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BACKGROUND: The computer-based electronic medical record (EMR) is an essential new technology in health care, contributing to high-quality patient care and efficient patient management. The majority of southern European countries, however, have not yet implemented universal EMR systems and many efforts are still ongoing. We describe the development of an EMR system and its pilot implementation and evaluation in two previously computernaïve public primary care centres in Cyprus. METHODS: One urban and one rural primary care centre along with their personnel (physicians and nurses) were selected to participate. Both qualitative and quantitative evaluation tools were used during the implementation phase. Qualitative data analysis was based on the framework approach, whereas quantitative assessment was based on a nine-item questionnaire and EMR usage parameters. RESULTS: Two public primary care centres participated, and a total often health professionals served as EMR system evaluators. Physicians and nurses rated EMR relatively highly, while patients were the most enthusiastic supporters for the new information system. Major implementation impediments were the physicians' perceptions that EMR usage negatively affected their workflow, physicians' legal concerns, lack of incentives, system breakdowns, software design problems, transition difficulties and lack of familiarity with electronic equipment. CONCLUSION: The importance of combining qualitative and quantitative evaluation tools is highlighted. More efforts are needed for the universal adoption and routine use of EMR in the primary care system of Cyprus as several barriers to adoption exist; however, none is insurmountable. Computerised systems could improve efficiency and quality of care in Cyprus, benefiting the entire population. [ABSTRACT FROM AUTHOR]

Background: Quality Improvement Interventions require significant financial investments, and therefore demand careful consideration in their design in order to maximize potential benefits. In this correspondence we present the methodological approach of a multifaceted quality improvement intervention aiming to improve quality of care in primary care, properly tailored for a country such as Cyprus where general practice is currently seeking recognition.Methods: Our methodological approach was focused on the design of an open label, community-based intervention controlled trial using all patients from two urban and two rural public primary care centers diagnosed with hypertension and type II diabetes mellitus. The design of our intervention was grounded on a strong theoretical framework that included the Unified Theory of Acceptance and Use of Technology, and the Chronic Care Model, which synthesize evidence-based system changes in accordance with the Theory of Planned Behavior and the Theory of Reasoned Action. The primary outcome measure was improvement in the quality of care for two chronic diseases evaluated through specific clinical indicators, as well as the patient satisfaction assessed by the EUROPEP questionnaire and additional personal interviews.Results: We designed a multifaceted quality improvement intervention model, supported by a varying degree of scientific evidence, tailored to local needs and specific country characteristics. Overall, the main components of the intervention were the development and adoption of an electronic medical record and the introduction of clinical guidelines for the management of the targeted chronic diseases facilitated by the necessary model of organizational changes.Conclusion: Health planners and policy makers need to be aware of the potential use of certain theoretical models and applied methodology as well as inexpensive tools that may be suitably tailored to the local needs, in order to effectively design quality improvement interventions in primary care settings. [ABSTRACT FROM AUTHOR]

Empowerment, the process by which a person is enabled to increase control over decisions concerning their life, is a multidimensional construct that has been extensively discussed by various disciplines for more than four decades. Several empowerment models have been presented, based on different approaches. This paper proposes a four-step model, based on individual and contextual awareness and advancement. Disparate factors may positively or negatively affect empowerment, including gender, race, culture, education, financial autonomy, socioeconomic status, family, neighborhood, religion, social cohesion, civic society, and political context. Empowerment has been extensively discussed in parallel with health promotion, since it is expected to positively affect health, both on the level of the individual and community, as well as in the context of the patient-healthcare professional relationship. Considering the position of women in patriarchal societies, where women may experience feelings of powerlessness, their social position and more importantly health may be adversely affected. Gender biases that were developed due to the marginalized position of women in different societies, coupled with paternalistic approaches of healthcare professionals, may significantly contribute to higher comorbidity, albeit longer life expectancy for women. Empowerment can therefore be a powerful tool for achieving equity in health and improving women's well-being.

Vitamin C or ascorbic acid is a water-soluble vitamin capable of directly donating electrons to reactive oxygen species, attenuating electrical remodeling, and cardiac dysfunction in patients undergoing cardiac surgery (CS), considered one of the most effective defenses against free radicals in the blood, thus being one of the first antioxidants consumed during oxidative stress. The aim of this review is to assess the effects of perioperative administration of vitamin C in CS patients. A comprehensive literature search was conducted in order to identify prospective cohort studies and/or randomized controlled trials reporting on the perioperative effects of vitamin C among adult patients undergoing CS. Studies published between January 1980 to December 2022 were included in our search, resulting in a total of 31 articles that met all our inclusion criteria. There seems to be a beneficial effect of vitamin C supplementation in arrhythmias such as in postoperative atrial fibrillation, reduction of ICU length of stay, and hospital length of stay, reduction in postoperative ventilation time, in inotropic demand, and in postoperative fatigue. Vitamin C can act as a scavenger of free radicals to decrease the peroxidation of the lipids present in the cell membrane, and to protect the myocardium postoperatively from ischemia/reperfusion injury, thus attenuating oxidative stress and inflammation. It represents a readily available and cost-effective strategy that could improve the outcome of patients undergoing CS, by reducing the risk of serious cardiovascular adverse events, both perioperatively and postoperatively., Competing Interests: The authors declare that they have no conflict of interest with respect to the current study.Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background and Objectives : The effective management of chronic diseases, particularly hereditary and rare diseases and thalassaemia, is an important indicator of the quality of healthcare systems. We aimed to assess healthcare services in different countries for thalassaemia patients by using publicly available health indicators and by surveying thalassaemia patients and their caregivers. Materials and Methods : We reviewed official worldwide databases from the WHO, World Bank, and scientific resources, and we used a structured patient-tailored self-completed questionnaire to survey thalassaemia patients and their caregivers in 2023. Results : A total of 2082 participants were surveyed (mean age, 27 years; males, 42%). About 1 in 4 respondents did not complete high-school education, while 24% had a bachelor's degree. About a third of respondents were married and were in either full- or part-time employment. The vast majority (~80%) had initiated transfusion therapy between 1 and 4 years of age. Only 42% reported no delays in receiving blood transfusion, while 47% reported occasional delays and 8% serious delays. About half of patients reported being very satisfied (11%) or satisfied (38%) with the quality of services provided, while 1 in 3 patients reported being unsatisfied or very unsatisfied, and that their access to treatment was difficult or very difficult due to traveling expenses and the high cost of treatment. Conclusions : Important improvements in the care of thalassaemia patients have been documented during the past few decades. Nevertheless, additional focus is required through national healthcare systems to effectively address the many unmet needs revealed by our recent survey, as well as to achieve satisfactory patient outcomes.

Cardiac rehabilitation (CR) constitutes a valuable therapeutic approach for patients with a broad spectrum of cardiovascular diseases facilitating the development and maintenance of a desirable level of physical, social, and psychological functioning following the onset of cardiovascular disease. Nowadays, cardiac rehabilitation programs emphasize the use of a multidisciplinary approach. The current review aims at presenting the state-of-the-art knowledge on the indications of patients entering cardiac rehabilitation programs, including their core components, duration, and effectiveness. Following a careful review of the international literature, we conclude that there are significant differences between the most commonly cited international CR guidelines as well as additional limitations and gaps in knowledge. Despite the benefits associated with CR and despite their widespread acceptance, CR referrals and program attendance remains low, while many questions have not been so far addressed through scientific research. Overall, the findings of our study suggest a critical need for the development of robust and evidence-based standardized CR interventions to increase their use and effectiveness throughout the world., Competing Interests: Disclosure: The authors have no conflicts of interest to report., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Firefighters are required to perform physically strenuous tasks such as hose drags, victim rescues, forcible entries and stair climbs to complete their public safety mission. Occupational-specific tasks are often used to evaluate the ability of firefighters to adequately/safely perform their duties. Depending on the regions, occupational-specific tasks include six to eight individual tasks, which emphasize distinct aspects of their physical fitness, while also requiring different levels of cardiovascular (CVH) and musculoskeletal health (MSH). Therefore, the aim of this study was to evaluate the relationship between specific occupational task performance and measures of physical fitness, cardiovascular and musculoskeletal health., Methods: Using a cross-sectional design, 282 full-time male and female firefighters were recruited. A researcher-generated questionnaire and physical measures were used to collect data on sociodemographic characteristics, CVH, MSH and weekly physical activity habits. Physical measures were used to collect data on physical fitness and occupational-specific task performance., Results: Absolute cardiorespiratory fitness (abV̇O2max), grip strength, leg strength, push-ups, sit-ups and lean body mass (all p < 0.001) had an inverse association with completion times on all occupational-specific tasks. Age was positively related to the performance of all tasks (all p < 0.05). Higher heart rate variability (HRV) was associated with better performance on all tasks (all p < 0.05). Bodyfat percentage (BF%) and diastolic blood pressure were positively associated with the step-up task (p < 0.05). Lower back musculoskeletal injury (LoBMSI), musculoskeletal discomfort (MSD), and lower limb MSD were associated with a decreased odds of passing the step-up. Upper body MSIs (UBMSI), LoBMSIs and Lower back MSD were associated with decreased odds of passing the rescue drag., Conclusion: Firefighters that were taller, leaner, stronger and fitter with a more favourable CVH profile, higher HRV and less musculoskeletal discomfort performed best on all occupational-specific tasks., (© 2023. The Author(s).)

Introduction: To perform their work efficiently and safely, firefighters should maintain all aspects of physical fitness. Cardiac-related incidents are the leading cause of duty-related deaths in firefighters, and many firefighters have poor musculoskeletal health (MSH) that hinder their occupational performance (OP). Establishing the relationship between physical fitness, cardiovascular health (CVH), MSH and OP may add new insight on the most significant factors influencing OP in firefighters, specifically in the City of Cape Town Fire and Rescue Service (CoCTFS), which had not been studied before. Therefore, the purpose of this study was to investigate whether physical fitness, CVH and MSH were associated with OP in firefighters, in the COCTFRS., Methods: This cross-sectional study included 283 full-time firefighters aged 20-65 years from Cape Town, South Africa. A researcher-generated questionnaire was used to collect data on sociodemographic characteristics, lifestyle factors and MSH. Physical measures were used to collect information on physical fitness, CVH, and OP [using a physical ability test (PAT)]. Linear and binary logistic regressions, adjusted for age, sex, height and weekly metabolic equivalent minutes (WMETM), multivariate analysis of covariance (MANCOVA), adjusted for age, sex, height and body mass index (BMI) and backward stepwise regressions were used to investigate the associations between the various constructs., Results: From multivariable analyses, age, lean body mass, body fat percentage (BF%), estimated absolute oxygen consumption (abV̇O 2max ), grip strength, leg strength, push-ups, sit-ups, WMETM and heart rate variability were associated with PAT completion times (all p  < 0.01). The MANCOVA showed a significant difference between performance categories of the PAT based on physical fitness and CVH (both p  < 0.001). WMETM, BF%, abV̇O 2max , grip strength, leg strength and sit-ups explained the highest proportion (50.5%) of the variation in PAT completion times., Conclusion: Younger, non-obese, fitter and stronger firefighters, with a better CVH status, performed significantly better and were most likely to pass the PAT in firefighters, in Cape Town, South Africa. Firefighters should maintain high levels of physical fitness and a good level of CVH to ensure a satisfactory level of OP., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Ras, Smith, Kengne, Soteriades and Leach.)

Rare Diseases (RDs) in adolescents are characterized by low frequency and clinical heterogeneity, are chronic and deliberating and demand a multidisciplinary approach as well as costly and specialized treatments. Comprehending patients' and parents' needs through a mixed systematic review is essential for healthcare system planning. This mixed systematic review explored barriers to and facilitators of effective care for adolescents with RDs as perceived by patients and their parents. Three databases (2008-2023) were searched and twenty-five articles were selected and critically appraised with the Mixed Methods Appraisal Tool (MMAT; version 2018). The review followed a convergent integrated approach for data extraction according to Joanna Briggs Institute's (JBI) mixed method systematic review (MMSR) methodology. Subsequent reflexive thematic analysis categorized the barriers and facilitators into five levels (intrapersonal, interpersonal, institutional, community and public policy) following the conceptual framework of the socio-ecological model for healthcare promotion. Barriers on the institutional and public policy level stood out as the most frequently reported, resulting in unmet care needs and frustrating family dynamics. National and regional healthcare policies are rarely actually linked to pragmatic intervention programs with a measurable impact on patients' welfare. Targeted strategies involving primary care infrastructure and personnel for better coordination and management of the disease are discussed.

Introduction: Firefighters are often placed in situations that require high levels of physical exertion, leading to significant strain on firefighters' musculoskeletal system, predisposing them to musculoskeletal discomfort (MSD) and/or musculoskeletal injury (MSI). Physical fitness programs are often recommended and justified, in part, to prevent injuries. The aim of this study was to determine the association between physical fitness and musculoskeletal health (MSH) in firefighters. Methods: A total of 308 full-time firefighters took part in the study conducted in Cape Town, South Africa. Physical fitness tests encompassed a non-exercise estimation for cardiorespiratory fitness, grip and leg strength for upper and lower body strength, push-ups and sit-ups for muscular endurance, and sit-and-reach for flexibility. The Nordic Musculoskeletal Questionnaire and Cornell Musculoskeletal Discomfort Questionnaire were used to determine MSIs and MSD, respectively. A p -value <0.05 indicated statistical significance. Results: Every one-unit increase in AbVO2max, push-ups, sit-ups, and sit-and-reach decreased the odds of firefighters reporting MSIs by 5% ( p = 0.005), 3% ( p = 0.017), 3% ( p = 0.006), and 3% ( p = 0.034), respectively. Every one repetition increase in push-up capacity increased the odds of firefighters reporting neck, elbow and forearm, wrist and hand, and thigh discomfort by 3% ( p = 0.039), 4% ( p = 0.031), 5% ( p = 0.002), and 5%` ( p = 0.007), respectively. Every one repetition increase in sit-up capacity increased the odds of firefighters reporting upper back discomfort and thigh discomfort by 5% ( p = 0.045) and 7% ( p = 0.013), respectively. Conclusion: Maintenance of physical fitness is likely beneficial in reducing MSIs, which, however, may increase the feeling of MSD in firefighters. In addition, it may be noticed that there is an ideal level of physical fitness that is conducive to the reduction of MSIs and should be studied further., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Ras, Soteriades, Smith, Kengne and Leach.)

Objective: The aim of the study is to determine the association between cardiovascular health (CVH) and musculoskeletal health in firefighters., Methods: This cross-sectional study involved 309 full-time firefighters aged 20 to 65 years. Cardiovascular health encompassed cardiovascular disease risk factors, risk scores, CVH metrics, and heart rate variability. Musculoskeletal health was assessed using two validated questionnaires., Results: Increasing age ( P = 0.004), body mass index ( P < 0.001), body fat percentage ( P < 0.001), diastolic blood pressure ( P = 0.003), total cholesterol ( P = 0.006), and Framingham risk score ( P = 0.011) increased the risk of reporting musculoskeletal injuries (MSIs). Obesity ( P = 0.018), hypertension ( P = 0.034), and dyslipidemia ( P = 0.005) increased the risk of reporting MSIs. Musculoskeletal discomfort was associated with total cholesterol ( P = 0.0.34) and low-density lipoprotein ( P = 0.014)., Conclusions: Adverse cardiovascular disease risk profile was associated with MSIs and musculoskeletal discomfort in firefighters. Firefighters should maintain an ideal CVH profile, especially as they age., Competing Interests: Conflict of interest: None declared., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Occupational and Environmental Medicine.)

Physician shortage is a major concern in many health care systems globally, while healthcare leadership constitutes one of the most vital factors within human resource management. Our study examined the relationship between managers' leadership styles and physicians' intent to leave their current position. In this cross-sectional national survey, questionnaires were distributed to all physicians working in the public health sector of Cyprus. Most demographic characteristics evaluated by chi-square or Mann-Whitney test, were statistically significantly different between those who intended to leave their job and those who did not. The results of our study demonstrated that transformational leadership has a positive influence on retention of physicians in public hospitals, while non leadership infers a negative influence. Developing leadership skills in physician supervisors is of a great importance for organizations to make a large impact on health professionals' retention and overall performance.

Objectives: Organisational commitment, job satisfaction and intention to leave constitute important characteristics of health professionals' employment status. Our study aimed at investigating the level of organisational commitment, job satisfaction in association with intention to leave among physicians., Design: A cross-sectional study., Setting: A survey was conducted using self-administered questionnaires (the Organizational Commitment Questionnaire and the Job Satisfaction Survey) among all physicians working in the public health sector of Cyprus (October 2016-January 2017)., Participants: Out of 690 physicians working in the public health sector who received an invitation to participate, 511 completed the survey and 9 were excluded. Therefore, 502 physicians were included in the final analysis (response rate 73%). A total of 188 cases were excluded because they were undetermined with respect to their intention to leave and a total of 75 cases were excluded from the regression analysis due to missing values on at least one variable or due to having values considered as outliers. Therefore, a total of 239 physicians (120 men and 119 women) were included in the current analysis., Primary and Secondary Outcome Measures: Physicians' intention to leave., Results: A considerably large percentage of physicians (72.8%) working in the public hospitals and healthcare centres of Cyprus reported their intention to leave their job. Moreover, the majority of employees in public hospitals (78.4%) intended to leave their job, while only 21.6% of employees in health centres reported an intention to leave (p<0.001). The study also confirmed that organisational commitment and job satisfaction were negatively correlated with intention to leave. In addition, the results of this study demonstrate that certain demographics also influence physicians' intention to leave including age, gender and medical specialisation., Conclusions: Certain physicians' demographics, organisational commitment and job satisfaction constitute important parameters influencing physicians' intention to leave their job., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Firefighters perform strenuous work in dangerous and unpredictable environments requiring optimal physical conditioning. The aim of this study was to investigate the association between physical fitness and cardiovascular health (CVH) in firefighters. This cross-sectional study systematically recruited 309 full-time male and female firefighters between the ages of 20 to 65 years in Cape Town, South Africa. Physical fitness was assessed using absolute (abV̇O 2max ) and relative oxygen consumption (relVO 2max ), grip and leg strength, push-ups and sit-ups, sit-and-reach for flexibility and lean body mass (LBM). CVH encompassed age, smoking, blood pressure (BP), blood glucose, lipid profile, body mass index, body fat percentage (BF%), and waist circumference. Linear regressions and logistic regressions were applied. Multivariable analysis indicated that relVO 2max was associated with systolic BP ( p < 0.001), diastolic BP ( p < 0.001), non-fasting blood glucose ( p < 0.001), and total cholesterol ( p = 0.037). Poor CVH index was negatively associated with relV̇O 2max ( p < 0.001), leg strength ( p = 0.019), and push-ups ( p = 0.012). Furthermore, age was inversely associated with V̇O 2max ( p < 0.001), push-up and sit-up capacity ( p < 0.001), and sit-and-reach ( p < 0.001). BF% was negatively associated with abV̇O 2max ( p < 0.001), grip and leg strength ( p < 0.001), push-ups ( p = 0.008), sit-ups ( p < 0.001), and LBM ( p < 0.001). Cardiorespiratory fitness, muscular strength, and muscular endurance were significantly associated with a better overall CVH profile.

Approximately 45% of on-duty related mortalities were due to sudden cardiac death, with many of these fatalities related to cardiovascular disease and overexertion, while performing emergency duties. Therefore, the aim of this systematic review was to determine the association between cardiovascular disease risk factors and cardiorespiratory fitness in firefighters. A literature search of PubMed, SCOPUS, Web of Science, Embase, EBSCOHost, and ScienceDirect was conducted; the Rayyan ® intelligent systematic review tool was used to screen and select studies for inclusion. The appraisal tool for cross-sectional studies and the Critical Appraisal Skills Programme toolkit were used for methodological assessment of included studies. Data were analyzed using the Review Manager 5.3 and MedCalc ® statistical softwares to determine the effects of obesity (Z = 10.29, p < 0.001) and aging (Z = 4.72, p < 0.001) on cardiorespiratory fitness. Furthermore, there was a significant effect for cardiorespiratory fitness level on systolic blood pressure (Z = 5.94, p < 0.001), diastolic blood pressure (Z = 2.45, p < 0.001), total cholesterol levels (Z = 3.80, p < 0.001), low-density lipoprotein cholesterol (Z = 4.44, p < 0.001), triglycerides (Z = 3.76, p < 0.001) and blood glucose concentration (Z = 4.78, p < 0.001). Cardiovascular disease risk factors and cardiorespiratory fitness were significantly and inversely associated in firefighters. Fire service departments should adopt behavioral intervention strategies to maintain optimum cardiovascular disease risk factor profiles and cardiorespiratory fitness among firefighters to ensure their occupational well-being.

Firefighters’ face life threatening situations and are frequently exposed to numerous physical, chemical, biological, ergonomic and psychosocial hazards. The purpose of this pilot study was to investigate the feasibility of conducting a large-scale study on cardiovascular and musculoskeletal health, physical fitness and occupational performance of firefighters. We conducted a cross-sectional pilot study by recruiting 36 firefighters. A researcher-generated questionnaire and physical measures were used to collect data on sociodemographic characteristics, cardiovascular and musculoskeletal health, physical fitness and occupational performance using a physical ability test (PAT). We documented a high equipment and intra-assessor reliability (r > 0.9). The potential logistic and/or administrative obstacles in the context of a larger study were discerned. Data were successfully retrieved using available equipment and survey instruments. Hypertension (30.6%) dyslipidaemia (33.3%), obesity (36.1%) and physical inactivity (66.7%) were the most prevalent cardiovascular disease risk factors. A significant difference between genders in total PAT completion time was also seen (p < 0.001). Cardiorespiratory fitness, lean body mass, grip strength and leg strength were significantly associated with occupational performance (p < 0.001). The pilot study supports the larger study feasibility and verified equipment and assessors’ reliability for research. Cardiovascular health, musculoskeletal health and physical fitness may be related to PAT performance.

Background : Firefighting is a strenuous occupation, which necessitates that firefighters stay in good physical condition and maintain adequate cardiovascular and musculoskeletal fitness to perform their duties with minimal health and safety risks. The aim of this review is to determine the effects of cardiovascular disease risk factors, musculoskeletal health, and physical fitness on the occupational performance of firefighters. Methods: PubMed/Medline, SCOPUS, Web of Science, EBSCOHost, and ScienceDirect were searched without time-restriction. The appraisal tool for cross-sectional studies and the Critical Appraisal Skills Programme toolkit were used to conduct the methodological assessment. Data were analyzed using Review Manager 5.3, and MedCalc ® statistical software. Results: Age had a moderate effect on occupational performance (Z = 5.15, p < 0.001), whereas gender had a large effect size on occupational performance (Z = 4.24, p < 0.001). A significant moderate negative correlation was found between cardiorespiratory fitness and occupational performance (R = -0.584, p < 0.001). Significant low negative correlations were found between upper body endurance (R = -0.344, p < 0.001), abdominal endurance (R = -0.308, p < 0.001), grip strength (R = -0.421, p < 0.001), upper body strength (R = -0.318, p < 0.001), and lower body strength (R = -0.216, p = 0.020) and occupational performance. Conclusions: Aged firefighters with poor body composition and lower levels of physical fitness performed worse on all occupational performance tasks.

Introduction: Firefighting is a hazardous occupation, where firefighters are involved in life-threatening situations, being placed under tremendous physical strain, while wearing heavy and insulated equipment to protect them from chemicals, fumes and high temperatures. This necessitates that firefighter stay in good physical condition and maintain adequate cardiovascular fitness to cope with these stressors and perform their duties with minimal health risks. The aim of this systematic review and meta-analysis is to determine the effect of cardiovascular health, musculoskeletal health and physical fitness on the occupational performance of firefighters., Methods and Analysis: All study types and designs will be included and appraised. The following electronic databases will be searched: PubMed/Medline, Scopus, Web of Science, Embase, EBSCOHost and CINAHL, with no restrictions on publication date. The literature search will be conducted comprehensively to enable the capturing of as many relevant articles as possible but will be limited to English-language papers only. A combination of the appropriate terms (search string) will be used to ensure the inclusion of the relevant components of the participants, exposure, comparison and outcome. A researcher-generated form with the key characteristics of each study will be used to retrieve all relevant details from the selected studies for initial eligibility screening. The Rayyan Intelligent Systematic Review tool will be used to screen and select studies for inclusion, and information from the included studies will be captured on the researcher-generated data extraction form. The The appraisal tool for cross-sectional studies (AXIS) checklist and the Critical Appraisal Skills Programme toolkit will be used to conduct the methodological assessment of each study. Data will be analysed using Review Manager V.5.3. Generated results will be presented using a combination of figures, graphs and tables. The synthesis of quantitative data (using a meta-analysis methodology) will involve the integration of quantitative findings from multiple studies to achieve coherence., Ethics and Dissemination: This study obtained ethical clearance from the University of the Western Cape Biomedical Research Ethics Committee (BM21/10/9). We will disseminate the findings of in peer-reviewed journals and at national and international conferences. The protocol will form part of a chapter for a doctoral thesis., Prospero Registration Number: CRD42021258898., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background Mortality in the general population is one of the most robust measures used to examine epidemiological trends over time and especially over periods of public health crises such as the current coronavirus disease 2019 (COVID-19) pandemic. Methodology In this study, we analyzed information reported by the Cyprus Ministry of Health to the European Statistical Office (Eurostat), which includes weekly all-cause mortality over the period 2016-2021. In addition, we used data collected by the European Centre for Disease Prevention and Control regarding daily reported COVID-19 cases and COVID-19-related deaths. Results Based on our data analysis, we observed a substantial increase of 9.7% in all-cause mortality in Cyprus in 2021 compared to 2020, with an overall mortality increase of 16.5% in 2021 compared to the mean mortality of the previous five years. Particularly, we documented a sharp increase over the third and the fourth quarters of the year 2021. Conclusions The substantial increase in mortality in Cyprus in 2021 is not entirely explained by COVID-19 deaths and is parallel to the concurrent vaccination campaign. This concerning observation should be comprehensively investigated by the National and European public health authorities to identify and address the underlying causes., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Avraam et al.)

The aim of our study was to evaluate the potential association between physical activity and occupational stress among firefighters. Data were collected from Cypriot firefighters through a web-based battery of internationally validated questionnaires completed anonymously (COPSOQ, DASS). A total of 430 firefighters (response rate 68%) completed the survey (age range: 21-60 years). More than half of the firefighters (54%) reported either no or minimal physical activity. A total of 11% of firefighters reported moderate to extremely severe stress based on the DASS-S scale. Using multivariable-adjusted logistic regression models, we showed that firefighters who exercised had 50% lower risk of occupational stress, and using a categorical model, we found that every hour per week of increased physical activity among firefighters was associated with 16% lower risk of occupational stress after adjusting for age, education, smoking, and body mass index (OR = 1.16; p = 0.05). In addition, our findings suggest an inverse dose-response relationship between physical activity and occupational stress among firefighters. Physical activity appears to be inversely associated with occupational stress and serves as an important mitigating factor of occupational stress in firefighters. Further research is warranted to evaluate the potential effect of exercise interventions on occupational stress, and the overall mental health of firefighters and other occupational groups.

The persistence of the coronavirus disease 2019 (COVID-19) pandemic has triggered research into limiting transmission, morbidity and mortality, thus warranting a comprehensive approach to guide balanced healthcare policies with respect to people's physical and mental health. The mainstay priority during COVID-19 is to achieve widespread immunity, which could be established through natural contact or vaccination. Deep knowledge of the immune response combined with recent specific data indicates the potential inferiority of induced immunity against infection. Moreover, the prevention of transmission has been founded on general non-pharmacological measures of protection, albeit debate exists considering their efficacy and, among other issues, their socio-psychological burden. The second line of defense is engaged after infection and is supported by a plethora of studied agents, such as antibiotics, steroids and non-steroid anti-inflammatory drugs, antiviral medications and other biological agents that have been proposed, though variability in terms of benefits and adverse events has not allowed distinct solutions, albeit certain treatments might have a role in prevention and/or treatment of the disease. This narrative review summarizes the existing literature on the advantages and weaknesses of current COVID-19 management measures, thus underlining the necessity of acting based on the classical principle of " ofeleein i mi vlaptin ", that is, to help or not to harm.

Arterial hypertension is a risk factor for several pathologies, mainly including cardio-cerebrovascular diseases, which rank as leading causes of morbidity and mortality worldwide. Arterial hypertension also constitutes a fundamental component of the metabolic syndrome. Helicobacter pylori infection is one of the most common types of chronic infection globally and displays a plethora of both gastric and extragastric effects. Among other entities, Helicobacter pylori has been implicated in the pathogenesis of the metabolic syndrome. Within this review, we illustrate the current state-of-the-art evidence, which may link several components of the Helicobacter pylori -related metabolic syndrome, including non-alcoholic fatty liver disease and arterial hypertension. In particular, current knowledge of how Helicobacter pylori exerts its virulence through dietary, inflammatory and metabolic pathways will be discussed. Although there is still no causative link between these entities, the emerging evidence from both basic and clinical research supports the proposal that several components of the Helicobacter pylori infection-related metabolic syndrome present an important risk factor in the development of arterial hypertension. The triad of Helicobacter pylori infection, the metabolic syndrome, and hypertension represents a crucial worldwide health problem on a pandemic scale with high morbidity and mortality, like COVID-19, thereby requiring awareness and appropriate management on a global scale.

Introduction: Banning smoking at home, schools, children's playgrounds and indoor environments, constitutes an integral part of tobacco control efforts to prevent uptake of smoking among young teenagers. We aimed at exploring the role of teenagers as facilitators of change in enforcing a home no-smoking rule following school-based anti-tobacco programs and examining the effect of home no-smoking rule on teenagers' intention to smoke., Methods: A school-based intervention-control study was implemented during the 2016-2017 academic year among middle-school students in Athens, Greece. The experiential learning intervention was delivered using an interdisciplinary approach, bridging excerpts from ancient classical Greek myths and ancient classical literature, with their decoded archetypal symbols applied in a smoking and tobacco control paradigm. An anonymous selfadministered questionnaire was used at baseline, and at follow-up at 3 months to evaluate program effectiveness. A chi-squared test was used for categorical variables and a t-test for continuous variables. Cohen's distance (d) was employed to examine the intervention effect size. A two-tailed p≤0.05 was considered statistically significant using IBM SPSS V.22., Results: In all, 351 students participated. At baseline, 47.5% in the intervention group reported a home no-smoking rule and 86% indicated being unlikely to smoke, these increased to 61.3% (p=0.016) and 98.2% (p<0.001) at followup, respectively. Cohen's d value was calculated to estimate the effect size of intervention. A large effect size of intervention was found in the intervention group (d=1.24), whilst d=0.19 in the control group., Conclusions: Our study showed that our intervention led to the increase of no-smoking rules at home and to a negative intention towards smoking of adolescents. Consequently, we provide evidence that students are effective vehicles for carrying anti-smoking messages to their home environment including the no-smoking rule. Additionally, we confirmed previous reports that home no-smoking rule is associated with a negative intention to smoke and risk of smoking., Competing Interests: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported., (© 2021 Mpousiou D. et al.)

Introduction: School-based tobacco control programs exhibit great variety. Our study aimed to evaluate the effectiveness of an experiential learning smoking prevention program in facilitating knowledge acquisition, forging healthy attitudes, and decreasing intention to smoke., Methods: A school-based intervention-control study was implemented during the 2016-2017 academic year among middle-school students in Athens, Greece. The experiential learning intervention was delivered using an interdisciplinary approach, bridging excerpts from ancient classical Greek myths, Aesop fables and ancient classical literature (Aristotle, Herodotus, Plutarch, Xenophon, Homer's Epics), with their decoded archetypal symbols applied in a smoking and tobacco control paradigm. An anonymous self-administered questionnaire was used at baseline and at follow-up at 3 months to evaluate program effectiveness., Results: A total of 351 students participated in our study; 181 (51.6%) in the intervention group and 170 (48.4%) in the control group. The mean age of student participants was 13 years (SD=0.96). Students in the intervention group were more likely to improve their knowledge of the adverse effects of smoking, develop attitudes against smoking and report a negative intention to smoke in the first year following the intervention, compared to the control group., Conclusions: This study provides evidence that school-based experiential learning smoking prevention programs improve smoking-related knowledge, enhance anti-smoking attitudes and reinforce negative intentions toward tobacco products., Competing Interests: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported., (© 2021 Mpousiou D.P. et al.)

Background The widespread reach of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its consequences have severely affected the consistency of healthcare systems around the world and caused millions of deaths to date. Understanding the coronavirus disease 2019 (COVID-19) manifestation, progression, and management is crucial for the healthcare personnel caring for COVID-19 patients within the intensive care unit (ICU), as well as for the patients' health progression. Methods A prospective observational study was used to investigate the progression of critically ill COVID-19 positive patients who were admitted to the ICU of Nicosia General Hospital from March 10 to May 1, 2020. All patients over the age of 18 were included in the study; their data were anonymously collected using the institution's electronic medical record system and analyzed in Microsoft Excel (Microsoft Corporation, Redmond, WA). Pregnant women, children, and prisoners were excluded. Results During the study period, a total of 19 patients with a positive result on a reverse-transcriptase polymerase chain reaction (RT-PCR) were included in the study; 74% were men and their mean age was 64 years. Sixty-three percent of the patients were obese, 53% had a history of confirmed hypertension, 68% were admitted with severe respiratory failure, and all of them required invasive mechanical ventilation. Patients were categorized into four groups of ventilation based on the H or L ventilation phenotype in association with co-morbidities. Prone position in the first mechanical ventilation days was found to be more advantageous in L than H phenotype patients, 68% required vasopressor support, and 42% developed acute kidney injury (AKI) during their ICU stay. Diarrhea was with a median day of onset of eight days. Lactate levels above 2 mmol/L in the first four days of admission were correlated with a negative outcome. Nine patients (47%) were successfully discharged from the ICU while 10 (53%) died during their stay. Conclusion In critically ill patients, male gender and obesity are significant risk factors for ICU admission due to COVID-19, and early prone position, mechanical ventilation, and low positive end-expiratory pressures (PEEP) values may be beneficial, especially in the L phenotype category patients. Patients' ventilation phenotype during ICU admission and hospitalization seemed to determine the outcome. Clinical improvement might have been higher and possibly ICU mortality lower if remdesivir was available. Hydroxychloroquine did not seem to improve patient outcomes, a consistent find, as suggested by other studies; on the contrary, it may have contributed to increased mortality rates., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Kastoris et al.)

The current severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic warrants an imperative necessity for effective and safe vaccination, to restrain Coronavirus disease 2019 (COVID-19) including transmissibility, morbidity, and mortality. In this regard, intensive medical and biological research leading to the development of an arsenal of vaccines, albeit incomplete preconditioned evaluation, due to emergency. The subsequent scientific gap raises some concerns in the medical community and the general public. More specifically, the accelerated vaccine development downgraded the value of necessary pre-clinical studies to elicit medium- and long-term beneficial or harmful consequences. Previous experience and pathophysiological background of coronaviruses' infections and vaccine technologies, combined with the global vaccines' application, underlined the obligation of a cautious and qualitative approach, to illuminate potential vaccination-related adverse events. Moreover, the high SARS-CoV-2 mutation potential and the already aggregated genetical alterations provoke a rational vagueness and uncertainty concerning vaccines' efficacy against dominant strains and the respective clinical immunity. This review critically summarizes existing evidence and queries regarding SARS-CoV-2 vaccines, to motivate scientists' and clinicians' interest for an optimal, individualized, and holistic management of this unprecedented pandemic.

Nicotine dependence is one of the main reasons for the continuation of smoking among adolescents. Loss of autonomy (LOA) is a measure of dependence. This study is the first to investigate LOA and its determinants among Greek adolescents. In 2013, 13-to-15-year-old middle-school students were selected by multi-stage clustered sampling. LOA was evaluated with the Hooked-on-Nicotine Checklist (HONC). Multiple univariate analysis was used to assess the association between adolescent demographics, smoking habits, and loss of autonomy. Three-hundred thirty-nine current smokers responded to the questionnaire (response rate: 82.3%). Of these respondents, 51.2% were male and 88.8% reported at least one LOA symptom. The mean HONC score was 4.13/10 (95% CI: 3.82-4.45). Higher scores were negatively associated with lower smoking frequency (cumulative odds ratio (cOR): 0.240, 95% CI: 0.144-0.400) and positively associated with lower age at first cigarette (cOR: 2.29, 95% CI: 1.38-3.82). Female gender was significantly associated with the prevalence but not the degree of LOA. Overall, the prevalence and the degree of nicotine dependence among adolescent smokers in Greece is similar to other countries. Frequent smoking and initiation of smoking at a younger age are linked to nicotine dependence, although it was not possible to make causal inferences. The relationship between nicotine dependence and gender remains unclear.

Background: Occupational exposure to cytotoxic drugs is associated with various unfavorable health outcomes. This protocol reports a methodology for a systematic review and meta-analysis that aims to systematically review the published literature and quantify the level of environmental contamination of healthcare settings with cytotoxic drugs., Methods: This protocol is developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol-2015 (PRISMA-P) guidelines. Six electronic databases (PubMed, Web of Science, Scopus, Cochrane Library, CINAHL, and EMBASE) will be searched with no restrictions on publication period. Eligible studies will be identified and data will be extracted using a predefined data extraction form by at least two independent reviewers following best practice. Eligible studies should report calculated or calculable estimates on the proportion of positive samples tested for cytotoxic drugs and/or estimates on the concentration of the cytotoxic drug(s) in the tested samples. Risk of bias (RoB) will be assessed by using the RoB in Studies estimating Prevalence of Exposure to Occupational risk factors (RoB-SPEO) tool, which developed by the World Health Organization (WHO) and International Labour Organization (ILO) for environmental and occupational health systematic reviews. The random-effects model will be used to perform meta-analyses., Discussion: Occupational exposure to cytotoxic drugs is associated with short- and long-term adverse health outcomes. Following this protocol, the review to be carried out will be the first to fill an evidence gap on the environmental contamination of healthcare settings with cytotoxic drugs. The findings of this review will help in the understanding of the risk of occupational exposure of healthcare workers to cytotoxic drugs and facilitate the identification of priority areas for specific interventions., Ethics and Dissemination: The systematic review methodology does not require ethics approval due to the nature of the study design. The results of the systematic review will be published in a peer-reviewed journal and will be publicly available., Systematic Review Registration: PROSPERO CRD42020162780 , dated July 14, 2020.

Background: Few data were available on smoking and smokeless tobacco use in South Asian migrants in the United Arab Emirates (UAE). This study aimed to identify the prevalence and correlates of cigarette smoking and smokeless tobacco use in male South Asian migrants in the UAE., Methods: We used a cross-sectional study to recruit a random representative sample of male South Asian migrants, including Indian (n = 433), Pakistani (n = 383) and Bangladeshi (n = 559) nationalities. We used multivariable logistic regression analysis to identify significant correlates of cigarettes smoking and smokeless tobacco use., Results: 1375 South Asian migrant adult males participated in the study (response rate 76%) with a mean age of 34 years (SD ± 10). The overall prevalence of cigarette smoking was 28% (95%CI 25-30%) and smokeless tobacco use was 11% (95%CI 10-13%). The prevalence of current cigarette smoking was 21, 23, and 37% among participants from India, Pakistan and Bangladesh, respectively. The prevalence of current smokeless tobacco use was 6, 12, and 16% for Indian, Pakistani, and Bangladeshi participants, respectively. Among study participants, Bangladeshi nationality, hypertension, and alcohol use were significant correlates of current cigarette smoking. Significant correlates of smokeless tobacco use included increased age, less than college level education, alcohol use, and Pakistani or Bangladeshi nationality., Conclusions: Current smoking and smokeless tobacco use in South Asian migrants represent a significant public health burden in the UAE. Effective public health measures are needed to reduce tobacco use in this migrant population.

(1) Background: Pedestrian injuries (PIs) represent a significant proportion of road traffic injuries. Our aim was to investigate the incidence and mortality of PIs in different age groups and sociodemographic index (SDI) categories between 1990 and 2017. (2) Method: Estimates of age-standardized incidence and mortality along with trends of PIs by SDI levels were obtained from the Global Burden of Disease from 1990 to 2017. We also forecasted the trends across all the SDI categories until 2040 using the Statistical Package for the Social Sciences (SPSS Statistics for Windows, version 23.0, Chicago, IL, USA) time series expert modeler. (3) Results: Globally, the incidence of PIs increased by 3.31% (-9.94 to 16.56) in 2017 compared to 1990. Men have higher incidence of PIs than women. Forecasted incidence was 132.02 (127.37 to 136.66) per 100,000 population in 2020, 101.52 (65.99 to 137.05) in 2030, and reduced further to 71.02 (10.62 to 152.65) by 2040. Globally across all SDI categories, there was a decreasing trend in mortality due to PIs with the global estimated percentage reduction of 37.12% (-45.19 to -29.04). (4) Conclusions: The results show that PIs are still a burden for all SDI categories despite some variation. Although incidence and mortality are expected to decrease globally, some SDI categories and specific vulnerable age groups may require particular attention. Further studies addressing incidence and mortality patterns in vulnerable SDI categories are needed.

Aim To quantify the global incidence and mortality of adverse effects of medical treatment (AEMT) and forecast the possible emerging trends of AEMT. Materials and methods We analyzed the latest data from the Global Burden of Disease (GBD) 2017 study. We describe the burden of AEMT based on age- and region-specific incidence and mortality rates between 1990 and 2017. Additionally, we evaluated the change of burden due to AEMT by different periods between 1990 and 2017, and compared the age-standardized incidence and mortality rates among different World Health Organization (WHO) regions. Results Globally, AEMT incidence rates varied across WHO regions and countries. The estimated age-standardized average incidence rates of AEMT were 309 [95% uncertainty interval (UI), 270 to 351], 340 (298 to 384), 401 (348 to 458), and 439 (376 to 505) per 100,000 population across the world in 1990, 2000, 2010, and 2017, respectively, showing an increasing trend in the new occurrence of adverse events. The incidence rate among women (469/100,000) was higher compared to men (409/100,000) in 2017. Between 1990 and 2017, we observed an upward trend in the incidence rates of AEMT across global regions, with a substantial increase in the incidence by 42% (27 to 57) between the years 1990 and 2017, translated to an annualized rate of incline of 1.5%. In the age group of 60-64 years, the incidence rates increased by 96% in 2017 compared to 1990. The global incidence rate due to AEMT is forecasted to increase to 446.94 (433.65 to 460.22) by 2020, 478.49 (376.88 to 580.09) in 2030, and to reach 510.03 (276.58 to 743.49) per 100,000 by 2040. We observed a decline in mortality rates due to AEMT across global regions, and the annualized rate of mortality change was -0.90 percentage points between 1990 and 2017. Overall, the AEMT mortality rate was higher in men (1.73/100,000) than in women (1.48/100,000), and age-specific mortality rates showed a bimodal increase between the age group of birth to one year, and an increase in the age group of 65 years and above. The global mortality rate due to AEMT is expected to be 1.55 (1.48 to 1.61) in 2020, 1.37 (0.88 to 1.86 ) in 2030 and 1.2 deaths per 100,000 (0.08 to 2.32) by 2040. Conclusion Using the GBD 2017 study data, we found an increase in the incidence of AEMT, and an overall decrease in the mortality rate between 1990 and 2017, with varying estimates between different countries and regions, gender and age groups. The forecast analysis displayed the same trends - an increase in AEMT incidence and a decline in mortality between 2020 and 2040. The high burden of AEMT warrants the implementation of robust policies in the healthcare system including appropriate patient safety training for the healthcare professionals, and safe culture of feedback with the implementation of electronic medical records to achieve WHO patient safety strategy goals., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Nauman et al.)

Aim To quantify and update the years of life lost (YLL), years lived with disability (YLD) and disability-adjusted life years (DALY) due to the adverse effects of medical treatment (AEMT) between 1990 and 2017. Subject and methods We analyzed the latest dataset from the Global Burden of Disease (GBD) 2017 study. We described the burden of AEMT based on the number of DALY. We additionally evaluated the global age and sex-specific DALY and compared the age-standardized rates of DALY across the World Health Organization (WHO) regions from 1990 to 2017. Results Worldwide, the total DALYs due to AEMT were 84.93 [95% uncertainty interval (UI), 62.52 to 102.21] in 1990 and 62.79 (52.09 to 75.45) in 2017 per 100,000 population. The global percentage of change in DALY showed a negative trend of -26.06 % (-41.52 to -10.59) across all WHO regions between 1990 and 2017. The YLD has increased during the period from 1997 to 2017 by 29.47% (17.87 to 41.06). In 2017, men were affected more than women with a DALY of 66.78 in comparison to 58.91 DALY in women. DALY rates per 100,000 were highest across all the WHO regions in the first years of life. The predicted DALY rates were 59.92 (57.52 to 62.32) in the year 2020, 50.36 (32.03 to 68.70) in 2030, and 40.8 (-1.33 to 82.93) in 2040. Conclusion Using the GBD 2017 study data, we found a decrease in the DALY rate due to AEMT between 1990 and 2017 with a varying range of DALY between different WHO regions. DALY also differed by age and sex. The forecasting analyses showed a decrease in DALY due to AEMTs with a significant drop in the European region when compared to the African and American regions. However, the increasing trend for YLD signifies an increasing burden of people living with poor health due to AEMT. Our study proposes to identify disability due to AEMT as a significant public health crisis and calls for policymakers to create a robust revised policy., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Khan et al.)

Background: Cytotoxic drugs constitute an important workplace hazard in the hospital environment. Our aim was to conduct an environmental assessment of hazardous drugs in the Oncology Center of Cyprus., Methods: Wipe samples were obtained from 42 workplace areas of the Oncology Center including two pairs of gloves in an initial assessment, while 10 samples were obtained at follow-up 3 years later. Potential contamination with cyclophosphamide (CP), ifosphamide (IF) and 5-fluorouracil (5-FU) and other cytotoxic medications was examined using the GC-MSMS system (CP, IF) and the HPLC system with UV detection (5-FU) method, respectively., Results: Wipe sample contamination was detected at 11.9% and 15% in the initial and follow-up assessment, respectively. Both pairs of gloves assessed were free from contamination. The results showed contamination with cyclophosphamide on the work space inside the isolator, on a day-care office phone and on the central pharmacy bench. Ifosphamide was only detected on the floor of a patient's room. Contamination with 5-fluorouracil was found only on the surface of a prepared IV infusion bag. The levels of contamination in the positive samples ranged from 0.05 to 10.12 ng/cm2., Conclusions: The overall percentage of sample contamination at the Oncology Center was very low compared to other centers around the world. In addition, the detected levels of contamination with cytotoxic drugs were relatively low with the exception of the workspace inside the biological safety cabinet. These results in both assessments may reflect the implementation of comprehensive control measures including employee training, technological equipment and effective cleaning procedures., Competing Interests: The authors have declared that no competing interests exist.

Background: Individuals with established cardiovascular disease (CVD) and risk factors such as age, smoking, hypertension, and diabetes mellitus are at an increased risk of recurrent cardiovascular events and death. The incidence rate of recurrent CVD events varies between countries and populations. The United Arab Emirates (UAE) has one of the highest age-standardized death rates for CVD worldwide. The aim of our study was to estimate the incidence rates and determine the predictors of recurrent CVD events among UAE nationals., Methods: We investigated an outpatient-based cohort of patients with a history of CVD visiting Tawam Hospital between April 1, 2008 and December 31, 2008. They were followed-up until July 31, 2018. Univariable and multivariable Cox proportional hazards regression models were used to determine the association between major CVD risk factors and the risk of CVD recurrence., Results: A total of 216 patients (167 males, 49 females) with a history of CVD were included. They were followed for a median (interquartile range) of 8.1 (5.5-9.3) years, with a total of 1184 patient-years of follow-up. The overall incidence rate of recurrent CVD events was 92.1 per 1000 patient-years. The 8-year cumulative incidence was 73.7%. Age, female sex, and diabetes mellitus were significant predictors of recurrent CVD events, where females had a 1.96 times higher risk of recurrent CVD events than males., Conclusion: Significant predictors of recurrent CVD events are older age, female sex, and diabetes mellitus. The incidence rate of recurrent CVD events was 92.1 per 1000 patient-years. Preventive measures, based on international guidelines for CVD management, may improve CVD morbidity and mortality in the UAE population.

Objective: A systematic literature review and meta-analysis was conducted on the association between firefighting and cancer., Methods: A comprehensive literature search of databases including Medline, EMBASE, Biosis, NIOSHTIC2, Web of Science, Cancerlit, and HealthStar, for the period between 1966 to January 2007, was conducted. We also retrieved additional studies by manual searching., Results: A total of 49 studies were included in the meta-analysis. We found statistically significant associations between firefighting and cancers of bladder, brain and CNS, and colorectal cancers, consistent with several previous risk estimates. We also found statistically significant associations of firefighting with non-Hodgkin's lymphoma, skin melanoma, prostate, and testicular cancer. For kidney, Hodgkin's lymphoma, leukemia, lymphosarcoma and reticulosarcoma, multiple myeloma, and pancreatic cancer, we found some statistically significant but less consistent results. For all other cancers evaluated (esophageal, laryngeal, oral and pharyngeal, liver and gallbladder, lung, lymphatic and hematopoietic, non-melanoma skin cancer, stomach, and urinary cancer) we did not find any statistically significant associations., Conclusions: Although our meta-analysis showed statistically significant increased risks of either cancer incidence or mortality of certain cancers in association with firefighting, a number of important limitations of the underlying studies exist, which, precluded our ability to arrive at definitive conclusions regarding causation.

Objectives: Numerous studies reported that achieving near-normal glycated haemoglobin (HbA1c) levels in patients with diabetes may delay or even prevent vascular complications. However, information regarding the impact of non-optimal HbA1c control on adverse health outcomes in an Arab population is unknown. The aim of this study was to estimate the fraction of deaths and potential years of life lost (PYLL) attributable to non-optimal HbA1c control among Emirati men and women with diabetes in the United Arab Emirates (UAE)., Design: A retrospective cohort study., Setting: This study was conducted in outpatient clinics at a tertiary care centre in Al Ain, UAE, between April 2008 and September 2018., Participants: The sample comprised of 583 adult UAE nationals, aged≥18 years, with diabetes. Overall, 57% (n=332) of the study participants were men and 43% (n=251) were women., Exposure: Non-optimal HbA1c control, defined as HbA1c≥6.5%., Primary Outcome Measure: All-cause mortality, defined as death from any cause., Results: At the end of the 9-year follow-up period, 86 (14.8%) participants died. Overall, up to 33% (95% CI 2% to 63%) of deaths were attributable to non-optimal HbA1c control among patients with diabetes mellitus (DM). Stratified by sex, the adjusted fraction of avoidable mortality was 17% (95% CI -23% to 57%) for men and 50% (95% CI 3% to 98%) for women. Both deaths and PYLL attributable to non-optimal HbA1c control were higher in women compared with men., Conclusions: Up to one-third of all deaths in adult UAE nationals with DM could be attributed to non-optimal HbA1c control. Effective sex-specific interventions and healthcare quality-improvement programmes should urgently be implemented., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Investigate psychological distress and its link to stress management interventions in the financial industry (FI) in comparison to the human services (HS) sector., Method: Observational study across participating organizations in FI (66) and HS (81). Web-based version of depression anxiety stress scales (21 questions) and eight questions related to stress prevention interventions adopted by employers., Results: Indicated that FI workers are twice as likely as HS employees to present with stress and depression. Differences emerged on the availability of support at the workplace: FI workers reporting total lack of psychological support, although other forms of wellbeing promotion were more frequent. Close to 60% of individuals in the HS group reported no support (48% in the FI)., Conclusion: Workers in the FI industry have increased levels of workplace stress that could be possibly attributed to absence of prevention interventions at the workplace.

Objectives: The aim of this study was to evaluate the potential association between occupational stress and musculoskeletal symptoms in firefighters., Material and Methods: Data were collected among Cypriot firefighters through a battery of adapted questionnaires completed anonymously., Results: A total of 430 firefighters (a response rate of 68%) completed the survey (the age range: 21-60 years). A total of 11% of firefighters reported moderate to extremely severe stress through the Copenhagen Psychosocial Questionnaire and Depression, Anxiety and Stress Scale . A total of 40% of firefighters reported musculoskeletal symptoms, the most frequent being back pain. Multivariable-adjusted logistic regression models showed that occupational stress was associated with a 50% higher risk of musculoskeletal symptoms in firefighters after adjusting for age, smoking and obesity (OR = 1.52, p = 0.04). In addition, a positive dose-response relationship was found between occupational stress and musculoskeletal symptoms., Conclusions: Occupational stress constitutes a significant risk for firefighters and is associated with higher prevalence of musculoskeletal symptoms at work. Int J Occup Med Environ Health. 2019;32(3):341-52., (This work is available in Open Access model and licensed under a CC BY-NC 3.0 PL license.)