Characterizing Helicobacter pylori cagA in Myanmar

BACKGROUND/AIMS: Differences in the Helicobacter pylori infection rate are not sufficient to clarify the dissimilarity of gastric cancer incidence between Myanmar and its neighboring countries. To better understand this trend, the H. pylori virulence gene cagA was characterized in Myanmar. METHODS: Glutamate-proline-isoleucine-tyrosine-alanine (EPIYA) patterns and CagA multimerization (CM) motifs of cagA genotypes were examined by performing polymerase chain reactions and DNA sequencing. RESULTS: Of 69 tested H. pylori strains, cagA-positive patients had significantly more severe histological scores in their antrum than cagA-negative patients. Sequence analysis revealed that 94.1% of strains had Western-type cagA containing an EPIYA motif (92.6%) or EPIYT motif (6.4%). The intestinal metaplasia scores in the antral of patients infected with the ABC and ABCC types of cagA were significantly higher than those of patients with AB-type cagA. Interestingly, in patients infected with H. pylori, 46.3% of strains with three EPIYA motifs contained two identical Western-typical CM motifs, and these patients showed significantly higher antrum inflammation scores than patients infected with two identical nontypical-CM motif strains (p=0.02). CONCLUSIONS: In Myanmarese strains, Western-type cagA was predominant. The presence of CM motifs and the proportion of multiple EPIYA-C segments might partially explain the intermediate gastric cancer risk found in Myanmar.

Single Nucleotide Polymorphism at +276 g>T of the Adiponectin gene and Plasma Adiponectin Level in Myanmar Type 2 Diabetic Patients / Journal of the ASEAN Federation of Endocrine Societies

Objective@#The aim of the study was to investigate the association between single nucleotide polymorphisms (SNP) at rs 1501299 (SNP+276 G>T) of the adiponectin gene and plasma adiponectin levels in type 2 diabetes mellitus (T2DM) patients in Myanmar.@*Methodology@#One hundred T2DM patients and 104 non-diabetic subjects were included in this cross-sectional analytical study. Genotype frequencies were determined by polymerase chain reaction - restriction fragment length polymorphism (PCR-RFLP) method. Plasma adiponectin level was measured by enzyme-linked immunosorbent assay (ELISA). @*Result@#Genotype frequencies (GG, GT, TT) of SNP+276 in diabetic patients were 39%, 48% and 13%, respectively. The GT and TT genotypes were more frequent in T2DM patients (OR 1.98, 95% CI, 1.10-3.55; p=0.02 and OR 4.07, 95% CI, 1.34-12.3; p=0.01), respectively. The T allele of SNP+276 was significantly associated with T2DM (OR 1.96, 95% CI, 1.27-3.01; p=0.002). Mean plasma adiponectin level was significantly lower than in T2DM patients (27.41±16.7 μg/mL) compared to non-diabetic subjects (37.19±26.77 μg/mL) (p=0.002)@*Conclusion@#SNP+276 at rs 1501299 of the adiponectin gene was associated with type 2 diabetes and low plasma adiponectin levels in this Myanmar population.

The efficacy of sequential treatment for Helicobacter Pylori eradication.

Myanmar is a high prevalence area of H pylori infection with sero-prevalence rate of 69%. The clarithromycin-based triple therapy is commonly used as empiric first line treatment for H pylori infection in Myanmar. However, the efficacy of sequential treatment for Myanmar patients with H pylori infection has not been investigated. The objective of the present study is to determine the efficacy and safety of sequential treatment for Helicobacter pylori eradication in dyspeptic patients. A total of 100 dyspeptic patients aged > 18 years with proved Helicobacter pylori infection were randomly assigned to receive either 10 day sequential therapy or 10 day triple therapy. After completion of treatment, compliance and side effects were assessed. The outcomes of the eradication therapy were assessed 4 weeks after treatment by the 13C urea breath test. The success rate of H pylori eradication between the sequential therapy and the triple therapy was not significant (85.7% Vs 95.1%, p = 0.147). The triple therapy had 66.7% relative risk reduction (RRR), 9.4% absolute risk reduction (ARR) and 11 number need to treat (NNT). The adverse events between two study groups did not differ significantly (23.8% Vs 31.7%, P = 0.422). Good compliance was achieved in all patients of two study population. The result of this study could not prove that the efficacy of sequential treatment was superior to that of triple treatment for H pylori eradication in Myanmar dyspeptic patients.

H. pylori infection among Buddhist monks in the selected regions of Myanmar.

Background: The prevalence of H. pylori infection is different in various regions of Myanmar, and the results of studies are contradictory regarding incidence of H. pylori infection. The infection rate of H. pylori among the monks could reflect the prevalence of the particular region studied. Objectives: The present study was aimed to determine the Helicobacter pylori status among asymptomatic Buddhist monks in Myanmar, and to observe the efficacy of clarithromycin based first line therapy by using C14 Urea Breath Test (PY test). Method: The Buddhist monks 17 years of age and above from the monasteries of both middle and lower Myanmar were selected by purposive sampling method. After filling out the questionnaire,H.pylori infection was detected by 14C-UBT (PY test, microCOUNTLite Liquid Scintillation Counter). H.pylori positive subjects were treated with 10 days' course of clarithromycin containing standard triple therapy as a first line.14C-UBT test was repeated at week 4 to check for H.pylori eradication status. Results: A total of 399 monks (from Bago and Mandalay city) were enrolled in this study. The mean age was 23.51+/ 8.907 years (range: 18 - 97). Urea breath test was positive in 65.4% of the monks. The prevalence of H. pylori infection was radically similar in different monasteries of different cities: Bago and Mandalay (67.52% ν 63.18%, p = 0.33). Among H. pylori infected monks, 67.7% achieved eradication with clarithromycin containing standard triple therapy. Conclusion: High H. pylori infection rates were found in asymptomatic Buddhist Myanmar monks and the standard triple therapy had moderate efficacy.

A summary of the clinical practice guidelines for the management of patients with Peripheral Arterial Disease in Myanmar / Journal of the ASEAN Federation of Endocrine Societies

@#Peripheral artery disease (PAD) broadly encompasses vascular diseases caused primarily by atherosclerosis and thromboembolic pathophysiologic processes that alter the normal structure and function of the aorta, its visceral arterial branches, and the arteries of the lower extremity. The aims of the Myanmar clinical practice guidelines for the management of patients with PAD are to assist physicians in selecting the best management strategies for an individual patient with peripheral artery disease with main focus on lower extremity artery disease (LEAD) due to atherosclerosis, to help the physician to make decisions in their daily practice, and to aid in appropriate referrals to specialists. Early detection and treatment guidelines for the treatment of PAD are important to reduce the morbidity and mortality of patients with vascular problems in Myanmar.

Scenario of the twins with suspected congenital rubella syndrome (CRS) in Yangon, Myanmar

Rubella is a common cause of childhood rash and fever. Congenital rubella syndrome (CRS) can lead to deafness, heart disease, cataracts, and a variety of other permanent manifestations. In order to identify the disease burden of rubella infection, CRS surveillance among infants in Yangon was conducted for two consecutive years from December 2000 to December 2002, as a WHO-funded study. Among the 13 participating hospitals, the Special Care Baby Unit of the Central Women‘s Hospital in Yangon reported 17 infants with suspected CRS. Interestingly, three sets of twins with suspected CRS were reported. One ml of blood was collected from each infant after obtaining informed consent, then tested for the presence of rubella antibody (Immunoglobulin M and G) by the ELISA method, and for the presence of rubella viral RNA by the RT-PCR method. Furthermore, nucleotide sequencing and genotype identification of samples from two cases with positive rubella RNA were performed. All 3 sets of twins were IgM negative. However, rubella RNA was detected by RT-PCR in twin 1A who showed no obvious clinical signs, and in twin 2B who had patent ductus arteriosus, splenomegaly and hepatomegaly. Nucleotide sequences of PCR positive cases revealed genotype Ia sequences. Twin 2B was identified as having deafness of the left ear on audiometry assessment conducted at 5 years and 4 months of age. Both twins of twin set-2 were IgG positive at age 12 days, but turned out to be negative by the age of 9 months. Both twins of twin set-3 presented with splenomegaly and died before 2 months of age, probably due to other infections. Our findings revealed the different scenario of twins with suspected CRS. It is expected to serve as a valuable addition to the medical literature as there were very few reports on twins with CRS.

Evaluation of dengue blot test

Dengue blot test is a dot enzyme immuno-assay which detects the antibodies to dengue virus of all tyes (1 to 4). The result of the test can be obtained after three hours.In the management od dengue haemorrhagic fever confirmation of diagnosis should be made at early stage.This requires a test which is highly specific, highly sensitive and quick.To determine the usefulness of dengue blot test in diagnosing dengue haemorrhagic fever, this study was carried out in 319 patients who were clinically diagnosed as dengue haemorrhagic fever at Yangon Children Hospital.They were tested for both blot test and standard test of haemagglutination inhibition (HI).Blot test was positive in 304 patients out of which only one is negative for HI test (True positive 303 false positive 1).Out of 15 patients who were negative for blot test 10 were positive for HI test (True negative 5, false negative 10).This test was found to be highly sensitive (sensitivity 96

), and specific (specificity 83

).Positive predictive valve was 99.6

but negative predictive value was only 33.3

.

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).

Bacterial pathogens and drug susceptibility pattern: from diarrhoea cases of children

Stool specimens from 200 cases of children with ages of less than five years with history of acute diarrhoea from Yangon Children's Hospital were proceeded for isolation of bacterial pathogens. Enterotoxigenic Escherichia coli ETEC (15.5 per cent), enteropathogenic Escherichia coli EPEC (19 per cent), Shigellae (3.5 per cent), Salmonellae (2.5 per cent), ETEC + EPEC (6.5 per cent), ETEC+Shigellae (1.0 per cent) were isolated. Antibiotic susceptibility pattern of EPEC revealed that they were resistant to ampicillin (96 per cent), tetracycline (90 per cent), streptomycin (82 per cent), chloramphenicol (80 per cent) and septrin (61 per cent); but were sensitive to nalidixic acid (100 per cent), furazolidone (92 per cent), sisomycin (90 per cent), gentamicin (88 per cent), norfloxacin (70 per cent), and cephalothin (66 per cent). For Shigellae they were resistant to ampicillin (100 per cent), cephalothin, chloramphenicol, furazolidone, streptomycin (66.7 per cent) but were 100

sensitive to sisomycin, minocycline, norfloxacin, gentamicin; tobramycin (89 per cent), neomycin (67 per cent) and septrin (56 per cent). For Salmonellae they were resistant to ampicillin (100 per cent), chloramphenicol and tetracycline (80 per cent) but were 100 per cent sensitive to cephalothin, furazolidone, gentamicin, nalidixic acid, norfloxacin, septrin and sisomycin. For ETEC they were resistant to ampicillin (100 per cent), tetracycline (79 per cent), chloramphenicol (53 per cent) and septrin (53 per cent ). They were 100 per cent sensitive to cephalothin, furazolidone, gentamicin, nalidixic acid, neomycin, norfloxacin, septrin and sisomycin.

Glutaraldehyde gelification time-a highly acceptable bedside tool in the assessment of children tuberculosis

Glutarldehyde gelification time (GGT) was determined three times in fifty-three children with the clinical diagnosis of tuberculosis supported by CxR evidence, once before the initiation of treatment (GGTO) and twice within six months of antituberculous treatment, at three months interval (GGT3 and GGT6 respectively). The values of GGTO are shortened in 46 cases (86.8 per cent). GGT3 and GGT6 revealed shorten in 27 cases (50.9 per cent) and 6 cases (11.3 per cent ) respectively. This significant change of GGT during treatment could be used as a supportive evidence to clinical judgment in the assessment of response to treatment in childhood tuberculosis.

Cryptosporidiosis among children with diarrhoea and dysentery from Yangon Children's Hospital

Cryptosporidiosis among children who attended Yangon Children's Hospital from March to October 1996 was studied. A total of 396 stool samples were collected after admission to the hospital. Simultaneously, a set of questions was filled to ascertain the duration and motion of diarrhoea of children. Stool characteristics were also recorded. Cryptosporidium oocysts were detected by staining with Kinyoun's acid modified method by Haley and Standard 1973. Random samples of 238 male and 158 female children of ages ranging from one month to ten years old were included in this study. It was found that the duration of diarrhoea ranged from one to 150 days. Number of motions also ranged from one to 40 times per day. Diarrhoea with either blood or mucous (dysentery) was found in 61 cases (15.4 per cent). cryptosporidium oocysts were found in 5 cases (1.3 per cent) of children; three were from watery diarrhoea cases and two from dysentery cases. From the cases detected, the age range was from 10 months to five years and the duration of illness was from 3 to 30 days. Four cases were with moderate degree of dehydration and one case was associated with HIV infection.

Growth of thalassaemic children in Myanmar

The growth of thalassaemic children was studied at the Day-Care-Room in Yangon Children's Hospital. Most of these patients came to the Day-Care-Room for transfusion only, when their pretransfusion haemoglobin level became very low (range 3-8.2 g/dl, median 5.0 g/dl). Their spleens and livers were moderate to markedly enlarged. The percentage of children who had below median -2SD for weight and height for age were 68.8 percent and 72.9 percent respectively. There was no much difference between growth of boys and girls. The rising trend of percentage of children who had low weitht and height for age was found as they became loder. To get a better growth and a better quality of life, the pretransfusion haemoglobin level should be maintained at > 6 g/dl (probably 6-9 g/dl).

Is oral rice-based electrolyte solution superior to glucose electrolyte solution in acute chidhood diarrhoea?

In a controlled trial of oral rehydration therapy, the efficacy and safety of rice-based electrolyte solution was compared with standard WHO oral rehydration solution. Ninety eight male children aged 4 months to 10 years presenting with watery diarrhoea of less than 72 hours prior to hospitalization were studied. 48 were treated with standard WHO oral rehydration solution (ORS) and 50 patients with an improved formulation which contained 100 gm of rice (instead of glucose) with 25 mg of amylase in addition to electrolytes. The clinical characteristics of the two groups on, admission were comparable. Although there was a consistent trend towards reduction in stool volume and better gain in body weight in children with cholera treated with rece-based ORS, significant difference was noted only in 6-12 hour stool output and in the first 6 hour weight gain. Stool volume was significantly reduced during the 24 to 48 hour perild in all diarrhoeal patients receiving rice-based ORS. Thus, amylyte digested rice-based ORS is as effective as the Standard WHO ORS and have some therapeutic advantage in the treatment of acute childhood diarrhoea.

The effect of intramuscular loading dose of quinine on Myanmar patients (children and adults) with falciparum malaria

The effect of three doses of intramuscular quinine followed by oral quinine on ten adults and ten children with falciparum malaria (half of each group were highly parasitised) were studied. There were no complications associated with this method of therapy. the level of serum quinine in all the adults reached above the minimal inhibitory concentration (MIC) from the 2nd hour of the drug administration. So this method of administration should be recommended for severely ill patients before referral to hospitals. Anong the children, eight responded well to the therapy and the serum quinine level rose above MIC level from the second hour as in adults. There were two patients who failed to respone to the treatment. One had persistantly high level of quinine and was misdiagnosed as a case of cerebral malaria instead of quinine toxicity. He responded well when quinine was omitted and replaced with mefloquine. Another child had persistantly low level of quinine. He developed cerebral sings and symptoms and also responded well to mefloquine. Thus it is suggested that the level of serum quinine should be monitroed in children if possible, or toxicity ot quinine should be watched.

Risk factors in children with acute respiratory infections

1826 children attending the Outpatients Department of Mandalay General Hospital from 1st February 1986 to 31st January 1987 with acute respiratory infection (ARI) related symptoms and sings were studied. They were followed up till they died or were well and the classification was done considering the clinical presentation, the response to treatment and the discharge status of the patient. The risk factors which determine the severity of ARI among the presenting clinical signs and symptoms were determined. The severe forms of ARI tend to occu in younger age groups and in malnourished children. Chest indrawing, inability to drink and nasal flaring were found to be absolute risk factors in ARI. In addition, temperature of > 38 degree C, pulse rate of > 120/min and respiratory rate of > 40/min were found to be important risk factors inthe morbidity and mortality of children with ARI.

Thalassemia in the outpatient department of the Yangon Children's Hospital in Myanmar: basic hematological values of thalassemia traits.

The present study was conducted in the Outpatient Department (OPD) of Yangon Children's Hospital (YCH) during June to November 1990 to determine the hematological data of 133 Myanmar patients with thalassemia trait who were the parents of patients with known beta-thalassemia major or hemoglobin E (Hb E)/beta-thalassemia. The mean values of hemoglobin (Hb) concentration, packed cell volume (PCV), mean cell hemoglobin (MCH) and mean cell volume (MCV) were significantly lower than normal controls but the mean cell hemoglobin concentration (MCHC) was the same as controls. Increased osmotic resistance tested in 0.36% buffered saline was detected in 81-97% of cases depending on the cut-off point. High levels of Hb A2 (> 3.5%) were found in 93% of cases whereas Hb F was increased (> 0.8%) only in 23% of cases. Although the mean red cell count (RBC) was significantly higher than normal, only 79% of thalassemia traits were detected if the RBC count of > 5.0 x 10(12)/1 was taken as the discrimination limit. Other discrimination functions such as MCH/RBC, MCV/RBC, (MCV)2 x MCH x 0.01 and MCV-(RBC/10(12)/1)-(5 x Hb) - 3.4 or - 8.4 were tested for their utility in diagnosing thalassemia traits. All of them were found not to be superior to each of the simple tests (MCV, MCH, Hb A2 or osmotic fragility) in diagnosing thalassemia traits. The one tube osmotic fragility test is a the suitable test to be used in future thalassemia screening programs in Myanmar.

Thalassemia in the outpatient department of the Yangon Children's Hospital in Myanmar: cost analysis of the day-care-room services for thalassemia.

A cost analysis study for the fiscal year 1989-1990 was conducted in the day care room (DCR) for thalassemia patients at the Yangon Children's Hospital in Myanmar to provide a basis for future cost-effectiveness, cost-benefit and efficiency analyses. Two types of costs, hospital costs and costs borne by the patients' families were studied by reviewing hospital records and by interviewing family members of patients. Of the total cost of DCR services for thalassemia 74 to 75% was contributed by material costs most of which were for imported items. The cost of each transfusion visit and the annual cost per patient were Kyats 166.5 to 173.3 and Kyats 1,108.6 to 1,208.7, respectively. The median cost (range) per treatment visit and the averaged annual median cost (range) borne by the patients' families were Kyats 21 (0-302) and Kyats 107 (0-1,509), respectively.

Thalassemia in the outpatient department of the Yangon Children's Hospital in Myanmar: knowledge, attitudes and practice in relation to thalassemia.

A maternal knowledge, attitudes and practice (KAP) study concerning the nature and prevention of thalassemia was carried out at the Yangon Children's Hospital in Myanmar. The KAP information was collected using a pretested schedule. Only 18 to 28% of the mothers knew at least one of the statements: thalassemia is a genetic disorder; both parents of thalassemic children carry abnormal genes; there is a 25% chance of recurrence in each subsequent pregnancy. Eighty-two per cent of the respondents decided not to have a further pregnancy for fear of recurrence and of these 62% were currently practising contraception. Oral contraception was the most commonly used method (56%). The median scores as well as the percent responses in favor of the three attitude scales relating to limiting thalassemic children, prenatal diagnosis and termination of pregnancy were high. Although there is a need to increase the community awareness of thalassemia in Myanmar, there is a possibility that prenatal diagnosis and pregnancy termination will be accepted for the prevention of thalassemia.

The pathognomonic value of symptoms and signa in the management of acute respiratory infections in young children

1826 children attending the out patient department of Mandalay General Hospital, from 1st February 1986 to 31st January 1987 with acute respiratory infection (ARI) related symptoms were classified by the primafry health workers as mild, moderate and severe ARI cases (i.e. initial classification). These children were again examined by the investigator (doctor) and appropriate treatment was given. The cases were followed up till they died or were well. The final classification was done considering the clinical presentation, response to the treatment and the outcome of the patient. To deteremine the pathognomonic value of clinical signs and symptoms in classification of severity of ARI cases, different criteria for classification of severe ARI were laid down, the ilnitial and final classification were compared and their respective sensitivity and specificity were calculated. It is concluded that out of the clinical signs and symptoms of respiratory distress, tachypnoea, chest indrawing and inability to drink were found to be important clinical signs and sylmptoms in determination of the severity of ARI. In addition to the criteria proposed by the WHO, very fast breathing (i.e respiratory rate over 70/min) with or without wheeze should be one of the criteria in classification of servere ARI.