Antibiotic resistance patterns and therapeutic outcomes of pediatric Helicobacter pylori infection in a high-migrant Singaporean cohort.

BACKGROUND: Variation in Helicobacter pylori (H. pylori) disease in terms of prevalence and antibiotic resistance prevails globally requiring a need to develop region-specific surveillance. We aimed to assess the influence of immigration factors upon the interpretation of local Singaporean epidemiological trends in antimicrobial susceptibility patterns and therapeutic outcomes in children with culture-positive H. pylori. MATERIALS AND METHODS: We retrospectively analyzed eradication outcomes of children with culture-proven H. pylori infections between 2011 and 2020 at our center, and we also analyzed the antimicrobial susceptibility profiles of the corresponding H. pylori isolates. The cohort was classified into two groups: (1) Native Singaporeans and (2) Non-native Singaporeans (First-/Second-generation immigrants and Non-residents) to correlate with resistance patterns and eradication outcomes. H. pylori culture was done via Kirby-Bauer disk diffusion for the era 2011-2016 and bioMérieux E test for 2016-2020. RESULTS: A total of 70 children (median age 14 [2-17] years) were included in the analysis. 42.9% (30/70) of the cohort displayed some form of antibiotic resistance; clarithromycin resistance was the most prevalent (30.0%), followed by metronidazole (27.5%) and amoxicillin (7.1%). Comparing to natives, non-native Singaporeans were significantly younger at presentation (mean 11.7 vs. 13.7 years, p = 0.043), and a significantly higher proportion of non-natives carried clarithromycin-resistant (51.4% vs. 8.6%, p < 0.001), metronidazole-resistant (47.1% vs. 8.6%, p < 0.001), or multidrug-resistant (resistant to ≥2 drugs) (40.0% vs. 2.9%, p < 0.001] strains. Non-natives were significantly more likely to fail first-line eradication therapy (48.5% failure vs. 23.3%, p = 0.038). The proportion of pan-sensitive H. pylori was significantly lower in first-generation (25.0%, p = 0.001) and second-generation (42.9%, p = 0.018) immigrants compared to natives (82.86%). These conclusions did not vary when the analysis was repeated for each culture method. CONCLUSIONS: An antibiotic susceptibility-based approach should be advocated for all patients but especially so for non-natives, who are at higher risk for antimicrobial resistant strains and poorer eradication outcomes.

Long-term outcome after liver transplantation in children with type 1 glycogen storage disease.

Patients with GSD type 1 (von Gierke disease) are initially managed medically to maintain normoglycemia. However, if they do not achieve good metabolic control, LT is then considered. We describe the long-term outcome of 6 children with GSD type 1 who underwent LT. Retrospective chart review of the data of 6 children with GSD type 1 who underwent LT at National University Hospital, Singapore, from May 1998 to October 2018, was performed. The median (IQR) age at diagnosis of the GSD was 1 year (0.92-5.50) and at transplant was 13.88 years (11.46-16.38). All of the patients had elevated liver enzymes, hypercholesterolemia, hypertriglyceridemia, and hyperlactatemia prior to transplant. All of the patients are alive at the time of analysis and follow-up. None of them required a re-transplant. For the three patients who had hypoglycemia pretransplant, there was no recurrence post-transplant. All of the patients had normalization of liver enzymes by 1 year post-transplant. Long-term outcome of patients with GSD who underwent LT has been positive with improvement in metabolic control for most patients. We report the unusual finding of two siblings with persistent hyperuricemia post-transplant requiring allopurinol.

Health-related quality of life, clinical outcomes, and subjective experiences of parent donors of pediatric liver transplant recipients.

PURPOSE: The understanding of the HRQOL issues for parent donors of children who underwent LDLT is lacking. We evaluated the HRQOL of donor and non-donor parents, described their subjective experiences and identified factors associated with lower HRQOL post-donation. METHODS: This is a cross-sectional study of parent donors whose children underwent LDLT, using SF-36v2 Health Survey to measure HRQOL, and a self-developed questionnaire to evaluate their subjective experiences. RESULTS: Of 32 pairs of donor and non-donor parents, 27 donor and 19 non-donor parents responded. The data of respondents were analyzed. Both donor and non-donor parents' SF-36v2 norm-based scores were average or above average as compared to the Singapore population. Donors who made lifestyle changes post-donation (adopting a healthy balanced diet, regular physical activity, quitting smoking, and moderate alcohol intake) were associated with lower GH (P = 0.009) and PF (P = 0.002) scores. Donors who took more than 3 months for full recovery had lower RP (P = 0.022) and BP scores (P = 0.038). On multivariate analysis, recipient complication of Clavien grade 3 or 4 was associated with increased RP score by 8.71 points (95% CI: 1.74-15.68), after adjusting for time taken for full recovery. Majority (88.8%) had self-reported recovery time under 6 months and returned to work within 3 months (74.0%). CONCLUSIONS: Donors with factors potentially associated with lower HRQOL may need more support to ensure better HRQOL outcomes post-donation.

Endoscopic retrograde cholangio-pancreatography in the management of biliary complications after paediatric liver transplantation - a retrospective study.

The published paediatric experience with endoscopic retrograde cholangio-pancreatography (ERCP) in the diagnosis and management of biliary complications following liver transplantation (LT) is limited. We describe our experience with ERCP in the management of children following LT who presented with biliary complications, over a 20-year period (1995-2014). The retrospectively reviewed data are summarized descriptively. Of 94 children (47 boys) who received 102 liver transplants at our centre, seven children (five boys, two girls) underwent ERCP after liver transplantation. In total, 25 ERCP procedures were carried out in these patients. The median age at liver transplantation was 10.7 (3.9-16.2) years. The median interval between LT and the first ERCP was 28 days (12 days-6.8 years). All patients were on standard calcineurin-inhibitor-based immunosuppression regimens. Six of the seven patients underwent ERCP on more than one occasion [median number of ERCP sessions per patient- 4, (1-6)]. Seventeen procedures were carried out under conscious sedation, remaining eight under general anaesthesia. Sedation was achieved employing a standard regimen (Midazolam 5 mg with Pethidine 50 mg) and occasionally Fentanyl. ERCP is an effective and safe intervention from both diagnostic and therapeutic point of view, in the management of post-LT biliary complications in children.

Risk factors and clinical outcomes of pediatric liver transplant recipients with post-transplant lymphoproliferative disease in a multi-ethnic Asian cohort.

BACKGROUND: We aimed to evaluate clinical characteristics, risk factors, and disease outcomes for liver transplant recipients (LTR) with post-transplant lymphoproliferative disease (PTLD) at our center. METHODS: Retrospective review of data of all pediatric LTR (1991-2015) was conducted. RESULTS: The overall incidence of PTLD was 16.4% (18/110), the majority (13/18) were early lesions, while 3/18 were polymorphic/monomorphic PTLD. The risk factors significant on univariate analysis were as follows: mean age (years) at transplant (1.66 vs 4.76, P = .006); age <2 years at transplant (odds ratio [OR] 3.53 [95% confidence interval [CI]: 1.16-10.73], P = .026); cytomegalovirus (CMV) primary infection (OR 11.39 [95% CI: 3.44-37.7], P < .001); recipient CMV seronegativity (OR 7.50 [95% CI: 2.02-27.78], P = .003); presence of CMV end-organ disease (OR 4.00 [95% CI: 1.22-13.16], P = .022); Chinese ethnicity; and higher mean duration of intravenous ganciclovir prophylaxis. In multivariate analysis, CMV primary infection (OR 5.22 [95% CI: 1.25-21.87], P = .024), CMV seronegativity (OR 5.91 [95% CI: 1.13-30.90, P = .035]), and having acute cellular rejections (ACR) prior to PTLD (OR 5.53 [95% CI: 1.43-21.48, P = .013]) were significant risk factors for PTLD, with the latter two factors having a synergistic effect in increasing PTLD risk in a stratified analysis. The final multivariate model in predicting the risk of PTLD, utilizing CMV primary infection, recipient CMV seronegativity, and ACR before PTLD as predictive variables, was statistically significant (likelihood ratio chi square statistic = 25.18, P < .0001 with df = 3). CONCLUSIONS: We report a unique clinicopathologic and risk factor profile in our cohort-early lesion PTLD accounts for the majority and the incidence of monomorphic PTLD remains low. In addition, we show a synergism between CMV naivety and ACR on PTLD risk, a higher prevalence of gastrointestinal manifestations, and a lack of significant association with Epstein-Barr virus seronegativity.

Consensus and contentious statements on the use of probiotics in clinical practice: A south east Asian gastro-neuro motility association working team report.

The concept of consuming microorganisms in the treatment of a medical condition and in health maintenance has gained much attraction, giving rise to an abundance of medical claims and of health supplements. This study identified relevant clinical questions on the therapeutic use of probiotics and reviewed the literature in irritable bowel syndrome, inflammatory bowel disease, impaired intestinal immunity, liver disease, intestinal infections, and common childhood digestive disorders. Statements were developed to address these clinical questions. A panel of experienced clinicians was tasked to critically evaluate and debate the available data. Both consensus and contentious statements are presented to provide to clinicians a perspective on the potential of probiotics and importantly their limitations.

De novo aortopathy and cardiovascular outcomes in paediatric liver transplant recipients.

With the increase in long-term survival of post-transplant children, there is a paradigm shift in the emphasis of post-transplant care. We describe de novo cardiovascular abnormalities, which occurred in otherwise asymptomatic paediatric liver transplant recipients, who received liver allografts between 1991 and 2014 at the National University Hospital, Singapore, detected during routine post-transplant monitoring. A total of 96 paediatric liver transplants were performed in 90 children. After transplant, 7/90 (7.8%) recipients were identified with new-onset aortopathy. Glycogen storage disease type I (42.9% versus 2.4%; p<0.001) and recipient Epstein-Barr virus seropositivity (85.7 versus 31.0%, p=0.004) were significant risk factors for aortopathy on univariate analysis. On multivariate analysis, only glycogen storage disease type I remained as the significant risk factor (odds ratio 51.3 [95% confidence intervals: 1.1-2498.1, p=0.047]). Liver transplant is a double-edged sword that reverses certain cardiopulmonary complications of end-stage liver disease but may induce de novo structural cardiac injury in the form of aortic dilation.

Endoscopic Evaluation in Children With End-Stage Liver Disease-Associated Portal Hypertension Awaiting Liver Transplant.

OBJECTIVES: Routine oesophago-gastro-duodenoscopy (OGD) pre-liver transplantation (LT) for evaluation and management of gastrointestinal (GI) pathology, in particular GI varices secondary to portal hypertension, is common practice in adult LT programmes. There is no universal consensus for this practice in children. We report our endoscopic experience in children with end-stage liver disease (ESLD) pre-LT. METHODS: Retrospective audit of LT database and review of OGD findings of patients who had undergone endoscopy preceding LT. RESULTS: Of 69 patients with ESLD, 50 (72.4%) had pre-LT OGD, 37 of which were done electively, whereas the remaining 13 were event driven. Forty-eight (96%) patients who underwent OGD had abnormalities, in which 38 (76%) patients had varices and 23 (46%) had portal hypertensive gastropathy. Eleven (22%) patients required therapeutic intervention at initial OGD either with endoscopic variceal band ligation or endoscopic sclerotherapy. Compared with the group who underwent elective OGDs, the group who had event-driven OGDs had a significantly higher requirement for endoscopic intervention (P < 0.0001), occurrence of rebleeding (P < 0.029) and requirement for repeat OGDs (P = 0.014). There was no significant difference in terms of patient (P = 0.2746) or graft survival (P = 0.3192) between the 2 groups. CONCLUSIONS: The role of pre-LT OGDs in patients with ESLD associated with portal hypertension is possibly limited to control of bleeding during episodes of GI bleed, where the aim would be to stabilize the patient until eventual LT. Multicentre prospective studies are required to provide more evidence on the use of routine endoscopy for pre-LT assessment in children.

Current information and Asian perspectives on long-chain polyunsaturated fatty acids in pregnancy, lactation, and infancy: systematic review and practice recommendations from an early nutrition academy workshop.

The Early Nutrition Academy supported a systematic review of human studies on the roles of pre- and postnatal long-chain polyunsaturated fatty acids (LC-PUFA) published from 2008 to 2013 and an expert workshop that reviewed the information and developed recommendations, considering particularly Asian populations. An increased supply of n-3 LC-PUFA during pregnancy reduces the risk of preterm birth before 34 weeks of gestation. Pregnant women should achieve an additional supply ≥200 mg docosahexaenic acid (DHA)/day, usually achieving a total intake ≥300 mg DHA/day. Higher intakes (600-800 mg DHA/day) may provide greater protection against early preterm birth. Some studies indicate beneficial effects of pre- and postnatal DHA supply on child neurodevelopment and allergy risk. Breast-feeding is the best choice for infants. Breast-feeding women should get ≥200 mg DHA/day to achieve a human milk DHA content of ∼0.3% fatty acids. Infant formula for term infants should contain DHA and arachidonic acid (AA) to provide 100 mg DHA/day and 140 mg AA/day. A supply of 100 mg DHA/day should continue during the second half of infancy. We do not provide quantitative advice on AA levels in follow-on formula fed after the introduction of complimentary feeding due to a lack of sufficient data and considerable variation in the AA amounts provided by complimentary foods. Reasonable intakes for very-low-birth weight infants are 18-60 mg/kg/day DHA and 18-45 mg/kg/day AA, while higher intakes (55-60 mg/kg/day DHA, ∼1% fatty acids; 35-45 mg/kg/day AA, ∼0.6-0.75%) appear preferable. Research on the requirements and effects of LC-PUFA during pregnancy, lactation, and early childhood should continue. © 2014 S. Karger AG, Basel.

Cholangitis in children with biliary atresia: health-care resource utilisation.

AIM: Cholangitis is a well-known complication that contributes to morbidity, mortality, as well as health-care utilisation in children with biliary atresia who have undergone the Kasai portoenterostomy. The aim of the study was to determine the common causative organisms for cholangitis and characterise its burden, health-care resource and service utilisation and cost. METHODS: This was a retrospective chart review of children who underwent Kasai portoenterostomy in our institution from 1988 to 2011. The causative organisms were identified based on culture reports. The burden of the disease was estimated based on the number of patients experiencing one or more episodes of cholangitis. Health-care resource and service utilisation were based on different categories, and cost was computed based on the charges at the institution. RESULTS: Twenty-seven (64.3%) out of 42 children included in the analysis experienced at least one episode of cholangitis. There were a total of 97 episodes of cholangitis, with an average of 3.6 (1-15) episodes per patient. The average length of stay per episode of cholangitis was 14.8 (2-64) days. Common organisms isolated during blood cultures were Klebsiella pneumoniae, Enterococcus, Escherichia coli and Pseudomonas aeruginosa. The estimated cost per in-patient admission of 15 days (rounded off) for a single episode of cholangitis was $SG 8986.61 ($US 7369.02). CONCLUSION: The knowledge about the incidence and cost of cholangitis will allow physicians to counsel parents of children newly diagnosed with biliary atresia and to better prepare them both emotionally and financially for what to expect.

Compositional requirements of follow-up formula for use in infancy: recommendations of an international expert group coordinated by the Early Nutrition Academy.

The follow-up formula (FUF) standard of Codex Alimentarius adopted in 1987 does not correspond to the recently updated Codex infant formula (IF) standard and current scientific knowledge. New Zealand proposed a revision of the FUF Codex standard and asked the non-profit Early Nutrition Academy, in collaboration with the Federation of International Societies for Paediatric Gastroenterology, Hepatology, and Nutrition (FISPGHAN), for a consultation with paediatric nutrition experts to provide scientific guidance. This global expert group strongly supports breastfeeding. FUF are considered dispensable because IF can substitute for breastfeeding throughout infancy, but FUF are widely used and thus the outdated current FUF standard should be revised. Like IF, FUF serve as breast milk substitutes; hence their marketing should respect appropriate standards. The compositional requirements for FUF for infants from 6 months onwards presented here were unanimously agreed upon. For some nutrients, the compositional requirements for FUF differ from those of IF due to differing needs with infant maturation as well as a rising contribution of an increasingly diversified diet with advancing age. FUF should be fed with adequate complementary feeding that is also appropriate for partially breastfed infants. FUF could be fed also after the age of 1 year without safety concerns, but different compositional requirements should be applied for optimal, age-adapted milk-based formulations for young children used only after the age of 1 year. This has not been considered as part of this review and should be the subject of further consideration.

Incidence of intussusception in Singaporean children aged less than 2 years: a hospital-based prospective study.

BACKGROUND: Continuous surveillance for intussusception (IS) is important for monitoring the safety of second-generation rotavirus vaccines. The present study aimed to assess the incidence of IS in Singaporean children aged < 2 years. METHODS: This was a prospective, hospital-based, multi-center surveillance conducted in seven hospitals - two public hospitals and five private medical centers between May 2002 and June 2010 in Singapore. Diagnosis of IS (definite, probable, possible, suspected) was based on the case definition developed by the Brighton Collaboration. Children < 2 years of age who were diagnosed with IS were enrolled in this study. Incidence of IS was calculated per 100,000 child-year with its 95% confidence interval. RESULTS: Of the 178 children enrolled, 167 children with definite IS cases were considered for final analyses; 11 were excluded (six diagnosed as probable IS and four diagnosed as suspected IS; one child's parents withdrew consent). Mean age of children with definite IS was 11.6 ± 6 months; 67.7% were males. The overall incidence of IS was 28.9 (95% CI: 23.0-34.8) and 26.1 (95% CI: 22.2-30.0) per 100,000 child-year in children < 1 year and < 2 years of age, respectively. The majority of IS cases (20 [12.0%]) were reported in children aged 6 months. Most children (98.2% [164/167]) recovered, two (1.2%) children recovered with sequelae and one (0.6%) child died of septic shock. CONCLUSIONS: The incidence of IS remained low and stable in Singaporean children aged < 2 years during the study period (May 2002 to June 2010). TRIAL REGISTRATION: NCT01177839.

Safety and reactogenicity of DTPa-HBV-IPV/Hib and DTPa-IPV/I-Hib vaccines in a post-marketing surveillance setting.

Combination vaccines have been shown to improve the timeliness of vaccination and vaccine coverage. Safety and reactogenicity of combined diphtheria-tetanus-acellular pertussis-inactivated poliovirus and Haemophilus influenzae type b vaccine (DTPa-IPV/Hib, Infanrix IPV+Hib, GlaxoSmithKline Biologicals) was assessed in two clinical studies. In Study A, 2,590 subjects received DTPa-IPV/Hib at 3, 4 and 5 months of age with a booster at 18 months. In Study B, 702 subjects received the same schedule but with DTPa-hepatitis B-IPV/Hib (DTPa-HBV-IPV/Hib, Infanrix hexa, GlaxoSmithKline Biologicals) vaccine administered at 5 months of age. Reactogenicity was assessed for four days after each dose using diary cards. Serious adverse events (SAEs) were assessed until 24 months of age. The vaccines were well tolerated. After primary vaccination, irritability was the most frequently reported grade 3 general symptom (0.8% of doses in both studies). Fever (axillary) > 39 degrees C was infrequent (0.3% of doses in Study A; 0.5% of doses in Study B). After the booster dose, the most frequently reported grade 3 symptom was redness (5%) in Study A and pain (0.5%) in Study B. An axillary temperature > 39 degrees C was reported in 1.1% of subjects. Throughout the study period, 646 SAEs were reported, of which 6 SAEs were considered to be vaccination-related. The reactogenicity and safety profile of the combined DTPa-IPV/Hib vaccine was good when used for primary and booster vaccinations in over 3,000 Singaporean infants. Substitution of DTPa-IPV/Hib with DTPa-HBV-IPV/Hib at Month 5 reduced the number of injections required at this age by one.

Recommendations for the adjuvant use of the poly-antibiotic-resistant probiotic Bacillus clausii (O/C, SIN, N/R, T) in acute, chronic, and antibiotic-associated diarrhea in children: consensus from Asian experts.

This paper proposes recommendations for probiotics in pediatric gastrointestinal diseases in the Asia-Pacific region. Evidence-based recommendations and randomized controlled trials in the region are included. Cultural aspects, health management issues and economic factors were also considered. Final recommendations were approved by utilizing a modified Delphi process and applying the Likert scale in an electronic voting process. Bacillus clausii was recommended as an adjunct treatment with oral rehydration solution for acute viral diarrhea. B. clausii may also be considered for prevention of antibiotic-associated diarrhea, Clostridium difficile-induced diarrhea, and as adjunct treatment of Helicobacter pylori. There is insufficient evidence for recommendations in other conditions. Despite a diversity of epidemiological, socioeconomical and health system conditions, similar recommendations currently apply to most Asia-Pacific countries. Ideally, these need to be validated with local randomized-controlled trials.

Liver transplantation in the developing world.

PURPOSE OF REVIEW: The purpose of the present paper is to review the problems of paediatric liver transplantation encountered by the developing world and to review the progress made. RECENT FINDINGS: Setting up of a transplant programme in the developing world is associated with multiple issues, including manpower training and lack of resources. Ethical issues, donor problems and lack of awareness about the benefit of liver transplantations among the medical profession and public are major problems. In countries where the programmes have been successfully established, the outcome and long-term survival rates are comparable to those of the developed world. The complication rates are similar to those in developed countries. De-novo hepatitis B is a risk factor among the recipients and maintaining a high anti-hepatitis B among the recipients prior to transplantation appears to be the solution. SUMMARY: Various problems encountered in the developing countries are reviewed. The long-term actuarial survival rates in those countries are encouraging.

Characteristics and outcome of primary sclerosing cholangitis associated with inflammatory bowel disease in Asian children.

BACKGROUND: Current knowledge on the clinical features and natural history of childhood primary sclerosing cholangitis - inflammatory bowel disease in Asia is limited. We described the presenting features and natural history of primary sclerosing cholangitis-inflammatory bowel disease seen in a cohort of Southeast Asian children. METHODS: We conducted a retrospective review of childhood primary sclerosing cholangitis-inflammatory bowel disease from three tertiary centers in Singapore and Malaysia. RESULTS: Of 24 patients (boys, 58%; median age at diagnosis: 6.3 years) with primary sclerosing cholangitis-inflammatory bowel disease (ulcerative colitis, n = 21; Crohn's disease, n = 1; undifferentiated, n = 2), 63% (n = 15) were diagnosed during follow-up for colitis, and 21% (n = 5) presented with acute or chronic hepatitis, 17% (n = 4) presented simultaneously. Disease phenotype of liver involvement showed 79% had sclerosing cholangitis-autoimmune hepatitis overlap, 54% large duct disease, and 46% small duct disease. All patients received immunosuppression therapy. At final review after a median [±S.D.] duration follow-up of 4.7 [±3.8] years, 12.5% patients had normal liver enzymes, 75% persistent disease, and 12.5% liver failure. The proportion of patients with liver cirrhosis increased from 13% at diagnosis to 29%; 21% had portal hypertension, and 17% had liver dysfunction. One patient required liver transplant. Transplant-free survival was 95%. For colitis, 95% had pancolitis, 27% rectal sparing, and 11% backwash ileitis at initial presentation. At final review, 67% patients had quiescent bowel disease with immunosuppression. One patient who had UC with pancolitis which was diagnosed at 3 years old developed colorectal cancer at 22 years of age. All patients survived. CONCLUSIONS: Liver disease in primary sclerosing cholangitis-inflammatory bowel disease in Asian children has variable severity. With immunosuppression, two-thirds of patients have quiescent bowel disease but the majority have persistent cholangitis and progressive liver disease.

Rapid detection of enterovirus 71 by real-time TaqMan RT-PCR.

BACKGROUND: Enterovirus 71 (EV71) is the main etiological agent of Hand, Foot and Mouth Disease (HFMD) and has been associated with neurological complications which resulted in fatalities during recent outbreaks in Asia Pacific region. OBJECTIVE: Develop a real-time TaqMan RT-PCR for rapid detection of EV71. STUDY DESIGN: Specific primers and probe were designed based on highly conserved VP1 region of EV71. The sensitivity of the real-time RT-PCR was evaluated with 67 clinical specimens collected from pediatric patients with suspected HFMD. RESULTS: Our real-time TaqMan RT-PCR showed 100% specificity in detecting EV71 and showed an analytical sensitivity of 5 viral copies. High sensitivity was also achieved in detecting EV71 directly from clinical specimens. CONCLUSIONS: Real-time TaqMan RT-PCR offers a rapid and sensitive method to detect EV71 from clinical specimens, and will allow quarantine measures to be taken more effectively during outbreaks.

Development of multiplex real-time hybridization probe reverse transcriptase polymerase chain reaction for specific detection and differentiation of Enterovirus 71 and Coxsackievirus A16.

Large outbreaks of hand, foot, and mouth disease have been reported in the Asia Pacific region over the last few years and resulted in significant fatalities. The 2 main etiologic agents are Enterovirus 71 (EV71) and Coxsackievirus A16 (CA16). Both viruses are closely related genetically and show similar clinical symptoms. However, EV71 are associated with neurologic complications and can lead to fatalities. In this study, we developed a multiplex real-time hybridization probe reverse transcriptase polymerase chain reaction to detect and differentiate EV71 from CA16 using the LightCycler (Roche Molecular Biochemicals). Specific primers and hybridization probes were designed based on highly conserved VP1 region of EV71 or CA16. Our results showed high specificity and sensitivities in detecting EV71 or CA16 from 67 clinical specimens, and no other enterovirus serotype was detected. Rapid diagnosis to differentiate EV71 from CA16 in outbreak situations will enable pediatricians to identify and manage the patients more effectively.

Immunogenicity, reactogenicity and safety of a diphtheria-tetanus-acellular pertussis-inactivated polio and Haemophilus influenzae type b vaccine in a placebo-controlled rotavirus vaccine study.

INTRODUCTION: In recent years, acellular pertussis combination vaccines have facilitated compliance with and coverage of the national immunisation programme in Singapore. This phase-II study (Rota-007) evaluated the immunogenicity, reactogenicity and safety of a DTPa-IPV/Hib combined vaccine when co-administered with a rotavirus vaccine. MATERIALS AND METHODS: A total of 2464 children aged 3 months were vaccinated with DTPa-IPV/Hib together with a randomised 1:3 ratio of either placebo (n=653) or 1 of 3 different formulations of a rotavirus vaccine. Blood samples were collected for immunogenicity analysis 1 month after the third DTPa-IPV/Hib vaccine dose in a subset of subjects (n = 640). Local and general reactogenicity and unsolicited adverse events were recorded during the follow-up after each vaccination. RESULTS: Serological analysis showed >95% response for all antigens in the co-administered DTPa-IPV/Hib vaccine, with no difference between the rotavirus vaccine and placebo groups. No differences in adverse events and reactogenicity were reported in the rotavirus vaccine and placebo groups. Only 0.2% of the subjects reported Grade 3 adverse events. Three subjects (from the vaccine groups) died during the study, which were assessed by the investigators as unrelated to vaccination. No deaths were reported in the placebo group. CONCLUSION: The combined DTPa- IPV/Hib vaccine is safe, well tolerated and highly immunogenic when given alone or coadministered with the rotavirus vaccine for infants in Singapore.

Complementary and alternative medicine (CAM) practices and dietary patterns in children with inflammatory bowel disease in Singapore and Malaysia.

BACKGROUND: The use of complementary and alternative medicine (CAM) has been associated with adverse effects and self-imposed dietary restrictions. The prevalence of its use in Asian children with inflammatory bowel disease (IBD) is unknown. We aimed to determine the prevalence, types, and factors associated with the use of CAM among children with IBD from Singapore and Malaysia, and to ascertain if dietary restriction was prevalent in patients who used CAM. METHODS: A cross-sectional study was conducted in which parents of children with IBD attending two tertiary pediatric IBD referral centres in Singapore and Malaysia were interviewed. Data about demographics, conventional treatment, complementary therapies and dietary patterns were collected in a questionnaire. RESULTS: Of 64 children with IBD interviewed, 83% (n = 53) reported the use of CAM (Singapore [90%] vs. Malaysia [76%]; p = 0.152). The median number of CAM agents used was two (range 1-10). The three most common types of CAM used were probiotics (64%), vitamin and mineral supplements (55%), and food-based therapies (36%). Among individual CAM categories, the use of food-based therapies was correlated significantly with nationality (r = 0.497, p < 0.001), history of weight loss due to IBD (r = 0.340, p = 0.013) and avoidance of certain foods to prevent a relapse (r = 0.289, p = 0.036). Parents who rated their child's disease activity as more severe were less likely to use CAM (r = -0.257, p = 0.041). Fifty-nine percent of CAM users reported physician awareness of their CAM use. The overall self-perceived efficacy of CAM in improving IBD symptoms was 34%. Of the dietary patterns explored, only intake of dairy products was associated with CAM use (r = 0.306, p = 0.019). CONCLUSION: Use of CAM is prevalent in children with IBD in Malaysia and Singapore. Further studies to elucidate reasons influencing CAM use, dietary patterns and efficacy of commonly used CAM would be required.