Objectives: To determine the incidence and characteristics of superinfections in mechanically ventilated COVID-19 patients, and the impact of dexamethasone as standard therapy. Methods: This multicentre, observational, retrospective study included patients >= 18 years admitted from March 1 st 2020 to January 31 st 2021 with COVID-19 infection who received mechanical ventilation. Patient characteristics, clinical characteristics, therapy and survival were examined. Results: 155/156 patients (115 men, mean age 62 years, range 26-84 years) were included. 67 patients (43%) had 90 superinfections, pneumonia dominated (78%). Superinfections were associated with receiving dexamethasone (66% vs 32%, p < 0.0 0 01), autoimmune disease (18% vs 5.7%, p < 0.016) and with longer ICU stays (26 vs 17 days, p < 0,001). Invasive fungal infections were reported exclusively in dexamethasone-treated patients [8/67 (12%) vs 0/88 (0%), p < 0.0 0 01]. Unadjusted 90-day survival did not differ between patients with or without superinfections (64% vs 73%, p = 0.25), but was lower in patients receiving dexamethasone versus not (58% vs 78%, p = 0.007). In multiple regression analysis, superinfection was associated with dexamethasone use [OR 3.7 (1.80-7.61), p < 0.001], pre-existing autoimmune disease [OR 3.82 (1.13-12.9), p = 0.031] and length of ICU stay [OR 1.05 p < 0.001]. Conclusions: In critically ill COVID-19 patients, dexamethasone as standard of care was strongly and independently associated with superinfections. (c) 2022 The Author(s). Published by Elsevier Ltd on behalf of The British Infection Association. This is an open access article under the CC BY license ( http://creativecommons.org/licenses/by/4.0/ )

BacgroundSuper-infections in COVID-19 patients with acute respiratory distress syndrome (ARDS) on mechanical ventilation were initially reported to be rare. Little is known of their incidence after dexamethasone was introduced as standard care. We aimed to determine the incidence and characteristics of superinfections in mechanically ventilated COVID-19 patients during the course of the COVID-19 pandemic, and explore the possible impact of the introduction of dexamethasone as standard therapy. MethodsIn this national, multi-center, observational, retrospective study we included patients ≥ 18 years admitted from March 1 st 2020 to January 31 st 2021 with polymerase chain reaction (PCR)-confirmed SARSCoV-2 infection treated with invasive mechanical ventilation. Data was collected from electronic health records. Patient characteristics, clinical findings, microbiology, length of stay and 90-day survival were examined with backwards stepwise multiple regression. Results155 patients (115 men, mean age 62 years, range 26-84 years) were included. 73 patients (47%) had a total of 101 superinfections where pneumonia dominated (70%). Superinfections were more commonly observed in patients receiving dexamethasone (67% vs 30%, p<0.0001), and in patients with pre-existing autoimmune disease (18% vs 5%, p<0.01). Invasive fungal infections were reported exclusively in dexamethasone-treated patients [9/72 (13%) vs 0/83 (0%), p<0.0001]. There was no difference in 90-day survival between patients with and patients without superinfections (64% versus 73%, p=0.238). In multiple regression analysis, superinfection was associated with dexamethasone use [OR 5.35 (2.62–11.35), p<0.001], pre-existing autoimmune disease [OR 4.90 (1.50–19.4), p=0.008] and higher lymphocyte count at the time of admission [OR 2.31 (1.23–4.86), p=0.009]. ConclusionIn critically ill COVID-19 patients receiving invasive ventilation, introduction of dexamethasone as standard of care was strongly and independently associated with superinfections. A focus on this complication is warranted when studying alternative anti-inflammatory therapy.

MINNEORDVår gode kollega og venn Eivind Ragnhildstveit døde 30.juli 2020, 76 år gammel.Han vokste opp i Hålandsdalen.E er endt skolegang fly et han til Bergen for å studere medisin.Han utviklet tidlig interesse for infeksjonssykdommer

Outbreaks of multidrug resistant bacteria including vancomycin-resistant enterococci (VRE) in healthcare institutions are increasing in Norway, despite a low level of resistance compared to other European countries. In this study, we describe epidemiological relatedness of vancomycin-resistant Enterococcus faecium isolated during an outbreak at a Norwegian hospital in 2012–2013. During the outbreak, 9454 fecal samples were screened for VRE by culture and/or PCR. Isolates from 86 patients carrying the vanA resistance gene were characterized using pulsed-field gel electrophoresis (PFGE), MALDI-TOF mass spectrometry and single nucleotide polymorphism typing. PFGE revealed two main clusters, the first comprised 56 isolates related to an initial outbreak strain, and the second comprised 21 isolates originating from a later introduced strain, together causing two partly overlapping outbreaks. Nine isolates, including the index case were not related to the two outbreak clusters. In conclusion, the epidemiological analyses show that the outbreak was discovered by coincidence, and that infection control measures were successful. All typing methods identified the two outbreak clusters, and the experiment congruence between the MALDI-TOF and the PFGE clustering was 63.2%, with a strong correlation (r = 72.4%). Despite lower resolution compared to PFGE, MALDI-TOF may provide an efficient mean for real-time monitoring spread of infection.

Background: In Norway, the epidemiological situation of candidemia is followed closely. We have previously demonstrated the highest incidence of candidemia in elderly >65years of age. However, knowledge of other aspects of this infection is lacking.Objective: The aim of this nationwide, retrospective study was to examine risk factors, therapeutic practice and outcome in adult candidemia patients according to age.Methods: We retrieved data from medical records from patients who developed candidemia in Norway between 1 January 2008 and 31 December 2012. Data were analyzed according to age, younger patients being between 18 and 65 years, elderly being 65 years of age.Results: From 771 eligible patients, 738 patients (95.7%) were included (58% men, mean age 65.2years, 58.1% being 65years). Exposure to health-care related risk factors for candidemia were significantly more common in the younger patients (neutropenia, central venous catheter, mechanical ventilation and chemotherapy) who received empirical treatment more often than the elderly (29.8% vs. 21.7%, p=.01). More elderly did not received any antifungal therapy (27.3% vs 16.8%, p<0001) and had higher mortality compared to younger patients (45.5% vs 23.9%, p<.0001). In the study population, mortality was higher with age (per 10-years increase, OR 1.43;1.28-1.59, p<0.0001), in patients not receiving targeted therapy (OR 2.5; CI 1.82-3.36, p<.0001) or any therapy at all (OR 4.64; 3.23-6.68, p<.0001).Conclusions: Risk factors for candidemia, treatment and outcome differed significantly according to age. Given the increasing numbers of elderly, scrutiny on our clinical practice is warranted.

Background & Aims: On-going risk behaviour can lead to hepatitis C virus (HCV) reinfection following successful treatment. We aimed to assess the incidence of persistent HCV reinfection in a population of people who inject drugs (PWID) who had achieved sustained virological response (SVR) seven years earlier.Methods: In 2004-2006 we conducted a multicentre treatment trial comprising HCV genotype 2 or 3 patients in Sweden, Norway and Denmark (NORTH-C). Six months of abstinence from injecting drug use (IDU) was required before treatment. All Norwegian patients who had obtained SVR (n = 161) were eligible for participation in this long-term follow-up study assessing virological and behavioural characteristics.Results: Follow-up data were available in 138 of 161 (86%) individuals. Persistent reinfection was identified in 10 of 94 (11%) individuals with a history of IDU prior to treatment (incidence rate 1.7/100 person-years (PY); 95% CI 0.8-3.1) and in 10 of 37 (27%) individuals who had relapsed to IDU after treatment (incidence rate 4.9/100 PY; 95% CI 2.3-8.9). Although relapse to IDU perfectly predicted reinfection, no baseline factor was associated with reinfection. Relapse to IDU was associated with age <30 years (vs. >= 40 years) at treatment (adjusted odds ratio [aOR] 7.03; 95% CI 1.78-27.8) and low education level (aOR 3.64; 95% CI 1.44-9.18).Conclusions: Over time, persistent HCV reinfection was common among individuals who had relapsed to IDU after treatment. Reinfection should be systematically addressed and prevented when providing HCV care for PWID. (C) 2016 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

In May 2005, a long-distance outbreak of Legionnaires’ disease (LD) caused by Legionella pneumophila serogroup 1 occurred in south-east Norway. The initial outbreak investigation without serology identified 56 laboratory-confirmed LD cases of whom 10 died. However, 116 patients with community-acquired pneumonia might belong to the outbreak based on epidemiological investigations, but acute laboratory tests other than serology were negative or not performed. To assess the true extent of the outbreak, we evaluated two serological assays in order to reclassify the 116 patients with indeterminate case status.

BACKGROUND AND AIMS:In Norway, data on the aetiology of community-acquired pneumonia (CAP) in hospitalized patients are limited. The aims of this study were to investigate the bacterial aetiology of CAP in hospitalized patients in Norway, risk factors for CAP and possible differences in risk factors between patients with Legionnaire's disease and pneumonia because of other causes.METHODS:Adult patients with radiologically confirmed CAP admitted to hospital were eligible for the study. Routine aerobic and Legionella culture of sputum, blood culture, urinary antigen test for Legionella pneumophila and Streptococcus pneumoniae, polymerase chain reaction detection of Chlamydophila pneumoniae, Mycoplasma pneumoniae and Bordetella pertussis from throat specimens, and serology for L. pneumophila serogroup 1-6 were performed. A questionnaire, which included demographic and clinical data, risk factors and treatment, was completed.RESULTS:We included 374 patients through a 20-month study period in 2007-2008. The aetiological agent was detected in 37% of cases. S. pneumoniae (20%) was the most prevalent agent, followed by Haemophilus influenzae (6%) and Legionella spp. (6%). Eight Legionella cases were diagnosed by urinary antigen test, of which four also had positive serology. In addition, 13 Legionella cases were diagnosed by serology. The degree of comorbidity was high. An increased risk of hospital-diagnosed Legionella pneumonia was found among patients with a diagnosis of chronic congestive heart failure.CONCLUSION:Our results indicate that S. pneumoniae is the most common bacterial cause of pneumonia in hospitalized patients, and the prevalence of Legionella pneumonia is probably higher in Norway than recognized previously.

Introduction: European studies have reported that Legionella pneumonia accounts for 0-10% of the cases of CAP in hospitalized patients. In Norway, data on the etiology of CAP in hospitalized patients is limited, and Legionella pneumonia has been considered a rare disease. Aim: To investigate the frequency of Legionella pneumonia among hospitalized CAP-patients in Norway. Methods: Adult patients with radiologically confirmed CAP were prospectively included at the main acute care hospitals of two counties in Norway (Telemark and Ostfold) during a 20-month study period in 2007-2008. Microbiological analyses included culture of blood and sputum, urinary antigen testing for Streptococcus pneumoniae and Legionella pneumophila serogroup 1, real time polymerase chain reaction (PCR) of a throat swab for atypical agents, and serology for L. pneumophila seroroup 1-6. Results: A total of 374 patients were included in the study. Legionella pneumonia was identified in 21 cases (6%). Eight cases were identified during the hospital stay by urinary antigen testing, and 13 cases were identified later by serology, of whom four were classified as probable cases (single high convalescent titer). Three of the patients were part of a small outbreak of Legionella , and another two patients probably were infected from the same hot tub. Two of the cases might have been travel-associated. Otherwise, S. pneumoniae was the most common etiological agent detected (20%), followed by Haemophilus influenzae (6%). Conclusion: Legionella pneumonia seems to be more prevalent than previously recognized in Norway, and testing for Legionella should be considered more frequently than current practice.

The role of dairy fat in the aetiology of myocardial infarction (MI) is controversial. The aim of this study was to evaluate the association between intake of dairy fat and dairy products, and risk of a first acute MI. A total of 111 MI patients with a first acute MI and 107 population controls (men and women, age 45 75 years) were studied. Diet was assessed using a 180-item food frequency questionnaire. The MI cases had higher intake of total fat, but lower intake of saturated fat and dairy fat than the control persons. No effect of dairy fat or saturated fat on the odds ratio for MI was observed, however. A significant inverse trend in odds of MI for intake of cheese was observed, but the trend was no longer significant after adjustment for smoking. The results suggest that intake of fat from dairy products may not be associated with increased risk of having a first MI. The healthy control persons had a diet that differed from the diet of the MI patients in many aspects, and dairy products were a part of this diet. This may have protected them from having a first MI.

Certain dietary patterns may be related to the risk of CVD. We hypothesised that a plant-centred dietary pattern would be associated with a reduced risk of first myocardial infarction (MI). A case–control study of Norwegian men and postmenopausal women (age 45–75 years) was performed. A FFQ was administered, generally within 3 d after incident MI (n 106 cases). Controls (n 105) were frequency matched on sex, age and geographic location. On the FFQ, 190 items were categorised into thirty-five food groups and an a priori healthy diet pattern score was created. We estimated OR using logistic regression with adjustment for energy intake, family history of heart disease, marital status, current smoking, education and age. Among food groups, the risk of MI was significantly higher per sd of butter and margarine (OR 1·66 (95 % CI 1·12, 2·46)), and lower per sd of tomatoes (OR 0·53 (95 % CI 0·35, 0·79)), high-fat fish (OR 0·57 (95 % CI 0·38, 0·86)), wine (OR 0·58 (95 % CI 0·41, 0·83)), salad (OR 0·59 (95 % CI 0·40, 0·87)), wholegrain breakfast cereals (OR 0·64 (95 % CI 0·45, 0·90)), cruciferous vegetables (OR 0·66 (95 % CI 0·47, 0·93)) and non-hydrogenated vegetable oil (OR 0·68 (95 % CI 0·49, 0·95)). An abundance of cases were found to have a low a priori healthy diet pattern score. A dietary pattern emphasising nutrient-rich plant foods and high-fat fish and low in trans fatty acids was associated with decreased risk of MI among Norwegians.

BACKGROUND:On 21 May 2005, the Norwegian health authorities were alerted by officials from a local hospital that several recent patients had received the diagnosis of legionnaires disease; all patients resided in 2 neighboring municipalities. We investigated the outbreak to identify the source and to implement control measures.METHODS:We interviewed all surviving case patients and investigated and harvested samples from 23 businesses with cooling towers and other potential infection sources. The locations of the businesses and the patients' residences and movements were mapped. We calculated attack rates and risk ratios among people living within various radii of each potential source. Isolates of Legionella pneumophila were compared using molecular methods.RESULTS:Among 56 case patients, 10 died. The case patients became ill 12-25 May, resided up to 20 km apart, and had not visited places in common. Those living up to 1 km from a particular air scrubber had the highest risk ratio, and only for this source did the risk ratio decrease as the radius widened. Genetically identical L. pneumophila serogroup 1 isolates were recovered from patients and the air scrubber. The air scrubber is an industrial pollution-control device that cleans air for dust particles by spraying with water. The circulating water had a high organic content, pH of 8-9, and temperature of 40 degrees C. The air was expelled at 20 m/s and contained a high amount of aerosolized water.CONCLUSIONS:The high velocity, large drift, and high humidity in the air scrubber may have contributed to the wide spread of Legionella species, probably for >10 km. The risk of Legionella spread from air scrubbers should be assessed.

Populations with a high intake of saturated fat are shown to have a high mortality of coronary heart disease (CHD) (Renaud and Lanzmann-Petithory, 2001). This is one reason why intake of milk fat has been considered an important factor related to the high incidence of CHD in western countries. A large number of metabolic studies have shown that the saturated fatty acids lauric (12:0), myristic (14:0) and palmitic acid (16:0) increase serum total and LDL cholesterol (Kris-Etherton and Yu, 1997). It has been difficult, however, to demonstrate a clear relationship between intake of saturated fat and risk of cardiovascular disease in large observational studies. A significant positive association was found in two prospective studies (McGee et al., 1984; Kushi et al., 1985), but in others, weak or no association were found (Garcia-Palmieri et al., 1980; Gordon et al., 1981; Shekelle et al., 1981; Kromhout and de Lezenne, 1984; McGee et al., 1984; Kushi et al., 1985; Ascherio et al., 1996; Hu et al., 1997; Pietinen et al., 1997). Other observational studies have shown seemingly paradoxical positive metabolic effects like reduced body mass index (BMI), waist circumference, LDL/HDL ratio, serum triglycerides and blood pressure, associated with dairy products (Smedman et al., 1999; Mennen et al., 2000; Pereira et al., 2002), and Elwood et al. (2004), suggesting that consumption of milk products may be associated with a small reduction in risk of heart disease and stroke. Pentadecanoic acid (15:0) and heptadecanoic acid (17:0) are characteristic for milk fat. They are synthesized by the bacterial flora in the rumen of ruminants (Wu and Palmquist, 1991), and cannot be synthesized in the human body. Another fatty acid, 14:0, is mainly present in milk fat. In most human tissues, the substrate specificities of the component enzymes involved in chain elongation and chain termination ensure that 16:0 is the major product. However, in the mammary glands, shorter chain fatty acids are synthesized due to the presence of a tissue-specific chain-terminating enzyme, thioesterase II (Thompson and Smith, 1985). All three fatty acids (14:0, 15:0 and 17:0) are also present in ruminant fat (beef and lamb meat) and in fat from fish, but generally, dairy products are the main source. The fatty acid composition of adipose tissue partly reflects the relative proportion of fatty acids in the diet (London et al., 1991), and Wolk et al. (1998, 2001) have shown that the content of 14:0, 15:0 and 17:0 in adipose tissue and serum lipid fractions are valid biomarkers for long-term intake of dairy fat in populations with high intake of such products. In epidemiologic studies, use of biomarkers may provide a more accurate and objective measure for long-term intake than information from dietary questionnaires. In this case–control study, we have correlated the content of fatty acids with origin from milk fat in subcutaneous fat to the risk of having a first myocardial infarction (MI) in a moderately high-risk population. This work is part of a larger study investigating the association between fatty acid composition in adipose tissue and serum lipids, and risk of a first MI (Pedersen et al., 2000; Yli-Jama et al., 2002). Cases were diagnosed (typical history, ECG and enzyme changes) with a first MI (ICD 9-code 410), and admitted to hospital within 24 h of manifesting symptoms. The cases were recruited from the coronary care units of Ullevål Hospital in Oslo (51 cases) and Østfold Central Hospital in Fredrikstad and Sarpsborg. Control subjects were 107 healthy men and women without a history of MI, recruited from the study population catchment area and frequency-matched for age in 5-year intervals. The controls were recruited from the population in the catchment areas of patients. As it was thought that population-based samples would result in low response rates, controls were recruited among friends and relatives of cases and project collaborators, state and municipal employees and people attending recreation centres for elderly and retired. A fasting blood sample was taken from all subjects. Serum was separated after 30 min at room temperature by centrifugation at 2500 g for 10 min and immediately stored at -70°C until analysis. In cases admitted to Østfold Central Hospital, the sample was drawn within 24 h after the acute phase of disease, and in cases admitted to Ullevål University Hospital the sample was drawn within the third day. Anthropometric measures (weight, height, waist-and-hip circumference) were taken directly from all subjects after a detailed interview on cardiovascular disease risk factors and dietary habits. Odds ratios (OR) with 95% confidence intervals (CI) for MI were calculated for the quartiles of the chosen fatty acids by use of logistic regression analysis. The analyses were based on the distribution among control subjects, with the lowest quartile used as reference. Tests for linear trends across quartiles of the fatty acids were performed by assigning the quartiles as continuous variables in the model. Different multivariate models were used to identify as to which effect the potential confounders had on the association between the fatty acids and MI. The first model included age and sex, considering the fact that the patients and the controls were not pair-matched to each other. In the second model, waist–hip ratio was added, and in the third model current smoking (smoker/nonsmoker) and family history of CHD (with/without) were added. Statistical analyses were performed using the statistical package SPSS 11.0 (SPSS Inc., Chicago, IL, USA). P-values 0.05 were considered significant. Contents of 14:0, 15:0 and 17:0 in adipose tissue of controls were positively correlated to each other (Table 3) but not to total very long chain n-3 fatty acids. None of the fatty acids were correlated to total energy intake (data not shown). Pentadecanoic acid was positively correlated to serum cholesterol (Table 3). Significant negative trends in ORs adjusted for age and sex were found for 14:1 and 17:1 in adipose tissue and the trend remained significant after additional adjustment for waist-to-hip ratio, smoking and family history (Table 4). Smoking is an important risk factor for MI, and the proportion of current smokers was much higher among cases (60%) than among control persons (20%). It is not likely that smoking is biologically connected to fatty acids, and no significant interaction with smoking was found for 15:0 (P=0.10), 14:1 (P=0.66) or 17:1 (P=0.25). When splitting the data into smokers and nonsmokers, the trends in OR over quartiles of different fatty acids were decreasing both for smokers and nonsmokers, but the number of subjects in each group was too small to achieve statistical significance and to draw any conclusions (Table 5). Significantly reduced odds for MI were observed for the second, third and fourth quartiles of 15:0 in adipose tissue. Significantly reduced trends in ORs for MI were also observed for 14:1 and 17:1. Age and sex adjusted OR for 14:0 in adipose tissue was significantly reduced in the fourth compared to the first quartile, but the significance disappeared when adjusting for waist-to-hip ratio. The strength of this study is the use of biomarkers for long-term intake of dairy fat. The subcutaneous fatty acid composition reflects the long-term dietary intake over periods of years prior to the sampling (Katan et al., 1997). It is therefore most unlikely that the reported associations should be due to changes in dietary habits due to the cardiac event, especially as all the patients except two were completely unaware of having CHD prior to the episode, which led to inclusion in the study. Lifestyle factors have been adjusted for in the statistical model, but there may be differences between the two groups in other lifestyle factors than those adjusted for in this study, for instance diet. The content of trans fatty acids in adipose tissue was higher among cases than among controls, which probably reflects a higher intake of margarine among cases (Pedersen et al., 2000). In addition, the control subjects had a significantly higher intake of vegetables, fruit, berries, cereals, fat fish and wine than cases (paper under preparation). It seems that the control subjects had a healthier lifestyle than the MI patients as a total. Thus, residual confounding cannot be excluded. The control subjects in this study were chosen among friends and relatives of the patients, as well as other available persons from the same area. They had on average 3 years more education than the patients, and only 20% were smokers. A previous study of a random sample of the Norwegian population showed that in an age group comparable to ours, 29% of the men were smokers and the mean length of education was 10.4 years (Johansson et al., 1997). Our control subjects thus had a slightly lower number of smokers and more education than expected. Thus, we cannot exclude the possibility that selection bias in part may explain our results. In order to correct for the differences in risk factors between the groups, we have adjusted for some variables in the multivariate models. Smoking and waist-to-hip ratio were adjusted for, but not other health-related factors associated with education. To adjust for education together with smoking may be considered unreasonable as the association between smoking and education is strong (Jenum et al., 2001). However, the difference in educational length between the cases and controls in our study may also reflect the striking social gradient in risk for CHD (Jenum et al., 1998). Thus, any sampling of patients with MI is likely to result in a population with less education and probably also higher number of smokers than a healthy control group. There is also a strong social gradient with regard to food choice corresponding to what was observed in the present study (Johansson et al., 1999). Another aspect is that the patients may have reduced their milk fat intake because of a family history of CHD. The association between 14:0, 15:0 and 17:0 in adipose tissue of controls (Table 3) is a clear indication of a common source, namely milk fat. The main sources of these three fatty acids in the Norwegian diet is milk fat and fat from fish, and we cannot exclude that the content of 14:0, 15:0 and 17:0 in adipose tissue also may reflect intake of fat from fish, but this is unlikely since no associations were found between the three fatty acids and VLCn-3 fatty acids, which are exclusively derived from fish or fish oil. Until the end of 1990s, margarines in Norway contained partially hydrogenated fish oil or soybean oil, and the use of coconut or coconut oil, which are good sources of 14:0, has been near to zero in the Norwegian diet. The control subjects had significantly higher proportions of 14:0, 15:0 and 17:0 in adipose tissue than MI cases, and a significant negative association between MI and 15:0 was found after adjustment for age, sex, smoking, waist-to-hip ratio and education. The mono-unsaturated fatty acids 14:1 cis and 17:1 cis also differed significantly between case subjects and controls with the highest levels in controls (Table 2), and a significant negative association with MI was found after adjustment for age, sex, waist-to-hip ratio, smoking and family history (Table 4). These mono-unsaturated fatty acids are most probably produced in the human body by desaturation of 14:0 and 17:0. As 14:0, 15:0 and 17:0 in adipose tissue only reflect the intake of dairy fat, the results do not give information about what sort of milk products were consumed by the test persons. We cannot exclude the possibility that other factors than fat in dairy products are responsible for the effect on risk for MI that is shown in our study. For instance, many studies have shown that dietary calcium promotes the excretion of fats as Ca soaps in faeces (Bhattacharyya et al., 1969; Renaud and Lanzmann-Petithory, 2001; Lorenzen et al., 2005). It is also possible that milk products may contain some factors leading to MI, and others that are protective, in different proportions in different milk products. Thus, the effect on risk of MI will most probably be influenced by the choice of milk products in the diet. Dietary data showed that the control persons had a mean daily intake of 39 g cheese and 350 g milk and yoghurt, which is a common intake of dairy products in Norway. The only dairy products that differed between cases and control subjects were cheese and ice cream, with a higher intake among control persons (to be published). Two intervention studies have investigated the effect of different milk products on risk factors for CHD and the results from these studies have shown that cheese is less cholesterol increasing than butter (Biong et al., 2004; Tholstrup et al., 2004). Results from epidemiological studies have shown positive associations between intake of milk and CHD deaths, over different countries and times, while cheese does not appear to be associated, indicating that cheese may differ from other dairy products in association with CHD (Artaud-Wild et al., 1993; Moss and Freed, 2003). The proportions of 15:0 and 17:0 in serum lipids have in two studies been shown to be valid markers for dairy fat intake (Smedman et al., 1999; Wolk et al., 2001). The results from the present study are in line with previous findings from a Swedish case–control study (Warensjo et al., 2004), which showed that high proportions of 15:0 and 17:0 in serum phospholipids are associated with reduced risk of first acute MI. In that study, correlations between clinical variables associated with the metabolic syndrome (MS) and MI, and markers of milk fat intake were investigated, and significant negative correlations between markers and serum triacylglycerols, cholesterol, insulin, leptin, PAI-1 ag and BMI were found. The same negative correlations between biomarkers of milk fat intake and clinical variables were found in a prospective cohort study of elderly men (Smedman et al., 1999). In that study, negative associations were found between 15:0 in serum cholesterol esters and phospholipids, and BMI, body weight, Apo B, hip- and waist circumference, whereas positive correlations were found for Apo AI and HDL cholesterol. Another study investigated correlations between 15:0 in cholesterol esters and metabolic variables in young adolescents, and found negative correlations between 15:0 and serum cholesterol in both girls and boys (Samuelson et al., 2001). The lack of consistency in earlier studies investigating the association between intake of saturated fat and MI may be partly explained by the large measurement error inherent in dietary studies. Other confounding factors in epidemiologic studies may be recall bias and genetic variants and different levels of intake of saturated fat and dairy fat among different ethnic groups. In the present and the Swedish studies, these confounders are removed because of use of biomarkers, and the Swedish population is highly comparable with the Norwegian population both in genetic characteristics, dietary habits, lifestyle and dairy intake. Another study – the Cardia Study – investigating the relation between intake of dairy products and cardiovascular disease has found that dietary patterns characterized by increased dairy consumption have a strong inverse association with MS among overweight adults and may reduce risk of type 2 diabetes and cardiovascular disease (Pereira et al., 2002). Individuals with MS have an increased risk of developing CHD (Reaven, 1993), and many cases in the present study had clinical characteristics typical for MS (elevated serum triglycerides, blood pressure, waist-to-hip ratio, and reduced serum HDL) (Table 1). The higher intake of dairy fat, reflected by the proportions of 14:0, 15:0 and 17:0 in adipose tissue, and the reduced risk of having a first MI among the control persons, may indicate that a diet with a certain content of dairy fat, or some other component of milk, may protect against developing MS. A positive correlation was found between 15:0 in adipose tissue and serum total cholesterol of control persons (Table 3). This indicates that the possible positive effect of dairy products on MS may be attributed to other risk factors than total cholesterol. Obesity, and especially central obesity, is part of MS (Reaven, 1993). Cases in our study had significant higher waist-to-hip ratio than controls, and biomarkers of milk fat intake showed significant negative correlation to waist-to-hip ratio and BMI. Even though the correlations were weak, they indicate that intake of dairy products, reflected by markers in adipose tissue, may represent a weak protection against overweight, especially central obesity. This is supported by epidemiologic and experimental studies, suggesting that dairy products may have favourable effects on body weight in children (Carruth and Skinner, 2001) and adults (Davies et al, 2000; Lin et al, 2000; Zemel et al, 2000). In these studies, calcium is suggested as the factor responsible for the effect on body weight. In summary, our results show that persons with relatively ample dairy fat consumption as reflected by markers in adipose tissue, in particular C15:0, may possibly be protected against a first MI. We cannot conclude whether a high intake of dairy fat or a proportional low intake of other types of fat, for example, trans fatty acids, is responsible for the effect. Neither can we conclude that the effect is caused by the fat itself or by some other components of the dairy products. This needs to be further elucidated. Owing to the nature of case–control studies, here visualised by selection bias, confounding and the fact that dairy products have different composition, we cannot conclude that the reduced risk of MI is caused by dairy products alone, but rather that the control persons in our study have had a healthy lifestyle protecting them from having a first MI, and that dairy fat has been a part of this lifestyle. Results from this study also indicate that the causal effects may be on some other factors than serum total cholesterol. Further investigation is needed to verify our results and to clarify whether there are differences between different dairy products on risk of MI. We thank Kari Almendingen, Hege Møklebust Rebnord, Ragnhild Lekven Fimreite and Thomas S Haugen for their effort in the main study.

The onset of central nervous system (CNS) cryptococcosis may be acute or insidious. Acute manifestations with neurological signs and symptoms are more common in immunosuppressed patients. We present two cases with AIDS and cryptococcal meningitis and discuss treatment options and stress that the host immune response should be considered along with the infecting agent during treatment.

Cutaneous myiasis is the infestation of skin or mucous membranes with larvae of flies. We describe a case of imported cutaneous infestation with Dermatobia hominis acquired in South America. The diagnosis should be suspected in a patient with a secreting, non-healing furuncular skin lesion and relevant travel history.

Objective: To study the association between content of fatty acids from milk fat (14:0, 15:0 and 17:0) in adipose tissue and risk of a first myocardial infarction (MI). Design and subjects: A case–control study with 99 patients and 98 population controls both men and postmenopausal women, age 45–75 year. Adipose tissue fatty acids were determined by gas–liquid chromatography. Results: The content of 14:0, 14:1, 15:0, 17:0 and 17:1 were all significantly higher in adipose tissue of controls than of the patients. Age and sex adjusted odds ratios (OR) for MI were significantly reduced with increasing quartiles of 14:0, 14:1, 15:0 and 17:1 in adipose tissue, but except for 15:0 (OR=0.36, 95% CI 0.13–0.99), the trend was no longer significant after further adjustment for waist-to-hip ratio, smoking and family history for coronary heart disease. Correlations between 14:0 and 15:0 in adipose tissue, and waist-to-hip ratio were significantly negative ( r =−0.22 for both, P <0.01). Conclusion: Our study suggests that intake of dairy fat or some other component of dairy products, as reflected by C15:0 as marker in adipose tissue, may protect persons at increased risk from having a first MI, and that the causal effects may rely on other factors than serum cholesterol. Sponsorship: Throne Holst's foundation for Nutrition Research, Research Council of Norway, The Norwegian Association of Margarine Producers, DeNoFa Fabriker A/S, TINE BA.

Objectives. To investigate the association between composition of serum free fatty acid (FFA) fraction and risk of a first myocardial infarction (MI).Design. A case-control design.Setting. The patients were recruited from Ulleval Hospital in Oslo and Ostfold Central Hospital in Fredrikstad and Sarpsborg, Norway.Subjects. A total of 103 patients with first MI and 104 population controls, both men and postmenopausal women, age 45-75 years.Results. The mean molar percentage content of docosahexaenoic (DHA), eicosapentaenoic (EPA), stearic and myristic acid in the serum FFA fraction was significantly lower in cases than in controls, whereas that of oleic and linoleic acid was higher in cases. Increased percentage content of total very long-chain omega-3 fatty acids (VLC n-3) in serum FFA was associated with decreased risk of MI. Multivariate odds ratio (OR), adjusted for age, sex, waist-hip ratio, smoking, family history of coronary heart disease (CHD) and years of education was 0.20 (95% CI 0.06-0.63) for the highest vs. lowest quartile. Also increased content of stearic acid was associated with decreased risk. Multivariate OR adjusted as above was 0.38 (95% CI 0.14-1.04) for the highest versus lowest quartile. After adjustment for oleic acid, however, the inverse linear trend was no longer significant.Conclusions. The percentage content of VLC n-3 as well as of stearic acid in serum FFA was inversely associated with risk of myocardial infarction. That of VLC n-3 may reflect diet. but additionally these free fatty acids might in some way be related to the pathogenetic process and not only reflect their content in adipose tissue.

Background: Adipose tissue is a storage organ for dietary fat. During fasting, fatty acids are released into serum as free fatty acids (FFA). Experimental studies indicate that fatty acids are selectively mobilised from adipose tissue into serum. The aim of this study was to investigate whether the composition of the serum FFA fraction reflects selective mobilisation in the fasting state in humans. Methods: The fatty acid composition of fasting serum FFA and adipose tissue were analysed from 112 patients with myocardial infarction and 107 healthy control subjects using gas–liquid chromatography. The subjects' habitual diet was analysed using a food-frequency questionnaire. Results: Significant correlations were found between serum FFA and adipose tissue, particularly for the percentage content of linoleic acid (r=0.73), eicosapentaenoic acid (r=0.68), α-linolenic acid (r=0.67) and palmitoleic acid (r=0.60). Percentage contents of palmitic, stearic, linoleic, α-linolenic, eicosapentaenoic and docosahexaenoic acid were higher in serum FFA than in adipose tissue, whereas oleic and palmitoleic acid were relatively more abundant in adipose tissue. This may indicate that the former group of fatty acids is preferentially mobilised from adipose tissue into serum. High correlations for polyunsaturated fatty acids were observed between percentage contents of dietary and adipose tissue fatty acids. The correlation of fatty acids between diet and serum FFA was weak, but a tendency towards higher correlations for polyunsaturated fatty acids was observed. Conclusions: Our findings are compatible with the hypothesis that, in the fasting state, fatty acids are selectively mobilised from adipose tissue into serum FFA.