Antonis A. Kousoulis

Exploring health care reform in a changing Europe: Lessons from Greece

Abstract The economic crisis is the major theme in the Eurozone and its impact on public health and outcomes is largely discussed. Under this pressure, concerns of further inequalities exist that may have an impact on the burden of several diseases in certain European countries. In this context, Greece is currently an issue of top interest in any international economic discussion. Although the background of the recession has been largely discussed as a political crisis, its health effects on the population, as well as the key role of primary care and general practice/family medicine in health care reform remain to be explored. Serving both the worldwide trend of orienting health care systems towards strengthened primary care and the inner need for minimizing the demand and lessening the burden from the dysfunctional and costly hospital-care system, the economic crisis sets the perfect timing for prioritizing primary health care. In this article a unique window of opportunity for health care reform in Greece is examined, attempting to establish the axes of an example of how health care system can be reshaped amidst the economic crisis. Equity, quality, value framework, medical professionalism, information technology and decentralization emerge as topics of central interest. There is no doubt that Europe is transitioning under challenging social, economic and public health perspectives. However, taking Greece as an example, the current economic situation sets a good timing for health care reform and the key messages of this paper could be used by other countries facing similar problems.

Serum folate and B12 levels in association with cognitive impairment among seniors: results from the VELESTINO study in Greece and meta-analysis.

Objective: To summarize existing evidence on the effect of serum folate and vitamin B12 levels on cognitive impairment among elders via a meta-analysis, also including unpublished data from a cross-sectional study of seniors ( > 65 years) residing in Velestino, Greece. Method: Serum measurements and Mini-Mental State Examination (MMSE) assessments were available for 593 Velestinians. In addition, 12 studies availing data on folate blood levels (N = 9,747) and 9 on B12 (N = 8,122) were identified following a search algorithm; pooled effect estimates were derived. Results: Cognitive impairment (MMSE < 24) among Velestenians was associated with lower education level in both genders; decreased social activity, depressive symptoms and low folate levels in males; older age in females. Meta-analyses showed an adverse effect of low-folate levels on cognition (OR: 1.66, 95% CI: 1.40-1.96); B12 was nonsignificantly associated (OR: 1.11, 95% CI: 0.88-1.40). Discussion: Low folate levels are associated with cognitive impairment of seniors; underlying pathophysiological mechanisms should be further explored.

Folate and B12 serum levels in association with depression in the aged: a systematic review and meta-analysis

Objectives: To systematically review and meta-analyse existing evidence on the association between folate/B12, and depression among the aged people. Methods: Following PRISMA/STROBE guidelines, the Medline abstracts were retrieved using an algorithm comprising relevant MeSH terms. Publications on the association of folate/B12 serum measurements with depression were abstracted independently by two reviewers and included in both gender and gender-specific meta-analyses, following recarculations of published data as appropriate. The Newcastle-Ottawa scale was used to evaluate the quality of included studies. Results: Both gender data were contributed by 11 folate-related (7949 individuals) and 9 B12-related studies (6308 individuals), whereas gender-specific data by 4 folate-related (3409 individuals) and 3 B12-related studies (1934 individuals). A statistically significant overall association between both exposures of interest (low folate and B12 levels) and depression was observed (ORfolate:1.23, 95%CI:1.07–1.43, ORB12:1.20, 95%CI:1.02–1.42). Gender-specific estimates pointed to a statistically significant positive association between low B12 levels and depression only among women (OR:1.33, 95%CI:1.02–1.74); the gender specific associations of low folate levels with depression were, however, non-significant and of counter-direction (ORfemales:1.37, 95%CI:0.90–2.07; ORmales:0.84, 95%CI:0.57–1.25). Conclusion: Low folate and B12 serum levels seem to be associated with depression in the aged. The gender-specific analyses are confined to a positive association of low B12 with depression among older women and call for further research in this direction.

Access to health for refugees in Greece: lessons in inequalities

Eastern Greek islands have been direct passageways of (mainly Syrian) refugees to the European continent over the past year. However, basic medical care has been insufficient. Despite calls for reform, the Greek healthcare system has for many years been costly and dysfunctional, lacking universal equity of access. Thus, mainly volunteers look after the refugee camps in the Greek islands under adverse conditions. Communicable diseases, trauma related injuries and mental health problems are the most common issues facing the refugees. The rapid changes in the epidemiology of multiple conditions that are seen in countries with high immigration rates, like Greece, demand pragmatic solutions. Best available knowledge should be used in delivering health interventions. So far, Greece is failed by international aid, and cross-border policies have not effectively tackled underlying reasons for ill-health in this context, like poverty, conflict and equity of access.

The Plague of Thebes, a Historical Epidemic in Sophocles’ Oedipus Rex

Brucella abortus may have been the etiologic agent.

Neurosurgery During the Bronze Age: A Skull Trepanation in 1900 BC Greece

OBJECTIVE Paleoneurosurgery represents a comparatively new developing direction of neurosurgery dealing with archaeological skull and spine finds and studying their neurosurgical aspects. Trepanation of the cranial vault was a widespread surgical procedure in antiquity and the most convincing evidence of the ancient origin of neurosurgery. The present study considers a case of trepanation from the Middle Bronze Age Greece (1900-1600 B.C.). METHODS The skull under study belongs to skeletal material unearthed from Kirra, Delphi (Central Greece). Macroscopic examination and palpation, as well as three-dimensional computed tomography, were used in this study. RESULTS There is osteological evidence that the skull belongs to a man who died at 30-35 years of age. The procedure of trepanation was performed on the right parietal bone. Both macroscopic and computed tomography evaluation demonstrate an intravital bone reaction at the edges of the aperture. Projected on the right surface of the brain, the trepanation is located on the level of the central groove. The small dimensions and the symmetrical shape of this hole give us an indication that it was made by a metal tool. CONCLUSION We conclude that this paleopathological case provides valuable information about the condition of life and the pre-Hippocratic neurosurgical practice in Bronze Age Greece.

Malaria in Laconia, Greece, then and now: a 2500-year-old pattern

BACKGROUND Malaria is still an active threat in many areas of the world. In Greece, in an area of the Laconia region, malaria epidemics have been recorded since as early as the 5(th) century BC. A local outbreak of malaria was reported in the summer/autumn of 2011. METHOD A comparative research study of historical and modern sources was carried out in order to explore the malaria outbreaks occurring in the area of Laconia, Greece. RESULTS The study revealed that the central area (Elos and Skala), the peak season (early autumn), the Plasmodium species (P. vivax), the mosquito vector (Anopheles sacharovi), and the risk factors (wetlands and population movements) have, more or less, remained unchanged throughout the 2500-year span in Laconia. CONCLUSIONS Unique regional features preserve a seemingly recurring pattern of malaria outbreaks in this area of Greece. This study, based on low-cost effective research, offers a clear public health message. The Greek authorities responsible for health policy could build upon these findings in order to achieve the desired eradication.

Paleopathological findings in radiographs of ancient and modern Greek skulls

ObjectiveThe skull, when portrayed radiologically, can be a useful tool in detecting signs of systemic diseases and results of pathological growth mechanisms. The aim of this study was therefore to examine, compare, and classify findings in cranial configuration of pathological origin, in modern and ancient skulls.Materials and methodsThe material consists of 240 modern and 141 ancient dry skulls. Three radiographs for each skull (lateral, anteroposterior, basilar) provide enough evidence for differential diagnoses.ResultsCases of osteoporosis are among the interesting pathological findings. A prevalence of female modern skulls in those determined as osteoporotic skulls is noted. Special interest is placed on the area of the sella turcica and many variations, regarding the shape and texture, are recognized both in ancient and modern skulls. Malignancies and important causes of cranial destruction are identified in both skull collections. Diploid thickening and osteolytic areas appear commonly among ancient remains. Moreover, from the ancient skull collection, one case possibly recognizable as fibrous dysplasia is noted while another case with an unusual exostosis gives rise to many questions.ConclusionsInterpreted with caution, the results of the present study, which can serve as an approach of paleopathology and paleoradiology, indicate similarity trends in cranial configuration of pathologic origin in modern and ancient people. Radiography and cephalometry were the main diagnostic tools used to gather evidence and are evaluated as a quite appropriate method to examine anthropological material and assess the internal structure of skeletal remains since they are non-destructive techniques.

Refugee crisis in Greece: not a one-country job

During the past years, tens of thousands of refugees have arrived at the rocky coasts of the island of Lesbos, Greece; occasionally in hundreds in one day, while thousands of their compatriots have not made it alive (Lancet 2015; Abbasi et al. 2015). Starting mainly from Syria, they have arrived in Greece first by walking through rough areas to the western coasts of Turkey, and then via a long, costly and highly risky trip in inflatable, overcrowded boats (Abbasi et al. 2015). Lesbos is situated on one of the most direct passages to the European continent and is refugees’ hopeful safe haven. It has come to represent asylums seekers’ gateway to a potential escape from a troubled past. However, upon arrival to Greece, the desperate travelers have encountered a new set of challenges. Greece has not received consistent support from other European countries. Notable exceptions include buses offered by the United National High Commissioner for Refugees (UNHCR) to transport people to Moria in Lesbos, where Frontex (agency of the European Union) staff have been screening and identifying refugees. Moria hosts a hotspot, an EU-run reception centre to identify and fingerprint migrants and refugees. Following the EU and Turkey agreement on refugee movement, Moria has been largely operating as a detention camp. It is there that refugees have queued for their registration by the Greek police authorities, received necessary documentation to continue their trip to other European countries (Germany, Hungary, UK among others) (Abbasi et al. 2015), or been deported. Often a few have disappeared in the island’s countryside during the night, remaining anonymous, unaccounted for and eventually undocumented. Lesbos saw a new influx of asylum seekers in early summer as well as riots in June. It is in this context, that the lack of a longterm sustainable solution to address the violation of the basic rights of thousands of refugees going through Greece remains important. International public health authorities would have a role to play in assessing the unsafe and unsanitary conditions of the hotspots. Further, as a significant number of refugees are being detained in camps for months, they incur eventually far higher costs to receiving societies than becoming integrated (Razum and Bozorgmehr 2015). This new health crisis in Greece is reflecting the extent of the problem on the other receiving end: Syria. During the recent conflicts, wide destruction of health care facilities, lack of secure routes, shortage in medicines, reemergence of polio and widespread famine and malnutrition have been recorded (Ben Taleb et al. 2015). Syria faces a human tragedy and remains a sad reminder of the impact that neglected determinants, like conflict and politics, have on public health. This leaves Greece to experience the consequences of the Eastern Mediterranean refugee crisis to the utmost degree (Lancet 2015). The country faces a significant economic and social crisis and its approach to healthcare delivery has known problems, A. A. Kousoulis M. Ioakeim-Ioannidou K. P. Economopoulos Society of Junior Doctors, Athens, Greece

Joseph Gensoul and the earliest illustrated operations for maxillary sinus carcinoma

Surgery has evolved along with anatomical illustrations through the ages. Joseph Gensoul (1797–1858), an important figure of the great Lyonnaise medical tradition of the 19th century, was occupied with many different surgical diseases, mostly diseases of the face. Apart from his many contributions stand various techniques on ophthalmological, otorhinolaryngological and oral and maxillofacial surgery. In this context, two rare illustrations depicting an innovative facial surgical operation performed by the great surgeon Joseph Gensoul are thoroughly analyzed. The two illustrations represent the “before” and “after” phases of Gensoul’s most eminent operation, most probably practiced for a maxillary sinus carcinoma. This surgical operation is probably the earliest recorded of its kind in the history of surgery, even though the development of maxillary surgery is connected with the practice of Irwin Moure, who also practiced a type of lateral rhinotomy about a century later than Gensoul. Surgical illustrations are closely related to the history of surgery in every corner of the world.