Investigating predictors of well-being in type 2 diabetes mellitus patients: the role of undiagnosed depression

Type 2 diabetes mellitus (T2DM) is a common metabolic disorder with various medical and psychological adverse effects. Well-being in patients with T2DM is often compromised. The aim of the present study was to investigate clinicodemographic predictors of well-being in patients with T2DM with no known psychiatric history and explore the mediatory role of undiagnosed anxiety and depression. We recruited 175 outpatients with T2DM (54.3% males, aged 34-79 (mean 59.9) years) followed-up at the Diabetes Center of the General Hospital of Nikaia-Peiraeus in Athens. Patients included had no severe diabetes-related complications or known psychiatric history. Well-being was measured with the Mental Health Continuum Short-Form (MHC-SF), a novel 14-item tool measuring the emotional (EWB), social (SWB) and psychological (PWB) dimensions of well-being, as well as a total score of well-being (WBT). Hospital Anxiety and Depression Scale (HADS) was used for screening for undiagnosed anxiety (HADS-A) and depression (HADS-D). Patients' demographics, Body Mass Index (BMI), glycemic control (HbA1c), T2DM duration, comorbid hypertension or dyslipidemia and type of antidiabetic medication were investigated as predictors of well-being or its dimensions in stepwise linear regression models, also including or excluding HADS-A and HADS-D. Mediational effects of HADS-A and HADS-D were explored in structural equation models through path analyses. Results showed that 21.1% of participants had comorbid depression (HADS-D≥11) and 5.1% comorbid anxiety disorder (HADS-A≥11). In the models without HADS, higher WBT as well as EWB and PWB were significantly predicted by lower HbA1c (all p=0.001) and lower BMI (p=0.015, 0.019 and 0.030, respectively). After being included in the model, HADS-A and HADS-D significantly predicted WBT and every dimension of well-being, but the effects of HbA1c and BMI were no longer statistically significant. In path analyses, the indirect effects of HbA1c and BMI on well-being via HADS-D were statistically significant, while the direct and indirect effects via HADS-A were not. Therefore, the effects of HbA1c and BMI on EWB, PWB and WBT were completely mediated by HADS-D. Concludingly, this is the first study using MHC-SF to measure well-being in patients with T2DM. High levels of undiagnosed depression were recorded, in agreement with other studies. Depression was predicted by HbA1c and BMI and finally predicted well-being. Undiagnosed depression fully explained the effects of HbA1c and BMI on well-being. The interplay of glycemic control and positive mental health should be further investigated.

Associated autoimmunity in Type 1 Diabetes and latent autoimmune diabetes of adults: The role of glutamic-acid decarboxylase autoantibodies

AIMS

To determine the prevalence of Associated Autoimmune Diseases (AADs) in Latent Autoimmune Diabetes of Adults (LADA) versus autoimmune Type 1 Diabetes (T1D) and the role of glutamic-acid decarboxylase antibodies (GADA) and other factors.

METHODS

Adults with autoimmune diabetes mellitus (DM) were recruited from the Diabetes Center of Nikaia-Piraeus Hospital. Demographic and clinical parameters were recorded and anti-pancreatic and organ-specific antibodies were measured.

RESULTS

Of 160 patients, 33.75% had one AAD and 24.37% had two or more. Patients with LADA had higher overall prevalence of AADs, mainly autoimmune thyroiditis and gastritis. Celiac disease was present only in T1D. GADA positive patients had higher prevalence of AADs and multiple autoimmunity, especially thyroiditis and gastritis. Patients with LADA had higher rates of positive GADA or islet-cell antibodies (ICA). After controlling for LADA, GADA remained a significant predictor of AADs. Female gender and chronological age were also significant predictors of AADs.

CONCLUSIONS

AADs were present in 58.13% of patients. Patients with LADA were more prone to a generalized autoimmune disorder than those with T1D. AADs development was significantly associated with female sex, older age and positive GADA, which proved an independent marker of associated autoimmunity.

Twenty-year trends in the prescription costs of Type 2 diabetes: Real world data and empirical analysis in Greece

AIMS

To estimate and compare the prescription costs for the management of patients with diabetes over a period of 20 years in Greece, based on real world data.

METHODS

The records of outpatients with T2D, monitored at three diabetes centres, were examined in four cross-sections (1998, 2006, 2012, 2018). Prescribed medicines per patient, along with a set of clinical indicators were recorded. Annual costs of pharmaceutical treatment per patient were calculated by using each year's nominal retail prices, as well as by adjusting for 2018 price levels, in order to account for price differences over time.

RESULTS

4066 patients were included in the analysis. Prescription patterns indicate a quick uptake of the new classes of glucose-lowering drugs and a reduction in the proportional use of sulfonylurea and glitazone. Adjusting for 2018 prices, the average total annual prescription cost per patient was 381.54 Euros (s.d. 297.44) in 1998 and 1147.21 Euros (s.d. 814.39) in 2018. Glucose-lowering drug costs per patient increase from 1998 onwards, whereas the costs of antihypertensive, antiplatelet and lipid-lowering treatment declined gradually, especially after 2006.

CONCLUSIONS

Per patient prescription costs for glucose-lowering drugs present a steep increase, in Greece over the last 20 years. Real-world evidence studies that compare this increase with the changes in patient outcomes are essential in order to examine whether a costs-vs-outcomes balance is optimal.

Profile and factors associated with glycaemic control of patients with type 2 diabetes in Greece: results from the diabetes registry

BACKGROUND

Strict glycaemic control early in the treatment process has been shown to reduce the occurrence of micro- and macro- vascular complications of diabetes in the long-term. Thus, treatment guidelines advise early intensification of treatment to achieve glycaemic control goals. However, evidence in Greece suggests that, despite guideline recommendations, glycaemic control among patients with T2DM remains challenging. This study presents the demographic and clinical characteristics of patients with T2DM in Greece using data from an electronic registry designed specifically for this treatment category and investigates the factors that are independently associated with glycaemic control.

METHODS

This is a multi-center, observational, cross-sectional study to investigate epidemiological and clinical factors affecting glycaemic control among patients with T2DM in Greece. Data was collected via a web-based disease registry, the Diabetes Registry, which operated from January 1st to December 31st, 2017. Five large specialized diabetes centers operating in Greek hospitals participated in the study.

RESULTS

Data for 1141 patients were retrieved (aged 63.02 ± 12.65 years, 56.9% male). Glycaemic control (Hb1Ac < 7%) was not achieved in 57.1% of patients. Factors independently associated with poor glycaemic control were: family history of diabetes [OR: 1.53, 95% CI: 1.06-2.23], BMI score between 25 to 30 [OR: 2.08, 95% CI: 1.05-4.13] or over 30 [OR: 2.12, 95% CI 1.12-4.07], elevated LDL levels [OR: 1.53, 95% 1.06-2.21] and low HDL levels [OR: 2.12, 95% CI: 1.44-3.12]. Lastly, use of injectable antidiabetic agents (in monotherapy or in combination) was less likely to be associated with poor glycaemic control versus treatment with combination of oral and injectable agents [OR: 0.50, 95% CI: 0.24-1.01]. This association was found to be marginally statistically significant.

CONCLUSION

Inadequate lipid control, family history of diabetes and presence of obesity (ΒΜΙ ≥ 30 kg/m²) were associated with poor glycaemic control among study sample, whereas use of injectable antidiabetic agents was less likely to be associated with poor glycaemic control. These findings indicate how complex optimal glycaemic control is, highlighting the need for tailored interventions in high-risk subpopulations with T2DM.

Assessment of the effect of drying temperature and composition on the biochemical methane potential of in-house dried household food waste

Household food waste management and treatment has been recognised as a significant issue worldwide and at a European Union level. Source-separation of household food waste following drying at source presents a viable solution to this problem. The present research aims at investigating the effect of drying of model household food waste at different temperatures (i.e. 63 ±3 °C and 83 ±3 °C) on its biochemical methane potential. The drying process was carried out using a prototype household waste dryer. The model sample consisted of 77%w/w vegetables and fruits (48%w/w and 29%w/w, respectively), 12%w/w pasta/rice, 6%w/w meat and fish, 3%w/w bread and bakery and 2%w/w dairy. Moreover, drying at the same temperatures was applied for two household food wastes samples with different composition, in order to assess the influence of the samples' composition on both the drying process and the methane generation. For all temperatures used, the higher %w/w mass reduction was observed for model waste (MD) (67.39%w/w and 75.79%w/w for 63 °C and 83 °C, respectively), then for rich-in-protein content (PRO) (66.18%w/w and 69.73%w/w for 63 °C and 83 °C, respectively) and finally for rich-in-fat content (FAT) samples (54.35%w/w and 66.31%w/w for 63 °C and 83 °C, respectively), which confirmed the effectiveness of the drying process. The biochemical methane potential experiments have confirmed that the substrate produced the highest methane yields was the FAT, producing 524.25 ±2.86 L CH4 kg^-1 volatile solids.

Clinical audit as a tool to optimize contracted private healthcare provision: Testing the waters in resource-deprived Greece

Background and Aims:

Clinical audit is applied to optimize clinical practice and quality of healthcare services while controlling for money spent, critically in resource-deprived settings. This case study reports on the outcomes of a retrospective clinical audit on private hospitalizations, for which reimbursement had been pending by the Health Care Organization for Public Servants (OPAD) in Greece. This case study is the first effort by a social insurance organization in Greece to employ external clinical audit before settling contracted private healthcare charges.

Methods:

One thousand two hundred hospitalization records were reviewed retrospectively and a fully anonymized clinical audit summary report created for each one of them by a team of clinical audit experts, proposing evidence-based cuts in pending charges where medical services were deemed clinically unnecessary. These audit reports were then collated and analysed to test trends in overcharges among hospitalized insureds per reason for hospitalization.

Results:

The clinical audit report concluded that 17.4% of a total reimbursement claim of €12,387,702.18 should not be reimbursed, as it corresponded to unnecessary or not fully justifiable according to evidence-based, best practice, medical service provision. The majority of proposed cuts were related to charges for medical devices, which are borne directly by social insurance with no patient or private insurance co-payment.

Conclusion:

Clinical audit of hospital practice may be a key tool to optimize care provision, address supplier-induced demand and effectively manage costs for national health insurance, especially in circumstances of budgetary constraints, such as in austerity-stricken settings or developing national healthcare systems.

Analysis of tar compounds and quantification of naphthalene from thermal treatment of household biowaste

Household biowaste represent the organic fraction of municipal solid waste and are an underutilized resource. Although previous studies have performed pyrolysis of organic waste, the vast majority has been on specific presorted feedstock or conventional lignocellulosic streams. Therefore, there is a lack of pyrolysis applications on representative food waste as retrieved from households and this can be attributed primarily to their high water content and their degradability. But via the intermediate step of drying, long-term storage and thermal treatment have become possible. In the framework of this study, household biowaste were pyrolyzed for the production of carbonaceous materials with a main focus on the analysis of produced tar compounds. Tars can be corrosive or cause clogging and disrupt the operation of pyrolysis and gasification plants. Their analysis has faced several difficulties due to inconsistency in the methodologies that have been applied by various groups. The tar protocol has provided a solid framework for consistent analysis of tars but until now has been solely used for the case of gasification. This study aimed to apply the tar protocol for pyrolysis and to enhance the detectability of the method for a wider range of tars by means of elemental analysis, attenuated total reflectance (ATR) and gas chromatography-mass spectrometry (GC-MS). GC- MS was performed by means of a specific column for PAHs identification and calibration methods were developed for the proper quantification of naphthalene which is the dominant tar compound. The results of the analysis showed that naphthalene concentration increased from torrefaction to carbonization but then decreased significantly for high temperature pyrolysis at 860 °C.

Improvement of home composting process of food waste using different minerals

This article presents the experimental study of the process of composting in a prototype home-scale system with a special focus on process improvement by using different additives (i.e. woodchips, perlite, vermiculite and zeolite). The interventions with different bulking agents were realized through composting cycles using substrates with 10% additives in specific mixtures of kitchen waste materials. The pre-selected proportion of the mixtures examined was 3:1:1 in cellulosic:proteins:carbohydrates, in order to achieve an initial C/N ratio equal to 30. The control of the initial properties of the examined substrates aimed at the consequent improvement of the properties of the final product (compost). The results indicated that composting process was enhanced with the use of additives and especially the case of zeolite and perlite provided the best results, in terms of efficient temperature evolution (>55 °C for 4 consecutive days). Carbon to nitrogen ratios decreased by 40% from the initial values for the reactors were minerals were added, while for the bioreactor tested with woodchips the reduction was slight, showing slowest degradation rate. Moisture content of produced compost varied within the range of 55-64% d.m., while nutrient content (K, Na, Ca, Mg) was in accordance with the limit values reported in literature. Finally, the composts obtained, exhibited a satisfactory degree of maturity, fulfilling the criterion related to the absence of phytotoxic compounds.

Thermochemical valorization and characterization of household biowaste

Valorization of municipal solid waste (MSW), by means of energy and material recovery, is considered to be a crucial step for sustainable waste management. A significant fraction of MSW is comprised from food waste, the treatment of which is still a challenge. Therefore, the conventional disposal of food waste in landfills is being gradually replaced by recycling aerobic treatment, anaerobic digestion and waste-to-energy. In principle, thermal processes like combustion and gasification are preferred for the recovery of energy due to the higher electrical efficiency and the significantly less time required for the process to be completed when compared to biological process, i.e. composting, anaerobic digestion and transesterification. Nonetheless, the high water content and the molecular structure of biowaste are constraining factors in regard to the application of thermal conversion pathways. Investigating alternative solutions for the pre-treatment and more energy efficient handling of this waste fraction may provide pathways for the optimization of the whole process. In this study, by means of utilizing drying/milling as an intermediate step, thermal treatment of household biowaste has become possible. Household biowaste has been thermally processed in a bench scale reactor by means of torrefaction, carbonization and high temperature pyrolysis. According to the operational conditions, fluctuating fractions of biochar, bio-oil (tar) and syngas were recovered. The thermochemical properties of the feedstock and products were analyzed by means of Simultaneous Thermal Analysis (STA), Ultimate and Proximate analysis and Attenuated Total Reflectance (ATR). The analysis of the products shows that torrefaction of dried household biowaste produces an energy dense fuel and high temperature pyrolysis produces a graphite-like material with relatively high yield.

Combination of decentralized waste drying and SSF techniques for household biowaste minimization and ethanol production

The results of the demonstration of an innovative household biowaste management and treatment scheme established in two Greek Municipalities for the production of lignocellulosic ethanol using dehydrated household biowaste as a substrate, are presented within this research. This is the first time that biowaste drying was tested at a decentralized level for the production of ethanol using the Simultaneous Saccharification and Fermentation (SSF) process, at a pilot scale in Greece. The decentralized biowaste drying method proved that the household biowaste mass and volume reduction may reach 80% through the dehydration process used. The chemical characteristics related to lignocellulosic ethanol production have proved to differ substantially between seasons thus; special attention should be given to the process applied for ethanol production mainly regarding the enzyme quality and quantity used during the pretreatment stage. The maximum ethanol production achieved was 29.12g/L, approximately 60% of the maximum theoretical yield based on the substrate's sugar content. The use of the decentralized waste drying as an alternative approach for household biowaste minimization and the production of second generation ethanol is considered to be a promising approach for efficient biowaste management and treatment in the future.

Utilisation of biomass gasification by-products for onsite energy production

Small scale biomass gasification is a sector with growth and increasing applications owing to the environmental goals of the European Union and the incentivised policies of most European countries. This study addresses two aspects, which are at the centre of attention concerning the operation and development of small scale gasifiers; reuse of waste and increase of energy efficiency. Several authors have denoted that the low electrical efficiency of these systems is the main barrier for further commercial development. In addition, gasification has several by-products that have no further use and are discarded as waste. In the framework of this manuscript, a secondary reactor is introduced and modelled. The main operating principle is the utilisation of char and flue gases for further energy production. These by-products are reformed into secondary producer gas by means of a secondary reactor. In addition, a set of heat exchangers capture the waste heat and optimise the process. This case study is modelled in a MATLAB-Cantera environment. The model is non-stoichiometric and applies the Gibbs minimisation principle. The simulations show that some of the thermal energy is depleted during the process owing to the preheating of flue gases. Nonetheless, the addition of a secondary reactor results in an increase of the electrical power production efficiency and the combined heat and power (CHP) efficiency.

Prevalence of Major Cardiovascular Risk Factors and Coronary Heart Disease in a Sample of Greek Adults: The Saronikos Study

Background:

Comprehensive data regarding prevalence of coronary heart disease (CHD) and associated factors in different geographical regions are very important to our understanding of global distribution and evolution of CHD. The aim of this study was to assess the current prevalence of self-reported risk factors and CHD in Greek adult population.

Methods:

A community-based cross-sectional study was conducted in May 2014, during an election day, among residents of Saronikos municipality (Attica region). Data were collected from face-to-face interviews. The study sample included 2636 subjects (men, 49.5%; mean age, 50.5; range 20-95 years), with similar age and sex distribution to the target population.

Results:

The age-standardized prevalence rates of five major risk factors were as follows: type 2 diabetes 11.1%, hypercholesterolemia (cholesterol>240 mg/dl or using cholesterol-lowering medication) 23.8%, hypertension 27.2%, current smoking 38.9% and physical inactivity 43%. Of the participants, only 21% were free of any of these factors. Clustering of two to five risk factors was more frequent among persons aged 50 years and older as compared with younger ones (60% vs 27%, P=0.000). The age-adjusted prevalence of CHD was 6.3% (in men, 8.9%; in women, 3.8%) and that of myocardial infarction was 3.6% (in men, 5.2%; in women, 2.1%). According to multivariate analysis age, gender, education level, obesity, diabetes, hypercholesterolemia, hypertension and ever smoking were strongly associated with CHD.

Conclusion:

Classic risk factors are highly prevalent and frequently clustered, especially in adults aged 50 years and older. These findings raise concerns about future trends of already increased rates of CHD. Multifactorial and integrated population-based interventions need to be applied to reduce the burden of cardiovascular conditions.

An overview of platforms for cloud based development

This paper provides an overview of the state of the art technologies for software development in cloud environments. The surveyed systems cover the whole spectrum of cloud-based development including integrated programming environments, code repositories, software modeling, composition and documentation tools, and application management and orchestration. In this work we evaluate the existing cloud development ecosystem based on a wide number of characteristics like applicability (e.g. programming and database technologies supported), productivity enhancement (e.g. editor capabilities, debugging tools), support for collaboration (e.g. repository functionality, version control) and post-development application hosting and we compare the surveyed systems. The conducted survey proves that software engineering in the cloud era has made its initial steps showing potential to provide concrete implementation and execution environments for cloud-based applications. However, a number of important challenges need to be addressed for this approach to be viable. These challenges are discussed in the article, while a conclusion is drawn that although several steps have been made, a compact and reliable solution does not yet exist.

Research on the drying kinetics of household food waste for the development and optimization of domestic waste drying technique

Domestic food waste drying foresees the significant reduction of household food waste mass through the hygienic removal of its moisture content at source. In this manuscript, a new approach for the development and optimization of an innovative household waste dryer for the effective dehydration of food waste at source is presented. Food waste samples were dehydrated with the use of the heated air-drying technique under different air-drying conditions, namely air temperature and air velocity, in order to investigate their drying kinetics. Different thin-layer drying models have been applied, in which the drying constant is a function of the process variables. The Midilli model demonstrated the best performance in fitting the experimental data in all tested samples, whereas it was found that food waste drying is greatly affected by temperature and to a smaller scale by air velocity. Due to the increased moisture content of food waste, an appropriate configuration of the drying process variables can lead to a total reduction of its mass by 87% w/w, thus achieving a sustainable residence time and energy consumption level. Thus, the development of a domestic waste dryer can be proved to be economically and environmentally viable in the future.

Dessert formulation using sucralose and dextrin affects favorably postprandial response to glucose, insulin, and C-peptide in type 2 diabetic patients

BACKGROUND

Dessert compositions may conform to diabetic diet when it contains low sugar or artificial sweetener to replace sugar. However, it is still questionable whether glycemic control in type 2 diabetes patients is improved by the use of diet-conforming dessert compositions.

OBJECTIVE

To compare, in type 2 diabetes patients, the glycemic, insulin, and C-peptide responses to seven modified dessert compositions for diabetics (D-dessert) with the response to seven similar desserts of non-modified composition, used as control desserts (C-dessert).

METHODS

Seventy type 2 diabetes patients were allocated to seven groups of ten. On three occasions, each patient received either the meal which consisted of bread and cheese, or the meal and D-dessert, or the meal and the respective C-dessert. Differences in postprandial glucose, insulin, and C-peptide were evaluated using analysis of repeated measures at 0, 30, 60, 90, and 120 min after consumption.

RESULTS

D-cake and D-pastry cream resulted in lower glucose levels (8.81 ± 0.32 mmol/l and 8.67 ± 0.36 mmol/l, respectively) and D-strawberry jelly in lower insulin levels (16.46 ± 2.66 μU/ml) than the respective C-desserts (9.99 ± 0.32 mmol/l for C-cake, 9.28 ± 0.36 mmol/l for C-pastry cream, and 27.42 ± 2.66 μU/ml for C-strawberry jelly) (p < 0.05). Compared with the meal, D-cake did not increase glucose or insulin levels (p < 0.05), while C-cake did (p < 0.05). D-pastry cream increased glucose to a lesser extent than C-pastry cream (p < 0.05). Similar effects were reported for D-milk dessert, D-millefeuille, and D-chocolate on glucose, insulin, and C-peptide at specific timepoints. D-crème caramel showed no effect.

CONCLUSIONS

Some desserts formulated with sugar substitutes and soluble fiber may have a favorable effect on postprandial levels of glucose, insulin, and C-peptide in type 2 diabetic patients.

Relationship between alcohol consumption and control of hypertension among elderly Greeks. The Nemea primary care study

BACKGROUND

The aim of this study was to evaluate the significance of alcohol intake in relation to blood pressure control in treated subjects and to determine if there is a causative link between alcohol and inadequate control of hypertension.

METHODS

Our study population comprised 637 elderly individuals who reside in Nemea and in four other villages located in Corinthia, Peloponnesus, of which 615 were included in the analysis. The average age was 73.5±6.15 years. A special epidemiological questionnaire was completed by each participant and the blood pressure (BP) was measured according to a predefined protocol. Odds ratios were calculated and adjusted for potential confounders.

RESULTS

The overall prevalence of hypertension was 69.1%, 70.7% in men and 67.0% in women. In total, 11% of the hypertensives were not aware of having hypertension. Of those who were aware of having hypertension 91.0% were being treated. Among treated hypertensives 49.1% had systolic BP<140 mmHg and diastolic BP<90 mmHg. Only heavy drinking (>300 g/week) was found to be related with hypertension control.

CONCLUSIONS

Our study showed that the level of control among the elderly, in a Greek population, is positively associated with alcohol intake only for heavy drinking. The role of alcohol consumption in hypertension in the elderly needs further investigation.

Serum selenium levels do not differ in type 2 diabetic subjects with and without coronary artery disease

BACKGROUND

The aim of the present study was to investigate whether selenium levels differ between type 2 diabetic subjects with and without coronary artery disease (CAD).

METHODS

A total of 200 subjects with type 2 diabetes (100 with CAD and 100 without CAD), consecutively selected from the diabetes outpatient clinic of our hospital were enrolled into the study. A detailed medical history and a physical examination were obtained by all the participants.

RESULTS

Serum selenium levels did not differ between diabetic subjects with and without CAD (102.40 ± 31.10 vs. 108.86 ± 33.88 microg/L, p = 0.16). In diabetic subjects with CAD multivariate linear regression analysis demonstrated significant independent associations between selenium and sex (beta = 0.21, p = 0.03) and glucose levels (beta = 0.25, p = 0.008). In diabetic subjects without CAD multivariate linear regression analysis demonstrated significant independent associations between selenium and peripheral artery disease (beta = 0.16, p = 0.05) and glucose levels (beta = -0.09, p = 0.05).

CONCLUSION

Serum selenium levels did not differ between diabetic subjects with and without CAD. In diabetic subjects with CAD, the only determinants of serum selenium levels were sex and glucose levels. In diabetic subjects without CAD the only determinants of serum selenium levels were peripheral artery disease and glucose levels.

Prevalence of target organ damage in hypertensive subjects attending primary care: C.V.P.C. study (epidemiological cardio-vascular study in primary care)

Background

Except for the established risk factors, presence of target organ damage has an important role in the treatment of hypertensive subjects. The aim of the present study was to estimate the prevalence of target organ damage in primary care subjects.

Methods

This multi-centre, cross-sectional survey of 115 primary care physicians recruited 1095 consecutive subjects with hypertension: 611 men (55.8%); and 484 women (44.2%). A detailed history for the presence of cardiovascular disease and a thorough clinical examination was performed to each subject.

Results

Of the total study population, 44.5% (n = 487) had target organ damage (33.0% had left ventricular hypertrophy, 21.8% increased carotid intima media thickness, 11.0% elevated plasma creatinine levels and 14.6% microalbuminuria). Target organ damage was more prevalent in males than in females (P = 0.05). In addition, males had more often increased carotid intima media thickness than females (P = 0.009). On the contrary, females had more often microalbuminuria (P = 0.06) than males. No differences were observed between the two genders regarding left ventricular hypertrophy (P = 0.35) and elevated plasma creatinine levels (P = 0.21). Logistic regression analysis showed associations between target organ damage and dyslipidemia (P < 0.001), presence of metabolic syndrome (P = 0.005), diabetes (P < 0.001) and coronary artery disease (P < 0.001).

Conclusion

A significant proportion of hypertensive subjects in primary care had documented associated target organ damage, with left ventricular hypertrophy being the most prevalent target organ damage.

Plasma glucose levels and white blood cell count are related with ankle brachial index in type 2 diabetic subjects

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a major risk factor for peripheral arterial disease (PAD). A simple, noninvasive method for the estimation of PAD is ankle brachial index (ABI). The aim of the present study was to determine whether there is an association between ABI and cardiovascular risk factors in T2DM subjects without apparent macrovascular disease.

METHODS

A total of 125 T2DM subjects (84 males, 41 females, mean age ± standard deviation 62.2 ± 9.1 years) who had no apparent macrovascular disease and who attended the Health Center of Erymantheia between January 2008 and June 2009 were recruited to the study.

RESULTS

Of the study subjects 20% (n=25) had ABI <0.90. Univariate linear regression analysis showed that ABI was significantly associated with history of hypertension (p=0.02), fasting serum glucose levels (p=0.02), serum urea levels (p=0.005), serum uric acid levels (p=0.007) and white blood cell (WBC) count (p=0.04). Multivariate linear regression analysis demonstrated significant independent associations between ABI and fasting serum glucose levels (p=0.03) as well as WBC count (p=0.03).

CONCLUSIONS

Elevated plasma glucose and WBC count increase the risk of PAD in asymptomatic diabetics.

Self-medication with antibiotics in rural population in Greece: a cross-sectional multicenter study

BACKGROUND

Self-medication is an important driver of antimicrobial overuse as well as a worldwide problem. The aim of the present study was to estimate the use of antibiotics, without medical prescription, in a sample of rural population presenting in primary care in southern Greece.

METHODS

The study included data from 1,139 randomly selected adults (545 men/594 women, mean age +/- SD: 56.2 +/- 19.8 years), who visited the 6 rural Health Centres of southern Greece, between November 2009 and January 2010. The eligible participants were sought out on a one-to-one basis and asked to answer an anonymous questionnaire.

RESULTS

Use of antibiotics within the past 12 months was reported by 888 participants (77.9%). 508 individuals (44.6%) reported that they had received antibiotics without medical prescription at least one time. The major source of self-medication was the pharmacy without prescription (76.2%). The antibiotics most frequently used for self-medication were amoxicillin (18.3%), amoxicillin/clavulanic acid (15.4%), cefaclor (9.7%), cefuroxim (7.9%), cefprozil (4.7%) and ciprofloxacin (2.3%). Fever (41.2%), common cold (32.0%) and sore throat (20.6%) were the most frequent indications for the use of self-medicated antibiotics.

CONCLUSION

In Greece, despite the open and rapid access to primary care services, it appears that a high proportion of rural adult population use antibiotics without medical prescription preferably for fever and common cold.

Prevalence of asymptomatic bacteriuria in type 2 diabetic subjects with and without microalbuminuria

Background

Diabetic subjects, especially women, show high prevalence of asymptomatic bacteriuria (ASB). The aim of the present study was to evaluate the prevalence of ASB in subjects with type 2 diabetes mellitus (T2D) with and without microalbuminuria (MA).

Findings

A hundred diabetic subjects with MA (53 males/47 females, mean age ± standard deviation: 65.5 ± 11.1 years) and 100 diabetic subjects without MA (52 males/48 females, mean age ± standard deviation: 65.4 ± 11.3 years), consecutively attending the outpatient diabetes clinic of our hospital were recruited in the study. Subjects with overt diabetic nephropathy or nephropathy from other causes were excluded. In addition, subjects with symptoms of urinary track infection or use of antimicrobial drugs in the last 14 days were excluded by the study.

Diabetic subjects with MA showed increased prevalence of ASB compared to diabetic subjects without MA (21% versus 8%, P < 0.001, respectively). Escherichia coli was the most prevalent pathogen isolated in diabetic subjects with and without MA (12% versus 3.0%, P = 0.01, respectively) followed by Proteus mirabilis (6% versus 5%, P = 0.75, respectively) and Klebsiella spp (5% versus 1%, P = 0.09, respectively). Univariate logistic analysis showed that ASB was associated with the presence of coronary artery disease [odds ratio (OR): 0.29, 95% Confidence Intervals (95% CI): 0.09-0.95, P = 0.04] and gender (OR: 0.09, 95% CI: 0.02-0.35, P < 0.001) in the diabetic study group with MA.

Conclusions

ASB is more prevalent among T2D subjects with MA. Screening for ASB is warranted in diabetic patients especially if pyuria is detected in urine analysis since ASB has been found to be a risk factor for developing symptomatic urinary tract infection.

Prevalence of thyroid dysfunction among greek type 2 diabetic patients attending an outpatient clinic

Background

The aim of the present study was to determine the prevalence of thyroid dysfunction in patients with type 2 diabetes (T2D) attending an outpatient clinic.

Methods

We examined thyroid dysfunction in a total of 1,092 patients with T2D.

Results

Prevalence rate of thyroid dysfunction was 12.3%. In the group with thyroid dysfunction there was an excess of females in comparison with the group without thyroid dysfunction (P < 0.001). In addition, patients with thyroid dysfunction had higher values of body mass index (P = 0.03) and HDL-cholesterol levels (P = 0.01), and lower values of LDL-cholesterol levels (P = 0.001) in comparison with patients without thyroid dysfunction. Multivariate analysis demonstrated that presence of thyroid dysfunction was related with gender (OR: 0.220, 95% CI: 0.141 - 0.352) and LDL-cholesterol levels (OR: 0.990, 95% CI: 0.985 - 0.995).

Conclusions

The prevalence of thyroid dysfunction among Greek diabetic patients is 12.3%. Diabetic women were more frequently affected than men. Presence of thyroid dysfunction was associated with lower levels of LDL-cholesterol concentrations.

Keywords

Type 2 diabetes mellitus; Thyroid dysfunction; Hypothyroidism; Gender; LDL-cholesterol; Greece

Trends in the management of type 2 diabetes and its prescription drug costs in Greece (1998 & 2006)

AIMS Aim of the present study is to compare control of hyperglycaemia and other diabetes-related cardiovascular risk factors during the years 1998 and 2006 and to estimate the change in the cost of medications prescribed for this purpose. METHODS We compared the medical records of all patients who were regularly followed in three major diabetes centers located in Athens and Piraeus, Greece, during 1998, with those who were examined at the same centers during 2006. The cost of medications was calculated in Euros per patient-year (euroPY), using the 2006 official Greek market prices. RESULTS A total of 1 743 eligible files were included in the study (805 files from 1998 and 938 from 2006). HbA (1c), LDL-cholesterol and blood pressure improved significantly in 2006 as compared to 1998 (7.0% vs. 8.1%, 2.9 mmol/l vs. 3.9 mmol/l and 134.9/77.6 mmHg vs. 139.3/80.9 mmHg respectively, p<0.001 for all comparisons). Treatment of hyperglycaemia was more intense and had a different pattern in 2006. The proportion of patients receiving antihypertensive, hypolipidaemic and antiplatelet drugs increased from 48.8% to 74.4%, from 15.2% to 61.2% and from 17.6% to 51.1% respectively (p<0.001 for all comparisons). A highly significant increase in the cost per patient-year was observed for all classes of medications in 2006. The total cost of all diabetes-related medications increased in 2006 by 221.1% (from 341.3+/-276.0 euroPY to 1095.8+/-634.1 euroPY). CONCLUSIONS Control of cardiovascular risk factors of patients with T2D, regularly followed by diabetes specialists, improved significantly in 2006 as compared to 1998. This improvement, however, was associated with a considerable increase in the cost of medications prescribed for treatment of these parameters.

Seasonal variation in fasting glucose and HbA1c in patients with type 2 diabetes

Seasonal variations in fasting glucose and HbA1c levels in 638 diabetic patients (attending a primary care diabetic clinic during 2003-2007) were examined and found to be significantly higher in colder than in warmer months. Moreover, there were apparent peaks in fasting glucose levels after Christmas and Easter months. This study provides further evidence of monthly fluctuations in glycemic control, underscoring the need to consider seasonal/cultural effects when managing diabetic patients.

Familial history of diabetes and clinical characteristics in Greek subjects with type 2 diabetes

BACKGROUND

A lot of studies have showed an excess maternal transmission of type 2 diabetes (T2D). The aim, therefore, of the present study was to estimate the prevalence of familial history of T2D in Greek patients, and to evaluate its potential effect on the patient's metabolic control and the presence of diabetic complications.

METHODS

A total of 1,473 T2D patients were recruited. Those with diabetic mothers, diabetic fathers, diabetic relatives other than parents and no known diabetic relatives, were considered separately.

RESULTS

The prevalence of diabetes in the mother, the father and relatives other than parents, was 27.7, 11.0 and 10.7%, respectively. Patients with paternal diabetes had a higher prevalence of hypertension (64.8 vs. 57.1%, P = 0.05) and lower LDL-cholesterol levels (115.12 +/- 39.76 vs. 127.13 +/- 46.53 mg/dl, P = 0.006) than patients with diabetes in the mother. Patients with familial diabetes were significantly younger (P < 0.001), with lower age at diabetes diagnosis (P < 0.001) than those without diabetic relatives. Patients with a diabetic parent had higher body mass index (BMI) (31.22 +/- 5.87 vs. 30.67 +/- 5.35 Kg/m2, P = 0.08), higher prevalence of dyslipidemia (49.8 vs. 44.6%, P = 0.06) and retinopathy (17.9 vs. 14.5%, P = 0.08) compared with patients with no diabetic relatives. No difference in the degree of metabolic control and the prevalence of chronic complications were observed.

CONCLUSION

The present study showed an excess maternal transmission of T2D in a sample of Greek diabetic patients. However, no different influence was found between maternal and paternal diabetes on the clinical characteristics of diabetic patients except for LDL-cholesterol levels and presence of hypertension. The presence of a family history of diabetes resulted to an early onset of the disease to the offspring.

Prevalence of depressive symptoms among non insulin treated Greek type 2 diabetic subjects

BACKGROUND

Depression is common among diabetic subjects. We conducted the present study to estimate the prevalence of depression in subjects with type 2 diabetes (T2D) in Greece.

METHODS

The study sample consisted of 320 T2D subjects without overt macrovascular disease attending the diabetes outpatient clinic of our hospital, from June 2007 to December 2007. Depressive symptoms were measured using the 21-item Beck Depression Inventory, modified for use in diabetic subjects.

RESULTS

Of the study subjects 107 (33.4%) reported elevated depressive symptoms. More women than men with diabetes reported symptoms of depression (48.4% vs. 12.7%, P < 0.001). In the female study group, depressive symptoms were correlated with HbA1c (P = 0.04), and duration of diabetes (P = 0.004). In the male study group, univariate linear regression analysis showed no significant relationships between depressive symptoms and the testing variables.

CONCLUSION

The prevalence of depression in Greek T2D subjects is high. Diabetic female subjects showed increased levels of depressive symptoms compared with male subjects. Independent risk factors of depressive symptoms in diabetic female subjects were diabetes duration and glycemic control.

Prevalence trends for myocardial infarction and conventional risk factors among Greek adults (2002-06)

AIM

To examine trends in the prevalence of myocardial infarction (MI) and conventional risk factors in Greek adults between 2002 and 2006.

DESIGN

Repeated cross-sectional study.

METHODS

Self-reported data from surveys given in Salamis during two election days in 2002 and 2006 were analysed. The same sampling method and procedures were used on both surveys. The study sample included 2805 and 3478 subjects (> or =20 years) in 2002 and 2006, respectively, with similar age and sex distribution to the target population.

RESULTS

The prevalence of MI increased from 4.1% (men, 6.3%; women, 1.9%) in 2002 to 4.8% (men, 7.3%; women, 2.2%) in 2006 (P = 0.18). At the same time, prevalence rates of major risk factors were as follows: diabetes increased from 8.7% to 10.3% (P = 0.037), hypertension from 20.1% to 25.7% (P < 0.001) and hypercholesterolemia (cholesterol >240 mg/dl or the use of cholesterol-lowering medication) increased from 17.5% to 22.3% (P < 0.001). Prevalence of current smokers in 2002 (defined as persons who smoked > or =5 cigarettes/day) was 37.0% and in 2006 (defined as those who smoked > or =1 cigarettes/day) was 40.1%. Logistic regression analysis showed that the aforementioned risk factors were significantly associated with MI in both surveys; the factor that showed the greatest magnitude of association with MI was hypercholesterolemia, followed by diabetes, hypertension and smoking.

CONCLUSION

These findings show that, in the Greek population, prevalence of MI continues to rise (at approximately 4% per year). This trend seems to be driven by a persistently high prevalence of smoking and the rapidly increasing burden of diabetes, hypertension and hypercholesterolemia.

Rising prevalence of diabetes among Greek adults: findings from two consecutive surveys in the same target population

AIMS

To examine trends in the prevalence of self-reported diabetes between 2002 and 2006 among urban adults in Greece.

METHODS

Data were derived from two consecutive population-based surveys conducted in Salamis, during two election days (13 October 2002 and 15 October 2006). In both surveys was used the same selection procedure and data were collected using the same questionnaire, completed by almost the same team of interviewers. There were randomly selected 2805 adults (> or =20 years) in 2002 and 3478 in 2006, with similar age and sex distribution to the target population.

RESULTS

The overall crude prevalence of diabetes increased significantly, from 245 (8.7%) in 2002 to 358 (10.3%) in 2006 (P=0.037). The age-adjusted prevalence of diabetes among adults was 8.2% (men, 8.5%; women, 7.8%) in 2002 and 9.5% (men, 9.7%; women, 9.3%) in 2006. These changes correspond to a total increasing rate of 16% (4% per year). At the same time, the age-adjusted prevalence of obesity increased from 17.9 to 21.1%, giving an increase of 18% (P<0.05); however, the prevalence of overweight did not increase (43.8-42.9%).

CONCLUSIONS

Our findings show that the prevalence of diabetes is rising rapidly in the Greek population and appears to be increasing in parallel with prevalence of obesity.

Poor hypertension control in Greek patients with diabetes in rural areas. The VANK study in primary care

INTRODUCTION

This study aimed to determine hypertension prevalence and levels of awareness, treatment and control of hypertension among diabetic patients using data from the VANK study.

METHODS

The sample consisted of 221 men and women (122/99) diagnosed with type 2 diabetes. Semi-structured interviews were conducted with all participants. Controlled hypertension definition was based on having a systolic blood pressure (BP) of <130 mmHg and diastolic BP of <85 mmHg in subjects taking antihypertensive medications.

RESULTS

The mean +/- SD BP was 141.6 +/- 17.4 mmHg and 81.2 +/- 9.4 mmHg for systolic and diastolic BPs, respectively. Systolic and diastolic BP was higher in men than in women. The overall prevalence of hypertension was 194/221 (87.7%). In total, 34.1% of patients (66/194) were not aware of having hypertension. Of those who were aware of having hypertension (n = 128, 65.9%), all were treated. Among those treated, only 11 persons (11/194, 5.6%) had systolic BP <130 mmHg and diastolic BP <85 mmHg. Sixty-two (38.7%) had systolic BP <140 mmHg and diastolic BP <90 mmHg.

CONCLUSION

Although all of the diagnosed hypertensive patients (n = 128) received antihypertensive drug therapy, in only 8.6% (11/128) the treatment was effective (BP <130/85 mmHg). Translating our findings into clinical practice, there is a need for aggressive treatment of hypertension from primary care physicians, as well as regular surveillance to detect developing hypertension in diabetic patients.

Smoking habits and associated factors among Greek physicians

OBJECTIVE

To investigate the smoking habits and associated risk factors among Greek physicians.

STUDY DESIGN

Cross-sectional survey of a randomly selected sample of Greek physicians.

METHODS

A national sample of 1284 physicians (718 men, 566 women) participated in the study, which was conducted between September 2003 and June 2005. Data were collected through an anonymous self-completed questionnaire. Logistic regression was used to analyse the influence of different factors on the probability of a physician being a current or former smoker.

RESULTS

Overall, 38.6% of the physicians (40% of men; 37% of women) currently smoked, 13.8% were former smokers, and 47.6% had never smoked. Eighty-three per cent of smokers reported starting smoking before the age of 25 years, with half of them during medical school (aged 19-24 years). Multivariate analyses revealed that physicians who were male, unmarried, divorced or widowed, surgeons or anaesthetists, and residents were more likely to be current smokers. Former smokers were more likely to be older, male and born in a rural area. Moreover, the odds of being a current or former smoker were significantly higher among physicians with a history of parents who smoked. The proportion of physicians who reported counselling patients (often or always) to stop smoking was lower among current smokers compared with those who never smoked or those who were former smokers (74.4% vs. 85.3% vs. 84.7%, P<0.0001).

CONCLUSIONS

The prevalence of smoking among Greek physicians is exceedingly high and similar to that of the general population. More effective interventions that reduce smoking in the medical community should be implemented immediately so that physicians will be better able to fulfil their function as role models for the general population.

Seropositivity to Chlamydia pneumoniae or Helicobacter pylori and coronary artery disease

Our aim was to investigate the relationship between the serologic status concerning Chlamydia pneumoniae and Helicobacter pylori with the presence of coronary artery disease (CAD), which remain a controversial issue in literature. We studied 208 patients with CAD and 94 controls with no evidence of obstructive CAD; all of them angiographically confirmed. The seropositivity to C. pneumoniae was 91% in patients with CAD vs 86% in controls (P>0.05). The H. pylori seroprevalence rates were 77% and 68%, respectively (P>0.05). The multivariate analysis, adjusting for age, sex, educational level, diabetes, hypertension, obesity, smoking, family history of CAD and lipids, confirmed the results of univariate analysis. Therefore, this study adds evidence against the association of seropositivity to C. pneumoniae and H. pylori with angiographically documented CAD.

Risk factors for severe hypoglycaemia in type 2 diabetic patients admitted to hospital in Piraeus, Greece

A 3-year study assessed the prevalence and causes of severe treatment-related hypoglycaemia in type 2 diabetes mellitus patients admitted to hospital in Piraeus. Out of the 2858 patients admitted, 207 (7.2%) had severe hypoglycaemia: 72 were being managed with insulin, 132 oral hypoglycaemic drugs and 3 combined insulin/oral drugs. Only 28.5% of patients were attending a diabetes clinic. The cause of the hypoglycaemic attack could be determined for 86.1% of cases; 30.8% were due to a missed meal. Interviews showed that education and level of knowledge about diabetes mellitus, and particularly hypoglycaemia symptoms, was inadequate. Logistic regression analysis showed that knowledge about diabetes mellitus correlated with educational status and with follow-up in a diabetes clinic.