Antonios Bertsias

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

BackgroundIrrational 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.MethodsThis 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.ResultsMedian 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.ConclusionsEvidence 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.

Studying the burden of community-acquired pneumonia in adults aged ⩾ 50 years in primary health care: an observational study in rural Crete, Greece

Background:Community-acquired pneumonia (CAP) is a potentially life-threatening condition that often requires hospitalisation particularly in the elderly population or in patients with comorbidities.Aims:The aims of this study were to estimate the CAP frequency and severity in a well-defined primary healthcare setting in rural Crete, to record patient characteristics, their immunisation status and to estimate hospitalisation frequency and determinants.Methods:An observational study was designed and implemented in a rural setting within the prefecture of Heraklion in the island of Crete, Greece. Eligible patients were those aged 50 years or above, presenting with CAP based on signs and symptoms and positive X-ray findings.Results:A total of 124 CAP cases were recorded, 40 of which (32.3%) were hospitalised. Τhe age-standardised CAP incidence was estimated to be 236.7 cases per 100,000 persons aged ⩾50 years. Forty-three patients (35.2%) were vaccinated against pneumococcus. The most frequent chronic illnesses were heart disease (64.5%), chronic obstructive pulmonary disease (32.5%), and type 2 diabetes (21%). Hospitalisation determinants included advanced age (⩾74 years, Odds ratio (OR) 7.13; P value=0.001; 95% confidence interval (CI), 2.23–22.79), obesity (OR 3.36, P=0.037; 95% CI, 1.08–10.52), ⩾40 pack-years of smoking (OR 3.82, P value=0.040; 95% CI, 1.07–18.42), presence of multimorbidity (OR 5.77, P value=0.003; 95% CI, 1.81–18.42) and pneumococcal vaccination (OR 0.29, P value=0.041; 95% CI, 0.09–0.95).Conclusions:This study highlighted patient characteristics and aspects of CAP epidemiology in the context of a rural primary care setting in southern Europe where limited data have been published until now.

Volume and methodological quality of randomized controlled trials in laparoscopic surgery: assessment over a 10-year period

BACKGROUND Measures have been taken to improve methodological quality of randomized controlled trials (RCTs). This review systematically assessed the trends in volume and methodological quality of RCTs on minimally invasive surgery within a 10-year period. DATA SOURCES RCTs on minimally invasive surgery were searched in the 10 most cited general surgical journals and the 5 most cited journals of laparoscopic interest for the years 2002 and 2012. Bibliometric and methodological quality components were abstracted using the Scottish Intercollegiate Guidelines Network. The pooled number of RCTs from low-contribution regions demonstrated an increasing proportion of the total published RCTs, compensating for a concomitant decrease of the respective contributions from Europe and North America. International collaborations were more frequent in 2012. Acceptable or high quality RCTs accounted for 37.9% and 54.4% of RCTs published in 2002 and 2012, respectively. Components of external validity were poorly reported. CONCLUSIONS Both the volume and the reporting quality of laparoscopic RCTs have increased from 2002 to 2012, but there seems to be ample room for improvement of methodological quality.

Epidemiology and burden of systemic lupus erythematosus in a Southern European population: data from the community-based lupus registry of Crete, Greece

Objectives Several population-based studies on systemic lupus erythematosus (SLE) have been reported, yet community-based, individual-case validated, comprehensive reports are missing. We studied the SLE epidemiology and burden on the island of Crete during 1999–2013. Methods Multisource case-finding included patients ≥15 years old. Cases were ascertained by the ACR 1997, SLICC 2012 criteria and rheumatologist diagnosis, and validated through synthesis of medical charts, administrative and patient-generated data. Results Overall age-adjusted/sex-adjusted incidence was 7.4 (95% CI 6.8 to 7.9) per 100 000 persons/year, with stabilising trends in women but increasing in men, and average (±SD) age of diagnosis at 43 (±15) years. Adjusted and crude prevalence (December 2013) was 123.4 (113.9 to 132.9) and 143 (133 to 154)/105 (165/105 in urban vs 123/105 in rural regions, p<0.001), respectively. Age-adjusted/sex-adjusted nephritis incidence was 0.6 (0.4 to 0.8) with stable trends, whereas that of neuropsychiatric SLE was 0.5 (0.4 to 0.7) per 100 000 persons/year and increasing. Although half of prevalent cases had mild manifestations, 30.5% developed organ damage after 7.2 (±6.6) years of disease duration, with the neuropsychiatric domain most frequently afflicted, and 4.4% of patients with nephritis developed end-stage renal disease. The ACR 1997 and SLICC 2012 classification criteria showed high concordance (87%), yet physician-based diagnosis occurred earlier than criteria-based in about 20% of cases. Conclusions By the use of a comprehensive methodology, we describe the full spectrum of SLE from the community to tertiary care, with almost half of the cases having mild disease, yet with significant damage accrual. SLE is not rare, affects predominantly middle-aged women and is increasingly recognised in men. Neuropsychiatric disease is an emerging frontier in lupus prevention and care.

Almost half of octogenarians and nonagenarians admitted acutely to internal medicine ward die during admission or within 6 months after discharge: time to redefine treatment goals?

Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Ahmed: coauthor. WilliamsHooker: committee and help with design of study. Polly, Roach: committee. Stockton: assistance with analysis. Sponsor’s Role: None.

The Cretan Aging Cohort: Cohort Description and Burden of Dementia and Mild Cognitive Impairment

Our aim was to explore the burden of dementia in the Cretan Aging Cohort, comprised of 3140 persons aged ≥60 years (56.8% women, 5.8 ± 3.3 years formal education, 86.2% living in rural areas) who attended selected primary health-care facilities on the island of Crete, Greece. In the first study phase, a formal diagnosis of dementia had been reached in 4.0% of the participants. However, when selected 505 participants underwent thorough neuropsychiatric evaluation in the second phase of this study (344 with Mini-Mental State Examination [MMSE] <24 and 161 with MMSE ≥24), and results were extrapolated to the entire cohort, the prevalence of dementia and mild cognitive impairment was estimated at 10.8% (9.7%-11.9%) and 32.4% (30.8%-34.0%), respectively. Using both the field diagnostic data and the extrapolated data, the highest dementia prevalence (27.2%) was found in the 80- to 84-year-old group, who also showed the lowest educational level, apparently due to lack of schooling during World War II.

Cognitive screening tools for primary care settings: examining the ‘Test Your Memory’ and ‘General Practitioner assessment of Cognition’ tools in a rural aging population in Greece

Abstract Background: Under conditions of high demand for primary care services in a setting of low financial resources, there is need for brief, easily administered cognitive screening tools for use in the primary care setting, especially in rural areas. However, interpretation of these cognitive tests’ results requires knowledge on their susceptibility to cultural, educational and demographic patient characteristics. Objectives: To assess the clinical validity of the ‘Test Your Memory’ (TYM) and ‘General Practitioner assessment of Cognition’ (GPCog) which was specifically designed for primary care practice, in a rural primary care setting in Greece, utilizing the ‘Mini Mental State Examination’ (MMSE) as a reference standard. Methods: The MMSE, TYM, and GPCog were administered to a random sample of 319 community dwelling Greek adults aged 60 to 89 years in 11 rural Primary Healthcare Centres of the Prefecture of Heraklion on the island of Crete, Greece. Analyses examined (a) The association of each instrument with demographic factors and MMSE and (b) optimal cut-off scores, sensitivity and specificity against MMSE-based cognitive impairment risk using ROC analyses with the MMSE 23/24 point cut-off as a reference standard. Results: We found a sensitivity of 80% and a specificity of 77% for TYM (35/36 or 38/39 cut-off, depending on education). Corresponding values were 89% and 61% for GPCog (7/8 cut-off), respectively. Conclusion: The TYM and GPCog instruments appear to be suitable for routine use in the primary care setting as tools for cognitive impairment risk detection in elderly rural populations.

Lack of Improvement Over Time in Methodological Quality of Randomized Trials on Laparoscopic Surgery Training.

a Center for Minimally Invasive Surgery, Hospital Neuwerk, Mönchengladbach , Germany; b Department of General Surgery, University Hospital of Heraklion, and c Department of Social Medicine, Biostatistics Laboratory, Faculty of Medicine, University of Crete, Crete , Greece; d Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool , UK; e Department of General Surgery, Sisters of Charity Hospital, Linz , and

A Systematic Review and Analysis of Factors Associated with Methodological Quality in Laparoscopic Randomized Controlled Trials

Several methods for assessment of methodological quality in randomized controlled trials (RCTs) have been developed during the past few years. Factors associated with quality in laparoscopic surgery have not been defined till date. The aim of this study was to investigate the relationship between bibliometric and the methodological quality of laparoscopic RCTs. The PubMed search engine was queried to identify RCTs on minimally invasive surgery published in 2012 in the 10 highest impact factor surgery journals and the 5 highest impact factor laparoscopic journals. Eligible studies were blindly assessed by two independent investigators using the Scottish Intercollegiate Guidelines Network (SIGN) tool for RCTs. Univariate and multivariate analyses were performed to identify potential associations with methodological quality. A total of 114 relevant RCTs were identified. More than half of the trials were of high or acceptable quality. Half of the reports provided information on comparative demographic data and only 21% performed intention-to-treat analysis. RCTs with sample size of at least 60 patients presented higher methodological quality (p = 0.025). Upon multiple regression, reporting on preoperative care and the experience level of surgeons were independent factors of quality.