Al-hijamah (wet cupping therapy of prophetic medicine) significantly and safely reduces iron overload and oxidative stress in thalassemic children: a novel pilot study

Figures & data

Figure 1 Preparation for performing Al-hijamah (wet cupping therapy of prophetic medicine).

Notes: (A) The sterile disposable new set of cups includes 12 cups of variable sizes and a hand-held pump. Large-sized cups are put at the upper back and upper chest. Antiseptic solution, eg, povidone iodine; sterile disposable sharp scalpels (size no 11); sterile cotton; sterile new gloves and clean sterile atmosphere at hospitals are the prerequisites for performing Al-hijamah. (B) Sterilization using povidone iodine cleaning from inside outward to clean all the areas in the upper back for application of cups. (C) First suction step of Al-hijamah. Using sucking cups where the negative pressure is created through manual suction and skin upliftings are created inside sucking cups. Sucking cups are put at the upper back region (at skin over 7th cervical vertebra and skin directly below 7th cervical vertebra scapular regions). (D) Inside sucking cups, skin upliftings are created beneath which exist collected fluids (local interstitial fluids+filtered fluids from skin capillaries) that cannot be excreted due to the presence of intact keratinized outermost layer of epithelium (skin barrier). The collected excreted fluids contain both disease-related substances and disease-causing substances (causative pathological substances, eg, ferritin, from serum and tissue deposits in iron overload conditions and oxidative stress indicators, eg, malondialdehyde).

Figure 2 Skin scarification step (superficial skin scarifications; the Arabic term is shartat mihjam) to open the intact skin barrier and enhance dermatological excretion. Notes: (A) Line of demarcation of the skin upliftings after removal of the cups of the first sucking step. (B) Handling the scalpel for skin scarification is similar to holding a pen. Scarifications should be superficial scratches. The golden standard when making scarifications is to touch but never cut the skin. (C) Superficial skin scarifications (the Arabic term is shartat mihjam) should be productive to get optimal excretory function and therapeutic benefits after Al-hijamah (wet cupping therapy of prophetic medicine). Superficial skin scarifications (the Arabic term is shartat mihjam) should not be nonproductive or partially productive. (D) Productive shartat mihjam is the Arabic term given to the superficial skin scarifications (~0.1 mm in depth that preserves the structure of the superficial fenestrated dermal capillaries) that are confined to the skin dome (skin uplifting created after the first suction step). Skin scarifications of Al-hijamah denote the hand skills that differentiate one skillful practitioner from another. Skin scarifications should be multiple, longitudinal (~1–2 mm in length, ie, not pinpoint pricks), in parallel rows, equally distributed and productive.

Figure 3 Second suction step is done immediately after skin scarifications.

Notes: (A and B) Bloody excretion starts to come out through the skin scratches (superficial skin scarifications; the Arabic term is shartat mihjam) in a rapid rate in the beginning and then slows down until stopping due to formation of blood clots. Bloody excretion persists until clotting occurs. (C) Bloody excretion is not profuse or causes hemorrhage if superficial skin scarifications (the Arabic term is shartat mihjam) are superficial and not deep. Causative pathological substances, eg, ferritin, iron, cholesterol, ROS and others, are directly excreted in the bloody excretion causing partial clearance of patient’s blood and interstitial spaces. (D) Blood clots are cleaned with sterile cotton, and sucking cups are evacuated. Suction is repeated for two to three times until no material comes out. Skin upliftings and scarifications are sterilized with povidone iodine. They disappear within many hours to few days. There is no need for antibiotics. (E) The same first suction step is applied to the upper part of the chest. (F) The same superficial skin scarification step is applied to the upper part of the chest. (G) Bloody excretion occurring through Al-hijamah is minimal (average 50 cc that does not aggravate the anemic status of thalassemia).
Abbreviation: ROS, reactive oxygen species.

Figure 4 ICT plus Al-hijamah (wet cupping therapy of prophetic medicine) significantly decreased both serum ferritin and free radicals and improved the antioxidant power.

Notes: All studied children are thalassemic children receiving ICT. The control group did not undergo Al-hijamah treatment. There is no healthy control. (A) ICT plus Al-hijamah significantly decreased serum ferritin (***P<0.001). (B) ICT plus Al-hijamah significantly decreased serum malondialdehyde (P<0.05). (C) ICT plus Al-hijamah significantly improved TAC (***P<0.001).
Abbreviations: ICT, iron chelation therapy; TAC, total antioxidant capacity.

Table S1 Effect of Al-hijamah (wet cupping therapy of prophetic medicine) as an effective PIET in reducing iron overload and oxidative stress with subsequent increase in TAC

Patient no	Serum ferritin (ng/mL)		Serum malondialdehyde (nM/L)		Mean TAC (mM/L)
	Before Al-hijamah	After Al-hijamah	Before Al-hijamah	After Al-hijamah	Before Al-hijamah	After Al-hijamah
^Citation1	2,864	1,426	29.5	14	0.23	0.59
^Citation2	1,407	1,005	30.9	19.1	0.4	0.67
^Citation3	1,000	977	25.5	12.2	0.35	0.55
^Citation4	3,215	2,712	27.9	13.9	0.32	0.72
^Citation5	2,105	1,900	22.2	^Citation7	0.15	0.51
^Citation6	7,251	6,120	28.5	14.2	0.29	0.72
^Citation7	2,799	2,182	50.1	19.6	0.27	0.6
8	9,210	8,530	32.2	^Citation15	0.23	0.59
9	2,210	1,148	30.1	14.9	0.39	0.7
^Citation10	3,316	1,990	29.5	7.4	0.28	0.63
^Citation11	4,200	400	22.5	7.6	0.14	0.61
^Citation12	2,325	1,870	32.5	19.9	0.28	0.56
13	3,400	2,241	277	12.5	0.14	0.73
14	7,527	6,692	29.3	13.5	0.28	0.58
^Citation15	1,988	1,065	30.9	11.3	0.15	0.83
16	3,215	2,398	26.8	14.8	0.22	0.77
17	2,799	2,182	32.2	15.1	0.15	0.8
18	9,210	8,530	27.9	7.9	0.31	0.69
19	2,210	1,148	25.6	10	0.26	0.8
20	3,316	1,990	32	14	0.27	0.69
Mean	3,778.35	2,825.3	42.155	13.195	0.2555	0.667
SD	2,466.986853	2,499.65789	55.56347224	3.85725222	0.07983370	0.0925145
SEM	551.8986249	559.207582	12.43030699	0.86291996	0.01785989	0.0206967

Abbreviations: PIET, percutaneous iron excretion therapy; TAC, total antioxidant capacity; SEM, standard error of mean.

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