Factors affecting quality of life in children and adolescents with thalassemia in Iraqi Kurdistan

Health-Related Quality of Life of Adolescents With Non-transfusion-Dependent Thalassemia in Basrah, Iraq

BACKGROUND

Thalassemia is a chronic inherited disease with the potential for serious clinical and psychological effects. In the case of thalassemia, a cure is not currently accessible, and lifelong treatment is required. Health-related quality of life (HRQoL) is considered a crucial health outcome.

OBJECTIVES

This study aims to assess the HRQoL of children and adolescents with non-transfusion-dependent thalassemia (NTDT) and compare it with that of beta-thalassemia major (β-TM) and healthy subjects.

PATIENTS AND METHODS

This case-control study included 88 patients with NTDT and 153 age- and gender-matched healthy children and adolescents. In addition, we included 70 registered patients with β-TM. We used the short-form health survey questionnaire to assess HRQoL.

RESULTS

Of the 88 patients, 41 were diagnosed with alpha-thalassemia intermedia (α-TI; hemoglobin H disease), and 47 were with beta-thalassemia intermedia (β-TI). HRQoL domains were significantly higher in healthy children and adolescents compared to NTDT patients (P<0.001); the role emotion domain was the most affected in NTDT patients (51.92 ± 3.37), followed by general health (52.72 ± 3.05) and role physical (53.59 ± 3.13). α-TI patients had significantly higher HRQoL domains than patients with β-TI. The study also indicated that NTDT patients had significantly better QoL scores compared to β-TM patients (P<0.001) across all domains.

CONCLUSIONS

NTDT patients have a lower HRQoL compared to healthy controls. However, their HRQoL scores are significantly better than those of patients with β-TM. Among NTDT patients, those with α-TI have significantly better HRQoL scores compared to patients with β-TI.

Quality of life, mood disorders, and cognitive impairment in adults with β-thalassemia

Advances in understanding the disease process in β-thalassemia supported development of various treatment strategies that resulted in improved survival. Improved survival, however, allowed multiple morbidities to manifest and cemented the need for frequent, lifelong treatment. This has directly impacted patients' health-related quality of life and opened the door for various psychiatric and cognitive disorders to potentially develop. In this review, we summarize available evidence on quality of life, depression and anxiety, suicidality, and cognitive impairment in adult patients with β-thalassemia while sharing our personal insights from experience in treating patients with both transfusion-dependent and non-transfusion-dependent forms.

Quality of life and thalassemia in India: A scoping review

In recent years, a multitude of studies have been conducted to investigate the assessment of quality of life (QoL) among individuals affected by thalassemia. This scoping review aimed to examine the existing knowledge regarding the QoL and its associated factors among individuals with thalassemia in India. Databases, such as PubMed, SCOPUS, Web of Science, and the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines, were searched. A total of nine articles were included in the review. The included studies mainly investigated children. The Pediatric Quality of Life Inventory (PedsQL) is the most common instrument used most often. Overall, the research findings indicate that individuals who underwent blood transfusion exhibited a lower QoL than those who did not receive blood transfusion. Additionally, it was observed that children diagnosed with thalassemia reported a lower QoL than adults. Nevertheless, the studies exhibited notable methodological deficiencies that constrained the validity and generalizability of the results. Hence, it is imperative to undertake comprehensive QoL research encompassing all regions of India and various thalassemia populations within the country to bridge this evidentiary void.

Hepatitis C and Thalassemia: A Story with (Almost) a Happy Ending

Donor screening has nearly eliminated the risk of hepatitis C virus post-transfusion transmission in resource-rich settings. Moreover, the use of direct antiviral agents made it possible to treat the majority of patients with thalassemia and hepatitis C. However, this achievement, while extremely significant, does not erase the effects of the virus in terms of fibrogenesis and mutagenic risk, and adult patients with thalassemia are facing the long-term consequences of the chronic infection both on the liver and extrahepatically. As in the general population, it is in mainly patients with cirrhosis who are increasing in age, even though they are now HCV RNA-negative, who are at risk of hepatocellular carcinoma, which continues to be statistically much more frequent in individuals with than without thalassemia. In certain resource-limited settings, the World Health Organization has estimated that up to 25 percent of blood donations do not undergo screening. It is therefore not surprising that hepatitis virus infection is still the most prevalent in patients with thalassemia worldwide.

An Epidemiological Study of the Quality of Life of Children With Beta-Thalassemia Major (β-TM) and Its Correlates in Kolkata, West Bengal, India

Background and objectives In contrast to their peers who are healthy, children with thalassemia disease are likely to have a lower quality of life (QoL). Knowledge of attributes affecting the QoL of thalassemic children may help identify key areas of intervention to improve it. Thus, the current study was envisioned to find out the quality of life (QoL) of children with beta-thalassemia major (β-TM) and its various correlates. Methods Between May 2016 and April 2017, an institution-based cross-sectional observational study was conducted in the thalassemia unit of Calcutta National Medical College and Hospital (CNMC&H), Kolkata, West Bengal, India. During the study period, 328 β-TM children and their carers were interviewed using a structured schedule. Results In the final multivariable logistic regression model, thalassemic children who were residing in an urban area (adjusted odds ratio (AOR) (95% confidence interval (CI)): 2.1 (1.1-4.0)), had mothers with a higher educational level (middle and above) (AOR (95%CI): 2.1 (1.1-4.0)), had working parents (AOR (95%CI): 2.7 (1.2-6.3)), had no family history of thalassemia (AOR (95%CI): 3.5 (1.6-8.0)), received less number of blood transfusion in the previous year (<12) (AOR (95%CI): 2.1(1.1-4.2)), had higher pre-transfusional hemoglobin (Hb) level (AOR (95%CI): 1.7(1.1-2.6)), had no transfusion-transmitted infections (TTIs) (AOR (95%CI): 2.8 (1.5-5.2)), had higher body mass index (BMI) Z score (AOR (95%CI): 1.6 (1.1-2.2)), and had higher Carer Quality of Life (CarerQoL) score (>5) (AOR (95%CI): 3.2 (1.6-6.2)) were more likely to have favorable QoL (Pediatric Quality of Life Inventory (PedsQL) score > 54.3). Interpretation and conclusions The QoL of the study participants was significantly correlated with their carers' CarerQoL, mother's educational level, parent's working status, place of residence, family history of the disease, blood transfusion frequency, pre-transfusional Hb level, and nutritional and comorbidity status.

Comparing the effects of self- care education by lecture and smartphone application on self-efficacy of patients with thalassemia

BACKGROUND

Patients with the thalassemia have a basic requirement for self-efficacy regarding their treatment procedure. The present study aimed to compare the effect of self-care education via a smartphone application and lectures on the self-efficacy of patients with thalassemia.

METHODS

In the present quasi-experimental study, 99 patients with thalassemia at Shahid Beheshti Hospital in Yasuj, Iran, in 2019 who were eligible to enter the study, were selected. The block randomization was done with the block sizes of 3, 6, and 9, and participants were randomly assigned to 3 groups: smartphone application (A), lecture intervention (B), and control (c). Smartphone application and lecture interventions were performed for intervention groups A and B, respectively, during 8 weeks. Scherer's self-efficacy measure was used to collect the data at baseline and eight weeks after the intervention. Data were analyzed by SPSS-version 25 software using Paired t-test, Wilcoxon and Kruskal-Wallis tests.

RESULTS

Ninety-nine patients with thalassemia with a mean (SD) age of 25 (6) and 58 females (58.59%) participated in the present study. The results indicated a significant difference in self-efficacy among 3 groups after intervention (P = 0.001). However, self-care education with smartphone application revealed a significant increase in the mean (SD) of self-efficacy of the patients with thalassemia 68.36(8.45) compared to the lecture method 62.55 (7.3) (P = 0.003) and control 62.09 (6.7) (P = 0.001). There were no significant differences among the self-efficacy scores of the patients in lecture intervention and control groups.

CONCLUSIONS

The results revealed that smartphone application was a suitable educational software to promote self-efficacy in patients with thalassemia. It is recommended to use smartphone application methods to improve the self-efficacy levels of patients with thalassemia.

Understanding the Association between Red Blood Cell Transfusion Utilization and Humanistic and Economic Burden in Patients with β-Thalassemia from the Patients' Perspective

We assessed the humanistic and economic burden of chronic red blood cell (RBC) transfusions on patients with β-thalassemia. This cross-sectional, US-based study included adults (≥18 years) who self-reported a β-thalassemia physician diagnosis and had received ≥1 RBC transfusion in the past 6 months. The outcomes included the Functional Assessment of Cancer Therapy-Anemia (FACT-An), Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and ad hoc questions about treatment experience, side effects, direct/indirect costs, and psychological burden. Overall, 100 patients completed the survey, of whom 70% experienced "moderate" to "extremely high" burden due to RBC transfusions, 81% reported iron overload, 42% reported compromised social lives. The mean FACT-An score was 132 (higher score indicates better outcomes; 0-188). Mean scores were 33/52 for fatigue and 20/28 for anemia symptoms in the previous 7 days. Health-related quality of life (HRQoL) temporarily improved after RBC transfusion, although patients continued to experience mild-to-severe depression and anxiety, substantial direct costs, compromised employment, and suboptimal quality of life. Over 6 months, patients dedicated a mean of 173 h to transfusion requirements and incurred out-of-pocket costs of USD 2239 for transfusions and USD 896 for additional care costs. These findings highlight the need for new treatment options to improve patient HRQoL and economic outcomes.

Determinants of Quality of Life in Children with Inborn Errors of Metabolism Receiving a Restricted Diet

OBJECTIVE

To investigate the determinants of quality of life (QoL) in children with inborn errors of metabolism with restricted diet (IEMRDs) using a single theory-based multidimensional model.

STUDY DESIGN

In this multicenter cross-sectional study, data from children aged 8-17 years with IEMRDs (except phenylketonuria) and their parents were collected from January 2015 to December 2017. Measurements included a child's self-reported QoL, self-rated behavioral problems and anxiety, and parental anxiety. Based on hypotheses from a literature-built theoretical model linking demographic, clinical, family environment, and psychosocial characteristics to QoL either directly or indirectly, associations of these factors with a child's self-rated QoL were examined using a structural equation modeling approach.

RESULTS

A total of 312 children (mean [SD] age, 12.2 [2.6] years; 51% boys [n = 160]) were included. Higher levels of trait anxiety and behavioral problems in children were the most important factors associated with poorer QoL (standardized path coefficients, -0.71 and -0.23, respectively). In addition, higher parent trait anxiety, younger age at diagnosis, and a disease requiring an emergency diet were associated with poorer QoL in these children. The final model fit the data closely according to conventional goodness-of-fit statistics and explained 86% of the QoL variance.

CONCLUSIONS

Psychosocial factors appear to be major determinants of QoL impairment in children with IEMRDs. These factors should be addressed in clinical practice as part of the global treatment plan for a child with IEMRD. Future studies based on a longitudinal design should consider coping strategies when exploring potential predictive factors of QoL.

Oral Health-Related Quality-of-Life According to Dental Caries Severity, Body Mass Index and Sociodemographic Indicators in Children with Special Health Care Needs

This study aimed to assess the impact of dental caries’ severity, body mass index (BMI), and sociodemographic factors on oral health-related quality of life (OHRQoL) for special health care needs (SHCN) children and the suitability of their caregivers as proxies to determine OHRQoL. This cross-sectional study recruited 107 pairs of SHCN children and their caregivers and asked them to complete a questionnaire on sociodemographic issues as well as the Arabic version of the early childhood oral health impact scale (A-ECOHIS). This was followed by a dental examination. Dental caries was measured using the dmft/DMFT index, while caries’ severity was also determined. The children’s height and weight were measured, and BMI (kg/m²) was recorded. Data were analyzed statistically using t-test, one-way ANOVA, and Poisson regression models. Our results revealed that the A-ECOHIS score was 10.93, while the OHRQoL was affected in 95.3% of children. The most-reported item was ‘pain in the teeth, mouth, or jaws’ (48.7%). By regression analysis, caries-free children (Odds Ratio (OR): 0.650) or those who had moderate caries (OR: 0.551) were less likely to have a negative impact on their OHRQoL than those with severe caries. Additionally, those whose caregivers had a maximum primary education (OR: 0.656) or whose occupation was in the health sector (OR: 0.721) were less likely to have a negative impact on their OHRQoL. Those who were ≤ 6 years old (OR: 1.188) were more likely to have a negative impact. BMI did not have a significant impact on the OHRQoL of the children. Further, we detected a significant positive correlation between children’s dmft/DMFT scores and the A-ECOHIS scores reported by the mothers. Given these variables, which included dental caries’ severity, but not BMI, and caregivers’ education level and occupation, plus the child’s age group, we found a significant impact on the OHRQoL. However, we found that mothers were better proxies for their children’s OHRQoL.

Patient-reported Outcome Measures in Pediatric Non-Malignant Hematology: A Systematic Review

Patient-reported outcome measures (PROMs) are questionnaires completed by patients or caregivers without influence by health care professionals. As such, PROMs show subjective health experiences, enhance the clinical information available to providers, and inform clinical action. The objective of this systematic review is to identify and list which validated PROMs have been used to monitor health-related quality of life in pediatric patients with nonmalignant hematology (hemophilia, immune thrombocytopenia, sickle cell disease, and thalassemia). Databases (MEDLINE, Embase, HaPI, CINAHL, and PsycTESTS) were searched to identify publications that validated or used PROMs as an outcome measure in the 4 disease groups. Overall, 209 articles met the inclusion criteria, identifying 113 PROMs. Of the 113 identified PROMs, 95 are generic and can be used in multiple disease groups. The Pediatric Quality of Life Generic Core Scales was the most frequently used generic PROM (68 studies). The 18 remaining PROMs were disease specific. The results of this review, together with the COSMIN tool for selecting outcome measures, will allow clinicians to evaluate the PROMs that are best suited to their patient population. In addition, the focus groups are currently being conducted with patients, parents, and clinicians to determine the optimal use of PROMs in the clinical environment.

Association Between Caregivers' Family Management and Quality of Life in Children with Chronic Disease in Southern Thailand

PURPOSE

Caring for children with chronic diseases, caregivers have to manage their child's daily life to prevent complications and improve their quality of life. This study investigated family management of children with chronic diseases, quality of life of children, and correlation between family management of caregivers and quality of life of children as perceived by the caregivers.

PATIENTS AND METHODS

This cross-sectional study collected data from 200 pairs of caregivers and children with asthma, anemia, and thalassemia aged 5 to 12 years after receiving treatment and follow-up in the pediatric outpatient department of the tertiary hospital, June to November 2020. Research instruments comprised a Family Management Measure (FaMM) and the Pediatric Quality of Life Inventory (PedsQL 4.0). Data were analyzed using descriptive and Spearman rank correlation coefficient statistics.

RESULTS

The caregivers of children obtained a mean score on family management of 166.88 (S.D.= 11.32). The quality of life of children with chronic illness had a mean score of 66.59 (S.D.= 18.63). Correlation analysis revealed that easy family management of the caregivers had a positive correlation with the quality of life of children with chronic diseases. On the contrary, difficulty in family management negatively correlated with the quality of life of the children.

CONCLUSION

Most caregivers could have easy family management in caring for the children. In summary, easy family management will allow children with chronic illness to receive decent care from their caregivers, contributing to improved quality of life.

Health-Related Quality of Life in Thai Children with Thalassemia as Evaluated by PedsQL and EQ-5D-Y: A Single-Center Experience

Background

Thalassemia remains a challenging chronic disease in Thailand, but national prenatal screening, along with better treatment and management, may have improved health-related quality of life (HRQoL) for pediatric patients. We aimed to measure the HRQoL of transfusion-dependent (TDT) and non-transfusion dependent (NTDT) of these pediatric patients at our institute.

Methods

We included all patients 2 – 18 years old, with TDT and NTDT, using the Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL) and the EuroQol Group's Five Dimensions for Youth (EQ-5D-Y) instruments. Patients and caregivers responded as appropriate for age.

Results

Mean PedsQL total summary scores (TSS) (SD) of child self-reports and parent proxy-reports were 81.00 (10.94) and 78.84 (16.72) from 150 participants. Mean EQ-5D-Y VAS (SD) for children was 89.27 (11.56) and 86.72 (10.62) for parent proxies. The most problematic EQ-5D-Y dimension was “having pain or discomfort”. These scores had significant correlations between the child and parental proxy perspectives, as well as between the PedsQL and EQ-5D-Y. An age of 8 – 12 years and oral chelation therapy predicted lower self-reported PedsQL TSS. Parental proxy-report predictors for reduced PedsQL TSS and EQ-5D-Y VAS were primary school education for children, parental proxy secondary school education, Universal Coverage insurance, and TDT.

Conclusion

HRQoL scores of our pediatric thalassemia patients had improved from the previous decade, and these findings may represent our better standard of care. Some sociodemographic and clinical characteristics may present negative impacts on HRQoL. More exploration is needed to understand predictors and further improve HRQoL, especially for TDT patients.

Complications and Challenges in the Management of Iraqi Patients with β-Thalassemia Major: A Single-center Experience

OBJECTIVES

We sought to assess the complications and challenges facing the management of β-thalassemia major (β-TM) in Iraq.

METHODS

A total of 150 consecutive patients with β-TM who were registered at a main thalassemia center in Northern Iraq were enrolled in the study. The patients had their records reviewed, were clinically evaluated, and investigated for various complications.

RESULTS

Our patient cohort had a median age of 13 years (range: 1-35 years) and a male to female ratio of 1:1.2. Their median serum ferritin was 2762 µg/L, all were on regular transfusions, 94.7% were on chelation therapy, and 38.0% were splenectomized. Pre-transfusion hemoglobin levels were 3 9.0 g/dL in 38.7% of the patients. Short stature was encountered in 33.9% of those aged ≤ 20 years, and skeletal changes were noted in 50.7%. Iron overload associated complications, including hypogonadism, hypothyroidism, hypoparathyroidism, diabetes mellitus, and heart failure, were encountered in 52.8%, 7.3%, 3.3%, 3.3%, and 2.7%, respectively. Hepatitis C virus (HCV) antibodies were detectable in 35.3%, while HIV antibodies and hepatitis B surface antigen were not detectable in any. Patients with diabetes mellitus, heart failure, HCV antibodies, and hypoparathyroidism were significantly older than those without these complications. Hypogonadism was the only complication associated with significantly higher serum ferritin levels. Hypogonadism, heart failure, HCV antibodies, and diabetes were significantly more frequent among the splenectomized patients.

CONCLUSIONS

The management of β-TM in this cohort of Iraqi patients is still suboptimal, and the need to ensure timely transfusions and optimize chelation, as well as a more robust iron overload assessment, should be underscored.