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Book of Abstracts Student theses Class 97 2003 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 South- America 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 97. 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 Cancer mammae 1990 – et årsmateriale Abelseth, Bente Kristin Haugland, Birte Toft Supervisors: Jan Erik Varhaug, professor/seksjonsoverlege og Turid Aas, overlege Insitutt for kirurgiske fag, UiB/Endokrinkirurgisk seksjon, Haukeland Universitetssykehus Background: In 1996 four Norwegian counties, including Hordaland County, started a program with breast cancer screening mammography for all women aged 50-69 years. In this analysis we look at a group of patients from 1990. We have done this partly because it has its own interest to describe the situation at that time, and partly to obtain a material to be compared with a similar one from year 2000. In that way we will see how the breast cancer picture may have changed after screening mammography was introduced. Methods: We analyzed the surgical medical files of those women who were admitted to the Endocrine Surgical Department at Haukeland University hospital in the period from 01.01.90 till 31.12.90, under the diagnosis breast cancer. We have excluded those women who did not have a newly diagnosed breast cancer at that time. All together, 82 patients were included in our material. Results: We have analyzed how breast cancer was discovered, which diagnostic methods were used, and which treatment was given. We have also looked at the histopathology of the tumor, the complications the women suffered, and the follow up. One of the interesting discoveries we made was that 20 % of the tumors were found in women who did not have any symptom of breast cancer disease, and that 4,9 % had in situ carcinoma. Discussion: We have analyzed a relatively small number of patients, and it is difficult to draw any firm conclusions. The majority of tumors (80 %) were clinically detectable at the time of diagnosis. Twenty one % of the cancers were TNM-stage 3 or 4. The question is whether the screening program that was introduced five years after our material, have improved this picture. We will be able to tell when the results from year 2000 are analyzed. Numbers from the first screening round in Hordaland county, show that a larger number of women were diagnosed with cancer in stage 1 (81 % vs. 60 % for comparable age groups.) The most important factor for improving survival from breast cancer, is to diagnose the tumor at an earlier stage. Kardiovaskulær sykdom hos pasienter med diabetes. Årsaker, forebygging og behandling. Aksdal, Hilde Supervisor: Sylvi Aanderud, professor/overlege Seksjon for endokrinologi, Institutt for indremedisin, UiB 2 –3 % of the population of Norway have diabetes mellitus (DM). Type 2 DM outnumbers type 1 four times. Numerous of patients don’t even know they have the disease. Worldwide there are probably 100 million people with DM, and the number is likely to reach 215 millions in 2010. The reasons for this enormous increase in incidens are more elderly people and an unhealthy lifestyle where consume of calories is larger than consumption. Coronary heart disease (CHD) is the most important cause of death in this group of patients.. Men and women with DM have respectively 2-3 and 3-6 times higher risk of CHD. The background for this phenomenon is familiar modifiable risk factors like dyslipidemia, insulin resistens syndrome (IRS), hypertension, smoking and hyperglycemia. It is important to consider the possibility of good primary and secondary intervention. Factors like diet, physical activity and smoking should be attacked first. The doctors must believe that intervention of lifestyle is important, and follow up. If this type of prevention and treatment doesn’t give desirable effect, one should consider the need of medical treatment. Treatment of dyslipidemia can be either indirect or direct. The former is by improved control over hyperglycemia, the latter by lipid reducing agents. Statins are no prescribed more often. There is still a potential for higher start doses. Better follow up could uncover the need for even higher doses. There are several strategies for treatment, according to type of dyslipidemia. In the treatment of hypertension traditional antihypertensiva like beta blockers or tiazids can be used. ACE inhibitors are recommended, though, since these probably have other cardiovascular protective qualities in addition. So far, we have no studies proving significant reduction in CVD by treatment of hyperglycemia. Through Metformin treatment, and the favourable effect on adipositas, one might expect a reduced risk of CVD. The new glitazons, the so called “insulin sensitizers” are participating in long-term studies with cardiovascular endpoints. Prevention and treatment should include much more than controlling B-glucose. Patients with DM need a highly comprehensive treatment. Early intrahospital defibrillation Alnes, Eirik Buanes Supervisor: Ivar Austlid, universitetslektor/overlege Medisinsk ferdighetssenter, UiB/Akuttmedisinsk seksjon, Haukeland Universitetssykehus Introduction: According to international guidelines, intrahospital patients experiencing cardiac arrest should be defibrillated within 3 minutes. At Haukeland University Hospital in Bergen, Norway, the time from cardiac arrest to defibrillation varied from 0 - 16 minutes, with a median time of 5 minutes. If time to defibrillation is reduced to 3 minutes, survival from cardiac arrest is likely to double. General wards at Haukeland University Hospital are equipped with manual defibrillators that require rhythm recognition skills. In Las Vegas, USA, simple semiautomatic defibrillators have been distributed in casinos. This has reduced the time from cardiac arrest to defibrillation from 10.7 to 4.4 minutes and increased the survival to hospital discharge from 29% to 53%. In this study we aim to determine whether intrahospital distribution of semiautomatic defibrillators will reduce the time from cardiac arrest to defibrillation in general wards. Method: Two general wards at Haukeland University Hospital were compared. We placed a modern semiautomatic defibrillator in one of the wards, and a modern manual defibrillator in the other ward. Doctors and nurses in each ward received only written information describing how to resuscitate and defibrillate a patient with cardiac arrest. One week after the information was handed out we performed a series of tests by placing a resuscitation manikin in a patient bed, triggering the alarm and allowing ward employees to resuscitate the manikin. Tests were performed at both wards in parallel and repeated 6 months after the initial information was handed out. A total of 41 tests were completed. Results: In our material the median time from alarm to delivery of the first shock was 2 minutes 39 seconds, a significant improvement when compared to the median time of 5 minutes prior to the intervention. The semiautomatic defibrillator delivered the first shock within 3 minutes in 80% of the cases whereas the manual defibrillator delivered the first shock within 3 minutes in 50% of the cases. (p<0.05; Mann-Whitney U-test) If we combine the results of both defibrillators to examine the effect of the training programme, we find that 1 week after handing out the written information ward employees manage to defibrillate the manikin within 3 minutes in 70% of the cases. The same holds true 6 months later; the first shock is delivered within three minutes in 70% of the cases. Conclusion: It is possible to reduce the time to defibrillation in patients experiencing cardiac arrest in general wards by placing simple, semiautomatic defibrillators within the wards. A training programme consisting of written information on resuscitation, followed by testing of resuscitation skills within the ward, allows skills to be maintained better than traditional training programmes. Traditional training programmes employ most of the resources into the course itself, whereas we have utilized nearly all our resources in the practical testing of resuscitation skills within the ward. With our programme we have spent only half the amount of instruction-resources compared to the standard Norwegian defibrillation-course recommended by the Norwegian Resuscitation Council. In addition, ward personnel did not need time off for training purposes. Hjerterate- og hudlednings responser til bilder av kjente og ukjente ansikt og objekt hos barn med autisme Heartrate- and skin conductance responses to pictures of familiar and unfamiliar faces and objects in autistic children Avdovic, Damir Aunan, Torbjørn Supervisor: Kjell Morten Stormark, forsker, dr. psychol. Regionsenter for barn og unges psykiske helse, UiB Background. The purpose of our study has been to measure facial recognition with the physiological parameters heart rate and skin conductance rate, in children with autism. The goal has been to see if the former reported difficulties in facial recognition are caused by general cognitive and/or perceptual deficits. Methods and material. 10 children with autism (mean age 6,2 years), 9 children with Down syndrome (mean age 6,8 years), and 10 normally developed children (mean age 5,3 years) were presented to pictures of familiar and unfamiliar faces and objects. Heart rate (HR) and skin conductance responses (SCR) were recorded during the presentation of the pictures. Results. The children without any developmental delay showed marked deceleration in HR to pictures of faces compared to objects, and larger deceleration to unfamiliar versus familiar faces. The also showed a larger increase in SCR to familiar faces compared to unfamiliar faces. The autistic children showed no difference in HR or SCR to familiar and unfamiliar faces, but showed a larger increase in SCR to known objects compared to unknown objects. The children with Down syndrome did not differ in responses to faces and objects, familiar or unfamiliar. Interpretation. The fact that autistic children differ in their autonomic responses to familiar and unfamiliar objects, makes it unlikely that failure to respond to faces is caused by decreased cognitive abilities or a more generalized perceptual disturbance. It is more likely reflecting specific problems with relating to social and emotional stimuli, like the human face. ALS – Har riluzol effekt? Axe, Birgit Grini Hasselø, Cecilie Supervisor: Johan A. Aarlie, professor dr.med./avd.overlege Institutt for klinisk medisin, UiB/Nevrologisk avdeling, Haukeland Universitetssykehus ALS is a fatal disease that affects both upper and lower motor neurones. It has often a rapid progression, and in almost all cases it leads to death within a few years. The disease is familial in 10% of the cases, and the rest are sporadic. The pathogenesis seems to be multifactorial and may include glutamate mediated excitotoxity, free radical effects and genetic function disturbances. A wide range of drugs have been tested in order to slow the progression of the disease, including calcium channel blockers and immunosuppressiva. The only effective drug so far is riluzol, a glutamat-inhibitor. In addition, important treatment includes multidisciplinary teams helping the patients to deal with the different problems that occur as a consequence of the pareses; dysphagia, respiratory insufficiency, dysarthria and spasms. This survey includes 40 patients with the diagnosis ALS (amyotrophic lateral sclerosis). 20 of these patients were diagnosed in the period 1980-1985, and the other 20 were diagnosed in the period 1995-2000. The patients in the last group have all been treated with riluzol, and none in the first group. We have observed the time elapsed from symptoms appear until death (or tracheostomia) of the patients. We found that those patients treated with riluzol have an estimated survival time 8 months longer than those who did not receive riluxol. The survey also includes a study of the effect of riluzol on the different types on onset of ALS, and in addition the possible effect of early riluzol treatment. Contusio Bulbi Bakken, Marit S. Farstad, Hilde Supervisor: Gunnar Høvding, professor/overlege Institutt for klinisk medisin, UiB/Øyeavdelingen, Haukeland Universitetssykehus Background: Blunt bulb contusions occur frequently, especially among young people, and are often followed by complications. Out aim was to reveal possible changes related to bulb contusions over time, especially regarding to causal relations and extent of severity. All this to be able to recommend eye wear protection in risk situations. Material and methods: Case records of all patient admitted to Øyeavdleingen, Haukeland sykshus with the diagnosis contusio bulbi in the years 1965-99 were examined. The material contains 245 case records, 136 from the first period and 109 from the second. Ten different parametres were compared. Results: The amount of women with the diagnosis contusio bulbi was doubled over the period of 30 years, but the increase was not statistically significant. This probably due to the fact that even in the last 5 year period women represented ony 11 % of the patients with bulb contusions. The decreased amount of children and young adults (<20 years) was highly significant (p<0,002), there was also an increased amount of injuries amoung people between 21 and 30 years (p<0,05), and people aged 71 or older (p<0,01). The average age at the time of injury increased by 7,6 years between the two periods in question. Eye injuries in the months of April and May were statistically more frequent in the sixties than in the nineties (p<0,05), while eye injuries in November and December were more frequent (p<0,01) in the last period. The enhanced share of eye injuries caused by different sports activities was highly significant (p<0,002), as was the decline in injuries caused by child’s play (p<0,002). There were no statistically significant changes in the other mail groups (work, home/leisure time, traffic, violence, illness). Neither regarding numbers and types of findings at the time of hospitalization, nor numbers and types of later complications there were significant changes. Seventyeight patients (32,8%) had one or more complications. Changes in visual findins (at the time of hospitalixation and later control examinations) were not statistically significant between the periods 1965-69 and 1995-99, but there was a highly significant decrease in the amount of control examinations (p<0,002). Heriditær spastisk paraparese Bjørdal, Stine Åstrøm, Grethe Supervisor: Laurence Bindoff, professor Seksjon for nevrologi, Institutt for klinisk medisin, UiB Objective: To study the prevalence and type of HSP among patients in Hordaland. Design: Retrospective study. Method: We traced all patients with HSP by searching 140 journals identified by IDC 9- and 10 hospital codes. We studied the journals by using a questionnaire. The data was then plotted into Microsoft access and analysed. Results/conclusion: of the 140 patients, 20 had been given the diagnosis HSP previously. That gave the prevalence of 20/440000. Due to clinical variability and possibility that some patients may be misdiagnosed, we included all patients that could possibly have HSP. In this case the prevalence rose to 36/440000. The distribution between pure HSP and complicated form of HSP was 50:50 in our study. The results were comparable to other studies of HSP in Europe. Preklinisk undervisning ved UiB for kull 97 – tilbakeblikk 1,5 år etter. En studentevaluering med fokus på anatomi. Bjørnstad, Carl Christian L. Supervisor: Torvid Kiserud, professor Seksjon for obstetrikk og gynekologi, Institutt for klinisk medisin, UiB In order to evaluate the preclinical teaching, anatomy in particular, a questionnaire was distributed to the student class of -97 one and a half years after they had entered their clinical studies. Out of a total of 143 students, 57 (40%) answered the questionnaire. This low number of responses implies that the results should be interpreted with caution. 16% of the students felt that they did not acquire the knowledge required to perform as a clinican, while 83% felt they got this knowledge. The most requested types of education was to incorporate more clinical examples in the lectures, emphasizing general principles instead of details at lectures and teaching in small-sized groups using senior students. Although four out of five students attended over 75% of the lectures, this form of learning was the least popular. Arguments for not attending included poor quality of lectures, preferring self-studying and other private reasons. One of three students felt that the results they achieved at the anatomy exam did not reflect their knowledge of the subject. On the other hand, one of ten students felt that they performed better on the exam than they had expected. The qualities of a doctor that the students felt were most important were that the doctor had a thorough knowledge of the basics, good communication and social skills. Every third student felt that some students having failed the exam could have become adequate doctors. However, half of the students did not know, or had no opinion, whether students failed in the exam. Is this linked to the fact that only 12% thought empathy was important atribute of a good doctor? Does that indicate that the curriculum has left little space for anything else than the body as a biomechanical unit? Although the education provides ample room for improvement, most students felt they had a sufficient background in anatomy to fully appreciate the clinical education. Reduced cardiovascular reactivity to stress during acclimatization to high altitude (4200 m) Bjørntvedt, Trude Lygre, Kristin B. Skåre, Christiane Supervisor: Morten Rostrup, overlege dr.med. Akuttmedisinsk avdeling, Medisinsk divisjon, Ullevål universitetssykehus In the present study we assessed the changes in cardiovascular reactivity during the early phase of acclimatization to high altitude. It has previously been demonstrated indices of reduced sympathetic activity and reduced cardiovascular reactivity during such acclimatization in a laboratory study. The current study looks at similar indices in a field context. In the present study 8 subjects were gradually exposed to hypobaric hypoxia by stepwise ascent to 4200 m over 3 days. Heart rate (HR), blood pressure and oxygen saturation were measured at rest, during a cold pressor test (CPT) and after 5 minutes recovery. Data are given by mean ± SEM. At 4200 there was a significantly decreased cardiovascular response to CPT compared to sea level. The systolic (SBP) and diastolic blood pressure (DBP) responses decreased significantly with increasing altitude (Δ SBP 14 ± 2 % at sea level vs. 4 ± 2 % at 4200 m and Δ DBP 30 ± 7 % at sea level vs. 7 ± 4 % at 4200 m, P ≤ 0.05). There were significant increases in resting SBP, DBP and HR during the ascent (111 ± 4 mmHg at sea level vs. 123 ± 5 mmHg at 4200 m, 62 ± 2 mmHg at sea level vs. 80 ± 5 mmHg at 4200 m and 57 ± 3 beats/min at sea level vs. 72 ± 4 beats/min at 4200 m, respectively, P ≤ 0.05). Oxygen saturation decreased with increasing altitude (98 ± 0.3 vs. 85 ± 1.2 %, P ≤ 0.001). There was a partial recovery of oxygen saturation from the first to the last day at 4200 m (88 ± 0.9 %, P ≤ 0.04). We conclude that there is a reduction in cardiovascular reactivity during stepwise acclimatization to high altitude. MARK-Medisinerstudentenes Alternative RøykfriKampanje En beskrivelse og foreløpig evaluering Bjaanæs, Snorre Supervisor: Per Bakke, professor Institutt for Indremedisin, UiB MARK is the alternative antismoking campaign of the medical students at the University of Bergen. After being challenged by the pulmonary Department at Haukeland University Hospital 10 medical students created an anti smoking project aimed at pupils in the secondary schools. In 2001 the project was tried out on a pilot class of students. Two secondary school classes are invited each time to half a day of intervention at the Haukeland University Hospital. 6 medical students are teaching. The pupils rotate between 5 posts. The topics on the various posts are pathology, coronary heart disease, chronic obstructive lung disease, positive and negative arguments for smoking, and finally pregnancy. A search on PubMed has not shown similar anti smoking campaigns. The anti smoking projects have emphasized teaching of the pupils, but incorporating the pupils into the hospitals for the anti smoking campaign has not been done before. Nine hundred pupils from the 9th and 10th class level have now completed the intervention. An evaluation based on 373 questioners completed immediately after the intervention is positive. Only 6% of the pupils think that the intervention has no effect. Of the 373 pupils there were 17% smokers. There were more girls than boys smoking, but smoking boys reported higher cigarette consumption than smoking girls. About 85% of the girls wanted to stop smoking while the corresponding figure among the boys is 37%. All together 78% of the pupils think that this intervention will prevent somebody in their class from taking up smoking, 37% think that the day will cause some of the smokers in class to stop. The pathology post is the most popular (40%), while 45% state that none of the posts were inefficient. Based on this immediate evaluation we have chosen to continue the project while waiting for the 12 months evaluation regarding the effect of this intervention on smoking rates in secondary school. Vitamin A i helse og sykdom Borge, Dorthe Marie Supervisor: Bjarne Bjorvatn, professor Senter for internasjonal helse, UiB The term vitamin A is used for retinoids having the same biological activity as retinol. Vitamin A is essential to health and is generally acquired by humans with a healthy diet. It has been known for a long time that vitamin A is required to maintain a normal vision and that vitamin A deficiency can lead to blindness. In addition, Vitamin A is necessary for the life, growth and development of higher animal species through its effect on differentiation and proliferation of a lot of different types of cells. Vitamin A deficiency is a major contributor to childhood mortality and is also a contributing factor to maternal deaths. Every year, several million children in developing countries die before they reach schoolage, many during the first year of life. Seven out of ten of these deaths are due to acute respiratory infections (mostly pneumonia), diarrhoea, measles, malaria or malnutrition - or more commonly, some combination of these conditions. These children are also at high risk of vitamin A deficiency, a factor known to contribute to most of these causes of disease and death. The World Health Organization estimates that 250 million preschool children worldwide are vitamin A deficient. Out of these, about 3 million develop eye symptoms, between 250,000 and 500,000 are becoming blind. Vitamin A deficiency can be corrected by a number of strategies, including a) improving diet by better use of available vegetables, b) food fortification, c) agricultural efforts and d) supplementation. Provision of high doses vitamin A supplementation every 4-6 months not only protects against blindness, but also has a significant impact on the general health of preschool children, reducing the mortality and morbidity to a large degree. Although traditionally, most studies related to vitamin A have been carried out in children, recent research indicates that among both mothers and children with vitamin A deficiency morbidity and mortality can be reduced significantly by vitamin A supplementation. Det kliniske bilde ved arvelig ALS Brattrud, Anja Otrebska Supervisor: Johan A. Aarli, professor dr.med./avd.overlege Institutt for klinisk medisin, UiB/Nevrologisk avdeling, Haukeland Universitetssykehus Background: Amyotrophic lateral sclerosis is a progressive, fatal disease which affects motor neurons in cerebral cortex, brain stem and spinal cord. The clinical features are paresis, muscle wasting, fasciculations, spastisity and hyperreflexia. The disease has an annual incidens of 2/100 000 and 5-10% of the cases are hereditary. The object of this study was to study the clinical eatures in patients with hereditary ALS at Department of Neurology, Haukeland University Hospital. Material/methods: Journals of patients with two or more cases of ALS in the family were reviewed retrospectively and the data were then compared to data from other larger studys. From 6 patientjournals from 4 different families, we found a total of 23 cases in the 4 families. Results: The average age of onset in patients with ALS in our hospital was 53.7 years. 75% had symptoms from their extremities at presentation and 25% had bulbar symptoms. The clinical features showed great familial heterogeneity. Our patients had an average duration of illness of 3.1 years and a survival time of 2.0 years. The patients with bulbar symptoms at presentation had the most sinister prognosis. The sex ration was 1.2:1 (M/F 12:10). The inheritance pattern was autosomal domonant with high/complete penetrance. Conclusion: Hereditary ALS has a somewhat lower age of onset compared to sporadic ALS. The symptoms at presentation are similar to those of sporadic ALS, while the survival time is shorter. Our data on hereditary ALS were similar to findings in other studys, exept from the age of onset, which was higher than the age found in greater studies. Kva kan legen gjera for å oppnå tillit og reell kommunikasjon i lege-pasient- forholdet? What can the doctor do to gain trust and real communication in the patient- doctor-relationship? Braut, Grethe Regine Supervisor: Ole Frithjof Norheim, professor Seksjon for allmennmedisin, Institutt for samfunnsmedisinske fag, UiB The first part of this paper gives a review of a selection of articles published in TNLF 1996/1- 2001/17 on the subject of patient-doctor-relationship. It shows what Norwegian physisians and others have written in regard to my leading question. To find relevant articles I used a number of keywords to search on the website of TNLF. I excluded articles on special diagnostic groups and patient groups. There has been a shift in general practise towards the humanistic, patient-centered methods of both ideologic and resultoriented reasons. Part two provides a presentation and evaluation of two major theoretical and practical methods of patient-doctor-communication. Both patientcentered method and narrative method states the importance of equality in the therapeutic meeting, and gives the patient opportunity to address issues of subjective importance. De verbo anatomico Brekke, Ragnvald Ljones Supervisor: Torvid Kiserud, professor Seksjon for obstetrikk og gynekologi, Institutt for klinisk medisin, UiB The basis of this assignment is to create a didactic tool for medical students in the study of anatomy. Today's students have less education in Latin and nomenclature than what they used to have in earlier times. This combined with the fact that anatomy still uses a classical nomenclature, makes it probably even more difficult to learn all the “foreign” words, which one meets in this subject. In an attempt to make it a little easier to acquire all these new words, I've developed a “pseudoetymological” dictionary to the booklet VISCERA, which is used as guidance during dissection. In addition I've made a small survey of the historical development of the medical nomenclature. I chose to do so attempting to explain why anatomy has ended up with a very conservative and classical use of language. I also hope that this can contribute to placing the assignment in a bigger medical linguistic context, and by that help to bring a greater understanding of the language we use in the medical surroundings in general. Endring i forekomst og dødelighet for ustabilt koronar syndrom i perioden 1973-2001 ved Haukeland Universitetssykehus The change in incidence and mortality of unstable coronary syndrome in the period 1973-2001 at Haukeland University Hospital Butt, Noreen Supervisor: Jan Erik Nordrehaug, professor/avd.overlege Institutt for indremedisin, UiB/Hjerteavdelingen, Haukeland Universitetssykehus Background: The epidemiology of cardiovascular disease has changed. The number of patients with myocardial infarction has decreased while the number of unstable angina patients has been increasing. The tendency has gone towards less large Q-wave infarctions and an increase in smaller non-Q-wave myodardial infarctions. The total number of patients with cardiovascular disease is increasing, while the overall mortality has been decreasing. This feature can be due to the improvement in the medi al treatment. The improved treatment strategies can explain the fall in number of myocardial infarctions and the fall in mortality. That is the reason why we have presented the treatment strategies for unstable coronary syndrome based on large trials. Material and methods: All patients admitted to Haukeland University Hospital in 1973- 1998 with unstable angina and myocardial infarction were registered. In addition patients with unstable angina in 1999-2001 were also inclulded. A total of 6684 patients were included in the study, 3551 with myocardial infarction and 3133 with unstable angina. We studied the median number of days in hospital, 30 days mortality and survival up to five years for both study groups. Results: We observed a decrease in 30 day fatality rate in both groups. There was a fall in mortality from 44% (1973) to 22% (1997), a difference of 22% in the myocardial infarction group. There was an improvement in the five-year survival follow up of the myocardial infarction group in certain time periods. On the other hand the improvement in prognosis for the unstable angina patients was more even in the whole period. The number of patients with myocardial infarction and the number of myocardial infarctions in the hospital has been almost constant in the period from 1973 to 1997, while the number of unstable angina patients in the period 1973-2001 has been increasing. Interpretation: The reasons behind the improvement in prognosis are not clear yet. Probably it can be related to the change in lifestyle. In addition the improvement is also due to improved modern treatment of unstable coronary syndrome. The time of improvement in mortality corresponds to the implementation of new medical treatment strategy. It is important to develop treatment strategy. It is important to development treatment strategies for unstable coronary syndrome. We therefore discuss important strategies for the treatment of unstable coronary syndrome. Kirurgisk behandling av lungekreft ved Haukeland Sykehus 1989 – 2000 Båtevik, Roy Supervisors: Ketil Grong, professor og Lodve Stangeland, 1.amanuensis Institutt for kirurgiske fag, UiB Background: Every year approximately 1840 patients are diagnosed with primary lung carcinoma in Norway. Some of these patients with localized non-small cell lung carcinoma are candidates for surgical resection of the tumor. The aim of this study was to evaluate postoperative survival with relation to tumor classification. Material and methods: A total of 255 patients with non-small cell lung carcinoma underwent resection and pathological staging at Haukeland Hospital in the period from 30.01.1988 to 07.06.2000. 186 of these were included in this study, because tissue of their rumors has been investigated at STAMI in Oslo for an accurate histological diagnosis. For these patients the records have been investigated and information plotted in an Access database. Survival rates were calculated with the Kaplan-Meier method on the basis of overall accumulated deaths. Results: Postoperative mortality was 1,9% and 6,9% for lobectomi and pneumonectomy, respectively. Survival of the patients depends on tumor staging after the operation. Kaplan Meier diagrams show a five year survival rate of 46%, 21,7% and 18,7% for histological stage I, II and III, respectively. Conclusions: The results from this group of patients from Haukeland Hospital accordance with five-year survivalrate found in similar patient studies from other institutions. Foramen ovale changes in growth-restricted fetuses Chedid, Ghantous 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 foramen ovale (FO). Based on the hypothesis that the FO is expended to permit more flow, we determined the size of the FO in growth-restricted human fetuses. Methods Thirty-one women with singleton pregnancies complicated with growth- restriction (<5 percentile) were examined at gestational weeks 24-39. The diameter between the FO valve and the atrial septum was determined during maximum excursion in a horizontal transection of the fetal heart. Correspondingly, the transverse diameter of the right atrium (RA) was noted. Pulsatility Index (PI) was detrmined in the umbilical artery and absent or reversed diastolic flow (ARED) was noted. The measurements were compared to reference population using z-score. Results Compared to normally grown fetuses, the growth-restricted had a smaller diameter of the FO (p=0.002), particularly when expressed as a relative size by the ratio FO/RA(P<0.0001). This effect was seen mainly ?32 weeks of gestation (p=0.003 and p<0.0001, respectively), and was not significant later in pregnancy.There was a strong negative relationship between relative size of the FO (FO/RA) and increased degrees of placental compromise expressed by the umbilical artery waveform ( overall p<0.0001). Conclusions FO in growth-restricted fetuses is smaller than in normally grown, particularly in fetuses with placental hemodynamic compromise before 32 weeks of gestation. The smaller FO support the assumption that a progressive detrioration affects the left ventricle more than right, and in keeping with compensatory mechanisms such as increased reversed flow through the isthmus aortae. Virkningsmekanismer bak Misteltein og Phytohaemagglutinin lektiner i tidlig stimulering av immunforsvaret Christiansen, Tove Camilla Supervisor: Ian F. Pryme, professor Seksjon for biokjemi og molekylærbiologi, Institutt for biomedisin, The background of lectin research at the Department of Biochemistry and Molecular Biology, IBMB, was investigated. A series of experiments were then undertaken to investigate further the immunostimulatory effect of lectins on macrophages and lymphocytes isolated from mice spleens. Mistletoe extracts have been used in cancer treatment for more than 80 years, and the results have been varying. Lectins are proteins with a mono- og disaccharide attached. They are resistant to degradation in the gut, and thus may be given orally. There are several types of lectins, the best known are Mistletoe lectins, Phytohaemagglutinin (PHA) lectin, and Concanavalin-A (Con-A) lectin. Mistletoe lectins (ML) are divided into several subgroups, ML-1, ML-2, and ML-3. We have used ML-1 in our laboratory because this is the subtype most used in cancer research. Experiments have shown that it is vital that ML-1 is given orally for it to bind to cells in Peyers patches in the gut mucosa and thereby induce growth of the small intestine and cause stimulation of the immune cells through second messengers. Polyamines have been shown to be involved in mechanisms involving cell proliferation. One of the earliest reactions in this process is the induction of the enzyme ornithine decarboxylase (ODC), which is the first enzyme in the biosynthesis of polyamines. All known tumour promoters induce ODC. A selective inhibitor of ODC activity, α-difluoromethylornithine (DFMO), has not been effective in vivo in spite of great expectations, this may partly be because tumour cells are not dependent on endogenous polyamine synthesis since polyamines can be supplied continously from the body pool. Lectins cause hyperplasia of the gut epithelium and this draws an increased amount of polyamines away from the body pool and into the small intestine epithelium. The hypothesis is that this leaves less polyamines available for a growing tumour. Polyamine content and tumour size in animals fed a Lactalbumin diet (LA) with 7,5 mg/g ML-1 added, and injected with murine non-Hodgkins lymphoma cells to form solid tumours, is reduced significantly. Apart from the direct effect on the growth of the small intestine, ML-1 has long been known to be profoundly immunostimulatory. Other lectins such as PHA and Con-A stimulate lymphocytes in vitro. Several trials have shown that lectins, particularly ML-1, have potent immunostimulatory effects in vivo. Modulation of the immune system affects the utilisation of nutrients by tissues through a cytokine response. In this study, macrophages and lymphocytes from spleen from mice injected with murine non-Hodgkin cells and fed PHA in the diet were compared with mice fed control diets and injected with the same cells. Results showed that spleens from mice fed on PHA were considerably smaller than controls. Lymphocytes from the spleen in the group fed on PHA could not be stimulated in vitro. This was in contrast to lymphocytes from the LA group. The results were not statistically significant. The tendency shown may be due to a higher degree of lymphocyte stimulation in vivo in the group fed on PHA. The lymphocytes have migrated to the tumour and are no longer residing in the spleen. Macrophages collected from the peritoneal cavity by lavage showed a slightly higher liberation of the cytokine TNF-α, but results were not statistically significant. Possible errors in the trial are little control regarding the amount of PHA ingested by each animal and remaining erythrocytes in the macrophage supernatant after wash causes the latter because hemolysis influences absorption studies, or optical density (OD). PHA is a much less potent immunostimulatory agent than Mistletoe. Forther experiments with a controlled oral administration of lectins, with emphasis on ML-1, are necessary to further clarify the effects of orally fed lectins on the immune system. Mors alder og svangerskap: Fødselsutfall Dale, Kjetil Samuel Danielsen, Tor Jørgen Endresen, Stian Supervisors: Lorentz Irgens, professor og Rolf Skjærven, professor Seksjon for epidemiologi og medisinsk statistikk, Institutt for samfunnsmedisinske fag, UiB Objective: In our study we have tried to find out whether extreme maternal age is a disadvantage for the child, and whether this tendency has changed over the last thirty years. By the expression “extreme age”, we mean mothers being teenagers (<20 years old) or elderly women (≥ 35 years old). Material and method: The material is drawn from the Medical Birth Registry of Norway, and includes every primiparous women in Norway during the period 1967-1998 (a total of 738.688 births). Multiple pregnancies and pregnancies of women with related partners are excluded from the material. We have compared primiparous teenagers to all primiparous women being twenty years or older. Also, we have compared primiparous elderly women to all primiparous women younger than thirty-five years old. The material has been divided into two periods, 1967-82 and 1983-98, to see whether time has had an effect on the variables we have examined. The variables we examined were: short period of gestation (<253 days), congenital malformations, perinatal mortality (stillborn or dead ≤ 6 days), high birthweight (> 4500 g), low birthweight (< 2500g) and very low birthweight (< 1500g). Results: For the period 1983-98, elderly women had an increased chance for unfortunate outcome for the following variables: low virthweight (< 2500 g) OR=1,20 (95% CI 1,14 – 1,26), very low birthweight (< 1500 g) OR=2,12 (95% CI 1,90-2,37), short period of gestation (< 253 d) OR = 1,65 (95% CI 1,53-1,76), congenital malformations OR=1,24 (95% CI 1,14- 1,35, and perinatal mortality OR=1,29 (95% CI 1,17-1,42). For the period 1983-98, young women had an increased chance for unfortunate outcome for the following variables: perinatal mortality OR=1,24 (95% CI 1,17-1,42), short period of gestation (< 253 d) OR = 1,28 (95% CI 1,22-1,35), low birthweight (< 2500 g) OR=1,74 (95% CI 1,63 – 1,80), very low birthweight (< 1500 g) OR=1,19 (95% CI 1,08-1,30). We found a significant interaction of time (p<0,001) for short period of gestation and for congenital malformations. There was an increase in unfortunate pregnancy outcomes from the first period to the second period for all variables examined exept for perinatal mortality. Conclusion: Extreme low maternal age is unfavourable for the child. This effect decreases closer to the twenties. It is very unfavourable for the child if the mother waits until she is 35 years or older. For the variables we looked into, there was much more unfavourable for the child having a primipara mother aged 35 or older than a teenaged mother. A Survey on Child Nutrition in Bhaktapur, Nepal: Complementary Diet and Time of Weaning Eide, Hanne Havstad, Hege Supervisor: Dr. Tor Strand Senter for internasjonal helse, UiB Existing guidelines on child nutrition recommends exclusive breastfeeding for the first 6 months of infant life. We wanted to investigate child nutrition with the main focus on complementary diet and weaning times. Furthermore, to assess whether a connection between complementary food, time of weaning and stunting/wasting existed. Methods: A questionnaire on child and family food habits was made and administered to the caretakers of children in Bhaktapur, Nepal. Five hundred and ninety children between the age of 6 and 35 months were subsequently included in the study. Results: Twenty-four percent of the enrolled children were wasted and twenty-seven were stunted. Forty-three percent of the children were given solid food before the age of 4 months. This early introduction of complementary food was associated with a 1.49 (95% CI: 1.01, 2.23) fold increased odds of becoming stunted. Conclusion: Our findings indicate that the children are introduced to solid food too early compared to what is recommended and that this poor feeding practice impairs growth. Kronisk/postviralt utmattelsessyndrom etter mononukleose. 1. Litteraturstudie 2. Et klinisk materiale fra Haukeland Universitetssykehus Ekanger, Christian Halland, Frode Supervisor: Harald Nyland, professor/overlege Institutt for klinisk medisin, UiB/Nevrologisk avdeling, Haukeland Universitetssykehus Epstein-Barr is a member of the herpesvirus family and one of the most common human viruses. As many as 95 % of adults between 35 and 40 years of age have been infected. The classic clinical presentation of the virus is mononucleosis with fever, sore throat, and swollen lymph glands. The diagnosis is made from the clinical findings, but usually laboratory tests are needed for confirmation. EBV-infection has complications falling in to different categories. The neurologic complications include viral meningitis, encephalitis and neuromuscular complications. Sometimes involvement of the nervous system is the only manifestation of infection. The introduction of cerebrospinal fluid polymerase chain reaction for Epstein-Barr virus DNA has improved diagnosis, and has enabled cerebrospinal fluid monitoring of therapy. Generally, the prognosis of nervous involvement is good, but also recently it has been reported fatal cases. Antiviral treatment has not yet been confirmed effective. Chronic fatigue syndrome, myalgic encephalomyelitis (CFS/ME) is a clinical syndrome defined as having new and incessent exhaustion, energyloss, physical and mental fatigue that substantially reduces activity level. The syndrome can be observed after a number of viral infections and is reported to occur in 10 % of patients with mononucleosis. We are presenting data obtained from clinical examination of 56 patients referred to Department of Neurology, Haukeland University Hospital, suspected of having this disease. In this report we have described the clinical features through a questionnaire in addition to the results from neurological examinations including electroencephalography and serologic studies of Epstein- Barr virus. Røyking i svangerskapet Engebretsen, Ingunn Marie Stadskleiv Supervisor: Kjell Haug, professor Seksjon for sosialmedisin, Institutt for samfunnsmedisinske fag, UiB In developed countries nearly every fourth woman smoke, but just seven do that in developing countries. Nearly every second man smokes in both developing and developed countries. In USA people have been quitting smoking the last years, but in developing countries they gradually smoke more. In Norway about thirty per cent of men and women smoke, and every fifth pregnant woman smokes. The rate of women starting to smoke has been decreasing the last thirty years. At the same time there have also been national anti-smoking campaigns. Women with low education, young age, multipara, who smoke a lot and maybe are single are the women smoking most in pregnancy. First of all children of smoking mothers are on average 200 g lighter than children of non-smoking mothers. Some studies show that the more mothers smoke the lower birth weight the children get. Unpublished data from the Norwegian Birth Registry from 1999 show that it is the first five cigarettes, which give the biggest fall in birth weight. It is most harmful to smoke in the second and third trimester when birth weight is considered. Just reducing the amounts of cigarettes do not give a weight benefit. Smoking mothers run a greater risk for having Small for Gestitional Age infants. Passive smoking can affect the birth weight, but that is not a big problem in Norway. Smoking is one important factor, which increses the risk for having a child who dies from Sudden Infant Death Syndrome; more than ten cigarettes a day increase the risk three times. Increased upper respiratory tract infection rate of children with smoking parents is one explanation. Foetal mortality in pregnancy and still birth is increased with smoking mothers. Cleft lip/palate (SL/P) is more frequent when there is smoking in pregnancy. Renal Glomeruli reduction both in size and number, hypospadias and chryptorchidism can also have smoking as one of their causes. Asthma and reduced lung function is associated with maternal smoking. Many kinds of cancers are more frequent among children of smoking mothers, especially testis cancers are more frequent among children of smoking mothers, especially testis cancer is increased among men in Copenhagen where women smoke more than anywhere else in Europe. Smoking just before pregnancy also increases the risk for some cancers. Breastfeeding is also reduced among smoking mothers. This can be due to the cigarettes effect on the hormone balance and that the quality of milk changes. Even though smoking among pregnant women has been reduced the last years, it is important that we do not forget this is a big and preventable health problem for the mother and child. Drug treatment of Alzheimer`s disease- background and possibilities Fauske, Hildegunn Knapstad Supervisor: Johan A. Aarli, professor/avd.overlege Institutt for klinisk medisin, UiB/Nevrologisk avdeling, Haukeland Universitetssykehus Background: Alzheimer`s disease is a disease that so far has no effective treatment. People in general are frightened by the thought of getting this degenerative disease. Since the pathological background for the disease is not completely understood, the research is also on a basical level. Material and methods: The following is a literature-based review on current treatment perspectives. Results and interpretation: The cholinergic hypotesis has been the background for drug treatment of Alzheimer`s disease since the 1970s until now. Recent study shows that persons with mild cognitive impairment have an upregulated cholinergic system. The authors postulate that mild cognitive impairment is the prestage to Alzheimer`s disease, and that Alzheimer`s disease is manifest when the compensation mechanisms seen in mild cognitive impairment are vanished. Gir økt mosjon bedret adferd hos personer med barneautisme? Does an increase in exercise improve the behavior in persons with autism? Flem, Bernt-Olaf Lian Jørgensen, Robert Sundal, Kim Erik Supervisor: Einar Heiervang, overlege dr.med. Regionsenter for barne- og ungdomspsykiatri, UiB Design: The study is based on registration of behavior and exercise in a period of two months Subjects: Two persons with childautism who both have behavior problems Main outcome measures: We have measured behavior problems using a individually adjusted scheme, and measured the amount of exercise registered as daily walking. Results: Person 1 showed improvement in one behavior parameter and person 2 showed improvement in two combinations of behavior parameters. Conclusion: An increase in exercise is assosiated with improved behavior for the persons in the experiment. No negativ development in behavior was registrated in the second month of the experiment. Risk factors of dyskinesias and hallucinations in Parkinson’s disease? Fredriksen, Kristin Jørstad Aanensen, Karoline Supervisor: Ole-Bjørn Tysnes, overlege prof.dr.med. Nevrologisk avdeling, Haukeland Universitetssykehus Objectives: The aim of the present work was to study the occurrence of the levodopa- assosciated symptoms dyskinesias and hallucinations in a Norwegian Parkinson population. Materials and methods: Files of patients that had been hospitalised for Parkinson’s disease at Haukeland University Hospital, Norway, during the period 1990 to 1995 were carefully reviewed for demographic data, clinical data and treatment regimens. Results: Fiftynine per cent of the patients developed dyskinesias at some time of the observation. The 5 and 10 years risk of having developed dyskinesias was 25% and 54%. Young age at onset and high initial levodopa dose were independent risk factors. The risk of dyskinesias was similar in patients on levodopa alone and in patients on levodopa plus dopamine agonists or deprenyl. The risk of developing hallucinations was 20% in 10 years. Conclusion: Levodopa-induced symptoms are frequent in Parkinson’s disease, but less frequent in this Norwegian cohort than generally reported. Careful use of levodopa may reduce the risk of dyskinesias. Cholerapreventive work in Mozambique Furnes, Geirmund Strøm, Jan Harald Supervisor: Nina Langeland, professor/overlege Institutt for indremedisin, UiB/Medisinsk avdeling, Haukeland Universitetssykehus Objective: To assesshow the volunteers in Cruz Vermelha de Mocambique (CVM) experienced their working situation and performed preventive work during the cholera epidemic in 1997-1998. To compare the findings in Maputo Province to Maputo City. Design: Data were collected through interviews using both a structured questionnaire and unstructured conversation in groups. Setting: Maputo Province and Maputo City, December 1999-January 2000. Subjects: Volunteers in CVM Main outcome measures: Sociodemographical differences Door-to-door campaign Implementation Follow-up and leadership Results: Twenty-five and thirty-five volunteers were interviewed in Maputo Province and Maputo City, respectivelly (the values from the city are written in parenthesis). Mean age: 35.7 years, standard deviation (SD) = 11.1 (24.7 years, SD = 4.7). Experience as a volunteer: 8.5 years, SD = 3.6 (6.9 years, SD = 4.0). Distribution of gender: 80% women (69% women). Public education: 5.4 years, SD = 2.4 (8.5 years, SD = 1.7). In both areas 52% reported having the door-to-door campaign as the main activity. In both areas 67% said they were able to change the families’ behaviour “much” concerning water-treatment and oral rehydration therapy (ORT). Fifty-six percent (74%) felt they were appreciated by CVM. The degree of follow-up seemed to be less in the province. Conclusion: Most volunteers felt they did an important job and were willing to do it again. Cholera preventive work could be recommended to be included as a daily activity for CVM. Recruiting and follow-up of the volunteers were less focused in the province than the city. The Management of Severe Malnutrition in a Hospital Setting in Uganda, and Suggestions for Low Cost Improvments Gjerpen, Jeanne Hoel, Hedda Supervisor: Thorkild Tylleskär, professor Senter for internasjonal helse, UiB Background Severe malnoutrition in children is a potentially life threatening disorder which requires very careful management even in hospitals in order to avoid a high case fatality rate. We wanted to study the management of these children in a hospital setting in Kampala, Uganda, in order to identify gaps, and suggest some low-cost improvements. Methods We did a survey of recent literature in the field of severe malnutrition, and looked at the recent recommendations for management. We studied the management of severe malnutrition in Mulago Hospital, Uganda, through case-studies and participatory observation during a 6 week period June-July 2002. Also, we did a study using questionnaires, to get an overview over the patients anthropometrics and socio-economic setting. On the background the above, we suggested some low-cost improvements, that could possibly reduce the morbidity and mortality of these children. Findings Our suggestions for low-cost improvements were as followed: An increased use and understanding of the already existing guidelines for management; more accurate recording of the child's condition and treatment; more efficient prevention of initial hypoglycaemia and hypothermia; increased surveillance of feeding, and increasing infection control. Our impression was that these measures could possibly reduce the mortality and morbidity of severely malnourished children. Ekstrauterin graviditet etter sterilisering Gjerstad, Hedvig Supervisor: Roar Sandvei, professor Seksjon for obstetrikk og gynekologi, Institutt for klinisk medisin, UiB Background The aim of this study was to estimate the frequency of women suffering an ectopic pregnancy following tubal sterilization.We also intended to see the results in relation to the methods used during the sterilization procedures. Material and methods. We conducted a retrospective cohort study of a hospital material of 1535 patients with the discharge diagnosis of ectopic pregnancy. The patients were admitted to Haukeland University Hospital during the years 1985- 2001. We reviewed the medical records of all these women, to see how many who had been previously sterilized. The surgical methods, by which the sterilization procedures had been conducted, were also recorded. In addition we noticed if the procedure was performed post partum, post abortum or as an interval procedure. Results Of 1535 women with the discharge diagnosis of ectopic pregnancy, 35 had undergone previous tubal sterilization. Ten of the 35 women had been refertilized by tubal anastomosis before their incidence of ectopic pregnancy, and were therefore excluded from the analysis. Thus 25 women were included in the study. We also found that 220 (15.3%) of the women had become pregnant with an IUCD in situ, and 15.2% of the study population had suffered repeated ectopic pregnancies. The mean age of all the women with ectopic pregnancy was 30.1 years (16-47 years), and those who experienced ectopic pregnancy subsequent to tubal sterilization were 36.0 years (27-46 years). The mean interval between tubal sterilization and ectopic pregnancy was 57.8 months (5-176 months). Interpretation Our data suggests that that the possibility of pregnancy must be considered in women who have undergone tubal sterilization. The risk of the pregnancy to be ectopic is greater than that of an intrauterine pregnancy. The increased risk is supposed to last during the fertile period of life. Description of Clinical and Epidemiologic Aspects of Escherichia coli O157:H7 infections in the State of Georgia, United States of America, 1993-2001. Granå, Ronny Supervisor: Blake, Paul A., MPH Department of Human Resources, Atlanta, Georgia In the years 1993-2001 there were confirmed 372 cases of E. coli O157:H7 infections in Georgia. The number of cases of E. coli O157:H7 infections reported in Georgia rose between 1993 and 1997, peaked in 1998 and has been stable in subseqent years. The fact that there has been no increase in the annual number of cases since 1998 may reflect a measure of success in controlling E. coli O157:H7 infections. 31% of cases were part of identified outbreaks. In 1993-2001 four large outbreaks occurred in the years 1995, 1996, 1998 and 2001 affecting a total number of 62 persons.E. coli O157:H7 infecions are much more common during the summer and early fall months. Children in the 1-4 year age group have a remarkably higher incidence of E. coli O157:H7 infections, this age group is also much more likely than infected persons in other age groups to develop hemolytic uremic syndrome. The incidence of E. coli O157:H7 infections fall off through the adult years until the age 50, after it begins to climb. During 2000-2001 the two persons known to have died were both elderly, 76 and 81 years of age. In 1993-2001 the incidence of E. coli O157:H7 infections was almost three fold lower in Georgias African-American population than in the white population. There was also a concentration of reported cases in northern Georgia. Among cases reported in 2000-2001 almost all of the cases (96%) had diarrhea, and a large majority (74%) had bloody diarrhea. Forty-one (39%) of the cases in 2000-2001 were hospitalized, the median duration of hospitalization was 4 days. The mean age of hospitalized cases was 23.3 years, and 17.6 years for non-hospitalized cases. The rate of hopitalized cases is substantially higher for persons 60 or more years of age. Newborns reaction to tape recordings of their own and other babies cries Griffiths, Silja Torvik Thorsen, Anna Maja Holm Supervisor: Kjell Morten Stormark, dr. psychol Regionsenter for barn og unges psykiske helse, UiB Self perception in newborns Several studies have shown that newborns are subjectively aware of themselves as unique individuals The purpose of this study was to examine if newborns would distinguish the tape- recordings of their own crying from that of another newborn.. The study was performed at Kvinneklinikken, Haukeland sykehus. We filmed behavioral responses of 14 newborns when they were listening to audio-recordings of their own or another newborns' crying. Both audiorecordings were presented while the subjects were in two different states, once when the children were calm, and once when they were crying. Thus, the experiment consisted of four conditions: calm / own crying, calm / peers' crying, crying / own crying and crying / peers' crying. We scored the amount of time the children were crying for each of the four situations. The time (in seconds) before the child changed from being calm to crying, and vice versa, was also scored. The results showed that the children cried for a longer duration when they were crying initially than when they were calm, no matter which audiorecording they heard. It also took the newborns longer to change from crying to calm than vice versa when they were presented with the audio-recordings. This was particularly pronounced when they were presented with the audiorecordings of their own crying. This suggests that newborns can differentiate between their own and peers' distress crying. One could speculate whether this may reflect an early, innate sense of self in the newborn. Angiogenese: effekt av trening på serumnivå av basic Fibroblast Growth Factor (bFGF)" Angiogenesis: Effect of exercise activity on serum levels of basic fibroblast growth factor. Grøvan, Fredrik Supervisor: Øystein Bruserud, professor/overlege Institutt for indremedisin, UiB/Medisinsk avdeling, Haukeland Universitetssykehus Research in the field of angiogenesis started in the seventies and today it is a vast field involving many different medical disciplines. Physiologic angiogenesis is a strictly controlled process, and loss of control is a hallmark of pathologic angiogenesis. More than 20 endogenous substances released locally or systemically have pro- or antiangiogenic effects, and basic fibroblast growth factor (bFGF) is one of the most important proangiogenic substances. During exercise training new vessels are formed locally in skeletal muscle. In our study we investigated whether intensive physical activity in young, regularly trained male kayakers affected serum levels of bFGF. The levels were determined before and immediately after 45 minutes of intensive physical activity. The results showed that serum levels of bFGF were significantly decreased after exercise. Spedbarnskolikk – en oversikt Haugland, Christian Supervisor: Edda Olafsdottir Seksjon for pediatri, Institutt for klinisk medisin, UiB This paper reviews current litterature about infantile colic, as regards to ethiology, prognosis and documented therapies. Infantile colic is characterised by excessive crying which subsides within 3 months. It is still not known what causes colic – whether gastrointestinal or behavioural dysfunction is the problem, or whether there’s actually no pathology at all. In any case, children who have had colic are not more prone to illness than other children later in life. Various therapies have been tried, very few of them are well documented. There is a significant placebo effect. Dicyclomine is likely to be beneficial, but unfortunately this drug can have serious side-effects. Elimination of cow’s milk can be beneficial for some children, as can sucrose. Dimethicon and chiropractic therapy are widely used, but are not effective. Other treatments have shown promising results, but the studies are too small or have too many important methodological problems to draw conclusions from. Prevalensen av røyking blant kroniske smertepasienter henvist til en tverrfaglig smerteklinikk – farmakologisk betydning? Heimen, Anja Supervisors: Ole Jacob Broch, professor og Rae Frances Bell, seksjonsoverlege Institutt for farmakologi, UiB og Anestesi- og intensivavdelingen, Haukeland Universitetssykehus Background: It is a general impression that many patients with chronic pain are smokers. Existing studies show that smoking influences drugmetabolism. In this study we have determined the number of smokert in a random group of chronic pain patients, and examined how much tobacco they use, which drugs they are treated with and possible pharmacological significanse. Methods: This is a retrospective study. The journals of one hundred consecutive patients evaluated at a multidiciplinary pain clinic were examined. Information regarding tobacco, alcohol, age and gender was registered. A Medline-search was performed to collect information from available literature regarding the interaction of tobacco with analgesic metabolism. Results: We found that a greater number of patients with chonic pain-problems were tobacco-users (65%) compared to the general Norwegian population (33%). Thirty three percent of the Norwegian female population are regular smokers compared to 67% of females in the study group. The amount of tobacco consumed by the study group was significantly higher compared to the general population. The Medline search revealed several studies reporting interactions between cigarette smoking and the metabolism of different analgesics. Conclusion: Relatively few analgesic drugs have been investigated regarding interactions with tobacco smoking. Available literature indicates that tobacco smoking influences drug metabolism. This study revealed that a large percent of chronic pain patients in the study population are smokers. An important treatment goal is reduction of tobacco consumption. Genterapi ved HIS infeksjon Herikstad, Ragnar Supervisor: Birgitta Åsjø, professor Avdeling for mikrobiologi og immunologi, Gades institutt, UiB Though much progress has been made in the treatment of the human immunodeficiency virus (HIV) infection, and the introduction of highly active antiretroviral therapy (HAART) has improved the prognosis and quality of life considerably, we are still without any curative therapy. Many alternative treatment strategies are being explored; among them is the rather new discipline of gene therapy. In this article we look in particular at results that have been published so far from clinical trials. The different approaches can be divided into two main categories depending on whether they aim to stop viral replication or to destroy infected cells. So far the results from 3 phase I studies have been published, several more are still in progress and a few phase II protocols have been approved by the National Institute of Health (NIH). While we are still far from a cure, the last years results have led to excitement in the field. This article reviews some of the strategies for a possible use of gene transfer for the treatment of HIV infection. Clinical Trials on the Treatment of Arrhythmia in ventricular Dysfunction: Primary prevention in post-myocardial Infarction, primary and secondary prevention in congestive Heart Failure Herstad, Jon Power, Øystein Supervisor: Per Ivar Hoff, overlege Hjerteavdelingen, Haukeland Universitetssykehus Background Cardiovascular disease is still the most common cause of death in developed countries. Of all deaths due to cardiovascular causes, sudden death accounts for approximately 50%, and the majority of such deaths are caused by acute ventricular tachyarrhythmias. Even though the identification of common cardiovascular risk factors such as smoking, hypertension and hyperlipidemia is straightforward, these determinants estimate the risk of underlying disease rather than the risk of the event immediately responsible for death. This has lead clinicians and scientists to investigate whether it is possible to determine more specific markers of the risk of death from arrhythmia. In this paper we try to review the clinical trials that have led to current routines of management in ventricular arrhythmia in post-MI patients and patients with congestive heart failure. Furthermore we highlight recent trials and the ongoing discussion concerning the use of Implantable Cardioverter Defibrillators (ICD) as an alternative approach in treating this population of patients. Methods A review of the clinical trials on the treatment of arrhythmia in ventricular dysfunction: Primary post-myocardial infarction trials, primary and secondary prevention in congestive heart failure. We present the most established pharmacological approach in the prevention of ventricular arrhythmia, namely amiodarone, as well as a brief historical introduction to the use of the ICD. We compare trials promoting these substantially different approaches in preventing ventricular arrythmia, and focus on medical implications, cost-effectiveness, risk- stratification and quality of life. Conclusion ICDs seem more beneficial than drug therapy for secondary prevention of sudden cardiac deaths and for primary prevention in certain high-risk groups. However, further research is needed to develop accurate risk stratification tools, to determine the economic impact of ICD therapy in different subgroups of patients, and to evaluate quality-of-life issues. And with new trials suggesting worsening heart failure after ICD-implantation in certain subgroups, the importance of stratification in unquestionable. Glutamat som tilsetningsstoff og dets innvirkning på symptomer hos pasienter med funksjonell dyspepsi Hessen, Siw Margrethe Supervisors: Trygve Hausken, professor dr.med./overlege og Ina Hjelland, stipendiat Institutt for indremedisin, UiB/Gastroenterologisk seksjon, Medisinsk avdeling, Haukeland Universitetssykehus Background/aims: Patients with functional dyspepsia often have meal-induced dyspeptic symptoms. They seem to react particularly strong after ingestion of Tor Klar Kjøttsuppe. We wanted to study wether it could be the content of glutamate (MSG) in this soup that was responsible for the intens symptoms found in these patients. Methodology: In 10 patients with functional dyspepsia, symptoms, the area of gastric antrum and fundus, and the diameter of the sagital fundus were recorded, as measured with 2D ultrasound, before, at 0 min, 10 min, and 20 min after ingestion of 500 ml of bullion in 4 min. In all subject this was recorded on two separate visits, where they, in randomized order, on one occation were served standard Toro Klar Kjøttsuppe with glutamate, on the other soup without glutamate. With exeption of the glutamate, the two soups were identical. Results: Scores of all the symptome showed a tendency to be higher after ingestion of the glutamatefree soup. The results were only significant for the symptom nausea at 20 min after they had stopped drinking (p=0.04). We found no significant difference in the antral ultrasound recordings, but there was a slight tendency of the antral volume, expressed by these 2D measures, to be higher after ingestion of the standard soup. The fundus diameter and area, however, seemed to be higher after the glutamatfree soup. The fundus diameter and area, however, seemed to be higher after the glutamatfree soup. These differences were, however, also not statistically significant. Conclusion: Nothing in our study supports the hypothesis that it is glutamate in foodstuffs that is the symptom-inducing factor in patients with functional dyspepsia. On the contrary, it can seem as if removing the glutamate actually makes these people worse. It is possible that glutamate in food can work by stimulating the vago-vagal reflex pathway, and consequently lead to better relaxation of the stomach after ingestion of a meal. More research needs to be done to establish if this is the case. Pneumothorax – beskrivelse av et pasientmateriale Hjelle, Kjersti Supervisor: Sverre Sørenson Seksjon for lungemedisin, Institutt for indremedisin, UiB Objectives The objective of this study was to search for more information on the subject of spontaneous pneumothorax, an acute pulmonary disease that seems to occur spontaneously without any reason. Why does it occur, and which patients are most likely to have it? By studying a patient material and register 14 different parameters, I have tried to find explanations and figure out the importance of each factor in producing disease. It was also an objective to describe the outcome of the different treatment alternatives. Methods I orderes lists of patients that were admitted with an ICD-10 diagnosis code of spontaneous pneumothorax in the years 1998 and 1999, and excluded those who were found to have an iatrogenic pneumothorax. Manually I searched all of the 98 patient records to register my 14 parameters. I have also counted the results manually. Results Basically, I found that the typical patient having primary spontaneous pneumothorax is a young, smoking man with low socio-economic status. I found no connection between physical activity and the disease whatsoever. There is a clear-cut connection between smoking and the degree of disease. Non-smokers did have a smaller pneumothorax than smokers, and sadly, three fourth of this patient population were smokers. The question is whether the high consume of cigarettes is reated to the low socio-economic status of the group or not. More than 42% of the patients with a primary spontaneous pneumothorax had some kind of “pulmonary set-back” in the immediate past or at present when they were admitted. In addition to the smoking and a possible genetic predisposition, this may have been contributing factors to the occurrence of spontaneous disease. Treatment; obviously simple aspiration (and conservative treatment) are the alternatives having the lowest degree of relapses and amount of days in the ward, but it is important to take into consideration that those patients that were treated with these methods had a smaller pneumothorax in the first place, and so we cannot assume that the good coutcome was solely because of the simple aspiration itself. Utredning av primære immundefekter hos barn med hovedvekt på bruk og tolkning av laboratorieundersøkelser Holstad, Kristin Støfring, Ingunn Supervisor: Einar K. Kristoffersen, førsteamanuensis/overlege Gades institutt, UiB/Immunologisk seksjon, Avdeling for mikrobiologi og immunologi, Haukeland Universitetssykehus Primary immunodeficiencies (PID) in children are rare disorders. This work is based on present written knowledge about PID. An overview on the different types of PID and a suggestion for which laboratorytests to investigate is presented. The immunesystem is very complex, and can be classified into four groups; cellular immunity, humoral immunity, the complement system and the fagocytic system. This work presents the immunodeficiencies according to this classification. A thorough medical history, physical examination and if necessary laboratory tests constitute the investigation. The medical history should be thorough and pinpointed, and preferably indicate the location of the defect in the immunesystem. This makes the doctor able to order laboratorytests according to the conclusions of the medical history. This work presents and describes the most useful laboratorytests used in further investigation. The tests are grouped according to which part of the immunesystem they describe. The final objective is to be able to make a quick diagnosis and to carry out the correct treatment. This can be done following our suggestion of how to investigate PID. In this perspective the investigation will be cost– and timesaving and of benefit to the patients. Kunsten å leve med atopisk eksem – og dets behandlere Hopsnes, Solveig Eide, Gunn-Vivian Supervisors: Svein Helland, professor dr.med./overlege og Tore Morken, seksjonsoverlege Institutt for indremedisin, UiB/Hudavdelingen, Haukeland Universitetssykehus Objectives: The objective of the survey was to find if there is correspondence between dermatology, alternative medicine and the patients own thoughts with regards to causes, symptom increasing factors, symptom relieving factors and different types of treatment for atopic eczema. Methods: A sizeable questionnaire was answered by 27 patients; 10 alternative therapists, 9 nurses and 14 doctors, of whom 8 were dermatologists. This article is structured in chapters. An introduction describes the methods used, amongst other topics. The following section describes facts about symptoms and findings, etiology and various types of treatment according to dermatologists and alternative medicine respectively. Next follow the results, presented in diagrams and tables. The discussion is subdivided into the topics causality, outer irritation factors, diet, climate, psychosocial relations, treatment, alternative treatment and qualitative patient information. Results: Patients with atopic dermatitis form a heterogeneous group, and their responses to treatment often show individual variation. However, the groups in the survey share views on quite a few questions. Negative effects from soap, wool and sweat, and positive effects from moderately warm climate, natural sunbathing and bathing in the sea are examples. Practically all the participants agree that genetics is the single most important etiologic factor. The major differences are that alternative therapists believe most strongly in negative effects from various food intakes, less in the effect of outer irritation factors and in recovering effects from local corticosteroids. The doctors in the survey have less faith in allergies as a cause for the symptoms. They do not regard computers or coffee as important worsening factors, and have less faith in positive effects from fatty fish and cod liver oil. The patients, in comparison to the other groups, emphasis negative effects from negative frames of mind. More or less all of them have seen good effects from moisturizing creams, sunbathing and local corticosteroids. Quite a few patients have also tried different herbal creams with a positive effect. Furthermore, the patients mention dietary restrictions and homeopathy as the best treatments within alternative medicine. Conclusions: Disagreement between the groups was relatively small. More often than not, the different groups of health workers share views. The patients will probably benefit from an open communication between the practitioners and willingness to learn from each other and from the patients. There is, however, much to gain from individually customised treatment and information regarding simple practical adjustments. Radiær keratotomi – en retrospektiv studie Høvding, Pål Ueland, Hans Olav Supervisor: Gunnar Høvding, professor dr.med./overlege Institutt for klinisk medisin, UiB/Øyeavdelingen, Haukeland Universitetssykehus During the years 1988 – 1991 215 refractive surgery procedures were performed at the Department of Ophtalmology, Haukeland University Hospital, using the method of keratotomy. Fiftyeight pasients who had undergone radial keratotomy (RK) for myopia, in some cases with an additional transverse keratotomy (KT) for astigmatism, participated in a postoperative follow-up study between 1991-1992. This paper reports the pre- and postoperative data in these patients, including their subjective opinion of the outcome of the operation. There was no statistically significant difference between the pre- and postoperativ corneal thickness after radial keratotomy. The mean reduction of spherical equivalent was 3,0D. Among the patients operated on both eyes there was a significant correlation between the reduction of myopia in the right and left eye. Only the preoperative spherical ezuivalent was found to have a significant influence on the reduction of myopia, the effect increasing with increased preoperative myopia. While the preoperative uncorrected visual acuity in the majority of most patients was only finger counting, 67% achieved a postoperative uncorrected visual acuity of 0,5 or better. As much as 95% of the patients were satisfied or very satisfied with the outcome of the operation. The degree of patient satisfaction was significantly correlated to both reduction of myopia and to postoperative uncorrected visual acuity. Glare, unstability of vision and complaints associated with driving in the dark were among the most frequently reported side effects after surgery. However, none of these problem prevented the patients from being operated on their second eye. Robotic Project Høvik, Berit Helen Supervisors: Kay E. Davies, professor og Laurence A. Bindoff, professor Department of Human Anatomy and Genetics, University of Oxford og Seksjon for nevrologi, Institutt for klinisk medisin, UiB The robotic mouse is an autosomal dominant mutant that arose from a large-scale chemical mutagenesis programme. It has a jerky, ataxic gait and develops adult-onset Purkinje cell loss in the cerebellum in a striking region-specific pattern, as well as cataracts. Genetic and physical mapping of the disease locus led to the identification of a missense mutation in a highly conserved region of Af4, a putative transcription factor that has been previously implicated in leukemogenesis. We demonstrate that Af4 is specifically expressed in Purkinje cells and that a gain of function mutation in Af4 leads to neurodegeneration. My role in this project was the morphometric analysis of Purkinje cell loss. Medisinstudenters holdninger til seksualitet Iversen, Jan Olav Supervisor: Kåre-Steinar Tveit, universitetslektor Hudavdelingen, Haukeland Universitetssykehus The medical students of today are the physicians of tomorrow. Their attitudes towards sexuality and erotica may influence their ability to talk about this subject with their patients. The purpose of this paper was to report upon medical students attitudes towards sexuality and erotica. A total of 587 students at the Faculty of Medicine and The Faculty of Dentistry at the University of Bergen, answered an anonymous self administered questionnaire concerning their own sexual experience, including questions about sexual fantasies and attitudes. Of the respondents there were 64 students of dentistry, all attending the first year of their education. The remainder of the respondents (523) were medical students at their two pre- clinical years, and in the clinical part of their education. Grouping the respondents revealed several significant differences among the respondents. Male students tended to be more erotophilic than the female respondents. Their attitudes towards an unconventional sexual life-style, were more positive then for the female respondents. Female respondents tended to be more positive towards homosexuality then the male respondents. Students who had debuted sexually, were more erotophilic then the not- debuted students. This was found both for the group of students seen as one, and when the respondents were grouped according to their sex (difference between males debuted and not- debuted, and between females debuted-not debuted). We also found that non-religious students tended to be more erotophilic, more positive towards an unconventional sexual life- style, and more positive towards homosexuality than religious students. There were no differences among students of dentistry and medical students. Several significant differences indicate great challenges in changing the attitudes towards sexuality, among the physicians of tomorrow. It is necessary to conduct further research on how students and physicians attitudes influence their ability to talk about sexually related subjects. Skjebnezapping – medisinsk grunnopplæring, legestudenters dannelse og den etiske fordring Johansson, Kjell Arne Ohldieck, Christian Aase, Margrethe Supervisor: Edvin Schei, førsteamanuensis Seksjon for allmennmedisin, Institutt for samfunnsmedisinske fag, UiB As medical students,we go through a process which profoundly alters our emotional lives, our identity and our understanding of reality. However, the development of personal insight, behavior and empathy in a professional context is to a large extent left to ourselves and is only occasionally the subject of discussion or explicitly expressed in terms of goals or ideals. The fact that current medical practice is rarely scrutinized, makes it all too easy for us to uncritically adjust to the current medical culture as expressed by the physicians` behaviour and actions. Brief and isolated confrontations with the suffering and vulnerability of patients unavoidably evoke emotional reactions in us and raises difficult questions for us. These reactions are seldom commented on or indeed dealt with as part of our formal education. In this article our own experiences of bedside teaching at the hospital will be described and illustrated with the help of key features of the ethical teachings of the Danish philosopher Knud Ejlert Løgstrup. His appreciation of man as fundamentally relational challenges the modern belief that people are separate, autonomous individuals. His philosophy also represents an alternative to the objectifying perspective of man that we become familiarised with through our medical training. Adjuvant treatment for breast cancer during 1983-91 Johnsen, Svein Joar A. Supervisor: Gun Anker Onkologisk avdeling, Haukeland Universitetssykehus Background Adjuvant hormonal therapy and chemotherapy were recommended for selected groups of patients with breast cancer since 1981. New directives for adjuvant treatment of breast cancer were given in 1988. The new recommendations suggested Tamoxifen as adjuvant hormonal therapy to patients with hormone receptor positive or hormone receptor status unknown tumors in primary breast cancer stadium 2. Additional treatment with an adjuvant CMF- regime for a period of 3-6 months was also described in the proposal. We intended to survey which adjuvant treatment was given prior to and after the new directions. We therefore recorded nodal status, hormonal treatment, chemotherapy and radiotherapy given. Methods The Cancer Registry of Norway made a selection of patients from given criteria for the periods 1983-87 and 1989-91. The study included women with: 1) diagnosed primary breast cancer in stadium 2 and 2) premenopausal condition aged 40-55. The diagnostic criteria of breast cancer stadium 2 are node positive (pN+) tumour ≤5,0cm. The total number of patients contenting the diagnostic criteria were 115 and 73 of them were treated during 1983-87 and 42 during 1989-91. Results Total number of 65 (89%) patients received adjuvant treatment during 1983-87 and 40 (95%) patients from 1989-91. 30 (41%) patients received adjuvant hormonal therapy during 1983-87 and 31 (74%) patients received hormonal therapy during 1989-91 . After distribution of new directives in 1988 20 (48%) patients received adjuvant Tamoxifen and 4 (10%) patients received during the period 1989-91. Interpretations and conclusion Our conclusion is that patients during both periods are treated according to the recommendations given. We find a significant increase in adjuvant hormonal therapy given after the distribution of new directives in 1988. Røykevaner blant medisinerstudentene i Bergen 2002 Jonassen, Trygve Valaker, Trine Supervisor: Per Bakke, professor dr.med. Seksjon for lungemedisin, Institutt for indremedisin, UiB Background: Little is known regarding Norwegian medical students' smoking habits. It's been well documented that smoking cessation is the measure with greatest potential in reducing disease. Doctors who smoke are not as involved as their non-smoking colleagues when it comes to promoting smoking cessation among their patients. Daily cigarette smoking among Norwegian doctors is now about 6%. By examining the smoking habits of today's students, we might make some predictions on the smoking habits of future doctors. Method: The study was done by handing out questionnaires at plenum lectures to all medical students at the University of Bergen during the spring term -02. The students who were not present, were reached by mail. Results: The compliance was 97%(866/894). Eight questionnaires were excluded from the study. The total included thus numbered 858. The study revealed that 53,1% of the students had never smoked, 14,1% were ex-smokers, 28,1% were occasional smokers and 4,7% reported that they smoke regularly. No differences were found regarding age, gender or how long the students had attended medical school. Interpretation: The high percentage of occasional smokers, indicates that the prevalence of smoking among Norwegian doctors will rise. The fact that one third of the students either smokes regularly or occasionally, can be taken as a sign of lacking attitudes among today's medical students towards the health hazards of tobacco use. En sammenlignende tversnittsstudie av postoperative sårinfeksjoner i et vestlig sykehus versus et sykehus i den tredje verden Jørgensen,Andreas Vik Andenæs, Amund Meidell (class 98) Supervisor: Kjell Andenæs, dr.med. In 1999 we made a protocol in co-operation with our supervisor, PhD Kjell Andenæs. The protocol was sent to two hospitals, one in Ngaoundere in Cameroon, and one in Istanbul. The purpose was to perform a comparative cross-sectional surveillance study regarding postoperative wound infections (PWI)`s in a western hospital versus an African hospital. The study and definition of PWI was mainly based on a scoring system for PWI as described in the thesis “Plastic surgery and postoperative wound infection” (16). With no clinical experience and with only a brief introduction to the subject by our supervisor, who also gave us relevant articles, most of the clinical evaluation was done by the hospital staff. We therefore were very dependent on the co-operation with the local doctors. Leukocyttmigrasjon og filterstudiet; et aktuelt og enkelt “In Vitro” studie av kjemotakse hos den polymorfonukleære leukocytt Kilhus, Kristin Stenhaug Supervisor: Alfred Halstensen, professor Institutt for indremedisin, UiB Locomotion is generally agreed to be important for the accumulation of leukocytes at sites of inflammation and infection. A variety of methods have been devised for the study of details surrounding chemotaxis and leukocyte migration. Throughout history many different methods have been presented, many of these have subsequently been replaced by newer and allegedly better alternatives. In 1962 Boyden introduced the membrane filter method. Today, the membrane filter study, with its more recent modifications, has become the technique of choice for studies of leukocyte migration in vitro. The filter membrane study utilizes commercially available and disposable chambers gathered in multichamber apparatus, this makes the method easy to learn and rapid to perform allowing multiple samples to be handeled at the same time. Factors mentioned above have most probably resulted in the great popularity and attention granted the filter study today. This assay presents basic methodological principles of the practiticability of the filter membrane study and at the same time focuses on the technical challenges and miscalculations often seen when carrying out the method. In a busy working day it often happens that blood samples are stored for some time before the laboratory assistant has time to handle and analyse them. In this connection we have examined the effect of storage on leukocyte migration. An other aspect of interest is the comparison between leukocyte migration in heparine kept cells with migration in EDTA kept cells. Heparine kept leukocytes have earlier been the alternative of choice when carrying out the filter membrane study. If it was to be proven that EDTA kept leukocytes migrate satisfactorily, these cells could be employed customarly in such studies, making it easier to procure material when already taken for other purposes. Results obtained through the laboratory work are presented and discussed. Finally, practical and theoretical experience achieved through working with this paper is evaluated. Ebola- og Marburgvirus – et litteraturstudium med fokus på Kikwitepidemien i Kongo 1995 Kjelby, Eirik Supervisor: Nina Langeland, professor dr.med. Institutt for indremedisin, UiB Ebola- og Marburgvirus cause disease which is classified as viral haemorrhagic fevers. Disease caused by Marburg virus first erupted in a research facility in Germany in 1967. The virus source was probably monkeys imported from Africa for research purposes. The Ebola virus first came to human attention during the epidemics in Zaire and Sudan in 1976. The symptoms consisted of astenia, vomitting, abdominal pain, myalgias, arthralgias, headache, fever and haemorrhagic manifestations. Some of the patients developed a characteristic maculopapulous rash. After these first outbreaks there have been numerable minor outbreaks and a few larger epidemics of Ebola. The Marburg virus has been a rarer cause of disease, but did cause a larger epidemic in the Democratic Republic of Congo (DRC) in 1999. So far four subtypes of the Ebola virus have been discovered of which three are African in origin and one comes from the Philippines. Nobody knows where the viruses originally come from. Infected primates also get sick. Primates are therefore not thought of as the host species. The virus spreads from patient to patient via body fluids and can also infect by direct skin contact with deceased. The mortality of sich patients varies from 25-90%. Death usually takes place 6-9 days after the first symptoms occur. The patients die in shock with multiorgan failure. Post-mortem examination has shown focal necrosis in multiple organs including lymphoid tissue. The diagnosis is attained from ELISA detection of IgM antibodies, virus culture or PCR-amplification. Today there does not exist any effective treatment. Hospital care concentrates on preventing spread of the infection. The Ebola epidemic in Kikwit, a city in DRC, in 1995 is described in more detail in the last part of this review. This leads to a great interest for the disease in the international press. The review focuses on the positive and negative consequences of this media interest. In addition a couple of papers which deal with recording of symptoms, epidemiological studies and a treatment experiment with full blood transfusions are described. Finally some conclusions are drawn concerning the situation today – what is being done and what should be done? Oppfølging av pasienter med små uopererte Ventrikkel Septum Defekter Follow-up of patients with small unoperated Ventricular Septal Defects Kjærvik, Cato Marskar, Bernt Johan Supervisor: Gunnar Norgård, professor dr.med. Institutt for klinisk medisin, UiB Background: The aim of this study was to assess the physical performance, general health, incidence of endocarditis and the knowledge and use of prophylactic antibiotics to prevent endocarditis in a group of children and adolescents with an isolated ventricular septal defect (VSD) too small to warrant operation. We also conducted a search in available litterature to evaluate the current guidelines and indications for closure of this type of congenital heart defect. Material and methods: A group of 33 patients diagnosed as having an isolated, small (<35%) ventricular septal defect, received a questionnaire addressing the issue of general health, physical performance and endocarditis. All patients were evaluated by heart catheterization and had a VSD considered too small to warrant operation. 17 patients completed and returned the questionnaire. We compared our results with other studies addressing these issues. Results: All patients in our study are enjoying good health and are reported to have a normal physical performance. 76% reported knowledge of routine endocarditis prophylaxis, but only 46% had actually used it at some time. 12% used it regularly. There were no incidences of bacterial endocarditis amongst our candidates. Discussion: Our study was designed to collect subjective information from patients on general health and physical performance. Other investigations addressing the same issues, but using an objective approach have found a subnormal physical performance and a higher percentage of complications than in our study. The knowledge and use of prophylactic antibiotics to prevent endocarditis is similar to other studies. No patients had suffered bacterial endocarditis. This may be due to the small number of patients included in our study and the low mean age in our study population. Considering our findings and other available studies it looks like patients with a small, isolated ventricular septal defect are in good health compared to their peers. The incidence of heart related complications is similar to the incidence of complications related to open heart surgery. The surgical techniques of open heart surgery have improved since its introduction and new non-invasive techniques are being evaluated. Conclusion: All patients in our study are enjoying good health and are reported to have a normal physical performance. The knowledge and use of endocarditis prophylaxis is not acceptable. The consequences of suffering bacterial endocarditis are severe. Prophylaxis is cheap, safe and effective in preventing bacterial endocarditis. More emphasis must be placed on communicating this knowledge to patients. Given that patients with a small, isolated ventricular septal defect are thoroughly investigated and diagnosed, we find that the guidelines for surgical closure of an isolated, small ventricular septal defect are adequate. Personlighet og prestasjoner hos en norsk sydpolekspedisjon Personality and performance among a Norwegian South Pole expedition Kristoffersen, Stian Veileder: Holger Ursin, professor dr.med. Institutt for fysiologisk psykologi, UiB Background: The right personal qualifications are assumed to be an important determinant for succeeding under extreme conditions as a South Pole expedition. To predict and measure personal qualifications is important in the selection of candidates for such tasks. Material and methods: This study follows a Norwegian South Pole expedition with four participants. The group stayed in Antarctica for 14 months from December 1999 to March 2001. Two of the participants crossed Antarctica from 21 December 2000 to 4 March 2001. The group was tested before, under and after the expedition. Prior to departure all four participants answered the questionnaire Selection of Antarctic Personnel, SOAP. SOAP is developed as part of an international research project for selecting personnel, and is tested for 300 seekers and participants in expeditions by British Antarctic Survey. The answers from the four were compared to this background material. To follow the participants’ performance we used several methods. As a measure of stress level, cortisol in saliva was taken monthly. During the Antarctic crossing the skiers answered “Antarctic Questionnaire”. As soon as possible after arrival Norway we did an individual debriefing using a structured interview based on Antarctic Questionnaire. The purpose of this interview was to get an impression of the performance of the group and each of the participants. Results and interpretation: The SOAP-questionnaire unveils a significant difference of personality between the two main participants of the expedition. Debriefing tells that to the extent there were conflicts within the group, these two were the ones involved. This study suggests that SOAP could be useful in selecting personnel for tasks like this. Høy alder og kirurgi? En oppfølgingsstudie av pasienter eldre enn 85 år operert ved Haukeland sykehus kirurgiske avdeling Kvelvane, Christer Lindblad, Martin Supervisors: Åke Andrén-Sandberg, professor og Odd Søreide, professor Institutt for kirurgiske fag, UiB Background: The surgeons often have to consider whether the patient should be operated or not. Normally, surgeons use generelly accepted indications or common criteria to decide whether surgery is indicated or not. But when concidering indications for surgery on very old patients, other criteria might be added. Such considerations must be based on factors known to predict outcome, for instance mental status and home situation. How does age affect the potential benefits from surgery? Methods: In a retrospective cohort study based on patient journals at the Department of surgery Haukeland University Hospital, 62 elderly patients above 85 years of age, undergoing surgery during year 2000, were followed up with telehpone-interview two years postoperative. Data elements recorded were age, sex, diagnosis on admission, past medical history, mental status, Karnofski Index, postoperative stay and home situation. We devided the population into groups for survivors and dead, and compared the two groups, related to potential prognostic factors. Results: After a follow up of two years, 37 of the subjects were dead and 25 had survived. We found that in the group of those patient who died; there were more acute operations, they had more often deteriorated mental status, their past medical history were more serious and they often came directly from an other institution. Based on the diagnosis at admission, it was one particular diagnosis that was more frequent in the group of the dead, that was arterial insufficiency. Conclusions: Patients surviving two years have maintained their quality of life. Therefore age per se should not be a single factor in determining treatment strategy. Factors found to influence outcome negatively were; impaired mental status, low Karnofski-index, serious past medical history and admission directly from an institution. Patients admitted for arterial insufficiency carry a special risk, but this can probably be explained on the basis on the mentioned factors. Mot utryddelse av polioviruset – strategier, utfordringer og gjenstående problemer Kvideland, Katrin Lysberg, Ane Supervisor: Maja Sommerfelt Grønvold, professor Avdeling for mikrobiologi og immunologi, Gades institutt, UiB For centuries poliovirus has been sweeping the world, destroying the lives of millions by causing disease, paralysis and even death of the ones touched. In its wake there are still more millions affected by the dreaded disease of poliomyelitis; the families, the friends and relatives of the victims. Knowing that by far the greatest group of victims are young children, only adds to the disaster. The World’s Health Organisation launched a brave new program I 1988, namely the resolve to eradicate poliomyelitis and its etiologic agent, poliovirus, from the face og the earth by 2001. The time estimate has since been changed to 2005. By May 2003 the number of countries where poliovirus is endemic had decreased from 127 in 1988, to seven. To reach this ambitious goal, the WHO has worked out elaborate strategiew. The simple premise is to vaccinate as many as possible of the young children under five years of age in all endemic countries, and in this way immunise entire generations. The vaccine of choice is the OPV, oral polio vaccine, consisting of attenuated virus and developed by Dr. Albert Sabin in 1961. The Eradication Program also includes provisions for surveillance of polio occurrence, strategies for ending the vaccinationactivities and the safe containment of the virus in a world free of polio. In this paper we examine the strategies for a successful vaccination operation, and the challenges met by the WHO during this work, such as warfare and frequent cross-border population movement. We also look at the preparations for ending the vaccination program, and lastly we discuss the calculated risk of keeping this hazardous virus confined to laboratories once eradication is complete. Er det kroppen min? Ei empirisk kartlegging av kroppsbilete hos gutar og jenter. Laupsa, Lena Nævdal, Randi Supervisor: Kjell Morten Stormark, førsteamanuensis II Regionsenter for barn og unges psykiske helse, UiB Background: Previous reports suggest that there are major differences between hos males and females view their own body. The purpose of this study was to empirically investigate how males and females estimate their body size. Material and Mathods: Twenty-three male and twenty-eight female, healthy young adults were presented with a series of pictures of themselves, another person and an object, which were manipulated in width, so that the motifs appeared either narrower or wider than real size. The subjects were asked to adjust the width of the motifs to what they recognized as the original size. Results: No total differences between males and females in their estimation of the pictures were found. The females significantly underestimated the picture of the other person, and also tended to underestimate the pictures of themselves compared to the males. Conclusion: These findings support the idea that there are gender differences in estimation of body size. Sammenhengen mellom plasmakonsentrasjon av Vaskulær Endotelial Vekstfaktor (VEGF) og IGFBP-3 proteaseaktivitet hos brystkreftpasienter Lehmann, Sjur Supervisor: Svein Inge Helle, overlege dr. philos. Onkologisk avdeling, Haukeland universitetssykehus Angiogenesis is one of the key elements in the process of tumour growth and metastasis. Previous studies have shown elevated levels of the important angiogenetic growth factor Vascular Endothelial Growth Factor (VEGF) in cancer patients. There is also an increase in the activity of spesific proteases for Insulinlike Growth Factor - Binding Protein - 3 (IGFBP-3 protease). As VEGF increases capillary permeability and IGFBP-3 protease is abundant in extracellular fluid, we hypothetised a positive correlation between plasma levels of these parameters in breast cancer patients. EDTA-plasma from 54 breast cancer patients with known protease activities was sampled and VEGF-levels determined by ELISA. Statistical analysis of the results indicated a positive, though not significant, correlation (p=0.228). Mean VEGF concentrations for samples in the high protease activity range were compared to samples in the low activity range, yielding no significant difference. Conclusion: No significant correlation could be demonstrated between IGBP-3 protease acticity and VEGF concentration in these samples. Tuberkulose ved Haukeland sykehus i 1989 og 1999 Lied, Anbjørn Elgvin Supervisor: Odd Mørkve, førsteamanuensis, overlege, dr. med. Senter for internasjonal helse, UiB Setting: Treatment for tuberculosis at Haukeland University Hospital, Bergen, Norway Objectives: To investigate resistance, cure rate, symptoms and adverse effects associated with tuberculosis and treatment for tuberculosis in a Norwegian city. Design: A retrospective analysis of 28 patients with tuberculosis in 1989 and 1999. Results: Resistance: Isoniazid (18%), streptomycin (21%). We did not find resistance for rifampicin, ethambutol or multidrug resistance. The cure rate was 79%, 7% died, and 14% defaulted. Most frequent symptoms where cough with or without sputum and unspecific symptoms. Haemoptysis occurred rarely. 11% did not have any symptoms. 33% experienced serious adverse effects. These resulted in suspension of one drug in half of the cases. Most frequent where: Skin rash with itching, gastrointestinal disturbances and fever. Conclusion: In this study there is a higher occurrence of resistance than in comparable countries. The cure rate is below WHO target, this is mainly caused by a high proportion of immigrants. The symptoms have changed compared to the traditional, with a very low occurrence of haemoptysis. Serious adverse effects where common, but did not result in discontinuation of therapy. Effekt av “dobbel glutamat” hos pasienter med funksjonell dyspepsi Lilleøren, Unn Hege Supervisor: Trygve Hausken, professor dr.med./overlege Institutt for indremedisin, UiB/Gastroenterologisk seksjon, Medisinsk avdeling, HUS Background/Aims: Patients with functional dyspepsia often have meal-induced dyspeptic symptoms. They seem to react particularly strong after ingestion of clear meat soup rich on glutamate (Toro Klar Kjøttsuppe). A former study examined the possibility that it could be the content of glutamate (MSG) in the soup that was responsible for the intense symptoms found in these patients after ingestion of the soup. The results did not support this hypothesis. On the contrary it seemed that removing the glutamate from the soup made the symptoms worse. We wanted to examine whether a increase in the glutamate-content of the soup would further improve the symptoms in these patients. Method: In 10 patients with functional dyspepsia, symptoms (pain, nausea, epigastric fullness, epigastric discomfort and satiation) was recorded by a visual analoge scale (VAS) before, at 0 min, 10 min and 20 min after ingestion of 500 ml clear meat soup in 4 min. The area of gastric antrum and sagittal fundus, and the frontal diameter of the fundus was recorded, as measured with 2D ultrasound, before, at 0 min, 10 min and 20 min after ingestion of 500 ml clear meat soup in 4 min. In all subjects this was recorded on two separate occasions, where they, in randomised order, on one occasion were served clear meat soup with single dose of glutamate, on the other clear meat soup with double dose of glutamate. Except of the glutamate-content, the two soups were identical. Results: Total scores of the symptoms showed a tendency to be lower at 10 min and 20 min after ingestion of the suop with double dose of glutamate. The differences were not statistical significant at neither 10 nor 20 minutes. At 0 min after ingestion of soup the total scores of symptoms were virtually identical for the two soups. Differences in ultrasound recordings were only significant for frontal diameter of the fundus at 0 min after ingestion of soup (p=0,04). There were a slight tendency, though, of the antral areal, fundusareal and the fundusdiameter to be higher after ingestion of soup with double dose of glutamate, but these differences were, however, not statistically significant. Conclusion: Our results supports the hypothesis that glutamate may improve the intensity of symptoms, gastric accomodation and visceral hypersensitivity in patients with functional dyspepsia. However, the results were not statistically significant. More research need to be done to establish if this is the case. Antibodies against Enterotoxigenic Escherichia coli and Vibrio cholerae in Young Children in Bhaktapur, Nepal Lindemark, Frode Supervisors: Harleen M.S. Grewal, førsteamanuensis og Tor A. Strand, stipendiat Avdeling for mikrobiologi og immunologi, Gades institutt og Senter for internasjonal helse Introduction: Diarrheal diseases are estimated to account for up to a quarter of childhood deaths in developing countries. Community-based studies have identified enterotoxigenic Escherichia coli (ETEC) as the most frequent cause of diarrhea among children under five. ETEC and Vibrio cholerae produce immunologically cross-reacting toxins [LT and cholera toxin (CT), respectively] that play a key role in their pathogenicity. Protection against these infections is probably mediated by antibacterial antibodies at the mucosal surface in the gut and by secretory IgA antitoxin antibodies. In order to be efficacious, vaccines against enteric infections should induce a specific secretory IgA (SIgA) as well as an adequate systemic immune response. Serum anti-toxin antibodies (against ETEC LT and CT), though a marker of prior exposure, may not reflect protection. Objectives: 1) Describe natural immunity to ETEC infections; and 2) describe age specific antibody levels at baseline in a group of Nepali children that participated in a vaccine trial. Design: We determined age specific vibriocidal and anti-toxin antibody levels at baseline in 94 Nepali children 32 - 59 months of age who took part in a trial examining whether zinc modulates the immune responses to a cholera B subunit toxoid whole cell vaccine (Dukoral®). Results: In the analyses of 66 and 69 sera, there were no associations between age and the levels of anti-CTB IgG or IgA, respectively, at baseline. Furthermore, there were also no associations between age and vibriocidal antibody levels (n=94). Prionsykdommer Lund, Stein Arve Supervisor: Maja A. Sommerfelt Grønvold, professor Avdeling for mikrobiologi og immunologi, Gades institutt, UiB Prion diseases are a group of rare yet fatal neurological diseased affecting both animals and man. The most widely known members of this group are Creutzfeldt-Jakob disease (CJD) and Kuru in man, Scrapie in sheep and Bovine Spongiform Encephalopathy (BSE/”Mad Cow Disease”) in cattle. Disease arises when a naturally occurring hos protein, the prion, acquires an altered secondary structure that is resistant to natural breakdown and accumulates in the cell. These diseases can be inherited or occur sporadically. Transmission can be iatrogenic between patients through the use of surgical instruments, the use of human derived growth factor and cornea and dura mater grafts. In the mid 1980’s a severe epidemic of BSE developed amongst cattle in the United Kingdom. It is most likely that the animals became infected through consumption of industrial feed derived from slaughter waste. BSE is now considered to be the most probable cause of a new prion disease in humans called variant CJD (vCJD) acquired through the ingestion of contaminated beef. Due to the long incubation period it is not yet clear how many people are affected. Diagnosing prion diseases is difficult. Brain biopsy is not generelly recommended. At present the only definitive diagnosis can be made at autopsy. Sampling of interstitial fluid in mice by subcutaneous and intermuscular wicks Markhus, Carl Erik Supervisor: Helge Wiig, professor dr.med. Seksjon for fysiologi, Institutt for biomedisin, UiB Colloid osmotic pressure (Л) is one of the factors determining transcapillary fluid flux. By use of a wick method, first described by Aukland and Fadnes (1) and later modified for use in muscles by Wiig (2), we were able to isolate interstitial fluid from mouse subcutis and skeletal muscle. Three-stranded, dry nylon wicks were inserted post mortem to avoid local inflammation and thus, eliminating protein extravasation and wick fluid contamination. Wick fluid Лi (in mmHg) averaged 18.7 ± 2.2 (means ± SD) in plasma and 9.1 ± 2.1 and 12.5 ± 1.7 in subcutis and muscle, respectively. The corresponding albumin and globulin concentrations (in mg/ml) were 31.5 ± 2.8 and 11.0 ± 1.6 in plasma, 20.3 ± 3.0 and 2.9 ± 0.5 in subcutis and 21.3 ± 1.1 and 3.2 ± 0.6 in muscle. HPLC analysis of plasma and wick fluid, al showed similar patterns, with peaks at 7.7 ml and 11.4 ml, representing the globulin fraction, and a peak at 12.8 ml, representing the albumin area. Only a minor peak in the myoglobin area was observed, indicating an almost insignificant leakage of intracellular proteins to wick fluid, both from subcutis and muscle. Plasma protein extravasation, evaluated by leakage of 125I-human serum albumin, showed that contamination of wick fluid by plasma proteins was negligible. Induction of net capillary filtration by injection of saline, led to average Л of 14.5 ± 1,4m 6.8 ± 0.8 and 7.7 ± 1.0 mmHg in plasma, subcutis and muscle, respectively. We conclude that the wick technique easily can be adapted for use in mice, and may represent a reliable method to isolate interstitial fluid and to study transcapillary fluid flux in this species. Regulering av angiogenese i aggressive maligne melanomer Mathew, Seema Supervisor : Lars A. Akslen, professor Avdeling for Patologi, Gades institutt, UiB A malignant melanoma is a melanocyte-derived tumor that originates primarily from nevi. This is among the cancer forms that are increasing in the western world. Ultraviolet radiation, sunburns in childhood, fair skin type, familial occurrence and multiple moles are important risk factors. Since the response to radiation treatment is low, the first choice of treatment is surgical excision. The prognosis, being related to Breslow's tumor thickness, decreases with thickness > 3,5mm. Tumor cells need sufficient nutrients and oxygen for growth and metastasis. This is due to a balanced interplay between pro- and antiangiogenic factors. bFGF, VEGF, IL-8 are among factors that act synergistically. bFGF induces neovascularisation by both autocrine and paracrine mechanisms. The aim of the project was to look into the importance of bFGF in angiogenesis and tumor progress. A total of 202 human tissue samples from aggressive malignant melanomas and lymph nodes were analyzed by immunohistochemistry and TMA technique to identify bFGF. bFGF and its association with different parameters (mean vessel density, prognosis, etc.) was determined by the SPSS statistic program. 78% of the tumor associated endothelium showed positive staining for bFGF, whereas few of the tumor cells (29%) were FGF+. As expected, bFGF expression was correlated to mean vessel density. In addition, we found significantly increased lymph vessel density and survival with FGF positive endothelium. The latter finding is probably attributed to FGF's role as a differensiation factor in endothelial cells. The conclusion must be that FGF is a factor vital to the stimulation and upholding of adequate vascularisation, but it is not the most decisive factor for tumor growth and metastasis. Individual factors can modulate the effects of others, and more studies are needed. The challenge lies in finding effective antiangiogenic therapies. DiGeorges syndrom Seks pasienter – en kasusserie fra Senter for Medisinsk Genetikk Melhus, Janne Dahle Supervisor: Jaran Apold, professor Senter for medisinsk genetikk, UiB DiGeorge´s syndrome has been recognized since 1965, and the most extensive part of the research related to the syndrome has been focused on the most common malformations; the cardiac features, cleft palate, thymus- and parathyroid gland-hypoplasia and the characteristic facial features. The patients are found to have a deletion of the long arm of chromosome 22, a defect which arises a spontaneous mutation in 80-90% of the cases, and it is inherited in an autosomal dominant pattern. The deletion occurs in 1 of 3000-4000 individuals. This paper reviews the medical records of six patients who have been referred to the Center of Medical Genetics at Haukeland University hospital in Bergen, Norway. The cases demonstrate the great need for multidisciplinary care, which is highly developed in Norway, but they also reveal that the majority of the patients have already reached puberty before they are diagnosed. This fact suggests that there is a lack of knowledge about the syndrome among the primary care centers and in the pedagogic- psychological service for schoolchildren. The reviewed cases also show that we still know too little about the language- and learning disabilities and psychiatric problems these patients face, and the hope is that these areas will receive greater attention in the future. Er det skadelig for hørselen å spille i brassband? Moen, Henrik Sundt Supervisor: Ola Lind, overlege dr.med. Høresentralen, Haukeland universitetssykehus Sound pressure measurements were performed in five different brass bands, and a questionnaire regarding the experience of the sound pressure among 164 brass band musicians was also performed. On the background of audiometry measurements performed in similar studies in symphonic orchestras, and by comparing sound pressure measurements performed in brass bands, the goal was to find out if playing in brass band is a hazard to hearing, and also if the sound pressure is in conflict with official regulations (Forskrift om støy på arbeidsplassen). The results show that the sound pressure in most cases exceed the limits set by official regulations. At the same time, playing in brass band does not seem to be a hazard to hearing. Nevertheless, the questionnaire shows that there is a widespread opinion that there is a too high sound pressure in brass band, and that there is a concern for the future consequence on hearing from the high sound pressure level. The epidemiology of tuberculosis Mokgwathi, Gaorutwe Supervisor: Aksel Schreiner, professor Institutt for indremedisin, UiB Tuberculosis kills 2 million people each year. The global epidemic is growing and becoming more threatening. The breakdown in health services, the spread of HIV/AIDS and the emergence of multi-drug resistant TB are contributing to the worsening impact of the disease. In Africa in the last decade, HIV is the single most important factor that determines the increased incidence of TB. The objectives of TB control programmes are to reduce mortality, morbidity and disease transmission, while avoiding the development of multi-drug resistant TB. The WHO recommended treatment strategy for detection and cure of TB is the “Directly Observed Therapy Strategy” (DOTS). The epidemiological surveillance methods are the tuberculin test, the chest X-ray, and the bacterial examination of sputum by microscopy and culture. The administrative and environmental control measures are aimed at reducing M. tuberculosis tranmission. As an example, a brief analysis of the TB programme in Mahalaphye district is described. Døgnvariasjoner har ikke stor innvirkning på serumverdier av løselige (s) L- selectin, s-intercellulær adhesjonsmolekyl-1 (sICAM-1) og trombopoietin (TPO) hos friske voksne. Circadian variations do not have a major impact on serum levels of soluble (s) l-selectin(CD63l), s-intercellular adhesion molecule 1 (sICAM-1/CD54) and trombopoietin in healthy individuals. Mosevoll, Knut Anders Supervisor: Øystein Bruserud, professor Institutt for indremedisin, UiB Several studies have been done to reweal how leukocytes migrate, and which mediators that modulate migration. Several soluble adhesion molecules and cytokines are important mediators, and can be detected in human serum. Some of these mediators show altered serum levels in hematopoietic malignancies, autoimmune diseases or serious infections. In the present study we examined whether serum levels of soluble (s) L-selectin and soluble intercellular adhesion molecule-1 (sICAM-1), that both are expressed by immunocompetent and hematopoietic cells, and the hematopoietic growth factor Thrombopoietin (Tpo) show circadian variations in healthy adults. The results reweal that venous serum levels of all three mediators showed only minimal variations when measured regularly during a 24 hour period. In contrast, previous studies have demonstrated that these levels are markedly altered for example during serious bacterial infections. Taken together my results demonstrate that serum sampling at standardized times is not necessary in future studies of the possible clinical use of these serum levels. Resistance to anti-tuberculosis drugs in Mycobacterium tuberculosis with emphasis on drug resistant strains isolated in Botswana Motswakadikgwe, Thusego Supervisor: Bjarne Bjorvatn, professor Senter for internasjonal helse, UiB 1995-1996 SURVEY: Background: Botswana, southern Africa, were the tuberculosis (TB) case rate increased by 120% from 1989 to 1996 in spite of a decade of implementation of the directly observed therapy, short course (DOTS) strategy. Objective: To determine the prevalence of and risk factors for drug-resistant TB in an epidemic setting. Design: Systematic national random survey of newly diagnosed pulmonary TB and all patients requiring retreatment during 1995-1996. Interviews were conducted, human immunodeficiency virus (HIV) testing was offered, and drug susceptibility testing was performed on isoniazid, rifampicin, streptomycin and ethambutol. Results: Resistance to at least one drug was identified in 16 (3.7%) new cases (95% Confidence Interval (CI) = 2.2-5.8) and 18 (14.9%) retreatment cases (95% CI=9.3-22.1). One (0.2%) new case (95% CI=0.01-1.5) and seven (5.8%) retreatment cases (95% CI=2.6- 11.1) had resistance to at least isoniazid and rifampicin (multidrug-resistant TB). Retreatment cases with MDR-TB were significantly more likely to have worked in the mines in South Africa than were cases with fully susceptible isolates. Of 240 patients tested for HIV, 117 (48.8%) were positive; the prevalence was similar among new and retreatment cases, and was not a risk factor for drug resistance in either group. Conclusion: During the HIV and TB co-epidemics in sub-Saharan Africa, widely implemented DOTS may help to control drug-resistant TB. However, the TB case rate can be expected to continue to climb in spite of the implementation of the DOTS strategy. 1999 SURVEY. Background: Botswana, where HIV prevalence was 38% among adults and the TB rate was 584/100,000 in 2000. A 1995-6 survey demonstrated low levels of anti-TB drug resistance. Objective: Because TB drug resistance may increase rapidly in HIV-infected populations, a second survey was undertaken in 1999 to determine any increase in anti-TB drug resistance. Design: Sputum specimens positive for acid-fast bacilli from patients without prior TB treatment (new patients), and all sputum specimens from all patients reporting prior TB treatment (retreatment patients) were collected nationwide. Specimens were cultured for Mycobacterium tuberculosis and tested for resdistance to isoniazid, rifampicin, ethambutol, and streptomycin. Results: January to May 1999, 783 patients were consecutively enrolled from all districts. Of these, 483 (61.7%) were male, median age was 33 years, and 82% were new patients. Drug resistance occurred in 6.3% of new patients (95% CI=4.6-8.6) and 22.8% of retreatment patients (95% CI=16.5-30.1). Resistance to at least isoniazid and rifampicin (=MDR-TB) was found in 0.5% of new (95% CI=0.1-1.3) and 9.0% of retreatment patients (95% CI=5.1-14.5). Concusion: Despite the high HIV prevalence, antituberculosis drug resistance remains relatively low in Botswana, probably as a result of a well-functioning TB programme. Periodic surveys will be essential to adequately determine any significant trend. Hypoglykemi hos diabetikere – med fokus på hypoglykemi-assosiert autonom svikt og “unawareness” Mulelid, Runar Supervisor: Hrafnkell Thordarson, seksjonsoverlege Endokrinologisk seksjon, Medisinsk avdeling, Haraldsplass Diakonale Sykehus Hypoglycemia is the main limiting factor in the treatment of diabetes mellitus type 1. Hypoglycemia normally causes a neuroendocrine reaction including increased production of glucagon and adrenalin. However, repeated hypoglycemic episodes reduce this response in many diabetic patients. This is called hypoglycemia-associated autonom failure and leads both to defective glucose counterregulation and disappearance of normal hypoglycemic symptoms (unawareness). The patients will therefore reach neuroglycopenia directly with reduced cognitive function and reduced consciousness. This makes it difficult for the patient to help himself. Hypoglycemia-associated autonomic failure and unawareness therefore increase the risk of severe hypoglycemia. Even though hypoglycemia happens much more seldom in patients with diabetes mellitus type 2 than in those with diabetes mellitus type 1, experiments have shown that patients with advanced type 2 disease can develop hypoglycemia-associated autonomic failure in the same way as patients with diabetes mellitus type 1. Several experiments have shown that unawareness can be reversed if the patient avoids hypoglycemia over a period of 2-3 weeks. This way the patient can regain symptoms of hypoglycemia at higher glucose levels than what is necessary for cognitive dysfunction. Experiments also show that the adrenalin component of the counterregulation – at least partly – can be increased if hypoglycemia is avoided. However, in practice it is very difficult to both manage good metabolic control and avoid hypoglycemic episodes at the same time. Many therapists will doubt if this is possible with the technology and treatment of today. The challenge is to make treatment procedures which ensure good metabolic control, but which at the same time reduce the frequency of hypoglycemic episodes. Skadeforekomst i norsk judo med særlig vekt på kneskader Injuries in Norwegian judo, with emphasis on knee injurie. Myrebø, Esther A. Supervisor: Sverre Mæhlum, dr.med. Pfizer Norge AS The intention of this survey was to get an overview of the injuries occurring in Norgegian judo, particularly looking at knee injuries, as there seemed to be an increase in serious knee injuries among competitors at a high level. There has never been a similar survey in Norway. A special questionnaire was made. The sample is small and cannot be considered, representative, since the total population (judo players aged 14 and more registered with the Norwegian Judo Federation) is unknown for the period as the federations register was lost just before the questionnaires were sent out. No conclusions can therefore be drawn. Totally 114 persons was included in the survey two years after the beginning of the study, 77 men and 37 women. 107 of these were still active in judo, seven had quit because of injuries, 3 by injuries caused in judo (we have no information as to what kind of injuries caused this). The injury rate was 52%. This is very high compared with other studies, and is probably an expression of a biased sample. We did not find any difference in the frequency of injuries between the sexes. The highest rate of injury was among senior competitors at a high level with many years of experience in judo. The rate among beginners was considerably lower at 21%. Most injuries were to shoulder, elbow, knee and ankle. This is in concordance with other studies. This survey, while not conclusive, can be used as a reference for new studies. These should be based on a greater population based on e.g. registers from the federation and new revised questionnaires sent to each individual. Supraventrikulære tachykardier som følge av ekstra ledningsbaner mellom atriene og ventriklene Nakling, Christian Supervisors: Ole Jørgen Ohm, professor/overlege og Jian Chen, post doktor Institutt for indremedisin, UiB og Hjerteavdelingen, Haukeland universitetssykehus Background Supraventricular tachycardias (SVT) caused by extra conduction pathways between the atria and the ventricles are relatively common disorders, and some have quite annoying symptoms. The aim of this study was to review the options of treatment for SVT and evaluate symptomatology and the results and complications of radiofrequency ablation (RFA). Material and methods To find the success- and complication rate of RFA, the results of all patients with SVT treated by RFA at Haukeland sykehus from 01.01.01.-30.09.01 were investigated. Three different types of SVT (atrioventricular nodal reentry tachycardia = AVNRT, Wolff Parkinson White Syndrome = WPW-syndrome and concealed accessory pathway =concealed AP) were studied. 56 patients had AVNRT (38 women and 18 men), 18 had WPW-syndrome (6 women and 12 men) and 14 had concealed AP (6 women and 8 men). The patients had an age range of 7-78 years (mean 42.2 years). In addition 20 patients hospitalized due to RFA treatment were interviewed with focus on symptoms and complaints during daily activities. A quality-of-life form was filled out by every patient. These forms were made especially for this study. Results The RFA treatment was successful in 55 of 56 patients (98,2 %) with AVNRT, 15 of 16 patients (83,3%) with WPW-syndrome and 14 of 14 patients (100 %) with concealed AP. Generally there were few complications. In the patient group with AVNRT, two developed transient pericarditis and one developed an temporary AV-block. One of the patients with concealed AP developed transient pericarditis after the RFA treatment. The quality-of-life study reflected that most of the patients had some annoying symptoms, but only a few were markedly affected in their daily activities. This affection was influenced by the duration and frequency of the SVT attacks, and by precipitating factors of the attacks. Conclusion SVT caused by extra conduction pathways between the atria and the ventricles is treated effectively by RFA. There is a high rate of success and a low complication rate. The patients are permanently healed, avoid side effects of antiarrhythmic drugs and often achieve higher quality of life. This makes RFA a treatment of first choice to patients with these types of heart rhythm disorders. Depresjon og koronarsykdom Nesheim, kjersti Supervisor: Ottar Nygård, overlege/post doktor Hjerteavdelingen, Haukeland universitetssykehus/Institutt for indremedisin, UiB Background: Coronary heart disease and depression are both significant health problems. Data suggest a connection between the two diseases. Purpose: To critically evaluate data that suggest a connection between disorders, discuss possible mechanisms that may underlay the association, and assess if this should influence the treatment of choice of the diseases. Method: A literature study using the literature database PubMed. The most important search items are ”mental depression”, ”myocardial infarction”, and ”coronary artery disease”. Conclusion: Data from prospective studies do not suggest that depression leads to development of coronary heart disease and myocardial infarction. There is however good documentation that depression is associated with a 30-40 % increased risk of reinfarction and death after acute myocardial infarction. The elevated risk can be caused by increased activity in the sympathetic nerve system, increased peripheral serotonine level and altered platelet activity. The effect on the long-term prognosis can also be caused by an unfavorable health behavior among depressed patients. There are still no data from large-scale randomized studies that may clarify whether medical antidepressant treatment can improve prognosis among depressed patients with coronary heart disease. A recent study however shows that sertraline may be safely administered and improves depressive symptoms among patients with acute myocardial infarction. The treatment was also associated with a clear, but non- significant reduction in overall cardiovascular events during follow-up. Trengs det nye retningslinjer for håndtering av pasienter med lette hodeskader ? Nummedal, Bjørnar Supervisor: Haldor Slettebø Nevrokirurgisk avdeling, Haukeland universitetssykehus Mild head injury is a common cause of admission to Norwegian hospitals. The objective of the management of patients with mild head injury is early detection and treatment of intracranial hematomas, which is a rare but potentially fatal complication. The article focuses on today’s management of mild head injury patients in hospitals, and to determine whether it is suitable to introduce new management guidelines. The article shows that there is considerable management variation between hospitals. About half of Norwegian hospitals admit by routine all mild head injury patients. It is advocated that CT scan could be used more efficient in the management. New management guidelines are suggested based on literature, that include use of Head Injury Severity Scale (HISS), more extensive use of CT scan and early discharge of patients with minimal risk of complications. The introduction of the suggested guidelines would be cost saving without reducing the quality of the management of patients with mild head injury. Folat og svangerskap Nystad, May Britt Petersen, Therese Supervisors: Anne Kjersti Daltveit, førsteamanuensis og Stein Emil Vollset, professor Seksjon for forebyggende medisin og Seksjon for medisinsk statistikk, Institutt for samfunnsmedisinske fag, UiB Introduction: The National Council on Nutrition and Physical Activity, Oslo, recommended in 1998 that Norwegian women planning pregnancy should take folate-subtitutes before conception and in the three first months of pregnancy to reduce the risk of neural tube defects. Their report recommended information campaigns towards fertile women and health workers as information providers. We wanted to find out whether the use of folate related to pregnancy has increased after this recommendation, and in which way health personnel help increasing knowledge. Material and methods: Part I - Using data from the Medical Birth Registry of Norway, with information about 176 929 womens pregnancies during the period 1999-2001, we have looked for the association between folate/multivitamin use and variables like socio-economic, geography and smoking. Part II - We have done an interview with 24 public health nurses within Bergen community about their knowledge, attitudes and practice when it comes to information about folate to fertile women Results: Part I - Women`s use of folate and multivitamins before and during pregnancy has increased in the period 1999-2001. The folate use before pregnancy increased from 4.1 % to 8.9 % in this periode. Largest increase in folate use was during pregnancy from 15.3 % to 28.2 %. Those who use most folate are women above 30 years of age, married or cohabitants, women working fulltime, women giving birth for their first time and women living within the health region east*. Smoking is negatively assosiated with folate use. Part II - Public health nurses within Bergen municipality that information about folate and pregnancy is important, but they do not regard it as their task to inform fertile women about it. They state that reason for this is that they do not see the target group in the right period of time. Their knowledge about folate is good, but nearly half of them did not know that folatesupplements is important also before conception. Conclusion: Our data shows that the recommendations from the National Council on Nutrition and Physical Activity has reached fertile women, some groups more than others. This can be used in the planning of new information campaigns to reach those with less knowledge. The knowledge has also reached the public health nurses, but they do not give knowledge to fertile women. They have insufficient knowledge about when folate supplements should be taken, this can explain why they do not regard themselves as natural intermediary of this knowledge. We regard the public health nurses as an important provider of information about folate through the school health service and health station work if they are informed that folate is important to take also before pregnancy. Even though the knowledge and use of folate for health personnel and fertile women has increased in the periode 1999-2001, the usage is still too low to expect a significant decline in the number of neural tube defects. Kontroll med egen helse før og etter utryddelse av Helicobacter pylori ved ulcussykdom Nytrøen, Gunhild Supervisor: Ingvard Wilhelmsen, professor, dr.med/overlege Institutt for indremedisin, UiB Background: The role of psychological factors in peptic ulcer disease is still open to discussion. Aim: To examine health locus of control in patients before and after eradication of Helicobacter pylori. Our hypothesis is that their sense of control regarding own health will increase if they are cured of their ulcer disease. Methods: 74 H.pylori-positive patients with relapsing duodenal ulcers and 78 control subjects without dyspepsia where included in a prospective, controlled trial. The patients were compared to normal controls two years before and ten years after eradication of H.pylori. Patients and controls answered 18 questions in a questionnaire called Health Locus of Control Scale (HLCS). HLCS records whether individuals believe that their health is controlled by internal, external or chance factors. Results: At the time of inclusion there was no significant difference in patients and controls regarding health beliefs. At the 10 year follow-up external and chance beliefs were not significantly different, but the patients had significantly less internal control than the controls. Conclusions: These results are inconsistent with our hypothesis. It turned out that the patients attained a feeling of having less internal control after their peptic ulcer had been cured. This was found by comparing them to themselves 10 years ago, and in comparing them to the normal controls now. Perhaps the healthy controls have an unrealistic belief that one can control one’s health. While the patients who have gone through a long period of illness, followed by a period of good health, have learned that life is uncertain. Through this the patients become more aware of the fact that humans have little influence over our health. Medikamentell behandling i svangerskapet Nøkling, Cathrine H Supervisor: Anders Lund, professor Seksjon for psykiatri, Institutt for klinisk medisin, UiB Objective: This paper discusses medical treatment of depression during pregnancy. The arguments for treating a depression with medicaton versus the possibility of adverse effects with prenatal antidepressant exposure on perinatal outcome are discussed. To assist physicians in optimizing treatment plans for childbearing women with depression, a guideline for medical treatment is presented. A decision-making plan to structure the information given to the women in the context of a risk-benefit discussion is also presented. Method: A search on the words “depression”, “pregnancy” and “antidepressant” was done on medline from 1993-2003. The articles that were used are all published in well recognized journals. Results: Neither tricyclic antidepressant (TCA) nor selective serotonin reuptake inhibitors (SSRI) is associated with major birth defects. Two studies suggest an increased risk of low birthweight, premature birth and a decrease in Apgarscore when exposed to SSRI during third trimester. Untreated depression is also known to increase the risk of low birthweight and early delivery. Conclusion: Women with moderat to severe depression should receive somatic antidepressive treatment since the adverse effects of a non-treated fulminant depression is considered most serious. To ensure good compliance, it is essential that the patient receive information regarding the disease, its possible treatment options and outcome. The physician must identify the womans perception of risk and “significant others” who might influence the decision-making process. Sjelelig næring i oppveksten – om behovet for myter og eventyr The Spiritual Nourishment of Children and Young People - about the need for myths and fairy tales. Ohldieck, Annabel Supervisor: Jon Geir Høyersten, overlege Sandviken sykehus The aim of this study is to elucidate the function of myths and fairy tales in children's and young people's search for meaning and identity. It is written in the light of the current cultural environment's significance for the way in which the individual perceives him/herself and the world. Background material for this study is gleaned from the work of a number of prominent psychologists and psychiatrists. They maintain that a range of psychological illnesses are the result of the lack of myths in today's society, which could otherwise provide ways of understanding the world. Harvard psychologist, Jerome Bruner states, “ When the prevailing myths are no longer adjusted to the changes in man's condition, frustrations will arise; firstly in the form of a mythoclast, and then in the lonely search for an inner identity.” Developments in recent history have promoted science and rational thinking, perhaps at the expense of the forms of understanding that myths represent. This development contrasts considerably with earlier times and cultures, when great importance was attached to the mythical. Myths acted as models of explanation for a number of central conditions relating to man's view of life; from ethical and moral guidelines to deep religious questions, such as The Creation. Myths and fairy tales incorporated society's values; individuals discovered their identities with the help of myths. Psychoanalyst C.G. Jung wrote, “For the sake of reason, `mytholising' is a sterile speculation, but for the mind it is a health-bringing activity; it gives existence a lustre that one would prefer not to be without” Progress in the name of reason, can have supplanted other means of reaching understanding. This, in turn, can have negatively affected our spiritual life, making it more vulnerable. Rollo May writes about this, “A healthy society provides its citizens with relief from neurotic feelings of guilt and exaggerated worries, through its myths.” Suicide statistics among young people today highlight an alarming development. Drug misuse continues to increase. Families are breaking up and traditions are in decline. Scientific and technological developments cause changes in society at an accelerating speed. All these conditions place great demands on man's ability to create an inner structure and meaning. May writes, “Those who want to maintain their reason, will necessarily look for order and coherence in the stream of impressions, feelings and ideas that enter their consciousness, either from the inside or the outside. Each one of us is forced to take standpoints that in earlier times were decided by the family, tradition, the church or the state. There is a need to create myths that make our experiences meaningful.” In “the lonely search for an inner identity” and the search for meaningful coherence, today's children and young people have little support from myths. “As long as the world and society are without myths that express beliefs and ethical ideals, depression and suicide will flourish.” (May) The hypotheses: 1. The absence of myths makes it difficult for children and young people to develop their identities. 2. The images that myths create open doors into parts of a person's life, that direct speech would have difficulty in describing. This means that myths are of particular importance to children and young people. In this work, I have used the term “identity” as it is used in ego-psychology, in particular E. Erikson's Development Theory. The approach is in the form of interpretation and I have relied upon Gadamer's hermeneutic. The method is therefore phenomenalistic - hermeneutic It is my wish that this study will stimulate to raising the awareness of the healing properties of myths in work with children and young people. Anvendelse av MRI i studiet av eksperimentell og klinisk tumorfysiologi med vekt på angiogenese Oppegaard, Oddvar Supervisor: Arvid Lundervold, førsteamanuensis Seksjon for nevrovitenskap, Fysiologisk institutt, UiB There exist a great number of different MR-techniques, and every year seems to bring forth a new method of application or a new pulssequence, which opens up new imaging possibilities. The potensial is great, and it is hard to keep up with the rapid development. This report gives a review of some of the traditional MRI-techniques and applications, as well as a peek at the cutting edge of experimental use. It is focused on the possibilities within cancer research, and especially the study of angiogenesis. MR can be used to investigate multiple parametres and aspects of tumor physiology and biology, for instance tumor vasculature (incl. perfusion and permeability) and metabolism. Some of these parametres have been shown to correlate closely to tumor type and grading, as well as risk of metastasis and mortality. This provides a basis for more precise diagnostic and prognostic evaluation, optimization of treatment and for better monitoring of therapeutic response. Volvulus coli sigmoidei – belyst ut fra et klinisk materiale Pedersen, Sigrun Ringdal Supervisor: Arne Skarstein, professor dr.med. Kirurgisk avdeling, Haukeland universitetssykehus Background: Volvulus is a term used to describe a loop of bowel twisted on its mesentery. The segment of bowel most frequently affected is the sigmoid colon. The patients are often elderly who suffer from concurrent illnesses. Many have neurological or psychiatrical diagnoses, and a considerable number of patients have a history of chronic constipation. How to treat this group of patients most adequately has been a matter of dispute for years. The attitude towards offering operation has been relatively liberal when dealing with young and otherwise healthy patients. The aim is to avoid multiple recurrences during the many years left to live. When faced with elderly patients, the approach has been somewhat different. Many are impaired in consequence of ageing and comorbidity, and surgery may represent a great hazard. On the other hand, mortality has turned out to increase with multiple recurrences, and the frequencies of recurrences are clearly less when the most appropriate operative treatment has been performed. Whether decompression using a rectal tube should be the only treatment, or whether operation should be considered, either acutely or electively, is therefore a matter of judgement in each individual case. By seeking information from patient’s medical records at the Department of Surgery, Haukeland University Hospital, we hoped to establish an answer to whether surgery in some cases has been postponed too long, or whether a more conservative approach generelly seems appropriate. Material and Method: All medical records of patients with the diagnosis volvulus discharged from the Department of Surgery, Haukeland University Hospital, during the period of 1990-99, were reviewed. There were 51 patients with sigmoid volvulus, and this constituted 65% of all cases of volvulus. Results: Based on each patient’s first case record during this decade, the average age of those with sigmoid volvulus was 66.78% of these patients suffered from neurological or psychiatrical illnesses and/or chronic constipation. 42 patients had their first admission with volvulus, while 9 patients had been admitted and treated for sigmoid volvulus on earlier occations. In most cases, the diagnosis was confirmed by plain abdominal x-rays. In the remainder, barium enema was used, or the diagnosis was established during operation. 34 patients were conservatively treated, 12 patients went through surgery, in 3 cases barium enema proved to be sufficient treatment, and 2 patients were merely observed. The operative procedures chosen were sigmoid resection and primary anastomosis or Hartmann’s procedure. Postoperative complications in terms of pneumonia, ileus and atonic colon occurred in 36% of these cases. 24 patients (47%) escaped new admissions during this decade. Among the rest, there were 50 new admissions, and 38 were results of recurrences. Most recurrences occurred among those conservatively treated. 14 new operations were performed, som electively and others acutely. Two of the operations were performed laparoscopically. At the end of this decade, 24 of the 51 patients had died, and three of these deaths were directly associated with admissions for sigmoid volvulus. Conclusion: A ow recurrence rate following operation supports the view that radical treatment is the best solution among patients without contraindications. Among old and frail patients, the approach should be more cautious. Based on the results from our study, the risk of postoperative complications is relatively high (36%). Since a considerable number of patients never experience recurrence, we consider it best still to follow the policy of choosing a conservative approach to treatment among those at particular risk, where postoperative complications could be disastrous. Legen som moralsk aktør – et medisinsk-etisk essay basert på tre kasuistikker Reiakvam, Kyrre K Supervisor: Stein Husebø, overlege Bergen Røde Kors sykehjem In this essay a medical student presents an analysis of three medical cases, focusing on the ethical problems and questions attached to them and on the doctor’s role as a moral agent. The study is partly a literature study, in that the analysis depends on thoughts from a broad selection of relevant texts concerning medical ethics (see the literature list for details). The selection consists of thorough and basic standard works in the field of medical ethics or bio- ethics, and shorter books and articles dealing with narrower parts of the field, especially texts that treat difficult questions that doctors need to ask and answer in their encounters with seriously ill and dying people. An extra emphasis is put on central bio-ethical concepts like the principle of beneficence, paternalism, patient autonomy, informed consent, and futility, and these key words (among others) have been used in the PubMed search for relevant literature.A presentation of the most important concepts is found in the first part of the essay. The study also has a practical side: The reflections on bio-ethics concern situations that the author has taken part in as an observer. During the fall of 2001, the student followed the doctors at Bergen Røde Kors Sykehjem in their work with five seriously ill patients and their closest family. In this field work he observed conversations between doctors and patients, doctors and patient’s close family members and between doctors, nurses and nursers’ assistants. He also made interviews of his own of patients and their family members. Two of these cases are presented in this essay, in addition to one case that is taken from one of the student’s internship periods during the fourth year of medical school. The use of informed consent was initially the central point of investigation; but as the study evolved, more and more emphasis was put on the idea of the doctor as a moral agent, as presented in a book by David Lamb. In the conclusion it is pointed out that the significance of the doctor’s role as a moral agent seemed greater than initially believed, and it is stressed that this, as much as it is often an irrefutable fact, doesn’t have to represent a danger for the patient’s integrity and well being – as long as the doctor is aware of and concerned about that part of her role. Atherosclerose og koronar hjartesjukdom Reikvam, Håkon Supervisor: Karel Kier-Jan Kuiper, overlege Hjerteavdelingen, Haukeland universitetssykehus Cardiovascular disease is the most common reason to morbidity and mortality in Norway. The last year of research has brought attention to oxidative modification of LDL-particles, and the importance of the antioxidantsystem of the body in protection against atherosclerosis and coronary heart disease. The bodys antioxidantsystem exists of both antioxidant enzymsystem and antioxidantsystem dependent on dietary supplementation. By the last one vitamin E, vitamin C, carotenoides og flavonoides are of highly interest. Reduction in the level of circulating cholesterol and LDL, both by drugs and by diet, is well documented in reduction the atherogenesis and the probability of cardiovascular incidents. Today treatment of coronarydisease includes both drugs and invasive methods. Despite the last year of research, our knowledge is still incomplete about optimal profylaxis and treatment or coronarydisease, particularly about the optimal combination of different components. Still our few good advices to the patients are a variable diet, regular physical activity and avoid tobacco smoke. Bilateral brystkreft Bilateral Breast Cancer Reitan, Bernt Christian Supervisor: Bjørn O. Mæhle, førsteamanuensis og Lars A. Akslen, professor Avdeling for patologi, Gades institutt, UiB Background: There is uncertainty as to whether women with bilateral breast cancer carry a prognosis worse than women with unilateral disease, and how common the development of bilateral disease is. The purpose of this study was to examine the frequency and prognosis of patients with bilateral breast cancer. Methods: 3881 patients were treated for breast cancer between 1970 -1995 and were followed to the end of 2000 for development of bilateral breast cancer. Information on time and cause of death was available from The Norwegian Central Bureau of Statistics to desember 1999. Information on age at operation, tumour size, lymph node status, date and type of operation and treatment before the operation was present in most patients. Results: 107 women (2.8 %) developed bilateral breast cancer. 20 patients (0.5 %) had synchronous bilateral cancer defined as presentation of the second tumour 6 months or less after the first one. Bilateral disease gave statistical significant worse prognosis than unilateral disease from time of the second tumour. There was no difference in prognosis between the two groups of patients from time of first tumour. Metachronous and synchronous bilateral patients had similar prognosis. Cox regression analyses with time-dependent covariate gave 2.68 times higher risk of dying from bilateral than unilateral breast cancer. Conclusions: 2,8 % of the women developed bilateral breast cancer. Women with bilateral disease had a disease outcome similar to those with unilateral disease from the time of the first tumour. After development of the second tumour bilateral patients had poorer prognosis than unilateral patients. Bilateral patients with metachronous and synchronous disease had similar prognosis. Patients with bilateral disease had 2.68 times higher risk of dying of the disease than those with unilateral breast cancer. Diagnostiske metoder ved akutt appendicitt Rieser, Heidi Supervisor: Asgaut Viste, professor dr.med. Institutt for kirurgiske fag, UiB Background: 20% of appendectomies reveal a normal appendix. It is therefore of interest to analyse the different methods applied in diagnosing acute appendicitis; clinical examination along with deDombal score, blood leucocyte-level (lpk), C-reactive protein-level (CRP), abdominal ultrasound examination and urine tests. Patients and methods: We performed a retrospective study of 100 patients admitted to Haukeland sykehus, Bergen, during 2000 and 2001. All patients were operated due to suspected acute appendicitis. Based on diagnosis, the material was divided into two groups; acute appendicitis – group A, normal appendix – group B. Clinical findings and lab tests were recorded for both groups, with special emphasis on analysing the relationship between inflammatory markers (CRP, lpk) and diagnosis. In addition, a ROC-analysis was performed to evaluate inflammatory markers’ limit values to decide highest sensitivity and specificity values. Results: The study showed that there was a significant difference between the groups considering the factors CRP, lpk, and deDombal-score. Urine tests and temperature had no significant values in this study. Group A had mean deDombal-score at 3, group B at 2. Most frequent symptoms in group A were defence and indirect pain sensation. Pain migration gave highest odds ratio (9,6). Mean CRP value was 64 in group A, and 22 in group B. In patients with CRP above 8 mg/dl sensitivity and specificity was 80% and 56% respectively, PPV=91% and NPV=35%. 17 patients in group A had CRP less or equal to 8 mg/dl. No patients in group B had CRP > 100 mg/dl. Lpk mean value was 15 in group A and 10 in group B. Lpk > 11 x 109 cells/l gave a sensitivity value of 80 %, specificity of 69%, PPV=93% and NPV=39%. 16 patients in group A had lpk < 10 x 109 cells/l. In group A five patients had both lpk and CRP within reference values, and 55 patients had both markers increased. In group B six patients had both CRP and lpk within normal area, while 2 patients had both increased. The ROC-curve showed that the cut-off values for CRP and lpk with the highest sensitivity and specificity were CRP > 12 mg/dl and lpk > 11 x 109 cells/l. The sensitivity was 76% and 80% respectively. The specificity was 69% for both markers, which gives a rate of 31% false positives. Interpretation: A significant difference was found between the two groups respecting deDombal-score, lpk and CRP values. The highest sensitivity and specificity was found for lpk > 11 x 109 cells/l and CRP > 8 mg/dl. Both had low sensitivity and high false positives, and must therefore be characterized as poor diagnostic tests. In conclusion, lab tests can only be used to support the clinical diagnosis of acute appendicitis. Livsstilsintervensjon ved diabetes mellitus type 2 Rotlid, Cecilie Supervisor: Sylvi Aanderud, professor dr.med./overlege Institutt for indremedisin/Endokrinologisk seksjon, Medisinsk avdeling, Haukeland universitetssykehus The aim of this essay is to study the relation between lifestyle and the development of diabetes mellitus type 2 and to find out if it is shown that lifestyle intervention has a preventive effect on the development of type 2 diabetes. The illness has today become a regular medical condition and the prevalence has increased considerably all over the workld during the last ten years. Regarding the increasing incidence and the consequenses of the disease, both for the patient and the society, it’s important to make serious efforts to stop this development. There is clear relationship between the increasing indicence and the modern, western lifestyle with less physical activity and an unhealthy diet. It’s done several clinical trials to examine if lifestyle intervention has a preventive effect on type 2 diabetes in persons at high risk. These studies all conclude that increased physical activity and a healthier diet reduce the incidence of type 2 diabetes. The challenge is how to get people to make those changes in lifestyle. It is suggested that the authorities should focus on this epidemic disease and establish information campaignes and try to reverse this serious development. Non-Motor problems in patients with Parkinson’s disease Sandviknes, Kenneth Supervisor: Jan Petter Larsen, professor Seksjon for nevrologi, Institutt for klinisk medisin, UiB Parkinson`s disease (PD) is a chronic, progressive, neurodegenerativ disease which mainly affects older people. In Norway around 7000 people is suffering from the disease. The cause is still unknown and there is no cure. The main focus has traditionally been in evaluation and treating the motor problems and there is now a fairly good symptomatic treatment. However, PD may also cause non-motor problems, which may have profound implications on the quality of life. Among these, depression and sleeping problems are recently found to be the two most important factors for reducing quality of life in patients with PD. During the past years greater emphasis has been placed on the total impact of the disease on the patientes` lives, thereby letting the non-motor problems be focused. This review article tries to highlight the non-motor problems of PD, which affect a substantial portion of the patients. According to recent studies, 88 % of the patients have at least one non-motor problem, many are experiencing a lot more. The disease may cause problems in a variety of areas such as psyche, cognition and sleep, bowels, bladder and skin. Neuropsychiatric problems are most frequent, but many suffer a mild degree of autonome dysfunction. More complex problems can be seen, including fatigue, sexual problems and pain. It`s important to recognize these problems and the patient`s quality of life; in this way an optimal treatment can be given. The article is partly based upon publicated research form The Central Hospital of Rogaland, Norway, and partly upon articles found through systematic search in medical databases. Metoder for svangerskapsavbrudd i Norge med hovedvekt på medisinske metoder Schou, Synne Supervisor: Magnar Ulstein, professor dr.med. Seksjon for obstetrikk og gynekologi, Institutt for klinisk medisin, UiB Background: Induced abortion is a controversial issue which is often debated. The medical termination of pregnancy in the first trimester became an option in Norway in 1998 and is a relatively new offer to women who want to terminate their pregnancy. The objectives of this paper is to present the Norwegian statistics of abortion, summarize the legislation of abortion and review the methods available for termination of pregnancy with especially focus on the medical method. Other medical conditions for which the medicaments can be used and availability in other countries, will also be mentioned. Method: Literature: The paper is mainly based on articles found in databases such as PubMed, Medline and Cochrane, informasionpapers on abortion, the annual reports from Statistisk sentralbyrå and textbooks in gynecology, pharmacology and endocrinology. Key words: Abort, Medical Abortion, Induced Abortion, Mifepristone. Results: Todays statute of abortion has been in force from 1979 and gives the woman right to terminate her pregnancy before the end of week 12. After this date, the woman has to apply to a committee to get her abortion approved. After the 22. week of pregnancy the embryo is defined to be capable of living and induced abortion is no longer allowed. The number of abortions was predicted to increase after the introduction of the medical method, but the number has remained between 13000 and 15000 annually. However, the share of abortion performed medically has been increasing and represented in 2002 49 percent of of induced abortions performed before the end of week 9. In Norway, a women can choose between the surgical and medical method before the end of the 9. week of her pregnancy. In the 10.-12. week, only surgical abortion is offered, and in the 2. trimester, medication is used. The surgical method consists of cervical dilatation and vacuum aspiration. In medical termination of pregnancy, two drugs are used; the antiprogestin Mifepristone, which causes sloughing of the uterine lining and etachment of the products of conception, and the prostaglandin analogue Misoprostol, which stimulates uterine contractions. 200 mg of Mifepristone is given orally by day 1 and 800 microgram of Misoprostol is administered vaginally after 48 hours. Some women start bleeding after the intake of Mifepristone and a few experience complete expulsion before the administration of the prostaglandin. In about 50% of women, abortion occur within 4 hours after the prostaglandin has been given, and 4 out of 5 are finished after 24 hours. For women with a pregnancy of less than 63 days duration, the success rate of the Mifepristone-Misoprostol procedure ranges from 92 to 96% and several clinical trials show that the medical and surgical method are now equal options as regards risk of failure and acceptability to the women. Mifepriston is also used as cervix-softener before surgical abortion in the 1. trimester and as pretreatment before abortion with prostaglandin analouges in the 2. trimester. There have also been promising results regarding the use as a contraceptive and in the treatment of spontaneous abortion, leiomyoma and certain cancers. Mifepristone is now available in 27 countries. There are both political, ethical and/or economic reasons why some countries are not willing to make the drug available and other combinations have therefore been tried with successful results; Methotrexat-Misoprostol and repeated doses of misoprostol. Conclusion: The medical method for termination of pregnancy is a satisfactory alternative to surgery as regards the rate of success and side effects. The method is now often recommended because the woman then avoid complications to anesthesia and surgery. There have also been promising results for use at 10 – 13 weeks gestation, but further clinica trials are required to confirm the findings. The controversy around Mifepristone as an abortifacient agent has delayed further clinical investigation, but over the last few years, more cliical trials have been performed which shows potential use in other medical conditions. The introduction of medical abortion has not increased the number of abortions as some people feared. In many countries, Mifepristone is not available and other medical procedures for termination of pregnancy have also showed to be successful. Kombinert testmetode for måling av anstrengelsesutløst bronkial obstruksjon og maksimalt oksygenopptak. En metodevalidering. Shehzad, Kasher Supervisor: Britt T. Skadberg, seksjonsoverlege, dr.med. Barneklinikken, Haukeland universitetssykehus Introduction: Exercise induced asthma (EIA) is a common manifestation of asthma and occurs in 70-80% of untreated asthmatic patients. EIA may influence daily life activities in children and teenagers, and an accurate diagnosis of EIA is necessary for optimal treatment. Furthermore, pulmonary as well as cardiac disease may influence on oxygen uptake. The aim of the present study was to assess and compare the ability of a new developed and modified test protocol, “Modified EIA”, to measure bronchial hyperreactivity and oxygen uptake with two separate tests, “Standard EIA” and “Modified Bruce”. Methods: An open, randomized study of nine asthmatic children and 14 healthy teenagers was performed. The results of “Modified EIA” and “Standard EIA” and “Modified Bruce” and Modified EIA”, were compared for the astmatics and healthy teenagers, respectively. Basic lung function was measured before running and 1,3,6,10 and 15 min after the run. Oxygen uptake, heart rate and ventilation were continuously recorded. Bronchial hyperreactivity was estimated by the percentage decrease in forced expiratory volume first second, FEV1, and working capacity by maximum oxygen uptake perminute and kilo body weight. Results: There were no significant differences of any key parameters of lung function or ergometry (forced vital capacity, FVC, forced expiratory volume first second, FEV1 or midxpiratory flow, FEF50, maximum fall in FEV1 maximum oxygen uptake, max VO2, heart rate or respiratory rate) in either group or test combination. Conclusion: Comparable test results suggest that the ”Modified EIA” protocol has the ability to replace the two traditional tests saving both the patients for exhaustion and unnecessary workload on the technicians in our laboratory. Epidemiologi av muskel- og skjelettplager i Hordaland Sirnes, Eivind Sødal, Erlend Supervisor: Grethe S. Tell, professor og Eha Nurk, stipendiat Seksjon for epidemiologi og medisinsk statistikk, Institutt for samfunnsmedisinske fag, UiB Background: Musculoskelatel complaints are widespread and a major public health problem in western countries. Prevention and treatment are challenging because etiologic factors are not fully understood. The objective was to estimate the prevalence of and identify possible risk factors for musculoskeletal complaints. Material and methods: A cross sectional study including 11,566 men and 13,660 women aged 40-49 and 70-74 years who completed a questionnaire in The Hordaland Health Study ’97-’99 (HUSK). Results: Musculoskeletal pain and/or stiffness lasting at least three months during the past year was reported by 4,461 men (39%) and 6,713 women (49%). The prevalence increased with age among women. Musculoskeletal complaints were associated with low educational attainment and smoking among both men and women 40-49 years old, and with high body mass index (BMI) and low physical activity among women. Among the oldest, complaints were associated with low educational attainment among men and with smoking, high BMI and low physical activity among women. A dose-response relationship between smoking and musculoskeletal complaints was found, with a stronger effect among women than men. Interpretation: Musculoskeletal complaints were common, with a higher prevalence among women than men. The results indicate that musculoskeletal complaints may be prevented or reduced by quitting smoking. Substitusjonsbehandling og livskvalitet Soltvedt, Åshild Supervisor: Fred Holsten, professor dr.med. Seksjon for psykiatri, Institutt for klinisk medisin, UiB Background: Since the Norwegian Governments in the late nineties decided to legalize use of the synthetical opioid Methadone in treatment of heroine addicts, there has been a continuous debate discussing the effect of this treatment. Based on this I decided to study the history of methadone, the background for the public Norwegian methadone programme, and different methods used to evaluate the effect of this treatment. Methode: Litterature study: Central search words: Methadone, addiction tretment, quality of life, dual diagnosis, Results: When the Norwegian Governments in 1997 decided to legalize the use of Methadone in treatment of heroine addicts, it was, in an international context, nothing new about that. But according to traditional Norwegian drug policy, it was quite revolutionary. A programme was formed with straight rules for admission, treatment and exclusion. It was underlined that the primary goal was rehabilitation, with less focus on habilitation. Several studies show increased prevalence of psychiatric problems among drug addicts compared with the rest of the population. Only a few studies have tried to investigate the reason for this, and these conclude with that there is no simple causal connections. A common way of measuring efficiency of treatment is to study in which scale the patients choose to remain in treatment. This is not a satisfying measurement of the methadone maintenance treatment. Aspects as patient satisfaction, the use of other drugs and level of rehabilitation has to be included in evaluation of this kind of treatment. Substance abuse is a very complicated problem, where many different factors have an impact on the treatment result. The process of rehabilitation continues over many years. This together with the high level of mortality and suffering of this population make it even more difficult to investigate the efficiency of treatment. A common feature of the articles and reports that discuss this is that quality of life, self experienced as well as objectively measured should be a part of this measurement. The fact that also opiate users who are not able to follow the strict rules of the methadone programme report a increased quality of life, has lead to a new debate about whether habilitation should be an indication for the treatment. Øsofagusperforasjoner ved Haukeland Universitetssykehus Esophageal perforations at Haukeland University Hospital Stein, Arne W. Supervisor: Asgaut Viste, professor dr.med. Institutt for kirurgiske fag, UiB Background: Perforation of the esophagus is a rare, but severe condition that is associated with high mortality in most studies. The literature is inconsistent on many questions like prognosis, most important prognostic factors and optimal treatment. Method/Material: In ten years from 1988 to 1998 there was 16 patients treated for perforation of the esophagus at Haukeland University Hospital. The journals were reviewed with focus on etiology, localization, clinical presentation, time to diagnosis and treatment, and treatment received. Length of hospitalization, stay in intensive care unit and complications were analyzed. Results: Of 16 patients there were 14 men and 2 women with median age 65,5 years (25-90). Perforations were due to endoscopic procedures in 7, abdominal operation in 2 and spontaneous in 7. Most (69%) were located in the distal esophagus with the rest equally distributed between proximal esophagus and abdomen. Eleven patients had underlying esophageal disease: stricture in 5 and esophagitis in 6. Five perforations were diagnosed late (>24 h): 2 spontaneous and 3 iatrogenic. Patients with spontaneous perforations typical presented with chest pain and dyspnea. Patients with iatrogenic perforations had a more heterogenic presentation with fever as the most common finding. X-ray of the esophagus with water soluble contrast established the correct diagnosis in most cases, and had a 69 % sensitivity. 5 patients received conservative treatment, 8 had primary closure, 2 had resection and one was treated with a self - expanding stent. There were no deaths in our material. Total hospital stay was 4 to 131 days, median 43. Nine patients needed a stay in an intensive care unit, median 25 days (2-83). 12 patients had one or more complications, 6 had a sequela. One had a reinforced closure of the perforation after the first broke down, four others had some kind of reoperation because of complications. Factors that influenced morbidity were etiology, localisation, age and treatment received.. Conclusions: Perforation during operation with fundoplicatio was clearly the most serious etiology. The fact that late diagnosis was a more common finding among the iatrogenic perforations warrants a high degree of suspicion for perforation of the esophagus in these patients. In support of the view that conservative treatment is appropriate in carefully selected patients we find that patients who received such treatment had significantly lower morbidity then patients that were operated. The absence of any mortality is remarkable and support the assumption made in some other newer studies that the mortality for this condition is getting lower in parallel with improved treatment options regarding antibiotics and parenteral nutruition. Patientnära analysering av CK-MB, Troponin I och Myoglobin I diagnostiken av akut hjärtinfarkt. En evaluering. Point of care testing for CK-MB, Troponin I and Myoglobin in the diagnosis of acute myocardial infarction. An evaluation. Stjärne, Johan Supervisor: Rune J. Ulvik, professor Institutt for klinisk biokjemi, UiB Background: Coronary heart disease is the leading course of illness and death in the Western World. There is a need of a more sensitive diagnosis of AMI, correct risk stratification of patients and fewer false negative diagnoses. The importance of biochemical markers in diagnosis of coronary heart disease has increased due to new effective markers and more precise methods of analysis. The need to detect myocardial damage under development has increased due to new therapeutic strategies. A fast and correct placement of patients into the right level of care also has economic implication. There has been developed bedside instruments for fast analysis of biochemical markers. We wanted to try such an instrument in the emergency department at Haukeland Hospital. The intention was to compare rapid analysis of myoglobin, CK-MB and TnI with the routine analysis of CK-MB and TnI, in the diagnosis of AMI. The study also had some minor goals (see page 13-14). One of these was to examine the increase of patients with possible AMI diagnosis, at first analyse, after introduction of a new TnI AMI cut off. Another minor goal was to evaluate the importance of myoglobin analysis in the emergency department. Matherials and method: The study was done between 20/3 and 11/4 -00. 56 patients were included. In 46 of the patients (the main group) markers were analyzed due to primary AMI suspicion. The rest of the patients (the side group) had no primary AMI suspicion, but still markers were analysed. For rapid analysis of heart markers we borrowed Dade Behrings Stratus CS. The ordinary diagnosis was running parallel. After the collection of data from Stratus CS and LKB we noted the final diagnosis of the patients. Results: Correlation curve for CK-MB (n=44): y = 1.0071 x + 0.2029. R2 = 0.9779. Correlation curve for TnI (n=46): y = 1.2712 x + 0.0531. R2 = 0.9862. (y = Stratus CS, x = LKB) In the main group 22% of the patients got the final diagnosis AMI. 40 of 41 patients though either currently or previosly had some heart disease. The sensitivity for final AMI diagnosis in the first analyses was 44% for Stratus CS and 56% for LKB. With some modifications we got the sensitivity 50% and 63% respectively, see page 33-34. The specificity was 97% in both methods. Stratus CS was more sensitive for registrations of low TnI values, and in Stratus CS there was more or less an abnormal TnI in all patients with final AMI diagnosis. Stratus CS probably shortens TAT from about 2-3 hours to about 30 minutes. Stratus CS analysis was simple, but a correct use depends on incorporation of new routines in the emergency department and in the lab. Introduction of a new AMI cut off increased the number of patients with possible AMI diagnosis, at first analyse, from 6 to 12 patients. Myoglobin analysis alone revealed no major extra information, but 75% of the patients who tested positive in all tree markers got the final diagnosis AMI. Only 20% of the patients who tested positive in two markers got the final diagnosis AMI. Conclusion: The data from Stratus CS and LKB showed a good correlation. About one fifth of the patients with primary AMI suspicion got the final diagnosis AMI. Most of the patients though had some current or previous heart disease. The sensitivity for the final AMI diagnosis, at the time for the first analysis, was generally low but a little higher in LKB. The specificity was high and equal in both methods. Stratus CS is more sensitive for low TnI concentrations. In risk stratification and due to a new AMI cut off this can be of importance. Stratus CS shortens TAT and is easy to use. A new AMI cut off will increase the number of patients with the final diagnosis AMI. The importance of myoglobin analysis in the emergency department probably has to be evaluated in larger studies. But parallel analysis of many markers seems to be useful. BNP and heart failure - current issues Storebråten, Gøril Supervisor: Kjell Breivik, overlege Hjerteavdelingen, Haukeland universitetssykehus Congestive heart failure is a common with high morbidity and mortality. It is characterised by chronic overactivation of sodium- and water retaining neurohormons and vasoconstrictor hormones. Over time this maladaptive response leads to fibrosis and hypertrophy of the heart and further progression of the dysfunction of ventricular function. Humans have several endogenous systems that are countering these effects. One mechanism is the endogenous vasodilator system that includes natriuretic peptides, nitric oxide and prostaglandin. These systems have natriuretic, diuretic, and antimitogenic effects and counteract the vasocontriction. In heart failure these natriuretic and vasodilator effects are overwhelmed by the influenses that lead to vasoconstriction, salt and water retention and abnormal cellular growth. The natriuretic peptides include the hormones ANP, BNP, CNP and Urodilatin. The actions of ANP and BNP are similar and tend to oppose those of Ang2. BNP is a hormone mainly produced in the heart ventricles in response to increasing wall- tension and the plasma concentration is raised in heart failure. The discovery of BNP it has created excitement because of the multiple possibilities it may posses in different aspects of heart failure. The excitement was increased when a rapid point-of-care test for BNP was developed and approved. In this paper will some important aspects of BNP and congestive heart failure be discussed; Many studies suggest that a measurement of BNP can be helpful in ruling out a diagnosis of heart failure in patients with symptoms like fluid retention, exercise intolerance or dyspnea. BNP might also be useful in assessing outcomes in patients with established heart failure and it may have prognostic value for risk stratification in patients with acute coronary syndromes. There is also some promising research on how BNP can be used to fine tune the treatment of heart failure. Circulating plasma BNP concentration can be raised artificially for treatment purposes. This can be done in different situations; As an infusion or with orally active drugs that inhibit parts of the elimination of BNP. These drugs may play a part in the future treatment of heart failure. Multippel sklerose og spinalvæske forandringer Sundal, Christina Supervisor: Christian Vedeler, professor Seksjon for nevrologi, Institutt for klinisk medisin, UiB MS is a chronic, immune mediated, inflammatory disease, affecting the Central Nervous System,CNS, in persons with a genetic predisposition. The diagnosis is in principal an exclusion diagnosis, thus other causes of multiple lesions in the CNS have to be ruled out. There are no simple laboratory tests, symptom scores, or investigations giving the diagnosis. The clinical picture consists of the examiner pointing out symptoms and motor or sensory deficits correlating to a results of other investigations. The disease usually has a chronic and progressive course, and will eventually lead to more or less distinct loss of function. The etiology of the disease is still not clear, but it is presumed to include genetic predisposition, different agents, and auto-immune mechanisms affecting the CNS. There is no curative treatment for the disease. This retrospective study is based on medical journals from 34 patients with relapsing, remitting MS, RRMS. All the patients were diagnosed according to the Poser criteria, and have in addition had a genotyping of IL-10 and Fc-receptor 3b, FcR 3b. The aim of the study was to investigate an eventual correlation between the number of cells, bands found in CSF, and IgG-index, in relation to MS prognosis and IL-10 and FcR 3b gene polymorphisms. The material showed a significant correlation between oligoclonal bands (OCB) in CSF and the amount of cells in CSF. It also revealed a tendency for CSF IgG to be higher in the patiens with a higher number of cells, in addition to more than 5 OCB. The analysis of the results also showed that few OCB coupled with a low cell number in the CSF, correlated to a favourable prognosis. The measured amounts of CSF IgG was found to be higher in the IL-10 592 genotype AA, compared to genotype AC and CC ,thus correlating to a worse prognosis. No significant correlations to the FcR 3b were found. The conclusion of the study is that CSF findings can be prognostic valuable for MS and that anti-inflammatory therapi is of great importence. Kroppsbilde hos ungdom Svendsrud, Ingvild Supervisor: Anders Bærheim, professor Seksjon for allmennmedisin, Institutt for samfunnsmedisinske fag, UiB Eating disorders is a substantial health problem among adolescents in the western countries today. Heavy focusing on loosing weight and a perfect body image in our culture, are thought to have impact on the prevalence of eating disorders. Knowledge about the body image among normal adolescents in the same cultural settings may be useful. Aim: To evaluate normal adolescents’ ideas about their body, body image, ideal body and link between body image and self-confidence. Material and methods: The students in two classes at Tank’s secondary high school in Bergen. They were asked to answer a free text questionnaire, focusing on their thoughts about the body image. 39 pupils completed the questionnaire, 19 girls and 20 boys. The material was analysed using Georgi’s method for qualitative analysis as modified by Malterud. Results: The boys and the girls opinions were clearly different. Some of the boys were satisfied with their body, and paid little interest in body and appearance. Many girls descibed that their self-confidence depended on their body image. The girls wanted to have bigger breast and less belly, butt and thighs. The boys wanted more and bigger muscles, and focused on function. Discussion: Our results may be useful for school physicians, school nurses and teachers when discussing body image with adolescents. Does introduction of roluzole and PEG affect time to diagnosis and survival in ALS? Svindland, Jostein Supervisor: Ole-Bjørn Tysnes, professor dr.med. Seksjon for nevrologi, Institutt for klinisk medisin, UiB Objectives: To study the effect of introduction of new treatments in ALS on survival and diagnostic delay. Methods: Riluzole was introduced as treatment option in ALS in Norway in 1995 and PEG has during the last decade been used in cases with bulbar symptoms. All patients diagnosed as ALS in Haukeland University Hospital were registered for the periods 1985 to 1989 and 1995 to 1999. Files were reviwed for time of symptom onset, diagnosis and treatment. Norwegian National Statistics were reviewed for time of death. Results: 37 ALS cases were diagnosed during the first period, 41 during the last. Clinical characteristics were similar. There was no difference in survival between the two periods. Patients treated with riluzole had similar survival as other comparable cases. Similarly, bulbar cased treated with PEG during the last period had similar survival as bulbar ALS patients not receiving PEG during the first period. Median time from onset to diagnosis was 12 months in both periods. Conclusions: This historical review failed to show any effects on new treatment options on survival or diagnostic delay in ALS. Eventuelle fordeler med den nye typen antipsykotika. Hvor mye brukes de i klinikken? Svingen, Gard F. Supervisor: Hugo A. Jørgensen, professor dr.med. Seksjon for psykiatri, Institutt for klinisk medisin, UiB The use of traditional antipsychotics in the treatment of long-time schizophrenia has been conflicted by severe, and potentially fatal, side effects. Even though their effect on positive symptoms has been acceptable, they have shown to lack proper effect on the negative symptoms due to schizophrenia. In addition, a great number of patients have not shown significant clinical response, even though receiving appropriate doses of traditional antipsychotics. Recently, novel antipsychotics with different pharmacokinetic and –dynamic properties, have entered the market. The producers of novel antipsychotics have claimed the new drugs far more acceptable in terms of side effects and effect on negative symptoms. By studying mainly review articles, using PubMed and Medline, we have come to the conclusion that novel antipsychotics do have a more acceptable side effect profile, especially when it comes to extrapyramidal symptoms and tardive dyskinesia. They also tend to treat megative symptoms and improve patients’ cognitive functions better than traditional drugs. In addition, some of the new drugs have shown a particular effect in treatment-resistant schizophrenics. Yet, the new antipsychotics have shown to be able to induce significant weight gain and diabetes, and in the case of Clozapine, leukopehia or agranulocytosis. In addition, we made a study on the use of novel antipsychotics in a Norwegian psychiatric hospital. The conclusion is that Norway may lag behind the USA in the switching to second- generation antipsychotics, but more studies are needed to say this for sure. Brain Function and Neural Networking Modeling Sæthre, Kristian R. Supervisor: Arvid Lundervold, førsteamanuensis, dr.med. Seksjon for fysiologi, Institutt for biomedisin, UiB The last 15 years there has been a significant increase in the number of neuroscientist who uses computer models to simulate brain function. A new scientific field has emerged called Computational Neuroscience. The computational power of today's computers together with advances in our knowledge of the brain has laid the basis of which a new and groundbreaking exploration of the brain is possible. Realistic biology-based modeling of the nervous system based on computer simulations, gives the opportunity to test experimental results and simulate experiments that are impossible to do directly on nerve tissue. Such computer simulations will ask for new biological experiments to test new hypotheses that emerge. Precise and detailed understanding of the brain function on a neural level will probably be essential to future understanding of diseases like Schizophrenia, Alzheimer, Multiple Sclerosis, Parkinson, and other diseases related to the nervous system. This report gives a review of some of the fundamental principles that modern modeling of neurons and neural networks are based on. The report will demonstrate some of the methods used in neural modeling when seeking new insight about how the brain works. A few of the most used computer programs will be described briefly. Example of neural modeling in dementia research and research on Parkinson's disease will also be presented. Acupuncture Treatment in the Prevention of Uncomplicated Recurrent Lower Urinary Tract Infection in Adult Women Sødal, Liv Inger F Fagerheim, Siri U. (Hovland, class 98) Supervisor: Anders Bærheim, professor Seksjon for allmennmedisin, Institutt for samfunnsmedisinske fag, UiB Background: In a previous study, acupuncture treatment reduced the reinfection rate in cystitis-prone women. We wanted to re-evaluate this effect. Mathods: Ninety-four cystitis-prone women were randomised to acupuncture treatment or no treatment. Main effect parameter was occurrences of cystitis during 6 months observation time. Residual urine was measured using ultrasound. Results: The incidence rate (episodes/person-month) of acute, bacterial cystitis in the acupuncture group was 0.049 versus 0.108 in the non-treated group, incidence rate ratio = 0.45 (95% C.I. = 0.23-0.86). Women receiving acupuncture had mean residual urine of 35.4 ml at inclusion compared to 18.2 ml 6 months after treatment, p ≤ 0.01. There was no change in the untreated group. Conclusions: Acupuncture reduced the infection rate among cystitis-prone adult females, corresponding to a reduction in their residual urine. The Incidence of Crohn’s Disease in Hordaland county 1999 and 2000: A retrospective case-control study, and a literature review. Thorsen, Elin C O Supervisor: Kåre Vetvik, førsteamanuensis Institutt for indremedisin, UiB The first part of this paper is a review of the literature concerning some aspects of Crohn’s disease. The second part is a retrospective case-control study. The aim of this study was to assess the incidence of Crohn’s disease in Hordaland during 1999-2000. We also studied life- style and disease parameters and compared them with the literature. To include patients the questionnaires were sent to hospitals and specialists. All of them accepted to participate in the study. A total of 44 patients were included. This resulted in an incidence of 5.04/100 000 per year. The highest age-specific incidence rate was between 20-29 years of age, calculated to 10.8. The F7M-ration was 1:1.26. There were more of the participants with only a secondary school diploma than in the general population giving an OR of 1.7. Nine per cent of the patients had a first-degree relative who also suffered from CD. Epidemiology of Crohn’s disease Epidemiological studies are important to get a better understanding of the very complex aetiology of Crohn’s disease (CD). The incidence of CD has increased over the past decades. There was a rapid increase in the incidence of CD during 1965-1980. This increase seems to level off in most of the western countries at the moment (1). In a study from Copenhagen the incidence of CD was increasing during the period from 1970-78 with a mean value of 2.7105 inhabitants (2). Crohn’s disease is more common in females than among males. The M/F sex ratio in Western countries was 0.9 (3). In a Swedish study the male-female ratio was found to be 1:1.12 (4). Smokers have a twofold risk of developing CD compared to non-smokers (4,5). Nasale vaksiner; Neseslimhinnens egnethet som administrasjonssted for antigener i vaksinesammenheng. Toft, Ingrid Supervisor: Roland Jonsson, professor Broegelmanns forskningslaboratorium, Gades institutt, UiB Background, goal and results: The majority of human pathogens gain entrance to the body via the mucosal surface, which, both because of its area and the fact that it harbours 80% of the body's immunocompetent cells, is considered the main barrier betweenthe body interior and the surroundings. There is an independent mucosal immune system which operates separately from the systemic immune system. This mucosal immune system is best stimulated by antigens administered directly at mucosal surfaces and not that well by parenteral vaccination. To be able to exploit the potential of the mucosa associated immune system, much effort is invested in trying to develop vaccines which could be administered mucosally. In this overview, the reasons why the nose could be a suitable site for vaccine administration are discussed. The discussion is based on current knowledge in mucosal immunology and the anatomy and function of the nasal lymphoid tissue. There is already many promising results in this field. Nasal vaccines could be designed towards several pathogens. But we still do not have all the understanding needed when it comes to the regulation and interconnections in the mucosal immune system. Time will show if nasal administration of antigens becomes a preferred way of vaccination. Method: Material for this overview was found by searching on Pub Med for "Vaccines, nasal" MRI of patients operated for transposition of the great arteries with Senning technique Tveiten, Hallgeir Supervisor: Terje H. Larsen, overlege/professor Radiologisk avdeling, Haukeland universitetssykehus/Seksjon for anatomi og cellebiologi, Institut for biomedisin, UiB Background: Transposition of the great arteries (TGA) is a serious congenital heart lesion who requires early surgery. Former, the method of atrial switch was performed. Blood from the lungs was diverted to the right ventricle (HV) and the blood from systemic circulation was diverted to the left ventricle (VV). HV then becomes the systemic ventricle and is exposed to greater workload than in normal hearts. In this study we wanted to evaluate atrial switch operated patients with MRI, especially the function of HV, and evaluate MRI as a method for this. Material and method: 12 patients and 8 healthy were studied. A 1, 5 Tesla Siemens Vision MT MRI was used. In the study we used two different methods, velocity mapping technique of the ascending aorta and pulmonal artery and CINE technique of the ventricles. In the vessels peak velocity, mean velocity and blood flow were registered. In the ventricles stroke volume (SV), end- diastolic volume (EDV), end-systolic volume (ESV), ejection fraction (EF) and myocardial mass of VV were measured. Results: One of the patients was excluded because the quality of the images was not good enough. In two patients only flow quantification in the vessels were performed for the same reason. In the pulmonal artery we found higher velocity compared to ascending aorta in the patient group. The opposite results were found in the control group. We found no significant differences in blood flow, SV or EF when comparing the groups. On the other hand we found a difference between SV of the ventricles, measured with CINE technique, and blood flow of the vessels, measured with velocity mapping technique. As expected, the mass of VV myocardium was greater in the controls compared to the patients. We also observed that the normally delayed contraction of the HV compared to VV was preserved in the patients. Conclusion: Since we found difference between the blood flow measured in the vessels and the ventricles, should probably one method be used if patients are followed up. Eventually can the methods be used as supplements to each other. All the patients felt healthy before the study, so the small differences between the patient and control group were as expected. The greater muscular mass in VV of the controls was also expected. Female Genital Mutilation Tysnes, Karin N Supervisors: Gunnar Kvåle, professor, Institutt for Internasjonal Helse, UiB og Rachel Manongi, Department of Community Health, KCMC, Tanzania Female genital mutilation has been practiced worldwide, and affects today almost 137 million women. Every year further 2 million are at risk. The practice includes different forms of modification of the female external genitalia for non-medical reasons. There are several justifications that vary between different regions and tribes. They include, among others: reduction of womenæs sexual desire to ensure virginity, chasity and fidelity, removal of “the male elements” and a poisonous clitoris, provide a greater stimulation for the husband during sex, etc. There are many serious complications related to FGM, including haemorrhage, shock, damage to nearby structures (urethra, bladder, vagina, anus), infections and prolonged labour. Today FGM is considered a serious violation of women’s human rights, and should therefore not be justified in the name of culture or tradition. As an attempt to eliminate the practice, there has been med legislation against FGM in both African and European countries. Further have medicalization of the practice been a controversial issue, where WHO has stated a consistent condemnation. This report gives a review of FGM and all of its aspects and problems, based on other articles and reviews. We have also presented a study on attitudes towards FGM in health professionals in Moshi, Tanzania. 3 months were spent in KCMC, mainly in Labour Ward. 22 auestionnaires about FGM were given to doctors, nurses and medical students. Many cases of FGM were seen and discussed with the doctors in the Labour Ward. The questionnaires showed mainly similar attitudes towards FGM, and no significant differences betseen ages and sex were found. The majority considered FGM to be a violation of universal human and women’s rights, and that it should be prohibited. There were some disagreements about how to eliminate the practice. Less than 50% wanted specific legislation, but over 90% were against medicalization of FGM. Reasons for this were no medical indication and that it would lead to its promotion. Most believed in health education about complications and bad effects of FGM. About ¼ suggested alternatives for the practice, e.g. traditional dances. Almost none would ever perform FGM themselves. The majority had seen patients undergone FGM, type 2 were rapported to be the most common. They reported to see complications, e.g. perineal tears during delivery, prolonged labour, haemorrhage, infections and sexual problems. Only a small fraction believed in positive aspects of FGM, and they mentioned the value and respect of tradition. The health personnel at KCMC have a great deal of knowledge about the issue FGM. It is also obvious that they have thought about the problems related to it. They want to end the practice and have specific ideas of how to do it. However you can find that some are critical towards “Europeans” who judge African customs like this. It seems clear that cooperation between cultures and the spreading of knowledge about the practice of FGM is the best and most effective way to eliminate it. HIV vaksine / Immunbasert terapi Ukkelberg, Oddvin Supervisor: Anne Margaritha Dyrhol Riise, post doktor Institutt for indremedisin, UiB This review describes HIV-1 vaccines in the battle against AIDS. I have tried to focus on the present status for design and testing of vaccines, not only used in a prophylactic manner, but also used in at therapeutic manner. My impression is undoubtedly that the ongoing research to find an effective vaccine is enormous. The first phase I clinical trial took place in USA in 1987. Since then more than 30 candidate vaccines have been tested in more than 60 phase I and II clinical trials, but no effective vaccine has been found. Very few vaccine candidates reach phase III clinical trials, partly because of the complex interaction between the HIV-1 virus and the immune system, and partly because of the expenses involved when performing large vaccine trials. Also ethical issues make the trials complicated. So far it is only AIDSVAX that has been in phase III clinical trials for a long time. Tat-Vaccine has just recently started in phase III clinical trials. A decision not to proceed with ALVAC 1452 in a phase III trial was just made due to methodological problems, whereas ALVAC 1521 is planned to enter phase III trial in a short time. In the case of AIDSVAX the problem has been to overcome virus variability, a classical problem in HIV-1 vaccine design. However, the use of new adjuvants, delivery methods and combinational vaccine regimens bring hope for an effective prophylactic HIV-1 vaccine in the future. Despite that no break through has been reached, the use of therapeutic vaccine in . Despite that no break through has been reached, the use of therapeutic vaccines to boost the immune system is promising in many trials. As our understanding of the HIV-1 specific immunity increases, therapeutic vaccines most likely will become an opportunity for many HIV-1 infected people, also with the aim to totally eradicate the virus in them. Prenatal diagnostikk og selektiv abort – ein litteraturbasert gjennomgang av argument i lys av ein etisk modell Vattøy, Gyril Supervisor: Guri Rørtveit, stipendiat Seksjon for allmennmedisin, Institutt for samfunnsmedisinske fag, UiB Ethical models have been developed to support diffcult decisions in medicine. Developments in genetic technology and sampling methods result in great changes in prenatal diagnostics. One ethical model is selected in this thesis to assess arguments used in the debate on selective abortion as a consequense of prenatal diagnosis. Relevant litterature on the practice of prenatal diagnosis and selective abortion in Norway is reviewed. The ethical model used is called a ”principle-based model”. It is based on the following four basic principles: The principle of beneficence, the principle of non- maleficence, the principle of respect for autonomy, and the principle of justice. These principles are presented in more detail, and thereafter applied on some arguments used in the debate on selective abortion. Application of this ethical theory highlights important themes of each argument. The issues may be controversial, but the model contributes to an unprejudiced discussion and gives a good foundation for choice of action. The principle-based model can be applied on most ethical problems in medicine. The four principles are easy to remember, and they also allow more extensive ethical analysis. Parent Management Training og Multisystemisk Terapi. Behandlingsmetoder for barn og unge med alvorlige atferdsvansker Wergeland, Gro Janne Henningsen Supervisor: Einar Heiervang, førsteamanuensis Seksjon for psykiatri, Institutt for klinisk medisin, UiB Conduct disorder is one of the most frequent reasons for referral to child and adolescent treatment services in Norway. This work is a litterature study of three different therapeutic models used in treatment of children with conduct disorder; Patterson's and Webster-Stratton's Parent Management Training models, and Multisystemic Therapy. Children presenting with a high level of aggression, hostility and rule-breaking at young ages run a noticeably risk of developing antisocial behavior. Longitudinal studies have shown that this is the best predictor for commitment of criminal acts and other problems in adult life. Early onset and severe symptomathology are associated with poor prognosis. Studies have shown that prevention is possible. There have been significant advances in treatment. In 1997 the Norwegian Research Council arranged a conference on children with conduct disorder. Based on topics discussed at this conference, an expert comittee recommended that a systematic study aimed at evaluating the effects of PMT and MST should be conducted in Norway. In 1999, two studies were started, with a three year follow-up period. This period will end in 2002. A third study started in 2001, and will end in 2004. Parent Management Training refers to procedures in which parents are trained to alter their child's behavior in the home. Two separate PMT approaches have been developed by Gerald Patterson and by Carolyn Webster-Stratton. Multisystemic Therapy focuses on systems in which behavior is embedded and on altering these systems in concrete ways that can influence behavior. PMT and MST have been evaluated in randomised, controlled outcome trials, and show good effect on reducing antisocial behavior compared to control groups. Similar studies are currently conducted in Norway. Interleukin 10 genpolymorfismer og respons på interferon behandling hos pasienter med multippel sklerose Wergeland, Stig Supervisor: Kjell-Morten Myhr, overlege dr.med. Nasjonalt Kompetansesenter for Multippel Sklerose, Nevrologisk avdeling, Haukeland Universitetssykehus Introduction The cytokine interleukin 10 (IL-10) has been shown to elicit an antiinflammatory response in the pathogenesis of multiple sclerosis (MS). Polymorphisms in the promoter region of the IL- 10 gene have been shown to influence its expression. Three polymorphisms are of significance, -1082 (G/A), -819 (T/C) and -592 (A/C), making up several haplotype combinations, associated with either high, medium or low IL-10 expression. These polymorphisms have been shown to influence the desease activity and –course of some autoimmune and infectious diseases, as hepatitis C. In hepatitic C, they have also been shown to influence initial treatment response to IFN-α. Aim To study wether polymorphisms in the IL-10 gene influences interferon (IFN) treatment response in MS. Materials and methods 63 patients (43 women and 20 men), with a mean duration of MS of 8,3 years were included in the study. DNA was extracted from patient blood samples, and analyzed for IL-10 polymorphisms by polymerase chain reaction (PCR) and gene sequencing. All patients were evaluated with concern to disability (Expanded Disability Status Scale, EDSS), and disease activity on magnetic resonance imaging. Disability and disease activity were evaluated against IL-10 expression haplotypes. Results Patients with low IL-10 expression haplotypes had significantly fewer (0,77 ± +0,36) new contrast-enhancing MRI lesions compared to other patients (2,45 ± 0,57) (p=0,05). However, overall comparison of the three groups showed no significant differences (p=0,12). With regards to occurrence of new T2W lesions, no significant differences were detected (p=0,49). There were no significant difference in change in EDSS-score between high, medium or low IL-10 expression haplotypes (p=0,73). Occurrence of new relapses were the same in the three groups (p=0,61). 5/12 patients with high, 9/30 patients with medium and 9/19 patients with low IL-10 expression sufferred one or more relapses during a 6 month period after treatment initiation. Conclusion In this small sample of MS patients, polymorphisms in the promoter region of the IL-10 gene may seem to influence clinical IFN treatment response in MS measured by T1W contrast enhancing lesions. Further prospective studies seem necessary to establish the exact influence of IL-10 gene polymorphisms on interferon treatment response in MS. Carriage rate of group B streptococci in pregnant women and colonization of their babies. A study at Kilimanjaro Christian Medical Centre (KCMC), Tanzania and literature review Wilhelmsen, Marianne Supervisors: Nina Langeland, professor dr.med., Institutt for indremedisin, UiB Noel E. Sam, dr., Department of microbiology, KCMC, Tanzania og Claus Klingenberg, dr., Barneavdelingen, Universitetssykehuset Nord-Norge Background: Group B Streptococci (GBS) seems to be more common as a cause of neonatal infections in many industrialized countries compared to developing countries. In a previous three month survey at the neonatal ward, Kilimanjaro Christian Medical Centre (KCMC) from December 1998 to march 1999 there were no cases of GBS septicaemia among 247 admissions. Among ten cases with significant bacterial growth from blood cultures, S. aureus was the most common bacteria isolate. Of 66 positive cultures from blood, skin and ulcer base, there were no cases of GBS. The following study was performed to determine the colonization rate of GBS in delivering women at KCMC. Methods/results: Vaginal swabs were collected from 153 women admitted at labour ward, KCMC, from December 1999 through January 2000. Ear swabs from 89 of their newborn children were also collected (including to twin pairs). GBS was isolated from ten of the women. This equals a colonization rate of 6.5%. GBS was also isolated from two of the children. Conclusions: The GBS colonization rate of 6.5% probably represent an underestimated value because of sub-optimal routines for sample collection and laboratory techniques. 6.5% is lower than the mean estimated from other studies in Sub-Saharan countries. The GBS colonization rate in developing countries seems to vary within the same range as in industrialized countries. According to these observations, low colonization rate is not a plausible explanation for the low incidence of neonatal GBS infection in developing countries. Other possible explanations are genetic differences in susceptibility to develop disease, differences in GBS strains and their virulence, different levels of antibodies to GBS disease. The great uncertainty in estimating the incidence also makes it difficult to compare the results from different studies. En deskriptiv studie av PTSD hos voksne som har opplevd krig I Bosnia og Hercegovina Zvizdic, Asja Supervisor: Kjell Morten Stormark, forsker dr.psychol. Regionsenter for barn og unges psykiske helse, UiB PTSD (post traumatic stress disorder) develops after a traumatic and life threatening event. Diagnosis includes 3 categories of symptoms: 1. Intrusive with reliving of a trauma 2. Avoiding of stimuli associated with the trauma and emotional numbness 3. Persistent hyperarousal that was not there before Bosnia and Hercegovina went through extraordinary war condition where neighbours became enemies and fought each other. This makes it interesting to look at PTSD victims in Bosnia. I wanted to see what patient population with diagnosis PTSD participate in the treatment and if PTSD has the connection with stressors and premorbidity relationships. Summer 2002, 23 patients took part in a group therapy at the psychiatric hospital in Sarajevo. I went through these patients’ charts. Charts are filled after a standard procedure using different variables. All information in the charts is self reported by the patients themselves. The results are showing that most of the patients were middle aged men. 2 have previously had a psychiatric disorder, 4 had a close family member suffering from a psychiatric disorder and 2 had unadjusted premorbid personality before the war. Everyone has experienced life threatening traumas and intense and constant fear. There were otherwise no known other risk factors. Many are still suffering but refusing to seek help. It is very stigmatising to seek psychiatric help. Today it is being accentuated on informing people about this disorder and destigmatising it. Cognitive therapy in general practice Åkre, Jørgen Supervisor: Tone Tangen Haug, professor Seksjon for psykiatri, Institutt for klinisk medisin, UiB Purpose of the study: In this literature study the main goal has been to describe application of cognitive therapy in general practice. At first an overview regarding general aspects of cognitive therapy is given. The importance of intersubjectivity and therapeutic relation is emphasized. Further on, different approaches of cognitive therapy in general practice are presented. Cognitive therapy or elements of this in different relevant conditions such as stress, somatic disease, somatization, hypochondriasis, depression, social phobia, panic disorder and specific phobias, is discussed. One of the main issues has been to describe cognitive therapy, and it`s feasibility for general practitioners. Method: Literature study. Results: Several studies describe the use of cognitive therapy and/or elements of this in general practice, even though there are few randomized controlled studies. Coping with stress and somatic disease are areas where cognitive techniques seem to be useful. Likewise, there is evidence for prevention of disability in patients with chronic spinal pain provided cognitive interventions. Cognitive-behavioural treatment in groups can be effective for patients with somatoform conditions. An understanding of patients` cognitive content seems to be of special importance regarding hypochondriasis, where this again can be the startpoint for cognitive restructuring. Cognitive treatment and problemsolving techniques are effective in mild to moderate depression, and have been proved to be equally effective as medication. Some studies show a reduction in relapse rate of depression given this therapy, and another aspect is increased compliance. Cognitive therapy in panic disorder with agoraphobia had a more robust and persistent outcome than medication with antidepressants alone. Treatment of social phobia with exposure therapy in general practice has shown to be feasible and effective. Conclusion: Cognitive therapy is applicable for a range of conditions seen in general practice. An increased use of cognitive therapy or elements of this by general practitioners, would be desirable. The most important aspect regarding feasibility in general practice, is probably a strong interest in cognitive techniques and therapeutic relation by the doctor. Mors alder og svangerskap: Mors helse, komplikasjoner og forløsningsmetode Aanderaa, Elisabeth Danielsen, Gabrielle Dale, Kjetil Samuel Supervisors: Lorentz M. Irgens, professor dr.med. og Rolv Skjærven, professor dr.philos Medisinsk fødselsregister, Institutt for samfunnsmedisinske fag, UiB Objective: In our study we have tried to find out whether extreme maternal age is a disadvantage for the child, and whether this tendency has changed over the last thirty years. By the expression “extreme age”, we mean mothers being teenagers (<20 years old) or elderly women (≥35 years old). Material and method: The material is drawn from the Medical Birth Registry of Norway, and includes every primiparous women in Norway during the period 1976-1998 (a total of 738688 births). Multiple pregnancies and pregnancies of women with related partners are excluded from the material. We have compared primiparous teenagers to all primiparous women being twenty years or older. Also, we have compared primiparous elderly women to all primiparous women younger than thirty-five years old. The material has been divided into two periods, 1967-82 and 1983-98, to see whether time has had an effect on the variables we have examined. The variables we examined, were: apgarscore, caesarian section, preeclampsia, breech presentation and delivery with forceps or vacuum. Results: For the period 1983-98, elderly women had an increased chance for unfortunate outcome for the following variables: apgarscore OR=1,37 (95% CI 1,20-1,56), diabetes OR 2,14 (95% CI 1,84-2,50), caesarean operations OR=3,26 (95% CI 3,14-3,38), preeclampsia OR=1,26 (95% CI 1,17-1,35), breech presentation OR=1,45 (95% CI 1,35-1,56), forceps and vacuum OR=1,59 (95% CI 1,52-1,66). We found a significant interaction of time (p<0,001) for caesarean operations, preeclampsia, breech presentation and the use of forceps and vacuum. There was an increase in unfortunate outcomes of pregnancies from the first period to the second, for all variables examined. For the period 1983-98, younger women had an decreased chance for unfortunate outcome for the following variables; forceps and vacuum OR=0,57 (95% CI 0,55-0,59), diabetes OR=0,54 (95% CI 0,45-0,64), caesarean operations OR=0,65 (95% CI 0,62-0,67) and breech presentation OR=0,68 (95% CI 0,64-0,72). Conclusion: Extreme low maternal age is unfavourable for the child. This effect decreases closer to the twenties. From the variables we have looked into, there was no obvious unfavourable influence of the health of the mothers during their pregnancies or deliveries. On the other hand, if a woman waits until she is thirtyfive years old or older before she gets her first child, it is unfavourable both for the child and for the mother during her pregnancy and delivery. Pparγ-aktivering og dens effekt på celleproliferasjon i MCF-7 celler i kultur Aase, Jenny Hild Supervisor: Gunnar Mellgren, førsteamanuensis dr.med. Hormonlaboratoriet, Institutt for indremedisin, UiB The peroxisome proliferator-activated receptor γ is a transcription factor shown to play a crucial role in the control of cellular growth and differentiation. Especially, the recently emerged concept of ligand-dependent PPARγ-mediated inhibition of cancer cell proliferation, is of clinical interest to cancer therapy. Tetradecylthioacetic acid (TTA) is a sulphur- substituted saturated fatty acid analog and a known ligand for PAARγ. It has also been shown to inhibit cell proliferation in gliomacells from rat. Rosglitazone (BRL) is a thiazolidinedione (anti-diabetic drug) and known to be a PPARγ-agonist. In this study, we wanted to investigate if TTA inhibits cell growth via PAARγ dependent pathways. We used cancercells from breast tumors (MCF-7), as they have shown to be the most sensitive in inhibition of growth with another syntetic PPAR-ligand, Troglitazone. Transfection experiments confirmed that TTA stimulates PPARγ. We then introduced the PPARγ-stimulating cofactor TIF-2 in another transfection experiment. The transfected cells were treated with different consentrations of TTA and BRL, and the results showed that the cofactor TIF-2 enhances PPARγ-mediated transcription both in the presence of TTA, and the spesific ligand BRL. Finally, we performed a growth experiment where 3H-thymidin was incorporated in the DNA of MCF-7 cells, and used as a measure of proliferation. Cells treated with TTA showed inhibited proliferation in a dose-dependent manner. Cells treated with BRL did not show any significant growth inhibition. Thus, in conlution, our results indicate that TTA inhibits proliferation of MCF-7 cells in culture, but the effect is not mediated via PPARγ.
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