Patients' attitudes and knowledge about drug use: a survey in Turkish family healthcare centres and state hospitals

Background/aim: Irrational drug use is a common problem. This study aimed to evaluate patients' knowledge and habits concerning drug use, and compare them in terms of some sociodemographic characteristics. Materials and methods: A face-to-face questionnaire was given to outpatients from family healthcare centres (FHCs) and state hospitals (SHs) in 12 provinces in Turkey during May 2010. A total of 4470 patients (FHCs: 2209; SHs: 2261) responded to the questionnaire (response rate: 93.1%). Results: Getting prescriptions without a physical examination was common (second place in FHCs; third place in SHs); 51.0% stated that they wanted physicians to prescribe drugs that they had used before. More than half stated that antibiotics cured every illness. In addition, 55.9% reported that their relatives recommended drugs to them when they got ill; 37.1% reported that they recommended them to relatives as well. Of the survey respondents, 70.5% stated that they had stopped their medications before the recommended time. Patients' knowledge and attitudes about drug use showed significant differences in comparisons of sex, age, educational level, and social security. Conclusion: Patients' knowledge and attitudes about drugs were far from rational. To eliminate irrational use of drugs, public education about drug use is needed.

PRescriptiOn PattERns of Oral Anticoagulants in Nonvalvular Atrial Fibrillation (PROPER study).

INTRODUCTION: Inappropriate use of oral anticoagulants (OACs) have not been well investigatedand, however, may be frequent in real-world practice in patients with nonvalvular atrial fibrillation (NVAF). This study was designed to evaluate the prescription patterns and appropriateness of OACs in patients with NVAF in real-world clinical settings. METHODS: We performed a prospective, observational study (NCT02366338). A total of 148 patients with NVAF were screened for OAC prescription. Appropriateness of prescribing was evaluated using 9 criteria of the Medication Appropriateness Index (MAI): indication, choice, dosage, modalities and practicability of administration, drug-drug interactions, drug-disease interactions, duplication, and duration. For each criterion, the evaluator has to rate whether the medication is (A) appropriate, (B) inappropriate but with limited clinical importance, and (C) inappropriate. RESULTS: Of 148 patients, 73 (50%) were on warfarin (group 1), 39 (26%) were on rivaroxaban (group 2), and 36 (24%) were on dabigatran therapy (group 3). The MAI showed that 83% of group 1, 28% of group 2, and 47% of group 3 patients had at least 1 inappropriate criterion. Moreover, according to the choice criterion, 37% of group 1, 8% of group 2 and 5% of group 3 were rated as inappropriate, and dosage was not appropriate in 77% of group 1, 23% of group 2, and 42% of group 3. CONCLUSION: Inappropriate drug use is frequent among patients with NVAF not only for warfarin but also for NOACs. Although there is an apparent improvement in thromboprophylaxis of NVAF, much more effort is needed for appropriate use of OACs.

Cutaneous microvascular reactivity and aortic elasticity in coronary artery disease: Comparison of the laser Doppler flowmetry and echocardiography.

BACKGROUND AND AIM: Decreased vascular reactivity in atherosclerosis was previously shown. In our study, it was aimed to demonstrate the decreased vascular functions in both microvascular and macrovascular tissues and to estimate any correlation between them. METHODS: Twenty-five control outpatients with no coronary artery disease (CAD) history and 26 outpatients with CAD history were enrolled in the study. Local cutaneous post-occlusive reactive hyperemia (PORH) responses after three minutes of brachial occlusion with a pneumatic cuff were recorded noninvasively by a Perimed Periflux 5010 laser Doppler flow system. Aortic distensibility and stiffness indexes were recorded noninvasively by a two-dimensional Doppler echocardiography machine (Vivid S6 GE Medical System, Horten, Norway). RESULTS: Except for the medication history of subjects, there were no significant demographic differences between the CAD and control groups. Peak flow (PF), resting flow (RF) and biological zero(BZ) laser Doppler measurements were not decreased, but PF-RF/RF (%), PF-BZ/BF (%), hyperemia repayment and PORH indexes were significantly decreased in the CAD group (P=0.005, P=0.024, P=0.017, P=0.006, respectively) with laser Doppler measurements. Aortic strain (%) and aortic distensibility (cm3/dyn-1) measurements were significantly decreased in the CAD group (P=0.005, P=0.013). However, there was no correlation between microvascular indexes (hyperemia repayment index, PORH index) and macrovascular indexes (aortic strain and aortic distensibility). DISCUSSION: Different corrupted vascular tonus regulator systems in arteries of varying diameter, different major reactive responses to the stimuli or, finally, the lack of a number of subjects to obtain a significant level may be responsible for the irrelevant correlation analysis. CONCLUSION: The differences in arterial beds (both aorta and microcirculation) may be examined to assess the cardiovascular risk in patients with history of CAD.

Rationale, design and methodology of the RAMSES Study: ReAl-life Multicenter Survey Evaluating Stroke Prevention Strategies.

OBJECTIVE: Atrial fibrillation is the most common arrhythmia and is associated with a five- fold increased risk of thromboembolic events. Vitamin K antagonists (VKAs) have been the mainstay of oral anticoagulant prophylaxis and the data on stroke prevention strategies are limited to VKA era. The purpose of this study is to evaluate the use of VKA, non-Vitamin K antagonist oral anticoagulants (NOAC), and antiplatelet agents in patients with non-valvular atrial fibrillation (NVAF). METHODS: The ReAl-life Multicenter Survey Evaluating Stroke prevention strategies in Turkey (RAMSES) is an observational, multicenter, prospective study of patients with NVAF. The study targeted enrollment of 7835 patients from 68 sites in Turkey. All the data will be collected at one point in time and current clinical practice will be evaluated. (ClinicalTrials.gov number NCT02344901). RESULTS: Baseline characteristics of patients, antithrombotic therapies, transition to NOACs and rate/rhythm control strategies will be evaluated. CONCLUSION: The RAMSES registry will be the largest study in Turkish NVAF patients. The study will provide insights into real-world problems and anticoagulant treatment in patients with NVAF.

The effect of Gly-Gln [ß-endorphin30-31] on morphine-evoked serotonin and GABA efflux in the nucleus accumbens of conscious rats.

Glycyl-L-glutamine (Gly-Gln; ß-endorphin30-31) is an endogenous dipeptide synthesized through the post-translational processing of ß-endorphin1-31. Central Gly-Gln administration inhibits the rewarding properties of morphine and attenuates morphine tolerance, dependence and withdrawal although it does not interfere with morphine analgesia. In an earlier study, we found that Gly-Gln inhibits morphine-induced dopamine efflux in the nucleus accumbens (NAc), consistent with its ability to inhibit morphine reward. To further investigate the mechanism responsible for its central effects we tested whether i.c.v. Gly-Gln administration influences the rise in extracellular serotonin and GABA concentrations evoked by morphine in the NAc. Conscious rats were treated with Gly-Gln (100nmol/5µl) or saline i.c.v. followed, 2min later, by morphine (2.5mg/kg) or saline i.p. and extracellular serotonin and GABA concentrations were analyzed by microdialysis and HPLC. Morphine administration increased extracellular serotonin and GABA concentrations significantly within 20min, as shown previously. Unexpectedly, Gly-Gln also increased extracellular serotonin concentrations significantly in control animals. Combined treatment with Gly-Gln+morphine also elevated extracellular serotonin concentrations although the magnitude of the response did not differ significantly from the effect of Gly-Gln or morphine, given alone suggesting that Gly-Gln suppressed morphine induced serotonin efflux. Gly-Gln abolished the morphine-induced rise in extracellular GABA concentrations but had no effect on extracellular GABA when given alone to otherwise untreated animals. These data show that Gly-Gln stimulates NAc serotonin efflux and, together with earlier studies, support the hypothesis that Gly-Gln inhibits the rewarding effects of morphine by modulating morphine induced dopamine, GABA and serotonin efflux in the NAc.

Central injection of CDP-choline suppresses serum ghrelin levels while increasing serum leptin levels in rats.

In this study we aimed to test central administration of CDP-choline on serum ghrelin, leptin, glucose and corticosterone levels in rats. Intracerebroventricular (i.c.v.) 0.5, 1.0 and 2.0 µmol CDP-choline and saline were administered to male Wistar-Albino rats. For the measurement of serum leptin and ghrelin levels, blood samples were obtained baseline and at 5, 15, 30, 60 and 120 min following i.c.v. CDP-choline injection. Equimolar doses of i.c.v. choline (1.0 µmol) and cytidine (1.0 µmol) were administered and measurements were repeated throughout the second round of the experiment. Atropine (10 µg) and mecamylamine (50 µg) were injected intracerebroventricularly prior to CDP-choline and measurements repeated in the third round of the experiment. After 1 µmol CDP-choline injection, serum ghrelin levels were suppressed significantly at 60 min (P=0.025), whereas serum leptin levels were increased at 60 and 120 min (P=0.012 and P=0.017 respectively). CDP-choline injections also induced a dose- and time-dependent increase in serum glucose and corticosterone levels. The effect of choline on serum leptin and ghrelin levels was similar with CDP-choline while no effect was seen with cytidine. Suppression of serum ghrelin levels was eliminated through mecamylamine pretreatment while a rise in leptin was prevented by both atropine and mecamylamine pretreatments. In conclusion; centrally injected CDP-choline suppressed serum ghrelin levels while increasing serum leptin levels. The observed effects following receptor antagonist treatment suggest that nicotinic receptors play a role in suppression of serum ghrelin levels,whereas nicotinic and muscarinic receptors both play a part in the increase of serum leptin levels.

Aspects of physicians' attitudes towards the rational use of drugs at a training and research hospital: a survey study.

PURPOSE: The rational use of drugs (RUD) is primarily the responsibility of physicians. The aim of this study was to investigate whether physicians are aware of RUD principles and how they apply them in daily medical practice. METHODS: A total 136 physicians working at the Kartal Training and Research Hospital in Istanbul were enrolled in the study between February and March 2012. A face-to-face interview was conducted with physicians to assess their knowledge and attitude regarding RUD. RESULTS: A large majority of the physicians declared that consultation time was insufficient (84 %). The data obtained from the survey indicate that 54 % of the enrolled physicians monitored the therapeutic outcome and that 27 % found the information given to the patient to be sufficient. Participating physicians stated that the less known characteristics of the drugs they prescribed were drug interactions, traceability in market, and price. The most preferred reference source was Vademecum (a drug guideline prepared by the private sector). Two major factors contributing to prescribing patterns were "self study" and "observation of teachers" at clinical training. There was a significant difference between internists-surgeons and residents-specialists in the number of prescribed drugs per prescription (p < 0.001) and in the information provided to the patient on the prescribed drugs (name, effect, dose, instructions, possible side effect) (p < 0.05), respectively. CONCLUSIONS: Our findings overall show that the principles of RUD were not fully applied in daily medical practice by the participating physicians. One important reason for this is a heavy patient load, which requires a change in managerial practices within the healthcare system. The other, more essential explanation is education; consequently, serious consideration should be given to including effective clinical pharmacotherapy training and RUD courses in the medical education curriculum.

Patients' experience and perspectives on the rational use of drugs in Turkey: a survey study.

AIM: Physicians' inappropriate prescribing habits affect patients' lives both medically and financially. To avoid these unwanted situations, the World Health Organization defined the rational use of drugs (RUD) in 1985. This study aimed to investigate whether patients were as informed about their diagnosis and medication as anticipated and their knowledge about the RUD in general. METHODS: A questionnaire was given to 260 patients being treated at the Kartal Training and Research Hospital between February and March 2012. RESULTS: Most of the patients declared that they were not informed enough about their diagnosis and not all of the physicians evaluated their therapies. These undesirable conditions were due to high daily examined patient numbers. A total of 68.6% of patients stated that time allotted per patient was 0-10 minutes, 33.1% found the information given sufficient, and 11.3% were told to repeat back narratives about their treatments. Instructions and warnings given by physicians about prescribed drugs did not fully meet the RUD criteria. The majority of referred patients were willing to be educated about the subject. CONCLUSION: These results showed that heavy patient load seriously affects the RUD process. Improvement of the current health system should be given serious consideration. After sufficient arrangements have been made in this field, patients will be able to be informed properly about medicines prescribed by their physicians. Also, public education programs will be helpful to raise awareness of the subject on a larger scale.

Glycyl-glutamine (beta-endorphin(30-31)) inhibits morphine-induced dopamine efflux in the nucleus accumbens.

Glycyl-glutamine (Gly-Gln) is an endogenous dipeptide that is synthesized from beta-endorphin post-translationally. Previously, we showed that Gly-Gln prevents acquisition of morphine-conditioned place preference, a behavioral test of morphine reward, but does not interfere with morphine analgesia. In this study, we tested the hypothesis that Gly-Gln inhibits morphine reward by blocking morphine-induced dopamine efflux in the nucleus accumbens (NAc). Extracellular dopamine and 3,4-dihydroxyphenylacetic acid (DOPAC) were sampled by microdialysis and analyzed by high-performance liquid chromatography with electrochemical detection. Guide cannulas were implanted in the right NAc and left lateral ventricle of male Sprague-Dawley rats stereotaxically. Approximately 24 h later, a microdialysis probe was inserted into the NAc and perfused at 1 microl/min. Gly-Gln (1, 3, 30, or 100 nmol/5 microl) or saline was administered intracerebroventricularly, morphine (2.5 mg/kg) was injected intraperitoneally (i.p.) 2 min later, and extracellular dopamine and DOPAC were sampled at 20-min intervals. Morphine administration increased extracellular dopamine concentrations by approximately 600% within 40 min. Gly-Gln pretreatment inhibited the rise in extracellular dopamine in a dose-related manner; the lowest significantly inhibitory dose was 1 nmol. Gly-Gln also inhibited the morphine-induced rise in extracellular DOPAC concentrations but did not affect extracellular dopamine or DOPAC in control animals. Gly-Gln (100 nmol/5 microl) prevented morphine-induced dopamine efflux in rats treated with morphine chronically (10 mg/kg, i.p. twice daily for 6 days), although it did not affect DOPAC concentrations significantly. These data support the hypothesis that Gly-Gln abolishes the rewarding effect of morphine by inhibiting the ability of morphine to stimulate dopamine release in the NAc.