A study of the evolution of the third COVID-19 pandemic wave in the Athens metropolitan area, Greece, through two cross-sectional seroepidemiological surveys: March, June 2021

We studied the third coronavirus disease 2019 (COVID‐19) pandemic wave in Athens metropolitan area (3 738 901 inhabitants) through two seroepidemiological surveys. Persons presenting in 12 healthcare facilities across Athens in March and June 2021 were studied (764 and 901, respectively). Immunoglobulin G antibodies against severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) spike protein were measured by a chemiluminescent microparticle immunoassay. In March the seroprevalence rate was 11.6%, meaning that 435 208 residents of Athens had evidence of immunity. The respective values in June were 55.7% and 2 082 568 residents. The highest seroprevalence rates attributed to SARS‐CoV‐2 infection were recorded in persons <18 years (16.3% in March and 31.6% in June), while immunity was mainly vaccine‐induced in persons 18–64 years and >65 years. Infection‐attributed immunity also increased in older‐age groups. Wide ranges in seroprevalence rates were noted across areas in March and June. The highest seroprevalence rates were recorded in Piraeus (47.2%) and West Attica (37.5%). However, the highest increase (>5 times) occurred in Piraeus and the South Section of Athens, which are among the most densely populated areas in Athens. In both study periods, history of COVID‐19 or febrile episode, and having a cohabitant with COVID‐19 were associated with increased risk for seropositivity among unvaccinated persons (p values <0.001 for all). Residing in Piraeus, the South Section or West Attica was associated with increased risk for seropositivity in June (p values <0.001). Wide heterogeneity in seroprevalence rates was found across areas in Athens, which is mainly attributed to population density. The impact of population mobility and socioeconomic status should be explored.

Stress Hyperglycemia in Children and Adolescents as a Prognostic Indicator for the Development of Type 1 Diabetes Mellitus

Hyperglycemia is a common manifestation in the course of severe disease and is the result of acute metabolic and hormonal changes associated with various factors such as trauma, stress, surgery, or infection. Numerous studies demonstrate the association of adverse clinical events with stress hyperglycemia. This article briefly describes the pathophysiological mechanisms which lead to hyperglycemia under stressful circumstances particularly in the pediatric and adolescent population. The importance of prevention of hyperglycemia, especially for children, is emphasized and the existing models for the prediction of diabetes are presented. The available studies on the association between stress hyperglycemia and progress to type 1 diabetes mellitus are presented, implying a possible role for stress hyperglycemia as part of a broader prognostic model for the prediction and prevention of overt disease in susceptible patients.

Excess mortality due to pandrug-resistant Acinetobacter baumannii infections in hospitalized patients

BACKGROUND

Pandrug-resistant Acinetobacter baumannii (PDRAB) is increasingly being reported as a nosocomial pathogen worldwide, but determining its clinical impact is challenging.

AIM

To assess the spectrum of excess mortality attributable to PDRAB infection in acute care settings.

METHODS

This four-year cohort study was conducted in a tertiary-care referral hospital in Greece to estimate excess in-hospital mortality due to PDRAB infection by comparing patients infected to those colonized with PDRAB by means of competing risks survival analysis.

FINDINGS

The study cohort comprised 91 patients (median age: 67 years; 77% men). For most patients, PDRAB was first isolated in the intensive care unit (ICU) (N = 51; 57%) or following ICU discharge (N = 26; 29%). Overall in-hospital mortality was 68% (95% confidence interval (CI): 57.5-77.5%). PDRAB-infected patients (N = 62; 68%) and PDRAB-colonized patients (N = 29; 32%) had similar baseline characteristics, but the absolute excess risk of 30-day mortality in infected patients compared to colonized patients was 34% (95% CI: 14-54%). Multivariable competing risks regression showed that PDRAB infection significantly increased the daily hazard of 30-day in-hospital death (cause-specific hazard ratio (csHR): 3.10; 95% CI: 1.33-7.21) while simultaneously decreasing the daily rate of discharge (csHR: 0.24; 95% CI: 0.08-0.74), thereby leading to longer hospitalization. Stronger effects were observed for bloodstream infections.

CONCLUSION

New effective antimicrobials would be expected to prevent mortality in one of every three patients treated for PDRAB infection and reduce their length of hospitalization. However, available therapeutic options remain extremely limited and emphasis on preventing healthcare-associated transmission of PDRAB is ever more important.

Gram-negative bacteria as emerging pathogens affecting mortality in skin and soft tissue infections

INTRODUCTION

Skin and soft tissue infections (SSTIs) are commonly encountered in clinical practice and mainly caused by gram-positive cocci such as S.aureus and β-hemolytic streptococci. Complicated SSTIs involving deeper tissues often necessitate surgical intervention and occur in patients with significant comorbidities such as diabetes or immunocompromising conditions.

METHODS

In this study, we retrospectively reviewed the epidemiology, clinical characteristics, microbiology, and treatment of patients admitted with SSTI during a five-year period in the Internal Medicine Department of a tertiary hospital.

RESULTS

During the study period, 317 patients were recorded, with a mean age of 72.1 years. The most common underlying medical conditions were diabetes mellitus, chronic kidney disease, and heart failure. Cultures were positive in 23.3 % of cases, 62.2 % of which were polymicrobial. The most frequently isolated microorganisms were Enterococci, Escherichia coli, and Pseudomonas aeruginosa. Significant antimicrobial resistance rates were noted, in particular for gram-negative microorganisms. Mortality was higher than described in the literature and associated with age, comorbidities, and infection by gram-negative microorganisms.

CONCLUSION

This study denotes the role of gram-negative bacteria in SSTI epidemiology. Therapeutic protocols regarding the empiric treatment of SSTIs should necessarily take into account the local epidemiology of isolated pathogens and antimicrobial resistance. HIPPOKRATIA 2018, 22(1): 23-28.

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.

Emergence of pan-resistance in KPC-2 carbapenemase-producing Klebsiella pneumoniae in Crete, Greece: a close call

OBJECTIVES

KPC-2-producing Klebsiella pneumoniae (KPC-KP) ST258 has been rapidly expanding and is often associated with serious nosocomial infections. Last-line antibiotics such as colistin and tigecycline often remain the only treatment option. We describe here the evolving genetic background of KPC-KP isolates in Crete, Greece.

METHODS

We tested the antibiotic susceptibility of 34 clinical isolates from patients hospitalized in 2010 and 2013-14. Whole-genome sequences of these isolates were analysed for acquired resistance genes and gene mutations.

RESULTS

All KPC-KP isolates belonged to ST258 with the exception of one ST147 isolate. From 2014, 26% of isolates were non-susceptible to all antibiotics, compared with 0 of 11 isolates from 2010. Colistin resistance was associated with mutations in mgrB, which was present in 61% of isolates from 2014. Core-genome MLST analysis showed that pan-resistant isolates were closely related and appeared in two separate clusters.

CONCLUSIONS

KPC-KP is rapidly evolving to pan-resistance in Crete. We identified molecular resistance markers for pan-resistant isolates and showed that core-genome MLST is a promising tool for molecular fingerprinting of KPC-KP ST258.

Controversies in guidelines for the control of multidrug-resistant Gram-negative bacteria in EU countries

The various guidelines that are available for multidrug-resistant Gram-negative bacteria are useful, and contain broad areas of agreement. However, there are also important areas of controversy between the guidelines in terms of the details of applying contact precautions, single-room isolation and active surveillance cultures, differences in the approach to environmental cleaning and disinfection, and whether or not to perform staff and patient cohorting, healthcare worker screening or patient decolonization. The evidence-base is extremely limited and further research is urgently required to inform an evidence-based approach to multidrug-resistant Gram-negative bacteria prevention and control.

The role of primary care physicians in early diagnosis and treatment of chronic gastrointestinal diseases

Chronic gastrointestinal disorders are a source of substantial morbidity, mortality, and cost. They are common in general practice, and the primary care physician (PCP) has a central role in the early detection and management of these problems. The need to make cost-effective diagnostic and treatment decisions, avoid unnecessary investigation and referral, provide long-term effective control of symptoms, and minimize the risk of complications constitute the main challenges that PCPs face. The literature review shows that, although best practice standards are available, a considerable number of PCPs do not routinely follow them. Low rates of colorectal cancer screening, suboptimal testing and treatment of Helicobacter pylori infection, inappropriate use of proton pump inhibitors, and the fact that most PCPs are still approaching the irritable bowel disease as a diagnosis of exclusion represent the main gaps between evidence-based guidelines and clinical practice. This manuscript points out that updating of knowledge and skills of PCPs via continuing medical education is the only way for better adherence with standards and improving quality of care for patients with gastrointestinal diseases.

Surveillance of Monthly Antimicrobial Consumption Rates Stratified by Patient-Care Area: A Tool for Triggering and Targeting Antibiotic Policy Changes in the Hospital

The profile and temporal trends of antimicrobial use were investigated at a university hospital. Aggregate data were analyzed according to the ATC/DDD methodology. During 1998-2002, hospital-wide antimicrobial use increased by 22%, from 86.97 to 106.24 defined daily doses per 100 bed-days [DDD/100BD]. Pooled usage rates in DDD/100BD, overall percentage increases and annual average increase rates were respectively 109.97, 35.6%, 8.1 for Medical wards, 98.21, 48.7%, 9.1 for Intensive Care Units and 74.46, 34.3%, 5.7 for Hemato-oncology wards. Surgical wards had a fairly constant usage rate (98.36). A shift towards the newer broad-spectrum antibiotics, to the detriment of the older penicillins and cephalosporins, was noted in all hospital areas. Surveillance of antimicrobial consumption using the ATC/DDD system provided a clear picture of its profile. Monthly rates over a sufficient surveillance period allowed the assessment of temporal trends. Stratification of rates according to clinical service allowed areas of concern to be specified and targeted antibiotic policy changes to be initiated.

Psychological factors and stress in inflammatory bowel disease

The role of psychological distress and personality as predisposing factors for the development of inflammatory bowel disease (IBD) remains controversial. Attempts to investigate the role of psychological factors in IBD exhibited rather conflicting results. Among the studies concerning the effects of stress or depression on the course of IBD, the majority suggest that stress worsened IBD, the rest giving either negative or inconclusive results. However, application of strategies, including avoidance of coping and training patients in problem solving or emotion-oriented, could influence the course of IBD. Large controlled clinical trials are needed in order to clarify the impact of psychological interventions on the quality of life and the course of disease.

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.

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.

Risk factors for colorectal polyps: findings from a Greek case-control study

There is a body of evidence showing that several lifestyle and dietary factors are associated with colorectal polyps' formation; however, the magnitude of this association in diverse populations remains unclear. The aim of this study was to investigate this association in a Greek sample.

MATERIAL AND METHOD

The study comprised of 52 subjects with histologically confirmed advanced colorectal polyps and 52 healthy controls. Data concerning lifestyle and dietary factors were collected using a validated questionnaire. Logistic regression analysis was used to estimate odds ratios and 95% confidence intervals after adjustment for potential confounders.

RESULTS

Physical activity level (95% CI 0.032-0.953, P = 0.044) and consumption of yoghurt (95% CI 0.969-0.996, P = 0.024), cheese (95% CI 0.932-0.996, P = 0.030), fish (95% CI 0.782-0.964, P = 0.008), vegetables (95% CI 0.965-0.998, P = 0.029), and garlic (95% CI 0.005-0.671, P = 0.022) were inversely associated with colorectal polyps. Increasing age (95% CI 1.005-1.231, P = 0.039) and central obesity (95% CI 1.001-1.019, P = 0.025) were strongly associated with their presence.

CONCLUSION

Our study indicates that a cluster of modifiable risk factors have significant impact on colorectal polyps' occurrence in Greek population.

Infections by pandrug-resistant gram-negative bacteria: clinical profile, therapeutic management, and outcome in a series of 21 patients

Clinical reports on infections by pandrug-resistant (PDR) bacteria are scarce. This observational case series study was conducted during a 2-year period at a university hospital. Patients infected by PDR gram-negative bacteria comprised the study cohort. An isolate was defined as PDR if it was resistant to all antibiotic classes available for empirical treatment. A total of 21 patients infected by PDR gram-negative bacteria were recorded. The mean APACHE II score on admission was 18.8, the mean Charlson comorbidity index was 2.9, and 20 (95.2%) patients had a history of intensive care unit hospitalization. All patients had recent exposure to multiple antibiotics (median, 6 antibiotic groups). Infections occurred at a mean of 41.5 days after admission. The mean length of stay after infection was 54.6 days and 5 (23.8%) patients died due to the infection. Treatment was mainly based on a colistin-containing regimen (47.6%) or tigecycline (33.3%). All patients treated with tigecycline had total resolution of the infection and a notably shorter length of hospital stay after infection. In conclusion, PDR gram-negative bacterial infections are associated with considerable prolongation of hospitalization and mortality, although the mortality is not as high as that expected. Tigecycline appears to be effective for the successful treatment of PDR infections

Similar response to adalimumab in patients with active Crohn's disease either naive to biologic agents or with prior loss of response or intolerance to infliximab

The aim of this study was to investigate the efficacy of adalimumab, in patients with moderately active Crohn's disease (CD), either naive to biologic agents or with prior loss of response or intolerance to infliximab.

MATERIAL AND METHOD

A total number of 30 patients with moderately active CD (14 men, 16 women, aged 38.5 +/- 14.4 yr) either naive to biologic agent treatment (19 pts (65%)) or with loss of response or intolerance to infliximab (11 pts (35%)), were enrolled to 4-wk trial with treatment with subcutaneous adalimumab 160 mg injection at week 0, 80 mg at week 2 and then 40 mg every other week. Outcome measures included the ability to tolerate adalimumab and clinical remission (defined as a CDAI score < or =150 points) and clinical response (defined as a decrease in the CDAI) > or =70 points). Eleven patients (37%) were smokers, 5(16%) ex-smokers and 14 (47%) non-smokers. Five patients (16%) had a positive family history for IBD. Duration of disease was 10.7 +/- 8.1 yr. Coexistence of extraintestinal manifestations was noticed in 12 (40%) patients. Vienna Classification of CD was A1=24 (80%), A2=6 (20%), L1=8 (26.7%), L2=6 (20%), L3=15 (50%), L4=1 (3.3%), B1=15 (50%), B2=5 (16.7%), B3=10 (33.3%).

RESULTS

Remission was observed in 19 (63.3%) and clinical response in 9 (30%) patients. Two patients (6.7%) showed no response. No significant differences between patients with loss of response or intolerance to infliximab and the group of naive patients were noticed. Comparison between smokers and non smokers revealed significant difference in the response rate in favour of non-smokers (P < 0.002). A trend (P = 0.064) towards a significant difference in the response rate of the group of smokers according to the number of cigarettes smoked per day was observed. Patients with short duration of disease (<10 yr) had significantly better response compared to the group of patients with long (>10 yr) duration of disease. Similarly, patients with extraintestinal manifestations showed significantly better response (P = 0.044). None of the patients in both groups experienced acute or delayed hypersensitivity reactions during treatment with adalimumab.

CONCLUSION

Adalimumab is well tolerated and appears to be a beneficial option for patients with CD who have not previously treated with biologic agents or have lost their response to, or cannot tolerate infliximab, with non-smokers, patients with short duration of CD, and patients with extraintestinal manifestations having a better clinical response.

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.

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.

The dynamic relationship between antibiotic use and the incidence of vancomycin-resistant Enterococcus: time-series modelling of 7-year surveillance data in a tertiary-care hospital

The role of antibiotics in the epidemiology of vancomycin-resistant Enterococcus (VRE) has been studied extensively, but controversies remain as to which, and to what extent, antibiotics facilitate the emergence and dissemination of VRE in hospitals. Aggregate data on the use of several antibiotic classes in terms of defined daily doses (DDD) per 100 patient-days (PD), and VRE incidence rates in terms of clinical isolates per 1000 PD, were evaluated during a 7-year period at a tertiary-care hospital. Time-series analysis (autoregressive integrated moving average (ARIMA) and transfer function models) was used to quantify the temporal effect of antibiotic use on VRE incidence and estimate effect-delays. The incidence rate of VRE observed in a specific bimester was found to be a function of its value during the preceding bimester and of prior changes in the volume of use of four antibiotic classes. In particular, an increase of one DDD/100 PD in the use of glycopeptides, fluoroquinolones, extended-spectrum cephalosporins and beta-lactam-beta-lactamase inhibitor combinations resulted, independently, in average changes of +0.024, +0.015, + 0.020 and -0.010 isolates per 1000 PD in the incidence of VRE, with average delays of 2, 4, 2 and 6 months, respectively, which explained 56% of the observed variation in VRE rates over time. Efforts to reduce VRE cross-transmission should be supplemented by targeted antibiotic control policies. The use of glycopeptides, broad-spectrum cephalosporins and fluoroquinolones in high amounts should be the targets of such policies. Penicillin-beta-lactamase inhibitor combinations might be suitable substitutes for extended-spectrum cephalosporins.

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.

Granulomatous cheilitis associated with exacerbations of Crohn's disease: a case report

Introduction

Crohn's disease is a disease involving the whole gastrointestinal tract from the mouth to the anus. Oral lesions are considered to be an important extraintestinal manifestation. Granulomatous cheilitis has been recognized as an early manifestation of Crohn's disease. It may follow, coincide with or precede the onset of Crohn's disease. The aim of this presentation is to describe a rare case of a patient with Crohn's disease in whom significant swelling of the lower lip not only preceded the diagnosis of Crohn's disease for two years, but it manifested as an early clinical index of the recurrence of the intestinal disease as well.

Case presentation

A man aged 25 was admitted in our department on August 1999 with chronic diarrhea and loss of weight. His bowel symptoms started in 1998 at the age of 24. However, two years previously (June 1996) he noticed a swelling of the lower lip, which contrasted significantly with the previously normal appearance of his mouth. A lip biopsy performed at that time was compatible with granulomatous cheilitis. Crohn's disease involving the terminal ileum and large bowel was diagnosed in 1998 and confirmed on the basis of colonoscopy, enteroclysis and histology findings of the small and large bowel. Conservative treatment resulted in clinical and laboratory improvement of the bowel symptoms and lip swelling. During the following years the disease was active with exacerbations and remissions of mild to moderate severity. The swelling of the lower lip occurred in parallel with the exacerbations of the bowel disease, returning to normal during periods of remission.

Conclusion

Significant swelling of the lower lip due to granulomatous cheilitis could be the first manifestation of Crohn's disease, preceding intestinal symptoms. Exacerbation of the lip lesion could be an early clinical sign of a relapse of the underlying intestinal disease.

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.

Murine typhus in Cyprus: 21 paediatric cases

The aim of this article is to present the manifestations of Rickettsia typhi infection in childhood. Twenty-one children under 15 years of age were hospitalised in the Department of Paediatrics of the Archbishop Makarios Hospital in Nicosia, Cyprus, from 2000 to 2006 with Rickettsia typhi infection. Ten of them were boys and 11 were girls. The median age was eight years (range four to 13 years). The most common clinical features were fever (100%) and rash (57%). Lymphadenopathy, usually cervical, was also a frequent finding (37%). Severe headache was rather infrequent (29%). Splenomegaly or hepatomegaly were less frequent findings (24% and 10%, respectively). Mild elevation of liver enzymes (AST and ALT elevated >1-fold in 81% and 75%, respectively) was the most frequent laboratory finding. Thrombocytopenia (28%) and leucopenia (17%) were less frequent. Nearly half of the patients (10/21) came from four neighbouring villages, where most residents work in agriculture. All of the children were treated with appropriate antibiotic regimens and had complete recovery. Rickettsia typhi infection should be considered in the differential diagnosis of children who present during the summer or early autumn months with prolonged fever and rash with or without lymphadenopathy.

Pregnancy and inflammatory bowel disease: a prospective case-control study

OBJECTIVE

Taking into account the relative confusion in the literature concerning the influence of pregnancy on the underlying inflammatory bowel disease (IBD) and vice versa, as well as the influence of drugs on the foetus and the gestation itself, we performed this prospective study, in order to further elucidate this interesting topic.

PATIENTS AND METHODS

Prospective follow-up study of 9 pregnant women with previously established IBD, 4 with ulcerative colitis (UC) and 5 with Crohn's disease (CD). Results were compared to those of 9 non-pregnant women with IBD with similar clinico-demographic characteristics (disease control group), and 18 healthy pregnancy women (healthy control group).

RESULTS

(a) Patients with IBD and gestation vs. healthy control group: Significantly impaired body weight in newborns from IBD mothers compared to healthy women (2530 +/- 961 g vs. 3242 +/- 582 g, P = 0.035) was found. Significantly more cases of therapeutic or spontaneous abortion and premature delivery in pregnant women with IBD compared to healthy pregnant women [5/ 9(56.6%) vs 1/18 (5.6%), P = 0.008] were also noticed. Concerning drug consumption, it was noticed that azathioprine was taken regularly in one case of spontaneous abortion and in one case of premature delivery. No significant differences concerning other parameters such as smoking habit and death of foetus were observed. (b) Patients with IBD and gestation vs. patients with IBD without gestation: No significant differences in the history of various parameters of the disease (number of operations, presence of fistulas), previous gestations, and course of the disease during the period of gestation were found. (c) Course of the disease six months after delivery: No significant differences between patients with IBD and pregnancy and disease control group were noticed.

CONCLUSION

It is concluded that gestation in women with IBD is accompanied by some unwanted events such as premature delivery, therapeutic or spontaneous abortion, and reduced newborn body weight. Clinicians must bear in mind the possibility of the appearance of some unwanted events in pregnant women with IBD during their gestation.

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.

Mediterranean Spotted Fever in Crete, Greece: Clinical and Therapeutic Data of 15 Consecutive Patients

The clinical, epidemiological, and therapeutic aspects of 15 patients with Mediterranean spotted fever (MSF), admitted to the Internal Medicine Department of the General Hospital of Sitia (southeastern Crete, Greece) between December 2000 and July 2003, were studied. Diagnosis was made on the basis of clinical signs and symptoms and was confirmed by serology. Of the patients studied, 67% were men and 33% women, with a median age of 52 years (range of 23-76 years). Ten cases (67%) were diagnosed between May and July. Of all the patients, 93% had a history of contact with animals, mainly with sheep (11 patients, 73%), while 53% of them had a history of tick-bite (33%), or reported the presence of ticks in their environment (20%). The typical eschar lesion (tache noir) at the tick-bite site was present in 53% of the patients, while the rash was present in 87% of them. Laboratory findings included leukopenia (47%), thrombocytopenia (54%), elevation of transaminases (80%), hyponatremia (33%), and microscopic hematuria (80%). Four patients (27%) displayed pulmonary infiltrates on chest radiography. All patients were treated with doxycycline (200 mg daily) and recovered rapidly. Renal function deteriorated in one patient with chronic renal failure, but he recovered thereafter.

Surveillance of antibiotic use in hospitals: methods, trends and targets

A standardised antibiotic surveillance system is an essential requirement of all antibiotic control strategies. Antibiotic use can be quantified accurately using patient-level surveillance, although this is not feasible for most hospitals. Instead, population-level surveillance is a more realistic alternative for ongoing and systematic monitoring of antibiotic use. Monitoring of aggregate, ward-supply data on a monthly basis, stratification by patient care area, and analysis by the anatomical therapeutic chemical/defined daily dose (ATC/DDD) system, adjusting for bed-occupancy, provides a clear picture of antibiotic consumption density and time-trends within a hospital. When usage rates are supplemented and interpreted according to changes in hospital resource indicators, benchmarking is facilitated. This provides an efficient tool for triggering and targeting antibiotic control interventions.

Favorable response to subcutaneous administration of infliximab in rats with experimental colitis

AIM: To investigate the influence of infliximab (Remicade) on experimental colitis produced by 2,4,6,trinitrobenzene sulfonic acid (TNBS) in rats.

METHODS: Thirty-six Wistar rats were allocated into four groups (three groups of six animals each and a fourth of 12 animals). Six more healthy animals served as normal controls (Group 5). Group 1: colitis was induced by intracolonic installation of 25 mg of TNBS dissolved in 0.25 mL of 50% ethanol and infliximab was subcutaneously administered at a dose of 5 mg/kg BW; Group 2: colitis was induced and infliximab was subcutaneously administered at a dose of 10 mg/kg BW; Group 3: colitis was induced and infliximab was subcutaneously administered at a dose of 15 mg/kg BW; Group 4: colitis was induced without treatment with infliximab. Infliximab was administered on d 2–6. On the 7^th d, all animals were killed. The colon was fixed in 10% buffered formalin and examined by light microscopy for the presence and activity of colitis and the extent of tissue damage. Tumor necrosis factor-alpha (TNF-α) and malondialdehyde (MDA) were also measured.

RESULTS: Significant differences concerning the presence of reparable lesions and the extent of bowel mucosa without active inflammation in all groups of animals treated with infliximab compared with controls were found. Significant reduction of the tissue levels of TNF-α in all groups of treated animals as compared with the untreated ones was found (0.47±0.44, 1.09±0.86, 0.43±0.31 vs 18.73±10.53 respectively). Significant reduction in the tissue levels of MDA was noticed in group 1 as compared to group 4, as well as between groups 2 and 4.

CONCLUSION: Subcutaneous administration of infliximab reduces the inflammatory activity as well as tissue TNF-α and MDA levels in chemical colitis in rats. Infliximab at a dose of 5 mg/kg BW achieves better histological results and produces higher reduction of the levels of TNF-α than at a dose of 10 mg/kg BW. Infliximab at a dose of 5 mg/kg BW produces higher reduction of tissue MDA levels than at a dose of 15 mg/kg BW.

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.

Nosocomial lower respiratory tract infections: prevalence and risk factors in 14 Greek hospitals

Nosocomial lower respiratory tract infections (NLRTIs) are associated with significant morbidity and mortality. The aim of this study was to investigate the epidemiological features of NLRTIs in Greece, where knowledge about these infections is limited. Two point-prevalence studies of hospital-acquired infections were carried out in 14 Greek hospitals located throughout the country, one in 1999 and one in 2000. NLRTIs were diagnosed in accordance with the Centers for Disease Control and Prevention (CDC) definitions. Among the 7,120 hospitalized patients registered during the two studies, 610 (8.6%) cases of hospital-acquired infections were identified, of which 200 (32.8%) were NLRTIs. Sixty-nine (34.5%) patients had pneumonia, and the remaining 131 (65.5%) patients had bronchitis. The greatest prevalence of NLRTI was found in the adult ICUs (30.4%). Male gender, age >65 years, mechanical ventilation, tracheostomy, an intravenous central line, and an indwelling urethral catheter were the main risk factors. There was no significant difference in the incidence of NLRTI among hospital-acquired infections between the 1999 study and the 2000 study. The causative microorganism was identified in 78 of 200 (39%) cases, and 103 strains were isolated. The majority of strains (67%) were gram-negative bacteria. The most frequently isolated microorganisms were Pseudomonas aeruginosa (22.3%), Acinetobacter spp. (19.4%), Klebsiella pneumoniae (12.6%), and Staphylococcus aureus (10.7%). There was no difference between the two prevalence studies in the frequency of isolation of the microorganisms. NLRTI was the leading cause of morbidity and mortality among hospitalized patients with hospital-acquired infections in Greek hospitals. Gram-negative microorganisms were the most frequently isolated pathogens.

Acute ST-segment elevation myocardial infarction after amoxycillin-induced anaphylactic shock in a young adult with normal coronary arteries: a case report

Background

Acute myocardial infarction (MI) following anaphylaxis is rare, especially in subjects with normal coronary arteries. The exact pathogenetic mechanism of MI in anaphylaxis remains unclear.

Case presentation

The case of a 32-year-old asthmatic male with systemic anaphylaxis, due to oral intake of 500 mg amoxycillin, complicated by acute ST-elevation MI is the subject of this report. Following admission to the local Health Center and almost simultaneously with the second dose of subcutaneous epinephrine (0.2 mg), the patient developed acute myocardial injury. Coronary arteriography, performed before discharge, showed no evidence of obstructive coronary artery disease. In vivo allergological evaluation disclosed strong sensitivity to amoxycillin and the minor (allergenic) determinants of penicillin.

Conclusion

Acute ST-elevation MI is a rare but potential complication of anaphylactic reactions, even in young adults with normal coronary arteries. Coronary artery spasm appears to be the main causative mechanism of MI in the setting of "cardiac anaphylaxis". However, on top of the vasoactive reaction, a thrombotic occlusion, induced by mast cell-derived mediators and facilitated by prolonged hypotension, cannot be excluded as a possible contributory factor.