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Abstract Background Health systems need tools to assess patient’s experience of service, but existing tools lack reliability and validity assessment. Our aim is to investigate the factor structure, reliability, validity, item parameters and interpretability of the parent version of the Experience of Service Questionnaire (ESQ) for practical use in Greece. Methods A total of 265 caregivers that were using mental health services in Greece participated in this study as part of the Nationwide cross-sectional survey from the Child and Adolescent Mental Health Initiative (CAMHI). Confirmatory Factor Analysis was used to test factor structure. Reliability of all models were measured with omega coefficients. Tobit regression analysis was used to test for convergent and discriminant validity with specifically designed questions. Item parameters were assessed via Item Response Theory. Interpretability was assessed by means of IRT-based scores. Results We found that ESQ is best represented and scored as a unidimensional construct, given potential subscales would not have enough reliability apart from a general factor. Convergent and discriminant validity was demonstrated, as caregivers who perceived that their child benefited from the received mental health care had 6.50 higher summed scores (SMD = 1.14, p

BackgroundThe mental health system in Greece faces challenges to complete its transition to a community-oriented model, having significant concerns for child and adolescent care due to lower coverage and service gaps. This component of the mental health system has not been comprehensively evaluated.MethodsWe conducted a review of the mental health care system for children and adolescents in Greece. For a field assessment, we directly collected data from mental health services to map availability and distribution. We analyzed the needs of human resources using professional register data and the national census.ResultsThe National Health Care Service (ESY, Εθνικό Σύστημα Υγείας) is the public health system in Greece, characterized by public governance but significant private participation. Although ESY aims for universal care, gaps in population coverage and high user fees create barriers to access. Embedded within ESY, the mental health system is shifting towards a community-oriented structure since the psychiatric reform. For children and adolescents, there is a developing framework for regionalization and community services, including day centers, inpatient facilities, outpatient departments, and school-based psychoeducational facilities. However, services lack coordination in a stepped care model. Patient pathways are not established and primary care rarely involves child mental health, leading to direct access to specialists. Services operate in isolation due to the absence of online registers. There is no systematic performance monitoring, yet some assessments indicate that professional practices may lack evidence-based guidelines. Our mapping highlighted a scarcity of public structures, with an unbalanced regional distribution and many underserved areas. Child and adolescent psychiatrists are predominantly affiliated with the private sector, leading to professional gaps in the public system.ConclusionsOur assessment identifies an established framework for a community-oriented, universally accessible mental health system, yet several barriers impede its full realization. These include an inconsistent primary healthcare system, a shortage of specialists in the public sector, imbalanced service distribution, lack of coordination among providers, underfunding, and absence of quality monitoring. We propose interventions to promote child and adolescent mental health in primary care, coordinate patient pathways, establish standards of care, and monitor performance.

Abstract Background In the context of Greece, many instruments measuring constructs pertinent to child and adolescent mental health lacked a locally-validated, freely-available version. As part of a nationwide survey, we translated and cross-culturally adapted a collection of seventeen brief, largely-employed assessment tools that can be used at scale. Methods This study is part of the Child and Adolescent Mental Health Initiative in Greece (CAMHI), a capacity-building program focusing on enhancing mental health care for children and adolescents living in Greece. We conducted a nationwide survey assessing mental health symptoms, parenting practices, service availability and quality, mental health literacy and stigma, and professional practices within the country. As part of this process, we selected outcomes and instruments after consulting the International Consortium for Health Outcomes Measurement (ICHOM) and the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN). From our selection, we identified 17 instruments that did not have a Greek-validated version available for use. These instruments were translated and cross-culturally adapted following a structured procedure, including independent back-and-forth translations, synthesis of versions, expert revision, and pilot testing. Some instruments were slightly modified to meet CAMHI survey purposes. Results A cross-culturally adapted version in Greek was made available for the following instruments: Pediatric Symptoms Checklist (PSC); Deliberate Self Harm Inventory (DSH) (modified); Child and Adolescent Trauma Screen-2 (CATS-2); ABCD Screen Use (modified); Swanson, Nolan, and Pelham-IV (SNAP-IV); Parent Behavior Inventory (PBI); Mental Health Literacy Scale (MHLS)—(modified); Australian Mental Health Vignettes; Reported and Intended Behavior Scale (RIBS); Barriers to Access to Care (BACE) (modified); Experience of Service Questionnaire (ESQ) (modified); and Multitheoretical List of Therapeutic Interventions (MULTI-30) (modified). Conclusion A collection of these widely-used assessment tools is now adapted for the local context and freely accessible at [ https://osf.io/crz6h/ ]. Researchers and health professionals in Greece can utilize this resource to screen, evaluate, and monitor various constructs related to mental health in accordance with the most effective practices.

Mobile mental health units (MMHUs) have been proposed as an effective model to serve the mental health needs of remote underserved areas. In 2013, the Department of Psychiatry, University of Crete, started a pilot MMHU to cover the needs of remote rural areas of the Heraklion Prefecture. The main objectives were early detection, prevention and therapy of patients with severe psychiatric disorders, without access to regular psychiatric care. In addition to regular visits to primary care health centers, a community support network was established. During this 10-year period, the MMHU has evaluated 3343 patients and performed 19,935 visits. The most frequent diagnoses are depression and anxiety (52.7%) whereas psychosis and bipolar disorders are the third (12.7%) and fifth most frequent diagnoses (4.7%). Half of the patients with depression/anxiety were older than 65 years and one third were living alone. Furthermore, the first visit with the MMHU of severely mentally ill was about 15 years later from the self-reported onset of psychotic symptoms. We discuss how to improve our ability to detect and intervene earlier in patients with severe mental illness, and how to address effectively, both pharmacologically and psychosocially, the depression and loneliness of older individuals living in small remote communities.

IntroductionAlthough the link between sleep and memory function is well established, associations between sleep macrostructure and memory function in normal cognition and Mild Cognitive Impairment remain unclear. We aimed to investigate the longitudinal associations of baseline objectively assessed sleep quality and duration, as well as time in bed, with verbal memory capacity over a 7–9 year period. Participants are a well-characterized subsample of 148 persons (mean age at baseline: 72.8 ± 6.7 years) from the Cretan Aging Cohort. Based on comprehensive neuropsychiatric and neuropsychological evaluation at baseline, participants were diagnosed with Mild Cognitive Impairment (MCI; n = 79) or found to be cognitively unimpaired (CNI; n = 69). Sleep quality/quantity was estimated from a 3-day consecutive actigraphy recording, whereas verbal memory capacity was examined using the Rey Auditory Verbal Learning Test (RAVLT) and the Greek Passage Memory Test at baseline and follow-up. Panel models were applied to the data using AMOS including several sociodemographic and clinical covariates.ResultsSleep efficiency at baseline directly predicted subsequent memory performance in the total group (immediate passage recall: β = 0.266, p = 0.001; immediate word list recall: β = 0.172, p = 0.01; delayed passage retrieval: β = 0.214, p = 0.002) with the effects in Passage Memory reaching significance in both clinical groups. Wake after sleep onset time directly predicted follow-up immediate passage recall in the total sample (β = −0.211, p = 0.001) and in the MCI group (β = −0.235, p = 0.02). In the total sample, longer 24-h sleep duration was associated with reduced memory performance indirectly through increased sleep duration at follow-up (immediate passage recall: β = −0.045, p = 0.01; passage retention index: β = −0.051, p = 0.01; RAVLT-delayed recall: β = −0.048, p = 0.009; RAVLT-retention index:β = −0.066, p = 0.004). Similar indirect effects were found for baseline 24-h time in bed. Indirect effects of sleep duration/time in bed were found predominantly in the MCI group.DiscussionFindings corroborate and expand previous work suggesting that poor sleep quality and long sleep duration predict worse memory function in elderly. Timely interventions to improve sleep could help prevent or delay age-related memory decline among non-demented elderly.

IntroductionTranscranial electric stimulation (TES) is a neuromodulation approach that applies low-intensity electrical current to the brain and has been proposed as a treatment for insomnia. Electrostatic therapy is a kind of TES and people do not have a feeling of electrical stimuli when the voltage of static electricity is lower than 2,000 volts. However, no studies have examined the effects of electrostatic therapy on objective sleep and daytime symptoms in patients with insomnia.Materials and methodsThirty chronic insomnia patients were included. All patients received a 6 week electrostatic therapy and three comprehensive assessments including two consecutive polysomnography (PSG) and daytime symptoms assessments, at pre-treatment, 3 week and 6 week of treatment. Insomnia Severity Index (ISI) was used to assess the severity of insomnia. Multiple sleep latency test (MSLT), Epworth Sleepiness Scale (ESS), and Flinders Fatigue Scale (FFS) were used to assess objective and self-reported daytime sleepiness and fatigue, respectively. Attention network test (ANT) was used to assess attention levels.ResultsTotal ISI scores decreased significantly at 3 weeks (p < 0.001) and 6 weeks (p < 0.001) after initiation of treatment. Furthermore, objective total sleep time (TST, p = 0.020) and sleep efficiency (SE, p = 0.009) increased and wake time after sleep onset (p = 0.012) decreased significantly after 6 weeks electrostatic therapy. Regarding daytime symptoms, ESS and FFS scores decreased significantly at 3 weeks (ESS, p = 0.047; FFS, p = 0.017) and 6 weeks (ESS, p = 0.008; FFS, p = 0.003) after initiation of treatment. Moreover, executive control improved significantly from pre-treatment to 3 weeks (p = 0.006) and 6 weeks (p = 0.013) and altering network improved significantly at 6 weeks (p = 0.003) after initiation of treatment. Secondary analyses showed that TST and SE improved significantly after electrostatic therapy in insomnia patients who slept < 390 min (all p-value < 0.05). However, no significant changes regarding TST and SE were observed in insomnia patients who slept ≥ 390 min.ConclusionElectrostatic therapy improves both nighttime sleep and daytime symptoms in patients with chronic insomnia. The effect on objective sleep appears to be stronger in patient with objective short sleep duration. Electrostatic therapy might be a therapeutic choice for insomnia patients with difficulty maintaining sleep and not responding to behavioral treatments.Clinical trial registration[www.clinicaltrials.gov], identifier [ChiCTR2100051590].

Abstract Background The 2019 coronavirus disease (COVID-19) has disrupted millions of lives and commerce. We investigated psychological reactions and insomnia during the COVID-19 outbreak in adults with mental health disorders (MDs). Methods A self-reported psychological and sleep online survey was conducted in China between February 5th to 19th, 2020. A total of 244 adults with MDs and 1116 controls matched for age, gender and sites were included. Worsened symptoms of anxiety, depressive and insomnia were defined when severity levels shifted to a more severe category compared to pre-COVID-19. Results During the COVID-19 outbreak, we found significantly increased prevalence of anxiety (MDs: 54.9% vs. 49.6%, controls: 25.5% vs. 14.3%), depression (MDs: 63.9% vs. 61.5%, controls: 29.9% vs. 21.2%) and insomnia (MDs: 66.0% vs. 57.8%, controls: 31.5% vs. 24.8%) compared to pre-COVID-19 period (all P-value

Background: Few studies have investigated depression-anxiety in adolescents/young adults in Greece. We examined the prevalence of depression/anxiety and its correlates in a large, representative, population-based sample of young Greeks. Methods: A structured telephone questionnaire was conducted in 2771 adolescents/young adults aged between 15 and 24 years (mean age: 20.47 ± 2.83 years). Depression/anxiety symptoms were assessed using the PHQ-9 and GAD-7 scales, respectively. Sociodemographics, mental health, and psychological parameters were also examined. Moderate to severe depression and anxiety symptoms were defined with PHQ-9≥10 and GAD-7≥10, respectively. Analysis was conducted using multivariable linear and logistic regression models. Results: In our sample, 803 (29%) and 416 (15%) participants reported depressive and anxiety symptoms, respectively. In multivariable analysis, depression was associated with female sex, younger age, mental health history, substance use, dyslexia, lower quality of life and social seclusion (all p

Background: Depression is a frequent and serious disease often undiagnosed in elderly. We aimed to examine (1) the prevalence/correlates associated with depression and (2) the magnitude of depression underdiagnosis/related factors, in a large community-dwelling elderly population in Crete/Greece visiting Primary Health Care (PHC) settings. Methods: A sub-sample of 2428 non-demented individuals with Mini Mental State Examination (MMSE)>19 were recruited from a population-based cohort of 3140 elderly (>60 years). In phase I, all participants were assessed with a structured questionnaire including demographics, life-style, sleep, physical health and cognitive function. Diagnosis of depression was based on history/treatment of depression. In phase II, in a sub-sample of 293 participants, depression was diagnosed after a thorough extensive neuropsychiatric/neuropsychological evaluation. Results: In phase I, 10.8% reported a diagnosis/treatment of depression. In multivariate analysis, female gender, lack of physical activity, caregiver dependence and use of benzodiazepines were associated with depression. In phase II, depression was prevalent in 28.7% of our sample, whereas about 61% of those diagnosed with depression were undetected in phase I. Factors associated with non-detection of depression were sleep complaints/subjective short sleep, low MMSE and medical comorbidities. Two screening questions related to mood increased possibility to detect undiagnosed depression up to 90%. Limitations: Due to the cross-sectional design, causality between correlated factors cannot be examined. Conclusion: Prevalence of depression is high and largely underdiagnosed in elderly in Crete/Greece. Sleep and memory complaints appear to be surrogate markers of depression, whereas screening mood in PHC settings may significantly increase detection of depression in elders.

Introduction: Dementia severely affects the quality of life of patients and their caregivers; however, it is often not adequately addressed in the context of a primary care consultation, especially in patients with multi-morbidity.Study Population and Methods: A cross-sectional study was conducted between March-2013 and December-2014 among 3,140 consecutive patients aged >60 years visiting 14 primary health care practices in Crete, Greece. The Mini-Mental-State-Examination [MMSE] was used to measure cognitive status using the conventional 24-point cut-off. Participants who scored low on MMSE were matched with a group of elders scoring >24 points, according to age and education; both groups underwent comprehensive neuropsychiatric and neuropsychological assessment. For the diagnosis of dementia and Mild-Cognitive-Impairment (MCI), the Diagnostic and Statistical Manual-of-Mental-Disorders (DSM-IV) criteria and the International-Working-Group (IWG) criteria were used. Chronic conditions were categorized according to ICD-10 categories. Logistic regression was used to provide associations between chronic illnesses and cognitive impairment according to MMSE scores. Generalized Linear Model Lasso Regularization was used for feature selection in MMSE items. A two-layer artificial neural network model was used to classify participants as impaired (dementia/MCI) vs. non-impaired.Results: In the total sample of 3,140 participants (42.1% men; mean age 73.7 SD = 7.8 years), low MMSE scores were identified in 645 (20.5%) participants. Among participants with low MMSE scores 344 (54.1%) underwent comprehensive neuropsychiatric evaluation and 185 (53.8%) were diagnosed with Mild-Cognitive-Impairment (MCI) and 118 (34.3%) with dementia. Mental and behavioral disorders (F00-F99) and diseases of the nervous system (G00-G99) increased the odds of low MMSE scores in both genders. Generalized linear model lasso regularization indicated that 7/30 MMSE questions contributed the most to the classification of patients as impaired (dementia/MCI) vs. non-impaired with a combined accuracy of 82.0%. These MMSE items were questions 5, 13, 19, 20, 22, 23, and 26 of the Greek version of MMSE assessing orientation in time, repetition, calculation, registration, and visuo-constructive ability.Conclusions: Our study identified certain chronic illness-complexes that were associated with low MMSE scores within the context of primary care consultation. Also, our analysis indicated that seven MMSE items provide strong evidence for the presence of dementia or MCI.

Objectives Cognitive impairment is known to have a significant impact on the quality of life of individuals and their caregivers, yet it is often underdiagnosed. The objective of this study is to assess the extent of cognitive impairment among elders visiting primary healthcare (PHC) practice settings, to explore associated risk factors and discuss current care challenges for PHC providers.Design A cross-sectional study was conducted between March 2013 and May 2014.Setting Fourteen PHC units located in rural and urban areas of the Heraklion district in Crete, Greece.Participants Consecutive visitors aged at least 60 years attending selected PHC practices.Primary and secondary outcome measures The Mini-Mental State Examination (MMSE) was used to indicate cognitive status. Associations of low MMSE scores (≤23/24, adjusted for education level) with 12 socio-demographic factors, comorbidities and lifestyle factors were assessed.Results A total of 3140 PHC patients met inclusion criteria (43.2% male; mean age 73.7±7.8 years). The average MMSE score was 26.0±3.8; 26.7±3.5 in male and 25.4±3.9 in female participants (p

Abstract Background Recently, suicides in Greece have drawn national and international interest due to the current economic crisis. According to published reports, suicides in Greece have increased up to 40% and Crete has been highlighted as an area with the sharpest increase. Aim To investigate the suicide mortality rates in Crete between 1999 and 2013 and their association with the economic crisis. Methods Data on suicides were selected from the Department of Forensic Medicine files of the University of Crete. Results Our analysis showed that (1) Crete, has the highest suicide mortality rate in Greece, however no significant increase was observed between 1999 and 2013, (2) there were opposing trends between men and women, with women showing a decrease whereas men showed an increase in that period, (3) there was a significant increase of suicides in middle-aged men (40–64 yrs) and elderly, although the highest unemployment rates were observed in young men and women, and (4) finally, there was a regional shift of suicides with a significant decrease in Western Crete and a significant increase in Eastern Crete. Conclusions Although, Crete has the highest suicide mortality rates in Greece, we did not observe an overall increase during the last 15 years, including the period of economic crisis. Furthermore, there was an increase in middle-aged and elderly men, whereas young men and women showed oppositional trends during the years of austerity. This may be related to the culturally different expectations for the two genders, as well as that younger individuals may find refuge to either strong family ties or by immigrating abroad. Finally, the relative increase of suicides in Eastern Crete may be explained by factors, such as the lack of community mental health services in that area.

Abstract Background Individuals with schizophrenia spectrum disorders use the Internet for general and health-related purposes. Their ability to find, understand, and apply the health information they acquire online in order to make appropriate health decisions – known as eHealth literacy – has never been investigated. The European agenda strives to limit health inequalities and enhance mental health literacy. Nevertheless, each European member state varies in levels of Internet use and online health information-seeking. This study aimed to examine computer/Internet use for general and health-related purposes, eHealth literacy, and attitudes toward computer/Internet among adults with schizophrenia spectrum disorders from two distant European regions. Methods Data were collected from mental health services of psychiatric clinics in Finland (FI) and Greece (GR). A total of 229 patients (FI = 128, GR = 101) participated in the questionnaire survey. The data analysis included evaluation of frequencies and group comparisons with multiple linear and logistic regression models. Results The majority of Finnish participants were current Internet users (FI = 111, 87%, vs. GR = 33, 33%, P

Depression is characterized by mental, emotional and executive dysfunction. Among its symptoms, sleep disturbance and anxiety are very common. The effects of depression and its treatment may have an impact on driving behaviour. In order to evaluate driving performance in depression, 13 patients and 18 healthy controls completed questionnaires and scales and were tested in a driving simulator. Driving simulator data included lateral position (LP), speed and distance from the preceding vehicle. History of collisions was associated with depression, body mass index (BMI) and next-day consequences of sleep disturbance. Aggressive driving was associated with fatigue and sleep disturbances. Concerning driving simulator data, a reduced ability to maintain constant vehicle velocity was positively correlated to BMI and insomnia. An LP towards the middle of the road was associated with anxiety. On the other hand, an LP towards the shoulder was associated with depression and next-day consequences of sleep disturbance, while a positive correlation was found between distance from the preceding vehicle and use of drugs with potential hypnotic effects; both these findings show that patients suffering from depression seem to realize the effects of certain symptoms on their driving ability and thus drive in a more defensive way than controls.

Background and aims: Physiologic and metabolic changes following spinal cord injury (SCI) lead to an increased risk of malnutrition. The Global Leadership Initiative on Malnutrition (GLIM) is a three-step approach to diagnose malnutrition: 1) screening; 2) phenotypic and etiological criteria; and 3) malnutrition severity. The main aim of this study was to assess malnutrition in patients with SCI, according to the GLIM criteria. Methods: Patients with SCI (≥ 18 years) admitted to rehabilitation were included. Anthropometrics, food intake, and inflammation were assessed on admission. Fat-free mass index (FFMI) was estimated from bioimpedance analysis. Malnutrition was diagnosed by the GLIM criteria, using the Malnutrition Universal Screening Tool (MUST) as the first step screening tool. Sensitivity and specificity analyses were performed. Results: In total, 66 patients were assessed (50 men) with a mean age of 51.4 (± 17.4) years and median time since injury was 37.5 (10–450) days. The mean body mass index was 24.7 (± 4.2) kg/m2, and 1-month involuntary weight loss was 5.7 (± 4.4)%. FFMI for men was 17.3 (± 1.9) and for women 15.3 (± 1.6) kg/m2. Forty-one patients (62%) were malnourished according to the GLIM criteria: 27 moderately and 14 severely malnourished. MUST was not able to detect malnutrition risk of nine patients, giving a moderate agreement (kappa 0.66), with a sensitivity of 0.78 and a specificity of 0.92 compared to the GLIM diagnosis. Conclusions: In this cross-sectional study, 62% of subacute SCI patients were malnourished according to the GLIM criteria. The screening tool MUST showed moderate agreement with the GLIM criteria and did not detect risk of all patients with a malnutrition diagnosis. The clinical implications of these findings need further investigation.

Abstract The EFSA Scientific Committee has updated its 2010 Guidance on risk–benefit assessment (RBA) of foods. The update addresses methodological developments and regulatory needs. While it retains the stepwise RBA approach, it provides additional methods for complex assessments, such as multiple chemical hazards and all relevant health effects impacting different population subgroups. The updated guidance includes approaches for systematic identification, prioritisation and selection of hazardous and beneficial food components. It also offers updates relevant to characterising adverse and beneficial effects, such as measures of effect size and dose–response modelling. The guidance expands options for characterising risks and benefits, incorporating variability, uncertainty, severity categorisation and ranking of different (beneficial or adverse) effects. The impact of different types of health effects is assessed qualitatively or quantitatively, depending on the problem formulation, scope of the RBA question and data availability. The integration of risks and benefits often involves value‐based judgements and should ideally be performed with the risk–benefit manager. Metrics such as Disability‐Adjusted Life Years (DALYs) and Quality‐Adjusted Life Years (QALYs) can be used. Additional approaches are presented, such as probability of all relevant effects and/or effects of given severities and their integration using severity weight functions. The update includes practical guidance on reporting results, interpreting outcomes and communicating the outcome of an RBA, considering consumer perspectives and responses to advice.

Abstract This guidance document provides a tiered framework for risk assessors and facilitates risk managers in making decisions concerning the approval of active substances (AS) that are chemicals in plant protection products (PPPs) and biocidal products, and authorisation of the products. Based on the approaches presented in this document, a conclusion can be drawn on the impact of water treatment processes on residues of the AS or its metabolites in surface water and/or groundwater abstracted for the production of drinking water, i.e. the formation of transformation products (TPs). This guidance enables the identification of actual public health concerns from exposure to harmful compounds generated during the processing of water for the production of drinking water, and it focuses on water treatment methods commonly used in the European Union (EU). The tiered framework determines whether residues from PPP use or residues from biocidal product use can be present in water at water abstraction locations. Approaches, including experimental methods, are described that can be used to assess whether harmful TPs may form during water treatment and, if so, how to assess the impact of exposure to these water treatment TPs (tTPs) and other residues including environmental TPs (eTPs) on human and domesticated animal health through the consumption of TPs via drinking water. The types of studies or information that would be required are described while avoiding vertebrate testing as much as possible. The framework integrates the use of weight‐of‐evidence and, when possible alternative (new approach) methods to avoid as far as possible the need for additional testing.

Abstract Copper is an essential micronutrient and also a regulated product used in organic and in conventional farming pest management. Both deficiency and excessive exposure to copper can have adverse health effects. In this Scientific Opinion, the EFSA 2021 harmonised approach for establishing health‐based guidance values (HBGVs) for substances that are regulated products and also nutrients was used to resolve the divergent existing HBGVs for copper. The tightly regulated homeostasis prevents toxicity manifestation in the short term, but the development of chronic copper toxicity is dependent on copper homeostasis and its tissue retention. Evidence from Wilson disease suggests that hepatic retention is indicative of potential future and possibly sudden onset of copper toxicity under conditions of continuous intake. Hence, emphasis was placed on copper retention as an early marker of potential adverse effects. The relationships between (a) chronic copper exposure and its retention in the body, particularly the liver, and (b) hepatic copper concentrations and evidence of toxicity were examined. The Scientific Committee (SC) concludes that no retention of copper is expected to occur with intake of 5 mg/day and established an Acceptable Daily Intake (ADI) of 0.07 mg/kg bw. A refined dietary exposure assessment was performed, assessing contribution from dietary and non‐dietary sources. Background copper levels are a significant source of copper. The contribution of copper from its use as plant protection product (PPP), food and feed additives or fertilisers is negligible. The use of copper in fertilisers or PPPs contributes to copper accumulation in soil. Infant formula and follow‐on formula are important contributors to dietary exposure of copper in infants and toddlers. Contribution from non‐oral sources is negligible. Dietary exposure to total copper does not exceed the HBGV in adolescents, adults, elderly and the very elderly. Neither hepatic copper retention nor adverse effects are expected to occur from the estimated copper exposure in children due to higher nutrient requirements related to growth.

In a 90-day GLP-compliant study groups of Sprague-Dawley rats (10/sex/group) were fed diets containing β-ionone epoxide, a fragrance material and a flavoring substance, at dietary concentrations providing target intakes of 0, 20, 40 and 80 mg/kg bw/day. There were no deaths and no adverse changes in clinical observations, ophthalmological examinations, body weight, body weight gain, food consumption, food efficiency; hematology, serum chemistry, urinalysis parameters; or in macroscopic findings attributable to β-ionone epoxide administration. Increased absolute and relative liver weights in high dose females without correlating hepatic histopathological findings were considered non-adverse. Cortical vacuolation of adrenal zona fasciculata was observed in high-dose males but was considered non-adverse due to the nondegenerative nature of this alteration. β-Ionone epoxide did not influence estrus cyclicity in females and did not affect sperm morphology or epididymal sperm count, homogenization-resistant spermatid count and motility measurements in male rats. The no-observed-adverse-effect level (NOAEL) for administration of β-ionone epoxide in the diet was determined to be the highest dose tested of 80 mg/kg bw/day.

Objective: The objective was to explore factors affecting stress levels in hospitalized patients after implementation of fast-track (FT) protocol in hepatopancreatobiliary surgery. Methods: This was a prospective cross-sectional study, where 90 patients were included. Exploration of environmental postoperative stress levels was conducted by serum adrenocorticotropic hormone and cortisol levels, the Intensive Care Unit Environmental Stressor Scale, and three self-reported Numeric Analog Scale questions, with regard to emotional/stress level, specifically “How sad do you feel right now?” “How stressed do you feel right now?” and “How optimistic do you feel right now, about the future?” at 3 time points: (T1) Before surgery, (T2) the day of surgery, and (T3) the 3rd postoperative day. The trial profile is conformed according to the CONSORT guidelines. Statistical analysis was carried out by SPSS software version 22 (IBM SPSS software, Chicago, Illinois, USA) at a significance level of 0.05. Results: Serum cortisol T2levels were positively correlated with the day of removal the drainage tube (rho = 0.235, P = 0.027). Furthermore, serum cortisol T3levels were positively correlated with age and body mass index and negatively with the day of drainage tube removal (rho = 0.231, P = 0.028, rho = 0.235, P = 0.026, and rho = −0.279, P = 0.008, respectively). Conclusions: The findings of this study highlight that after evaluation of stress levels; nurses could interfere and reduce stress levels, knowing the factors which cause the increased stress levels, after the implementation of FT protocols.