Background Over the past 10 years, infection has remained as the main cause of illness and mortality among children with Acute Lymphoblastic Leukemia on chemotherapy. The high incidence of Hospital-Acquired Pneumonia in children with Acute Lymphoblastic Leukemia on chemotherapy with risk factors should be intervened earlier Methods An observational case control study of children with Acute Lymphoblastic Leukemia on chemotherapy. Patient with Hospital-Acquired Pneumonia considered as case and patient without Hospital-Acquired Pneumonia as control to analyze risk factors that affect the incidence of Hospital-Acquired Pneumonia in children with Acute Lymphoblastic Leukemia on chemotherapy from 2016 to 2018 was performed in the pediatric ward Dr. Soetomo General Academic Hospital with a total sampling technique. Nine risk factors were analyzed: age, gender, nutritional status, length of stay, risk stratification, chemotherapy phase, anemia, neutropenia, and thrombocytopenia. Bivariate and multivariate analysis using chi-square, continuity correction, and logistic regression was used for statistical analysis. Results 120 children enrolled the study. Analyzed of risk factors showed risk stratification (p = 0.009), chemotherapy phase (p < 0.001), and neutropenia (p < 0.001) was proven to significantly affect the incidence of Hospital-Acquired Pneumonia in children with Acute Lymphoblastic Leukemia on chemotherapy. Age, gender, nutritional status, length of stay, anemia, and thrombocytopenia were not proven to be a risk factor that affects the incidence of Hospital-Acquired Pneumonia in children with Acute Lymphoblastic Leukemia on chemotherapy. Conclusion The incidence of Hospital-Acquired Pneumonia in children with Acute Lymphoblastic Leukemia on chemotherapy is significantly affected by the risk stratification, chemotherapy phase, and neutropenia.

Background: Overexpression of the antiapoptotic protein Bcl-2 causes apoptosis to stop and conversely the increased expression of the proapoptotic protein Bax makes lymphoblasts easy to destroy. The Bax/Bcl-2 ratio plays a role in the balance of apoptosis, immortality, resistance, and outcome of chemotherapy. We analyzed the relationship between the Bax/BCl-2 ratio and the outcome of induction phase chemotherapy in pediatric Acute Lymphoblastic Leukemia (ALL). Methods: This research was conducted with a prospective observational study on pediatric ALL aged 1-18 years who were newly diagnosed based on bone marrow aspiration (morphology and immunophenotyping) at Dr. Soetomo General Hospital, Surabaya on October 2020 to March 2021. Expression of Bcl-2, Bax, and Bax/Bcl-2 protein ratio was measured by the flow cytometry method from lymphoblast on bone marrow aspirate samples before and after induction phase chemotherapy according to the 2018 Childhood ALL Indonesian Protocol. The outcomes evaluated were survival and remission rate (lymphoblasts in the bone marrow less than 5%). We used the Mann-Whitney U test and Wilcoxon Signed Rank test to analyze the differences between protein expression with p<0.05 for a two-tailed test. Results: We included 17/26 pediatric ALL, consisting of 88% male, 94% LLA-L1, 76% B cell ALL and 24% T cell ALL. Mean expression of Bax, Bcl-2, and Bax/Bcl-2 protein ratio before chemotherapy among pediatric ALL who alive (N=11) and dead (N=6) were not significantly different (p>0.05). All children who completed the induction phase of chemotherapy went into remission. Bax and Bcl-2 expression before and after chemotherapy showed no difference (p>0.05). The Bax/Bcl-2 ratio increased from 1.74(SD 1.846) to 6.17(4.139) with p=0.021. Conclusion: Expression of Bax, Bcl-2, and Bax/Bcl-2 protein ratio at the beginning of diagnosis did not affect the survival of pediatric ALL after the induction phase of chemotherapy. The Bax/Bcl-2 protein ratio increased 3.5 times in pediatric ALL with remission outcomes, indicating proapoptotic dominance.

Background: Utilization of a specified questionnaire to measure the Health-related quality of life (HRQoL) in children with hemophilia is unusual especially in a country with resources limited settings. The objective of this study is to analyze the quality of life (QoL) of children with hemophilia A and the clinical factors that affect them. Methods: A cross-sectional study was conducted in September 2021. The participants were children with hemophilia A who were registered at the Indonesian Hemophilia Society Association (IHSA) in Surabaya. Inpatients, children with cognitive impairment, mental health disorder, aged 8 to 16 years old and cannot read, and declined to participate are not included. The questionnaires are using Hemophilia-Specific Quality of Life (Haemo-QoL) which have been validated in Bahasa Indonesia. HRQoL was assessed for 3 age groups (I: 4 to 7; II: 8 to 12; and III: 13 to 16 years). Results: All participants (21 children) were male with a median age of 148 months. More than half (52.4%) of the children had mild hemophilia, followed by moderate hemophilia. The mean total Haemo-QoL score was 38.57 (+9.52). The youngest age group are experienced the highest disturbance in the family dimension, followed by the sports school dimension; children in the second and third age group were impaired in friends and sports school dimension. There was no significant correlation between clinical factors studied and the QoL of children with hemophilia A. Conclusion: The QoL of the youngest age groups must be prioritized due to susceptibility to the family dimension. Appropriate and prompt treatment plays a major role because the treatment of this disease does not depend on the severity of the patient’s clinical factors.

Background: Daunorubicine, a type of anthracycline, is a drug commonly used in cancer chemotherapy that increases survival rate but consequently compromises with cardiovascular outcomes in some patients. Thus, preventing the early progression of cardiotoxicity is important to improve the treatment outcome in childhood acute lymhoblastic leukemia (ALL). Objective: The present study aimed to identify the risk factors in anthracycline-induced early cardiotoxicity in childhood ALL. Methods: This retrospective study was conducted by observing ALL-diagnosed children from 2014 to 2019 in Dr. Soetomo General Hospital. There were 49 patients who met the inclusion criteria and were treated with chemotherapy using Indonesian Childhood ALL Protocol 2013. Echocardiography was performed by pediatric cardiologists to compare before and at any given time after anthracycline therapy. Early cardiotoxicity was defined as a decline of left ventricle ejection fraction (LVEF) greater than 10% with a final LVEF < 53% during the first year of anthracycline administration. Risk factors such as sex, age, risk stratification group, and cumulative dose were identified by using multiple logistic regression. Diagnostic performance of cumulative anthracycline dose was evaluated by receiver operating characteristic (ROC) curve. Results: Early anthracycline-induced cardiotoxicity was observed in 5 out of 49 patients. The median cumulative dose of anthracycline was 143.69±72.68 mg/m 2 . Thirty-three patients experienced a decreasing LVEF. The factors associated with early cardiomyopathy were age of ≥ 4 years (PR= 1.128; 95% CI: 1.015-1.254; p= 0.001), high risk group (PR= 1.135; 95% CI: 1.016-1.269; p= 0.001), and cumulative dose of ≥120 mg / m 2 (CI= 1.161; 95% CI:1.019-1.332). Conclusion: Age of ≥ 4 years, risk group, and cumulative dose of ≥120 mg/m 2 are significant risk factors for early cardiomyopathy in childhood ALL.

Background Acute lymphoblastic leukemia (ALL) is a neoplastic disease resulting from somatic mutation in the lymphoid progenitor cells, often occuring in children aged 2-5 years, predominantly in males. Results from the induction phase of chemtherapy are used to measure success, but the failure remission rate is still high. Increased apoptosis of cancer cells, as induced by CD4 + and CD8 + T-cells, is an indicator of prognosis and response to chemotherapy. Objective To assess for correlations between CD4 + , CD8 + , or CD4 + /CD8 + ratio to the chemotherapy induction phase response (i.e., apoptosis) in pediatric ALL patients. Methods This observational analytical cohort study was done in 25 pediatric ALL patients. Whole blood (3 mL) with EDTA anticoagulant were used to measure absolute counts of CD4 + , CD8 + , and CD4 + /CD8 + ratio. Peripheral blood mononuclear cells (PBMC) were examined for apoptosis. The principle of CD4 + , CD8 + examination was bond between antigens on the surface of the leukocyte in the blood with fluorochrome labeled antibodies in the reagents, while the principle of apoptosis examination was FITC Annexin V will bonds with phosphatidylserine that moves out of the cell when the cell undergoes apoptosis, then intercalation with propidium iodide (PI). All examination were detected by flow cytometry BD FACSCalibur. Results Subjects were 25 newly-diagnosed, pediatric ALL patients (64% males and 36% females). Most subjects were 3 years of age (20%). Numbers of CD4 + and CD8 + cells, as well as CD4 + / CD8 + ratio were significantly decreased after chemotherapy. However, apoptosis was not significantly different before and after chemotherapy (P=0.689), There were significant negative