Malignant Hyperthermia in Bariatric Surgery: A Case Study With Clinical, Pathophysiological, Biochemical and Biophysical Correlations.

Malignant hyperthermia (MH) is an acute pharmacogenetic disorder, which while uncommon is potentially fatal. MH is a calcium channelopathy of skeletal muscle in which a constant increase of intracytoplasmic Ca2+ concentration occurs causing a change in cellular metabolism. A hypermetabolic state develops when susceptible patients are exposed to halogenated volatile inhalational anesthetic agents and depolarizing muscle relaxants and/or extreme physical activity in hot environments. MH presents variable clinical expression. During an episode of MH, the patient may present clinical signs and laboratory findings including masseter muscle spasm, tachycardia, rise in end-tidal CO2 (EtCO2), tachypnea, hyperthermia, cyanosis, metabolic acidosis, rhabdomyolysis, hyperkalemia, myoglobinuria, hyperlactacidemia, and acute renal failure. The aim of this case report is to describe an episode of MH associated with the use of halogenated anesthetic during bariatric surgery. A 29-year-old Brazilian man was admitted to the hospital to undergo a bariatric surgery. The patient's relevant medical history included morbid obesity grade III, allergy to sulfa-based drugs and severe obstructive sleep apnea. Preoperative evaluations with cardiopulmonary exercise testing, echocardiogram and electrocardiogram showed no anatomical and functional changes of the patient's heart. Surgical procedures lasted for 4 h, without complications, but the evolution of the patient's condition indicated oliguria and acute breathing insufficiency. Five hours after the patient was placed under mechanical ventilation in the intensive care unit, he started to present clinical signs of hypermetabolic state, with tremors, excessive sweating, and rapid body temperature increases. In the postoperative period, the patient had hyperglycemia, hypocalcemia, hypernatremia, hyperkalemia, changes in creatine phosphokinase (CPK), aspartate transaminase (AST), alanine aminotransferase (ALT), urea and creatine concentrations, and metabolic and respiratory acidosis. Urinalysis showed traces of proteinuria, presence of ketones, leukocytes, red blood cells, and urobilinogen. In our case report, MH crisis was diagnosed late; the dantrolene was not administrated because it was not available and the patient died. This detailed case report of MH episode triggered by isoflurane anesthetic during bariatric surgery allowed us to describe the severity and lethality of this hypermetabolic syndrome. Dantrolene should be mandatory in all operating rooms. Knowledge of the symptoms, an early diagnosis and an adequate treatment can prevent the death of patients in MH crisis.

Secondary hemostasis studies of crude venom and isolated proteins from the snake Crotalus durissus terrificus.

Among the activities triggered by Crotalus durissus terrificus snake venom, coagulation is intriguing and contradictory since the venom contains both coagulant and anticoagulant precursor proteins. This work describes the in vitro effects of crude venom and purified proteins from snake Crotalus durissus terrificus as they affect coagulation factors of clotting pathways. Coagulant and/or anticoagulant activities of crude venom, and purified proteins were all analyzed directly in human plasma. Clots formed by crude venom and Gyroxin presented as flexible hyaline masses in punctiform distribution. Clot formation time evaluation of isolated proteins with PT and APTT assays made it possible to infer that these proteins interfere in all coagulation pathways. However, regarding ophidism by C. d. terrificus, Gyroxin acts directly, breaking down fibrinogen to fibrin and increasing the amount plasminogen activator, which results in the formation of thrombi. Crotoxin complex, Crotoxin A and Crotoxin B proteins can act in prothrombinase complex formation; Crotoxin B can inhibit prothrombinase complex formation by direct interaction with Factor Xa. Crotamine interacts with negatively charged regions of differing coagulation factors in all coagulation pathways, and possesses a whole set of activities causing dysfunction, activation and/or inhibition of natural anticoagulants and disturbing hemostasis.

Linear B-cell epitopes in BthTX-1, BthTX-II and BthA-1, phospholipase A2's from Bothrops jararacussu snake venom, recognized by therapeutically neutralizing commercial horse antivenom.

The benefits from treatment with antivenom sera are indubitable. However, the mechanism for toxin neutralization has not been completely elucidated. A mixture of anti-bothropic and anti-crotalic horse antivenom has been reported to be more effective in neutralizing the effects of Bothrops jararacussu snake venom than anti-bothropic antivenom alone. This study determined which regions in the three PLA2s from B. jararacussu snake venom are bound by antibodies in tetravalent anti-bothropic and monovalent anti-crotalic commercial horse antivenom. Mapping experiments of BthTX-I, BthTX-II and BthA-I using two small libraries of 69 peptides each revealed six major IgG-binding epitopes that were recognized by both anti-bothropic and anti-crotalic horse antivenom. Two epitopes in BthTX-I were only recognized by the anti-bothropic horse antivenom, while anti-crotalic horse antivenom recognized four unique epitopes across the three PLA2s. Our studies suggest that the harmful activities of the PLA2s present in the venom of B. jararacussu are neutralized by the combinatorial treatment with both antivenom sera through their complementary binding sites, which provides a wide coverage on the PLA2s. This is the first peptide microarray of PLA2s from B. jararacussu snake venom to survey the performance of commercial horse antiophidic antivenom. Regions recognized by the protective antivenom sera are prime candidates for improved venom cocktails or a chimeric protein encoding the multiple epitopes to immunize animals as well as for designing future synthetic vaccines.

Structural and phylogenetic studies with MjTX-I reveal a multi-oligomeric toxin--a novel feature in Lys49-PLA2s protein class.

The mortality caused by snakebites is more damaging than many tropical diseases, such as dengue haemorrhagic fever, cholera, leishmaniasis, schistosomiasis and Chagas disease. For this reason, snakebite envenoming adversely affects health services of tropical and subtropical countries and is recognized as a neglected disease by the World Health Organization. One of the main components of snake venoms is the Lys49-phospholipases A2, which is catalytically inactive but possesses other toxic and pharmacological activities. Preliminary studies with MjTX-I from Bothrops moojeni snake venom revealed intriguing new structural and functional characteristics compared to other bothropic Lys49-PLA2s. We present in this article a comprehensive study with MjTX-I using several techniques, including crystallography, small angle X-ray scattering, analytical size-exclusion chromatography, dynamic light scattering, myographic studies, bioinformatics and molecular phylogenetic analyses.Based in all these experiments we demonstrated that MjTX-I is probably a unique Lys49-PLA2, which may adopt different oligomeric forms depending on the physical-chemical environment. Furthermore, we showed that its myotoxic activity is dramatically low compared to other Lys49-PLA2s, probably due to the novel oligomeric conformations and important mutations in the C-terminal region of the protein. The phylogenetic analysis also showed that this toxin is clearly distinct from other bothropic Lys49-PLA2s, in conformity with the peculiar oligomeric characteristics of MjTX-I and possible emergence of new functionalities in response to environmental changes and adaptation to new preys.

Isolation and expression of a hypotensive and anti-platelet acidic phospholipase A2 from Bothrops moojeni snake venom.

Phospholipases A(2) are important components of snake venoms, the basic isoforms have been more extensively studied than the acidic groups, maybe due to their higher toxicity. Trying to better understand the role of the acidic isoforms on the envenomation process, an acidic phospholipase A(2) was purified from Bothrops moojeni snake venom through two chromatographic steps (BmooPLA(2)). The enzyme showed a relative molecular mass of 13,601Da, pI 5.2, high phospholipase activity, bactericidal effect, moderate cytotoxic activity and was able to inhibit platelet aggregation. Moreover, BmooPLA(2) induced moderate in vivo edema and hypotensive effect. The 414bp cDNA encoding the BmooPLA(2) was cloned and expressed in Escherichia coli. The recombinant BmooPLA(2) showed phospholipase and inhibitory activities on platelet aggregation similar to those of the native protein. A comparative study between BmooPLA(2), the acidic (BthA-I) and basic (BthTX-II) PLA(2) from B. jararacussu venom showed that the effects of BmooPLA(2) and BthA-I-PLA(2) are similar. BmooPLA(2) is the first isolated and characterized non-myotoxic PLA(2) from B. moojeni snake venom. The recombinant PLA(2) can substitute the native toxin in studies aiming its biotechnological application in order to help the preservation of this endangered species. These data along with the preliminary structural studies here reported will provide a better understanding of this important class of proteins.

Crystallization and preliminary X-ray diffraction studies of BmooPLA2-I, a platelet-aggregation inhibitor and hypotensive phospholipase A2 from Bothrops moojeni venom.

Phospholipases A(2) (PLA(2)s) are enzymes that cause the liberation of fatty acids and lysophospholipids by the hydrolysis of membrane phospholipids. In addition to their catalytic action, a wide variety of pharmacological activities have been described for snake-venom PLA(2)s. BmooPLA(2)-I is an acidic, nontoxic and catalytic PLA(2) isolated from Bothrops moojeni snake venom which exhibits an inhibitory effect on platelet aggregation, an immediate decrease in blood pressure, inducing oedema at a low concentration, and an effective bactericidal effect. BmooPLA(2)-I has been crystallized and X-ray diffraction data have been collected to 1.6 Šresolution using a synchrotron-radiation source. The crystals belonged to space group C222(1), with unit-cell parameters a = 39.7, b = 53.2, c = 89.2 Å. The molecular-replacement solution of BmooPLA(2)-I indicated a monomeric conformation, which is in agreement with nondenaturing electrophoresis and dynamic light-scattering experiments. A comparative study of this enzyme with the acidic PLA(2) from B. jararacussu (BthA-I) and other toxic and nontoxic PLA(2)s may provide important insights into the functional aspects of this class of proteins.

Molecular characterization of an acidic phospholipase A(2) from Bothrops pirajai snake venom: synthetic C-terminal peptide identifies its antiplatelet region.

This paper describes a biochemical and pharmacological characterization of BpirPLA(2)-I, the first acidic Asp49-PLA(2) isolated from Bothrops pirajai. BpirPLA(2)-I caused hypotension in vivo, presented phospholipolytic activity upon artificial substrates and inhibitory effects on platelet aggregation in vitro. Moreover, a synthetic peptide of BpirPLA(2)-I, comprising residues of the C-terminal region, reproduced the antiplatelet activity of the intact protein. A cDNA fragment of 366 bp encompassing the mature form of BpirPLA(2)-I was cloned by reverse transcriptase-PCR of B. pirajai venom gland total RNA. A Bayesian phylogenetic analysis indicated that BpirPLA(2)-I forms a clade with other acid Asp49-PLA(2) enzymes from the Bothrops genus, which are characterized by the high catalytic activity associated with anticoagulant or hypotensive activity or both. Comparison of the electrostatic potential (EP) on the molecular surfaces calculated from a BpirPLA(2)-I homology model and from the crystallographic models of a group of close homologues revealed that the greatest number of charge inversions occurred on the face opposite to the active site entrance, particularly in the Ca(2+) ion binding loop. This observation suggests a possible relationship between the basic or acid character of PLA(2) enzymes and the functionality of the Ca(2+) ion binding loop.

Enzymatic and structural characterization of a basic phospholipase A(2) from the sea anemone Condylactis gigantea.

This work aimed at the isolation and structural/functional characterization of a phospholipase A(2) (CgPLA(2)) from the extract of the anemone Condylactis gigantea. CgPLA(2) was isolated with a high purity level through three chromatographic steps, showing pI 8.6 and molecular weights of 14,500 and 29,000 for the monomer and dimer, respectively. CgPLA(2) showed a high catalytic activity upon fluorescent phospholipids inducing no direct hemolytic activity. This enzyme, which is Ca(2+)-dependent, showed a lower stability against temperature and pH variations when compared with snake venom enzymes. The enzymatic activity was significantly reduced or completely abolished after chemical modification of CgPLA(2) with BPB. Its cDNA was then obtained, with 357 base pairs which codified for a mature protein of 119 amino acid residues. A comparative analysis of the primary structure of CgPLA(2) revealed 84%, 61%, 43% and 42% similarity to the PLA(2)s from Adamsia carciniopados, Nematostella vectensis, Vipera russelli russelli and Bothrops jararacussu, respectively.

Comparison between apo and complexed structures of bothropstoxin-I reveals the role of Lys122 and Ca(2+)-binding loop region for the catalytically inactive Lys49-PLA(2)s.

Phospholipases A(2) (Asp49-PLA(2)s) are enzymes responsible for cellular membrane disruption through Ca(2+)-dependent hydrolysis of phospholipids. A class of these proteins (Lys49-PLA(2)s) does not show catalytic activity but can exert a pronounced local myotoxic effect that is not neutralized by serum therapy. In this work, we present five structures of Lys49-PLA(2)s from snakes of the Bothrops genus in apo form, complexed with PEG molecules and chemically modified by p-bromofenacil bromide (BPB), a classic inhibitor of PLA(2). We present herein an extensive structural analysis including: (i) the function of hydrophobic long-chain molecules as Lys49-PLA(2)s inhibitors, (ii) the role of Lys122, previously indicated as being responsible for Lys49-PLA(2)s catalytic inactivity and, (iii) a structural comparison of the Ca(2+)-binding loop region between Lys49 and Asp49-PLA(2)s. The Lys122 analysis of 30 different monomers for apo and complexed Lys49-PLA(2)s structures shows that this residue is very flexible and may bind to different carboxyl groups giving stability to the crystal structures. The structural comparisons of the Ca(2+)-binding loop region between Lys49 and Asp49-PLA(2)s reveal the importance of the Tyr28 residue conservation in Asp49-PLA(2)s to the integrity of this loop. The Tyr28 residue stabilizes this region by an interaction with Gly35 residue. In Lys49-PLA(2)s and low-catalytic Asp49-PLA(2)s this interaction does not occur, preventing the binding of Ca(2+).

Crystal structure of a phospholipase A(2) homolog complexed with p-bromophenacyl bromide reveals important structural changes associated with the inhibition of myotoxic activity.

For the first time, the structure of a catalytic inactive phospholipase A(2) homolog (Lys49-PLA(2)s) complexed with p-bromophenacyl bromide (BPB) has been solved by X-ray crystallography. Lys49-PLA(2)s are among the main components of Viperidae snake venoms, causing myonecrosis and other actions despite their catalytic inactivity. BPB, a classic inhibitor of catalytic-active PLA(2)s, has been used since the 1970s because it binds specifically the His48 residue of the catalytic site. Curiously, when Lys49-PLA(2) is chemically modified by BPB, it causes a partial inhibition of the myotoxic function which is associated with the C-terminus and not with the catalytic site. The structure of PrTX-I complexed to BPB revealed unambiguously that the inhibitor binds covalently to His48, causing a distortion of the Ca(2)(+)-binding loop region and C-terminus rearrangement in one of its monomers. The comparison between the apo and BPB-complexed PrTX-I structures showed an increased symmetry between the two monomers with the formation of an interchain hydrogen bond between Tyr119 residues. PrTX-I undergoes tertiary and quaternary structural changes when complexed to BPB which could be related to reduction of myotoxicity and other toxic activities. We also proposed a novel myotoxic inhibition hypothesis integrating "myotoxic" and "active" sites for bothropic Lys49-PLA(2)s.

Insights into the role of oligomeric state on the biological activities of crotoxin: crystal structure of a tetrameric phospholipase A2 formed by two isoforms of crotoxin B from Crotalus durissus terrificus venom.

Crotoxin B (CB or Cdt PLA(2)) is a basic Asp49-PLA(2) found in the venom of Crotalus durissus terrificus and it is one of the subunits that constitute the crotoxin (Cro). This heterodimeric toxin, main component of the C. d. terrificus venom, is completed by an acidic, nontoxic, and nonenzymatic component (crotoxin A, CA or crotapotin), and it is related to important envenomation effects such as neurological disorders, myotoxicity, and renal failure. Although Cro has been crystallized since 1938, no crystal structure of this toxin or its subunits is currently available. In this work, the authors present the crystal structure of a novel tetrameric complex formed by two dimers of crotoxin B isoforms (CB1 and CB2). The results suggest that these assemblies are stable in solution and show that Ser1 and Glu92 of CB1 and CB2, respectively, play an important role in the oligomerization. The tetrameric and dimeric conformations resulting from the association of the isoforms may increase the neurotoxicity of the toxin CB by the creation of new binding sites, which could improve the affinity of the molecular complexes to the presynaptic membrane.

Crystal structure of a myotoxic Asp49-phospholipase A2 with low catalytic activity: Insights into Ca2+-independent catalytic mechanism.

A myotoxic Asp49-phospholipase A2 (Asp49-PLA2) with low catalytic activity (BthTX-II from Bothrops jararacussu venom) was crystallized and the molecular-replacement solution has been obtained with a dimer in the asymmetric unit. The quaternary structure of BthTX-II resembles the myotoxic Asp49-PLA2 PrTX-III (piratoxin III from B. pirajai venom) and all non-catalytic and myotoxic dimeric Lys49-PLA2S. Despite of this, BthTX-II is different from the highly catalytic and non-myotoxic BthA-I (acidic PLA2 from B. jararacussu) and other Asp49-PLA2S. BthTX-II structure showed a severe distortion of calcium-binding loop leading to displacement of the C-terminal region. Tyr28 side chain, present in this region, is in an opposite position in relation to the same residue in the catalytic activity Asp49-PLA2S, making a hydrogen bond with the atom O delta 2 of the catalytically active Asp49, which should coordinate the calcium. This high distortion may also be confirmed by the inability of BthTX-II to bind Na+ ions at the Ca2+-binding loop, despite of the crystallization to have occurred in the presence of this ion. In contrast, other Asp49-PLA2S which are able to bind Ca2+ ions are also able to bind Na+ ions at this loop. The comparison with other catalytic, non-catalytic and inhibited PLA2S indicates that the BthTX-II is not able to bind calcium ions; consequently, we suggest that its low catalytic function is based on an alternative way compared with other PLA2S.

Preliminary X-ray crystallographic studies of a Lys49-phospholipase A2 homologue from Bothrops pirajai venom complexed with p-bromo-phenacyl bromide and alpha-tocopherol inhibitors.

PrTX-I, a non-catalytic and myotoxic Lys49-PLA(2) from Bothrops pirajai venom has been crystallized alone and in complex with bromophenacyl bromide (BPB), alpha tocopherol and alpha tocopherol acetate inhibitors. These crystals have shown to diffract X-rays between 2.34 and 1.65 A resolution. All complexes crystals are isomorphous and belong to the space group P2(1) whereas native PrTX-I crystals belong to the P3(1)21.

Crystallization and preliminary X-ray diffraction studies of two myotoxic Lys49-phospholipases A2 complexed with alpha-tocopherol.

BnSP-7 and BnSP-6, two Lys49-phospholipase A2 isolated from Bothrops neuwiedi pauloensis snake venom, were co-crystallized with alpha-tocopherol and X-ray diffraction data were collected for both complexes (2.2 and 2.6 A). A new "alternative" quaternary conformation for these two complexes compared with all other dimeric Lys49-PLA2 has been observed.

Hemoglobinas AS/alfa talassemia: importância diagnóstica / Hemoglobins AS/alpha thalassemia: diagnostic importance

Portadores de traço falciforme (hemoglobina AS) associados a talassemia alfa apresentam alterações na morfologia dos eritrócitos, normalmente ausentes nos heterozigotos para esta variante de hemoglobina. A interação entre hemoglobina S e talassemia alfa tem sido descrita como um dos fatores responsáveis pela melhora no quadro clínico de portadores homozigotos de hemoglobina S (anemia falciforme), diminuindo os episódios de crises de falcização. Os mecanismos genéticos desta influência são avaliados em análises moleculares dos genes da globina humana. Com o objetivo de verificar a presença de talassemia alfa em portadores de hemoglobina S em heterozigose, com presença de anemia, encaminhados ao Laboratório de Hemoglobinas do Departamento de Biologia da UNESP, de São José do Rio Preto, analisamos 1.002 amostras de sangue com traço falciforme, no período de 1990 a 1998. As amostras foram colhidas com EDTA como anticoagulante, após prévia autorização dos portadores. Para o diagnóstico laboratorial as amostras de sangue foram submetidas a procedimentos eletroforéticos em pH alcalino e ácido e pesquisa citológica de hemoglobina H. Os procedimentos eletroforéticos confirmaram a presença de hemoglobina AS. A pesquisa citológica evidenciou a presença de talassemia alfa. Deste total analisado, 16 (1,59 por cento) amostras de sangue apresentaram a associação entre hemoglobina AS e alfa talassemia, sendo que duas eram de indivíduos de uma mesma família. Os resultados obtidos nos direcionaram a sugerir aos laboratórios de rotina que realizem a pesquisa de alfa talassemia entre os portadores de hemoglobina AS, com presença de anemia, para verificar a interação com talassemia alfa, fornecendo assim aos portadores informação importante sobre seu perfil hematológico.

Sickle Cell disease is a generic term for a group ofgenetic disorders characterized by thepredominance of hemoglobin S. These disorders include Sickle Cell anemia, the Sickle Cell betaThalassemia syndromes, and Hemoglobinopathies in which hemoglobin S is in association withanother abnormal hemoglobin, such ashemoglobin S/C. The Sickle Cell trait (hemoglobin AS) associated with Alpha Thalassemia presentsalterations in the red blood cells morphology,usually absent in the heterozygous for thishemoglobin variant. ........... The genetic mechanisms of this influence are evaluated using molecular analyses of the human globin genes. With the objective ofverifying the presence of alpha Thalassemia inheterozygous of hemoglobin S, with anemia, sentto the Laboratory of Hemoglobins, Department ofBiology, UNESP, São José do Rio Preto, SP, weanalyzed 1002 blood samples with Sickle Cell trait, n the period from 1990 to 1998. The samples werepicked with EDTA 5% as anticoagulant, afterprevious authorization of the carriers.Appropriated counseling and managementrequires definitive diagnosis. For the laboratorialdiagnosis the blood samples were submitted toelectrophoretic procedures in alkaline and acidpH and cytological evaluation of hemoglobin H.The electrophoretic procedures confirmed thepresence of hemoglobin AS. The cytologicalevaluation evidenced the presence of alphaThalassemia. Of this total analyzed, 16(1,59%)blood samples presented the associationbetween hemoglobin AS and alphaThalassemia and two individuals belonged ofthe same family. Our results addressed us tosuggest to the routine laboratories, that isimportant to accomplish the research of alphaThalassemia among the Sickle Cell trait, withanemia, to verify the interaction with alphaThalassemia, supplying to the carriers aimportant information on its hematologicalprofile, genetic pattern of hemoglobinopathiesand the appropriated counseling.

Hemoglobinas anormais e dificuldade diagnóstica / Abnormal hemoglobins

As hemoglobinas humanas, com padrão de herança definido geneticamente, apresentam variações polimórficas características dentro de nossa população, na dependência dos grupos raciais que formam cada região. Aparecem sob a forma de variantes de hemoglobinas ou talassemias, sendo mais freqüentes, no Brasil, os tipos variantes S e C e as talassemias alfa e beta, todas na forma heterozigota. Durante o ano de 1999, amostras de sangue de 506 indivíduos com anemia a esclarecer ou que já passaram por alguma triagem de hemoglobinopatias foram encaminhadas ao Centro de Referência de Hemoglobinas da UNESP, para confirmação diagnóstica e submetidas a procedimentos eletroforéticos, análises bioquímicas e citológicas, para caracterização das hemoglobinas anormais. O objetivo do presente estudo foi verificar quais tipos de hemoglobinas anormais apresentam maior dificuldade diagnóstica. As amostras foram provenientes de 24 cidades de doze estados. Os resultados mostraram que 354 indivíduos (69,96 por cento) apresentaram hemoglobinas anormais, sendo 30 Hb AS (5,93 por cento), 5 Hb AC (0,98 por cento), 76 sugestivos de talassemia alfa heterozigota (15,02 por cento), 134 sugestivos de talassemia beta heterozigota (26,48 por cento) e 109 com outras formas de hemoglobinas anormais (21,54 por cento), que incluem variantes raras e interações de diferentes formas de talassemias e hemoglobinas variantes. Concluiu-se que, apesar da melhoria técnica oferecida atualmente e a constante formação de recursos humanos capacitados, as talassemias em sua forma heterozigota (210 indivíduos -- 41,50 por cento) são responsáveis pela maior dificuldade diagnóstica, seguido da caracterização de variantes raras e formas interativas de hemoglobinopatias (109 indivíduos -- 21,54 por cento), sugerindo que se deve aumentar a capacidade de formação de pessoal e as informações a respeito destas alterações genéticas em nossa população.

The human hemoglobins, with genetically definedinheritance patterns, have shown characteristicpolymorphic variation within the Brazilianpopulation, depending on the racial groups of eachregion. They have appeared under the form ofhemoglobin variants or thalassemias, the varianttypes S and C and the alpha and beta thalassemiasbeing more common, all of them in heterozygoteform. During the year of 1999, blood samples from506 individuals, with suspected anemia or thathad already passed through hemoglobinopathiesscreening, were sent to the Hemoglobin ReferenceCenter – UNESP for diagnostic confirmation andsubmitted to electrophoresis proceedings,biochemical and cytological analyses in order tocharacterize the type of abnormal hemoglobins.The goal of the present study was to verify whichabnormal hemoglobin types show greaterdiagnostic difficulty. The samples came from 24cities in twelve states. The results showed that 354(69.96%) individuals presented abnormalhemoglobins, 30 (5.93%) being Hb AS, 5 (0.98%)being Hb AC, 76 (15.02%) suggestive ofheterozygote alpha thalassemia, 134 (26.48%)suggestive of heterozygote beta thalassemia and 109(21.54%) with other forms of abnormalhemoglobin, including rare variants and differentforms of thalassemias and variant hemoglobininteractions. It has been concluded that, despitethe improved techniques currently available anda constant influx of capacitated personnel, theheterozygote form of thalassemias (210 individuals– 41.50%) is challenging to diagnose, followed indifficulty by rare variant characterization andinteractive forms of hemoglobinopathies (109individuals – 21,54%), suggesting that the capacityfor production of qualified professionals andinformation about these genetic changes in ourpopulation should be increased.