Tuberculosis screening in migrants in selected European countries shows wide disparities.

Well-established tuberculosis screening units in Western Europe were selectively sampled. Three screening units in Norway, two in the UK, one in the Netherlands and one in Switzerland were evaluated. The aim of this study was to describe a range of service models used at a number of individual tuberculosis units for the screening of new entrants into Europe. Semi-structured interviews were conducted with clinicians, nurses and administrators from a selected sample of European tuberculosis screening units. An outline of key themes to be addressed was forwarded to units ahead of scheduled interviews. Themes included the history of the unit, structure, processes and outputs involved in screening new entrants for tuberculosis. Considerable variation in screening services exists in the approaches studied. Units are sited in transit camps or as units within hospital facilities. Staff capacity and administration varies from one clinic per week with few dedicated staff to fully dedicated units. Only one site recorded symptoms; tuberculin testing was universal in children, but varied in adults; chest radiograph screening was universal except at one site where a positive tuberculin skin test or symptoms were required in those <35 yrs of age before ordering a radiograph. Few output data are routinely and systematically collected, which hinders comparison and determination of effectiveness and efficiency. Service models for screening new immigrants for tuberculosis appear to vary in Western Europe. The systematic collection of data would make international comparisons between units easier and help draw conclusions that might usefully inform service development.

Complement activation in injured patients occurs immediately and is dependent on the severity of the trauma.

In order to study the factors related to complement activation, the complement activation products C3bc and TCC were measured in plasma at admittance and during the stay in the intensive care unit in 108 consecutive patients with multiple injuries. These patients were admitted to the surgical department during a 4-month period. Complement activation occurred immediately after the trauma and correlated strongly with the Injury Severity Score and was inversely correlated to the Base Excess. Complement activation also correlated with the number of transfusions. Sepsis caused complement activation later during the stay in hospital. All seven patients developing the adult respiratory distress syndrome (ARDS) had increased complement activation, either on admission or later during the stay in the intensive care unit. Complement activation is known to contribute to organ damage following ischemia and reperfusion. Clinical studies have demonstrated the importance of early restoration of adequate circulation and the present demonstration of a strong negative correlation between complement activation and Base Excess indicates that early restoration of aerobic metabolism may reduce complement activation and the risk for organ dysfunction.

Low faecal carrier rate of vancomycin resistant enterococci in Norwegian hospital patients.

The faecal carrier rate of vancomycin resistant enterococci (VRE) was surveyed among 616 patients in selected departments of 7 Norwegian hospitals. One Enterococcus gallinarum isolate harbouring a vanB2 element was recovered from a child with malignant disease treated with vancomycin and ceftazidime. No vancomycin resistant Enterococcus faecalis or Enterococcus faecium were detected and no VRE isolates of the VanA type were identified. The low level of VRE carriage corresponds to the limited use of glycopeptide antibiotics for human therapeutic purposes in Norway. It indicates a low risk of acquiring VRE infections in Norwegian hospitals.

[Treatment of hyperactivity and attention deficit with amphetamine. Experience with five adult prisoners]. / Behandling av hyperaktivitet og oppmerksomhetssvikt med amfetamin. Erfaringer med fem voksne sikringsdømte.

Attention deficit hyperactivity disorder (ADHD) is a fairly common syndrome within child psychiatry. Stimulant medication is an important part of the treatment of the disorder. According to the literature, 30-50% of children with ADHD will still suffer from symptoms when they reach adulthood. The syndrome is a risk factor for various psychiatric disorders, drug and alcohol abuse, and criminality. There is some evidence that even adult patients may benefit from stimulant medication. ADHD was diagnosed and stimulant medication was started in five adult men who had been imprisoned for serious crimes of violence. The response to treatment was good in all of them. After 4-6 years two had been successfully rehabilitated.

[Quality adjusted life years in assessment of preventive measures. Should blood donors be tested for HTLV-I/II infections?]. / Kvalitetsjusterte leveår i vurderingen av forebyggende helsearbeid. Bør blodgivere testes for HTLV-I/II-infeksjon?

In planning preventive health measures, quality adjusted life-years (QALYs) are useful as a measure of benefit. As an example, the question of whether blood donors should be routinely tested for antibodies to the Human T-lymphotropic viruses I and II (HTLV I/II) is analysed. A mathematical model was set up to describe the consequences, in terms of lost life-years and years with disease due to transfusion-mediated infection (if testing is not performed) or years with reduced quality of life (in the case of testing). These future outcomes were discounted and converted to QALYs. The cost per QALY is about NOK 2.33 million when the prevalence is 1 per 50,000 blood donors, and is reduced to 190,000 per QALY when the prevalence is 10 per 50,000. Using QALYs in evaluation of preventive medicine can be complicated, and calls for cooperation between epidemiologists and health economists.

[Heroin related overdose problems]. / Overdoseproblematikk med heroin.

During the first ten months of 1992 the Oslo Ambulance Department registered 716 incidences of assumed drug-related intoxications. 80% happened in down town Oslo. 19 cases of asystoly were recorded, 13 of the patients recovered after treatment, without sequelae. Five of these patients left the location after emergency help and they refused hospitalization. 432 of the patients were unconscious when the ambulance personal arrived, 472 were treated with naloxone both by the intramuscular and the intravenous route. Most of the persons refused further observation. A team of specially trained out reach workers offers help after acute medical treatment by means of "streetwork". The intervention is directed at addicts who have experienced an overdose.

[Development of ambulance services in Norway--from transportation to medical activities]. / Ambulansetjenestens utvikling i Norge--fra transport til medisinsk virksomhet.

In the course of 100 years ambulance services in Norway have developed from purely transport facilities to mobile medical units. The first ambulance manned by doctors appeared in 1967, and since 1974 a two-year course of training has been available to ambulance personnel. However, as the ambulance services are run on a regional basis, and as official approval of ambulance personnel as paramedical staff is still lacking, there are manifest regional differences in the quality of the services.

[Criteria of death and time of death--do Norwegian physicians follow laws and regulations?]. / Dødskriterier og dødstidspunkt--følger legene norske lover og forskrifter?

In Norway, death is defined as total and irreversible damage of the whole central nervous system. This means that the time of death is some minutes after circulatory arrest. The time lapse may vary from about five minutes up to 45 minutes, depending on the temperature in the brain when the circulation ceased. Five cases of spontaneous circulation after cessation of resuscitation are described. All the patients had asystoly, diagnosed on ECG by anaesthesiologists. The resuscitation had lasted for 30 minutes when the crew of the ambulance, which included a doctor, gave up. Two of the patients left the hospital alive, three died after some hours. One of the patients had no cerebral sequelae, the other developed dementia. Circulation may also start spontaneously after the doctor has diagnosed circulatory arrest in patients suffering from suffocation and exsanguination.

[Cardiopulmonary resuscitation attempts at Ullevål hospital during January 1989-July 1990]. / Hjerte-lunge-redningsforsøk ved Ullevål sykehus januar 1989-juli 1990.

During the period January 1989 to July 1990, 68 in-hospital cardiopulmonary resuscitations were attempted in 65 patients at Ullevål Hospital. The total number of deaths during the same period was 2,166. 21 patients survived initially (32%). Nine patients died later, and 12 patients (18%) were discharged from hospital without major cerebral disability. Six patients were alive at follow-up 13-25 months after cardiopulmonary resuscitation. No differences in survival were found between males and females, or between patients under and over 70 years of age.

[Accidental hypothermia. Risk factors in 29 patients with body temperature of 30 degrees C and below]. / Aksidentell hypotermi. Risikofaktorer hos 29 pasienter med kroppstemperatur under 30 C grader.

29 patients with a body temperature below 30 degrees C (mean 26.4 degrees C) were treated during the period 1982-88, both years inclusive. Eight patients were severely hypotensive (systolic blood pressure less than 60 mm Hg) and two had ventricular fibrillation on admission. Bradycardia (less than 60 beats per minute) was noted in ten patients. 12 patients were rewarmed by surface warming, 17 by extracorporeal circulation with femoral cannulation. 22 patients (76%) were discharged alive. Age, sex, body temperature, method and rate of rewarming, serum electrolytes, acidosis and the use of blood components did not influence the outcome. Renal failure was the only complication associated with a fatal outcome. Severe hypotension on admission tended to increase mortality, but logistic regression analysis identified the mode of cooling as the only independent risk factor for death. A patient cooled indoors had an odd risk of 10.6 of hospital mortality compared to one found outdoors. For the sake of convenience, in hospitals with the available resources rewarming by extracorporeal circulation may be used in patients with circulatory arrest, since this is the easiest way to control and support failing circulation. In all other cases carefully monitored surface rewarming should be used as this necessitates less use of hospital resources and produces equally good results.

[Acute pulmonary dysfunction in adults. Adult respiratory distress syndrome--ARDS]. / Akutt lungesvikt hos voksne. Adult respiratory distress syndrome--ARDS.

During a 3-year period 0.1% of all patients undergoing surgery and 0.3% of the patients submitted for trauma developed ARDS. The diagnosis was based on strict criteria. Mortality among the 42 patients was 45.2%. Abdominal sepsis was associated with high mortality, trauma with a much better prognosis. Swan-Ganz catheters were used in 81% of the patients. The measurements were characterized by high pulmonary vascular resistance and increased intrapulmonary shunting. However, the initial recordings showed only small differences between survivors and fatal cases as regards haemodynamics and blood gas parameters. Mortality was associated with low diuresis, heart failure, need of inotropic support and on age of over 50 years. The significance of invasive central monitoring is discussed.

Placebo-controlled comparison of single intramuscular doses of ketorolac tromethamine and pethidine for post-operative analgesia.

The analgesic efficacy and safety of single doses of 10 mg and 30 mg ketorolac tromethamine and 100 mg pethidine were evaluated in a double-blind, parallel-group study. The drugs were administered intramuscularly to patients experiencing moderate, severe or very severe pain immediately following major abdominal surgery. A total of 129 patients were randomly assigned to receive either active drug (n = 32 for each treatment group) or placebo (n = 33), and the patients assessed pain intensity and pain relief on a visual analogue scale at regular intervals over the following 8 h. During the first 2 h, pethidine had a more rapid onset of action than ketorolac or placebo, and thereafter 100 mg pethidine and 30 mg ketorolac were equally effective. Ketorolac, at a dose of 10 or 30 mg, and 100 mg pethidine were clinically and statistically more effective than placebo, with 30 mg ketorolac having a similar efficacy to 100 mg pethidine over the 8-h study period and 10 mg ketorolac being slightly less effective than 30 mg ketorolac. No serious adverse events were reported.

[Blood transfusion in heart surgery]. / Blodtransfusjoner ved hjertekirurgi.

We have studied the effect of blood-saving measures in open heart surgery. Such measures were introduced in 1987. All fluids administered on the day of operation and on the first postoperative day were registered in all cardiac patients operated during one month in 1986, 1987, 1988. In 1986 the patients were exposed to a median of 21 donors while in 1988 they were exposed to a median of 2 donors. The reduction in transfusions was achieved by substituting plasma by polygeline, by giving thrombocytes only when there was a low thrombocyte count and by accepting a hemoglobin value of 9 g/100 ml before transfusion of erythrocytes. In 1988 most postoperatively drained blood was retransfused using a Sorensen retransfusion set. The reduction in transfusions has reduced the cost of each open heart operation by NOK 11,662.