Letter from Greece

Two years after our previous communication with a Letter from Greece, the world is entirely different. A novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged and coronavirus disease 2019 (COVID-19) is the major respiratory condition discussed for over 1 year now, not only in respiratory fora, but also in all the news channels of the planet. Back in 2019, our country was struggling to exit 10-year-long financial crisis and now we are in the middle of the deepest healthcare crisis of our generation. How is Greece doing lately respiratory-wise and how do we see the upcoming future? Greece has done relatively well so far in the pandemic, despite long-standing deficiencies in the national healthcare system. On 5 March 2021, Greece, with an estimated population of 10.7 million, has performed more than 5.5 million SARS-CoV-2 tests and we had 201,677 confirmed cases or 1.9% of the population (ranking 72nd worldwide, https://en. wikipedia.org/wiki/Template:COVID-19_pandemic_data), while we experienced 6664 deaths (https://covid19.gov.gr/covid19-liveanalytics/). In addition, 3.3% of the population have been fully vaccinated (ranking sixth in the European Union, https://www. euronews.com/2021/03/05/covid-19-vaccinations-in-europewhich-countries-are-leading-the-way). Gaps in health care are still evident in our country, both in terms of human resources and in facilities, and these cross-sectional numbers are of questionable importance in such an ongoing dynamic phenomenon, proven by the fact that we are currently facing a larger third wave of the pandemic. However, they are indicative of the massive effort undertaken by doctors and healthcare professionals in the first two waves. During the first wave of the pandemic, we entered a race for the multidisciplinary management of hospitalized patients with COVID-19, in close collaboration with colleagues from internal medicine, infectious diseases and intensive care, and we developed dedicated COVID departments to provide the best possible care. At the same time, we observed a major reduction in hospitalizations for respiratory diseases compared to the previous years. In a retrospective observational study, we evaluated respiratory disease hospitalization rates across nine tertiary hospitals in Greece during March and April 2020 and compared those with the corresponding periods of 2018 and 2019. We observed a reduction of over 45% in hospital admissions compared to the two previous years, the greatest being in sleep apnoea, asthma and chronic obstructive pulmonary disease. At the same time, a different group of authors observed a very low incidence of COVID-19 infection in patients with idiopathic pulmonary fibrosis (two cases in 550 patients evaluated in referral centres). These observations may be a consequence both of the social distancing measures and the increased discipline of patients with chronic respiratory disorders. On the positive side, a significant parameter in the low rates of hospitalizations for respiratory disorders in Greece may have been the significant role of office-based respiratory physicians in the outpatient management of chronic respiratory patients during the COVID-19 pandemic. The development of algorithms for the evaluation of severity and allocation to designated care may have further supported these outcomes. The Greek experience showed that collaboration between primary care and hospital care, in coordination by the authorities, resulted in the effective management during the first wave of the pandemic of COVID-19 in our country. In these tough times, Greece also contributed to the global effort for COVID-19 research with 683 publications, ranking 29th in 207 countries, based on data retrieved from Clarivate’s Web of Science (https://www.ekt.gr/en/news/ 25308). In parallel, the quest for the development of new technologies and digital solutions is in the frontline of research, and one of the most highlighted areas of research is artificial intelligence and machine learning techniques. In a systematic review of artificial intelligence techniques in asthma, our group was able to recognize that this is a rapidly developing field that, however, needs to be refined in the future to reach clinical applications. Telemedicine and techniques for remote monitoring and management of patients have been in the spotlight of interest and intense research during these times. We have all experienced missed appointments with patients with severe chronic respiratory disease and some of our patients may have missed important treatments, especially in the early days of the pandemic. To support these unmet needs, we tried to use novel technologies for remote monitoring and management. For example, a significant aid in the management of patients with severe asthma in our department has been the implementation of portable spirometry (Air Next Spirometer; NuvoAir, Sweden) and the use of multiple electronic channels to contact our patients. Our learnings are likely to reform the follow-up and management of patients with chronic respiratory conditions in the future. Medical education has been a major challenge during the pandemic and, as in all areas of education, we have incorporated digital technologies for the teaching of medical students. Nevertheless, a significant part of face-to-face training has not taken place during the pandemic. Novel technologies, including online simulation platforms and the Received: 11 March 2021 Accepted: 22 March 2021