Promoting rational antibiotic use in Turkey and among Turkish migrants in Europe - implications of a qualitative study in four countries.

BACKGROUND: Antimicrobial resistance is considered one of the major threats to global health. The emergence of resistant microorganisms is a consequence of irrational use of antibiotics. In Turkey, the consumption of antibiotics is relatively high and antibiotics are among the most commonly used drugs. However, Turkey has adopted new, more restrictive policies and regulations on antibiotics. In addition, Turkish migrants to EU countries, such as Germany, the Netherlands and Sweden, may encounter health systems that promote a more restrictive and rational antibiotic use. The objective of this paper was to explore the variation in implemented policies related to rational antibiotic use that citizens in Turkey and Turkish migrants in Germany, the Netherlands and Sweden are subjected to and to discuss the implications for the promotion of rational antibiotic use. Data were collected through focus groups and individual interviews with citizens, physicians and pharmacists in the four countries. In total, 130 respondents were interviewed. Content analysis was used. RESULTS: Three relevant themes were identified: Implementation of regulations and recommendations, Access to antibiotics and Need for health communication. Irrational use of antibiotics was reported mainly in Turkey. While it had become less likely to get antibiotics without a prescription, non-prescribed antibiotics remained a problem in Turkey. In the three EU countries, there were also alternative ways of getting antibiotics. Low levels of knowledge about the rational antibiotic use were reported in Turkey, while there were several sources of information on this in the EU countries. Communication with and trust in physicians were considered to be important. There were also system barriers, such as lacking opportunities for physicians to manage care in accordance with current evidence in Turkey and factors limiting access to care in EU countries. CONCLUSIONS: Several fields of importance for promoting rational antibiotic use were identified. There is a need for harmonisation of health-related regulations and policy programmes. Antibiotics should only be available with a prescription. Programmes for rational antibiotic use should be implemented on a broad scale, in medical care, at pharmacies and in the population. Methods for health communication and patient-centred care should be further developed and implemented in this field.

Vascularised fatty tissue: its role in prevention of the symptoms of Frey syndrome after parotidectomy.

We studied 37 consecutive patients who had parotidectomies between 2008 and 2017 and who had vascular fat flaps inserted to replace the excised parotid tissue and prevent Frey syndrome. They were followed up for 1-9 years to check for the relevant symptoms. We studied 17 female and 20 male patients, mean age 52 (range 19-78) years. The flaps took a maximum of 17minutes to dissect. There was no donor site morbidity, the vascular fat flap was stable in all cases for up to nine years, and none of the patients complained of symptoms of Frey syndrome.

[Challenges of Diversity-Sensitive Care in Medical Rehabilitation]. / Herausforderungen einer diversitätssensiblen Versorgung in der medizinischen Rehabilitation.

Diversity markers such as sex, migration background and socioeconomic status are associated with different needs and expectations in health care. In rehabilitation these needs and expectations are often not adequately accounted for. This may affect health care outcomes. In order to improve rehabilitative care, it is not sufficient to only focus on selected diversity criteria such as migration background. This has two reasons: First, health care users are defined by a wide range of different diversity markers; second, diversity markers are closely interrelated. Diversity management allows to address the population as a whole by establishing conditions in health care institutions which permit to cater for the diversity of all health care users, thereby allowing to provide a more patient-oriented health care.

Self-rated treatment outcomes in medical rehabilitation among German and non-German nationals residing in Germany: an exploratory cross-sectional study.

BACKGROUND: In many European countries, foreign nationals experience, on average, less favorable treatment outcomes in rehabilitative care than the respective majority population. In Germany, this for example is reflected in a lower occupational performance and a higher risk of disability retirement after rehabilitation as analyses of routine data show. However, little is known about the perspective of health care users. The aim of the present study was to compare self-rated treatment outcomes between German and non-German nationals undergoing in-patient medical rehabilitation in Germany. METHODS: We analyzed data from a cross-sectional representative rehabilitation patient survey of 239,811 patients from 642 clinics in Germany who completed about 3 weeks of in-patient rehabilitative treatment. The self-rating of the treatment outcome was based on a dichotomized Likert scale consisting of three items. A multilevel logistic regression analysis adjusted for various demographic, socio-economic, health and other covariates was conducted to examine differences in the self-rated treatment outcome between German and non-German nationals. RESULTS: Of the 239,811 respondents 0.9% were nationals from Turkey, 0.8% had a nationality from a former Yugoslavian country, 0.9% held a nationality from the South European countries Portugal, Spain, Italy or Greece and 1.9% were nationals from other countries. Non-German nationals reported a less favorable self-rated outcome than Germans. Adjusted odds ratios [OR] for reporting a less favorable treatment outcome were 1.24 (95%-confidence interval [95%-CI]: 1.12-1.37) for nationals from the South European countries Portugal/Spain/Italy/Greece, 1.62 (95%-CI: 1.45-1.80) for Turkish nationals and 1.68 (95%-CI: 1.52-1.85) for nationals from Former Yugoslavia. CONCLUSIONS: Knowledge on health outcomes from the patients' point of view is important for the provision of patient-centered health care. Our study showed that non-German nationals report less favorable outcomes of rehabilitative care than Germans. This may be due to cultural and religious needs not sufficiently addressed by health care providers. In order to improve rehabilitative care for non-German nationals, rehabilitative services must become sensitive to the needs of this population group. Diversity management can contribute to this process.

[Prevention among migrants--problems in health care provision and suggested solutions illustrated for the field of medical rehabilitation]. / Versorgungsprobleme und mögliche Lösungsstrategien bei Menschen mit Migrationshintergrund.

In Germany, 16 million people have a migration background. As compared to the majority population, they have higher prevalences of some chronic diseases and are at a higher risk of occupational accidents, occupational diseases and retirement due to disability. Preventive health care services, therefore, are of high relevance in this population group.  As a result of barriers to health care access and effectiveness, people with a migration background, however, benefit less from preventive services than the majority population. This is particularly the case for rehabilitation. In order to improve preventive health care for people with a migration background sustainably, current health care services must become sensitive to the needs of this population group. Diversity management can contribute to this process.

[Health care among older people with Turkish migration background: qualitative survey of health mediators]. / Gesundheitsversorgung älterer Menschen mit türkischem Migrationshintergrund: Qualitative Befragung von Gesundheitsmediatoren.

BACKGROUND: Older people with a Turkish migration background face various barriers in terms of access to and quality of health care. Providing health care according to their subjective and objective needs is of increasing importance considering demographic aging. The aim of this study was to illustrate challenges older migrants experience in the health care process from the viewpoint of health mediators. METHOD: Construct interviews were conducted with six health mediators and were analyzed by means of content analysis. RESULTS: The interviews showed three different challenges in health care for people with a Turkish migration background. These were the patients' coping with the disease, their health beliefs, and factors associated with the health care process and the doctor-patient relationship. CONCLUSION: The study highlights that it is important to make health care institutions aware of the culture specific characteristics of illness and therapy beliefs among people with a Turkish migrations background. Diversity management is an adequate strategy to adjust health care to the needs and requirements of an increasingly diverse population.

[The use of routine data to study rehabilitative care in populations with a migrational background: potential and limitations]. / Die Nutzung von Routinedaten in der rehabilitationswissenschaftlichen Versorgungsforschung bei Menschen mit Migrationshintergrund: Möglichkeiten und Grenzen.

OBJECTIVE: Little is known about the rehabilitative care of populations with a migrational background. Using the assessment of rehabilitation effectiveness as an example, we outline the potentials and limitations routine data from social security carriers has for this research field. METHODS: We draw on an 80% random sample of all completed medical rehabilitations in the year 2006 funded by the German Statutory Pension Insurance Scheme (n=634 529). The assessment of rehabilitation effectiveness was based on the occupational performance at the time the rehabilitation was completed. Migrational background was defined by nationality. By means of logistic regression adjusted for socio-economic/-demographic and health-related variables, we examine whether rehabilitation effectiveness differs between German and non-German nationals. RESULTS AND DISCUSSION: Non-German nationals have a higher chance of completing medical rehabilitation with a lower occupational performance - irrespective of differences in socio-economic/-demographic and health-related variables. Odds ratios for a lower rehabilitation effectiveness were 1.23 [95%-CI=1.16;1.30] for Turkish nationals and 1.47 [95%-CI=1.38;1.56] for persons from the former Yugoslavia. Different aspects limit the validity of the analysis. (1) By using nationality, only a selection of all persons with a migrational background can be identified. (2) Important covariates cannot be considered. (3) The assessment of rehabilitation effectiveness is inaccurate, because valid data on occupational performance prior to rehabilitation is missing. CONCLUSION: Similar to routine data from other social security carriers, data from the German Statutory Pension Insurance Scheme has limitations for health services research on populations with a migrational background. Solutions comprise the application of computer-aided procedures for an accurate operationalisation of migrational background and the use of survey data for a valid assessment of rehabilitation effectiveness.

[Indebtedness and mortality: analysis at county and city levels in Germany]. / Privatverschuldung und Mortalität: Untersuchung auf Ebene der Kreise und kreisfreien Städte Deutschlands.

INTRODUCTION: Little is known about the influence of individual debts on health inequalities in Germany. Studies from English-language countries have shown that indebtedness is a great burden in every-day life that leads to mental stress and is related to negative health outcomes. Our paper, for the first time, analyses the role of indebtedness on mortality in Germany. METHODS: Using ecological level data of Germany's 439 administrative districts, we assessed the role of unemployment, income, educational level, population density, regional prosperity, number of hospital beds and of the independent effect of indebtedness on mortality. The variance explained by indebtedness was determined by means of multiple linear regression models. Data were provided by the Federal Statistical Office of Germany and Schufa Holding AG. RESULTS: Indebtedness and unemployment are moderately correlated. Even so, a significant independent effect of indebtedness on mortality can be shown. Indebtedness contributes to the explanation of health inequalities and, together with other socioeconomic factors and the federal state, explains 59% of the variance in age-standardised district level mortality. Indebtedness explains 6% of variance. CONCLUSION: For the first time in Germany, this study shows that indebtedness not only influences population health as a result of low income or unemployment but also has an independent, albeit rather small, effect. Studies focussing on social inequity and health should further examine the role of indebtedness and also include an analysis on the individual level.

Mitotic chromosome condensation in the rDNA requires TRF4 and DNA topoisomerase I in Saccharomyces cerevisiae.

DNA topoisomerase I (topo I) is known to participate in the process of DNA replication, but is not essential in Saccharomyces cerevisiae. The TRF4 gene is also nonessential and was identified in a screen for mutations that are inviable in combination with a top1 null mutation. Here we report the surprising finding that a top1 trf4-ts double mutant is defective in the mitotic events of chromosome condensation, spindle elongation, and nuclear segregation, but not in DNA replication. Direct examination of rDNA-containing mitotic chromosomes demonstrates that a top1 trf4-ts mutant fails both to establish and to maintain chromosome condensation in the rDNA at mitosis. We show that the Trf4p associates physically with both Smclp and Smc2p, the S. cerevisiae homologs of Xenopus proteins that are required for mitotic chromosome condensation in vitro. The defect in the top1 trf4-ts mutant is sensed by the MAD1-dependent spindle assembly checkpoint but not by the RAD9-dependent DNA damage checkpoint, further supporting the notion that chromosome structure influences spindle assembly. These data indicate that TOP1 (encoding topo I) and TRF4 participate in overlapping or dependent steps in mitotic chromosome condensation and serve to define a previously unrecognized biological function of topo I.

Cloning, mapping, and in vivo localization of a human member of the PKCI-1 protein family (PRKCNH1).

We report here the complete cDNA sequence, genomic mapping, and immunolocalization of the first human member of the protein kinase C inhibitor (PKCI-1) gene family. The predicted human protein (hPKCI-1) is 96% identical to bovine and 53% identical to maize members, indicating the great evolutionary conservation of this protein family. The hPKCI-1 gene (HGMV-approved symbol PRKCNH1) maps to human chromosome 5q31.2 by fluorescence in situ hybridization. Indirect immunofluorescence shows that hPKCI-1 localizes to cytoskeletal structures in the cytoplasm of a human fibroblast cell line and is largely excluded from the nucleus. The cytoplasmic localization of hPKCI-1 is consistent with a postulated role in mediating a membrane-derived signal in response to ionizing radiation.

The product of the ataxia-telangiectasia group D complementing gene, ATDC, interacts with a protein kinase C substrate and inhibitor.

Ataxia-telangiectasia (AT) is an autosomal recessive human genetic disease characterized by immunological, neurological, and developmental defects and an increased risk of cancer. Cells from individuals with AT show sensitivity to ionizing radiation, elevated recombination, cell cycle abnormalities, and aberrant cytoskeletal organization. The molecular basis of the defect is unknown. A candidate AT gene (ATDC) was isolated on the basis of its ability to complement the ionizing radiation sensitivity of AT group D fibroblasts. Whether ATDC is mutated in any AT patients is not known. We have found that the ATDC protein physically interacts with the intermediate-filament protein vimentin, which is a protein kinase C substrate and colocalizing protein, and with an inhibitor of protein kinase C, hPKCI-1. Indirect immunofluorescence analysis of cultured cells transfected with a plasmid encoding an epitope-tagged ATDC protein localizes the protein to vimentin filaments. We suggest that the ATDC and hPKCI-1 proteins may be components of a signal transduction pathway that is induced by ionizing radiation and mediated by protein kinase C.

Identification of novel regions of altered DNA copy number in small cell lung tumors.

Identification of the genetic alterations that occur in tumors is an important approach to understanding tumorigenesis. We have used comparative genomic hybridization (CGH), a novel molecular cytogenetic method, to identify the gross DNA copy number changes that commonly occur in small cell lung cancer (SCLC). We analyzed ten SCLC tumors (seven primary tumors and three metastases) from eight patients. We found frequent increases in DNA copy number on chromosome arms 5p, 8q, 3q, and Xq and frequent decreases in copy number on chromosome arms 3p, 17p, 5q, 8p, 13q, and 4p. The increase in copy number at 8q24 (MYC) and decreases at 17p13 (TP53), 13q14 (RB), and 3p have previously been identified in SCLC with other methods. Many of the other regions in which we detected common copy number changes have not been reported to be regions of common alteration in SCLC tumors. Comparison of copy number changes between a primary tumor and a metastasis from the same patient showed that they were more closely related to each other than to any of the other tumors. The results of direct CGH analysis of SCLC tumors reported here confirm the existence of copy number changes that we identified previously by using cell lines.

Frequent novel DNA copy number increase in squamous cell head and neck tumors.

We have undertaken a study of DNA copy number changes in head and neck squamous cell carcinomas to identify novel DNA copy number changes and to determine the significance of previous findings of cytogenetic alterations in cultured cells. Comparative genomic hybridization was performed on genomic DNA extracted from ten tumors. A novel copy number gain on chromosome 3q26-27 and a loss of chromosome 3p were found at high frequency (> or = 50% of tumors). Many other novel chromosomal copy number changes were identified but occurred at a lower frequency. In addition, our data confirm that DNA copy number changes that frequently occur in cultured cells, such as loss of chromosome 3p, also occur in tumors. Frequently altered loci may encode oncogenes or tumor suppressor genes involved in head and neck squamous cell carcinoma tumorigenesis.

Identification of frequent novel genetic alterations in small cell lung carcinoma.

We have performed a comprehensive analysis of the DNA copy number changes that occur in 18 small cell lung carcinoma cell lines using comparative genomic hybridization (Kallioniemi et al., Science (Washington DC). 258: 818-821, 1992). DNA copy number abnormalities detected in this study include previously identified increases at 1p22-32 (L-myc), 2p24-25 (N-myc), and 8q24 (c-myc) and decreases at 17p13 (p53), 13q14 (RB), and 3p. In addition, novel DNA copy number increases were detected at 5p, 1q24, and Xq26, and novel decreases were found at 22q12.1-13.1, 10q26, and 16p11.2. Many of the most common DNA copy number changes revealed are at loci not previously recognized to be important in small cell lung cancer. In addition, a number of the DNA copy number changes, including increases at 1p22-32, 2p24-25, and 3q22-25 and a decrease on 18p, were found to occur preferentially in small cell lung carcinoma lines of the "variant" phenotype. This correlation suggests that genes may reside at these loci whose overexpression or inactivation contributes to the radiation resistance or aggressive growth phenotypes characteristic of this subtype of small cell lung carcinoma.

The pho regulon-dependent Ugp uptake system for glycerol-3-phosphate in Escherichia coli is trans inhibited by Pi.

sn-Glycerol-3-phosphate (G3P) or glyceryl phosphoryl phosphodiesters, the substrates of the phoB-dependent Ugp transport system, when transported exclusively through this system, can serve as a sole source of phosphate but not as a sole source of carbon (H. Schweizer, M. Argast, and W. Boos, J. Bacteriol. 150:1154-1163, 1982). In order to explain this phenomenon, we tested two possibilities: repression of the pho regulon by Ugp-mediated transport and feedback inhibition by internal G3P or its degradation product Pi. Using an ugp-lacZ fusion, we found that the expression of ugp does not decline upon exposure to G3P, in contrast to the repressing effect of transport of Pi via the Pst system. This indicated that the Ugp system becomes inhibited after the uptake and metabolism of G3P. Using 32P-labeled G3P, we observed that little Pi is released by cells taking up G3P via the Ugp system but large amounts of Pi are released when the cells are taking up G3P via the GlpT system. Using a glpD mutant that could not oxidize G3P but which could still phosphorylate exogenous glycerol to G3P after GlpF-mediated transport of glycerol, we could not find trans inhibition of Ugp-mediated uptake of exogenous 14C-G3P. However, when allowing uptake of Pi via Pst, we observed a time-dependent inhibition of 14C-G3P taken up by the Ugp transport system. Inhibition was half maximal after 2 min and could be elicited by Pi concentrations below 0.5 mM. Cells had to be starved for Pi in order to observe this inhibition. We conclude that the activity of the Ugp transport system is controlled by the level of internal phosphate.

lpsZ, a lipopolysaccharide gene involved in symbiosis of Rhizobium meliloti.

lpsZ+ is an allele that allows exo (exopolysaccharide-deficient) mutants of Rhizobium meliloti to invade nodules by modifying rhizobial lipopolysaccharide. We have cloned and sequenced the lpsZ gene. The predicted LpsZ protein has a molecular weight of 48,589 and is probably localized in the cytoplasm. A beta-glucuronidase fusion in the lpsZ gene indicates that lpsZ is not regulated by oxygen or nitrogen.

Rhizobium meliloti chromosomal loci required for suppression of exopolysaccharide mutations by lipopolysaccharide.

Mutants of alfalfa symbiont Rhizobium meliloti SU47 that fail to make extracellular polysaccharide (exo mutants) induce the formation of nodules that are devoid of bacteria and consequently do not fix nitrogen. This Fix- phenotype can be suppressed by an R. meliloti Rm41 gene that affects lipopolysaccharide structure. Here we describe mutations preventing suppression that map at two new chromosomal loci, lpsY and lpsX, present in both strains. Two other lps mutations isolated previously from SU47 also prevented suppression.

Characteristics of a ugp-encoded and phoB-dependent glycerophosphoryl diester phosphodiesterase which is physically dependent on the ugp transport system of Escherichia coli.

The ugp-encoded transport system of Escherichia coli accumulates sn-glycerol-3-phosphate with high affinity; it is binding protein mediated and part of the pho regulon. Here, we report that glycerophosphoryl diesters (deacylated phospholipids) are also high-affinity substrates for the ugp-encoded system. The diesters are not taken up in an unaltered form but are hydrolyzed during transport to sn-glycerol-3-phosphate plus the corresponding alcohols. The enzyme responsible for this reaction is not essential for the translocation of sn-glycerol-3-phosphate or for the glycerophosphoryl diesters but can only hydrolyze diesters that are in the process of being transported. Diesters in the periplasm or in the cytoplasm were not recognized, and no enzymatic activity could be detected in cellular extracts. The enzyme is encoded by the last gene in the ugp operon, termed ugpQ. The product of the ugpQ gene, expressed in minicells, has an apparent molecular weight of 17,500. We present evidence that only one major phoB-dependent promoter controls all ugp genes.