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Introduction Factors predictive for death from snake envenomation vary between studies, possibly due to variation in host genetic factors and venom composition. This study aimed to evaluate predictive factors for death from snake envenomation in Myanmar. Methods A prospective study was performed among adult patients with snakebite admitted to tertiary hospitals in Yangon, Myanmar, from May 2015 to August 2016. Data including clinical variables and laboratory parameters, management, and outcomes were evaluated. Multivariate regression analysis was performed to evaluate factors predictive for death at the time of presentation to the hospital. Results Of the 246 patients with snake envenomation recruited into the study, 225 (92%) survived and 21 (8%) died during hospitalization. The snake species responsible for a bite was identified in 74 (30%) of the patients; the majority of bites were from Russell's vipers (63 patients, 85%). The independent factors predictive for death included 1) duration from bite to arrival at the hospital >1 h (odds ratio [OR]: 9.0, 95% confidence interval [CI]: 1.1–75.2; P =0.04); 2) white blood cell counts >20 ×10 3 cells·μL -1 (OR: 8.9, 95% CI: 2.3–33.7; P =0.001); and 3) the presence of capillary leakage (OR: 3.7, 95% CI: 1.2–11.2; P =0.02). A delay in antivenom administration >4 h increases risk of death (11/21 deaths). Conclusions Patients who present with these independent predictive factors should be recognized and provided with early appropriate intervention to reduce the mortality rate among adults with snake envenomation in Myanmar.

The World Federation of Medical Education encourages the teaching of generic skills including communication skills, together with technical skill training in medical schools. Medical Universities in Myanmar started teaching communication skills as a formal content in the curriculum five years ago. But it was included in the assessment as an Objectively Structured Clinical Examination (OSCE) station, starting only from 2012. The underlying philosophy is that improving the communication between doctor and patient will improve the ability to gather the information needed to solve the problems of a particular patient and in presenting the formulated problem list and management plan. The aim of this study is to determine the pass rate of the Communication Skills (CS) station and association between communication skills score and Objectively Structured Long-case Assessment Record (OSLAR) score. It was a retrospective cross-sectional descriptive study analyzing the scores of the last three completion tests of 363 final-year medical students, in University of Medicine 2, in Yangon, Myanmar. In the communication skills station, 290 out of 363 (79.9%) passed. For OSLAR, the pass rate was 288 out of 363 (79.3%), and for OSCE it was 279 out of 363 (76.9%). There was a significant association between passing communication skills and OSLAR ( ? 2 = 10.2, p = .001). Especially, there was correlation between the history taking part of OSLAR scores and CS scores ( r = .257, p = 0.000). To test whether it was because of the phenomenon that good students will pass whatever station it is and poor students will fail, association between communication skills score and OSCE (the station where the students do not need to speak and are tested for manual skills only) was analyzed. There was no association between those two skill stations.

Background Lupus nephritis (LN) occurs in up to 60% of adults with systemic lupus erythematosus (SLE) and is a predictor of poor survival. Cyclophosphamide (CYC) is regarded as the most effective immunosuppressive medication to improve survival for patients with LN. Objective This prospective hospital-based study was conducted to identify the effect of glutathione S transferase Pi-1 (GSTP1) genotypes on the efficacy and safety of CYC aggressive therapy. Methods We enrolled SLE nephropathy patients admitted to the Department of Rheumatology of the 500-bed Yangon Specialty Hospital (YSH), Yangon, Myanmar, who received CYC aggressive therapy for 6 months according to treatment guidelines for SLE patients with renal involvement. The frequencies of I/I, I/V and V/V GSTP1 genotypes were determined using the polymerase chain reaction-restriction fragment length polymorphism method. The efficacy of CYC aggressive therapy between LN patients with wild GSTP1 (I/I) and those with polymorphic GSTP1 (I/V or V/V) genotypes was evaluated by comparing 24-h urinary protein levels and assessing the remission rates at 3 and 6 months after initiation of CYC. CYC-related myelotoxicity was assessed by reviewing complete blood picture results on the 10th day after CYC treatment. Results In total, 95 eligible patients were recruited. The frequencies of I/I, I/V and V/V GSTP1 genotypes were 54.7, 41.1 and 4.2%, respectively. At 3 and 6 months after CYC treatment, mean 24-h urinary protein had significantly decreased from baseline in both wild and polymorphic genotype groups (p < 0.001). No significant differences were seen between the wild and polymorphic genotype groups with regard to changes in 24-h urinary protein levels, remission at 3 and 6 months or myelotoxicity. Conclusion CYC aggressive therapy had similar efficacy and caused no significant differences in myelotoxicity in wild GSTP1 (I/I) and polymorphic GSTP1 (I/V or V/V) genotypes in patients treated according to YSH guidelines for SLE patients with renal involvement.

Despite the availability of proven measures to prevent the disease, rabies now kills more people in Myanmar than malaria. Although there are challenges in controlling rabies in such a large and culturally diverse country, Myanmar's successful National Malaria Control Program demonstrates what can be achieved with sufficient political, financial, and scientific commitment. Presently, however, Myanmar lacks a comparable program to coordinate the multifaceted approach that is necessary to control rabies. The national government has invested heavily in improving access to postexposure prophylaxis, but there should also be an emphasis on other, more cost-effective strategies, particularly mass canine vaccination, which has been an essential component of successful rabies elimination programs in other countries. Continued health system strengthening is also required to improve primary health care, while decentralization of laboratory diagnostic services is needed to facilitate more timely, rational, and cost-effective use of postexposure prophylaxis.

Background Snakebite-related acute kidney injury (AKI) is a common community-acquired AKI in tropical countries leading to death and disability. The aims of this study were to (1) determine the occurrence of snakebite-related AKI, (2) assess factors at presentation that are associated with snakebite-related AKI, and (3) determine the outcomes of patients with snakebite-related AKI. Methods We conducted a prospective observational study of patients with snake envenomation at the three academic tertiary care hospitals in Yangon, Myanmar between March 2015 and June 2016. Patient data including baseline characteristics, clinical and laboratory findings, hospital management, and outcomes were recorded in a case report form. A stepwise multivariate logistic regression analysis using a backward selection method determined independent factors significantly associated with AKI. Results AKI was observed in 140 patients (54.3%), the majority of whom were AKI stage III (110 patients, 78.6%). AKI occurred at presentation and developed during hospitalization in 88 (62.9%) and 52 patients (37.1%), respectively. Twenty-seven patients died (19.3%), and 69 patients (49.3%) required dialysis. On multivariate logistic regression analysis, (1) snakebites from the Viperidae family (odds ratio [OR]: 9.65, 95% confidence interval [CI]: 2.42–38.44; p = 0.001), (2) WBC >10 × 103 cells/μL (OR: 3.55, 95% CI: 1.35–9.34; p = 0.010), (3) overt disseminated intravascular coagulation (OR: 2.23, 95% CI: 1.02–4.89; p = 0.045), (4) serum creatine kinase >500 IU/L (OR: 4.06, 95% CI: 1.71–9.63; p = 0.001), (5) serum sodium

Definitions of abnormal urine findings and electrolyte abnormalities. Table S2. Definitions of clinical parameters of snake envenoming according to the WHO 2010 guidelines. Table S3. Baseline characteristics and pre-hospital management among 258 adults with snakebite envenomation, Yangon, Myanmar, 2015–2016. Table S4. Clinical presentation among 258 adults with snakebite envenomation, Yangon, Myanmar, 2015–2016. Table S5. Laboratory parameters at presentation among 258 adults with snakebite envenomation, Yangon, Myanmar, 2015–2016. Table S6. Management and outcomes among 258 adults with snakebite envenomation, Yangon, Myanmar, 2015–2016. Table S7. Clinical parameters among 164 adults bitten by Viperidae or presenting the clinical syndrome of Viperidae (86 patients with acute kidney injury at presentation and 78 patients without acute kidney injury). Table S8. Laboratory parameters among 164 adults bitten by Viperidae or presenting the clinical syndrome of Viperidae (86 patients with acute kidney injury at presentation and 78 patients without acute kidney injury). Table S9. Management and outcomes among 164 adults bitten by Viperidae or presenting the clinical syndrome of Viperidae (86 patients with acute kidney injury at presentation and 78 patients without acute kidney injury). Table S10. Clinical parameters among 128 adults bitten by Viperidae or presenting the clinical syndrome of Viperidae (50 patients who developed acute kidney injury during hospitalization and 78 patients without acute kidney injury). Table S11. Laboratory parameters among 128 adults bitten by Viperidae or presenting the clinical syndrome of Viperidae (50 patients who developed acute kidney injury during hospitalization and 78 patients without acute kidney injury). Table S12. Management and outcomes among 128 adults bitten by Viperidae or presenting the clinical syndrome of Viperidae (50 patients who developed acute kidney injury during hospitalization and 78 patients without acute kidney injury). The supplementary tables provide additional data to help interpret the results of the study. (DOCX 92 kb)

Background There has been an impressive recent reduction in the global incidence of malaria, but the development of artemisinin resistance in the Greater Mekong Region threatens this progress. Increasing artemisinin resistance is particularly important in Myanmar, as it is the country in the Greater Mekong Region with the greatest malaria burden. If malaria is to be eliminated in the region, it is essential to define the spatial and temporal epidemiology of the disease in Myanmar to inform control strategies optimally. Results Between the years 2005 and 2014 there was an 81.1 % decline in the reported annual incidence of malaria in Myanmar (1341.8 cases per 100,000 population to 253.3 cases per 100,000 population). In the same period, there was a 93.5 % decline in reported annual mortality from malaria (3.79 deaths per 100,000 population to 0.25 deaths per 100,000 population) and a 87.2 % decline in the proportion of hospitalizations due to malaria (7.8 to 1.0 %). Chin State had the highest reported malaria incidence and mortality at the end of the study period, although socio-economic and geographical factors appear a more likely explanation for this finding than artemisinin resistance. The reduced malaria burden coincided with significant upscaling of disease control measures by the national government with support from international partners. These programmes included the training and deployment of over 40,000 community health care workers, the coverage of over 60 % of the at-risk population with insecticide-treated bed nets and significant efforts to improve access to artemesinin-based combination treatment. Beyond these malaria-specific programmes, increased general investment in the health sector, changing population demographics and deforestation are also likely to have contributed to the decline in malaria incidence seen over this time. Conclusions There has been a dramatic fall in the burden of malaria in Myanmar since 2005. However, with the rise of artemisinin resistance, continued political, financial and scientific commitment is required if the ambitious goal of malaria elimination in the country is to be realized.