Leishmaniasis in Greece: Prospects of transitioning to a One Health surveillance system

Leishmaniasis is a high burden neglected disease in the Mediterranean ecoregion, lacking surveillance attention. We aimed to provide an overview of the state of leishmaniasis surveillance in Greece, investigating the prospect of transitioning to a One Health surveillance system. We conducted a narrative review describing human and animal leishmaniasis data from Greece, including entomological findings. Through a separate review process, we describe the current leishmaniasis surveillance system pertaining to humans, animals, vectors and the environment. Additionally, we distributed likert-scale questionnaires to key informants, capturing expert-view on the necessity, existing levels and barriers of OH leishmaniasis surveillance in Greece. We identified key system strengths, weaknesses, opportunities and threats respective to a OH transition through SWOT analysis. Greece is endemic for zoonotic visceral leishmaniasis (VL) and canine leishmaniasis (CanL), displaying an increasing VL trend in recent years and high national Leishmania seroprevalence rates in dogs (range: 13.8-23.4 %). Mandatory leishmaniasis notification in humans and animals, human case-based investigations, and active case finding activities in stray dogs, comprise valuable system components of high OH operational relevance. Conversely, the existing CanL surveillance governance and the lack of systematic entomological surveillance constitute important drawbacks. Moreover, the current context of public health and animal health financial constraints in Greece may impede a strategic OH transition in leishmaniasis surveillance. On the contrary, Greece's OH experience in West Nile Virus surveillance in conjunction with leishmaniasis-expert consensus on the necessity of OH surveillance and key barriers to its realization, compose important transition opportunities. Despite shortfalls in human, animal and vector surveillance, existing system characteristics, structures and practices comprise a promising basis for developing OH cross-sectoral leishmaniasis surveillance activities in Greece.

The impact of COVID-19 pandemic on Primary Health Care through 'health providers' eyes': Α qualitative study of focus groups and individual interviews in Greece

BACKGROUND

Primary Health Care (PHC) was the cornerstone of the pandemic response.

OBJECTIVES

We aimed to explore the positive and negative impact of the pandemic, during its final wave, through 'PHC providers' eyes', as well as their recommendations towards restructuring and enhancing PHC services.

METHODS

A two-phase qualitative study was conducted, pursuing data triangulation from Focus Groups (FGs) and individual, semi-structured interviews for the purposes of data completeness and confirmation (summer 2022 and spring 2023, respectively). A purposive sample of settings was employed, including in total five PHC units according to location with different population distribution; one in Athens (FGs) and four in Northern Greece (interviews). Inductive content analysis was used.

RESULTS

In total, 24 PHC professionals participated in FGs, whereas 17 were individually interviewed. Our findings reflect a general understanding of the pandemic's positive imprint, namely acceleration of digitalisation, establishment of health protection measures, recognition of PHC's role, raise in public awareness of primary prevention, team-cooperation, increase in providers' self-efficacy, appointment of health professionals and re-organisation of accessibility. The negative impact is summarised in fatigue/burnout in PHC providers, patient safety concerns and changes in patients' behaviour. To increase resilience, participants suggest restructuring PHC, recruiting PHC personnel and enhancing digital infrastructure, maintenance of sanitary protection measures, investment in quality, and empowering patients through health literacy.

CONCLUSION

Based on the lessons learnt, building further on the pandemic-accelerated digitalisation, emphasising on quality improvement and patient safety, ensuring providers' well-being, and empowering citizens through health literacy could be key in promoting PHC resilience.

Nutritional value of cereal-based gluten-free products and comparison to that of gluten containing counterparts in the Greek market

Nutritional value of the Gluten-free products (GFPs) has been highly debated. Aiming to assess the nutritional value of the cereal-based GFPs in the Greek market, information from the nutritional label and the ingredients list, of all GFPs and their gluten-containing (GC) counterparts available in a supermarket offering the greatest availability in the capital of Greece, were recorded. The sample consisted of 913 products: 351 GFPs and 562 GCPs, classified into 12 categories (e.g., breads, melbas, breakfast cereals, cereal bars, pasta, flours, cookies). With minor exceptions, comparisons among all food categories regarding nutrient profile and nutritional claims showed mixed results, though supporting an overly comparable nutritional profile of the GFPs. Still, a quarter of all GFPs presented an unhealthy nutritional profile. The findings of the present study are highly in agreement with those of relevant studies in the literature, that do not support an inferior nutritional profile compared to GC counterparts.

The application of GIS technology in building a multivariate taphonomic profile for improving PMI estimations in Greece

Environmental conditions highly affect decomposition rates and therefore a forensic practitioner should consider context-specific information when estimating the post mortem interval (PMI). Traditional methods of collecting environmental data, however, are time-consuming and often impractical for large-scale studies or routine forensic investigations. This study developed an automated computer method by employing the technology of geographic information systems (GIS) and Python programming language to provide contextual information for bodies found outdoors in Greece. The generated coding script underwent testing on 95 bodies in various stages of decomposition, which were examined between the years 1999 and 2022 at the National and Kapodistrian University of Athens and the Forensic Medical Service of Thessaloniki. Using ArcGIS Pro software and publicly available online data, a multilayer map was developed. Individual layers included high-resolution aerial images and data on the European Nature Information System ecosystem type, the Köppen-Geiger climatic type, the population density, the elevation, and the slope. Additionally, 99 national weather stations and their corresponding meteorological data were integrated. By leveraging the geographical coordinates of the recovery site of each case and information about the decedent's disappearance and recovery dates, this script automatically generates details from each of the above layers. Additionally, it calculates the accumulated degree days (ADD) and accumulated humidity days (AHD) values by extracting data from the nearest weather station. The GIS-based approach enables rapid, objective, and reproducible taphonomic profile construction, which can greatly improve the reliability of PMI estimations. By utilizing this method, forensic practitioners can accurately evaluate environmental effects on decomposition, thus standardizing taphonomic profiling globally.

Automated Detection of Neurodevelopmental Disorders Using Face-to-Face Mobile Technology Among Typically Developing Greek Children: Randomized Controlled Trial

BACKGROUND

Neurodevelopmental disorders (NDs) are characterized by heterogeneity, complexity, and interactions among multiple domains with long-lasting effects in adulthood. Early and accurate identification of children at risk for NDs is crucial for timely intervention, yet many cases remain undiagnosed, leading to missed opportunities for effective interventions. Digital tools can help clinicians assist and identify NDs. The concept of using serious games to enhance health care has gained attention among a growing group of scientists, entrepreneurs, and clinicians.

OBJECTIVE

This study aims to explore the core principles of automated mobile detection of NDs in typically developing Greek children, using a serious game developed within the SmartSpeech project, designed to evaluate multiple developmental domains through principal component analysis (PCA).

METHODS

A total of 229 typically developing children aged 4 to 12 years participated in the study. The recruitment process involved open calls through public and private health and educational institutions across Greece. Parents were thoroughly informed about the study's objectives and procedures, and written consent was obtained. Children engaged under the clinician's face-to-face supervision with the serious game "Apsou," which assesses 18 developmental domains, including speech, language, psychomotor, cognitive, psychoemotional, and hearing abilities. Data from the children's interactions were analyzed using PCA to identify key components and underlying principles of ND detection.

RESULTS

A sample of 229 typically developing preschoolers and early school-aged children played the Apsou mobile serious game for automated detection of NDs. Performing a PCA, the findings identified 5 main components accounting for about 80% of the data variability that potentially have significant prognostic implications for a safe diagnosis of NDs. Varimax rotation explained 61.44% of the total variance. The results underscore key theoretical principles crucial for the automated detection of NDs. These principles encompass communication skills, speech and language development, vocal processing, cognitive skills and sensory functions, and visual-spatial skills. These components align with the theoretical principles of child development and provide a robust framework for automated ND detection.

CONCLUSIONS

The study highlights the feasibility and effectiveness of using serious games for early ND detection in children. The identified principal components offer valuable insights into critical developmental domains, paving the way for the development of advanced machine learning applications to support highly accurate predictions and classifications for automated screening, diagnosis, prognosis, or intervention planning in ND clinical decision-making. Future research should focus on validating these findings across diverse populations integrating additional features such as biometric data and longitudinal tracking to enhance the accuracy and reliability of automated detection systems.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06633874; https://clinicaltrials.gov/study/NCT06633874.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-https://doi.org/10.3390/signals4020021.

Assessing stigma: Health and social worker regard towards working with people using illicit drugs in Athens, Greece

BACKGROUND

After the 2008 Global Financial Crisis and resulting economic austerity, the rise in illicit drug use engendered an increased need for people who use drugs (PWUD) to access medical care, compounded by the COVID-19 pandemic. Research shows that perceptions of medical staff towards PWUD facilitate or act as a barrier to accessing health care. This study provides a better understanding of health and social work professionals' perceptions by assessing stigma levels towards PWUD in Athens, Greece.

METHODS

This is a mixed-method study. It calculates the stigma score for professionals (n = 60) and the stigma score associated with specific drugs based on the Medical Condition Regard Scale through a quantitative analysis of responses to a semi-structured online survey about attitudes of health and social work professionals towards PWUD. It draws on the qualitative analysis of 12 semi-structured interviews with 16 service managers, providers, and health services advocates working in the charity sector to determine whether perceptions of PWUD affect writing and implementing policy and protocols for services.

RESULTS

Stigma towards PWUD exists amongst health and social work professionals in Athens. Professionals who have worked with PWUD for longer periods of time, professionals who have had specific training on working with PWUD, and professionals who feel that they have the necessary training to work with PWUD all demonstrated a higher stigma score than those reporting the opposite. Cannabis and opioids were associated with lower stigma scores while shisha had the highest level of stigma associated with it. Finally, professional environments are not conducive to alleviating stigma as the lack of training specific to stigma, the lack of professional supervision, and worker burn-out are key barriers faced by professionals in their everyday practice.

CONCLUSIONS

Reducing and eliminating stigma towards PWUD among health and social workers requires immediate action. Measures to be taken include: introducing training programs focused on stigma towards PWUD to healthcare providers, social workers, lawyers, police, the media; increasing professional supervision on field work for health and social workers; introducing low barrier health care and specialist units. Peers and field-focused organisations should meaningfully participate in drug and alcohol policymaking, program development, and implementation.

Factors That Affect the Acceptance of Educational AI Tools by Greek Teachers-A Structural Equation Modelling Study

The discussion around integrating AI technologies into educational practice is current among scholars and in sociopolitical circles. This study examines the factors influencing teachers' acceptance of educational AI tool (EAIT) use, aiming to inform the development of a pedagogical framework for the responsible integration of AI tools in education. A conceptual model was developed by amalgamating constructs of TAM (perceived usefulness and perceived ease of use) and UTAUT (social influence and facilitating conditions) while integrating the variables of perceived trust and personal innovativeness and considering the impact of teachers' pedagogical beliefs. A total of 342 Greek teachers participated in the quantitative survey conducted. The proposed model was evaluated using partial least squares structural equation modelling (PLS-SEM). The findings illuminated perceived usefulness as the most significant predictor of teachers' behavioural intention to use EAIT. The research also revealed that social influence and personal innovativeness exert considerable influence. While constructivist pedagogical beliefs were found to have no direct impact on EAIT acceptance, the results indicated that educators who embrace those teaching methods exhibit a high propensity to perceive EAIT as useful and trustworthy. Furthermore, the study's analysis demonstrated that trust had a significantly positive effect on usefulness, and innovativeness influences positively and significantly both usefulness and ease of use.

First Confirmed Description of Acremonium egyptiacum from Greece and Molecular Identification of Acremonium and Acremonium-like Clinical Isolates

Acremonium and the recently separated acremonium-like genera, such as Sarocladium, are emerging causes of opportunistic disease in humans, mainly post-traumatic infections in immunocompetent hosts, but also invasive infections in immunocompromised patients, such as those undergoing transplantation. Acremonium egyptiacum has emerged as the major pathogenic Acremonium species in humans, implicated mainly in nail but also in disseminated and organ specific infections. In this first study of acremonium-like clinical isolates in Greece, 34 isolates were identified and typed by sequencing the internal transcribed spacer, and their antifungal susceptibility was determined by a modified CLSI standard M38 3rd Edition method for filamentous fungi. A. egyptiacum was the primary species (18 isolates) followed by Sarocladium kiliense (8), Acremonium charticola, Gliomastix polychroma, Proxiovicillium blochii, Sarocladium terricola, Sarocladium zeae, and Stanjemonium dichromosporum (all with one isolate). Two isolates, each with a novel ITS sequence, possibly represent undescribed species with an affinity to Emericellopsis. All three A. egyptiacum ITS barcode types described to date were identified, with 3 being the major type. Flutrimazole, lanoconazole, and luliconazole presented the lower minimum inhibitory concentration (MIC) values against A. egyptiacum, with a geometric mean (GM) MIC of 2.50, 1.92, and 1.57 μg/mL, respectively. Amphotericin B, itraconazole, posaconazole, voriconazole, terbinafine, amorolfine, and griseofulvin MICs were overall high (GM 12.79-29.49 μg/mL). An analysis of variance performed on absolute values showed that flutrimazole, lanoconazole, and luliconazole were equivalent and notably lower than those of all the other drugs tested against A. egyptiacum. Antifungal susceptibility of the three different A. egyptiacum genotypes was homogeneous. Overall, the high MICs recorded for all systemically administered drugs, and for some topical antifungals against the tested A. egyptiacum and other acremonium-like clinical isolates, justify the routine susceptibility testing of clinical isolates.

Evaluation of the attributable fraction and burden of HPV-related oropharyngeal cancers in Greece-the ORPHEAS study

BACKGROUND

Herein, we evaluated the attributable fraction (AF) of human papillomavirus (HPV)-mediated (HPV+) oropharyngeal carcinomas (OPCs) in Greece over a recent calendar period.

PATIENTS AND METHODS

ORPHEAS, a retrospective, observational, multicenter, cross-sectional study with prospective recruitment, included adult patients with OPC in 2017-2022, each of them with a high-quality, treatment-naïve tumor specimen. The primary endpoint was the HPV-AF, defined as combined positivity for p16INK4a (p16) overexpression and HPV DNA presence by central laboratory testing, among included patients. Other endpoints evaluated the HPV+/HPV- patient/disease characteristics at OPC diagnosis and the HPV subtypes for HPV+ patients.

RESULTS

144/147 patients with available HPV status by central laboratory testing were analyzed [median age: 60.0 years; males: 111 (77.1%)]. The most common tumor anatomical sites were the tonsils (70/147, 48.6%) and the base of the tongue (51, 35.4%), and most patients were at the American Joint Committee on Cancer eighth edition TNM (tumor-node-metastasis) stages III (25, 22.7%) and IV (43, 39.1%). The HPV-AF was 52.1% (75/144; 95% confidence interval 43.6% to 60.5%). Most HPV+ patients were infected by an HPV type targeted by the 9-valent HPV vaccine (72/75, 96.0%), especially HPV16 (70/75, 93.3%). HPV+ compared with HPV- patients were younger (median age 58.0 versus 64.0 years; P = 0.003); more likely to have tumors in the tonsils (65.0% versus 30.4%; P < 0.001); less likely to have tumors in the base of the tongue (25.3% versus 46.4%; P = 0.008); and less frequently at TNM stage IV (20.4% versus 57.1%; overall P < 0.001).

CONCLUSIONS

In Greece, we observed a high HPV-AF (52.1%) in OPC, approximating the AFs reported for some Northern European countries. HPV+ versus HPV- patients were younger, more frequently with tonsillar tumors, and less frequently at TNM stage IV. Since most patients were infected by ≥1 HPV type targeted by the 9-valent vaccine, the HPV+ OPC burden could be mitigated through a routine HPV gender-neutral vaccination program.

The use of minimum common data set in the development of the Greek Fragility Hip Fracture Registry in the Greek health care setting: the first year of its pilot implementation

The first Fragility Hip Fracture Registry has been established in Greece. The in-hospital length of stay was 10.8 days and was significantly influenced by the delayed surgical fixation. The increased age, the higher ASA grade, and the male gender influenced negatively the 30-day mortality, which reached 7.5%.

BACKGROUND

The increased incidence of fragility hip fractures constitutes a great challenge to the health care professionals and causes a significant burden on national health care systems around the globe. Fragility hip fracture registries have been used in many countries in order to document the cotemporary situation in each country and to identify potential weaknesses of the local health care systems.

AIM

The aim of the herein study is to present the results of the pilot implementation of the first fragility hip fracture registry in Greece, which was developed by the Greek Chapter of Fragility Fracture Network (FFN Gr), and use the neural networks in the analysis of the results.

MATERIALS AND METHODS

Seven orthopaedic departments from six different hospitals in Greece participated in the present pilot study. All fragility hip fractures from September 2022 until December 2023 were prospectively collected and documented using a central database. For this purpose, the 22 points of minimum common data set, proposed by the Global Fragility Fracture Network, with the addition of the 30-day mortality was used.

RESULTS

A total of 1009 patients who sustained a fragility hip fracture were included in the study. The mean age of the cohort was 82.2 ± 8.6 years with the majority of patients being female (72%). Sixty percent (60%) of the patients had an extracapsular hip fracture, with a mean ASA grade 2.6 ± 0.8. Intramedullary nailing and hip hemiarthroplasty were the surgical treatments of choice in the majority of extra- and intra-capsular hip fractures respectively. The mean hospital length of stay of the patients was 10.8 ± 8.5 days, and the 30-day mortality was 7.5%. The multivariant analysis revealed that the age, the ASA grade and the male gender had a significant contribution to the 30-day mortality. The neural network model had a significant under-the-curve predictive value (0.778), with age being the most important predictive factor. The length of stay was significantly influenced only by the delayed surgical fixation (more than 36 h from admission).

CONCLUSIONS

The present pilot study provides evidence that establishing a fragility hip fracture registry in Greece is feasible and demonstrates that the minimum common data set can be used as the base of any new registry. In Greece, patients with a fragility hip fracture stay in the hospital for approximately 11 days and have 7.5% 30-day mortality. Unfortunately, due to the logistics of the public healthcare system, they do not receive surgical fixation in a timely manner, which is a factor that negatively affects their length of in-hospital stay.

Comparison of Adulthood Criteria Endorsed by Emerging Adults and Their Parents in Greece: A Mixed-Method Study

Although there is extensive research on the adulthood criteria endorsed by emerging adults, there is very limited evidence on the comparison between emerging adults and their parents regarding this issue. Moreover, in these comparison studies, only quantitative methodology was used. Therefore, the present study uses a mixed-method design to investigate similarities and differences in the prevalence of the endorsed adulthood criteria between emerging adults and their parents, between male and female emerging adults, and between fathers and mothers. Participants were 251 emerging adult students, aged 18.0 to 25.9 (M = 19.9; 50.2% females), and 341 parents of these emerging adults, aged 33.6 to 61.9 (M = 50.4; 58.4% mothers). They completed the Markers of Adulthood Scale and named the three criteria that they considered most important for a person to be considered an adult. An inductive-deductive coding scheme was used. The analyses exhibited a high consensus between emerging adults and their parents in the endorsement of adulthood criteria. Only criteria related to Independence and to the Self were reported more frequently by emerging adults than their parents. A strong agreement between genders in both age groups was also found. The contribution of this study is twofold. First, it supports the idea that in Greece adulthood is a construct that is largely shared by emerging adults and their parents. Second, it illustrates how a mixed-method design can complement quantitative studies and extend their findings.

Determinants of health-related quality of life of patients with type 2 diabetes and multimorbidity: a cross-sectional study

PURPOSE

To examine the determinants of health-related quality of life (HRQoL) of patients with type 2 diabetes (PwD) and multimorbidity (MM) (at least one co-occurring condition besides T2D) among sociodemographic, disease-related, and MM variables and the association of MM with therapeutic targets.

METHODS

A total of 179 PwD attending primary care (PC) in Greece answered the 15 dimension HRQoL (15D) questionnaire between August 2019 and October 2020. Sociodemographic, disease-related, and MM characteristics were recorded. MM was categorized as concordant or discordant based on whether or not it was related to the pathophysiology of T2D. Independent predictors of the 15D score were examined in stepwise regression models among sociodemographic, disease-related, and MM variables and the association of MM with glycated hemoglobin (A1C) and low-density lipoprotein cholesterol (LDL-C) was assessed.

RESULTS

The mean 15D score was 0.85 ± 0.11 and the mean MM count was 4.3 ± 1.8. Significant predictors of a higher 15D score were male gender, married state, higher monthly income, and more physical activity. Significant predictors of a lower 15D score were employment, depression, musculoskeletal disease, coronary artery disease, neuropathy, and MM count, but discordant had a stronger effect than concordant MM. Increasing MM count was not significantly correlated with A1C and was correlated with lower LDL-C.

CONCLUSION

Non-medical (physical activity and sociodemographic) rather than disease-related characteristics and discordant more than concordant co-occurring conditions affected HRQoL of multimorbid PwD who did not have worse (A1C) or achieved better (LDL-C) therapeutic targets. A generalist approach to the non-medical needs and overall health conditions of PwD could be promoted in PC within the social determinants of health and MM.

Transthyretin amyloidosis cardiomyopathy in Greece: Clinical insights from the National Referral Center

BACKGROUND

Clinical characteristics and outcomes of patients with transthyretin amyloidosis cardiomyopathy (ATTR-CM) vary by region, necessitating the acquisition of country-specific evidence for proper management.

METHODS

This is an observational study including sequential patients presenting in the Amyloidosis Reference Center of Greece, from 01/2014 to 12/2022. ATTR-CM was diagnosed by positive scintigraphy and exclusion of light-chain amyloidosis or positive biopsy typing. Genetic testing was performed in all cases.

RESULTS

In total, 109 ATTR-CM patients were included (median age, 81 years) of which 15 carried TTR mutations (27% Val30Met). Most patients (82%) presented with heart failure and 59% with atrial fibrillation, while 10% had aortic stenosis. Importantly, 78 (71.6%) had clinically significant extracardiac manifestations (45% musculoskeletal disorder, 40% peripheral neuropathy, and 33% gastrointestinal symptoms). Sixty-five (60%) received disease-specific treatment with tafamidis. Estimated median survival was 48 months; advanced NYHA class, National Amyloidosis Center stage, eGFR<45 ml/kg/1.73 m2, NT-pro-BNP>5000 pg/mL were associated with worse survival, while tafamidis treatment was associated with improved survival in patients with IVS≥ 12 mm.

DISCUSSION

These are the first data describing the characteristics, management, and outcomes of patients with ATTR-CM in Greece, which could influence local guidelines.

Indications of younger age at menarche in Greek adolescents but with no relation to body mass index

PURPOSE

This study aimed to present recent trends in the pubertal timing of a Greek female sample.

METHODS

Data were collected retrospectively from medical records of healthy females aged 6-18 years who attended a tertiary Adolescent Friendly Health Center over a 5-year period (2016-2020) and included gestational age, birth anthropometrics, and age of thelarche and/or pubarche and/or menarche, along with corresponding anthropometric, hormonal, and biochemical measurements.

RESULTS

Data from 298 girls' medical records were included in the analysis. Median age at menarche, thelarche, and pubarche was 12, 9, and 9 years, respectively. The mean interval between pubertal onset and menarche was 1.99 years. The mean body mass index (BMI) at menarche and thelarche was 20.99 kg/m2 and 18.90 kg/m2, respectively. The mean weight at menarche was 49.6 kg, whereas the mean height difference between thelarche and menarche was 19.17 cm. Among participants, 6.3% had premature menarche, while 24.0% had premature thelarche. Birth weight was moderately correlated with BMI at thelarche/pubarche (rs=0.334, p = 0.005). Birth weight and BMI at thelarche/pubarche were not predictive of premature menarche or premature thelarche. Median (interquartile range, IQR) levels at menarche vs. thelarche were significantly higher for insulin-like growth factor-1 [358.00 (140.50) vs. 176.00 (55.00) ng/ml], follicle stimulation hormone [5.65 (3.14) vs. 3.10 (4.23) mIU/ml], testosterone [25.50 (31.00) vs. 13.00 (21.00) ng/dl], dehydroepiandrosterone sulfate [117.00 (112.50) vs. 46.40 (51.90) µg/dl], and insulin [17.40 (15.05) vs. 8.47 (4.97) µIU/ml].

CONCLUSION

The timing of pubertal stages in the Greek female sample studied followed the recent international downward trends. Younger age at menarche was not related to BMI.

Moderate to Severe Osteoarthritis: What is the Economic Burden for Patients and the Health Care System? Insights from the "PONOS" Study

OBJECTIVE

To assess the economic burden of moderate to severe osteoarthritis (OA) management for patients and the health care system in Greece.

DESIGN

A noninterventional, cross-sectional, prospective, epidemiological analysis of data from the medical records of patients with moderate to severe OA, recruited in a single visit from 9 sites in Greece. Outcomes included health care resource use (direct/indirect costs) associated with this patient population.

RESULTS

A total of 164 patients were included in the analysis: mean age was 70.5 years, and the majority of participants were females (78.7%). The presence of comorbidities was reported by 87.2% of patients, with hypertension being the most frequently reported (53.7%). Paracetamol was the most commonly used analgesic treatment (96%), followed by systemic nonsteroidal anti-inflammatory drugs (NSAIDs) (75%) and opioids (50%). The mean overall annual direct costs per patient was estimated at 1,675.3€, with approximately half incurred by the National Health Insurance Fund, whereas the mean overall annual indirect cost (absenteeism of patients and informal caregivers) was estimated at 3,501.4€. Joint replacement (JR) procedures and paid care were the major drivers of annual direct costs in this patient population (4,326.3€ and 9,360.0€, respectively).

CONCLUSIONS

This real-world analysis of direct and indirect costs confirmed the substantial economic burden imposed by moderate to severe OA to the health care system and the patients. Our findings emphasize the need for interventions to enhance disease management, to improve patients' health outcomes and reduce the global burden of OA on society.

Dirofilaria immitis and Dirofilaria repens: Investigating the Prevalence of Zoonotic Parasites in Dogs and Humans in a Hyperenzootic Area

The mosquito-borne zoonotic nematode parasites Dirofilaria immitis and Dirofilaria repens primarily affect dogs. In recent years, their distribution has expanded due to various factors influencing vector-borne pathogens. This study aimed to investigate the comparative prevalence of infection in dogs and humans within a hyperenzootic region of Europe, and to estimate the proportional relationship between infection prevalence in dogs and humans, within the concept of "One Health". To this end, 604 blood samples from dogs and 625 serum samples from humans living in the Thrace region of northeastern Greece were collected. The dog samples were examined for Dirofilaria spp. microfilariae using Kott's test and for D. immitis antigen using a commercial serological test. The human sera were analyzed for both parasites by Western blot. The overall prevalence of infection in dogs was 177 (29.3%), with 173 (28.6%) testing positive for D. immitis and 7 (1.2%) for D. repens, including 6 (1%) cases of mixed infection. Specific IgG antibodies were detected in 42 (6.7%) human samples, with 24 (3.8%) positive for D. immitis and 18 (2.9%) for D. repens. The infection proportion in humans was 23.4% of the corresponding canine infections, indicating a high risk of human infection in this hyperenzootic region.

Nationwide Mortality Trends from 2001 to 2020 in Greece: Health Policy Implications under the Scope of Aging Societies

INTRODUCTION

This nationwide study aims to analyze mortality trends for all individual causes in Greece from 2001 to 2020, with a specific focus on 2020 - a year influenced by the coronavirus pandemic. As Greece is the fastest-aging country in Europe, the study's findings can be generalized guiding the re-evaluation of global health policies.

METHODS

Data on the population and the number of deaths were retrieved from the Hellenic Statistical Authority. We calculated age-standardized mortality rates (ASMR) and cause-specific mortality rates by gender in three age groups (0-64, 65-79, and 80+) from 2001 to 2020. Proportional mortalities for 2020 were determined. Statistical analysis used generalized linear models with Python Programming Language.

RESULTS

From 2001 to 2020, cardiovascular diseases (CVD) ASMR decreased by 42,7% (p<0,0001), with declines in most sub-causes, except for hypertensive diseases, which increased by 2,8-fold (p<0,0001). In 2020, the proportional mortalities of the three leading causes were 34,9% for CVD, 23,5% for neoplasms, and 9,6% for respiratory diseases (RD). In 2020, CVD dominate in ages 80+ (39,3%), while neoplasms prevail in ages 0-79 (37,7%). Among cardiovascular sub-causes, cerebrovascular diseases dominate in ages 80+ (30,3%), while ischemic heart diseases prevail in ages 0-79 (up to 60,0%).

CONCLUSIONS

The global phenomenon of population aging necessitates a re-framing of health policies in our aging societies, focusing on diseases with either a high mortality burden, such as CVD, neoplasms, and RD, or those experiencing increasing trends, such as hypertensive diseases.

Epidemiological Investigation of Animal Brucellosis in Domestic Ruminants in Greece from 2015 to 2022 and Genetic Characterization of Prevalent Strains

Brucellosis is one of the most important zoonotic diseases in Greece, causing a significant burden on both human and animal vitality as well as economic loss. The present study was conducted from 2015 to 2022 on 711,415 serum samples by determining the seroepidemiology of Brucellosis among livestock in 24 geographical areas in Greece using the Rose Bengal Test (RBT) and the complement fixation test (CFT) and further performing genetic analysis of Brucella spp. by species-specific real-time PCR and MLVA Brucella analysis. A total of 3086 serum samples from goats, sheep, and cattle showed positive results using the RBT and CFT, and only strongly positive samples (n = 800) were preserved in the Βlood Bank of the Veterinary Laboratory of Brucellosis. From these, 212 sera samples were randomly selected for molecular and genetic analysis. The results indicated that the incidence rate of Brucellosis is higher in cattle herds in comparison with other animal species. Overall, 48 samples tested positive by real-time PCR, of which forty-seven of them were B. abortus and one was B. melitensis. Genetic analysis of two B. abortus samples revealed a common pattern, indicating two Bruce04, two Bruce18, four Bruce07, two Bruce09, three Bruce16, and four Bruce30 for both samples, which, interestingly, were not identical with the known genotypes in the public MLVA Brucella database. Our findings substantiate that animal Brucellosis remains a health issue in Greece, with a stable but apparent incidence rate, and further investigation is needed to fully characterize the newly identified Brucella strains in Greece.

Factors influencing use of eHealth services during and after the COVID-19 pandemic

OBJECTIVES

The rapid advancement of information and communication technologies has made eHealth applications increasingly available and accessible. The COVID-19 pandemic has accelerated the need for remote health service provision. This research aims to explore the usage, perceptions, and knowledge of eHealth interventions during and after the COVID-19 pandemic.

METHODS

A cross-sectional survey was conducted in 2021 (during the pandemic) and 2023 (post-pandemic) using a structured questionnaire based on the Technology Acceptance Model (TAM) and the eHealth Literacy Scale (eHEALS). The survey, conducted in Greece, included 638 participants in total (277 in 2021 and 361 in 2023). Structural equation modeling was employed to assess the factors influencing eHealth adoption.

RESULTS

The findings indicate a slight increase in positive perceptions of eHealth usefulness, intention to use, and actual usage over the 2 years. However, concerns remain regarding the ease of use and eHealth literacy. eHealth literacy significantly predicts the perceived usefulness and ease of use of eHealth services, both of which predict the intention to use them. Additionally, higher education levels are positively associated with eHealth literacy, while older age is negatively associated with ease of use. Gender did not significantly impact these factors. These findings were consistent across both surveys.

CONCLUSIONS

Policy-makers should focus on simplifying eHealth services, removing technical barriers, and enhancing the population's eHealth literacy to promote wider adoption of eHealth services.

Emergence of NDM-1-Producing Pseudomonas aeruginosa Nosocomial Isolates in Attica Region of Greece

Here, we report on the emergence and spread of multidrug-resistant NDM-1-producing P. aeruginosa isolates from patients hospitalized in the Attica region, Greece, in 2022 to provide data on their resistome, their virulome, the genetic environment of blaNDM-1, and their molecular epidemiology. A total of 17 carbapenem-resistant P. aeruginosa isolates identified as NDM-producers by immunochromatography at the hospital level were sent to the Central Public Health Laboratory, in the frame of the laboratory surveillance of carbapenem-resistant pathogens, for further characterization. The initial screening for genetic AMR determinants was carried out by PCR and the MDR Direct Flow Chip assay. Typing was performed by MLST and DLST, the latter in a subset of isolates. Further analysis was performed by whole-genome sequencing (WGS) of six isolates from both hospitals to analyze their entire genomes and elucidate their genetic relatedness. All isolates were allocated to international high-risk clones, sixteen to ST773 and one to ST308. Five ST773 and the sole ST308 isolate were found to harbor the blaNDM-1 gene, along with various other ARGs integrated into their chromosomes, as well as with a wide variety of virulence genes. The blaNDM-1 gene was located in the integrative and conjugative elements ICE6600-like and ICETn43716385 in ST773 and ST308 isolates, respectively. Single-nucleotide polymorphism analysis of the five ST773 isolates indicated their clonal spread in both hospitals. These results suggested that two different molecular events contributed to the emergence of NDM-1-producing P. aeruginosa isolates in Athenian hospitals, highlighting the need for ongoing surveillance.

Evaluating ChatGPT 4.0's User Satisfaction Among Doctors Across Different Medical Departments

In an era increasingly focused on integrating Artificial Intelligence (AI) into healthcare, the utility and user satisfaction of AI applications like ChatGPT have become pivotal research areas. This study, conducted in Greece, engaged 193 doctors from various medical departments who interacted with ChatGPT 4.0 through a custom web application. The participants, representing a diverse range of medical specialties, received responses from the specific chatbot tailored to their specific departmental inquiries. Their satisfaction was gauged using a validated form featuring a 1-to-5 rating scale. The results highlighted a possible correlation between the doctors' medical departments and their satisfaction levels with ChatGPT 4.0. Significantly, doctors from certain departments (like General Surgery and Cardiology) reported lower satisfaction scores, ranging from 2.73 to 2.80 out of 5, in contrast to their colleagues from departments like Biopathology and Orthopedics, who scored between 4.00 and 4.46 out of 5. This variation in satisfaction levels underscores the diverse needs within different medical specialties and illuminates both the potential of ChatGPT and the areas needing improvement, especially in delivering department-specific medical information. Despite its limitations, ChatGPT version 4.0 is emerging as a valuable tool in the medical community, indicating potential future advancements and more extensive integration into healthcare practices. The study's findings are crucial in understanding the distinct preferences and requirements of healthcare professionals across various medical departments, thereby guiding the future development of AI tools in healthcare.

ENhancinG vAGinal dElivery in Greece through educational and behavioral interventions among maternity care providers regarding labor management: the ENGAGE stepped-wedge randomized prospective trial protocol

BACKGROUND

There is an emerging need to systematically investigate the causes for the increased cesarean section rates in Greece and undertake interventions so as to substantially reduce its rates. To this end, the ability of the participating Greek obstetricians to follow evidence-based guidelines and respond to other educational and behavioral interventions while managing labor will be explored, along with barriers and enablers. Herein discussed is the protocol of a stepped-wedge designed intervention trial in Greek maternity units with the aforementioned goals in mind, named ENGAGE (ENhancinG vAGinal dElivery in Greece).

METHODS

Twenty-two selected maternity units in Greece will participate in a multicenter stepped-wedge randomized prospective trial involving 20,000 to 25,000 births, with two of them entering the intervention period of the study each month (stepped randomization). The maternity care units entering the study will apply the suggested interventions for a period of 8-18 months depending on the time they enter the intervention stage of the study. There will also be an initial phase of the study lasting from 8 to 18 months including observation and recording of the routine practice (cesarean section, vaginal birth, and maternal and perinatal morbidity and mortality) in the participating units. The second phase, the intervention period, will include such interventions as the application of the HSOG (the Hellenic Society of Obstetrics and Gynecology) Guidelines on labor management, training on the correct interpretation of cardiotocography, and dealing with emergencies in vaginal deliveries, while the steering committee members will be available to discuss and implement organizational and behavioral changes, answer questions, clarify relevant issues, and provide practical instructions to the participating healthcare professionals during regular visits or video conferences. Furthermore, during the study, the results will be available for the participating units in order for them to monitor their own performance while also receiving feedback regarding their rates. Τhe final 2-month phase of the study will be devoted to completing follow-up questionnaires with data concerning maternal and neonatal morbidities that occurred after the completion of the intervention period. The total duration of the study is estimated at 28 months. The primary outcome assessed will be the cesarean section rate change and the secondary outcomes will be maternal and neonatal morbidity and mortality.

DISCUSSION

The study is expected to yield new information on the effects, advantages, possibilities, and challenges of consistent clinical engagement and implementation of behavioral, educational, and organizational interventions described in detail in the protocol on cesarean section practice in Greece. The results may lead to new insights into means of improving the quality of maternal and neonatal care, particularly since this represents a shared effort to reduce the high cesarean section rates in Greece and, moreover, points the way to their reduction in other countries.

TRIAL REGISTRATION

NCT04504500 (ClinicalTrials.gov). The trial was prospectively registered. Ethics Reference No: 320/23.6.2020, Bioethics and Conduct Committee, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.

Influenza Vaccination of Nursing Students: A Cross-Sectional Study of Uptake, Knowledge, Attitudes, and Practices in Greece

Influenza immunization includes a yearly repeated vaccine offered to every healthcare worker, including nursing students, with a high risk of contracting this viral disease. This study aimed to investigate the vaccination coverage, knowledge, attitudes, and practices of nursing students against influenza in Greece. A cross-sectional study was conducted in the Attica region between September 2022 and July 2023, with the use of an anonymous reference questionnaire. Data from 1261 nursing students were recorded (response rate: 68.6%). The study found that 23% of the sample were vaccinated against influenza for the flu season 2022-2023, and 42% were vaccinated for the previous flu season. Knowledge scores regarding influenza ranged from 0% to 100%, with a mean value of 55 (SD = 18.8%). A higher level of knowledge about influenza was associated with more appropriate attitudes and practices toward the disease (p < 0.001). Notably, participants in their second, third, or fourth year of study and beyond exhibited more suitable attitudes and practices towards the flu compared to those in their first year of study (p < 0.05). The emergence of low vaccination coverage identifies the need for departments of nursing studies to proceed with the design of educational and intervention programs on infection control.

Molecular Investigation of Small Ruminant Abortions Using a 10-Plex HRM-qPCR Technique: A Novel Approach in Routine Diagnostics

The objective of this study was to apply and preliminarily evaluate a High-Resolution Melting (HRM) analysis technique coupled with qPCR, that allows the simultaneous detection of 10 different ruminant abortogenic pathogens, for investigating abortions in sheep and goats throughout Greece. A total of 264 ovine and caprine vaginal swabs were obtained the week following the abortion from aborted females and analyzed using a commercially available kit (ID Gene™ Ruminant Abortion Multiplex HRM, Innovative Diagnostics). Results indicated a high prevalence of Coxiella burnetii and Chlamydophila spp., which were detected in 48.9% and 42.4% of the vaginal swabs, respectively. Results for these most commonly detected pathogens were compared with those of a well-established commercial qPCR kit, with near-perfect agreement. Toxoplasma gondii, Salmonella spp., Brucella spp., Anaplasma phagocytophilum, Campylobacter fetus, and Neospora caninum were also identified, the two latter reported for the first time in the country in small ruminants. Mixed infections occurred in 35.6% of the animals examined. This technique allows for the simultaneous detection of many abortogenic pathogens in an accurate and cost-effective assay. Detection of uncommon or not previously reported pathogens in various cases indicates that their role in ovine and caprine abortions may be underestimated.

Association of Lifestyle Behaviors with Quality of Life in Patients with COPD: A Cross-Sectional Study in Primary Care

Background/Objectives: The association between healthy lifestyle behaviors and their effect on quality of life among patients with COPD remains unclear. Therefore, the aim of this study was to explore the lifestyle behaviors and their association with the disease-specific quality of life among a primary care population with COPD in Greece. Methods: This cross-sectional study included 236 participants aged 40 years and older from the COCARE COPD study. The healthy lifestyle index (HLI) was created based on smoking, alcohol consumption, BMI, physical activity, and sleep duration, with each factor categorized as either healthy (1) or unhealthy (0). The HLI ranged from 0 (least healthy) to 5 (healthiest). COPD-specific quality of life was assessed using the COPD assessment test (CAT), where higher scores indicate poorer health status. Multiple logistic regression was used to analyze the association between HLI and CAT scores, adjusting for confounders. Results: Half of the participants were non-smokers or former smokers, while 92% reported consuming low levels of alcohol (less than 14 units per week). Additionally, 56% had a BMI below 30, indicating they were not obese. Surprisingly, only 32% engaged in regular exercise, with at least 150 min per week, and only 25% reported getting adequate sleep, ranging from 7 to 9 h per night. Importantly, poorer health status was inversely associated with non/former smoking (OR: 0.543, 95% CI: 0.282-1.049), physical activity (OR: 0.238, 95% CI: 0.122-0.463), and adequate sleep (OR: 0.337, 95% CI: 0.160-0.710). Patients with higher HLI scores were less likely to have poor health status. Conclusions: In conclusion, our findings indicate that a significant proportion of patients with COPD failed to adhere to a minimum of three out of five healthy behaviors. Additionally, a higher number of healthy lifestyle factors defined by a high HLI score were independently associated with a better disease-specific quality of life. This is particularly important for COPD where quality of life is in the epicenter of management. Therefore, healthcare providers could significantly improve the management of COPD and patient outcomes by targeting and improving these lifestyle behaviors with targeted and holistic intervention strategies.