Evaluation of Blood Pressure Status and Mortality in Turkey: Findings from Chronic Diseases and Risk Factors Cohort Study.

Background and objectives: An important Non-Communicable Disease risk factor, hypertension (HT), is highly prevalent and controlled HT rates are not sufficient which increases the risk of developing premature deaths. The purpose of the study is to evaluate differences in all-cause and cardiovascular-related mortality according to HT status by using national data from Chronic Diseases and Risk Factors Survey in Turkey (2011-2017). Materials and Methods: Cox regression models were used to estimate hazard ratios (HR) for predicting the all-cause and cardiovascular system-related mortalities. Median follow-up period was 6.2 years. Results: Among individuals with HT, 41.8% was untreated, 30.1% received treatment and had controlled blood pressure, and 28.1% were under treatment but had uncontrolled BP levels. The hazard for mortality among treated & uncontrolled hypertensive participants was significantly higher for all-cause (HR = 1.32, 95% CI = 1.06-1.65), cardiovascular (HR = 2.11, 95% CI = 1.46-3.06), heart disease (HR = 2.24, 95% CI = 1.46-3.43), and Coronary Heart Disease mortality (HR = 2.66, 95% CI = 1.56-4.53) compared to normotensive participants. Conclusions: Individuals with HT who were treated but do not have controlled blood pressure in Turkey had a significantly increased risk of Cardiovascular Disease and all-cause mortality. Along with studies investigating the causes of uncontrolled blood pressure despite initiation of treatment, support should be provided to patients in cases of non-adherence to antihypertensive medication or life change recommendations.

Avaliação de Padrões Pressóricos Dipper e Não-Dipper e Qualidade de Vida entre Pacientes com Doença Pulmonar Obstrutiva Crônica / Evaluation of Dipper and Non-dipper Blood Pressure Patterns and Quality of Life Among Patients with Chronic Obstructive Pulmonary Disease

Resumo Fundamento O padrão pressórico não-dipper é definido por uma redução inferior a 10% na pressão arterial noturna e está associado a doenças cardiovasculares. Acredita-se que a inflamação desempenhe um papel na patogênese da doença pulmonar obstrutiva crônica (DPOC) e no padrão pressórico não-dipper e ambas as doenças estão associadas a uma qualidade de vida mais baixa. Objetivo O objetivo deste estudo foi o de investigar os efeitos do padrão pressórico não-dipper em pacientes com DPOC. Métodos Foi realizado um estudo transversal incluindo 142 pacientes com DPOC. O Questionário Respiratório de Saint George e a Escala de Qualidade de Vida Euro foram utilizados para a coleta de dados. Para entender a rigidez arterial, o índice de aumento e a velocidade da onda de pulso foram medidos; subsequentemente, foi realizada a monitorização ambulatorial da pressão arterial de 24 horas. Foi aplicado um modelo de regressão logística multivariável para entender a relação entre as diferentes variáveis independentes e o padrão pressórico. Foram considerados estatisticamente significativos valores de p inferiores a 0,05. Resultados Como resultado, 76,1% (n = 108) dos pacientes apresentaram o padrão pressórico não-dipper. Os pacientes com padrão não-dipper apresentaram valores mais altos de proteína C reativa (OR: 1,123; IC 95%: 1,016;1,242), índice de aumento (OR: 1,057; IC 95%: 1,011;1,105) e pontuação total no Questionário Respiratório de Saint George (OR: 1,021; IC 95%: 1,001;1,042), em comparação com os pacientes com padrão dipper. Adicionalmente, com o aumento do número de pessoas que habitavam o domicílio, verificou-se que o padrão pressórico não-dipper era mais frequente (OR: 1,339; IC 95%:1,009;1,777). Conclusão O padrão pressórico não-dipper pode aumentar o risco cardiovascular ao desencadear a inflamação e pode afetar adversamente o prognóstico da DPOC diminuindo a qualidade de vida relacionada à doença. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Abstract Background Non-dipper blood pressure is defined by less than a 10% reduction in nighttime blood pressure, and it is associated with cardiovascular disease. Inflammation is thought to play a role in the pathogenesis of both chronic obstructive pulmonary disease (COPD) and non-dipper blood pressure pattern, and both diseases are associated with lower quality of life. Objective The aim of this study was to investigate the effects of non-dipper blood pressure pattern in patients with COPD. Methods A cross-sectional study was carried out with 142 patients with COPD. The Saint George Respiratory Questionnaire and the Euro Quality of Life Scale were used to collect data. To understand arterial stiffness, the augmentation index and pulse wave velocity were measured, and 24-hour ambulatory blood pressure monitoring was subsequently performed. A multivariable logistic regression model was used to understand the relationship between different independent variables and blood pressure pattern. P values lower than 0.05 were considered statistically significant. Results As a result, 76.1% (n = 108) of the patients had non-dipper blood pressure pattern. Non-dipper patients had higher C-reactive protein (OR:1.123; 95% CI:1.016;1.242), augmentation index (OR: 1.057; 95% CI: 1.011;1.105) and Saint George Respiratory Questionnaire total score (OR: 1.021; 95% CI: 1.001;1.042) than dipper patients. Also, as the number of people living at home increased, non-dipper blood pressure pattern was found to be more frequent (OR: 1.339; 95% CI: 1.009;1.777). Conclusion Non-dipper blood pressure pattern may increase cardiovascular risk by triggering inflammation and may adversely affect the prognosis of COPD by lowering the disease-related quality of life. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Evaluation of Dipper and Non-dipper Blood Pressure Patterns and Quality of Life Among Patients with Chronic Obstructive Pulmonary Disease. / Avaliação de Padrões Pressóricos Dipper e Não-Dipper e Qualidade de Vida entre Pacientes com Doença Pulmonar Obstrutiva Crônica.

BACKGROUND: Non-dipper blood pressure is defined by less than a 10% reduction in nighttime blood pressure, and it is associated with cardiovascular disease. Inflammation is thought to play a role in the pathogenesis of both chronic obstructive pulmonary disease (COPD) and non-dipper blood pressure pattern, and both diseases are associated with lower quality of life. OBJECTIVE: The aim of this study was to investigate the effects of non-dipper blood pressure pattern in patients with COPD. METHODS: A cross-sectional study was carried out with 142 patients with COPD. The Saint George Respiratory Questionnaire and the Euro Quality of Life Scale were used to collect data. To understand arterial stiffness, the augmentation index and pulse wave velocity were measured, and 24-hour ambulatory blood pressure monitoring was subsequently performed. A multivariable logistic regression model was used to understand the relationship between different independent variables and blood pressure pattern. P values lower than 0.05 were considered statistically significant. RESULTS: As a result, 76.1% (n = 108) of the patients had non-dipper blood pressure pattern. Non-dipper patients had higher C-reactive protein (OR:1.123; 95% CI:1.016;1.242), augmentation index (OR: 1.057; 95% CI: 1.011;1.105) and Saint George Respiratory Questionnaire total score (OR: 1.021; 95% CI: 1.001;1.042) than dipper patients. Also, as the number of people living at home increased, non-dipper blood pressure pattern was found to be more frequent (OR: 1.339; 95% CI: 1.009;1.777). CONCLUSION: Non-dipper blood pressure pattern may increase cardiovascular risk by triggering inflammation and may adversely affect the prognosis of COPD by lowering the disease-related quality of life. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).

FUNDAMENTO: O padrão pressórico não-dipper é definido por uma redução inferior a 10% na pressão arterial noturna e está associado a doenças cardiovasculares. Acredita-se que a inflamação desempenhe um papel na patogênese da doença pulmonar obstrutiva crônica (DPOC) e no padrão pressórico não-dipper e ambas as doenças estão associadas a uma qualidade de vida mais baixa. OBJETIVO: O objetivo deste estudo foi o de investigar os efeitos do padrão pressórico não-dipper em pacientes com DPOC. MÉTODOS: Foi realizado um estudo transversal incluindo 142 pacientes com DPOC. O Questionário Respiratório de Saint George e a Escala de Qualidade de Vida Euro foram utilizados para a coleta de dados. Para entender a rigidez arterial, o índice de aumento e a velocidade da onda de pulso foram medidos; subsequentemente, foi realizada a monitorização ambulatorial da pressão arterial de 24 horas. Foi aplicado um modelo de regressão logística multivariável para entender a relação entre as diferentes variáveis independentes e o padrão pressórico. Foram considerados estatisticamente significativos valores de p inferiores a 0,05. RESULTADOS: Como resultado, 76,1% (n = 108) dos pacientes apresentaram o padrão pressórico não-dipper. Os pacientes com padrão não-dipper apresentaram valores mais altos de proteína C reativa (OR: 1,123; IC 95%: 1,016;1,242), índice de aumento (OR: 1,057; IC 95%: 1,011;1,105) e pontuação total no Questionário Respiratório de Saint George (OR: 1,021; IC 95%: 1,001;1,042), em comparação com os pacientes com padrão dipper. Adicionalmente, com o aumento do número de pessoas que habitavam o domicílio, verificou-se que o padrão pressórico não-dipper era mais frequente (OR: 1,339; IC 95%:1,009;1,777). CONCLUSÃO: O padrão pressórico não-dipper pode aumentar o risco cardiovascular ao desencadear a inflamação e pode afetar adversamente o prognóstico da DPOC diminuindo a qualidade de vida relacionada à doença. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).

Relationship between Postmenopausal Vitamin D Level, Menopausal Symptoms and Sexual Functions.

OBJECTIVE: To determine whether vitamin D levels correlate with menopausal symptoms and female sexual functions. STUDY DESIGN: A cross-sectional study. PLACE AND DURATION OF STUDY: Izmir Katip Celebi University Hospital, Izmir, Turkey, between February and October 2017. METHODOLOGY: Menopausal and sexual active ladies aged 40-70 years were inducted. Those with psychiatric disorders, endocive abnormalities, related therapy, and malignancy were excluded. Menopause Rating Scale (MRS), and the Female Sexual Function Index (FSFI) were used to collect data. Also blood samples were collected from the patients. The study's data were examined with logistic and linear regression models. RESULTS: Total MRS scale scores of the 303 subjects with one of the following conditions had a higher menopause symptom score; chronic disease, vaginal discharge, chronic pain, unsatisfied with sex, sleep problems, and low vitamin D level (p=0.023, p=0.007, p<0.001, p<0.001, p=0.017, and p<0.001; respectively). It was found that those who have middle income level were more likely to have better sexual function (OR: 0.209, 95% CI: 0.065; 0.671) compared to those who have low income level. It was found that those with higher MRS somatic complaint (OR: 1.274; 95% CI: 1.087; 1.494) and urogenital complaint (OR: 1.670; 95% CI: 1.326; 2.102) and ones with lower vitamin D levels (OR: 0.963; %95 CI: 0.941; 0.987) were more likely to report complaints for sexual function disorders. CONCLUSION: Vitamin D of all women in menopause should be evaluated. High vitamin D levels should reduce menopausal symptoms and positively affect sexual function.

Health-related quality of life and perceived health status of Turkish population.

PURPOSE: This study was conducted to assess the health-related quality of life (HRQOL) and perceived health status of the Turkish population. METHODS: The data came from a nationwide survey, which was conducted by Ministry of Health on prevalence and risk factors for chronic diseases in Turkey, with a representative random sample of 18,477 people aged ≥ 15 years from Turkey. Each family physician invited two individuals selected from their registered population to the Family Health Center, conducted the survey by face to face interviews using an electronic form. HRQOL was determined using EQ-5D-3L scale. RESULTS: In Turkish population, each four women out of 10, two men out of 10 have problems in pain/discomfort and anxiety/depression dimensions of the scale; three women out of 10, one man out of 10 have some or severe problems in mobility. Proportion of people without health problems (health state 11,111) were 64,1% in men, 40,7% in women. The mean VAS score for males was 71.5 ± 0.2 (95% CI 70.9-72.1), 66.4 ± 0.2 (95% CI 65.8-66.9) for females (p < 0.05).The most important determinants of having a problem in any of the five dimensions are age, gender, education, diabetes mellitus, coronary heart disease, stroke, alzheimer, cancer, renal failure. The OR of having some or severe problems in any dimensions was 4.6 (95% CI 38-5.4) for over 65-74 and 7.5 (95% CI 5.8-9.6) for over 75 compared to 15-24 age group. CONCLUSIONS: The perceived health level and HRQOL is worse in women, in older age groups, in people from lower socioeconomical status.

How primary care reforms influenced health indicators in Manisa district in Turkey: Lessons for general practitioners.

BACKGROUND: Turkish health reforms began in 2003 and brought some significant changes in primary care services. Few studies in Turkey compare the shift from health centres (HC) to family physicians (FP) approach, which was initiated by reforms. OBJECTIVES: This study compares health status indicators during the HC period before reforms (2003-2007) and the FP period after reforms (2008-2012) in Turkey. METHODS: This study encompasses time series data consisting of the results of a 10-year assessment (2003-2012) in Manisa district. All the data were obtained electronically and by month. The intersection points of the regression curves of these two periods and the beta coefficients were compared using segmented linear regression analysis. RESULTS: The mean number of follow-up per person/year during the HC period in infants (10.5), pregnant women (6.6) and women (1.8) was significantly higher than the mean number of follow-up during the FP period in infants (6.7), pregnant women (5.6) and women (0.9). Rates of BCG and measles vaccinations were significantly higher during the FP period; however, rates of HBV and DPT were same. The mean number of outpatient services per person/year during the FP period (3.3) was significantly higher than HC period (2.8). Within non-communicable diseases, no difference was detected for hypertension prevalence. Within communicable diseases, there was no difference for rabies suspected bites but acute haemorrhagic gastroenteritis significantly decreased. The infant mortality rate and under five-year child mortality rate significantly increased during the FP period. CONCLUSION: Primary care services should be reorganized and integrated with public health services.

Is 18F-FDG PET/CT a valuable diagnostic tool for verifying accelerated atherosclerosis secondary to diabetes mellitus on insulin in the aortic segments and large arteries?

OBJECTIVE: Fluorine-18 fluorodeoxylglucose positron emission tomography/computed tomography (18F-FDG PET/CT) has a well-established role for detection and quantification of atherosclerotic inflammatory disease using standardized uptake value (SUV) measurements. Our aim was to compare the inflammatory and macroscopic calcification processes of atherosclerosis in the aortic segments and large arteries of subjects with insulin dependent diametes mellitus (IDDM) compared to those of age-matched controls via 18F-FDG PET/CT. PATIENTS AND METHODS: A hundred and ten subjects who underwent 18F-FDG PET/CT imaging for oncological diseases were retrospectively studied. Fifty five were diabetics on insulin and 55 were age-matched controls. Average SUVmax and SUVmean for four segments of aorta and for common iliac arteries and femoral arteries were measured and compared between subject groups. Presence or absence of macroscopic calcification on CT images for each arterial segment was also noted and compared between these groups. RESULTS: Average SUVmax and SUVmean were statistically significantly greater in subjects with IDDM compared to controls in all arterial segments (P≤0.001). Presence of calcification on CT was more frequently encountered in 6 of the 8 segments in subjects with IDDM, and there was statistically significantly difference for the descending aorta and abdominal aorta. CONCLUSION: Our results show that inflammatory component of atherosclerosis was more severe in all aortic segments in subjects with IDDM compared to those of controls. Presence of macroscopic calcification also detected to be more frequently encountered in the descending thoracic and abdominal aorta in subjects with IDDM. Fluorine-18-FDG PET/CT is a valuable diagnostic tool for detecting and semi-quantifying accelerated atherosclerotic inflammatory and calcific changes secondary to diabetes mellitus treated with insulin in the aortic segments and large arteries.

Maternal SSRI discontinuation, use, psychiatric disorder and the risk of autism in children: a meta-analysis of cohort studies.

We undertook an exclusive meta-analysis of cohort studies investigating the possible link between prenatal selective serotonin reuptake inhibitor (SSRI) exposure and autism spectrum disorders (ASD) in children to further investigate our previous suggestion of confounding by indication. The point estimates regarding the following cohorts were extracted and pooled: (1) pregnant women who discontinued SSRI until 3 months before pregnancy; (2) pregnant women who were exposed to SSRI during pregnancy; and (3) pregnant women with maternal psychiatric disorder but no exposure to SSRI during pregnancy. Although the pooled point estimate of the first cohort showed a trend for increase, it did not reach significance. The pooled point estimates of the latter cohorts showed a significant association with ASD which strengthens our previous suggestion of confounding by indication. Future studies should be adequately designed to differentiate whether the previously suggested association is a result of maternal psychiatric disorder or SSRI exposure or both.

Counselling pregnant women at the crossroads of Europe and Asia: effect of Teratology Information Service in Turkey.

Background Previous studies from western countries demonstrated the effectiveness of Teratology Information Service (TIS) counselling in reducing the teratogenic risk perception of pregnant women. Objective To assess whether TIS counselling would be effective in reducing the teratogenic risk perception of the Turkish pregnant women. Setting A TIS (Terafar) operating in a university hospital in Turkey. Methods A cross-sectional survey study. Pregnant women with non-teratogenic medication exposures were asked to assign scores on visual analogue scales (VAS) in response to the questions aiming to measure their teratogenic risk perception. The mean score before and after counselling were compared and the associations with maternal socio-demographic characteristics were analysed using SPSS (Version 20.0). Main outcome measures The differences in the mean scores of the perception regarding the baseline risk of pregnancy, own teratogenic risk and the likelihood of termination of pregnancy before and after counselling and their possible associations with maternal socio-demographic characteristics. Results 102 pregnant women participated in the study. The counselling significantly reduced the mean own teratogenic risk perception score and the mean score for the likelihood of termination of pregnancy whereas the mean baseline risk perception score was not significantly changed. Pregnancy week <8 and the exposed number of active ingredients <3 were significantly associated with the difference in the mean score for the likelihood of termination of pregnancy. Conclusions TIS counselling lowers the teratogenic risk perception of Turkish pregnant women and increases their likelihood to continue the pregnancy as it does in the western countries.

Prenatal selective serotonin reuptake inhibitor use and the risk of autism spectrum disorder in children: A systematic review and meta-analysis.

OBJECTIVE: To determine whether an up-to-date systematic review and meta-analysis of observational studies would support the previously suggested associations regarding prenatal selective serotonin reuptake inhibitor (SSRI) use and the risk for autism spectrum disorders (ASD) in children. METHODS: PubMed/MEDLINE, Cochrane Central Register of Controlled Trials and Reprotox databases were searched; observational studies with an exposed and unexposed group were included. RESULTS: The meta-analysis of case-control studies demonstrated a significantly increased risk of ASD in the children whose mothers were prenatally exposed to SSRIs during different exposure time windows (except third trimester). The qualitative review of the cohort studies suggested inconsistent findings. CONCLUSIONS: The significant association between preconception-only SSRI exposure and ASD in the children and negative/inconsistent findings among cohort studies weaken the significant associations detected in this meta-analysis. We suggest that confounding by indication still cannot be ruled out regarding prenatal SSRI exposure and ASD in children.

Potential benefits of healthy food and lifestyle policies for reducing coronary heart disease mortality in Turkish adults by 2025: a modelling study.

OBJECTIVE: This study uses a modelling approach to compare the potential impact of future risk factor scenarios relating to smoking, physical activity levels, dietary salt, saturated fat intake, mean body mass index (BMI) levels, diabetes prevalence and fruit and vegetable (F&V) consumption on future coronary heart disease (CHD) mortality in Turkey for year 2025. DESIGN: A CHD mortality model previously developed and validated in Turkey was extended to predict potential trends in CHD mortality from 2008 to 2025. SETTING: Using risk factor trends data from recent surveys as a baseline, we modelled alternative evidence-based future risk factor scenarios (modest/ideal scenarios). Probabilistic sensitivity analyses were conducted to account for uncertainties. SUBJECT: Projected populations in 2025 (aged 25-84) of 54 million in Turkey. RESULTS: Assuming lower mortality, modest policy changes in risk factors would result in ∼25 635 (range: 20 290-31 125) fewer CHD deaths in the year 2025; 35.6% attributed to reductions in salt consumption, 20.9% to falls in diabetes, 14.6% to declines in saturated fat intake and 13.6% to increase in F&V intake. In the ideal scenario, 45 950 (range: 36 780-55 450) CHD deaths could be prevented in 2025. Again, 33.2% of this would be attributed to reductions in salt reduction, 19.8% to increases in F&V intake, 16.7% to reductions in saturated fat intake and 14.0% to the fall in diabetes prevalence. CONCLUSIONS: Only modest risk factor changes in salt, saturated/unsaturated fats and F&V intake could prevent around 16 000 CHD deaths in the year 2025 in Turkey, even assuming mortality continues to decline. Implementation of population-based, multisectoral interventions to reduce salt and saturated fat consumption and increase F&V consumption should be scaled up in Turkey.

Determinants of prevalence, awareness, treatment and control of high LDL-C in Turkey.

OBJECTIVE: High blood cholesterol is one of the main modifiable risk factors for cardiovascular diseases (CVDs). The aim of the study is to determine the factors associated with the prevalence, awareness, treatment, and control of high "low-density lipoprotein-cholesterol" (LDL-C) among adults aged ≥20 years in Turkey. METHODS: We used data from Chronic Diseases and Risk Factors Survey conducted in 2011-2012. The presence of high LDL-C, lipid-lowering treatment eligibility, and achievement of target LDL-C were defined according to the third Adult Treatment Panel guidelines on treatment of high cholesterol. Multivariate logistic regression analyses were performed to determine the associations between participant characteristics and high LDL-C prevalence, awareness, treatment, and control. RESULTS: Framingham risk score categorization was performed for 13121 individuals aged ≥20 years. Approximately, 28% of the participants presented with high LDL-C. Among those with high LDL-C, 55.8% were aware of their situation; among those aware of high LDL-C, 46.9% were receiving lipid-lowering medication, and 50.6% of individuals who were receiving treatment achieved target LDL-C levels on the basis of their coronary heart disease (CHD) risk. Control of high LDL-C was negatively associated with the presence of diabetes mellitus (odds ratio: 0.36, 95% CI: 0.27-0.49, p<0.001). CONCLUSION: Despite the high awareness rates, there was a high proportion of adults who did not receive treatment or achieve recommended levels of LDL-C during treatment. The low treatment and control levels among individuals based on their CHD risk levels call for a better application of recommendations regarding personal preventive measures and treatments in Turkey.

Determinants of Breast and Cervical Cancer Screening Uptake Among Women in Turkey.

The aim of the study was to assess the influence of sociodemographic characteristics on breast and cervical cancer screening among women 30 years and older in Turkey. We used data from the National Chronic Diseases and Risk Factors Survey conducted by the Ministry of Health in 2011. Multivariate logistic regression analysis was used to assess the association of sociodemographic factors, lifestyle variables, and cancer screening. Overall, 22.0% of women ever had a Pap smear test for cervical cancer screening and 19.0% ever had a mammography for breast cancer screening(n = 6846). Individuals with a university degree, social security, doing moderate physical activity, and consuming 5 portions of fruit or vegetable/day were more likely to receive Pap smear test and mammography. Residing in the eastern region and living in rural area was associated with lower likelihood of receiving both types of screening.

Determinants of prevalence, awareness, treatment and control of high LDL-C in Turkey.

OBJECTIVE: High blood cholesterol is one of the main modifiable risk factors for cardiovascular diseases (CVDs). The aim of the study is to determine the factors associated with the prevalence, awareness, treatment, and control of high "low-density lipoprotein-cholesterol" (LDL-C) among adults aged ≥20 years in Turkey. METHODS: We used data from Chronic Diseases and Risk Factors Survey conducted in 2011-2012. The presence of high LDL-C, lipid-lowering treatment eligibility, and achievement of target LDL-C were defined according to the third Adult Treatment Panel guidelines on treatment of high cholesterol. Multivariate logistic regression analyses were performed to determine the associations between participant characteristics and high LDL-C prevalence, awareness, treatment, and control. RESULTS: Framingham risk score categorization was performed for 13121 individuals aged ≥20 years. Approximately, 28% of the participants presented with high LDL-C. Among those with high LDL-C, 55.8% were aware of their situation; among those aware of high LDL-C, 46.9% were receiving lipidlowering medication, and 50.6% of individuals who were receiving treatment achieved target LDL-C levels on the basis of their coronary heart disease (CHD) risk. Control of high LDL-C was negatively associated with the presence of diabetes mellitus (odds ratio: 0.36, 95% CI:0.27-0.49, p<0.001). CONCLUSION: Despite the high awareness rates, there was a high proportion of adults who did not receive treatment or achieve recommended levels of LDL-C during treatment. The low treatment and control levels among individuals based on their CHD risk levels call for a better application of recommendations regarding personal preventive measures and treatments in Turkey.

Contrasting cardiovascular mortality trends in Eastern Mediterranean populations: Contributions from risk factor changes and treatments.

BACKGROUND: Middle income countries are facing an epidemic of non-communicable diseases, especially coronary heart disease (CHD). We used a validated CHD mortality model (IMPACT) to explain recent trends in Tunisia, Syria, the occupied Palestinian territory (oPt) and Turkey. METHODS: Data on populations, mortality, patient numbers, treatments and risk factor trends from national and local surveys in each country were collated over two time points (1995-97; 2006-09); integrated and analysed using the IMPACT model. RESULTS: Risk factor trends: Smoking prevalence was high in men, persisting in Syria but decreasing in Tunisia, oPt and Turkey. BMI rose by 1-2 kg/m(2) and diabetes prevalence increased by 40%-50%. Mean systolic blood pressure and cholesterol levels increased in Tunisia and Syria. Mortality trends: Age-standardised CHD mortality rates rose by 20% in Tunisia and 62% in Syria. Much of this increase (79% and 72% respectively) was attributed to adverse trends in major risk factors, occurring despite some improvements in treatment uptake. CHD mortality rates fell by 17% in oPt and by 25% in Turkey, with risk factor changes accounting for around 46% and 30% of this reduction respectively. Increased uptake of community treatments (drug treatments for chronic angina, heart failure, hypertension and secondary prevention after a cardiac event) accounted for most of the remainder. DISCUSSION: CHD death rates are rising in Tunisia and Syria, whilst oPt and Turkey demonstrate clear falls, reflecting improvements in major risk factors with contributions from medical treatments. However, smoking prevalence remains very high in men; obesity and diabetes levels are rising dramatically.

Estimating the potential contribution of stroke treatments and preventative policies to reduce the stroke and ischemic heart disease mortality in Turkey up to 2032: a modelling study.

BACKGROUND: Stroke and Ischemic Heart Diseases (IHD) are the main cause of premature deaths globally, including Turkey. There is substantial potential to reduce stroke and IHD mortality burden; particularly by improving diet and health behaviours at the population level. Our aim is to estimate and compare the potential impact of ischemic stroke treatment vs population level policies on ischemic stroke and IHD deaths in Turkey if achieved like other developed countries up to 2022 and 2032. METHODS: We developed a Markov model for the Turkish population aged >35 years. The model follows the population over a time horizon of 10 and 20 years. We modelled seven policy scenarios: a baseline scenario, three ischemic stroke treatment improvement scenarios and three population level policy intervention scenarios (based on target reductions in dietary salt, transfat and unsaturated fat intake, smoking prevalence and increases in fruit and vegetable consumption). Parameter uncertainty was explored by including probabilistic sensitivity analysis. RESULTS: In the baseline scenario, we forecast that approximately 655,180 ischemic stroke and IHD deaths (306,500 in men; 348,600 in women) may occur in the age group of 35-94 between 2012 and 2022 in Turkey. Feasible interventions in population level policies might prevent approximately 108,000 (62,580-326,700) fewer stroke and IHD deaths. This could result in approximately a 17% reduction in total stroke and IHD deaths in 2022. Approximately 32%, 29%, 11% and 6% of that figure could be attributed to a decreased consumption of transfat, dietary salt, saturated fats and fall in smoking prevalence and 22% could be attributed to increased fruit and vegetable consumption. Feasible improvements in ischemic stroke treatment could prevent approximately 9% fewer ischemic stroke and IHD deaths by 2022. CONCLUSIONS: Our modeling study suggests that effective and evidence-based food policies at the population level could massively contribute to reduction in ischemic stroke and IHD mortality in a decade and deliver bigger gains compared to healthcare based interventions for primary and secondary prevention.

Explaining inequalities in Health Care Utilization among Turkish adults: Findings from Health Survey 2008.

BACKGROUND: Turkish health system showed major improvements in health outcomes since initiation of the Health Transition Programme (HTP) in 2003, however little is known regarding income-related inequalities in health care use. The aim of this study was to assess horizontal inequities in health care use in Turkey. METHODS: We used the data from Turkish Health Survey 2008 with 14,655 respondents. We calculated concentration index (C) and horizontal inequity index (HI) to measure the socioeconomic inequalities in utilization of general practitioner (GP) care, specialist care, inpatient care, dental care and emergency care. Contributions of each factor to the observed inequality in health care utilization were assessed through decomposition method. RESULTS: There was a significant pro-rich inequality in specialist care and oral health care utilization among individuals as indicated by positive values of HI (=0.1149) and HI (=0.1137), respectively. However, the poor were more likely to utilize emergency care (HI=-0.0461) and inpatient care (HI=-0.0731). GP care was also slightly pro-poor distributed (HI=-0.0042). CONCLUSION: Pro-poor income-related inequalities in health care use were largely explained by greater health care need among low income groups, while non-need factors were the main determinants for pro-rich utilization (education, residence area). Inequalities in dental and specialist care linked to low income, low education level and rural areas should be given priority by decision makers to reduce the negative impact of utilization on health. Our results provide some evidence of inequity in 2008, after the introduction of HTP and provide a baseline against which the effects of the new reforms can be assessed.

Cardiovascular risk factor trends in the Eastern Mediterranean region: evidence from four countries is alarming.

OBJECTIVES: Many Eastern Mediterranean countries are undergoing dramatic socioeconomic, demographic and life style changes and face noncommunicable disease (NCD) epidemics. We evaluated recent trends in major NCD risk factors in occupied Palestinian territories (OPT), Turkey, Syria and Tunisia. METHODS: We searched published and unpublished sources for systolic blood pressure (SBP), diabetes, smoking, body mass index (BMI), and cholesterol trends for both men and women aged 35-84 in each country from 1995 to 2009. RESULTS: Smoking prevalence was stable over time in Tunisia and Syria, but decreasing in Turkey (annual change -0.9%) and OPT (annual change -0.7%). Mean BMI (annual change of 0.1% for Turkey, 0.2% for OPT and Tunisia and 0.3% in Syria) and diabetes (annual change of 0.3% for Turkey, 0.4% for OPT and Tunisia and 0.7% in Syria) prevalence increased in each country. SBP levels increased slightly in Tunisia and Syria but decreased in OPT and Turkey. CONCLUSIONS: Recent risk factor trends are worrying. Good quality data on the extent and determinants of NCDs are essential to respond the changing health needs of populations with burgeoning NCD epidemics.

Priority setting for the prevention and control of cardiovascular diseases: multi-criteria decision analysis in four eastern Mediterranean countries.

OBJECTIVES: To explore the feasibility of using a simple multi-criteria decision analysis method with policy makers/key stakeholders to prioritize cardiovascular disease (CVD) policies in four Mediterranean countries: Palestine, Syria, Tunisia and Turkey. METHODS: A simple multi-criteria decision analysis (MCDA) method was piloted. A mixed methods study was used to identify a preliminary list of policy options in each country. These policies were rated by different policymakers/stakeholders against pre-identified criteria to generate a priority score for each policy and then rank the policies. RESULTS: Twenty-five different policies were rated in the four countries to create a country-specific list of CVD prevention and control policies. The response rate was 100% in each country. The top policies were mostly population level interventions and health systems' level policies. CONCLUSIONS: Successful collaboration between policy makers/stakeholders and researchers was established in this small pilot study. MCDA appeared to be feasible and effective. Future applications should aim to engage a larger, representative sample of policy makers, especially from outside the health sector. Weighting the selected criteria might also be assessed.

Determinants of inpatient costs of angina pectoris, myocardial infarction, and heart failure in a university hospital setting in Turkey.

OBJECTIVE: This study aimed to determine the correlates of in-hospital costs for angina pectoris (AP), myocardial infarction (MI), and heart failure (HF) in a university hospital setting. METHODS: This is a retrospective cost-of-illness study using data from the records of patients who were admitted with AP, MI, or HF to Dokuz Eylül University Hospital during 2008. Direct medical costs were calculated from the Social Security Institute perspective using a bottom-up approach. Socio-demographic and clinical information was abstracted from patient files. Costs were presented in Turkish lira (TL). A generalized linear model was used in the multivariate analysis. RESULTS: We included 337 in-patients in total in the study. AP was present in 26.4% (n=89), MI was present in 55.8% (n=188), and HF was present in 17.8% (n=60) of patients. MI was the most costly disease (2760 TL), followed by HF (2350 TL) and AP (1881 TL). The largest proportion of the total cost was formed by medical interventions (27.5%), followed by surgery (22.2%). Presence of DM, smoking, diagnosis of MI, HF, need for intensive care, and resulting in death were strong predictors of treatment costs. CONCLUSION: Both preadmission characteristics of patients (diabetes mellitus, smoking, use of anti-aggregant before admission) and in-patient characteristics (diagnosis, coronary artery bypass grafting, intensive care need, death) predicted the hospital cost of cardiovascular diseases (CVDs) independently. Our results may be used as input for health-economic models and economic evaluations to support the decision-making of reimbursement and the cost-effectiveness of public health interventions in healthcare.