Factors Related to the Quality of Life in Children with Transfusion-Dependent Thalassemia

Objective: Increased survival rate of patients with Transfusion-dependent Thalassemia (TDT) should be in line with their good quality of life (QoL). The study aimed to analyze the relationship between sociodemographic factors and clinical characteristics with the QoL of children with TDT. Methods: A cross-sectional study was conducted at Hasan Sadikin General Hospital from December 2022 to February 2023. A total of 158 eligible subjects aged 5-18 years with TDT were included in the analysis. QoL assessment was performed using child self-report and parent-proxy report questionnaires, along with physical examination findings. Bivariate and multivariate analyses were conducted to analyze the data. Results: A total of 158 subjects who met the research criteria were included in the analysis. Of 58.9% of children with TDT had a low adherence rate to iron chelating therapy (ICT). School function had the lowest score in QoL based on child-self report and parent proxy. Gender (p<0,05) and adherence to ICT (p<0,05) were significantly associated with lower quality of life. Conclusion: Female and adherence to ICT were predictors of children with TDT's QoL.

Survival and Treatment Outcomes of Childhood Acute Lymphoblastic Leukemia in a Low-Middle Income Country: A Single-Center Experience in West Java, Indonesia

Purpose

This study aimed to determine the survival rates and treatment outcomes of patients with childhood Acute Lymphoblastic Leukemia (ALL) in a single-center study at Indonesia.

Patients and Methods

Factors contributing to the relapse and survival of ALL in Bandung, Indonesia, were evaluated. Data were collected from the medical record and the Indonesian Pediatric Cancer Registry (IPCAR). Subsequently, univariate and multivariate analyses were evaluated using Cox proportional hazard regression and Kaplan Meier was used for survival analysis. An analytic observational study was conducted on newly diagnosed children aged 1-18 with ALL from January 2019 to December 2022.

Results

A total of 137 children were included in the analysis, 30 (21,9%) were dropped out during treatment and 60.5% died during the study period. Most of the deaths occurred after relapse in 32 (38.5%) with a high early relapse (70.5%), occurring mainly during the maintenance phase (42.4%). At the one-year mark, the observed overall survival (OS) rate was at 36%, while event-free survival (EFS) was lower, at 19%. Univariate Cox regression analysis showed that the leucocyte counts at diagnosis (p=0.005) and response to induction phase (p < 0.008) was associated with the death of ALL. Furthermore, a response to induction phase was significant [hazard ratio 4.67 (CI 95%: 1.64-13.29); p = 0.004] in the multivariate analysis.

Conclusion

In conclusion, this study underscored the persistent challenges of high treatment discontinuation rates and the occurrence of very early relapses in low- to middle-income countries (LMICs), which significantly impacted the OS of children diagnosed with ALL.

Allergic Reactions to E. coli Asparaginase are Associated with Decreased Asparaginase Activity in an Indonesian Pediatric Population with ALL

PURPOSE

The asparaginase's (ASP) utility for ALL treatment is limited by neutralizing antibodies, which is problematic in countries whose access limited to alternative preparations. ASP antibody levels and activity was measured during remission induction and associated with allergy manifestations.

METHODS

E. coli ASP was dosed at 7500 IU/m2. ASP IgG antibody levels were quantified at the beginning and end of induction. ASP activity was measured 24 hours after 1st and 5th dose (standard-risk) or 7th dose (high-risk patients) administration, and within 24 hours in case of allergic reactions. Allergy was monitored by CTCAE version 3. Parametric and non-parametric was performed for data analysis.

RESULTS

ASP antibody and activity levels were available in 41/63 consecutive patients. Allergic manifestations occurred in 13/41, with urticaria being the most frequent. There were no significant differences in subject characteristics based on allergic reactions. The 5th dose was the most frequent time of onset. Antibody levels in allergy group at the end of induction did not differ from those at baseline (p<0.05). Using a 24-hour level of 100 mU/mL as a threshold for adequate ASP activity, 6/13 patients with allergy had adequate levels compared to 26/28 patients without (p<0.05). The ASP activity level at the end of induction phase in both groups did not show a significant decrement.

CONCLUSION

The E. coli ASP activity with adequate levels were significantly higher in non-allergy group. Its activity level was not accompanied by increment of IgG in allergic group indicates other factors might affect activity levels in allergy group.

Type of cancer and complementary and alternative medicine are determinant factors for the patient delay experienced by children with cancer: A study in West Java, Indonesia

INTRODUCTION

Most pediatric cancer patients in developing countries present at an advanced stage due to delayed diagnosis, being an important barrier to effective care. The objective of this study was to evaluate the associated factor of patient delay and explore significant parental practice-associated risk factor to patient delay.

METHODS

This was a sequential mixed methodology, utilizing data from the Indonesian Pediatric Cancer Registry for clinical variables and completed interviews with parents using structured questionnaires to obtain their sociodemographic data. A binary logistic regression analysis model was fitted to identify factors associated with patient delay. Additional semi-structured interviews related to parental practice of using complementary and alternative medicine (CAM) were administered to 30 parents. Thematic framework analysis was performed on qualitative data to explore determinant factors of parental practice of using CAM.

RESULTS

We interviewed 356 parents with children with cancer. The median patient delay was 14 days (interquartile range [IQR]: 6-46.5 days). The most extended delay was in patients with malignant bone tumors (median 66, IQR: 14-126). In multivariable logistic regression analysis, solid cancer (odds ratio [OR] = 5.22, 95% confidence interval [CI]: 2.79-9.77, p < .001) and use of CAM (OR = 1.86, 95% CI: 1.13-3.08, p = .015) were associated with patient delay. Qualitative interviews highlighted key issues relative to determinant parental factors using CAM, including vague initial childhood cancer symptoms, parental health-seeking behavior, CAM availability and accessibility, also barriers of healthcare facilities.

CONCLUSION

Type of cancer and use of CAM are essential factors that cause patient delay. It should be addressed in the future childhood cancer awareness and childhood cancer diagnosis pathway.

Knowledge towards Thalassemia and Willingness to Screen among Students in Public Senior High School 3 Bandung

Background: Thalassemia carrier screening is a major preventive measure  potentially influenced by the level of knowledge, particularly in adolescents. Therefore, this study aimed to analyze the effect of health education on knowledge of thalassemia in adolescents and its association with their willingness to do thalassemia screening.Methods: A cross-sectional study was conducted using data regarding knowledge of thalassemia before and after health education sessions from 229 students at Public Senior High-School 3 Bandung. All participants attended a one-day health education in July 2019. A questionnaire was filled in to measure their knowledge regarding thalassemia before and after the session, including knowledge on etiology and definition, risk of disease, clinical manifestations, treatment, complication, prognosis, and disease prevention. Only data with complete questionnaire responses were included. These responses were scored quantitatively and analyzed for their association with participants’ willingness to screen. Results: Participants were knowledgeable concerning thalassemia before the health education session (median, range: 60.0, 25.0-90.0), and knowledge was increased significantly after the education session (median, range: 80.0, 35.0-100.0) with an increased median difference=19.99 (p-value <0.001). Although there was no significant association between the overall post-test score on participants’ willingness to screen (p-value >0.05), the willingness was slightly associated with improved knowledge regarding the risk of disease (OR: 1.02; 95%CI: 1.00-1.03; p-value <0.005). Conclusion: Health education regarding thalassemia significantly increases general knowledge of thalassemia. However, improving knowledge is not significant in influencing adolescents’ motivation to take the screening tests.

FVIII inhibitor surveillance in children with hemophilia A in Indonesia: a report from the Indonesian Pediatric Hematology-Oncology Working Group

Background

Factor VIII (FVIII) inhibitor diagnosis and surveillance in Indonesia are challenging owing to geographic conditions and the lack of laboratory facilities nationwide for inhibitor assays. This study aimed to determine the prevalence of FVIII inhibitors in children diagnosed with hemophilia A (HA) in Indonesia.

Methods

A cross-sectional study was conducted in 12 hospitals in eight provinces of Indonesia between 2020 and 2021. Factor VIII inhibitor screening was performed in a central hemostasis laboratory for all children with HA (≤18 yr) who had received a minimum of 10 exposure days to clotting factor concentrates. The FVIII inhibitor titer was determined using the Bethesda assay.

Results

Children (388) were enrolled in this study, including 219 (56.4%), 131 (33.8%), and 38 (9.4%) with severe, moderate, and mild HA, respectively. The prevalence of children who developed FVIII inhibitors was 37 out of 388 (9.6%). Factor VIII inhibitors were found in 25/219 (11.4%) severe, 11/131 (8.3%) moderate, and 1/38 (2.6%) children with mild HA. Thirteen children had low-titer inhibitors and 24 had high-titer inhibitors, with a median of 9.44 (1.48‒412.0) Bethesda Units. Among 13 children with low-titer inhibitors, eight underwent a confirmation test, of which five tested negative and were classified as transient. A significant difference in annual joint bleeding rate was found between patients with low and high inhibitor titers and those without inhibitors (P＜0.001).

Conclusion

Factor VIII inhibitor prevalence in Indonesia was relatively low. However, the risk factors that may contribute to FVIII inhibitor development among Indonesian patients require further study.

Association between 25-Hydroxyvitamin D and Mental-Emotional Status in Children during Their First 1000 Days of Life

Vitamin D receptors are widely expressed in brain tissue, including in the limbic system that plays a role in children's mental and emotional development. This study aimed to analyze the relationship between 25-(OH)-D level and children's mental-emotional development during their first 1000 days of life. A cross-sectional study was conducted on children aged ≤2 years old in Waled and Sukabumi regions using secondary data from previous cohort investigations entitled "The Role of Vitamin D in Efforts to Reduce Maternal and Infant mortality". The measurement of 25-(OH)-D concentration and assessment of the mental-emotional development were performed using the Ages and Stages Questionnaires: Social-Emotional (ASQ-SE) questionnaire. Other child and maternal characteristics, and several laboratory results, were also obtained. Statistical analyses were performed using the Spearman rank, Pearson correlation test, and multivariate linear regression analysis. A total of ninety-two children were included, and the median vitamin D level of the population was 20.17 ng/mL (IQR 4.43–49.97). The correlation analysis showed that no significant relationship between children's mental-emotional scores and the parameters tested, including the concentration of 25-(OH)-D (correlation coefficient 0.08; p=0.446). There was no relationship between the vitamin D concentration and mental-emotional development. Based on these results, it is concluded that there is no correlation between 25-(OH)-D concentration and children’s mental-emotional development during the first 1000 days of life. However, further investigations are recommended to eliminate various confounding factors.

Tata Laksana Terkini Talasemia ?: Terapi Target

Talasemia ? adalah bentuk hemoglobinopati yang merupakan penyakit monogenik diturunkan terbanyak di dunia ditandai defek yang menyebabkan produksi globin ? berkurang atau tidak ada.  Ketidakseimbangan rantai globin ?/? menyebabkan rangkaian proses eritropoesis inefektif dan peningkatan absorpsi besi yang pada akhirnya mengakibatkan anemia hemolitik kronis dan kelebihan besi.  Secara konvensional tata laksana utama talasemia ? berat adalah transfusi darah dan obat kelasi besi yang masih memiliki banyak keterbatasan dan tantangan meskipun telah berdampak pada peningkatan kesintasan dan kualitas hidup penyandang talasemia ? mayor. Pemahaman mendalam terhadap molekular dan patofisiologi talasemia-? membuka jalan bagi strategi pendekatan terapi baru yang diklasifikasikan atas 3 kategori, yaitu koreksi ketidakseimbangan rantai globin melalui pengembangan transplantasi sumsum tulang dan terapi gen; mengintervensi eritropoesis inefektif sehingga transfusi darah dan kelasi besi berkurang; dan modulasi disregulasi besi untuk mengendalikan kadar besi. Dengan demikian, strategi pendekatan terapi baru menjanjikan penurunan kebutuhan transfusi darah dan kelasi besi yang lebih menyamankan pasien dan diharapkan juga menurunkan biaya tata laksana. 

Favourable Response to Chemotherapy in Ora-Located Intraocular Retinoblastoma Grade B, C, and D: A Case Series

Background: We aim to analyze which tumor location gives more favorable chemotherapy response in intraocular retinoblastoma grade B, C, and D as well as to report the first case series in Indonesia. Methods: Six boys with age ranging from 10 weeks to 47 months old were recruited into the study from April 2019 to January 2020 at National Eye Centre, Cicendo Eye Hospital, and Hasan Sadikin General Hospital, Bandung, West Java, Indonesia. Retinoblastoma (RB) patients underwent examination under anesthesia (EUA). Tumor size and location were evaluated by using RetCam pre and post 2 cycles of chemotherapy. The tumors were classified according to the International Intraocular Retinoblastoma Classification. Results: There were two patients with unilateral RB and four patients with bilateral RB. All patients had leukocoria and sought medical advice within 12 months of onset. There were one tumor in the macular zone, six tumors in the equatorial zone, and two tumors in the ora zone. Two cycles of intravenous vincristine, etoposide, and carboplatin (VEC) were administered and the tumor diameter was re-evaluated afterwards. The tumor size was decreased following 2 cycles of chemotherapy. Conclusions: Ora zone showed a more favorable chemotherapy response.

The incidence and mortality of childhood acute lymphoblastic leukemia in Indonesia: A systematic review and meta-analysis

Background

The incidence of childhood ALL in Indonesia is still largely unknown. The widely mentioned statistics from other countries turn out to be only estimated figures. Other data do not specify the types of leukemia and are not specifically focused on children. Therefore, this study aims to pool incidence and mortality statistics from available studies in Indonesia.

Methods

We searched five different academic databases, including Pubmed, MEDLINE, Cochrane Library, Science Direct, and Google Scholar. Three Indonesian databases, such as the Indonesian Scientific Journal Database (ISJD), Neliti, and Indonesia One Search, were also utilized. Incidence was expressed as per 100,000 children. We used the Newcastle-Ottawa scale (NOS) to assess the quality of cohort studies. The inclusion criteria are cohort studies published in the languages of English or Indonesian. For this analysis, we define children as 0–18 years old.

Findings

The incidence rate for childhood ALL was found to be 4.32 per 100,000 children (95% CI 2.65–5.99) with a prediction interval of 1.98 to 9.42 per 100,000 children. The incidence rate is higher in males, with 2.45 per 100,000 children (95% CI 1.98–2.91) and a prediction interval of 1.90 to 3.16 per 100,000 children. As for females, the incidence rate is 2.05 per 100,000 children (95% CI 1.52–2.77) with a prediction interval of 1.52 to 2.77 per 100,000 children. The mortality of childhood ALL ranges from 0.44 to 5.3 deaths per 100,000 children, while the CFR is 3.58% with varying true effect sizes of 2.84% to 4.52%.

Interpretation

With 79.5 million children living in Indonesia in 2018, this means that there were roughly 3,434 new cases of childhood ALL. An organized effort between multiple sectors is needed to improve the registries of childhood ALL in Indonesia.

Potential Use of Patient-Specific Induced Pluripotent Stem Cell for Liver Fibrosis Thalassemia Treatment Management

Thalassemia is the most common inherited single gene blood disease worldwide and present a significant health problem in the world. Approximately, 1.5% of the global populations (An estimated 80–90 million people) are carriers of β-thalassemia. Around 5% of Indonesia population is thought to carry the thalassemia gene. The globin imbalance in β-thalassemia major causes hemolysis and ineffective erythropoiesis which results in anemia leading to increases of iron absorption. Furthermore, repeated blood transfusion and long-term increased iron absorption will lead to excessive accumulation of iron in vital organs, especially in the liver, causes liver fibrosis then leading to liver disease. Iron overload can be controlled by iron chelating drugs with the risk of side effects; therefore, a breakthrough is needed. Stem cell technology has a potential to provide novel insight in thalassemia major, through induced pluripotent stem cells (iPSCs) who has the ability to differentiate into hepatic stellate cells (HSCs)-like cells. iPSCs derived HSC-like cells (iPSC-HSCs) present the phenotypic and functional characteristics of HSCs. The utilization of iPSCs is a new option in personalized thalassemia management.

Parental Factors Contribute to Childhood Cancer Abandonment Treatment During COVID-19

Factors influence a person’s health seeking behavior related to abandonment rate on pediatric oncology treatment during this pandemic is unknown. The aim is to identify factors influencing abandonment rates in early pandemic. This was a cross-sectional studies during early pandemic and analyze factors in parents whose children had treatment for malignancy contribute to their children’s abandonment treatment rate through guided interview using questionnaire. The characteristic related significantly with treatment abandonment is maternal education. It is found that patients whose mother had education less than secondary school was 1.315 (CI 1.013-1.707) having risk experience abandonment treatment. Parental perception related to impact of COVID-19 was significantly related to treatment abandonment rate with RR 0.202 (CI 0.86-0.471). Patients whose parents have positive perception how abandonment treatment affect their child outcome, believe that doctor has taken step to prevent COVID-19 transmission during treatment, and receive information about COVID-19, having less risk being abandonment treatment.

Extended family thalassemia screening as a feasible alternative method to be implemented in identifying carriers in West Java, Indonesia

The thalassemia screening program in Indonesia mostly conducted sporadically. Ideal prospective screening is still limited. This study aimed to compare thalassemia screening methods using the extended family approach with and without a history of severe thalassemia and the feasibility of implementing extended family screening method. A case control study was conducted in Dr. Hasan Sadikin General Hospital Bandung with 3 generations of extended families. Data were collected from 150 subjects of 8 extended families with severe thalassemia as an index case entry and 151 subjects of 12 families with no history of thalassemia. All subjects were examined for Hb, MCV, MCH, and peripheral blood smear (PBS) as initial laboratory examinations. Subjects with MCV < 80 fL, MCH < 27 pg, and suggestive findings on PBS continued hemoglobin analysis. Carrier status was determined by definition. All subjects consented to undergo screening and voluntarily participated. The proportion of thalassemia carriers and the participation rate between the 2 groups were compared. Sixty-four of 150 (42.7%) and 16 of 151 (10.6%) carriers were identified in both the case and control group (p < 0.001). The participation rate was 42-88 vs. 23-100% (p = 0.244). The mean age was 31.9 ± 21.2 vs. 31.1 ± 20.8 years (p = 0.782). The median family size was 28.5 vs. 20 subjects per family (p = 0.245). The types of identified thalassemia carrier in both groups consisted of β-thalassemia, β-thalassemia/HbE, suspected α-thalassemia, and β-thalassemia Hb variant. All carriers continued the counseling process. The extended family method seems feasible to be implemented for thalassemia screening in West Java, Indonesia.

Serum TNF-α Level as a Possible Predictor of Inhibitor Levels in Severe Hemophilia A

BACKGROUND

The development of factor VIII (FVIII) inhibitor in patients with hemophilia A (PWHA) is a great challenge for hemophilia care. Both genetic and environmental factors led to complications in PWHA. The development of inhibitory antibodies is usually induced by the immune response. Tumor necrosis factor α (TNF-α), one of the cytokines, might contribute to its polymorphism. In this study, we investigated the clinical factors, level of serum TNF-α, and polymorphism of c.-308G > A TNF - α gene in inhibitor development in severe PWHA.

METHODS

A cross-sectional study was conducted among all PWHA in West Java province. The clinical parameters, FVIII, FVIII inhibitor, and serum TNF-α level were assessed. The genotyping of -380G > A TNF-α gene polymorphism was performed using polymerase chain reaction and Sanger sequencing.

RESULTS

Among the 258 PWHA, 216 (83.7%) were identified as severe PWHA. The FVIII inhibitor was identified in 90/216 (41.6%) of severe PWHA, consisting of 45 high-titer inhibitors (HTI) and 45 low-titer inhibitors (LTI). There was a significant correlation between serum TNF-α level and the development of HTI (p = 0.043). The cutoff point of serum TNF-α level, which can be used to differentiate between HTI and LTI, was 11.45 pg/mL. The frequency of FVIII replacement therapy was significant only in HTI of severe PWHA regarding serum TNF-α level (p = 0.028). There is no correlation between polymorphisms of -380G > A TNF-α gene and inhibitor development (p = 0.645).

CONCLUSIONS

The prevalence of FVIII inhibitor in severe PWHA in West Java, Indonesia, was 41.6%. The frequency of replacement therapy is a risk factor for inhibitor development. Serum TNF-α level might be used to differentiate between high and low inhibitor levels in severe hemophilia A, and this might support decision making regarding treatment options for inhibitor in severe hemophilia A.

Monitoring Of High-Dose Methotrexate (Mtx)-Related Toxicity and Mtx Levels in Children with Acute Lymphoblastic Leukemia: A Pilot-Study in Indonesia

The administration of high-dose methotrexate (HD-MTX) requires an accurate monitoring of blood MTX levels to determine the regimen of leucovorin rescue and urine alkalinization to prevent toxicity. However, it is technically and logistically challenging to screen patients routinely in limited-resource settings. This study aimed to evaluate blood MTX levels at 24- and 48-hours from start of infusion in relation to clinical toxicity in childhood ALL.

METHODS

A prospective cohort study was conducted on 32 consecutive children with acute lymphoblastic leukemia (ALL) who had received at least one cycle of 1 g/m2 HD-MTX intravenous infusion as a part of consolidation treatment based on the 2013 Indonesian ALL Protocol. In total, 68 cycles were evaluated. Serum MTX concentrations were measured using enzyme immunoassay. MTX toxicity was categorized using common toxicity criteria (CTCAE) 3.0 version. The association between MTX level and clinical toxicity was assessed by non-parametric analysis.

RESULTS

The 24-hours MTX level was median 29.8 ng/mL (0.065 µmol/L) (IQR 8.1-390.6) with a modest decrease in 48-hours MTX serum level in all cycles (median 28.3 ng/mL and 0.062 µmol/L; IQR 0.35-28.7; p <0.05). The two most common toxicities were hepatotoxicity (32.2%) and neutropenia (30.9%). Nephrotoxicity and febrile neutropenia occurred in 8.8% and 5.8% of patients, respectively, with low percentage of mucositis (4.3%) and thrombocytopenia (5.6%) recorded.  No statistically significant association was found between MTX levels and clinical toxicity, except for liver toxicity.

CONCLUSION

Serum MTX levels at 24-hours and 48-hours are low, followed by only 4.4% grade III/IV hepatotoxicity and 26,4% grade III/IV neutropenia. There is no significant association between the clinical toxicity and MTX levels at the two points of measurement. An attempt to increase the MTX dose and/or to introduce a loading dose should be considered in subsequent ALL protocol as supported by further pharmacokinetic MTX studies in the Indonesian population.

Differences in Bleeding Episodes in Severe Hemophilia A Based on Nutritional Status

Background: Hemophilia A is a congenital bleeding disorder caused by the deficiency of coagulation factor VIII and is characterized by joint bleeding, especially in weight-bearing joints. An excess weight may cause bleeding in hemophilia due to increased joint tension. This study aimed to determine the differences in bleeding episodes between severe hemophilia A patients with and without excess weight. Method: A comparative observational analytic study was conducted in March-November 2019 using a cross-sectional design. Subjects were patients with severe hemophilia A registered in the Indonesian Hemophilia Society Association in West Java and had had severe hemophilia A for at least two years old with complete data on date of birth, height, weight, and bleeding intensity. Subjects were divided into groups with excess weight (excess weight) and without excess weight (non-excess weight). Nutritional status in adults was determined based on age-specific percentile BMI. Bleeding episodes were determined as frequency of bleeding in one year. The Mann-Whitney statistical test was used to observe the difference between groups. Result: Of 226 severe hemophilia A patients registered, only 155 patients were included. Of these, 121 patients did not have excess weight and 34 had excess weight. The median bleeding episodes of in the non-excess weight and excess weight groups were 24(1-48) and 24(8-48), respectively (p=0.761). Conclusion: There is no difference in bleeding episodes Between severe hemophilia A patients with excess weight and without excess weight. However, good nutrition education needs to be provided to these patients since excess weight may increase bleeding in joints.

Osteocalcin expression of platelet-rich fibrin (PRF) and platelet-rich plasma (PRP) added with hydroxyapatite (HA) in rabbit’s post extraction tooth sockets

Introduction: Platelets play an important role in wound healing because it is a reservoir for growth factors and cytokines which is important in bone regeneration and soft tissue healing. The purpose of this study was to compare the use of scaffolds in platelet-rich fibrin (PRF) and platelet-rich plasma (PRP) which added with hydroxyapatite (HA) in the socket healing process after tooth extraction in the value of regenerating an alveolar bone tissue. Methods: The research was conducted at biomedical laboratory Bandung Islamic University. Eighteen rabbits (Oryctolagus cuniculus) with extracted anterior and inferior teeth were divided into 2 treatment groups and 3 observation times. The tooth socket is filled with PRF (Group 1) and PRP + HA (Group 2). The observation was conducted on Day 3, Day 7 and Day 14. Immunoexpression Osteocalcin was performed to assess the healing process of alveolar bone. Data was analyzed with the SPSS software program. Analysis of normality data by Shapiro-Wilk test, homogeneity of variance with Levene's test and comparison between treatment groups with the Chi-square test. Results: Group 1 shown the average score was higher than in Group 2 with a strong category of 72.2% for Group 1 and 56.6% for Group 2. Based on statistically,  there was no difference in osteocalcin immunoexpression between Group 1 and Group 2 with the p-value>0.05. Conclusion: Regeneration of rabbit’s alveolar bone tissue by application of PRF and PRP plus HA as scaffolds have results was similar. The use of PRF in post-extraction wound recovery is a better choice because it has an easy procedure and lower cost.

Hubungan antara Red Cell Distribution Width dan Kejadian Sepsis Neonatorum Bayi Prematur

Latar belakang. Sepsis neonatorum merupakan penyebab utama kematian bayi. Perjalanan awal neonatus sepsis sulit dikenali sehingga diperlukan penilaian klinis dan laboratorium menyeluruh. Red cell distribution width (RDW) sebagai parameter karakteristik eritrosit telah digunakan pada pasien dewasa, anak, dan neonatus cukup bulan sepsis. Belum banyak studi dilakukan pada bayi prematur. Tujuan. Mengetahui hubungan antara RDW dan kejadian sepsis neonatorum bayi prematur.Metode. Penelitian observasional potong lintang pada bayi prematur gestasi 28-<37 minggu dengan risiko infeksi yang dirawat di Bagian Neonatologi Rumah Sakit Hasan Sadikin bulan Desember 2018. Subjek memenuhi kriteria inklusi dilakukan penilaian kejadian sepsis dengan skor modifikasi Tollner dan pemeriksaan RDW. Analisis data menggunakan uji chi-kuadrat dan uji Kruskal-Wallis.Hasil. Dari 39 subjek ditemukan 7 bayi (17,9%) sepsis neonatorum, 11 bayi (28,2%) diduga sepsis dan 21 bayi (53,8%) tidak sepsis. Seluruh subjek memiliki rerata berat badan lahir 1732 gram dan median gestasi 34 minggu. Bayi prematur sepsis memiliki median RDW lebih besar (17,8%) dibandingkan bayi diduga (16,5%) dan tidak sepsis (16,7%). RDW normal didapati pada 55% bayi tidak sepsis, 33% bayi diduga sepsis dan 12% bayi sepsis. Terdapat hubungan bermakna antara peningkatan RDW dan kejadian sepsis neonatorum dengan p=0,006 (p<0,05). Kesimpulan. Peningkatan RDW berhubungan dengan neonatus prematur sepsis.

Laporan kasus berbasis bukti: Pedoman Skrining Populasi dengan Risiko Tinggi Talasemia

Latar belakang. Talasemia merupakan penyakit keturunan akibat kelainan sel darah merah yang belum dapat disembuhkan, tetapi dapat dicegah. Berbagai studi memperlihatkan bahwa program pencegahan melalui skrining talasemia jauh lebih menguntungkan dibandingkan pengobatan. Skrining dapat dilakukan melalui berbagai metode, di antaranya skrining populasi umum dan populasi khusus. Sampai saat ini belum ada pedoman skrining khusus pada populasi dengan risiko tinggi. Tujuan. Mengumpulkan bukti ilmiah mengenai validitas, manfaat, dan rekomendasi metode skrining keluarga (cascade family screening) pada penyandang talasemia.Metode. Penelusuran pustaka secara daring lewat Pubmed Clinical Queries, Cochrane Library, dan Google Scholar.Hasil. Didapatkan tiga artikel studi potong lintang yang berhubungan dengan pertanyaan klinis penelitian. Ketiga penelitian tersebut mempraktikan skrining kaskade pada anggota keluarga pasien talasemia-β mayor dalam tiga generasi. Studi pertama (Ansari, dkk) menunjukkan 62,2% anggota keluarga yang diskrining merupakan pembawa sifat talasemia beta. Studi kedua (Gorakshakar, dkk) menunjukkan angka pembawa sifat sebesar 21,9%. Studi ketiga (Baig, dkk) menunjukkan angka pembawa sifat sebesar 44,4%. Angka ini lebih besar dari frekuensi pembawa sifat talasemia dari populasi umum sebesar 5−8%. Kesimpulan. Skrining kaskade merupakan pilihan yang efektif dan praktikal dibandingkan dengan skrining populasi pada negara-negara dengan keterbatasan biaya dan sumber daya fasilitas kesehatan.

Temporal association between serious bleeding and immunization: vitamin K deficiency as main causative factor

BACKGROUND

Bleeding as an adverse event following immunization (AEFI) that is rarely reported in children, although it can be a parental concern. Bleeding episodes ranging in severity from mild to severe and defined as any external and/or internal bleeding can be caused by acquired or hereditary disorders. This study analyzes whether bleeding episodes in children that were recorded as AEFIs are causally associated with immunization and elaborates their etiology.

METHODS

A cross-sectional study of 388 AEFI cases in children from West Java Provincial Committee in Indonesia confirmed by case findings from 2000 until 2017.

RESULTS

Of the total number of cases studied, 55 (14%) involved children aged 5 days to 12 years who presented with bleeding and were referred to a provincial hospital. Analysis revealed that 32 cases were most likely caused by acquired prothrombin complex deficiency (APCD) and 30 of these APCD cases were strongly suspected to be manifestations of vitamin K deficiency bleeding (VKDB). All VKDB subjects were aged 5 days to 3 months without a history of administration of prophylactic vitamin K. When a World Health Organization classification was used, most bleeding cases in this study became coincidental events with a temporal association with immunization. A causality assessment suggested that these cases were causally unrelated.

CONCLUSION

Most cases of bleeding reported as an AEFI were found to be VKDB, which is considered a coincidental event following immunization with a temporal association, and an unrelated category based on the results of a causality assessment. Vitamin K should be administered to all newborns as a prophylactic and AEFI surveillance should be improved based on the low numbers of AEFI reported in Indonesia.

Hubungan antara Nilai C−Reactive Protein, Immature To Total Neutrophil Ratio, dan Red Cell Distribution Width dengan Kejadian Sepsis Neonatorum Bayi Prematur

Latar belakang. Bayi prematur rentan terhadap infeksi yang berisiko sepsis akibat sistem imun yang belum sempurna. Deteksi dini sepsis neonatorum dapat dilakukan dengan menggunakan sistem penilaian modifikasi Tollner yang berdasarkan penilaian klinis dan parameter laboratorium, seperti C-Reactive Protein (CRP), rasio Immature to Total Neutrophil (rasio I/T), dan Red Cell Distribution Width (RDW). Pemeriksaan RDW menunjukkan heterogenitas eritrosit akibat detruksi eritrosit oleh suatu proses infeksi.Tujuan. Mengetahui hubungan antara nilai CRP, rasio I/T, dan RDW dengan kejadian sepsis neonatorum bayi prematur. Metode. Studi kasus kontrol menggunakan data sekunder rekam medis dengan subjek penelitian bayi prematur usia gestasi 28-<37 minggu yang dirawat di ruang neonatus Rumah Sakit Hasan Sadikin (RSHS) periode Desember 2018−Mei 2019. Kelompok kasus adalah bayi prematur sepsis, sedangkan kelompok kontrol adalah bayi prematur sakit tidak sepsis yang dilakukan pemeriksaan CRP, rasio I/T, dan RDW. Data dianalisis secara bivariat dan multivariat dengan regresi logistik menggunakan program SPSS dan STATA.Hasil. Penelitian ini melibatkan 30 bayi prematur sepsis dan 30 bayi prematur tidak sakit (kontrol). Analisis bivariat menunjukkan nilai CRP dan rasio IT berhubungan bermakna terhadap kejadian sepsis dengan masing-masing p<0,001 dan p<0,011. Analisis multivariat dengan regresi logistik menunjukkan nilai CRP >0,64 mg/dL berisiko 32 kali terhadap kejadian sepsis (p<0,001) dibandingkan rasio I/T >0,119 dan RDW >18,7% yang masing-masing 3,2 kali (p=0,446) dan 0,9 kali (p=0,947) terhadap kejadian sepsis.Kesimpulan. Pemeriksaan CRP merupakan pemeriksaan yang lebih baik dalam membantu menegakkan diagnosis sepsis neonatorum bayi prematur dibandingkan pemeriksaan rasio I/T dan RDW.

Evaluasi Fungsi Ginjal pada Penyandang Talasemia-β Mayor Anak

Latar belakang. Informasi keterlibatan ginjal pada penyandang talasemia-β mayor anak masih sedikit. Disfungsi ginjal dipengaruhi berbagai faktor seperti anemia kronis, hipoksia kronis, dan hemosiderosis. Neutrophil gelatinase associated lipocaline urin (NGALu) merupakan penanda biologis dini yang sensitif dan spesifik terhadap gangguan ginjal. Tujuan. Menilai disfungsi ginjal pada penyandang talasemia-β mayor anak menggunakan NGALu.Metode. Penelitian dengan rancang potong lintang dilaksanakan Oktober–November 2018. Subjek adalah penyandang talasemia β mayor anak di RS. Hasan Sadikin yang menggunakan kelasi besi deferiprondan dipilih secara consecutive sampling. Heteroanamnesis pada orang tua mengenai riwayat penyakit dan frekuensi transfusi. Terhadap subjek penelitian dilakukan pemeriksaan feritin serum, kreatinin serum, dan NGALu. Uji statistik menggunakan uji korelasi rank Spearman dengan nilai kemaknaan p<0,05.Hasil. Sebanyak 71 subjek yang memenuhi kriteria penelitian, terdiri dari 46 laki-laki dan 25 perempuan. Kadar rerata kreatinin serum 0,38±0,08 mg/dL, median feritin 2897,1 ng/mL, median NGALu 13,8 ng/mL. Peningkatan kadar NGALu ditemukan 11 (15%) subjek. Didapatkan korelasi negatif antara frekuensi transfusi dan kadar NGALu (r= -0,294, p=0,006). Tidak terdapat korelasi baik antara feritin serum dengan kreatinin serum maupun feritin serum dan NGALuKesimpulan. Disfungsi ginjal sudah terindikasi terjadi pada penyandang talasemia-β mayor anak.

The effect of the chitosan-collagen membrane on wound healing process in rat mandibular defect

Background:

Collagen and chitosan are potential biomaterials for medical applications; chitosan-collagen membranes are used as a barrier membrane in guided tissue regeneration and guided bone regeneration.

Aims:

The purpose of this study was to analyze the effect of the chitosan-collagen membrane on wound healing in rat mandibular defect by counting the number of fibroblasts and new blood vessels.

Materials and Methods:

As much as 24 male Wistar rats were divided into two groups, the treatment and control group. Bone defects were made In the rat mandible with diamond bur with a diameter of 2 mm, then the defect was covered with a chitosan-collagen membrane, and the control group was covered without application of chitosan-collagen membrane. After the 3^rd, 7^th, 14^th, and the 21^st day, the defect site was analyzed histologically. The number of fibroblasts and blood vessels was counted under a light microscope, at five fields with ×1000 and ×400 microscope magnification.

Statistical Analysis Used:

This study was done by using analysis of variance and unpaired t-test.

Results:

The average number of fibroblasts and blood vessels in the treatment group was higher than the control group. There was a significant difference in the number of fibroblasts on the 3^rd and 7^th day (P = 0.001; P = 0.001) and the number of blood vessels on the 3^rd day (P = 0.04).

Conclusion:

The chitosan-collagen membrane was able to increase the number of fibroblasts and new blood vessels in the wound healing process.

Korelasi Feritin Serum dengan Neopterin Serum pada Penyandang Talasemia-β Mayor Anak di Rumah Sakit Umum Pusat Dr. Hasan Sadikin

Latar belakang. Penyandang talasemia-β mayor berisiko lebih tinggi mengalami infeksi akibat disfungsi sistem imun karena kelebihan besi. Beban besi tubuh dapat ditunjukkan oleh kadar feritin serum (FS) sementara kadar neopterin serum (NS) merupakan penanda sensitif imunitas seluler tubuh.Tujuan. Mengetahui korelasi kadar FS dengan NS pada penyandang talasemia-β mayor anak.Metode. Studi potong lintang dilakukan pada penyandang talasemia-β mayor anak secara konsekutif yang telah mengalami kelebihan besi di Klinik Talasemia Anak RSUP Dr Hasan Sadikin pada Februari 2018. Subjek penelitian dipilih secara konsekutif. Kadar FS diperiksa dengan metoda immunoassay (CLIA), sedangkan NS dengan ELISA. Analisis statistik menggunakan korelasi rank Spearman, kemaknaan ditentukan berdasarkan nilai p<0,05. Hasil. Empat puluh anak memenuhi kriteria penelitian, terdiri dari 58% laki-laki dan 48% berusia lebih dari 10 tahun. Median kadar FS dan NS adalah 3391,1 ng/mL dan 0,57 nmol/L dengan rentang FS dan NS, yaitu 1038,1–7490,2 ng/mL dan 0,118–2,220 nmol/L. Secara keseluruhan korelasi kadar FS dengan NS diperoleh r= -0,474; p=0,002, sementara pada kadar FS <2000ng/mL didapatkan korelasi positif (r= 0,250).Kesimpulan. Kadar neopterin serum berkorelasi dengan kadar feritin serum, FS tidak dapat digunakan untuk memprediksi status imun pada penyandang talasemia-β mayor anak.

Perbedaan Kadar Feritin Serum Pada Penyandang Talasemia β Mayor yang Mengalami Hipotiroid dan Eutiroid

Latar belakang. Komplikasi penumpukan besi pada organ tiroid berupa hipotiroid. Sebagian besar penelitian yang meneliti hubungan feritin serum dan hipotiroid mendapatkan hasil yang tidak bermakna. Penumpukan besi pada organ dapat dipengaruhi oleh faktor genetik sehingga menyebabkan perbedaan hasil penelitian.Tujuan. Menentukan perbedaan feritin serum pada penyandang talasemia β mayor dengan hipotiroid dan eutiroid.Metode. Jenis penelitian ini adalah analitik observasional rancangan cross sectional pada penyandang talasemia β mayor di poliklinik anak Hemato-Onkologi RSUP Dr. Hasan Sadikin. Subjek diperiksakan TSH, FT4, T3 dan feritin, dibagi menjadi kelompok hipotiroid dan eutiroid, kemudian diklasifikasikan menjadi hipotiroid nyata, subklinis, sekunder dan eutiroid. Analisis menggunakan Uji Mann Whitney dan Kruskall Wallis.Hasil. Subjek penelitian 68 anak, 38 subjek (55%) mengalami hipotiroid. Feritin serum kelompok hipotiroid 3275 ng/dL, berbanding 3648 ng/dL pada eutiroid, tidak berbeda bermakna (p=0,443). Terdapat hubungan feritin serum dengan klasifikasi hipotiroid. Feritin serum berdasarkan klasifikasi hipotiroid nyata, subklinis, sekunder dan eutiroid secara berurutan sebesar 6575, 2687, 4089, dan 3648 ng/mL (p=0,027). Analisis posthoc mendapatkan hipotiroid nyata dan subklinis berbeda bermakna.Kesimpulan. Hasil penelitian ini menunjukkan feritin serum tidak berbeda pada kelompok hipotiroid dan eutiroid, tetapi berbeda pada hipotiroid nyata dan subklinis. Hasil penelitian mendorong dilakukan evaluasi profil tiroid secara rutin sejak dini.

Mutation spectrum of β-globin gene in thalassemia patients at Hasan Sadikin Hospital - West Java Indonesia

Thalassemia is the most common hereditary haemolytic anemia in Southeast Asia, in which Indonesia is among countries that are at a high risk for thalassemia. It has been reported that mutation in the beta-globin gene is responsible in severe Thalassemia. However, the spectrum of beta-globin gene mutations in Indonesian population varies in different regions . Thus, this study aimed to identify the most prevalent mutation of Thalassemia patients from the Hasan Sadikin Hospital, Bandung, using this as a reference hospital for Thalassemia in West Java. The three most prevalent mutations of beta globin (IVS1nt5, Cd26 (HbE), and IVS1nt1), were conducted in the beginning of this study. Mutations of 291 samples were detected by PCR-RFLP in the Molecular Genetic Laboratory, Faculty of Medicine Universitas Padjadjaran, Bandung. The prevalence of the beta globin gene mutation types were 47.4% IVS1nt5 homozygote, 9.9% compound heterozygote IVS1nt5/HbE, 5.4% compound heterozygote IVS1nt5/IVS1nt1, 1.4% compound heterozygote HbE/IVS1nt1, 1% HbE homozygote, 14.4% Compound heterzygote IVS1nt5/… (no paired mutation), 2.06% compound heterozygote HbE/… (no paired mutation), 1.3% compound heterozygote IVS1nt1/… (no paired mutation), and 7 samples were unidentified. The thalassemia mutation IVS1nt5 homozygote is the most common mutation found in Thalassemia patients at Hasan Sadikin Hospital, Bandung. The samples with unidentified results might carry mutations other than the three that are observed in the present study.

Korelasi Kadar Feritin dengan Jumlah CD4, CD8, dan Rasio CD4/CD8 pada Penyandang Talasemia Mayor Anak

Latar belakang. Pada talasemia mayor, peningkatan penyerapan besi dan transfusi darah regular mengakibatkan penumpukan besi pada berbagai organ dan gangguan sistem imun melalui berbagai mekanisme. Keadaan ini berkaitan dengan risiko infeksi pada penyandang talasemia mayor anak.Tujuan. Untuk menganalisis korelasi kadar feritin dengan jumlah CD4, CD8, dan rasio CD4/CD8 pada penyandang talasemia mayor anak.Metode. Penelitian observasional analitik menggunakan rancangan potong lintang, subjek 30 anak yang memenuhi kriteria penelitian. Analisis data menggunakan uji korelasi.Hasil. Didapatkan jumlah CD4 absolut, CD4%, CD8 absolut dan rasio CD4/CD8 menurun. Selain itu, terdapat jumlah CD4 absolut, CD8 absolut dan CD8% meningkat. Pada kelompok usia ≤5 tahun, korelasi kadar feritin dengan CD8 absolut, CD8%, dan rasio CD4/CD8 berturut-turut menghasilkan koefisien korelasi 0,691, 0,557, -0,680, dan p<0,05. Sementara pada kelompok lama terapi ≤5 tahun korelasi kadar feritin dengan CD8 absolut, CD8%, dan rasio CD4/CD8 menghasilkan koefisien korelasi 0,709, 0,571, -0,726 dengan p<0,05. Kesimpulan. Tidak terdapat korelasi antara kadar feritin dengan jumlah CD4, CD8, rasio CD4/CD8. Peningkatan kadar feritin akan diikuti dengan peningkatan jumlah CD8 absolut dan CD8%, serta penurunan rasio CD4/CD8 pada penyandang talasemia mayor anak berdasar atas usia dan lama terapi ≤5 tahun.

Severe α-thalassemia intermedia due to a compound heterozygosity for the highly unstable Hb Adana (HBA2: c.179G>A) and a novel codon 24 (HBA2: c.75T>A) mutation

HBA2

We report a novel mutation at codon 24 of the α2-globin gene (HBA2: c.75T > A) found in a Sundanese family. This novel mutation was detected during prenatal diagnosis. The couple already had a 7-year-old boy who exhibited clinically severe α-thalassemia intermedia (α-TI), and he was found to be a compound heterozygote for the novel mutation at codon 24 and the previously described Hb Adana (HBA2: c.179G > A) at codon 59 of the α2-globin gene. The father was a carrier of the novel point mutation and showed normal hemoglobin (Hb) and a low mean corpuscular volume (MCV) and mean corpuscular Hb (MCH) value.