Prevalence and Characteristics of Self-Reported Adult Asthma in Cyprus: A Population-Based Observational Study.

Purpose: To estimate the prevalence of asthma in adults, by gender and age, in urban and rural areas of Cyprus. Patients and Methods: This was a population-based, random-digit dialing, telephone nation-wide survey to recruit patients with asthma. Among 8996 random landline-telephone contacted from the five major urban and rural regions of Cyprus, 1914 were finally met the age criterion of ≥18 years old and 572 completed valid screening for prevalence estimation. The participants filled a short screening questionnaire in order for asthma cases to be recognized. Then, asthma cases filled the main ECRHS II questionnaire and were evaluated by a pulmonary physician. All underwent spirometry. Data on demographic characteristics, educational level, profession, smoking status, Body Mass Index (BMI), Total IgE and Eosinophil Cationic Protein levels were measured. Results: The overall prevalence of bronchial asthma in adults in Cyprus was 5.57% (61.1% men and 38.9% women). Among the participants with self-reported bronchial asthma 36.1% were current smokers, while 12.3% were obese (BMI >30). A total value of IgE >115 IU and Eosinophil Cationic Protein (ECP) >20 IU was found in 40% of the participants with established bronchial asthma. Wheezing and chest tightness were the most frequently reported symptoms in asthma patients (36.1% and 34.5%, respectively), while 36.5% experienced at least one exacerbation during the last year. Interestingly, most of the patients were under-treated (14.2% were on maintenance asthma treatment, and 18% used solely reliever medication). Conclusion: This was the first study estimating asthma prevalence in Cyprus. Asthma affects almost 6% of the adult population, with higher prevalence in urban areas and in men compared to women. Interestingly, one-third of the patients were uncontrolled and under-treated. This study revealed that in Cyprus there is space for improvement in the management of asthma.

Setting Objective Clinical Assessment Tools for Circadian Rhythm Sleep-Wake Disorders - A Community-Based Cross-Sectional Epidemiological Study.

INTRODUCTION: Circadian rhythm sleep-wake disorder (CRSWD) is an often-misdiagnosed group of sleep disturbances with limited data concerning diagnostic and therapeutic algorithms in the general population. Therefore, reported prevalence varies in the literature due to different case definitions, methodological, and environmental factors. OBJECTIVES: The purpose of our cross-sectional study was to estimate the prevalence of CRSWD in the general population of Cyprus and to suggest clinical parameters for the assessment of atypical sleep schedules. The estimation was carried out by introducing normal preset sleep time limits, according to the imposed local environment and by administering well-established questionnaires for symptoms and consequence dysfunction, as objective evaluation tools. METHODS: In a nationwide epidemiological survey, 4118 Cypriot adult participants, selected and stratified to represent the general population, were interviewed on sleep habits and complaints by computer-assisted telephone interviewing (CATI). In the second stage, 250 adults were randomly selected from the initial representative sample, for a CRSWD assessment. According to the proposed diagnostic criteria, patients were interviewed about sleepiness and/or insomnia, and daytime dysfunction (fatigue, anxiety, and depression). They were also assessed by a weekly sleep diary for sleep schedules. Finally, all participants underwent a Type III Sleep Study, to rule out obstructive sleep apnea. RESULTS: From 195 enrolled participants (response rate 78%), 25 individuals (12.8%) met the criteria for CRSWD. The two most prevalent disorders were delayed sleep-wake phase disorder (DSWPD) (10pts, 5.1%) and shift work sleep disorder (SWD) (13, 6.7%). Less prevalent disorders included irregular sleep-wake rhythm disorder (ISWRD) (1, 0.5%) and advanced sleep-wake phase disorder (ASWPD) (1, 0.5%). CONCLUSIONS: According to our data, CRSWDs are common in the general population of Cyprus, especially DSWPD and SWD. Affected individuals usually suffer from sleep deprivation and complain about insomnia, sleepiness and depression.

The Complex Interaction Between the Major Sleep Symptoms, the Severity of Obstructive Sleep Apnea, and Sleep Quality.

Introduction: Little information exists in the general population whether clinical presentation phenotypes of obstructive sleep apnea (OSA) differ in terms of sleep quality and comorbidities. Aim: The purpose of our study was to assess possible differences between symptomatic and asymptomatic OSA patients concerning syndrome's severity, patients' sleep quality, and comorbidities. Subjects and methods: First, in a nationwide, stratified, epidemiological survey, 4,118 Cypriot adult participants were interviewed about sleep habits and complaints. In the second stage of the survey, 264 randomly selected adults underwent a type III sleep study for possible OSA. Additionally, they completed the Greek version of Pittsburgh Sleep Quality Index (Gr-PSQI), Epworth Sleepiness Scale (ESS), Athens Insomnia Scale (AIS), and Hospital Anxiety and Depression Scale (HADS). Results: From 264 enrolled participants, 155 individuals (40 females and 115 males) were first diagnosed with OSA. Among these 155 patients, 34% had ESS ≥ 10 and 49% AIS ≥ 6. One or both symptoms present categorized the individual as symptomatic (60%) and neither major symptom as asymptomatic (40%). There were no significant statistical differences (SSDs) between the two groups (symptomatic-asymptomatic) with regard to anthropometrics [age or gender; neck, abdomen, and hip circumferences; and body mass index (BMI)]. The two groups had no differences in OSA severity-as expressed by apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and mean oxyhemoglobin saturation (SaO2)-and in cardiometabolic comorbidities. Symptomatic patients expressed anxiety and depression more often than asymptomatics (p < 0.001) and had poorer subjective sleep quality (Gr-PSQI, p < 0.001). According to PSQI questionnaire, there were no SSDs regarding hours in bed and the use of sleep medications, but there were significant differences in the subjective perception of sleep quality (p < 0.001), sleep efficiency (p < 0.001), duration of sleep (p = 0.001), sleep latency (p = 0.007), daytime dysfunction (p < 0.001), and finally sleep disturbances (p < 0.001). Conclusion: According to our data, OSA patients reporting insomnia-like symptoms and/or sleepiness do not represent a more severe phenotype, by the classic definition of OSA, but their subjective sleep quality is compromised, causing a vicious cycle of anxiety or depression.

Association between Respiratory Sleep Indices and Cardiovascular Disease in Sleep Apnea-A Community-Based Study in Cyprus.

Obstructive sleep apnea (OSA) is a chronic and prevalent disorder, strongly associated with cardiovascular disease (CVD). The apnea-hypopnea index (AHI), or respiratory event index (REI), and the oxygen desaturation index (ODI) are the clinical metrics of sleep apnea in terms of diagnosis and severity. However, AHI, or REI, does not quantify OSA-related hypoxemia and poorly predicts the consequences of sleep apnea in cardiometabolic diseases. Moreover, it is unclear whether ODI correlates with CVD in OSA. Our study aimed to examine the possible associations between respiratory sleep indices and CVD in OSA, in a non-clinic-based population in Cyprus. We screened 344 subjects of a stratified, total sample of 4118 eligible responders. All participants were adults (age 18+), residing in Cyprus. Each patient answered with a detailed clinical history in terms of CVD. A type III sleep test was performed on 282 subjects (81.97%). OSA (REI ≥ 15) was diagnosed in 92 patients (32.62%, Group A). REI < 15 was observed in the remaining 190 subjects (67.37%, Group B). In OSA group A, 40 individuals (43%) reported hypertension, 17 (18.5%) arrhythmias, 10 (11%) heart failure, 9 (9.8%) ischemic heart disease and 2 (2%) previous stroke, versus 46 (24%), 21 (11%), 7 (3.7%), 12 (6.3%) and 6 (3%), in Group B, respectively. Hypertension correlated with REI (p = 0.001), ODI (p = 0.003) and mean SaO2 (p < 0.001). Arrhythmias correlated with mean SaO2 (p = 0.001) and time spent under 90% oxygen saturation (p = 0.040). Heart failure correlated with REI (p = 0.043), especially in the supine position (0.036). No statistically significant correlations were observed between ischemic heart disease or stroke and REI, ODI and mean SaO2. The pathogenesis underlying CVD in OSA is variable. According to our data, hypertension correlated with REI, ODI and mean SaO2. Arrhythmias correlated only with hypoxemia (mean SaO2), whereas heart failure correlated only with REI, especially in the supine position.

Estimating obstructive sleep apnea in Cyprus: a randomised, stratified epidemiological study using STOP-Bang sleep apnea questionnaire.

INTRODUCTION: Several epidemiological studies have demonstrated that Obstructive Sleep Apnea (OSA) is a highly prevalent disorder in the general population and increases over time all over the world. The high prevalence is in part due to increasing rates of obesity. However, estimates of OSA prevalence in Southern Europe are generally lacking. AIM: The aim of our study was to predict the risk of OSA in the general population of Cyprus, the southeast part of Europe, by using a dedicated questionnaire like STOP-Bang. SUBJECTS AND METHOD: We screened 5736 sample housing units for eligible adults and a total population of 4118 eligible responders completed the STOP-Bang questionnaire. Participants were all adults, age 18 + residing in Cyprus. The sample was stratified according to the last demographic report (2016) by district, rural or urban area, gender and age and the estimated sample size needed was 2000. Our survey was conducted by Computer Aided Telephone Interviewing (CATI) method. The question about Neck Circumference was removed from the final evaluation due to the uncertainty of most of the participants and the risk of bias. RESULTS: From a total of 4118 participants (2252 males - 54.7%, 1862 females - 45.3%), with 46.6% over 50 years old, 2641 (64.1%) were at low risk for OSA (0-2 positive answers), 1200 (29.1%) at intermediate risk (3-4 positive answers) and 277 (6.7%) at high risk (≥5 positive answers). In sum, 29.9% responded positively for snoring, 39.3% for feeling tired or sleepy during the day, 12.3% for observed apnea during sleep, and 24.6% for having or being treated for hypertension. Class II and III obesity with Body Mass Index (BMI) > 35 kgr/m2 was observed in 192 subjects (4.7%). In the subpopulation of obese participants (BMI>30 kg/m2), intermediate to high risk of OSA was present in 45%, whereas in obesity class II and III the percentage reached almost 90%. CONCLUSIONS: Our survey yielded that the prevalence of intermediate to high risk for OSA was 50% in males and 18% in females, in the general population of Cyprus. These findings were similar to previously reported high OSA prevalence worldwide, considering the fact that a single questionnaire is only a screening tool and cannot alone diagnose sleep apnea.

Prevalence and Forms of Workplace Bullying Among Health-care Professionals in Cyprus: Greek Version of "Leymann Inventory of Psychological Terror" Instrument.

BACKGROUND: Workplace bulling is a pervasive phenomenon with negative consequences for the health of victims and the productivity of organizations. The aim of this study was to measure the prevalence and forms of workplace bullying among employees working at the public health-care sector of Cyprus using the Greek version of Leymann Inventory of Psychological Terror (LIPT) instrument. METHODS: A translation process was followed from the French to the Greek version of LIPT questionnaire. Test-retest reliability expressed by Pearson's correlation coefficient was 0.98 indicating excellent reproducibility. Internal consistency reliability assessed by Cronbach α coefficient was 0.87 suggesting high reliability. LIPT instrument was distributed among 403 employees working at the primary health-care setting and at the largest public hospital of Cyprus with response rate of 73.4%. RESULTS: Women comprised the majority of participants (71.4%). Mean age was 43.3 years. Prevalence of workplace bulling according to Leymann's definition was 5.9%. Most common forms of bullying were "Being continuously interrupted" (17.2%) and "continuously being given new work assignments" (13.5%). Women were significantly more often exposed to at least one mobbing behavior than men within the previous year (49% vs. 35.7%, p = 0.038), whereas nurses were significantly exposed to at least one mobbing behavior as compared to physicians (53.3% vs. 31.4%, p = 0.004). CONCLUSION: This was the first study that examined the prevalence of workplace bullying in the public health-care sector by elaborating the Greek version of LIPT instrument. Results showed that workplace bullying is a common and complex phenomenon among health-care organizations.

The economic burden of adult asthma in Cyprus; a prevalence-based cost of illness study.

BACKGROUND: Asthma is one of the main non-infectious diseases of the respiratory system with substantial economic burden worldwide. The objective of this study was to estimate the economic burden of adult asthma in Cyprus during 2015. METHODS: A retrospective probabilistic prevalence-based cost of illness model was developed to calculate the economic burden of asthma including direct and indirect costs. The bottom-up approach (person-based data) was used for the calculation of direct costs while for the calculation of indirect costs the approach of human capital was employed. In addition, bootstrapped sensitivity analysis with 1000 bootstrap simulations was performed in order to calculate a 95% Confidence Interval (CI). RESULTS: Mean patient cost of asthma in Cyprus in 2015 was estimated at €579.64 (95% CI: €376.90-€813.68). Direct costs accounted for 82.08% of the overall expenses, €475.75 per patient (95% CI: €296.94-€697.69). Indirect costs of €103.89 (95% CI: €49.59-€181.46) accounted for 17.92% of the overall expenses. CONCLUSION: This was the first study in Cyprus, which used bootstrapped prevalence-based cost of illness model to estimate the cost of asthma. This study confirms that asthma is an expensive disease for the society. In addition, it provides important information and analysis of the economic consequences of asthma to policy makers in order to strengthen surveillance of the disease as well as draft the national health policy accordingly.

Smoking prevalence and associated risk factors among healthcare professionals in Nicosia general hospital, Cyprus: a cross-sectional study.

BACKGROUND: In recent years, a significant progress has been achieved globally in reduction of smoking among physicians and nurses, however, in some countries the smoking prevalence of health professionals is maintained at very high levels, without significant difference from the general population. This study aims to investigate the prevalence of smoking among physicians and nurses working at Nicosia General Hospital, as well as their knowledge and attitudes towards smoking cessation strategies. METHODS: This is a cross-sectional questionnaire-based study. The study consisted of 119 doctors and 392 nurses currently working at Nicosia General Hospital in Cyprus. Study participants were recruited from all hospital wards between May and June 2008. Both physicians and nurses were asked to answer an anonymous questionnaire, which included questions regarding their smoking habits, knowledge and attitudes about smoking and smoking cessation strategies. RESULTS: Overall smoking prevalence among healthcare professionals was 28.2 % (28.6 % among physicians and 28.1 % among nurses). Multivariate analysis revealed that being male, younger than 34 years old, unmarried and with a family history of smoking were associated with increased likelihood of being a current smoker. An impressive 72 % of current smokers reported that they wished to quit smoking, however, only 5.6 % of physicians and 6.9 % of nurses, reported ever using any smoking cessation aids. Never- smokers counseled their patients to quit smoking more often (96.4 %) compared to former (84.6 %) and current smokers (72.7 %), (p < 0.001). In addition, those who felt more confident about their knowledge regarding smoking cessation, reported counseling their patients to quit smoking more often compared to those who did not (92 % vs 60 %, p < 0.001). CONCLUSIONS: Smoking prevalence among physicians and nurses working at Nicosia General Hospital was similar to that of the general Cypriot population. Further training of healthcare professionals towards smoking cessation strategies is needed in order to improve their knowledge and consequently their efforts on counseling and support to their patients who wish to quit smoking.

A Cost-benefit Analysis of a Proposed Immigrant Latent Tuberculosis Infection Screening Program for Cyprus.

INTRODUCTION: The study explored the potential economic benefit of an expanded screening program of immigrants before entrance to Cyprus as a policy to reduce the overall cost of tuberculosis (TB). Thus, the aim of this study is to study whether screening all immigrants coming from countries (including European Union countries) with high incidence of tuberculosis would be in the economic interest of the Republic of Cyprus or not. METHODS: In order to assess whether it could be economically beneficial for Cyprus to expand the screening checks for TB to all immigrants coming from high prevalence countries, a Cost-Benefit Analysis (CBA) was employed, and the Net Present Value (NPV) of the project was calculated. In order to assess for uncertainty, sensitivity analysis using different scenarios, was conducted. RESULTS: The analysis has a fifteen year length of implementation period and the base year (Year 0) was 2011. The NPV was estimated at €3,188,653 which is greater than zero; therefore, the expansion of screening diagnostic tests for TB to European citizens coming from countries with high prevalence of TB will have a significant benefit to the Cypriot economy and society. This result is also supported by the fact that all "what-if scenarios" of the sensitivity analysis yielded a positive NPV. CONCLUSION: Our study concludes that testing all immigrants, including immigrants from high prevalence European countries that are not currently tested for TB, would be a cost-saving strategy to reduce the cost of treating TB in Cyprus.

Expression of YKL-40 and MIP-1a proteins in exudates and transudates: biomarkers for differential diagnosis of pleural effusions? A pilot study.

BACKGROUND: YKL-40 is an extracellular matrix glycoprotein with a significant role in tissue inflammation and remodeling. MIP-1a has chemotactic and pro-inflammatory properties, and is induced by YKL-40 in several lung disorders. The aim of this study was to determine the levels of YKL-40 and MIP-1a in blood serum and pleural fluids of various pulmonary diseases, and to evaluate their potential role as differential diagnosis biomarkers. METHODS: We recruited 60 patients (age: 62.5 ± 20.6 years) with pleural effusions: 49 exudates and 11 transudates (T). Exudates were further classified based on the underlying disease: ten with tuberculosis (TB), 13 with lung cancer (LCa), 15 with metastatic cancer (MCa) of non-lung origin and 11 with parapneumonic (PN) effusions. YKL-40 and MIP-1a levels were measured by ELISA. RESULTS: Pleural YKL-40 levels (ng/ml) were similar among all patient groups (TB: 399 ± 36, LCa: 401 ± 112, MCa: 416 ± 34, PN: 401 ± 50, T: 399 ± 42, p = 0.92). On the contrary, YKL-40 was significantly lower in the serum of TB patients (TB: 58 ± 22, LCa: 212 ± 106, MCa: 254 ± 140, PN: 265 ± 140, T: 229 ± 123, p < 0.001). Pleural MIP-1a protein levels (ng/ml) were statistically lower only in patients with LCa (TB: 25.0 ± 20.2, LCa: 7.3 ± 6.0, MCa: 16.1 ± 14.9, PN: 25.4 ± 27.9, T: 18.5 ± 7.9, p = 0.012), a finding also observed in serum MIP-1a levels (TB: 17.1 ± 7.6, LCa: 9.4 ± 7.0, MCa: 28.7 ± 28.7, PN: 33.3 ± 24.0, T: 22.9 ± 8.7, p = 0.003). CONCLUSIONS: Our data suggest that both YKL-40 and MIP-1a, particularly in serum, could prove useful for the differentiation of pleural effusions in clinical practice, especially of TB or LCa origin. However, large-scale studies are needed to validate these findings.

Organizational culture in the primary healthcare setting of Cyprus.

BACKGROUND: The concept of organizational culture is important in understanding the behaviour of individuals in organizations as they manage external demands and internal social changes. Cyprus healthcare system is under restructuring and soon a new healthcare scheme will be implemented starting at the Primary Healthcare (PHC) level. The aim of the study was to investigate the underlying culture encountered in the PHC setting of Cyprus and to identify possible differences in desired and prevailing cultures among healthcare professionals. METHODS: The population of the study included all general practitioners (GPs) and nursing staff working at the 42 PHC centres throughout the island. The shortened version of the Organizational Culture Profile questionnaire comprising 28 statements on organizational values was used in the study. The instrument was already translated and validated in Greek and cross-cultural adaptation was performed. Participants were required to indicate the organization's characteristic cultural values orientation along a five-point Likert scale ranging from "Very Much = 1" to "Not at all= 5". Statistical analysis was performed using SPSS 16.0. Student t-test was used to compare means between two groups of variables whereas for more than two groups analysis of variance (ANOVA) was applied. RESULTS: From the total of 306 healthcare professionals, 223 participated in the study (72.9%). The majority of participants were women (75.3%) and mean age was 42.6 ± 10.7 years. Culture dimension "performance orientation" was the desired culture among healthcare professionals (mean: 1.39 ± 0.45). "Supportiveness" and "social responsibility" were the main cultures encountered in PHC (means: 2.37 ± 0.80, 2.38 ± 0.83). Statistical significant differences were identified between desired and prevailing cultures for all culture dimensions (p= 0.000). CONCLUSIONS: This was the first study performed in Cyprus assessing organizational culture in the PHC setting. In the forthcoming health system reform, healthcare professionals will face challenges both at organizational level and professional status. Results of the study can serve as background knowledge for leaders and policy makers who seek interventions to improve performance before the implementation of a new national healthcare scheme.