Current trends in the management of beta thalassemia

Red blood cell alloimmunization in blood transfusion-dependent β thalassemia major patients in Sana'a City-Yemen

The development of erythrocyte alloantibodies complicates transfusion therapy in β thalassemia major patients. These antibodies increase the need for blood and intensify transfusion complications. Data on erythrocyte alloimmunization is scarce in Yemeni thalassemia patients. We studied the frequency of alloimmunization in multitransfused β-thalassemia major patients and investigated risk factors that affect antibody formation. Blood samples were taken from 100 β thalassemia major patients who received multitransfused leukodepleted packed red-blood cells. Antibody screening and identification were performed by indirect antiglobulin test using the gel column technique. All patients were tested for autoantibodies using autocontrol and direct antiglobulin test. No adsorption test was done as no autoantibodies were detected in any patient. In our study of 100 β-thalassemia patients, 50 were male and 50 were female with ages ranging from 1 to 30 years. Alloantibodies were present in 6% of patients, while no autoantibodies were detected. Of the 17 alloantibodies identified, the majority were directed against Kell (41.2%) and Rh (29.4%) blood groups. Alloimmunization was significantly associated with age group and sex (p = 0.013, p = 0.030), respectively in β thalassemia major patients. The development of alloantibodies was not significantly associated with duration, total number of transfusions and splenectomy (P = 0.445, P = 0.125, P = 0.647). No autoantibodies found in patients with β thalassemia major. The study found low rates of erythrocyte alloimmunization in multitransfused β-thalassemia major patients, but significant alloantibodies were produced primarily from Kell and Rh blood groups, suggesting the need for providing phenotypically matched cells for selective antigens to improve transfusion efficiency.

Long-Term Effects of Iron Chelating Agents on Ocular Function in Patients with Thalassemia Major

Background

The aim of this study is to evaluate eye structures and function in patients receiving iron chelating therapy and to assess whether a correlation exists between the onset of ocular alterations and the intake of iron chelating drugs.

Methods

A prospective cohort study was performed. Eighty-eight patients, composed of children and adults with thalassemia major (TM) who are taking or had taken iron chelating drugs (deferoxamine, deferiprone or deferasirox), have been initially enrolled in the study. The final sample featured 80 patients, including 18 children and 62 adults. These subjects received an eye examination to evaluate intraocular pressure (IOP), best corrected visual acuity (BCVA), the presence of refractive defects, cornea, anterior chamber, lens, fundus oculi, visual field and mean retinal nerve fiber layer (RNFL) thickness. Logistic regression model analysis was performed in order to assess any correlation. In addition, a literature search regarding the relation between iron chelating drugs and ocular adverse events was carried out to compare the results obtained with the evidence in the literature.

Results

Logistic regression did not report a significant correlation between the intake of iron chelating drugs and the onset of anterior ocular segment alterations, lens opacities, retinal diseases, optical neuropathies, astigmatism, visual field and RNFL thickness defects. Logistic regression returned a statistically significant correlation between myopia and iron chelation therapy (p-value 0.04; OR 1.05) and also between presbyopia and total duration of therapy with deferoxamine (p-value 0.03; OR 1.21). Although intraocular pressure levels remained within the normal range, a significant correlation with the length of deferoxamine therapy has been found (p-value 0.002; association coefficient -0.12). A negative correlation between deferiprone and presbyopia has also been observed.

Conclusion

Iron chelation therapy is not associated with severe visual function alterations. Limitation of deferoxamine treatment can help prevent ocular complications. Deferiprone and/or deferasirox may be preferable, especially in patients over age 40 years.

Left ventricular systolic dyssynchrony index and endothelial dysfunction parameters as subclinical predictors of cardiovascular involvement in patients with beta-thalassemia major

OBJECTIVE

Cardiovascular iron load is the leading cause of morbidity and mortality in beta-thalassemia major (β-TM). However, many patients remain asymptomatic until the late stage. In this cross-sectional study, we investigated the role of three-dimensional (3D) echocardiography and endothelial dysfunction parameters in asymptomatic β-TM patients, and the relationship between these parameters and cardiac magnetic resonance imaging (MRI) T2* value.

METHODS

A total of 51 asymptomatic β-TM patients receiving regular blood transfusions were divided into two groups based on cardiac MRI-T2* values (MRI-T2*<20 ms and ≥20 ms), which MRI-T2*<20 ms determines myocardial iron load and evaluated by two-dimensional (2D) and 3D-echocardiography including endothelial dysfunction parameters. The relationships between ferritin levels, 2D and 3D-echocardiography measurements, endothelial dysfunction parameters, and cardiac MRI-T2* values were investigated.

RESULTS

All left ventricle ejection fraction (LVEF) obtained by 2D-echocardiography were normal (≥50%). LVEF-3D (53.25 ± 2.33 vs. 58.81 + 1.02), SDI12 (6.53 ± 0.56 vs. 2.85 + 0.48), and SDI16 (7.65 ± 0.75 vs. 3.26 + 0.49) were significantly different and negatively correlated between groups with MRI-T2*<20 ms and ≥20 ms, respectively. Flow-mediated dilatation (FMD) (6.08% ± 0.34% vs. 14.46% ± 1.12), aortic strain (7.79% ± 2.19% vs. 12.76% ± 4.19), ferritin levels were significantly different and negatively correlated between groups with MRI-T2*<20 ms and ≥20 ms, respectively. Higher ferritin, SDI12/16 were significant independent predictors of MR-T2* < 20 ms. SDI16 > 5.5, SDI12 > 4.3 predicted MRI-T2*<20ms with a sensitivity of 92%, specificity of 81% (AUC 0.85, P < .001), and sensitivity of 92%, specificity of 78% (AUC 0.83, P < .001), respectively.

CONCLUSION

SDI12/16 calculated by 3D-echocardiography may be a promising predictors of cardiovascular iron load and, decreased LVEF-3D, FMD, and aortic strain might be good indicators of subclinical cardiovascular involvement of β-TM.

Prevalence of Transfusion Transmitted Infections and the Quality of Life in β-thalassemia Major Patients

Objectives To determine the prevalence of hepatitis B, hepatitis C, and human immunodeficiency virus (HIV) in chronically transfused β-thalassemia major (TM) patients, and to assess their quality of life (QoL). Methods This cross-sectional study was conducted in three different thalassemia centers located in Peshawar, Khyber Pakhtunkhwa from January to July 2019. These centers provide screened blood and essential medical care for thalassemia patients. These centers include the Fatimid Foundation, Hamza Foundation, and Rehman Medical Institute, Peshawar, Khyber Pakhtunkhwa. A total of 431 blood transfusion-dependent β-thalassemia patients registered at these centers were selected. QoL in β-TM patients was assessed by a newly developed instrument, the TranQoL questionnaire. For the data analysis procedure, Microsoft Excel and Statistical Package for the Social Sciences; version 22 (SPSS Inc., Chicago, IL) was used. Results A total of 431 patients were included in our study. The ages ranged from five years to 23 years with a mean age of 11.54 ± 3.6 years; 58.93% were male and the rest were female with a male to female ratio of 1.43:1. A total of 129 (29.93%) patients were infected by transfusion-transmitted infections (TTIs). Hepatitis C virus (HCV) was found prevalent in 23.66%, hepatitis B virus (HBV) was found in 4.87%, and HIV was found prevalent in 1.39% cases. The results showed a high proportion of HCV in males 27.95% as compared to females 17.51% (p value = 0.31). Patients were divided into high (good) QoL score of >50 and low (poor) score of <50. In patients with hepatitis C, the QoL was poor in 90 (88.23%) patients and was good in only 12 (11.76%) patients (p value=0.01); in the hepatitis B group, it was good in only eight (38.09%) and poor in 13 (61.90%) patients (p-value 0.04), and for patients with HIV, it was poor in all six patients (p=0.001). Conclusion Our study concludes that transfusion-transmitted disease is very high and that HCV is the leading TTI followed by HBV and HIV. QoL in patients with TTIs was poor. The use of advanced technology in blood screening, voluntary donations, donor selection, and asepsis during blood transfusion is imperative to curtail the transmission.

Comprehensive patient care improves quality of life in transfusion dependent patients with β-thalassemia

Objectives:

To investigate levels of quality of life (QOL) among thalassemia patients at the Hereditary Blood Disorders Center in Al-Madinah Al-Munawarah, Kingdom of Saudi Arabia.

Methods:

A cross-sectional study was performed on 43 transfusion dependent thalassemia patients compared with 43 normal subjects, as a control, using the World Health Organization Quality Of Life - Brief questionnaire between May 2012 and September 2012 at the Hereditary Blood Disorders Center, Maternity and Children Hospital in Al-Madinah Al-Munawarah, Kingdom of Saudi Arabia.

Results:

Forty-three thalassemia patients were examined, 23 males and 20 females, and compared with 43 peers (control group), 24 males and 19 females. There was no statistical difference between patients and controls for psychological domains (53.4 versus 56.9, p=0.059) and environmental domains (56.6 versus 57.0, p=0.884). Patients had better social QOL than the control group (39.3 versus 31.7, p=0.003), while the control group had better physical QOL (55.4 versus 61.9, p=0.047). Among patients, there was no statistical difference in QOL domains for variables of age, desferroxamine use, serum ferritin level, disease severity, presence of complications; splenectomy status, hepatitis C virus status, or family history.

Conclusion:

Quality of life in thalassemia patients is similar to the control group particularly social life, though physical health is less. Improvement of patients care from all aspects will improve their QOL. More studies in this field are needed with a bigger sample size.

Relationship Between Serum Hepcidin and Ferritin Levels in Patients With Thalassemia Major and Intermedia in Southern Iran

BACKGROUND

Hepcidin is a key regulator of iron absorption in humans. It is mainly affected by hypoxia and iron stores.

OBJECTIVES

The current study aimed to determine the correlation between serum hepcidin and ferritin levels in patients with Thalassemia Major (TM) and Thalassemia Intermedia (TI).

PATIENTS AND METHODS

The current cross-sectional study investigated 88 randomly selected patients with Thalassemia, 48 TM and 40 TI, registered at the Thalassemia Clinic of Shiraz University of Medical Sciences, a referral center for Thalassemia in Southern Iran in 2013. All patients with TI were receiving Hydroxyurea (HU) 10 - 15 mg/kg/day for at least 10 years. The serum hepcidin, ferritin levels, hemoglobin (Hb) and nucleated Red Blood Cell (RBC) of the two groups were measured.

RESULTS

No statistically significant correlation was observed between serum hepcidin and ferritin levels in any of the two groups of patients with TM (rs = 0.02, P = 0.892) or TI (rs = 0.055, P = 0.734). The median Interquartile Range (IQR) for serum hepcidin and ferritin levels were significantly higher in TM compared to TI group, (hepcidin: 87.6 (43.9) vs. 51.8 (23.4), P < 0.001; ferritin: 2208 (3761) vs. 465 (632), P < 0.001).

CONCLUSIONS

There was insignificant correlation between serum hepcidin and ferritin levels in the two groups of patients with TM and TI. It seems that regulation of hepcidin in patients with Thalassemia is more affected by erythropoeitic activity than iron stores. Also, hepcidin levels were significantly higher in patients with TM than TI, possibly due to higher erythropoeitic activity in TI. In TI, it seems that low dose HU increases Hb levels and leads to transfusion-independence, but it is not high enough to suppress bone marrow activity and ineffective erythropoiesis. Consequently, serum hepcidin level decreases.

Examining the usefulness of a Family Empowerment Program guided by the Illness Beliefs Model for families caring for a child with thalassemia

The purpose of this pilot study was to design, implement, and evaluate a Family Empowerment Program (FEP), guided by the Illness Beliefs Model. Participants included 25 Thai family members who were the primary caregivers of a child with thalassemia. In Phase I, data were collected from participants using individual in-depth interviews and focus groups before involvement in the FEP. In Phase II, 12 hr of FEP sessions were offered to groups of participants. Content analysis of the audiotaped FEP sessions is reported in this article. Family caregivers reported that the FEP helped them share beliefs and experiences related to caring for their child with thalassemia, make decisions related to families' problems/needs and beliefs, provide each other mutual social support, and develop increased ability to manage care for their chronically ill child through sharing information and learning from other family caregivers about family functioning, family management, and family relationships. Future research is needed to examine the FEP intervention under more controlled conditions with measures that include family functioning and child health outcomes.

Quality of Life of Adolescents With Transfusion-dependent Thalassemia and Their Siblings: A Cross-sectional Study

Transfusion-dependent thalassemia (TDT) and its treatment affect the physical, emotional, and social functioning, impairing the quality of life (QoL). There are few studies on QoL of adolescent with TDT. Its effect on their siblings' QoL has not been studied so far. In this cross-sectional study, 40 adolescents with TDT, 28 siblings, and 40 controls were studied to assess the QoL of adolescents thalassemics, and their siblings using the shorter version of World Health Organization Quality of Life instrument, the WHOQOL-BREF. Thalassemics had poor perception of their general health and scored significantly lower in all the subscales compared with the controls. Lowest mean subscale scores were for physical (57.7 vs. 72.4, P<0.001), and psychological domains (56.7 vs. 72.3, P<0.001). Their siblings also scored significantly less in environment domain. Prevalence of school dropout, short stature, and delayed puberty were significantly higher in thalassemics. Pretransfusion hemoglobin, age at onset of anemia, and chronological age were found to be significant predictors of total summary scores. This study showed that the concept of QoL is a cumulative reflection of individual and disease variables and highlights the negative impact of thalassemia on the patients' QoL and some aspects of their siblings' lives also.

'Reflex' HPLC testing as a screening modality for variant hemoglobins: a pilot study of 1310 cases at a pediatric referral hospital

OBJECTIVE

High-performance liquid chromatography (HPLC) has been evaluated as useful technique for detection of variant hemoglobins in newborn screening, ethnicity-based screening, and patients with abnormal hemoglobin electrophoresis. This study aimed at evaluating this technique as 'reflex' testing in a pediatric referral center.

METHODS

This study included 1317 children visiting the pediatric hospital, who underwent HPLC analysis on anticoagulated blood samples. These patients were divided into clinician-requisitioned HPLC (group A), 'reflex' testing for anemia (group B), and unrelated etiologies (group C). HPLC graphs were evaluated for various hemoglobins. Statistical analysis was performed for comparison between these groups for frequency of abnormal HPLC assay and various red cell parameters.

RESULTS

The frequency of abnormal HPLC assay was 22.89% in group A (125 of 546 cases), 26.89% in group B (78 of 290 cases), and 31.8% in group C (153 of 781 cases) with statistically significant difference. The most frequent variant in all three groups was thalassemia trait. Thalassemia intermedia and major, both were detected in few patients in groups B and C.

CONCLUSION

'Reflex' testing for hemoglobin variants can be undertaken for pediatric samples to enhance detection of these variants and avoid an additional venepuncture.

Thalassemia Major in Adults: Short Stature, Hyperpigmentation, Inadequate Chelation, and Transfusion-Transmitted Infections are Key Features

Background:

Effective transfusion and chelation have prolonged the quality and longevity of life in thalassemics, who now survive into adulthood. Hence, adult physicians need to be aware of their clinical and laboratory profile and the problems faced by them.

Aim:

The present study was aimed to evaluate the clinical profile of adult thalassemics.

Materials and Methods:

Adult (>18 years) thalassemia major patients (n=19) were evaluated clinically and fasting pretransfusion blood samples were analyzed for complete blood counts, kidney and liver function tests, plasma glucose, serum ferritin, and thyroid hormone levels.

Results:

Average age was 21.65±2.47 years (range 19–28 years), 42.1% had Body mass index (BMI) <18.5. Splenectomy had been performed in 47.4% before reaching adulthood, males significantly outnumbered females (72% vs. 12.5%). Hemoglobin levels <8 g/dl were observed in 31.6% and none had serum ferritin levels in the recommended range suggesting inadequacy of both transfusion and chelation. Indirect hyperbilirubinemia was observed in 21.1% patients although kidney functions, serum protein, and albumin were normal in all patients. Electrocardiographic abnormalities, diabetes mellitus or hypothyroidism were absent. Five patients (26.3%) had contracted transfusion-transmitted viral infections – 21.1% and 5.3% respectively had antibodies to hepatitis C virus and HIV, while 5.3% were positive for Australia antigen. All patients were receiving chelation therapy – deferiprone alone (78.9%) or along with desferrioxamine (21.1%). Average dose of deferiprone being used was 95±8 mg/kg.

Conclusion:

Adult thalassemia major patients present with a distinct clinical profile having low BMI, generalized hyperpigmentation, most are splenectomized, have low hemoglobin, inadequate chelation and harbor transfusion-transmitted infections. Adult physician needs to be aware of this profile.

Psychometric properties of the Specific Thalassemia Quality of Life Instrument for adults

BACKGROUND

No specific questionnaire has been developed to assess the health-related quality of life of thalassemia patients. Thus, the main objective of this study was to develop, according to psychometric standards, a self-administered Specific Thalassemia Quality of Life Instrument (STQOLI) for adult patients.

METHODS

First, a qualitative phase was conducted to generate items and identify domains using the critical analysis incident technique and a literature review. A list of easily comprehensible, non-redundant items was defined using the Delphi technique and a pilot study on ten thalassemia patients. This phase involved both patients and experts. The second step was a quantitative validation phase comprising a study of 128 thalassemia patients in a single hospital. It was designed to select items, identify dimensions, and measure reliability and internal and concurrent validity. The psychometric and scaling properties of the proposed 41-item Specific Thalassemia Quality of Life Instrument were then assessed among patients recruited from the Thalassemia Unit at the General Hospital of Nikaia, Greece.

RESULTS

The final questionnaire had 41 items comprising four main domains and one global item about general health. The factorial structure was satisfactory (loading > 0.40 on each factor of the four domains for all items). Interscale correlations ranged from 0.06 to 0.78, Cronbach's α-coefficients were 0.78 for the psychosocial domain, 0.77 for the chelation domain, 0.72 for the transfusion domain, 0.81 for the disease and symptoms domain, and 0.840 for the total score of the questionnaire.

CONCLUSION

The 41-item Specific Thalassemia Quality of Life Instrument seems to be a valid tool for assessing health-related quality of life for patients with thalassemia. More research is needed to explore the universal properties of the questionnaire.

Sex steroid priming for induction of puberty in thalassemia patients with pulsatile reversible hypogonadotrophic hypogonadism

Growth and pubertal disturbances are the most common causes of morbidity, affecting 60-80% β-thalassemia major (β-TM) patients worldwide, due mainly to hypogonadotrophic hypogonadism (HH). We undertook a 6-year prospective study of 55 Indian β-TM children with stunted growth and absent or arrested puberty, aged 15-18 years with pulsatile HH, to evaluate the role of low dose sex steroid priming (6-12 months) for physiological induction of puberty. Eighty percent responded favorably with increase in height, growth spurt and completed pubertal maturation [Tanner stage 4-5 (T4-T5)] and 20% moved from T2 to T3. There was biochemical improvement in maturation of hypothalamic-pituitary (H-P) axis. Those younger than 15 years with minimal iron load had the best outcome. Our data suggest that sex steroid priming is a feasible method of induction of physiological puberty in β-TM patients with sexual infantilism and reversible apulsatile HH, especially in younger patients with minimal iron loads.

Self-reported level of and factors influencing the compliance to desferrioxamine therapy in multitransfused thalassaemias

AIM

To analyse the self-reported degree of and factors influencing the compliance to desferrioxamine (DFO) therapy in children with transfusion-dependent thalassaemia major in Malaysia.

METHODS

A cross-sectional study was conducted on all children with thalassaemia major on DFO attending Likas Hospital, Sabah, in September 2008. Patients or carer-providers were interviewed to report on the degree of compliance as either highly (administering >90% of DFO), moderately (51-90%), poorly (1%-50%) or non-compliant (0%) to DFO in the preceding month. The latest serum ferritin levels were noted.

RESULTS

The median (range) age at first blood transfusion of these 139 (73 males, median (range) age at interview: 9.0 years (2-16 years)) patients were 1.0 year (2 months to 10 years). The median (range) duration of regular DFO therapy was 2 years (2 months to 10 years). Forty-three (31%) of the patients reported themselves to be highly compliant, 70 (50%) moderately and 26 (19%) poorly or non-compliant. Multivariate analysis showed that a lower family income negatively affected the degree of compliance, while family support positively affected the degree of compliance to DFO. No correlation existed between self-reported degree of compliance and latest serum ferritin level (6444 ± µmol/L; P = 0.186).

CONCLUSION

The self-reported compliance to DFO therapy was moderate in this cohort of patients with thalassaemia major in Malaysia. The serum ferritin level was high, possibly because of the relatively short duration of DFO therapy and compliance. Oral iron chelator should be considered to improve the compliance to iron chelation.

Factors affecting health-related quality of life in Thai children with thalassemia

Background

Knowledge of the factors associated with health-related quality of life (HRQOL) among patients with thalassemia is essential in developing more suitable clinical, counseling, and social support programs to improve treatment outcomes of these patients. In light of the limited research in this area, this study aims to examine factors associated with HRQOL among children and adolescents with thalassemia in Thailand.

Methods

A cross-sectional survey was conducted in three selected hospitals in Thailand during June to November 2006. PedsQL™ 4.0 Generic Core Scale (Thai version) was used to assess HRQOL in 315 thalassemia patients between 5 and 18 years of age. Other related clinical characteristics of the patients were collected via medical record review.

Results

The mean (SD) of the total summary score was 76.67 (11.40), while the means (SD) for the Physical Health Summary score and Psychosocial Health Summary score were 78.24 (14.77) and 75.54 (12.76), respectively. The school functioning subscale scored the lowest, with a mean of 67.89 (SD = 15.92). The following factors significantly affected the HRQOL of the patients: age; age at onset of anemia and age at first transfusion; pre-transfusion hemoglobin (Hb) level; receiving a blood transfusion during the previous three months; and disease severity. In addition, iron chelation therapy had a significant negative effect on HRQOL in the school functioning subscale. In contrast, serum ferritin level, frequency of blood transfusions per year, and gender were not significantly related to HRQOL among these patients. The results from multivariate analysis also confirmed these findings.

Conclusions

To improve HRQOL of thalassemia patients, suitable programs aimed at providing psychosocial support and a link between the patient, school officials, the family and the physician are important, especially in terms of improving the school functioning score. The findings also confirmed the importance of maintaining a pre-transfusion Hb level of at least 9-10.5 g/dL. In addition, special care and attention should be given to patients with a severe condition, and those who are receiving subcutaneous iron chelation therapy.

Skin diseases in patients with beta-thalassemia major

BACKGROUND

Beta-thalassemia major affects multiple organs and is associated with considerable morbidity and mortality. The goal of this analysis was to document the frequency of skin diseases among patients with beta-thalassemia major.

METHODS

A sample of 78 patients with beta-thalassemia major was recruited and interviewed at the thalassemia clinic between April and June 2008. A dermatologist completed a skin examination of each patient and recorded any skin disease present. The patients' laboratory results and treatment modalities were recorded from the charts.

RESULTS

Sixty-five (83.3%) of the 78 patients examined had a diagnosed skin disease: pruritus (37.2%), xerosis (34.6%), scars (24.4%), ephelides (23.1%), skin irritation/erythema caused by deferoxamine pump (12.8%), idiopathic guttate hypomelanosis (6.4%), pityriasis alba (6.4%), tinea infections (5.1%), verruca vulgaris (5.1%), urticaria (3.8%), hyperhidrosis, contact dermatitis, and acne (2.6%), necrobiosis lipoidica (1.3%), melasma (1.3%), and others (14.1%). Pruritus and xerosis increased in frequency with age. The mean serum ferritin level was higher in patients with xerosis than in those without (5607.7 +/- 2997.5 ng/mL and 4285.2 +/- 4732.4 ng/mL, respectively) (P1/4 0.005). Moreover, xerosis was observed significantly more frequently inpatients using deferoxamine and deferiprone than in those using deferasirox (P1/4 0.047, P1/4 0.027, and P1/4 0.273, respectively).

CONCLUSION

Skin diseases, especially pruritus and xerosis, are observed highly frequently inpatients with beta-thalassemia major. Treatment is needed for these patients who already have other significant morbidities.

Anxiety and depression affects life and sleep quality in adults with beta-thalassemia

PURPOSE

The aim of this study was to investigate the association of anxiety and depression symptoms with health related quality of life (HRQoL) and sleep quality in patients with beta-thalassemia.

METHODS

In a cross-sectional study between 2006 and 2007, 292 thalassemic patients were assessed for symptoms of anxiety and depression (Hospital Anxiety Depression Scale; HADS), HRQoL (Short Form-36, SF-36) and quality of sleep (Pittsburgh Sleep Quality Index; PSQI). Linear regression models were used to determine possible predictive value of high anxiety and depressive symptoms on HRQoL and sleep quality, separately.

RESULTS

Mental and physical quality of life scores were predicted by symptoms of depression and somatic comorbidities. Total sleep quality was predicted by anxiety symptoms and somatic comorbidities.

CONCLUSIONS

Screening for anxiety and depression in patients with thalassemia is essential. Further studies should test if appropriate treatment of these conditions may improve patients HRQoL and sleep quality or not.