Efficiency and productivity assessment of public hospitals in Greece during the crisis period 2009-2012.

BACKGROUND: This study is an initial effort to examine the dynamics of efficiency and productivity in Greek public hospitals during the first phase of the crisis 2009-2012. Data were collected by the Ministry of Health after several quality controls ensuring comparability and validity of hospital inputs and outputs. Productivity is estimated using the Malmquist Indicator, decomposing the estimated values into efficiency and technological change. METHODS: Hospital efficiency and productivity growth are calculated by bootstrapping the non-parametric Malmquist analysis. The advantage of this method is the estimation efficiency and productivity through the corresponding confidence intervals. Additionally, a Random-effects Tobit model is explored to investigate the impact of contextual factors on the magnitude of efficiency. RESULTS: Findings reveal substantial variations in hospital productivity over the period from 2009 to 2012. The economic crisis of 2009 had a negative impact in productivity. The average Malmquist Productivity Indicator (MPI) score is 0.72 with unity signifying stable production. Approximately 91% of the hospitals score lower than unity. Substantial increase is observed between 2010 and 2011, as indicated by the average MPI score which fluctuates to 1.52. Moreover, technology change scored more than unity in more than 75% of hospitals. The last period (2011-2012) has shown stabilization in the expansionary process of productivity. The main factors contributing to overall productivity gains are increases in occupancy rates, type and size of the hospital. CONCLUSIONS: This paper attempts to offer insights in efficiency and productivity growth for public hospitals in Greece. The results suggest that the average hospital experienced substantial productivity growth between 2009 and 2012 as indicated by variations in MPI. Almost all of the productivity increase was due to technology change which could be explained by the concurrent managerial and financing healthcare reforms. Hospitals operating under decreasing returns to scale could achieve higher efficiency rates by reducing their capacity. However, certain social objectives should also be considered. Emphasis perhaps should be placed in utilizing and advancing managerial and organizational reforms, so that the benefits of technological improvements will have a continuing positive impact in the future.

Impact of influenza infection on children's hospital admissions during two seasons in Athens, Greece.

A prospective epidemiologic surveillance of hospitalizations associated with influenza was conducted in order to calculate population-based hospitalization rates. Eligible children were 6 months to 13 years of age and were admitted to one of the two large children's hospitals in the Athens area during two influenza seasons. Nasopharyngeal aspirates were tested for influenza by a polymerase reaction assay. Influenza accounted for 9.9-11.8% of all admissions during the influenza season and the overall annual rate of hospitalizations was 13.6-16.8 cases per 10,000 children being highest for children under 5 years of age (26-31.2/10,000 children). Febrile seizures and acute otitis media were the two most common complications associated with influenza and antibiotics were administered to 61% of flu positive patients. Influenza is associated with high hospitalization rates among young children and these may be substantially reduced with the introduction of routine immunization.

The epidemiology of varicella in school-aged Greek children before the implementation of universal vaccination.

Data on local epidemiology is necessary when deciding on the introduction of a vaccine. Parents of children attending 1st and 6th grades completed a questionnaire on demographical data and varicella history. Analyzing 70,226 questionnaires, varicella was reported in 63.6% and 78.6% of 1st and 6th grade children, respectively (mean age 4.75 years), indicating that a quarter of children entering adolescence are susceptible. Children attending day care and children with older siblings had contracted chickenpox at a younger age. In conclusion, in Greece, in addition to introducing universal varicella vaccination, it is necessary to identify older children at risk and offer catch-up vaccination.

Human rhinoviruses in otitis media with effusion.

Frequent viral upper respiratory tract infections (URTI) are considered to be risk factors for otitis media with effusion (OME). Atopy has also been associated with both OME and viral infections. The aim of this study was to evaluate the presence of viruses in middle ear effusions (MEE) in children 2-7 yr old with OME, and to determine risk factors for virus detection in the MEE. MEE samples, collected at the time of myringotomy from 37 children with OME were assessed. Physical examination, skin prick tests and a standardized questionnaire on OME and allergy were also performed. Viral RNA was detected by the use of reverse transcription PCR (RT-PCR). Fifteen samples (40.5%) were positive for rhinovirus (RV). One enterovirus and no other respiratory viruses were detected. Two out of five (40%), 3/7 (43%) and 10/25 (40%) were positive for RV in acute, subacute and chronic cases, respectively. Children with frequent episodes of OM, with early onset of OM (<2 yr old), and a positive family history of allergy had a statistically increased risk of RV detection. The two groups were comparable with respect to all other parameters examined. RV is the predominant virus recovered by RT-PCR in the middle ear cavity of children with asymptomatic OME, especially those with a history of longstanding OME or repeated episodes, or children with a family history of allergy. Interactions between allergy and RV infections are likely to predispose to middle ear disease.

Invasive meningococcal disease presenting as Henoch-Schonlein purpura.

Henoch-Schonlein purpura (HSP) is an acute systemic form of vasculitis that has been associated with a number of viral and bacterial infections. Described here are the cases of two children with invasive meningococcal disease who presented with clinical and laboratory findings typical of HSP. Meningococcal infection may have been the trigger for the manifestation of HSP in these patients.

Etiology of community-acquired pneumonia in hospitalized school-age children: evidence for high prevalence of viral infections.

BACKGROUND: Community-acquired pneumonia (CAP) in young children is most commonly associated with viral infections; however, the role of viruses in CAP of school-age children is still inconclusive. METHODS: Seventy-five school-age children hospitalized with CAP were prospectively evaluated for the presence of viral and bacterial pathogens. Nasopharyngeal washes were examined by polymerase chain reaction for viruses and atypical bacteria. Antibody assays to detect bacterial pathogens in acute-phase and convalescent-phase serum samples were also performed. RESULTS: A viral infection was identified in 65% of cases. Rhinovirus RNA was detected in 45% of patients; infection with another virus occurred in 31%. The most common bacterial pathogen was Mycoplasma pneumoniae, which was diagnosed in 35% of cases. Chlamydia pneumoniae DNA was not detected in any patient; results of serological tests were positive in only 2 patients (3%). Mixed infections were documented in 35% of patients, and the majority were a viral-bacterial combination. CONCLUSIONS: The high prevalence of viral and mixed viral-bacterial infections supports the notion that the presence of a virus, acting either as a direct or an indirect pathogen, may be the rule rather than the exception in the development of CAP in school-age children requiring hospitalization.

Pleuropulmonary blastoma in childhood. A malignant degeneration of pulmonary cysts.

Pleuropulmonary blastoma (PPB) is an extremely rare intrathoracic neoplasm of early childhood with an unfavorable outcome. In this article, two children with PPB associated with pre-existing pulmonary cysts are presented. It is emphasized that surgical excision is the treatment of choice for all pulmonary cysts.

Burden of respiratory syncytial viral infections on paediatric hospitals: a two-year prospective epidemiological study.

This study was designed to prospectively investigate the hospitalisation patterns for respiratory syncytial virus (RSV) disease in children up to 2 years of age, both healthy full-term children and high-risk children. The aim was to evaluate children hospitalised for a respiratory tract infection in four regions and seven paediatric hospital departments or clinics in Greece and to estimate the burden of RSV disease on paediatric hospital beds, as well as to determine the target high-risk age group over two consecutive respiratory infection seasons. Among a total of 1,710 children, the overall prevalence of RSV disease was 33.1%, but prevalence differed between seasons (27% vs. 37.7%, P<0.01). The peak prevalence of RSV disease occurred in February, with the onset in November and the end in May. The monthly distribution was similar in all regions. RSV positivity was strongly associated with young age (4.7 vs. 6.6 months, P<0.001); classification within a high-risk group (43% vs. 32.6%, P=0.04); lower respiratory tract infection (93.8% vs. 86%, P=0.001), particularly bronchiolitis (80.9% vs. 63.9%, P=0.001); more severe disease (P<0.001); longer stay in hospital (P<0.001); and poorer outcome (P<0.001). RSV infections accounted for 38% of the total hospitalisation days for all respiratory infections, and 77% of the hospitalisation days for RSV infection were for infants less than 6 months of age.

Is peptic ulcer a common cause of upper gastrointestinal symptoms?

UNLABELLED: The aim of the study was to investigate retrospectively a cohort of children with peptic ulcer disease during a period that covers the recent changes in diagnosis and management of the disease. Over a period of 9 years, 2550 children underwent upper gastrointestinal endoscopy for various reasons. All children, in whom a diagnosis of primary peptic ulcer was established, were included in the study. Previous and current medical history, family history, endoscopic and histological outcome were evaluated and the children were regularly followed-up on an out-patient basis. Primary peptic ulcer was diagnosed in 52 (10 gastric and 42 duodenal, 2%) out of 2550 children. The median age of children with gastric ulcer was 6.5 years, whereas of those with duodenal ulcer was 10.5 years (P=0.04). With regard to clinical symptoms no significant difference was found between children with and without ulcer. The prevalence of Helicobacter pylori infection was significantly higher in children with duodenal ulcer (62%) compared to those with gastric ulcer (20%; P < 0.001). At first follow-up visit, 1 month after the end of treatment, 19 symptomatic children underwent a repeat endoscopy, which showed ulcer healing in 95% and failure in H. pylori eradication in 27%. During the long-term follow-up (median 3.5 years), six children became symptomatic. Two of them had duodenal ulcer associated with positive H. pylori. CONCLUSION: Peptic ulcer disease is an uncommon disorder in childhood with non specific clinical features; it seems that efficient treatment and successful Helicobacter pylori eradication result in clinical improvement and cure as well as in long-term healing of ulcers.

Analysis of Btk mutations in patients with X-linked agammaglobulinaemia (XLA) and determination of carrier status in normal female relatives: a nationwide study of Btk deficiency in Greece.

Bruton's tyrosine kinase (Btk) is a nonreceptor tyrosine kinase, critical for B-cell development and function. Mutations that inactivate this kinase were found in families with X-linked agammaglobulinaemia (XLA). In this study the Btk gene was analyzed in 13 registered Greek patients with XLA phenotype originated from 12 unrelated families, in order to provide a definite diagnosis of the XLA. The structure of Btk was analyzed at the cDNA level using the recently developed method, NIRCA (Non-Isotopic-Rnase-Cleavage-Assay). Alterations were detected in all patients and sequencing analysis confirmed the results and defined six novel XLA-associated Btk mutations (three missense mutations: C337G, L346R, L452P; one nonsense mutation: Y392X, and two frameshift alterations: c1211-1212delA, c1306-1307insA). Having defined the genetic alteration in the affected males of these families, the information was used to design polymerase chain reaction (PCR) primers and the Btk segments containing the mutated sequences were amplified from peripheral blood derived genomic DNA of potential female carriers. The PCR products were directly sequenced and carrier status was determined in 12 out of 16 phenotypically normal females analyzed. This protocol can be used once the nature of the Btk mutation has been defined in one of the affected males and provides a convenient, simple and reliable way to determine the carrier status of other female family members. Molecular genetic analysis constitutes a determinative tool for the definitive diagnosis of XLA and may allow accurate carrier and prenatal diagnosis for genetic counselling.

Fiber intake and childhood appendicitis.

In order to investigate the possible role of fiber in the etiology of acute appendicitis, 203 consecutive appendectomized children with histologically proved appendicitis and 1922 controls were studied by the diet history method. Statistics were performed by multivariate analysis of variance, discriminant analysis and chi 2. Appendectomized children had statistically significant lower mean daily intake of fiber (17.4 g versus 20.4 g, P < 0.001) including all fiber fractions: cellulose, uronic acid, pentose, exose and lignin. No statistical difference was found for energy, protein, carbohydrate and fat intake. Discriminant analysis proved that only cellulose and exose are independently correlated to appendicitis and lower fiber intake is thought to be the cause in 70% of the cases. Recurrent abdominal pain, chronic constipation and positive family history of appendectomy were more frequent in appendectomized children (P < 0.001). This study gives evidence that low fiber intake could play an important role in the pathogenesis of appendicitis.

Upper gastrointestinal disease, Helicobacter pylori and recurrent abdominal pain.

Over a 5-y period, 396 children complaining of recurrent abdominal pain (RAP) underwent upper gastrointestinal endoscopy in order to identify any underlying organic pathology and determine the prevalence of Helicobacter pylori (H. pylori) infection. Histologically confirmed mucosal inflammation was found in 338 out of 396 children (85.4%); in 113 of 396 patients (28.5%), H. pylori was identified on the gastric mucosa. Significant discriminating factors between H. pylori positive and negative children with RAP included age (mean age for positive 11 y vs. 8.1 y for negative, p < 0.01) and gender (male gender predominance in the H. pylori positive, p < 0.001). No significant difference was found between H. pylori positive and negative groups regarding incidence and character of the presenting symptoms. All H. pylori positive children (100%) had abnormal histology compared with 225 out of 283 negative ones (79.5%). Histologically confirmed gastritis was the most prominent finding in H. pylori positive children compared with H. pylori negative (98.2% vs. 19%, p < 0.001). Conversely, oesophagitis was more common in H. pylori negative children (47.7% vs. 27.4%, p < 0.001). The incidence of peptic ulcer was higher in H. pylori infected patients than in the H. pylori negative group (5.3% vs. 1%, p < 0.05). Our data suggest that gastrointestinal pathology is more common than previously thought in children with RAP, while H. pylori infection is a relatively important factor in the etiology of upper gastrointestinal inflammation in RAP syndrome.

Diet and chronic constipation in children: the role of fiber.

BACKGROUND: Chronic constipation is one of the most common disorders in Western countries and despite numerous clinical, pathophysiologic, and epidemiologic studies its cause is still unclear. Several hypotheses have been proposed and according to experimental studies and clinical observation, fiber intake could play a role in its pathogenesis. The purpose of this case-control study was to examine the possible correlation of idiopathic chronic constipation in children and dietary intake, particularly fiber intake. METHODS: A randomized sample of children (291 children with constipation and 1602 controls) aged 2 to 14 years was taken from three of the 52 counties of Greece. Stratification was performed on the basis of urban, rural, or suburban location and socioeconomic status. The nutritional data were obtained from a 3-day dietary record and a dietary history. Statistical analysis was performed with multivariate tests, multivariate analysis of variance, discriminant analysis, and chi-square analysis according to the characteristics of the correlated variables. RESULTS: Constipated children had a lower caloric and nutrient intake (p < 0.001), lower body weight/height (p < 0.001), and higher prevalence of reported anorexia (p < 0.001). Discriminant analysis indicated that dietary fiber alone was independently negatively correlated with chronic constipation, despite the age and the age of onset of constipation. Relative risk also had a negative correlation with fiber intake (p < 0.001). Of the main fiber fractions only cellulose and pentose were independently correlated with chronic constipation. CONCLUSIONS: Lack of fiber may play an important role in the etiology of chronic idiopathic constipation in children.

In vivo effect of sodium valproate on mouse liver.

The in vivo effect of sodium valproate (SV) on the activity of uridine diphosphate glucuronosyltransferase (UDP-GT) and hepatotoxicity in the mouse liver was studied. Mice were injected intraperitoneally (IP) with SV at doses varying from 50 to 800 mg/kg per day, for six consecutive days (dose-response group) or at a standard dose of 300 mg/g per day for 2-10 days (time-response group), whereas the controls were injected with normal saline. Valproic acid levels had a positive correlation to the dose (P < 0.001) and duration of drug administration (P = 0.006). A gradual increase in UDP-GT activity was observed in doses of up to approximately 400 mg/kg per day, whereas in higher doses the enzyme activity gradually decreased. The time course of UDP-GT activity at the standard dose of 300 mg/kg per day increased progressively, with a maximum up to the sixth day and then had a gradual reduction. Hepatic necrosis (which was unrelated to the dose or the duration of drug administration) was found in 13% of the SV-treated animals and in none of the controls. We conclude that at an optimal dose (300-400 mg/kg per day) and at a time course of 6 days, SV causes liver UDP-GT induction, whereas in higher doses and longer duration of administration, UDP-GT activity is gradually reduced. SV also causes hepatotoxicity unrelated to dose and time course.

Herpes zoster in children.

BACKGROUND: The clinical studies of series of children with herpes zoster (HZ) are rather limited. OBJECTIVE: The purpose of this study was to evaluate the epidemiologic conditions, clinical manifestations, therapy, and outcome of HZ in children. METHODS: Twenty-one patients with HZ have been studied. Five patients who had herpes simplex virus infection were excluded. The laboratory diagnosis was made by fluorescent techniques. Acyclovir was administered systematically for 2 more days after no new lesions had developed. RESULTS: Thirteen patients (group A) were immunocompromised; eight patients (group B) were otherwise healthy. Two patients from group B had intrauterine varicella; the other six patients had had varicella under the age of 4 years. Three patients were recently exposed to varicella. The duration of HZ was significantly longer in group A than in group B, but the outcome was good in all patients. CONCLUSION: Herpes simplex virus infection may simulate the pattern of HZ; varicella in early childhood is a risk factor for HZ in otherwise healthy children; exposure of a child to varicella may cause reactivation of latent HZ virus; and acyclovir therapy within 3 days of exanthem onset prevents significant morbidity and death in immunocompromised children with HZ.

Elevated serum prolactin concentrations in phenylketonuric patients on a 'loose diet'.

OBJECTIVE: High levels of phenylalanine (Phe) have been shown to reduce dopamine (DA) and noradrenaline (NA) production. We have therefore evaluated whether increased serum Phe concentrations lead to increased prolactin (PRL) secretion in phenylketonuria. PATIENTS: Forty-two patients with classical phenylketonuria were divided into two groups. Group A (n = 19) adhered very strictly to their special diet (Phe = 0.09 +/- 0.039 mmol/l) and Group B (n = 23) were on a 'loose diet' (Phe = 0.77 +/- 0.45 mmol/l). Thirty healthy children of comparable age served as controls. MEASUREMENTS: PRL was measured by RIA, and Phe and tyrosine (Tyr) with an amino-acid autoanalyser. Adrenaline (A), noradrenaline (NA), and dopamine (DA) were measured by HPLC. RESULTS: Serum PRL in group B patients (1595 +/- 57 mU/l) was significantly raised compared to Group A patients (243 +/- 57 mU/l) and controls (201 +/- 55 mU/l) (P < 0.001). Serum DA, A and NA in group B were lower than in group A patients and controls. Serum Phe in group B patients was significantly correlated to serum PRL (r = 0.59) and DA (r = -0.41). Irregular menses were observed in 1/10 women from group A but in 10/13 in group B. CONCLUSION: High serum phenylalanine concentrations in phenylketonuric patients not strictly adhering to their diets are correlated with high serum PRL and low serum dopamine concentrations, and a high prevalence of menstrual irregularities.

Juvenile chronic arthritis profile in Greek children.

BACKGROUND: Juvenile chronic arthritis (JCA) is the commonest autoimmune rheumatic disease in childhood and presents different clinical subtypes. Juvenile chronic arthritis is considered to be of a polygenic nature and its genetic background is still under investigation. The clinical profile of JCA in the Greek population has not been studied completely. This study retrospectively analyzed the clinical and immunological features of JCA in Greek children presented between 1989 and 1994. Human leukocyte antigen (HLA)-positive or -negative associations in the different clinical subtypes were also detected. The findings of this study were correlated with those reported from other populations. METHODS AND RESULTS: Antinuclear antibodies (ANA) anti-ds DNA and anti-extractable nuclear antigen antibodies were estimated by immunofluorescent and ELISA assays. Human leukocyte antigen typing was performed by microlymphocytotoxicity, using immunobeads. The peak ages of JCA onset were between 2 and 5 years and also between 9 and 12 years. There was a high female predominance in pauciarticular and polyarticular groups. The most common disease was pauciarticular (58.7%) followed by systemic (25%) arthritis. The incidence of eye involvement was 12.5% and presented only in the pauciarticular group. Overall, ANA positivity was 53.7%, increasing to 90% in pauciarticular cases associated with chronic uveitis. In the early onset (EOPA) pauciarticular subtype, positive-HLA associations with alleles DR11 and DR8 were shown. In the late onset pauciarticular (LOPA) group only B27 allele was increased. CONCLUSIONS: The results of this retrospective study did not reveal major differences between JCA in Greek children compared with other Caucasian series.