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.

¿Son los criterios de vigilancia activa suficientes para predecir el cáncer de próstata de estadio avanzado? / Are active surveillance criteria sufficient for predicting advanced stage prostate cancer patients?

Objetivos: Examinar los resultados del tratamiento en pacientes con cáncer de próstata (CP) tratados con prostatectomía radical (PR) que podrían ser buenos candidatos para vigilancia activa (VA) y evaluar la confianza y fiabilidad de los criterios de VA para predecir la enfermedad en estadios avanzados (puntuación de Gleason en PR ≥ 7 o estadio patológico T3). Métodos: Entre 2005 y 2012 se examinaron los registros de 401 pacientes sometidos a PR con un diagnóstico de CP. De estos pacientes 173 resultaron ser candidatos para VA. Los criterios de inclusión fueron los siguientes: estadio clínico T2a o inferior, PSA < 10 ng/ml, 2 o menos núcleos afectados por cáncer, ningún núcleo con una afectación máxima por cáncer del 50% o más y ninguna puntuación de Gleason mayor de 3 en la muestra. Resultados: Los análisis univariantes revelaron que los pacientes con un estadio más avanzado de la enfermedad tenían una densidad del antígeno prostático específico (PSAD) más elevada, un mayor porcentaje máximo (% máx) de núcleos positivos y un mayor volumen tumoral en PR. En los análisis multivariantes la PSAD, el % máx de núcleos positivos y el volumen tumoral en PR eran factores estadísticamente significativos de enfermedad en estadios avanzados. Los análisis ROC revelaron que el volumen tumoral en PR es un buen test de la enfermedad en estadio avanzado. Conclusiones: Se debería considerar reducir los valores umbral de PSAD y % máx en núcleos positivos como criterios de inclusión para VA. Si se pudiera calcular el volumen tumoral antes de la PR podríamos minimizar los fracasos del tratamiento (exceso o falta de tratamiento) de CP. Quizás los nuevos protocolos de biopsias, los biomarcadores de tejidos y la tecnología de imágenes moleculares puedan perfeccionar los criterios para VA

Objectives: To examine the treatment outcomes of the prostate cancer (PCa) patients treated by radical prostatectomy (RP) who could be good candidates for active surveillance (AS) and test the confidence and reliability of the AS criteria for predicting advanced stage disease (RP Gleason score ≥7 or pathological stage T3). Methods: Between 2005 and 2012 the records of the 401 patients who underwent RP with a diagnosis of PCa were examined. Of these patients, 173 were found to be candidates of AS. The inclusion criteria were as follows; clinical stage T2a or less, PSA < 10 ng/ml, 2 or fewer cores involved with cancer, no single core with 50% or greater maximum involvement of cancer, and no Gleason grade greater than 3 in the specimen. Results: Univariate analyses revealed that patients with advanced stage disease have higher prostate specific antigen density (PSAD), higher maximum percent (max %) in positive cores and higher RP tumor volumes. In multivariate analyses PSAD, max % in positive cores and RP tumor volumes were statistically significant determinants for advanced stage disease. ROC analyses revealed that the RP tumor volume is a good test on advanced stage disease. Conclusions: Decreasing the cutoff values for PSAD and max% in positive cores should be considered for AS inclusion criteria. If we could calculate the tumor volume before RP, we can minimize the treatment failures (over or under treatment) of PCa. Perhaps new biopsy protocols, tissue biomarkers, and molecular imaging technology may refine AS criteria

Objectives: To examine the treatment outcomes of the prostate cancer (PCa) patients treated by radical prostatectomy (RP) who could be good candidates for active surveillance (AS) and test the confidence and reliability of the AS criteria for predicting advanced stage disease (RP Gleason score ≥7 or pathological stage T3). Methods: Between 2005 and 2012 the records of the 401 patients who underwent RP with a diagnosis of PCa were examined. Of these patients, 173 were found to be candidates of AS. The inclusion criteria were as follows; clinical stage T2a or less, PSA < 10 ng/ml, 2 or fewer cores involved with cancer, no single core with 50% or greater maximum involvement of cancer, and no Gleason grade greater than 3 in the specimen. Results: Univariate analyses revealed that patients with advanced stage disease have higher prostate specific antigen density (PSAD), higher maximum percent (max %) in positive cores and higher RP tumor volumes. In multivariate analyses PSAD, max % in positive cores and RP tumor volumes were statistically significant determinants for advanced stage disease. ROC analyses revealed that the RP tumor volume is a good test on advanced stage disease. Conclusions: Decreasing the cutoff values for PSAD and max% in positive cores should be considered for AS inclusion criteria. If we could calculate the tumor volume before RP, we can minimize the treatment failures (over or under treatment) of PCa. Perhaps new biopsy protocols, tissue biomarkers, and molecular imaging technology may refine AS criteria

Are active surveillance criteria sufficient for predicting advanced stage prostate cancer patients?

OBJECTIVES: To examine the treatment outcomes of the prostate cancer (PCa) patients treated by radical prostatectomy (RP) who could be good candidates for active surveillance (AS) and test the confidence and reliability of the AS criterias for predicting advanced stage disease (RP Gleason score≥7 or Pathological stage T3). METHODS: Between 2005 and 2012 the records of the 401 patients who underwent RP with a diagnosis of PCa were examined. Of these patients, 173 were found to be candidates of AS. The inclusion criteria were as follows; clinical stage T2a or less, PSA<10ng/ml, 2 or fewer cores involved with cancer, no single core with 50% or greater maximum involvement of cancer, and no Gleason grade greater than 3 in the specimen. RESULTS: Univariate analyzes revealed that patients with advanced stage disease have higher prostate specific antigen density (PSAD), higher maximum percent (max%) in positive cores and higher RP tumor volumes. In multivariate analyzes PSAD, max% in positive cores and RP tumor volumes were statistically significant determinants for advanced stage disease. ROC analyzes revealed that the RP tumor volume is a good test on advanced stage disease. CONCLUSIONS: Decreasing the cutoff values for PSAD and max% in positive cores should be considered for AS inclusion criteria. If we could calculate the tumor volume before RP, we can minimize the treatment failures (over or undertreatment) of PCa. Perhaps new biopsy protocols, tissue biomarkers, and molecular imaging technology may refine AS criteria.

The value of spectrophotometric intracutaneous analysis in the noninvasive diagnosis of nonmelanoma skin cancers.

BACKGROUND: Spectrophotometric intracutaneous analysis (SIAscopy) is a recently introduced, noninvasive, rapid and practical method for monitoring pigmented lesions, which calculates the amount of collagen, melanin and haemoglobin deep in the papillary dermis. AIM: To evaluate the value of SIAscopy in the diagnosis of nonmelanoma skin cancers (NMSC). METHODS: In total, 80 lesions of 76 patients were clinically evaluated by the first investigator, and the data recorded. Eight months after the clinical evaluation, all lesions were evaluated again by the same investigator, using images (SIAgraphs) obtained by the SIAscope. All SIAgraphs were also evaluated by a second investigator, and all dermatoscopic images by a third, independently of each other. All diagnoses were compared with histopathological diagnoses. RESULTS: The clinical diagnosis was calculated to have a sensitivity of 79% and specificity of 84%. The SIAscopic diagnoses of the first and second investigators had a sensitivity of 55% and 93%, and a specificity of 88% and 53%, respectively, while the dermatoscopic diagnoses of the third investigator had a sensitivity of 86% and specificity of 80%. There was no statistical accordance between the first and second investigators according to the accuracy of SIAscopic diagnoses (P < 0.01). The area under the curve for the receiver operator characteristic was 0.82 for clinical diagnosis, 0.73 and 0.80 for the SIAscopic evaluation of the first and the second investigators, respectively, and 0.87 for the dermatoscopic evaluation of the third investigator. CONCLUSIONS: Our findings show that dermatoscopic findings are more valuable than SIAscopic and clinical findings for the noninvasive diagnosis of NMSC. We consider that SIAscopy makes no substantial contribution towards the differential diagnosis of NMSC.

Children and firearms in Turkish homes.

BACKGROUND: Unintentional firearm injuries are an important cause of preventable deaths and disabilities among children. Keeping firearms at home and letting children to see or touch them increases the risk of injury. METHODS: This cross-sectional study was conducted to estimate the extent of the firearm problem in an Anatolian province in Turkey. A random sample of families were approached and were asked to answer a series of questions completed by research assistants. RESULTS: In 974 randomly selected households, there were 2129 children aged less than 18 years, 11.1% of the fathers have a job in the firearms industry or in the security sector, and 12.3% of the households kept a firearm at home. Only 25.6% of the firearms were kept in a safe place, and 29.3% of the firearms and ammunition were kept separately. Overall, 70.9% of the children whose parents have firearms saw the firearm and 27.2% had handled it. CONCLUSIONS: Results of this study pointed to the urgent need for preventive measures for the physical separation of guns from children. The establishment of effective firearms safety programmes requires an understanding of the culture and routine behaviours of the target population.

WITHDRAWN: Transoesophageal Echocardiographic Diagnosis of Aortico-Left Atrial Fistula in Aortic Valve Endocarditis.

The publisher regrets that this was an accidental duplication of an article that has already been published in Eur. J. Echocardiogr., 4 (2003) 221-222, . The duplicate article has therefore been withdrawn.

Transoesophageal echocardiographic diagnosis of aortico-left atrial fistula in aortic valve endocarditis.

Intra-cardiac fistulas are rarely seen and they are estimated to account for <1% of all cases of infective endocarditis. Fistulization of paravalvular abscesses has been found in 6% to 9% of cases. This is a report of an unusual communication between the abscess region in the aortic root and the left atrium. A 44-year-old patient diagnosed with infective endocarditis had continuous fevers despite antibiotic therapy. Transoesophageal echocardiography revealed multiple vegetations on aortic valve, fistulization of an aortic root abscess to the left atrium and mitral regurgitation and moderate aortic regurgitation. At surgery, multiple vegetations on the aortic valve and a large abscess cavity establishing direct communication between aortic root and the left atrial cavity through a fistulous tract were discovered. This experience demonstrates the improved sensitivity and specificity of transoesophageal echocardiography in defining periannular extension of infective endocarditis.

A case of coronary artery fistula draining into the pericardium causing hematoma.

A 28-yr old female patient admitted to our clinic because of dyspnea and chest pain. Her transesophageal echocardiography demonstrated a huge mass on the anterolateral wall of the left ventricle causing dysfunction of the myocardium. Coronary angiography demonstrated left anterior descending artery fistula draining into the pericardial cystic mass. Hydatic cyst was suspected and ELISA and hemagglutinin tests were both negative for Echinococcus granulosus. Magnetic resonance image of the heart showed a mass thought to be a hematoma inside the cyst. She underwent surgery. The cystic lesion with a pure hematoma inside, was excised, and the fistula between left anterior descending artery and the mass was ligated without any complications. To our knowledge, this is the first case of a pericardial hematoma due to a coronary artery fistula, in the English literature.

A cardiac papillary fibroelastoma with chordal location.

Papillary fibroelastomas, which were initially incidental findings at autopsy and surgery, are now being recognized with increasing frequency with the widespread use of echocardiography. Because of their embolic potential, an aggressive treatment approach is generally accepted. We report a papillary fibroelastoma located at the chorda of the anterior mitral leaflet that underwent conservative follow-up for 8 years without any complications. Because most of the cardiac papillary fibroelastoma cases reported are incidental findings, the question of whether symptomless fibroelastomas must be removed or other factors contribute to the embolic nature of the selected cases remains a challenge for the future.

Ruptured aneurysm of the sinus of Valsalva into the left ventricle: a case report and review of the literature.

This report describes a case of right coronary sinus of Valsalva aneurysm which ruptured into the left ventricle. The diagnosis was made with two-dimensional transthoracic echocardiography which showed an abnormal structure extending from the aortic root into the left ventricle adjacent to the interventricular septum. Subsequent examinations with transesophageal echocardiography and aortic root angiography and surgical findings confirmed the diagnosis of transthoracic echocardiography. The patient underwent aortic valve replacement. At follow-up 12 months later, the patient was without symptoms and repeated echocardiographic examinations showed no recurrence.

Labour migration from Turkey.

PIP: This study is concerned with Turkish labor migration to Western Europe. Earlier and recent patterns of labor migration, characteristics of migrants by occupation, area of destination, and by geographical origins are discussed. Economic and demographic consequences of labor migration are also analyzed. It is estimated that Turkey's population will reach 73 million at the year 2000 with the present growth rate of 2.48% annually. Considering the efforts made to slow down the present high fertility rates and assuming that the decrease in labor force participation during 1970-1980 continues, the author concludes that the labor supply will increase with a growth rate of 2% annually for the next 13-15 years. Thus, the labor supply will reach 26.6 million people in the year 2000 from the 1980 level of 17.8 million. Assuming also that the income/employment elasticity of .25 which was observed throughout the period of 1960-1980 will not change until 2000, the annual growth rate of employment may be estimated as 1.5%. Thus, the number of people employed will reach 20 million in the year 1990 and 23.2 million in the year 2000. 8.8 million people will join the labor market as new entrants between 1980 and 2000. Only 6 million people out of 8.8 million will be employed. Thus, in the year 2000, it is estimated that 2.8 million new unemployed people will be added to the already open unemployment figure 1980 census data give the number of unemployed as .6 million people. Adding the 2.8 million new unemployed to this figure totals 3.4 million unemployed in 2000. The State Planning Organization's estimate of labor surplus for 1980 was 2.5 million people. When 2.8 million unemployed people are added to this figure, the labor surplus for the year 2000 reaches 5.3 million people.^ieng

[Breast feeding in Turkey: the demographic, socio-economic aspects and relationship to infant/child mortality (author's transl)]. / Turkiye'de emzirme demografik, sosyo-ekonomik yonleri ve cocukolumieri ile iliskisi.

PIP: 1978 Turkish Fertility Survey data were used in this study and the main findings were the following. The percentage of breastfed children born within the 3 years prior to the date of the survey was 89.1%. The percentage of second-to-youngest children who were breastfed was 92.66% while the same figure was 93.32% for the last child; the mean duration of breastfeeding was 11.91, 16.89, and 15.87 months, respectively. Unwanted children were breastfed for a longer period of time than those who were wanted because of the contraceptive effect of breastfeeding. Study results indicate that breastfeeding continued longer among those women with less education. The duration of breastfeeding gradually declined from East Anatolia to the west and from the villages to the cities. A positive relation was found between the duration of breastfeeding and mother's age and boys were breastfed for longer than girls. A statistically significant relation between breastfeeding duration and infant mortality was found in the closed interval but all other independent variables considered jointly, however, provided an explanation for only 13.6% of the changes in breastfeeding. It is suggested that many variables which could not be included in the scope of this survey affect the process of breastfeeding. (author's modified)^ieng