https://doi.org/10.15218/ejnm.2020.02 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article Evaluation of Effectiveness of Wet Cupping versus Blood Donation on Hematological Parameters in Healthy Young Adults ABSTRACT INTRODUCTION Therapeutic phlebotomy also known as venesection or bloodletting is the thera- peutic removal of blood from the body that has been practiced since ancient times to treat illnesses [1]. It began in Egypt around 3000 years ago then spread around the world [2, 3]. Its use gradually declined in the late 19th century and it was almost abandoned during the 20th century [4, 5]. In the past, bloodletting was practiced using lancets, cupping, and the application of leeches for localized bleeding to virtual- ly treat illnesses [6, 5]. At present day, however, therapeutic phlebotomy is being used in modern medicine as an essential part of the treatment for various disorders including hemochromatosis, polycythemia vera and porphyria cutanea tarda [7]. Despite significant advances in conven- tional medicine, there is a high preva- lence and increased public interest Background and objectives: Therapeutic phlebotomy is the removal of blood from the body that has been practiced since ancient time for treating illnesses. Recently, interest in wet- cupping to treat various hematological disorders particularly polycythemia in pub- lic has grown. The present study aims to evaluate the effectiveness of wet-cupping versus blood donation on hematological parameters. Methods: In this pre and post-test experimental study, a total of 60 healthy young adults were purposively assigned non-randomly either in cupping (n=30) or blood donation (n=30) groups. Blood samples were collected from all subjects to measure hematological parameters before and one week after interventions. Subjects of wet-cupping and blood donation were matched in age and baseline hematological parameters. The hematologi- cal parameters were analyzed using hematology analyzer (Symex, Japan). Results: The findings of the study showed a significant difference in hematological pa- rameters of wet-cupping and blood donation including hemoglobin level (Hb) (14.87 g/dl vs. 14.39 g/dl), packed cell volume (PCV) (44.78 % vs. 42.91 %), and red blood cell (RBC) (5.27 1012/uL vs. 4.94 1012/uL), respectively. While the values of other parameters were not different significantly; mean cell volume (MCV) (85.15 fl vs. 86.95 fl), mean corpuscu- lar hemoglobin (MCH) (28.31 pg vs. 29.20 pg), mean corpuscular hemoglobin concentra- tion (MCHC) (33.24 g/dl vs. 33.57 g/dl), red cell distribution width (RDW) (12.53 % vs. 12.40 %), platelet (245.77 109/L vs. 246.27 109/L), and white blood cell (WBC) (7.47 109/ L vs. 7.47 109/L), respectively. Conclusion: The present study concluded that both wet-cupping and blood donation are effective interventions in reducing HB, PCV, and RBC along with increase platelets in blood donation only. Keywords: Wet-cupping; Blood donation; Hematological parameters Zuhair Rishdi Mustafa; Department of Nursing, College of Nursing, University of Duhok, Duhok, Iraq. )Correspondence: zuhair.mustafa@uod.ac ) Sabri Khalaf Sheiko; Department of Medicine, College of Medicine, University of Duhok, Duhok, Iraq. 11 Erbil Journal of Nursing & Midwifery Received: 7/4/2019 Accepted: 23/9/2019 Published: 30/5/2020 mailto:zuhair.mustafa@uod.ac https://doi.org/10.15218/ejnm.2020.02 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article in complementary and alternative medi- cine (CAM) [8].Cupping is a method that uses local evacuation or distraction of mor- bid blood by glasses or cups. Generally, cupping is of two types; wet which means cupping with bloodletting and dry cupping means cupping without bloodletting [9]. Nevertheless, the mechanism of action of cupping therapy is not entirely understood [10]. Few randomized control trials have investigated the effectiveness of wet- cupping with various limitations [11]. In general, the body of CAM literature on cupping is inconclusive [12]. Positive out- comes are reported in many developing countries compared with the negative re- sults reported by the industrialized world [11]. In Iraq, information and exact statis- tics on the prevalence of CAM use specifi- cally cupping therapy is not yet available [13]. Interest in wet-cupping among the public to treat various hematological disor- ders, particularly polycythemia, has grown considerably in recent years. Therefore, the effectiveness of wet-cupping on hema- tological parameters has not been suffi- ciently investigated. The current clinical trial was performed to investigate the effectiveness of wet-cupping versus blood donation on hematological indicators. The author hypothesized that wet-cupping is more effective in reducing packed cell vol- ume (PCV) compared to other categories of complete blood count while the blood do- nation was speculated to be more effective in hemoglobin level. Study design and sampling In the present quasi-experimental study, a total of 80 healthy adult male aged between 22 and 62 years were purposively screened for eli- gibility criteria after obtaining official per- mission. The participants were optionally allocated non-randomly to cupping therapy (n=40) and blood donation (n=40) groups according to inclusion and exclusion crite- ria. The subjects of the study were Kurdish volunteers from the community and were the staff of the Duhok Governorates over four months from November 2018 to Feb- ruary 2019. The subjects were matched in age and hematological parameters before final analysis, therefore, 10 cases were ex- cluded from each group to make homoge- neity. Finally, 30 subjects were included in each group of the study. Those persons who agreed to participate in the study were referred to the study clinician (second author) for complete physician and clinical examinations. The hematologi- cal parameters were analyzed using hema- tology analyzer (Symex, Japan). The inclu- sion criteria for the selection of the subject were: aged ≥18 years old, male, and re- gardless of socio-demographic perspec- tives, hemoglobin (Hb) level ≥13.5 gm/dl, and weight ≥55 kg. The participants diag- nosed with the organ failures (hepatic fail- ure, heart failure, and renal failure), ane- mia, cancer, hemophilia or similar hemato- logical conditions were excluded from the study. Moreover, those utilizing pacemak- ers, taking chemotherapy, immunosup- pressive drugs, anticoagulants, who had a previous blood donation within three months, who had a previous blood transfu- sion within six months, or who had wet- cupping less than three months ago were not included in the study. Also, the pa- tients at risk of hypotension as diagnosed by the clinician were excluded from both interventions, cupping and blood donation. Clinical procedures and treatment. Wet-cupping procedure: Wet-cupping was completed by the first author (nurse prac- titioner/under the supervision of a certi- fied clinician) in a private clinic. Before cupping therapy, the 40 participants were requested to fast for 4 hours to allow blood to be distributed in the body but not in the stomach for digestion. Cupping was 12 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2020.02 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article of rest and 250 ml of fruit juice. Moreover, the participants were advised to avoid bathing and swimming for 12 hours follow- ing the cupping procedure to prevent de- lays in wound healing. Figure 1: A view of points on the skin in which wet-cupping therapy was applied Blood donation: The reference population referred to Duhok Blood Donation Centre and consisted of 40 male volunteer blood donors. All participants were referred for the procedure following performing the required coordination. According to the roles of the bank, the subjects with a he- moglobin level of ≥ 13.5 g/dl, with a mini- mum weight of ≥ 55Kg, not fasting, not taking any medication during the last 48 hours were included in the procedure. Each subject donated a total of 450 ml of whole blood according to the blood bank policy from their antecubital vein. Each participant was offered a few minutes of rest and 250 ml of fruit juice as a measure against fainting due to blood donation. Measurement and data collection Baseline information: The baseline and demographic characteristics of the sub- jects, including age, smoking (yes/ no) and its attributes were defined as light smoker: those who smoked 1-9 cigarettes/day, moderate smoker: those who smoked 10- 19 cigarettes/day, and heavy smoker: those who smoked ≥20 cigarettes/day or hookah [16]. In addition, current chronic diseases (yes/ no), past medical history/ past surgical history (yes/no), occupation, education level, place of residence (urban/ rural), recent blood donation/cupping at room temperature between 20 to 25 degrees Celsius to avoid vasoconstriction caused by cold weather. Before the inter- vention, the steps of the protocol were ex- plained to the participants. Blood pressure was measured before the procedure began as a pre-test assessment. All participants were requested to be in the prone position in bed with raising legs 30 degrees to avoid fainting. A manual hand suction pump was used for cupping procedure with disposa- ble cups of capacity 100 ml each. Five sites of the upper back were selected including: over seventh cervical vertebra, bilateral peri-spinal areas of the neck, and thoracic spine for the procedure (see Figure 1) [14]. An antiseptic solution (70% Ethanol) was used to clean the application areas. Each procedure lasted for around 20 minutes and was conducted aseptically in five steps as follows [15]. Scarification: The cups were removed, and ten superficial horizontal incisions 0.1-0.2 mm in depth and 1–2 cm in length parallel to each other were made on each chosen area of the skin using sterile surgical blades size 15. This technique avoids scar lesion and enhances faster healing. Blood-letting: The cups were re-applied on the skin, and the suctioning was repeated. The cups were left on the designated areas of the skin for 10 minutes then the blood sucked out through the incisions. Negative pressure was repeated by pumping every 3 minutes to enhance suctioning as cups filled with the blood and decreased suc- tioning ability. Removal: The cups were removed after 10 minutes and the used cups, blood, and sur- gical blades were discarded safely. Clean and dressing: The selection areas for cupping were disinfected using povidone iodine 4 % followed by placement of sterile pads. As a measure against adverse reac- tions such as fainting due to bloodletting, all participants were offered a few minutes 13 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2020.02 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article the independent t-test, Chi-square, or Fish- er’s; exact tests. The paired t-test was per- formed for examining the difference of he- matological parameters between pre and post-intervention in both groups. The effect size (Cohen’s d) was calculated by G*Power 3.3.9. Also, independent t-test was performed to examine the difference in hematological indicators between post- intervention study groups. The multivari- ate analysis model was performed to in- vestigate the predictors of hematological parameters in both study groups. The null hypothesis was rejected in a P-value of less than 0.05. The statistical calculations were performed in the Statistical Package for Social Sciences (SPSS: 25 IBM). The total sample size required for the pre- sent study was calculated based on the measurement of RBC from the first 5 cases of each group separately. The mean (Sta. deviation) of the first five cases of the cup- ping group was 5.30 (SD: 0.43). Based on our expectation to a reduction to 5.0 (SD: 0.28) following the procedure, t-test: two dependent means (matched pairs), the ac- tual power of 0.95, α: 0.05, and the effect size: 0.79, 23 subjects were required for the study. The mean (Sta. deviation) of the first five cases of blood donation group was 5.44 (SD: 0.30). According to the ex- pectation of the authors to a reduction to 5.12 (SD: 0.38); t-test: two dependent means (matched pairs); actual power of 0.95; t: 2.10, α: 0.05, and the effect size: 0.84, a total of 18 persons were required for the study. Ethical approval. The ethical approval of the present clinical trial was obtained from the research ethics com- mittee of General Directorate of Health of Duhok as reference number: 17102018-8 and written informed consent from all par- ticipants before clinical assessment. 14 Erbil Journal of Nursing & Midwifery therapy (yes/ no), and blood pressure were collected through the self-reported technique. For the eligibility criteria, the volunteers were screened through labora- tory tests and physical examinations. Two mL of venous blood was collected before the commencement of procedures to test hematological parameters. Subjects with Hb level ≥ 13.5 g/dl were considered to be illegible for the study according to the blood bank policy, although this is not in line with World Health Organization 2012 Guidelines on Assessing Donor Suitability for Blood Donation [17], which stated that the recommended Hb level for donation should not be less than 13.0 g/dl for males. The blood pressure of the subjects was measured from both arms upon the subjects sitting after a few minutes of rest using blood pressure mercury (ALPK2 Ja- pan). Hematological parameters testing After blood sample was obtained from veins through standard procedure, two mL of blood was collected by a tube with eth- ylenediamine tetraacetic acid (EDTA) anti- coagulant for hematologic tests directly before and after the procedures and ana- lyzed within 1-2 hours after obtaining the blood sample, meanwhile, the samples were kept in refrigerator. Pre- and post- cupping and blood donation hematological values were measured in the blood. Pa- rameters such as Hb, PCV, RBC, MCV, MCH, MCHC, RDW, platelet, and WBC were analyzed using hematology analyzer (Symex, Japan). The descriptive purposes of the study were determined in frequency and distri- bution or mean and standard deviation. The homogeneity of the hematological pa- rameters and age in both study groups were examined in an independent t-test. Also, the comparison of baseline infor- mation of both groups was examined in https://doi.org/10.15218/ejnm.2020.02 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article 15 Erbil Journal of Nursing & Midwifery Two mL of blood was obtained from partic- ipants one week later after interventions. The analysis of the results showed that subjects of wet-cupping and blood dona- tion groups were similar in age (37.67 vs. 38.13 years, P= 0.790), chronic disease (P=0.222), smoking (P=0.121), residency (P=0.274), and past surgical history (P=0.390), see Table 1. However, subjects in cupping were more likely to have a less professional occupa- tion as well as a lower level of education compared to their counterparts in blood donation group (P= 0.007 and P=0.004) respectively (Table 1). The hematological parameters between the subjects of both study groups were matched before final analysis. In line with the inclusion criteria, the mean values of Hb for both wet-cupping and blood dona- tion were 15.33 and 15.63 g/dl, P= 0.065) respectively (Table 2). Table 1: Comparison of general information between the subjects in cupping therapy and blood donation Characteristics (N=60) Cupping (n=30) Blood Donation (n=30) P-Value (Two-Sided) Age (Year) Range 37.67 (6.57) 22-49 38.13 (6.91) 25-52 0.790* Chronic Disease 9 (30) 5 (16.7) 0.222** Smoker 18 (60) 12 (40) 0.121** Smoking Type Moderate Heavy 1 (5.6) 17 (94.4) 3 (25) 9 (75) 0.274*** Residency Urban Rural 29 (96.7) 1 (3.3) 30 (100) 0 (0) 1.00*** Occupation Unemployed (Students) Worker Governmental employed Profession 1 (3.3) 13 (43.3) 16 (53.3) 0 (0) 1 (3.3) 4 (13.3) 20 (66.7) 5 (16.7) 0.007*** Education Illiterate Primary school graduate Intermediate school graduate High School graduate Institute graduate College graduate Postgraduate graduate 8 (26.7) 3 (10) 8 (26.7) 3 (10) 4 (13.3) 4 (13.3) 0 (0) 5 (16.7) 0 (0) 1 (3.3) 6 (20) 5 (16.7) 6 (20) 7 (23.3) 0.004*** Past Surgical History 10 (33.3) 7 (23.3) 0.390** *Independent t-test, **Chi-square, and ***Fishers’ exact tests were performed for statistical analyses. The bold numbers show significant differences. RESULTS https://doi.org/10.15218/ejnm.2020.02 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article 16 Erbil Journal of Nursing & Midwifery The complications found in subjects underwent wet-cupping therapy were Bul- lae formation (n=3), discomfort in the re- gion that underwent cupping (n=1), and dizziness (n=1). Also, the complications in blood donation were local reactions (hematomas due to extravasation during procedure (n=1), dizziness (n=1), hypoten- sion (n=1), and local reactions (hematoma due to extravasation after procedure) (n=3) (not shown in Tables). The present study found a significant difference be- tween pre and one week later assessment in some hematological parameters in both cupping and blood donation groups. In the cupping group, significant changes were observed in Hb level (MD: Mean Differ- ence: -0.46, P=<0.001), PCV (MD: -1.64, P=<0.001), and RBC (MD: -0.17, P=<0.001).However,no significant changes were observed in MCV (MD: -0.40, P=0.256), MCH (MD: +0.03, P=0.740), MCHC (MD: +0.19, P=0.123), RDW (MD: +0.07, P=0.529), Platelet (MD: +7.20, P=0.081), and WBC (MD: -0.32, P=0.083) P=<0.001). Similarly, significant differences were seen in the blood donation group in Hb level (MD: -1.25, P=<0.001), PCV (MD: - 3.98, P=<0.001), RBC (MD: -0.46, P=<0.001). Correspondingly as cupping intervention, the other parameters in blood donation group did not change significantly; including MCV (MD: -0.17, P=0.652), MCH (MD: +0.18, P=0.097), MCHC (MD: +0.20, P=0.117), RDW (MD: -0.09, P=0.365), and WBC (MD= -1.20, P=0.460), but a significant increase in the platelet count (MD: +14.43, P=0.011) was observed (Table 3). In a comparison of post-intervention of hematological parameters between cup- ping and blood donation groups, there was a significant difference in some indi- cators. The subjects in wet-cupping ther- apy had a higher level of Hb (14.87 g/dl vs. 14.39 g/dl, P=0.018), PCV (44.78 % vs. 42.91 %, P=0.009), and RBC (5.27 1012/uL vs. 4.94 1012/uL, P=0.001), re- spectively. The subjects were compara- ble in other hematological parameters (P>0.05), see Table 4. The different hematological parameters between two study groups (Hb, PCV, and RBC) were considered dependent varia- bles and other baseline and hematologi- cal factors as independent variables in the multivariate analysis model. The analysis did not find any another predic- tor for this difference except the inter- vention (Table 5). Table 2: Comparison of pre-intervention assessment of hematological parameters be- tween cupping and blood donation groups Independent t-test was performed for statistical analyses. Hematological parameters (n=60) Cupping (n=30) Donation (n=30) P-Value (Two-Sided) Mean SD Mean SD HB (g/dl) 15.33 0.70 15.63 0.54 0.065 PCV (%) 46.42 2.68 46.89 1.79 0.431 RBC (1012/uL) 5.44 0.39 5.40 0.29 0.655 MCV (fl) 85.55 3.91 87.11 3.48 0.108 MCH (pg) 28.28 1.51 29.02 1.56 0.068 MCHC (g/dl) 33.05 0.80 33.37 1.12 0.215 RDW (%) 12.45 0.80 12.50 0.49 0.801 Platelet (109/L) 238.57 44.83 231.83 53.40 0.599 WBC (109/L) 7.79 2.04 8.67 8.48 0.584 https://doi.org/10.15218/ejnm.2020.02 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article 17 Erbil Journal of Nursing & Midwifery Cupping (n=30) Pre Mean Pre SD Post Mean Post SD Mean Difference P-Value (Two-Sided) HB (g/dl) 15.33 0.70 14.87 0.81 -0.46 <0.001 PCV (%) 46.42 2.68 44.78 2.59 -1.64 <0.001 RBC (1012/uL) 5.44 0.39 5.27 0.37 -0.17 <0.001 MCV (fl) 85.55 3.91 85.15 3.72 -0.40 0.256 MCH (pg) 28.28 1.51 28.31 1.60 +0.03 0.740 MCHC (g/dl) 33.05 0.80 33.24 0.86 +0.19 0.123 RDW (%) 12.45 0.80 12.53 0.68 +0.07 0.529 Platelet (109/L) 238.57 44.83 245.77 48.27 +7.20 0.081 WBC (109/L) 7.79 2.04 7.47 1.950 -0.32 0.083 Blood Donation (n=30) Pre Mean Pre SD Post Mean Post SD Mean Difference P-Value (Two-Sided) HB (g/dl) 15.63 0.54 14.39 0.73 -1.25 <0.001 PCV (%) 46.89 1.79 42.91 2.82 -3.98 <0.001 RBC (1012/uL) 5.40 0.29 4.94 0.36 -0.46 <0.001 MCV (fl) 87.11 3.48 86.95 3.63 -0.17 0.652 MCH (pg) 29.02 1.56 29.20 1.44 +0.18 0.097 MCHC (g/dl) 33.37 1.12 33.57 0.94 +0.20 0.117 RDW (%) 12.50 0.49 12.40 0.57 -0.09 0.365 Platelet (109/L) 231.83 53.40 246.27 55.13 +14.43 0.011 WBC (109/L) 8.67 8.48 7.47 1.40 -1.20 0.460 Table 3: Comparison of hematological parameters before and after intervention in cup- ping and blood donation groups Paired t-test was performed for statistical analysis. The bold numbers show significant differences. Table 4: Comparison of post-intervention assessment of hematological parameters be- tween cupping and blood donation groups Hematological param- eters (n=60) Cupping (n=30) Donation (n=30) P-Value (Two-Sided) Mean SD Mean SD HB (g/dl) 14.87 0.81 14.39 0.738 0.018 PCV (%) 44.78 2.59 42.91 2.82 0.009 RBC (1012/UL) 5.27 0.37 4.94 0.36 0.001 MCV (fl) 85.15 3.72 86.95 3.63 0.064 MCH (pg) 28.31 1.60 29.20 1.44 0.028 MCHC (g/dl) 33.24 0.86 33.57 0.94 0.165 RDW (%) 12.53 0.68 12.40 0.57 0.446 Platelet (109/L) 245.77 48.27 246.27 55.13 0.970 WBC (109/L) 7.47 1.95 7.47 1.40 > 0.99 Independent t-test was performed for statistical analyses. The bold numbers show significant differences. https://doi.org/10.15218/ejnm.2020.02 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article 18 Erbil Journal of Nursing & Midwifery Table 5: Predictors of Hb, RBC, and PCV in cupping and blood donation groups Predictors Dependent Variable F Score P-value Partial Eta Squared (Effect Size) Study Intervention HB 6.646 0.020 0.281 PCV 6.644 0.020 0.281 RBC 6.534 0.020 0.278 Smoking Type HB 0.302 0.590 0.017 PCV 0.280 0.604 0.016 RBC 0.198 0.662 0.012 Chronic Disease HB 0.011 0.989 0.001 PCV 0.008 0.992 0.001 RBC 0.013 0.987 0.002 PSH HB 0.193 0.666 0.011 PCV 0.148 0.705 0.009 RBC 0.061 0.808 0.004 Age HB 0.097 0.759 0.006 PCV 0.100 0.755 0.006 RBC 0.146 0.707 0.009 MCV (fl) HB 0.006 0.938 < 0.001 PCV 0.011 0.919 0.001 RBC 0.140 0.713 0.008 MCH MCH (pg) HB 0.003 0.960 < 0.001 PCV 0.006 0.939 < 0.001 RBC 0.036 0.852 0.002 MCHC (g/dl) HB 0.058 0.813 0.003 PCV 0.184 0.673 0.011 RBC 0.301 0.591 0.017 RDW (%) HB 2.176 0.158 0.113 PCV 2.261 0.151 0.117 RBC 2.460 0.135 0.126 Platelet (109/L) HB 1.063 0.317 0.059 PCV 1.025 0.326 0.057 RBC 0.919 0.351 0.051 WBC (109/L) HB < 0.001 0.986 < 0.001 PCV < 0.001 0.992 < 0.001 RBC 0.001 0.970 < 0.001 Multivariate analysis model was performed for statistical analysis. https://doi.org/10.15218/ejnm.2020.02 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article 19 Erbil Journal of Nursing & Midwifery The present investigation showed both wet-cupping and blood donation interven- tions are effective to reduce Hb, PCV, and RBC, but blood donation is more powerful than cupping in the reduction of the he- matological parameters. Furthermore, some indicators including platelet count elevated in subjects who underwent blood donation. During the last few decades, there has been considerable interest in wet-cupping among the public. The effec- tiveness of wet-cupping on hematological parameters has not been fully explored. Studies on the effect of blood donation on hematological parameters are well docu- mented in the literature. Whereas, no re- search investigated the outcomes of wet- cupping on same parameters except the few studies that examined the blood with- drawn from the wet- cupping and com- pared to venous blood. For example, a study by Mahdavi and colleagues was car- ried out in 56 healthy volunteer men 20- 40 years old. Blood samples from cupping showed a significant increase in Hb, Hct, RBC, MCH, viscosity and platelet count as compared to venous blood samples. In contrast, no significant difference was ob- served in WBC, MCH, and MCV [18]. The authors hypothesized that Hb concentra- tion and RBCs count are so dense in cup- ping samples which were relatively high compared to those in venous blood sam- ples. The results of our study are in line with this study except for platelet count in which no significant change occurred post wet-cupping. However, there are contra- dictory findings as well. Abdullah et al. [19] compared cupping blood and venous blood samples of ten healthy male and female individuals through a pilot study and concluded that all parameters have similar values to those observed in the initial assessment. It is believed that blood donation reduces hematological param- eters. Our findings reveal significant changes in most hematological parame- ters after the intervention. As men- tioned earlier, studies on the effective- ness of blood donation on hematological changes are well documented in the lit- erature although they did not measure RBC count. For example, A study by Cliville et al. [20] addressed variations in hematological and other parameters in 30 patients of both genders. There was a significant decrease in Hb and Hct levels after the donation of the blood. This re- sulted in an increase in reticulocytes, MCV and RDW. However, the platelet count and WBC count remained un- changed. Similar findings were reported by Beyan and colleagues [21]. Moreover, Das et al. [22] examined hematological values pre- and post-donation proce- dure and concluded that the values of Hb, Hct, platelet, and WBC counts were dropped significantly among the donors. The findings of our study are in agree- ment with these studies except platelet count that increased significantly in our study after therapeutic phlebotomy. This could be due to a possible change in erythropoietin levels following blood donation caused iron depletion and platelet count enrichment [23]. In view of the fact that erythropoietin may in- crease platelet count by stimulating bone marrow thrombopoiesis [24]. Alt- hough some drawbacks of repeated blood donation have been documented in the literature such as a poor iron con- dition in repeated blood donors [25], nevertheless several benefits were also reported in the literature including poly- cythemia, hemochromatosis, porphyria cutanea tarda, and sickle cell disease [7, 26]. Furthermore, phlebotomy can lower the risk of cardiovascular disease by decreasing whole blood viscosity, DISCUSSION https://doi.org/10.15218/ejnm.2020.02 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article 20 Erbil Journal of Nursing & Midwifery plasma viscosity, Hct, and fibrinogen, and iron stores [5, 27]. In this region, a recent study by Getta and Ahmad et al [28] in- vestigated the purpose of blood donation and identified the main reasons for blood donations among regular donors were relieving headaches (45%), polycythemia, neck and shoulder pains, dizziness, insom- nia, and sleepiness. While the reasons for donations by the first time donors were to help relatives (31%), it is evident that the benefits of blood donation outweighed its drawbacks. Concerning the safety of wet- cupping, this intervention is generally safe based on outcomes of a meta-analysis done by Cao et al. [29]. Therefore, the cupping procedure in the current study was also safe with minimal side effects occurring during the procedure such as bullae formation in one cup area, discom- fort in the region that underwent cupping, and dizziness. Blood donation on the oth- er hand was also relatively safe except for a few complaints that occurred during do- nation including dizziness, hypotension, and local hematomas as a result of extrav- asation which arose a week later. Strength and limitation The strong point of the study must be traced in the design and the strict inclu- sion and exclusion criteria. While, the au- thors faced an issue to include females in the study due to the cultural aspects of the region. The present study concluded that both wet-cupping and blood donation are effective interventions in reducing HB, PCV, and RBC along with increase plate- lets in blood donation only. The present study found cupping therapy as a safe procedure The authors would like to present their profound thanks to Mr. Deldar M. Abdulah for his kind review and those persons accepted to participate in the procedure. The authors were only finan- cial supporters of the study. The authors report no conflicts of interest to declare [1] Hyson JM. Leech therapy: a history. Journal of the History Of Dentistry.2005 53(1):P: 25- 7. [2] Parapia LA. History of bloodletting by phle- botomy. British Journal of Haematolo- gy.2008;143(4):P: 490-5. [3] Greenstone G. The history of bloodletting. BC Medical Journal. 2010;52(1):P: 12-4. [4] Orosz JJ. A Short History of Bloodletting. 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