Prognostic indicators in patients with snakebite: Analysis of two-year data from a township hospital in central Myanmar.

Background: Rural people seek medical treatment for snakebite at peripheral health care facilities. Hence, identification of the characteristics, which can be used at peripheral levels of health care as reliable predictors of mortality, are required. Methods: Hospital records of 101 patients (70 males and 31 females) with age ranging from 3 to 80 years, admitted to Nahtogyi township hospital in central Myanmar during January 2005 to December 2006 were reviewed retrospectively. Binary logistic regression was used for estimating odds ratio (OR) and 95% Confidence Interval (CI) for various prognostic indicators of mortality. Results: Almost all snakebites were on extremities; more in legs (62%) than hands (37%). Most (52.5%) bites occurred in the morning (4 am to noon). Mean (SD) time for bite-to-hospital and bite-to-injection of anti-snake venom (ASV) was 134.6 (78.6) and 167 (187.8) minutes respectively. Eleven cases (10.9%) had died. Case fatality ratio (CFR) was significantly higher in 39 patients with un-clotted blood as compared to 62 patients with clotted blood (25.6% vs 1.6%, p <0.0005). Significantly higher CFR was observed in 49 patients who received ASV in >2 hours after the bite compared to 52 cases who received ASV within two hours (9.9% vs 0.9%, p <0.0001). Odds ratio of fatality were higher among those who had urine output of <400 ml in the first 24 hours (OR 26.4; 95% CI 2.4 to 288.3), un-clotted blood (OR 4.6; 95% CI 0.3 to 66.7), bite-to-injection time of >2 hours (OR 4; 95% CI 0.1 to 219.8) bite-to-hospital time of >2 hours (OR 3.1; 95%CI 0.1 to 136.3) and bites in the morning (OR 2; 95% CI 0.3 to 16.0). Conclusions: Clinical parameters could be used by healthcare providers to identify snakebite patients for referral, who may have fatal outcome.

A study on thiamine nutritional status of Khayan Township

As staple food of Myanmar is rice, there is a risk to develop thiamine deficiency. So a study was conducted in Khayan township to assess its thiamine nutritional status. Transketolase enzyme activity stimulation test of 59 pregnant women and 26 lactating mothers were studied and 12.9 per cent of them were found to be in deficient state. Thiamine concentration of breast milk samples collected from 31 lactating mothers was also measured; the mean value was 6.7 + or - 4.3 mcg/100ml. Rice samples were collected from conventinal type rice mills, Huller type rice mills and residences of Paukone village, and their thiamine content were 59.7 + or - 23.6 mcg/100gm (n=5), 66.8 + or - 22.7 mcg/100gm (n=20) and 73.97 + or - 41.2 mcg/100gm (n=26) respectively. Boiled rice samples were also collected from Paukone village and the mean thiamine content was 10.74 + or - 8.73 mcg/100gm (n=33). Thus it seems that thiamine nutritional status of Khayan is not in a satisfactory state.

Orocaecal transit time measured by breath hydrogen test in pre-school children

The orocaecal transit time (OCTT) was measured in 90 healthy children aged 1 to 5 years with the hydrogen breath test using lactulose (10 g in 10 per cent aqueous solution) as the test meal. The re1ationships between OCTT and gender, age, malnutrition status were assessed. The OCTT for 1.5 year-old children was 90.2 +/- 20.25 min (mean +/- SD). There was no significant difference in mean OCTT between boys and girls (89.03 +/- 15.45 vs. 91.05+/- 23.24). The mean OCTT of children who were still breast-fed (92.86+/-27.1 min) was also not different from those who were completely weaned (89.15+/-17.0 min). There was also no difference in OCTT between malnourished and non-malnourished children, and between age groups (1-2 y, 2-3 y, 3-4 y and 4-5 y).

Maturation of foetal thyroid hormone synthesis and regulation

A total of 343 pairs of maternal serum and foetal cord serum samples were assayed for thyroxine (T4), triiodothyronine (T3) and thyrotropin (TSH) levels. Foetal serum total T4 levels showed a positive correlation not only with gestational age(r=0.14) but also with maternal serum T4 levels (r=0.42). Although these correlations were not very strong, they were statistically significant. Foetuses were found to be T3 deficient for all gestational age groups in the study. Despite these deficient levels, there was still a significant positive correlation between foetal serum T3 levels and the maternal serum T3 levels (r=0.24). Foetal serum TSH levels were about three times higher than the corresponding maternal levels for all gestational age groups. High TSH levels in the face of deficient T3 levels for all gestational age groups in the study indicated that the function of the foetal hypothalamic-pituitary feedback control system of the thyroid gland has been well established even before the foetal maturity.

Histopathological severity of antral gastritis in relationship to Helicobacter pylori colonisation

The association between Helicobacter pylori (HP) colonisation in gastric antrum and the degree of severity and activity of gastritis and the concomitant relationship with gastric atrophy and intestinal metaplastic changes were studied. A total of 204 pieces of endoscopic biopsy tissues were collected from the outpatient endoscopy unit of New Yangon General Hospital in 1994. Routine Haematoxylin and Eosin stain as well as special stains such as modified Giemsa and Carbol fuchsin stains were used for bacterial identification and quantitative analysis. a significant correlation (P value <0.001) was obtained between density of HP colonisation and severity of gastritis as well as its activity (p value <0.001). However, no significant degree of atrophic changes and intestinal metaplastic changes were noted in these biopsies. a continuation for a better understanding of the pathogenesis of HP and its consequences is necessary.

Post-mortem histological and dissecting microscopic appearance of the proximal jejunum of Myanmar children

A comparative morphological study of jejunal villi under the dissecting microscope and their histological changes under the light microscope was performed on 100 childhood necropsies from Yangon Children Hospital. they were from a-day-old meonate to twelve-year-old children. Four patterns of villi morphology were observed under the dissecting microscope: finger-like, tongue-like, leave-like and ridge villi. Histologically, inflammatory cells infiltration in the lamina propria and submucosa with vascular congestion of graded severity were observed. There is no correlation between villi morphology and histological changes. Tongue-like and leave-like villi could be regarded as normal for our children. Although histological examination of the post-mortem jejunal materials yields limited value, it could be of supportive or additive value if studied simultaneously with the dissecting microscopy.

Hormone levels in Russell's viper bite follow-up patients

Studies of cliniccal features of hypopituitarism and/or any endocrine daficiency and hormone levels were carried out in systemic envenomed Russell's viper bite victims of more than one year duration. Eighteen follow-up patients with history of post viper bite ranging from one to seven years were studied. Serum cortisol were assayed in all but serum ACTH, HGH and urinary cortisol and HGH were made in four patients. Eight were found to have clinical evidence of endocrine deficiency and their hormone levels were on the low side, although statistically not significant. Symptomless patients also have abnormal pituitary function. Chronic ill-health with vague clinical presentation in post viper bite cases should always raise the possibility of chronic pituitary dysfunction.

Comparison of lactose breath hydrogen test and milk breath hydrogen test in the diagnosis of lactose malabsorption

In both clinical and field situations, breath hydrogen analysis has been widely used in evaluating lactose malabsorption. It is as accurate as other tolerance tests and has an advantage of being noninvasive. The use of milk (360 ml) as a test meal for breath hydrogen test was evaluated in 16 adult subjects (8M:8F), age ranging from 20 to 50 years. Lactose (17.6 g) breath hydrogen test was used as standard test. Of 16 subjects tested, 5 subjects were found to be lactose absorbers and 11 subjects were lactose malabsorbers by lactose breath hydrogen test. In milk breath hydrogen test, the same 5 subjects were found to be lactose absorbers and 8 out of 11 subjects (lactose malabsorbers) were detected as lactose malabsorbers. The present study demonstrates that breath hydrogen test using milk (360 ml) as a test meal has a sensitivity of 73 per cent and a specificity of 100 per cent and could be used as an alternative test in the diagnosis of lactose malabosorption.

Circulating and urinary cortisol, ACTH & HGH levels of normal Myanmar subjects

Cortisol, adrenocorticotropic hormone (ACTH), human growth hormone (HGH), overnight urinary cortisol and HGH levels were measured in 31 apparently normal healthy volunteers (21 males and 10 females) at the Thayawady Township Hospital. Measurement of circulating hormonal levels was performed by using commercial radioimmunoassay kits. All volunteers were admitted to the hospital for a period of 48 hours and cortisol, ACTH, HGH were measured four times in 24 hours (9:00 hr, 12 noon, 18 hr and 24 hr) consecutively for 48 hours. Overnight urinary cortisol and HGH levels were also measured after a protein load was given on the second night. Serum ACTH level was 15.82 uU/L (range 0.02 to 150.0 uU/L) and the average 24 hour serum HGH level was 7.55 mU/L (range 0.01 to 37.0 mU/L). Serum cortisol was found to be in the range of 21.0 nmol/L to 700.0 nmol/L with a 24 hr average of 227.95 nmol/L. Overnight urinary cortisol and HGH ranged from 0.089 to 27.7 ug and 4.0 to 230 uU respectively.

Breath methane excretion status in children with lactose malabsorption

We carried out a study to determine breath methane excretion status in relation to lactose absorption in children. The lactose absorption status of 125 children aged 1 to 12 years was defined using the hydrogen breath test using lactose test meal (2 g/kg, maximum 50 g). Lactose malabsorption was detected in 16.7 percent of children aged 1-2.9 years, the prevalence increasing with age to 39.5 percent of 3-5.9 year-olds and 88.5 years, the prevalence increasing with age to 39.5 percent of 3-5.9 year-olds and 88.5 percent of 6-8.9 years and reaching 91.7 percent 9-11.9 year-old children. We measured breath methane excretion status in 69 children (56 lactose-malabsorbers and 13 lactose-absorbers) and found significantly higher breath methane excretion in lactose-malabsorbers.

Evaluation of copper sulfate method for screening anaemia

The haemoglobin values of 102 blood samples were determined by 3 different observers; the first two observers using the copper sulfate method, and the third observer using the cyanmethaemoglobin method. The sensitivity and specificity of copper sulfate method was callculated at haemoglobin levels of 80 g/l and 100 g/l with comparison to the cyanmethaemoglobin method. At 80 g/l level, it was found to be 100 percent sensitive with a specificity of 70 percent. At 110 g/l level, the sensitivity was reduced to 82 percent while the specificity increased to 100 percent. The numbers of cases that were either correctly or incorrectly diagnosed by each observer were not significantly different and a good agreement (Kappa statistic = 0.82, 95 percent Confidence Intervals 0.77 to 0.87) was found between the two observers. The copper sulfate method was found to be reasonably accurate for screening anaemia.

Seasonal pattern of enterotoxigenic Escherichia coli (ETEC) in children under three years of age

Children aged one month to three years from Yangon Children Hospital were studied. A total of 923 cases of diarrhoea and 932 cases of control were included in this study. The total isolation rate of ETEC was 232 cases (25.2 percent) and 55 casea (5.9 percent) from diarrhoea and control cases respectively. In the diarrhoea group, out of 232 cases of ETEC, 43 cases (4.7 percent) were STLT, 134 cases (14.5 percent) were ST and 55 cases (6.0 percent) were LT. In the control group, out of 55 cases of ETEC, 6 cases (0.6 percent) were STLT, 21 cases (2.3 percent) were ST and 28 cases (3.0 percent) were LT. Although ETEC was found in children all the year round, the incidence rate was higher during the months of February to July with the highest peak of 47.0 percent in June. ETEC occurred in the control cases with the maximum isolation rate of 16 percent in June.

Breath methane analysis in the diagnosis of rice carbohydrate malabsorption

Rice carbohydrate malabsorption is common in Myanmar village children and adults. The diagnosis is dependent on the use of a rice breath hydrogen test which has potential limitations. As methane production has been identified in almost 20 percent of Myanmar children under age 5, it was possible that an increased carbohydrate load in the colon consequent upon rice malabsorption may provide increased substrate for methanogenic bacteria in the left colon. A rise in methane production might be reflected in fasting breath methane concentration and therefore simplify the diagnosis of rece malabsorption. 79 children had a rice breath hydrogen test with measurement of hydrogen over a four hour period allied with a breath methane measurement and anthropometric measurement. There was no correlation between rice malabsorption and methane production and the measurement of breath methane does not, therefore, correlate with the rice absorption status.

Nutritional status and intestinal parasitosis in school-enrolled and non-enrolled school-age children in Yangon

In Myanmar, over 38 percent of children in the age-group 5-9 years were never enrolled in school in 1990. Also, there is a lack of information on the comparative prevalence of malnutrition and intestinal parasitosis among school-enrolled and non-enrolled school-age children in Myanmar. We, therefore, undertook a cross-sectional survey comprising 3325 school children from 13 primary schools and 164 non-enrolled school-age children from neighbouring quarters in Tharkayta and Mingaladon townships of Yangon during December 1993. Height and weight of the children were measured and a total of 944 stool samples, including 148 non-enrolled children, were examined for the presence of intestinal parasites. Expressing the nutritional status as standard deviation scores for weight-for-height, the prevalence of wasting among 5-10 years non-enrolled school-age children was 19.8 percent, while that for school children of similar age was 13.9 percent. In addition, non-enrolled school-age children had higher infection rates than school children regarding Ascaris Lumbricoides (66.9 percent vs 50.1 percent), Trichuris trichiura (38.5 percent vs 23.9 percent), and Giardia lamblia (5.4 percent vs 2.7 percent). The policy implication of this study is that health and nutritional status of non-enrolled school-age children needs to be promoted and this should be partly solved by the provision of regular and periodic mass chemotherapy against major intestinal parasitoses influencing nutritional status.