Tumours in Iceland. 10. Malignant tumours of the female breast. A histological classification, laterality, survival and epidemiological considerations.

The Icelandic Cancer Registry has records of 1,720 cases of malignant tumours of the female breast diagnosed in 1,659 patients in the 30-year period 1955-1984. Of these, 1,658 tumours were invasive. Sufficient histological material existed for 1,666 malignant tumours to make it possible to classify them according to the criteria published by the WHO. The most frequent histological type was Ductal carcinoma: 1,064 neoplasms, or 64%. Second in frequency was Lobular carcinoma: 175 neoplasms, or 10%; third was Mucinous carcinoma: 115 neoplasms, or 7%; and fourth in frequency was Medullary carcinoma: 69 neoplasms, or 4%. The incidence of carcinoma of the breast increased by 74% from 37.0 per 100,000 per annum in 1955-59 to 64.4 per 100,000 in 1980-84. This increase in incidence affected all morphological types, but Lobular and Mucinous more than Ductal and Medullary. The survival times have improved with time. Unilateral tumours were 710 in the right and 837 in the left breast. Both breasts were involved 167 times (106 patients), and in 6 patients the side was not recorded. A second primary was more likely to develop when the first one was in the right breast. This study of malignant tumours of the breast is the tenth in a series of investigations into histological classification of tumours occurring in Iceland.

Latent thyroid carcinoma in Iceland at autopsy.

The annual incidence rate of thyroid carcinoma in Iceland is high, 4.4 pr. 100,000 men, and 11.7 pr. 100,000 women, as published by the Icelandic Cancer Registry for the period 1955-1984. This rate is more than twice that in the other Nordic countries and one of the highest incidence rates reported anywhere. This led us to investigate the prevalence rate of latent thyroid carcinoma in Iceland. We serially sectioned and examined thyroid glands from 201 consecutive forensic autopsies. Altogether, sixteen carcinomas were identified in fourteen glands: fourteen papillary, one follicular and one medullary carcinoma. We conclude that the prevalence rate of latent thyroid carcinoma in each sex does not follow the frequency distribution of clinical disease, being 7.5% in males and 5.1% in females. Comparisons between populations show the same lack of consistency. Further, most, but not all, latent carcinomas of the thyroid gland are of the papillary type. These findings suggest that promoting factors might be of particular importance where incidence and mortality rates are high, but further research is needed into the role of host resistance.

The Nordic Study on schizophrenic patients living in the community. Subjective needs and perceived help.

In a community sample of 418 persons diagnosed with schizophrenia, subjective needs and perceived help was measured by the Camberwell Assessment of Need (CAN). The mean number of reported needs was 6.2 and the mean number of unmet needs 2.6. The prevalence of needs varied substantially between the need areas from 3.6% ('telephone') to 84.0% ('psychotic symptoms'). The rate of satisfaction estimated as the percentage of persons satisfied with the help provided within an area varied between 20.0% ('telephone') and 80.6% ('food'). The need areas concerning social and interpersonal functioning demonstrated the highest proportion of unmet to total needs. In a majority of need areas the patients received more help from services than from relatives, but in the areas of social relations the informal network provided substantial help. In general the patients reported a need for help from services clearly exceeding the actual amount of help received. In a linear regression model symptom load (BPRS) and impaired functioning (GAF) were significant predictors of the need status, explaining 30% of the variance in total needs and 20% of the variance in unmet needs. It is concluded that the mental health system fails to detect and alleviate needs in several areas of major importance to schizophrenic patients. Enhanced collaboration between the care system and the informal network to systematically map the need profile of the patients seems necessary to minimise the gap between perceived needs and received help.

Predictors of subjective quality of life in schizophrenic patients living in the community. A Nordic multicentre study.

As part of a Nordic multi-centre study investigating the life and care situation of community samples of schizophrenic patients the aim of the present part of the study was to examine the relationship between global subjective quality of life and objective life conditions, clinical characteristics including psychopathology and number of needs for care, subjective factors such as satisfaction with different life domains, social network, and self-esteem. A sample of 418 persons with schizophrenia from 10 sites was used. The results of a final multiple regression analysis, explaining 52.3% of the variance, showed that five subjective factors were significantly associated with global subjective quality of life, together with one objective indicator, to have a close friend. No clinical characteristics were associated with global subjective quality of life. The largest part of the variance was explained by satisfaction with health, 36.3% of the variance, and self-esteem, 7.3% of the variance. It is concluded that the actual relationship between objective life conditions and subjectively experienced quality of life still remains unclear. Furthermore, it seems obvious that personality related factors such as self-esteem, mastery and sense of autonomy also play a role in the appraisal of subjective quality of life, which implies that factors like these are important to consider in clinical and social interventions for patients with schizophrenia in order to improve quality of life for these persons.

[Death and dying - definition and determination.].

For the first half of this century there was no major dispute over the criteria for death. This was to change dramatically with major technological breakthroughs in modern medicine starting with the advent of the respirators. The consequences of their use raised serious questions about the traditional ways of diagnosing death. Today there are two different philosophical positions about what it means to be dead in terms of brain functions: One, which is not currently law in any jurisdiction, would pronounce a person dead when there is an irreversible loss of higher brain functions. This has been called cognitive death. The patient is not in a coma, because arousal mechanisms are present, the brain stem functions being relatively intact. The other philosophical position considers a person dead if there is an irreversible loss of the functions of the brain stem or the entire brain. The neurologic syndrome of brain death has been accepted by the medical profession as a distinct clinical entity that experienced physicians can diagnose with an extremely high degree of certainty, and can usually easily be distinguished from other neurologic syndromes. However, we must not lose sight of the fact that this is less a conclusion than a beginning. It is the task of philosophy to offer analyses of personhood and of personal identity that might support practical formulations for the determination of death and theology has reflected upon the meaning of death, if not its definition, from time immemorial. To define the death of a human being we must recognize the characteristics that are essential to humaneness. It is quite inadequate to limit the discussion to the death of the heart or the brain.

Causes of death in a subarctic population.

Some of the main causes of death prior to 1900 are mentioned, including disastrous epidemics of high mortality such as plague, smallpox and the so-called hunger epidemics. Also discussed are two chronic diseases remarkable for Iceland in old times i.e., leprosy and hydatid disease. In the first third of the 20th century, infectious diseases still were the main cause of death in Iceland. The importance of tuberculosis in this connection is stressed. The very high infant mortality up to the beginning of this century is stressed. The changes in the main causes of death in the last decades are described and the growing influence of degenerative vascular diseases and cancer in that connection pointed out. Last, the remarkable fall in the infant mortality and increasing life expectancy from the beginning of this century with growing prosperity of the nation is stressed.

Association between changes in psychiatric services and increases in suicide rates.

The purpose of the study is to discover whether there is an association between changes in the psychiatric services offered by the largest psychiatric hospital in Iceland during the period 1955-1978 and changes in the rate of suicide. Marked changes occurred in the services after 1965. The rate of suicide in the patient population was significantly higher during 1965-1978 than during 1955-1964. It is concluded that the changes in the psychiatric services are associated with an increase in the rate of suicide and that this increase may to some extent be a side effect of therapeutic methods introduced after 1965. The conclusion is thought to imply the necessity for further evaluation of those therapeutic methods as applied in the hospital and increasing the application of measures for the prevention of suicide.

Tumours in Iceland. 9. Malignant tumours of the ovary. A histological classification, epidemiological considerations and survival.

In the period 1955-1979, 337 patients with carcinoma of the ovary were reported to the Icelandic Cancer Registry. Sufficient histological material existed for 314 of these to make it possible to classify the tumours according to the Histological Typing of Ovarian Tumours of WHO (11). The tumour was in the right ovary in 85 and the left in another 85 patients. In 137 patients both ovaries were involved at the time of diagnosis and in 30 patients the side was not known. The most frequent tumours were the group of serous adenocarcinomas, papillary adenocarcinomas and papillary cystadenocarcinomas (IA3a), occurring in 113 patients, giving an age-standardized incidence of 4.4 per 100.000. Second in frequency was the endometrioid adenocarcinoma (IC3a1), in 58 patients, and the third the group of mucinous adenocarcinoma and cystadenocarcinomas (IB3a) in 43 patients. The fourth type in frequency was undifferentiated carcinoma (IG) in 18 patients. During the period, the overall incidence of ovarian cancer did not change. However, there was an increase in the frequency of mucinous and endometrioid types of carcinoma and a decrease in serous carcinoma. Granulosa cell carcinoma was found to have been under-reported to the Icelandic Cancer Registry. ABO blood groups for 192 of the patients were available and showed a significant excess of blood group A, with patients of blood group B significantly fewer than expected. This study of malignant tumours of the ovary is the ninth in a series of investigations into the histological classification of tumours occurring in Iceland during the 20-year period between 1955 and 1974. The tumours occurring in the period 1975-1979 were included in this particular study to increase the number available for classification.

[The role of carbon monoxide and ethanol in fire casualties: A retrospective study of carboxyhemoglobin and blood ethanol levels in fire victims].

The study included 36 fire casualties that were submitted to post-mortem pathological and toxicological examination at the Departments of Forensic Medicine and Pharmacology, University of Iceland, during the period 1971-1990. Twenty eight were males and eigth females. The mean age was 45.3 years (range 3-74 years). Carboxyhemoglobin levels ranged from 0-84%, mean 53.5% (fig. 1) and were considered fatal (> approximately 50%) in 24 cases. Fourteen victims with fatal carboxyhemoglobin levels had no significant burn injuries. Death was therefore attributed to carbon monoxide poisoning alone. In these cases carboxyhemoglobin levels (mean 65.5%, range 49-84) were lower than those found in cases of fatal car exhaust poisonings (mean 73.0%, range 47-87%) investigated by us in the same period (8). The difference was statistically significant (t-test, P<0.01). It supports the idea that combustion products, other than carbon monoxide, may contribute to the toxic effect of fires. Ethanol was found in blood in two thirds (24) of the cases. Blood ethanol levels were in the range 0.47-4.37%0 (mean 2.34%o). Blood ethanol levels and prevalence of inebriation were compared to those found in other fatal accidents investigated by us in the same period. Ethanol levels were significantly higher in the fire cases and inebriation more common than in the reference group (t-test, P<0.01; Chi-square, P<0.001, df=l). Although poisoning with carbon monoxide is of major importance in fire casualties it should not be disregarded that inebriation may often be an equally important factor. This was in fact strongly indicated by our results.

Thyroid cancer in an iodide rich area: a histopathological study.

A comparison of the incidence of the different histological types of thyroid carcinoma in an area of high dietary iodide and an area of normal iodide intake has been made. The areas chosen were Iceland and the region of Northeast Scotland centred on Aberdeen; both areas have clearly defined populations served by a single pathology laboratory. All definite and dubious thyroid carcinomas from both regions were examined and classified by the same two pathologists. The age-specific incidence rates for papillary carcinoma in surgical specimens in both areas rose with age; they were five times higher in Iceland (high iodide area) than in Northeast Scotland. The numbers of follicular carcinomas were small, and this tumor was relatively less frequent in Iceland than Aberdeen. These findings, together with the known high relative frequency of follicular carcinoma and low frequency of papillary carcinoma in areas of endemic goitre, lead to the suggestion that the incidence of papillary carcinoma and follicular carcinoma are separately influenced by dietary iodide, papillary carcinoma being high in areas of high iodide intake and low in areas with low dietary iodide. No evidence to implicate lymphocytic thyroiditis, radiation or genetic factors in the genesis of thyroid carcinoma in Iceland or Northeast Scotland was found in this study. Undifferentiated carcinoma was about three times as common in Iceland as in Northeast Scotland. Malignant lymphoma of the thyroid was suprisingly common in Northeast Scotland, possibly related to the high frequency of thyroiditis found in this region. These studies suggest that the incidence of different histological types of thyroid malignancy is influenced by different etiological factors. They also provide support for the subdivision of thyroid malignancy into these different types, and for the general importance of accurate histological typing in cancer epidemiology.

Observer variation in histologic classification of thyroid cancer.

Histologic slides of 696 cases of thyroid cancer reported to the national cancer registries of Finland, Iceland, Norway and Sweden were reviewed by 5 Nordic pathologists in order to determine the observer variation between the pathologists, as well as the reproducibility of the WHO classification of thyroid tumours. In 58% of the cases all observers agreed upon the diagnosis and in 82% at least three of them agreed. The observer disagreement was lowest for papillary carcinoma (7%) and highest for follicular carcinoma (27%). The corresponding figures for anaplastic and medullary carcinomas were 18% and 23%, respectively. The most common diverging diagnosis for cases finally interpreted as papillary carcinoma was follicular carcinoma, and for cases finally interpreted as follicular carcinoma, a benign thyroid lesion. The results of the present study clearly indicate the necessity of having all cases reviewed by the same pathologist or group of pathologists in order to obtain reliable results for comparative studies.

Reproductive factors and risk for breast cancer in Iceland.

A previous publication has shown that there has been a great increase in the incidence of breast cancer in Iceland. The present study was undertaken to evaluate the importance of known risk factors connected with the reroductive history of the women. In a prospective investigation of a cohort of 31,453 women we confirmed previous findings of the increased risk following higher age at first pregnancy and for nulliparous women. The age at first pregnancy and the proportion of nulliparous women have decreased with time in the Icelandic population so that these factors should have tended to decrease the risk, making the found increase still more important. The effect of parity is that the risk decreases with larger number of children and this effect is independent of the effect of age at first pregnancy. Lower age at menarche increases the breast cancer risk, but the contribution of that factor to the overall risk is negligible.

Incidence of different morphological types of thyroid cancer in the Nordic countries.

In order to determine the incidence of different morphological types of thyroid cancer in the Nordic countries, all cases of thyroid cancer reported to the national cancer registries of Finland, Iceland, Norway and Sweden over periods ranging from 1 to 14 years were re-examined (a total of 706 cases) by one or two pathologists from each country. The age-adjusted incidence rate for Iceland was clearly higher than those for the other Nordic countries. The rate for Finland was the lowest, and a five-fold difference was seen between Iceland and Finland. The differences in the incidence rates applied to all age groups and to both sexes. The differences also concerned all histological types and were more pronounced for papillary and medullary carcinomas. In papillary carcinoma, an almost 10-fold difference was found between Finland and Iceland. The causes of the differences are not known. There has been and probably still is some endemic goitre in Finland, Norway and Sweden, but no endemic goitre occurs in Iceland. Thus, no positive association was found between the presence of endemic goitre and the risk of follicular carcinoma. There was a marked negative association between endemic goitre and the risk of papillary carcinoma.

Living situation, subjective quality of life and social network among individuals with schizophrenia living in community settings.

OBJECTIVE: To investigate the relationships between characteristics of the living situation in the community and subjective quality of life and social network among community-based individuals with schizophrenia. METHOD: A total of 418 individuals with schizophrenia from 10 sites were interviewed with regard to quality of life, psychopathology, social network and needs for care. Characteristics of the living situation investigated were: living alone or not, living with family or not, and having an independent or a sheltered housing situation. RESULTS: An independent housing situation was related to a better quality of life concerning living situation and living with the family to a better quality of life concerning family relations. An independent housing situation was associated with a better social network regarding availability and adequacy of emotional relations. CONCLUSION: People with schizophrenia with an independent housing situation have a better quality of life associated with more favorable perceptions of independence, influence, and privacy. Their social network is better irrespective of whether they live alone or not, or with family or not.

A prospective comparative study of clinical and pathological characteristics in Icelandic and Danish patients with gastric ulcer, duodenal ulcer, and X-ray negative dyspepsia. II. Histological results.

The occurrence of gastritis in antral and body mucosa is compared in an Icelandic and a Danish group of patients with gastric ulcer, duodenal ulcer, and X-ray negative dyspepsia. In all 93 Icelandic and 88 Danish patients were examined. All signs of antral gastritis were more frequent in Icelandic than in Danish patients, but only the incidence of superficial inflammation and decreased mucus content in surface and crypt epithelium differed significantly. In body mucosa pseudopyloric metaplasia was more frequent in Iceland and occurred equally freqeuntly in all three diseases. A statistically significant correlation was found between macroscopic gastritis and occurrence of antral superficial inflammation and between smoking and superficial inflammation and decreased mucus content in the pyloric biopsy specimen. The presence of histological gastritis was not correlated to the intake of alcohol and salicylic acid, nor to the presence of pain at the time of investigation.

A prospective comparative study of clinical and histological characteristics in Icelandic and Danish patients with gastric ulcer, duodenal ulcer, and X-ray negative dyspepsia. I. Design and clinical features.

Iceland (IS) and Denmark (DK) are ethnically, culturally, and economically closely related Nordic countries, but gastric cancer is much more frequent in Iceland, and other differences in the occurrence rates of gastric diseases are also suspected. Therefore a cooperative study was initiated comparing Icelandic and Danish patients with gastric ulcer (GU), duodenal ulcer (DU), and X-ray negative dyspepsia (XND) as regards clinical features, external factors of possible importance for gastritis and cancer, gastroscopic appearance, and histological gastric mucosal changes. The project lasted one year and comprised 93 Icelandic and 88 Danish patients. A large number of comparisons showed a high degree of similarity between Icelandic and Danish patients. Significant differences were found in tobacco consumption (DK greater than IS), duration of symptoms in XND (IS greater than DK), whereas the positon ratio of GU (IS less than DK) and acetylsalicylic acid consumption (DK greater than IS) showed non-significant trends. Significant difference was found between the occurrence of diffuse macroscopic changes of the gastric mucosa (IS greater than DK), which corresponds to the histological differences to be described in a subsequent article.

Familial breast cancer in Iceland.

Women who have relatives known to have had breast cancer are at an increased risk of getting the disease compared with the general population. On the basis of an extensive collection of family trees of women with breast cancer, the magnitude of this increase in risk is computed. Previously published results on other breast cancer risk factors are drawn upon and it has been possible to take account of some of these e.g., age, decade of birth, age at first childbirth and parity in the risk estimates. The relative risk with such adjustment is found to be 2.59 for mothers and 2.56 for sisters.