Timing of paediatric orchidopexy in universal healthcare systems: international administrative data cohort study.

BACKGROUND: International guidelines in 2008 recommended orchidopexy for undescended testis at 6-12 months of age to reduce the risk of testicular cancer and infertility. Using administrative data from England, Finland, Ontario (Canada), Scotland and Sweden (with data from Victoria (Australia) and Iceland in supplementary analyses), the aim of this study was to investigate compliance with these guidelines and identify potential socioeconomic inequities in the timing of surgery before 1 and 3 years. METHODS: All boys born in 2003-2011 with a diagnosis code of undescended testis and procedure codes indicating orchidopexy before their fifth birthday were identified from administrative health records. Trends in the proportion of orchidopexies performed before 1 and 3 years of age were investigated, as were socioeconomic inequities in adherence to the guidelines. RESULTS: Across all jurisdictions, the proportion of orchidopexies occurring before the first birthday increased over the study period. By 2011, from 7·6 per cent (Sweden) to 27·9 per cent (Scotland) of boys had undergone orchidopexy by their first birthday and 71·5 per cent (Sweden) to 90·4 per cent (Scotland) by 3 years of age. There was limited evidence of socioeconomic inequities for orchidopexy before the introduction of guidelines (2008). Across all jurisdictions for boys born after 2008, there was consistent evidence of inequities in orchidopexy by the first birthday, favouring higher socioeconomic position. Absolute differences in these proportions between the highest and lowest socioeconomic groups ranged from 2·5 to 5·9 per cent across jurisdictions. CONCLUSION: Consistent lack of adherence to the guidelines across jurisdictions questions whether the guidelines are appropriate.

ANTECEDENTES: En el 2008, las guías internacionales recomendaban efectuar una orquidopexia para los testículos no descendidos entre los seis y los 12 meses de edad para reducir los riesgos de cáncer testicular e infertilidad. Utilizando datos administrativos de Inglaterra, Finlandia, Ontario (Canadá), Escocia y Suecia (con datos de Victoria, Australia e Islandia para análisis complementarios), el objetivo de este estudio fue investigar el cumplimiento de estas guías y la identificación de posibles desigualdades socioeconómicas con relación al momento de la cirugía antes de 1 y 3 años de edad. MÉTODOS: A partir de los registros administrativos de salud, se identificaron todos los niños nacidos entre 2003 y 2011 con código diagnóstico de testículos no descendidos y con código de procedimiento correspondiente a orquidopexia antes de cumplir 5 años. Se investigaron las tendencias en la proporción de orquidopexias realizadas antes de 1 y 3 años de edad, respectivamente, al igual que las desigualdades socioeconómicas en el cumplimiento de las directrices de las guías. RESULTADOS: En todas las jurisdicciones, la proporción de orquidopexias realizadas antes del primer año de vida aumentó durante el periodo de estudio. En 2011, del 7,6% (Suecia) al 27,9% (Escocia) de los niños habían sido sometidos a orquidopexia en su primer año de vida y del 71,5% (Suecia) al 90,4% (Escocia) a los 3 años de edad. Hubo evidencia limitada de las inequidades socioeconómicas para la orquidopexia antes de la introducción de las guías (2008). En todas las jurisdicciones para los niños nacidos después de 2008, hubo evidencia consistente de inequidades para la práctica de una orquidopexia en el primer año de vida en favor de una posición socioeconómica más alta (socioeconomic position, SEP). Las diferencias absolutas en estas proporciones entre los grupos SEP más altos y más bajos oscilaron entre el 2,5% y el 5,9% en todas las jurisdicciones. CONCLUSIÓN: La falta de adherencia a las guías observada consistentemente en todas las jurisdicciones cuestiona si las guías son apropiadas.

HBO and gas gangrene. A case report.

A 58-year old man, in a mediocre health condition, was admitted into Landspitallin Fossvogur, the University of Reykjavik City Hospital, Iceland, because of fever, chills, local pain and swelling due to the presence of a big old wound in his left heel. The first clinical appearance showed a gas gangrene of the area. The patient immediately underwent a surgical debridement and a fasciotomy, and antibiotic intravenous therapy and hyperbaric oxygen therapy (HBOT) were started. During the treatment the patient suffered for a multi-organ failure syndrome (MOFS), was admitted in ICU and survived. A total of 52 HBO sessions were performed and one month since the admission into the hospital the patient received a skin transplant. He achieved a complete restitutio ad integrum after 78 days of hospitalization. Gas gangrene is a fulminating infection caused by the genus of Clostridia. If not treated, it leads to the death of the host. The actual treatment for gas gangrene includes surgery, antibiotics, general resuscitative measures and HBOT.

Health education and cholera in rural Guinea-bissau.

OBJECTIVE: The study was undertaken to explore local ideas about cholera and the diffusion of official health educational messages for cholera prevention and to assess whether such messages contributed to changed behavior in the population. METHODS: During the ongoing cholera epidemic in 1994 in Guinea-Bissau, West Africa, a roster of all adult residents in a rural community was established. From this roster of 458 adults, 53 of 60 randomly chosen residents were interviewed for qualitative data on cholera and its prevention. RESULTS: Local preventive rituals performed contributed to high awareness of the epidemic. Radio and word-of-mouth communication were the most important sources of information on cholera, whereas posters and television did not effectively reach the population. All persons with cholera rapidly sought care. Thirty-four (64%) of 53 participants recalled at least one preventive measure; specifically, treatment of water with lemon was mentioned by 21 (40%) of respondents. None of the respondents could explain how cholera is transmitted to humans. CONCLUSIONS: To improve compliance with recommended preventive measures, these should take local conceptions of diseases into account and be few in number, practical, and effective. The impact of the radio could be increased if those who hear the message are urged to spread the recommendation, especially to women who take care of food, water, and general hygiene in the household.

Infant feeding practices during the first six months of life in a rural area in Tanzania.

OBJECTIVE: To assess breastfeeding practices in infants aged 0-6 months, focussing particularly on beliefs, knowledge and practices affecting exclusive breastfeeding. DESIGN: A house-to-house survey with individual interviews using a structured questionnaire, key informants interviews and focus group discussions. PARTICIPANTS: One hundred and seven mothers were interviewed, nearly all of those living in Nkinga community with infants less than seven months old. The focus group discussions and key informant interviews were also held. SETTING: Nkinga community, Igunga District, Tabora region, Tanzania. RESULTS: Sixty four per cent of the sample was put to the breast within two to eleven hours. Prelacteal feeds were given to about 25% of the infants. The type of prelacteal fluid given was mainly glucose water in hospital and plain water with home deliveries. Forty six per cent of the mothers discarded colostrum. The median duration of exclusive breastfeeding was about two months and of full breastfeeding was about four months. CONCLUSION: The average duration of exclusive breastfeeding, though far below recommended levels, is higher than is found in most studies in Africa and Tanzania. This may be due to the efforts of hospital staff who had received special training on breastfeeding in recent years.

Epidemic cholera in Guinea-Bissau: the challenge of preventing deaths in rural West Africa.

OBJECTIVES: An epidemiologic investigation was conducted to identify factors associated with cholera mortality in a rural African setting and interventions likely to prevent deaths in future epidemics. METHODS: The authors reviewed surveillance data from rural Biombo, Guinea-Bissau, interviewed family members of persons who died of cholera, and conducted a case-control study in the catchment area of a health center with a high case:fatality ratio (CFR). RESULTS: Forty-three deaths occurred among the 1169 persons who reported to health centers with cholera during the epidemic (CFR = 3.7%). Delayed rehydration and over-hydration probably contributed to 10 of these deaths. An additional 19 cholera deaths occurred outside health centers. In the case-control study, persons with cholera who died were 5.4 times (95% CI = 1.0-53.4) more likely to be in poor health or intoxicated at illness onset than persons with cholera who survived. Fatal cases were 6.0 times (95% CI = 1.1-60.8) more likely to not attend the health center than survivors. CONCLUSIONS: The low overall CFR in Biombo, compared to CFRs reported during other epidemics in sub-Saharan Africa, suggests that medical care provided at rudimentary rural health centers prevented numerous deaths. Additional deaths may be prevented by strengthening the infrastructure of health services in the rural areas and by enhanced public education regarding the need for persons with cholera to promptly seek medical care.

First do no harm: making oral rehydration solution safer in a cholera epidemic.

Oral rehydration solution (ORS) is lifesaving therapy for cholera and pediatric diarrhea. During a cholera epidemic in Guinea-Bissau, we evaluated the microbiologic quality of ORS prepared at a hospital and tested a simple intervention using special vessels for disinfecting tap water with bleach and for preparing, storing, and dispensing ORS. Few coliform bacteria and Escherichia coli were recovered from tap water; however, pre-intervention ORS contained numerous bacteria including E. coli and toxigenic Vibrio cholerae O1. In contrast, ORS samples from intervention vessels had few or no coliform bacteria, no E. coli, and no V. cholerae. Mean pre-intervention counts of coliform bacteria (3.4 x 10(7) colony-forming units [cfu]/100 ml) and E. coli (6.2 x 10(3) cfu) decreased significantly during the intervention period to 3.6 x 10(2) cfu and 0 cfu, respectively (P < 0.001). This simple system using bleach disinfectant and special storage vessels prevents bacterial contamination of ORS and reduces the risk of nosocomial transmission of cholera and other enteric pathogens.

PIP: This paper evaluates the microbiologic quality of oral rehydration solution (ORS) prepared at a hospital during a cholera epidemic in Guinea-Bissau. The study tested a simple intervention using special vessels for disinfecting tap water with bleach and for preparing, storing, and dispensing ORS. Subjects included approximately 80% of the cholera patients seeking treatment, who were referred to the cholera ward of Simao-Mendes National Hospital. Results suggest that only few coliform bacteria and Escherichia coli were recovered from tap water; however, pre-intervention ORS contained numerous bacteria including E. coli and toxigenic Vibrio cholerae O1. In contrast, ORS samples from intervention vessels had few or no coliform bacteria, no E. coli, and no V. cholerae. This simple system using bleach disinfectant and special storage vessels prevents bacterial contamination of ORS and reduces the risk of nosocomial transmission of cholera and other enteric pathogens.

Funerals during the 1994 cholera epidemic in Guinea-Bissau, West Africa: the need for disinfection of bodies of persons dying of cholera.

The 1994 cholera epidemic in Guinea-Bissau resulted in 15,878 reported cases and 306 deaths. Early in the epidemic, although the health ministry mandated that the bodies of persons dying of cholera be disinfected, outbreaks occurred in several villages following funerals in the region of Biombo. To determine the influence of disinfection and funeral activities on cholera transmission, we analysed surveillance data and conducted a case-control study following a funeral. The attack rate during the week following funerals was higher in villages where bodies were not disinfected (risk ratio = 2.6, 95% confidence interval [CI] 1.9-3.8). Cholera was strongly associated with eating at a funeral with a non-disinfected corpse (odds ratio [OR] = 14.5, 95% CI 0.9-786) and with touching (i.e., transporting, washing) the body (OR = 36.2, 95% CI 2.6-1769). During cholera epidemics, in addition to other cholera prevention activities, health officials should inform community leaders about the risk of cholera transmission during funerals, meals should not be served at funerals, and bodies of persons dying of cholera should be disinfected.

Selective compartmentalization of gammadelta-T lymphocytes in human breastmilk.

In human breastmilk, T lymphocytes with gammadelta-receptor (TCR) are more frequent than those with alphabeta-TCR, in comparison with peripheral blood. Differential representation has also been demonstrated for subpopulations of gammadelta-T cells. Reactivity was visualized with three monoclonal antibodies against Vdelta1, Vdelta2 and Vgamma2 on T cells from the breastmilk and peripheral blood of 12 women who had recently given birth. Confirming the results with Vdelta1, it was found that Vdelta1 (p < 0.01) and Vgamma2 (p < 0.05) but not Vdelta2 were overrepresented on T cells in milk as compared with blood. This selective compartmentalization seems to reflect the homing of certain cells to the mammary gland.

[Operations for liver injury 1968-93. A review from the Reykjavik City Hospital.].

OBJECTIVE: The purpose of the study was to disclose the operative experience with liver injuries at the Reykjavik City Hospital for the years 1968-1993 and compare the results to those reported by others. MATERIAL AND METHODS: Journals for all patients undergoing an operation for liver injury during the period were studied. Age and sex, cause of injury, condition on arrival at the hospital, additional injuries, length of the operation, number of transfusions, hospital stay, indications for surgery, type of surgery, complications and mortality were all noted. The abbreviated injury severity scale (AIS-90) was used to classify the liver injuries. The injury severity score (ISS) was calculated for each patient. RESULTS: There were 41 patients, 28 males and 13 females. The median age was 20 years (5-78) and one fourth were children under 10 years. Blunt trauma caused 84% of the injuries and traffic accident the most common cause. Seventeen patients (42.5%) were in shock (systolic BP under 90) on arrival and 12 (29%) were still in shock at the beginning of the operation. Each patient had on the average 2.22 additional injuries inside or outside the abdomen. The number of transfusions required, hospital stay and operative time were extremely variable the median being 1.4 liters, 100 minutes and 15 days respectively. The most common indication for laparatomy was shock or fluid in the abdomen as shown by ultrasound and signs of peritoneal irritation. The liver was bleeding at the time of surgery in 51.3% of cases. Bleeding could in most instances be controlled with sutures. Three patients underwent a major hepatic resection and all survived. One of the three had an associated vena cava injury. There were 20 major complications of which abdominal sepsis and renal failure were the most common. Seven patients died (17%) but only one of liver bleeding on the operating table. Others died from brain injury, chest injury or multiple organ failure. Seventy one per cent had minor or moderate injury to the liver (class I or II) while 29% had major or massive injury (class III or VI). Twenty three patients (56%) had injury severity score (ISS) under 16. One of these 23 patients died, an elderly man with cirrhosis and incurable carcinoma of the liver. Other patients who died had ISS of 41 or higher. In this series are only patients who underwent an operation. In recent years there has been a growing tendency to treat liver injury without operation. From 1988-93 seven of 15 patients with liver injury were treated without operation. CONCLUSIONS: Most of the results in this study are similar to those reported by others. The mortality is low when compared to authors who mostly have closed injuries in their series as we do. No patient with normal liver before the accident died unless he had ISS of 41 or higher. This fact along with the low mortality seem to indicate that treatment was of high standard.

[Traumatic rupture of the thoracic aorta in iceland 1980-1989.].

INTRODUCTION: Since an article was published by Parmley in 1958 it has been generally known that patients with traumatic rupture of the thoracic aorta do not all die immediately. Parmley found that 20% of the victims who did not have an associated cardiac injury lived long enough to be brought to a hospital making a repair of the injury at least a possibility. During the seventies and eighties an increasing number of case reports was published where the aortic injury had been successfully repaired and in a few major institutions 30-40 such operations had been performed. PURPOSE: The purpose of the study was to disclose the incidence of traumatic rupture of the thoracic aorta in Iceland, the causes of the injury, the location of the rupture in the vessel and to discover how many reach to a hospital alive and are being treated. METHODS: The autopsy reports of the Section of Forensic Medicine in the Institute for Pathology at the University of Iceland from 1980 through 1989 were thoroughly studied. It is believed that autopsy was performed in practically all cases of accidental death in the study period. The injury severity score was calculated for each individual indicating the magnitude of the total injury and chances of survival. The hospital records of those admitted were studied in a similar manner. The time from the accident to admission was noted when on record. RESULTS: The study revealed 57 cases of traumatic rupture of the thoracic aorta which gives an incidence of approximately 2.3 per 100,000 inhabitants per year. Traffic accidents were the most common cause (77%) and fall from height the second most common. Traffic accidents happened most frequently in the latter part of the week during summer and fall. The use of seatbelts is unknown. The victim was most commonly the driver or a passenger in the front seat. Twenty nine par cent of the drivers were drunk. Eighty four per cent of the victims were men, most of them young. The vessel ruptured most often at the isthmus (75%). Thirty nine of the victims (68.4%) died at the scene of the accident and fifteen (26.3%) were dead on arrival to the hospital in spite of apparantly speedy ambulance services. Only three patients reached the hospital alive (5.3%). In most instances the aortic rupture was only a part of a very serious multitrauma. One aortic rupture which presented as a continuous bleeding from the left chest was successfully repaired immediately after arrival using simple clamp and sew technic. The patient made a full recovery and is well 11 years after the accident. CONCLUSIONS: The study shows that all but three (5.3%) of the cases with traumatic rupture of the thoracic aorta died at the scene of the accident or were dead upon arrival to the hospital. In most instances the aortic rupture is only a part of a most serious multitrauma. Patients with rupture of the descending aorta, without major associated injuries, who are brought quickly to the hospital can be saved by surgically repairing the artery.

Does age at the start of breast feeding influence infantile diarrhoea morbidity? A case-control study in periurban Guinea-Bissau.

Colostrum protects the newborn from intestinal infection by its content of secretory immunoglobulin A and other immediately acting factors. It may also induce maturation of the child's gastrointestinal immune defences, thus contributing to the protection against diarrhoeal disease later in infancy. To test this hypothesis, a case-control study on breast feeding and diarrhoea was carried out in a periurban community in Guinea-Bissau. The child's age at the start of breast feeding was ascertained soon after birth (n = 279). Subsequent cases of acute diarrhoea (n = 66) were identified at 3-monthly examinations, and four concurrent controls were randomly selected among attendants. Three separate estimates of association showed that the cases tended to have started breast feeding later after birth than the diarrhoea-free controls, but no single test was statistically significant. Early breast feeding might have consequences for diarrhoeal morbidity after the neonatal period.

[Cystadenoma of the pancreas. Three case reports and a review.].

Cystic neoplasms of the pancreas are pathologically divided into macrocystic and microcystic adenomas. Macrocystic adenomas are multilocular, composed of large cysts (>2 cm), with or without septa, lined with columnar mucin-producing epithelium. This type has malignant potential. The microcystic adenomas are composed of many tiny cysts (<2 cm) lined by small cuboidal cells containing glycogen but little or no mucin. This adenoma is completely benign and is therefore important to differentiate from the former. Cystadenomas represent 10-15% of cystic lesions of the pancreas. Roughly one-half of the cystadenomas of the pancreas are found to be microcystic. The remainder is accounted for by the mucinous cystic neoplasms, either macrocystic adenomas or cystadenocarcinomas. These adenomas occur most frequently in middle aged women. Upper abdominal pain and weight loss are often the presenting symptoms. An abdominal mass can often be palpated during physical examination of these patients. Ultrasound and CT of the abdomen are the most useful diagnostic tools in the evaluation of cystic lesions of the pancreas. CT can also be helpful in differentiating microcystic from macrocystic adenomas. It is possible to do a CT or ultrasound guided percutaneous aspiration for diagnosis of the lesions. This technique permits preoperative cytologic and biochemical analysis of the cyst content. Surgery however is often necessary for accurate diagnosis where the tumor is biopsied for histology. The primary pancreatic lesions to be considered in the differential diagnosis include pseudocyst, whether of inflammatory or traumatic origin, congenital cysts, ductal adenocarcinoma or islet cell tumors. Some agree that surgical resection may not be mandatory if an accurate diagnosis of microcystic adenoma can be made. Others emphasize that all pancreatic cystadenomas can have malignant potential and that total excision should be the treatment of choice. Both macrocystic adenomas and cystadenocarcino notmas have a slow and indolent course and tend to be well resectable in spite of late diagnosis. Three cases of pancreatic cystadenomas have been diagnosed in Iceland since 1972. These cases are presented here with a review of the literature.

[Laparoscopic cholecystectomies. First 100 attempted cases at Reykjavik City Hospital].

An account is given of the first 100 attempted laparoscopic cholecystectomies at Borgarspitalinn, Reykjavik City Hospital. The mean age of the patients was 48.7 years with a range of 17-86 years. Seventy seven of the patients were women and 23 men. Ten patients (10%) had acute cholecystitis but others had uncomplicated cholelithiasis. In 10 patients the operation was converted to conventional open cholecystectomy, in most cases because of acute inflammation or adhesions from previous surgery but in one case because of haemorrhage. Five patients had complications, all of which can be considered minor. There was no common bile duct injury and no mortality. No patient required reoperation. The mean operative time for the laparoscopic cholecystectomies was 102 minutes (range 50-222 minutes) and 75% of the operations were completed within two hours. The mean operative time for the first 30 laparoscopic cholecystectomies was 109.7 minutes and dropped to 94.3 minutes for the last 30. The operative time has continued to decrease with further experience. Fifty four percent of the patients who underwent laparoscopic cholecystectomies were discharged from hospital on the first postoperative day and a further 32% on the 2nd day after surgery. The hospital stay was on average four days shorter than after the conventional open cholecystectomies performed in the last months prior to commencing laparoscopic surgery. Eighty three percent of the patients were back to work or previous activity within two weeks of surgery compared to only 11.4% of patients who had undergone open cholecystectomies. Laparoscopic cholecystectomy is felt to be a safe procedure and highly cost-effective.

Age at breast feeding start and postneonatal growth and survival.

Colostrum has important anti-infective properties. It may also somehow promote the development of the child's immunological system. Discarding colostrum, as practised in some cultures, could thus have adverse health consequences beyond the neonatal period. To test this hypothesis, the age at breast feeding start of 734 healthy newborns in urban Guinea-Bissau was ascertained. The children were then prospectively followed up to 3 years of age. Eighty nine deaths occurred during the study. The probability of death in the age interval 28 days to 3 years was about 20%. The child's age at breast feeding start had no statistical impact on postneonatal growth or survival. As a single measure, early breast feeding start is not likely to make much difference for the long term growth or survival of children living under material poverty conditions.

Colostrum and ideas about bad milk: a case study from Guinea-Bissau.

The study aims to explore ideas about bad milk found among women in Guinea-Bissau. Interviews were held with 20 elderly knowledgeable rural women. Interinformant agreement was high within each ethnic group studied. All the informants recognized colostrum but disliked its consistency. Depending on ethnical background, it was considered good, of no special value or harmful to the newborn baby. Further, all the informants held that mature breast milk could turn bad, e.g. in case of mother's sickness or adultery. Suspected bad milk can be diagnosed by putting an ant into it to observe if it dies. The condition of bad milk can be treated by various procedures. The findings are discussed in relation to similar ideas existing in other societies and to views on the quality of maternal milk held in the industrialized countries. It is proposed that the idea of producing bad milk may be an important determinant of breastfeeding performance generally. Restrictions imposed on the breastfeeding woman, with the intention of producing healthier breast milk, may actually contribute to a decline in breastfeeding.

Determinants of delayed initiation of breastfeeding: a community and hospital study from Guinea-Bissau.

A prospective study on the timing of breastfeeding start in Bissau was undertaken in a periurban community (n = 734), and at the Central Hospital (n = 414). Only single, full-term, healthy children born by the vaginal route were included, the purpose being to characterize mothers who delay breastfeeding start for reasons not related to disease. Multivariate failure-time analysis (Cox' regression) was used to relate the child's age at breastfeeding start to a set of independent variables. In the community, those tending to delay breastfeeding start were mothers from the largest ethnic group in the country, mothers who had given birth at times other than the evening hours (6-12 pm) and mothers who had not attended antenatal clinics. At the hospital, delayed initiation was found among young mothers and mothers from one sparsely represented ethnic group. The most important determinant of delayed breastfeeding start was negative cultural ideas about colostrum.

PIP: In Guinea-Bissau, researchers analyzed January 1984-April 1986 data on 734 mother-infant pairs registered at health centers in the periurban settlement of Bandim and March 1984-May 1986 data on 414 mother-infant pairs at the maternity ward of the Hospital Simao Mendes in Bissau to determine when mothers begin breast feeding and learn determinants of delayed breast feeding. In Bandim, the most significant determinant of delaying breast feeding among mothers in the community study was being a member of the Balanta ethnic group, the largest technic group in the country (p=.0001). This may have been because the Balanta believe the colostrum harms the infant. Membership in the Mancanha ethnic group, the country's smallest, was a determinant of delayed breast feeding among the women in the hospital study (p=.0001). The researchers could not identify a reason for this effect among Mancanha women. Community mothers who delivered anytime before 6 pm and after midnight (p=.0001)especially between midnight and 5 am (p=.0002) and noon to 5 pm (p=.0354) tended to delay breast feeding. The 3rd determinant of delaying breast feeding among the women in the community study was no prenatal care (p=.0001). Prenatal care had no effect on delayed or early breast feeding among the women in the hospital study. Young maternal age (20 years) was another determinant of delayed breast feeding among the women in the hospital study (p=.0001). Women who delivered in 1985 in the hospital were more likely to initiate breast feeding early (p=.0001) but this was not the case in 1984 and 1986, however. Public health officials planned to sue these results to design and target education about the benefits of early initiation of breast feeding.

Cancer of the pancreas in Iceland. An epidemiologic and clinical study, 1974-85.

A retrospective study was performed of all patients diagnosed as having pancreatic cancer in Iceland during the period 1974-85 (12 years). The incidence of the disease during the period according to this study was 10.7 per 100,000 males and 9.8 per 100,000 females, with age-adjusted world standard incidences of 9.0 per 100,000 males and 6.7 per 100,000 females. A total of 301 patients were identified; adequate information could be obtained for 281 patients, and 225 (74.8%) had the diagnosis histologically confirmed. Two hundred and five patients with adenocarcinoma were accepted for detailed analysis. Of the patients with adenocarcinoma 139 (67.8%) were diagnosed at laparotomy, and 33 of them had the tumour resected, with an operative mortality of 12.1%. The cancer was located in the head of the pancreas in 102 patients (49.8%), and in 159 (77.6%) metastases were found at the time of diagnosis. The median survival time for the patients with adenocarcinoma was 95.4 days (SD +/- 11.1 days), although there were two patients in this group who were alive 5 years after diagnosis. The median survival for the total group of 281 patients was 98.3 days (SD +/- 11.0 days), although 6 of these patients lived for more than 5 years. The percentage of histologically confirmed tumours in Iceland is high compared with many previously reported studies.

Adenocarcinoma of the vermiform appendix. A population study.

We report seven cases of adenocarcinoma of the vermiform appendix occurring in Iceland during 1974-1989. The patients ranged in age from 25-83 years, mean age 55.1 years. There were five males and two females. Five had mucinous adenocarcinoma, two had adenocarcinoma. Four patients presented with symptoms and signs of acute appendicitis and all had surgically resectable disease. Three of these patients were alive with no evidence of disease four months, two years and 15 years after presentation; one death of disease occurred seven years after ileocecal resection. In three cases, the clinical presentation was that of metastatic adenocarcinoma of unknown origin. Of these patients two were diagnosed at autopsy and one after appendectomy for perforated appendicitis. Survival in this group was six weeks, three months and twelve months, respectively. In none of our patients was the diagnosis made preoperatively and no tumors were found in appendices removed incidental to other intra-abdominal operations. The incidence of adenocarcinoma of the vermiform appendix in Iceland during 1974-1989 was approximately 0.2 cases/100.000/year.