Abstract: The prevalence and risk factors of hepatitis A, B, and C (HAV, HBV, and HCV) markers were compared in non-Roma and Roma children who lived in a deprived suburb of Athens, Greece. The study included 216 children, 118 Roma and 98 non-Roma of 9 years median age (range 5-15 years). Among Roma children 98.3% had detectable antibodies to HAV, compared with 32.7% among non-Romas (P < 0.0001). Regarding HBV, 22% Roma children were identified with evidence of past infection (anti-HBc(+)), among whom five (4% of the total) were chronic carriers (HBsAg(+)), whereas no past infection was detected among the non-Romas (P < 0.0001). Markers of past HBV vaccination (anti-HBs(+), anti-HBc(-)) were detected in only 14% Roma but 96% non-Roma children (P-value < 0.0001). There was some indication for intrafamilial transmission of HAV and HBV in Roma school children. Unfavorable living conditions, frequent residency change, lack of child insurance and primary healthcare delivery were significantly associated with seroprevalence of HBV infection among Romas. No child in either group was found positive for HCV markers. These findings document high socioeconomic differentials with regards to preventable communicable diseases, such as HAV and HBV and underline the need for enhancing health policy action targeting pockets of minority childhood populations. Whereas, uptake of HBV vaccination is rather optimal in this general population, the high seroprevalence of HAV among Romas, also calls for implementing general vaccination for HAV, early in life. J. Med. Virol. 80:791-797, 2008. (c) 2008 Wiley-Liss, Inc.

Abstract: OBJECTIVE: To compare cause-specific unintentional injury mortality trends among elderly (65+) in the European Union over a 10-year period. METHOD: Overall and cause-specific data for 23 out of the 29 EU and European Free Trade Association countries with population >/= 1,000,000 were retrieved from the World Health Organization (WHO), and age-standardized mortality rates for the first and last 3 available years of the study period were calculated. Proportional mortality changes were estimated through linear regression. RESULTS: Circa 1993, country-specific rates varied widely (>fourfold), but this gap is closing and a statistically significant downward trend in overall mortality is noted circa 2002, in about half of the countries. Rates from falls were reduced by 4.3%, from motor vehicle traffic by 3.1%, and from smoke, fire, and flames by 3.1%. DISCUSSION: A large proportion of EU countries enjoys steady declining trends by major unintentional injury mortality category. Success factors and barriers underlying these benchmarking patterns should be further explored to accelerate the process of injury reduction.

Abstract: BACKGROUND: Monitoring time trends in the incidence of childhood leukaemias and lymphomas requires a well functioning and continuously data collecting system. In countries missing official cancer registries, like Greece, ad hoc nationwide registration of incident childhood leukaemias and lymphomas could provide a useful tool also for the elucidation of underlying etiology and monitoring socioeconomic differentials in health care delivery. METHODS: We registered all cases and produced age-, gender-, type- and immunophenotype-specific figures as well as overall crude and age adjusted annual incidence rates and secular trends for 863 leukaemia and 311 lymphoma incident cases diagnosed in children under 15 years across Greece during 1996-2006, namely the first 11 years of the Nationwide Registry for Childhood Hematological Malignancies (NaReCHeM). RESULTS: The epidemiological profile of leukaemias/lymphomas in Greece is in line with those noted in industrialized countries. No secular trends are observed for either malignancy during the studied period. The calculated incidence for leukaemia (46.60 cases per 1 million children annually), however, is among the highest in the EU-27 (19% higher than average; p< 0.0001), a finding unlikely to be explained by registration artefacts. By contrast, the calculated incidence for lymphoma (16.8 cases per 1 million children annually) is around the EU-27 average. CONCLUSIONS: Minimal secular changes of childhood leukaemias/lymphomas have been noted recently, in EU-27, which cannot be easily interpretable in countries of relatively small population size.Therefore, enrichment of centralized EU databases such as the Automated Childhood Cancer Information System (ACCIS) should be encouraged to generate sufficient statistical power for monitoring time trends. It is of interest, however, to further explore whether the variant lifestyle patterns across EU population groups might be responsible for the observed excess leukaemia incidence in countries, such as Greece.

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Abstract: BACKGROUND: Solar radiation has been identified as a principal factor for the causation of melanoma, whereas changing lifestyle patterns associated with obesity and diabetes might also contribute to the increasing incidence of the malignancy. No study has investigated the role of leptin, a hormone whose levels increase in obesity and which has also been related to cancer. PATIENTS AND METHODS: Fifty-five patients with incident melanomas and 165 age- and gender-matched healthy controls were interviewed on the basis of a questionnaire that covers phenotypic features, sociodemographic and medical history variables, lifestyle habits and frequency of consumption of major food groups. Anthropometrical measures were also recorded and blood samples were obtained for determination of serum leptin levels. Adjusted odds ratios (ORs) for melanoma risk were derived through multiple logistic regression analyses. RESULTS: An excess melanoma risk was observed for sun sensitive individuals and those with high circulating levels of leptin (OR: 1.56, 95% confidence interval 1.07-2.28, P = 0.02), after controlling for obesity indices, diabetes mellitus and education. Increased physical exercise, lower alcohol consumption and plant food consumption seem to play a protective role against melanoma development. CONCLUSIONS: Melanoma risk was found to be positively associated with serum leptin levels and inversely with healthy lifestyle factors. The findings need to be confirmed in prospective studies.

Abstract: OBJECTIVE: To analyse international variation in clinical injury incidence, and explore the performance of different injury indicators in cross-country comparisons. METHODS: Hospital discharge data of seven European countries (Austria, Denmark, Ireland, Netherlands, Norway, England and Wales) were analysed. We tested existing and newly developed indicators based on (a) health care use, (b) anatomical criteria, or (c) expected health outcome: admissions excluding day-cases (a), hospital stay 4+ (a) and 7+ days (a), (serious) long-bone fractures (b), selected radiological verifiable fractures 'SRVFs' (b), and indicators based on international (Global Burden of Disease) and Dutch disability weights). Assessment criteria were reduction in incidence variation and length of stay in hospital, and the association between incidence and mortality rates. RESULTS: Indicators based on health care use led to increased variation in incidence rates. Long bone fractures and SRVFs, and both indicators based on injuries with moderate to high disability showed similar variation in clinical incidence compared to the crude rates, smaller variation in median length of stay in hospital and a good association with mortality rates. CONCLUSION: No perfect or near perfect indicators of clinical injury incidence exist. For international comparisons, indicators based on disability weights, SRVFs and long bone fractures may be sensible indicators to use, in the absence of a direct measure of anatomical severity.

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Abstract: BACKGROUND: Decreased circulating levels of adiponectin, an adipocyte-secreted hormone and endogenous insulin sensitizer, have been associated with several obesity-related malignancies. Thiazolidinedione administration, which increases adiponectin levels, decreases risk for lung cancer. Whether circulating adiponectin levels are associated with lung cancer and/or whether adiponectin receptors are expressed in lung cancer remains unknown. METHODS: We conducted a case-control study of 85 patients with incidental, histologically confirmed lung cancer and 170 healthy controls matched by gender and age. In a separate study, archival lung specimens from 134 cancerous and 8 noncancerous tissues were examined for relative expression of adiponectin receptors AdipoR1 and AdipoR2 using immunohistochemistry. RESULTS: Tobacco smoking, heavy alcohol intake and education were all associated with lung cancer risk, whereas serum adiponectin levels were not significantly different between cases and controls (multiple logistic regression, odds ratio per SD of adiponectin among controls: 1.13, 95% confidence interval: 0.64-2.02). Adiponectin levels were significantly lower (odds ratio: 0.25, 95% confidence interval: 0.10-0.78) among patients with advanced compared to those with limited disease stage. Expression of adiponectin receptors was apparent only in the cancerous lung tissue (64.2% AdipoR1 and 61.9% AdipoR2 in cancerous vs. 0% among noncancerous tissue). Specifically, AdipoR1 was expressed in all disease types, but no difference was noted with disease stage, whereas AdipoR2 was mainly expressed in the non-small cell carcinomas and more prominently in the advanced disease stage (80%). CONCLUSIONS: Circulating adiponectin levels are not different in cases of this malignancy - which seems to be unrelated to obesity and insulin resistance - compared to their healthy controls, though hormonal levels were significantly lower in advanced versus limited lung cancer. Both adiponectin receptors were expressed in cancerous lung tissue, but not in normal control tissue and there was a differential expression by disease stage. These findings should be further explored, especially in the context of the recently reported protective effect of thiazolidinediones in diabetic patients with lung cancer.

Abstract: Adiponectin is a novel endogenous insulin sensitizer, secreted by mature adipocytes. Circulating levels of adiponectin are inversely associated with obesity and insulin resistance. Because obesity is a risk factor for renal cell carcinoma (RCC), we hypothesized that low adiponectin levels are associated with RCC. To evaluate this hypothesis, we conducted a case- control study of 70 patients with histologically confirmed RCC and 280 healthy controls matched by gender, age and county of residence. Study subjects were interviewed and blood samples were collected during a 32-month period in Athens, Greece. Serum adiponectin levels were statistically, significantly and inversely associated with RCC when compared with controls (OR=0.76, p=0.05) and this association remained practically unchanged after controlling for BMI; the introduction of waist to hip ratio along with adiponectin in the multiple logistic regression analysis model rendered the association between adiponectin and RCC risk insignificant, indicating that altered levels of adiponectin may mediate the effect of central or intra-abdominal obesity on RCC. Prospective studies as well as studies exploring underlying mechanisms are needed to fully explore the role of adiponectin in predicting future risk of RCC in humans.

Abstract: OBJECTIVE: To assess injury-related mortality, disability and disability-adjusted life years (DALYs) in six European countries. METHODS: Epidemiological data (hospital discharge registers, emergency department registers, mortality databases) were obtained for Austria, Denmark, Ireland, Netherlands, Norway, and the United Kingdom (England and Wales). For each country, the burden of injury was estimated in years lost due to premature mortality (YLL), years lived with disability (YLD), and DALYs (per 1000 persons). FINDINGS: We observed marked differences in the burden of injury between countries. Austria lost the largest number of DALYs (25 per 1000 persons), followed by Denmark, Norway and Ireland (17-20 per 1000 persons). In the Netherlands and United Kingdom, the total burden due to injuries was relatively low (12 per 1000 persons). The variation between countries was attributable to a high variation in premature mortality (YLL varied from 9-17 per 1000 persons) and disability (YLD varied from 2-8 per 1000 persons). In all countries, males aged 25-44 years represented one third of the total injury burden, mainly due to traffic and intentional injuries. Spinal cord injury and skull-brain injury resulted in the highest burden due to permanent disability. CONCLUSION: The burden of injury varies considerably among the six participating European countries, but males aged 15-24 years are responsible for a disproportionate share of the assessed burden of injury in all countries. Consistent injury control policy is supported by high-quality summary measures of population health. There is an urgent need for standardized data on the incidence and functional consequences of injury.

Abstract: BACKGROUND: This study aims to explore the debatable role of allergy in breast cancer (BC) by using country-specific biological markers, namely levels of the most prevalent allergen-specific immunoglobulin E in Greece. PATIENTS AND METHODS: Blood samples and clinical information were collected over a 30-month period from 103 women with histologically-confirmed BC and 103 controls from two university hospitals in Athens. Allergen-specific IgE, against the 12 prevailing allergens in Greece were determined; thereafter, a score comprising the sum of the individual values for this battery of serological IgE determinations was created. Bivariate and multiple logistic regression analyses were undertaken using case-control status as the outcome and IgE-scores as the predictor variable, controlling for socio-demographic, gynecological and lifestyle confounders. RESULTS: The serum IgE score seemed to be positively related to BC (OR: approximately 1.73; CI: 0.95-3.14; p-value: 0.07). A positive correlation between serological evidence and allergic history among controls was also found (p-value: 0.06). CONCLUSION: This investigation suggests an IgE-mediated allergic response among women with BC in comparison to their controls. The finding needs confirmation by immuno-epidemiological investigation to clarify the directionality of this association and whether laboratory-ascertained atopy can be considered as a risk-marker of susceptibility in the development of BC.

Abstract: OBJECTIVES: To explore whether the inverse association of sun exposure with non Hodgkin lymphoma among adults is also evident among the childhood population and test the specificity of the relation by contrasting the findings to those for Hodgkin lymphoma. METHODS: A total of 87 cases of childhood (0-14 years) with non Hodgkin lymphoma and 71 with Hodgkin lymphoma, diagnosed in Greece through the national network of childhood Hematology-Oncology Units, during a 7-year period, along with 164 age- and gender-matched control children were enrolled in the study. The guardians of all eligible children were interviewed in person on the basis of a structured questionnaire covering socio-demographic, anthropometric, and perinatal characteristics. Average time of sunbathing per year at a seaside resort was used as a proxy variable of exposure to sun controlling for use of sun protection measures. RESULTS: The estimated incidence of 10.2 cases per 1,000,000 children-years {95% Confidence Intervals (CI), 8.4-12.1} for NHL during the study period in Greece is around the average figure in countries of the European Union. There was an inverse association of sun exposure with Non Hodgkin lymphoma, namely, for an increment of 15 days of sunbathing at seaside resorts children had almost 40% lower risk (Odds Ratio: 0.60, 95% CI: 0.43-0.83), whereas no such association was evident for Hodgkin lymphoma. The risk for non Hodgkin lymphoma has been found to be statistically and significantly higher in birth weight (Odds ratio: 1.42 and 95% CI, 1.04-1.92, for every 500 g increment), whereas there was no substantial indication that maternal education or maternal smoking during the child's life were important risk factors for the disease. CONCLUSIONS: This is the first study to provide epidemiological evidence that increased sun exposure of children may also be associated with a decreased risk of developing childhood non Hodgkin, but not Hodgkin lymphoma.

Abstract: The objective of this study was to quantify improvements in survival due to chemotherapy among children with medulloblastoma treated during the last three decades at a university unit in Greece, compare these gains with figures derived from a specialized unit in the United States and explore the role of extrinsic factors affecting survival. The records of all children with medulloblastoma (n=50) treated at the University Childhood Oncology Unit in Athens, Greece during the period 1973-2003 were reviewed. The role on survival of socio-demographic factors was studied by modeling the data through Cox's proportional-hazards regression, controlling for the mode of treatment (chemotherapy, yes vs. no), whereas survival of children with medulloblastoma treated in Greece was compared with that of 76 children treated in a specialized center in the United States during a respective period. After adjustment for demographic factors, children with medulloblastoma who received adjuvant therapy in Greece had an approximately four times higher instantaneous rate of remaining alive than those who did not (P=0.05). The 5-year survival of children with medulloblastoma treated at specialized medical centers in Greece and the United States was 66 and 63%, respectively. Despite the comparable figure with that of an acceptable standard, however, there was a suggestion (P=0.07) that a rural place of residence in Greece is a poor prognostic indicator. Assuming inherently similar age of occurrence in urban and rural areas, children from rural areas in this study had a more advanced age at diagnosis than those residing in urban Greece (mean age: 7.9 vs. 6.6 years) with a 5-year survival of 57 and 73%, respectively. As expected, incorporation of adjuvant chemotherapy in the treatment of Greek children with medulloblastoma has yielded remarkable improvement in 5-year survival, comparable to that of technologically advanced countries. On the contrary, children residing in rural areas of the country seem to enjoy less favorable prognosis, possibly owing to delays in diagnosis or limited access to optimal treatment facilities.

Abstract: OBJECTIVES: To compare patient- and injury-related characteristics of trauma victims and pre-hospital trauma care systems among different developed and developing countries. METHOD: We collated de-identified patient-level data from national or local trauma registries in Australia, Austria, Canada, Greece, Germany, Iran, Mexico, New Zealand, the Netherlands, the United Kingdom and the United States. Patient and injury-related characteristics of trauma victims with injury severity score (ISS) >15 and the pre-hospital trauma care provided to these patients were compared among different countries. RESULTS: A total of 30,339 subjects from one or several regions in 11 countries were included in this analysis. Austria (51%), Germany (41%) and Australia (30%) reported the highest proportion of air ambulance use. Monterrey, Mexico (median 10.1min) and Montreal, Canada (median 16.1min) reported the shortest and Germany (median: 30min) and Austria (median: 26min) reported the longest scene time. Use of intravenous fluid therapy among advanced EMS systems without physicians as pre-hospital care providers, varied from 30% (in the Netherlands) to 55% (in the US). The corresponding percentages in advanced EMS systems with physicians actively involved in pre-hospital trauma care, excluding Montreal in Canada, ranged from 63% (in London, in the UK) to 75% in Germany and Austria. Austria and Germany also reported the highest percentage of pre-hospital intubation (61% and 56%, respectively). CONCLUSION: This study provides an early look at international variability in patient mix, process of care, and performance of different pre-hospital trauma care systems worldwide. International efforts should be devoted to developing a minimum standard data set for trauma patients.

Abstract: AIMS: The wide variation of unintentional (accidental) injury mortality rates in the European Union (EU) member states suggests that there is high potential for prevention. This paper attempts to quantify the potential for saving lives in this part of the world if all 25 member states were to learn from the experience of countries with advanced injury prevention records. METHODS: Unintentional injury mortality data (latest three available years), including denominator population estimates, were obtained from the World Health Organization (WHO) mortality database for all 22 EU countries with a population of more than one million. Annual average age-adjusted injury mortality rates were used to derive the potential for saving of lives under two scenarios: (a) if all EU member states matched the country with the lowest unintentional rate for all causes of injury combined; (b) if the benchmark was alternatively the country with the lowest unintentional injury cause-specific rate. Separate calculations were performed for children (0-14), adults (15-64), and the elderly (65 and over). RESULTS: Under the first scenario, over 73,000 lives could have been saved in the EU 25 in a single year, notably nearly half (47.4%) fewer unintentional injury deaths could be observed in children, over half in adult (54%), and two-fifths (38%) in the elderly. Under the second, more optimistic, scenario 59% of childhood and adult and 75% of unintentional injury deaths among the elderly would have been avoided. CONCLUSIONS: A substantial proportion of lives lost due to unintentional injury might be saved if all countries were to achieve the lowest unintentional injury mortality rates in the EU. The above calculations are based on a simple theoretical model but there is increasing evidence on the array of existing effective preventive interventions and improved trauma care calls for public health action in each member state that could in practice halt, to the extent possible, the unintentional injury epidemic.

Abstract: OBJECTIVES: To explore whether an intervention during mandatory schooling can lead to age-specific changes in water safety knowledge and attitudes. METHODS: Age-specific questionnaires were distributed to 202 kindergarten and grade one pupils, 220 elementary school pupils and 337 pupils attending the first three high school grades in Greater Athens. The information was used to design an educational package that was subsequently presented to pupils of the same grades and similar socio-demographic profiles attending different schools in the same area. One month later, a post-exposure evaluation was conducted using the initial questionnaires, in which 115, 205 and 321 pupils from the respective grade categories provided their responses. In order to compare the performance of pupils exposed to the educational intervention with that of pupils who participated only in the initial assessment, mean differences in scores measuring overall knowledge and attitudes were estimated within each of the three grade groups adjusting for age, gender, sibship size, maternal education and swimming knowledge. RESULTS: Among kindergarten and grade one pupils, those who received the intervention scored significantly higher for knowledge (17.40%, 95% CI 6.41% to 28.39%) and attitudes (23.64%, 95% CI 4.48% to 42.79%). Among elementary school pupils the gains in knowledge were less evident (14.58%, 95% CI -3.05% to 32.21%)) and almost null in attitudes (5.64%, 95% CI -11.47% to 22.77%). Further advancement of age showed no improvement in knowledge (-0.15%, 95% CI -5.30% to 4.99%) and a minimal, insignificant increase in attitudes (6.32%, 95% CI -1.87% to 14.52%) among exposed high school pupils. CONCLUSION: The school-based intervention resulted in considerable positive changes in knowledge and attitudes among very young pupils. Elementary schooling seems to provide meagre opportunities to simply improve knowledge. Alternative/complementary approaches should be sought in any attempt to modify behavior.

Abstract: AIM: Melanoma, a malignancy with steadily increasing prevalence, has been associated not only with sun exposure but also with phenotypic characteristics including obesity. Adiponectin, an adipocyte secreted endogenous insulin sensitizer, has been found to play a protective role in several obesity related cancers but has not yet been studied in relation to melanoma. We investigated the association of circulating adiponectin levels with melanoma in Greece, a country with rather low incidence of the disease and high annual sunshine levels. METHODS: In the context of a case-control study, we studied over a 22-month period 55 patients with incident, histologically confirmed melanoma cases and 165 healthy controls matched for gender and age. RESULTS: After controlling for the possible confounding effect of education, body mass index and waist-to-hip ratio in multiple logistic regression analyses, sun sensitive skin type was significantly and positively associated with melanoma risk (OR: 2.48, 95% Confidence Interval: 1.22-5.10, p: 0.01). On the contrary, there was a sizeable, though non-significant, inverse association of serum adiponectin levels with the disease (OR: 0.75, 95% Confidence Interval: 0.52-1.10, p: 0.14). CONCLUSION: A protective role of adiponectin in the development of melanoma cannot be excluded given the presented empirical evidence (25% reduction per one SD of adiponectin) and the direct anti-neoplastic features of the hormone. The results are intriguing enough to point to the need for further investigation.

Abstract: Two web-based Delphi surveys were used to derive feasible cost-effective injury prevention actions aimed for the development of a policy document in the European Union. Forty nine experts out of 92 contacted, comprising the members of the European Union Working Party on Accidents and Injuries (WP-AI) and world experts were polled in order to define and subsequently rank, according to perceived level of importance, key injury prevention priorities (1st survey). Subsequently, 38 of initially contacted experts, contributed to the production of a list of cost-effective actions to address each of the top priorities, whereas 32 were also willing to score them (2nd survey). The 10 top priorities delivered by world experts coincided to those delivered by the WP-AI, except that the former group top-ten prioritized �increase injury research/data collection/injury awareness� instead of the �childhood injuries in general�, chosen by the WP-AI panel. Efficient prevention actions at the population level proposed by all experts mainly focus on passive injury prevention measures (in particular targeting unintentional injuries), whereas actions targeting behavioral modification were considered less efficient, at least in the short run. The importance of research funds as a prerequisite for both injury surveillance and analyses of existing data sources was again emphasized, whereas linkage of alternative injury records seems to receive a low feasibility score. The hierarchical list of priorities and actions for injury prevention along with most efficient policies is hoped to facilitate the European Union and individual member states to adopt initiatives deemed to curb the injury epidemic.

Abstract: Whether serum testosterone (T) can become an adjunct test able to validate the PSA-weighted risk of prostate cancer (PR.CA) in the "grey" diagnostic area (PSA =3.0 to <10.0 ng/ml) was investigated. Seven hundred and eighteen men participated in a prostate screening program using the cutoff PSA value of > or =3.0 ng/ml. PR.CA was found in 26% (22/85) of men with PSA testing within the "grey" diagnostic area and 58% (7/12) with PSA testing > or =10 ng/ml, among the 97 men who agreed to undergo transrectal ultrasound-guided biopsy (TRUS-guided biopsy). The PSA values showed a statistically significant positive association with diagnosis of PR.CA, whereas T and the T/PSA ratio were inversely and significantly related to the disease. In addition, out of 718 subjects, 45 (2.6%) were found to have a T value <2.6 ng/ml and another 78 (10.8%) had "low normal T value" (2.6> or = T <3.0 ng/ml). Of the hypogonadal men, 16 received testosterone enanthate (depot T; 250 mg/ml oily injection, intramuscularly: i.m.; TRT) and three had PSA levels >3.0 ng/mlpost-TRT; one was eventually diagnosed with PR.CA. An empirically-determined cut-off of the T/PSA ratio [>95 ("negative") or <0.95 ("positive")] was found to be optimal with regard to both sensitivity/specificity. This test was "positive" among 95.5% of the PR.CA patients, whereas 81% of biopsies confirmed that non-PR.CA had a "negative" TIPSA ratio, indicating that this ratio can become an adjunct screening test in assessing the risk of PR. CA; in particular, the odds of PR. CA increasing sharply (1/0.08= 12.5 times) with a decrease of the TIPSA ratio by one standard deviation. We conclude that the measurement of the serum T value can become an adjunct test validating further the PSA-weighted risk of PR. CA within the "grey" diagnostic area.

Abstract: OBJECTIVE: To explore the scope for reducing the number of intentional injury deaths, hypothesizing that all European Union (EU) countries are able to match the experience of the country with the lowest mortality rate for intentional injuries. DESIGN: Intentional injury mortality data for the three last available years and denominator population estimates were obtained from the World Health Organisation mortality database for the 22 EU countries with more than one million population. To estimate the potential saving of lives, the yearly average age adjusted injury mortality rates were calculated. This issue done for children (0-14), adults (15-64), and elderly people (65 and over), both including and excluding deaths from undetermined cause. MAIN OUTCOME MEASURES: Number of lives that might potentially be saved if all EU member states matched the lowest intentional injury rate reported by an EU member state. RESULTS: Over 73% of all intentional injury deaths could have been avoided if all EU countries matched the country with the lowest intentional injury mortality rate. EU member states would have suffered about 600 fewer intentional injury deaths in children, about 40 000 fewer adult deaths, and over 14 000 fewer intentional injury deaths in the elderly. This amounts to over 55 000 lives in a single year. CONCLUSIONS: Many lives lost through injury might be saved if all countries were to achieve the lowest intentional injury mortality rates reported in the EU. How this theoretical observation might be translated into practice needs to be further explored as the international variation in intentional injury mortality rates in the EU results from a range of factors.

Abstract: The early (intrauterine and neonatal) life environment plays an important role in programming the susceptibility in later life to chronic degenerative diseases, such as obesity, cardiovascular diseases, diabetes mellitus, cancer and osteoporosis.Among other hormones, leptin plays a major role in the regulation of the overall metabolism and has multiple neuroendocrine (adeno- and neuro-hypophysis axes and the hypothalamus-pituitary-adrenal axis) and immune functions.The hormone exerts its actions beginning in the early life time period, regulating the intrauterine and early extrauterine life growth and development, as well as the adaptation to extrauterine life, neonatal thermogenesis and response to stress. Recent findings also support a role of leptin in the process of fetal bone remodeling and brain development.Therefore, it is of interest to explore the physiology of leptin in early life, as well as those factors that may perturb the balance of the hormone with pathological consequences in terms of confining an increased risk for disease in later life.This review aims to summarize reported findings concerning the role of leptin in early life, as well as the association of fetal, maternal and placental factors with leptin levels, while attempting to speculate mechanisms through which these factors may influence the risk for developing chronic diseases in later life.

Abstract: Data on doping among young non-professional athletes are scarce. In order to estimate the prevalence and predictors of doping use, a standardized, anonymous questionnaire was self-administered by 2650 tertiary education students from five European Union countries (Finland, France, Germany, Greece, Italy) and Israel. The reported usage rate of a doping agent (at least once) was 2.6%, with no significant variation in the frequency of doping reporting among the participating countries. Doping was, however, less common among students of biomedical schools (OR: 0.49, 95% CI: 0.27-0.89) and was higher among males (OR: 2.16, 95% CI: 1.25-3.74). Students, who use to drink coffee or recall frequent occasions of involvement in drunkenness episodes, were more likely (twice and three times, respectively) to report doping, and students using nutritional supplements or having participated in a major athletic event were more likely (four times and twice, respectively) to report doping in comparison with students who do not. Of note is the high odds ratio for reporting individual doping when having a friend who uses doping (OR: 8.61, 95% CI: 4.49-16.53). Given the large size of the physically active young individuals in the population and the small number of professional athletes, doping in the general population may be, in absolute terms, as sizeable problem as it is among the professional athletes. There was evidence that high-risk behaviour and supplement use increased the risk of doping.

Abstract: OBJECTIVES: To estimate the incidence and epidemiological profile of childhood (0-14 years) Hodgkin's lymphoma in Greece derived by the network of childhood Hematology-Oncology departments on the basis of all 95 newly diagnosed cases during a seven-year period. METHODS: Seventy-one of these cases were individually age and gender matched to an equal number of controls. RESULTS: The incidence of childhood Hodgkin Lymphoma reached a relatively high figure of 7.8 per million children-years, with an age distribution (2.2 for children 0-4; 6.3 for those 5-9 and 13.9 for those 10-14-years-old) and male to female ratio (1.7:1) similar to that reported from other cancer registries. Childhood Hodgkin's lymphoma was more common among children living in less crowded quarters (odds ratio (OR): 6.5 and 95% confidence intervals (95% CI): 1.4-30.7), among those who have changed residence 60 to 18 months before the onset of the index disease (OR: 4.4, and 95% CI = 1.4-14.0), among those whose families owned a cat (OR: 5.5, 95% CI = 1.2-25.6) but not among those whose families owned a dog and marginally more common, among those with a history of infectious mononucleosis (OR: 5.0, 95% CI = 0.6-42.8). CONCLUSIONS: Our results point to infectious agent(s) as playing an etiological role but do not allow discrimination among the delayed establishment of the herd immunity hypothesis, the population mixing hypothesis or that invoking transmission of the agent(s) from the non-human reservoir.

Abstract: BACKGROUND: The aim of the current study is to investigate the relationship between physical anhedonia and psychopathological parameters, pharmacological parameters or motor side-effects in a sample of inpatients with schizophrenia in an acute episode of their illness. METHOD: Eighty one patients with schizophrenia, consecutively admitted, with an acute episode of their illness, at the Eginition Hospital, Department of Psychiatry, University of Athens, during a one-year period were investigated regarding possible relationships between physical anhedonia, social-demographic data and clinical parameters as well as motor side-effects, induced by antipsychotic agents. All patients were assessed using the Chapman Revised Physical Anhedonia Scale (RPAS), the Positive and Negative Syndrome Scale (PANSS), the Rating Scale for Extrapyramidal Side-Effects (EPSE), the Barnes Akathisia Rating Scale (BARS) and the Abnormal Involuntary Movement Scale (AIMS). Simple cross tabulations were initially employed. Subsequently, multiple regression analysis was performed. RESULTS: Both positive and negative symptoms were associated with physical anhedonia. A positive association between physical anhedonia and the non-paranoid sub-category of schizophrenia was also proved. CONCLUSION: According to these results, it seems that in the acute phase of schizophrenia, physical anhedonia may be a contributing factor to patient's psychopathology.

Abstract: OBJECTIVE: To assess the relation between specific flavonoid classes and peripheral arterial occlusive disease (PAOD), an important manifestation of atherosclerosis. DESIGN: Using data from a case-control study conducted in Greece in 1980 on the nutritional epidemiology of PAOD, we have exploited recently published databases on the content of foods in specific flavonoid classes to assess the relation between intake of these compounds and PAOD. SETTING: A major teaching hospital in Athens, Greece. SUBJECTS: Cases were 100 patients with PAOD and controls 100 patients with minor surgical conditions admitted to the same hospital. INTERVENTIONS: No interventions. All cases and controls were interviewed in the hospital wards, and a 110-food item semiquantitative food frequency questionnaire was administered by the same interviewer. RESULTS: Flavonols, flavones and perhaps flavan-3-ols were inversely associated with PAOD risk, the odds ratios (and 95% confidence intervals) for increments equal to the corresponding standard deviations being 0.41 (0.20-0.86), 0.56 (0.32-0.96) and 0.53 (0.26-1.05), respectively. Total flavonoids were also significantly inversely associated with PAOD. CONCLUSIONS: On the basis of these results, the biological properties of flavonoids and evidence concerning their relation to other manifestations of atherosclerosis, we conclude that dietary intake of specific classes of flavonoids, as well as total flavonoids, may have a protective effect against PAOD. SPONSORSHIP: This study was partially supported by a grant to Harvard University by the Samourkas Foundation.

Abstract: Adiponectin, an adipocyte-specific secretory protein known to induce apoptosis, has been reported to be inversely related to breast and endometrial cancers and recently found to inhibit proliferation of myeloid but not lymphoid cell lines. We hypothesised that adiponectin may be inversely associated with acute myeloblastic leukaemia (AML), but not with acute lymphoblastic leukaemia of B (ALL-B) or T (ALL-T) cell origin in children. Blood samples and clinical information were collected over the period 1996-2000 from 201 children (0-14 years old) with leukaemia (22 AML, 161 ALL-B and 18 ALL-T cases) through a national network of childhood Hematology-Oncology units in Greece and from 201 controls hospitalised for minor pediatric ailments. Serum adiponectin levels were measured under code, at the Beth Israel Deaconess Medical Center, Boston, MA, USA using a radioimmunoassay procedure. Each of the three leukaemia groups was compared with the control group through multiple logistic regression. Odds ratios (OR) and 95% confidence intervals (95% CI) for an increase of adiponectin equal to 1 s.d. among controls were estimated controlling for gender, age, as well as for height and weight, expressed in age-gender-specific centiles of Greek growth curves. Adiponectin was inversely associated with AML (OR=0.56; 95% CI, 0.34-0.94), whereas it was not significantly associated with either ALL-B (OR=0.88; 95% CI, 0.71-1.10) or ALL-T (OR=1.08; 95% CI, 0.67-1.72). Biological plausibility and empirical evidence point to the importance of this hormone in the pathogenesis of childhood AML.

Abstract: OBJECTIVE: To investigate predictors of circulating leptin in healthy full-term newborns and to explore the relationship with anthropometric variables, serum levels of adiponectin and the major components of the IGF system at birth. To explore whether leptin levels are regulated by breastfeeding vs. formula feeding. DESIGN: Observational cross-sectional study. PATIENTS: Three hundred and nineteen healthy full-term newborns delivered during 1999 in Athens, Greece. MEASUREMENTS: Anthropometric measurements, formula feeding information and blood samples were obtained. Leptin and adiponectin determinations were performed using a radioimmunoassay (RIA). RESULTS: Multivariate regression analyses showed that leptin levels were positively associated with female gender, newborn length, ponderal index and IGF-I levels, but not with adiponectin levels. Newborns who were fed exclusively with milk formulas had more than twice the leptin levels of those who were exclusively breastfed. CONCLUSIONS: Leptin levels are positively related to female gender and anthropometric characteristics of neonates but, contrary to studies in adults, are not correlated with adiponectin levels. We also found evidence that formula feeding imparts a considerable increase in leptin levels in newborns.

Abstract: PURPOSE: To identify measures that should reduce the incidence of burn injuries resulting from motorcycle exhaust pipes through epidemiological analysis of such injuries. BASIC PROCEDURES: During a 5-year period, 251 persons who suffered burn injuries related to motorcycle exhaust pipes have contacted four major hospitals belonging to the Emergency Department Injury Surveillance System (EDISS) operating since 1996 in Greece. These burn injuries were studied in relation to person, environment and vehicle characteristics. MAIN FINDINGS: The estimated countrywide incidence of burns from motorcycle exhaust pipes was 17 per 100,000 person-years (208 per 100,000 motorcycle-years). The incidence was two times higher for children than for older persons and among the latter it was 60% higher among females than among males. Most of burn injuries (70.5%) concerned motorcycle passengers, mainly when getting on or off motorcycle, with peak incidence during summer. The most frequent location of burn wounds was below the knee and particularly the right leg. It was estimated that the risk of motorcycle exhaust pipe burns when wearing shorts could be reduced by 46% through wearing long pants. Among the victims 65.3% experienced second degree burns. PRINCIPAL CONCLUSIONS: Motorcycle exhaust burns could be substantially reduced by systematically wearing long pants, by incorporating in the design of motorcycles external thermo resistant shields with adequate distance to the exhaust pipe, and by avoiding riding with children on motorcycles.

Abstract: BACKGROUND: Unintentional injuries in childhood constitute a significant public health problem. Our purpose is to estimate the incidence of identifiable unintentional childhood injuries of any type and severity, and to document risk factors of non-transient nature. METHODS: We have undertaken a prospective population-based investigation in a Greek town with a population of 748 children (0-14 years old). All identifiable injuries have been monitored during a twelve-month period through information provided by the health care outlets or educational institutions as well as the police station and the regional hospital. RESULTS: The overall incidence was 28.2 per 100 person-years (95% confidence interval from 24.4 to 32.0), whereas the incidence of injuries with Hopkins Injury Severity Score equal to or higher than four was 6.3 with 95% confidence interval 4.5 to 8.1. The incidence of total injuries was higher among boys than among girls (p<0.01) and the gender difference was particularly evident among older children. Almost half of the injuries were due to falls and more than 20% were due to cutting. Children of younger and less educated parents have higher risk for injury and children from families with more injuries were more likely to be injured themselves. There was no evidence that somatometric characteristics were associated with injury risk. CONCLUSION: The incidence of unintentional childhood injuries is high and represents a considerable health burden. Family related variables are important risk factors for childhood injuries, whereas somatometric characteristics play a minimal role. Key points: Incidence and risk factors of all injuries in a population-based study among children. About 28 per 100 children got injured over a period of one year. There is evidence that younger paternal age and lower education may be associated with increased injury risk. Family related variables seem to be important risk factors for childhood injuries, whereas somatometric characteristics play minimal role.

Abstract: AIMS: The results of an infant car-restraint loan scheme and evaluate its cost-effectiveness are presented. METHODS: The intervention programme was initiated in 1996. Car-restraints, donated by manufacturers, were lent for a six-month period to eligible prospective parents for a modest fee. Specially trained health visitors performed in-person interviews with the participating parents. The data were collected and recorded on a pre-coded questionnaire. Cross-tabulations and multiple logistic regression were performed to analyse the data. Subsequent purchase of a next-stage car restraint, suitable for older children (up to four years of age) was considered as a proxy measure of the success of the programme. This information, along with the detailed operational and financial data collected during the implementation phase of the programme, was used to develop a model to assess the cost-effectiveness of a countrywide intervention. RESULTS: During a two-year period 188 families participated in a survey. On return of the infant car restraint, 92% of the participants reported proper use of the device and 82% had already purchased the second-stage car restraint. Parental age, gender, or educational status was not predictive of positive parental road safety practices for the newly born, whereas history of parental seat-belt use--as a proxy of personal road safety behaviour--was positively correlated with the likelihood of purchasing a second-stage car-restraint device. The cost-effectiveness ratio varies between 418.00 euro and 3,225.00 euro per life-year saved, depending on whether the modest administrative fee is considered. CONCLUSIONS: On the basis of plausible assumptions, a loan programme of infant car-restraints was shown to be particularly cost effective.

Abstract: It has been reported that the cyclin-dependent kinase inhibitor (CDKI) gene p15INK4B is frequently inactivated by genetic alterations and may be responsible for various malignant tumours. Another way of inactivation of this CDKI is by hypermethylation of 5'CpG islands in the promoter region of the p15INK4B gene and this inactivation seems to be a frequent event in various haematological malignancies. In the present study, we investigated the methylation status of the p151NK4B gene to clarify its role in the pathogenesis of childhood acute myeloid (AML) and acute lymphoblastic leukaemia (ALL). The study included 23 cases of B-cell origin ALL, 13 cases of T-cell origin ALL, 32 cases of AML, and 10 apparently healthy controls. Hypermethylation was studied by methylation-specific polymerase chain reaction. Hypermethylation of the p15INK4B gene was more frequent in cases with T-cell origin ALL (46.2%), but similar among children with B-cell origin ALL (13.0%) and AML (18.8%). Hypermethylation of p15INK4B may be involved in the pathogenesis of T-cell origin ALL, but not in that of AML or B-cell origin ALL.

Abstract: BACKGROUND: Depression in late life is common and has serious consequences on function, medical co-morbidity, quality of life, and use of medical services. OBJECTIVE: To estimate the age- and gender-specific prevalence of depression among people over 60 years of age, and to examine correlates of depression, in particular the relationship between depression and cognitive impairment. METHOD: From a total of 965 inhabitants, aged over 60 years, in Velestino, a rural town in central Greece, 608 were accessible and constituted the target population. During a five-month period in 2000, a trained health visitor interviewed all study participants. The interview covered socio-demographic characteristics, medical history, and administration of the 15-question Geriatric Depression Scale (GDS-15) and the Mini Mental Scale Examination instrument (MMSE). RESULTS: The prevalence of mild or more severe depression (GDS> or =7) was 27%, while the prevalence of moderate to severe depression (GDS> or =11) was 12%. Increasing age, female gender, lower education, and being currently unmarried were associated with higher risk of depression in univariate regression models, but these associations disappeared after controlling for cognitive function, except for the association with marital status. Cognitive impairment was strongly associated with increased risk for depression. The co-morbid presence of digestive, neurological and heart conditions was also associated with increased risk for depression, while cancer was not. CONCLUSION: In a rural Greek area, the prevalence of depression in late life is high. Depression was more common among unmarried individuals, those with significant cognitive impairment, and in association with specific medical conditions.

Abstract: AIM: To assess the relative occurrence of non motor-vehicle knee injuries and identify important clusters that can be targeted for preventive interventions. METHODS: The study subjects covered 2167 children (0-14 years) who suffered non motor-vehicle knee injuries out of 66870 registered during a three-year period in an established Emergency Department Injury Surveillance System (EDISS). A more serious joint injury was identified in 263 (12%) children, whereas the remaining 1904 children had only soft tissue knee injuries. RESULTS: The incidence of non motor-vehicle knee injuries was estimated at 6.5 per 1000 children-years. Both the incidence of knee injuries and the male-to-female ratio increase with increasing age, reflecting the gender and age pattern of physical activity. Three clusters were identified: The first consisted of more serious knee injuries among older children, frequently resulting after a fall from stairs or a collision in school during winter months; the second cluster consisted of rather minor knee injuries occurring mostly among younger girls at home or in playgrounds, following a fall after stumbling or hit by an object while playing, especially during the summer; the third cluster comprised injuries among older boys, sustained mainly subsequent to overexertion in a sports area. CONCLUSION: Knee injuries tend to be more common among boys but more serious among girls. More and less serious knee injuries tend to fall into distinct clusters that could facilitate prioritization of preventive measures.

Abstract: BACKGROUND: Sunshine is considered to have a beneficial impact on mood. Interestingly, it has been consistently found that the incidence of suicide reaches a peak during early summer. METHODS: In order to explore the pattern of sunshine and suicide risk in a time frame of up to nine days and investigate possible lag and duration parameters of sunshine in the triggering of suicide, Greek daily suicide and solar radiance data were analyzed for a 10-year period using logistic regression models. RESULTS: The solar radiance during the day before the suicide event was significantly associated with an increased suicide risk (OR=1.020 per MW/m2). The average solar radiance during the four previous days was also significantly associated with an increased suicide risk (OR=1.031 per MW/m2). Differences among genders include the longer sunshine exposure needed in males to trigger suicide, compared to females and a lag period of three to four days that was found to lapse in females till the suicide. The increase in suicide risk in June compared to December, attributable to the daily sunshine effect, varies from 52% to 88%, thus explaining the already known suicide monthly seasonality. LIMITATIONS: No individual data on solar radiance exposure, mental disorders, alcohol consumption or suicide method were available. CONCLUSION: The effect of sunshine in the triggering of suicide may be mediated through a mechanism with a specific lag and duration effect, during the nine days preceding suicide. We hypothesize that sunshine acts as a natural antidepressant which first improves motivation, then only later improves mood, thereby creating a potential short-term increased risk of suicide initially upon its application.

Abstract: Because leukemia clone-specific chromosomal abnormalities are present at birth in children who later develop leukemia, it has been hypothesized that maternal factors, including nutrition during pregnancy, might affect the risk of acute lymphoblastic leukemia (ALL) among young children. We have evaluated this hypothesis in a nationwide case-control study of ALL among children ages 12 to 59 months in Greece. Children (n=131) with ALL were gender and age matched to control children (n=131) hospitalized for minor conditions between 1999 and 2003. The mothers of the children were interviewed in person by trained interviewers who used an extensive food frequency questionnaire addressing diet during the index pregnancy. The analysis was done by modeling the data through conditional logistic regression, also controlling for total energy intake and possible confounding factors. Odds ratios (OR) and 95% confidence intervals (95% CI) were expressed per quintile increase of maternal intake during pregnancy of the specified food group. The risk of ALL in the offspring was lower with increased maternal intake of fruits (OR, 0.72; 95% CI, 0.57-0.91), vegetables (OR, 0.76; 95% CI, 0.60-0.95), and fish and seafood (OR, 0.72; 95% CI, 0.59-0.89) and higher with increased maternal intake of sugars and syrups (OR, 1.32; 95% CI, 1.05-1.67) and meat and meat products (OR, 1.25; 95% CI, 1.00-1.57). Children of women who tend to consume during their pregnancies what is currently considered to be a healthy diet maybe at lower risk of ALL.

Abstract: BACKGROUND: The quality improvement effort in clinical practice has focused mostly on 'performance quality', i.e. on the development of comprehensive, evidence-based guidelines. This study aimed to assess the 'conformance quality', i.e. the extent to which guidelines once developed are correctly and consistently applied. It also aimed to assess the existence of quality gaps in the treatment of certain patient segments as defined by age or gender and to investigate methods to improve overall conformance quality. METHODS: A retrospective audit of clinical practice in a well-defined oncology setting was undertaken and the results compared to those obtained from prospectively applying an internally developed clinical protocol in the same setting and using specific tools to increase conformance quality. RESULTS: All indicators showed improvement after the implementation of the protocol that in many cases reached statistical significance, while in the entire cohort advanced age was associated (although not significantly) with sub-optimal delivery of care. A 'learning curve' phenomenon in the implementation of quality initiatives was detected, with all indicators improving substantially in the second part of the prospective study. CONCLUSIONS: Clinicians should pay separate attention to the implementation of chosen protocols and employ specific tools to increase conformance quality in patient care.

Abstract: This study aims to evaluate the burden and patterns of non-motorized bicycle related injuries in Greece. Emergency departments of four hospitals across the country, forming an Emergency Department Injury Surveillance System (EDISS), provided injury occurrence data. Exposure data, such as person time spent cycling as well as patterns of bicycle use, were derived from a school survey undertaken by the Center for Research and Prevention of Injuries. Population data were obtained from the National Statistical Service of Greece. Nationwide incidence rates of bicycle related injuries were estimated. In order to assess patterns of injuries, a Barell diagnostic matrix was constructed, in which bicycle injuries that occurred on roads were compared to off road ones in order to identify correlates of the generally more serious on road injuries. 2711 children with bicycle related injuries (4.8%) were found among the 56132 injured children 0-14 years recorded in EDISS during a three-year period. The incidence of bicycle related injuries was estimated at about 7.9 per 1 000 children-years or about 20 per 1 000 bicycle using children per year. Almost half of the children sustained head injuries. No child was wearing a helmet either among those injured or among the school survey participants. 12% of bicycle injuries required hospitalization. Injuries are common among bicycle using children in Greece, they frequently affect the head and are generally serious. In spite of this unenviable situation, dedicated bicycle lanes are almost non-existent and bicycle helmet promotion campaigns have not yet been conducted.

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Abstract: Adiponectin, an adipocyte-secreted hormone, is closely and inversely associated with insulin resistance and was recently found to be inversely and independently associated with endometrial cancer. Because insulin resistance in the setting of obesity has also been associated with the development of breast cancer, we have hypothesized that decreased adiponectin levels might underlie the association between breast cancer and obesity/insulin resistance. We evaluated the association of adiponectin with the occurrence of breast cancer in a case-control study comprising 174 women with newly diagnosed, histologically confirmed breast cancer and 167 controls. We found an inverse, fairly strong, and statistically significant association of serum adiponectin with breast cancer (odds ratio, 0.84; 95% confidence interval, 0.71-0.99). Importantly, despite a fairly robust inverse association of adiponectin with breast cancer risk among postmenopausal women (odds ratio, 0.82; 95% confidence interval, 0.67-1.00), no such significant association between adiponectin and breast cancer was found among premenopausal women. The observed associations were independent of possible effects of major components of the IGF system, leptin, body mass index, sociodemographic variables, and known risk factors for breast cancer. Future studies are needed to prove causality and provide further insights into both the mechanisms underlying the actions of this hormone and its potential role in breast cancer.

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Abstract: An evaluation of the role of socioeconomic factors in the survival of children with leukaemia, controlling for major clinical prognostic indicators, has been attempted in very few studies and the role of these factors may be different in various cultural settings. Our investigation aims to study the independent role of socioeconomic factors on the prognosis of childhood acute lymphoblastic leukaemia (ALL) in Greece. During a 7-year period (1996-2002) 293 cases of incident ALL were diagnosed and followed up in four Childhood Haematology-Oncology Units, which covered over half of all childhood ALL cases nationwide. At the time of diagnosis, information concerning age, gender, maternal schooling, maternal marital status, sibship size, distance of residence from the treating centre, attendance of day care centre and clinical information was recorded. The influence of these factors on survival was studied by modelling the data through Cox's proportional-hazards regression. After adjustment for clinical prognostic factors, children of mothers who were not currently married, were of low educational level or were living far from the treating centre tended to have lower survival (P-values 0.02, 0.14 and 0.08, respectively). There was also evidence that two factors that are predictive of disease occurrence, that is sibship size and attendance of day care centre, may also predict survival (P-values 0.04 and 0.26, respectively). In conclusion, socioeconomic factors are likely to influence survival from ALL at least in some sociocultural contexts. Moreover, there is evidence that factors that could affect incidence of ALL through modulation of herd immunity may also have prognostic implications for this disease.

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Abstract: OBJECTIVE: To assess the incidence of fall injuries among infants in Greece, overall and by type of nursery equipment. DESIGN: Review of data from a large injury database. SETTING: The Emergency Department Injury Surveillance System in Greece. PATIENTS: A total of 2672 injured infants. INTERVENTIONS: Specially trained health visitors performed in-person interviews with the children's guardians, using a precoded questionnaire. The results of an independent survey of 777 mothers of noninjured children younger than 2 years attending the same emergency departments were used to allow quantification of the role of specific nursery equipment in the causation of infant fall injuries. MAIN OUTCOME MEASURES: Annual rate of injury by falling in infants, overall and by cause. RESULTS: About 4400 infant fall injuries occur annually in Greece, corresponding to an annual incidence rate of 44 injuries per 1000 infants. The incidence of falls increases with increasing infant age. A high percentage of severe injuries was detected, most of them concussions (14.3%) and fractures (9.4%). Approximately 10% of infants with fall-related injuries required hospitalization. More than 36% of fall injuries involved nursery equipment. Infant walker use was associated with a higher incidence of falls (about 9 per 1000 infant-years), and these falls occasionally involved stairs and caused serious injuries. Infant bouncers, strollers, and changing tables were all associated with a similar incidence of falls (about 4 per 1000 infant-years). CONCLUSIONS: Falls are a common cause of serious infant injuries, and nursery equipment is frequently involved in the injury-causing event.

Abstract: BACKGROUND: While routine immunizations are very safe, their administration to healthy children requires minimization of immunization programmatic errors. In order to estimate the incidence and ascertain the nature of reported immunization errors in the Greek childhood population, we have undertaken a study using data from the National Poison Information Center in Greece, which also has the responsibility to address medication-induced errors. METHODS: All immunization errors concerning children and reported to the National Poison Information Center during the 2-yr period 1999-2000 were retrieved and the conditions of their occurrence were examined. The incidence of reported errors was calculated under the assumption that during each year 100,000 children are born in Greece, and during their childhood they receive a total of about 20 immunization doses of all childhood immunizations. RESULTS: There were 40 immunization errors reported, corresponding to a reported incidence of about 11 per million immunization doses. Of these errors, 20 concerned OPV, 13 DTP, 5 MMR, 1 Haemophilus influenza and 1 Hepatitis B immunizations. In 12 instances an erroneous route was used (out of which 11 concerned OPV), whereas overdose was documented in 13 instances (out of which 8 concerned OPV). The third most common error was administration of DTP instead of the recommended Td vaccine. No adverse patient outcomes were reported. CONCLUSIONS: In Greece, reported errors in immunization practice are relatively rare. Packaging modifications (about one in three errors in this study) of the OPV and DTP could further reduce their incidence.

Abstract: BACKGROUND: Injuries represent an important public health problem but their incidence is difficult to estimate. METHODS: We conducted a population-based household survey in Greece covering 4079 interviewed individuals. The interviewees reported, for themselves and for cohabitating adults (age 15 years and older; n = 7157), injuries that occurred during the preceding year. Major injuries were defined as those requiring contact with a health institution. We compared these survey data with data obtained through a national Emergency Department Injury Surveillance System (EDISS). RESULTS: For the month closest to the survey interview, the incidence reported for the responders was 5.9 per 100 person-year, whereas the incidence for cohabitating adults was 3.7 per 100 person-years. These incidence rates declined for months more remote to the interview. Comparison of survey and EDISS data suggested that survey reporting was less accurate for nontraffic-related injuries. Taking into account possible recall and telescoping biases, the best survey estimate of the national annual number of major injuries is 525,000 (5.9 per 100 person-year), whereas the EDISS data yielded an estimate of 1,150,000 major injuries (12.9 per 100 person-years) CONCLUSIONS: Comparison of survey and EDISS data systems provides quantitative assessment of accuracy of the survey data in relation to time of injury before report date, to severity of injury, and to whether the injury is to the interviewee or to a cohabitant. The 2 systems could be used in a complementary way, although EDISS generates information that is medically more accurate and is a more cost-effective data collection system.

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Abstract: OBJECTIVE: To calculate the preventable fraction of unintentional childhood injury deaths in the United States. DESIGN: Ecological study of cause specific unintentional childhood injury mortality rates across the 50 states (and the District of Columbia) of the United States (US) over the 10 year period 1989-98. METHODS: The internet accessible database from the National Center for Injury Prevention and Control was used in order to estimate unintentional childhood (0-14 years) injury mortality rates by external cause and time trends over the study period for each of the US states and for the four major geographical regions of the country. In the principal analysis, a calculation was made of the fraction and absolute number of unintentional childhood injury deaths that could have been prevented annually if the mortality rate in the region with the lowest rate also existed in the remaining three. In another scenario, the lowest external cause specific unintentional childhood injury mortality rates from the 50 US states and the District of Columbia were summed to provide the "ideal" lowest conceivable unintentional childhood injury mortality rate from all causes. Ecological correlations between unintentional childhood injury mortality rates from specified external causes, median income, and percent of the population with a college degree were made. MAIN OUTCOME MEASURES: Unintentional childhood injury mortality rates by cause. RESULTS: Unintentional childhood injury mortality rate declined by 3.5% per year in the country as a whole. If every region of the US had experienced the same injury rate as the Northeast, then one third of all unintentional childhood injuries would not have occurred. More optimistic scenarios indicate that up to two thirds of all unintentional childhood injury deaths could be prevented. Across states, unintentional childhood injury mortality is strongly inversely related to median income. CONCLUSIONS: About one third of all unintentional childhood injury deaths in the US are preventable with the means and resources available in the Northeastern states. Among the relevant characteristics in the Northeast region, in comparison with other US regions, are the higher education level of parents, the lower gun ownership, the higher population density that implies shorter distances traveled by cars, a better developed emergency medical system, and the existence of several injury prevention programs.

Abstract: BACKGROUND: This study aims to estimate the burden and describe the profile of equestrian injuries in Greece, where horses, donkeys, and mules are still used in agriculture and where horse riding is a popular leisure activity. METHODS: Prospectively collected information on 140,823 injuries reported in the national Emergency Department Injury Surveillance System was examined and 244 equestrian-related injuries that occurred during farming, equestrian sports, or horse racing were analyzed. RESULTS: The estimated countrywide injury incidence for farming and equestrian sports combined was 21 per 100,000 person-years, but it was 160 times higher for horse-racing personnel. Men had higher rates of racing injuries and women had higher rates of equestrian sport injuries. Fractures accounted for 39.0% of injuries in horse racing and 30.5% in farming; head injuries accounted for approximately 50% of injuries among farmers. Farming injuries were more serious, with 25% requiring hospitalization. Analysis through the Barell matrix pointed to the role of spurs in the causation of ankle fractures and dislocations and the likely contribution of helmets in preventing traumatic brain injuries. CONCLUSION: Equestrian-related injuries are a serious but underappreciated health problem and merit targeted prevention efforts for each category affected.

Abstract: OBJECTIVE: To assess serum adiponectin levels of neonates in relation to ponderal index and birth length with and without adjustment for potential confounding factors including maternal factors and perinatal characteristics. DESIGN: A cross-sectional study. METHODS: Three hundred and three newborns (Caucasian, singleton, full term, with a birth weight of > or =2500 g, and apparently healthy) were included in the study. Blood samples were collected from the newborns no later than the fifth day of life for measurements of adiponectin and major IGF system components (IGF-I, IGF-II, IGF binding protein-3 (IGFBP-3)). The data were analyzed using simple and multiple regression analyses. RESULTS: Adiponectin is substantially higher in neonates than in adults, with no evidence of the gender dimorphism observed among adults. We found an inverse association between neonatal adiponectin levels and newborn ponderal index and a positive association with newborn length by univariate analysis. We also found a statistically significant inverse association of adiponectin with jaundice/bilirubin, and a marginally significant positive association of this hormone with IGFBP-3 but no significant association with any maternal factors. In multivariate analysis, the inverse association between serum adiponectin and ponderal index does not remain significant after adjustment for potential confounding factors. In contrast, neonatal adiponectin levels correlate inversely significantly and independently with liver maturity and IGF-II and tend to remain positively associated with IGFBP-3 and increased birth length. CONCLUSIONS: An inverse association of adiponectin with ponderal index by univariate analysis is not independent from confounding factors. In contrast, the positive association between serum adiponectin and birth length may reflect either a direct effect of adiponectin or an adiponectin-mediated increase in the sensitivity of tissues to insulin and components of the IGF system, and needs to be explored further.

Abstract: Adiponectin is a hormone secreted exclusively by adipocytes, and obesity is an established risk factor for endometrial cancer. We have, thus, evaluated the association of adiponectin with the occurrence of endometrial cancer. Questionnaire information and blood samples were taken before treatment from 84 women with newly diagnosed, histologically confirmed endometrial cancer and 84 control women who were admitted for minor gynecologic problems, mainly pelvic prolapse. Adiponectin levels were measured by immunoassay. The results were analyzed through multiple logistic regression and controlled for known risk factors for endometrial cancer, leptin, as well as major components of the IGF system (IGF-I, IGF-II, and IGF-binding protein 3). Among control women, there was no significant association of adiponectin with age or parity. Although there was no association of adiponectin with endometrial cancer among women 65 yr or older, there was an inverse, fairly strong, and statistically significant inverse association among younger women. Among women younger than 65 yr, an increase of adiponectin by 1 SD was associated with a more than 50% reduction of the risk for endometrial cancer [odds ratio (OR) 0.44; 95% confidence interval (CI) 0.24-0.81], even after controlling for body mass index and other potential confounders. Among all women, the adjusted OR for a 1 SD increase in adiponectin was not significant (OR, 0.78; 95% CI, 0.56-1.10) but was significant for a one quintile increase in adiponectin (OR, 0.74; 95% CI, 0.56-0.97). In women younger than 65 yr, among whom obesity represents a powerful risk factor for endometrial cancer, adiponectin is inversely and significantly related to the risk of this disease. This association is independent of possible effects of major components of the IGF system, leptin, body mass index, sociodemographic variables, and known endometrial cancer risk factors. Future studies are needed to prove causality and provide insight on both the mechanism of action of this hormone and its potential role in endometrial cancer.

Abstract: OBJECTIVES: Insulin-like growth factor I (IGF-I) and other components of the IGF system have been implicated in the etiology of several human malignancies. We have undertaken a case-control study among Greek women to explore the relation of major components of the IGF system (IGF-I, IGF-II and IGF-binding protein 3, IGFBP-3) with endometrial cancer risk. METHODS: During a 1-year period (1999), 84 incident cases of histologically confirmed endometrial cancer were compared with 84 control women admitted to the same clinical department for small gynecological operations, mainly pelvic prolapse. Data were modeled through multiple logistic regression. RESULTS: Endometrial cancer was positively associated with IGF-II and inversely with IGF-I. Both associations were statistically significant and they appear symmetrical around the null value. IGFBP-3 is positively associated with endometrial cancer risk, but this association does not reach statistical significance. CONCLUSIONS: This study adds to the gradually developing consensus that components of the IGF system play a central role in human carcinogenesis. It is possible that IGF-II, rather than IGF-I, is closely linked to the etiology of endometrial cancer, the form of cancer most strongly associated with obesity.

Abstract: There is adequate evidence that growth during the perinatal period is linked to the risk of several adult onset diseases, and recent findings indicate that the insulin-like growth factor (IGF) system is involved in prenatal growth, as reflected in birthweight. However, whether major components of the IGF system are involved in the immediate post-natal growth has not been studied. Maternal questionnaires were completed, and laboratory measurements of several variables, including IGF-I, IGF-II and IGF-binding protein-3 (IGFBP-3), were made for a total of 331 apparently healthy full-term newborns, from whom routine blood samples were taken during the first 5 days of their life. Birthweight and weight at the time of bleeding were among the recorded variables, and the difference divided by the age in days of the newborn was considered as reflecting immediate postnatal growth velocity. Immediate postnatal growth velocity was strongly positively associated with IGF-I. The squared adjusted correlation coefficient was 0.29 when IGF-I was incorporated in the model predicting postnatal growth velocity but was only 0.08 when IGF-I was excluded. In contrast, IGF-II and IGFBP-3 had no effect on postnatal growth velocity. It thus appears that IGF-I underlies growth during the immediate postnatal period. To the extent that perinatal growth may affect adult onset diseases, the findings of this study suggest that the action of IGF-I during the immediate postnatal period may represent a process of major importance.

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Abstract: OBJECTIVE: To compare the differential implications of sociodemographic and situational factors on the risk of injury among disabled and non-disabled children. DESIGN: Data from the Emergency Department Injury Surveillance System (EDISS) were used to compare, in a quasi case-control approach, injured children with or without disability with respect to sociodemographic, event and injury variables, and to estimate adjusted odds ratios for the injury in a disabled rather than a non-disabled child. SETTING: Two teaching hospitals in Athens and two district hospitals in the countryside that participate in the EDISS. PATIENTS: In the five year period 1996-2000, 110 066 children were recorded with injuries; 251 among them were identified as having a motor/psychomotor or sensory disability before the injury event. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Mechanism of injury, type of injury, risk-predisposing socioeconomic and environmental variables, odds ratio for injury occurrence. RESULTS: Falls and brain concussion are proportionally more common among disabled children, whereas upper limb and overexertion injuries are less common among them. Urban environment, migrant status, and cold months are also associated with increased odds for injuries to occur among disabled rather than non-disabled children. The odds ratio for the occurrence of an injury among disabled children increases with increasing age. CONCLUSIONS: The results of the study provide the information for the targeting of trials of preventive measure in disabled children at increased risk of severe injuries.

Abstract: OBJECTIVES: To assess the characteristics of occupational and leisure farm injuries in Greece. METHODOLOGY: During a five-year period (1996-2000), 4,326 unintentional farm injuries have been recorded by the Emergency Department Injury Surveillance System in Greece. Data concerning demographic variables, accident conditions, and injury characteristics were collected by in person interviews. The data were analyzed by simple cross-tabulation and hierarchical cluster analysis. RESULTS: Injuries from falls on the same level are mainly lower-limb fractures and occur during the winter among older women. Falls from higher level concern migrant workers, who also tend to suffer severe multiple injuries, including concussions, particularly during autumn. Injuries resulting from cutting and piercing instruments, as well as from machinery, are generally open wounds in the upper-limbs, suffered by young migrant workers. Head injuries resulting from striking against an object are more generally spread across socio-demographic variables. Overexertion is the dominant mechanism for dislocations and sprains in the lower limbs. Snake and insect bites are common among younger migrant workers during summer, and they affect the upper limbs during manual work close to the ground. Non-traffic injuries from vehicles are frequently severe, involving head concussion of generally young individuals. CONCLUSIONS: In Greece, farm injuries are frequently serious and require hospitalization. These injuries show distinct patterns among older women (lower-limb fractures), young individuals (non-traffic vehicle-related injuries) and migrant workers (injuries from cutting and piercing instruments, falls from high level, and bites). Prevention strategies should give priority to these population groups. These prevention strategies should include guidance for poorly educated workers, including migrants, enforcement of safety regulations concerning farming machinery, and discouragement of risky farming activities among elderly individuals, particularly women.

Abstract: BACKGROUND: There are an estimated one million completed suicides per year worldwide. As a response to increasing concern about suicide within Europe, the EUROSAVE (European Review of Suicide and Violence Epidemiology) study was undertaken to examine recent trends in the epidemiology of suicide and self-inflicted injury mortality in the European Union (EU). METHODS: Suicide and self-inflicted injury mortality data for the 15 EU countries for the years 1984-1998 were obtained from the World Health Organisation (WHO), the European Statistical Office of the European Commission (EUROSTAT) and national statistical agencies. Data were also obtained for a second group of deaths classified as 'undetermined' or 'other violence'. Age-standardized mortality rates were calculated and examined for trends over time. RESULTS: Finland had the highest suicide rate, while Greece had the lowest for the latest available year (1997). Age-standardized suicide rates tended to be lowest in the Mediterranean countries. Significant downward linear time trends in suicide mortality were observed in most countries, although rates varied markedly between countries. Both Ireland and Spain displayed significant upward linear trends in suicide mortality. Portugal had the highest rate of undetermined deaths both in 1984 and 1998 while Greece had the lowest in both 1984 and 1997. Five countries (including Ireland and Spain) showed significant downward trends in deaths due to undetermined causes whereas Belgium and Germany showed borderline significant upward linear trends in deaths due to undetermined causes. CONCLUSIONS: Although suicide rates in most countries seem to be decreasing, the validity of the data is uncertain. Misclassification may contribute to the geographical and temporal variation in suicide rates in some EU countries but it does not explain the phenomenon. More detailed research comparing suicide-recording procedures and practices across the EU is required. In the absence of adequate EU wide data on suicide epidemiology, effective prevention of this distressing phenomenon is likely to remain elusive.

Abstract: BACKGROUND: Knee injuries represent an important category of road traffic injuries among children, and they are heterogeneous in their aetiology. The aims of this study were to estimate the incidence of road traffic childhood knee injuries in Greece by age and gender, point out their time, place and person co-ordinates and identify clusters with distinct characteristics with a view to potential preventive interventions. METHODS: During a 3-year period, 305 children with knee injuries resulting from a road traffic accident were identified among the 66,870 children with injuries recorded in the Emergency Department Injury Surveillance System (EDISS) of Greece. Using previously derived sampling ratios and national data on childhood population, incidence data by age and gender were estimated. Hierarchical analysis was undertaken for cluster identification. RESULTS: The incidence of road traffic knee injuries was 97.5 per 100,000 children-years. The incidence increased with age and was higher among boys than among girls. Most childhood knee injuries (50.2%) occur among pedestrians, and the majority (90.9%) of the children or their guardians admitted responsibility in crossing the road. Of the 31 children injured as car passengers, the vast majority (87.1%) were unrestrained, and a large fraction (38.7%) were front seat passengers. Two clusters were identified: the first consisted of younger children who resided mostly in the Athens area and suffered less serious knee injuries as pedestrians or car passengers during the colder months; the second consisted of older children, frequently tourists, who suffered more serious injuries as cyclists while vacationing. CONCLUSIONS: Many of the children who suffered road traffic knee injuries as pedestrians admitted responsibility in road crossing, whereas a large proportion of children who were injured as car passengers were injured while improperly seated in the front and without seatbelt protection. Older children, frequently tourists, were at high risk of knee injuries while using motorcycles and bicycles.

Abstract: We conducted a study using a newly developed dataset based on Emergency Departments records of a network of hospitals from Greece on injuries from dog bites. Our goal is three-fold: (a) to investigate if surrogate factors of leisure time are associated with increased risk of injury from bites; (b) to address recently reported contradictory results on putative association of lunar periods and injuries from dog bites; and (c) to offer a general methodology for addressing similar case-only designs with combined factors of which some can exhibit cyclical patterns. To address these goals, we used a case-only design of our dataset, and conducted an analysis where we controlled simultaneously for weekday/weekend effects, season of year (winter, spring/fall, summer), and lunar periods, because any one of these factors can contribute to the degree of exposure to injuries from dog bites. We found that increased risk of injury from bites was associated with weekends versus weekdays (RR=1.19, 95% CI: 1.10-1.29), summer versus winter (RR=1.24, 95% CI: 1.11-1.39), and fall or spring versus winter (RR=1.31, 95% CI: 1.19-1.45). The results support the hypothesis that longer leisure time at these levels of factors does increase the risk of having a bite injury. Moreover, after controlling for these factors, risk of bite injury was not associated with moon periods, thereby also helping settle a longstanding argument.

Abstract: Participation in sports is a health promotion activity that entails an important injury risk. This study presents data on sport injuries among adults, derived from an established European Union injury monitoring process. Data originated from interviews conducted at hospital Emergency Departments in six European Union countries, namely Austria, Denmark, France, Greece, the Netherlands, and the United Kingdom, using a common, pre-coded questionnaire, which elicits information regarding socio-demographic variables, event coordinates and injury characteristics. We examined all cases of sport injuries that have been recorded among adults (15+ years old) during a one-year period (1998). Sports injuries were examined in schools, in organised settings (when the activity was taking place under the auspices of sports federation, clubs or similar organizations) and in spontaneous (non-organised) activities as well as in specific types of sports by demographics and injury descriptive variable. Emergency department data show that sport injuries are common injuries of considerable severity, since about one third of them are fractures and approximately 4% of cases require hospitalisation. Among males, football and basketball are responsible for the majority of sports injuries whereas gymnastics and volleyball are responsible for most injuries among females. This study highlights the importance of injury surveillance in assessing the magnitude and characteristics of sport injuries.

Abstract: The purpose of this research was to investigate determinants of the insulin-like growth factor (IGF) system among healthy full-term newborns and explore their relation with anthropometric variables at birth. Components of the IGF system have been implicated in the pathogenesis of several forms of cancer, and perinatal events have been linked to chronic diseases in later life. Measurements of weight and length, as well as blood samples, were obtained from 331 healthy full-term newborns delivered during 1999 in Athens, Greece. Because the liver is important for IGF production, newborns were chosen to have bilirubin levels either < or = 8 mg/dl or > or = 12 mg/dl to operationally distinguish them according to the liver function. IGF-I, IGF-II, and IGF binding protein-3 were inversely associated with the presence of neonatal jaundice and blood creatinine, after controlling for blood protein levels. IGF-I increased rapidly and significantly over a period of a few days and was strongly positively associated with both birth weight and ponderal index. Newborn levels of IGF-I declined with maternal age. In comparison with first-born newborns, later-born ones had significantly higher blood IGF-I levels. We conclude that IGF-I plays a dominant role in growth during the perinatal period and that all three studied components of the IGF system are sensitive to liver and kidney function. These findings provide an insight into the processes involved in perinatal growth.

Abstract: BACKGROUND: We have assessed the ability of the Emergency Department Injury Surveillance System (EDISS), a registration network operating with limited resources, to predict the burden and pattern of injuries in the whole Greece. METHODS: We have compared hospitalizations calculated on the basis of EDISS with those routinely recorded by the National Statistical Service countrywide. EDISS relies on data collected in the Emergency Departments of four hospitals, two located in the Greater Athens area, and two district hospitals in the remaining Greece. EDISS data concern hospitalized and non-hospitalized patients of all ages, with all types of injuries irrespectively of their etiology or intent. RESULTS: Over a three-year period 148 835 subjects with injuries were interviewed. Using sampling ratios of 2.2% for all injuries outside Greater Athens and for adults in Greater Athens but 28.9% for childhood injuries, the total annual number of injuries in Greece was estimated at 1.53 million (95% confidence interval: 1.48-1.57 million). Of those, about 18% concern children less than 15 years old. The difference between the EDISS estimated and the actually recorded hospitalized injuries was, in preliminary terms, acceptable. DISCUSSION: Of the ten major categories of injuries, seven among children and five among adults have shown deviations of less than 20%. For the remaining categories deviations were larger but in only one instance did the difference exceed 50%. It is concluded, that for a small and relatively homogeneous country, like Greece, injury data provided by four large hospitals can generate reasonably reliable estimates for large categories of injuries.

Abstract: The risk of endometrial cancer is positively associated with obesity, but the role of specific nutrients remains unclear. Given the distinct characteristics of the Greek diet and the low incidence of this form of cancer among Greek women, we undertook a case-control study to investigate the association of endometrial cancer with food groups and micronutrients. Cases were 84 women with histologically confirmed endometrial cancer and controls were 84 women with intact uterus admitted to the same teaching hospital in Athens, Greece. Consumption of pulses, nuts, and seeds was significantly inversely related to the risk for endometrial cancer. No other significant association with food groups was detected, although a protective effect of added lipids, which in the Greek diet are primarily represented by olive oil, was highly suggestive. Retinol, nicotinic acid, vitamin B- 6, and riboflavin were inversely associated with the disease. These findings need to be replicated, because this was a relatively small study with the statistical power to detect only strong associations between cases and controls; they appear, however, to support a role of diet in the etiology of endometrial cancer.

Abstract: Several reports indicate that suicide follows a seasonal pattern with a dominant peak during the month of maximum daylight. The purpose of this study was to evaluate the hypothesis that sunshine exposure may trigger suicidal behavior. We found a remarkably consistent pattern of seasonality with peak incidence around June in the northern hemisphere and December in the southern hemisphere. Moreover, there was a positive association between the seasonal amplitude of suicide (measured by relative risk) and total sunshine in the corresponding country. These findings indicate that sunshine may have a triggering effect on suicide, and suggests further research in the field of sunshine-regulated hormones, particularly melatonin.

Abstract: OBJECTIVE: To depict the magnitude and spectrum of childhood injuries attributable to falls from bunk beds in comparison with conventional beds and to outline sociodemographic risk factors and injury characteristics. STUDY DESIGN: Case-control investigation. SETTING: Accident and emergency departments of four hospitals in Greece, namely a teaching children's hospital and a trauma hospital in Greater Athens and the two district hospitals in the Magnesia county and the Corfu island. PATIENTS: During the three year period 1996-98, 1881 children (0-14 years) presenting with bed fall injuries were recorded by the Emergency Department Injury Surveillance System (EDISS). Out of these, 197 children with falls from bunk beds served as cases and 1684 children with falls from conventional beds served as controls. RESULTS: From the analysis and a nationwide extrapolation, it was calculated that each year about 5000 children in Greece (total population 10 million) seek medical attendance at an emergency department for a bed injury, corresponding to an estimated incidence of about 3 per 1000 children years. Out of bed fall injuries, 10.5% are from bunk beds, 10.4% from cribs, 3.1% from cots, and 76.0% from other conventional beds. Falls from the bed ladder accounted for 8% of all bunk bed injuries. Boys are at higher risk for falls from beds but there is no evidence that the proportion is different depending on the type of bed used. Relatively few falls from bunk beds are recorded outside the crowded apartments of Greater Athens or among migrant children. The increased relative risk of injuries from bunk bed falls during the sleeping hours indicates the higher risk of injury after a fall from a bunk rather than a conventional bed. Injuries from bunk bed falls are generally more serious than those from conventional bed falls (overrepresentation of brain injuries, fractures, multiple injuries, and injuries requiring hospitalisation). Overall, it can be estimated that almost half of the sleep related bunk bed injuries are easily preventable. CONCLUSIONS: Falls from bunk beds represent a non-negligible childhood injury risk. A sizeable fraction can be avoided with simple design modifications of the product, such as use of side rails in the upper bed or removal of the bed ladder when not in use.

Abstract: Injuries related to central heating devices represent a non-negligible fraction of all indoor injuries among children with mechanical lesions, outnumbering burns. Prevention strategies refer mainly to modifications or safer use of the appliances and improvements in building design.

Abstract: OBJECTIVE: The etiology of most cases of myelodysplastic syndromes (MDS) has not been elucidated. We have undertaken an investigation in Greece to determine the risk profile of adult de-novo MDS. METHODS: A case-control investigation was conducted in a large Veterans' hospital over a five-year period, covering 84 MDS cases and 84 age- and gender-matched controls with minor non-neoplastic non-infectious conditions from the same study base. Cases and controls reported to the medically trained principal investigator lifestyle characteristics and medical histories, with emphasis on autoimmune disorders and allergic conditions. RESULTS: Alcohol intake and tobacco smoking jointly increased significantly the risk of MDS (odd ratio contrasting ever smokers and regular drinkers of at least one glass per day to never smokers and drinkers of less than one glass per day: 9.54. 95% CI 3.52-25.82) whereas each of these factors alone had limited effect. There was also evidence that autoimmune conditions, but not allergic disorders, were positively associated with MDS risk, irrespective of their occurrence during the recent (less than ten years) or the remote (more than ten years) past (OR 3.34, 95% CI 1.15-9.74; OR 3.50, 95% CI 1.19-10.26, respectively). CONCLUSION: We found evidence that both exogenous and endogenous factors may play a role in the etiology of the so-called "de novo" myelodysplastic syndromes, but these findings need further confirmation.

Abstract: Among European countries, Greece has the lowest incidence of and mortality from endometrial cancer. We have undertaken a case-control study aiming to identify possible reasons for this. Cases were 84 women with histologically confirmed incident endometrial cancer, whereas controls were another 84 women with intact uterus admitted for small gynaecological operations, mainly pelvic prolapse. Women provided information concerning socio-economic, reproductive and medical variables. Most findings were in line with those previously reported from other investigations; no association was as striking as to suggest an effect modification that could underlay the favourable position of Greece with respect to endometrial cancer. Novel findings were the statistically significant inverse associations of endometrial cancer with coffee drinking and suggestive inverse associations with height-induced abortions. Low average height of Greek women, high frequency of induced abortions and low frequency of replacement oestrogens use may contribute to the lower endometrial cancer incidence in Greece.

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Abstract: Pre- and perinatal conditions and processes may affect the risk for some forms of cancer in later life, while the insulin-like growth factor (IGF) system may play a role in both early somatic growth and later carcinogenesis. Birth weight and length, and the variation of major components of the IGF system immediately after birth, were analyzed in relation to selected physiological and pathological variables. The study comprised 331 healthy full-term newborns from whom blood samples were taken during routine phlebotomy no later than the fifth day of life. Measurements of IGF-I, IGF-II and IGF-binding protein-3 concentrations were performed. Birth length and weight were measured and information on socio-economic and medical variables was recorded. The concentrations of all three proteins were lower when blood bilirubin levels were high, possibly as a result of compromised liver function and/or as a component of an activated acute phase reaction. Birth weight was significantly higher by about 46 g among children whose IGF-I was higher by one SD, while the associations of birth weight and length with other components of the IGF system were in the predicted directions, albeit only in trend. We conclude that in early life, growth is related to the IGF system, mostly IGF-I. The latter is lower in children with jaundice, possibly because of hepatic dysfunction and/or as part of an acute phase reaction. We speculate that elevations of IGF-I in early life might explain the increased risk of cancer in individuals born with a higher birth weight.

Abstract: OBJECTIVES: Intimate partner violence (IPV) is an important sociocultural and public health problem. This study aims to assess sociodemographic and injury characteristics of IPV victims among adults in a traditional southern European population. SETTING: Accident and emergency departments of three sentinel hospitals in Greece participating in the Emergency Department Injury Surveillance System (EDISS). METHODS: Data on sociodemographic variables, as well as event and injury characteristics were retrieved from the EDISS database during the three year period 1996-98. Out of a total of 27 319 injured women aged 19 years or more, 312 (1.1%) were reported as IPV related and were compared with 26 466 women with unintentional injuries. Among the 35 174 men with injuries 39 (0.1%) were reported as IPV related and were compared with 34 049 men with unintentional injuries. The data were analyzed through simple cross tabulations and multiple logistic regression. Positive predicted values for selected injury characteristics were also calculated. RESULTS: IPV is more common in rural than in urban areas of Greece. Women are 10 times more frequently IPV victims but men are also IPV victims; younger women and older men are disproportionately affected by IPV. The relative frequency of the phenomenon increases during the late evening and night hours. Certain types of injuries, notably multiple facial injuries, and presentation of the injured person on his/her own at the emergency department or combinations of predictive characteristics are strongly indicative of IPV. CONCLUSIONS: Injuries due to IPV are not uncommon in Greece, not withstanding the traditional structure of the society and the tendency of under-reporting. Certain injury characteristics have high positive predictive values and could be used in screening protocols aiming at the correct identification of the underlying external cause in injuries that may be caused by IPV.

Abstract: The concentration of T-cell receptor rearrangement excision DNA circles (TRECs) in peripheral blood mononuclear cells (PBMCs) is currently known to be a marker of recent thymic emigrants. We evaluated the hypothesis that TREC values would be lower in childhood T-cell hematopoietic malignancies than in childhood B-cell acute lymphoblastic leukemia (ALL) or healthy controls because the former category may reflect compromised thymic function. From the Greek national childhood leukemia/lymphoma database we obtained all 30 available T-cell leukemia/non-Hodgkin's lymphoma cases, 30 age- and sex-matched childhood B-cell origin cases of ALL and 60 healthy hospital controls. We compared TREC levels in PBMCs using a real-time PCR assay. There was highly significant reduction of TREC values in children with T-cell malignancies (median 3,100 TRECs/10(6) PBMCs), whereas children with B-cell origin ALL had slightly but nonsignificantly lower TREC values compared to healthy children (medians 19,300 and 22,500 TRECs/10(6) PBMCs, respectively). During a median follow-up period of about 19 months, only 4 children died. All of them had a T-cell hematopoietic malignancy and relatively low TREC values. The number of TRECs was higher among healthy girls than among healthy boys, and a similar pattern was evident in T-cell malignancies. It appears that there is a pattern of concordance of high TREC values with better disease prognosis in hematologic childhood malignancies. This applies to specific disease entities with better prognosis (B-cell origin ALL having higher TREC values than T-cell leukemia/lymphoma) and to gender, another important predictor of prognosis conditional on disease entity (girls having higher TREC values than boys); however, it may also be true for the survival of individual patients. These preliminary findings can be used as hypothesis-generating indications that should be confirmed in larger data sets.

Abstract: BACKGROUND: Carcinoma of the oral cavity is one of the most common cancers worldwide. Tobacco smoking and the consumption of alcoholic beverages are significant risk factors but to the authors' knowledge the role of nutrition is not adequately understood. The authors undertook an epidemiologic study of oral carcinoma occurring in Greece, where tobacco smoking and alcohol consumption are common but the incidence of the disease is among the lowest reported in Europe. METHODS: One hundred six patients with histologically confirmed incident oral carcinoma and an equal number of control subjects matched for age and gender were studied. Dietary information was assessed through a validated extensive food frequency questionnaire and the data were analyzed using conditional logistic regression. RESULTS: After adjustment for energy intake, tobacco smoking, and alcohol consumption, there was evidence that the consumption of cereals, fruits, dairy products, and added lipids (which in Greece are represented mostly by olive oil) was found to be associated inversely with the risk of oral carcinoma. Only with respect to meat and meat products was there adequate evidence of a positive association with the risk of oral carcinoma. Among the micronutrients studied, riboflavin, magnesium, and iron appeared to be correlated inversely with the disease. CONCLUSIONS: Fruits, cereals, dairy products, and olive oil appear to convey protection against oral carcinoma and their effects may be mediated through higher intakes of riboflavin, iron, and magnesium. The low incidence of oral carcinoma reported in Greece may be explained in part by the higher consumption of the food groups and micronutrients that appear to protect against the disease.

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Abstract: The aim of this case-control study was to identify and quantify risk factors of injuries in playgrounds, where children spend an increasing amount of time in developed countries. The study took place in Greater Athens during 1999. A continuous Emergency Departments Injury Surveillance System (EDISS) of hospitals that cover about 30% of the children's time at risk in Greater Athens identified 777 injuries in public and private playgrounds out of a total of 17 497 injuries. Public playgrounds differ from private ones, because the former generally have more equipment, usually of greater height, with less resilient surfaces, and supervision relies mainly on parents or guardians. Patterns of type of playground use were assessed in a sample of 294 children from the same study base who served as a control group in a hierarchical case-control design. The annual incidence of playground injuries in Greater Athens was about 7 in 1000 among boys and 4 in 1000 among girls, with a 2.2 times higher risk for an injury in public than in private playgrounds (95% confidence interval 1.61-3.07). Children in public vs private playgrounds had a statistically significant eight times higher odds for concussion and six times higher for open wounds, whereas the odds for long bone fractures were four and for other fractures two; swings, slides and seesaws were the types of equipment most frequently associated with injuries. It was further shown that supervision of children was suboptimal (< 60%) in both public and private playgrounds, and children in private playgrounds sustained an unduly high frequency of sprain/ dislocation injuries (odds ratio 1.75) because they were encouraged to play bare-footed. CONCLUSION: Close to 50% of playground injuries could be prevented by structural and equipment changes, while further reduction could be accomplished through simple measures including closer supervision and encouraging children to wear proper shoes and use protective equipment whenever necessary.

Abstract: BACKGROUND/AIM: Because leptin is a hormone associated with obesity and reproduction, we attempted to examine whether there is a relationship between leptin and endometrial cancer. METHODS: Cases were 84 women with histologically confirmed incident endometrial cancer, whereas controls were 84 women admitted to the same hospital for small surgical operations. The serum leptin levels were determined in fasting morning blood samples by using radioimmunoassay. The mean values of leptin levels among cases and controls were compared with simple t test, and the data were further analyzed using multiple logistic regression procedures. RESULTS: The serum leptin levels were 36.7 +/- (SD) 25.7 ng/ml among cases and 26.9 +/- 19.8 ng/ml among controls (p = 0.006). After adjustment for known risk factors of endometrial cancer, components of the insulin-like growth factor system did not confound the association of leptin with endometrial cancer, but this association was eliminated, when the body mass index was adjusted for. Thus, the odds ratio for an increment of 1 SD of blood leptin was 1.52 (p = 0.03) before adjustment for body mass index, but only 1.13 (p = 0.62) after adjustment for it. CONCLUSIONS: In a case-control study of incident endometrial cancer in Greece, we found evidence that leptin is strongly positively associated with endometrial cancer. It cannot be conclusively inferred, however, whether leptin elevation, as a consequence of obesity, plays a role in endometrial carcinogenesis or whether it is a simple correlate of obesity.

Abstract: Oral and pharyngeal cancer (OC) mortality is very low in Greece, especially among men, compared to other European countries. We conducted a case-control study of OC in Athens, and obtained information on tobacco, alcohol use and other potential risk factors and confounding variables for 110 incident cases and 115 hospital-based controls. We used multivariate logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Tobacco smoking (pack years, P(trend)=0.01) and alcohol use (drinks/week, P(trend)=0.07) were independent risk factors, with a multiplicative effect for combined exposures (OR, 8.3; 95% CI, 2.4-29.1, for >28 alcohol drinks/week and >50 pack years of cigarette smoking). The type of alcoholic beverage also seemed important: drinking ouzo and tsipouro (liquors of high ethanol concentration) was associated with greater increased OC risk than drinking comparable amounts of wine, beer or dark spirits. While alcohol drinking is more common for male cases versus controls, few men reported regularly consuming large quantities of ethanol associated with highest risk of OC in other studies. This may partially explain the low rates of male OC mortality in Greece. Among the 38% of our cases who were women, however, neither smoking nor alcohol drinking frequencies were significantly elevated compared to controls, and so the etiology of OC risk in females requires further investigation.

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Abstract: OBJECTIVE: To investigate whether the three principal components of the insulin-like growth factor (IGF) system, IGF-1, IGF-2 and IGF binding protein-3 (IGFBP-3), are associated with survival from childhood leukemia. PATIENTS AND METHODS: 116 children, 0--14 years old, with newly diagnosed and bone-marrow-biopsy-confirmed acute childhood leukemia between 1993 and 1996 were followed up until death or March 31, 1998. IGF-1, IGF-2 and IGFBP-3 were measured at diagnosis and clinical data, including presence of hepatosplenomegaly and number of white blood cells, were available. RESULTS: After controlling for gender, age, indicators of clinical severity and the other measured components of the IGF system there was a statistically significant (p < 0.05) inverse association of IGFBP-3 with survival. An increment of one standard deviation in IGFBP-3 was associated with a 65% reduction of the death hazard among the children with leukemia. Neither IGF-1 nor IGF-2 was associated with survival in this data set. CONCLUSION: The presented empirical evidence in conjunction with the fact that IGFBP-3 modulates IGF-1 and IGF-2 bioavailability and is likely to have proapoptotic effects makes this compound a plausible independent predictor of survival from childhood leukemia.

Abstract: OBJECTIVE: Acute lymphoblastic leukemia (ALL) among children may be a rare outcome of a delayed non-specific infection in situations of overall low herd immunity. We evaluated the hypothesis as to whether newly diagnosed ALL cases, compared to their controls, are characterized by lower herd immunity, as reflected in a more seronegative spectrum to several agents, with the exception of a strongly positive response to a single infectious agent, assumed to trigger ALL. METHODS: The study included 94 incident cases of ALL, from all pediatric hematology-oncology units of Greece, and 94, matched for age and gender, controls hospitalized with minor non-infectious conditions. The past exposure to common infections was assessed using 10 serological markers. RESULTS: There was little evidence for an association of ALL with the serology of any of the studied infectious agents among the very young children. In contrast, among children aged 5 years or older, leukemia was inversely associated with seropositivity to Epstein-Barr virus, human herpes virus-6, Mycoplasma pneumoniae and parvovirus B19. CONCLUSIONS: Among children aged 5 years or older the risk of leukemia may be higher when the low herd immunity for several agents is challenged by late infection from an agent that, as a rule, would attack children at a younger age.

Abstract: The aim of this study was to investigate whether socioeconomic status of town of residence is associated with risk for childhood pedestrian injuries. The study population consisted of all pedestrian victims, aged 0-14 y, who lived in towns of Greater Athens and who presented to the Emergency Department of a major Children's Hospital during the period 1996-98. The towns were divided into three categories by socioeconomic status according to the proportion of (a) adult household heads with a higher education degree and (b) households with less than one person per room. The rate of pedestrian injuries was estimated by socioeconomic status of the residential town and by place of accident (inside or outside the respective town). The pedestrian injury rate ranged from 5.5 to 12 injured children among a 10000 childhood population per year, with an almost twofold excess among children residing in the less wealthy towns compared with the wealthier ones. The social gradient was steeper for injuries occurring outside the residential town. The population fractions of pedestrian injury rates attributable to educational level and household crowding differentials, regardless of the place of accident, were 39% and 25%, respectively. CONCLUSIONS: There is a considerable social gradient for childhood injuries irrespective of place of accident, a finding that could be partly attributable to lower socioeconomic background rather than to adverse environmental factors prevailing in less wealthy towns. Our findings indicate that there is a need for preventive programmes targeting people as well as places of low socioeconomic status.

Abstract: OBJECTIVE: To assess the effect(s) of transient events which are perceived as stressful on the inseption of preterm delivery. DESIGN: A case-control study, with immature infants as cases and borderline term babies as controls. SETTING: A teaching maternity hospital in Athens. POPULATION: All infants born at less than 37 weeks of gestation, during a twelve-month period. METHODS: Information was collected about maternal socio-demographic and lifestyle characteristics, clinical variables and stressful events occurring within two weeks prior to delivery. MAIN OUTCOME MEASURES: Factors affecting the risk of preterm delivery. RESULTS: Extreme prematurity (<33 weeks) is more common among younger (<25 years of age) and older (>29 years of age) women and is positively associated with parity, body mass index and smoking, whereas it is inversely associated with educational level, regular physical exercise and serious nausea/vomiting. After controlling for these factors, however, only coitus during the last weeks of pregnancy had a significant triggering effect on prematurity (P = 0.004, odds ratio 3.21, 95% CI 1.45 to 7.09 for very immature babies, and P = 0.04, OR = 2.20, 95% CI 1.03 to 4.70 for immature babies). On the contrary, several events perceived as stressful, such as illness of relatives or friends, husband's departure, loss of employment, were unrelated to the onset of premature labour. CONCLUSIONS: Coitus during the last few weeks of pregnancy appears to increase the risk of preterm delivery, while a possible detrimental effect of physical exertion seems more limited. Stressful events should not receive undue attention as possible causes of preterm delivery.

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Abstract: AIMS: To examine the extent of undiagnosed child abuse in Greece by studying young children with femoral fractures, which may be associated with abuse. METHODS: Fifty seven consecutive cases of children under 6 years of age with femoral fracture were identified from the Emergency Department Injury Surveillance System database. Controls were 4162 children with other orthopaedic injuries from the same database. RESULTS: Whereas in the literature about one third of femoral injuries among young children are attributed to child abuse, no child in the studied series had been diagnosed or even investigated in this context. Nevertheless, the pattern of occurrence of femoral injuries was compatible with that of child abuse, in that patients were frequently very young boys of low socioeconomic status, and the accident had frequently occurred under poorly identified or implausible conditions at time periods when most family members were crowded at home. CONCLUSIONS: Epidemiological risk factors for child abuse characterise femoral fractures in young children in Greece. It appears that child abuse is present in this country as in most other cultures. There is a clear need for refocusing medical personnel and hospital social services so that the problem is revealed, quantified, and appropriately dealt with.

Abstract: AIM: It has been gradually recognized that intentional injuries among children represent a largely hidden problem in modern societies. With the exception of mortality, population-based data from Greece have not been previously reported. To assess the magnitude and the characteristics of intentional injuries among children aged 0-14 years old, data from the population-based Emergency Department Injury Surveillance System (EDISS) database during the period 1996-97 were used. METHODS: EDISS relies on personal interviews with children and their escorts who contact the emergency departments of three hospitals. Two of these hospitals are district hospitals of the county of Magnesia and the island of Corfu, whereas the other is a university children's hospital that covers the Greater Athens area on alternative days. RESULTS: Among 46.807 children recorded in EDISS, 108 injuries (0.23%) were attributed to acts of violence. Among the 108 intentional injuries, only 11 were caused by firearms or other weapons and only 4 concerned infants. In comparison to unintentional home and leisure injuries, intentional childhood injuries increase significantly with age and they are more common among migrant children. They occur more frequently during late night and early morning hours, they are more serious, and they are more often multiple and concentrated on the head. CONCLUSIONS: In Greece. a problem of violence directed against children does exist. The actual magnitude of this problem is difficult to estimate, but its size appears to be smaller in comparison with that reported in other populations.

Abstract: Since sports participation entails the risk of injuries that account for substantial morbidity and disability, the existence of adequate epidemiological information is essential for the development of sound preventive strategies. In this study, we present data on the occurrence of sports injuries among children in six European countries, namely Austria, Denmark, France, Greece, The Netherlands, and the United Kingdom. An operational definition for sports injuries was developed, and comparable data from the European Home and Leisure Accident Surveillance System, an established injury surveillance system operating in 12 European union countries, were collected from the participating member states, during a 1-year period (1998). Sports injuries were examined in schools, in organised and unorganised settings, and in specific types of sports by demographics and injury descriptive variables. Sports injuries represent a quantitatively important and sufficiently serious problem in European union countries, accounting for an estimated annual number of about a quarter of a million outpatient visits in two of the participating countries, which provide national estimates. It is evident, that sport injuries are not only common but also injuries of considerable severity, since a large fraction represents fractures, while approximately 4% of the total require hospitalisation. Football and basketball among male children are, in declining order, the two sports responsible for the most frequent injuries in the European union countries, whereas gymnastics and volleyball prevail among females. The study indicates the importance of injury surveillance in describing the epidemiology of sports injuries and provides an estimate of the magnitude and the profile of sport injuries that take place annually in European union countries.

Abstract: Infant acute leukemia (IAL) frequently involves breakage and recombination of the MLL gene with one of several potential partner genes. These gene fusions arise in utero and are similar to those found in leukemias secondary to chemotherapy with inhibitors of topoisomerase II (topo-II). This has led to the hypothesis that in utero exposures to chemicals may cause IAL via an effect on topo-II. We report a pilot case-control study of IAL across different countries and ethnic groups. Cases (n = 136) were population-based in most centers. Controls (n = 266) were selected from inpatients and outpatients at hospitals serving the same populations. MLL rearrangement status was derived by Southern blot analysis, and maternal exposure data were obtained by interviews using a structured questionnaire. Apart from the use of cigarettes and alcohol, very few mothers reported exposure to known topo-II inhibitors. Significant case-control differences were apparent for ingestion of several groups of drugs, including herbal medicines and drugs classified as "DNA-damaging," and for exposure to pesticides with the last two being largely attributable, respectively, to one nonsteroidal anti-inflammatory drug, dipyrone, and mosquitocidals (including Baygon). Elevated odds ratios were observed for MLL+ve (but not MLL-ve) leukemias (2.31 for DNA-damaging drugs, P = 0.03; 5.84 for dipyrone, P = 0.001; and 9.68 for mosquitocidals, P = 0.003). Although it is unclear at present whether these particular exposures operate via an effect on topo-II, the data suggest that specific chemical exposures of the fetus during pregnancy may cause MLL gene fusions. Given the widespread use of dipyrone, Baygon, and other carbamate-based insecticides in certain settings, confirmation of these apparent associations is urgently required.

Abstract: BACKGROUND: It has been suggested that prolonged exposure to sunlight may induce systemic or local immune alterations, which may facilitate the development of skin cancer and, perhaps, non-Hodgkin's lymphona. The effects of prolonged sunlight exposure on peripheral blood cells were studied. METHODS: Leukocytes and lymphocyte subpopulations of 12 volunteers aged 10-45 were investigated before and after a 3-week summer holiday in seaside resorts in Greece. Lymphocyte phenotypes were estimated using monoclonal antibodies and flow cytometry. RESULTS: There were no significant differences with respect to total numbers of T cells, T-helper/inducer, T-suppressor/cytotoxic, B cells or HLA-Dr+ cells. However, we have found evidence of lymphocyte stimulation, reflected in an increase in cells expressing the interleukin-2 receptor (IL-2R) and, more specifically, an increase in the T cells expressing IL-2R and HLA-Dr antigens. An increase in natural killer cells has also been noticed. CONCLUSIONS: These findings suggest that prolonged intense exposure to sunlight may be associated with immunostimulation, rather than immunosuppression.

Abstract: Road traffic crashes (RTCs) are responsible for a substantial fraction of morbidity and mortality and are responsible for more years of life lost than most of human diseases. In this review, we have tried to delineate behavioral factors that collectively represent the principal cause of three out of five RTCs and contribute to the causation of most of the remaining. Although sharp distinctions are not always possible, a classification of behavioral factors is both necessary and feasible. Thus, behavioral factors can be distinguished as (i) those that reduce capability on a long-term basis (inexperience, aging, disease and disability, alcoholism, drug abuse), (ii) those that reduce capability on a short-term basis (drowsiness, fatigue, acute alcohol intoxication, short term drug effects, binge eating, acute psychological stress, temporary distraction), (iii) those that promote risk taking behavior with long-term impact (overestimation of capabilities, macho attitude, habitual speeding, habitual disregard of traffic regulations, indecent driving behavior, non-use of seat belt or helmet, inappropriate sitting while driving, accident proneness) and (iv) those that promote risk taking behavior with short-term impact (moderate ethanol intake, psychotropic drugs, motor vehicle crime, suicidal behavior, compulsive acts). The classification aims to assist in the conceptualization of the problem that may also contribute to behavior modification-based efforts.

Abstract: OBJECTIVE(S): To study regionalized acute injury services on an island with high seasonal fluctuation of the population at risk. STUDY PARTICIPANTS: Of 9432 individuals with traumatic injuries who contacted the hospital during 1996, 1204 were hospitalized. Information was recorded on several injury-related clinical and sociodemographic variables. Possible residual disabilities, 6 months after the injury, were also assessed. MAIN OUTCOME MEASURES: Injury Severity Score (ISS), clinical outcome and duration of hospitalization, odds of transfer to other institutions. RESULTS: Non-residents, whether Greek or foreign nationals are hospitalized for shorter periods. Motor vehicle accident victims are hospitalized on average for 15% longer. Injury victims admitted on a Friday are hospitalized for a longer period. Finally, ISS is a powerful positive predictor of duration of hospitalization. Male injury victims, those injured during late night or early morning and patients injured in July are more likely to be transferred to another institution. Age of the patient and ISS are powerful and independent predictors of an unfavourable outcome. CONCLUSION: The extra demand created by injured tourists is reflected in the seasonality of admissions for injuries. The district hospital of Kerkyra cannot be considered as deficient in comparison to other district hospitals. Nevertheless, the suboptimal function of the hospital, with respect to injuries, is reflected in the high proportion of injured patients transferred when the injury occurs outside the full working schedule of the hospital. Patients with burns, bone fractures or dislocations and head injuries or concussion are transferred with an overall frequency of about 15%--too high to be compatible with a well functioning secondary care institution.

Abstract: An average of 6000 children (0-14-y-old) died every year from injuries in the European Union during the last decade. Although the trends are overall favorable, injuries continue to represent the leading cause of death in this age group. The aim of this paper is to present childhood-injury-related public health issues and consider possible remedies of contemporary epidemiologic methods as applied to injury epidemiology and prevention. It has been estimated that half of the lives lost to childhood injuries could have been saved if all European Union countries matched the accomplishments of the country with the lowest mortality rate in each injury category. There is no specific pattern of association between Gross Domestic Product and incidence of motor-vehicle accidents by category of road user, whereas fatality from motor-vehicle accidents seems to be inversely, strongly and significantly related to Gross Domestic Product. CONCLUSION: The ongoing development of large injury databases in the European Union is a prerequisite for understanding the complex interactions that lead to a childhood injury. Moreover, possible remedies for overcoming the genuine problems associated with the application of traditional epidemiologic methods to the investigation of the frequently transient in nature causes of injuries should be considered.

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Abstract: OBJECTIVE: Insulin-like growth factor-1 (IGF-1) and its principal binding protein-3 (IGFBP-3) are central in the mediation of the effect of growth hormone, and the IGF system has been reported to play a role in the pathogenesis of childhood leukemia. METHODS: To further evaluate the hypothesis connecting the IGF system to this disease, we have examined whether IGF-1 and IGFBP-3 are associated with the two main endogenous risk factors for childhood leukemia, namely gender and birth weight, since boys and heavier newborns are known to be at higher risk. IGF-1 and IGFBP-3 were measured under code in the serum of 118 apparently healthy children aged 0-14 years and the values of each of these components were regressed on age, gender and birth weight. Insulin-like growth factor-2 (IGF-2), as a dependent variable, and anemia during the corresponding pregnancy, as a predictor variable, were also evaluated for exploratory purposes. RESULTS: In the total data set, IGF-1 was positively associated with birth weight (p = 0.0001), whereas girls had higher levels of IGFBP-3 (p = 0.01). CONCLUSIONS: It appears that the associations of measured components of the IGF system with the examined risk factors for childhood leukemia are largely compatible with those that would have been expected, if this system played a role in the pathogenesis of childhood leukemia.

Abstract: We studied the relation of certain endocrine-related variables among 23 cases of male breast cancer and 76 apparently healthy male controls. There were significant inverse associations with smoking (P = 0.03), birth order (P = 0.02) and reported frequency of orgasms in later life (P = 0.0004). The study provides strong indirect evidence that endocrine factors are important in the aetiology of male breast cancer.

Abstract: OBJECTIVES: Because both breast cancer and the hormone leptin are associated with obesity and reproductive phenomena in women, we have examined whether there is a relationship between leptin and breast cancer among premenopausal and postmenopausal women. We have also evaluated in this dataset the association of IGF-I with breast cancer. METHODS: Seventy-five cases, diagnosed during mammographic screening, with incident breast cancer were matched for age and type of permanent residence with seventy-five controls from those screened negative in the same study base. RESULTS: There was no evidence for an association between IGF-I and either premenopausal or postmenopausal breast cancer risk or between leptin and postmenopausal breast cancer. Among premenopausal women, however, there was a strong and statistically significant inverse association of leptin with breast cancer. CONCLUSION: We did not confirm the positive association, reported from other investigations, of IGF-I with premenopausal breast cancer risk. We have found evidence, however, that leptin may be inversely related to breast cancer risk among premenopausal women. The latter finding is not biologically implausible and deserves to be examined in additional datasets.

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Abstract: BACKGROUND: Policies and measures for the prevention of human immunodeficiency virus Type 1 (HIV-1) transmission require adequate information about the risk profile of AIDS which is time-, place- and population-dependent. We have studied the risk factors for AIDS among men in Greece, a country with relatively low incidence of AIDS. METHODS: A case-control study of all male patients with incident disease, who have been diagnosed in the major university-affiliated, AIDS Unit from February 1995 through August 1997 was conducted in Athens, Greece, a country with relatively low incidence of AIDS. Eighty-three AIDS patients were enrolled and an equal number of orthopaedic patients as controls. All interviews were conducted by the same physician and took place in the hospital. RESULTS: There were no differences among heterosexual men with AIDS, homo- or bi-sexual men with AIDS, and controls with respect to any socio-economic variable. The odds ratio for AIDS among homo- or bi-sexual men, in comparison with heterosexual men, was 51.5 (95% confidence intervals 21.6-122.7). Blood transfusion, intravenous drug abuse and haemophilia were less important risk factors for AIDS in this study. Condom use was generally very low and there was a tendency for lesser use among men at highest risk for HIV transmission, that is, those with a preference for receptive anal intercourse. CONCLUSIONS: AIDS among men in Greece is mainly driven by homosexual behaviour, but the relatively high proportion of bisexual men and the relatively low frequency of condom use are warning signs for the potential of the epidemic to expand in the future. The relatively low incidence of AIDS in Greece, in comparison with other European populations, may be due to a phase difference in the epidemic, but it could also be due to the traditional role separation of homosexuals in this geographical area, and the easy accessibility of disposable syringes and needles in Greece.

Abstract: OBJECTIVES: Helmet use is the best preventive measure available against two wheel motorized vehicle (TWMV) related head injuries. In some countries, however, helmets are used only by a minority of TWMV riders. In collaboration with the Road Traffic Police Department, an inspection survey was undertaken to assess the prevalence and to determine predictors of helmet use. SETTING: The Greater Athens area, Greece, during July and August 1998. METHODS: A total of 982 TWMVs were stopped, 349 of which had two riders (36%). All riders were interviewed by staff members of the Centre for Research and Prevention of Injuries among the Young. RESULTS: The average prevalence of helmet use was 20.2%. It ranged from 9.7% on small suburban roads to 50.8% on highways. Prevalence of use was significantly lower during the weekend days and at night. Women were significantly more likely to wear a helmet and, controlling for gender, drivers were significantly more likely to be helmet users. Riders of more powerful TWMVs and passengers, who themselves had a TWMV driving license, were helmet users more frequently. Among non-users, the majority (46%) indicated that "the helmet made them feel uncomfortable", particularly in warm weather, whereas 18% claimed that there was little need for a helmet in low speed riding. CONCLUSIONS: A multipronged campaign is urgently needed in Greece to increase the prevalence of helmet use by TWMV riders. The campaign should include not only police enforcement but also initiatives to make helmets more convenient to wear and less expensive.

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Abstract: OBJECTIVES: To investigate whether left handed children are at increased risk for injuries, particularly upper limb injuries. SETTING: Athens, Greece, during a six month period in 1995-96. METHODS: Cases were 129 children 4-14 years old with unintentional upper limb injuries from a population based injury database. Two control children matched for gender and age were selected from among those seen at the same medical institution for minor, non-injury ailments. On the basis of information provided by the children and their guardians, sociodemographic variables were recorded, hand preference was assessed, and each child's activity score was calculated through an abbreviated version of Achenbach's scale. RESULTS: Left handed children have a moderately increased upper limb injury risk with a tendency of recurrence of this injury. The risk of upper limb injury is also raised among children of young fathers, whereas it appears to be inversely related to crowding index and activity score--three variables that were controlled for as potential confounders. CONCLUSIONS: This study provides limited support for the hypothesis that left handed children are at increased risk for injury. The excess risk, if genuine, is likely to be limited to cultural settings in which right handedness is perceived as the norm.

Abstract: BACKGROUND: To date it is not known whether gastric juice vitamin C levels are influenced by Helicobacter pylori CagA(+) strains. The aim of the present study, therefore, was to study the impact of H. pylori CagA status on gastric juice vitamin C levels. MATERIALS AND METHODS: We studied 30 H. pylori(+) patients, and the results were compared with 10 endoscopically and histologically normal H. pylori(-) subjects (control group) who were similar to the H. pylori(+) group in terms of age and sex. In all patients, gastric juice vitamin C levels were determined and the severity of gastritis was graded on a scale of 0 (absent) to 3 (severe). CagA was determined by immunoblotting the sera from patients against H. pylori antigens. RESULTS: Among 30 H. pylori(+) patients, 20 were CagA(+) and 10 CagA(-). In the entire group of H. pylori(+) patients, the median gastric juice vitamin C levels (mg L-1) were 16.35 (range 3.5-33.6) and were significantly lower (P < 0.001) than in the control group of H. pylori(-) patients [35.5 (23.1-50.2)]. In addition, in the entire group of H. pylori(+) patients there was a highly significant (P < 0.0001) inverse correlation between the gastritis activity score and the gastric juice vitamin C levels. In the group of H. pylori CagA(+) patients, the median levels of gastric juice vitamin C were 13.8 (3.5-31.2) and were significantly lower than the corresponding levels in both the H. pylori CagA(-) group [24.8 (22-33.6), P < 0.01] and the H. pylori(-) control group [35.5 (23.1-50.2), P < 0.001], the last groups being similar. Furthermore, the gastritis activity median score in the H. pylori CagA(+) group [2 (1-3)] was significantly higher (P < 0.05) than in the H. pylori CagA(-) group [1 (1-2)]. CONCLUSION: These data indicate that infection with CagA(+) H. pylori strains significantly lowers the gastric juice vitamin C levels in comparison with CagA(-) H. pylori strains, which might have a significant impact on gastric carcinogenesis.

Abstract: The EUROCLUS study assembled incidence data for 13,551 cases of childhood leukaemia (CL) diagnosed between 1980 and 1989 in 17 countries (or regions of countries). These were referenced by location at diagnosis to small census areas of which there were 25,723 in the study area. Population counts, surface area and, hence, population density were available for all these small areas. Previous analyses have shown limited extra-Poisson variation (EPV) of case counts within small areas; this is most pronounced in areas of intermediate population density (150-499 persons/km2). In this study, the data set was examined in more detail for evidence that variations in incidence and EPV of CL are associated with population density. Incidence showed a curvilinear association with population density and was highest in areas which were somewhat more densely populated (500-750 persons/km2), where the incidence rate ratio relative to areas having > or = 1000 persons/km2 was 1.16 (95% confidence interval 1.07-1.26) and the P value for quadratic trend across eight strata of population density was 0.02. Incidence in these areas is uniformly elevated and showed no evidence of heterogeneity (i.e. EPV). Statistically significant evidence of EPV was evident amongst some of the areas previously classified as intermediate density areas (specifically, those with a density of 250-499 persons/km2, P < 0.001 for CL). These results were interpreted in terms of the current aetiological hypotheses for CL which propose that exposure to localised epidemics of one or more common infectious agent may contribute to the development of leukaemia. They suggest that such epidemics arise regularly in moderately densely populated areas and also sporadically in areas which are somewhat less densely populated. Although other interpretations are possible, these results may assist in the identification of characteristics which infectious agents must possess if direct or indirect causes of CL.

Abstract: Data concerning injury hazards among tourists are difficult to obtain because estimates of person-time denominators are rarely available. Existing sources are limited to enumeration of injured or killed persons by nationality and type of injury and the analysis can only rely on proportional indicators. Since 1995, the Regional Hospital in the tourist island of Kerkyra (Corfu) has been covering all types of accidents including road traffic injuries, in the context of the Emergency Department Injury Surveillance System (EDISS). The catchment area of this hospital practically coincides with the island population. About 15% of all accidents are traffic-related among either permanent residents or Greek tourists, but they represent 40% among tourists of foreign nationalities. This is suggestive, but far from conclusive evidence, that traffic injuries may be more common among foreign tourists. There are indications that accidents among foreign tourists overall are slightly more serious. Among Greek tourists, the ratio between peak and non-peak period is similar for non-traffic injuries (7.4) and traffic injuries (6.8), whereas among foreign tourists the corresponding ratio is 9.2 for non traffic injuries and 15.0 for traffic injuries. This pattern is difficult to explain in terms other than an excess risk of traffic injuries among foreign tourists.

Abstract: OBJECTIVES: This study assessed the effectiveness of a comprehensive campaign to increase seat belt use in Athens. METHODS: In 1996 a survey focusing on seat belt use was undertaken among occupants of 1400 passenger cars. From October 1997 to June 1998 the campaign was implemented; during the campaign, seat belt law enforcement was not intensified. In 1998 another inspection survey of 2250 cars was undertaken. RESULTS: The program brought only a 6% increase in compliance, but there was an estimated gain of about 50 averted deaths and 1500 averted injuries. CONCLUSIONS: An intensive campaign to increase seat belt use, conducted in the absence of increased law enforcement, resulted in moderate gains.

Abstract: The aetiology of most cases of childhood leukaemia remains unknown, but several studies have indicated that increased birthweight and height are risk factors for the disease. Since insulin-like growth factor-I (IGF-I) mediates the effect of growth hormone and has been positively associated with prostate cancer, we have evaluated the role of this hormone and its principal binding protein, IGFBP-3, in the aetiology of childhood leukaemia. Incident cases of childhood leukaemia from those recorded by a national network of childhood oncologists were enrolled in our study. Controls were children hospitalised for acute conditions of no more than moderate severity with matching for gender, age and maternal place of residence. Blood measurements of IGF-I and IGFBP-3 were undertaken using commercially available radioimmunoassays. Serum IGF-I values decreased by about 1.7% per month, and the rate of decline was higher, though not significantly so, among cases (2.1% per month) than among controls (1.4%). There was no significant association between IGF-I and the likelihood of childhood leukaemia, but an increment of 1 microg/ml of IGFBP-3 was associated with a substantial and statistically significant reduction of childhood leukaemia by 28% (95% confidence interval 7% to 45%). Because IGFBP-3 is essentially a binding protein, we interpret our findings as indicating that bioavailable IGF-I may play an important role in the aetiology of childhood leukaemia. The much smaller quantities and the inherent instability of IGF-I in the blood in comparison to those of IGFBP-3 are likely to hinder documentation of an underlying positive association of IGF-I with the disease.

Abstract:

Abstract: OBJECTIVE: To study the distribution of antibiotic resistant Escherichia coli in the fecal flora of healthy children in Greece. METHODS: Rectal swabs were collected from 181 children, not suffering from infections and not undergoing antibiotic treatment, aged 6 months to 6 years, outpatients of a pediatric hospital, and plated on McConkey agar with ampicillin or trimethoprim. Isolated resistant colonies were identified to the species level and E. coli strains were studied further by molecular methods. RESULTS: Forty-four per cent of the children carried resistant E. coli, and in 20% resistance was transferable. Forty-seven per cent of the children with no history of antibiotic consumption during the last year were found to carry resistant strains in their feces, and transferable R plasmids were present in 23% of them. Forty per cent of the strains and 30% of the transconjugants were multiresistant. Although plasmids of various molecular weights and restriction endonuclease digest patterns were identified, six 60-MDa and four 80-MDa plasmids, originating from epidemiologically unrelated children, were found to be similar. CONCLUSION: Normal flora E. coli in Greece seems to constitute an important reservoir of resistance genes. Eradication of resistance from a population that comes into frequent contact with antibiotics seems to be difficult.

Abstract: Blood samples were taken from, and interviews were conducted with, 76 persons injured in motor vehicle crashes, and from 126 controls with a home and leisure injury. The analysis was undertaken by modelling the data through conditional logistic regression, controlling for gender- and age-matched variables and other potentially confounding variables, including education and visual acuity. Detectable alcohol levels were associated with a 4.9 relative risk (95% confidence intervals 1.4 to 16.8). The population attributable fraction was about 10% with wide confidence intervals. There was no evidence for a safe threshold in these data. The increased injury risk associated with detectable blood-alcohol levels was disproportionally, albeit non-significantly, elevated among occasional drinkers in comparison to regular drinkers. We conclude that alcohol intake is an important cause of road traffic injuries even in the context of the Mediterranean countries where alcohol is taken in moderation and mainly in the form of wine during meals.

Abstract: The EUROCLUS project included information on residence at diagnosis for 13351 cases of childhood leukaemia diagnosed in the period 1980-89 in defined geographical regions in 17 countries. A formal algorithm permits identification of small census areas as containing case excesses. The present analysis examines spatial-temporal patterns of the cases (n = 970) within these clustered areas. The objectives were, first, to compare these results with those from an analysis conducted for UK data for the period 1966-83, and, second, to extend them to consider infant leukaemias. A modification of the Knox test investigates, within the small areas, temporal overlap between cases in a subgroup of interest at a putative critical time and all other cases at any time between birth and diagnosis. Critical times were specified in advance as follows: for cases of acute lymphoblastic leukaemia aged 2-4 years, the 18-month period preceding diagnosis; for cases of total leukaemia aged 5-14 years, 1 year before to 1 year after birth; and for infant cases (diagnosed < 1 year), 1 year before to 6 months after birth. Each of the analyses found evidence of excess space-time overlap compared with that expected; these were 10% (P = 0.005), 15% (P= 0.0002) and 26% (P= 0.03) respectively. The results are interpreted in terms of an infectious origin of childhood leukaemia.

Abstract: During a 12-month period 239 children who presented with a burn injury at the Emergency Department of a teaching children's hospital in Athens, with city-wide coverage, and 239 gender- and age-matched controls with minor non-injury ailments were interviewed. The questionnaire covered sociodemographic characteristics of the children and their families, information allowing the construction of a burn avoidance index in their homes and items from the Achenback scale that were synthesized into a child activity score. The data were analyzed through conditional logistic regression. In general, socio-demographic variables were not of overwhelming importance, although some of the findings indicate that supervision lapses and barefoot walking of gypsy children increase the risk of burn injuries. The kitchen in an inherently high risk place for injuries and the powerful inverse association of the burn avoidance index with burn injury risk points towards steps that could be easily taken and impart substantial protection. There was no evidence in this study of burn injury proneness or that hyperactivity of the child increased the risk of burn injury; indeed, the results point in the opposite direction. Our results strongly support the view that childhood burn injuries are largely environmentally conditioned and, accordingly, easily preventable.

Abstract: The role of maternal diet in the development of the fetal brain has not been adequately explored. Marine n-3 fatty acids have, however, been proposed to be important for brain development. The present case-control study aimed to investigate the relationship between dietary intake during pregnancy and the occurrence of cerebral palsy (CP) in the offspring. Children with CP (n 109), born between 1984 and 1988 to mothers residing in the Greater Athens area, were identified at any time in 1991 or 1992 through institutions delivering care and rehabilitation. Successful nutritional interviews were conducted with ninety-one of these children. Controls were chosen among the neighbours of the CP cases or were healthy siblings of children with neurological diseases other than CP, seen by the same neurologists as the children with CP. A total of 278 control children were chosen, and 246 of them were included in the nutritional study. Guardians of all children were interviewed in person on the basis of a questionnaire covering obstetric, perinatal socioeconomic and environmental variables. A validated semiquantitative food-frequency questionnaire of 111 food items was used to estimate maternal dietary intake during pregnancy. Statistical analysis was done by modelling the data through logistic regression. Food groups controlling for energy intake were alternatively and simultaneously introduced in a core model containing non-nutritional confounding variables. Consumption of cereals (mostly bread) and fish intake were inversely associated with CP (P < 0.05 and P < 0.09 respectively) whereas consumption of meat was associated with increased risk (P < 0.02). A protective effect of fish consumption and a detrimental effect of meat intake have been suggested on the basis of earlier work and appear to be biologically plausible. If corroborated by other studies, these results could contribute to our understanding of the nutritional influences on fetal brain development.

Abstract: We used a case-crossover design to evaluate short-term effects of several exposures on the risk of childhood accident. One hundred fifty-six hospitalized children with injuries responded to an interviewer-administered questionnaire that included, among other variables, information concerning transient exposures that had terminated within 26 hours before the occurrence of the accident. We considered the 2-hour interval preceding the accident as the likely effect period and made within-individual comparisons between this period and the remaining 2-hour intervals during which the child was awake. We used conditional logistic regression analyses to evaluate the effect of the transient exposures on the occurrence of childhood accidents. We present univariate and multivariate analyses adjusting for possible within-person confounding by exposure to more than one exposure simultaneously and for clock time. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were as follows: for strenuous physical activity, OR = 24.2, 95% CI = 10.8-54.4; for intellectual exertion, OR = 9.0, 95% CI = 1.9-25.8; for involvement in family quarrels, OR = 2.6, 95% CI = 0.4-16.9; for school examination, OR = 3.8, 95% CI = 1.5-9.4; and for a pleasing event, OR = 3.4, 95% CI = 1.5-8.2. Other transient exposures were not associated with increased accident risk. Comparison of the overall frequency of reported transient events between the first of the control intervals (3rd and 4th hours before the accident) and the 2-hour interval covering the 25th and 26th hours before the accident suggested that information bias may have led to slight overreporting of transient exposures during the period most proximal to the accident; this bias, however, was too small to explain the marked risk elevations associated with the indicated transient exposures. We conclude that several transient exposures are important component causes in the occurrence of childhood accidents.

Abstract: The protective effect of child restraint and the relative safety of front and rear seating in a population where children often travel unrestrained was assessed in a population based case-control study. The cases were all 129 children aged 0-11 years injured as car passengers in a motor vehicle accident who contacted, during 1996, one of the two major children's hospitals in Athens; emergency cases are accepted by the two hospitals on alternate days throughout the year, thus generating a random sample of children injured as car passengers. The prevalence of the studied exposures in the study base was estimated from an inspection survey comprising a random sample of 191 children of the same age who travelled in passenger cars. The survey was conducted by medical staff from our centre in collaboration with the road traffic police. Odds ratios (ORs) were calculated after adjustment for confounding factors through the Mantel-Haenszel procedure. The OR for injury was 3.3 among unrestrained children compared with restrained children (comparison essentially limited to children aged 0-4 years) and 5.0 for children seated in the front compared with those seated in the rear (comparison essentially limited among unrestrained children). Protective effect estimates derived from this analytical study suggest that in Greece about two thirds of all childhood injuries from car crashes could have been avoided through the regular use of a proper child restraint. The data also indicate that, in the absence of a child restraint system, a rear seating position conveys substantial protection and could explain the low mortality of children as car passengers in Greece, a country which is characterised by a high overall road traffic mortality as well as a high childhood accident mortality.

Abstract: We have investigated the relationship between consumption of food groups and intake of energy-generating macronutrients on the one hand, and birthweight on the other among apparently healthy singleton, term babies. Three hundred and sixty-eight women who delivered in six maternity clinics in two Greek cities during specified days over an 8-month period completed a 190-item, interviewer-administered, validated, semiquantitative food frequency questionnaire. Study participants also provided information on sociodemographic, reproductive and lifestyle variables. Data were analysed using multiple regression modelling. Nutritional variables were energy-adjusted, and non-nutritional correlates of birthweight were accounted for. The analysis revealed most of the established non-nutritional associations of birthweight -- an indication of study validity. Among food groups, meat and meat products and fish and sea food were suggestively associated with increased birthweight (two tailed P-values 0.08 and 0.16, respectively). Among energy-generating nutrients, monounsaturated fat was positively associated with birthweight and significantly so in several of the models. We consider our findings are considered as compatible with hypotheses linking fish and meat intake to fetal growth and as indicative of a positive association between intake of monounsaturated fat and birthweight.

Abstract: The interpretation of reports of clusters of childhood leukaemia is difficult, first because little is known about the causes of the disease, and second because there is insufficient information on whether cases show a generalized tendency to cluster geographically. The EUROCLUS project is a European collaborative study whose primary objective is to determine whether the residence locations of cases at diagnosis show a general tendency towards spatial clustering. The second objective is to interpret any patterns observed and, in particular, to see if clustering can be explained in terms of either infectious agents or environmental hazards as aetiological agents. The spatial distribution of 13351 cases of childhood leukaemia diagnosed in 17 countries between 1980 and 1989 has been analysed using the Potthoff-Whittinghill method. The overall results show statistically significant evidence of clustering of total childhood leukaemia within small census areas (P=0.03) but the magnitude of the clustering is small (extra-Poisson component of variance (%) = 1.7 with 90% confidence interval 0.2-3.1). The clustering is most marked in areas that have intermediate population density (150-499 persons km[-2]). It cannot be attributed to any specific age group at diagnosis or cell type and involves spatial aggregation of cases of different ages and cell types. The results indicate that intense clusters are a rare phenomenon that merit careful investigation, although aetiological insights are more likely to come from investigation of large numbers of cases. We present a method for detecting clustering that is simple and readily available to cancer registries and similar groups.

Abstract: It has been established that seat belt use by car occupants and helmet use by motorcycle riders substantially reduces the risk of serious and fatal injuries following accidents. No study, however, has evaluated the motor vehicle deaths that could be prevented in Greece by general use of these devices, even though this country has the highest mortality from motor vehicle accidents in the European Union. We have estimated the odds ratios (OR) for death rather than injury in a motor vehicle accident by seat belt use among occupants of passenger cars or helmet use among motorcycle riders, using a nationwide database in which persons killed or injured in road traffic accidents in 1985 and 1994 were recorded. The study base included 910 dead and 19,511 injured persons for 1985 and 1203 dead and 22,186 injured persons for 1994. The OR and 95% confidence intervals (CI) for death rather than injury was 0.69 (CI: 0.58 to 0.81, p < 10(-5)) for seat belt users versus non-users and 0.64 (CI: 0.51 to 0.81; p < 10(-3)) for helmet users versus non-users. There was evidence that the protective effect of these passive safety devices increased from 1985 to 1994 probably reflecting technological improvements. The proportion of all deaths that could have been avoided if all car occupants used seat belts was estimated to 27%, whereas 38% of motorcycle deaths could have been avoided if all motorcycle riders used helmets. These proportions translate to about 500 deaths per year, mostly deaths among young men.

Abstract: OBJECTIVES: This study was undertaken to evaluate the performance of the score for neonatal acute physiology (SNAP) in Greece, to examine the predictive power of SNAP calculated during the 12 hours after admission in comparison with customarily calculated SNAP during the first 24 hours, and to assess SNAP during the second 12 hours from admission as a measure of response to treatment. METHODOLOGY: A total of 579 newborns admitted to three neonatal intensive care units (NICUs) from two cities in Greece were enrolled in the study; SNAP was determined during the first 12 hours, the second 12 hours, and the first 24 hours from admission to the NICU and calculated using an algorithm based on deviations from normal values of 26 physiologic parameters. RESULTS: All three variants of SNAP were powerful predictors of vital status at discharge, as well as of duration of stay among survivors. A five-point increase in SNAP in the first 12 hours corresponds to a more than twofold ratio in the odds for death, whereas a five-unit difference in SNAP from the second 12 hours corresponds to a more than threefold ratio. The combined 24-hour score was similar to that for the first 12 hours. A considerable advantage of SNAP was its independence from more traditional predictors of neonatal death, notably gestational age, birth weight, and Apgar score. The combination of all of these predictors improved further the overall predictive potential. CONCLUSIONS: SNAP is a useful tool in medical research and can be applied in different population groups. Its independence from birth weight underlines its added value to predict fatality ratios. Moreover, the results of the present study indicate that SNAP can be estimated without loss of predictive efficiency during the first 12 hours from admission to the NICU, whereas SNAP during the second 12 hours adequately reflects the effectiveness of early medical interventions.

Abstract:

Abstract: The risk profile of childhood leukaemia in Greece was studied through a case-control investigation that included all 153 incident cases of the disease, ascertained throughout the country during 1993 and 1994, and two hospital controls for every case matched for gender, age and place of residence. The data were analysed using conditional logistic regression and the associations are expressed in terms of adjusted odds ratios (OR) and their 95% confidence intervals. Cases were born to mothers of a higher standard education, the OR for an increment of four schooling years being 1.48 (1.17-1.87) and had higher birth weight, the OR for an increment of 500g being 1.36 (1.04-1.77). Pet ownership and birth after a pregnancy with anaemia were associated with increased risk, the ORs being 2.18 (1.14-4.16) and 2.60 (1.39-4.86) respectively. From the frequency analyses, indicative inverse associations were found with birth order, household crowding and previous hospitalization with allergic diseases, whereas indicative positive associations were found with diabetes mellitus during pregnancy and with neonatal jaundice. Substantial or significant elevations were not found with respect to maternal smoking and coffee drinking during pregnancy, diagnostic radiography and ultrasonographic examinations or blood transfusions. A significant inverse association with maternal consumption of alcohol could be due to multiple comparisons, but a detrimental effect can probably be excluded. A non-significant positive association with total shots of viral vaccinations and a weak non-significant inverse association with breast feeding were also found. We interpret the findings of this study as being compatible with acute childhood leukaemia being linked with delayed development of herd immunity to fairly common infectious agents, in conjunction with accelerated perinatal and early post-natal growth.

Abstract: BACKGROUND: We have evaluated high-risk behavior of adolescents 12 to 17 years of age on the basis of seven binomial psychosocial variables in order to assess whether there is a tendency of these variables to cluster in the same individuals and to identify socioeconomic covariates of risky behavior. METHODS: Study participants were 547 adolescents from four high schools in Greece: two in rural areas, one in an upper-medium socioeconomic class areas, and one in a low-to-medium socioeconomic class area of Athens. Clustering was assessed by evaluating concordance of high-risk attributes examined in pairs, and was expressed as a series of odds ratios (ORs) as well as by factor analysis. RESULTS: All but one OR were higher than the null value, but they were particularly high with respect to smoking and nonuse of safety belts (OR = 3.2, P < 10(-4)), smoking and binge drinking (OR = 3.3, P < 10(-4)), smoking and riding with a drunk driver (OR = 5.3, P = 10(-4)), smoking and driving under the influence of alcohol (OR = 9.7, P < 10(-4)), nonuse of oral contraceptives and riding a car with a drunk driver (OR = 15.4, P = 0.002), and driving under the influence of alcohol and riding with a drunk driver (OR = 18.6, P < 10(-4)). Factor analysis indicated that risky behavior could be explained in terms of two component factors, namely carelessness in the context of self interest and irresponsible sexual behavior. A composite index integrating information of all seven high-risk indicators regressed on sociodemographic characteristics showed that risky behavior increased sharply with age and was concentrated strongly in the low-education families and the lower income areas. CONCLUSIONS: Several aspects of high-risk behavior tend to aggregate in the same individuals, and the clustering pattern has already been developed by late adolescence, mostly among the less privileged families and population groups. It appears that socioeconomic class health differentials may have strong roots in late adolescence.

Abstract: A total of 872 children aged up to 14 years, who were diagnosed with leukemia in Greece during the decade 1980-89, were allocated by place of residence to the 601 administrative districts of the country. Evaluation of spatial clustering was done using the Potthoff-Whittinghill method, which validly assesses heterogeneity of leukemia risk among districts with variable expected numbers of cases. There was highly significant evidence for spatial clustering occurring particularly among children living in urban and, to a lesser extent, semi-urban areas. The evidence was stronger for children younger than 10 years old, applied also to children in different five-year age groups, and persisted when cases of acute lymphoblastic leukemia were analyzed separately. These findings provide support to the hypothesis that localized environmental exposures could contribute to the etiology of childhood leukemia, but they cannot distinguish between exposures of physical or chemical nature, nor can they exclude socially conditioned patterns of exposure to infectious agents.

Abstract: BACKGROUND: During the 20-month period September 1993 to April 1995, a health education injury prevention programme focusing on home injuries among the young (< or = 18 years old) and elderly (> or = 65 years old) on the Greek island of Naxos was undertaken, its effectiveness was evaluated by comparing the subsequent injury experience in sentinel population groups in Naxos as well as in Spetses, another island of similar sociodemographic profile, where no such intervention programme had been formally implemented. METHODS: On the island-of Naxos an injury prevention campaign was initially undertaken involving virtually all opinion leaders and implemented through lectures, workshops and publicity in the local media. The main intervention focused on 172 households on the island of Naxos and was done by trained local collaborators who visited each household weekly to provide injury prevention advice and assess home safety. Similar visits were done by untrained collaborators in 177 households on the island of Spetses in order to assure collaboration of household members in the comparative evaluation stage of the programme. The process evaluation was based on ascertained changes of safety features and attitudes in the participating households, whereas the outcome evaluation was based on the incidence of injuries among members of the participating households in the two islands over a period of 8.5 months (255 days). RESULTS: On the intervention island of Naxos there were statistically significant improvements with respect to 11 of the 28 examined variables, whereas on the island of Spetses, such improvement was only noted for one variable. The age-adjusted incidence rate ratio of injuries overall among the target groups, contrasting the intervention and the control households was 0.85 with 90% confidence interval (CI): 0.69-1.05. With respect to home accidents the corresponding ratio was 0.79 with 90% CI: 0.60-1.04. CONCLUSIONS: An intensive and focused injury prevention intervention had only modest success when injuries themselves were the outcome variable.

Abstract: Serum concentrations of immunoglobulin IgG1, IgG2, IgG3 and IgG4 were determined by radial immunodiffusion in a sample of 414 healthy Greek children, who were admitted to the major Teaching Hospital for Children in Athens for minor surgical operations. Statistical analysis was performed by multiple regression after logarithmic transformation of the immunoglobulin values. There was a statistically significant increase of IgG3 with age, whereas IgG1, IgG2 and IgG4 levels reached a turning point at the age of five years. Older than 5 years male children were found to have marginally higher IgG4 levels than females. Low socioeconomic class was positively and significantly associated (9% increase) with IgG1 levels only among the older age group. History of frequent infections was associated with a 16% increase of IgG1 levels in the younger (less than 5 years) (p = 0.01) and with a 47% increase of IgG4 among the older age group (p = 0.03). Atopic history was associated with a 16% increase of IgG1 in the younger (p = 0.02). The findings of the present study provide an insight on the determinants and the clinical significance of IgG subclass levels among children.

Abstract: OBJECTIVE: To estimate the incidence of unintentional childhood injuries resulting from accidental poisonings in the Greater Athens area and to ascertain what fraction of this incidence could be linked to specified conditions, amenable to preventive interventions. METHODS: Prospective study over 12 months of 670 children hospitalized 224 hours for accidental poisoning. Site: Two pediatric hospitals and three smaller units in Greater Athens admitting children < or = 15 years old. Information was recorded in a semistructured questionnaire and the data were analyzed through simple stratification by one or more variables. Results Accidental poisoning requiring hospitalization > or = 24 hours was 50% higher among boys than among girls, peaked towards the end of the second year, and declined sharply after the fourth year of life with an estimated incidence of 500 cases per 100,000 among children > or = 5 years old. Cigarettes were the most common agent among infants, whereas medicinal products dominated all other childhood periods. Detergents, petroleum products, and pesticides each contributed about 10% of all poisonings with detergents peaking during the second year of life, petroleum products during the third year, and pesticides remaining constant, in proportional terms, throughout childhood. During the working hours of the day the incidence of poisonings was 80% higher than during the late afternoon and evening hours or the weekends, the times when both parents are usually at home; the excess was statistically significant. The presence of both parents at home in the afternoon hours was associated with an almost 50% reduction of hospitalized poisoning. The accessibility of products with poisoning potential was of major importance. Some specific conditions that led to the incident included storage of potentially poisoning products in the refrigerator, storage of such products in containers of innocuous products, without proper labeling, and parental errors in medication. CONCLUSIONS: Unintentional childhood poisoning further reflects an interaction between inappropriate storage of consumer products and suboptimal supervision during the housekeeping hours of the day.

Abstract:

Abstract: In order to assess consumption of the calcium rich dairy products, intake of non alcoholic beverages and physical activity as risk factors for bone fractures among schoolage children, a case control study was undertaken in Athens, Greece. During 1995 one hundred children 7 to 14 years old (74 boys and 26 girls) with single uncomplicated fractures of the upper and lower extremities and no evidence of coexisting metabolic condition affecting bone fragility were compared with 100 age- and gender-matched controls. The analysis was undertaken by modeling the data through conditional logistic regression. Several indicators point to an increased risk of fractures among physically active children, although none of the individual variables was statistically significant. Somatometric factors were not related to fractures, although children with more advanced stage of development at Tanner's scale were apparently at increased risk. Intake of dairy products and of carbonated non cola beverages was not related to the occurrence of fractures. By contrast, intake of non carbonated beverages, mainly fruit juices, and of cola beverages were significantly associated with elevated risks of fractures [for an increase of one-half can per day, the odds ratios and associated 95% confidence intervals were 1.6 (1.2 to 2.3) and 1.7 (1.2 to 2.6) respectively]. In the absence of other common elements between cola and non carbonated beverages the positive associations of these beverages, with bone fractures probably reflect the increased rehydration needs of active children who are also at high risk for injuries.

Abstract: Residential proximity to electrical power lines of different voltage in relation to childhood leukemia was investigated through a case-control study undertaken in Greece during 1993-1994. The study comprised 117 incident cases of childhood leukemia and 202 age-, gender- and place-of-residence-matched controls. Four measures of exposure to magnetic fields were developed, using data provided by the Public Power Corporation of Greece: Voltage (V) divided by the distance (d), V/d2, V/d3 and an adaptation of the Wertheimer-Leeper code. Conditional-logistic-regression modeling was used to adjust for potential confounding influences of 18 variables. No significant trends of childhood leukemia risk with increasing exposure levels were noted, nor were there statistically significant elevations of disease risk at the higher exposure levels in each measure of exposure. These results do not support a causal link between residential proximity to electrical high-voltage wires and childhood leukemia risk, but in themselves do not refute a weak empirical association.

Abstract: During the six-month period April to September 1995, all 730 road traffic injury victims who contacted any of the three hospitals of the Heraklion District in the island of Crete, directly or through the Medical Emergency Transportation Network, were recorded. A special form was completed containing information about selected characteristics of the victims, nature of the injuries and conditions of the accident. All 39 fatalities owing to road traffic accidents were also registered. In the absence of data concerning the person-time at risk only proportional analyses could be performed. On the basis of Greek hospital discharge statistics in Heraklion District during 1992, one foreigner visitor was discharged owing to injuries of any type for every 18 Greeks. The corresponding ratio for road traffic accidents is close to 1:3, underlying the importance of road traffic accidents as the major health hazard during pleasure travelling. Left-side driving country nationals were at an increased risk for traffic accident when they drove a rented rather than an owned vehicle (p = 0.02), possibly on account of maladaptation during the adjustment period in the country of visit. Moreover, road traffic victims from left-side driving countries compared with foreigners from right-side driving countries were involved 2.5 times more frequently in accidents in which overpassing or other driving maneuvers require reflexes conditioned on reverse directionality (p = 0.02). Alcohol abuse was reported as a primary cause of accident in a significantly higher proportion of foreign nationals (p < 10(-6)) reflecting the fact that the latter group was on vacation. Alcohol intoxication was more common among Eastern European victims than among victims from European Union countries (p < 10(-5)). The likelihood of death following hospitalization ranged from 0% among those with a Glascow Coma Scale (GCS) score of 8 or higher, to 90% among those with GCS less than 8. After adjustment for exact GCS score there was no difference in the probability of death or the likelihood for admission to intensive care unit between Greek and foreign nationals. Road traffic accidents are a major hazard during pleasure travelling and victims of such accidents among travellers have a distinct epidemiologic profile compared with accidents of a similar nature among locals.

Abstract: Because AIDS is largely transmitted through sexual intercourse, the descriptive epidemiology of sexually transmitted diseases of short incubation period could presage the incidence trend of AIDS after a time interval that approximates the incubation period of the disease. We have evaluated this hypothesis using data from the 50 states in the United States routinely reported to the Centers of Disease Control and Prevention from 1979 to 1994. We have estimated the dependence of the slope of the annual incidence rate of AIDS over the period 1987-1994 on the intercept and the slope of one or more of three common sexually transmitted diseases: gonorrhea, chancroid, and syphilis. When the parameters of two sexually transmitted diseases were used as predictor variables, the adjusted multiple correlation coefficient (Radj) ranged from 0.70 to 0.77. When the parameters of all three sexually transmitted diseases studied were used in the regression model, the Radj reached a high value of 0.79. We conclude that incidence data of three common sexually transmitted diseases during an 8-year period presage the evolution of the AIDS epidemic during the subsequent 8-year period.

Abstract: There is evidence that sex hormones and intrauterine factors are involved in the etiology of testicular cancer. We evaluated the importance of perinatal and adult life correlates of sex hormones as risk factors for testicular cancer in a case control study of 97 incident, histologically confirmed cases, residents of the Greater Athens area and environs, who were diagnosed in the 3 specialized cancer hospitals and the major General Hospital in Athens during the 2 year period 1993-94. Cases were age-matched to 2 healthy controls from the same study base. Both cases and controls as well as their mothers were interviewed by the same investigator and the data were analyzed through conditional logistic regression. The odds ratio for testicular cancer was elevated among persons born after a pregnancy characterized by severe nausea. Among the adult life factors, higher body mass was associated with reduced risk, as was evidence of baldness. To the extent that nausea during pregnancy reflects higher levels of pregnancy estrogens on the one hand, and baldness is linked to androgens on the other, our data suggest that estrogens in the intrauterine life and androgens at later stages may have sequential opposing effects for the development of testicular cancer.

Abstract: Several factors are known to affect birthweight and their effects are variously mediated through gestational duration or through fetal growth conditional on this gestation. In order to quantify independent associations of birthweight conditional and unconditional on gestational age, all 2538 mothers of singleton babies delivered during 1993 in two Maternity Hospitals in Athens were interviewed and their obstetric records abstracted. Birthweight was modelled as outcome variable through multiple regression including 32 potentially predictive factors. The regression model was fitted with and without gestational age as an additional independent variable in order to apportion birthweight associations into those independent of, or mediated through, gestational length. The factors studied were found to be classifiable into the following categories: factors associated with birthweight mostly through increases in gestational duration, either positively (age at menarche, long menstrual cycles, parity 4 or higher), or negatively (single motherhood, maternal age, tobacco smoking); those associated with birthweight mostly through increase of birthweight conditional on gestational duration, either positively (male gender, short menstrual cycles, maternal pre-pregnancy weight, anaemia, oedema) or inversely (employment during pregnancy, stillbirth, primiparity, pregnancy induced hypertension, coffee drinking); and those associated with birthweight through apparently dual effects, either positively (maternal education) or inversely (perceived stress, bleeding during pregnancy). The other studied factors were not demonstrably related to birthweight in this data set. Identification and quantification of these relations is useful for understanding underlying physiological and pathophysiological processes and for increasing specificity in exploring the association of birthweight with adult onset diseases, like coronary heart disease or cancer.

Abstract: A population-based case-control study of the determinants of stillbirths was conducted in Greece from 1989 to 1991. All reported stillbirths after 28 weeks of pregnancy (N = 2,006) during the three year study period comprised the case group. The control group derived from random sampling of 10% of all livebirths in Greece, during the same period (N = 30,705). The data were analysed by modelling through multiple logistic regression. The adjusted relative risk of stillbirth was significantly higher for males compared to females. A statistically significant monotonic increase in relative risk was observed with shorter gestational age, low maternal education, and older maternal age. Birthweight and parity showed a statistically significant U-shaped association with stillbirth risk, with a higher risk being observed among both low and high birthweight deliveries, as well as among primiparous or multiparous (4+) mothers. Positive associations of stillbirth with multiple births, out-of-wedlock marriage and non-Greek-orthodox maternal religion were noted in crude analyses, but these associations almost disappeared in logistic regression model. Maternal urban or rural residence showed no relation to risk. Overall, the prospective risk of stillbirth after the 24th week of gestation in Greece has been estimated to be higher than that in Japan (a more developed country) with more than 40% of stillbirths occurring after the 36th week of pregnancy.

Abstract: The accident which occurred during the night of April 25-26, 1986 in reactor 4 of the Chernobyl nuclear power plant in the Ukraine released considerable amounts of radioactive substances into the environment. Outside the former USSR, the highest levels of contamination were recorded in Bulgaria, Austria, Greece and Romania, followed by other countries of Central, Southeast and Northern Europe. Studies of the health consequences of the accident have been carried out in these countries, as well as in other countries in Europe. This report presents the results of a critical review of cancer studies of the exposed population in Europe, carried out on the occasion of the 10th anniversary of the Chernobyl accident. Overall, three is no evidence to date of a major public health impact of the Chernobyl accident in the field of cancer in countries of Europe outside the former USSR.

Abstract: OBJECTIVES: To identify child or family related risk factors for unintentional childhood poisoning in Greece and to explore whether product specific poisonings might have special features that make them amenable to preventive interventions. SETTING: A case-control study was undertaken in Athens, Greece in 1995. Cases were 100 consecutive children brought with poisoning to the emergency clinics of the two university affiliated children's hospitals. For every case two age, gender, and hospital matched controls were chosen from among children brought to the outpatient clinics of these hospitals on the same date. METHODS: All children and their guardians were interviewed by the same person using a standard questionnaire that covered demographic, socioeconomic, behavioral, and past injury characteristics. Information was also obtained concerning type and conditions of poisoning for cases. Statistical analysis was undertaken by modeling the data using conditional logistic regression. RESULTS: Socioeconomic factors were not important risk indicators in these data but children living with other than both parents were at increased risk (odds ratio (OR) = 4.7, p = 0.08), as were children with a history of previous poisoning that required medical care (OR = 5.1, p = 0.05). Unintentional poisonings caused by chewing or swallowing cigarettes were concentrated in families where both parents were smokers. CONCLUSIONS: Absence of a parent appears to be associated with increased likelihood of childhood poisoning. The importance of product accessibility is underlined by the concentration of tobacco poisoning among children of parents who were both smokers. In the cultural context of this study, sociodemographic factors do not appear to represent demonstrable risk factors. Instead, control of childhood poisoning should be concentrated on safe packaging, storage, and disposal of potentially hazardous products.

Abstract: In the context of a project aiming to assess risk factors affecting health status of Greek adolescents, 380 adolescents aged 12-17 years were randomly selected from two rural high schools of similar socioeconomic status, and from two urban schools of different socioeconomic level, namely urban/lower and urban/ higher. Dental examinations were carried out according to WHO diagnostic criteria; oral hygiene habits were recorded through personal interviews; and diet was assessed through interviewer-administered, semi-quantitative food frequency questionnaires. The percentage of caries-free adolescents varied from 24.3 in the age group of 12-13 years to 13.2 in the age group 16-17 years; mean (SE) DMFT values were 3.7 (0.3) in the younger age group and 5.9 (0.4) in the older age group whereas mean (SE) DMFS values were respectively 5.6 (0.5) and 9.9 (0.9). Multiple regression analysis-derived results showed that dental health, measured through either DMFT or DMFS indices, was significantly better among younger and male adolescents; among higher socioeconomic class urban residents; among those brushing their teeth at least once per day; and among those who had better school performance. There was evidence that intake of vegetables and milk products was associated with lower DMFS and DMFT indices, whereas there was a non-significant tendency for sugar intake to be associated with higher values of these indices. In contemporary Greek society there are substantial social inequalities with respect to dental health; these are due, in part, to differences in oral hygiene habits and patterns of dietary intakes. High risk groups should be identified among the underprivileged for targeted health education efforts and delivery of more intensive dental care services.

Abstract: Age at menarche is one of the few established risk factors for breast cancer; identification of its exogenous determinants could throw light on the origins of breast cancer. We have undertaken an epidemiologic study in Greece to ascertain whether: 1) energy intake, an indicator of physical activity, is associated with later age at menarche; 2) energy-adjusted fat intake is related to earlier age at menarche; and 3) other macronutrients and anthropometric variables are predictors of age at menarche. Anthropometric, socio-economic, familiar, nutritional and lifestyle predictors of age at menarche were studied by interviewing in person 345 female students 9 to 16 years old attending 8 schools of Greater Athens. Menarche was the outcome variable in a proportional hazards model assessing the mutually adjusted incidence rate ratio by a series of predictor variables. In a complementary analysis, age at menarche was the dependent variable among menstruating girls. Consistent results were derived from the main and the complementary analysis. Increased height and body mass index accelerate the occurrence of menarche. Maternal and daughter's ages at menarche are correlated, but there is no evidence of an association with paternal education. Various measures of moderate physical activity as well as increased total energy intake were associated with a delay in age at menarche. Energy-adjusted macronutrients were not associated with age at menarche. It appears that an alteration of energy balance in early life through increased physical activity could delay age at menarche and reduce the risk for breast cancer in later life.

Abstract: There has been no documented increase in childhood leukaemia following the Chernobyl accident. However, different forms of childhood leukaemia may not be equally susceptible to radiation carcinogenesis. Infant leukaemia is a distinct form associated with a specific genetic abnormality. Outside the former Soviet Union, contamination resulting from the Chernobyl accident has been highest in Greece and Austria and high also in the Scandinavian countries. All childhood leukaemia cases diagnosed throughout Greece since 1 January 1980 have been recorded. Here we report that infants exposed in utero to ionizing radiation from the Chernobyl accident had 2.6 times the incidence of leukaemia compared to unexposed children (95% confidence interval, 1.4 to 5.1; P approximately 0.003), and those born to mothers residing in regions with high radioactive fallout were at higher risk of developing infant leukaemia. No significant difference in leukaemia incidence was found among children aged 12 to 47 months. Preconceptional irradiation had no demonstrable effect on leukaemia risk at any of the studied age groups.

Abstract: OBJECTIVES: To identify conditions related to baby walker injuries in a Greek population. DESIGN: Analysis of all baby walker related injuries recorded during a 12 month period by the childhood injury surveillance system established in one of the two teaching hospitals for children serving the population of Athens. SETTING: Emergency clinics of A Kyriakou Children's Hospital in Athens, Greece. SUBJECTS: 49 babies with baby walker related injuries brought to the emergency clinics during the period May 1994 to April 1995. RESULTS: The incidence of these injuries was 16 per thousand person years of users, or 3.5 per thousand babies per year. More boys than girls were brought to the hospital for these injuries and the incidence density was highest during the ninth and 10th month of age. Falls from heights, particularly stairs, were the most frequent cause of baby walker related injuries, especially among younger babies. The majority of these injuries were of minor severity, but three babies had bone fractures and one had a second degree facial burn. Six babies required hospitalization and for seven others, a follow up visit was needed. The higher proportion of hospitalization among girls than boys raises the possibility that boys with minor injuries are more frequently brought to the hospital. CONCLUSIONS: Baby walkers impart a significant risk of injury from a consumer product that provides no clearly identifiable benefit. As most baby walker injuries happen on stairs, modifications in product design are required to reduce these injuries. Moreover, parents should be forcefully advised of the risks and predisposing conditions, if baby walkers are to be used at all.

Abstract: Caesarean section rates have increased in Greece by almost 50% during the last 13 years. We conducted a study in Athens, Greece, to assess the importance of a series of medical and socioeconomic factors in the use of Caesarean section or operative vaginal procedures, rather than a non-operative process, for the delivery of singleton, liveborn babies of primiparous mothers. We used a case control approach to compare 444 babies delivered through a Caesarean section and 130 delivered through operative vaginal delivery with 1235 normally delivered babies in a public and a private hospital. Data were analysed through multiple logistic regression. Caesarean section was more commonly performed in older, shorter or overweight mothers and for high and low birth-weight babies, as well as in response to several obstetric complications and following in-vitro fertilization. A similar pattern was noted with respect to operative vaginal delivery, except that this procedure was not unusually frequent among overweight women and was not encountered in this study among children born after in-vitro fertilization. Caesarean section was performed twice as often in the public teaching hospital as in a private maternity hospital, and operative vaginal delivery was several times more common in the former than in the latter, after controlling for biomedical risk factors. The unequal distribution of operative delivery procedures between the public and the private hospital raises questions about the justification of their performance in a substantial fraction of deliveries, and indicates that social factors condition their use.

Abstract: The method introduced by Knox for evaluation of space-time clustering has been applied to 872 cases of childhood (0-14 year old) leukaemia diagnosed in Greece over the 10 year period 1980-89. Greek towns are characterised by substantial population mixing due to internal migration, whereas there is relative isolation in mountainous rural areas. Predetermined space (5 km) and time (1 year) limits were used on the basis of previous reports in order to define the clustering cell. There is highly significant evidence for clustering of childhood leukaemia in Greece as a whole, the observed number of pairs that are close in both spaces and time exceeding the expected number by 5.2% (P = 0.004). The excess is particularly evident for leukaemia cases in 0 to 4-year-old children, among whom the observed number of pairs that are close in both space and time exceeded the expected number by 9.4% (P = 0.004). There is no evidence of space-time clustering for leukaemia cases older than 5 years. The overall pattern is descriptively similar in urban and semiurban areas and is especially marked for acute lymphoblastic leukaemia at the childhood peak ages (2-4 years) with an excess of 19% (P = 0.0006). In the rural population there is evidence for clustering of cases belonging to older and broader age groups, a phenomenon compatible with a delay in the development of herd immunity against putative infectious aetiological agents. The findings of the present study provide support for the hypothesis that a substantial proportion of cases of childhood leukaemia may arise as a rare sequel to exposure to an agent or agents, most probably viral in nature.

Abstract: Extrinsic and intrinsic risk factors for injuries among the elderly in Greece were investigated in a hospital based case-control study. Cases were 200 elderly persons, residents of the Greater Athens area, who contacted the "Laiko" University Hospital for accident-related injuries, during a 10-month period, whereas the control series comprised 385 elderly who, during the same period, contacted the same hospital for non-injury related medical reasons. Data were analyzed by modeling through multiple logistic regression. Statistically significant associations were found for smoking vs non-smoking [odds ratio (OR) 2.40; 95% confidence interval (CI) 1.22-4.70], moderate use of alcoholic beverages vs non use (OR 0.37; CI 0.23-0.61) and house safety score (OR 0.72; CI 0.56-0.93 for an improvement by 1 unit). Non statistically significant positive associations were noted with history of previous hospitalizations for injury, chronic central nervous system conditions, defective hearing, refractive eye disorders, current use of psychoactive drugs, excessive use of alcoholic beverages, other than ground floor residency, cohabitation with fewer members and other than currently married status. Restricted activity was assessed in subsamples of cases and controls and was associated with somewhat reduced risk for injury (OR for one unit increase in a 10 unit modified Groningen activity scale is 1.06; CI 0.99 to 1.13). Overall, these results suggest that there is a constellation of plausible risk factors for injuries among the elderly.

Abstract: The purpose of this study was to investigate the relation between a series of maternal, antenatal, perinatal, socioeconomic and environmental variables and the occurrence of cerebral palsy (CP) in a setting different from those in which previous analytic epidemiologic studies had been undertaken. The study was of case-control design and included 103 children with cerebral palsy born between 1984 and 1988 and residents of the Greater Athens area at any time during 1991 and 1992. Controls were chosen among the neighbors of the index case or were healthy siblings of children with neurological diseases other than CP seen by the same neurologists as the children with CP; a total of 254 control children were eventually included. Statistical analysis was done by modeling the data through unconditional logistic regression. Statistically significant (p < 0.05) risk factors of potential causal importance were: twin membership (OR = 10.2), gestational age (OR = 0.5 per 4 weeks), birth weight conditional on gestational age (OR = 0.9 per 100 g), congenital malformations (OR = 7.5), unhealthy placenta (OR = 6.6), placenta previa (6 cases, no controls), abnormal amniotic fluid (OR = 3.6), head circumference more than 36 cm (OR = 9.0), general anesthesia during labor (OR = 4.3), forceps delivery (OR = 6.8), and birth trauma (OR = 11.5). Among children with no identifiable prenatal risk factors there was no excess prevalence of one or more perinatal risk factors in CP cases compared to controls, which implies that the latter factors impart their effect through interactions with co-existing prenatal or other risk factors.

Abstract: Serum levels of immunoglobulin E (IgE) were determined by enzyme immunoassay in 414 Greek infants and children of both sexes, 1 month to 14 years old. The children were admitted to the "Aghia Sophia" Teaching Hospital for Children (Athens, Greece) for surgical corrections of minor anatomic abnormalities, but they were otherwise healthy. Statistical analysis was performed through multiple regression after logarithmic transformation of the immunoglobulin values. IgE levels increased significantly by about 80% per year up to the age of 5 years, without noticeable impact of age on these levels thereafter. History of allergic disease showed a significant positive association with serum levels of IgE in both younger (less than 5 years) and older children. History of frequent infections was positively associated with IgE levels, although the relation was statistically significant only in the older age group, IgE levels in Greek children appear to be higher than the corresponding levels of children living in northern Europe, but much lower than those of children in Southeast Asia, a fact that may reflect different exposure level during childhood to infections known to influence IgE levels.

Abstract: Serum levels of immunoglobulins G, A and M were determined by nephelometry in 414 infants and children aged 1 month to 14 years. The children were admitted to "Aghia Sophia" Teaching Hospital for Children for surgical corrections of minor anatomical abnormalities, but they were otherwise healthy. Statistical analysis was performed through multiple regression after logarithmic transformation of the immunoglobulin values. Immunoglobulin G (IgG) levels increased significantly by 18% per year until the age of 5 years and by 2% per year thereafter. Among children less than 5 years old, IgG levels tended to increase significantly with the number of doses of either DTP or Sabin vaccine. Immunoglobulin A (IgA) levels increased significantly by 27% until the age of 7 years and by 4% thereafter. Among children less than 7 years old, history of breast feeding was significantly associated with higher levels of IgA. Vaccination with either DTP or Sabin was associated with elevation of IgA levels among younger and, to a lesser extent, older children, but the elevations did not reach statistical significance. Immunoglobulin M (IgM) levels increased rapidly during the first 12 months of life and very slowly thereafter and they were significantly higher among girls. Among children less than one year old, there was evidence that vaccination with either DTP or Sabin was associated with elevated IgM levels, although the differences were not statistically significant possibly because of small numbers of infants in the study sample.(ABSTRACT TRUNCATED AT 250 WORDS)

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Abstract: OBJECTIVES: To examine whether biosocial variables and auditory acuity are risk factors for injuries among children. SETTING: Children with injuries who presented at the emergency clinics of one of the two university hospitals for children in Athens, Greece between December 1993 and April 1994. METHODS: 144 children aged 5-14 years, residents of Athens, were brought to the emergency clinics for a moderate to severe injury. For each of these children one hospital control, matched for age and sex, and one classmate control similarly matched were identified. A standard interview form was completed for all 432 children and acouometric and tympanometric examinations were performed in each of them. Analysis was done through conditional logistic regression. RESULTS: The likelihood of an accident was higher in children of younger fathers (odds ratio (OR) = 0.7, p = 0.04), children of mothers with non-professional jobs (OR = 1.9, p = 0.03) as well as in children of higher birth order (OR = 1.7, p = 0.01), in those with predominantly other than parental daily supervision (OR = 2.6, p = 0.001), and those with a history of previous accident (OR = 1.3, p = 0.002). Somatometric factors, school performance, use of corrective eyeglasses and subnormal auditory acuity were not found to be risk factors, but auditory imbalance and abnormal tympanograms were positively related to the risk of childhood injury (OR = 2.6, p = 0.02; and OR = 2.3, p = 0.08 respectively). CONCLUSIONS: the findings of this study underline the importance of attentive supervision and safety training of children living in modern cities; they also suggest that children with auditory imbalance and history of an accident are at higher injury risk and they should be targeted with specific intervention programs.

Abstract: Mortality from childhood leukemia was examined particularly in rural countries in relation to any major rural-urban migration. Significant increases have been found in other situations of rural population mixing as predicted by the infection hypothesis. The 1950s and 1960s were of most interest since it preceded the decline in mortality brought about by effective chemotherapy in many countries. The 33 countries covered were all those in the World Health Organization's mortality database. No sensitive measure of rural-urban migration is available for international comparisons. However, it seems noteworthy that Greece and Italy, the two countries with the most striking levels of rural migration in the 1950s and 1960s, also had unusually high mortality rates from childhood leukemia. Greece was most affected proportionally by these population movements and from 1958 to 1972 had the highest recorded mortality from this cause in the world. The problems of international comparisons of mortality data dictate caution in drawing conclusions. However, against a background of other work on population mixing, and in the light of certain considerations, we suggest that the marked rural population mixing in Greece and Italy may have contributed to their high mortality rates from childhood leukemia in the 1950s and 1960s.

Abstract: A study of blood lipid levels in adolescent students in rural and urban areas of Greece was undertaken. Blood samples were drawn from 307 adolescents aged 12 to 18 years attending two rural and two urban high schools of different socioeconomic level (urban/lower, urban/higher). Obesity among adolescents had statistically significant detrimental effects on the lipids profile, being associated with higher total and low-density-lipoprotein (LDL) cholesterol and lower high-density-lipoprotein (HDL) cholesterol levels. Adolescents living in urban areas had substantially and significantly higher levels of total and LDL cholesterol, but among urban residents, higher socioeconomic status was associated with lower levels of total and LDL cholesterol. There was no clear evidence that total, LDL, and HDL cholesterol levels were substantially affected by qualitative aspects of diet as evaluated through a food frequency questionnaire. The results of this study indicate that the traditional Mediterranean pattern of living and eating in the rural areas of Greece is associated with a favorable lipid profile in adolescents, which may explain the very low incidence of coronary heart disease (CHD) in these areas. In urban areas lipid profiles are satisfactory in children of high socioeconomic status but unfavorable in children of low- to middle-class families, which are known to be at higher risk for CHD.

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Abstract: The association between selected demographic variables and birth weight on the one hand and a composite hand preference score based on seven hand tasks (each performed twice) on the other was investigated in a sample of 1387 male and female schoolchildren aged 5 to 10 years old. In multiple regression models left-handedness was significantly more common among boys and among children of better educated mothers and tended to decrease with age. No association was found with respect to urban or rural residence or birth order. Increased birth weight was associated with right-handedness in boys but with left-handedness in girls, and the birth weight by sex interaction term was statistically significant (p = 0.037). The demographic associations in the present study are compatible with those reported previously. The different associations of birth weight with hand preference in boys and girls indicate that the prenatal hormonal factors that affect brain lateralization and handedness are qualitatively or quantitatively different in the two sexes and may be differentially associated with birth weight.

Abstract: Injury prevention is an integral part of quality child-care programs. National standards relating to injury prevention have been published by the APHA and the AAP. The majority of these standards are preventive in nature and stress injury prevention in the development of policies and procedures and in the implementation of daily practices in child-care programs. Although it may not be possible to prevent all injuries in child-care settings, it is important for care givers, parents, and health professionals to identify potential hazards in the child-care environment. Once these hazards are identified, preventive corrective actions directed toward both environmental modifications and individual behaviors can be promoted to keep the incidence of injuries as low as possible.

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Abstract: One hundred and twenty children first diagnosed as having acute leukemia between 1988 and 1992 in Athens, Greece, were followed until May 15, 1993. The socioeconomic status of the children's families was assessed by means of paternal occupation, paternal schooling, maternal schooling, ownership of a car, ability to choose a private medical facility and freedom in the choice of the attending physician. The analysis was done by proportional-hazards modelling, controlling for age and gender. All six socioeconomic indicators, alternatively evaluated, showed that fatality rates were higher in the lower socioeconomic groups, although nominal statistical significance was reached for only one of them. With respect to family ownership of a private car, the fatality rate ratio between children of families who own a car and children of families who do not was 0.29 with a 95% confidence interval of 0.13-0.62 (p = 0.002). These results suggest that in Greece, socially disadvantaged children have a less favorable survival from childhood leukemia.

Abstract: Parts of Greece have been exposed to fallout radiation from the Chernobyl accident as much as any of the countries boardering with the former Soviet Union, because of the direction of the prevailing winds after the accident. Although fallout radiation did not reach levels expected to be associated with measurable effects, there is widespread concern in Greece that the incidence of childhood leukemia may be rising in the more heavily affected parts of Greece. Patient discharge data from all Greek hospitals treating childhood leukemia were used to calculate the annual incidence of the disease from January 1980 to June 1986 (preaccident period), from July 1986 to June 1988 (immediate postaccident period) and from July 1988 to June 1991 ("relevant" post-accident period, that accommodates the presumed latent period of the disease). Fallout radiation measurements (in Bq/kg Cs-137) were used to create 17 regions of similar (within regions) but highly variable (between regions) levels of fallout deposition. Background radiation (in Bq/kg Ra-226) and annual incidence of childhood leukemia by region were also estimated. There was no evidence of increased incidence of childhood leukemia during the immediate or the "relevant" post-Chernobyl period in any part of the country. Furthermore, regression analyses did not show any significant or suggestive association of childhood leukemia by region with either background or fallout radiation. These results indicate that the Chernobyl accident did not affect noticeably the incidence of childhood leukemia in Greece during the five-year post accident period.

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Abstract: Data from an international case-control study of breast cancer that was conducted in the 1960s were used to examine whether multiple births affect the risk of breast cancer in the mother. Among 2821 parous breast-cancer patients, 88 had had one or more multiple births, whereas among 8882 controls 247 had had one or more multiple births; the logistic-regression-adjusted odds ratio (OR) was 1.21, the 95% confidence interval (CI), 0.94 to 1.55. The OR was significantly elevated during the 15-year period following the latest multiple birth (1.76; CI, 1.12 to 2.75), but declined toward the null afterwards. A late first pregnancy imparted a substantially higher breast-cancer risk when it was multiple rather than singleton; the OR was 2.34 for a multiple and 1.48 for a singleton first pregnancy when the cutoff point was 30 years, and 4.58 and 1.57, respectively, when the cutoff point was 35 years. Since multiple pregnancies are characterized by higher levels of pregnancy estrogens, the results of this study would be compatible with the hypothesis that these hormones may be responsible for the transient increase in breast-cancer risk following a term pregnancy and, in particular, a multiple term pregnancy. The long-term reduction of breast-cancer risk is probably due to a different mechanism, most likely the terminal differentiation of susceptible mammary-gland cells.

Abstract: Over a 14-year period (1976-89) 679 deaths from childhood leukemia were registered in Greece and the corresponding mortality over this period declined by almost 70%, with no evidence of differential reduction by gender or population type. For each of the nine geographical regions of the country, slopes of decreasing mortality from childhood leukemia over the study period were calculated and correlated with the corresponding slopes of increasing electric power consumption over the 16-year period 1970-85 (allowing for a postulated latency of about 5 years). A positive association was noted, which however was not statistically significant (p approximately 0.26). Studies of similar nature conducted in larger countries over more extended periods could contribute to the resolution of the controversy surrounding the role of electric power-generated extremely low frequency electric and magnetic fields in the etiology of childhood leukemia.

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Abstract: Medical records concerning pediatric or adolescent patients first diagnosed with Crohn's disease or ulcerative colitis in two New York hospitals during a 5-year period (1986 to 1990) were abstracted, and information concerning sex, age, race, birthplace, sibship size, birth order, maternal age at birth, month of birth, duration of breast-feeding, and maternal smoking was recorded. Medical records of patients presenting at the respective pediatric gastroenterology departments immediately before or after the patients with inflammatory bowel disease were seen were also abstracted in order to generate a control series. Data concerning 68 patients with Crohn's disease, 39 patients with ulcerative colitis, and 202 control patients were analyzed through multiple logistic regression. Breast-feeding was negatively associated with Crohn's disease (P approximately 0.04) and ulcerative colitis (P approximately 0.07), with relative risk point estimates around 0.5 and with evidence of duration-dependent trends in both instances. There was no evidence of association of either disease with maternal age at birth, birth order, maternal smoking, or season of birth.

Abstract: Serum levels of alpha-1-antitrypsin were measured by radial immunodiffusion, and phenotypes were determined by electrofocusing in acrylamide gel in 160 subjects who were used as controls in a case-control study of hepatocellular carcinoma (HCC). The results were studied in relation to age, sex, diagnostic category, tobacco smoking, consumption of alcoholic beverages, presence of hepatitis B surface antigen (HBsAg), and serum levels of alphafetoprotein (AFP) by modeling the data through multiple regression. There was no relation of serum alpha-1-antitrypsin values with sex, HBsAg, AFP, consumption of alcoholic beverages, and diagnostic category (p > 0.25). By contrast, there were statistically significant dose-dependent positive associations of serum alpha-1-antitrypsin with age and tobacco smoking (p < 0.01 in both instances). The positive association of serum alpha-1-antitrypsin with tobacco smoking and the previously reported excessive elevation of serum alpha-1-antitrypsin in hepatitis B-negative tobacco-related cases of HCC suggest that alpha-1-antitrypsin is intimately related to the pathogenetic process linking tobacco smoking to HCC.

Abstract: The causation of breast cancer in certain strains of mice by a virus that can be transmitted vertically, through the milk produced during lactation, has led to the hypothesis that a similar phenomenon could exist in humans. There have been laboratory-based studies in humans suggesting that a virus may be involved in the etiology of female breast cancer although other investigations did not support this hypothesis. Descriptive data and epidemiologic evidence of ecologic nature do not indicate a role of lactation in the causation of human breast cancer, but the hypothesis has not been adequately assessed in analytic epidemiologic studies. A nested case-control study undertaken in Sweden to examine the role of prenatal factors on breast cancer risk in the offspring, allowed the evaluation of the importance of breast-feeding in the causation of this disease. Standardised records concerning women born at the Uppsala University Hospital from 1874 to 1954 were linked with invasive breast cancer incident cases, identified through their unique national registration number in the Swedish Cancer Registry during 1958-1990. For each case with breast cancer, the females born to the first three mothers admitted after the case's mother were selected as potential matching controls. Only controls living in Sweden and free from breast cancer until the time of diagnosis of breast cancer in the corresponding case were eventually included in the study. The analysis was based on 458 cases of breast cancer born in singleton pregnancies and 1,197 singleton age- and birth date-matched controls. Breast-feeding was not a significant or suggestive risk factor for breast cancer in the offspring; compared to women who at discharge were wholly or partly breastfed, women who as newborn were not breastfed had a relative risk of breast cancer of 0.97 with 95% confidence interval 0.44-2.17 (P = 0.95).

Abstract: Total estrogens, estradiol and estriol were determined by radioimmunoassay in the blood of 141 pregnant women during their 26th and 31st weeks of pregnancy, and the results were correlated with dietary patterns and nutrient intakes during pregnancy, assessed through a semiquantitative food frequency questionnaire. No food group or nutrient showed a significant (p less than 0.05) association with any of the examined hormones at both the 26th and the 31st week of pregnancy. Relatively more consistent were a positive association between consumption of starchy roots (potatoes) and all the indicated hormones, and a negative association between vitamin A and estradiol and total estrogens; however, the multitude of comparisons hinders a biologic interpretation at this time. There was suggestive evidence that weight gain up to the 31st week of pregnancy was positively associated with both total estrogens (p = 0.09) and estradiol (p = 0.11). The present study has limitations reflecting the relatively small sample size and the problems inherent in epidemiologic methods assessing nutritional intakes. However, the findings suggest that quantitative aspects of diet, as reflected in pregnancy weight gain, may be more important than dietary composition in influencing levels of pregnancy estrogens and in affecting the occurrence of gonadal germ cell tumors and other conditions that may be associated with them.

Abstract: Pregnancy estrogens are substantially elevated in twin pregnancies and are likely to be more so in the case of dizygotic twins. If levels of pregnancy estrogens were positively related to breast cancer risk in the offspring, female twin members would be expected to be at slightly higher risk. Data from an international case-control study were utilized to assess this hypothesis. The analysis was based on 870 cases with breast cancer and 2,641 hospital controls from two sites: Glamorgan, Wales (1965-1967), and Boston, Massachusetts (1965-1966). Seventeen cases were members of twin pairs, and 8 of them had a twin brother; 33 controls were members of twin pairs and 14 had a twin brother. Among all women, the odds ratios for breast cancer were as follows: for twins with brothers, 1.54 (95% confidence interval (CI) 0.64-3.71); for twins with sisters, 1.30 (95% CI 0.58-2.92); and for all twins, 1.40 (95% CI 0.77-2.55). The odds ratios were higher among premenopausal women. These findings are not conclusive, but they are compatible with the hypothesis that pregnancy estrogens may affect the risk of breast cancer in the offspring.

Abstract: Total estrogen (TE), estradiol (E2), estriol (E3), and human placental lactogen (hPL) levels were determined by radioimmunoassay in the blood of 141 pregnant women during their 26th and 31st weeks of pregnancy and the results were studied in relation to coffee and alcohol intake. After controlling for maternal age, maternal weight at the corresponding week of pregnancy, parity, and tobacco smoking, as well as for mutual confounding effects, coffee intake, ascertained at the 26th week, was found to be negatively related to pregnancy E2 levels (P = 0.04 during the 26th week, and P = .16 during the 31st week), whereas alcohol intake, also ascertained at the 26th week, was found to be positively related to pregnancy TE levels (P = .04 during the 26th week, and P = .18 during the 31st week). The negative relation between coffee consumption on the one hand and E2 (and possibly TE) levels on the other may be responsible for the inverse association between maternal coffee intake and birth weight; the latter association has been repeatedly confirmed in the literature, although it was neither strong nor statistically significant in the present study. The relations of maternal coffee and alcohol consumption with pregnancy estrogen levels, if confirmed, could be utilized in studies exploring the role of prenatal exposure to these hormones in the etiology of gonadal germ-cell tumors and possibly other diseases.

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Abstract: A case-control study concerning the association between diet and peripheral arterial occlusive disease was conducted in Athens, Greece. The case series consisted of 100 patients with this disease, whereas controls were 100 patients with conditions requiring minor surgical care who were admitted to the same teaching hospital. Diet was ascertained through a semiquantitative food frequency questionnaire. Nutrient intakes for individuals were estimated by multiplying the nutrient content of a selected typical portion size for each specified food item by the frequency that the food was used per month and summing these estimates for all food items. Data were analyzed using multiple logistic regression procedures, controlling for total energy intake by taking nutrient residuals and by using multivariate nutrient density models. Saturated fatty acids (odds ratio (OR) and 95% confidence interval (CI) contrasting the 75th centile (upper) with the 25th centile = 1.96 and 1.14-3.39), proteins (OR = 2.86, 95% CI 1.47-5.55), and dietary cholesterol (OR = 6.07, 95% CI 2.74-13.46) were associated with increased risk of peripheral arterial occlusive disease, whereas polyunsaturated fatty acids (OR = 0.48, 95% CI 0.24-0.93) and crude fiber (OR = 0.33, 95% CI 0.17-0.64) were related to reduced risk. Monounsaturated fatty acids and, by inference, olive oil occupy an intermediate neutral position between polyunsaturates and saturates (corresponding OR = 1.14, 95% CI 0.68-1.91). Higher intakes of fiber and vitamin C were associated with lower risk of peripheral arterial occlusive disease. The low occurrence of atherosclerotic diseases in Greece and other Mediterranean countries may be due to the substitution of olive oil in place of saturated fats and/or the consumption of a diet high in vegetables, fruits, and other fiber-containing foods.

Abstract: It has been suggested that tobacco smoking during pregnancy reduces birth weight by lowering production rates or levels of total pregnancy estrogens. To evaluate this hypothesis, we examined total estrogen levels by radioimmunoassay in the blood of 141 pregnant women attending the maternity clinic of a major university hospital in Athens during their 26th week of pregnancy. Forty-nine of these women were regular smokers before and during their pregnancy, whereas the remaining 92 had never been regular smokers and did not smoke at all during their pregnancy. Birth weight of offspring was lower among smokers than among nonsmokers by 190.8 g, with a 90% confidence interval of 41.1 to 340.5 g, and higher among women with higher serum estrogen levels (slope b = 1.2 g per 1000 pg/ml with a 90% CI of 0.2 to 2.2 g). There was, however, only a small negative relation between tobacco smoking and serum estrogen levels; in smokers, total estrogen levels were reduced to 91% of the corresponding levels among nonsmokers.

Abstract: The European Code Against Cancer (ECAC) was administered to four groups of women, each comprising about 50 women. In the first group, the Greek translation of the original code was given; in the second group a set of explanatory cartoons was given in addition to the code; in the third group a more simplified version of the code was administered; lastly, in the fourth group the code was administered and in addition, mothers were tutored for about 15 minutes by a psychologist. A comparison group of 76 women were not exposed to ECAC. After 4 to 7 days, all women were given a 78-item questionnaire, probing their perceived knowledge (PK) about cancer etiology and prevention, their accurate knowledge (AK) and eventually their correct knowledge (CK), (all expressed in %). No difference, with respect to any of the above three parameters was noted between the three groups of women who were given the ECAC, the ECAC with cartoons or the modified ECAC without individual tutoring on the one hand and the comparison group on the other. By contrast, there was a substantial and highly significant improvement of knowledge among women who were given the ECAC and who were also individually tutored; this difference in CK was accounted for by improvement in both PK and AK. Improvement was particularly evident in respect to questions dealing with cancer screening, nutritional and occupational cancers, whereas there was little improvement with respect to knowledge concerning some aspects of tobacco smoking and exposure to radiation. CK about cancer etiology and prevention was positively correlated with AK about contraception and nonsmoking status, even among women of the same age and educational status.

Abstract: Total estrogens (TE), estradiol (E2), estriol (E3), and human placental lactogen (hPL) were determined by radioimmunoassay in the blood of 126 pregnant women during their 26th and 31st weeks of pregnancy and the results were studied in relation to maternal age and parity. Total estrogens and E2 were lowest among the youngest women (less than 20 years) and highest among women aged 20-24 years, whereas older women (25+ years) had, on the average, intermediate values. For E3 the pattern was qualitatively similar to that of TE and E2 but less striking, and no maternal age pattern was evident with respect to hPL. Within maternal age groups, TE and E2 were higher among women in the first, than among those in their second, full-term pregnancy; the difference was about seven percent for TE (P = 0.14) and about 14 percent for E2 (P = 0.05). No parity patterns were evident with respect to E3 and hPL. There were fairly strong correlations between the determinations of the same hormone in the same woman during the 26th and 31st weeks of pregnancy; Pearson correlation coefficients were 0.60 for TE, 0.78 for E2, 0.60 for E3, and 0.72 for hPL. Since the risk of breast cancer increases apparently monotonically with maternal age at birth, the present data are equivocal with respect to the hypothesis linking levels of pregnancy estrogens to risk of breast cancer in the offspring. However, the data are compatible with hypotheses linking excessive pregnancy-estrogen exposure to conditions more common among first-born individuals, including testicular cancer and cryptorchidism.

Abstract: A case-control study concerning peripheral arterial occlusive disease (PAOD) was conducted in Athens, Greece. The case series consisted of 100 patients with PAOD as principle diagnosis admitted consecutively to a major teaching hospital in Athens during an 18-month period. The controls were patients hospitalized in the same hospital during the same period as the index cases for conditions requiring minor surgical care. All cases and controls were interviewed by the same person about several socioeconomic, demographic and medical variables; blood pressure and blood glucose values were also recorded. Data were analysed using multiple logistic regression procedures, controlling for age, sex and years of schooling. Tobacco smoking, systolic blood pressure, diabetes mellitus, heavy alcohol drinking and excessive coffee consumption were all strong independent risk factors with eight-fold or more differences in risk. It appears that PAOD as an atherosclerotic disease with low short-term fatality reveals in more contrasting terms the aetiological importance of factors involved in the atherosclerotic process as compared to atherosclerotic conditions with higher short-term fatality like coronary heart disease (CHD) which may also have stronger thrombotic components.

Abstract: Socioeconomic factors are at least as important as narrowly defined medical care factors in determining the health status of the population. They also provide a stimulus for further research in the field of socioeconomic epidemiology.

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