Duran Canatan

Hemoglobinopathy control program in Turkey.

Hemoglobinopathies are a very important health problem in Turkey. To date many studies have been performed but there has been no national hemoglobinopathy control program (HCP). After the Turkish National Hemoglobinopathy Council (TNHC) was created all centers, foundations, and associations were combined into one organization controlled by the Ministry of Health (MOH). The MOH and the TNHC have started to register the results of the screening of 377,339 healthy subjects from 16 different cities and the recorded average frequency of the β-thalassemia trait was 4.3%. The highest prevalence of theβ-thalassemia trait (13.1%) was found in the Antalya region and of the HbS trait (10%) in the Çukurova region. Next, written regulations for the Fight against Hereditary Blood Disease were published especially for preventing and treating hemoglobinopathies. The MOH and the TNHC selected 33 provinces situated in the Thrace, Marmara, Aegean, Mediterranean and South Eastern regions with a high birth prevalence of severe hemoglobinopathies. The hemoglobinopathy scientific committee was set up, a guidebook was published and a national HCP was started in these high-risk provinces.

Modulation of redox pathways in neutrophils from sickle cell disease patients

OBJECTIVE Interaction of nitric oxide (NO) with enzymatic sources of reactive species exerts modulatory actions on inflammatory signaling mechanisms. MATERIALS AND METHODS NADPH oxidase, total peroxidase, cyclooxygenase (COX) activity, and NO consumption were measured in neutrophils isolated from sickle cell disease (SCD) patients and healthy controls. Glutathione (GSH) levels and expression of inducible NO synthase (NOS-2) were also analyzed to assess intracellular redox state and NO production, respectively. RESULTS Functional assay of NADPH oxidase was performed by measuring superoxide release, which was similar in control and SCD, both at basal conditions and in response to N-formyl-methionyl-leucyl-phenylalanine stimulation. Peroxidase activity, assessed spectrophotometrically, was not significantly different in SCD neutrophils compared to controls. Total COX activity, measured via an assay kit, was significantly increased in SCD neutrophils. The increase in total COX activity observed in SCD was due to enhanced activity of COX-2, differentiated by using the isoform-specific inhibitors DuP-697 and SC-560. Western blot analysis of COX-2 protein in SCD and control neutrophils confirmed increased enzyme activity in the diseased group. Western blot analysis of neutrophil lysates from SCD patients showed significantly increased NOS-2 protein content, compared to controls. Spectrophotometric measurement of GSH and nitrate/nitrite levels showed a decrease in GSH and an increase in nitrate/nitrite content in SCD neutrophils. Electrochemical measurement of NO consumption both under basal conditions and after N-formyl-methionyl-leucyl-phenylalanine stimulation revealed a significant decrease in SCD neutrophils compared to controls. CONCLUSIONS Depletion of GSH in SCD neutrophils may impact on rates of NO consumption and reflects increased oxidative stress associated with neutrophil activation.

Psychosocial burden of [beta]-thalassaemia major in Antalya, south Turkey

beta-thalassaemia is a recessively inherited blood disorder characterised by chronic anaemia. It requires monthly blood transfusions and regular iron chelation. Thousands of affected children are born annually and the magnitude of the problem is most severe in developing countries. Ninety-nine children and 32 adults with thalassaemia major, and 112 parents of patients were interviewed in Antalya, south Turkey, using specifically designed questionnaires to evaluate psychosocial burden. The education of most of the thalassaemic children of school age (60%) was affected, mainly due to having to attend hospital for investigation and transfusions. A high level of parental anxiety (82%) was reported. Nearly half of the families (47%) had employment and financial problems as a result of thalassaemia, yet there was a low level of marital breakdown (1.8%). A substantial majority (93%) of the parental couples would have chosen to terminate an affected pregnancy if they had known that the foetus had thalassaemia major. The results reflect the need for a national policy for public education and screening of thalassaemia in Turkey in order to offer prenatal diagnosis for all families at risk of homozygous thalassaemia.

Fluorosis and its hematological effects

Although it has been reported that fluoride ingestion has no influence on various indices of hematopoiesis, some research has been published that excessive fluoride developed anemia and eosinophilia of leukocytes. Isparta is situated on the lake region of Turkey where fluorosis is endemic. Our aim was to explore the hematological effects in rats induced by fluoride. In this study, Wistar-Albino rats were used, divided into two groups as control and fluorized. While the control group was administered commercial water (including 0.07 ppm fluoride), the fluorized group was administered 100 ppm fluoride in commercial drinking water for four months. At the end of four months, hematological indices (Hb, Hct, MCV, MCH, RDW, RBC, WBC, and platelet counts) were measured. In addition, bone marrow samples were investigated. Mean leukocyte counts (WBC) in the control group and fluorized group were 7.07 (2.62-12.25) and 2.76 (3.13-5.24)-/103/mm3, respectively. We observed displastic changes on granulocytes in the bone marrow samples of the fluorized group. Although there were significant statistical changes in WBC, we did not determine red blood cell and platelet changes in the fluorized group.

The effects of chelators on zinc levels in patients with thalassemia major.

Zinc which is an essential element has very important effects on growth and immune system in patients with thalassemia major (TM). The effects of two oral iron chelator agents, desferrioxamine (DFO) and deferiprone (DFP), on zinc levels were investigated in previous studies and they were found to cause zinc deficiency. Zinc level alteration by the new chelator deferasirox (DFX) is not present in the literature. The aim of this study was to examine the effects of different oral chelators on serum and urine zinc levels in TM patients. Zinc levels are compared in the patients who received different chelators: only DFX, combined chelation with DFO plus DFP and the healthy control group. A total of 56 patients with TM were involved in this study: 39 patients received only DFX and 17 patients were given combined treatment DFO+DFP between August 2008 and August 2009. In addition, a control group was established from the healthy population. Blood was taken from all the patients for serum zinc levels and 24hour-urine samples were collected for urine zinc levels. Serum zinc levels were found to be 64.8±14.8μg/dL in DFX group and 66.5±15.1μg/dL in DFO+DFP group. These levels were statistically lower than that in the control group (149±54.3μg/dL) (p<0.05), but there was no statistically difference between the two different chelation groups (p>0.05). The urine zinc levels of DFX and DFO+DFP group were 662.2±428.2μg/day and 1182.3±980.3μg/day respectively (p<0.05). Urinary zinc excretion in the chelation groups (DFX and DFO+DFP) was significantly higher than the control group (395.1±208.9μg/day) (p<0.05). As a conclusion, the new chelation agent, DFX, also leads to zinc deficiency, though its urinary zinc excretion is lower. New studies are required to examine the effects of DFX on zinc extensively. Zinc levels of patients with TM should be followed up regularly and zinc supply should be given at early ages.

ANALYSIS OF PEDIATRIC THROMBOTIC PATIENTS IN TURKEY

This study analyzes the data of thrombotic children who were followed up in different pediatric referral centers of Turkey, to obtain more general data on the diagnosis, risk factors, management, and outcome of thrombosis in Turkish children. A simple two-page questionnaire was distributed among contact people from each center to standardize data collection. Thirteen pediatric referral centers responded to the invitation and the total number of cases was 271. All children were diagnosed with thromboembolic disease between January 1995 and October 2001. Median age at time of first thrombotic event was 7.0 years. Of the children 4% of the cases were neonates, 12% were infants less than 1 year old, and 17% were adolescents. Thromboembolic event was mostly located in the cerebral vascular system (32%), deep venous system of the limbs, femoral and iliac veins (24%), portal veins (10%), and intracardiac region (9%). Acquired risk factors were present in 86% of the children. Infection was the most common underlying risk factor. Inherited risk factors were present in 30% of the children. FVL was the most common inherited risk factor. Acquired and inherited risk factors were present simultaneously in 19% of the patients. Eleven children had a history of familial thrombosis. Due to the local treatment preferences, the treatment of the children varied greatly. Outcome of the 142 patients (52%) was reported: 88 (62%) patients had complete resolution, 47 (33%) had complications, 12 (9%) had recurrent thrombosis, and 34 (24%) died. Three children (2.1%) died as a direct consequence of their thromboembolic disease. The significant morbidity and mortality found in this study supports the need for multicentric prospective clinical trials to obtain more generalizable data on management and outcome of thrombosis in Turkish children.

The association between intragenic SNP haplotypes and mutations of the beta globin gene in a Turkish population

Identification of the beta globin gene mutation-related haplotypes is of interest for the delineation of the clinical heterogeneity as well as understanding of the origin and spreading of the beta globin gene mutations. We screened the whole beta globin gene in 197 Turkish patients by direct sequencing and performed Haploview analyses for beta globin gene haplotyping using five common intragenic SNPs; rs713040, rs10768683, rs7480526, rs7946748, and rs1609812. We found 25 different beta globin gene point mutations by sequencing. A Turkish type of inv/del mutation by MLPA and Gap-PCR was also detected with additional studies. The seven most common mutations with higher frequency of 5% were IVS-I-110 (G>A) (35.6%), Hb S(10.6%), IVS-I-6 (T>C) (7.4%), IVS-I-1 (G>A) (6.9%), IVS-II-1 (G>A) (6.9%), Cod8(-AA) (6%), IVS-II-745 (C>G) (5.1%) and accounted for 78.7% of all mutations. We identified seven different haplotypes (Haplotype I-VII) using five intragenic single nucleotide polymorphisms (SNPs) genotyped by sequencing of the beta globin gene. The association between the mutations and the haplotypes was defined for 16 different mutations. We suggest that haplotyping by these five intragenic SNPs will provide useful information about the origin of the mutations and gene flow among as well as the explanation of the clinical heterogeneity.

Bone mineral density in thalassemia major patients from antalya, Turkey.

Aim. We assessed the bone mineral density and related parameters in nine adults, thirty-eight pubertal, prepubertal totally forty-seven patients with thalassemia major living in Antalya, Turkey. Materials and Methods. We measured height and pubertal staging in last five years by six-month intervals. Average ferritin and hemoglobin concentrations were calculated for last three years. The levels of hydroxyproline, calcium, phosphorus, and creatinine were measured in 24 h urine, and those of parathormone, IGF 1, osteocalcine, alkaline phosphatase, calcium, ionized calcium, magnesium, phosphorus, creatine, blood glucose, thyroid stimulating hormone, alanine transaminase, and aspartate transaminase were determined in serum, and also the bone mineral density was measured. Results. The average L1–L4 bone mass density was 27.1 ± 10.1 g cm−2; the average bone mineral content was 0.65  ±  0.11 g. of the patients with a Z-score under 2.5. A moderate relationship was found between the bone mass density age and height. Subjects in low pubertal staging and short stature (<3% percentile) have significantly lower bone mass densities P < 0.001. Conclusion. he prevalence of osteoporosis is high in patients with thalassemia major, possibly related to delayed puberty.

The Thalassemia center of Antalya State Hospital: 15 years of experience (1994 to 2008).

The Thalassemia center of Antalya State Hospital was established in 1994 in Antalya, Turkey. The number of newborns with thalassemia decreased statistically because of actions taken as a result of prevention studies. A total of 388 patients, including 246 with thalassemia major (63.4%), 86 with thalassemia intermediate (22.1%), 23 with sickle cell+&bgr;-thalassemia (5.9%), 20 with sickle cell disease (5.1%), and 13 with other hemoglobin abnormalities (3.3%), were studied. Complications were found to be as follows: cardiomyopathy in 45 of them (11.5%), diabetes mellitus in 10 (2.5%), hypothyroidism in 17 (4.3%), hypoparathyroidism in 2 (0.5%), osteoporosis in 53 (13.6%), growth retardation in 110 (28.3%), and hypogonadism in 75 patients (19.3%). The incidence of autoantibody and alloantibody in patients with thalassemia major was 5.6% and 10.5%, respectively. Transfusion-transmission diseases evaluated in patients found the incidence of hepatit A virus IgG to be 97.5%, that of HBs Ab to be 99.5%, HBs Ag to be 0.5%, HCV Ab to be 18%, CMV IgG to be 72.3%, CMV IgM to be 2%, and HIV-Ab to be 0%. Therefore, for the first time in our country the thalassemia center was established as a model and included subunits and a team. It served all patients for 15 years until the team was dispersed; thereafter, most of the patients were not followed up on a regular basis.

The Antioxidant Effects of Capparis Ovata and Deferasirox in Patients with Thalassemia Major

Iron overload and auto-oxidation of unpaired globin chains is the main cause of oxidative stress in thalassemia. We aimed to show the additive antioxidant effect of capparis Ovata and deferasirox in thalassemic patients. A total number of 40 thalassemia major patient aged between 7-30 years, who have been taken regular red cell 15 cc/kg/month to maintain Hb >10 gr/dl) and chelation (30 mg/kg/day ICL-670) for one year are involved. They were divided into two groups as control and study group randomly. Both study and control groups were followed by regular transfusion and chelation therapy. In addition study group has been taken capparis marmalade at the breakfast with a dose of a dessert-spoon (12.5 gr) younger than 10 years and a soup-spoon (25 gr) older than 10 years for 6 months. Hematological and biochemical parameters, ferritin at every month and oxidative-antioxidant status (MDA, CAT, Gpx, SOD) were measured at the beginning and at the end of the study. Serum ferritin and MDA levels declined significiantly in both groups (for ferritin; control group p=0.00; study group p=0.00) during the study but a much more decrease occured at MDA levels in the capparis given group (p=0.02). There was no statistically significant difference between the groups at the initial and last SOD CAT, GPX, SOD levels. Further more in the study group a significant decrease in liver function tests has been occured (AST p= 0.05, ALT p= 0.01). The high levels of MDA in iron overloaded thalassemic patients is the best marker of oxidative stres. Generally decreased iron burden was associated with decreased oxidant damage. In vitro it was shown that iron chelators such as deferoxamine and deferipron neutrolyse intraselluler free iron and inhibits oxidation. Our findings suggest that combination of capparis with deferasirox maybe have additive effect on decreasing the oxidative damage and hepatoxicity.