Work and humanization in health: experiences within SUS / Trabajo y humanización en la salud: experiencias con el SUS / Trabalho e humanização em saúde: experiências com o SUS

Abstract This paper describes experiences in Brazilian public health during the worst health crisis in Brazilian history, due to the threats of COVID-19. It highlights the work in health in its multiple dimensions and nuances, emphasizing the SUS Humanization Policy (PNH) which recognizes the unfavorable and oppressive conditions in health work. It rejects both the victimized or passive positions workers and managers sometimes take on one hand and the idealization of solutions that stem from outside workers' context or those which are hetero determined, on the other. The paper describes PNH's tools as strategies for workers' collectives to increase their analysis and intervention capacities, thus engaging in new ways of organizing and reinventing work.

Resumen Este artículo describe las experiencias en la salud pública brasileña durante la peor crisis sanitaria de la historia de Brasil, debido a las amenazas del COVID-19. Destaca el trabajo en salud en sus múltiples dimensiones y matices. Destaca el trabajo en salud en sus múltiples dimensiones y matices, enfatizando la Política de Humanización del SUS (PNH) que reconoce las condiciones desfavorables y opresivas del trabajo en salud. Rechaza, por un lado, las posiciones victimizadas o pasivas que a veces asumen los trabajadores y gestores y, por otro, la idealización de soluciones que provienen de fuera del contexto de los trabajadores o que están heterodeterminadas. El documento describe las herramientas de la PNH como estrategias para que los colectivos de trabajadores aumenten sus capacidades de análisis e intervención, participando así en nuevas formas de organizar y reinventar el trabajo.

Resumo Este estudo descreve experiências na saúde pública brasileira. Foi elaborado durante a pior crise de saúde da história brasileira, devido às ameaças da COVID-19. Destacamos o trabalho em saúde dentro das suas múltiplas dimensões e nuances, enfatizando a Política de Humanização do SUS (PNH) que visa reconhecer condições desfavoráveis e opressivas no trabalho de saúde e rejeitar tanto os trabalhadores e gestores vitimizados ou passivos, por vezes devido ao seu trabalho diário, as soluções decorrentes do contexto externo dos trabalhadores e as mudanças heterodeterminadas. Descrevemos os instrumentos da política de humanização do SUS como estratégias para os colectivos aumentarem as suas capacidades de análise e intervenção, engajando-se assim em novas formas de organização e reinvenção do trabalho.

Diagnóstico por citometría de flujo de la hemoglobinuria paroxística nocturna / Diagnosis of paroxysmal nocturnal hemoglobinuria by flow cytometry

Introducción: La hemoglobinuria paroxística (HPN) nocturna es una enfermedad clonal, adquirida y no maligna de la célula madre hematopoyética. En este padecimiento se encuentra afectado el anclaje a la membrana celular de moléculas como el CD55 y CD59, fundamentales en la regulación de la lisis mediada por el complemento. Por su elevada especificidad y sensibilidad, la citometría de flujo multiparamétrica (CFM) es el método de elección para el diagnóstico de esta enfermedad. Objetivo: Establecer un algoritmo diagnóstico de la HPN por CMF. Métodos: Se analizó una muestra de sangre periférica para CFM de un paciente con sospecha de HPN. El inmunofenotipaje celular se realizó con un panel de anticuerpos monoclonales dirigidos contra los antígenos que se expresan en la membrana citoplasmática mediante su anclaje al glicosilfosfatidilinositol. Las muestras se leyeron en un citómetro GALLIOS, Beckman Coulter y los datos obtenidos se analizaron con el empleo del programa informático Kaluza. Resultados: Se identificaron cuatro clones HPN. En los granulocitos se observó un clon HPN de aproximadamente 90 por ciento, con deficiencia en la expresión de CD16, CD24, CD55 y CD59. En los monocitos se observaron dos clones: (1) clon CD14_CD59_ y (2) clon CD14_CD59+ con tamaños clonales de 59,77 por ciento y 19,45 por ciento, respectivamente. En los eritrocitos se identificó un clon de 19,98 por ciento y de determinó el grado de afectación. Conclusiones: El algoritmo de análisis propuesto permite identificar las poblaciones celulares con clones HPN. Además, dichos clones pueden ser cuantificados en cuanto a tamaño clonal y expresividad de los antígenos dependientes de anclaje a glicosilfosfatidilinositol. Con la CFM se logra determinar con elevada sensibilidad el grado de afectación de los eritrocitos en la expresión de CD59 como medida directa de la susceptibilidad que experimentan a la lisis por el complemento(AU)

Introduction: The paroxysmal nocturnal hemoglobinuria (PNH) is a clonal, acquired disease and not malignant hematopoietic stem cell. In this condition, the anchor to the cell membrane of molecules such as the CD55 and CD59 is affected, This antigens are fundamental in the regulation of the complement-mediated lysis. By its high specificity and sensitivity multiparametric flow cytometry (MFC) is the goal standard for the diagnosis of this disease. Objective: To establish a diagnosis of PNH by MFC algorithm. Methods: A sample of peripheral blood of a patient with suspicion of PNH was analyzed by MFC. The cell immunophenotyping was carried out using a panel of monoclonal antibodies directed against antigens that are expressed in the cytoplasmic membrane through its the glycosylphosphatidylinositol anchor. The samples were read in a Cytometer GALLIOS, Beckman Coulter and the data obtained were analyzed with the use of the Kaluza software. Results: We identified four clones HPN. A HPN clone of approximately 90 percent, was observed in granulocytes with deficiency in the expression of CD16, CD24, CD55, CD59. In the monocytes were two clones: (1) CD14-CD59- clone and (2) CD14-CD59 + clone, with size clone of 59.77 percent and 19.45 percent, respectively. A clone of 19.98 percent was identified in erythrocytes and determined the degree of involvement of the same. Conclusions: The proposed analysis algorithm allows to identify cellular populations with clones PNH. In addition, these clones can be quantified in terms of size clonal and expressiveness of anchor to glycosylphosphatidylinositol antigen dependent. With the MFC is achieved with high sensitivity to determine the degree of involvement of the erythrocytes in the expression of CD59 as a direct measure of susceptibility undergoing lysis by complement(AU)

Predictive Factors of Mortality in Population of Patients with Paroxysmal Nocturnal Hemoglobinuria (PNH): Results from a Korean PNH Registry

Paroxysmal nocturnal hemoglobinuria (PNH) is a progressive, systemic, life-threatening disease, characterized by chronic uncontrolled complement activation. A retrospective analysis of 301 Korean PNH patients who had not received eculizumab was performed to systematically identify the clinical symptoms and signs predictive of mortality. PNH patients with hemolysis (lactate dehydrogenase [LDH] > or = 1.5 x the upper limit of normal [ULN]) have a 4.8-fold higher mortality rate compared with the age- and sex-matched general population (P < 0.001). In contrast, patients with LDH < 1.5 x ULN have a similar mortality rate as the general population (P = 0.824). Thromboembolism (TE) (odds ratio [OR] 7.11; 95% confidence interval [CI] (3.052-16.562), renal impairment (OR, 2.953; 95% CI, 1.116-7.818) and PNH-cytopenia (OR, 2.547; 95% CI, 1.159-5.597) are independent risk factors for mortality, with mortality rates 14-fold (P < 0.001), 8-fold (P < 0.001), and 6.2-fold (P < 0.001) greater than that of the age- and sex-matched general population, respectively. The combination of hemolysis and 1 or more of the clinical symptoms such as abdominal pain, chest pain, or dyspnea, resulted in a much greater increased mortality rate when compared with patients with just the individual symptom alone or just hemolysis. Early identification of risk factors related to mortality is crucial for the management of PNH. This trial was registered at www.clinicaltrials.gov as NCT01224483.

Two Cases of Acute Renal Failure Complicating Paroxysmal Nocturnal Hemoglobinuria in Children

Paroxysmal nocturnal hemoglobinuria(PNH) is an acquired hematologic disorder characterized by intravascular hemolysis, nocturnal hemoglobinuria, thrombotic events and bone marrow failure. It rarely occurs in children and can be complicated by acute renal failure(ARF). Here, we present two cases of ARF complicating PNH which has not been reported yet in Korean children. We suggest that PNH should be considered in differential diagnosis of ARF in children associated with intravascular hemolysis.

Estudio ultraestructural de las plaquetas de pacientes con hemoglobinuria paroxística nocturna / Ultrastructural study of platelets patients with paroxysmal nocturnal hemoglobinuria

Introduction. Paroxysmal nocturnal hemoglobinuria (PNH) is a hemolytic anemia characterized by intravascular hemolysis, cytopenias and venous thrombosis. Previous studies in patients with PNH have shown platelet abnormalities; however, their association with the clinical development of the sickness has not still been determined. Material and methods. In this study, we compared the morphology and distribution pattern of actin, myosin, tubulin and p-selectin in resting and activated platelets from 22 PNH patients and healthy donors by transmission electron microscopy and immunofluorescence. Results. The PNH platelet ultrastructure of resting and activated with different agonists (ADP, collagen and thrombin) showed morphological changes which suggested the presence of circulating platelets. The developed structures during the adhesion process (filopodia and lamellipodia formation), as well as the pattern distribution of actin, myosin, tubulin and p-selectin in PNH platelets were not modified in relation to control platelets. Conclusion. Morphological changes in resting platelets were related with p-selectin expression suggesting its determination as thrombosis indicator.

Introducción. La hemoglobinuria paroxística nocturna (HPN) es una anemia hemolítica caracterizada por hemolisis intravascular, citopenias y trombosis venosa. Estudios previos en pacientes con HPN han revelado anormalidades plaquetarias; sin embargo, no se ha determinado su asociación con el desarrollo clínico de la enfermedad. Material y métodos. En el presente estudio se comparó la morfología y el patrón de distribución de actina, miosina, tubulina y P-selectina en plaquetas en reposo y activadas provenientes de 22 pacientes con HPN y de individuos sanos por microscopía electrónica de transmisión e inmunoñuorescencia. Resultados. La ultraestructura de las plaquetas de individuos con HPN en reposo y activadas en suspensión con diferentes agonistas (ADP, colágena y trombina) mostró cambios morfológicos que sugirieron la presencia de plaquetas activadas circulantes. Las estructuras desarrolladas durante el proceso de adhesión (formación de filopodios, lamelipodios), así como el patrón de distribución de actina, miosina, tubulina y P-selectina, no se modificaron en las plaquetas de los pacientes con HPN en relación con el testigo. Conclusión. Los cambios morfológicos en plaquetas en reposo fueron relacionados con la expresión de P-selectina, por lo que se sugiere su determinación como un parámetro indicativo de un posible riesgo trombótico.

Flaer detection for paroxysmal nocturnal hemoglobinuria / 基础医学与临床

Objective To establish a new method using Flaer for detecting abnormal clone in patients with paroxysmal nocturnal hemoglobinuria(PNH).Methods Peripheral WBC and bone marrow mononuclear cells from patients with PNH and normal controls were isolated and stained with flaer,CD55 PE,CD59 FITC and CD34 PE.Results PNH cells can easily be distinguished by flare.Compared with CD55,CD59,Flaer showed advantage in detecting minor clone of PNH,either in peripheral blood or in CD34+ bone marrow cells.Conclusion Flaer can be a new,simple and effective method to detect PNH clone,and especially when the PNH clone is small.

Diagnosis of Paroxysmal Nocturnal Hemoglobinuria (PNH) by the REDQUANT and the CELLQUANT kits / 대한진단검사의학회지

BACKGROUND: Paroximal nocturnal hemoglobinuria (PNH) is a disorder of the pluripotent stem cells resulting in a deficient expression of membrane-bound GPI-anchored proteins in different cell types. We evaluated REDQUANT and CELLQUANT kits (Biocytex, Marseille, France) for PNH test. METHODS: Seventy patients with peripheral blood cytopenia and 16 healthy controls were studied. RBCs and granulocytes were tested for CD55 and CD59 expression using the REDQUANT and CELLQUANT kits and an Epics XL flow cytometer. According to the manufacturer's instruction, results were interpreted abnormal when more than 3% of cells were deficient in the expression of CD55 or CD59, and a test was considered positive for PNH if three of the four markers tested were abnormal. RESULTS: The percentage of CD55/CD59 deficient RBCs and granulocytes was 0.3/3.1 and 3.5/ 10.0, respectively, in the patient group, and 0.1/1.0 and 0.3/9.7, respectively, in the control group. PNH was diagnosed in three patients who had a deficiency in the expression of three or four antigens; two other patients showed a deficiency in two antigens. There were many who had CD59 deficiency only: on granulocytes in 30 patients and 11 controls, and on RBCs in 6 patients and 2 controls. One patient had CD55 deficient granulocytes. CONCLUSIONS: The REDQUANT/CELLQUANT kit is a standardized method and does not require normal samples as the control, but one should be cautious in interpreting the results showing CD59 expression on granulocytes.

The study of CD55,CD59,CD34 on the early diagnosis of AA-PNH / 中国免疫学杂志

Objective:To study the significance of CD55,CD59 and CD34 in the early diagnosis of aplastic anemia-paroxysmal nocturnal hemoglobi nuria(AA-PNH),and to search for a sensitive marker of the early diagnosis,so as to achieve the objective of early finding,early diagnosis and early treatment.Methods:CD55,CD59 and CD34 in AA-PNH patients were detected by Flow cytometry,the relationship among CD55,CD59 and CD34 in AA-PNH patients,PNH,AA patients and control group were studied to find out their statistic relevance.Results:The levels of CD55,CD59 and CD34 of PNH and AA-PNH were significantly lower than AA group and any other group and control group,the markers were positively correlated with hemolysis degree and were earlier than other markers of hemolysis.Conclusion:CD55,CD59 and CD34 antigens may act as the most sensitive marker of early diagnosis in PNH and AA-PNH syndrome,and have a close correlation with prognosis.

Mutation Analysis of PIG-A Gene in Korean Patients with Paroxysmal Nocturnal Hemoglobinuria / 대한혈액학회지

BACKGROUND: Paroxysmal nocturnal hemoglobinuria (PNH) is caused by deficient biosynthesis of the glycosylphosphatidylinositol (GPI) anchor in hemopoietic stem cells. Mutation of phosphatidyl inositol glycan class A (PIG-A) gene, an X-linked gene that participates in the first step of GPI anchor biosynthesis, is responsible for PNH. Characteristics of somatic mutation of PIG-A gene in the Korean patients with PNH and their relationships to clinical characteristics were analyzed. METHODS: Twenty five patients with PNH and a donor of bone marrow transplantation were selected. Ham tests, sucrose hemolysis tests and CD59 expressions of erythrocytes and granulocytes were performed to confirm diagnosis. Dideoxy fingerprinting (ddF) was used to screen mutations, and direct sequencing of DNA was performed to characterize the mutations. RESULTS: The mutations of PIG-A gene were found in twelve cases and ten of them were novel mutations. There were five deletions, six substitutions and a insertion. Therewere six premature terminations, three abnormal splicings, a missense and two nonsense mutations. There were six point mutations and six frameshift mutations. Five cases of hypoplastic PNH showed mutations only in exons, but three in seven cases of hemolytic PNH showed mutations in introns. Two cases with symptoms of venous thrombosis showed mutations in exon 3. CONCLUSION: There were ten novel mutations among twelve mutations in the Korean patients with PNH and characteristics of the mutations were variable without any remarkable hot spot in sites and types. The characteristics of mutation were not correlated with the results of clinical courses of the patients with PNH.

CD59 Analysis and Screening of PIG-A Gene Mutation in Aplastic Anemia, Myelodysplastic Syndrome and Paroxysmal Nocturnal Hemoglobinuria / 대한임상병리학회지

BACKGROUND: Aplastic anemia(AA), myelodysplastic syndrome(MDS) and paroxysmal nocturnal hemoglobinuria(PNH) are hematopoietic stem cell disorders. To investigate the pathogenetic links, we performed CD59 analysis and screened PIG-A gene mutation in the patients with AA, MDS, and PNH developed from AA or MDS. METHODS: We analyzed the proportion of the patients with CD59-deficient cells by flow cytometry for CD59 in 42 patients with AA or MDS and eight patients with PNH developed from AA or MDS. The mutations of PIG-A gene were screened with dideoxy fingerprinting(ddF). RESULTS: In normal controls, the proportion of the RBCs normally expressing CD59 was 97.2+/-1.9% and that of the granulocytes was 98.4%+/-1.5%. In patients with AA or MDS, 9.5%(4/42) had CD59 deficiency on RBCs and 10.3%(3/29) on granulocytes. In patients whose CD59 on both RBCs and granulocytes were analyzed, 17.2%(5/29) showed reduced CD59 in at least one cell lineage. Screening test using ddF revealed abnormal band shifts in three patients with PNH developed from AA or MDS. CONCLUSION: We found the presence of PNH clones in the patients with AA or MDS. And it was indirectly confirmed by ddF that PNH arisen from AA or MDS is also associated with the mutations of PIG-A gene as classical PNH. CD59 analysis in AA or MDS will be helpful for the early diagnosis of PNH.

A Case of Coexistence with Myelodysplastic Syndrome and Paroxysmal Nocturnal Hemoglobinuria: Confirmed by Reticulocytes Survival Test and Glycosylphosphatidylinositol (GPI)-linked Protein Test / 대한혈액학회지

A patient presenting paroxysmal nocturnal hemoglobinuria (PNH) cloned cells in the course of myelodysplastic syndrome (MDS) with reticulocytosis is described. The bone marrow biopsy demonstrated erythroid hyperplasia and moderate dysplasia. Mild hemoglobinuria was detected but the Ham test was negative. The reticulocyte survival test revealed sustained survival curve indicating delayed reticulocyte maturation regarded as the characteristic of MDS cloned erythroid cells. The glycosylphosphatidylinositol-linked protein deficient neutrophils and erythrocytes population regarded as PNH clones were identified by flow cytometric analysis using monoclonal antibody. From these results, we concluded that MDS and PNH cloned cells were coexisited in this patient. In this patient, long-term follow-up observation could clarify whether MDS and PNH were arising from the same clone or from two distinct clones.