RESUMO Este relato descreve um cão com anemia e TIM associada ao fenobarbital, tratado com prednisolona, e boa resposta após associação com três transplantes de 2,5x106 células-tronco mesenquimais alogênicas. Após o primeiro transplante, o número de plaquetas melhorou, mas começou a regredir após três semanas. Contudo, pode-se reduzir a dose de corticosteroide. Após a segunda e terceira administrações, observaram-se novos aumentos. A contagem de plaquetas variou de 102.000 a 365.000 até o final do acompanhamento, sem necessidade de aumentar as doses de prednisolona. Embora a terapia com fenobarbital seja associada à trombocitopenia, não foi possível alterar a terapia anticonvulsivante. A resposta à corticoterapia foi parcial. A terapia celular foi associada à melhora na contagem plaquetária, sem efeitos adversos relacionados e, dessa forma, pode ser considerada segura. Efeitos na contagem de plaquetas foram transitórios, mas, até o final do acompanhamento, não se observou trombocitopenia severa. Com base na observação de que o número de plaquetas caiu poucas semanas após a terapia celular, mais aplicações seriam benéficas, no intuito de manter a contagem de plaquetas mais alta. prednisolona 25x106 x 2 5x106 2,5x10 célulastronco células tronco alogênicas transplante melhorou Contudo podese corticosteroide administrações observaramse observaram aumentos 102000 102 000 102.00 365000 365 365.00 acompanhamento anticonvulsivante parcial plaquetária forma segura transitórios severa benéficas alta 25x10 5x10 2,5x1 10200 10 00 102.0 36500 36 365.0 25x1 5x1 2,5x 1020 1 0 102. 3650 3 365. 25x 5x

ABSTRACT This report describes a dog with anemia and ITP, associated with phenobarbital, treated with prednisolone with a good response after association with three intravenous transplantations of 2.5x106 allogenic Mesenchymal Stem-Cells. After the first transplantation, the number of platelets had an improvement, but started to decrease after three weeks. However, the dose of corticosteroid could be reduced. After the second and third administrations, new increases were observed. The platelet count varied from 102,000 to 365,000 until the end of follow-up and without increase of prednisolone doses. Although phenobarbital therapy has been associated with thrombocytopenia, it was not possible to change the anti-convulsant therapy. The response to corticosteroid-based therapy was partial. Cell therapy was followed by an improvement in platelet count with no observed side effects and therefore could be considered safe. Effects on platelet count were transitory, but until the end of follow-up, no severe thrombocytopenia was observed. Based on the observation that platelet numbers dropped a few weeks after cell therapy, more applications would be beneficial in order to maintain higher platelet counts. ITP 25x106 x 2 5x106 2.5x10 StemCells. StemCells Stem Cells. Cells Stem-Cells transplantation However reduced administrations 102000 102 000 102,00 365000 365 365,00 followup follow up doses anticonvulsant anti convulsant corticosteroidbased based partial safe transitory followup, up, counts 25x10 5x10 2.5x1 10200 10 00 102,0 36500 36 365,0 25x1 5x1 2.5x 1020 1 0 102, 3650 3 365, 25x 5x

RESUMO A hepatite crônica (HC) é caracterizada pela substituição dos hepatócitos por tecido fibrótico após injúria, em vez de regeneração do parênquima funcional, e a terapia não é curativa. A terapia com células-tronco tem mostrado potencial para reduzir a fibrose hepática. Este relato descreve o manejo de um cão com HC com abordagem baseada em células mesenquimais. Uma cadela de 13 anos foi atendida com perda de peso, êmese, diarreia e letargia. Previamente, fora diagnosticada com HC. Exames de sangue mostraram hipoalbuminemia, aumento das atividades da alanina aminotransferase (ALT) e fosfatase alcalina (FA), e anemia. Três transfusões de 2,5x106 células mesenquimais derivadas foram realizadas. Após a primeira transfusão, o tutor relatou melhora nos sinais clínicos. A bioquímica sérica evidenciou redução na atividade da FA. Após a segunda administração, houve redução nas atividades séricas da ALT e da FA, que continuaram caindo após a terceira transfusão. Houve aumento nas concentrações de albumina e proteína plasmática total. Após seis meses, o cão retornou para controle. Foram observados avanço na melhora dos sinais clínicos, nova redução na atividade da ALT e leve aumento da FA. A terapia baseada em células-tronco pode ser considerada alternativa promissora para doenças hepáticas crônicas. Neste relato, demonstrou segurança e eficácia. (HC injúria funcional curativa célulastronco tronco hepática 1 peso êmese letargia Previamente hipoalbuminemia (ALT FA , (FA) anemia 25x106 x 2 5x106 2,5x10 realizadas transfusão clínicos administração total meses controle crônicas eficácia (FA 25x10 5x10 2,5x1 25x1 5x1 2,5x 25x 5x

ABSTRACT Chronic hepatitis (CH) is characterized by the replacement of hepatocytes for fibrotic tissue after injury, and treatment is not curative. Stem cell therapy has shown potential to reduce liver fibrosis. This report describes the management of a dog with CH with a mesenchymal cell-based approach. A 13-year old dog was presented with weight loss, vomiting, diarrhea, and lethargy. She was previously diagnosed with CH. Blood analysis showed hypoalbuminemia, increased serum activities of alanine aminotransferase (ALT) and alkaline phosphatase (ALP), and anemia. Three 2.5x106 bone marrow-derived mesenchymal cells transplantations were performed. After the first transplantation, the owner reported an improvement in clinical signs. Biochemistry evidenced a reduction in ALP activity. After the second administration, serum biochemistry showed a decrease in serum ALT and ALP activities, which kept falling after the third transplantation. There was an increase in albumin and total plasmatic proteins concentration. After six months, the dog came back for control and further improvement in clinical signs, new decrease in ALT activity and a mild increase in ALP concentration was observed. Increase in total and plasmatic protein were also observed. Stem cell-based therapy may be considered a promising alternative for liver diseases. It was safe and showed efficacy in this report. (CH injury curative fibrosis cellbased based approach 13year year 13 loss vomiting diarrhea lethargy hypoalbuminemia (ALT ALP, , (ALP) anemia 25x106 x 2 5x106 2.5x10 marrowderived marrow derived performed transplantation signs administration months observed diseases 1 (ALP 25x10 5x10 2.5x1 25x1 5x1 2.5x 25x 5x

RESUMO Amostras de plasma rico em plaquetas de 50 cavalos saudáveis, de cinco raças diferentes (Puro Sangue de Corrida, Crioula, Brasileiro de Hipismo, Pônei Brasileiro e sem raça definida), foram investigadas quanto à concentração plaquetária em relação à raça, à idade e ao sexo. Além disso, um escore foi estabelecido para correlacionar o aspecto físico do PRP com a contagem plaquetária. A contagem celular foi realizada por um analisador hematológico automático e pelo método manual. A análise física baseou-se na cor, no aspecto e na capacidade de separar hemocomponentes. Pôneis tiveram concentração plaquetária significativamente maior que os Brasileiros de Hipismo (P<0,05), mas as demais comparações entre raças não apresentaram diferença quanto à contagem plaquetária. Não houve diferença para o gênero, mas a idade demonstrou correlação fraca com as concentrações plaquetárias do PRP (rs = -0,24). A maioria dos PRPs apresentaram coloração amarela, e a separação dos hemocomponentes não mostrou correlação com a contagem plaquetária, mas o aspecto apresentou uma correlação moderada (rs = 0,30). Os resultados deste estudo sugerem que a concentração plaquetária do PRP pode ser influenciada por fatores intrínsecos, como a raça. Além disso, a análise do aspecto do PRP pode ajudar na avaliação da qualidade do produto quando não há acesso à contagem plaquetária.

ABSTRACT Platelet rich plasma samples from 50 healthy horses of five different breeds (Thoroughbreds - TB, Brazilian Criollo Horses - BCH, Brazilian Sport Horses - BSH, Miniature Horses - MH and Crossbred Horses - CB), were investigated as to breed, age, and gender effect for platelet concentration. Moreover, a score for physical analysis was established to correlate PRP physical aspect with platelet count. Platelet count was performed by an automatic hematology analyzer and by manual count. PRP physical analysis was based on color, aspect, and capacity to separate blood components. MH showed significant higher platelet concentration than BSH (p<0.05), while the other breed comparisons showed no significant difference. There was no significant difference for gender but there was a weak correlation of age with PRP platelet concentrations (rs = -0.24). Most of the PRP presented yellow color, the separation of blood components showed no correlation, but the aspect showed a moderate correlation (rs = 0.30) with platelet count. Results suggest that PRP platelet concentration can be influenced by intrinsic factors such as breed. Additionally, the analysis of PRP aspect can help to evaluate the quality of the product when there is no access to platelet counts.

The thalassaemias are a group of inherited blood disorders characterised by decreased or absent globin chain synthesis. Classification of thalassaemia is based on the type of globin chain that is deficient. There are four globin chain subtypes, viz. α, β, γ and δ; deficiencies of these are designated as α-, β-, γ- or δ-thalassaemia, respectively. As genetic defects or deletions may affect one or more globin genes, a variety of clinical phenotypes may be encountered. Heterozygotes (thalassaemia carriers) enjoy partial protection against malaria, with consequential survival advantage. This explains the unexpectedly high gene frequencies found in malaria-endemic areas. South Africa is not a malaria-endemic area, and therefore has a predictably low prevalence of thalassaemia and other inherited Hb disorders. However, because of migration, these conditions are increasingly encountered in countries not endemic to malaria. In this issue (part 1 of the 2-part CME series), discussion is centred around epidemiology, pathophysiology, clinical features and diagnosis. Management is discussed in the next issue (part 2).

RESUMO Investigaram-se os efeitos locais e sistêmicos da oxigenoterapia hiperbárica em camundongos BALB / C, submetidos a dois tempos de exposição diferentes, sob atmosfera 2,4 (ATM). Quinze animais foram divididos em três grupos (GI, GII e controle) e submetidos à excisão cirúrgica de fragmento de pele de aproximadamente um centímetro quadrado da região dorsal. As feridas foram tratadas e acompanhadas por 21 dias. No grupo controle, a ferida foi limpa uma vez ao dia, com solução estéril de NaCl 0,9%. Camundongos GI e GII foram submetidos à oxigenoterapia hiperbárica diária de 30 ou 60 minutos de sessões, respectivamente. As feridas foram fotografadas a cada três dias, e suas superfícies analisadas por um analisador de imagens. Aos 21 dias, todos os animais foram submetidos à eutanásia para análise histopatológica da pele, do pulmão e do fígado, em busca de eventuais alterações na cicatrização da ferida ou nos órgãos analisados. Animais pertencentes ao GI apresentaram cicatrização mais rápida de feridas cutâneas em comparação aos outros grupos. Já os animais do GII apresentaram retardo na cicatrização da ferida e alterações pulmonares e microcirculatórias. Esses achados permitem concluir que o tempo de exposição ao oxigênio em ambiente hiperbárico é fundamental e pode auxiliar ou atrapalhar a cicatrização de feridas cutâneas ou mesmo ser deletério para outros órgãos.

ABSTRACT We investigated the local and systemic effects of hyperbaric oxygen therapy in BALB/C mice, exposed to two different exposure times, under 2.4 atmosphere (ATM). Fifteen animals were divided into three groups (GI, GII and Control) and underwent a surgical excision of a skin fragment of approximately one square centimeter of the dorsal region. The wounds were treated and monitored for 21 days. In the control group, the wound was cleaned once a day with sterile 0.9% NaCl solution. GI and GII mice were submitted to daily hyperbaric oxygen therapy of 30 or 60minutes sessions, respectively. The wounds were photographed every three days and their surfaces were analyzed by an image analyzer. At 21 days, all animals were euthanatized for histopathological analysis of the skin, lungs and liver in order to identify eventual alterations in wound healing or in the analyzed organs. Animals belonging to GI showed a faster skin wound healing in comparison to the other groups. Animals from GII, however, showed a delayed wound healing process and exhibited lung and microcirculatory alterations. These findings allow us to conclude that the exposure time to the oxygen in hyperbaric environment is crucial and can help or disturb skin wound healing or even be deleterious to other organs.

BACKGROUND. Familial disease is implicated in 20 - 50% of cases of idiopathic dilated cardiomyopathy (IDCM) worldwide. The contribution of familial factors to IDCM in the Johannesburg area, South Africa, is unknown. OBJECTIVES. To describe the demographic details of patients with IDCM who presented at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), and to determine if there is evidence of familial disease through family history assessment and clinical screening of relatives. METHODS. This was a single-centre, cohort study performed at a quaternary care centre at CMJAH. Fifty unrelated probands diagnosed with IDCM and available first- and second-degree relatives were included in the study. A three-generation family pedigree was drawn up for all 50 probands. The pedigrees were analysed to identify the presence or absence of familial disease and categorised as positive, intermediate, negative or unreliable according to the family history obtained. From the 50 proband cases, there were 21 family members available for screening for features of IDCM. Eighty-two family members (55 first-degree and 27 second-degree relatives) were screened clinically. Screening included a personal history, full physical examination, electrocardiogram (ECG) and echocardiogram. RESULTS. The mean age at diagnosis of IDCM in the probands was 41.7 (standard deviation (SD) 12.4) years. The majority of probands were males (n=38; 76%). Of 50 pedigrees analysed, 14 (28%) were positive and likely to be indicative of familial dilated cardiomyopathy (DCM), and 9 (18%) patients were at intermediate risk of familial disease. Eighty-two asymptomatic family members were screened, with a median age of 33 (range 11 - 76) years. No asymptomatic family members were identified with features of DCM or presymptomatic DCM. Eleven of the 21 families screened had relatives with possible presymptomatic DCM identified by abnormalities on the echocardiogram in 3 families (14.3%) (4 individuals; all first-degree relatives of the index case) or identified on the basis of a conduction defect (an arrhythmia or first-/ second-/third-degree heart block) in 8 families (72.7%) (11 individuals; 9 first-degree and 2 second-degree relatives). CONCLUSIONS. Screening for IDCM should include a three-generation family history and clinical screening of all first-degree family members. As IDCM has an age-related penetrance, at-risk family members should receive follow-up for screening to assess symptoms and signs of IDCM. Genetic testing would potentially identify family members at high risk, who would benefit from screening; this might be a less expensive option.

Genetic testing has been available for many years. Recently, the potential for increased and more precise diagnostic testing has expanded, with the introduction of next-generation sequencing technologies. Testing is complex and requires the experience of medical geneticists and genetic counsellors to assist in selecting the most appropriate test for a patient, as well as in interpreting the large data sets that arise from such testing. The most appropriate test for a patient may require analysis of only one base of DNA, or one gene, one panel, a whole exome or a whole genome. The interpretation of positive findings is challenging and requires careful distinction between benign and pathogenic variants. Variants of uncertain significance occur; unexpected findings are not infrequent and require careful interpretation and management. The paucity of data on normal variation poses specific challenges on the African continent.

Although rare, CALM/AF10 is a chromosomal rearrangement found in immature T-cell acute lymphoblastic leukemia (T-ALL), acute myeloid leukemia, and mixed phenotype acute leukemia of T/myeloid lineages with poor prognosis. Moreover, this translocation is detected in 50% of T-ALL patients with gamma/delta T cell receptor rearrangement, frequently associated with low expression of transcription factor CCAAT/enhancer-binding protein alpha (CEBPA). However, the relevance of CEBPA low expression for CALM/AF10 leukemogenesis has not yet been evaluated. We generated double mutant mice, which express the Lck-CALM/AF10 fusion gene and are haploinsufficient for the Cebpa gene. To characterize the hematopoiesis, we quantified hematopoietic stem cells, myeloid progenitor cells, megakaryocyte-erythrocyte progenitor cells, common myeloid progenitor cells, and granulocyte-macrophage progenitor cells. No significant difference was detected in any of the progenitor subsets. Finally, we tested if Cebpa haploinsufficiency would lead to the expansion of Mac-1+/B220+/c-Kit+ cells proposed as the CALM/AF10 leukemic progenitor. Less than 1% of bone marrow cells expressed Mac-1, B220, and c-Kit with no significant difference between groups. Our results showed that the reduction of Cebpa gene expression in Lck-CALM/AF10 mice did not affect their hematopoiesis or induce leukemia. Our data corroborated previous studies suggesting that the CALM/AF10 leukemia-initiating cells are early progenitors with lymphoid/myeloid differentiating potential.

We present a case of a young female patient diagnosed clinically and molecularly with V-EDS and briefly review the published literature on this severe condition. Additionally, the case is used to highlight the need for early confirmation of diagnosis and appropriate referral to allow surveillance, intervention and genetic counselling.

Fanconi anaemia (FA) is an inherited genetic disorder characterised by somatic anomalies, bone marrow failure and an increased predisposition to solid tumours and haematological malignancies. South African (SA) black and Afrikaner individuals are at higher than average risk for this condition owing to genetic founder mutations in certain Fanconi-associated genes. This review explores the epidemiology, clinical presentation, diagnostic modalities and recommended care of affected patients, focusing on the founder population groups in SA. The early diagnosis of FA is important and provides improved opportunities for early intervention, but remains challenging.

Triploidy is a chromosomal abnormality caused by an additional set of haploid chromosomes. It is a common cause of early first-trimester miscarriages. Only very rarely are babies with triploidy born alive and even more rarely do they survive beyond the first few days of life. We present here a case of a term baby with confirmed paternal (diandric) triploidy and some unusual features, who survived for 50 days, and review the literature on those who survived.

BACKGROUND. Fanconi anaemia (FA) is a rare genetic disorder of impaired DNA repair that results in physical and haematological consequences in affected individuals. In South Africa (SA), individuals with Afrikaner ancestry are at an increased risk of inheriting disease-causing FA mutations, owing to the three common FANCA (FA, complementation group A) founder mutations present in this population subgroup. OBJECTIVES. To describe the physical phenotype of SA patients with FANCA mutations for the purpose of recommending appropriate care for affected individuals. METHODS. A structured clinical examination and file-based review were used to evaluate the physical phenotype of 7 patients with compound heterozygous and homozygous FANCA founder mutations, and 1 patient with confirmed FANCA complementation analysis. Descriptive statistical analysis was used to determine the frequency of physical anomalies in Afrikaner patients and to compare the described phenotype to other FA cohorts, including a previously clinically characterised black SA FA cohort. RESULTS. An earlier age of diagnosis of FA in Afrikaner patients, a high frequency of somatic anomalies and a higher-than-expected incidence of the VACTERL/H phenotype were noted. CONCLUSIONS. Based on our findings, recommendations for the care of FA patients with Afrikaner ancestry are made, including renal ultrasound evaluation at diagnosis and hearing screening.

BACKGROUND. Fukutin-related protein (FKRP) muscular dystrophy is an autosomal recessive disorder caused by mutations in the FKRP gene. The condition is often misdiagnosed as a dystrophinopathy. A previously unreported mutation, c.1100T>C in exon 4 of FKRP, had been identified in homozygous form in two white South African (SA) Afrikaner patients clinically diagnosed with a dystrophinopathy. Objectives. To investigate whether the c.1100T>C mutation and the common European FKRP mutation c.826C>A are present in other patients of Afrikaner origin with suspected dystrophinopathy, and whether a founder haplotype exists. METHODS. The c.1100T>C mutation was initially tested for using an amplification refractory mutation system technique in 45 white SA Afrikaner patients who had tested negative using multiplex ligation probe amplification screening for exonic deletions/duplications in the dystrophin gene. Sequencing analysis was used to confirm the c.1100T>C mutation and screen for the c.826C>A mutation. Two cohorts (each numbering 100) of Afrikaans and other white controls were screened for the c.1100T>C and c.826C>A mutations, respectively. RESULTS. Of the 45 patients, 8 patients (17.8%) were homozygous for c.1100T>C, 2 (4.4%) were compound heterozygotes for c.1100T>C and c.826C>A, and 1(2.2%) was heterozygous for c.1100T>C with a second unidentified mutation. The c.1100T>C mutation was found in 1/100 controls, but no heterozygotes for the c.826C>A mutation were identified. Linked marker analysis for c.1100T>C showed a common haplotype, suggesting a probable founder mutation in the SA Afrikaner population. CONCLUSION. FKRP mutations may be relatively common in Afrikaners, and screening should be considered in patients who have a suggestive phenotype and test negative for a dystrophinopathy. This test will be useful for offering diagnostic, carrier and prenatal testing for affected individuals and their families. As FKRP muscular dystrophy is autosomal recessive in inheritance, the implications of a positive diagnosis in a family differ significantly from those of an X-linked dystrophinopathy.

BACKGROUND: Germline pathogenic mutations in cancer susceptibility genes result in inherited cancer syndromes. In the Afrikaner population of South Africa (SA), three founder mutations in the BRCA genes that lead to hereditary breast and ovarian cancer syndrome (HBOCS) have been identified. OBJECTIVES: To investigate the uptake and type of molecular testing performed on patients for HBOCS, to determine the prevalence of the three Afrikaner founder BRCA mutations as well as non-founder BRCA mutations in the study population, and to analyse the utility of two mutation prediction models (Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA) and Manchester scoring method) in assisting with the decision for the most cost-effective testing option. METHODS: A retrospective file review was performed on counsellees of self-reported Afrikaner ancestry from Johannesburg, SA (2001 -2014), with a personal or family history of breast and/or ovarian cancer. Demographic and family history information was recorded and Manchester and BOADICEA scores were calculated for each patient. RESULTS: Of 86 unrelated counsellees whose files were reviewed, 54 (62.8%) underwent BRCA genetic testing; 18 (33.3%) tested positive for a mutation, and 14 of these (77.8%) for an Afrikaner founder mutation. Twelve counsellees had the BRCA2 c.7934delG mutation. Four non-founder mutations were identified. BOADICEA scores were significantly higher in counsellees who tested positive for a mutation than in those who tested negative. CONCLUSIONS: Founder mutation testing should be performed as a first-line option. BOADICEA is very useful in identifying counsellees at high risk for a BRCA mutation and also assists with the decision to pursue further testing following a negative founder mutation result. These findings assist in guiding an informed genetic counselling service for at-risk individuals with an Afrikaner background.

BACKGROUND: In families with hereditary cancer, at-risk individuals can benefit from genetic counselling and testing. General practitioners (GPs) are ideally placed to identify such families and refer them appropriately. OBJECTIVE: To assess the practices, knowledge and attitudes of GPs regarding common hereditary cancers. METHODS: An exploratory research design was used. An existing questionnaire was adapted, piloted and mailed to 196 GPs in Johannesburg, South Africa. The 61 GPs (31.1%) who completed and returned the questionnaire constituted the final sample. Data were analysed using descriptive statistics. RESULTS: The GPs obtained some information on cancer family history from their patients, but not enough to assess the risks. Altogether 22 (36.1%) of the GPs referred patients to appropriate facilities for assessment and testing, while 32 (52.5%) were aware of genetic testing services. Most (38/61, 62.3%) were not familiar with the genetic counselling facilities available, but they felt patients should have counselling before testing. Less than half knew about possible paternal inheritance, or the low rate of hereditary mutations and their penetrance. Overall, the majority of GPs (53/61, 86.9%) were interested in learning more about cancer genetics and available services, and they expected to play an increasing role in the field in the future. CONCLUSIONS: Many of the GPs in this study had limited knowledge about inherited cancers, cancer risk management and genetic services. Appropriate education needs to be increased so that they are better equipped to identify and refer families at risk.