Traditional Bhutanese medicine (gSo-BA Rig-PA): an integrated part of the formal health care services

Traditional medicine in Bhutan is known as gSo-ba Rig-pa and is one of the oldest surviving medical traditions in the world. Other medical systems, such as Chinese medicine, Indian Ayurvedic medicine, Unani medicine, Greco-Roman medicine and the country's rich cultures and traditions have greatly influenced the way traditional Bhutanese medicine evolved. However, Buddhist philosophy remains the mainstream of this medical system. gSo-ba Rig-pa's principles are based on the perception the human body is composed of three main elements: rLung ('Air'), mKhris-pa ('Bile') and Bad-kan ('Phlegm'). When these three elements are balanced in the body a person is said to be healthy. The pathophysiology is also different from other medical systems, and the close link to Buddhism is reflected in the spiritual dimensions and the perception that all suffering is caused by ignorance. The treatment of diseases includes behavioral modification, physiotherapy, herbal medicines, minor surgery and spiritual healing. This makes the traditional Bhutanese medicine a unique and holistic health care system. The traditional medicine is an integrated and recognized part of the formal health care services in Bhutan under the auspices of the Ministry of Health. The article highlights three main points which can be learned from the Bhutanese experience: (1) the strong tradition of herbal medicines within gSo-ba Rig-pa forms a unique opportunity to prospect for new leads for development of pharmaceuticals, (2) the availability of the traditional medicine along with biomedicine broadens the health care choices for patients, and (3) the experiences of integrating two conceptually very different health care systems within one ministry contains important managerial lessons to be learned.     

Emergence of multidrug-resistant Salmonella enterica serovar Typhi associated with a class 1 integron carrying the dfrA7 gene cassette in Nepal

A total of 121 Salmonella enterica serovars Typhi and Paratyphi A isolated from enteric fever patients at a university hospital in Nepal between February 2004 and January 2006 were tested for their antimicrobial susceptibility. The occurrence and cassette content of integrons as well as the molecular mechanisms of resistance among the multidrug-resistant (MDR) S. Typhi were evaluated. Thirty-nine percent of the isolates were susceptible to all the antimicrobial agents tested. Seven of the S. Typhi strains were MDR. None of the 121 S. enterica isolates were resistant to ciprofloxacin, cefazolin, rifampicin or kanamycin. All MDR S. Typhi isolates contained a class 1 integron with a single cassette, dfrA7, conferring resistance to trimethoprim. Pulsed-field gel electrophoresis (PFGE) of XbaI-generated genomic restriction fragments yielded 12 different patterns. Five of the seven MDR isolates containing class 1 integrons had an identical PFGE pattern. Resistance to sulfamethoxazole, streptomycin, ampicillin, tetracycline and chloramphenicol was mediated by sul1, strA-strB, blaTEM-like, tetB and catA genes, respectively. To the best of our knowledge, this is the first report of integron-associated multidrug resistance as well as the first molecular characterisation of the mechanism of resistance of S. Typhi isolated from Nepal. This study indicates the spread of integron-associated multidrug resistance in S. Typhi in Nepal.     

Local dissemination of multidrug-resistant Acinetobacter baumannii clones in a Thai hospital

A total of 83 Acinetobacter baumannii isolates from patients attending a tertiary care university hospital in Thailand were investigated for their clonal relatedness, antimicrobial susceptibility profiles, and integron carriage. Susceptibility profiles showed that 56 (67%) of these isolates exhibited multiple drug resistance (MDR). Pulsed-field gel electrophoresis (PFGE) showed that 73% of these resistant isolates were clustered into three predominant PFGE types: 6, 7, and 36. This suggested that the high number of isolates exhibiting MDR phenotypes observed in the hospital is, to some extent, due to the spread of these three resistant clones. Class 1 integrase genes were detected in all MDR isolates belonging to PFGE type 6, most MDR isolates belonging to PFGE type 7 and none of the isolates belonging to PFGE type 36. Five different class 1 gene cassette arrays, dfrA1-orfC, bla(IMP-14)-aac6', aacA4- catB8-aadA1, aacC1-orfX-orfX'-aadA1a, and aacC1-orfX-orfX-orfX'-aadA1a, were identified, of which the bla(IMP-14)-aac6' array has only been found in Thai isolates. Two isolates identified in this study carried a class 2 integrase gene with a 2.2 kb cassette array containing aadA1-sat-dfrA1.     

Diversity and Origin of Dengue Virus Serotypes 1, 2, and 3, Bhutan

To determine the serotype and genotype of dengue virus (DENV) in Bhutan, we conducted phylogenetic analyses of complete envelope gene sequences. DENV-2 (Cosmopolitan genotype) predominated in 2004, and DENV-3 (genotype III) predominated in 2005–2006; these viruses were imported from India. Primary dengue infections outnumbered secondary infections, suggesting recent emergence.     

Spitz nevus of the tongue with pseudoepitheliomatous hyperplasia: report of three cases of a pseudomalignant condition

Three cases of Spitz nevus of the tongue associated with pseudoepitheliomatous hyperplasia are reported: two occurring in children and one in an adult. The location at an unusual site and the complex pattern resulting from the intimate admixture of the neoplastic melanocytic component and the hyperplastic keratinocytic component led in each case to consider diagnoses such as malignant melanoma and invasive squamous cell carcinoma. Staining for S-100 protein and keratin was useful to identify and separate the two components. Spitz nevus of the tongue carries some intriguing similarities with granular cell tumor, suggesting a possible histogenetic and pathogenetic relationship.     

Investigation and Control of Anthrax Outbreak at the Human–Animal Interface,Bhutan, 2010

In 2010, we investigated anthrax outbreak in Bhutan. A total of 43 domestic animals died, and cutaneous anthrax developed in 9 persons, and 1 died. All affected persons had contact with the carcasses of infected animals. Comprehensive preparedness and response guidelines are needed to increase public awareness of anthrax in Bhutan.