Blood pressure and pulse pressure development in a population sample of women with special reference to basal body mass and distribution of body fat and their changes during 24 years.

OBJECTIVE: To study blood pressure and pulse pressure longitudinally and their association with basal and change of body mass index (BMI) and waist to hip ratio (WHR). DESIGN: A prospective population study of 1462 women in Gothenburg, Sweden, aged 38-60 y at baseline, with a longitudinal follow-up of 24 y. OUTCOME MEASURES: Incidence of hypertension, systolic and diastolic blood pressure, and pulse pressure at baseline and after 12 and 24 y of follow-up. RESULTS: Systolic and diastolic blood pressure as well as pulse pressure increased with age and turned down again at high age. BMI and WHR at baseline were each independently associated with baseline systolic and diastolic blood pressure, but only BMI with pulse pressure. However, baseline BMI and WHR were not associated with change of systolic, diastolic or pulse pressure during 12 or 24 y of follow-up. Increase in BMI during the follow-up period was associated with increase in systolic and diastolic blood pressure but not with increase in pulse pressure. There were no such associations with WHR changes which, were either unrelated or in one analysis inversely related with blood pressure changes. When considering incidence of hypertension during the first 12 y of follow-up, BMI and change in BMI were significant predictors, independent of WHR. CONCLUSION: Age, BMI and increments in BMI seem to be strong predictors for hypertension and increased systolic and diastolic blood pressure in women. In contrast, WHR plays a lesser and uncertain role in the development of hypertension in middle-aged women. Changes in BMI seem not to be accompanied by changes in pulse pressure during a long time follow-up.

Microproteinuria and long-term prognosis with respect to renal function and survival in normotensive and hypertensive women--a 24-year follow-up of a representative population sample of women in Gothenburg, Sweden.

OBJECTIVE: This study aimed to assess albuminuria and subclinical proteinuria, their association with hypertension and their role as predictors of hypertension, impaired renal function and mortality. MATERIAL AND METHODS: A baseline population study comprising 1462 women in five different age groups in Gothenburg, Sweden, was carried out in 1968-69. Comprehensive clinical examinations and laboratory tests were performed, including blood pressure measurement and an Albustix test. A systematic subsample of women additionally collected a 24 h urine sample for quantitative protein analysis. Values of urinary protein (u-protein) excretion between 80 and 300 mg/24 h were defined as microproteinuria. The results described in this paper are based on a 24-year follow-up. RESULTS: The baseline Albustix test was positive in 6.8% of 1458 women, from whom a urine sample was obtained. Of 741 baseline urine collections for u-protein excretion, 16.9% were in the microproteinuric range (80-300 mg/24 h), 1.1% in the macroproteinuric range (> 300 mg/24 h) and 82.1% in the normoproteinuric range (< 80 mg/24 h). Hypertension was more common in Albustix-positive women than in those with negative Albustix, and hypertension was also more prevalent in women with microproteinuria than in women with normoproteinuria. Neither positive Albustix nor microproteinuria was related to later renal impairment. Hypertension was associated with increased mortality in both Albustix-positive and Albustix-negative women, and in women with both normoproteinuria and microproteinuria at baseline. The mortality ratio during the follow-up period was, however, not significantly influenced by positive Albustix or by microproteinuria at baseline, in either hypertensive or non-hypertensive women. CONCLUSIONS: This study demonstrated that both a positive Albustix test and microproteinuria were associated with hypertension. Hypertension at baseline increased the risk for death during the follow-up period, while neither albuminuria, defined as a positive Albustix test, nor microproteinuria was associated with an impaired long-term prognosis with respect to renal function or survival in this cohort of Swedish middle-aged women during 24 years of follow-up. Microproteinuria in otherwise healthy normotensive or hypertensive women does not appear to impair the long-term prognosis.

Prevalence of postherpetic neuralgia after a first episode of herpes zoster: prospective study with long term follow up.

OBJECTIVE: To estimate the frequency, duration, and clinical importance of postherpetic neuralgia after a single episode of herpes zoster. DESIGN: Prospective cohort study with long term follow up. SETTING: Primary health care in Iceland. PARTICIPANTS: 421 patients with a single episode of herpes zoster. MAIN OUTCOME MEASURES: Age and sex distribution of patients with herpes zoster, point prevalence of postherpetic neuralgia, and severity of pain at 1, 3, 6, and 12 months and up to 7.6 years after the outbreak of zoster. RESULTS: Among patients younger than 60 years, the risk of postherpetic neuralgia three months after the start of the zoster rash was 1.8% (95% confidence interval 0.59% to 4.18%) and pain was mild in all cases. In patients 60 years and older, the risk of postherpetic neuralgia increased but the pain was usually mild or moderate. After three months severe pain was recorded in two patients older than 60 years (1.7%, 2.14% to 6.15%). After 12 months no patient reported severe pain and 14 patients (3.3%) had mild or moderate pain. Seven of these became pain free within two to seven years, and five reported mild pain and one moderate pain after 7.6 years of follow up. Sex was not a predictor of postherpetic neuralgia. Possible immunomodulating comorbidity (such as malignancy, systemic steroid use, diabetes) was present in 17 patients. CONCLUSIONS: The probability of longstanding pain of clinical importance after herpes zoster is low in an unselected population of primary care patients essentially untreated with antiviral drugs.

Out-of-hours service in rural areas. An observational study of accessibility, attitudes and quality standards among general practitioners in Iceland.

OBJECTIVES: To examine the access, workload, duties, commitments and quality standards of primary care physicians (GPs) resulting from out-of-hours service. SETTING: All GPs (n = 96) in rural Iceland. MAIN OUTCOME MEASURES: Answers to a postal survey. RESULTS: The participation rate was 80%. The GPs estimated that in 97% of the cases they could be contacted within 5 minutes in an emergency. Under usual circumstances (weather conditions) and within a distance of 10 km, 70% of them could reach the patient within 30 minutes of receiving the call. In severe weather conditions, 50% of the GPs in smaller districts (650-6000 inhabitants) estimated that it could take up to 5 hours or more to reach the patient (which could happen once a year). In the least populated districts, 84% of the GPs had to be on call 14 days or more per month. Serious emergencies (involving special training such as cardiac resuscitation or tracheal intubation) were relatively rare, and GPs expressed the necessity for regular refresher courses in such fields. CONCLUSIONS: Modern telecommunication networks guarantee good access to out-of-hours service. The workload and on-call duties are great and do not comply with European Union (EU) recommendations regarding minimal rest time. If GPs in rural areas are to be expected to provide frontline health care, including in severe emergency situations, regular training courses are needed.

Urinary tract infections, antibiotic resistance and sales of antimicrobial drugs--an observational study of uncomplicated urinary tract infections in Icelandic women.

OBJECTIVES: To analyse the antimicrobial susceptibility pattern of bacteria causing symptomatic but otherwise uncomplicated lower urinary tract infections (UTI) in primary health care and the sales of antimicrobial drugs. SETTING: Primary health care in Akureyri District, Northern Iceland, with about 17400 inhabitants. PATIENTS: A total of 516 episodes of symptomatic but otherwise uncomplicated lower UTI in women 10 to 69 years of age. MAIN OUTCOME MEASURES: Number of verified UTI, bacterial species, antimicrobial susceptibility pattern, and total sales of antimicrobial drugs. RESULTS: Escherichia coli was by far the most common cause of UTI (83%), followed by Staphylococcus saprophyticus (7%). Infections caused by E. coli resistant to ampicillin accounted for 36% of cases, with the corresponding figures for sulfafurazol being 37%, cephalothin 45%, trimethoprim 13% and mecillinam 14%. Only 1% of the strains were resistant to nitrofurantoin. The total use of antimicrobial drugs was 17.4 DDD/1000 inhabitants/day. CONCLUSIONS: The resistance of bacteria causing uncomplicated UTI to common antimicrobials is high and must be taken into account when selecting treatment strategies. High consumption of antibiotics in the community indicates possible association.

Indicators of health and well-being in Iceland and Sweden. A comparative study of various indicators concerning standards of living and mortality.

OBJECTIVE: To study various indicators concerning health and well-being in two Nordic countries with special attention to standards of living and mortality. DESIGN: Comparative study of the mortality rates from various causes of death during the years 1983-1992 and some indicators of standard of living derived from official reports and registers in Iceland and Sweden. SETTING, SUBJECTS: The total populations of Iceland and Sweden. MAIN OUTCOME MEASURES: Mortality rates, indicators of living standard, gross domestic product and demographic variables such as divorces and unemployment. RESULTS: The mortality rates for all causes of death were similar for women in Iceland and Sweden during 1983-1992 but were lower for men in Iceland than in Sweden. The mortality rates from cardiovascular diseases decreased during the study period. The rates for malignant disease were higher in Iceland for both men and women. Iceland has a larger population growth but a much lower population density. Most of the demographic variables were similar in the two countries. Unemployment rates were higher in Sweden. CONCLUSION: In spite of large similarities between Iceland and Sweden in socio-demographic variables there are substantial differences in mortality rates between the countries. The causes for these mortality differences are obscure and should be further investigated.

Adverse reactions to food and food allergy in young children in Iceland and Sweden.

OBJECTIVE: To investigate the prevalence of adverse reactions to food and food allergy in Icelandic and Swedish 18-month-old children. DESIGN: Prospective multicentre comparative study. SETTING: Primary health care centres in Sweden and Iceland. SUBJECTS: A total of 324 children in Iceland and 328 in Sweden who attended for regular 18-month check-up. MAIN OUTCOME MEASURES: Adverse reaction to food according to questionnaire, and food allergy according to skin prick tests and double blind food challenge tests. RESULTS: Adverse reactions to food were reported in 27% of children in Iceland and 28% in Sweden. Food allergy was confirmed in 2.0% in both countries. Allergy among other family members was reported in 45% of the Icelandic children and 62% in the Swedish (p < 0.001). Indoor smoking was reported by 30% of the Icelandic families and 3% of the Swedish. Respiratory infections were reported significantly more often in Icelandic children than Swedish. CONCLUSION: Adverse reactions to food and food allergy were similar in Icelandic and Swedish children. At the age of 18 months one can expect to confirm food allergy in approximately one out of 15 children with reported adverse reactions to food.

[Referrals to specialists: evaluation of general practitioners' need for assistance from specialists in other fields.].

OBJECTIVE: To examine prospectively the longterm pattern of referrals of one family practitioner. MATERIAL AND METHODS: Over a period of 8.5 years (1989-1998), the referral process of one general practitioner (GP) during his daytime practice in the Akureyri district (inhabitants around 17,000), Iceland, was examined. In this area there were 11 GPs working at the Community Health Centre, and 40 specialists, most of whom were based at the Community Hospital or working as consultants in their pri-vate practice. RESULTS: In the 8.5 year period one GP (one of the authors, HThornS) had 40,634 patient encounters with 8,463 persons (4.7 encounters per person). Of those, 24,952 (61%) were office visits by 7,208 persons (3.5 visits per person). A total of 1672 patients were referred to a specialist, of whom 215 were emergency cases. The number of referrals was 41 per 1000 total encounters, and 67 of 1000 office encounters. There were 1613 (96.5%) completed written responses from the specialists. Most were referred to internists (28%), orthopaedists (16%), general surgeons (12%), ear, nose and throat specialists (11%), paediatrists (8%) and gynaecologists (8%). Of those referred to internists, 43% were referred to gastroenterologists and 25% to cardiologists. There were 339 referrals for patients younger than 16 years (54% boys). Of those, 41% were referred to paediatrists, 26% to an ear, nose and throat specialists, 9% to orthopaedists and 7% to surgeons. CONCLUSIONS: The use of a written referral works well in Akureyri. Information on the number and types of referrals could be useful for determining the appropriateness for allocations and future development of speciality resources in each area. It could also serve as a method to help family practitioners choose areas of their continuous medical education.

Alcohol habits in Swedish women: observations from the population study of women in Gothenburg, Sweden 1968-1993.

In a prospective population study of women in Gothenburg, Sweden, three examinations were conducted with 12-year intervals between 1968-1969 and 1992-1993. There were 1462 participants aged 38-60 years in the baseline study in 1968-1969, with a participation rate of 90.1%. This paper describes longitudinal changes and secular trends with respect to women's alcohol habits. An alcohol frequency questionnaire was validated at baseline and was re-administered at all examinations. Between 1968-1969 and 1980-1981, the proportion of alcohol abstainers decreased significantly both in 38-year-old and 50-year-old women. Women reporting alcohol intake at least once per week had higher socio-economic status and higher education than other women. Serum gamma-glutamyl transpepsidase concentration was higher in women with the heavier alcohol intake, while a number of potential cardiovascular risk indicators were higher in women with the lower intake. Daily intake of wine and spirits was about as common at all three examinations, whereas moderate intake of wine and spirits was more common in 1980-1981 and 1992-1993 than in 1968-1969. There seemed to be an increase in overall consumption of alcohol, mainly due to the increase in moderate drinking, but there was no indication of a large increase in heavy consumption of alcohol.

Herpes zoster in children and adolescents.

OBJECTIVES: To follow the clinical course of herpes zoster and to determine the incidence, frequency of complications and association with malignancy in children and adolescents. DESIGN: Prospective cohort study in a primary health care setting in Iceland. The main outcome measures were age and sex distribution of patients and discomfort or pain 1, 3 and 12 months after the rash and general health before and 3 to 6 years after the zoster episode. RESULTS: During observation of the target population for a period of 75750 person years, 121 episodes of acute zoster developed (incidence 1.6/1000/year) in 118 patients. End points were gained for all 118 patients after 554 person years of follow-up. Systemic acyclovir was never used. No patient developed postherpetic neuralgia, moderate or severe pain or any pain lasting longer than 1 month from start of the rash (95% confidence interval, 0 to 0.03). Potential immunomodulating conditions were diagnosed in 3 patients (2.5%) within 3 months of contracting zoster. Only 5 (4%) had a history of severe diseases. CONCLUSIONS: The probability of postherpetic neuralgia in children and adolescents is extremely low. Zoster is seldom associated with undiagnosed malignancy in the primary care setting.

Bacteriuria in a population sample of women: 24-year follow-up study. Results from the prospective population-based study of women in Gothenburg, Sweden.

The aims of the study were to estimate the prevalence of bacteriuria in a female urban population, to follow up the same population over the years, and to relate bacteriuria to long-term prognosis with respect to mortality and kidney disease. The study was based on a randomly selected population sample comprising 1462 women aged 38-60 years at entrance to the study in 1968-69 with an initial participation rate of 90.1%. Bacteriuria was observed in 3-5%, increasing with age, and most often asymptomatic. Bacteriuria on one occasion meant increased risk of having bacteriuria 6 and 12 years later. The percentages of different types of bacteria and the resistance pattern were similar initially and at follow-up studies after 6 and 12 years. There were no differences in mortality or incidence of severe kidney disease during a 24-year follow-up between those with and those without bacteriuria in the baseline study.

Acute bronchitis in adults. How close do we come to its aetiology in general practice?

OBJECTIVE: To investigate how close we can come to the aetiology of acute bronchitis in adults in a primary care setting. DESIGN: Prospective study. SETTING: General practice population in Gardabaer district, south-western Iceland. SUBJECTS: 140 patients > or = 16 years old who were diagnosed as having acute bronchitis during a two-year period (1992-1993). MAIN OUTCOME MEASURES: Laboratory investigations (twice with a minimum four-week interval), used in general practice to analyse respiratory tract infections. They included serology for Chlamydia pneumoniae, Mycoplasma pneumoniae, respiratory tract viruses, and the level of C-reactive protein. RESULTS: Of a total of 140 patients, two blood samples were taken on scheduled time in 113 patients. Serology confirmed recent infection in 18 (16%) of these patients. Only two (2%) had a bacterial infection (one C. pneumoniae, one M. pneumoniae). The others (84%) did not have a significant increase in antibody titres. Only four (4%) had C-reactive protein levels higher than 48 mg/l. CONCLUSIONS: The study indicates that it is difficult to come close to a precise aetiology with respect to infectious agents of acute bronchitis in general practice. We conclude that the disease is rarely caused by atypical bacteria such as C. pneumoniae and M. pneumoniae, and rarely caused by bacterial infections severe enough significantly to increase the level of C-reactive protein.

[Out of hours service in the Icelandic primary health care sector: an observational study.].

BACKGROUND: Decisive changes have occurred in out of hours service in recent years, prompted by technological and methodological progress, improved communications and public demand. Concurrently, physicians' leisure time has come under increasing pressure. AIMS: To examine the workload, duties and com notmitments of primary care physicians (GPs) resulting from out of hours service. Further, to assess the organisation and quality of out of hours service and possible differences between urban and rural areas. MATERIAL AND METHODS: A postal survey containing 58 questions was sent to all primary health care physicians holding posts for at least six months on March 1st 1996. Of a total of 143 GPs, answers were returned from 100 (70%). RESULTS: All GPs on call (100%) were equipped with radios, mobile phones or pagers. They estimated that in 95% of the cases they could be contacted within five minutes jn an emergency. In an emergency and bad weather conditions 82% of doctors in urban areas could attend their patients within 30 minutes, and 100% within 60 minutes. Similar figures for rural areas were 10% within 30 minutes and 18% within 60 minutes. In the least populated districts 84% of the practitioners had to be on call 14 days or more per month. Serious emergencies (involving special training such as cardiac resuscitation or tracheal intubation) were relatively rare, and GPs expressed the necessity for regular refreshing courses in such fields. CONCLUSIONS: Access to doctors is good in this country. Workload and on-call duties are significantly heavier here than abroad, to some extent owing to outdated organisation. Various possibilities exist for improvement in the quality and reliability of out of hours service, but to be effective they must be supplemented by professional counselling and support, and facilities for further training in these fields.

[Hypnotics and tranquillisers. Patients' knowledge and attitudes.].

OBJECTIVE: To elicit patients' views and attitudes towards the use of hypnotics and tranquillisers and their knowledge about such drugs and household remedies. MATERIAL AND METHODS: During 1986-1993 a total of 577 individuals in Egilsstaethir district (3029 inhabitants) had used sedatives and/or tranquillisers. Out of this group a stratified randomised sample composing 208 individuals, received a questionnaire with 22 or 24 questions about the use of tranquillisers and hypnotics. RESULTS: The mean age was 55.1 years for users of tranquillisers, 60.1 years for the users of hypnotics. Women were in majority in both groups, most of them were married and working outside the home. Users of tranquillisers were divided into two main categories i.e. daily users and occasional users. Only a few used tranquillisers two or three times daily. Many used tranquillisers only as sleeping medicine. A fourth of the participants began using hypnotics after sleeping problems of less than one month. Doctors usually prescribed the medicines the first time they were used. 55% have tried household remedies against anxiety and sleeping problems. A majority had tried to stop using these medicines. Feelings of guilt because of the use of medicines was not common. Participants were well informed about how much sleep is needed. CONCLUSION: Our results show that most of the patients in the research area had gripped their doctors' message regarding sleeping problems, health promotion and the risk of addiction after continuous use of hypnotics and tranquillisers. It is however likely, that more education in this direction can further increase health promotion and minimise the use of drugs.

What attendance rate can be achieved for Pap smear screening? A case-control study of the characteristics of non-attenders and results of reminder efforts.

OBJECTIVE: To understand participation failures in a national Pap smear screening programme by studying characteristics of non-attenders and results of further reminder efforts. DESIGN: A case-control and an intervention study. SETTING: The community health centre in the town of Hafnarfjördur, Iceland. SUBJECTS: The target population comprised 2510 women aged 35-69, who were invited regularly every second year for cervical cancer screening. MAIN RESULTS: 2241 (89.3%) had attended screening during the preceding five years, 102 (4.1%) had never attended, and 167 (6.7%) had attended previously but not during the preceding five years. Women with a mental disorder and those who had never married were more likely not to attend. The most usual explanations given by non-attenders were that they did not like to participate, or they felt they did not need to, some of them because their uterus had been removed. Of the non-attenders 29 (10.8%) came for a Pap smear after repeated reminding efforts. CONCLUSIONS: Total participation rate in cervical cancer screening programmes in Iceland is high. When efforts are taken to lower the non-attendance rate it has to be kept in mind that many women are unwilling or unable to participate in such preventive measures.

Do antimicrobials increase the carriage rate of penicillin resistant pneumococci in children? Cross sectional prevalence study.

OBJECTIVE: To study the correlation of antimicrobial consumption with the carriage rate of penicillin resistant and multiresistant pneumococci in children. DESIGN: Cross sectional and analytical prevalence study. SETTING: Five different communities in Iceland. MAIN OUTCOME MEASURE: Prevalence of nasopharyngeal carriage of penicillin resistant pneumococci in children aged under 7 years in relation to antibiotic use as determined by information from parents, patient's records, and total sales of antimicrobials from local pharmacies in four study areas. RESULTS: Total antimicrobial sales for children (6223 prescriptions) among the four areas for which data were available ranged from 9.6 to 23.2 defined daily doses per 1000 children daily (1.1 to 2.6 courses yearly per child). Children under 2 consumed twice as much as 2-6 year olds (20.5 v 10.9 defined daily doses per 1000 children daily). Nasopharyngeal specimens were obtained from 919 children, representing 15-38% of the peer population groups in the different areas. Pneumococci were carried by 484 (52.7%) of the children, 47 (9.7%) of the isolates being resistant to penicillin or multiresistant. By multivariate analysis age (< 2 years), area (highest antimicrobial consumption), and individual use of antimicrobials significantly influenced the odds of carrying penicillin resistant pneumococci. By univariate analysis, recent antimicrobial use (two to seven weeks) and use of co-trimoxazole were also significantly associated with carriage of penicillin resistant pneumococci. CONCLUSIONS: Antimicrobial use, with regard to both individual use and total antimicrobial consumption in the community, is strongly associated with nasopharyngeal carriage of penicillin resistant pneumococci in children. Control measures to reduce the prevalence of penicillin resistant pneumococci should include reducing the use of antimicrobials in community health care.

Health problems in family practice. An Icelandic multicentre study.

OBJECTIVE: To establish epidemiological data on the health problems within family practice in Iceland by multicentre analysis of well-defined geographic areas. DESIGN: Prospective practice audit. SUBJECTS AND SETTINGS: Thirteen Icelandic health centres (HC) with computerized contact data from 1 January - 31 December 1988. MAIN OUTCOME MEASURES: Health problems during one year in a population, as perceived by health care providers. RESULTS: A total of 176 384 health problems during one year in a population of 31 248, as perceived by the health care provider, were analysed. Musculoskeletal disorders accounted for 9.3% of all health problems (prevalence 210.6/1000 inhabitants), respiratory disorders 9.4% (189.9/1000), accidents 7.4% (203.2/1000), cardiovascular disorders 7.4% (112.0/1000) and mental disorders 6.1% (87.6/1000). The commonest single health problems were: hypertension, upper respiratory tract infections and non-articular rheumatism. The health problems accounting for the most frequent contacts were: mental disorders (4.0 contacts per individual per year), cardiovascular (3.7), and endocrine, nutrition and metabolic (3.2). CONCLUSION: Problem-oriented medical records from HCs, computerized in a uniform standardized way, can give extensive information about the content and burden of health problems in family practice and presumably public health. Our results are valuable because the population (the denominator) and the geographic study area are well defined. This information is an important part of clinical epidemiology and can be of great value for educators and health care planners.

Breast-feeding in Iceland. Predictive factors and effects of interventive measures.

The aim of this study was to analyse how long babies born in Akureyri district in 1990 were breast-fed, compared with babies born in 1985. Possible predictive factors for the length of breast-feeding were studied by univariate and multivariate analyses. From 1985 to 1990, the proportion of infants exclusively breast-fed at the age of 3 months increased from 57% to 70% (p < 0.01) and for those breast-fed exclusively or partially, from 67% to 83% (p < 0.01). By 1990, 64% of all babies were breast-fed at the age of 6 months, compared with 43% in 1985 (p < 0.01). The factor with the strongest correlation with a long breast-feeding period was a well educated father. Other factors correlated with the duration of breast-feeding were the mother's age, number of previous children, attending a maternity course, and being a non-smoker. It is concluded that real beneficial changes regarding the duration of breast-feeding in Iceland have been observed during the last decade, but the objectives of the preventive measures recommended by health authorities have not yet been reached.