Healthy diets positively associated with health-related quality of life in children and adolescents from low socioeconomic areas: Findings from the Greek Food Aid Program, DIATROFI

OBJECTIVES

To assess the relationship of diet with health-related quality of life (HRQoL) in vulnerable children and adolescents.

METHODS

Data included 6583 children and adolescents (aged 3-18 years old) from the Greek Food-Aid DIATROFI Program in the 2015 to 2016 and 2017 to 2018 school years. HRQoL was measured with the Pediatric Quality of Life Inventory questionnaire and diet with food frequency questionnaires. The healthy plant-based diet index (hPDI), animal score, and dietary patterns were investigated.

RESULTS

The hPDI and animal score were associated with good HRQoL (odds ratio [OR] [95% confidence interval], 10-unit increase: ORhPDI = 1.28 [1.05, 1.57], ORanimal = 1.51 [1.14, 2.00]) and physical (ORanimal = 1.62 [1.23, 2.13]), emotional (ORhPDI = 1.30 [1.07, 1.58], ORanimal = 1.41 [1.08, 1.85]) and school function (ORhPDI = 1.32 [1.09, 1.59], ORanimal = 1.46 [1.12, 1.89]). Dietary patterns of fruits, raw vegetables, and cheese were associated with good HRQoL (OR of 1-unit increase: 1.22 [1.13, 1.32]), and physical OR = 1.18 [1.09, 1.27]) and emotional function (OR = 1.09 [1.02, 1.18]). Starchy foods and sweetened beverages were associated with poor HRQoL (OR = 0.75 [0.63, 0.90]), and emotional (OR = 0.80 [0.68, 0.95]) and school function (OR = 0.72 [0.61, 0.85]).

CONCLUSION

Healthy diets and dietary patterns were positively associated with the HRQoL of vulnerable children and adolescents, which may offer opportunities for prevention.

Qualitative research for improving Access to Vaccination for Newly Arrived Migrants (AcToVx4NAM)

Background

Increasing vaccination uptake among vulnerable groups constitutes a high priority across Europe. Access to Vaccination for Newly Arrived Migrants (AcToVx4NAM) is a 3-year project (Grant n 101018349, 3rd EU Health Programme) with a mission to increase vaccination uptake in Newly Arrived Migrants (NAM) regardless of legal status. AcToVx4NAM will improve health system Vaccination Literacy (VL) and vaccination access, by making access conditions more equitable and guaranteed.

Methods

Across 8 countries research took place to identify barriers, enablers and solutions to system level problems. Qualitative analysis through focus groups and interviews took place with professionals who work with NAMs including administrative personnel, cultural mediators, policy officers as well as physicians, nurses, social and mental health care professionals. Research examined barriers across the different dimensions that constitute the ActoVax4NAM General Conceptual Framework namely Entitlement, Reachability - Adherence (vs. hesitancy), Achievement of vaccination (execution and completion) and Evaluation.

Results

A number of common system level barriers were identified related to gaps in the registration process and problems in reaching people eligible for vaccinations. Not all NAMs face the same problems in terms of accessing the health system (i.e asylum seekers vs economic migrants). Communication breaks exist between the various services involved with delivering care and vaccination to NAMs while the lack of appropriate culturally sensitive and appropriate informative material still remains. The role of non-medical personnel in promoting vaccinations was emphasized as well as the importance of evaluating and disseminating best practice.

Conclusions

Findings direct to specific evidence based solutions with an emphasis on tailored made to specific needs activities.

Key messages

• Shift focus from individual level barriers to system level barriers considering all hubs of the vaccination process.

• Address vaccination needs of NAM early to stress the importance of prevention in the health integration process.

Health system barriers to HPV and MMR vaccination in recent migrants/refugees in Greece

Background

Migrants have lower vaccination rates compared to the general population and report multiple barriers in accessing related services. We explored practices and perceptions regarding MMR & HPV vaccinations in migrant children & adolescents from third countries to inform the development of tailored interventions to increase vaccination coverage. Third country nationals for the RIVER-EU project are migrants arriving to the EU from countries beyond Europe (the Middle East, Asia & Africa) escaping civil conflict, war, and poverty.

Methods

A qualitative study was conducted in the wider Athens area as part of the RIVER-EU project. Four Focus Groups and 23 semi-structured interviews were conducted with health care professionals, children and parents with a migrant background. Data were analysed using thematic content analysis. Findings: Identified barriers relate to the lack of standard operational procedures at system level that would define a schedule of vaccinations for migrants. Migrant vaccinations are subject to availability of vaccines (MMR as opposed to HPV) and potential threat of outbreaks (MMR vs HPV). There is no consistent, unified recording system of vaccinations while at system level there is a lack of trained cultural mediators. Targeted health promotion campaigns are rare while the few related activities that do exist are not systematically evaluated.

Conclusions

MMR vaccination is more frequent compared to HPV which is not prioritised by the target group or health professionals. Nevertheless, the target group is open to learning more about HPV while the important role of mothers concerning vaccinations emerged as crucial. Health professionals focus more on MMR due to the availability of the vaccine and the threat of outbreaks. The vaccination system has flaws and inconsistencies with a lack of vaccination related data. There is urgent need for culturally appropriate vaccination and appropriately evaluated vaccination campaigns.

Pilot action within the framework of the Mig-HealthCare project - implementation of community-based pilot studies addressing health inequalities of migrants and refugees

In the framework of the Mig-HealthCare project, a roadmap to community-based health care was developed including a toolbox and an algorithm. The Mig-HealthCare partners piloted parts of the roadmap in 8 EU countries. Piloting included actions on health promotion issues for migrants/refugees, mental health issues, non-communicable diseases, screening for breast and cervical cancer and vaccination issues. Two recommended practices were also piloted among migrants/refugees namely the 'circle of health' and health mentors while the Greek partner tested the developed algorithm in various health settings. All pilots were evaluated using common and pilot specific indicators for (a) appropriateness: the extent to which the piloted interventions were suitable for the target groups (service providers and/or migrants/refugees) (b) effectiveness: the extent to which the pilots' objectives were achieved, or are expected to be achieved, taking into account their relative importance (c) satisfaction: the extent to which pilots meet or surpass target groups and stakeholders (refugee/migrants, service providers and local population) expectation and needs (d) sustainability: the continuation of benefits from the pilot. Sustainability in the pilot implementation context is the ability of key target groups to sustain pilot benefits. Moreover, the impact of the interventions and their results should be sustainable in time. The impact of the pilots on the study population as well as implications for community-level health services are discussed.

Discrimination accessing to health care services: Feelings of migrants and misunderstandings of professionals

Discrimination against migrants in healthcare settings and also the negative impact of this discrimination on their health are well documented. These experiences of discrimination may present a barrier to accessing or seeking appropriate health care. For this reason, the Mig-HealthCare project aimed to study the perceived feeling of discrimination against migrants and explore the perception of community members regarding health-related issues about migrants. In order to answer both questions, based on a mix-methods design, the Mig-Healthcare consortium collected data from 1,286 questionnaires completed by migrants/refugees in 10 EU countries and carried out 6 focus groups and 5 individual interviews in 7 countries.

Quantitative results show increased levels of mental health-related symptoms among migrants/refugees as well as dental health problems. The majority of respondents in all countries of the interview, needed more information about their rights and the way to use the health care services, while in Greece migrants showed the biggest need for more information about several health topics.

Moreover, qualitative results pointed out the presence of deeply rooted misconceptions towards migrants and refugees that span across different thematic areas: migrants and refugees represent a vector for the transmission of new or eradicated diseases and a burden for the already overstretched welfare system since they often demand preferential pathways to health or social services at the expenses of the local population.

Implications for the quality of healthcare services available for migrants/refugees are discussed as well as health issues which are of particular importance to this population. Feelings of discrimination and the extent to which they influence the quality of care received are analysed in combination with health being a basic human right to which need to all people have equal rights.

Testing the Mig-HealthCare Algorithm in Greece

The Mig-HealthCare Algorithm is a tool, comprising a set of questions developed with the aim to (a) guide the user on how to access all the categories and tools that are available through the Roadmap & Toolbox (b) help the user identify the health issues of importance when providing care to a specific migrant/refugee. At the end of a series of questions, a brief report summarizing the main outcomes is generated. The algorithm was tested in Greece in two mainland reception centres and a local hospital in an area serving migrants/refugees. Results discuss the usefulness of the algorithm for improving the delivery of appropriate health services to migrants/refugees and its importance in raising awareness about the health conditions which are crucial for migrants/refugees and are expected to pose a significant burden on the health care systems of host countries unless dealt with adequately at an early stage.

Modelling healthcare access for migrants and refugees in Europe: identifying the major health issues

The Mig-HealthCare systematically searched to identify the key health areas of refugee/migrant health in order to facilitate interventions that help access to care services for migrants and refugees. The literature review was carried out in March 2018 using 3 large scientific databases using a combination of search terms following the PRISMA methodology and a standard set of items used to report on systematic reviews. Based on the predefined inclusion and exclusion criteria, a total of 118 publications were used for data extraction. It is important to note, that in almost all of the sources identified, the following cross-cutting factors were described as influencing access to healthcare: Continuity of Information, how it relates to policy, how it differs between health services and across-borders. Furthermore, the organizational coordination among social and health care providers in the host country determinates the successful access to healthcare of migrants/refugees.Language & Communication takes into consideration both the healthcare service and its provision of translators and cultural mediators, and the host country language proficiency of the migrant/refugee.Organizational improvement of access and delivery of health care services for migrants and refugees in addition to Cultural Competence of the healthcare providers meaning the ability to maximize their sensitivity in the service of care to culturally diverse groups.Health literacy understood as the motivation and competences of the migrant population to access, understand, appraise, and apply health information.

Additionally, the health issues of particular importance for migrants/refugees as emerged from the systematic review, including mental health, maternal/child health, health promotion, NCDs and chronic diseases, Oral/|Dental health, and Vaccinations should be included in planning future needs and healthcare access.

Short-term and long-term effectiveness of an e-coaching application; the INHERIT project

Background

Lifestyle e-coaching applications have the potential to be successful in changing people’s lifestyles although it is unclear whether such support would indeed help people with lower socioeconomic status (SES). The aim of the present study, conducted within the INHERIT EU project, was to investigate the effectiveness of a lifestyle e-coaching application in increasing physical activity (PA) in lower SES groups and whether such an increase is sustained after its prolonged use.

Methods

A two-site (Greece: N = 105, Netherlands: N = 89), two arm [Greece: 50 (experimental) and 55 (control), Netherlands: 45 (experimental) and 44 (control)], parallel group, randomized controlled trial proceeded in three phases over 19 weeks, comparing PA (as measured by the IPAQ questionnaire) of participants using a lifestyle e-coaching application with participants not using any such application. Inclusion criteria involved participants to be in low SES, have an age of 18-65 years and an estimated level of physical activity of less than 210 minutes/week, while they needed to possess a smartphone, willing to install the application and being fluent in Dutch or Greek.

Results

Results showed that the use of the app significantly improved participants’ PA in both countries, at 6 (Greece: p = 0.015, Netherlands: p = 0.003) and 19 weeks (Greece: p = 0.002, Netherlands: p < 0.001), while the effect was even higher for low physically active participants as measured at baseline, after both time periods. Compared to the control group, after adjusting for several characteristics, the experimental group achieved a better improvement of PA at 19 weeks compared to baseline (p = 0.006) and week 6 (p = 0.007).

Conclusions

Positive effects on participants’ PA after 19 weeks were observed, with the findings suggesting that the longer the application is used, the greater the improvement of PA, while the effect was more obvious among those following a sedentary lifestyle as measured at baseline.

Key messages

E-coaching applications could be useful in promoting physical activity among people from low SES. E-coaching applications are cost effective and environmentally friendly methods of promoting physical activity. Uptake by national health systems should be examined further.

Health Communication needs of health professionals in Europe – the H-COM cross sectional study

Background

Effective communication between Health Professionals (HP) and patients is crucial for the overall functioning of the healthcare system with positive impacts on readmission rates, treatment outcomes, adherence and costs. However, health communication training is limited especially during medical training. In the framework of the EU H-COM project an exploration of health communication needs and gaps and preferred training methods was performed among HP.

Methods

A cross-sectional online survey was conducted among 702 health professionals (Physicians: n = 315; Nurses: n = 258; Other: n = 129) through a purpose made questionnaire available in English, Greek, Polish, Spanish and German.

Results

Health communication training is considered necessary for physicians (89.8%) and nurses (89.7%), although 42.4% of them never received relevant training in the past. Professional status (p < 0.001), age (p = 0.079), gender (p = 0.090) and years of experience (p = 0.012) affected the likelihood of not having received such training, with physicians, HPs aged 45-54 years old, males and those having 6-10 years of experience being most in need. At least 50.0% reported encountering problems in communicating with their patients and facing several barriers either in primary health care settings and hospitals or in private practice. The ability to listen and answer patients, deliver bad news and obtain medical history were the most important communication skills identified, while the most suitable training method was learning relevant practical skills. The availability of such trainings is reported as being fair or poor at all educational levels by the majority.

Conclusions

Health communication training is considered important although currently not available to the extent needed. This research provides evidence concerning the preferred type, frequency and mode of health communication training providing also insight on differences between various HPs.

Key messages

Health communication training is crucial but inadequate in Europe. There are specific training needs and preferences among HP which need to be considered. Health communication training needs to be adapted and tailored to professionals’ age, experience and status.

Survey on the physical and mental health among migrants and refugees in ten European countries

This study discusses the main findings of the quantitative research conducted within the Mig-HealthCare consortium countries to explore the physical and mental health of migrants and refugees. The study population is defined as migrants/refugees who have been residing in Europe, for at least 6 months and up to 5 years. In order to be able to capture the recent migration flow, the analysis was based on 1169 questionnaires collected in 10 EU-Member States, answered by adult migrants residing less than 5 years in the specific country.

A total of 29% of migrants stated that their health is poor or fair. Overall, 56.9% of migrants needed health care services during the last 6 months, however approximately one in four did not have access to them. The most frequent problems were long waiting times, not being able to organize an appointment, not knowing where to go, lack of communication and long distances. The most frequent chronic health problem migrants/refugees face is caries and headaches/migraines, followed by psychological disease and sleep disorders. Approximately one in three women have been pregnant since entering the current EU country, whereas one in four have had a miscarriage or abortion and 21.5% are currently pregnant.

Summing up, most of the migrants face common medical problems such as bad teeth, headaches and psychological problems. However long waiting times, not knowing where to go and lack of communication are barriers to accessing healthcare. The fact that the immunization status of migrants/refugees is unclear, a significant number suffer from serious chronic diseases and the limited breast and cervical cancer screening of female migrants/refugees pose serious threats to their health and important challenges for the health services of Europe.

Analysis of needs, expectations and capacities of health and social care professionals in order to provide culturally adapted care

The Mig-HealthCare consortium conducted a qualitative study of the health care needs of vulnerable migrants/refugees in Europe. The research was conducted between Fall 2017 and Spring 2018. In total, 20 focus group discussions or, where necessary individual interviews (19), were organised with health care professionals and service providers; policymakers; and representatives from Non-Governmental Organisations - NGOs. Thematic qualitative analysis was employed. The main results of the analysis show that:

Health care provision for migrants is uneven throughout the EU and variations exist even within the same country. Health care providers and NGOs agree that health care for migrants is inadequate and biased in favour of particular conditions and cases (minors, pregnant women and acute conditions). Challenges faced by different countries vary; while in some countries the main issue is legal access, in other basic needs such as sanitation and basic infrastructure were emphasised. Austerity measures following the 2008 financial crisis have negatively affected the health care system in general, which in turn has negatively affected the provision of health care for migrants/refugees. Discrimination linked to socio-economic and ethnic conditions is reported as a barrier to equal health care access. Knowledge, language and communication on both the demand and the supply side of health care provision emerge as crucial to ensure equal access for migrants/refugees. Gender may act as a barrier with women tending to be more marginalised in the host country, in terms of language proficiency and health literacy, lowering health care access. One of the main challenges for providing equal health care access for migrants has to do with the ability to balance a universal right to health with the particular means of achieving it. The evidence collected here shows how this tension between end and means is at work in different moments of the provision of health care for migrants/refugees.

Food insecurity and social determinants of students’ low adherence to the Mediterranean diet

Background

Despite the fact that the Meditteranean diet is highly beneficiary for people’s health, there are many factors which cause disparities in the level of adherence. The aim of the present work was to investigate the effect of household food insecurity (FI) on adherence to the Mediterranean diet (AMD), to explore the participants’ characteristics modifying the studied relationship and find the social determinants of students’ low adherence to the specific dietary pattern.

Methods

A cross-sectional study with 140 schools and 4,242 students was conducted in Greece (2017-2018). Especially designed and validated instruments were used to record students’ sociodemographic characteristics, household’s FI status and students’ AMD. Analysis of Variance (ANOVA) and Covariance (ANCOVA) was used to investigate the effect of FI and to identify the significant social determinants of students’ AMD, according to students’ school grade.

Results

After adjusting for other characteristics, students whose both parents are born in other countries, spend at most 4 hours/week on TV/electronic games, live in the regions of Peloponnese, Central Macedonia or Attica and attend primary schools adhere more to the Mediterranean diet, while higher level of physical activity and lower FI are significantly associated with better AMD. Parents’ educational level in nursery schools (p = 0.002) and employment status in nursery schools (p = 0.012) and in high schools/ lyceums (p = 0.008) were found to modify significantly the studied relationship in the univariate analysis, while school grade (p = 0.013) and physical activity (p = 0.088) were found to modify the studied relationship in the multivariable analysis.

Conclusions

Several demographic, socioeconomic and lifestyle characteristics were significantly associated with students’ AMD. Thus, emphasis should be given on the design of special programs to reduce household FI and intervene in the rest characteristics.

Key messages

Researchers and policymakers should consider food insecurity as important risk factor for school-aged children, particularly for those who live in poverty. Emphasis should be given on the design of special low-cost programs aiming to reduce food insecurity.

Best practices addressing healthcare care access of migrants and refugees in European countries

Mig-healthCare has identified sources in the countries and languages of the consortium providing guidance for community-based healthcare for migrants and refugees. A total of 54 sources that refer to best practices in seven European countries were identified. Results were categorized along with the themes: organization, communication, training, education and facilities & services. Successful organizational measures were a close collaboration with different governmental authorities, NGOs, community organizations and various local service providers. Moreover, engagement with members from both the host community and the migrant/refugee community in the design and implementation phases is essential. The need to track all activities through data collection and periodic evaluations is important in order to evaluate the effectiveness of systems. Funding was mentioned as important to secure continuity of projects and systems. Bridging communication barriers is a major facilitator to reduce health disparities. Differences in the types of practices and challenges per country were noted. Translators and cultural mediators are a key element in successful implementation, but across EU there is a need for more specialized staff to face the cultural barriers of the large variation in refugee/migrant backgrounds. The empowerment of migrants/refugees in promoting well-being through the engagement of the host community to help reduce stigma and discrimination is a successful strategy facilitating the access to care due to the increase of their health literacy skills. Finally, tailored services to give an answer to the specific needs of migrants and refugees are important, for example at first reception centres, standard medical screening and psychosocial risk assessment was recommended. Through this analysis, we can distinguish community-based care models elements facilitating the access of migrants and refugees to healthcare.

Predictions concerning the use of health care services in Europe by migrants/refugees and the Mig-HealthCare Roadmap & Toolbox

Based on the multiple levels of research conducted within the project the consortium developed a roadmap & toolbox which includes the following categories: Continuity of information, Language Culture & Communication, Mental Health, Vaccinations, Maternal/child health, Health promotion, Oral health/Dental Care and NCDs while the Toolbox contains tools on these categories in different languages. The roadmap & toolbox is accessible through the project website. In addition, different scenarios, giving a comprehensive picture of the foreseen situation and the evidence-based policies and actions needed to maximize the effective delivery and sensitivity in the service of care to culturally diverse population groups were developed focusing on mental health, chronic disease management and oral health. Refugees and migrants tend to have a higher prevalence of mental distress compared to non-refugees. For the challenge of lack of recording mental health of migrants/refugees, improving the collaboration between ‘migrant-specific’ organizations is needed. Health care systems in Europe will have to accommodate the high demand for health care services for chronic conditions among migrants/refugees in the coming years. Implications such as the impact of poverty, level of health literacy and/or the cultural adaption of the measures need to be considered when planning to address future trends related to non-communicable diseases including diabetes among migrants/refugees. The provision of oral care presents great variability across the European countries, but in most cases, it is characterized by high cost and restricted range of services if offered within the state health systems. Migrants /refugees will not be able to meet the high cost of private dental care. Local community interventions have been proven very effective.

Physician-patient communication: A qualitative study of perceptions, barriers, and needs in 4 EU MS

Background

Good physician-patient communication is an important aspect of patient-centered care and contributes to positive health outcomes. However there is a lack of standard EU communication training policies for physicians. This study explores the barriers to good communication for both physicians and patients across four EU countries as part of the EU-funded Project “H-COM”, Health Communication Training for Health Professionals.

Methods

Eight focus groups were conducted with a total of 31 patients and 38 physicians from Germany, Greece, Spain, and Cyprus. Three themes were covered; perceptions, barriers and needs for health communication.

Results

Commonalities and differences between countries and target groups were identified, with participants discussing attitudinal, emotional, educational, and systemic barriers to good communication. Identified barriers among patients include a deeply embedded hierarchical notion and arrogance among physicians, inadequate or difficult to understand language, busy schedules. Among doctors barriers identified were mostly systemic having to do with busy schedules, large number of patients, and lack of time. Participants especially patients indicated a significant gap in health communication knowledge, skills, and training for physicians, with several regional differences being present especially between Mediterranean and central European countries.

Conclusions

The results imply a strong need for communication training, tailored accordingly in specific countries. Further development of policies related to the inclusion of such training in medical studies across EU would be of great importance.

Key messages

There are differences concerning health communication needs and barriers between EU regions and the development of tailored training. Although identified as important there is a lack of health communication training in certain EU MS and an urgent need to incorporate training in basic medical and nursing education.

Perceptions of parents and children, participating in a school-based feeding programme in disadvantaged areas in Greece: a qualitative study

AIM

The aim of this work was to explore parents' and children's attitudes towards healthy eating and the free provision of a daily school meal in underprivileged areas of Greece.

METHODS

Twenty focus groups were conducted in 14 schools. Eligible participants were children/adolescents and their parents, who were recipients of a food aid, healthy nutrition school-based programme. Their perceptions towards healthy eating and related barriers, experience of a school feeding programme, other nutrition intervention initiatives were qualitatively evaluated.

RESULTS

Most of the parents referred to the Mediterranean diet as a healthy dietary pattern. Nearly all parents were aware of their effect as role models and commented on the benefits of eating together as a family, as well as on the importance of improving their own dietary habits. Parents reported using various methods to promote a healthy diet, as part of their parenting role. They perceived their role as difficult, as they have to deal with children's resistance, financial constraints arising from the current economic crisis in Greece and busy work schedules. All students perceived the school feeding programme as health-promoting, reflecting their parents' perceptions.

CONCLUSION

The present findings indicate that although the traditional Mediterranean diet was perceived by the majority of the adults as a health and traditional dietary pattern, parents reported several barriers related to its adoption. In particular, the most common barriers included financial difficulties, limited time for food preparation and children's resistance to consume healthy foods.

The influence of dietary patterns on the development of thyroid cancer

To elucidate the role of diet in the development of thyroid cancer, we conducted a case-control study of 113 persons with histologically-verified thyroid cancer and 138 controls, matched by age, gender and health unit. Socio-economic data, known risk factors and food consumption of more than 100 items were recorded by interviewer-administered prestructured questionnaire. Factor analysis was used to identify possible dietary patterns and logistic regression analysis was used to explore the effect of food items or dietary patterns on thyroid cancer. After adjustment for age, gender, body mass index (BMI), and total energy intake, significant positive associations were observed for pork consumption, while negative ones were observed for tomatoes, lemons and pasta. Dietary patterns of fruits, raw vegetables and mixed raw vegetables and fruits, led to a reduced risk (corresponding odds ratios (ORs) 0.68, 0.71, 0.73) for all thyroid cancers and similar figures were obtained for papillary thyroid cancers. A dietary pattern of fish and cooked vegetables led to an increased risk (OR 2.79) of follicular cancer.

Taxonomic characterization of two rubber degrading bacteria belonging to the species Gordonia polyisoprenivorans and analysis of hyper variable regions of 16S rDNA sequences

Two cis-1,4-polyisoprene (isoprene rubber) degrading bacteria, strains VH2 and Y2K, were identified as strains of the species Gordonia polyisoprenivorans belonging to the Corynebacterineae, a suborder of the order Actinomycetales. Both showed characteristic growth and degradation of isoprene rubber as described previously for the type strain of G. polyisoprenivorans Kd2 (DSM 44302(T)). For strain VH2 the chemotaxonomic properties were investigated, and DNA-DNA hybridization experiments with the type strain revealed the affiliation to the species G. polyisoprenivorans. The comparison of the 16S rDNA sequences, and especially hyper variable regions of these, led to the classification of strain Y2K to the same species. At present, the species G. polyisoprenivorans comprises three different isolates which share the ability to degrade isoprene rubber potently but which were obtained from different geographic regions.

Occupation and leukemia: a population-based case-control study in Iowa and Minnesota

BACKGROUND

Studies have suggested that risk of leukemia may be associated with occupational or industrial exposures and risk may vary by the histological type of the disease.

METHODS

A population-based case-control study was conducted in Iowa and Minnesota to evaluate the association between various occupations, industries, and occupational exposures and leukemia risk. A total of 513 cases and 1,087 controls was included in the study. A lifetime occupational history and other risk factor information were collected through in-person interviews, and a job-exposure matrix was used to assess possible risks associated with specific exposures.

RESULTS

A significantly increased risk of leukemia was observed among agricultural service industries and among nursing and healthcare workers. Janitors, cleaners, and light truck drivers also experienced increased risk. Those employed in plumbing, heating and air conditioning industries, and sales of nondurable goods (such as paints and varnishes) had an increased risk. Printers, painters, and workers in the food and metal industries had a nonsignificantly increased risk of leukemia. Analyses by specific exposures and histology of leukemia showed that risk of leukemia associated with occupational or industrial exposures may vary by histological type of the disease.

CONCLUSIONS

An increased risk of leukemia among workers employed in agricultural industries, nursing and healthcare workers, and in a few occupations with possible exposure to solvents is consistent with earlier studies. Associations of risk with occupations not observed previously deserve further assessment. Published 2001 Wiley-Liss, Inc.

Urinary estrogen metabolites and mammographic parenchymal patterns in postmenopausal women

It has been hypothesized that women who metabolize their endogenous estrogens predominantly via 16(alpha)-hydroxylation rather than via 2-hydroxylation and, as a result, have a low ratio of 2-hydroxyestrone (2-OHE1):16(alpha)-hydroxyestrone (16(alpha)-OHE1) are at an increased risk of breast cancer. Epidemiological evidence in support of this hypothesis is scarce and mostly based on measurements made after the onset of the disease. To gain insight into the role of these metabolites in the etiology of breast cancer, we assessed their relationship with high-density Wolfe mammographic parenchymal patterns (P2/DY), a recognized indicator of risk of this tumor. The study was nested within a large cross-sectional survey on determinants of mammographic patterns carried out in a population-based breast screening program in Northern Greece. Urinary levels of 2-OHE1 and 16(alpha)-OHE1 were measured in a random sample of 70 postmenopausal women with P2/DY mammographic patterns and in a random sample of 70 women with N1 mammographic patterns, individually matched to the P2/DY women on year of birth, years since menopause and date of urine collection. Women with a P2/DY pattern had, on average, 58% higher levels of 2-OHE1 (P = 0.002) and 15% higher levels of 16(alpha)-OHE1 (P = 0.37) than those with an N1 pattern. The ratio of 2-OHE1:16(alpha)-OHE1 was 35% higher (P = 0.005) in women with a P2/DY pattern. Women in the highest one-third of this ratio were six times more likely to have a P2/DY pattern than those in the lowest one-third after adjusting for potential confounders (prevalence odds ratio, 6.2; 95% CI, 1.7-22.9; test for linear trend, P = 0.002). These findings seem to suggest that a high, rather than a low, 2-OHE1:16(alpha)-OHE1 ratio may be associated with an increase in breast cancer risk at postmenopausal ages, unless the pathway through which estrogen metabolites may affect breast cancer risk is unrelated to mammographic parenchymal patterns.

Comparisons of cervical cancer screening programmes in the European Union

This paper summarises the similarities and differences between the cervical cancer screening programmes operating in the 15 Member States of the European Union as presented in the separate papers prepared by each country. The screening programmes are compared in terms of their duration of operation, type and sources of funding, invitation methodology, target population, organisation and quality assurance methodology with the aim of shedding some light upon the current situation of cervical cancer screening within the European Union.

Cervical cancer screening in Greece

The aim of this study was to describe the state of the art in cervical cancer screening in Greece by presenting the two regionally organised screening programmes that currently operate in the country. Both programmes were initiated in 1991 and are partly funded by the European Union. The Ormylia screening programme covers the population of Halkidiki (Northern Greece), a predominantly rural area. The second programme covers the regions of Messinia and Ilia (Southern Greece). Both programmes are targeted at women aged 25-64 years of age and a Papanicolaou (Pap) smear test is recommended every 2-3 years. Electoral and municipal registries are used to identify the target population and personal invitations are sent to the eligible women in the screening programme. The Ormylia programme is based at the Centre 'Our Lady Who Loves Mankind', whereas mobile units are used by the Messinia and Ilia programme. Slide reading for the Ormylia programme is performed in the cytology laboratory of Alexandra Hospital in Athens and epidemiological support is provided by the Department of Hygiene and Epidemiology (Medical School, University of Athens). A specifically designed database is used for data recording. Over 80% of the target population in the region have already been screened. Communication of results is by means of a personal letter upon a negative result and in person upon a suspicious result. Quality assurance in both programmes is based on the European protocol. These two programmes are the sole organised cervical cancer screening activities in Greece in the absence of a national programme. They employ well-trained personnel, they use modern equipment and have strict quality assurance procedures.

Biodegradation of cis-1,4-polyisoprene rubbers by distinct actinomycetes: microbial strategies and detailed surface analysis

Several actinomycetes isolated from nature were able to use both natural rubber (NR) and synthetic cis-1,4-polyisoprene rubber (IR) as a sole source of carbon. According to their degradation behavior, they were divided into two groups. Representatives of the first group grew only in direct contact to the rubber substrate and led to considerable disintegration of the material during cultivation. The second group consisted of weaker rubber decomposers that did not grow adhesively, as indicated by the formation of clear zones (translucent halos) around bacterial colonies after cultivation on NR dispersed in mineral agar. Taxonomic analysis of four selected strains based on 16S rRNA similarity examinations revealed two Gordonia sp. strains, VH2 and Kb2, and one Mycobacterium fortuitum strain, NF4, belonging to the first group as well as one Micromonospora aurantiaca strain, W2b, belonging to the second group. Schiff's reagent staining tests performed for each of the strains indicated colonization of the rubber surface, formation of a bacterial biofilm, and occurrence of compounds containing aldehyde groups during cultivation with NR latex gloves. Detailed analysis by means of scanning electron microscopy yielded further evidence for the two different microbial strategies and clarified the colonization efficiency. Thereby, strains VH2, Kb2, and NF4 directly adhered to and merged into the rubber material, while strain W2b produced mycelial corridors, especially on the surface of IR. Fourier transform infrared spectroscopy comprising the attenuated total reflectance technique was applied on NR latex gloves overgrown by cells of the Gordonia strains, which were the strongest rubber decomposers. Spectra demonstrated the decrease in number of cis-1,4 double bonds, the formation of carbonyl groups, and the change of the overall chemical environment, indicating that an oxidative attack at the double bond is the first metabolic step of the biodegradation process.

Effect of pretreatment of rubber material on its biodegradability by various rubber degrading bacteria

The effect of pretreatment of several cis-1,4-polyisoprene containing rubbers on their biodegradability was examined. Tests were carried out with six recently isolated and characterized rubber degrading bacteria belonging to the genera Gordonia (strains Kb2, Kd2 and VH2), Mycobacterium, Micromonospora and Pseudomonas. All strains were able to use natural rubber (NR) as well as NR latex gloves as sole carbon source. Extraction of NR latex gloves by organic solvents resulted in an enhancement of growth for three of the selected strains. On the other hand, growth of Gordonia sp. (strain Kb2 and Kd2), Mycobacterium fortuitum NF4 and Micromonospora aurantiaca W2b on synthetic cis-1,4-polyisoprene did only occur after removal of the antioxidants, that are usually added during manufacture to prevent aging of the materials. Detailed degradation studies performed with Gordonia sp. Kb2 revealed an enhanced mineralization of pretreated NR latex gloves and mineralization of purified natural rubber (NR), indicating the actual mineralization of cis-1,4-polyisoprene rubber constituent even after removal of non-rubber constituent that may act as co-metabolic substrate and support microbial growth. Further analysis by scanning electron microscopy (SEM) clearly demonstrated the enhanced colonization efficiency of these bacteria towards pretreated NR latex gloves. Colonization was additionally visualized by staining of overgrown NR latex gloves with Schiff's reagent, and the purple color produced in the area of degradation was an evidence for the accumulation of aldehydes containing oligomers. Further enhancement of latex gloves degradation could be achieved after successive replacement of mineral salts medium during cultivation. Thereby, a rapid disintegration of untreated NR latex gloves material was accomplished by Gordonia sp. strain VH2.

A gram-negative bacterium, identified as Pseudomonas aeruginosa AL98, is a potent degrader of natural rubber and synthetic cis-1, 4-polyisoprene

A Gram-negative bacterium, strain AL98, was isolated from foul water inside of a deteriorated car tire on a farmer's field in Münster, Germany. The strain was able to considerably disintegrate natural rubber (NR), either in the raw state as NR latex concentrate or in the vulcanized state as NR latex glove, as well as raw synthetic cis-1,4-polyisoprene (IR). Determination of carbon dioxide evolution and living cell number during batch cultivation with each of the materials as sole source of carbon, revealed mineralization of the rubber polymer during biomass increase. Surface investigation by scanning electron microscopy gave evidence for an adhesive growth behavior of the strain proceeding by colonizing the rubber surface, merging into the rubber and forming a biofilm prior to disintegration of the material. Schiff's reagent staining performed with NR latex gloves indicated production and accumulation of aldehyde groups during colonization. The solid glove substrate disappeared completely after a prolonged cultivation period as a result of continuous degradation. Taxonomic analyses of the strain, which were also based on similarity examination of the complete 16S rRNA gene, revealed classification of strain AL98 as a strain of Pseudomonas aeruginosa. This is the first report about the isolation of a Gram-negative bacterium exhibiting strong rubber decomposing properties.

Dietary factors in relation to rheumatoid arthritis: a role for olive oil and cooked vegetables?

BACKGROUND

Although several studies showed that risk of rheumatoid arthritis (RA) is inversely associated with consumption of n-3 fatty acids, the one study showing that olive oil may have a protective role has not yet been confirmed.

OBJECTIVE

We examined the relation between dietary factors and risk of RA in persons from southern Greece.

DESIGN

We studied 145 RA patients and 188 control subjects who provided information on demographic and socioeconomic variables, prior medical and family history, and present disease status. Subjects responded to an interviewer-administered, validated, food-frequency questionnaire that assessed the consumption of >100 food items. We calculated chi-square statistics for linear trend and odds ratios (ORs) for the development of RA in relation to the consumption of olive oil, fish, vegetables, and a series of food groups classified in quartiles.

RESULTS

Risk of developing RA was inversely and significantly associated only with cooked vegetables (OR: 0.39) and olive oil (OR: 0.39) by univariate analysis. A significant trend was observed with increasing olive oil (chi-square: 4.28; P = 0.03) and cooked vegetable (chi-square: 10. 48; P = 0.001) consumption. Multiple logistic regression analysis models confirmed the independent and inverse association between olive oil or cooked vegetable consumption and risk of RA (OR: 0.38 and 0.24, respectively).

CONCLUSIONS

Consumption of both cooked vegetables and olive oil was inversely and independently associated with risk of RA in this population. Further research is needed to elucidate the underlying mechanisms of this finding, which may include the antioxidant properties or the high n-9 fatty acid content of the olive oil.

Gordonia polyisoprenivorans sp. nov., a rubber-degrading actinomycete isolated from an automobile tyre

A rubber-degrading bacterium (strain Kd2T) was isolated from fouling tyre water inside a deteriorated automobile tyre. The strain was aerobic, Grampositive, produced elementary branching hyphae which fragmented into rod/coccus-like elements and showed chemotaxonomic markers which were consistent with the classification of Gordonia, i.e. meso-diaminopimelic acid, N-glycolyl muramic acid, arabinose and galactose as diagnostic sugars, a fatty acid pattern composed of unbranched saturated and monounsaturated fatty acids with a considerable amount of tuberculostearic acid, and mycolic acids comprising 58-66 carbon atoms with two principal mycolic acids C60 and C62 counting for over 60%. Results of 16S rDNA analyses as well as chemotaxonomic results, led to the conclusion that Gordonia sp. strain Kd2T (= DSM 44302T) represents a new species within the genus Gordonia for which the name Gordonia polyisoprenivorans is proposed.

Dietary fat and carbohydrates are independently associated with circulating insulin-like growth factor 1 and insulin-like growth factor-binding protein 3 concentrations in healthy adults

PURPOSE

To evaluate and quantify the association between consumption of specific food groups/macronutrients and concentrations of serum insulin-like growth factor 1 (IGF-1) and insulin-like growth factor-binding protein 3 (IGFBP-3).

SUBJECTS AND METHODS

Data from a comprehensive food-frequency questionnaire administered to 115 healthy subjects were used to study cross-sectionally the relationship between nutritional factors and circulating IGF-1 and IGFBP-3 concentrations. Adjustment for the effect of total energy intake and a series of epidemiologic parameters (age, sex, height, body mass index, smoking, alcohol consumption, and coffee drinking) was implemented through multivariate linear regression.

RESULTS

We observed that serum levels of IGF-1 are positively associated with consumption of red meats, fats, and oils. In addition, serum levels of IGF-1 are independently and positively associated with energy intake from lipids and negatively associated with energy intake from carbohydrates. Finally, serum levels of IGFBP-3 are independently and negatively associated with energy intake from saturated fat.

CONCLUSION

Serum IGF-1 and/or IGFBP-3 concentrations are associated with red meat, carbohydrate intake, and fat intake and, thus, may mediate the effect of these dietary factors on the pathogenesis of several disease states. Additional studies are needed to further quantify these associations and elucidate the underlying mechanisms.

Age, sex, and smoking are predictors of circulating insulin-like growth factor 1 and insulin-like growth factor-binding protein 3

PURPOSE

Insulin-like growth factor (IGF-1) and its major binding protein (IGF-BP3) have recently been implicated in the pathogenesis of several malignancies. However, anthropometric and lifestyle predictors of these hormones have not been elucidated. Here we report the results of a cross-sectional study.

SUBJECTS AND METHODS

This cross-sectional study examines the relationship of a series of epidemiologic parameters (age, sex, height, body mass index, smoking, alcohol consumption, and coffee drinking) with IGF-1 and IGF-BP3 in a sample of 130 healthy adults.

RESULTS

We observed that serum levels of IGF-1 are higher, whereas levels of IGF-BP3 are lower, in men than in women. In addition, serum levels of IGF-1 are independently and negatively associated with age and positively associated with pack-year history of smoking. Finally, serum levels of IGF-BP3 are independently and negatively associated with the number of cigarettes smoked per day or pack-year history of smoking.

CONCLUSION

Age, sex, and smoking are independent predictors of IGF-1 and/or IGF-BP3. The influence of these epidemiologic variables on the pathogenesis of disease states associated with IGF-1 and IGF-BP3 warrants further exploration.

Lung cancer and occupational risk factors in Greece

This study estimated the proportion of lung cancer in Greece that was attributable to occupational exposure. Two hundred eighty-two patients with lung cancer and 494 controls were interviewed about their socioeconomic characteristics, sex, age, and occupational, smoking, and residential histories. Each subject was classified as exposed or unexposed to known occupational lung carcinogens. Because of the small number of females exposed, only males were included in the multivariate analyses. When the occupationally exposed subjects were compared with the unexposed subjects and an adjustment for smoking was made, the relative risk for lung cancer was 2.9 (95% confidence interval, 1.95-4.31). If 5% to 10% of the Greek population were occupationally exposed, the attributable risk would be 9.9% to 16.6%, respectively. Occupational exposures conferred an additional risk that was approximately threefold that of smoking alone. Risks increased in a dose-response fashion with increasing cigarette consumption.

Reported influenza in pregnancy and childhood tumour

The present study was conducted to test the hypothesis that exposure to influenza in pregnancy increases the risk of tumour of certain type in childhood. Children ages 17 years or less diagnosed in Greece with brain tumours or neuroblastomas from 1982 to 1993 (n = 94) were contrasted to 210 controls selected from the same hospitals. Mothers of these children were interviewed about a variety of possible etiologic factors. The prevalence of influenza in Greece for each year during the period 1984-1992 was also compared with the number of children born during the same year who subsequently developed brain tumour or neuroblastoma. The results indicate a significant association between influenza in pregnant women and occurrence of tumour in index child (OR: 3.15, 95% CI: 1.13-8.77). These results persisted when adjustment for potential confounding factors was made. The findings should be interpreted cautiously because of lack of serologic documentation of information about infection obtained in interviews. A positive correlation (r = 0.74) of the number of tumour births by year of birth with the prevalence of influenza during the same year was also noted. This exploratory study is one of the few case-control studies of the epidemiology of childhood tumours in children, and the results suggest directions for future epidemiologic studies in this relatively uncharted field.

Corrected QT interval in relation to the severity of diabetic autonomic neuropathy

The aim of this study was to investigate to what extent the existence of objective signs of diabetic autonomic neuropathy affects the corrected QT interval (QTc) in diabetic subjects. A total of 105 diabetic subjects (type 1, n = 53; type 2, n = 52) as well as 40 matched (by age and sex) control subjects were studied. All subjects underwent the battery of five Ewing tests. Autonomic neuropathy was diagnosed if two of the five tests were abnormal. In addition, the result of each test was considered as normal (grade = 0), borderline (grade = 1) or abnormal (grade = 2), and on the basis of the sum of the scores we calculated a total score for autonomic neuropathy. The QTc interval was measured at rest, and a value > 440 ms was considered abnormal. The QTc interval was significantly more prolonged in diabetic persons with autonomic neuropathy than in those without neutopathy and in control subjects: 408.4 +/- 24.2 ms vs. 394.6 +/- 27.9 ms and 393.6 +/- 25.5 ms respectively (P = 0.001). Furthermore, multivariate analysis controlling for age, sex, systolic and diastolic blood pressure, body mass index (BMI), waist-hip ratio (WHR), smoking, type and duration of diabetes, type of treatment, HBA1c and total score of autonomic neuropathy eliminated the role of all these factors as potential confounders except for the total score of autonomic neuropathy, which was found to affect QTc interval independently and significantly (P = 0.012). In summary, the present study confirmed the well-known relation between autonomic neuropathy and QTc interval; in addition, it showed that QTc prolongation is associated with major degrees of autonomic neuropathy.

Family history as a risk factor for rheumatoid arthritis: a case-control study

OBJECTIVE

To investigate the risk of rheumatoid arthritis (RA) in the first degree relatives and to investigate whether the sex of the parent influences the pattern of inheritance.

METHODS

An interview based case-control study, with subjects serially matched for age and sex. We analyzed 126 cases (hospital cases) and 94 controls (derived from the same hospitals), who gave information for family history of RA. Data concerning RA history among siblings and parents were computerized and analyzed univariately and multivariately.

RESULTS

The odds ratio (OR) for developing RA is 4.4 (p < 0.001) if a first degree relative reported having the disease and 5.4 (p < 0.01) if a female first degree relative reported having the disease. For females the OR is 7.0 (p < 0.01) if the first degree relative is female. When the analysis was restricted to parents only, it was found that mothers with RA predispose their daughters and sons to develop RA more (OR = 8.6, p < 0.01, for daughters and 4.8, p < 0.05, for both sexes) than fathers (OR = 1.1 and 1.9, respectively).

CONCLUSION

This case-control study confirms the familial clustering of RA and suggests that mothers confer susceptibility to RA on their offspring more often than fathers.

HLA-DRB1 alleles in Greek rheumatoid arthritis patients and their association with clinical characteristics

The association of certain HLA-DRB1 alleles in Green rheumatoid arthritis (RA) patients with several features of the disease, the gender of the patient and the age at onset was investigated. This case control study includes 86 Greek RA patients and 130 healthy controls unrelated to the patients. HLA typing was performed by polymerase chain reaction (PCR) and hybridization with sequence-specific oligonucleotide (SSO) probes. HLA-DR4 was significantly increased in RA patients. The alleles *0101, *0401, *0405 and *1001 were associated with a higher risk of RA. The *0408 allele was absent from our patients. Sixty-five per cent of RA patients carried the 'sharp epitope' (SE) compared with 31.5% of controls. The risk for RA in individuals carrying a single allele positive for SE was 2.85 times higher, and for those carrying two alleles positive for SE 8.57 times higher, than in SE-negative individuals. The risk was higher in those carrying the *0401 allele, followed by *0405 and *0101, while the genotype *0401/*0404 was absent. Alleles positive for SE comprise a predisposing factor for RA at an early age, particularly in men, and are associated with positive rheumatoid factor, nodules and erosions.

Analysis of fructans from higher plants by matrix-assisted laser desorption/ionization mass spectrometry

In this communication both matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS) and high-performance anion-exchange chromatography (HPAEC) have been applied to analyze fructans from higher plants. Size distribution of a commercially available fructan preparation from Dahlia variabilis L. was determined by MALDI-MS. Molecular masses ranged from 2,000 up to 6,000 Da with a peak value of distribution at 2,635 Da. Essentially the same pattern was obtained using HPAEC. Low-molecular-weight fructans from onion bulbs (Allium cepa L.) were studied in more detail. Tissue extracts were analyzed by MALDI-MS without any analyte purification. Mass-spectra of both proteins and oligosaccharides were obtained. For identification, metastable ion scanning was performed. Neither deproteinization nor deionization of the samples affected the oligosaccharide pattern. Using HPAEC, a more complex oligosaccharide pattern was obtained because isomeric glycans were differentiated. However, the overall size distribution was similar to that obtained by MALDI-MS. In further experiments epidermal or parenchyma cell layers of the onion bulb were placed into matrix solution and were then subjected to MALDI-MS and metastable ion scanning as well. By taking this approach, analyte desorption was achieved immediately from plant tissue. Oligosaccharide mass spectra were essentially the same as those of the extracts. To our knowledge, this is the first time that MALDI-MS has been applied as a microprobe to plant tissue. Finally MALDI-MS analysis was performed using single-cell extracts from onion tissues without any purification of the analyte.