Almost 50,000 volunteers participate at Redome, the Brazilian Bone Marrow Donor Registry

Striking progress has been observed in the number of volunteer donors for hematopoietic stem cell transplantation in the last years in Brazil. By the end of 1998, the number of donors barely reached 4200 but it has grown progressively. It was close to 48,000 by the end of May 1993. It is possible to notice a steady increase from the first (1993 to 2000) to the last years (2001 to 2003). The regulation of each procedure by the Brazilian Health System, with the collaboration of the Hematology Societies, was essential for the success of Redome and for the stem cell transplantation program in Brazil. However, when analyzing these results some problems were detected: 95% of Redome donors come from the south and southeastern regions of the country, while few donors are from the north, northeast, and central parts of Brazil. The different miscegenation of races in different regions and states of Brazil makes this an important issue: to represent the whole Brazilian population, Redome must improve the donor search in such places. It also became clear that several other centers involved in unrelated hematopoietic transplantation must be accredited to avoid a long line of patients with compatible donors a waiting transplantation.

Hepatitis C virus in long-term bone marrow transplant survivors

The hepatitis C virus (HCV) infection may change the outcome of patients undergoing stem cell transplantation. This study aimed at determining the prevalence of the HCV antibody in patients who were alive 10 or more years after BMT, defining the annual progression rate of hepatic fibrosis in those patients, and identifying cases of cirrhosis among those who were positive for HCV antibody. Between 1979 and 1990, 259 patients had a bone marrow transplant, and 91 were alive in March 2000. Of those, 80 were included in the study after having been scanned for serum HCV antibodies. A total of 39 were positive (48.8%), one was indeterminate and 40 were negative (50%). The patients who were HCV positive or undetermined were called for a medical appointment and 22 (55%) attended. A total of 16 patients (72.7%) were male, the mean age was 37.8+/-9.2 years and all of them had had an allogeneic transplant. Of the 22 patients studied, 12 (54.5%) agreed to have a liver biopsy. Hepatic fibrosis was diagnosed in 10 patients. The hepatic fibrosis annual progression rate was 0.156 UF/year. Among the anti-HCV-positive patients assessed, three (13.6%) already had cirrhosis.

Validation of the EBMT risk score in chronic myeloid leukemia in Brazil and allogeneic transplant outcome

BACKGROUND AND OBJECTIVES

The management of chronic myeloid leukemia (CML) has changed radically since the introduction of imatinib therapy. The decision of whether to offer a patient a hematopoietic stem cell transplant (HSCT) must be based on the probability of success of the procedure. The aim of this retrospective analysis of 1,084 CML patients who received an allogeneic HSCT in 10 Brazilian Centers between February 1983 and March 2003 was to validate the EBMT risk score.

DESIGN AND METHODS

The study population comprised 647 (60%) males and 437 (40%) females, with a median age of 32 years old (range 1 - 59); 898 (83%) were in chronic phase, 146 (13%) were in accelerated phase and 40 (4%) were in blast crisis; 151 (14%) were younger than 20 years old, 620 (57%) were between 20 and 40 and 313 (29%) were older than 40; 1,025 (94%) received an HLA fully matched sibling transplant and only 59 (6%) received an unrelated transplant. In 283 cases (26%) a male recipient received a graft from a female donor. The interval from diagnosis to transplantation was less than 12 months in 223 (21%) cases and greater in 861 (79%). The overall survival, disease-free survival, transplant-related mortality and relapse incidence were 49%, 50%, 45% and 25%, respectively.

RESULTS

Of the 1084 patients, 179 (17%) had a risk score of 0 or 1, 397 (37%) had a score of 2, 345 (32%) had a score of 3, 135 (12%) had a score of 4 and 28 (2%) a score of 5 or 6. The overall survival (OS) rate in patients with risk scores 0-1 and 2 was similar (58% and 55%, respectively) but significantly better than that in patients with scores 3 or more (score 3 - 44%, 4 - 36 % and 5-6 - 27%, respectively) pp<0.001). Disease-free survival (DFS) and transplant related mortality (TRM) in a patients with a score of 3 or more were 46% and 49%, respectively and the relapse rate beyond score 5-6 was 77%. Disease status had a negative impact on all outcomes (OS, DFS, TRM, and relapse). The OS rate for male recipients of a graft from a female donor was 40% compared to 52% among the other donor-recipient pairs (p=0.004). DFS and TRM were significant for disease phase and female donor-male recipient (p<0.001 and p<0.003, respectively). In our experience, age and interval between diagnosis and transplant did influence OS, DFS, TRM, and relapse rate.

INTERPRETATION AND CONCLUSIONS

Our results validate the EBMT risk score in the context of a developing country and confirm its usefulness for making point decisions in the imatinib era.

Lack of mutations in the human telomerase RNA component (hTERC) gene in Fanconi's anemia

As some patients with Fanconi s anemia (FA) present excessive telomere shortening correlating with poor outcome, we investigated whether human telomerase RNA component (hTERC) mutations also play a role in telomere shortening in 115 FA patients. Only one patient was heterozygous for the G58A polymorphism. No other mutation or deletion was found. We conclude that hTERC gene mutations do not contribute to telomere shortening in FA.

O câncer e sua representação simbólica

O presente estudo, objetiva investigar a representação simbólica do câncer em profissionais da área de saúde, pacientes, familiares e população em geral. Investigou-se, as imagens simbólicas que permeiam a atitude de cada um perante a convivência com o câncer por meio de questionário. Os resultados indicaram informações ricas de subjetividade, independentemente das diferenças demográficas. A imagética interfere na percepção, na reação e na distribuição do tempo que cada um determina para a escuta da singularidade daquele que adoece com o câncer e/ou com a contaminação simbólica. Na medida em que o fantasma da morte acompanha o paciente em seus movimentos, espera-se que este estudo possa contribuir para que se busquem formas de aprimoramento do tratamento do paciente com câncer. No entanto, para ajudar o outro, é preciso, primeiramente, redimensionar a própria formação imagética; afinal, nós, profissionais da área de saúde, também somos semeadores das imagens que se reproduzem ao longo dos séculos, apesar de toda a evolução científica.

Fusarium infection in hematopoietic stem cell transplant recipients

To characterize the epidemiology and prognostic factors of invasive fusariosis in hematopoietic stem cell transplant (HSCT) recipients, the records of HSCT recipients from 9 hospitals (7 in Brazil and 2 in the United States) were retrospectively reviewed. Sixty-one cases were identified: 54 in allogeneic HSCT recipients and 7 in autologous HSCT recipients. The incidence of fusariosis among allogeneic HSCT recipients varied between a range of 4.21-5.0 cases per 1000 in human leukocyte antigen (HLA)--matched related transplant recipients to 20.19 cases per 1000 in HLA-mismatched transplant recipients. The median time period between transplantation and diagnosis of fusariosis was 48 days. Among allogeneic HSCT recipients, a trimodal distribution was observed: a first peak before engraftment, a second peak at a median of 62 days after transplantation, and a third peak >1 year after transplantation. The actuarial survival was 13% (median, 13 days). Persistent neutropenia was the single prognostic factor for death identified by multivariate analysis.

[Evaluation of genotoxic and/or co-genotoxic effects in cells exposed in vitro to extremely-low frequency electromagnetic fields]

During the last two decades, concerns have arisen regarding a possible association between extremely-low frequency (ELF) electromagnetic fields (EMF) exposure and cancer incidence (e.g. childhood acute leukaemia, cancer of the nervous system, and lymphomas). In 1979, Wertheimer and Leeper firstly reported an excess of cancer mortality among children living in homes located near power lines and presumably exposed to elevated magnetic fields. Subsequently, a large number of epidemiological studies investigated the possible association between residential or occupational exposure to ELF-EMF and cancer. Several in vivo and in vitro models have been investigated with the effort to determine a link, if any, between such fields and mutagenesis and to determine the possible mechanism of cancer risk. However, a causal relationship between exposure to ELF-EMF and cancer has been suggested but has not been unequivocally demonstrated. In 1998, following an analysis of the results retrieved in the literature, the U.S. National Institute of Environmental Health Sciences proposed to apply a "possible human carcinogen" category (Group 2B) to ELF-EMF. More recently, in 2002, the same classification for ELF-MF was proposed by the International Agency for Research on Cancer. In this in vitro approach, to test the genotoxic and/or co-genotoxic potency of ELF-MF, we used the alkaline single-cell microgel-electrophoresis (comet) assay and the cytokinesis block micronucleus test. Co-exposure assays were performed in the presence of N-methyl-N'-nitro-N-nitrosoguanidine (MNNG), 4-nitroquinoline N-oxide (4NQO), benzene, 1,4-benzenediol (1,4-BD), or 1,2,4-benzenetriol (1,2,4-BT). An ELF-MF (50 Hz, 5 mT) was obtained by a system composed of capsulated induction coils. ELF-MF alone was unable to cause direct primary DNA damage. Whereas, an increased extent of DNA damage was observed in cells co-exposed to ELF-MF and MNNG, 1,4-BD, or 1,2,4-BT. An opposite trend was observed in cells treated with 4NQO and co-exposed to ELF-MF. Moreover, the frequency of micronucleated cells in ELF-MF-exposed cells was higher than in control cultures. Our findings suggest that the tested ELF-MF (50 Hz, 5 mT) possess genotoxic (micronucleus test) and co-genotoxic (comet assay) capabilities. The possibility that ELF-MF might interfere with the genotoxic activity of xenobiotics has important implications, since human populations are likely to be exposed to a variety of genotoxic agents concomitantly with exposure to this type of physical agent.

Unrelated cord blood transplantation for childhood acute myeloid leukemia: a Eurocord Group analysis

Results of unrelated cord blood transplantation (UCBT) in childhood acute myeloid leukemia (AML) have not been previously reported. We analyzed 95 children receiving UCB transplants for AML (20 in first complete remission [CR1], 47 in CR2, and 28 in more advanced stage). Poor prognosis cytogenetic abnormalities were identified in 29 cases. Most patients received a 1 or 2 HLA antigens-mismatched UCB transplants. The median number of collected nucleated cells (NCs) was 5.2 x 107/kg. Cumulative incidence (CI) of neutrophil recovery was 78% +/- 4%, acute graft-versus-host disease (GVHD) was 35% +/- 5%, and 100-day transplantation-related mortality (TRM) was 20% +/- 4%. In multivariable analysis, a collected NC dose higher than 5.2 x 107/kg was associated with a lower 100-day TRM. The 2-year CI of relapse was 29% +/- 5% and was associated with disease status. The 2-year leukemia-free survival (LFS) was 42% +/- 5% (59% +/- 11% in CR1, 50% +/- 8% in CR2, and 21% +/- 9% for children not in CR). Children with poor prognosis cytogenetic features had similar LFS compared with other patients (44% +/- 11% vs 40% +/- 8%). In CR2, LFS was not influenced by the length of CR1 (53% +/- 11% in CR1 < 9.5 months compared with 50% +/- 12% in later relapses). We conclude that UCBT is a therapeutic option for children with very poor-prognosis AML and who lack an HLA-identical sibling.

Micronucleus induction in cells co-exposed in vitro to 50 Hz magnetic field and benzene, 1,4-benzenediol (hydroquinone) or 1,2,4-benzenetriol☆

The generation, transmission (e.g. power lines, transformers, service wires, and electrical panels), and use (e.g. home appliances, such as electric blankets, shavers, and televisions) of electrical energy is associated with the production of weak electric and magnetic fields (EMF) which oscillate 50 (Europe) or 60 (USA) times per second (power-line frequency), falling in the extremely-low frequency (ELF) region of the electromagnetic spectrum. Epidemiological reports suggest a possible association between exposure to ELF-EMF and an increased risk of cancer (e.g. childhood acute leukaemia). Benzene is an established human leukomogen. This xenobiotic, which is unlikely to be the ultimate carcinogen, is metabolized in the liver to its primary metabolite phenol, which is hydroxylated to hydroquinone (1,4-benzenediol) and 1,2,4-benzenetriol. In this in vitro approach, to test the genotoxic and / or co-genotoxic potency of ELF-EMF, the cytokinesis block micronucleus (MN) method with Jurkat cells has been used. A 50 Hz magnetic field (MF) of 5 mT field strength was applied for different length of time (from 1 to 24 h), either alone or with benzene, 1,4-benzenediol, or 1,2,4-benzenetriol. Our preliminary results show that, after 24 h exposure, the frequency of micronucleated cells in MF-exposed cultures is 1.9 fold higher than in sham-exposed (control) cultures. Benzene exposure does not show any cytogenetic activity, whereas 1,4-benzenediol or 1,2,4-benzenetriol alone significantly affect the number of MN in Jurkat cells, as compared to untreated cultures. Moreover, co-exposure to ELF-MF does not seem to affect the frequency of micronuclei induced by benzene, 1,4-benzenediol, or 1,2,4-benzenetriol.

Comparison of PCR, enzyme immunoassay and conventional culture for adenovirus detection in bone marrow transplant patients with hemorrhagic cystitis

BACKGROUND

Adenovirus-associated hemorrhagic cystitis (HC) has become a recognized sequel of immunosuppression. The diagnosis of viral infection is usually determined by viral cultures.

OBJECTIVES

Analysis of different diagnostic methods for adenovirus (AdV) detection in bone marrow transplant patients with hemorrhagic cystitis.

STUDY DESIGN

We describe a prospective study for AdV detection in the urine of patients with hematuria in the first 100 days after bone marrow transplant (BMT), comparing different laboratory techniques, PCR, enzyme immunoassay (EIA) and conventional culture.

RESULTS

A total of 143 urine samples were analyzed, 75 collected in the pre-transplant period with and without hematuria and 68 post-transplant, only with microscopic or macroscopic hematuria. After BMT, hematuria occurred in 38.9% of patients, being more frequent in unrelated donor transplants. AdV was isolated in one pre-transplant patient without symptoms and in three post-transplant patients with HC grades 3 and 4 (severe), who were in month 2 or 3 post-transplant. Compared to culture as the gold standard, the accuracy, specificity and sensitivity of EIA were 95, 30 and 100% and for PCR were 63, 100 and 60%, respectively.

CONCLUSIONS

We concluded that despite technical difficulties and the long time that elapsed before results were obtained, cell culture still remains the best method for adenovirus detection in the urine of patients with hemorrhagic cystitis.

Respiratory tract viral infections in bone marrow transplant patients

BACKGROUND

Community respiratory viruses such as respiratory syncytial virus (RSV), adenovirus, influenza A, influenza B, and the parainfluenza group are frequent causes of respiratory disease in bone marrow transplant (BMT) patients.

MATERIAL AND METHODS

During the period from March 1993 to August 1999, 810 samples of respiratory secretions, nasopharyngeal aspirate (NPA) or bronchoalveolar lavage (BAL), from 722 patients with upper respiratory infections symptoms at the BMT unit of the Federal University in the state of Paraná, Brazil were evaluated for respiratory virus infection.

RESULTS

One hundred thirty-six (17%) samples were reactive in 62 patients. RSV was found in 30 of 62 (48%), influenza A in 14 of 62 (23%), influenza B in 9 of 62 (15%), parainfluenza group in 7 of 62 (11%), and adenovirus in 2 of 62 (3%) infected patients. The most frequent clinical manifestations were cough and fever. Pneumonia occurred in 19 of 62 (31%) cases. The mortality rate was 23 of 62 (37%), being higher among patients infected with adenovirus and influenza A.

CONCLUSIONS

Infections in BMT patients occurred during the outbreak period of these viruses in the community, highlighting the need to establish surveillance measures in units with immunocompromised patients in addition to the development of sensitive and rapid diagnostic tests for the detection of these viruses in patients with respiratory symptoms.

Outcome predictors of 84 patients with hematologic malignancies and Fusarium infection

BACKGROUND

Invasive infection by Fusarium sp. is associated with high mortality in patients with hematologic cancer. Yet to the authors' knowledge, little is known regarding predictors of adverse outcome.

METHODS

The authors conducted a retrospective review of the records of patients with hematologic carcinoma and invasive fusariosis who were treated at one institution in the U.S. and at 11 centers in Brazil.

RESULTS

The records of 84 patients were evaluated. Neutropenia was present in 83% and 33 patients had undergone stem cell transplantation. Only 18 patients (21%) were alive 90 days after the diagnosis of fusariosis. Multivariate predictors of poor outcome were persistent neutropenia (hazard ratio [HR] of 5.43; 95% confidence interval [95% CI], 2.64-11.11) and use of corticosteroids (HR of 2.18; 95% CI, 1.98-3.96). The actuarial survival rate of patients without any of these factors was 67% compared with 30% for patients who recovered from neutropenia but were receiving corticosteroids and 4% for patients with persistent neutropenia only. None of the patients with both risk factors survived (P<0.0001).

CONCLUSIONS

Measures to reduce the duration of neutropenia, as well as the judicious use of corticosteroids, may reduce the high mortality rate of fusariosis in patients with hematologic cancer.

Spectrum of sequence variation in the FANCG gene: an International Fanconi Anemia Registry (IFAR) study

Fanconi anemia (FA) is a genetically heterogeneous autosomal recessive syndrome associated with chromosomal instability, hypersensitivity to DNA cross-linking agents, and predisposition to malignancy. The gene for FA complementation group G (FANCG) was the third FA gene to be cloned, and was found to be identical with human XRCC9, which maps to 9p13. The cDNA is predicted to encode a polypeptide of 622 amino acids, with no sequence similarities to any other known protein or motifs that could point to a molecular function for FANCG/XRCC9. We used single strand conformational polymorphism analysis (SSCP) to screen genomic DNA from a panel of 307 racially and ethnically diverse unrelated FA patients from the International Fanconi Anemia Registry (IFAR) for variants in FANCG. Twenty-seven abnormal SSCP patterns were found; 18 of these variants appear to be pathogenic mutations while nine are likely to be nonpathogenic polymorphisms. Direct sequencing of genomic DNA from seven FA-G probands with one mutant allele not detected in the SSCP study and three additional probands assigned to the FA-G complementation group by retroviral correction with FANCG resulted in the detection of nine additional pathogenic mutations and two common SNPs. Conditions for rapid screening for these mutations by DHPLC for use in a clinical laboratory setting were established. The most common FANCG mutations in the IFAR population were: IVS8-2A>G (seven Portuguese-Brazilian probands), IVS11+1G>C (seven French-Acadian probands), 1794_1803del10 (seven European probands), and IVS3+1G>C (five Korean or Japanese probands). Our data suggest that the Portuguese-Brazilian, French-Acadian, and Korean/Japanese mutations were likely to have been present in a founding member of each of these populations.

Aplastic anemia in Brazil: incidence and risk factors

This study is the first large-scale epidemiological investigation of acquired aplastic anemia (AAA) in South America. The objective was to estimate the incidence and to identify risk factors for AAA in Brazil. A national case-control study was conducted to investigate the risk factors for the disease. One hundred twenty-five cases and 129 controls were included. Multiple logistic regression was used in the estimation of odds ratios (OR) to control confounding. The size of Brazil made it unfeasible to estimate the incidence of AAA in the whole country, and we limited the calculation to the state of Parana. The annual incidence of AAA in Parana was 2.4 cases/10(6) inhabitants. There was no positive association between chloramphenicol use and AAA (OR 0.4; 95% CI: 0.1-2.9). The OR of AAA associated with household pesticides that include organophosphates in their composition was 2.7 (1.0-8.4). The OR for the usage of unspecified thinner and/or acetone for at least 7 days was 3.0 (1.2-7.3). Cases of AAA in Brazil seem to be associated with some factors traditionally related to this disease, such as certain solvents and the incidence is similar to what has been reported from Europe.