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Surgery in Iceland.

Icelandic surgeons provide a wide range of modern surgical services with excellent results. How can a nation of fewer than 300,000 persons accomplish this? The main reasons are a thriving economy, a high standard of living and education, and the training of surgeons. All Icelandic surgeons receive their training overseas, many at university hospitals in the other Nordic countries, particularly Sweden. Others receive training in the United States and Great Britain. Almost 50% of the general and orthopedic surgeons hold PhD degrees from major universities in the Nordic countries. In some other surgical subspecialties, an even greater number possess a PhD degree. This diverse background of training creates a stimulating and international outlook among the surgeons. All types of surgery are performed in Iceland, with the exception of surgery for complicated congenital heart disease and transplantation. Recently a living related renal transplant program was started with promising results.

Biomedical Research↗

Common founder mutation in the LDL receptor gene causing familial hypercholesterolaemia in the Icelandic population.

Haplotype analysis in 18 apparently unrelated families with familial hypercholesterolaemia (FH) in Iceland has identified at least five different chromosomes cosegregating with hypercholesterolaemia. The most common haplotype was identified in 11 of the 18 families, indicating a responsible for FH in the Icelandic population. By using single-strand conformation polymorphism (SSCP) and direct sequencing of amplified DNA, we identified a novel mutation (a T to a C) in the second nucleotide in the 5' part of intron 4 in the LDL receptor gene. This mutation was present in approximately 60% of the FH families (10/18), supporting the prediction of a common founder. These families could be traced to a common ancestor in half of the cases by going back no further than the eighteenth century. The mutation was predicted to affect correct splicing of exon 4, and analysis at the cellular level demonstrated an abnormal mRNA containing intron 4 sequence in lymphoblastoid cells from a patient carrying this mutation. Translation of the mRNA would lead to a premature stop codon and a truncated nonfunctional protein of 285 amino acids. The novel sequence change created a new restriction site for the restriction endonuclease NlaIII, and using this assay, 29 unrelated individuals with possible FH attending a lipid clinic for treatment were examined for this mutation. Two individuals in this group of patients were found to be carriers of this mutation, supporting the suggestion of a founder mutation. Using this assay for the detection of FH in the Icelandic population should identify > 60% of these individuals.

Cells, Cultured↗

The inheritance of rheumatoid arthritis in Iceland.

OBJECTIVE: Rheumatoid arthritis (RA) is the most common form of inflammatory arthritis. Although there is a large body of evidence suggesting that RA is immune mediated, the etiology remains unresolved. Twin studies have shown disease concordance rates of approximately 15% in monozygotic twins and 4% in dizygotic twins, while the estimated risk ratio for siblings of RA patients ranges from 5 to 8. Our goal was to use genealogic data from Iceland to further investigate the genetic component of RA. METHODS: Data were obtained from a population-based, computerized genealogy database that was developed to examine multigenerational relationships among individuals in the relatively homogeneous population of Iceland. Using an algorithm, the minimum founder test, we calculated the least number of founders required to account for a list of RA patients, and compared it with 1,000 sets of same-sized matched control groups. In addition, we estimated the kinship coefficient and risk ratios for relatives of the RA patients. RESULTS: Several familial clustering tests demonstrated that the RA patients were more related to each other than were the average control set of Icelanders. A significantly fewer number of founders was necessary to account for our patient list than for the random sets of matched controls (P < 0.001), and the average pairwise identity-by-descent sharing was greater among the patients than among the control sets (P < 0.001). In addition, there was an increased risk of RA in first- and second-degree relatives of the patients; e.g., for siblings, the risk ratio was 4.38 (95% confidence interval 3.26-5.67), and for uncles/aunts, the risk ratio was 1.95 (95% confidence interval 1.52-2.43). CONCLUSION: The familial component of RA is shown to extend beyond the nuclear family, thus providing stronger evidence for a significant genetic component to RA.

Algorithms↗

The inheritance of hand osteoarthritis in Iceland.

OBJECTIVE: To assess the contribution of genetics to hand osteoarthritis (HOA) and its subsets in the Icelandic population. METHODS: A list of 2,919 HOA patients, constituting 1% of the Icelandic population, was compiled through nationwide sources. This patient list was cross-referenced with a comprehensive Icelandic genealogy database, enabling the use of algorithms to assess familiality of HOA. Two methods were used: the average pairwise kinship coefficient (KC) of the patients, and the relative risk (RR) of HOA in relatives of patients. In each case, the results were compared with 1,000 control sets of similar composition with regard to number, age, and sex, generated from the genealogy database. RESULTS: The KC for patients was significantly higher than for the control sets and was proportional to the degree of both interphalangeal (IP) and thumb base (first carpometacarpal [CMC] joint) involvement. The RR of HOA in sisters of women in the study was 2.0 (P < 0.001), while the RR in spouses was not significantly different from that in controls. The RR increased with the severity of the disease. Thus, sisters of women with severe IP HOA had an RR of 5.0 and sisters of those with severe first CMC involvement had an RR of 6.9. The increased risk also extended beyond the nuclear family, with significantly increased risk in cousins. CONCLUSION: Patients seeking medical services for HOA are more related to each other than matched controls, supporting the role of a genetic component in the disease. The genetic influence in both IP and first CMC HOA appears to be similar and increases with increasing severity of the disease.

Adult↗

Familial risk of colon and rectal cancer in Iceland: evidence for different etiologic factors?

The aim of this study was to characterize the familial risk of colon and rectal cancer using 2 population-based registries in Iceland, the Icelandic Cancer Registry and a genealogy database. The standardized incidence ratio (SIR) was used to estimate the risk among relatives of colorectal cancer index cases diagnosed in Iceland over a 46-year period (1955-2000). The 2,770 colorectal cancer patients had 23,272 first-degree relatives. Among first-degree relatives, there was an increased risk of both colon (SIR 1.47, 95% confidence interval (CI) 1.34-1.62) and rectal cancer (SIR 1.24, 95% CI 1.04-1.47). An increased risk of colon cancer was observed among siblings of colon cancer patients (SIR 2.03, 95% CI 1.76-2.33), whereas no such increase was observed for parents or offspring. Furthermore, the risk of rectal cancer was only increased among brothers (SIR 2.46 95% CI 1.46-3.89) of rectal cancer patients and not among their sisters (SIR 1.0 95% CI 0.40-2.06). The added risk of colon cancer among first-degree relatives was independent of site of colon cancer in the proband. Our results confirm that family history of colorectal cancer is a risk factor for the disease. However, family history has a different association with colon cancer than with rectal cancer, suggesting that the 2 cancer types may have different etiologic factors. Our results have implications for colon and rectal cancer screening programs.

Aged↗

Frequency and effect of human apolipoprotein A-IV polymorphism on lipid and lipoprotein levels in an Icelandic population.

Human apolipoprotein A-IV (apo A-IV) exhibits a genetic polymorphism with two common alleles, A-IV1 and A-IV2, in Caucasian populations. We have investigated this polymorphism in the Icelandic population. The frequencies of the two alleles are significantly different from middel European populations with a higher frequency of the A-IV2 allele (0.117 versus 0.077) occurring in Iceland. The alleles at the apo A-IV locus have significant effects on plasma high density lipoprotein cholesterol (HDL-C) and triglyceride levels. The average effect of the A-IV2 allele is to raise HDL-C by 4.9 mg/dl and to lower triglyceride levels by 19.4 mg/dl. We estimate that the genetic variability at the apo A-IV gene locus accounts for 3.1% of the total variability of HDL-C and for 2.8% of the total variability of triglycerides in the population from Iceland. This confirms and extends our previous observations on apo A-IV allele effects in Tyroleans in an independent population.

Alleles↗

An epidemic of hepatitis B virus infection among intravenous drug users in Iceland.

This study describes an outbreak of hepatitis B primarily among intravenous drug users in Iceland which has a population with a very low incidence of hepatitis B virus infection. The incidence of acute hepatitis B is generally low in the Nordic Countries, in the order of one to five cases per 100,000 people per year. Between 1989 and 1992 there was an outbreak of hepatitis B virus infection primarily among the intravenous drug user (IVDU) population in Iceland. At the Department of Medical Virology, University of Iceland there were 44 cases of acute hepatitis B identified during the peak year 1990, an incidence of 16.9 cases of acute hepatitis B per 100,000 people. 63.6% of these were known to be IVDUs. The seroprevalence of the hepatitis B core antibody (anti-HBc) marker was assessed among 1100 randomly selected individuals. The average prevalence of this marker was 2.9% and rose from zero at the age of 15 and younger to 6.5% at the age of 65 and older. Among IVDUs attending a detoxification clinic in 1990 the prevalence of the anti-HBc was 32%. In contrast, those attending the same clinic, due to alcoholism only, did not have a significantly higher prevalence of anti-HBc than the group used for comparison.

Adolescent↗

A marked decline in the prevalence and incidence of intermittent claudication in Icelandic men 1968-1986: a strong relationship to smoking and serum cholesterol--the Reykjavik Study.

The epidemiology of peripheral vascular disease has been studied much less extensively than the epidemiology of coronary heart disease (CHD). The prospective Reykjavik Study gave an opportunity to monitor secular trends from 1968 to 1986 of clinical intermittent claudication (IC) amongst Icelandic males, aged 34-80 and to assess the importance of possible risk factors. Both prevalence and incidence of IC decreased sharply after 1970 in all age groups, and this decline occurred a few years earlier than the decline of CHD in Iceland. The only significant risk factors for intermittent claudication, in addition to age, were smoking which increased the risk of IC 8- to 10-fold and serum cholesterol level. Approximately one-half of the striking decline in the incidence of IC can be explained by decreased smoking and cholesterol levels amongst Icelandic men. A follow-up study verified that IC patients stood twice the risk of cardiovascular and total mortality as non-IC patients, indicating that IC is a high risk group which should receive all possible preventive measures.

Adult↗

Cardiac structure and exercise blood pressure in urban and rural Canadian men of Icelandic descent.

The objective of the study was to determine the relationship between exercise systolic blood pressure (ESBP), during bicycle ergometry, and echocardiographically determined left ventricular structure in rural and urban Canadian men of Icelandic descent. The study was cross-sectional in design. The settings were urban Winnipeg and the rural Interlake District in the province of Manitoba, Canada. Subjects were adult male volunteers from families of wholly Icelandic descent. The subjects were 30 to 60 years of age and had supine blood pressure < 160/95 mm Hg. Anthropomorphic measurements, echocardiography and sphygmomanometry, at rest and during bicycle ergometry, were performed on all subjects. Prevalence of exaggerated ESBP (> or = 200 mm Hg) and left ventricular hypertrophy (LVH) was not significantly different in the two groups. In all but one individual LVH was classified as eccentric hypertrophy. In both urban and rural subjects with exaggerated ESBP, left ventricular mass index (LVMI) was greater than in those subjects without exaggerated ESBP. The LVMI correlated with ESBP at the highest workloads (> or = 150 W). Multivariate analysis of all subjects showed that cardiac index, ESBP, body mass index, and low exercise heart rate were predictive of LVMI. There was no significant difference in prevalence of ESBP or LVH between urban and rural Manitobans of Icelandic descent. However, LVMI levels were lower, and values for ESBP greater, in the rural group compared with the urban group. Within each of the two groups there was a positive association between ESBP and LVMI; hence, the study supports findings of our previous investigation showing evidence of early target organ effects in normotensive men with an exaggerated ESBP.

Adult↗

BRCA2, but not BRCA1, mutations account for familial ovarian cancer in Iceland: a population-based study.

A single founder mutation in each of the BRCA genes has been identified in Iceland. The frequency of the BRCA1 G5193A and BRCA2 999del5 mutations in all ovarian cancer patients diagnosed over the period 1991-2000 was determined. Mutation status was correlated with family history, tumour morphology and age at diagnosis. Samples from 86% of cases (179 carcinomas and 74 borderline tumours) were available. In the carcinomas, BRCA1 and BRCA2 mutations were present in 1.2% and 6% of cases, respectively. No BRCA mutations were found in the borderline tumours. Odds Ratio (OR) of developing ovarian cancer was 20.65 for BRCA2 carriers. Family history of breast/ovarian cancer was present for 70% of BRCA2 carriers and approximately 14% for non-carriers with carcinoma. In conclusion, BRCA2 999del5 is present in 6% of ovarian cancer cases in Iceland and is associated with a 20-fold increase in the risk of the disease. The BRCA1 G5193A mutation is too rare to contribute significantly to ovarian cancer in Iceland.

Adolescent↗

Temporal trends of organochlorine contamination in Black Guillemots in Iceland from 1976 to 1996.

The levels of several different persistent organochlorines (OCs) in Black Guillemots Cepphus grylle, collected during the summers of 1976-1996 at Breioafjörour in W-Iceland, were investigated. The levels of about 40 different organochlorines (PCBs, DDTs, chlordanes, toxaphenes, HCH, HCB) were compared with respect to age, sex, fat content, and year of collection. The levels of PCBs correlated very closely with those of DDE, indicating long-range transport as the major source of these contaminants in Iceland, with the ratio PCBs/DDE mostly in the range of 2-5. Unlike the Gyrfalcon Falco rusticolus, the organochlorine levels did not seem to accumulate substantially with age, neither in males nor females. The variation in the levels of OCs at the age of 2 years was even greater than the variation in OC levels over an age range of 12 years. In immature birds the levels of PCBs, DDE, HCB and beta-HCH declined very slowly (T(1/2) from 12 to 20 years) over the years 1976-1996, whereas the levels of alpha-HCH and p,p'-DDT declined much faster. The levels of trans-nonachlor, alpha-chlordane, gamma-chlordane, oxychlordane, and toxaphene did not correlate with the year of collection. As the Black Guillemot is mostly a resident seabird, feeding mainly on small fish and invertebrates, this investigation should give a good indication of the temporal trends of organochlorine pollution at Breioafjörour, Iceland, during this 20 year period and is likely to reflect baseline trends in the marine environment of the North-Atlantic Ocean.

Animals↗

Deregulating the pharmacy market: the case of Iceland and Norway.

The pharmacy market in many European countries is characterised by individually owned pharmacies that operate under tight government control regarding barriers to entry, scope of activities and profit margins. Many countries are, however, in the process of introducing pro-competitive policies, including possibilities to own several pharmacies and competition based on price. In Iceland and Norway, restrictions to ownership and competition were relaxed in 1996 and 2001, respectively. In both countries, the new policies quickly led to horizontal integration and concentration of the market, and in Norway the merging pharmacy groups integrated vertically with wholesalers. By 2004, two pharmacy groups in Iceland and three pharmacy groups in Norway controlled 85 and 97% of the markets, respectively. In combination with remaining barriers to entry, this market concentration may call for additional pro-competitive interventions to prevent unfavourable developments. Such policies will simultaneously make it more difficult to uphold traditional social objectives related to pharmacy services. Experiences in both Iceland and Norway highlight the complexity of managing reforms that fundamentally influence competitive behaviour.

Economic Competition↗

Reliability and validity of the Icelandic version of the Problem Area in Diabetes (PAID) Scale.

BACKGROUND: Diabetes is a burdensome disease that increases distress among people with diabetes. OBJECTIVES: To test the validity and reliability of an Icelandic version of the problem area in diabetes scale (PAID) and to assess the hitherto unknown distress level of Icelandic people with insulin requiring diabetes. DESIGN: Methodological research design. SETTING: Diabetes clinics. PARTICIPANTS: People with insulin-dependent diabetes, between 18 and 61 years. METHODS: All instruments were translated using a back-translation technique. Participants answered three consecutive questionnaires in succession, the PAID scale, the diabetes empowerment scale (DES) and the diabetes knowledge test (DKT). Principical component analysis with varimax rotation was conducted on the PAID scale to identify latent factors. RESULTS: Factor analysis revealed two factors: (a) distress in relation to life with diabetes, with Cronbach alpha coefficient of 0.93 and (b) distress in relation to management of diabetes, with Cronbach alpha coefficient of 0.88, for PAID overall Cronbach alpha coefficient was 0.94. PAID showed neither floor nor ceilings effects. Propositions set to indicate validity were generally met. However, PAID's factor structure and predictive validity needs to be tested further. CONCLUSIONS: The Icelandic version of PAID is sufficiently psychometrically robust. PAID is simple to administer and by using the scale clinicians can identify people at risk for developing diabetes-related distress. The results are comparable to results from studies in other countries using the PAID scale.

Adaptation, Psychological↗

Front-line management, staffing and nurse-doctor relationships as predictors of nurse and patient outcomes. a survey of Icelandic hospital nurses.

OBJECTIVE: To investigate aspects of nurses' work environments linked with job outcomes and assessments of quality of care in an Icelandic hospital. BACKGROUND: Prior research suggests that poor working environments in hospitals significantly hinder retention of nurses and high quality patient care. On the other hand, hospitals with high retention rates (such as Magnet hospitals) show supportive management, professional autonomy, good inter-professional relations and nurse job satisfaction, reduced nurse burnout and improved quality of patient care. METHODS: Cross-sectional survey of 695 nurses at Landspitali University Hospital, Reykjavík. Nurses' work environments were measured using the nursing work index-revised (NWI-R) and examined as predictors of job satisfaction, the Maslach burnout inventory (MBI) and nurse-assessed quality of patient care using linear and logistic regression approaches. RESULTS: An Icelandic adaptation of the NWI-R showed a five-factor structure similar to that of Lake (2002). After controlling for nurses' personal characteristics, job satisfaction, emotional exhaustion and nurse rated quality of care were found to be independently associated with perceptions of support from unit-level managers, staffing adequacy, and nurse-doctor relations. CONCLUSIONS: The NWI-R measures elements of hospital nurses' work environments that predict job outcomes and nurses' ratings of the quality of patient care in Iceland. Efforts to improve and maintain nurses' relations with nurse managers and doctors, as well as their perceptions of staffing adequacy, will likely improve nurse job satisfaction and employee retention, and may improve the quality of patient care.

Cross-Sectional Studies↗

Pathological findings in harbour porpoises (Phocoena phocoena) from Norwegian and Icelandic waters.

A study of 37 by-caught harbour porpoises from Icelandic and Norwegian waters showed that most were in good or moderate nutritional condition and none was severely emaciated. Mild infection with lungworms (Halocercus invaginatus, Pseudalius inflexus, Torynurus convolutus) was found in 84% of the Icelandic and 91% of the Norwegian animals, usually associated with bronchopneumonia which was rarely severe. Most (91%) of the animals had parasites in the stomach and intestine (Anisakis simplex, Contracaecum osculatum, Pholeter gastrophilus), and Campula oblonga was present in the liver and pancreas of 88 and 21%, respectively. Oesophagitis, gastritis, cholangitis, pericholangitis, pancreatitis and lymphadenitis were almost exclusively associated with parasitic infection and usually mild. Bacterial isolates were obtained from 50 to 55% of the animals but were not considered to be clinically significant. There was no indication of morbillivirus infection. Icelandic and Norwegian animals showed a thicker blubber layer and a lower incidence of severe lesions, especially in the respiratory tract, as compared with reports of by-caught animals from the Baltic Sea.

Animals↗

Levels and enantiomeric ratios of alpha-HCH, oxychlordane, and PCB 149 in blubber of harbour seals (Phoca vitulina) and grey seals (Halichoerus grypus) from Iceland and further species.

The chiral stationary phase beta-TBDM (35% heptakis(6-O-tert.-butyldimethylsilyl-2,3-di-O-methyl)-beta-cyc lod extrin in OV-1701) was applied to study the enantioenrichment of alpha-HCH, oxychlordane, and PCB 149 in blubber of two seal species from Iceland by gas chromatography with electron capture detection. The examined harbour seals (Phoca vitulina) and grey seals (Halichoerus grypus) showed alpha-HCH enantiomeric ratios (ER) > 1. The ER of PCB 149 was comparable in the two species from Iceland but for oxychlordane ER < 1 was observed in harbour seals while the oxychlordane ER in grey seals was > 1. In blubber of Weddell seals (Leptonychotes Weddelli) from the Antarctic we determined an alpha-HCH ER < 1 which is in contrast to the Icelandic seal species and a sample from Lake Baikal.

Animals↗

Multiple sclerosis and canine distemper in Iceland.

Iceland offers a favourable opportunity to examine the suggested relationship between canine distemper and multiple sclerosis. Distemper is not enzootic in Iceland and distemper immunisation is not practised. However, importations result in occasional epizootics, three of which have occurred since 1909. Careful enumeration of multiple sclerosis indicates that there were 129 cases during the period 1946--65. When these cases are subdivided into six regions, by place of birth, regional period-prevalence rates were highest in two regions partially involved by distemper only once in the past 70 years. Also, there was substantial prevalence in a third region, encompassing Reykjavik, where the dog population has been kept very low for over 50 years. The Icelandic experience indicates that multiple sclerosis can occur at high incidence in the virtual absence of canine distemper or in the presence of a very small dog population.

Animals↗

"Iceland Inc."?: On the ethics of commercial population genomics.

A detailed analysis of the Icelandic commercial population-wide genomics database project of deCODE Genetics was performed for the purpose of providing ethics insights into public/private efforts to develop genetic databases. This analysis examines the moral differences between the general case of governmental collection of medical data for public health purposes and the centralized collection planned in Iceland. Both the process of developing the database and its design vary in significant ways from typical government data collection and analysis activities. Because of these differences, the database may serve the interests of deCODE more than it serves the interests of the public, undermining the claim that presumed consent for this data collection and its proprietary use is ethical. We believe that there is an evolving consensus that informed consent of participants must be secured for population-based genetics databases and research. The Iceland model provides an informative counterexample that holds key ethics lessons for similar ventures.

Databases, Genetic↗