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National Institutes of Health Consensus Development Project on criteria for clinical trials in chronic graft-versus-host disease: I. Diagnosis and staging working group report. Biol Blood Marrow Transplant. Patients indicated that the workshop was what they had expected and that they were glad to have been able to contribute to this training session. In addition to time limitations to evaluate and complete the scoring forms of each patient, specific difficulties in determining the percentage of BSA associated with certain types of skin and mouth lesions were discussed, reviewed and reconciled during the training sessions that followed the practical evaluation session.

Specific areas of difficulties and need for clarification identified during the training session included: a determining the fraction of erythema in movable and non-movable sclerosis, Figure 1 ; b scoring all elements of cutaneous features i. Both the grip strength and the walk tests were thought to be important measures to evaluate functional performance of patients with chronic GvHD and feasible tests to be conducted in clinical trials.

Teaching points on Oral Medicine MEC during the training session was the basic evaluation of the mouth to score the four clinical signs of chronic GvHD including: hyperkeratotic plaques, ulcers, erythema and mucocele. Hyperkeratotic plaques, ulcers and erythema manifestations should be evaluated on the lips, labial mucosa, buccal mucosa, tongue and soft palate, while mucocele only on labial mucosa and soft palate.

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For the subjective evaluation of oral symptoms, complaints of dry mouth, altered taste, pain and tenderness with or without limitations in oral ingestion are considered. It is important to note that the definition of oral sensitivity is related to spicy food ingestion or use of toothpaste, therefore distinct from mouth pain, which is recorded separately in another scale. Our workshop was well received and viewed as an appropriate model to evaluate chronic GvHD using the NIH and other measurement tools and to train investigators interested in participating in clinical trials in Brazil.

Graft-versus-host disease: part II. Management of cutaneous graft-versus-host disease.

In this workshop, evaluators had difficulties in scoring the extent of involvement of certain types of skin manifestations. As reported by others, 12,15 variability in the chronic GvHD scoring were also noted using the NIH and other scoring measurement tools, but results of the inter and intra-evaluator variability improved with subsequent training. The time required for adequate evaluation and completion of various tools used to score chronic GvHD in the current workshop was greater than 20 minutes per patient.

However, time to evaluate and score patients with chronic GvHD may be shorter for physicians who follow their own patients and with increased experience in using the scoring tools.

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One objective evaluation missing in the current NIH and other available tools noticed by the dentist is the scoring of xerostomia and oral mucosa atrophy, resulting in a gap in the oral assessment of chronic GvHD that may underestimate the oral score. Difficulties in scoring certain types of skin manifestations were noted. For instance, evaluation of erythema in patients receiving PUVA could result in an overestimation of erythema not related to chronic GvHD.

The point was made that erythema caused by photochemotherapy such as PUVA 16,17 is usually diffuse, non-pruritic and limited to treatment-exposed areas that often resolves within 48 to 72 hours.

Another area of difficulty was in scoring poikiloderma atrophic with pigmentary skin changes using the Vienna Skin Scale. For example, a patient with hypo- and hyper-pigmentation and erythema without sclerosis would be scored as Grade 1 but as Grades if the poikiloderma is secondary to sclerosis movable or non-movable. Therefore, recognizing the diagnosis of chronic GvHD lesions is critical for adequately scoring the skin according to the Vienna Skin Scale.

Cutaneous Graft-Versus-Host Disease (Graft-Versus-Host Disease)

Another teaching point by the dermatologist MMS about the Vienna Skin Scale was on how to recognize skin lichen planus-like lesions and cutaneous sclerosis in hyperor hypo-pigmentation areas. Considering that hyper- and hypo-pigmentation are often associated with diagnostic cutaneous manifestations of chronic GvHD, such lesions should be scored in the Vienna Skin Scale as either Grade 2 lichen-planus like presentation or Grade 3 or Grade 4 if, respectively, movable or non-movable sclerosis is present.

Variability in the scoring of chronic GvHD represents a limitation of available tools with potential impact on the interpretation of results in multicenter clinical trials. Appropriate training of investigators is therefore necessary in the utilization of the scoring tool chosen for consistency of the evaluator, especially in studies aimed to evaluate the extent and types of skin involvement of chronic GvHD. This workshop was useful to clarify several questions related to the NIH and other evaluation tools that are used in studies of chronic GvHD.

The feasibility of this study motivated the GeDECH to put together a similar education workshop session during the annual meeting of the Brazilian Society of Bone Marrow Transplantation in August to expand the training of new investigators interested in participating in future GeDECH studies.

Chronic Graft Versus Host Disease : Interdisciplinary Management -

The second workshop had more than 30 participants from more than 8 institutions and was well received. The NIH chronic GvHD criteria for clinical diagnosis, staging and other proposed measures to evaluate treatment response in clinical trials represent an important first step towards the development of better treatment and to improve survival and quality of life of affected patients. We demonstrated the feasibility of conducting a workshop on the NIH chronic GvHD tools and other cutaneous measures as a model to evaluate and train Brazilian investigators participating in multicenter clinical trials.

Several areas of difficulties in the evaluation of patients with chronic GvHD according to the NIH and other tools were identified. Results of this workshop support the need of training investigators interested in participating in future chronic GvHD clinical trials and suggest the need for simplifying current tools to evaluate chronic GvHD especially regarding the cutaneous involvement measurements. Cutler C, Antin JH. Chronic graft-versus-host disease. Curr Opin Oncol.

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Biol Blood Marrow Transplant. Pavletic have been pioneers in the recognition of the multi-organ complexity of this disease and have gathered the input of a variety of subspecialist physicians for this book. This book fills the gap in practical literature on chronic GVHD, providing a comprehensive, up-to-date, and clinically relevant resource for anyone who deals with cancer patients post-transplant.

Voselsang and Steven Z. Pavletic, pioneers in the recognition of the multi-organ complexity of this disease, have included in the writing of this book a refreshing variety of subspecialists It is easy to predict that it will have [a] permanent place in medical history with [a] strong impact [on] future understanding of the disease. Help Centre.

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