Quarterly scientific journal

Rostrum of Asclepius Vol 22, 2 (2023): April- June 2023

Vima AsklipiouRostrum of Asclepius Vol 22, 2 (2023): April- June 2023


A tribute to Moses Elisaf | 285-286

Anastasia Kotanidou


COVID-19: Health inequalities, impacts and social protection support measures | 287-306

Asimina Gatou , Ioannis Apostolakis , Pavlos Sarafis


Introduction: The pandemic of COVID-19 has generated an intense interest for research in social inequalities in health. Their existence, apart from the negative consequences that create for the function of the welfare state, causes variations in the health care provided. Impacts are therefore being made in the areas of social protection, although efforts are being made to implement relief measures by the government.

Purpose: This literature review deals with the existence and deterioration of health inequalities in combination with their impact on social protection and the newly established recovery measures in the midst of the COVID-19 pandemic.

Material-Method: From the analysis of the individual topics, a review was carried out from electronic databases of Pubmed, Elsevier, Lancet, as well as from books, websites and electronic journals through the free access provided by the internal network of the university. The keywords used in the search in Greek and English database were: health inequalities, factors affecting inequalities, deterioration of health inequalities, effects on social protection, social protection measures.

Results: Health inequalities have a dual character that affects both the level of health and health care. There are a variety of factors from biological, social to health system factors that seem to affect them. In addition, there is a deterioration of existing health inequalities as well as negative effects in various areas of social protection. However, several supportive measures have been put in place in the areas of unemployment protection, sickness protection, income protection, housing and welfare.

Conclusions: There was a deterioration of health inequalities and dysfunction of social protection. Nevertheless, the completion of the legislative framework of support in the fields of social protection was considered necessary.

Keywords: health inequalities, factors affecting inequalities, deterioration of health inequalities, effects on social protection, social protection measures

Changing dietary behavior by introducing alternative proteins into the diet of health professionals | 307-317

Iliana Tsampoula , Martha Kelesi-Stavropoulou , Evridiki Kampa , Ioanna Papathanasiou , Panagiotis Krithimos


Introduction: Alternative proteins are essential for human nutrition, they consist of macronutrients that help build muscle groups, strengthen the immune system and many essential functions for life. Adopting any useful habit requires a change of mindset and consequently a change of behavior.  When the person is trained to recognize and manage a pathogenic condition that is a brake on their health then they can see a substantial change in the way they think. When the person is trained to recognize and manage a pathogenic condition that is a brake on their health then they can see a substantial change in the way they think.

Aim: Investigating the modification of eating behavior by introducing alternative proteins in the diet of health professionals.

Methodology: A review of peer-reviewed articles and studies published in English and Greek over the last decade in the PubMed, Cohrane Libray and Google Scholar databases from January 1, 2022 to April 1, 2022.

Results: Alternative proteins are rich in nutrients and their production and consumption is encouraged. However, it has been shown that the consumption and nutritional behavior of individuals concerning alternative proteins is determined by biological, psychological and socio-political factors.

Conclusions: It is important that there is sufficient information of the population about the nutritional value of alternative proteins, which could be undertaken by health professionals since they are responsible for informing and following the medical instructions given to patients. Any form of behavior that is consolidated can be modified through a new learning process that will be personalized and will aim at the best possible health of the person concerned.

Keywords: Alternative proteins, nutrional value, nutrional behavior, plant based proteins, entomophagy.

Keywords: Alternative proteins, Nutritional value, nutriotional behavior, plant based proteins, Entomophagy

Special Article

The impact of safety culture and safety climate on achieving patient safety in healthcare organizations | 388-398

Georgia Kyriakeli , Vassilios Kotsis



Patient safety is a strategic pursuit for Healthcare Organizations whose mission is to provide high-quality services. The Institute of Medicine's report "To Err is Human: Building a Safer Health System" in 2000 highlighted the clinical "errors" that can occur in the delivery of care as a critical factor in reducing the level of patient safety and quality of healthcare services. Since then, many international Health Organizations have adopted policies/actions to build a safe working environment and related hospital conditions. Critical is the emerging patient safety culture, defined by healthcare professionals' shared values, beliefs, behaviors, and sense of safety. Organizations with a positive safety culture are distinguished for adopting safe/good clinical practices that ensure and promote service quality. A patient safety culture assessment is a strong recommendation for Healthcare Organization Management and is achieved using specific, multi-level measurement tools/questionnaires. Additionally, the impact of the safety climate is crucial, reflecting the procedures, priorities, and how the organization operates, which is a key criterion for assessing its safety level. Understanding and effective administrative management of the mechanism and influencing factors in shaping the patient safety culture and climate can create robust, quality, and efficient health systems, with accompanying economic benefits.

Keywords: Patient safety, safety culture, safety climate, healthcare organizations

The Primary Health Care and its potential in Public Health | 333-347

Fany Pegiou


Primary Health Care, involves a dynamic and interdependent relationship with health care users, as it is their first contact with the health care system. According to the objectives of the World Health Organization and the principles of the Alma-Ata Declaration (1978), Primary Health Care is the starting point in achieving global health and social well-being. However, there is considerable unevenness in its structure, role as well as function internationally, confirming and highlighting the existence of different health systems. Although in Greece, it has not yet taken the place it truly deserves, however, both the socio-economic impact of the global financial crisis of 2009 and the persistent COVID-19 pandemic, highlight the central importance and role of Primary Health Care towards achieving quality and equity in public health. A review of the literature and a search of articles of the last decade on this topic in international databases, PubMed, Google Scholar and Elsevier in Greek and English was conducted. From the literature review, the necessity of shifting, transforming and investing in Primary Health Care was highlighted, as research has proven in practice to be not only the most effective, but also the most economically viable approach to socialpolicy making at national and global level.

Keywords: Primary Health Care, National Health System in Greece, long-term care, social policy, Public health

Medicine and Humanities: removing barriers and the road to the "third culture" | 348-374

Eleni Mavroeidi



This article attempts to provide a brief overview of the Medical Humanities and Health Humanities fields. Using the concept of “interdisciplinarity” as a guiding principle, scientists emphasized the importance of fostering a climate of dialogue and collaboration between applied sciences and the humanities. The facts are presented in the form of a historical retrospective, with the names of the exponents and periodicals that served as "milestones" in the field of Medical Humanities mentioned. The plethora of discussions surrounding the Medical Humanities, of course, further evolves the field's dynamics, prompting many scholars to discuss its evolution into the Health Humanities. This field integrates the humanities and social sciences into medical reality so that health professionals can learn a new way of knowing and practicing in the difficult “arena” of healthcare delivery. In this context, medical schools in American and European universities follow an equivalent interdisciplinary affiliation, introducing courses from the environment of Medical Humanities as well as Health Humanities. In Greece, the humanitarian directions in medical school academic curricula are framed by courses in history of medicine, philosophy of medicine, and medical ethics, which promote a climate of dialogue and interdisciplinary cooperation.

Keywords: Medical Humanities, Health Humanities, Interdisciplinarity, Medicine, Literature

The Electronic Health Record in the General Health System of Cyprus | 375-387

Periklis Rompolas , Panicos Masouras , Sotiris Avgousti


The Electronic Health Record (EHR) is, as a technological tool, the most representative expression of eHealth services which is a strategic priority in health systems internationally. In recent years, the European Union has systematically focused on the implementation of e-Health services in its Member States, with the development of a cross-border health services framework. In this context, special emphasis is given to the maintenance and circulation of registers and electronic prescribing. From 2019, Cyprus applies universally the IHY in its General Health System (GESY) with its main users being doctors, but also with the possibility of use by other health professionals. In relation to the EHR in Cyprus there is not much research data available, as reflected in a small number of related studies. Especially after 2019, a milestone year in relation to the institution of EHR in GESY, the views and attitudes of health professionals as users have not been reflected. Knowledge and interpretation of the views and attitudes of health professionals, regarding the use and acceptance of a technology, are necessary conditions for evaluating the degree of fulfillment of its strategic goals. This event is of particular value with a view to the viability of the EHR as a technological innovation, in the light of health policy designers.

Keywords: Electronic Health Record, General Health System, Cyprus

Health promotion in patients with chronic diseases | 318-332

Pinelopi Petropoulou


Chronic diseases are on a steady upward trend, they have replaced epidemics, infections, the lack of sanitary conditions as causes and affect the patient's quality of life as defined by the World Health Organization. In recent years, the use of new technologies makes it faster and more immediate to inform health professionals about the patient's health status, thus contributing to the reduction of diagnosis and hospitalization time, but also to the easy and immediate recall of medical data at any time and from any point, reducing travel and the risk of infection in times of pandemics and other epidemics. It aims to prevent, maintain and promote health and prevent the worsening of disease as well as treatment in individuals, the family and the community. The new Telemedicine model significantly improves access to the care provided and its quality by ensuring potential continuous remote monitoring while making the patient a participant in the decision-making regarding their health. The term Telemedicine is considered to highlight broader goals that cover the production of good health and the support of Public Health, including informing and educating the public, collecting and managing statistical and epidemiological data, connecting with other agencies and health care services that involved in patient management. Thus, the nursing units will not be isolated incident response centers. On the contrary, the applications of telemedicine contribute decisively to the formation of open centers for the provision of medical care, where hospitals, health centers and practices can be connected to each other, creating an integrated network for the provision of medical services. Particular emphasis must be placed on the utilization of existing structures and the creation of new Primary Health Care infrastructures, development of regional telemedicine centers and home care for groups of patients with chronic diseases who cannot move or have access to health services due to other difficulties.

Keywords: Chronic diseases, e-health applications, quality of life, telemedicine, public health

Original Paper

Postoperative risk assessment of MI and nursing workload in ICU patients | 447-462

Panagiota Manthou , Georgios Lioliousis , Anna Korobeli , Panagiotis Vasileiou , Georgios Fildisis


Background: The high cost of care and the increased mortality of patients undergoing non-cardiac surgery with myocardial ischemia (MI) dictate the monitoring of the nursing workload (NWL) and its correlation with outcomes such as mortality in intensive care unit (ICU).

Aim: The application of the Nursing Activities Score in patients who underwent non-cardiac surgery and developed myocardial ischemia in the ICU.

Material and Method: The study was conducted in a general ICU, in a sample of 105 adult patients. Data collection was performed by the use of three instruments:(a) The Nursing Activities Score (NAS), (b) the revised cardiac risk index (Lee Index), and c) the CHA2DS2-VASc score. The correlation of MI and mortality with NWL, and other preoperative variables was studied. The significance levels are bilateral and the statistical significance was set at 0.05. The statistical program SPSS 22.0 was used for the analysis.

Results: MI rates were significantly higher in patients with comorbidities (p <0.015). Higher CHA2VASC2 score was associated with a significantly higher probability of MI. In the 1st 24 hours the NWL was similar in all cases (p = 0.947). At the 2nd and 3rd 24 hours the NWL was significantly higher in patients with MI (p <0.001). The NWL was significantly higher in patients with MI who died in all 24 hours.

Conclusions: The increased severity of the clinical condition of postoperative patients with MI, but also the lack of studies to investigate NWL in these patients indicate the need for further research.


Prognostic scoring systems value (APACHE II,SAPS II) in terms of outcome for hospitalized in an ICU patients | 463-481

Konstantoula Koutsaggeli , Chrysi Prouzou , Antonia Kalogianni , Georgia Toylia , Ioannis Kalemikerakis



BackgroundSeverity indicators are useful tools for the intensive care unit staff, as they can predict the outcome of patients. However, it is important to check their prognostic value.

Aim: Τo compare the prognostic capacity of the SAPS II and APACHE II score, both in terms of outcome and length of stay in an ICU.

Method: This is a prospective observational study, using a sample of 68 patients who were hospitalized in an ICU of a hospital in Athens. APACHE II and SAPS II were calculated considering the worst values of the first 24 hours of hospitalization. The area under the curve (AUC) was used to test the discrimination in predicting survival, while the Hosmer-Lemeshow test was used to calibrate the indicators. Multiple linear regression was performed to recognize the prognostic factors of the length of stay and multiple logistic regression to highlight the prognostic factors of the patient΄s outcome.

Results: 64.7% of patients (n=68) were male. The mean (± SA) age was 58.88 (± 18.11) years. 44.1% (n=30) were admitted by surgery. 82.4% of patients needed mechanical support. 23.5% of patients died and the length of hospital stay was 25.00 (15.00 - 38.50) days. The mean score on the APACHE II scale was 16.35 (± 7.96), and SAPS II score was 35.01 (± 27.11). The mean predicted mortality based on the APACHE II scale was 29.27% (± 19.44%) and on the SAPS II scale 35.01% (± 27.11). Predictors of outcome were the scores and the duration of mechanical ventilation. The length of stay had a positively statistically significant correlation with both scores. Prognostic factors of the duration of hospitalization were the two scores and the duration of mechanical ventilation.

Conclusions: Both scores have good discrimination and calibration to predict the outcome. They are also predictive factors of the length of stay of patients in the ICU.

Keywords: intensive care units, outcome, length of stay, APACHE II, SAPS II

Bloodstream infection in patients with Diabetes Mellitus | 413-431

Panagiota Kamitsa , Stavroula Baka



Introduction: People with diabetes have an increased susceptibility to infections and an increased risk of developing bloodstream infections (BSI). Diabetic patients are more prone to sepsis and have more complications than non-diabetics.

Aim: The aim of the present study was to investigate the role of the Quick Sequential Organ Failure Assessment Score (qSOFA) as a method for detecting precursors of poor prognosis in patients with/without diabetes mellitus.

Material-Methods: This is a prospective observational study. The sample of the study consisted of adult patients who were hospitalized in Pathological departments and had BSI. The qSOFA score was calculated daily based on the parameters and only its maximum value was recorded each day.

Results: The study included 243 patients aged 72.1±15.5 years. In all, 25.1% of patients had diabetes and 59% had complications of diabetes. The positive day of the patients was 5.2±9.4 days. The majority of patients (67.1%) had an infection from the community. Totally,72% of the microorganisms isolated were Gram negative and 28% Gram positive. The duration of hospitalization of patients was 18.1±14.5 days, while the duration of hospitalization of patients with DM was 18.5±15.6 days. Patients with nosocomial infection compared with those with community-based infection had significantly longer positivity days (13±13.1vs. 1.3±1.6,p<0.05), with a significantly higher rate of resistant strain (48, 8% vs. 28.8%,p<0.05) and had significantly longer hospital stay (27.9±18.3vs. 13.3±8.9,p<0.05), QS6 score (0.6±0.7vs. 0.4±0.6, p<0.05), QS7 (0.6±0.7vs. 0.3±0.6, p<0.05), QS8 (0.6±0.7vs. 0.3±0.6,p<0.05) and QS29 (0.8±0.8vs. 0, p<0.05). Patients who had qSOFA≤1 compared with those who had qSOFA≥2 were significantly younger (70.8±16.2vs. 76.8±11.5,p<0.05), died significantly lower (16,9%vs. 72.2%,p<0.05) and had significantly longer hospital stay (18.8±15.1vs. 15.7. 12.1,p <0.05). Diabetes mellitus was negatively associated with the scores qSOFA25(r=-0.424), qSOFA29(r=-0.575), qSOFA30(r=-0.575), qSOFA31(r=-0.564) and qSOFA33(r=-0.674).

Conclusions: Bloodstream infections remain a significant complication in people with diabetes and the awareness of health professionals has the potential to reduce morbidity through early identification, management and prevention of infections.

Keywords: diabetes, becteremia, resistance, qSOFA score, outcome

Organizational culture: exploring existing and desired organizational culture in health services | 432-

Agoritsa Koulouri



Introduction: The set of values, beliefs and expectations that are widespread and accepted within an organization compose its organizational culture. The common culture acts as a cohesive link between the members of the health team, increasing both the sense of trust of the participants and the cohesion of the team.

Aim: The main purpose of this study was to investigate the organizational culture of health professionals and the assessment of the identification or differentiation of the existing organizational culture from what members of the team deem as a desired one.

Methodology: A cross-sectional study was conducted involving 155 health professionals working in public and private health care. The research tool used was the Organizational Culture Assessment Instrument - OCAI questionnaire, which quantitatively measures the quality parameters of the culture. It has 24 questions through which the six key dimensions of organizational culture for the present and the future are approached. The answers correspond to four different types of organizational culture with different orientations, assumptions, practices and values. The statistical analysis of the data was done with SPSS v24.

Results: The predominant culture of the organizations of the participants was the Hierarchical Culture (27%) in which the organization focuses on coordination, stability and predictability. The next existing culture was the Market one, where the main characteristics were those of goal-orientation, competitive spirit and a demanding leadership. The culture of Generation (28%) in which the organization is interested in its employees and their personal development has emerged as a desirable culture. Second to that was the Open System culture, which promotes innovation and emphasizes the external environment, change and competitiveness. There was no identification of the existing culture with the desired one.

Conclusion: The investigation and measurement of organizational culture in health services can contribute to the qualitative upgrade of offered health care through the adoption of common standards, perceptions and behaviors.

Keywords: Organizational culture, existing / desired culture, health organizations, health services.

Missed nursing care related to in-patient oral care: a focus group study | 399-412

Georgios Efstathiou , Evridiki Papastavrou , Melanie Charalambous , Persefoni Lambrou-Christodoulou , Iraklis Irakleous , Anastasios Merkouris



Introduction: Oral health is considered essential for individuals’ well-being. Poor oral health has a negative impact on overall human health while contributing and predisposing to other diseases. It has been documented that nurses delay or omit oral care of hospitalized patients resulting in increased risk and vulnerability to adverse events.

Aim: To gain an in-depth understanding on how nurses perceive oral care and their views on how the phenomenon of missed oral care can be prevented.

Methods: Four focus groups were organized (n=30) to explore the issue under study. Nurses working in medical and surgical departments in 3 acute care hospitals participated in June 2019. The discussions were coordinated by an independent moderator, using a semi structured interview guide. Data were analyzed through a thematic analysis.

Findings: The findings confirm that oral care of hospitalized patients is often omitted and is not acknowledged as an important patient need. The barriers and facilitators that affect oral care positively or negatively were divided into themes that include patient characteristics, nurses’ knowledge, and skills, and as well as the nurse work environment.

Conclusions: Since barriers and facilitators exist, it recommended that nurses could focus on those aspects that will improve oral health care since it contributes to the enhancement of patient satisfaction and wellbeing.

Keywords: missed nursing care, perceptions, nursing practice, nursing knowledge, oral care, hospitalized patients

Systematic Review

Effectiveness of mobile apps on glycemic control in adults with type 2 diabetes: a systematic review of randomized controlled trials | 503-521

Elissavet Lykoudi , Eleni Dokoutsidou , Eugenia Vlachou , Nikoletta Margari


Abstract Introduction: The rising global prevalence of diabetes mellitus has necessitated the implementation of prompt interventions to manage diabetes. The advent of several technological developments and especially mobile technology has been assumed to present great potential to deliver prompt and cost-effective interventions for patients with diabetes. Aim: The present study aims to investigate the efficacy of interventions based on mobile apps in terms of glycemic control attainment among adults with type 2 Diabetes Mellitus (T2DM). Methodology: A research was constructed on online database PubMed and Scopus. Inclusion criteria were included randomized controlled trials (RCTs), investigating mobile app-based interventions among adult patients with T2 DM, whilst the main outcome investigated was the assessment of the changes in glycosylated Hemoglobin A1c (HbA1c) levels. Results: By applying the eligibility criteria 181 RCTs with full text. Across them 12 trials met the inclusion criteria for the present study and involved 2.533 patients with T2 DM, where the interventions were based on mobile applications. These app-based interventions were found to be efficient in obtaining glycemic control in terms of lowering HbA1c and improving several other secondary outcomes including self-management, quality of life and disease awareness. Conclusions: The usage of mobile health (mHealth) applications seems to be efficient in glycemic control of patients with diabetes as shown by the reduction of HbA1c levels. Future studies are needed, in order to evaluate the impact of such applications on diabetes care in the long term and their potential to support more diverse populations worldwide.

Keywords: type 2 Diabetes, Mellitus, mobile apps, self-management, glycosylated Hemoglobin A1c, self-monitoring of blood glucose

The use of the high flow nasal cannula in infants and children with bronchiolitis | 482-502

Georgios Gkourlias , Charalampia Nteli , Maria Zoi Oikonomakou , Michail Anthrakopoulos , Xenophon Sinopidis , Christina Marvaki


ABSTRACT Introduction: Bronchiolitis is one of the most common viral infections, and occurs most often in young children and infants under 2 years of age. The high flow nasal cannula system is a non-invasive system of oxygen therapy and is the basic therapeutic approach applied to newborns and infants with severe bronchiolitis. Purpose. The purpose of this Systematic Review was to investigate the use of high flow nasal cannula in neonates and infants with bronchitis. Material - Methods: For the systematic review, complete research studies were searched in the Google Scholar and PubMed electronic databases during the period January 2010 - September 2020. The keywords used were: Bronchiolitis, HFNC, High Flow Nasal Cannula, ventilation modes, infants and neonates, as well as combination of them. Results: After a critical analysis of the literature from the 150 published articles, 16 met the inclusion criteria of the study. The 13 articles compare the high flow nasal cannula system with other forms of oxygen therapy where it has been shown that the use of the former is more efficient compared to other ventilation methods. Three were evaluated clinical and laboratory features that can predict the course of the patient's disease using a high flow nasal cannula. Conclusions: A review of the current literature shows that the use of high flow nasal cannula is a safe method of oxygen therapy with potential benefit compared to older interventional and non-invasive methods.

Keywords: HFNC, high flow nasal cannula, bronchiolitis, infants,  treatment

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