Giorgi’s phenomenological approach. Subjects: 14 doctors at various levels of neonatal experience, recruited from two government-owned NICUs in India. Main outcome measures: Description reflecting the nature and experiences of ethical dilemmas. Results: All doctors reported situations where question of withdrawal was experienced as the worst part of their job. They felt they are not educcated in how to handle it, and some had never talked about ethics before. They were especially concerned about non-medical aspects not considered in current treatment guidelines. Descriptions of personal experiences concerned the responsibility they feel knowing their decisions influence the family’s economy and reputation, siblings amount of food and education, other cuildren in the unit’s access to equipment and the use of resources in an underprivileged population. Sometimes lack of resources, usually ventilators, drives them to prioritise what baby should get the chance to live. Other dilemmas reported were difficulties co-operating with uneducated and poop parents. Conclusion: Whild Western doctors seem to focus on the individual child’s rights and problems, Indian doctors tend to refer to consequences for other children and for parents and society. There is a need for research and development of quidelines regarding differences in resources, patient groups and how to handle cultural and religious concerns.

Paternal occupational expusure to radiofrequent electromagnetic fields and birth defects
Mjøen, Geir Harald Sætre, Dag Ottar

Supervisors: Lorentz M. Irgens, professor dr.med. og Rolv Terje Lie, professor dr.philos. Seksjon for epidemiologi og medisinsk statistikk, Institutt for samfunnsmedisinske fag, UiB

Background: Radiofrequency radiation(RFR) has been suggested as a causative agent for different types of diseases and reproductive outcomes. In lack of conclusive evidence, there is agreement on the need for further investigations. The objective of the present study was to assess associations between paternal occupational exposure to RFR, and adverse pregnancy outcomes including birth defects in their offspring using population-based data from Norway.

Material and methods: We used data from the Medical Birth Registry of Norway on reproductive outcomes, and data from Norwegian population censuses on paternal occupation linked by use of the national identification number on all citizens. An expert panel from the Norwegian Radiation Protection Agency categorized occupations into three levels of exposure. Logistic regression was used to analyze the relation between paternal exposure and birth defects, and the results were adjusted for year of birth and mothers municipality of residence. Results: An elevated adjusted risk was observed for genital defects in the offspring of fathers most likely to be exposed. There was also a significant increase in the numbers of premature and low birth weight births in this group. On the other hand, a significant decrease in the risk of premature birth in the group that was probably exposed, rendered this finding inconsistent. Conclusion: The positive results in this study are to be interpreted carefully, because of the large impact of confounding factors and misclassification bias, especially in relation to determining the level of exposure in the different occupational groups. The significantly positive results for genital defects, prematurity and low birth weight need to be examined further. The study is reassuring by not being able to identify categories of jobs with assumed high exposure with high risks of birth defects in general. There is a need for more exact criteria for exposure assessment, as this is an important potential source of error.

Birth registration at Kilimanjaro Christian Medical Centre, Moshi, Tanzania
Moen, Jon Magnus Netland, Hallstein

Supervisor: Rolv Terje Lie, professor dr.philos. Seksjon for epidemiologi og medisinsk statistikk, Institutt for samfunnsmedisinske fag, UiB

Background: Birth registration is valuable in social medicine and for research purposes. Centre for International Health (CIH) has therefore, in co-operation with the Medical birth registry in Bergen, aimed at establishing a medical birth registry at Kilimanjaro Christian Medical Centre(KCMC) in Moshi, Tanzania. Method: A questionnaire in English (annex) is used by specially trained midwives at the Department of Gynaecology and Obstetrics at KCMC. The midwives are responsible for interviewing the pregnant women and the data is then plotted in a database by a part time working secretary. There are, per Feb 2003, approximately 7000 births registered in the database. We have used the statistical programme SPSS 11.5 to define a group with poorer sanitary conditions (Selection 1) and make a demographic description of it. Then we used a ttest and a chi-square test on birth-weight, gestational age and perinatal morbidity to compare it with the population in general. Results: Demographic characteristics in the group with poorer sanitary conditions (Selection 1) is: a larger part comes from rural areas (90.2 against 56.9%), the educational level is generally lower (83.4 against 71.3% have primary or no education), a higher percentage are farmers (52.6 against 31.7%), reference to antenatal care (by medical personnel) is higher (38.1 against 27.1%), the share of Masais is higher (1.8 against 0.8 %). By means of a t-test, we find a significant difference between the group with poorer sanitary conditions (Selection 1) and the total population in mean birth-weight (respectively M= 2963g, SD= 596g and M= 3053g, SD= 550g). Chi-square test shows a significant difference with a 9.6% (Selection 1) against 6.2% share of pre-term labours. OR for pre-term labour in the selection is 1,61. The incidence of stillbirths and transferral to the Paediatrics department is respectively 5.5% and 15.6% (Selection 1) and 3.5% and 12.7% in the total population. Conclusion: Mothers with poor domestic sanitary conditions have a number of characteristics concerning demographic factors such as level of education, career and residential pattern. Mean birth weight is significantly lower amongst newborns in this group compared to other births at KCMC. In addition, the frequency of neonatal mortality and morbidity is significantly higher. Inquiries concerning gestational age at time of birth and pre-term labour are inconclusive, due to insufficient statistic material in this aspect.

Antibiotic consumption in Dar es Salaam, Tanzania
Myklebust, Tor Vidar Njærheim, Arne Christian

Supervisor: Nina Langeland, professor dr.med. Institutt for indremedisin, UiB

Background: In high-income countries, antibiotic consumption is thoroughly described. Although there is less information available from low-income countries, there are studies indicating that both prescription and consumption of antibiotics often are erratic in these settings. The aim of the study was to make a description of the various antibiotics sold from private pharmacies in Dar es Salaam, and try to correlate it to the antibiotic resistance reported in the city, and price of the respective antibiotic. Methods: A questionnaire (annex 2) was used to obtain information on the quantity of various forms and strenghts of antibiotics sold at 15 randomly selected private pharmacies in Dar es Salaam. The consumption data collected from the pharmacies, are based on the sales record over the period September to November 2000. It was a retrospective study, and the collections of the questionaire took place in the period December 2000 to January 2001. We have readjusted the consumption to defined daily dose (DDD)12 for each antibiotics. Finally we collected a price list from a representative pharmacy in Dar es Salaam (annex 3). The results were readjusted into price per DDD for each antibiotic. Results: The penicillins ampicillin(tbl/inj), amoxicillin(tbl/inj), amoxicillin-clavulanate(tbl), cloxacillin(tbl) and ampicillin-cloxacillin(ampiclox)(tbl), have a total market cap of 31,9 percent. Another large group, beside the broad spectrum penicillins, are the tetracyclines. They constitute 19,8% of the total sale. Another major group are macrolides (erythromycin tbl/inj and azithromycin tbl), which have a market share of 9,1%. Quinolones (ciprofloxacin and other fluoroquinolones) are also commonly consumed, with a 13,8% share. Some of the specific antibiotic types, which are not included in the groups mentioned above, make up a significant part of the total sale; metronidazole (8,6%), co-trimoxazole (5,2%) and trimethroprim (4,6%). The cheepest drugs are tetracyclines (60 TSH/DDD), metronidazole (75 TSH/DDD) and cotrimoxazole (106 TSH/DDD). Cefuroxim is the most expensive drug (41600 TSH/DDD). The second most expensive antibiotics are ampicillin(inj.) and cefalexin, both 2000 TSH/DDD. Conclusions: The antibiotic consumption pattern seems to be in accordance with price. The antibiotics with the biggest sales in Dar es Salaam, are the cheapest. Microbial diagnosis and resistance patterns, which are necessary to provide ideal treatment to infectious diseases, are probably of minor significance. The consequence is improper use of antibiotics, and development of resistance 6.

Patch-clamping av amakrinceller i rotteretina. Funksjonelle egenskaper ved non-NMDA-type glutamatreseptorer på stavamakrinceller
Mørkve, Svein Harald

Supervisor: Espen Hartveit, professor dr.med. Seksjon for anatomi og cellebiologi, Institutt for biomedisin, UiB

The properties of non-NMDA glutamate receptor channels in AII amacrine cells were studied by patch-clamp recording from rat retinal slices. Using the voltage-clamp technique and applying agonists, antagonists and modulators to intact cells and patches, we have determined which types of ionotropic non-NMDA-type glutamate receptors the AII amacrine cells express. We have also to some extent elucidated which subunits these receptor channels may be composed of. Application of AMPA or kainate to intact cells evoked current with no apparent desensitization (EC50=118 µM for APMA and 169 µM for kainate). Application of AMPA to patches evoked desensitizing responses with EC50 of 217 and 88 µM for the peak- and steadystate-responses, respectively. Kainate-evoked responses of patches displayed no desensitization (EC50=162 µM). Cyclothiazide strongly potentiated AMPA-evoked resonses and the AMPA receptor antagonist GYKI 53655 inhibited both AMPA- and kainate-evoked responses (IC50=0,5-1,7 µM). Pre-equilibration with GYKI 53655 completely blocked the response to kainate and pretreatment with concanavaline A did not unmask any response mediated by kainate receptors. AMPA- and kainate-evoked currents reversed close to 0mV. AMPA-evoked peakand steady-state-response components in patches displayed linear and outwardly rectifying IV-relations with an RI (ratio of the slope conductances at +40mV and -60mV) of 0,96±0,11 and 5,6±1,3, respectively. AMPA-evoked currents displayed a voltage-dependent relaxation after steps to positive or negative membrane potentials, indicating that the outward rectification of the steady-state response is caused by a voltage-dependent kinetic parameter of channel gating. Under bi-ionic conditions ([Ca++]out=30 mM, [Cs+]in=171 mM), the reversal potentials of AMPA- and kainate-evoked currents indicated channels with significant Ca++ permeability (PCa/PCs=1,9-2,1). Thus, our resulta indicate the expression of voltage-sensitive-, high-affinity- AMPA-receptors with significant Ca++ permeability, and no expression of high-affinity kainate receptors.

Long-term outcome after symphysiolysis
Mørkved, Lars Marius

Supervisors: Anders Mølster, professor og Arnbjørn Rodt, overlege Institutt for kirurgiske fag, UiB/Ortopetisk avdeling, Haukeland Universitetssykehus

Introduction: An unstable pelvic ring fracture represents a severe injury and is associated with high morbidity and mortality. Symphysiolysis caused by a high energy trauma is often a part of this picture. The purpose of this study was to describe the impairment and functional outcome of patients with symphysiolysis. In addition I wanted to discover a possible connection between the treatment and the long-term outcome. Material and methods: The material consisted of 14 patients operated at Haukeland University Hospital between 1970 and 2000. They were all less than 60 years of age and had symphysiolysis caused by high energy trauma (except 1 who was injured during delivery). The information about the patients was collected from journals and telephone-interviews. They were classified according to the Tile-scale. In addition other scales collected from comparable studies were used to measure activity, quality of life and clinical results. Results: 12 men and 2 women with a median age of 32 were included. No one had any former pelvic injury. 8 were injured in traffic-accidents. According to the Tile-scale, there were 6 B- and 8 C-injuries. 13 were treated with open reduction and internal fixation, and 1 with Hoffmannfixation until union. 2 patients had complications in due to the surgical operation (one had probably a deep infection and one had lateral cutaneous nerve of thigh affected, when collecting bone from the hip). No one of the patients has any pain or discomfort from the symphysis today, even the 8 patients with remaining osteosynthesis plate. The average walking-ability today is 4,8 (1-6, where 6 is normal walking-ability.), while the average pain today, the whole body included, is 4,4 (0-6, where 6 is no pain). Conclusions: Most patients with symphysiolysis are multi-traumatized. Open reduction and internal fixation gives a satisfying result. There is probably no need to remove implants used for osteosynthesis if not indicated by pain and discomfort. It seems important to stabilize the symphysis shortly after the rupture in order to get satisfying results. Even though a pelvic fracture is a major trauma, it does not necessarily give the patient sequels in a long period of time. The majority will eventually get a satisfying level of function and will approve of both the treatment and the results.

Mistelteinlektiner i cancerterapi
Nawaz, Beenish Nielsen, Ingunn Karina

Supervisor: Ian F. Pryme, professor Seksjon for biokjemi og molekylærbiologi, Institutt for biomedisin, UiB

Cancer is a common cause of morbidity and mortality in the world. The incidence is increasing, especially in the developed countries. In spite of the treatment available today, it is still not possible to cure all cancer patients. Moreover, there are many side effects related to some of these treatments. Thus, there is need for new approaches. Mistletoe lectins (ML) have been shown to reduce tumour growth in some animal studies. Its mechanisms of actions are the following:  Immunomodulating effect by binding to Peyer’s patches and inducing cytokine production  Anti-angiogeneic action  Apoptose-inducing action  Hyperplasi of the short bowel ML has no serious side-effects compared with some traditional forms of cancer treatment like surgery, chemotherapy and radiation. It is known that chemotherapy and radiation can damage the small bowel of the gut. Thus, chemoterapy and radiation can be combined with oral intake of ML, which stimulates growth of the small bowel and can reduce the damaging effects of these treatment forms. We have interviewed some cancer patients who voluntarily had tried ML (PALM-treatment) to prove this. Only a small proportion of these patients reported nausea and vomiting as the only side effect. This could easily be overcome by drinking cold water and using a smaller dosage of ML. However, ML has long been regarded as being toxic for humans, but these new findings indicate that is not the case. There is still need for more studies to find the mechanism of action of ML in detail.

Ikke le – ikke gråte Postpartumskikker hos vietnamesiske kvinner I Norge
Nguyen, Hoang Oanh

Supervisor: Guri Rørtveit, dr.med. Seksjon for allmennmedisin, Institutt for samfunnsmedisinske fag, UiB

Background The Vietnamese woman presents in the postpartumperiod culturally specific customs that may seem incomprehensible for Norwegian health care prividers. Questions have been raised whether these customs could be in conflict with the practice of todays evidencebased medicine in Norway. Objective To describe the special customs of Vietnamese women in Norway during the postpartum period. Are these health hazards? Is it possible based on the available literature to optimalize the health care for this group? Material/methods Group-discussions and literature review Results Group-conversations and literature had quite coherent findings concerning the restrictions in nutrition, physical activity and bathing. In addition, group discussions revealed many potentially healthhazardious customs that were not mentioned in the literature. When a woman gives birth, she loses heat (yang) as explained in the confucion theory about yin/yang, and she tries to restore the ideal balance. The customs were practised by reasons to restore warmth, optimalize breastmilkproduction and prevent sickness later in life. The customs described differ greatly from that actually practised in Norway. Conclusion Based upon the group-conversations, there existed more healthhazardious customs that were not described in the literature available. Studies are needed on a more representative selection of Vietnamese women, and the morbidity of this group should be looked closer upon before the consideration of eventual interventions.

Nyvaskede leger – en studie av den medisinske såpeopera
Nielsen, Rune

Supervisor: Anders Bærheim, professor Seksjon for allmennmedisin, Institutt for samfunnsmedisinske fag, UiB

Background Health providers are constantly exposed for patients’ cultural expressions during their work. Television is a central agent forming out cultural surroundings. The aim of this study has been to elucidate how a specific genre – the medical soap opera – represent health related issues, and shape our expectations to the health system. Material and methods The first part of the study is a genre-analysis based on media science, literary theory, narrative based medicine and medical search engines. The second part of the study applies these theoretical elements on the series Emergency Room (ER). Using text analysis I’ve reviewed in detail one episode, focusing on the genre-analysis in a media-text. Results The medical soap opera is a genre characterised by qualities as a narration, its focus on the physician outside his role as physician and by a glamour medical reality. These theoretical considerations support how soap operas focus on the physician as a type in the clinical consultation. The narrative qualities of the soap opera are found to satisfy people’s desire for more causality in daily life. Wish fulfilment was a central function the soap opera. Parallels may be drawn to how narrative based medicine focus on the story’s central role in the consultation. Conclusions In sum, medical soap operas fulfil people’s desire for a more comprehensive health system, showing the health actors as human beings rather than just a white coat.

Søvn hos medisinerstudenter
Omland, Marianne Nygaard, Vibeke Kvanvik

Supervisor: Bjørn Bjorvatn, professor dr.med. Seksjon for allmennmedisin, Institutt for samfunnsmedisinske fag, UiB

Background About 1/3 of the population report sleeping problemns from time to time. There have been done many epidemiologic studies on sleeping problems, but most of them are from foreign countries and investigate sleeping patterns in retrospect. Only a few have been done prospectively by using sleeping diaries and actigraphy. We have been studying sleeping patterns and sleeping problems prospectively amongst medical students, i.e. young people in Norway. Method 56 medical students at the University of Bergen participated in our study. The criteria of inclusion were medical students between the age of 20 and 30. Their sleeping patterns were registered prospectively with the help of sleeping diary and actigraphy over a period of two weeks, and retrospectively with questionnaire. Results and interpretation Our results show that there are not many students with sleeping problems that can be measured objectively. No one suffers from narcolepsy, but three of the students reported symptoms of slepp apnoea syndrome. Sleeping efficiency is a good parameter reflecting sleeping problems. According to the sleeping diaries, none of the students met the requrements for pathological sleeping efficiency (<85%). Not many students reported early morning awakenings or repeated awakenings during sleep. Pathological sleeping latency (>30 min) were registered in 12% of the student’s sleeping diaries. Only two students regard themselves as having a sleeping problem. One of them has been using sleeping pills. Except from the one student, neither medicine nor alcohol has been used as aid to help falling asleep. Compared to the students self-reported need for sleep, 37% of them lack one hour or more during the night, and many feel tired at daytime. 41% of all the students feel tired during most of the day. According to the Epworth Sleeping Scale, 17% of the students suffer from pathological sleepiness during daytime. This may reflect that many students do not get enough sleep. Our results show discrepancy between some of the self reported and objectively measured values. More than half of the students experience increased tiredness in a certain time of day, 62% reports this to be between 13:00 and 16:00. At this time medical students usually have lectures. One of the interesting findings, is that students feel more tired during the day if they spent the morning in bed after awakening.

Cancer mammae 2000 - et årsmateriale
Nytveit, Monica Næss, Hege

Supervisor: Jan Erik Varhaug, professor dr.med. Endokrinkirurgisk seksjon, Institutt for kirurgiske fag, UiB

Background Mammography is being used as a screening method,intended to diagnose breast cancer at an early stage,so as to reduce the mortality of the disease. Systematically organised screening of asymptomatic women was implemented in Norway in the autumn of 2003,called "The Mammography Program"-where every Norwegian woman between 50 and 69 years of age every other year is being offered a mammography of her breasts. We have analyzed a patient-material from the year 2000, and compared it to an equivalent material,with data from 1990 to see how the picture has changed,from 5 years before the implementation of the screening-programme,till 5 years after. (Hordaland started screening in 1996, as a try-out project.) Methods We have analyzed the surgical medical files of the patients who were admitted to the Endocrine Surgical Department at Haukeland University Hospital in the period from 01.01.00 until 31.12.00, with newly diagnosed breast cancer. We found that a total of 192 patients fulfilled our inclusion-criteria. We have analyzed how the cancer was disclosed, which diagnostic methods were used,treatment,pathology,complications and follow-up. We have also compared our findings to the ones from the 1990-material. For practical purposes we have done a continuous comparison throughout the text. Results In the 2000-material,only 56% of the newly discovered breast cancers caused symptoms,and 9,9% of the tumors were in situ cancer. In comparison to the 1990-material it was found that as many as 80% of the tumors caused symptoms or clinical findings at the time of diagnosis,and that in situ cancer made up 4,9% of the tumors. The results show that breast cancer was diagnosed earlier in 2000, which probably can be attributed to the mass screening introduced in 1996.

Glutamate release from neuronal hippocampal cultures characterized by an immunocytochemical approach
Oltedal, Leif

Supervisor: Svend Davanger, førsteamanuensis dr.med. Seksjon for anatomi og cellebiologi, Institutt for biomedisin, UiB

I have investigated the release and depletion of glutamate from presynaptic terminals and cytoplasmic compartments by an immunocytochemical approach. My observations indicate that upon continuous, strong depolarization, vesicular uptake of glutamate from the cytosolic compartment and subsequent vesicular exocytosis is sufficient to essentially deplete neurons of their stores of the amino acid. Initially, the results of the present approach correspond to similar findings with other methods: Prolonged depolarization with 90mM K+ caused a significant reduction in glutamate labeling in boutons and cytoplasmic areas (i.e. dendrites and cell bodies). The number of boutons where release exceeded replenishment increased continuously with time of stimulation. This depletion was Ca2+ dependent, indicating mainly vesicular release mechanisms. Depletion also from dendritic regions occurred through calcium dependent mechanisms. Depolarization with 35mM K+ caused a sustainable release of glutamate. Some glutamate positive terminals were not endo/exocytotically active (i.e. silent), as indicated by lack of FM1-43 uptake. My methodological approach fills a gap between biochemical and electrophysiological methods, allowing me to demonstrate the depletion of glutamate from specific cellular areas of intact neurons.

I: Søvn, døgnrytmer og skiftarbeid II: Søvnproblem hos skiftarbeidarar i oljeindustrien i nordsjøen.
Omenås, Ivar Nagelgaard

Supervisor: Bjørn Bjorvatn, professor dr.med. Seksjon for allmennmedisin, Institutt for samfunnsmedisinske fag, UiB

Oil is the most important export article in Norway, in 2002 sale of oil and natural gas made up more than half of norwegian export. The work in the offshore oil industry is not without risk, and error of judgement and accidents can have severe consequences for the workers, the environment and the economy. It is therefore important that working conditions are good, letting workers do their work in a safe way at all times. It is also important to know about the consequences of night and shift work in other work areas, eg in health care, and to know about what can be done to reduce negative ones, both for the individual and for the society. Offshore workers are well suited for investigation of circadian rythms, since they are hardly exposed to light when they are offshore, and neither are they exposed to a normal day rythm. This paper discusses sleep and circadian rythms in general, and examines to which degree a group of shift workers at the Statfjord C oilrig have sleep and sleep rythm problems. It is therefore a part of the work of mapping the signficance of shift- and night work for health and safety. The paper has two parts. Part one is a study of litterature dealing with sleep, what controls sleep, the need for sleep, circadian rythms and shift work in general. It discusses the possible harms of shift- and night work. Part two examines a survey about sleep and circadian rythms in shift workers on the oil rig Statfjord C. 69 workers participated by completing a questionaire once. No objective measures where made. The results from the survey show that the participants change to a night rythm quite fast, but need more time to change back. This is in concordance with findings from earlier studies. Many, about 90 percent, report a sleep problem. About half feel that their sleep problem is affecting their performance at work. The participants sleep about as much when they work night shifts as they usually do. Their use of sleeping medicine is moderate. Almost none have tried bright light treatment, but relatively many have used melatonin. There still is some interest in bright light treatment, one out of four participants believe this can have a positive effect on the quality of sleep.

Postviralt utmattelsessyndrom – en studie av klinisk bilde og utløsende faktorer hos 168 pasienter
Opedal, Ingvild Karin Tønder, Siv

Supervisors: Harald Nyland, professor dr.med./overlege, Seksjon for nevrologi, Institutt for klinisk medisin, UiB/Nevrologisk avdeling, Haukeland US Helge Myrmel, seksjonsoverlege, Mikrobiologisk avdeling, Haukeland Universitetssykehus Jan Aarseth, statistiker, Nasjonalt MS-register

Chronic Fatigue Syndrome, Myalgic Encephalomyelitis (CFS/ME) is a clinical syndrome defined as having new and incessant exhaustion, energiloss, physical and mental fatigue that substantially reduces activity level. We are presenting data obtained from clinical examination of patients referred to Department of Neurology, Haukeland University Hospital, suspected of having this disease. We have compared our findings with published reports from England, Australia and Canada. A typical patient with the condition is a woman at the age of 34 who had an acute illness with fewer days to week prior to outbreak of symptoms. The cardinal symptoms are post-exertional malaise and/or fatigue, sleep dysfunctions, and pain, two ore more neurological/cognitive manifestations and one or more symptoms from the autonomic, neuroendocrine and immune system. Physical and mental activity deteriorates her loss of energy. Even the slightest effort may lead to extreme exhaustion that can last weeks or months. It is not easy to find the biologic cursor of this condition. In this report we have described the trigger factors and a clinical feature through questionnaires in addition to serologic studies for virus/bacteria.

Late Onset Myasthenia Gravis - Gjennomgang av et journalmateriale for å sammenligne funn ved tidlig og sen debut av sykdommen
Otterlei, Renate

Supervisor: Johan A. Aarli, professor dr.med./avd.overlege Seksjon for nevrologi, Institutt for klinisk medisin, UiB/Nevrologisk avdeling, Haukeland Universitetssykehus

Myasthenia gravis has a bimodal distribution of age at onset for both sexes. Based on this evidence MG is now considered to consist of two different subtypes; early onset myasthenia gravis (EOMG) and late onset myasthenia gravis (LOMG). It has been established that the prevalence of late onset MG has increased. At the same time there has been a change in the age structure of the population of western societies. The percentage of individuals more than 50 years of age has increased considerably during the last 75 years, leading to a relative increase in the frequency of late onset MG (Aarli, 1997 and 1999). Is the increased number of new cases in the LOMG group merely a reflection of this demographical change, or are we observing a true increase in prevalence for this form of the disease? The objective of this study was to examine data from the Department of Neurology, Haukeland University Hospital. The material includes all admissions from 1950 until today. Three aspects have been emphasized: investigation of age distribution at onset, comparison of year at onset for EOMG and LOMG, and calculation of prevalence of MG and LOMG in Hordaland. The results were compared with the findings in previous studies. Articles and other types of literature have been surveyed. This paper starts with a description of myasthenia gravis, then the late onset type is discussed in more detail. Subsequently the results from the study is being visualized in the form of graphic representations and as results of calculations. The data indicate that the increase in number of new cases of LOMG between 1950 and 1995 is not just a result of the change of age distribution in Hordaland - we are in fact observing an increase in prevalence for LOMG during this period of time. There is a decrease in the number of persons with onset of the disease after 1995, and as the percentage of individuals in the population more than 50 years of age has continued to rise, we here observe a decrease in prevalence. This supports the statement that the increase in prevalence for LOMG can not be explained solely by the change of age distribution in the population.

Cannabinoids in palliative medicine. A literature review.
Pongo, Mariann

Supervisor: Dagny Faksvåg Haugen, overlege dr.med. Kompetansesenter i lindrende behandling Helseregion Vest

Cannabis is found naturally in the plant Cannabis Sativa. There is evidence that cannabis was used for medical purposes as far back as 5000 years ago. Cannabinoids are the active compounds found in cannabis. The main component is Δ9-THC (tetrahydrocannabinol). Cannabinoids mediate their effects through two types of receptors, one central and one peripheral. Endogenous cannabinoids are compounds that bind to these receptors. Anandamine is the best studied endogenous cannabinoid so far. To this day only two cannabinoids are approved for clinical use. Dronabinol (Marinol), a synthetic form of Δ9-THC dissolved in sesame seed oil, is available in the USA, Canada, South Africa, Australia, New Zealand, and some countries in Europe such as Denmark, while nabilone (Cesamet), another synthetic cannabinoid, is available in Canada, Great Britain and Australia. The indications for both drugs are post-chemotherapeutic nausea and vomiting, and anorexia and cachexia associated with AIDS. Other indications such as muscle spasms, pain, convulsions, glaucoma, and migraine have been suggested. Four papers make up the basis of this study; two of them meta-analyses concerning cannabinoids as antiemetics and analgesics, one paper concerning cannabinoids as an appetite stimulant, and the last paper is a comprehensive review of the literature concerning the medical efficacy of cannabinoids and marijuana in general. Studies have shown that cannabinoids are effective in patients with AIDS-associated anorexia and cachexia, with evidence for a weight-stabilizing effect. Patients undergoing chemotherapy report better antiemetic effect of cannabinoids than of placebo, and cannabinoids also turned out to be better than conventional antiemetics for patients receiving moderately emetic chemotherapy regimens. There is also some evidence that cannabinoids have an effect on muscle spasms related to MS, and on neuropathic pain. Cannabinoids showed a greater analgesic effect than placebo, an effect compared to 60 mg of Codeine. Cannabinoids were less effective than NSAIDs for cancer pain and chronic non-malignant pain. The use of cannabinoids for medical purposes is heavily hampered by its high frequency of unwanted side effects. More studies with a higher number of patients are necessary to evaluate the place for cannabinoids in clinical medicine. Cannabinoids should be compared to newer generation drugs and studied in combination with other drugs that might increase their effects and reduce the frequency and severity of side effects. The differentiation of other cannabinoids might be a way to go, or even to consider other ways of administration. Receptors for cannabinoids have been detected in the spinal cord, suggesting that intrathecal administration of cannabinoid agonists might give sufficient analgesic effect without the unfortunate psycotrophic effects. The endogenous cannabinoids might represent the most interesting field for further development in the future. The identification of specific binding sites for cannabinoids provides an opportunity to develop more specific synthetic compounds with the same effects as cannabinoids, but without their unwanted side effects.

Degree of shunting through the ductus venosus in fetuses suffering from growth-restriction
Press, Kenneth

Supervisor: Torvid Kiserud, professor Seksjon for obstetrikk og gynekologi, Institutt for klinisk medisin, UiB

Objective In animal experiments hypoxemia induces an increased shunting through the fetal ductus venosus (DV). We assume that the same mechanism is operated in human fetuses suffering from growth-restriction. Methods Forty women with singleton pregnancies complicated with growth-restriction (birthweight ≤5 percentile) were examined at gestational weeks 24-39. The diameter and blood flow velocity were determined at the intra-abdominal portion of the umbilical vein and at the isthmus of the ductus venosus. Pulsatility Index (PI) was noted. The measurements were compared to reference population using standard deviation score. Results A total of 34 fetuses of 40 proved to have a birthweight ≤5 percentile and had a complete set of measurements for the statistics. Compared to normally grown fetuses, the growthrestricted fetuses shunted a higher proportion of umbilical blood through the DV (p=0.048). The effect was mainly found in the group with ARED flow in the umbilical artery (p<0.0001), predominantly found in fetuses ≤32 weeks of gestation. When using increasing umbilical artery pulsation as a measure of increased placental compromise, there was a trend towards higher degree of shunting with increasing degree of compromise. Conclusions Ductus venosus shunting is more pronounced in the growth-restricted than in normally grown fetuses, particularly in fetuses with placental hemodynamic compromise before 32 weeks of gestation. This supports the assumption that similar mechanisms of compensatory redistribution found animal experiments during hypoxemia are activated in human fetuses with sustained placental compromise.

Effekt av fiskefôr tilsatt vegetabilsk olje sammenliknet med tradisjonelle polyumettete fettsyrer, effekt av denne oppdrettslaksen på insulinsensitivitet og plasmalipider hos premenopausale kvinner
Raspotnig, Margrethe

Supervisors: Rolf K. Berge, professor Seksjon for medisinsk biokjemi, Institutt for indremedisin, UiB Et samarbeid mellom UiB, Gastronomisk institutt i Stavanger, Akvaforsk i Ås og EWOS i Bergen

Background The positive effects of omega-3 fatty acids on health and disease are well known. This study was conducted to investigate the effect of a high daily intake of salmon on insulin sensitivity and plasma lipids in premenopausal women with high BMI and low insulin sensitivity. Two different types of salmon were made for this study, the feed containing 30% of either soya oil or fish oil. A second aim of the study was to see whether the soya oil fed salmon had the same beneficial health effects as the traditional one. The background of replacing marine oil with vegetable oil is the need for alternatives to marine ingredients in aquafeeds. Methods 26 women were selected for this double-blind crossover study. The participants were chosen at random for a diet containing fish oil fed salmon or soya oil fed salmon. The daily intake was 150 g, 5 days a week, for 8 weeks. Results There was a significant reduction in systolic and diastolic blood pressure. There was also seen a significant reduction in LDL/ HDLratio, triglycerides and insulin-C-peptide. The reduction in insulin-C-peptide could be a result of increased insulin sensitivity. No significant difference between the two diets was observed. Conclusions/ Interpretation This is one of few studies where fish meals have been used as the source of omega-3 fatty acids. The reduction in insulin-C-peptide can therefore be a result of beneficial effects of other components in salmon, e.g fish protein, and this is now a question of great scientific interest. A high daily intake of salmon can not be recommended as antihypertensive treatment, but could be important in preventing the condition. There was not observed any harmful effects of soya oil fed salmon, and there is no evidence that this salmon has less beneficial health effects than the fish oil fed salmon.

The modern diagnosis of Tuberculosis with emphasis on detection of urine lipoarabinomannan
Runde, Martin

Supervisor: Bjarne Bjorvatn, professor dr.med. Senter for internasjonal helse, UiB

Tuberculosis (TB) has been known for more than 100 years, but still about 2 million people die from tuberculosis each year. Despite decades of effective antibiotic treatment, the situation is still not under control. Since the mid-eighties, there has been an increase in the incidence of TB. The main reasons for this is the HIV/AIDS epidemy, lack of compliance, and the development of multiresistant strains of M. tuberculosis (Mtb). In spite of the great spread of TB, we are still short of good laboratory methods that suit the clinical work. Most of TB cases occur in countries that lack economical recources, laboratory facilities, and often qualified personell. Thus, there is a great need for a cheap, simple and high quality method for detection of TB. Lipoarabinomannan (LAM) is a component of the Mtb cell wall. It is not metabolised and is excreted through urine. A dip-stick double sandwich ELISA method is developed for urin detection of LAM. This urine test is highly sensitive. An Ethiopian study included 200 TB patients and 800 non-TB patients. Of the 200 defined TB patients was 139 (69,5%) AFB positive and 61 AFB negative. 81,3% of the AFB positive and 57,4% of the AFB negative was LAM-positive. The sensitivity and specificity was respectively 74,0% and 86,9%. In the most difficult group, namely the clinically suspected AFB negative TB patients, almost 60% was LAM positive. With no acceptable gold standard method available, it is difficult to draw conclusions. It seems to be necessary with further investigations comparing LAM in urine and for example PCR and also determine sensitivity and spesifisity in relation to HIV co-infection.

Dyspeptiske symptom indusert ved drikketest hjå pasientar under strålebehandling for cancer prostata
Saltnes, Barbro

Supervisor: Trygve Hausken, professor dr.med. Seksjon for gastroenterologi, Institutt for indremedisin UiB

Symptoms of acute gastrointestinal toxicity occur in the majority of patients during radiation treatment for malignant pelvic disease. The symptoms vary in intensity and character, and may be sufficiently severe to forestall optimal completion of the planned treatment in some patients. The development of inflammation depends on total irradiation dose, fraction size, fraction interval, treatment time, and treatment volume. The severity of acute radiation symptoms is the main predictor for the development of chronic rectal injury. Symptoms tend to increase in frequency during radiotherapy and decrease after cessation of radiation. The pathogenesis of acute radiation symptoms is only partly elucidated. Apart from the acute mucosal inflammation, dysmotility seems to play an important role. Generally, symptoms increase in frequency and intensity early during radioterapy: abdominal pain, loose stools, tenesmus, blood in the stools, bloating, nausea, and fecal incontinence. Modern radiotherapy is highly targeted to avoid side-effects from normal tissues and other organs. With the introduction of three-dimensional conformal radiotherapy more normal tissues are spared. In our study we wanted to see if differences in motility can explain these problems. Why do radiation against the pelvic region start symptoms in the upper gastrointestinal tract? We looked at 13 patients with localised cancer prostatae, who got radiation treatment during 7 weeks at Haukeland hospital, Bergen. The examinations were done before they started the radiation treatment, and then 6 weeks afterwards. We studied UL-recording of the stomach; The size of antrum shows good correlation to the amount of liquid (Toro-soup) in the entricle, and a big antrum may show a delayed emptying of the ventricle. When measuring the size of antrum after definite time after a standardised meal, you can see it as an expression of ventricle-emptying. We also studied the patients own evaluations of symptoms (pain, fulling and nausea) before and after a meal of soup. We did not find any significant difference in drinking capacity, gastric volume, gastric emptying or symptoms in these patients.

Erytropoietisk protoporfyri i Norge
Sandberg, Synne Margrethe Steinsrud, Ingeborg Sundsdal (class 99)

Supervisor: Sverre Sandberg, professor dr.med./avd.overlege NOKLUS, Institutt for samfunnsmedisinske fag, UiB/Nasjonals kompetansesenter for porfyrisykdommer, Lab for kinisk biokjemi, Haukeland Universitetssykehus

The porphyrias are diseases caused by a defect in the biosynthesis of heme. Erythropoietic protoporphyria, EPP, which is one of many porphyrias, is inherited and caused by a partial deficiency of ferrochelatase. Ferrochelatase catalyses the chelation of iron into protoporphyrin to form heme. Norwegian EPP-patients have not been studied earlier. A questionnaire was sent from the Norwegian Porphyria register to all the patients registered by NAPOS, the Norwegian Porphyria centre, during march 2003. The study deals with patient reported symptoms and the effect of the disease on their daily life. An interview with one of the patients was also done. There was a great variation in how long it took from the start of the symptoms to the establishment of the diagnosis EPP. It varied between 2 and 66 years, with a mean time of 17.5 years. There was a tendency that the patients with high values of erythrocyte protopophyrin, e-pp, got the symptoms earlier than those with lower values, but it was not found that these patients got the diagnosis earlier. 75 % of the patients reported symptoms before they were two years old. The symptoms occurred on the parts of the body exposed to sun-light, most often hands and face. The symptoms reported are burning sensations in the skin, swollen skin, sore skin with crusts and blisters after sun exposure. Some patients also report that light from special bulbs, wind, draught and cold can provoke the symptoms. The only way they can be free of symptoms is to avoid exposure. To release the symptoms the patients use cold baths, wet towels and ice. Some have been treated with betacaroten but not all of them reported that the treatment was successful. Most patients use sunprotective lotions, like tanningcremes and suncremes with or without physical blockers. Half of the patients see a doctor at regular intervals because of the disease. All the patients reported that the illness with the limitations it brings affect their quality of life. The degree of reduction in subjective reported quality of life was not related to the amount of e-pp, nor to sex or age.

Alder som prognostisk faktor ved eggstokkreft
Sandvei, Anders

Supervisor: Roar Sandvei, professor dr.med. Seksjon for obstetrikk og gynekologi, Institutt for klinisk medisin, UiB

In a retrospective analysis prognostic factors with special reference to age and FIGO stage were studied in 435 patients with ovarian cancer treated from 1985 through 1994. Eighteen patients were excluded from the study because of incomplete dataset. Mean age of the patients was 59,6 years (12-92). Ninety-five per cent had epithelial ovarian cancer, and 76% of the patients were postmenopausal. Overall five years survival was 42%. We used life table method and calculated with Cox regression analysis hazard ratio (95%-CI) for survival adjusted for parity, tumor stage, histologic type and grade. The analysis was performed stage for stage, and for different age groups. The five year survival was 77% for patients below 40 years of age, 55% in the age group 40-49 years, 37% in the group 50-59 years, 42% in the group 60-69 years, and only 27% for patients older than 70 years of age. We conclude that age is an independent prognostic factor in ovarian cancer.

Humoral- og mukosa-immunrespons etter influensavaksinering hos type-1 diabetikere
Seime, Anne

Supervisor: Lars R. Haaheim, professor Seksjon for mikrobiologi og immunologi, Gades institutt, UiB

Diabetes patients suffer frequent complications and some excess mortality after influenza virus infection. Despite widespread agreement that diabetic patients should be routinely vaccinated against influenza, some reports claim that diabetics have a poor immune response to influenza vaccine. We have performed a pilot study to examine the humoral immune response of juvenile diabetics and matched healthy controls vaccinated with inactivated trivalent influenza vaccine. By enzyme-linked immunospot assay, ELISPOT, we found that both groups had comparable magnitude and kinetics of influenza-specific antibody secreting cell response. The influenzaspecific antibody response in both serum and oral fluid were similar for both groups, and also showing a kinetic profile in accordance with our earlier data for healthy adults. Out study did not detect a difference in the humoral immune response between juvenile diabetics and healthy controls.

Nanoteknologi og medisin
Skudem, Martine

Supervisor: Bjørn Stokke, Institutt for fysikk, NTNU

Nanotechnology is a science working on the level of atoms and molecules. Research on the use of nanotechnology in medicine has increased significantly over the last years, and some medical products based on nanotechnology are in production. In Norway little is known about nanotechnology and most medical doctors don’t know how nanotechnology can come to affect their everyday clinical practice. This article therefore address what nanotechnology is about, and describes four important subjects in clinical use. The subjects I have chosen to focus on are smart-drugs, prosthetic materials and tissue engineering, molecular imaging and contrast agents and biosensors. Within these subjects I’ll present different approaches and products that already are being manufactured. At the end I’ll look in to some ethical aspects concerning the technology. The purpose of the article is to give medical doctors an idea of what nanotechnology is about, with emphasis on clinical use in the four chosen subjects.

Sosial fobi – hvordan fange opp, diagnostisere og behandle i allmennpraksis. How to diagnose and treat social phobia in primary care medicine?
Solheim, Sara Cecilie Wilhelmsen Lock, Kristine L.

Supervisor: Fred Holsten, professor dr.med. Seksjon for psykiatri, Institutt for klinisk medisin, UiB

Social phobia or Social anxiety disorder (SAD), is a widely under diagnosed condition in spite of the fact that it is the third most frequent psychiatric disorder after depression and alcohol abuse. SAD has been known ever since ancient times, but it was not until 1980, when it was included in the DSM system, that it was considered to be a diagnose and taken seriously. Studies have shown that lifetime prevalence is 10-15%. But how does primary care physicians diagnose and treat this condition? As we have illustrated in this presentation, there are a few simple key questions that can be used to identify the symptoms which include fear and avoidance of the following situations: public speaking, eating and drinking in public, talking to strangers and asking someone for the way or out on a date. If the patient answers affirmative to several of these questions, it should be performed a Liebowitz test. A total score of 40 or more could mean that the patient is suffering from social phobia. But whether the patient is a candidate for treatment or not, depends on how severe the symptoms are, how much fear and avoidance effects his or her daily function and if he or she is motivated for treatment. There is no obvious “treatment of choice” of social phobia although studies have shown good results using psychopharmacologic treatment, essentially SSRI. Therefore SSRI is practically considered to be first choice. However, studies show that the combination between psychotherapy and psychopharmacologic treatment provide better results than either treatment alone.

Detection of the secretory pathway proteins sec 6 and sec 8 in rat organ tissue
Strand, Kirsten

Supervisor: Svend Davanger, dr.med. Seksjon for anatomi og cellebiologi, Institutt for biomedisin, UiB

A whole array of cellular functions - including membrane growth, protein sorting, the development of cell polarity and neuronal communication - all depend on the correct delivery of secretory vesicles to their target. In the past years, we have gained knowledge in the field of how this process is regulated and directed. However, there are still some missing links. A set of proteins called the exocyst complex might give us the answer we are looking for. It seems as though these proteins might assemble as they direct the vesicles towards their site of docking and fusion. Wondering about the roles of the different subunits, we performed immunocytochemical labelling of two of the proteins in the complex, sec6 and sec8. The results lead us to believe that the proteins do have their separate functions and localisation. Whereas sec6 seems to be membrane-bound, either to the vesicles themselves or to the site of docking, sec8 might perform its role in the cytosol, possibly being recruited towards the other subunits once docking and fusion is about to occur.

Volumberegninger med 3-Dimensjonal ultralyd. Nøyaktighet ved målinger av små volumer. In vivo and in vitro volume estimation of rat kidneys and small phantoms using three-dimensional ultrasonography and a position sensor.
Strømmen, Kenneth

Supervisor: Knut Matre, professor dr. philos Institutt for indremedisin, UiB

The objective of this study was to evaluate the accuracy of small volume measurements, both in vivo and in vitro using phantoms and rat kidneys, with a three-dimensional (3D) ultrasound system. Balloons were injected with a known volume (called true volume) of temperated (37.5 °C) saline and then lowered into a reservoir with the same temperated saline for ultrasound scanning. The 3D data were transferred to a computer and dedicated software was used to estimate the volume. Kidneys from different rats were scanned in vivo, the kidneys were then surgically removed and scanned in vitro in a reservoir of temperated saline. Two independent investigators manually traced the outer contours of the balloons and kidneys. The volume of each kidney was also measured using the Archimedes principle (true volumes). The 3D ultrasound system demonstrated good agreement between 3D ultrasound volume estimates and the true volumes. In the in vitro balloon experiment we concluded that 95 % of all points lie between 0 % and 19 % overestimation. The interobserver variation was very low, 0.01 ± 0.02 ml. The results from the kidneys in vivo showed that estimated volumes had a tendency to underestimate. The comparison of true and estimated volumes was good, but better for the in vitro parts. In the in vivo part 95 % of all the differences between estimated and true volumes lies between - 0.964 ml and 0.388 ml. The interobserver variation was 0.16 ± 0.15 ml. In the in vitro kidney part, 95 % of all the differences between estimated and true volumes lies between - 0.215 ml and 0.293 ml. The interobserver variation was 0.01 ± 0.19 ml. The conclusion is that volume estimation of small organs or phantoms, using this 3D ultrasound method, showed a very good agreement with true volumes. Key words: 3D ultrasound; Volume estimation; Small volumes; Balloons; Rat kidneys; Position and orientation measurement system.

An insight in the daily lives of three women with disabled children in Botswana. A qualitative study.
Strøno, Kari Todnem, Silje Longva

Supervisor: Anne Karen Bjelland, professor dr.polit. Institutt for sosialantropologi, UiB

Background As medical students we had often in our studies experienced focus on evaluating reasons for why people get ill. How some manage to stay healthy, on the other hand, considering qualities like potentials and strength of the affected, had been largely ignored. We found that empirical studies from behavioural medicine, however, confirmed the fact that prevalence and progress of various diseases depend on the resources of the individual. Finding this interesting, we decided to do a project concerning the life situation of three women with disabled children in Botswana. The primary objective was to study and analyse the factors involved in these women’s coping with their daily life. Methods Qualitative oriented research methods have been used to illuminate our study, which includes research and field work. The fieldwork took place in Botswana in the period October 00 – March 01. Findings In literature, from observations and during interviews with the targeted women, we recognized several factors incorporated in coping. We chose to divide these factors into two groups; external and internal factors. External factors include beliefs, support from family and local community, knowledge, earlier experiences, meeting with similarly disposed and the degree of disability. Internal factors include self-confidence and independence, social capacity and interests, intelligence and creativity, internal control, activity and energy and physical health. Interpretation Our project is not a systematic research on a representative selection of women with disabled children. We do therefore not claim that our results have transferable validity. Our findings concerning the mothers’ degree of coping, however, were of a slightly less positive character than previous research had concluded. We therefore suggest that a more comprehensive and up to date research in this field should be considered.

Fetalt alkoholsyndrom
Sundberg, Annica

Supervisor: Kjell Haug, professor dr.med. Seksjon for sosialmedisin, Institutt for samfunnsmedisinske fag, UiB

The objective of this study was to evaluate the literature of consequences of prenatal alcohol exposure, incidence of maternal alcohol abuse, differences in the amount and pattern of alcohol ingestion and attitudes toward alcohol consumption among pregnant women. I have done Medline searchas well as search through the medical journals of the Nordic countries. Fetal alcohol syndrome (FAS) is a seldom but serious damage on fetus due to excessive alcohol abuse during pregnancy. FAS is the leading cause of mild mental retardation in Western world. The prevalence of FAS varies in different populations, because of differences in patterns of alcohol consumption, socioeconomic status and poor nutrition. The cognitive defects are the most serious symptoms, but also morphological anomalies and intrauterine growth retardation are diagnostic criteries. Brain is most sensitive to alcohol, there is evidence of harmful effects of moderate alcohol consumption, even from one drink per week. Alcohol consumption is strongly correlated to smoking, maternal age, lower socio-economic status and a partner who use alcohol. Most women reduse their alcohol consumption in pregnancy. In Norway 30% drink regularly, mostly small amounts <1 drink. Just 2% rapport regular binge drinking. Asking women about their drinking habits should still be a part of prenatal care and no alcohol during pregnancy remains the best medical advice.

Treatment of hypochondriasis- a review of the currently available litterature on this topic.
Sørland, Ragnhild Øvstebø

Supervisor: Tone Tangen Haug, professor Seksjon for psykiatri, Institutt for klinisk medisin, UiB

Background: The central feature of hypochondriasis is an enduring tendency to misinterpret innocuous physical symptoms and signs as evidence of serious illness. This occurs without adequate organic pathology to account for the degree of psychological response, and despite medical reassurance. The condition was long regarded as refractory to treatment. Today, different treatment strategies have proved otherwise. Cognitive-behavioural treatment has shown promising results when applied to hypochondriasis. The aim of this study was to make a review of the prevalence and the treatment of hypochondriasis, with emphasis on the latter. Method: The litterature I used in my review was published between 1986 and 2002. I searched for litterature on the subject in the PubMed database, and I made use of textbooks in psychiatry. Results: Cognitive-behavioural treatment has shown to be effective in the few controlled trials published so far. Alternative treatments seem to have effect in the treatment of hypochondriasis as well. Exposure therapy, explanatory therapy and behavioural stress management are viable methods in helping these pasients according to a small number of controlled randomized studies. Some articles presents reattribution techniques and reassurance as important tools in the management of hypochondriasis. The knowledge of pharmacotherapy of hypochondriasis is still limited, and futher research is required. Conclusion: Different treatment strategies have been tried in the management of hypochondriasis. Cognitive-behavioural therapy seems to be an effective treatment for this condition, but other treatments have shown positive results as well. Several articles express a demand for futher research. Even though final conclusions cannot yet be drawn, there has been much progress in the understanding of hypochondriasis and the need for proper treatment.

Risk factors for sudden cardiac death in the long QT syndrome
Thorsen, Paul Joachim

Supervisors: Gottfried Greve, professor/overlege, Seksjon for pediatri, Institutt for klinisk medisin, UiB/Hjerteavdelingen, Haukeland Universitetssykehus Ansgar Berg, post doktor/kst overlege, Seksjon for pediatri, Institutt for klinisk medisin, UiB/Barneklinikken, Haukeland Universitetssykehus Per Ivar Hoff, overlege, Hjerteavdelingen, Haukeland Universitetssykehus

Background: Long QT Syndrome is a relatively rare and not well-known condition. The syndrome involves a prolongation of the QT-interval corrected for heart rate (QTc) on ECG, and the typical clinical presentation is the occurrence of syncope or cardiac arrest in usually young and healthy individuals. Cardiac events can be precipitated by use of certain drugs and environmental factors. The purpose of the present study is to gather knowledge about Long QT Syndrome and give guidelines regarding medication and other risk factors that may worsen the condition. Material and methods: The present article is based on articles obtained by search in PubMed from 1966 through 2004, for all English-language articles related to the QT interval, and examination of their references. Additional information was achieved from some key-sites about the subject, on the Internet, and among experienced colleagues. Results: The symptoms are syncope, cardiac arrest, often related to psychic or physical stress in young, usually healthy individuals. The syndrome is commonly caused by mutations in the potassium channel, or by lack of inactivation of the sodium channels, and it can be inherited or acquired. The most common courses of acquired conditions is the use of medication, electrolyte abnormalities, intra-cranial disease, dietary deficiencies, congenital heart disease, myocardial infarction, dilated cardiomyopathy, prolaps of the mitral valves, bradycardi and severe malnourish among anorexic patients. Interpretation: It is important to have knowledge about Long QT Syndrome. The treatment is primarily to remove potential risk factors and to avoid situations that involves physical or emotional stress, and medically by beta-blockers, pacemakers and ICD.

The epidemiology of major injuries in Hordaland En epidemiologisk studie av alvorlig skadde pasienter i Hordaland
Tjøstheim, Kim Helen

Supervisors: Kari Schrøder Hansen, overlege dr.med. og Asgaut Viste, professor Akuttmedisinsk seksjon, Haukeland Universitetssykehus og Institutt for kirurgiske fag, UiB

Background We wanted to study the epidemiology of major injuries in Hordaland. Material and methods We undertook a prospectiv collection of data from medical records on injured patients with ISS 9 admitted to Haukeland University Hospital in Bergen, Norway, during 2000. Patients died before hospital admission or brought in for coroner’s inquest were included. Results Of the 283 patients included in the study 213 were males and 70 females. The overall median age was 37 years, for men 32 years, and for women 56 years. The male:female ratio was 3:1. Injury rates for males exceed those for females in all age groups except among the elderly. The highest incidence rate could be attributed to men of 20 - 29 years. 58 per cent of the patienst had an ISS < 16, and 42 per cent had ISS >15. Traffic (47%) and fall (42%) were the main injury causes. 54 per cent of the traffic accidents were related to car accidents and of these collisions accounted for 62 per cent, driving off the road caused 32 per cent, and of 5 per cent no further data were attained. Interpretation The study shows that there is a potential for further injury prevention among young adult men and elderly women.

Selective processing of linguistic and pictorial food stimuli in females with anorexia and bulimia nervosa
Torkildsen, Øivind

Supervisor: Kjell Morten Stormark, Regionsenter for barn og unges psykiske helse, UiB

Running head: Stroop-interference and eating disorders The purpose of this study was to examine selective attention to linguistic and pictorial representations of food stimuli in twenty females with eating disorders (anorexia, bulimia nervosa or a combination of both) and 24 female controls. The subjects were presented with color, food, emotional and neutral stimuli in a modified Stroop color-naming task. If persons with eating disorders' attention really are biased by food stimuli, one would expect them to evidence the same delays in detecting the color of the pictorial as linguistic representations. The results showed that the Eating disorder group was overall slower than the Controls to all words (including the food words) and to pictures depicting food stimuli (but not any other pictures). The Eating disorder group was also slower in naming the color of both food and emotional than neutral stimuli, both for the linguistic and pictorial stimuli. These findings suggest that the biased attention to food stimuli in females with bulimia and anorexia nervosa is not restricted to linguistic representations. In addition, the biased attention to the emotional words and pictures suggests that processing of negative stimuli also is important in the maintenance of eating disorder, in addition to the dysfunctional concerns about stimuli related to food and eating.

Poliovirus: En klinisk oversikt og strategi for utrydding
Tran, Hiep Ngoc

Supervisors: Lars Haarr, professor dr.med, Seksjon for mikrobiologi og immunologi, Gades institutt, UiB Tiina Rekand, ass.lege., Nevrologisk avdeling, Haukeland Universitetssykehus

The paralytic potential of the poliovirus was recognized as early as the 14th century B.C.. Natural infection is thought to begin with oral ingestion, replication in the alimentary mucosa, and migration into the lymph nodes, then into the blood. The circulating virus then invades the CNS and replicates particularly in the motor neurons. Paralytic poliomyelitis occurs as a result of neuronal destruction. Survivors of the acute disease, after decades of clinical stability, may develop a new neuro-muscular pathology called the post-polio syndrome (PPS). Both a killed and an oral live attenuated vaccine were developed, independently, in the 1950s by Salk and Sabin, respectively. Intensive vaccination, starting in the early 1960s, has led to nearly total eradication of poliovirus in most industrialized countries, and significant progress has been made towards the global eradication of poliomyelitis. Unfortunately, unlike most other vaccines, Sabin oral poliovirus vaccine (OPV) strains commonly spread from vaccinees to close non-immune contacts and are genetically unstable, regaining certain wild virus characteristics upon replication in the human gut. The strategy for stopping immunisation must therefore both maximize the benefits and minimize the risk. WHO Polio Eradication Initiative has clearly recognized that it is currently fighting poliovirus circulation on two fronts, as it must prevent the emergence of circulating vaccine derived polio viruses (cVDPVs) while at the same time eliminating the last pockets of wild poliovirus circulation. Polio eradication has had a positive impact on other public health initiatives. Coverage rates for other vaccine-preventable diseases have risen sharply in recent years.

Sensoriske (CGRP, SP) og sympatiske (NPY) nevropeptider I ureter fra spontant hypertensive rotter (SHR)
Undersrud, Erling Sandøy

Supervisor: Karin J. Heyeraas, professor dr.odont. Seksjon for fysiologi, Institutt for biomedisin, UiB

The objective of this study has been to compare the distribution and quantity of the sensory neuropeptides calcitonin gene-related peptide and substance P, and the sympathetic neuropeptide Y in ureters from spontaneosly hypertensive rats (SHR) and normotensive (Wistar-Kyoto) rats. The study is based upon randomly chosen unilateral ureters from 4 SHR and 4 Wistar-Kyoto rats; altogether 8 rats. The ureters were excised from anesthezised rats and then immunohistochemically treated, using the so called ABC-technique, upon which the results were analyzed using a light microscope. The results are interesting, especially regarding the findings in ureters marked with antibodies against neuropeptide Y. These show a possible, but highly plausible darker staining in the adventitial layer of SHR than normotensive rats. This is likely to be due to the higher degree of sympathetic activation in hypertensive rats, but for these findings to be verified, a statistically significant quantitative study must be performed.

Er sult og metthet "magefølelser"? Om gastrointestinaltraktens rolle i fødeinntaksreguleringen
Valeur, Jørgen

Supervisor: Karen Blaauw Helle, professor dr.philos. Seksjon for fysiologi, Institutt for biomedisin, UiB

Objective Diseases pertaining to body weight and food intake constitute a significant field of clinical medicine. Basic knowledge of the biological mechanisms regulating hunger and satiety is important for understanding these diseases. This study aims at illuminating the role of the gastrointestinal tract in the short and long term regulation of food intake. Method The literature was identified on PubMed. In addition, relevant books were examined. Results/discussion The gastrointestinal tract has a number of sensory, humoral and neural mechanisms that can regulate food intake. The gut`s ability to signal satiety is better understood than its ability to signal hunger. Signals from the gastrointestinal tract seem to be essential for the short term regulation of food intake, and to give vital contributions to the long term regulation of food intake.

Alternativ kreftbehandling; teoriar om verknadsmekanismar og nyare forsking på nokre typar behandling
Vikane, Kristin Sekse

Supervisor: Knut-Jan Andersen, professor Institutt for indremedisin,UiB

Alternative treatment methods are frequently used, also by cancer patients. There is a variety of different methods, which makes it difficult for both patients and professional health care takers to know what might be useful or not. The aim of this study has been to gain more knowledge about the use of alternative cancer treatment among cancer patients. Furthermore, I have chosen to focus more closely on 4 different treatment methods; shark cartilage, pectins, mistletoe and garlic. Methods: I started with searhcing in the library and on the internet for litterature on alternative cancer treatment in general. Later on I specified my searching into shark cartilage, pectin, mistletoe and garlic; mainly searching PubMed for research results over the last 10 years. Results: I found that the use of alternative treatment is relatively common among cancer patients. Norwegian cancer patients do not seem to be any different from other nationalities it is natural to compare with regarding this matter. There is a number of factors predicting what kind of treatment patients choose; for example gender, education and type of cancer. The research on some of the treatments is still at an early fase (pectins), while others has been in focus for several decades (mistletoe). In spite of a great number of studies on shark cartilage, pectins, mistletoe and garlic, the results of this research is still in an early fase. There is a lack of clinical evidence, which makes it difficult to consider the effects of treatment properly. Conclusion: Many cancer patients are interested in- and/or use alternative treatment methods. Access to information via for example the internet keeps patients well informed on the different alternatives. Therefore it is important that health care professionals have enough knowledge, so that they can guide cancer patients in what might be useful for them. Further research on shark cartilage, pectins, mistletoe and garlic is needed to obtain best possible treatment for cancer patients.

1. En litteraturgjennomgang 2. Analyser basert på data fra Den norske Mor & Barn undersøkelsen

Vogt, Elinor Chelsom

Supervisor: Kjell Haug, professor dr.med. Seksjon for sosialmedisin, Institutt for samfunnsmedisinske fag, UiB

Objectives By reviewing the most recent literature on the nausea and vomiting of pregnancy I attempted to obtain a deeper insight into the relevant problems on this theme. Materials and methods The literature searches were done by an interest search in Medline and Cochrane. The searches were concentrated on the words “hyperemesis gravidarum” (HG) and “nausea and vomiting of pregnancy” (NVP). The number of references exceeded 1000. About 40 articles were selected for further examination. The chosen articles were those most recently published on the subject and explored the etiology, pathophysiology and co-morbidity between NVP and other conditions. Results The literature studied could be grouped in the following categories: Hormonal, gastrointestinal, dietary, psychosocial and neurological theories. In addition to these are the theories of biological evolution, and physiological functional models which focus on the origins of NVP. None of the theories pretend to give a full explanation of the phenomenon, but they provide associations to other contributing factors. An overview of the interaction between the various factors is presented in a multifactorial model of etiology. The theories are placed in the following categories: predisposing factores, direct physiological stimuli and modifying factors. Conclusion NVP is a condition which affects a large proportion of pregnant women. The clinical picture is varied with a number of etiological and pathophysiological mechanisms involved.

Dendrittisk proteinsyntese og dens mulige rolle I synaptisk plastisitet
Wathle, Gaute Kjellevold

Supervisor: Clive Bramham, professor Seksjon for fysiologi, Institutt for biomedisin, UiB

Synapses need synthesis of new proteins when they change their properties. Until now it has been assumed that all parts of this synthesis occurs in the soma of the neurone. Recent research tells us that this is not quite true. In 1982 Steward and Levy discovered that postsynaptical spines in the hippocampus contains polyribosomes (1). When parts of the transcriptional apparatus where found in dendrites, one saw the possibility that dendrites may have their own protein synthesis. In 1988 Garner found mRNA for the protein MAP2 in dendrites (2). After this, more parts of the transcriptional apparatus have been found in dendrites, and also many different mRNA’s have been found here. Today it is believed that some part of the protein synthesis of the meurone occurs in dendrites, and that this plays its part in the plasticity of the central nervous system. Protein synthesis in other parts of the cell than adjacent to the nucleus has been known to occur in other cells than neurones. It is well known that Drosophila oocytes produce many proteins in the cell periphery to guide both cellular development and the anterior/posterior pattern (3,4). Similar systems exist in both fibroblasts and oligodendrocytes. This may be evidence for the fact that transport of mRNA to the periphery of the cell, and tranlation here, is a conserved mekanism in all differentiated cells. Synaptic changes cannot occur without new proteins being synthesised very fast. Proteins produced in the synapse are more readily available for the dendrite than proteins produced adjacent to the nucleus. In this article I will try to descibe how neurones transport mRNA from the nucleus to the dendrites, and how mRNA is tranlated here. I will also try to describe how these mechanisms are regulated, and how they contribute to the plasticity of the central nervous system. I have gained knowledge on the issue by reading articles that are written by different authors. These authors disagree when it comes to the conclusions of the research done on this subject. Therefore we cannot look upon the theories in this article as absolute true, but as likely theories based on new research.

Characterization and comparison of the CYP2D-genelocus of humans and chimpanzees Karakterisering og sammenlikning av CYP2D-genlokus hos menneske og sjimpanse
Wintherthun, Elisabeth

Supervisors: Vidar M. Steen, professor dr.med. og Anders Molven, professor dr.scient. Fagområdene for medisinsk genetikk og molekylærmedisin, Institutt for klinisk medisin, UiB

Background: In this study, we have characterised the CYP2D-locus of the chimpanzee. This gene-locus codes for a part of the liver's cytochrome P450-enzyme system, which is responsible for metabolising many different drugs, nutrients, chemicals and plant toxins. The genes of the CYP2D-locus have presumably evolved to detoxify nutrients many million years ago. The human CYP2D-locus consists of two inactive genes (pseudogenes), CYP2D7 and CYP2D8, and the active gene CYP2D6. Studies indicate that the evolution of the CYP2Dlocus and the development of the human apes have coincided in time. Aims and methods: A Southern-blot analysis had earlier indicated that chimpanzees have a CYP2D-locus that is very similar to its human counterpart. We therefore chose to do an amplification of overlapping fragments from the entire chimpanzee CYP2D-locus by longPCR, presuming that there would be a high degree of sequence-similarity to the human locus. Through DNA sequencing with subsequent computer-analysis we aimed at determining the structure of the chimpanzee CYP2D-locus, and to compare the results with human CYP2D sequence. Results: We found that the chimpanzee CYP2D-locus is structurally almost identical with the human CYP2D locus. Analysing six different chimpanzees, we found that CYP2D7 had a promoter structure and an open reading-frame indicating that the chimpanzee CYP2D7 gene is active, in contrast to the situation in humans. Chimpanzee CYP2D6 codes for a protein with 98.6% predicted amino acid similarity to the human CYP2D6-protein (debrisoquin-4hydroxylase). We were not able to verify if chimpanzees have a transcribed and translated CYP2D7 gene because the gene is so structurally similar to the CYP2D6 gene that it is very difficult to separate the gene-products experimentally. The chimpanzee CYP2D8 gene had many of the inactivating mutations seen in human CYP2D8. We therefore believe that CYP2D8 is a pseudogene in the chimpanzees, too.

Bruk av helsetenester i Guatemala
Øgaard, Øystein Fjetland

Supervisor: Tone Smith-Sivertsen, førsteamanuensis Seksjon for allmennmedisin, Institutt for samfunnsmedisinske fag, UiB

Objectives This study examines the use of health services in rural areas of Guatemala. It also focuses on the differences between private and public health care. The study tries to get an overview of variables that affect health care behaviour. Ethnicity is one such variable that is examined. Finally this report presenta a model for explaining health care behaviour. Methods The study is primarily based on literature researches, mainly in the database PubMed. This is supplemented with the author’s personal experiences in the health sector in Guatemala. Results Treatment at home is very common in rural areas of Guatemala. The most common thing to do when somebody gets ill is to seek advice from family member or from friends. This is also the case for areas with high access to professional health care. Modern health services are much more frequently used than traditional ones – also by indigenous people, who still use traditional health services more than others though. Seeking advice and medicines from pharmacies without consulting a doctor is a widespread practice. This often leads to incorrect treatment because the pharmacy workers lack medical training. The study did not demonstrate any systematic quality differences between private and public doctors. Discussion There are many factors that can be correlated to health care behaviour. Income, access to health services, social network, health beliefs, education, ethnicity and expectations to health services are examples of such factors. The report argues that all these factors contribute to a person’s identity, and that health care behaviour mainly is decided by this identity. Implications Measures that can improve the medical skills of pharmacy workers will probably have a very positive impact on treatment results and people’s health educational level. In the process of planning and building a health system one should have in mind the identity of the people for whom the health system is meant. In that way it is possible to deliver health services which are culturally acceptable, and which people will use.

Skadevirkninger av snus
Østhus, Dag Rune

Supervisor: Kjell Haug, professor dr.med. Seksjon for sosialmedisin, Institutt for samfunnsmedisinske fag, UiB

The usage of oral tobacco has increased considerably the last decades. In 1986 one third of all the conscripts in the North Norway were using snuff. It has therefore been necessary to intensify research on harmful effects associated with the useage of snuff. There is still a lot of discussion concerning the local effects of snuff. It seems to be well proved that a change in the mucous membrane is induced where the snuff is placed, but whether or not this change is to be clasified as premalignant is still a matter of disagreement. Studies tend to pull in both directions, maintaining different points of view among leading scientists. Two comprehensive clinical studies among Swedish building workers show an increased occurrence of hypertension among the snuff-users combined with a higher risk of lethal heart and vascular diseases. The weakness of these studies is, however, that they pay no attention to the aspect of alcohol consumption among the subjects studied. A study adjusting the datas according to this factor proved no higher risk of cardiovascular disease. Snuff conveys more nicotine to the body thanb smoking tobacco, and the negative impact of nicotine among smokers related to heart and vascular diseases is well documented. It is therefore most likely that snuff harms the cardiovascular system to a certain extent. A Norwegian study shows that the usage of snuff doubles the risk of injuries during physical training. Another study has for the first time proved a connection between use of oral tobacco and type 2 diabetes. The study shows that users of snuff have approximately 1,5 times higher prevalence of diabetes than non-users. This is, however, a small study, making many scientists questioning the result. Concerning cancer in general it has been difficult finding a connection to usage of snuff. Three studies proved an association between oral tobacco usage and prostata cancer. There has also been found an increased risk of pancreatic cancer in two studies. Apart from this, no connection with head, neck, stomack, intestinal or bladder cancer has been demonstrated. Several studies reveal gingival recession where the snuff is placed, but no documentation concerning higher frequencies of tooth damage and gum infections is available.

Kartlegge søvn hos autister
Øyane, Nicolas

Supervisor: Bjørn Bjorvatn, førsteamanuensis dr.med. Seksjon for allmennmedisin, Institutt for samfunnsmedisinske fag, UiB

Sleep problems are commonkly reported in children with autistic disorders. Most studies are based on sleep questionnaires and sleep diaries, but polysomnographic and actigraphic data have also been used. In this study, we investigated sleep in older subjects (aged 15-25 years) with autism and Asperger syndrome, using sleep questionnaires, sleep diaries and actigraphy. We wanted to compare the subjective findings with the objective actigraphic recordings. Although the sleep questionnaires, answered by parents and caretakers, only revealed a moderate amount of sleep problems among the subjects, a greater extent of sleep disturbances was recorded with actigraphy. According to actigraphy, low sleep efficiency (below 85%) or long sleep latency (more than 30 minutes) were seen in 80% of the subjects. There was no early morning awakening contrary to some earlier reports. This study suggests that even though subjective complaints of sleep disturbances are less common in adolescents and young adults with autism, this may be due to an adaptation process rather than an actual reduction in sleep disturbances.

SERMs Selektive Østrogen Reseptor Modulatorar – eit litteraturstudium
Aakra, Borghild

Supervisor: Ernst A. Lien, professor dr.med. Seksjon for endokrinologi, Institutt for indremedisin, UiB

Background Selective Estrogen Receptor Modulators (SERMs) are a group of medicaments, which all mediate their action by binding to the Estrogen Receptor (ER). SERMs are endocrine agents used in breast cancer therapy. SERMs have both an estrogen agonistic and antagonistic action, with their action being different on different estrogen responding tissues. One SERM, Raloxifene (RAL), is approved for treatment or prevention of osteoporosis in postmenopausal women. Another SERM, Tamoxifen (TAM), is the worldwide most used agent in cancer therapy, and was in the USA in 1988 approved for preventive use in women who are at increased risk for breast cancer. Being antagonistic in mammary tissue makes TAM valuable in breast cancer treatment, being agonistic in endometrial tissue makes in controversial in the preventive setting. Wide research aiming at finding the “perfect SERM”, which habitate the preferred and valuable properties, excluding the hazardious ones, is ongoing. Material and methods Forty articles concerning the different aspects of SERMs have been studied. The results of some studies concerning TAM in the preventive setting are available, and are presented. Concerned are also the pharmacokinetics and dynamics of different SERMs and some of the presumed mechanisms for development of Multi Drug Resistance (MDR). The unwanted actions of SERMs are important issues and are presented. Findings and interpretation SERMs used in the preventive setting are worldwide discussed, and several studies show an increased risk of tromboembolic disease and endometrial malignancy with TAM use. One prevention study shows a significant excess of deaths from all causes among TAM users versus placebo. The overall evidence supports a reduction in the risk of breast cancer, but whether this benefit outweighs the risks and side-effects of TAM, when used by healthy women for prevention of breast cancer, is unclear. The optimal dose used in the preventive setting is also not known, and may be the key for abolishing the unwanted side effects and at the same time maintaining the wanted effects.

Appendikostomi for fekalinkontinens hos barn og unge med myelomeningocele
Aase, Lene Jeanette Grasmo

Supervisors: Kristian Sommerfelt, førsteamanuensis dr.med. og Tove Berstad, overlege Seksjon for pediatri, Institutt for klinisk medisin, UiB og Barnekirurgisk seksjon, kir. Avd. Haukeland Universitetssykehus

Background Myelomeningocele is a congenital condition where the central nervous system is affected; it may cause paresis in the bladder, colon and lower extremities. For the patients, faecal incontinence and obstipation are troublesome problems that are difficult to treat successfully. Material and methods 13 persons were included in the study. Faecal incontinence was the main indication for appendicostomy for antegrade irrigation. Five patients underwent laparoscopic surgery, the rest had an open laparotomy. The appendix was pulled out and anastomosed to the skin. In that way it made a channel through which a cateter could be introduced. Water could be instilled and the bowel emptied by irrigation. Results and interpretation No patient continued major soiling. Five leaked small quantities of faeces, in two there was some mucus discharge from the stoma, and one patient had problems with the irrigation. All patients were able to carry out the irrigation themselves, but a main problem was to motivate them to be responsible. This seemed to be correlated to the age of the child. Appendicostomy is therefore an effective method in the treatment of faecal soiling when all other conservative methods have failed.