Insurance-based disparities in breast cancer treatment pathways in a universal healthcare system: a qualitative study.

BACKGROUND: The influence of healthcare system factors on treatment pathways for breast cancer has been studied extensively in lower-middle-income countries (LMICs), but in upper-middle-income countries (UMICs), this area is understudied. This article focuses on the experiences of breast cancer patients in Türkiye, a UMIC with a universal healthcare system. It explores variations in treatment pathways based on the type of health insurance provider (private or state). METHODS: The study uses an exploratory qualitative method based on in-depth interviews with 12 breast cancer patients. The inclusion criteria were Turkish nationality, female gender, and having received treatment from a private hospital within one year of the interview. A purposeful sampling strategy was employed to recruit patients who had either social health insurance only or who had private health insurance in addition to their social health insurance. A two-stage thematic analysis of the interview data was conducted. First, we examined whether the type of insurance provider makes a difference in treatment pathways; we then identified healthcare system factors that explain these differences. RESULTS: The study revealed two distinct pathways to treatment. These differ in terms of financial protection, service coverage, and patients' sense of equity. Patients with private insurance reported easy access to timely and comprehensive treatment. Those without, however, had to navigate complicated routes to treatment; they generally had to resort to seeking treatment from more than one hospital. We found two healthcare system factors that explained the differences: a failure to fully enforce the mandates of the state's social health insurance in the private hospital sector and growing reliance on private insurance to gain access to essential services. CONCLUSIONS: Based on data from the Turkish case, we conclude that healthcare system factors are indeed influential in shaping treatment pathways for breast cancer in UMICs with universal healthcare. These factors include a failure to fully enforce the mandates of the state's social health insurance programme in the private hospital sector and a growing reliance on private insurance to gain access to essential services. We note that this contrasts dramatically with the situation in LMICs, where the main factors are low-quality care and shortages of medical staff, medicines, and technologies.

Cytokine profile in lambs naturally infected with sheeppox virus.

In this study, in order to reveal the immune response against the disease in naturally infected sheep with SPPV, the expressions of various pro- or anti-inflammatory cytokines such as tumour necrosis factor alpha (TNF-α), interferon gamma (IFN-γ), interleukin-1beta (IL-1ß), interleukin-2 (IL-2), interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-10 (IL-10) and interleukin-12 (IL-12) were evaluated immunohistochemically. The material of this study consisted of tissue samples taken from 24 sheep, which were brought as dead for routine histopathological examination to the Department of Pathology. Avidin-biotin-peroxidase method was used for immunohistochemistry. Characteristic pox lesions were observed in the skin, lungs and kidneys. In histopathological examinations, pox cells, which are very characteristic for the diagnosis of the disease, were observed in all three tissues. Capripoxvirus nucleic acid was detected in 8 of the 24 tissues. Samples were sequenced, and a phylogenetic tree was constructed with reference strains from GenBank. Strains from the study clustered with sheeppox virus references. In conclusion, the levels of pro-inflammatory cytokines such as TNF-α, IFN-γ, IL-1ß, IL-2, IL-8 and IL12 (Th1) were much more dominant compared to the levels of anti-inflammatory cytokines: IL-10 and IL-6 (Th2). This supported the fact that the cellular immune response is much more effective than the humoral immune response in sheeppox.

Rethinking Universal Health Coverage: A qualitative study of patient organisation perspectives on the Turkish health-care system.

Universal health coverage (UHC) has been elevated to the status of a global policy target, but this was at the expense of losing its aspirational meaning. As a case in point, Turkey has been one of the countries that has achieved UHC, according to the technocratic definition. This article employs a combination of deductive and inductive thematic analysis methods to explore patient organisation (PO) perspectives on the Turkish health-care system based on 26 respondent interviews from 19 POs in Istanbul. Highlighting the inadequacy of the technocratic definition of UHC, the article maintains that an analysis of PO perspectives opens the way for a nuanced and bottom-up assessment of essential service coverage and financial protection by identifying elusive gaps in both dimensions that would otherwise be lost in generalist evaluations. The findings also underline the importance of keeping intact the UHC's aspirational element to enable POs to participate in the politics of priority setting in health care.

A contextual policy analysis of a cash programme in a humanitarian setting: the case of the Emergency Social Safety Net in Turkey.

The Emergency Social Safety Net (ESSN) programme, which was launched in 2016, has become the central element of the humanitarian response to the plight of Syrian refugees in Turkey and an instrument of European migration control policies. This paper offers a contextual analysis of this European Union-funded cash assistance scheme by examining the modes of interaction between its major assumptions and the broader humanitarian response in the context of Turkey. It finds that the ESSN comes with compromises on humanitarian principles and standards, amplifies the protection and assistance divide, and fails to address the realities of Turkey with respect to the country's housing and labour markets and weak protection framework. The paper concludes that a more inclusive approach to eligibility and higher transfer payments can contribute to the addressing of assistance needs provided that cash support is combined with robust protection programming and the implementation of sector-specific projects and policies.

Phylogenetic analysis of West Nile virus: first report of lineage 1 in donkey in Turkey.

West Nile virus (WNV), a member of the Flaviviridae, is a major arbovirus that causes West Nile fever. Previous data showed the prevalence of the WNV serologically and molecular in Turkey, and the presence of lineage 1 in horses and humans has been reported. This is the first notification of partial phylogeny of WNV detected in donkeys in the northeast of Turkey (on the Iranian border). Blood serum samples collected from 25 donkeys without clinical symptoms were tested by RT-PCR. Sequence analysis of the sample detected as positive was performed. Multiple sequence alignments of reference sequences taken from GenBank were performed using the ClustalW method using the MEGA6 program. Partial nucleotide sequences of the capsid gene coding region revealed that the strains are closely related to viruses of lineage 1, clade 1a. According to the phylogenetic tree, the TUR/Igdir/donkey strain was included in the same cluster as the strain (KJ958922) previously obtained from horses in Turkey and the strain (GQ851658) from the Central African Republic. This study is the first report to show the circulation of WNV lineage 1 in donkeys in Turkey.

Effects of several production methods on technological, textural and sensorial properties of emmer (Triticum turgidum ssp. dicoccum) bulgur.

In recent years, the interest in primitive wheat species including emmer (Triticum turgidum ssp. dicoccum) wheat and their characteristics have increased due to natural food trends. Bulgur is a nutritious and healthy product with long shelf life, produced from hard wheat species without the need for any additives. The basis of this study was to reveal the potential for bulgur production by the six production methods, combinations of three cooking (traditional, autoclave, microwave) and two drying (hot-air, microwave) methods of emmer wheat. In addition to some physical, chemical and technological properties of emmer wheat, yield, color, cooking time and textural and sensorial properties of the bulgur samples were investigated and statistically significant differences (p < 0.05) were recorded among the bulgur samples. Autoclave cooking had a negative effect on color and got the lowest sensorial acceptability scores. Microwave drying increased fine bulgur formation and shortened the cooking time. The volume and weight increase indexes were increased more than hot-air drying thanks to physical effects of microwave drying on the structure. According to the texture analysis results, microwave cooking increased the adhesivity, and microwave drying increased hardness and springiness. In conclusion, emmer wheat have great potential for bulgur production, and traditional cooked + hot air dried samples had better bulgur properties in overall.

Timing of rehabilitation in children with obstetric upper trunk brachial plexus palsy.

OBJECTIVES: The initiation timing of rehabilitation in children with obstetric brachial plexus palsy is controversial. The aim of the present study is to evaluate the effectiveness of rehabilitation timing to the functional outcomes of patients with obstetric upper trunk brachial plexus palsy. MATERIAL AND METHODS: Twenty-nine patients, who did not previously received any rehabilitation programme but attended our outpatient clinic, were included for the study. The electrophysiological findings, obstetric characteristics, and demographic features of the patients were recorded. The range of motion (ROM) of shoulders, elbows, and wrists and the strength of the muscles associated with these joints were evaluated. Modified Mallet Scale (MMS) was used for functional evaluation. A 4-week rehabilitation programme was performed twice at 2-month intervals. Patients were divided into three groups according to their ages as follows: 1-3 years old (group 1), 3-5 years old (group 2), and 5-7 years old (group 3). The ROMs, muscle strengths, and MMS scores of the patients were all evaluated. RESULTS: Two out of 29 patients were female (6.9%) and 27 were male (93.1%). All 29 patients had right upper extremity palsy (100%). The MMS scores, ROMs, and muscle strength of the upper extremities had improved in all the groups following the standardized rehabilitation programme. CONCLUSIONS: A rehabilitation programme is the best choice of treatment before surgical procedures in patients with mild to moderate obstetric upper trunk brachial plexus palsy regardless of age and the initiation time.

The psychometric evaluation of the Turkish version of the Mann Assessment of Swallowing Ability in patients in the early period after stroke

Background/aim: The Mann Assessment of Swallowing Ability (MASA) is an efficient tool that allows physicians to determine the alertness, cooperation, and respiration of patients, which are important factors when assessing swallowing . This study aimed to translate the MASA into Turkish (T-MASA) and to assess its reliability and validity in patients during the early period after a stroke . Materials and methods: The scale was administered to 141 patients in the early period after a stroke. For reliability, both internal consistency (Cronbach's alpha and corrected item-to-total correlations) and interrater reliability were analyzed. The procedures were scored by two blinded independent expert observers. The validity was assessed using the convergent validity. The cut-off value of the T-MASA for dysphagia was accepted as 169 points. The correlation between the MASA and endoscopic evaluation was evaluated. Results: The T-MASA showed good internal consistency using Cronbach's alpha (0.899­0.901) and corrected item-to-total correlations. In addition, the intraclass correlation coefficient scores indicated excellent agreement. A significant moderate negative correlation was found between endoscopic evaluation and the T-MASA in terms of the presence of dysphagia (r: ­0.324, r: ­0.302, respectively, and both P = 0.001) Conclusion: Our results suggest that the Turkish version of the MASA is a valid and reliable instrument when determining dysphagia in patients in the early period after a stroke.

Effect of different production techniques on bioactive compounds and antioxidant capacity of einkorn (Triticum monococcum L.) and durum (Triticum turgidum subsp. durum) bulgur.

BACKGROUND: The influence of cooking (traditional, microwave, autoclave) and drying techniques (microwave and hot air) on bioactive compounds in the production of einkorn and durum bulgur were investigated. Total phenolic content (TPC), total yellow pigment (TYP), total antioxidant capacity (DPPH• , ABTS•+ , FRAP), soluble free (SF), soluble conjugated (SC) and insoluble bound (IB) phenolic acid contents of the samples were determined. RESULTS: For both wheats, a significant amount of antioxidant capacity was preserved after bulgur production. TPC was found to be higher in einkorn but it was exposed to greater loss during bulgur production than durum. The amount of TYP was found to be two-fold higher in einkorn than in durum. Ferulic acid was recorded as the most phenolic acid, and chlorogenic was the least phenolic acid in both wheats. The maximum loss during bulgur production was determined in the SC fraction for einkorn and in the SF fraction for durum. CONCLUSION: In respect of the results of the analysis, microwave cooking + hot air drying treatment could be favourable for bulgur production for both wheats. © 2016 Society of Chemical Industry.

Influence of water biscuit processing and kernel puffing on the phenolic acid content and the antioxidant activity of einkorn and bread wheat.

The whole meal flour of wheat is rich in phenolic acids, which provide a relevant antioxidant activity to food products. Aim of this research was to assess the influence of processing on phenolic acid content and antioxidant activity of whole meal flour water biscuits and puffed kernels of einkorn and bread wheat. To this end, the evolution of syringaldehyde, ferulic, vanillic, syringic, p-coumaric, p-hydroxybenzoic, and caffeic acids was studied during manufacturing. Overall, from flour to water biscuit, the total soluble conjugated phenolic acids increased slightly in einkorn, while the insoluble bound phenolic acids decreased in all the accessions as a consequence of losses during the mixing step. In the puffed kernels, instead, the total soluble conjugated phenolic acids increased markedly, while the bound phenolics did not show any clear change, evidencing their high thermal stability. The antioxidant activity, measured by FRAP and ABTS, increased during processing and was highest under the most drastic puffing conditions.

Etiologic Subtypes of Watershed Infarcts.

BACKGROUND: Two types of watershed infarcts (WI) are recognized. Internal WI are usually attributed to either severe stenosis in large arteries or acute hypotensive events, whereas external WI are thought to be caused by embolism. The aim of this study was to determine the etiologic background and prognosis of external and internal WI in our patients. METHODS: We reviewed the medical records and diffusion-weighted images of the patients who were admitted to our stroke unit with acute ischemic stroke between January 2012 and November 2014. The demographics, clinical features, radiologic investigations, and other etiologic tests of the patients with internal or external WI were recorded. We determined etiologic stroke subtypes according to the automated Causative Classification System. RESULTS: Fifty-three patients with WI were detected in our registry. Twenty-two (41.5%) of them were women. The mean age was 69 ± 12.8 (33-98) years. Twenty-one (39.6%) patients had external WI: 7 (33.3%) of them had large-artery atherosclerosis (LAA), 8 (38.1%) patients had cardioembolism, 3 (14.3%) patients had stroke due to other causes (vasculitis; n = 3), and etiologic subtype was undetermined in 3 patients (14.3%). Thirty-two (60.4%) patients had internal WI: 21 (65.6.%) of them had LAA, 5 (15.6%) patients had cardioembolism, 3 (9.4%) patients had stroke due to other causes (aneurysm; n = 1, hypercoagulability due to chronic myeloid leukemia; n = 1, vasculitis; n = 1), and etiologic subtype of 3 (9.4%) patients remained cryptogenic. LAA was significantly associated with internal WI (P = .024). Hypertension was more common in patients with internal WI (P = .035). CONCLUSIONS: In this series, cardioembolism was the most common etiologic subtype in the patients with external WI, whereas internal WI were significantly associated with LAA. Uncommon causes should also be investigated in cryptogenic patients.

The role of private healthcare sector actors in health service delivery and financing policy processes in low-and middle-income countries: a scoping review.

The expansion of the private healthcare sector in some low-income and middle-income countries (LMICs) has raised key questions and debates regarding the governance of this sector, and the role of actors representing the sector in policy processes. Research on the role played by this sector, understood here as private hospitals, pharmacies and insurance companies, remains underdeveloped in the literature. In this paper, we present the results of a scoping review focused on synthesising scholarship on the role of private healthcare sector actors in health policy processes pertaining to health service delivery and financing in LMICs. We explore the role of organisations or groups-for example, individual companies, corporations or interest groups-representing healthcare sector actors, and use a conceptual framework of institutions, ideas, interests and networks to guide our analysis. The screening process resulted in 15 papers identified for data extraction. We found that the literature in this domain is highly interdisciplinary but nascent, with largely descriptive work and undertheorisation of policy process dynamics. Many studies described institutional mechanisms enabling private sector participation in decision-making in generic terms. Some studies reported competing institutional frameworks for particular policy areas (eg, commerce compared with health in the context of medical tourism). Private healthcare actors showed considerable heterogeneity in their organisation. Papers also referred to a range of strategies used by these actors. Finally, policy outcomes described in the cases were highly context specific and dependent on the interaction between institutions, interests, ideas and networks. Overall, our analysis suggests that the role of private healthcare actors in health policy processes in LMICs, particularly emerging industries such as hospitals, holds key insights that will be crucial to understanding and managing their role in expanding health service access.

Cell proliferation and apoptosis in canine oral papillomatosis.

This study was aimed at the evaluation of cell proliferation, p53 level and apoptotic index by immunohistochemical methods in canine oral papillomatosis. The study material comprised of tumor tissue samples taken from six dogs being admitted to the Pathology Department of Faculty of Veterinary Medicine, Kafkas University, Kars, Türkiye. Choice of immunohistochemical staining was avidin-biotin peroxidase method. Cases of canine oral papillomatosis, determined to have been caused by canine papillomavirus-1, were found to have a rather high cell proliferation index. Furthermore, all cases were immunohisto-chemically demonstrated to carry a mutant p53 gene. Despite the mutation of p53 gene, the shift in the Bax/Bcl-2 ratio of dogs diagnosed with tumor was in favor of the pro-apoptotic Bax gene. The apoptotic mechanism was determined to occur through both the caspase-dependent and caspase-independent pathways. While the lesions occupied the entire oral cavity in some cases, histopathologically, malignant transformation was not detected in any of the six cases.

Evaluation of the relationship between inflammatory reaction and interleukins in ovine pulmonary adenocarcinomas.

In this study, it was aimed to investigate the association between inflammatory reaction of tumoral microenvironments with interleukin responses in ovine pulmonary adenocarcinomas (OPAs). Material of the study consisted of 26 sheep lung tissue samples being brought to the Pathology Department for routine diagnosis. Cases were collected between years 2009 - 2021; pre-diagnosis was based on clinical symptoms, anamnesis and gross lesion of the lungs. These tissues were designated in two groups as control (n = 6) and OPA (n = 20) groups. Choice of immunohistochemical staining was avidin-biotin peroxidase method. Reverse transcription polymerase chain reaction (RT-PCR) was used to confirm Jaagsiekte sheep retrovirus from paraffin-embedded tissues. On gross examination of OPAs, lesions seen were mostly in the caudal lobes of the lung, 1.00 - 2.00 cm in diameter as gray-white consolidated foci and in microscopic observation, tumor cells showed acinar, papillary or mixed growths. No expressions of interleukin (2 and 8) were observed in the control group. All OPAs cases were positive for interleukins (2 and 8) expressions. A total of eight tissue samples were detected as positives through RT-PCR. In conclusion, in this study, it was determined that interleukin-2 and interleukin-8 were produced from tumor microenvironment elements, especially tumor-associated macrophages, and these interleukins showed pro-inflammatory effects. Interleukins and the inflammatory reaction may promote the development of OPA.

Molecular characterisation of ovine herpesvirus type 2 (OvHV-2) in Turkey.

In this study, the physical examination of 22 cattle revealed clinical signs of malignant catarrhal fever (MCF). Peripheral blood leukocyte (PBL) samples of the 22 cattle, and nasal (n = 7) and conjunctival (n = 9) swab samples from 16 sheep from two different farms, were taken for laboratory examination. The clinical diagnosis of MCF in cows was confirmed by the detection of ovine herpesvirus type 2 (OvHV-2) DNA by polymerase chain reaction (PCR). OvHV-2 DNA was detected by nested-PCR in PBL of one cow with clinical signs and nasal (1/7)-conjunctival(1/9) swab samples of two sheep housed in the same barn. According to the sequence analysis, three slightly divergent viruses were detected. The results indicate the need for additional research in different regions of Turkey to gain a better understanding of the incidence of MCF and its implications for the livestock industry.

The effects of the degree of pleural invasion on survival in patients with non-small cell lung cancer undergoing surgical resection.

Background: The aim of this study was to evaluate the degree and size of pleural invasion in non-small cell lung cancer patients and to compare its relationship with the survival time. Methods: Between January 2008 and June 2019, a total of 164 patients (143 males, 21 females; median age: 64.65 years; range 39 to 92 years) who underwent surgical resection with a diagnosis of non-small cell lung cancer and who were found to have pleural invasion histopathologically were retrospectively analyzed. The control group consisted of 105 patients (95 males, 10 females; median age: 61.7 years; range, 32 to 82 years) who underwent surgical resection but who were not found to have pleural invasion histopathologically during the same time period. Survival time was compared between the groups. Results: Median survival was 52 months in the group with pleural invasion, while it was 70.6 months in the group without pleural invasion. In the pleural invasion group, the patients who underwent sublobar resection had shorter survival. The degree of pleural invasion (p=0.028), advanced age (p=0.022), and lymph node involvement (p=0.011) were found to be poor prognostic factors for survival. Conclusion: In non-small cell lung cancer patients, the increase in the degree and size of pleural invasion is negatively correlated with the survival time and this is thought to be associated with advanced disease stage.

Molecular characterization of Bovine virus diarrhea viruses species 2 (BVDV-2) from cattle in Turkey.

Five BVDV species 2 (BVDV-2) isolates were detected from cattle in Turkey. Phylogenetic analysis was performed based on the 5' untranslated regions (UTRs) and E2 coding gene regions, respectively. The isolates were closely related to BVDV-2a strains from North America and Canada used as references. This is the first report of the detection of BVDV-2 in naturally infected Turkish cattle. It is important to consider BVDV-2 for planning future BVDV control and vaccination programs in Turkey.

Temporomandibular Joint Dysfunction and Impaired Stomatognathic Alignment: A Problem Beyond Swallowing in Patients With Stroke.

The aim of this study is to evaluate the efficacy of supervised structured exercise programme in post stroke patients with temporomandibular joint dysfunction (TMJD). 30 post stroke patients diagnosed as TMJD according to "diagnostic criteria for temporomandibular disorders" (DC/TMD) were included for the study. A structured exercise programme including active and active-assisted range of motion (ROM) exercises for neck and temporomandibular joint (TMJ), chins tuck exercises, breathing and relaxing exercises and posture exercises were performed. Cervical ROMs including flexion, extansion, lateral flexion and rotation, Mann assessment of swallowing ability (MASA) and mini mental state exam (MMSE) scores, maximal mouth opening (MMO) and craniomandibular index (CMI) of the patients compared at baseline, 1st and 6th month after supervised rehabilitation procedure. All parameters were significantly improved both in 1st and 6th month evaluation. At 6th month evaluation, the cervical ROMs of the patients improved from severe to mild restriction (p = 0.001), the mean MASA score of the patients improved from moderate to mild swallowing disorder (p = 0.001), mean MMSE score of 30 patients was accepted as normal (p = 0.001), mean MMO of the patients was 56.00 ± 4.84 mm and mean CMI was 0.16 ± 0.05 indicating that the patients had a "mild" limitation in mouth opening and "mild" dysfunction in TMJ (p = 0.001 respectively). Our structured supervised exercise programme improves swallowing quality by establishing proper stomatognathic alignment and TMJ function.

Ultrasonographic Measurement of Talar Cartilage Thickness in Patients With Cerebral Palsy.

OBJECTIVE: Foot deformities are one of the most common musculoskeletal problems in children with cerebral palsy (CP). These deformities affect the walking ability and function of the patients. Talar cartilage is the hyaline joint cartilage of the tibiotalar joint that plantarflexes and dorsiflexes of the ankle. The aim of this study was to determine whether talar cartilage thickness was affected in children with ambulant diplegic CP. DESIGN: Forty patients with diplegic CP (19 boys, 21 girls) and 40 age-, sex-, and weight-matched healthy control subjects (20 boys, 20 girls) were included in the study. The demographic and clinical characteristics of the patients, including age, sex, and body mass index, were recorded. Patients were classified using the Gross Motor Function Classification System. A 12-MHz linear probe was used for ultrasonographic cartilage measurements at the tibiotalar joint according to European Musculoskeletal Ultrasound Study Group (EURO-MUSCULUS) and the Ultrasound Study Group in Physical and Rehabilitation Medicine (USPRM) scanning protocols. RESULTS: Mean talar cartilage thickness was significantly decreased in the CP group compared with the healthy control group (P < 0.001). There was a significant negative correlation between Gross Motor Function Classification System levels and talar cartilage thickness measurements (P < 0.001, Tb = -0.695). CONCLUSION: This study demonstrates that patients with CP have a thinner talar cartilage compared with healthy control subjects.