Utilization and outcomes of tracheostomies in the intensive care unit in Iceland in 2007-2020: A descriptive study

BACKGROUND

Tracheostomies are commonly utilized in ICU patients due to prolonged mechanical ventilation, upper airway obstruction, or surgery in the face/neck region. However, practices regarding the timing of placement and utilization vary. This study provides a nationwide overview of tracheostomy utilization and outcomes in the ICU over a 14-year period.

METHODS

A retrospective study including all patients that received a tracheostomy during their ICU stay in Iceland between 2007 and 2020. Data were retrieved from hospital records on admission cause, comorbidities, indication for tracheostomy insertion, duration of mechanical ventilation before and after tracheostomy placement, extubation attempts, complications, length of ICU and hospital stay and survival. Descriptive statistics were provided, and survival analysis was performed using Cox regression.

RESULTS

A total of 336 patients (median age 64 years, 33% females) received a tracheostomy during the study period. The most common indication for tracheostomy insertion was respiratory failure, followed by neurological disorders. The median duration of mechanical ventilation prior to tracheostomy insertion was 9 days and at least one extubation had been attempted in 35% of the cases. Percutaneous tracheostomies were 32%. The overall rate of complications was 25% and the most common short-term complication was bleeding (5%). In-hospital mortality was 33%. The one- and five-year survival rate was 60% and 44%, respectively.

CONCLUSIONS

We describe a whole-nation practice of tracheostomies. A notable finding is the relatively low rate of extubation attempts prior to tracheostomy insertion. Future work should focus on standardization of assessing the need for tracheostomy and the role of extubation attempts prior to tracheostomy placement.

Management of acute atrial fibrillation in the intensive care unit: An international survey

BACKGROUND

Atrial fibrillation (AF) is common in intensive care unit (ICU) patients and is associated with poor outcomes. Different management strategies exist, but the evidence is limited and derived from non-ICU patients. This international survey of ICU doctors evaluated the preferred management of acute AF in ICU patients.

METHOD

We conducted an international online survey of ICU doctors with 27 questions about the preferred management of acute AF in the ICU, including antiarrhythmic therapy in hemodynamically stable and unstable patients and use of anticoagulant therapy.

RESULTS

A total of 910 respondents from 70 ICUs in 14 countries participated in the survey with 24%-100% of doctors from sites responding. Most ICUs (80%) did not have a local guideline for the management of acute AF. The preferred first-line strategy for the management of hemodynamically stable patients with acute AF was observation (95% of respondents), rhythm control (3%), or rate control (2%). For hemodynamically unstable patients, the preferred strategy was observation (48%), rhythm control (48%), or rate control (4%). Overall, preferred antiarrhythmic interventions included amiodarone, direct current cardioversion, beta-blockers other than sotalol, and magnesium in that order. A total of 67% preferred using anticoagulant therapy in ICU patients with AF, among whom 61% preferred therapeutic dose anticoagulants and 39% prophylactic dose anticoagulants.

CONCLUSION

This international survey indicated considerable practice variation among ICU doctors in the clinical management of acute AF, including the overall management strategies and the use of antiarrhythmic interventions and anticoagulants.

Community screening for glucose intolerance in middle-aged Icelandic men. Deterioration to diabetes over a period of 71/2 years

A number of 2203 middle-aged Icelandic men (aged 34-61 years) participated in a health survey in Reykjavik in 1967-68. Blood glucose in the fasting state and during an oral glucose tolerance test (OGTT) showed a unimodal distribution with a slight skewness towards higher values. A positive age gradient was established, which showed an increment of about 7 mg/dl per decade in capillary blood sugar values at 11/2 hours after a 50 g oral glucose load. The age gradient was mostly independent of age-related changes in body weight. A 71/2 year followup of the eligible participants (response rate 80%) showed an overall 1% incidence of metabolic deterioration to "overt diabetes" during this period. Those with positive screening tests (50 g OFTT) at baseline were at greater risk of developing diabetes, but the incidence of deterioration in this group was low, about 1% per year. The progression to diabetes was significantly related to body weight at baseline, suggesting that weight reduction might be beneficial in individuals showing impaired glucose tolerance at medical examination. This study, however, lends support to recent reports showing that mildly impaired glucose tolerance cannot be equated with early diabetes.

Simultaneous mutations in CA and Vif of Maedi-Visna virus cause attenuated replication in macrophages and reduced infectivity in vivo

Maedi-visna virus (MVV) is a lentivirus of sheep sharing several key features with the primate lentiviruses. The virus causes slowly progressive diseases, mainly in the lungs and the central nervous system of sheep. Here, we investigate the molecular basis for the differential growth phenotypes of two MVV isolates. One of the isolates, KV1772, replicates well in a number of cell lines and is highly pathogenic in sheep. The second isolate, KS1, no longer grows on macrophages or causes disease. The two virus isolates differ by 129 nucleotide substitutions and two deletions of 3 and 15 nucleotides in the env gene. To determine the molecular nature of the lesions responsible for the restrictive growth phenotype, chimeric viruses were constructed and used to map the phenotype. An L120R mutation in the CA domain, together with a P205S mutation in Vif (but neither alone), could fully convert KV1772 to the restrictive growth phenotype. These results suggest a functional interaction between CA and Vif in MVV replication, a property that may relate to the innate antiretroviral defense mechanisms in sheep.

The improved survival of experimental animals fed with fish oil is suppressed by a leukotriene inhibitor

Fish oil is believed to alter the immune response and improve survival after infections in experimental animals. This effect may be due to altered production of the leukotrienes (LT). We, therefore, performed a study in order to evaluate whether the effect of fish oil on the immune response of experimental animals is mediated through altered production of the LT. Female NMRI mice in four groups were fed with fish oil, fish oil with 5-lipoxygenase (5-LO) inhibitor (Zileuton, Abbott Laboratories, Chicago, IL, USA), corn oil or corn oil with 5-LO inhibitor. After 6 weeks, the mice were infected with Klebsiella pneumoniae and the survival was monitored. The experiment was performed twice. Analysis was performed mainly on data pooled from both experiments. The survival of the groups fed with fish oil was increased, compared to that of all the other groups and when compared to the groups fed with fish oil with 5-LO inhibitor (log-rank test) the difference was significant (P = 0.007). It has been postulated that the effect of fish oil on the immune system is mediated through altered production of LT. In our study, blocking of the production of the LT eliminated the beneficial effects of fish oil. Our results are in concord with the hypothesis that the effect of fish oil is, at least partly, mediated through altered production of LT.

Development of immunoglobulin A in infancy and childhood

Serum and salivary concentrations of immunoglobulin A1 (IgA1) and IgA2 were studied in 105 Icelandic children aged 0-12 years. Serum concentrations of both IgA1 and IgA2 increased slightly (P < 0.001) during childhood. The salivary IgA1/IgA2 ratio tended to decrease during the same period; this trend is less apparent when omitting the youngest children. The salivary IgA1 and IgA2 output could be high, even in children with low levels of serum IgA. Only polymeric IgA was found in whole saliva. Interestingly, in serum, most IgA1 and IgA2 were polymeric during infancy. The proportion of polymeric IgA decreased, when the concentration of IgA increased. The polymeric form of IgA might provide the infant with better protection against invading microorganisms by activation of the innate immune mechanisms.

[Homocysteine, folate and cobalamin in Icelandic men and women.]

OBJECTIVE

To determine reference intervals and interquartile ranges for total homocysteine (Hcy) folate and cobalamin in Icelandic men and women and to evaluate the correlation of Hcy to serum levels of the vitamins folate and cobalamin.

MATERIAL AND METHODS

Blood samples were collected from 449 individuals over a period of three months, 291 men (mean age 48.3 years) and 158 women (mean age 49.8 years). Plasma Hcy was measured by a HPLC method with fluorescence detection; folate and cobalamin levels in serum were measured by an electroimmunochemical method on an ELECSYS system from Roche.

RESULTS

The reference interval for Hcy, between 2.5% and 97.5% fractiles, estimated by parametric statistics, are 6.2-17.5 micromol/L for men and 4.8-14.1 micromol/L for women. Similarly the 95% reference intervals for folate and cobalamin were estimated using parametric statistics. A significant negative correlation was found between concentrations of folate and Hcy for both men and women (p<0.01) with a correlation coefficient of -0.39 and also between cobalamin and Hcy where the correlation coefficient is -0.20.

CONCLUSIONS

Reference interval for Hcy from the general presumed healthy population is estimated here for the first time in Icelandic men and women and will be of value in cardiovascular risk assessments. The negative correlation between Hcy and folate and also Hcy and cobalamin, is in agreement with results from other studies and suggests that an improved vitamin status might be beneficial in lowering Hcy in a section of the population as has been suggested in numerous studies in other countries.

[Trends in overweight and obesity in 45-64 year old men and women in Reykjavik 1975-1994.]

OBJECTIVE

The aim of this study was to assess possible changes in the prevalence of overweight and obesity in Iceland during the last decades. Furthermore, the possible effect of dietary changes on the observed trend in obesity prevalence was evaluated.

MATERIAL AND METHODS

Participants came from stages III-V in the Reykjavik Health Study and the Reykjavik part of the MONICA studies from the period 1975-1994. The age groups 45-54 years and 55-64 years were examined. Only the information from the first visit of each person was included. The body mass index (BMI) for the participants was calculated and the percentage of those subjects considered overweight and obese according to WHO standards evaluated, using 25BMI<30 kg/m(2) as the cut-off point for overweight and BMI30 kg/m(2) as the cut-off point for obesity. Also, the observed trend in obesity prevalence is compared to changes in diet that have occurred in the same period.

RESULTS

The results show that the mean weight and height of both men and women have been increasing during the study period. However, weight has increased more than can be accounted for by increased height, resulting in increased BMI. At the same time, the prevalence of overweight and obesity have increased, the relative increase in obesity far exceeding the relative increase in overweight. The prevalence of obesity more than doubled in both age groups of women during the study period, according to trend analyses. At the end of the period, almost 15% (95% confidence interval (CI), 9-22%) in the younger group of women and 25% (95% CI, 17-34%) in the older group were classified as obese. In the younger group of men, the prevalence of obesity almost doubled, while the observed increase in the older group was not statistically significant, according to trend analyses. The prevalence of obesity in the final period was about 19% (95% CI, 13-27%) and 17% (95% CI, 11-25%) in the younger and older groups of men, respectively. According to the food supply statistics there have been insignificant changes in the consumption of energy nutrients during the period.

CONCLUSIONS

Overweight and obesity are becoming more common among middle-aged men and women in Reykjavik, during the period 1975-1994 and the rate of increase being comparable to that observed in many Western countries. It is urgent to respond to this problem by promoting a healthier lifestyle, both with respect to diet and physical activity.

Serum immunoglobulinD in infants and children

Serum immunoglobulinD (IgD) concentration is usually low in healthy individuals as compared to other immunoglobulin classes. Most studies on serum IgD are concerned with serum levels in healthy adults but reference values for young children and infants are not easily available. In order to establish age specific reference values we measured IgD levels in serum of 184 healthy Icelandic children, age 0-14 years and 60 healthy blood donors age 18-63, using the ELISA technique. Special attention was paid to the youngest age groups. Results showed low IgD values in infants and young children, gradually increasing until the age of 10 but then decreasing with age. We conclude that IgD gradually increases with age in childhood as other immunoglobulin classes but later declines. These findings can be of importance in revealing the function of IgD in the immune system as well as in the diagnosis of the hyper-IgD syndrome.

P.A. Schleisner: a pioneer in epidemiology

In 1847 Schleisner (b. 1818) was sent from Copenhagen to the Vestmanna Islands in Iceland to study the epidemic of tetanus neonatorum. The neonatal mortality in those islands at that time was 600-740 per 1000 children. He built a small hospital and introduced treatment with Peru balsam of the umbilicus. Schleisner probably assumed that the infection was caused by airborne infection, contact infection or poor hygiene. The neonatal mortality fell to about 50 per 1000. Schleisner published his results in 1849. Semmelweiss published his observations in 1850 and Snow successfully fought the cholera epidemic in London in 1854. Schleisner deserves recognition as a pioneer in the field of epidemiology.

The ms2io6A37 modification of tRNA in Salmonella typhimurium regulates growth on citric acid cycle intermediates

The modified nucleoside 2-methylthio-N-6-isopentenyl adenosine (ms2i6A) is present in position 37 (adjacent to and 3' of the anticodon) of tRNAs that read codons beginning with U except tRNA(i.v. Ser) in Escherichia coli. In Salmonella typhimurium, 2-methylthio-N-6-(cis-hydroxy)isopentenyl adenosine (ms2io6A; also referred to as 2-methylthio cis-ribozeatin) is found in tRNA, most likely in the species that have ms2i6A in E. coli. Mutants (miaE) of S. typhimurium in which ms2i6A hydroxylation is blocked are unable to grow aerobically on the dicarboxylic acids of the citric acid cycle. Such mutants have normal uptake of dicarboxylic acids and functional enzymes of the citric acid cycle and the aerobic respiratory chain. The ability of S. typhimurium to grow on succinate, fumarate, and malate is dependent on the state of modification in position 37 of those tRNAs normally having ms2io6A37 and is not due to a second cellular function of tRNA (ms2io6A37)hydroxylase, the miaE gene product. We suggest that S. typhimurium senses the hydroxylation status of the isopentenyl group of the tRNA and will grow on succinate, fumarate, or malate only if the isopentenyl group is hydroxylated.

Influenza vaccination in 22 developed countries: an update to 1995

This study expands and updates through 1995 our earlier report on influenza vaccine use in 18 developed countries. Five of the six countries with high levels of vaccine use in 1992 (> or = 130 doses/1000 population) showed little change or slight declines over the subsequent 3 years. The exception was the United States, where a new federal program for vaccination reimbursement for the elderly helped to increase vaccine distribution from 144 to 239 doses/1000 population. The six countries with medium levels of vaccine use in 1992 (76-96 doses/1000 population) increased to > or = 100 doses/1000 population by 1995. Among the six low-use countries in 1992 (< or = 65 doses/1000 population), only Finland showed substantial improvement (96 doses/1000 population) in 1995. Four new countries were added to the study. In Germany, vaccine use increased to 80 doses/1000 population in 1995, but in Ireland it remained at a low level (48 doses/1000 population). In Korea, vaccine use increased from 17 to 95 doses/ 1000 population during the period 1987-1995. In Japan, very high levels of vaccine use (approximately 280 doses/1000 population) in the early 1980s were associated with vaccination programs for school children. However, vaccine use fell precipitously when these programs were discontinued, and only 2 and 8 doses/1000 population were used in 1994 and 1995, respectively. In all 22 countries, higher levels of vaccine use were associated with vaccination reimbursement programs under national or social health insurance and were not correlated with different levels of economic development. Excluding Japan, in 1995 there was still a greater than fourfold difference between the highest and lowest levels of vaccine use among the other 21 countries in the study. Given its well established clinical effectiveness and cost-effectiveness, none of these countries has yet achieved the full benefits of its programs for influenza vaccination.

Users of antiasthma drugs in Iceland: a drug utilization study

There has been an increasing consensus worldwide on how to treat asthma, and, simultaneously, an increase in the sales of antiasthma drugs. However, little is known about actual drug use, dosage, combinations of drugs, etc., or about the clinical characteristics of patients using these drugs. All individuals with prescriptions for antiasthma drugs, who came to Icelandic pharmacies during March 1994, were invited to participate. By means of questionnaires, the pharmacists recorded the age and gender of the patient, the specialty of the prescribing doctor, as well as the name of the drug, total amount prescribed, and dosage. The patients were asked to answer another questionnaire on their clinical diagnosis, usage of other antiasthma drugs, etc. The pharmacists registered 2,026 individuals, with 2,687 prescriptions: 1,574 for beta2-agonists, 838 for inhaled corticosteroids, 208 for theophylline, 48 for anticholinergic drugs, and 19 for cromoglycates. One thousand, three hundred and fifty one patients answered the questionnaires. The majority (67%) claimed to have asthma, 18% chronic bronchitis, 11% emphysema and 5% other diseases or symptoms. Among those aged > or = 16 yrs with asthma, 93% used beta2-agonists, 62% inhaled corticosteroids, 19% theophylline, and very few used other drugs. The most commonly used combination (57%) was beta2-agonists with inhaled corticosteroids. Thirty one per cent used beta2-agonists as monotherapy, and 5% used only inhaled corticosteroids. Theophylline was used mainly in combination with beta2-agonists and inhaled corticosteroids. In conclusion, our data suggest that two thirds of antiasthma drug users have asthma and that most are treated according to present guidelines. The use of inhaled corticosteroids, however, seems somewhat less than optimal.

What is the long term value of multiphasic health screening and the initial judgement of benefit?

The long term effects of multiphasic health screening (MHS) are rarely studied. In 1964 a random sample of 546 women and 544 men born 1899, 1904, 1909, 1914 or 1919 equally distributed on cohorts from the Swedish town Eskilstuna were invited to examination. For several reasons 167 persons (15%) did not participate in the study. In 1969 the whole sample was invited to a second MHS together with a control group that had not been exposed to MHS. Furthermore, 79 of those alive 1989 born 1899 or 1904 and examined 1964 and 1969 were reexamined. Over all survival rate 1989 for those examined 1964 was for males 18% and for females 35%. Screening instruments 1964 and 1969 were questionnaires, laboratory tests, antropometric measurements, ECG, measurement of blood pressure, chest radiography, peak expiratory flow (PEF), tonometry and fundoscopy of the eyes, audiometric screening, dental, gynecological and general clinical examination. Systolic hypertension for both sexes, low PEF and smoking, low cholesterol in women were negatively related to survival. Of 18 diabetics only one was alive at follow-up. No association was found between BMI and mortality for men, but some (1964 p < 0.01; 1969 p < 0.05) for women. Altogether 87 individuals were 1969 judged to have had some benefit of the MHS in 1964, 40 of them substantial. This was, however, not statistically significantly associated with improved survival. Of the reexamined survivors 86% reported to be generally satisfied with their life situation. The prognostic value of graded benefit was analysed in some detail. The survival to age 85 in the group allotted any benefit was somewhat less good (37%) than in the group with no benefit (44%). The difference did not reach statistical significance.

[Incidence and prevalence of positive tuberculin skin test reactions among schoolchildren.]

OBJECTIVES

To investigate the incidence and prevalence of positive tuberculin skin test reactions in schoolchildren from six to 16 years of age.

MATERIAL AND METHODS

Data from tuberculin test school surveys in Reykjavik during the years 1958 to 1991 are available for almost all individuals of each age cohort. During 1958 to 1991 schoolchildren from six to 16 years of age were tested annually. In Iceland regular BCG vaccination in children or aldults has never been applied.

RESULTS

Incidence of positive tests in all ages fell from 2.5 (per 1000 tested per year) from 1958 down to 0.5 in the mid seventies and after that the incidence remained low. Prevalence of positive tests for the same age group in different age cohorts showed that for each age group from seven to 16 years positive tests were most common at the beginning of the study period but decreased successively to the beginning of the seventies. The prevalence of positive tests was low and almost unchanged during 1976 to 1991 and varied from 0 -1.6 (per 1000 tested per year) among children seven to eight years of age, 0-2.9 among children 11 to 12 years of age and from 0-3.8 among those aged 15 to 16 years.

CONCLUSION

During the last decade little has been gained by systematic testing for tuberculosis as a tool for finding newly infected persons or carriers of M. Tuberculosis. It seems to us that the results of this study do not justify systematic testing for tuberculous infection in all schoolchildren. Increased emphasis should be placed on testing among risk groups such as immigrants from countries where tuberculosis is endemic. Recent infection due to M. Tuberculosis is a high risk factor for tuberculosis. Search for newly infected persons in close contact with infectious patients with tuberculosis should have priority next to the diagnosis and treatment of the patients. Tests for tuberculosis among those who want to immigrate to Iceland circumscribe another risk group where containment of tuberculosis is possible.

Mutation in the structural gene for release factor 1 (RF-1) of Salmonella typhimurium inhibits cell division

A temperature-sensitive mutant of Salmonella typhimurium LT2 was isolated. At the nonpermissive temperature cell division stopped and multinucleated filaments were formed. DNA, RNA, or protein synthesis was not affected until after about two generations. Different physiological conditions, such as anaerobiosis and different growth media, suppress the division deficiency at high temperatures. Certain mutations causing a reduced polypeptide chain elongation rate also suppress the division deficiency. The mutation is recessive and shown to be in the structural gene for release factor I (prfA). DNA sequencing of both the wild-type (prfA+) and mutant (prfA101) allele revealed a GC-to-AT transition in codon 168. Like other known prfA mutants, prfA101 can suppress amber mutations. The division defect in the prfA101 mutant strain could not be suppressed by overexpression of the ftsQAZ operon. Moreover, at the nonpermissive temperature the mutant shows a normal heat shock and SOS response and has a normal ppGpp level. We conclude that the prfA101-mediated defect in cell division is not directed through any of these metabolic pathways, which are all known to affect cell division. We speculate that the altered release factor I induces aberrant synthesis of an unidentified protein(s) involved in the elaborate process of septation.

[Antiasthmatic drugs in Iceland - an epidemiological survey.]

The use of antiasthmatic drugs in Iceland has increased considerably during the last 15 years. The aim of this study was to assess in a well-defined epidemiological population the characteristics of those using antiasthmatic drugs; age, gender, speciality of prescribing doctor, dosage and combinations of drugs. Also their clinical diagnosis and symptoms. All individuals with prescriptions for antiasthmatic drugs that came to Icelandic pharmacies during March 1994 were invited to participate. Altogether 2026 individuals accepted (2687 prescriptions). There were proportionally more young males and middle aged females (p<0.0001). The prescriptions for beta2-adrenergic drugs were 1574, 838 for inhaled corticosteroids, 208 for theofylline, 49 for anticholinergic drugs and 19 for natrium chromoglycate. General practitioners had prescribed 68% of the drugs, 16.3% were from pulmonary physicians and/or allergists, 6.4% from pediatricians and 9.3% from other doctors. The treatment had been started by specialists other than general practitioners in more than 60% of cases. Among those using inhaled drugs 95% had been tought how to do so. The majority (66.9%) claimed that they were using the drugs because of asthma, 17.8% because of chronic bronchitis, 10.7% because of emphysema and 4.6% for other reasons. There were altogether 591 individuals (2=16 years) with asthma who answered the questionnaire. Among them 93% used beta2-adrenergic drugs, 62% inhaled corticoseroids, 19% theofylline and very few used other drugs. The most commonly used combination (57%) was beta-adrenergic drugs and inhaled corticoseroids. Altogether 31% used beta2-adrenergic drugs as monotherapy and 5% had only inhaled corticosteroids. Theofylline is mainly used in combination with beta-adrenergic drugs and inhaled corticosteroids. Its use as monotherapy is infrequent (2%). Among those 209 asthma patients who had used oral corticosteroids the last 12 months, 73% were using some kind of inhaled corticosteroids and 27% not.

[Measurement of thyroid autoantibodies in Graves' disease.]

It is thought that dietary iodine may play a role in thyroid autoimmune reactivity. Iceland is an iodine rich area and therefore it seemed interesting to measure autoantibodies against TSH receptor (TRAb), thyroid peroxidase (TPO) and thyroglobulin (TG) in Icelandic patients with Graves' disease. Serum samples were collected from 47 patients with untreated Graves' disease, 73 patients with Graves' disease that had been treated with radioiodine (U1I), most of them (56) hypothyroid following the treatment and therefore on T4 replacement, others euthyroid. Measurements were also done on samples from a reference group of 74 healthy volunteers. All reference values are 0.95 fractile. Untreated patients with Graves' disease had TRAb values over reference range in 68.1% of cases being similar to what others have observed. The untreated patients with Graves' disease had TPO antibody measurement positive in 50.0% of cases and TG antibodies in 34.7%. This is much lower frequency of positive tests than observed elsewhere when measured with ELISA. Although methodological factors might play a role, this difference could also be explained by difference in iodine intake. The antibodies were less frequent in radioiodine treated patients than in the untreated ones. This is in agreement with the observation that serum levels of these antibodies tend to decrease with time from treatment. The antibody measurements did not differentiate between radioiodine treated patients with Graves' disease needing T4 replacement and those who did not.

Influenza vaccination in 18 developed countries, 1980-1992

Influenza continues to be an important cause of preventable morbidity and mortality. Although influenza vaccine is widely recommended for older high-risk individuals, no studies have compared its use in different countries. We gathered information on influenza vaccine distribution in 18 developed countries for the period 1980-1992. During the 1980s there was a > or = 10-fold difference in annual per capita vaccine distribution among these countries, and in 1992 the difference was still more than 7-fold. Several countries demonstrated large increases in vaccine use over the study period, some showing substantial increases in specific years. Thirteen of the 18 countries recommend influenza vaccination for all elderly persons and 11 countries provide reimbursement for vaccination through national or social health insurance. These countries tend to have higher levels of vaccine use. Historical, economic and political factors also affect vaccination practices and policies, but their relationships to differences in vaccine use between countries are not known. A better understanding of why the use of influenza vaccine varies among countries will be important if its protective benefits are to be fully realized.

Synthesis and function of isopentenyl adenosine derivatives in tRNA

Isopentenyl adenosine derivatives can be found next to the anticodon (position 37) in tRNA from both the Bacteria and Eucarya domains. These modified nucleosides improve the efficiency of tRNA in translation, can increase and decrease translational fidelity, and make the tRNA less codon context sensitive. In bacteria the synthesis of isopentenyl adenosine derivatives seems to be linked to iron metabolism and central metabolic pathways.

Structure of TGF-beta 1-induced human immunoglobulin C alpha 1 and C alpha 2 germ-line transcripts

We have characterized the structure of the human immunoglobulin C alpha 1 and C alpha 2 germ-line transcripts that are synthesized upon treatment of human B lymphocytes with Branhamella catarrhalis (a B cell mitogen) and transforming growth factor beta 1 (TGF-beta 1). These transcripts initiate upstream of the switch alpha 1 and switch alpha 2 regions and contain, together with the C alpha 1 and C alpha 2 sequences, additional exons designated according to the generally accepted nomenclature I alpha 1 and I alpha 2 respectively. The I alpha exons are spliced directly onto the acceptor splice site of the CH1 domains of the C alpha 1 and C alpha 2 genes. As in other previously characterized germ-line transcripts, stop codons present in all three reading frames prevent translation of the C alpha 1 and C alpha 2 heavy-chain coding sequences. The longest open reading frame (ORF) present in the I exons can code for a polypeptide of only 26 amino acids. The human I alpha exons do not show any significant sequence homology with the corresponding mouse I alpha exon. However, comparison of nucleotide sequences of the genomic mouse and human I alpha regions demonstrated the presence of an approximately 300 bp highly conserved element located immediately upstream of the transcription initiation sites of the human and mouse C alpha germ-line transcripts. The isolation of the C alpha 1 and C alpha 2 germ-line transcripts will further facilitate the characterization of the molecular events responsible for the regulation of the human C alpha heavy chain loci.

A survey of primary health services in rural Iceland

This article describes the results of a follow-up study of primary health services in rural Iceland during one week in October 1981. The initial study, which was conducted in September 1974, was the first major study in Iceland of medical services outside hospitals. The aims of the present study were to collect data on primary health services, and to compare results with the study in 1974. Data from 58 doctors and other personnel in 31 health centres are included in the analysis. The annual average number of contacts with the health centres was estimated at 4.9 per inhabitant, median 4.8. Comparable figures in 1974 were 4.6 and 4.5, respectively. Each doctor on average served 1,303 inhabitants, range 674 to 2,051. The most common reasons for contacts were: preventive measures, respiratory diseases, and diseases of the musculoskeletal system. The most common actions taken were, in order of frequency: prescriptions, advice, and minor examinations. Referrals to specialists, measured as the percentage of all contacts, were 2.8% in 1981, compared to 3.1% in 1974. Referrals to hospitals and other health institutions were also less frequent in 1981. On average, physicians worked more than 50 hours per week, and over half of them carried out additional hospital duties.

Unemployment-related lifestyle changes and health disturbances in adolescents and children in the western countries

According to official statistics 11 million under 25's, thereof 5-6 million under 20's in the 12 OECD member states are unemployed at any given time. In depth studies show that this figure is at least 40-50% higher. In many countries a systematic under-reporting exists in the registration of unemployed. Surveys used to show more relevant figures. Unemployment hits mainly adolescents, school leavers, young adults (unskilled male and female) immigrants and then, indirectly, those who are in need of familial and social support, i.e. the frail, sick, disabled children and old people. In many cities in Europe 40-50% of 18-25 year olds are unemployed and figures as high as 90% have been reported (inner cities). Unemployment is endangering the socio-economic status of people, in spite of short-time unemployment benefits and is creating inequalities in health and serious social misfits. Loss of job or the mere prospect of becoming jobless have, in follow-up studies on an individual level, been found to cause elevated blood pressure and serum cholesterol, increased concentration of blood catecholamine and elimination of noradrenaline, an increase in the frequency of stress and psychosomatic diseases. After regaining employment, these values have normalized. Unemployment is therefore considered by many as a real source of stress. Chronic stress is now considered as a major contributor to cardiovascular diseases, ulcers, asthma and some other diseases. According to several well designed and controlled studies on the individual level in the developed countries, the majority of young people do not learn to cope with unemployment. It fosters isolation, loss of self-esteem, frustration and hopelessness.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevention of congenital rubella in Iceland by antibody screening and immunization of seronegative females

A programme to eradicate congenital rubella from Iceland was started in 1979, based on (1) screening of all females aged 12-45 years for rubella antibodies and (2) vaccination of all seronegative persons with the RA/27/3 rubella vaccine, given free of charge. Thus, individual protection was offered to all who needed it. The collection of serum samples was planned to last for 2 years while, simultaneously, the already established rubella screening and immunization programmes for 12-year-old schoolgirls and pregnant women continued.During assessment in 1983, 95.2% of females in the first 7 age groups (by now aged 14-20 years) participating in the school programme had been tested and 80.4% of them were found to be naturally immune. Of the seronegatives, 93.7% were subsequently vaccinated, thus giving an overall immunity rate of 98.8%. Among the women in the peak of the childbearing period (by now aged 21-35 years), 84.4% had been tested and 92.7% were found to be naturally immune; vaccination of 61.4% of seronegative individuals then gave an overall immunity rate of 97.2% for this age group.If it is assumed that the natural immunity rate of females still untested is like that of the above groups, then the percentage of non-immune persons is at present 2.1% in the younger group and 3.4% in the older.

A medical record and information system for primary health care in Iceland. The Egilsstadir Project

In Iceland a problem oriented medical record system for primary health care has been developed. A contact-form is used to record data on all contacts between the inhabitants in a district and the health center. A minicomputer is used for retrieval and analysis. One rural health center using this system has been successful in recording a basic set of data on all contacts taking place since 1976 and linking these data to the national register data for the population in the district. Most health centers in Iceland are now adopting this system, because it seems to be: A valuable aid in the treatment of patients, which improves the quality of the treatment. A useful source of information of the health of the population, which among other things makes possible the identification of those at special risk. A good instrument for research and teaching. A useful source of statistics on the primary care services.

Dobutamine in the rejecting transplanted heart

Dopamine is commonly used to improve cardiac output and to maintain peripheral perfusion after myocardial injury. It has several advantages over other catecholamines. At effective inotropic dose levels, dopamine produces less peripheral vasoconstriction than norepinephrine. Dopamine also causes fewer arrhythmias than isoproterenol. This is a case report of a heart transplant patient who began rejecting and developed heart failure. In addition to the immunosuppressive agents, dopamine was used initially as the vasopressor with marked deterioration in the patient's condition. Dobutamine, a new inotropic agent, was substituted for dopamine with subsequent improvement in cardiac function. The authors concluded that dobutamine may be the most appropriate agent to use in the rejecting transplanted heart because of the former's direct action on the heart. Dobutamine may also be preferred for support of the cardiac outputs of patients with chronic heart failure.

Control of addictive drugs in Iceland 1976--78

During the years 1972--76 drug prescriptions and sales of drugs were surveyed in Iceland. Compared with the other Nordic countries, except Denmark, sales of the psychotropic drugs which may lead to addiction were highest in Iceland, as previously reported. Here we explain the efforts of the Icelandic health authorities to reduce the legitimate consumption of psychotropic drugs. These efforts are mainly directed towards doctors' prescriptions to outpatients. A survey of prescriptions and sales of drugs in Iceland in 1976--78 revealed that (1) the number of individuals receiving drugs subject to reporting in Iceland decreased by 40% between 1976 and 1978; (2) the prescribed amount of hypnotics and sedatives subject to reporting decreased by 45% in the same period; (3) the prescribed amount of narcotic analgesics decreased by 20%; (4) the prescribed amount of amphetamines and related drugs decreased by 40%; and (5) the amount sold of diazepam and related drugs decreased by 20%. The available data suggest that EDB-registration of prescriptions subject to recording and feedback to doctors about their prescribing habits contributes to a reduction in the use of the drugs recorded.

The cost of treatment of dermatological disorders in hospital versus health centre

Well-run outpatient services and reasonable charges to patients for drugs have led to reduced hospitalisation of dermatological patients and hence a reduction in the total cost of nursing and treating such patients in comparison with previous years, when there was greater emphasis on hospital treatment. There is at present no waiting list for dermatological beds at the National Hospital.

A population study of rheumatoid factor in Iceland. A 5-year follow-up of 50 women with rheumatoid factor (RF)

The subject of this paper is a 5-year follow-up of 50 women found with Rose-Waaler Titre greater than or equal 1 : 10 or with a Acryl Fixation Titre greater than or equal 1 : 10 in a general health survey conducted in the Reykjavik area in 1968-1969. The average annual incidence of RA was 2.3 percent. Of four women who died during the follow-up period, three were amongst those with the highest titres. Two of the decreased had cancer mammae and one had lung cancer. Changes in RF-titres and New York Criteria are also discussed. It is suggested that RF-positives could be divided in three different riskgroups.