The state of ethics education at medical schools in Turkey: taking stock and looking forward.

BACKGROUND: Ethics teaching is globally considered an essential part of medical education fostering professionalism. It does not only provide knowledge for good clinical conduct, but also trains medical students as virtuous practitioners. Although Turkey has had a considerable experience in ethics education of healthcare professionals, the general state of ethics curricula at medical schools in Turkey is unknown. METHODS: The purpose of this study was to collect comprehensive data about the ethics education programs at medical schools in Turkey. To this aim, we designed a cross-sectional descriptive questionnaire survey which focuses on the content, teaching years, teaching, assessment and evaluation methodologies, workforce and infrastructure. We delivered the questionnaire to all medical schools in Turkey. Seventy-nine medical schools participated in this study (response rate: 78%). RESULTS: Although most institutions had an undergraduate ethics curriculum (91.1%), the findings suggest deficiency of teaching personnel (34.2% had no instructors). Furthermore, the distribution and composition of the workforce was imbalanced. The content varies largely among institutions. Medical schools with an ethics department were more likely to diversify teaching topics. However, ethics education was largely based on the four-principle approach. The content was usually conveyed to students theoretically. Around 90% of schools had classroom lectures. It is the only method used at one-third of them. Clinical ethics education was mostly lacking. Multiple-choice tests were widely used to assess and evaluate student attainments (86.1%). CONCLUSIONS: Staff qualified to teach ethics and ethics education integrated into the six-year medical curriculum given by a multidisciplinary team are urgent necessities. Considering teaching, assessment and evaluation methodologies used, most medical schools seem to fall short of fostering students to develop ethical attitudes. Endeavors aiming for modern topics should be encouraged. As the organization ethics education change continuously, we think that a platform for monitoring ethics education at medical schools in Turkey should be established. Such a body would help ethics instructors to network and find solutions to current problems and build shared wisdom.

The Programmed Cell Death Ligand 1 and Lipocalin 2 Expressions in Primary Breast Cancer and Their Associations with Molecular Subtypes and Prognostic Factors.

Purpose: Breast cancers exhibit molecular heterogeneity, leading to diverse clinical outcomes and therapeutic responses. Immune checkpoint inhibitors targeting PD-L1 have shown promise in various malignancies, including breast cancer. Lipocalin 2 (LCN2) has also been associated with tumor aggressiveness and prognostic potential in breast cancers. However, the expression of PD-L1 and LCN2 in breast cancer subtypes and their prognostic implications remains poorly investigated. Methods: A retrospective analysis of 89 primary breast cancer cases was conducted to assess PD-L1 and LCN2 expressions using immunohistochemistry. Cases were classified into four different molecular subtypes based on ER, PR, HER2, and Ki-67 status. Associations between PD-L1 and LCN2 expressions and various prognostic factors were examined. Results: Although low expression of LCN2 (Allred score of <3) was observed even in normal breast tissue, LCN2 expression with increasing Allred score (≥3) positively correlated with the histological grade, high Ki-67 proliferation index, and ER/PR negativity. Significant elevations of LCN2 and PD-L1 expressions were observed in triple-negative and HER2-positive breast cancers. Conclusion: The results of the study highlight the association of LCN2 with known prognostic factors and molecular subtypes. To identify potential immunotherapy recipients, it would be useful to evaluate LCN2 as well as PD-L1 immune targets in different subgroups of breast cancer patients. Further studies with larger patient numbers are warranted to validate these observations and establish standardized scoring criteria for LCN2 expression assessment.

The Changing Prevalence of Non-Alcoholic Fatty Liver Disease (NAFLD) in Turkey in the Last Decade.

BACKGROUND/AIMS: The true prevalence of Non-Alcoholic Fatty Liver Disease (NAFLD) is unknown in Turkey due to a lack of population-based studies. The aim of this study was (i) to determine the overall and region-specific prevalence of NAFLD in Turkey; (ii) to analyze the factors associated with the prevalence; and (iii) to determine the nationwide change in the prevalence of NAFLD in the last decade. MATERIALS AND METHODS: The 10-year data (2007 to 2016) of 113,239 apparently healthy subjects visiting the check-up clinics of Acibadem Hospitals Group were retrospectively analyzed. A subgroup of patients (n=8120) statistically representing the bigger cohort were selected. The prevalence was analyzed according to ultrasound findings, age, sex, body mass index (BMI), geographical region, and time periods trisected as 2007-2010, 2011-2013 and 2014-2016. RESULTS: The overall prevalence of NAFLD in Turkey was found to be 48.3%. It was highest among people >50 years of age (65.6%), male sex (64.0%), with a BMI>25 kg/m2 (63.5%) and in Central and Eastern Anatolia regions (57.1% and 55.7%, respectively). The prevalence of NAFLD was 43.5% between 2007-2010, 47.6% between 2011-2013 and 53.1% between 2014-2016 and the rate of increase was 22%. Multivariate analysis showed that male sex, serum alanine aminotransferase (ALT) level, older age, BMI, type-II diabetes mellitus, hypertension and dyslipidemia were independent factors associated with NAFLD. CONCLUSION: NAFLD is a highly prevalent disease affecting almost half of the Turkish population (48.3%). We are faced with a dramatic increase in NAFLD prevalence in the past 10 years.

Determination of the upper limits of normal serum alanine aminotransferase (ALT) level in healthy Turkish population.

Background and Aim: Recent studies have reported that the widely accepted range of upper limits of normal (ULN) alanine aminotransferase (ALT) levels (ULN<40U/L) is high for the healthy population. We aimed to find the correct ULN level for men and women in a presumed healthy liver population group. Materials and Methods: The data of 7410 healthy subjects visiting the check-up clinics were retrospectively analysed in this study. Patients were divided in to "healthy liver group" (n=2694) and "high-risk liver group" (n=4716) based on fatty liver on ultrasound, existing of chronic liver disease, ongoing significant alcohol consumption, diabetes mellitus and dyslipidaemia. Receiver operating characteristic (ROC) curves were generated and the area under the curve (AUC) was calculated at the 95th percentiles for both men and women. Results: The AUC score of ALT for men was 0.92, and the ULN for the serum ALT in men was found as 32.10 U/L (sensitivity of 0.89, specificity 0.85). The AUC score of ALT for women was 0.90, and the ULN for serum ALT was found as 23.15 U/L (sensitivity of 0.90, the specificity of 0.88). Conclusion: ULN for serum ALT level should be lowered and different cut-off values should be used for men (32.10 U/L) and women (23.15 U/L).

Patient's perspective: an important issue not to be overlooked in assessing acne severity.

Acne has significant negative effects on an individual's psychosocial functions. There is not always a correlation between the severity of acne and its impact on quality of life. Our objective was to evaluate the correlation between quality of life scales and both the physician's and patient's assessments of acne severity and to find out which quality of life scale is more sensitive to changes in acne severity by using generic and acne specific scales. One hundred and twenty acne patients were enrolled. The physician's assessment of acne severity was made by means of Global Acne Grading System. Patients evaluated their acne severity on a 10-point Likert-type scale. Quality of life was measured by the Turkish version of Acne Quality of Life (AQOL) scale and Short Form-36 (SF-36). One hundred and seven patients answered the questions of the AQOL scale completely and were included in the statistical analysis. The AQOL scale did not correlate with the physician's assessment of acne severity whereas there was a correlation between patients' self assessments and AQOL scale. No correlation was found between SF-36 and either the physician's or patients' own assessments. Assessment of acne should not be limited to objective acne severity measures but also include patients' self assessments and acne specific quality of life scales. These measures, which provide a better understanding of patients' perception of severity, are important tools when taking treatment decisions.

[The prevalence of depression and its associated factors among resident doctors working in a training hospital in Istanbul]. / Istanbul'da Bir Egitim Hastanesinde Calisan Tipta Uzmanlik Ogrencilerinde Depresyon Yayginligi ve Iliskili Etkenler.

OBJECTIVES: The objectives of this study were to determine the prevalence of depression and to evaluate the association of sociodemographic factors, as well as aspects of the work environment, with depression among resident doctors working in a training hospital in Istanbul. METHODS: This cross-sectional study was conducted in a teaching hospital which has 332 residents in Istanbul. The required sample size was determined to be 207. The study population was stratified proportionally according to hospital departments and a random sampling method was used. Data were collected with a questionnaire consisting of sociodemographic variables, the Beck Depression Inventory (BDI), and the Minnesota Job Satisfaction Questionnaire (MJSQ). The associations were studied through univariate and multivariate analyses. FINDINGS: The study included 156 residents who agreed to participate (response rate: 75.3%). The prevalence rate of probable depression was 16.0% (95% CI: 10.7-22.7). In the multivariate analysis, the rate of depression was significantly higher among women compared to men (OR: 5.16, 95% CI: 1.51-17.68, p<0.01). Age, marital status, hospital department, duration of residency, number of night shifts, and duration of exposure to daylight in the work environment were not associated with depression. Among the participants, 90.4% did not want to get a feedback concerning their BDI scores. A negative correlation was determined between depression and job satisfaction scores. CONCLUSION: Among resident doctors, women in particular should be evaluated as an important at-risk group for depression. Prevention and control programs that also include components for reducing stigma should be implemented.

The effects of hyperthermic intraperitoneal chemoperfusion on colonic anastomosis: an experimental study in a rat model.

INTRODUCTION: Cytoreductive surgery (CRS) with subsequent hyperthermic intraperitoneal chemotherapy (HIPEC) is a promising modality to treat and prevent peritoneal metastases. However, this treatment is associated with signficant morbidity and mortality. Whether or not CRS with HIPEC interferes with anastomotic healing has also been debated. This study was designed to investigate the effects of mitomycin C, cisplatin, oxaliplatin, and doxorubicin used in HIPEC treatment on colonic anastomosis healing in a rat model. METHODS: Sixty Wistar albino rats were employed in the study. Sigmoid resection and end-to-end colorectal anastomosis was performed in all rats. Group 1 rats underwent the surgical procedure alone, while group 2 rats were given hyperthermic intraperitoneal lavage with heated saline following surgery. Groups 3, 4, 5, and 6 had surgery with concomitant HIPEC treatment with mitomycin C, cisplatin, oxaliplatin, and doxorubicin, respectively. Anastomotic bursting pressures and hydroxyproline levels were evaluated. RESULTS: Regarding the hydroxyproline levels, groups 1 and 2 showed significantly higher values than other groups (p<0.001). However, there was no significant difference between the HIPEC treatment groups (groups 3, 4, 5, and 6) (p>0.05). When groups were compared regarding bursting pressure values, no significant differences were observed (p = 0.81). CONCLUSIONS: This study demonstrated that the HIPEC procedure with mitomycin C, cisplatin, oxaliplatin and doxorubicin had negative effects on hydroxyproline levels, but had no detrimental effect on anastomotic bursting pressure in a rat model.

Prevalence of hypertension and its association with obesity among school children aged 6-15 living in Sakarya Province in Turkey.

BACKGROUND/AIM: Childhood hypertension and its association with obesity are becoming important issues worldwide. The prevalence of hypertension and obesity are growing in both developed and developing countries. This paper aimed to determine the prevalence of hypertension among school-aged children in Sakarya (western part of Turkey) and to determine whether or not obesity is associated with hypertension. MATERIALS AND METHODS: Twelve schools were randomly selected from an area in the center of the Sakarya. A total of 2166 students participated in the study. The students were visited at school, and their weights, heights, and blood pressures were measured. The World Health Organization references were used to determine the prevalence of overweightness, obesity, and hypertension. RESULTS: The prevalences of hypertension and obesity were 15.1% (n = 326) and 18.0% (n = 390), respectively. Overweightness, obesity included, was found to be present in 26.3% of the children. Sex and obesity were found to be associated with hypertension; nevertheless, a positive family history of hypertension was not associated with hypertension in children. CONCLUSION: The prevalence of obesity and hypertension are high among school children of 6-15 years of age in Sakarya. Obesity is associated with hypertension. Blood pressure measurements should be part of routine clinical examination, especially in obese children.

Knowledge, attitudes and misconceptions of primary care physicians regarding fever in children: a cross sectional study.

BACKGROUND: Fever is an extremely common sign in paediatric patients and the most common cause for a child to be taken to the doctor. The literature indicates that physicians and parents have too many misconceptions and conflicting results about fever management. In this study we aim to identify knowledge, attitudes and misconceptions of primary care physicians regarding fever in children. METHODS: This cross-sectional study was conducted in April-May 2010 involving primary care physicians (n=80). The physicians were surveyed using a self-administered questionnaire. Descriptive statistics were used. RESULTS: In our study only 10% of the physicians knew that a body temperature of above 37.2 °C according to an auxiliary measurement is defined as fever. Only 26.2% of the physicians took into consideration signs and symptoms other than fever to prescribe antipyretics. 85% of the physicians prescribed antipyretics to control fever or prevent complications of fever especially febrile seizures. Most of the physicians (76.3%) in this study reported that the height of fever may be used as an indicator for severe bacterial infection. A great majority of physicians (91.3%) stated that they advised parents to alternate the use of ibuprofen and paracetamol. CONCLUSIONS: There were misconceptions about the management and complications of fever. There is a perceived need to improve the recognition, assessment, and management of fever with regards to underlying illnesses in children.

Maternal psychological problems associated with neonatal intensive care admission.

Background. Mothers of infants admitted to a neonatal intensive care unit (NICU) are believed to have heightened distress. The purpose of this paper was to determine depression and anxiety symptoms and attachment style in NICU mothers. Methods. The NICU group consisted of mothers whose infants were admitted to the NICU and the control group consisted of mothers of healthy term infants. The psychosocial assessments were done at the first month. Results. The mean Edinburgh Postpartum Depression (EPDS) score of NICU mothers was significantly higher than that of the control group mothers (9.6 +/- 5.6 versus 7.3 +/- 4.9, P = .005). NICU mothers who had high EPDS (>/=13) scores had significantly higher anxiety scores and insecure attachment style in comparison to the subgroup of NICU mothers who had low EPDS scores. Conclusion. Mothers of NICU babies had higher EPDS scores. Mothers who had higher EPDS scores had higher anxiety scores as well. These NICU mothers should receive appropriate counseling during the hospitalization of their babies.

Anaesthesia for caesarean section in the presence of multivalvular heart disease and severe pulmonary hypertension: a case report.

INTRODUCTION: Pulmonary hypertension is a rare condition and in combination with pregnancy, it can result in high maternal mortality. Mitral stenosis is one of the complicated cardiac diseases that may occur during pregnancy. In this report, we describe our management of such a case, which was even more difficult in combination with pulmonary hypertension, mitral stenosis, and aortic and tricuspid valve insufficiency requiring emergency caesarean section under general anaesthesia. CASE PRESENTATION: A 29-year-old primiparae was presented to the anaesthetic department for an urgent caesarean section with a diagnosis of severe pulmonary hypertension in combination with mitral stenosis. The patient was hospitalized prepartum and received oxygen therapy and anticoagulation with heparin. The patient was monitored during labour and delivery with oximetry and arterial and central venous pressure line. Pulmonary arterial lines were not used due to an increased risk and questionable usefulness. Echocardiography revealed a systolic pulmonary arterial pressure of 75 mmHg, and mitral stenosis, aortic and tricuspid valve insufficiency. We decided to proceed under general anaesthesia. Anaesthesia was induced with etomidate, and succinylcholine. Dopamine and nitroglycerin infusion was preoperatively started and infusion was also preoperatively continued. Hemodynamic parameters were stable during delivery. Neonatal weight and apgar score were satisfactory. After the delivery of a healthy baby, oxytocin was administered. Surgery was completed uneventfully. During the postoperative period, the patient received furosemide and morphine. As the arterial blood gas analyses were stable and the chest-ray was normal, the patient was extubated postoperatively in the second hour in ICU. CONCLUSION: Patients with significant multivalvular heart disease require careful preoperative, multidisciplinary assessment and anesthetic planning before delivery in order to optimize cardiac function during the peripartum period and make informed decisions regarding the mode of delivery and anaesthetic technique.

Hemodynamic and anesthetic advantages of dexmedetomidine, an alpha 2-agonist, for surgery in prone position.

The alpha2-agonist dexmedetomidine (Dex), a sedative and analgesic, reduces heart rate (HR) and blood pressure, and has been used in the practice of anesthesia. In this study, we aimed to evaluate the effects of Dex on hemodynamic variables, anesthetic sparing effects, and recovery profiles in patients who underwent surgery in prone position. The prone position itself can cause a decrease in the systemic blood pressure. Forty patients who undergo lumbar discectomy were randomly assigned to receive either Dex (a loading dose 1 microg/ kg in 10 minutes followed by an infusion rate of 0.2 microg/ kg/ hr) or saline. In both groups, the anesthesia was induced with fentanyl, thiopental and rocuronium, and maintained with desflurane in 50% N(2)O. Mean arterial blood pressure (MAP), HR, cardiac output (CO), and level of anesthesia were monitored. Recovery times and analgesic requirements were also recorded. As a response to endotracheal intubation, a significant increase in MAP and HR was observed in the control group compared to the Dex group, but no difference in CO. The recovery times were significantly shorter in the Dex group compared to the control group. Anesthetic and analgesic requirements of the Dex group were lower than controls. Thus, the use of Dex caused no detrimental effects on the hemodynamic variables in prone position. In addition, Dex decreased pressure response to intubation, and anesthetic and analgesic requirements, shortened recovery times, and decreased postoperative pain level. Dex may be an alternative to currently used adjunctive anesthetic agents in lumbar discectomy operations.