Persistent thrombocytopenia following dengue fever: What should we do?

Thrombocytopenia is a common laboratory finding in dengue infection. However, it usually resolves as the patient recovers from the infection. Persistent thrombocytopenia following dengue infection requires further investigation. Here, we present a case of immune thrombocytopenic purpura (ITP) following dengue infection complicated by intracranial bleeding.

A comparison of dabigatran and warfarin for stroke prevention in elderly Asian population with nonvalvular atrial fibrillation: An audit of current practice in Malaysia.

INTRODUCTION: Atrial fibrillation (AF) is the most common cardiac arrhythmia with significant morbidity and mortality in relation to thromboembolic stroke. Our study aimed to evaluate the safety and efficacy of dabigatran in stroke prevention in elderly patient with nonvalvular AF with regard to the risk of ischemic stroke and intracranial haemorrhage (ICH) in real-world setting. METHODS: A retrospective cohort study of 200 patients on dabigatran and warfarin from January 2009 till September 2016 was carried out. Data were collected for 100 patients on dabigatran and 100 patients on warfarin. RESULTS: The mean follow-up period was 340.7±322.3 days for dabigatran group and 410.5±321.2 days for warfarin group. The mean time in therapeutic range (TTR) was 52±18.7%. The mean CHA2DS2 -VASc score for dabigatran group was 4.4±1.1 while 5.0±1.5 for warfarin group. None in dabigatran group experienced ischemic stroke compared to one patient in warfarin group (p=0.316). There was one patient in dabigatran group suffered from ICH compared to none in warfarin group (p=0.316). Four patients in warfarin group experienced minor bleeding, while none from dabigatran group (p=0.043). CONCLUSION: Overall bleeding events were significantly lower in dabigatran group compared to warfarin group. In the presence of suboptimal TTR rates and inconveniences with warfarin therapy, non-vitamin-K antagonist oral anticoagulants (NOAC) are the preferred agents for stroke prevention in elderly Asian patients for nonvalvular AF.

Ministry of Health clinical practice guidelines: Chronic Hepatitis B Infection.

The Ministry of Health (MOH) publishes clinical practice guidelines on Chronic Hepatitis B Infection to provide doctors and patients in Singapore with evidence-based guidance on managing important medical conditions. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on Chronic Hepatitis B Infection, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website (http://www.moh.gov.sg/mohcorp/publications.aspx?id=26108). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Minimal hepatic encephalopathy runs a fluctuating course: results from a three-year prospective cohort follow-up study.

INTRODUCTION: Minimal hepatic encephalopathy (mHE) has been reported in up to 84 percent of cirrhotics. The natural history of mHE has not been well-described. We designed a three-year prospective cohort study to determine the prevalence and natural history of mHE among cirrhotic patients. METHODS: The patient cohort comprising 62 consecutive outpatients with cirrhosis were assessed at baseline and followed-up with a repeat assessment three years later. The assessments include: (1) Neuropsychometric analysis (digit-symbol substitution test, block-design test, number-connection test A); (2) Clinical, biochemical assessment; and (3) Quality of life (QOL) assessment (abbreviated sickness impact profile). RESULTS: Baseline characteristics were: age 52.9 +/- 11.0 years; Child's A:B:C was 46:14:2. mHE was detected in 33.9 percent of the cohort. Older age, a higher Child-Pugh score and female gender were independently associated with mHE. mHE was associated with a poorer QOL. Follow-up assessment three years later showed that seven patients had died, while six were lost to follow-up; these patients had significantly higher baseline Child's scores. Of the remaining patients, 36/49 (73 percent) agreed to a repeat evaluation. In this group, none had mHE. QOL remained impaired despite the resolution of mHE. CONCLUSION: It has been shown for the first time that mHE can revert to a normal state in a significant proportion of patients with well-compensated cirrhosis.

Gaseous emboli detection based on a dual-wavelet transform analysis.

Emboli monitoring is nowadays based on the assessment of microembolic signals by Doppler ultrasound. However, the present systems have problems in detecting multiple emboli. A more dedicated algorithm for post-processing of the recorded Doppler signals was proposed. Based on the hypothesis that single and multiple gaseous emboli can be quantified by combining discrete and continuous wavelet transformation, the aim of this study was to detect gaseous emboli and to validate our method visually. A flow rig was used where gaseous emboli were generated. Doppler signals and visual validation data of gaseous emboli were acquired simultaneously. Microembolic signals were extracted and analysed using wavelet transformation. Results were validated against a visual reference. At various degrees of bubble generation, the system had 100 per cent detection during a low frequency of bubble generation but an estimation error of 7.4 per cent during a high frequency of bubble generation. The estimation error varied between -7.4 and +3 per cent. The system had a higher rate of success in detecting large gaseous emboli in small numbers than small gaseous emboli in large numbers. Single and double emboli were successfully detected and separated, whereas gaseous emboli clouds could be detected but not quantified. Being able to separate simultaneous gaseous emboli may offer new means of increasing detectability for embolism monitoring.

Significant non-alcoholic fatty liver disease is found in non-diabetic, pre-obese Chinese in Singapore.

INTRODUCTION: To characterise the anthropometrical and metabolic parameters of a group of non-diabetic and non-obese patients who had histologically-proven nonalcoholic steatohepatitis (NASH). METHODS: During September 1997 to November 1999, consent for liver biopsies were sought from a consecutive series of patients, whose body mass index (BMI) were equal to or less than 30 kg per square metres, and who had persistently elevated serum alanine transaminase (more than 2.5 times upper limit of normal for more than six months), with no associated viral hepatitis, alcohol or drug-induced liver disease, hereditary liver disease and diabetes mellitus. Patients who were found to have steatohepatitis histologically were further studied. Their body weight, height, waist and hip circumferences were taken, and fasting serum lipid and glucose measured. Serum insulin was measured in six patients and insulin resistance (IR) was calculated by homeostasis model assessment. Oral glucose tolerance tests were done if fasting glucose levels were greater than 6 mmol/L. All liver biopsies were reviewed by a single histopathologist. Three age- and sex-matched controls were randomly selected for each patient. RESULTS: 11 of 12 patients who underwent liver biopsies were found to have NASH. All 11 were Chinese: eight males and three females. 73 percent of them had hepatic fibrosis. Overall, compared to controls, they had significantly higher body weight, BMI, IR and triglyceridaemia. The female patients also had a higher waist-hip ratio than controls. None had diabetes mellitus, and one had impaired glucose tolerance/fasting glycaemia. Nine out of 11 had BMI between 25 and 30 kg per square metres. CONCLUSION: Significant histological changes of NASH with hepatic fibrosis were found in Singaporean Chinese non-diabetic patients with BMI of less than 30 kg per square metres.

The correlation between cytopenia and esophageal varices in patients with liver cirrhosis.

This retrospective study analysed the case records of 200 patients in the Department of Gastroenterology, Singapore General Hospital from February 2000 to January 2001 who had liver cirrhosis and underwent gastroscopy for the detection of varices. The aim of this study was to determine any relationship between leucopenia, thrombocytopenia and the occurrence of esophageal varices in a cirrhotic population. Our results showed that the diagnostic yield of varices grade 2 and 3 was 6.3% if platelet count was > 150,000/mm3, 25% if platelet count was 100,000 to 150,000/mm3, 38.9% if platelet count was 50,000-99,000/mm3 and 100% if platelet count was <50,000/mm3. Similarly, the diagnostic yield of varices grade 2 and 3 was 19.4% if total white count was > 4,000/mm3, 66.7% if total white count was 3,000- 4,000/mm3 and 94.8% if total white count was < 3,000/mm5. We conclude that thrombocytopenia and leucopenia can be used to stratify risk for occurrence of esophageal varices in cirrhotic patients and gastroscopy will have a high yield for varices when platelet count is < 150,000/mm3 or total white is < 4,000/mm.

MARS therapy in critically ill patients with advanced malignancy: a clinical and technical report.

BACKGROUND/METHODS: Molecular Adsorbent Recirculating System (MARS) was used in three consecutive critically ill patients at the Singapore General Hospital with advanced malignancy and acute liver failure (ALF). Case 1 was a male patient with hepatocellular carcinoma (HCC) for which initial right hepatectomy was followed by left hepatectomy 5 months later for recurrent HCC. The postoperative course following second surgery was complicated by severe methicillin-resistant Staphylococcus aureus (MRSA) sepsis, mild azotaemia and subacute cholestatic liver failure. MARS was used thrice in this patient. Case 2 was a female patient with advanced acute lymphoblastic leukaemia (ALL) with post bone marrow transplantation (BMT) acute haemolytic-uraemic syndrome (HUS) secondary to cyclosporin A (Cy A), cytomegalovirus (CMV) infection, severe nosocomial pneumonia, acute renal failure (ARF) treated with continuous haemofiltration and acute veno-occlusive disease resulting in Budd-Chiari syndrome. The latter precipitated ALF. MARS was instituted twice. Case 3 was a male patient with advanced, refractory Hodgkin's disease previously treated with multiple courses of chemotherapy. ALF developed secondary to acute viral hepatitis B flare. He was given a trial of MARS once in the ICU. All the three patients eventually died. RESULTS: Mean MARS intradialytic systemic pressures were as follows: systolic pressure range was 95 +/- 17 to 128 +/- 17 mmHg and diastolic pressure range was 51 +/- 5 to 67 +/- 7 mmHg. Pressure at albumin dialysate exit point from dialyser 1 (Ae) ranged from 253 +/- 11 to 339 +/- 15 mmHg and that at albumin dialysate entry point into dialyser 1 (Aa) ranged from 142 +/- 11 to 210 +/- 6 mmHg. Ultrafiltration (UF) was 633 +/- 622 mL over mean treatment duration of 6.3 +/- 0.9 h with a total heparin dose of 1583 +/- 817 IU. Coagulation status pre- and 6-h post-MARS was similar: aPTT (P=0.116) and platelet count (P=0.753). There were no bleeding complications or circuit thromboses. MARS had a significant de-uraemization effect (pre- and post-MARS serum creatinine and urea: P=0.046 and 0.028, respectively) but did not significantly attenuate blood lactate, ammonia or total bilirubin levels. Albumin dialysate (Ae - Aa) urea and creatinine concentrations appeared to be sharply attenuated after 6 h of MARS. In contrast, the removal of total bilirubin by albumin dialysate from the blood compartment appeared to plateau after 4 h of continuous MARS operation. CONCLUSIONS: MARS was well-tolerated in critically ill patients with advanced and complicated cancer. Low-dose heparin was safe and did not compromise MARS circuit integrity. Although MARS had a significant de-uraemization effect, this appeared to be limited by the duration of MARS operation. Our data suggested that such a limit was reached earlier for total bilirubin. More data are needed to confirm the present findings and further delineate the saturation limit of MARS for different toxins that accumulate in ALF. This would affect the optimal duration of MARS therapy.

Gastrointestinal Cytomegalovirus infection in non-human immunodeficiency virus infected patients.

This is a retrospective study of fourteen patients who had proven Cytomegalovirus (CMV) infection of the gastrointestinal tract with no Human Immunodeficiency virus infection. The median age was 60.5 (Range 28 to 81) years. Eight patients were below (Group 1) and six above sixty five years old (Group 2). Areas of gastro-intestinal involvement were: oesophagus (2), stomach (1), colon (10) and multiple sites (1). Seven patients from Group 1 had received immunosuppressive therapy at the time of presentation and one had diabetes mellitus. We found a high prevalence of co-morbidities such as chronic renal failure and diabetes mellitus in Group 2. At median follow up of 13.9 months, there was a mortality rate of 50%. Only four patients were treated with ganciclovir. Our study concludes that the gastrointestinal CMV diseases in young patients were associated with immunosuppression whereas the older patients had chronic renal failure or diabetes.

Analog and digital FPGA implementation of BRIN for optimization problems.

The binary relation inference network (BRIN) shows promise in obtaining the global optimal solution for optimization problem, which is time independent of the problem size. However, the realization of this method is dependent on the implementation platforms. We studied analog and digital FPGA implementation platforms. Analog implementation of BRIN for two different directed graph problems is studied. As transitive closure problems can transform to a special case of shortest path problems or a special case of maximum spanning tree problems, two different forms of BRIN are discussed. Their circuits using common analog integrated circuits are investigated. The BRIN solution for critical path problems is expressed and is implemented using the separated building block circuit and the combined building block circuit. As these circuits are different, the response time of these networks will be different. The advancement of field programmable gate arrays (FPGAs) in recent years, allowing millions of gates on a single chip and accompanying with high-level design tools, has allowed the implementation of very complex networks. With this exemption on manual circuit construction and availability of efficient design platform, the BRIN architecture could be built in a much more efficient way. Problems on bandwidth are removed by taking all previous external connections to the inside of the chip. By transforming BRIN to FPGA (Xilinx XC4010XL and XCV800 Virtex), we implement a synchronous network with computations in a finite number of steps. Two case studies are presented, with correct results verified from simulation implementation. Resource consumption on FPGAs is studied showing that Virtex devices are more suitable for the expansion of network in future developments.

Helicobacter pylori infection is unlikely to be transmitted between partners: evidence from genotypic study in partners of infected patients.

INTRODUCTION: We postulated that the oro-oral route of transmission between spouses could be an important route of transmission of Helicobacter pylori. AIMS: To estimate the prevalence of different genotypes of H. pylori as distinguished by the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method in our local population, and to compare the genotypes of H. pylori isolated from patients and their spouses. METHODS: Gastric biopsies were obtained from 183 dyspeptic patients during endoscopy. PCR for H. pylori was carried out using the uceC gene for amplification, and PCR products were digested further for RFLP analysis using the enzyme MboI. Spouses of H. pylori-positive index cases were screened for the infection using serological testing; if found to be positive serologically, endoscopy and gastric biopsies were performed for genotypic study of the micro-organism. For couples with indistinguishable H. pylori strain on RFLP with restriction endonuclease MboI, the process of RFLP was repeated with digestion of the PCR products using restriction endonuclease HhaI. RESULTS: We established our PCR technique to be 89.5% sensitive and 95.5% specific. Eighty-nine subjects were found to be H. pylori positive by PCR, and eight different genotypic strains were found according to our RFLP analysis. Two genotypes accounted for 80.8% of the cases. Sixteen of 31 spouses tested serologically for H. pylori were positive. All 13 spouses who agreed to undergo endoscopy were PCR positive for H. pylori. Five couples shared indistinguishable H. pylori genotypes, but this strain was also the commonest genotype in our local population, as based on RFLP with restriction endonuclease MboI. Further RFLP on the PCR products on these five couples using restriction endonucleases HhaI showed that the H. pylori isolated from these five couples were of different strains. CONCLUSION: The oro-oral route of transmission between spouses is unlikely to be an important mode for H. pylori infection.

Prevalence of hepatitis G virus infection in patients with liver diseases in Singapore.

The prevalence of hepatitis G virus (HGV) infection in patients with liver diseases in Singapore and its pathogenic role in these patients was studied. One hundred and forty-eight patients who had chronic hepatitis or acute non A-E hepatitis were studied. Presence of HGV RNA was determined by nested polymerase chain reaction of the 5'non-coding region of the virus in all the patients. Hepatitis G IgG antibody to the envelope (E2) antigen was tested with an enzyme immunoassay (Boehringer Mannheim, Singapore) in 76 of them. Most patients (93%) were ethnically Chinese, predominantly males (74%) and chronic hepatitis B (72%) patients. Others had chronic hepatitis C (19%) or cryptogenic cirrhosis (6%). Four patients had acute non A-E hepatitis. HGV RNA and anti-HGenv were present in 3.5% and 8.3% of those with chronic liver disease. HGV infection did not account for any of the acute non A-E hepatitis and most of the cryptogenic cirrhosis.

Efficacy of a nitroimidazole containing tripletherapy regime in Singapore.

BACKGROUND: There has been a gradual increase in the proportion of Singapore patients with metronidazole resistant strains of Helicobacter pylori. We studied the efficacy of a nitroimidazole containing regime in eradicating H. pylori. METHODS: Consecutive treatment naive patients with peptic ulcer disease and culture proven H. pylori were recruited. From each patient, two antral biopsies were taken for rapid urease test and two for histology. Two biopsies each from the gastric antrum and corpus were taken for H. pylori culture. Antibiotic sensitivity to amoxycillin, metronidazole, clarithromycin and tetracycline were tested using the disc diffusion method. Patients were treated with lansoprazole 30 mg bd, tinidazole 500 mg bd and clarithromycin 500 mg bd for seven days. Successful eradication was defined as either negative urea breath tests 4 and 12 weeks after treatment, or negative histology and culture at least four weeks after the end of treatment. RESULTS: A total of 64 patients were culture positive (51 males, 13 females). Forty-two patients had duodenal ulcers (DU), 17 gastric ulcers (GU), and 5 DU and GU. Metronidazole resistance was detected in 16 patients (25%). Three of the 16 patients (19%) had a mixed population of resistant and sensitive strains of H. pylori. None of the H. pylori isolates were resistant to amoxycillin, tetracycline or clarithromycin. Overall, eradication was achieved in 51/64 patients (80%). Eradication rate was 88% (42/48) among those with metronidazole sensitive strains, and 56% (9/16) among those with metronidazole resistant strains (p < 0.02). CONCLUSION: A high proportion of our patients with metronidazole resistant strains of H. pylori failed eradication therapy when a nitroimidazole containing regime was used. It may not be appropriate to use a nitroimidazole containing without prior knowledge of the antibiotic sensitivity pattern of the H. pylori isolate.

Extrahepatic bile duct length in the Singapore population.

BACKGROUND: Although the length of the common bile duct is well documented, the length of extrahepatic biliary tree is less well studied, particularly in among the Asian population. The extrahepatic bile duct (BD) length is defined as the measurement from the hepatic hilum to the papilla. OBJECTIVE: This study was performed to assess the normal range of extrahepatic BD length, as defined above, in the Singapore population. This information would be useful in assisting the local endoscopy unit in procuring the different lengths of biliary stents. METHOD: Between 1.8.96 to 1.12.97, 486 cholangiograms were obtained post-ERCP, of which only 100 cholangiograms that were representative of a non-distorted BD were used for analysis. The BD length, taken from the mid-point of the confluence of the left and right hepatic ducts at the hilum to the papilla, was measured with a string placed on the cholangiogram. The true length was obtained after correction for radiological magnification. RESULTS: The range of bile duct lengths followed a normal distribution curve with a mean length of 9.6 cm. The range was from 6.9 cm to 12.6 cm. With respect to the length of stents commonly deployed, the cumulative percentage of BD length less than and equal to 7-, 9-, 10- and 12-cm were 1%, 38%, 57% and 98% respectively. CONCLUSION: From a practical point of view, this study suggests that endobiliary stent of 5 cm in length should be readily available for drainage of distal CBD strictures as 1% of our population has BD length less than 7 cm. However, as 2% of the population has BD length greater than 12 cm, 15 cm stents should be available in the endoscopy unit for drainage of hilar obstructions/strictures.

Survey of dyspepsia management in community.

INTRODUCTION: Dyspepsia is a common complaint and represents an important health problem in the community. The aim of the study was to survey the diagnostic approach and management of dyspepsia and Helicobacter pylori (H. pylori) infection by primary care physicians. METHODS: Questionnaires were given to 70 medical officers (MO) working in government polyclinics and 70 general practitioners (GP) in private practice. RESULTS: Questionnaires were returned from 68 MO's (response rate 97%) and 61 GP's (response rate 87%). Only 20% of MO and 50% of GP prescribed H. pylori eradication therapy. Of those who have prescribed eradication therapy, 70% would confirm H. pylori infection before therapy (50% for gastroscopy, 19% for Urea Breath test, 25% for laboratory based serology, 6% for office based serology test kits). 85% would prescribe triple therapy against 15% for dual therapy. Proton pump inhibitor (PPI) is the acid suppression agent most commonly prescribed (77%) in regimens of eradication therapy; the remaining would prescribe either bismuth subcitrate or H2 antagonists. Only 8% of respondents would confirm eradication after therapy. CONCLUSION: Less than half of the primary care physicians surveyed prescribed H. pylori eradication therapy. The main reason given for not prescribing therapy was lack of facility for testing the infection. Of those who prescribed eradication therapy, majority would order the correct and reliable investigations to confirm the infection. Most of them would prescribe triple therapy which is the recommended eradication regimens.

Cap-fitted gastroscopy improves visualization and targeting of lesions.

BACKGROUND: Difficulty with visualization and targeting of lesions to obtain biopsy specimens or for endoscopic treatment during diagnostic and therapeutic EGD may be due to a tangential approach, endoscope tip instability, or close proximity to the lesion resulting in a "red-out." Cap-fitted EGD (CF-EGD) adds a "tactile" dimension and enhances visualization and targeting of lesions by allowing manipulation of tangential sites to a more "en-face" approach, thereby improving tip stability and maintaining close apposition to the lesion without losing the endoscopic view. MATERIALS AND METHODS: A recycled transparent cap from a multiband variceal ligator was evaluated during EGD. Where lesions were deemed to be suboptimally visualized or targeted, CF-EGD was performed during the same procedure. Nineteen patients had CF-EGD after conventional EGD. RESULTS: Lesions were located in the duodenal bulb (7), apex of the bulb (5), descending duodenum (1), pylorus (1), posterior gastric wall (3), incisura (1), cardia (1), and afferent limb (Billroth II) (2). Diagnoses were duodenal ulcer (7), duodenal varix (1), gastric metaplasia (1), duodenal Crohn's disease (1), duodenal polyp (3), gastric ulcer (3), antral cancer (1), gastric polyp (1), and anastomotic ulcer (2). Targeted biopsy specimens were obtained in 7, bleeding ulcers treated in 4 (3 duodenal ulcer, 1 anastomotic), and a duodenal polyp (2.5 cm diameter) was removed in 1. CONCLUSIONS: This adaptation of a recycled transparent cap is simple, safe, and effective and improves visualization and targeting of lesions.

Percutaneous endoscopic gastrostomy--indications and outcome of our experience at the Singapore General Hospital.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) is widely used for patients with dysphagia from neurological causes and head and neck malignancy. We examined the indications, complication rates and long term outcome of PEG inserted in our department. METHODS: We performed a study of PEG inserted in our department between January 1995 to March 2000. Consecutive patients with PEG inserted during this period were identified from our database that contained demographic data, primary and secondary underlying medical conditions, and immediate complications after the procedure. Casenotes were reviewed and caregivers (relatives or staff at nursing homes) were contacted for information on long term outcome at the time of this study between April 2000. Data was collected in standard form designed for this study. RESULTS: 181 cases of PEG insertion were performed during the study period. 174 patients were successfully followed up and reviewed. The median age was 70.5 (range 24 to 93) years old and there were 111 males. Indications for PEG insertion were: cerebrovascular diseases (60.4%), Parkinson's disease and other neuromuscular disorders (10.9%), nasopharyngeal carcinoma and other upper gastrointestinal malignancies (24.7%), and head injury (4%). Superficial wound infection (22.4%) and granuloma formation (31%) were common minor complications. Major complications were infrequent: peritonitis (2.3%) and gastrointestinal bleeding (0.6%). The mortality rates were 11.5% and 28.2% at one and six months respectively. Only one death from peritonitis was directly attributed to the procedure, most deaths were due to underlying co-morbidities with pneumonia being the most common cause. The proportion of the first PEG tubes removed or replaced were 12.2% and 35.5% at one and six months respectively. Thirty tubes were replaced due to blockage at median interval of 9.6 months. 9.7% of PEG tubes functioned longer than 24 months. CONCLUSIONS: Our results confirm the safety of PEG tubes in elderly patients with multiple co-morbidities. Major complications of the procedure were infrequent but produced grave consequences in these elderly patients with multiple co-morbidities. As such, patients considered for PEG feeding should have reasonable prognosis and the procedure is inappropriate for patients with rapidly progressive and incurable diseases.

Gastrointestinal manifestations of systemic lupus erythematosus.

Gastrointestinal symptoms are common in patients with systemic lupus erythematosus (SLE) and can be due to primary gastrointestinal disorders, complications of therapy or SLE itself. In this case report, we describe three different presentations and causes of gastrointestinal complaints in patients with SLE. Diagnostic and management problems are discussed.

Isolation of a single strain of Helicobacter pylori from the antrum and body of individual patients.

OBJECTIVES: This study aimed to determine intra-patient colonization patterns of Helicobacter pylori strains based on DNA fingerprinting and antibiotic susceptibility. METHODS: Two biopsies, one from the antrum and one from the body of the stomach, were taken from 97 patients. Prior informed consent was obtained. The status of cagA gene of H. pylori strains was analysed by using the polymerase chain reaction (PCR) technique, while DNA fingerprints were generated by PCR-based, random amplified polymorphic DNA (RAPD) fingerprinting. The antibiotic susceptibility of the H. pylori isolates was examined by the disk diffusion method. RESULTS: A total of 51 pairs of H. pylori strains were isolated from both antrum and body specimens of 51 patients. This included two patients who were endoscoped twice because of treatment failure. All strains were positive for cagA gene by PCR. These 51 patients were found to harbour a single strain of H. pylori with identical or highly similar DNA profiles by PCR-based RAPD fingerprinting. In four of the 51 pairs, the DNA patterns of H. pylori from antrum and body showed minor differences, while three pairs of strains with different metronidazole sensitivities showed identical DNA fingerprints. Interestingly, the two treatment failure patients remained colonized with the strains that had the same RAPD fingerprinting patterns before and after treatment. CONCLUSION: The present study demonstrates that a single H. pylori strain colonizes a single stomach. However, this single genotypic strain may exhibit different metronidazole susceptibility in different parts of stomach.

Primary leiomyoma of the liver.

This case report describes a primary hepatic leiomyoma presenting as a mass lesion detected on ultrasonography of the abdomen in an asymptomatic hepatitis B carrier on routine surveillance. Primary leiomyomata of the liver are rare occurrences, with only 9 cases reported in the literature. The presenting features of primary hepatic leiomyomata and diagnostic approach towards such lesions are discussed. The significance of such tumours in the immunocompromised is also mentioned.