Two-Month Consumption of Orange Juice Enriched with Vitamin D3 and Probiotics Decreases Body Weight, Insulin Resistance, Blood Lipids, and Arterial Blood Pressure in High-Cardiometabolic-Risk Patients on a Westernized Type Diet: Results from a Randomized Clinical Trial.

This study examined the effects of orange juice (OJ) supplemented with vitamin D3 (2000 IU) and probiotics (Lacticaseibacillus casei Shirota and Lacticaseibacillus rhamnosus GG, 108 cfu/mL) on cardiometabolic risk factors in overweight and obese adults following a Westernized-type diet. Fifty-three high-risk individuals were randomly assigned to one of two groups. Over 8 weeks, one group consumed a vitamin D3 and probiotic-enriched OJ and the other regular OJ (control). Diets remained unchanged and were documented through food diaries. Measures of metabolic and inflammatory markers and blood pressure were measured at the start and end of the study. Post-intervention, the enriched OJ group showed the following significant metabolic improvements (without changes in triglycerides, inflammation, or central blood pressure): reduced fasting insulin, peripheral blood pressure, body weight (-1.4 kg 95% CI: -2.4, -0.4), energy (-270 kcal 95% CI: -553.2, -13.7), macronutrient (dietary fat -238 kcal 95% CI: -11.9, -1.0; carbohydrates -155 kcal 95% CI: -282.4, -27.3; sugars -16.1 g 95% CI: -11.9, -1.0) intake, and better lipid profiles (total cholesterol -10.3 mg/dL 95% CI: -21.4, 0.9; LDL-C -7 mg/dL 95% CI: -13.5, -0.5). The enriched OJ led to weight loss, less energy/macronutrient consumption, improved lipid profiles, and increased insulin sensitivity after 8 weeks in those following a Westernized diet, thus indicating potential benefits for cardiometabolic risk. This study was a part of FunJuice-T2EDK-01922, which was funded by the EU Regional Development Fund and Greek National Resources.

Relaxation Techniques in Low Back Pain Patients: A Randomized Controlled Trial.

Low back pain (LBP) is a common problem, affecting 11% of the population in Greece. Pain can last upwards of 6 wk and impact functional ability and quality of life. Treating LBP often includes the use of alternative methods, such as relaxation techniques. We tested whether relaxation techniques could reduce stress and pain and improve quality of life. Patients engaged in methods such as diaphragmatic breathing, progressive muscular relaxation, autogenic training, and guided imagery. The treatment group consisted of 31 randomized patients and the control group had 33. The treatment group followed an 8-wk relaxation program with weekly sessions and practiced techniques every day by listening to a compact disk at home (2×/d). The control group did not follow relaxation techniques. No statistically significant differences were present regarding the Perceived Stress Scale, body-mass index, and satisfaction with functional ability. However, statistically significant differences were found in the Brief Pain Inventory score and multidimensional locus of control. We also found decreases in all three cortisol measurements for the treatment group. Relaxation techniques provide positive results in pain reduction and cortisol decrease and must therefore be incorporated into rehabilitation protocols.

An 8-week Stress Management Program in Information Technology Professionals and the Role of a New Cognitive Behavioral Method: a Pilot Randomized Controlled Trial.

AIM: The aim of this study is to compare and evaluate the sort-term benefits of the effects of an 8-week stress management techniques in information technology professionals. METHODS: In this parallel randomized controlled trial, participants were randomly assigned to either the stress management group (n=40; relaxation breathing, progressive muscle relaxation, guided imagery) or in the Pythagorean Self awareness group (n=41). Self-reported validated measures were used to evaluate perceived stress, health locus of control, anxiety and depression. RESULTS: All groups were found with significantly better cognitive speed and verbal memory at the end of the follow-up. Taking into account the group by time interaction coefficients, PSAT was found significantly superior to standard SM with regards to depression, emotional intelligence, lifestyle and personal control and verbal memory suggesting that verbal memory improvement through time should be mostly attributed to PSAT. On the other hand, the cognitive speed improvement during follow-up should be attributed to both interventions. CONCLUSIONS: These findings provide important insight into the role of stress management. Future studies should focus on randomized, controlled trials with larger samples and longer follow-up times.

Suicide Mortality Patterns in Greek Work Force before and during the Economic Crisis.

Background: The global recession of 2007 has attracted research attention in regard to a possible increase of deaths by suicide among employed populations. The aim of the current study was to update the first Greek study on suicide mortality among broad occupational groups during 2000⁻2009, with the last available data covering the first period of economic crisis and recession in Greece. Methods: Data on suicide deaths for the age groups of 15⁻39, 40⁻49 and 50⁻59, between 2000⁻2013 were retrieved from the national statististical authority of Greece, ELSTAT. The coding of suicide used was X60⁻X84 (intentional self-harm), based on the 10th International Classification of Diseases (ICD-10). Comparative mortality ratio (CMR) and exact 95% confidence intervals (CI) are presented. Results: Males and females in the occupational group of clerks exhibited high and increased CMRs during the crisis period (2010⁻2013). Although high ratios for males in elementary, agricultural and fishery and armed forces occupational groups were monitored during the whole period, a decrease was evident during the crisis period. Increased trends in CMRs during the crisis were monitored for both males and females in the broad occupational group of members including managers, executives and directors. In addition, females especially in the 50⁻59 age group showed increased ratios and trends in several occupational groups during the crisis, especially in technologists and associate professionals, plant and machine operators and assemblers, professionals, and craft and related trade workers. Conclusions: Austerity-related stress should alert key stakeholders and provide mental health and suicide prevention interventions for employed occupations.

Adherence to Treatment in Stroke Patients.

Background: Compliance with medication in patients who have suffered stroke is usually not-optimal. This study aims to measure the level of compliance with the treatment and to identify socio-demographic, clinical, and subjective factors related to the long-term compliance of stroke patients with their treatment. Methods: 140 patients (66.4% males) suffered an ischemic stroke at least six months old, participated in the survey. Compliance was measured using the Medication Adherence Report Scale and the quality of life by the Stroke Specific Quality of Life questionnaire. Furthermore, the Beliefs about Medicines Questionnaire and the Brief Illness Perception Questionnaire on perceptions about the disease were assessed. The doctor⁻patient relationship was assessed by the Common-Sense Model of Self-Regulation questionnaire and the family support was assessed by the FSS scale. Univariate and multivariate analysis was employed to identify the significant factors affecting compliance in these stroke patients. Results: In 68.6% of patients the compliance was classified as optimal, in 25.7% as partial and as poor in 5.7%; the last two categories were treated as sub-optimal compliance in multivariate analysis. The high compliance was related to patient's mental state (OR:3.94 95% CI: 1.84⁻4.46), the perception medication necessity (OR:1.26 95% CI: 1.01⁻1.56), and the doctor⁻patient communication (OR:1.76 95% CI: 1.15⁻2.70). Men showed a lower compliance than women, as well as increased concerns about taking medication (OR: 0.83, 95% CI: 0.69⁻0.99). Paradoxically, the work /productivity related quality of life was inversely associated with compliance (OR (95% CI): 0.44 (0.23 to 0.82)). Conclusions: The perception of medication necessity and the doctor⁻patient communication are manageable factors associated with compliance in treating patients who have suffered stroke. In addition, rehabilitation and return to work programs should consider these factors when providing support to those persons.

Screening Olive Leaves from Unexploited Traditional Greek Cultivars for Their Phenolic Antioxidant Dynamic.

Quality characteristics of olive products significantly depend on cultivar (cv), among other factors. In this study, seven traditional, noncommercial Greek cultivars, along with the commercial Spanish Arbequina cv., were examined for the phenolic antioxidant dynamic of their leaves. Polar extracts (aqueous, methanol, and ethanol) were analyzed for Total Phenol (TP), Flavonoid (TFL), Hydroxycinnamic Acid Derivatives (THAD), Flavonol (TFLVN) contents, DPPH radical scavenging ability, and Ferric Reducing Capacity (FRAP). Selective characteristics of olive leaf methanol extracts for all cultivars were re-examined on a second sampling period. Olive leaf is considered a rich source of phenolic antioxidants total phenol content reaching 29.3 ± 1.3, 30.6 ± 0.4, and 27.0 ± 1.1 mg caffeic acid/g dry leaf for aqueous, methanol, and ethanol extracts, respectively) and all cultivars were considered of equal bioactive dynamic. TP data derived from Folin⁻Ciocalteu and another spectrophotometric assay employed presented a high correlation for all examined cases (R² = 71.5⁻86.9%). High correlation (R² = 0.92) was also found between TP and FRAP findings of aqueous extracts. Olive leaf is considered a promising source of phenolic antioxidants irrelevant to cultivar and therefore even cultivars less effective for oil or table olive production could be efficiently exploited for the bioactive dynamic of their leaves.

Response to letter to the editor from Dr Rahman Shiri: The challenging topic of suicide across occupational groups.

We thank Dr Rahman Shiri (1) for his careful reading of our systematic review and meta-analysis on suicide among agricultural, forestry, and fishery workers (2). Our paper had the objective of providing a pooled effect size of suicide for this occupational group. Suicide is a crucial issue in public and occupational health. Suicide has a multifactorial etiology and recent systematic reviews and meta-analyses have pointed out the role of occupational exposures, mainly psychosocial work stressors, as risk factors for suicide (3, 4). Suicide is a very rare event in the general population and still more seldom in the working population. Indeed, unemployed and economically inactive people have a higher risk of suicide compared to employed people (5, 6). However, the total number of suicides is greater in the employed population than among the economically inactive or unemployed (6). Shiri's letter (1) questioned several aspects of our review and meta-analysis. One comment related to the single reference database used in our review and a suggestion that our review could not be considered to be systematic. The review was based on Medline because our main interest was in quantitative epidemiologic studies. This is the largest database for biomedical literature and we would argue the most pertinent. Furthermore, we checked the reference lists of the most recent papers and literature reviews, and Shiri did not report any paper that was missing. No review, whether searching one or more databases, can expect to be totally exhaustive. There may always be missing studies, especially if we consider grey literature. Thus we assert that our review was systematic, while acknowledging that it may not be perfectly comprehensive. Shiri suggested an absence of quality assessment of the studies included in our meta-analysis. First, quality was considered in the context of our comments in the discussion section. Second, as suggested by Rothman et al (7), quality assessment was replaced by regression analyses of the effect of each quality item (study characteristics, ie, study design, effect measure, reference group, and adjustment). Third, because most studies included in this review were based on objective data (census, administrative, or register data), they were free of many of the sources of bias that exist in studies where information on exposure and outcome must be collected from participants. Consequently, many of the items related to quality were not pertinent, such as response and follow-up rates, coverage and representativeness of the sample, selection, etc. Contrary to what Shiri suggested, all study designs can be informative in this topic because all of them are able to provide an unbiased estimate of the effect size. In addition, the prospective and case-control studies may have shortcomings. For example, we excluded five studies including three prospective and case-control studies in the sensibility analysis because the group of interest was defined on the basis of the exposure to chemicals (pesticides) rather than job title. Our choice to retain the least adjusted models was justified because aggregated data were used for the meta-analysis. Therefore, unless all included studies adjusted for the same covariates measured in the same way, adjusted estimates cannot be meaningfully provided in an aggregate data meta-analysis. In addition, as the objective was above all descriptive and not etiological or explanatory, and as it is the norm in the exploration of social inequalities in health (8), the results from the least (gender- and age-) adjusted models were in line with the objective. Indeed, including more adjustment variables could lead to overadjustment as they may be intermediate variables on the causal pathways between occupation and suicide. Our strategy was in line with previous meta-analyses on similar topics (9-11). Consequently, we would argue that our results are not likely to be largely due to confounding, contrary to the comment by Shiri. Indeed, the study of the contribution of underlying factors in explaining social inequalities in health outcomes is a fully-fledged topic of research (12-15), but this is relevant research to conduct after demonstrating that inequalities exist between social or occupational groups. Several of Shiri's comments were about statistical aspects of our analyses. First, it was suggested that we did not correctly extract the confidence intervals for the estimates of several studies. We disagree. We used the STATA metan suite of commands using log-transformed effect sizes and standard errors. Our figure 1 and the values of effect sizes and confidence intervals were provided by STATA, this explains why there may be small differences in these values compared with the results published in some studies. Using log-transformed effect sizes and confidence intervals, the analysis provided the same results. Second, our subgroup comparison was based on subsamples that were independent. As not all studies provided information for these subgroups, each subgroup was treated as a unit of analysis. This strategy allows the use of all relevant subgroups and comparisons between them (16). Third, we were also criticized for the use of random-effects models. Random-effects models are generally more plausible for meta-analysis based on studies from the published literature, because the fixed-effect model assumed that the entire corpus of literature has been obtained, ie, that every study has been or ever will be written on the topic has been included, which is an implausible assumption. We also assumed differences in effect size between studies and between subgroups, and the use of random-effects models was consistent with such an assumption. However, random-effects models produce wider confidence intervals compared to fixed-effect models (16). These models are thus more conservative, making our results all the more robust. One of Shiri's comments related to the reference group used in the studies for the comparison of agricultural, forestry, and fishery workers. Although we reported that the studies using a specific occupational group as reference group provided a higher effect size than the studies using other reference groups, we did not explicitly recognize and state in the paper that the results for Japan were based on two studies using a specific occupational group as reference; we concede that this may explain why we found a much more elevated effect size for Japan. Shiri's results (1) allow to conclude that the difference between Japan and the other geographic areas could be explained by the choice of reference group-we are grateful to him for raising this point. However, we would note that the effect size of suicide was still elevated and significant for agricultural, forestry, and fishery workers even after this change in the reference group for these two studies. Nevertheless, the choice of the optimal reference group is not obvious. If we consider the general population as the reference group, as unemployed people and economically inactive people (including people who may not be working due to illness or disability) are part of it and have a higher risk of suicide than employed people, the effect size provided by the nine studies using the general population as the reference is likely to be underestimated, which may contribute to an underestimation of the observed effect size of suicide among agricultural, forestry, and fishery workers in our study. The comparison was made in our paper with the other occupational groups (ie, the working population except the group of interest) as the reference, which was used by nine other studies, but this did not allow to determine the exact rank of the group of interest in the occupational hierarchy. Another relevant choice would have been to retain the group with the lowest suicide risk (for example, the high-skilled occupational group) as the reference, which would have led to a much higher effect size of suicide for agricultural, forestry, and fishery workers. To conclude, as statistical power in detecting differences between subgroups may be low in subgroup analyses and meta-regression, the absence of significant results according to subgroups found in our results cannot be interpreted as evidence that the effect size is the same across subgroups. Consequently, our meta-analysis reporting a significant excess of risk of suicide among agricultural, forestry, and fishery workers may also be a good incentive for more research among this group of workers to (i) confirm this observed excess of risk using differing methodological approaches to meta-analysis and (ii) explore the potential differences within this group and the underlying factors that may explain this excess of risk. References 1. Shiri R. Suicide among agricultural, forestry, and fishery workers. Scand J Work Environ Health - online first. https://doi.org/10.5271/sjweh.3697 2. Klingelschmidt J, Milner A, Khireddine-Medouni I, Witt K, Alexopoulos EC, Toivanen S, et al. Suicide among agricultural, forestry, and fishery workers: a systematic literature review and meta-analysis. Scand J Work Environ Health - online first. https://doi.org/10.5271/sjweh.3682 3. Milner A, Witt K, LaMontagne AD, Niedhammer I. Psychosocial job stressors and suicidality: a meta-analysis and systematic review. Occup Environ Med - online first. https://doi.org/10.1136/oemed-2017-104531 4. Leach LS, Poyser C, Butterworth P. Workplace bullying and the association with suicidal ideation/thoughts and behaviour: a systematic review. Occup Environ Med. 2017;74(1):72-9. https://doi.org/10.1136/oemed-2016-103726 5. Milner A, Page A, LaMontagne AD. Long-term unemployment and suicide: a systematic review and meta-analysis. PLoS One. 2013;8(1):e51333. https://doi.org/10.1371/journal.pone.0051333 6. Milner A, Morrell S, Lamontagne AD. Economically inactive, unemployed and employed suicides in Australia byage and sex over a 10-year period: what was the impact of the 2007 economic recession? Int J Epidemiol. 2014;43(5):1500-7. https://doi.org/10.1093/ije/dyu148 7. Rothman KJ, Greenland S, Lash TL. Modern Epidemiology - Third Edition. Philadelphia: Wolters Kluwer Health - Lippincott Williams & Wilkins; 2008. 8. Lundberg I, Hemmingsson T, Hogstedt C. Work and social inequalities in health in Europe. Brussels: P.I.E. Peter Lang SA; 2007. 9. Milner A, Spittal MJ, Pirkis J, Lamontagne AD. Suicide by occupation: systematic review and meta-analysis. Br J Psychiatry. 2013;203(6):409-16. https://doi.org/10.1192/bjp.bp.113.128405 10. Lorant V, Deliege D, Eaton W, Robert A, Philippot P, Ansseau M. Socioeconomic inequalities in depression: a meta-analysis. Am J Epidemiol. 2003;157(2):98-112. https://doi.org/10.1093/aje/kwf182 11. Grittner U, Kuntsche S, Gmel G, Bloomfield K. Alcohol consumption and social inequality at the individual and country levels--results from an international study. Eur J Public Health. 2013;23(2):332-9. https://doi.org/10.1093/eurpub/cks044 12. Niedhammer I, Bourgkard E, Chau N. Occupational and behavioural factors in the explanation of social inequalities in premature and total mortality: a 12.5-year follow-up in the Lorhandicap study. Eur J Epidemiol. 2011;26(1):1-12. https://doi.org/10.1007/s10654-010-9506-9 13. Niedhammer I, Chastang JF, David S, Kelleher C. The contribution of occupational factors to social inequalities in health: findings from the national French SUMER survey. Soc Sci Med. 2008;67(11):1870-81. https://doi.org/10.1016/j.socscimed.2008.09.007 14. Chazelle E, Lemogne C, Morgan K, Kelleher CC, Chastang JF, Niedhammer I. Explanations of educational differences in major depression and generalised anxiety disorder in the Irish population. J Affect Disord. 2011;134(1-3):304-14. https://doi.org/10.1016/j.jad.2011.05.049 15. Niedhammer I, Lesuffleur T, Coutrot T, Chastang JF. Contribution of working conditions to occupational inequalities in depressive symptoms: results from the national French SUMER survey. Int Arch Occup Environ Health. 2016;89(6):1025-37.https://doi.org/10.1007/s00420-016-1142-6 16. Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. Introduction to meta-analysis: John Wiley & Sons, Ltd. ISBN: 978-0-470-05724-7; 2009. https://doi.org/10.1002/9780470743386.

Suicide among agricultural, forestry, and fishery workers: a systematic literature review and meta-analysis.

Objectives This review aimed to quantify suicide risk among agricultural, forestry, and fishery workers and study potential variations of risk within this population. Methods We conducted a systematic literature review and meta-analysis from 1995 to 2016 using MEDLINE and following the PRISMA guidelines. A pooled effect size of suicide risk among the population of interest was calculated using meta-analysis. Subgroup analyses were conducted to investigate whether effect size differed according to population or study characteristics. Meta-regression was used to identify sources of heterogeneity. Results The systematic review identified 65 studies, of which 32 were included in the meta-analysis. Pooled effect size was 1.48 [95% confidence interval (CI) 1.30-1.68] representing an excess of suicide risk among the population of interest. Subgroup analysis showed that this effect size varied according to geographic area, with a higher effect size in Japan. The following study characteristics were found to contribute to the between-study variance: reference group, measure of effect size, and study design. Conclusions Our findings suggest an excess of suicide risk among agricultural, forestry, and fishery workers and demonstrated that this excess may be even higher for these groups in Japan. This review highlights the need for suicide prevention policies focusing on this specific population of workers. More research is also needed to better understand the underlying factors that may increase suicide risk in this population.

Recovery and Return to Work After a Pelvic Fracture.

BACKGROUND: Pelvic ring fractures (PRFs) may influence the daily activities and quality of life of the injured. The aim of this retrospective study was to explore the functional outcomes and factors related to return to work (RTW) after PRF. METHODS: During the years 2003-2012, 282 injured individuals aged 20-55 years on the date of the accident, were hospitalized and treated for PRFs in a large tertiary hospital in Athens, Greece. One hundred and three patients were traced and contacted; 77 who were on paid employment prior to the accident gave their informed consent to participate in the survey, which was conducted in early 2015 through telephone interviews. The questionnaire included variables related to injury, treatment and activities, and the Majeed pelvic score. Univariate and multiple regression analyses were used for statistical assessment. RESULTS: Almost half of the injured (46.7%) fully RTW, and earning losses were reported to be 35% after PRF. The univariate analysis confirmed that RTW was significantly related to accident site (labor or not), the magnitude of the accident's force, concomitant injuries, duration of hospitalization, time to RTW, engagement to the same sport, Majeed score, and complications such as limp and pain as well as urologic and sexual complaints (p < 0.05 for all). On multiple logistic regression analysis, the accident sustained out of work (odds ratio: 6.472, 95% confidence interval: 1.626-25.769) and Majeed score (odds ratio: 3.749, 95% confidence interval: 2.092-6.720) were identified as independent predictive factors of full RTW. CONCLUSION: PRFs have severe socioeconomic consequences. Possible predictors of RTW should be taken into account for health management and policies.

Upper extremity disorders in heavy industry workers in Greece.

AIM: To investigate the disability due to musculoskeletal disorders of the upper extremities in heavy industry workers. METHODS: The population under study consisted of 802 employees, both white- and blue-collar, working in a shipyard industry in Athens, Greece. Data were collected through the distribution of questionnaires and the recording of individual and job-related characteristics during the period 2006-2009. The questionnaires used were the Quick Disabilities of the Arm, Shoulder and Hand (QD) Outcome Measure, the Work Ability Index (WAI) and the Short-Form-36 (SF-36) Health Survey. The QD was divided into three parameters - movement restrictions in everyday activities, work and sports/music activities - and the SF-36 into two items, physical and emotional. Multiple linear regression analysis was performed by means of the SPSS v.22 for Windows Statistical Package. RESULTS: The answers given by the participants for the QD did not reveal great discomfort regarding the execution of manual tasks, with the majority of the participants scoring under 5%, meaning no disability. After conducting multiple linear regression, age revealed a positive association with the parameter of restrictions in everyday activities (b = 0.64, P = 0.000). Basic education showed a statistically significant association regarding restrictions during leisure activities, with b = 2.140 (P = 0.029) for compulsory education graduates. WAI's final score displayed negative charging in the regression analysis of all three parameters, with b = -0.142 (P = 0.0), b = -0.099 (P = 0.055) and b = -0.376 (P = 0.001) respectively, while the physical and emotional components of SF-36 associated with movement restrictions only in daily activities and work. The participants' specialty made no statistically significant associations with any of the three parameters of the QD. CONCLUSION: Increased musculoskeletal disorders of the upper extremity are associated with older age, lower basic education and physical and mental/emotional health and reduced working ability.

Stress Sources and Manifestations in a Nationwide Sample of Pre-Primary, Primary, and Secondary Educators in Greece.

BACKGROUND: Teachers experience high levels of stress as a result of their professional duties, and research has shown a growing interest in this phenomenon during the recent years. Aim of this study was to explore the associations of stress sources and manifestations with individual and job-related characteristics in educators of all levels. METHODS: In a cross-sectional design, following an informative e-campaign on the study aims through the official and the main teachers' portals in Greece, respondents completed online the teachers stress inventory (TSI) and the 14-item Perceived Stress Scale. Nine hundred seventy-four male and 2473 female pre-primary, primary, and secondary educators with a mean age of 41.2 years responded. RESULTS: Women and younger teachers reported significantly higher levels of stress, mainly due to lack of time and other work-related stressors, and also more emotional and gastronomic manifestations. Increased age and working experience were associated with lower levels of several stress sources. Teachers of administrative positions had increased time management stressors, but less professional distress, professional investment, and discipline and motivation stressors. Additionally, working and residing far from family increased teachers' stress levels associated with control, motivation, and investment. Teachers of pre-primary education had reduced professional investment and motivation stress factors, while vocational lyceum teachers of secondary education reported less work-related stressors and manifestations and more discipline and motivation-related ones. Having students supported or in need of support from special educators and students with difficulties in speaking or comprehension was associated with most of the teachers' stress sources and manifestations (i.e., TSI subscales). Finally, colleagues' and mainly supervisors' support seemed to provide a strong and consistent protection against both stress sources and manifestations. CONCLUSION: Stress factors and manifestations vary among educators by gender, seniority, and teaching level. Training in coping and communication skills starting in teachers' undergraduate studies might have a major impact on their stress alleviation.

Suicide Mortality Across Broad Occupational Groups in Greece: A Descriptive Study.

BACKGROUND: Several studies have investigated the relationship between specific occupations and suicide mortality, as suicide rates differ by profession. The aim of this study was to investigate suicide mortality ratios across broad occupational groups in Greece for both sexes in the period 2000-2009. METHODS: Data of suicide deaths were retrieved from the Hellenic Statistical Authority and comparative mortality ratios were calculated. Occupational classification was based on the International Classification of Occupations (ISCO-88) and the coding for Intentional self-harm (X60-X84) was based on the international classification of diseases (ICD-10). RESULTS: Male dominant occupations, mainly armed forces, skilled farmers and elementary workers, and female high-skilled occupations were seen as high risk groups for suicide in a period of 10 years. The age-productive group of 30-39 years in Greek male elementary workers and the 50-59 age-productive group of Greek professional women proved to have the most elevated number of suicide deaths. CONCLUSION: Further research is needed into the work-related stressors of occupations with high suicide mortality risk and focused suicide prevention strategies should be applied within vulnerable working age populations.

Validation of the World Health Organization Disability Assessment Schedule (WHO-DAS II) in Greek and its added value to the Short Form 36 (SF-36) in a sample of people with or without disabilities.

BACKGROUND: There is controversy and ongoing interest on the measurement of functionality in the personal and social level. OBJECTIVES: (1) to validate the Greek version of the World Health Organization Disability Assessment Schedule (WHO DAS II) and (2) to determine its added value to the physical and psychological health subscales of the Short Form 36 (SF-36). METHODS: In a cross-sectional design, data were collected between December 2014 and March 2015 by using three questionnaires (WHO DAS II, SF-36, PSS-14) in a sample of people with disabilities (n = 101) and without disabilities (n = 109) in Athens, Greece. WHO DAS II internal consistency, construct and criterion-related validity were assessed by Cronbach alpha, exploratory factor analysis and correlations; its added value by multivariable linear regression. RESULTS: Cronbach Alpha's were satisfactory for the WHO DAS II, PSS-14 and SF-36 (0.85, 0.88 and 0.96 respectively). Exploratory factor analysis confirmed the existence of one or two factors in people with or without disabilities, respectively. WHO DAS II score showed significant negative correlation with the physical and mental health scale of SF-36 score, especially strong for physical health while was positively related to PSS-14 score. In multivariate analysis mental health appraisal was related to perceived stress in both groups. CONCLUSIONS: This study support the validity of the Greek version of WHO DAS II and warranted its use in assessment and follow up of people with disabilities, contributing to the development of suitable policies to cover their needs and providing comparable data with other surveys using the same instrument.

COPD characteristics and socioeconomic burden in Hellenic correctional institutions.

BACKGROUND: The high prevalence of smoking (80%) in Greek correctional institutions is anticipated to result in high prevalence of COPD in such settings. AIM: The aim of the Greek obstructive luNg disease epidemiOlogy and health economics Study In corrective institutionS (GNOSIS) is to determine the prevalence of smoking and COPD among inmates and to assess the health-related quality of life. METHODS: GNOSIS, a cross-sectional epidemiological study, was conducted between March 2011 and December 2011 in seven correctional institutions in Greece. RESULTS: A total of 552 participants, 91.3% male, median age of 43.0 years (interquartile range: 35-53), were enrolled. COPD prevalence was 6.0% and was found to increase with age (18.6% among those ≥60 years), length of prison stay, and length of sentence. Of the participants diagnosed with COPD, 36.4% were diagnosed with Global initiative for chronic Obstructive Lung Disease (GOLD) stage I and 51.5% were diagnosed with stage II. Dyspnea severity was assessed as grades 0-1 on the medical research council dyspnea scale for 88.3%, while 31% reported ≥2 COPD exacerbations in the past year. Seventy-nine percent of the total number of the participants were smokers, with a median smoking of 20.0 cigarettes per day, while 42.9% were assessed as having a strong addiction to nicotine. The median EuroQol visual analog scale score was 70.0 (interquartile range: 60.0-90.0). Problems in the dimension of anxiety/depression were reported by 82.8%. CONCLUSION: The results of the study support the notion that the prevalence of COPD among inmates of Greek correctional institutions may increase in the following years. The findings underscore the importance of taking actions to limit COPD prevalence and its risk factors in the Greek correctional system.

Frequency and risk factors of COPD exacerbations and hospitalizations: a nationwide study in Greece (Greek Obstructive Lung Disease Epidemiology and health ecoNomics: GOLDEN study).

BACKGROUND: COPD exacerbations and hospitalizations have been associated with poor prognosis for the COPD patient. OBJECTIVE: To evaluate the frequency and risk factors of COPD exacerbations, hospitalizations, and admissions to intensive care units (ICUs) in Greece by a nationwide cross-sectional study. MATERIALS AND METHODS: A nationwide observational, multicenter, cross-sectional study was conducted in the clinical practice setting of respiratory medicine physicians over a 6 month-period (October 2010 to March 2011). A total of 6,125 COPD patients were recruited by 199 respiratory physicians. RESULTS: Participants had a median age of 68.0 years, 71.3% were males, and 71.8% suffered from comorbidities. The median disease duration was 10.0 years. Of the patients, 45.3% were classified as having GOLD (Global initiative for chronic Obstructive Lung Disease) stage III or IV COPD. Patients with four or more comorbidities had 78.5% and threefold-higher than expected number of exacerbations and hospitalizations, respectively, as well as fivefold-higher risk of admission to the ICU compared to those with no comorbidities. Obese patients had 6.2% fewer expected exacerbations compared to those with a normal body mass index. Patients with GOLD stage IV had 74.5% and fivefold-higher expected number of exacerbations and hospitalizations, respectively, and nearly threefold-higher risk of admission to the ICU compared to stage I patients. An additional risk factor for exacerbations and hospitalizations was low compliance with treatment: 45% of patients reported forgetting to take their medication, and 81% reported a preference for a treatment with a lower dosing frequency. CONCLUSION: Comorbidities, disease severity, and compliance with treatment were identified as the most notable risk factors for exacerbations, hospitalizations, and ICU admissions. The results point to the need for a multifactorial approach for the COPD patient and for the development of strategies that can increase patient compliance with treatment.

Monitoring interhospital transfers in Western Greece during 2003-2011: its role in health policy.

INTRODUCTION: Interhospital transfers (ITs) could provide insight into regional healthcare efficiency and evidence for policy-making. The aim of this study was to analyse ITs carried out in the Western Greece region over a nine-year period. METHODS: Archives of the National Center of Emergency Medical Services of Patras and official healthcare resources were used to analyze patient transfers from rural to 'reception' hospitals in the area, during the period 2003-2011, by hospital, medical, seasonal and population variations. RESULTS: A total of 2500 ITs from the eight rural hospitals to the central ones in the metropolitan area of Patras were monitored yearly. Transfer rates per population ranged between less than 0.3% and more than 1.0%. Only a few patients transferred outside the area (0.9%). Almost 10% of total transfers regarded diagnostic evaluation (mostly CT scan). Transfer rates were inversely related to hospital admission rates (Pearson -0.973, p=0.027), while time (in minutes) (Pearson -0.903, =0.036) and distance (in kilometers) between the rural and central hospitals (Pearson -0.907, p=0.034) also exhibited significant relationships. The level of understaffing does not have a clear effect on ITs. CONCLUSIONS: By monitoring ITs, it becomes evident where efforts should be prioritized and which of the interconnections should be optimized in a specific network of health care. In this case, interventions should be focused towards the (a) very high transfer rates from the general hospital (GH) of Aigio, (b) lack of orthopedists at GH Kalavryta, which could provide a 24 hour emergency service in a tourist ski area, (c) understaffing in the microbiological laboratory and lack of a CT scanner at GH Mesologi, and (d) lack of radiologists in several hospitals, rendering the installed equipment worthless. By monitoring the ITs, real needs and win-win actions may emerge in the complex interplay of infrastructural factors.

Characteristics of prevalent and new COPD cases in Greece: the GOLDEN study.

BACKGROUND: Greece has one of the highest rates of smoking and chronic obstructive pulmonary disease (COPD) in Europe. AIM: The study aimed to record both the disease characteristics among a sample of Greek COPD patients and the nationwide rates of newly diagnosed COPD cases. METHODS: In this noninterventional, epidemiological cross-sectional study, a representative nationwide sample of 45 respiratory centers provided data on the following: 1) the demographic and clinical characteristics of COPD patients and 2) newly diagnosed COPD cases monitored over a period of 6 months by each physician. RESULTS: Data from 6,125 COPD patients were collected. Advanced age (median age: 68 years), male predominance (71.3%), largely overweight status with median body mass index (BMI) =27.5 kg/m(2), high percentage of current and ex-smokers (89.8%), and presence of comorbidities (81.9%) were evident in the sample. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 criteria, majority of the COPD patients had moderate or severe airflow limitation (61%). Severity of airflow limitation was significantly associated with older age, male sex, obesity, ex-smoking status, and presence of comorbidity (all P-values <0.001). A total of 61.3% of the patients received medication, mostly bronchodilators (64.4%) and fixed-dose combinations of long-acting ß2-agonists and inhaled corticosteroids (39.9%), while 35.9% reported taking medication on demand. The majority (81.1%) of patients reported a preference for fewer inhalations of their bronchodilator therapy. Based on the mixed-effect Poisson model, the rate of newly diagnosed COPD cases was estimated to be 18.2% (95% confidence interval: 14.9-22.3) per pulmonologist/3 months. Of those newly diagnosed, the majority of patients had mild or moderate airflow limitation (78.2%). CONCLUSION: The Greek Obstructive Lung Disease Epidemiology and health ecoNomics study reflected the real-life profile of COPD patients and provided evidence on the profile of new COPD cases in Greece. Various demographic factors were delineated, which can assist in designing more effective diagnostic and management strategies for COPD in Greece.

Hearing loss in shipyard employees.

BACKGROUND: Noise-induced hearing loss (NIHL) is one of the most prevalent occupational illnesses, with a higher incidence in the heavy industry. OBJECTIVES OF THE STUDY: The aim of this study is to investigate the prevalence of NIHL in Greece and explore its correlations with other job and individual-related factors. MATERIALS AND METHODS: Questionnaires were administered, and audiograms were conducted to 757 employees of a shipyard company in Greece, both white- and blue-collar, during the period 2006-2009. A modification of the 1979' equation of the American Academy of Otolaryngology was used to calculate hearing loss. Statistical analysis was conducted by means of the SPSS v. 17. RESULTS: A 27.1% of the employees were hearing handicap. Hearing loss was correlated with age, past medical history of ear disease (Meniere's disease, acoustic neuroma, otosclerosis) or injury, hyperlipidemia, job title and level of education. A few questions on subjective hearing ability and symptoms showed strong discriminatory power of hearing pathology. CONCLUSIONS: The results of this study emphasize the burden of disease in the shipyard industry, and the need for continuous monitoring, implementation of preventive measures and hearing conservation programs.

Teacher Stress Inventory: validation of the Greek version and perceived stress levels among 3,447 educators.

BACKGROUND: The Teacher Stress Inventory (TSI) is an instrument for measuring occupational stress in teachers. This study aimed to translate and adapt it for use in Greece, and then assess its reliability and validity. METHODS: The Greek versions of the TSI and the 14-item Perceived Stress Scale (PSS-14) were posted on all Greek educators' official sites during May 2012. A nationwide sample of 3,447 teachers of all levels and specialties completed the questionnaires via the Internet. Reliability was determined by the calculation of Cronbach's alpha coefficient. Confirmatory factor analysis was conducted and validity was further examined by investigating the correlation of the TSI with the PSS-14 and their association with demographics and work-related factors. RESULTS: Satisfactory Cronbach's alpha values (above 0.70) were found for all TSI dimensions. Confirmatory factor analysis confirmed the two-factor construct of TSI (root mean square error of approximation, comparative fit index, and goodness-of-fit index values were 0.079, 0.956, and 0.951, respectively), confirming the pre-established theory for the two latent variables, Stress Sources and Stress Manifestations. Significant correlations were found between TSI subscales, PSS-14 sex, age, lack of support, and students' difficulties. CONCLUSION: The Greek version of the TSI was found to have satisfactory psychometric properties, and its use for assessing stress in Greek teachers is warranted.

Reliability and Validity of the Greek Version of the Job Content Questionnaire in Greek Health Care Workers.

BACKGROUND: The Job Content Questionnaire (JCQ), which is based on the Demand-Control-Support model, is designed to measure the psychosocial characteristics of the respondent's work, and has been identified to predict health and psychological outcomes. The purpose of this study was to investigate the psychometric properties of this instrument and the subsequent adaptation of its scales to the population of Greek health workers. METHODS: The Greek version of the JCQ was developed by using forward- and back-translation in accordance with the JCQ policy. The reliability and validity of the measure were investigated in a sample of health workers working in a hospital in Athens, Greece. The internal consistency of the scales was examined based on Cronbach α coefficients, and the validity was evaluated subjecting the items of the three main scales of the JCQ (decision latitude, psychological job demands, and social support) to exploratory and confirmatory factor analysis. RESULTS: The reliability of the scales was found to be acceptable for all the scales, except for the skill discretion subscale. Confirmatory factor analysis confirmed a slightly modified version of the original construct including several items to more than one factor. CONCLUSION: Our findings suggest that the Greek JCQ is reliable and valid for investigating psychosocial job characteristics among Greek health workers.