Warfarin is associated with higher rates of epistaxis compared to direct oral anticoagulants: A nationwide propensity score-weighted study.

BACKGROUND: Although epistaxis is one of the most common side effects of oral anticoagulation, it is unclear whether epistaxis rates vary between different oral anticoagulants (OAC). OBJECTIVE: To compare rates of clinically relevant epistaxis between OAC. METHODS: Epistaxis event rates were compared between new users of apixaban, dabigatran, rivaroxaban, and warfarin in a nationwide population-based cohort study over a 5-year study period, 2014-2019. Data was collected from the Icelandic Medicine Registry and the five major hospitals in Iceland. Inverse probability weighting (IPW) was used to yield balanced baseline characteristics, and epistaxis rates were compared using Kaplan-Meier survival estimates and Cox regression. RESULTS: During the study period, 2098 patients received apixaban, 474 dabigatran, 3106 rivaroxaban, and 1403 warfarin. In total, 93 patients presented with clinically relevant epistaxis, including 11 (12%) major epistaxis events and one fatal epistaxis episode. Furthermore, seven patients (9%) with non-major epistaxis later presented with major bleeding during the follow-up period. Warfarin use was associated with higher rates of epistaxis compared to apixaban (2.2 events per 100-person years (events/100-py) vs. 0.6 events/100-py, hazard ratio [HR] 4.22, 95% confidence interval [CI] 2.08-8.59, p < 0.001), rivaroxaban (2.2 events/100-py vs. 1.0 events/100-py, HR 2.26, 95% CI 1.28-4.01, p = 0.005), and dabigatran (2.2 events/100-py vs. no events, HR n/a, p < 0.001). CONCLUSION: Warfarin treatment was associated with higher rates of clinically relevant epistaxis compared to direct oral anticoagulants.

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

BACKGROUND: Tracheostomies are commonly utilized in ICU patients due to prolonged mechanical ventilation, upper airway obstruction, or surgery in the face/neck region. However, practices regarding the timing of placement and utilization vary. This study provides a nationwide overview of tracheostomy utilization and outcomes in the ICU over a 14-year period. METHODS: A retrospective study including all patients that received a tracheostomy during their ICU stay in Iceland between 2007 and 2020. Data were retrieved from hospital records on admission cause, comorbidities, indication for tracheostomy insertion, duration of mechanical ventilation before and after tracheostomy placement, extubation attempts, complications, length of ICU and hospital stay and survival. Descriptive statistics were provided, and survival analysis was performed using Cox regression. RESULTS: A total of 336 patients (median age 64 years, 33% females) received a tracheostomy during the study period. The most common indication for tracheostomy insertion was respiratory failure, followed by neurological disorders. The median duration of mechanical ventilation prior to tracheostomy insertion was 9 days and at least one extubation had been attempted in 35% of the cases. Percutaneous tracheostomies were 32%. The overall rate of complications was 25% and the most common short-term complication was bleeding (5%). In-hospital mortality was 33%. The one- and five-year survival rate was 60% and 44%, respectively. CONCLUSIONS: We describe a whole-nation practice of tracheostomies. A notable finding is the relatively low rate of extubation attempts prior to tracheostomy insertion. Future work should focus on standardization of assessing the need for tracheostomy and the role of extubation attempts prior to tracheostomy placement.

Salivary gland tumours in Iceland 1986-2015: a nationwide epidemiological analysis over a 30-year time period.

Salivary gland tumours (SGT) are a vast and heterogenous group of neoplasms. There is a relative lack of comprehensive nationwide epidemiological studies on the subject. The aim of this nationwide analysis was to gain insight into epidemiological traits, such as site, incidence and histological subtypes of SGT in general. Patients diagnosed with a primary SGT between 1986 and 2015 were identified from The Icelandic Cancer Registry and registries from all pathology departments in Iceland. Information on age, sex, tumour location and histology was retrieved from pathology reports. A total of 687 patients were diagnosed with a SGT, 609 (89%) were benign and 78 (11%) malignant. 9% of parotid gland tumours, 22% of submandibular gland tumours and 26% of minor SGT were malignant. The most common malignant tumours were mucoepidermoid carcinoma, acinic cell carcinoma and adenoid cystic carcinoma. The incidence of benign SGT was 4.9 per 100 000 among men and 7.0 per 100 000 among women. The incidence of malignant tumours was 0.59 per 100 000 for men and 0.79 per 100 000 for women. The proportion of malignant SGT is lower than most often reported. Only 10% of parotid gland tumours, 20% of submandibular gland tumours and 25% of minor salivary gland tumours are malignant.

[Evaluation of a thyroid nodule].

Thyroid nodules are common and their incidence has increased due to various factors. Systematic approach to the work-up of thyroid nodules is necessary to decrease overdiagnosis as well as over treatment. Applying the trifecta of history, physicial examination and high-resolution ultrasound (HRUS) as well as fine needle aspiration biopsy (FNAB) with added TSH measurement is important in the work-up. HRUS is a central part in the diagnostic approach, being able to risk classify nodules and selecting nodules for FNAB. Systematic analysis of aspirates is necessary to simplify communication between cytologists and clinicians. 1Department of Otolaryngology - Head and Neck Surgery, Landspitali, Fossvogi, 2Department of Medicine, University of Iceland. Key words: thyroid nodule, thyroid cancer, ultrasound, cytology Correspondence: Geir Tryggvason, geirt@lsh.is.

Hearing in older adults with exfoliation syndrome/exfoliation glaucoma or primary open-angle glaucoma.

PURPOSE: To determine whether adults, aged 66-96 years, with exfoliation syndrome (XFS)/exfoliation glaucoma (XFG), or primary open-angle glaucoma (POAG) have poorer hearing than controls of similar age. METHODS: Case (XFS/XFG and POAG) and control status was diagnosed in the Reykjavik Glaucoma Studies (RGS) using slit-lamp examination, visual field testing and optic disc photographs; the RGS data were merged with the Age, Gene/Environment Susceptibility-Reykjavik Study that collected hearing data using air-conduction, pure-tone thresholds obtained at 0.5, 1, 2, 3, 4, 6 and 8 kHz categorized by better ear and worse ear, based on pure-tone averages (PTAs) calculated separately for low and middle frequencies (PTA512 - mean of thresholds at 0.5, 1 and 2 kHz) and high frequencies (PTA3468 - mean of thresholds at 3, 4, 6 and 8 kHz). Multivariable linear regression was used to test for differences in PTAs between cases and controls. RESULTS: The mean age for 158 XFS/XFG cases (30.4% male) was 77.4 years, 95 POAG cases (35.8% male) was 77.9 years, and 123 controls (46.3% male) was 76.8 years. Using multivariable linear regression analysis, there were no consistent, statistically significant differences in PTAs between the two case groups and controls in either the low- or high-frequency range, even when stratified by age group. CONCLUSION: Among the older individuals examined in this study hearing loss is highly prevalent and strongly associated with male gender and increasing age. As we did not find consistent statistically significant difference in hearing between cases and controls the diagnosis of XFS/XFG or POAG does not as such routinely call for audiological evaluation.

Epithelioid angiomyolipoma of the liver: case report and review of the literature.

Hepatic angiomyolipoma is a rare tumor. Here we describe a case and review the literature.

Accuracy of fine-needle aspiration and imaging in the preoperative workup of salivary gland mass lesions treated surgically.

OBJECTIVES/HYPOTHESIS: Fine-needle aspiration (FNA) biopsy and imaging are commonly used in the preoperative assessment of salivary gland mass lesions. The goal of this retrospective study was to clarify the role of FNA and imaging in the workup of salivary gland masses. STUDY DESIGN: Retrospective cohort study. METHODS: A computer search identified patients with an FNA of a salivary gland lesion with subsequent excision during a 10-year study period. Chart review of study patients was performed, and information on site of lesion, age, gender, radiologic diagnosis, pain in the tumor area, and facial paralysis was recorded and analyzed. RESULTS: There were 543 patients who had an FNA and subsequent histopathology. The majority of the tumors were in the parotid gland (n = 492, 90.9%), followed by submandibular gland (n = 45, 8.3%). The incidence of malignancy across all sites was 29.7%. The mean patient age was 54.1 years, and 54.1% were female. The sensitivity and specificity of FNA were 85.7% and 99.5%, respectively. Positive predictive value (PPV) was 98.6%, and negative predictive value (NPV) was 94.3%. A total of 464 patients had available radiologic studies. For the radiological diagnoses, sensitivity was 81.8% and specificity was 67.3%, whereas PPV and NPV were 52.7% and 89.3%, respectively. CONCLUSIONS: FNA is a reliable method of preoperatively assessing both benign and malignant salivary gland lesions. Preoperative imaging has a lower sensitivity and specificity than FNA in differentiating malignant from benign tumors. Older age, pain, and facial paralysis are clinical features independently associated with malignancy.

Epidemiology of sebaceous carcinoma of the head and neck: implications for lymph node management.

BACKGROUND: The purpose of this study was to describe the incidence of nodal disease in sebaceous carcinoma and its impact on survival. METHODS: Data from the 17 registries of the Surveillance, Epidemiology, and End Results (SEER) database was retrospectively collected for sebaceous carcinoma from 1973 to 2007. Information on location, histologic grade, stage of disease, and survival was gathered. RESULTS: One thousand eight hundred thirty-six sebaceous carcinomas were diagnosed during the time period: 633 (34.5%) in the eyelid and 786 (42.8%) in the extraocular head and neck skin. Eyelid sebaceous carcinomas had higher histologic grade compared with tumors in extraocular sites (p < .001). Ocular sebaceous carcinomas had a higher incidence of regional or distant metastases at presentation (4.4%) compared with extraocular head and neck sites (0.9%; p = .03). There was a high incidence of N+ disease in poorly differentiated ocular sebaceous carcinomas (15.2%). CONCLUSION: The incidence of nodal disease was higher with eyelid tumors. Sentinel lymph node biopsy can be considered for eyelid tumors, but not for non-eyelid head and neck tumors.

Radiographic association of schwannomas with sensory ganglia.

OBJECTIVE: Clinical experience suggests that the majority of schwannomas arise within sensory ganglia, suggesting that intraganglionic glial cells represent a potential cell of origin for schwannomas. To support this clinical impression, we reviewed magnetic resonance imaging (MRI) studies performed over a 5-year period at our institution to determine the relationship of cranial and spinal nerve schwannomas with the ganglia of the associated nerves. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: Patients undergoing imaging study at our institution over a 5-year period. INTERVENTION(S): Radiographic images at our institution were reviewed as well as published studies to determine the anatomic location of schwannomas. MAIN OUTCOME MEASURE(S): Anatomic location of schwannomas. RESULTS: A total of 372 patients were found over the 5-year study period, 31 of those were diagnosed with neurofibromatosis Type 2 (NF2). Vestibular schwannomas comprised the greatest number of schwannomas, followed by spinal schwannomas. In NF2 patients, spinal schwannomas were the most common tumor, followed by vestibular schwannomas. In NF2 patients and those with sporadic schwannomas, the overwhelming majority of tumors arose in nerves with a sensory component and were associated with the sensory ganglia of the nerves (562/607, 92.6%). Very few tumors arose from pure motor nerves. This is supported by review of published articles on anatomic location of schwannomas. CONCLUSION: Schwannomas are strongly associated anatomically with the ganglia of sensory nerves. These findings raise the possibility that intraganglionic glial cells give rise to the majority of schwannomas.

Tyrosine kinase mutations in gastrointestinal stromal tumors in a nation-wide study in Iceland.

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. It is characterized by activating mutations in the tyrosine kinase genes c-kit or PDGFRA. This study examined the mutation rate and type in a population-based material. All gastrointestinal mesenchymal tumors over the years 1990-2004 were evaluated and GIST tumors identified using immunohistochemistry (c-kit) and conventional pathologic parameters. Paraffin sections from all tumors were subjected to mutation analysis on exons 9, 11, 13 and 17 of the c-kit gene and exons 12 and 18 of the PDGFRA gene. To screen for mutations, we used a highly sensitive conformation-sensitive gel electrophoresis (CSGE) and to define the mutated alleles, we employed direct automated DNA sequencing. All c-kit-positive gastrointestinal mesenchymal tumors were entered into the study. Fifty-six tumors from 55 patients were analyzed. Mutations were found in 52 tumors representing a 92.9% mutational rate. Most of the mutations were found in c-kit exon 11 (76.8%), followed by c-kit exon 9 (10.7%). PDGFRA mutations were only found in three tumors. No correlation of mutation type with biologic behavior was found. This population-based study, using a sensitive CSGE method, identifies mutations in the great majority of patients with GIST.

[Head and neck squamous cell cancer]. / Flöguthekjukrabbamein á höfud- og hálssvaedi.

Head and neck squamous cell carcinoma (HNSCC) is relatively common and is strongly related to smoking and alcohol consumption but infection by human papillomavirus has also emerged as a risk factor for HNSCC. The treatment of these tumors is complicated and patients are best served by a multidisciplinary team. The therapy now commonly involves a multidisciplinary approach including surgery, radiation treatment and chemotherapy. Lower stage disease carries a relatively good prognosis. The treatment of metastatic HNSCC remains unsatisfactory and the prognosis of these patients is poor.

Clinical study on gastrointestinal stromal tumors (GIST) in Iceland, 1990-2003.

This is a whole population-based study on clinical symptoms, surgical treatment, and outcome of GIST. All mesenchymal tumors in the digestive tract diagnosed from 1990 to 2003 were identified. All reports were reviewed, all tumors were stained with antibodies to c-kit, and the diagnosis of GIST was confirmed. Clinical, pathological, treatment, and outcome data were analyzed. The study included 53 patients with GIST. The mean age at diagnosis was 65.8+/-13.6 years (SD). Tumor distribution included 62% in the upper, 32% in the middle, and 6% in the lower digestive tract. Mean tumor size was 4.9+/-4.4 cm (SD). Gastrointestinal (GI) bleeding was the main symptom in 53% (20/38) of symptomatic cases; most presented with acute gastrointestinal bleeding. Complete surgical resection was performed in 87% (46/53) of patients. Eight of the 53 tumors (15.1%) metastasized, 7 of which were nongastric. The disease-specific death rate at 5 years was 85%, and 5-year survival after complete resection was 64.1%. We conclude that GISTs are often found incidentally but GI bleeding is the most common presentation. Five-year survival is better than previously reported and gastric GIST seems to be more benign than nongastric. GIST seems to metastasize mainly intra-abdominally.

[Gastrointestinal Stromal Tumour (GIST). Case report]. / Strómaaexli í meltingarvegi.

In 1987 a 73 year old man was diagnosed with a malignant sarcoma of the anus. It was originally regarded as a leiomyosarcoma. Fourteen years later the original diagnoses of the specimen was reviewed and the diagnosis was changed to GIST (gastrointestinal stromal tumour). This diagnosis was confirmed with appropriate immunohistochemical staining on the tumour tissue. This is the first case of GIST in the anus diagnosed in Iceland.

Gastrointestinal stromal tumors in Iceland, 1990-2003: the icelandic GIST study, a population-based incidence and pathologic risk stratification study.

Gastrointestinal stromal tumor (GIST) is a newly defined clinical and pathologic entity. This study examines the whole population-based incidence of GIST as well as pathologic risk stratification schemes. All patients diagnosed in Iceland with a gastrointestinal mesenchymal tumor over the years 1990-2003 were evaluated with an immunohistochemical panel including staining for c-kit. The age-adjusted incidence of GIST was calculated. Size, mitotic rate per 50 HPF and various other pathologic parameters were evaluated. Each tumor was categorized into 1 of 4 recently defined NIH risk stratification categories. Fifty-seven of the mesenchymal gastrointestinal tumors were positive for c-kit and therefore categorized as GIST. The annual incidence for the study period is 1.1 per 100,000. The median age of patients was 65.8 years and median tumor size was 4.6 cm. Only 2 of 35 gastric tumors fall into the NIH high-risk category while half of the nongastric tumors (11 of 22) fall into this high-risk category. Eight of the 57 tumors (14%) metastasized, 7 of which were nongastric. The positive predictive value for malignant behavior of the high-risk category is 46%. The negative predictive value of low- and very-low-risk NIH category is 100%. Pathologic predictors of malignant behavior are tumor size, mitotic rate, mucosal disruption, necrosis and high cellularity. Nongastric GISTs are clearly at much higher risk of a malignant behavior than gastric GISTs. This population-based GIST study estimates the incidence of GISTs at 1.1 per 100,000 and furthermore supports the NIH consensus categories for the prediction of malignant behavior of GISTs.

[Public comprehension of medical terminology.].

The quality of doctor-patient communication is critical for the practice of medicine. Studies show that effective communication results in patient satisfaction and improved compliance. To better understand one aspect of this complex phenomenon we estimated the ability of people to comprehend 11 commonly used medical terms. We used multiple choice questions in a telephone survey of 1167 Icelanders aged 16-75 years. Results (% of participants with correct answers): Gastroesophageal reflux (72), emphysema (25), steroids (40), one tablet twice a day (79), side effects (67), bronchitis (68), white blood cells (56), erythrocyte sedimentation rate (33), diabetes mellitus (72), antibiotics (87), chronic obstructive pulmonary disease (42). Variables associated with better comprehension were: Female gender (better in 7/10 questions), university degree (10/10) and high income (9/10). Decision tree analysis showed that education had the most impact. The youngest participants (age 16-24) had the worst outcome in seven out of 10 questions. The results define certain medical terms that require more careful explanation than others. They also indicate that those of young age, low socioeconomic status and less educated require more help in understanding medical terms. Interestingly, 21% of participants failed to understand a very simple medication order, emphasizing the importance of explaining these in detail. The data may also have implications for informed consent. A larger study exploring the public comprehension of multiple medical terms should be considered.