Real-world practice of Helicobacter pylori management: A survey among physicians in Southeast Asia

BACKGROUND

Multidrug-resistant Helicobacter pylori strains are emerging in Southeast Asia. This study evaluates the region's real-world practice in H. pylori management.

MATERIALS AND METHODS

Physicians who managed H. pylori eradication in daily practice across 10 Southeast Asian countries were invited to participate in an online questionnaire, which included questions about the local availability of antimicrobial susceptibility tests (ASTs) and their preferred eradication regimens in real-world practice. An empiric regimen was considered inappropriate if it did not follow the local guidelines/consensus, particularly if it contained antibiotics with a high reported resistance rate or was recommended not to be empirically used worldwide.

RESULTS

There were 564 valid responses, including 314 (55.7%) from gastroenterologists (GIs) and 250 (44.3%) from non-GI physicians. ASTs were unavailable in 41.7%. In countries with low and intermediate clarithromycin resistance, the most common first-line regimen was PAC (proton pump inhibitor [PPI], amoxicillin, clarithromycin) (72.7% and 73.2%, respectively). Regarding second-line therapy, the most common regimen was bismuth-based quadruple therapy, PBMT (PPI, bismuth, metronidazole, tetracycline) (50.0% and 59.8%, respectively), if other regimens were used as first-line treatment. Concomitant therapy (PPI, amoxicillin, clarithromycin, metronidazole) (30.5% and 25.9%, respectively) and PAL (PPI, amoxicillin, levofloxacin) (22.7% and 27.7%, respectively) were favored if PBMT had been used as first-line treatment. In countries with high clarithromycin resistance, the most common first-line regimen was PBMT, but the utilization rate was only 57.7%. Alarmingly, PAC was prescribed in 27.8% of patients, ranking as the second most common regimen, and its prescription rate was higher in non-GI physicians than GI physicians (40.1% vs. 16.2%, p < 0.001).

CONCLUSIONS

Choosing inappropriate regimens containing antibiotics with high resistance rates is not uncommon in Southeast Asia, especially among non-GI physicians. In countries with high clarithromycin resistance, the PBMT regimen is underutilized.

2021 Asia-Pacific Graves' Disease Consortium Survey of Clinical Practice Patterns in the Management of Graves' Disease

AIM

Although Graves' disease (GD) is common in endocrine practices worldwide, global differences in diagnosis and management remain. We sought to assess the current practices for GD in countries across Asia and the Pacific (APAC), and to compare these with previously published surveys from North America and Europe.

METHODS

A web-based survey on GD management was conducted on practicing clinicians. Responses from 542 clinicians were received and subsequently analysed and compared to outcomes from similar surveys from other regions.

RESULTS

A total of 542 respondents participated in the survey, 515 (95%) of whom completed all sections. Of these, 86% were medical specialists, 11% surgeons, and 3% nuclear medicine physicians. In addition to serum thyroid-stimulating hormone (TSH) and free thyroxine assays, most respondents would request TSH-receptor autoantibody (TRAb) measurement (68%) during initial work-up. Thyroid ultrasound is requested by about half of respondents (53%), while the use of nuclear medicine scans is limited. The preferred first-line treatment is anti-thyroid drug (ATD) therapy (79%) with methimazole (MMI) or carbimazole (CBZ), followed by radioiodine (RAI; 19%) and surgery (2%). In case of surgery, one-third of respondents would opt for a subtotal rather than a total thyroidectomy. In case of mild Graves orbitopathy (GO), ATDs (67%) remains the preferred treatment, but a larger proportion of clinicians prefer surgery (20%). For a patient with intention to conceive, the preferred treatment pattern remained unchanged, although propylthiouracil (PTU) became the preferred ATD-agent during the first trimester. In comparison to European and American practices, marked differences were noted in the relatively infrequent usage of nuclear medicine scans and the overall higher use of a ATDs and β-blockers and adjunctive ATD-treatment during RAI in the APAC-group.

CONCLUSION

Although regional differences regarding the diagnosis and management of GD are apparent in this first pan-Asia-Pacific survey, this study reveals the overall approach to the management of this disease in Asia-Pacific generally tends to fall between the trends appreciated in the American and European cohorts.

Health interventions for migrants and refugees in host Southeast Asian countries: a systematic review

Background

Understanding the different types of health interventions that have been conducted for migrants and refugees is crucial for the improvement and implementation of future health interventions for these populations. This systematic review aimed to identify and to look at the scope and outcomes of health interventions focused on migrants and refugees in the main host counties in Southeast Asia which are Thailand, Singapore, and Malaysia.

Methods

This study was conducted in line with the PRISMA guidelines and its protocol has been submitted to PROSPERO. The following databases were searched until June 2021: PubMed, Web of Science, Science Direct, Cochrane, and Google Scholar. Studies were excluded if: 1) they were conducted outside Thailand, Singapore, and Malaysia; 2) had only had qualitative results; 3) were non-peer reviewed; 4) not written in English.

Results

The search yielded 8,266 studies, out of which 33 were included in the review. The majority of the studies (79%) were conducted in Thailand of which most were focused on migrants or refugees from Myanmar (85%). Besides two randomized controlled trials (RCTs) of mental health interventions, most Thai studies were observational (81%) and focused on infectious disease-related interventions (33%) or the evaluation of health-related programs (29%). Six studies were conducted in Malaysia (18%) of which 4 assessed mental health interventions in refugees. Three of these studies were RCTs, whereas 1 was an observational study. Only 1 study was situated in Singapore and was an RCT evaluating treatments for COVID-19 in migrant workers. Even in studies with similar interventions, outcomes were too diverse to conduct a meta-analysis.

Conclusions

The low number of studies highlights the gap in literature on health interventions for migrants and refugees, especially in Malaysia and Singapore. More rigorous and cohesive intervention-related research needs to be conducted in Southeast Asia.

Key messages

• More intervention-related research for migrant and refugee populations in the main Southeast Asian host countries is needed.

• Interventions for migrant and refugee populations in host countries in Southeast Asia often do not follow the gold standard RCT study design, limiting the knowledge on their effectiveness.

Efficacy of international web-based educational intervention in the detection of high-risk flat and depressed colorectal lesions higher (CATCH project) with a video: Randomized trial

OBJECTIVES

Three subcategories of high-risk flat and depressed lesions (FDLs), laterally spreading tumors non-granular type (LST-NG), depressed lesions, and large sessile serrated lesions (SSLs), are highly attributable to post-colonoscopy colorectal cancer (CRC). Efficient and organized educational programs on detecting high-risk FDLs are lacking. We aimed to explore whether a web-based educational intervention with training on FIND clues (fold deformation, intensive stool/mucus attachment, no vessel visibility, and demarcated reddish area) may improve the ability to detect high-risk FDLs.

METHODS

This was an international web-based randomized control trial that enrolled non-expert endoscopists in 13 Asian countries. The participants were randomized into either education or non-education group. All participants took the pre-test and post-test to read 60 endoscopic images (40 high-risk FDLs, five polypoid, 15 no lesions) and answered whether there was a lesion. Only the education group received a self-education program (video and training questions and answers) between the tests. The primary outcome was a detection rate of high-risk FDLs.

RESULTS

In total, 284 participants were randomized. After excluding non-responders, the final data analyses were based on 139 participants in the education group and 130 in the non-education group. The detection rate of high-risk FDLs in the education group significantly improved by 14.7% (66.6-81.3%) compared with -0.8% (70.8-70.0%) in the non-education group. Similarly, the detection rate of LST-NG, depressed lesions, and large SSLs significantly increased only in the education group by 12.7%, 12.0%, and 21.6%, respectively.

CONCLUSION

Short self-education focusing on detecting high-risk FDLs was effective for Asian non-expert endoscopists. (UMIN000042348).

Asian Best Practices for Care of Diabetes in Elderly (ABCDE)

The elderly population with diabetes is diverse with the majority experiencing a decline in physical and mental capabilities, impacting the entire diabetes management process. Therefore, a need for geriatric-specific guidelines, especially for the Asian population, was identified and subsequently developed by an expert panel across government and private institutions from several Asian countries. The panel considered clinical evidence (landmark trials, position papers, expert opinions), recommendations from several important societies along with their decades of clinical experience and expertise, while meticulously devising thorough geriatric-specific tailored management strategies. The creation of the ABCDE best practices document underscores and explores the gaps and challenges and determines optimal methods for diabetes management of the elderly population in the Asian region.

Emerging inflammatory bowel disease demographics, phenotype, and treatment in South Asia, South-East Asia, and Middle East: Preliminary findings from the Inflammatory Bowel Disease-Emerging Nations' Consortium

BACKGROUND AND AIM

Inflammatory bowel disease (IBD) is emerging in the newly industrialized countries of South Asia, South-East Asia, and the Middle East, yet epidemiological data are scarce.

METHODS

We performed a cross-sectional study of IBD demographics, disease phenotype, and treatment across 38 centers in 15 countries of South Asia, South-East Asia, and Middle East. Intergroup comparisons included gross national income (GNI) per capita.

RESULTS

Among 10 400 patients, ulcerative colitis (UC) was twice as common as Crohn's disease (CD), with a male predominance (UC 6678, CD 3495, IBD unclassified 227, and 58% male). Peak age of onset was in the third decade, with a low proportion of elderly-onset IBD (5% age > 60). Familial IBD was rare (5%). The extent of UC was predominantly distal (proctitis/left sided 67%), with most being treated with mesalamine (94%), steroids (54%), or immunomodulators (31%). Ileocolic CD (43%) was the commonest, with low rates of perianal disease (8%) and only 6% smokers. Diagnostic delay for CD was common (median 12 months; interquartile range 5-30). Treatment of CD included mesalamine, steroids, and immunomodulators (61%, 51%, and 56%, respectively), but a fifth received empirical antitubercular therapy. Treatment with biologics was uncommon (4% UC and 13% CD), which increased in countries with higher GNI per capita. Surgery rates were 0.1 (UC) and 2 (CD) per 100 patients per year.

CONCLUSIONS

The IBD-ENC cohort provides insight into IBD in South-East Asia and the Middle East, but is not yet population based. UC is twice as common as CD, familial disease is uncommon, and rates of surgery are low. Biologic use correlates with per capita GNI.

Defining the endoscopic ultrasound features of chronic pancreatitis in Asians: a multicenter validation study

BACKGROUND

Although endoscopic ultrasound (EUS) features and criteria have been described in chronic pancreatitis, challenges remain with interoperator variability and ease of adoption. The aim of this study was to define and validate the EUS features of chronic pancreatitis in a multicenter prospective study in Asia.

METHOD

The study was divided into two parts: the first part was conducted to derive the EUS features of chronic pancreatitis with adequate interoperator agreement; the second was to prospectively evaluate these features in a multicenter cross-sectional study and determine the optimal combination of features for the diagnosis of chronic pancreatitis. Prospectively enrolled cases had standard internationally validated radiologic or histologic features of chronic pancreatitis, and controls were patients without chronic pancreatitis who underwent EUS examination.

RESULTS

The top six EUS features that had good interobserver agreement (mean kappa 0.73, range 0.60 - 0.90) were selected to be further evaluated in part II of the study. These included: hyperechoic foci with shadowing, lobularity with honeycombing, cysts, dilated main pancreatic duct, dilated side branches, and calculi in the main pancreatic duct. A total of 284 subjects (132 cases, 152 controls) were enrolled from 12 centers in Asia. All six features had high accuracy ranging from 63.3 % to 89.1 %. Two or more of these six EUS features accurately defined chronic pancreatitis (sensitivity 94.7 %, specificity 98.0 %), with an area under the receiver operating curve of 0.986.

CONCLUSION

This multicenter Asian study characterized and defined the EUS features of chronic pancreatitis. This provides a useful tool in clinical practice and further research in pancreatic cancer surveillance.

Initiation of basal bolus insulin therapy

Most practice guidelines recommend the use of longacting or pre-mixed insulin at the initiation of insulin therapy in type 2 diabetes, especially in patients not achieving glycaemic goals. Nonetheless, there are some specific indications where basal bolus insulin is the preferred regimen for insulin initiation. These include the "5S" situations - 'Severe' hyperglycaemia, 'Symptomatic' diabetes, 'Sick' diabetes (acute or chronic comorbidity), 'Special' situations (pregnancy, childhood, adolescence) and 'Secondary' diabetes (pancreatic, drug-induced, endocrine disorders). This review describes a practical approach to initiation and follow up of basal bolus insulin regimens.

Glucocrinology of Modern Sulfonylureas: Clinical Evidence and Practice-Based Opinion from an International Expert Group

AIM

The primary objective of this document is to develop practice-based expert group opinion on certain important but less discussed endocrine and metabolic effects of modern sulfonylureas (SUs) and their usage in the management of diabetes mellitus (DM).

BACKGROUND

Modern SUs may be considered a panacea in DM care with their beneficial extra-pancreatic, pleiotropic, and cardiovascular effects. Safe glycemic control with SUs could be achieved with appropriate patient selection, drug and dosage selection, and patient empowerment. Additionally, sulfonylureas also exhibit certain endocrine and metabolic effects, which could be considered beneficial in the management of DM. In this regard, a group of international clinical experts discussed the less known beneficial aspects of SUs and safe and smart prescription of modern SUs in DM care.

RESULTS

The concept of glucocrinology or the relationship of glycemia with the endocrine system was emphasized during the meetings. Clinical experts arrived at a consensus for the usage of modern SUs in the presence of other endocrine dysfunction and the impact of these drugs on endocrine health. The beneficial pleiotropic and cardiovascular effects of modern SUs were also discussed. The key discussion points were considered to develop clinical expert opinions for the use of modern SUs in persons with DM. Clinical expert opinions were developed for indications, pleiotropic benefits, cardiovascular outcomes, adherence, and safe use of modern SUs.

CONCLUSIONS

Appropriate clinical judgement coupled with a patient-centered approach is crucial to achieve the best outcome in persons with DM. Owing to their safety, efficacy, extra-pancreatic benefits including effects on endocrine and metabolic aspects, and low cost of therapy, modern SUs could be considered as drugs/agents of choice for the treatment of diabetes.

FUNDING

Sanofi India.

BE-SMART (Basal Early Strategies to Maximize HbA1c Reduction with Oral Therapy): Expert Opinion

The past three decades have seen a quadruple rise in the number of people affected by diabetes mellitus worldwide, with the disease being the ninth major cause of mortality. Type 2 diabetes mellitus (T2DM) often remains undiagnosed for several years due to its asymptomatic nature during the initial stages. In India, 70% of diagnosed diabetes cases remain uncontrolled. Current guidelines endorse the initiation of insulin early in the course of the disease, specifically in patients with HbA1c > 10%, as the use of oral agents alone is unlikely to achieve glycemic targets. Early insulin initiation and optimization of glycemic control using insulin titration algorithms and patient empowerment can facilitate the effective management of uncontrolled diabetes. Early glucose control has sustained benefits in people with diabetes. However, insulin initiation, dose adjustment, and the need to repeatedly assess blood glucose levels are often perplexing for both physicians and patients, and there are misconceptions and concerns regarding its use. Hence, an early transition to insulin and ideal intensification of treatment may aid in delaying the onset of diabetes complications. This opinion statement was formulated by an expert panel on the basis of existing guidelines, clinical experience, and economic and cultural contexts. The statement stresses the timely and appropriate use of basal insulin in T2DM. It focuses on the seven vital Ts-treatment initiation, timing of administration, transportation and storage, technique of administration, targets for titration, tablets, and tools for monitoring.Funding: Sanofi.

The Lipo- Phenotypic Screening Tool for Familial Hypercholesterolaemia

Familial hypercholesterolaemia (FH) is a common disorder of lipid metabolism. However, it is rarely diagnosed in time, leading to a high burden of preventable cardiovascular (CV) morbidity. The authors describe a lipophenotypic screening tool, which can be used by clinicians to screen for FH. This simple construct is based on history, physical examination, lipid profile and non-invasive cardioimaging. Structured as a bidirectional three column rubric, this tool should be able to improve clinical skills and teaching related to FH.

Euthymia in Diabetes: Clinical Evidence and Practice-Based Opinion from an International Expert Group

AIM

To develop an evidence-based expert group opinion on various types of euthymia associated with diabetes mellitus (DM) and its management.

BACKGROUND

Diabetes mellitus is a metabolic syndrome characterized by diverse biomedical and psychosocial features. Emotional health disturbances may lead to psychological and psychiatric dysfunction and may negatively influence glycemic control. Patients with DM may experience diabetes distress (DD) associated with burden of self-care, interpersonal issues, and emotional worries regarding the ability to cope with the illness. Euthymia or a state of positive mental health and psychological well-being should be considered a key outcome of diabetes care. Therefore, to achieve optimal outcomes, the consideration and measurement of psychological and psychiatric aspects along with glycemic levels are very important. A group of multidisciplinary clinical experts came together in an international meeting held in India to develop a workable concept for euthymia in diabetes care. A multidisciplinary approach was suggested to enhance the clinical outcomes and facilitate patient-centered care. During the meeting emphasis was given to the concept of a euthymia model in diabetes care. This model focuses on enhancement of self-care skills in diabetic patients and preventative health awareness among diabetes care providers. Euthymia also encompasses patient-provider communication to aid enhancement of coping skills.

RESULTS

After due discussions and extensive deliberations, the expert group provided several recommendations on implementing the concept of euthymia in DM care.

CONCLUSIONS

Introduction of the concept of euthymia in routine clinical practice is important to improve the quality of life and coping skills in patients with DM. A timely clinical assessment of psychological and psychiatric aspects along with patient-reported outcomes of diabetes contributes to overall health and well-being of affected individuals.

FUNDING

Sanofi India.

SAT-127 Hypoglycemic Episodes in Type 2 Diabetes Mellitus : Continuous Glucose Monitoring Versus Self Monitoring of Blood Glucose

Introduction: Strict glycemic control with lifestyle modifications has been emphasized to prevent microvascular and macrovascular diabetic complications. However patients treated with intensive treatment often experienced more frequent episodes of hypoglycemia than did those treated with the standard treatment. Moreover, resent trials revealed that episodes of severe hypoglycemia were associated with an increased risk of subsequent mortality and morbidity. The use of CGM can detect both symptomatic and silent hypoglycaemia and can therefore prevent hypoglycaemia related morbidities and mortality. Aim: To detect occurrence of hypoglycaemic episodes by continuous glucose monitoring (CGM) and self monitoring of blood glucose (SMBG) in type 2 diabetic patients Methods: Ninety one type 2 diabetes mellitus patients who have Hb A1C ≤ 7.5 % and treated with insulin or insulin secretagogue (sulphonylureas and meglitinides) were included in this study. After making history taking and physical examination, they were instructed to record their food diary, medication history, to perform SMBG 4 times per day and to wear CGM for 72 hours period. At the end of 72 hours, CGM was removed from patient's body and data were submitted to Medtronic database. The report on continuous monitoring of patients’ blood glucose were downloaded from the database and interpreted for hypoglycemic episodes. Results: During study period, 16 patients (17.6 %) experienced symptomatic and 14 patients (15.4%) experienced silent hypoglycaemias which were detected by SMBG. In comparison, 16 patients (17.6%) experienced symptomatic whereas 17 patients (18.7%) experienced silent hypoglycaemiaby using CGM system. The accuracy of CGM had 93.4% sensitivity and 96.7% specificity in detection of hypoglycemia in study population. So it had overall accuracy of 95.6%. However, the numbers of hypoglycemic episodes detected by CGM were higher compared to SMBG (43 versus 107) within 72 hours of observation.Most of the hypoglycaemic episodes occurred in AM1 (00:00 AM to 6:00AM) ie,nocturnal followed by PM2 (18:01 PM 23:59 PM) ie, post dinner to bed time. Conclusion: We concluded that hypoglycemia is relatively common in fairly controlled type 2 diabetic patients. The accuracy of CGM was 95.6% in overall which is very good accuracy. With regards to the detection of number of hypoglycemic episodes, CGM is more reliable.

Diabetes Management and the Buddhist Philosophy: Toward Holistic Care

Buddhist philosophy is a way of life that transcends the borders of religion and focuses on the alleviation of suffering. The core teaching of Buddha was the Four Noble Truths: there is suffering, suffering is caused by clinging and ignorance, there is a way out of suffering and that way is the Noble Eightfold Path. The medical analogy in diabetes care would include identification of diabetes, understanding its etiopathogenesis, and how prognosis can be improved with appropriate care and management of this chronic disorder. Gaining awareness about the cause of illness and conducting our lives in a manner that nourishes and maintains long-term good health leads to improved outcomes for individuals living with diabetes and improve their overall well-being. The Noble Eightfold Path in Buddhism constitutes of right view, right resolve, right speech, right action, right livelihood, right effort, right mindfulness, and right concentration. These elements of the Eightfold Path can be taken as guiding principles in diabetes care. Buddhist meditation techniques, including mindfulness meditation-based strategies, have been used for stress reduction and management of chronic disorders such as chronic pain, depression, anxiety, hypertension, and diabetes. In this article, we focus on how Buddhist philosophy offers several suggestions, precepts, and practices that guide a diabetic individual toward holistic health.

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.

Consensus Recommendations on Sulfonylurea and Sulfonylurea Combinations in the Management of Type 2 Diabetes Mellitus - International Task Force

For decades, sulfonylureas (SUs) have been important drugs in the antidiabetic therapeutic armamentarium. They have been used as monotherapy as well as combination therapy. Focus on newer drugs and concerns about the risk of severe hypoglycemia and weight gain with some SUs have led to discussion on their safety and utility. It has to be borne in mind that the adverse events associated with SUs should not be ascribed to the whole class, as many modern SUs, such as glimepiride and gliclazide modified release, are associated with better safety profiles. Furthermore, individualization of treatment, using SUs in combination with other drugs, backed with careful monitoring and patient education, ensures maximum benefits with minimal side effects. The current guidelines, developed by experts from Africa, Asia, and the Middle East, promote the safe and smart use of SUs in combination with other glucose-lowering drugs.

Lessons for the Health-care Practitioner from Buddhism

From its earliest days, Buddhism has been closely intertwined with the practice of medicine, both being concerned in their own way in the alleviation and prevention of human suffering. However, while the connection between Buddhism and healthcare has long been noted, there is scarce literature on how Buddhist philosophy can guide health-care practitioners in their professional as well as personal lives. In the sutras, we find analogies that describe the Buddha as a doctor, knowledge of Dharma as the treatment, and all lay people as patients. The occurrence of disease is closely related to one's mental, physical and spiritual health, society, culture, and environment. It is not enough to approach medicine in a manner that simply eradicates symptoms; the psychosocial aspects of disease and its mind based causes and remedies must be a primary consideration. Holistic care involves harmonization of all these elements, and the Buddhist philosophy offers great insight for the physician. The Buddhist medical literature lays out moral guidelines and ethics for a health-care practitioner and this has corollaries in the principles of medical ethics: nonmaleficence, benevolence, justice, and autonomy. There is emphasis on loving-kindness, compassion, empathy, and equanimity as key attributes of an ideal physician. The practice of medicine is a stressful profession with physician burnout an often neglected problem. Mindfulness meditation, as developed in Buddhism, can help health-care professionals cope up with the stress and develop the essential attributes to improve patient care and self-care. This article outlines the spiritual and ethical values which underlie Buddhist concern for the sick and gives an overview of lessons which health-care practitioners can imbibe from Buddhism.

Helicobacter pylori bab characterization in clinical isolates from Bhutan, Myanmar, Nepal and Bangladesh

BACKGROUND

Helicobacter pylori BabA is an important outer membrane protein that involves in the attachment to the gastric mucosa and enhances the virulence property of the bacterium. This study was aimed to characterize the bab genotypes, to evaluate its association with cagA, vacA and clinical diseases as well as degree of gastric inflammation.

METHODS

H. pylori isolates from four countries were subjected for the characterization of bab. The locus specific forward and bab specific reverse primers were used to get the specific products by PCR, which could distinguish the three locus (A, B and C). The histological activities were evaluated according to the Updated Sydney system.

RESULT

In patients from high risk countries (Bhutan and Myanmar) relatively higher frequencies of strains with babA-positivity (91.8% and 90.7%, respectively), babA at locus A (98% and 91.2%, respectively) and with single babA (96.8% and 91.2%, respectively) were found. Strains with two loci occupied were the most prevalent in Bhutan (84.6%), Myanmar (74.7%), Nepal (58.3%) and Bangladesh (56.9%). The genotype babA at locus A/babB at locus B/bab-negative at locus C (babA/babB/-) was the most common genotype isolated from Bhutan (82.7%), Myanmar (58.7%), Nepal (32%) and Bangladesh (31.4%) among all genotypes assessed. This genotype was also associated with the peptic ulcer disease (P = 0.013) when compared to gastritis. babA-positive characteristics and the genotype babA/babB/- exhibited the enhanced histological activities.

CONCLUSIONS

The higher prevalence of virulence associated babA-positive characteristics and enhanced histological activities in Bhutan than in Myanmar, Nepal and Bangladesh might partly explain why the peoples in Bhutan are at higher risk for developing severe gastric complications.

Choice of Insulin in Type 2 Diabetes: A Southeast Asian Perspective

Southeast Asia faces a diabetes epidemic, which has created significant challenges for health care. The unique Asian diabetes phenotype, coupled with peculiar lifestyle, diet, and healthcare-seeking behavior, makes it imperative to develop clinical pathways and guidelines which address local needs and requirements. From an insulin-centric viewpoint, the preparations prescribed in such pathways should be effective, safe, well tolerated, nonintrusive, and suitable for the use in multiple clinical situations including initiation and intensification. This brief communication describes the utility of premixed or dual action insulin in such clinical pathways and guidelines.

Gaps and challenges to integrating diabetes care in Myanmar

In common with other low-income countries, diabetes is a growing challenge for Myanmar. Gaps and challenges exist in political commitment, policy development, the health system, treatment-seeking behaviour and the role of traditional medicine. National policies aimed at prevention - such as to promote healthy food, create a healthy environment conducive to increased physical activity, restrict marketing of unhealthy food, and initiate mass awareness-raising programmes - need to be strengthened. Moreover, existing initiatives for prevention of noncommunicable-disease (NCD) are channelled vertically rather than being horizontally integrated. Primary health care is traditionally orientated more towards prevention of infectious diseases and staff often lack training in prevention and control of NCDs. Capacity-building activities have been modest to date, and retaining trained health workers in diabetes-oriented activities is a challenge. The World Health Organization Package of Essential Noncommunicable (PEN) disease interventions for primary health care in low-resource settings has been piloted in Yangon Region and country-wide expansion awaits ministerial approval. Recently, the Myanmar Diabetes Care Model was proposed by the Myanmar Diabetes Association, with the aims of both bridging the gap in diabetes care between rural and urban areas and strengthening care at the secondary and tertiary levels. However, implementation will require policy development for essential drugs and equipment, capacity-strengthening of health-care workers, and an appropriate referral and health-information system.

The influence of tumor location, histology, and patient ethnicity on the accuracy of EUS in staging gastric and gastroesophageal junction (GEJ) cancers

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Background: Endoscopic ultrasound (EUS) is a routine staging test performed in patients with gastric and GEJ cancers and is highly valuable in treatment planning. The reported accuracy varies from 40% to 90%. We aim to investigate the staging performance of EUS at our institution and hypothesize that EUS accuracy can be influenced by tumor location, histology, and patient ethnicity. Methods: We performed a retrospective analysis of patients diagnosed with gastric and GEJ cancer between January 2006 and June 2015 who had EUS proceeded directly by surgery. T and N staging by EUS were analyzed for their sensitivity, specificity, and positive (PPV) and negative predictive values using surgery as the gold standard. The following variables were evaluated: tumor histology (intestinal or diffuse type), location (GEJ, cardia, body, or antrum), and patient ethnicity (Asian versus non-Asian). Results: Over 46 patients who met the inclusion criteria, EUS had T and N accuracy of 47.8% and 58.7%, respectively (p <.05). EUS had high specificity (88%) but low sensitivity (38%) for N staging. In predicting T staging, EUS was most accurate when the tumor was located in the body (72%, n = 7) and least accurate in the cardia (33%, n = 6) with 46% (n = 13) in the GEJ and 45% (n = 20) in the antrum. EUS tended to upstage the T value when a tumor is located in the body or GEJ, and downstage it in the cardia or antrum. The PPV using EUS for T1, T2, T3, and T4 were 89%, 22%, 45%, and 57%, respectively. The PPV using EUS for N staging was 73%. EUS was more accurate for T in Asians (55%, n = 33) than in non-Asians (31%, n = 13), and in intestinal type (56%) than diffuse (36%). For N staging, it was most accurate in the body (86%) and least accurate in the GEJ (50%). It was also more accurate in diffuse tumors (79%) than intestinal (52%) and more accurate in non-Asians (77%) than in Asians (53%). Conclusions: EUS as a common tool in preoperative staging may be inaccurate when performed in community hospitals. The predictive rate appears to vary in Asian vs non-Asian patients and in intestinal vs diffuse tumors. It is most predictive when the tumor is T1 and located in the gastric body. A prospective study is needed to confirm these findings.

Prevalence of Helicobacter pylori infection and atrophic gastritis in patients with dyspeptic symptoms in Myanmar

AIM: To survey the detailed analyses for Helicobacter pylori (H. pylori) infection and gastric mucosal status in Myanmar.

METHODS: A total of 252 volunteers with dyspeptic symptoms (155 female and 97 male; mean age of 43.6 ± 14.2 years) was participated in Yangon and Mandalay. The status of H. pylori infection was determined based on 5 different tests including rapid urease test, culture, histology, immunohistochemistry and serology. Histological scores were evaluated according to the update Sydney system and the Operative Link for Gastritis Assessment system. Pepsinogen (PG) I and PG II were measured using enzyme-linked immunosorbent assays.

RESULTS: The overall prevalence of H. pylori infection was 48.0%. There was no relationship between age and infection rate. Even in young group (less than 29 years old), the H. pylori infection rate was relatively high (41.9%). The prevalence of H. pylori infection was significantly higher in Yangon than that of Mandalay. H. pylori infection was significantly associated with the presence of gastric mucosal atrophy. All 7 subjects with peptic ulcer were infected with H. pylori. Although H. pylori-positive subjects showed stronger gastritis than H. pylori-negative subjects, most cases had mild gastritis.

CONCLUSION: We revealed the prevalence of H. pylori infection in patients with dyspeptic symptoms in Myanmar. The H. pylori infection was a risk factor for peptic ulcer and stronger gastritis.

South Asian women with diabetes: Psychosocial challenges and management: Consensus statement

Diabetes is the ninth leading cause of death in women globally. In South Asians mortality in women with diabetes stands second highest. There is a marked gender discrimination which is faced by women across South Asia esp in access to services and support for diabetes, resulting in high rates of morbidity and mortality in women with diabetes. The most important risk factor identified for the diabetes epidemic is obesity along with genetic susceptibility. Lack of health care, social and cultural disparity, discrimination at work, disparity in marriage, restricted medical facilities are prevalent. Diabetes and depression are common in women. Increasing age, low level of education, low socioeconomic conditions, difficulties posed in finding partners, frequent divorce and family history of psychiatric illness are significant risk factors for diabetes and depression. Such patients usually have poor metabolic control, higher complication rates, increased healthcare costs, lost productivity, lower quality of life as well as increased risk of death. Preconception counseling should be incorporated in the routine diabetes clinic visit for all women of childbearing potential. Women with diabetes should have information and access to contraception. Proper family planning counseling and psychological support can help stop practices such as female foeticide and multiple pregnancies. Psychological support to patients and their families are needed to break the barrier. There is emerging evidence that women with diabetes are more prone to untoward outcomes as compared to men. Central obesity, metabolic syndrome and the polycystic ovary syndrome show ethnic specific differences in South Asian women. Optimal sexuality is an integral part of holistic health. Shortage of trained female health care professionals, lack of privacy in over-crowded health care facilities, a social taboo attached to such matters, and lack of confidence in patients contribute to the neglect of sexual issues in women attending diabetes clinics across South Asia. Guidelines for counselling in female sexual dysfunction, written in culturally appropriate manner for South Asia, are needed. Diabetes affects women more severely because of their unique biological, cultural and socioeconomic circumstances. Women have limited access to health care facilities because of illiteracy, ignorance and negative social customs. Transcending the gender hierarchy and inequality is a formidable challenge. Sensitising men, empowering women on self care and providing peer support maybe the answer to this challenge. It is essential for health care providers to use appropriate coping mechanism such as building psychological contact with the patient, including family and friends as part of social support and empower patient with complete process of managing diabetes. Increasing awareness through the media, seminars, posters, group discussions and education, regular monitoring and consulting the doctor, support group for women and facilities for aerobic exercises are recommended. The health care systems should consider custom-designed prevention and control programs tailored for women based on local and regional attitudes on health care, cultural beliefs, and available social support systems. Policies that empower adolescent girls and young women to take control of their metabolic management must be encouraged. Provision of gender specific diabetes education with a holistic life-cycle approach is recommended.

BAMBI gene is epigenetically silenced in subset of high-grade bladder cancer

The bone morphogenetic protein (BMP) and activin membrane-bound inhibitor (BAMBI) is a transmembrane TGFRI/BMPRI-related pseudoreceptor, antagonizes transforming growth factor (TGF)-beta/BMP signaling by inhibiting the formation of functional authentic receptor complexes (TGFRI/BMPRI and TGFRII/BMPRII). On the assumption that BAMBI gene expression is epigenetically altered during human bladder cancer progression, we screened the expression of BAMBI protein by immunohistochemistry and the methylation status of the BAMBI promoter. In the normal or reactive urothelium, BAMBI expression was mostly overlapped with that of BMPRI, and a similar colocalization pattern was noted in low-grade papillary cancers. In high-grade and invasive cancers, however, mainly two reciprocal immunohistochemical expression patterns were observed: BAMBI-low/BMPRI-high, and BAMBI-high/BMPRI-low, indicating that BAMBI expression is controlled such that it does not interfere with the responsiveness of high-grade cancer cells to TGF-beta/BMP signaling. Moreover, methylation of the BAMBI gene correlated significantly with negative BAMBI expression in bladder tumors. Although BAMBI overexpression significantly increased the number of apoptotic cells in T24 line, knock-down small interfering RNA showed no remarkable change. Cell motility assay revealed that on treatment with either TGF-beta1 or BMP2, T24 and HTB9 lines showed a marked increase in the number of migrated cells which, however, decreased significantly through the forced expression of BAMBI. Since certain subsets of aggressive tumors often promote cell motility, invasion and survival by inducing epithelial-to-mesenchymal transition through TGF-beta/BMP in an autocrine and paracrine manner, hypermethylation of the BAMBI gene promoter that leads to BAMBI gene suppression may be one of the epigenetic events affecting the invasiveness or aggressiveness of bladder cancers.

Hepatitis B virus polymerase mutations during antiviral therapy in a patient following liver transplantation

BACKGROUND/AIMS

The purpose of this study was to investigate possible resistance mutations which arose in the polymerase gene of hepatitis B virus (HBV) in a patient with severe recurrent HBV infection following liver transplantation. The patient's management included antiviral chemotherapy for almost 4 years comprising ganciclovir, foscarnet and famciclovir. In the last 2.5 years of famciclovir treatment, an increase in serum HBV DNA levels and a reduced sensitivity of the virion-associated DNA polymerase to penciclovir triphosphate were observed.

METHODS

The viral polymerase gene and X gene were sequenced from serum samples collected at representative time intervals covering the entire treatment period.

RESULTS

No mutations were detected in the X gene. Three nucleotide mutations, each of which resulted in an altered amino acid sequence, were detected in the polymerase gene after 816 days of total antiviral therapy (370 days of famciclovir). Two of these mutations were detected by direct sequencing and the third was detected after cloning and was present in 10% of the clones. All three mutations occurred in "region B" of RNA-dependent DNA polymerases. The HBV polymerase has similarities to both RNA and DNA polymerases. These mutations in the HBV polymerase gene were located in a similar area to the penciclovir-induced mutations observed in the herpes simplex virus DNA polymerase gene.

CONCLUSIONS

Three mutations within the HBV polymerase gene were detected which were associated with a reduced penciclovir sensitivity.

Variations of hepatitis B virus precore/core gene sequence in acute and fulminant hepatitis B

Variations of the hepatitis B virus (HBV) precore/core sequence has been shown to play a role in the development of active liver disease in chronic hepatitis B. Whether this is also an important viral factor in the pathogenesis of acute and fulminant hepatitis B is unknown. To determine the precore/core gene sequence in patients with acute and fulminant hepatitis B, 11 patients with fulminant hepatitis B and seven patients with acute hepatitis B were studied. The sequences of precore/core gene were determined by direct sequencing of the polymerase chain reaction amplicons generated from the HBV isolated from patients' serum. For the 11 patients with fulminant hepatitis B, the precore/core regions were successfully amplified in 10 patients. Eight patients exhibited precore stop codon mutations. In addition, nine of the 10 fulminant hepatitis B patients had frequent nucleotide substitutions with corresponding changes in the predicted amino acid sequences in the mid-core and the 5' terminus region of the core gene. In contrast, precore stop codon mutants were not detected, and variations of the HBV core gene were minimal in patients with acute hepatitis B. The association of HBV precore mutants and HBV core gene variations with fulminant hepatitis B and not acute hepatitis B suggested that these variations may be important in modulating the clinical course of HBV infection.

Evolution of the hepatitis B virus gene during chronic infection in seven patients

We analyzed the evolution of the precore/core gene of hepatitis B virus (HBV) over a period of 6 to 11 years in seven patients with chronic HBV infection, who exhibited a variety of clinical features. Sequence analysis revealed the following results: (1) HBeAg to anti-HBe seroconversion was correlated roughly with the occurrence of precore-defective mutants, and several years appeared to be required for complete replacement of wild types by mutants; (2) core gene mutations preceded precore-defective mutations and tended to increase with time, although not cumulatively. They occurred not only during serum alanine aminotransferase (ALT) elevations but also after ALT returned to normal; (3) ALT fluctuations appeared to subside with complete replacement of the wild type by the mutant type and/or substantial accumulation of core gene mutations; (4) unexpectedly, the anti-HBe-positive "healthy" carrier was found to harbor the wild type precore gene, as did the HBeAg-positive "healthy" carrier; however, the core gene of the former evolved at a rapid rate; and (5) a partial deletion was recognized in the core gene at the onset of fatal hepatic failure in one patient. Thus, the precore/core mutation was closely related with the clinical features in the patients.

Completely or nearly identical hepatitis B virus strains replicate between patients with acute or fulminant hepatitis B and their respective infectious sources

Five patients with acute hepatitis B and four with fulminant hepatitis B were selected for sequencing of the precore/core gene of the virus strains. Furthermore, identical sequencing was done with the HBV of the infectious sources, i.e., the sexual partner in eight cases and a natural child (chronic carrier) infecting the mother in one case. Of the subjects responsible for the infection, four were healthy HBV carriers, three suffered from chronic hepatitis B, and one from acute and one from fulminant hepatitis B. The nucleotide sequences of HBV from both the patients and the implicated sources of infection exhibited perfect identity of the precore region and perfect or high identity of the core region. The completely or nearly identical strain of virus seemed to proliferate successively in the patients following the transmission from the infecting individuals regardless of sequence variations and infectious status. In two cases a peculiar pattern of infection and disease was found: In one married couple the husband, during the incubation period of acute hepatitis B, infected his wife, who developed fulminant hepatitis. In another married couple, both partners ultimately developed fulminant hepatitis (the wife being the source of the infection).

Detection of precore/core-mutant hepatitis B virus genome in patients with acute or fulminant hepatitis without serological markers for recent HBV infection

To confirm the possibility that some hepatitis B virus (HBV) variants do not induce HB s antigen (HBsAg), anti-HB core antibody (anti-HBc) and anti-HBc IgM in a transient infection, polymerase chain reaction (PCR) was performed in 20 patients with acute hepatitis and 7 patients with fulminant hepatitis. Patients were diagnosed with non-A, non-B hepatitis by serological markers at admission. PCR successfully amplified the precore/core gene in 5 (25%) of the patients with acute hepatitis and 2 (29%) of the patients with fulminant hepatitis. Subsequent sequencing revealed frequent mutations including precore-defects in the precore/core gene.

An epidemic outbreak of hepatitis E in Yangon of Myanmar: antibody assay and animal transmission of the virus

An epidemic outbreak of hepatitis E occurred in an army recruit camp of Yangon, Myanmar, in October 1989. One hundred and eleven patients among 600 residents were hospitalized. As high as 83.7% of these patients were positive for the acute phase antibody against hepatitis E virus by an enzyme-linked immunosorbent assay developed in our laboratory. Also, 30.6% of 49 symptom-free residents examined were positive for the antibody. We prepared a stool extract from six patients and inoculated it into 10 rhesus monkeys for a series of three sub-passages. All of them developed acute biochemical hepatitis along with an elevation of antibody levels. A rechallenge with viruses of the present outbreak failed to provoke hepatitis in two monkeys that had previously recovered from acute hepatitis caused by an isolate of sporadic hepatitis E of the same area. Similarly, the rechallenge of the sporadic strain did not induce hepatitis in two monkeys that had been previously infected with the epidemic virus. These data suggested that the subjects would obtain neutralizing antibodies against the hepatitis E virus once infected, and many adult inhabitants of the endemic area had no protective antibodies and were still susceptible to hepatitis E infection.

Sequence and gene structure of the hepatitis E virus isolated from Myanmar

Hepatitis E virus (HEV) is a causative agent of enterically transmitted non-A, non-B hepatitis. Hepatitis E occurs not only in sporadic forms but also in epidemic outbreaks in the developing world. We have revealed the nucleotide and predicted amino acid sequences of full cDNA of HEV isolated from sporadic hepatitis E of Myanmar. The genome is 7194 nucleotides long, followed by a poly(A) tail, and has three open reading frames. The nonstructural gene is located in the 5' terminus, while the structural gene is situated in the 3' terminus. Our HEV strain has 98.5% nucleic acid identity with the HEV strain cloned by workers at Genelabs Incorporated from Myanmar. The difference is point nucleotide substitutions. There is a high degree of nucleotide relatedness among HEVs isolated from the same geographical location.

Sequence comparison of the capsid region of hepatitis E viruses isolated from Myanmar and China

Hepatitis E viruses (HEVs) were isolated during epidemics, one from Myanmar (formerly called Burma) and one from China and were partially sequenced. Another HEV Myanmar strain from sporadic hepatitis was previously sequenced by us. A cDNA sequence comparison was performed among them in the 3'-terminal region, approximately 750-base long. This region contained at least two immunological epitopes and was considered to correspond to the structural protein. The nucleotide sequence identity was 97.2% between the two Myanmar strains and 93.3 and 92.5% between the two Myanmar and the China strain. The deduced amino acid sequence identity ranged from 98.4 to 100.0% among the three strains. Thus this segment was well conserved on the amino acid level among the different strains isolated from these two Asian countries, although the China strain diverged more from the Myanmar strains on the nucleotide sequence level. This data may provide important information for the development of a vaccine and for identification of the virological link between different geographical locations.

Vitamin B12 R-binder localization in the human uterus: an immunohistochemical study

The localization of vitamin B12 R-binder in the uterus was studied by use of an immunoperoxidase technique. Positive staining by anti-R-binder antiserum was observed in the columnar epithelium of the endocervix (18/18 cases) and in the surface epithelium of the endometrium (8/21 cases). Staining was usually seen in the apical portion of the epithelium; cytoplasmic staining in the endocervical columnar epithelium was intense. The secretory products in the endocervical glands showed positive staining. The endometrial glandular epithelium did not stain (0/24 cases). Metaplastic squamous epithelium of the endocervix showed positive staining (3/18 cases). The native squamous epithelium as well as the stromal components of the cervix, endometrium, and myometrium were negative for R-binder. This study shows that R-binder is localized in the uterus, especially in the endocervical glands. The R-binder in the endocervix may have antimicrobial activity in the uterus as in other organs, such as the intestines and mammary glands.