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.

Therapeutic Outcomes of Pediatric Acute Myeloblastic Leukemia Patients at a Tertiary Hospital in Bandung, Indonesia

Background: Acute myeloblastic leukemia (AML) is a subtype of leukemia characterized by myeloid infiltration into the bone marrow, blood, and other tissues. AML ranks 5th malignancy in children and the prognosis is poor. After chemotherapy, the outcomes vary. Therefore, this study aimed to provide further insight into the therapeutic outcomes of pediatric AML patients. Methods: This study was conducted with a cross-sectional descriptive method. The data were obtained from the medical records of children diagnosed with AML at the Department of Child Health of Dr. Hasan Sadikin General Hospital in 2017–2019 with the total sampling method. Data including age at determination, gender, laboratory values including hemoglobin, leukocyte, thrombocyte as well as blast cell count on peripheral blood smear were collected. Also, the bone marrow punctures gathered were clustered based on the French-American-British (FAB) classification. Data were presented in tables. Results: In total, 46 data of AML patients were retrieved, with the age category at first diagnosis was >5–12 years (48%) and predominantly males (63%), children with moderate anemia (41%), leukocytosis (35%), severe thrombocytopenia (46%), and blast cell count ≥20% (83%). AML-M2 was the most common subtype (30.4%). The majority of patients (91%) underwent chemotherapy and most (45%) patients died during chemotherapy Conclusion: The outcome of AML therapy among children is mostly poor, and particularly die during chemotherapy. Early detection and follow-up of patients to continue therapy are important aspects to reduce the mortality rate of AML.

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.

Convalescent plasma therapy in obese severe COVID-19 adolescents: Two cases report

BACKGROUND

In Indonesia, 175 cases resulted in death in children from March to December 2020. Studies regarding Convalescent Plasma Therapy's (CPT) safety and efficacy in children are scarce. Our case report was the first to write CPT in Indonesian children.

CASE PRESENTATION

In our case, two obese children with progressive shortness of breath, worsening cough, and high fever, the findings met severe COVID-19 criteria. We performed CPT for these patients and the patient's condition was improved and able to be discharged.

DISCUSSION

Severe COVID-19 with or without comorbid was the indication of CPT which had been approved by the U.S. FDA and Indonesian Pediatrics Society. The key factors associated with CPT efficacy were the donor's titer antibody, the treatment time point, and the patient's comorbidities. The clinical impact showed an improvement by the combination therapy of CPT and remdesivir.

CONCLUSION

We noted that CPT might be well tolerated, could improve the clinical impact of severe COVID-19 in adolescents, and have no adverse events as well. CPT for severe COVID-19 cases in children had the potential to be developed in studies with better designs and stronger levels of evidence.

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.

Transfusion Reactions in Pediatric Cancer Patients

Background: Transfusion is an essential component of supportive management for cancer patients with anemia and thrombocytopenia. It is generally safe; however, it has several risks and complications including those caused by transfusion reactions. This study aimed to describe transfusion reactions in pediatric cancer patients in a tertiary hospital in Indonesia. Methods: This was a descriptive cross-sectional study with a total sampling method. A prospective analysis was performed on episodes of blood transfusion in pediatric patients aged younger than 18 years old with cancer and were hospitalized at the Department of Child Health of the hospital from July to August 2019. After the consent of the parents, the patients were interviewed for various transfusion reactions. Data collected were presented using tables and charts. Results: Leukemia was the most frequent cancer in children cancer patients who need transfusion. Out of 42 children included, 155 episodes of transfusion were observed with 22 episodes showed transfusion reactions (14.2%). The most frequent manifestations were pruritus (31.8%), followed by combination of pruritus and erythema (27.4%) and fever (13.6%). These reactions appeared mostly in 1 to 2 hours (27.2%), with most were mild reactions (59.1%). Conclusion: Transfusion reactions mostly occurred among pediatric patients with cancer in the acute phase with clinical manifestation of allergic reactions, predominantly mild. Early identification of these reactions would result in better treatment and prevention for recurrence of transfusion reactions.

Clinical Characteristics of Rhabdomyosarcoma in Children: A 4-Year Study in a Tertiary Hospital

Background: Rhabdomyosarcoma (RMS) is the most common soft-tissue sarcomas (STS) in children. Even though the survival rate has increased, the mortality rates remain significantly higher in developing countries due to delay in diagnosis contributed by its diverse and clinical manifestations. This study aimed to describe the clinical characteristics of RMS patients at the Department of Child Health, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia. Methods: A descriptive cross-sectional retrospective study was conducted using a total sampling method on medical records of RMS patients aged ≤ 18-year-old during a 4-year period (2015-2018). Data on patient demographics, clinical manifestations, biopsy procedure, histopathological subtype, tumor size, primary site, pre-treatment staging, and treatment were reviewed and presented. Results: Of 30 data retrieved, male (57%), aged 1 to 5-year-old (47%), and diagnosed through open biopsy (63%) comprised the majority of the patients. More than half of the patients came with advanced stage of the disease (80%) and were treated with chemotherapy (83%). Most RMS patients had a tumor located in the head and neck region (40%) with a size of >5 cm (70%) and embryonal subtypes (43%). The remaining patients experienced alveolar subtype (17%), spindle cell subtype (13%), and unknown subtype (27%) of RMS. Conclusion: Children with a tumor in the head and neck region should be suspected as rhabdomyosarcoma, as there are various clinical characteristics of RMS in children found in this study.

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.

Hubungan Subtipe Sel Limfosit dengan Tingkat Remisi Pascakemoterapi Fase Induksi Leukemia Limfoblastik Akut

Latar belakang. Angka remisi pascakemoterapi LLA masih belum memuaskan, banyak faktor yang memengaruhi belum optimalnya luaran terapi LLA, salah satunya adalah faktor subtipe sel limfosit LLA. Tujuan. Melihat hubungan subtipe sel limfosit dengan tingkat remisi pascakemoterapi fase induksi LLA.Metode. Penelitian kohort prospektif dilakukan di RS dr. Hasan Sadikin Bandung dari bulan Februari-September 2016. Subyek adalah anak <14 tahun yang baru didiagnosis LLA berdasarkan hasil aspirasi sumsum tulang. Diambil sampel darah perifer untuk dilakukan pemeriksaan immunophenotyping agar dapat diketahui subtipe sel limfositnya, dilakukan kemoterapi fase induksi selama 6 minggu berdasarkan protokol terapi. Dilakukan aspirasi sumsum tulang evaluasi untuk melihat tingkat remisinya. Analisis statistik dilakukan dengan uji Fisher-exact. Hasil. Terdapat 40 subjek yang memenuhi kriteria inklusi dan menjalani kemoterapi fase induksi. Dari 40 subjek, 26 menyelesaikan kemoterapi fase induksi, dan dari 26 subjek yang dilakukan evaluasi aspirasi sumsum tulang, 20/26 mengalami remisi lengkap dan 6/26 tidak remisi. Terdapat 18/24 subjek sel B-LLA yang mengalami remisi lengkap dan 6/24 tidak remisi, sedangkan penderita sel T-LLA yang mengalami remisi lengkap 2/2 subjek. Tidak terdapat perbedaan yang bermakna antara subtipe sel limfosit dengan tingkat remisi pascakemoterapi fase induksi (p=0,585). Kesimpulan. Subtipe sel limfosit tidak berpengaruh terhadap tingkat remisi pascakemoterapi fase induksi.