HIV testing and ART initiation in people who inject drugs and are placed on methadone in Kachin State, Myanmar.

SETTING: People who inject drugs (PWID) enrolled for methadone maintenance therapy (MMT) and never previously tested for human immunodeficiency virus (HIV) in Myitkyina Drug Dependency Treatment Hospital, Myitkyina, Kachin State, Myanmar. OBJECTIVES: To compare before (2016) and after (2018) adoption of 'Test and Treat' guidelines for antiretroviral therapy (ART): 1) the demographic profile of PWID, 2) HIV testing uptake and ART initiation in those diagnosed HIV-positive, and 3) time taken for events. DESIGN: This was a cohort study using secondary programme data. RESULTS: In 2016 and 2018, there were respectively 141 and 146 PWID: all were male except for one female and age distribution between the 2 years was similar. In 2018, significantly more PWID were HIV-tested than in 2016 (85% vs. 45%; P ≤ 0.001). Among those tested, the proportions who were HIV-positive were similar (37% in 2016 and 38% in 2018). In 2018, significantly fewer HIV-positive PWID were started on ART than in 2016 (19% vs. 48%; P = 0.01). Median times between enrolment on MMT and HIV testing (2 vs. 1 day) and between being diagnosed HIV-positive and started on ART (31 vs. 17 days) for 2016 and 2018 were not significantly different. CONCLUSION: ART uptake decreased in 2018 compared with 2016, and ways to rectify this are urgently needed.

Attrition during pre-ART and ART time periods among adolescents enrolled in Integrated HIV Care Programme in Myanmar, 2005-2017.

Retaining adolescents (aged 10-19 years), living with HIV (ALHIV) on antiretroviral therapy (ART) is challenging. In Myanmar, 1269 ALHIV were under an Integrated HIV Care (IHC) Programme by June 2017 and their attrition (death and lost to follow-up) rates were not assessed before. We undertook a cohort study using routinely collected data of ALHIV enrolled into HIV care from July 2005 to June 2017 and assessed their attrition rates in June 2018 by time-to-event analysis. Of 1269 enrolled, 197(16%) and of 1054 initiated ART, 224 (21%) had an attrition defining event. The pre-ART and ART attrition rates were 21.8 (95% CI 19.0-25.1) and 6.4 (95% CI 5.6-7.3) per 100 person-years follow-up, respectively. The factors 'at enrolment' that were associated with higher hazards of attrition were: (1) WHO stage 3 or 4; (2) haemoglobin <10 gm/dl; (3) no documented CD4 cell counts, hepatitis B and C test results; and (4) injection drug use. Baseline hazards were high during the initial 1-2 years and after 5-6 years. The pre-ART and ART attrition rates in ALHIV were lower than those in Africa but higher than the children under IHC. This warrants designing and implementing additional care tailored to the needs of ALHIV under IHC.

Correction: Signal peptidase complex 18, encoded by SEC11A, contributes to progression via TGF-α secretion in gastric cancer.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Fully vs. partially integrated services for TB-HIV in Myanmar: a health services review and a cohort study.

In Myanmar, integrated services for tuberculosis (TB) and human immunodeficiency virus (HIV) are operated either fully (as one single unit) or partially (each vertical programme provides both services). To review the fully and partially integrated services for TB-HIV and to assess their TB treatment outcomes. We analysed the compiled service database and conducted a cohort study on newly registered TB-HIV patients in 12 townships in Myanmar. No significant association between region/state and types of integration was detected. Townships with partially integrated services had a significantly larger population size, higher proportion of urban population as well as higher TB and TB-HIV case notification rates; however, the cartridge-based Xpert® MTB/RIF assay was used less frequently than in townships with fully integrated services. Treatment completion rate and unfavourable outcomes were not significantly different between the two models, although fully integrated services reported a higher cure rate. These mixed results suggest that during expansion of fully integrated services, the progress of treatment outcomes should be monitored carefully. .

IPT in people living with HIV in Myanmar: a five-fold decrease in incidence of TB disease and all-cause mortality.

SETTING: Myanmar, a country with a high human immunodeficiency virus-tuberculosis (HIV-TB) burden, where the tuberculin skin test or interferon-gamma release assays are not routinely available for the diagnosis of latent tuberculous infection. OBJECTIVE: To assess the effect of isoniazid (INH) preventive therapy (IPT) on the risk of TB disease and mortality among people living with HIV (PLHIV). DESIGN: A retrospective cohort study of routinely collected data on PLHIV enrolled into care between 2009 and 2014. RESULTS: Of 7177 patients (median age 36 years, interquartile range 31-42; 53% male) included in the study, 1278 (18%) patients received IPT. Among patients receiving IPT, 855 (67%) completed 6 or 9 months of INH. Patients who completed IPT had a significantly lower risk of incident TB than those who never received IPT (adjusted hazard ratio [aHR] 0.21, 95%CI 0.12-0.34) after controlling for potential confounders. PLHIV who received IPT had a significantly lower risk of death than those who never received IPT (PLHIV who completed IPT, aHR 0.25, 95%CI 0.16-0.37; those who received but did not complete IPT, aHR 0.55, 95%CI 0.37-0.82). CONCLUSION: Among PLHIV in Myanmar, completing a course of IPT significantly reduced the risk of TB disease, and receiving IPT significantly reduced the risk of death.

High prevalence and incidence of tuberculosis in people living with the HIV in Mandalay, Myanmar, 2011-2017.

SETTING: Two human immunodeficiency virus (HIV) clinics providing antiretroviral therapy (ART), Mandalay, Myanmar. OBJECTIVE: To assess prevalent TB at enrolment, incident TB during follow-up and associated risk factors in adult people living with HIV (PLHIV) between 2011 and 2017. DESIGN: Cohort study using secondary data. RESULTS: Of 11 777 PLHIV, 2911 (25%) had prevalent TB at or within 6 weeks of enrolment. Independent risk factors for prevalent TB were being male or single/widowed, daily alcohol consumption, CD4 count 200 cells/µl and anaemia. During 6 years follow-up in 8866 PLHIV with no prevalent TB, the rate of new TB was 2.9 per 100 person-years (95%CI 2.6-3.1). Cumulative TB incidence was 9.6%, with 370 (72%) of 517 new TB cases occurring in the first year. Independent risk factors for incident TB were being male and anaemia. Incident TB was highest in the first year of ART, in PLHIV with CD4 counts 200 cells/µl and those not receiving isoniazid preventive therapy (IPT). Incident TB declined with time on ART and rising CD4 counts. CONCLUSION: Prevalent and incident TB were high in PLHIV in the Mandalay clinics. Consideration should be given to earlier TB diagnosis using more sensitive diagnostic tools, effective ART and scaling up IPT.

Treatment outcome of tuberculosis patients detected using accelerated vs. passive case finding in Myanmar.

SETTING: Several projects involving accelerated or active case finding (ACF) of tuberculosis (TB) cases are being implemented in Myanmar. However, there is a concern that patients detected using ACF have poorer TB treatment outcomes than those detected using passive case finding (PCF). OBJECTIVE: To assess differences in the demographics, clinical profile and treatment outcomes of patients detected using ACF and PCF. DESIGN: Retrospective cohort study of TB patients diagnosed and enrolled for treatment during 2014-2016. RESULTS: Of 16 048 patients enrolled, 2226 (16%) were detected using ACF; the treatment success rate (cured and completed) was 88%. A higher proportion of cases detected using ACF were aged 55 years, human immunodeficiency virus (HIV) negative and sputum smear-positive pulmonary TB. After adjusting for differences in demographic and clinical characteristics, we found that treatment outcomes in patients detected using ACF and PCF were not significantly different (adjusted relative risk [aRR] 0.89, 95%CI 0.78-1.00). Male sex, age  55 years, patients with a previous history of TB and HIV positivity were independently associated with unsuccessful outcomes. CONCLUSION: ACF detected a significant proportion of TB cases in study townships; treatment outcomes in cases detected using ACF and those detected using PCF were similar. More tailored interventions are needed to improve treatment outcomes in patients at a higher risk of unsuccessful treatment outcomes.

HIV, HBV and HCV in people who inject drugs and are placed on methadone maintenance therapy, Yangon, Myanmar.

Setting: Two drug treatment centres (DTCs) for people who inject drugs (PWID) and are enrolled in methadone maintenance therapy (MMT), Yangon, Myanmar. Objectives: To determine, in PWID enrolled for MMT from 2015 to 2017, 1) testing uptake and results for human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV); 2) risk factors for infection; and 3) retention in care and risk factors for loss to follow-up (LTFU). Design: Cohort study using secondary data. Results: Of 642 PWID, 578 (90.0%) were tested for HIV, HBV and/or HCV. Overall, 404 (69.9%) were infected: 316 (78.2%) had one infection and the remainder had dual/triple infections. Testing uptake was generally better in 2015 and 2016 than in 2017. Prevalence of HIV infection was 15-17%, for HBV it was 4-7%, and for HCV it was 68-76%. Age >30 years, being single and duration of drug use were independent risk factors for infection. Retention in MMT at 6 months was 76% and declined thereafter. Experimental use of drugs and needle sharing were independent risk factors for LTFU. Conclusion: PWID enrolled in MMT in Yangon had high rates of HIV, HBV and HCV, and retention in care declined with time. Ways to improve individual tracing, programmatic retention and linkage to care are needed.

Contexte : Deux centres de traitement de l'addiction (DTC) pour les utilisateurs de drogues injectables (PWID) qui sont enrôlés dans un traitement d'entretien à la méthadone (MMT), Yangon, Myanmar.Objectif : Déterminer parmi les PWID enrôlés en MMT de 2015 à 2017 1) la couverture et les résultats des tests de virus de l'immunodéficience humaine (VIH), de l'hépatite B (HBV) et de l'hépatite C (HCV) ; 2) les facteurs de risque d'infection ; et 3) la rétention en soins et les facteurs de risque de pertes de vue (LTFU).Schéma : Etude de cohorte basée sur des données secondaires.Résultats : Il y a eu 642 PWID, dont 578 (90,0%) ont été testés pour le VIH, le HBV et/ou le VHC. Au total, 404 (69,9%) étaient infectés ; 316 (78,2%) avaient une seule infection et le reste avait deux ou trois infections. La couverture des tests a généralement été meilleure en 2015 et 2016 qu'en 2017. La prévalence de l'infection a été de 15­17% pour le VIH, de 4­7% pour le HBV et de 68­76% pour le HCV. Un âge > 30 ans, le fait d'être célibataire et la durée de la consommation de drogues ont été des facteurs de risque indépendants d'infection. La rétention en MMT à 6 mois a été de 76% et a décliné ensuite. L'usage expérimental de drogues et le partage d'aiguilles ont été des facteurs de risque indépendants de LTFU.Conclusion : Les PWID enrôlés en MMT à Yangon ont eu des taux élevés de VIH, d'HBV et d'HCV et la rétention en soins a décliné avec le temps. Il faut trouver des stratégies visant à améliorer le suivi individuel, la rétention dans le programme et les liens avec la prise en charge.

Marco de referencia: Dos centros de tratamiento de la drogadicción destinados a las personas que consumen drogas inyectables, inscritas en el tratamiento de mantenimiento con metadona de Yangon, en Birmania.Objetivos: Determinar en las personas que consumen drogas inyectables inscritas en el programa de mantenimiento con metadona del 2015 al 2017 las siguientes características: 1) la utilización de las pruebas diagnósticas de la infección por el virus de la inmunodeficiencia humana (VIH), el virus de la hepatitis B (VHB) y de la hepatitis C (VHC) y sus resultados; 2) los factores de riesgo de contraer la infección; y 3) la proporción de retención en la atención y los factores de riesgo de pérdida durante el seguimiento.Método: Estudio de cohortes a partir de datos secundarios.Resultados: Se inscribieron en los centros 642 consumidores de drogas inyectables, de los cuales 578 (90,0%) recibieron las pruebas diagnósticas del VIH, el VHB o el VHC. En general, 404 personas estaban infectadas (69,9%), de las cuales 316 padecían una monoinfección (78,2%) y el resto una infección doble o triple. En general, la utilización de las pruebas fue mayor en el 2015 y el 2016 que en el 2017. La prevalencia de infección por el VIH fue de 15% a 17%, por el VHB fue de 4% a 7% y por el VHC de 68% a 76%. Los factores de riesgo independientes de padecer una infección fueron la edad superior a los 30 años, el hecho de no tener pareja y la duración del consumo de drogas. La retención en el tratamiento de mantenimiento con metadona a los 6 meses fue 76% y en adelante disminuyó. Los factores de riesgo independientes de pérdida durante el seguimiento fueron el consumo experimental de drogas y el uso compartido de agujas.Conclusión: Las personas que consumen drogas inyectables que se inscriben en el programa de mantenimiento con metadona en Yangon exhibieron tasas altas de infección por el VIH, el VHB y el VHC y su retención en la atención disminuyó con el transcurso del tiempo. Se precisan estrategias que mejoren el seguimiento individual, la retención en los programas y la vinculación con la atención.

Timing of antiretroviral therapy and TB treatment outcomes in patients with TB-HIV in Myanmar.

SETTING: Integrated HIV Care programme, Mandalay, Myanmar. OBJECTIVES: To determine time to starting antiretroviral treatment (ART) in relation to anti-tuberculosis treatment (ATT) and its association with TB treatment outcomes in patients co-infected with tuberculosis (TB) and the human immunodeficiency virus (HIV) enrolled from 2011 to 2014. DESIGN: Retrospective cohort study. RESULTS: Of 1708 TB-HIV patients, 1565 (92%) started ATT first and 143 (8%) started ART first. Treatment outcomes were missing for 226 patients and were thus not included. In those starting ATT first, the median time to starting ART was 8.6 weeks. ART was initiated after 8 weeks in 830 (53%) patients. Unsuccessful outcome was found in 7%, with anaemia being an independent predictor. In patients starting ART first, the median time to starting ATT was 21.6 weeks. ATT was initiated within 3 months in 56 (39%) patients. Unsuccessful outcome was found in 12%, and in 20% of those starting ATT within 3 months. Patients with CD4 count <100/mm(3) had a four times higher risk of an unsuccessful outcome. CONCLUSIONS: Timing of ART in relation to ATT was not an independent risk factor for unsuccessful outcome. Extensive screening for TB with rapid and sensitive diagnostic tests in HIV-infected persons and close monitoring of anaemia and immunosuppression are recommended to further improve TB treatment outcomes among patients with TB-HIV.

Contexte : Programme intégré de prise en charge du virus de l'immunodéficience humaine (VIH), Mandalay, Myanmar.Objectifs : Chez les patients atteints de tuberculose (TB) et VIH enrôlés entre 2011 et 2014, déterminer la date du début du traitement antirétroviral (TAR) en relation avec le traitement antituberculeux (ATT) et son association avec le résultat d'ATT.Schéma : Etude rétrospective de cohorte.Résultats : Sur 1708 patients TB-VIH, 1565 (92%) ont débuté l'ATT en premier et 143 (8%) ont commencé le TAR en premier. Le résultat du traitement a été manquant pour 226 patients qui n'ont pas été inclus. Chez les patients ayant débuté l'ATT en premier, le délai médian de mise en route du TAR a été de 8,6 semaines. L'initiation du TAR a été retardée d'un délai médian de 8 semaines chez 830 (53%) patients. Parmi ces patients, 7% ont eu un résultat médiocre, avec une anémie qui a constitué un facteur de risque indépendant. Chez les patients ayant débuté le TAR en premier, le délai médian de mise en route de l'ATT a été de 21,6 semaines. L'ATT a été initié au cours des 3 mois chez 56 (39%) patients. Le traitement a échoué chez 12% des patients et chez 20% de ceux qui ont débuté l'ATT dans les 3 mois. Les patients ayant des CD4 <100/mm3 ont eu un risque quatre fois plus élevé d'échec.Conclusions: La chronologie du TAR en rapport avec l'ATT n'a pas été un facteur de risque indépendant d'échec du traitement. Un dépistage extensif de la TB avec des tests de diagnostic rapides et sensibles chez les personnes infectées par le VIH et un suivi étroit de l'anémie et de l'immunosuppression sont recommandés afin d'améliorer encore le résultat du traitement de TB parmi les patients TB-VIH.

Marco de referencia: El programa integrado de atención de la infección por el virus de la inmunodeficiencia humana (VIH) en Mandalay, en Birmania.Objetivos: Determinar el lapso entre el comienzo del tratamiento antirretrovírico (ART) y el inicio del tratamiento antituberculoso (ATT) en los pacientes coinfectados registrados del 2011 al 2014 y su asociación con el desenlace del ATT.Método: Fue este un estudio retrospectivo de cohortes.Resultados: De los 1708 pacientes coinfectados por el VIH y la tuberculosis (TB), 1565 iniciaron primero el ATT (92%) y 143 comenzaron en primer lugar el ART (8%). Se excluyeron 226 casos que carecían de registro del desenlace terapéutico. En los pacientes que iniciaron en primer lugar el ATT, la mediana del lapso hasta el comienzo del ART fue 8,6 semanas; este tratamiento se inició después de 8 semanas en 830 pacientes (53%). Se observó un desenlace terapéutico desfavorable en 7% de estos pacientes; la principal variable independiente asociada fue la presencia de anemia. Cuando el ART se inició en primer lugar, la mediana hasta el comienzo del ATT fue 21,6 semanas; este tratamiento se inició durante los 3 primeros meses en 56 pacientes (39%). Se observó un desenlace terapéutico desfavorable en 12% de estos pacientes y en 20% de los pacientes que iniciaron el ART en los primeros 3 meses. El riesgo de un desenlace desfavorable fue cuatro veces más alto en los pacientes con un recuento de linfocitos CD4 <100 células/mm3.Conclusión: La coordinación cronológica del ART y el ATT no representó un factor independiente de riesgo de obtener un desenlace desfavorable. Se recomienda la detección sistemática de la TB en los pacientes infectados por el VIH mediante pruebas diagnósticas rápidas y sensibles y una supervisión cuidadosa de la anemia y la inmunodepresión, con el objeto de obtener aun mejores desenlaces del ATT en los pacientes aquejados de coinfección TB-VIH.

Signal peptidase complex 18, encoded by SEC11A, contributes to progression via TGF-α secretion in gastric cancer.

We built an in-house oligonucleotide array on which 394 genes were selected based on our Serial Analysis of Gene Expression (SAGE) data and previously reported array data and listed several genes related to cancer progression. Among these, we focused on SEC11A, which encodes the SPC18 protein. SEC11A mRNA expression was measured by quantitative reverse transcription-polymerase chain reaction (qRT-PCR) in gastric cancer (GC) tissue samples. Expression and distribution of SPC18 protein were investigated by immunohistochemical analysis in two independent GC cohorts (Hiroshima cohort, n=99 and Chiba cohort, n=989). To determine the effect of SPC18 on cell viability and invasiveness in vitro, MTT and Boyden chamber invasion assays were performed. To evaluate the influence of SPC18 on cell growth in vivo, GC cells were injected into severe combined immunodeficiency mice. Levels of TGF-α and EGF in media from the GC cells were measured by enzyme-linked immunosorbent assay (ELISA). Studies in human tissue revealed overexpression of SEC11A mRNA in 40% of 42 GC samples by qRT-PCR. Immunohistochemical analysis of SPC18 revealed that 26 and 20% of GC cases were SPC18-positive in the Hiroshima and Chiba cohorts, respectively. In both cohorts, the Kaplan-Meier analysis showed poorer survival in SPC18-positive GC cases than in SPC18-negative GC cases. Forced expression of SPC18 activates GC cell growth in vitro and in vivo. The levels of TGF-α in culture media from GC cells were reduced by knockdown of SPC18. These results indicate that SPC18 contributes to malignant progression through promotion of TGF-α secretion in GC.

The innovative osmotic membrane bioreactor (OMBR) for reuse of wastewater.

An innovative osmotic membrane bioreactor (OMBR) is currently under development for the reclamation of wastewater, which combines activated sludge treatment and forward osmosis (FO) membrane separation with a RO post-treatment. The research focus is FO membrane fouling and performance using different activated sludge investigated both at laboratory scale (membrane area of 112cm2) and at on-site bench scale (flat sheet membrane area of 0.1 m2). FO performance on laboratory-scale (i) increased with temperature due to a decrease in viscosity and (ii) was independent of the type of activated sludge. Draw solution leakage increased with temperature and varied for different activated sludge. FO performance on bench-scale (i) increased with osmotic driving force, (ii) depended on the membrane orientation due to internal concentration polarization and (iii) was invariant to feed flow decrease and air injection at the feed and draw side. Draw solution leakage could not be evaluated on bench-scale due to experimental limitation. Membrane fouling was not found on laboratory scale and bench-scale, however, partially reversible fouling was found on laboratory scale for FO membranes facing the draw solution. Economic assessment indicated a minimum flux of 15L.m-2 h-1 at 0.5M NaCl for OMBR-RO to be cost effective, depending on the FO membrane price.

A pilot study of dental caries status in relation to knowledge, attitudes and practices in oral health in Myanmar.

This study was to determine the dental caries prevalence among the Myanmar population, and to investigate the correlations between oral clinical indices and knowledge, attitudes and practices (KAP) on oral health. Subjects were randomly selected from 140,000 people residing in the Kyauktan township in a cross-sectional community-based study. The present analysis was confined to 739 subjects (353 males and 386 females) aged 12, 35-44 and 65-74 years, who were divided into two specified groups based on urban or rural location. KAP on oral health data and social demographic information were collected, while dental caries status was assessed by DMFT. The mean number of decayed teeth (DT) in rural areas was higher than that in urban areas, while the mean number of filled teeth (FT) in rural areas was lower than that in urban areas. Mean knowledge and attitude scores for correct answers were also significantly higher for the urban than the rural subjects. There were statistically significant correlations between the correct/incorrect responses to knowledge and attitude questionnaires on oral health and the mean number of DMFT. KAP pertaining to oral health of Myanmar population, especially those of rural subjects, might not be satisfactory and related to threaten their dental caries status.

A simplified in vivo drug sensitivity test for malaria in the field.

The study was intended to develop a simple and reliable in vivo field test for monitoring of sensitivity of P.falciparum to antimalarials. The test is to be used as a built in sustainable monitoring system and applied at regular frequencies to provide guidance in developing a country-wide antimalarial drug policy. The study was conducted as a hospital based study in Mon State in Mudon, Kamawet and Pa-auk hospitals. The criteria matched malaria patients were treated with standard dosages of chloroquine, sulfadoxine-pyrimethamine and mefloquine and blood films were taken on days 0, 2, 3, 4, 7, 14 and 28. The assessment of the in vivo drug response of P.falciparum on days 2, 3 and 4 were compared with WHO standard 28 days and 7 day tests. The following successful tests were carried out for 7 days with different antimalarials: 171 tests with chloroquine and sulfadoxine-pyrimethamine and 167 tests with mefloquine. Tests were also carried out for 28 days: 59 tests with chloroquine, 77 tests with sulfadoxine-pyrimethamine and 78 tests with mefloquine. The results found that 3 day tests, taking blood films on days 0 and 3, can be reliably used as an adjunct to 28-day tests. Since the test is simple and can be used extensively and sustainably throughout the country and the results are applicable to be used for epidemiological purposes, the method is suggested for use as a built-in monitoring method for the malaria control program.

Antimicrobial susceptibilities of Haemophilus species in Hong Kong.

Altogether 403 Haemophilus spp. were isolated in seven hospital laboratories in Hong Kong during June 1986, mostly from sputum. Of these 73% were Haemophilus influenzae and 27% Haemophilus parainfluenzae. All the isolates of H. influenzae were non-capsulated; Haemophilus spp. were not isolated from blood or cerebrospinal fluid (CSF) during the period of the study. Antimicrobial resistance, including multiple resistance, was common. Of all the strains of H. influenzae, 20% were resistant to 1 mg/l ampicillin, (all except one by production of TEM-1 beta-lactamase), 65% were resistant to 0.5 mg/l erythromycin, 25% to 1 mg/l tetracycline, 14% to 1 mg/l chloramphenicol (mediated by the production of a chloramphenicol-destroying enzyme) and less than 1% to 8 mg/l cefaclor and 0.5 mg/l trimethoprim. All isolates were susceptible to cephamandole and cefuroxime. Haemophilus parainfluenzae showed similar susceptibilities, except that a greater proportion of strains was sensitive to erythromycin and chloramphenicol. Only 50% of the ampicillin-resistant strains of H. influenzae and H. parainfluenzae contained detectable plasmids of 2-55 Mdal arranged in six to nine different plasmid profiles. Resistance to ampicillin and chloramphenicol has increased markedly in isolates of H. influenzae in Hong Kong over the last 5 years. This resistance may be associated with transposable genes.

Determination of methicillin-resistance in Staphylococcus aureus by agar dilution and disc diffusion methods.

Four-hundred and seventy-six isolates of Staphylococcus aureus from patients in Hong Kong were tested for methicillin-resistance by agar dilution and disc diffusion methods, using heavy inocula. With Mueller-Hinton agar incubated at 30 degrees C for 24 h, 216 (MRSA) isolates were resistant to 8 mg/l of methicillin and grew up to the edge of a 10 micrograms methicillin disc, and 260 strains were susceptible to greater than or equal to 4 mg/l methicillin and produced inhibition zones of at least 20 mm diameter. Incubation for 48 h, the addition of sodium chloride, or the use of a 5 micrograms disc had little effect on these results, but a significant number of MRSA strains produced inhibition zones when disc diffusion tests were incubated at 35 degrees C, and many sensitive strains showed scanty growth on salt-containing agar at high methicillin concentrations in agar dilution tests. Iso-Sensitest agar did not appear to support the growth of the minority resistant populations of MRSA unless supplemented with menadione and thiamine, and even with supplemented Iso-Sensitest medium a few presumptively resistant strains appeared methicillin-sensitive in both disc diffusion and agar dilution tests.

Isolated chylopericardium due to mediastinal lymphangiomatous hamartoma;.

Isolated chylopericardium is a rare cause of pericardial effusion. Intrapericardial chyle was first noticed by Hasebroek (1888) at necropsy. Twenty years ago Groves and Effler (1954) first reported a clinical case of isolated chylopericardium. The present case is similar to theirs in several respects, and is the nineteenth case to be reported. To our knowledge this is the first British report of an isolated chylopericardium and is the fourth case of isolated chylopericardium due to a mediastinal lymphangiomatous hamartoma to be successfully treated.