FORTH Institute of Mediterranean Studies

OBJECTIVES: To develop recommendations for the management of adult and paediatric lupus nephritis (LN). METHODS: The available evidence was systematically reviewed using the PubMed database. A modified Delphi method was used to compile questions, elicit expert opinions and reach consensus. RESULTS: Immunosuppressive treatment should be guided by renal biopsy, and aiming for complete renal response (proteinuria <0.5 g/24 h with normal or near-normal renal function). Hydroxychloroquine is recommended for all patients with LN. Because of a more favourable efficacy/toxicity ratio, as initial treatment for patients with class III-IV(A) or (A/C) (±V) LN according to the International Society of Nephrology/Renal Pathology Society 2003 classification, mycophenolic acid (MPA) or low-dose intravenous cyclophosphamide (CY) in combination with glucocorticoids is recommended. In patients with adverse clinical or histological features, CY can be prescribed at higher doses, while azathioprine is an alternative for milder cases. For pure class V LN with nephrotic-range proteinuria, MPA in combination with oral glucocorticoids is recommended as initial treatment. In patients improving after initial treatment, subsequent immunosuppression with MPA or azathioprine is recommended for at least 3 years; in such cases, initial treatment with MPA should be followed by MPA. For MPA or CY failures, switching to the other agent, or to rituximab, is the suggested course of action. In anticipation of pregnancy, patients should be switched to appropriate medications without reducing the intensity of treatment. There is no evidence to suggest that management of LN should differ in children versus adults. CONCLUSIONS: Recommendations for the management of LN were developed using an evidence-based approach followed by expert consensus.

Changing collective behaviour and supporting non-pharmaceutical interventions is an important component in mitigating virus transmission during a pandemic. In a large international collaboration (Study 1, N = 49,968 across 67 countries), we investigated self-reported factors associated with public health behaviours (e.g., spatial distancing and stricter hygiene) and endorsed public policy interventions (e.g., closing bars and restaurants) during the early stage of the COVID-19 pandemic (April-May 2020). Respondents who reported identifying more strongly with their nation consistently reported greater engagement in public health behaviours and support for public health policies. Results were similar for representative and non-representative national samples. Study 2 (N = 42 countries) conceptually replicated the central finding using aggregate indices of national identity (obtained using the World Values Survey) and a measure of actual behaviour change during the pandemic (obtained from Google mobility reports). Higher levels of national identification prior to the pandemic predicted lower mobility during the early stage of the pandemic (r = -0.40). We discuss the potential implications of links between national identity, leadership, and public health for managing COVID-19 and future pandemics.

Abstract The extent and impact of climate‐related extreme events depend on the underlying meteorological, hydrological, or climatological drivers as well as on human factors such as land use or population density. Here we quantify the pure effect of historical and future climate change on the exposure of land and population to extreme climate impact events using an unprecedentedly large ensemble of harmonized climate impact simulations from the Inter‐Sectoral Impact Model Intercomparison Project phase 2b. Our results indicate that global warming has already more than doubled both the global land area and the global population annually exposed to all six categories of extreme events considered: river floods, tropical cyclones, crop failure, wildfires, droughts, and heatwaves. Global warming of 2°C relative to preindustrial conditions is projected to lead to a more than fivefold increase in cross‐category aggregate exposure globally. Changes in exposure are unevenly distributed, with tropical and subtropical regions facing larger increases than higher latitudes. The largest increases in overall exposure are projected for the population of South Asia.

BACKGROUND: Assessing the overall burden of healthcare-associated infections (HAIs) is challenging, but imperative in evaluating the cost-effectiveness of infection control programs. This study aimed to estimate the point prevalence and annual incidence of HAIs in Greece and assess the excess length of stay (LOS) and mortality attributable to HAIs, overall and for main infection sites and tracer antimicrobial resistance (AMR) phenotypes and pathogens. PATIENTS AND METHODS: This prevalent cohort study used a nationally representative cross-section of 8,247 inpatients in 37 acute care hospitals to record active HAIs of all types at baseline and overall LOS and in-hospital mortality up to 90 days following hospital admission. HAI incidence was estimated using prevalence-to-incidence conversion methods. Excess mortality and LOS were assessed by Cox regression and multistate models correcting for confounding and time-dependent biases. RESULTS: HAIs were encountered with daily prevalence of 9.1% (95% confidence interval [CI] 7.8%-10.6%). The estimated annual HAI incidence was 5.2% (95% CI 4.4%-5.3%), corresponding to approximately 121,000 (95% CI 103,500-123,700) affected patients each year in the country. Ninety-day mortality risk was increased by 80% in patients with HAI compared to those without HAI (adjusted hazard ratio 1.8; 95% CI 1.3-2.6). Lower respiratory tract infections, bloodstream infections, and multiple concurrent HAIs doubled the risk of death, whereas surgical site and urinary tract infections were not associated with increased mortality. AMR had significant impact on the daily risk of 90-day mortality, which was increased by 90%-110% in patients infected by carbapenem-resistant gram-negative pathogens. HAIs increased LOS for an average of 4.3 (95% CI 2.4-6.2) additional days. Mean excess LOS exceeded 20 days in infections caused by major carbapenem-resistant gram-negative pathogens. CONCLUSION: HAIs, alongside with increasing AMR, pose significant burden to the hospital system. Burden estimates obtained in this study will be valuable in future evaluations of infection prevention programs.

Abstract On site observation is the most common way of monitoring cultural heritage sites and monuments in Cyprus. However, this procedure that includes data collection, periodical observations, and multivariate risk assessment analysis is difficult to accomplish with the traditional practices and methods since it is time consuming and expensive. Furthermore, many archaeological sites and monuments are located at inaccessible areas, far away from the main road network and urban areas. Satellite remote sensing and Geographical Information Systems (GIS) can successfully confront this problem by providing the scientists with integrated monitoring of the study areas and the unique advantage to store and manipulate a large amount of spatial and attribute data simultaneously. Actually the monitoring and identification of several natural and anthropogenic hazards in the vicinity of the cultural heritage sites in Cyprus, seems to be one of the main priorities of its governmental and municipal authorities. This study aims to integrate both satellite remote sensing techniques and GIS in a multidisciplinary approach, for monitoring anthropogenic and natural hazards with the use of archived and up-to-date multitemporal remotely sensed images in the study area, namely in areas nearby cultural heritage sites and monuments in Cyprus. In this study anthropogenic hazards include urbanisation and extended land use changes in the surroundings of archaeological sites and natural hazards concern seismicity and sea erosion.

Abstract Within the framework of disaster risk management, this article proposes an interdisciplinary method for the analysis of multiple natural hazards, including climate change’s influences, in the context of cultural heritage. A taxonomy of natural hazards applicable to cultural heritage was developed based on the existing theoretical and conceptual frameworks. Sudden-onset hazards, such as earthquakes and floods, and slow-onset hazards, such as wetting–drying cycles and biological contamination, were incorporated into the hazard assessment procedure. Future alteration of conditions due to climate change, such as change in heat waves’ duration, was also taken into account. The proposed hazard assessment framework was applied to the case of the Historic Centre of Rethymno, a city on the northern coast of the island of Crete in Greece, to identify, analyze, and prioritize the hazards that have the potential to cause damage to the center’s historic structures. The assessment procedure includes climate model projections, GIS spatial modeling and mapping, and finally a hazard analysis matrix to enable the sharing of a better understanding of multiple hazards with the stakeholders. The results can facilitate decision making by providing the vulnerability and risk analysis with the nature and spatial distribution of the significant hazards within the study area and its setting.

BACKGROUND: The predictive role of many cytokines has not been well defined in Acute Respiratory Distress Syndrome (ARDS). METHODS: We measured prospectively IL-4, IL-6, IL-6 receptor, IL-8, and IL-10, in the serum and bronchoalveolar lavage fluid (BALF) in 59 patients who were admitted to ICU in order to identify predictive factors for the course and outcome of ARDS. The patients were divided into three groups: those fulfilling the criteria for ARDS (n = 20, group A), those at risk for ARDS and developed ARDS within 48 hours (n = 12, group B), and those at risk for ARDS but never developed ARDS (n = 27, group C). RESULTS: An excellent negative predictive value for ARDS development was found for IL-6 in BALF and serum (100% and 95%, respectively). IL-8 in BALF and IL-8 and IL-10 serum levels were higher in non-survivors in all studied groups, and were associated with a high negative predictive value. A significant correlation was found between IL-8 and APACHE score (r = 0.60, p < 0.0001). Similarly, IL-6 and IL-6r were highly correlated with PaO2/FiO2 (r = -0.27, p < 0.05 and r = -0.55, p < 0.0001, respectively). CONCLUSIONS: BALF and serum levels of the studied cytokines on admission may provide valuable information for ARDS development in patients at risk, and outcome in patients either in ARDS or in at risk for ARDS.

The use of questionnaires for soundscape evaluation is a key aspect of soundscape research. Since standards and protocols mainly exist in English, using an appropriate translation and cross-cultural adaptation (CCA) methodology is necessary to maintain content equivalence between source and target language. However, many examples can be found in the literature where no appropriate methodology was applied. This study addresses the neglected aspect of the translation and CCA process in soundscape research by selecting, applying and evaluating an appropriate methodology. After a survey of the relevant literature, an approach based on a combined technique of the forward translation, synthesis, back translation, pre-test and a committee approach was selected. Additional translation guidelines drawn from the literature are suggested and implemented. For the case study of the Greek translation of ISO/TS 12913–2:2018 attributes (Method A), the steps of the methodology were applied by four independent translation groups with different compositions according to the biculturalism and bilingualism of the group members. A method for categorization of bilinguals according to the literature is proposed. In order to compare and validate the results, translated and original attributes were used in listening tests with Greek and English participants respectively, and principal component analysis (PCA) was applied. The most important findings of this research are: the results of the bicultural translation group were closer to the PCA results of the English participants for every attribute, translation of bilingual groups may not be always sufficient, translation errors may be misinterpreted for cross-cultural differences without proper application of a translation methodology and the process of back translation can be effective, especially in cases where there are not corresponding words in the target language. Finally, PCA can be used as a validation methodology for comparison of different translations.

Staging of tumors is very important in treatment and surgical decision making, as well as in predicting disease recurrence and prognosis. This review focuses on the different available classifications of juvenile nasopharyngeal angiofibroma (JNA) and their impact on the evaluation, management, and prognosis of JNA. The literature was reviewed, and publications on JNA staging were examined. Our MEDLINE search of the entire English-language literature found no review article on the current available staging systems for JNA. In this article, we review the common JNA classification systems that have been published, and we discuss some of their advantages and disadvantages. The most commonly used staging systems for JNA are the Radkowski and the Andrews-Fisch staging systems. However, some newer staging systems that are based on advances in technology and surgical approaches-the Onerci, INCan, and UPMC systems-have shown promising utility, and they will probably gain popularity in the future.

Contrast-induced acute kidney injury (CIAKI) is a severe complication associated with the use of iodinated contrast media (CM); a sudden but potentially reversible fall in glomerular filtration rate (GFR) typically occurring 48-72 hours after CM administration. Principal risk factors related with the presentation of CIAKI are preexisting chronic kidney disease and diabetes mellitus. Studies on CIAKI present considerable complexity because of differences in CM type and dose, controversies in definition and baseline comorbidities. Despite that, it should be noted that CIAKI poses a serious health problem because it is a very common cause of hospitalacquired AKI, linked to increased morbidity and mortality and utilizing growing healthcare resources. The pathogenesis of CIAKI is heterogeneous and, thus, is incompletely understood. Three basic mechanisms appear to simultaneously occur for CIAKI development: Renal vasoconstriction and medullary hypoxia, tubular cell toxicity and reactive oxygen species formation. The relative contribution of each one of these mechanisms is unknown but they ultimately lead to epithelial and endothelial cell apoptosis and GFR reduction. Further research is needed in order to better clarify CIAKI pathophysiology and accordingly introduce effective preventive and therapeutic strategies.

The COVID-19 pandemic has affected all domains of human life, including the economic and social fabric of societies. One of the central strategies for managing public health throughout the pandemic has been through persuasive messaging and collective behaviour change. To help scholars better understand the social and moral psychology behind public health behaviour, we present a dataset comprising of 51,404 individuals from 69 countries. This dataset was collected for the International Collaboration on Social & Moral Psychology of COVID-19 project (ICSMP COVID-19). This social science survey invited participants around the world to complete a series of moral and psychological measures and public health attitudes about COVID-19 during an early phase of the COVID-19 pandemic (between April and June 2020). The survey included seven broad categories of questions: COVID-19 beliefs and compliance behaviours; identity and social attitudes; ideology; health and well-being; moral beliefs and motivation; personality traits; and demographic variables. We report both raw and cleaned data, along with all survey materials, data visualisations, and psychometric evaluations of key variables.

Peer Reviewed

Abstract The European Space Agency (ESA), through the Climate Change Initiative (CCI), is currently providing nearly 4 decades of global satellite‐observed, fully homogenized soil moisture data for the uppermost 2–5 cm of the soil layer. These data are valuable as they comprise one of the most complete remotely sensed soil moisture data sets available in time and space. One main limitation of the ESA CCI soil moisture data set is the limited soil depth at which the moisture content is represented. In order to address this critical gap, we (a) estimate and calibrate the Soil Water Index using ESA CCI soil moisture against in situ observations from the International Soil Moisture Network and then (b) leverage machine learning techniques and physical soil, climate, and vegetation descriptors at a global scale to regionalize the calibration. We use this calibration to assess the root‐zone soil moisture for the period 2001–2018. The results are compared against the European Centre for Medium‐Range Weather Forecasts, ERA5 Land, and the Famine Early Warning Systems Network Land Data Assimilation System reanalyses soil moisture data sets, showing a good agreement, mainly over mid latitudes. This work contributes to the exploitation of ESA CCI soil moisture data, while the produced data can support large‐scale soil moisture‐related studies.

PERSEUS project aims to identify the most relevant pressures exerted on the ecosystems of the Southern European Seas (SES), highlighting knowledge and data gaps that endanger the achievement of SES Good Environmental Status (GES) as mandated by the Marine Strategy Framework Directive (MSFD). A complementary approach has been adopted, by a meta-analysis of existing literature on pressure/impact/knowledge gaps summarized in tables related to the MSFD descriptors, discriminating open waters from coastal areas. A comparative assessment of the Initial Assessments (IAs) for five SES countries has been also independently performed. The comparison between meta-analysis results and IAs shows similarities for coastal areas only. Major knowledge gaps have been detected for the biodiversity, marine food web, marine litter and underwater noise descriptors. The meta-analysis also allowed the identification of additional research themes targeting research topics that are requested to the achievement of GES.

This work explores the applicability and effectiveness of electrical resistivity tomography in mapping archaeological relics in the shallow marine environment. The approach consists of a methodology based on numerical simulation models validated with comparison to field data. Numerical modelling includes the testing of different electrode arrays suitable for multi‐channel resistivity instruments (dipole–dipole, pole–dipole, and gradient). The electrodes are placed at fixed positions either floating on the sea surface or submerged at the bottom of the sea. Additional tests are made concerning the resolving capabilities of electrical resistivity tomography with various seawater depths and target characteristics (dimensions and burial depth of the targets). Although valid a priori information, in terms of water resistivity and thickness, can be useful for constraining the inversion, it should be used judiciously to prevent erroneous information leading to misleading results. Finally, an application of the method at a field site is presented not only for verifying the theoretical results but also at the same time for proposing techniques to overcome problems that can occur due to the special environment. Numerical and field electrical resistivity tomography results indicated the utility of the method in reconstructing off‐shore cultural features, demonstrating at the same time its applicability to be integrated in wider archaeological projects.

Abstract A versatile analytical methodology is presented, that combines the application of two mobile laser-based analytical techniques, Raman microscopy and laser-induced breakdown spectroscopy (LIBS), for the analysis of materials in historical and archaeological objects and monuments. In the present study, the proposed methodology was employed in the context of analytical campaigns aiming to investigate paint materials used on the island of Crete during the Venetian and Ottoman periods, thirteenth to nineteenth century CE. The first series of campaigns were conducted at the Historical Museum of Crete, Heraklion, Greece, and provided for the first time compositional data concerning the pigment palette used for painting Ottoman sculpture in Crete. In the second series, campaigns were performed outdoors for studying pigments in the sculptured door frames of two small medieval churches situated at rural locations in the greater Heraklion area. Raman and LIBS analyses gather complementary compositional data, molecular and elemental respectively, which, taken jointly, enable, in most cases, identification of pigments and accessory materials in paint layers, providing also stratigraphic information. With both instruments, measurements are performed directly on the surface of the objects or monuments, with no need for any sampling or sample preparation and thus analytical studies can be conducted rapidly and routinely in the context of a museum setting, a conservation laboratory or even outdoors. A standardized procedure that facilitates data collection and interpretation, interdisciplinary cooperation and presentation of results is adopted that optimizes the overall efficiency of the analytical campaigns.

An omnidirectional source is required in many acoustic measurements. Commonly a dodecahedron speaker is used but due to various factors (e.g., high cost, transportation difficulties) other acoustic sources are sometimes preferred. In this review, fifteen acoustic source alternatives to a dodecahedron speaker are presented while emphasis is placed on features such as omnidirectionality, repeatability, adequate sound pressure levels, even frequency response, accuracy in measurement of acoustic parameters and fulfillment of ISO 3382-1 source requirements. Some of the alternative acoustic sources have the appropriate features to provide usable results for acoustic measurements, some have acoustic characteristics better than a dodecahedron speaker (e.g., omnidirectionality in the high-frequency range), while some can potentially fulfill the ISO 3382-1 source requirements. Collected data from this review can be used in many areas (e.g., ISO measurements, head-related transfer functions measurements) for the appropriate selection of an acoustic source according to the expected use. Finally, suggestions for uses and future work are given aimed at achieving further advances in this field.

Familial microscopic hematuria (FMH) is associated with a genetically heterogeneous group of conditions including the collagen-IV nephropathies, the heritable C3/CFHR5 nephropathy and the glomerulopathy with fibronectin deposits. The clinical course varies widely, ranging from isolated benign familial hematuria to end-stage renal disease (ESRD) later in life. We investigated 24 families using next generation sequencing (NGS) for 5 genes: COL4A3, COL4A4, COL4A5, CFHR5 and FN1. In 17 families (71%), we found 15 pathogenic mutations in COL4A3/A4/A5, 9 of them novel. In 5 families patients inherited classical AS with hemizygous X-linked COL4A5 mutations. Even more patients developed later-onset Alport-related nephropathy having inherited heterozygous COL4A3/A4 mutations that cause thin basement membranes. Amongst 62 heterozygous or hemizygous patients, 8 (13%) reached ESRD, while 25% of patients with heterozygous COL4A3/A4 mutations, aged >50-years, reached ESRD. In conclusion, COL4A mutations comprise a frequent cause of FMH. Heterozygous COL4A3/A4 mutations predispose to renal function impairment, supporting that thin basement membrane nephropathy is not always benign. The molecular diagnosis is essential for differentiating the X-linked from the autosomal recessive and dominant inheritance. Finally, NGS technology is established as the gold standard for the diagnosis of FMH and associated collagen-IV glomerulopathies, frequently averting the need for invasive renal biopsies.

Abstract The recent achievement of fusion ignition with laser-driven technologies at the National Ignition Facility sets a historic accomplishment in fusion energy research. This accomplishment paves the way for using laser inertial fusion as a viable approach for future energy production. Europe has a unique opportunity to empower research in this field internationally, and the scientific community is eager to engage in this journey. We propose establishing a European programme on inertial-fusion energy with the mission to demonstrate laser-driven ignition in the direct-drive scheme and to develop pathway technologies for the commercial fusion reactor. The proposed roadmap is based on four complementary axes: (i) the physics of laser–plasma interaction and burning plasmas; (ii) high-energy high repetition rate laser technology; (iii) fusion reactor technology and materials; and (iv) reinforcement of the laser fusion community by international education and training programmes. We foresee collaboration with universities, research centres and industry and establishing joint activities with the private sector involved in laser fusion. This project aims to stimulate a broad range of high-profile industrial developments in laser, plasma and radiation technologies along with the expected high-level socio-economic impact.

AIM: To present the current treatment approach for oroantral fistula causing maxillary sinusitis. DESIGN: Case series. Four cases of oroantral fistula (diameters: 6, 9, 11 and 13 mm) due to chronic maxillary sinusitis were treated by excision of all diseased oroantral fistula tissue, followed by endoscopic creation of a large middle antrostomy and closure of the fistula using buccal flaps. A synthetic surgical glue and local alveolar bone were used. RESULTS: Patients were followed up for six months to three years; all were considered cured. CONCLUSION: Most surgeons use buccal or palatal flaps, combined with the Caldwell-Luc procedure, to treat chronic odontogenic sinusitis and to repair fistulae more than 5 mm in diameter. This study supports the hypothesis that an endoscopic technique could be successfully used in patients with oroantral fistula causing chronic maxillary sinusitis of dental origin, instead of the Caldwell-Luc procedure, at least in patients with a small to medium-sized oroantral fistula.