Gender Disparities in Psychological Disturbances and Quality of Life Among Adolescent and Adult Patients with Thalassemia: A Review.

Thalassemia is a chronic disease caused by impaired globin chain synthesis, leading to ineffective erythropoiesis, hemolysis, and chronic anemia. The treatment of patients with thalassemia, including blood transfusion combined with chelation therapy has progressed and improved their survival and prognosis. However, thalassemia-related psychological problems and impaired health-related quality of life (QoL) challenges still exist. Gender is one of the factors that has been suggested, to contribute to the disparities in psychological outcomes. This review article examined the evidence for gender differences in psychological disturbances and QoL in adolescent and adult patients with thalassemia. A non-systematic search of the literature was conducted in PubMed and Google Scholar for English full-text available from 2013 to 2023. We identified 23 studies with a sample size ≥ 100 that examined gender disparities in anxiety, depression, and QoL in adolescent and adult patients with thalassemia (mean prevalence of female = 53.1%; mean age = 28 years). Our review shows that there are gender disparities in psychological distress and QoL in adolescent and adult patients with thalassemia. Statistically significant gender differences were demonstrated in 62% of the psychological and QoL outcomes from 16 studies. Female patients had a higher prevalence of anxiety, depression, and poorer QoL in some studies. However, further studies with sufficient power and design are necessary to confirm the existence of gender disparities in psychological disturbances and QoL outcomes.

Piperine Enhances the Antimalarial Activity of Curcumin in Plasmodium berghei ANKA-Infected Mice: A Novel Approach for Malaria Prophylaxis.

Malaria is a prevalent vector-borne infectious disease in tropical regions, particularly in the absence of effective vaccines and because of the emergence resistance of Plasmodium to available antimalarial drugs. An alternative strategy for malaria eradication could be the combination of existing compounds that possess antimalarial activity to target multiple stages of the parasite. This study evaluated the antimalarial activity of a combination of curcumin and piperine in mice. A total of 42 mice were assigned to six groups depending on the treatment administered: group I (normal group) with aquadest; group II (negative control) with 0.2 ml DMSO; group III received a standard malarial drug (artesunate 5 mg/kg BW); groups IV, V, and VI with curcumin 300 mg/kg BW, curcumin 300 mg/kg BW and piperine 20 mg/kg BW, and piperine 20 mg/kg BW, respectively. The antimalarial activity was evaluated using prophylactic assays in Plasmodium berghei ANKA-infected mice, including the percentage parasitemia, clinical signs, survival rate, serum biochemical analysis, parasitic load in the liver, and liver histopathology. All treatments showed significant (p < 0.05) antiplasmodial activity, with considerable parasite inhibition (>50%), curcumin 300 mg/kg BW (60.22%), curcumin 300 mg/kg BW, and piperine 20 mg/kg BW (77.94%) except for piperine 20 mg/kg BW (47.20%), eliciting greater inhibition relative to that of artesunate (51.18%). The delayed onset of clinical symptoms and prolonged survival rate were also significant (p < 0.05) in the combination of curcumin and piperine treated group. In addition, the low parasitic load in the liver and mild histopathological changes in the liver suggest that the combination of curcumin and piperine had synergistic or additive effects. These findings demonstrate the promising use of these combined compounds as a malarial prophylactic. Further studies were recommended to assess their clinical usefulness.

Cell-free fetal DNA as a non-invasive method using pyrosequencing in detecting beta-globin gene mutation: A pilot study from area with limited facilities in Indonesia.

Background: Thalassemia is a monogenic, autosomal recessive, inherited disorder of the red blood cells caused by mutations or deletions in the globin gene. Approximately 6-10% of the Indonesian population carries the ß-globin gene mutation; however, premarital screening is rarely conducted, and antenatal screening is optional. We explored the use of cell-free fetal DNA (cffDNA) as a potential non-invasive method of detecting the fetal ß-globin gene mutation prenatally in pregnant women. Materials and methods: Pregnant mothers (n = 10), who were known carriers of thalassemia and who had a history of having borne a baby with thalassemia major, and their carrier husbands (n = 4) were recruited after providing consent. EDTA blood was drawn, and maternal DNA, including cffDNA, and paternal DNA were isolated. Maternal contamination tests were conducted using the variable number tandem repeat test for ApoB and D1S80 loci. Allele quantification was performed by pyrosequencing. Known mutations from the bio-archived DNA of patients with thalassemia major (n = 16) were run alongside as a control. Results: In total, 7 out of 10 cffDNA successfully passed the maternal contamination test. The results of the allele quantification showed that six fetuses were predictive carriers of IVS1nt5 and one was predictive normal, in line with the allele quantification for the bio-archived DNA from patients with thalassemia major. The minimum threshold percentage for mutant A allele at cd26 was 32%, mutant T allele at IVS1nt1 was 23%, and mutant C allele at IVS1nt5 was 39%. Conclusion: Taking cffDNA from the mother's blood proved useful as a non-invasive means of detecting the ß-globin gene mutation using pyrosequencing allele quantification. This non-invasive method is of great interest for prenatal diagnosis in settings with limited facilities, as it minimizes the risk of abortion. Further study of other mutations of the ß-globin gene is needed.

Global Globin Network Consensus Paper: Classification and Stratified Roadmaps for Improved Thalassaemia Care and Prevention in 32 Countries.

The Global Globin Network (GGN) is a project-wide initiative of the Human Variome/Global Variome Project (HVP) focusing on haemoglobinopathies to build the capacity for genomic diagnosis, clinical services, and research in low- and middle-income countries. At present, there is no framework to evaluate the improvement of care, treatment, and prevention of thalassaemia and other haemoglobinopathies globally, despite thalassaemia being one of the most common monogenic diseases worldwide. Here, we propose a universally applicable system for evaluating and grouping countries based on qualitative indicators according to the quality of care, treatment, and prevention of haemoglobinopathies. We also apply this system to GGN countries as proof of principle. To this end, qualitative indicators were extracted from the IthaMaps database of the ITHANET portal, which allowed four groups of countries (A, B, C, and D) to be defined based on major qualitative indicators, supported by minor qualitative indicators for countries with limited resource settings and by the overall haemoglobinopathy carrier frequency for the target countries of immigration. The proposed rubrics and accumulative scores will help analyse the performance and improvement of care, treatment, and prevention of haemoglobinopathies in the GGN and beyond. Our proposed criteria complement future data collection from GGN countries to help monitor the quality of services for haemoglobinopathies, provide ongoing estimates for services and epidemiology in GGN countries, and note the contribution of the GGN to a local and global reduction of disease burden.

Oral Administration of Piperine as Curative and Prophylaxis Reduces Parasitaemia in Plasmodium berghei ANKA-Infected Mice.

Malaria remains a public health problem and a leading cause of death worldwide. Consequently, the discovery of novel agents, including substances from medicinal plants, is urgently needed. Piper nigrum has long been used by the community in the treatment of the symptoms of malaria. In a previous study, Piper nigrum was demonstrated to exhibit promising antiplasmodial activity against Plasmodium falciparum 3D7 and INDO strains. The aim of this study was to further investigate the antimalarial activity (curative and prophylactic) of piperine (a major isolated constituent of Piper nigrum) in Plasmodium berghei ANKA-infected mice. Piperine 10, 20, and 40 mg/kg body weight (bw), artesunate 5 mg/kg bw, and DMSO were administered orally for four days to different groups of Swiss Webster mice. Then, mice were monitored for parasitaemia, body weight, rectal temperature, survival rate, and clinical parameters. Piperine 40 mg/kg bw in curative and prophylactic tests had the maximum parasitaemia chemosuppression of 79.21% and 58.8% (p < 0.05), respectively, with a significant effect on the survival rate compared with control animals. In the curative test, piperine 40 mg/kg bw reduced the mean clinical score compared with the control group. Additionally, piperine showed an ability to protect organs (lungs, liver, spleen, and kidneys) from some damage in a dose-dependent manner. This study can be used as a basis for further discovery of novel chemotherapeutic or chemoprophylactic compounds.

The Potential use of a Curcumin-Piperine Combination as an Antimalarial Agent: A Systematic Review.

Malaria remains a significant global health problem, but the development of effective antimalarial drugs is challenging due to the parasite's complex life cycle and lack of knowledge about the critical specific stages. Medicinal plants have been investigated as adjuvant therapy for malaria, so this systematic review summarizes 46 primary articles published until December 2020 that discuss curcumin and piperine as antimalarial agents. The selected articles discussed their antioxidant, anti-inflammatory, and antiapoptosis properties, as well as their mechanism of action against Plasmodium species. Curcumin is a potent antioxidant, damages parasite DNA, and may promote an immune response against Plasmodium by increasing reactive oxygen species (ROS), while piperine is also a potent antioxidant that potentiates the effects of curcumin. Hence, combining these compounds is likely to have the same effect as chloroquine, that is, attenuate and restrict parasite development, thereby reducing parasitemia and increasing host survival. This systematic review presents new information regarding the development of a curcumin-piperine combination for future malaria therapy.

Iron Overload in Transfusion-Dependent Indonesian Thalassemic Patients.

Thalassemia is a genetic disease caused by disruption of globin chain synthesis leading to severe anemia and thus regular blood transfusion is necessary. However, there have been known transfusions-related consequences, including iron overload and multi-organ damage. The aims of this study were to evaluate liver and cardiac function in youth and adult transfusion-dependent Indonesian thalassemic patients and to assess its correlation with serum ferritin levels, as well as T2 ∗ magnetic resonance imaging (MRI). Transfusion-dependent thalassemic (TDT) outpatients (n = 66; mean age, 21.5 ± 7.2 years) were carried out for the complete assessment consisting of blood test including liver enzyme and serum ferritin, followed by electrocardiography (ECG) and echocardiography. Subjects were also divided by serum ferritin levels into three groups: < 2500 ng/mL, 2500-5000 ng/mL, and >5000 ng/mL. Additionally, subgroup analysis in patients with T2∗ MRI assessment was conducted. In terms of age of first blood transfusion, subjects with ferritin >5000 ng/mL were the youngest among others. The alanine aminotransferase (ALT) levels in group with serum ferritin >5000 ng/mL were significantly higher than those of the group with serum ferritin <2500 ng/mL. Additionally, youth and adult TDT patients whose serum ferritin >5000 ng/mL had significantly lower tricuspid annular plane systolic excursion (TAPSE) when compared with those who had serum ferritin <2500 ng/mL. Similarly, TAPSE in patients with moderate cardiac siderosis based on cardiac T2∗ MRI was significantly lower than those without cardiac siderosis. There was significant, but only moderate correlation between serum ferritin and cardiac T2∗ MRI. Based on these findings, it is important to routinely monitor iron accumulation-related complications, including liver and cardiac damage in youth and adult TDT patients.

Correlation between Serum Fatty Acid Binding Protein 4 (FABP4) Levels and Cardiac Function in Patients with Thalassemia Major.

BACKGROUND: Patients with thalassemia major may suffer from complications due to iron overload. It has been suggested that several adipokines may play a potential role in the development of complications in thalassemia. Fatty acid-binding protein 4 (FABP4) is one of the adipokines, bridging several aspects of metabolic and inflammatory pathways. Little is known about the relationship between this adipokine and cardiac and liver function, especially in patients with thalassemia major. AIMS: This study is aimed at determining serum FABP4 levels in patients with thalassemia major and whether its concentration correlated with serum ferritin levels, as well as cardiac and liver function. METHODS: Thalassemia major outpatients (n = 48) completed laboratory examination, echocardiography, and electrocardiography. RESULTS: The mean age was 21.9 ± 8.0 years. A negative and weak correlation between serum ferritin and FABP4 was observed (r = -0.291, p < 0.05). In addition, there was moderate and positive correlation between left atrial volume index (LAVI) and FABP4 (r = 0.316, p < 0.05). CONCLUSIONS: Serum FABP4 correlated with serum ferritin and cardiac function in patients with thalassemia major. FABP4 may be a potential clinical biomarker for cardiac dysfunction via metabolic and inflammatory pathways due to iron accumulation and toxicity in patients with thalassemia major.

Hypoxia-inducible factor-1α in acute ischemic stroke: neuroprotection for better clinical outcome.

BACKGROUND: Hypoxia-inducible factor-1α (HIF-1α) is a transcription factor which maintains cellular homeostasis in response to hypoxia. It can trigger apoptosis while stimulating angiogenesis process and decrease neurological deficit after an ischemic stroke. Up until now, this protein complex has not been widely investigated especially in stroke patient. OBJECTIVE: Here, we examined the potential of HIF-1α as a marker for neuroplasticity process after ischemic stroke. METHODS: Serum HIF-1α were measured in acute ischemic stroke patients. National Institute of Health Stroke Scale (NIHSS) were assessed on the admission and discharge day (between days 7 and 14). Ischemic stroke divided into 2 groups: large vessel disease (LVD, n = 31) and small vessel disease (SVD, n = 27). Statistical significances were calculated with Spearman rank test. RESULTS: A total of 58 patients, 31 with large artery atherosclerosis LVD and 27 with small vessel disease (SVD) were included in this study. HIF-1α level in LVD group was 0.5225 ± 0.2459 ng/mL and in SVD group was 0.3815 ± 0.121 ng/mL. HIF-1α was higher (p = 0.004) in LVD group than in SVD group. The initial NIHSS score in LVD group was 15.46 ± 2.61 and discharge NIHSS score was 13.31 ± 3.449. Initial NIHSS score in SVD group was 6.07 ± 1.82 and the discharge NIHSS was 5.703 ± 1.7055. In both SVD and LVD group, HIF-1α were significantly correlated with initial NIHSS (both p < 0.001) and discharge NIHSS (p < 0.0383 r = 0.94, p < 0.001, r = 0.93, respectively). CONCLUSIONS: HIF-1α has a strong correlation with NIHSS and it may be used as predictor in acute ischemic stroke outcome.

Anemia Prevalence after Iron Supplementation among Pregnant Women in Midwifes Practice of Primary Health Care Facilities in Eastern Indonesia.

BACKGROUND: Iron deficiency anemia (IDA) in pregnant women is common, and iron supplementation is given during pregnancy to reduce birth complication. This study aimed to explore the prevalence of anemia and type of anemia after iron supplementation among pregnant women in the eastern part of Indonesia. METHODS: A cross-sectional study design was conducted between January and March 2019 in three Primary Health Care (PHC) facilities at Kupang, West Timor. After consent, pregnant women who had taken their iron supplementation for at least 3 months were asked for iron pills intake by using a self-designed questionnaire and by counting the pills leftover. Complete blood count examination was performed, and the type of anemia was assessed using Shine and Lal index (SLI; MCV ∗ MCV ∗ MCH/100) to determine whether anemia was due to iron deficiency or ß-thalassemia trait (ß-TT). In a subset of iron tablets distributed in the PHCs, Fe-concentration was measured. RESULTS: Of 102 pregnant women included, only 25.5% had taken the pills with a pill count of >80%. Interestingly, Fe-concentration in the pills from three different PHC facilities varied between 75% and 100%. After iron supplementation, however, anemia was detected in 34.3%, and based on SLI, 14.7% was suspected because of iron deficiency and 19.6% was suspective of ß-TT. Of note, nonanemic pregnant women (17.6%) had also low SLI, suggesting ß-TT or other hemoglobinopathies. CONCLUSION: Assessment of Shine and Lal index as the first step to screen the type of anemia in pregnant women from a limited area is of potential value, especially because Indonesia is located in the thalassemia belt area. An integrative approach and counseling among pregnant women with ß-TT and their partners will increase thalassemia awareness and optimal birth management.

Germline Mutations and Polymorphisms of Androgen Receptor in Prostate Cancer Patients: Frequency and Results of in Silico Analysis

Background: Germline and somatic polymorphisms and mutations of the Androgen Receptor (AR) gene are known to be associated with the incidence of prostate cancer (PCa) in different populations. In this study we assessed germline AR polymorphisms and mutations in PCa patients with prediction of pathogenicity of the identified mutations by in silico analysis. Methods: Diagnosis of PCa was based on histopathology of prostate tissue (Gleason Score criteria) and serum prostate-specific antigen (PSA) levels. Genomic DNA was extracted from peripheral blood of 38 patients. All exons and exon-intron boundaries of AR were amplified using polymerase chain reactions (PCR) followed by Sanger sequencing. In silico analysis was performed using Polyphen-2 and Mutation Taster®. Results: Two polymorphisms, CAG repeat sequence (13-34 repeats in length) and p.Pro214Glu (MAF: 0.0789) located in exon 1 were identified. A missense mutation (c.47C>A/p.Pro146Glu) and in-frame deletion of a CAG sequence leading to loss of Arginine at codon 85 (c.252_254delCAG/p.Arg85-) were identified in a 70 year old patient with a Gleason Score and PSA level of 2 and 2.4ng/dL, respectively. His PSA level decreased to < 0.5 ng/dL after 9 months of androgen deprivation therapy. Identified mutations were predicted to be non-disease causing by Polyphen-2 and Mutation Taster®. Conclusion: Our data demonstrated that the frequency of germline mutations of AR was low in PCa patients in Indonesia (5.26%: 2/38 alleles), so that they are not likely to be major etiological factors. The in silico analysis of identified AR mutations in this study corroborated the clinopathology features of the patient.

Fcγ receptor III expression and morphological maturity on neutrophil are associated with higher iron level of major beta-thalassemia.

Lifetime blood transfusion experienced by major ß-thalassemia patients complicated with iron overload, therefore, may lead to their tissue injury. Ultimately, free toxic iron may alter immune response via dysregulation of immune cell activity producing prolonged effector reaction. Neutrophil as one of the vital innate immune cell despite serves as the first line of defense resulting acute inflammation has a pivotal role in chronic inflammation while releasing the toxic substance that interferes biological processes. This process is initiated by one of them by activation of Fcγ Receptor III (CD16), a neutrophil membrane-bound protein. A cross-sectional laboratory study involving lysed-erythrocyte heparinized whole blood of fifty pediatric major ß-thalassemia patients treated with monoclonal antibodies i.e. CD16, CD14, and HLA-DR, dissected into CD16+ and CD16++ population using flow cytometry. Expression of Fcγ Receptor III was measured as Median Fluorescent Intensity (MFI). Hematology and iron status were measured. A correlation analysis was done. MFI of CD16 neutrophil [509.5 (371 - 796.5)] and ferritin level [(3209 µg/L, 1862 - 4564)] was positively correlated (r = 0.4, P = 0.007). Respectively, ferritin and serum iron were found negatively correlated with segmented neutrophils (r = -0.3, P = 0.02; r = -0.3, P = 0.02). Change in CD16 expression may implicate preliminarily neutrophil activation as a response of iron-overloaded tissue and result in chronic inflammation in ß-thalassemia patients. However, the maturity of this cell may be altered.  Future study in the understanding of neutrophil-mediated inflammation, particularly related to immune complexes and functionality, is imperative to be explored.

Low Hemoglobin among Pregnant Women in Midwives Practice of Primary Health Care, Jatinangor, Indonesia: Iron Deficiency Anemia or ß-Thalassemia Trait?

Low hemoglobin (Hb) or anemia is common among pregnant women in developing countries which may cause adverse pregnancy outcomes and maternal deaths. Our study aimed to assess Hb level measured by midwives in primary health care facility at rural area of Jatinangor, Indonesia, and to explore whether the anemia was due to iron deficiency (IDA) or ß-thalassemia trait (ß-TT). Pregnant women (n = 105) had finger prick test for Hb level during a regular antenatal care examination from October to November 2016. Hb level by finger prick test was compared with venous blood, measured by complete blood count (CBC). Indices including MCV and MCH and indices of Shine & Lal, Mentzer, Srivastava, Engels & Frase, Ehsani, and Sirdah were analyzed to differentiate anemia due to IDA and anemia due to suspect ß-TT. HbA2 was measured to confirm ß-TT. Anemic pregnant women were found in 86.7% by finger prick test compared to 21.9% (n = 23) by CBC. The prevalence of ß-TT in our study was 5.7%. Hb measurement among pregnant women in low resource area is highly important; however, finger prick test in this study showed a high frequency of anemia which may lead to iron oversupplementation. A standard CBC is encouraged; MCV and MCH would help midwives to identify ß-TT.

HPV genotyping linear assay test comparison in cervical cancer patients: implications for HPV prevalence and molecular epidemiology in a limited-resource area in Bandung, Indonesia.

BACKGROUND: Persistent infection with high risk human papillomavirus (hrHPV) is strongly associated with cervical cancer. Normal cervical cells may also harbor hrHPV, and detection of early hrHPV infection may minimize risk of cervical cancer development. This study aimed to compare two commercial HPV genotyping assays that may affordable for early screening in a limited-resource setting in Bandung, Indonesia. MATERIALS AND METHODS: DNA from cervical biopsies with histologically confirmed as squamous cell cervical cacinoma were HPV genotyped by Linear Assay 1 (Roche Diagnostics, Mannheim, Germany) or Linear Assay 2 (Digene HPV Genotyping RH Test, Qiagen Gaithersburg, MD). In a subset of samples of each group, HPV genotype results were then compared. RESULTS: Of 28 samples genotyped by linear assay 1, 22 (78.6%) demonstrated multiple infections with HPV-16 and other hrHPV types 18, 45 and/or 52. In another set of 38 samples genotyped by linear assay 2, 28 (68.4%) were mostly single infections by hrHPV type 16 or 18. Interestingly, 4 samples that had been tested by both kits showed discordant results. CONCLUSIONS: In a limited-resource area such as in Indonesia, country with a high prevalence of HPV infection a reliable cervical screening test in general population for early hrHPV detection is needed. Geographical variation in HPV genotyping result might have impacts for HPV prevalence and molecular epidemiology as the distribution in HPV genotypes should give clear information to assess the impact of HPV prophylactic vaccines.