Immunization Simulation Using Actual-Size Infant Manikins for Medical Students in Indonesia: A Quasi-Experimental Study

INTRODUCTION

Manikins are tools used in simulation training for medical students to develop important skills, one of which is immunization. However, conventional manikins often do not resemble the actual size of an infant's arm or leg. This study aimed to determine the impact of using actual-size manikins on students' knowledge and practical skills, evaluate their confidence in immunization practice, and assess students' responses and feedback regarding the practice using actual-size manikins.

METHODS

This was a quasi-experimental study involving medical students at the Faculty of Medicine, Universitas Indonesia, from October 2020 to April 2021. Students in the intervention group used newly developed actual-size infant arm and leg manikins, while the control group used conventional manikins. All students underwent the objective structured clinical examination (OSCE) and the scores were compared between the 2 groups. Within the intervention group, data on pretest and posttest scores, feedback questionnaires, and self-confidence assessments were also obtained and analyzed.

RESULTS

A total of 205 students were included. Statistically significant difference was found in the OSCE scores between the intervention and control groups (P < 0.01). Students in the intervention group (n = 108) showed significant improvement in knowledge scores after the workshop (P < 0.01). Most students (81.7%) expressed confidence in administering vaccines to live patients after practicing with manikins. In addition, 98.2% of students (n = 107) acknowledged the benefits of practicing with actual-size manikins in accurately determining the injection sites.

CONCLUSIONS

Simulation with the actual-size manikins significantly improved students' knowledge and practical immunization skills, leading to increased confidence and competence in their immunization skills.

Transition practice for primary immunodeficiency diseases in Southeast Asia: a regional survey

Introduction

With increased diagnostic capabilities and treatment modalities in the field of primary immunodeficiencies (PID), many pediatric patients survive beyond childhood and experience a change of care to the adult-oriented healthcare system. Unfortunately, the transition pathways for PID are less clearly defined, resulting in deterioration of quality of care in adulthood. Hence, this is the first regional study to address PID clinicians' opinions on practices and challenges of transition care in 7 Southeast Asia (SEA) countries.

Methods

We adopted a cross-sectional study design through an online survey platform to enquire opinions of transition practices from expert representatives in 7 SEA countries.

Results

Regionally, 3 out 7 countries reported having no practice of transition care. Among cited challenges were reluctant adaptation by patients and caregivers to unfamiliarized adult healthcare systems, inadequate ratio of adult immunologists to patients and lack of facilities for transfer.

Discussion and conclusion

Our study provides evidence to advocate policy makers on the importance of standardized integration of transition practice towards betterment of transiting PID patients into adulthood.

Comparison Between Self-Deliberate Practice and Directed Learning Training Methods for Basic Life Support Knowledge and High-Quality Cardiopulmonary Resuscitation Skill Retention in Second-Year Medical Students 3 and 6 Months After Training

Background

Cardiopulmonary resuscitation (CPR) requires well-trained medical personnel. Multiple learning methods can be done for CPR skills training. This study aimed to compare self-deliberate practice (SDP) method and directed learning (DL) method to improve basic life support (BLS) knowledge and CPR skill performance in medical students.

Methods

This is an experimental, single-blind, randomized controlled trial study of 40 medical students from February to July 2019. Forty subjects were randomly assigned into SDP and DL groups through a voluntary sampling method. Both groups attended a 1-day course and then practiced once a month for 3 months. The DL group had practice sessions with assigned tutors, while the SDP group had to practice by themselves. Examination of BLS knowledge and CPR performance quality (compression depth, rate, and performance score) was collected before and after course lecture, after a skills training, 3 and 6 months after training.

Results

Subject characteristics of both groups were comparable. Significant knowledge and skill improvement were found in the DL group and the SDP group when compared to their knowledge and skill before training. There were no significant differences between both groups in BLS knowledge and CPR performance quality in all examination periods.

Conclusion

Both SDP and DL teaching methods show significant improvement and excellent retention in BLS knowledge and high-quality CPR performance. These two learning methods are both feasible and bring positive results for students.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01746-7.

Cultivating patient-centered care competence through a telemedicine-based course: An explorative study of undergraduate medical students' self-reflective writing

Background

The COVID-19 pandemic has encouraged adaptations of learning methods in clinical clerkship. There have been limited reports on the merits of involving medical students in telemedicine. This study, therefore, aims to investigate students' reflection on what they learned and identify the challenges and benefits of doctor-patient interaction through their experience in a telemedicine-based course.

Methods

A 4 week telemedicine-based course for medical students to participate in telemonitoring of COVID-19 patients undergoing self-isolation was conducted. This is a qualitative study using an interpretive phenomenology design to investigate students' self-reflection on their experiences in monitoring COVID-19 patients. Students were asked to reflect on their experience upon completion of the course through 750-1,000 words essays. A thematic analysis which considers units of meaning based on students' experiences was completed.

Results

Our study identified four main themes gathered from students' experiences related to the telemedicine-based course: communication and education, professionalism and professional identity formation, system-based practice, and patient-centered care.

Conclusion

The course was part of an integrative effort involving multiple parties to tackle the burden on the nation's healthcare system during the pandemic. Telemedicine is part of future medical practice which supports the medical curriculum adaptability along with attempts to develop future-proof medical doctors through various clinical learning experiences.

A COVID-19 self-isolation monitoring module for FMUI undergraduate medical students: Linking learning and service needs during the pandemic surge in Indonesia

To ensure that students continued receiving adequate yet safe clinical exposure during the COVID-19 pandemic, the Faculty of Medicine at Universitas Indonesia (FMUI) created the Module of COVID-19 Self-Isolation Monitoring which aims to equip students with the knowledge and skill to monitor confirmed and close contact cases of COVID-19. Module development, divided into four phases: preparation, orientation, implementation, and evaluation phase, started as soon as the delta wave of COVID-19 cases forced medical students to halt their offline clinical rotations. A quantitative secondary data were obtained from student and patient satisfaction questionnaires and on students' performance and reflection. We analyzed the distribution of module evaluation, the student's discussion score during the module, the students' interest in participating as Covid-19 volunteers before and after the module's deployment, and the correlation between learning outcomes and satisfaction. A total of 372 patients were monitored by 208 students during the 4-week module. The response rates were above 80%, with the majority agreeing that students found this module well-organized and fulfilled their expectations. There was a significant increase in discussion scores from weeks 1 to 4, a significant difference in the proportion of students interested in COVID-19 volunteering before and after the module completion as well as a significant low correlation between the patient's monitoring score sheet and the reflection essay towards the patient's satisfaction. We should still improve tutors' time management, tutors' provision of triggering questions for critical thinking skills, and tutors' feedback for students. The module met patient expectations and is expected to assist tutors in providing feedback and examples of doctor-patient communication, thus accelerating students' competence in patient interaction. Further evaluation is needed regarding knowledge transfer, the impact on community health, and the faculty development program, especially regarding how tutors fulfill their roles as medical educators.

Respons Klinis Pemberian Tocilizumab Dibandingkan Anakinra dalam Tata Laksana Artritis Idiopatik Juvenil Sistemik

Latar belakang. Artritis idiopatik juvenil (AIJ) sistemik merupakan penyakit inflamasi sistemik yang tidak hanya melibatkan sendi tetapi juga keterlibatan sistemik dan merupakan tipe terberat dari AIJ. Tatalaksana standar yang diberikan sering tidak memberikan respons klinis optimal sehingga meningkatkan morbiditas dan mortalitas. Pemberian agen biologis seperti tocilizumab atau anakinra merupakan pilihan agen biologis untuk tatalaksana AIJ sistemik. Tujuan. Mengumpulkan bukti ilmiah tentang efektivitas pemberian tocilizumab dibandingkan anakinra dalam tatalaksana AIJ sitemik. Metode. Pencarian artikel dilakukan secara daring menggunakan instrumen kata kunci yang sesuai melalui basis data Pubmed, Cochrane dan Google Scholar pada bulan Februari 2022.Hasil. Penelusuran dilakukan dan didapatkan dua artikel dengan kohort retrospektif. Remisi klinis pada kelompok tocilizumab berkisar sekitar 44-45%, sedangkan pada kelompok anakinra berkisar 25-38%. Kesimpulan. Tocilizumab memberikan respons klinis yang lebih baik dibandingkan anakinra dalam tatalaksana AIJ sistemik.

Targeted Gene Sanger Sequencing Should Remain the First-Tier Genetic Test for Children Suspected to Have the Five Common X-Linked Inborn Errors of Immunity

To address inborn errors of immunity (IEI) which were underdiagnosed in resource-limited regions, our centre developed and offered free genetic testing for the most common IEI by Sanger sequencing (SS) since 2001. With the establishment of The Asian Primary Immunodeficiency (APID) Network in 2009, the awareness and definitive diagnosis of IEI were further improved with collaboration among centres caring for IEI patients from East and Southeast Asia. We also started to use whole exome sequencing (WES) for undiagnosed cases and further extended our collaboration with centres from South Asia and Africa. With the increased use of Next Generation Sequencing (NGS), we have shifted our diagnostic practice from SS to WES. However, SS was still one of the key diagnostic tools for IEI for the past two decades. Our centre has performed 2,024 IEI SS genetic tests, with in-house protocol designed specifically for 84 genes, in 1,376 patients with 744 identified to have disease-causing mutations (54.1%). The high diagnostic rate after just one round of targeted gene SS for each of the 5 common IEI (X-linked agammaglobulinemia (XLA) 77.4%, Wiskott–Aldrich syndrome (WAS) 69.2%, X-linked chronic granulomatous disease (XCGD) 59.5%, X-linked severe combined immunodeficiency (XSCID) 51.1%, and X-linked hyper-IgM syndrome (HIGM1) 58.1%) demonstrated targeted gene SS should remain the first-tier genetic test for the 5 common X-linked IEI.

Clinical Features of Multisystem Inflammatory Syndrome in Children Associated with COVID-19 in Indonesia

BACKGROUND

While the number of cases of multisystem inflammatory syndrome in children (MIS-C) is increasing, reported cases in Asian countries are still low, particularly in Indonesia. This study aimed to describe the characteristics of patients with MIS-C in a tertiary referral hospital in Indonesia.

METHODS

This is a cross-sectional study with collected data of patients with MIS-C admitted to Dr. Cipto Mangunkusumo from March 2020 to April 2021.

RESULTS

The first case of MIS-C was detected 5 months after the first reported coronavirus disease 2019 case in Indonesia. Thirteen patients out of 158 positive admitted patients for COVID-19 were diagnosed with MIS-C during the study period. Of these 13 patients, 2 patients (15%) had a fatal outcome. Subjects were predominantly male, and the median age was 7.58 years (IQR 12.3) years. Most patients required mechanical ventilation (7 out of 13 patients) and intubation (8 out of 13 patients). Patients who needed intubation usually needed mechanical ventilation. All inflammatory markers, white blood cells, neutrophil counts, and all coagulation factor parameters (except for normal prothrombin time and activated partial prothrombin time) were elevated. The median time to MIS-C diagnosis was 2 days in the survivor group (n = 11) compared to 8.5 days in the non-survivor group (n = 2). Compared to the non-survivor group, those who survived spent more days in the hospital, received vasopressors earlier, and did not require mechanical ventilation as early as the non-survivors.

CONCLUSIONS

Our work highlights the differences in MIS-C clinical course, treatment, and clinical outcomes between the two groups.

Perbandingan Kriteria ACR-1997 dan SLICC-2012 dalam Diagnosis Lupus Eritematosus Sistemik pada Anak

Latar belakang. Lupus eritematosus sistemik merupakan penyakit autoimun sistemik pada jaringan ikat yang bersifat kronik dan progresif, terutama pada anak. Hingga saat ini belum ada diagnosis baku emas, sehingga untuk menegakkan diagnosis dapat menggunakan kriteria The American College of Rheumatology (ACR) tahun 1997 atau The Systemic Lupus International Collaborating Clinics (SLICC) tahun 2012.Tujuan. Mengumpulkan bukti ilmiah perbandingan penggunaan kriteria ACR-1997 dan SLICC-2012 dalam diagnosis lupus eritematosus sistemik pada anak.Metode. Penelusuran literatur secara sistematis secara daring melalui database Pubmed dan Cochrane. Analisis dilakukan menggunakan Review Manager dan model hierarchical summary receiver operating characteristic (HSROC) pada studi meta-analsiis. Kualitas studi dinilai dengan QUADAS-2.Hasil. Satu artikel telaah sistematis dan meta-analisis dan satu artikel studi longitudinal dilakukan telaah kritis. Kualitas kedua studi dinilai baik. Studi oleh Hartman dkk menunjukkan kriteria ACR-1997 lebih dianjurkan sebagai kriteria klasifikasi LES pada anak karena lebih spesifik (94,1% vs 82%) dan menghindari terjadinya positif palsu. Studi kedua oleh Lythgoe dkk menunjukkan SLICC-2012 lebih sensitif (92,9% vs 84,1%) dan secara lebih dini mengklasifikasi pasien anak dengan LES.Kesimpulan. Kriteria SLICC-2012 memiliki sensitivitas yang lebih tinggi dalam klasifikasi LES pada anak tetapi memiliki spesifisitas yang lebih rendah dibandingkan ACR-1997. Namun, SLICC-2012 dapat mengklasifikasi LES lebih dini secara signifikan dibandingkan ACR-1997.

Mortality in children with positive SARS-CoV-2 polymerase chain reaction test: Lessons learned from a tertiary referral hospital in Indonesia

Background

The incidence of coronavirus disease 2019 (COVID-19) is still increasing rapidly, but little is known about the prevalence and characteristics of fatal cases in children in Indonesia. This study aimed to describe the characteristics of children with COVID-19 with fatal outcomes in a tertiary referral hospital in Indonesia.

Methods

This cross-sectional study used data collected from the medical records of patients with COVID-19 admitted to Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia from March to October 2020.

Results

During the study period, 490 patients were admitted and diagnosed with suspected and probable COVID-19. Of these patients, 50 (10.2%) were confirmed to have COVID-19, and 20 (40%) had a fatal outcome. The fatality rate was higher in patients aged ≥10 years, categorized with severe disease upon admission, PaO₂/FiO₂ ratio ≤300 mmHg and chronic underlying diseases. The most common clinical manifestations were generalized symptoms, while acute respiratory distress syndrome (8/20) and septic shock (7/20) were the two most common causes of death. Increased procalcitonin, D-dimer, lactate dehydrogenase and presepsin levels were found in all fatal cases. One patient met the criteria of multisystem inflammatory syndrome in children.

Conclusion

Our work highlights the high mortality rate in paediatric patients with positive SARS-CoV-2 polymerase chain reaction test. These findings might be related to or co-incided with COVID-19 infection. Further studies are needed to improve understanding of the role of severe acute respiratory syndrome coronavirus-2 in elaborating the mechanisms leading to death in children with comorbidities.

Serotypes and antibiotic susceptibility profile of Streptococcus pneumoniae isolated from nasopharynges of children infected with HIV in Jakarta, Indonesia, pre- and post-pneumococcal vaccination

The aim of this prospective study was to investigate the serotypes and antibiotic susceptibility of S. pneumoniae carried by children infected with HIV before and after vaccination with the seven-valent pneumococcal conjugate vaccine in Jakarta, Indonesia in 2013. We collected nasopharyngeal swab specimens from 52 children pre-vaccination and 6 months post-vaccination. Serotyping was performed by conventional multiplex polymerase chain reaction and Quellung reaction. The antibiotic susceptibility profile was obtained by disc diffusion. We determined that 27 (52%) and 24 (46%) of the 52 children carried S. pneumoniae during pre- and post-vaccination periods, respectively with the majority of the isolates being non-vaccine type strains (85% pre-vaccination and 75% post-vaccination). Serotypes 34, 6C, and 16F (two strains each) were the most commonly identified serotypes at pre-vaccination. Serotypes 23A (three strains) and 19F (two strains) were the most commonly identified serotypes post-vaccination. In general, isolates were most commonly susceptible to chloramphenicol (88%) and clindamycin (88%), followed by erythromycin (84%), trimethoprim-sulphamethoxazole (69%), tetracycline (61%), and penicillin (59%). In conclusion, serotypes of S. pneumoniae isolated from the nasopharynges of children infected with HIV varied and were more likely to be non-vaccine type strains both before and after vaccination.

Current Perspectives and Unmet Needs of Primary Immunodeficiency Care in Asia Pacific

Background: The Asia Pacific Society for Immunodeficiencies (APSID) conducted nine primary immunodeficiency (PID) Schools in 5 years since inauguration to provide PID care training for early career physicians in Asia Pacific, a region with divergent needs in PID resources and training.

Objective: To identify differences in PID patient care resource and training needs across Asia Pacific and propose a corresponding action plan.

Methods: The Human Development Index (HDI) indicates the degree of socio-economic development in each country/region. Information related to investigations and learning issues were extracted from the abstracts and personal statements from all Schools and mapped onto resource and training needs. Correlations between HDI and country/region-specific parameters were tested by two-tailed Pearson correlation.

Results: A total of 427 abstracts were received in nine Schools between 2015 and 2020, predominantly on immunodeficiencies affecting cellular and humoral immunity. Genetic confirmation was described in 61.8% of abstracts, and its absence negatively correlated with HDI (r = −0.696, p = 0.004). Essential immunologic and genetic tests were not available in 25.4 and 29.5% of abstracts, respectively, and their absence negatively correlated with HDI (r = −0.788, p < 0.001; r = −0.739, p = 0.002). HDI positively correlated with average testing level (r = 0.742, p = 0.002). Cases from medium-HDI countries/regions focused on learning how to investigate a patient for PIDs in cases of severe or atypical infections, whereas those from very-high-HDI countries/regions, from which most faculty members originated, listed hematopoietic stem cell transplantation and gene therapy, newborn screening, and research as learning issues more frequently.

Conclusion: There are unique HDI-related PID resource and training needs in each country/region. APSID proposes HDI group-specific strategies to improve PID care and education in her member countries/regions. Further quantitative analysis of needs in PID care in Asia Pacific is needed for lobbying governments to increase their support for PID care and research.

Lactobacillus reuteri DSM 17938 Improves Feeding Intolerance in Preterm Infants

PURPOSE

Feeding tolerance is extremely important in preterm infants. This study aimed to evaluate whether preterm infants receiving Lactobacillus reuteri DSM 17938 would develop fewer symptoms of feeding intolerance. Secondary outcomes were duration of parenteral nutrition, time to reach full feeding, length of hospital stay, sepsis, necrotizing enterocolitis (NEC), diarrhea, and mortality.

METHODS

This double-blind randomized controlled trial of L. reuteri DSM 17938 versus placebo included 94 neonates with a gestational age of 28-34 weeks and birth weight of 1,000-1,800 g.

RESULTS

Feeding intolerance (vomiting and/or distension) was less common in the probiotic group than in the placebo group (8.5% vs. 25.5%; relative risk, 0.33; 95% confidence interval, 0.12-0.96; p=0.03). No significant intergroup differences were found in proven sepsis, time to reach full feeding, length of hospital stay, or diarrhea. The prevalence of NEC (stages 2 and 3) was 6.4% in the placebo group vs. 0% in the probiotic group (relative risk, 1.07; 95% confidence interval, 0.99-1.15; p=0.24). Mortality rates were 2.1% in the probiotic group and 8.5% in the placebo group, p=0.36).

CONCLUSION

The administration of L. reuteri DSM 17938 to preterm infants was safe and significantly reduced feeding intolerance. No significant differences were found in any other secondary outcomes.

Karakteristik Infeksi Sitomegalovirus pada Anak dengan Infeksi HIV di RSUPN Cipto Mangunkusumo

Latar belakang. Infeksi sitomegalovirus (CMV) adalah infeksi oportunistik virus yang tersering pada anak dengan infeksi HIV. Setelah era penggunaan terapi ARV prevalensi infeksi sitomegalovirus pada anak dengan infeksi HIV di negara berkembang belum mengalami penurunan bermakna. Tujuan. Mengetahui prevalensi , karakteristik demografi, manifestasi klinis, terapi, dan luaran infeksi sitomegalovirus pada anak ≤18 tahun dengan infeksi HIV di RSUPN Cipto Mangunkusumo tahun 2003-2018. Metode. Studi retrospektif deskriptif dilakukan terhadap seluruh anak ≤18 tahun dengan infeksi HIV di RSUPN Cipto Mangunkusumo pada tahun 2003-2018. Evaluasi infeksi sitomegalovirus dilakukan terhadap subyek yang memiliki manifestasi klinis sugestif infeksi sitomegalovirus. Hasil. Prevalensi infeksi sitomegalovirus pada anak dengan HIV di RSUPN Cipto Mengunkusumo tahun 2018 adalah 6%, meningkat 5 kali dibandingkan dengan tahun 2007. Total anak yang mengalami ko-infeksi HIV-CMV adalah 36 orang. Sebagian besar subyek adalah lelaki, berusia 49 bulan (rentang 2-191 bulan), belum menggunakan ARV, dengan rerata CD4 382 sel/μL (11%). Manifetasi klinis tersering adalah demam ≥2 minggu, peningkatan enzim transaminase, dan diare kronik. Titer IgM dan IgG reaktif didapatkan pada 22 dan 32 subyek. Materi DNA sitomegalovirus terdeteksi pada 25 subyek. Infeksi sitomegalovirus terbanyak terjadi dalam bentuk sindrom sitomegalovirus (15/36), korioretinitis (9/36), dan hepatitis (6/36). Immune reconstitution syndrome didapatkan pada empat subyek. Seluruh subyek mendapatkan terapi inisial dengan gansiklovir, valgansiklovir, atau kombinasi keduanya. Tidak ada subyek yang meninggal saat terapi inisial, tetapi 11 subyek memiliki morbiditas permanen dengan 9 subyek di antaranya mengalami low vision atau kebutaan. Kesimpulan. Prevalensi infeksi sitomegalovirus pada anak dengan infeksi HIV sebesar 6%. Infeksi sitomegalovirus perlu diwaspadai pada anak HIV dalam keadaan imunosupresi berat yang mengalami demam ≥2 minggu disertai manifestai klinis terkait organ target. 

Faktor Risiko Obstructive Sleep Apnea pada Anak Sindrom Down​

Latar belakang. Sindrom Down merupakan kelainan kromosom tersering. Anak dengan sindrom Down (SD) di berbagai negara memiliki beberapa faktor risiko terhadap OSA dengan prevalensii antara 30%-60%, dibandingkan 0,7%-2% pada populasi umum. Hingga saat ini belum ada data mengenai OSA pada anak sindrom Down di Indonesia. Tujuan. Mengidentifikasi prevalensi OSA pada anak sindrom Down dan menganalisis hubungan antara habitual snoring, obesitas, penyakit alergi di saluran napas, hipertrofi tonsil, dan hipertrofi adenoid sebagai faktor risiko OSA pada anak sindrom Down. Metode. Penelitian potong lintang dilakukan pada anak sindrom Down berusia 3-18 tahun yang tergabung dalam Yayasan POTADS. Penelitian dilakukan di Poliklinik Respirologi IKA FKUI RSCM dari bulan Juli 2016 hingga Juli 2017. Penegakan diagnosis OSA menggunakan nilai batas AHI≥3 pada pemeriksaan poligrafi. Faktor- risiko yang dianggap berpengaruh dianalisis secara multivariat. Hasil. Penelitian dilakukan terhadap 42 subjek dengan hasil prevalensi OSA pada anak dengan SD 61,9%. Sebesar 42,9% merupakan OSA derajat ringan, 14,3% OSA sedang, dan 4,8% OSA berat. Pada analisis multivariat didapatkan faktor risiko yang bermakna yaitu habitual snoring (p=0,022 dan PR 8,85; IK 1,37-57) dan hipertrofi adenoid (p=0,006 dan PR 12,93; IK 2,09-79). Kesimpulan. Prevalensi OSA pada anak sindrom Down sebesar 61,9%. Faktor risiko yang bermakna yaitu habitual snoring dan hipertrofi adenoid.

Thalassemia Alfa Mayor dengan Mutasi Non-Delesi Heterozigot Ganda

Seorang anak perempuan berusia 3 tahun dengan gejala klinis anemia berat,hepatosplenomegali, dan memerlukan tranfusi darah teratur. Gejala klinis telah timbulsaat pasien berusia 3 bulan. Hapusan darah tepi menunjukkan gambaran hipokrom,mikrositosis, dan anisopoikilositosis. Kadar HbA2 normal, HbF sedikit meningkat, danterdapat HbBart’s. Ayah dan ibu memiliki gambaran hematologis yang mendekati normal.Analisis DNA menunjukkan dua mutasi non-delesi (mutasi titik) pada gen globin a2yaitu pada kodon 59 (GGCglisin→GACaspartat) dan IVS2-nt142 (AG→AA). Kasus ini adalahkasus pertama yang ditemukan di Departemen Ilmu Kesehatan Anak RS. Dr. CiptoMangunkusumo Jakarta yang mempunyai mutasi heterozigot ganda pada kodon 59 danIVS2-nt142. Gejala klinis thalassemia mayor diakibatkan adanya mutasi kodon 59 yangmenghasilkan varian hemoglobin yang tidak stabil (HbAdana) disertai adanya mutasinon-delesi pada IVS2-nt142 yang menyebabkan proses mRNA yang tidak normal.

Terapi Antiretroviral Lini Kedua pada HIV Anak di RS. Cipto Mangunkusumo

Latar belakang. Akses terhadap terapi antiretroviral (ARV) semakin mudah saat ini dan membuat angka harapan hidup anak terinfeksi HIV semakin panjang. Dalam penanganan jangka panjang anak terinfeksi HIV, salah satu masalah baru yang timbul adalah gagal terapi dan resistensi obat. Tujuan. Menilai karakteristik pasien anak terinfeksi di RS. Cipto Mangunkusumo yang menggunakan terapi ARV lini kedua dan indikasi penggantian ke terapi ARV lini kedua.Metode. Penelitian kohort pasien anak terinfeksi HIV di RS Cipto Mangunkusumo sejak tahun 2002. Kriteria inklusi adalah pasien anak terinfeksi HIV yang berobat di RS Cipto Mangunkusumo sejak tahun 2002 sampai April 2012 dan menggunakan salah satu obat antiretroviral lini kedua. Data yang diambil adalah data demografis, kada CD4, jumlah virus, stadium klinis, dan kombinasi terapi ARV.Hasil. Empatratus empat pasien anak terinfeksi HIV dan 44 (10,9%) menggunakan terapi antiretroviral lini kedua. Sebagian besar (59,1%) gagal terapi adalah kombinasi antara kegagalan virologi, imunologis, dan klinis. Median usia saat memulai terapi ARV lini kedua 69 (26-177) bulan. Median lama subyek menggunakan terapi ARV lini pertama 9 (13-176) bulan. Seluruh subyek penelitian menggunakan lopinavir/ritonavir sebagai salah satu obat ARV lini kedua dengan kombinasi terbanyak adalah didanosin, lamivudin, dan lopinavir/ritonavir (40,9%). Efek samping didapatkan pada 2 pasien akibat abacavir. Sebagian besar subyek (19/25) yang diperiksa jumlah virus pada 6-12 sesudah menggunakan ARV lini kedua mempunyai hasil tidak terdeteksi.Kesimpulan. Jumlah pasien yang menggunakan terapi ARV lini kedua tidak terlalu banyak karena deteksi kegagalan terapi masih lebih banyak berdasarkan kegagalan klinis dan imunologis.

Studi Observasional Pasca-Pemasaran Formula Isolat Protein Kedelai pada Bayi dengan Gejala Sugestif Alergi Terhadap Protein Susu Sapi

Latar belakang. Fomula berbasis isolat protein kedelai banyak digunakan untuk anak-anak dengan alergi susu sapi di Indonesia. Namun, diperlukan penelitian untuk mendapatkan gambaran penerimaan orangtua dan toleransi saluran cerna pada penggunaan formula isolat protein kedelai.Tujuan. Pertama, menentukan penerimaan orangtua terhadap pemberian suatu isolat protein kedelai pada bayi yang diduga mengalami alergi terhadap protein susu sapi. Kedua, mengetahui toleransi saluran cerna pada pemberian susu formula tersebut.Metode. Suatu studi pasca-pemasaran, prospektif, multisenter yang dilakukan di Jakarta, Bandung, Surabaya, Yogyakarta, Solo, dan Denpasar sejak September 2011 sampai April 2012. Subyek berusia antara 6 bulan hingga 1 tahun dengan gejala dugaan alergi terhadap protein susu sapi yang diberikan formula isolat protein kedelai dan diamati selama 4 minggu. Luaran yang diharapkan adalah penerimaan orangtua terhadap pemberian formula isolat protein kedelai dan toleransi saluran cerna terhadap pemberian isolat protein kedelai.Hasil. Diteliti 534 subyek yang dapat dianalisis selama periode penelitian. Mayoritas orangtua (84%) merasa puas dengan formula isolat protein kedelai, 83% orangtua berencana untuk melanjutkan pemberian susu formula karena berkurang (31,5%) dan hilangnya gejala yang diduga akibat alergi susu sapi (32,4%). Gejala klinis yang diduga akibat alergi terhadap protein susu sapi menurun pada setiap kunjungan berikutnya. Tidak ada efek samping serius yang dilaporkan selama periode penelitian.Kesimpulan. Penelitian ini menemukan tingkat penerimaan orangtua dan toleransi saluran cerna yang baik terhadap pemberian formula isolat protein kedelai kepada bayi dengan gejala sugestif alergi terhadap protein susu sapi. Formula isolat protein kedelai cukup aman dijadikan sebagai formula alternatif pengganti pada anak dengan alergi susu sapi.

Early Height and Weight Changes in Children Using Cotrimoxazole Prophylaxis With Antiretroviral Therapy

BACKGROUND

The growth benefits of cotrimoxazole during early antiretroviral therapy (ART) are not well characterized.

METHODS

Individuals enrolled in the Therapeutics Research, Education, and AIDS Training in Asia Pediatric HIV Observational Database were included if they started ART at ages 1 month-14 years and had both height and weight measurements available at ART initiation (baseline). Generalized estimating equations were used to identify factors associated with change in height-for-age z-score (HAZ), follow-up HAZ ≥ -2, change in weight-for-age z-score (WAZ), and follow-up WAZ ≥ -2.

RESULTS

A total of 3217 children were eligible for analysis. The adjusted mean change in HAZ among cotrimoxazole and non-cotrimoxazole users did not differ significantly over the first 24 months of ART. In children who were stunted (HAZ < -2) at baseline, cotrimoxazole use was not associated with a follow-up HAZ ≥ -2. The adjusted mean change in WAZ among children with a baseline CD4 percentage (CD4%) >25% became significantly different between cotrimoxazole and non-cotrimoxazole users after 6 months of ART and remained significant after 24 months (overall P < .01). Similar changes in WAZ were observed in those with a baseline CD4% between 10% and 24% (overall P < .01). Cotrimoxazole use was not associated with a significant difference in follow-up WAZ in children with a baseline CD4% <10%. In those underweight (WAZ < -2) at baseline, cotrimoxazole use was associated with a follow-up WAZ ≥ -2 (adjusted odds ratio, 1.70 vs not using cotrimoxazole [95% confidence interval, 1.28-2.25], P < .01). This association was driven by children with a baseline CD4% ≥10%.

CONCLUSIONS

Cotrimoxazole use is associated with benefits to WAZ but not HAZ during early ART in Asian children.

The management of food allergy in Indonesia

Prevalence of allergic diseases is increasing worldwide, including food allergy. It is different between countries because food allergy can vary by culture and population. Prevalence of food allergy in Indonesia is unknown; therefore it is not known yet the burden and impact of food allergy in our population. However, we already start to formulate guidelines for diagnosis and management of food allergy, especially cow's milk allergy.

Outcomes of prevention of HIV mother-to-child transmission in Cipto Mangunkusumo Hospital

Background Human immunodeficiency virus (HIV) infectionis increasing worldwide. One foute of HIV transmission is frommother to child, during pregnancy, delivery or breastfeeding.Prevention of mother􀁂to􀁂child transmission may be an effectivestrategy to reduce the cases of new HIV infections.Objectives To investigate the incidence of HIV infection ininfants born to mothers with HIV and who received prophylactictherapy at birth, as well as to note the outcomes of HIVinfectedchildren in this program.Methods This retrospective study was carried out over a 9􀁂yearperiod, from January 20 03 to December 2011. The participantswere HIVexposed infants who attended the HIV clinic, at theDepartment of Child Health, Cipto Mangunkusumo Hospital,Jakarta. Infants were treated according to the prevention ofmother􀁂to􀁂child transmission (PMTCT) protocol at CMH.Parents' and infants' data was recorded. The end point of thisstudy was recording of HIVinfection status in the infants.Results There were 238 infants included in this study. HIVinfection was confirmed in 6 (2.5%) infants, while 170 (71.4%)subjects were uninfected, and 62 (26.1%) subjects were lostto follow􀁂up. No subjects who underwent complete PMTCTmanagement were infected. Most subjects were male, full􀁂tenn,and delivered by caesarean section in our hospital. The mostfrequently observed parental risk factor was intravenous druguse. Maternal antiretroviral therapy (ART) was given duringpregnancy in most cases. Morbidities in all subjects were low.Conclusion The PMTCT program at CMH was effective forreducing the number ofHIVinfected infants from mothers withHIY. [Paediatrlndanes. 2012;52:294-9]. 

Soy protein sensitization in cow’s milk allergy patients

Background The management of cow’s milk allergy (CMA) isavoidance of cow’s milk as strictly as possible. Extensive hydrolyzedprotein and amino acid based formulas are recommended dietaryproducts for treatment of CMA. However, they have somedisadvantages, such as bitter taste and high cost. Alternativeprotein sources from vegetable proteins, such as soy, can be usedas milk-substitute. Previous studies showed the prevalence of soyallergy in CMA patients in Western countries ranged between 0to 63%, but the prevalence in Asia was not greater than 20% andno data about this prevalence in Indonesia.Objectives To determine the proportion of soy proteinsensitization in CMA patients and characteristics of CMA patientswho were sensitized to soy protein.Methods Fifty seven CMA patients who consumed soy proteinwere taken their blood sample to examine the soy-specific IgE.Results From 57 CMA patients, we found only 18% of patientswho were sensitized to soy protein. Seven out of ten CMA patientswho were sensitized to soy protein were under 12 months old.Atopic dermatitis was the most frequent clinical manifestation(8/10) and all of them had family history of atopic diseases. Soysensitization in IgE-mediated and non-IgE mediated CMA were6/10 and 4/10, respectively.Conclusions Proportion of soy sensitization in CMA patients inthis study was 18%. Soy protein can be used as an alternative forcow’s milk substitute in CMA patients.