Lessons Learned from 17 Years of Multidisciplinary Care for DSD Patients at A Single Indonesian Center

BACKGROUND

Our Multidisciplinary Team (MDT) is a large specialized team based in Semarang, Indonesia that cares for a wide variety of pediatric and adult individuals with Differences of Sex Development (DSD) from across Indonesia. Here we describe our work over the last 17 years.

METHODS

We analyzed phenotypic, hormonal and genetic findings from clinical records for all patients referred to our MDT during the period 2004 to 2020.

RESULTS

Among 1184 DSD patients, 10% had sex chromosome DSD, 67% had 46,XY DSD and 23% had 46,XX DSD. The most common sex chromosome anomaly was Turner syndrome (45,X) (55 cases). For patients with 46,XY DSD under-masculinization was the most common diagnosis (311 cases) and for 46,XX DSD a defect of Müllerian development was most common (131 cases) followed by Congenital Adrenal Hyperplasia (CAH) (116 cases). Sanger sequencing, MLPA and targeted gene sequencing of 257 patients with 46,XY DSD found likely causative variants in 21% (55 cases), with 13 diagnostic genes implicated. The most affected gene coded for the Androgen Receptor. Molecular analysis identified a diagnosis for 69 of 116 patients with CAH, with 62 carrying variants in CYP21A2 including four novel variants, and seven patients carrying variants in CYP11B1. In many cases these genetic diagnoses influenced the clinical management of patients and families.

CONCLUSIONS

Our work has highlighted the occurrence of different DSDs in Indonesia. By applying sequencing technologies as part of our clinical care, we have delivered a number of genetic diagnoses and identified novel pathogenic variants in some genes, which may be clinically specific to Indonesia. Genetics can inform many aspects of DSD clinical management, and whilst many of our patients remain undiagnosed, we hope that future testing may provide answers for even more.

The Role of Body Mass Index, Advanced Age, and Low Educational Attainment in Mild Cognitive Impairment among the Older Adult Population: A Study in a Rural Area in Indonesia

This study evaluated the prevalence of mild cognitive impairment (MCI) and factors associated with MCI among older adults in a rural area of Indonesia. This cross-sectional study was conducted in a rural area of East Java, Indonesia. Four hundred and twenty-seven older adults aged ≥60 years were included in the study. MCI was assessed using the Brain Health Test Cognitive Tool. Data related to possible risk factors were obtained using semi-structured questionnaires. The indirect body mass index was determined based on ulnar length. The prevalence of MCI was 12.9%. Being underweight (<18.5 kg/m2) (odds ratio [OR], 2.42; 95% confidence interval [CI], 1.17-4.97; p = 0.016), requiring assistance to manage money or medications (OR, 2.72; 95% CI, 1.02-7.23; p = 0.045), age ≥70 years (OR, 2.50; 95% CI, 1.11-5.60; p = 0.026), and having an educational attainment of ≤6 years (OR, 4.92; 95% CI, 1.92-12.60; p = 0.001) were significantly associated with MCI. In this Indonesian older adult population, underweight people who had an educational attainment of <6 years, those aged ≥70 years, and those who needed assistance to manage money or medications were more likely to have MCI.

Corrigendum: Challenges in the treatment of late-identified untreated congenital adrenal hyperplasia due to CYP11B1 deficiency: Lessons from a developing country

[This corrects the article DOI: 10.3389/fendo.2022.1015973.].

Challenges in the treatment of late-identified untreated congenital adrenal hyperplasia due to CYP11B1 deficiency: Lessons from a developing country

BACKGROUND

Congenital Adrenal Hyperplasia (CAH) due to CYP11B1 is a rare autosomal recessive adrenal disorder that causes a decrease in cortisol production and accumulation of adrenal androgens and steroid precursors with mineralocorticoid activity. Clinical manifestations include cortisol deficiency, ambiguous genitalia in females (differences of sex development (DSD)), and hypertension. Medical treatment recommendations are well defined, consisting of glucocorticoid treatment to substitute glucocorticoid deficiency and consequently normalize adrenal androgen and precursors levels. Current guidelines also emphasize the need for specialized multidisciplinary DSD teams and psychosocial support. In many developing countries, care for DSD patients, especially when caused by an adrenal disease, is challenging due to the lack of infrastructure, knowledge, and medication.

OBJECTIVE

The study aims to report the conflicting decision-making process of medical treatment and sex assignment in late-identified CAH patients in developing countries.

METHODS

We describe the clinical and biochemical findings and the psychological assessment of five affected but untreated family members with CAH due to CYP11B1 deficiency.

RESULTS

All patients had a 46,XX karyotype, ambiguous genitalia, low cortisol levels, and hypertension. Two identified as males, two as females, and one had undecided gender. The patients were counselled that refusing treatment will lead to infertility and the potential risk of developing Addisonian crisis and severe hypertension. However, all 46,XX CAH males refused treatment with glucocorticoids due to the expected lowering of adrenal androgens as their main source of testosterone. None of the patients developed Addisonian crisis, probably due to some residual cortisol activity and glucocorticoid activity of elevated adrenal steroid precursors.

CONCLUSION

Medical treatment and sex assignment in late-identified 46,XX CAH patients in Indonesia may often depend on local and cultural factors. The management of DSD conditions may have to be individualized and integrated into the psychological and social context of the affected family.

Protectivity and safety following recombinant hepatitis B vaccine with different source of bulk compared to hepatitis B (Bio Farma) vaccine in Indonesia

Purpose

Indonesia, a high populous and the second-highest country in epidemicity of hepatitis B in South-East Asia require maintaining its capacity of monovalent hepatitis B production to keep up with both the national immunization program and global needs. To keep the sustainability of the vaccine, a new bulk is needed to be made available. This study aims to evaluate the immunogenicity and safety of Bio Farma newly formulated recombinant hepatitis B vaccines, which came from different sources of bulk, compared to the already registered hepatitis B vaccine.

Materials and Methods

An experimental, randomized, double-blind, cohort intervention phase II clinical trial was conducted on three recombinant hepatitis B vaccines from different bulk sources, with Bio Farma registered hepatitis B vaccine as the control group. A total of 536 participants around age 10 to 40 years old were thricely vaccinated with twice serological assessments. The subject’s safety was monitored for 28 days after each vaccination.

Results

Of 536 enrolled participants, 521 finished the vaccination and serology assessments. The investigational products were proven not to be inferior to the control. All vaccines were well tolerated. No differences in rates of local and systemic reactions were seen between the investigational products and control. No serious adverse event was found to be related to the investigational vaccines.

Conclusion

Investigational vaccines are shown to be equally immunogenic and safe as the control vaccine.

Analysis of the androgen receptor (AR) gene in a cohort of Indonesian undermasculinized 46, XY DSD patients

Background

Pathogenic variants in the androgen receptor (AR) gene located on chromosome Xq11-12, are known to cause varying degrees of undermasculinization in 46, XY individuals. The aim of this study was to investigate the frequency of pathogenic variants in the AR gene in a cohort of 46, XY undermasculinized individuals from Indonesia who were suspected of having androgen insensitivity syndrome (AIS). All patients with 46, XY DSD referred to our center between 1994 and 2019 were collected from our clinical database. All 46, XY DSD patients without a prior molecular diagnosis with an external masculinization score (EMS) ≤ 9 were included in this study. All exons and intron–exon boundaries of AR gene were analyzed using Sanger sequencing to identify pathogenic variants of the AR gene.

Results

A cohort of 75 undermasculinized patients were selected for the study. Direct Sanger sequencing of all eight exons of the AR gene led to a genetic diagnosis in 11 patients (14.67%). All of the variants identified (p.Arg841His; p.Ile604Asn; p.Val731Met; p.Pro672Ser; p.Gln739Arg; p.Ser302Glufs*3) have been previously reported in patients with AIS.

Conclusions

This is the first study in Indonesia that highlights the significance of molecular analysis in providing a definitive diagnosis of AIS for patients with 46, XY DSD undermasculinization. This is an uncommon finding in the Indonesian population presenting with 46, XY DSD undermasculinization. A genetic diagnosis allows optimal clinical management and genetic counseling for patients and their families. As 46, XY DSD can be caused by pathogenic variants in other genes involved in gonadal development and differentiation, further genetic analysis, such as whole exome sequencing, should be carried out on those patients that did not carry an AR variant.

Efek tepung ulat sagu (Rhynchophorus ferrugineus) terhadap penurunan kadar malondialdehyde (MDA) pada tikus Wistar dengan diet rendah protein

Kwashiorkor is protein-energy malnutrition (PEM) caused by protein deficiency. Sago worm flour (Rhynchophorus ferrugineus) can reduce malondialdehyde (MDA) caused by the high content of the amino acids glycine, lysine, and phenylalanine. The study aimed to prove the effect of sago worm flour on MDA levels in Wistar rats with a low protein diet. A true experimental-pre-post control group. The intervention was given for 28 days to 28 Wistar rats, divided into four groups with each group of seven rats. The dose of sago starch was 0,36 g/100 g rat body weight/day (P1), and a dose of 1,36 g/100 g rat body weight/day (P2) for rats fed a low diet protein. The treatment group was compared with a group of mice given a low diet protein (K +) and a group of healthy mice (K-). Serum MDA levels were measured by the TBARs method. Statistical analysis used paired t-test or Wilcoxon test and one-way ANOVA/Kruskal Wallis test. The results of decreasing MDA levels were in the P1 and P2 groups (p= 0,000). There was a difference in MDA levels in the P1 and P2 groups compared to the K + group (P= 0,000). There was a difference that decreased MDA levels between P1 and P2 (p= 0,000). In conclusion, sago worm flour at a dose of 0,36 g/100 g of rats/day and a dose of 1,36 g/100 g of body weight of rats/day can reduce MDA levels

Perbaikan kadar trigliserida dan Hs-CRP pada tikus Wistar Diabetes Mellitus tipe 2 dengan biskuit biji bunga matahari

Diabetes Mellitus is a group of metabolic diseases characterized by hyperglycemia due to defects in insulin secretion or insulin action. Increased glucose allows free fatty acids to enter as raw material for forming triglycerides. Hs-CRP can be used to identify the most sensitive inflammatory markers in diabetes. This study aims to analyze the effect of sunflower seed biscuits on triglyceride levels and Hs-CRP in Wistar rats with type 2 diabetes mellitus. The method is a true experiment with a randomized pre-post test with a control group design. The research sample size was 24 male Wistar rats, divided into four control groups K(-), K(+), and treatment P1, P2. The intervention was carried out for 28 days, and triglycerides were measured by spectrophotometer, and Hs-CRP was measured using the ELISA method. Statistical analysis used three tests, namely the Paired T-Test, the Kruskal Wallis test, and the Spearman correlation test. There are differences after the intervention and changes between groups with triglyceride values before intervention 145 mg/dl and after intervention 145 mg/dl and Hs-CRP values before intervention 14.8 mg/l and after intervention 14,8 mg/l. Changes between groups of triglyceride and Hs-CRP levels after statistical tests (p= 0,000) and (p= 0,000), respectively. The conclusion is a provision of sunflower seed biscuits showed an effect on triglyceride and Hs-CRP levels of type 2 diabetes mellitus rats. The lowest decrease in triglyceride and Hs-CRP levels was found in the treated rats with a dose of 1440 mg / 200 g of rats

Etlingera elatior (Jack) R.M, Sm Containing Diet Normalizes Some Metabolic Syndrome Markers due to High-fat High-fructose Diet in Wistar Rats

Background:

Etlingera elatior (Ee) contains phytochemical compounds that are rich in antioxidants, which may reduce several biochemical markers of metabolic syndrome (MetS).

Objective:

We aimed to study the effect of fresh Etlingera elatior (FEe) and steamed Etlingera elatior (SEe) as a part of rat diet on body weight, serum lipid, and malondialdehyde (MDA) level in Wistar rats with MetS induced by a high-fat, high-fructose diet.

Methods:

Our research was a true experimental randomized control group design with pre- and post-test. A total of 24 male Wistar rats were divided randomly into the following four groups: 1) Control, fed standard rat diet during the whole duration of the study, 2) HFFr-Sd, fed high-fat high- -fructose (HFFr) diet for 29 days, followed by 29 days of the standard diet, 3) HFFr-FEe, fed HFFr diet for 29 days, followed by 29 days of a standard diet containing 33.3% FEe, and 4) HFFr-SEe, fed HFFr diet for 29 days, followed by 29 days of a standard diet containing 33.3% SEe. The HFFr diet was given at 15 g/day along with fructose drink (20% pure fructose) at 100 ml/day. The diets in each group after the MetS induction period are referred to as intervention diets. Data at the end of HFFr (pre) and intervention diets (post) were analyzed by paired t-test. The data among groups were analyzed by one-way analysis of variance followed by post hoc test.

Results:

HFFr diet for 29 days induced MetS in Wistar rats fulfilling the criteria of obesity (Lee Index), hypertriglyceridemia, and decreased high-density lipoprotein cholesterol (HDL-C). Also, there was a significant increase in serum total cholesterol, low-density lipoprotein cholesterol (LDL-C), and MDA level (p < 0.05). Feeding a diet containing FEe or SEe can significantly reduce body weight, serum triglyceride, total cholesterol, LDL-C, and MDA, and increase HDL-C levels (p < 0.05). The effect of FEe was more pronounced in ameliorating body weight and lipid profile than SEe.

Conclusion:

Fresh Ee and Steamed Ee can ameliorate obesity, dyslipidemia, and oxidative stress in MetS Wistar rats induced by a high-fat, high-fructose diet. It suggests that dietary Ee accounting for one-third of daily standard diet can assist in normalizing some MetS markers in rats.

The Effect of Tempe Gembus on High-Sensitivity C-Reactive Protein and Adiponectine Levels in Rats with Metabolic Syndrome

Metabolic syndrome can affect the inflammatory state which results in increased high-sensitivity C-reactive protein (hs CRP) and decreased adiponectin levels. Tempe gembus is a functional food that can reduce the risk of metabolic syndrome through the inflammatory pathway. This study applied a quasi experimental method, with a post-test only control group design. Sprague Dawley rats (n=30) were divided into 2 control groups (K- and K+) and 3 treatment groups (P1, P2, P3) which were given a 4-wk diet that included 2.5 g (P1), 5 g (P2), and 7.5 g (P3) of tempe gembus. Adiponectin and hs CRP levels were measured with ELISA. Statistical analysis was done with a one-way ANOVA test and a Kruskal Wallis test. It apprears that administering tempe gembus in these amounts can reduce the hs CRP levels (p=0.037) and increase adiponectin levels in rats with metabolic syndrome (p=0.008). This research has shown that a 2.5 g of tempe gembus can have a strong effect on hs CRP and 5 g of tempe gembus have a strong effect on adiponectin.

Erratum: The use of high-resolution melting techniques for mutation screening of diseases caused by trinucleotide repeats expansion, with emphasis on the <em> AR </em> gene

[This corrects the article DOI: 10.13181/mji.v28i2.3008]

The use of high-resolution melting techniques for mutation screening of diseases caused by trinucleotide repeats expansion, with emphasis on the <em> AR </em> gene

BACKGROUND Trinucleotide repeat expansion (TRE) diseases are genetic diseases caused by an increase in the number of CAG, CGG, and CTG codons. CAG repeat expansion in exon 1 of the androgen receptor (AR) gene is known to be associated with disorders of sex development (DSD) and spinal and bulbar muscular atrophy (SBMA). Because the traditional Southern blot for CAG repeat expansion is laborious and time-consuming, this study was aimed to use high-resolution melting (HRM) analysis to screen the CAG repeat length of the AR gene in Indonesian patients with DSD. METHODS In total, 30 male patients with DSD (46, XY), one male patient with SBMA, and 30 healthy males (control) were included in the study. The CAG repeat length was determined using HRM analysis, and Sanger sequencing was used to confirm the CAG repeat length. RESULTS For the DSD cases and controls, the melting temperature (Tm) was within the normal range of 89–91.05°C; however, Tm was 92.65°C for the SBMA case. Sanger sequencing confirmed that DSD cases had 13–27 CAG repeats, and the SBMA case had 54 CAG repeats. CONCLUSIONS HRM analysis using polymerase chain reaction is a sensitive, effective, and rapid technique for screening CAG repeat expansion in exon 1 of the AR gene. This is the first technique for AR gene screening that may be applicable to other TRE diseases.

Effect of Peer Education on Self Care Patients Diabetes Mellitus in RSUD Panembahan Senopati Bantul Yogyakarta

<p><em>Self Care is an implementation of activities based on self-awareness and conducted by the individual itself to meet the needs in maintaining life, health, and well-being in accordance with the state of health and illness.Employment of independence conducted by patients Diabetes Mellitus (DM) called self care DM with one of the goals in performing independent actions is to control the Diabetes Mellitus so as to minimize the occurrence of complications.Edukasi is a source of information that can help diabetes mellitus patients in taking decisions appropriate self-care nursing actions.The purpose of this study is to determine the influence of peer education against self care in patients with Diabetes Mellitus. Type of quantitative research with quasi experimental research design pre-test and post-test control group. The number of samples in this study were 21 patients with Diabetes Mellitus in the Hospital according to inclusion criteria and exclusion in the study. Sampling using purposive sampling technique, data collection using questionnaire The Personal Models Of Self Care Diabetes Questionnaire that consists of 9 items of questions. The research analysis used univariate and frequency distribution. The results showed that patients with Diabetes Mellitus self care category as much as 16, 7% and self care with less good category as much as 83, 3 %. Based on the results of the study, it can be concluded that self care nursing diabetes mellitus patients in performing self actions to minimize the occurrence of complications in the category less good.</em></p>

Genetic Analysis Reveals Complete Androgen Insensitivity Syndrome in Female Children Surgically Treated for Inguinal Hernia

Background: Complete androgen insensitivity syndrome (CAIS) is a congenital condition caused by genetic defects in the androgen receptor (AR) gene located on the X chromosome, which lead to a phenotypical female individual with a 46, XY karyotype. Early diagnosis of CAIS is essential for proper clinical management, allows assessment of familial risk and contributes to healthcare decisions. However, diagnosis of CAIS can be overlooked in girls with inguinal hernia, resulting in inappropriate management. Methods: Five female patients from three unrelated families presented to our genetic clinic with primary amenorrhea. Each patient had been diagnosed with inguinal hernia in childhood and had undergone hernia repair without further investigation into what was contained in the hernial sac. We carried out physical examination, cytogenetic studies, hormonal evaluation, and molecular analysis to establish a comprehensive diagnosis. Family history and pedigree were collated to identify at-risk family members. Results: All patients presented with female external genitalia. Cytogenetic studies revealed a 46, XY karyotype and hormonal analysis suggested a diagnosis of CAIS. Sequencing of the AR gene in all patients and suspected family members revealed pathogenic variants in the AR gene and confirmed the molecular diagnosis of CAIS. Conclusions: We report the delayed diagnosis of CAIS in female Indonesian patients with a history of inguinal hernia in childhood. An early diagnosis of CAIS is essential for appropriate clinical management, as well as assessing familial risk. Increasing awareness among clinicians is paramount, and we encourage a CAIS diagnosis to be considered in any patient presenting with female appearance and inguinal hernia.

Life Quality Of End Of Life Patient's Family in Intensive Care Units

<p><em>Fifty percent of end-of-life patients spend the last time of their life in the Intensive Care Unit (ICU). End of life conditions have an impact on the psychological, physical, social, and family environment that affect the quality of life of other families. Family welfare will have an impact on care outcomes, hospitalization time, and patient stressor levels. The purpose of this study was to explore the life quality of end of life patient's family in ICU. This research used qualitative method with descriptive phenomenology approach. Sampling was done by purposive sampling technique with 9 participants. data were collected through in-depth interviews and analyzed using the Colaizzi method.  </em><em>The data validity was designed to meet the principle of triangulation of researchers and theory. The results showed 7 dimensions of life quality of end of life patient's family of physical health (fatigue, sleep disorder, headache, decreased appetite), mental health (anxiety, sadness, hope of improved family health condition), spiritual health (acceptance), health social (social support), daily life (daily life adjustment), financial health (financial burden), and environment (opportunity to get information, family infrastructure). </em><em> </em><em>This study concludes that end of life condition of critical patients impacts on the 7 dimensions of family life quality. Nurses should pay attention to the family life quality because it affected the condition of the patient  and family as the care service unit.</em></p><p><em> </em></p><p><strong>Keywords</strong>: <em>Life Quality, Family, End Of Life, Intensive Care Unit</em></p><p><em> </em></p><p><strong></strong><strong><br /></strong><em></em><strong></strong></p>

The Description Of Diabetics’ Acceptance Stage Toward Diabetes Mellitus’ Diagnoses

<p class="Normal1" align="center"><strong>Abstract</strong></p><p class="Normal1" align="center"><strong> </strong></p><p>Diabetes Mellitus (DM) is a chronic condition which requires various kinds of lifetime treatment which cause grief. Grief has stages which can be passed though normally with the attainment of acceptance stage. Acceptance attainment renders a description maintaining that grief in its process is undergone normally through uncomplicated grief reaction and emotional responsiveness. A diabetics who manages to attain the acceptance stage will have a better glycemic control, while a diabetics with a low acceptance stage may experience an ineffective coping, improper self-treatment, and distress increase, all of which end up in a bad glycemic control which causes physical complications. This suggests that a description of s’ acceptance stage is important to identify. Accordingly, the aim of this research is to identify and analyze the description of diabetics’ acceptance of DM diagnoses. The method utilized is descriptive-observational, the data collected using the ‘Acceptance of Disease and Impairments Questionnaire’ (ADIQ). The analysis employed in this research is a descriptive analysis. The sampling technique used is consecutive sampling. The research result shows that, based on the diagram of ADIQ administered on 20 s, there are 30% found to be in the stage of acceptance, while there exist 70% to be in the stage of not yet attaining acceptance, which comprises denial (20%), resistance (10%), and sorrow (40%). Failure in attaining the acceptance stage is caused by the s’ still being in the states of denial, resistance, and sorrow. Based on the research result, it can be concluded that the s dominantly stay at the stage of not yet attaining acceptance. The diabetics who have attained acceptance may still be exposed to the risk of undergoing a maladaptive response which may trigger depression, anxiety, worsened physical health, self-treatment discontinuation, powerlessness, low self-esteem, social isolation, even suicidal drive. This is all caused by grief which constitutes a fluctuate condition where every diabetes can contribute to describing his or her condition at every stage.</p><p> </p><strong><em>Keywords</em></strong><em>: stages of grief, acceptance, denial, resistance, sorrow</em>

Quality of Life in Late-Treated Patients With Disorders of Sex Development: Insights for Patient-Centered Care

Background: Patients with a disorder of sex development (DSD) are born with atypical genitals or may develop atypical genitals and atypical body appearance, if left untreated. Health related quality of life (HRQoL) was assessed in Indonesian patients to whom diagnostic procedures and medical intervention had been delayed. Method: Comparison of 118 patients born with DSD, aged 6-41 years (60 children, 24 adolescents, and 34 adults) and 118 healthy control subjects matched for gender, age, and residential setting. HRQoL was measured using a translation of the TACQOL/TAAQOL. Results: According to parental and children's report, children with DSD reported more problems in social functioning and had less positive moods. Girls, in particular, reported problems in cognitive functioning. Adult patients reported more depressive moods, especially women, who reported more anger. No differences were found between in the adolescent groups. Conclusion: The data suggest that Indonesian children with DSD experienced more problems in social contact than non-affected Indonesian children, whereas Indonesian adults with DSD suffered from negative emotions more often than non-affected Indonesians. These findings on HRQoL are in line with findings on emotional functioning.

Variants in congenital hypogonadotrophic hypogonadism genes identified in an Indonesian cohort of 46,XY under-virilised boys

Background

Congenital hypogonadotrophic hypogonadism (CHH) and Kallmann syndrome (KS) are caused by disruption to the hypothalamic-pituitary-gonadal (H-P-G) axis. In particular, reduced production, secretion or action of gonadotrophin-releasing hormone (GnRH) is often responsible. Various genes, many of which play a role in the development and function of the GnRH neurons, have been implicated in these disorders. Clinically, CHH and KS are heterogeneous; however, in 46,XY patients, they can be characterised by under-virilisation phenotypes such as cryptorchidism and micropenis or delayed puberty. In rare cases, hypospadias may also be present.

Results

Here, we describe genetic mutational analysis of CHH genes in Indonesian 46,XY disorder of sex development patients with under-virilisation. We present 11 male patients with varying degrees of under-virilisation who have rare variants in known CHH genes. Interestingly, many of these patients had hypospadias.

Conclusions

We postulate that variants in CHH genes, in particular PROKR2, PROK2, WDR11 and FGFR1 with CHD7, may contribute to under-virilisation phenotypes including hypospadias in Indonesia.

Disorders of sex development: insights from targeted gene sequencing of a large international patient cohort

Background

Disorders of sex development (DSD) are congenital conditions in which chromosomal, gonadal, or phenotypic sex is atypical. Clinical management of DSD is often difficult and currently only 13% of patients receive an accurate clinical genetic diagnosis. To address this we have developed a massively parallel sequencing targeted DSD gene panel which allows us to sequence all 64 known diagnostic DSD genes and candidate genes simultaneously.

Results

We analyzed DNA from the largest reported international cohort of patients with DSD (278 patients with 46,XY DSD and 48 with 46,XX DSD). Our targeted gene panel compares favorably with other sequencing platforms. We found a total of 28 diagnostic genes that are implicated in DSD, highlighting the genetic spectrum of this disorder. Sequencing revealed 93 previously unreported DSD gene variants. Overall, we identified a likely genetic diagnosis in 43% of patients with 46,XY DSD. In patients with 46,XY disorders of androgen synthesis and action the genetic diagnosis rate reached 60%. Surprisingly, little difference in diagnostic rate was observed between singletons and trios. In many cases our findings are informative as to the likely cause of the DSD, which will facilitate clinical management.

Conclusions

Our massively parallel sequencing targeted DSD gene panel represents an economical means of improving the genetic diagnostic capability for patients affected by DSD. Implementation of this panel in a large cohort of patients has expanded our understanding of the underlying genetic etiology of DSD. The inclusion of research candidate genes also provides an invaluable resource for future identification of novel genes.

Electronic supplementary material

The online version of this article (doi:10.1186/s13059-016-1105-y) contains supplementary material, which is available to authorized users.

Gender Development in Indonesian Children, Adolescents, and Adults with Disorders of Sex Development

In most Western countries, clinical management of disorders of sex development (DSD), including ambiguous genitalia, begins at diagnosis soon after birth. For many Indonesian patients born with ambiguous genitalia, limited medical treatment is available. Consequently, affected individuals are raised with ambiguous genitalia and atypical secondary sex characteristics. We investigated gender identity and gender role behavior in 118 Indonesian subjects (77 males, 41 females) with different types of DSD in comparison with 118 healthy controls matched for gender, age, and residential setting (rural, suburban, or urban). In Study 1, we report on methodological aspects of the investigation, including scale adaptation, pilot testing, and determining reliability and validity of measures. In Study 2, we report on gender development in 60 children (42 boys, 18 girls), 24 adolescents (15 boys, 9 girls), and 34 adults (19 men, 15 women) with DSD. The majority of participants with DSD never received any medical or surgical treatment prior to this study. We observed a gender change in all age groups, with the greatest incidence in adults. Among patients who changed, most changed from female to male, possessed a 46,XY karyotype, and had experienced significant masculinization during life. Gender identity confusion and cross-gender behavior was more frequently observed in children with DSD raised as girls compared to boys. Puberty and associated masculinization were related to gender problems in individuals with 46,XY DSD raised female. An integrated clinical and psychological follow-up on gender outcome is necessary prior to puberty and adulthood.

Emotional and behavioral problems in late-identified Indonesian patients with disorders of sex development

OBJECTIVE

The aim of this study is to investigate emotional and behavioral problems among Indonesian patients with disorders of sex development (DSD) who recently came under clinical management. As diagnostic procedures and treatment had been delayed, patients progressively developed ambiguous bodies, difficult to conceal from outsiders.

METHOD

We compared 118 Indonesian patients with DSD aged 6-41 years (60 children, 24 adolescents, 34 adults) and 118 healthy control subjects matched for age, gender, and residential settings. We used the Child Behavioral Checklist (CBCL), Youth Self-Report (YSR), and Adult Self-Report (ASR) to examine differences between patient and control groups as well as differences within patients groups.

RESULTS

On the CBCL, parents of young children with DSD reported significantly more emotional and behavioral problems than parents of matched control. Parents of daughters with CAH reported that their daughters withdrew themselves from social interactions. On the ASR, adults with DSD reported significantly more internalizing problems than controls, particularly anxiety and depression. No other differences in emotional functioning were found across different diagnostic groups.

CONCLUSIONS

Indonesian patients with DSD who were untreated for most of their lives suffered more emotional and behavioral problems than matched controls. Differences and similarities between our findings and observations in patients from Western countries will be discussed.

Body image and sexuality in Indonesian adults with a disorder of sex development (DSD)

In Indonesia, disorders of sex development (DSDs) are not well recognized and medical care for affected individuals is scarce. Consequently, many patients live with ambiguous genitalia and appearance. We compared reported outcomes on body image, sexual functioning, and sexual orientation of 39 adults with DSDs (aged 18 to 41) and 39 healthy controls matched for gender, age, and residential setting (urban, suburban, rural). Differences in gender and treatment status (treated or untreated) were also explored. On body image, adults with DSDs reported dissatisfaction with sex-related body parts. Compared to the matched controls, women with DSDs reported greater sexual distress, and men with DSDs reported lower erectile and ejaculation frequencies, and more dissatisfaction with sexual life but not with sexual desire and activities. Men with DSDs who had undergone genital surgery reported higher erectile and ejaculation frequencies than untreated men. More women than men in the DSDs group reported a nonexclusive heterosexual orientation. DSDs and infertility had a great impact on sexuality. Fear of ostracism complicated DSD acceptance. Findings were compared to those of Western studies. Based on these results, education about DSDs and their psychosexual consequences may help reduce the sexual distress and problems in adults with DSDs and improve quality of life.

Correlation between androstenedione and 17-hydroxyprogesterone levels in the saliva and plasma of patients with congenital adrenal hyperplasia

INTRODUCTION

Congenital adrenal hyperplasia (CAH) or adrenogenital syndrome is the most common cause of female ambiguous genitalia. Management of such patients involves medical treatment using glucocorticoids such as hydrocortisone, prednisone or dexamethasone. Monitoring is done by measurement of 17-hydroxyprogesterone (17-OHP) or androstenedione in serum, plasma or saliva. The aim of this study was to develop a system of monitoring steroid treatment in CAH patients using only saliva.

METHODS

We studied the saliva of 24 CAH patients who received glucocorticoid replacement therapy. The patients were asked to collect saliva upon awakening, and in the afternoon and evening. The levels of 17-OHP and androstenedione in the saliva as well as in serum were then measured by immunoassay.

RESULTS

There was a significant positive correlation between 17-OHP in serum and in saliva (R equals 0.929, p-value less than 0.01). A significant positive correlation between androstenedione level in saliva and serum was also found (R equals 0.611, p-value less than 0.01). This study also revealed a significant positive correlation between androstenedione and 17-OHP in serum (R equals 0.647, p-value less than 0.01) and saliva (R equals 0.799, p-value less than 0.01). All patients showed increased level of 17-OHP and androstenedione in the sample collected upon awakening.

CONCLUSION

Determination of salivary androstenedione and 17-OHP in CAH patients could be a useful alternative to the measurement of these hormones in serum.