Publications by authors named "Maria Tsironi"

82 Publications

External validation of International Classification of Injury Severity Score to predict mortality in a Greek adult trauma population.

Injury 2021 Oct 10. Epub 2021 Oct 10.

Department of Nursing, Faculty of Human Movement and Quality of Life Sciences, University of the Peloponnese, 28 Karaiskaki, N. Penteli Attikis, Tripoli 15239, Greece.

Introduction: The International Classification of diseases- based Injury Severity Score (ICISS) obtained by empirically derived diagnosis-specific survival probabilities (DSPs) is the best-known risk-adjustment measure to predict mortality. Recently, a new set of pooled DSPs has been proposed by the International Collaborative Effort on Injury Statistics but it remains to be externally validated in other cohorts. The aim of this study was to externally validate the ICISS using international DSPs and compare its prognostic performance with local DSPs derived from Greek adult trauma population.

Materials And Methods: This retrospective single-center cohort study enrolled adult trauma patients (≥ 16 years) hospitalized between January 2015 and December 2019 and temporally divided into derivation (n = 21,614) and validation cohorts (n = 14,889). Two different ICISS values were calculated for each patient using two different sets of DSPs: international (ICISSint) and local (ICISSgr). The primary outcome was in-hospital mortality. Models' prediction was performed using discrimination and calibration statistics.

Results: ICISSint displayed good discrimination in derivation (AUC = 0.836 CI 95% 0.819-0.852) and validation cohort (AUC = 0.817 CI 95% 0.797-0.836). Calibration using visual analysis showed accurate prediction at patients with low mortality risk, especially below 30%. ICISSgr yielded better discrimination (AUC = 0.834 CI 95% 0.814-0.854 vs 0.817 CI 95% 0.797-0.836, p ˂ .05) and marginally improved overall accuracy (Brier score = 0.0216 vs 0.0223) compared with the ICISSint in the validation cohort. Incorporation of age and sex in both models enhanced further their performance as reflected by superior discrimination (p ˂ .05) and closer calibration curve to the identity line in the validation cohort.

Conclusion: This study supports the use of international DSPs for the ICISS to predict mortality in contemporary trauma patients and provides evidence regarding the potential benefit of applying local DSPs. Further research is warranted to confirm our findings and recommend the widespread use of ICISS as a valid measure that is easily obtained from administrative data based on ICD-10 codes.
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http://dx.doi.org/10.1016/j.injury.2021.10.003DOI Listing
October 2021

Impact of a 246 Km ultra-marathon running race on heart: Insights from advanced deformation analysis.

Eur J Sport Sci 2021 May 30:1-9. Epub 2021 May 30.

Sports Medicine Laboratory, Department of Physical Education and Sports Science, Aristotle University of Thessaloniki, Thessaloniki, Greece.

Although previous studies suggest that prolonged intense exercise such as marathon running transitorily alters cardiac function, there is little information regarding ultramarathon races. Aim of this study was to investigate the acute impact of ultra-endurance exercise (UEE) on heart, applying advanced strain imaging. Echocardiographic assessment was performed the day before and at the finish line of "Spartathlon": A 246 Km ultra-marathon running race. 2D speckle-tracking echocardiography was performed in all four chambers, evaluating longitudinal strain (LS) for both ventricles and atria. Peak strain values and temporal parameters adjusted for heart rate were extracted from the derived curves. Out of 60 participants initially screened, 27 athletes (19 male, age 45 ± 7 years) finished the race in 33:34:27(28:50:38-35:07:07) hours. Absolute values of right (RV) and left ventricular (LV) LS (RVLS -22.9 ± 3.6 pre- to -21.2 ± 3.0% post-, =0.04 and LVLS -20.9 ± 2.3 pre- to -18.8 ± 2.0 post-, =0.009) slightly decreased post-race, whereas atrial strain did not change. RV and LV LS decrease was caused mainly by strain impairment of basal regions with apical preservation. Inter-chamber relationships assessed through RV/LV, LV/LA, RV/RA and RA/LA peak values' ratios remained unchanged from pre to post-race. Finally, UEE caused an extension of the systolic phase of cardiac cycle with concomitant diastole reduction (<0.001 for all strain curves). Conclusively, ventricular LS strain as well as effective diastolic period slightly decreased, whereas atrial strain and inter-chamber relationships remained unchanged after running a 246-km-ultra-marathon race. These changes may be attributed to concomitant pre- and afterload alterations following UEE.
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http://dx.doi.org/10.1080/17461391.2021.1930194DOI Listing
May 2021

Arterial Function after a 246 km Ultra-marathon Running Race.

Int J Sports Med 2021 Apr 26. Epub 2021 Apr 26.

Department of Physical Education & Sports Science, Aristotle University of Thessaloniki, Sports Medicine Laboratory, Thermi, Greece.

There is little research about the effects of ultra-endurance exercise on arterial morphological and functional properties. The aim was to assess the acute changes of the carotid-femoral pulse wave velocity and carotid doppler-derived parameters following an ultra-marathon race as well as the intima-media thickness of the carotid artery in ultra-marathon runners. Twenty athletes were examined at baseline and within 10 mins after a 246 km running race. Measurements included carotid-femoral pulse wave velocity, peak-systolic and end-diastolic velocities of carotid artery blood flow, pulsatility and resistivity indices and blood biochemical parameters. The intima-media thickness of the right and left carotid artery was measured before the race. Arterial stiffness and carotid artery intima media thickness at rest remained within known normal limits. The ultra-marathon race significantly increased carotid-femoral pulse wave velocity by 22.6% and pulsatility index by 10.2%. There was a decrease in body weight by 3.35% and an increase of all biochemical markers of muscle damage after the race. Additionally, C-reactive protein was correlated with both pulsatility and resistivity indices post-race. This study shows that immediately after a 246 km ultra-marathon running race, acute increase of arterial stiffness and vascular resistance were evident. The carotid artery thickness of ultra-marathon runners was within normal range.
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http://dx.doi.org/10.1055/a-1467-6508DOI Listing
April 2021

Increased serum levels of fibroblast growth factor 23 after an ultradistance run.

J Sci Med Sport 2021 Mar 23;24(3):297-300. Epub 2020 Sep 23.

Institute of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Austria.

Objectives: Healthy bones need to be loaded on a regular basis. However, overstrenuous exercise causes uncoupling of bone metabolism. Thus, it is important to be aware of exercise-induced alterations in bone metabolism. The aim of this observational study was to determine whether participation in an ultradistance run has an impact on the phosphaturic hormone fibroblast growth factor 23 (FGF23), which is produced by osteocytes and suppresses osteoblast differentiation as well as matix mineralization.

Design: Observational study.

Methods: Nine participants of the Spartathlon (246km) had venous blood samples taken before and within 15min after finishing the race as well as during recovery. Serum levels of FGF23, phosphate, and blood urea nitrogen were determined.

Results: FGF23 increased 6.5-fold from pre-race to post-race (2.2pmol/L [IQR: 0.4; 3.2pmol/L] to 14.4pmol/L [IQR: 4.7; 20.0pmol/L]; p=0.001). Thereafter, serum levels of FGF23 fell to 1.4pmol/L [IQR: 0.5; 1.7pmol/L] (p<0.0001). The differences in FGF23 levels between pre-race and recovery (3 days after the start) did not achieve statistical significance (p=0.614). Serum levels of phosphate and blood urea nitrogen also did not change significantly.

Conclusions: Since FGF23 plays a central role in mineral homeostasis, the transient overexpression of FGF23 may be an important contributor to the short-term uncoupling of bone metabolism induced by overstrenuous exercise.
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http://dx.doi.org/10.1016/j.jsams.2020.09.010DOI Listing
March 2021

The Importance of an Active Case Detection (ACD) Programme for Malaria among Migrants from Malaria Endemic Countries: The Greek Experience in a Receptive and Vulnerable Area.

Int J Environ Res Public Health 2020 06 8;17(11). Epub 2020 Jun 8.

Department of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, 22 Papakyriazi St., 41222 Larissa, Greece.

Greece has been malaria-free since 1974. In October 2011, following an outbreak of 36 locally acquired malaria (LAM) cases in Evrotas Municipality, a Pro-Active Case Detection (PACD) program for malaria was implemented among migrants from malaria-endemic countries, to support early diagnosis and treatment of cases. We evaluated the PACD program for the years 2012-2017 using indicators such as the number of locally acquired cases, the detection rate/sensitivity and the timeliness of diagnosis and treatment. We visited each migrant home every 7-15 days to screen migrants for malaria symptoms, performing Rapid Diagnostic Tests (RDTs) and blood smears on symptomatic patients. We estimated: (i) the number of malaria cases detected by the PACD, divided by the total number of reported malaria cases during the same period among the same population; (ii) the time between onset of symptoms, diagnosis and initiation of treatment. The total number of migrants who were screened for malaria symptoms for the years 2012-2017 was 5057 with 84,169 fever screenings conducted, while 2288 RDTs and 1736 blood smears were performed. During the same period, 53 imported malaria cases were detected, while incidence of malaria among migrants was estimated at 1.8% annually. Ten and one LAM cases were also reported in 2012 and 2015, respectively. Sensitivity of PACD ranged from 86% to 100%; median timeliness between onset of symptoms and diagnosis decreased from 72 h in 2012 to 12 h in 2017 (83% decrease), while timeliness between diagnosis and treatment initiation was 0 h. The implementation of PACD could be considered an effective prevention and response tool against malaria re-introduction.
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http://dx.doi.org/10.3390/ijerph17114080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7312366PMC
June 2020

Exploring the determinants of the cardiac changes after ultra-long duration exercise: The echocardiographic Spartathlon study.

Eur J Prev Cardiol 2020 09 3;27(14):1467-1477. Epub 2020 Feb 3.

Laboratory of Sports Medicine, Sports Medicine Division, Aristotle University of Thessaloniki, Greece.

Aim: The investigation of the pathophysiological determinants of cardiac changes following ultra-long duration exercise.

Methods: Twenty-seven runners who finished a 246 km running race were examined both before and after the finish of the race. Examinations included echocardiography and measurement of body weight and blood biochemical parameters.

Results: Exercise increased left ventricular end-diastolic interventricular septum thickness (LVIVSd) ( < 0.001) and posterior wall thickness (LVPWTd) ( = 0.001) and right ventricular end-diastolic area ( = 0.005), while reduced tricuspid annular plane systolic excursion (TAPSE) ( = 0.004). A minor decrease in the peak absolute values of both left ventricular (from -20.9 ± 2.3% to -18.8 ± 2.0%,  = 0.009) and right ventricular (from -22.9 ± 3.6% to -21.2 ± 3.0%,  = 0.040) global longitudinal strains occurred. There was decrease in body weight ( < 0.001) and increase in both circulating high-sensitivity troponin I ( = 0.028) and amino-terminal pro-B type natriuretic peptide (NT-proBNP) ( = 0.018). The change in the sum of LVIVSd and LVPWTd correlated negatively with percentage change of body weight ( = -0.416,  = 0.049). The only independent determinant of post-exercise NT-proBNP was pulmonary artery systolic pressure ( = 0.797,  = 0.002). Post-exercise NT-proBNP correlated positively with percentage changes of basal (RVbas) ( = 0.582,  = 0.037) and mid-cavity (RVmid) ( = 0.618,  = 0.043) right ventricular diameters and negatively with percentage change of TAPSE ( = -0.720,  = 0.008). Similar correlations with RVbas, RVmid and TAPSE were found for pulmonary artery systolic pressure. Post-exercise high-sensitivity troponin I correlated negatively with percentage change of body weight ( = -0.601,  = 0.039), but was not associated with any cardiac parameter.

Conclusion: The main cardiac effects of ultra-long duration exercise were the decrease in left ventricular end-diastolic dimensions and increase in left ventricular wall thickness, as well as minimal dilatation and alteration in systolic function of right ventricle, possibly due to the altered exercise-related right ventricular afterload.
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http://dx.doi.org/10.1177/2047487319898782DOI Listing
September 2020

Correlation of Dietary Advanced Glycation End Products with the Hematological and Biochemical Markers of Patients with Chronic Kidney Disease Undergoing Hemodialysis.

Cureus 2019 Dec 12;11(12):e6360. Epub 2019 Dec 12.

Nursing, Faculty of Health Sciences, University of Peloponnese, Tripolis, GRC.

Aim The advanced glycation end products (AGEs) are among the mechanisms responsible for the pathogenesis and development of chronic kidney disease. The aim of this study was to estimate the dietary AGE intake and to assess its correlation with hematological and biochemical markers of patients with end-stage renal disease (ESRD) undergoing hemodialysis. Materials and methods For this study, a structured questionnaire of the exogenous AGEs was developed, whose reliability and validity were evaluated in the pilot phase of the study including 50 participants. The questionnaire was issued to 605 participants (305 ESRD patients undergoing hemodialysis and 300 controls), and a blood sample was obtained through which hematological and biochemical markers were analyzed. Results It was noted that patients with ESRD consume large quantities of dietary AGEs not only in absolute values but also in comparison with control subjects (p = 0.001), attributed mainly to the methods of product processing as well as cooking. It was also ascertained that dietary AGEs were correlated (p < 0.005) with fasting glucose and glycated hemoglobin (HbA1c) and with lipidemic profile markers, such as triglyceride, as well as inflammation markers, such as erythrocyte sedimentation rate, ferritin, and C-reactive protein. All the aforementioned markers show abnormally increased levels in patients with ERSD and diabetes compared with healthy subjects. Conclusion Patients with ESRD consuming foods favoring AGE formations combined with increased endogenous AGE burden the body with their harmful action. If the specific group of patients adopt dietary habits contributing to the containment or the inhibition of AGE formation, then this would lead to the improvement of their hematological and biochemical markers and in terms of the effects of AGEs on their health is deemed imperative through the creation of consulting and prevention programs.
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http://dx.doi.org/10.7759/cureus.6360DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6957054PMC
December 2019

The Effect of Fatigue and Pain Self- Efficacy on Health-Related Quality of Life Among Patients with Multiple Sclerosis.

Mater Sociomed 2019 Mar;31(1):40-44

Ministry of Health, Athens, Greece.

Introduction: Health-related quality of life is a major issue among patients with Multiple sclerosis (MS).

Aim: To explore the effect of fatigue and pain self-efficacy on health-related quality of life among patients with MS.

Methods: Between March and May 2018, 85 MS patients from a large Hospital of Athens region completed the questionnaires: a) Missoula-VITAS Quality of Life Index-15, which examines 5 dimensions of quality of life, b) Pain Self Efficacy Questionnaire which measures the pain self-efficacy that an individual perceives, c) Fatigue Assessment Scale (FAS) which measures fatigue, d) a questionnaire about the sociodemographic elements. Statistical analysis was performed using the IBM SPSS Statistics version 21. The significance level was set up to 0.001.

Results: Fatigue might predict the dimension of quality of life "Function" while Pain Self-Efficacy might, also, predict the dimension of quality of life "Interpersonal". A strong correlation was found between the dimensions of quality of life "Well-being" and "Transcendent" and between "Interpersonal" and Pain Self-Efficacy. The total score of fatigue was strongly correlated with Physical Fatigue and very strongly correlated with Mental Fatigue.

Conclusion: Fatigue and Pain Self-Efficacy are important predictors of the dimensions of quality of life among patients with MS. Pain in MS has to be taken into serious consideration in every patient with MS.
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http://dx.doi.org/10.5455/msm.2019.31.40-44DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6511379PMC
March 2019

Seroprevalence in a High-Risk Population in Greece: A Cross-Sectional Study.

Interdiscip Perspect Infect Dis 2018 25;2018:8751921. Epub 2018 Dec 25.

Laboratory of Epidemiology and Prevention of Hemoglobinopathies, Acute and Chronic Diseases, Department of Nursing, University of Peloponnese, Valioti & Plateon, 23100 Sparta, Laconia, Greece.

Introduction: Brucellosis is a zoonosis with high occupational risk. However, seroprevalence of antibodies among occupational groups is not known, since studies in endemic countries are rare.

Methods: A cross-sectional seroprevalence study was conducted among livestock farmers in an endemic region in Greece. A low-risk group of individuals that just moved in the region was used as controls. Rose Bengal, Wright standard tube agglutination (STA) tests, and specific IgG and IgM antibodies using ELISA were evaluated; differences and odds ratios were calculated. Results were compared with studies from other endemic regions.

Results: 100 livestock farmers and family members and 34 first-year students were enrolled. Rose Bengal results were 18% positive versus 0% (p=0.007); Wright STAs for were 8% versus 2.9% (p=0.448) and for they were 2% versus 2.9% (p=0.588). ELISA IgG was positive in 8% of farmers versus 2.9% of students (p=0.448). Parallel testing with Rose Bengal and ELISA IgG was positive in 3% versus 0% (p=0.571). No significant odds ratios were calculated for Wright STAs and ELISA IgG.

Conclusions: Healthy livestock farmers may present with positive Rose Bengal test but this translates to true seroprevalence in only a small proportion. Livestock farmers have no significant seroprevalence that may obscure diagnosis of acute brucellosis in clinical settings.
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http://dx.doi.org/10.1155/2018/8751921DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6323493PMC
December 2018

Are Burnout Syndrome and Depression Predictors for Aggressive Behavior Among Mental Health Care Professionals?

Med Arch 2018 Oct;72(4):244-248

Department of Psychology, University of Central Lancashire, Athens, Greece.

Aim: This study aims to examine the possible relation between depression and burnout as predictors to aggressive behaviors among mental healthcare professionals.

Methods: For the purposes of this study 72 mental health care professionals were recruited and were evaluated in three questionnaires which were provided to them online. Firstly regarding depression, the Center for Epidemiologic Studies Depression Scale (CES-D) was administered, secondly, concerning burnout, Maslach Burnout Inventory (MBI) was applied and finally, regarding aggression, the Aggression Questionnaire (GAQ) was employed. Statistical data analysis was performed using the IBM SPSS Statistics Version 19. The level of statistical significance was set at up at 0.05.

Results: The results showed that depression is considered to be a statistically significant predictor of aggressive behaviors. However, burnout was not found to be a statistically significant predictor of aggression. In addition, a statistically significant relationship was found between burnout and depression.

Conclusions: It seems to be of essential importance for mental healthcare professionals to be provided with support and assistance in order to diminish the potential high-stress levels and in that way to overcome depression and burnout of those who work in mental health settings.
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http://dx.doi.org/10.5455/medarh.2018.72.244-248DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6195016PMC
October 2018

The impact of education on knowledge, adherence and quality of life among patients on haemodialysis.

Qual Life Res 2019 Jan 3;28(1):73-83. Epub 2018 Sep 3.

Department of Nursing, University of Peloponnese, Efstathiou & Stamatikis Valioti and Plateon, 23100, Sparta, Greece.

Purpose: The purpose of the study was to assess the impact of an educational intervention on the level of knowledge, quality of life (QoL) and adherence to the treatment regimen among haemodialysis (HD) patients as well as to describe the association between these variables.

Methods: In this quasi-experimental interventional study, 50 HD patients at a HD centre in Western Attica were randomly assigned into intervention (N = 25, received education and a booklet) and control (N = 25, received only the booklet) groups. Knowledge, adherence and quality of life were measured pre- and post-intervention using the Kidney Disease Questionnaire, the GR-Simplified Medication Adherence Questionnaire-HD and Missoula Vitas Quality of Life Index-15, respectively. The statistical analysis of the data was performed with the help of the Statistical Program SPSS version 19.0. The statistical significance level was set up at 0.05.

Results: The increase of knowledge, adherence and QoL levels in the intervention group was significantly higher compared to the control group. There was no significant correlation between knowledge and adherence scores after the intervention. However, a significant positive correlation was found between the change in the overall QoL and the changes in the total adherence score as well as the adherence to the fluids and dietary behaviour.

Conclusions: An educational intervention can improve knowledge, adherence and QoL among HD patients. The increase of knowledge level is not associated with increased adherence. However, the increase of adherence may improve some dimensions of QoL.
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http://dx.doi.org/10.1007/s11136-018-1989-yDOI Listing
January 2019

Measuring the reliability and validity of the Greek edition of the Diabetes Quality of Life Brief Clinical Inventory.

Diabetes Res Clin Pract 2018 Jun 26;140:61-71. Epub 2018 Mar 26.

Department of Nursing, University of Peloponnese, Sparta, Greece. Electronic address:

Background: The present study focuses on studying the validity and reliability of the Greek edition of DQOL-BCI. DQOL-BCI includes 15 questions-elements that are evaluated on a 5-grade scale like Likert and two general form-shapes.

Methods: The translation process was conducted in conformity with the guidelines of EuroQol group. A non-random sample of 65 people-patients diagnosed with diabetes I and II was selected. The questionnaire that was used to collect the data was the translated version of DQOL-BCI, and included the demographic characteristics of the interviewees. The content validity of DQOL-BCI was re-examined from a team of five experts (expert panel) for qualitative and quantitative performance. The completion of the questionnaire was done via a personal interview.

Results: The sample consisted of 58 people (35 men and 23 women, 59.9 ± 10.9 years). The translation of the questionnaire was found appropriate in accordance to the peculiarities of the Greek language and culture. The largest deviation of values is observed in QOL1 (1.71) in comparison to QOL6 (2.98). The difference between the standard deviations is close to 0.6. The statistics results of the tests showed satisfactory content validity and high construct validity, while the high values for Cronbach alpha index (0.95) reveal high reliability and internal consistency.

Conclusions: The Greek version of DQOL-BCI has acceptable psychometric properties and appears to demonstrate high internal reliability and satisfactory construct validity, which allows its use as an important tool in evaluating the quality of life of diabetic patients in relation to their health.
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http://dx.doi.org/10.1016/j.diabres.2018.01.019DOI Listing
June 2018

The Effect of Nutrition and Sleep Habits on Predisposition for Metabolic Syndrome in Greek Children.

J Pediatr Nurs 2018 May - Jun;40:e2-e8. Epub 2018 May 7.

Department of Nursing, Faculty of Human Movement and Quality of Life Sciences, University of Peloponnese, Sparta, Greece. Electronic address:

Purpose: To investigate the effect of lifestyle habits in childhood Metabolic Syndrome (MTS).

Design And Methods: Descriptive correlation study with 480 participants (5-12 years old) using a specially designed questionnaire was conducted. Anthropometric and biochemical analyses were performed.

Results: Fifteen percent of children exhibited predisposition for MTS. Regarding sleep habits, logistic regression analysis (LRA) showed that hour of sleep -before 22:00- was associated with decreased waist circumference (WC%) (p = .026). Midday siesta was negatively correlated with systolic (SBP) (p = .001) and diastolic blood pressure (DBP) (p = .046). In children without MTS, lack of sleep and night time sleep was positively correlated with DBP (p = .044) and fasting blood glucose (FBG) (p = .005). Regarding nutrition habits, fast food consumption was positively correlated with SBP (p = .006) and meat consumption was positively correlated with both Body Mass Index% (BMI%) (p = .038) and WC% (p = .023). LRA showed that fruit (p = .001) and legume (p = .040) consumption was associated with decreased FBG; fish consumption with decreased Low Density Lipoprotein (LDL) cholesterol (p = .031), vegetable (p = .054) and cereal consumption (p = .012) with decreased DBP. In children with MTS, fruits were associated with increased FBG (p = .034). In children without MTS, meat consumption was associated with increased LDL (p = .024), cereal with increased WC% (p = .002) and olive products with increased High Density Lipoprotein (HDL) cholesterol and BMI% (p = .037).

Conclusions: The adoption of both balanced diet and sleep habits seemed to be crucial for the prevention of MTS.

Practice Implications: Clinical health nurses could develop and implement preventive intervention programs in order to avoid metabolic complications in adulthood.
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http://dx.doi.org/10.1016/j.pedn.2018.01.012DOI Listing
October 2018

Mental health, loneliness, and illness perception outcomes in quality of life among young breast cancer patients after mastectomy: the role of breast reconstruction.

Qual Life Res 2018 02 8;27(2):539-543. Epub 2017 Nov 8.

Department of Nursing, University of Peloponnese, Efstathiou & Stamatikis Valioti and Plateon Sparta, 23100, Tripoli, Greece.

Purpose: Το explore the relationship between mental health (depression, anxiety, and stress), loneliness, and illness perception with health-related quality of life (HRQoL) in young breast cancer patients, within a year after mastectomy, and to investigate the role of breast reconstruction.

Methods: Eighty-one women with stage II breast cancer-35 with breast reconstruction and 46 without breast reconstruction-completed the Missoula-VITAS Quality of Life Index-15, the Depression Anxiety Stress Scale 21, the UCLA Loneliness Scale, the Brief Illness Perception Questionnaire, and a questionnaire with demographic and medical information. Statistical analysis was performed using IBM SPSS Statistics version 20.

Results: Breast reconstruction was a significant predictor of total HRQoL and its domains. Women with breast reconstruction had better HRQoL, significantly better mental health, less stress and anxiety levels but experienced more physical discomfort and perceived higher level of physical distress compared to the ones without breast reconstruction. On the contrary, patients without breast reconstruction had higher level of loneliness, which was found to be correlated with poor HRQoL and higher levels of anxiety. Negative illness perceptions were associated with poor HRQoL for both groups.

Conclusions: Breast reconstruction is not a panacea for patients in improving HRQoL.
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http://dx.doi.org/10.1007/s11136-017-1735-xDOI Listing
February 2018

Safe Use of Defibrillators: A Case Study in Greek Registered Nurses.

Adv Exp Med Biol 2017;989:285-289

Department of Nursing, Faculty of Human Movement and Quality of Life Sciences, University of Peloponnese, Sparta, Greece.

International literature reveals the deficit of nurses' knowledge on the defibrillator and the need to implement continuing education training courses relative to clinical issues.The purpose of this study was the evaluation of Greek registered nurses' knowledge on the safe use of the defibrillator before and after a 2-h workshop. Anonymous self-administered validated questionnaire consisted of two parts was used to collect the data, after the written consent of the participants. The sample consisted of 65 participants (12 men and 53 women) and the output data were analyzed with SPSS v. 19.0 (SPSS Inc., Chicago, IL). The quantitative variables are expressed as mean values (SD) or as median values (interquartile range = IQR) while the qualitative variables are expressed as absolute and relative frequencies. For the comparison of the proportions of the correct answers before and after the intervention, McNemar tests were used. A knowledge score was computed for every participant from all correct answers and converted to a scale from 0 to 100 (where 0 = none correct answer and 100 = all answers were correct). Paired Student's t-tests were used for the comparison of the knowledge score before and after the intervention. All reported p values are two-tailed and the statistical significance was set at p < 0.05. The mean knowledge score increased significantly from 66.7% to 91.3% after the intervention. The study showed that the implementation of educational programs contributes positively to update registered nurses' knowledge on clinical issues, which cannot be replenished only through undergraduate education and experience.
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http://dx.doi.org/10.1007/978-3-319-57348-9_26DOI Listing
May 2019

Evaluation of Pulse Oximetry Knowledge of Greek Registered Nurses.

Adv Exp Med Biol 2017;988:89-96

Department of Nursing, Faculty of Human Movement and Quality of Life Sciences, University of Peloponnese, Sparta, Greece.

Proper use and evaluation of the pulse oximeter readings in everyday clinical practice are related to patient safety and quality of provided patient healthcare. Purpose of this study was the evaluation of Greek registered nurses' knowledge in pulse oximetry before and after an educational intervention implemented in a 2-h educational intervention (workshop). Anonymous self-administered validated questionnaire consisted of two parts was used to collect the data, after the written consent of the author, in a sample consisted of 78 participants (12 men and 66 women) and the output data were analyzed with SPSS v. 19.0 (SPSS Inc., Chicago, IL). The quantitative variables are expressed as mean values (SD) or as median values (interquartile range = IQR) while the qualitative variables are expressed as absolute and relative frequencies. For the comparison of the proportions of the correct answers before and after the intervention, Mc Nemar tests were used. A knowledge score was computed for every participant from all correct answers and converted to a scale from 0 to 100 (where 0 = none correct answer and 100 = all answers were correct). Paired Student's t-tests were used for the comparison of the knowledge score before and after the intervention. All reported p values are two-tailed and the statistical significance was set at p < 0.05. The mean knowledge score increased significantly from 73.4 to 80.5% after the intervention. The study showed that the implementation of educational programs contributes positively to update registered nurses' Knowledge on clinical issues, which cannot be replenished only through undergraduate education and experience.
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http://dx.doi.org/10.1007/978-3-319-56246-9_7DOI Listing
May 2019

Does Health Perception, Dietary Habits and Lifestyle Effect Optimism? A Quantitative and Qualitative Study.

Adv Exp Med Biol 2017;988:49-61

Faculty of Human Movement and Quality of Life Sciences, Department of Nursing, Efstathiou & Stamatikis Valioti and Plateon, University of Peloponnese, Sparti, 23100, Greece.

The aim of the study was to investigate the relationship between optimism, general health perception, nutritional habits and lifestyle. A quantitative study was conducted on 500 Greek adults. A standardized questionnaire was used which consisted of the General Health Self-Assessment Questionnaire (GHSAQ), the Life Orientation Test-Revised (GrLOT-R), the dietary habits and lifestyle questionnaire. A qualitative study was conducted through interviews and focus groups. Participants' average score of GrLot-R was 20.47 (±4.017) units. The highest GrLot-R score was statistically correlated to more frequent consumption of fruits, salads, dairy products, olive oil, high-fibre cereals and water and to the lower consumption of canned products. Multivariate analysis showed that optimism is significantly positively predicted by the factors "Vitamin K & A", "Vitamin C", and negatively by "Preservatives." There was also a positive correlation between GrLot-R and GHSAQ. The qualitative study analysis showed that physical exercise, duration/quality of sleeping, family and stress affected participants' optimism. It seems that intrinsic factors as vitamins, preservatives, a healthy lifestyle and extrinsic factors as the family background and the environment that someone is raised, affect the level of optimism.
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http://dx.doi.org/10.1007/978-3-319-56246-9_4DOI Listing
May 2019

Detecting the Diversity of and Endosymbionts Hosted by Isolates.

Front Microbiol 2017 28;8:1188. Epub 2017 Jun 28.

Department of Biopathology and Clinical Microbiology, Athens Medical School, Aeginition HospitalAthens, Greece.

The symbiosis of and is the first described association between two obligate human parasites. is the niche and the vector for the transmission of infection. This clinically significant symbiosis may affect virulence and susceptibility to treatment. The aims of this study were to investigate the intracellularly present and species in strains isolated from the vaginal discharge of infected women as well as to trace the diversity pattern among the species detected in the isolated strains. Hundred pure cultures were isolated from ~7,500 patient specimens presented with clinical purulent vaginitis. PCR and sequencing for spp. were performed in DNA extracted from the pure cultures. In addition, vaginal discharge samples were cultured for the presence of and . Phylogenetic analysis assisted the identification of interspecies relationships between the and isolates. Fifty four percentage of isolates were harboring spp. Phylogenetic analysis revealed three distinct clusters, two with already characterized and spp. (37% of total spp.), whereas one group formed a distinct cluster matched with the newly identified species (59.3%) and one or more unknown spp. (3.7%). strains associated with vaginal infection might host intracellular mycoplasmas or ureaplasmas. Intracellular Mollicutes that remain undetected in the extracellular environment when conventional diagnostic methods are implemented may comprise either novel species, such as , or unknown species with yet unexplored clinical significance.
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http://dx.doi.org/10.3389/fmicb.2017.01188DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5487939PMC
June 2017

A Modified Version of the Greek Simplified Medication Adherence Questionnaire for Hemodialysis Patients.

Health Psychol Res 2017 May 16;5(1):6647. Epub 2017 May 16.

Department of Nursing, University of Peloponnese, Athens, Greece.

Non-adherence to the therapeutic regimen is an increasingly growing problem especially among patients undergoing hemodialysis. The aim of this study was to modify the Greek version of Simplified Medication Adherence Questionnaire (GR-SMAQ) for patients undergoing hemodialysis (GR-SMAQ-HD) and explore its validity and reliability. Between June 2016 and November 2016 a group of patients undergoing hemodialysis (N=107) completed the Greek version of SMAQ. The study was carried out in three Dialysis Units of Hospitals of Athens and Peloponnese region, Greece. The form of GR-SMAQ was modified specifically for renal patients while four additional items were added so as the tool study all aspects of adherence to hemodialysis regimen. Construct validity was checked through exploratory factor analysis with principal Component Analysis with the Equamax method. Test-retest reliability and internal consistency were tested. Statistical analysis was performed using the IBM SPSS Statistics version 21. The significance level was set up at 5%. The Greek version of SMAQ for patients undergoing hemodialysis includes eight questions. Three factors emerged from factor analysis. Cronbach's a coefficient was 0.742 for the whole scale and for each subscale was for 0.75, for 0.856 and for was 0.717. The total mean score was 6.29 (±1.82). GR-SMAQ-HD is a reliable and valuable tool that can be used by hemodialysis nurses and students of nursing for detection of adherence levels in clinical practice.
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http://dx.doi.org/10.4081/hpr.2017.6647DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5452632PMC
May 2017

The Role of miRNAs in Common Inflammatory Arthropathies: Osteoarthritis and Gouty Arthritis.

Biomolecules 2016 11 11;6(4). Epub 2016 Nov 11.

Department of Nursing, Faculty of Human Movement and Quality of Life Sciences, University of Peloponnese, Orthias Artemidos and Plateon St, GR-23100 Sparti, Greece.

MicroRNAs (miRNAs) are small, non-coding RNA species that are highly evolutionarily conserved, from higher invertebrates to man. Up to 1000 miRNAs have been identified in human cells thus far, where they are key regulators of the expression of numerous targets at the post-transcriptional level. They are implicated in various processes, including cell differentiation, metabolism, and inflammation. An expanding list of miRNAs is known to be involved in the pathogenesis of common, non-autoimmune inflammatory diseases. Interestingly, osteoarthritis (OA) is now being conceptualized as a metabolic disease, as there is a correlation among hyperuricemia and metabolic syndrome (MetS). Experimental evidence suggests that metabolic deregulation is a commonality between these different pathological entities, and that miRNAs are key players in the modulation of metabolic routes. In light of these findings, this review discusses the role of miRNAs in OA and gouty arthritis, as well as the possible therapeutic targetability of miRNAs in these diseases.
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http://dx.doi.org/10.3390/biom6040044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5197954PMC
November 2016

Pregnancy in women with thalassemia: challenges and solutions.

Int J Womens Health 2016 8;8:441-51. Epub 2016 Sep 8.

Department of Nursing, University of Peloponnese, Sparta, Greece.

Advances in treatment of thalassemia have led to the aging of thalassemic patients, and consequently concern about successful reproductive outcome is augmented. Although women with thalassemia intermedia only were considered competent of achieving pregnancy, case series reveal the willingness of both thalassemia major and thalassemia intermedia women to have a family. Pregnancy in general is characterized by dynamic multiple-system changes and increased susceptibility to oxidative stress, while homozygous, transfusion-dependent, β-thalassemia patients manifest cardiac, hepatic, endocrine, and metabolic disorders attributable to chronic anoxia and iron overload and thalassemia intermedia, usually nontransfused, is associated with augmented risk of thromboembolic events. Pregnancy in thalassemia should be considered a high risk for both mother and fetus, and favorable outcomes are the result of continuous preconception, antenatal, and postpartum assessment and management by a team of thalassemia experts.
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http://dx.doi.org/10.2147/IJWH.S89308DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5019437PMC
September 2016

Unexploited Antineoplastic Effects of Commercially Available Anti-Diabetic Drugs.

Pharmaceuticals (Basel) 2016 May 6;9(2). Epub 2016 May 6.

Department of Nursing, Faculty of Human Movement and Quality of Life Sciences, University of Peloponnese, Orthias Artemidos and Plateon St, Sparti GR-23100, Greece.

The development of efficacious antitumor compounds with minimal toxicity is a hot research topic. Numerous cancer cell targeted agents are evaluated daily in laboratories for their antitumorigenicity at the pre-clinical level, but the process of their introduction into the market is costly and time-consuming. More importantly, even if these new antitumor agents manage to gain approval, clinicians have no former experience with them. Accruing evidence supports the idea that several medications already used to treat pathologies other than cancer display pleiotropic effects, exhibiting multi-level anti-cancer activity and chemosensitizing properties. This review aims to present the anticancer properties of marketed drugs (i.e., metformin and pioglitazone) used for the management of diabetes mellitus (DM) type II. Mode of action, pre-clinical in vitro and in vivo or clinical data as well as clinical applicability are discussed here. Given the precious multi-year clinical experience with these non-antineoplastic drugs their repurposing in oncology is a challenging alternative that would aid towards the development of therapeutic schemes with less toxicity than those of conventional chemotherapeutic agents. More importantly, harnessing the antitumor function of these agents would save precious time from bench to bedside to aid the fight in the arena of cancer.
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http://dx.doi.org/10.3390/ph9020024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4932542PMC
May 2016

Variable cost of ICU care, a micro-costing analysis.

Intensive Crit Care Nurs 2016 Aug 11;35:66-73. Epub 2016 Apr 11.

Nursing Department, National and Kapodistrian University of Athens, Greece; University ICU, Ag. Anargiroi General Hospital, Kaliftaki 41, 14564 Kiffissia, Greece. Electronic address:

Intensive care unit (ICU) costs account for a great part of a hospital's expenses. The objective of the present study was to measure the patient-specific cost of ICU treatment, to identify the most important cost drivers in ICU and to examine the role of various contributing factors in cost configuration. A retrospective cost analysis of all ICU patients who were admitted during 2011 in a Greek General, seven-bed ICU and stayed for at least 24hours was performed, by applying bottom-up analysis. Data collected included demographics and the exact cost of every single material used for patients' care. Prices were yielded from the hospital's purchasing costs and from the national price list of the imaging and laboratory tests, which was provided by the Ministry of Health. A total of 138 patients were included. Variable cost per ICU day was €573.18. A substantial cost variation was found in the total costs obtained for individual patients (median: €3443, range: €243.70-€116,355). Medicines were responsible for more than half of the cost and antibiotics accounted for the largest part of it, followed by blood products and cardiovascular drugs. Medical cause of admission, severe illness and increased length of stay, mechanical ventilation and dialysis were the factors associated with cost escalation. ICU variable cost is patient-specific, varies according to each patient's needs and is influenced by several factors. The exact estimation of variable cost is a pre-requisite in order to control ICU expenses.
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http://dx.doi.org/10.1016/j.iccn.2016.01.001DOI Listing
August 2016

Improving Fellowship Training in Microsurgery: A Threshold Concepts Perspective on the Curricula of Fellowship Programs.

J Reconstr Microsurg 2015 Oct 28;31(8):579-89. Epub 2015 Jul 28.

Educational Development Unit, Imperial College London, London, United Kingdom.

Background: The theory of "threshold concepts" argues that within every discipline there is knowledge that transforms understanding and leads to a previously inaccessible way of thinking, without which the learner cannot progress. This study investigates the factors influencing the development of the characteristic ways of thinking and practicing as a microsurgeon during a microsurgical fellowship. We analyze the challenges in the development of these characteristics during focused fellowship training in microsurgery, of which some could potentially represent "threshold concepts."

Methods: A qualitative research methodology was followed. Semistructured interviews with trainers and trainees from microsurgical units in the United Kingdom (UK) and the United States (US) were conducted. Data were analyzed using the Dedoose (Manhattan Beach, CA) qualitative data analysis software and interpreted using the theory of "threshold concepts."

Results: Five trainees and four trainers from the UK and the US participated in this research project. Although initially some trainees had particular difficulty in developing their practical microsurgical skills, this improved rapidly with adequate practice. Cognitive skills and especially the ability to expect the unexpected and the ability recognize complications presented as a significant challenge for trainees and transformed their understandings regarding the qualities of a microsurgeon.

Conclusions: Microsurgical fellowship curricula can be redesigned using the theory of threshold concepts, creating a dynamic framework that addresses individual trainee needs to develop the practical and cognitive skills necessary for independent practice of microsurgery.
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http://dx.doi.org/10.1055/s-0035-1558461DOI Listing
October 2015

Changes in Serum Levels of Myokines and Wnt-Antagonists after an Ultramarathon Race.

PLoS One 2015 6;10(7):e0132478. Epub 2015 Jul 6.

Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria.

Background: Regular physical activities have a positive effect on the muscular skeletal system but overstrenuous exercise may be different. Transiently suppressed bone formation and increased bone resorption after participation in a 246-km ultradistance race has been demonstrated.

Purpose: The aim of this study was to analyze effects of the Spartathlon race on novel musculoskeletal markers.

Methods: Venous blood samples were obtained before and immediately after the race from 19 participants of the Spartathlon. From 9 runners who were available 3 days after the start blood was drawn for a third time. Serum levels of myostatin, an inhibitor of myogenic differentiation, and its opponent follistatin as well as sclerostin and dickkopf-1, both of them inhibitors of the wnt signaling pathway, and markers of bone turnover were determined.

Results: Serum levels of myostatin were significantly higher after the race. Serum follistatin only showed a transient increase. Sclerostin levels did not significantly differ before and after the race, whereas dickkopf-1 levels were significantly decreased. At follow-up a decrement of sclerostin and dickkopf-1 levels was seen. Serum cathepsin K levels did not change.

Conclusion: The increase of serum levels of myostatin appears to reflect muscle catabolic processes induced by overstrenuous exercise. After the short-term uncoupling of bone turnover participation in an ultradistance race seems to initiate a long-term positive effect on bone indicated by the low-level inhibition of the Wnt/β-catenin signaling pathway.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0132478PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4493015PMC
May 2016

Marketed nonsteroidal anti-inflammatory agents, antihypertensives, and human immunodeficiency virus protease inhibitors: as-yet-unused weapons of the oncologists' arsenal.

Ther Clin Risk Manag 2015 18;11:807-19. Epub 2015 May 18.

Department of Nursing, Faculty of Human Movement and Quality of Life Sciences, University of Peloponnese, Sparta, Greece.

Experimental data indicate that several pharmacological agents that have long been used for the management of various diseases unrelated to cancer exhibit profound in vitro and in vivo anticancer activity. This is of major clinical importance, since it would possibly aid in reassessing the therapeutic use of currently used agents for which clinicians already have experience. Further, this would obviate the time-consuming process required for the development and the approval of novel antineoplastic drugs. Herein, both pre-clinical and clinical data concerning the antineoplastic function of distinct commercially available pharmacological agents that are not currently used in the field of oncology, ie, nonsteroidal anti-inflammatory drugs, antihypertensive agents, and anti-human immunodeficiency virus agents inhibiting viral protease, are reviewed. The aim is to provide integrated information regarding not only the molecular basis of the antitumor function of these agents but also the applicability of the reevaluation of their therapeutic range in the clinical setting.
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http://dx.doi.org/10.2147/TCRM.S82049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4445694PMC
June 2015

Assessment of nursing staff's theoretical knowledge of cardiovascular resuscitation in an NHS public hospital.

Hellenic J Cardiol 2015 Mar-Apr;56(2):149-53

General Hospital Asklepieio Voulas, Athens, Greece.

Introduction: The effective provision of cardiopulmonary resuscitation (CPR) increases patient survival and reduces in-hospital mortality. Nursing staff, as front-line healthcare professionals, are often the first present at cardiovascular arrests and respond by providing CPR. Their training has an impact on the efficiency of CPR and consequently on health outcomes; thus, assessment of their status in that respect may provide useful information for decision making.

Methods: A cross-sectional study was undertaken in an NHS hospital in Greece to assess the theoretical knowledge of nurses and assistant nurses in relation to CPR. The study population surveyed consisted of nurses and assistant nurses of a specific public hospital.

Results: The study revealed that nursing staff had poor theoretical knowledge, with a mean score for correct answers in the written test of 50.6 ± 25.9% and a mean 4.1 ± 2 correct answers. Fifty-three percent of participants reported taking part in a refresher course after attending a first course, while only 13.2% had participated in a relevant training program during the last 6 months prior to the study. Registered nurses who possessed a university (p=0.016) or a technological institution (p<0.001) diploma, achieved 36.1% and 20.9% higher mean scores, respectively, in the written test in comparison to assistant nurses. The vast majority (91.9%) of the participants expressed their willingness to participate in CPR training courses.

Conclusions: It is crucial for nursing staff to participate in CPR courses in order to refresh and update their theoretical knowledge and performance skills and consequently to improve the safety and effectiveness of care.
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December 2015

Sun burn incidence and knowledge of greek elementary and high school children about sun protection.

Asian Pac J Cancer Prev 2015 ;16(4):1529-34

Faculty of Social Sciences, University of Peloponnese, Korinthos, Greece E-mail :

Introduction: Overexposure to sun radiation and particularly its accumulation during childhood and adolescence is a significant risk factor for skin cancer development. The sun burn is particularly important.

Aim: To estimate sun burn incidence in young pupils in a coastal area of Greece.

Materials And Methods: Two surveys were conducted in a school population in the same district in Greece, over different periods of time, in young people 9 to 18 years old (n=2 977). Anonymous questionnaires were completed. Levels of significance were two- tailed and statistical significance was set at p=0.05. SPSS 17.0 software was used for statistical analysis.

Results: From the individual characteristics of the participants it was shown that the majority of them had dark hair and fair skin, whereas a significant percentage reported the existence of moles on face and their body (83.4% vs 68.1%). The sun burn incidence was high in adolescents and the younger pupils (41.9% vs 55.6%). The younger aged children who were living in an urban area had significantly higher rates of sun burn than those living in semi-urban areas (33.8% vs 24.8%, p=0.020). As far as the knowledge of pupils about the risks of sun radiation it was shown that the elementary school pupils had better knowledge than those at high school. Finally, those with better knowledge had the fewer sun burns (Mean 2.83 SD 0.87, p<0.001).

Conclusions: The contribution of knowledge to the decrease of sun burn incidence is important as long as this is continuous. Therefore, the education should concern not only children but also teachers and parents in the context of continuous and systematic programs of health education.
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http://dx.doi.org/10.7314/apjcp.2015.16.4.1529DOI Listing
December 2015

Prevalence of Brucella antibodies on a previously acute brucellosis infected population: sensitivity, specificity and predictive values of Rose Bengal and Wright standard tube agglutination tests.

Infection 2015 Jun 28;43(3):325-30. Epub 2015 Feb 28.

Nursing Department, University of Peloponnesus, Orthias Artemidos and Plateon, 23100, Sparta, Greece,

Purpose: Brucellosis is a zoonosis with worldwide distribution. The presence of antibodies after acute infection and the prevalence of positive serology in endemic area are not well documented.

Methods: Patients hospitalized with acute brucellosis were relocated 3-13 years after the initial infection. Hospital records of the initial infection were retrieved, and examination of Brucella antibodies using Rose Bengal test (RBT) and Wright standard tube agglutination (STA) test was performed.

Results: Eighty-three patients were hospitalized from 2000 to 2010; 50.6 % were farmers and 37.4 % livestock farmers. All had febrile illness and various focal complications. All had positive serology, and 82.2 % had positive blood cultures; 91.5 % were treated with streptomycin plus doxycycline. Seventy-two (86.7 %) were relocated on follow-up. Nine (12.5 %) had positive RBT and STA up to 1/320. Occupational history was associated with positive serology (p = 0.0172), and 8/9 of the positive individuals were livestock farmers (38.0 % of the livestock farmers checked). Residence, years after the infection, clinical presentation of brucellosis and treatment were not associated with serology results. Both tests had excellent sensitivity (nearly 100 %), specificity 87.5 % and excellent negative predictive value (nearly 100 %); however, positive predictive value was only 11.4 %.

Conclusions: Rapid and low-cost tests as RBT and STA are still very useful in diagnosing acute brucellosis; however, every positive test must be examined together with clinical symptoms and occupational history. The tests can be used as screening tests in endemic populations to rule out acute brucellosis.
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http://dx.doi.org/10.1007/s15010-015-0748-zDOI Listing
June 2015

Brucella endocarditis as a late onset complication of brucellosis.

Case Rep Infect Dis 2015 2;2015:836826. Epub 2015 Feb 2.

Faculty of Nursing, University of Peloponnese, Orthias Artemidos & Plataion, 23100 Sparta, Greece.

Brucella endocarditis (BE) is a rare but life threatening complication of brucellosis. We present a case report of a patient with relapsing brucellosis complicated with aortic valve endocarditis. The patient underwent valve replacement and required prolonged antibiotic treatment because of rupture of the noncoronary leaflet and development of congestive heart failure. Since the onset of endocarditis in patients with brucellosis is not known, proper follow-up is required in order to identify any late onset complications, especially in endemic areas.
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http://dx.doi.org/10.1155/2015/836826DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4332751PMC
February 2015
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