Document k647QNOnbjx93RBV4z07n1JyE

PROGRESS REPORT December 2003 I. ANALYSIS OF DISEASE PROGRESSION FOR APLASTIC ANEMIA, MYELODYSPLASTIC SYNDROME, ACUTE MYELOGENOUS LEUKEMIA AND BENZENE POISONING IN SHANGHAI, CHINA II. MOLECULAR EPIDEMIOLOGY OF BENZENE-EXPOSED WORKERS IN SHANGHAI, CHINA Richard D. Irons A MULTICENTER INTERNATIONAL STUDY Molecular Toxicology and Environmental Health Sciences Program Dept. of Pharmaceutical Sciences, School of Pharmacy Department of Pathology, School of Medicine University of Colorado Health Sciences Center, Denver, CO. School of Public Health, Hua Shan Hospital, Cancer Hospital, Fudan University Medical Center, Shanghai, China SHELL-MCCLURG-056195 Overall Status of Budget Comparison of actual to budget projections cited in this report were derived from the updated budget projections provided to API in September 2002 (Appendix A). JCML initiated clinical laboratory functions in 3rd quarter, with the case referral rate increasing progressively for a total of 225 during the last 5 months of 2003. Consequently, we are undergoing a transition in the budgetary tracking process and are continually evaluating resource allocation based on study contingencies. During the second half of 2003 a total of $1,077,479 was expensed compared to a projected budget of $2,039,466. This resulted in $961,987 in funds budgeted but not expensed during this period (Table 1). These figures are subject to modification pending an update of subcontract agreements that reflect post SRP budgetary expenditures as well as laboratory and field contingencies that we are currently addressing and that are discussed in the Progress Section. Table 1. Budget Summary (Reporting Period) Report (6103-12103) Category Personnel Operating Expenses Su bcontracts Travel Equipment Indirect TOTALS Budgeted Expenditures $293,007 $230,328 $259,003 $162,834 $988,733 $565,870 $4,127 $0 $350,000 $17,000 $144,596 $101,447 $2,039,466 $1,077,479 Variance $62,679 $96,169 $422,863 $4,127 $333,000 $43,149 $961,987 The budgeted amounts are the sum of each category from Jun-03 through Dec-03. 2 SHELL-MCCLURG-056196 Table 2. Budget Summary (Entire Project) Totals from 9/01-12103 Category Personnel Operating Expenses Su bcontracts Travel Equipment Indirect TOTALS Budgeted Expenditures $1,369,623 $1,255,819 $848,969 $627,106 $3,456,406 $2,437,102 $39,414 $8,993 $1,560,213 $1,191,150 $613,082 $523,312 $7,887,707 $6,043,482 Variance $113,804 $221,863 $1,019,304 $30,421 $369,063 $89,770 $1,844,225 The budgeted amounts are the sum of each category from Sept-Ol through Dec-03. PERSONNEL Savings in personnel are temporary and reflect some reshuffling of staff actIvItIes. The administrative costs of the project continue to increase in order to keep pace with administrative, accounting and regulatory requirements. In addition, we periodically have to make late phase changes in the database as well as provide continuing daily maintenance of the computer network, both at UCRSC and in Shanghai. Also, because of Chinese import restrictions, we are routinely required to negotiate and administer contracts and requisition of much of the supplies and reagents for JCML from UCRSC and then ship them to China. We are using this strategy approximately twice as much as we originally planned due to inefficiencies in Chinese purchasing/import practices. To date this has resulted in some cost shifting but no demonstrable budgetary excursions as reflected in the summary tables. JCML OPERATING EXPENSE/CASE-SPECIFIC COSTS Operating expenses are beginning to escalate to keep pace with JCML laboratory activities and case accrual. We are monitoring these activities with a view toward evaluating their impact on the overall budget. We have made some headway in developing a mechanism to track subjectspecific diagnostic and case accrual costs and have made a tentative comparison between our original budgetary projections and JCML operating expenses and subject costs for the 4th quarter of 2003, which is the first quarter we have experienced full laboratory clinical operation. Our original 4th quarter estimated subject costs were $268,618 versus actuals of $262,700. In contrast, our 4th quarter estimated personnel and maintenance costs for Fudan were $81,363 versus actuals of $138,384. The latter includes charges for minor equipment as well as reorganization of the CC, DP and ME exposure assessment teams discussed below. 3 SHELL-MCCLURG-056197 SUBCONTRACTS We are currently extending the agreement with ExxonMobil Biomedical. All others have been renewed through 2004. We are anticipating a significant redistribution of workscope among Chinese subcontractors that will be reflected in the 2004 budget. EQUIPMENT Equipment funds were originally budgeted for December 2003 in order to deal with contingencies we anticipated developing after laboratory start up. These expenses were postponed due to the delay in startup. However, with late breaking changes described in the Progress Section we anticipate that the majority of these funds will be expensed in 2004 as originally planned. 4 SHELL-MCCLURG-056198 AppendixA. China Project Budget Projections provided API in September 2002. Dec-01 P@~Wlijjl)I}" ~~&:~rng';jp~ijg~1~;'1~?I?? )');'t';;;I))))~';'t';';1/1 )))ii"i'jl ))))';;')'j')ll Budgeted I $13,131 $jJl:;~liti~~ti}""""'I)) ) ) ))) I) ))))) ))I? ))) ) )?I)) ) ))))1 )))'~;~"'tC)lJl ) ) ))))1 )))j";I''t~'jj ) jf';;'/'il )) ji 'j' Ij;1 ) ))) ) )I??)) ) ) )I) ) ) ) ))il) )j);;'j;'~I? ))j)':,,' '/"1) ) ji'lJ;j'~';/1 ))I? ) ) )) ))) ))1)) ) ) ) )))1 ~~~J~t:~il) )'":'~-;"Jt~'I) ));)'m'I;'a)}"';)'sn )m'])';' a ));'}j"'I'Jn )));I]s';))I)) )')D'}ft;~'l) )'E'J;"~,, I? ))}j);')}n )iJ";"j'jj )?i'~n-')'EI ))J';'/ I' 'j"II Budgeted ijqWPMW() 1// ) / ) /11)) / ) / )1 / ) / )))1 ) / ) /)1 / i / ))1 ) / ) /)1 / ) / i)l/ ) / ) //1) / ) / ))1/ ) / ) / I) / ) / ) I) ) / ) / )1 lnWfiJ(d}I)) ) / i )1) / / i ))1/ / ) ) //1 ) ) / / /1 ) / /i)//I / / ) ) /1// ) ) / /1) ) / / ) I) / / ) ))1/ / ) ) /)1 ) ) / /)1 ) / i ))) /1 Budgeted (J) I m r r sI : () () r C ;a G) ocI.n (J) ....lo. <D <D PROGRESS REPORT JCML Laboratory Clinical Activities JCML began routine full service clinical operations around the beginning of August 2003. These activities include: routine hematology, bone marrow aspirate analysis, bone marrow and lymph node histopathology, clinical chemistry-liver enzymes, serology, flow cytometric analysis of blood, bone marrow and lymph node preparations, cytogenetics, FISH and molecular genetics. As of December 31 S\ after the first 5 months of operations, approximately 190 cases had been referred to JCML for diagnosis as part of the clinical operation. (The case contact rate has continued to increase with over 270 cases having been seen by the end of 6 months.) An external pathology review was conducted in October 2003. As of October 31, 106 cases have successfully undergone secondary pathology review. Preliminary estimates suggest approximately a 50% concordance between initial hospital case diagnosis (if any) and the JCML diagnosis, and in excess of a 90% concordance between the JCML diagnosis and secondary pathology review. The latter is an acceptable standard of concordance between US laboratories. Clinical Service Statistics An important measure of clinical laboratory service performance is the time from sample collection to the availability oftest results (i.e. turn-around times (TAT)). The TAT for routine hematology in support of the 23 referring hospitals is normally under 2 hours with no excursions in routine clinical cases beyond 4 hours as of 12/31/03. Routine analyses of bone marrow aspirates average 3-7 days. For acute cases, preliminary aspirate analyses are available within 1-3 days. Flow cytometric analysis of bone marrow or lymph node preparations are completed within 1-4 days. The TAT for cytogenetics analyses averages 6-10 days with 70-80% being completed within 7 days. FISH analyses are 90% completed within less than 7 days. For acute cases, cytogenetics are completed within 5 days and FISH analyses within 2-3 days. The AML abnormal frequency rate is 57.14% for cytogenetics and 60% combined for cytogenetics and FISH. For the lymphoma cases, the abnormal cytogenetics rate is close to 80%. These statistics exceed the performance of most US clinical laboratories. The TAT for bone marrow or lymph node histology is 5-7 days. At present, the TAT for bone marrow or lymph node histology is 5-7 days and case-specific availability of control slides is spotty. This is not an acceptable standard of performance, and efforts are underway to correct the situation. DNA and RNA are routinely isolated from samples received the same day, with all samples processed within 24 hours. Random RNA samples are subjected to electrophoresis, with visual confirmation of the l8S and 28S fractions demonstrating quality RNA. Additional quality control for DNA samples is provided by the amplification of the FLT-3 gene, performed on all samples from a given week on the first day of the following week. At present, routine molecular analyses performed in the laboratory include analysis of FLT-3 internal tandem duplication by PCR and FLT-3 6 SH ELL-MCCLU RG-056200 amino acid substitution at D835 using RFLP, BCRIABL confirmation by rtPCR, and TCR beta or gamma chain gene rearrangements by PCR and hetero/homoduplex analysis. Additional study mandated molecular analyses (~. HHV8, NQ01) are not time sensitive and will be processed as time allows. Initially, MNC from all blood and bone marrow samples coming into JCML were preserved in two aliquots each using 3-4 ml of starting material. This volume of starting material is sub optimal. However, randomly selected samples demonstrate greater than 90% viability upon thawing. Initial EBV viral lots harvested from cells obtained in Shanghai have failed to transform both patient samples and test samples. Therefore, EBV supernatant was prepared in Colorado and shipped to Shanghai. This material has been used to successfully immortalize test cultures. Efforts are underway to increase the transformation efficiency of the culturing process and increase the starting blood sample volume. Patient cultures are now in the process of being immortalized using MNC that have been cryopreserved for subsequent immortalization. Sample thawing viability for December was determined to be 99.4%. Case Control (CC) !Disease Progression (DP) Case Accrual By December 31 st approximately 190 cases were referred to JCML for diagnosis as part of the clinical operation, and, as of October 31, 106 cases have successfully undergone secondary pathology review. The case contact rate has not reached a steady state but continues to increase with over 270 cases accrued by the end of 6 months. Diagnoses qualifying for inclusion in the CC or DP studies represented 83% of the total case contacts with 17% of cases being diagnosed as non-qualifying or excluded conditions. Individual disease diagnoses included: AML 42, NHL 66, AA 17, and MDS 26. Again, these numbers should be interpreted with caution because JCML has not yet reached a steady state with respect to rate of clinical case accrual. Whether this reflects a progressively increasing case accrual or fluctuating admissions is not understood at this time. Exposure Assessment A variety of problems associated with procedure de-bugging, coordination and implementation led to an initial lag in exposure assessment operations relative to JCML case accrual. Early on, these issues were magnified by the high case accrual rate. However, we have re-organized the exposure assessment teams, which have undergone additional training and are now operational. By mid-January over 460 subjects had been entered into the exposure assessment program. The first stage assignment (exposed, unexposed, uncertain) produced a rapid initial sorting. From that stage, 12 subjects were classified as "exposed" for benzene, and are undergoing a more thorough quantitative assessment. The "uncertain" category included 67 subjects for which further information is needed (~. review of IPHS database work site inspections). Many of these uncertain ratings are expected to be transferred into the "benzene exposed" category. An additional 35 "other exposures" (i.e. other workplace hazards of concern besides benzene) have 7 SHELL-MCCLURG-056201 been identified and classified and another 270 subjects were classified as having no exposure or ''unexposed''. Independently, the Exposure Assessment (EA) team has compiled the Chinese literature for information on benzene exposure. District IPHS written records (not in the central database) and specific factory records are also being located. A Fudan team member has also initiated quality assurance overviews for the IPHS database searching process. Control Selection for CCIDP We have periodically reviewed the demographic characteristics and diagnoses for controls in order to ensure that procedures outlined in the protocol are being implemented correctly in the field. These periodic audits have shown that the matching criteria are being followed (i.e. controls are being successfully matched according to age and gender). However, we have determined that, on occasion, the protocol is not uniformly applied in all hospitals. Specifically, the selection of a control subject with the closest time of admission to that of a study subject is not always adhered to. Therefore, we met with clinical coordinators and reemphasized the control selection procedure with regard to time of admission/diagnosis. Some hospitals do not have a central admissions log, making it impossible to ensure that the control with the closest time of diagnosis is identified. In lieu of this, we are currently reviewing the procedures in every hospital separately, to assess whether there is any systematic bias in selecting controls. Molecular Epidemiology (ME) Study Phase 1 activities. The longitudinal exposure analysis of workers is progressing well. We have been successful in identifying several factories from which benzene workers were examined by hospitals over the past several years, and have correlated these with benzene monitoring data in the IPHS database. Professor Ni has identified a subset of factories that historically may have experienced high concentrations of benzene exposure. These are being investigated on a factory-by-factory basis. To date, we have identified a small number of facilities that have both good monitoring data and good medical records. A review and abstraction of medical records for workers in these facilities is underway. In addition, we also have located the medical records for 194 individual cases of benzene poisoning that presented at local hospitals over approximately the past 5 years. Analysis of this data set has begun, and medical record retrieval and abstraction is underway for all of these activities. Phase 2a and 2b activites. We have recruited some workers to Phase 2a as part of a screening survey and an intensive two-week exposure analysis of a high exposure rubber products factory. Additional factory identification and recruitment activities are underway. Factory participation for Phase 2b has proven to be more difficult than initially envisioned. We originally anticipated recruiting subjects from adjacent or even distant provinces. Accordingly we are now simultaneously exploring suitable facilities, 8 SH ELL-MCCLU RG-056202 both in Shanghai and outside Shanghai. In addition, although originally we planned to rely heavily on IPHS staff to introduce the project to Factory Management we are currently evaluating several sites outside Shanghai, based on initial contact by Professor Ni, President of the Chinese Academy of Occupational Medicine. Benzene and Metabolite Analyses At UCHSC we set out to develop a minimal step method for the extraction and quantitation of the benzene metabolites from blood and bone marrow: phenol (PH), catechol (CAT), hydroquinone (HQ) and trans,trans-muconic acid (MA). The rationale for this approach was to design the simplest procedures possible for extraction and analysis of these compounds that facilitate implementation in Shanghai, utilizing existing instrumentation (GCIMS). Our reasoning proved to be prescient. The final method was based on liquid phase extraction with ascorbic acid, acetonitrile and toluene. Deuterated derivatives for each metabolite were purchased or synthesized and employed as internal standards. The limit of detection for PH, CAT and HQ in blood samples was in the nanogram range. There is no commercial source for deuterated trans,trans-muconic acid[1,2,5,6-13C]. Therefore synthesis was achieved by refluxing a solution of triphenylphosphine and ethyl[l,2- 13C2]bromoacetate in a mixture of acetonitrile and dichloromethane (ml) that was washed, dehydrated over magnesium sulfate and dissolved in dimethylformamide (DMF) to which glyoxal trimeric dehydrate was added to give the muconic acid diethyl ester. This was then dissolved in THF and lithium hydroxide in water. The solvents were evaporated under reduced pressure and the residue was suspended in a mixture of toluene and hydrochloric acid (pH 2.0). Publication of the method and analysis of background levels of benzene metabolites in the blood and bone marrow of unexposed volunteers awaits measurements that are still forthcoming from SMCDCP and that have been frustrated by events at SMCDCP discussed below. Following on the recommendation of the SRP at the annual meeting in August, we investigated the possibility of measuring sPMA in urine of ME Phase 2b subjects. A direct, linear relationship exists between the internal dose of benzene and the rate of excretion of sPMA. Urinary sPMA is therefore an useful biomarker of exposure to benzene. The measurement can be easily performed using a small volume of urine, collected at an appropriate time relative to potential exposure. The strategy we have adopted for analysis of urinary sPMA is an enzyme-linked immunoabsorbant assay (ELISA). Therefore, we have negotiated a site license to employ ELISA assay owned by AB Biomonitoring, Ltd, Cardiff, UK. This methodology will be implemented following approval of the addition of urinary collection to our Phase 2b clinical protocol. ***Recent Development as/of February 19, 2004*** Despite two years time, the SMCDC has failed to successfully adapt these analytical methods for analysis of blood and bone marrow, and, for that matter, has not provided entirely satisfactory results for the measurement of benzene in air or any results for 9 SH ELL-MCCLU RG-056203 exhaled breath analysis. The stated reasons are many, including serious illness in senior technical personnel resulting in a chronic lack of leadership, instrumentation problems that remain unresolved, and the inability or lack of resolve to commit adequate personnel and time to the project. We recently completed a detailed analysis of CDC analytical capability that included inspection and review of methods and procedures by Professor Zheng Xixing of Fudan University and David Chang of ExxonMobil. We have concluded that CDC has provided less than desired performance for analytical support for benzene or benzene metabolites. Among the issues that remain unresolved are: 1) in all cases, standard curves remain inadequate and are extrapolated from high values; 2) split sample analysis reveals an unacceptable and consistently low bias in contrast to paired samples analyzed by an AIHA certified laboratory; 3) despite several deadlines and adequate guidance they have not developed a satisfactory method of analysis for benzene in exhaled breath or benzene metabolites in blood and bone marrow. These issues have been the subject of frequent discussion with SMCDC staff and management as they have unfolded over the last year. Therefore, after protracted negotiations and little sign of success, we have terminated our agreement with SMCDC to conduct analyses as part of the project. We are collaborating with Fudan University to transfer all analytical activities to JCML with a minimum of delay. Because this is a very recent development we have not had an opportunity to evaluate every impact that this contingency will have on the project. Quality Assessment Issues Elements of QAlQC have been referred to throughout this report as they specifically refer to other areas, such as Exposure Assessment, Control Selection, JCML clinical laboratory operations and benzene metabolism. In order to improve overall coordination, professor Liang Youxin has been assigned the task of supervising QAlQC for exposure assessment, and the data entry process has been streamlined. Gail Joregenson from Exxonmobil visited JCML in early 2004 to consult with and evaluate the overall process and to coordinate late phase database changes which will be reported in the next progress report. Conclusions During the last 6 months we have successfully begun JCML clinical and research operations and are routinely diagnosing blood and lymphoid diseases for the 23 participating hospitals in Shanghai. Operating a combined clinical and research laboratory of this magnitude in the local Shanghai environment creates a number of unique challenges. In most areas of clinical operation, based on objective criteria, we meet or exceed the standards of many of our US counterparts. We have successfully undergone our first external pathology diagnostic review, which was a milestone. We are preparing for the second review which will be conducted in April 2004. In the research arena all processes are up to speed except immortalization of cell lines. For EBV immortalization, the problems have been identified and largely resolved as of February, 2004. In some clinical areas we need to provide additional support, training for and coordination with our clinicians and laboratory colleagues in Shanghai in order to 10 SH ELL-MCCLU RG-056204 improve local standards of practice to meet CAP operational criteria. These relatively small details will continue to be addressed, but for the moment we are on track and functional. I believe we are on the way to becoming both a US and Chinese referral laboratory. The caseload number and variety of diseases encountered is remarkable. We are accruing an acceptable or greater than predicted number of study cases based on our initial projections, and the rate continues to grow. Control selection for CC/DP has required additional training and orientation of clinical coordinators and the recognition that the 23 participating hospitals have markedly different capabilities and standards when it comes to tracking patient admissions. We are developing individualized approaches to deal with these issues and standardize as much as possible the control selection process. Exposure assessment under the leadership of the Fudan team got off to a predictably slower start than JCML. Progress on EA improved after we reorganized the exposure assessment operation and conducted an intensive training initiative to streamline the process. This effort has been a collaborative one, requiring the expertise and attention of all the major US collaborators on this project as well as our colleagues at Fudan University. The EA operation is improving with a renewed understanding of the need for ongoing training and continued guidance by US personnel. Although we have had very good experiences interacting with and recruiting factory workers, we have experienced some challenges in encouraging factory management participation in the ME study. We have taken a multifaceted approach to dealing with this process including: attempting to fine tune the approach of IPHS to initiating factory involvement, exploring political solutions, actively pursuing leads outside of town. It has come as somewhat of a surprise that our biggest challenge has turned out to be obtaining high quality analytical support. However, in the absence of any demonstrable improvement in SMCDCP analytical capabilities over the past year, the need for a change in tactics has become imminent. Our immediate focus is on achieving a rapid and efficient transition to bring the analytical capabilities necessary for the project on line at JCML. To this end we are experiencing active cooperation and support from Fudan University. The goal is to have this implemented before the next 6 month reporting period. Analytical support for benzene air monitoring should be implemented faster than that. 11 SH ELL-MCCLU RG-056205 To: BHRC Oversight Committee (E-mail) <benzconsort-oc@listserve.api.org>; BHRC Technical Committee (E-mail) <benzconsort-tc@listserve.api.org>; BHRC Communications Committee (E-mail) <benzconsort-cc@ listserve. api. org> From: Matt Todd <ToddM@api.org> Cc: Bcc: Received Date: 2004-03-05 20: 18:30 GMT Subject: Shanghai Health Study Update: March 5, 2004 Shanghai Health Study Update Announcements: * A revised draft agenda is posted on the SHS Update page for the March 8th Oversight Committee conference call at 2PM EST. * The agenda and follow up thank you letter from the meeting with Ed Murphy and Jim Williams at API on February 27th is posted on the Oversight page. * The Communications Committee conference call draft minutes are posted on the Communications page. The next call is scheduled for April 7th at 2PM EST. * The progress report from Dr. Irons for the DP and ME studies is posted on the Technical page. * If you have any announcements that you would like to be posted, please send an email to Matthew Todd at toddm@api.org. Matthew Todd Regulatory Analysis and Scientific Affairs American Petroleum Institute 1220 L Street NW Washington, DC 20005 p: (202)682-8319 f: (202)682-8031 www.api.org SH ELL-MCCLU RG-056206 To: benzene-srp@ listserve. api. org <benzene-srp@ listserve. api. org>; benzene- erp@ listserve. api. org <benzene-erp@ listserve. api. org> From: Bruce Jarnot <jarnotb@api.org> Cc: benzconsort-tc@ listserve. api. org <benzconsort-tc@ listserve. api. org> Bcc: Received Date: 2004-03-09 19:00:30 GMT Subject: Shanghai Benzene ERP & SRP... For Review: proposed changes to Protocols & Consent Forms Subject: ERP & SRP Review of Proposed Changes to Study Protocols & Informed Consent Forms SHS Ethics & Science Review Panels - Attached for your review and comment (or approval) are 7 files containing the protocol and informed consent (IC) form changes proposed by Richard Irons, in response to SRP recommendations communicated in Jerry Rice's Memo of 17 October 2003. The SRP Memo and these attached files can also be found on the SHS internet website, in the Panel Member Information / Documents page. ACTION - please reply with your comments or approval by Monday, 29 March (20 days from now). Thank you, and with best regards - Bruce ***** Bruce M. Jarnot, Ph.D., DABT American Petroleum Institute Regulatory and Scientific Affairs 1220 L Street, NW (Suite 900) Washington, DC 20005-4070 phone: (202) 682-8473 fax: -8031 email: jarnotb@api.org Attachments: DP Control Consent rev.doc DP SA-1 consent rev.doc DP Subject Consent rev.doc ME 2b consent rev.doc ME blood consent rev.doc ME Control consent rev.doc Summary of Protocol changes. doc SH ELL-MCCLU RG-056207 Consent Form Approval: SA-I DP Medical Center of Fudan University The Shanghai Hematology Society and the University of Colorado Health Sciences Center Joint Laboratory for Clinical and Molecular Studies Protocol Title: Disease Progression Principal Investigators: Professor Fu Hua; Professor Richard D. Irons SUBJECT CONSENT Patient Bone Marrow and Blood Donation Date: February 19, 2004 Description: . You are being asked to take part in a research study of diseases of the blood and lymphoid system and the effect of benzene on blood cells because of its prevalence in the population.. In order to diagnose your disease, your physician has asked you to undergo a series of tests. Your physician has ordered these tests no matter whether you agree to participate in this study or not. However, if you choose to participate, the tests performed may provide more detailed and useful information for use in the diagnosis of your disease. Medical research information will be collected to enhance basic medical knowledge and to improve the diagnosis, treatment, and prevention of diseases such as you may have. The research being conducted is for scientific discovery and the results will not be used to seek any commercial profit. The tests we will perform are more sophisticated than those you would routinely receive in the hospital, and the information obtained from these tests will be provided to your physician to help in the diagnosis of your disease. Your cells will be tested and grown in the laboratory. These procedures may result in the development of a cell line that can be grown for many years that will be used in these and future studies. This cell line will be used to study genes that may influence susceptibility to blood diseases. Therefore, if you choose to participate in this research you may also receive clinical benefits. If you consent to participate in this study, you will also be asked to fill out a questionnaire and answer some questions concerning your job history and related activities. Procedures Involved: As part of your normal treatment, blood (1520 ml) will be taken from your arm, and bone marrow, one biopsy (a small piece of bone marrow) and one aspiration (up to 10 ml.) will be taken from your hip. If the aspiration does not provide enough sample you will be asked to have a second biopsy. Whether you choose to participate in the study or not, these are the same procedures that your physician has ordered for diagnosis of your disease. As part of this research project, you may be asked to provide bone marrow and blood again in the future as Page I of3 Initials - - - SH ELL-MCCLU RG-056208 part of the continued monitoring of your disease. If you are asked to donate additional blood or bone marrow it will be at 6-month intervals up to a 4-year period. Discomforts and Risks: Blood: For the follow-up, 15 20 ml of blood will be removed by putting a needle into your vein. This is a standard method used to obtain blood for tests. You will feel pain when the needle goes into the vein. A bruise may form at the site. Bone Marrow: When a bone marrow biopsies and aspirations are taken there is a lot of pain for a short time (about 10 - 20 seconds). There are no additional risks apart from the normal bone marrow donation that is part of your normal care. This study may involve unforeseeable risks. Benefits: The results of tests performed on your bone marrow and blood cells will be used by your physician for the diagnosis and monitoring of your disease. The testing results will be part of your medical records for better health care management. They will also be used to help us better understand the nature and cause of your blood disease. Collaborating Institutions: You are being asked to participate in a collaborative study being conducted by Fudan University Medical Center, the Shanghai Hematology Society and the University of Colorado Health Sciences Center, Denver, USA. Cost to Subject: There is no cost to you for participating in this study. If you agree to this interview you will be making a contribution to research so you will receive 1360 RMB each time as a reward which will be used to pay some of your medical costs. You will also be asked to give an interview and answer some questions for which you will directly receive an additional payment of 240 RMB each time as a reward. Study Withdrawal: You may choose not to enter or withdraw from the study at any time. Invitation for Questions: The researchers carrying out this study are professor Richard Irons and professor Hua Fu. You may ask any questions you have now. If you have questions later, you may call Liu Jiamin at 86-21-54237202. You will be given a copy of this form to keep. If you have questions regarding your rights as a research subject, please call professor Ye Zhurong of the Medical Ethic Review Committee Fudan University at 86-21-65643684. Confidentiality: Your physician/investigator, Fudan University Medical Center, the University of Colorado Health Sciences Center, COMIRB, the Medical Ethic Review Committee of Fudan University and the Study Sponsors will treat your identity with professional standards of confidentiality. However, health care professionals conducting this study have the right to inspect your medical records relating to this research for the purpose of verifying data. Because of the need to release information to these parties, absolute confidentiality cannot be guaranteed. Page 20f3 Initials - - - SH ELL-MCCLU RG-056209 The results of this research study may be presented at meetings or in publications; however, your identity will not be disclosed in those presentations. Injury and Compensation: If you are hurt by this research, we will provide medical care. The cost of medical care will be provided by the study's sponsor. Authorization: I have read this paper about the study or it was read to me. I understand the possible risks and benefits of this study. I know that being in this study is voluntary. I choose to be in this study: I know I can stop being in the study and I will still get the usual medical care. I will get a copy of this consent form. (initial all the previous pages of the consent form). I give my permission for my bone marrow, blood and blood cells to be stored for future use by study investigators in other research projects. I also give permission for the data and results of these studies to be used in other research projects. Signature: subject / print name date Consent form explained by: signature / print name date Investigator: date Page 3 of3 Initials - - - SHELL-MCCLURG-056210