Whole-genome sequencing analysis of multidrug-resistant Mycobacterium tuberculosis from Java, Indonesia.

Introduction. Multidrug-resistant tuberculosis (MDR-TB) is a major public health problem globally, including in Indonesia. Whole-genome sequencing (WGS) analysis has rarely been used for the study of TB and MDR-TB in Indonesia.Aim. We evaluated the use of WGS for drug-susceptibility testing (DST) and to investigate the population structure of drug-resistant Mycobacterium tuberculosis in Java, Indonesia.Methodology. Thirty suspected MDR-TB isolates were subjected to MGIT 960 system (MGIT)-based DST and to WGS. Phylogenetic analysis was done using the WGS data. Results obtained using MGIT-based DST and WGS-based DST were compared.Results. Agreement between WGS and MGIT was 93.33 % for rifampicin, 83.33 % for isoniazid and 76.67 % for streptomycin but only 63.33 % for ethambutol. Moderate WGS-MGIT agreement was found for second-line drugs including amikacin, kanamycin and fluoroquinolone (73.33-76.67 %). MDR-TB was more common in isolates of the East Asian Lineage (63.3%). No evidence of clonal transmission of DR-TB was found among members of the tested population.Conclusion. Our study demonstrated the applicability of WGS for DST and molecular epidemiology of DR-TB in Java, Indonesia. We found no transmission of DR-TB in Indonesia.

Clinical characteristics and outcomes of community and hospital-acquired Acinetobacter baumannii bacteremia.

PURPOSE: We aimed to characterize clinical manifestations of the patients with bacteremia due to community-acquired Acinetobacter baumannii and evaluate the outcomes of these patients. METHODS: We conducted a retrospective study to include adult patients with A. baumannii bacteremia and then classified them into two groups: community-acquired A. baumannii bacteremia and hospital-acquired A. baumannii bacteremia. Characteristics and outcomes between 2 groups were compared. The Galleria mellonella infection survival model was used to determine the virulence of A. baumannii in these 2 groups. RESULTS: There were 63 patients with A. baumannii bacteremia: 21 patients with community-acquired (CA) bacteremia and 42 patients with hospital-acquired (HA) bacteremia. Three patients with CA bacteremia were excluded due to healthcare-associated risks of infection. The remaining 18 patients with CA bacteremia had carbapenem-susceptible A. baumannii (CA-CSAB). Among the 42 patients with HA bacteremia, 11 patients had carbapenem-susceptible A. baumannii (HA-CSAB) and 31 patients had carbapenem-resistant A. baumannii (HA-CRAB). The 30-day mortality rates of those with CA-CSAB did not differ from those with HA-CSAB bacteremia but were significantly lower than those with HA-CRAB (p = 0.003). The factors influencing 30-day mortality were infection with CRAB (p = 0.004), appropriate empirical antimicrobial therapy (p = 0.002), and higher Acute Physiology and Chronic Health Evaluation II score (p < 0.001). The G. mellonella assay showed no differences in survival rates among CA-CSAB, HA-CSAB, and HA-CRAB. CONCLUSIONS: Patients with bacteremia due to CA-CSAB and HA-CSAB had similar outcomes. Similar virulences of CA-CSAB and HA-CSAB were confirmed with the G. mellonella infection model.

Fatty Acid Profiles of Various Vegetable Oils and the Association between the Use of Palm Oil vs. Peanut Oil and Risk Factors for Non-Communicable Diseases in Yangon Region, Myanmar.

The majority of vegetable oils used in food preparation in Myanmar are imported and sold non-branded. Little is known about their fatty acid (FA) content. We aimed to investigate the FA composition of commonly used vegetable oils in the Yangon region, and the association between the use of palm oil vs. peanut oil and risk factors for non-communicable disease (NCD). A multistage cluster survey was conducted in 2016, and 128 oil samples from 114 households were collected. Data on NCD risk factors were obtained from a household-based survey in the same region, between 2013 and 2014. The oils most commonly sampled were non-branded peanut oil (43%) and non-branded palm oil (19%). Non-branded palm oil had a significantly higher content of saturated fatty acids (36.1 g/100 g) and a lower content of polyunsaturated fatty acids (9.3 g/100 g) than branded palm oil. No significant differences were observed regarding peanut oil. Among men, palm oil users had significantly lower mean fasting plasma glucose levels and mean BMI than peanut oil users. Among women, palm oil users had significantly higher mean diastolic blood pressure, and higher mean levels of total cholesterol and triglycerides, than peanut oil users. Regulation of the marketing of non-branded oils should be encouraged.

Traditional Mongolian, Traditional Chinese, and Western Medicine Hospitals: System Review and Patient Survey on Expectations and Perceptions of Quality of Healthcare in Inner Mongolia, China.

BACKGROUND: In Inner Mongolia of China, traditional Mongolian medicine (TMM), traditional Chinese medicine (TCM), and western medicine (WM) are all supported by the government. This study compares the background and performance of these three types of medicines. METHODS: The World Health Organization's Six Building Blocks framework was used for the system review. Data were collected from literature review and key informant interviews. A cross-sectional survey was conducted in three types of hospitals at the provincial, municipal (city), and prefectural (county) levels from April to August, 2016. Eight hospitals were included and, within each one, patients from four outpatient departments were selected. A total of 1,322 patients were interviewed about their expectations and perceptions of the health service. RESULTS: Government support for TMM includes higher budget allocation and a higher reimbursement rate. TMM is preferred by Mongolian people, those living in pasturing areas, and those seeking treatment for musculoskeletal problems/injuries. Patients attending TMM hospitals had the highest expectations and perceptions of the health service in general. However, human resources and research capacity of TMM are relatively limited. CONCLUSION: To further enhance the role of the popular TMM for local minority's health, human resources and research capacity strengthening are essential.

Signal detection for Thai traditional medicine: examination of national pharmacovigilance data using reporting odds ratio and reported population attributable risk.

Herbal containing medicine consumption has increased while the awareness of adverse drug reaction (ADR) was less than conventional medicine. Early detection of unexpected numbers of ADRs from herbal medicines' reports which are abnormal from the whole database needs quantification. Disproportionality analysis has been performed for signal detection by using reporting odds ratio (ROR) as measurement. The impact of having medicine as exposures in each ADR should be measured by using reported population attributable risks (RPAR). This study aimed to quantify the contribution of Thai traditional medicine (TTM) to ADR reports and to assess the association between TTMs and serious adverse drug reactions. Data were retrieved from the adverse drug reaction surveillance database, Thai-Food and Drug Administration from 2002 to 2013. Crude and adjusted RORs for each drug-ADR pair and RPARs were computed. TTM contributed only 0.001% of all serious ADRs reported. Out of 4208 TTM-ADR pairs were examined, three had the statistically significant RORs, namely Andrographis paniculata and anaphylactic shock (ROR 2.32, 95% CI 1.03, 5.21); green traditional medicine and Stevens-Johnson syndrome (ROR 13.04, 95% CI 5.4-31.51) and Derris scandens Benth and angioedema (ROR 2.71, 95% CI 1.05-6.95). Their RPARs ranged from 0.05% to 0.16%. We conclude that TTMs need more intensive surveillance.

Clinical outcomes of hospital-acquired infection with Acinetobacter nosocomialis and Acinetobacter pittii.

The role of Acinetobacter nosocomialis and Acinetobacter pittii, which belong to the A. calcoaceticus-A. baumannii complex, in hospital-acquired infections is increasingly recognized. Here we describe a retrospective cohort study of hospital-acquired A. calcoaceticus-A. baumannii complex infections at a university hospital in Thailand. A total of 222 unique cases were identified between January 2010 and December 2011. The genomospecies of the A. calcoaceticus-A. baumannii complex isolates were classified as follows: A. baumannii, 197 (89%); A. nosocomialis, 18 (8%); and A. pittii, 7 (3%). All A. nosocomialis and A. pittii isolates were susceptible to imipenem and meropenem. The patients infected with A. nosocomialis and A. pittii had lower 30-day mortality than those infected with carbapenem-susceptible A. baumannii (P = 0.025) and carbapenem-resistant A. baumannii (P = 0.013). The factors influencing 30-day mortality were infection with non-baumannii A. calcoaceticus-A. baumannii complex (hazard ratio [HR], 0.12; 95% confidence interval [CI], 0.03 to 0.51; P = 0.004), infection with carbapenem-resistant A. baumannii (HR, 1.57; 95% CI, 0.89 to 2.79; P = 0.105), appropriate empirical antimicrobial therapy (HR, 0.38; 95% CI, 0.23 to 0.61; P < 0.001), and higher acute physiology and chronic health evaluation II (APACHE II) score (HR, 1.15; 95% CI, 1.10 to 1.19; P < 0.001). In Galleria mellonella assays, the survival rates were significantly higher for the larvae infected with A. nosocomialis or A. pittii than for those infected with either carbapenem-susceptible A. baumannii or carbapenem-resistant A. baumannii, but no differences in survival rates were observed between carbapenem-susceptible A. baumannii and carbapenem-resistant A. baumannii. These findings suggest intrinsic differences in virulence between non-baumannii A. calcoaceticus-A. baumannii complex species and A. baumannii but not between carbapenem-susceptible and resistant A. baumannii.

Identifying the Zheng in psoriatic patients based on latent class analysis of traditional Chinese medicine symptoms and signs.

BACKGROUND: There are approximately five Zhengs reported in psoriatic patients. Systematic data collection and proper analysis for the classification of psoriasis have been lacking. This study aims to cluster the Zhengs in psoriatic patients based on the application of a checklist of traditional Chinese medicine (TCM) symptoms and signs followed by latent class analysis (LCA). METHODS: A cross-sectional study of 507 psoriatic patients aged above 10 years was performed in Yunnan Provincial Hospital of TCM and the First Affiliated Hospital of Kunming Medicine University from October 2010 to September 2011 using a TCM symptoms and signs checklist obtained from 16 TCM experts by the Delphi technique. LCA was applied to obtain the best fitted model for clustering of symptoms and signs that can be interpreted as underlying Zhengs of psoriasis. RESULTS: The LCA identified three Zhengs: dampness-heat Zheng (35.1%); blood heat Zheng (34.7%); and yin deficiency and blood dryness Zheng (30.2%). The first Zheng was associated with winter, the second with male sex, old age, smoking, and drinking alcohol, and the third with outpatient status, which reflected a mild disease course. CONCLUSIONS: In this study, 507 psoriasis patients were clustered into three Zhengs, which had different associated factors.

Developing a diagnostic checklist of traditional Chinese medicine symptoms and signs for psoriasis: a Delphi study.

BACKGROUND: Psoriasis is a chronic inflammatory skin disease with a genetic basis. Its ill-defined causes make it difficult to diagnose. This study aims to develop a diagnostic checklist for psoriasis classification in the context of traditional Chinese medicine. METHODS: A Delphi study was conducted with three rounds by a panel of 16 dermatology experts to develop a checklist for traditional Chinese medicine symptoms and signs of psoriasis. Dermatology experts in psoriasis research, nine in Yunnan and seven in Beijing, were selected as the expert panel. The initial list of symptoms and signs in psoriasis was developed by reviewing the literature retrieved from Chinese and English journals. Experts rated each item of the list on a 5-point Likert scale. The list was revised and re-evaluated in the same manner for a total of 3 rounds before it was finalized. RESULTS: One hundred and thirty items were extracted from the literature review. After three rounds of expert ratings, 96 items were retained with eight domains: color, type and shape of skin lesion, physical expression, tongue and coating, pulse, associated factors, and living environment. Intraclass correlation coefficient and Kappa statistics indicated an inter-rater agreement in the final checklist. CONCLUSION: A checklist containing 96 items in 8 domains was developed for psoriasis diagnosis using traditional Chinese medicine symptoms and signs.

Analysis of prescription database extracted from standard textbooks of traditional Dai medicine.

BACKGROUND: Traditional Dai Medicine (TDM) is one of the four major ethnomedicine of China. In 2007 a group of experts produced a set of seven Dai medical textbooks on this subject. The first two were selected as the main data source to analyse well recognized prescriptions. OBJECTIVE: To quantify patterns of prescriptions, common ingredients, indications and usages of TDM. METHODS: A relational database linking the prescriptions, ingredients, herb names, indications, and usages was set up. Frequency of pattern of combination and common ingredients were tabulated. RESULTS: A total of 200 prescriptions and 402 herbs were compiled. Prescriptions based on "wind" disorders, a detoxification theory that most commonly deals with symptoms of digestive system diseases, accounted for over one third of all prescriptions. The major methods of preparations mostly used roots and whole herbs. CONCLUSION: The information extracted from the relational database may be useful for understanding symptomatic treatments. Antidote and detoxification theory deserves further research.

Application of Delphi technique in identification of appropriate screening questions for chronic low back pain from traditional Chinese medicine experts' opinions.

OBJECTIVE: The goal of the present study was to obtain a standard list of traditional Chinese medicine (TCM) symptoms and signs for screening chronic low back pain (cLBP) from a group of experts and to assess agreement and consistency among their opinions on the items of a questionnaire. DESIGN, SETTINGS, AND SUBJECTS: The study design involved three rounds of modified Delphi technique, and it was carried out by 13 experts in orthopedics, massage, and acupuncture working in four hospitals affiliated with Yunnan University of Traditional Chinese Medicine, China. OUTCOME MEASURES: The outcome was measured on the 5-score Likert-scale self-administered checklists. RESULTS: A review of eight textbooks identified 12 pain characteristics, 11 associated factors, and 25 physical and tongue diagnostic expressions as important factors in the TCM diagnosis of cLBP. These 48 diagnostic characteristics were rated by 13 experts as "not important" to "very important" on a scale of 1-5. After three rounds of rating, 13 characteristics were eliminated from the list, with the final numbers for each group being 8, 11, and 16, respectively. Seven items based on Western medicine were also added by the experts. The intra-class correlation (ICC) coefficient for agreement among the experts was 0.2 at the end. Intra-rater, between rounds, consecutive pair-wise median kappa values were 0.53 and 0.66. Analysis of variance using items appearing in all three rounds revealed significant effects of expert and group of symptoms and signs (p < 0.001) and nonsignificant differences among scores of the same expert in the three rounds (p = 0.97). Mean score of physical and tongue expressions was significantly (p < 0.001) lower than that of all other groups of symptoms and signs. CONCLUSIONS: Modern TCM experts have de-emphasized the items on physical and tongue expressions and have adopted instead those from Western medicine. Intra-expert agreement across items was low, and each expert tended to stick to her/his original opinions.

The prevalence and determinants of iron deficiency anemia in rural Thai-Muslim pregnant women in Pattani Province.

This study was conducted in order to describe the type of anemia and risk factors for iron deficiency anemia in Pattani Province, Thailand. A cross-sectional survey was conducted from March to October 1997 in five randomly selected districts, choosing villages in the catchment area of a random sample of 30 out of 57 health centers (HC). All resident eligible pregnant women (PW) at 32-40 weeks of gestation without any overt diseases were selected. Food intake and antenatal health history were assessed by a food frequency questionnaire, health questionnaire and a review of HC records. Of the 180 enrolled PW, the prevalence of iron deficiency (ID), iron deficiency anemia (IDA) and other anemia were 34.4, 37.8 and 7.8%, respectively. PW in the last group were excluded from the analysis of predictors of iron status. Stool samples were obtained from 130 PW. The prevalences of hookworm, Ascaris and Trichuris were 47, 48 and 25 %, respectively. The number of ante-natal care (ANC) visits ranged from 0-8 with a median of 3 visits. Of those PW who visited, 97% reported receiving iron tablets. The compliance rate with iron tablets was low especially in the third trimester (9-12 %). Ordinal logistic regression showed that the risks for ID and IDA were reduced with statistical significance at a gestational age greater than 34 weeks, with more than three ANC visits, and increased consumption of meat and calories, but increased with hookworm infection. Compliance with iron tablet supplementation did not significantly reduce the risk for ID and IDA. In this study, PW had high percentages of ID and IDA. The risk factors identified in this report require intervention to eliminate them.

Evaluation of World Health Organization partograph implementation by midwives for maternity home birth in Medan, Indonesia.

OBJECTIVE: to assess the effectiveness of promoting the use of the World Health Organization (WHO) partograph by midwives for labour in a maternity home by comparing outcomes after birth. SETTING: Medan city, North Sumatera Province, Indonesia. PARTICIPANTS: 20 midwives who regularly conducted births in maternity homes, randomly allocated into two equal groups. DESIGN: cluster randomised-control trial. INTERVENTION: under supervision from a team of obstetricians, midwives in the intervention group were introduced to the WHO partograph, trained in its use and instructed to use it in subsequent labours. MEASUREMENTS AND FINDINGS: there were 304 eligible women with vertex presentations among 358 labouring women in the intervention group and 322 among 363 in the control group. Among the intervention group, 304 (92.4%) partographs were correctly completed. From 71 women with the graph beyond the alert line, 42 (65%) were referred to hospital. Introducing the partograph significantly increased referral rate, and reduced the number of vaginal examinations, oxytocin use and obstructed labour. The proportions of caesarean sections and prolonged labour were not significantly reduced. Apgar scores of less than 7 at 1min was reduced significantly, whereas Apgar scores at 5mins and requirement for neonatal resuscitation were not significantly different. Fetal death and early neonatal death rates were too low to compare. IMPLICATIONS FOR PRACTICE: a training programme with follow-up supervision and monitoring may be of use when introducing the WHO partograph in other similar settings, and the findings of this study suggest that the appropriate time of referral needs more emphasis in continuing education. CONCLUSION: the WHO partograph should be promoted for use by midwives who care for labouring women in a maternity home.

Once-weekly and 5-days a week iron supplementation differentially affect cognitive function but not school performance in Thai children.

Many studies have reported comparable hemoglobin response in subjects given intermittent and daily iron supplements. However, the effect of intermittent iron supplementation on impaired cognitive function, one of the serious consequences of iron deficiency among children, has not been studied. We investigated the effects of 1 d/wk (weekly) and 5 d/wk (daily) iron supplementation on changes in results of intelligence quotient (IQ), Thai language, and mathematics tests among Thai primary schoolchildren. A double-blind, randomized, placebo-controlled trial was conducted. Primary schoolchildren (n = 397) were randomly assigned to receive iron supplements daily or weekly or placebo. Ferrous sulfate (300 mg) or placebo tablets were given under direct observation by the researcher for 16 wk. Changes in IQ, and Thai language and mathematics scores were then compared. The increases in hemoglobin concentration were comparable in the weekly and daily iron supplementation groups but serum ferritin increased more in the children supplemented daily. Children receiving daily iron supplements, however, had a significantly lower increase in IQ (3 +/- 12 points) than those receiving the supplement weekly (6 +/- 12 points) or placebo (6 +/- 12 points), whereas the last-mentioned two groups did not differ. Z-scores of Thai language and mathematics test results did not differ among the groups. We conclude that weekly iron supplementation is the regimen of choice in this study community.

Once weekly is superior to daily iron supplementation on height gain but not on hematological improvement among schoolchildren in Thailand.

Intermittent iron supplementation has been suggested as a replacement for daily iron supplements for reducing anemia in developing countries. The effects of once weekly and daily iron supplementation on hemoglobin (Hb), serum ferritin (SF), prevalence of anemia, weight and height are compared in this study. Primary schoolchildren (n = 397) from two selected schools in the Hat Yai rural area, southern Thailand, were recruited in 1999. All children received Albendazole and then randomly received ferrous sulfate (300 mg/tablet) either daily or weekly, or a placebo for 16 wk. The average increase in Hb was not significantly different between the daily (mean +/- SD; 6.5 +/- 6.0 g/L) and weekly (5.7 +/- 6.3 g/L) groups. However, the average increase in SF was greater (P < 0.01) in the daily (mean +/- SD; 39.8 +/- 30.3 microg/L) than the weekly (13.4 +/- 17.3 microg/L) group. All cases of iron deficiency anemia were abolished in both daily and weekly groups, whereas no reduction in prevalence occurred in the placebo group. Height gain was greater in children who received weekly (mean +/- SD; 2.6 +/- 0.9 cm) than in those who received daily iron (mean +/- SD; 2.3 +/- 0.8 cm), (P < 0.01). Weight gain, weight-for-age and height-for-age were not significantly different among the intervention groups. It is concluded that a weekly iron dose is more effective than a daily dose in height gain but not in hematological improvement over 16 wk of supplementation.