Conselho Nacional de Desenvolvimento CientÃfico e TecnolÃgico / A anemia falciforme (AF) à uma hemoglobinopatia hereditÃria autossÃmica causada por uma mutaÃÃo pontual no gene da beta globina gerando uma hemoglobina anormal denominada de hemoglobina S (HbS), em homozigose. A doenÃa se caracteriza por apresentar uma variabilidade do quadro clÃnico, que se deve à mÃltiplos fatores, dentre eles a concentraÃÃo de hemoglobina fetal (HbF), os haplÃtipos do gene da beta globina e os polimorfismos do gene BCL11A, entre outros. A avaliaÃÃo dos moduladores genÃticos na AF tem sido desenvolvida com a finalidade de melhorar o entendimento da sua fisiopatologia e direcionar a abordagem terapÃutica objetivando sua individualizaÃÃo. A pesquisa se propÃs a determinar a modulaÃÃo genÃtica dos polimorfismos do gene BCL11A (rs4671393, rs7557939 e rs1186868) sobre o perfil inflamatÃrio, hemolÃtico, no estresse oxidativo e nas concentraÃÃes das HbF, HbS nos pacientes portadores de AF, em estado estacionÃrio. O estudo foi do tipo transversal e analÃtico com 42 pacientes adultos, em acompanhamento ambulatorial no Hospital UniversitÃrio Walter CantÃdio (HUWC), com diagnÃstico molecular e haplÃtipos do gene da beta globina S previamente realizados. Os pacientes estavam em uso de HidroxiurÃia (HU), em mÃdia, 20mg/kg de peso corporal. Amostras biolÃgicas de sangue perifÃrico foram obtidas para a realizaÃÃo dos exames laboratoriais: as dosagens das citocinas prà inflamatÃrias IL-6, IL-17, TNF-alpha e das antiinflamatÃrias IL-10 e TGF-beta, por Elisa; contagem de reticulÃcitos por metodologia manual, dosagem de metemoglobina (MetHb) e lactato desidrogenase (LDH), por espectrofotometria; do nitrito (NOx), malonaldeÃdo (MDA) sÃricos, as enzimas antioxidantes eritrocitÃrias, catalase (CAT) e da glutationa peroxidase (GPx) por kits e espectrofotometria. Os polimorfismos genÃticos do gene BCL11A nas regiÃes, rs4671393, rs7557939 e rs1186868 foram determinados por Real Time PCR. As dosagens da HbF e HbS foram realizadas por HPLC (High Performance Liquid Chromatography). Os dados idade, sexo e eventos clÃnicos foram obtidos dos prontuÃrios. Toda a anÃlise estatÃstica foi realizada usando o software livre R, na versÃo 3.1.2. Para anÃlise da frequÃncia do sexo e dos genÃtipos, por regiÃo e das associaÃÃes entre o tipo de haplÃtipo e dos eventos clÃnicos com as regiÃes do BCL11A, foram usados os testes de Qui-quadrado e o exato de Fisher. Realizou-se o teste paramÃtrico de ANOVA (obtido sob suposiÃÃes distribucionais), bem como o teste nÃo-paramÃtrico de Kruskal-Wallis para a anÃlise da associaÃÃo dos genÃtipos do gene BCL11A com a idade, os nÃveis de HbS, HbF, perfil inflamatÃrio, hemolÃtico e do estresse oxidativo. Foi considerado significante ao nÃvel de 5%. A maioria dos pacientes (57,14%) era do sexo feminino. A idade dos pacientes incluÃdos foi de 18 a 65 anos, com valor mÃdio e mediano de 35,1 e 33 anos, respectivamente. Somente a rs7557939 do BCL11A, o genÃtipo A/G foi o mais prevalente e a prevalÃncia do genÃtipo A/G foi maior nas mulheres , enquanto nos homens a prevalÃncia maior foi do genÃtipo A/A. No entanto, a rs1186868 do BCL11A, a maioria (56,52%) das mulheres apresentaram o genÃtipo C/T e a metade dos homens apresentaram o genÃtipo T/T. Nenhuma regiÃo do gene BCL11A apresentou associaÃÃo significativa com os haplÃtipos do gene da beta globina S. Em relaÃÃo a moduÃÃo do gene BCL11A com os nÃveis de HbS e HbF, verificou-se que na rs1186868 houve resultado significativo do genÃtipo mutante T/T, que apresentou maiores nÃveis de HbS e menores nÃveis de HbF. Na rs7557939 houve uma diminuiÃÃo significante de HbF no alelo mutante A/A, porÃm, nÃo houve relaÃÃo com a HbS. NÃo houve associaÃÃo entre os SNPs, nas trÃs regiÃes estudadas, com relaÃÃo ao nÃmero mÃdio/mediano dos moduladores inflamatÃrios, marcadores de hemÃlise, do estresse oxidativo e dos eventos clÃnicos, ao nÃvel de 5%.Os achados reforÃam a hipÃtese da moduÃÃo genÃtica dos polimorfismos do gene BCL11A em relaÃÃo aos nÃveis de HbF, onde os alelos selvagens, nas regiÃes rs7557939 e rs1186868 apresentaram um carÃter protetor no prognÃstico em decorÃncia de terem apresentado aumento dos nÃveis de HbF, nos pacientes com AF do estudo.

INTRODUÇÃO: As Hemoglobinopatias podem ser divididas em Talassemias e Doença Falciforme (DF), mas do ponto de vista clínico, ambas apresentam um quadro de anemia hemolítica crônica, o que acarreta uma série de complicações, entre estas a Hipertensão Pulmonar (HP). Estima-se que cerca de 20-40% da população com DF/talassemia apresente HP, sendo que este diagnóstico está associado a uma elevada morbi-mortalidade. Poucos estudos avaliaram esta prevalência em crianças. O Objetivo deste estudo foi avaliar a prevalência desta complicação na população pediátrica, e associá-la com características clínicas e laboratoriais. MÉTODOS: Estudo de Corte Transversal, com avaliação de 45 pacientes com diagnóstico de DF ou Talassemia maior/ intermédia entre 3-18 anos, atendidos de forma consecutiva no ambulatório de Hemoglobinopatias do HCPA. Os pacientes foram submetidos a um ecocardiograma para estimativa da pressão sistólica da artéria pulmonar, sendo que foi considerado como tendo risco de HP os pacientes com velocidade de regurgitação tricúspide (VRT) ≥ 2,5m/s. Foram obtidos dados clínicos e laboratoriais para avaliação dos parâmetros hemolíticos, função hepática e renal por levantamento de prontuário e comparados os grupos. RESULTADOS: 15% (6/40) dos pacientes apresentaram VRT ≥ 2,5m/s, sugestivo de HP, sendo que destes pacientes todos tinham diagnóstico de Anemia Falciforme (AF). Considerando apenas esta população, a prevalência de HP aumenta para 20% (6/30). A população com VRT ≥ 2,5m/s apresentou média de idade mais elevada, Hb mais baixa, RDW mais alargado, reticulócitos e LDH mais elevado que o grupo com VRT < 2,5m/s. A principal intercorrência clínica nesta população foi a ocorrência de priapismo (p< 0,05). CONCLUSÕES: Os pacientes com Hemoglobinopatias estão em risco aumentado para desenvolvimento de HP desde a infância, principalmente aqueles com AF. Estes pacientes apresentam os parâmetros laboratoriais sugestivos de hemólise alterados, assim como outros sintomas associados ao quadro hemolítico como o priapismo quando comparados com pacientes com VRT normal. Desta forma sugere-se a realização de triagem com ecocardiograma nesta população de forma precoce. / INTRODUCTION: The Hemoglobinopathies can be divided in Thalassemias and Sickle Cell Disease (SCD), but clinically both present with chronic hemolytic anemia, which leads to various complications, one of them being Pulmonary Hypertension (PH). About 20-40% of patients with SCD have PH, and this diagnosis is associated with a high risk of mortality. The objective of this study was to estimate the prevalence of this complication in the pediatric population, and associate clinical and laboratory characteristics. METHODS: A cross sectional descriptive study, with the evaluation of 45 patients with diagnosis of SCD or thalassemia major/intermedia between 3-18 years, which received treatment at the Hemoglobinopathies ambulatory at HCPA. The patients were submitted to an echocardiogram to estimate the pulmonary artery systolic pressure, being considered to have PH patients with a tricuspid regurgitate jet velocity (TRV) ≥ 2.5m/s. Clinical and laboratory data were obtained to evaluate hemolytic parameters, renal and liver function and compared between groups. RESULTS: 15% (6/40) of patients had a TRV ≥ 2.5m/s, suggestive of PH, of which all had Sickle Cell Anemia (SCA). Considering this group of patients alone the prevalence would be of 20% (6/30). Patients with TRV ≥ 2.5m/s had a higher median age, lower hemoglobin count, higher RDW, reticulocyte and DHL then patients with a TRV < 2.5m/s. The major clinical feature was the occurrence of priapism (p<0,05). CONCLUSIONS: Patients with diagnosis of hemoglobinopathies are at higher risk of developing PH since early childhood, especially those with SCA. These patients showed a higher level of hemolytic parameters, as well as symptoms associated with hemolysis, like priapism, when compared with patients with a normal TRV. Therefore, it would be indicated to submit these patients to an echocardiogram routinely in their early years.

Background: With increasing technological advancements, healthcare providers are adopting electronic health records (EHRs) and new health information technology systems. Consequently, data from these systems is accumulating at a faster rate creating a need for more robust ways of capturing, storing and processing the data. Big data analytics is used in extracting insight form such large amounts of medical data and is increasingly becoming a valuable practice for healthcare organisations. Could these strategies be applied in disease management? Especially in rare conditions like Sickle Cell Disease (SCD)? The study answers the following research questions;1. What Data Management practices are used in Sickle Cell Anaemia management?2. What areas in the management of sickle cell anaemia could benefit from use of big data Analytics?3. What are the challenges of applying big data analytics in the management of sickle cell anaemia?Purpose: The purpose of this research was to serve as pre-study in establishing the opportunities and challenges of applying big data analytics in the management of SCDMethod: The study adopted both deductive and inductive approaches. Data was collected through interviews based on a framework which was modified specifically for this study. It was then inductively analysed to answer the research questions.Conclusion: Although there is a lot of potential for big data analytics in SCD in areas like population health management, evidence-based medicine and personalised care, its adoption is not a surety. This is because of lack of interoperability between the existing systems and strenuous legal compliant processes in data acquisition.

La drépanocytose est une maladie chronique et génétique de l’hémoglobine. Elle se caractérise par la survenue très précoce de crises de douleurs extrêmement intenses et le plus souvent imprévisibles. Le seul traitement qui permet, à l’heure actuelle, d’obtenir la guérison du malade est la transplantation de cellules souches hématopoïétiques à partir d’un donneur compatible et apparenté. Or, si la greffe est curative, elle est aussi un processus dangereux et incertain qui conduit à une prise de risque importante. En outre, la guérison n’offre pas le retour à un état de santé d’avant la maladie, mais l’accès à un état inédit et jusque-là inconnu, elle conduit donc le sujet à opérer d’importants remaniements, notamment identitaires.Dans une première partie, nous décrirons la drépanocytose dans ses dimensions somatiques, anthropologiques et psychiques afin de déployer les différents aspects qui contribuent à sa puissance identificatoire. Puis, nous nous intéresserons aux effets de la greffe et aux remaniements qu’elle provoque, depuis son annonce et jusqu’à 20 ans après la transplantation. Notre objectif est d’interroger la notion de guérison telle qu’elle est annoncée par le monde médical et de soutenir qu’elle ne peut se réduire aux seuls effets somatiques. Nous souhaitons, ainsi, plaider pour l’organisation systématique d’un accompagnement des effets psychiques induits par ce processus complexe, radical et profondément bouleversant, à toutes ses étapes, tant chez l’adulte que chez l’enfant. / Sickle cell disease is a chronic and genetic disease of hemoglobin. It is characterized by the very early onset of extremely intense and often unpredictable pain attacks. The only treatment that currently enables the patient to be cured is the transplantation of hematopoietic stem cells from a compatible and related donor. However, if the graft is curative, it is also a dangerous and uncertain process that leads to significant risk taking. In addition, healing does not offer a return to a state of health before the disease, but access to a new and unknown state, it leads the subject to make major changes, notably identitary.In a first part, we will describe sickle cell disease in its somatic, anthropological and psychic dimensions in order to deploy the various aspects that contribute to its identificatory power. Then, we will focus on the effects of the transplant and the changes it causes, since its announcement and until 20 years after transplantation. Our goal is to question the notion of healing as it is announced by the medical world and to argue that it can not be reduced only to somatic effects. We thus wish to advocate for the systematic organization of an accompaniment of the psychic effects induced by this complex radical and deeply upsetting process, at all its stages, for the adult as well as for the child.

Intracellular polymerization of deoxygenated sickle hemoglobin (Hb S) remains the principal cause of the pathophysiology associated with sickle cell disease (SCD). Naturally occurring and synthetic allosteric effectors of hemoglobin (AEH) have been investigated as potential therapeutic agents for the treatment of SCD. Several aromatic aldehydes, including vanillin, have been studied previously as AEHs for their antisickling activities. Specifically, these compounds form Schiff- base adduct with Hb to stabilize the oxygenated (R) state, increase Hb affinity for O2 and concomitantly prevent the hypoxia-induced primary pathophysiology of Hb S polymerization and RBC sickling, in turn, ameliorating several of the cascading secondary adverse effects. These compounds, however, undergo significant metabolism leading to suboptimal pharmacokinetic properties, e.g. short duration of pharmacologic action and low bioavailability. These drawbacks have severely hampered the use of aromatic aldehydes as AEHs to treat SCD. To counter these challenges, we designed and synthesized 14 novel compounds (PP- compounds) based on previously studied pyridyl derivative of vanillin. These modifications were expected to increase binding interactions with the protein and thus stabilize the Schiff-base adduct, as well as lead to perturbation of the surface-located F-helix that would stereospecifically destabilize polymer contacts. We investigated the in vitro pharmacokinetic/pharmacodynamic properties of these newly synthesized compounds to ascertain sustained binding and modification of normal human Hb. Subsequently, we conducted in vitro screening assays to test for inhibition of sickling, modification of Hb to the high-affinity form, as well as for a direct left-shift in oxygen equilibrium curves (OEC). Three selected compounds, PP6, PP10, and PP14, that demonstrated not only high antisickling activity but also showed sustained pharmacologic action were chosen for preliminary in vivo studies. Our results showed maximal levels of Hb modification, which were sustained for the entire 24 h experimental period. In contrast, TD-7 after reaching maximum effect at 1 h gradually decreased in potency and at 24 h has lost 45% of its activity, consistent with the low bioavailability of this compound. These findings suggested that our modifications appeared to successfully limit drug metabolism in red blood cells. Most of these compounds showed almost complete inhibition of sickling at 2 mM concentration; with significant modification of Hb to a higher affinity Hb as well as an increase in O2 affinity of Hb. Interestingly, while TD-7 demonstrated a clear linear correlation between its ability to increase Hb-O2 affinity and antisickling activity, PP2, PP3, PP6, PP9, PP10, and PP14, showed a weak correlation between these parameters. In fact, these compounds demonstrated high antisickling effect despite only marginally increasing Hb affinity for O2. This observation indicated that these compounds possibly exhibit the dual mechanism of antisickling activity. We hypothesize that their secondary mechanism of action is due to interactions with the surface located αF-helix that would lead to direct or stereospecific inhibition of polymer formation. To establish the mode of interaction with Hb, we further conducted x-ray crystallography studies and co-crystallized PP2, PP6, PP9 and PP11 with CO-liganded Hb. Our studies showed that these compounds bind in symmetry-related fashion at the α-cleft of Hb to form Schiff-base adducts with the N-terminal Val1 and showed direct interactions with the F-helix which overall enhanced interactions with Hb. PP6, PP10, and PP14 demonstrated significant in vivo modification of intracellular Hb in mice after IP administration, with increasing levels from 1 h to the 6 h experimental period. They also showed corresponding changes in O2 affinity observed at 3 h and 6 h, compared to 0 h pre-treatment samples in vivo. Thus, our results establish these compounds as a novel, promising group of potent anti-sickling agents, demonstrate their proposed mechanism of action and provide proof-of-concept justifications for our structure-based approach to developing potent therapeutics for SCD.

Because of the high mortality rate of sickle cell disease (SCD) patients who do not continue care into adulthood, researchers have paid increasing attention to the health care transition experiences of SCD patients. However, a gap exists regarding patients' perspectives of care transition related to their quality of life. The purpose of this phenomenological study, guided by the biosocial-ecological systems model, was to explore the lived health care transition experiences of SCD patients in relation to their health-related quality of life. Data collection included open-ended interviews with 12 patients in the Southwestern United States. Colaizzi's (1978) method of phenomenological data analysis was used to identify themes, including resistance to transition; inadequate transitional support; lack of autonomy and education; fear, anxiety, and stress; and managing other life changes. Results contribute to the existing research on SCD health care transition, broaden understanding of the transition process and provide guidance for improving transition programs.

Children with Sickle Cell Disease (SCD) face medical, psychosocial, and cognitive challenges, which may impede their social and academic functioning. These complications can be lessened through the implementation of comprehensive interventions. This study reviews one comprehensive intervention, a support group, for children with SCD and their families, and reviews the challenges faced by the children and family who participate in the support group as well as those who do not participate. The study has a mixed-method design because the families participated in focus groups, and they completed quantitative instruments, including a knowledge survey, a behavior rating scale, and an instrument to measure the degree that SCD affects one's life. Most children rated SCD as affecting their life a little bit and were knowledgeable in SCD. The children who did not participate in the support group reported less symptoms and a smaller impact on their lives than those who did participate. The results from the behavior rating scale did not reveal any significant behavior problems in these children; however, those who did not participate in the support group had higher ratings than those who did. These results imply that individuals with SCD who are less impacted by the disease may be less likely to attend a support group than those who are more impacted. Additionally, a theme analysis from the focus groups revealed key themes, such as keeping SCD a secret, getting made fun of, missing school, missing PE class, hospital visits, and experiences with pain crises. The findings from this study indicate that SCD does impact the life of children with the disease; however, the impact may be unknown to others and may differ among individuals. The results also imply that school personnel and other students in schools must be accurately informed about the manifestations of SCD to best promote healthy physical and psychosocial development in children with SCD. Finally, support groups can help to reduce symptoms and complications related to the disease.

O metabolismo de nutrientes abriga um alto potencial para o desenvolvimento de novos alvos quimioterápicos para o tratamento do parasita da malária Plasmodium falciparum. A partir de ensaios de crescimento do parasita dentro de eritrócitos geneticamente diferentes, concentrando-se na via catabólica da hemoglobina plasmodial usando parasitas transgênicos, a natureza protetora das variantes da hemoglobina foi investigada. Sendo que Falcipain 2 (FP2) prolifera três vezes mais elevada no sangue de células falciformes do que o Mock, a célula de controle. Adicionalmente, estudos de inibidores indicam que FP2 é uma proteína essencial para o parasita. Em cooperação com o DESY em Hamburgo, Alemanha a estrutura cristalina da amino peptidase P foi resolvida difratando até 1,7 Å. / The metabolism of nutrients harbors a high potential for the development of new chemotherapeutic targets for the treatment of the malaria parasite Plasmodium falciparum. From parasite growth assays within genetically different erythrocytes, concentrating on the catabolic pathway of plasmodial hemoglobin using transgenic parasites, the protective nature of hemoglobin variants was investigated. Since Falcipain 2 (FP2) proliferates three times higher in sickle cell blood than the Mock, the control cell. In addition, inhibitor studies indicate that FP2 is an essential protein for the parasite. In cooperation with DESY in Hamburg, Germany the crystalline structure of the amino peptidase P was resolved diffracting up to 1.7 Å.

Until first half of the XX century, sickle cell disease was practically limited to the malaria endemic areas and countries having known an important surge of African slaves. Today, migratory flows and progress of medicine have modified considerably the distribution of sickle cell disease which is from now on a frequent affection in Western Europe. The preventive implementation of medical care makes it possible to reduce morbidity and mortality associated with this pathology. Stake of a medical policy and economic interests, neonatal screening for hemoglobin disorders justifies then fully the implementation of powerful and adapted means. In order to initiate a newborn screening programme in our centre, we developed various immunological tests allowing to identify the sickle hemoglobin. We first of all developed an indirect immunoassay and led a population study on 46082 Belgian newborns and 1825 neonates from Central Africa. The performances of this assay were improved thereafter by conceiving a competitive test. Next, for reasons independent of our will, we had unfortunately to abandon the immunological approach. This methodology was thus supplanted in our center by an innovative method for this indication: the mass spectrometry. Our promising results currently authorize us to perennialize our policy in the neonatal screening for sickle cell disease and open the way for new developments in other fields. / Jusquà la première moitié du XXe siècle, la drépanocytose se limitait pratiquement aux zones dendémie palustre et aux pays ayant connu un important afflux desclaves dorigine africaine. Aujourdhui, les flux migratoires et les progrès de la médecine ont considérablement modifié la distribution de cette maladie qui est désormais une affection fréquente en Europe occidentale. La prise en charge précoce permet de réduire la morbidité et la mortalité associées à cette maladie. Enjeu dune politique sanitaire et dintérêts économiques, le dépistage néonatal de la drépanocytose justifie donc ainsi pleinement la mise en uvre de moyens performants et adaptés. Afin dinitier un programme de dépistage au sein de notre centre, nous avons initialement développé divers tests immunologiques permettant didentifier lhémoglobine anormale. Nous avons tout dabord mis au point un immunoessai indirect et conduit une étude de population sur 46082 nouveau-nés belges et 1825 bébés originaires dAfrique centrale. Les performances de lessai ont par la suite été améliorées en concevant un test compétitif. Lapprovisionnement laborieux danticorps nécessaires aux tests de détection a par la suite entravé notre programme. En effet, la commercialisation en a été interrompue et la production danticorps monoclonaux par nos moyens propres na pas été couronnée du succès escompté. Lapproche immunologique du dépistage néonatal de la drépanocytose a ainsi été supplantée dans notre centre par une méthode novatrice pour cette indication : la spectrométrie de masse. Nos résultats prometteurs nous autorisent actuellement à pérenniser notre nouvelle façon de faire dans le dépistage néonatal de la drépanocytose et ouvre la voie pour de nouveaux développements dans dautres domaines.

Pregnancy in women with hemoglobinopathy has been associated with an increased risk of adverse pregnancy outcomes. We conducted a historical cohort study using Discharge Abstract Database for the fiscal year 1991-1992 through 2007-2008. We estimated the frequency of pregnant women with hemoglobinopathy and examined their associations with adverse pregnancy outcomes. Women with sickle cell disease are more likely to develop pre-eclampsia and preterm labor, and to undergo cesarean delivery than women with nutritional deficiency anemia, suggesting that there are other mechanisms beyond anemia that may be responsible for an increased risk of adverse pregnancy outcomes. The data suggested a synergistic effect of hemoglobinopathy and pre-eclampsia on preterm labor and cesarean delivery. Prediction models for pre-eclampsia, preterm labor and cesarean delivery were created and internally validated for women with hemoglobinopathy, with satisfactory discrimination and calibration.