Long-term exposure to ozone and children's respiratory health: Results from the RESPOZE study.

BACKGROUND: Although there is evidence on the effects of short-term ozone (O3) exposures on children's respiratory health, few studies have reported results on the effects of long-term exposures. We report the effects of long-term exposure to O3 on respiratory health outcomes in 10-11-year old children. METHODS: We conducted a panel study in a sample of the general population of school children in two cities with high average O3 concentrations, Athens and Thessaloniki, Greece. All 186 participating students were followed up intensively for 5 weeks spreading across a school year. Data was collected through questionnaires, weekly personal O3 measurements, spirometry, FeNO and time-activity diaries. Long-term O3 exposure was assessed using fixed site measurements and modeling, calibrated for personal exposures. The associations between measured lung function parameters and lung function growth over the study period, as well as FeNO and the occurrence of symptoms with long-term O3 exposure were assessed through the application of multiple mixed effects 2-level regression models, adjusting for confounders and for short-term exposures. RESULTS: A 10 µg/m3 increase in calibrated long-term O3exposure, using measurements from fixed site monitors was associated with lower FVC and FEV1 by 17 mL (95% Confidence Interval: 5-28) and 13 mL (3-21) respectively and small decreases in lung growth: 0.008% (0.002-0.014%) for FVC and 0.006% (0.000-0.012%) in FEV1 over the study period. No association was observed with PEF, FeNO or the occurrence of symptoms. A similar pattern was observed when the exposure estimates from the dispersion models were employed. CONCLUSIONS: Our study provides evidence that long-term O3 exposure is associated with reduced lung volumes and growth.

Determination of total and lung-deposited particle surface area concentrations, in central Athens, Greece.

Numerous health studies have linked the exposure to particulate matter with adverse health effects, while there is an increasing scientific interest in the particle metrics of surface area (SA) and lung-deposited SA (LDSA) concentration. In the present study, two integrated SA estimation methods, both based on widely used instrumentation, were applied at an urban traffic environment in Athens for a 6-month period. The first estimation method used the size distribution by number to estimate SA (average SA1 669.3 ± 229.0 µm2 cm-3), while the second method used a simple inversion scheme that incorporates number and mass concentrations (average SA2 1627.9 ± 562.8 µm2 cm-3). In pairwise comparisons, SA2 levels were found two times greater than the corresponding SA1, but exhibited a strong correlation (r = 0.73). SA1 and SA2 concentrations correlated well with the traffic-related pollutants NOx (r = 0.64 and 0.78) and equivalent black carbon (r = 0.53 and 0.51). The diurnal variation of SA1 concentrations by size range indicated traffic as a major controlling factor. Estimated LDSA (53.9 µm2 cm-3 on average) concentrations were also clearly affected by anthropogenic emissions with more pronounced associations in the 0.01-0.4 µm range (r = 0.66 with NOx and r = 0.65 with equivalent black carbon). Validating estimated LDSA through simultaneous measurements with a reference instrument revealed that the estimation method underestimates LDSA by a factor between 2 and 3, exhibiting, however, a high correlation (r = 0.79). Overall, the performance of estimation methods appear satisfactory and indicate that a trustworthy assessment of the temporal variability of SA and LDSA concentration metrics can be provided in real time, on the basis of relatively lower-cost instrumentation, especially in view of recent advances in particle sensing technologies.

Determinants of personal exposure to ozone in school children. Results from a panel study in Greece.

BACKGROUND: In the wider framework of the RESPOZE (ReSPiratory effects of OZone Exposure in Greek children) panel study, we investigated possible determinants of O3 exposure of school children, measured with personal passive samplers, in Athens and Thessaloniki, Greece. METHODS: Personal exposure to O3 was measured for five weeks spread along the academic year 2013-14, in 186 school children in Athens and Thessaloniki, Greece. At the same time, at-school outdoor measurements were performed and ambient levels of 8-h daily maximum O3 from fixed sites were collected. We also collected information on lifestyle and housing characteristics through an extended general questionnaire (GQ) and each participant completed daily time activity diaries (TADs) during the study period. RESULTS: Mean outdoor concentrations were higher during the warmer months, in the suburbs of the cities and in Athens. Personal exposure concentrations were significantly lower compared to outdoor. Daily levels of at-school outdoor and ambient levels of O3 from fixed sites were significant determinants of personal exposure to O3. For a 10µg/m3 increase in at-school outdoor O3 concentrations and PM10 measurements a 20.9% (95% CI: 13%, 28%) increase in personal exposure to O3 was found. For a half an hour more spent in transportation an average increase of 7% (95% CI: 0.3%, 14.6%) in personal exposure to O3 was observed. Among other possible determinants, time spent in transportation (TAD variable) and duration of open windows were the ones associated with personal O3 exposure levels. CONCLUSIONS: Our results support the use of outdoor and ambient measurements from fixed sites in epidemiological studies as a proxy of personal exposure to O3, but this has to be calibrated taking into account personal measurements and time-activity patterns.

Source apportionment of fine and ultrafine particle number concentrations in a major city of the Eastern Mediterranean.

Ultrafine particles (UFP) are recognized as an emerging pollutant able to induce serious health effects. However, quantitative information regarding the contributions of UFP sources is generally limited. This study evaluates statistical (k-means clustering) and receptor models (Positive Matrix Factorization - PMF) using particle number size distributions (PNSD), along with chemical speciation data, measured at an urban background supersite in Athens, Greece, aiming to characterize their sources. PNSD measurements (10-487 nm) were performed during three distinct periods (warm, cold, and lockdown cold). Traffic and residential biomass burning (BB) produced high UFP number concentrations (NUFP) in the cold period (+107 % compared to summer), while the lockdown restrictions reduced NUFP (-42 %). The five groups produced by cluster analysis that were common among periods were linked to high- and low-traffic, new particle formation (NPF), urban background and regional aerosols. PMF source apportionment identified 5 and 6 factors during warm and cold periods, respectively, indicating that traffic particles dominated NUFP (64-78 % in all periods), while accumulation-mode particles and volume concentrations were controlled by processed aerosol, and especially in the cold periods by BB emissions. A nucleation factor linked to NPF contributed 7-11 % to NUFP. Comparing the two cold periods (business-as-usual, lockdown), important lockdown reductions (-46 %) were seen for fresh traffic contributions to total number concentration (Ntotal). The impact of the source attributed to NPF also eroded (-41 % for Ntotal). Due to the large reduction (-47 % for Ntotal) observed also for the BB source during the lockdown (reduced wood usage due to a milder winter), the relative contributions of all sources did not change considerably (fractional reductions <7 % for Ntotal). The quantitative results, bolstered by source apportionment combining PNSD and online chemical composition measurements, indicate the potential to constrain UFP levels by regulating traffic and residential emissions, with a large upside for population exposure control.

Source apportionment of particle-bound polycyclic aromatic hydrocarbons (PAHs), oxygenated PAHs (OPAHs), and their associated long-term health risks in a major European city.

Many studies have drawn attention to the associations of oxygenated polycyclic aromatic hydrocarbons (OPAHs) with harmful health effects, advocating for their systematic monitoring alongside simple PAHs to better understand the aerosol carcinogenic potential in urban areas. To address this need, this study conducted an extensive PM2.5 sampling campaign in Athens, Greece, at the Thissio Supersite of the National Observatory of Athens, from December 2018 to July 2021, aiming to characterize the levels and variability of polycyclic aromatic compounds (PACs), perform source apportionment, and assess health risk. Cumulative OPAH concentrations (Σ-OPAHs) were in the same range as Σ-PAHs (annual average 4.2 and 5.6 ng m-3, respectively). They exhibited a common seasonal profile with enhanced levels during the heating seasons, primarily attributed to residential wood burning (RWB). The episodic impact of biomass burning was also observed during a peri-urban wildfire event in May 2021, when PAH and OPAH concentrations increased by a factor of three compared to the monthly average. The study period also included the winter 2020-2021 COVID-19 lockdown, during which PAH and OPAH levels decreased by >50 % compared to past winters. Positive matrix factorization (PMF) source apportionment, based on a carbonaceous aerosol speciation dataset, identified PAC sources related to RWB, local traffic (gasoline vehicles) and urban traffic (including diesel emissions), as well as an impact of regional organic aerosol. Despite its seasonal character, RWB accounted for nearly half of Σ-PAH and over two-thirds of Σ-OPAH concentrations. Using the estimated source profiles and contributions, the source-specific carcinogenic potency of the studied PACs was calculated, revealing that almost 50 % was related to RWB. These findings underscore the urgent need to regulate domestic biomass burning at a European level, which can provide concrete benefits for improving urban air quality, towards the new stricter EU standards, and reducing long-term health effects.

Spatiotemporal Gradients of PAH Concentrations in Greek Cities and Associated Exposure Impacts.

To study the spatiotemporal variability of particle-bound polycyclic aromatic hydrocarbons (PAHs) and assess their carcinogenic potential in six contrasting urban environments in Greece, a total of 305 filter samples were collected and analyzed. Sampling sites included a variety of urban background, traffic (Athens, Ioannina and Heraklion), rural (Xanthi) and near-port locations (Piraeus and Volos). When considering the sum of 16 U.S. EPA priority PAHs, as well as that of the six EU-proposed members, average concentrations observed across locations during summer varied moderately (0.4-2.2 ng m-3) and independently of the population of each site, with the highest values observed in the areas of Piraeus and Volos that are affected by port and industrial activities. Winter levels were significantly higher and more spatially variable compared to summer, with the seasonal enhancement ranging from 7 times in Piraeus to 98 times in Ioannina, indicating the large impact of PAH emissions from residential wood burning. Regarding benzo(a)pyrene (BaP), an IARC Group 1 carcinogen and the only EU-regulated PAH, the winter/summer ratios were 24-33 in Athens, Volos, Heraklion and Xanthi; 60 in Piraeus; and 480 in Ioannina, which is afflicted by severe wood-burning pollution events. An excellent correlation was observed between organic carbon (OC) and benzo(a)pyrene (BaP) during the cold period at all urban sites (r2 > 0.8) with stable BaP/OC slopes (0.09-0.14 × 10-3), highlighting the potential use of OC as a proxy for the estimation of BaP in winter conditions. The identified spatiotemporal contrasts, which were explored for the first time for PAHs at such a scale in the Eastern Mediterranean, provide important insights into sources and controlling atmospheric conditions and reveal large deviations in exposure risks among cities that raise the issue of environmental injustice on a national level.

Inter-annual trends of ultrafine particles in urban Europe.

Ultrafine particles (UFP, those with diameters ≤ 100 nm), have been reported to potentially penetrate deeply into the respiratory system, translocate through the alveoli, and affect various organs, potentially correlating with increased mortality. The aim of this study is to assess long-term trends (5-11 years) in mostly urban UFP concentrations based on measurements of particle number size distributions (PNSD). Additionally, concentrations of other pollutants and meteorological variables were evaluated to support the interpretations. PNSD datasets from 12 urban background (UB), 5 traffic (TR), 3 suburban background (SUB) and 1 regional background (RB) sites in 15 European cities and 1 in the USA were evaluated. The non-parametric Theil-Sen's method was used to detect monotonic trends. Meta-analyses were carried out to assess the overall trends and those for different environments. The results showed significant decreases in NO, NO2, BC, CO, and particle concentrations in the Aitken (25-100 nm) and the Accumulation (100-800 nm) modes, suggesting a positive impact of the implementation of EURO 5/V and 6/VI vehicle standards on European air quality. The growing use of Diesel Particle Filters (DPFs) might also have clearly reduced exhaust emissions of BC, PM, and the Aitken and Accumulation mode particles. However, as reported by prior studies, there remains an issue of poor control of Nucleation mode particles (smaller than 25 nm), which are not fully reduced with current DPFs, without emission controls for semi-volatile organic compounds, and might have different origins than road traffic. Thus, contrasting trends for Nucleation mode particles were obtained across the cities studied. This mode also affected the UFP and total PNC trends because of the high proportion of Nucleation mode particles in both concentration ranges. It was also found that the urban temperature increasing trends might have also influenced those of PNC, Nucleation and Aitken modes.

Ozone exposure assessment for children in Greece - Results from the RESPOZE study.

Ozone exposure of 179 children in Athens and Thessaloniki, Greece was assessed during 2013-2014, by repeated weekly personal measurements, using passive samplers. O3 was also monitored at school locations of participants to characterize community-level ambient exposure. Average personal concentrations in the two cities (5.0 and 2.8ppb in Athens and Thessaloniki, respectively) were considerably lower than ambient concentrations (with mean personal/ambient ratios of 0.13-0.15). The temporal variation of personal concentrations followed the -typical for low-latitude areas- pattern of cold-warm seasons. However, differences were detected between temporal distributions of personal and ambient concentrations, since personal exposures were affected by additional factors which present seasonal variability, such as outdoor activity and house ventilation. Significant spatial contrasts were observed between urban and suburban areas, for personal concentrations in Athens, with higher exposure for children residing in the N-NE part of the area. In Thessaloniki, spatial variations in personal concentrations were less pronounced, echoing the spatial pattern of ambient concentrations, a result of complex local meteorology and the smaller geographical expansion of the study area. Ambient concentration was identified as the most important factor influencing personal exposures (correlation coefficients between 0.36 and 0.67). Associations appeared to be stronger with ambient concentrations measured at school locations of children, than to those reported by the nearest site of the air quality monitoring network, indicating the importance of community-representative outdoor monitoring for characterization of personal-ambient relationships. Time spent outdoors by children was limited (>90% of the time they remained indoors), but -due to the lack of indoor sources- it was found to exert significant influence on personal concentrations, affecting inter-subject and spatiotemporal variability. Additional parameters that were identified as relevant for the determination of personal concentrations were indoor ventilation conditions (specifically indoor times with windows open) and the use of wood-burning in open fireplaces for heating as an ozone sink.

Weekly Personal Ozone Exposure and Respiratory Health in a Panel of Greek Schoolchildren.

BACKGROUND: The association of ozone exposure with respiratory outcomes has been investigated in epidemiologic studies mainly including asthmatic children. The findings reported had methodological gaps and inconsistencies. OBJECTIVES: We aimed to investigate effects of personal ozone exposure on various respiratory outcomes in school-age children generally representative of the population during their normal activities. METHODS: We conducted a panel study in a representative sample of school-age children in the two major cities of Greece, Athens and Thessaloniki. We followed 188, 10- to 11-y-old, elementary school students for 5 wk spread throughout the 2013­2014 academic year, during which ozone was measured using personal samplers. At the end of each study week, spirometry was performed by trained physicians, and the fractional concentration of nitric oxide in exhaled air (FeNO) was measured. Students kept a daily time­activity­symptom diary and measured PEF (peak expiratory flow) using peak flow meters. Mixed models accounting for repeated measurements were applied. RESULTS: An increase of 10 µg/m3 in weekly ozone concentration was associated with a decrease in FVC (forced vital capacity) and FEV1 (forced expiratory volume in 1 s) of 0.03 L [95% confidence interval (CI): −0.05, −0.01] and 0.01 L (95% CI: −0.03, 0.003) respectively. The same increase in exposure was associated with a 11.10% (95% CI: 4.23, 18.43) increase in FeNO and 19% (95% CI: −0.53, 42.75) increase in days with any symptom. The effect estimates were robust to PM10 adjustment. No inverse association was found between ozone exposure and PEF. CONCLUSIONS: The study provides evidence that airway inflammation and the frequency of respiratory symptoms increase, whereas lung function decreases with increased ozone exposure in schoolchildren. https://doi.org/10.1289/EHP635.

Effect of Ambient Ozone Exposure Assessed by Individual Monitors on Nasal Function and Exhaled NO Among School Children in the Area of Thessaloniki, Greece.

OBJECTIVES: The study of short-term effects of environmental ozone exposure on nasal airflow, lung function, and airway inflammation. METHODS: Ninety one children-47 underwent rhinomanometry-were included. The study was carried out during the 2013 to 2014 academic year. Activity questionnaires and personal O3 samplers were distributed and 1 week later, respiratory measurements were performed. Daily measurements of outdoor ozone were also considered. RESULTS: A 10 µg/m increase in weekly personal ozone exposure concentrations was associated with a non-statistically significant 12.7% decrease in nasal inspiratory airflow (29.4% during the high ozone period). When the outdoor exposure of the same and the previous day were taken into account the corresponding figures were 13.48% and 43.58% (P = 0.02). CONCLUSIONS: There is an indication for increased risk of nasal obstruction during exposure to high ozone.

Is daily exposure to ozone associated with respiratory morbidity and lung function in a representative sample of schoolchildren? Results from a panel study in Greece.

Previous time series or panel studies of asthmatics have reported respiratory health effects following short-term exposure to ozone (O3). We followed 186 children aged 10 years old in Athens and Thessaloniki, Greece for 5 weeks during the academic year 2013-2014 and recorded daily their respiratory symptoms, absenteeism and peak expiratory flow (PEF). We applied mixed models controlling for various possible confounders to investigate the daily associations between O3 exposure - derived from weekly personal and fixed school site measurements calibrated using daily values of the fixed monitoring site nearest to the child's school location - and PEF, presence of any symptom, cough and stuffy nose, as well as absenteeism. We tested the robustness of our findings to varying modeling assumptions and confounders and investigated effect modification patterns by medication use, time spent outdoors and prevalence of asthma. A 10 µg/m3 increase in O3 personal exposure was associated with increased odds of any symptom (odds ratio (OR): 1.19, 95% confidence interval (CI): 0.98, 1.44), largely attributed to the increase in the odds of stuffy nose (OR: 1.23, 95% CI: 1.00, 1.51). PEF and absenteeism were not related to O3 exposure. Our results were robust to several sensitivity analyses. Effects were modified by medication use as presence of symptoms but also decreases in PEF were mainly reported among non-users, while our effect estimates were not driven by the asthmatic subgroup of children. Our findings indicate that short-term O3 exposure may be associated with respiratory symptoms extending previously reported results for asthmatics to the general population.

Spatial variation of PM elemental composition between and within 20 European study areas--Results of the ESCAPE project.

An increasing number of epidemiological studies suggest that adverse health effects of air pollution may be related to particulate matter (PM) composition, particularly trace metals. However, we lack comprehensive data on the spatial distribution of these elements. We measured PM2.5 and PM10 in twenty study areas across Europe in three seasonal two-week periods over a year using Harvard impactors and standardized protocols. In each area, we selected street (ST), urban (UB) and regional background (RB) sites (totaling 20) to characterize local spatial variability. Elemental composition was determined by energy-dispersive X-ray fluorescence analysis of all PM2.5 and PM10 filters. We selected a priori eight (Cu, Fe, K, Ni, S, Si, V, Zn) well-detected elements of health interest, which also roughly represented different sources including traffic, industry, ports, and wood burning. PM elemental composition varied greatly across Europe, indicating different regional influences. Average street to urban background ratios ranged from 0.90 (V) to 1.60 (Cu) for PM2.5 and from 0.93 (V) to 2.28 (Cu) for PM10. Our selected PM elements were variably correlated with the main pollutants (PM2.5, PM10, PM2.5 absorbance, NO2 and NOx) across Europe: in general, Cu and Fe in all size fractions were highly correlated (Pearson correlations above 0.75); Si and Zn in the coarse fractions were modestly correlated (between 0.5 and 0.75); and the remaining elements in the various size fractions had lower correlations (around 0.5 or below). This variability in correlation demonstrated the distinctly different spatial distributions of most of the elements. Variability of PM10_Cu and Fe was mostly due to within-study area differences (67% and 64% of overall variance, respectively) versus between-study area and exceeded that of most other traffic-related pollutants, including NO2 and soot, signaling the importance of non-tailpipe (e.g., brake wear) emissions in PM.

Neural network and multiple regression models for PM10 prediction in Athens: a comparative assessment.

Particulate atmospheric pollution in urban areas is considered to have significant impact on human health. Therefore, the ability to make accurate predictions of particulate ambient concentrations is important to improve public awareness and air quality management. This study examines the possibility of using neural network methods as tools for daily average particulate matter with aerodynamic diameter <10 microm (PM10) concentration forecasting, providing an alternative to statistical models widely used up to this day. Based on a data inventory, in a fixed central site in Athens, Greece, ranging over a two-year period, and using mainly meteorological variables as inputs, neural network models and multiple linear regression models were developed and evaluated. Comparison statistics used indicate that the neural network approach has an edge over regression models, expressed both in terms of prediction error (root mean square error values lower by 8.2-9.4%) and of episodic prediction ability (false alarm rate values lower by 7-13%). The results demonstrate that artificial neural networks (ANNs), if properly trained and formed, can provide adequate solutions to particulate pollution prognostic demands.

Performance of multi-city land use regression models for nitrogen dioxide and fine particles.

BACKGROUND: Land use regression (LUR) models have been developed mostly to explain intraurban variations in air pollution based on often small local monitoring campaigns. Transferability of LUR models from city to city has been investigated, but little is known about the performance of models based on large numbers of monitoring sites covering a large area. OBJECTIVES: We aimed to develop European and regional LUR models and to examine their transferability to areas not used for model development. METHODS: We evaluated LUR models for nitrogen dioxide (NO2) and particulate matter (PM; PM2.5, PM2.5 absorbance) by combining standardized measurement data from 17 (PM) and 23 (NO2) ESCAPE (European Study of Cohorts for Air Pollution Effects) study areas across 14 European countries for PM and NO2. Models were evaluated with cross-validation (CV) and hold-out validation (HV). We investigated the transferability of the models by successively excluding each study area from model building. RESULTS: The European model explained 56% of the concentration variability across all sites for NO2, 86% for PM2.5, and 70% for PM2.5 absorbance. The HV R2s were only slightly lower than the model R2 (NO2, 54%; PM2.5, 80%; PM2.5 absorbance, 70%). The European NO2, PM2.5, and PM2.5 absorbance models explained a median of 59%, 48%, and 70% of within-area variability in individual areas. The transferred models predicted a modest-to-large fraction of variability in areas that were excluded from model building (median R2: NO2, 59%; PM2.5, 42%; PM2.5 absorbance, 67%). CONCLUSIONS: Using a large data set from 23 European study areas, we were able to develop LUR models for NO2 and PM metrics that predicted measurements made at independent sites and areas reasonably well. This finding is useful for assessing exposure in health studies conducted in areas where no measurements were conducted.

The fate of abstracts presented at annual meetings of the Society for Cardiothoracic Surgery in Great Britain and Ireland from 1993 to 2007.

Although the presentation of original research to learned societies is valuable, the target should be publication in a peer-reviewed journal. Therefore, the strength of a meeting may be assessed by the rate of the subsequent publication of papers from the presented abstracts. We conducted an analysis of abstracts presented at consecutive annual meetings of the Society for Cardiothoracic Surgery (SCTS) in Great Britain and Ireland over a 15-year period. Abstract books and other documentation from the 1993-2007 meetings were reviewed; abstracts from other major Cardiothoracic Surgery meetings held in 2007 were also reviewed. Medline was searched to identify the peer-reviewed publications arising from each work presented. For abstracts presented at SCTS in 2003-07, the factors potentially associated with publication were analysed by logistic regression. If no publications were identified, authors were contacted through a standardized email questionnaire to ascertain its status and reasons for non-publication. Over the 15-year period, 909 abstracts were presented at the SCTS meetings. The rate of publication rose from ~30% in the mid-1990s to consistently >60% from recent meetings, with a high of 81.3% from 2006. However, in comparison with other Cardiothoracic Surgery meetings in 2007, the chance of subsequent publication from SCTS (66.7%) was lower than from the European Association for Cardio-Thoracic Surgery (75.0%), the American Association for Thoracic Surgery (83.9%) and The Society of Thoracic Surgeons (72.5%) meetings. For abstracts presented at the last five SCTS meetings, publication was most commonly in a speciality journal (56.3%) and the median time for publication was 15 months (range -24 to 63 months) with 14 papers published prior to presentation at the meeting. On regression analysis, the only factor associated with publication was the study design comparing randomized trials and systematic reviews with other types of study (P < 0.01). Of the 90 unpublished abstracts, 48 (53.3%) authors replied to an email questionnaire revealing that 41 (85.4%) were never submitted for publication. The most common reasons given were low priority (29.6%) and low likelihood of acceptance (24.1%). In recent years, the annual meeting of the Society has become a forum for the presentation of high-quality research that usually withstands peer-review, most commonly in a speciality journal. The rate of publication has increased to consistently >60%, although those that remain unpublished are generally never submitted. This compares favourably with national meetings of other surgical societies, although it is lower than other major cardiothoracic meetings which have an affiliated journal. At a time when it has been suggested that medical research in the UK is in decline, cardiothoracic surgery appears to be thriving.

Factors influencing the pre- and in-hospital management of acute stroke--data from a Greek tertiary care hospital.

In a prospective observational study, data on pre- and in-hospital management of acute stroke patients were collected from 100 consecutive patients admitted to the emergency room (ER) of Papageorgiou Hospital, a tertiary health care facility in Thessaloniki, Greece. Public emergency services were used by 58% of the patients, and 42% were brought by their relatives. 27% of the patients arrived within 1.5 h, 45% within 3 h, and 71% within 6 h from symptom onset. The median interval from ER arrival to examination by a board-certified neurologist was 20 min (range 5-40 min). Time from ER arrival until brain CT scan ranged from 17 min to 28 h, with a median of 1.7 h. The majority (57%) of acute stroke patients reached hospital and received adequate diagnostic and treatment within 6 h, and approximately 30% even within 3 h from symptom onset. Thus, and in contrast to widespread perception, there is a time window for hyper-acute stroke treatment in Greek public hospitals. However, the fraction of patients eligible for acute treatment may be increased by shortening both the interval from symptom onset to hospital arrival, and also the door-to-CT interval.