Cognitive Flexibility and Social Responsiveness in Children and Adolescents with Tourette Syndrome.

This study examined cognitive flexibility and social responsiveness in children and adolescents with Tourette Syndrome (TS). Thirty one subjects with TS were compared to 32 age-matched healthy controls. Assessments included semi-structured interviews to assess psychopathology, parent-rated Social Responsiveness Scale (SRS) and a brief neuropsychological battery selected as measures of cognitive flexibility. Completion time for both Trail Making Tests (TMT-A and TMT-B) were significantly longer for TS group than controls, however the difference in perseverative errors on Wisconsin Card Sorting Test (WCST) was not significant. SRS total score was significantly higher in the TS group compared to controls, indicating greater impairment in social responsiveness. Group difference for TMTs and SRS failed to reach significance after controlling for co-occurring conditions. Clinicians might consider social impairment in the evaluation plan of children and adolescents with Tourette syndrome.

Health policy analysis for prevention and control of cardiovascular diseases and diabetes mellitus in Turkey.

OBJECTIVES: Current capacity of the Turkish health system is reviewed to evaluate and develop appropriate policies for cardiovascular diseases (CVD), diabetes mellitus (DM) and related risk factors. METHODS: This paper qualitatively evaluates existing policies; interviews with key informants (KIs); and rapid appraisal fieldwork in clinical settings about CVD-DM through the framework of Walt and Gilson (Health Policy Plan 9:353-370, 1994). RESULTS: Document review shows that prevention and control of CVD-DM were strongly addressed in Turkey, yet no document mentioned country-wide early detection or screening programs. KIs indicated over-fragmented management of CVD-DM by the Ministry of Health (MoH). Coordination among the MoH, organizational structure at provincial level and civil society organizations are poor where mutual trust is a significant problem according to KIs. Clinical setting findings point to a complete lack of a referral structure and a lack of follow-up, compounding the absence of functioning health information systems for patient records. CONCLUSIONS: Primary care services for CVD-DM require urgent attention, focusing particularly on the training of staff in public facilities, the integration of patient data, referrals and follow-up across all levels of the health system.

Evaluation of vitamin D supplementation doses during pregnancy in a population at high risk for deficiency.

AIM/BACKGROUND: Vitamin D supplementation during pregnancy is a well-accepted recommendation worldwide; however, the debate about the correct dose is ongoing. We aimed to compare daily doses of 600, 1,200, and 2,000 IU in this randomized, controlled study. METHODS: The study group consisted of 91 pregnant women aged 16-42 years admitted to Kocaeli Maternity and Children Hospital between April 2011 and April 2012. The participants were randomly divided into 3 groups. 600, 1,200, and 2,000 IU/day of vitamin D was supplemented to group 1 (control group, n = 31), group 2 (n = 31), and group 3 (n = 32), respectively. Serum calcium, 25-hydroxyvitamin D (25OHD), and the calcium/creatinine ratio in spot urine samples were measured in the follow-up period. The serum calcium and 25OHD levels of the mothers' infants were measured as well. RESULTS: The frequency of vitamin D sufficiency after supplementation was 80% in group 3 and it was significantly higher than in groups 1 (42%) and 2 (39%) (p = 0.03). The frequency of vitamin D sufficiency in the infants of the participants was 91% in group 3 and it was significantly higher than in groups 1 (36%) and 2 (52%) (p = 0.006). CONCLUSIONS: At least 2,000 IU/day of vitamin D is needed to ensure adequate vitamin D status in pregnancy and early infancy.

A cross-sectional survey of repetitive behaviors and restricted interests in a typically developing Turkish child population.

This study examined compulsive-like behaviors (CLBs) which are higher-order types of Repetitive Behaviors And Restricted Interests (RBRIs) in typically developing children in Turkey. Caregivers of 1,204 children between 8 and 72 months were interviewed with Childhood Routines Inventory (CRI) by trained interviewers in a cross-sectional survey. Factor analysis of the CRI revealed two factor structures comprising "just right behaviors" and "repetitive/sensory sensitivity behaviors". CLB frequency peaked at 2-4 years with declines after age four. In contrast to the previous CRI studies reporting no gender difference, CLBs were more common in males in 12-23 and 48-59 month age groups on both total CLB frequency and repetitive/sensory sensitivity behaviors. Also ages of onsets for CRI items were somewhat later than reported in other samples. Our findings supported the findings of the previous CRI studies while also revealing new perspectives in need of further investigation.

Health system challenges of cardiovascular disease and diabetes in four Eastern Mediterranean countries.

This paper presents evidence from research into health system challenges of cardiovascular disease (CVD) and diabetes in four Eastern Mediterranean countries: the occupied Palestinian territory, Syria, Tunisia and Turkey. We address two questions. How has the health system in each country been conceptualised and organised to manage the provision of care for those with CVD or diabetes? And what were key concerns about the institutional ability to address this challenge? Research took place from 2009 to 2010, shortly before the political upheavals in the region, and notably in Syria and Tunisia. Data collection involved a review of key documents, interviews with key informants and brief data collection in clinics. In analysing the data, we adopted the analytical schema proposed by Walt and Gilson, distinguishing content, actors, context and process. Key findings from each country highlighted concerns about fragmented provision and a lack of coordination. Specific concerns included: the lack of patient referral pathways, functioning health information systems and investment in staff. Regarding issues underlying these 'visible' problems in managing these diseases, we highlight implications of the wider systemic pressure for reform of health-sector finance in each country, based on neoliberal models.

Twelve-year trends in the prevalence and risk factors of diabetes and prediabetes in Turkish adults.

There is concern about an emerging diabetes epidemic in Turkey. We aimed to determine the prevalence of diagnosed and undiagnosed diabetes, prediabetes and their 12-year trends and to identify risk factors for diabetes in the adult Turkish population. A cross-sectional, population-based survey, 'TURDEP-II' included 26,499 randomly sampled adults aged ≥ 20 years (response rate: 87 %). Fasting glucose and biochemical parameters were measured in all; then a OGTT was performed to identify diabetes and prediabetes in eligible participants. The prevalence of diabetes was 16.5 % (new 7.5 %), translating to 6.5 million adults with diabetes in Turkey. It was higher in women than men (p = 0.008). The age-standardized prevalence to the TURDEP-I population (performed in 1997-98) was 13.7 % (if same diagnostic definition was applied diabetes prevalence is calculated 11.4 %). The prevalence of isolated-IFG and impaired glucose tolerance (IGT), and combined prediabetes was 14.7, 7.9, and 8.2 %, respectively; and that of obesity 36 % and hypertension 31.4 %. Compared to TURDEP-I; the rate of increase for diabetes: 90 %, IGT: 106 %, obesity: 40 % and central obesity: 35 %, but hypertension decreased by 11 % during the last 12 years. In women age, waist, body mass index (BMI), hypertension, low education, and living environment; in men age, BMI, and hypertension were independently associated with an increased prevalence of diabetes. In women current smoking, and in men being single were associated with a reduced risk. These results from one of the largest nationally representative surveys carried out so far show that diabetes has rapidly become a major public health challenge in Turkey. The figures are alarming and underscore the urgent need for national programs to prevent diabetes, to manage the illness and thus prevent complications.

Violence against women: the perspective of academic women.

BACKGROUND: Opinion surveys about potential causes of violence against women (VAW) are uncommon. This study explores academic women's opinions about VAW and the ways of reducing violence. METHODS: Quantitative and qualitative methods were used in this descriptive study. One hundred-and-fifteen academicians participated in the study from two universities. A questionnaire was used regarding the definition and the causes of VAW, the risk groups and opinions about the solutions. Additionally, two authors interviewed 8 academicians from universities other than that of the interviewing author. RESULTS: Academicians discussed the problem from the perspective of "gender-based violence" rather than "family violence". The majority of the participants stated that nonworking women of low socioeconomic status are most at risk for VAW. They indicated that psychological violence is more prevalent against educated women, whilst physical violence is more likely to occur against uneducated and nonworking women. Perpetrator related factors were the most frequently stated causes of VAW. Thirty-five percent of the academicians defined themselves as at risk of some act of VAW. Recommendations for actions against violence were empowerment of women, increasing the educational levels in the society, and legal measures. CONCLUSIONS: Academic women introduced an ecological approach for the explanation of VAW by stressing the importance of taking into account the global context of the occurrence of VAW. Similar studies with various community members -including men- will help to define targeted interventions.

The impact of a faculty development program: evaluation based on the self-assessment of medical educators from preclinical and clinical disciplines.

Self-assessment tools have previously been used to assess the impact of a faculty development program on the teaching skills of medical educators. In this study, we aimed to assess the impact of a faculty development program on the teaching performances of faculty members in relation to their medical disciplines and academic positions. A faculty-training program consisted of "training skills" and "student assessment instruments" courses. The impact of the program was evaluated by self-reporting of faculty members (a total of 225 reports) 1-2 yr after the program. Both courses were found to be beneficial by nearly all of the attendants. Clinicians benefited more from some topics in the student assessment course and could apply the structured learning and assessment guides, structured oral examination, and objective structured clinical examination more efficiently than their peers from preclinical departments. In conclusion, the results demonstrated that the participants of the faculty development program modified their teaching activities according to the demands of their clinical practice. The correlations between the benefits and behavioral changes were statistically significant.

Metabolic syndrome in obese Turkish children and adolescents: comparison of two diagnostic models.

There is no consensus on whether or not the diagnostic criteria of metabolic syndrome (MS) defined for adults [National Cholesterol Education Panel (NCEP) and World Health Organization (WHO)] can be used in childhood as well. We aimed to compare prevalence of metabolic syndrome among obese children and adolescents using WHO and NCEP guidelines. A total of 112 obese children and adolescents were assessed. MS was diagnosed according to both modified WHO and NCEP criteria using cut-off values for children. Abnormal glucose homeostasis was identified in 46.6% of the subjects. Fasting glucose levels for all subjects were less than 110 mg/dl and no subjects had type 2 diabetes. Overall, dyslipidemia was present in 42.9% and hypertension in 42.9% of the subjects. While 24% of the subjects were diagnosed as MS according to NCEP, a rate of 38.8% were diagnosed according to WHO-defined MS. There was a moderate agreement between NCEP and WHO guidelines. More children were diagnosed as MS based on the WHO guidelines. This may lead to better monitoring for these children and prevention of their chronic diseases in the future. Therefore, we recommend using WHO guidelines in the diagnosis of MS with a specific emphasis on definition of abnormal glucose homeostasis.

Natural history and risk factors of early respiratory responses to exposure to cotton dust in newly exposed workers.

OBJECTIVE: A prospective study of newly exposed cotton workers was performed to investigate the natural history of respiratory symptoms and lung function changes. METHODS: A total of 157 workers naive to cotton dust exposure were investigated by questionnaire, spirometry, and skin tests. They were examined before employment (baseline) and at the end of the first week, and the first, third, sixth, and 12th month after starting work. Acute airway response was defined as either a cross-first-shift or a cross-week fall in forced expiratory volume in one second (FEV1). The longitudinal change of lung function over the year was also calculated. Five hundred seventy-two personal dust sampling and 191 endotoxin measurements were performed to assess the exposure. RESULTS: Forty percent of workers reported work-related symptoms in the first week of the study. Smoking, endotoxin, and dust concentrations were risk factors for all work-related symptoms. Acute airway responses were witnessed after immediate exposure. Female status was the only factor found to be predictive of acute airway response. The mean longitudinal fall in FEV1 at 1 year was 65.5 mL (standard error = 37.2). Age, early respiratory symptoms, and early fall in cross-week FEV1 were found to predict the 12-month fall in FEV1. Cross-first-shift and cross-week falls in FEV1 reduced in magnitude during the course of the study. CONCLUSIONS: This study of workers naive to cotton dust exposure has demonstrated that respiratory symptoms and acute airway responses develop early following first exposure, and a tolerance effect develops in those workers with the continued exposure. Current smoking and increasing exposure predicts the development of work-related lower respiratory tract symptoms, while early symptoms and acute airway changes across the working week predict the longitudinal loss of lung function at 1 year.

Drug utilization and teratogenicity risk categories during pregnancy.

A limited number of studies have investigated in detail the use of drugs during pregnancy. Researchers in the present study investigated the details of drug utilization in pregnant women during the month before pregnancy, at the time that they became aware of the pregnancy, and during the first trimester. Face-to-face interviews were conducted with 359 pregnant women who were admitted to the fetal medicine unit at a university hospital for diagnosis and follow-up. A questionnaire was used to document sociodemographic characteristics and details of drug use. Drugs were categorized according to the US Food and Drug Administration fetal risk classification. Mean maternal age was 29.9+/-5.1 y, and mean gestational age was 19.6+/-9.5 wk. Many of the pregnant women studied (46.6%) were university graduates, and most (61.9%) had a relatively high annual income. Mean gestational age when participants first learned of their pregnancy was 39.8+/-16.4 d. One hundred seventeen participants (32.6%) used drugs during the month before conception, 54 (15%) at the time when they learned of their pregnancy, 180 (50.1%) at the time of the interview, and 289 (80.5%) during the first trimester. The percentages of drugs in categories D and X used by these subjects were 14%, 13.5%, 2.9%, and 5.9%, respectively. Most of the drugs were hormones. The total rate of drug utilization was not high before and during the first trimester of pregnancy. A considerable number of women were using drugs from the D and X categories; however, these numbers decreased significantly when women learned of their pregnancies. Intake of folic acid, vitamins, and iron was very low during the preconception period and was not high enough during the first trimester; this suggests that particular attention should be paid to the use of beneficial "safe" drugs during the preconception and early pregnancy periods.

Antihypertensive drug utilization at health centres in a district of Istanbul.

OBJECTIVE: Since irrational use of antihypertensives has considerable clinical and economical consequences, this study was conducted to evaluate antihypertensive drug utilization in hypertension at seven State Health Centres in Istanbul. METHOD: A total of 297 hypertensive patients who accepted to participate in the study were evaluated by a face-to-face questionnaire and a copy of their prescriptions were collected for prescription analysis. RESULTS: Angiotensin-converting enzyme (ACE) inhibitors (31.7%), calcium channel blockers (28.8%), diuretics (16.2%), beta blockers (7.5%) and others (15.8%) have been prescribed. There were no statistically significant relation between prescribed antihypertensive drug groups and gender, age, and NSAIDs co-prescribing. The most frequent comorbidity in hypertensive patients was diabetes mellitus (10.4%) and calcium channel blockers (35.5%) have been prescribed to them as a first antihypertensive medication. Average cost per prescription was $42.7 +/- 38.1. According to the patients' self-reporting, the majority of them (85%) were prescribed without a physical examination. The physicians failed to write the prescriptions appropriately; only 5% of the scripts contained all information about the drug(s) and use instructions in full format. CONCLUSION: The present study indicates that GPs working at primary healthcare centres were rational in terms of antihypertensive drug choice. However, they poorly applied rational pharmacotherapy principles such as (a) writing a "good" prescription which is easily readable by the pharmacist and the patient and that contains full essential information; (b) a medical examination of the patient to assess her/his current clinical condition; and (c) taking care of not prescribing drugs with potential interaction like antihypertensives and NSAIDs together.

Nasopharyngeal carriage of penicillin-resistant Streptococcus pneumoniae in healthy children.

Streptococcus pneumoniae carriage is a risk factor for the development of respiratory system infections and the spread of penicillin-resistant strains. The aim of this study was to investigate nasopharyngeal carriage of S. pneumoniae in healthy children and resistance to penicillin and other antimicrobials and to assess related risk factors. Nasopharyngeal specimens collected from healthy children less than six years of age, visiting a Mother and Child Health Center for health control, were investigated microbiologically between February-March 2004. Carriage rate was 37.2% (n=112/301); 33.9% intermediate and 5.4% high penicillin resistance were detected. According to multivariate analysis, carriage rate was inversely related to number of rooms (OR:0.574) and child age (OR:0.978), while penicillin resistance was correlated well with antibiotic use in the last two months (OR:2.193). Decreased sensitivity plus resistance to other antimicrobials were: trimethoprim-sulfamethoxazole (TMP-SMX) 45.6%; erythromycin 16.1%, tetracycline 16.1%; clindamycin 9.8%, and ofloxacin 3.6% in pneumococcal isolates, which increased significantly (p<0.05) to 72.7%, 31.8%, 27.3%, 20.5%, and 6.8%, respectively, in penicillin non-sensitive S. pneumoniae (PNSSP) except for ofloxacin. Overall multidrug resistance was 17.9%, while PNSSP exhibited a resistance rate of 38.6%. In conclusion, S. pneumoniae carriage rates determined in healthy children were high and PNSSP strains also showed increased resistance to other antimicrobials.

Analysis of risk factors for sternal surgical site infection: emphasizing the appropriate ventilation of the operating theaters.

OBJECTIVE: To determine the incidence of and identify risk factors for sternal surgical site infection (SSI). DESIGN: Prospective cohort study. Data on potential risk factors, including the type of operating theater and infection data, were collected prospectively and analyzed by multivariate analysis. SETTING: Siyami Ersek Thoracic and Cardiovascular Surgery Hospital, a 700-bed teaching hospital and the largest center for cardiac surgery in Turkey. The cardiothoracic unit performs approximately 3,000 cardiac operations per year. PATIENTS: All adult patients who underwent cardiac surgery with sternotomy between January 14, 2002, and July 1, 2002, and who survived at least 4 days after surgery were included in the study. RESULTS: Potential risk factor data were complete for 991 patients. There was sternal SSI in 41 patients (4.1%). Female sex, diabetes mellitus, operation performed in the older operating theaters, and duration of procedure exceeding 5 hours were identified as independent risk factors for sternal SSI. CONCLUSIONS: Female and diabetic patients are at higher risk for sternal SSI and should be followed up carefully after cardiac surgery to prevent the development of sternal SSI. Reducing the duration of surgery could reduce the rate of postoperative sternal SSI. The operating theater environment may have an important role in the pathogenesis of sternal SSI, and appropriate ventilation of the operating theaters would be critical in the prevention of sternal SSI.

Expanding family planning options: offering the Standard Days Method to women in Istanbul.

BACKGROUND: This study introduced the Standard Days Method (SDM), a fertility awareness-based method of family planning, to couples in a region of Istanbul, Turkey who were using a method of low effectiveness or no family planning method. The objective was to determine potential demand for, and satisfaction with, the SDM. METHODS: A total of 657 couples were selected by systematic sampling and offered the SDM. Those accepting this method were interviewed 1 and 3 months after starting the SDM. RESULTS: Some 47% of the participants were satisfied with the method and intended to continue using it. CONCLUSIONS: Potential demand for the SDM was 80.3% (278/346 eligible women) among couples who were using a method of low effectiveness or no family planning method. Our results suggest that adding the SDM to the contraceptive method mix may benefit Turkish women.

The relationships between candidemia and candidal colonization and virulence factors of the colonizing strains in preterm infants.

Premature infants are at high risk of developing candidal infections originating from their own normal flora or from the hospital environment. This study involves the surveillance cultures and blood cultures of candidemic preterm infants with low birth weights who have been analyzed for colonization period and status, and for virulence factors such as acid proteinase and phospholipase. Arbitrarily primed-polymerase chain reaction (AP-PCR) was applied to the blood culture isolates of the babies with candidemia and their last colonizing strains in order to determine whether the source of fungemia was the rectum. Of 65 colonized infants, 6.2% developed candidemia with identical strains originating from their rectum according to their PCR patterns. Our findings indicate that the properties of the colonizing yeasts such as increase in number--although not statistically significant because of the small sample size--and/or exhibition of strong hydrolytic enzyme activities through a long duration of colonization might contribute to the development of candidemia in preterms.

Patient knowledge about drugs prescribed at primary healthcare facilities.

OBJECTIVE: Providing adequate information to the patients about their drugs is an essential principle of rational pharmacotherapy. This study investigates the knowledge of general practice patients about their drugs, since the level of knowledge of the patient about the medication is highly associated with the outcome of the therapy. METHODS: A total of 1618 patients who applied to primary healthcare centers in Istanbul and accepted to participate in the study were asked about the name(s) and effect(s) of the drug(s) on their prescriptions. Factors that might influence the background knowledge and perception of patients such as sociodemographic characteristics, drug-use habits and practitioners' attitudes were also questioned. Information provided by the patients was compared with the prescriptions. RESULTS: Only 10.9% of the respondents could recall the names of their drug(s) correctly. Level of education, and gender, had a positive impact on recalling drug names. Patients, who received a refill prescription, with a chronic disease, and who had self-medication before applying to the health center reported more accurate information. Less than half of the practitioners had informed their patients about the drug effects; and 7% of the patients have been requested to repeat the instructions and warnings about his/her medication(s). The patients to name their drugs correctly also knew the drug effects twice as much the patients who could not recall their drug(s)' name. The drugs which were correctly named were the ones used in chronic diseases. CONCLUSION: It appears that patients, particularly who are poorly educated, males, and who received a first prescription know little about their prescribed drugs. These results suggest that patients' education about drugs is an important issue regarding rational drug use which deserves urgent improvement.

Attitudes of married individuals towards oral contraceptives: a qualitative study in Istanbul, Turkey.

OBJECTIVE: To determine positive and negative attitudes of married Turkish women and men regarding the use of oral contraceptives (OCs). METHODS: Twenty focus group discussions were conducted during the period October 1998-March 1999 in Umraniye, which is one of the densely populated districts of Istanbul. RESULTS: Most of the negative attitudes relating to OCs stemmed from concerns over side effects, particularly in the male focus groups. Health care professionals' behaviour, lack of concern or bias, and their reluctance to prescribe also limited the uptake of OCs. The female groups had very positive attitudes towards OCs compared to those of the male groups. It was identified that although OCs are largely provided free of charge in Turkey, beliefs and attitudes towards them are the important factors which affect the uptake of the method. CONCLUSION: Special efforts may be needed to educate these groups and also to teach the health professionals about family planning counselling.

Prescribing habits of general practitioners in the treatment of childhood respiratory-tract infections.

OBJECTIVE: In the present study, prescribing behavior of general practitioners (GPs) was investigated in the example of childhood upper and lower respiratory-tract infections (URTIs and LRTIs). STUDY DESIGN: A face-to-face interview was performed with 352 parents admitted to seven primary health care centers for their children diagnosed with URTI or LRTI. Prescriptions ( n=331) written by 25 GPs working at these centers were analyzed regarding legibility, format and suitability of drug choice. RESULTS: Almost 60% of parents had self-medicated their children prior to admitting to the doctor. Of the patients, 29 (8.2%) were not examined by the physicians, but were directly prescribed medicine. The physicians did not tell the diagnosis to 25.3% of the patients, did not inform 41.2% of them about the drugs and did not caution 95.7% about the side effects. Further, the physicians did not inform 42.6% of the patients about drug use instructions, did not inform 83.5% about the warnings and did not inform 81.2% about non-drug treatment. Approximately 5% of the individuals remembered the name of the drugs. Only 26.3% of the prescriptions were easily readable, and only five scripts (1.5%) contained all necessary information. The majority of the patients were given antibiotics, penicillin+beta lactamase inhibitors being the first. Paracetamol was the most frequently prescribed analgesic/antipyretic for both indications, followed by nimesulide and ibuprofen. CONCLUSIONS: The present study revealed inappropriate drug use in the treatment of respiratory-tract infections in children at the primary health care level in a district of Istanbul, Turkey. Furthermore, it has been shown that GPs practicing at primary health care centers should be trained to give adequate information about the disease and the treatment to the patients/parents to achieve good compliance and optimal drug therapy for children.