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Amaç: Salgın hastalık dönemlerinde, ülkelerin en çok zorlandıkları durumlardan biri de aşı karşıtı politikalardır. Aşı uygulamalarının hukuki boyutlarından dolayı bireyler aşı olmaya zorlanamamakta, sadece teşvik edilebilmektedir. Bireylerin aşı olmalarını etkileyen birçok faktör olmasına karşın ülkelerin her birine zaman ve kaynak ayrılabilmesi çok mümkün değildir. Bu nedenle çalışmamızın amacı, vatandaşların aşılanmaya teşvik edilebil- mesi için gerekli olan en uygun stratejinin belirlenmesidir. Gereç ve Yöntemler: Dünya Sağlık Örgütünün belirlemiş olduğu bireyleri aşıya teşvik edici kriterler küresel bulanık [spherical fuzzy (SF)] DEMATEL yöntemi ile analiz edilmiştir. SF-DEMATEL, kriterler arasında önem ağır- lığı belirlemede kullanılan bir yöntemdir. Bu sayede aşılanmayı artıracak kriterler arasında en önemli olanları belirlenerek uygun stratejiler gelişti- rilebilecektir. Bulgular: Aşı karşıtı politikalarda en fazla teşvik eden ana kriterin bağlamsal etkiler olduğu sonucuna varılmıştır. Ağırlıklandırma katsayılarına bakıldığında, bağlamsal etkiler 0,37, aşı ve aşılanmaya ait etkileri 0,36 ve birey ve grup etkileri 0,26 hesaplanmıştır. Alt kriterler bazında da yasalar/politikalar aşı teşvikinde oldukça etkilidir. Yasalar/poli- tikalar kriterinin ağırlığı 0,164, iletişim ve medya araçları kriterinin ağırlığı 0,160 ve ilaç endüstrisi kriterinin ağırlığı 0,159 olarak hesaplanmıştır. Sonuç: Bağlamsal etkiler, ana kriterinin alt kriteri olan politikalar/yasalar aşı teşvikinde en önemli argüman olarak karşımıza çıkmıştır. Ülkeler aşı teşvikini yaygınlaştırmak için belirlenen tüm kriterlere emek, zaman ve bütçe ayıramayacağı için analiz sonucunda en önemli etken olarak bulunan yasalara/politikalara ağırlık vermesi büyük oranda çözüm olacaktır. Bireyleri aşı olmaya teşvik etmek için devletin yetkili makamlarının yürüttüğü politikaların, aşılanmanın gerekli ve zararsız olduğu yönünde olmalıdır. Ayrıca yürütülen politikaların, halkı bilgilendirmeye yönelik gerçekleştirilmesi, aşı hakkında halka doğru bilgilerin iletilmesi yönünde olması hâlinde aşı karşıtlığı azalacaktır. ABSTRACT Objective: One of the most difficult situations for countries during pandemics is anti-vaccine policies. Due to the legal aspects of vaccination practices, individuals cannot be forced to be vaccinated, they can only be encouraged. Because these incentives are often inadequate or made incorrectly, vaccination of citizens cannot be achieved at the desired level. Although there are many factors that affect individuals to be vaccinated, it is not possible for countries to allocate time and resources to each. Therefore, the aim of our study is to find the most significant criteria for countries with scarce resources to encourage their citizens to get vaccinated and to develop a strategy accordingly. Material and Methods: The criteria for encouraging individuals to vaccinate, determined by the World Health Organization, were analyzed with the spherical fuzzy (SF) DEMATEL method. SF-DEMATEL is a method used to determine the weight of importance among the criteria. In this way, the most important ones among the criteria that will increase vaccination will be determined and appropriate strategies will be developed. Results: It was concluded that the main criterion most encouraging in anti-vaccine policies is contextual effects. Considering the weighting coefficients, contextual effects were calculated as 0.37, vaccine and vaccination effects of 0.36, and individual and group effects of 0.26. Laws/policies on the basis of sub-criteria are also very effective in promoting vaccination. The weight of the law/policies criterion is calculated as 0.164, the weight of the communication and media tools criterion as 0.160 and the weight of the pharmaceutical industry criterion as 0.159. Conclusion: Policies/laws, which are the sub-criteria of the contextual effects main criterion, have emerged as the most important argument in vaccine promotion. Since countries cannot allocate effort, time and budget to all criteria determined to promote vaccine promotion, it will be a solution to a great extent that they focus on laws/policies, which are the most important factors as a result of the analysis. To encourage individuals to be vaccinated; the policies of the competent authorities of the state should be that vaccination is necessary and harmless. In addition, if the policies carried out are aimed at informing the public and conveying accurate information about the vaccine to the public, anti-vaccination will decrease.

Sağlık hizmet sunucusu olan hastaneler, kaliteden ödün vermeden sürdürelebilirliklerini sağlamak için sağlık hizmetlerini minimum maliyetle, kaynaklarını etkin ve verimli şekilde kullanmalıdırlar. Kaynakların etkin ve verimli kullanılması ise yapılacak maliyet analiz çalışmaları ile mümkün olmaktadır. Yapılacak maliyet analiz çalışmaları hem hastaneler hem de Sosyal Güvenlik Kurumu(SGK) için faydalı olacaktır.SGK, sık görülen hastalıklar ve geri ödeme işlemlerinin kolaylaştırılması için paket fiyat uygulaması kapsamına birçok hastalığı almıştır. Bu hastalıklardan biri de Appendektomi'dir. Bu araştırmada bir Üniversite Hastanesi'nde 1 Ocak 2017-31 Aralık 2017 tarihleri arasında Appendektomi ameliyatı ile Appendektomi Laparoskopik ameliyatı olan hastaların faturaları incelenerek söz konusu ameliyatların maliyet analizi yapılmıştır. Çalışmanın evrenini 203 hasta oluştururken ikinci bir ameliyat kodlanan hastalar çalışmadan çıkarılmış ve 143 hasta üzerinden değerlendirme yapılmıştır. Yapılan maliyet analizi çalışması neticesinde SGK'nın geri ödediği ücretlerin hizmet sağlayıcı kurum olan hastanelerin katlanmış olduğu üretim maliyetlerinin çok altında olduğu ve hastanenin zarar ettiği tespit edilmiştir. Hospitals that are health service providers must use health services efficiently and efficiently with minimum cost to ensure their sustainability without sacrificing quality. Effective and efficient use of resources is possible through cost analysis studies. The cost analysis work to be done will be beneficial for both the hospitals and the Social Security Institution.Social Security Institution has received many diseases within the scope of package price application for facilitating frequent diseases and reimbursement transactions. One of these diseases is Appendektomi. In this research, Appendectomy and Appendectomy between January 1, 2017 and December 31, 2017 in a university hospital were investigated and the cost analysis of these operations was performed by examining the invoices of patients who had Appendectomy Laparoscopic surgery. 203 patients were included in the study's universe, and a second operation was performed without coding patients and 143 patients were evaluated.As a result of the cost analysis study, it has been determined that the salaries paid by the Social Security Institution are far below the production costs of hospitals, which are service providers, and the hospital is harmed. 134

Iron overload is considered as a significant cause of morbidity and mortality in hematopoietic stem cell transplant (HSCT) recipients. The presence of hemochromatosis gene (HFE) mutations might exacerbate iron toxicity in the post-transplant setting. This prospective study was planned to evaluate the genetic spectrum of HFE mutations in Turkish patients undergoing HSCT and the impact of HFE genotype on transplant morbidity and mortality. HFE genotypes of 102 patients [median age, 27.5 years (16-64 years); male/female, 73:29], who underwent allogeneic HSCT, were analyzed. Twenty-two patients were heterozygous and 1 patient was homozygous for the H63D mutation, while the C282Y mutation was observed in none of our patients. The frequency of invasive fungal infections (IFI) was significantly higher in H63D-mutated patients (p = 0.004). H63D mutation was identified as an independent risk factor for the development of IFI (p = 0.006, OR = 0.554, SE = 0.208), without an impact on overall survival and transplant-related mortality. The multifactorial iron-overloaded state in HSCT recipients might affect the phenotypic expression of HFE mutations and alter the severity of clinical presentation. The impact of HFE genotype on iron parameters and transplant-related morbidity and mortality should be validated with further studies.

Background: Genetic polymorphisms may play role in the pathophysiology of nonalcoholic steatohepatitis (NASH). Objectives: We purposed to assess the role of interleukin 6 (IL 6) and interleukin 8 (IL 8) gene polymorphisms in the pathogenesis of NASH. Patients and Methods: Consecutive patients with biopsy proven NASH and age- and gender-matched healthy individuals with normal liver function tests and normal ultrasonography were enrolled in the study. Histopathological findings were recorded according to nonalcoholic fatty liver disease activity score (NAS). Patients were classified according to fibrosis scores as fibrosis score < 2 (mild fibrosis group) and fibrosis score ≥ 2 (significant fibrosis group). Blood samples were collected and genomic DNA isolation kit was used to evaluate genetic polymorphisms. Results: Of thirty-eight patients, 27 (71%) were in mild fibrosis group and 11 (29%) in significant fibrosis group. Thirty-eight age- and gender-matched healthy controls were enrolled in the study. The frequencies of genotypes G/C and G/G of IL 6 among the NASH group and healthy controls were 39.5% and 60.5% vs. 53.6% and 46.4%, respectively (P = 0.32). The frequencies of the genotypes of IL 8 among the NASH group were 47.2%, 44.6%, and 8.2% for T/T, A/T, and A/A, and in healthy controls were 50%, 28.6% and 21.4%, respectively, (P = 0.568). The differences between IL 8 gene T/A and T/T genotypes were not significant statistically (P > 0.05). However, the frequency of A/A genotype in significant fibrosis group was higher than the mild fibrosis group (P = 0.0016). The differences of -251 A/T polymorphism in the IL 8 and -174 C/G polymorphism in the IL 6 were not statistically significant between fibrosis groups (P > 0.05). Conclusions: IL6 and IL8 gene polymorphisms have no role in NASH pathogenesis and liver fibrosis process, but presence of the A/A genotype in the IL8 gene is associated with disease progression.

The aim of the present study was to investigate the prognostic role of pre- and/or early post-autologous stem cell transplantation (ASCT) (18)F-flourodeoxyglucose (FDG) positron emission tomography (PET) in patients with relapsed/refractory Hodgkin lymphoma. Forty-three consecutive patients were enrolled in this study. FDG-PET/CT was performed following salvage chemotherapy within 6 weeks of undergoing ASCT and at the first month after ASCT. FDG-PET positivity was found in 26 patients before ASCT and in 13 patients after ASCT. The patients who had negative PET scan before or after ASCT had significantly better outcomes in terms of overall survival (OS) and progression-free survival (PFS). Pre- and post-ASCT FDG-PET positivity was found to be independently associated with PFS while post-ASCT FDG-PET was an independent factor with an impact on OS in multivariate analysis. (18)F-flourodeoxyglucose positron emission tomography imaging may be useful in predicting prognosis after ASCT. Furthermore, effective treatment options including allogeneic stem cell transplantation might be considered in patients with positive FDG-PET scan after salvage chemotherapy and ASCT.

Sinüzoidal Obstrüksiyon Sendromu (SOS), HKHN'nin nedeni bilinmeyen ciddi bir karaciğer komplikasyonudur. Yeni yapılan çalışmalarda çeşitli etyolojik faktörler içerisinde artmış demir yükü SOS için bir sirk faktörü olarak bildirilmiştir. Benin ve malin hastalıklardan özllikle inefektif eritropoez ve artmış transfüzyon ihtiyacı ile seyredenlerde demir yükü artar ve ferritin seviyesi yükselir. Karaciğer demirin depolandığı ve dolayısı ile artmış demir yükü ile oluşan oksidatif stresden etkilenen temel bölgedir. Kuzeyyarım kürede en sık saptanan genetik mutasyon olan HFE de demir yükünü arttırır. Bu çalışmada, çelişitli hematolojik malinitesi nedeni ile HKHN endikasyonu olan hastalarda HFE gen mutasyon sıklığını inceledik. Aynı zamanda HFE gen mutasyonlarının HKHN öncesi demir parametrelerine etkisini, SOS gelişimine katkısını ve ilk 100 sağkalımı ile ilişkisini de inceledik.Hiçbir hastada C282Y mutasyonuna rastlanmazken, H63D allel sıklığı %24,8 bulundu. Çalışmamızın kohortu, Türk popülasyonu ile karşılaştırıldığında (%13,6±5,8) H63D allel sıklığında hematolojik malignitelerde artmış bulundu. HFE mutasyonlarının demir yüküne ve 100 gün sağkalıma etkisi göeterilemedi. Allojenik HKHN yapılan 20 hastada SOS saptandı. Otolog HKHN' göre allojenik HKHN SOS için risk olarak bulundu (p=0,001). HKHN öncesi yüksek serum ferritin seviyesi ve hazırlık rejiminde TBI bulunması SOS için bağımsız risk faktörü olarak bulundu (sırası ile OR=1,0001 ve OR=6,93). Ferritin değerinin ilk 100 gün toplam sağkalımla negatif ilişkisi gösterildi (p=0,003).Sonuç olarak, transplantasyon öncesi demir yükü, ransplantasyonun sonucu için önemli rol oynamaktadır. Heterozigot H63D mutasyonu HKHN hastalarında demir yüküne katkıda bulunmamakta iken homozigot H63D mutasyonu için veriler yetersizdir. Demir yükü durumunun bilinmesi SOS gelişimi için risk faktörlerinin belirlenip buna göre tedavi düzenlenmesi flebotomi ve/veya demir şelasyonu gibi için önemlidir. Sinusoidal obstruction Syndrome (SOS) is a serious hepatic complication of hematopoietic stem cell transplantation (HSCT) with uncretain etiology. Increased iron stores, have recently been reported to be among the various risk factors predisposing HSCT recipients to SOS. Benign and malignant hematological disease, particularly the ones associated with ineffective hematopoesis and increased transfusion requirements have increased body iron stores and elevated serum ferritin levels. Liver as the major site of iron depositon is particularly susceptible to oxidative stress produced by increased body iron stores. HFE mutations which is the most common genetic disorder of the Northern hemisphere, is also associated with increased body iron stores. We investigated the prevelance of HFE genotypes in various hematological malignancies reqiring HSCT. We also analysed whether the presence of HFE mutations further increases the iron overload in HSCT recipients and predsiposes them to SOS. Day +100 mortality and its relationship with the HFE genotype was also assesed. HFE H63D and C282Y genotypes were determined in 93 HSCT recipents who were evaluated prospectively for the development of SOS. The influence of the HFE genotype on serum iron parameters was also tested.No C282Y mutation was detected while H63D allele frequency was %24,8. Our data suggests that HFE H63D mutation frequency was increased in our patient cohort with various hematological malignancies compared to the general Turkish population (%13,6±5,6). While we could not demonstarte any effect of HFE genotypes on neither the iron status nor on 100 day mortality. Twenty patients had developed SOS all of whom had undergone allogenic HSCT. Allogenic HSCT was found to be a risk factor for SOS (p=0,001). Elevated pretransplant ferritin levels and TBI was independent risk factors for SOS (OR=1,0001 and 6,93, respectively). Serum ferritin was also found to be inversely corralated with day 100 mortality (p=0,003).In conclusion, pretransplantation iron overload seems to play an important role in transplantation outcome. The presence of hetrozigot H63D mutation does not seem to contribute to increased iron overload in HSCT recipients while the role of homozigot mutation remains to be verified. Determination of iron stores might facilitate risk-stratificaiton and developing strategies such as phlebotomy and/or iron chelation to prevent SOS. 105

Hepatitis B infection is a serious health problem in endemic areas particularly among immunocompromised patients. The more profound immunosuppression in recipients of hematopoietic stem cell transplantations (HCT) can lead to more complicated hepatitis B virus (HBV)-related events. Despite the high risk of recipient infection allogeneic HCT donors with HBV infection are not excluded in the absence of an alternative donor. A 25 year-old man with severe aplastic anemia underwent allogeneic HCT from his HLA-identical sibling. The patient was hepatitis B naive and had normal liver function tests. However the donor had hepatitis B surface antigen (HbsAg) positivity, and collected stem cells were positive for HBV DNA (1 × 104 copies/mL). Lamivudine was initiated to treat the patient prior to transplantation. Forty days after the HCT, the patient displayed hepatitis B surface antibody (HBsAb), hepatitis B core antibody (HBcAb), and hepatitis B e antibody (HBeAb), with HBV-DNA negativity. Cyclosporine was tapered and finally stopped at day + 256. On day +368, 112 days after the cessation of cyclosporine HBV reactivation was detected with an HBV-DNA level of 10 × 104 copies/mL despite lamivudine. After demonstration of the YMDD mutation, adefovir dipivoxil was combined with lamivudine. The HBV-DNA became negative; AST ALT levels decreased to normal levels after a month of combination therapy. In conclusion adefovir was effective to treat lamivudine-resistant HBV infection in an allogeneic HCT recipient.