High antibiotic resistance rates in Helicobacter pylori strains in Turkey over 20 years: implications for gastric disease treatment.

OBJECTIVE: Helicobacter pylori (Hp) eradication therapy is crucial for preventing the development of gastritis, peptic ulcers, and gastric cancer. An increase in resistance against antibiotics used in the eradication of Hp is remarkable. This meta-analysis aims to examine the resistance rates of Hp strains isolated in Turkey over the last 20 years against clarithromycin (CLR), metronidazole (MTZ), levofloxacin (LVX), tetracycline (TET), and amoxicillin (AMX) antibiotics. BASIC METHODS: Literature search was carried out in electronic databases, by searching articles published in Turkish and English with the keywords ' helicobacter pylori ' or 'Hp' and 'antibiotic resistance' and 'Turkey'. That meta-analysis was carried out using random-effect model. First, the 20-year period data between 2002 and 2021 in Turkey were planned to be analyzed. As a second stage, the period between 2002 and 2011 was classified as Group 1, and the period between 2012 and 2021 as Group 2 for analysis, with the objective of revealing the 10-year temporal variation in antibiotic resistance rates. MAIN RESULTS: In gastric biopsy specimens, 34 data from 29 studies were included in the analysis. Between 2002-2021, CLR resistance rate was 30.9% (95% CI: 25.9-36.2) in 2615 Hp strains. Specifically, in Group 1, the CLR resistance rate was 31% in 1912 strains, and in Group 2, it was 30.7% in 703 strains. The MTZ resistance rate was found to be 31.9% (95% CI: 19.8-45.4) in 789 strains, with rates of 21.5% in Group 1 and 46.6% in Group 2. The overall LVX resistance rate was 25.6%, with rates of 26.9% in Group 1 and 24.8% in Group 2. The 20-year TET resistance rate was 0.8%, with 1.50% in Group 1 and 0.2% in Group 2. The overall AMX resistance rate was 2.9%, 3.8% between 2002-2011, and 1.4% between 2012-2021. PRINCIPAL CONCLUSION: Hp strains in Turkey exhibit high resistance rates due to frequent use of CLR, MTZ, and LVX antibiotics. However, a significant decrease has been observed in TET and AMX resistance to Hp in the last 10 years. Considering the CLR resistance rate surpasses 20%, we suggest reconsidering the use of conventional triple drug therapy as a first-line treatment. Instead, we recommend bismuth-containing quadruple therapy or sequential therapies (without bismuth) for first-line treatment, given the lower rates of TET and AMX resistance. Regimens containing a combination of AMX, CLR, and MTZ should be given priority in second-line therapy. Finally, in centers offering culture and antibiogram opportunities, regulating the Hp eradication treatment based on the antibiogram results is obviously more appropriate.

Molecular epidemiological investigation of carbapenem resistant Klebsiella pneumoniae isolated from intensive care unit patients of six geographical regions of Turkey.

INTRODUCTION: Klebsiella pneumonia causes serious infections in hospitalized patients. In recent years, carbapenem-resistant infections increased in the world. The molecular epidemiological investigation of carbapenem-resistant K. pneumoniae isolates was aimed in this study. METHODOLOGY: Fifty carbapenem-resistant K. pneumoniae isolates from six geographical regions of Turkey between September 2019-2020 were included in the study. The disk diffusion method was used for the antibiotic susceptibility testing. The microdilution confirmed colistin susceptibility. Genetic diversity was investigated by MLST (Multi-Locus Sequence Typing). RESULTS: The resistance rates were as follows: 49 (98%) for meropenem, 47 (94%) imipenem, 50 (100%) ertapenem, 30 (60%) colistin and amoxicillin-clavulanate, 49 (98%) ceftriaxone, 48 (96%) cefepime, 50 (100%) piperacillin-tazobactam, 47 (94%) ciprofloxacin, 40 (80%) amikacin, 37 (74%) gentamicin. An isolate resistant to colistin by disk diffusion was found as susceptible to microdilution. ST 2096 was the most common (n:16) sequence type by MLST. ST 101 (n:7), ST14 (n:6), ST 147 and ST 15 (n:4), ST391 (n:3), ST 377 and ST16 (n:2), ST22, ST 307, ST 985, ST 336, ST 345, and ST 3681 (n:1) were classified in other isolates. In Istanbul and Ankara ST2096 was common. Among Turkey isolates, the most common clonal complexes (CC) were CC14 (n:26) and CC11 (n = 7). CONCLUSIONS: In Turkey, a polyclonal population of CC14 throughout the country and inter-hospital spread were indicated. The use of molecular typing tools will highlight understanding the transmission dynamics.

A meta-analysis of antibiotic resistance rates in Pseudomonas aeruginosa isolated in blood cultures in Turkey between 2007 and 2017.

OBJECTIVE: The prevalence of Pseudomonas aeruginosa has remained stable in recent years, and resistant strains has increased dramatically. In this meta-analysis, we aimed to analyze the P. aeruginosa strains isolated from blood cultures in Turkey during the last 11 years and to reveal their antimicrobial susceptibility. METHODS: Data collected between 2007 and 2017 were divided into two groups as Group-1; 2007-2011 and Group-2; 2012-2017. The differences in antibiotic resistance rates between Group-1 and Group-2 were analyzed. The study data were included according to PRISMA criteria, then meta-analysis was performed. RESULTS: A total of 30 study data from 25 studies were included in the study. The prevalence rate of meropenem (MEM) resistance in P. aeruginosa in Turkey was 25.1% (95% Cl: 20.65-29.83) according to a meta-analysis of 637 isolates. MEM resistance rates in Group-1 and Group-2 were 23.4% (95% Cl: 18.34-28.99) and 29.3% (95% Cl: 21.23-38.23), respectively. The prevalence rate of imipenem (IMP) resistance in P. aeruginosa in Turkey was 26.8% (%95 Cl: 23.40-30.35) according to a meta-analysis of 1421 isolates. IMP resistance rates in Group-1 and Group-2 were 26.2% (95% Cl: 22.41-30.27) and 28.4% (95% Cl: 21.57-35.88), respectively. Ciprofloxacin (CIP) resistance rate was 27.04% (95% Cl: 21.88-32.52) in 1388 isolates. CIP resistance rates in Group-1 and Group-2 were 30.8% (95% Cl: 24.35-37.56) and 18.6% (95% Cl: 10.72-28.11), respectively. The prevalence rate of piperacillin-tazobactam (TZP) resistance in P. aeruginosa in Turkey was 29.2% (95% Cl: 21.058-38.088) according to a meta-analysis of 1030 isolates. TZP resistance rates in Group-1 and Group-2 were 26.1% (95% Cl: 17.76-35.31) and 38.2% (95% Cl: 18.48-60.27), respectively. CONCLUSION: There is a remarkable increase in resistance rates in P. aeruginosa to MEM and TZP in Turkey due to frequent use. Other antibiotics with antipseudomonal effect should be prioritized in the treatment of these infections.

Evaluation of the effectiveness and safety of adding ivermectin to treatment in severe COVID-19 patients.

BACKGROUND AND OBJECTIVES: An effective treatment option is not yet available for SARS-CoV2, which causes the COVID-19 pandemic and whose effects are felt more and more every day. Ivermectin is among the drugs whose effectiveness in treatment has been investigated. In this study; it was aimed to investigate the presence of gene mutations that alter ivermectin metabolism and cause toxic effects in patients with severe COVID-19 pneumonia, and to evaluate the effectiveness and safety of ivermectin use in the treatment of patients without mutation. MATERIALS AND METHODS: Patients with severe COVID19 pneumonia were included in the study, which was planned as a prospective, randomized, controlled, single-blind phase 3 study. Two groups, the study group and the control group, took part in the study. Ivermectin 200 mcg/kg/day for 5 days in the form of a solution prepared for enteral use added to the reference treatment protocol -hydroxychloroquine + favipiravir + azithromycin- of patients included in the study group. Patients in the control group were given only reference treatment with 3 other drugs without ivermectin. The presence of mutations was investigated by performing sequence analysis in the mdr1/abcab1 gene with the Sanger method in patients included in the study group according to randomization. Patients with mutations were excluded from the study and ivermectin treatment was not continued. Patients were followed for 5 days after treatment. At the end of the treatment and follow-up period, clinical response and changes in laboratory parameters were evaluated. RESULTS: A total of 66 patients, 36 in the study group and 30 in the control group were included in the study. Mutations affecting ivermectin metabolism was detected in genetic tests of six (16.7%) patients in the study group and they were excluded from the study. At the end of the 5-day follow-up period, the rate of clinical improvement was 73.3% (22/30) in the study group and was 53.3% (16/30) in the control group (p = 0.10). At the end of the study, mortality developed in 6 patients (20%) in the study group and in 9 (30%) patients in the control group (p = 0.37). At the end of the follow-up period, the average peripheral capillary oxygen saturation (SpO2) values of the study and control groups were found to be 93.5 and 93.0%, respectively. Partial pressure of oxygen (PaO2)/FiO2 ratios were determined as 236.3 ± 85.7 and 220.8 ± 127.3 in the study and control groups, respectively. While the blood lymphocyte count was higher in the study group compared to the control group (1698 ± 1438 and 1256 ± 710, respectively) at the end of the follow-up period (p = 0.24); reduction in serum C-reactive protein (CRP), ferritin and D-dimer levels was more pronounced in the study group (p = 0.02, p = 0.005 and p = 0.03, respectively). CONCLUSIONS: According to the findings obtained, ivermectin can provide an increase in clinical recovery, improvement in prognostic laboratory parameters and a decrease in mortality rates even when used in patients with severe COVID-19. Consequently, ivermectin should be considered as an alternative drug that can be used in the treatment of COVID-19 disease or as an additional option to existing protocols.

Real-World Data from Turkey: Is Sofosbuvir/Ledipasvir With or Without Ribavirin Treatment for Chronic Hepatitis C Really Effective?

BACKGROUND: In this study, we aimed to investigate the efficacy and safety of sofosbuvir-based therapies in the treatment of chronic hepatitis C in real-world clinical practice. METHODS: Data from patients with chronic hepatitis C treated with SOF/LDV ± RBV or SOF/RBV in 31 centers across Turkey between April 1, 2017, and August 31, 2018, were recorded in a nationwide database among infectious disease specialists. Demographics, clinical, and virological outcomes were analyzed. RESULTS: A total of 552 patients were included in the study. The mean age of the patients was 51.28 ± 14.2, and 293 (55.8%) were female. The majority had HCV genotype 1b infection (65%), 75.04% of the patients underwent treatment, and non-cirrhosis was present at baseline in 381 patients (72.6%). SOF/LDV ± RBV treatment was given to 477 patients and 48 patients received SOF/RBV according to HCV genotype. The total SVR12 rate was 99% in all patients. Five patients experienced disease relapse during the study and all of them were genotype 2. In patients infected with HCV GT2, SVR12 was 77.3%. SVR was 100% in all patients infected with other HCV genotypes. All treatments were well tolerated by patients without causing severe adverse events. Side effects and side effects-associated treatment discontinuation rates were 28.2% and 0.4%, respectively. Weakness (13.7%) was the common side effect. CONCLUSION: The present real-world data of 525 patients with HCV genotypes 1, 1a, 1b, 3, 4, and 5 who underwent SOF/LDV ± RBV treatment in Turkey demonstrated a high efficacy and safety profile. HCV GT2 patients should be treated with more efficacious treatment.

Demographic, clinical and laboratory characteristics for differential diagnosis of peripheral lymphadenopathy (LAP) and the etiologic distribution of LAP in adults; a multicenter, nested case-control study including 1401 patients from Turkey.

Peripheral lymphadenopathy (LAP) is an important and common abnormal finding of the physical exam in general medical practice. We aimed to reveal the LAP etiology and demographic, clinical and laboratory variables that may be useful in the differential evaluation of LAP. This multicenter, nested case-control study including 1401 patients between 2014 and 2019 was conducted in 19 tertiary teaching and research hospitals from different regions in Turkey. The ratio of infectious, malign and autoimmune/inflammatory diseases was 31.3%, 5% and 0.3%, respectively. In 870 (62%) of patients had nonspecific etiology. Extrapulmonary tuberculosis (n: 235, 16.8%) was the most frequent cause of LAP. The ratio of infective etiology of LAP was significantly lower in patients older than 65 years-old compared to younger patients with the rate of 66.67% and 83.84%, respectively (p 0.016, OR 0.386, 95% Cl 0.186-0.803). The probability of malign etiology was higher both in patients who are older than 45 years-old (p < 0.001, OR 3.23, 95% Cl 1.99-5.26) and older than 65 years-old (p 0.002, OR 3.36, 95% Cl 1.69-6.68). Age, localization and duration of LAP, leukocytosis, anemia, thrombocytopenia, CRP and sedimentation rate were important parameters to differentiate infections. Size of lymph node and splenomegaly in addition to the parameters above were useful parameters for differentiating malign from benign etiology. Despite the improvements in diagnostic tools, reaching a definite differential diagnosis of lymphadenopathy is still challenging. Our results may help clinicians to decide in which cases they need an aggressive workup and set strategies on optimizing the diagnostic approach of adulthood lymphadenopathy.

Evaluation of 170 Followed-up Cases Treated for Hydatid Disease: A Multicentre Study.

OBJECTIVE: To determine the clinical characteristics of patients with cystic echinococcosis and the diagnostic and therapeutic approaches used. METHODS: This is a multicentre, retrospective study. Patients from six centres who were diagnosed with hydatid cysts in the last five years were evaluated. RESULTS: The mean age was 45.4±17.4 years, and 54.7% were female. The most common complaints were abdominal pain, nausea and vomiting, and the most common physical examination finding was abdominal tenderness. Most patients were diagnosed within 2-6 months. Anaemia and eosinophilia were the most common laboratory findings. The liver was the most commonly involved organ (n=153, 90%). One hundred twenty-five (73.5%) patients underwent ultrasonography. The largest cyst was present in the liver at stage four, and its diameter was 160x170 mm. The rates of the negative, grey zone and positive results were 9.4%, 8.8% and 81.8%. Surgery was more common (n=72, 42.4%) than puncture, aspiration, injection, and re-aspiration treatments (n=14, 8.2%). Of the 47 patients who had a recurrence, 22 (46.8%) had a history of hydatid cyst treatment. CONCLUSION: Hydatid disease, which is endemic in our country, is diagnosed at a late stage. In terms of disease diagnosis, serological tests may be misleading. It was not possible to compare the success rates according to the treatment choices because of the lack of randomisation of stages and sizes of the lesions.

Difference in Toxoplasma gondii Seroprevalence Rates Due to Low and High CD4 Counts in Patients with HIV/AIDS

Objective: Since symptomatic toxoplasmosis in in human immunodeficiency virus (HIV)/Acquired immunodeficiency syndrome (AIDS) almost always occurs as a result of reactivation of chronic infection, screening Toxoplasma serology has an important role in the follow up of the main disease in these populations. In this meta-analysis, we aimed to reveal the difference in the seroprevalence rates of Toxoplasma gondii infection between groups in relation to CD4 counts (CD4-counts ≥200 and <200 cells/mm3) HIV-infected population. Methods: The meta-analysis was performed by searching for the studies in English that were published in the last 20-year period in databases including PubMed, Google Scholar, Embase, Science Direct and Web of Science. The process of searching was carried out using the keywords: "Acquired immunodeficiency syndrome", "AIDS", "Human immunodeficiency virus", "HIV", "Toxoplasma", "Toxoplasmosis", "Toxoplasma gondii", "seroprevalence", "prevalence" and "immunoglobulin G". Results: A total of 16 studies including 3982 seropositive samples of T. gondii, 2792 of which were in first group (HIV positive patients with CD4-counts ≥200 cells/mm3) and 1190 were in second group (HIV positive patients with CD4-counts <200 cells/mm3), were included in the meta-analysis. The seroprevalence of T. gondii was 40.03% in HIV-positive patients with CD4 counts ≥200 cells/mm3, and 43.5% in the group with CD4 counts <200 cells/mm3. Seroprevalence rates in the studies included in the meta-analysis showed variability (heterogeneity) in both groups and heterogeneity between studies was higher in group 1 [Group 1; Cochran Q=994.16, DF=15, I²=98.49%, p<0.0001 and group 2; Cochran Q=368.50, DF=15, I²=95.93%, p<0.0001]. Conclusion: We concluded that HIV/AIDS patients with low CD4 counts have higher epidemiological risk as well as immunological risk of toxoplasmosis. To the best of our knowledge, this is the first meta-analysis evaluating the seroprevalence of T. gondii in AIDS/HIV population by comparing the seroprevalance of T. gondii in subgroups formed according to CD4 counts.

Overuse of prophylaxis in HBsAg and/or anti-HBc positive patients after increasing awareness to prevent reactivation in patients receiving immunosuppressive therapies: How rational are our prophylaxis decisions according to the literature?

Screening prior to initiation of immunosuppressive therapy, and decision making between the initiation of hepatitis B virus (HBV) prophylaxis and monitoring with the intent of on-demand anti-HBV therapy initiation are the key determinants to prevent reactivation of HBV. Patients over 18 years of age with HBsAg and/or anti-HBc positivity, who received HBV prophylaxis due to immunosuppressive treatments between 2013 and 2019, enrolled in this retrospective descriptive study. We tried to create awareness about the reactivation of hepatitis among clinicians in our hospital from the beginning of 2017, via warnings at the hospital data management system and via in-service training activities. Changes or differences between two-time period groups (first group between 2013 and 2016, the second between 2017 and 2018) and between four reactivation risk groups (low, moderate, high and very high) were analyzed. Of 125 patients who received immunosuppressive therapies and HBV prophylaxis, 52 (41.6%) were HBsAg positive while 73 (58.4%) were anti-HBc positive/HBsAg negative. Eighteen of the patients were in the 1st-period-years and 107 were in the second. The ratio of anti-HBc positive/HBsAg negative patients increased from 22.22% (n: 4) to 64.49% (n: 69) in the 2nd period (p: 0.001). In the 1st period, 16.67% of the patients had hepatitis B surface antibodies (anti-HBs), which increased to 46.73% during the 2nd period. The ratio of patients with HBV DNA positivity was found to be 55.56% in the first period and 33.87% in the second. Patients in the moderate (1-10%) and high (10-30%) reactivation risk groups were predominant, with rates of 38.89% and 33.33% of all the patients during the 1st period, respectively. However, the number of patients with a low reactivation risk increased 19-fold (from 2 to 38) and reached a proportion of 35.51% of all patients during the 2nd period. There was also a 6.33-fold increase (from 6 to 38) in the number of patients with high reactivation risk, reaching a rate of 35.51% during the 2nd period. None of the patients developed HBV reactivation when HBV prophylaxis was initiated before (n:11), concurrently (n:81) with or after (n:33) the immunosuppressive therapy. Awareness of HBV reactivation among clinicians has significantly increased in recent years mainly due to in-service training activities in our hospital. This rapid progress in awareness resulted in increased rates of screening for HBV and therefore increased the number of anti-HBc positive/HBsAg negative patients. However, it also led to the overuse of HBV prophylaxis even in low-risk patients.

The seroprevalence of Rubella in pregnant women in Turkey: a meta-analysis research of 90988 Rubella IgM, 84398 Rubella IgG, and 522 avidity results.

OBJECTIVE: Rubella infection prevalence in pregnant women can vary from country to country, or even across regions in the same country. In this metaanalysis, the seroprevalence Rubella among pregnant women in Turkey in the last decade was evaluated. MATERIALS AND METHODS: Studies conducted in Turkey between 2007 and 2017 were analyzed, and differences in seroprevalence between provinces were compared by evaluating Rubella immunoglobulin (Ig)-G, IgM, and IgG avidity results in pregnancy in this period. A data search was performed using the search terms Rubella, kizamikçik, gebe, hamile, pregnancy, Türkiye, Turkey in Google Scholar, PubMed, Web of Science, Türk Medline, and the YÖK thesis database center. RESULTS: A total of 26 articles associated with the seroprevalence of Rubella among pregnant women in Turkey were enrolled in the meta-analysis. As a result of an analysis of 84398 Rubella IgG, and 90988 Rubella IgM serology tests among pregnant women in 26 studies; Rubella IgG and IgM seroprevalence rates in pregnant woman in Turkey were found as 93.47% (95% CI: 91.72 to 95.03) and 0.783% (95% CI: 0.505 to 1.120), respectively. Rubella IgG low, intermediate, and high avidity rates were 4.66% (95% CI: 0.969 to 10.906), 7.51% (95% CI: 5.101 to 10.345), and 93.55% (95% CI: 82.584 to 99.311), respectively. CONCLUSION: The Rubella IgG seropositivity rate in Turkey among pregnant woman is high, whereas it is low for IgM. These rates may be considered as the result of successful immunization policies and practices. In a few provinces, it is necessary to revise the Rubella immunization procedures and adult vaccination strategies should be developed in order to control Rubella infections in adults, including pregnant women.

Platelet-rich plasma as an additional therapeutic option for infected wounds with multi-drug resistant bacteria: in vitro antibacterial activity study.

PURPOSE: Infected wounds, such as diabetic foot infections, are mostly polymicrobial and microorganisms have high resistance rates to antimicrobials. Infected wounds in diabetic patients have high cost, morbidity, and mortality rates. Based on these facts, there is a need for supportive localized treatment options such as platelet-rich plasma (PRP) implementations. Demonstrating the in vitro antimicrobial effect, our aim was to lead up to clinical trials of localized PRP implementations in infected wounds such as diabetic foot infections. In this study, we aimed to demonstrate the in vitro antibacterial activity of PRP against methicilin-resistant Staphylococcus aureus (MRSA) and three more multi-drug resistant bacteria species that are important and hard-to-treat in wound infections. MATERIALS AND METHODS: In vitro antimicrobial activity of autologous PRP, platelet-poor plasma (PPP), and phosphate-buffered saline (PBS) on methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus spp., extended spectrum beta lactamase producing Klebsiella pneumoniae, and carbapenem-resistant Pseudomonas aeruginosa was compared by assessment of bacterial growth on agar plates and antimicrobial susceptibility test results. RESULTS: When compared to control group, PRP and PPP significantly suppressed bacterial growth of MRSA, K. pneumoniae, and P. aeruginosa at 1st, 2nd, 5th, and 10th hours of incubation (p < 0.05). VRE was the only bacteria that PRP and PPP showed limited activity against. When compared to PPP, PRP showed higher activity against MRSA, K. pneumoniae, and P. aeruginosa. However, the differences between PRP and PPP were statistically significant only against MRSA and P. aeruginosa at the first hour of incubation. CONCLUSIONS: Emerging PRP and other platelet-derived products seem to be promising alternative tools besides antibiotic treatment, debridement, negative pressure wound therapy, hyperbaric oxygen therapy, and other treatment options for treating diabetic foot infections.

Evaluating the effect of donor anxiety levels and lifestyle characteristics on the activation of platelet concentrates.

BACKGROUND: Smoking, alcohol use, performing regular physical exercise, dietary habits, and anxiety level may cause platelet activation. We aimed to evaluate the anxiety levels, smoking status, alcohol intake, and sportive habits of donors, and determine their impact on the quality of apheresis-platelets. METHODS: State and Transient Anxiety Inventory (STAI) was used to determine the level of donors' anxiety. STAI has two subscales: S-anxiety scale (STAI-I) and T-anxiety scale (STAI-II), each comprising 20 questions rated on a 4-point Likert scale. Data on smoking, alcohol consumption, and performing regular physical exercise were obtained from a questionnaire filled out before donation. Flow cytometric analysis was used to quantify activated platelets. RESULTS: The STAI-I level of 86 participants was normal, while that of 12 was higher. No significant difference was found in the active platelet absolute count [1.8×1011 (2.7) and 1.4×1011 (1.3), respectively; P=0.665] between donors with normal STAI-I levels and those with higher STAI-I levels. Of 98 donors, 42 had normal STAI-II levels, while 56 had higher STAI-II levels. No significant difference was found in the active platelet absolute count [2.3×1011 (3.1) and 1.5×1011 (2.3), respectively; P=0.224] between donors with normal STAI-II levels and those with higher STAI-II levels. Platelet counts of individuals who perform regular physical exercise were significantly higher than those of individuals who did not perform regular physical exercise (6.3±1.4×1011 vs. 5.5±1.4×1011). CONCLUSION: The quality of apheresis platelets is not affected by anxiety levels and lifestyle characteristics of blood donors. There is no need to organize apheresis blood donor pool considering with these subjects.

Diagnostic Dilemma for Low Viremia with Significant Fibrosis; is Hepatitis B Virus DNA Threshold Level a Good Indicator for Predicting Liver Damage?

BACKGROUND: The most important difficulties about management of hepatitis B are still determining the liver damage and the right time to start antiviral therapy. AIMS: To reveal the role of hepatitis B virus DNA threshold level for prediction of liver fibrosis and inflammation in young-aged hepatitis B e-antigen negative chronic hepatitis B patients. STUDY DESIGN: Diagnostic accuracy study. METHODS: A total of 273 hepatitis B e-antigen negative young chronic hepatitis B patients with any hepatitis B virus DNA levels between 2008 and 2016, who had liver biopsy after at least 6 months follow up period, enrolled in this retrospective study. We created two groups as case and control, cases with hepatitis B virus DNA levels below 2000 IU/mL and controls with hepatitis B virus DNA levels over 2000 IU/mL. Having histological activity index ≥4 or/and fibrosis scores ≥2 were defined as significant histological abnormality. Then, we analyzed the relationship between these groups. RESULTS: We showed that significant fibrosis may occur in one third of young chronic hepatitis B patients with low viremia (30.2%, n=42/139 in cases, 55.2%, n=74/134 in controls). Among the 42 cases with low viremia and significant fibrosis, 21.4% had alanine aminotransferase level between 40-59 U/L, 42.8% had alanine aminotransferase level between 60-79 U/L, and 35.7% had alanine aminotransferase level over 80 U/L. There was weak correlation between hepatitis B virus DNA threshold level and fibrosis score (p<0.001, rho=0.253). The optimum serum hepatitis B virus DNA threshold level in our study for predicting significant fibrosis was 1293 IU/mL (p<0.001, AUC: 0.657±0.034). The optimum alanine aminotransferase threshold level for predicting significant histological activity index and fibrosis was 64.5 and 59.5 U/L, respectively. The sensitivity and the specificity of 1293 vs 2000 IU/mL hepatitis B virus DNA threshold with 60 U/L alanine aminotransferase threshold level for predicting F≥2 fibrosis score were similar (sensitivity: 0.43 and 0.38, specificity: 0.76 and 0.77, respectively). CONCLUSION: Significant fibrosis may occur even in young cases with low viremia. It is not possible to define a single threshold hepatitis B virus DNA level for differentiating inactive carriers from patients with hepatitis B e-antigen-negative chronic hepatitis. Diagnostic accuracy of hepatitis B virus DNA with alanine aminotransferase thresholds for the prediction of significant fibrosis is weak.

Changes in acute viral hepatitis epidemiology in the Turkish adult population: A multicenter study.

BACKGROUND/AIMS: The present study aimed to determine the changes in the epidemiology of hepatitis in recent years in an adult Turkish population. MATERIALS AND METHODS: Overall, 852 patients with acute viral hepatitis from 17 centers were included in this study. Their sociodemographic characteristics, clinical courses, treatments, and laboratory findings were retrospectively analyzed. RESULTS: The most commonly found microorganisms were the hepatitis B virus (55.2%) and hepatitis A virus (37.6%), and the types of acute viral hepatitis differed significantly according to the age group (p≤0.001). The most frequently reported symptom was fatigue (73.7%), and the most common complications were cholecystitis (0.4%) and fulminant hepatitis (0.4%). The median hospital stay was 9 days (range 1-373). In total, 40.8% patients with acute hepatitis B virus developed immunity. CONCLUSION: In Turkey, there are significantly large adolescent and adult populations susceptible to acute viral hepatitis. Therefore, larger vaccination programs covering these age groups should be implemented.

Bringing Packed Red Blood Cells to the Point of Combat Injury: Are We There Yet?

Objective: Hemorrhage is the leading cause of injury-related prehospital mortality. We investigated worst-case scenarios and possible requirements of the Turkish military. As we plan to use blood resources during casualty transport, the impact of transport-related mechanical stress on packed red blood cells (PRBCs) was analyzed. Materials and Methods: The in vitro experiment was performed in the environmental test laboratories of ASELSAN®. Operational vibrations of potential casualty transport mediums such as Sikorsky helicopters, Kirpi® armored vehicles, and the NATO vibration standard MIL-STD-810G software program were recorded. The most powerful mechanical stress, which was created by the NATO standard, was applied to 15 units of fresh (≤7 days) and 10 units of old (>7 days) PRBCs in a blood cooler box. The vibrations were simulated with a TDS v895 Medium-Force Shaker Device. On-site blood samples were analyzed at 0, 6, and 24 h for biochemical and biomechanical analyses. Results: The mean (±standard deviation) age of fresh and old PRBCs was 4.9±2.2 and 32.8±11.8 days, respectively. Six-hour mechanical damage of fresh PRBCs was demonstrated by increased erythrocyte fragmentation rates (p=0.015), hemolysis rates (p=0.003), and supernatant potassium levels (p=0.003) and decreased hematocrit levels (p=0.015). Old PRBC hemolysis rates (p=0.015), supernatant potassium levels (p=0.015), and supernatant hemoglobin (p=0.015) were increased and hematocrit levels were decreased (p=0.015) within 6 h. Two (13%) units of fresh PRBCs and none of the old PRBCs were eligible for transfusion after 6 h of mechanical stress. Conclusion: When an austere combat environment was simulated for 24 h, fresh and old PRBC hemolysis rates were above the quality criteria. Currently, the technology to overcome this mechanical damage does not seem to exist. In light of the above data, a new national project is being performed.

Generation of Platelet Microparticles after Cryopreservation of Apheresis Platelet Concentrates Contributes to Hemostatic Activity.

OBJECTIVE: In the last decade, substantial evidence has accumulated about the use of cryopreserved platelet concentrates, especially in trauma. However, little reference has been made in these studies to the morphological and functional changes of platelets. Recently platelets have been shown to be activated by cryopreservation processes and to undergo procoagulant membrane changes resulting in the generation of platelet-derived microparticles (PMPs), platelet degranulation, and release of platelet-derived growth factors (PDGFs). We assessed the viabilities and the PMP and PDGF levels of cryopreserved platelets, and their relation with thrombin generation. MATERIALS AND METHODS: Apheresis platelet concentrates (APCs) from 20 donors were stored for 1 day and cryopreserved with 6% dimethyl sulfoxide. Cryopreserved APCs were kept at -80 °C for 1 day. Thawed APCs (100 mL) were diluted with 20 mL of autologous plasma and specimens were analyzed for viabilities and PMPs by flow cytometry, for thrombin generation by calibrated automated thrombogram, and for PDGFs by enzyme-linked immunosorbent assay testing. RESULTS: The mean PMP and PDGF levels in freeze-thawed APCs were significantly higher (2763±399.4/µL vs. 319.9±80.5/µL, p<0.001 and 550.9±73.6 pg/mL vs. 96.5±49 pg/mL, p<0.001, respectively), but the viability rates were significantly lower (68.2±13.7% vs. 94±7.5%, p<.001) than those of fresh APCs. The mean endogenous thrombin potential (ETP) of freeze-thawed APCs was significantly higher than that of the fresh APCs (3406.1±430.4 nM.min vs. 2757.6±485.7 nM.min, p<0.001). Moreover, there was a significant positive poor correlation between ETP levels and PMP levels (r=0.192, p=0.014). CONCLUSION: Our results showed that, after cryopreservation, while levels of PMPs were increasing, significantly higher and earlier thrombin formation was occurring in the samples analyzed despite the significant decrease in viability. Considering the damage caused by the freezing process and the scarcity of evidence for their in vivo superiority, frozen platelets should be considered for use in austere environments, reserving fresh platelets for prophylactic use in blood banks.

Is one-size-fits-all strategy adequate for platelet storage?

BACKGROUND: Platelet suspensions (PSs) are stored at room temperature. However, recent reports show that PSs stored at 4 °C possess superior hemostatic properties. We compared the viabilities and thrombin generation capacities of PSs stored either at 4 °C or 22 °C hours. MATERIALS AND METHODS: Twenty units of apheresis derived platelets (ADPs) from 20 male donors and 20 units of random platelet suspensions (RPSs) from another 20 male donors were obtained. Half of the ADPs and half of the RPSs (10 units/per group) were stored at 4 °C, the other halves of ADPs and RPSs (10 units/per group) were stored in agitators at 22 °C for 48 hours. The flow cytometric viability tests and thrombin generation tests of the PSs were assessed. RESULTS: The viabilities of both ADPs and RPSs group platelets, stored either at 4 °C or 22 °C for 48 hours, were not statistically significantly different. The ADPs and RPSs stored at 4 °C generated significantly higher peak thrombin levels than the platelets stored at 22 °C. Moreover, the ADPs group stored at 4 °C showed significantly shorter time to thrombin generation and reach peak levels. CONCLUSION: The PSs stored at 4 °C showed higher and faster thrombin generation capacities than the room temperature PSs. Given the superior hemostatic properties of refrigerated platelets, creating different storage temperature capabilities for specific transfusion purposes may be a prudent approach, especially for improving the outcome of bleeding trauma casualties.

A strategical re-thinking on National Blood Donor Pool: Anti-HBc positivity related re-entry mechanisms.

BACKGROUND AND OBJECTIVES: Screening of blood donations for antibodies against hepatitis B core antigen (anti-HBc) is used to prevent transfusion transmitted hepatitis B virus (HBV) infection. In this study, we studied the magnitude of blood donor gain by using a re-entry mechanism in our Blood Bank of Gulhane Military Academy of Medicine. MATERIALS AND METHODS: Between January and May 2013, 5148 voluntary blood donors were screened by ELISA method for HBsAg, anti-HBc total and other screening markers, prospectively. Samples with repeated reactivity for the presence of anti-HBc were further tested with four supplemental assays. RESULTS: We detected 515 (10%) anti-HBc positive and 4612 (90%) anti-HBc negative cases in 5127 HBsAg negative serum samples. A total of 461 (89.5%) blood units were reactive for at least one additional serologic parameter and 54 were (10.5%) negative. Isolated anti-HBc positivity rate was 1.3% (69/5127). In the isolated anti-HBc positive samples, 54 were also anti-HBe and HBeAg negative. HBV DNA was not detected in any of the samples. CONCLUSION: Applying the EDQM criteria would decrease our blood donor loss from 10% to 5.4%. As alternative re-entry mechanisms have already been presented in the literature, institution of a new policy is needed to enhance the limited blood donor pool in our system.

Freezing of Apheresis Platelet Concentrates in 6% Dimethyl Sulfoxide: The First Preliminary Study in Turkey.

OBJECTIVE: Transfusion of platelet suspensions is an essential part of patient care for certain clinical indications. In this pioneering study in Turkey, we aimed to assess the in vitro hemostatic functions of platelets after cryopreservation. MATERIALS AND METHODS: Seven units of platelet concentrates were obtained by apheresis. Each apheresis platelet concentrate (APC) was divided into 2 equal volumes and frozen with 6% dimethyl sulfoxide (DMSO). The 14 frozen units of APCs were kept at -80 °C for 1 day. APCs were thawed at 37 °C and diluted either with autologous plasma or 0.9% NaCl. The volume and residual numbers of leukocytes and platelets were tested in both before-freezing and post-thawing periods. Aggregation and thrombin generation tests were used to analyze the in vitro hemostatic functions of platelets. Flow-cytometric analysis was used to assess the presence of frozen treated platelets and their viability. RESULTS: The residual number of leukocytes in both dilution groups was <1x106. The mean platelet recovery rate in the plasma-diluted group (88.1±9.5%) was higher than that in the 0.9% NaCl-diluted group (63±10%). These results were compatible with the European Directorate for the Quality of Medicines quality criteria. Expectedly, there was no aggregation response to platelet aggregation test. The mean thrombin generation potential of post-thaw APCs was higher in the plasma-diluted group (2411 nmol/L per minute) when compared to both the 0.9% NaCl-diluted group (1913 nmol/L per minute) and the before-freezing period (1681 nmol/L per minute). The flow-cytometric analysis results for the viability of APCs after cryopreservation were 94.9% and 96.6% in the plasma and 0.9% NaCl groups, respectively. CONCLUSION: Cryopreservation of platelets with 6% DMSO and storage at -80 °C increases their shelf life from 7 days to 2 years. Besides the increase in hemostatic functions of platelets, the cryopreservation process also does not affect their viability rates.

In vitro efficacy of frozen erythrocytes: implementation of new strategic blood stores to alleviate resource shortage (issue revisited).

BACKGROUND/AIM: Currently, the provision of blood products largely depends on walking blood banks and limited amounts of stored blood with short shelf lives. We aimed to compare the efficacy of erythrocyte concentrate (ECs) by pre- and postfreezing in vitro tests. MATERIALS AND METHODS: In our study, 10 ECs were glycerolized, frozen, thawed, and then deglycerolized using the Naval Blood Research Laboratory method. In addition to using the standard tests, ATP and 2,3-DPG levels and the viability of erythrocytes were also determined. RESULTS: The prefreezing mean viability rates of erythrocytes changed from 89.7 ± 13.7% to 98.6 ± 1.8% after thawing and deglycerolization. Prefreezing and day 0 ATP levels (1.64 ± 0.15 µmol/g Hb and 1.81 ± 0.14 µmol/g Hb, respectively) were similar. The 2,3-DPG levels decreased from 18.09 ± 4.78 µmol/g Hb measured before the procedure to 10.41 ± 4.58 µmol/g Hb on day 0. The mean hemolysis rates and supernatant Hb levels changed from 0.21 ± 0.11% to 0.36 ± 0.12% and 1 ± 0.5 g/L to 1.5 ± 0.5 g/L, respectively. CONCLUSION: The test results showed the efficacy of the frozen-thawed ECs to be used in humans for a broad spectrum of clinical indications. As a part of a contingency plan, national frozen blood reserves need to be established.