Emil Larus Sigurdsson

BACKGROUND: We aimed to characterize the genetic architecture of resistant hypertension (rHTN), which affects up to 18% of hypertensive individuals and increases cardiovascular disease risk. METHODS: We conducted a genome-wide association study on rHTN, defined as use of 3 or more concomitant antihypertensive drugs for at least 6 months without reaching blood pressure target (in the 3-drug case), comparing it to controlled hypertension (cHTN), in which persons on 1 or 2 antihypertensives for at least 6 months reach target BP after 30 days of therapy initiation. The study included 23 508 rHTN cases and 24 393 cHTN controls, identified through drug prescription and blood pressure data from Iceland (deCODE), the UK (UK Biobank), and the US (eMERGE). Further analyses included comparisons with all hypertensive individuals (diagnosed with International Classification of Diseases, Tenth Revision code I10) and normotensives (no hypertension diagnosis). RESULTS: We found 24 rHTN variants, 17 of which used published BP variants as prior. Fifteen risk-increasing rHTN alleles are associated with lower serum potassium and increased hyperaldosteronism risk. Individuals with rHTN and cHTN had lower potassium levels before drug therapy than normotensives. All antihypertensive drug classes increased potassium levels in cHTN, while only aldosterone antagonists increased levels in rHTN. Mendelian randomization analysis was consistent with rHTN being a manifestation of hyperaldosteronism. The variant conferring the largest effect on both rHTN and hyperaldosteronism is a stop-gain variant in ENPEP in the aldosterone pathway. CONCLUSIONS: We discovered sequence variants that have different effects on rHTN and cHTN. Our study indicates that genetically determined hyperaldosteronism may be largely accountable for rHTN.

Objectives: Preoperative optimisation programmes aim to reduce complications after total joint arthroplasty (TJA), yet long-term effects on superficial surgical site infections (SSI), periprosthetic joint infections (PJI) and overall health remain unclear. This study evaluated the long-term impact of preoperative optimisation in cooperation with hospital and primary healthcare on infection outcomes and general health following elective primary lower extremity TJA. Design: In this prospective quasi-experimental study, 1484 patients undergoing TJA were followed postoperatively. The intervention group underwent a multifactorial optimisation process 6–12 months preoperatively, while the control group received conventional preparation. Setting: Landspitali University Hospital and Primary Health Care in Iceland treating patients undergoing primary TJA between August 2018 and December 2022. Participants: The intervention group comprised 746 patients and the control group 738. Of the intervention group, 77% received surgery during the COVID-19 pandemic versus 5% in the control group. Outcome measures: Outcomes included incidence of superficial SSI at 1 year and PJI and postoperative health and mortality at 3 years. Results: Superficial SSI occurred in 5.9% of the intervention group versus 7.9% in the control group (HR 0.67; 95% CI 0.45 to 1.01), with 95% versus 98% appearing within 6 weeks. PJI occurred in 2.0% versus 1.1%, respectively (HR 1.80; 95% CI 0.76 to 4.30). Most PJIs (80 vs 88%) followed superficial SSI, the majority within a week. Progression from superficial SSI to PJI was higher in the intervention group (27.3% vs 12.1%). No significant differences were found in postoperative health or mortality. Conclusions: At 1 year postoperatively, no significant long-term reductions in superficial SSI were found, nor at 3 years in PJI or general health. Confounding factors, including COVID-19-related disruptions and organisational changes, may have influenced outcomes. The study emphasises the importance of prospective evaluation of preoperative optimisation strategies as well as organisational and practice changes on patient outcome. Trial registration number: NCT05399186 .

PURPOSE Respiratory symptoms are the most common presenting complaint in primary care. Often these symptoms are self resolving, but they can indicate a severe illness. With increasing physician workload and health care costs, triaging patients before in-person consultations would be helpful, possibly offering low-risk patients other means of communication. The objective of this study was to train a machine learning model to triage patients with respiratory symptoms before visiting a primary care clinic and examine patient outcomes in the context of the triage. METHODS We trained a machine learning model, using clinical features only available before a medical visit. Clinical text notes were extracted from 1,500 records for patients that received 1 of 7 International Classification of Diseases 10th Revision codes (J00, J10, JII, J15, J20, J44, J45). All primary care clinics in the Reykjavík area of Iceland were included. The model scored patients in 2 extrinsic data sets and divided them into 10 risk groups (higher values having greater risk). We analyzed selected outcomes in each group. RESULTS Risk groups 1 through 5 consisted of younger patients with lower C-reactive protein values, re-evaluation rates in primary and emergency care, antibiotic prescription rates, chest x-ray (CXR) referrals, and CXRs with signs of pneumonia, compared with groups 6 through 10. Groups 1 through 5 had no CXRs with signs of pneumonia or diagnosis of pneumonia by a physician. CONCLUSIONS The model triaged patients in line with expected outcomes. The model can reduce the number of CXR referrals by eliminating them in risk groups 1 through 5, thus decreasing clinically insignificant incidentaloma findings without input from clinicians.

The healthcare systems in many countries are struggling. They fail to provide adequate services. Both hospitals and primary care providers are dealing with heavy workload and are challenged by lack...

The COVID-19 pandemic has had a large and varying impact on primary care. This paper studies changes in the tasks of general practitioners (GPs) and associated staff during the COVID-19 pandemic. Data from the PRICOV-19 study of 5093 GPs in 38 countries were used. We constructed a scale for task changes and performed multilevel analyses. The scale was reliable at both GP and country level. Clustering of task changes at country level was considerable (25%). During the pandemic, staff members were more involved in giving information and recommendations to patients contacting the practice by phone, and they were more involved in triage. GPs took on additional responsibilities and were more involved in reaching out to patients. Problems due to staff absence, when dealt with internally, were related to more task changes. Task changes were larger in practices employing a wider range of professional groups. Whilst GPs were happy with the task changes in practices with more changes, they also felt the need for further training. A higher-than-average proportion of elderly people and people with a chronic condition in the practice were related to task changes. The number of infections in a country during the first wave of the pandemic was related to task changes. Other characteristics at country level were not associated with task changes. Future research on the sustainability of task changes after the pandemic is needed.

Clinical Text Notes (CTNs) contain physicians' reasoning process, written in an unstructured free text format, as they examine and interview patients. In recent years, several studies have been published that provide evidence for the utility of machine learning for predicting doctors' diagnoses from CTNs, a task known as ICD coding. Data annotation is time consuming, particularly when a degree of specialization is needed, as is the case for medical data. This paper presents a method of augmenting a sparsely annotated dataset of Icelandic CTNs with a machine-learned imputation in a semi-self-supervised manner. We train a neural network on a small set of annotated CTNs and use it to extract clinical features from a set of un-annotated CTNs. These clinical features consist of answers to about a thousand potential questions that a physician might find the answers to during a consultation of a patient. The features are then used to train a classifier for the diagnosis of certain types of diseases. We report the results of an evaluation of this data augmentation method over three tiers of data availability to the physician. Our data augmentation method shows a significant positive effect which is diminished when clinical features from the examination of the patient and diagnostics are made available. We recommend our method for augmenting scarce datasets for systems that take decisions based on clinical features that do not include examinations or tests.

INTRODUCTION: High blood pressure (HT) is one of the main risk factors for cardiovascular diseases which in 2010 caused one third of all mortality in the world. Untreated, HT can cause stroke, myocardial infarction, heart failure, dementia, kidney failure, atherosclerosis and eye diseases. The main aim of this study was to find out how HT is treated in primary care in the capital area of Iceland. MATERIAL AND METHODS: The study is a descriptive retrospective cross-sectional study covering the years 2010, 2014 and 2019. Information about all patients over 18 years old diagnosed with HT were gathered from computerised medical records at every primary care center in the Capital area. RESULTS: The number of individuals diagnosed with HT increased during the study period and the mean age did also increase. The sex ratio changed with more men diagnosed than women. Of 25.873 patients diagnosed with HT in the year 2010, 63.4% received drug treatment. In 2019 this percentage had dropped 60.9% (p<0.001). Of those on antihypertensive drug treatment the proportion receiving one, two or three drugs remained same from 2010-2019. The most common group of drugs used were diuretics (C03), beta-blockers (C07), calcium channel blockers (C08) and renin-angiotensin-aldosteron-system (RAAS) inhibitors (C09). The proportion af these drug groups changed significantly during the study. Fever patients were treated by diuretics (p<0.001) or beta-blockers (p<0.001) but the number treated by calcium channel blockers (p<0.001) or RAAS inhibitors increased (p<0.001). During the whole stud period 44.1% of the patients reached the target goals. The proportion of patients who reached the target goals in different health care center was specifically for the year 2019. Just over 41% of HT patients reached the targets goals. However, two health care centers achieved notably different results with only one third of the patients attaining the goals. CONCLUSION: As has recently been shown in epidemiologic studies hypertension in Iceland is both underdiagnosed and undertreated although the country ranks high on both counts in international comparison. Furthermore, the fact that under half of hypertensive patients in general practice in the capital area reach the targeted treatment goals, cannot be considered an acceptable. Thus, it is of immense importance to improve both the diagnosis and the treatment of HT.

INTRODUCTION: In recent decades there has been a notable increase in the prescription of opioids in western countries. With this rise in use of opioids the risk of side effects, opioid abuse and deaths linked to opioids have become more apparent. The increase in opioid prescription may partly stem from a change in attitude in relation to pain management. Research has shown that pain is among the most common reasons people seek medical care and chronic pain is prevalent. Iceland is leading the Nordic countries in opioid prescriptions. OBJECTIVE: To examine prescriptions of opioids in primary car in Iceland for all age group from 2008 to 2017. METHODS: The research included all opioid prescription in every health clinic in the capital area in Iceland the between 2008 and 2017. Population in the capital area in this time period was between 201 and 222 thousand people. Data was collected from medical records database of the primary health care and approximatley 68.000 individuals had received a prescription for opioids during the research period. RESULTS: During the research period there was a 17,2% (p<0,01) increase in DDD/1000 inhabitants/day (Defined daily dose) for opioids. About a third of those who got the prescription were men and that ratio did not change during the period. proportionately, the biggest change in DDD/1000 inhabitants/day was in the age group made of people 90 years old and older, about 40,5% (p<0,01). The biggest increase in number of people getting a prescription for opioids was in the age group 30-39, about 25,5% (p<0,01). Number of prescriptions increased in every category of opioids, measured in DDD/1000 inhabitants/day,15,3% (p<0,01) in parkódin, 20,7% (p<0,01) in parkódín forte, 4,7% (p<0,01) in tramadol and 85,6% (p<0,01) in the strongest opioids. Discussion: the evolution of prescriptions for every type of opioid to the clients of the health clinics in the capital area that occured in the years from 2008 to 2017, proportionately highest for the strongest opioids, should encourage a review of pain treatment within the health clinics and development within that field.

The wellbeing of doctors and other health care workers (HCWs) is extremely important for the health care service. Stress and work overload definitely affect the quality of care for patients and als...

Objective To describe how the primary healthcare (PHC) in Iceland changed its strategy to handle the COVID-19 pandemic. Design Descriptive observational study. Setting Reykjavik, the capital of Iceland. Population The Reykjavik area has a total of 233 000 inhabitants. Main outcome measures The number and the mode of consultations carried out. Drug prescriptions and changes in the 10 most common diagnoses made in PHC. Laboratory tests including COVID-19 tests. Average numbers in March and April 2020 compared with the same months in 2018 and 2019. Results Pragmatic strategies and new tasks were rapidly applied to the clinical work to meet the foreseen healthcare needs caused by the pandemic. The number of daytime consultations increased by 35% or from 780 to 1051/1000 inhabitants (pConclusions As the first point of contact in the COVID-19 pandemic, the PHC in Iceland managed to change its strategy swiftly while preserving traditional maternity and well-child care, indicating a very solid PHC with substantial flexibility in its organisation.