The Turkish experience with therapeutic plasma exchange: A national survey.

Therapeutic plasma exchange (TPE) is used to treat more than 60 diseases worldwide and has drawn growing interest. Little is known about the current situation of TPE activity in Turkey, so we developed a survey to obtain information about this timely topic. We collected data on TPE from 28 apheresis units throughout Turkey. We performed a total of 24,912 TPE procedures with 3203 patients over the past decade. Twenty years ago, the majority of procedures were performed for neurological and hematological disorders, and today, most TPE procedures are done for the same reasons. The only historical change has been an increase in TPE procedures in renal conditions. Currently, renal conditions were more frequently an indication for TPE than rheumatic conditions. Fresh frozen plasma was the most frequently used replacement fluid, followed by 5% albumin, used in 57.9% and 34.6% of procedures, respectively. The most frequently used anticoagulants in TPE were ACD-A and heparin/ACD-A, used with 1671 (52.2%) and 1164 (36.4%) patients, respectively. The frequency of adverse events (AEs) was 12.6%. The most common AEs were hypocalcemia-related symptoms, hypotension, and urticaria. We encountered no severe AEs that led to severe morbidity and mortality. Overall, more than two thirds of the patients showed improvement in the underlying disease. Here, we report on a nationwide survey on TPE activity in Turkey. We conclude that there has been a great increase in apheresis science, and the number of TPE procedures conducted in Turkey has increased steadily over time. Finally, we would like to point out that our past experiences and published international guidelines were the most important tools in gaining expertise regarding TPE.

A multicenter experience of thrombotic microangiopathies in Turkey: The Turkish Hematology Research and Education Group (ThREG)-TMA01 study.

Thrombotic microangiopathies (TMAs) are rare, but life-threatening disorders characterized by microangiopathic hemolytic anemia and thrombocytopenia (MAHAT) associated with multiorgan dysfunction as a result of microvascular thrombosis and tissue ischemia. The differentiation of the etiology is of utmost importance as the pathophysiological basis will dictate the choice of appropriate treatment. We retrospectively evaluated 154 (99 females and 55 males) patients who received therapeutic plasma exchange (TPE) due to a presumptive diagnosis of TMA, who had serum ADAMTS13 activity/anti-ADAMTS13 antibody analysis at the time of hospital admission. The median age of the study cohort was 36 (14-84). 67 (43.5%), 32 (20.8%), 27 (17.5%) and 28 (18.2%) patients were diagnosed as thrombotic thrombocytopenic purpura (TTP), infection/complement-associated hemolytic uremic syndrome (IA/CA-HUS), secondary TMA and TMA-not otherwise specified (TMA-NOS), respectively. Patients received a median of 18 (1-75) plasma volume exchanges for 14 (153) days. 81 (52.6%) patients received concomitant steroid therapy with TPE. Treatment responses could be evaluated in 137 patients. 90 patients (65.7%) achieved clinical remission following TPE, while 47 (34.3%) patients had non-responsive disease. 25 (18.2%) non-responsive patients died during follow-up. Our study present real-life data on the distribution and follow-up of patients with TMAs who were referred to therapeutic apheresis centers for the application of TPE.

What is the role of apheresis technology in stem cell transplantation?

Since the demonstration that hematopoietic cells are present in circulating blood, peripheral blood stem cell transplantation (PBSCT) has become an area of interest. The invention of growth factors such as the granulocyte colony-stimulating factor (G-CSF) and the availability of apheresis techniques allowed the wide application of peripheral blood stem cells (PBSC) in both autologous and allogeneic hematopoietic stem cell transplantation settings. It has been since 1986 that clinically introduced, peripheral blood stem cells replaced bone marrow as a stem-cell source to nearly 100% in the autologous and to approximately 75% in the allogeneic transplantation setting. During this period of time, remarkable development occurred in both stem cell mobilizing agents (i.e. CXCR4 antagonists) and apheresis techniques. Currently, apheresis technology is being increasingly used in not only for collection of PBSC or blood product support, but also for treatment and/or prevention of several transplantations related complications. Apheresis technology also allows to manipulate stem cells and thus provides opportunity to curative treatment of certain diseases.

Autologous hematopoietic progenitor cell mobilization and collection in adult patients presenting with multiple myeloma and lymphoma: A position-statement from the Turkish Society of Apheresis (TSA).

Autologous hematopoietic cell transplantation (AHCT) is a routinely used procedure in the treatment of adult patients presenting with multiple myeloma (MM), Hodgkin lymphoma (HL) and various subtypes of non-Hodgkin lymphoma (NHL) in upfront and relapsed/refractory settings. Successful hematopoietic progenitor cell mobilization (HPCM) and collection are the rate limiting first steps for application of AHCT. In 2015, almost 1700 AHCT procedures have been performed for MM, HL and NHL in Turkey. Although there are recently published consensus guidelines addressing critical issues regarding autologous HPCM, there is a tremendous heterogeneity in terms of mobilization strategies of transplant centers across the world. In order to pave the way to a more standardized HPCM approach in Turkey, Turkish Society of Apheresis (TSA) assembled a working group consisting of experts in the field. Here we report the position statement of TSA regarding autologous HPCM mobilization strategies in adult patients presenting with MM and lymphoma.

Current practice of autologous hematopoietic progenitor cell mobilization in adult patients with multiple myeloma and lymphoma: The results of a survey from Turkish hematology research and education group (ThREG).

Autologous hematopoietic cell transplantation (AHCT) is an established treatment option for adult patients presenting with multiple myeloma (MM), Hodgkin lymphoma (HL) and various subtypes of non-Hodgkin lymphoma (NHL) in upfront and/or relapsed/refractory disease settings. Although there are recently published consensus guidelines addressing critical issues regarding autologous hematopoietic progenitor cell mobilization (HPCM), mobilization strategies of transplant centers show high variability in terms of routine practice. In order to understand the current institutional policies regarding HPCM in Turkey and to obtain the required basic data for preparation of a national positional statement on this issue, Turkish Hematology Research and Education Group (ThREG) conducted a web-based HPCM survey. The survey was designed to include multiple-choice questions regarding institutional practice of HPCM in adults presenting MM, HL, and NHL. The representatives of 27 adult HCT centers participated to the study. Here we report the results of this survey shedding light on the real-world experience in Turkey in terms of autologous HPCM mobilization strategies in patients presenting with MM and lymphoma.

Acute promyelocytic leukemia, centre, experience, Turkey.

Acute promyelocytic leukemia (APL) is a specific type of acute myeloid leukemia (AML) and has distinct hematopathologic, cytogenetic, clinical and molecular features. This study was a retrospective review of 18 adult patients (10 male, 8 female; mean age of 32.17 ± 5.66 (15-61 years) with APL at our department from January 2006 to December 2011. Following induction therapy, 17 patients achieved CR, 1 of 18 patients died of result bleeding within thirty-sixth hours of admission. In two of 18 patients developed RAS. The relapse rate was 27% (5/18). Fourteen of 18 patients (77%) have been followed in remission. APL is a malignancy requiring quick diagnosis, efficient treatment and supportive care system. ATO, one of the important therapy option in the treatment of APL, cannot be obtained easily in developing countries. This may lead to an increase in the mortality rates. The studies should be made with more number of patients and a longer period of time for accurate results.

Therapeutic plasma exchange in patients with neurological diseases: multicenter retrospective analysis.

Therapeutic plasma exchange (TPE), is a procedure, changing pathologic substances in the plasma of patients with replacement fluid. TPE has an increasing list of indications in recent years such as neurological, connective tissue, hematological, nephrological, endocrinological and metabolic disorders. We report our multicenter data about therapeutic plasma exchange in patients with neurological diseases. Six University Hospitals' aphaeresis units medical records about neurologic diseases were reviewed retrospectively. Hundred and fifteen patients and 771 TPE sessions from six aphaeresis units' were included to this study. Of the 115 patients, 53 (46%) were men and 62 (54%) were women. The median age was 50 (range: 5-85) years. Of these patients 58.3% were Guillain-Barre syndrome (GBS), 17.4% were acute disseminated encephalomyelitis (ADEM), 10.4% were chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), 7% were multiple sclerosis, 6.1% were myasthenia gravis (MG) and 0.9% were Wilson disease (WD). The median number of TPE sessions per patient was 5 (range 1-72). Human albumin was used as a replacement fluid in 66% and fresh frozen plasma was used in 34% of cases. TPE was done through central venous catheters in 66%, and peripheral venous access in 34% of patients. Some complications were seen in patients (18.3%) during TPE sessions. These complications were, complications related to catheter placement procedure (8.7%), hypotension (3.5%), hypocalcaemia (3.5%) and allergic reactions (1.7%). The complication ratios were 2.7% in total 771 TPE procedures. TPE procedure was terminated in 6% of sessions depending on these complications. Overall responses to TPE were noted in 89.5% of patients. In conclusion; Therapeutic plasma exchange is an effective treatment option in several neurologic diseases.

Therapeutic plasma exchange in patients with thrombotic thrombocytopenic purpura: a retrospective multicenter study.

UNLABELLED: Thrombotic thrombocytopenic purpura (TTP) is a particular form of thrombotic microangiopathy typically characterized by thrombocytopenia, microangiopathic hemolytic anemia, fever, neurological abnormalities, and renal dysfunction. TTP requires a rapid diagnosis and an adapted management in emergency. Daily sessions of therapeutic plasma exchange (TPE) remain the basis of management of TTP. Also, TTP is a rare disease that is fatal if it is not treated. TPE has resulted in excellent remission and survival rates in TTP patients. AIM: We aimed to present our experience in 163 patients with TTP treated with TPE during the past 5years from 10 centers of Turkey. PATIENTS AND METHODS: One hundered and sixty-three patients with TTP treated with TPE during the past 5years from 10 centers of Turkey were retrospectively evaluated. TPE was carried out 1-1.5times plasma volume. Fresh frozen plasma (FFP) was used as the replacement fluid. TPE was performed daily until normalization of serum lactate dehydrogenase (LDH) and recovery of the platelet count to >150×10(9)/dL. TPE was then slowly tapered. Clinical data, the number of TPE, other given therapy modalities, treatment outcomes, and TPE complications were recorded. RESULTS: Fifty-eight percent (95/163) of the patients were females. The median age of the patients was 42years (range; 16-82). The median age of male patients was significantly higher than female (53 vs. 34years; p<0.001). All patients had thrombocytopenia and microangiopathic hemolytic anemia. At the same time, 82.8% (135/163) of patients had neurological abnormalities, 78.5% (128/163) of patients had renal dysfunction, and 89% (145/163) of patients had fever. Also, 10.4% (17/163) of patients had three of the five criteria, 10.4% (17/163) of patients had four of the five criteria, and 6.1% (10/163) of patients had all of the five criteria. Primary TTP comprised of 85.9% (140/163) of the patients and secondary TTP comprised of 14.1% (23/163) of the patients. Malignancy was the most common cause in secondary TTP. The median number of TPE was 13 (range; 1-80). The number of TPE was significantly higher in complete response (CR) patients (median 15.0 vs. 3.5; p<0.001). CR was achieved in 85.3% (139/163) of the patients. Similar results were achieved with TPE in both primary and secondary TTP (85% vs. 87%, respectively; p=0.806). There was no advantage of TPE+prednisolone compared to TPE alone in terms of CR rates (82.1% vs. 76.7%; p=0.746). CR was not achieved in 14.7% (24/163) of the patients and these patients died of TTP related causes. There were no statistical differences in terms of mortality rate between patients with secondary and primary TTP [15% (21/140) vs. 13% (3/23); p=0.806]. But, we obtained significant statistical differences in terms of mortality rate between patients on TPE alone and TPE+prednisolone [14% (12/86) vs. 3% (2/67), p<0.001]. CONCLUSIONS: TPE is an effective treatment for TTP and is associated with high CR rate in both primary and secondary TTP. Thrombocytopenia together with microangiopathic hemolytic anemia is mandatory for the diagnosis of TTP and if these two criteria met in a patient, TPE should be performed immediately.

Thrombotic thrombocytopenic purpura: A single - Centre experience.

We aimed to describe the characteristics, treatment regime, and 6-month all-cause mortality of thrombotic thrombocytopenic purpura (TTP) patients treated with total plasma exchange in the our clinic. Thirteen patients were included in the study. Mortality rates of TTP have improved over the last three decades but they are still too high according to modern therapy expectations. Etiology directed treatment should be added to total plasma exchange in secondary TTP cases. Based on TTPs' immunologic etiology, immune modulator and immune suppressor agents have been applied together with total plasma exchange, but mostly in anecdotal case reports or with questionable responses.

Thrombotic thrombocytopenic purpura associated with Brucella infection.

Thrombotic thrombocytopenic purpura (TTP) is characterized by disseminated thrombotic occlusions located in the microcirculation and a syndrome of microangiopathic hemolytic anemia (MAHA), thrombocytopenia, fever, and renal and neurologic abnormalities. Although several factors such as viral and bacterial pathogens, pancreatitis, drugs, collagen-vascular diseases, cancers, and pregnancy have been reported to be associated with TTP, brucellosis is an exceptional cause of this disorder. We represent a 19-year-old woman applying to our outpatient department with the complaints of headache, fever, sweat, malaise, and jaundice. Clinical signs and laboratory findings were consistent with TTP. Brucella agglutination was found to be 1/320 positive. After the administration of therapeutic plasma exchange, all symptoms and laboratory abnormalities improved dramatically. Antibiotic therapy directed to Brucella infection was initiated and no recurrence of TTP was seen.

Effect of high fat diet on the volume of liver and quantitative feature of Kupffer cells in the female rat: a stereological and ultrastructural study.

BACKGROUND: The role of Kupffer cells (KCs) in nonalcoholic steatohepatitis (NASH) which is regarded as a major cause of cryptogenic cirrhosis of the liver was investigated using stereological methods and electron microscopy in the rat model. To our knowledge, there is no stereological study on the volume of liver, total number, numerical density, and nuclear height of KCs of liver in the female rat fed with a high fat diet (HFD) in the literature. METHOD: 16 female Sprague Dawley rats were randomized into HFD and control group, with HFD and standard diet for 12 weeks, respectively. In this study, two basic research methods were used to analyze the samples. One was histopathological observation at both light and electron microscopic level. The other was stereological methods that consist of Cavalieri principle for liver volume estimation and physical disector method for estimation of numerical density and total number of KCs in the liver. RESULTS: Liver volume, both mean numerical density and total number of KCs, were statistically increased in HFD rats. Ultrastructurally, a significant decrease in the mean nuclear height of KCs in HFD rats was also found. In the control group, no abnormal change was observed, but in the HFD group, some changes such as diffuse steatosis, mononuclear cell infiltration, necrosis, fibrosis, accumulation of fat droplets and intra-cytoplasmic vacuoles, and swollen mitochondria with irregular membranes were observed in the hepatocytes. CONCLUSION: The number and activity of KCs are increased significantly in NASH induced by HFD, and KCs might be involved in the pathogenesis of steatohepatitis as previously attributed as a major cause of cryptogenic cirrhosis of the liver.

Spuriously high phosphate level which is promptly resolved after plasmapheresis in a patient with multiple myeloma.

We present a 57 year old female patient with IgG multiple myeloma and marked hyperphosphatemia. The patient had no clinical symptoms related to hyperphosphatemia. Serum inorganic phosphate measurements were repeated on sulfosalicylic acid deproteinized serum samples, yielding normal phosphate levels. We realized that this hyperphosphatemia was spurious because of high paraprotein levels. Afterwards, therapeutic plasma exchange (TPE) was administered due to hyperviscosity and bleeding tendency. After the administration of TPE, serum phosphate was reduced to normal level. Therapeutic plasma exchange resulted in steady-state serum phosphate levels during the three months follow up period. We concluded that high phosphate levels must be confirmed by measuring in deproteinized serum samples in multiple myeloma patients in order to distinguish pseudohyperphosphatemia from the true ones. In addition, TPE effectively reduces the spuriously elevated phosphate levels possibly by removing paraproteins.

[Seroprevalence of parvovirus B19 in patients with chronic idiopathic thrombocytopenic purpura]. / Kronik idiopatik trombositopenik purpura olgularinda parvovirus B19 seroprevalansi.

Although there are several studies indicating the relationship between parvovirus B19 (PV-B19) and acute idiopathic thrombocytopenic purpura (ITP) which is a form seen frequently in children, the data are not enough in terms of chronic ITP, which is a more insidious form frequently seen in adults. The aim of this study was to investigate PV-B19 seroprevalence in adult chronic ITP cases diagnosed at the haematology clinics of Atatürk University Research Hospital in Erzurum (located in eastern Anatolia, Turkey). A total of 61 patients (38 female, 23 male; mean age: 34.4 +/- 11.2 years) and 60 healthy control subjects (30 female, 30 male; mean age: 35.6 +/- 9.6 years) were included to the study. All possible etiological agents and factors other than PV-B19 were eliminated on the basis of clinical and laboratory findings. PV-B19 antibodies were screened by ELISA method, and 73.7% (45/61) of the patients were found IgG, whereas 3.2% (2/61) were found IgM seropositive. In the control group, these rates were detected as 38.3% (23/60) and 1.6% (1/60), respectively. IgG antibodies were negative in the two patients and one control who were positive for IgM. The presence of PV-B19 DNA was investigated in all of the three IgM positive subjects, and was found positive in only one patient by real-time polymerase chain reaction (PCR). The difference between patient and control groups with regard to IgG seropositivity was found statistically significant (p < 0.01), however statistical evaluation could not be performed for IgM seropositivity because of the low number of cases. As a result although the rate of IgG positivity was found statistically higher in the ITP patients in our study, this data is inefficient for the evaluation of relationship between PV-B19 and chronic ITP, indicating the need for further studies.

Morphological alterations produced by zinc deficiency in rat sciatic nerve: a histological, electron microscopic, and stereological study.

Zinc (Zn) is an essential trace element for humans and animals. It is required for normal growth, gene expression, wound healing, protein metabolism, immune function, and membrane integrity. In this study, unbiased stereological methods have been used to quantify the effects of Zn deficiency on the sectioned surface area and the number of myelinated axons in the sciatic nerve of rats. Animals were fed a Zn-deficient or Zn-sufficient diet for a period of 4 weeks. At the end of this time, the samples of sciatic nerves were removed from the animals, processed for electron microscopy and embedded in resin. The Zn-deficient group of rats was found to have a lower body weight compared to rats in the control group (P < 0.05). The sectioned surface area of nerve cross-section and myelinated axon number in Zn-deficient rats decreased by 20% and 29%, respectively, compared to the control group. A significant correlation between sectioned surface area and myelinated axon number was also determined. Morphological findings were as follows: on light microscopy, it was determined that certain abnormalities occur specifically in the experimental group, such as collapsed nerve fascicles, irregular profiles of and degeneration in myelin sheaths, and on electron microscopy, extensive myelin damage was seen in Zn-deficient groups compared with control groups. This study suggests that peripheral nerves require Zn for development and preservation of their structure.

Genotoxic effect of ribavirin in patients with Crimean-Congo hemorrhagic fever.

In this study, we investigated the in vivo genotoxicity of ribavirin in humans, studying 3 patients with Crimean-Congo hemorrhagic fever who were treated with high-dose ribavirin. In order to evaluate genotoxicity, both the micronucleus (MN) test and the sister chromatid exchange (SCE) test were used. In all patients, blood samples were taken during and after therapy. Whole blood cultures were performed for 72 h and the MN assay and SCE test were then carried out to demonstrate the genotoxicity. In all patients, both SCE and MN amounts were found to be higher in the samples which were taken during therapy than in those at 1 month after therapy. The results of our study reveal that ribavirin has a reversible in vivo genotoxic effect on humans.

Prevalence of Hepatitis G Virus in Blood Donors and Recipients.

We evaluated the prevalence of hepatitis G virus (HGV) infection in patients who had received multiple blood components and in blood donors and the possible coinfection with hepatitis C virus (HCV). Eighty patients who had received multiple blood components and 70 eligible blood donors, as controls were included in this study. HGV RNA was determined by reverse polymerase chain reaction in serum. HGV-RNA was detected in three (3.7%) of patients and in one (1.4%) of controls. Statistical analysis showed no difference between the groups (p> 0.05). HGV and HCV coinfection was not observed in both patient and control groups. Although the most important risk factor for HGV infection was found to be blood transfusions in various studies, this study showed that there is not significant relationship between blood components transfusion and HGV infection.

Relation of coronary collateral circulation with red cell distribution width in patients with non-ST elevation myocardial infarction.

OBJECTIVES: We aimed to investigate the relationship between red cell distribution width (RDW) value and coronary collateral circulation (CCC) in patients with non-ST elevation myocardial infarction (NSTEMI). METHODS: The study population consisted of 322 consecutive patients with NSTEMI. The patients were classified into impaired CCC (group 1, Rentrop grades 0-1) or good CCC (group 2, Rentrop grades 2-3). Baseline RDW was measured as part of the automated complete blood count. RESULTS: The RDW values were significantly higher in patients with impaired CCC than in those with good CCC (17.2 ± 2.3 vs 14.5 ± 2.5, P < .001). In multivariate logistic regression analysis, RDW (odds ratio: 1.52, 95% confidence interval: 1.30-1.78, P < .001), baseline creatine kinase MB (CK-MB), and absence of preinfarction angina were found to be the independent predictors of impaired CCC. In receiver-operating characteristic curve analysis, the RDW value >15.5 yielded an area under curve value of 0.783, with 77% sensitivity and 73% specificity. CONCLUSIONS: Our study results demonstrated that, high RDW, high CK-MB, and absence of preinfarction angina were found to be independent predictors of impaired CCC.

Comparative study of three angiotensin II type 1 receptor antagonists in preventing liver fibrosis in diabetic rats: stereology, histopathology, and electron microscopy.

The presence of liver disease in patients with progressively worsening insulin resistance may not be recognized until patients develop manifestations of the metabolic syndrome such as diabetes, hypertension, hyperlipidemia, and vascular disease. It was aimed to investigate whether three angiotensin II type 1 receptor antagonists (ARBs) (olmesartan, losartan, and valsartan) had preventive effect against hepatic fibrosis and this was a common characteristic among ARBs. In current study, 25 adult male rats were used and divided into five groups: the non-diabetic healthy group, alloxan induced diabetic (AID) control group, AID losartan group, AID valsartan group and AID olmesartan group. According to numerical density of hepatocytes, significant difference was found between the non-diabetic healthy group and diabetic control group. All treatments groups were significant when compared to diabetic control group. In diabetic control group it was examined swelling, irregular cristae arrangement in some of mitochondria. It was also determined mitochondria membrane degeneration in some areas of section profiles. In diabetic rats treated with losartan group, there were necrotic hepatocytes. In diabetic rats treated with valsartan group, predominantly, findings were similar to losartan group. In diabetic rats treated with olmesertan group, plates of hepatocytes were quite regular. There were hardly necrotic cells. Not only other organelles such as RER, SER and lysosom but also mitochondrial structures had normal appearance. In the diabetic control group electron microscopy revealed edema in both the cytoplasm and perinuclear area and the nuclear membranes appeared damaged. In conclusion, it was established that the most protective ARB the liver in diabetic rats was olmesartan, followed by losartan.

Prognostic significance of antithrombin activity in patients with crimean-congo hemorrhagic Fever.

OBJECTIVE: Crimean-Congo hemorrhagic fever (CCHF) is a tick-borne viral hemorrhagic fever. Disseminated intravascular coagulation (DIC) is an important complication of this disease, especially in severe and fatal cases. Antithrombin (AT) acts as an anticoagulant by inactivating thrombin, Factor IX, Factor X and Factor XI. We conducted this study to investigate the AT levels and their prognostic value in CCHF. MATERIALS AND METHODS: Twenty-eight confirmed CCHF patients were included in this study. Diagnosis of the disease was made by CCHF IgM and/or PCR positivity. Patients were grouped based on the severity criteria described previously. The patients with platelet counts <20 000×10(6) cell/L, white blood counts >10×10(9) cell/L, prothrombin times >60 seconds, aspartate aminotransferase levels >700 IU/L or alanine aminotransferase levels >900 IU/L were accepted as severe cases. Patients whose illnesses were self-limited and who did not require blood component replacement were accepted as mild cases, and patients who improved but required blood component replacement were accepted as moderate cases. Blood samples were obtained on the day that the patient had the lowest platelet count and before any thrombocyte replacement. The antithrombin activity was measured using a chromogenic substrate test (Diagnostica Stago STA Compact) at a research laboratory. RESULTS: Twenty-two (78.6%) of the cases were mild, 3 (10.7%) were moderate, and 3 were (10.7%) severe. The mean AT value was 101% for mild cases, 116.6 % for moderate cases, and 88% for severe cases (p>0.05). Although there were no statistically significant differences between the AT values, the mean AT activity was lower in severe CCHF cases. CONCLUSION: The AT activity may have been decreased in severe CCHF cases. Further studies with greater numbers of patients are required to determine the level of AT activity and its correlation with disease severity and the prognosis of CCHF.

A simple, safe and effective approach to prevent postdural puncture headache: epidural saline injection.

OBJECTIVE: In this study, we investigated the safety and effectiveness of epidural saline injection to prevent post-dural puncture headache (PDPH) in patients with acute lymphoblastic leukemia (ALL). MATERIALS AND METHODS: Thirty-three patients with ALL undergoing induction therapy were accepted for the study. Four to six courses of intrathecal methotrexate therapy were administered to each patient for central nervous system prophylaxis. Patients were divided into two groups. Lumbar puncture (LP) was performed without any additional intervention in the first group (18 cases), whereas 20 mL of isotonic saline was injected into the epidural space in the second group (15 cases). The frequency and severity of PDPH were compared between the two groups. RESULTS: Thirteen patients from the first group and five patients from the second group experienced at least one PDPH episode. In total, 54 PDPH episodes were reported in both groups. The rate of headache due to the LP was significantly higher in the first group than in the second group (48.8% vs. 16.4%, p<0.001). On the other hand, the severity of pain was also significantly higher in the first group (mean pain scores were 5.6 ± 1.62 vs. 3.07 ± 1.18, p<0.001). Furthermore, two patients from the first group (11.11%) developed generalized convulsion attacks, and one of those patients experienced pulmonary arrest necessitating respiratory support. No serious complications were observed in the second group. CONCLUSIONS: Our study shows that isotonic saline injection into the epidural space after LP is a safe and effective approach to prevent PDPH and related complications.