Publications by authors named "Michael Anthracopoulos"

48 Publications

Changing trends in the prevalence of childhood asthma over 40 years in Greece.

Pediatr Pulmonol 2021 Oct 20;56(10):3242-3249. Epub 2021 Jul 20.

Respiratory Unit, Department of Pediatrics, University Hospital of Patras and University of Patras Medical School, Rion, Patras, Greece.

Background: A series of repeated questionnaire surveys among 8- to 9-year-old school children in the city of Patras, Greece, demonstrated a continuous rise in the prevalence of wheeze/asthma from 1978 to 2003, with a plateau between 2003 and 2008. We further investigated wheeze/asthma trends within the same environment over the last decade.

Methods: Two follow-up surveys were conducted in 2013 (N = 2554) and 2018 (N = 2648). Physician-diagnosed wheeze and asthma were analyzed in relation to their occurrence (recent-onset: within the last 2 years; noncurrent: before 2 years; persistent: both prior and within the last 2 years). In 2018, spirometry was also performed in participants reporting symptoms and in a sample of healthy controls.

Results: The prevalence of current wheeze/asthma declined from 6.9% in 2008% to 5.2% in 2013% and 4.3% in 2018. The persistent and noncurrent wheeze/asthma groups followed this overall trend (P-for-trend <0.001), while the prevalence of recent-onset wheeze/asthma remained unchanged (P-for-trend >0.05). Persistent and noncurrent wheezers were also more frequently diagnosed with asthma, in contrast to those with recent-onset wheeze. The FEV z-score was less than -1 in 32.1% of children with recent-onset and in 22.4% of those with persistent wheeze/asthma; both rates were higher than those of the Noncurrent wheeze/asthma group (7.1%; p < .05) and of healthy controls (3.5%; p < .001).

Conclusions: The prevalence of childhood wheeze/asthma has declined significantly during the last decade in Greece. The reversing trend may in part be attributed to changing asthma perceptions among physicians and/or parents, especially in the case of younger children with troublesome respiratory symptoms.
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http://dx.doi.org/10.1002/ppul.25575DOI Listing
October 2021

Pediatric Pulmonary Function Testing in COVID-19 Pandemic and Beyond. A Position Statement From the Hellenic Pediatric Respiratory Society.

Front Pediatr 2021 21;9:673322. Epub 2021 May 21.

Pediatric Pulmonology Unit, 3rd Department of Pediatrics, Hippokration Hospital of Thessaloniki, Thessaloniki, Greece.

As the COVID-19 pandemic is still evolving, guidelines on pulmonary function testing that may dynamically adapt to sudden epidemiologic changes are required. This paper presents the recommendations of the Hellenic Pediatric Respiratory Society (HPRS) on pulmonary function testing in children and adolescents during the COVID-19 era. Following an extensive review of the relevant literature, we recommend that pulmonary function tests should be carried out after careful evaluation of the epidemiologic load, structured clinical screening of all candidates, and application of special protective measures to minimize the risk of viral cross infection. These principles have been integrated into a dynamic action plan that may readily adapt to the phase of the pandemic.
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http://dx.doi.org/10.3389/fped.2021.673322DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8175853PMC
May 2021

Lung Function Variability in Children and Adolescents With and Without Asthma (LUV Study): Protocol for a Prospective, Nonrandomized, Clinical Trial.

JMIR Res Protoc 2020 Aug 7;9(8):e20350. Epub 2020 Aug 7.

Pediatric Respiratory Unit, University Hospital of Patras, Patras, Greece.

Background: Variability analysis of peak expiratory flow (PEF) and forced expiratory volume at 1 second (FEV1) has been used in research to predict exacerbations in adults with asthma. However, there is a paucity of data regarding PEF and FEV1 variability in healthy children and adolescents and those with asthma.

Objective: The objective of this study is the assessment of PEF and FEV1 variability in (1) healthy children and adolescents, to define the normal daily fluctuation of PEF and FEV1 and the parameters that may influence it, and (2) children and adolescents with asthma, to explore the differences from healthy subjects and reveal any specific variability changes prior to exacerbation.

Methods: The study will include 100 healthy children and adolescents aged 6-18 years (assessment of normal PEF and FEV1 variability) and 100 children and adolescents of the same age with diagnosed asthma (assessment of PEF and FEV1 variability in subjects with asthma). PEF and FEV1 measurements will be performed using an ultraportable spirometer (Spirobank Smart; MIR Medical International Research) capable of smartphone connection. Measurements will be performed twice a day between 7 AM and 9 AM and between 7 PM and 9 PM and will be dispatched via email to a central database for a period of 3 months. PEF and FEV1 variability will be assessed by detrended fluctuation and sample entropy analysis, aiming to define the normal pattern (healthy controls) and to detect and quantify any deviations among individuals with asthma. The anticipated duration of the study is 24 months.

Results: The study is funded by the "C. Caratheodory" Programme of the University of Patras, Greece (PN 47014/24.9.2018). It was approved by the Ethics Committee (decision 218/19-03-2019) and the Scientific Board (decision 329/02-04-2019) of the University Hospital of Patras, Greece. Patient recruitment started in January 2020, and as of June 2020, 100 healthy children have been enrolled (74 of them have completed the measurements). The anticipated duration of the study is 24 months. The first part of the study (assessment of lung function variability in healthy children and adolescents) will be completed in August 2020, and the results will be available for publication by October 2020.

Conclusions: Healthy children and adolescents may present normal short- and long-term fluctuations in lung function; the pattern of this variability may be influenced by age, sex, and environmental conditions. Significant lung function variability may also be present in children and adolescents with asthma, but the patterns may differ from those observed in healthy children and adolescents. Such data would improve our understanding regarding the chronobiology of asthma and permit the development of integrated tools for assessing the level of control and risk of future exacerbations.

Trial Registration: ClinicalTrials.gov NCT04163146; https://clinicaltrials.gov/ct2/show/NCT04163146.

International Registered Report Identifier (irrid): DERR1-10.2196/20350.
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http://dx.doi.org/10.2196/20350DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442949PMC
August 2020

emm Types and clusters and macrolide resistance of pediatric group A streptococcal isolates in Central Greece during 2011-2017.

PLoS One 2020 7;15(5):e0232777. Epub 2020 May 7.

Department of Microbiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, Larissa, Greece.

Background: The surveillance of emm types and macrolide susceptibility of group A streptococcus (GAS) in various areas and time periods enhances the understanding of the epidemiology of GAS infections and may guide treatment strategies and the formulation of type-specific vaccines. Greece has emerged as a country with high macrolide use. However, studies suggest a gradual reduction in macrolide consumption after 2007.

Methods: During a 7-year period (2011-2017), 604 GAS isolates were recovered from consecutive children presenting with pharyngeal or nonpharyngeal infections in Central Greece; 517 viable isolates underwent molecular analysis, including emm typing.

Results: Isolates belonged to 20 different emm types (in decreasing order of prevalence: 1, 89, 4, 12, 28, 3, 75 and 6, accounting for 88.2% of total isolates). The emm types comprised 10 emm clusters (five most common clusters: E4, A-C3, E1, A-C4 and A-C5). The emm89 isolates were acapsular ('new clade'). Overall macrolide resistance rate was 15.4%, and cMLSB emerged as the predominant resistance phenotype (56.4%). The lowest annual resistance rates occurred in 2014 (13.1%), 2016 (5.5%) and 2017(8.0%) (P for trend = 0.002). Consumption of macrolide/lincosamide/streptogramin B declined by 22.6% during 2011-2017. Macrolide resistance and emm28 and emm77 types were associated (both P<0.001). The most frequently identified genetic lineages of macrolide-resistant GAS included emm28/ST52, emm77/ST63, emm12/ST36, emm89/ST101 and emm4/ST39. We estimated that 98.8% of the isolates belonged to emm types incorporated into a novel 30-valent M protein vaccine.

Conclusions: In Central Greece during 2011-2017, the acapsular emm89 isolates comprised the second most prevalent type. Susceptibility testing and molecular analyses revealed decreasing GAS macrolide resistance rates, which may be attributed to the reduction in the consumption of macrolides and/or the reduced circulation of macrolide-resistant clones in recent years. Such data may provide valuable baseline information in targeting therapeutic intervention and the formulation of type-specific GAS vaccines.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0232777PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7205280PMC
August 2020

Asthma: A Loss of Post-natal Homeostatic Control of Airways Smooth Muscle With Regression Toward a Pre-natal State.

Front Pediatr 2020 16;8:95. Epub 2020 Apr 16.

Division of Paediatrics & Child Health, Perth Children's Hospital, University of Western Australia, Perth, WA, Australia.

The defining feature of asthma is loss of normal post-natal homeostatic control of airways smooth muscle (ASM). This is the key feature that distinguishes asthma from all other forms of respiratory disease. Failure to focus on impaired ASM homeostasis largely explains our failure to find a cure and contributes to the widespread excessive morbidity associated with the condition despite the presence of effective therapies. The mechanisms responsible for destabilizing the normal tight control of ASM and hence airways caliber in post-natal life are unknown but it is clear that atopic inflammation is neither necessary nor sufficient. Loss of homeostasis results in excessive ASM contraction which, in those with , is manifest by variations in airflow resistance over periods of time. During viral , the ability to respond to bronchodilators is partially or almost completely lost, resulting in ASM being "locked down" in a contracted state. Corticosteroids appear to restore normal or near normal homeostasis in those with poor control and restore bronchodilator responsiveness during exacerbations. The mechanism of action of corticosteroids is unknown and the assumption that their action is solely due to "anti-inflammatory" effects needs to be challenged. ASM, in evolutionary terms, dates to the earliest land dwelling creatures that required muscle to empty primitive lungs. ASM appears very early in embryonic development and active peristalsis is essential for the formation of the lungs. However, in post-natal life its only role appears to be to maintain airways in a configuration that minimizes resistance to airflow and dead space. In health, significant constriction is actively prevented, presumably through classic negative feedback loops. Disruption of this robust homeostatic control can develop at any age and results in asthma. In order to develop a cure, we need to move from our current focus on immunology and inflammatory pathways to work that will lead to an understanding of the mechanisms that contribute to ASM stability in health and how this is disrupted to cause asthma. This requires a radical change in the focus of most of "asthma research."
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http://dx.doi.org/10.3389/fped.2020.00095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7176812PMC
April 2020

Nebulised hypertonic saline for acute bronchiolitis or 'there and back again' to use Tolkien's subtitle for The Hobbit.

Acta Paediatr 2016 09;105(9):1006-8

Respiratory Unit, Department of Paediatrics, University Hospital of Patras, School of Medicine of the University of Patras, Rion-Patras, Greece.

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http://dx.doi.org/10.1111/apa.13509DOI Listing
September 2016

The Forced Oscillation Technique in Paediatric Respiratory Practice.

Paediatr Respir Rev 2016 Mar 10;18:46-51. Epub 2015 Nov 10.

Paediatric Respiratory Unit, University Hospital of Patras, Patras, Greece. Electronic address:

The Forced Oscillation Technique (FOT) is a lung function modality based on the application of an external oscillatory signal in order to determine the mechanical response of the respiratory system. The method is in principal noninvasive and requires minimal patient cooperation, which makes it suitable for use in young paediatric patients. The FOT has been successfully applied in various paediatric respiratory disorders, such as asthma, cystic fibrosis, and chronic lung disease of prematurity, in order to assess airway obstruction, bronchodilator response, and airway responsiveness after bronchoprovocation challenge. This technique may be more sensitive than spirometry in identifying disturbances of peripheral airways and assessing the level of asthma control or the effectiveness of therapy at the long term. Further research is required to determine the exact role of the FOT in paediatric lung function testing and to incorporate the method in specific diagnostic and management algorithms.
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http://dx.doi.org/10.1016/j.prrv.2015.11.001DOI Listing
March 2016

Increased β-glucuronidase activity in bronchoalveolar lavage fluid of children with bacterial lung infection: A case-control study.

Respirology 2015 Nov 14;20(8):1248-54. Epub 2015 Jul 14.

Respiratory Unit, Department of Paediatrics, University General Hospital of Patras, Rion-Patras, Greece.

Background And Objective: β-Glucuronidase is a lysosomal enzyme released into the extracellular fluid during inflammation. Increased β-glucuronidase activity in the cerebrospinal and peritoneal fluid has been shown to be a useful marker of bacterial inflammation. We explored the role of β-glucuronidase in the detection of bacterial infection in bronchoalveolar lavage fluid (BALF) of paediatric patients.

Methods: In this case-control study, % polymorphonuclear cell count (PMN%), β-glucuronidase activity, interleukin-8 (IL-8), tumour necrosis factor-α (TNF-α) and elastase were measured in culture-positive (≥10(4) cfu/mL, C+) and -negative (C-) BALF samples obtained from children.

Results: A total of 92 BALF samples were analysed. The median β-glucuronidase activity (measured in nanomoles of 4-methylumbelliferone (4-MU)/mL BALF/h) was 246.4 in C+ (interquartile range: 71.2-751) and 21.9 in C- (4.0-40.8) (P < 0.001). The levels of TNF-α and IL-8 were increased in C+ as compared with C- (5.4 (1.7-12.6) vs 0.7 (0.2-6.2) pg/mL, P < 0.001 and 288 (76-4300) vs 287 (89-1566) pg/mL, P = 0.042, respectively). Elastase level and PMN% did not differ significantly (50 (21-149) vs 26 (15-59) ng/mL, P = 0.051 and 20 (9-40) vs 18 (9-34) %, P = 0.674, respectively). The area under the curve of β-glucuronidase activity (0.856, 95% confidence interval (CI): 0.767-0.920) was higher than that of TNF-α (0.718; 95% CI: 0.614-0.806; P = 0.040), IL-8 (0.623; 95% CI: 0.516-0.722; P = 0.001), elastase (0.645; 95% CI: 0.514-0.761; P = 0.008) and PMN% (0.526; 95 % CI: 0.418-0.632; P < 0.001).

Conclusions: This study demonstrates a significant increase of β-glucuronidase activity in BALF of children with culture-positive bacterial inflammation. In our population β-glucuronidase activity showed superior predictive ability for bacterial lung infection than other markers of inflammation.
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http://dx.doi.org/10.1111/resp.12596DOI Listing
November 2015

Investigating the associations between Mediterranean diet, physical activity and living environment with childhood asthma using path analysis.

Endocr Metab Immune Disord Drug Targets 2014 ;14(3):226-33

Dept Nutrition and Dietetics, Harokopio University, Athens, Greece, 46 Paleon Polemiston St., 16674 Glyfada, Greece.

Objective: To investigate the role of the Mediterranean diet and physical activity with relation to living environment and childhood asthma.

Methods: 1125 children (529 boys), 10 to 12 years old were recruited either in an urban environment (Athens, n = 700) or rural environment (n = 425) in Greece. A path analytic model was developed to assess the causal relation between urban environment and asthma prevalence (standardized ISAAC questionnaire), through the mediation of the Mediterranean diet (evaluated by the KIDMED food frequency questionnaire) and physical activity (evaluated by the PALQ physical activity questionnaire).

Results: The proposed model had a very good fit (χ2/df ratio =1.05, RMSEA=0.007, 90% confidence interval: 0.01 to 0.046, p=0.97, CFI = 0.98). A significant total positive effect was found between urban environment and asthma symptoms (standardized beta= 0.09, p<0.001). Adherence to the Mediterranean diet was related negatively with asthma symptoms (standardized beta = -0.224, p<0.001). An inverse mediating effect of the Mediterranean diet was observed for the urban environment - asthma relation (standardized beta=-0.029, p<0.001) while physical activity had no significant contribution (p=0.62), adjusted for several confounders.

Conclusions: The Mediterranean diet may protect against the harmful effect of urban environment on childhood asthma.
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http://dx.doi.org/10.2174/1871530314666140826102514DOI Listing
August 2015

'They said it was bronchiolitis; is it going to turn into asthma doctor?'.

Respirology 2014 Nov 19;19(8):1158-64. Epub 2014 Aug 19.

1st Paediatric Department, Aristotle University of Thessaloniki, Hippokrateion General Hospital, Thessaloniki, Greece.

Acute bronchiolitis is a common paediatric disease of infancy. Its association with subsequent asthma development has puzzled clinicians and epidemiologists for decades. This article reviews the current state of knowledge regarding the role of acute bronchiolitis in the inception of asthma. There is little doubt that acute bronchiolitis is associated with an increased risk of recurrent wheezing throughout the primary school years although the direction of causality--i.e. whether bronchiolitis in infancy leads to asthma or it merely represents the first clinical presentation of predisposition to asthma--is uncertain. Existing evidence suggests that both host factors (e.g. prematurity, atopic predisposition) and acute viral infection characteristics (e.g. type of virus, severity) are operating in this relationship, perhaps with variable involvement in different individuals. Further clarification of these issues will help paediatricians provide evidence-based information regarding the long-term prognosis of this common disease to the families, and at the same time, it will facilitate prophylactic approaches and therapeutic strategies.
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http://dx.doi.org/10.1111/resp.12371DOI Listing
November 2014

RespDoc: a new clinical decision support system for childhood asthma management based on Fraction of Exhaled Nitric Oxide (FeNO) measurements.

Annu Int Conf IEEE Eng Med Biol Soc 2013 ;2013:1306-9

The use of Fraction of Exhaled Nitric Oxide (FeNO) for measurement of inflammation in the respiratory system is a good way to assess the level of asthma in children. In this paper we present a new Clinical Decision Support System (CDSS) for Childhood Asthma Management based on FeNO, which is named RespDoc. The core of RespDoc is a decision making algorithm and a patient's monitoring process that are extensively analyzed in the paper. The performance of RespDoc is tested through the process and assessment of archived patients' data.
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http://dx.doi.org/10.1109/EMBC.2013.6609748DOI Listing
August 2015

The mediating effect of parents' educational status on the association between adherence to the Mediterranean diet and childhood obesity: the PANACEA study.

Int J Public Health 2013 Jun 6;58(3):401-8. Epub 2012 Nov 6.

Department of Nutrition and Dietetics, Harokopio University, 70 Eleftheriou Venizelou Str., PC 17671, Athens, Greece.

Objectives: To investigate the potential mediating effect of parental education on the association between adherence to the Mediterranean diet and obesity, in 10-12 years old children.

Methods: A cross-sectional survey was performed among 1,125 (529 male) children in Greece. Children and their parents completed standardized questionnaires, which evaluated parents' educational level and dietary habits. Body mass index was calculated and children were classified as normal, overweight or obese (IOTF classification). Adherence to the Mediterranean diet was assessed using the KIDMED score.

Results: 27.7% of the children were overweight and 6.3% were obese; 12.3% of children reported high adherence to the Mediterranean diet. Multi-adjusted analysis, stratified by parental education, revealed that adherence to the Mediterranean diet was inversely associated with children's obesity status only in families in which at least one parent was of higher educational level (stratum-specific adjusted odds ratio: 0.41; 95% CI 0.17-0.98), but not those in which both parents were of low educational level.

Conclusions: Parental education status seems to play a mediating role in the beneficial effect of Mediterranean diet on children's obesity status.
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http://dx.doi.org/10.1007/s00038-012-0424-3DOI Listing
June 2013

Bacterial bronchitis caused by Streptococcus pneumoniae and nontypable Haemophilus influenzae in children: the impact of vaccination.

Chest 2013 Jan;143(1):152-157

Department of Respiratory Medicine, Sheffield Children's NHS Foundation Trust, Sheffield, England. Electronic address:

Background: Protracted bacterial bronchitis is a major cause of persistent cough in childhood. The organisms most commonly isolated are nontypable Haemophilus influenzae and Streptococcus pneumoniae . There are no studies addressing typing of these organisms when recovered from the lower airways.

Methods: Isolates of these two organisms (identified in BAL samples from children undergoing routine investigation of a chronic cough thought to be attributable to a protracted bacterial bronchitis) were subject to typing. Samples were collected in Sheffield, England, and Athens, Greece. The majority of the children from Sheffield had received pneumococcal-conjugate vaccines 7 or 13 (PCV-7 or PCV-13) conjugate vaccine but only a minority of Greek children had received PCV-7.

Results: All 18 S pneumoniae isolates from Greek BAL samples are serotypes contained in PCV-13 while 10 are contained in PCV-7. In contrast, 28 of the 39 samples from Sheffield contained serotypes that are not included in PCV-13. All 26 of the nontypable H influenzae samples obtained in Sheffield produced distinct multilocus variable-number tandem repeat analysis profiles. There was a significant difference between children from Athens and Sheffield in the distribution of serotypes contained or not contained in the pneumococcal vaccine ( P = .04). More specifically, immunization with pneumococcal vaccine was related with isolation of S pneumoniae serotypes not included in the vaccine (OR, 0.021; CI, 0.003-0.115; P < .001).

Conclusions: The data suggest that both vaccine and nonvaccine S pneumoniae serotypes may play a role in protracted bacterial bronchitis and provide some hints that serotype replacement may occur in response to the introduction of conjugate vaccines.
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http://dx.doi.org/10.1378/chest.12-0623DOI Listing
January 2013

Physical activity and exercise-induced bronchoconstriction in Greek schoolchildren.

Pediatr Pulmonol 2012 Nov 18;47(11):1080-7. Epub 2012 Jul 18.

Department of Paediatrics, School of Medicine, University of Patras, Rion, Patras, Greece.

Objective: To investigate the association between physical activity and exercise-induced bronchoconstriction (EIB) in an urban population sample of schoolchildren, taking into account potential confounders such as asthma symptoms and overweight.

Methods: Children aged 10-12 years answered validated questionnaires on physical activity (Physical Activity and Lifestyle Questionnaire) and asthma symptoms (ISAAC questionnaire), and were categorized according to their body mass index (BMI). EIB (FEV(1) decrease from baseline ≥13%) was assessed by a standardized free running Exercise Challenge Test (ECT).

Results: Six hundred seven children completed the ECT. There were no differences among asthma groups (diagnosed asthma, asthma-related symptoms not diagnosed as asthma, no asthma-related symptoms) regarding total daily energy expenditure and time spent in mild (1.1-2.9 metabolic equivalents-METs), moderate (3-6 METs), and vigorous (>6 METs) activities. Only overweight/obese EIB-positive children had shorter duration of vigorous activity as compared to their EIB-negative or non-overweight/obese EIB-positive peers. Total daily energy expenditure and duration of mild- and moderate-intensity activity were negatively associated with EIB independently of BMI status or asthma-related symptoms.

Conclusions: Decreased levels of physical activity are associated with EIB irrespectively of BMI status and asthma-related symptoms. Longitudinal studies are needed to confirm the negative impact of sedentary lifestyle on the development of EIB suggested by these findings.
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http://dx.doi.org/10.1002/ppul.22620DOI Listing
November 2012

The association between leisure-time physical activities and asthma symptoms among 10- to 12-year-old children: the effect of living environment in the PANACEA study.

J Asthma 2012 May 2;49(4):342-8. Epub 2012 Feb 2.

Department of Nutrition and Dietetics, Harokopio University, Athens, Greece.

Objective: This study evaluated the interrelationships of living environment, physical activity, lifestyle/dietary habits, and nutritional status on the prevalence of childhood asthma.

Methods: In a cross-sectional survey 1125 children (529 boys), 10 to 12 years old, were selected from 18 schools located in an urban environment (Athens, n = 700) and from 10 schools located in rural areas (n = 425) in Greece.

Results: Children living in Athens had higher likelihood of "ever had" asthma compared with children living in rural areas (odds ratio (OR) = 1.78, 95% confidence interval (CI) = 1.25-2.54), after adjusting for age and sex. After adjusting for age, sex, body mass index, and adherence to the Mediterranean diet (KIDMED score), leisure-time physical activity was inversely associated with "ever had" asthma. When stratifying by county of residence, a trend toward reduced asthma symptoms among children engaged in outdoor physical activities during their leisure time who reside in rural (but not urban) environment was observed (OR = 0.88, 95% CI = 0.77-1.01).

Conclusions: The inverse relationship between asthma symptoms and leisure-time physical activity in the rural environment and the lack of an association between asthma symptoms and organized sports-related activities should draw the attention of public healthcare authorities. Their efforts should focus on the planning of a sustainable natural environment, which will promote the physical health of children and reduce the burden of childhood asthma.
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http://dx.doi.org/10.3109/02770903.2011.652328DOI Listing
May 2012

Prevalence trends of rhinoconjunctivitis, eczema, and atopic asthma in Greek schoolchildren: four surveys during 1991-2008.

Allergy Asthma Proc 2011 Nov-Dec;32(6):56-62

Respiratory Unit, Department of Pediatrics, University Hospital of Patras, Rio-Patras, Greece.

After a continuous increase of asthma, hay fever, and eczema during 1991-2003 among schoolchildren in Patras, Greece, the prevalence of current wheeze/asthma (diagnosed wheezing and/or asthma in the past 2 years) has reached a plateau (6.9%) during the period 2004-2008. Using methodology identical to the three previously conducted cross-sectional, parental questionnaire surveys (1991, n = 2417; 1998, n = 3076; 2003, n = 2725) we examined further trends in the prevalence of rhinoconjunctivitis and eczema in the same urban environment among third and fourth grade schoolchildren (8-9 years old) in 2008 (n = 2688). In the four surveys, respective prevalence rates of rhinoconjunctivitis were 2.1, 3.4, 4.6, and 5.1% (absolute prevalence increase: 1998 versus 1991, 61.9%; 2003 versus 1998, 35.5%; 2008 versus 2003, 10.9%) and those of eczema were 4.5, 6.3, 9.5, and 10.8% (absolute prevalence increase: 1998 versus 1991, 40.0%; 2003 versus 1998, 50.8%; 2008 versus 2003, 13.7%; sex-adjusted p for trend, <0.001). Among current wheezer/asthmatic patients there was an increase in lifetime rhinoconjunctivitis (sex-adjusted p for trend, <0.001) and lifetime eczema (sex-adjusted p for tend, <0.001) over the period 1991-2008. The proportion of atopic wheeze/asthma (current asthma with lifetime rhinoconjunctivitis and/or eczema) increased further during 2003-2008 (p < 0.05; p for trend during 1991-2008, <0.001). In conclusion, there is a continuous increase in the prevalence of allergic manifestations-rhinoconjunctivitis and eczema-among preadolescent children in Patras, Greece, during the period 1991-2008. After a steep rise during 1991-2003, the frequency of atopic wheeze/asthma continued to increase at a decelerating rate during 2003-2008, while wheeze/asthma prevalence remained unchanged during the same 5-year period.
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http://dx.doi.org/10.2500/aap.2011.32.3504DOI Listing
May 2012

Urban environment adherence to the Mediterranean diet and prevalence of asthma symptoms among 10- to 12-year-old children: The Physical Activity, Nutrition, and Allergies in Children Examined in Athens study.

Allergy Asthma Proc 2011 Sep-Oct;32(5):351-8

Department of Nutrition and Dietetics, Harokopio University, Athens, Greece.

Epidemiological studies have revealed several associations between asthma symptoms and environmental and dietary factors, but the potential environment- diet interactions on asthma incidence have rarely been investigated. The aim of this work was to evaluate the interrelationships between urban/rural environment, adherence to a healthy dietary pattern, the Mediterranean diet, and childhood asthma. A cross-sectional survey was performed and 1125 (529 boys), 10- to 12-year-old children were selected from 18 schools located in urban Athens area (n = 700) and from 10 schools located in rural areas of Ilia and Viotia (n = 425), Greece. Children and their parents completed standardized questionnaires, which evaluated, among others, environmental factors and dietary habits. Asthma was defined according to Phase II of the International Study on Allergies and Asthma in Childhood criteria. Adherence to the Mediterranean diet was assessed using the Mediterranean and Diet Quality Index for children and adolescents (KIDMED) score. Living in urban areas was associated with higher odds of ever had asthma symptoms by 1.78 times (95% confidence interval [CI], 1.25-2.54) when compared with rural areas. In contrast, 1-unit increase in the KIDMED score was associated with 16% lower likelihood of having asthma symptoms (95% CI, 0.77-0.91), after adjusting for various confounders. When stratifying the analysis by area of living it was observed that adherence to the Mediterranean diet was associated with lower likelihood of asthma in both urban and rural areas (urban, odds ratio [OR] = 0.81, 95% CI, 0.73-0.91; rural, OR = 0.87, 95% CI, 0.75-1.00). Urban environment seems to increase the likelihood of childhood asthma, whereas adherence to the healthy Mediterranean dietary pattern could mediate the aforementioned association and confers significant protection.
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http://dx.doi.org/10.2500/aap.2011.32.3463DOI Listing
April 2012

Pulse oximetry in pediatric practice.

Pediatrics 2011 Oct 19;128(4):740-52. Epub 2011 Sep 19.

Respiratory Unit, Department of Pediatrics, University Hospital of Patras, Rio, 265 04 Patras, Greece.

The introduction of pulse oximetry in clinical practice has allowed for simple, noninvasive, and reasonably accurate estimation of arterial oxygen saturation. Pulse oximetry is routinely used in the emergency department, the pediatric ward, and in pediatric intensive and perioperative care. However, clinically relevant principles and inherent limitations of the method are not always well understood by health care professionals caring for children. The calculation of the percentage of arterial oxyhemoglobin is based on the distinct characteristics of light absorption in the red and infrared spectra by oxygenated versus deoxygenated hemoglobin and takes advantage of the variation in light absorption caused by the pulsatility of arterial blood. Computation of oxygen saturation is achieved with the use of calibration algorithms. Safe use of pulse oximetry requires knowledge of its limitations, which include motion artifacts, poor perfusion at the site of measurement, irregular rhythms, ambient light or electromagnetic interference, skin pigmentation, nail polish, calibration assumptions, probe positioning, time lag in detecting hypoxic events, venous pulsation, intravenous dyes, and presence of abnormal hemoglobin molecules. In this review we describe the physiologic principles and limitations of pulse oximetry, discuss normal values, and highlight its importance in common pediatric diseases, in which the principle mechanism of hypoxemia is ventilation/perfusion mismatch (eg, asthma exacerbation, acute bronchiolitis, pneumonia) versus hypoventilation (eg, laryngotracheitis, vocal cord dysfunction, foreign-body aspiration in the larynx or trachea). Additional technologic advancements in pulse oximetry and its incorporation into evidence-based clinical algorithms will improve the efficiency of the method in daily pediatric practice.
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http://dx.doi.org/10.1542/peds.2011-0271DOI Listing
October 2011

Seven-days-ahead forecasting of childhood asthma admissions using artificial neural networks in Athens, Greece.

Int J Environ Health Res 2012 19;22(2):93-104. Epub 2011 Aug 19.

Department of Mechanical Engineering, Technological Education Institute of Piraeus, Athens, Greece.

Artificial Neural Network (ANN) models were developed and applied in order to predict the total weekly number of Childhood Asthma Admission (CAA) at the greater Athens area (GAA) in Greece. Hourly meteorological data from the National Observatory of Athens and ambient air pollution data from seven different areas within the GAA for the period 2001-2004 were used. Asthma admissions for the same period were obtained from hospital registries of the three main Children's Hospitals of Athens. Three different ANN models were developed and trained in order to forecast the CAA for the subgroups of 0-4, 5-14-year olds, and for the whole study population. The results of this work have shown that ANNs could give an adequate forecast of the total weekly number of CAA in relation to the bioclimatic and air pollution conditions. The forecasted numbers are in very good agreement with the observed real total weekly numbers of CAA.
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http://dx.doi.org/10.1080/09603123.2011.605876DOI Listing
July 2012

Adherence to the Mediterranean type of diet is associated with lower prevalence of asthma symptoms, among 10-12 years old children: the PANACEA study.

Pediatr Allergy Immunol 2011 May;22(3):283-9

Unit of Human Nutrition, Department of Food Science and Technology, Agricultural University of Athens, Athens, Greece.

Epidemiological studies have shown several associations between asthma symptoms and dietary factors. The aim of this work was to evaluate the relationship between adherence to the Mediterranean diet and childhood asthma. A cross-sectional analysis was performed on 700 children (323 boys), 10-12 yr old, selected from 18 schools located in Athens greater area. Children and their parents completed questionnaires, which evaluated, among others, dietary habits. Asthma was defined according to ISAAC II criteria. Adherence to the Mediterranean diet was evaluated using the KIDMED score (theoretical range 0-12). Higher KIDMED score corresponds to greater adherence to the Mediterranean diet. Greater adherence to the Mediterranean diet was inversely associated with ever had wheeze (p = 0.001), exercise wheeze (p = 0.004), ever had diagnosed asthma (p = 0.002) and with any asthma symptoms (p < 0.001). One-unit increase in the KIDMED score was associated with 14% lower likelihood of having asthma symptoms (odds ratio = 0.86, 95% confidence interval 0.75-0.98), after adjusting for various confounders. No significant associations were found between asthma symptoms and consumption of fruits (p = 0.25), vegetables (p = 0.97), legumes (p = 0.76), cereals (p = 0.71), dairy (p = 0.61), salty snacks (p = 0.53), or margarine/butter (p = 0.42) consumption, while increased fish and meat intake was associated with less asthma symptoms (p = 0.04 and p = 0.01, respectively). Our findings suggest an inverse relationship between level of adherence to the Mediterranean diet and prevalence of asthma in school-aged children.
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http://dx.doi.org/10.1111/j.1399-3038.2010.01113.xDOI Listing
May 2011

Bronchoscopic and high-resolution CT scan findings in children with chronic wet cough.

Chest 2011 Aug 17;140(2):317-323. Epub 2011 Mar 17.

Department of Allergy-Pneumonology, Penteli Children's Hospital, P. Penteli, Greece.

Background: Chronic wet cough strongly suggests endobronchial infection, which, if left untreated, may progress to established bronchiectasis. Our aim was to compare the effectiveness of chest high-resolution CT (HRCT) scanning and flexible bronchoscopy (FB) in detecting airway abnormalities in children with chronic wet cough and to explore the association between radiologic and bronchoscopic/BAL findings.

Methods: We retrospectively evaluated a selected population of 93 children (0.6-16.4 years) with wet cough for > 6 weeks who were referred to a specialized center and deemed unlikely to have asthma. All patients were submitted to hematologic investigations, chest radiographs (CXRs), HRCT scanning, and FB/BAL. HRCT scans were scored with the Bhalla method, and bronchoscopic findings of bronchitis were grouped into five grades of severity.

Results: Positive HRCT scan findings were present in 70 (75.2%) patients (P = .76). A positive correlation was found between Bhalla score and duration of cough (ρ = 0.23, P = .028). FB/BAL was superior to HRCT scan in detecting abnormalities (P < .001). The Bhalla score correlated positively with type III (OR, 5.44; 95% CI, 1.92-15.40; P = .001) and type IV (OR, 8.91; 95% CI, 2.53-15.42; P = .001) bronchoscopic lesions; it also correlated positively with the percentage of neutrophils in the BAL (ρ = 0.23, P = .036).

Conclusions: HRCT scanning detected airway wall thickening and bronchiectasis, and the severity of the findings correlated positively with the length of clinical symptoms and the intensity of neutrophilic inflammation in the airways. However, HRCT scanning was less sensitive than FB/BAL in detecting airway abnormalities. The two modalities should be considered complementary in the evaluation of prolonged wet cough.
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http://dx.doi.org/10.1378/chest.10-3050DOI Listing
August 2011

Sex-specific trends in prevalence of childhood asthma over 30 years in Patras, Greece.

Acta Paediatr 2011 Jul 29;100(7):1000-5. Epub 2011 Mar 29.

Respiratory Unit, Department of Paediatrics, University Hospital of Patras, School of Medicine of the University of Patras, Rion, Patras, Greece.

Aim:  According to four surveys conducted during 1978-2003, the prevalence of childhood asthma and wheezing has risen in the city of Patras, Greece, albeit at a decelerating rate. We examined sex-specific wheeze and asthma prevalence in the same urban environment in 2008.

Methods: A cross-sectional parental questionnaire survey was performed in 2008 among third and fourth grade schoolchildren (8-9 year old), which was identical to previously conducted surveys in 1978 (n = 3003), 1991 (n = 2417), 1998 (n = 3076) and 2003 (n = 2725).

Results: The prevalence of current wheeze and asthma in 1978, 1991, 1998, 2003 and 2008 (n = 2688) was 1.5%, 4.6%, 6.0%, 6.9% and 6.9%, respectively (p for trend <0.001). Respective values for lifetime (ever had) wheeze and asthma in the 1991-2008 surveys were 8.0%, 9.6%, 12.4% and 12.6% (p for trend <0.001). The male:female ratio of current and lifetime wheeze and asthma increased during the 30-year surveillance period (p for trend <0.001). Irrespective of sex, diagnosed asthma declined among current wheezers by 17% (p < 0.001), but not among non-current ones (6.7%, p = 0.16) during 2003-2008.

Conclusions: Childhood wheeze and asthma have reached a plateau in an urban environment in Greece, while the male:female ratio increased. Asthma diagnosis declined among schoolage but not preschool wheezers during 2003-2008.
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http://dx.doi.org/10.1111/j.1651-2227.2011.02255.xDOI Listing
July 2011

Salty-snack eating, television or video-game viewing, and asthma symptoms among 10- to 12-year-old children: the PANACEA study.

J Am Diet Assoc 2011 Feb;111(2):251-7

Unit of Human Nutrition, Department of Food Science and Technology, Agricultural University of Athens, Athens, Greece.

Background: Salty-snack consumption, as well as the amount of time children spend watching television or playing video games, have been implicated in the development of asthma; however, results are still conflicting.

Objective: The aim of this work was to evaluate the association of salty-snack eating and television/video-game viewing with childhood asthma symptoms.

Design: Cross-sectional study.

Settings: Seven hundred children (323 male), 10 to 12 years old, from 18 schools located in the greater area of Athens were enrolled. Children and their parents completed questionnaires, which evaluated, among other things, dietary habits. Adherence to the Mediterranean diet was evaluated using the KIDMED (Mediterranean Diet Quality Index for Children and Adolescents) score.

Statistical Analysis: The association of children's characteristics with asthma symptoms was performed by calculating the odds ratios and corresponding 95% confidence intervals.

Results: Overall lifetime prevalence of asthma symptoms was 23.7% (27.6% boys, 20.4% girls; P=0.03). Forty-eight percent of children reported salty-snack consumption (≥ 1 times/week). Salty-snack consumption was positively associated with the hours of television/video-game viewing (P=0.04) and inversely with the KIDMED score (P=0.02). Consumption of salty snacks (>3 times/week vs never/rare) was associated with a 4.8-times higher likelihood of having asthma symptoms (95% confidence interval: 1.50 to 15.8), irrespective of potential confounders. The associations of salty-snack eating and asthma symptoms were more prominent in children who watched television or played video games >2 hours/day. In addition, adherence to the Mediterranean diet was inversely associated with the likelihood of asthma symptoms.

Conclusions: Unhealthy lifestyle behaviors, such as salty-snack eating and television/video-game viewing were strongly associated with the presence of asthma symptoms. Future interventions and public health messages should be focused on changing these behaviors from the early stages of life.
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http://dx.doi.org/10.1016/j.jada.2010.10.051DOI Listing
February 2011

Knowledge on pulse oximetry among pediatric health care professionals: a multicenter survey.

Pediatrics 2010 Sep 2;126(3):e657-62. Epub 2010 Aug 2.

University Hospital of Patras, Department of Pediatrics, Respiratory Unit, Rio, Patras, 265 04, Greece.

Objectives: The objective of this study was to assess the knowledge on pulse oximetry among health care professionals involved in pediatric care.

Methods: A multiple-choice questionnaire was distributed to 505 pediatric health care professionals from 19 hospitals and health centers throughout Greece. Exploratory factor analysis was performed to identify underlying factors that could explain most of the variance of the responses. The mean test and factor scores were calculated and compared between clinical settings.

Results: The mean test score was 61.9+/-18.1%. After factor analysis, 2 distinct groups of deficits in knowledge regarding pulse oximetry were identified: 1 was interpreted as relating to practical knowledge and the other to theoretical knowledge. The mean score of the items that assessed practical knowledge was 82.7+/-12.5% and of those that assessed theoretical knowledge was 44.2+/-21.7%. Pediatricians and family practitioners, participants from level 3 institutions, and health care professionals working in ICUs scored better, particularly on the items that assessed theoretical knowledge. Logistic regression analysis revealed that only participants from level 3 institutions and those from ICUs had a greater likelihood of achieving a higher score (total score odds ratio: level 3, 2.89, ICU, 8.13; theoretical knowledge odds ratio: level 3, 3.40, ICU, 10.95).

Conclusions: Pediatric health care professionals have marked deficiencies in their knowledge on pulse oximetry, particularly in regard to the principles underlying the method and its limitations. Strategies that are directed at improving knowledge on pulse oximetry are urgently needed at all levels of experience in pediatric care.
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http://dx.doi.org/10.1542/peds.2010-0849DOI Listing
September 2010

Outdoor particulate matter and childhood asthma admissions in Athens, Greece: a time-series study.

Environ Health 2010 Jul 28;9:45. Epub 2010 Jul 28.

Laboratory of Climatology and Atmospheric Environment, Department of Geology and Geoenvironment, University of Athens, Panepistimioupolis, 157 84 Athens, Greece.

Background: Particulate matter with diameter less than 10 micrometers (PM10) that originates from anthropogenic activities and natural sources may settle in the bronchi and cause adverse effects possibly via oxidative stress in susceptible individuals, such as asthmatic children. This study aimed to investigate the effect of outdoor PM10 concentrations on childhood asthma admissions (CAA) in Athens, Greece.

Methods: Daily counts of CAA from the three Children's Hospitals within the greater Athens' area were obtained from the hospital records during a four-year period (2001-2004, n = 3602 children). Mean daily PM10 concentrations recorded by the air pollution-monitoring network of the greater Athens area were also collected. The relationship between CAA and PM10 concentrations was investigated using the Generalized Linear Models with Poisson distribution and logistic analysis.

Results: There was a statistically significant (95% CL) relationship between CAA and mean daily PM10 concentrations on the day of exposure (+3.8% for 10 microg/m3 increase in PM10 concentrations), while a 1-day lag (+3.4% for 10 microg/m3 increase in PM10 concentrations) and a 4-day lag (+4.3% for 10 microg/m3 increase in PM10 concentrations) were observed for older asthmatic children (5-14 year-old). High mean daily PM10 concentration (the highest 10%; >65.69 microg/m3) doubled the risk of asthma exacerbations even in younger asthmatic children (0-4 year-old).

Conclusions: Our results provide evidence of the adverse effect of PM10 on the rates of paediatric asthma exacerbations and hospital admissions. A four-day lag effect between PM10 peak exposure and asthma admissions was also observed in the older age group.
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http://dx.doi.org/10.1186/1476-069X-9-45DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2920864PMC
July 2010

Endocrine-immune interactions in adrenal function of asthmatic children on inhaled corticosteroids.

Neuroimmunomodulation 2009 29;16(5):333-9. Epub 2009 Jun 29.

Department of Allergy-Pneumonology, Penteli Children's Hospital, Palea Penteli, Greece.

The present review highlights adrenal function in the context of endocrine-immune interactions and hypothalamic-pituitary-adrenal (HPA) axis activity in asthmatic children on long-term treatment with inhaled corticosteroids (ICS). Activation of the HPA axis by specific cytokines increases the release of cortisol, which in turn feeds back and suppresses the immune reaction. Reduced responsiveness of the HPA axis in patients with various chronic allergic inflammatory disorders and a blunted HPA axis response of poorly controlled asthmatics before long-term treatment with ICS have been reported. It appears that pro- and anti-inflammatory cytokines may be involved in the attenuation of cortisol and ACTH responses to stress in these patients. ICS as anti-inflammatory agents may have favorable effects in asthmatics with baseline subnormal adrenal responses, thus improving adrenal function during successful long-term treatment; on the other hand, few patients on conventional doses may experience further deterioration of adrenal function, a phenomenon that most likely is genetically determined. When ICS are administered at high doses, secondary adrenal insufficiency due to the excessive exogenous corticosteroid certainly may become manifest.
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http://dx.doi.org/10.1159/000216191DOI Listing
September 2009

Asthma symptoms and airway narrowing in children growing up in an urban versus rural environment.

J Asthma 2009 Apr;46(3):244-51

Department of Allergy-Pneumonology, Penteli Children's Hospital, P. Penteli, Athens, Greece.

The development of asthma and allergy appears to be the result of gene-environment interaction. Potential environmental risk factors such as outdoor and indoor air pollution, infections, allergen exposure, diet, and lifestyle patterns may trigger respiratory symptoms and compromise lung function in children. Specific features of urban and rural lifestyle may constitute distinct risk factors but may also coexist within certain socioeconomic levels. Children of rural environments are at lower risk for asthma and aeroallergen sensitization. The protective effect has been associated with close contact with large animals, but the genetic factor also plays a contributory role. Children with prolonged exposure to urban environment are at increased risk of reduced lung function and those that reside in polluted areas exhibit slower lung growth. It is possible that polluted urban environment per se facilitates subclinical small airway disease. Evidence to date supports a strong relation between residential area as a potential risk factor for childhood asthma symptoms and airway obstruction and a western type of socioeconomic development.
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http://dx.doi.org/10.1080/02770900802647516DOI Listing
April 2009

Birthweight, breast-feeding, parental weight and prevalence of obesity in schoolchildren aged 10-12 years, in Greece; the Physical Activity, Nutrition and Allergies in Children Examined in Athens (PANACEA) study.

Pediatr Int 2008 Aug;50(4):563-8

Department of Nutrition-Dietetics, Harokopio University, Greece.

Background: The purpose of the present study was to determine the prevalence of overweight and obesity in a sample of Greek children aged 10-12 years, and to evaluate these rates in relation to parental weight and birthweight.

Methods: During the 2005-2006 school period, 700 schoolchildren (323 boys, 377 girls) were randomly recruited from 18 schools, in Athens. Height and weight were measured and body mass index (BMI) was calculated. Cut-off points for BMI defining obesity and overweight for gender and age were calculated in accordance with international standards.

Results: Overall, 8.6% of boys and 9.0% of girls were obese, and 33.9% of boys and 22.1% of girls were overweight. Having an obese parent increased the odds of having an overweight or obese child (P < 0.01). Compared to non-breast-fed, boys who were breast-fed for >3 months had 70% lower likelihood of being overweight or obese (P < 0.01) and breast-fed girls had 80% lower odds (P < 0.01). Excessive birthweight (>3500 g) increased by 2.5-fold the likelihood of being overweight or obese only in girls (P < 0.05).

Conclusions: Parental weight, lack of breast-feeding and excess birthweight (in girls) were significant predictors of overweight or obesity in Greek children aged 10-12 years.
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http://dx.doi.org/10.1111/j.1442-200X.2008.02612.xDOI Listing
August 2008
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