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Abstract Introduction Suprascapular nerve neuropathy constitutes an unusual cause of shoulder weakness, with the most common etiology being nerve compression from a ganglion cyst at the suprascapular or spinoglenoid notch. We present a puzzling case of a man with suprascapular nerve neuropathy that may have been associated with an appendectomy. The case was attributed to nerve injury as the most likely cause that may have occurred during improper post-operative patient mobilization. Case presentation A 23-year-old Caucasian man presented to an orthopedic surgeon with a history of left shoulder weakness of several weeks' duration. The patient complained of pain and inability to lift minimal weight, such as a glass of water, following an appendectomy. His orthopedic clinical examination revealed obvious atrophy of the supraspinatus and infraspinatus muscles and 2 of 5 muscle strength scores on flexion resistance and external rotation resistance. Magnetic resonance imaging showed diffuse high signal intensity within the supraspinatus and infraspinatus muscles and early signs of minimal fatty infiltration consistent with denervation changes. No compression of the suprascapular nerve in the suprascapular or spinoglenoid notch was noted. Electromyographic studies showed active denervation effects in the supraspinatus muscle and more prominent in the left infraspinatus muscle. The findings were compatible with damage to the suprascapular nerve, especially the part supplying the infraspinatus muscle. On the basis of the patient's history, clinical examination, and imaging studies, the diagnosis was suspected to be associated with a possible traction injury of the suprascapular nerve that could have occurred during the patient's transfer from the operating table following an appendectomy. Conclusion Our case report may provide important insight into patient transfer techniques used by hospital personnel, may elucidate the clinical significance of careful movement of patients following general anesthesia, and may have important implications for patient safety techniques, including those outlined in the World Health Organization Surgical Safety Checklist program.

Abstract 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 Background Data on the prevalence of tobacco use among teenagers in Greece are limited. We examined the prevalence of smoking among middle-school students in Greece using the Global Youth Tobacco Survey (GYTS). Methods The Global Youth Tobacco Survey was implemented in Greece during the academic year 2004 – 2005 by the University of Thessaly and the National School of Public Health. Data were collected using the GYTS self-administered anonymous questionnaire, which was distributed by specifically trained field workers to a nationally representative sample of middle-school students aged 13–15 years (through randomly selected schools and classes), randomly selected through a two-stage cluster sample design. Data processing and statistical analyses were performed at the Centers for Disease Control and Prevention (CDC). Results About one third of the students 32.1% (29.4 – 35.0) reported that they had tried tobacco in the past, while 16.2% (14.3 – 18.4) reported being current users of tobacco products. In addition, 1 in 4 of ever smokers reported that they began smoking before the age of 10 years old. Almost 1 in 5 never smokers reported being susceptible to initiate smoking in the next year and about 89.8% (88.3 – 91.1) of the respondents were exposed to environmental tobacco smoke in their homes and 94.1% (93.2 – 94.9) in public places. Finally, a strikingly high number of students 95% (89.5 – 97.7) reported that they were able to buy their own cigarettes without restrictions. Conclusion The results of the GYTS show that the prevalence of smoking in middle-school children is alarmingly high in Greece. Smoking among young people constitutes a significant problem that is destined to worsen in the absence of any comprehensive efforts focused on strict anti-smoking legislation, policies and tobacco control interventions targeting children at a young age.

Abstract Background Research in the fields of Preventive Medicine, Occupational/Environmental Medicine, Epidemiology and Public Health play an important role in the advancement of knowledge. In order to map the research production around the world we performed a bibliometric analysis in the above fields. Methods All articles published by different world regions in the above mentioned scientific fields and cited in the Journal Citation Reports (JCR) database of the Institute for Scientific Information (ISI) during the period 1995 and 2003, were evaluated. The research production of different world regions was adjusted for: a) the gross domestic product in 1995 US dollars, and b) the population size of each region. Results A total of 48,861 articles were retrieved and categorized. The USA led the research production in all three subcategories. The percentage of articles published by USA researchers was 43%, 44% and 61% in the Preventive Medicine, Epidemiology, and Public Health subcategories, respectively. Canada and Western Europe shared the second position in the first two subcategories, while Oceania researchers ranked second in the field of Public Health. Conclusion USA researchers maintain a leadership position in the production of scientific articles in the fields of Preventive Medicine, Occupational/Environmental Medicine and Epidemiology, at a level similar to other scientific disciplines, while USA contribution to science in the field of Public Health is by all means outstanding. Less developed regions would need to support their researchers in the above fields in order to improve scientific production and advancement of knowledge in their countries.

Abstract Background A long-term active surveillance of Q fever was conducted in Cyprus organized in two phases. Methods Following serological tests and identification of seropositive humans and animals for C. burnetii in two villages (VIL1 and VIL2), all seronegative individuals were followed up for one year on a monthly basis by trained physicians to detect possible seroconversion for Q fever. In the second phase of the study, active surveillance for one year was conducted in the entire Cyprus. Physicians were following specific case definition criteria for Q fever. Standardized questionnaires, a geographical information system on a regional level, Immunofluorescence Assay (IFA) examinations and shell vial technique were used. Results Eighty-one seronegative humans and 239 seronegative animals from both villages participated in the first phase surveillance period of Q fever. Despite the small number of confirmed clinical cases (2 humans and 1 goat), a significant percentage of new seropositives for C. burnetii (44.4% of human participants and 13.8% of animals) was detected at the end of the year. During the second phase of surveillance, 82 humans, 100 goats, and 76 sheep were considered suspected cases of Q fever. However, only 9 human, 8 goat, and 4 sheep cases were serologically confirmed, while C. burnetii was isolated from three human and two animal samples. The human incidence rate was estimated at 1.2 per 100,000 population per year. Conclusion A small number of confirmed clinical cases of Q fever were observed despite the high seroprevalence for C. burnetii in human and animal population of Cyprus. Most of the cases in the local population of Cyprus appear to be subclinical. Moreover further studies should investigate the role of ticks in the epidemiology of Q fever and their relation to human seropositivity.

Abstract Background The Olympic Games constitute a first-class opportunity to promote athleticism and health messages. Little is known, however on the impact of Olympic Games on the development of health-promotion programs for the general population. Our objective was to identify and describe the population-based health-promotion programs implemented in relation to the Athens 2004 Olympic and Para Olympic Games. Methods A cross-sectional survey of all stakeholders of the Games, including the Athens 2004 Organizing Committee, all ministries of the Greek government, the National School of Public Health, all municipalities hosting Olympic events and all official private sponsors of the Games, was conducted after the conclusion of the Games. Results A total of 44 agencies were surveyed, 40 responded (91%), and ten (10) health-promotion programs were identified. Two programs were implemented by the Athens 2004 Organizing Committee, 2 from the Greek ministries, 2 from the National School of Public Health, 1 from municipalities, and 3 from official private sponsors of the Games. The total cost of the programs was estimated at 943,000 Euros; a relatively small fraction (0.08%) of the overall cost of the Games. Conclusion Greece has made a small, however, significant step forward, on health promotion, in the context of the Olympic Games. The International Olympic Committee and the future hosting countries, including China, are encouraged to elaborate on this idea and offer the world a promising future for public health.

Abstract Background The use of geographical information system (GIS) technologies in public health surveillance is gradually gaining momentum around the world and many applications have already been reported in the literature. In this study, GIS technology was used to help county departments of Public Health to implement environmental health surveillance for the Athens 2004 Olympic and Para Olympic Games. Methods In order to assess the workload in each Olympic county, 19 registry forms and 17 standardized inspection forms were developed to register and inspect environmental health items requiring inspection (Hotels, restaurants, swimming pools, water supply system etc), respectively. Furthermore, related databases were created using Epi Info 2002 and a geographical information system (GIS) were used to implement an integrated Environmental Health inspection program. The project was conducted in Athens by the Olympic Planning Unit (OPU) of the National School of Public Health, in close cooperation with the Ministry of Health and Social Solidarity and the corresponding departments of Public Health in all municipalities that were scheduled to host events during the Athens 2004 Olympic and Para Olympic games. Results A total of 44,741 premises of environmental health interest were geocoded into GIS databases and several electronic maps were developed. Using such maps in association with specific criteria, we first identified the maximum workload required to execute environmental health inspections in all premises within the eleven Olympic County Departments of Public Health. Six different scenarios were created for each county, based on devised algorithms in order to design the most effective and realistic inspection program using the available inspectors from each municipality. Furthermore, GIS applications were used to organize the daily inspection program for the Olympic games, provide coloured displays of the inspection results and link those results with the public health surveillance of specific cases or outbreak investigation. Conclusion Our computerised program exhibited significant efficiency in facilitating the prudent use of public health resources in implementing environmental health inspections in densely populated urban areas as well as in rural counties. Furthermore, the application of simple algorithms in integrating human and other resources provided tailored and cost-effective applications to different public health agencies.

Abstract Background Coronary heart disease (CHD) is responsible for 45% of on-duty deaths among United States firefighters. We sought to identify occupational and personal risk factors associated with on-duty CHD death. Methods We performed a case-control study, selecting 52 male firefighters whose CHD deaths were investigated by the National Institute for Occupational Safety and Health. We selected two control populations: 51 male firefighters who died of on-duty trauma; and 310 male firefighters examined in 1996/1997, whose vital status and continued professional activity were re-documented in 1998. Results The circadian pattern of CHD deaths was associated with emergency response calls: 77% of CHD deaths and 61% of emergency dispatches occurred between noon and midnight. Compared to non-emergency duties, fire suppression (OR = 64.1, 95% CI 7.4–556); training (OR = 7.6, 95% CI 1.8–31.3) and alarm response (OR = 5.6, 95% CI 1.1–28.8) carried significantly higher relative risks of CHD death. Compared to the active firefighters, the CHD victims had a significantly higher prevalence of cardiovascular risk factors in multivariate regression models: age ≥ 45 years (OR 6.5, 95% CI 2.6–15.9), current smoking (OR 7.0, 95% CI 2.8–17.4), hypertension (OR 4.7, 95% CI 2.0–11.1), and a prior diagnosis of arterial-occlusive disease (OR 15.6, 95% CI 3.5–68.6). Conclusions Our findings strongly support that most on-duty CHD fatalities are work-precipitated and occur in firefighters with underlying CHD. Improved fitness promotion, medical screening and medical management could prevent many of these premature deaths.