Morbidity During the Early Interwar Period (1923-27): A Historical-Epidemiological Study of 15,146 Cases Treated at the "Agios Dimitrios" Hospital in Thessaloniki, Greece

Background and objective The period spanning 1923-1927 was a turbulent period in Greek history following the catastrophic defeat of the Greek army in September 1922, known as the "Asia Minor Catastrophe". The massive settlement of refugees in Thessaloniki, Greece, entailed massive economic, public health, and social challenges. The present historical-epidemiological study aims to evaluate the diseases of individuals hospitalized at the "Agios Dimitrios" Hospital in Thessaloniki during the aforementioned period. Materials and methods This study involved 15,146 consecutive patients (January 1923-March 1927) treated at the hospital. Data were collected from the General Hospital of Thessaloniki "Agios Dimitrios" and were manually entered into a pre-coded database. Descriptive statistics were calculated. In addition, the case fatality rates (CFR) were calculated; the respective 95% confidence intervals (CI) were estimated. Results The most frequent causes for admission to the hospital were as follows: normal delivery/delivery without disclosed sequalae (n=1915, 12.7%), followed by tuberculosis (n=1514, 10.0%), malaria (n=1438, 9.5%), injuries/falls/fractures (n=1394, 9.2%), pneumonia/pleuritis (n=1010, 6.7%), appendicitis (n=623, 4.1%), dysentery/enterocolitis/typhoid (n=489, 3.2%), salpingitis/salpingo-oophoritis (n=358, 2.4%), soft tissue abscesses (n=309, 2.0%), hernias (n=295, 2.0%), rabies (n=239, 1.6%), metrorrhagia/menorrhagia (n=233, 1.5%), ocular cataract (n=225, 1.5%), postpartum infections/endometritis (n=181, 1.2%), uterine discomfort/uterine pain (n=162, 1.1%), nephritis/uremia (n=157, 1.0%), miscarriage (n=155, 1.0%), skin infections/inflammations excluding abscesses (n=152, 1.0%), otitis/mastoiditis/labyrinthitis (n=96, 0.6%), and peptic ulcer (n=93, 0.6%). Tuberculosis was particularly associated with high CFR (49.5%, 95% CI: 47.2-52.3%), followed by nephritis/uremia (CFR: 37.6%), dysentery/infectious enterocolitis/typhoid (CFR: 24.3%), peptic ulcer (CFR: 22.6%), pneumonia/pleuritis (CFR: 16.1%), postpartum infections/endometritis (CFR: 15.5%). Conclusions Infections predominated in the disease spectrum of the hospitalized population. The documented fatality rates were high; poor outcomes may reflect the socioeconomic adversities and limited medical means and resources available at that time.

Religiosity, Well-Being and 'Slowing Down' Ageing Damage: A Literature Review

Telomere length (TL) represents an important marker of cellular aging. Its shortening affects human health and longevity by inducing senescence, apoptosis, and oncogenesis. Advanced ageing and negative behavioral and lifestyle factors decrease TL. The relationship between positive psycho-social factors and longer telomeres has given rise to a growing number of research efforts. Among these, religiosity poses a particular interest since it is associated with a wide range of favorable health outcomes. In this direction, recent literature reports, suggest a positive link between religiosity and TL. Underlying mechanisms for this association are not yet clarified.

In this review, we would like to summarize the current knowledge on the link between religiosity and TL. Taking this opportunity, we recall findings from a cohort study in rural Crete, Greece that adds evidence on the discussion of potential psycho-social mediators which some may prevent shortening of TL.

Measuring the burden of herpes zoster and post herpetic neuralgia within primary care in rural Crete, Greece

Background

Research has indicated that general practitioners (GPs) have good clinical judgment in regards to diagnosing and managing herpes zoster (HZ) within clinical practice in a country with limited resources for primary care and general practice. The objective of the current study was to assess the burden of HZ and post herpetic neuralgia (PHN) within rural general practices in Crete, Greece.

Methods

The current study took place within a rural setting in Crete, Greece during the period of November 2007 to November 2009 within the catchment area in which the Cretan Rural Practice-based Research Network is operating. In total 19 GP's from 14 health care units in rural Crete were invited to participate, covering a total turnover patient population of approximately 25, 000 subjects. For the purpose of this study an electronic record database was constructed and used as the main tool for monitoring HZ and PHN incidence. Stress related data was also collected with the use of the Short Anxiety Screening Test (SAST).

Results

The crude incidence rate of HZ was 1.4/1000 patients/year throughout the entire network of health centers and satellite practices, while among satellite practices alone it was calculated at 1.3/1000 patients/year. Additionally, the standardised incidence density within satellite practices was calculated at 1.6/1000 patients/year. In regards to the stress associated with HZ and PHN, the latter were found to have lower levels of anxiety, as assessed through the SAST score (17.4 ± 3.9 vs. 21.1 ± 5.7; p = 0.029).

Conclusions

The implementation of an electronic surveillance system was feasible so as to measure the burden of HZ and PHN within the rural general practice setting in Crete.

Comparison between two different measures of self-rated health: a single-question measure and a visual analogue scale

INTRODUCTION

Self-rated health (SRH) is a useful concept for research and health planning, and an important indicator of population health.

AIM

The present study aims to evaluate the appropriateness of two different measures used to assess SRH, a single question with a five-response Likert-type scale and a visual analogue scale (VAS), by studying the correlation between the two measures and the factors influencing response rates according to respondent characteristics.

MATERIAL AND METHODS

A population-based postal survey was carried out within the framework of a World Health Organisation (WHO) project, with a national sample of randomly selected geographically stratified individuals. The factors influencing SRH using each measure were determined. The comparison of the two measures was also studied with respect to response frequencies and differences in association with potential determinants (age, sex, income, education). Answering to each measure depending upon answering to the other measure was also tested.

RESULTS

The maximum correlation between the two measures was p = -0.78 (p < 0.001). Age, sex, income and education had an effect on SRH as measured using both measures. More people replies to the single question measure irrespective of any particular socio-economic characteristic. Generally, those completing the VAS were women of higher income.

CONCLUSIONS

The two measures are moderately correlated, the structure of the questionnaire and sequence of questions seems to affect correlation, and the single question yields higher response rate than VAS does. Still, other factors may also play a significant explanatory role in SRH among the Greek population and in relation to which measure is used.

Studying the association between musculoskeletal disorders, quality of life and mental health. A primary care pilot study in rural Crete, Greece

Background

The burden of musculoskeletal disorders (MSD) on the general health and well-being of the population has been documented in various studies. The objective of this study was to explore the association between MSD and the quality of life and mental health of patients and to discuss issues concerning care seeking patterns in rural Greece.

Methods

Patients registered at one rural Primary Care Centre (PCC) in Crete were invited to complete the Nordic Musculoskeletal Questionnaire (NMQ) for the analysis of musculoskeletal symptoms, together with validated instruments for measuring health related quality of life (SF-36) and mental distress (GHQ-28).

Results

The prevalence rate of MSD was found to be 71.2%, with low back and knee pain being the most common symptoms. Most conditions significantly impaired the quality of life, especially the physical dimensions of SF-36. Depression was strongly correlated to most MSD (p < 0.001). Multiple logistic analyses revealed that patients who consulted the PCC due to MSD were likely to have more mental distress or impaired physical functioning compared to those who did not.

Conclusion

Musculoskeletal disorders were common in patients attending the rural PCC of this study and were associated with a poor quality of life and mental distress that affected their consultation behaviour.

Translation of the Neck Disability Index and validation of the Greek version in a sample of neck pain patients

BACKGROUND

Neck pain is a highly prevalent condition resulting in major disability. Standard scales for measuring disability in patients with neck pain have a pivotal role in research and clinical settings. The Neck Disability Index (NDI) is a valid and reliable tool, designed to measure disability in activities of daily living due to neck pain. The purpose of our study was the translation and validation of the NDI in a Greek primary care population with neck complaints.

METHODS

The original version of the questionnaire was used. Based on international standards, the translation strategy comprised forward translations, reconciliation, backward translation and pre-testing steps. The validation procedure concerned the exploration of internal consistency (Cronbach alpha), test-retest reliability (Intraclass Correlation Coefficient, Bland and Altman method), construct validity (exploratory factor analysis) and responsiveness (Spearman correlation coefficient, Standard Error of Measurement and Minimal Detectable Change) of the questionnaire. Data quality was also assessed through completeness of data and floor/ceiling effects.

RESULTS

The translation procedure resulted in the Greek modified version of the NDI. The latter was culturally adapted through the pre-testing phase. The validation procedure raised a large amount of missing data due to low applicability, which were assessed with two methods. Floor or ceiling effects were not observed. Cronbach alpha was calculated as 0.85, which was interpreted as good internal consistency. Intraclass correlation coefficient was found to be 0.93 (95% CI 0.84-0.97), which was considered as very good test-retest reliability. Factor analysis yielded one factor with Eigenvalue 4.48 explaining 44.77% of variance. The Spearman correlation coefficient (0.3; P = 0.02) revealed some relation between the change score in the NDI and Global Rating of Change (GROC). The SEM and MDC were calculated as 0.64 and 1.78 respectively.

CONCLUSION

The Greek version of the NDI measures disability in patients with neck pain in a reliable, valid and responsive manner. It is considered a useful tool for research and clinical settings in Greek Primary Health Care.

Risk factors for ischaemic heart disease in a Cretan rural population: a twelve year follow-up study

BACKGROUND

Crete has been of great epidemiological interest ever since the publication of the Seven Countries Study. In 1988 a well-defined area of rural Crete was studied, with only scarce signs of coronary heart disease (CHD) despite the unfavorable risk profile. The same population was re-examined twelve years later aiming to describe the trends of CHD risk factors over time and discuss some key points on the natural course of coronary heart disease in a rural population of Crete.

METHODS AND RESULTS

We re-examined 200 subjects (80.7% of those still living in the area, 62.4 +/- 17.0 years old). The prevalence of risk factors for CHD was high with 65.9% of men and 65.1% of women being hypertensive, 14.3% of men and 16.5% of women being diabetic, 44% of men being active smokers and more than 40% of both sexes having hyperlipidaemia. Accordingly, 77.5% of the population had a calculated Framingham Risk Score (FRS) > or = 15%, significantly higher compared to baseline (p < 0.001). The overall occurrence rate for CHD events was calculated at 7.1 per 1000 person-years (95% confidence interval: 6.8-7.3).

CONCLUSION

The study confirms the unfavorable risk factor profile of a well defined rural population in Crete. Its actual effect on the observed incidence of coronary events in Cretans remains yet to be defined.

Overweight and obesity in Greek warship personnel: prevalence and correlations

OBJECTIVE

To estimate the prevalence of obesity among the personnel of a Greek warship and to highlight the potential relationship of the body-mass index (BMI).

METHODS

Data on behavioural and demographic characteristics, among 274 men of a Greek warship, aged between 19 and 38 years, were analysed.

RESULTS

26.5% of participants were overweight and 4.7% obese. BMI was correlated with age, and cigarette pack-years, and inverse correlated with the aerobic exercise. No significant associations were found between BMI and alcohol consumption.

CONCLUSION

A relatively high proportion of obesity was found in a Greek military population. Intervention and prevention measures should be targeted at the promotion of physical activity and the reduction of the smoking behaviour of personnel.

Smoking behavior of Greek warship personnel

The results from a study undertaken to assess the smoking behavior of Greek warship personnel found that of the 274 participants, ages 19 to 38 years, 59.5% were current smokers who started the habit between the ages of 15 and 21 years. However, 33.1% of these current smokers started smoking after entering the Greek Navy. There were statistically significant associations between the habit of smoking and the occurrences of respiratory tract infections, alcohol consumption, lack of aerobic exercise during leisure time, and educational level of the personnel. Another significant association was between the age of introduction into the habit of smoking and the number of cigarettes smoked daily, with the level of education being a contributing factor. The method of entry into the Greek Navy and the rank held made a significant contribution to the time period of initiation into the habit of smoking. The impact of military life on the smoking behavior of the shipboard personnel is discussed and suitable intervention strategies have been recommended.

Mental distress and sociodemographic variables: a study of Greek warship personnel

BACKGROUND

Mental disorders have been found to be the main cause of maladjustment and early discharge of the personnel in the Hellenic Navy and the armed forces in general. This study investigates the mental health status of a warship's military personnel by use of a widely used self-administered scale.

METHODS

The 28-item Greek version of the General Health Questionnaire was administered to 281 men aboard a Greek warship to determine their mental health status and to examine possible associations with sociodemographic variables (rank, educational level, marital status).

RESULTS

A high prevalence of General Health questionnaire cases (48.8%) was found which indicated conscripts as the group with the greater tendency for problems of adjustment and performance among the personnel of the warship. A negative association was found between educational level and psychological distress, whereas married subjects were found to have better levels of psychological well-being as defined by lower General Health questionnaire scores, compared with unmarried subjects.

CONCLUSIONS

Although a further methodological and more sophisticated inquiry is necessary, the findings of the present study could be useful for the design of mental health interventions in the naval and the military setting.

Measuring the prevalence of diabetes mellitus in a Greek primary health care district

BACKGROUND

Diabetes mellitus is a common disease in developed countries, but in Greece national figures on its prevalence are lacking.

OBJECTIVES

The aim of this study was to identify the burden of known diabetes mellitus through its estimation in the area of responsibility of the Spili Health Centre, based on the health information system that had been established in Primary Health Care in rural Crete.

METHOD

The diagnosis of diabetes was retrospectively documented by reviewing all medical records (n = 47151) at the Spili Health Centre and its five regional outposts during the period 1/6/1988-1/7/1993. The diagnostic criteria of WHO were used to establish the diagnosis.

RESULTS

After excluding the patients who had died, we found 210 patients with diabetes mellitus. Thirty cases were evaluated with OGTT because of mild but not diagnostic elevations of fasting plasma glucose, on more than one occasion. The prevalence of diabetes after age and sex standardization of that for the European population was estimated at 1.52% (1.31% in males and 1.68 in females).

CONCLUSIONS

Our study shows that: 1) the role of the GPs and one appropriate information system in measuring the prevalence of known diabetes mellitus are now considered important within the Greek context; 2) diabetes mellitus seems not to be a rare disease in rural Crete. The estimated prevalence appears to be similar to the prevalence rates reported in other areas of rural Greece.

Mortality rates in a cardiovascular 'low-risk' population in rural Crete

A research project in primary health care has been in progress since 1988 in an agricultural area of Crete, with the aim of surveying the cardiovascular risk profile and following the incidence of cardiovascular disease in the population over time. In the present paper we have investigated the mortality rates and the causes of death in 1989 and 1990 of the population of the Agios Vassilios county (n = 7758). Furthermore, whenever possible, we have checked the accuracy of the certified causes of death against the case record system introduced in 1988 in the health centre. During 1989 and 1990, 267 subjects died in the research area, 234 of whom were > 65 years old. Diseases of the circulatory system (mostly congestive heart failure) accounted for 46% of all deaths. The corresponding figure for neoplasms was 18%. The standardized mortality from ischaemic heart disease was found to be very low in both men and women, 37.9 and 41.9 per 100,000 per year, respectively, in comparison with that of Greece as a whole in 1989, 140.0 and 59.5, respectively. These figures were considerably lower than those reported in 1988 from for example Sweden, 303.6 and 153.3, respectively. The standardized mortality from cerebrovascular disease in Agios Vassilios county was found to be somewhat lower than the national figures in 1989, 118.1 and 107.0 in males and females versus 135.7 and 142.1, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Electrocardiographic signs of coronary heart disease in a "low risk" population in rural Crete

BACKGROUND

Ischemic heart disease (IHD) has been shown to be very uncommon in the population of Crete. Therefore, we established a research project in a rural part of Crete to survey the cardiovascular risk profile and follow the incidence of cardiovascular disease over time. This study investigated the prevalence of ECG abnormalities in the population of five villages and compared the prevalence of hypertension, obesity, diabetes, and hypercholesterolemia in those with and without ECG signs of IHD.

METHODS

A cross-sectional study was conducted in a group from 15 to 79 years of age (n = 1218); overall attendance was 926 (76%). Studies included case history, clinical status, laboratory variables, and 12-lead ECG. Technically acceptable ECGs were read and coded blindly for 895 subjects (97%).

RESULTS

Minnesota codes suggesting "Probable IHD" were recorded in 3.3% of the women and 3.5% of the men from 45 to 79 years of age. Hypertension was more common in subjects with than in those without "Probable IHD." This also tended to be the case for diabetes. Cholesterol and body mass index were relatively high in both groups.

CONCLUSIONS

The present prevalence of "Probable IHD" in Cretans appears to be very similar to that observed in other population surveys. Also, the contemporary cardiovascular risk factor profile in the population was quite unfavorable, with a relatively high prevalence of smoking, dyslipidemia, hypertension, and diabetes. The prevalence of "Probable IHD" was lowest in the village where the health center was situated (1% vs 4.5%), and this difference was also reflected in differences among the villages of some important risk factors for IHD as well as in the way patients with hypertension and other diseases were cared for. Thus, it seems IHD is becoming more prevalent in the "low risk" population of Crete. This may very well be a result of a more unfavorable lifestyle and a higher rate of risk factors than before.

Differences in the diagnose panorama in primary health care in Dalby, Sweden and Spili, Crete

We have compared the use of primary health care and the diagnoses at visits to doctors in the Spili Health Centre (SHC) in Crete and the Dalby Health Centre (DHC) in Sweden. In DHC more patients per 1000 population visited the doctors than in SHC. This was so regardless of age-group and sex, in fact more or less regardless of diagnosis. Other differences between the populations were: The diagnosis acute otitis media was more frequent in the Dalby children than in the Spili ones. The opposite was true of "head injuries" which were more frequent in the Spili boys. Visits to doctors for bronchitis was more frequent in the Spili men, maybe because of the extensive smoking habits of Cretan men. Visits for diseases of the musculoskeletal system were more frequent in DHC than in SHC. A hypothesis worth testing is that this was influenced by differences in the health insurance and sick benefit systems. Angina pectoris was fairly frequent in both areas but cardiosclerosis (including healed myocardial infarction) was more common in DHC than in SHC. Use of primary health care may be influenced by the need for health care in the population, the accessibility of the health care facilities, the costs for the patients, the quality of care as perceived by the patients and by other sociocultural factors. Comparative studies, even though fairly uncommon today, may be of use in generating hypotheses about the impact of different factors on the use of health care.

Characteristics of the 'metabolic syndrome X' in a cardiovascular low risk population in Crete

We have studied hypertension, obesity, diabetes and hypercholesterolaemia in those aged 45-79 years in the Cretan low risk population of Spili (n = 249; attendance 82%) to see if these conditions interacted in the same way as previously described for high risk populations. Hypertension, diabetes, obesity, and hypercholesterolaemia were found to be at least as prevalent in Spili as in Sweden. Furthermore, the previously described 'Metabolic Syndrome X', with insulin resistance and hyperinsulinaemia as a common denominator also seemed to exist in the Spili population where patients with these conditions had higher insulin and C-peptide levels than normals. Our finding should be viewed against the low prevalence of past myocardial infarction in Cretan men from Spili reported by us and confirming the results of the Seven Countries Study.

Risk factors for ischaemic heart disease in a Greek population. A cross-sectional study of men and women living in the village of Spili in Crete

We have established a research project in primary health care in Crete with the aim of surveying the cardiovascular risk profile of a defined 'low-risk' population. The study population comprised all men and women aged 15-79 years in the village of Spili (n = 445); the overall attendance rate was 77% (greater than or equal to 82% in those aged 45 years and above). In this cross-sectional study we found a high (44%) prevalence of smoking in men aged 45-64 years as well as a high alcohol intake (48% drank greater than or equal to 210 g of pure alcohol every week). Furthermore, there was a high cholesterol level (6.2 mmol.l-1), and a high prevalence of hypertension and diabetes. Against this background it is somewhat surprising that we did not find any signs of post-myocardial infarction in Spili men aged 63 and under. It is possible that positive factors, i.e. the closely knit social networks, the low unemployment rate, the hard water, and some of the dietary habits, e.g. the high consumption of olive oil, may counter-balance the negative factors mentioned above. It is also possible that the low risk factors in the past explain the low incidence of myocardial infarction today, and that this will change in the years to come.

Use of primary health care in Spili, Crete, and in Dalby, Sweden

A computerized medical record system was introduced in Greek primary health care (PHC) in the village of Spili in Crete. The present study was carried out to study similarities and differences in the pattern of PHC use in Dalby Health Centre, Sweden (DHC), and Spili Health Centre, Greece (SHC). In both Dalby and Spili more than half the population contacted their respective health centre during 1989. Patients contacted DHC more often than SHC, 3.33 vs 2.30 times. Relatively more females than males used the health services in Dalby (64% vs 50%) but not in Spili (57% vs 55%). More visits were made by appointment at DHC than SHC (36.0% vs 12.6%). There were great similarities in the two areas in the ten most common diagnoses, analysed in four age-groups. In both areas, acute upper respiratory infections dominated in the youngest age-groups, and hypertension and diabetes in those aged 45 years and above.