Could the Majority of the Greek and Cypriot Population Be Vitamin D Deficient?

OBJECTIVE: Hypovitaminosis D is prevalent in epidemic proportions in many developed countries. The aim of this study is to investigate the prevalence of adequate 25-hydroxyvitamin D [25(OH)D] levels in two Mediterranean countries, Greece and Cyprus. METHODS: Data such as 25(OH)D, the month of blood sample collection, and demographic information were blindly collected from 8780 Greek and 2594 Cypriot individuals over 5 years. Comorbidities were also recorded for 839 Greek subjects. Univariate and multivariate analyses were used to examine the relationship between these variables and 25(OH)D levels. RESULTS: In the samples studied, 72.7% of the Greek and 69.3% of the Cypriot population sample had inadequate levels of 25(OH)D. The mean level for the Greek subjects was 25.1 ng/mL and for Cypriots 25.8 ng/mL. For both samples, only month and gender were significantly associated with 25(OH)D levels, and the highest mean levels were recorded in September. For the recorded diseases, the lowest levels were recorded in sickle cell anaemia 13.6 ± 10.2 ng/mL, autoimmune diseases 13.0 ± 8.4 ng/mL, and cancer 22.6 ± 9.5 ng/mL. CONCLUSIONS: The prevalence of vitamin D deficiency is paradoxically high in both Mediterranean countries.

High-Intensity Functional Training Improves Cardiorespiratory Fitness and Neuromuscular Performance Without Inflammation or Muscle Damage.

ABSTRACT: Posnakidis, G, Aphamis, G, Giannaki, CD, Mougios, V, Aristotelous, P, Samoutis, G, and Bogdanis, GC. High-intensity functional training improves cardiorespiratory fitness and neuromuscular performance without inflammation or muscle damage. J Strength Cond Res 36(3): 615-623, 2022-We examined the effects of high-intensity functional training (HIFT) on cardiorespiratory and neuromuscular performance, as well as on inflammatory and muscle damage markers. Thirteen physically active healthy volunteers (aged 28.3 ± 3.8 years, 5 men and 8 women) underwent 8 weeks of a group HIFT program performed 3 times per week. Each session consisted of 4 rounds of a 9-exercise circuit (30-second exercise and 15-second recovery). During the first and last weeks of training, venous blood was sampled daily to monitor changes in serum C-reactive protein (CRP) and creatine kinase (CK). After 8 weeks of HIFT, body fat decreased by 0.64 ± 1.01 kg (p = 0.041), maximal oxygen uptake improved by 1.9 ± 2.2 ml·kg-1·min-1 (p = 0.009), countermovement jump by 2.6 ± 1.5 cm (p = 0.001), bench press 1-repetition maximum (1RM) by 4.5 ± 3.8 kg (p = 0.001), maximum number of bench press repetitions at 65% 1RM by 4 ± 5 repetitions (p = 0.03), and abdominal muscle endurance by 6 ± 4 repetitions (p < 0.001). In both week 1 and week 8 of training, CK increased mildly in the morning after the first session of the week (main effect for day, p = 0.008), whereas no significant changes were observed in CRP (p = 0.31). During week 8, CK on all days was ∼32% lower compared with week 1 (160 vs. 235 U·L-1; main effect of week 1 vs. week 8, p = 0.027), whereas CRP remained unchanged (p = 0.225). This HIFT program was effective in improving cardiorespiratory and neuromuscular physical fitness without causing significant inflammation or muscle damage in physically active subjects.

Health vs. wealth: Employer, employee and policy-maker perspectives on occupational heat stress across multiple European industries.

Successful implementation of cooling strategies obviously depends on identifying effective interventions, but in industrial settings, it is equally important to consider feasibility and economic viability. Many cooling interventions are available, but the decision processes affecting adoption by end-users are not well elucidated. We therefore arranged two series of meetings with stakeholders to identify knowledge gaps, receive feedback on proposed cooling interventions, and discuss factors affecting implementation of heat-health interventions. This included four meetings attended by employers, employees, and health and safety officers (n = 41), and three meetings attended primarily by policy makers (n = 74), with feedback obtained via qualitative and quantitative questionnaires and focus group discussions. On a 10-point scale, both employers and employees valued worker safety (9.1 ± 1.8; mean±SD) and health (8.5 ± 1.9) as more important than protecting company profits (6.3 ± 2.3). Of the respondents, 41% were unaware of any cooling strategies at their company and of those who were aware, only 30% thought the interventions were effective. Following presentation of proposed interventions, the respondents rated "facilitated hydration", "optimization of clothing/protective equipment", and "rescheduling of work tasks" as the top-three preferred solutions. The main barriers for adopting cooling interventions were cost, feasibility, employer perceptions, and legislation. In conclusion, preventing negative health and safety effects was deemed to be more important than preventing productivity loss. Regardless of work sector or occupation, both health and wealth were emphasized as important parameters and considered as somewhat interrelated. However, a large fraction of the European worker force lacks information on effective measures to mitigate occupational heat stress. List of abbreviations: OH-Stress: Occupational heat stress; WBGT: Wet Bulb Globe Temperature.

Mental Health Disorders During the COVID-19 Outbreak in Cyprus.

Cyprus has been affected by COVID-19 since March 2019. With a case fatality rate of 2.6% (until June 2020) and the social isolation measures enforced on the population, the population's mental health has been affected. We aimed to assess the mental health burden of the Cypriot population during the outbreak and to explore the potential influence factors. Using a web-based cross-sectional survey, we collected data from 216 volunteers regarding demographic data, COVID-19-related knowledge, generalized anxiety disorder (GAD), and major depressive symptoms. The overall prevalence of GAD and major depressive symptoms of the public were 13.89% and 8.33%, respectively. No demographic had shown any statistical significance with GAD. The younger age group of the study showed a statistically significant association with major depressive symptoms when compared to the adult population in both univariate and multivariable analyses. Our study identified a mental health burden of the Cypriot population, especially the younger age groups. As part of the preparedness for situations as the one we are experiencing and the future impact the pandemic may have on society, interventions should be focused on vulnerable groups of the population to alleviate the psychosocial effects.

Re-engineering the Cypriot healthcare service system.

BACKGROUND: The Cypriot healthcare system has undergone a number of major transformations since the induction of the Republic of Cyprus in the European Union over 10 years ago. Currently Cyprus is undergoing a major reform, namely the introduction of a primary care driven national healthcare system. The aim of the study was to assess the existing state of training, support, quality, guidelines and infrastructure towards a better healthcare system in Cyprus. METHODS: This is a mixed-methods study combining statistical data until October 2016 and workshop discussions delivered in Cyprus in November 2015. We used anonymised data provided: (1a) by the Cyprus Medical Association of all registered medical doctors up to October 2016; (1b); by the Ministry of Health (MoH) Health Monitoring Unit up to October 2016; (2) during a workshop organised with representatives from the Royal College of Physicians, the European Commission and the Health Insurance Organization. RESULTS: The gender ratio of men over women is disproportionate, with over 85% of the medical doctors undertaking their training in Greece, Eastern Europe and neighbouring countries, while the current record does not hold a relevant specialty information for 4 out of 10 doctors. The results show lack of statutory inspection systems, application of revalidation principles or implementation of peer-review clinical services on the island. There are eight proposed recommendations made by the workshop participants towards the transformation of the Cypriot healthcare system and the development of the Cyprus Quality Improvement Institute. These are aimed at addressing gaps in quality of care, adherence to clinical guidelines and implementation of audits, development of doctors' revalidation and peer-review of clinical services, accreditation of service implementation, establishment of a statutory inspection system as well as the set-up of an incentives program as part of the general healthcare system (GHS) of Cyprus. CONCLUSIONS: Current efforts for the implementation of the new GHS in Cyprus call for adequate training and support of the medical workforce, transparent and safer quality of care provision through the implementation of clinical guidelines and capacity-building infrastructure.

Cultivating a Therapeutic Compassionate Relationship: The 3S Approach.

In the last decade, a plethora of healthcare research and literature was produced and, indeed, confirms the absolute need to cultivate a therapeutic and compassionate relationship between carer and patient/family, especially in the face of a long-term and /or life-threatening condition. We introduce the 3S model as an approach to cultivate a therapeutic relationship between the carer and the patient/family. It is based on some fundamental traditional skills which may be innate for some but may need to be awakened and cultivated for others, all for the benefit of each of the members of the involved triad: patients, family, and healthcare professionals. The 3S approach aids in developing a therapeutic relationship that involves compassion and can be easily applied with significant results, especially in the context of chronic disease management. However, more research is needed to quantify the impact of this 3S approach on the therapeutic relationship and chronic disease management.

Happiness and physical activity levels of first year medical students studying in Cyprus: a cross-sectional survey.

BACKGROUND: Levels of physical activity and happiness may impact the health and performance of future doctors. The specific relationship between physical activity and happiness among first year medical students is unclear. The purpose of this study was to investigate these variables and how they relate within first year, graduate entry Bachelor of Medicine, Bachelor of Surgery students studying in Cyprus. METHODS: Self-administered questionnaires were provided for all first year medical students at the St. George's University of London medical programme delivered by the University of Nicosia Medical School in Cyprus. Physical activity was assessed using the International Physical Activity Questionnaire Short Form and happiness was assessed using the Short Depression Happiness Scale. Surveys were completed by 79 of the 120 students (median age of 24 years). Happiness and continuous measures of physical activity amounts were investigated using spearman's rank-order correlation. Mann-Whitney U Tests were used to make further comparisons between the physical activity levels across happy and depressed groups and gender, as well as to compare the levels of happiness reported by each gender. RESULTS: High levels of physical activity were evident in 60.8% of students. Results suggested depression among 15.2% of students. A positive correlation was observed between happiness and amount of vigorous intensity physical activity among female students (p < 0.05), but not males. Happy females performed more vigorous physical activity than depressed females (p < 0.05). The total amount of physical activity performed, as well as level of happiness, did not significantly differ between genders. CONCLUSIONS: A relationship exists between physical activity and happiness among female first year medical students. The intensity of physical activity may play an important role within this group. There appears to be relatively high levels of physical activity and low levels of depression among male and female first year medical students studying in Cyprus. This study provides new knowledge regarding relationships between happiness and physical activity among first year medical students, and is also the first characterization of happiness and physical activity habits among students in Cyprus. This may help to inform future policies aimed at promoting health and wellness within student communities.

Effects of High vs. Low Glycemic Index of Post-Exercise Meals on Sleep and Exercise Performance: A Randomized, Double-Blind, Counterbalanced Polysomnographic Study.

The aim of the current study was to investigate the effect of the glycemic index of post-exercise meals on sleep quality and quantity, and assess whether those changes could affect the next day's exercise performance. Following a baseline/familiarization phase, 10 recreationally trained male volunteers (23.2 ± 1.8 years) underwent two double-blinded, randomized, counterbalanced crossover trials. In both trials, participants performed sprint interval training (SIT) in the evening. Post-exercise, participants consumed a meal with a high (HGI) or low (LGI) glycemic index. Sleep parameters were assessed by a full night polysomnography (PSG). The following morning, exercise performance was evaluated by the countermovement jump (CMJ) test, a visual reaction time (VRT) test and a 5-km cycling time trial (TT). Total sleep time (TST) and sleep efficiency were greater in the HGI trial compared to the LGI trial (p < 0.05), while sleep onset latency was shortened by four-fold (p < 0.05) and VRT decreased by 8.9% (p < 0.05) in the HGI trial compared to the LGI trial. The performance in both 5-km TT and CMJ did not differ between trials. A moderate to strong correlation was found between the difference in TST and the VRT between the two trials (p < 0.05). In conclusion, this is the first study to show that a high glycemic index meal, following a single spring interval training session, can improve both sleep duration and sleep efficiency, while reducing in parallel sleep onset latency. Those improvements in sleep did not affect jumping ability and aerobic endurance performance. In contrast, the visual reaction time increased proportionally to sleep improvements.

The contribution of Cyprus to non-communicable diseases and biomedical research from 2002 to 2013: implications for evidence-based health policy.

BACKGROUND: Non-communicable diseases (NCDs) are the leading causes of disease burden and mortality at the European level and in Cyprus. This research was conducted to map the research activities of Cypriot institutions in five NCDs, namely oncology, cardiovascular diseases, diabetes, mental health and respiratory conditions. METHODS: For the period 2002-2013, research in Cyprus was assessed on its biomedical outputs and compared to the rest of Europe relative to their GDP. The research output in the five NCDs was obtained and contrasted to their respective disease burdens. The results from each of the five NCDs showed the amount of cross-country collaboration with other researchers from other European countries and from the rest of the world, and the research level of the papers on a clinical to basic scale. For each NCD field the research application was assessed, whereas for oncology the research type was also assessed. Information was collected on the development of clinical guidelines, on Cypriot newspapers reporting on medical and policy documents and advisory committees' output as well as research and funding organisations available in Cyprus, for potential evaluation of impact in health policy on the five NCDs. RESULTS: Cypriot biomedical research output appeared appropriate in volume compared with its wealth and the expected value from a regression line for other European countries. However, it was focused particularly on the molecular mechanisms of transmittable or hereditary diseases, rather than on the five NCDs. Cyprus performs well in palliative care, which receives funding from several local charities and other non-profit organisations. Cyprus has the highest relative burden from diabetes in Europe, but the subject is largely neglected by researchers. Similarly, it suffers more from mental disorders than most of the rest of Europe, but the amount of research is relatively small. Respiratory conditions research is under-funded and under-researched too. CONCLUSIONS: The biomedical research portfolio in Cyprus is adequate in volume, but not well fitted to its pattern of disease. The means whereby research can be used to improve healthcare in the country are also unsatisfactory, although the Ministry of Health is now developing a comprehensive plan which will include the development of clinical guidelines and proposals for the evaluation of how healthcare is delivered on the island.

Improving quality care for diabetes in the community: What do Cypriot patients want?

OBJECTIVE: To measure patient preferences for their diabetic care in community setting. DESIGN: Discrete-choice survey. SETTING: Community setting (primary physician and hospital sites) in Cyprus. PARTICIPANTS: Diabetic patients attending community sites. MAIN OUTCOME MEASURE(S): Patient preferences, to estimate which components of quality healthcare service people value, their relative importance but also the potential shift to shared decision-making (SDM). RESULTS: Older respondents with experience of the private sector already received SDM (managing their care and choosing their treatments; detailed and accurate information, continuity of care; compassion for their personal situation) from their primary care physician with waiting time shorter than 1 h. They valued their 'current' option and they did not want to change it with other services. Younger people from the public sector valued a change in policy and wanted to move from their 'current' to alternative diabetic care services where the waiting times were shorter, they could not only manage their care but also choose their treatments (together with receiving information, continuity of care and compassionate care). Individuals agreed with receiving multidisciplinary care from a team of healthcare providers but they mostly preferred being supported by their primary care physician. The pooled sample valued their 'current' option but they also supported policy changes that would implement SDM service for everybody. CONCLUSIONS: Diabetic patients value SDM and are willing to support a shift of practice to receive it not only in the private but also in the public sector. The forthcoming National Health Insurance Service would aim to address such developments as anticipated both in the European Troika's recommendations and the relevant laws.

Acquire, apply, and activate knowledge: A pyramid model for teaching and integrating cultural competence in medical curricula.

The importance of cultural competence in health care has been more acknowledged since modern societies are becoming increasingly multi-cultural. Research evidence shows that cultural competence is associated with improved skills and patient satisfaction, and it also seems to have a positive impact on adherence to therapy. Based on this evidence, the acknowledged importance of cultural competence and its poor integration into medical curricula, we present a pyramid model for building cultural competence into medical curricula whereby medical students can enhance their skills through acquiring, applying and activating knowledge.

Time-motion analysis as a novel approach for evaluating the impact of environmental heat exposure on labor loss in agriculture workers.

Introduction: In this study we (i) introduced time-motion analysis for assessing the impact of workplace heat on the work shift time spent doing labor (WTL) of grape-picking workers, (ii) examined whether seasonal environmental differences can influence their WTL, and (iii) investigated whether their WTL can be assessed by monitoring productivity or the vineyard manager's estimate of WTL. Methods: Seven grape-picking workers were assessed during the summer and/or autumn via video throughout four work shifts. Results: Air temperature (26.8 ± 4.8°C), wet bulb globe temperature (WBGT; 25.2 ± 4.1°C), universal thermal climate index (UTCI; 35.2 ± 6.7°C), and solar radiation (719.1 ± 187.5 W/m2) were associated with changes in mean skin temperature (1.7 ± 1.8°C) (p < 0.05). Time-motion analysis showed that 12.4% (summer 15.3% vs. autumn 10.0%; p < 0.001) of total work shift time was spent on irregular breaks (WTB). There was a 0.8%, 0.8%, 0.6%, and 2.1% increase in hourly WTB for every degree Celsius increase in temperature, WBGT, UTCI, and mean skin temperature, respectively (p < 0.01). Seasonal changes in UTCI explained 64.0% of the seasonal changes in WTL (p = 0.017). Productivity explained 36.6% of the variance in WTL (p < 0.001), while the vineyard manager's WTL estimate was too optimistic (p < 0.001) and explained only 2.8% of the variance in the true WTL (p = 0.456). Conclusion: Time-motion analysis accurately assesses WTL, evaluating every second spent by each worker during every work shift. The studied grape-picking workers experienced increased workplace heat, leading to significant labor loss. Monitoring productivity or the vineyard manager's estimate of each worker's WTL did not completely reflect the true WTL in these grape-picking workers.

Implementing shared-decision-making for diabetes care across country settings: What really matters to people?

CONTEXT: Growing evidence of improved clinical outcomes and patient/professional satisfaction supports shared-decision-making (SDM) services as an effective primary care interventions for diabetes. However, only a few countries have actually adopted them (e.g. England). In other European countries (e.g. Cyprus) there is awareness that patients play a crucial role in decision-making, and SDM services could be considered as innovative strategies to promote the actual implementation of patient rights legislation and strengthen primary care. OBJECTIVE: to understand preferences of people with diabetes when choosing their care, and how they value alternative SDM services compared to their 'current' option. Preferences were collected from patients based in England, where SDM is already in place at national level, and Cyprus, where people are new to it, using a discrete-choice-experiment (DCE) survey. RESULTS: Cypriots valued choosing alternative SDM services compared to their 'current' option, whereas the English preferred their status quo to other services. Having the primary-care-physician as healthcare provider, receiving compassionate care, receiving detailed and accurate information about their care, continuity of care, choosing their care management and treatment, and reduced waiting time were the SDM characteristics that Cypriots valued; the English preferred similar factors, apart from information/continuity of care. CONCLUSION: People with diabetes do value SDM and different SDM models may fit different groups according to their personal experience and country specific settings.

Assessing Patient Participation in Health Policy Decision-Making in Cyprus.

Although the importance of patient participation in the design and evaluation of health programs and services is well-documented, there is scarcity of research with regard to patient association (PA) participation in health policy decision-making processes. To this end, the present study aimed to validate further a previously developed instrument as well as to investigate the degree of PA participation in health policy decision-making in Cyprus. A convenient sample of 114 patients-members of patients associations took part in the study. Participants were recruited from an umbrella organization, the Pancyprian Federation of Patient Associations and Friends (PFPA). PA participation in health policy decision-making was assessed with the Health Democracy Index (HDI), an original 8-item tool. To explore its psychometric properties, Cronbach α was computed as regards to its internal consistency, while its convergent validity was tested against a self-rated question enquiring about the degree of PA participation in health policy decision-making. The findings revealed that the HDI has good internal consistency and convergent validity. Furthermore, PAs were found to participate more in consultations in health-related organizations and the Ministry of Health (MoH) as well as in reforms or crucial decisions in health policy. Lower levels were documented with regard to participation in hospital boards, ethics committees in clinical trials and health technology assessment (HTA) procedures. Overall, PA participation levels were found to be lower than the mid-point of the scale. Targeted interventions aiming to facilitate patients' involvement in health policy decision-making processes and to increase its impact are greatly needed in Cyprus.

General Practitioners' intention to prescribe and prescribing patterns in selected European settings: The OTCSOCIOMED project.

The aim of this paper is to explore general practitioners' (GPs) prescribing intentions and patterns across different European regions using the Theory of Planned Behavior (TPB). A cross-sectional study was undertaken in selected geographically defined Primary Health Care areas in Cyprus, Czech Republic (CZ), France, Greece, Malta, Sweden and Turkey. Face-to-face interviews were conducted using a TPB-based questionnaire. The number of GP participants ranged from 39 to 145 per country. Possible associations between TPB direct measures (attitudes, subjective norms (SN) and perceived behavioral control (PBC)) and intention to prescribe were assessed by country. On average, GPs thought positively of, and claimed to be in control of, prescribing. Correlations between TPB explanatory measures and prescribing intention were weak, with TPB direct measures explaining about 25% of the variance in intention to prescribe in Malta and CZ but only between 3% and 5% in Greece, Sweden and Turkey. SN appeared influential in GPs from Malta; attitude and PBC were statistically significant in GPs from CZ. GPs' prescribing intentions and patterns differed across participating countries, indicating that country-specific interventions are likely to be appropriate. Irrational prescribing behaviors were more apparent in the countries where an integrated primary care system has still not been fully developed and policies promoting the rational use of medicines are lacking. Demand-side measures aimed at modifying GPs prescribing behavior are deemed necessary.

Irrational prescribing of over-the-counter (OTC) medicines in general practice: testing the feasibility of an educational intervention among physicians in five European countries.

BACKGROUND: Irrational prescribing of over-the-counter (OTC) medicines in general practice is common in Southern Europe. Recent findings from a research project funded by the European Commission (FP7), the "OTC SOCIOMED", conducted in seven European countries, indicate that physicians in countries in the Mediterranean Europe region prescribe medicines to a higher degree in comparison to physicians in other participating European countries. In light of these findings, a feasibility study has been designed to explore the acceptance of a pilot educational intervention targeting physicians in general practice in various settings in the Mediterranean Europe region. METHODS: This feasibility study utilized an educational intervention was designed using the Theory of Planned Behaviour (TPB). It took place in geographically-defined primary care areas in Cyprus, France, Greece, Malta, and Turkey. General Practitioners (GPs) were recruited in each country and randomly assigned into two study groups in each of the participating countries. The intervention included a one-day intensive training programme, a poster presentation, and regular visits of trained professionals to the workplaces of participants. Reminder messages and email messages were, also, sent to participants over a 4-week period. A pre- and post-test evaluation study design with quantitative and qualitative data was employed. The primary outcome of this feasibility pilot intervention was to reduce GPs' intention to provide medicines following the educational intervention, and its secondary outcomes included a reduction of prescribed medicines following the intervention, as well as an assessment of its practicality and acceptance by the participating GPs. RESULTS: Median intention scores in the intervention groups were reduced, following the educational intervention, in comparison to the control group. Descriptive analysis of related questions indicated a high overall acceptance and perceived practicality of the intervention programme by GPs, with median scores above 5 on a 7-point Likert scale. CONCLUSIONS: Evidence from this intervention will estimate the parameters required to design a larger study aimed at assessing the effectiveness of such educational interventions. In addition, it could also help inform health policy makers and decision makers regarding the management of behavioural changes in the prescribing patterns of physicians in Mediterranean Europe, particularly in Southern European countries.

A pilot quality improvement intervention in patients with diabetes and hypertension in primary care settings of Cyprus.

BACKGROUND: The achievement of quality of care constitutes a priority for modern health care systems. The objective of our study was to evaluate a quality improvement intervention in primary care of Cyprus. METHODS: In a two-arm non-randomized controlled study in primary care centres in Cyprus, all patients with hypertension (HTN) and diabetes (n = 539) were invited. In one urban and one rural centre, a quality improvement programme was implemented; two other centres (one urban and one rural) served as control practices. The intervention mainly consisted of the introduction of clinical disease management guidelines and an electronic medical record system. The primary outcome measurement was improvement of specific clinical indicators for HTN and diabetes. Patients' satisfaction was evaluated using the European Task Force on Patient Evaluations of General Practice (EUROPEP) questionnaire over an 18-month follow-up period. RESULTS: Five hundred and four patients completed the study, 278 patients in the intervention practices and 226 patients in the control practices. Mean results for blood pressure, total cholesterol and low density lipoprotein-cholesterol and three annual performance measures (urine protein testing, dilated eye and foot examination) had improved at 18-month follow-up in the intervention as compared to the control group. There was no improvement of HbA1c levels. Patients' satisfaction improved in the intervention practices (improvement of 10/23 EUROPEP items) but decreased in the control group (decline of 20/23 items). CONCLUSIONS: A pilot multifaceted quality improvement intervention programme for patients with diabetes and HTN implemented in primary care settings in Cyprus showed promising results. Future studies need to involve a broader number of practices and patient populations.