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Journal: Tidsskrift for den Norske lægeforening : tidsskrift for praktisk medicin, ny række


Hand pain is a relatively common complaint, and careful anamnesis and clinical examination may reveal its aetiology. Multiple joint involvement suggests either osteoarthritis or inflammatory arthritis. In the returning traveller, a more exotic explanation might be the case. A 31 year old woman was referred to our outpatient clinic for evaluation due to peripheral joint arthralgia. The symptoms started six months earlier, on the same day she returned from a three-week holiday in India. There were no signs of inflammatory arthritis or osteoarthritis. Blood tests were normal. Chikungunya virus serology was positive. The patient received symptomatic treatment with nonsteroid anti-inflammatory drugs and improved over a period of months. We describe the first case of Chikungunya fever diagnosed in our hospital.

Concepts: Inflammation, Hospital, Rheumatoid arthritis, Greek loanwords, Osteoarthritis, Non-steroidal anti-inflammatory drug, Arthralgia, Chikungunya


BACKGROUND Iron deficiency and iron deficiency anaemia are frequent problems in both the primary and the specialist health services. It is important to detect iron deficiency and to determine the causal relationship because iron deficiency may be secondary to a serious disease. The diagnosis of iron deficiency is largely based on biochemical and haematological laboratory findings, but there is no standardisation or consensus on the interpretation of these findings.METHOD Non-systematic search in the PubMed database with a discretionary selection of articles, based on the authors' knowledge of the field.RESULTS Ferritin measurement is the most important analysis in the study of iron deficiency, but there is no consensus on the diagnostic cut-off. It is usual in Norway today to use a ferritin level of < 12 - 20 μg/L, but at this low level the sensitivity for detecting iron deficiency is very low. A number of studies show that if the diagnostic cut-off is increased to the order of 30 μg/L the sensitivity is significantly higher for only a small reduction in specificity.INTERPRETATION When studying iron deficiency as a cause of anaemia, the diagnostic cut-off for detecting deficiency should be higher than that used today. The ferritin level increases with inflammation and ought in practice to be considered in conjunction with the CRP level. The level of transferrin receptor in plasma increases with iron deficiency without being influenced by inflammation and is therefore a good supplement to ferritin measurement. Measurement of iron, transferrin and transferrin saturation provides little information additional to that provided by ferritin in iron deficiency studies.

Concepts: Hemoglobin, Iron, Anemia, Hematology, Iron deficiency anemia, Transferrin, Serum iron, Iron metabolism


BACKGROUND: Increasing life expectancy in persons with Down’s syndrome requires knowledge about conditions that are frequently observed in adults who have the syndrome, and to which health personnel need to pay special attention.KNOWLEDGE BASE: The article is based on a literature search in PubMed, as well as the authors' clinical experience with this group of patients.RESULTS: Altered immune function, muscular hypotonia, developmental disorders of the head and neck and premature ageing contribute to health problems. The group is subject to infections, especially in the airways and the digestive tract. Congenital heart disorders may also result in symptoms in adulthood. In addition, many develop disorders of the mitral valve, including those who have no congenital heart failure. Hypothyreosis develops in up to half of the patients, and coeliac disease in one of every five. Obstructive sleep apnoea syndrome occurs in an estimated half of the patients. Sensorineural hearing loss and cataracts can be observed from before the age of 30. Atlantoaxial instability sometimes occurs, and a radiological examination of the neck must be undertaken prior to interventions under narcosis. Behavioural change with loss of skills and withdrawal, psychomotoric retardation and mutism are frequently observed from the age of 30 onwards, and may be symptoms of mental disorders or the onset of Alzheimer’s disease.INTERPRETATION: There is a need for regular health check-ups for adults with Down’s syndrome, and we recommend that an annual health examination should be undertaken by the regular GP. We also recommend screening for hearing loss and cataracts, every third and fifth year respectively. In case of complex symptomatologies, especially those related to neurological and psychiatric conditions, the patient can be referred to the habilitation services.

Concepts: Medicine, Cancer, Senescence, Heart, Sleep, Sleep apnea, Obstructive sleep apnea, Down syndrome


BACKGROUND Posterior cortical atrophy is a neurodegenerative condition with atrophy of posterior parts of the cerebral cortex, including the visual cortex and parts of the parietal and temporal cortices. It presents early, in the 50s or 60s, with nonspecific visual disturbances that are often misinterpreted as ophthalmological, which can delay the diagnosis. The purpose of this article is to present current knowledge about symptoms, diagnostics and treatment of this condition.METHOD The review is based on a selection of relevant articles in PubMed and on the authors' own experience with the patient group.RESULTS Posterior cortical atrophy causes gradually increasing impairment in reading, distance judgement, and the ability to perceive complex images. Examination of higher visual functions, neuropsychological testing, and neuroimaging contribute to diagnosis. In the early stages, patients do not have problems with memory or insight, but cognitive impairment and dementia can develop. It is unclear whether the condition is a variant of Alzheimer’s disease, or whether it is a separate disease entity. There is no established treatment, but practical measures such as the aid of social care workers, telephones with large keypads, computers with voice recognition software and audiobooks can be useful.INTERPRETATION Currently available treatment has very limited effect on the disease itself. Nevertheless it is important to identify and diagnose the condition in its early stages in order to be able to offer patients practical assistance in their daily lives.

Concepts: Alzheimer's disease, Brain, Medical terms, Diagnosis, Cerebral cortex, Temporal lobe, Cerebrum, Cortical column


BACKGROUND Many Norwegians have embraced the low-carb trend and choose butter and bacon instead of brown bread and carrots. This entails a dramatic change in the total intake of fat and the intake of saturated fat. We have investigated how a low-carb diet can affect the lipid profile in healthy adults with a normal bodyweight.MATERIAL AND METHOD Seven healthy female participants with normal bodyweight underwent a four-week trial of a low-carb diet (< 20 - 25 grams of carbohydrates/day). Daily diet registrations were made during the trial period, and diet data for three randomly selected days were included in the estimates. Blood samples and weight data were collected as fasting values prior to and after the intervention.RESULTS Standardised diet data were available for six participants. On a low-carb diet, the energy intake from carbohydrates accounted for a median of 3 (spread: 2 - 5) per cent of the total energy intake. The intake of fat accounted for 71 (67 - 78) per cent of total energy, while protein accounted for 26 (19 - 31) of total energy intake. At baseline, the median value of total cholesterol was 4.1 mmol/L (dispersion: 3.3 - 5.7) and LDL cholesterol was 2.2 (1.8 - 3.4) mmol/L. The values increased to 5.2 (3.7 - 8.8) mmol/L and 3.1 (1.9 - 6.2) mmol/L for total and LDL cholesterol respectively. The absolute changes correspond to a percentage increase in total cholesterol of 33 (14 - 71) % and in LDL cholesterol of 41 (9 - 84) %. Median weight change amounted to -1.2 kg (-2.8 - 0.6).INTERPRETATION A diet with little carbohydrate and a great deal of protein and fat resulted in a considerably heightened level of total cholesterol and LDL cholesterol in young, healthy women with a normal bodyweight. The findings indicate that a low-carb diet may have a negative impact on individual risk profiles. However, the study is small-scale and the results must be interpreted with caution.

Concepts: Cholesterol, Metabolism, Nutrition, Obesity, Carbohydrate, Low-carbohydrate diet, Ketosis, Zone diet


Background: Many children with ADHD develop epilepsy, and approximately 20 % of children with epilepsy also have ADHD. In this article we discuss the use of EEG in connection with ADHD in children, with emphasis on the diagnosis of comorbid epilepsy.Method: The article is based on a literature search in PubMed, personal literature archives and the authors' own experience with the use of EEG, treatment of epilepsy and the diagnosis and treatment of ADHD in children and adolescents.Results: A moderately elevated prevalence of epileptiform EEG activity is described in children with ADHD without epilepsy compared with healthy children, during both wakefulness and sleep. Selected material and a lack of controlled blinded studies probably explain much of this difference. The significance of epileptiform EEG activity in children with ADHD without seizures is uncertain. Evaluating the extent to which EEG findings may explain the symptoms and whether anti-epileptic drugs should be tried is a specialist task. In many studies, spectral analysis of the frequency content of the EEG (QEEG) has shown higher slow theta activity and a higher theta/beta ratio in children with ADHD.Interpretation: Seizure symptoms, disturbed sleep quality, significant changes in behaviour or regression of cognitive ability in children with ADHD should lead to paediatric neurological assessment with EEG and possibly a 24-hour EEG. In our view, the QEEG variables are artifact-prone and biologically unspecific. We therefore do not recommend the use of QEEG as a stand-alone diagnostic marker.

Concepts: Greek loanwords, Neurology, Electroencephalography, Epilepsy, Anticonvulsant, Seizure, Status epilepticus, Myoclonus


BACKGROUND Increasing attention is being paid to research misconduct in academic journals and in the media, but we know relatively little about its extent or attitudes to research misconduct, or how these are changing. This study therefore aims to investigate PhD candidates' knowledge, own actions and attitudes to specific forms of research misconduct.MATERIAL AND METHOD In autumn 2015, an anonymous questionnaire survey was distributed to all participants in the introductory course for PhD candidates at the Faculty of Medicine at the University of Oslo.RESULTS Altogether 77 PhD candidates (79 %) responded to the questionnaire. A total of 62 % conducted clinical research and 25 % conducted basic research. Around one in four had heard about serious forms of research misconduct in the previous year, and around 4 % were aware of various forms of serious research misconduct in their own department in the previous year. Compared to earlier studies, an increasing number (16 %) responded that they had been subjected to unethical pressure with regard to inclusion or order of authors. Approximately two-thirds were uncertain of whether their department had written policies for academic conduct. One-third of PhD candidates did not disassociate themselves from actions that are generally viewed as scientific misconduct. One-tenth thought it acceptable to falsify or fabricate data in order to expedite publication, one-fifth did not object to taking the credit for others' ideas, and almost half did not believe it was wrong to attempt a number of methods of analysis until one arrived at a significant answer.INTERPRETATION PhD candidates at the Faculty of Medicine were aware of research misconduct, both generally and from their own department. They themselves reported some type of scientific misconduct, and a large majority were uncertain of their department’s guidelines. Some of the candidates also accepted several forms of research misconduct.

Concepts: Scientific method, Medicine, Epistemology, Academic publishing, Science, Research, Scientific misconduct, Plagiarism


BACKGROUND A high rate of attendance among women invited to the Norwegian Breast Cancer Screening Programme (NBCSP) is essential to achieve optimal effect, including reduction in breast cancer mortality. This article describes attendance in the programme by county, period and women’s age at invitation.MATERIAL AND METHOD All women in the age group 50 - 69 years who are registered in the National Population Register are invited to attend the NBCSP every second year. In the study period 2007 - 2014, 2 142 369 invitations were sent, and 1 600 293 screening examinations were performed for 710 169 women. Use of the data is pursuant to the Cancer Registry Regulations.RESULTS Altogether 84 % of the women invited attended at least once in the study period. The average attendance rate per screening round was 75 %. In Rogaland, Nordland and Sogn og Fjordane counties more than 80 % attended, while in Oslo the figure was 62 %. The highest rate of attendance recorded was for women in the age group 62 - 67 years. The attendance in the prior screening round was of influence for reattendance.INTERPRETATION The mammography screening programme has a high level of acceptance among women in the target group. Possible reasons for the variation in attendance among the county districts should be identified.

Concepts: Cancer, Breast cancer, Metastasis, Estrogen, Mammography, Norway, Counties of Norway, Sogn og Fjordane


BACKGROUND Rotavirus is a common cause of gastroenteritis in children. Neurological manifestations associated with rotavirus infections are well described and range from benign afebrile convulsions to lethal encephalopathy or encephalitis.CASE PRESENTATION We present an uncommon neurological manifestation in a Caucasian child in the course of a rotavirus infection. A 4-year old girl presented with mutism, hypotonia and reduced consciousness. Magnetic resonance imaging revealed diffusion abnormalities in the splenium corpus callosum and bilaterally in the nuclei dentate in the cerebellum. She was diagnosed with rotavirus cerebellitis.INTERPRETATION Her clinical symptoms and the magnetic resonance imaging abnormalities were uncommon and previously described in only a few Caucasian children. The outcome has varied, and some children have shown long term neurological sequela. Treatment with immunoglobulins and corticosteroids has been used in similar cases, but there is no established treatment for this condition.

Concepts: Brain, Rotavirus, Corpus callosum


It is well known that statins can have a toxic effect on musculature, but less widely known that they can also trigger progressive autoimmune myopathy. Statin-associated autoimmune myopathy is characterised by proximal muscle weakness, antibodies to 3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGCR) in serum, and necrosis without lymphocytic infiltration on muscle biopsy.

Concepts: Immune system, Metabolism, Statin, Muscle, Muscular system, Creatine kinase, Neuromuscular disease, Muscle weakness