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The urgent need to treat presumptive bacterial or fungal infections in neutropenic patients has meant that initial therapy is empiric and based on the pathogens most likely to be responsible, and drug resistance. The traditional empirical treatment in Norway has been penicillin G and an aminoglycoside, and this combination has been criticized over recent y. We wished to analyse the microbiological spectrum and susceptibility patterns of pathogens causing bacteraemia in febrile neutropenic patients. This was a prospective multicentre study. During the study period of 2 y, a total of 282 episodes of fever involving 243 neutropenic patients was observed. In 34% of episodes bacteraemia was documented. Overall, 40% of the episodes were caused by Gram-positive organisms, 41% by Gram-negative organisms and 19% were polymicrobial. The most frequently isolated bacteria were Escherichia coli (25.6%), a- and non-haemolytic streptococci (15.6%), coagulase-negative staphylococci (12.4%) and Klebsiella spp. (7.4%). None of the Gram-negative isolates was resistant to gentamicin, meropenem, ceftazidime or ciprofloxacin. Only 5 coagulase-negative staphylococci isolates were resistant to both penicillin G and aminoglycoside. The overall mortality rate was 7%, and 1.2% due to confirmed bacteraemic infection.

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

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

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

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

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

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

Leukocyte adhesiveness was studied by measuring the retention of leukocytes in glass bead columns after the passage of heparinized whole blood or leukocyte suspensions. Leukocytes adhered readily to glass beads and independently of divalent cations when proteins were absent. Addition of plasma inhibited leukocyte adherence which became increasingly dependent on divalent cations. In conflict with results reported from nylon wool column experiments, we could not demonstrate a leukocyte adherence augmenting effect of zymosan activated plasma or plasma from patients with inflammatory diseases or patients undergoing hemodialysis. Ethanol and lidocaine gave a dose response inhibition of leukocyte adherence. The conflicting results obtained with the nylon wool and the glass head column techniques in conditions with "augmented adherence" may be due to retention of leukocyte aggregates in the nylon wool columns.

Slit-lamp vitreous fluorophotometry (VF) has been used by several investigators to document the early breakdown of the blood-ocular barrier. After an injection of fluorescein, levels of fluorescein in the vitreous humor are reported to be elevated in diabetic patients compared with controls even when there is no retinal pathologic condition discernible by angiography or ophthalmoscopy. We have examined the technique of VF in normal persons and have identified several potential sources of error in the determination of vitreous fluorescein levels. Fluorescein in the choroidal circulation significantly influences VF readings taken at the retinal surface and in the posterior vitreous. This effect is modulated by ocular pigmentation, with heavy pigmentation of dark-eyed normals more effectively screening out choroidal fluorescence than the light pigmentation of blue-eyed subjects. Influence of choroidal fluorescein extends toward the midvitreous, and the range of influence is directly related to the slit width of the exciting light. At narrow slit widths the effect is diminished but can never be completely eliminated. Blood fluorescein levels decrease with time, and since choroidal fluorescein contributes to VF values, the time after injection that VF reading are taken is a critical parameter.

Human neutrophils were irradiated with light at 340-380 nm in the presence of low concentrations of protoporphyrin or uroporphyrin. At increasing light doses or increasing concentrations of protoporphyrin, the neutrophils rapidly lost the ability of locomotion. Also, neutrophil chemiluminescence and hexose-monophosphate shunt activity rapidly declined. An early event was leakage of endogenous K(+) followed by lactate dehydrogenase and at a later stage leakage of particle-bound acid phosphatase. A number of cellular enzymes were inactivated, the susceptibility to inactivation decreased in the order: succinate dehydrogenase greater than lactate dehydrogenase greater than glutamate dehydrogenase greater than acid phosphatase. Uroporphyrin had no effect on neutrophil functions, leakage of K(+), or cellular enzymes. The results suggest that photodamage to the plasma membrane and the mitochondria are earlier events than photodamage to lysosomes.

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

The adhesion of leukocytes to glass beads in protein-free media was quantitatively high and not dependent on divalent cations. Addition of plasma, albumin or gelatin in increasing concentrations gradually reduced leukocyte adhesion, which then became increasingly dependent on divalent cations. Heat inactivation of plasma did not affect leukocyte adhesion. Leukocyte migration in glass capillary tubes, which was dependent on a heat labile plasma factor, was promoted by each of the proteins listed and by siliconizing the tubes. Leukocyte migration in millipore filters was enhanced when albumin was present in the cell starting compartment. Lidocain reduced both leukocyte adhesion to protein-coated glass and leukocyte migration in capillary tubes and millipores filters. Ethanol reduced leukocyte adhesion and leukocyte filter migration. E. coli endotoxin enhanced adhesion of leukocytes but inhibited their migration in tubes and filters. The findings indicate the existence of a relationship between adhesion and migration of leukocytes.

Three patients with leukemia developed corneal toxicity while receiving high doses (3 g/m2) of systemic cytarabine. Symptoms began five to seven days after initiation of treatment with high doses of systemic cytarabine and consisted of ocular pain, tearing, foreign-body sensation, photophobia, and blurred vision. All three patients developed bilateral conjunctival hyperemia and fine corneal epithelial opacities and refractile microcysts that were more numerous in the central than in the peripheral cornea. The symptoms disappeared without treatment in approximately one week. The corneal changes we observed with high doses of systemic cytarabine resembled descriptions of corneal toxicity from topical cytarabine and were probably secondary to inhibition of DNA synthesis in the corneal epithelium.

Granulocyte and platelet adhesiveness were measured in 36 patients with haematologic diseases, using a glass bead column assay. Platelet adhesiveness (PA) was reduced in malignant paraproteinaemia (l3/20), leukaemia (10/11) and myeloproliferative diseases (3/5). Granulocyte adhesiveness (GA) was reduced in most patients with paraproteinaemia and leukaemia, but results of measurements in whole blood and in suspensions of leucocytes in autologous plasma were poorly correlated due to the influence of abnormal platelet function and/or concentration on the measurement of GA in whole blood. The results of experiments combining leucocytes and plasma from patients and controls indicate that impaired GA in paraproteinaemia is due to a plasma factor, whereas a cellular defect is responsible for the reduced GA in leukaemia.

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

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

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

Two sisters, aged 38 and 32, suffering from cerebrotendinous xanthomatosis are described. The most important clinical findings were xanthomas, central nervous affection with motor and mental dysfunction, EEG changes and juvenile cataract. The diagnosis was established by the demonstration of increased amounts of cholestanol in serum. Both sisters had amenorrhea, and their excretion of dehydroepiandrosterone in the urine was increased. In the elder sister, the levels of urinary 17-keto steroids, androsterone and estradiol were also increased. Other unusual features of the disease in the elder sister were hyper-prebeta-lipoproteinemia and serum cholesterol in the higher normal range.

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

Erythrocyte sedimentation significantly influenced test results when leucocyte retention in glass bead columns was used as a measure of leucocyte adhesiveness. In blood with elevated ESR, this influence was especially evident. Erythrocyte sedimentation highly increased leucocyte retention in vertical columns with a downward flow, whereas in slightly tilted columns with an upward flow, the retention was reduced. The error in measurements caused by erythrocyte sedimentation could be corrected by means of the haematocrit values in samples and eluates. Correction was better for results obtained with slightly elevated than with vertical columns. The granulocyte retention rates increased with increasing sample size, whereas lymphocyte retention remained constant.

The influence of platelets and erythrocytes on the retention of leucocytes in glass bead columns was studied. Leucocyte retention increased when platelet retention was stimulated by the presence of erythrocytes. In the presence of only a few erythrocytes, platelet retention was low, and platelets did not influence leucocyte retention. When only a small number of platelets was present, erythrocytes inhibited leucocyte retention. The platelet-dependent leucocyte retention increased as the volume passed through the columns was increased. However, the platelet-independent leucocyte retention did not change when the sample size was increased. In blood from patient with thrombocytopenia or defect in platelet function and in normal blood treated with inhibitor of platelet adhesion, neutrophil retention was reduced. However, erythrocyte-free leucocyte suspensions from these cases showed normal leucocyte retention. Thus, experiments with whole blood may serve as a model for the study of platelet-leucocyte interaction. However, for the study of leucocyte adhesiveness per se, isolated leucocytes seem more suitable than whole blood.

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

Fatal hepatitis associated with intake of carbamazepine occurred in two females, 37 and 23 years old. The former used carbamazepine to prevent alcohol withdrawal symptoms. She had also been treated with disulfiram. The latter had used the drug as the only medication for epilepsy. This report supports the view that carbamazepine may induce serious hepatic damage.