IMC Journal of Medical Science

IMC Journal of Medical Science https://imcjms.com Ibrahim Medical College Journal of Medical Science <![CDATA[Histomorphological patterns and diagnostic utility of crush and imprint smear cytology in mucormycosis: a prospective study]]> Ruquiya Afrose Zikki Hasan Fatima Mohd. Yasir Zubair* Mahboob Hasan Sayeedul Hasan Arif Mohammad Aftab Mehtab Ahmad https://imcjms.com/journal_full_text/589 2025-12-23 09:36:18 Original Article Abstract Introduction: Mucormycosis is a rare but deadly fungal infection that often affects those with weakened immune systems. With the rise in predisposing factors such as diabetes, use of steroids, rise in cases of cancer, among others, cases of mucormycosis are increasingly being observed. A surge of cases was noted due to the situation arising out of the COVID-19 pandemic. Materials and methods: This study analyzed various histo-morphological tissue reaction patterns associated with mucormycosis and explored the utility of crush smear and imprint smear cytology in confirming the presence of fungi. A total of 63 samples were taken. Meticulous history and clinical examination were done. History of COVID-19 infection, diabetes mellitus, hospitalization, intensive care stay, and steroid therapy was taken into account. Biopsy specimens (rhino-orbital, sino-nasal, rhino-cerebral and bone) received in normal saline were first subjected to cytopathological examination using both crush smears and imprint smears and further processed for histopathological examination. Results: The mean age of the patients was 48.76 ± 13.24 years. Male preponderance was seen with male to female ratio of 1.65:1. An overwhelming majority (92.6%) of patients had a history of COVID-19 infection. Pre-existing diabetes mellitus was found in 83.3% of patients, steroid intake in 72% of patients, and medical oxygen administration in 46.3% of patients. Out of 63 clinically suspected patients, 54 (85.7%) cases were diagnosed with mucormycosis on histopathology. The most common site involved was rhino-orbital (62.9%), followed by sino-nasal (25.9%) and rhino-cerebral (7.4%). Five histo-morphological patterns were identified namely infarct-like necrosis with or without angio-invasion (50%), exudative pattern (24%), mixed pattern (11%), granulomatous (9%) and predominantly histiocytic pattern (6%). With histopathology as gold standard, crush smear cytology yielded a sensitivity of 72.2% (95% confidence interval/CI: 58.4-83.5%), specificity of 77.8% (95% CI: 40.0-97.2%), positive predictive value (PPV) of 95.1% (95% CI: 83.5-99.4%) and negative predictive value (NPV) of 31.8% (95% CI: 13.9-54.9%), with overall diagnostic accuracy of 73.0%. Imprint smear cytology showed marginally better performance with sensitivity of 75.9% (95% CI: 62.4-86.5%), specificity of 77.8% (95% CI: 40.0-97.2%), PPV of 95.3% (95% CI: 84.2-99.4%) and NPV of 31.8% (95% CI: 13.9-54.9%), with overall diagnostic accuracy of 76.2%. Conclusion: Various histo-morphological patterns encountered on histopathological examination help us keep the suspicion index high and warrant extensive examination for fungi. Histopathology remains the gold standard, providing prompt and definitive diagnosis, essential for establishing surgical and antifungal therapy, prognostication and evaluation of treatment response. Both crush smear and imprint cytology demonstrate high sensitivities (72-76%) and excellent PPVs (>95%), making them valuable rapid diagnostic tools for confirming mucormycosis when positive results are obtained. However, their low NPVs (31.8%) indicate that negative cytology results cannot reliably exclude mucormycosis, and histopathological examination remains mandatory in clinically suspected cases with negative cytological findings. January 2026; Vol. 20(1):001, DOI: https://doi.org/10.55010/imcjms.20.001 *Correspondence: Mohd. Yasir Zubair, Department of Community Medicine, VALASMC, Etah, UP, India. Email: yasmuhsin@gmail.com. © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License(CC BY 4.0). *Abbreviations: COVID- Coronavirus Disease, SARS CoV 2- Severe Acute Respiratory Syndrome Corona-Virus 2, AIDS- Acquired Immuno-Deficiency Syndrome, DM- Diabetes Mellitus, CECT- Contrast Enhanced Computerized Tomography, PAS- Periodic Acid Schiff, H & E- Hematoxylin and Eosin, ACE- Angiotensin-Converting Enzyme   Introduction Since its outbreak in Wuhan, China, in December 2019, Coronavirus Disease (COVID-19) caused by Severe Acute Respiratory Syndrome Corona-Virus 2 (SARS CoV-2) has spread rapidly across the world and led to a major pandemic. The evolution of the virus into different strains over the following few years led to subsequent waves and local outbreaks. India experienced a deadly second wave beginning in March 2021.Adding more burden to such a challenging situation, mucormycosis, an invasive fungal disease, exhibited a significant surge in patients with COVID-19 [1]. Mucormycosis is an opportunistic infection caused by the ubiquitous bread mould fungi belonging to the mucormycetes family. A severe disease spurred on by Rhizopus was initially named phycomycosis or zygomycosisin 1885 by Paltauf [2]. The same entity was later termed as mucormycosis in 1957 by American pathologist Baker [3]. Mucormycosis is a rare but deadly fungal infection that often affects those with weakened immune system. It is the third most common cause of invasive fungal infection, following aspergillosis and candidiasis and causes life-threatening rhino-cerebral disease [4]. Mucor and Rhizopus are the most common causative agents, followed by Lichtheimia, Apophysomyces, Rhizomucor, and Cunninghamella[5,6]. Mucormycosis is generally seen in the immunocompromised population. Individuals with diabetes mellitus, AIDS, organ transplant, and malignancy are especially predisposed to the infection [7]. The common causes attributed to the rise of mucormycosis in patients with COVID-19 are uncontrolled diabetes, hematologic malignancies, solid organ transplant recipients, stem cell transplantation, prolonged neutropenia, excessive use of corticosteroids for immunosuppression, and long-term stays in the intensive care unit [8,9]. Most cases of mucormycosis in patients with history of COVID-19 were detected around a month after the diagnosis of severe or moderate COVID-19 that required oxygen assistance in conjunction with steroid therapy [10]. Glucocorticoids have been used extensively to treat a range of diseases, including COVID-19, influenza, and middle-east respiratory syndrome. Moreover, SARS CoV-2 increases the secretion of hyperglycemic hormones such as glucocorticoids, which abnormally raises blood glucose levels [11]One of the main reasons for the increased production of glycosylation end products, oxidative stress, pro-inflammatory cytokines, etc., is hyperglycemia. Diabetic patients experience tissue inflammation, thus elevating the risk of infection [12]. Nevertheless, prompt diagnosis of mucormycosis is necessary for initiating early life-saving medical and surgical intervention. Based on clinical suspicion, clinicians usually advise contrast-enhanced computerized tomography (CECT), fungal culture and biopsy for fungal infections [13,14]. Since mucormycetes are ubiquitous in nature, culture, which generally takes more than a week, often gives ambiguous results. Hence, a crush and imprint smear by cytology and histopathological examination is helpful in quick and conclusive diagnosis. Due to a lack of population-level data on the Indian population, the prevalence of mucormycosis may be 70 times higher than global estimations [15]. In the present study, we aimed to study crush and imprint smear cytology as a rapid screening tool along with various histo-morphological tissue reaction patterns associated with mucormycosis and analyze their utility in confirming the presence of fungi.   Materials and methods The study was conducted in the department of pathology, Jawaharlal Nehru Medical College, Aligarh, from May 2021 to November 2021, when a rapid surge of mucormycosis cases started to occur in India. The hospital admitted patients with suspected mucormycosis of all ages and either sex, whose samples were sent to the department of pathology for histological examination. Samples having scant material were excluded. During the study period, a total of 63 samples were found adequate for inclusion. Detailed history and clinical examination were done. History of COVID-19 infection, diabetes mellitus, hospitalization, intensive care stay and steroid therapy were taken into account. Biopsy specimens received in normal saline were first subjected to cytopathological examination using crush and imprint smear, and then they were further processed for histopathological examination. For cytological examination, a small tissue with a grossly necrotic and black area was taken from the biopsy. For each biopsy, three to fourcrush smears and one imprint smear were prepared using tissue from necrotic areas. Smears were processed and examined using H and E stain, PAS stain, and papanicolaou stains [16]. Each smear was evaluated for hyphae, spores, necrosis, giant cells, granuloma, and inflammatory infiltration. The slides were prepared for examination in around two hours. All the smears were meticulously searched for fungal hyphae, spores and conidia or fruiting bodies. The presence of necrosis, giant cells, granuloma and inflammatory infiltrate were also noted. The same biopsy tissue was then fixed in 10% formalin for about 18 hours and subjected to routine histological processing. A gross examination was performed, noting the presence of necrosis, black crusting, thrombotic vessels, and bony erosion in maxillectomy or mandibulectomy specimens. This was followed by the preparation of paraffin-embedded sections. The tissue samples were stained with routine H and E and PASstains. Histopathological examination included an assessment of fungal morphology (aseptate or pauci-septate, broad [3–25 μm], ribbon-like, hyaline hyphae with irregular or right-angle branching), fungal load (classified as mild, moderate, or severe), and histomorphological patterns such as tissue necrosis, composition of the inflammatory infiltrate, and tissue invasion. Angioinvasion was identified by the presence of fungal hyphae infiltrating the endothelium or lying within the vascular lumen. Co-infection with other fungi, such as Aspergillus or Candida, was also evaluated. For diagnostic confirmation, fungal culture was performed on a subset of cases using protocols described by Skiada et al. [13], while PCR identification could not be carried out due to resource limitations. On histopathology, the fungi were identified by broad-based, pauci-septate hyphae with right to obtuse angle branching, which was PAS positive. Tissue necrosis, the composition of inflammatory infiltrate, and tissue invasion were taken into account to study the histo-morphological patterns. Based on these, five main patterns were recognized: infarct-like necrosis pattern, exudative pattern, mixed pattern (necrotic and exudative), granulomatous pattern and predominantly histiocytic pattern. All participants (or primary caretakers when needed) received a full explanation of the study, including its voluntary nature, confidentiality, and data use. They could ask questions and withdraw at any time. Written informed consent was obtained, and all institutional ethical guidelines for human research were followed. The data was entered in MS Excel (2010) and was imported to IBMSPSS version 20.0 for analysis.   Results The mean age of the patients was 48.76 ± 13.24 years, with ages ranging from 21-78 years. Male preponderance was seen in our study with male to female ratio of 1.65:1. Out of 63 suspected patients, 54 (85.7%) cases were diagnosed with mucormycosis on histopathology. Of these 54, an overwhelming majority (92.6%, n=50) of patients had a history of COVID-19 infection. A history of pre-existing diabetes mellitus was found in 83.3% (n=45) patients. It was found that 72% (n=39) of the patient had a history of steroid intake, and a history of medical oxygen administration was found in 46.3% (n=25) of patients. No other predisposing condition was found in our patients. The analysis of clinical presentation revealed that necrosis and black crusting of turbinates was seen in 59.2% (n=32) cases, facial swelling and ophthalmoplegia were seen in 44.4% (n=24) and 53.7% (n=29) cases, respectively and only 3.7% (n=2) of them presented with gingivitis and loosening of teeth. Symptoms associated with cerebral involvement, such as headache, hemiplegia and altered sensorium, were found in 5.5% (n=3) cases (Figure-1).     Figure-1: Clinical presentation of patients     Figure-2: Sites involving mucormycosis infection  The most common site involved was rhino-orbital (62.9%, n=34), followed by sino-nasal (25.9%, n=14) and rhino-cerebral (7.4%, n=4). Unusual involvement of maxillary bone was found in 2 cases (Figure-2).The most common histopathological pattern encountered was infarct-like necrosis in 40.7% (n=22) cases with or without angio-invasion, followed by an exudative pattern found in 24% (n=13) of cases. Subsequently, mixed pattern (11%, n=6), granulomatous (9%, n=5) and predominantly histiocytic pattern (6%, n=3) were found (Figures-3a-3f). Notably, Splendore- Hoeppli phenomenon was a frequent finding in the exudative pattern (Figure-3g). The fungal load was highest in the necrotic tissue.     Figure-3: (a) Infarct-like necrosis: Fragmented broad based aseptate fungal hyphae in necrotic background. (b) Infarction with angioinvasion (see arrow). (c) Exudative pattern with the neutrophilic response with abscess (see arrow). (d) Mixed pattern showing both infarct type as well as exudative pattern. Fungal hyphae were found in an exudative pattern (inset). (e) Granulomatous response. (f) Histiocytic pattern. (g) Splendore–Hoeppli phenomenon.   Two cases with bony involvement were subjected to extensive examination. Of these, one case which initially showed only extensive infarct-like necrosis and mixed necrotic and inflammatory patterns later demonstrated fungal hyphae in the follow-up bony resection specimens. A thorough search of fungal filament in the other case led to the identification of fragmented fungal hyphae in a blood vessel. PAS stain played a pivotal role in identifying fungal elements in these cases. Also, there were three cases which showed co-infection with other fungi. Co-infection with Candida was identified in two cases, and one case showed Aspergillus like hyphaealong with mucormycosis. Candida was identified by the presence of pseudo-hyphae. Interestingly, a single case with squamous cell carcinoma having both Mucor and Candida infection was found. Among the remaining nine cases that were negative for mucormycosis, the histomorphological findings in two cases were consistent with an inflammatory nasal polyp, while the other seven cases showed mildly hypertrophic mucosal epithelium with a mild chronic inflammatory infiltrate in the stroma. For crushed smear cytopathology (Table-1), of the 54 histopathologically confirmed positive cases, 39 were correctly identified as positive, while 15 yielded false negative results. Among the 9 histopathologically negative cases, 7 were correctly identified as negative and 2 showed false positive results. Thus, crushed smear demonstrated a sensitivity of 72.2% (95% CI: 58.4-83.5%), specificity of 77.8% (95% CI: 40.0-97.2%), PPVof 95.1% (95% CI: 83.5-99.4%), and NPV of 31.8% (95% CI: 13.9-54.9%). The overall diagnostic accuracy was 73.0% (95% CI: 60.3-83.4%).   Table-1: Performance of cytopathology (crushed smear) against histopathology as gold standard     Imprint smear cytopathology (Table-2) showed marginally better performance. Of the 54 histopathologically positive cases, 41 were correctly identified as positive with 13 false negatives, while 7 of 9 negative cases were correctly identified with 2 false positives. Thus, imprint smear yielded a sensitivity of 75.9% (95% CI: 62.4-86.5%), specificity of 77.8% (95% CI: 40.0-97.2%), PPV of 95.3% (95% CI: 84.2-99.4%), and NPV of 31.8% (95% CI: 13.9-54.9%). The overall diagnostic accuracy was 76.2% (95% CI: 63.8-86.0%).   Table-2: Performance of cytopathology (imprint smear) against histopathology as gold standard     Table-3 demonstrates the site-specific diagnostic performance of crush smear and imprint cytology against histopathology as the gold standard among the 54 histopathologically confirmed mucormycosis cases. Both cytological methods showed variable detection rates across different anatomical sites. Rhino-orbital samples constituted the majority of cases (n=34, 63.0%), with crush smear cytology detecting mucormycosis in 82.4% (28/34) of cases and imprint cytology showing slightly better performance at 85.3% (29/34). For sino-nasal specimens (n=14, 25.9%), the detection rates were lower, with crush smears positive in 64.3% (9/14) and imprint smears in 71.4% (10/14) of cases. Rhino-cerebral involvement (n=4, 7.4%) showed identical detection rates for both methods at 75.0% (3/4). The two cases with bone involvement (3.7%) demonstrated the lowest detection rates, with both crush and imprint cytology identifying mucormycosis in only 50% (1/2) of cases. Overall, across all anatomical sites, imprint cytology demonstrated a higher cumulative detection rate of 79.6% (43/54) compared to 75.9% (41/54) for crush smear cytology when evaluated against histopathology-confirmed cases.   Table-3: Crushed and Imprint smear against gold standard histology across anatomical sites     Discussion Mucormycosis is predominantly seen in immune-compromised individuals. It is a fulminant disease with high rates of morbidity and mortality. In the background of the COVID-19 pandemic, an increasing number of cases of mucormycosis started to occur [17]. Primary factors attributed to the increased incidence of COVID-19-associated mucormycosis are hypoxia associated with involvement of the lungs by SARS COV-2 virus, endocrine disturbances leading to hyperglycemia and acidosis, and altered host immunity caused by leucopenia, phagocytic dysfunction and irrational use of the steroid [9,18]. The post-COVID-19 fungal infections were almost misdiagnosed based on the data from the retrospective analysis of SARS and influenza from different countries, particularly China [19]. In this context its crucial to be vigilant for fungal infection probability particularly where any of predisposing factors are present. Diabetes mellitus, which was the single most important predisposing factor in our study, was found in 83.3% of cases, followed by steroid intake in 72% of cases. A previous study by Prakash et al. in 2019 showed 57% of patients with uncontrolled diabetes had mucormycosis in the pre-COVID era [15]. A recent study conducted by John et al. in 2021 on confirmed cases of mucormycosis in people with COVID-19 confirmed that DM was seen in 93% of cases while 88% had received steroid therapy [20]. In 2021, Al-Tawfiq et al. discovered that mucormycosis occurred in 19 patients with uncontrolled diabetes mellitus and also had corticosteroid administration [21]. These findings are consistent with our study, which also showed a high association of mucormycosis in patients with COVID-19 who had DM and had received steroid therapy. India is considered the diabetes capital of the world, with an alarming increase in diabetic patients. With this alarming increase in diabetes, cases of mucormycosis may also be speculated to increase thus underscoring the importance of being vigilant regarding this severe complication. With regards to clinical presentation, in this study, necrosis and black crusting of turbinates was seen in 59% of cases, facial swelling and ophthalmoplegia were seen in 44% and 53% of cases respectively, 3% of them presented with gingivitis and loosening of teeth and symptoms associated with cerebral involvement such as headache, hemiplegia and altered sensorium, were found in 5.5% of cases. This is similar to Goel et al. who reported that mucosal necrosis was seen in 48% of cases and external ophthalmoplegia in 59%, while signs of brain involvement occurred in 18% of the cases which were characterized by hemiplegia, altered mental status, stupor and coma [22]. Mucormycosis can involve the sinuses (sino-nasal) and progressively involve the orbits (rhino-orbital) and central nervous system (rhino-orbito-cerbral). It can also involve the lung, gastrointestinal tract, skin and jaw bones. Even though, lung is the most common organ to be affected in disseminated disease [20], no case of pulmonary involvement was found. Rhino-orbital mucormycosis has been seen to be more common in patients with poorly controlled diabetes mellitus. In contrast, patients with haematological malignancies, neutropenia or organ transplant are more prone to get pulmonary mucormycosis [10]. It has been speculated that before pulmonary progression, the increased propensity of SARS CoV-2 for ACE-2 receptors in nasal mucosalead to breach in the integrity of the mucosa which may in turn lead to the colonization of fungi in the nasal mucosa and its rhino-orbital presentation. In the current study, the most common site involved was rhino-orbital (63%), followed by sino-nasal (25.9%) and rhino-cerebral (7%). Similar findings were depicted by Goel et al., who concluded that extent of involvement determined the prognosis significantly [22]. Singh et al., in their study of mucormycosis in patients with COVID-19 from India and abroad, found that the most specific organ involved with mucormycosis was the nose and sinus (88.9%), followed by rhino-orbital (56.7%) and rhino-orbital-cerebral (22.2%) type [14]. Microscopically, the most common histopathological pattern encountered was infarct-like necrosis in 40.7% (n=22) cases with or without angio-invasion, followed by an exudative pattern found in 24% (n=13) of cases. Subsequently, mixed pattern (11%, n=6), granulomatous (9%, n=5) and predominantly histiocytic pattern (6%, n=3) were found. Ganesan et al. in their study on mucormycosis cases during the pandemic reported acute type of inflammation in 73.33% and granulomatous inflammation in 23.33% cases. Bony invasion and perineural invasion were observed in 8.33% and 91.67% cases, respectively [23]. The study done by Goel et al. in 33 cases found the granulomatous pattern to be the most common pattern. However, some amount of tissue necrosis was seen in all the cases, but no association of the extent of necrosis was found to the outcome of patients [22]. Cytopathology offers the critical advantage of yielding results within a day, making it invaluable for rapid clinical decision-making in suspected mucormycosis cases. In our study, the overall diagnostic accuracy of imprint and crush smear cytology (76.2% vs 73.0%) suggests that imprint smears may better preserve fungal morphology, enhancing detection [13,22], though the clinical significance of this difference requires validation with larger sample sizes. The excellent positive predictive values (>95%) observed for both cytological methods have important clinical implications; when cytology is positive, clinicians can confidently initiate antifungal therapy and plan surgical debridement without delay, potentially improving patient outcomes in this rapidly progressive and life-threatening infection. This makes cytopathology an invaluable tool for rapid confirmation and therapeutic decision-making. However, the low negative predictive values (31.8% for both methods) warrant careful interpretation and represent a critical limitation of cytological diagnosis. This means that approximately two-thirds of cases showing negative cytology may harbor mucormycosis on definitive histopathological examination. The low NPV can be attributed to several factors; for example, the patchy and focal distribution of fungal elements within extensively necrotic tissue, sampling variability inherent to cytological preparations where only a small portion of tissue is examined, the inability of cytology to process all submitted tissue comprehensively, fragmentation or paucicellular nature of fungal hyphae in some areas, and the limited capability of cytology to detect angioinvasion or bone invasion features that are crucial for definitive diagnosis and staging. These limitations underscore that negative cytology cannot be used to exclude or rule out mucormycosis in clinically suspected cases, and histopathological examination with extensive tissue sampling remains mandatory. Findings of the current study differ from some published literature where cytology has been reported with higher sensitivity. This discrepancy likely reflects differences in sampling techniques, the extent of necrosis in submitted specimens, and the experience of cytopathologists in recognizing fragmented fungal elements. Nevertheless, our data align with the general consensus that cytology, while rapid and useful for confirmation, has inherent limitations for exclusion of fungal infections. Fungal culture, though considered a gold standard for species identification, is not diagnostic of mucormycosis because of the ubiquitous nature of the fungi. Moreover, it usually takes 3-5 days to grow under ideal conditions. Diagnosis of mucormycosis by culture is rather challenging compared to other fungal infections because under normal laboratory conditions failure of sporulation is high and initial processing of hyphal elements may damage the hyphae rendering it non-viable [24]. The presence of non-viable fungal elements in necrotic biopsy tissue can also lead to negative culture results. While fungal culture is usually required for the identification of a genus, it has no implication on initial treatment decisions, which must be based on rapid histopathological or cytological confirmation. A high index of suspicion for mucormycosis while encountering the typical histomorphological patterns in suspected cases where no evidence of fungal elements was found initially helped in prompt diagnosis and management. Based on detailed observation, a meticulous search for fungal elements in cases with characteristic tissue reaction patterns proved invaluable. After extensive and careful examination, one case showed fragmented broad aseptate fungal hyphae within a blood vessel, and another case showed fragmented fungal hyphae within giant cells. These findings became evident only after serial sectioning of the submitted tissue and application of PAS stain. In two additional cases, fungal elements were identified only in follow-up specimens of resected jawbone, highlighting the importance of repeat sampling when clinical suspicion remains high despite initial negative results. This experience underscores several critical points- familiarity with various histo-morphological patterns associated with mucormycosis is essential for maintaining diagnostic vigilance; fungal hyphae can be easily missed in routine H & E sections, particularly in areas of extensive necrosis, hence PAS stain plays an indispensable role in diagnosis; serial sectioning and examination of multiple tissue levels significantly improves fungal detection and when clinical suspicion is high, negative initial results should prompt repeat biopsies or more extensive surgical sampling rather than exclusion of the diagnosis. Early and accurate diagnosis is necessary to initiate appropriate management promptly. The extent of surgery, the dose and duration of amphotericin B administration, and modification of immunosuppressive therapy all depend upon the histological confirmation and features of mucormycosis [22]. Therefore, a systematic approach combining rapid cytological screening with comprehensive histopathological examination optimizes diagnostic accuracy and facilitates timely therapeutic intervention.   Conclusion The findings confirm a strong association between prior SARS CoV-2 infection, diabetes mellitus, and corticosteroid exposure as pivotal predisposing factors for mucormycosis development. The predominance of rhino-orbital involvement with characteristic clinical signs underscores the aggressive and invasive nature of this fungal disease. Histopathological examination, identifying distinctive pauci-septate, broad hyphae with angioinvasion, remains the diagnostic gold standard for confirmation. Importantly, the data demonstrate that both crush smear and imprint cytology offer rapid, reliable, and minimally invasive diagnostic alternatives with reasonably good sensitivities (72.2% and 75.9% respectively) and excellent positive predictive values (>95%). These high positive predictive values indicate that when cytology is positive, clinicians can confidently proceed with antifungal treatment and surgical intervention without delay, enabling earlier therapeutic decision-making in suspected cases. However, both cytological methods demonstrated identical low negative predictive values meaning that approximately two-thirds of cases with negative cytology may actually harbor mucormycosis on histopathological examination. This critically important finding indicates that negative cytology results cannot be used to exclude or rule out mucormycosis in clinically suspected cases. The low NPV likely reflects the patchy distribution of fungal elements in necrotic tissue, sampling variability inherent to cytological preparations, and the limited tissue volume examined in cytological smears compared to comprehensive histopathological sectioning. The identification of diverse histo-morphological patterns in this study where infarct-like necrosis was the most common (50%), followed by exudative (24%), mixed (11%), granulomatous (9%), and histiocytic patterns (6%) further enriches the understanding of host-pathogen interactions and highlights the importance of recognizing these patterns to maintain high clinical suspicion. These patterns may also inform prognosis and treatment response evaluation. The findings advocate a complementary diagnostic approach: cytological methods (crush smear or imprint smear) serve as valuable frontline rapid tools that, when positive, can expedite treatment initiation within hours. However, when cytology is negative in clinically suspected cases, confirmatory histopathological examination with extensive tissue sampling and serial sectioning remains absolutely essential. The application of PAS stain plays a crucial role in identifying fungal elements, particularly in cases with extensive necrosis where fungi may be fragmented or scarce. In summary, crush smear and imprint cytology are excellent for rapid confirmation of mucormycosis (ruling in disease when positive) but inadequate for exclusion (ruling out disease when negative). Integrating rapid cytological screening with mandatory confirmatory histopathology in negative cases optimizes diagnostic accuracy and helps mitigate the significant morbidity and mortality associated with this aggressive fungal infection. Future research should focus on expanding molecular diagnostic capabilities, evaluating the cost-effectiveness of various diagnostic strategies, and assessing long-term outcomes in mucormycosis patients to refine clinical management protocols further.   Conflict of interest Authors have no conflict of interest to declare.   Ethical statement This study was approved by the Institutional Ethics Committee, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, (Reg. No. ECR/1418/Inst/UP/2020) bearing the file no. IECJNMC/691 dated 27/04/2021.   References 1.     Aranjani JM, Manuel A, Abdul Razack HI, Mathew ST. COVID-19-associated mucormycosis: evidence-based critical review of an emerging infection burden during the pandemic's second wave in India. PLoS Negl Trop Dis. 2021; 15(11): e0009921. doi:10.1371/journal.pntd.0009921. 2.     Singh K, Kumar S, Shastri S, Sudershan A, Mansotra V. Black fungus immunosuppressive epidemic with Covid-19 associated mucormycosis (zygomycosis): a clinical and diagnostic perspective from India. Immunogenetics. 2022; 74(2): 197-206. doi:10.1007/s00251-021-01226-5. 3.     Baker RD. Mucormycosis; a new disease?.J Am Med Assoc. 1957; 163(10): 805-808. doi:10.1001/jama.1957.02970450007003. 4.     Dignani MC. Epidemiology of invasive fungal diseases on the basis of autopsy reports. F1000Prime Rep. 2014; 6:81. doi:10.12703/P6-81. 5.     Park HR, Voigt K. Interaction of Zygomycetes with innate immune cells reconsidered with respect to ecology, morphology, evolution and infection biology: a mini-review. Mycoses. 2014; 57 Suppl 3: 31-39. doi:10.1111/myc.12235. 6.     Farmakiotis D, Kontoyiannis DP. Mucormycoses. Infect Dis Clin North Am. 2016; 30(1): 143-163. doi:10.1016/j.idc.2015.10.011. 7.     Baldin C, Ibrahim AS. Molecular mechanisms of mucormycosis-the bitter and the sweet. PLoS Pathog. 2017; 13(8): e1006408. doi:10.1371/journal.ppat.1006408. 8.     Raut A, Huy NT. Rising incidence of mucormycosis in patients with COVID-19: another challenge for India amidst the second wave?. Lancet Respir Med. 2021; 9(8): e77. doi:10.1016/S2213-2600(21)00265-4. 9.     Khatri A, Chang KM, Berlinrut I, Wallach F. Mucormycosis after Coronavirus disease 2019 infection in a heart transplant recipient - case report and review of literature. J Mycol Med. 2021; 31(2): 101125. doi:10.1016/j.mycmed.2021.101125. 10.  Jeong W, Keighley C, Wolfe R, Lee WL, Slavin MA, Chen SCA, et al. Contemporary management and clinical outcomes of mucormycosis: a systematic review and meta-analysis of case reports. Int J Antimicrob Agents. 2019; 53(5): 589-597. doi:10.1016/j.ijantimicag.2019.01.002. 11.  Wang A, Zhao W, Xu Z, Gu J. Timely blood glucose management for the outbreak of 2019 novel coronavirus disease (COVID-19) is urgently needed. Diabetes Res Clin Pract. 2020; 162: 108118. doi:10.1016/j.diabres.2020.108118. 12.  Knapp S. Diabetes and infection: is there a link?--A mini-review. Gerontology. 2013; 59(2): 99-104. doi:10.1159/000345107. 13.  Skiada A, Pavleas I, Drogari-Apiranthitou M. Epidemiology and diagnosis of mucormycosis: an update. J Fungi (Basel). 2020; 6(4): 265. doi:10.3390/jof6040265. 14.  Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: a systematic review of cases reported worldwide and in India. Diabetes Metab Syndr. 2021; 15(4): 102146. doi:10.1016/j.dsx.2021.05.019. 15.  Prakash H, Chakrabarti A. Global epidemiology of mucormycosis. J Fungi (Basel). 2019; 5(1): 26. doi:10.3390/jof5010026. 16.  Suvarna SK, Layton C, Bancroft JD. Bancroft’s Theory and Practice of Histological Techniques. 8th ed. Elsevier; 2018. doi: 10.1016/C2015-0-00143-5. 17.  Parfrey NA. Improved diagnosis and prognosis of mucormycosis. a clinicopathologic study of 33 cases. Medicine (Baltimore). 1986; 65(2): 113-123. doi:10.1097/00005792-198603000-00004. 18.  Challa S. Mucormycosis: pathogenesis and pathology. Curr Fungal Infect Rep. 2019; 13(8): 11–20. doi:10.1007/s12281-019-0337-1. 19.  Song G, Liang G, Liu W. Fungal co-infections associated with global COVID-19 pandemic: a clinical and diagnostic perspective from China. Mycopathologia. 2020; 185(4): 599-606. doi:10.1007/s11046-020-00462-9. 20.  John TM, Jacob CN, Kontoyiannis DP. When uncontrolled diabetes mellitus and severe COVID-19 converge: the perfect storm for mucormycosis. J Fungi (Basel). 2021; 7(4): 298. doi:10.3390/jof7040298. 21.  Al-Tawfiq JA, Alhumaid S, Alshukairi AN, Temsah MH, Barry M, Al Mutair A, et al. COVID-19 and mucormycosis superinfection: the perfect storm. Infection. 2021; 49(5): 833-853. doi:10.1007/s15010-021-01670-1. 22.  Goel A, Kini U, Shetty S. Role of histopathology as an aid to prognosis in rhino-orbito-cerebral zygomycosis.Indian J Pathol Microbiol. 2010; 53(2): 253-257. doi:10.4103/0377-4929.64342. 23.  Ganesan N, Sivanandam S. Histomorphological features of mucormycosis with rise and fall of COVID-19 pandemic. Pathol Res Pract. 2022; 236: 153981. doi:10.1016/j.prp.2022.153981. 24.  Spellberg B, Edwards J Jr, Ibrahim A. Novel perspectives on mucormycosis: pathophysiology, presentation, and management. Clin Microbiol Rev. 2005; 18(3): 556-569. doi:10.1128/CMR.18.3.556-569.2005.   Cite this article as: Afrose R, Fatima ZH, Zubair MY, Hasan M, Arif SH, Aftab M, et al.Histomorphological patterns and diagnostic utility of crush and imprint smear cytology in mucormycosis: a prospective study.IMC J Med Sci. 2026; 20(1):001. DOI:https://doi.org/10.55010/imcjms.20.001. <![CDATA[Comparison of four different multi-detector computed tomography based split renal function (SRF) evaluation methods and their correlation with nuclear scintigraphy derived SRF for functional assessment of potential living renal donors]]> Sarfraz Ahmad Raghunandan Prasad Hira Lal Sukanta Barai Aneesh Srivastava S Danish Iqbaal* https://imcjms.com/journal_full_text/595 2026-01-25 12:37:04 Original Article January 2026; Vol. 20(1):002 Abstract Background and Objectives: Preoperative anatomical and functional evaluation of donor kidneys is crucial for successful renal transplantation. While multi-detector computed tomography (MDCT) angiography is the standard imaging modality for anatomical assessment, nuclear scintigraphy using Technetium-99m Diethylenetriamine Pentaacetate (Tc-99m DTPA) remains the gold standard for evaluating split renal function (SRF). However, MDCT-based SRF estimation has recently emerged as a viable alternative. The aim of this study is to compare four different MDCT-based SRF measurement techniques and assess their correlation with SRF obtained from nuclear scintigraphy. Materials and Methods: This prospective study included 111 living kidney donors from 2019 to 2021 who underwent MDCT angiography. SRF was estimated using four CT-based methods: total renal volume, cortical renal volume, ellipsoid method (all using semi-automated ROI-Region of Interest), and differential attenuation of contrast. All measurements were performed using an Advantage Workstation (GE). The calculated SRFs were compared with Tc-99m DTPA-based SRF using the Pearson correlation coefficient. Results: The mean age of donors was 44.32±10.25 years (range: 22–69). All four MDCT-based methods showed statistically significant correlation with nuclear scintigraphy SRF. For the right kidney, correlation coefficients (r) were 0.574 (total renal volume), 0.509 (cortical volume), 0.288 (ellipsoid method), and 0.323 (contrast attenuation); for the left kidney, r-values were 0.513, 0.473, 0.262, and 0.251, respectively (all p<0.001). Conclusion: MDCT-based SRF measurements demonstrate a significant correlation with nuclear scintigraphy. Given that MDCT angiography is routinely performed for anatomical evaluation, it can serve as a comprehensive, single-modality approach for both anatomical and functional assessment in living kidney donors. January 2026; Vol. 20(1):002. DOI: https://doi.org/10.55010/imcjms.20.002 *Correspondence: S Danish Iqbaal, Department of Community Medicine, Indira Gandhi Institute of Medical Sciences, Patna-800014, Bihar, India. Email: iqbalsdalig@gmail.com © 2026 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License(CC BY 4.0).   Introduction Renal transplantation has emerged as the treatment of choice for patients with end-stage renal disease (ESRD). It improves the quality of life and reduces the mortality risk of most patients as compared to the other available alternative treatments like maintenance hemodialysis (MHD) [1].  For successful renal transplantation, comprehensive preoperative anatomical and functional evaluation of the kidneys of potential living donors is of paramount importance, along with genetic workup [2].  Out of both kidneys from a living donor, the kidney to be harvested is decided by the principle of the nephron mass hypothesis, which suggests that the larger or more dominant kidney should remain with the donor. However, there are no universally recommended guidelines as to what difference in volume or functional asymmetry is acceptable when selecting an individual for living donor nephrectomy. Some centers have used a 60/40 split as a relative contraindication to donation [3]. Currently, multidetector computed tomography (MDCT) renal angiography is considered an investigation of choice for anatomical evaluation of kidneys and their vascular mapping, including anatomical variations, which are crucial for successful harvest and renal transplant. For functional assessments like glomerular filtration rate (GFR) and split renal function (SRF), nuclear scintigraphy is considered the gold standard. In recent decades, several studies have shown that MDCT can also be used as an effective tool for measuring SRF in kidneys. MDCT can be used to measure kidney volume (total renal volume and cortical renal volume). And by volumes, we can calculate the SRF of kidneys, as volume reflects the split renal function. There are various MDCT-based SRF estimation techniques that have been found to be as sensitive as nuclear scintigraphy [4,5]. CT volumetry methods such as ellipsoid volumetry, total parenchymal volumetry, and renal cortex volumetry have been studied in detail and have been found effective methods for estimating SRF [6]. The purpose of this study is to compare MDCT-calculated SRF with nuclear scintigraphy-measured SRF.   Materials and Methods This prospective analytical study was conducted at a tertiary care center in the department of radiology in collaboration with the Department of Nuclear Medicine, the Department of Urology, and the Department of Nephrology at the Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, during the periods of 2019 and 2021. Volunteer living kidney donors who were already scheduled for MDCT imaging for anatomical and vascular evaluation were recruited in the study after fulfilling the inclusion and exclusion criteria. There were 111 participants included in the study from 130 enrolled patients. The 19 patients were excluded from the study as they didn't meet inclusion criteria. After explaining the nature of the study and taking informed consent, CT angiography was performed as per the protocol in Table-1. CT renal volumetry (total renal volume and cortical renal volume) was done by the semi-automated ROI method and the ellipsoid method at Advantage Workstation of GE by two experienced radiologists with good training and experience of 3 years and 18 years, respectively. As per protocol in our institution for renal donor evaluation, all these prospective voluntary kidney donors underwent a Technetium-99m DTPA renal scan for SRF measurement preoperatively.   Table-1: CT parameters for 128 channel Multi-detector Scanner     CT image acquisition: The MDCT was performed on a 128-channel scanner (brilliance CT, Philips Medical System, Netherlands) at the abovementioned institution. All donors were asked to drink 600 mL of plain water before CT examination, then asked to empty their bladders before taking a CT scan. First, a pre-contrast MDCT of the abdomen was obtained from the top of the left hemidiaphragm to the symphysis pubis during end-inspiration. Through consistent window settings, anatomical landmarks, and protocolized slice thickness, we have tried to minimize bias. A 100ml CM (Iohexol 350 mg/mL) at the rate of 4.0 mL/sec was administered through an 18G cannula placed in the right antecubital fossa by a power injector, followed by 20ml normal saline chaser. As per institutional protocol, images were acquired in late arterial (corticomedullary phase) from the top of the left hemidiaphragm to symphysis pubis after a delay of 15 seconds from the moment the HU (Hounsfield Units) of the subdiaphragmatic aorta reaches up to 150 HU by the bolus tracking method. Split renal function calculation: Renal volume was calculated by the following methods: The semiautomated region of interest (ROI) tool was applied in the corticomedullary phase, and the total volume of the kidney was calculated. The collecting system, fat in the renal sinus, and renal space and renal occupying lesions of water density were excluded by preset software thresholds. Using this volume, SRF was calculated as: SRF (R or L kidney) = R or L kidney volume/R+L kidney volume. Only renal cortex volume was calculated in the corticomedullary phase. Using this volume, SRF was calculated as SRF (R or L kidney) = R or L renal cortical volume (RCV)/R+L RCV. Renal volume was calculated by the modified ellipsoid method (height x width x depth x π/6). Depth and width were calculated in axial slices, and height was calculated in the plane of the kidney in the sagittal plane, in the corticomedullary phase of image acquisition and SRF was calculated as R or L kidney= R or L kidney volume by the ellipsoid method/R +L kidney total volume by the ellipsoid method. The difference between the mean attenuation in the arterial series (Art Att) and the pre-contrast series (Pre Att) was multiplied by the mean of the respective parenchymal volumes (Art Vol and Pre Vol) to measure the accumulation (Art Acc) of contrast in each individual kidney during the arterial phase.  Art Acc= (Art Att − Pre Att) × {(Art Vol + Pre Vol)/2} Once this procedure was completed for both the left and right kidneys in the arterial phase, the total arterial contrast accumulation (Art Acc) on the right was divided by the sum of the total arterial contrast accumulation in both kidneys to determine the relative clearance of the contrast media from the right kidney in the arterial phase (Rt Art Split). Rt Art Split= Rt Art Acc/ (Lt Art Acc + Rt Art Acc). Estimation of SRF by renal scintigraphy: For differential renal function an angiographic perfusion study was performed using 1 mCi (millicurie) of 99m Tc-diethylenetriamine pentaacetic acid (DTPA) with donor in the supine position and the scintillation camera detector positioned so that the bifurcation of the aorta, iliac arteries, and urinary bladder in addition to the kidneys appeared in the camera field. Three second sequential exposures were obtained as long as the activity was clearly localized in the arterial system and kidney. This was followed by a 40-sec static image to evaluate renal size and shape. Subsequently, activity was quantified over the individual kidneys and bladder by the use of either the split crystal or region. Statistical analysis: The normality of the continuous variable was assessed, and variables were considered normally distributed when the standard normal variate (Z) value of the skewness was ±3.29. The continuous variables were presented in mean± standard deviation/median (interquartile range) and range (minimum-maximum). The categorical variables were presented in frequency (percentage). A paired samples t test was used to test the change in mean score between paired observations (pre-post). To compare the means between two unpaired groups, independent samples t-tests were used, while to compare the means among more than two groups, a one-way ANOVA test was used, followed by multiple comparisons using the Bonferroni method. To compare the proportions between the groups, a chi-square test was used. To assess the linear relationship between two continuous variables, the Pearson correlation coefficient was used. A p-value <0.001 was taken as statistically significant. The data was analyzed by Statistical Package for Social Sciences, version 26 (SPSS-26, IBM, Chicago, USA).     Figure-1a: Cortical volume by the semiautomatic region of interest tool     Figure-1b: Total volume by the semiautomatic region of interest tool     Figure-1c: Width and thickness by ellipsoid method     Figure-1d: Width and thickness by ellipsoid method Figure-1 (a,b,c and d): The process of measuring of kidney volume, the semiautomatic region of interest (ROI) tool was applied slice by slice on axial corticomedullary phase images (a) for cortical volume and (b) for total volume. In ellipsoid method, width and thickness was taken in axial plane, length in sagittal plane, (c) and (d).     Figure-2: Estimation of total renal volume on coronal plane     Figure-3: Volume rendered images for total volume calculation   Results A total of 111 donors were finally evaluated. For the 111 donors, age was 44.32±10.25 years (mean± SD), and the range was 22-69 years, while the median of the donors was 44 years. Most of the donors belonged to the age group 41-50 years (n = 39, 35.14%), followed by 31-40 years (n = 35, 31.53%), while the least were in the age group 61-70 years (n = 9, 8.04%). The majority of the participating donors were females (n = 91, 82.0%). The mean creatinine of donors was 0.8 mg/dL with a range of 0.7 to 1.4 mg/dL(Table-2, Figures- 4a and 4b).   Table-2: Demographic characteristics of kidney donors     Figure- 4a: Pie chart showing age distribution and percentage of the study participants     Figure-4b: Pie chart showing sex distribution and percentage of the study participants   SRF measurement using CT volumetry methods: Total renal volume (semiautomated ROI method): The mean (±SD) CT derived left split renal function (SRF) for renal donors was 50.47±2.49% and SRF ranged from 43.30% to 57%. The mean (±SD) CT derived right split renal function (SRF) for renal donors was 49.51±2.49% and SRF ranged from 43% to 56.70%. Total renal volume (ellipsoid method): The mean (±SD) CT derived left split renal function (SRF) for renal donors was 49.10±4.57% and SRF ranged from 35% to 59.80%. The mean (±SD) CT derived right split renal function (SRF) for renal donors was 50.85±4.54% and SRF ranged from 40.20% to 65%. Cortical renal volume method: The mean (±SD) CT derived left split renal function (SRF) for renal donors was 50.27±2.49% and SRF ranged from 43% to 57%. The mean (±SD) CT derived right split renal function (SRF) for renal donors was 49.65±2.59% and SRF ranged from 42.70% to 57%. Differential attenuation of contrast method: The mean (±SD) CT derived left split renal function (SRF) for renal donors was 50.71±3.69% and SRF ranged from 35.50% to 59%. The mean (±SD) CT derived right split renal function (SRF) for renal donors was 49.30±3.67% and SRF ranged from 41% to 64.50%. SRF measurement using DTPA: The mean (±SD) DTPA derived left split renal function for renal donors was 50.71±3.69%and SRF ranged from 35.5% to 59%. The mean (±SD) CT derived right split renal function for renal donors was 50.19±3.49% and SRF ranged from 38% to 60%. Comparison of SRF measured using CT volumetry methods and DTPA method: SRF measurement was done using MDCT as well as DTPA of the donors for the left and right kidneys. Pearson correlation coefficient was calculated for SRF measurements between MDCT methods and DTPA method. Results indicated that there was a significant correlation between the MDCT methods and DTPA method for the left kidney and right kidney at P value <.01 (Table 3a and 3b, Fig 5a, 5b, 5c and 5d).   Table-3a: SRF correlation between MDCT methods and DTPA method – Right kidney     Table-3b: SRF correlation between MDCT methods and DTPA method – Left kidney     Figure-5a: Scattered diagram showing correlation between semi-automate ROI method SRF and DTPA method SRF.     Figure-5b: Scatter diagram showing correlation between ellipsoid method SRF and DTPA method SRF     Figure-5c: Scatter diagram showing correlation between cortical renal volume method SRF and DTPA method SRF.     Figure-5d: Scatter diagram showing correlation between differential attenuation of contrast method SRF and DTPA method SRF   Discussion At present, MDCT angiography is the gold standard for anatomical evaluation of living renal donors. Namasivayam S et al. [7]. For functional evaluations like GFR and SRF, nuclear scintigraphy is considered the gold standard. Several studies have been published regarding the use of MDCT to calculate SRF. Several studies have also compared CT parenchymal volumetry methods (total renal volume by semiautomated ROI method, ellipsoid method, and cortical renal volume method) and the differential attenuation of contrast method with nuclear scintigraphy to estimate SRF and have shown moderate correlation between the two techniques (Table-4), suggesting that MDCT can be an alternative to nuclear medicine scintigraphy for determining SRF. The correlation coefficients for the best-performing method (3D ROI) are 0.574 (right) and 0.513 (left), which are moderate only, but for clinical decision-making, particularly regarding donor selection, higher accuracy may be warranted. While the correlation between MDCT-derived SRF and nuclear scintigraphy was moderate, this reflects real-world clinical variability and underscores the need for complementary evaluation in donor selection. This will result in a reduction in radiation exposure to the patients, optimum utilization of imaging resources, reduced preoperative workup cost, and a more convenient algorithm for the potential donor.    Table-4: Comparison between MDCT derived SRF and renal scintigraphy SRF of our study with previous studies     In the present study, the correlation coefficient was calculated for SRF measurements by MDCT volumetry methods and the Tc99mDTPA method. The inter-observer variation was qualitatively minimal. Results indicated that there was a statistically significant correlation between two methods for the left and right kidneys. Future studies correlating MDCT-derived SRF with post-donation renal function would further establish the method's clinical utility.   Limitations There are a few limitations in this study, as the sample size is small and it is a single-center study. A large sample size and multicenter study should be conducted in the future to further explore the feasibility of MDCT as an alternative to the nuclear scintigraphy method. Agreement between MDCT and nuclear SRF is not presented, which is critical to assess clinical interchangeability. Inter-observer variability with different levels of experience involved in volumetric measurements is not discussed.   Conclusion The MDCT angiography is routinely done for the anatomical assessment of living renal donors. Different renal MDCT-based methods of SRF measurement have shown significant correlation as compared to SRF measured by Nuclear Scintigraphy Tc-99m DTPA methods. We propose that MDCT can be used as a one-stop solution for anatomical and functional evaluation of renal donors and become an important modality in the coming future.   Conflict of interest Authors have no conflict of interest to declare.   Ethical statement Ethical clearance was obtained from the Institutional Ethics Committee of Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow (IEC code: 2020-32-MD-114).   References 1.     Shahbazi F, Ranjbaran M, Karami-far S, Soori H, Manesh HJ. Graft survival rate of renal transplantation during a period of 10 years in Iran. J Res Med Sci. 2015; 20(11): 1046-52. doi:10.4103/1735-1995.172814. 2.     Letourneau JG, Day DL, Ascher NL, Castaneda-Zuniga WR. Imaging of renal transplants. AJR Am J Roentgenol. 1988; 150(4): 833-838. doi:10.2214/ajr.150.4.833. 3.     Alejandro D, John P, Chandru P. Sundaram CP, Taber TE, Mujtaba MA, et al.Correlation between CT-based measured renal volumes and nuclear-renography-based split renal function in living kidney donors. Clinical diagnostic utility and practice patterns. Clin Transplant. 2014; 28(6): 675-682. doi:10.1111/ctr.12365. 4.     Brown SC, O'reilly PH. Iohexol clearance for the determination of glomerular filtration rate in clinical practice: evidence for a new gold standard. J Urol. 1991; 146(3): 675-679. doi:10.1016/s0022-5347(17)37891-6. 5.     Gates GF. Split renal function testing using Tc-99m DTPA. A rapid technique for determining differential glomerular filtration. Clin Nucl Med. 1983; 8(9): 400-407. doi:10.1097/00003072-198309000-00003. 6.     Halleck F, Diederichs G, Koehlitz T, Slowinski T, Engelken F, Liefeldt L, et al. Volume matters: CT-based renal cortex volume measurement in the evaluation of living kidney donors. Transpl Int. 2013; 26(12): 1208-1216. doi:10.1111/tri.12195. 7.     Namasivayam S, Kalra MK, Small WC, Torres WE, Mittal PK. Multidetector row computed tomography evaluation of potential living laparoscopic renal donors: the story so far. Curr Probl Diagn Radiol. 2006; 35(3): 102-114. doi:10.1067/j.cpradiol.2006.02.005.     Cite this article as: Ahmad S, Prasad R, Lal H, Barai S, Srivastava A, Iqbaal SD. Comparison of four different multi-detector computed tomography based split renal function (SRF) evaluation methods and their correlation with nuclear scintigraphy derived SRF for functional assessment of potential living renal donors. IMC J Med Sci. 2026; 20(1):002. DOI: https://doi.org/10.55010/imcjms.20.002. <![CDATA[Changes in corneal endothelial cell density and central corneal thickness in patients with type 2 diabetes mellitus]]> Umama Islam* Ferdous Akhter Jolly Md. Ferdous Hossain Md. Faizul Ahasan https://imcjms.com/journal_full_text/597 2026-02-24 11:44:00 Original Article January 2026; Vol. 20(1):004 Abstract Background and objectives: The corneal endothelium is essential for maintaining corneal transparency and visual function. Chronic hyperglycaemia in type 2 diabetes mellitus (T2DM) can impair endothelial pump activity, resulting in reduced endothelial cell density (ECD) and increased central corneal thickness (CCT). Because endothelial cells do not regenerate, progressive cell loss may lead to irreversible endothelial decompensation. This study evaluates the association of T2DM with ECD and CCT and examines how these parameters relate to diabetes duration, glycaemic control (HbA1c) and diabetic retinopathy (DR). Materials and methods: This cross-sectional study, conducted at BIRDEM General Hospital, included 86 patients with T2DM and 86 individuals in the non-diabetic group. The T2DM group was subdivided by DR status (no DR, non-proliferative DR and proliferative DR). Following standard ophthalmic examinations, specular microscopy was performed to measure ECD and CCT in the right eye. Data were analyzed using t-test, ANOVA, correlation analysis and multivariate regression (SPSS version 26). Results: Individuals with T2DM demonstrated a significant loss of endothelial cells, with mean ECD 275 cells/mm² lower than the non-diabetic group (2585·18 ± 263·12 vs 2860·06 ± 244·45 cells/mm²; p<0·001). CCT did not differ significantly between groups (527·60 ± 32·93 vs 524·37 ± 40·81 µm; p=0·568). In multivariate regression, age contributed to a loss of 21·25 cells/mm² per year (p<0·001), while T2DM independently accounted for an additional loss of 191·12 cells/mm² (p<0·001). Increasing intraocular pressure (IOP) had no significant effect on ECD (loss of 15·17 cells/mm² per mmHg; p=0·277). Conclusion: T2DM is associated with substantial endothelial cell loss, which is accentuated by longer disease duration, poor glycaemic control and the presence of DR, whereas CCT remains unaffected. January 2026; Vol. 20(1):004. DOI: https://doi.org/10.55010/imcjms.20.004 *Correspondence: Umama Islam, Cornea, LASIK & Refractive Surgery, Vision Eye Hospital, 229, Green Road, Dhanmondi, Dhaka-1205.Email: dr.umamaislam@gmail.com. © 2026 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License(CC BY 4.0   Introduction Diabetes Mellitus (DM) is a critical global health issue requiring continuous medical supervision and comprehensive risk-reduction strategies beyond glucose control [1]. With the growing prevalence of DM, many organs, including the eyes, are increasingly vulnerable to damage. While Diabetic Retinopathy (DR) is the most widely recognized ocular complication, DM also affects the cornea, particularly the corneal endothelium, causing both structural and functional alterations. These changes may include reduced endothelial cell density (ECD), altered cell size and shape andincreased central corneal thickness (CCT), all of which have the potential to impair vision [2]. The cornea, a transparent tissue essential for transmitting light to the retina and forming clear retinal images, consists of five layers, with the endothelium playing a pivotal role in maintaining corneal transparency [3]. Endothelial cells have the highest density at birth but decline naturally with age at approximately 0.6% per year [4], a process compensated by increased cell size (polymegathism) and variation in cell shape (pleomorphism) [5]. DM exacerbates these age-related changes by causing delayed wound healing, reduced corneal sensitivity and endothelial dysfunction [2]. Persistent hyperglycaemia contributes to endothelial abnormalities such as decreased ECD, increased CCT, reduced hexagonality, polymegathism and pleomorphism [6]. Elevated blood glucose induces aldose reductase activity, leading to sorbitol accumulation, deposition of advanced glycation end products (AGEs), endothelial cell loss and impaired corneal transparency [7]. Furthermore, inflammation and oxidative stress associated with DR can disrupt corneal physiology, further altering endothelial cell morphology and function [8]. Pan-retinal photocoagulation (PRP), a standard treatment for proliferative diabetic retinopathy (PDR), may also lead to endothelial cell damage, reflected by reduced ECD and increased CCT [9]. Specular microscopy, an optical technique that records corneal endothelial reflections, consistently demonstrates reduced ECD, decreased cell hexagonality and increased CCT in individuals with DM [10]. Cataract surgery adds further risk to endothelial integrity, particularly in older patients with DM, where the natural decline in ECD is compounded by diabetes-related endothelial vulnerability [11]. Data on diabetes-related corneal endothelial alterations in Bangladesh remain limited despite the growing burden of T2DM. Corneal endothelial cell loss and morphological abnormalities may compromise corneal transparency and increase the risk of adverse outcomes following intraocular surgery. Assessment of ECD, CV, HEX and CCT therefore has important clinical relevance in diabetic populations. This study evaluated corneal endothelial characteristics in patients with T2DM compared with non-diabetic individuals and examined their associations with DM duration, HbA1c, DR and relevant ocular parameters.   Materials and methods This cross-sectional study was conducted at BIRDEM General Hospital between September 2022 and August 2023 and included 86 adults with T2DM and 86 individuals in the non-diabetic group, recruited through consecutive sampling. Participants were aged 35–60 years and provided written informed consent. Inclusion required confirmed T2DM for the diabetic group and normal fasting glucose and HbA1c values for the non-diabetic group. In contrast, individuals with ocular surface disease, corneal endothelial dystrophy, previous ocular trauma or surgery, elevated intraocular pressure (IOP), contact lens wear, ocular infection, long-term topical medication use, or high myopia (>–6.0 D) were excluded. Ethical approval was obtained from the ethical review committee of BIRDEM General Hospital. All participants underwent comprehensive right-eye evaluations including specular microscopy (NIDEK CEM-30, USA), best-corrected visual acuity testing, intraocular pressure measurement andslit-lamp and fundus examination. Specular microscopy parameters included endothelial cell density, average cell area, coefficient of variation, percentage of hexagonal cells and central corneal thickness. Fasting glucose, 2-hour postprandial glucose and HbA1c levels of the individuals were assessed as well. Diabetic participants were categorized into no diabetic retinopathy (no-DR), non-proliferative DR and proliferative DR groups. Data were analyzed using SPSS version 26 with Student’s t test and ANOVA for continuous variables, χ² test for categorical variables and multiple regression analyses to assess relationships, with significance defined as p<0.05.   Results The mean age was significantly higher in the type 2 diabetes mellitus (T2DM) group compared with the non-diabetic group (50.88 ± 5.71 vs. 48.35 ± 7.14 years, p = 0.011). Age-group distribution (p = 0.564) and gender (p = 0.360) did not differ significantly between groups. HbA1c (%)—reported as mean ± SD—was markedly higher among individuals with T2DM (9.24 ± 2.14%) compared with non-diabetics (5.91 ± 0.16%, p < 0.001). IOP showed no significant between-group difference (14.07 ± 1.33 vs. 13.70 ± 1.39mmHg, p = 0.075) (Table-1).   Table-1: Demographic characteristics, HbA1c and IOP of the study population (n=172)     The ECD was significantly lower in the T2DM group (2585.18 ± 263.12 cells/mm²) compared to the non-diabetic group (2860.06 ± 244.45 cells/mm², p<0.001). The coefficient of variation (CV) was significantly higher in the T2DM group (31.89 ± 4.70%) than in the non-diabetic group (30.19 ± 4.20%, p=0.013). The percentage of hexagonal cells (HEX) was significantly lower in the T2DM group (64.52 ± 6.36%) compared to the non-diabetic group (66.95 ± 5.84%, p=0.010). However, there was no significant difference in CCT between the groups (527.60 ± 32.93 µm vs. 524.37 ± 40.81 µm, p=0.568) (Table-2).   Table-2: Comparison of endothelial cell characteristics between two groups.     ECD was significantly lower in patients with >10 years of T2DM (2486.69 ± 260.93) compared to ≤10 years (2679.20 ± 231.13, p<0.001). Similarly, ECD declined in those with HbA1c >7.5% (2532.28 ± 262.60) versus ≤7.5% (2730.08 ± 207.82, p=0.002). Among DR subgroups, ECD was lowest in PDR cases (2215.27 ± 213.53), followed by NPDR (2589.35 ± 235.67) and no DR (2669.27 ± 213.23, p<0.001). CCT differences were not statistically significant for duration of DM (p=0.299), HbA1c levels (p=0.197), or DR status (p=0.929) (Table-3).   Table-3: Association of ECD and CCT with the duration of T2DM, HbA1c levels and DR status.     Multivariate regression analysis demonstrated that increasing age was significantly associated with a decrease in ECD (B = -21.247, p<0.001), with each year contributing to a reduction of approximately 21 cells/mm². T2DM was also a significant independent predictor of lower ECD (B = -191.124, p<0.001), indicating a reduction of 191 cells/mm² in diabetic individuals compared to non-diabetic participants. Intraocular pressure (IOP) did not show a statistically significant association with ECD (B = -15.174, p=0.277) (Table-4).   Table-4: Multivariate regression analysis of factors influencing corneal ECD (n=172)     Discussion The corneal endothelium plays a central role in maintaining stromal deturgescence and optical clarity and its dysfunction poses a risk for postoperative complications and vision loss. Chronic hyperglycaemia in type 2 diabetes mellitus (T2DM) contributes to oxidative stress, accumulation of advanced glycation endproducts and microvascular compromise, all of which may impair endothelial structure and function [1]. In this study, patients with T2DM demonstrated significantly reduced endothelial cell density (ECD) compared with non-diabetic controls, consistent with previous reports by Kim and Kim [12] and Jha et al. [13]. These findings underscore the susceptibility of endothelial cells to metabolic injury and long-term hyperglycaemic exposure. Importantly, T2DM was also associated with a higher coefficient of variation (CV) and reduced hexagonality. These parameters are clinically meaningful: increased CV reflects greater variability in cell size (polymegathism), while reduced hexagonality indicates loss of the normal hexagonal architecture (pleomorphism). Both changes signal endothelial stress and reduced physiological reserve, even before substantial ECD loss becomes clinically apparent. Similar alterations have been reported in other diabetic cohorts [12,13], whereas Kadri et al. found no significant differences [14], suggesting possible heterogeneity related to ethnicity, glycaemic control, imaging technique, or disease duration. Central corneal thickness (CCT) did not differ significantly between groups, aligning with findings from Çolak et al. [15] and Sudhir et al. [16]. However, some studies, such as Taşlı et al. [17], have reported increased CCT in diabetic individuals, possibly reflecting endothelial pump dysfunction in more advanced disease. The absence of CCT changes in our cohort suggests relatively preserved deturgescence despite measurable morphological endothelial alterations. Longer diabetes duration (≥10 years) and poorer glycaemic control (HbA1c >7.5%) were associated with significantly lower ECD, consistent with the cumulative impact of chronic hyperglycaemia reported by Storr-Paulsen et al. [18]. However, other studies such as Choo et al. [19] have shown fewerclear associations, highlighting inter-individual variability in metabolic susceptibility. Additionally, ECD was lowest in patients with proliferative diabetic retinopathy (PDR), echoing the findings of Jha et al. [13], although El-Agamy et al. [20] reported no significant association. These discrepancies warrant further investigation into the shared microvascular pathways linking retinopathy severity and endothelial degeneration. T2DM is associated with significant corneal endothelial alterations, including reduced ECD and increased morphological variability, reflecting diminished endothelial reserve even without increased CCT. These subclinical changes may predispose patients to postoperative corneal oedema and delayed visual recovery, underscoring the value of routine endothelial assessment for surgical planning and risk stratification, particularly in patients with long-standing DM, poor glycaemic control, or DR. In conclusion, endothelial compromise can occur despite normal CCT and incorporating corneal endothelial evaluation into routine ocular care may optimise perioperative management.   Recommendations Multicentre prospective studies with long-term follow-up are needed to confirm these findings. Limitations This study’s cross-sectional, single-centre design and moderate sample size limit causal inference and generalisability and longitudinal changes or postoperative outcomes were not assessed.   Funding The study wasself-funded.   Conflict of interest The authors declare that they have no financial, personal, or institutional conflicts of interest that could have influenced the preparation or outcomes of this study.   Ethical Approval Ethical approval was obtained from the Ethical Review Committee of BIRDEM Academy.   Reference 1.     American Diabetes Association. Standards of care in diabetes-2023 abridged for primary care providers. Clin Diabetes. 2022; 41(1): 4-31. doi:10.2337/cd23-as01. 2.     Ljubimov AV. Diabetic complications in the cornea. Vision Res. 2017; 139: 138-152. doi:10.1016/j.visres.2017.03.002. 3.     Sahu PK, Das GK, Agrawal S, Kumar S. Comparative evaluation of corneal endothelium in patients with diabetes undergoing phacoemulsification. Middle East Afr. J. Ophthalmol. 2017; 24(2): 74-80. doi:10.4103/meajo.MEAJO_242_15. 4.     Zhang K, Zhao L, Zhu C, Nan W, Ding X, Dong Y, et al. The effect of diabetes on corneal endothelium: a meta-analysis. BMC Ophthalmol. 2021; 21(1): 78. doi:10.1186/s12886-020-01785-3. 5.     Ahn YJ, Choi SI, Yum HR, Shin SY, Park SH. Clinical features in children with posterior polymorphous corneal dystrophy. Optom Vis Sci. 2017; 94(4): 476-481. doi:10.1097/OPX.0000000000001039. 6.     Inoue K, Kato S, Inoue Y, Amano S, Oshika T. The corneal endothelium and thickness in type II diabetes mellitus. Jpn J Ophthalmol. 2002; 46(1): 65-69. doi:10.1016/s0021-5155(01)00458-0. 7.     Thakur S, Gupta SK, Ali V, Singh P, Verma M. Aldose reductase: a cause and a potential target for the treatment of diabetic complications. Arch Pharm Res. 2021; 44(7): 655-667. doi:10.1007/s12272-021-01343-5. 8.     Tangvarasittichai O, Tangvarasittichai S. Oxidative stress, ocular disease and diabetes retinopathy. Curr Pharm Des. 2018; 24(40): 4726-41. doi:10.2174/1381612825666190115121531. 9.     Ostadian F, Farrahi F, Cheraghian B, Nejad AM. Panretinal photocoagulation laser in diabetic retinopathy patients. Pak J Med Health Sci. 2021; 15(6): 1820-1823. doi:10.53350/pjmhs211561820. 10.  Islam QU, Mehboob MA, Amin ZA. Comparison of corneal morphological characteristics between diabetic and non diabetic population. Pak J Med Sci. 2017; 33(6): 1307-1311. doi:10.12669/pjms.336.13628. 11.  Kudva AA, Lasrado AS, Hegde S, Kadri R, Devika P, Shetty A. Corneal endothelial cell changes in diabetics versus age group matched nondiabetics after manual small incision cataract surgery. Indian J Ophthalmol. 2020; 68(1): 72-76. doi:10.4103/ijo.IJO_406_19. 12.  Kim YJ, Kim TG. The effects of type 2 diabetes mellitus on the corneal endothelium and central corneal thickness. Sci Rep. 2021; 11(1): 8324. doi:10.1038/s41598-021-87896-3. 13.  Jha A, Verma A, Alagorie AR. Association of severity of diabetic retinopathy with corneal endothelial and thickness changes in patients with diabetes mellitus. Eye. 2022; 36(6): 1202-8. doi:10.1038/s41433-021-01606-x. 14.  Kadri R, Sasalatti N, Hegde S, Kudva AA, Parameshwar D, Shetty A. Corneal endothelial cell characteristics and central corneal thickness in patients with type 2 diabetes mellitus. Ker J of Ophthalmol. 2021; 33(1): 56-60. doi:10.4103/kjo.kjo_91_20. 15.  Çolak S, Kazanci B, Ozçelik Soba D, Ozdamar Erol Y, Yilmazbas P. Effects of diabetes duration and HgA1C level on corneal endothelial morphology. Eur J Ophthalmol. 2021; 31(3): 967-975. doi:10.1177/1120672120914812. 16.  Sudhir RR, Raman R, Sharma T. Changes in the corneal endothelial cell density and morphology in patients with type 2 diabetes mellitus: a population-based study, Sankara Nethralaya Diabetic Retinopathy and Molecular Genetics Study (SN-DREAMS, Report 23). Cornea. 2012; 31(10): 1119-22. doi:10.1097/ico.0b013e31823f8e00. 17.  Taşlı NG, Icel E, Karakurt Y, Ucak T, Ugurlu A, Yilmaz H, et al. The findings of corneal specular microscopy in patients with type-2 diabetes mellitus. BMC ophthalmol. 2020; 20(1): 1-7. doi:10.1186/s12886-020-01488-9. 18.  Storr‐Paulsen A, Singh A, Jeppesen H, Norregaard JC, Thulesen J. Corneal endothelial morphology and central thickness in patients with type II diabetes mellitus. Acta Ophthalmol. 2014; 92(2): 158-160. doi:10.1111/aos.12064. 19.  Choo M, Prakash K, Samsudin A, Soong T, Ramli N, Kadir A. Corneal changes in type II diabetes mellitus in Malaysia. Int J Ophthalmol. 2010; 3(3): 234-236. doi:10.3980/j.issn.2222-3959.2010.03.12. 20.  El-Agamy A, Alsubaie S. Corneal endothelium and central corneal thickness changes in type 2 diabetes mellitus. Clin Ophthalmol. 2017; 11: 481-486. doi:10.2147/OPTH.S126217.   Cite this article as: Islam U, Jolly FA, Hossain MF, Ahasan MF. Changes in corneal endothelial cell density and central corneal thickness in patients with type 2 diabetes mellitus. IMC J Med Sci. 2026; 20(1):004. DOI: https://doi.org/10.55010/imcjms.20.004. <![CDATA[Sodium intake and blood pressure regulation in CKD: a systematic review and meta-analysis]]> Williams Tarimobowei Tabowei Chikadibia Fyneface Amadi https://imcjms.com/journal_full_text/596 2026-02-05 12:20:31 Review January 2026; Vol. 20(1):003 Abstract Background and objective: Salt intake is an important factor in blood pressure regulation in chronic kidney disease (CKD). This review assessed the impact of salt intake on blood pressure (BP) among CKD patients taking age and duration of intake into consideration. Materials and methods: Using PRISMA guidelines, a systematic literature search was carried out on Semantic Scholar, ScienceDirect, and PubMed databases. The inclusion criteria were guided by the PICO framework. A total of 337 studies were gathered, after screening 8 studies met the criteria for quality assessment and data extraction (primary outcomes: systolic and diastolic BP). A random-effects model determined the overall effect sizes and heterogeneity across the studies. Results: Low sodium intake significantly (p=0.02) reduced systolic blood pressure (SBP) but did not affect the diastolic blood pressure (DBP). High sodium intake had no significant effect on either systolic or diastolic BP. CKD patients aged≤50 years had lower systolic and diastolic blood pressure compared to patients >50 years. Additionally, long-term low salt intake had lower systolic and diastolic BP compared to short-term intake in patients with CKD. Conclusion: Low dietary sodium intake improves only systolic BP in CKD patients, especially in younger individuals. CKD patients may benefit more from long-term salt reduction than short-term intake. January 2026; Vol. 20(1):003.  DOI: https://doi.org/10.55010/imcjms.20.003 *Correspondence: Chikadibia Fyneface Amadi, Department of Medical Laboratory Science, PAMO University of Medical Sciences, Rivers State, Nigeria. Email: worldwaiting@yahoo.com. © 2026 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License(CC BY 4.0)   Introduction Chronic kidney disease (CKD) is a progressive and degenerative disorder marked by a gradual decline in renal function, which can eventually lead to end-stage renal disease (ESRD). At this advanced stage, the kidneys lose their capacity to function effectively without medical intervention, necessitating either dialysis or a kidney transplant for survival [1]. Globally, CKD affects approximately 10% of the population, with its prevalence increasing with age and among individuals with comorbidities such as diabetes, hypertension, and cardiovascular disease. Furthermore, certain ethnic groups demonstrate a higher susceptibility to CKD, highlighting the complex interaction of genetic, socioeconomic, and environmental factors. The disease advances through five stages, ranging from mild renal impairment (Stage 1) to severe renal failure (Stage 5). A particularly insidious aspect of CKD is its asymptomatic nature in the early stages, often resulting in delayed diagnosis and treatment. As CKD progresses, patients may exhibit symptoms such as fatigue, edema (notably in the legs and ankles), shortness of breath, persistent itching, and alterations in urinary patterns. These symptoms reflect the kidneys' declining ability to filter waste products, balance electrolytes, and regulate fluid levels in the body [2]. The progression of CKD is closely linked to chronic conditions such as diabetes, hypertension, and glomerulonephritis, all of which contribute to a gradual decline in the glomerular filtration rate (GFR), a key indicator of kidney function. GFR measures the efficiency with which the kidneys filter blood, and a declining GFR signals worsening renal function. As renal function deteriorates, waste products and fluids accumulate in the body, exacerbating hypertension and creating a vicious cycle of kidney damage and elevated blood pressure [1]. Blood pressure is typically measured by two values: systolic blood pressure (SBP), which indicates the pressure in the arteries during heart contractions, and diastolic blood pressure (DBP), which reflects the arterial pressure when the heart is at rest between beats. In CKD patients, both SBP and DBP are often elevated due to fluid overload and increased peripheral vascular resistance, a condition in which blood vessels constrict, compelling the heart to work harder to pump blood [2]. Salt intake plays a crucial role in managing blood pressure, especially in CKD patients. Excessive salt intake causes water retention, an increase in blood volume, and consequently, higher blood pressure. Conversely, reducing sodium intake can decrease blood volume and lower blood pressure, which is particularly advantageous for CKD patients whose kidneys are often compromised in their ability to excrete sodium [3]. The regulation of sodium and its impact on blood pressure in CKD involves complex molecular mechanisms. One of the central pathways is the renin-angiotensin-aldosterone system (RAAS), which is activated when sodium levels are low. The process initiates with the kidneys releasing renin, an enzyme that catalyzes the conversion of angiotensinogen, a liver-produced protein, into angiotensin I. Angiotensin I is then transformed into angiotensin II by the angiotensin-converting enzyme (ACE), mainly in the lungs. Angiotensin II, a potent vasoconstrictor, narrows blood vessels, increasing blood pressure. Additionally, angiotensin II stimulates the secretion of aldosterone from the adrenal glands, which prompts the kidneys to reabsorb sodium and water, further elevating blood volume and pressure [4]. High sodium intake can also activate the sympathetic nervous system, which controls the "fight or flight" response, increasing heart rate and peripheral vascular resistance. In response to these effects, the heart releases natriuretic peptides in response to increased blood volume and pressure. These peptides promote sodium excretion by the kidneys and cause vasodilation, or the widening of blood vessels, to lower blood pressure [5]. In CKD, the impaired function of nephrons diminishes the kidneys’ ability to excrete sodium effectively. This leads to fluid retention, exacerbating hypertension. Moreover, CKD is often accompanied by elevated levels of inflammatory mediators such as tumor necrosis factor-alpha (TNF-α) and transforming growth factor-beta (TGF-β). These cytokines promote fibrosis, or scarring, in the kidneys, further reducing renal function and worsening the disease [6][7]. Elevated sodium levels also contribute to oxidative stress, an imbalance between the generation of harmful reactive oxygen species (ROS) and the body's ability to neutralize them. ROS can harm renal cells, speed up CKD progression, and lead to inflammation and fibrosis [8]. Hypertension in CKD is further exacerbated by endothelial dysfunction, in which the inner lining of blood vessels fails to function normally. Oxidative stress impairs the production of nitric oxide (NO), a molecule that aids in the relaxation of blood vessels. This impairment leads to vasoconstriction and increases vascular resistance, raising blood pressure. Additionally, changes in vascular smooth muscle cells, induced by angiotensin II and high sodium levels, lead to the proliferation and hypertrophy (enlargement) of these cells, contributing to vascular stiffness and elevated blood pressure [9]. Volume overload from fluid retention, further increases blood volume and pressure, exacerbating hypertension in CKD patients [10]. Aldosterone stimulates salt and water reabsorption in the kidneys, increasing blood volume and pressure. High salt consumption has a substantial impact on this system because it causes greater water retention, which raises blood pressure even further. (Created by the author with Biorender).     Figure-1: Depicts the RAAS and its role in blood pressure regulation, emphasizing important components and processes. Low blood pressure causes the kidneys to release renin, which then transforms angiotensinogen from the liver to angiotensin I. ACE from the lungs then transforms angiotensin I to angiotensin II. Angiotensin II causes vasoconstriction, which raises blood pressure and encourages the adrenal cortex to release aldosterone. Diagram self-created by (J112133) using Biorender.   Previous research on sodium intake in CKD patients has yielded varied results. For instance, a study by Shi et al. (2022) [11] observed that CKD patients who consumed less than 2 grams of sodium per day experienced reductions in both SBP and DBP, with potentially additive effects when combined with antihypertensive medications. This finding suggests that low sodium intake could be an effective strategy for managing blood pressure in chronic kidney disease patients, particularly when used alongside other treatments. Similarly, a meta-analysis conducted by Filippini et al. (2021) [12] supported these findings, indicating that low sodium intake could significantly lower both SBP and DBP, highlighting the importance of dietary sodium restriction in blood pressure management for CKD patients. Conversely, high sodium intake has been associated with adverse effects on blood pressure in CKD patients. A study by Jaques et al. (2021) [13] reported that consuming more than 4 grams of sodium per day increased both SBP and DBP, along with a higher risk of cardiovascular events. This accentuates the potential dangers of high sodium consumption in CKD patients, who are already at an increased risk of cardiovascular complications. Similarly, another study by Borrelli et al. (2020) [5] noted that high sodium intake could exacerbate hypertension and proteinuria (the presence of excess protein in the urine), potentially accelerating CKD progression. A meta-analysis by Graudal et al. (2020) [14] further indicated significant increases in SBP and DBP with high sodium intake, reinforcing the link between sodium consumption and blood pressure in CKD patients. However, several studies have produced conflicting findings. Youssef (2022) [15] proposed that the relationship between sodium intake and blood pressure is not linear, suggesting that moderate sodium intake may be associated with the best cardiovascular outcomes. This finding indicates that both very low and very high sodium intakes might be detrimental and that an optimal range of sodium intake exists. Additionally, another study by Gupta et al. (2023) [16] found no clear benefit of low sodium intake for reducing blood pressure or cardiovascular events in the general population, suggesting that the effects of sodium intake might vary between CKD patients and the wider population. These findings suggest that the relationship between sodium intake and blood pressure is complex and may vary depending on individual patient characteristics. Furthermore, age-related differences in blood pressure response to sodium intake are also crucial in CKD management. A study by Crawford-Faucher et al. (2017) [17] suggested that older chronic kidney disease patients may experience greater blood pressure reductions with low sodium intake compared to younger patients. This could be due to age-related changes in kidney function and sodium sensitivity, which may render older patients more responsive to sodium reduction. Conversely, younger patients might exhibit more pronounced blood pressure increases with high sodium intake, as reported by Bailey & Dhaun (2024) [18]. A meta-analysis conducted by Stamler et al. (2018) [19] highlighted that age might moderate the blood pressure response to sodium intake, suggesting the need for age-specific guidelines in managing CKD patients. The duration of sodium intake adjustments can also influence blood pressure outcomes. Huang et al. (2018) indicated that short-term sodium reduction could lead to immediate decreases in SBP and DBP, with more pronounced effects over the long term [20]. This finding suggests that even temporary reductions in sodium intake can benefit chronic kidney disease patients, but sustained reductions may be necessary for long-term blood pressure control. Another study by Cook et al. (2007) [21] demonstrated that long-term sodium reduction was associated with sustained blood pressure control and reduced cardiovascular events, emphasizing the importance of maintaining a low-sodium diet over time for CKD patients. Despite extensive research, significant gaps remain in understanding the optimal effects of sodium intake on blood pressure in CKD patients. Considering the essential role of sodium intake in blood pressure regulation and the inconsistency in study outcomes, it is clear that additional research is needed to better understand the relationship between sodium intake and blood pressure in this population. This meta-analysis seeks to investigate how varying levels of sodium intake, both low and high, influence systolic and diastolic blood pressure, assesses how these effects differ by age, and compare the blood pressure responses in chronic kidney disease patients to short-term versus long-term low sodium intake. By investigating these variables, this analysis could provide a comprehensive understanding of how sodium intake influences blood pressure in CKD patients, potentially providing more effective dietary guidelines and management strategies. The goal is to improve outcomes for CKD patients by identifying the most effective approaches to managing blood pressure through dietary sodium intake.   Materials and methods This systematic review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [22]. The review aimed to synthesize the evidence on the effects of sodium intake on blood pressure regulation in patients with chronic kidney disease (CKD). A comprehensive literature search was conducted using three electronic databases, Semantic Scholar, ScienceDirect and PubMed’, with the use of Boolean operators. The search strategy combined medical subject headings (MeSH), and free-text terms related to 'sodium intake', 'dietary sodium', 'salt intake', 'blood pressure regulation', 'hypertension', and 'chronic kidney disease'. Boolean operators AND, OR, and NOT were used to refine the search, this helped to enhance and optimize search outcomes, furthermore filters were used to ensure the results were specific. The table below provides the exact Boolean functions/queries and filters used for each databases searched.   Table-1: Databases for search queries/Boolean functions     Table-1 showed the databases searched, the queries and Boolean function used in the search, the filters used and number of identified studies. Three databases (sematic scholar, ScienceDirect and PubMed) were searched. Sematic scholar search identification was 269 in June 2024 when the search was made using the exact string and filters provided in the table above, ScienceDirect identified 56 studies in June 2024 when the search on the database was made using the exact string and filters provided in the table above. Finally, 12 studies were identified in PubMed search in June 2024 using the exact string and filters provided in the table above. Inclusion Criteria: This review included studies that followed the PICO criteria; Population (chronic kidney disease patient), Intervention (varying levels of dietary sodium intake), Comparison (blood pressure level before and after sodium intake), Outcomes (primary outcome: systolic and diastolic blood pressure) and Study Design (randomized controlled trials, RCTs). The studies included were primary studies. In addition, open access articles published in peer-review journals were included to ensure data quality as peer review journals undergo critical manuscript evaluation process by experts in the field prior to publication. To ensure language proficiency, reduce translation costs, and minimize the time required for the review process only studies published in English were included; however, potential language bias is acknowledged. Exclusion Criteria: Studies were excluded if they did not include the population of interest (patients with CKD), the intervention of interest (dietary salt), and primary outcome of interest which is blood pressure. Additionally, reviews, secondary studies, editorials and commentaries, unpublished articles and gray literature, and website and social media publications were excluded. Animal studies and cross-sectional studies were also excluded. Gray literature was excluded to prioritize peer-reviewed publications that have undergone rigorous quality appraisal and editorial scrutiny. Exclusion was also applied to reduce bias or heterogeneity, since lack of standardized methodologies or reporting guidelines in gray literature can introduce bias, however, we acknowledged that recent advancements in unpublished findings may be omitted, however priority was placed on high-confidence evidence available in peer-reviewed journal articles indexed in reputable repositories. Data extraction and management: Data extraction was conducted manually, and the data of interest was collated on an Excel sheet. Extracted data included study characteristics (author, year, study design), participant characteristics (sample size, age, CKD stage) intervention details (duration, sodium intake levels), outcome measures (systolic and diastolic blood pressure), study results and conclusions. Zotero, a widely used reference manager [23] was used in the management of the references from the selected studies. The extracted data from the selected studies were saved in Microsoft Excel. These collated secondary data were then used to create the study characteristics table and for subsequent use for descriptive analysis, and meta-analysis. Quality Assessment: The quality of the included studies was assessed using the Jadad tool for randomized controlled trials (RCTs) [24]. This evaluation is crucial for understanding the methodological rigor and potential biases that could affect the reliability of the study findings. The assessment criteria included randomization (evaluating the method used to generate the randomization sequence), blinding (determining if blinding was applied to participants and personnel) and withdrawals (to know if the research work gave opportunities for participants to withdraw from the work). Each quality assessment criterion had a maximum score of 2 except for withdrawal, such that studies not conforming to the quality parameter assessed scored 0 while partial compliance score 1. Since 3 criteria are being assessed, a study can only have a maximum score of 6. Studies with a score of at least 3 were considered of sufficient quality and included for further analysis.   Table-2: Quality assessment report using randomized clinical trial using JADAD tool     Table-2 showed the outcome of quality assessment of each included study using JADAD tool. All studies passed the quality assessment set at a cut-off score of 3. The studies by Saran et al. [25], Akdag et al. [26], O’Callaghan et al. [29] and McMahon et al. [31] had the highest overall quality as they fully complied with randomization, blinding and withdrawal. Studies by De Brito-Ashurst et al. [27], Meuleman et al. [28], Taylor et al. [30] and Slagman et al. [32] had the lowest met the threshold quality score of 3/5. Data synthesis and analysis: Data synthesis involved the meta-analysis of the extracted data from the selected studies. RevMan analytical tool was used to pool quantitative data by using the random-effects model to account for variability among studies [33]. Heterogeneity was assessed using the I² statistic [34]. Subgroup analyses were performed to descriptively compare the levels of blood pressure (systolic and diastolic) between age groups and duration (short and long term) of low salt intake to understand how age and duration of salt intake affect blood pressure level in CKD patients   Results From the Figure-2 presented below, a total of 337 studies were Identified, and a final total of 8 studies passed the PRISMA guideline [22] for eligibility for data extraction. Table-3 shows the characteristics of the included studies. From the table, 8 studies were presented. All presented studies were published between 2012 to 2023 and involved CKD patients, including those on haemodialysis. The sample size of the presented studies was between 12 to 138. All studies were randomised clinical trials (RCT) involving both males and females but with more males than females in all studies with complete data (without missing data). The studies captured participants from a wide group ranging from 18 to 68 years. Each presented study had at least one level of salt intake.     Figure-2: PRISMA Flowchart   Table-3: Study characteristics     The forest plot in Figure-3 presents the meta-analysis of the effect of low salt intake on systolic blood pressure in CKD patients, here a total of seven studies were assessed [25-31]. The result revealed a significant reduction in systolic blood pressure in CKD patients following low salt intake, with a pooled difference of 1.47 (95%: C.I [0.25, 2.69], p=0.02, Z= 2.36). Also, the result showed that significant heterogeneity existed among the studies (I2= 98%, P<0.00001).     Figure-3: Forest plot on the effect of low salt intake on systolic blood pressure in CKD patients     Figure-4: Forest Plot on the effect of low salt intake on diastolic blood pressure in CKD patients   The meta-analysis included in Figure-4 indicated that low salt intake had no effect on diastolic blood pressure in CKD patients. with a pooled difference of 0.45 (95%: C.I [-0.24, 1.13], p=0.20, Z= 1.28). Considerable heterogeneity was observed among the studies (I2= 94%, P<0.00001).     Figure-5: Forest Plot showing the effect of high salt intake on systolic blood pressure in CKD Patients   The forest plot in Figure-5 shows the meta-analysis of the effect of high salt intake on systolic blood pressure in CKD patients. The analysis indicated that high salt intake had no significant effect on systolic blood pressure in CKD patients, with a pooled difference of 0.16 (95%: C.I [-0.17, 0.49], p=0.35, Z= 0.94). No significant heterogeneity was observed among the studies (I2= 7%, P=0.36).     Figure-6: Forest Plot on the effect of high salt intake on diastolic blood pressure in CKD Patients   Figure-6 presents the meta-analysis of the effect of high salt intake on diastolic blood pressure in CKD patients. The result showed that there was no significant effect of high salt intake on diastolic blood pressure in CKD patients, with a pooled mean difference of -0.04 (95%: C.I [-0.41, 0.34], p=0.85, Z= 0.19). No significant heterogeneity was observed among the studies (I2= 0%, P=0.51).     Figure-7: Age-based difference in systolic blood pressure among CKD Patient on low salt intake   Figure-7 presents the mean systolic blood pressure between two age groups: patients older than 50 years and those aged 50 years or younger. The chart shows that CKD patients aged 50 years or younger had slightly lower systolic blood pressure compared to CKD patients older than 50 years.     Figure-8: Age-based difference in diastolic blood pressure among CKD patients on low salt intake   Figure-8 presents the mean diastolic blood pressure levels in two groups of CKD patients: older than 50 years and those aged 50 years or younger. The results indicate that CKD patients less than or equal to 50 years of age had relatively lower diastolic blood pressure compared to CKD patients older than 50 years of age. Table-4 below shows the systolic blood pressure across short-term and long-term salt intervention. The results showed that the systolic blood pressure in the short-term salt treatment ranged between 125±12 mmHg to 144.9±13.1 mmHg while in long term salt intervention, the diastolic blood pressure ranged between 125±1.2 mmHg to 141.3 mmHg.   Table-4: Systolic blood pressure levels across short term and long-term studies       Figure-9: Comparison of systolic blood pressure between short-term (<2 months) and long-term (>2 months) low sodium intake in CKD patients   Figure-9 presents the summary results of short-term (≤2months) and long-term (>2months) low salt intake on systolic blood pressure levels in CKD patients. The results show that studies examining long-term low salt intake reported lower systolic blood pressure averaging 130.32 mmHg, compared to those on short-term low salt intake which reported higher systolic blood pressure, averaging 132.58 mmHg. Table-5 presents the diastolic blood pressure across short-term and long-term salt interventions. The results indicate that the diastolic blood pressure, in the short-term salt treatment ranged between 79.4±9.4 mmHg to 83±1 mmHg, while in long term salt intervention, it ranged between 69±10 mmHg to 83 mmHg. The summary results of short-term (≤2months) and long-term (>2months) low salt intake on diastolic blood pressure levels was presented in Figure-10. The result showed that studies on long-term low salt intake in CKD patients had lower diastolic blood pressure averaging 75.25 mmHg compared to those on short-term low salt intake which had higher diastolic blood pressure averaging 80.97 mmHg.   Table-5: Diastolic blood pressure levels across short term and long-term studies       Figure-10: Comparison of diastolic blood pressure between short-term (≤2 months) and long-term (>2 months) durations on low sodium intake in CKD patients   Discussion The relationship between sodium intake and blood pressure in chronic kidney disease (CKD) patients has been a contentious topic in nephrology and dietary research. The pooled analysis revealed a statistically significant but clinically modest reduction in systolic blood pressure (−1.47 mmHg) associated with low salt intake across seven studies [25-31]. While this effect size is small, it suggests that even modest dietary sodium restriction may contribute to blood pressure lowering in chronic kidney disease (CKD) patients. Given the cumulative benefits of non-pharmacological interventions in hypertension management, this reduction—though limited—could still support dietary sodium modification as part of a broader therapeutic strategy for CKD patients. Additionally, the consistent finding of SBP reduction across multiple studies highlights the robustness of this association, despite the inherent variability in study designs and populations. This finding aligns with the physiological understanding that lower sodium intake can reduce extracellular fluid volume, cardiac output, and vascular resistance. Sodium restriction may also enhance renal function by reducing glomerular hypertension and hyperfiltration, which are detrimental in chronic kidney disease [35].  The variability in responses to sodium intake suggests the potential for personalized nutrition plans tailored to individual patients' physiological responses. This could involve genetic testing, metabolic profiling, or other advanced diagnostic tools to determine the optimal sodium intake for each patient. Such personalized approaches could significantly enhance the effectiveness of dietary interventions by accounting for individual differences in sodium sensitivity and metabolic pathways. Conversely, the pooled data from the six studies showed no significant effect of low salt intake on diastolic blood pressure, with a mean difference of 0.45 mmHg [26-31]. This suggests that dietary sodium reduction may not have a meaningful impact on DBP. The mechanisms through which dietary sodium influences systolic blood pressure and diastolic blood pressure may differ, with DBP being more influenced by peripheral vascular resistance and arterial stiffness than systolic blood pressure, which is primarily determined by cardiac output and systemic vascular resistance [36]. However, the significant effect in SBP and the lack of significant effect in DBP must be interpreted cautiously due to the high heterogeneity observed in both outcomes. This high heterogeneity suggests substantial variability across the included studies, possibly stemming from differences in baseline characteristics, variations in the degree of sodium reduction, and differences in intervention duration [37]. This study also reports significant reductions in systolic blood pressure with low sodium intake in CKD patients [11,20,38-40]. A recent Cochrane meta-analysis by Aminde et al. (2023) [41] also found that reducing salt intake by approximately 4.2 grams per day led to a significant decrease in both systolic blood pressure and diastolic blood pressure. While the evidence supporting the effect of low sodium intake on SBP is compelling, the findings regarding DBP are less straightforward, indicating a lack of significant effect and raising questions about the different mechanisms through which dietary sodium influences systolic blood pressure and diastolic blood pressure. Combining dietary sodium restriction with other integrative medicine approaches, such as mindfulness practices, stress reduction techniques, and complementary therapies, could offer synergistic benefits for blood pressure management in CKD patients. These holistic approaches could address the multifaceted nature of hypertension and improve overall well-being, potentially enhancing the effectiveness of dietary interventions. Contrary to the expected hypertensive effect of high sodium intake, findings from the current study revealed that high sodium intake did not have a significant impact on systolic blood pressure in chronic kidney disease patients. The pooled effect size from four studies was 0.16, indicating no significant change in SBP with high sodium intake [26, 30-32]. Additionally, the low heterogeneity suggests consistent results across different study populations and methodologies. The consistent results highlight the need for a more individualized approach in managing sodium intake in CKD patients, considering the unique pathophysiological context of each patient. One possible explanation for the non-significant effect of high sodium intake on SBP could be adaptive physiological mechanisms in CKD patients that mitigate the impact of sodium on blood pressure. CKD is often associated with altered sodium handling and volume regulation due to impaired renal function, which might blunt the pressor response to sodium [42]. Furthermore, CKD patients are commonly prescribed antihypertensive medications, which could confound the impact of sodium intake on blood pressure. These medications, depending on their specific mechanisms of action, may mitigate the hypertensive effects of sodium. Some antihypertensive drugs reduce sodium reabsorption in the kidneys, thereby diminishing the potential increase in blood pressure caused by high sodium intake [43]. The inconsistent reporting of antihypertensive medication use in the included studies introduces a variable that could partially account for the observed lack of significant effect. Similarly, the meta-analysis as deduced from three studies found a non-significant effect of high sodium intake on DBP, with a pooled effect size of -0.04 and no significant heterogeneity [26][30][31]. These findings align with the results for SBP, suggesting a consistent lack of significant impact of high sodium intake on blood pressure parameters in CKD patients. The lack of effect on DBP supports the hypothesis that CKD patients may have an attenuated blood pressure response to sodium [42]. These findings question the traditional view of sodium-induced hypertension, especially within the context of CKD. Despite the well-established link between high sodium intake and hypertension in the general population, CKD patients may exhibit a different response due to their unique pathophysiological state [44]. These results suggest that a one-size-fits-all approach to sodium restriction may not be appropriate for all CKD patients and highlight the importance of personalized dietary recommendations. Other research also challenge these findings, a systematic review by Smyth et al. (2014) [45] and a meta-analysis by Kim et al. (2021) [46] examining the effect of urinary angiotensinogen and high-salt diet on blood pressure in CKD patients found that high sodium intake significantly increased both SBP and DBP. Furthermore, the examination of age-related differences in blood pressure responses to low salt intake revealed distinct patterns in both SBP and DBP. Analysis of data from eight studies demonstrated age-based variations in how blood pressure is affected by low salt intake. Younger and middle-aged CKD patients (that is, those under 50 years) experienced a slight reduction in SBP and a more pronounced reduced in DBP compared to CKD patients over 50 years. The improved response in younger patients could be attributed to better vascular health and fewer additional health conditions, which enhance their ability to adapt to dietary changes. Older individuals often have more advanced vascular changes and additional health challenges that might reduce the effectiveness of low salt interventions [47]. Similarly, reductions in DBP are more significant among younger and middle-aged patients. The trends observed in DBP align with those seen in SBP, indicating that younger patients benefit more from low salt intake. These findings suggest consistent physiological mechanisms, driving these improvements across both types of blood pressure measurements. However, it is important to consider that the benefits observed in younger patients may not directly translate to older populations, where different therapeutic strategies might be required to achieve similar blood pressure control. Further research is needed to explore how age-specific factors such as hormone levels, sodium sensitivity, and medication interactions influence the response to dietary sodium interventions in CKD patients. Considerable variability is observed across the studies for both SBP and DBP. The effects of low salt intake on blood pressure vary significantly between short-term (≤2 months) and long-term (>2 months) interventions. Short-term interventions typically produce SBP values ranging from 125±12 mmHg to 144.9±13.1 mmHg. McMahon et al. (2012) [31] and Taylor et al. (2018) [32] reported particularly high values (144.9±13.1 mmHg and 137±3 mmHg, respectively), suggesting that short-term low salt intake may not be sufficient to achieve significant and sustained reductions in SBP. In contrast, long-term interventions generally result in lower and more stable SBP values. Research by Akdag et al. (2015) [26] and Meuleman et al. (2017) [28] showed SBP values of 140±14 mmHg and 130.3±2.3 mmHg, respectively. This indicates that prolonged adherence to a low-salt diet can yield more substantial and lasting reductions in SBP. The distinction between short-term and long-term effects is critical in understanding the full impact of sodium reduction on blood pressure. While short-term interventions might capture the initial, acute responses to sodium reduction, including diuresis and changes in vascular tone, long-term interventions likely reflect more stable physiological adaptations, such as improved arterial compliance and better volume control, which are necessary for sustained blood pressure reductions. Moreover, long-term adherence to dietary sodium restriction could lead to behavioral and lifestyle changes that reinforce the positive effects on blood pressure, contributing to overall cardiovascular health. Short-term low-salt intake interventions showed DBP values ranging from 79.8±0.8 mmHg to 89.9±2.8mmHg. Notably, studies by McMahon et al. (2012) [31] and Taylor et al. (2018) [32] report DBP values of 87.9±1.4 mmHg and 89.9±2.8 mmHg, respectively, indicating limited impact of short-term dietary changes. Conversely, long-term interventions generally result in lower and more stable DBP values, ranging from 76.2±1.2 mmHg to 81.6±9.5 mmHg. Research by Akdag et al. (2015) [26] and Meuleman et al. (2017) [28] showed DBP values of 80±6 mmHg and 81.6±9.5 mmHg, respectively, indicating more substantial reductions in DBP with prolonged adherence to a low-salt diet. These findings suggest that the benefits of sodium reduction on DBP may take longer to manifest compared to SBP, possibly due to the different physiological processes involved. The more gradual improvement in DBP with long-term sodium restriction highlights the importance of patient persistence and support in maintaining dietary changes, as the full benefits may not be immediately apparent. While short-term interventions can produce rapid but modest improvements in SBP and DBP, these changes often lack stability [39]. This could be due to the body's initial adaptive responses to sodium reduction, such as diuresis and natriuresis, which may not sustain long-term benefits. Long-term adherence to a low-salt diet leads to more significant and stable reductions in both SBP and DBP. Prolonged dietary changes may result in better regulation of extracellular fluid volume, sustained improvements in vascular resistance, and enhanced renal function, contributing to lasting blood pressure control [11][48]. The enduring impact of long-term sodium reduction on blood pressure, particularly in the context of CKD, underpins the importance of sustained dietary interventions as part of a comprehensive management plan for these patients. Continued research is needed to identify the most effective strategies for promoting long-term adherence to sodium restriction, as well as to further elucidate the underlying mechanisms that drive these beneficial effects.   Recommendations Based on the findings of this systematic review and meta-analysis, several recommendations can be made for clinical practice and future research. Healthcare providers should consider recommending low sodium intake as part of dietary management for CKD patients to achieve better SBP control. Given the greater benefit observed in younger and middle-aged patients, personalized dietary recommendations based on age and other patient characteristics may enhance effectiveness. Long-term dietary interventions should be emphasized over short-term changes. Sustained reduction in sodium intake is more likely to result in significant and consistent blood pressure improvements. Clinical guidelines should be updated to reflect the evidence supporting the benefits of low sodium intake for SBP reduction in CKD patients. Clear thresholds for low sodium intake and detailed recommendations on the duration of dietary interventions should be provided. Additional research is required to investigate the mechanisms behind the differing effects of sodium intake on SBP and DBP. Understanding these mechanisms can help tailor dietary recommendations more effectively. More high-quality, randomized controlled trials with standardized protocols for sodium reduction and blood pressure measurement are essential to reduce heterogeneity and improve the reliability of findings. Research should also investigate the long-term effects of sodium reduction on cardiovascular outcomes in CKD patients, as well as the role of concurrent pharmacotherapy and other lifestyle modifications in enhancing the benefits of dietary sodium reduction. Limitation Several constraints should be considered when interpreting these results. Firstly, the high heterogeneity observed in the analysis of low sodium intake on SBP (I² = 98%) and DBP (I² = 94%) suggests substantial variability among the included studies. This variability could stem from differences in study design, baseline characteristics, degree of sodium reduction, and duration of interventions.  The included studies exhibited varying methodological quality, with potential biases such as lack of blinding and randomization influencing the outcomes. Additionally, data availability and consistency were additional challenges. Not all studies provided detailed information on the baseline characteristics of participants, and there were inconsistencies in how blood pressure was measured and reported. The factors could affect the reliability of pooled estimates and the generalizability of the findings to the broader CKD population.   Conclusion This systematic review and meta-analysis explored the effects of sodium intake on blood pressure in patients with chronic kidney disease. Findings suggest that a reduced sodium intake significantly lowers SBP. This supports the hypothesis that reducing sodium intake can have beneficial effects on blood pressure management in CKD patients. The reduction in SBP can be attributed to the physiological mechanisms of decreased extracellular fluid volume, reduced cardiac output, and lower vascular resistance. However, the impact on DBP was not significant, suggesting that diastolic pressure may not be as responsive to sodium reduction. Contrarily, high sodium intake did not show a significant effect on SBP or DBP in CKD patients challenging the conventional understanding of sodium-induced hypertension, particularly in the CKD context. Adaptive physiological mechanisms in CKD, such as altered sodium handling and volume regulation, might mitigate the expected hypertensive response. The lack of significant effect on DBP with both low and high sodium intake further underlines the complexity of blood pressure regulation in CKD. Age-based analysis revealed that younger and middle-aged CKD patients benefit more from low sodium intake compared to older patients, indicating that age-related vascular changes and comorbidities may influence the effectiveness of dietary interventions. Additionally, long-term sodium reduction (over two months) proved more effective in reducing both SBP and DBP compared to short-term interventions, highlighting the importance of sustained dietary changes for optimal blood pressure control.   Acknowledgments We extend our acknowledgments to friends and families who morally supported during the course. Very importantly, we extend appreciations to Department of Biomedical Science, Chester Medical School, and University of Chester for providing the platform and approval for this research.   Author’s contributions WTT developed the manuscript. CFA performed the meta-analysis and other statistics.   Conflict of interest Authors declared no conflict of interest.   Funding The research work was self-sponsored.   Ethical Considerations As this study involved the analysis of previously published data, no ethical approval was required. However, ethical considerations for conducting and reporting systematic reviews were strictly followed to ensure transparency, accuracy, and reproducibility of the findings. On the other hand, all data obtained from the published works were duly cited as required in academic and research writing.   References 1.     Levey AS, de Jong PE, Coresh J, El Nahas M, Astor BC, Matsushita K, et al. The definition, classification, and prognosis of chronic kidney disease: a KDIGO Controversies Conference report. Kidney Int. 2011; 80(1): 17-28. doi: 10.1038/ki.2010.483. 2.     Bakris GL, Ritz E. World Kidney Day 2009: hypertension and kidney disease is a marriage that should be prevented. Am J Kidney Dis. 2009; 53(3): 373-376. doi:10.1053/j.ajkd.2009.01.006 3.     He FJ, Li J, Macgregor GA. Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. BMJ. 2013; 346: f1325. doi:10.1136/bmj.f1325. 4.     Weir MR, Dzau VJ. The renin-angiotensin-aldosterone system: a specific target for hypertension management. Am J Hypertens. 1999; 12(12 Pt 3): 205S-213S. doi:10.1016/s0895-7061(99)00103-x. 5.     Borrelli S, Provenzano M, Gagliardi I, Michael A, Liberti ME, De Nicola L, et al. Sodium intake and chronic kidney disease. Int J Mol Sci. 2020; 21(13): 4744. doi:10.3390/ijms21134744. 6.     López-Hernández FJ, López-Novoa JM. Role of TGF-β in chronic kidney disease: an integration of tubular, glomerular and vascular effects. Cell Tissue Res. 2012; 347(1): 141-154. doi:10.1007/s00441-011-1275-6. 7.     Gu YY, Liu XS, Huang XR, Yu XQ, Lan HY. Diverse role of TGF-β in kidney disease. Front Cell Dev Biol. 2020; 8: 123. doi:10.3389/fcell.2020.00123. 8.     Ling XC, Kuo KL. Oxidative stress in chronic kidney disease. Ren Replace Ther. 2018; 4: 53. doi: 10.1186/s41100-018-0195-2. 9.     Vila Cuenca M, Hordijk PL, Vervloet MG. Most exposed: the endothelium in chronic kidney disease. Nephrol Dial Transplant. 2020; 35(9): 1478-1487. doi:10.1093/ndt/gfz055. 10.  Huang Y, Di Lorenzo A, Jiang W, Cantalupo A, Sessa WC, Giordano FJ. Hypoxia-inducible factor-1α in vascular smooth muscle regulates blood pressure homeostasis through a peroxisome proliferator-activated receptor-γ-angiotensin II receptor type 1 axis. Hypertension. 2013; 62(3): 634-640. doi:10.1161/HYPERTENSIONAHA.111.00160. 11.  Shi H, Su X, Li C, Guo W, Wang L. Effect of a low-salt diet on chronic kidney disease outcomes: a systematic review and meta-analysis. BMJ Open. 2022; 12(1): e050843. doi:10.1136/bmjopen-2021-050843. 12.  Filippini T, Malavolti M, Whelton PK, Naska A, Orsini N, Vinceti M. Blood pressure effects of sodium reduction: dose-response meta-analysis of experimental studies. Circulation. 2021; 143(16): 1542-1567. doi:10.1161/CIRCULATIONAHA.120.050371. 13.  Jaques DA, Wuerzner G, Ponte B. Sodium intake as a cardiovascular risk factor: a narrative review. Nutrients. 2021; 13(9): 3177. doi:10.3390/nu13093177. 14.  Graudal NA, Hubeck-Graudal T, Jurgens G. Effects of low sodium diet versus high sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol, and triglyceride. Cochrane Database Syst Rev. 2011; (11): CD004022. doi:10.1002/14651858.CD004022.pub3. 15.  Youssef GS. Salt and hypertension: current views.E-Journal of Cardiology Practice. 2022; Available from: https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-22/salt-and-hypertension-current-views. [cited in July 2024]. 16.  Gupta DK, Lewis CE, Varady KA, Su YR, Madhur MS, Lackland DT, et al. Effect of dietary sodium on blood pressure: a crossover trial. JAMA. 2023; 330(23): 2258-2266. doi:10.1001/jama.2023.23651. 17.  Crawford-Faucher A, Huijon RM. Effects of altered dietary salt intake in patients with chronic kidney disease. Am Fam Physician. 2017; 95(7): 423-424. 18.  Bailey MA, Dhaun N. Salt sensitivity: causes, consequences, and recent advances. Hypertension. 2024; 81(3): 476-489. doi:10.1161/HYPERTENSIONAHA.123.17959. 19.  Stamler J, Chan Q, Daviglus ML, Dyer AR, Van Horn L, Garside DB, et al.Relation of dietary sodium (salt) to blood pressure and its possible modulation by other dietary factors: the INTERMAP study. Hypertension. 2018; 71(4): 631-637. doi:10.1161/HYPERTENSIONAHA.117.09928. 20.  Huang L, Trieu K, Yoshimura S, Neal B, Woodward M, Campbell NRC, et al. Effect of dose and duration of reduction in dietary sodium on blood pressure levels: systematic review and meta-analysis of randomised trials. BMJ. 2020; 368: m315. doi:10.1136/bmj.m315. 21.  Cook NR, Cutler JA, Obarzanek E, Buring JE, Rexrode KM, Kumanyika SK, et al.Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the trials of hypertension prevention (TOHP). BMJ. 2007; 334(7599): 885-888. doi:10.1136/bmj.39147.604896.55. 22.  Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021; 372: n71. doi:10.1136/bmj.n71. 23.  Resourceful Scholar's Hub. Zotero reference management guide [Internet]. Available from: https://resourcefulscholarshub.com/zotero-reference-management-guide/. [cited in July 2024]. 24.  Kim KS, Chung JH, Park HJ, Shin WJ, Lee BH, Lee SW. Quality assessment and relevant clinical impact of randomized controlled trials of varicocele: next step to good-quality randomized controlled trial of varicocele treatment. World J Mens Health. 2022; 40(2): 290-298. doi: 10.5534/wjmh.200167. 25.  Saran R, Padilla RL, Gillespie BW, Heung M, Hummel SL, Derebail VK, et al. A randomized crossover trial of dietary sodium restriction in stage 3-4 CKD. Clin J Am Soc Nephrol. 2017; 12(3): 399-407. doi: 10.2215/CJN.01120216. 26.  Akdag S, Akyol A, Cakmak HA, Tosu AR, Asker M, Yaman M, et al. The effect of low-sodium dialysate on ambulatory blood pressure measurement parameters in patients undergoing hemodialysis. Ther. Clin Risk Manag. 2015; 11: 1829-35. doi: 10.2147/TCRM.S94889. 27.  de Brito-Ashurst I, Perry L, Sanders TA, Thomas JE, Dobbie H, Varagunam M, et al. The role of salt intake and salt sensitivity in the management of hypertension in South Asian people with chronic kidney disease: a randomised controlled trial. Heart. 2013; 99(17): 1256-60. doi: 10.1136/heartjnl-2013-303688. 28.  Meuleman Y, Hoekstra T, Dekker FW, Navis G, Vogt L, van der Boog PJM, et al. Sodium restriction in patients with CKD: a randomized controlled trial of self-management support. Am J Kidney Dis. 2017; 69(5): 576-586. doi: 10.1053/j.ajkd.2016.08.042. 29.  O’Callaghan CA, Camidge C, Thomas R, Reschen ME, Maycock AJ, Lasserson DS, et al. Evaluation of a simple low-cost intervention to empower people with CKD to reduce their dietary salt intake: OxCKD1, a multicenter randomized controlled trial. Kidney360. 2023; 4(7): 890-898. doi:10.34067/KID.0000000000000160. 30.  Taylor AHM, Rankin AJ, McQuarrie EP, Freel EM, Homer NZM, Andrew R, et al. Non-uniform relationship between salt status and aldosterone activity in patients with chronic kidney disease. Clin Sci (Lond). 2018; 132(2): 285-294. doi:10.1042/CS20171603. 31.  McMahon EJ, Bauer JD, Hawley CM, Isbel NM, Stowasser M, Johnson DW, et al. The effect of lowering salt intake on ambulatory blood pressure to reduce cardiovascular risk in chronic kidney disease (LowSALT CKD study): protocol of a randomized trial. BMC Nephrol. 2012; 13: 137. doi: 10.1186/1471-2369-13-137. 32.  Slagman MCJ, Waanders F, Vogt L, Damman K, Hemmelder M, Navis G, et al. Elevated N-terminal pro-brain natriuretic peptide levels predict an enhanced anti-hypertensive and anti-proteinuric benefit of dietary sodium restriction and diuretics, but not angiotensin receptor blockade, in proteinuric renal patients. Nephrol Dial Transplant. 2012; 27(3): 983-990. doi:10.1093/ndt/gfr408. 33.  University of Melbourne. RevMan - Systematic reviews & meta-analyses [Internet].Available from: https://unimelb.libguides.com/sysrev/revman.[cited in July 2024]. 34.  Frank RA, Salameh JP, Islam N, Yang B, Murad MH, Mustafa R, et al. How to critically appraise and interpret systematic reviews and meta-analyses of diagnostic accuracy: a user guide. Radiology. 2023; 307(3): e221437. doi: 10.1148/radiol.221437. 35.  Chrysohoou C, Mantzouranis E, Dimitroglou Y, Mavroudis A, Tsioufis K. Fluid and salt balance and the role of nutrition in heart failure. Nutrients. 2022; 14(7): 1386. doi: 10.3390/nu14071386. 36.  Shahoud JS, Sanvictores T, Aeddula NR. Physiology, Arterial Pressure Regulation. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023. 37.  Hodson EM, Cooper TE. Altered dietary salt intake for preventing diabetic kidney disease and its progression. Cochrane Database Syst Rev. 2023; 1(1): CD006763. doi: 10.1002/14651858.CD006763.pub3. 38.  Juraschek SP, Miller ER 3rd, Weaver CM, Appel LJ. Effects of sodium reduction and the DASH diet in relation to baseline blood pressure. J Am Coll Cardiol. 2017; 70(23): 2841-2848. doi: 10.1016/j.jacc.2017.10.011. 39.  Singh M, Goto K, Wisinski J. Reduced dietary salt for patients with chronic kidney disease. Am Fam Physician. 2022; 105(5): 466-467. 40.  Hooper L, Bartlett C, Davey Smith G, Ebrahim S. Systematic review of long term effects of advice to reduce dietary salt in adults.BMJ. 2002; 325(7365): 628. doi: 10.1136/bmj.325.7365.628. 41.  Aminde LN, Wanjau MN, Cobiac LJ, Veerman JL. Estimated impact of achieving the Australian national sodium reduction targets on blood pressure, chronic kidney disease burden and healthcare costs: a modelling study. Nutrients. 2023; 15(2): 318. doi: 10.3390/nu15020318. 42.  Khan S, Floris M, Pani A, Rosner MH. Sodium and volume disorders in advanced chronic kidney disease. Adv Chronic Kidney Dis. 2016; 23(4): 240-6. doi: 10.1053/j.ackd.2015.12.003. 43.  Pugh D, Gallacher PJ, Dhaun N. Management of hypertension in chronic kidney disease. Drugs. 2019; 79(4): 365-379. doi: 10.1007/s40265-019-1064-1. Erratum in: Drugs. 2020; 80(13): 1381. doi: 10.1007/s40265-020-01388-8. 44.  Wang AY, Mallamaci F, Zoccali C. What is central to renal nutrition: protein or sodium intake? Clin Kidney J. 2023; 16(11): 1824-1833. doi: 10.1093/ckj/sfad151. 45.  Smyth A, O'Donnell MJ, Yusuf S, Clase CM, Teo KK, Canavan M, et al. Sodium intake and renal outcomes: a systematic review. Am J Hypertens. 2014; 27(10): 1277-84. doi: 10.1093/ajh/hpt294. 46.  Kim HY, Choi HS, Kim CS, Bae EH, Ma SK, Sung SA, et al. Effect of urinary angiotensinogen and high-salt diet on blood pressure in patients with chronic kidney disease: results from the Korean cohort study for outcome in patients with chronic kidney disease (KNOW-CKD). Korean J Intern Med. 2021; 36(3): 659-667. doi: 10.3904/kjim.2020.077. 47.  Garofalo C, Provenzano M, Andreucci M, Pisani A, De Nicola L, Conte G, et al. Predictive effect of salt intake on patient and kidney survival in non-dialysis CKD: competing risk analysis in older versus younger patients under nephrology care. Nephrol Dial Transplant. 2021; 36(12): 2232-2240. doi: 10.1093/ndt/gfaa252. 48.  Cobb M, Pacitti D. The importance of sodium restrictions in chronic kidney disease. J Ren Nutr. 2018; 28(5): e37-e40. doi: 10.1053/j.jrn.2018.02.001.     Cite this article as: Tabowei WT, Amadi CF. Sodium intake and blood pressure regulation in CKD: a systematic review and meta-analysis. IMC J Med Sci. 2026; 20(1):003. DOI: https://doi.org/10.55010/imcjms.20.003. <![CDATA[Efficacy and safety of lentivirus gene therapy in the correction of sickle cell disease]]> Sammy Joshua Ioanna Myrtzious Kanaki Perpetua U. Emeagi Chikadibia Fyneface Amadi* https://imcjms.com/journal_full_text/576 2025-09-07 12:13:20 Review July 2025; Vol. 19(2):007 Background and objective: Lentivirus gene therapy (LGT) is an emerging therapy for sickle cell disease (SCD), although its efficacy and safety are under evaluation in clinical trials. This review assessed the efficacy and safety of LGT in relation to hydroxyurea (HU). Results: There was a significant increase (p-value<0.00001) in haemoglobin (Hb) level after LGT and production of HbAT87Q and foetal haemoglobin (HbF). Clinical outcome decreased significantly, and no hospitalization was required following LGT. A significant age-related difference in the LGT outcome was observed. Mode 1 treatment had significantly higher (p=0.004) outcome compared to mode 2 treatment. There was a significant increase (p<0.00001) in treatment outcome in SCD patients treated with LGT compared to those treated with HU. Gastroenteritis and leucopenia were the most reported adverse effects. July 2025; Vol. 19(2):007.  DOI: https://doi.org/10.55010/imcjms.19.018 *Correspondence: Chikadibia Fyneface Amadi, Department of Medical Laboratory Science, PAMO University of Medical Sciences, Rivers State, Nigeria. Email: worldwaiting@yahoo.com. © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License(CC BY 4.0). Introduction The pathophysiology of SCD is intricate, involving several factors, such as hemolysis, vaso-occlusion, inflammation, oxidative stress, endothelial dysfunction, and hypercoagulability [6-8]. Treatment of SCD aims to prevent or mitigate the frequency and severity of complications, enhance quality of life, and extend lifespan of the patient. Existing therapeutic approaches encompass supportive care, pharmacological agents, and hematopoietic stem cell transplantation (HSCT) [9,10]. Various supportive care approaches include hydration, analgesics and antibiotics administration, blood transfusions, and immunization modalities [11,12]. Among pharmacological agents, hydroxyurea stands out—an agent boosting fetal hemoglobin production, thereby reducing the polymerization of hemoglobin S and the sickling of RBCs [12]. Demonstrating efficacy, hydroxyurea has been linked to a decrease in pain crises, incidents of acute chest syndrome, hospitalizations, and increased mortality rate in SCD patients [13]. Nevertheless, challenges such as variable response, adverse effects, and compliance issues temper its utility [14]. At present, a cutting-edge alternative in SCD intervention is gene therapy, aiming to rectify the underlying genetic anomaly at its source. This innovative approach involves the introduction of a functional gene into specific target cells, notably hematopoietic stem cells (HSCs), to bring about modifications in their gene expression and phenotype character [16]. Gene therapies broadly fall into two categories: gene addition and gene editing. Gene addition involves incorporating a therapeutic gene into the genome of the target cells without altering existing genes [16]. On the other hand, gene editing entails the precise modification or correction of the target gene, employing advanced tools such as zinc finger nucleases, transcription activator-like effector nucleases, or the CRISPR-Cas9 system [17,18]. One of the most exciting advances in sickle cell disease (SCD) treatment is the use of CRISPR/Cas9 gene editing, a technology that allows scientists to make precise changes to DNA. Generally, CRISPR is palindromic sequence in bacterial genome which can be excised by the cas9 enzyme, allowing scientists to modify, edit, insert or delete genes according to convenience. This breakthrough has led to CASGEVY™ (exagamglo gene autotemcel, or exa-cel), the first FDA-approved CRISPR-based therapy for SCD, developed by Vertex Pharmaceuticals and CRISPR Therapeutics. CASGEVY works by editing a patient’s own stem cells to boost the production of fetal hemoglobin (HbF), which helps counteract the harmful effects of sickle hemoglobin [19,20]. The FDA approval of CASGEVY in late 2023 was a landmark moment not just for SCD patients, but for the entire field of gene therapy. For decades, researchers have been working toward a true cure for SCD, and this therapy represents a major step forward. Clinical trials have shown that CASGEVY can dramatically reduce or even eliminate pain crises in many patients, offering hope for a life free from the most debilitating symptoms of SCD [21]. Beyond its clinical success, CASGEVY’s approval also sets a precedent for future gene-editing treatments, proving that CRISPR technology can be both safe and effective in treating genetic disorders. While challenges like cost and accessibility remain, this therapy opens a new era of personalized medicine for SCD patients [22,23].   (B) In Vivo Gene Therapy: Systemic delivery of a gene-modifying agent with affinity for HSCs directly targets cells within the patient's body, providing a streamlined and less invasive gene therapy approach. The efficacy of LGT hinges on the type of therapeutic gene delivered by the lentiviral vector [29]. In the context of sickle cell disease (SCD), there are two primary strategies for LGT: anti-sickling gene therapy and globin gene therapy [16,25-34]. Anti-sickling gene therapy entails the delivery of a gene encoding a modified hemoglobin variant capable of preventing or reducing the polymerization and sickling of hemoglobin S [32-34]. Examples of anti-sickling genes include hemoglobin F (HbF), the fetal form of hemoglobin typically silenced after birth, and hemoglobin A (HbA), the normal adult form of hemoglobin mutated in SCD [32-34]. Other examples involve hemoglobin A2 (HbA2), a minor adult hemoglobin form, and hemoglobin mutants like hemoglobin E (HbE) and hemoglobin G (HbG), both possessing reduced affinity for hemoglobin S [32-35].     To gauge the effectiveness of this therapeutic approach, a range of assessment methods is employed. In vitro analyses are conducted to scrutinize alterations in vector titers and transduction efficacy [42]. In vivo studies entail the transplantation of vector- or mock-transduced cells into animal models to evaluate therapeutic effectiveness [42]. Rigorous clinical trials are undertaken to assess the safety and efficacy of the lentiviral vector, the in vivo gene transfer clinical protocol, and the sustained correction of associated pathological symptoms [43]. The evaluation of vector integration sites is crucial to ensure the safety of the gene therapy [43]. Additionally, measuring degradative metabolite levels in patients during treatment aids in evaluating therapeutic efficacy [43]. The monitoring of clinical endpoints involves observing changes in disease symptoms, the frequency of disease-related complications, and the overall health and quality of life of patients [44]. These outcomes aim to improve oxygen-carrying capacity, minimize painful episodes, prevent life-threatening complications, and enhance the overall well-being of individuals with SCD. While LGT has shown promising outcomes, it is essential to acknowledge certain limitations that warrant attention. These limitations are limited patient numbers, short follow-up periods, and a deficiency in long-term data [47]. To strengthen the robustness of LGT's safety and efficacy profile, further studies are imperative. These studies should delve into critical parameters such as lentiviral vector design, conditioning regimens, transduction protocols, and comparative analyses with alternative gene therapy strategies [47]. Additionally, the optimization of clinical endpoints and the resolution of practical challenges, including cost, accessibility, ethics, and regulation, are pivotal for propelling LGT toward becoming a viable treatment for Sickle Cell Disease [47].   The Preferred Reporting Items for Systematic Review and Meta-analysis (PRIMSA) protocol of 2015 [49] was followed in the step-by-step development of the review to ensure reproducibility and transparency in the review process. The summary of the PRISMA protocol was reported using a PRISMA flowchart. Exclusion criteria: Studies not relevant to LGT in SCD such as other haemoglobinopathies like thalassemia were excluded. Animal studies, editorials and review articles, original studies using other forms of gene therapy were also excluded. Search strategy: A comprehensive search strategy was developed using a combination of Boolean function [50] and filters to narrow the study to original articles and clinical trials (randomized and non-randomized clinical trials) with advanced search including specific keywords like “lentivirus sickle cell disease” particularly for ScienceDirect. It is important to mention that the search strategy was adjusted to the specific provisions of each database.   Data management: All search results from the listed databases were first imported and managed by EndNote software, after which they were exported as XML files to Covidence for screening, selection, extraction and quality assessment of the included studies. Leveraging on the features of the software (EndNote), streamlining the process of reference formatting of included studies to the desired citation style was possible [51]. Covidence is a web-based tool for systematic review management [52,53] following PRISMA guideline, including title and abstract screening, full text screening, quality assessment. The Covidence tool was also used for data extraction and PRISMA flowchart generation [52,53]. Quality assessment: Virtually all the studies included were in the 1/2 phase of clinical trial. Since these phases of studies are typical of pilot studies, the checklist tool used was put into consideration to capture the peculiarity of such studies because studies in early phase clinical trials may require modifications in their quality assessment due to their uniqueness. In this case the studies were neither a full-scale clinical nor randomized clinical trial. To fulfill this purpose, the University of Chicago checklist for pilot studies was used to judge the quality of each study. It reflected at parameters such as the study’s goal, the reason for doing it, whether the way data was collected matched the goal, the number of participants (though not in a strict statistical way), if the data collection method would work in a larger study, and whether there was a good reason to move forward with a full-scale study.[54]. Ethical consideration: Following the fact that the review depended on already published data (secondary data) available in the public domain for public use, ethical clearance was not required for the commencement of the study. However, all used data from the secondary sources were duly cited. Results   Figure-3: PRISMA Flowchart Figure-3 above shows the PRISMA flowchart illustrating the review process. Out of449 studies, 10 were considered eligible for quality assessment and onward data extraction. Study Design Treatment Summary of the findings Studies on Hydroxyurea therapy Lad et al., 2022 [65] Clinical trial SCD patients Sample size: 138 Mean age: ≤14 yrs Hydoxyurea; Dose(CD34+) (cells/Kg):18.7 24 months The study showed that post-treatment hemoglobin levels averaged 9.2 g/dL with 25.6% HbF production. Clinical outcomes showed minimal vaso-occlusive pain (3.6%) and no chest pain, though non-cardiac pain remained prevalent at 54.3%. Hospitalization data was not reported Hoppe et al., 1999 [66] Clinical trial Severe SCD patients Sample size: 8 Mean age: 3.7 yrs Hydroxyurea; Dose(CD34+) (cells/Kg): 27 137 weeks The study demonstrated the highest hemoglobin improvement among hydroxyurea studies (10.7 g/dL) with 19% HbF. Notably eliminated all vaso-occlusive and non-cardiac pain, but reported a 20% hospitalization rate post-treatment Ofakunrin et al., 2018 [67] Quasi-experimental study SCA patients Sample size: 54 Mean age: 8.4 yrs Hydroxyurea; Dose(CD34+) (cells/Kg): n/m     12 months The study achieved hemoglobin levels of 9.3 g/dL, though HbF percentages were not documented. The study reported complete resolution of both vaso-occlusive and non-cardiac pain (0% for both), with no reported hospitalizations. PTA interval: Post-treatment assessment interval; SCD: Sickle cell disease; SCA: Sickle cell anaemia; n/m: Not mentioned   Meta-analysis of the efficacy of a treatment (Lentivirus gene therapy) in managing sickle cell disease based on Haemoglobin     Figure-4 shows that among the seven studies, there was statistical difference among the groups of the studies (Z=2.20, P<0.03). This implies significant reduction in Hemoglobin before gene therapy (MD= -3.50, 95% C.I [-6.63, -0.38]). Also, significant heterogeneity was seen across the studies (I2= 99%; P<0.00001). Table-3: Summary of the efficacy of a treatment (lentivirus gene therapy) in managing sickle cell disease     Table-4: Proportion of HBAT87Q and HbF among the studies       Age dependent variation in treatment outcome     Table-6 provides a summary of descriptive statistics related to age-dependent variation in treatment outcomes for sickle cell disease across different studies. The table includes data on the ages of individuals who participated in the studies. The average age of the participants across all studies is approximately 22 years, with an age interval spanning from 14 to 32 years. The table presents various treatment outcomes, including the percentage of HbAT87Q treatment, the percentage of HbF treatment, absolute reticulocyte count (ARC) after treatment, and lactate dehydrogenase (LD) levels after treatment. Table-6: Summary of descriptive statistics on age dependent variation in treatment outcome   Mode 2: represents treatment targeted at improving HbF level. Figure-6 below shows the meta-analysis of treatment outcome based on mode of action of lentiviral gene therapy across the studies. It was seen that there was a significant mean difference between the mode 1 and mode 2 groups and Lentiviral gene therapy favoured mode 1 action (IV=-14.69, 95% CI [-24.61, -4.77], Z=2.90, p=0.004). Significant heterogeneity existed among the groups (I2= 100%, P<0.00001). Treatment outcome based on disease severity Figure-7: Forest Plot showing treatment outcome based on disease severity (SSCD versus SCD)       Based on Figure-8 as illustrated, the meta-analysis of treatment outcome based on duration of treatment assessment revealed no effect for duration of treatment assessment at 1 year duration term and <1 year duration term (OR, 0.78, 95% [0.34, 1.79), Z=0.59, p=0.55). Meta-analysis of treatment outcome between lentivirus gene therapy and hydroxyurea for SCD     Table-7 presents a summary of descriptive statistics comparing treatment outcome (HbF) between two different approaches for managing sickle cell disease (SCD): lentivirus gene therapy and hydroxyurea treatment.     Comparison clinical outcome between lentivirus gene therapy and Hydroxyurea for SCD Figure-10: Forest plot showing the comparison of clinical outcomes between lentivirus gene therapy and Hydroxyurea for SCD The meta-analysis of the comparison of clinical outcomes between lentivirus gene therapy and hydroxyurea for SCD (Figure-10) showed that there was no significant difference between lentivirus gene therapy and hydroxyurea for SCD (IV=1.88, 95%, [-10.50, 14.26], Z=0.30, P=0.77). There wassignificant heterogeneity among the studies (I2=100%, P<0.00001). Discussion The substantial increase in Hb levels indicated a positive response to the therapy, as higher Hb levels are generally desirable in managing sickle cell disease. A reduction in absolute reticulocyte count (ARC) is typically seen as a positive response to treatment in sickle cell disease as well as a decrease in lactate dehydrogenase (LD) levels. All these changes in the parameters are often indicative of improved red blood cell health. These findings are in consonance with the study conducted by Abraham in 2021 who reported that increase in Hb level is an indication of improvement of red blood cell health and treatment success [25,68]. This is to say that the decrease in ARC and LD levels reported in this review were suggestive of therapeutic success of LGT in SCD patients whose red blood cells were often destroyed or lysed due to their sickle shape. In general, the increase in Hb, and decrease in ARC and LD levels suggested that the therapy was effective in improving the health of individuals with SCD [69]. Clinical outcomes such as vaso-occlusive pain, chest pain syndrome, hospitalization and non-cardiac pain were assessed among the studies. The findings revealed that there were no reported cases of hospitalization after treatment although there were few reported cases of vaso-occlusive pain [58,60,63], chest pain syndrome [60,64], and non-cardiac pain [58,60,63]. These findings support the fact that LGT improves the quality of life as reported by other studies [58,72-74]. It is noteworthy that LGT provides therapeutic intervention via any of the two mechanisms: gene addition [16] and promoting HbF production [25-33]. In comparing between modes of treatment, since the results showed that there was significant improvement in the treatment outcome in mode 1 compared to mode 1I, it implies that the LGT was more effective when the treatment was targeted towards correcting the mutant gene than when treatment was targeted towards improving HbF level. This means that whether the LGT was made to fix the faulty gene or to increase fetal hemoglobin levels, both approaches showed better treatment result, although correcting the mutant gene provided better therapeutic achievement than improving foetal haemoglobin level.Till now, no study has compared the treatment outcomes between these two modes. The study conducted by Demirci and Germino-Watnick who reported improvements in total Hb levels in lentiGlobin gene and BCL11A shmiR gene infusion [33,76] supports the fact that both modes of treatments achieved therapeutic success. The result presented in Figure-6 highlighted the diversity in the duration of treatment assessment across the studies, however, the duration of the treatment (whether long term or short term) did not make any difference in the success achieved. This may be due to the sustained presence of the corrected gene in the haematopoietic stem cell infused in the treatment process, resulting in continuous production of healthy red blood cells and improved treatment outcome. This is supported by the works conducted by Kanter and Drakopoulou in 2021 and 2022 respectively who reported long term effectiveness of LGT [16,78]. When it comes to the percentage of HbF, it appears that lentivirus gene therapy, as seen in Esrick et al. [59], and Malik et al. [62] resulted in slightly higher percentages compared to HU treatment. However, it is important to note that these changes may be due to chance, or on various factors, including individual patient characteristics, the specific protocol used in each study, mechanism of drug action and the duration of treatment. Some safety concerns were identified in course of this review. One study identified some safety concerns such as occurrence of Type 1 diabetes and respiratory infection, but he reported those adverse effects were not necessarily related to the effect of the administered treatment (LGT) [59]. Hydroxyurea treatment was reported to have a few safety concerns also such as leucopenia, myelosuppression, brain infarction. However, although there was no leading or most frequent safety issue identified, leucopenia was consistent in both HU treatment and LGT. This may be due to the impact the treatments have on haematopoietic system and bone marrow. Studies have established a dose-dependent relationship of leucopenia occurrence in HU [80]. Based on previous reports by Kanter and Ofakunrin, the leucopenia may be due to neutropenia which gave rise to the condition febrile neutropenia reported by them [16,61]. Contrarily, Lad and his colleagues did not identify any adverse effect after the administration of HU [67].   This study comprehensively examined the efficacy, clinical outcomes, and safety of LGT for sickle cell disease (SCD) in comparison with HU. This review has revealed that although both treatment interventions provided improvement in the laboratory data like haemoglobin level, LGT had better treatment achievement compared to HU. While both treatments had improvements in the clinical outcomes, there was no significant difference in the improvement levels between both treatments. This suggests that both treatment approaches have comparable outcomes in terms of managing these clinical manifestations of SCD.   To gain better comprehensive understanding of the comparative effectiveness of these treatments and their long-term impact on the quality of life for individuals with SCD, further research, including large-scale clinical trials and extended follow-up studies is imperative. Since LGT has better efficacy and comparable safety concerns with HU, LGT may be considered a better treatment option for SCD patients. Owing to the fact there were limited studies in LGT, most studies on LGT were currently non-randomized clinical trials, and therefore, it is recommended that future studies should be designed as randomized controlled clinical trials. Further research should build upon the lessons learned from early clinical trials and preclinical models to refine treatment protocols and enhance the safety profile of LGT. Limitation   We extend our acknowledgments to family members, friends and academic colleagues who provided various kinds of support on this research journey. Very importantly, we extend our appreciation to Department of Biomedical Science, College of Medicine, University of Chester for providing the platform and approval for this research. Author’s contributions Conflict of interest Funding   <![CDATA[The prevalence of Helicobacter pylori infection among students of a medical college in Bangladesh]]> Shahida Akter* Rehana Khatun Aunta Melan Saimun Nahar Rumana Elisha Khandker Mohsina Mahmud Fahmida Rahman Md. Shariful Alam Jilani https://imcjms.com/journal_full_text/584 2025-11-10 10:54:34 Original Article July 2025; Vol. 19(2):009 Abstract Background and objectives: The prevalence of Helicobacter pylori infection differs in relation to the human population, age, living conditions, lifestyle, socioeconomic status and geographic location. The purpose of the present study was to evaluate the prevalence of H.pylori infection among students of Ibrahim Medical College, Dhaka, Bangladesh. Materials and methods: This cross-sectional study was conducted at the K.A. Monsur Research Laboratory, Department of Microbiology, Ibrahim Medical College. A structured questionnaire was used to collect socio-demographic information and clinical history. Blood and stool samples were collected from each participant. Serum H. pylori CagA IgG and H.pylori IgA antibodies were determined using enzyme-linked immunosorbent assay (ELISA), and H. pylori stool antigen (HPSAg) was detected by immunochromatographic test (ICT). Results: A total of 85 participants were enrolled in this study. The overall H. pylori infection rate was 69.4% by positive stool antigen test and /or the presence of H. pylori specific CagA IgG or IgA antibodies in serum. H. pylori stool antigen was detected in 9 (10.6%) individuals, of whom 8 (88.9%) were also positive for H. pylori specific CagA IgG and / or IgA antibodies. Among 85 participants, CagA IgG and IgA were positive in 43 (50.6%) and 46 (54.1%) students, respectively, while 31 (36.5%) were positive for both antibodies. IgA positivity rate was significantly higher (p≤0.005) in individuals who tested positive for CagA-IgG compared to those negative for CagA-IgG antibody. Gastrointestinal symptoms were reported by 17 (20.0%) participants, while 68 (80.0%) were asymptomatic. No significant difference in antibody positivity rates was observed between symptomatic and asymptomatic individuals in this study. Conclusion: The study revealed that H. pylori infection is common among the medical students in Bangladesh. This underscores the importance of improving awareness and early detection strategies among medical students to minimize transmission and associated health risks. July 2025; Vol. 19(2):009.  DOI: https://doi.org/10.55010/imcjms.19.019 *Correspondence: Shahida Akter, Department of Microbiology. Ibrahim Medical College, 1/A Ibrahim Sarani, Shegunbagicha, Dhaka-1000, Bangladesh. Email: shahidamicro@gmail.com © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License(CC BY 4.0).   Introduction Helicobacter pylori (H. pylori) is a gram-negative, spiral-shaped, microaerophilic bacterium that colonizes the human gastric mucosa. A large number of people remain asymptomatic despite being infected with H. pylori [1]. Once acquired, the infection persists throughout life unless treated with specific antimicrobials [2]. Chronic infection by H. pylori is recognized as the leading cause of gastric and duodenal ulcer disease and is also associated with gastric adenocarcinoma and mucosa- associated lymphoid tissue (MALT)[3,4]. A 2017 meta-analysis found that the overall global prevalence of H.pylori infection was 44.3%, with a higher rate of 50.8% in developing countries compared to 34.7% in developed countries [5]. In 2024, the prevalence of H. pylori infection among the asymptomatic urban population of Bangladesh was reported to be 40.5% [6]. In 2022, H. pylori-specific IgG and IgA antibodies were detected in 64.9% and 55.1% of participants, respectively, among the asymptomatic rural population in Bangladesh [7]. H. pylori infection is primarily transmitted through fecal-oral, oral-oral, or gastro-oral routes, often due to poor sanitation, overcrowding, contaminated water, and low levels of education, especially in early childhood [8-10]. Prevalence of H. pylori is strongly age-dependent, rising steadily from childhood through middle age, and then declining in the very elderly due to gastric atrophy and increased antibiotic use [11]. Both Habib et al. and Rahman et al. reported that the highest rates of infection were observed in individuals under 30 years of age, with detection rates of 78.3% and 50%, respectively [12,13]. Accurate diagnosis and effective management of H.pylori infection can greatly contribute to its eradication and prevent disease complications. Data on the prevalence of H. pylori infection among medical college students in Bangladesh are limited. Studying this population is particularly important because of their frequent exposure to healthcare settings, which has been implicated as a significant risk factor for acquiring H. pylori infection by several studies [14,15]. Liu et al. reported that the overall prevalence of H. pylori infection was 70.0% among medical personnel, compared to that of 44.6% among the general population in China [16]. In addition, the students often share communal living spaces, such as hostels, which may further facilitate transmission. As future healthcare providers, identifying asymptomatic carriers and associated risk factors can inform early interventions and guide targeted public health strategies for this group [17]. The present study aimed to evaluate the prevalence of H. pylori infection among medical students affiliated with a tertiary-level hospital in Dhaka, Bangladesh, by detecting H. pylori antigen in stool and, H. pylori-specific IgA and CagA-IgG antibodies in serum using serologic methods.   Materials and Methods Sample collection and laboratory work were done at K. A. Monsur Research Laboratory, at the Department of Microbiology of Ibrahim Medical College, Dhaka. This cross-sectional study was conducted in 2021 among 85 fourth-year MBBS students studying at Ibrahim Medical College. Fourth-year students were selected purposively as the MBBS curriculum covers Microbiology during the fourth year. After explaining the nature and purpose of the study, all participants provided informed written consent. A structured questionnaire was used to record socio-demographic information and clinical history. The study was approved by the Institutional Ethical Committee and Research Review Board of Ibrahim Medical College. All consenting fourth-year students were included in the study, irrespective of age, gender, nationality or presence of dyspeptic symptoms. Dyspeptic symptoms were defined as having two or more of the following gastrointestinal symptoms: dyspepsia, abdominal pain, nausea, vomiting and belching [18]. Individuals without any of these symptoms were considered as asymptomatic for H. pylori infection. Students who had taken antibiotics, colloidal bismuth compounds, proton pump inhibitors (PPIs) or H2 blockers within four weeks prior to sample collection were excluded. H. pylori infection was defined if an individual was found positive for H.pylori antigen in stool and/or anti-H. pylori CagA-IgG and/or anti-H. pylori IgA in serum using serologic methods [7]. Approximately 2.5 ml blood sample was collected from each participant. After centrifugation at 1500 rpm for 10 minutes, separated serum was stored at -20℃ and used later for detection of H. pylori IgA and CagA-IgG antibodies. Approximately 20-30 grams of fresh stool sample was collected from each participant in a clean, wide-mouth and screw-capped container, and tested for H. pylori stool antigen within 6 hours of collection. Stool antigen was detected by immune chromatography using ABON one strip H.pylori antigen ICT test device (Inverness Medical Innovation Hong Kong Ltd., Hong Kong). Approximately 50 mg of stool was obtained from at least three different areas of each stool specimen. The stool was then mixed with supplied extraction buffer solution using a vortex mixer, and centrifuged at 4000 rpm for 5 minutes. After centrifugation, two drops of supernatant were transferred into the sample well of the test device and kept at room temperature for 10 minutes. The result was then recorded. A positive result was indicated by the presence of purple-pink line along with the control line. When only the control line appeared, the result was considered negative. If no control line appeared, the result was termed as invalid. Serum anti-H. pylori CagA-IgG and anti-H.pylori IgA antibodies were determined by quantitative enzyme-linked immune sorbent assay (ELISA) using commercial kits namely CagA IgG ELISA and Helicobacter pylori IgA ELISA (DRG International Inc., USA), respectively. The tests were performed and interpreted according to the manufacturer’s instructions. The present study did not evaluate the sensitivity and specificity of the test methods. However, the manufacturer (DRG International Inc., USA) reported that the sensitivity and specificity of both ELISA kits are greater than 90% for detecting H. pylori-specific antibodies. This is comparable to previously reported results for other H. pylori ELISAs, which demonstrated a sensitivity of 97.6% and a specificity of 90.5%. [19]. Participants who were positive for H. pylori stool antigen were treated with a proton pump inhibitor (PPI) and the two antibiotics, amoxicillin and metronidazole, for 14 days to eradicate H. pylori infection [20,21]. Statistical analyses were performed using Statistical Product and Service Solutions (SPSS), version 20. Categorical values between two groups were compared using chi-square test. Differences were considered statistically significant at p≤ 0.05.   Result A total of 85participants were enrolled in this study, with a mean age of 22.01 (SD ±1.14) years. Of them, 29 (34.11%) were male and 56 (65.88%) were female. All participants came from middle- or upper-class backgrounds with the majority having graduate parents (87.1% of fathers, and 71.8% of mothers). All subjects reported practicing hand hygiene and drinking safe water. Among 85 participants tested, 59 (69.4%) were positive for H. pylori infection either by positive stool antigen test or by the presence of serum H. pylori-specific CagA-IgG or IgA antibodies.   Table-1: Comparison of H. pylori stool antigen with the presence of serum anti-H. pylori CagA-IgG and anti-H. pylori IgA antibodies     Among 85 individuals tested, 9 (10.6%) were positive for H. pylori stool antigen, of whom 8 were also positive for H. pylori-specific CagA-IgG and/or IgA antibodies. Out of 76 stool antigen-negative cases, 50 demonstrated positive result for CagA-IgG and/or IgA antibodies. There was no significant association between stool antigen positivity and presence of H. pylori-specific antibodies among the study population. Overall, 58 (68.2%) participants tested positive for H. pylori infection using antibody-based methods. (Table-1).   Table-2: Comparison of serum anti-H. pylori CagA-IgG with anti-H. pylori IgA of the study population (N=85)     Among 85 enrolled students, anti-H. pylori CagA-IgG and IgA antibodies were detected in 43 (50.6%) and 46 (54.1%) individuals, respectively. Both antibodies were detected in 31 cases. IgA positivity rate was significantly higher (p≤0.005) in individuals who tested positive for CagA-IgG compared to those who were negative for Cag-IgG antibody. (Table-2)   Table-3: The relationship between serum anti-H. pylori CagA-IgG and anti-H.pylori IgA antibodies among symptomatic and asymptomatic cases.     Table-3 shows that, out of 85 participants, 17 (20.0%) complained of gastrointestinal symptoms whereas 68 (80.0%) were asymptomatic. No significant difference was observed in antibody positivity rates between symptomatic and asymptomatic individuals in this study.   Table-4: Comparison of H. pylori stool antigen with the symptomatic and asymptomatic cases     Table-4 shows that, out of 85 participants, 17 (20.0%) complained of gastrointestinal symptoms whereas 68 (80.0%) were asymptomatic. A statistically significant association was found between stool antigen positivity and the presence of symptoms among the study population.   Discussion It is widely recognized that H. pylori is associated not only with peptic ulcer disease but also with gastric carcinoma and MALT lymphoma [22]. Several studies have shown that the prevalence of H. pylori among medical personnel tends to be higher than that in general population, one reason being their frequent exposure to hospital settings [23-25]. The present study aimed to evaluate prevalence of H. pylori infection among fourth-year MBBS students studying at Ibrahim Medical College, Dhaka. In this study, an individual was considered positive for H. pylori infection based on a positive stool antigen test and/or the presence of H. pylori-specific CagA-IgG and/or IgA antibodies in serum. Overall, 69.4% of the study population tested positive for H. pylori infection in this study. However, an overall detection rate of 79.5% was observed in a previous study conducted in Bangladesh among asymptomatic rural children and adolescents [7]. The comparatively lower detection rate in this study may be attributed to better hygienic practices among medical students, who predominantly came from higher educational and socio-economic backgrounds [26]. Approximately 10.6% of individuals demonstrated a positive stool antigen test in the current study. Detection of H. pylori antigen in stool indicates active infection [27]. Rajan et al. found a stool antigen positivity rate of 8.4% in a hospital-based study in Singapore, which is consistent with this finding [28]. In contrast, Mazumder et al. detected stool antigen in 24.9% of enrolled children and adolescents in a rural area of Bangladesh [7]. This discrepancy may be attributed to lower hygienic practices among children compared to the adult subjects in the current study, as well as differences in socio-economic status and availability of sanitation facilities. The prevalence of H. pylori-specific antibodies was reported as 55.8% using immunochromatography among students at a medical university in Iraq, compared to an overall 68.2% antibody positivity rate observed in the present study [29]. This discrepancy may be due to the higher sensitivity of ELISA-based assays in contrast to ICT. Although 8 of the 9 participants who were positive for H. pylori stool antigen also tested positive for CagA-IgG and/or IgA antibodies, the association was not statistically significant, likely due to the small number of stool antigen-positive cases. In our study, IgA positivity rate was significantly higher in individuals who tested positive for CagA-IgG antibody compared to those who were negative for CagA-IgG which corroborates the finding of Rautelin et al. (2000), who theorized that CagA- positive infections may induce a markedly higher IgA response than CagA-negative infections. CagA is an immunodominant protein of H. pylori, which is associated with cytoskeletal rearrangements and morphological changes in the host cell [30-33]. Previous research suggests that CagA-positive H. pylori strains are more likely to induce gastric inflammation and the subsequent development of peptic ulcer disease and gastric cancer compared to infections with CagA-negative strains [34-37]. In the present study, 31 (36.5%) participants tested positive for both CagA-IgG and IgA antibodies. Rautelin et al. observed that two-thirds of the subjects demonstrating both CagA-IgG and IgA antibodies had more severe gastric inflammation and were probably at higher risk for severe long-term sequelae [33]. In this study, antibody positivity did not differ significantly between participants with and without gastrointestinal symptoms, which is consistent with the findings of several studies conducted in Bangladesh and other Asian countries [38-41]. The current study showed that a large proportion of the study population demonstrated both IgA and CagA-IgG classes of H. pylori-specific antibodies. The simultaneous presence of these antibodies is important, regardless of symptom status, as it increases the risk of complications such as peptic ulcer disease and gastric carcinoma.  Stool antigen (HpSA) positivity was observed in35.2%ofsymptomatic individuals. Detection of H. pylori antigen (HpSA) in stool among symptomatic individuals indicates an active infection. Patients having two or more gastrointestinal symptoms were more likely to demonstrate a positive stool antigen test which is consistent with the findings of other studies conducted in Bangladesh and other Asian countries [27,42,43]. The organism is primarily transmitted through contaminated water and food, as well as direct person-to-person contact. Therefore, raising awareness among medical students is essential to help reduce the transmission. A limitation of our study was that only fourth-year MBBS students were included. However, it is fundamental to conduct large-scale studies which not only investigate the prevalence of the H. pylori among medical students but also thoroughly evaluate the determinants contributing to its transmission.   Conclusion The study revealed that H. pylori infection is highly prevalent among medical students in Bangladesh. Given the risk of transmission and potential ling-term complications, it is essential to increase awareness and implement early detection strategies in this population. Further large-scale studies are required to assess the prevalence across different groups and to identify the key determinants contributing to infection and transmission.   Conflict of interest The authors declare that there is no conflict of interest.   Funding This study was funded by Ibrahim Medical College.   Author contributions Authors’ contributions SA: sample/data collection, laboratory work, data entry and analysis and manuscript writing; RK: data collection, laboratory work. AM: Data entry and analysis, editing of manuscript.SN and EK sample/data collection; SPSS: data entry; MM: data collection, data entry. FR: sample/data collection, laboratory work, data entry and analysis; MSAJ: Idea generation, study design, data analysis.   References 1.     Cover TL, Blaser MJ. Helicobacter pylori in health and disease. Gastroenterology. 2009; 136(6): 1863-1873. doi:10.1053/j.gastro.2009.01.073. 2.     Miranda AC, Machado RS, Silva EM, Kawakami E. Seroprevalence of Helicobacter pylori infection among children of low socioeconomic level in São Paulo. Sao Paulo Med J. 2010; 128(4): 187-191. doi:10.1590/s1516-31802010000400002. 3.     Goodwin CS, Worsley BW. Microbiology of Helicobacter pylori. Gastroenterol Clin North Am. 1993; 22(1): 5-19. 4.     Sachs G, Scott DR, Wen Y. Gastric infection by Helicobacter pylori. Curr Gastroenterol Rep. 2011; 13(6): 540-546. doi:10.1007/s11894-011-0226-4. 5.     Hooi JKY, Lai WY, Ng WK, Suen MMY, Underwood FE, Tanyingoh D, et al. Global prevalence of Helicobacter pyloriinfection: systematic review and meta-analysis. Gastroenterology. 2017; 153(2): 420-429. doi:10.1053/j.gastro.2017.04.022. 6.     Jarin I, Ahmed T, Nahar J J. Understanding Helicobacter pylori Infection Prevalence and Associated Factors in slum and swampy areas of Narayanganj, Bangladesh: Findings from Medical Camps. 7.     Mazumder S, Rahman F, Akter F, Khatun R, Akter S, Saha SP, et al. Asymptomatic Helicobacter pylori infection among rural children and adolescents in Bangladesh. IMC J Med Sci. 2022; 16(2): 007. doi: https://doi.org/10.55010/imcjms.16.017. 8.     Windle HJ, Kelleher D, Crabtree JE. Childhood Helicobacter pylori infection and growth impairment in developing countries: a vicious cycle? Pediatrics. 2007; 119(3): e754-9. doi:10.1542/peds.2006-2196. 9.     Nicoline FT, Ndip RN. A South African perspective on Helicobacter pylori: prevalence, epidemiology and antimicrobial chemotherapy. Afr J Microbiol. 2013; 7(21): 2430-7. doi:10.5897/AJMR2013.5594. 10.  Ahmed KS, Khan AA, Ahmed I, Tiwari SK, Habeeb MA, Ali SM, et al. Prevalence study to elucidate the transmission pathways of Helicobacter pylori at oral and gastroduodenal sites of a South Indian population. Singap Med J. 2006; 47(4): 291–6. 11.  Wang X, Shu X, Li Q, LiY, Chen Z, Wang Y, et al. Prevalence and risk factors of Helicobacter pylori infection in Wuwei, a high-risk area for gastric cancer in northwest China: an all-ages population-based cross-sectional study. Helicobacter. 2021; 26(4): e12810. doi:10.1111/hel.12810. 12.  Habib AM, Alam MJ, Rudra B, Quader A, Al-Forkan M. Analysis of Helicobacter pylori prevalence in Chittagong, Bangladesh, based on PCR and CLO test. Microbiol Insights. 2016; 9: 47-50. doi:10.4137/MBI.S39858. 13.  Rhaman MM, Rahman F, Mazumder S, Sayeed MA, Haq JA. Helicobacter pylori infection in asymptomatic rural Bangladeshi population. IMC J Med Sci. 2021; 15(1): 41-6. doi:10.3329/imcjms.v15i1.54201. 14.  Lin SK, Lambert JR, Schembri MA, Nicholson L, Korman MG. Helicobacter pylori prevalence in endoscopy and medical staff. J Gastroen Hepatol. 1994; 9(4): 319-324. doi:10.1111/j.1440-1746.1994.tb01249.x. 15.  Mastromarino P, Conti C, Donato K, Strappini PM, Cattaruzza MS, Orsi GB.Does hospital work constitute a risk factor for Helicobacter pylori infection? J Hosp Infect. 2005; 60(3): 261–268. doi: 10.1016/j.jhin.2004.12.019. 16.  Jahan H, Chowdhury OA, Uddin MJ. Helicobacter pylori infection on medical students: A study on MAG Osmani Medical College, Bangladesh. African Journal of Virology. 2013; 7(2): 001-005. 17.  Naser NKAA, Bashir MBM, Ali ASMA. Prevalence and associated risk factors of Helicobacter pylori infection among medical students at Shendi University, Sudan. BMC Gastroenterol. 2025; 25(1): 466. doi:10.1186/s12876-025-04074-9. 18.  Ferdaus SJ, Paul SK, Nasreen SA, Haque N, Sadekuzzaman M, Karim MR, et al. The prevalence, risk factors, and antimicrobial resistance determinants of Helicobacter pylori detected in dyspeptic patients in North–Central Bangladesh. Infect Dis Rep. 2024; 16(2): 181-8. doi:10.3390/idr16020014. 19.  Tshibangu-Kabamba E, Phuc BH, Tuan VP, Fauzia KA, Kabongo-Tshibaka A, Kayiba NK, et al. Assessment of the diagnostic accuracy and relevance of a novel ELISA system developed for seroepidemiologic surveys of Helicobacter pylori infection in African settings. PLoS Negl Trop Dis. 2021; 15(9): e0009763. doi:10.1371/journal.pntd.0009763. 20.  Khurana R, Fischbach L, Chiba N, Van Zanten SV, Sherman PM, George BA, et al. Meta-analysis: Helicobacter pylori eradication treatment efficacy in children. Aliment Pharmacol Ther. 2007; 25(5): 523-536. doi:10.1111/j.1365-2036.2006.03236.x. 21.  de Boer WA, Tytgat GN. Regular review: treatment of Helicobacter pylori infection. BMJ. 2000; 320(7226): 31-34. doi:10.1136/bmj.320.7226.31. 22.  Yi M, Chen S, Yi X, Zhang F, Zhou X, Zeng M, et al. Helicobacter pylori infection process: from the molecular world to clinical treatment. Front Microbiol. 2025; 16: 1541140. doi:10.3389/fmicb.2025.1541140. 23.  Braden B, Duan LP, Caspary WF, Lembcke B. Endoscopy is not a risk factor for Helicobacter pylori infection--but medical practice is. Gastrointest Endosc. 1997; 46(4): 305-310. doi:10.1016/s0016-5107(97)70115-9. 24.  Liu WZ, Xiao SD, Jiang SJ, Li RR, Pang ZJ. Seroprevalence of Helicobacter pylori infection in medical staff in Shanghai. Scand J Gastroenterol. 1996; 31(8): 749-752. doi:10.3109/00365529609010346. 25.  Nishikawa J, Kawai H, Takahashi A, Seki T, Yoshikawa N, Akita Y, et al. Seroprevalence of immunoglobulin G antibodies against Helicobacter pylori among endoscopy personnel in Japan. Gastrointest Endosc. 1998; 48(3): 237-243. doi:10.1016/s0016-5107(98)70184-1. 26.  Almadi MA, Aljebreen AM, Tounesi FA, Abdo AA. Helicobacter pylori prevalence among medical students in a high endemic area. Saudi Med J. 2007; 28(6): 896-898. 27.  Al Ofairi BA, Saeed MK, Al-Qubaty M, Abdulkareem AM, Al-Jahrani MA. Diagnostic value of IgG antibody and stool antigen tests for chronic Helicobacter pylori infections in Ibb Governorate, Yemen. Sci Rep. 2024; 14(1): 7536. doi:10.1038/s41598-024-58165-w. 28.  Rajan C, Chiou FK, Ho CWW. Prevalence, Management, and Outcomes of Non-invasive Helicobacter pylori testing in children at a tertiary paediatric hospital in Singapore. Pediatr Gastroenterol Hepatol Nutr. 2024; 27(6): 336–344. doi:10.5223/pghn.2024.27.6.336. 29.  Hussen BM, Qader SS, Ahmed HF, Ahmed SH. Ahmed. The prevalence of Helicobacter pylori among university students in Iraq. Indian Journal of Science and Technology. 2013; 6(8): 1-5. doi: 10.17485/ijst/2013/v6i8.4. 30.  Segal ED, Cha J, Lo J, Falkow S, Tompkins LS. Altered states: involvement of phosphorylated CagA in the induction of host cell growth changes by Helicobacter pylori. Proc Natl Acad Sci U S A. 1999; 96(25): 14559-14564. doi:10.1073/pnas.96.25.14559. 31.  Asahi M, Azuma T, Ito S, Ito Y, Suto H, Nagai Y, et al. Helicobacter pyloriCagA protein can be tyrosine phosphorylated in gastric epithelial cells. J Exp Med. 2000; 191(4): 593-602. doi:10.1084/jem.191.4.593. 32.  Odenbreit S, Piils J, Sedlmaier B, Gerland E, Fischer W, Haas R. Translocation of Helicobacter pyloriCagA into gastric epithelial cells by type IV secretion. Science. 2000; 287(5457): 1497-1500. doi:10.1126/science.287.5457.1497. 33.  Stein M, Rappuoli R, Covacci A. Tyrosine phosphorylation of the Helicobacter pyloriCagA antigen after cag-driven host cell translocation. Proc Natl Acad Sci U S A. 2000; 97(3): 1263-1268. doi:10.1073/pnas.97.3.1263. 34.  Crabtree JE, Taylor JD, Wyatt JI, Heatley RV, Shallcross TM, Tompkins DS, et al. Mucosal IgA recognition of Helicobacter pylori 120 kDa protein, peptic ulceration, and gastric pathology. Lancet. 1991; 338(8763): 332-335. doi:10.1016/0140-6736(91)90477-7. 35.  Peek RM, Miller GG, Tham KT, Perez-Perez GI, Zhao X, Atherton JC, et al. Heightened inflammatory response and cytokine expression in vivo to cagA+ Helicobacter pylori strains. Lab Invest. 1995; 73(6): 760-70. 36.  Parsonnet J, Friedman GD, Orentreich N, Vogelman H. Risk for gastric cancer in people with CagA positive or CagA negative Helicobacter pylori infection. Gut. 1997; 40(3): 297-301. doi:10.1136/gut.40.3.297. 37.  Blaser MJ, Perez-Perez GI, Kleanthouse H, Cover T, Peek R, Chyou P, et al. Infection with Helicobacter pylori strains possessing cagA is associated with an increased risk of developing adenocarcinoma of the stomach. Cancer Res. 1995; 55(10): 2111-2115. 38. Perveen I, Saha M, Hasan MQ. Is there decreasing prevalence of Helicobacter Pyloriinfection in patients with dyspepsia? Journal of Chittagong Medical College Teachers' Association. 2022; 33(1): 97-102. doi:10.3329/jcmcta.v33i1.67265. 39.  Jenks PJ, Mégraud F, Labigne A. Clinical outcome after infection with Helicobacter pylori does not appear to be reliably predicted by the presence of any of the genes of the cag pathogenicity island. Gut. 1998; 43(6): 752-758. doi:10.1136/gut.43.6.752. 40.  Hua J, Zheng PY, Yeoh KG, Ho B. The status of the cagA gene does not predict Helicobacter pylori-associated peptic ulcer disease in Singapore. Microbios. 2000; 102(402): 113-120. 41.  Yang JC, Wang TH, Wang HJ, Kuo CH, Wang JT, Wang WC. Genetic analysis of the cytotoxin-associated gene and the vacuolating toxin gene in Helicobacter pylori strains isolated from Taiwanese patients. Am J Gastroenterol. 1997; 92(8): 1316-1321. 42.  Sultana A, Ahmed S, Ahmed EU, Nuruddin Chowdhury AF, Kalam A, Rahman A et al. Stool Antigen Test is Effective and Sensitive for Detecting Helicobacter Pylori Infection in Bangladeshi Peptic Ulcer Patients. medRxiv. 2021: 2021-10. 43.  Ebar MH, Ahmed MO. Frequency of H. pylori Infection among Patients with Gastrointestinal Symptoms Attending Somali Sudanese Specialized Hospital (SSSH), Mogadishu, Somalia. Asian journal of medicine and health. 2023; 21(8): 27-31.     Cite this article as:  Akter S, Khatun R, Melan A, Rumana SN, Khandker E, Mahmud M, et al. The prevalence of Helicobacter pylori infection among students of a medical college in Bangladesh. IMC J Med Sci. 2025; 19(2):009. DOI:https://doi.org/10.55010/imcjms.19.019 <![CDATA[Cutaneous adverse drug reactions and their impact on the quality of life of patients: a study at a tertiary care centre]]> Shivani* Rajesh Sinha Amrendra Kumar Arya Kranti Chandan Jaykar U.K Pallavi https://imcjms.com/journal_full_text/572 2025-08-14 12:33:16 Original Article July 2025; Vol. 19(2):006 Abstract Background and objective: Cutaneous adverse drug reactions (CADRs) encompass a wide spectrum of drug-induced skin and mucosal manifestations, ranging from mild rashes to severe cutaneous adverse reactions (SCARs), such as toxic epidermal necrolysis. Early recognition and prompt withdrawal of the causative drug are vital for better outcomes. CADRs are increasingly common due to polypharmacy, yet regional data on their patterns and causative agents remain limited. This study aims to identify the clinical and epidemiological patterns of CADRs and to assess their impact on quality of life using the Dermatology Life Quality Index (DLQI). Materials and methods: This cross-sectional observational study included 84 patients with clinically suspected CADRs from January to December 2024. Data were collected through patient interviews, clinical examinations, and the assessment using the Naranjo causality scale. DLQI was used to evaluate the psychosocial burden associated with CADRs. Results: Fixed drug eruption was the most common presentation (25%), followed by maculopapular eruptions (11.9%) and urticaria (9.5%). SCARs accounted for 17.9% cases. Antimicrobials (57.2%) were the most frequently implicated drugs. Generalized lesions and pruritus were significantly associated with higher DLQI scores. DLQI Score interpretation reveals that 3.6% patients have no effects whereas 46.7% patients are moderately affected. Based on the Naranjo algorithm, causality was classified as probable in 76.2%, possible in 14.3%, and definite in 9.5% of cases. Conclusion: CADRs significantly impact quality of life, especially in severe cases or those with strong drug causality. Antimicrobials, nonsteroidal anti-inflammatory drugs (NSAIDs), and antiepileptics were major causative agents. These findings underscore the importance of early detection, comprehensive drug history-taking, and a patient-centred approach to mitigate both the physical and psychological burdens of CADRs. July 2025; Vol. 19(2):006.  DOI: https://doi.org/10.55010/imcjms.19.015 *Correspondence: Shivani, Department of Dermatology, Venereology, and Leprology, Indira Gandhi Institute of Medical Science (IGIMS), Patna-800014,Bihar, India. Email: drshivani4847@gmail.com. © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License(CC BY 4.0).   Introduction Adverse drug reactions (ADRs) are unintended and harmful responses to drugs administered at therapeutic doses, posing a major challenge to patient safety and treatment efficacy [1]. They contribute to increased morbidity, hospitalizations, and overall healthcare costs [2]. CADRs affect approximately 2–3% of hospitalized patients and account for 10–30% of all reported ADRs [3-5]. They encompass a broad clinical spectrum, ranging from mild conditions like fixed drug eruptions (FDE) and maculopapular rashes to severe and life-threatening disorders, including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS), and generalized bullous fixed drug eruption (GBFDE) [6]. The likelihood that a specific drug was responsible for the adverse cutaneous reaction was assessed using the Naranjo algorithm [7], a validated and standardized tool consisting of ten structured questions. This algorithm evaluates various aspects including the temporal relationship between drug administration and onset of the reaction, dechallenge and rechallenge outcomes, the existence of alternative causes, known drug associations, prior patient experience, and objective evidence. The Naranjo algorithm was chosen for its widespread use in pharmacovigilance and its structured, reproducible format, which makes it well-suited for assessing causality in diverse types of CADRs. To systematically assess the impact of CADRs on health-related quality of life (HRQoL), the Dermatology Life Quality Index (DLQI) is commonly used. Developed by Finlay and Khan in 1994, the DLQI is a 10-item questionnaire covering symptoms and feelings, daily activities, leisure, work and school, personal relationships, and treatment [9]. In CADRs, lesions on visible areas such as face and hands can negatively affect self-esteem and social interactions; while symptoms like pruritus, burning, and pain further impair quality of life [8]. DLQI scores often reflect not only just physical symptoms but also the emotional and social consequences of visible skin damage [10]. Importantly, although drug withdrawal is critical for managing CADRS, it can disrupt treatment of underlying diseases, potentially leading to anxiety, disease relapse, or reliance on less effective therapies, thereby compounding the patient’s overall burden. Despite their prevalence, regional data - especially from underrepresented areas like Bihar, India - remain limited. This study aims to characterize the clinical spectrum of CADRs, identify causative drugs, assess causality using the Naranjo algorithm, and evaluate the impact on quality of life using the DLQI.   Materials and methods A hospital-based, cross-sectional observational study was conducted over one year (January–December 2024) in the dermatology outpatient department of a tertiary care centre in Eastern India, following Institutional Ethics Committee approval. A total of 84 patients of all ages and genders with clinically suspected CADRs caused bymodern medicine were enrolled consecutively. Inclusioncriteria required documented recent drug use and informed consent. Reactions attributed to homeopathic, ayurvedic, or other indigenous medicines were excluded. A structured proforma was used to document demographic data, drug history, clinical features, comorbidities, and lab parameters. Causality was assessed using the Naranjo algorithm, in which each question is scored as +1, 0, or –1.  The total score classifies the reaction as definite (≥9), probable (5–8), possible (1–4), or doubtful (≤0). In this study, responses to each question were determined based on a review of clinical history, drug exposure timelines, clinical course, and laboratory investigations. The DLQI was used to assess the impact of CADRs on health-related quality of life (HRQoL), with a total score range of 0–30. Data were analysed using IBM SPSS version 23. Descriptive statistics were used to summarise the variables. Categorical variables were compared using the Chi-square test, while continuous variables were analysed using the Mann–Whitney U and Kruskal–Wallis tests, as appropriate. Inter-rater agreement for causality assessment was evaluated using the Kappa statistic. A p-value ≤0.05 was considered statistically significant. For multiple-response variables, each response was coded and analysed as a percentage of total responses. Drug withdrawal was advised for all patients except those with acneiform eruptions from antitubercular therapy. Each patient received a drug card listing offending and cross-reactive drugs, along with counselling to avoid self-medication and to seek medical advice before future drug use.   Results The study included 84 patients (49 females, 35 males), with a female-to-male ratio of 1.4:1. The mean age was 32.2 years, ranging from 3 to 71 years. (Table-1)   Table-1: Age and sex distribution of patients     Associated symptoms such as fever, pain, itching, and swelling were reported in 77 patients (91.7%), with itching being the most frequently observed, present in 55 patients (65.5%) (Table-2). A prior history of drug reactions was noted in 22 patients (26.2%).   Table-2: Basic parameters of CADRs among study participants     Fixed drug eruption (FDE) was the most common clinical pattern of CADRs, observed in 25% of patients, followed by maculopapular eruptions (11.9%) and drug-induced urticaria (9.5%) (Figures-1–3).Less frequent presentations included acneiform eruptions, pigmentary changes, angioedema, and severe reactions such as SJS-TEN (Table-3).   Table-3: Frequency of distribution of cutaneous adverse drug reaction patterns       Figure-1: Fixed drug eruption secondary to metronidazole.     Figure-2: Maculopapular eruption secondary to amoxicillin.     Figure-3: Urticaria secondary to co-trimoxazole.   Antimicrobials were the most commonly implicated drug class in CADRs (57.2%), followed by NSAIDs (13.1%) and antiepileptics (11.9%) (Table-4).   Table-4: Distribution of various drugs causing CADRs     Among antimicrobials, beta-lactams (41.7%) and fluoroquinolones (22.9%) were most frequently involved. FDEswere primarily caused by fluoroquinolone–nitroimidazole combinations (33.3%), fluoroquinolones alone (28.6%), NSAIDs (14.3%), and sulphonamides (9.5%). Significant associations were observed for fluoroquinolones and NSAIDs (Chi-square = 11.42, p < 0.01). Maculopapular eruptions were primarily associated with beta-lactams (40%), NSAIDs (20%), and antiepileptics (10%), all showing statistically significant associations (Chi-square = 10.37, p < 0.01). Urticaria was most frequently triggered by NSAIDs (37.5%), beta-lactams (25%), and sulphonamides (12.5%), with NSAIDs showing a significant association (Chi-square = 9.15, p < 0.05). Rare cases included two instances of generalized bullous fixed drug eruption (GBFDE), attributed to allopurinol and naproxen; one paediatric case of cyclosporine-induced reversible hypertrichosis in a patient with psoriasis; and one elderly patient who developed methotrexate-induced cutaneous ulceration while concurrently using NSAIDs (Figures-4 and -5).     Figure-4: Hypertrichosis secondary to cyclosporine in a paediatric psoriasis patient that reversed on stopping cyclosporine.     Figure-5: Methotrexate induced mucocutaneous ulceration in a chronic plaque psoriasis patient.   Severe cutaneous adverse reactions (SCARs) accounted for 17.86% of all CADRs, with SJS-TEN being the most common presentation (33.34%), followed by exfoliative dermatitis, AGEP, DRESS, and GBFDE (Figures-6–8). Anticonvulsants were the leading causative group (53.4%), with phenytoin implicated in 6 of 15 cases, followed by antimicrobials. The female-to-male ratio among SCAR cases was 1.5:1. Ophthalmic complications were observed in six patients, and one case of SCAR resulted in death due to sepsis.     Figure-6: Stevens- Johnson syndrome (SJS) in a patient secondary to cotrimoxazole.     Figure-7: Erythroderma secondary to phenytoin.     Figure-8: Generalized bullous fixed drug eruption secondary to naproxen.   Cutaneous involvement alone was observed in 48.8% of patients, while 51.2% exhibited both cutaneous and mucosal involvement. Among cases with mucosal involvement, the genital area was most commonly affected (46.5%), followed by oral cavity (32.5%) and both sites (20.9%). Most CADRs were associated with drugs prescribed for upper respiratory infections and fever (35.7%), diarrhoea (30.9%), and seizure disorders (26.2%). Using the Naranjo algorithm, causality was classified as probable in 76.2% of cases, possible in 14.3%, and definite in 9.5%. The DLQI revealed a considerable impact on quality of life, with the domains of symptoms and feelings, daily activities, and leisure most affected (71.4%). (Table-5) Notably, 10.7% of patients reported significant distress related to the withdrawal of essential medications. Patients with generalized lesions had significantly higher DLQI scores than those with localized involvement (p < 0.05). Higher DLQI scores were also correlated with stronger drug-reaction causality (p <0.05). SCARs, particularly SJS-TEN, had the greatest impact on quality of life (p <0.001) (Table-6).   Table-5: Distribution of patients according to Dermatology Life Quality Index (DLQI) scores     Table-6: Association of DLQI with various parameters     Discussion This study found FDE to be the most common cutaneous adverse drug reaction (25%), followed by maculopapular rash (11.9%) and urticaria (9.5%). Antimicrobials were the leading causative group (57.2%), primarily beta-lactams and fluoroquinolones. SCARs comprised 17.86% of cases. DLQI scores indicated a moderate to severe impact on quality of life in the majority of patients (65.5%). In this study, a slight female predominance (F:M = 1.4:1) was observed, which aligns with the findings of Padukadan and Thappa [11]. However, in contrast, Jha et al. [12] reported a male preponderance in their study. Rademaker [13], however, found that female patients have a 1.5 to 1.7-fold increased risk of developing an ADR compared to male patients. While the reasons for this increased risk are not fully understood, several factors may contribute, including differences in pharmacokinetics, immune responses, hormonal influences, and medication utilization patterns between genders [13, 14]. For example, females tend to have a higher body fat percentage, smaller organ sizes, and lower glomerular filtration rates, all of which can impact the pharmacodynamics and pharmacokinetics of drugs [15]. The largest proportion of patients (39.3%) in this study was in the 21–30-year age group, which is consistent with findings from previous studies by Sharma et al. [15] and Sinha et al. [16]. This trend may be attributed to the fact that drug reactions are more common in the middle-aged population, which also coincides with the significant proportion of the Indian population within this age group and likely reflects greater healthcare access and medication use among young adults. The findings of this studyalign closely with previous studies conducted in India. Padukadan and Thappa [11] also reported FDE as the most common CADR (31.1%), followed by maculopapular rash (12.2%). Similarly, Sharma et al. [15] and Sinha et al. [16] documented FDE as the predominant pattern (33.3% and 48.61%, respectively). This suggests a consistent pattern in Indian populations, possibly due to high over-the-counter availability and frequent self-medication with antimicrobials and NSAIDs. In this study, 57.2% of the total reactions were attributed to antimicrobials, followed by NSAIDs (13.1%) and anticonvulsants (11.9%). These findings are concordant with those reported by Patel et al., Sharma et al., Sinha et al., and Nandha et al. [6,15,16,17]. Easy access to antibiotics without prescription and widespread empirical antibiotic use in India could explain the higher incidence of antimicrobial-induced CADRs. In contrast, Noel et al. [18] found antiepileptics to be the most common offending drug, while Al-Raaie et al. [19] identified NSAIDs as the leading cause. These variations may be explained by differences in drug prescribing and usage patterns across different populations. Among antimicrobials, beta-lactams were the most commonly implicated, accounting for 41.7% of cases, followed by fluoroquinolones (22.9%), sulpha drugs (12.5%), and nitroimidazoles (10.4%). Among NSAIDs, ibuprofen was the most frequently involved (45.3%), followed by diclofenac (26.7%) and naproxen (22.4%). Other drugs identified included acetaminophen, indomethacin, and mefenamic acid. Phenytoin (57%) was the most implicated anticonvulsant, followed by carbamazepine, which is consistent with findings by Sinha et al. and Sudharani et al. [16,20] Among the FDE cases, fluoroquinolone-imidazole combination drugs, commonly used for gastrointestinal infections were the most commonly implicated, followed by fluoroquinolones, which aligns with the findings of Sinha et al. [16]. In contrast, earlier studies by Patel et al. [6] and Padukadan and Thappa [11] identified cotrimoxazole as the most implicated drug. The shift in the pattern of drug-related FDE cases may be attributed to changing prescription trends and the widespread over the counter (OTC) use of fluoroquinolones. Maculopapular rashes were primarily associated with beta-lactam antibiotics, especially amoxicillin, followed by NSAIDs and anticonvulsants. This is consistent with Sharma et al. [15] and likely reflects the extensive use of amoxicillin in both hospital and outpatient settings. In this study, SCARs accounted for 17.86% of the cases, which is concordant with the findings of Sinha et al. [16] (25%) and Sasidharanpillai et al. [21] (13.20%), but contrasts with Patel et al.'s study [6] (8.17%). The higher prevalence of SCARs in the current study may reflect differences in regional prescribing practices, genetic susceptibility, or comorbid conditions of the population studied. The finding that anticonvulsants were the predominant drug class implicated in SCARs concurs with multiple prior studies [6,15,19]. This association can be explained by the unique pharmacokinetic and immunological properties of these agents. Anticonvulsants such as phenytoin, carbamazepine, and lamotrigine are well-known triggers of severe hypersensitivity reactions like SJS-TEN, primarily mediated through T-cell activation. Genetic susceptibility further modulates this risk, with specific alleles such as HLA-B*1502 strongly linked to carbamazepine-induced SJS-TEN, particularly in Southeast Asian and Indian populations [22]. Healthcare providers should, therefore, monitor patients closely when prescribing anticonvulsants, especially in populationat increased risk. Although studies on the impact of CADRs on quality of life (QOL) are limited, existing studies consistently demonstrate that these reactions significantly impair patients' well-being. CADRs often cause discomfort, distress, and social embarrassment, leading to profound effects on both physical and emotional health [23,24]. In this study, symptoms and feelings, daily activities, and leisure were the most affected domains, with 71.4% of patients reporting significant impact. This highlights that CADRs extend beyond physical health, deeply influencing emotional well-being and social interactions. Furthermore, a significant association was found between DLQI scores and drug-reaction causality. Reactions that were more likely to be caused by a specific drug tended to cause greater concern or distress. This may be due to more severe symptoms or the need to stop essential medications. Severe cutaneous adverse reactions (SCARs), particularly Stevens–Johnson syndrome and toxic epidermal necrolysis (SJS-TEN), were associated with the greatest reduction in quality of life. These findings are not unexpected, given the life-threatening nature and long-term sequelae of these reactions. Additionally, 10.7% of patients experienced significant psychological distress following the withdrawal of the offending drug, particularly when the drug was essential for managing chronic conditions. The anxiety related to discontinuing critical medication illustrates the complex relationship between physical and mental health challenges in managing CADRs. This emphasizes the importance for healthcare providers to address both the physical symptoms and psychological effects, implementing comprehensive care strategies that support the holistic well-being of patients. The management of CADRs primarily focuses on supportive care, which includes the immediate withdrawal of the offending drugs. For alleviating pruritus, antihistamines, mild topical steroids, and moisturizing lotions are commonly prescribed. In more severe cases, systemic treatments such as steroids, cyclosporine, and immunoglobulins may be required. SCARs, including SJS, TEN, erythroderma, and DRESS, often necessitate hospitalization due to their severity. In this study, the suspected drugs were withdrawn in 95.87% of the cases, highlighting the importance of promptly discontinuing the causative agent to prevent further complications. Regional variations observed in causative drugs underscore the need for localized pharmacovigilance data. Establishing institutional ADR reporting systems and contributing to national pharmacovigilance programs will strengthen collective efforts toward safer medication practices   Limitations This study was limited by the absence of confirmatory in-vitro tests (e.g., lymphocyte transformation and patch tests) due to resource constraints. Furthermore, the relatively small sample size and single-centred, observational nature of the study may limit the generalizability of findings. Recall bias regarding drug history is another potential limitation.   Conclusion CADRs range from mild rashes to severe, life-threatening conditions. In the absence of definitive diagnostic tools, clinical vigilance and early recognition of cutaneous patterns are critical. A thorough drug history and cautious prescribing, especially in high-risk individuals are essential, along with minimizing the use of unnecessary medications. Patient education on the dangers of self-medication and over-the-counter drug use is crucial. Given the significant psychological and quality-of-life impact of CADRs, empathetic counselling and holistic care are necessary. Strengthening pharmacovigilance through timely reporting and adopting a multidisciplinary approach can enhance drug safety and help reduce the burden of CADRs.   References 1.     World Health Organization. The importance of pharmacovigilance: safety monitoring of medicinal products. Geneva: World Health Organization; 2002. p. 1-48. 2.     Pirmohamed M, James S, Meakin S, Green C, Scott AK, Walley TJ, et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18,820 patients. BMJ. 2004; 329 (7456): 15-19. doi:10.1136/bmj.329.7456.15. 3.     Bigby M, Jick S, Jick H, Arndt K. Drug-induced cutaneous reactions. A report from the Boston collaborative drug surveillance program on 15,438 consecutive inpatients, 1975 to 1982. JAMA. 1986; 256(24): 3358-3363. doi:10.1001/jama.256.24.3358 4.     Choon SE, Lai NM. An epidemiological and clinical analysis of cutaneous adverse drug reactions seen in a tertiary hospital in Johor, Malaysia.  Indian J Dermatol Venereol Leprol. 2012; 78(6): 734-739. doi:10.4103/0378-6323.102367. 5.     Arulmani R, Rajendran SD, Suresh B. Adverse drug reaction monitoring in a secondary care hospital in South India.Br J Clin Pharmacol. 2008; 65(2): 210-216. doi:10.1111/j.1365-2125.2007.02993.x. 6.     Patel TK, Thakkar SH, Sharma D. Cutaneous adverse drug reactions in Indian population: A systematic review. Indian Dermatol Online J. 2014; 5(Suppl 2): S76-S86. doi:10.4103/2229-5178.146165. 7.     Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther. 1981; 30(2): 239-245. doi:10.1038/clpt.1981.154. 8.     Zheng L, Jin HB, Guan YY, Yang J. Pharmacovigilance of cutaneous adverse drug reactions in associations with drugs and medical conditions: a retrospective study of hospitalized patients. BMC Pharmacol Toxicol. 2022; 23(1): 62. doi:10.1186/s40360-022-00603-4. 9.     Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI)--a simple practical measure for routine clinical use. Clin Exp Dermatol. 1994; 19(3): 210-216. doi:10.1111/j.1365-2230.1994.tb01167.x. 10.  Basra MK, Fenech R, Gatt RM, Salek MS, Finlay AY. The Dermatology Life Quality Index 1994-2007: a comprehensive review of validation data and clinical results. Br J Dermatol. 2008; 159(5): 997-1035. doi:10.1111/j.1365-2133.2008.08832.x. 11.  Pudukadan D, Thappa DM. Adverse cutaneous drug reactions: clinical pattern and causative agents in a tertiary care center in South India. Indian J Dermatol Venereol Leprol. 2004; 70(1): 20-24. 12.  Jha N, Alexander E, Kanish B, Badyal DK. A study of cutaneous adverse drug reactions in a tertiary care center in Punjab. Indian Dermatol Online J. 2018; 9(5): 299-303. doi:10.4103/idoj.IDOJ_81_18. 13.  Rademaker M. Do women have more adverse drug reactions?. Am J Clin Dermatol. 2001; 2(6): 349-351. doi:10.2165/00128071-200102060-00001. 14.  Alomar MJ. Factors affecting the development of adverse drug reactions (Review article). Saudi Pharm J. 2014; 22(2): 83-94. doi:10.1016/j.jsps.2013.02.003. 15.  Sharma R, Dogra D, Dogra N. A study of cutaneous adverse drug reactions at a tertiary center in Jammu, India. Indian Dermatol Online J. 2015; 6(3): 168-171. doi:10.4103/2229-5178.156384. 16.  Sinha S, Kar C, Das S, Dutta A, De A. A Clinico-epidemiological study of cutaneous adverse drug reactions in a tertiary care centre of Eastern India. Indian J Dermatol. 2024; 69(1): 106. doi:10.4103/ijd.ijd_944_20. 17.  Nandha R, Gupta A, Hashmi A. Cutaneous adverse drug reactions in a tertiary care teaching hospital: A North Indian perspective. Int J Appl Basic Med Res. 2011; 1(1): 50-53. doi:10.4103/2229-516X.81982. 18.  Noel MV, Sushma M, Guido S. Cutaneous adverse drug reactions in hospitalized patients in a tertiary care centre. Indian J Pharmacol. 2004; 36(5): 292–295. 19.  Al-Raaie F, Banodkar DD. Epidemiological study of cutaneous adverse drug reactions in oman. Oman Med J. 2008; 23(1): 21-27. 20.  Sudharani C, Udayakumar B, Geetakiran A. Adverse cutaneous drug reactions to anticonvulsants –a study at a tertiary care center in Telangana. IOSR J Dent Med Sci. 2016; 15(2): 11–15. doi:10.9790/0853-15251115. 21.  Sasidharanpillai S, Riyaz N, Khader A, Rajan U, Binitha MP, Sureshan DN. Severe cutaneous adverse drug reactions: a clinicoepidemiological study. Indian J Dermatol. 2015; 60(1): 102. doi:10.4103/0019-5154.147834. 22.  Dean L, Kane M, Pratt VM, Scott SA, Pirmohamed M, Esquivel B, et al. Phenytoin therapy and HLA-B*15:02 and CYP2C9 genotype. In: Pratt VM, Scott SA, Pirmohamed M, Esquivel B, Kattman BL, Malheiro AJ, eds. Medical Genetics Summaries. Bethesda (MD): National Center for Biotechnology Information (US); 2016. 23.  Del Pozzo-Magaña BR, Rieder MJ, Lazo-Langner A. Quality of life in children with adverse drug reactions: a narrative and systematic review. Br J Clin Pharmacol. 2015; 80(4): 827-833. doi:10.1111/bcp.12423. 24.  Krishnarajan D, Sivasakthi K, Ariyamol R, Kumar DN, Varghese S. A prospective observational study of chemotherapy-induced adverse drug reaction and the quality of life in cancer patients in a tertiary care hospital. J Cancer Res Ther. 2021; 17(2): 530-536. doi:10.4103/jcrt.JCRT_1015_19.       Cite this article as: Shivani, Sinha R, Arya AK, Jaykar KC, Pallavi UK. Cutaneous adverse drug reactions and their impact on the quality of life of patients: a study at a tertiary care centre. IMC J Med Sci. 2025; 19(2): 006. DOI:https://doi.org/10.55010/imcjms.19.015. <![CDATA[Knowledge on melioidosis among healthcare workers of Bangladesh]]> Sraboni Mazumder Tabiha Binte Hannan Fahmida Rahman Saika Farook Forhad Uddin Hasan Chowdhury Lovely Barai Chandan Kumar Roy Kutub Uddin Ahamed Md. Shariful Alam Jilani Fazle Rabbi Chowdhury https://imcjms.com/journal_full_text/571 2025-07-28 12:53:00 Original Article July 2025; Vol. 19(2):005 Abstract Background and objectives: Despite being a definite endemic zone for melioidosis, very few cases have been reported from Bangladesh. Lack of awareness among clinicians, microbiologists and medical technologists might be a major concern. To combat this, a training workshop was launched to refine diagnostic and management skills among healthcare professionals of Bangladesh. Materials and methods: Initially, a pre-test was conducted with a questionnaire containing 20 multiple choice questions focusing on epidemiology, diagnosis and management of Burkholderia pseudomallei infection. Following the pre-test, training sessions containing lectures on melioidosis (including video demonstration) were held and at the end of the sessions, assessment of the knowledge was acquired by a post-test with the same questionnaire. Results: A total of 113 clinicians, microbiologists and medical technologists from 20 public and private medical college and hospitals around Bangladesh participated in pre-test and 87 in post-test after the workshop. Our results documented that the mean percentage of pre-test score was 62.4 ± 22.9 which indicates a considerable gap of knowledge among healthcare professionals regarding melioidosis and B. pseudomallei. The mean percentage of post-test score significantly (p = 0.0001) increased to 79.2 ± 16.5 after the training session. Conclusion: Awareness and skill development programs could play vital role to reduce the knowledge gaps among health care providers about melioidosis. This will increase the yield of diagnosis of this notorious infection and many lives could be saved. July 2025; Vol. 19(2):005.  DOI: https://doi.org/10.55010/imcjms.19.014 *Correspondence: Sraboni Mazumder, Department of Microbiology, Ibrahim Medical College, 1/A Segunbagicha Road, Dhaka-1000 Bangladesh. E-mail: mazumder.sraboni@gmail.com. © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License(CC BY 4.0).   Introduction Melioidosis is a neglected tropical disease (NTD) caused by a highly pathogenic gram-negative bacterium, Burkholderia pseudomallei (BP), and is an important cause of sepsis globally [1,2]. Although the disease is endemic in Southeast Asia and northern Australia, many cases have also been reported in non-endemic zones [3,4]. About 20% of community-acquired sepsis in Thailand is caused by melioidosis, and around 2,000 to 3,000 new cases are detected each year [5,6]. However, the true global burden of melioidosis remains poorly understood due to a large number of undetected cases in endemic regions [7]. In 2011, B. pseudomallei was first isolated from soil in different regions of Bangladesh, and since then, the country has been considered a definite endemic zone for melioidosis [8,9]. A regression model estimated approximately 16,931 cases annually with a mortality rate of 56% (around 9,500 deaths) in Bangladesh [7]. Despite this, only a few cases have been reported so far [8]. Several small-scale awareness activities and isolated training efforts have been undertaken in Bangladesh to address this gap. However, these programs have often lacked nationwide coverage, consistent reinforcement, or structured follow-up, which limits their long-term impact. Consequently, awareness and diagnostic capacity among healthcare professionals remain inadequate, resulting in underreporting and misdiagnosis of melioidosis cases. Similar gaps in knowledge and awareness have also been observed in other endemic countries such as Thailand and northern Australia, where comprehensive, repeated training and targeted community awareness programs have shown to be effective in improving diagnosis and management of melioidosis [10,11]. To help bridge this gap in Bangladesh, our study aimed to conduct a pre-test and post-test assessment of knowledge on melioidosis among healthcare providers following a virtual training workshop. The objectives were to evaluate baseline knowledge among clinicians, microbiologists, and medical technologists, provide targeted training, and assess knowledge improvement after the program. The training was organized through collaboration among the Centers for Disease Control and Prevention (CDC), Ibrahim Medical College, BIRDEM General Hospital, Bangabandhu Sheikh Mujib Medical University, and the Bangladesh Society of Tropical and Infections Disease (BSTID), supported by the CDC-HSP capacity development project on melioidosis. The findings of this study can guide the design of future awareness and capacity-building campaigns to improve diagnosis and management of this neglected but potentially deadly infection.   Materials and methods The study was designed as a pre- and post-test study and conducted online through the Zoom Cloud Meetings application during the COVID-19 pandemic. A structured questionnaire containing 20 multiple-choice questions (MCQs) was prepared and validated by experienced clinicians and microbiologists specializing in melioidosis. The questionnaire focused on the epidemiology, diagnosis, and management of Burkholderia pseudomallei. A total of 113 clinicians, microbiologists, and medical technologists from 20 public and private medical colleges and hospitals in 13 districts participated in the pre-test before the training program. The training consisted of a four-day series of interactive lectures delivered via Zoom using PowerPoint presentations and video demonstrations, followed by interactive question-answer sessions. Participation was tracked through Zoom attendance records and submission of responses via Google Forms. The same questionnaire was administered as a post-test at the end of the training to assess knowledge retention.   Results Pre-and post-test questionnaires included 20 multiple choice questions to test knowledge of healthcare professionals regarding melioidosis. A total of 113 participants responded to the pre-test questionnaires, while only 87 of them attended the post-test questionnaire, indicating a post-test dropout rate of approximately 23%. Male (61, 54%) participants were more in number than female (52, 46%). More than half of the participants (64, 56.6%) were microbiologists, followed by 33 (29.2%) clinicians, and 16 (14.2%) medical technologists. The gender distribution of the participants and their occupation are shown in Table-1. Answering patterns to the questions are shown in Table-2.   Table-1: Gender and occupation of the study population (N = 113)     Epidemiology of Burkholderia pseudomallei: During pre-test, 98.1% of the respondents could identify that BP is the causative agent of melioidosis and 98.1% could state that the organism is a bacterium. Only 60.2% of the responders knew that Bangladesh is a definite endemic country for melioidosis on pre-test. Most participants (90.8%) could correctly identify skin penetration as one of the routes of transmissions. Nevertheless, ingestion (66.3%) and inhalation (83.2%) were not known to be common routes of transmission, which showed promising improvement on post-test. Most of the participants could state that soil exposure (97.1%) is a source of infection. However, the majority of the respondents did not know of food (65%) and cattle (74.7%) as the sources of BP infection. Many respondents were not aware that dog and pig can also be infected by this bacterium and were ameliorated (51.9% and 83.1% respectively) after the training session on post-test. Almost all participants (98.9%) could answer correctly that agricultural workers are the high-risk group for melioidosis on post-test, whereas only 35.1% of the participants were aware of construction workers as high-risk population. Thalassemia, as a common co-morbid association with melioidosis, was commonly missed by 48.3% of the participants, which showed better results on post-test (28%). Clinical and laboratory diagnosis of Burkholderia pseudomallei infection: Participants on pre-test knew that melioidosis can present with abscess (97%), pneumonia (92.9%), septicemia (89.7%), and septic arthritis (70.2%); however, only 40.7% of them could answer that BP may also present with urinary tract infection. Participants’ knowledge on these variables was developed further after the training session. Most of the participants were well oriented that blood, sputum, pus, joint fluid and urine samples could yield to growth of BP for laboratory diagnosis. More than 97% of the health care workers of this study knew that culture is the gold standard laboratory test for the diagnosis of melioidosis; 87.4% stated correctly about the safety pin appearance of the bacteria in Gram stain and 91.7% knew Ashdown agar media is the selective media for isolation of this organism. Nonetheless, only 34.1% health care workers answered correctly on pre-test that MacConkey’s agar media is a selective media for isolation of the organism and was improved to 41.8% on post-test. More than 90% heath care personnel mentioned tuberculosis as a differential diagnosis of melioidosis; on the other hand, only a negligible proportion of participants (20%) identified typhoid as a differential diagnosis for melioidosis, which increased to 39% on post-test. However, whereas 70% of the participants and 48.8% participants could identify brucellosis and leptospirosis as differentials for melioidosis in the pre-test, the post-test percentage was much lower (55.4% and 35.1% respectively). The participants’ knowledge on case fatality rate of melioidosis was also very low in both pre-test and post-test. Management of melioidosis: Majority of participants knew that melioidosis requires prolonged antibiotic therapy for three or more months. More than 90% of the responders could reply correctly on intrinsic antibiotic resistance pattern of BP on post-test (> 67% on pre-test). Majority of the participants had the knowledge regarding ceftazidime (90.3%) and meropenem (83.5%) being sensitive to BP as well as drug of choice for melioidosis, which also was seen to be enhanced after the training session (96.5% and 97.7% respectively).   Table-2: Correct responses to the questions before and after the training amongst the participants   BP has a unique sensitivity pattern to certain antibiotics. It is sensitive to ceftazidime, meropenem, imipenem and co-amoxiclav, doxycycline, trimethoprim-sulfamethoxazole. On the other hand, it exhibits intrinsic resistance to penicillin, aminoglycosides, first and second generation cephalosporins, macrolides, and colistin [21,22]. More than 30% respondents erroneously indicated cotrimoxazole as resistant drug for melioidosis. In addition, 31.7% of health care personnel did not know that ceftriaxone is not an appropriate choice of antibiotic to treat melioidosis and more than one-third of participants had misconception regarding co-amoxiclav which can be used to treat melioidosis patient. This knowledge gap might create difficulty in treating patients appropriately and contribute to higher mortality rates. Therefore, during the training session, elaborative lectures on these specific topics were ensured to help the participants improvise their knowledge gaps. The participants came into consensus that, while reporting a culture, it should be mentioned that only carbapenems and ceftazidime shall be prescribed for intensive phase. The antibiotic choice for maintenance phase also needs to be notified in the culture report. Pre- and post-test studies are done mainly to assess the impact of an intervention among a group of people. Our study has concluded with significant improvement in knowledge regarding epidemiology, risk factors, clinical presentation, laboratory diagnosis, and management of melioidosis on post-test compared with the pre-test scores. However, there was low retention of knowledge regarding the case fatality rate, differential diagnoses, and high-risk population identification regarding melioidosis. To address these gaps, future workshops and in-person training sessions can be organized to provide more interactive learning and practical discussion, which may help improve knowledge on case fatality rate, differential diagnosis, and high-risk populations.In a previous study conducted in Thailand, video clips were found to be more beneficial in increasing adherence among the participants and could positively influence their awareness regarding preventive behaviors for melioidosis [23]. Hence, audio-visual representation of the preventive measures could be a potential mode of raising awareness of this NTD among healthcare workers, as well as the general population. Awareness campaigns are very crucial to refine knowledge about the infectious diseases in tropical regions. This is the key to improving the diagnostic yield, and treatment modalities, as well as reducing mortality of medically important NTDs like melioidosis in endemic zones.   Conclusion Increasing knowledge through training among clinicians, microbiologists and lab personnel is a vital tool to control melioidosis in our country. To increase awareness among healthcare providers, it is mandatory to organize effective education campaigns and hospital-based training program all over the country. This will not only aid in circulating knowledge, but also improvise the diagnostic and management skills of the skilled professionals. We suggest dissemination of knowledge about epidemiology, diagnosis and management of BP to health professionals through regular hands-on training programs.   Limitations We believe our study has certain limitations. First, the sample size was very small. Larger studies can be done in future to critically compare pre-test and post-test performance. Secondly, only 87 out of 113 people participated in post-test assessment. Thirdly, as the session was carried out online, the level of engagement of the participants could not be evaluated although, the performance improvement in post-test analysis indicates towards sufficient engagement of the respondents. Assessing after six months could give a better retention status, which should be considered in future. Abbreviations- NTD: Neglected Tropical Disease; BP: Burkholderia pseudomallei; CDC: Centers for Disease Control and Prevention; BSTID: Bangladesh Society of Tropical and Infections Disease; BSMM: Bangladesh Society of Medical Microbiologists; CDC-HSP: Centers for Disease Control and Prevention-Health Security Partners.   Acknowledgements We acknowledge CDC-HSP (Centers for Disease Control and Prevention-Health Security Partners) capacity development project on melioidosis in Bangladesh for funding this project. We acknowledge Prof. David Dance, Prof. Chiranjay Mukhopadhyay, Prof. M A Faiz, Prof. Jalaluddin Ashraful Haq, Prof. Md. Ruhul Amin, Prof. Ahmed Abu Saleh and Prof. Md Robed Amin for their participation in the workshop and deliberation of expert comments. We are also grateful to Prof. Md Nazmul Islam, Director CDC, DGHS, Government of Bangladesh and his office to support this project.   Author contributions Sraboni Mazumder: Investigation, Formal analysis, Project administration, Writing – original draft, Writing – review and editing. Tabiha Binte Hannan: Formal analysis, Writing – review and editing. Fahmida Rahman: Investigation, Formal Analysis, Writing – review and editing. Saika Farook: Investigation, Project administration. Forhad Uddin Hasan Chowdhury: Investigation, Project administration. Lovely Barai: Investigation, Project administration, Writing – review and editing. Chandan Kumar Roy: Investigation, Project administration, Writing – review and editing. Kutub Uddin Ahamed: Investigation, Project administration. Md. Shariful Alam Jilani: Conceptualization, Investigation, Project administration, Writing – review and editing. Fazle Rabbi Chowdhury: Conceptualization, Methodology, Project administration, Formal analysis, Writing – review and editing.   Funding Not applicable.   Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.   Ethics approval and consent to participants Informed consent was taken from all participants.   References 1.     Keluangkhot V, Pethsouvanh R, Strobel M. Mélioïdose [Melioidosis].Med Mal Infect. 2005; 35(10): 469-475. doi:10.1016/j.medmal.2005.08.001. 2.     Ganesan V, Sundaramoorthy R, Subramanian S. Melioidosis-Series of Seven Cases from Madurai, Tamil Nadu, India. Indian J Crit Care Med. 2019; 23(3): 149-151. doi:10.5005/jp-journals-10071-23139. 3.     Mukhopadhyay C, Shaw T, Varghese GM, Dance DAB. Melioidosis in South Asia (India, Nepal, Pakistan, Bhutan and Afghanistan). Trop Med Infect Dis. 2018; 3(2): 51. doi:10.3390/tropicalmed3020051. 4.     Currie BJ, Dance DA, Cheng AC. The global distribution of Burkholderia pseudomallei and melioidosis: an update.Trans R Soc Trop Med Hyg. 2008; 102 Suppl 1: S1-S4. doi:10.1016/S0035-9203(08)70002-6. 5.     Chaowagul W, White NJ, Dance DA, Wattanagoon Y, Naigowit P, Davis TM, et al. Melioidosis: a major cause of community-acquired septicemia in northeastern Thailand. J Infect Dis. 1989; 159(5): 890-899. doi:10.1093/infdis/159.5.890. 6.     Limmathurotsakul D, Wongratanacheewin S, Teerawattanasook N, Wongsuvan G, Chaisuksant S, Chetchotisakd P, et al. Increasing incidence of human melioidosis in Northeast Thailand.Am J Trop Med Hyg. 2010; 82(6): 1113-1117. doi:10.4269/ajtmh.2010.10-0038. 7.     Limmathurotsakul D, Golding N, Dance DA, Messina JP, Pigott DM, Moyes CL, et al. Predicted global distribution of Burkholderia pseudomallei and burden of melioidosis. Nat Microbiol. 2016; 1(1): 15008. doi:10.1038/nmicrobiol.2015.8. 8.     Chowdhury FR, Roy CK, Barai L, Paul S, Chowdhury FUH, Mazumder S, et al. Melioidosis: A neglected infection in Bangladesh. J Med. 2021; 22: 139–145. doi:10.3329/jom.v22i2.56705. 9.     Jilani MSA, Robayet JAM, Mohiuddin M, Hasan MR, Ahsan CR, Haq JA. Burkholderia pseudomallei: Its detection in soil and seroprevalence in Bangladesh. PLoS Negl Trop Dis. 2016; 10(1): e0004301. doi:10.1371/journal.pntd.0004301. 10. Weeratunga MP, Mayo M, Kaestli M, Currie BJ. Melioidosis knowledge awareness in three distinct groups in the tropical northern territory of Australia. Trop Med Infect Dis. 2024; 9(4): 71. doi:10.3390/tropicalmed9040071. 11.  Smith S, Buikstra E, Rubenach S, Preston-Thomas A, Hanson J. Limited awareness of melioidosis in high-risk populations despite an increasing incidence of the disease in Far North Queensland, Australia. Am J Trop Med Hyg. 2022; 107(6): 1278-1280. doi:10.4269/ajtmh.22-0160. 12. Almarhabi H, Munshi A, Althobaiti M, AljohaniS, Abu Shanab R, Althaqafi A. Melioidosis pneumonia in Saudi Arabia: A rare case report and review of the literature. Cureus. 2022; 14(2): e21871. doi:10.7759/cureus.21871. 13. Wiersinga WJ, Virk HS, Torres AG, Currie BJ, Peacock SJ, Dance DAB, et al. Melioidosis. Nat Rev Dis Primers. 2018; 4: 17107. doi:10.1038/nrdp.2017.107. 14. Chowdhury S, Barai L, Afroze SR, Ghosh PK, Afroz F, Rahman H, et al. The epidemiology of melioidosis and its association with diabetes mellitus: A systematic review and meta-analysis. Pathogens. 2022; 11(2): 149. doi:10.3390/pathogens11020149. 15. Hemarajata P, Baghdadi JD, Hoffman R, Humphries RM. Burkholderia pseudomallei: Challenges for the clinical microbiology laboratory. J Clin Microbiol. 2016; 54(12): 2866-2873. doi:10.1128/JCM.01636-16. 16. Gassiep I, Armstrong M, Norton R. Human Melioidosis. Clin Microbiol Rev. 2020; 33(2): e00006-19. doi:10.1128/CMR.00006-19. 17. Peeters M, Ombele S, Chung P, Tsoumanis A, Lim K, Long L, et al. Slow growth of Burkholderia pseudomallei compared to other pathogens in an adapted blood culture system in Phnom Penh, Cambodia. J Med Microbiol. 2019; 68(8): 1159-1166. doi:10.1099/jmm.0.001011. 18. Wuthiekanun V, Dance DA, Wattanagoon Y, Supputtamongkol Y, Chaowagul W, White NJ. The use of selective media for the isolation of Pseudomonas pseudomallei in clinical practice.J Med Microbiol. 1990; 33(2): 121-126. doi:10.1099/00222615-33-2-121. 19. Chowdhury FR, Jilani MSA, Barai L, Rahman T, Saha MR, Amin MR, et al. Melioidosis in Bangladesh: A clinical and epidemiological analysis of culture-confirmed cases. Trop Med Infect Dis. 2018; 3(2): 40. doi:10.3390/tropicalmed3020040. 20.  Tauran PM, Wahyunie S, Saad F, Dahesihdewi A, Graciella M, Muhammad M, et al. Emergence of melioidosis in Indonesia and today's challenges. Trop Med Infect Dis. 2018; 3(1): 32. doi:10.3390/tropicalmed3010032. 21.  Hassan MR, Vijayalakshmi N, Pani SP, Peng NP, Mehenderkar R, Voralu K, et al. Antimicrobial susceptibility patterns of Burkholderia pseudomallei among melioidosis cases in Kedah, Malaysia. Southeast Asian J Trop Med Public Health. 2014; 45(3): 680-688. 22.  Crowe A, McMahon N, Currie BJ, Baird RW. Current antimicrobial susceptibility of first-episode melioidosis Burkholderia pseudomallei isolates from the Northern Territory, Australia. Int J Antimicrob Agents. 2014; 44(2):160-162. doi:10.1016/j.ijantimicag.2014.04.012. 23.  Chansrichavala P, Wongsuwan N, Suddee S, Malasit M, Hongsuwan M, Wannapinij P, et al. Public awareness of melioidosis in Thailand and potential use of video clips as educational tools. PLoS One. 2015; 10(3): e0121311. doi:10.1371/journal.pone.0121311.     Cite this article as: Mazumder S, Hannan TB, Rahman F, Farook S, Chowdhury FUH, Barai L, et al. Knowledge on melioidosis among healthcare workers of Bangladesh. IMC J Med Sci. 2025; 19(2):005. DOI:https://doi.org/10.55010/imcjms.19.014 <![CDATA[Analysis of plateletpheresis donor deferral patterns over two years at a tertiary care hospital in Dhaka, Bangladesh]]> Farida Parvin* Tashmim Farhana Dipta Zakia Akter Mohammad Abdul Aleem Tamanna Mahfuza Tarin Jannatul Ferdous Reshma Mohammad Ali Samira Humaira Habib https://imcjms.com/journal_full_text/568 2025-06-19 11:20:43 Original Article July 2025; Vol. 19(2):003 Abstract Background and objective: Plateletpheresis involves the separation of platelets from healthy donor blood, with the remaining components returned to the donor’s circulation. With the increasing demand for aphaeretic platelets, the transfusion medicine department plays a crucial role in ensuring the availability of safe blood products when required. This study aimed to determine the frequency and underlying reasons for donor deferral during plateletpheresis. Materials and Methods: This study was conducted in the Transfusion Medicine Department of BIRDEM General Hospital in Dhaka from January 2021 to December 2022. Apheresis donors of either sex who attended the department were selected and evaluated for deferral by physicians in accordance with the Standard Operating Procedure (SOP) outlined in the hospital protocol [1]. Data on deferred plateletpheresis donors were recorded manually in a register book and analyzed retrospectively. Results: A total of 318 plateletpheresis donors were screened during this study period, of whom 43 (13.52%) were deferred for various reasons. The majority of the deferrals (93.9%) were temporary. The major causes of donor deferral were poor venous access (27.7%, mostly in females), low platelet count (16.2%), and the use of medications, most commonly analgesics, at 11.4%. Conclusion: This study demonstrated that venous access plays a vital role in donor deferral. Additionally, low platelet count and use of antiplatelet drug can significantly impact the apheretic donor eligibility. Revising the selection criteria for plateletpheresis donors could substantially enhance donor participation and reduce deferral rates. Furthermore, continued efforts to provide advanced training for technical personnel and ensure effective supervision by Transfusion Medicine Specialists will contribute to minimizing donor deferrals.July 2025; Vol. 19(2):003. DOI: https://doi.org/10.55010/imcjms.19.012*Correspondence: Farida Parvin, Department of Transfusion Medicine & Clinical Haematology, BIRDEM General Hospital, Dhaka, Bangladesh. E-mail: dr.farida1984@gmail.com. © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0).   Introduction Donor selection for plateletpheresis is essential to ensure the safety of both the donor and the recipient. The demand of plateletpheresis increases significantly in our country during dengue season. It is also highly beneficial for prophylactic platelet transfusions in various haematological disorders. However, donors may be deferred from platelet donations due to temporary or permanent reasons. Special attention is crucial during the selection and deferral process of apheresis platelet donors, as plateletpheresis differs significantly from whole blood donation. Plateletpheresis is an automated procedure in which whole blood is drawn from a donor, processed to separate platelets, referred to as single donor platelets (SDP), the remaining blood components are returned to the donor [2]. A routine plateletpheresis procedure session typically lasts between 1 to 1.5 hours. The product is collected using a closed automated system and can be stored for up to 5 days. Normally, the number of platelets collected in an apheresis product is equivalent to 6 to 8 units of random donor platelets (RDPs) [3]. SDP offers several advantages over RDP, including a higher yield, which allows for longer intervals between platelet transfusions. Additionally, it significantly reduces the risk of transfusion-transmitted diseases, alloimmunization, and febrile nonhemolytic reactions due to reduced donor exposure [4,5,6]. Platelets are used both therapeutically and prophylactically, particularly benefiting patients with thrombocytopenia. Therapeutic platelet transfusion is indicated when the platelet count is less than 50x10^9/L in the presence of diffuse microvascular bleeding. Prophylactically, platelets are administered to prevent bleeding or control active bleeding [7]. Proper donor selection is crucial for ensuring an adequate supply of blood components, as donors are the only source. The primary objective of the current study was to investigate the causes and frequency of donor deferral during plateletpheresis.   Materials and methods This single center observational study was conducted on 275 apheresis donors who attended the Transfusion Medicine department at BIRDEM General Hospital, Dhaka, from January 2021 to December 2022. Donors of both sexes were purposively selected. Selection or deferral was based on a comprehensive medical history obtained through a questionnaire, followed by a complete physical examination and assessment of vital parameters, in accordance with the criteria for Single Donor Platelet (SDP) preparation as outlined by the Directorate General of Health Services (DGHS). The eligibility criteria included a minimum weight of 60 kg, an age range between 18 to 60 years, and a haemoglobin level of at least 12.5 g/dl. Donors who had taken aspirin containing medications within the past 36 hours were generally deferred. There had to be a minimum interval of 48 hours between procedures, and donors were not permitted to undergo the procedure more than twice a week or more than 24 times in a year. Additional requirements included a platelet count of more than 1.5 lakh, absence of any illness, negative test results for HBsAg, HCV, HIV, syphilis and malariaand the presence of adequate venous access, with firm, large and palpable veins in both arms. After the preliminary selection of donors, their blood samples were tested for CBC (Complete Blood Count), focusing primarily on Hb, hematocrit (Hct), and platelet count. Samples were also screened for Transfusion Transmitted Infections (TTI) including HIV (Human Immunodeficiency Virus), Hepatitis B virus (HBsAg), Hepatitis C virus (Anti HCV), Syphilis, and Malaria using Rapid Immunochromatographic tests. If any CBC or TTI test result was abnormal, the donor was given appropriate counseling and referred to the relevant department for further evaluation and management. Plateletpheresis procedures were performed using the Haemonetics MCS+ with intermittent flow.   Results During the study period, a total of 318 donors were screened for plateletpheresis of whom 275 (86.48%) donors were accepted and 43 (13.52%) were deferred for various reasons. All 275 donors accepted for plateletpheresis were male. Among the deferred donors, 28 (65.12%) were male and 15 (34.88%) were female, as shown in Figure-1. The deferred apheresis blood donors were classified as either temporary or permanent, with 40 (93.03%) cases of temporary deferral and 3 (6.97%) cases of permanent deferral, as shown in Figure-2. In this study, most of the deferred donors- 22 (51.16%)- were between the ages of 26 and 35 years, as shown in Figure-3. The major causes of temporary donor deferral were poor venous access (25.58%, mostly in females), low platelet count (16.28%) and recent use of medications (most commonly analgesic in 11.62% cases). The least common cause was a non-matching blood group (2.32%) between donor and recipient, as shown in Table-1. In our present study, the most common cause of permanent deferral was seropositivity for Hepatitis B, as shown in Table-1.     Figure -1: Distribution of Donor Deferral According to Gender (n=43)       Figure-2: Types of donor deferral (n=43)     Figure-3: Distribution of deferred donors according to age group (n=43)   Table-1: Deferral types & causes of donor deferral (n=43)     Discussion The donor deferral process prior to blood donation is a vital step in safeguarding recipients from transfusion-related complications and in minimizing any negative impact on donor motivation. It is important to note that the donor deferral criteria may vary between regions and among different blood donation centers [8]. In our study, the deferral rate among apheresis donors was approximately 13.52%, attributed to various causes. This rate is comparable to the lowest deferral rate reported in the literature by Pandey et al. [9], who observed a deferral rate of 10.6%. Higher donor deferral rates, ranging from 18.02% to 28.03%, have been reported in several studies [10-13]. These findings indicate variability in donor selection criteria, demographic differences, and institutional policies. Notably, the highest deferral rates during plateletpheresis procedures were reported Yadav et al. [14] (43.2%) and Syal et al. [15] (44.2%), suggesting more stringent donor eligibility protocols or higher prevalence of temporary deferral factors in those populations. In the present study, the majority of deferred donors (51.16%) were between the ages of 26 and 35 years, which is consistent with the findings reported in several studies [10,12,15,16]. This age group often represents the largest proportion of the donor population, reflecting their active participation in voluntary blood donation programs. Additionally, donors in this age range may be more susceptible to temporary deferral factors such as minor illnesses, recent medication use, or lifestyle-related issues, which can transiently affect eligibility. Understanding the demographic profile of deferred donors helps tailor targeted interventions and counselling to reduce deferral rates and encourage donor retention in this key age group. Notably, in the present study, all the female (15 in number) donors were deferred, primarily due to low haemoglobin levels, or being underweight. This is likely due to high prevalence of iron deficiency anaemia among women. Tondon et al. [13], also highlighted challenges in recruiting female donors citing factors such as low body weight, physiological blood loss, and inadequate dietary intake. Existing literature has consistently reported lower participation of women as plateletpheresis donors. In this study, we observed that the majority of donors (93.03%) were deferred for temporary reasons, indicating that most deferrals could be reversed with appropriate follow-up and management. This finding is consistent with the results reported by Seema et al. [11], who observed a temporary deferral rate of 89.65%, and Arora et al. [16], who reported a similar rate of 93.28%. Such high proportions of temporary deferrals suggest the potential to retain and re-engage a large pool of deferred donors by addressing short-term deferral causes. Similar trends have also been reported by Mehmet et al. [17], further supporting the predominance of temporary over permanent deferrals in apheresis donor populations. These findings emphasize the importance of donor education, proper counselling, and periodic re-evaluation to minimize donor loss and maintain an adequate donor base. Mehmet et al. [17], observed that the main reason of donor deferral was unsuitable venous access (25.7%), a finding that aligns to our study (25.58%). As we know, proper venous access, firm, large and palpable veins in both arms, is essential to maintain a return blood flow of at least 70-80 ml/min during the plateletpheresis procedure. In our study, the second most common reason for apheresis donor deferral was low platelet count (16.28%), which aligns closely with the findings of Kusumgar et al. [18], who reported a deferral rate of 21% for the same cause. However, other studies [10-12] identified low platelet count as the leading cause of donor deferral, with higher rates of 31.61%, 44.82%, and 43.5%, respectively. These variations likely reflect regional differences in donor demographics, screening criteria, and health status. The third most common cause of donor deferral in our study was recent use of medications, such as NSAIDs or antibiotics (11.62%), which is comparable to the 14.7% reported by Mehmet et al. [17]. Regarding permanent deferrals, Hepatitis B positivity was the most frequent cause, consistent with findings reported in some studies [11-12,16]. These findings highlight the importance of continuous evaluation and refinement of donor selection criteria to ensure both donor safety and an adequate supply of platelets.   Conclusion The demand for platelets collected through apheresis procedures is steadily increasing in routine medical and surgical practices. Careful selection of plateletpheresis donors is essential to ensure a higher yield of platelets. Effective counseling to deferred donors can help bridge the gap between the demand for and supply of Single Donor Platelets (SDPs). Remodeling the eligibility criteria for plateletpheresis donors, along with appropriate education, counseling, and reassurance, can play an integral role in retaining new donors. Continued efforts to enhance training modules for technical personnel, along with supervision provided by Transfusion Specialists, can contribute significantly to reduce donor deferrals.   Conflict of interest Authors have no conflicts of interest to declare   Funding None   References 1.     Claudia C, Meghan D, Susan TJ, Louis M, Joseph S. Whole blood and apheresis collection of blood components intended for transfusion. In: Claudia C, Meghan D, Susan TJ, Louis M, Joseph S, editors. Technical Manual AABB. 21st eds. Maryland, USA: AABB; 2023. 2.     Suresh B, Arun R, Yashovardhan A, Deepthi K, Sreedhar BKV,Jothibai D. Changes in pre- and post-donation haematological parameters in plateletpheresis donors. J Clin Sci Res. 2014; 3(2): 85-89. doi:10.15380/2277-5706.JCSR.13.046. 3.     Saran RK. Apheresis. In: Saran RK, editor. Transfusion Medicine Technical Manual. 2nd eds. New Delhi: Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India; 2003. p. 229-243. 4.     Slichter SJ; Trial to Reduce Alloimmunization to Platelets Study Group. Leukocyte reduction and ultraviolet B irradiation of platelets to prevent alloimmunization and refractoriness to platelet transfusions. N Engl J Med. 1997; 337(26): 1861-1869. doi:10.1056/NEJM199712253372601. 5.     Koerner TA, Vo TL, Eacker KE, Strauss RG. The predictive value of three definitions of platelet transfusion refractoriness. Transfusion. 1988; 28(Suppl): 33S. 6.     Chaudhary R, Das SS, Khetan D, Sinha P. Effect of donor variables on yield in single donor plateletpheresis by continuous flow cell separator. Transfus Apher Sci. 2006; 34(2): 157-161. doi:10.1016/j.transci.2005.09.040. 7. Kaufman RM, Djulbegovic B, Gernsheimer T, et al. Platelet transfusion: a clinical practice guideline from the AABB. Ann Intern Med. 2015; 162(3): 205-213. doi:10.7326/M14-1589 8.     Galea G, Gillon J, Urbaniak SJ, Ribbons CA. Study on medical donor deferrals at sessions. Transfus Med. 1996; 6: 37–43. doi: 10.1046/j.1365-3148.1996.d01-50.X. 9.     Pandey P, Tiwari AK, Sharma J, Singh MB, Dixit S, Raina V. A prospective quality evaluation of single donor platelets (SDP) - an experience of a tertiary healthcare center in India. Transfus Apher Sci. 2012; 46(2): 163-167. doi:10.1016/j.transci.2012.01.012. 10.  Vujhini SK, Kumar KM, Bogi MK, Shanthi B. A retrospective analysis of donor deferral characteristics for plateletpheresis in a tertiary care hospital, South India. Glob J Transfus Med. 2018; 3(1): 52-55. doi:10.4103/GJTM.GJTM_3_18. 11.  Seema D, Manocha H, Agarwal D, Sharma S.An analysis of deferral pattern in plateletpheresis donors. J Cont Med A Dent. 2015; 3(3): 24-27. doi:10.18049/jcmad/335. 12. Pujani M, Jyotsna PL, Bahadur S, Pahuja S, Pathak C, Jain M. Donor deferral characteristics for plateletpheresis at a tertiary care center in India- a retrospective analysis. J Clin Diagn Res. 2014; 8(7): FC01-FC3. doi:10.7860/JCDR/2014/8131.4563. 13.  Tondon R, Pandey P, Chaudhry R. A 3-year analysis of plateletpheresis donor deferral pattern in a tertiary health care institute: assessing the current donor selection criteria in Indian scenario. J Clin Apher. 2008; 23(4): 123-128. doi:10.1002/jca.20171. 14.  Yadav BK, Shrivastava H, Katharia R, Chaudhary RK. Plateletpheresis donor deferral pattern: A retrospective 4-year data analysis at tertiary care center in India. Asian J Transfus Sci. 2022; 16(2): 214-218. doi:10.4103/ajts.ajts_96_22. 15. Syal N, Kukar N, Maharishi RN, Handa A, Aggarwal D. Donor deferral pattern for plateletpheresis at a tertiary care teaching hospital. Sch J Appl Med Sci. 2017; 5: 3145-9. 16.  Arora D, Garg K, Kaushik A, Sharma R, Rawat DS, Mandal AK. A retrospective analysis of apheresis donor deferral and adverse reactions at a tertiary care centre in India. J Clin Diagn Res. 2016; 10(11): EC22-EC24. doi:10.7860/JCDR/2016/20707.8925. 17.  Dogu MH, Hacioglu S. Analysis of plateletpheresis donor deferral rate, characteristics, and its preventability. J Appl Hematol. 2017; 8(1): 12-15. doi: 10.4103/joah.joah_6_17. 18.  Kusumgar R, Mehta S, Shah M, Rajvanshi R. A two years study of deferral among platelet pheresis donors in a cancer care Institute. Pathol Lab Med. 2014; 6: 37-9.      Cite this article as: Parvin F, Dipta TF, Akter Z, Aleem MA, Tarin TM, Reshma JF, et al. Analysis of plateletpheresis donor deferral patterns over two years at a tertiary care hospital in Dhaka, Bangladesh. IMC J Med Sci. 2025; 19(2):003. DOI:https://doi.org/10.55010/imcjms.19.012 <![CDATA[Oxytocin is an important determinant of psychosocial behavior: a study conducted in three secondary schools in rural Bangladesh]]> Nehlin Tomalika Rishad Mahzabeen Naima Ahmed Sadya Afroz AHG Morshed MA Sayeed* https://imcjms.com/journal_full_text/567 2025-05-26 10:57:44 Original Article July 2025; Vol. 19(2):002 Abstract Background and objectives: Increasing psychosocial dysfunction (PD) is a major mental health issue globally. Deviation from normal mental health in early childhood leads to severe sequelae in adulthood, jeopardizing not only the individual affected but also his family, community and the entire society as a whole. Social crimes indicate mental health disorders of society. Early detection and intervention of behavioral disorders are expected to prevent such an increasing trend. The study aims to measure the prevalence of psychosocial dysfunction in secondary school- going children and to determine its biological risk variables. Materials and methods: Three secondary high schools in rural communities were purposively selected. Students aged 11 – 18 years from classes six to ten were selected randomly. Having purposively selected 3 schools, the student participants were randomly selected based on class roll numbers 5, 15, 25, 35, 45, 55, 65 - --- 95; ten from each class for the girls (10 X 5 = 50). Likewise, for the boys, 20 from each class according to Class Roll No: 5, 10, 15, 20, 25 ---- 100. PSC35 was used for scoring psychosocial behavior. The class teachers filled out the questionnaire in consultation with parents or caretakers. Investigations included: a) anthropometry (height, weight, waist- and hip-girth), blood pressure; b) biochemistry profile (blood glucose, dopamine, serotonin, cortisol and oxytocin). PSC35 ≥23 was taken as the cut-off for PD. Results: A total of 250 students (boys / girls = 165/85) participated. The prevalence of PD was found to be 36.4% (boys / girls = 25.6 / 10.8%; p=0.332). Compared with the girls, the boys had significantly higher central obesity (WHR, p=0.018; WHtR, p<0.001) than girls, whereas the girls had higher FBG (p<0.001), cortisol (p = 0.009) and OT (p<0.001). Comparisons between those with PD (PSC35 ≥23) and without PD (PSC35<23) showed that PD group had significantly lower OT (p=0.015). Pearson’s correlation estimated that OT had negative correlations (r = - 0.159, p = 0.016) with PSC35. Multiple comparisons of risk variables based on PSC35-tertiles by ANOVA (Scheffe) showed the higher tertile had significantly lower OT (p = 0.008). Logistic regression (binary) also proved lower OT was significantly associated with PD. Conclusions: This cross-sectional study revealed a higher prevalence of PD among the school students. It investigated major biological risk variables (obesity, blood pressure, blood glucose and neurotransmitters), and whether these variables contribute to PD. Of the investigated variables, lower OT level was found to be significantly associated with PD and proved to be an important risk. Further study may be initiated to confirm our study findings. Acronyms – BMI – body mass index (weight in kg/height in met sq.), DBP – diastolic blood pressure, FBG – fasting blood glucose, MAP –mean arterial pressure [(MAP = DBP + 1/3 (SBP – DBP)], SD- standard deviation, WHR – waist-to-hip ratio, WHtR- waist-to-height ratio, SBP – systolic blood pressure; PSC35 – pediatric symptom checklist 35. PD- Psychological dysfunction: [ADHD – attention deficiency hyperactive disorders, CD – conduct disorders, ODD – oppositional defiant disorders]. July 2025; Vol. 19(2):002.  DOI: https://doi.org/10.55010/imcjms.19.011 *Correspondence: M Abu Sayeed, Department of Community Medicine and Public Health, Ibrahim Medical College, 1/A, Ibrahim Sarani, Segunbagicha, Dhaka 1000, Bangladesh. Email: sayeed1950@gmail.com © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License(CC BY 4.0).   Introduction Bangladesh is the most densely populated country in the world (total 172 million; 1329/sq km). According to the Bangladesh bureau of statistics (BBS), almost half of the population is below age 30y. A total of 33 million students are enrolled in 1.6 million primary educational institutes. Despite all efforts, Bangladesh experiences a sizeable dropout rate of about 18% at the primary level (‘Primary enrolment rate 98%’, 2020), which increases to 50% at the secondary level (Ministry of Education, 2011; Sarker et al., 2019). The factors causing such an alarming dropout rate are unknown. May be worthy to note – this population age-group is most important considering young energetic productive force, future development and dynamic strength of the country. It may also be noted that there is an increasing rate of social crimes indicating a deterioration of healthy attitude and behavior, inflicting mental health and crimes. Increasing rate of Juvenile delinquency may contribute to these crimes. According to UNICEF “there are 36 million teenagers in Bangladesh. Since 2012, the police headquarters has had records of juvenile crime. In 2012, 751 children and teenagers were accused in 484 cases. In the first six months of 2020, 1191 were arrested in 821 cases. Sources in the social welfare directorate said that most of these teenagers were arrested under the case of drug, murder, and rape and sent to the correctional centers. The above-mentioned findings suggest that the young and most potential population is at risk of dropping out of school, thus increasing the rate of juvenile delinquency. From Bangladesh’s perspective, it has been reported that poverty, broken families, social and economic inequalities and discrepancies are the causes of such juvenile delinquencies [1]. A very recent study in China on ‘Antisocial Behavior and Antisocial Personality Disorder (ASPD) among Youth’ showed that ASPD affects all youth irrespective of class and ethnicity [2,3]. An extensive review by Perrotta G et al. on Behavior and Conduct Disorder in Childhood, highlights the main predictive elements in preadolescents and adolescents that can be correlated with the symptoms of distinctive disorders in deviant and criminal conduct. Early detection and intervention in all forms, including therapeutic measures, can encourage behavioral improvement of those who are still not adults [3]. Regarding neurophysiology, some neurotransmitters (chemical messengers) play an important role in the brain by influencing mood and behavior like dopamine, serotonin, oxytocin, cortisol, norepinephrine, and endorphins [2,4]. Abnormalities (quality or quantity) of these chemical messengers may relate to behavioral disorders. Of them, oxytocin (OT) has been studied in relation to social bonding and has been termed as ‘love hormone’, ‘cuddling chemical’ and ‘hormone of sociostasis’ [4-6]. John Tully et al.opined oxytocin as a master regulator of social affiliation, social connection, and adaptive reproductive behaviors [7]. OT plays a very vital role in maintaining ‘Love and longevity’ [8]. The effect of OT on empathy and socialization was also reported from Argentina [9]. Based on the above findings – a) an alarming number of dropouts from schools, b) increasing involvement of youth in anti-social behavior, c) deteriorating mental and social health, eventually leading to juvenile crimes, this study aims to screen PD among secondary school children aged 11 – 18 years. Additionally, the study addresses some important metabolic (obesity, blood pressure, blood glucose) and neurotransmitters (dopamine, serotonin, oxytocin and cortisol) risks.   Material and methods The study protocol was duly approved by the Ibrahim Medical College Institutional Review Board (IMC IRB). Three secondary schools were selected purposively –two in Kharua, Nandal upazila (one boys’ school and one girls’) under Mymensingh. The third school having co-education, was selected in Vulbaria, Santhia under Pabna. For each selected school, local social leaders, parents and schoolteachers including the headmasters, were communicated with. They were informed about the objectives and the procedural details of the study. The selection of three secondary schools was purposive. Having purposively selected 3 schools the student participants were randomly selected based on class roll no: 5, 15, 25, 35, 45, 55, 65 - --- 95; ten from each class for the girls (10 X 5 = 50). Likewise, for the boys 20 from each class according to class roll no: 5, 10, 15, 20, 25 ---- 100. The eligibility criteria of the participants are based on class roll no. and willingness (assessed by class teacher) to volunteer for the investigation that needs blood sample. The schoolteachers kindly volunteered to fill out questionnaires on Pediatric Symptom Checklist-35 (PSC35) [10]. The parents / guardians of each student were interviewed by his / her respective class teachers. Having completed the questionnaires (PSC35), the data collected was computerized. The eligibility lists of the participants were prepared and printed. The investigation date and site at school were announced following consultation with teachers. The eligible participants were advised to attend the investigation site in the morning with an overnight fast. The teachers maintained a disciplined queue of the participants during investigations. At first, a brief clinical history (present illness, medications) was taken from each participant. Anthropometry (height, weight, waist- and hip-girth) and blood pressure were taken. Fasting blood samples were collected, centrifuged and serum samples were refrigerated and transported to Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrinology and Metabolic Disorders (BIRDEM). Cold chain was strictly maintained while transporting. The Lab investigations included fasting blood glucose (mmol/L), neurotransmitters [dopamine (pg/ml), serotonin (ng/ml), cortisol (ng/ml) and oxytocin (pg/ml)]. These were assayed in BIRDEM Endocrine Labusinga commercially competitive ELISA-based kit (DRG, USA). Diagnostic cut-off: Psychological dysfunctions (PD /behavioral disorders – ADHD, CD, ODD) were diagnosed based on PSC35 ≥23 [10,11]. Statistical analysis: The prevalence of PD was presented in percentages. All quantitative variables were expressed in mean with SD and 95% CI. The biophysical characteristics were compared between boys and girls using an independent t-test and so were the comparisons between students with and without PD. ANOVA compare the quantitative variables among the PSC35-tertiles. SPSS version 20.0 was used for all statistical analyses and p<0.05 was accepted as the level of significance. Logistic regression analysis estimated the biophysical variables as the independent and the PD (PSC35 ≥23) as the dependent variable. For the regression analysis, the quantitative variables were dichotomized into qualitative based on median– WHtR2 (<0.42 v ≥0.42), FBG2 (<6.0 v ≥6.0 mmol/l), Dopamine2 (<32.4 v ≥32.4 pg/ml), serotonin2 (<141.2 v ≥141.2ng/ml), cortisol2 (96.14 v ≥ 96.14ng/ml) and oxytocin2 (<109.5 v ≥109.5 pg/ml). For PD tertiles, the values are lower, middle and upper, <22, 22-28 and >28, respectively.   Results A total of 250 (boys / girls = 165/85) students took part in the study. The prevalence of PD was 36.4% (boys / girls = 25.6 / 10.8%, p=0.332; Table-1).   Table-1: Prevalence of psychosocial dysfunction by sex (boys / girls = 165 / 85)     The mean (SD) values and 95% CI of investigated variables were showing in Table-2. The biophysical variables included anthropometry (BMI, WHR, and WHtR), blood pressure, dopamine, serotonin, cortisol  and  OT.  Comparisons  between  boys  and girls of the variables are shown in Table-3. The boys had significantly higher central obesity (WHR, p=0.018; WHtR, p<0.001) than girls, whereas the girls had higher FBG (p<0.001), cortisol (p = 0.009) and OT (p<0.001).   Table-2: Biophysical characteristics of the participants (boys and girls: n =250: mean (SD) and 95% CI     Table-3: Comparison of biophysical characteristics (N= boys /girls = 165/85)     Correlations among the variables controlling for age and sex were displayed in Table-4. OT had significant positive correlation with dopamine (p=0.001), cortisol (p<0.001), serotonin (p=0.004), but significant negative correlation with PSC35 (p=0.016). No other neurotransmitters showed such association with PSC35.   Table-4: Correlations among biophysical variables controlling sex and class/age     As the 95% CI of PSC35 of all participants was found (20.8 – 22.6) in Table-2, the cut-off for PD was taken ≥23. Thus, a table was constructed based on this cut-off (PSC35: <23 vs. ≥23, Table-5) for comparisons of the investigated variables. None of the neurotransmitters differed except OT, which was found significantly lower in the PSC35 ≥23 group than those with PSC35 <23 (p=0.015).   Table-5: Students with normal PSC35 compared with those with higher PSC35 <23 vs. ≥23)     Figure-1A showed a declining trend of OT with the increasing PSC quartiles. At PSC<16, OT level was found 177 pg/ml, which came down to 126 pg/ml at PSC >26, though not significant. The other neurotransmitters showed no change with PSC35 level. Again, in Figure-1B obesity variables (BMI, WHtR), FBG and MAP did not show any change with varying PSC35 levels.     Figure-1A: Mean values of Dopamine, Cortisol, Serotonin and Oxytocin by quartiles (Q1 = <16, Q2 = 17-21, Q3 = 22-26, Q4 = >26) of PSC35. Oxytocin showed declining as PSC35 rising, though not significant. Other neurotransmitters showed no change.     Figure-1B: Mean values of WHtR, BMI, FBG and MAP by quartiles (quartiles (Q1 = <16, Q2 = 17-21, Q3 = 22-26, Q4 = >26) of PSC35) of PSC35.   Multiple comparisons of biophysical variables, based on PSC –tertiles, were estimated by ANOVA (Post-hoc, Scheffe) in Tables-6a and 6b. Of all four neurotransmitters, only OT was found to be associated with higher PSC (182.6 pg/ ml in the first tertile vs. 124.3 pg/ ml in third tertile; p = 0.008). This   finding   indicates   that   PD   was   significantly associated with lower OT level.   Table-6a: ANOVA: multiple comparisons of biophysical variables by post hoc (Scheffe) based on PSC35 Tertiles of Pediatric symptoms Checklist 35 as dependent     Table-6b: ANOVA: multiple comparisons of biophysical variables by post hoc (Scheffe) based on PSC35 tertiles of Pediatric symptom Checklist 35 as dependent     Furthermore, the studied risk variables were estimated by binary logistic regression taking PSC35 ≥23 as the dependent variables (Table-7). The analysis also proved low OT (<110 pg/ ml) was a significant predictor of psychological dysfunction.   Table-7: Binary logistic regression estimated the risks for psychological dysfunctions taking PSC35 ≥23 as the dependent and others as independent variables. Method – Backward stepwise, conditional     Discussions The study is the first of its kind with regard to – a) screening of behavior and conduct disorder in childhood and adolescence in a Bangladeshi population; b) addressing some major biological risks (neurotransmitters) related to PD (ADHD, CD, ODD). The importance of the study is focused on identifying risks in early life, which may help prevent juvenile crimes, eventually preventing serious adult delinquencies. Therefore, the future impact of this study is enormous, expecting acrime-free healthy society. There have been a substantial number of studies related to “mental health disorders” conducted in Bangladesh [1,13-16]. Most studies addressed prevalence, causes and / or risks of juvenile delinquencies in Bangladesh. All these study conclusions were mostly limited to incriminating – family disharmony, inequality, illiteracy, migration, poverty and social environment. None of them addressed biologic risks like nutritional abnormalities (malnutrition, obesity), metabolic abnormalities (blood pressure, blood glucose) and those related to neurotransmitters (dopamine, serotonin, cortisol, OT). In this regard, this study explored a new horizon to delve into. Many studies justify future research on the role of OT in psychological development and maintenance [3,5,6–10]. More and more studies are emphasizing neurotransmitters’ (chemical messengers) role in modulating behavior, personality, empathy, emotion, socializing aptitude and so on [17–22]. This study encompassed some biologic variables to determine whether any of them had an association with PD. The collected data was presented in eight tables and two figures. The baseline information on these variables related to mental health dysfunction could not be compared due to the scarcity of such studies among the secondary school children. The study findings may be taken as future reference for this age group population. All the presented data (Table-4, 5, 6a, 6b and figure-1A) indicated lower OT was significantly associated with psychological dysfunction. Additionally, binary logistic regression (Table-7), of all the investigated variables unequivocally proved, low OT to be an important predictor of this disorder. The risk association of this study is consistent with all the above cited literature. It is not overemphasized that this study attempted to create public awareness regarding the starting point of juvenile delinquencies, as varying psychosocial disorders among childhood originate very insidiously. Neither the children nor their parents, teachers, caretakers are aware of the effect of neurotransmitters on psychosocial abnormalities. These OT deficient children are usually traumatized by their family members, neighbors, teachers, friends and peers. These innocent and underdog children born with OT deficiency, lacking social bonding ability, behave unfriendly, receiving unkindness in return, are often traumatized. Thus, this creates a vicious cycle. This is an unfortunate condition, exposed to an unfavorable society with no love, no affection and no empathy leading them only to despair–likely to commit crimes. Some literature had extensive reviews explaining OT regarding diverse mechanisms, physiological effects, Nature’s’ medicine and therapeutic promise [5,8,9,10]. Its multifaceted physiological effects invite the attention of mental health professionals for psychiatric, developmental, and neurodegenerative disorders. Denoting our limitations, we could not analyze the association between OT deficiency and metabolic syndrome, though central obesity had a significant negative correlation with OT (r= -0.212, p<0.01). Endorphin and encephalin, the other neurotransmitters could not be included. Finally, the history of parenting, socio-economic status, dietary habits, sleep, physical activities and cultural practices, which influence mental health, could not be assessed.   Conclusions The study estimated the prevalence of PD among the school students. Additionally, it investigated the biological variables influencing mental health problems. It studied neurotransmitters along with obesity, blood pressure and blood glucose for the association with psychosocial abnormalities. Low OT level was proved to be an important risk. Further study may be initiated to confirm or establish the study findings.   Acknowledgements We are grateful to the Endocrine Lab of BIRDEM for assaying biochemical samples. We are also thankful to the teachers and students of Kharua high school and Ashefa Girls High School in Nandail, Mymensingh. We are also indebted to teachers and students of Vulbaria High School, Santhia, Pabna.   Authors’ contribution NT: Protocol writing, questionnaire development; RM, NA, SA: questionnaire development; AHGM: performed biochemical tests; MAS: research idea, study design, data analysis, manuscript writing.   Conflict of interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.   Fund The study was funded by Ibrahim Medical College.   References 1.     Khuda-E-Kudrot. Juvenile delinquency, its causes and justice system in Bangladesh: a critical analysis. J. S. Asian Stud. 2019; 7(3): 109-118. doi:10.33687/jsas.007.03.3097. 2.     Bosch OJ, Young LJ. Oxytocin and social relationships: from attachment to bond disruption. Curr Top Behav Neurosci. 2018; 35: 97-117. doi:10.1007/7854_2017_10. 3.     Zhou Q, Wan Y, Wang J, Yang L, Shen F, Ni Q, et al. Antisocial behavior and antisocial personality disorder among youth in ethnic minority areas in china: a cross-sectional study. Alpha Psychiatry. 2024; 25(4): 526-532. doi:10.5152/alphapsychiatry.2024.241622. 4.     Perrotta G, Fabiano G, Posta F. The psychopathological evolution of “Behavior and Conduct Disorder in Childhood”: Deviant and criminal traits in preadolescence and adolescence. A review. Open J Pediatr Child Health. 2023; 8(1): 045-059. doi:10.17352/ojpch.000051. 5.     Folorunsho IL, Harry NM, Udegbe DC, Jessa D. Impact of oxytocin on social bonding and its potential as a treatment for social anxiety disorder. World Journal of Biology Pharmacy and Health Sciences (WJBPHS). 2024; 19(1): 197–204. doi:10.30574/wjbphs.2024.19.1.0418. 6.     Kingsbury MA. The intertwining of oxytocin's effects on social affiliation and inflammation. Compr Psychoneuroendocrinol. 2024; 19: 100239. doi:10.1016/j.cpnec.2024.100239. 7.     Tully J, Sethi A, Griem J, Paloyelis Y, Craig MC, Williams SCR, et al. Oxytocin normalizes the implicit processing of fearful faces in psychopathy: a randomized crossover study using fMRI. Nat Ment Health. 2023; 1(6): 420-427. doi:10.1038/s44220-023-00067-3. 8.     Horn AJ, Carter CS. Love and longevity: A social dependency hypothesis. Compr Psychoneuroendocrinol. 2021; 8: 100088. doi:10.1016/j.cpnec.2021.100088. 9.     Carter CS, Kenkel WM, MacLean EL, Wilson SR, Perkeybile AM, Yee JR, et al. Is Oxytocin "Nature's Medicine"? Pharmacol Rev. 2020; 72(4): 829-861. doi:10.1124/pr.120.019398. 10.  Orlando MS, Farrington DP, Jollife D. Empathy and repeat offending of young offenders in Argentina. International Journal of Comparative and Applied Criminal Justice. 2021; 47(3): 221–233. doi:10.1080/01924036.2021.1989609. 11.  Murphy JM, Arnett HL, Bishop SJ, Jellinek MS, Reede JY. Screening for psychosocial dysfunction in pediatric practice. A naturalistic study of the Pediatric Symptom Checklist. Clin Pediatr (Phila). 1992; 31(11): 660-667. doi:10.1177/000992289203101104. 12.  Perrotta G, Fabiano G. Behavioural disorders in children and adolescents: Definition, clinical contexts, neurobiological profiles and clinical treatments. Open J Pediatr Child Health (OJPed). 2021; 6(1): 005-015. doi:10.17352/ojpch.000030. 13.  Al-Mamun F, Islam J, Muhit M, Mamun MA. Prevalence of emotional and behavioral problems among adolescents in Bangladesh. Soc Psychiatry Psychiatr Epidemiol. 2024; 59(12): 2215-2225. doi:10.1007/s00127-024-02673-7. 14.  Sarker I. Astudy on juvenile delinquency in Bangladesh its causes and consequences. East African Scholars Multidiscip Bull. 2023; 6(4): 30-36. doi:10.36349/easjmb.2023.v06i04.001. 15.  Mamun MA, Misti JM, Hasan ME, Al-Mamun F, ALmerab MM, Islam J, et al. Feature contributions and predictive accuracy in modeling adolescent daytime sleepiness using machine learning: The MeLiSA Study. Brain Sci. 2024; 14(10): 1015. doi:10.3390/brainsci14101015. 16.  Sharmin S. Prevalence and factors of juvenile delinquency in Bangladesh: An empirical analysis. Jagannath University Journal of Arts. 2021; 11(1): 231-246. 17.  Carrasco JL, Buenache E, MacDowell KS, de la Vega I, López-Villatoro JM, Moreno B, et al. Decreased oxytocin plasma levels and oxytocin receptor expression in borderline personality disorder. Acta Psychiatr Scand. 2020; 142(4): 319-325. doi:10.1111/acps.13222. 18.  Bertsch K, Herpertz SC. Oxytocin and borderline personality disorder. Curr Top Behav Neurosci. 2018; 35: 499-514. doi:10. 1007/7854_2017_26. 19.  Galvez-Merlin A, López-Villatoro JM, de la Higuera-Gonzalez P, de la Torre-Luque, McDowellK, Díaz-Marsá M, et al. Decreased oxytocin levels related to social cognition impairment in borderline personality disorder. Acta Psychiatr Scand. 2024; 149(6): 458‐466. doi:10.1111/acps.13679. 20.  Aguilar-Raab C, Eckstein M, Geracitano S, Prevost M, Gold I, Heinrichs M, et al. Oxytocin modulates the cognitive appraisal of the own and others close intimate relationships. Frontiers in Neuroscience. 2019; 13: 714. doi:10.3389/fnins.2019.00714. 21.  Alvares GA, Chen NT, Balleine BW, Hickie IB, Guastella AJ. Oxytocin selectively moderates negative cognitive appraisals in high trait anxious males. Psychoneuroendocrinology. 2012; 37(12): 2022-2031. doi:10.1016/j.psyneuen.2012.04.018. 22.  vanGoozen SHM, Fairchild G. Neuroendocrine and neurotransmitter correlates in children with antisocial behavior. Horm Behav. 2006; 50(4): 647-654. doi:10.1016/j.yhbeh.2006.06.021.     Cite this article as: Tomalika N, Mahzabeen R, Ahmed N, Afroz S, Morshed AHG, Sayeed MA. Oxytocin is an important determinant of psychosocial behavior: a study conducted in three secondary schools in rural Bangladesh. IMC J Med Sci. 2025; 19(2):002. DOI: https://doi.org/10.55010/imcjms.19.011 <![CDATA[Acute anxiety cases in emergency department following the November 23, 2022 Düzce earthquake]]> Kudret Selki Salih Karakoyun Mehmet Cihat Demir Özkan Kömürcü Aziz Alper Ayasli Alp Kaan Furkan Kıcıroğlu Mustafa Boğan https://imcjms.com/journal_full_text/561 2025-04-24 10:54:56 Original Article July 2025; Vol. 19(2):001 Abstract Background and objectives: Human and material losses associated with earthquakes are traumatic enough to trigger serious symptoms of post-traumatic stress disorder (PTSD), depression, anxiety, and other mental health issues. It is expected that after an earthquake, an increased number of patients with acute anxiety symptoms would present to the emergency department (ED) of a hospital. Therefore, this study determined the magnitude of the acute anxiety cases that reported to the ED of a tertiary care hospital within the 48-hour period following the earthquake that occurred in Düzce, Turkey, on November 23, 2022. Materials and Methods: Patients presenting to the emergency department over a 48-hour period following the earthquake starting from 04:08 on November 23, 2022, and one week before and after the earthquake were included in the study. Socio-demographic and clinical data were collected retrospectively from hospital records. The severity of anxiety symptoms was assessed with the Faces Anxiety Scale. Results: In the first 48 hours after the earthquake, a total of 224 patients applied to the ED with earthquake-related complaints. Of these patients, 59 (26.34%) presented with acute anxiety symptoms. A significantly (p <0.05) increased number of acute anxiety-related patients (8.4%) visited the ED following the earthquake compared to the 48-hour period one week before and after the earthquake (1.3% and 0.4%). Conclusion: The study has demonstrated that immediately after the earthquake, as expected, the ED of hospital encounters increased cases with anxiety symptoms along with an increase in trauma cases. Therefore, healthcare professionals should be able to recognize and manage not only trauma but also psychiatric symptoms in earthquake situations. July 2025; Vol. 19(2):001.  DOI: https://doi.org/10.55010/imcjms.19.010 *Correspondence: Mustafa Boğan, Emergency Department, School of Medicine,  Düzce University, Düzce, Turkey, Posta code: 81620. Email: mustafabogan@hotmail.com; © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License(CC BY 4.0).   Introduction Earthquakes are among the mass events that cause significant loss of life and property [1-3]. Even in the midst of a disaster, the healthcare system must continue to function both to survive and to serve. Emergency departments (ED), as is the case with all natural disasters, become the initial point of contact for affected individuals during earthquakes. Catastrophic events like earthquakes notably increase the intensity of patient influx within the first 24-48 hours [4]. Issues stemming from the surge of in-patient admissions, insufficient space to accommodate the influx of patients in the ED, and the documentation of each medical condition have become a paramount load on the healthcare providers during this initial period [5]. Furthermore, due to healthcare personnel being occupied with treating patients in disaster situations, the comprehensive documentation of individual medical cases becomes a lower priority, leading to gaps in data recording [1,2,6]. Turkey is located on the Alpine-Himalayan orogenic belt. Eighty four percent (84%) of our country's territory is situated within earthquake-prone zones, and 71% of the population resides in regions vulnerable to earthquakes [7]. In recent years, catastrophic events such as the 1999 Marmara earthquake, the 1999 Düzce earthquake, the 2011 Van earthquake, the 2020 Elazığ earthquake, the 2020 İzmir earthquake, and the 2023 Kahramanmaraş earthquake have resulted in significant loss of life and property [8]. On November 23, 2022, at 04:08 local time, an earthquake with a magnitude of Ml=6.0 (Mw 6.0) struck Düzce [9]. Since it was a superficial earthquake, its acceleration was quite high [1,12] and it was classified as an VIII (severe-destructive) earthquake according to the Modified Mercalli intensity scale [8]. Almost all houses in the city were damaged, and 800 buildings were demolished due to heavy damage [9]. Following the earthquake in 1999 (this earthquake had a magnitude of 7.5 Mw, Modified Mercalli intensity scale IX-Violent, and an acceleration of 1.49), which resulted in a significant loss of life and injuries, the city of Düzce became highly sensitive to earthquake risks [10]. This heightened sensitivity led to more rigorous urban planning efforts and construction practices aimed at earthquake resilience [9]. As a result, the earthquake in 2022 was weathered with relatively few casualties and injuries [9]. Although the city did not experience extensive destruction and loss of life, from a healthcare perspective, the earthquake had its most significant impact on the ED of the hospital. During the November 2022 earthquake, two patients lost their lives in the ED, one due to an acute myocardial infarction and the other due to intracranial hemorrhage resulting from a fall while trying to escape. While this earthquake did not have a severe impact in terms of loss of life compared to previous earthquakes, it did result in significant property damage and a surge in patient admissions to the ED. The city's experience with earthquakes has not only caused physical but also psychological issues [11,12]. In a study examining psychological problems following the earthquake, using random household samples from two towns affected by the November 1999 earthquake (Bolu and Düzce), it was shown that Düzce, which was closer to the epicenter, had a higher prevalence of post-traumatic stress disorder (PTSD) and depression [12]. Another study conducted in Düzce demonstrated that earthquake-related general uncertainty, ambiguity, chaos, and an insecure environment could trigger intense anxiety, fear, and the development of PTSD, particularly in individuals with obsessive-compulsive and paranoid personality disorders [11]. It has been shown that the human and material losses associated with earthquakes are traumatic enough to trigger serious symptoms of PTSD, depression, anxiety, and other mental health issues [13]. Therefore, the aim of this study was to determine the magnitude of acute anxiety cases that reported to the ED in the 48 hours following the earthquake and their ratio to total patients seeking emergency care at a tertiary care hospital in Düzce – the earthquake-affected area. Also, we investigated whether patients presenting with acute anxiety symptoms to the ED during the earthquake subsequently sought psychiatric outpatient care.   Materials and methods This study was conducted retrospectively at a Health Research and Application Hospital. Ethical approval for the study was obtained from the local ethics committee (Date: 20.03.2023, Decision No: 2023/46). Patient data were obtained from the hospital's electronic database and the ED records. Patients presenting with trauma and acute anxiety to the emergency department within a 48-hour period of the earthquake in Düzce starting from 04:08 on November 23, 2022, and 1 week before and after the earthquake over 48 hours period were included in the study. The data collected included the date and time of patient admissions, triage codes (green, yellow, red, black), ages, genders, presenting complaints (anxiety, trauma), whether patients presenting with anxiety complaints had a prior psychiatric diagnosis, the presence of accompanying traumas, whether they sought psychiatric outpatient care after the earthquake (within 3 months), the number of patients who developed trauma due to anxiety, and the total number of patients admitted to inpatient services at the hospital. The triage color codes were assigned according to the START triage system [14]. To determine whether there was a subsequent psychiatric referral after the ED admission, the hospital's automation system was checked, and in some cases, patients were contacted by phone to ascertain this information. Patients with missing records and lacking descriptive information such as name and age were excluded from the study. There were no patients with a black triage code admission. Patients presenting with acute anxiety symptoms were determined according to their chief complaints and the severity of the complaints. Main symptoms of acute anxiety considered were nausea, feeling light-headed or dizzy, body pins and needles, feeling restless or unable to sit still, headache, backache or other aches and pains, rapid breathing, feeling of fast, strong heartbeat, sweating, or hot flashes. The severity of symptoms was assessed with the Faces Anxiety Scale developed by McKinley et al [15]. Patients scoring 3 or more were considered to have an acute anxiety attack. Patients with any evidence of trauma were excluded from this category. Statistical Analysis: Descriptive statistics were presented as counts and percentages. For independent categorical variables, the Pearson chi-square test and Fisher's exact test were used as appropriate. Statistical analyses were performed using SPSS software, version 23 (IBM, Chicago, IL, United States), for Windows.   Results In the first 48-hour period after the earthquake, the total number of patients reported to ED was 701, of which 224 were earthquake-related. Out of these 224 patients, 59 (26.34%) presented with acute anxiety symptoms. A total of 182 (81.25%) patients sought medical attention on the first day. Triage code was yellow for 189 (84.38%) patients. Of the total patients, 120 (53.57%) were female, and majority of those presented with acute anxiety symptoms [n=40 (67.80%)], while the majority of trauma cases [n=85 (51.52%)] were male. The median age of the total cases was 34 (1-92) years, and those presented with acute anxiety symptoms had a median age of 30 (16-84) years. Among all patients, 6 (2.67%) were hospitalized, all of whom had serious trauma (Table-1).   Table-1: Descriptive data of patients arriving in the first 48 hours after the earthquake     Out of 59 patients presented with acute anxiety, 18 (30.5%) had previously diagnosed psychiatric disorders and only 5 (8.5%) of them experienced physical trauma, but without any associated lesions or complaints. Eleven (18.6%) patients had visited the psychiatric outpatient clinic within 3 months after the earthquake (Table-2). Four of these patients received a psychiatric diagnosis for the first time, and the others had a previously known psychiatric diagnosis.   Table-2: Profile of patients presenting with acute anxiety (n=59)     Table-3 shows the visits of anxiety related patients to ED following the occurrence of earthquake compared to 1 week before and after the earthquake over 48 hours period. In the 48-hour period before and after one week of the earthquake, the total number of patients visiting ED was 715, and 544, of which 9 (1.3%) and 2 (0.4%) patients respectively presented with acute anxiety. In the 48-hour period following earthquake, the total number of patients was 701, of which 224 were earthquake-related and 59 (8.4%) of total admissions presented with acute anxiety (p<0.05, Pearson Chi-Square test).   Table-3: Visit of anxiety-related patients to ED over 48 hour’s period 1 week before and after earthquake compared to 48 hours following earthquake     Discussion The present study evaluated acute emergency department visits following the severe earthquake that occurred in Düzce on November 23, 2022. Despite the high destructive power of the earthquake, there were not many casualties and physical injuries due to the city's preparedness [9]. Most patients did not experience any physical injuries. Additionally, about one-third had a known psychiatric disorder. Natural disasters trigger anxiety and worry in everyone at the outset, which is a natural response. Therefore, in addition to trauma, another common complain during natural disasters such as earthquakes is anxiety disorders (especially panic disorder). These feelings can turn into serious psychiatric disorders if they do not decrease over time. Due to individual factors such as the severity of the destruction and personal losses such as losing loved ones, individuals are affected to varying degrees, leading to the development of psychiatric symptoms in some people [16]. Earthquakes invite a wide range of psychiatric conditions such as anxiety, depression, suicide, and PTSD [17]. It is known that high-trauma events like earthquakes can cause acute exacerbations of psychiatric symptoms in individuals who already have psychiatric diagnoses [18]. Furthermore, it has been shown that emotional stress can lead to ischemic heart diseases and acute myocardial infarctions [19], and respiratory diseases may increase due to changes in housing conditions [20].Sometimes, traumatic injuries have been reported to occur as a result of panic within the home, due to collisions with objects [21]. In most people, the impact of a traumatic event is known to decrease over time. A study has shown that approximately 90% of individuals experience a significant psychological trauma in their lifetime, and about 11.2% of people develop long-term psychiatric disorders such as PTSD after exposure to trauma [22]. Individuals who develop PTSD, when exposed to even an ordinary situation associated with the traumatic event, develop 'fear conditioning' and their bodies respond as if they are reliving the trauma [23]. The most common anxiety disorders seen after an earthquake are panic disorder and generalized anxiety disorder [24]. While the diagnosis of these disorders is made by psychiatrists according to DSM-5, most patients experiencing an anxiety crisis as a result of a triggering event seek emergency care [25]. Patients experiencing an anxiety crisis often complain of symptoms such as palpitations, difficulty in breathing, restlessness, irritability, tension, inability to sit still, chest pain, syncope, and headache [26]. These findings may be observed in patients presenting to the ED [26]. In the acute phase, almost half of children over 8 years of age exhibit acute stress-related psychological effects [27]. Due to its rich symptomology, panic attacks have been shown to receive a misdiagnosis rate of nearly 85% in one study [28]. In most cases, the symptoms of a panic attack are resolved spontaneously over time. What reassures patients the most is realizing that the situation they are anxious about is not actually happening [29]. During a disaster, it is expected that the most affected patients would seek help primarily for the physical effects of the disaster. However, Beaglehole et al. reported that a significant portion of patients sought care for acute anxiety symptoms following the earthquake in Christchurch, New Zealand, in February 2011. However, daily admissions to inpatient mental health services decreased, and bed occupancy rates decreased over time [30]. Also, the experience of the earthquake in Düzce in 1999, and the extensive destruction it caused, indicate that despite the population's physical and structural preparedness, they are emotionally quite vulnerable. Satıcı et al. conducted a study following the earthquake in Turkey on February 6, 2023, and showed that earthquake fear increased psychological problems and decreased overall well-being in our country [31]. Almeida et al. [32] examined non-trauma hospital admissions after the earthquake in Kathmandu, the capital of Nepal, on April 25, 2015. Although the number of admissions for mental and behavioral disorders decreased numerically in 40 days following the earthquake, there was a slight proportional increase (less than 3% of all admissions). However, this was not statistically significant. Another study conducted during the same earthquake showed that only 0.8% of admissions in the acute phase were related to mental illnesses [33]. In Turkey, after the earthquake in the Aegean Sea in 2020, out of 154 patients who visited the ED, one had symptoms of anxiety disorder, such as palpitations, and one had symptoms of headache and syncope [34]. After the 2010 Yushu earthquake in China, 1.3% (n=9) of patients admitted in the acute phase had mental illnesses [35]. In our study, during the acute phase, which we defined as the first 48 hours, 26.34% of patients presented with symptoms of acute anxiety. This rate was considerably higher than in many studies in the literature. However, our study has some limitations. There are two hospitals in the city with similar capacities, and the data of this study belong to a single center. In this study, anxiety diagnoses at the time of the earthquake were evaluated according to symptoms and the Faces Anxiety Scale, and it was not possible to use any other scales due to the high number of visits to the emergency room. For a standard disaster plan, priority is expected to be given to trauma patients. However, despite the high destructive power, and due to the city's preparedness [9], there were not many casualties and injuries in the earthquake that occurred in Düzce on November 23, 2022. On the other hand, a good number of patients presented with symptoms of anxiety disorder, and the majority of these patients had no previously known psychiatric illness. The findings of our study indicate that in the case of a natural calamity like an earthquake, disaster preparedness should include plans for both trauma and psychiatric case. Emergency medicine physicians and trauma surgeons, as healthcare professionals, should be capable of recognizing and managing not only trauma but also psychological issues. It should be taken into consideration that even with minimal destruction, an increase in psychiatric problems may be observed.   Authors’ Contributions KS, MB contributed to conception; SK, KS, MB contributed to design; MCD, MB contributed to supervision; KS,ÖK contributed to data collection and processing; AAA, AKFK, KS contributed to analysis and interpretation; KS, MB, contributed to literature review; AAA, SK, MB, KS contributed to writing; KS, MCD, MB contributed to critical review.   Conflict of interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article   Ethical statement Ethics committee approval was obtained from the local ethics committee (Date: 20.03.2023, Decision No: 2023/46).   Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.   References 1.     Mahoney LE, Reutershan TP. Catastrophic disasters and the design of disaster medical care systems. Ann Emerg Med. 1987; 16(9): 1085-1091. doi:10.1016/s0196-0644(87)80764-3. 2.     Council BSS, NEHR Program. Seismic considerations: health care facilities (Vol. 35). Federal Emergency Management Agency; 1990. 3.     Kang P, Lv Y, Deng Q, Liu Y, Zhang Y, Liu X, et al. Investigating Lushan earthquake victims' individual behavior response and rescue organization. Int J Environ Res Public Health. 2017; 14(12): 1556. doi:10.3390/ijerph14121556. 4.     Bulut M, Fedakar R, Akkose S, Akgoz S, Ozguc H, Tokyay R. Medical experience of a university hospital in Turkey after the 1999 Marmara earthquake. Emerg Med J. 2005; 22(7): 494-498. doi:10.1136/emj.2004.016295. 5.     Keskĭn Ö, Kalemoğlu M. Earthquake and triage [Deprem ve triaj]. Turkish Journal of Trauma and Emergency Surgery (Ulus Travma Derg). 2002; 8: 108-111. 6.     Lillibridge SR, Noji EK. The importance of medical records in disaster epidemiology research. J AHIMA. 1992; 63(10): 137-138. 7.     BülentG. A periodical approach to earthquake damages in Turkey; 3 Periods, 3 Earthquakes. Eastern Geography Journal. 2020; 25(43): 139-152. 8.     List of earthquakes in Turkey. https://en.wikipedia.org/wiki/List_of_earthquakes_in_Turkey. [Accessed in September, 2023]. 9.     Özalp S, Kürçer A, Avcu I, Gu T. November 23, 2022, Gölyaka (Düzce) earthquake (Mw 6.0) field observations and evaluations regarding the source fault. MTA Geosciences and Mining Journal. 2023; 3(3): 61-80. 10.  Utkucu M, Çetin C, Alptekin Ö. Spatial and temporal distribution of b and p values calculated from the aftershocks of the 12 November 1999 Düzce earthquake and evaluations for future seismic hazard. Geosciences (Yerbilimleri). 2005; 26(1): 75-91. 11.  Özçetin A, Maraş A, Ataoğlu A, Içmeli C. Relationship between trauma after earthquake and post-traumatic stress disorder and personality disorders. Duzce Medical Journal. 2008; 10(2): 8-18. 12.  Kiliç C, Ulusoy M. Psychological effects of the November 1999 earthquake in Turkey: an epidemiological study. Acta Psychiatr Scand. 2003; 108(3): 232-238. doi:10.1034/j.1600-0447.2003.00119.x. 13.  Cénat JM, McIntee SE, Blais-Rochette C. Symptoms of posttraumatic stress disorder, depression, anxiety and other mental health problems following the 2010 earthquake in Haiti: A systematic review and meta-analysis. J Affect Disord. 2020; 273: 55-85. doi:10.1016/j.jad.2020.04.046. 14.  Demirel ME, Ali İH, Boğan M. Emergency service experience following the terrorist attack in Mogadishu, 14 October 2017, a scene of lay rescuer triage. Am J Emerg Med. 2021; 40: 6-10. doi:10.1016/j.ajem.2020.12.005. 15.  McKinley S, Coote K, Stein-Parbury J. Development and testing of a Faces Scale for the assessment of anxiety in critically ill patients. J Adv Nurs. 2003; 41(1): 73-79. doi:10.1046/j.1365-2648.2003.02508.x. 16.  Altınöz A, Kaptanoğlu C. Mental conditions and disorders developing after human-induced mass traumatic events. Current in Psychiatry. 2018; 8(1): 1-8. 17.  Jahangiri K, Yousefi K, Mozafari A, Sahebi A. The prevalence of suicidal ıdeation after the earthquake: a systematic review and meta-analysis. Iran J Public Health.2020; 49(12): 2330-2338. doi:10.18502/ijph.v49i12.4815. 18.  Sönmez MB. Psychological effects of the earthquake, psychological support, and coping with fear. TOTBİD Dergisi. 2022; 21: 337-343. doi:10.5578/totbid.dergisi.2022.46. 19.  Chan C, Elliott J, Troughton R, et al. Acute myocardial infarction and stress cardiomyopathy following the Christchurch earthquakes. PLoS One. 2013; 8(7): e68504. doi:10.1371/journal.pone.0068504. 20.  Yamanda S, Hanagama M, Kobayashi S, Satou H, Tokuda S, Niu K, et al. The impact of the 2011 Great East Japan earthquake on hospitalisation for respiratory disease in a rapidly aging society: a retrospective descriptive and cross-sectional study at the disaster base hospital in Ishinomaki. BMJ Open. 2013; 3(1): e000865. doi:10.1136/bmjopen-2012-000865. 21.  Mahue-Giangreco M, Mack W, Seligson H, Bourque LB. Risk factors associated with moderate and serious injuries attributable to the 1994 Northridge Earthquake, Los Angeles, California. Ann Epidemiol. 2001; 11(5): 347-357. doi:10.1016/s1047-2797(01)00220-4. 22.  Fanai M, Khan MAB. Acute Stress Disorder. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK563253/. [Accessed in September, 2023]. 23.  van der Kolk B. Posttraumatic stress disorder and the nature of trauma. Dialogues Clin Neurosci. 2000; 2(1): 7-22. doi:10.31887/DCNS.2000.2.1/bvdkolk. 24.  Lima B, Pai S, Toledo V, Caris L, Haro JM, Lozano J, et al. Emotional distress in disaster victims. A follow-up study. J Nerv Ment Dis. 1993; 181(6): 388-393. doi:10.1097/00005053-199306000-00009. 25.  Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). DSM-5 (5th ed.). https://www.psychiatry.org/psychiatrists/practice/dsm. [Accessed in September, 2023]. 26.  Manjunatha N, Ram D. Panic disorder in general medical practice- A narrative review. J Family Med Prim Care. 2022; 11(3): 861-869. doi:10.4103/jfmpc.jfmpc_888_21. 27.  Mondal R, Sarkar S, Banerjee I, Hazra A, Majumder D, Sabui T, et al. Acute stress-related psychological impact in children following devastating natural disaster, the Sikkim earthquake (2011), India. J Neurosci Rural Pract. 2013; 4(Suppl 1): S19-S23. doi:10.4103/0976-3147.116434. 28.  Vermani M, Marcus M, Katzman MA. Rates of detection of mood and anxiety disorders in primary care: a descriptive, cross-sectional study. Prim Care Companion CNS Disord. 2011; 13:PCC.10m01013. 29.  Maisto D, Barca L, Van den Bergh O, Pezzulo G. Perception and misperception of bodily symptoms from an active inference perspective: Modelling the case of panic disorder. Psychol Rev. 2021; 128(4): 690-710. doi:10.1037/rev0000290. 30.  Beaglehole B, Bell C, Beveridge J, Frampton C. Psychiatric admissions fall following the Christchurch earthquakes: an audit of inpatient data. Aust N Z J Psychiatry. 2015; 49(4): 346-350. doi:10.1177/0004867414560651. 31.  Satıcı SA, Okur S, Deniz ME, Karaağaç ZG, Yilmaz FB, Kütük H, et al. The development and initial validation of the Earthquake Fear Scale: Its links to personality traits, psychological distress, harmony in life, and mental wellbeing. Stress Health. 2024; 40(2): e3306. doi:10.1002/smi.3306. 32.  de Almeida MM, Schlüter BS, van Loenhout JAF, Thapa SS, Kumar KC, Singh R, et al. Changes in patient admissions after the 2015 Earthquake: a tertiary hospital-based study in Kathmandu, Nepal. Sci Rep. 2020; 10(1): 4956. doi:10.1038/s41598-020-61901-7. 33.  de Almeida MM, van Loenhout JAF, Thapa SS, Kumar KC, Schlüter BS, Singh R, et al. Clinical and demographic profile of admitted victims in a tertiary hospital after the 2015 earthquake in Nepal. PLoS One. 2019; 14(7): e0220016. doi:10.1371/journal.pone.0220016. 34.  Çağıran Z, Sertöz N, Karaman S, Özen D, Demirkoparan M, Uyar M, et al. Our clinical experiences in the earthquake victims who came to our university after the 2020 Aegean Sea earthquake during the COVID-19 pandemic. Turkish J Trauma & Emergency Surgery (Uluslararası Travma ve Acil Cerrahi Dergisi). 2023; 29(3): 310-315. doi:10.14744/tjtes.2022.39549. 35.  Kang P, Zhang L, Liang W, Zhu Z, Liu Y, Liu X, et al. Medical evacuation management and clinical characteristics of 3,255 inpatients after the 2010 Yushu earthquake in China. J Trauma Acute Care Surg. 2012; 72(6): 1626-1633. doi:10.1097/TA.0b013e3182479e07.     Cite this article as: Selki K, Karakoyun S, Demir MC, Kömürcü Ö, Ayasli AA. Kıcıroğlu AKF, Boğan M. Acute anxiety cases in emergency department following the November 23, 2022Düzce earthquake. IMC J Med Sci. 2025; 19(2):001. DOI: https://doi.org/10.55010/imcjms.19.010 <![CDATA[Septicemic melioidosis in a young adult with transfusion-dependent β-thalassemia major]]> Farhan Muhib Saika Farook* Md. Belayet Hossain Mir Sajedul Karim Md. Shariful Alam Jilani https://imcjms.com/journal_full_text/575 2025-09-13 11:57:51 Clinical Case Report July 2025; Vol. 19(2):008 Abstract Melioidosis, a neglected infection in Bangladesh, is caused by Burkholderia pseudomallei and carries high mortality, if not diagnosed or treated timely. Individuals with transfusion-dependent β-thalassemia major make a person especially vulnerable to Burkholderia pseudomallei infection owing to iron overload and immune dysfunction. Here, we report a fatal case of septicemic melioidosis in a 24-year-old man with Hb E β-thalassemia major who presented with fever, dyspnea, a cervical abscess, and septicemia. This case highlights the threat of melioidosis in thalassemia patients and emphasizes the importance of timely recognition and targeted therapy in endemic settings. July 2025; Vol. 19(2):008,  DOI: https://doi.org/10.55010/imcjms.19.017 *Correspondence: Saika Farook, Department of Microbiology, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka, Bangladesh. E-mail: sairana15@yahoo.com. © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License(CC BY 4.0).   Introduction Melioidosis, caused by Burkholderia pseudomallei, is a potentially life-threatening infectious disease that is endemic in South-East Asia and northern Australia and is increasingly recognized in South Asia, including Bangladesh [1]. The bacterium is widely present in soil and surface water, and human infection typically occurs through percutaneous inoculation, inhalation, or ingestion [2]. The disease manifests as pneumonia, septicemia, localized abscesses, or chronic disseminated infection, with mortality rates reported between 14–40% despite treatment [1,3]. In Bangladesh, the true incidence of melioidosis remains unclear due to underdiagnosis owing to limited laboratory capacity and lack of clinical awareness [1,4]. Underlying conditions that compromise immune function markedly increase susceptibility to B. pseudomallei infection. Transfusion-dependent β-thalassemia major represents one such high-risk state, with immune dysfunction attributed to impaired neutrophil activity, chronic iron overload from repeated transfusions, and hyposplenism [3,5]. These factors significantly reduce host defense against intracellular pathogens such as B. pseudomallei. Pediatric and young adult patients with β-thalassemia major may develop severe, atypical, or disseminated forms of melioidosis, due to delayed diagnosis and resulting in adverse outcomes [6,7]. Although sporadic reports from South and South-East Asia have described this co-morbidity in melioidosis cases, data from Bangladesh are scarce despite the concurrent endemicity of both conditions [8]. In Bangladesh, an estimated 6–12% of the population, approximately 10 to 19 million people carry the β-thalassemia trait [9]. A 2005 study on school children from six districts of Bangladesh, using hemoglobin electrophoresis, reported an overall β-thalassemia carrier rate to be 4.1%, with the highest prevalence recorded in Barishal division at 8.1% [10]. On the contrary, till now around 150 cases of melioidosis have been reported from this country, and only a single case of septicemic melioidosis with β-thalassemia minor in a Bangladeshi farmer was reported till today [4,8]. Therefore, if a thalassemia major patient presents with refractory infection despite antibiotic treatment, melioidosis should be suspected. We present here a rare case of septicemic melioidosis in a young adult with transfusion-dependent β-thalassemia major from coastal area of Bangladesh, emphasizing diagnostic delay, therapeutic challenges, and the need for heightened awareness among clinicians in endemic settings.   Case presentation A 24-year-old male student hailing from Barguna, a coastal area of Barishal district of Bangladesh, with a known history of Hb-E β-thalassemia major was admitted to a tertiary care hospital in the capital Dhaka with the chief complaints of fever for 20 days (maximum temperature recorded 104°C), dyspnoea for 5 days along with right-sided neck swelling for 3 days. The patient was diagnosed as a case of Hb E β-thalassemia major at 3 years of age based on complete blood count, Hb-electrophoresis and iron profile. He had splenectomy in 2008, following which regular blood transfusions were required every 3-4 weeks. On general examination, temperature was 103.8°C, blood pressure was 90/60 mmHg, SpO₂ was found 92% (room air). A swelling was present on the right side of the neck along with pallor and hepatomegaly. Respiratory findings revealed bilateral crepitations. The patient’s blood analysis demonstrated hemoglobin: 6.8 g/dL, total WBC: 23,170/µL (neutrophil count: 16,682/µL), platelets: 120,000/µL. Serum bilirubin was 4.6 mg/dL, while SGPT was found 130 U/L. Iron profile revealed total iron: 25.84 µg/dL, TIBC: 93 µg/dL and serum ferritin: 12,440.45 ng/mL (normal: 20–300 ng/mL in adult males). Ultrasonography of whole abdomen showed multiple tiny cystic lesions in both lobes of the liver suggestive of micro-abscesses, along with bilateral pleural effusion. Chest X-ray was advised but could not be done because of deteriorated condition of the patient. Blood culture revealed growth of B. pseudomallei, sensitive to ceftazidime, meropenem, co-amoxiclav, co-trimoxazole, and doxycycline; resistant to aminoglycosides and colistin. Therefore, the case was finally diagnosed as septicemic melioidosis in a β-thalassemic major patient. The patient was started on intravenous meropenem 6 days following the onset of symptoms (2 g every 8 hours) along with supportive transfusions and oxygen supplementation. Despite initial stabilization, his fever persisted, and respiratory status worsened. After 11 days of hospitalization, and 7 days of antibiotic administration, he succumbed to septicemia and multi-organ failure.     Figure-1: Growth of B. pseudomallei in MacConkey agar media from blood sample.     Figure-2: Ultrasonography of abdomen showing presence of multiple micro-abscesses in the liver   Discussion Melioidosis is a fatal endemic infectious disease caused by the gram-negative bacteria Burkholderia pseudomallei. This case from Bangladesh highlights the impact of melioidosis in a high-risk host with transfusion dependent thalassemia major. Multiple risk factors such as iron overload, splenectomy and chronic transfusions with immune dysregulation predisposed the patient to B. pseudomallei infection. The patient’s serum ferritin was more than 12,000 ng/mL, providing abundant free iron that facilitated the growth and virulence of B. pseudomallei [5]. Loss of splenic function markedly increases susceptibility to systemic bacterial infections, while regular transfusions further compromised host defenses [11]. Our patient presented with disseminated melioidosis, evident by the presence of hepatic micro-abscesses, neck abscess, pleural effusion, and sepsis. Although appropriate antibiotics were initiated within first day of diagnosis his severe iron overload and compromised immunity likely contributed to poor treatment outcome and death. Melioidosis in individuals with thalassemia is uncommon but recently increasingly recognized. In a retrospective study performed in Sabah, Malaysia it was found that, 41% of confirmed pediatric melioidosis patients had thalassemia major [5].The same study reported that during the period of 2011-2012, when iron chelation therapy was initiated in thalassemic patients, out of 860 patients, none of them were infected with melioidosis [5]. In case of our patient, iron chelation therapy was earlier prescribed following blood transfusion due to iron overload. However, owing to poverty and illiteracy, the patient could not comply with the suggested management. A case control study from Thailand in adult patients showed that people with thalassemia were about four times more likely to get melioidosis than adults with diabetes [12]. This suggests that thalassemia makes people more vulnerable, beyond the usual risk factors. Case reports specifically linking melioidosis with transfusion-dependent β-thalassemia have appeared from multiple endemic settings. A recent report from Thailand described disseminated disease in a patient with transfusion-dependent β-thalassemia major, highlighting severe multi-organ involvement and the need for early recognition and prolonged antibiotic therapy [6]. In Sri Lanka, a 7-year-old boy with β-thalassemia major developed chronic melioidosis with multiple hepatic abscesses like our case, illustrating the organism’s tropism for visceral abscesses in iron-overloaded hosts [7]. Immune dysregulation in β-thalassemia (including altered cytokine responses) and iron overload, common in transfusion-dependent and post-splenectomy patients facilitate B. pseudomallei growth and impaired its clearance, aligning with our patient’s marked hyperferritinemia [3]. The exact role of iron causing susceptibility to B. pseudomallei is not fully understood. Iron is essential for bacterial growth and is normally stored in the body bound to proteins such as transferrin, lactoferrin, and ferritin [9]. Many bacteria release small molecules called siderophores to capture iron, and these have been linked to virulence in pathogens like Vibrio parahaemolyticus [13]. In B. pseudomallei, the siderophore “malleobactin” has been shown to promote bacterial growth, especially in the presence of higher iron levels. However, the role of iron in B. pseudomallei infection is more complex [14,15]. A B. pseudomallei strain that lacked malleobactin was found to be just as virulent as normal strains. Such mutant strain uses alternative pathways, including the production of proteases that release iron from ferritin, a protein stored in excess in conditions like thalassemia [16,17].   Conclusion In Bangladesh, melioidosis remains under-recognized but is documented as endemic. National reviews summarize dozens of sporadic cases since 1960 [1,7]. There were no previously published Bangladeshi reports directly pairing thalassemia major with melioidosis. Global literature supports β-thalassemia, particularly transfusion-dependent disease with iron overload as a risk state for severe, disseminated melioidosis. Bangladesh is endemic for melioidosis; lack of local case documentation linking thalassemia major with B. pseudomallei infection likely reflects under-recognition rather than absence of association.   Author contributions: FM and SF wrote the manuscript and supervised the work; FM, SF, MBH and MSAJ were involved in diagnosis of the disease, analysis of the case and maintaining routine follow up; MSK collected and recorded patient’s data, performed and supervised the laboratory investigations. MSAJ contributed to editing the manuscript and was involved in providing critical insights regarding the management of the patient.   Funding: No funds were available for this study.   Declaration of patient consent: The authors certify that they have obtained all appropriate patient consent forms. In the form the patient had given his consent for his clinical information to be reported in the journal. The patient understood that his name and initials will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.   References 1.     Chowdhury FR, Jilani MS, Barai L, Rahman T, Saha MR, Amin MR, et al. Melioidosis in Bangladesh: a clinical and epidemiological analysis of culture-confirmed cases. Trop MedInfectDis. 2018; 3(2): 40. doi: 10.3390/tropicalmed3020040. 2.     Cheng AC, Currie BJ. Melioidosis: epidemiology, pathophysiology and management. Clin Microbiol Rev. 2005; 18(2): 383-416. doi: 10.1128/CMR.18.2.383-416.2005. 3.     Nithichanon A, Tussakhon I, Samer W, Kewcharoenwong C, Ato M, Bancroft GJ. Immune responses in beta-thalassaemia: heme oxygenase 1 reduces cytokine production and bactericidal activity of human leucocytes. Sci Rep. 2020; 10(1): 10297. doi: 10.1038/s41598-020-67346-2. 4.     Farook S, Muhib F, Karim MS, Jilani MSA.A case of melioidosis: still unresolvedand undetected in unexplored regions. JCRMHS. 2025; 10(5). doi: 10.55920/JCRMHS.2025.10.001457. 5.     Fong SM, Wong KJ, Fukushima M, Yeo TW. Thalassemia major is a major risk factor for pediatric melioidosis in Kota Kinabalu, Sabah, Malaysia. Clin Infect Dis. 2015; 60(12): 1802-7. doi: 10.1093/cid/civ189. 6.     Thaninee P, Panarat P. Disseminated melioidosis infection involving hepatosplenomegaly and massive extramedullary hematopoiesis. Am J Gastroentero. 2024; 119(2): 242. doi: 10.14309/ajg.0000000000002549. 7.     Dayasiri MB, Mudiyanse RM, Kudagammana HD, Rifaya MI, Dissanayaka P, Jeyaratnasingam C, et al. Melioidosis manifesting as severe emaciation and clinically indolent liver abscesses, in a child with beta thalassemia major. Sri Lanka J of Child Health. 2016; 45(2). doi: http://dx.doi.org/10.4038/sljch.v45i2.7617. 8.     Rahim MA, Khan MAY, Chowdhury TA, Ananna MA. Septicemic melioidosis complicating undiagnosed chronic kidney disease and beta-thalassemia minor in a Bangladeshi farmer. Saudi J Kidney Dis Transpl. 2020; 31(6): 1361–1366. doi: 10.4103/1319-2442.308358. 9.     Hossain MS, Hasan MM, Raheem E, Islam MS, Al Mosabbir A, Petrou M, et al. Lack of knowledge and misperceptions about thalassemia among college students in Bangladesh: a cross-sectional baseline study. Orphanet J. Rare Dis. 2020; 15(1): 54. doi: 10.1186/s13023-020-1323-y. 10.  Khan WA, Banu B, Amin SK, Selimuzzaman M, Rahman M, Hossain B, et al. Prevalence of beta thalassemia trait and Hb E trait in Bangladeshi school children and health burden of thalassemia in our population. Dhaka Shishu (Child.) Hosp. J. 2005; 21: 1–7. doi: 10.3390/thalassrep14030007. 11.  Brousse V, Buffet P, Rees D. The spleen and sickle cell disease: the sick (led) spleen. Br. J. Haematol. 2014; 166(2): 165-76. doi:10.1111/bjh.12950. 12.  Suputtamongkol Y, Chaowagul W, Chetchotisakd P,Lertpatanasuwun N, Intaranongpai S, Ruchutrakool T, et al. Risk factors for melioidosis and bacteremic melioidosis. Clin Infect Dis. 1999; 29(2): 408-13. doi: 10.1086/520223. 13.  Dai JH, Lee YS, Wong HC. Effects of iron limitation on production of a siderophore, outer membrane proteins, and hemolysin and on hydrophobicity, cell adherence, and lethality for mice of Vibrio parahaemolyticus. Infect Immun. 1992; 60(7): 2952-6. doi: 10.1128/iai.60.7.2952-2956.1992. 14.  Yang HM, Chaowagul WI, Sokol PA. Siderophore production by Pseudomonas pseudomallei. Infect Immun. 1991; 59(3): 776-80. doi: 10.1128/iai.59.3.776-780.1991. 15.  Yang HU, Kooi CD, Sokol PA. Ability of Pseudomonas pseudomallei malleobactin to acquire transferrin-bound, lactoferrin-bound, and cell-derived iron. Infect Immun. 1993; 61(2): 656-62. doi: 10.1128/iai.61.2.656-662.1993. 16.  Kvitko BH, Goodyear A, Propst KL, Dow SW, Schweizer HP. Burkholderia pseudomallei known siderophores and hemin uptake are dispensable for lethal murine melioidosis. PLoS Negl Trop Dis. 2012; 6(6): e1715. doi: 10.1371/journal.pntd.0001715. 17.  Higgs DR, Engel JD, Stamatoyannopoulos G. Thalassaemia. Lancet. 2012; 379(9813): 373-83. doi: 10.1016/S0140-6736(11)60283-3.     Cite this article as: Muhib F, Farook S, Hossain MB, Karim MS, Jilani MSA. Septicemic melioidosis in a young adult with transfusion-dependent β-thalassemia major. IMC J Med Sci. 2025; 19(2):008. DOI:https://doi.org/10.55010/imcjms.19.017 <![CDATA[Cesarean scar ectopic pregnancy: Reports of two cases]]> Nurun Naher* Maherunnessa Mehbuba Jahan Rinky Sakib Ashfaq https://imcjms.com/journal_full_text/569 2025-07-10 10:51:50 Clinical Case Report July 2025; Vol. 19(2):004 Abstract Cesarean scar ectopic pregnancy (CSEP) is a rare but increasingly recognized form of ectopic pregnancy, in which the blastocyst implants within the myometrial tissue at the site of a previous cesarean section scar. The global rise in cesarean delivery rates has led to a corresponding increase in the prevalence of CSEP, currently estimated at approximately 1 in 1,800 to 1 in 2,226 pregnancies. This condition poses a significant risk of life-threatening complications, including uterine rupture, massive hemorrhage, and potential loss of fertility if not diagnosed and managed promptly. We present two clinically distinct cases of CSEP managed at a tertiary care hospital in Dhaka. Both patients had a history of prior cesarean delivery and presented with different gestational ages and clinical manifestations. The first case involved a viable 8-week pregnancy implanted in the cesarean scar, diagnosed via transvaginal ultrasonography and managed surgically with hysterotomy. The second case presented as a missed abortion at 22 weeks and was later identified as an advanced cesarean scar ectopic pregnancy, requiring emergency laparotomy due to uterine wall protrusion and fetal demise. These cases underscore the importance of early diagnosis through imaging and individualized treatment planning based on the gestational age, viability, patient stability, and fertility desires. Prompt recognition and appropriate management are critical in minimizing maternal morbidity and optimizing outcomes. July 2025; Vol. 19(2):004. DOI: https://doi.org/10.55010/imcjms.19.013 *Correspondence: Nurun Naher, Obstetrics & Gynaecology Department, BIRDEM General Hospital, Dhaka, Bangladesh. E-mail: nayanbirdem@gmail.com. © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License(CC BY 4.0).   Introduction Cesarean scar ectopic pregnancy (CSEP) is a rare but increasingly recognized form of ectopic pregnancy, characterized by implantation of the gestational sac within the fibrous tissue of a previous cesarean section scar. It accounts for less than 1% of all ectopic pregnancies but carries a disproportionately high risk of severe maternal morbidity and mortality if not identified and managed early [1,2]. The incidence of CSEP has risen in recent decades in parallel with the global increase in cesarean delivery rates. In the United States, for example, cesarean sections accounted for 20.7% of births in 1996 and rose to 32.1% by 2021, reflecting a global trend that increases the population at risk for this condition [3]. Clinically, CSEP may present with nonspecific symptoms such as vaginal bleeding and lower abdominal pain, or it may be asymptomatic and discovered incidentally during early pregnancy imaging. If unrecognized, it can lead to catastrophic outcomes including uterine rupture, massive hemorrhage, placenta accreta spectrum (PAS), hysterectomy, and maternal death [4–6]. Therefore, a high index of suspicion is essential, especially in patients with a history of cesarean delivery presenting in early pregnancy. Diagnosis is most reliably achieved through high-resolution transvaginal ultrasonography (TVUS), often supported by Doppler imaging. Hallmark features include an empty uterine cavity, an empty cervical canal, and a gestational sac embedded at the anterior lower uterine segment at the cesarean scar site [7,8]. Management of CSEP is complex and must be individualized, taking into account the patient’s hemodynamic stability, gestational age, desire for future fertility, and institutional resources. Options include medical therapy (e.g., methotrexate), surgical excision via laparoscopy or laparotomy, hysteroscopic removal, and uterine artery embolization. Expectant management is generally contraindicated due to the high risk of severe complications [9,10]. We present two clinically distinct cases of cesarean scar ectopic pregnancy managed at a tertiary care center, highlighting diagnostic challenges and therapeutic considerations.   Case Presentation Case 1 A 34-year-old woman, gravida 4 para 1, presented with complaints of 8 weeks of amenorrhea, lower abdominal pain for 2 days, and 1 episode of per vaginal bleeding. She had a history of two first-trimester spontaneous abortions respectively 6 and 2 years earlier and one cesarean section delivery 7 years earlier. On examination, her vital signs were stable. Abdominal assessment revealed mild suprapubic tenderness, and on per vaginal examination, the cervix was closed with scant vaginal bleeding. Initial laboratory investigations showed a hemoglobin level of 11.4 g/dL and a serum TSH of 1.76 µIU/mL. A transvaginal ultrasound revealed a single live intrauterine gestation implanted within the myometrium at the site of the previous cesarean section scar. The endometrial cavity was empty, and a live embryo was identified with a crown-rump length of 16 mm, corresponding to a gestational age of 8 weeks and 1 day. Fetal cardiac activity was present with a heart rate of 156 beats per minute. Based on these findings, a diagnosis of cesarean scar ectopic pregnancy (CSEP) was made. Given the presence of fetal cardiac activity and the potential risk of uterine rupture, the patient was scheduled for surgical intervention rather than conservative management. under spinal anesthesia, laparoscopic hysterotomy was performed. Intra-operative findings included a bulging area at the site of the previous uterine scar, confirming the location of the ectopic pregnancy. The gestational sac was successfully extracted, and intra-operative bleeding was within normal limits (around 200 ml). Histopathological examination of the tissue confirmed the presence of products of conception consistent with a scar pregnancy. The patient had an uneventful postoperative recovery and was discharged in stable condition on the third postoperative day.     Figure-1: Intra-operative image showing a bulging in the previous uterine scar indicating cesarean section scar ectopic pregnancy.   Case 2 A 30-year-old woman, gravida 3 para 1, presented with a 22-week pregnancy complicated by a missed abortion and gestational hypertension. Her obstetric history included one lower segment cesarean section and one prior spontaneous abortion accordingly 4 and 6 years back. An initial ultrasound indicated a 21-week missed abortion. She was managed with misoprostol for induction of labor; however, on clinical examination, the uterus was consistent in size with a 20-week pregnancy, and the cervix remained closed despite repeated induction attempts.     Figure-2: Intra operative image of cesarean scar pregnancy     Figure-3: Macerated baby   Due to the failure of medical induction, a follow-up ultrasound was performed and the imaging revealed findings consistent with a 19-week cesarean scar ectopic pregnancy, with the gestational sac protruding through the anterior uterine wall at the site of the previous cesarean scar. Given the advanced gestational age and the risk of rupture, the decision was made to proceed with an emergency laparotomy. Intra-operatively, the amniotic sac containing a macerated fetus was found protruding through the anterior uterine wall at the previous scar site. The fetus and placental tissue were carefully extracted, and hemostasis was achieved. A fetus weighing 340 grams and a placenta weighing 150 grams were delivered. The postoperative course was uneventful, and the patient was discharged in stable condition on the fifth postoperative day.   Discussion Cesarean scar ectopic pregnancy (CSEP) is a rare but serious form of ectopic pregnancy where the gestational sac implants within the myometrium at the site of a previous cesarean section scar. Its incidence is increasing globally due to rising cesarean delivery rates and improved imaging modalities. In our report, Case 1 presented at 8 weeks and 1 day of gestation with mild abdominal pain and a single episode of per vaginal bleeding, while Case 2 was diagnosed much later at 19 weeks gestation after failed attempts at medical induction in a case of presumed missed abortion. These two cases illustrate the broad clinical spectrum of CSEP and the consequences of delayed or missed diagnosis. The mean age of patients diagnosed with CSEP in the literature predominantly falls within the early to mid-30s. This trend underscores the association between increased maternal age and the risk of CSEP, possibly due to factors such as higher parity and the cumulative effect of uterine surgeries like cesarean sections. Recent study supports the association between increased maternal age and the risk of cesarean scar ectopic pregnancy (CSEP). A 2022 study by Tang et al. reported a mean maternal age of 34.16 ± 4.4 years among CSEP patients, with 67.16% of cases occurring in women aged 30–39 years [11]. This trend underscores the link between advanced maternal age and the risk of CSEP, possibly due to factors such as higher parity and the cumulative effect of uterine surgeries like cesarean sections In these presented cases, the patients were aged 34 and 30 years, respectively, aligning with the age range reported in the literature. This consistency reinforces the importance of heightened clinical vigilance for CSEP in women within this age bracket, especially those with a history of cesarean delivery. According to the literature, the mean gestational age at the time of diagnosis is approximately 8.6 ± 2.2 weeks, with most cases identified during the first trimester due to routine early pregnancy ultrasonography and increasing clinical awareness [2]. This is consistent with Case 1, who was correctly diagnosed at around 8 weeks gestation. However, Case 2 highlights a significant delay in diagnosis, which is unusual but reported, especially when the diagnosis is missed initially or when the implantation is misinterpreted in structurally abnormal uteri such as bicornuate uterus [11]. This case progressed to the second trimester, which significantly increased the risk of uterine rupture and maternal morbidity. The most common symptoms in CSEP include vaginal bleeding and lower abdominal pain, as seen in Case 1. Literature reports that around 70–80% of patients present with vaginal bleeding, and 30–40% complain of abdominal pain [13]. However, asymptomatic cases have also been documented, typically diagnosed during routine early ultrasound scans [12]. Case 2 had no classic CSEP symptoms and was managed as a case of missed abortion with failed induction, until the final diagnosis was made intra-operatively, reflecting the challenge of diagnosing atypical or advanced CSEP. Transvaginal sonography (TVS) remains the gold standard for the early diagnosis of CSEP. Key sonographic features include an empty endometrial cavity and cervical canal, and a gestational sac embedded in the anterior uterine wall at the site of a cesarean scar with thin or absent myometrial tissue between the sac and bladder [14]. In Case 1, these findings were clearly noted at 8 weeks, supporting early and accurate diagnosis. In contrast, in Case 2, despite multiple sonographic evaluations, the CSEP diagnosis was delayed, possibly due to atypical presentation and anatomical challenges such as a suspected bicornuate uterus, highlighting the need for high clinical suspicion and experienced interpretation. Management of CSEP depends on gestational age, fetal viability, patient’s hemodynamic status, and desire for future fertility. Medical management with systemic or local methotrexate is preferred in early and stable cases, while surgical intervention is indicated in advanced gestation, failed medical therapy, or hemodynamic instability [1]. In Case 1, a hysterotomy and extraction were performed successfully at an early gestation, preserving fertility and avoiding complications. In Case 2, emergency laparotomy was necessary due to advanced gestation and failed medical induction. The fetus and placenta were removed surgically, and although the patient recovered well, the case underscores the increased risks associated with delayed diagnosis, including uterine rupture, massive haemorrhage, and potential fertility loss. These two cases highlight the clinical variability and diagnostic challenges of CSEP. While early diagnosis as in Case 1 allows for safer, conservative surgical management, delayed recognition, as in Case 2, can lead to significant complications and necessitate more invasive procedures. A high index of suspicion, especially in women with prior cesarean deliveries, combined with early TVS evaluation, is essential for prompt diagnosis and optimal management. Surgical intervention becomes necessary in cases where the diagnosis is delayed, gestational age is advanced or when there is active bleeding or failed medical management. Surgical options include laparotomy, laparoscopy and hysteroscopic resection. In cases of ongoing haemorrhage or suspected rupture laparotomy remains the most rapid and definitive approach [4]. Continuous clinician education and awareness are crucial to reduce morbidity and preserve reproductive potential in these women.   Conclusion Management of CSEP should be individualized and often requires a multidisciplinary approach involving obstetricians, radiologists, anaesthesiologist and in some cases intervention radiologists. Timely intervention is essential not only to prevent catastrophic complications but also to preserve future fertility. Increasing awareness among clinicians, early diagnostic vigilance in high-risk patients, and evidence-based, patient-centered management strategies are essential to improving clinical outcomes and reducing the burden of this rare but serious form of ectopic pregnancy.   Conflict of interest Nothing to declare.   Informed consent The patients have given consent for publication.   Funding source None   References 1.     Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol. 2006; 107(6): 1373-1381. doi:10.1097/01.AOG.0000218690.24494.ce. 2.     Seow KM, Huang LW, Lin YH, Lin MY, Tsai YL, Hwang JL. Cesarean scar pregnancy: issues in management. Ultrasound Obstet Gynecol. 2004; 23(3): 247-253. doi:10.1002/uog.974. 3.     Martin JA, Hamilton BE, Osterman MJK. Births in the United States, 2021. NCHS Data Brief. 2022; 442: 1-8. 4.     Timor-Tritsch IE, Monteagudo A, Calì G, D'Antonio F, Agten AK. Cesarean scar pregnancy: Patient counseling and management. Obstet Gynecol Clin North Am. 2019; 46(4): 813-828. doi:10.1016/j.ogc.2019.07.010. 5.     Xie RH, Guo X, Li M, Liao Y, Gaudet L, Walker M, et al. Risk factors and consequences of undiagnosed cesarean scar pregnancy: a cohort study in China. BMC Pregnancy Childbirth. 2019; 19(1): 383. doi:10.1186/s12884-019-2523-0. 6.     Fylstra DL. Ectopic pregnancy within a cesarean scar: a review. Obstet Gynecol Surv. 2002; 57(8): 537-543. doi:10.1097/00006254-200208000-00024. 7.     Timor-Tritsch IE, Monteagudo A, Santos R, Tsymbal T, Pineda G, Arslan AA. The diagnosis, treatment, and follow-up of cesarean scar pregnancy. Am J Obstet Gynecol. 2012; 207(1): 44.e1-13. doi:10.1016/j.ajog.2012.04.018. 8.     Lin S, Hsieh CJ, Tu Y, Li Y, Lee C, Hsu W, et al. New ultrasound grading system for cesarean scar pregnancy and its implications for management strategies: An observational cohort study. PLoS One. 2018; 13(8): e0202020. doi:10.1371/journal.pone.0202020. 9.     Gonzalez N, Tulandi T. Cesarean scar pregnancy: A systematic review. J Minim Invasive Gynecol. 2017; 24(5): 731-738. doi:10.1016/j.jmig.2017.02.020. 10.  Pickett CM, Minalt N, Higgins OM, Bernard C, Kasper KM. A laparoscopic approach to cesarean scar ectopic pregnancy. Am J Obstet Gynecol. 2022; 226(3): 417-419. doi:10.1016/j.ajog.2021.11.021. 11.  Tang P, Li X, Li W, Li Y, Zhang Y, Yang Y. The trend of the distribution of ectopic pregnancy sites and the clinical characteristics of caesarean scar pregnancy. Reprod Health. 2022; 19(1): 182. doi:10.1186/s12978-022-01472-0. 12.  Kaelin Agten A, Jurkovic D, Timor-Tritsch I, Jones N, Johnson S, Monteagudo A, et al. First-trimester cesarean scar pregnancy: a comparative analysis of treatment options from the international registry. Am J Obstet Gynecol. 2024; 230(6): 669.e1-669.e19. doi:10.1016/j.ajog.2023.10.028. 13.  Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ. First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment cesarean section scar. Ultrasound Obstet Gynecol. 2003; 21(3): 220-227. doi:10.1002/uog.56. 14.  Hwang JH, Lee JK, Oh MJ, Lee NW, Hur JY, Lee KW. Classification and management of cervical ectopic pregnancies: experience at a single institution. J Reprod Med. 2010; 55(11-12): 469-476.     Cite this article as: Naher N, Maherunnessa, Rinky MJ, Ashfaq S. Cesarean Scar Ectopic pregnancy: Reports of two Cases. IMC J Med Sci. 2025; 19(2):004. DOI:https://doi.org/10.55010/imcjms.19.013 <![CDATA[Antibody and serum bactericidal response to Burkholderia pseudomallei in acute localized and septicemic melioidosis cases with diabetes mellitus]]> Sraboni Mazumder* Md. Shariful Alam Jilani Lovely Barai KM Shahidul Islam https://imcjms.com/journal_full_text/557 2025-01-15 12:04:45 Original Article January 2025; Vol. 19(1):009 Abstract Background and objectives: Melioidosis, caused by the gram-negative bacillus Burkholderia pseudomallei, is a major cause of fatal community acquired infection in diabetic patients. Protective immune response in human melioidosis is not clearly understood yet. In this study, serum IgM/IgG and bactericidal antibody response to B. pseudomallei were determined in diabetic patients with acute localized abscess and septicemia. Material and methods: Culture positive melioidosis cases with diabetes mellitus were included in the study. Blood samples were collected from the respective cases in active phase of the disease within 1 or 2 days of being culture positive. Anti- B. pseudomallei IgM and IgG and serum bactericidal antibody were measured by ELISA and microplate based bactericidal assay respectively. Results: A total of 10 culture positive acute melioidosis cases with diabetes mellitus were included in the study. Out of 10 cases, 5 had abscess in different organs and 5 had septicemia. The mean age of the patients was 48.5 ± 3.91 years and 7 (70%) were male and 3 (30%) were female. The mean anti- B. pseudomallei IgM titer of septicemic and abscess cases were not significantly different (14,080 ± 4,489.13 vs. 19,200 ± 3,620.39; p = 0.4) while the mean IgG titers of two groups were > 204,800. Out of 10 cases, 9 (90%) were positive for serum bactericidal antibody. Mean serum bactericidal antibody titer of septicemia cases (66 ± 26) was not significantly (p = 0.72) different than those of localized infection (80 ± 28.28). Conclusion: The results indicate that high anti- B. pseudomallei IgM/IgG and serum bactericidal antibodies are induced in diabetic patients with septicemia and suppurative infections. This immune response in diabetics might be important to contain the infection and help in recovery. January 2025; Vol. 19(1):009.  DOI: https://doi.org/10.55010/imcjms.19.009 *Correspondence: Sraboni Mazumder, Department of Microbiology, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbaghicha, Dhaka, Bangladesh. Email: mazumder.sraboni@gmail.com; © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0).   Introduction Melioidosis, caused by gram-negative bacillus Burkholderia pseudomallei, is endemic in at least 45 countries across the tropical areas, and globally an estimated 89,000 deaths occur per year [1]. Studies in human have reported better survival of melioidosis patients in the presence of elevated anti-lipopolysaccharide II and anti-hemolysin co-regulated protein 1 IgG antibodies [2,3]. Also, humoral immune response to B. pseudomallei provided protection against infection in animal model [4]. Therefore, determining the role of antibody mediated protection in melioidosis would help in developing an effective vaccine and therapeutic monoclonal antibodies. Antibody dependent complement mediated bacterial killing is an important immune defense against intravascular invasion of bacterial pathogens and is mediated by formation of membrane attack complex assembled from terminal complement components on the bacterial cell envelope [5,6]. By this mechanism of immune response, Pseudomonas aeruginosa infecting chronically infected cystic fibrosis (CF) patients are eliminated thus reducing the risk of pseudomonal bacteremia/septicemia in CF patients [7-9]. Moreover, antibody-dependent complement mediated killing of meningococci provide protection against invasive meningococcal disease was observed [10]. On the contrary, no association between presence of anti- salmonella bactericidal activity and protection against typhoid was seen following vaccination with Ty21a or M01ZH09 [11]. However, bactericidal activity after vaccination correlated significantly with delayed disease onset, lower bacterial burden and decreased disease severity. Likewise in melioidosis cases, antibody dependent complement-mediated killing ability of host might be linked to the progression of localized infection to septicemia. The sensitivity or resistance of offending B. pseudomallei to antibody dependent complement mediated killing would help in understanding its association with disease progression. In view of the above, this study aimed to find out the serum bactericidal and antibody response against B. pseudomallei in diabetic melioidosis patients with different clinical manifestations. This would help to understand the role of serum bactericidal response on the progression and outcome of B. pseudomallei infection in diabetics.   Materials and methods The study was approved by the Institutional Review Board of Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) General Hospital, Dhaka, Bangladesh (Protocol code - BIRDEM/IRB/2017/69 and date of approval – 21/6/2017). Informed consent was obtained from all participants involved in the study. Study population and collection of samples: Culture positive melioidosis cases with diabetes mellitus admitted in BIRDEM General Hospital were included in the study. Diagnosis of diabetes mellitus (DM) was based on HbA1c level ≥ 6.5% or fasting plasma glucose (FPG) ≥ 7.0 mmol/L or two-hour plasma glucose ≥ 11.1 mmol/L by oral glucose tolerance test (OGTT) or a random plasma glucose of ≥ 11.1 mmol/L [12]. Blood samples were collected from the respective case in active phase of the disease within 1 or 2 days of being culture positive. About 3-5 ml of blood was collected aseptically and serum was separated immediately and stored at -20⁰C until tested. The serum samples of melioidosis patients were tested for anti- B. pseudomallei IgM and IgG antibodies and serum bactericidal antibody. Sera from healthy newborn babies (age less than 30 days) who were unlikely to get B. pseudomallei infection were used to determine the cut off for optical density (OD) value of ELISA test. Determination of anti- B. pseudomallei IgM and IgG antibodies by ELISA: Serum anti- B. pseudomallei IgM and IgG antibodies were measured by an in-house indirect ELISA as described by Jilani et al [13]. The 96-well flat bottom ELISA plate (Greiner Bio-One GmbH, Germany) was coated with sonicated whole cell antigen in carbonate/bicarbonate coating buffer (pH 9.6; 100 µl/well) and incubated overnight at 4⁰C. The plate was washed three times with phosphate buffered saline containing 0.05% Tween-20 (PBS-T, pH 7.4). To prevent non-specific binding, blocking buffer PBS-T containing 2% bovine serum albumin was added to each well (200 μl/well) and incubated at 37⁰C for 2 hours. The plate was then washed three times with PBS-T. To detect anti- B. pseudomallei IgM and IgG, 100 µl of serially diluted serum sample in PBS-T (1:100 to 1:204,800) was added per well. The plate was incubated for 4 hours at 37⁰C. After washing with PBS-T three times, 100 µl/well of horseradish peroxidase conjugated anti-human IgM and IgG antibodies at 1:4,000 dilutions (MP Biomedicals, USA) was added and incubated at 37⁰C for 2 hours. After washing three times with PBS-T, tetramethylbenzidine substrate (50 µl/well) was added and incubated at room temperature for 30 minutes in dark. The reaction was stopped by adding 50 µl of 2M H2SO4 per well and the optical density (OD) was read at 450 nm. Interpretation: A cut off OD values for anti- B. pseudomallei IgM and IgG antibodies were determined with sera from 15 newborn babies of Dhaka city, who were unlikely to get B. pseudomallei infection. The mean OD + 2 × SD of newborn sera was taken as cut off OD. The calculated cut off OD values for anti- B. pseudomallei IgM and IgG were 0.14 and 1.24 respectively. Any sample showing OD above these cut off values was considered positive. Bactericidal antibody assays: Serum bactericidal antibody assay was carried out with the strain of B. pseudomallei CS6887, MLST type ST56 [14]. The bacterial strain was isolated from a Bangladeshi melioidosis patient with septicemia. A microtiter plate based bactericidal assay was performed as described previously (15,16]. A single colony of B. pseudomallei grown overnight on MacConkey agar plate was inoculated in 5 ml of trypticase soya broth (TSB, Himedia Laboratories Pvt. Ltd., India) and incubated overnight at 37⁰C aerobically. The bacteria were harvested by centrifugation and suspended in cold phosphate-buffered saline (PBS; pH 7.4) having cell count of 3 × 108 CFU/ml. Guinea pig sera was used as external source of complement. A 1:10 dilution of guinea pig serum was prepared with cold PBS. A stock solution of bacteria plus complement containing 2.5 × 106 CFU/ml of bacteria was prepared by adding bacterial suspension to guinea pig complement and cold PBS. All serum samples were heated at 56⁰C for 30 minutes to inactivate complement in the test sera prior to use. Serial dilutions (two fold) of serum samples were prepared in cold PBS from 1:5 to 1:10,240 in sterile U bottom microtiter plate with lid (Greiner Bio-One GmbH, Germany). To each well containing 25 µl of serially diluted sera 25 µl of the mixture of bacteria, complement and PBS (2.5 × 106 CFU/ml) was added. Each plate had 4 control wells. Each control well contained 50 µl of (i) suspension of bacteria plus complement plus PBS, (ii) only serum, (iii), PBS and (iv) TSB. The control well (i) containing bacteria plus complement plus PBS without serum was included to determine bactericidal antibody titer of samples while control wells (ii), (iii) and (iv) were used to exclude the bacterial contamination in test procedure. The microtiter plate was incubated at 37⁰C for 1 hour. Then, TSB (150 µl/well) was added to each well and incubated overnight at 37⁰C. The OD values of the plates were measured at 595 nm. Interpretation: The bactericidal antibody titer was measured as the reciprocal of the highest serum dilutions causing a greater than 50% reduction of the OD when compared with the OD of the control well containing bacteria, complement and PBS without serum. To further confirm bacterial killing, viable bacterial cell count was performed by sub-culturing the content of the wells on Trypticase Soya Agar plate.   Results A total of 10 culture positive (B. pseudomallei) acute melioidosis cases with diabetes mellitus were included in the study. Out of 10 cases, 5 had localized infection in the form of abscess in different organs and 5 had septicemia (blood infection). B. pseudomallei was isolated from blood and from aspirated pus of septicemia and abscess cases respectively. The mean age of the patients was 48.5 ± 3.91 years and age ranged from 32 to 70 years. Mean age of the two groups was not significantly different (49.2 ± 5.7 and 47.8 ± 5.9 years; p = 0.86). Out of 10 cases, 7 (70%) were male and 3 (30%) were female (Table-1).   Table-1: Characteristics and anti- B. pseudomallei IgM, IgG and serum bactericidal antibody titers of study cases (N=10)     All 10 cases were positive for anti- B. pseudomallei IgM and IgG antibodies. The mean titer of anti- B. pseudomallei IgM and IgG of all cases were 16,640 ± 2995.04 and > 204,800 respectively. The mean anti- B. pseudomallei IgM titer of septicemic and abscess cases were not significantly different (14,080 ± 4,489.13 vs. 19,200 ± 3,620.39; p = 0.4) while the mean IgG titers of two groups were > 204,800. Out of 10 cases, 9 (90%) were positive for serum bactericidal antibody. Serum bactericidal antibody was negative in one 43 years old male patient with lung abscess. Mean serum bactericidal antibody titer of septicemia cases (66 ± 26) was not significantly (p = 0.72) different than those with localized infection (80 ± 28.28). Total mean bactericidal antibody titer of all cases was 72.22 ± 18.08.   Discussion B. pseudomallei is a highly pathogenic bacteria for human. The immune response in B. pseudomallei infection and its role in underlying pathology are not clear. Previous study has reported that there is no association between high antibody titers against whole cell B. pseudomallei antigens and protection against B. pseudomallei infection in human patients. In addition, the pathophysiology of being infected with B. pseudomallei in spite of having high background antibody titer in individuals residing in endemic zone is not clear [17]. On the other hand, an association of survival with high titer of antibodies to hemolysin co-regulated protein 1 was also reported [2]. Also, high antibody titer against B. pseudomallei is linked to survival of diabetic patients suffering from melioidosis [18]. Many studies used opsonic assays to investigate the role of antibodies in melioidosis [4,19]. In the present study, elevated levels of anti- B. pseudomallei IgM and IgG were found among all diabetic melioidosis patients and the antibodies were capable of complement mediated killing of B. pseudomallei. The lack of difference in antibody response between cases with septicemia and localized infection might be due to inoculating pathogen burden or undiagnosed underlying comorbidities in patients with localized abscess cases. Also, high antibody titer against B. pseudomallei has been reported among survivors of melioidosis patients with diabetes mellitus [18]. The mean bactericidal antibody titer of patients with septicemia and localized abscess was not significantly different from each other groups (66 ± 26 vs. 80 ± 28.28) except in one male patient with abscess where the bactericidal antibody was negative though IgM and IgG antibody titers were high. Similar magnitude of serum bactericidal antibody in both groups could be due to the fact that we could not ascertain the duration/ persistence of infecting bacteria in the hosts. Also, it indicates that in diabetic patients, serum sensitivity of bacteria due to complement mediated lysis might not be adequate to protect against bacteremia or septicemia. Also, the course of infection might depend on the type of infecting strains as serum sensitive and serum resistant strains were described previously for Burkholderia cepacia complex [20]. Negative bactericidal antibody in our patient could be due to the fact that the testing organism in our assay was serum resistant type. Further studies are necessary to exclude the above possibilities. The limitations of the present study were small sample size and lack of melioidosis cases without diabetes. Besides, the cases of this study might be an acute exaggeration of chronic B. pseudomallei infection. So, actual scenario of antibody response and its role could be deciphered if kinetics of the antibody titer and serum bactericidal antibody titer could be performed from the entry of the bacteria and onset of the infection. In addition, we have used a single strain in our SBA assay for all serum samples. The magnitude of bactericidal antibody could be actually different in patients with either septicemia or localized infection if, we could use corresponding strains in the assay to exclude the possibility of serum resistance of the testing strain in our assay. The study demonstrated that diabetic patients with melioidosis were capable of mounting good anti- B. pseudomallei IgM, IgG and bactericidal antibodies in both blood and localized infection types. Though there was equal bactericidal response in both groups, bactericidal antibody alone might not be enough to prevent the bacteremia in diabetic patients. Further studies with large number of cases are necessary to understand the complex immunopathology responsible for varied manifestation of melioidosis.   Authors’ contributions SM: laboratory investigation, analysis, writing original draft; MSAJ: methodology, resources, supervision and editing; LB: methodology, resources, supervision, KMSI: supervision, writing review & editing.   Competing interest The authors declare no conflict of interest.   Funding None.   References 1.     Limmathurotsakul D, Golding N, Dance DA, Messina JP, Pigott DM, Moyes CL, et al. Predicted global distribution of and burden of melioidosis. Nat Microb. 2016; 1: 15008. doi:10.1038/nmicrobiol.2015.8. 2.     Pumpuang A, Phunpang R, Ekchariyawat P, Dulsuk A, Loupha S, Kwawong K, et al. Distinct classes and subclasses of antibodies to hemolysin co-regulated protein 1 and O-polysaccharide and correlation with clinical characteristics of melioidosis patients. Sci Rep. 2019; 9: 13972. doi:10.1038/s41598-019-48828-4. 3.     Charuchaimontri C, Suputtamongkol Y, Nilakul C, Chaowagul W, Chetchotisakd P, Lertpatanasuwun N, et al. Antilipopolysaccharide II: an antibody protective against fatal melioidosis. Clin Infect Dis. 1999; 29: 813–818. doi:10.1086/520441. 4.     Chaichana P, Kronsteiner B, Rongkard P, Teparrukkul P, Limmathurotsakul D, Chantratita N, et al. Serum from melioidosis survivors diminished intracellular Burkholderia pseudomallei growth in macrophages: a brief research report. Front Cell Infect Microbiol. 2020; 10: 442. doi:10.3389/fcimb.2020.00442. 5.     Walport MJ. Complement. First of two parts.N Engl J Med. 2001; 344: 1058-1066. doi:10.1056/NEJM200104053441406. 6.     Frank MM, Joiner K, Hammer C. The function of antibody and complement in the lysis of bacteria. Rev Infect Dis. 1987; 9Suppl 5: S537-S545.doi:10.1093/clinids/9.supplement_5.s537. 7.     Speert DP, Farmer SW, Campbell ME, Musser JM, Selander RK, Kuo S. Conversion of Pseudomonas aeruginosa to the phenotype characteristic of strains from patients with cystic fibrosis. J Clin Microbiol. 1990; 28: 188-194. doi:10.1128/jcm.28.2.188-194.1990. 8.     Thomassen MJ, Demko CA. Serum bactericidal effect on Pseudomonas aeruginosa isolates from cystic fibrosis patients. Infect Immun. 1981; 33: 512-518. doi:10.1128/iai.33.2.512-518.1981. 9.     Holby N, Olling S. Pseudomonas aeruginosa infection in cystic fibrosis. Bactericidal effect of serum from normal individuals and patients with cystic fibrosis on P. aeruginosa strains from patients with cystic fibrosis or other diseases. Acta Pathol Microbiol Scand C. 1977; 85: 107-114. PMID: 404841. 10.  Findlow J, Balmer P, Borrow R. A review of complement sources used in serum bactericidal assays for evaluating immune responses to meningococcal ACWY conjugate vaccines. Hum VaccinImmunother. 2019; 15: 2491-2500. doi:10.1080/21645515.2019.1593082. 11.  Juel HB, Thomaides-Brears HB, Darton TC, Jones C, Jones E, Shrestha S, et al. Salmonella Typhi bactericidal antibodies reduce disease severity but do not protect against typhoid fever in a controlled human infection model. Front Immunol. 2018; 8: 1916. doi:10.3389/fimmu.2017.01916. 12.  American Diabetes Association.Classification and diagnosis of diabetes mellitus. Diabetes Care. 2017; 34: 2–7. 13.  Jilani MSA, Robayet JA, Mohiuddin M, Hasan MR, Ahsan CR, Haq JA. Burkholderia pseudomallei: its detection in soil and seroprevalence in Bangladesh. PLoSNegl Trop Dis. 2016; 10: e0004301. doi:10.1371/journal.pntd.0004301 14.  Jilani MSA, Farook S, Bhattacharjee A, Barai L, Ahsan CR, Haq JA, et al,. Phylogeographic characterization of Burkholderia pseudomallei isolated from Bangladesh. PLoSNegl Trop Dis. 2023; 17: e0011823. doi:10.1371/journal.pntd.0011823. 15.  Boyd MA, Tennant SM, Saague VA, Simon R, Muhsen K, Ramachandran G, et al. Serum bactericidal assays to evaluate typhoidal and nontyphoidal Salmonella vaccines. Clin Vaccine Immunol. 2014; 21: 712-721. doi:10.1128/CVI.00115-14. 16.  Qadri F, Mohi G, Hossain J, Azim T, Khan AM, Salam MA, et al. Comparison of the vibriocidal antibody response in cholera due to Vibrio cholerae O139 Bengal with the response in cholera due to Vibrio cholerae O1. Clin Diagn Lab Immunol. 1995; 2: 685-688. doi:10.1128/cdli.2.6.685-88.1995. 17.  Chaichana P, Jenjaroen K, Amornchai P, Chumseng S, Langla S, Rongkard P, et al. Antibodies in melioidosis: the role of the indirect hemagglutination assay in evaluating patients and exposed populations. Am J Trop Med Hyg. 2018; 99: 1378-1385. doi:10.4269/ajtmh.17-0998. 18.  Kronsteiner B, Chaichana P, Sumonwiriya M, Jenjaroen K, Chowdhury FR, Chumseng S, et al. Diabetes alters immune response patterns to acute melioidosis in humans. Eur J Immunol. 2019; 49: 1092-1106. doi:10.1002/eji.201848037. 19.  Zhang S, Feng SH, Li B, Kim HY, Rodriguez J, Tsai S, et al. In vitro and in vivo studies of monoclonal antibodies with prominent bactericidal activity against Burkholderia pseudomallei and Burkholderia mallei. Clin Vaccine Immunol. 2011; 18: 825-834. doi:10.1128/CVI.00533-10. 20.  Zlosnik JE, Gunaratnam LC, Speert DP. Serum susceptibility in clinical isolates of Burkholderia cepacia complex bacteria: development of a growth-based assay for high throughput determination. Front Cell Infect Microbiol. 2012; 2: 67. doi:10.3389/fcimb.2012.00067.       Cite this article as: Mazumder S, Jilani MSA, Barai L, Islam KMS. Antibody and serum bactericidal response to Burkholderia pseudomallei in acute localized and septicemic melioidosis cases with diabetes mellitus. IMC J Med Sci. 2025; 19(1): 009. DOI:https://doi.org/10.55010/imcjms.19.009 <![CDATA[Spectrum of thyroid disorders among patients with type 2 diabetes mellitus]]> Md Rakibul Hasan* Raisa Siddika Sayma Akther Mou Md Shahed Morshed https://imcjms.com/journal_full_text/556 2025-01-13 12:14:46 Original Article January 2025; Vol. 19(1):008 Abstract Background and objectives: Thyroid disorders (TD) are common among patients with type 2 diabetes mellitus (T2DM). Information on types of functional and structural TDs among Bangladeshi patients with T2DM is scarce in the literature. The present study aimed to determine the magnitude and characteristics of different TDs among Bangladeshi diabetic patients attending an urban healthcare center in Dhaka. Material and methods: The study included patients with T2DM who attended an urban Endocrinology Outpatient consultation center in Dhaka over a period of two years. Diagnosis of TDs was based either on previous medical records or on investigational results of thyroid functions/gland during the first visit. Standard criteria were used to diagnose TDs. Results: Total 1424 patients with T2DM were enrolled in the study. The mean age of the study population was 48.8 ± 12.9 years and 45.2% and 54.8% were male and female respectively. Among 1424 participants 217 (15.2%) had functional and/or structural abnormalities of thyroid gland. For those with abnormal thyroid function (14.3%), the most common was clinical hypothyroidism (10.5%), followed by subclinical hypothyroidism (2.6%), and clinical thyrotoxicosis (1.3%). Except for one, all patients with overt hypothyroidism had primary hypothyroidism. Among patients with overt thyrotoxicosis, Graves’ disease was the most common entity (50%). Multinodular goiter was the most frequent diagnosis among structural abnormalities (7 out of 13). Female sex (OR: 3.0, 95%CI: 1.5, 6.1, p=0.003) and obesity (OR: 2.3, 95%CI: 1.1, 5.0, p=0.039) had higher odds of having a diagnosis of overt hypothyroidism among patients with T2DM. Hypertension, dyslipidemia and obesity were significantly (p < 0.05) higher in diabetic patients with overt hypothyroidism. Conclusion: TDs especially hypothyroidism are common among female Bangladeshi patients with T2DM. Dyslipidemia and obesity are significantly more in overt hypothyroidism among patients with T2DM. January 2025; Vol. 19(1):008.  DOI: https://doi.org/10.55010/imcjms.19.008 *Correspondence: Md Rakibul Hasan, Department of Endocrinology, Medical College for Women and Hospital, Uttara, Dhaka 1230, Bangladesh. Email: dr.mrh46@gmail.com; © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License(CC BY 4.0).   Introduction Diabetes mellitus (DM) and thyroid disorders (TDs) are the two most commonly encountered endocrine disorders in day-to-day endocrinology practice [1]. Worldwide 1 in 10 adults (20-79 years) are living with DM with an estimated number of 537 million, and approximately 200 million people have been suffering from TD [2-3]. The prevalence of TDs varies in different age groups and geographical regions based on their iodine nutrition and autoimmune status [4-7]. Thyroid dysfunction affects blood glucose control by altering insulin sensitivity, secretion, and peripheral glucose utilization [8]. Very high blood glucose may also affect the thyroid hormone concentration [9]. Moreover, anti-diabetic drugs have also been reported to affect the thyroid function status [8]. TDs are very common in the general population with a prevalence ranging from 6.6% to 13.4% [10-11]. Many observational studies reported a relatively higher prevalence of TDs ranging from 10% to 24% in type 2 diabetes mellitus (T2DM) patients compared to non-diabetic counterparts [11,12]. Studies from Bangladesh have also very similar findings [13,14]. However, studies from Bangladesh had small sample sizes and inappropriately defined the clinical hypothyroidism and subclinical hypothyroidism affecting the overall prevalence [13]. All studies in diabetic patients reported only the functional status of the thyroid gland, omitting equally important structural disorders namely thyroid nodule, thyroid malignancy and multinodular goiter. Also, no published article from Bangladesh categorized types of hyperthyroidism based on the etiology. In view of the above, the present study aimed to determine the prevalence and associated clinical features of different TDs among Bangladeshi patients with T2DM.   Materials and methods The study was conducted at an Endocrinology Outpatient consultation center in Dhaka, Bangladesh. The study was approved by the Institutional Ethical committee of the Medical College for Women and Hospital, Uttara, Dhaka. Study participants’ identities were kept confidential and anonymous at all times. Study population: All consecutive non-pregnant T2DM patients, attending Endocrinology Outpatient consultation center from August 2022 to September 2024 were primarily selected for the study. T2DM patients with pregnancy/gestational diabetes, secondary, and other types of diabetic patients were excluded from the study. Patients’ clinical and demographic information were maintained in a prescription writing software database (Zilsoft Pro, Version 7.0). Clinical and demographic information of the study population were converted to an Excel document from the software database and imported to SPSS version 25.0 for statistical analysis. Diagnosis of TDs and other conditions: Diagnosis of TDs was based either on previous medical records or on investigational results of thyroid functions/gland during the first visit. The majority of the patients with TDs was previously diagnosed and came for routine follow-up for dose adjustment of existing medication. Functional TDs were diagnosed by symptoms suggestive of TDs, thyroid function tests namely serum thyroid stimulating hormone (TSH) and free thyroxine (FT4) tests. Estimation of TSH and FT4 was carried out by an indirect chemiluminescence method. Thyroid ultrasonogram findings were used to diagnose structural thyroid disease in suspected cases. In hyperthyroid patients, TSH receptor antibody (TRAb), thyroid scan, and radioactive iodine uptake tests were carried out to differentiate Graves’ disease from other causes of thyrotoxicosis. Following criteria were used to diagnose different types of TDs: a. For non-pregnant adults, a TSH range between 0.35 & 5.5µIU/mL and an FT4 range between 0.78 & 2.19 ng/dL, were considered normal based on laboratory cut-offs. b. Subclinical hypothyroidism (SCH): FT4= 0.78 – 2.19 ng/dL and TSH=5.5 to <20.0 µIU/m. c. Primary hypothyroidism: FT4< 0.78 ng/dL and TSH ≥20.0 µIU/mL d. Secondary hypothyroidism: FT4< 0.78 ng/dL and TSH= undetectable to <20.0 µIU/mL e. Subclinical thyrotoxicosis: FT4= 0.78 - 2.19 ng/dL and TSH <0.35 µIU/mL f. Primary thyrotoxicosis: FT4> 2.19 ng/dL and TSH <0.35 µIU/m. Solitary thyroid nodule and multinodular goiter were diagnosed based on ultrasonogram and thyroid scan findings while thyroid malignancy was diagnosed by histopathology. Clinical hypothyroid includes both primary and secondary hypothyroidism. Diabetes mellitus was diagnosed based on HbA1C and plasma glucose levels and classic symptoms of hyperglycemia or hyperglycemic crisis [15]. Hypertension was defined as systolic and diastolic blood pressure ≥140 and ≥90 mmHg respectively. A body mass index (BMI) over 30 kg/m2 was considered as obese (WHO, 2004). Statistical analysis: Continuous variables are expressed as the mean ± standard deviation (SD), or median with interquartile range (IQR) depending on their distribution. Categorical variables are presented as frequency (number) and the percent. The association of baseline characteristics with different thyroid dysfunctions was analyzed by Chi-square tests and post hoc from adjusted residuals. Multivariable binary logistic regression was used to see the predictive association of baseline characteristics for overt hypothyroidism. Any value of <0.05 was used for statistical significance.    Results Total 1424 patients with T2DM were enrolled in the study. The mean age of the study population was 48.8 ± 12.9 years. Majority (77.5%) was above 40 years of age and 45.2% and 54.8% were male and female respectively. Mean BMI of the participants was 29.2 ± 4.3 kg/ m2 while 24.9% was obese. Detail profile of the study participants is shown in Table-1. Overall prevalence of thyroid disorders was present in 217 (15.2%) T2DM cases. Of the total study population, 1220 DM patients were euthyroid (Table-1). Types of thyroid disorders in patients with DM are shown in Table-2. Out of 217 patients with TDs, 204 (14.3%) and 13 (0.9%) had functional and other structural diseases respectively. The most common functional abnormality was overt hypothyroidism (10.5%), followed by subclinical hypothyroidism (2.6%), and overt thyrotoxicosis (1.3%). All except one had primary hypothyroidism. There were no cases of subclinical thyrotoxicosis. Graves’ disease was the most common (9/18) cause of thyrotoxicosis. Of the total study population, 13 (0.9%) euthyroid cases had morphological abnormalities which included papillary thyroid carcinoma and goiters (Table-2).   Table-1: Distribution of age, gender and clinical status of thyroid gland of the study population (N=1424)     Table-2: Types of thyroid disorders in patients with T2DM (n= 1424)     Significant (p < 0.05) differences in the frequency of sex distribution were observed in overt hypothyroidism and euthyroidism cases (Table-3). There was an overall significant (p < 0.05) association of different thyroid disorders with both dyslipidemia and hypertension. Significantly (p < 0.05) more cases of overt hypothyroidism had hypertension, dyslipidemia and obesity while it was opposite for diabetic patients with subclinical hypothyroidism and overt thyrotoxicosis. BMI was significantly (p=0.001) higher among those with overt hypothyroidism than euthyroidism (p=0.001).   Table-3: Characteristics of diabetic patients with thyroid functional disorders (n= 1424)     A multivariable binary logistic regression model showed higher odds for female and obese individuals to have a diagnosis of clinical hypothyroidism than euthyroidism among people with DM (Table-4).   Table-4: Predictors of overt hypothyroidism (vs. euthyroidism) among people with DM (n=338)     Discussion In the present study, the overall TDs among T2DM patients were 15.2%.The most common form of thyroid dysfunction was overt hypothyroidism (10.5%), followed by subclinical hypothyroidism (2.6%), and overt thyrotoxicosis (1.3%). Female diabetics were more commonly affected compared to males in all types of thyroid dysfunctions. Female sex and obesity were found to be independent predictors of overt hypothyroidism in diabetes. Overt hypothyroidism was seen more commonly in the elderly population aged above 40 years though it was not statistically significant. Among the structural thyroid disorders, euthyroid multinodular goiter was most prevalent among the study group. Thyroid dysfunctions among DM patients were observed with almost similar frequency in studies from Oman (12.6%), India (13.7%), and from Brazil (14%) [16-18]. However, many studies reported a relatively higher prevalence of thyroid dysfunctions among T2DM patients from Bangladesh (23.5%), India (23.6%), Jordan (26.7%), and Saudi Arabia (28.5%) [14,19-21]. A recent systematic review and meta-analysis also reported a higher prevalence (20.24%) of TDs among T2DM patients [22]. The variation in the prevalence of thyroid dysfunction among diabetics may be related to the study design and sampling technique. Most of the patients in our study were previously diagnosed cases of thyroid dysfunction, and further thyroid function tests were only done in the presence of suggestive symptoms and risk factors of thyroid disease. This could contribute to a relatively low frequency of subclinical hypothyroidism in our study (2.6%). Structural thyroid disorders were not routinely screened among our patients. Diagnosis of structural thyroid disorders was only attempted if the patient presented with suggestive problems. Therefore, routine screening of structural thyroid disease could yield higher frequency in our study as had been seen in a large-scale retrospective study from China. They found the overall prevalence rate of thyroid nodule was 38.3% on thyroid ultrasonogram. Increasing age of the study participants and the presence of diabetes had significant and positive co-relation with the thyroid nodule and goiter [23]. In our study, the majority of thyroid dysfunctions were previously diagnosed. During the study period, only patients with suggestive symptoms of TDs were screened for possible thyroid dysfunction. So, overt hypothyroid cases constituted a large proportion in our study group. Subclinical thyroid disorders were seen as less prevalent as routine screening for thyroid dysfunction was not advised in asymptomatic patients. Many cross-sectional studies reported a high prevalence of subclinical hypothyroid cases in diabetics, which was not seen in our study. This could be attributed to the study design. Antibody status was not tested and therefore, type 1 DM could not be identified and excluded. Besides, this was a single-center study and hence not a true representative of entire country. Despite having these limitations, a large sample size provided the true representation of TDs in T2DM patients. Inclusion of structural TDs and biochemical indices in TDs in diabetic patients provided further valuable clinical information to the existing evidence. The observed frequency of thyroid dysfunction among T2DM patients was very high in our study, and females were more prone to develop thyroid dysfunctions. Females with obesity in the presence of T2DM should be routinely screened for clinical and subclinical hypothyroidism.   Conflict of Interest The authors have no conflicts of interest to declare.   Fund None.   References 1.     Ale AO, Odusan O. Spectrum of endocrine disorders as seen in a tertiary health facility in Sagamu, Southwest Nigeria. Niger Med J. 2019; 60(5): 252-256. DOI: 10.4103/nmj.NMJ_41_19. 2.     International Diabetes Federation. IDF Diabetes Atlas, 10th ed. Brussels, Belgium: 2021. Available at: https://www.diabetesatlas.org. 3.     Thyroid disease - more research needed. Lancet. 2012; 379(9821): 1076. DOI: 10.1016/S0140-6736(12)60445-0. 4.     Zhang X, Wang X, Hu H, Qu H, Xu Y, Li Q. Prevalence and trends of thyroid disease among adults, 1999-2018. Endocr Pract. 2023; 29(11): 875-880. DOI: 10.1016/j.eprac.2023.08.006. 5.     Fan X, Zhao L, Wang S, Song K, Wang B, Xie Y, et al. Relation between iodine nutrition and thyroid diseases in Qinghai, China. Front Endocrinol (Lausanne). 2023; 14: 1234482. DOI: 10.3389/fendo.2023.1234482. 6.     Unnikrishnan AG, Kalra S, Sahay RK, Bantwal G, John M, Tewari N. Prevalence of hypothyroidism in adults: An epidemiological study in eight cities of India. Indian J Endocrinol Metab. 2013; 17(4): 647-52. DOI: 10.4103/2230-8210.113755. 7.     Yan Y, You L, Wang X, Zhang Z, Li F, Wu H, et al. Iodine nutritional status, the prevalence of thyroid goiter and nodules in rural and urban residents: A cross-sectional study from Guangzhou, China. Endocr Connect. 2021; 10(12): 1550-1559. DOI: 10.1530/EC-21-0418. 8.     Eom YS, Wilson JR, Bernet VJ. Links between thyroid disorders and glucose homeostasis. Diabetes Metab J. 2022; 46(2): 239-256. DOI: 10.4093/dmj.2022.0013. 9.     Iwamoto Y, Kimura T, Tatsumi F, Sugisaki T, Kubo M, Nakao E, et al. Effect of hyperglycemia-related acute metabolic disturbance on thyroid function parameters in adults. Front Endocrinol (Lausanne). 2022; 13: 869869. DOI: 10.3389/fendo.2022.869869. 10.  Palma CC, Pavesi M, Nogueira VG, Clemente EL, Vasconcellos Mde F, Pereira LC Júnior, et al. Prevalence of thyroid dysfunction in patients with diabetes mellitus. Diabetol Metab Syndr. 2013; 5(1): 58. DOI: 10.1186/1758-5996-5-58. 11.  Umpierrez GE, Latif KA, Murphy MB, Lambeth HC, Stentz F, Bush A, et al. Thyroid dysfunction in patients with type 1 diabetes: A longitudinal study. Diabetes Care. 2003; 26(4): 1181-1185. DOI: 10.2337/diacare.26.4.1181. 12.  Gharib H, Tuttle RM, Baskin HJ, Fish LH, Singer PA, McDermott MT. Subclinical thyroid dysfunction: A joint statement on management from the American Association of Clinical Endocrinologists, the American Thyroid Association, and the Endocrine Society. J Clin Endocrinol Metab. 2005; 90(1): 581-585. DOI: 10.1210/jc.2004-1231. 13.  Moslem F, Bithi TS, Biswas A. Prevalence of thyroid dysfunction among type-2 diabetes patients in an urban diabetes hospital, Bangladesh. Open Sci J Clin Med. 2015; 3(3): 98-102. 14.  Khan NZ, Muttalib MA, Sultana GS. Association of thyroid hormone levels among type 2 diabetic patients attending a tertiary care hospital. Bangladesh Med Res Counc Bull. 2017; 42(2): 90-94. 15.  American Diabetes Association. Classification and diagnosis of diabetes mellitus. Diabetes Care. 2017; 34(1): 2-7. 16.  Al-Sumry S, Al-Ghelani T, Al-Badi H, Al-Azri M, Elshafie K. Thyroid diseases in Omani type 2 diabetics: A retrospective cross-sectional study. Adv Endocrinol. 2015; 2015: 1-6. DOI: 10.1155/2015/353121. 17.  Jain A, Patel RP. A study of thyroid disorder in type 2 diabetes mellitus. Sch J App Med Sci. 2016; 4(12B): 4318-4320. DOI: 10.36347/sjams.2016.v04i12.027. 18.  Palma CC, Pavesi M, Nogueira VG, Clemente EL, Vasconcellos Mde F, Pereira LC Júnior, et al. Prevalence of thyroid dysfunction in patients with diabetes mellitus. Diabetol Metab Syndr. 2013; 5(1): 58. doi: 10.1186/1758-5996-5-58. 19.  Asuti S, Purad S, Hosamani P. Pattern of thyroid dysfunction in Type II diabetes mellitus patients in a tertiary care center: A cross-sectional study. J Med Sci Health. 2023; 9(2): 204-210. DOI: 10.46347/jmsh.v9i2.23.125. 20.  Khassawneh AH, Al-Mistarehi AH, Zein Alaabdin AM, Khasawneh L, AlQuran TM, Kheirallah KA, et al. Prevalence and predictors of thyroid dysfunction among type 2 diabetic patients: a case–control study. Int J Gen Med. 2020; 13: 803-816. DOI://doi.org/10.2147/IJGM.S273900. 21.  Al-Geffari M, Ahmad NA, Al-Sharqawi AH, Youssef AM, Alnaqeb D, Al-Rubeaan K. Risk factors for thyroid dysfunction among type 2 diabetic patients in a highly diabetes mellitus prevalent society. Int J Endocrinol. 2013; 2013: 417920. doi: 10.1155/2013/417920. 22.  Hadgu R, Worede A, Ambachew S. Prevalence of thyroid dysfunction and associated factors among adult type 2 diabetes mellitus patients, 2000-2022: a systematic review and meta-analysis. Syst Rev. 2024; 13(1): 119. doi: 10.1186/s13643-024-02527-y. 23.  Xu J, Lau P, Ma Y, Zhao N, Yu X, Zhu H, Li Y. prevalence and associated factors of thyroid nodules among 52,003 Chinese ‘Healthy’ individuals in Beijing: A retrospective cross-sectional study. Risk Manag Healthc Policy. 2024; 17: 181-189. doi.org/10.2147/RMHP.S442062     Cite this article as: Hasan MR, Siddika R, Mou SA, Morshed MS. Spectrum of thyroid disorders among patients with type 2 diabetes mellitus. IMC J Med Sci. 2025; 19(1): 008. DOI:https://doi.org/10.55010/imcjms.19.008 <![CDATA[Assessment of dietary intake and its determinants in adult patients on anti-tubercular treatment in Aligarh, India: a cross sectional study]]> S Danish Iqbaal* M Athar Ansari Ali Jafar Abedi Saira Mehnaz Mohd Yasir Zubair Shahnawaz Ahmad https://imcjms.com/journal_full_text/555 2024-12-24 12:49:23 Original Article January 2025; Vol. 19(1):007 Abstract Background and objectives: Adequate nutrition and a good dietary practice play an important role in recovery from tuberculosis (TB). Improper dietary practice and poor nutrition lead to low immunity in the host and thus increase the risk of active TB in addition to relapse and mortality. The objective of the study was to assess the dietary intake and its determinants in patients on anti-tubercular treatment. Materials and methods: A cross-sectional study was conducted, in four Designated Microscopic Centres under the administration of the District TB Cell of Aligarh district from January 2020 to December 2021. Adult TB patients undergoing treatment between the ages of 18 to 60 years were enrolled. A semi-structured questionnaire was used as a study tool. The 24-hour recall method was used for eliciting dietary intake as it had less recall bias. The sufficient and insufficient dietary cut offs were chosen from the Indian Council for Medical Research (ICMR) nutrient guidelines for TB patients. The data was analyzed by appropriate statistical tests. Results: A total of 410 TB patients participated in the study. Majority (61.7%) of the patients were unemployed and 46.8% belonged to the lower middle class. Of the total cases, 83.2% patients were consuming energy below the Recommended Dietary Allowance (RDA). The protein intake was sub-optimal in 71%, while 52% were taking fat below RDA. Age, gender, and education of the participants were significantly associated (< 0.05) with their energy and protein intake. Conclusions: The participants’ intake of nutrients was suboptimal compared to RDA. Thus, there is a need to improve the nutritional status of TB patients. Therefore, findings of the study could be utilised to plan programs for improved nutritional care for under privileged TB patients living in rural and urban areas. *Correspondence: S. Danish Iqbaal, Senior Resident, Department of  Community Medicine, Indira Gandhi Institute of Medical Sciences, Patna-800014, Bihar, India. Email: iqbalsdalig@gmail.com; © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License(CC BY 4.0).   Introduction Tuberculosis (TB) is one of the oldest diseases known to mankind, caused by the bacterium Mycobacterium tuberculosis [1]. India has approximately 26% of global TB cases and it kills an estimated 480,000 Indians per year or more than 1,400 per day [2,3]. TB is curable, preventable, and effectively treated with anti-tubercular treatment (ATT) [4]. It has been known that there is a bidirectional link between TB and nutrition. TB can lead to malnutrition, and malnutrition may predispose to TB. Poor dietary intake and nutrition lead to low immunity, increasing susceptibility of the host, and increasing the risk of active TB by six to ten times, besides increasing the risk of relapse and mortality [5,6]. Weight loss among people with active TB can be caused by several factors, including reduced food intake due to loss of appetite, nausea and abdominal pain. It is also been associated with altered metabolism and malabsorption of nutrients and anti-TB drugs. Management of active TB disease needs 20–30% more energy, so diet and nutritional requirements are increased, but TB, as such, decreases appetite, leading to weight loss. Therefore, a good dietary practice and effective treatment improve the outcome of TB [7]. In view of the above, this study aimed to assess dietary practices of adult TB patients on anti-tubercular treatment residing in urban and rural areas.   Materials and methods This study was a cross-sectional study conducted in Aligarh from January 2020 to December 2021. Four Designated Microscopy Centres (DMCs) under the administration of the District TB Cell of Aligarh district were selected based on geographical contiguity, study feasibility, resources and the case load. Centers were located under the rural and urban TB units (TU). Two centers from each area were selected. The study participants were adult TB patients undergoing treatment between the ages of 18 to 60 years. Those who had comorbidities like hypertension, HIV, diabetes, and condition like pregnancy were excluded from the study. TB cases were enrolled by sequential sampling method from the complete list of registered TB patients of the respective DMCs [8]. A face-to face interview was conducted. A semi-structured questionnaire was used as a study tool. The questions were asked in locally known language, Hindi. A pilot study was conducted to assess the feasibility and appropriateness of the questionnaire and the flow of the interview. Subsequently, required modifications were made to the questionnaire. Based on the results of the pre-test exercise, the interview schedule was modified according to the responses elicited, and the words used in the questionnaire were modified to make them understandable for the participants. The 24-hour recall method was used for eliciting dietary intake as it had less recall bias. Due care was taken during the dietary history that participants were not on fast or feast in the last twenty-four hours. The sufficient and insufficient dietary cut offs used were based on the Indian Council for Medical Research (ICMR) nutrient guidelines for TB patients. The ICMR assumes that TB patients live a sedentary life due to the debilitating effects of the disease. Statistical analysis: Data entered in MS Excel and analyzed by IBM SPSS software version 20.0 (IBM Corp). Chi-square and other appropriate tests were used and thevalue of p < 0.05 was taken as significant. Ethical consideration: Approval for the study was obtained from the Institutional Ethics Committee, Jawaharlal Nehru Medical College, Aligarh Muslim University, along with the District TB Cell (DTC), Aligarh, for conducting the study. Informed consent was obtained from the participants, and confidentiality was ensured.   Results A total of 410 TB patients participated in the study. The majority of cases (62.4%) were in the age group of 18–30 years, and the mean age was 31.6 ±11.8 years. Approximately half (53.4%) of the TB cases were male, and 67.6% of participants were married. The majority of patients (56.3%) were from the Hindu community and 62.4% of the patients were from the general caste and illiterate patients comprised 38% of the study population. Of the total, 42.2% of patients resided in rural areas, whereas those in urban slum areas accounted for 39.5%. Majority (61.7%) of the patients were unemployed, 46.8% had ≤5 family members, and the remaining (53.2%) had a family size of >5 members while 64.9% of participants were from nuclear families. The data on socioeconomic class (modified B.G. Prasad) revealed that 46.8% of TB patients belonged to the lower middle (class IV) class as per the modified B.G. Prasad classification, 2019 (Table-1).   Table-1: Socio-demographic profile of study population (N=410)     Overall, most (83.2%) of TB patients daily energy intake was deficient. Most of the males (88.1%) and 77.5% of the females consumed less energy per day than the recommended RDA. Among all TB patients, the majority (71%) were taking less protein than the required amount. According to the RDA, 78.1% of males’ and 62.8% of females’ daily protein intake was insufficient. Overall, the majority (52%) of TB patients’ fat intake was sub-optimal according to RDA and 65.8% of males and 36.1% of females were consuming less fat less than recommended by the RDA (Table-2).   Table-2: Dietary intake status of the TB patients in comparison to RDA (Sedentary life style, ICMR, NIN Hyderabad, 2020; N=410)     Total mean energy intake of the TB patients was 1516 ± 332 k cal/day. The mean energy consumption by the male and female TB patients was 1587 ± 347 k cal/day, and 1434 ± 295 k cal/day respectively. Overall mean protein consumption by all TB patients was 45 ± 13 g/day. In total, mean fat intake was 23 ± 6 g/day. In male and female TB patients, the consumption was 23 ± 6 g/day and 22 ± 6 g/day, respectively (Table-3). It was observed that males’ daily energy intake was 75% of the RDA, while the same was 86% for females. Likewise, the protein intake with respect to the recommended RDA by males was 85%, whereas by females it was 93%. The fat intake in males was 92% of the advised RDA; however, in females, its consumption was higher than the RDA (Table-3).   Table-3: Nutrients intake and percentage of RDA (Sedentary lifestyle) energy, protein and fat consumption in TB patients (ICMR, NIN Hyderabad, 2020; N=410)     A statistically significant (p<0.05) association was found between age and energy intake. As age increased, the energy intake decreased. Gender, marital status, education, and occupation were also significantly associated (p< 0.05) with energy uptake. No significant association (p > 0.05) was found between social-economic class, caste, family size, type of family, and religion with energy intake among participants (Table-4). No significant association was found with calorie intake and that of treatment category, duration of initiation of ATT from illness, phase of medication. Patients with pulmonary TB (PTB) were more vulnerable to an energy-deprived diet against extra-pulmonary TB (EPTB), as shown in Table-4 (p<0.05). All MDR TB patients were consuming a statistically significant (p <0.05) sub-optimal level of energy (Table- 4).   Table-4: Association of socio-demographic factors and clinical profile with calorie intake of study participants (N=410)     Association of socio-demographic factors and clinical profile of TB patients with protein intake is shown in Table-5. There was a statistically significant (p<0.05) association of protein intake with age category, gender, and education. Protein intake was significantly (p<0.05) high among TB patients with higher education level compared to those with low education levels. Marital status, religion, caste, family size, family type, employment status, social class, or clinical profile of the patients had no significant (p > 0.05) association with protein intake of TB patients.   Table-5: Association of socio-demographic factors and clinical profile of TB patients with protein intake (N=410)     Discussion This study has demonstrated that the energy intake of 83.2% of the TB patients was below the RDA. The protein intake was sub-optimal in around three-fourths of the participants, while half of the patients were taking fats below RDA. Similar results were observed in a study in West Bengal, where 86.7% of the subjects were deficient in energy while 36.3% were deficient in fat intake [9]. Similar findings were also reported from Brazil, where most (85%) of subjects were deficient in energy, protein, and micro-nutrient intake as a daily requirement [10]. The nutrition survey of NNMB stated that 50 to 70 percent of the Indian population consume insufficient protein, fat and energy [11]. A study conducted in Karachi, Pakistan, found that mean energy intake of TB patients was 1321.77±506.19 k cal/day [12]. The difference with our study might be due to a different setting and a large number of participants from urban slums, whose dwellers are largely from lower socioeconomic backgrounds. Moreover, slightly higher energy consumption might be attributed to various social security and nutrition support programmes like the Nikshay Poshan Yojana (NPY) to TB patients in India. Strikingly similar results to our observation were reported by a survey report by Central Tuberculosis Division, MoHFW, India [7]. In concordance with our results, another study reported 19% less consumption of total energy with respect to RDA in TB patients [13]. Similar to our findings, a study from Kenya reported that male and female TB patients respectively consumed 85% and 81% of the RDA of energy [6]. Also, mean protein intake was 37 g/day and 38 g/day by males and females respectively, while fat consumption by men and women TB patients was 53% and 56% of the RDA respectively. These results also corroborate the findings in our study. A study conducted in Peru revealed that the mean calorie intake was 600 k cal/day among TB patients [14]. Another study in Nepal found that occupation was significantly associated with energy intake [15]. However in our study, no significant association was observed with energy intake and age, gender, and education. The present study also found no significant association with calorie intake and treatment category, duration of initiation of ATT from illness and phase of medication. However, it was observed that patients with PTB were more vulnerable to energy insufficiency than those having EPTB (p = 0.003). Study from Nepal also reported similar results except that they reported no significant association between type of TB (PTB and EPTB) and energy intake [15]. The present study was an interview-based cross-sectional study, thus subjected to recall bias. Also temporality could not be ascertained as it was a cross-sectional study. The 24-hour recall method was used to assess dietary intake, which had its own limitations. The findings of the study emphasize the need to increase awareness regarding the role of diet in TB prevention and treatment and also to address other social determinants of TB. Emphasis should be given on health education and dietary counselling by health personnel to TB patients and their care givers.   Author’s contribution All authors contributed equally   Conflicts of interest  Nil   Financial support and sponsorship  Nil   References 1.     World Health Organization. Global tuberculosis report. Geneva, Switzerland: WHO; 2019. https://www.who.int/publications/i/item/9789241565714 [Accessed on June 2022]. 2.     World Health Organization. Global Tuberculosis Report. Geneva, Switzerland: WHO; 2020. https://www.who.int/publications/i/item/9789240013131 [Accessed on May 2022]. 3.     Purty AJ. Detect-Treat-Prevent-Build: Strategy for TB elimination in India by 2025. Indian J Community Med. 2018; 43(1): 1-4. doi:10.4103/ijcm.IJCM_321_17. 4.     World Health Organization. WHO global lists of high burden countries for tuberculosis (TB), TB/HIV and multidrug/rifampicin-resistant TB (MDR/RR-TB). Geneva, Switzerland: WHO; 2021[Accessed on June 2022]. 5.     Feleke BE, Feleke TE, Biadglegne F. Nutritional status of tuberculosis patients, a comparative cross-sectional study. BMC Pulm Med. 2019; 19(1): 182. doi:10.1186/s12890-019-0953-0. 6.     Nthiga I, Mbithe D, Mugendi B, Nyangaresi D, Wambui T. Dietary practices of pulmonary tuberculosis patients attending clinic at Lodwar county and referral hospital, Turkana County, Kenya. Int J Food Sci Nutr. 2017; 2(1): 123-127. 7.     Central Tuberculosis Division, MoHFW. Guidance document: Nutritional care and support for patients with tuberculosis in India, New Delhi; 2017. https://www.tbcindia.gov.in/WriteReadData/Guidance Document-Nutritional Care [Accessed on January 2022]. 8.     Kothari CR, Garg G. Research methodology: methods and techniques. 4th ed. New Delhi: New Age International Publishers Limited; 2019. 9.     Mollah A, Shrivastava P, Das DK, Ray S. Nutritional status of adult tuberculosis patients in Burdwan municipality area of West Bengal. Indian J Community Health (IJCH). 2020; 32(2): 438-443. 10.  Bacelo AC, do Brasil PEAA, Cople-Rodrigues CDS, Ingebourg G, Paiva E, Ramalho A, et al. Dietary counseling adherence during tuberculosis treatment: A longitudinal study. Clin Nutr ESPEN. 2017; 17: 44-53. doi:10.1016/j.clnesp.2016.11.001. 11.  Indian Council of Medical Research. Nutrient requirements and recommended dietary allowances for Indians. ICMR, NIN Hyderabad; 2011. 12.  Afnan BH, Soomro S, Mughal S, Ali SA, Patel M, Ahmed N. Nutritional assessment tools in patients with pulmonary tuberculosis: A cross-sectional study. Asian Journal of Dietetics (AJD). 2020; 2(3): 113. 13.  Campos-Gongora E, Lopez-Martinez J, Huerta-Oros J, Arredondo-Mendoza GI, Jimenez-Salas Z. Nutritional status evaluation and nutrient intake in adult patients with pulmonary tuberculosis and their contacts. J Infect Dev Ctries. 2019; 13(4): 303-310. doi:10.3855/jidc.11267. 14.  Lee GO, Paz-Soldan VA, Riley-Powell AR, Gómez A, Tarazona-Meza C, Paliza KV, et al. Food choice and dietary intake among people with tuberculosis in Peru: implications for improving practice. Curr Dev Nutr. 2020; 4(2): nzaa001. doi:10.1093/cdn/nzaa001. 15.  Gurung LM, Bhatt LD, Karmacharya I, Yadav DK. Dietary practice and nutritional status of tuberculosis patients in Pokhara: a cross sectional study. Front Nutr. 2018; 5: 63. doi:10.3389/fnut.2018.00063.     Cite this article as: Iqbaal SD, Ansari MA, Abedi AJ, Mehnaz S, Zubair MY, Ahmad S. Assessment of dietary intake and its determinants in adult patients on anti-tubercular treatment in Aligarh, India: a cross sectional study. IMC J Med Sci. 2025; 19(1):007. DOI:https://doi.org/10.55010/imcjms.19.007 <![CDATA[Sociodemographic and behavioral risk factors for cervical cancer, its awareness and preventive practices among reproductive age group women in a slum area of Kolkata]]> Sinjita Dutta Shalini Pattanayak Afifa Ahamed Mausumi Basu* https://imcjms.com/journal_full_text/554 2024-12-21 12:29:23 Original Article January 2025; Vol. 19(1):006 Abstract Background and objectives: Women residing in Indian slums remain at risk of developing cervical cancer because of lack of awareness and effective screening programs. This study aimed at identifying sociodemographic and behavioral risk factors for cervical cancer, its awareness, and preventive practices among reproductive age-group women in a slum of Kolkata. Materials and methods: A descriptive, observational study with cross-sectional design, was conducted among women of age group 15 - 49 years residing in a slum area. A predesigned, pretested and semi-structured schedule was employed to obtain data from the study participants. Questionaire contained domains of sociodemographic characteristics, awareness regarding cervical cancer, behavioral risk factors and preventive practices. Data was analyzed using appropriate statistical tests and association of sociodemographic characteristics with awareness was assessed using binary logistic regression. Results: A total of 215 women were enrolled in the study and 62.8% were married and majority (61.8%) had secondary school and above level of education. Nearly 77% participants did not prefer to use barrier contraceptive methods and 8% had a history of unsafe abortion. Majority (76.3%) were unaware of cervical cancer. Out of 51 (23.7%) participants who were aware of the cervical caner, only 9.8% and 17.6% of the them could correctly identify the risk factors and signs and symptoms of cervical cancer respectively. Only 2 (3.9%) and 11 (21.5%) had heard about the screening methods and vaccine for the prevention of cervical cancer respectively. Conclusion: Extensive health promotion and educational campaigns are required to generate awareness against cervical cancer in under privileged community. January 2025; Vol. 19(1):006.  DOI:https://doi.org/10.55010/imcjms.19.006 Correspondence: Mausumi Basu, Department of Community Medicine, Institute of Post Graduate Medical Education and Research (IPGME&R), Kolkata- 700020, India. Email: basu.mausumi544@gmail.com; © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0).   Introduction  Global Cancer Observatory 2020 (GLOBOCAN 2020) estimated that cervical cancer is the fourth most common cancer in women worldwide [1]. In 2020, cervical cancer caused an estimated 604,127 cases and 341,831 deaths worldwide. About 96922 women are diagnosed with cervical cancer annually in India with an annual death rate of 60078 [2]. Indian has high age-standardised rate (ASR) of incidence of cervical cancer with 12.1 cases per 100,000 women in 2016 [3]. Cervical cancer is the commonest genital tract cancer, especially among women residing in developing countries. In response to this situation, the World Health Organization (WHO) launched a global strategy to accelerate the elimination of cervical cancer in November 2020 during the 73rd World Health Assembly. WHO’s key objectives for 2030 are to achieving 90% human papillomavirus (HPV) vaccination coverage for girls, 70% screening coverage, and 90% access to treatment of precancerous and cancerous lesions [4]. The low and middle income countries like India, have no guidelines for screening of cervical cancer. Mass immunization with human papillomavirus (HPV) vaccine is a major strategy for prevention of this cancer [5]. Despite the usefulness of cervical cancer vaccines, significant gaps still exist in the level of awareness and acceptability of the vaccine among women. The known risk factors for cervical cancer include infection with HPV types 16 and 18, poor socio-economic status, smoking, early age of marriage, early age of coitus, presence of multiple sex partners, and multiparity. Women residing in slum areas lack awareness regarding cervical cancer due to absence of effective implementation of screening and vaccination programs. The assessment of awareness, behavioral risk factors along with the sociodemographic profile of women is of utmost importance to plan appropriate measures for the prevention and control of cervical cancer including the introduction of appropriate and effective screening and vaccination programs. With this background, the current study was conducted to find out the awareness, and preventive practices  regarding cervical cancer among reproductive age-group women in a slum of Kolkata.   Materials and methods Study type, place and population: A descriptive, observational study with cross-sectional design, was conducted among women belonging to the reproductive age group of 15-49 years [6] residing in a slum area in Chetla, Kolkata, under Kolkata Municipal Corporation (KMC) Ward 81. This slum belonged to the urban field practice area of Institute of Post Graduate Medical Education and Research (IPGME&R) and Seth Sukhlal Karnani Memorial (SSKM) Hospital, Kolkata. The study was conducted for a period of 3 months from March 2023 to May 2023. Inclusion and exclusion criteria: Those who were present in their homes at the time of data collection and were mentally stable to give interview and provided consent were included in the study, while those who had been diagnosed with any precancerous or malignant lesion of the cervix or other reproductive organs and those who did not give informed written assent or consent for the study were excluded. Sample size and sampling technique: The sample size (n) was calculated by applying Cochran’s formula, which is: n= Z2 p(1-p)]/d2. Assuming p (prevalence of being aware of cervical cancer) = 20% [7], Z = 95% Confidence Interval (CI), d (absolute precision) = 5%, and after applying a 10% non-response rate, the final sample size obtained was 215. Consecutive sampling technique was employed to achieve the calculated sample size. Study tools and study technique: A predesigned, pretested and semi-structured schedule was employed to obtain data from the study participants. It contained a mixture of open-ended and semi-open, single and multiple-response questions and was developed in English language. Questionaire contained domains of sociodemographic characteristics, awareness regrading cervical cancer, behavioral risk factors and preventive practices. The schedule was validated for its content by two faculties from the Departments of Community Medicine and one faculty from Department of Obstetrics and Gynaecology of the institution and necessary changes were incorporated before pretesting it. The schedule was translated into local languages (Bengali and Hindi) by respective language experts (one for each language), and then retranslated back to ensure validity. Pretesting of the schedule was done on 20 reproductive age group women residing in the study setting, who were not included in the final sample. House-to-house visits were done during the data collection period and data were collected by face-to-face interviews and by review of records from all the eligible participants present in the household. The study participants were considered ‘aware’ of the risk factors, along with the signs and symptoms of cervical cancer only if they could correctly answer at least two out of all the questions asked in each domain. The participants were considered aware of the screening methods for cervical cancer only if they could correctly answer at least one out of all the questions asked regarding the same. Statistical analysis: Data were tabulated in Microsoft Office Excel 2021 and analyzed using Statistical Package for the Social Sciences (SPSS) version 25.0. Armonk, NY: IBM Corp. 2017. Categorical data were represented using mean (± SD) and frequency (percentage). Multivariable binary logistic regression analysis was performed to identify any associations between the sociodemographic characteristics of the study subjects with their awareness of cervical cancer. All the variables having a p-value < 0.2 in the univariate logistic regression were considered biologically plausible and included in the multivariable model to check for model fitness, after checking for multi-co-linearity (variance inflation factor > 10 and tolerance <0.1). A p-value of <0.05 at 95% Confidence Interval (CI) was taken as statistically significant. Ethical considerations:The study was approved by the Institutional Ethics Committee (IEC) of IPGME&R and SSKM Hospital, Kolkata (IPGME&R/IEC/2023/440). Informed written consent and assent were obtained from the study participants. Anonymity and confidentiality of the data were maintained throughout the study period.   Results A total of 215 participants were enrolled in the study. Almost half of the participants (49.7%) belonged to the age 20-30 years with the mean age being 25.2 (±6.7) years. Most of the participants (95.3%) followed Hinduism, 62.8% were married, 82.8% were either students or housewives and 53% belonged to ‘Upper-lower’ (Class IV) socioeconomic status according to the Modified B.G. Prasad Socioeconomic Status scale, updated in 2022 [8]. Nearly 18% had attained menarche below 12 years of age and 84.2% of respondents had history of cancer in the family, out of which 2 (0.9%) had a history of cervical cancer. Detail sociodemographic characterstics of the study particiant is shown in Table-1.   Table-1: Distribution of study participants according to their sociodemographic characteristics (n= 215)     Distribution of study participants according to their behavioral risk factors for cervical cancer is shown in Table-2. The age at marriage was < 16 completed years in 11.1% of the respondents and 138 (64.2%) participants had history of sexual intercourse, out of which only 22.3% preferred barrier methods (condoms) during intercourse. Only 4 (1.8%) of the study subjects had multiple sex partners. Nearly 35% of the participants reported white discharge per vagina, however, among them, 27.4% underwent treatment for the condition. Of the total participants, 91.2% used sanitary napkins during menstruation, but only 22.4% would change the napkin within 6 hours of using it. Among those who used clothes during menstruation, 84.2% would reuse them. Though almost all except 1 respondent cleaned their intimate areas during bathing, 18.6% did not clean their intimate areas after intercourse.   Table-2: Distribution of study participants according to their behavioral risk factors for cervical cancer     A majority (164/76.3%) of the participants had not heard about cervical cancer at all. Among those who had heard (51/23.7%), the most commonly reported source of information was friends and relatives (8.8%) [Figure-1].     Figure-1: Level of awareness regarding cervical cancer among the study participants (n=215)   Out of 51 participants who were aware of the cervical cancer, only 5 (9.8%) and 9 (17.6%) of the them could correctly identify the risk factors and signs and symptoms of cervical cancer respectively. Only 2 (3.9%) had heard about the screening methods for early detection of cervical cancer, while only 11 (21.5%) could correctly respond about any vaccine for the prevention of cervical cancer (Table-3).   Table-3: Level of awareness of the study participants regarding cervical cancer (n=51)     Among those who could correctly identify the risk factors, the most commonly identified risk factor was unhygienic practices, while among those who could correctly identify the signs and symptoms of cervical cancer, lower abdominal pain was the most commonly recognized symptom, followed by smelly white vaginal discharge and heavy menstrual bleeding. Only 2 (0.9%) participants had been screened for cervical cancer, but none had received the HPV vaccine. Table-4 shows multivariable binary logistic regression of awareness of study participants regarding cervical cancer on sociodemographic characteristics. Participants of age group 20-30 years (aOR 0.82, 95% CI 0.30-2.23; p = 0.007), married (aOR 0.24, 95% CI 0.01-3.18; p = 0.021) and those with a family history of any cancer (aOR 0.31, 95% CI 0.13-0.78; p = 0.012), had statistically significant lower odds of being unaware of cervical cancer, as compared to participants of other age-groups, those who were unmarried/divorced and those without a family history of any cancer respectively.   Table-4: Multivariable binary logistic regression showing the association of sociodemographic characteristics of study participants with their awareness of cervical cancer (n=215)     Discussion The present study investigated the sociodemographic and behavioral risk factors for cervical cancer, its awareness, and preventive practices among reproductive age-group women in a slum of Kolkata. The current study found only 23% had awareness of cervical cancer. On the contrary, a study conducted by Saha A et. al in Kolkata [9], among the elite medical colleges of the city, reported level of awareness as 43% about cervical cancer. This contrast in level of awareness could be due to lack of effective health education and communication and awareness programs and implementation of policies for generating awareness in poor resource settings like slum areas regarding cervical cancer. A study was conducted by Bevilacqua KG et al in Guatemala [10], wherein 80% of women had reported having ever been screened for cervical cancer. On the other hand, the present study revealed that none of the study participants had been screened for cervical cancer. In both the studies, poor personal hygiene or a lack of personal care was identified as the most common risk factor for cervical cancer. The findings points towards the absence of effective screening and vaccination programmes in the study area, along with lack of proper health education campaigns and programmes by the healthcare workers in creating awareness on the importance of maintaining personal hygiene in preventing cervical cancer in the community. In the current study, the participants responded that no screening services for cervical cancer were available in their nearby healthcare facilities. Whereas in a study conducted by Kaur S et al  [11] in India, nearly half of the participants agreed that there were screening facilities in the nearby healthcare centers. This sheds light into the unavailability of adequate screening, diagnostic and treatment services in the nearby healthcare facility in the current study area, which also exposes the disparities in healthcare access in relation to cervical cancer across the country. In a study done by Blödt et al in Berlin [12], which included both men and women belonging to the 18-25 years age group, 51% of women and 42% of men thought that only women could be infected with HPV and the majority did not know that HPV is sexually transmitted. In the same study, 40% of women had been vaccinated with the HPV vaccine. Also, in the multivariable analyses in the study, education, and past sexual intercourse remained borderline significant predictors of vaccine uptake. This is in contrast to the current study, which recruited only reproductive age group women, where the majority were unaware of cervical cancer, including its risk factors, causes, signs, symptoms, and none of them had received the HPV vaccine. Multivariable analyses in the current study revealed that the age of respondents, marital status and family history of cancer had statistically significant associations with their awareness of cervical cancer. The unvaccinated status of women in the present study highlights the need for developing adequate screening and vaccination facilities in the nearby healthcare centres. The current study revealed that majority of respondents were unaware of cervical cancer, and 21.5% could correctly respond about any vaccine for preventing cervical cancer. This is similar to a study conducted by Rančić et al [13] among female students from Serbia, where the awareness about HPV and the HPV vaccine was low, i.e., only 14.2% of the students had heard about both HPV and its vaccine. In the same study, the most commonly reported source of information regarding cervical cancer was social media, whereas, in the current study, the most common source of information regarding cervical cancer was friends and relatives. According to a study conducted by Khanna in Varanasi, India [14] where all study subjects belonged to the rural areas, the majority knew about cervical cancer as a type of cancer in women. Very few of them could name any screening method or a vaccine that could prevent cervical cancer. The major source of information on cervical cancer was family and friends. In the current study, which recruited women residing in a slum in Kolkata, with majority being unaware of cervical cancer and very few study subjects could name any screening method or vaccine for prevention of cervical cancer. In this study, the major source of information on cervical cancer was friends and relatives. This difference in knowledge on cervical cancer could be due to lack of adequate and uniform health education programmes and campaigns on cervical cancer across the country. A systematic review by Taneja et al [15] in 2021 revealed overall knowledge on cervical cancer among Indian women as 40.2%. In the present study, 76.3% of the participants did not hear about cervical cancer at all. A study in Nigeria by Olubodun et al [16] among women residing in urban slums, reported low level of knowledge about cervical cancer,  its screening and HPV immunization. The finding is similar to our study, which was also conducted among reproductive age group women in an urban slum, where majority lacked knowledge of cervical cancer, its screening and vaccination services. This highlights the need for increased mass campaigns in the community for promoting awareness about cervical cancer and its causes, risk factors and the importance of preventive measures. Public education campaigns can help dispel myths and misconceptions surrounding the disease and encourage women in low and middle income countries like India, to seek screening and vaccination services. A study conducted by Jones et al [17] in India, revealed 14.22% of respondents in the overall group and 14.39% in the priority screening group, reported receiving a prior cancer screening. Among women who had not received cancer screening, the most common reasons were "no provider recommendation" (42.18%) and not knowing they needed to be screened (40.76%). Another study conducted by Nilima et al [18] in India in 2022, revealed that older women had 1.16 times the odds of getting screened for cervical cancer as compared to their younger counterpart. The odds of cervical cancer screening among the women in richest wealth quintile was 2.5 times compared to the poorest. Those who are aware of STDs (Sexually Transmitted Diseases) have 1.39 times the odds of getting screened for cervical cancer. Wealth index, years of schooling, and religion have a substantial indirect and total impact on the screening. The present study reported that 76.3% of the participants had not heard about cervical cancer at all. Very few participants had been screened for cervical cancer but none of them had received the HPV vaccine. This focusses the need to implement policies regarding adequate diagnostic and treatment modalities to reduce the burden of cervical cancer among women in the low and middle-income countries like India. Present study had some limitations. The current study was conducted in only one slum area of Kolkata, hence it might not represent the overall awareness level of cervical cancer or behavioral risk factors and preventive practices of all the reproductive age group women, particularly those residing in the rural areas. Also, the study relied upon self-reported data, which might be subjected to social desirability bias. Overall, the study revealed that most of the women living in slum were unaware of cervical cancer, its risk factors, signs and symptoms. The findings from this study highlight the need for increased mass campaigns in the under privileged community for promoting awareness about the causes, risk factors and preventive practices of cervical cancer. Screening and vaccination facilities for cervical cancer should be made available at the health centers.   Authors contributions SD: Literature review, concept and study design, critically revising the article for important intellectual content, data analysis, interpretation, and manuscript preparation; SP: Literature review, concept and study design, submission for ethical approval, data collection, data analysis and interpretation, manuscript preparation; AA: Literature review, concept and study design, data analysis and interpretation, critically revising the manuscript; MB: Concept and design of study, statistical analysis and interpretation, critically revising the manuscript.   Conflicts of interest There are no conflicts of interest.   Fund Nil.   References 1.     Global Cancer Observatory: Cancer Today. Lyon, France: International Agency for Research on Cancer. 2020. Available from: https://gco.iarc.fr/today. 2.     Singh M, Jha RP, Shri N, Bhattacharyya K, Patel P, Dhamnetiya D. Secular trends in incidence and mortality of cervical cancer in India and its states, 1990-2019: data from the Global Burden of Disease 2019 Study. BMC Cancer. 2022; 22(1): 149. doi:10.1186/s12885-022-09232-w. 3.     Ramamoorthy T, Kulothungan V, Sathishkumar K, Tomy N, Mohan R, Balan S, Mathur P. Burden of cervical cancer in India: estimates of years of life lost, years lived with disability and disability adjusted life years at national and subnational levels using the National Cancer Registry Programme data. Reprod Health. 2024 Jul 29; 21(1): 111. doi: 10.1186/s12978-024-01837-7. 4.     Moukam AMD, Owono MSE, Kenfack B, Vassilakos P, Petignat P, SormaniJ,et al. "Cervical cancer screening: awareness is not enough". Understanding barriers to screening among women in West Cameroon-a qualitative study using focus groups. Reprod Health. 2021; 18(1): 147. doi:10.1186/s12978-021-01186-9. 5.     Enebe JT, Enebe NO, Agunwa CC, Nduagubam OC, Okafor II, Aniwada EC, et al.Awareness, acceptability and uptake of cervical cancer vaccination services among female secondary school teachers in Enugu, Nigeria: a cross-sectional study. Pan Afr Med J. 2021; 39: 62. doi:10.11604/pamj.2021.39.62.28824. 6.     Reproductive age group for women. Definition of reproductive age by Medical Dictionary-The Free Dictionary. Available from: https://medical-dictionary.thefreedictionary.com/ [Accessed on March 2023]. 7.     Kumar MS, Shanmugapriya PC, Kaur P. Acceptance of cervical and breast cancer screening and cancer awareness among women in Villupuram, Tamil Nadu, India: A cross sectional survey. Clin Epidemiol Glob Health. 2015; 3(1): 63-68. doi: 10.1016/j.cegh.2015.10.007. 8.     Pentapati SSK, Debnath DJ. Updated BG Prasad's classification for the year 2022. J Family Med Prim Care. 2023; 12(1): 189-190. doi:10.4103/jfmpc.jfmpc_1478_22. 9.     Saha A, Chaudhury AN, Bhowmik P, Chatterjee R. Awareness of cervical cancer among female students of premier colleges in Kolkata, India. Asian Pac J Cancer Prev. 2010; 11(4): 1085-1090. 10.  Bevilacqua KG, Gottschlich A, Murchland AR, Alvarez CS, Rivera-Andrade A, Meza R. Cervical cancer knowledge and barriers and facilitators to screening among women in two rural communities in Guatemala: a qualitative study. BMC Womens Health. 2022; 22(1): 197. doi:10.1186/s12905-022-01778-y. 11.  Kaur S, Sharma LM, Mishra V, Goyal MGB, Swasti S, Talele A, et al. Challenges in cervical cancer prevention: real-world scenario in India. South Asian J Cancer. 2023; 12(1): 9-16. doi:10.1055/s-0043-1764222. 12.  Blödt S, Holmberg C, Müller-Nordhorn J, Rieckmann N. Human Papillomavirus awareness, knowledge and vaccine acceptance: a survey among 18-25 year old male and female vocational school students in Berlin, Germany. Eur J Public Health. 2012; 22(6): 808-813. doi:10.1093/eurpub/ckr188. 13.  Rančić NK, Golubović MB, Ilić MV, Ignjatović AS, Živadinović RM, Đenić SN, et al.Knowledge about cervical cancer and awareness of Human Papillomavirus (HPV) and HPV vaccine among female students from Serbia. Medicina (Kaunas). 2020; 56(8): 406. doi:10.3390/medicina56080406. 14.  Khanna D. Evaluating knowledge regarding cervical cancer and its screening among woman in rural India. South Asian J Cancer. 2020; 9(3): 141-146. doi:10.1055/s-0041-1723072. 15.  Taneja N, Chawla B, Awasthi AA, Shrivastav KD, Jaggi VK, Janardhanan R. Knowledge, attitude, and practice on cervical cancer and screening among women in India: a review. Cancer Control. 2021; 28: 10732748211010799. doi:10.1177/10732748211010799. 16.  Olubodun T, Odukoya OO, Balogun MR. Knowledge, attitude and practice of cervical cancer prevention, among women residing in an urban slum in Lagos, South West, Nigeria. Pan Afr Med J. 2019; 32: 130. doi:10.11604/pamj.2019.32.130.14432. 17.  Jones M, Subramanian S, Jose R. Cancer screening behaviors and preferences among women in southern India. J Cancer Policy. 2023; 35: 100401. doi:10.1016/j.jcpo.2023.100401. 18.  Nilima N, Mani K, Kaushik S, Rai SN. Cervical cancer screening and associated barriers among women in India: a generalized structural equation modeling approach. Cancers (Basel). 2022; 14(13): 3076. doi:10.3390/cancers14133076.     Cite this article as: Dutta S, Pattanayak S, Ahamed A, Basu M. Sociodemographic and behavioral risk factors for cervical cancer, its awareness and preventive practices among reproductive age group women in a slum area of Kolkata. IMC J Med Sci. 2025; 19(1): 006. DOI:https://doi.org/10.55010/imcjms.19.006 <![CDATA[Pattern of ocular morbidity in a rural community in India]]> Mohd Yasir Zubair Ragul Jayaprakasam Sathiyamoorthy Tabassum Nawab Uzma Eram Saira Mehnaz https://imcjms.com/journal_full_text/553 2024-12-09 11:23:00 Original Article January 2025; Vol. 19(1):005 Abstract Background and objectives: Many conditions can affect eye health, and even those that do not cause vision impairment can produce pronounced morbidity. In this study, we have investigated the pattern of eye diseases at an eye out patient department (OPD) in a rural set up. Materials and methods: Eye OPD runs fortnightly at Rural Health Training Centre of Department of Community Medicine, JNMCH, AMU, Aligarh, India. Record from clinic register and patient files from the year 2016 to 2022 was accessed. Data was entered in SPSS version 20.0 software and analysed. Results: A total of 694 patients were enrolled in the study. Common ocular morbidities were refractive error (29.5%), presbyopia (21.6%), cataract (16.9%), pterygium (10.2%), conjunctivitis (8.9%) and corneal conditions (4.3%). Prevalence of refractive error was almost same in both male (30.6%) and female (33.1%). Presbyopia was significantly (p<0.05) higher in female (27.2%) compared to male (18.4%) patients while conjunctivitis was significantly (p<0.05) higher among males (15.3% vs. 6.1%). Refractive error and conjunctivitis were significantly (p<0.01) higher among patients aged less than 40 years while presbyopia, cataract and corneal conditions were significantly (p<0.05) higher among patients aged 40 years and above. Conclusion: A good proportion of patients with unoperated cataract reflect lack of accessible and affordable cataract operation services in rural areas. Findings of the study could be used to strengthen eye care services in rural areas. January 2025; Vol. 19(1):005.  DOI:https://doi.org/10.55010/imcjms.19.005 *Correspondence: Ragul Jayaprakasam Sathiyamoorthy, Department of Community Medicine, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh,  India. Email: ragulwaves@gmail.com; © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0).   Introduction The clinical as well as epidemiological profile of eye conditions varies in different parts of the world and is influenced by various factors like geographical, climatic, ethnic, socioeconomic and cultural factors [1]. The term ocular morbidity includes conditions both visual impairment and nonvisual ocular pathology [2]. World Health Organization (WHO) in its report in August, 2023 published that globally at least 2.2 billion people have a distance or near vision impairment. In at least almost in half of these cases, vision loss could have been prevented or has not been addressed yet [3]. Among these one billion people, the major morbidity causing distance visual impairment is cataract which is followed by refractive error, age-related macular degeneration (ARMD), glaucoma, and diabetic retinopathy [4]. The main condition leading to near vision impairment is presbyopia [5]. Ninety percent of the visually impaired population lives in low and middle-income countries (LMICs) such as India. India’s National Program for Prevention and Control of Blindness and Visual Impairment (NPCBVI) has been highly successful in reducing the prevalence of blindness from 1.4% in 1976 to 0.36% in 2019 in all age groups. However, urban-rural disparity exists with blindness (in people aged >50 years) being more common in rural areas compared to urban areas (2.14% vs. 1.80%) [6]. The ocular morbidities result in a decreased ability to perform activities of daily life, and should be investigated accordingly. In this study, we investigated the epidemiological profile and ocular morbid conditions (including nonvisual conditions) of patients attending eye clinic in a rural area. The findings of this study would help us understand pattern of ocular problems in rural set up which in turn shall be useful in effective planning and delivery of eye care services.   Material and methods The study was conducted on patients attending the eye clinic at Rural Health Training (RHTC) Centre of Jawaharlal Nehru Medical College located in Jawan block of Aligarh district, UP, India. The RHTC covers registered population of 6 villages namely Jawan, Sumera, Garhiya Bhojpur, Chhota Jawan, Jawan Sikandarpur and Tejpur. Eye clinics run outpatient departments (OPD) fortnightly at the centres. Secondary data was accessed and collected from clinic registers and patient files from the year 2016 to 2022. Data on patient included age, gender, clinical history and diagnosis. Meticulous extraction of information was done by a team of two members including an ophthalmologist. Data was entered in IBM SPSS version 20.0 software and appropriate statistical tests were applied to analyze the data.   Results A total of 1222 new patients presented at the eye out patient department (OPD) during the study period. Out of 1222 OPD patients, 694 (56.8%) were enrolled in this study. Prevalence of ocular diseases among the 694 patients is shown in Figure-1. Common ocular morbidities were refractive error (203, 29.5%), presbyopia (150, 21.6%), cataract (117, 16.9%), pterygium (71, 10.2%), conjunctivitis (62, 8.9%) and corneal conditions (30, 4.3%). These conditions altogether accounted for 633 (91.2%) patients. Remaining 61 cases (8.8%) had glaucoma, strabismus, lid pathologies and diabetic retinopathy. Of the total 62 conjunctivitis patients, 36 (58.06%) had allergic conjunctivitis and most of them presented during spring and summer months. Distribution of ocular morbidities among 633 cases according to gender is shown in Table-1. Refractive error was common in both male (30.6%) and female (33.1%). Presbyopia was significantly (p<0.05) higher in female (27.2%) compared to male (18.4%) patients while conjunctivitis was significantly (p<0.05) higher among males (15.3% vs. 6.1%). Table-2 shows the distribution of ocular morbidities in patients below and above 40 years of age. Refractive error (52.2%) and conjunctivitis (20.4%) were significantly (p<0.01) higher among people aged less than 40 years while presbyopia (29.7%), cataract (28%) and corneal conditions were significantly (p<0.05) higher among people aged 40 years and above.       Figure-1: Pattern of ocular morbidities in study population   Table-1: Ocular morbidities according to gender (n=633)     Table-2: Pattern of ocular morbidities in study patients below and above 40 years of age (n=633)     Discussion Our study had higher female patients compared to males. Studies from India and other countries also had similar observation [7-9]. In our study, majority of patients were aged above 40 years. This could be due the fact that presbyopia (near vision difficulty) and cataract were common ocular morbidity that begin over 40 years of age [10,11]. With regards to ocular morbidity pattern in our study, refractive error was the commonest, followed by presbyopia, cataract, pterygium and conjunctivitis. Similar pattern was reported in study from Nepal by Rizyal et al [12] and in northern India by Haq et al [13]. However, a higher prevalence of cataract (41.89%) was reported in a study from rural Allahabad, UP, India [14]. India’s National Program for Prevention and Control of Blindness and Visual Impairment (NPCBVI) has been instrumental in reducing the backlog of blindness due to cataract but continued presence of cataract blindness in rural areas highlights the need for continued efforts to reach out to the rural population and make surgical intervention feasible and accessible to them. Among the patients with refractive error in our study, 52.2% were aged less than 40 years. This is expected because myopia accounts for majority of refractive errors in this age group which starts in childhood and usually progresses till around 20 years of age [15]. A high proportion of refractive error highlights the need for further strengthening the school vision screening program and distribution of corrective glasses. In our study presbyopia accounted for 21.6% of the disease burden which is similar to reports by Kimani et al [16] and Courtright et al [15]. Of the total patients with presbyopia, 27.2% were females and only 18.4% were males. Rural females are often concerned about near vision because they do fine vision activities at home such as knitting and sewing. In our study, non-visual ocular pathologies towards ocular morbidities mainly conjunctivitis and pterygium was around 10%. These conditions need healthy practices with regards to ocular health for their prevention and control and thus provision for health education and behaviour change communication should be included in national programs [17-19]. In this study we have documented pattern of ocular morbidities from an eye clinic in a rural area. A high proportion of cataract patients in the OPD might reflect lack of affordable and accessible operation services in rural areas. Thus, there is need for further scale up of operative services to cover the yet unreached rural population. Similarly, higher prevalence of refractive errors and presbyopia underscores the need for strengthening vision screening services and provision of providing corrective glasses. Therefore, findings from the study could be utilised to plan improved eye care services in usually underserved rural areas leading to improvement in eye health of rural residents.   Conflicting Interest None   Fund Nil   References 1.     Ukponmwan CU. Pattern of ocular morbidity in Nigeria. Asian Pac J Trop Dis. 2013; 3(2): 164-166. doi:10.1016/S2222-1808(13)60064-X. 2.     Senyonjo L, Lindfield R, Mahmoud A, Kimani K, Sanda S, Schmidt E. Ocular morbidity and health seeking behaviour in Kwara state, Nigeria: implications for delivery of eye care services [published correction appears in PLoS One. 2014; 9(10): e112860]. PLoS One. 2014; 9(8): e104128. doi: 10.1371/journal.pone.0104128. 3.     WHO factsheet. Blindness and vision impairment. August 2023.Available from: Blindness and vision impairment (who.int); [Accessed on 5th April, 2024]. 4.     GBD 2019 Blindness and Vision Impairment Collaborators; Vision Loss Expert Group of the Global Burden of Disease Study. Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: the Right to Sight: an analysis for the Global Burden of Disease Study. Lancet Glob Health. 2021 Feb; 9(2): e144-e160. doi: 10.1016/S2214-109X(20)30489-7. Epub 2020 Dec 1. Erratum in: Lancet Glob Health. 2021 Apr; 9(4): e408. doi: 10.1016/S2214-109X(21)00050-4. 5.     Fricke TR, Tahhan N, Resnikoff S, Papas E, Burnett A, Ho SM, et al. Global prevalence of presbyopia and vision impairment from uncorrected presbyopia: systematic review, meta-analysis, and modelling. Ophthalmology. 2018; 125(10): 1492-1499. doi: 10.1016/j.ophtha.2018.04.013. 6.     MoHFW. The National Blindness and Visual Impairment Survey India 2015-2019 - A Summary report. Available from: File341.pdf (mohfw.gov.in) [Accessed on 10th April 2024]. 7.     Baldev VF, Chopra R, Batra N, Singh S. pattern of ocular morbidity in the elderly population of Northern India. J Clin Diagn Res. 2017; 11(8): NC20-NC23. doi:10.7860/JCDR/2017/27056.10496. 8.     Mehari ZA. A study of ocular morbidity of patients attending ophthalmic outreach services in rural Ethiopia. Int J Med Med Sci. 2013; 3(4): 450–454. 9.     Adegbehingbe BO, Majengbasan TO. Ocular health status of rural dwellers in south-western Nigeria. Aust J Rural Health. 2007; 15(4): 269-272. doi:10.1111/j.1440-1584.2007.00906.x. 10.  AAO. What is Presbyopia. 2022. Available from What Is Presbyopia? - American Academy of Ophthalmology (aao.org) [Accessed on 12th April 2024]. 11.  Nizami AA, Gurnani B, Gulani AC. Cataract. In: StatPearls. Treasure Island (FL): StatPearls Publishing; February 27, 2024. 12.  Rizyal A, Shakya S, Shrestha RK, Shrestha S. A study of ocular morbidity of patients attending a satellite clinic in Bhaktapur, Nepal. Nepal Med Coll J. 2010; 12(2): 87-89. 13.  Haq I, Khan Z, Khalique N, Amir A, Jilani FA, Zaidi M. Prevalence of common ocular morbidities in adult population of Aligarh. Indian J Community Med. 2009; 34(3): 195-201. doi:10.4103/0970-0218.55283. 14.  Singh A, Dwivedi S, Dabral SB, Bihari V, Rastogi AK, Kumar D. Ocular morbidity in the rural areas of Allahabad, India. Nepal J Ophthalmol. 2012; 4(1): 49-53. doi:10.3126/nepjoph.v4i1.5850. 15.  Courtright P, Hutchinson AK, Lewallen S. Visual impairment in children in middle- and lower-income countries. Arch Dis Child. 2011; 96(12): 1129-1134. doi:10.1136/archdischild-2011-300093. 16.  Kimani K, Lindfield R, Senyonjo L, Mwaniki A, Schmidt E. Prevalence and causes of ocular morbidity in Mbeere District, Kenya. Results of a population-based survey. PLoS One. 2013; 8(8): e70009. doi: 10.1371/journal.pone.0070009. 17.  Sacchetti M, Abicca I, Bruscolini A, Cavaliere C, Nebbioso M, Lambiase A. Allergic conjunctivitis: current concepts on pathogenesis and management. J Biol Regul Homeost Agents. 2018; 32(1 Suppl. 1): 49-60. 18.  QShaker M, Salcone E. An update on ocular allergy. Curr Opin Allergy Clin Immunol. 2016; 16(5): 505-510. doi:10.1097/ACI.0000000000000299. 19.  Sgrulletta R, Bonini S, Lambiase A, Bonini S. Allergy and infections: long-term improvement of vernal keratoconjunctivitis following viral conjunctivitis. Eur J Ophthalmol. 2006; 16(3): 470-473. doi:10.1177/112067210601600319.     Cite this article as:Zubair MY, Sathiyamoorthy RJ, Nawab T, Eram U, Mehnaz S. Pattern of ocular morbidity in a rural community in India. IMC J Med Sci. 2025; 19(1): 005. DOI:https://doi.org/10.55010/imcjms.19.005 <![CDATA[Women's satisfaction towards comprehensive abortion care and its determinants in Mekelle Health facilities, Tigray region, Northern Ethiopia: a mixed research approach]]> Kibrey Hadush Mussie Alemayehu Shishay Wahdey Dejene Ermias Sisay Moges https://imcjms.com/journal_full_text/552 2024-12-05 13:02:30 Original Article January 2025; Vol. 19(1):004 Abstract Background and objectives: Every year, it is estimated that half a million pregnancies in Ethiopia terminate in abortion. In Ethiopia, unsafe abortion is one of the leading causes of maternal death. Improving the quality of health care is one of the transformative agendas of Ethiopia's Health Sectoral Transformation Plan. Therefore, the main aim of this study was to assess women's satisfaction with comprehensive abortion care and its determinants in Mekelle health facilities, Tigray Region. Ethiopia. Materials and Methods: A facility-based cross-sectional study with a mixed research strategy was conducted. Women who receive abortion care at three health facilities in Mekelle constituted the study participants. The study participants were chosen using a systematic random sampling procedure with proportionate allocation. Data was collected through client exit interviews with mothers. A multiple linear regression model was used to investigate the determinants of client satisfaction. Result: A total of 317 mothers were enrolled in the study. Out of the 317 respondents, 168 (53%) were aged 20 to 24 years, with a mean age of 24.4± 4.9 years. The total mean score of client satisfaction with post-abortion care was 2.35 ± 0.24, and 273 (86.1%) of respondents were happy with the service provided by the health facilities. Based on multiple linear regression, a stronger art of care and respect resulted in a 70.8% increase in customer satisfaction. Additionally, the physical environment's safety would increase pleasure by 12.5%. Providing information about the procedure increased consumer satisfaction by 57.1%. An increase in service quality would increase client satisfaction by 84.1%. Conclusion: A safe environment, good art of care and respect, providing adequate information to the client, and better-quality care would improve client satisfaction.January 2025; Vol. 19(1):004. DOI: https://doi.org/10.55010/imcjms.19.004 *Correspondence: Sisay Moges, Department of Family Health, Hossana College of Health Sciences, Hossana, Ethiopia. Email: Sisaymoges55@gmail.com; © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License(CC BY 4.0).   Introduction About 99% of all abortions carried out in Africa are unsafe, and the risk of maternal death from an unsafe abortion is one in every 150 procedures, which is the highest in the world [1-4]. Ethiopia is one of the developing countries with the highest mortality rate, where unsafe abortion accounts for 32% of all maternal deaths [5]. According to the Health Sector Transformation Plan (HSTP), about half a million pregnancies are estimated to be aborted each year in Ethiopia, and an estimated 620,300 abortions were performed in 2014 [6]. The majority of abortions (66%) were performed by NGOs, while most post-abortion care (72%) was provided by public hospitals and health centers (7). The availability of comprehensive abortion care (CAC) services at all levels of the healthcare system, including medical abortion, has the potential to increase access to safe abortion, thereby reducing the burden of unsafe abortion. To reduce the morbidity and mortality due to unsafe abortion, Venture Strategies Innovations, the Bixby Center for Population, Health, and Sustainability at the University of California, Berkeley, and the Tigray Regional Health Bureau in Northern Ethiopia collaborated to initiate a pilot project to increase the access to comprehensive abortion care services. CAC services include standard pre and post procedure abortion care. Post-procedure care includes follow-up, provision of post-abortion family planning (PAFP), counseling on danger signs, sexually transmitted diseases (STD), and giving appointments [8-10]. However, Ethiopia has made major progress in making safe abortion accessible for many women, but many Ethiopian women continue to have abortions outside of health facilities, often under unsafe conditions [7]. Studies in Ethiopia revealed that approximately one-fourth of the clients of abortion services were not satisfied with the service. Studies on the quality of post-abortion care in Tigray show that 59.5% of clients are dissatisfied with the services [11-13]. Assuring client satisfaction during safe abortion care can decrease unsafe abortion because a satisfied client is a source of good information for others. Therefore, this study aimed to assess women satisfaction and its determinants towards comprehensive abortion services in Mekelle health facilities in north Ethiopia.   Methods and Materials Study setting, design, and participants: In this study, a mixed-methods approach in a convergent design was used in Mekelle health facilities. A mixed research method was used, and data were collected and analyzed concurrently but separately, then the results from the two data sources were merged and integrated. Study participants comprised of women who receive abortion care at health facilities in Mekelle Facilities were Mekelle Hospital, Family Guidance Association of Ethiopia (FGAE), and Marie Stopes International Ethiopia (MSIE) clinics. Sample size determination: The sample size for quantitative data was estimated using Epi-Info 7, considering the proportion of client satisfaction with post-abortion care in Ethiopia as 75% [11]. Besides, a 5% marginal error and a 95% confidence interval were used. Adding a 10% non-response rate, the maximum sample size required was 317. For qualitative data, a total of 50 procedures were observed proportionally in the selected health institution. For the quantitative data, systematic random sampling was used. Thus, one general hospital (Mekelle Hospital) and two NGOs' clinics (FGAE and MSIE) were selected for the study. Study participants were selected using proportional allocation to the size of client flow in each health facility (Figure-1).     Figure-1: Schematic presentation of the proportional allocation of study participants from three health facilities in Mekelle, 2020.   Data collection tools and procedure: Before actual data collection, the data collection tool (checklist) was pre-tested at Ayder Specialized Hospital on 5% of the total participants. The exit interview data collection method was used to minimize the bias introduced during data collection. And quantitative data were collected using a pretested questionnaire adapted and developed after reviewing different literature by bachelor nurses who were previously trained in abortion care. We used a checklist that was developed by the Federal Ministry of Health Services Quality Directorate for the assessment of client satisfaction, adapted and modified considering other tools developed by the 3-point Likert Scale, which ranges between 1 and 3 on the scale (1 = agree, 2 = neutral, 3 = disagree). The scores for each domain were calculated by summing the answers to all items in each domain and the clients' overall and component-wise satisfaction. Therefore, each client`s satisfaction score was measured out of 57. International Pregnancy Advisory Services (IPAS) tool and equipment and supply checklist adopted from Ethiopian abortion guidelines were used for observation. The observation, equipment availability assessment, and observation of procedures were conducted during the procedure of the service that was done by three health professionals who had TOT certification for comprehensive abortion care. Data processing and data analysis: Quantitative data were analyzed using SPSS version 25. The characteristics of study participants were summarized using descriptive statistics. Multiple linear regression was conducted to assess the predictors of client satisfaction and adjust for confounders. Statistical significance was determined using less than 5% of the level of significance with a 95% CI. Quantitative data analysis was done using thematic analysis. The qualitative finding was used for triangulation with the result of the quantitative data, explaining whether it was similar or contradicting.   Results Socio-demographic characteristics of the respondents Out of the 317 respondents, 168 (53%) were aged 20 to 24 years, with a mean age of 24.4 ± 4.9 years. The mean age of the participants for their first pregnancy was 21.85 ± 2.89 years, and the mean income was ETB 2971.43 ± 1775 ETB. Majority (62.5%) were single, and 198 (25.2%) were students. Nearly all (98.7%) clients were from Tigray, and nearly half (46.1%) of the study participants were orthodox religious followers, and nearly half (46.1%) had completed secondary school or above (Table-1).   Table-1: Socio-demographic characteristics of clients in health facilities of Mekelle, 2020 (n=317).     Reproductive history The majority of the clients were primigravida (242; 76%), and only 75 (23.8%) had at least one child. Of most clients, 66% were in the age category of 20–24 years during their first pregnancy. The commonest reasons listed for termination were incest (44%), followed by rape (34%). Around 92% of the pregnancies were terminated during the first trimester; 251 (85%) were safe abortions, and 77% utilized medical abortion (MA). The mean number of abortions was 1.8 ± 0.48 (Table-2).   Table-2: Reproductive history of clients in health facilities of Mekelle, 2020 (n=317).     Dimensions of client satisfaction Client satisfaction was measured using five factors: the art of care, the physical environment, information,privacy and confidentiality, and quality of care. Each dimension was evaluated using a distinct indication with a Likert-scaled score ranging from not satisfied (score=1) to satisfied (score=3). The art of caring was made up of five components, with mean scores ranging from 2.52 to 2.75. Items in this component stressed the relevance of the provider's interpersonal approach to women's satisfaction with care. The physical environment has five components, with mean values ranging from 2.51 to 2.64. This dimension's items concentrate on satisfaction with the physical environment in which care is administered. This component's items characterized the physical environment as having overall niceness, comfort, attractiveness, and conformability with the procedure and waiting room, as well as the cleanliness of facilities and equipment. This component's overall mean score was 2.62 ± 0.42. The information component has five items with mean scores ranging from 1.55 to 2.56. This component included statements concerning the type of information provided about treatment, such as follow-up care and post-abortion services. It also represents the need to make things easier for women by providing the necessary information about the operation. Post-abortion counselling received a minimum mean score of 2.21±0.42. The privacy and confidentiality section had four items, with a mean score ranging from 2.32 to 2.54. Those questions, with an overall mean score of 2.45±0.41, reflected how a woman's privacy was protected while she was being counselled and treated. The four components that composed the quality of care had a perceived mean score ranging from 2.01 to 2.76. This component, which included addressing the availability of suitable medical devices and supplies, examined women's impressions of service providers' competence and adherence to high diagnostic and treatment standards. The availability of equipment and materials had the lowest mean score (2.01), while the component's total mean score was 2.1 (Table-3).   Table-3: Dimensions of client satisfaction in health facilities of Mekelle, 2020.     Client satisfaction The total mean score of client satisfaction with post-abortion service was 2.35 ±0.24 out of 3.0, and 273 (86.1%) of the respondents were satisfied with the service given by the health institutions. When we compared the mean scores of satisfaction factors, quality care had the lowest mean score (2.10). Concerning post-abortion family planning services, FGAE, MSIE, and Mekelle Hospital provided the services to 88.5%, 57% and 25.7% participants respectively (Figure-2). Moreover, in-service providers of FGAE express that they have good experience giving counselling repeatedly during the MA. Only a few participants (5.4%, 11.5% and 12.9%) had to travel for more than an hour to reach the respective health facilities.     Figure-2: Participants’ response regarding availability of PAFP and IEC/BCC services and travel time to reach the health facilities of Mekelle. PAFP: post abortion family planning, IEC: information Education and Communication, BCC: behavioral change communication.   Factors driving client satisfaction in the quality of abortion service To produce a valid and rebuttable result, all of the relevant assumptions of multiple linear regression were reviewed. First, the linearity assumptions for continuous variables and the relationship between dependent and independent variables were evaluated using scatter plots, indicating that the linearity assumption was fulfilled. Furthermore, the collinearity criterion was fulfilled since there was no multicollinearity (VIF score was less than 10 and tolerance was greater than 0.2), the errors have constant variance (homoscedasticity), residuals are normally distributed, and there is no influential case in this model. According to the findings, a unit score rise in the art of care and respect resulted in a 70.8% boost in client satisfaction (β=0.708, 95%CI: 0.558, 0.959). When the mean score of physical environment safety increases by one unit, the satisfaction score increases by 12.5% (β=0.125, 95 % CI: 0.082, 0.167). Furthermore, information provision about the procedure would result in a 57.1% increase in client satisfaction with every unit increase in its score (β=0.571, 95% CI: 0.222, 0.801). Keeping clients' privacy and secrecy was another component that was significantly associated with client satisfaction (β=0.177, 95 % CI: 0.132, 0.222). Every unit increase in the mean score of the quality care component results in an 84.1% increase in customer satisfaction (β=0.841, 95% CI: 0.685, 0.996). However, after adjusting for covariates, age and number of pregnancies were not substantially related to satisfaction (Table-4).   Table-4: Multivariate linear regression analysis of predictors for client satisfaction on abortion care in Mekelle health facilities, Tigray region, Northern Ethiopia.   Observation of post abortion care (PAC) delivery Pre and post procedure service provision and care: The supply and delivery of pre- and post-procedural services and care were monitored and assessed among 50 clients. Hand washing was observed in 71% of the 50 procedures observed. Personal protective equipment, such as gloves, aprons, masks, and eye goggles, was used in 81% of procedures. This means that around 19% of the processes were performed without the use of personal protective equipment, indicating a material deficit. Furthermore, the availability of equipment, supplies, and drugs at health institutions to meet the Ministry of Health (MOH), World Health Organization (WHO), and international organizations such as IPAS' basic equipment requirements was investigated. We have chosen a list of WHO-recommended equipment, MOH-required supplies, and IPAS-required drugs. Thus, vital equipment such as Ambo bags, oral airways, suction apparatus, oral airways, and oxygen apparatus were missing in the health institution care units of service. Furthermore, laboratory supplies were in short supply at Mekelle Hospital and MSIE. Similarly, personal protection equipment was not provided in the Mekelle hospital because service providers at MSIE and Mekelle Hospital have said that the HIV test kit is not accessible. And 45% of the procedures exhibited signs of visual or auditory pain during physical examination, and only 15% of them appear to have sufficient pain control. During the process, patients were asked whether they were in pain, and in 85% of instances, there was evidence of discomfort, which was not appropriately controlled during the procedures, and only 17.2% were given pain medicine. The findings from quantitative and qualitative data are consistent in that the mean score for pain management had the lowest score Post-procedure safety and care were also monitored. Regarding vital signs, after the completion of the procedure, only 32% of the client’s vital signs were monitored. Regarding the counselling of PAFP, overall, 51% of clients received PAFP counseling. Similarly, regarding the counselling of STIs and HIV, only 14% of procedures received counseling.   Discussion Patient satisfaction measures the extent to which a patient is content with the health care received from health care providers. It has increasingly been recognized as one of the most vital signs of quality health care services. This study has shown that women’s satisfaction with CAC has five main underlying factors: the art of care, the physical environment, information, privacy and confidentiality, and the quality-of-care providers. A mean score of 2.35 for client satisfaction was observed in this study, with 86.1% satisfied considering the mean value as a cutoff point. That indicates that women who took part in this study reported that they were generally highly satisfied with the care. This is consistent with the findings of the study conducted in the Oromia and Amhara regional states of Ethiopia, which found that the majority of women rated high satisfaction with abortion services [14]. However, the level of satisfaction in this study was lower than the finding from a previous study in Tigray that most women (99%) rated their overall experience as “good” (vs. “bad” or “so-so”). In the study, when asked about the reasons for their rating, the most commonly mentioned reasons were that they were treated well by the provider, cramping was easy to tolerate, and the services provided were close to their home [15]. Client satisfaction in this study was 86.1%, which was nearly similar to studies conducted in Addis Ababa (92%) and Jimma (76.3%) town health facilities in Ethiopia [12,13].   On the other hand, client satisfaction level was reported as only 57.7% in Oromia town health facilities [16] . The difference might be due to the difference in the study setting; the current study included non-governmental clinics, so the service might be better off as compared to governmental facilities. In this study, 55% of clients rated the waiting time before the examination as good. It is lower than a study conducted in the Gurage Zone on the quality of post-abortion care, which was 76% [17]. This difference could be due to the measurement tools used. The study in Gurage asked whether it was long or short in terms of time, but our study had three scales: good, neutral, and poor. The 7-year difference in the period of the two studies could also affect the client's awareness level regarding the service. On the other hand, 44% of clients rated the adequacy of the counselling as good. In contrast to this, a similar study conducted in Addis Ababa was higher at 72.7% [12]. This difference could also be due to the measurement scales. In the observation part, during pre-procedure, service providers introduced themselves in 13% of the procedures. A study conducted in Tigray on post-abortion quality care in 2013 was in line with this finding [11]. Hand washing practice before and after the procedure reported in this study was 71%, which was way higher than a previous study done in Tigray on post-abortion care, which was only 11.1% [11]. This difference could be due to the setup of the health facilities where the studies were done. The previous study was conducted only in a government facility. On the other hand, the providers could increase hand washing practices due to fear of the new emerging fatal virus COVID-19. The provision of PAFP in this study was 51%, which was similar to the previous study in Tigray in 2013 [11]. The qualitative part also supports this finding. Service providers at Mekelle Hospital express that most of their clients do not voluntarily take family planning, and they have different reasons. In the case of spontaneous abortion, it is because they need to give birth early. On the other hand, in the case of safe abortion, the reason being that they they would not be exposed again and fear side effects. In this study, the art of care and quality care were identified as the major factors that predict satisfaction with CAC. As previous studies have shown that [18] patient satisfaction is greatly influenced by respectful treatments such as the provider's patience, compassion, and attentiveness. Given the sensitive nature of abortion treatment, it is not surprising that this element was deemed the most significant. Furthermore, based on observation data, the availability of appropriate medical devices and supplies and adherence to high diagnostic and treatment standards are the common drawbacks of health facilities that may affect client satisfaction. Similar to other previous studies [19,20], a safe physical atmosphere around the treatment area was discovered to be important to women getting abortion care. This indicates that attempts to improve quality should focus on the physical environment. We demonstrated that providing information regarding the process before the procedure is a crucial element that increases client satisfaction, implying that providing all necessary information is an essential component of high-quality abortion services. Similarly, the relevance of the information provided was also highlighted in an earlier study done in Addis Ababa [20] and the Oromia region, Ethiopia [16]. The information must be thorough, accurate, and simple to grasp, and it must be provided in a way that allows a woman to freely provide her fully informed permission while also being sensitive to her needs and viewpoints [21]. Furthermore, maintaining clients' privacy and secrecy was another factor that was strongly related to client satisfaction. Lack of privacy may dissuade women from obtaining safe and legal abortion options, leading to unsafe abortions. Privacy and secrecy are fundamental principles of medical ethics that must be upheld [22]. The study had some limitations. There might have been an observation bias of the healthcare professionals in this study. They might tend to follow protocols since they were aware that they are being watched. During the research period, quality services were occasionally threatened due to a shortage of coaches, cleaners, a crowded waiting area, transparent windows, and no separate abortion room. This study found that consumer satisfaction in healthcare institutions was good. However, there were gaps in adequate client counseling on the benefits and drawbacks of treatments. Follow-up monitoring of providers' counseling skills, distribution of IEC/BCC materials, and post-procedure follow-up should be strengthened. Healthcare institutions and providers should prioritize quality improvement, information dissemination, and proper client care and respect.   Acknowledgment We would like to thank Mekelle University, participants, data collectors, and supervisors.   Authors’ Contributions KHM contributed to the generation of the topic, methodology, and analysis. MA and SW contributed to critically reviewing the proposal, data analysis, and manuscript. SM and DE contributed to the data analysis and assisted in the development of the manuscript. All authors read and approved the final manuscript   Competing Interests The authors declare that they have no competing interests   Ethical consideration Ethical approval was obtained from the Health Research Ethical Review Committee (HRERC) of the College of Health Sciences at Mekelle University. A letter of permission was obtained from the School of Public Health with reference number ERC 1565/2020, and it was then submitted to the concerned body in the facility. Consent was obtained from the mothers and healthcare providers. The confidentiality of the collected data was secured. During observation, the oral consent of the provider was taken, and the privacy of clients was reserved.   Availability of data and materials If needed, the raw data in Excel format for this article is available.   Funding The study is not funded.   References 1.     World Health Organization (WHO). Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008, 6th edition. Geneva: World Health Organization, 2011. 2.     World Health Organization (WHO). Safe Abortion: Technical and Policy Guidance for Health Systems. Geneva: World Health Organization. 2012 3.     Grimes DA, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, Shah IH. Unsafe abortion: the preventable pandemic. Lancet. 2006; 368(9550): 1908-1919.         doi: 10.1016/S0140-6736(06)69481-6. 4.     Brookman-Amissah E, Moyo JB. Abortion law reform in sub-Saharan Africa: no turning back. Reprod Health Matters. 2004; 12(24 Suppl): 227-34. doi: 10.1016/s0968-8080(04)24026-5. 5.     Federal minster of health (FMOH). Technical and Procedural Guidelines for Safe Abortion Services in Ethiopia. Addis Ababa: Federal Ministry of Health of Ethiopia; 2006. 6.     Ministry of Health-Ethiopia. Health Sector Transformation Plan (HSTP II). 2020/21-2024/25. 7.     Singh S, Fetters T, Gebreselassie H, Abdella A, Gebrehiwot Y, Kumbi S AS. Induced Abortion and Postabortion Care in Ethiopia. Fact sheet. New York, USA: Guttmacher Institute. 2017 8.     Prata N, Gessessew A, Holston M, Moran M, Weinrib, R. Comprehensive Abortion Care Pilot Project in Tigray, Ethiopia. Final Report. Venture Strategies Innovations, Tigray Regional Health Bureau, Bixby Center for Population, Health and Sustainability; 2011. 9.     Welsh A, editor. RCOG Best practice in comprehensive abortion care. Paper No. 2 2015;. Published by the Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent’s Park, London NW1 4RG. 10.  IPPF. First trimester abortion guidelines and protocols. London SE1 3UZ United Kingdom: by the International Planned Parenthood Federation; 2005. 11.  Demtsu B, Gessessew B, Alemu A. Assessment of Quality and Determinant Factors of Post-Abortion Care in Governmental Hospitals of Tigray, Ethiopia, 2013. Fam Med Med Sci Res. 2014; 3(4). doi:10.4172/2327-4972.1000140 12.  Mulugeta T. Addis Ababa University Faculty of Medicine School of public health Addis Ababa University Faculty of Medicine School of public health. Assesment Qual Abort care. 2009; (July): 1–85. 13.  Kitila SB, Yadassa F. Client satisfaction with abortion service and associated factors among clients visiting health facilities in Jimma Town, Jimma, South West, Ethiopia. Quality Primary Care, 2016; 24(2): 67-76. 14.  Kumbi S, Melkamu Y, Yeneneh H. Quality of post-abortion care in public health facilities in Ethiopia. Ethiop J Heal Dev. 2008; 22(1): 26–33. 15.  Prata N,Gessessew A, Holston M, Weinrib R, Cartwright A. Benefits of introducing medical methods for abortion related services: The case of Tigray, Ethiopia. October 2011. Conference: 139st APHA Annual Meeting and Exposition 2011. 16.  Guteta F, Wirtu S, Getachew M and Kejela G. Client Satisfaction towards Quality of Safe Abortion Care in Nekemte Health Facilities, East Wollega Zone, Oromia Regional State, Ethiopia. J Womens Health, Issues and Care. 2022; 11: 1. 17.  Tesfaye G, Oljira L. Post abortion care quality status in health facilities of Guraghe zone, Ethiopia. Reprod Health. 2013 Jul 23; 10: 35. doi: 10.1186/1742-4755-10-35.. 18.  Crow R, Gage H, Hampson S, Hart J, Kimber A, Storey L, Thomas H. The measurement of satisfaction with healthcare: implications for practice from a systematic review of the literature. Health Technol Assess. 2002; 6(32): 1-244. doi: 10.3310/hta6320.; 19.  Wiebe ER, Sandhu S. Access to abortion: what women want from abortion services. J Obstet Gynaecol Can. 2008; 30(4): 327-331. doi: 10.1016/S1701-2163(16)32801-8. 20.  Mossie Chekol B, Abera Abdi D, Andualem Adal T. Dimensions of patient satisfaction with comprehensive abortion care in Addis Ababa, Ethiopia. Reprod Health. 2016; 13(1): 144. doi: 10.1186/s12978-016-0259-0. PMID: 27923388; 21.  Sedgh G, Singh S, Shah IH, Ahman E, Henshaw SK, Bankole A. Induced abortion: incidence and trends worldwide from 1995 to 2008. Lancet. 2012; 379(9816): 625-632. doi: 10.1016/S0140-6736(11)61786-8. 22.  Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012; 172(5): 405-11. doi: 10.1001/archinternmed.2011.1662.      Cite this article as: Hadush K, Alemayehu M, Wahdey S, Ermias D, Moges. Women's satisfaction towards comprehensive abortion care and its determinants in Mekelle Health facilities, Tigray region, Northern Ethiopia: a mixed research approach. IMC J Med Sci. 2025; 19(1): 004. DOI:https://doi.org/10.55010/imcjms.19.004 <![CDATA[Cardio-metabolic risk and morbidity of a cohort in a rural community of Bangladesh]]> Nehlin Tomalika Sadya Afroz Md Mohiuddin Tagar Naima Ahmed MA Sayeed https://imcjms.com/journal_full_text/551 2024-11-30 12:16:53 Original Article January 2025; Vol. 19(1):003 Abstract Background and objectives: Of the ever-increasing non-communicable diseases (NCDs), cardiometabolic morbidity and mortality constitute the major health burden world-wide. Several cross-sectional studies revealed the increasing prevalence of NCDs irrespective of cast, culture, ethnicity, socio-economic growth and geopolitical environment. Recent cross-sectional studies revealed South Asians are the most susceptible to cardiovascular diseases (CVD). Few cohort studies addressed cardiometabolic morbidity and related risks, particularly in the rural population.This study was carried out to find out the prevalence of metabolic syndrome (MetSyn) and its changes overtime in a rural cohort of Bangladesh. Methods: The study used baseline data of a study conducted in 2011- 2013 on prevalence of coronary artery disease among a cohort living in 16 villages. During 2021-2023, the baseline data collected in 2011-2013 were retrieved and the participants were searched and categorized into a) physically present, b) died and c) missing. Those who were present were requested to volunteer for re-investigations. Briefly the investigations included interviewing on social, family, personal and clinical history, anthropometry, blood pressure measurement, blood biochemistry and electrocardiography (ECG). Results: A total of 3928 people participated in baseline study of 2011- 2013. Of them, 1075 could be tracked by village and household. Of them, 953 were found alive. Of the 953 available participants, 651 (254 men and 397 women) volunteered to participate in 2021-2023 study. Compared to 2011-2013 baseline, the prevalence of MetSyn and type 2 diabetes mellitus (T2DM) increased to 31.6% and 5.2% from 7.5% and 0.8% respectively in 2021-2023. Similarly, compared to baseline, the prevalence of obesity and hypertension also showed significant increase overtime. Estimated incidence of MetSyn was 260.8 per 1000 population, which was more profound in women than men (W: M= 300.3:200.8). Conclusions: The study revealed a significant increase of obesity, hypertension, diabetes and metabolic syndrome within a decade indicating an emerging health burden among the rural people of Bangladesh. January 2025; Vol. 19(1):003.  DOI:https://doi.org/10.55010/imcjms.19.003 *Correspondence: MA Sayeed, Department of Community Medicine, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka 1000, Bangladesh.  Email: sayeed950@gmail.com; © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License(CC BY 4.0).   Introduction Globally non-communicable diseases (NCDs) are now considered as the most common causes of increasing morbidity and mortality in humans [1]. The significant burden of NCDs is related to global increase of metabolic diseases or syndrome [2]. Metabolic diseases include hypertension (HTN), type 2 diabetes mellitus (T2DM), dyslipidemia, obesity and non-alcoholic fatty liver disease [2,3]. Metabolic diseases have been increasing in the Southeast Asian Region (SEAR) [4-6] and the trend is also observed in Bangladesh [7-10]. However, there is paucity of studies on trends of metabolic diseases in rural population of Bangladesh. Therefore, the present study was undertaken to assess the trends in the prevalenceof metabolic diseases in a rural cohort of Bangladesh.   Materials and methods The present study was designed based on a cross-sectional study that assessed the prevalence of coronary artery disease in a rural population of 16 villages located about 100 km north-east of capital Dhaka. The baseline investigations of the cohort were done in the year 2011 through 2013. Data collection and analyses were completed in 2013 and the findings published in 2017 [9]. The baseline data of this cross-sectional study were retrieved. The participants’ lists with house number in 16 villages were used for searching and tracking the baseline participants. The participants of the baseline study (2011-2013) still living and present in the villages were approached and enrolled in the present study of 2021-2023. The detailed procedure is shown in Figure-1.     Figure-1: Flow chart showing study procedure   The investigations for the present study (2021-2023) were the same as the baseline one [9]. Briefly the investigations included interviewing on social, family, personal and clinical history, anthropometry (height, weight, waist- and hip-circumference), blood pressure measurement, biochemistry (FBG, Lipids, creatinine, SGPT) and electrocardiography (ECG). Metabolic syndrome was defined when 3 or more of the following 5 components were present: 1) waist circumference (≥88 cm for women and ≥102 cm for men), 2) triglycerides (≥150 mg/dL), 3) HDL cholesterol (<40 mg/dL for men and <50 mg/dL for women), 4) blood pressure (systolic ≥130 mm Hg, or diastolic ≥85 mm Hg, or both) and 5) fasting blood sugar (>5.6 mmol/l) [11]. Statistical analysis: The prevalence of biophysical characteristics is shown in percentages and 95% confidence interval. All biophysical values are presented as mean with (±SD). Correlations among variables were measured to determine whether their associations changed significantly at endpoint from the starting point.The trend of the prevalence rates was estimated by chi-sq trend, according to age quartiles, both at baseline and at endpoints. Paired t-test was used to find any significant differences between the two for each variable.   Results As mentioned, the study population of the present study was based on a population who took part in a cross-sectional study conducted in 2011-13 to estimate the prevalence of coronary artery disease. A total of 3928 participated at baseline [Figure-1]. At the endpoint 2021 -2023), 953 (24.3%) of 3928 were found alive, and were requested to participate. Of the 953 presently available baseline participants, 651 (men/women= 254/397) volunteered to participate in the endpoint investigation in 2021-2023. Thus, 651 individuals constituted the present study cohort. Table-1 illustrated the biophysical characteristics of this cohort at baseline (2011-13) and at endpoint (2021-23). Compared to baseline, a significant increase of general (BMI) or central (WHR/ WHtR) obesity was observed at endpoint. Height, as expected, reduced significantly (p<0.01). Biochemical variables (FBG, TG, and HDL) were also found increased significantly (p<0.001) at endpoint compared to baseline. In contrast, total cholesterol concentration showed no significant change. Table-1: The biophysical characteristics of the study cohort (n = 651) at baseline and endpoint     Table-2 shows the comparisons of different parameters of men and women participants at the endpoint assessment. Data revealed that mean BMI, WHR & WHtR were significantly higher among women in comparison to men. Table-2: Comparisons of biophysical characteristics between men and women of the cohort at endpoint            Correlations of the biophysical variables at baseline and endpoint are shown in Table-3 and 4, respectively. Obesity both general (BMI), and central (WHR, WHtR) had significant positive correlations with all blood pressure measures (SBP, DBP, MAP, for all p<0.001) though the correlations were not significant with FBG, TG, Chol and HDL at baseline (Table-3). For lipids, only cholesterol had significant positive correlation with SBP (p = 0.001) and MAP (p= 0.017) at baseline (Table-3). Similar significant positive correlations of obesity variables (BMI, WHR and WHtR) with the blood pressure measures (SBP, DBP, MAP) were found at endpoint (Table-4). Interestingly, though obesity did not correlate with metabolic components (FBG, cholesterol, TG, HDL) at baseline (Table-3), but at the endpoint (Table-4), TG correlated significantly with BMI and WHtR (p<0.001); and HDL had significant inverse correlation with BMI (r= - 0.09, p=0.015). Comparison of biophysical characteristics of the cohort with and without metabolic syndrome both at baseline (2011-2013) and at endpoint (2021-23) are shown in Table-5.   Table-3: Correlations of biophysical variables controlling for age and sex at baseline   Table-4: Correlations of biophysical variables controlling for age and sex at endpoint     Table-5: Comparisons of the study population (N=651) with and without metabolic syndrome (MetSyn) both at baseline (2011-2013) and at endpoint (2021-2023)     Figure-2 shows the prevalence of hypertension (SHTN, DHTN, MAHTN) in men and women at baseline (2011-13) and at endpoint in 2021-23. No significant difference was observed (p>0.05). The changes of prevalence of T2DM and MetSyn from baseline to endpoint are shown in Figure-3. At baseline, the prevalence of T2DM in men and women was 1.2% and 0.5% respectively while it increased to 6.7% and 4.3% at endpoint in 2021-2023. Over the decade, the prevalence of T2DM increased significantly to 5.2% from 0.8% (p<0.01) and the estimated incidence of T2DM was 44.9 per 1000 people per decade.  Development of MetSyn significantly (p<0.05) increased in both men and women over 10 years (endpoint) period compared to baseline in 2011-2013. The prevalence of MetSyn in the cohort was only 7.5% at baseline (2011-2013) which increased to 31.6% at endpoint in 2021-2023.The cohort revealed the incidence of MetSyn as 260.8 per 1000 population per decade. The women had higher incidence rate than men (W : M = 300.3 : 200.8) per 1000 people.     Figure-2: Prevalence (%) of hypertension (SHTN, DHTN, MAHTN) in men and women at baseline (2011-13) and at endpoint (2021-23). M: men, W: women.     Figure-3: Prevalence (%) of T2DM and metabolic syndrome (MetSyn) in men and women at baseline (2011-13) and at endpoint (2021-23). M: Men, W: Women, T: Total.   Figure-4 and 5 depict whether increasing age of the cohort influenced the prevalence of hypertension, diabetes or MetSyn of the study population at baseline and at end point respectively. The prevalence trend with advancing age was not significant (p>0.05) at baseline for all components. In contrast, after a decade, at the endpoint (2021-23) only the increasing trend for sHTN was found significant (p<0.01).     Figure-4: Trend of prevalence (%) of hypertension (sHTN, dHTN, MAHTN), T2DM and metabolic syndrome (MetSyn) at baseline (2011-13) by age-quartile (<25, 25- 29, 30-39, ≥40 years)     Figure-5: Trend of prevalence (%) of hypertension (sHTN, dHTN, MAHTN), T2DM and metabolic syndrome (MetSyn) at endpoint (2021-23) by age-quartile (<25, 25- 29, 30-39, ≥40 years)   Discussion This study is first of its kind addressing the trend of cardiometabolic morbidity over a decade in a cohort of population in a rural community of Bangladesh. Most of the reported studies on cardiometabolic morbidity and mortality from South Asian countries encompassed urban population. The most important aspect of our study is that it showed an alarming and increasing trend of cardiometabolic risks and diseases in rural people that represents the vast majority of Bangladeshi population. There are a few published data on the status of cardiometabolic syndrome or diseases on rural population of Bangladesh for comparison. However, in south Asia a very elegant cohort was initiated in 2010 as Cardiometabolic Risk Reduction in South Asia (CARRS) [12]. The study also observed increasing trend of general and central obesity among Asian population (Chennai, Delhi and Karachi) [12]. In the present study, all blood pressure measures (sHTN, dHTN, MAHTN) increased significantly among our cohort population within a decade. This observation is consistent with the findings of a study involving a large cohort of over 16,000 adults in India [4]. In our study, the most notable was the high increase of prevalence of diabetes and MetSyn from baseline to endpoint over a period of 10 years. Similar changes of prevalence and incidence of diabetes and MetSyn in South Asians have been reported in other studies, but most of those studies were conducted either in urban or metropolitan population [4,5,13-15]. However, our study cohort consisted of only rural population. Our cohort participants had a significant and noticeable increase of Chol, TG and LDL including significant reduced level of HDL at endpoint from its baseline level. This finding is not inconsistent with the findings of studies conducted on other south Asian cohort [6,16]. Our study addressed major cardiometabolic risks prevalent among the rural population of Bangladesh which constitute 60% of the total population of the country. It revealed significant increase of obesity, hypertension, diabetes and metabolic syndrome in rural people over a period of ten years. The prevalence of both T2DM and MetSyn increased more than five times within a decade. These findings invite the attention of all concerned to plan and take necessary preventive measures against this emerging health burden.   Acknowledgements Authors acknowledge the support of the Department of Community Medicine of Ibrahim Medical College for providing expertise and laboratory accessories. The local volunteers / field workers, school teachers and students helped in finding out the enlisted baseline participants. Additionally, they actively volunteered the study and informed the research team the whereabouts of the participants.   Ethical declaration The study protocol was approved by the Institutional Review Committee (IRC) of Bangladesh Diabetes Somity (BADAS). Informed written consent was obtained from each and every participant prior to the enrollment in the study.   Authors’ contributionNT and SA: contributed equally in protocol writing, data analysis and manuscript writing; MMT and NA: data collection and data entry; MAS: manuscript writing. Fund The study was funded by Ibrahim Medical College.   References 1.     NCD Countdown 2030 collaborators. NCD Countdown 2030: worldwide trends in non-communicable disease mortality and progress towards Sustainable Development Goal target 3.4. Lancet. 2018; 392(10152): 1072-1088. doi:10.1016/S0140-6736(18)31992-5. 2.     Chew NWS, Ng CH, Tan DJH, Kong G, LinC, Chin YH, et al. The global burden of metabolic disease: Data from 2000 to 2019. Cell Metab. 2023; 35(3): 414-428.e3. doi:10.1016/j.cmet.2023.02.003. 3.     Hasankhani MB, Mirzaei H, Karamoozian A. Global trend analysis of diabetes mellitus incidence, mortality, and mortality-to-incidence ratio from 1990 to 2019. Sci Rep. 2023; 13: 21908. doi:10.1038/s41598-023-49249-0. 4.     Prabhakaran D, Jeemon P, Ghosh S, Shivashankar R, Ajay VS, Kondal D, et al. Prevalence and incidence of hypertension: results from a representative cohort of over 16,000 adults in three cities of South Asia. Indian Heart J. 2017; 69(4): 434-441. doi:10.1016/j.ihj.2017.05.021. 6.     Fatmi Z, Kondal D, Shivashankar R, Iqbal R, Khan AA, Mohan D, et al. Prevalence of dyslipidaemia and factors associated with dyslipidaemia among South Asian adults: The Center for Cardiometabolic Risk Reduction in South Asia Cohort Study. Natl Med J India. 2020; 33(3): 137-145. doi:10.4103/0970-258X.314005. 8.     Chowdhury MZI, Haque MA, Farhana Z, Anik AM, Chowdhury AH, Haque SM, et al. Prevalence of cardiovascular disease among Bangladeshi adult population: a systematic review and meta-analysis of the studies. Vasc Health Risk Manag. 2018; 14: 165-181. doi:10.2147/VHRM.S166111. 10.   Nujhat S, Alam W, Parajuli A, Mohsen WAM, Banyira L, Gupta RD, et al. Prevalence of risk factors for non-communicable diseases in a rural population of Bangladesh: a cross-sectional study. Lancet Glob Health. 2020; 8: S21. doi:10.1016/S2214-109X(20)30162-5. <![CDATA[Prevalence of developmental dental hard-tissue anomalies among adolescents in southeastern Nigerian rural communities]]> Obehi. O Osadolor Aisosa. J Osadolor https://imcjms.com/journal_full_text/549 2024-11-23 12:45:07 Original Article January 2025; Vol. 19(1):002 Abstract Background and objectives: Dental anomalies are significant deviation in the normal size, structure, number, root formation or shape of a tooth. It can affect primary and permanent dentition. The aim of the present study was to determine the prevalence of developmental dental hard tissue anomalies in the permanent dentition of adolescents in two southeastern Nigerian rural communities. Materials and methods: This cross-sectional descriptive study was conducted among school children aged 12-13 years attending two public secondary schools. The schools were located in Nkanu-West and Udi Local Government areas in Enugu state. Oral examination for the presence or absence of developmental dental hard tissue anomalies was performed by a single examiner. Statistical analysis was done using SPSS Version 25. Results: A total of 61 (44.9%) males and 75(55.1%) females participated in the study. The age range of the children was 12 to 13 years with mean age of 12.49 ± 0.50 years. The prevalence of developmental dental hard tissue anomalies was 2.2%. Developmental dental hard tissue anomalies were seen only in females, higher among 13-year-old school children and school children from middle socioeconomic status. Enamel hypoplasia was seen more than peg shaped lateral incisor. There was no statistically significant association with sex (p = 0.25), age (p = 0.61), socioeconomic status (p= 0.25) and developmental dental hard tissue anomalies. Conclusion: The prevalence of developmental dental hard tissue anomalies was low in this study. Developmental dental hard tissue anomalies can affect aesthetics and quality of life. A visit to dental clinic for clinical assessment, preventive interventions and management is recommended. January 2025; Vol. 19(1):002.  DOI: https://doi.org/10.55010/imcjms.19.002 *Correspondence: Obehi. O Osadolor, Department of Child Dental Health, University of Nigeria Teaching Hospital, Ituku- ozalla, Enugu State. Nigeria. E-mail: osadolorobehi@yahoo.com; © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0).   Introduction Dental anomalies are differences or deviation in the normal size, structure, number, root formation or shape of a tooth [1-5]. It can affect a single tooth in isolated case or multiple teeth in syndromic case. Dental anomalies can present as hyperdontia, hypodontia, talon cusp, hypoplasia, peg-shaped lateral incisor, dentinogenesis imperfecta, taurodontism, microdontia, macrodontia, dens evaginatus, odontoma, germination, amelogenesis imperfecta, dens invaginatus and fusion [1-8]. Dental anomalies in children or adolescents had been assessed clinically by inspection and radiographically by use of x-rays in several epidemiological studies [1-8]. The prevalence of dental anomalies in a hospital-based study, among 8 to 12 years old children in Kuwait was 20.1% [5], 4.2 % among 12 to 15 year old Nigerian school children [3] and 3.2% among Nigerian preschool children [2]. The aim of this study was to determine the prevalence of developmental dental hard tissue anomalies in the permanent dentition of adolescents in two southeastern Nigerian rural communities.   Materials and methods A cross-sectional descriptive study was conducted among school children aged 12-13 years attending rural public secondary schools in Nkanu-West and Udi Local Government areas in Enugu state. The school children were randomly selected from each school. The inclusion criteria were children aged 12–13 years old attending public secondary school in selected rural communities. Informed consent was obtained from the parents of the school children and assent was obtained from the schoolchildren. The students were examined while seated in their classroom chair using natural daylight while the teeth were clean. Sample size for this study was calculated using the formula for cross-sectional study: N= z2P(1-P)/d2 [9], where N is the sample size, Z is the statistic corresponding to level of confidence, P is expected prevalence, and d is precision (corresponding to effect size). The total sample size for the two local government areas was 136 (68x2) considering prevalence of developmental dental hard tissue anomalies as 4.2 % from a previous study in Nigeria [3]. Socio-demographic data (age, sex, socio-economic status) was obtained using semi-structured questionnaire. Socio-economic status was determined by criteria used in a previous study [10] and socio-economic status designation combines father’s occupation with the mother’s level of education [10]. Oral examination for the presence or absence of developmental dental hard tissue anomalies was done by a single examiner (A Dentist). Prior to oral examination, the examiner was trained using clinical pictures of various presentations of developmental dental hard tissue anomalies. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) Version 25. Descriptive analysis was conducted to determine the prevalence of developmental dental hard tissue anomalies and association between dependent and the independent variables was determined using Fisher’s exact test.   Results Total 136 adolescents were enrolled in the study. Out of 136, 61(44.9%) were males and 75(55%) were females. The age range of the children was 12 to 13 years with mean age of 12.49 ± 0.5 years (Table-1). The prevalence of developmental dental hard tissue anomalies was 2.2%. Table-1 shows that developmental dental hard tissue anomalies were seen only in females, higher among 13-year-old school children and school children from middle socioeconomic status. Table-2 shows that enamel hypoplasia was seen more than peg shaped lateral incisor. Among the developmental dental hard tissue anomalies seen among the school children, 66.7% were enamel hypoplasia and 33.3% were peg shaped lateral incisor/microdontia. Peg shaped lateral incisor was seen on the left side of the maxillary arch. There was no statistically significant association between sex (p = 0.25), age (p = 0.61), socioeconomic status (p= 0.25) and developmental dental hard tissue anomalies.   Table-1: Profile of the study participants     Table-2: Prevalence of types of dental anomalies in the permanent dentition (n=136)     Discussion Dental anomalies can occur in primary teeth and permanent teeth. The development of the teeth is regulated by molecular and cellular interactions and any disruptions or disturbances during the phases of initiation, morphogenesis and histo-differentiation can lead to the development of dental anomalies [11-14]. Previous studies reported that mutations in some gene families such as Msh Homeobox 1 (MSX1) and paired box 9 (PAX9) may play a role in the development of different developmental dental anomalies [15,16]. The prevalence of developmental dental hard tissue anomalies in this study was lower than 17.5% among children seen in a hospital-based study in southwest Nigeria [1] and 26.6% among children seen during a household survey in southwest Nigeria [6]. A hospital-based study in Kuwait also reported the prevalence of developmental dental hard tissue anomalies as 20.1% among 8-12 year old children [5]. This finding could be as a result of the method of detection of dental anomalies, difference in geographic location and the influence of genetic, epigenetic and environmental factors in the development of dental anomalies. However, our finding was close to 4.2% seen among 12- to 15-year-old school children in southwest Nigeria [3] and 1.8% among children seen in a hospital-based study in Turkey [8]. In our study, dental anomalies were seen only in females, this observation was in agreement with previous studies of more occurrence of dental anomalies among females [1,3-5,8]. Dental anomalies were also higher among children of middle socioeconomic status, this finding agreed with previous study of more occurrence of dental anomalies among children of middle socioeconomic status [3], but different from previous study of more occurrence of dental anomalies among children of low and high socioeconomic status [6,2]. The most common dental anomaly in this study was enamel hypoplasia. The finding was consistent with findings of previous studies [1,3,6]. However, other studies have reported less enamel hypoplasia [2,5,8]. Radiographs were not taken to identify other anomalies in this study. This study was a public-school based study within the selected local government areas, the findings of this study might not represent adolescents attending private schools in the rural community and adolescents in communities within the selected local government areas that were not visited. The findings might also not represent adolescents absent at school during the days of data collection, and out of school children (adolescents not attending any school) in the rural community. There could be marked or slight variation in the prevalence of developmental dental hard tissue anomalies among adolescents in the selected rural communities when participants are selected from both public and private schools or seen during a household survey in the rural communities. The prevalence of developmental dental hard tissue anomalies was low. Enamel hypoplasia was the most common dental hard tissue anomaly seen. Developmental dental hard tissue anomalies can affect aesthetics and quality of life. A visit to dental clinic for clinical assessment, preventive interventions and management is recommended.   Acknowledgments Authors acknowledge all Principals and teachers of selected schools that assisted during data collection. Conflicts of interest Authors have no conflicts of interest to declare   Funding None References 1.     Olatosi OO, Oyapero A, Akinwande KO, Ayedun OS, Aladenika ET, Obe OI. Pattern and prevalence of dental anomalies among a paediatric population in Lagos, Nigeria. Niger Postgrad Med J. 2022; 29(2): 167-172. doi:10.4103/npmj.npmj_23_22. 2.     Onyejaka NK, Amobi EO, Olatosi OO. Sociodemographic and behavioral factors associated with developmental dental hard-tissue anomalies in children with primary dentition. Indian J Dent Sci. 2020; 12: 121-25. 3.     Popoola BO, Onyejaka N, Folayan MO. Prevalence of developmental dental hard tissue anomalies and association with caries and oral hygiene status of children in Southwestern, Nigeria. BMC Oral Health. 2016; 17(1): 8. doi:10.1186/s12903-016-0236-6. 4.     Gök RS, Alkış HT. Evaluation of dental anomaly prevalence and types by cone beam computed tomography in a subgroup of Turkish population. J Oral Health Oral Epidemiol. 2023; 12(4): 183–188. doi:10.34172/johoe.2023.31. 5.     Alanzi A, Bufersen N, Haider S, Abdulrahim M. Prevalence and distribution of dental anomalies in schoolchildren in Kuwait. Int Dent J. 2024; 74(3): 566-572. doi:10.1016/j.identj.2023.10.019. 6.     Temilola DO, Folayan MO, Fatusi O, Chukwumah NM, Onyejaka N, Oziegbe E, et al. The prevalence, pattern and clinical presentation of developmental dental hard-tissue anomalies in children with primary and mix dentition from Ile-Ife, Nigeria. BMC Oral Health. 2014; 14: 125. doi:10.1186/1472-6831-14-125. 7.     Orenuga O, Odukoya O. An epidemiological study of developmental defects of enamel in a group of Nigerian school children. Pesq Bras Odontoped Clin Integr João Pessoa. 2010; 10(3): 385-391. doi:10.4034/1519.0501.2010.0103.0009. 8.     Almaz ME, Sönmez IS, Oba AA. Prevalence and distribution of developmental dental anomalies in pediatric patients. Meandros Med Dental J. 2017; 18(2): 130-133. doi:10.4274/meandros.07279. 9.     Araoye MO. Research methodology with statistics for health and social sciences. 1st ed.Ilorin: Nathadex; 2003. p.117-21. 10.  Popoola BO, Denloye OO, Iyun OI. Influence of parental socioeconomic status on caries prevalence among children seen at the university college hospital, Ibadan. Ann Ib Postgrad Med. 2013; 11(2): 81-86. 11.  Ruangchan C, Ngamphiw C, Krasaesin A, Intarak N, Tongsima S, Kaewgahya M, et al. Genetic variants in KCTD1 are associated with isolated dental anomalies. Int J Mol Sci. 2024; 25(10): 5179. doi:10.3390/ijms25105179. 12.  Urzúa B, Ortega-Pinto A, Adorno-Farias D. Genetic etiology of development alterations affecting the number, size, form, structure and eruption of the teeth. J Oral Med and Dent Res. 2020; 1(2): 1-14. doi:10.52793/JOMDR.2020.1(2)-09. 13.  Hermans F, Hemeryck L, Lambrichts I, Bronckaers A, Vankelecom H. Intertwined signaling pathways governing tooth development: a give-and-take between canonical Wnt and Shh. Front Cell Dev Biol. 2021; 9: 758203. doi:10.3389/fcell.2021.758203. 14.  Tokavanich N, Wein MN, English JD, Ono N, Ono W. The role of Wnt signaling in postnatal tooth root development. Front Dent Med. 2021; 2: 769134. doi:10.3389/fdmed.2021.769134. 15.  Mostowska A, Kobielak A, Trzeciak WH. Molecular basis of non-syndromic tooth agenesis: mutations of MSX1 and PAX9 reflect their role in patterning human dentition. Eur J Oral Sci. 2003; 111(5): 365–370. doi:10.1034/j.1600-0722.2003.00069.x. 16.  Ceyhan D, Kirzioglu Z, Calapoglu NS. Mutations in the MSX1 gene in Turkish children with non-syndromic tooth agenesis and other dental anomalies. Indian J Dent. 2014; 5(4): 172–82. doi:10.4103/0975-962X.144717.     Cite this article as: Osadolor OO, Osadolor AJ. Prevalence of developmental dental hard-tissue anomalies among adolescents in southeastern Nigerian rural communities.IMC J Med Sci. 2025; 19(1):002. DOI: https://doi.org/10.55010/imcjms.19.002 <![CDATA[Diabetic kidney disease in Bangladesh: a cross-sectional study on screening, treatment and prevention practice]]> Wasim Md Mohosin Ul Haque Delwar Hossain Md Feroz Amin Tabassum Samad Masuda Mohsena Samira Humaira Habib Muhammad Abdur Rahim Mehruba Alam Md. Mostarshid Billah Mohammed Mehfuz-E-Khoda Tufayel Ahmed chowdhury Abdul Latif Shudhangshu Kumar Saha Rafi Nazrul Islam Tasnova Mahin Fatema Khanom Nehlin Tomalika Sadya Afroz Mahfuzur Rahman Bhuiyan Monami Islam Khan Md. Maminul Islam https://imcjms.com/journal_full_text/548 2024-11-19 12:59:05 Original Article January 2025; Vol. 19(1):001 Abstract Background and objectives: Diabetic kidney disease (DKD) is a leading complication of diabetes, contributing significantly to global cases of end-stage renal disease (ESRD). In Bangladesh, the rising prevalence of diabetes has made DKD a growing public health concern. An estimated 21.3% of diabetic patients in Bangladesh have some form of kidney impairment. The Diabetic Association of Bangladesh (BADAS) operates a network of healthcare centers that provide diabetes management across the country. Despite these efforts, significant gaps exist in DKD screening, patient education, and the use of renoprotective medications. This study aims to evaluate DKD in BADAS-affiliated healthcare centers, focusing on screening practices, management and patient education. Materials and Methods: This cross-sectional study was conducted in 8 BADAS-affiliated healthcare centers, representing diverse regions of Bangladesh. A total of 320 type 2 diabetic patients were selected using multi-stage sampling methods. Data were collected using structured questionnaires which included socio-demographic characteristics, clinical histories, comorbidities, body mass index (BMI), glycemic control status, blood pressure levels, medication usage, and diagnostic criteria for DKD. Blood samples were obtained to determine serum creatinine and HbA1c levels, and spot urine samples were collected to measure the urine albumin-to-creatinine ratio (uACR). Results: The prevalence of DKD was found to be 34.1%, with most cases in the early stages (Stage1:33% and Stage2: 45%). Screening practices were inadequate. Only 21.1% of participants with DKD were receiving renoprotective medications like ACE inhibitors or ARBs, and 35.8% were using SGLT2 inhibitors. Glycemic and blood pressure control were also suboptimal, with 81.9% of total participants having HbA1c levels ≥7% and 69.1% having uncontrolled hypertension. Of the entire study population, only 0.3% met all six prevention targets. Conclusion: DKD is prevalent among diabetic patients in BADAS-affiliated healthcare centers, with poor screening practices and underutilization of renoprotective medications. Systematic improvements in DKD management, including enhanced screening, medication use, and patient education, are essential to prevent progression to ESRD. January 2025; Vol. 19(1):001.  DOI: https://doi.org/10.55010/imcjms.19.001 *Correspondence: Wasim Md Mohosin Ul Haque, Department of Nephrology, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), 122 Kazi Nazrul Islam Avenue, Dhaka 1000, Bangladesh. Email: wmmhaque@live.com; © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0).   Introduction Diabetic kidney disease (DKD) is one of the most severe complications of diabetes, contributing significantly to global cases of end-stage renal disease (ESRD). It is estimated that DKD affects approximately 30-50% of diabetic patients worldwide, posing a substantial burden on healthcare systems, especially in low- and middle-income countries (LMICs) like Bangladesh [1,2]. DKD refers to the occurrence of chronic kidney disease (CKD) in individuals with diabetes. It is typically characterized by the presence of persistent albuminuria, a reduced glomerular filtration rate (GFR), and an elevated risk of cardiovascular disease [3]. The progression of DKD can be mitigated through early diagnosis and management of modifiable risk factors such as hyperglycaemia, hypertension, and lifestyle [4,5]. Bangladesh, with its rising diabetes prevalence, is facing a growing challenge of DKD. In 2021, an estimated 13.1 million people in the country were diagnosed with diabetes, and this number is projected to increase to 22.3 million by 2045 [6]. Among diabetic patients, the prevalence of DKD has been reported to be approximately 21.3%, underscoring the critical need for effective screening and management [7]. Despite the scale of this challenge, current screening protocols areinconsistent,and many healthcare facilities lack the necessary infrastructure for early diagnosis and specialized care. The Diabetic Association of Bangladesh (BADAS) operates 133 healthcare centers, including tertiary hospitals, which provide diabetes care across the country. Of these affiliated centers 61 at the district level and 29 at the Upazila level, collectively serving a total of 3,674,407 registered patients. These centers play a vital role in DKD management, yet significant gaps exist in patient education, screening practices, and the use of renoprotective medications [8]. Systematic interventions to address these gaps could substantially improve patient outcomes and reduce the long-term burden of DKD on Bangladesh’s healthcare system. This study aimedto evaluate the prevalence and management of DKD at diabetic healthcare centers in Bangladesh, focusing on key indicators such as screening practices, medication use, and patient education. The findings wouldbe useful for improvement ofcurrent management practice in DKD care by identifying the lapses.   Material and methods The study was conducted from May 15 to July 31, 2024.The study was approved by the institutional ethics and review board. Informed consent was obtained from all participants prior to the enrolment in the study. Data privacy and patient confidentiality were maintained. Study place and population: This cross-sectional study was conducted across 8healthcare centers affiliated with BADAS. 1center was randomly selected from each of the 8 divisions in Bangladesh to ensure regional diversity ofthe study participants. These centers provide essential diabetes care services, with varying infrastructure in terms of diagnostic and patient care facilities. Centers offering tertiary care services were excluded. The study included 40 participants conveniently selected from each of the 8centers. The inclusion criteria were all registered type 2 diabetic patients, regardless of renal status, who had been receiving care at BADAS-affiliated centers for at least one year. Patients with kidney disease due to other causes, pregnancy, or acute illness were excluded. Data collection tools and procedures: Data was collected using structured questionnaires which included socio-demographic characteristics, clinical histories, comorbidities, body mass index (BMI), glycemic control (measured via HbA1c), blood pressure levels, medication use, and diagnostic practices related toDKD. Blood samples were obtained to measure serum creatinine and HbA1c levels, while spot urine samples were collected to assess the urine albumin-to-creatinine ratio (uACR). All biochemical analyses were performed using standardized procedures to ensure accuracy and reliability. The presence of DKD was assessed by determining estimated glomerular filtration rate (eGFR) and urinary albumin creatinine ratio (uACR). Estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Patients with an eGFR of less than 60 mL/min/1.73 m² and/or signs of kidney damage, indicated by albuminuria (estimated via uACR), were classified as having DKD. Single urine and blood samples were collected from each enrolled participants for estimation of eGFR and uACR.   Results Center information and facilities: The study involved 8 healthcare centers affiliated with BADAS, all situated in urban districts. Among these centers, only 3(37.5%) offered inpatient care, while 5(62.5%) were equipped to conduct uACR tests. Half of the centers (50%) had nephrologists or endocrinologists available for consultation; the remainder depended on general practitioners. The average patient-to-doctor ratio stood at 22:1, with a range from 10 to 45 patients per doctor. Sociodemographic characteristics: Among the 320 participants, there was a higher proportion of females (60.3%) compared to males (39.7%). The average age of the participants was 55.3 years, and majority (56.6%) was within the 41 to 60 age group. Socio-economically, 42.5% of the participants were categorized as "rich," while 17.5% were classified as "poor." Notably, a significant portion (31.3%) had no formal education. Housewives constituted the largest occupational group, comprising 52.2% of the participants (Table-1).   Table-1: Socio-Demographic characteristics of theparticipants     Clinical characteristics and comorbidities: The average duration of diabetes among participants was 8.61 years, and for hypertension, it was 6.83 years. Hypertension was the most common comorbidity, affecting 37.8% of participants, followed by peripheral neuropathy, which was observed in 37.2%of cases. Diabetic retinopathy was present in 35.6% of participants, and smaller proportions had ischemic heart disease (12.2%) or chronic kidney disease (4.4%) (Table-2).   Table-2: Prevalence of comorbidities amongthe study participants     Lifestyle factors and risk behaviours: The analysis of lifestyle factors revealed that 9.4% of participants were current smokers, while 14.4% used smokeless tobacco. Alcohol consumption was rare, with only 1 participant (0.3%) currently using alcohol and 6 (1.9%) were past users. Anthropometric measurements, blood pressure and glycemic status: Detail anthropometric, blood pressure and glycemic status of study participants are shown in Table-3 and 4. The mean BMI of participants was 25.23 ± 4.75 kg/m², with 47.5% classified as obese and 21.6% as overweight. Obesity is a significant risk factor, contributing to both poor blood pressure and glycemic control. Nearly half of the participants were obese, which likely exacerbates the suboptimal control observed.Blood pressure control was inadequate, with 221 participants (69.1%) having uncontrolled hypertension (BP ≥130/80 mm Hg). Among those not previously diagnosed with hypertension, 63.3% (126 out of 199) had uncontrolled BP, indicating possible undiagnosed cases. The issue was more pronounced among known hypertensive individuals, with 78.5% (95 out of 121) unable to control their BP. Glycemic control was similarly suboptimal. Only 57 participants (17.9%) had optimal glycemic control (HbA1c<7%). The majority, 262 participants (82.1%), had elevated HbA1c levels (≥7%), with 100 participants (31.3%) having severe hyperglycemia (HbA1c >10%). The mean HbA1c was 9.33 ± 2.35% for males and 9.11 ± 2.22% for females.   Table-3: Mean anthropometric and blood pressure status of the total study participants (n=320)     Table-4: Anthropometric, blood pressure and glycemic status of the study participants (n=320)     Prevalence and staging of diabetic kidney disease (DKD): Out of 320 study participants, 109 (34.1%) had DKD, based on either a reduced eGFR or elevated uACR (Table-5). Of these, 24 individuals(7.5%) had a reduced eGFR, 102 (31.9%) had an elevated uACR while 17 (5.31%) exhibited both a reduced eGFR and elevated uACR. The majority of cases (n=85, 78%) were in the early stages of CKD (Stages 1 and 2), underscoring the critical need for early detection and timely intervention.   Table-5: Levels of uACR, eGFR, and CKD stages of in the study population     Management of diabetes and screening practicesfor hypertension and DKD: The study revealed significant gaps in the screening and management of diabetes, hypertension, and diabetic kidney disease (DKD) among the 320 participants. Only 18.8% had undergone HbA1c testing in the past year, and 62.8% were unaware of their blood pressure status. DKD screening was similarly inadequate. Of the total participants, 52.5% had never been tested for DKD. Among those who had been screened, only 48% received annual tests. Serum creatinine testing was notably underutilized, with just 3.4% of participants having undergone this diagnostic test, and none had been tested for eGFR or 24-hour urine protein. Of the 109 individuals diagnosed with chronic kidney disease (CKD) in the study, only 14 were previously aware of their condition, highlighting a significant gap in DKD screening. Furthermore, 42.9% of these 14 CKD patients were not under nephrology care, indicating limited access to specialized services and underscoring the need for improved screening and referral systems. Medication and management practices: Out of 320 participants, 208 (65%) were using anti-diabetic medications. There was notable underutilization of renoprotective therapies. Only 21.1% of DKD patients were prescribed ACE inhibitors or ARBs, and 35.8% were using SGLT2 inhibitors, both of which were essential for reducing proteinuria and slowing CKD progression. Additionally, despite the critical role of statins in managing cholesterol and reducing cardiovascular risks, only 27.5% of the CKD population were on statins. In contrast, known DKD patients had higher rates of ACE inhibitor/ARB (64.3%) and statin (57.1%) use (Table-6).   Table-6: Medication use by the study populations     Patient knowledge about DKD: Table-7 shows the overallknowledge and knowledge acquired from the diabetes healthcare centers of the study participantsaboutDKD. The knowledge was generally low, despite 83.75% recognizing that diabetes can harm the kidneys. Only 41.56% recognized the importance of urine albumin testing, and just 30% were aware that frothy urine might indicate kidney damage. Knowledge of critical DKD risk factors, such as high blood pressure and poorly controlled blood sugar, was also suboptimal. Notably, most participantsregardless of their knowledge levelacquired their information from healthcare centers, highlighting the essential role these centers play in patient education. This suggests that enhancing the availability and quality of information provided at these centers could significantly improve patients' overall understanding of DKD (Table-7).   Table-7: Knowledge of DKD among the study participants (n=320)     The analysis of the knowledge state of 14 known DKD patients revealed that 85.7% were aware of their disease stage and expressed satisfaction with the healthcare information provided. Of them, 64.3% had received education on DKD management, including diabetes control (91.7%) and blood pressure management (83.3%). Gaps were noted in areas such as cholesterol control (58.3%) and protein intake (50%). Awareness of key DKD risk factors, such as uncontrolled diabetes (85.7%) and high blood pressure (71.4%), was relatively high. However, fewer patients were knowledgeable about glucose control targets (30%) and lipid goals (20%). Despite this reasonable level of awareness, only 40% adhered to management guidelines, with 57.1% citing financial barriers as a significant obstacle. Overall, 85.7% of the DKD patients expressed satisfaction with the healthcare services offered by the centers. DKD prevention targets: In this study, a strikingly low percentage of participants achieved the recommended targets for the prevention of DKD (Table-8). Among the entire study population, only 0.3% met all six prevention targets, which included glycemic control, blood pressure control, weight management, tobacco avoidance, and the use of renoprotective medications (ACE inhibitors/ARBs) and statins. This gap was even more pronounced among the individuals with DKD, where none of the participants achieved all prevention targets, underscoring significant shortcomings in managing DKD risk factors.   Table-8: Gap in the DKD prevention targets in total and DKD populations     Discussion This study highlights the high prevalence of DKD in patients attending BADAS-affiliated diabetes healthcare centers in Bangladesh and underscores critical gaps in its management. The prevalence of DKD in this population, approximately 34.1%, is notably higher than previously reported estimates from similar studies in Bangladesh, which ranged around 21.3% [7]. This difference may reflect the growing burden of diabetes in Bangladesh, which is projected to rise sharply in the coming decades, with an estimated 22.3 million cases by 2045 [6]. Also, in the present study, DKD was diagnosed based on a single estimation of uACR and eGFR, which might have led to an overestimation of the prevalence of DKD. Future studies should incorporate repeated measures of uACR and eGFR to confirm the diagnoses of DKD. One of the key findings of this study is the suboptimal screening for DKD, with more than half of the participants never have undergone proper testing, such as uACR or eGFR assessments. This highlights a significant barrier to early diagnosis of DKD and timely intervention. Previous research has shown that early detection of DKD can substantially slow the disease progression and improve patient outcomes [6]. Current international guidelines recommend routine screening for albuminuria and eGFR in diabetic patients, but these practices remain inconsistent in many low-resource settings, including Bangladesh [9,10]. The present study also found that management practices of diabetes, hypertension and DKD were inadequate, with poor glycemic and blood pressure control among the majority of thepatients. These findings highlight significant gaps in hypertension management and glycemic control, further exacerbated by the high prevalence of obesity. Addressing these issues with aggressive interventions is essential to improving patient outcomes and preventing DKD.Only 19.7% of participants were using renoprotective medications such as ACE inhibitors or ARBs, despite their proven efficacy in slowing DKD progression. Recent advances in pharmacotherapy, such as use of SGLT2 inhibitors and non-steroidal mineralocorticoid receptor antagonists (NS-MRAs), have shown additional benefits in preserving renal function, yet their use remains limited due to cost and accessibility [11,12]. This underutilization of evidence-based therapies is a significant concern, as proper medication can substantially reduce the risk of progression to ESRD [1]. Lifestyle factors, including tobacco use and obesity, were also prevalent in the study population, further contributing to the risk of DKD progression. The findings suggest that greater emphasis on lifestyle interventions, such as smoking cessation and weight management, is needed to complement pharmacological treatments [13-16]. The relatively low levels of patient education on DKD symptoms and management also indicate the need for enhanced educational programs to improve disease awareness and self-care practices [17]. In conclusion, this study underscores the urgent need for systematic improvements in the screening, management, and education of DKD patients in Bangladesh. Enhancing access to renoprotective medications, implementing routine screening protocols, and providing comprehensive patient education are critical steps toward addressing the growing burden of DKD in the country. Future efforts should focus on overcoming the barriers to care, such as availability of diabetes care centers and cost, to ensure that all diabetic patients receive the necessary interventions to slow the progression of DKD and improve their quality of life.   Acknowledgments We acknowledge the support and advises provided by Prof. J. Ashraful Haq, Prof. Md. Faruque Pathan, Prof. Showkat Hossain and Prof. Masud Iqbal.   Conflict of Interest The authors have no conflicts of interest to declare. The funding bodies had no role in the design of the study, data collection, analysis, interpretation, or in the decision to publish the results   Fund The research was supported by a grant from Ibrahim Medical College and BIRDEM Academy.   References 1.     Banik S, Ghosh A. Prevalence of chronic kidney disease in Bangladesh: a systematic review and meta-analysis. Int Urol Nephrol. 2021; 53(4): 713-718. doi:10.1007/s11255-020-02597-6. 2.     Hussain S, Jamali MC, Habib A, Hussain MS, Akhtar M, Najmi AK. Diabetic kidney disease: an overview of prevalence, risk factors, and biomarkers. Clinical Epidemiology and Global Health (CEGH). 2021; 9: 2-6. doi:10.1016/j.cegh.2020.05.016. 3.     Aso Y. Cardiovascular disease in patients with diabetic nephropathy. Curr Mol Med. 2008; 8(6): 533-543. doi:10.2174/156652408785747960. 4.     Oellgaard J, Gæde P, Rossing P, Persson F, Parving HH, Pedersen O. Intensified multifactorial intervention in type 2 diabetics with microalbuminuria leads to long-term renal benefits [published correction appears in Kidney Int. 2017; 91(5): 1257. doi: 10.1016/j.kint.2017.03.007]. Kidney Int. 2017; 91(4): 982-988. doi:10.1016/j.kint.2016.11.023. 5.     Ueki K, Sasako T, Okazaki Y, Miyake K, Nangaku M, Ohashi Y, et al. Multifactorial intervention has a significant effect on diabetic kidney disease in patients with type 2 diabetes. Kidney Int. 2021; 99(1): 256-266. doi:10.1016/j.kint.2020.08.012. 6.     Sun H, Saeedi P, Karuranga S, Pinkepank M, Ogurtsova K, Duncan B, et al.IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045 [published correction appears in Diabetes Res Clin Pract. 2023; 204: 110945. doi:10.1016/j.diabres.2023.110945]. Diabetes Res Clin Pract. 2022; 183: 109119. doi:10.1016/j.diabres.2021.109119. 7.     Islam SMS, Salehin M, Zaman SB, Tansi T, Gupta RD, Barua L, et al.Factors associated with chronic kidney disease in patients with type 2 diabetes in Bangladesh. Int J Environ Res Public Health. 2021; 18(23): 12277. doi:10.3390/ijerph182312277. 8.     Ahsan KZ, Iqbal A, Jamil K, Haider MM, Khan SH, Chakraborty N,et al.Socioeconomic disparities in diabetes prevalence and management among the adult population in Bangladesh. PLoS One. 2022; 17(12): e0279228. doi:10.1371/journal.pone.0279228. 9.     Barzilay JI, Farag YMK, Durthaler J. Albuminuria: an underappreciated risk factor for cardiovascular disease. J Am Heart Assoc. 2024; 13(2): e030131. doi:10.1161/JAHA.123.030131. 10.  Farrell DR, Vassalotti JA. Screening, identifying, and treating chronic kidney disease: why, who, when, how, and what? BMC Nephrol. 2024; 25(1): 34. doi:10.1186/s12882-024-03466-5. 11.  Naaman SC, Bakris GL. Diabetic nephropathy: update on pillars of therapy slowing progression. Diabetes Care. 2023; 46(9): 1574-1586. doi:10.2337/dci23-0030. 12.  de Boer IH, Khunti K, Sadusky T, Tuttle KR, Neumiller JJ, Rhee CM, et al. Diabetes management in chronic kidney disease: a consensus report by the American Diabetes Association (ADA) and kidney disease: Improving Global Outcomes (KDIGO). Diabetes Care. 2022; 45(12): 3075-3090. doi:10.2337/dci22-0027. 13.  Hieshima K, Suzuki T, Sugiyama S, Kurinami N, Yoshida A, Miyamoto F, et al.Smoking cessation ameliorates microalbuminuria with reduction of blood pressure and pulse rate in patients with already diagnosed diabetes mellitus. J Clin Med Res. 2018; 10(6): 478-485. doi:10.14740/jocmr3400w. 14.  Schiffl H, Lang SM, Fischer R. Stopping smoking slows accelerated progression of renal failure in primary renal disease. J Nephrol. 2002; 15(3): 270-274. 15.  Phisitkul K, Hegazy K, Chuahirun T, Hudson C, Simoni J, Rajab H, et al. Continued smoking exacerbates but cessation ameliorates progression of early type 2 diabetic nephropathy. Am J Med Sci. 2008; 335(4): 284-291. doi:10.1097/MAJ.0b013e318156b799. 16.  Holland JA, Martin WP, Docherty NG, le Roux CW. Impact of intentional weight loss on diabetic kidney disease. Diabetes Obes Metab. 2019; 21(10): 2338-2341. doi:10.1111/dom.13813. 17.  Beck J, Greenwood DA, Blanton L, Bollinger ST, Butcher MK, Condon JE, et al.2017 National standards for diabetes self-management education and support. Diabetes Care. 2017; 40(10): 1409-1419. doi:10.2337/dci17-0025.     Cite this article as:Haque WMM, Hossain D, Amin MF, Samad T, Mohsena M, Habib SH, et al. Diabetic kidney disease in Bangladesh: a cross-sectional study on screening, treatment and prevention practice. IMC J Med Sci. 2025; 19(1): 001. DOI:https://doi.org/10.55010/imcjms.19.001 <![CDATA[Trends of COVID-19 mortality and hospitalization rates in southern states of the United States, 2020-2023]]> Bever-Leigh Holden Precious Patrick Edet Elizabeth A.K. Jones Amal K. Mitra https://imcjms.com/journal_full_text/520 2024-04-09 10:32:28 Original Article July 2024; Vol. 18(2):001 Abstract Background and Objectives: The COVID-19 pandemic, caused by the novel coronavirus SARS-CoV-2, has emerged as one of the most profound global health crises of the 21st century. In the United States, the impact of COVID-19 has been severe, with notable disparities observed in the Southern region. This study aims to evaluate trends in COVID-19 mortality and hospitalization rates in southern states over the course of 2020 to 2023 by presenting a comprehensive analysis of trends in COVID-19 outcomes within Southern states. Methods: Data for the study was collected from the COVID-19 Data Tracker, a resource provided by the Centers for Disease Control and Prevention (CDC). Stratification techniques were employed to categorize the sample into subgroups of Southern states (Arkansas, Alabama, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Texas, and Virginia). Joinpoint regression models were used to calculate Annual Percentage Change (APC) and Average Annual Percentage Change (AAPC). Results: Results showed a downward trend in both age adjusted APC and AAPC COVID-19 hospitalization rates and an upward trend in mortality rates for all southern states between 2020 to 2023. Only 3 out of the 12 states have age adjusted mortality rates that are lower than the national age adjusted mortality rate for COVID-19 (286.4 deaths per 100,000). COVID-19 vaccine coverage in 12 southern states is 61.8% - 91.3%. Conclusion:The study contributes to a deeper understanding of the evolving dynamics of COVID-19 pandemic within the southern U.S. states. The information would be a valuable guidance for public health strategies, resource allocation, and policymaking aimed at addressing this ongoing crisis. July 2024; Vol. 18(2):001.  DOI: https://doi.org/10.55010/imcjms.18.013 *Correspondence: Bever-Leigh Holden, Jackson State University, Department of Epidemiology and Biostatistics, Jackson, Mississippi, USA, Email:bever-leigh.i.holden@students.jsums.edu; beverleighholden@yahoo.com   Introduction The COVID-19 pandemic, caused by the novel coronavirus SARS-CoV-2, emerged as one of the most profound global health crises of the 21st century [1]. Since its inception in late 2019, this highly contagious and potentially lethal virus has threatened human population worldwide causing severe respiratory distress and life-threatening complications [2].  According to the World Health Organization (WHO), a total of 770,875,433 confirmed cases of COVID-19, including 6,959,316 deaths globally were reported as of September 27, 2023 [3].  In addition, the cumulative count of COVID-19 vaccine doses administered globally stands at 13,505,262,477 as of September 19, 2023 [3]. With millions of cases and fatalities recorded worldwide, this pandemic has not only strained healthcare systems but has also disrupted economies, education, and the daily lives of many [4].  In the United States (U.S.), the impact of COVID-19 has been severe, causing 6,368,333 hospitalizations and 1,144,539 deaths as of September 23, 2023 [3], with notable disparities reported, particularly among racial/ethnic minorities and in the Southern region of the country [6,7]. These outcomes have necessitated an unprecedented public health response, including lockdowns, social distancing, mask mandates, and the rapid development of vaccines [8]. As the U.S. grapples with the spread and devastating consequences of COVID-19, public health systems have been challenged to comprehend, mitigate, and respond effectively to the multifaceted dimensions of this disease threat. According to the CDC, the U.S. federal Public Health Emergency (PHE) declaration for COVID-19 concluded on May 11, 2023, leading to the expiration of the CDC's authorization to collect specific public health data [9]. The CDC is actively integrating its COVID-19 emergency response into existing programs, transitioning to sustainable public health practices [9]. The CDC remains committed to providing valuable COVID-19 updates for informed public health actions, especially for those at the highest risk, prioritizing the protection of the nation's public health [9]. One of such updates was released on September 8, 2023, in a CDC report titled, “Update on SARS CoV-2 Variant BA.2.86,” which announced a new COVID-19 variant called BA.2.86 [10]. According to the CDC, “the current increases in COVID-19 cases and hospitalizations in the United States are not being driven by BA.2.86 and instead are being caused by other predominantly circulating viruses” [10]. The CDC advises individuals aged 5 years and above to receive one dose of a 2023-2024 updated COVID-19 vaccine from Pfizer-BioNTech, Moderna, or Novavax, as a safeguard against severe illness caused by COVID-19 [11]. Southern states, characterized by their unique demographics, healthcare infrastructure, and policies, have faced distinct challenges in dealing with the pandemic [12,13]. These factors account for a high number of White Americans having elevated COVID-19 mortality rates. Additionally, research findings show that in 2022, Southern states including Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee, recorded the highest number of COVID-19-associated deaths, totaling 56,695 [5]. To comprehend the gravity of the situation, it is crucial to compare and contrast the experiences of Southern states with national averages as such comparisons enable the identification of COVID-19 patterns and disparities, measurement of COVID-19 trends over a pre-specified fixed interval utilizing Annual Percentage Change (APC) and Average Annual Percentage Change (AAPC) tools, and the assessment of potential factors contributing to variations in COVID-19 outcomes, such as mortality and hospitalization rates. While the COVID-19 pandemic has prompted a wealth of research, there remains a notable gap in the knowledge regarding COVID-19 trends, and APC and AAPC of hospitalization and mortality rates in Southern states. As a result, our current understanding of the pandemic's trajectory within the Southern states remains incomplete, limiting our ability to tailor public health responses, allocate resources effectively, and inform evidence-based policymaking in this region. To address this knowledge gap, it is imperative that researchers prioritize region-specific studies that employ robust methodologies to analyze APC and AAPC trends in hospitalization and mortality rates. Such research endeavors are essential not only for enhancing our comprehension of the evolving COVID-19 dynamics in the Southern states but also for shaping targeted interventions and public health strategies that can mitigate the impact of the virus in this distinct geographical context. To address this gap in knowledge, this study aims to evaluate trends in COVID-19 mortality and hospitalization rates in southern states over the course of 2020 to 2023 by presenting a comprehensive analysis of trends in COVID-19 outcomes within Southern states. Through a rigorous examination of these trends, we intend to shed light on the changing dynamics of COVID-19 within this region, thereby informing public health strategies, resource allocation, and policy decisions necessary to combat this ongoing crisis.   Materials and Methods Data Collection: Data was exported from the CDC’s COVID-19 Tracker. The database contains COVID-19 related surveillance data from each state in the United States. SAS Studio [15] was used to calculate standard error for joinpoint regression and MS excel/ text file was used to prepare data (variables: state, year, age adjusted rate, and standard error) for joinpoint regression software. Stratification was used to separate the sample into subgroups of southern states (Arkansas, Alabama, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Texas, and Virginia. Statistical Analysis: Age-adjusted rates and frequencies were extracted from the CDC database. SAS Studio [15] was used to calculate the standard error for the sample. U.S. Surveillance, Epidemiology, and End Results (SEER) Joinpoint regression program version 5.0 [16] was used to calculate Annual Percentage Change (APC) and Average Annual Percentage Change (AAPC) of hospitalization and mortality rates in southern states. Joinpoint regression describes trends and significant changes in trends.   Based on the Bayesian information criterion [17], the Empirical Quantile Method was used to identify the significant best fit line for trend 1. P-value was not calculated based on the method. However, each model tested for significance and listed the results for significance. Confidence intervals were calculated for APC and AAPC. Calculation of APC and AAPC: APC assumes the change at a constant percentage of the rate of the previous year to predict outcomes [18]. Therefore, the following regression model is used to estimate the APC for a series of data: , where  is the natural log of the rate in year “y”.   The APC from year “y” to year “y+1” =    =    =  The AAPC is a weighted average of the slope coefficients of the underlying joinpoint regression model with the weights equal to the length of each segment over the interval [19]. If we denote bi as the slope coefficient for the ith segment with i indexing the segments in the desired range of years, and wi as the length of each segment in the range of years, then:   Results Trends of COVID-19 hospitalization and mortality rates in 12 southern states of United States for the period of 2020-2023 have been analyzed. COVID-19 hospitalization and mortality rates  Details of hospitalizations and deaths due to COVID-19 during 2020-2023 in all the 12 southern states of US are shown in Table-1, 2 and 2a. Between 2020 to 2023, the southern states of the United States (Arkansas, Alabama, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas) have a total of 2,418,046 hospitalizations, and 420,659 COVID-19 deaths. During this period, all the 12 southern states have experienced declines in COVID-19 hospitalizations. Rate of age adjusted decline of COVID-19 hospitalization in 12 southern states ranged from 57.4% to 90.1% (Table-2a). Highest and lowest decline has been observed in Kentucky (90.1%) and Florida (57.4%) respectively between 2020 to 2023. From 2020-2023, Texas has the highest number of hospitalizations in the southern region (n=607,125, 25.1%) while Kentucky has the highest age adjusted hospitalization rate (62.9 per 100,000) (Table-1and 2).   Table-1: Rates of COVID-19 hospitalization, mortality and vaccination against SARS-CoV-2 in 12 southern states of US, 2020-2023 (As of September 9th)     Between 2020-2023, all the southern states have experienced increases in COVID-19 mortality. The changes within the age-adjusted COVID-19 mortality rates ranged from 61.0% to 78.1% for southern states between 2020-2023. Louisiana has the lowest (61.0%) while Kentucky has the highest (78.1%) increase in mortality rates among the southern states from 2020-2023. From 2020-2023, Texas has the highest number of deaths in the southern region (n=102,325, 24.3%; Table-1). However, Mississippi has the highest age adjusted mortality rate in the southern region (428 deaths per 100,000; Table-2).In terms of weekly COVID-19 deaths as of September 9, 2023, 5 states (41.7%) had 1-9 deaths (Arkansas, Alabama, Kentucky, Louisiana, and Mississippi), 6 states (50%) had 13-24 deaths (Virginia-13 deaths; Georgia-15 deaths; Texas-17 deaths; Tennessee and South Caroline- 19 deaths; North Carolina-24 deaths), and 1 state (8.3%) had 66 deaths (Florida).   Table-2: Trends in COVID-19 hospitalizations and deaths, 2020-2023     COVID-19 vaccine coverage  In the southern states, 85,900,123 individuals have been administered at least 1 vaccine dose (Table-1). All the southern states have more than 60% vaccination coverage with at least 1 dose of a vaccine. The range of COVID-19 vaccine coverage in 12 southern states is 61.8% to 91.3% (Table-1). Virginia has the highest (91.3%) while North Carolina has the lowest (61.8%) vaccine coverage. COVID-19 mortality by gender, age, and race/ethnicity in the Southern states Gender: Between 2020-2023, males had higher age adjusted COVID-19 mortality rates (136.6 deaths per 100,000 [2020]; 158.8 deaths per 100,000 [2021]; 80.0 deaths per 100,000 [2021]; 26.5 deaths per 100,000 [2023]) than females (108.4 deaths per 100,000 [2020]; 123.2 deaths per 100,000 [2021]; 64.8 deaths per 100,000 [2020]; 11.9 deaths per 100,000 [2023]) in southern states. Between 2020-2023, the age adjusted mortality rate declined by 80% in males and by 89.0% in females. (Table-3) The trend for the age-adjusted mortality rates in males and females consisted of 1 segment with a significant APC of -20.6% (-50.5% to 7.1%) and -17.8% (-45.8% to 10%) respectively (Table-3).   Table-2a: Changes in age-adjusted hospitalization and mortality rates in 12 southern states of US     Age: Between 2020-2023, adults 65 years and older had higher age-adjusted COVID-19 mortality rates (904.9 deaths per 100,000 [2020]; 1085.9 deaths per 100,000 [2021]; 655.1 deaths per 100,000 [2022]; 149.5 deaths per 100,000 [2023]) than any other age group in southern states. Between 2020-2023, the age-adjusted mortality rate remained 0% for the 0-17 age group, but it declined by 99.7%, 92.2% and 83.5% in the 18-39, 40-64 and > 65 years age groups respectively. Adults aged 65 years and older had the lowest decline in age-adjusted mortality rates among all age groups in southern states. The trend for the age-adjusted mortality rates in the 0-17 age group could not be calculated due to 0 COVID-19 morality rates within the reported years. The trend for the age-adjusted mortality rates in the 18-39 age group consisted of 1 segment with a significant APC of -0.8% (-63.7% to 99.2%) The values for 40-60 and above 65 years age groups are -7.5% (-75.6% to 138.3%) and -20.0% (-43.6% to 0.6%) respectively (Table- 3).   Table-3: Trends in COVID-19 mortality by gender, race/ethnicity, and age in southern states, 2020-2023     Race/Ethnicity: Between 2020-2023, Whites had higher age adjusted COVID-19 mortality rates (138 deaths per 100,000 [2021]; 78.6 deaths per 100,000 [2022]; 15.64 deaths per 100,000 [2023]) than Blacks, American Indian/ Alaska Native (Non-Hispanic), Asians/ Pacific Islander (Non-Hispanic), and Hispanic in each year of the pandemic except for 2020. During 2020, Blacks had a higher age-adjusted COVID-19 mortality rate (91.8 deaths per 100,000) than any other race/ethnicity in southern states. Between 2020-2023, the age adjusted mortality rate declined by 93.2% in Blacks, 100% in American Indians/Alaska Natives (Non-Hispanic), 98.3% in Asians/Pacific Islanders (Non-Hispanic), 89.9% in Hispanics, and 82.9% in Whites in southern states. Whites had the lowest decline in age-adjusted COVID-19 mortality rates during the period (Table -3). The trend for the age-adjusted mortality rates for American Indians/ Alaska Natives (Non-Hispanic) could not be calculated due to zero COVID-19 morality rates being reported within the reported years. The trend for the age-adjusted mortality rates in different ethnic groups is shown in detail in Table-3.   Discussion Among all southern states, there is a downward trend in both age adjusted, annual percentage change and average annual percentage change hospitalization rates between 2020 to 2023 (Table 2). However, there is an upward trend in age adjusted, annual percentage change, and average annual percentage change mortality rates in all southern states between 2020 to 2023. Only 3 out of the 12 southern states (25%) have age adjusted COVID-19 mortality rates that are lower than the national average for age adjusted COVID-19 mortality rates (286.4 deaths per 100,000) in the United States [20] These states are Virginia (235 deaths per 100,000), North Carolina (271 deaths per 100,000), and Florida (249 deaths per 100,000). These findings are attributed to Virginia (91.3%), North Carolina (90.2%), and Florida (82.6%) having vaccination rates surpassing or approaching 85%, which is the ideal rate of COVID-19 vaccinations to foster herd immunity [21]. Unfortunately, the other southern states have failed to fall within a significant range of the 85% vaccination rate goal for each state. In addition to low vaccination rates, changes in COVID-19 variants may also be responsible for upward trends in mortality within southern states. These findings emphasize a need for initiatives to address challenges surrounding COVID-19 related issues, such as vaccine misinformation, allocation of resources, strategic planning, and state policies. As of 2023, there is also a downward trend in mortality rates based on gender, age, and race in all southern states. However, the downward COVID-19 mortality trends by subgroups are lower in females, Whites (Non-Hispanic), and adults 65 years and older. Furthermore, Whites (Non-Hispanic), adults 65 years and older, and males have higher rates of morality than any other group within their respective categories between 2020-2023. These findings are attributed to COVID-19 related complexities within southern states related to socio-political factors. In southern states, white males tend to be more influenced by negative political views regarding PPE (Personal protection equipment), vaccines, and COVID-19 prevention because of their political affiliations. While southern states are experiencing downward trends in mortality by each subgroup, findings still suggest that whites, males, and 65 years and old still depict the need for further intervention and education. The impact of COVID-19 can vary substantially from one region to another, and there are various theories that can contribute to why certain areas, notably specific southern states, may bear a disproportionately significant burden from the pandemic. It is important to remember that COVID-19's influence could alter overtime as vaccination rates rise, new variations develop, and public health policies are implemented and revised. Regional disparities may also vary as communities adapt to changing circumstances and new data becomes available. Factors such as population density, vaccination hesitancy, healthcare infrastructure, public health measures, demographics, socioeconomic factors, and political and cultural factors all result in the disproportionate rates of mortality in southern regions of the United States. There was significant geographic variation in COVID-19 cases and fatalities, with certain states bearing a disproportionately higher incidence of the disease [22]. Controlling the spread of the virus is often more difficult in areas with a higher population density. Southern states like Florida and Texas have densely populated metropolitan areas, such as Miami and Houston, where the virus can spread more easily due to close proximity. There was also a distinct urban-rural gap seen, with urban areas having greater case counts, undoubtedly due to population density and mobility, whereas rural areas had fewer cases but faced challenges with healthcare access and resources. Trust in health experts, government, or public health institutions are closely related to risk perception about COVID-10 immunizations and vaccine adoption [23]. Tailored and evidence-based health communication is critical in encouraging beneficial health behaviors and winning folks' trust. Individuals agreed to accept the vaccine if it was required by their employer, if government officials gave clear and consistent communication about the infection and vaccine regarding the safety and effectiveness of the vaccine, or if it was suggested by their doctor or a health professional. The frequency with which people watched, listened to, or read the news reflected an increase in vaccine acceptance. However, the media frequently exaggerates the hazards of vaccination, which can contribute to lower vaccine acceptability among some populations. COVID-19 vaccinations and prevention strategies are critical for preserving public health, decreasing virus spread, and ultimately ending the pandemic. To overcome the obstacles posed by COVID-19, a mix of immunization, public health interventions, and responsible individual behavior is required.    Healthcare infrastructure availability and capacity can have a substantial impact on a region's ability to handle COVID-19 cases. Some southern states have struggled with hospital capacity and funding, putting an additional strain on the healthcare system. Shortly after the start of the pandemic in the United States, COVID-19 infections spread quickly, resulting in rapid increases in hospitalizations. At that time the influx put a burden on healthcare infrastructure, such as hospitals, clinics, and emergency services [24]. Many healthcare facilities were suffering from a lack of beds, ventilators, and other crucial services. The epidemic disrupted worldwide supply systems for medical goods and equipment. Personal protection equipment, ventilators, testing kits, and even pharmaceuticals were in short supply. To deal with the pandemic, healthcare infrastructure needed to react quickly. This frequently entailed repurposing non-traditional venues such as COVID-19 treatment centers, establishing field hospitals, and establishing specialist COVID-19 sections within existing healthcare facilities. The state’s public and private clinics and hospitals funding allotment, population size, and demand all contributed to the Southern states’ ability to provide immediate and equitable healthcare to those who sought prevention and treatment options. Differences in the adoption and adherence to public health measures, such as mask regulations, social distance, and lockdowns all impacted the spread of the virus globally. Variability in adherence to these strategies guided the effects and impact of the COVID-19 burden in various places, especially in Southern regions, where political figures and representatives guided the adoption, or lack thereof, of public health suggested/mandated guidelines. Increases in COVID-19 cases and deaths in the south and rural areas represented disproportionate rates compared to other parts of the country [25]. The findings emphasize the importance of further understanding the factors behind perceptions of COVID-19 risk in rural areas. During national catastrophes, the dissemination of scientifically sound and consistent information is crucial. COVID-19 mortality rates are heavily influenced by demographics. Age, gender, race/ethnicity, socioeconomic level, occupational risks, and underlying political and health issues can all influence an individual's chance of acquiring the disease and outcome [26,27,28]. Southern states exhibit a higher prevalence of comorbidities, which raises the risk of the severity of the disease if infected [26]. One of the most important demographic parameters influencing COVID-19 mortality is age. Elderly individuals, particularly those over the age of 65, are at a significantly higher risk of serious illness and death if they contract the disease. Younger individuals, particularly children, are often less affected. Early in the pandemic, men were found to have a greater fatality rate than women. This gender disparity could be attributed to a variety of variables, including immune response disparities, the incidence of underlying health disorders, and a person's belief in health-seeking attention/treatment [26]. COVID-19 mortality rates have been found to be unequally distributed between racial and ethnic groupings. Some minority groups, such as Black, and Hispanic have had higher death rates than Whites earlier in the pandemic, which was consistent with the findings of this study. This gap is frequently linked to socioeconomic issues, lack of access to healthcare, and increased prevalence. Individuals with lower socioeconomic level, such as those with poor access to healthcare, unstable housing, and employment that involve close contact with others, are more likely to be exposed to the virus and suffer serious implications. Individuals with preexisting health issues, such as heart disease, diabetes, obesity, and respiratory disorders, are predisposed to catastrophic COVID-19 results. Cities with dense residents frequently have greater death rates than rural areas. Certain occupations, such as healthcare personnel, first responders, and vital workers, stand a higher risk of acquiring viral infection. This can have an impact on death rates in various occupational populations. Socioeconomic factors can have a substantial impact on COVID-19 fatality rates. Inequities in access to healthcare facilities, quality of care, and individual habits, have an impact on outcomes. During the initial phase of the COVID-19 epidemic, individuals with limited incomes had restricted access to healthcare, which made early diagnosis and treatment more challenging [27]. People in low-wage occupations were frequently unable to work from home which caused them to be more vulnerable to the virus. Individuals with lower education levels were linked to lower health literacy, which resulted in less effective preventative measures and delayed medical care. A lack of or insufficient health insurance resulted in delayed or inadequate care, increasing the chance of catastrophic COVID-19 outcomes. Overcrowding or inadequate housing rendered social distancing and isolation impossible, leading to an increased likelihood of transmission within homes. Inadequate nutrition caused by food instability was found to weaken the immune system and worsen the results for people infected with the virus. Individuals with limited access to private transportation found it difficult to obtain medical treatment or visit testing and immunization sites. Individual behaviors such as mask-wearing, social distancing, and vaccine hesitancy influenced by socioeconomic disparities, affected COVID-19 outcomes. Economic insecurity, job loss, and social isolation also led to mental health problems, which affected COVID-19 outcomes. Public health response measures are frequently influenced by political and cultural variables. Political divisions or cultural attitudes on health measures such as masking and vaccination had an impact on the COVID-19 burden in some circumstances [27,28]. COVID-19 is a worldwide pandemic, and international political collaboration was critical to contain its spread. Policies governing foreign travel, trade, and vaccine delivery were critical in impacting the Southern region of the United States’ vulnerability to the virus. Clear and consistent messaging from political and social groups is important to persuade people to take precautionary measures to prevent morbidity and mortality. This study has some limitations. First, only individuals with confirmed COVID-19 cases were included in the study, which may have left out individuals with unconfirmed COVID-19 diagnosis. Second, based on the nature of the study, there is a low capacity to estimate associations. The study is important because it focuses on analyzing trends and changes of COVID-19 hospitalization and mortality over periods of time in all the Sothern states of US. In summary, COVID-19 pandemic had a significant impact on mortality rates in the United States, with southern regions bearing a disproportionate weight of deaths. COVID-19 has a substantial impact on global healthcare infrastructure, revealing both its strengths and weaknesses. It underlined the significance of robust and adaptive healthcare systems in responding to unforeseen problems such as COVID-19 pandemics. To address the gaps in healthcare system, public health and medical professionals must concentrate on underlying social and economic inequities as well as enhancing healthcare access for vulnerable groups. Public health measures, such as educational campaigns aimed at vulnerable communities, equal access to testing, treatment, and vaccination are crucial to contain and minimize COVID-19 pandemic. The measures can help minimizing COVID-19 mortality rates, especially in the southern states.   Author’s contribution EAKJ conceptualized the study; AKM validated the study and the original draft; BH, PPE and EAKJ prepared the original draft, reviewed and edited the manuscript.   Competing interest: No competing interest/conflict of interest.   Funding: None   References 1.     Centers for Disease Control and Prevention. COVID-19 and your health. 2023; https://www.cdc.gov/coronavirus/2019-ncov/your-health/about-covid-19.html. [Accessed on Oct. 01, 2023]. 2.     World Health Organization. Coronavirus disease (COVID-19) pandemic. https://www.who.int/europe/emergencies/situations/covid-19. [Accessed on Oct. 01, 2023]. 3.     World Health Organization.WHO COVID-19 dashboard. https://covid19.who.int.[Accessed on Oct. 01, 2023] 4.     Isasi F, Naylor MD, Skorton D, Grabowski DC, Hernández S, Rice VM. Patients, families, and communities COVID-19 impact assessment: Lessons learned and compelling needs. NAM Perspect. 2021; 2021: 10.31478/202111c. doi: 10.31478/202111c. 5.     Centers for Disease Control and Prevention. COVID data tracker.https://covid.cdc.gov/covid-data-tracker. [Accessed on Oct. 01, 2023]. 6.     Boehmer TK, Koumans EH, Skillen EL, Kappelman MD, Carton TW, Patel A, et al. Racial and ethnic disparities in outpatient treatment of COVID-19 - United States, January-July 2022. MMWR Morb Mortal Wkly Rep. 2022; 71(43): 1359-1365. doi: 10.15585/mmwr.mm7143a2. 7.     Lopez L 3rd, Hart LH 3rd, Katz MH. Racial and ethnic health disparities related to COVID-19. JAMA. 2021; 325(8): 719–720. doi:10.1001/jama.2020.26443. 8.     Mahase E. Covid-19: Lockdowns and masks helped reduce transmission, expert group finds. BMJ. 2023; 382:1959. doi:10.1136/bmj.p1959. 9.     Centers for Disease Control and Prevention. End of the federal COVID-19 public health emergency (PHE) declaration. 2023; https://www.cdc.gov/coronavirus/2019-ncov/your-health/end-of-phe.html. [Accessed on Nov. 20, 2023]. 10.  Centers for Disease Control and Prevention. Update on SARS CoV-2 variant BA.2.86. 2023; https://www.cdc.gov/respiratory-viruses/whats-new/covid-19-variant-update-2023-09-08.html. [Accessed on Nov. 20, 2023] 11.  Centers for Disease Control and Prevention. Stay up to date with COVID-19 vaccines. 2023; https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html. [Accessed on Nov. 20, 2023] 12.  Johnston CD, Chen RX. The COVID-19 pandemic and its impact on the southern United States. J Comp Fam Stud. 2020; 51(3–4): 314–323. doi: covidwho-972369. 13.  Laughland O. Death by structural poverty: US south struggles against Covid-19. 2020; https://www.theguardian.com/world/2020/aug/05/us-deep-south-racism-poverty-fuel-coronavirus-pandemic. [Accessed on Oct. 01, 2023]. 14.  Ahmad FB, Cisewski JA, Xu J, Anderson RN. COVID-19 mortality update - United States, 2022.MMWR Morb Mortal Wkly Rep. 2023; 72(18):493-496. doi:10.15585/mmwr.mm7218a4. 15.  SAS Studio, SAS Studio SAS Support. (n.d.) https://support.sas.com/en/software/studio-support.html. [Accessed on Nov. 22, 2023].  16.  National Cancer Institute. Division of Cancer Control & Population Sciences. Joinpoint Trend Analysis Software. 2023; https://surveillance.cancer.gov/joinpoint/ [Accessed on Nov. 22, 2023].  17.  Science Direct. Bayesian information criterion - an overview. (n.d.) https://www.sciencedirect.com/topics/social-sciences/bayesian-information-criterion. [Accessed on Nov. 22, 2023]. 18.  Joinpoint Help System. Annual percent change (APC) and confidence interval. https://surveillance.cancer.gov/help/joinpoint/setting-parameters/method-and-parameters-tab/apc-aapc-tau-confidence-intervals/estimate-average-percent-change-apc-and-confidence-interval. [Accessed on Nov. 22, 2023]. 19.  Joinpoint Help System. Average annual percent change (AAPC) and confidence interval. https://surveillance.cancer.gov/help/joinpoint/setting-parameters/method-and-parameters-tab/apc-aapc-tau-confidence-intervals/average-annual-percent-change-aapc#:~:text=Thus%2C%20the%20AAPC%20is%20computed,1%20%7D%20x%20100%20%3D%200.7. [Accessed on Nov. 22, 2023]. 20.  Centers for Disease Control and Prevention. Covid Data tracker. https://covid.cdc.gov/covid-data-tracker/#datatracker-home. [Accessed Nov. 22, 2023].  21.  Mitra AK. Epidemiology for Dummies. 1st ed. John Wiley & Sons; 2023. 22.  Jackson SL, Derakhshan S, Blackwood L, Lee L, Huang Q, Habets M, et al. Spatial disparities of COVID-19 cases and fatalities in United States counties. Int J Environ Res Public Health. 2021; 18(16): 8259. doi:10.3390/ijerph18168259. 23.  Joshi A, Kaur M, Kaur R, Grover A, Nash D, El-Mohandes A. Predictors of COVID-19 vaccine acceptance, intention, and hesitancy: A scoping review. Front Public Health. 2021; 9: 698111. doi:10.3389/fpubh.2021.698111. 24.  Ndayishimiye C, Sowada C, Dyjach P, Stasiak A, Middleton J, Lopes H, et al. Associations between the COVID-19 pandemic and hospital infrastructure adaptation and planning - a scoping review. Int J Environ Res Public Health. 2022; 19(13): 8195. doi:10.3390/ijerph19138195. 25.  Pro G, Schumacher K, Hubach R, Zaller N, Giano Z, Camplain R, et al. US trends in mask wearing during the COVID-19 pandemic depend on rurality. Rural Remote Health. 2021; 21(3): 6596. doi:10.22605/rrh6596. 26.  Kniep N, Achidi T, Flynn C, Gangur J, Khot M, Kueider L, et al.County-level sociodemographic factors associated with COVID-19 incidence and mortality in North and South Carolina. N C Med J. 2022; 83(5): 366–374. doi:10.18043/ncm.83.5.366. 27.  Aburto JM, Tilstra AM, Floridi G, Dowd JB. Significant impacts of the COVID-19 pandemic on race/ethnic differences in US mortality. Proc Natl Acad Sci. U S A. 2022; 119(35): e2205813119. doi:10.1073/pnas.2205813119.  28.  The Lancet Infectious Diseases. Political casualties of the COVID-19 pandemic. Lancet Infect Dis. 2020; 20(7): 755. doi:10.1016/s1473-3099(20)30496-5. [Editorial].Cite this article as:Holden B-L, Edet PP,  Jones EAK, Mitra AK. Trends of COVID-19 mortality and hospitalization rates in southern states of the United States, 2020-2023.  IMC J Med Sci. 2024; 18(2):001.  DOI: https://doi.org/10.55010/imcjms.18.013. <![CDATA[Extended spectrum beta-lactamase production and blaCTX-M gene in Escherichia coli and Klebsiella pneumoniae causing urinary tract infection at a tertiary care hospital in Nepal]]> Gaurab Pandey Anmol Karki Prashant Karki Chattra Thapa https://imcjms.com/journal_full_text/521 2024-04-09 12:06:39 Original Article July 2024; Vol. 18(2):002 Abstract Background and objective: Urinary tract infections (UTIs) are the most common bacterial infections where Escherichia coli (E. coli) and Klebsiella pneumoniae (K. pneumoniae) are the predominating pathogens. These pathogens have a high rate of antibiotic resistance and exhibit the production of extended-spectrum beta-lactamase (ESBL). This study investigated the antibiotic resistance pattern and ESBL production of E. coli and K. pneumoniae isolated from patients with UTIs attending a tertiary care hospital in Nepal by both phenotypic and genotypic techniques. Materials and methods: A cross-sectional study was performed where 4664 mid-stream urine specimens from suspected UTI cases were cultured. Isolated E. coli and K. pneumoniae were subjected to antibiotic susceptibility testing by Kirby Bauer disc diffusion method. Genotypic detection of blaCTX-M gene was performed using polymerase chain reaction (PCR). Results: Out of 4664 urine samples processed, 564 (12.1%) were positive for E. coli (475, 10.2%) and K. pneumonia (89, 1.9%). Out of the total 564 studied samples, 267 (47.3%) were MDR isolates (E. coli: 222, 46.7%; K. pneumoniae: 45, 50.6%) and 96 (17%) were positive for ESBL by double disc confirmatory test. Out of 24 ESBL positive E. coli and 6 K. pneumoniae, 19 (79.2%) and 3 (50%) respectively were positive for blaCTX-M gene. Conclusion: This study indicates high prevalence of MDR and ESBL producing E. coli and K. pneumoniae causing UTIs at an urban hospital setting in Nepal. July 2024; Vol. 18(2):002. DOI: https://doi.org/10.55010/imcjms.18.014 *Correspondence: Gaurab Pandey, Department of Medical Laboratory Science, Nobel College Affiliated to Pokhara University, Kathmandu, Nepal. Email: pandeygaurab67@gmail.com   Introduction Urinary tract infection (UTI) is a common bacterial infection encountered in medical practice [1-5]. Escherichia coli and Klebsiella pneumoniae are the two main bacteria frequently linked to urinary tract infections [3,6]. Additionally, these bacteria are also responsible for bloodstream, wound, and respiratory tract infections [7-11]. Antibiotics such as carbapenems, fluoroquinolones, β-lactams, and β-lactam/β-lactamase inhibitors are commonly used to treat urinary tract infections [8,12]. But as of late, many uropathogens have developed resistance to these widely used antimicrobial agents [8,12]. One of the significant classes of β-lactamases known as extended-spectrum β-lactamases (ESBLs) is capable of conferring resistance to a wide range of β-lactam antibiotics. These include the extended spectrum (or third generation) cephalosporins (namely cefotaxime, ceftriaxone, and ceftazidime) and monobactams (aztreonam), but not the cephamycins (namely cefoxitin) and carbapenems (imipenem, meropenem, and etrapenem) [2,13-18]. However, β-lactamase inhibitors such as tazobactam, clavulanic acid, and sulbactam can block these enzymes [14,18-21]. Long-term antibiotic exposure, extended hospital stay, instrumentation or catheterization, are the major risk factors for colonization or infection with ESBL-producing organisms [2,6,7,10,14,16,22,23]. Temoniera (TEM), sulfhydryl reagent variable (SHV), and cefotaximase-Munich (CTX-M) enzymes are the sources of the majority of ESBLs, which are encoded by the blaTEM, blaSHV, and blaCTX-M genes respectively [16,22,24,25]. Recently, CTX-M-type beta-lactamases are reported as the most common resistance factors in clinical settings worldwide [26]. Bacteria that possess the blaCTX-M gene are resistant to a wide range of cephalosporin classes. Therefore, it is important to continuously monitor ESBL producing E. coli and K. pneumoniae causing different types of infections in hospitals and a locality. This study aimed to determine antibiotic resistance pattern, ESBLs production, and blaCTX-M gene in E. coli and K. pneumoniae isolates from urine samples of suspected UTI cases.   Materials and methods This was a cross-sectional study conducted in the Department of Microbiology at Alka Hospital, Lalitpur, Nepal, from March 2023 to May 2023. The study population comprised of patients with clinically suspected UTIs from all age groups. The study was approved by Institutional Review Committee – Nobel College with the Ref No: BMM IRC 289/2019. Information on patient demographics (age, sex, and occupation) and relevant clinical history was collected from patients’ records in hospital folders. Mid-stream urine (MSU) sample was collected in a leak-proof, sterile, screw-capped container. Samples held for more than two hours at room temperature and improperly or unlabeled samples, were excluded from the study. Isolation and Identification of organisms: Urine samples were cultured following standard microbiological guidelines as described elsewhere [27]. Using a sterile calibrated loop (2 mm), the urine samples were streaked directly on MacConkey agar and Blood agar plates. These plates were incubated at 37 °C aerobically and after overnight incubation, they were checked for bacterial growth. Colony count was made, and the positive result was considered for plates showing more than or equal to 105 colony-forming units (CFU)/mL of urine based on Kass, Marple, and Sanford criteria [28]. The isolates were identified based on cultural characteristics in MacConkey agar and Blood agar, Gram staining, catalase test, oxidase test, and other relevant biochemical tests as per standard laboratory methods [29]. Antibiotic susceptibility testing: Antimicrobial susceptibility testing (AST) was done by the Kirby-Bauer disk diffusion technique using Muller Hinton agar [30]. All identified isolates of E. coli and K. pneumoniae were tested for susceptibility against amikacin (30 μg), amoxicillin (10 μg), gentamicin (10 μg), ceftazidime (30 μg), cefotaxime (30 μg), ceftriaxone (30 μg), cotrimoxazole (25 μg), ciprofloxacin (5 μg), nitrofurantoin (300 µg), nalidixic acid (30 μg), norfloxacin (5 μg), meropenem (10 μg), piperacillin/tazobactam (100/10 μg), imipenem (10 μg), tigecycline (15 μg), polymixin B (10 μg) and colistin (10 μg). Results were interpreted based on the Clinical and Laboratory Standards Institute (CLSI) 2016 guidelines [30,31]. The bacterial isolates showing resistance towards three or more different antibiotic classes were considered multidrug-resistant (MDR) [32].  Screening and confirmation of ESBL producers: The screening was done by disc diffusion technique using cefpodoxime (30 µg), cefotaxime (30 µg), ceftazidime (30 µg), ceftriaxone (30 µg), cefotaxime (30 µg), aztreonam (30 µg) discs. For confirmation, combined disc test was performed using ceftazidime (30 µg) alone, and ceftazidime + clavulanic acid (20 µg + 10 µg). A difference of ≥5 mm between the zone diameters of either of cephalosporin disks and their respective cephalosporin/clavulanate disk was taken to be phenotypic confirmation of ESBL production [30]. Amplification and detection of blaCTX-M gene using PCR method: From confirmed ESBL producers, plasmids were extracted using standard alkaline hydrolysis method. These plasmids served as the template for PCR. The blaCTX-M gene amplification was performed by PCR technique using specific primer: 5'-TTTGCGATGTGCAGTACCAGTAA-3' as a forward primer and 5'- CTCCGCTGCCGGTTTTATC-3' as a reverse primer [19]. A final volume of 25 µl was prepared by adding 12.5 µl master mix green go-Taq, 1 μl of forward and reverse primer each, 8.5 µl nuclease-free water, and 2 μl bacterial DNA. Amplification was performed with the following cycling conditions: initial denaturation at 940C for 5 minutes; followed by 30 cycles each of extended denaturation at 950C for 45 seconds, annealing for 620C for 45 seconds, extension at 720C at 30 seconds, and extended extension at 720C for 10 minutes. The PCR products and the DNA marker were visualized by using 2% agarose gel electrophoresis. Quality Control: E. coli ATCC 25922 and K. pneumoniae ATCC 700603 were used as negative and positive controls, respectively. For PCR already confirmed E. coli strains harboring blaCTX-M were taken as a positive control and nuclease free water as the negative control. Statistical analysis: The statistical analysis was performed in Statistical Package for Social Sciences (SPSS) version 25.0. Discrete variables were expressed into percentages. Categorical variables were compared using the Chi square test and a p-value <0.05 was considered a statistically significant finding.   Results Out of 4664 urine samples processed, 564 (12.1%) were positive for E. coli (475, 10.2%) and K. pneumonia (89, 1.9%). Among 564 studied samples, the sex wise distribution of the patients showed that 110 (19.5%) isolates were from male and 454 (80.5%) isolates were from female patients. Most organisms were isolated from the age group 21-40 years. Least organisms were isolated from age group 0 -20 years (Table-1).   Table-1: Age and sex-wise distribution of cases from whom E. coli and K. pneumoniae were isolated     Out of the total 564 studied samples, 267 (47.3%) were MDR isolates (E. coli: 222, 46.7%; K. pneumoniae: 45, 50.6%) and 96 (17%) were positive for ESBL by double disc confirmatory test (Table-2). Out of 222 MDR E. coli, 160 (72.1%) were ESBL positive by screening test while 82 (36.9%) became ESBL positive by confirmatory test. Similarly for K. pneumoniae, the ESBL positivity rate by screening and confirmatory test was 60% and 22.2% respectively.  The rate of ESBL positivity among non-MDR isolates of E. coli was 1.6% while none of the non-MDR K. pneumoniae was positive for ESBL (Table-2). There was a significant association between ESBL production and MDR isolates (p<0.001). But the rate of MDR and ESBL positivity was not significantly (p > 0.05) different between E. coli and K. pneumoniae.     Table-2: ESBL positivity in MDR and non-MDR E. coli and K. pneumoniae     Detail rate of ESBL positivity in MDR E. coli and K. pneumoniae isolated from male and female patients is shown in Table-3.  Among 222 MDR E. coli isolates, 52 (48.6%) and 170 (46.2%) were from male and female patients respectively.  Out of 107 and 368 E. coli isolates from male and female patients, 52 (48.6%) and 170 (46.2%) isolates were MDR respectively. The rate of ESBL producing MDR E. coli from male and female cases was not significantly (p>0.05) different (32.7% vs. 40.6%). Similarly, the rate of ESBL positive K. pneumoniae isolated from male and female   patients was not significantly (p>0.5) different (33.3% s. 21.4%).   Table-3: ESBL positivity in MDR E. coli and K. pneumoniae isolated from male and female patients     Age wise distribution of MDR and ESBL producing isolates is shown in Table-4. Rate of MDR E. coli and K. pneumoniae was significantly (p<0.05) higher among the older age groups compared to younger groups. The rate of ESBL producing E. coli and K. pneumoniae was not significantly different among the groups.   Table-4: Age wise distribution of MDR and ESBL producing E. coli and K. pneumoniae     About 40.7% to 67.7% E. coli isolates were resistant to quinolones, amoxicillin+clavulanate, co-trimoxazole and imipenem (Table-5).  Except imipenem, the rate of resistance of K. pneumoniae to these antibiotics was between 50%-90%. None of the E. coli and K. pneumoniae was resistant to colistin.  Amikacin, meropenem, tigecycline, nitrofurantoin, polymixin-B, and colistin were the most effective antibiotic for ESBL positive E. coli and K. pneumoniae.     Table-5: Antibiotic susceptibility pattern of ESBL producing E. coli and K. pneumoniae     Table-6: Distribution of blaCTX-M gene among ESBL-producing E. coli and K. pneumoniae isolates       Figure-1: Agarose gel electrophoresis of the amplified PCR product for blaCTX-M gene. Lane 1 and 16:100 bp DNA markers; Lane 2 and 17: negative control; Lane 3 and 18: positive control; Lane 4 to 15 and Lane 19 to 30: isolates tested for the presence of blaCTX-M gene (560 bp).   Discussion The present study sought to determine the rate of ESBL producing E. coli and K. pneumoniae isolates causing urinary tract infections. We found that these organisms had a high level of antibiotic resistance and were the most frequent cause of UTIs. In our series, E. coli and K. pneumoniae was isolated from 12.1% of the 4,664 urine specimens evaluated. This finding is comparable to other reported studies from Nepal [33-35]. Our study sought to determine how common ESBL producing E. coli and K. pneumoniae isolates from urinary tract infections. Of the total E. coli and K. pneumoniae isolates, 17% were ESBL producers. Other studies from Nepal and the region reported variable rates of ESBL producing E. coli and K. pneumoniae in urine and different clinical samples [33-38]. In our study, blaCTX-M gene was present in 79.2% and 50% of E. coli and K. pneumoniae respectively. Others have reported higher prevalence of blaCTX-M gene from 66.6% to 100% in E. coli and K. pneumoniae [19,35,39,40]. Variations in the volume and kind of antibiotic use as well as variations in the time of isolate collection may account for the variations in frequencies and prevalence of these genes. One of the noteworthy findings in the present study among ESBL producers was the high resistance rate to imipenem (67.7%) which is contrary to that found by Shakya et al [38] and Zeynudin et al [41] who reported the imipenem résistance rate as 0% and 1.90%, respectively. High imipenem resistance can be attributed to the prevalence of carbapenemase β-lactamases as well as a rise in the haphazard use of the antibiotics to treat infections [34]. Furthermore, both of the ESBL isolates in our investigation showed high resistance to amoxicillin+clavulanic acid. The finding is consistent with the findings of Shashwati et al [37]. Multidrug resistance trends can differ between countries or even hospitals within the same nation due to differences in antibiotic prescribing practices during infection and lapses in an efficient infection control program. The emergence of MDR and ESBL producing E. coli and K. pneumoniae isolates with high antibiotic – resistant rates to commonly used antibiotics and predominance of blaCTX-M-beta lactamase gene poses a serious concern to the clinicians and microbiologists. Regular monitoring of antibiotic susceptibility and associated genes along with rationale use of antibiotics for treating the predominant pathogens like E. coli and K. pneumoniae in healthcare facilities is essential to contain the spread of antibiotic résistance.   Author Contributions GP: Conceptualization and designing of the study, approval of SOP for the study, supervised the study, and validating the results, manuscript – writing, editing, reviewing and submitting; AK, PK and CT: Writing SOP for the study, sample collection, performing tests, result analysis, and reporting of the results, manuscript writing, literature search. Conflict of Interest The authors have no conflicts of interest to declare.   Ethics approval The ethical approval was granted by Institutional Review Committee – Nobel College with the Ref No: BMM IRC 289/2019.   Funding The authors did not receive any funding.   References 1.     Gharavi MJ, Zarei J, Roshani-Asl P, Yazdanyar Z, Sharif M, Rashidi N.Comprehensive study of antimicrobial susceptibility pattern and extended spectrum beta-lactamase (ESBL) prevalence in bacteria isolated from urine samples. Sci Rep. 2021; 11(1): 578. doi: 10.1038/s41598-020-79791-0. 2.     Yadav KK, Adhikari N, khadka R, Pant AD, Shah B. Multidrug resistant Enterobacteriaceae and extended spectrum β-lactamase producing Escherichia coli: a cross-sectional study in National Kidney Center, Nepal. Antimicrob Resist Infect Control. 2015; 4(42): 1-7. doi: 10.1186/s13756-015-0085-0. 3.     Subedi K, Lama S, Dahal U, Karki F, Pandey A, Paudyal R. Phenotypic detection of extended spectrum beta lactamase production from E. Coli and K. Pneumoniae in urinary samples among children. Tribhuvan University Journal of Microbiology (TUJM). 2020; 7: 75-82. doi: 10.3126/tujm.v7i0.33801. 4.     Tan CW, Chlebicki MP. Urinary tract infections in adults. Singapore Med J. 2016; 57(9):  485. doi: 10.11622/smedj.2016153. 5.     Akram M, Shahid M, Khan AU. Etiology and antibiotic resistance patterns of community-acquired urinary tract infections in JNMC Hospital Aligarh, India. Ann Clin Microbiol Antimicrob. 2007; 6(1): 1-7. doi: 10.1186/1476-0711-6-4. 6.     Enyinnaya SO, Iregbu KC, Jamal WY, Rotimi VO. Antibiotic susceptibility profiles and detection of genes mediating extended-spectrum β-lactamase (Esbl) production in escherichia coli isolates from National Hospital, Abuja. Niger J Clin Pract. 2022; 25(8): 1216-1220. doi: 10.4103/njcp.njcp_1390_21. 7.     Hasibuan M, Suryanto D, Kusumawati RL. Phenotypic and molecular detection of blaCTX-M gene extended-spectrum beta-lactamases in Escherichia coli and Klebsiella pneumoniae of north Sumatera isolates. IOP Conf Ser: Earth Environ Sci.2018; 130(012032): 20-32. doi: 10.1088/1755-1315/130/1/012032. 8.     Halabi MK, Lahlou FA, Diawara I, El Adouzi Y, Marnaoui R, Benmessaoud R, et al. Antibiotic resistance pattern of extended spectrum beta lactamase producing Escherichia coli isolated from patients with urinary tract infection in Morocco. Front Cell Infect Microbiol. 2021; 11: 720701. doi: 10.3389/fcimb.2021.720701. 9.     Babini GS, Livermore DM. Antimicrobial resistance amongst Klebsiella spp. collected from intensive care units in Southern and Western Europe in 1997–1998. J Antimicrob Chemother. 2000; 45(2): 183-189. doi: 10.1093/jac/45.2.183. 10.  Kayastha K, Dhungel B, Karki S, Adhikari B, Banjara MR, Rijal KR, et al. Extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella species in pediatric patients visiting International Friendship Children’s Hospital, Kathmandu, Nepal. Infect Dis (Auckl). 2020; 13: 1178633720909798. doi: 10.1177/1178633720909798. 11.  Kaper JB, Nataro JP, Mobley HL. Pathogenic Escherichia coli. Nat Rev Microbiol. 2004; 2(2): 123-140. doi: 10.1038/nrmicro818. 12.  Shrestha A, Acharya J, Amatya J, Paudyal R, Rijal N. Detection of beta-lactamases (ESBL and MBL) producing Gram-negative pathogens in National Public Health Laboratory of Nepal. Int J Microbiol. 2022; 2022: 5474388. doi: 10.1155/2022/5474388. 13.  Altayb HN, Siddig MAM, El Amin NM, Mukhtar MM. Prevalence of blaCTX-M, blaTEM, and blaSHV genes among extended-spectrum β-lactamases-producing clinical isolates of Enterobacteriaceae in different regions of Sudan. Sudan J Med Sci. 2021; 16(1): 5-16. doi: 10.18502/sjms.v16i1.8933. 14.  Somily AM, Habib HA, Absar MM, Arshad MZ, Manneh K, Al Subaie SS, et al. ESBL-producing Escherichia coli and Klebsiella pneumoniae at a tertiary care hospital in Saudi Arabia. J Infect Dev Ctries. 2014; 8(9): 1129-1136. doi: 10.3855/jidc.4292. 15.  Higgins O, Chueiri A, O’Connor L, Lahiff S, Burke L, Morris D, et al. Portable differential detection of CTX-M ESBL gene variants, blaCTX-M-1 and blaCTX-M-15, from Escherichia coliisolates and animal fecal samples using loop-primer endonuclease cleavage loop-mediated isothermal amplification. Microbiol Spectr. 2023; 11(1): e03316-22. doi: 10.1128/spectrum.03316-22. 16.  El Aila NA, Al Laham NA, Ayesh BM. Prevalence of extended spectrum beta lactamase and molecular detection of blaTEM, blaSHV and blaCTX-M genotypes among Gram negative bacilli isolates from pediatric patient population in Gaza strip. BMC Infect Dis. 2023; 23(1): 99. doi: 10.1186/s12879-023-08017-1. 17.  Shilpakar A, Ansari M, Rai KR, Rai G, Rai SK. Prevalence of multidrug-resistant and extended-spectrum beta-lactamase producing Gram-negative isolates from clinical samples in a tertiary care hospital of Nepal. Trop Med Health. 2021; 49(1): 23. doi: 10.1186/s41182-021-00313-3. 18.  RamadanAA, Abdelaziz NA, Amin MA, Aziz RK. Novel blaCTX-M variants and genotype-phenotype correlations among clinical isolates of extended spectrum beta lactamase-producing Escherichia coli. Sci Rep. 2019; 9(1): 4224. doi: 10.1038/s41598-019-39730-0. 19.  Lohani B, Sharma L, Adhikari H, Sah AK, Khanal AB, Basnet RB, et al.Predominance of CTX-M type extended spectrum β-lactamase (ESBL) producers among clinical isolates of Enterobacteriaceae in a tertiary care hospital, Kathmandu, Nepal. Open Microbiol J. 2019; 13(1): 28-33. doi: 10.2174/1874285801913010028. 20.  Paterson DL, Bonomo RA.Extended-spectrum β-lactamases: a clinical update. Clin Microbiol Rev. 2005; 18(4): 657-686. doi: 10.1128/CMR.18.4.657-686.2005. 21.  Mansury D, Motamedifar M, Sarvari J, Shirazi B, Khaledi A. Antibiotic susceptibility pattern and identification of extended spectrum β-lactamases (ESBLs) in clinical isolates of Klebsiella pneumoniae from Shiraz, Iran. Iran J Microbiol. 2016; 8(1): 55-61. 22.  Nwafia IN,Ohanu ME, Ebede SO, Ozumba UC.Molecular detection and antibiotic resistance pattern of extended-spectrum beta-lactamase producing Escherichia coli in a Tertiary Hospital in Enugu, Nigeria. Ann Clin Microbiol Antimicrob. 2019; 18(1): 41. doi: 10.1186/s12941-019-0342-9. 23.  Abrar S, Hussain S, Khan RA, Ain NU, Haider H, Riaz S.Prevalence of extended-spectrum-β-lactamase-producing Enterobacteriaceae: first systematic meta-analysis report from Pakistan. Antimicrob Resist Infect Control. 2018; 7: 26. doi: 10.1186/s13756-018-0309-1. 24.  Moghaddam MN, Beidokhti MH, Jamehdar SA, Ghahraman M.Genetic properties of blaCTX-M and blaPER β-lactamase genes in clinical isolates of Enterobacteriaceae by polymerase chain reaction. Iran J Basic Med Sci. 2014; 17(5): 378-383. 25.  Castanheira M, Simner PJ, Bradford PA. Extended-spectrum β-lactamases: an update on their characteristics, epidemiology and detection. JAC Antimicrob Resist. 2021; 3(3): dlab092. doi: 10.1093/jacamr/dlab092. 26.  D'Andrea MM, Arena F, Pallecchi L, Rossolini GM. CTX-M-type β-lactamases: a successful story of antibiotic resistance. Int J Med Microbiol. 2013; 303(6-7): 305-17. doi: 10.1016/j.ijmm.2013.02.008. 27.  Versalovic J. Manual of clinical microbiology, vol. 1. 10th ed. Washington, DC: American Society for Microbiology Press; 2011. 28.  Forbes BA, Sahm DF, Weissfeld AS, Bailey WR. Bailey & Scott’s Diagnostic Microbiology. 12th ed. St. Louis: Elsevier Mosby; 2007. 29.  Cheesbrough M. District laboratory practice in tropical countries, Part 2, 2nd ed. Tropical Health Technology, Norfolk: Cambridge University press; 2005. doi:10.1017/CBO9780511581304. 30.  Clinical and Laboratory Standards Institute (CLSI). Performance standards for antimicrobial susceptibility testing (M100S), 26th ed. Wayne P: CLSI; 2016. 31.  Humphries RM, Ambler J, Mitchell SL, Castanheira M, Dingle T, Hindler JA, et al. CLSI methods development and standardization working group best practices for evaluation of antimicrobial susceptibility tests. J Clin Microbiol. 2018; 56(4): e01934-17. doi:10.1128/JCM.01934-17. 32.  Magiorakos A-P, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect. 2012; 18(3): 268-281. doi:10.1111/j.1469-0691.2011.03570.x. 33.  Nepal K, Pant ND, Neupane B, Belbase A, Baidhya R, Shrestha RK, et al. Extended spectrum beta-lactamase and metallo beta-lactamase production among Escherichia coli and Klebsiella pneumoniae isolated from different clinical samples in a tertiary care hospital in Kathmandu, Nepal. Ann Clin Microbiol Antimicrob. 2017; 16(1): 62. doi:10.1186/s12941-017-0236-7. 34.  Ghimire A, Acharya B, Tuladhar R. Extended Spectrum β-Lactamase (ESBL) producing multidrug resistant gram-negative bacteria from various clinical specimens of patients visiting a tertiary care hospital. Tribhuvan University Journal of Microbiology (TUJM). 2017; 4(1): 1-8. doi:10.3126/tujm.v4i0.21667. 35.  Koirala S, Khadka S, Sapkota S, Sharma S, Khanal S, Thapa A, et al. Prevalence of CTX-M β-lactamases producing multidrug resistant Escherichia coli and Klebsiella pneumoniae among patients attending Bir Hospital, Nepal. Biomed Res Int. 2021; 2021: 9958294. doi:10.1155/2021/9958294. 36.  Baral P, Neupane S, Marasini BP, Ghimire KR, Lekhak B, Shrestha B. High prevalence of multidrug resistance in bacterial uropathogens from Kathmandu, Nepal. BMC Res Notes. 2012; 5: 38. doi:10.1186/1756-0500-5-38. 37.  Shashwati N, Kiran T, Dhanvijay AG. Study of extended spectrum β-lactamase producing Enterobacteriaceae and antibiotic coresistance in a tertiary care teaching hospital. J Nat Sci Biol Med. 2014; 5(1): 30-35. doi:10.4103/0976-9668.127280. 38.  Shakya P, Shrestha D, Maharjan E, Sharma VK, Paudyal R. ESBL production among E. coli and Klebsiella spp. causing urinary tract infection: a hospital based study. Open Microbiol J. 2017; 11:23-30. doi:10.2174/1874285801711010023. 39.  Parajuli NP, Maharjan P, Joshi G, Khanal PR. Emerging perils of extended spectrum β-lactamase producing Enterobacteriaceae clinical isolates in a teaching hospital of Nepal. Biomed Res Int. 2016; 2016: 1782835. doi:10.1155/2016/1782835. 40. Chaudhary MK, Jadhav I, Banjara MR. Molecular detection of plasmid mediated blaTEM, blaCTX− M, and blaSHV genes in extended spectrum β-Lactamase (ESBL) Escherichia coli from clinical samples. Ann Clin Microbiol Antimicrob. 2023; 22(1): 33. doi:10.1186/s12941-023-00584-0. 41.  Zeynudin A, Pritsch M, Schubert S, Messerer M, Liegl G, Hoelscher M, et al. Prevalence and antibiotic susceptibility pattern of CTX-M type extended-spectrum β-lactamases among clinical isolates of gram-negative bacilli in Jimma, Ethiopia. BMC Infect Dis. 2018; 18(1): 524. doi:10.1186/s12879-018-3436-7.Cite this article as:Pandey G, Karki A, Karki P, Thapa C. Extended spectrum beta-lactamase production and blaCTX-M gene in Escherichia coli and Klebsiella pneumoniae causing urinary tract infection at a tertiary care hospital in Nepal. IMC J Med Sci. 2024; 18(2):002. DOI: https://doi.org/10.55010/imcjms.18.014. <![CDATA[Association between mustard oil consumption and thrombocytopenia: a case-control study in Bangladesh ]]> Wasim Md Mohosin Ul Haque* Mashud Alam AKM Shaheen Ahmed Arif Mahmud https://imcjms.com/journal_full_text/529 2024-05-19 14:22:58 Original Article July 2024; Vol. 18(2):005 Abstract Background and objectives: Mustard oil, a common ingredient in South Asian cuisine, has been associated with both culinary appeal and potential health benefits. While studies suggest its role in reducing the risk of ischemic heart disease, concerns arise due to the presence of erucic acid, which has been linked to adverse cardiovascular effects and thrombocytopenia. This case-control study aimed to investigate the association between mustard oil consumption and thrombocytopenia in the Bangladeshi population. Materials and methods: Consecutive patients diagnosed with thrombocytopenia (platelet count < 150000/µL) were enrolled as cases, while controls were selected as the next consecutive patients with normal platelet counts, regardless of demographic characteristics or disease status. Data on demography, clinical variables and mustard oil consumption were collected from medical records and face-to-face interviews. Results: Seventy-six participants were included in the study of which 38 belonged to case and 38 to control groups. The mean age of the individuals in control and case groups was 57.5 and 58.2 years respectively (p = 0.808). Notably, 83.3% of cases reported using mustard oil compared to 28.3% of controls (p<0.001). Cases exhibited significantly (p < 0.001) lower platelet counts (114,789 ± 24,453 /µL) compared to controls (278,211 ± 84,595 /µL). Male gender and the use of mustard oil in cooking were identified as predictors of thrombocytopenia. No bleeding symptoms were observed, raising questions about the clinical significance of mustard oil-associated thrombocytopenia. Conclusion: The study underscores the need for further research to elucidate the complex relationship between mustard oil consumption, erucic acid, and thrombocytopenia, emphasizing the importance of dietary habits in health outcomes. July 2024; Vol. 18(2):005  DOI: https://doi.org/10.55010/imcjms.18.017 *Correspondence: Wasim Md Mohosin Ul Haque, Department of Nephrology, BIRDEM General Hospital, 122 Kazi Nazrul Islam Avenue, Dhaka 1000, Bangladesh. Email: wmmhaque@live.com   Introduction Mustard oil has long been a culinary staple in South Asian cuisine, valued not only for its distinctive flavour but also for its perceived health benefits [1]. While limited human clinical studies exist, research findings reveal a significant reduction in the risk of ischemic heart disease (IHD) associated with the consumption of mustard oil, particularly when compared to other cooking oils like sunflower oil [2]. Its unique fatty acid profile, characterized by low saturated fats and high alpha-linolenic acid (ALA), contributes to its cardioprotective effects by lowering LDL cholesterol levels and reducing the risk of ischemic heart disease. Additionally, its stability during cooking ensures the preservation of its nutritional integrity, making it a preferred choice for promoting heart health in Indian dietary practices [3]. However, the presence of erucic acid in mustard oil has raised concerns regarding its cardiovascular safety, prompting regulatory scrutiny and public debate [4]. Animal studies have indeed demonstrated potential adverse effects of erucic acid on heart health, such as myocardial lipidosis and cardiac lesions [5,6]. Additionally, erucic acid has been associated with thrombocytopenia in patients, particularly in the context of using Lorenzo's Oil, which contains high concentrations of erucic acid, for the treatment of X-linked adrenoleukodystrophy (X-ALD) [7,8]. Erucic acid, a monounsaturated omega-9 fatty acid, is present in varying concentrations across different cooking oils, with mustard oil and rapeseed oil (canola oil) being notable sources. Mustard oil, derived from seeds of the mustard family (Brassicaceae), typically contains around 41.8% erucic acid in commercial varieties, while traditional ghani mustard oil (extracted by using pestle and mortar) may have a slightly higher concentration, approximately 51.98% [9]. Rapeseed oil, commonly known as canola oil, initially had erucic acid levels ranging from 30% to 60% of total fatty acids, but modern cultivars have significantly lower levels, typically less than 2% [10]. Soybean oil and sunflower oil, commonly used in cooking, generally have negligible levels of erucic acid, making them safe options for consumption. While erucic acid was initially considered cardiotoxic, recent research has unveiled its potential medicinal properties. Despite its controversial history, erucic acid has been associated with antibacterial, antiviral, anti-inflammatory, and neuroprotective effects, suggesting a nuanced understanding of its health implications [11-14]. Amidst these discussions, anecdotal evidence suggests a possible link between mustard oil consumption and thrombocytopenia, prompting further investigation. This case-control study aims to explore whether mustard oil poses a risk factor for thrombocytopenia in the Bangladeshi population.   Methods The case-control study was conducted from December 2023 to March 2024 at a tertiary care hospital in Dhaka city. Informed verbal consent was obtained from each patient prior to the enrolment in the study. Consecutive patient diagnosed with thrombocytopenia (platelet count less than 150000/µL) [15] was enrolled as case, while control was selected as the next consecutive patient with normal platelet counts following each case, regardless of demographic characteristics or disease status. Data on patients’ demography, medical history, mustard oil consumption, complete blood count (CBC) results, and relevant clinical variables were collected from medical records and face-to-face interviews. Mustard oil consumption was defined as the habitual use of mustard oil as the primary cooking oil in participants' daily dietary practices. Statistical analysis involved logistic regression to assess the association between thrombocytopenia and potential risk factors or covariates. Unmatched controls were used to uncover unknown confounders, with logistic regression employed to minimize associated bias.   Results In this case-control study, the total study population comprised 76 participants, evenly distributed between the case and control groups, each consisting of 38 subjects. The mean age of the study population was 57.9 years, with controls and cases having mean age of 57.5 and 58.2 years, respectively. Statistical analysis revealed no significant difference in age between the control and case groups (p =0.808, mean difference -0.658, 95% CI [-6.023, 4.707]). The Table-1 presents the distribution of baseline characteristics between the control and case groups. Significant differences were observed in mustard oil consumption between the two groups (p<0.001). Notably, 83.3% of cases reported using mustard oil compared to 28.3% of controls, suggesting a potential association between mustard oil consumption and thrombocytopenia. No subjects exhibited any signs of bleeding within the study population, observed in both the control and case groups.   Table-1: Characteristics of control and case groups     Table-2 provides detailed information on quantitative variables, including age, platelet count, haemoglobin level, and serum creatinine level, for both control and case groups. While no significant differences were found in age, haemoglobin level, or serum creatinine level between the two groups, a substantial disparity in platelet counts was evident (p< 0.001). Cases exhibited significantly (p < 0.001) lower platelet counts (114,789 ± 24,453 /µL) compared to controls (278,211 ± 84,595 /µL).   Table-2: Difference in variables between control and case groups     In subsequent linear regression analysis, we examined the relationship between platelet concentration (PC) and two potential predictor variables: age and creatinine levels (Table-3). The results revealed that neither age (β = -0.184, p = 0.069) nor creatinine levels (β = -0.146, p = 0.143) showed a statistically significant association with platelet concentration, whereas a negative relationship was found between mustard oil consumption and platelet count.   Table-3: Regression coefficients for platelet count prediction     We conducted a logistic regression analysis to explore the associations between various factors and the presence of thrombocytopenia. Thrombocytopenia served as the dependent variable. The initial logistic regression model (Table-4) included several potential predictors of thrombocytopenia, such as sex, age, mustard oil use, creatinine level, CKD, DM, clopidogrel use, and aspirin use. Among these variables, sex (p = 0.028) and mustard oil consumption (p< 0.001) emerged as significant predictors of thrombocytopenia. Age, creatinine level, CKD, DM, clopidogrel use, and aspirin use did not show statistically significant associations with thrombocytopenia in this model.   Table-4: Logistic regression analysis results for the associations between various factors and thrombocytopenia (Model 1: Full Model)     In the reduced logistic regression model (Table-5), only sex and mustard oil consumption were retained as significant predictors of thrombocytopenia. Sex (female to male) exhibited a significant association with an increased risk of thrombocytopenia (p = 0.049, Exp(B) = 3.023, 95% CI [1.003, 9.110]), while mustard oil consumption showed a substantial risk elevation (p<0.001, Exp(B) = 12.134, 95% CI [3.694, 39.856]). Here the logistic regression model explains the 40.5% of the variation in the outcome.   Table-5: Logistic regression analysis results for the associations between only significant variables (sex and mustard oil) and thrombocytopenia (Model 2: Reduced Model)     Discussion The findings of this study suggest a significant association between mustard oil consumption and thrombocytopenia in the Bangladeshi population. Logistic regression analysis revealed that male sex and mustard oil use were significant predictors of thrombocytopenia. Prior research has implicated erucic acid, present in mustard oil, in thrombocytopenia development [7,8]. However, our study observed no bleeding symptoms among thrombocytopenic patients, and haemoglobin levels did not differ significantly between groups, raising questions about the clinical significance of mustard oil-associated thrombocytopenia and underscoring the need for further investigation. It is crucial to interpret these findings within the broader context of mustard oil's health effects and erucic acid's physiological role. While erucic acid has been implicated in thrombocytopenia development, particularly in the context of interventions like Lorenzo's oil, its overall impact on platelet function remains complex and multifaceted [16]. Further, the geographical distribution of constitutional macrothrombocytopenia overlaps significantly with areas where mustard oil consumption is prevalent in the Indian subcontinent [17,18]. This intriguing correlation raises the question: could a portion of individuals diagnosed with constitutional macrothrombocytopenia actually be experiencing thrombocytopenia as a result of mustard oil consumption?While animal studies have suggested potential adverse effects on heart health, recent research has underscored erucic acid's therapeutic potential across various medical applications. This duality necessitates a nuanced understanding of erucic acid's effects, considering both its potential risks and benefits. Limitations of this study include its retrospective nature, small sample size, and the absence of erucic acid blood level measurements. Future research should address these limitations and explore the underlying mechanisms of mustard oil's effects on platelet counts comprehensively. In conclusion, this study highlights the potential link between mustard oil consumption and thrombocytopenia in Bangladeshi population. While further research is needed to supplement these findings and elucidate the clinical implications, these results underscore the importance of dietary habits in thrombocytopenia development. Public health efforts should focus on raising awareness about the potential risks associated with mustard oil consumption and promoting healthier dietary choices.   Competing interest The author declares no conflict of interest.   Funding None   References 1.     Kaur R, Sharma AK, Rani R, Mawlong I, Rai PK. Medicinal qualities of mustard oil and its role in human health against chronic diseases: A review. J Dairy Foods Home Sci. 2019; 38(2): 98-104. doi: 10.18805/ajdfr.dr-1443 2.     Rastogi T, Reddy KS, Vaz M, Spiegelman D, Prabhakaran D, Willett WC, et al. Diet and risk of ischemic heart disease in India. Am J Clin Nutr. 2004; 79(4): 582-592. doi: 10.1093/ajcn/79.4.582. 3.     Manchanda SC, Passi SJ. Selecting healthy edible oil in the Indian context. Indian Heart J. 2016; 68(4): 447-449. doi: 10.1016/j.ihj.2016.05.004 4.     Poddar KH, Sikand G, Kalra D, Wong N, Duell PB. Mustard oil and cardiovascular health: Why the controversy? J Clin Lipidol. 2022; 16(1): 13-22. doi: 10.1016/j.jacl.2021.11.002 5.     Heijenskjöld L, Ernster L. Studies of the mode of action of erucic acid on heart metabolism. Acta Med Scand Suppl. 1975; 585:75-83. doi: 10.1111/j.0954-6820.1975.tb06560.x 6.     Charlton KM, Corner AH, Davey K, Kramer JK, Mahadevan S, Sauer FD. Cardiac lesions in rats fed rapeseed oils. Can J Comp Med. 1975; 39(3): 261-269. 7.     Zierz S, Schröder R, Unkrig CJ. Thrombocytopenia induced by erucic acid therapy in patients with X-linked adrenoleukodystrophy. Clin Investig. 1993; 71(10): 802-805. doi: 10.1007/bf00190322. 8.     Crowther MA, Barr RD, Kelton J, Whelan D, Greenwald M. Profound thrombocytopenia complicating dietary erucic acid therapy for adrenoleukodystrophy. Am J Hematol. 1995; 48(2): v132-133. doi: 10.1002/ajh.2830480217 9.     Sarwar MT, Rahman MH, Raza MS, Rouf SMA, Rahman MN. Determination of erucic acid content in traditional and commercial mustard oils of Bangladesh by gas-liquid chromatography. Adv Biochem. 2014; 2(1): 9-13. doi: 10.11648/j.ab.20140201.12 10.  Daun JK. Erucic acid levels in Western Canadian canola and rapeseed. J Am Oil Chem Soc. 1986; 63(3): 321-324. doi:10.1007/bf02546037 11.  Goc A, Niedzwiecki A, Rath M. Anti-borreliae efficacy of selected organic oils and fatty acids. BMC Complement Altern Med. 2019; 19(1): 40. doi: 10.1186/s12906-019-2450-7 12.  Liang X, Huang Y, Pan X, Hao Y, Chen X, Jiang H, et al. Erucic acid from Isatis indigotica Fort. suppresses influenza A virus replication and inflammation in vitro and in vivo through modulation of NF-κB and p38 MAPK pathway. J Pharm Anal. 2020; 10(2): 130-146. doi: 10.1016/j.jpha.2019.09.005 13.  Henry GE, Momin RA, Nair MG, Dewitt DL. Antioxidant and cyclooxygenase activities of fatty acids found in food. J Agric Food Chem. 2002; 50(8): 2231-2234. doi: 10.1021/jf0114381 14.  Kim E, Ko HJ, Jeon SJ, Lee S, Lee HE, Kim HN, et al. The memory-enhancing effect of erucic acid on scopolamine-induced cognitive impairment in mice. Pharmacol Biochem Behav. 2016; 142: 85-90. doi: 10.1016/j.pbb.2016.01.006 15.  Jinna S, Khandhar PB. Thrombocytopenia. [Updated 2023 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www. ncbi.nlm.nih.gov/books/NBK542208/ 16.  Galanty A, Grudzińska M, Paździora W, Paśko P. Erucic acid-both sides of the story: A concise review on its beneficial and toxic properties. Molecules. 2023; 28(4). doi: 10.3390/molecules28041924. 17.  Edupuganti HS; Krishnamurthy, V . Prevalence of constitutional macrothrombocytopenia in the immigrants of Northern and Eastern states of India. Indian J Pathol Microbiol. 2020; 63(4): 593-596. doi: 10.4103/IJPM.IJPM_20_20 18.  Naina HVK, Nair SC, Daniel D, George B, Chandy M. Asymptomatic constitutional macrothrombocytopenia among West Bengal blood donors. Am J Med. 2002; 112(9): 742-743.doi: https://doi.org/10.1016/S0002-9343(02)01114-2       Cite this article as: Haque WMM, Alam M, Ahmed AKMS, Mahmud A. Association between mustard oil consumption and thrombocytopenia: a case-control study in Bangladesh. IMC J Med Sci. 2024; 18(2):005. DOI: https://doi.org/10.55010/imcjms.18.017 <![CDATA[Relationship of epileptic seizures with lunar cycle and seasons]]> Erdal Yavuz* Kasim Turgut Umut Gülaçtı Irfan Aydın Mustafa Gürbüz Fatih Mehmet Aksoy Ebru Arslan Ali Arık https://imcjms.com/journal_full_text/530 2024-05-23 10:38:51 Original Article July 2024; Vol. 18(2):006 Abstract Background and objectives: Various factors facilitate seizures in patients with epilepsy. The relationship between the phases of the moon and neuropsychiatric conditions has been a matter of curiosity. The present study investigated whether patient presentations to the emergency department with epileptic seizures vary according to the phases of the moon, seasons, and daily air temperature. Materials and method: The study retrospectively included patients who presented to the emergency department with epileptic seizures over a one-year period. Patients with provoked seizures (head trauma, intracranial hemorrhage, etc.), pregnant women, and patients aged under 18 years were excluded. Patients’ age, gender, date and time of presentation to the emergency department were recorded. The effects of the phases of the moon and seasons on these presentations were investigated. Results:Total 255 patients (176 male, 79  female) met the inclusion criteria of the study. The majority of patients (67.1%) were aged 18-44 years. Majority of the patients (41.2%) did not previously used epileptic medication. The laboratory tests showed that the mean blood pH and lactate values were 7.31±0.11 and 4.59±4.12 mmol/L respectively. No statistically significant (p>0.05) relationship was observed regarding frequency of presentations of epileptic seizures and  the season and phases of the moon. Conclusion: The results of this study showed that the phases of the moon, air temperature, and seasons did not affect the frequency of epileptic seizures. July 2024; Vol. 18(2):006  DOI: https://doi.org/10.55010/imcjms.18.018 *Correspondence: Erdal Yavuz, Department of Emergency Medicine, Adiyaman University Medical Faculty, Adiyaman, Turkey. Email: erdal_yavuz15@hotmail.com   Introduction Epilepsy is a dysfunction in the brain’s neuronal activity that can develop abnormally, suddenly, and synchronously. Depending on the underlying cause, epileptic seizures are divided into two groups: primary and secondary. Additionally, epileptic seizures are classified as generalized or partial according to the nature of the seizure [1]. Epileptic seizures constitute a significant portion of patient presentations to the emergency department. It has been reported that 5% of emergency calls are due to epileptic seizures [2]. Sleep deprivation, alcohol intake, not taking prescribed medication, and bright lights have previously been reported as factors that facilitate seizures in patients with epilepsy [3]. However, there are different views concerning the increase in the frequency of seizures according to the phases of the moon [4,5]. In addition, the relationship between the phases of the moon and neuropsychiatric conditions has been a matter of curiosity for every society [6]. The relationship between the phases of the moon and various diseases, including psychiatric disorders, cardiac disorders, epileptic seizures, and stroke, has been examined. Nevertheless, there is not yet a definitive consensus on the effect of the phases of the moon on ocurane of epileptic seizures [7,8]. There are patients claiming that their seizures are predictably triggered or exacerbated by the full moon, which is supported by previous studies in the literature [5]. In contrast, several researchers have found no relationship between the phases of the moon and epileptic seizures [4,9,10]. This study evaluated the demographic characteristics of patients who presented to the emergency department with primary generalized epileptic seizures and investigated whether frequency of epileptic seizures varied according to the phases of the moon.   Materials and methods The study was approved by the local Ethics Committee (Number: 2022/9-10). Patients who presented to the emergency department with epileptic seizures over a one-year period from January 1, 2021, through December 31, 2021, were retrospectively identified from the hospital registry system using the diagnostic codes G.40 (epilepsy), G.40.8 (Other epilepsy and recurrent seizures), and G40.9 (Epilepsy, unspecified) [11]. Patients with reactive seizures due to head trauma, intracranial hemorrhage and other causes,  pregnant women, and patients under 18 years of age were excluded from the study.The patients’ presentation dates and times were recorded. Based on the date and time information, the phase of the moon during which each patient presented to the emergency department was determined using a website [12]. The presentations were grouped according to the phases of the moon: the new moon, the first quarter moon, the full moon, and the third quarter moon. The maximum and minimum values of air temperature for each presentation were obtained and recorded using a website [13]. The patients’ demographic characteristics, presentation season, age, laboratory values, and medication used were recorded from the patient files. Statistical analysis: The conformity of continuous data to the normal distribution was determined by the Kolmogorov-Smirnov test. Normally distributed data were analyzed by Student’s t-test, and non-normally distributed data were analyzed by the Mann-Whitney U test. The chi-square test was used to compare qualitative data. The Kruskal-Wallis test was performed to compare the data between the groups. P values of less than 0.05 were regarded as statistically significant. Analyses were performed on SPSS v. 21.0 software (IBM Corp. NY, USA)   Results The study included a total of 255 patients of which 176 and 79 were men and women respectively. The majority of the patients (67.1%) were aged 18-44 years. Evaluation of the frequency of presentations with epileptic seizures according to the phases of the moon revealed that most patients (27.5%) presented to the emergency department during the full moon. According to seasons, the most frequent presentations were observed in winter (30.2%). Out of 255 cases, 41.2% patients did not use any epileptic medication previously (Table-1).   Table-1: Demographic characteristics and time of presentation of cases at the emergency department     The laboratory parameters of the patients evaluated at the time of presentation to the emergency department showed that the mean  blood pH, lactate and glucose values were 7.3 ± 0.1, 4.6 ± 4.1 mmol/L and 138 ± 68.3 mg/dl respectively. The other laboratory parameters were within the normal ranges (Table-2).   Table-2: Laboratory parameters and airtemperature at the time of presentation of cases  to the emergency department     No significant difference was found in the frequency of epileptic presentations among the age groups (p>0.05). Concerning the gender evaluation, the highest rate of female patient presentations was seen during the new moon phase (30.4%), and the highest rate of male patient presentations occurred during the fool moon phase (27.3%). No statistically significant difference (p >0.05) was observed. The evaluation of presentations with epileptic seizures according to seasons revealed the highest frequency for winter, with a higher number of presentations being made during the new moon and full moon phases in this seasons, albeit with no statistically significant difference (p >0.05). The lactate level was >2 mmol/L in 74.3% (133/179) of the cases and did not significantly differ according to the phases of the moon (p >0.05). The use of multiple epileptic drugs was highest during the new moon phase, and that of single medication was highest during the third quarter of moon. Epileptic drug use did not exhibit a statistically significant difference according to the phases of the moon (p >0.05) (Table-3).   Table-3: Evaluation of variables of study cases according to the phases of the moon     Discussion Neuropsychiatric interactions with the phases of the moon have been a subject of curiosity for many years. A review of the studies on neurological and psychiatric conditions reveals no relationship between the phases of the moon and aggressive behavior [9] or psychiatric admissions [10]. Similar to our study, Wang et al. [4] did not find a relationship between the phases of the moon and epileptic seizures. In contrast, Polychronopoulos et al. [5] reported an increase in emergency department presentations due to seizures during the full moon phase. In our study, no relationship was found between the phases of the moon and epilepic seizures. There are many causes for high lactate levels. Lactate is produced by most tissues in the human body, with the highest production level found in muscles [14]. The relationship between the lactate level and epileptic seizures has not previously been examined. It is possible that the lactate level increases due to contraction and hypo-oxygenation of tissues during an epileptic seizure.The blood lactate levels of our patients were found to be high. Concerning the relationship between seasons and epileptic seizures, it has been reported that a multifactorial mechanism may be involved and that seasons do not have a direct effect on occurance of epileptic seizures. However, it has also been stated that body temperature is directly related to brain damage and seizures [15]. Although we observed a higher rate of presentations to the emergency department with epileptic seizures during the winter months, this did not reach a statistically significant level.  The results of this study showed that the phases of the moon, air temperature, and seasons did not affect the frequency of epileptic seizures.   References 1.     Thijs RD, Surges R, O'Brien TJ, Sander JW. Epilepsy in adults. Lancet. 2019; 393(10172): 689-701. doi: 10.1016/S0140-6736(18)32596-0. 2.     Bank AM, Bazil CW. Emergency management of epilepsy and seizures. Semin Neurol. 2019; 39(1): 73-81. doi: 10.1055/s-0038-1677008. 3.     Zhang Z, Wang M, Yuan S, Liu X. Alcohol, coffee, and milk intake in relation to epilepsy risk. Nutrients. 2022; 14(6): 1153. doi: 10.3390/nu14061153. 4.     Wang S, Boston R, Lawn N, Seneviratne U. Revisiting an ancient legend: influence of the lunar cycle on occurrence of first-ever unprovoked seizures. Intern Med J. 2022; 52(6): 1057-1060. doi: 10.1111/imj.15135. 5.     Polychronopoulos P, Argyriou AA, Sirrou V, Huliara V, Aplada M, Gourzis P, et al. Lunar phases and seizure occurrence: just an ancient legend? Neurology. 2006; 66(9): 1442-1443. doi: 10.1212/01.wnl.0000210482.75864.e8. 6.     Raison CL, Klein HM, Steckler M. The moon and madness reconsidered. J Affect Disord. 1999; 53(1): 99-106. doi: 10.1016/s0165-0327(99)00016-6. 7.     Iosif A, Ballon B. Bad moon rising: the persistent belief in lunar connections to madness. CMAJ. 2005; 173(12): 1498-500. doi: 10.1503/cmaj.051119. 8.     Altunışık E, Güntel M, Yavuz E, Arık A. Relationship of the lunar cycle and seasonality with stroke. Neurology Asia. 2021; 26(2): 223-231. 9.     Owen C, Tarantello C, Jones M, Tennant C. Lunar cycles and violent behaviour. Aust N Z J Psychiatry. 1998; 32(4): 496-499. doi: 10.3109/00048679809068322. 10.  Amaddeo F, Bisoffi G, Micciolo R, Piccinelli M, Tansella M. Frequency of contact with community-based psychiatric services and the lunar cycle: a 10-year case-register study. Soc Psychiatry Psychiatr Epidemiol. 1997; 32(6): 323-6. doi: 10.1007/BF00805436. 11.  https://icd.who.int/browse10/2019/en, [Accessed on: 3 November 2023] 12.  www.timeanddate.com, [Accessed on: 3 December 2023]. 13.  https://www.accuweather.com/, [Accessed on: 3 December 2023]. 14.  Bakker J, Nijsten MW, Jansen TC. Clinical use of lactate monitoring in critically ill patients. Ann Intensive Care. 2013; 3(1): 1-8. doi: 10.1186/2110-5820-3-12. 15.  Gulcebi MI, Bartolini E, Lee O, Lisgaras CP, Onat F, Mifsud J, et al. Climate change and epilepsy: Insights from clinical and basic science studies. Epilepsy Behav. 2021; 116: 107791. doi: 10.1016/j.yebeh.2021.107791.       Cite this article as: Yavuz E, Turgut K, Gülaçtı U, Aydın İ, Gürbüz M, Aksoy FM, Arslan E, Arık A. Relationship of epileptic seizures with lunar cycle and seasons. IMC J Med Sci. 2024; 18(2):006. DOI: https://doi.org/10.55010/imcjms.18.018 <![CDATA[Antimicrobial susceptibility pattern of Gram-negative uropathogens at a tertiary care hospital in Gujarat]]> Mihirkumar K Oza Shirishkumar Patel Beena Jagad Ravindra Jadeja Kairavi Desai* https://imcjms.com/journal_full_text/536 2024-06-26 11:16:58 Original Article July 2024; Vol. 18(2):007 Abstract Background and objectives: Urinary tract infections remain one of the most common infections in the community and susceptibility of uropathogens to commonly used antimicrobials has declined over the years. It is important to periodically study the antibiogram of uropathogens, so that empiric treatment can be determined using recent data and thus improving patient outcomes. The present study evaluated the antibiotic resistance trend of prevalent Gram-negative uropathogens in urine samples received at the microbiology laboratory at a tertiary care hospital. Material and methods: The study was conducted at the Department of Microbiology, Sir Takhtsinhji Hospital, Bhavnagar for one year period from March 2021 to February 2022. All received urine samples for culture and sensitivity were included in the study. All samples were subjected to culture and sensitivity using standard methods. Results: During study period, 918 (18.6%) organisms were isolated from 4938 urine samples. Out of 918, 85.1% (781) was Gram-negative and 9.8% was Gram-positive bacteria while 5.1% was Candida spp. Escherichia coli was the most prevalent (61.7%) of the total Gram-negative isolates. Gram-negative isolates were most resistant to amoxicillin/clavulanic acid, quinolones, trimethoprim/sulfamethoxazole. The rate of resistance to aminoglycosides, nitrofurantoin, third generation cephalosporins and carbapenems was comparatively low. Conclusion: Antimicrobial resistance of the prevalent uropathogens should be monitored routinely to plan effective empirical therapy. July 2024; Vol. 18(2):007. DOI: https://doi.org/10.55010/imcjms.18.019 *Correspondence:Kairavi Desai, Department of Microbiology, Government Medical College, Sir Takhtasinhji Hospital, Bhavnagar, Gujarat, India-364001. E-mail:drkairavi@yahoo.in   Introduction Urinary tract infection (UTI) is a common bacterial infection encountered in the community and hospitals. UTI accounts for 35% of total hospital acquired infections (HAIs). It is a leading cause of morbidity and healthcare expenditures in people of all ages [1]. Predisposing factors for UTI are age, gender, race, nutrition, hygiene, and immune status of the patients [2]. Post-menopausal women have a higher incidence of UTI due to uterine prolapse, less estrogen activity, altered vaginal microbiota, and associated co-morbid conditions like diabetes mellitus [3,4]. Prolonged hospital stay due to other medical and surgical problems and urinary catheterization are the most important risk factors among older people of both sexes. It is important to know the trends of antimicrobial susceptibility patterns of bacteria causing UTI at a given locality or hospital to ensure effective treatment. First and second generation cephalosporins, nitrofurantoin and fluoroquinolones are the most effective drugs for community acquired UTIs. On the other hand, parenteral therapy with third generation cephalosporins and carbapenems are often needed to treat nosocomial UTIs as the causative bacteria exhibit a high degree of resistance to commonly used antimicrobial agents [5,6]. Since patterns of antibiotic resistance in a wide variety of pathogenic organisms vary even over short period of time and depend on the site of isolation and different environments, periodic evaluation of antibacterial susceptibility of pathogenic bacteria is always needed. In view of the above, the current study was planned to find out the prevalence of Gram-negative uropathogens and their antimicrobial susceptibility patterns at a tertiary care hospital in Gujarat, India.   Materials and methods The study was conducted, at a tertiary care hospital, Bhavnagar, Gujarat, India from March 2021 to February 2022.The study was approved by the Institutional Sub-Ethical Committee prior to commencement of study. Ethical approval letter No. 1050/2021. Date: 24/02/2021. All the urine samples received for culture and sensitivity in microbiology laboratory were included in the study. Repeat urine samples from the same admission were excluded. Samples were processed immediately to ensure maximum recovery of the pathogen. Culture was performed on cystine-lactose-electrolyte deficient (CLED) agar and plates were incubated overnight at 35-370C [7]. A sample was considered culture positive if the bacterial count was ≥ 105 and ≥ 103 colony forming unit/mL (CFU/mL) for non-catheterized and catheterized patient respectively. The isolates were identified by motility and standard bio-chemical tests. Antibiotic susceptibility of organisms was performed by Kirby-Bauer disk diffusion method on Mueller-Hinton agar plates with following antibiotics: trimethoprim/sulfamethoxazole (23.75/1.25µg), nitrofurantoin (30µg), gentamicin (10µg), tobramycin (10µg ), amikacin (30µg), tetracycline (30µg), amoxicillin-clavulanic acid (20/10µg), ciprofloxacin (5µg), ofloxacin (5µg), norfloxacin (10µg), ceftriaxone (30µg), ceftazidime (30µg), cefotaxime (30µg), cefepime (30µg), piperacillin (100µg), piperacillin/tazobatum (100/10µg), and meropenem (10µg). Diameters of the zones of inhibition were interpreted according to CLSI 2022 guideline [8].   Results   Detail rate of resistance of total isolated Gram-negative uropathogens to different antimicrobial agents is shown in Table-2. Out of 781 Gram-negative bacteria, 81.2% were resistant to amoxicillin/clavulanic acid while least resistance was observed against meropenem and 3rd generation cephalosporins except ceftriaxone (Table-2). Table-2: Pattern of resistance of total isolated Gram-negative uropathogens to different antimicrobial agents (N=781)     <![CDATA[Anxiety levels and influencing factors among the relatives of patients presenting to the emergency department]]> Seçkin Bahar Sezgin* Hakan Topaçoğlu Özlem Dikme Özgür Dikme Şennaz Şahin Sıla Şadıllıoğlu https://imcjms.com/journal_full_text/537 2024-07-02 12:41:18 Original Article July 2024; Vol. 18(2):008 Abstract Background and objective: In recent years, the majority of incidents of increasing violence against healthcare workers, especially emergency department (ED) staff, have been perpetrated by family members of patients. Anxiety is one of the predictors of this violence in ED. The aims of this study were to measure anxiety levels among the relatives of ED patients at the time of presentation and to identify the factors that affect them. Materials and methods: In this prospective, cross-sectional study, 687 relatives of patients were included. The State-Trait Anxiety Inventory- State (STAI-S) and State-Trait Anxiety Inventory- Trait (STAI-T) scales were administered to assess state and trait anxiety levels. The data for the study were recorded using the SPSS 16.0 statistics program. Results: STAI-S averages were found to be statistically significantly higher than their STAI-T averages in parents (p = 0.036). A statistically significant difference was found between the state and trait anxieties of the group whose patients had a history of previous hospitalization (p = 0.013), previous surgeries (p = 0.009), presented with trauma (p=0.007), and received intervention in ED (p = 0.003). The state anxiety of the patient relatives who brought their patients to the ED by their own means was found to be statistically significantly higher than the trait anxiety (p=0.028). Conclusion: Our study showed that patient relatives whose patients presented to the ED due to trauma or had a history of surgery/hospitalization, or arrived at the hospital under their own means, experienced elevated anxiety levels. More multi-center studies are needed. July 2024; Vol. 18(2):008.  DOI: https://doi.org/10.55010/imcjms.18.020 *Correspondence: Seçkin Bahar Sezgin, Emergency Department,Gaziantep City Hospital, Gaziantep, Turkey. Email: seckinbahar34@gmail.com   Introduction Anxiety is an abnormal, groundless state of restlessness characterized by over-stimulation of the autonomic nervous system, with physical symptoms such as high blood pressure, tachycardia, tachypnea, and tremor, accompanied by concern, fear, and obsession [1-3]. Distinction between different experiences of anxiety is possible using Spielberger’s two-factor anxiety theory [4]. Types of anxiety have been measured by the State-Trait Anxiety Inventory (STAI) of Spielberger et al. [5]. State anxiety is the subjective fear experienced by an individual due to stressful situations, which intensifies during periods of heightened stress and diminishes upon resolution of the stress. Trait anxiety is the tendency of an individual to experience anxiety independent of the situation or to perceive situations as stressful. These individuals experience state anxiety more intensely than others do [6-8]. The STAI, a scale employed for assessing anxiety levels, consists of two distinct scales namely state anxiety scale (STAI-S) and trait anxiety scale (STAI-T)]. Items are rated from 1 to 4. The total score from both scales ranges from 20 to 80. A high score indicates high levels of anxiety, whereas a low score indicates low levels of anxiety [9]. The translation of the inventory into Turkish and the validity and reliability studies were performed by Oner et al. in 1983 [7]. Anxiety is identified as one of the predictors of this violence in emergency department [10]. Emergency department staff are more exposed to violence compared to other medical services personnel [11-13]. Acts of violence against healthcare workers in the emergency department are predominantly carried out by the relatives of patients [12-15]. In a study investigating the frequency and types of workplace violence experienced by doctors working in emergency departments in Turkey, it was found that 99% of the participants reported verbal violence, while 54% reported physical violence [14]. The purpose of this study was to determine the state and trait anxiety levels of patient relatives during patient presentation to the emergency department and to investigate the influencing factors.   Materials and methods The study was approved by the Cerrahpaşa University Ethics Committee; approval number: B-23 on 3th March 2011. Written consent was obtained from all study participants. Study population and methods: In this prospective, cross-sectional study, relatives of the patients, aged 18 years and older, presented to the emergency department in seven consecutive 24-hour periods were included. Average number of patients attended the emergency department in seven days was accepted as 3,344. Considering 10% prevalence of anxiety, we planned to include 687 relatives of patients aged 18 years and older to analyze their data within a 95% confidence interval and with a 2% deviation. Based on systematic sampling, one patient relative in every four presentations to the emergency department was included in the study. When a patient relative was not included because of exclusion criteria the order of systematic sampling was resumed without making any changes. The patient relatives who were mentally or intellectually impaired, were under psychiatric diagnosis and treatment, did not speak Turkish, were illiterate, did not give consent, could not communicate, and were accompanying patients requiring an urgent surgery were excluded from the study. Demographic and personal identification information from patient relatives participating in the study was collected. STAI-S and STAI-T scales were use to assess state and trait anxiety levels [5,7]. Seriousness of patient medical conditions was evaluated using a 5-point Likert test before the surveys. Surveys with unanswered questions were excluded from the analysis. Data were recorded using the SPSS 16.0 statistics program. The recorded data were analyzed by comparing STAI-S and STAI-T averages of the patient relatives to their demographic properties, the demographic properties of the related patients, and the backgrounds of both patient and relative. A chi-square test was used for analysis of categorical data, and a t-test was used for analysis of numerical data according to the number of samples.   Results In this prospective, cross-sectional study, 687 patient relatives aged 18 and older who presented to the emergency department in seven consecutive 24-hour periods were included. Out of total 687 patient relatives, 343 were female (49.9%) and 344 were male (50.1%). For the 687 patient relatives participating in the study, the STAI-S average score was 46.1±7.8, whereas the STAI-T average score was 45.4±8.0 (STAI-S range = 22–70; STA I-T range = 24–64). High STAI-S averages were statistically significant (t-test; p = 0.020). The statistical analysis of anxiety levels and subgroup tests for patient relatives participating in the study, based on factors such as gender, presence of chronic illness in the patient, whether the patient was brought in due to trauma, previous hospitalization history, surgical history in the patient's medical records, and the mode of arrival to the hospital (ambulance or self-arrival), is provided in Table-1.   Table-1: Anxiety levels and influencing factors in patient relatives presenting to emergency department     Most of the patient relatives accompanying were the parents of the patients (41.6%). Whether the patient was a first- or second-degree relative did not cause a statistically significant difference in the anxiety of the patient relative. In the sub-group analysis of patient relatives, STAI-S averages of those who brought their children to the hospital were found significantly (p = 0.036) higher than their STAI-T averages. According to the 5-point Likert scale, 424 (61.7%) patient relatives reported the severity of their relatives’ conditions as normal. However, no statistically significant differences were found between the STAI-S and STAI-T averages of the patient relatives who reported the severity of their relatives’ health problems as severe and those who reported them as normal or mild according to the 5-point Likert scale (Table-1). Nearly half (290; 42.2%) of the patients accompanied by the relatives received interventions, whereas 397 (57.8%) did not. For the relatives of the patients who did not receive an intervention, both the STAI-S and STAI-T averages were found significantly (<0.001) higher compared to the relatives of patients who received an intervention (Table-1). In the sub-group analysis, no statistically significant difference was found between the STAI-S and STAI-T of the relatives of patients who did not receive an intervention (t-test on paired samples; p = 0.719). However, a statistically significant difference was found between the STAI-S and STAI-T of the relatives of patients who received an intervention (t-test on paired groups, p = 0.003). More than one third (247; 36%) of the patient relatives had accompanied the patient to the emergency department in the past, whereas 440 (64%) were there for the first time. Of the patient relatives included in the study, the STAI-S and STAI-T averages of those in the emergency department with their relative for the first time were found significantly higher than those who had been in that position before (Table-1). In the sub-group analysis, no statistically significant difference was found between the STAI-S and STAI-T of either group (t-test on paired groups; p = 0.070 for the group that had previously accompanied and p = 0.146 for the group that had not previously accompanied). More than one third (254; 37%) of patient relatives had a history of previously presenting to the emergency department as a patient themselves, whereas 433 (63%) did not. The trait anxiety for the patient relatives who had not experienced self-presentation to the emergency department was significantly higher than that of patient relatives who had (Table-1). In the sub-group analysis for both groups, the state anxiety of the patient relatives in the latter group was found significantly higher than those in the former group (t-test on paired groups; p = 0.001). About one in 10 (67; 9.8%) patient relatives recounted a negative experience in their previous hospital presentations, whereas 620 (90.2%) patient relatives did not. About a quarter (151; 22%) of the patient relatives reported that they were presenting to that emergency department for the first time, whereas 536 (78%) had come to the same hospital before. This variable had no influence on state or trait anxiety levels of the patient relatives.   Discussion Anxiety is identified as one of the predictor of violence in emergency department [10]. Moreover, in recent years, incidents of violence against healthcare professionals have shown an increase [12]. Given the fast-paced environment of EDs, the sudden health problem of admitted patient and the fear of losing a loved one, higher state anxiety levels are deemed normal for patient relatives. In the STAI analysis with 40 as the boundary value, trait and state scores were over this value in most of our data, which suggests the presence of a general anxiety in the general population [16]. When under stress, individuals with a high level of trait anxiety are expected to demonstrate state anxiety reactions more quickly and frequently than those with a low level of trait anxiety [17]. In our investigation, the statistically significant high averages on STAI-S scale align with our anticipated outcomes. Studies investigating the anxiety levels of patients and patient relatives in the emergency department and the factors that affect these anxiety levels have been conducted in the past [18-20]. H.Y. Pi et al. found that female patient relatives had higher levels of anxiety than male patient relatives expressed in emergency departments [20]. Previous studies have shown that women have higher levels of state and trait anxiety than men do [21,22]. However, contrary to our expectations, the anxiety of patient relatives was not affected by gender in our study. Although not consistent with the literature, we attribute this lack of difference to potential social and cultural factors. A large majority of the patients presented to the emergency department accompanied by their first-degree relatives, who offer them support, trust, and comfort. In our study, being a first- or second-degree relative to the patient did not cause a statistically significant difference in anxiety levels, whereas being a patient's parent raised the state anxiety to a statistically significant degree. Martin et al. [19] found in their study that over 40% of parents experienced higher levels of state anxiety in the emergency department. We believe that this happens nearer relatives due to a greater sense of responsibility and emotional attachment to the patients compared to other relatives. In our study, of the patient relatives, 69.4% defined the health condition of their patients as normal or mild. Studies by Kılıçaslan et al. [23], and Ersel et al. [24] reported that 32.2% to 47.2% of the patients presenting to the emergency department did not actually have emergency conditions. However, Köse et al. observed that majority of the patients presenting to emergency department had no emergency conditions [25]. This situation could potentially result from the improper utilization of emergency services intended for expedited outpatient care. We were not expecting to find that the patient relatives' perceptions of the severity of their patients' health problems had no effect on their state anxiety levels. This lack of an effect may have been influenced by an unwillingness of the relative to acknowledge the severity of the issue or because they intentionally miss stated the condition as severe or very severe to access health services more quickly [26]. Our study also showed that the presence of a chronic disease and regular drug usage of the patient were not factors that affected the anxiety levels of the patient relatives. This lack of effect is likely because of the frequency with which the patient relatives have dealt with the issues and visited the emergency department or polyclinic facilities accordingly in the past. It can be assumed that these relatives have developed better mechanisms for coping with their anxiety [27-29]. Trait anxiety levels were higher in the patient relatives whose patients had a history of previous hospitalization or surgery. This finding suggests that dealing with previous hospitalizations, surgeries, and other life-or-death situations had negative effects on the trait anxiety of the patient relatives. In sub-group analysis of the patient relatives whose patients had a history of surgery or hospitalization, state anxiety was significantly higher than trait anxiety, which demonstrates that concern about experiencing similar events and previous hospital experience definitely increased state anxiety. On the contrary, the state anxiety of patient relatives with no previous hospital experience was not affected. State anxiety levels were higher in the patient relatives whose patients presented to the emergency department due to trauma or received intervention. As similar findings have been reported in previous studies, it is essential to anticipate the elevated anxiety levels among patient relatives presenting to the emergency department with trauma. Therefore, attention should be given to addressing the needs of patient relatives of such patients [30]. Although the trait anxiety of the patient relatives who had never previously self-presented to the emergency department was found significantly high, no significant difference was found between their trait anxiety and their state anxiety upon presentation to the emergency department. The fact that no difference was found in the sub-group analysis of the patient relatives who had not self-presented to the emergency department before suggests that these patient relatives may have had high baseline anxiety levels in their daily lives. The state anxiety of the patient relatives who had self-presented to the emergency department before was found significantly high. This finding might be due to their previous negative experiences with their disease, their distrust in the referral and administration of the emergency department, or their ability to more easily empathize with their patients. We found that 10.6% of patient relatives accompanied their patients to the emergency department by ambulance. The state anxiety of the patient relatives who brought their patients to the emergency department by their own means was found to be statistically significantly higher than the trait anxiety. This might be due to the fact that the relatives of patients who were brought by ambulance encountered a healthcare professional before they reached the hospital and began to receive healthcare services and information. In a conducted study, it was found that approximately one-third of the patient relatives might have believed that the health condition of their patient was more serious than it actually was and families had a need for explanations regarding the medical condition of the patient [30]. On the other hand, patient relatives who brought their patients by their own means had to handle all kinds of problems and stress themselves until they arrived at the hospital. The initial medical contact occurring before hospital admission could be considered an effective factor in reducing the anxiety of patient relatives.   Conclusion Our study revealed that, being a parent, having a history of hospitalization, surgery, presenting due to trauma, having intervention and bringing the patient by their own means were associated with higher levels of anxiety among the patient relatives. The early detection of anxiety, identified as an indicator of violence, could be a method for preventing incidents of violence in emergency services. Multi-center and more comprehensive studies on the causes, anxiety levels and expectations of patient relatives presenting to the emergency department, would contribute to planning measures to reduce anxiety and violence at the emergency department and as well improve patient management.   Authors’ contribution SBS: Study design, data collection, data analysis, manuscript writing; HT: Study design, statistical analysis; ÖzlemD: Data analysis, manuscript editing, literature review; ÖzgürD: Data analysis, manuscript writing; ŞennazŞ: Data collection, data analysis, literature review; SılaŞ: Data collection, data analysis   Conflict of Interest There are no conflicts of interest to declare.    Fund There was no external funding for this study.    References 1.     Öhman A. Fear and anxiety: Evolutionary, cognitive and clinical perspectives. In: Lewis M, Haviland-Jones JM, Barrett LF, editors. Handbook of Emotions. 3rd eds. New York: The Guilford Press; 2008; p 573-593. 2.     Shelton RC. Anxiety disorders, Chapter 19. In: Ebert MH, Loosen PT, Nurcombe B, Leckman JF, editors. Current diagnosis & treatment in psychiatry. 2nd eds. California: McGraw-Hill; 2008; p 328-341. 3.     Andrews G, Creamer M, Crino R, Hunt C, Lmpe L, Page AC. The treatment of anxiety disorders, clinician guides and patient manuals. 2nd eds. Cambridge: Cambridge University Press; 2003; p 5-24. 4.     Spielberger CD. Theory and research in anxiety. New York: Academic Press; 1966; p 3-32.. 5.     Spielberger CD, Gorsuch RL, Lushene RE. Manual for state-trait anxiety inventory. Palo Alto, California: Consulting Psychologists Press; 1970. 6.     Nager AL, Mahrer NE, Gold JI. State trait anxiety in the emergency department: an analysis of anticipatory and life stressors. Pediatr Emerg Care. 2010; 26(12): 897-901. doi: 10.1097/PEC.0b013e3181fe90eb. 7.     Oner N, LeCompte A. Manual of discontinuous state / trait anxiety inventory. 2nd eds. Istanbul: Bogazici University Press; 1998; p 1-26. 8.     Petit JR. Handbook of Emergency Psychiatry. Chapter 4-4: Anxiety. Philadelphia: Lippincott Williams & Wilkins; 2006; p 55-62. doi: 10.1097/PEC.0b013e3181fe90eb. 9.     Koroglu E, Aydemir O. The Scales Used in Psychiatry. Ankara, Physicians Broadcasting Union, 2007, p: 153-161. 10.  D’Ettore G, Pellicani V, Mazzotta M, Vullo A. Preventing and managing workplace violence against healthcare workers in Emergency Departments. Acta Biomed. 2018; 89(4-S): 28-36. doi: 10.23750/abm.v89i4-S.7113. 11.  Annagür BB. Violence towards health care staff: risk factors, aftereffects, evaluation and prevention. Current Approaches In Psychiatry. 2010; 2(2): 161-173. 12.  Türkmenoğlu B, Sümer HE. Frequency of healthcare workers’ exposure to violence in the city center of Sivas. Ankara Med J. 2017; 17(4): 216‐225. doi: 1017098/amj.364161. 13.  Coşkun S, Karahan S. Acil servis çalışanlarında şiddete maruz kalma durumunun incelenmesi [An analysis of exposure to violence in emergency service workers]. ACU Sağlık Bil Derg. 2019; 10: 493-499. doi: 10.31067/0.2018.90 14.  Sabak M, Al-Hadidi A, Oktay MM, Al B, Kazaz T, Kowalenko T, et al. Workplace violence in emergency departments in Turkey. Avicenna J Med. 2021; 11(3): 111-117. doi: 10.1055/s-0041-1732284. 15.  Aktaş E, Aydemir I. The determination of views of health professionals who exposed to violence about the "white code" implementation. Türkiye Klinikleri J Health Sci. 2018; 3(1): 32-47. doi: 10.536/healthsci.2017-57385. 16.  Julian LJ, Measures of anxiety: State- Trait Anxiety Inventory (STAI), Beck Anxiety Inventory (BAI), and Hospital Anxiety and Depression Scale- Anxiety (HADS-A). Arthritis Care Res (Hoboken), 2011; 63 Suppl 11(0 11): S467-S472. doi: 10.1002/acr.20561. 17.  LeComote WA, Oner N. Development of the Turkish Edition of the State Trait Anxiety Inventory. In: Spielberger CD, Guerrero D (eds). Cross Cultural Anxiety, First edition. Washington, DC, Hemisphere Publishing Corporation, 1976, p: 51-68. 18.  Kansagra SM, Rao SR, Sullivan AF, Gordon JA, Magid DJ, Kaushal R, et al. A survey of workplace violence across 65 U.S. emergency departments. Acad Emerg Med. 2008; 15(12): 1268-1274. doi: 10.1111/j.1553-2712.2008.00282.x. 19.  Martin RS, Hung I, Heyming TW, Fortier MA, Kain ZN. Predictors of parental anxiety in a paediatric emergency department.Emerg Med J. 2023; 40(10): 715-720. doi: 10.1136/emermed-2022-212917. 20.  Pi HY, Yang XO. Study on anxiety levels of patients' families in the emergency department. Zhonghua Hu Li Za Zhi. 1996; 31(11): 629-632. https://pubmed.ncbi.nlm.nih.gov/9304917/ 21.  Kıyohara LY, Kayano LK, Oliveira LM, Yamamoto MU, Inagaki MM, Ogawa NY, et al. Surgery information reduces anxiety in the pre-operative period. Rev Hosp Clin Fac Med Sao Paulo. 2004; 59(2): 51-56. doi: 10.1590/s0041-87812004000200001. 22.  Karaatmaca B, Şahiner UM, Soyer Ö, Sekerel BE. The impact of skin prick testing on pain perception and anxiety in children and parents. Allergol Immunopathol (Madr). 2021; 49(2): 72-79. doi: 10.15586/aei.v49i2.68. 23.  Kılıçaslan I, Bozan H, Oktay C, Goksu E. Demographic properties of patients presenting to the emergency department in Turkey. Tr J Emerg Med. 2005; 5(1): 5-13. https://turkjemergmed.com/abstract/506 24.  Ersel M, Karcioglu O, Yanturali S, Yuruktumen A, Sever M, Tunc MA.Emergency department utilization characteristics and evaluation for patient visit appropriateness from the patients' and physicians' point of view. Tr J Emerg Med. 2006; 6(1): 25-35. https://www.researchgate.net/publication/292124927_Emergency_department_utilization_characteristics_and_evaluation_for_patient_visit_appropriateness_from_the_patients'_and_physicians'_point_of_view 25.  Köse A, Köse B, Öncü MR, Tuğrul F. Admission appropriateness and profile of the patients attended to a state hospital emergency department. Gaziantep Med J. 2011; 17(2): 57-62. doi: 10.5455/GMJ-30-2011-27. 26.  Ekwall A, Gerdtz M, Manias E. Anxiety as a factor influencing satisfaction with emergency department care: perspectives of accompanying persons. J Clin Nurs. 2009; 18(24): 3489-3497. doi: 10.1111/j.1365-2702.2009.02873.x. 27.  Dahlén I, Janson C. Anxiety and depression are related to the outcome of emergency treatment in patients with obstructive pulmonary disease. Chest. 122(5): 1633-1637. doi: 10.1378/chest.122.5.1633. 28.  Demiryoguran NS, Karcioglu O, Topacoglu H, Kiyan S, Ozbay D, Onur E, et al. Anxiety disorder in patients with non-specific chest pain in the emergency setting. Emerg Med J. 2006; 23(2): 99-102. doi: 10.1136%2Femj.2005.025163. 29.  Margalith I, Shapiro A. Anxiety and patient participation in clinical decision-making: the case of patients with ureteral calculi. Soc Sci Med. 1997; 45(3): 419-427. doi: 10.1016/s0277-9536(96)00357-7. 30.  Kawakami C, Matsuoka M, Taki K. A study on the factors influencing the anxiety of family members in the emergency department. Fukuoka Igaku Zasshi. 2004; 95(3): 73-79. https://pubmed.ncbi.nlm.nih.gov/15164934/.      Cite this article as: Sezgin SB, Topaçoğlu H, Dikme Ö, Dikme Ö, Şahin S, Şadıllıoğlu S. Anxiety levels and influencing factors among the relatives of patients presenting to emergency department. IMC J Med Sci. 2024; 18(2):008. DOI:https://doi.org/10.55010/imcjms.18.020 <![CDATA[Seroprevalence of SARS-CoV-2 IgG antibodies among rural children aged 6-14 years in a selected block of West Bengal, India]]> Vineeta Shukla* Vivek Shukla Mausumi Basu Aparajita Mondal Mamunur Rashid Ripan Saha https://imcjms.com/journal_full_text/543 2024-07-11 10:38:32 Original Article July 2024; Vol. 18(2):010 Abstract Background and objectives: Children comprised a significant part of the population during the second and third waves of the COVID-19 pandemic. The objectives of this study were to estimate the seroprevalence of COVID-19 IgG antibody among the children aged 6 to 14 years and to determine, if any, the factors associated with seropositivity. Methods: This cross-sectional study was conducted in a selected block of West Bengal, India over a period of 1 year (April 2022-March 2023) among children. Thirty villages in the block were selected by cluster sampling technique. COVID-19 IgM/IgG Rapid Antibody Test Kit (ICMR approved) was used for the detection of SARS-CoV-2 IgG antibodies.  Data were analyzed by appropriate statistical tests. Results: Total 600 children were enrolled in the study.SARS-CoV-2 IgG antibody was positive in 57.2% children. The seropositivity rate (91.8%) was significantly (p<0.001) high among children of age group 12 to 14 years. Seropositivity rate was not significantly different between male and female children (46.4% vs. 53.6%; p>0.05). Conclusion: SARS-COV-2 IgG antibody was positive in a high proportion of children residing in rural areas indicating asymptomatic coronavirus infections among rural population. Socio-demographic factors such as higher age group and father’s education were significantly associated with seropositivity. July 2024; Vol. 18(2):010.  DOI:https://doi.org/10.55010/imcjms.18.022 *Correspondence: Vineeta Shukla, Department of Community Medicine, Infectious Diseases and Beliaghata General Hospital, Kolkata, India. Email: vineeta1992@gmail.com   Introduction Children are the foundation of any nation, and the health and welfare of its child population determines the progress of any country. The COVID-19 pandemic, which hasn't been formally declared over yet, has led to some significant advancement in the worldwide health care industry. Since children constituted a significant portion of the unprotected population during the second and third waves of the COVID-19 pandemic, their vulnerability was an important consideration. Children and adolescents are also susceptible to the infection and thus form a part of the transmission chain. In late 2021, different nations had reported COVID-19 outbreaks in schools and child care facilities. What is more striking is that children were often reported to have asymptomatic infections than adults in case of COVID-19 [1]. Even though SARS-CoV-2 was thought to impact children and adolescents more mildly than adults, it nonetheless affects a variety of systems, with the cardiovascular signs being most noticeable [2]. In addition to being extremely unwell and necessitating Intensive Care Unit (ICU) admissions, child death rate, particularly in those with Multisystem Inflammatory Syndrome in Children (MIS-C), have been reported as high as 9% [3]. According to the World Health Organization (WHO), children under five years of age represented 2% of reported global COVID-19 cases during January 2020 to October 2021 and older children (5 to 14 years) accounted for 7% of the cases [4]. There was limited seroprevalence data among children in late 2021. Also, the antibody response to SARS-CoV-2 among children was poorly characterized. Very few studies related to SARS-CoV-2 antibody detection among children were carried out in India in the years 2020 and 2021 and literature from West Bengal was scarce [5]. Following the second wave of COVID-19 cases in 2021, George et al. conducted a study in a rural area of Karnataka, India, and found that children's seroprevalence of antibodies to SARS CoV-2 was 45.9% [6]. In 2021, a multicenter study conducted by Misra et al. [7] found the prevalence of SARS-CoV-2 antibody among under-18-year-olds in both urban and rural areas as 55.7%, with a higher seropositivity rate among females. In another study, about 48.3% of children aged 5 to 17 in both urban and rural Kerala were found positive for COVID-19 antibody [8]. But there was no significant association with gender. In Delhi, India, seroprevalence of immunoglobulin G antibodies against SARS-CoV-2 among children aged 5 to 17 rose from 52.8% in January 2021 to 81.8% in September and October 2021, according to a repeated cross-sectional study [9]. Age and seropositivity correlated positively, but not with gender. There was a dearth of information about the status of seroprevalence of SARS-COV-2 IgG antibody among people of rural Bengal, especially among children. Therefore,, the present study was conducted in a block of West Bengal, India with objectives to estimate the seroprevalence of SARS-CoV-2 IgG antibody among rural children aged 6 to 14 years and to find the factors associated (if any) with seropositivity among them.   Materials and methods This descriptive cross-sectional study was carried out in Budge-Budge II block, West Bengal over a period of 12 months from April 2022 to March 2023. The study was approved by Institutional Ethics Committee (IPGME&R/IEC/2022/006, dated 21.01.2022). For children 7-11 years, informed oral assent in presence of parents and for children 12 - 14 years old, informed written assent was taken. Informed written consent was taken from all parents. Study population: Children aged 7 to 14 years who had been residing with their families in the block for last one year or more were included.Those who had a laboratory confirmed COVID-19 infection in the past or who had any symptoms of COVID-19 infection during the time of data collection were excluded. Sample size and sampling method: Considering 61.1%  seroprevalence of anti- SARS-CoV-2 IgG antibody rate [10]  and at 95% confidence interval (CI) and with 10% margin of error, the total sample size was calculated as  591 (after multiplying by 2 for design effect for cluster sampling and adding 20% as inconclusive). A total of 30 clusters were selected. Therefore, from each cluster (village) 591/30=19.7≈20 children were enrolled. Thirty villages were selected from a total of 61 villages using probability proportional to size method. Data collection: Before commencing data collection, an orientation cum training session was conducted involving the Block Medical Officer, Accredited Social Health Activists (ASHA), Auxiliary Nurse Midwives (ANMs) and other health workers followed by pretesting among 20 children of the same age group who were not included in the final sample. Information on socio-demographic, clinical, COVID-19 exposure related questions and vaccination details were collected in a predesigned, pretested, and structured questionnaire. Socio-demographic variables included: age, gender, type of family, socio-economic status, as per Modified BG Prasad Scale 2022 [11], parents’ education, and occupation. Information on COVID-19 related infection included: history of COVID-19 infection in family, vaccination status of family members, and number of doses of vaccine received. Collection of blood and test: About 30µL of whole blood was collected aseptically by finger prick and tested immediately for SARS-CoV-2 IgM or IgG antibodies by Oscar Covid-19 Rapid Antibody Test Kit (ICMR approved).The measurement range of the assay was from 0.40 U/ml to 250 U/ml. Levels of <0.80 and ≥0.80 U/ml were considered as negative and positive respectively according to the manufacturer’s recommendations. Blood sample was placed in the specimen well of the test kit. Two drops (100µL) of buffer solution (provided with the kit) were added to the specimen. The results were read after 15 minutes. If a coloured line appeared at the IgG level along with the control line, the results were interpreted as positive. Data analysis: Descriptive statistical measures such as frequencies, mean, standard deviation and confidence interval (CI) were determined. Z test for proportion was applied to test for significant difference between age groups and gender. Multivariable binary logistic regression was performed to find predictors of IgG positive test among the study population.    Results Out of 600 children, about 40.5% belonged to age group of 12-14 years and their mean age was 10.36 ± 2.53 years. A little more than half were females (54.7%) and more than 80% followed Hinduism by faith. About 86.3% resided in joint households and half of the families belonged to upper middle class (50.2%).There was a health care worker in only 1.2% of the families (Table-1). None of the children had undergone any kind of COVID-19 detection test prior to the study. A small proportion (64, 10.7%) of the families had a laboratory confirmed history of COVID-19 infection within last one year in at least one of the members. Out of those who tested positive, 4 required hospitalizations and 1 of them died (Table-2).   Table-1: Distribution of the study participants according to the socio-demographic profile (N=600)   <![CDATA[Side effects and perceptions among young adults in Bangladesh following COVID-19 vaccination: a single center study]]> Md. Faizul Ahasan* Nazma Haque Fouzia Begum Sharmin Rahman Sultana Farzana Mahbub Aziz Sheikh Ariful Islam https://imcjms.com/journal_full_text/544 2024-07-31 12:25:23 Original Article July 2024; Vol. 18(2):011 Abstract Background and objectives: COVID-19, caused by SARS-CoV-2, has led to a global pandemic with severe health, economic, and social impacts. Vaccination has emerged as a crucial mitigation strategy. Despite the pivotal role of COVID-19 vaccines in controlling the pandemic, vaccine hesitancy remains a significant concern globally, particularly among young adults. This study aimed to explore the side effects and perceptions of the young adults in Bangladesh following COVID-19 vaccination. Materials and methods: The study, conducted in April 2021 among 325 young Bangladeshi adults who received two doses of Sinopharm (BBIBP-CorV) vaccine against SAR-CoV-2. Participants completed a self-administered online questionnaire covering demographics, health history, post-vaccination adverse events, and perceptions about COVID-19 vaccine. A symptom scoring system, based on the interquartile range (IQR), was used to categorize the severity of the side effects. Data analysis utilized SPSS version 26.0, with appropriate tests for significance. Result: Total 325 participants (male - 64.6%, female - 68.9%) were enrolled. The mean age was 22 ± 1.6 years. Social media (43·1%) was the primary source of information about COVID-19. Vaccine related side effects were experienced by 40.9% and 47.1% participants following 1st and 2nd dose of vaccination respectively. Side effects were more prevalent after the second dose of vaccine, particularly in females (31·3% vs. 8·2%, p<0·001). Common side effects included fatigue (41·6%), injection site pain/swelling (36·7%) and headache (32·6%). In over 50% of participants, symptoms appeared within 8 hours following both doses. Symptoms resolved by taking rest at home in majority of participants. Participants with comorbidity reported significantly higher rate of side effects after the first dose (61.8% vs. 37·3%, p <0.05). Despite side effects, 69·8% felt reassured post-vaccination, 63·7% believed in its long-term safety, and 98·8% recommended vaccination to others. Conclusion: The Sinopharm COVID-19 vaccine was well-tolerated among young adults in Bangladesh. Though higher side effects after the second dose were observed in female participants, yet most maintained a positive perception, underscoring its acceptability and recommended vaccination to others. July 2024; Vol. 18(2):011. DOI:https://doi.org/10.55010/imcjms.18.023 *Correspondence: Md. Faizul Ahasan, Department of Pharmacology, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka 1000, Bangladesh. Email: arronnoo_shuvro@live.com   Introduction COVID-19, caused by SARS-CoV-2, was first identified in December 2019 in Wuhan, China [1]. It has since affected millions globally, causing over 3.7 million deaths [2,3] and leading to a global pandemic. The disease spreads primarily through respiratory droplets [4], resulting in widespread lockdowns, travel restrictions, and economic disruptions [5]. Substantial research funding has been directed towards combating COVID-19 [6]. While social distancing and quarantine measures can slow virus spread, they may not completely halt it [7]. Vaccination is considered the best approach to preventing severe complications and deaths [8]. GAVI and WHO, collaborating with other agencies, have expedited the development of effective vaccines [9]. More than eight COVID-19 vaccines have been approved for emergency use, including Sinopharm, Pfizer-BioNTech, AstraZeneca, Moderna, and Johnson & Johnson, each showing varying efficacy [10-12]. These vaccines have undergone multiple clinical trial phases to ensure safety [13] and have been proven to significantly reduce infection transmission [6].The first mass vaccination program began in early December 2020 [14]. As of July 2024, approximately 57% of the world population has received at least one dose of a COVID-19 vaccine, with 8.7 billion doses administered globally [15]. The United Arab Emirates (UAE) leads in vaccination rates, with over 5 million people vaccinated [3]. UAE approved the Sinopharm vaccine in December 2020, initiating mass vaccination campaigns [16]. Bangladesh began its mass vaccination program in January 2021, utilizing seven recommended vaccines: Moderna, Pfizer/BioNTech, Sputnik V, Johnson & Johnson, Oxford/AstraZeneca, Sinopharm, and Sinovac [17]. The Sinopharm COVID-19 vaccine, developed by China National Pharmaceutical Group, is an inactivated virus vaccine [18]. Administered in two doses the vaccine stimulates antibody production against the virus, and prevents potential SARS-CoV-2 infection [19]. Like other vaccines, Sinopharm can cause mild, temporary side effects [20,21], including injection site pain, fatigue, headache, muscle pain, and fever, indicative of the body's immune response [22]. The vaccine is adjuvanted with aluminum hydroxide to enhance immune response [10].Understanding public acceptance of COVID-19 vaccination is crucial for improving vaccine coverage rates [23]. Vaccine hesitancy, driven by safety concerns and side effects, poses a significant challenge [2,8]. The WHO has identified vaccine hesitancy as a global threat, emphasizing the need to address vaccine confidence and manage side effect perceptions [6]. Medical students, as young adults, can significantly influence public perception regarding acceptance of COVID-19 vaccine [22]. This study aimed to evaluate side effects and perceptions following Sinopharm COVID-19 vaccination among young adults in Bangladesh.   Materials and Methods This cross-sectional study involved young adults who received two doses of Sinopharm (BBIBP-CorV) COVID-19 vaccination against SARS-CoV-2 under the routine vaccination program of Government of Bangladesh. Participants completed a self-administered online questionnaire distributed via WhatsApp. The questionnaire, created using Google Forms, was developed following a literature review and insights from sources including the VAERS card (USA), WHO's COVID-19 Vaccine Explainer, and academic databases. It covered demographics, pre-vaccination health, vaccine perceptions, and post-vaccination effects. A pilot study was conducted to validate the questionnaire. A symptom scoring system, based on the interquartile range (IQR), was used to categorize the severity of the side effects of vaccine into mild (scores 1-4, IQR1), moderate (scores 5-10, IQR2) and severe (scores > 11, IQR3). Each reported symptom was assigned a score of 1, with a total possible score of 32. With an assumed 50.0% side effect rate, 95% confidence interval, and 5% margin of error, the target sample size was 384. Data were analyzed using SPSS version 26.0. Descriptive statistics and chi-square tests were used for analysis. The study was approved by the Ibrahim Medical College Institutional Review and Ethic Board.   Result  A total of 325 vaccinated participants were enrolled in the study. Total 203 and 221 participants provided information on vaccine related adverse effects after first and second dose of vaccination respectively. The majority of participants (60.3%) were aged 22-26 years with a mean age of 22.00 ± 1.58 years (range 19-26 years). Most participants were female (n=224, 68.9%). Regarding health status, 64.6% were healthy, while 35.4% had chronic illnesses, like allergies (20.9%), bronchial asthma (4.6%), and obesity (3.4%). Table-1 shows the detail demographic and health status of the participants.   Table-1: Demographic and health status of study population (n=325)     The primary sources of COVID-19 information were social media (43.1%), government-owned media (33.8%), and scientific/medical websites (18.5%). Prior to vaccination, 12.6% had suffered from COVID-19, while 4% infected with SARS-CoV-2 post-vaccination. Pfizer-BioNTech was the preferred vaccine (32.0%), followed by AstraZeneca/Oxford (15.1%) and Moderna (13.8%). Only 16.6% of participants were scared of vaccination, mainly due to concerns about adverse effects (61.1%) and safety/efficacy (16.7%) of the vaccine (Table-2).   Table-2: Response of study population regarding COVID-19 and its vaccine (n=325)     Detail of the side effects experienced by the responded is shown in Table-3 and 4. Out of total participants, 203 and 221 individuals responded regarding vaccine related side effects after 1st and 2nd dose of vaccination respectively. No side effect was reported by 59.1% and 52.9% participants while 83 (40.9%) and 104 (47.1%) participants experienced some degree of side effects following 1st and 2nd dose of vaccination respectively (Table-3). But the difference was not significant (p>0.05). Both after 1st and 2nd dose of vaccine, the overall occurrence of moderate side effects was significantly (p < 0.05) high compared to mild and severe types (first dose: 19.7% vs. 11.8% and 9.4%; 2nd dose: 24.9% vs. 11.3% and 10.9%). After the second dose, females experienced significantly (p < 0.05) higher rate of side effects compared to males (56.3% vs. 23%). Following the second dose, females had a higher rate of moderate side effects (31.3%) compared to males (8.2%) and this difference was statistically significant (p < 0.05).   Table-3: Side effect experienced by the recipients of first and second doses of Sinopharm vaccine     Table-4: Side effects after first and second dose of Sinopharm vaccine according to the gender     Detail clinical features of the side effects recorded among the participants following vaccination are shown in Table-5. In over 50% of participants, symptoms appeared within 8 hours following both doses, and the symptoms of the majority vaccine recipients were relieved by taking rest at home. Out of 115 participants having comorbid conditions,   Table-5: Clinical features of side effects after receiving 1st and 2nd dose of Sinopharm vaccine     34 and 27 responded regarding the post vaccination side effects after 1st and 2nd dose of vaccine (Table-6). After the 1st dose, the overall side effects was significantly (p < 0.05) higher in participants with comorbid condition compared to healthy individuals (61.8% vs.37.3%). Following the first and second dose, participants with more mild side effects (50% and 63%) compared to healthy individuals (32.0% and 40.2%). After the second dose, participants with comorbidity though had a higher rate of overall side effects (63%) compared to healthy (45.4%), but the difference was not statistically significant (p > 0.05). Table-7 shows that the prevalence of side effects generally increased after the second dose of the vaccine, although the differences did not reach statistical significance. The most common side effects were fatigue (33.5% vs. 41.6%, p=0.084), pain/swelling at the injection site (28.1% vs. 36.7%, p=0.060), and headache (23.6% vs. 32.6%, p=0.033) for the first and second doses, respectively. Other notable side effects included myalgia (21.2% vs. 27.1%, p=0.152) and drowsiness (2 8.1% vs. 34.4%, p=0.162). Various other side effects, such as nausea, change in blood pressure, and numbness/tingling/dizziness were reported with varying prevalence but did not show statistically significant differences between the doses.   Table-6: Comparison of side effect after first and second doses of Sinopharm vaccine, according to comorbidity status of the study population     Table-7: Prevalence of side effects after first (n=203) and second (n=221) doses of Sinopharm vaccine among the study participants     Following Sinopharm vaccination, females experienced significantly higher rates of several side effects (Table-8). For the first dose, side effects reported by females include fatigue (38.2%, p=0.042), pain/swelling at the injection site (33.8%, p=0.009), disturbance in sleep quality (11.8%, p=0.013), haziness in vision (12.5%, p=0.003), and excessive sweating (8.8%, p=0.045). Following the second dose of vaccination, significant side effects in female participants were fatigue (50.6%, p<0.001), pain/swelling at the injection site (43.1%, p=0.001), headache (42.5%, p<0.001), myalgia (33.1%, p=0.001), numbness/tingling/dizziness (49%, p=0.001), drowsiness (40.6%, p=0.002), nausea (13.8%, p=0.028), changes in blood pressure (12.5%, p=0.014), joint pain (21.3%, p=0.023), and palpitations (12.5%, p=0.041).   Table-8: Gender-specific prevalence of side effects after first and second doses of Sinopharm vaccine among the study participants     Regarding participants’ perceptions of the Sinopharm vaccine, most participants (69.8%) felt more reassured after vaccination, 63.7% believed in its long-term safety, 98.8% recognized the need to continue preventive measures, 46.8% reported increased vital sign monitoring, and 98.8% recommended COVID-19 vaccination to others (Table-9).   Table-9: Participants' perceptions regarding Sinopharm vaccine after vaccination (N=325)     Discussion COVID-19 vaccines have significantly impacted the epidemic, preventing widespread loss of life and reducing infections and complications. Despite their effectiveness, concerns about vaccine safety persist globally. This study aimed to explore the short term side effects and perceptions surrounding the COVID-19 vaccine among young adults aged 18-25 years in Bangladesh. The majority of participants were young adults (mean age 22.00 ± 1.58 years), predominantly female (68.9), with 64.6 being healthy and 35.4 having chronic illnesses. It was observed in the present study that the primary sources of COVID-19 information were social media, government-owned media, and scientific/medical websites. Our study revealed a higher prevalence of side effects following Sinopharm (BBIBP-CorV) COVID-19 vaccination among female participants, particularly after the second dose. Common side effects included fatigue, injection site pain/swelling, headache, and myalgia. Participants with chronic diseases experienced more side effects compared to healthy students, with a statistically significant difference in mild side effects after the first dose. Moderate side effects were more prevalent after the second dose, with symptoms typically appearing within 8 hours and lasting 1-3 days. Female participants experienced significantly higher rates of moderate side effects after the second dose compared to males. They also reported a wider range of side effects, including fatigue, injection site pain/swelling, sleep disturbances, and various systemic symptoms. Despite these side effects, most participants felt reassured after vaccination, believed in its long-term safety, and continued to adhere to preventive measures. The majority recommended COVID-19 vaccination to others, indicating a generally positive perception of the vaccine's benefits. Several studies indicate common side effects of Sinopharm COVID-19 vaccine as injection site pain and fever [25-28]. Other vaccines like CoronaVac, ChAdOx1, and mRNA-1273 show similar side effects [29-31]. Adenoviral vector vaccines induce higher localized pain than mRNA vaccines and inactivated types, as reported by Rehab Magdy et al [32]. These findings are consistent with our results. Vaccine injection fears and hesitancy were linked to post-vaccination side effects [22]. Hatmal et al. found that almost half of vaccine recipients were initially apprehensive about COVID-19 vaccination [19]. Vaccination rates increase with endorsement by trusted government health authorities, physician recommendations, and effective communication through official channels. Availability of vaccines at multiple sites and free distribution also enhance vaccination rates [3]. Our study found a higher incidence of adverse reactions after the second dose compared to first doses of the Sinopharm COVID-19 vaccine, consistent with previous research [27,28,33,34]. This might be attributed to the immune system's response involving inflammatory cytokine secretion following initial vaccination. Post-vaccination side effects typically emerged within 24 hours of both doses, subsiding within 72 hours, aligning with prior studies [34]. However, some research reported symptoms persisting for up to 3 days [35], possibly influenced by recipient demographics and sample size [36]. In our study, females exhibited a higher likelihood of experiencing adverse symptoms compared to males. Following the first dose, females showed more systemic, local, and respiratory manifestations, but after both doses, systemic signs, neurological symptoms, and local expressions were more prevalent in females. Similar findings were reported in studies involving the BBIBP-CorV (Sinopharm) vaccine [22,27,35,37] as well as in surveys of other COVID-19 vaccines and various inactivated virus vaccines [30,38,39]. The exact cause is uncertain, but it's speculated that females may have a more robust immune system, leading to increased cytokine and antibody responses [40]. Participants with comorbidity reported more symptoms after the first dose, contrasting with other studies' findings where individuals without comorbidity experienced more adverse effects [22,27,41]. This discrepancy might be related to variations in immune responsiveness among individuals with chronic conditions and warrants further investigation. The Sinopharm COVID-19 vaccine was generally well-tolerated among young adults in Bangladesh, with side effects more prevalent after the second dose and in female participants. Despite experiencing side effects, most participants maintained a positive perception about the vaccine, indicating its acceptability. The higher prevalence of side effects in females and those with chronic diseases suggests the need for tailored vaccination strategies and communication and counseling with these groups. The reliance on social media for COVID-19 information highlights the importance of utilizing these platforms for disseminating accurate vaccine-related information.   Conflict of interest No competing interest/conflict of interest.   Funding The study was funded by Ibrahim Medical College, Dhaka Bangladesh.   References 1.     Acter T, Uddin N, Das J, Akhter A, Choudhury TR, Kim S. Evolution of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as coronavirus disease 2019 (COVID-19) pandemic: A global health emergency. Sci Total Environ. 2020; 730: 138996.doi: 10.1016/j.scitotenv.2020.138996 2.     Wang J, Jing R, Lai X, Zhang H, Lyu Y, Knoll MD, et al. Acceptance of COVID-19 vaccination during the COVID-19 pandemic in China. Vaccines (Basel). 2020; 8(3): 482. doi:10.3390/vaccines8030482 3.     Ahamed F, Ganesan S, James A, Zaher WA. Understanding perception and acceptance of Sinopharm vaccine and vaccination against COVID–19 in the UAE. BMC Public Health. 2021; 21(1): 1602. doi:10.1186/s12889-021-11620-z. 4.     Wei M, Yang N, Wang F, Zhao G, Gao H, Li Y. Epidemiology of Coronavirus Disease 2019 (COVID-19) Caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Disaster Med Public Health Prep. 2020; 14(6): 796-804. doi:10.1017/dmp.2020.155. 5.     Shahid R, Umar M, Khan MM, Zeb S, Nadar A, Afzal S. Side effects of Sinopharm vaccine experienced by healthcare professionals of Holy Family Hospital, Rawalpindi, Pakistan. J Rawalpindi Med College. 2021; 25(1): 37-43. doi:10.37939/jrmc.v25i1.1645. 6.     Kabamba Nzaji M, Kabamba Ngombe L, Ngoie Mwamba G, et al. Acceptability of vaccination against COVID-19 among healthcare workers in the Democratic Republic of the Congo. Pragmat Obs Res. 2020; 11: 103-109. doi:10.2147/POR.S271096 7.     Thunström L, Newbold SC, Finnoff D, Ashworth M, Shogren JF. The benefits and costs of using social distancing to flatten the curve for COVID-19. J Benefit Cost Ana. 2020; 11(2): 179-195. doi:10.1017/bca.2020.12. 8.     Schwarzinger M, Watson V, Arwidson P, Alla F, Luchini S. COVID-19 vaccine hesitancy in a representative working-age population in France: a survey experiment based on vaccine characteristics. Lancet Public Health. 2021; 6(4): e210-e221. doi:10.1016/S2468-2667(21)00012-8 9.     World Health Organization, 2022. Accelerating the prevention, control and elimination of communicable diseases through integration: optimizing support from Gavi and the Global Fund. Regional Office for the Eastern Mediterranean: World Health Organization; 2022 Report No. EM/RC69/5. 10.  Jahromi M, Al Sheikh MH. Partial protection of Sinopharm vaccine against SARS COV2 during recent outbreak in Bahrain. Microb Pathog. 2021; 158: 105086. doi:10.1016/j.micpath.2021.105086 11.  Ndwandwe D, Wiysonge CS. COVID-19 vaccines. Ndwandwe D, Wiysonge CS. COVID-19 vaccines. Curr Opin Immunol. 2021; 71: 111-116. doi:10.1016/j.coi.2021.07.003. 12.  Milken Institute. Covid-19 Treatment and Vaccine Tracker 2021 [Available from: https://covid-19tracker.milkeninstitute.org/#vaccines_intro.] 13.  Baraniuk C. What do we know about China's covid-19 vaccines? BMJ. 2021; 373: n912. doi:10.1136/bmj.n912. 14.  Sankova MV, Nikolenko VN, Litvinova TM, Volel BA, Oganesyan MV, Vovkogon AD, et al. Vaccination as a significant factor influencing the psychoemotional state of medical students during the Sars-Cov-2 pandemic: an international aspect. Clin Pract Epidemiol Ment Health. 2023; 19: e174501792304060. doi:10.2174/1745-0179-v19-e230420-2022-49. 15.  Ritchie H, Ortiz-Ospina E, Beltekian D, Mathieu E, Hasell J, Macdonald B, el al. Our World in Data. Coronavirus (COVID-19) vaccinations. 2021; [Accessed March 16th. 2021] 16.  Al-Mohaithef M, Padhi BK. Determinants of COVID-19 vaccine acceptance in Saudi Arabia: a web-based national survey. J Multidiscip Healthc. 2020; 13: 1657-1663. doi:10.2147/JMDH.S276771. 17.  COVID19 Vaccine Tracker. Bangladesh – COVID19 Vaccine Tracker 2021 [Available from: https://covid19.trackvaccines.org/country/bangladesh/.] 18.  Cui X, Wang P, Wei Z. Emergency use of COVID-19 vaccines recommended by the World Health Organization (WHO) as of June 2021. Drug Discov Ther. 2021; 15(4): 222-224. doi:10.5582/ddt.2021.01064. 19.  Hatmal MM, Al-Hatamleh MA, Olaimat AN, Hatmal M, Alhaj-Qasem DM, Olaimat TM, et al. Side effects and perceptions following COVID-19 vaccination in Jordan: a randomized, cross-sectional study implementing machine learning for predicting severity of side effects. Vaccines (Basel). 2021; 9(6): 556. doi:10.3390/vaccines9060556. 20.  Shekhar R, Sheikh AB, Upadhyay S, Singh M, Kottewar S, Mir H, et al. COVID-19 vaccine acceptance among health care workers in the United States. Vaccines (Basel). 2021; 9(2): 119. doi:10.3390/vaccines9020119 21.  Ghiasi N, Valizadeh R, Arabsorkhi M, Hoseyni TS, Esfandiari K, Sadighpour T, et al. Efficacy and side effects of Sputnik V, Sinopharm and AstraZeneca vaccines to stop COVID-19; a review and discussion. Immunopathol Persa. 2021; 7(2): e31.  doi: 10.34172/ipp.2021.31. 22.  Saeed BQ, Al-Shahrabi R, Alhaj SS, Alkokhardi ZM, Adrees AO. Side effects and perceptions following Sinopharm COVID-19 vaccination. Int J Infect Dis. 2021; 111: 219-26. 23.  Omeish H, Najadat A, Al-Azzam S, Tarabin N, Hameed AA, Al-Gallab N, et al. Reported COVID-19 vaccines side effects among Jordanian population: a cross sectional study. Hum Vaccin Immunother. 2022; 18(1): 1981086. doi:10.1080/21645515.2021.1981086 24.  Elgendy MO, Abdelrahim MEA. Public awareness about coronavirus vaccine, vaccine acceptance, and hesitancy. J Med Virol. 2021; 93(12): 6535-6543. doi:10.1002/jmv.27199 25.  Xia S, Duan K, Zhang Y, Zhao D, Zhang H, Xie Z, et al. Effect of an inactivated vaccine against SARS-CoV-2 on safety and immunogenicity outcomes: interim analysis of 2 randomized clinical trials. JAMA. 2020; 324(10): 951-960. doi:10.1001/jama.2020.15543. 26.  World Health Organization. Job aid for COVID-19 vaccine administration: Beijing Institute of Biological Products Co., Ltd. (BIBP) COVID-19 Vaccine, by China National Biotec Group (CNBG), Sinopharm (International non-proprietary name: Covilo; BIBP-CorV). WHO Regional Office for Europe. 2021. 27.  Mahmood A, Shujaat SA, Hayat M, Ijaz F, Habib S, Sadaqat W, et al. Acute adverse effects of vaccines against SARS-COV-2. Cureus. 2022; 14(7): e27379. doi:10.7759/cureus.27379. 28.  Thonginnetra S, Tawinprai K, Niemsorn K, Promsena P, Tandhansakul M, Kasemlawan N, et al. Safety after BBIBP-CorV (Sinopharm) COVID-19 vaccine in adolescents aged 10–17 years in Thailand. Vaccines (Basel). 2022; 10(10): 1765. doi:10.3390/vaccines10101765. 29.  Camacho Moll ME, Salinas Martínez AM, Tovar Cisneros B, García Onofre JI, Navarrete Floriano G, Bermúdez de León M. Extension and severity of self-reported side effects of seven COVID-19 vaccines in Mexican population. Front Public Health. 2022; 10: 834744. doi:10.3389/fpubh.2022.834744. 30.  Menni C, Klaser K, May A, Polidori L, Capdevila J, Louca P, et al. Vaccine side-effects and SARS-CoV-2 infection after vaccination in users of the COVID Symptom Study app in the UK: a prospective observational study. Lancet Infect Dis. 2021; 21(7): 939-949. doi:10.1016/S1473-3099(21)00224-3. 31.  Attash HM, Al-Obaidy LM, Al-Qazaz HK. Which type of the promising COVID-19 vaccines produces minimal adverse effects? A retrospective cross-sectional study. Vaccines (Basel). 2022; 10(2): 186.  doi:10.3390/vaccines10020186. 32.  Magdy R, Khedr D, Yacoub O, Attia A, Abdelrahman MA, Mekkawy D. Epidemiological aspects of headache after different types of COVID‐19 vaccines: An online survey. Headache: Headache. 2022; 62(8): 1046-1052. doi:10.1111/head.14374. 33.  Boshra MS, Hussein RR, Mohsen M, Elberry AA, Altyar AE, Tammam M, et al. A battle against COVID-19: Vaccine hesitancy and awareness with a comparative study between Sinopharm and AstraZeneca. Vaccines (Basel). 2022; 10(2): 292. doi:10.3390/vaccines10020292. 34.  Al-Zidan R, Darweesh O, Salah M, Bebane P, Ahmed H, Abdulrazzaq G, et al. Are some COVID-19 vaccines better than others regarding the short-term side effects? Ceska Slov Farm. 2023; 72(1): 45-54. 35.  Hatmal MM, Al-Hatamleh MAI, Olaimat AN, Mohamud R, Fawaz M, Kateeb ET, et al. Reported adverse effects and attitudes among Arab populations following COVID-19 vaccination: a large-scale multinational  study implementing machine learning tools in predicting post-vaccination adverse effects based on predisposing factors. Vaccines (Basel). 2022; 10(3): 366. doi:10.3390/vaccines10030366Al 36.  Khames Aga QA, Alkhaffaf WH, Hatem TH, Nassir KF, Batineh Y, Dahham AT, et al. Safety of COVID‐19 vaccines. J Med Virol. 2021; 93(12): 6588-6594. doi:10.1002/jmv.27214. 37.  Meo AS, Masood A, Shabbir U, Ali H, Nadeem Z, Meo SA, et al. Adverse effects of Sinopharm COVID-19 vaccine among vaccinated medical students and health care workers. Vaccines (Basel). 2023; 11(1): 105. doi:10.3390/vaccines11010105. 38.  Riad A, Pokorná A, Attia S, Klugarová J, Koščík M, Klugar MJ. Prevalence of COVID-19 vaccine side effects among healthcare workers in the Czech Republic. J Clin Med. 2021; 10(7): 1428. doi:10.3390/jcm10071428. 39.  Almufty HB, Mohammed SA, Abdullah AM, Merza MA. Potential adverse effects of COVID19 vaccines among Iraqi population; a comparison between the three available vaccines in Iraq; a retrospective cross-sectional study. Diabetes Metab Syndr. 2021; 15(5): 102207. doi:10.1016/j.dsx.2021.102207. 40.  Klein SL, Jedlicka A, Pekosz AJ. The Xs and Y of immune responses to viral vaccines. [published correction appears in Lancet Infect Dis. 2010 Nov; 10(11): 740]. Lancet Infect Dis. 2010; 10(5): 338-349. doi:10.1016/S1473-3099(10)70049-9. 41.  Mohebbi A, Eterafi M, Fouladi N, Golizadeh M, Panahizadeh R, Habibzadeh S, et al. Adverse Effects Reported and Insights Following Sinopharm COVID-19 Vaccination. Curr Microbiol. 2023; 80(12): 377. doi: 10.1007/s00284-023-03432-8.      Cite this article as: Ahasan MF, Haque N, Begum F, Rahman S, Farzana S, Aziz M, Islam SA. Side effects and perceptions among young adults in Bangladesh following COVID-19 vaccination: a single center study. IMC J Med Sci. July 2024; Vol. 18(2):011. DOI:https://doi.org/10.55010/imcjms.18.023 <![CDATA[Antibody response and its persistence to an inactivated SARS-CoV-2 virus vaccine in young Bangladeshi adults: a prospective study]]> Nehlin Tomalika Md Faizul Ahasan Smita Debsarma Sadya Afroz Naima Ahmed Md Mohiuddin Tagar Rishad Mehzabeen Sraboni Mazumder Supti Prova Saha Rehana Khatun Fahmida Rahman Md. Shariful Alam Jilani Nazma Haque Masuda Mohsena https://imcjms.com/journal_full_text/546 2024-09-02 10:51:19 Original Article July 2024; Vol. 18(2):012 Abstract Background and objectives: COVID-19 vaccination program has become a global priority to combat the worldwide pandemic. Studies claimed that severity and case fatality could be minimized by vaccination. The durability of antibodies developed after vaccination is crucial for preventing COVID-19. The purpose of this study was to investigate the dynamics of antibody responses to an inactivated SARS-CoV-2 virus vaccine over time. Materials and method: The study was conducted from November 2021 to November 2022 among young adults. A pre-tested structured questionnaire was used to record the socio-demographic and clinical data of all the participants. All the participants were vaccinated with two doses of Sinopharm COVID-19 vaccine. Blood samples were collected for estimation of IgG antibodies to SARS-CoV-2 spike S1 protein by indirect ELISA. Biochemical parameters namely random blood sugar (RBS), lipid profile, total protein, thyroid stimulating hormone (TSH), FT4 (free thyroxin) and vitamin D levels were determined in baseline samples by standard methods. Result: Total 348 adults, aged 18-28 years, were enrolled and of which 35.3% and 64.7% were male and female respectively. Out of 348 participants, 51.7% was seropositive for anti- SARS-CoV-2 antibodies before receiving vaccination. Seropositivity was not significantly (p >0.05) different in male and female participants before and after vaccination. Seropositivity at 1 month after 1st dose and 4 and 7 months after 2nd dose of vaccination increased significantly (p <0.05) compared to pre-vaccination rate. Compared to pre-vaccination level, the mean anti- SARS-CoV-2 antibody levels increased significantly (p<0.05) at 1 month after 1st dose and 4 and 7 months following 2nd dose of vaccination. Among 41 seronegative (non-immune) individuals, seropositivity to SARS-CoV-2 increased significantly (<0.05) at 7 month after 2nd dose of vaccine compared to 1 month and 4 months following 1st and 2nd doses of vaccine respectively. Seropositivity was not significantly (p >0.05) different before and after vaccination in participants having adequate and insufficient/deficient vitamin D levels. Conclusion: The study revealed that a good proportion of young adults possessed anti- SARS-CoV-2 antibody before vaccination and the seropositivity increased to over 90% following vaccination with Sinopharm COVID-19 vaccine. High level of anti- SARS-CoV-2 antibody persisted 7 months after 2nd dose of vaccine. July 2024; Vol. 18(2):012.  DOI:https://doi.org/10.55010/imcjms.18.024 *Correspondence: Nehlin Tomalika, Department of Community Medicine & Public Health, Ibrahim Medical College, 1/A, Ibrahim Sarani, Segunbagicha, Dhaka 1000, Bangladesh. Email: nehlintomalika@gmail.com   Introduction The pandemic of coronavirus disease 2019 (COVID-19) is caused by a virus named severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). The dreadful disease was first reported on December, 2019 in Wuhan, China. According to the report of World Health Organization (WHO) of August, 2023 more than 769 million people became infected and nearly 7 million died throughout the world. Currently, a number of COVID-19 vaccines are available worldwide. These vaccines vary in terms of side-effects, immunogenicity, efficacy, and duration of protection [1].Vaccines, recommended by WHO and other health agencies provide active acquired immunity against the virus and blocks the virus transmission, consequently reducing the number of COVID-19 cases. Vaccination induced immune response are measured mainly by serum IgG antibodies and vaccine specific effecter T cells which indicate both humoral and cellular immunity respectively. Assessment of cellular immunity on large scale is not easy. Hence, quantitative measurement of antibodies is the mainstay of evaluation of vaccine effectiveness [2]. SARS-CoV-2 virus contains spike protein (S), envelope protein (E), membrane protein (M) and nucleocapsid protein (N). Of these four structural proteins, spike protein (S) interacts with hosts’ ACE2 and TMPRSS2 receptors for invading the host. Therefore regarding protection, the S protein is contemplated as the most suitable antigen for inducing effective antibody responses [3]. Several serological tests are used to measure antibody directed against the spike glycoprotein or its receptor binding domain (RBD) [4,5]. Many studies reported a significant decrease of anti-SARS-CoV-2 antibodies by 12 months after vaccination or natural infection [1-3], and eventually susceptibility to infection rises. Therefore, the current study aimed to assess the anti- SARS-CoV-2 antibody response and its persistence up to 7 months period after receiving two doses of Sinopharm vaccine (an inactivated SARS-CoV-2 virus vaccine) in young Bangladeshi adults.   Materials and methods This prospective study was conducted over a period of one year from November 2021 to November 2022.The study was approved by the Institutional Ethical Review Board of Ibrahim Medical College. Informed written consent was obtained from all participants after explaining the nature and purpose of the study. Study population, vaccination and collection of blood: Previously non-vaccinated adults, aged 18 -28 years, were selected as study participants irrespective of their history of COVID-19 infection. A pre-tested structured questionnaire (closed ended) was used to record the socio-demographic and clinical data of all the participants. All the participants were vaccinated with two doses of Sinopharm COVID-19 vaccine (Sinopharm Group Co., Ltd, China). The vaccine is an inactivated virus vaccine using SARS-CoV-2 viruses and has an efficacy rate of 78.1% [6]. Each participant received two doses of vaccine. First and second dose of vaccine was administered at the time of enrollment and 1 month after the first dose respectively. Before administering the first dose of vaccine 5 ml of venous blood was collected aseptically to determine the IgG antibody level against SARS-CoV-2 and to estimate some biochemical parameters. Second blood sample (3 ml) was collected 1 month after the first dose prior to the administration of 2nd dose of vaccine. Third and 4th samples (each 3 ml) were collected 4 and 7 months after the second dose of vaccination respectively. Estimation of IgG antibodies to receptor binding domain (RBD) of SARS-CoV-2: IgG antibodies to RBD of SARS-CoV-2 spike protein S1 (anti-RBDS1 IgG) was determined in serum by ELISA using DRG ELISA kit (EIA-6150; Marburg, Germany). ELISA test was performed according to manufacturer’s instruction. Concentration of anti-RBDS1 IgG antibody was expressed in DU/ml. Any sample showing antibody concentration above the cut off value of 5.4 DU/ml (1DU/ml=5.15IU/ml) was considered as positive. Biochemical tests: Biochemical parameters namely random blood sugar (RBS), lipid profile, total protein, thyroid stimulating hormone (TSH) and FT4 (free thyroxin) levels were determined in baseline samples by standard methods. Total 25-OH vitamin D level was estimated by DRG-25-OH vitamin D ELISA kit (Marburg, Germany). A cut off value of 30 to 100 ng/ml was considered sufficiency of vitamin D concentration. Statistical analysis: Data were analyzed and expressed in frequencies, mean, standard deviation and 95% confidence interval (CI). Association between baseline biochemical characteristics and antibody status of participants were determined by chi-square and student’s t-tests. Kruskal-Wallis test was done to compare the mean antibody levels measured in samples taken at four different time points. Mann-Whitney U test was done to find out which pairs of groups were significantly different.   Results Serum anti-SARS-CoV-2 spike IgG antibodies against COVID-19 were assessed at various intervals before and after vaccination. A total of 348 participants were enrolled in the study of which 123 (35.3%) and 225 (64.7%) were male and female respectively. A baseline sample was taken from 348 participants to check for the presence of SARS-CoV-2 IgG antibody as well as other biochemical parameters that might be associated with antibody responses against SARS-CoV-2. Table-1 shows the detail biochemical profile of the enrolled participants. Only 14.9% of participants had adequate levels of vitamin D (> 30 ng/ml).   Table-1: Baseline biochemical characteristics of the study population      Out of 348 participants, blood samples were obtained from 211 participants 1 month after 1st dose of vaccination and from 207 and 123 participants after 4 and 7 months following 2nd dose of vaccination respectively (Table-2). Out of 348 participants, 51.7% was seropositive for anti- SARS-CoV-2 antibodies prior to any vaccination. Seropositivity rates at 1 m after 1st dose of vaccination (74.4%) and 4 and 7 months after 2nd dose of vaccination increased (81.2% and 95.1%) significantly (p <0.05) compared to pre-vaccination state (51.7%). The mean anti- SARS-CoV-2 antibody (anti-RBDS1 IgG) level increased significantly (p<0.05) 1 month after 1st dose of vaccination and 4 and 7 months following 2nd dose of vaccination compared to pre-vaccination level. The mean anti- SARS-CoV-2 antibody levels were not significantly (p>0.05) different following 1month after 1st dose and 4 months after the 2nd dose of vaccination (Table-2). There was a steep rise of anti- SARS-CoV-2 antibody level at 7 month after the 2nd dose of vaccine compared to 4 month level (98.9 DU/ml from 35.7 DU/ml). Out of 348 enrolled participants, 86 provided all four blood samples at the defined time points. Out of 86, 52.3% participants were seropositive prior to vaccination and the positivity rate became 94.2% at 7 months after 2nd dose of vaccination. Table-3 shows the detail seropositivity rates and anti- SARS-CoV-2 antibody levels of 86 participants before and after vaccination up to 7 month following 2nd dose of vaccination.   Table-2: Seropositivity and anti- SARS-CoV-2 antibody levels in study participants before and at different time intervals following vaccination     Table-3: Seropositivity and anti- SARS-CoV-2 antibody levels in 86 participants from whom all four samples were obtained at defined time interval     Out of 41 seronegative (non-immune) individuals, 39% became seropositive 1month after the 1st dose of vaccine while 53.7% and 87.8% became seropositive by 4 and 7 months after 2nd dose respectively (Table-4). The seropositivity at 4 and 7 months following 2nd dose of vaccine were 37.7% and 63.5% respectively. The seropositivity increased significantly (p < 0.05) at 7 months after 2nd dose of vaccine compared to 1 month and 4 months following 1st and 2nd doses of vaccine.   Table-4: Seropositivity among non-immune (seronegative) participants at different time intervals following vaccination with Sinopharm COVID-19 vaccine     No significant (p >0.05) difference was observed between seropositivity and gender before and after vaccination (Table-5). Seropositivity according to the vitamin D status of the study population before and after vaccination is depicted in Table-6. Seropositivity before vaccination and 1 month after 1st dose, and 4 and 7 months following 2nd dose of vaccination were not significantly (p >0.05) different in participants having adequate and insufficient/deficient vitamin D levels.   Table-5: Anti- SARS-CoV-2 IgG antibody of the study population at different time points according to the gender     Table-6: Anti- SARS-CoV-2 IgG antibody status according to the vitamin D status of the study population before and after vaccination     Discussion In the current study, changes in antibody responses to Sinopharm vaccine against SARS-CoV-2 were evaluated from pre-vaccination up to 7 months after the 2nd dose of vaccine. It was observed that about half of the participants had anti- SARS-CoV-2 IgG antibodies before vaccination. Before vaccination, the mean antibody level in seropositive individuals was about 12 times higher (mean 27.6 DU/ml) than that of seronegative counterparts (mean 2.3 DU/ml). Seropositivity profile observed in our study is in agreement with previously reported studies [7-9]. In the current study, post vaccination anti- SARS-CoV-2 IgG antibody level was found higher among those who were seropositive before vaccination. A previous study showed that antibody levels after two doses of vaccine were similar to one dose in convalescent patients [10,11]. Though in the present study, a decrease in antibody concentration was observed 4 months after the 2nd dose of vaccine but the decline was not statistically significant. However, two separate studies also reported a steep decrease in anti- SARS-CoV-2 IgG at six months post-boost [1,2]. But no such decrease of anti- SARS-CoV-2 IgG antibodies was found by other investigators [12-15]. Antibody level starts to decline 3 and 6 months after vaccination indicating a waning immunity [10] and increases the potential of contracting infection over time. Khoury DS et al. [16] mentioned that the titer decreases by 50% every 108 days post-vaccination. According to Wheeler et al [17] waning of anti-RBD antibodies begins on day 45 following vaccination. Waning of antibodies depend on vaccine immunogenicity, as well as, other multiple factors like demography, co-morbidity, and the initiation and maintenance of memory cells [18,19]. Different vaccines may also induce different levels of antibody responses. Moreover, a substantial degree of heterogeneity exists in various immunoassays [20], with some focusing on investigation of nucleocapsid antibodies and others on spike antibodies. The persistence of anti- SARS-CoV-2 IgG also depends on whether the infections were symptomatic or not. Lower persistence of antibody was reported among asymptomatic individuals [21]. In the current study, a robust immune response after 7 months of the 2nd dose was observed, and the antibody titer was found to be significantly associated with the positive family history of infection of the participants. On inquiry it was revealed that 42% of participants had a positive family history of infection after varying times of post-boost and showed increased antibody titres (mean103.72 DU/ml). However, the participants who had no prior infection history also exhibited elevated antibody titres (mean 84.04 DU/ml). This increase in antibody titers could be attributed to the possibility of an asymptomatic infection. This finding underscores the significance of considering asymptomatic infection in understanding the immune response dynamics in a population. In our study about half of the non-immune individuals did not develop anti- SARS-CoV-2 IgG antibodies 4months after the second dose of vaccine. A study conducted in Bangladesh, also had the similar findings. In that study 24% of participants didn’t show any seroconversion after 1st dose of AstraZeneca vaccine [22]. Al-Momani et al [23] obtained the same findings in a study conducted in Jordan. They reported that the overall efficacy of the vaccine was only 67%. According to Parry et al., 13% of participants were non-reactive after 1st dose of AstraZeneca vaccine in elderly population [24]. The failure of development of antibody is might be due to geographical and ethnic variation. Appropriate maintenance of cold chain during and after transportation of the vaccine might also play a significant role. The results underline the importance of monitoring and research to assess the effectiveness of the vaccines, especially in the context of emerging variants. The study has some limitations. The dropout rate was very high in the current study. The study was initiated with 348 participants, and all four samples could be collected from only 86 participants. A particular group of participants with similar ages were chosen and their antibody status was evaluated for seven months; hence, the findings cannot be generalized.   Conclusion The current study has shown that individuals who received two doses of the Sinopharm SARS-CoV-2 vaccine exhibited elevated levels of antibodies. However, it is crucial to note that a proportion of vaccinated individuals failed to produce antibodies despite receiving both doses of the vaccine. These findings suggest the necessity for additional vaccine doses and a careful and thorough evaluation of antibody levels at a defined time intervals in a large population groups.   Acknowledgments We are grateful to the students of Ibrahim Medical College for their voluntary participation in the study. We appreciate the active cooperation of all the volunteers and technicians as well as cordial support of the Ibrahim Medical College authority.   Authors’ contribution NT: Protocol writing, data collection, data entry, data analysis and manuscript writing; MFAS: research idea and data collection; SD, SA: protocol writing, data collection and data entry; NA, MMT, RM: data collection and data entry; SM, SPS, RK, FR: laboratory work; MSAJ: research idea and laboratory work; NH: research idea; MM: research idea, study design, data analysis, manuscript writing.   Fund The study was funded by Ibrahim Medical College.   References 1.     Alharbi NK, Al-Tawfiq JA, Alwehaibe A, Alenazi MW, Almasoud A, Algaisi A, et al. Persistence of anti-SARS-CoV-2 spike IgG antibodies following COVID-19 vaccines. Infect Drug Resist. 2022; 15: 4127-4136. doi:10.2147/IDR.S362848. 2.     Bordi L, Sberna G, Piscioneri CN, Cocchiara RA, Miani A, Grammatico P, et al. Longitudinal dynamics of SARS-CoV-2 anti–receptor binding domain IgG antibodies in a wide population of health care workers after BNT162b2 vaccination. Int J Infect Dis. 2022; 122:174-177. doi:10.1016/j.ijid.2022.05.061. 3.     Xiang T, Liang B, Fang Y, Lu S, Li S, Wang H, et al. Declining levels of neutralizing antibodies against SARS-CoV-2 in convalescent COVID-19 patients one year post symptom onset. Front Immunol. 2021; 12: 708523. doi:10.3389/fimmu.2021.708523. 4.     Saker K, Escuret V, Pitiot V, Massardier-Pilonchéry A, Paul S, Mokdad B, et al. Evaluation of commercial anti-SARS-CoV-2 antibody assays and comparison of standardized titers in vaccinated health care workers. J Clin Microbiol. 2022; 60(1): e0174621. doi:10.1128/JCM.01746-21. 5.     Van Elslande J, Decru B, Jonckheere S, Van Wijngaerden E, Houben E, Vandecandelaere P, et al. Antibody response against SARS-CoV-2 spike protein and nucleoprotein evaluated by four automated immunoassay and three ELISAs. Clin Microbiol Infect. 2020; 26(11): 1557.e1-1557.e7. doi:10.1016/j.cmi.2020.07.038. 6.     World Health Organization. The Sinopharm COVID-19 vaccine: What you need to know. Geneva: World Health Organization; 2022. Available at https://www.who.int/news-room/feature-stories/detail/the-sinopharm-covid-19-vaccine-what-you-need-to-know[Accessed 15 Marh 2024]. 7.     Rahman F, Mazumder S, Farook S, Deb P, Saha SP, Akter F, et al. Antibody response to receptor-binding domain of SARS-CoV-2 spike protein following vaccination and natural infection with SARS-CoV-2. IMC J Med Sci. 2023; 17(1): 009. doi: https://doi.org/10.55010/imcjms.17.009. 8.     Prendecki M, Clarke C, Brown J, Cox A, Gleeson S, Guckian M, et al. Effect of previous SARS-CoV-2 infection on humoral and T-cell responses to single-dose BNT162b2 vaccine. Lancet. 2021; 397(10280): 1178-1181. doi:10.1016/S0140-6736(21)00502-X. 9.     Manisty C, Otter AD, Treibel TA, McKnight Á, Altmann DM, Brooks T, et al. Antibody response to first BNT162b2 dose in previously SARS-CoV-2-infected individuals. Lancet. 2021; 397(10279): 1057-1058. doi:10.1016/S0140-6736(21)00501-8. 10.  Naaber P, Tserel L, Kangro K, Sepp E, Jürjenson V, Adamson A, et al. Dynamics of antibody response to BNT162b2 vaccine after six months: a longitudinal prospective study. Lancet Reg Health Eur. 2021; 10: 100208. doi:10.1016/j.lanepe.2021.100208. 11.  Steensels D, Pierlet N, Penders J, Mesotten D, Heylen L. Comparison of SARS-CoV-2 antibody response following vaccination with BNT162b2 and mRNA-1273. JAMA 2021; 326(15): 1533-1535. doi:10.1001/jama.2021.15125. 12.  Sarjomaa M, Diep LM, Zhang C, Tveten Y, Reiso H, Thilesen C, et al. SARS-CoV-2 antibody persistence after five and twelve months: A cohort study from South-Eastern Norway. Plos one. 2022; 17(8): e0264667. doi:10.1371/journal.pone.0264667. 13.  Turner JS, Kim W, Kalaidina E, Goss CW, Rauseo AM, Schmitz AJ, et al. SARS-CoV-2 infection induces long-lived bone marrow plasma cells in humans. Nature. 2021; 595(7867): 421-425. doi:10.1038/s41586-021-03647-4. 14.  Dan JM, Mateus J, Kato Y, Hastie KM, Yu ED, Faliti CE, et al. Immunological memory to SARS-CoV-2 assessed for up to 8 months after infection. Science. 2021; 371(6529): eabf4063. doi:10.1126/science.abf4063. 15.  Tunheim G, Laake I, Robertson AH, Waalen K, Hungnes O, Næss LM, et al. Antibody levels in a cohort of pregnant women after the 2009 influenza A (H1N1) pandemic: waning and association with self‐reported severity and duration of illness. Influenza Other Respir Viruses. 2019; 13(2): 191-200. doi:10.1111/irv.12623. 16.  Khoury DS, Cromer D, Reynaldi A, Schlub TE, Wheatley AK, Juno JA, et al. Neutralizing antibody levels are highly predictive of immune protection from symptomatic SARS-CoV-2 infection. Nat Med. 2021; 27(7): 1205-1211. doi:10.1038/s41591-021-01377-8. 17.  Wheeler SE, Shurin GV, Yost M, Anderson A, Pinto L, Wells A, Shurin MR. Differential antibody response to mRNA COVID-19 vaccines in healthy subjects. MicrobiolSpectr. 2021; 9(1): 10-128. doi:10.1128/Spectrum.00341-21. 18.  Baumgarth N, Nikolich-Žugich J, Lee FE, Bhattacharya D. Antibody responses to SARS-CoV-2: let’s stick to known knowns. J Immunol. 2020; 205(9): 2342-2350. doi:10.4049/jimmunol.2000839. 19.  Khodadadi L, Cheng Q, Radbruch A, Hiepe F. The maintenance of memory plasma cells. Front Immunol. 2019; 10:721. doi:10.3389/fimmu.2019.00721. 20.  Anichini G, Gandolfo C, Terrosi C, Fabrizi S, Miceli GB, Savellini GG, et al. Antibody response to SARS‐CoV‐2 in infected patients with different clinical outcome. J Med Virol. 2021; 93(4): 2548-2552. doi:10.1002/jmv.26789. 21.  Long QX, Tang XJ, Shi QL, Li Q, Deng HJ, Yuan J, et al. Clinical and immunological assessment of asymptomatic SARS-CoV-2 infections. Nat Med. 2020; 26(8): 1200-1204. doi:10.1038/s41591-020-0965-6. 22.  Tanni NN, Nesa M, Kabir RB, Habib FB, Zaman R, Tania NEJ, et al. Antibody responses after Oxford AstraZeneca (Covishield) vaccine among healthcare workers in Dhaka Medical College, Dhaka, Bangladesh. Afr J Microbiol Res. 2022; 16(3): 115-120.doi: 10.5897/AJMR2021.9590. 23.  Al-Momani H, Aldajah K, Alda'ajah E, ALjafar Y, Abushawer Z. Effectiveness of Pfizer/BioNTech and Sinopharm COVID-19 vaccines in reducing hospital admissions in prince Hamza hospital, Jordan. Front Public Health. 2022; 10: 1008521. doi:10.3389/fpubh.2022.1008521. 24.  Parry H, Bruton R, Tut G, Ali M, Stephens C, Greenwood D, et al. Immunogenicity of single vaccination with BNT162b2 or ChAdOx1 nCoV-19 at 5–6 weeks post vaccine in participants aged 80 years or older: an exploratory analysis. Lancet Healthy Longev. 2021; 2(9): e554-e560. doi:10.1016/S2666-7568(21)00169-0.       Cite this article as: Tomalika N, Ahasan MF, Debsarma D, Afroz S, Ahmed N, Tagar MM, Mehzabeen R, Mazumder S, Saha SP, Khatun R, Rahman F, Jilani MSA, Haque N, Mohsena M. Antibody response and its persistence to an inactivated SARS-CoV-2 virus vaccine in young Bangladeshi adults: a prospective study. IMC J Med Sci. 2024; 18(2): 012. DOI: https://doi.org/10.55010/imcjms.17.024 <![CDATA[Pleomorphic adenoma of the submandibular gland: a case report]]> Vijay Kumar Tanweerul Huda Zeeshan Ahmad Rohit Kumar Mohd. Yasir Zubair https://imcjms.com/journal_full_text/524 2024-05-09 16:18:42 Clinical Case Report July 2024; Vol. 18(2):004 Abstract Salivary gland tumors are relatively rare and constitute only about 1-4 % of head and neck tumors. Pleomorphic adenoma (PA) is the most common benign tumor of salivary glands. Approximately 80% of pleomorphic adenomas occur in the parotid gland, rest 10-20% in submandibular and minor salivary glands. Here, we present a confirmed case of pleomorphic adenoma of the submandibular gland. July 2024; Vol. 18(2):004.  DOI: https://doi.org/10.55010/imcjms.18.016 *Correspondence: Zeeshan Ahmad, Department of Otorhinolaryngology, ESIC Medical College Hospital, Bihta , Patna - 801103, Bihar, India. Email: ahmad66zeeshan@gmail.com   On the basis of history and examination, tumour of right submandibular gland was suspected. Computerized tomography (CT) scan of neck was done to determine the extent of the lesion. Axial and coronal cut sections of CT scan showed evidence of a large lobulated, heterogeneously enhancing mass lesion involving the right submandibular gland (approx. 6.5cm× 5.4cm) [Figure-2a and 2b]. Fine needle aspiration cytology (FNAC) was done. The smear showed high cellularity, arranged in cohesive clusters and sheets. Myoepithelial cells including plasmacytoid cells, basaloid cells, along with stromal fragments were seen, suggesting pleomorphic adenoma.   <![CDATA[Long COVID: Epidemiology, post-COVID-19 manifestations, possible mechanisms, treatment, and prevention strategies – A review]]> M. S. Zaman Robert C. Sizemore https://imcjms.com/journal_full_text/523 2024-04-22 10:32:38 Review July 2024; Vol. 18(2):003 Abstract Background and objectives: The respiratory disease COVID-19 began in 2019 and quickly became a pandemic infecting millions of individuals across the globe. Many patients show lingering effects of the infection several days after testing negative for the disease. This has become known as “long COVID” and is defined by various sources as lasting anywhere from 4 weeks to  periods. This is a review of the existing literature on long COVID which offersextensive insights into its clinical features, diagnosis, and treatment. Materials and method: Information on clinical features, mechanisms, treatment options, preventive measures, and epidemiology of long COVID is derived from an extensive review of scientific journals and pertinent authoritative sources. Results: The virus enters the cells via angiotensin-converting enzyme 2(ACE2) receptors. ACE2 receptors are present on numerous cell types throughout the body and thus the virus can affect several organs resulting in avariety of different symptoms. Long COVID symptoms include fatigue, dyspnea, headache, brain fog, and symptoms related to cardiovascular and pulmonary systems. Fatigue can affect upwards of 93% of patients suffering from long COVID. Failure of the body to clear the virus could initiate this chronic effect. Studies indicate that the use of antiviral drugs at the early phase of COVID-19 could prevent long COVID symptoms. Vaccines against SARS-CoV-2 also might help prevent long COVID. Conclusion: Diagnosing and managing long COVID is challenging due to diverse symptoms, including mental health issues like anxiety and depression. Longitudinal studies and patient-oriented approaches are crucial for treatment, supported by policies and educational campaigns. Understanding the pathophysiology remains a top priority. July 2024; Vol. 18(2):003.  DOI: https://doi.org/10.55010/imcjms.18.015 *Correspondence: M. S. Zaman, Department of Biological Sciences, Alcorn State University, Lorman, MS 39096, USA; Department of Biology, South Texas College, McAllen, TX 78501, USA. Emails: zaman@alcorn.edu; mzaman@southtexascollege.edu   Introduction The respiratory disease COVID-19, caused by SARS-CoV-2 first emerged in Wuhan, China, in November 2019 and quickly became a pandemic. As of this writing in 2023, over 768.9 million confirmed cases of COVID-19 have been recorded worldwide, and more than 6.9 million deaths have been reported by the World Health Organization [1]. Since this data is based on reported cases only, it can be presumed that many more cases have probably gone undocumented. The clinical spectrum of COVID-19 ranges from asymptomatic to life-threatening infections [2]. The virus enters the cells via angiotensin-converting enzyme 2(ACE2) receptors. Once inside the cells, the virus undergoes replication, triggering immune responses [3]. ACE2 receptors are present on numerous cell types throughout the body, including those of the oral and nasal mucosa, lungs, heart, gastrointestinal tract, liver, kidneys, spleen, and brain, as well as arterial and venous endothelial cells, indicating how SARS-CoV-2 can potentially damage multiple organs [4,5]. Being a new disease, a lot of information on the manifestations of COVID-19 remains unexplained. Recent studies indicate that a segment of the patients who contracted and eventually tested negative for COVID-19 experienced prolonged and continued symptoms of the disease over varied periods. This prolonged post-disease illness, which cannot be explained by an alternative diagnosis, has been referred to as long COVID. Common manifestations of long COVID comprise of, but are not limited to cough, sore throat, shortness of breath, cardiovascular dysfunction, fatigue and weakness, anosmia, headaches, and diarrhea. An estimated 80 percent of people who recovered from COVID-19 could experience at least one long-term symptom [6,7]. The symptoms of long COVID can last for many weeks following SARS-CoV-2 infection. The term “long COVID” gained wide attention following a May 2020 report in BMJ Opinion, in which, an infectious disease professor shared his 7 weeks of negative health experience with unexplained symptoms following his COVID-19 infection [8]. The patient denoted his experience as “long COVID” [9], which is now a recognized term in scientific literature. The National Institute for Health and Care Excellence (NICE) describes long COVID as a collective symptom that lingers or develops after acute COVID-19 infection, and which cannot be elucidated by an alternative diagnosis [10]. The US Centers for Disease Control and Prevention (CDC) describes long COVID as symptoms that extend beyond four weeks after initial infection [11]. The National Institute of Health (NIH) supports the US Centers for Disease Control and Prevention (CDC) definition of long COVID-19, stating that the lasting post-COVID-19 symptoms may prolong for 4 to 12 weeks beyond COVID-19 infection [12]. Studies indicate that developing long-COVID is unrelated to the severity of the infection, or the nature of treatments patients receive during COVID-19 infection [13].Patients with both mild and acute symptoms could develop long COVID [14,15]. A 2020 study suggests that the percentage of people who developed long COVID was similar among patients who were treated with oxygen alone and with invasive ventilation [14]. Similarly, studies reported that the prevalence of long COVID was not much different between hospitalized and non-hospitalized COVID-19 patients [16]. Although there is no founded consensus about defining long COVID syndrome, based on the available information, this review will mainly discuss the varied symptoms of long COVID, organ abnormalities and dysfunctions caused by the disease, and possible causes and mechanisms of organ dysfunctions [7].   Materials and Methods The information presented in this narrative review encompasses insights from a comprehensive examination of scientific journals and authoritative sources, focusing on epidemiology, manifestations, organ abnormalities, systemic dysfunctions, possible mechanisms, and treatment related to COVID-19. The search strategy for this review involved utilizing keywords such as COVID-19, post-COVID symptoms, Long COVID, post-COVID conditions, long-haul COVID, post-acute COVID-19, post-COVID mechanisms, and post-COVID treatment regimen. To gather relevant data, various search engines, including Google Scholar, MEDLINE, PubMed, Scopus, CDC, and WHO websites, were employed. The search scope was limited to the period from 2020 to 2023. Inclusion criteria encompassed articles that detailed manifestations, organ abnormalities, systemic dysfunctions, possible mechanisms, epidemiology, and treatment. Exclusion criteria were applied to non-English articles and articles lacking full text. Researchers autonomously conducted article searches and evaluated the quality of each study, ultimately determining their inclusion in the review based on a thorough examination of the full text.   Results Epidemiology The sudden emergence of COVID-19 and the resultant pandemic threw the world’s healthcare systems into chaos, confusion, panic, and uncertainty. Reported COVID-19 incidences and mortality rates varied across countries. It is not so difficult to comprehend that at such a chaotic time, keeping or predicting an accurate incidence of SARS-CoV-2 infection and the mortality rate was not logistically possible. With this ambiguity concerning COVID-19 incidences, it is difficult to accurately predict the number of COVID-19 cases that could progress into long COVID. The disparity in the epidemiological data is mostly due to differences in the accuracy in diagnosis and the reporting methods used in reporting the incidences. All in all, a lot of COVID-19 cases probably went unreported or undocumented. The National Institute of Health (NIH) and the Center for Disease Control and Prevention (CDC) defined long COVID as the ongoing post-COVID symptoms that persist beyond four weeks from the initial infection [12,11]. To this point, the data generated from various studies show a wide variation in long COVID prevalence. The UK Office for National Statistics reported that between April and December 2020, the estimated five-week prevalence of long COVID symptoms was 22.1%, and the 12-week prevalence was 9.9% [17]. Other studies reported that the prevalence was 96% at 90 days [18], 32.6% at 60 days [19], and 76% at 6 months [20]. In a 2022 publication, Hanson et al. revealed that a global total of 144.7 million individuals encountered any of the three symptom clusters associated with long COVID during the years 2020 and 2021. The prevalence rates for the fatigue, respiratory, and cognitive clusters were 51% (16.9–92.4), 60.4% (18.9–89.1), and 35.4% (9.4–75.1) among long COVID cases, respectively. Individuals with milder acute COVID-19 cases demonstrated a faster-estimated recovery (median duration 3.99 months) compared to those hospitalized for the acute infection (median duration 8.84 months). After twelve months, 15.1% (10.3–21.1) of individuals still experienced long COVID symptoms [21]. According to a recent review article, long COVID is observed in a minimum of 10% of severe SARS-CoV-2 infections. The study indicates that over 200 symptoms have been identified, affecting various organ systems. The estimated global prevalence of long COVID is reported to be at least 65 million individuals [22]. Although, due to the disparity in the epidemiological data, it is difficult to understand the epidemiology of the disease, the interest of the scientific community in long COVID is mounting, which might help create a better understanding of the epidemiology of COVID-19 and long COVID.   Common symptoms of long COVID Data from a large study involving 3762 COVID patients from 56 countries revealed the presence of 205 symptoms involving 10 different organ systems, and of these, 66 symptoms persisted for over seven months after the patients tested negative for the disease. Some of these individuals could not resume their pre-COVID physical activities due to lingering post-COVID symptoms. About 77.7% of these patients reported fatigue as the most common symptom, 72.2% reported continued malaise, and 55.4% experienced cognitive dysfunction [18]. Ceban (2021) reported on the physical well-being of individuals 12 or more weeks following COVID-19 diagnosis and reported that about 32% and 22% were still experiencing fatigue and cognitive impairment, respectively [23]. Fatigue: Fatigue is a chronic symptom of post-COVID infections regardless of the severity of the disease. Goertz et al. (2020) reported that 92.9% of hospitalized and 93.5% of non-hospitalized patients suffered from fatigue at 79 days following the onset of the disease [16]. Post-COVID fatigue has been compared with myalgic encephalomyelitis (ME) and chronic fatigue syndrome (CFS), as both represent similar symptoms, such as fatigue, pain, autonomic, cognitive, and psychiatric dysfunctions [24]. It is difficult to pinpoint the causes of fatigue syndrome. Studies indicate that several factors may be responsible for post-COVID fatigue, such as SARS-CoV-2 infection possibly damaging skeletal muscle, causing weakness, and inflammation of myofibers. Damage to neuromuscular junctions may also contribute to fatigue [25-28]. Wostyn (2020) suggested that SARS-CoV-2 infection may affect the lymphatic system, resulting in toxic build-up in the CNS causing fatigue symptoms [29]. Additionally, chronic fatigue could be a set of psychosomatic factors caused by negative psychological and social factors associated with SARS-CoV-2 infection [30,31]. Dyspnea: Dyspnea (breathlessness) is a common manifestation following COVID-19 infection [15,32]. Carfì et al. (2020) reported that dyspnea was present among 43.4% of 143 post-COVID patients 60 days after COVID-19 onset [33]. According to the UK Office for National Statistics (2020), regardless of the disease severity, shallow breathing is a common symptom in people with long COVID [17]. This is probably due to a slow recovery of lung functions in post-COVID patients. Total lung capacity, forced vital capacity, and forced expiratory volume could also be affected in long COVID patients [34]. SARS-CoV-2 replicates within the epithelial cells of the lung. Thus, the probable cause of dyspnea in post-COVID patients could be linked to extensive inflammatory damage to the endothelial cells in these organs [35,36]. Studies suggest that for most post-COVID patients, these damages may not be a long-term issue [37]. However, older patients and patients with pre-existing pulmonary conditions may develop pulmonary fibrosis caused by high levels of cytokines, such as interleukin-6 (IL-6) [38-40]. Cardiovascular abnormalities: Cardiovascular abnormalities, such as chest pain, tachycardia, myocarditis, and elevated serum troponin levels occur in SARS-CoV-2 patients [41-47]. Such manifestations have also been observed in long-COVID patients [48,33,49]. Residual myocarditis has been reported in young individuals and athletes long after recovery from COVID-19 [49]. Cardiac muscle cells express numerous ACE2 receptors providing SARS-CoV-2 pathways to the myocardium [50]. Cardiovascular manifestation in long COVID patients could also be caused by prolonged inflammation and fibrosis of the myocardium [51]. Persistent and intense immune responses to SARS-CoV-2 infection may damage the sarcomeres of cardiac muscle cells. Chronic hypoxia caused by SARS-CoV-2 infection may also damage the cardiac muscle cells [52,53]. Goldstein (2020) reported that SARS-CoV-2 infection may distress the autonomic nervous system which also may lead to irregular cardiac activities [52,54]. Headache: Persistent headaches are one of the most frequent symptoms that accompany long COVID. The headaches vary in duration and occurrence. This could beattributedtocontinued activation of the nervous system and the immune system, and the instigation of trigeminovascular function, an etiology in various headaches [7].   Organ abnormalities and systemic dysfunction As stated earlier, SARS-CoV-2 enters cells via ACE2 receptors, therefore, cells, tissues, and organs with abundant ACE2 receptors, could be directly damaged by SARS-CoV-2 infection [50,55]. Crook et al. (2021) reported that SARS-CoV-2 could cause damage to the lungs, heart, blood vessels, brain, kidneys, GI tract, liver, pancreas, and spleen. Possible damage to skeletal muscles and neuromuscular junctions has been suspected in SARS-CoV-2 infection [25,27]. There is also very strong evidence of the consequences of SARS-CoV-2 and the endocrine system [56]. Dennis et al. (2020) reported that chronic systemic inflammation was commonly observed in post-COVID periods, long after the clearance of SARS-CoV-2 infection [14]. Such elevated inflammation could secondarily damage the tissues and organs, leading to multiple organ complications in long COVID patients [57-59]. Lungs: Long-term ongoing pulmonary complications have been observed in some post-COVID patients. The most common dysfunctions were breathing difficulties and shortness of breath. Studies suggest that about 25% of COVID-19 patients could experience insufficient pulmonary function for up to a year following the initial SARS-CoV-2 infection [60]. Post-COVID CT scans performed at 12 months following the infection revealed that almost 50% of the patients with severe SARS-CoV-2 infection had signs of fibrosis [61]. Such a change in pulmonary tissue could lead to insufficient lung functions and pulmonary complications. Heart and blood vessels: As stated earlier, cardiovascular abnormalities in long COVID patients include chest pain, tachycardia, myocarditis, and elevated serum troponin [41-46]. A study conducted between June 2020 and March 2021 evaluated 342 COVID-19 patients in 25 hospitals in the UK. The researchers observed elevated levels of troponin, a marker for acute myocardial injury and heart attack. MRI scans within 28 days following discharge showed myocardial scars and ventricular impairment [62]. Cytokine storms caused by SARS-CoV-2 infection can cause serious damage to cardiac tissues causing myocarditis, stress cardiomyopathy, damage to the endothelial lining of arteries and veins, and small blood vessels. This can lead to blood vessel inflammation, affecting heart rhythm including palpitations and ventricular arrhythmias. Symptoms of myocarditis may potentially mimic a heart attack [63]. Kidney: Subclinical acute kidney injury (AKI) as indicated by proteinuria and hematuria is relatively common in COVID-19 patients. Studies from the US, Europe, and Brazil reported AKI in COVID-19 patients [64]. Data indicated that COVID-19-related AKI was present in 28-34% of all hospitalized patients and 46-77% of ICU patients [65,66]. Studies also reported that post-COVID patients have significant chances of developing chronic kidney disease (CKD) and CKD patients have higher risks of congestive heart failure and diabetes [67]. Decreased kidney function has also been reported in 35% of post-COVID patients even 6 months after they tested negative for the virus [20]. The mechanism of COVID-19's effects on kidneys is not clearly understood. However, one possible explanation could be due to the significant interaction of the SARS-CoV-2 virus with ACE2 receptors. Kidneys are among the key targets of the SARS-COV-2 virus as ACE2 receptors are in abundance on the renal parenchyma [68]. Additionally, podocyte cells of the glomerular capsule and the proximal convoluted tubules express ACE2 genes, indicating that nephrons could be the possible targets for SARS-C0V-2 [69]. Moreover, ACE2 receptors may also associate COVID-19 with the renin-angiotensin system (RAS), and the kallikrein-kinin system (KKS) [70,71]. RAS helps regulate blood pressure by maintaining salt and water retention and vascular tone, and KKS is associated with blood pressure regulation, inflammation, and coagulation. Thus, SARS-CoV-2 infection may contribute to abnormal functioning of the RAS and the KKS. Gastrointestinal (GI) tract: Studies indicate that SARS CoV-2 infects the esophagus, stomach, small intestine, and colon. Mayo Clinic’s Division of Public Health and Infectious Diseases reported that in a study involving 147 COVID-19 patients, 16 percent of the patients reported GI-related symptoms about 100 days after COVID-19 infection. The study also reported that abdominal pain, constipation, diarrhea, and vomiting were among the common symptoms of SARS-CoV-2 infection [72]. Significant changes in gut microbiota during and post-COVID periods have been reported. Such alterations include the depletion of anti-inflammatory symbionts, such as Faecalibacterium,and the enhancement of opportunistic pathogens, such as Coprobacillus and Clostridium species [73]. Such changes in microbiota could play a major role in GI-related complications in post-COVID patients. The GI tract has a complex network of nerves. It is speculated that SARS-CoV-2 infection interferes with the gut-brain signaling processes causing post-COVID irritable bowel syndrome, resulting in abdominal pain and changes in bowel movements such as diarrhea or constipation. Such disorders are also known as DGBIs (Disordered Gut-brain Interactions) [74]. Nakhli et al. (2022) reported that the digestive symptoms observed in post-COVID were related to DGBI. DGBI also included heartburn, bloating, and swallowing difficulties [75]. Liver: Kolesova et al. (2021) reported possible liver fibrosis in about 5% of post-COVID patients [76]. Liver fibrosis was also reported by Heidari (2022) [77]. Milic et al. (2022) reported the prevalence of fatty liver in post-COVID patients [78]. De Lima et al. (2023) reported possible liver injury in long COVID patients indicated by abnormalliver enzymes and injury markers [79]. A study involving 243 patients, reported elevated levels of the liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST), along with other liver injury markers, such as lactate dehydrogenase (LDH), gamma-glutamyl transferase (GGT), and ferritin [79]. In another study, researchers reported elevated levels of ALT and AST in post-COVID patients. The researchers found abnormalities in liver functions in 28.4% of 461 patients [80]. A meta-analysis of 64 studies involving 11,245 COVID-19 patients revealed that the prevalence of elevated ALT and AST was 21.2% and 23.2% respectively [81].The fibrosis of the liver could be due to a result of chronic inflammation of liver tissue caused by SARS-CoV-2 infection, and elevated liver enzymes could be correlated with liver injury. Pancreas: Pancreatic cells express ample ACE2 receptors, and thus, the pancreas could be easily affected by SARS-CoV-2 infection [82].Hadi et al. (2020) reported acute pancreatitis in COVID-19 patients [83]. Liu et al. (2020) reported pancreatic injury caused by SARS-CoV-2 infection, detected by CT images and elevated blood serum lipase [51]. Researchers reported that 40% of the post-COVID patients showed mild impairment of pancreatic functions which was associated with diarrhea, fever, headache, and dyspnea even after 141 days following infection [14]. As stated earlier, ACE2 receptors are abundant in pancreatic cells possibly to a greater level than in pulmonarycells [82,51]. However, it is not known for certain if pancreatic damage is a direct result of viral infection within the pancreas or caused by the systemic inflammatory response seen during COVID-19 [84]. Spleen: Splenomegaly (enlarged spleen) in COVID-19 patients has been reported in several studies [14]. CT data indicated a moderate increase in spleen size and the increase was associated with COVID-19 severity [85]. Studies indicated that the impacts of COVID-19 on the spleen decreased the number of T and B lymphocytes leading to lymphocytopenia [86-88]. On the other hand, additional studies indicated a decrease in spleen size and T lymphocyte count [89]. Dennis et al. (2020) reported mild spleen damage in 4% of patients 141 days after they were tested negative for COVID-19 [14]. It is suggested that since the spleen expresses adequate ACE2 receptors, it could be directly attacked by SARS-CoV-2, and this could be the primary reason for splenic damage rather than intense systemic inflammation [4,86]. Muscle: SARS-CoV-2 infection negatively impacts skeletal muscle functions causing weakness, fatigue, and reduced mobility weeks after COVID-19 diagnosis. Skeletal muscles are essential for movement, posture maintenance, equilibrium, and normal physical activities. Thus, skeletal muscle dysfunction would reduce the quality of life.It has been suggested that respiratory muscle weakness could be used as a marker of the recovery process during long COVID [6]. SARS-CoV-2 invades the muscle cells through ACE 2 receptors. The virus-inflicted damage to the muscle cells could be direct as the virus replicates within the cells, interrupting cell function, or indirect via systemic inflammation, hypoxia, and myopathy [6]. Elevated levels of cytokines such as IL-2, IL-6, IL-10, and interferon-gamma impact muscle cell protein metabolism by decreasing anabolic functions and increasing catabolic functions, which could interfere with the safeguarding of muscle health and function [90]. Endocrine dysfunction: Endocrine organs express ACE2 receptors where the virus can trigger typical pro-inflammatory cytokines and acute phase reactants such as C-reactive protein. The damages include insufficient adrenal function and thyroid dysfunction, such as hypothyroidism, hyperthyroidism, and thyroiditis [57]. It has been noted that hyponatremia (low blood sodium) occurs in nearly a third of patients with COVID-19.In addition, the gonads and pancreas may be affected [91]. One clear area of concern is that endocrine failure due to long COVID may lead to progressive destruction of the pancreas. Data has shown that 10% of COVID-19 patients had newly diagnosed diabetes. However, Type 1 and Type 2 diabetics are more likely to have complications if they do get COVID-19 [92]. Studies also indicate that nondiabetic hospitalized COVID patients showed spikes in their blood sugar levels after leaving the hospital facility [93]. Immunological dysfunction: Another long-term effect of infection with COVID-19 is immune dysfunction which would make patients vulnerable to repeat infection as well as other infections [94]. Several reports have shown that infection with COVID-19 caused a severe decrease in CD8+ cytotoxic T cells and natural killer (NK) cells [95,96]. CD8+ T cells are important in controlling viral infections. Loss of CD8+ T cells has been observed in other viral infections and cancer so this is not unique to COVID [97]. Some claim that this loss is similar to that seen with HIV infections [94]. NK cells are also important for attacking virus-infected cells in an antigen-non-specific manner although recent reports suggest antigen-specific memory as well [98]. SARS-CoV-2 infection releases a flood of cytokines referred to as a cytokine storm. This amplified immune response may cause overwhelming inflammation in the body destroying healthy tissues and damaging vital organs [59]. Severe cytokine storm also occurs in Ebola infections [99]. Neurological dysfunction: Brain fog, headache, and fatigue are the most common neurological symptoms among long COVID patients [100]. Fatigue, hyposmia, and cognitive impairments were the most common post-COVID symptoms likely caused by nervous system dysfunction [101]. Another study published by Shanley et al. reportedthat fatigue (89.3%) and headache (80.4%) were the two most common neurologic symptoms among post-COVID patients. At a 6-month follow-up, most symptoms subsided; about 33% reported complete recovery. However, memory impairment (68.8%) and decreased concentration (61.5%) persisted [102]. In the USA, among long COVID patients, about 15 million people are affected by extreme fatigue and brain fog, causing an estimated 2-4 million people to leave the workforce [103]. The possible causes of brain fog in COVID have been studied by several researchers [104-106]. Immune response to the virus induces chronic inflammation that leads to microclots and impaired brain cell functions [107,101]. Additionally, increased cytokine production due to the infection-activated microglia cells also hampers new neuron formation in the hippocampus [104]. Thus, increased cytokine activity impairs neurogenesis, particularly in parts of the brain that are associated with memory [107]. Therefore, persistent cytokine production and chronic inflammatory responses may be associated with numerous problems including brain fog in long COVID cases. A study conducted in Bangladesh involved 385 post-COVID individuals, revealing persistent levels of depression (29.4%), anxiety (37.4%), and stress (18.2%). The study also noted extremely severe cases, with 3.6% experiencing depression, 6% anxiety, and 0.5% stress. Interestingly, there was no significant difference in depression and anxiety between suburban and rural populations, but stress levels were notably higher in the suburban group. Approximately 60% of participants had to reduce their heavy work schedules, yet moderate to minimal physical activities were less affected. Moreover, weakness and nervousness emerged as predominant factors hindering their socialization [108]. The key information concerning possible vital organ damage and systemic dysfunctions inflicted by SARS-CoV-2 infection, and long COVID manifestations are summarized in Table: 1.   Table-1: Summary of major systemic dysfunctions and manifestations in long COVID.       Long COVID in children Most long COVID information came from studies with adult patients. However, a few studies conducted on children or teen agers revealed that their symptoms were very much like those of adults. Crist (2022) indicated that there could be around 100 million people living with long-COVID, and its effects were equally disabling in both adults and young individuals. Even so, more studies are needed to validate such findings [109]. The UK Office for National Statistics indicated that in the United Kingdom alone, tens of thousands of younger subjects might have been suffering from long COVID. Among these long-COVID sufferers, about 44,000 were 2 to 11-year-olds and about 73,000 were 12 to 16-year-olds [110]. A large study from the United Kingdom involving young subjects (11 to 17-year-olds) revealed that two-thirds of the subjects reported three or more symptoms of long-COVID even three months after they were tested negative for the disease [111].   Treatment and prevention strategies At present, Long COVID lacks a definitive treatment. Collaborative efforts between patients and healthcare providers are crucial in planning personalized care strategies to effectively address post-COVID symptoms and enhance the overall quality of life. In general, current clinical practice utilizes a symptom-oriented approach to address long COVID. This involves a thorough evaluation incorporating medical history and examinations. For a comprehensive assessment, it's advised to conduct various tests including full blood count, renal function, C-reactive protein, liver function, thyroid function, hemoglobin A1c (HbA1c), vitamin D, magnesium, B12, folate, and ferritin levels [112]. The approach to treating long COVID could extend beyond symptomatic treatments through the collaboration of a specialized team of physicians. For instance, the University of California, Los Angeles (UCLA), offers personalized treatments to long COVID patients with the expertise of specialists in internal medicine, neurology, cardiology, and pulmonology. Additionally, UCLA Health (2024) highlights the provision of counseling and mental health support for individuals dealing with long COVID [113]. In a recent study, a synbiotic preparation (SIM01) was found to improve gut microbiota composition in patients with post-acute sequelae of SARS-CoV-2 (PACS). It increased beneficial bacteria and reduced pathogenic ones associated with PACS. The gut microbiota's connection to the immune response and blood cytokine profiling was noted. SIM01 also alleviated gastrointestinal symptoms resembling post-infectious irritable bowel syndrome. SIM01 helped reduce chronic fatigue syndrome by promoting butyrate-producing bacteria species. Prebiotic compounds in SIM01, including galacto-oligosaccharides, xylo-oligosaccharides and resistant dextrin, positively influenced gut microbiome composition. Furthermore, this study also indicated a possible connection between the gut, brain, and bacteria which could be related to mental symptoms, but more research is needed to fully understand it [114]. The National Institute for Health and Care Excellence (NICE) lays out evidence-backed methods for assessing and managing long COVID in patients [112]. Their guidelines suggest clinical examination for long COVID as early as 4 weeks after acute symptoms. Furthermore, the National Institute of Health Research (NIHR) has also provided recommendations regarding the assessment of long COVID symptoms, prioritizing care for specific populations [112,115]. Research suggests that monoclonal antibody treatments can target and neutralize the SARS-CoV-2 virus effectively. This sheds light on why certain individuals with long COVID experienced temporary symptom relief following their COVID-19 vaccination. Additionally, monoclonal antibodies might counter and replace nonfunctional antibodies that could inadvertently target our cells [116]. The World Health Organization (WHO) supports research priorities aimed at enhancing clinical understanding and creating treatments for long COVID. At the same time, healthcare experts are actively investigating clinical strategies to identify and address long COVID [112]. In addition to exploring treatment options, it would be beneficial for individuals experiencing long COVID to learn how to alleviate and handle the symptoms of the condition. The British Heart Foundation has released a Long COVID Recovery Guide that provides valuable tips on managing ailments like fatigue, breathlessness, brain fog, cognitive impairment, and joint and muscle pain. The guide also offers advice on boosting mood and supporting mental health [117]. Getting vaccinated against SARS-CoV-2 may reduce the risk of developing long COVID. According to the CDC, individuals who are not vaccinated against COVID-19 and contract the virus may be at a higher risk of experiencing long COVID compared to those who have been vaccinated. The CDC also highlights the possibility of multiple reinfections with SARS-CoV-2, with each instance carrying a potential risk of long COVID development. Additionally, it is noted that while most individuals with long COVID show evidence of infection or COVID-19 illness, there are cases where a person experiencing long COVID may not have tested positive for the virus or been aware of their infection [118]. Preventing long COVID should be a top priority for public and global health. New findings suggest that antiviral medications for SARS-CoV-2 could be effective in this prevention. Research indicates that nirmatrelvir (with ritonavir) reduced the risk of long COVID by 26%, and molnupiravir reduced it by 14% [119-121]. Exploratory analyses also showed that ensitrelvir may reduce the risk of long COVID [122]. Overall, these findings with nirmatrelvir, molnupiravir, and ensitrelvir suggest that using antivirals during the early phase of COVID-19 could be an important strategy to prevent long-lasting symptoms. Recently, Johns Hopkins Health Care has suggested the use of ICD-10 code U09.9 (International Classification of Disease) in the diagnosis and reporting of patients with Long COVID-19 [123].   Discussion Long COVID is a possible risk factor, i.e., not all COVID-19 patients suffer from it. Indeed, most of the patients do not exhibit long COVID manifestations. The actual number of patients with long COVID is unknown. However, it is estimated that between 7.7 to 23 million people are suffering from long COVID-related symptoms [124], whereas another study suggests that in the US, there are about 10-33 million working-age adults with long COVID [125]. What causes long COVID is also a challenging question to answer. The answer can be a mixture of speculations. One of the key reasons could be the duration of the virus in the infected patients. Viral RNA that remains in the body for longer than 14 days could cause long COVID. Studies indicate that about 42% of patients remain COVID-positive for 14 days or longer and for about 12% of patients, the duration is 90 days or longer [126]. Studies also suggest that in about 4% of the patients, viral RNA could be detected even 7 months after diagnosis with COVID-19, and in some immunocompromised patients, the virus might take about a year to be cleared from the body [125]. Viral elements were detected in intestinal, lung, appendix, and breast tissue for various lengths of time with a range of 100-462 days [127,128]. Several researchers believe that microclots that form in the body as a result of SARS-CoV-2 infection, could be involved with the sequelae of long COVID syndrome [129]. These microclots can block microcapillaries and prevent the exchange of oxygen in numerous organs and tissues. As these clots are resistant to fibrinolysis, this can cause a buildup and induce inflammatory responses as well [130,131] According to a report from the Yale University Iwasaki Lab in collaboration with the Mount Sini School of Medicine, exposure to SARS-CoV-2 may elevate the humoral immune response against the coronavirus and other non-coronavirus pathogens, such as Epstein-Barr virus. Such infection could also decrease the stress hormone cortisol level. Iwasaki hypothesized that acute infection disturbs trillions of normal flora bacteria and viruses in our bodies. This induces inflammation causing an imbalance in the body’s homeostasis. Additionally, the reactivation of dormant viruses could induce autoimmunity by triggering B and T cells [132]. In a large study where 1.5 million unvaccinated COVID-19 patients were compared with over 25 thousand vaccinated patients with breakthrough infections, the vaccine significantly reduced the risk of developing long COVID [133]. Recent data also suggests that there may be a genetic risk factor involved with long COVID [134,135].One study determined that genetic variants in the FOXP4 locus were associated with an increased risk for Long COVID. This was due to increased expression of FOXP4 in the lungs (particularly alveolar and immune cells) which they believe increased the severity of COVID-19 [135].   Limitations This review is constrained by the inherent bias associated with a literature review of a similar nature. The potential for bias could be mitigated through the adoption of a systematic review approach. Given that this study did not adhere to a systematic review methodology, the search strategies employed may not justify a thorough examination. Moreover, considering COVID-19's status as a novel disease, numerous uncertainties surround its understanding. The study's information spans approximately four years, yet the absence of a systematic method for bias assessment through meta-analysis raises concerns about potential bias in the study.   Conclusions Due to nonspecific and diverse symptoms, the diagnosis and management of long COVID remains a challenge. Mental health illnesses such as anxiety and depression further aggravate the challenges. Moreover, the systemic nature of this condition, affecting multiple organs and bodily systems, complicates its management and requires close collaboration between patients and healthcare providers. Studies indicate that the prolonged symptoms might be linked to the virus directly impacting various organ systems, including the immune system. Studies also suggest that the virus might persist in tissues, sustaining immune reactions and symptoms. Additionally, disruptions in cellular and molecular mechanisms, potentially affecting vascular function and causing microclotting issues across organs, are also suspected. Understanding these mechanisms is crucial to determine the treatment options. Longitudinal epidemiologic studies including clinical trials and patient-oriented approaches can bolster treatment strategies. Furthermore, educational campaigns, telemedicine integration, specialized care, and supportive policies would help to manage long COVID. Understanding the pathophysiology of long COVID illnesses and their management remains a priority.   Author contributions All authors have accepted responsibility for the entire content of this manuscript and approved its submission.   Conflict of interest The authors declare no conflict of interest, financial orotherwise.   Human and animal rights Not applicable.   Funding None   References 1.       World Health Organization. Coronavirus (COVID-19) Dashboard. 2022; Available at: https://covid19.who.int/. 2        Chen T, Wu D, Chen H, Yan W, Yang D, Chen G, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ. 2020; 368: m1091. doi: 10.1136/bmj.m1091. 3.       Hussman JP. Cellular and molecular pathways of COVID-19 and potential points of therapeutic intervention. Front Pharmacol. 2020; 11: 1169. doi: 10.3389/fphar.2020.01169. 4.       Hamming I, Timens W, Bulthuis ML, Lely AT, Navis G, van Goor H. Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. A first step in understanding SARS pathogenesis. J Pathol. 2004; 203(2): 631-7. doi: 10.1002/path.1570. 5.       Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020; 323(13): 1239-42. doi: 10.1001/jama.2020.2648. 6.       Montes-Ibarra M, Oliveira CLP, Orsso CE, Landi F, Marzetti E, Prado CM. The impact of long COVID-19 on muscle health. Clin Geriatr Med. 2022; 38(3): 545-557. doi: 10.1016/j.cger.2022.03.004. 7.       Tana C, Bentivegna E, Cho SJ, Harriott AM, Garcia-Azorin D, Labastida-Ramirez A, et al. Long COVID headache. J Headache Pain. 2022; 23(1): 93. doi: 10.1186/s10194-022-01450-8. 8.       Garner P. For 7 weeks I have been through a roller coaster of ill health, extreme emotions, and utter exhaustion. The BMJ Opinion. 2020; Available at: https://blogs.bmj.com/bmj/2020/05/05/paul-garner-peoplewho-have-a-more-protracted-illness-need-help-to-understand-andcope-with-the-constantly-shifting-bizarre-symptoms/. 9.       Perego E, Callard F, Stras L, Melville-Jóhannesson B, Pope R, Alwan NA. Why the patient-made term ‘long COVID’ is needed. Wellcome Open Res. 2020; 5: 224. doi: 10.12688/wellcomeopenres.16307.1. 10.    COVID-19 rapid guideline: managing the long-term effects of COVID-19. NICE (National Institute for Health and Care Excellence). 2020; Available  at: https://www.nice.org.uk/guidance/ng188/resources/covid19-rapid-guideline-managing-the-longterm-effects-of-covid19-pdf-51035515742. 11.    Datta SD, Talwar A, Lee JT. A proposed framework and timeline of the spectrum of disease due to SARS-CoV-2 infection: illness beyond acute infection and public health implications. JAMA. 2020; 324(22): 2251-2. doi: 10.1001/jama.2020.22717. 12.    Long COVID. NIH (National Institute of Health). 2023; Available at: https: //covid19.nih.gov/covid-19-topics/long-covid. 13.    Crook H, Raza S, Nowell J, Young M, Edison P. Long covid-mechanisms, risk factors, and management. BMJ. 2021; 374: n1648. doi: https://doi.org/10.1136/bmj.n1648. 14.    Dennis A, Wamil M, Alberts J, Oben J, Cuthbertson DJ, Wootton D, e al; Multiorgan impairment in low-risk individuals with post-COVID-19 syndrome: a prospective, community-based study. BMJ Open. 2021; 11(3): e048391. doi: 10.1136/bmjopen-2020-048391. 15.    Mandal S, Barnett J, Brill SE, Brown JS, Denneny EK, Hare SS, et al. ‘Long-COVID’: a cross-sectional study of persisting symptoms, biomarkers, and imaging abnormalities following hospitalization for COVID-19. Thorax. 2021; 76(4): 396-8. doi: 10.1136/thoraxjnl-2020-215818. 16.    Goërtz YMJ, Herck MV, Delbressine JM, Vaes AW, Meys R, Machado FVC, et al. Persistent symptoms 3 months after a SARS-CoV-2 infection: the post-COVID-19 syndrome? ERJ Open Res. 2020; 6(4): 00542-2020. doi:10.1183/23120541.00542-2020. 17.    Prevalence of long COVID symptoms and COVID-19 complications. UKNS (UK Office for National Statistics). 2020; Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/datasets/prevalenceoflongcovidsymptomsandcovid19complications. 18.    Davis HE, Assaf GS, McCorkell L, Wei H, Low RJ, Re’em Y, et al. Characterizing Long COVID in an International Cohort: 7 Months of Symptoms and Their Impact. E Clinic Med. 2021; 38: 101019. doi: 10.1016/j.eclinm.2021.101019. 19.    Chopra V, Flanders SA, O’Malley M, Malani AN, Prescott HC. Sixty-day outcomes among patients hospitalized with COVID-19. Ann Intern Med. 2021; 174(4): 576-8. doi:10.7326/M20-5661. 20.    Huang C, Huang L, Wang Y, Li X, Ren L, Gu X, et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet. 2021; 397(10270): 220-32. doi: 10.1016/S0140-6736(20)32656-8. 21.    Hanson SW, Abbafati C, Aerts JG, Al-Aly Z, Ashbaugh C, Ballouz T, et al. A global systematic analysis of the occurrence, severity, and recovery pattern of long COVID in 2020 and 2021. [Preprint]. JAMA. 2022; 328(16): 1604-1615. 22.    Davis HE, McCorkell L, Vogel JM, Topol EJ. Long COVID: Major findings, mechanisms and recommendations. Nat Rev Microbiol. 2023; 21(6): 408. doi: 10.1038/s41579-023-00896-0. 23.    Ceban F, Ling S, Lui LMW, Lee Y, Gill H, Teopiz KM, et al. Fatigue and cognitive impairment in Post-COVID-19 syndrome: A systemic review and meta-analysis. Brain BehavImmun. 2022; 101: 93-135. doi:10.1016/j.bbi.2021.12.020. 24.    Wong TL, Weitzer DJ. Long COVID and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)-a systemic review and comparison of clinical presentation and symptomatology. Medicina (Kaunas). 2021; 57(5): 418. doi: 10.3390/medicina57050418. 25.    Ferrandi PJ, Alway SE, Mohamed JS. The interaction between SARS-CoV-2 and ACE2 may have consequences for skeletal muscle viral susceptibility and myopathies. J Appl Physiol (1985). 2020; 129(4): 864-7. doi: 10.1152/japplphysiol.00321.2020. 26.    Jin M, Tong Q. Rhabdomyolysis as potential late complication associated with COVID-19. Emerg Infect Dis. 2020; 26(7): 1618-20. doi:10.3201/eid2607.200445. 27.    Arnold P, Njemini R, Vantieghem S, Duchateau J, Mets T, Beyer I, et al. Peripheral muscle fatigue in hospitalized geriatric patients is associated with circulating markers of inflammation. Exp Gerontol. 2017; 95: 128-35. doi: 10.1016/j.exger.2017.05.007. 28.    Chaudhuri A, Behan PO. Fatigue in neurological disorders. The Lancet. 2004; 363(9413): 978-88. doi: 10.1016/S0140-6736(04)15794-2. 29.    Wostyn P. COVID-19 and chronic fatigue syndrome: Is the worst yet to come? Med Hypotheses. 2021; 146: 110469. doi: 10.1016/j.mehy.2020.110469. 30.    Morgul E, Bener A, Atak M, Akyel S, Aktaş S, Bhugra D, et al. COVID-19 pandemic, and psychological fatigue in Turkey. Int J Soc Psychiatry. 2021; 67(2): 128-35. doi: 10.1177/0020764020941889. 31.    Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. The Lancet. 2020; 395(10227): 912-20. doi: 10.1016/S0140-6736(20)30460-8. 32.    Halpin SJ, McIvor C, Whyatt G, Adams A, Harvey O, McLean L, et al. Post-discharge symptoms and rehabilitation needs in survivors of COVID-19 infection: A cross-sectional evaluation. J Med Virol. 2021; 93(2): 1013-22. doi: 10.1002/ jmv.26368. 33.    Carfì A, Bernabei R, Landi F, Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent symptoms in patients after acute COVID-19. JAMA. 2020; 324(6): 603-5. doi:10.1001/jama.2020.12603. 34.    Mo X, Jian W, Su Z, Chen M, Peng H, Peng P, et al. Abnormal pulmonary function in COVID-19 patients at time of hospital discharge. Eur Respir J. 2020; 55(6): 2001217. doi: 10.1183/13993003.01217-2020. 35.    Kempuraj D, Selvakumar GP, Ahmed ME, Raikwar SP, Thangavel R, Khan A, et al. COVID-19, mast cells, cytokine storm, psychological stress, and neuroinflammation. Neuroscientist. 2020; 26(5-6): 402-14. doi: 10.1177/1073858420941476. 36.    Ackermann M, Verleden SE, Kuehnel M, Haverich A, Welte T, Laenger F, et al. Pulmonary vascular endothelialitis, thrombosis, and angiogenesis in covid-19. N Engl J Med. 2020; 383(2): 120-8.  doi:10.1056/NEJMoa2015432. 37.    Daher A, Balfanz P, Cornelissen C, Műller A, Berrgs I, Marx N, et al. Follow up of patients with severe coronavirus disease 2019 (COVID-19): pulmonary and extrapulmonary disease sequelae. Respir Med. 2020; 174: 106197. doi:10.1016/j.rmed.2020.106197. 38.    Han X, Fan Y, Alwalid O, Li N, Jia X, Yuan M, et al. Six-month follow-up chest CT findings after severe covid-19 pneumonia. Radiology. 2021; 299(1): E177-86. doi: 10.1148/radiol.2021203153. 39.    McElvaney OJ, McEvoy NL, McElvaney OF, Carroll TP, Murphy MP, Dunlea DM, et al. Characterization of the inflammatory response to severe covid-19 illness. Am J Respir Crit Care Med. 2020; 202: 812-21. doi: 10.1164/rccm.202005-1583OC. 40.    Moodley YP, Scaffidi AK, Misso NL, Keerthisingam G, McAnuly R, Laurent G, et al. Fibroblasts isolated from normal lungs and those with idiopathic pulmonary fibrosis differ in interleukin-6/gp130-mediated cell signaling and proliferation. Am J Pathol. 2003; 163(1): 345-54. doi:10.1016/S0002-9440(10)63658-9. 41.    Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020; 395(10229): 1054-62. doi:10.1016/S0140-6736(20)30566-3. 42.    Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, et al. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol. 2020; 5(7): 802-10. doi: 10.1001/jamacardio.2020.0950. 43.    Johansson M, Ståhlberg M, Runold M, Nygren-Bonnier M, Nilsson J, Olshansky B, et al. Long-haul post-COVID-19 symptoms presenting as a variant of postural orthostatic tachycardia syndrome: the Swedish experience. JACC Case Rep. 2021; 3(4): 573-80.           doi: 10.1016/j.jaccas.2021.01.009. 44.    Kanjwal K, Jamal S, Kichloo A, Grubb BP. New-onset postural orthostatic tachycardia syndrome following coronavirus disease 2019 infection. J Innov Card Rhythm Manag. 2020; 11(11): 4302-4. doi: 10.19102/icrm.2020.111102. 45.    Miglis MG, Prieto T, Shaik R, Muppidi S, Sinn DI, Jaradeh S. A case report of postural tachycardia syndrome after COVID-19. Clin Auton Res. 2020; 30(5): 449-51. doi: 10.1007/s10286-020-00727-9. 46.    Umapathi T, Poh MQW, Fan BE, Li KFC, George J, Tan JYL. Acute hyperhidrosis and postural tachycardia in a COVID-19 patient. Clin Auton Res. 2020; 30(6): 571-3. doi: 10.1007/s10286-020-00733-x. 47.    Dani M, Dirksen A, Taraborrelli P, Torocastro M, Panagopoulos D, Sutton R, et al. Autonomic dysfunction in ‘long COVID’: rationale, physiology, and management strategies. Clin Med (Lond). 2021; 21(1): e63-7. doi: 10.7861/clinmed.2020-0896. 48.    Puntmann VO, Carerj ML, Wieters I, Fahim M, Arendt C, Hoffmann J, et al. Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19). JAMA Cardiol. 2020; 5(11): 1265-73. doi: 10.1001/jamacardio.2020.3557. 49.    Rajpal S, Tong MS, Borchers J, Zareba KM, Obarski TP, Simonetti OP, et al. Cardiovascular magnetic resonance findings in competitive athletes recovering from COVID-19 infection. JAMA Cardiol. 2021; 6(1): 116-8. doi: 10.1001/jamacardio.2020.4916. 50.    Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular system. Nat Rev Cardiol. 2020; 17(5): 259-60. doi: 10.1038/s41569-020-0360-5. 51.    Liu PP, Blet A, Smyth D, Li H. The science underlying COVID-19: implications for the cardiovascular system. Circulation. 2020; 142(1): 68-78. doi: 10.1161/CIRCULATIONAHA.120.047549. 52.    Perez-Bermejo JA, Kang S, Rockwood SJ, Simoneau CR, Joy DA, Silva AC, et al. SARS-CoV-2 infection of human iPSC-derived cardiac cells predicts novel cytopathic features in hearts of COVID-19 patients. Sci Transl Med. 2021; 13(590): eabf7872. doi: 10.1126/scitranslmed.abf7872. 53.    Tavazzi G, Pellegrini C, Maurelli M, Belliato M, Sciutti F, Bottazzi A, et al. Myocardial localization of coronavirus in COVID-19 cardiogenic shock. Eur J Heart Fail. 2020; 22(5): 911-5. doi: 10.1002/ejhf.1828. 54.    Goldstein DS. The possible association between COVID-19 and postural tachycardia syndrome. Heart Rhythm. 2021; 18(4): 508-9. doi: 10.1016/j.hrthm.2020.12.007. 55.    Zaman MS, Sizemore RC. Diverse manifestations of COVID-19: some suggested mechanisms. Int J Environ Res Pub Health. 2021; 18(18): 9785. doi:10.3390/ijerph18189785. 56.    Mung SM, Jude EB. Interplay between endocrinology, metabolism, and COVID-19 Infection. Clin Med (Lond). 2021; 21(5): e499-e504. doi:10.7861/clinmed.2021-0200. 57.    Ruggeri RM, Campennì A, Siracusa M, Frazzetto G, Gullo D. Subacute thyroiditis in a patient infected with SARS-COV-2: an endocrine complication linked to the COVID-19 pandemic. Hormones (Athens). 2021; 20(1): 219-221. doi: 10.1007/s42000-020-00230-w. 58.    Zarbock A, Gomez H, Kellum JA. Sepsis-induced acute kidney injury revisited: pathophysiology, prevention, and future therapies. Curr Opin Crit Care. 2014; 20(6): 588-95. doi:10.1097/MCC.0000000000000153. 59.    Husain-Syed F, Slutsky AS, Ronco C. Lung-kidney cross-talk in the critically ill patient. Am J Respir Crit Care Med. 2016; 194(4): 402-14. doi: 10.1164/rccm.201602-0420CP. 60.    van Willigen HDG, Wynberg E, Verveen A, Dijkstra M, Verkaik BJ, Figaroa OJA, et al. One-fourth of COVID-19 patients have an impaired pulmonary function after 12 months of illness onset. PLoS One. 2023; 18(9): e0290893. doi: 10.1371/journal.pone.0290893. 61.    Centanaro GV, Rubio MC, Walther JLÁ, Martinez-Sagasti F, Hidalgo AA, Hernández RH, et al. Long-term outcomes of recovery of patients who survived COVID-19: LUNG INJURY COVID-19 study. Open Forum Infect Dis. 2022; 9(4): ofac098. doi: 10.1093/ofid/ofac098. 62.    Artico J, Shiwani H, Moon JC, Gorecka M, McCann GP, Roditi G, et al. Myocardial involvement after hospitalization for COVID-19 complicated by troponin elevation: a prospective, multicenter, observational study. Circulation. 2023; 147(5): 364-374. doi:10.1161/CIRCULATIONAHA.122.060632. 63.    Hopkins Medicine. Heart problems after COVID-19. Hopkins Med. 2022; Available at:https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/heart-problems-after-covid19. 64.    Ahmadian E, Khatibi SMH, Soofiyani SR, Abediazar S, Shoja MM, Ardalan M, et al. Covid-19 and kidney injury: Pathophysiology and molecular mechanisms. Rev Med Virol. 2021; 31(3): e2176. doi: 10.1002/rmv.2176. 65.    Hsu CM, Gupta S, Tighiouart H, Goyal N, Faugno AJ, Tariq A, et al. Kidney recovery and death in critically ill patients with COVID-19-associated acute kidney injury treated with dialysis: the STOP-COVID cohort study. Am J Kidney Dis. 2022; 79(3): 404-416. e401. doi:10.1053/j.ajkd.2021.11.004. 66.    Lumlertgul N, Pirondini L, Cooney E, Kok W, GregsonJ, Camporota L, et al. Acute kidney injury prevalence, progression, and long-term outcomes in critically ill patients with COVID-19: A cohort study. Ann Intensive Care. 2021; 11(1): 123. doi: 10.1186/s13613-021-00914-5. 67.    Schiffl H, Lang SM. Long-term interplay between COVID-19 and chronic kidney disease. Int Urol Nephrol. 2023; 55(8): 1977-1984. doi: 10.1007/s11255-023-03528-x. 68.    Pan XW, Xu D, Zhang H, Zhou W, Wang L, Cui X. Identification of a potential mechanism of acute kidney injury during the COVID‐19 outbreak: a study based on single‐cell transcriptome analysis. Intensive Care Med. 2020; 46(6): 1114-1116. doi: 10.1007/s00134-020-06026-1.  69.    Diao B, Wang C, Wang R, Feng Z, Tan Y, Wang H, et al. Human kidney is a target for novel severe acute respiratory syndrome coronavirus 2 infection. Nat Commun. 2021; 12(1): 2506. doi: 10.1038/s41467-021-22781-1. 70.    Malha L, Mueller FB, Pecker MS, Mann SJ, August P, Feig PU. COVID‐19 and the renin‐angiotensin system. KidneyInt Rep. 2020; 5(5): 563‐565. doi: 10.1016/j.ekir.2020.03.024. 71.    Tolouian R, Vahed SZ, GhiyasvandS,Tolouian A, Ardalan MR. COVID‐19 interactions with angiotensin‐converting enzyme 2 (ACE2) and the kinin system; looking at a potential treatment. J Renal Inj Prev. 2020; 9(2): e19. doi: 10.34172/jrip.2020.19. 72.    Theimer S. Long COVID and the digestive system: Mayo Clinic expert describes common symptoms. Mayo Clinic. 2022; Available at: https://newsnetwork.mayoclinic.org/discussion/long-covid-and-the-digestive-system-mayo-clinic-expert-describes-common-symptoms/. 73.    Zuo T, Zhang F, Lui GCY, Yeoh YK, Li AYL, Zhan H, et al. Alterations in gut microbiota of patients with COVID-19 during time of hospitalization. Gastroenterology. 2020; 159(3): 944-955. e8. doi:10.1053/j.gastro.2020.05.048. 74.    Vélez CD. Can Long COVID affect the gut? Harvard Health Publishing. 2023; Available at:https://www.health.harvard.edu/blog/can-long-covid-affect-the-gut-202303202903#:~:text=Since%202020%2C%20we've%20known,clear%20up%20as%20people%20recover. 75.    Nakhli RE, Shanker A, Sarosiek I, Boschman J, Espino K, Sigaroodi S, et al. Gastrointestinal symptoms, and the severity of COVID-19: disorders of gut-brain interaction are an outcome. Neurogastroenterol Motil. 2022; 34(9): e14368. doi:10.1111/nmo.14368. 76.    Kolesova O, Vanaga I, Laivacuma S, Derovs A, Kolesovs A, Radzina M, et al. Intriguing findings of liver fibrosis following COVID-19. BMC Gastroenterol. 2021; 21(1): 370. doi: 10.1186/s12876-021-01939-7. 77.    Heidari F.COVID-19 patients show liver injury months after infection. Rad Soc N Am. 2022; Available at: https://press.rsna.org/timssnet/media/pressreleases/PDF/pressreleasePDF.cfm?ID=2389. 78.    Milic J, Barbieri S, Gozzi L, Brigo A, Beghé B, Verduri A, et al. Metabolic-associated fatty liver disease is highly prevalent in the postacute COVID syndrome. Open Forum Infect Dis. 2022; 9(3): ofac003. doi:10.1093/ofid/ofac003. 79.    de Lima IC, de Menezes DC, Uesugi JHE, Bichara CNC, da Costa Vasconcelos PF, Quaresma JAS, et al. Liver function in patients with long-term coronavirus disease 2019 of up to 20 months: a cross-sectional study. Int J Environ Res Public Health. 2023; 20(7): 5281. doi: 10.3390/ijerph20075281. 80.    Liao X, Li D, Ma Z, Zhang L, Zheng B, Li Z, et al. 12-month post-discharge liver function test abnormalities among patients with covid-19: a single-center prospective cohort study. Front Cell Infect Microbiol. 2022; 12: 864933. doi:10.3389/fcimb.2022.864933. 81.    Wijarnpreecha K, Ungprasert P, Panjawatanan P, Harnois DM, Zaver HB, Ahmed A, et al. COVID-19 and liver injury: a meta-analysis. Eur J Gastroenterol Hepatol. 2021; 33(7): 990-995. doi: 10.1097/MEG.0000000000001817. 82.    Hoffmann M, Kleine-Weber H, Schroeder S, Krüger N, Herrler T, Erichsen S, et al. SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor. Cell. 2020; 181(2): 271-280.e8. doi:10.1016/j.cell.2020.02.052. 83.    Hadi A, Werge M, Kristiansen KT, Pedersen UG, Karstensen JG, Novovic S, et al. Corona virus disease‐19 (COVID‐19) associated with severe acute pancreatitis: case report on three family members. Pancreatology. 2020; 20(4): 665-667. doi: 10.1016/j.pan.2020.04.021. 84.    Zippi M, Hong W, Traversa G, Maccioni F, De Biase D, Gallo C, et al. Involvement of the exocrine pancreas during COVID-19 infection and possible pathogenetic hypothesis: a concise review. Infez Med. 2020; 28(4): 507-515. 85.    Tahtabasi M, Hosbul T, Karaman E, Akin Y, Konukoglu O, Sahiner F. Does COVID-19 cause an increase in spleen dimensions? possible effects of immune activation, hematopoietic suppression and microthrombosis. Clin Imaging. 2021; 79: 104-109. doi: 10.1016/j.clinimag.2021.04.035. 86,    Xu X, Chang XN, Pan HX, Su H, Huang B, Yang M, et al. Pathological changes of the spleen in ten patients with coronavirus disease 2019 (COVID-19) by postmortem needle autopsy. Zhonghua Bing Li Xue Za Zhi. 2020; 49(6): 576-582. doi: 10.3760/cma.j.cn112151-20200401-00278. 87.    Ihlow J, Michaelis E, Greuel S, Heynol V, Lehmann A, Radbruch H, et al. B cell depletion and signs of sepsis-acquired immunodeficiency in bone marrow and spleen of COVID-19 deceased. Int J Infect Dis. 2021; 103: 628-635. doi:10.1016/j.ijid.2020.12.078. 88.    Pessoa MSL, Lima CFC, Pimentel ACF, Costa JCG, Holanda JLB. Multisystemic infarctions in COVID-19: focus on the spleen. Eur J Case Rep Intern Med. 2020; 7(7): 001747. doi: 10.12890/2020_001747. 89.    Xie L, Lin Y, Deng Y, Lei B.The effect of SARS-CoV-2 on the spleen and T lymphocytes. Viral Immunol. 2021; 34(6): 416-420. doi:10.1089/vim.2020.0320. 90.    Webster JM, Kempen LJAP, Hardy RS, Langen RCJ. Inflammation and skeletal muscle waste during cachexia. Front Physiol. 2020; 11: 597675. doi: 10.3389/fphys.2020.597675. 91.    Mirza SA, Sheikh AAE, Barbera M, Ijaz Z, Javid MA, Shekhar R, et al. COVID-19 and the endocrine system: A review of the current information and misinformation. Infect Dis Rep. 2022; 14(2): 184-197. doi: 10.3390/idr14020023. 92.    Gęca T, Wojtowicz K, Guzik P, Góra T. Increased risk of COVID-19 in patients with diabetes mellitus-current challenges in pathophysiology, treatment and prevention. Int J Environ Res Public Health. 2022; 19(11): 6555. doi: 10.3390/ijerph19116555. 93.    Fischer K. Long COVID and diabetes. WebMD. 2022; Available at: https://www.webmd.com/covid/long-covid-diabetes. 94.    Kavanaugh K. COVID-19: Study suggests long-term damage to immune system. Infection Control Today. 2023; Available at: https://www.infectioncontroltoday.com/view/covid-19-study-suggests-long-term-damage-immune-system. 95.    Zheng M, Gao Y, Wang G, Song G, Liu S, Sun D, et al.Functional exhaustion of antiviral lymphocytes in COVID-19 patients. Cell Mol Immunol. 2020; 17(5): 533-535. doi:10.1038/s41423-020-0402-2. 96.    Rha MS, ShinEC. Activation or exhaustion of CD8+ T cells in patients with COVID-19. Cell Mol Immunol. 2021; 18(10): 2325-2333. doi: 10.1038/s41423-021-00750-4. 97.    McLane LM, Abdel-Hakeem MS, Wherry EJ. CD8 T cell exhaustion during chronic viral infection and cancer. Annu Rev Immunol. 2019; 37: 457-495. doi: 10.1146/annurev-immunol-041015-055318. 98.    Vivier E, Raulet DH, Moretta A, Caligiuri MA, Zitvogel L, Lanier LL, et al. Innate or adaptive immunity? the example of natural killer cells. Science. 2011; 331(6013): 44-49. doi: 10.1126/science.1198687. 99.    Sizemore RC, Zaman MS. Ebola virus and SARS-CoV-2: Similarities and differences. J Health Soc Sci. 2020; 5(2): 241-250. doi:10.19204/2020/blvr4. 100.  Lubell J. COVID and the brain: Neurological symptoms may persist. Am Med Assoc. 2023;  Available at: https://www.ama-assn.org/delivering-care/public-health/long-covid-and-brain-neurological-symptoms-may-persist. 101.  Mina Y, Enose-Akahata Y, Hammoud DA, Videckis AJ, Narpala SR, O’Connell SE, et al. Deep phenotyping of neurologic postacute sequelae of SARS-CoV-2 Infection. Neurol Neuroimmunol Neuroinflamm. 2023; 10(4): e200097. doi:10.1212/NXI.0000000000200097. 102.  Shanley JE, Valenciano AF, Timmons G, Miner AE, Kakarla V, Rempe T, et al. Longitudinal evaluation of neurologic-post acute sequelae SARS-CoV-2 infection symptoms. Ann Clin Trans Neurol. 2022; 9(7): 995-1010. doi:10.1002/acn3.51578. 103.  Sutherland S. Long COVID now looks like a neurological disease, helping doctors to focus treatments. Sci Am. 2023; Available at: https://www.scientificamerican.com/article/long-covid-now-looks-like-a-neurological-disease-helping-doctors-to-focus-treatments1/. 104.  Fernández-Castañeda A, Lu P, Geraghty AC, Song E, Lee M, Wood J, et al. Mild respiratory COVID can cause multi-lineage neural cell and myelin dysregulation. Cell. 2022; 185(14): 2452-2468. e16. doi: 10.1016/j.cell.2022.06.008. 105.  Nunn AVW, Guy GW, Brysch W, Bell JD. Understanding long COVID; mitochondrial health and adaptation-old pathways, new problems. Biomedicines. 2022; 10(12): 3113. doi: 10.3390/biomedicines10123113. 106.  Sia AL, Neo JE, Tan BJ, Tan E. "Brain fog" and COVID-19. Am J Med Sci. 2023; 365(5): 472-474. doi: 10.1016/j.amjms.2023.01.003. 107.  Ducharme J. What causes long COVID? micro blood clots may be to blame. Time. 2022; Available at: https://time.com/6238147/microclots-long-covid/. 108.  Tomalika N, Mahzabeen R, Tagar MM, Afroz S, Ahmed N, Mohsena M, et al. Impact of COVID-19 pandemic on the physical, mental and social health of the suburban and rural adult population in Bangladesh. IMC J Med Sci. 2024; 18(1): 007. doi:https://doi.org/10.55010/imcjms.18.007. 109.  Crist, C. More than 100 million people worldwide have or had long covid: Study. WebMD. 2021; Available at: https://www.webmd.com/lung/news/20211118/millions-worldwide-long-covid-study. 110.  Long COVID and kids: more research is urgently needed. Nature. 2022; 602(7896): 183. doi: 10.1038/d41586-022-00334-w. 111.  Stephenson T, Pereira SMP, Shafran R, de Stavola BL, Rojas N, McOwat K, et al. Physical and mental health 3 months after SARS-CoV-2 infection (long COVID) among adolescent in England (CLoCK): A national matched cohort study. Lancet Child Adolesc Health. 2022; 6(4): 230-239. doi:10.1016/S2352-4642(22)00022-0. 112.  Koc HC, Xiao J, Liu W, Li Y, Chen G. Long COVID and its management. Int J Biol Sci. 2022; 18(12): 4768-4780. doi: 10.7150/ijbs.75056. 113.  UCLA Health. Long COVID treatment. 2024; Available at: https://www.uclahealth.org/ medical-services/long-covid. 114.  Lau RI, Su Q, Lau ISF, Ching JYL, Wong MCS, Lau LHS, et al. A synbiotic preparation (SIM01) for post-acute COVID-19 syndrome in Hong Kong (RECOVERY): Arandomized, double-blind, placebo-controlled trial. Lancet Infect Dis. 2024; 24(3): 256-265. doi: 10.1016/S1473-3099(23)00685-0. 115.  Living with COVID-19. National Institute for Health and Care Research. NIHR. 2021; doi: 10.3310/themedreview_45225; Available at: https://evidence.nihr.ac.uk/collection/living-with-covid19-second-review/. 116.  Scheppke KA, Pepe PE, Jui J, Crowe RP, Scheppke EK, Klimas NG, et al. Remission of severe forms of long COVID following monoclonal antibody (MCA) infusions: A report of signal index cases and call for targeted research. Am J Emerg Med. 2024; 75: 122-127. doi: 10.1016/j.ajem.2023.09.051. 117.  Long Covid recovery guide: tips for fatigue and breathlessness.British Heart Foundation. 2023; Available at: https://www.bhf.org.uk/ informationsupport/heart-matters-magazine/news/coronavirus-and-your-health/long-covid-recovery. 118.  CDC. Long COVID or Post-COVID conditions. 2024; Available at: https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html. 119.  Xie Y, Choi T, Al-Aly Z. Association of treatment with nirmatrelvir and the risk of post-COVID-19 condition. JAMA Intern Med. 2023; 183(6): 554-564. doi:10.1001/jamainternmed.2023.0743. 120.  Xie Y, Choi T, Al-Aly Z. Molnupiravir and risk of post-acute sequelae of COVID-19: cohort study. BMJ. 2023; 381: e074572. doi:10.1136/bmj-2022-074572. 121.  Al-Aly Z. Prevention of long COVID: progress and challenges. Lancet Infect Dis. 2023; 23(7): 776-777. doi:10.1016/S1473-3099(23)00287-6. 122.  Uehara T, Yotsuyanagi H, Ohmagari N, Doi Y, Yamato M, Imamura T, et al. Ensitrelvir for mild-tomoderate COVID-19: phase 3 part of phase 2/3 study. 2023; Available at: https://www.shionogi.com/content/dam/shionogi/global/investors/ir-library/presentation/2022/CROI20230222.pdf. 123.  Johns Hopkins University. Available at: https://www.hopkinsmedicine.org/-/media/johns-hopkins-health-plans/documents/resources_guidelines/prup220-long-covid_correction.pdf 124.  Mishra S. How long does COVID-19 linger in your body? New report offers clues. National Geographic. 2022; Available at: https://www.nationalgeographic.com/science/article/persisting-coronavirus-could-drag-out-covid-19-symptoms. 125.  Burns A. What are the implications of long covid for employment and health coverage? KIFF. 2022; Available at: https://www.kff.org/policy-watch/what-are-the-implications-of-long-covid-for-employment-and-health-coverage/. 126.  Nussenblatt V, Roder AE, Das S, de Wit E, Youn J, Banakis S. et al. Yearlong COVID-19 infection reveals within-host evolution of SARS-CoV-2 in a patient with B-cell depletion. J Infect Dis. 2022; 225(7): 1118-1123. doi:10.1093/infdis/jiab622. 127.  Ceulemans LJ, Khan M, Yoo S, Zapiec B, Gerven LV, Slambrouck JV, et al. Persistence of SARS-CoV-2 RNA in lung tissue after mild COVID-19. Lancet Respir Med. 2021; 9(8): e78-e79. doi:10.1016/S2213-2600(21)00240-X. 128.  Gaebler C, Wang Z, Lorenzi JCC, Muecksch F, Finkin S, Tokuyama M, et al. Evolution of antibody immunity to SARS-CoV-2. Nature. 2021; 591: 639–644. doi: 10.1038/s41586-021-03207-w. 129.  Pretorius E, Vlok M, Venter C, Bezuidenhout JA, Laubscher GJ, Steenkamp J, et al. Persistent clotting protein pathology in Long COVID/Post-Acute Sequelae of COVID-19 (PASC) is accompanied by increased levels of antiplasmin. Cardiovasc Diabetol. 2021; 20(1): 172. doi:10.1186/s12933-021-01359-7. 130.  Bouck EG, Denorme F, Holle LA, Middleton EA, Blair AM, de Laat B, et al. COVID-19 and sepsis are associated with different abnormalities in plasma procoagulant and fibrinolytic activity. Arterioscler Thromb Vasc Biol. 2021; 41(1): 401-414. doi:10.1161/ATVBAHA.120.315338. 131.  Turner S, Naidoo CA, Usher TJ, Kruger A, Venter C, Laubscher GJ, et al. Increased levels of inflammatory molecules in blood of Long COVID patients point to thrombotic endothelialitis. Semin Thromb Hemost. 2024; 50(2): 288-294. doi:10.1055/s-0043-1769014. 132.  Iwasaki Lab. Immunology of Long COVID. Yale School of Med. 2022; Available at: https://medicine.yale.edu/lab/iwasaki/projects/immunology-long-covid/#:~:text=Here%20are%20some%20of%20the,levels%3B%20and%20abnormal%20leukocyte%20populations. 133.  Zisis SN, Durieux JC, Mouchati C, Perez JA, McComsey GA. The protective effect of COVID-19 vaccination on post-acute sequelae of covid-19: a multicenter study from a large national health research network. Open Forum Infect Dis. 2022; 9(7): ofac228. doi:10.1093/ofid/ofac228. 134.  Corpus M, Pintos I, Moreno-Torres V, Freidin MB, Fatumo S, Corral O, et al. Genomic determinants of long COVID. Res Sq. 2023; p.1-14. doi: 10.21203/rs.3.rs-2530935/v1. 135.  Ferreira LC, Gomes CEM, Rodrigues-Neto JF, Jeronimo SMB. Genome-wide association study of Long COVID. Infect Genet Evol. 2022; 106: 105379. doi:10.1016/j.meegid.2022.105379.     Zaman MS, Sizemore RC. Long COVID: Epidemiology, post-COVID-19 manifestations, possible mechanisms, treatment, and prevention strategies – A review. IMC J Med sci. 2024; 18(2): 003. DOI: https://doi.org/10.55010/imcjms.18.015. <![CDATA[Mustard oil consumption and Harris platelet syndrome: unveiling a dietary link to thrombocytopenia in the Indian subcontinent]]> Wasim Md Mohosin Ul Haque https://imcjms.com/journal_full_text/541 2024-07-07 11:01:42 Review July 2024; Vol. 18(2):009 Abstract Background and objectives: Asymptomatic thrombocytopenia, characterized by a reduced platelet count without bleeding symptoms, is notably prevalent in certain regions of India and Bangladesh, presenting a diagnostic challenge. A significant portion of healthy blood donors from Bangladesh and various parts of India, particularly West Bengal, exhibit this condition, termed Harris platelet syndrome (HPS). This review explores the potential correlation between mustard oil consumption, a common dietary staple in these regions, and the incidence of HPS. Methods: A comprehensive narrative review was conducted using systematic search strategies across databases such as Google Scholar, MEDLINE, PubMed, and Scopus. Keywords included "Harris platelet syndrome," "mustard oil consumption," "thrombocytopenia," and "erucic acid." Studies were selected based on relevance and quality, focusing on the epidemiology of HPS, dietary habits, and the thrombocytopenic effects of erucic acid. Results: HPS shows a significant geographical prevalence in the Indian subcontinent, notably in regions like West Bengal, Kashmir, and Assam. The review identifies a higher prevalence of thrombocytopenia in areas with predominant mustard oil usage. Studies highlight the association between dietary erucic acid from mustard oil and thrombocytopenia, with notable effects observed in patients treated with Lorenzo’s Oil, which contains erucic acid. Conclusions: The review highlights a significant association between mustard oil consumption and asymptomatic thrombocytopenia in the Indian subcontinent. The similarity in hematological profiles between HPS and erucic acid-induced thrombocytopenia underscores the need for further research. This includes measuring erucic acid levels in patients, conducting controlled dietary interventions, and genetic analyses to differentiate between genetic and environmental factors. July 2024; Vol. 18(2):009. DOI:https://doi.org/10.55010/imcjms.18.021 *Correspondence: Wasim Md MohosinUl Haque, Department of Nephrology, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), 122 Kazi Nazrul Islam Avenue, Dhaka-1000, Bangladesh. Email: wmmhaque@live.com   Introduction Asymptomatic thrombocytopenia, characterized by a reduced platelet count without bleeding symptoms, is prevalent in certain regions of India and Bangladesh. This poses a diagnostic challenge for clinicians encountering patients with unexplained low platelet counts during routine checkups. Although comprehensive epidemiological data for Bangladesh are sparse, a pivotal study conducted at Christian Medical College revealed that 8.5% of healthy blood donors from Bangladesh exhibited asymptomatic thrombocytopenia, which was arbitrarily diagnosed as Harris platelet syndrome (HPS) [1]. HPS, originally termed asymptomatic constitutional macrothrombocytopaenia (ACMT), was first identified in blood donors from West Bengal [2]. It was later renamed Harris platelet syndrome (HPS) to avoid confusion with congenital amegakaryocytic thrombocytopenia [1]. HPS is defined by the presence of thrombocytopenia and giant platelets without bleeding symptoms or MYH9 mutations. The disorder appears to be inherited in an autosomal dominant manner, although the specific genes responsible for HPS remain unidentified [1]. The geographic prevalence of HPS in the Indian subcontinent, particularly in regions such as West Bengal, Kashmir, and Assam, suggests a regional pattern influenced by genetic and environmental factors. One intriguing hypothesis is the potential link between dietary habits, specifically mustard oil consumption, and the prevalence of thrombocytopenia [3]. Mustard oil, rich in erucic acid, is a staple in many parts of Northern and Eastern India and neighbouring countries [4]. The potential thrombocytopenic effects of erucic acid, evidenced in conditions like adrenoleukodystrophy (ALD) treated with Lorenzo's Oil, further underscore the need to investigate this association [5-7]. This review aims to explore the epidemiology of HPS in the Indian subcontinent, its potential correlation with mustard oil consumption, and the underlying pathophysiology of erucic acid-induced thrombocytopenia.   Materials and methods This narrative review synthesizes insights from a comprehensive examination of scientific journals and authoritative sources, focusing on the epidemiology of HPS in the Indian subcontinent, its associations with mustard oil consumption, and the underlying pathophysiology of mustard oil-induced thrombocytopenia. To gather relevant data, a systematic search strategy was employed using keywords such as "constitutional asymptomatic macrothrombocytopenia," "Harris platelet syndrome," "mustard oil consumption," "epidemiology," "Indian subcontinent," and "erucic acid." Various databases, including Google Scholar, MEDLINE, PubMed, and Scopus, were utilized, with no restrictions on the search scope. Exclusion criteria were applied to non-English articles. Researcher independently conducted article searches and evaluated the quality of each study. The inclusion of studies in the review was based on a thorough examination of the full text, ensuring the relevance and reliability of the data presented.   Results Regional prevalence and characteristics HPS exhibits a distinct geographic distribution, with significant prevalence in the Indian subcontinent, particularly in northern and eastern regions such as Kashmir, West Bengal, and Assam, with potential extensions to Bangladesh, Nepal, and Bhutan (Figure-1, Table-1). A study at Christian Medical College, Vellore, screened 10,200 blood donors and found that prevalence rates are highest in Eastern India (35%), followed by Northern India (18%), Western India (8.5%), Southern India (4.5%), and neighbouring countries (8.5%) [1].     Figure-1: The geographic distribution of HPS. The dotted area indicates distribution of HPS cases [1].  Table-1:Geographical distribution of Harris platelet syndrome [1]     Summary of studies on macrothrombocytopenia in different regions of India is presented in Table-2. Key findings indicate significant regional variations in the prevalence of macrothrombocytopenia, with higher rates among people of north and eastern regions compared to other areas. Diagnostic advancements, such as the use of automated complete blood count (CBC) data and platelet histograms have been proven effective in identifying this condition. Genetic studies highlight the heterogeneity of macrothrombocytopenia. Clinical characteristics often include lower platelet counts and increased mean platelet volume, with no significant bleeding symptoms in most cases.   Table-2: Summary of studies on macrothrombocytopenia in different regions of India     Thrombocytopenia and mustard oil consumption The geographical distribution of HPS closely aligns with regions in the Indian subcontinent where mustard oil is commonly used as the primary cooking oil [1,4]. In contrast, regions where mustard oil is less popular, such as the southern and western parts of India, exhibit lower instances of thrombocytopenia. A study conducted in southern India highlights this disparity, revealing a significant difference in the prevalence of thrombocytopenia between immigrants from northern and north-eastern India (4.3%) and the local southern Indian population (0.66%) [8]. Similarly, asymptomatic thrombocytopenia is relatively uncommon in western India, with a study in Surat reporting its prevalence of only 1.95% among healthy college students [14]. These observations suggest a potential correlation between dietary habits, specifically mustard oil consumption, and thrombocytopenia prevalence. A case-control study in the Bangladeshi population found a significant link between mustard oil use and thrombocytopenia, with 83.3% of thrombocytopenia cases reporting mustard oil consumption compared to 28.3% of controls [3].   Erucic acid: the main contributor to mustard oil-associated thrombocytopenia Mustard oil, commonly used in Eastern and Northern India, contains high levels of erucic acid. Commercial varieties have 41.8% erucic acid, while traditional Ghani mustard oil contains about 51.98% [18]. Erucic acid, a monounsaturated omega-9 fatty acid also found in rapeseed oil, has been linked to thrombocytopenia in animal studies and in patients treated with Lorenzo's oil, a therapeutic agent containing 20% erucic acid [5-7,19]. Several studies have explored the impact of erucic acid on platelet count and morphology. A study on 46 ALD patients treated with Lorenzo's Oil observed significant thrombocytopenia in 19 patients, with platelet counts inversely correlated with erucic acid levels and platelet size. Thrombocytopenia resolved within 2 to 3 months after discontinuing erucic acid [6]. Another study reported decreased platelet counts in five patients with X-linked ALD upon erucic acid administration, with marked thrombocytopenia in three patients. Thrombocytopenia was fully reversible after discontinuing erucic acid [5]. A study by Johns Hopkins University found a significant decrease in mean platelet count over six months in ALD patients treated with Lorenzo's Oil, with alterations in platelet size and structure but no consistent abnormalities in platelet function tests [7]. Historical data also support the thrombocytopenic effects of erucic acid, as seen with rapeseed oil [20]. Additionally, a case report of a 73-year-old man with ALD who developed thrombocytopenia after using mustard oil further supports this association [21]. Key findings of the studies on the haematological effects of erucic acid in ALD patients are summarize in Table-3.   Table-3: Key Findings of the studies on the haematological effects of Lorenzo's Oil/erucic acid in ALD patients     Discussion The findings from this review highlight a significant geographical overlap between the prevalence of HPS and regions with high mustard oil consumption. The shared hematological profile between HPS and erucic acid-related thrombocytopenia, including thrombocytopenia with giant platelets and normal platelet function tests, suggests potential common underlying mechanisms. Despite significant reductions in platelet counts, the absence of bleeding symptoms indicates intact platelet functionality, a crucial clinical observation. The stable, non-progressive nature of HPS and the reversibility of erucic acid-related thrombocytopenia upon discontinuation of erucic acid intake highlight the potential influence of environmental factors, particularly dietary habits, in its aetiology. The exclusion of MYH9 mutations and other systemic issues reinforces the hypothesis of a dietary link with the condition. Given the high prevalence of mustard oil use in regions with notable HPS cases, dietary erucic acid could be a significant environmental contributor to thrombocytopenia. This correlation calls for more focused research to distinguish between the genetic basis of HPS and the environmental impacts of mustard oil consumption. Studies involving direct measurement of erucic acid levels in patients with HPS, alongside controlled dietary interventions and genetic analyses, are essential to elucidate the precise relationship between mustard oil and thrombocytopenia. Further research should explore the potential health implications for populations with high dietary intake of erucic acid. Understanding these correlations could lead to better management and prevention strategies for thrombocytopenia cases in affected regions. In conclusion, this review highlights the significant association between mustard oil consumption and asymptomatic thrombocytopenia in the Indian subcontinent. By drawing attention to the similarities between HPS and erucic acid-related thrombocytopenia, it provides a compelling case for further investigation into dietary influences on platelet biology. Enhanced understanding of these relationships could lead to improved diagnostic, therapeutic, and preventive strategies, ultimately benefiting the population at risk.   References 1.     Naina HVK, Nair SC, Harris S, Woodfield G, Rees MI. Harris syndrome - a geographic perspective. J Thromb Haemost. 2005; 3(11): 2581-2582. doi: 10.1111/j.1538-7836.2005.01601.x 2.     Naina HV, Nair SC, Daniel D, George B, Chandy M. Asymptomatic constitutional macrothrombocytopenia among West Bengal blood donors. Am J Med. 2002; 112(9):742-743. doi: 10.1016/s0002-9343(02)01114-2. 3.     Haque WMMUH, Alam M, Ahmed AS, Mahmud A. Association between mustard oil consumption and thrombocytopenia: a case-control study in Bangladesh. IMC J Med Sci. 2024; 18(2). doi: 10.55010/imcjms.18.017. 4.     Yadav P, Alivelu K, Kumar GDS, Sujatah M. Survey of per capita consumption of vegetable oil in India. Curr Sci. 2022; 123(9): 1159-1164.doi: 10.18520/cs/v123/i9/1159-1164 5.     Zierz S, Schröder R, Unkrig CJ. Thrombocytopenia induced by erucic acid therapy in patients with X-linked adrenoleukodystrophy. Clin Investig. 1993; 71(10): 802-805. doi: 10.1007/bf00190322. 6.     Zinkham WH, Kickler T, Borel J, Moser HW. Lorenzo’s oil and thrombocytopenia in patients with adrenoleukodystrophy. N Engl J Med. 1993; 328(15): 1126-1127. doi: 10.1056/NEJM199304153281513. 7.     Kickler TS, Zinkham WH, Moser A, Shankroff J, Borel J, Moser H. Effect of erucic acid on platelets in patients with adrenoleukodystrophy. Biochem Mol Med. 1996; 57(2): 125-133. doi: 10.1006/bmme.1996.0018. 8.     Edupuganti HS, Krishnamurthy V. Prevalence of constitutional macrothrombocytopenia in the immigrants of Northern and Eastern states of India. Indian J Pathol Microbiol. 2020; 63(4): 593-596. doi: 10.4103/IJPM.IJPM_20_20. 9.     Bhola A, Garg R, Sharma A, Gupta N, Kakkar N. Macrothrombocytopenia: Role of automated platelet data in diagnosis. Indian J Hematol Blood Transfus. 2023; 39(2): 284-293. doi: 10.1007/s12288-022-01590-6. 10.  Ali S, Ghosh K, Daly ME, Hampshire DJ, Makris M, Ghosh M, et al. Congenital macrothrombocytopenia is a heterogeneous disorder in India. Haemophilia. 2016; 22(4): 570-582. doi:10.1111/hae.12917. 11.  Naina HVK, Harris S. Platelet and red blood cell indices in Harris platelet syndrome. Platelets. 2010; 21(4): 303-306. doi: 10.3109/09537101003615402. 12.  Naina HVK, Nair SC, Daniel D, George B, Chandy M. Asymptomatic constitutional macrothrombocytopenia among West Bengal blood donors. Am J Med. 2002; 112(9): 742-743. doi: 10.1016/s0002-9343(02)01114-2. 13.  Kakkar N, John MJ, Mathew A. Macrothrombocytopenia in north India: role of automated platelet data in the detection of an under diagnosed entity. Indian J Hematol Blood Transfus. 2015; 31(1): 61-67. doi: 10.1007/s12288-014-0367-3. 14.  Patel P, Shah A, Mishra K, Ghosh K. Prevalence of macrothrombocytopenia in healthy college students in western India. Indian J Hematol Blood Transfus. 2019; 35(1): 144-148. doi: 10.1007/s12288-018-0970-9. 15.  Ali S, Ghosh K, Shetty S. Differential expression of genes involved in Bengal macrothrombocytopenia (BMTCP). Blood Cells Mol Dis. 2015; 55(4): 410-414. doi: 10.1016/j.bcmd.2015.09.005. 16.  Lorenzo FR, Tashi T, Koul P, Camp NJ, Thiagarajan P, Prchal JT. Inherited giant platelet disorder, Kashmiri thrombocytopenia, a common syndrome found in Srinagar, India. Blood. 2014; 124(21): 4211-4211. doi: 10.1182/blood.v124.21.4211.4211. 17.  Sultan N, Sharma SK. Prevalence of low platelet count and identification of associating determinants and genetic polymorphism in healthy individuals of upper Assam, India. Indian J Hematol Blood Transfus. 2019; 35(2): 332-338. doi: 10.1007/s12288-018-1007-0. 18.  Sarwar MT, Rahman MH, Raza MS, Rouf S, Rahman MN. Determination of erucic acid content in traditional and commercial mustard oils of Bangladesh by gas-liquid chromatography. Advances in Biochemistry. 2014; 2(1): 9-13. 19.  Kramer JKG, Sauer FD, Farnworth ER, Stevenson D, Rock GA. Hematological and lipid changes in newborn piglets fed milk‐replacer diets containing erucic acid. Lipids. 1998; 33(1): 1-10. doi: 10.1007/s11745-998-0174-1. 20.  Kramer JKG, Sauer FD, Pigden WJ. High and Low Erucic Acid Rapeseed Oils : Production, Usage, Chemistry, and Toxicological Evaluation. New York: Academic Press, 1983. 21.  Shin DS, Perlman S, Rosove MH. Romiplostim mitigates dose-limiting thrombocytopenia of erucic acid for adrenomyeloneuropathy. Br J Haematol. 2015; 171(5): 879-881. doi: 10.1111/bjh.13440. 22.  Aubourg P, Adamsbaum C, Lavallard-Rousseau MC, Rocchiccioli F, Cartier N, Jambaqué I, et al. A two-year trial of oleic and erucic acids (‘Lorenzo’s oil’) as treatment for adrenomyeloneuropathy. N Engl J Med. 1993; 329(11): 745-752. doi: 10.1056/NEJM199309093291101. 23.  Konijnenberg A, van Geel BM, Sturk A, Schaap MC, von dem Borne AE, de Bruijne-Admiraal LG, et al. Lorenzo’s oil and platelet activation in adrenomyeloneuropathy and asymptomatic X-linked adrenoleukodystrophy. Platelets. 1998; 9(1): 41-48. doi: 10.1080/09537109876997. 24.  van Geel BM, Assies J, Haverkort EB, Koelman JH, Verbeeten B, Jr., Wanders RJ, et al. Progression of abnormalities in adrenomyeloneuropathy and neurologically asymptomatic X-linked adrenoleukodystrophy despite treatment with ‘Lorenzo’s oil’. J Neurol Neurosurg Psychiatry. 1999; 67(3): 290-299. doi: 10.1136/jnnp.67.3.290. 25.  Chai BC, Siminoski K. Thrombocytopenia associated with use of Lorenzo’s oil. Am J Hematol. 1993; 44(4): 290-291. doi: 10.1002/ajh.2830440417. 26.  Crowther MA, Barr RD, Kelton J, Whelan D, Greenwald M. Profound thrombocytopenia complicating dietary erucic acid therapy for adrenoleukodystrophy. Am J Hematol. 1995; 48(2): 132-133. doi: 10.1002/ajh.2830480217.       Cite this article as: Haque WMM. Mustard oil consumption and Harris platelet syndrome: unveiling a dietary link to thrombocytopenia in the Indian subcontinent. IMC J Med Sci. 2024; 18(2):009. DOI:https://doi.org/10.55010/imcjms.18.021 <![CDATA[Short-term and low-dose liraglutide plus metformin decreased body mass index and insulin resistance more than metformin alone in obese women with polycystic ovary syndrome: An open-label randomized controlled study]]> Ahmed Hossain Hurjahan Banu Md. Shahed Morshed Shazia Afrine Muhammad Abul Hasanat https://imcjms.com/journal_full_text/479 2023-09-02 12:31:34 Original Article Abstract Background and objectives: Reduction of weight improves different manifestations of polycystic ovary syndrome (PCOS). This study compared the effects of liraglutide plus metformin versus metformin alone on weight loss and metabolic profiles in obese women with PCOS. Methods: This open-label randomized controlled clinical trial consecutively recruited newly-diagnosed PCOS patients of reproductive age with obesity (body mass index ≥ 27.5 kg/m2). Following randomization into two equal groups, Group-1 received treatment with metformin 1000 mg daily alone while Group-2 was given metformin 1000 mg plus subcutaneous (SC) liraglutide 1.2 mg daily for 12 weeks. Anthropometric, biochemical and hormonal data and ovarian morphology were assessed at baseline and after 12 weeks. Clinical information and side effects were recorded every four weeks after initiation of the treatment. Glucose, lipids, and all hormones were analyzed by glucose oxidase, precipitation method, and chemiluminescent microparticle immunoassay respectively. Insulin resistance was measured by homeostatic model assessment (HOMA-IR). Results: Study included 30 participants comprising 15 for each group. Among 15 participants, 5 dropped out from the Group-1 and 1 dropped out from the Group-2. The final analysis was done among 24 participants (Gr-1: 10 and Gr-2: 14). Waist and hip circumference (WC, HC) significantly (p <0.05) decreased in patients treated with only metformin. Menstrual irregularity, BMI (body mass index), HC, systolic blood pressure (BP), 2h-OGTT glucose, fasting insulin, and HOMA-IR significantly (p < 0.05) decreased in the patients of Group-2 after 12 weeks compared to baseline status. Percentage changes of weight, BMI and HOMA-IR improved significantly (p < 0.05) in cases of Group-2 than those in Group-1. Side effects were though numerically higher in the Group-2 patients, but reduced with time. Conclusions: Addition of liraglutide with metformin was superior to metformin alone for lowering of BMI and insulin resistance among obese PCOS women with acceptable side effects. IMC J Med Sci. 2024; 18(1):002. DOI: https://doi.org/10.55010/imcjms.18.002 *Correspondence: Muhammad Abul Hasanat, Room# 1524, Level-15, Block-D, Bangabandhu Sheikh Mujib Medical University (BSMMU), Shahbag, Dhaka-1000, Bangladesh. ORCID iD: orcid.org/0000-0001-8151-9792; Email: aryansowgat@gmail.com   Introduction Polycystic ovary syndrome is a heterogeneous condition with a combination of reproductive, cutaneous, and metabolic features. Although its pathogenesis is largely unknown, hyperandrogenism and insulin resistance are the main determinants of clinical features [1, 2]. According to one hypothesis, PCOS symptoms develop when the body is unable to adjust to excess hepato-visceral fat acquired during the perinatal period. The central fat is pro-inflammatory and promotes both hyperandrogenemia and insulin resistance by secreting several types of adipocytokines. Ultimately, a vicious cycle is created between fat tissues and androgen-producing tissues, which perpetuate the typical features of PCOS [3]. Obesity affects around two-thirds of PCOS patients and is now considered a secondary cause of PCOS [4]. Several studies have shown amelioration of all features of PCOS after weight loss by lifestyle management and bariatric surgery [5,6]. Besides, obesity increases the manifestations of PCOS including hyperandrogenism, and reduces the pregnancy rate [7]. Management of PCOS is essentially symptomatic. Patients having metabolic features are often treated with insulin sensitizers. This use of insulin sensitizers in PCOS is off-level but evidence-based [8]. Metformin is a weight-neutral drug; however, along with the improvement of different manifestations, there is also a reduction of weight especially in patients with obesity [9,10]. Other weight-reducing drugs, especially glucagon-like peptide-1 receptor agonists (GLP-1-RAs) are attractive options. Recent studies have shown a wide spectrum of weight reductions in different obesity-related conditions including diabetes mellitus (DM), nonalcoholic fatty liver disease, obstructive sleep apnea, etc. by different types of GLP-1-RAs [11]. Liraglutide is a once-daily injectable GLP-1-RA that has achieved the approval of the Food and Drug Administration (USA) for the management of DM and obesity [12]. It works through a variety of mechanisms, including inhibiting the hypothalamus appetite center and delaying stomach emptying [13]. Its weight-loss impact is independent of its principal adverse effects, nausea, and vomiting [14]. Patients from South-Asian backgrounds have more metabolic manifestations and may benefit more from GLP-1-RAs [15]. The efficacy and safety of liraglutide in the management of PCOS are not adequately evaluated. This study compared the effects of metformin vs. metformin plus liraglutide in obese PCOS women. Both groups received advice on standard lifestyle management on metabolic and hormonal manifestations of PCOS.   Materials and methods The study was conducted at the PCOS Clinic of the Department of Endocrinology of Bangabandhu Sheikh Mujib Medical University (BSMMU) during the period of January 2018 to August 2019. The study was conducted according to the World Medical Association’ Declaration of Helsinki and the research protocol was approved by the Institutional Review Board (IRB) of BSMMU (No. BSMMU/2018/11032, Dated: 15/09/2018). Informed written consent was taken from all participants. Study type and population: This open-label randomized controlled clinical trial consecutively recruited newly-diagnosed PCOS patients of reproductive age (15 – 45 years) with obesity (body mass index (BMI) ≥27.5 kg/m2) [16]. PCOS was diagnosed on the basis of the Revised 2003 Rotterdam criteria [17]. Sample size was calculated by [n= 2σ2 (Z α+ Z β)2 / (μ1 - μ 2)2] formula where at Zα = 1.96, Zβ= 0.85 at 80% power, expected mean weight change in metformin plus liraglutide group: μ1= 6.5,  expected mean weight change between groups: μ2= 1.2  and σ = 6.8 (pooled standard deviation (SD) for each group) [18]. Participants having similar endocrine disorders, DM, chronic kidney disease, chronic liver disease, history of pancreatitis, personal or family history of medullary carcinoma of the thyroid, history of taking metformin, hormonal contraceptive, anti-obesity, or anti-androgen drugs within the last 6 months were excluded. Intervention: All the study participants were divided into two groups by a computer-generated random number chart.  Group-1 (metformin group) was treated with metformin 500 mg twice daily orally and the Group-2 (metformin + liraglutide group) was treated with metformin 500 mg orally twice daily plus subcutaneous injection of liraglutide 1.2 mg once daily for 12 weeks. To reduce the side effects of liraglutide, the participants of Group-2 was given 0.6 mg liraglutide once daily for the first two weeks; then increased to 1.2 mg once daily from the third week onward. Standard lifestyle advice including a weight-based diet, physical activity, and behavioral modifications was provided to both groups. All patients were educated about symptoms, signs, and management of side effects. Each patient was provided with medication according to her assigned category. Follow-up and investigations: At the first visit, anthropometric, clinical and biochemical data were recorded in a standard data sheet. The second visit was 2 weeks after the initiation of the study to increase the dose of liraglutide to 1.2 mg. Subsequent visits were made every four weeks from the initiation of the study. Clinical and anthropometric data were taken at every visit. Biochemical and imaging data were taken at the first and final visits. Weight (kilogram) and height (centimeter) were measured by calibrated bathroom scale and mounted measuring tape respectively to calculate BMI (kg/m2). WC (centimeter) was measured by measuring tape at the level of the umbilicus while HC was measured at the level of the largest lateral extension of the hip, both in a horizontal plane. Blood pressure was measured by a calibrated sphygmomanometer (mm-Hg). Hirsutism was measured by using the modified Ferriman-Gallwey (mFG) score. Acne was observed over the face. Acanthosis nigricans was checked on the neck, axilla, and groin. Amenorrhea was considered if a women missed at least three menstrual periods in a row  while oligomenorrheawas diagnosed when inter-menstrual intervals was greater than 35 days [19,20]. Menstruation occurring for consecutive two months was considered regular menstruation. Tests done in fasting state included: luteinizing hormone (LH), follicle-stimulating hormone (FSH), total testosterone (TT), fasting insulin, plasma glucose and lipid profile, followed by a standard 75 g oral glucose tolerance test (OGTT). Blood glucose was measured by the glucose oxidase method and serum LH, FSH, and TT were measured by chemiluminescent microparticle immunoassay at diagnosis during the follicular phase of the menstrual cycle. Total cholesterol (TC), triglycerides (TG), and high-density lipoprotein cholesterol (HDL-C) were measured by architect Plus Ci4100 automated analyzer. The homeostatic model assessment of insulin resistance (HOMA-IR) was calculated using the formula = (fasting glucose, mmol/L × fasting insulin, µU/mL) ÷ 22.5 [21]. Data analysis: The statistical analysis was done by SPSS software (version- 22.0). Numerical data were expressed in mean ± SD or median inter-quartile range (IQR) depending on their distribution. Qualitative data were expressed in frequency (%). There were no missing data. The percentage changes were calculated as follows: percentage changes = {(values after 3 months – values at baseline) ÷ values at baseline} × 100. For quantitative variables, comparisons between groups were done by independent samples t-test or Mann-Whitney U test, and within groups were done by paired t-test or Wilcoxon matched-pair signed rank test as appropriate. For qualitative variables, the associations between two groups were analyzed by Fisher’s exact test, and within groups were assessed by the McNemar test. Statistical significance for decision-making was set at two-tailed p-values below 0.05.   Results Study included 30 participants comprising 15 for each group. Among 15 participants, five dropped out from the Group-1 and 1 dropped out from the Group-2. The final analysis was done among 24 participants. The study flow chart is shown in Figure-1.     Figure-1: The study flow chart showing the enrollment, interventionand follow up scheme of the study participants   Table-1 shows that participants from both groups were not significantly (p>0.05) different with respect to age, personal history of subfertility, family history of PCOS, subfertility, obesity, hypertension, diabetes  as well as thyroid and prolactin statuses.   Table-1: Baseline characteristics of the study population (N= 24)     The anthropometric, clinical, biochemical, hormonal and imaging profiles of the study groups in relation to intervention are shown in Table-2. Patients in Group-2 had significantly higher levels of serum FSH (p=0.012) and HOMA-IR (p=0.042) levels than patients in the Group-1 before intervention. WC (p=0.032) and HC (p=0.028) decreased significantly in patients taking only metformin. Menstrual irregularity significantly (p=0.002) became regular in patients of Group-2. Also, BMI (p<0.001), HC (p=0.037), systolic BP (p=0.043), 2H-OGTT glucose (p=0.016), fasting insulin (p=0.012), and HOMA-IR (p=0.003) improved significantly in patients of Group-2 after intervention.   Table-2: Anthropometric, Clinical, biochemical, hormonal, and imaging characteristics of Group-1 (n=10) and Group-2 (n=14) study population in relation to intervention (N= 24)     Comparison of percentage changes of different variables shows BMI (p=0.023) and HOMA-IR (p=0.026) significantly decreased in Group-2 than that of Group-1 patients (Table-3). Percentage of weight loss was significantly (p=0.015) higher in the patients of Group-2 compared to Group-1 patients (mean difference 3 kg). Although, at least 5% weight loss was observed in 20% (2/10) and 57.1% (8/14) cases after intervention in Group-1 and Group-2 cases respectively, the p-value did not reach a significant level (p =0.104). Different types of side effects, especially gastrointestinal, were numerically higher in the Group-2 cases than those in Group-1. However, their frequency reduced with time (Table-4).   Table-3: Comparison of the percentage changes of anthropometric, clinical biochemical, and hormonal parameters between the study groups (N= 24)     Table-4: Adverse effects observed among the study population during the interventions (n= 24)     Discussion This open-label RCT showed the superiority of short-term (12 weeks) and low-dose of liraglutide (1.2 mg/ day) plus metformin therapy (1 g/day) over metformin (1 g/day) alone, along with lifestyle management, in reduction of BMI, and HOMA-IR among obese patients with PCOS. However, we did not find significant differences in other metabolic as well as hormone profiles between the study groups. Although the gastrointestinal side effects were initially higher in the metformin plus liraglutide group than in the metformin group, they reduced with time. In our study, when liraglutide was added to metformin, along with improvement of BMI and HC, menstrual irregularity, systolic blood pressure, 2H-OGTT glucose, fasting insulin, and insulin resistance also improved. Several meta-analyses suggest that liraglutide is superior to metformin in the improvement of metabolic manifestations [22,23]. When liraglutide is added to metformin, there is a synergistic effect [24]. Both WC and HC have significantly improved in patients of metformin group and are consistent with the findings of other studies conducted among PCOS patients with a BMI ≥25 kg/m2 [25]. However, we did not observe improvements in BMI and other endocrine and metabolic abnormalities which could be due to the short duration and lower doses of metformin. Patients of metformin plus liraglutide group additionally had reduction of weight and BMI by 3% and 1.2% respectively of the baseline than those in metformin group. A meta-analysis comprising three RCTs has reported similar weight loss and reduction of BMI with metformin plus liraglutide compared to metformin alone [26]. Rather than using absolute values, we used percentage changes as our study groups differed by BMI at baseline. Although higher percentages of our Group-2 patients achieved at least 5% weight loss than the Goup-1 cases (57.1% vs. 20.0%), the association was not statistically significant. Study from Slovenia also reported 5% weight loss in 22% cases among their study population receiving liraglutide and metformin [18]. It appears from our findings that people from South Asian backgrounds might respond better than the European population to GLP-1-RA [15]. The Slovenian study group has also shown in other studies that the weight loss response to liraglutide depends on the dose, metabolic status, and genetic polymorphism of GLP-1-RA [27-29]. We also found significant reduction in insulin resistance in patients receiving liraglutide plus metformin than the metformin alone. However, two similar studies did not find significant differences in HOMA-IR levels between cases of liraglutide plus metformin and the metformin groups [8,30]. A meta-analysis which included four RCTs, showed a reduction of both fasting glucose and insulin in patients having metformin plus liraglutide than the metformin alone, however, the values of HOMA-IR were not mentioned [26]. In our study, other metabolic manifestations, including glucose and lipid profile, changed similarly in both the study groups. Jensterle et al. also found similar findings except for a favorable effect on 2H-OGTT glucose levels in cases with metformin plus liraglutide [18]. However, their participants received a double dose of metformin than our study participants. In our study, 2H-OGTT glucose and systolic BP improved only in our Group-2 cases while Jensterle et al. did not find improvement in BP. We did not find any improvement in hormonal status within or between the study groups. Again, these findings are similar to the study conducted by Jensterle et al [18]. On the other hand, Xing et al. found significant improvement in free androgen index, LH, and progesterone levels in cases receiving combination of metformin and liraglutide compared to those in metformin group, despite a lack of improvement of any metabolic variables including BMI and HOMA-IR [30]. They also prescribed 2 gm of metformin per day for both groups. The menstrual cycle significantly improved only in metformin plus liraglutide group. While Xing et al. found improvement in the menstrual cycle in both groups while Jensterle et al. did not find it in any group [30,18]. Hirsutism, acne, acanthosis nigricans and PCOM almost remained similar to baseline indicating the requirement of a longer duration of treatment for significant improvement. Cases of metformin plus liraglutide group experienced more gastrointestinal side effects than those in metformin group. Nausea, loose motion, and vomiting were the most frequent side effects which were generally mild to moderate and subsided with time. The hypoglycemic events were absent. The short-term safety profile of using liraglutide in obese PCOS patients seemed to be acceptable. However, it is currently impossible to obtain precise estimates of the long-term risk of serious adverse effects such as pancreatitis or precancerous pancreatic lesion that has been claimed by some to be associated with GLP-1 based therapies. Although, a few patients complained of abdominal pain, these were non-specific, not associated with elevated lipase, and improved with symptomatic management. The main limitation of this study was lost to the follow-up of 33% of participants in the metformin group. One participant from both groups became pregnant, and others left the study from the metformin only group which might be due to the open-label nature of the study. In conclusion, this study demonstrated that when liraglutide was added to metformin, even at low dosages and for a short period of time, coupled with lifestyle management, metabolic parameters such as BMI and insulin resistance decreased significantly in obese PCOS women. Despite high cost and injectable form, liraglutide's effectiveness with acceptable side effects may be explored for the therapy of obesity in PCOS patients. Long-term study and higher dose may be required to ameliorate other metabolic, androgenic and hormonal abnormalities of obese PCOS patients.   Authors’ contribution AH, HB, MAH: Conception and design; AH, MSM, SA: Acquisition, analysis, and interpretation of data; All: Manuscript drafting and revising it critically   Competing interest The authors have nothing to declare.   Funding This study was partially supported by a Research grant from Research and Development, BSMMU, Novo Nordisk Pharma, and Beximco Pharmaceuticals Ltd., Bangladesh.   References 1.     Singh S, Pal N, Shubham S, Sarma DK, Verma V, Marotta F, Kumar M. Polycystic ovary syndrome: Etiology, current management, and future therapeutics. J Clin Med. 2023; 12(4): 1454. DOI: 10.3390/jcm12041454. 2.     Harada M. Pathophysiology of polycystic ovary syndrome revisited: Current understanding and perspectives regarding future research. Reprod Med Biol. 2022; 21(1): e12487. DOI: 10.1002/rmb2.12487. 3.     deZegher F, López-Bermejo A, Ibáñez L. Central obesity, faster maturation, and 'PCOS' in girls. Trends Endocrinol Metab. 2018; 29(12): 815-818. DOI: 10.1016/j.tem.2018.09.005. 4.     Morshed MS, Banu H, Akhtar N, Sultana T, Begum A,  Zamilla M, et al. Luteinizing hormone to follicle-stimulating hormone ratio significantly correlates with androgen level and manifestations are more frequent with hyperandrogenemia in women with polycystic ovary syndrome. J Endocrinol Metab. 2021; 11(1): 14-21. DOI:10.14740/jem716. 5.     Pasquali R, Gambineri A, Cavazza C, Ibarra Gasparini D, Ciampaglia W, Cognigni GE, et al. Heterogeneity in the responsiveness to long-term lifestyle intervention and predictability in obese women with polycystic ovary syndrome. Eur J Endocrinol.2011; 164(1): 53-60. DOI: 10.1530/EJE-10-0692. 6.     Escobar-Morreale HF, Botella-Carretero JI, Alvarez-Blasco F, Sancho J, San Millán JL. The polycystic ovary syndrome associated with morbid obesity may resolve after weight loss induced by bariatric surgery. J Clin Endocrinol Metab. 2005; 90(12): 6364-6369. DOI: 10.1210/jc.2005-1490. 7.     Cena H, Chiovato L, Nappi RE. Obesity, polycystic ovary syndrome, and infertility: A new avenue for GLP-1 receptor agonists. J Clin Endocrinol Metab. 2020; 105(8): e2695–2709. DOI: 10.1210/clinem/dgaa285. 8.     Rocha AL, Oliveira FR, Azevedo RC, Silva VA, Peres TM, Candido AL, et al. Recent advances in the understanding and management of polycystic ovary syndrome. F1000Res. 2019; 8: F1000 Faculty Rev-565. DOI: 10.12688/f1000research.15318.1.  9.    Aktar N, Hasanat MA, Banu H, Tuqan S, Mustari M, Sultana T, et al. Effect of metformin therapy over hormone profile in newly diagnosed polycystic ovary syndrome- A nine months randomized controlled trial. Am Res J Endocrinol. 2016; 1: 1-9. DOI:10.21694/2577-8412.17002. 10.  Akhtar N, Banu H, Morshed MS, Sultana T, Begum A, Hasanat MA. Effects of metformin in polycystic ovary syndrome: a randomized, double-blind, placebo-controlled study. IMC J Med Sci.2021; 15(2): 1-12. DOI: 10.3329/imcjms.v15i2.55808. 11.  Yazıcı D, YapıcıEser H, Kıyıcı S, Sancak S, Sezer H, Uygur M, et al. Clinical impact of glucagon-like peptide-1 receptor analogs on the complications of obesity. Obes Facts. 2023; 16(2): 149-163. DOI: 10.1159/000526808. 12.  Jensterle M, Rizzo M, Haluzík M, Janež A. Efficacy of GLP-1 RA approved for weight management in patients with or without diabetes: A narrative review. Adv Ther. 2022; 39(6): 2452-2467. DOI: 10.1007/s12325-022-02153-x. 13.  Ard J, Fitch A, Fruh S, Herman L. Weight loss and maintenance related to the mechanism of action of glucagon-like peptide 1 receptor agonists. Adv Ther. 2021; 38(6): 2821-2839. DOI: 10.1007/s12325-021-01710-0. 14.  Abu-Hamdah R, Rabiee A, Meneilly GS, Shannon RP, Andersen DK, Elahi D. Clinical review: The extrapancreatic effects of glucagon-like peptide-1 and related peptides. J Clin Endocrinol Metab. 2009; 94(6): 1843-52. DOI: 10.1210/jc.2008-1296. 15.  Lee MMY, Ghouri N, McGuire DK, Rutter MK, Sattar N. Meta-analyses of results from randomized outcome trials comparing cardiovascular effects of SGLT2is and GLP-1RAs in Asian versus White patients with and without type 2 diabetes. Diabetes Care. 2021; 44(5): 1236-1241. DOI: 10.2337/dc20-3007. 16.  WHO Expert Consultation. Appropriate body-mass index for Asian populations and its     implications for policy and intervention strategies. Lancet. 2004; 363(9403): 157-163. DOI: 10.1016/S0140-6736(03)15268-3. 17.  The Rotterdam ESHRE/ASRM‐sponsored PCOS consensus workshop group, Revised 2003 consensus on diagnostic criteria and long‐term health risks related to polycystic ovary syndrome (PCOS), Human Reproduction. Volume 19, Issue 1, January 2004, Pages 41–47. DOI:10.1093/humrep/deh098. 18.  Jensterle Sever M, Kocjan T, Pfeifer M, Kravos NA, Janez A. Short-term combined treatment with liraglutide and metformin leads to significant weight loss in obese women with polycystic ovary syndrome and previous poor response to metformin. Eur J Endocrinol. 2014; 170(3): 451-459. DOI: 10.1530/EJE-13-0797. 19.  Begum M, Das S, Sharma, HK. Menstrual disorders: causes and natural remedies. J Pharm Chem Biol Sci. 2016; 4: 307–320. 20.  Klein DA, Poth MA. Amenorrhea: an approach to diagnosis and management. Am Fam Physician. 2013; 87(11): 781–788. 21.  Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner RC. Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia. 1985; 28(7): 412-419. DOI: 10.1007/BF00280883. 22.  Tian D, Chen W, Xu Q, Li X, Lv Q. Liraglutide monotherapy and add on therapy on obese women with polycystic ovarian syndromes: A systematic review and meta-analysis. Minerva Med. 2022; 113(3): 542-550. DOI: 10.23736/S0026-4806.21.07085-3. 23.  Wang FF, Wu Y, Zhu YH, Ding T, Batterham RL, Qu F, Hardiman PJ. Pharmacologic therapy to induce weight loss in women who have obesity/overweight with polycystic ovary syndrome: A systematic review and network meta-analysis. Obes Rev. 2018; 19(10): 1424-1445. DOI: 10.1111/obr.12720. 24.  Jensterle M, Goricar K, Janez A. Metformin as an initial adjunct to low-dose liraglutide enhances the weight-decreasing potential of liraglutide in obese polycystic ovary syndrome: Randomized control study. Exp Ther Med. 2016; 11(4): 1194-1200. DOI: 10.3892/etm.2016.3081. 25.  Guan Y, Wang D, Bu H, Zhao T, Wang H. The effect of metformin on polycystic ovary syndrome in overweight women: A systematic review and meta-analysis of randomized controlled trials. Int J Endocrinol. 2020; 2020: 5150684. DOI: 10.1155/2020/5150684. 26.  Ge JJ, Wang DJ, Song W, Shen SM, Ge WH. The effectiveness and safety of liraglutide in treating overweight/obese patients with polycystic ovary syndrome: a meta-analysis. J Endocrinol Invest.2022; 45(2): 261-273. DOI: 10.1007/s40618-021-01666-6. 27.  Jensterle M, Kravos NA, Goričar K, Janez A. Short-term effectiveness of low dose liraglutide in combination with metformin versus high dose liraglutide alone in treatment of obese PCOS: randomized trial. BMC Endocr Disord. 2017; 17(1): 5. DOI: 10.1186/s12902-017-0155-9. 28.  Jensterle M, Kravos NA, Pfeifer M, Kocjan T, Janez A. A 12-week treatment with the long-acting glucagon-like peptide 1 receptor agonist liraglutide leads to significant weight loss in a subset of obese women with newly diagnosed polycystic ovary syndrome. Hormones (Athens). 2015; 14(1): 81-90. DOI: 10.1007/BF03401383. 29.  Jensterle M, Pirš B, Goričar K, Dolžan V, Janež A. Genetic variability in GLP-1 receptor is associated with inter-individual differences in weight lowering potential of liraglutide in obese women with PCOS: a pilot study. Eur J Clin Pharmacol. 2015; 71(7): 817-824. DOI: 10.1007/s00228-015-1868-1. 30.  Xing C, Zhao H, Zhang J, He B. Effect of metformin versus metformin plus liraglutide on gonadal and metabolic profiles in overweight patients with polycystic ovary syndrome. Front Endocrinol (Lausanne). 2022; 13: 945609. DOI: 10.3389/fendo.2022.945609.       Cite this article as: Hossain M, Banu H, Morshed MS, Afrine S, Hasanat MA. Short-term and low-dose liraglutide plus metformin decreased body mass index and insulin resistance more than metformin alone in obese women with polycystic ovary syndrome: An open-label randomized controlled study. IMC J Med Sci. 2024; 18(1):002. DOI: https://doi.org/10.55010/imcjms.18.002 <![CDATA[Clinically significant minor blood group antigens amongst South Indian donor population]]> Soonam John Archana Kuruvanplackal Achankunju Madathingal Sugathan Suma Sasikala Nadanganan https://imcjms.com/journal_full_text/484 2023-09-12 10:03:24 Original Article IMC J Med Sci. 2024; 18(1):004 Abstract Background and objectives: Distribution of blood group antigen varies among different races. It is important to know the distribution of these antigens so as to provide a donor database that aid in providing compatible blood units for patients with multiple alloantibodies. The present study was conducted to determine the distribution of clinically significant minor blood group antigens amongst the South Indian blood donors.  Materials and methods: Blood samples were collected from healthy regular repeat voluntary blood donors of same ethnicity attending a tertiary care hospital in South Kerala. Clinically significant blood antigens of the ABO, Rh (D, C, c, E, and e), Kell, Duffy and Kidd blood group systems were determined. The ABO and Rh(D) grouping were performed by tube technique using monoclonal antisera. Column agglutination technique was used to phenotype Rh, Kell, Duffy and Kidd antigens. Results: Total 200 healthy repeat voluntary blood donors were enrolled in the study. Out of 200 donors, 92% were RhD positive. Among the Rh antigens, the e antigen was positive in 97.8 % and 100% among the Rh(D) positive and Rh(D) negative donors respectively. No E antigen was detected in RhD negative donors. Total 6 and 2 Rh phenotypes were observed among the Rh(D) positive and negative donors respectively. R1R1 and Rr were the most frequent phenotypes among the RhD positive and negative donors (47.28% and 93.75%) respectively. Among the Kell blood group antigens, K and Kpb antigens were present in 100% of our donors while in Duffy and Kidd system Fya and Jka were most predominant (89% and 87%) respectively. Conclusions: The findings of the present study would be helpful in developing in-house panel cells. Moreover, a rare donor registry of donors typed negative for a high-frequency antigen can be formulated. IMC J Med Sci. 2024; 18(1):004. DOI: https://doi.org/10.55010/imcjms.18.004 *Correspondence: Soonam John, Department of Transfusion Medicine, Government Medical College, Parippally, Kollam, Kerala,India. Email: johnsoonam@gmail.com   Introduction The blood transfusion requirement for the treatment of haemoglobinopathies in India is on an increase at a rate of 30 units per patient annually [1]. These chronically transfused patients develop clinically significant antibodies which can result in hemolytic transfusion reactions and haemolytic disease of fetus and newborn. The traditional practice is to provide antigen-negative blood when an antibody against a blood group system has been formed [2]. In these patients it is really tedious to find a compatible unit, especially if multiple antibodies have been formed in the patient. The situation can be worsened if an emergency transfusion is required. There are currently 44 recognised blood group systems containing 354 red cell antigens [3]. There exists racial and ethnic differences in blood group antigen distributions [4-7]. There is very little information available regarding distribution of various clinically significant minor blood group antigens in South India. The present study was conducted to determine the frequency of clinically significant minor blood group antigens - Rh (C, c, E and e), Kell (K, k, Kpa and Kpb), Kidd (Jka and Jkb), Duffy (Fya and Fyb) amongst regular voluntary blood donors and to form a donor database on red blood cell (RBC) antigens in the South Indian population.   Materials and methods This prospective descriptive study was conducted in the Model Blood Bank, Department of Transfusion Medicine, Government Medical College, Thiruvananthapuram, after approval by the Institutional Research and Ethics Committee. The hospital is a major tertiary care hospital in South Kerala, with super speciality, emergency, and surgical services. Blood samples were collected from healthy repeat voluntary blood donors between September 2018 and August 2019. Blood donors were selected from the state of Kerala (a state in South India) while donors who were from the other Indian states and foreign citizens were excluded so as to incorporate study participants with same ethnicity. The donors were selected as per the criteria laid down by the Drugs and Cosmetics Act, 1940 and Rules, 1945 and departmental Standard Operating Procedures (SOP). Written informed consent was obtained from each donor at the time of donor counselling and screening. About 2ml of blood sample was collected from each donor in sample tubes containing ethylenediaminetetraacetic acid (EDTA) anticoagulant. Phenotyping of red cell antigens were performed immediately after the blood collection. Every day, ten donor samples were typed and every tenth donor sample was included in the study. Clinically significant blood antigens of the ABO, Rh (D, C, c, E, and e), Kell, Duffy and Kidd blood group systems were studied. The ABO and Rh(D) grouping were performed by tube technique using monoclonal antisera (Tulip Diagnostics, India). The blood units tested positive for Rh(D) antigen were labelled as Rh(D) positive. The Rh(D) negative units were further tested for the presence of weak D by column agglutination technique, using IgG monoclonal antisera anti-D (Tulip Diagnostics, Goa, India). All blood samples were phenotyped for Rh(C, c, E, e), Kell, Duffy and Kidd antigens using column agglutination technique. The phenotyping was done using the ID-Diaclon gel cards (Bio-Rad, Cressier, Switzerland). A 0.8% low-ionic strength solution was used for the preparation of red cell suspension. One positive and one negative control for each antigen were selected from the commercial cell panels (DiaCell and DiaPanel, Bio-Rad, Cressier, Switzerland). The column agglutination test for antigen phenotyping was performed as per the manufacturer's instructions. The test results thus derived using the CAT were graded from negative to 4+ reaction.   Results Blood samples from 200 donors were typed for ABO, Rh (D, C, c, E and e), Kell, Duffy and Kidd antigens. The distribution of ABO and Rh blood groups is shown in Table-1. The most common group was found to be O (38%), followed by A (31%), B (26%), and AB (5%). Of these, 184 (92%) donors were Rh(D) positive and the remaining 16 (8%) donors were Rh(D) negative. Among the Rh antigens, the e antigen was found to be the most prevalent with a frequency of 97.8% and 100% among the Rh(D) positive and Rh(D) negative donors respectively (Table-2). The C antigen was found more frequently in Rh(D) positive donors compared to Rh(D) negative donors (90.8% vs. 6.3%, respectively). The c antigen was expressed by 100% of D negative donors, while only 40.76 % D positive donors expressed the c antigen. The E antigen was found in 19% RhD positive donors.   Table-1: Distribution of ABO and Rh blood groups of the study population (N=200)     Table-2: Prevalence of Rh antigens among RhD positive and negative donors     Table-3 depicts the phenotype frequencies of Rh-positive and Rh-negative groups. A total of 6 and 2 Rh phenotypes were observed among the Rh(D) positive and negative donors respectively. Among Rh positive group, R1R1 phenotype was the most frequent (47.3%), followed by the R1r (31.5%) and R1R2 (11%). Among the Rh(D) negative donors, the Rr phenotype was observed to be the most frequent (93.7%), followed by the r'r (6.3%).   Table-3: Phenotype distribution of Rh-positive (n =184) and Rh-negative groups (n=16)     Table-4 enumerates the prevalence of other minor antigens. In the Kell blood group system, the K and Kpa antigens were absent in all donors. The k (Cellano) and Kpb antigens were found in 100% of our donors. In the Duffy blood group system, Fya and Fyb antigens were expressed by 89% and 57.5% of the donors respectively. In the Kidd blood group system, the Jka antigen was found in 87% of the donors, while 62% of the donors expressed the Jkb antigen on their red cells. Detail Kell, Duffy and Kidd phenotype frequencies among the donors is illustrated in Table-5.   Table-4: Prevalence of other red cell antigens among the study population (N=200)     Table-5: Distribution of Kell, Duffy and Kidd phenotypes in study population (N=200).     Discussion Antibodies to ABO, Rh and other clinically significant antigens are known to cause hemolytic transfusion reaction, hemolytic disease of the fetus and newborn (HDFN), or shortened survival of transfused red cells [4]. Thorough knowledge of these clinically significant antigens can help in prevention of allo-immunization in chronic multi-transfused patients. The prevalence study of such antigens is available for Caucasians and Black races [5-7], whereas only limited information is there regarding the prevalence of these antigens in Indian population. In the present study, the ABO blood group antigen frequencies showed the prevalence as O > B > A > AB which was similar to other studies from South India [8,9] but in contrast to some Indian studies where B blood group was reported more prevalent [10,11]. It is due to the multiethnic population of our country and as a result studies in different region of India reported varied prevalence of ABO blood group. In India, the frequency of D negative antigen varies from 5% to 10% [8-12]. The frequency of Rh(D) positive in our study was 92%, whereas only 8% were Rh(D) negative. The e, D and C antigens were found to have the highest frequency. The C antigen was found to be more associated with presence of D antigen (90.8%). The R1R1 phenotype was the most frequent among Rh(D) positive donors and Rr among the Rh(D) negative donors. This is similar to other studies from India [9-14]. The K antigen was not detected in any of our donor samples. The prevalence has been shown to vary among different Indian populations. One study from India reported a low K antigen prevalence of only 0.79% [15]. The K-k+ was certainly the most common phenotype observed in our donor population. In the Kidd blood group system, Jk(a+b+) was the most common phenotype, accounting for 49%. No Jk (a-b-) phenotype was observed. This was similar to studies by Makroo et al in which the sample size was much higher than our study [12]. Regarding the Duffy blood group system, the results observed were similar to other studies from the country. The null phenotype Fy(a-b-) was not detected, which was similar to other Indian studies but contrary to a study conducted in Western India, which demonstrated Fy(a-b-) as the most prevalent (48.7%) phenotype [16]. The finding of red cell antigen prevalence in our study is beneficial in providing appropriate immunohematology laboratory services with limited resources. A cost-effective in-house antibody screening panel of cells can be developed based on the regional antigen prevalence. The data can be used for finding the number of units to be cross matched to find a compatible unit in allosensitized multi-transfused patients. A rare donor registry can be developed and if introduced would be helpful to the entire nation in future.   Acknowledgment As the extended phenotyping for antigens is not performed routinely in our Blood bank, the authors thank State Board of Medical Research for funding this study.   Conflict of interest The authors declare no conflict of interest.   Fund The study was funded by State Board of Medical Research.   References 1.     Sinha S, Seth T, Colah RB, Bittles AH. Haemoglobinopathies in India: estimates of blood requirements and treatment costs for the decade 2017-2026. J Community Genet. 2020 Jan; 11(1): 39-45. doi: 10.1007/s12687-019-00410-1. 2.     Matteocci A, Pierelli L. Red blood cell alloimmunization in sickle cell disease and in thalassaemia: current status, future perspectives and potential role of molecular typing. Vox Sang. 2014 Apr; 106(3): 197-208. doi: 10.1111/vox.12086. 3.     ISBT Terminology Committee. Red Cell Immunogenetics and Blood Group Terminology. International Society of Blood Transfusion. 2023. Archived from the original on 7 October 2022. Available from http://www.isbtweb.org/working-parties/red-cell-immunogenetics-and-blood-group-terminology/ 4.     Poole J, Daniels G. Blood group antibodies and their significance in transfusion medicine. Transfus Med Rev. 2007; 21(1): 58-71. doi: 10.1016/j.tmrv.2006.08.003. 5.     Brecher ME. Technical manual, American Association of Blood Banks, Bethesda, Md, USA, 15th edition, 2005. 6.     Daniels G. Human blood groups, Blackwell Science, Oxford, UK, 2nd edition, 2002. doi:10.1002/9780470987018 7.     Harmening D. Modern blood banking and transfusion practices, FA Davis Company, Philadelphia, PA, USA, 5th edition, 2005. 8.     John S. Prevalence of ABO and rhesus blood groups in blood donors: a study from a tertiary care centre in South Kerala. Int J Contemp Med Res. 2017; 4(11): 2314-2316. 9.     Subramaniyan R. Phenotyping of clinically significant blood group antigens among the South Indian donor population. Hematol Transfus Cell Ther. 2023; 45 Suppl 2(Suppl 2): S30-S35. doi: 10.1016/j.htct.2021.11.012. 10.  Prinja N, Narain R. ABO, Rh, and kell blood group antigen frequencies in blood donors at the tertiary care hospital of Northwestern India. Asian J Transfus Sci. 2020; 14: 179-84. doi: 10.4103/ajts.AJTS_34_19. 11.  Agarwal N, Thapliyal RM, Chatterjee K. Blood group phenotype frequencies in blood donors from a tertiary care hospital in north India. Blood Res. 2013; 48: 51‑54. doi: 10.5045/br.2013.48.1.51. 12.  Makroo RN, Bhatia A, Gupta R, Phillip J. Prevalence of Rh, Duffy, Kell, Kidd & MNSs blood group antigens in the Indian blood donor population. Indian J Med Res. 2013; 137(3): 521-526. 13.  Setya D, Tiwari AK, Arora D, Mitra S, Mehta SP, Aggarwal G. The frequent and the unusual red cell phenotypes in Indian blood donors: a quest for rare donors. Transfus Apher Sci. 2020; 59(4): 102765. doi: 10.1016/j.transci.2020.102765.  14. Nanu A, Thapliyal RM. Blood group gene frequency in a selected north Indian population. Indian J Med Res. 1997; 106: 242–246. 15.  Basu D, Datta SS, Montemayor C, Bhattacharya P, Mukherjee K, Flegel WA. ABO, Rhesus, and Kell antigens, alleles, and haplotypes in West Bengal, India. Transfus Med Hemother. 2018; 45(1): 62-66. doi: 10.1159/000475507. 16.  Kahar MA, Patel RD. Phenotype frequencies of blood group systems (Rh, Kell, Kidd, Duffy, MNS, P, Lewis, and Lutheran) in blood donors of south Gujarat, India. Asian J Transfus Sci. 2014; 8: 51–55. doi: 10.4103/0973-6247.126693.       Cite this article as: John S, Achankunju AK, Suma MS, Nadanganan S. Clinically significant minor blood group antigens amongst South Indian donor population. IMC J Med Sci. 2024; 18(1):004. DOI: https://doi.org/10.55010/imcjms.18.004 <![CDATA[Nasal carriage of methicillin and inducible clindamycin resistant Staphylococcus aureus among healthcare workers in a tertiary care hospital, Kathmandu, Nepal]]> Gaurab Pandey Ashrit Sharma Ghimire Luniva Maharjan Binita Maharjan Ashmita Upadhaya Anita Sah https://imcjms.com/journal_full_text/498 2023-10-22 11:32:44 Original Article IMC J Med Sci. 2024; 18(1):005 Abstract Introduction and Objectives: Transmission of methicillin-resistant Staphylococcus aureus (MRSA) from healthcare workers is one of the most frequent causes of nosocomial infections globally. There is a significant burden of nosocomial MRSA infections in low and low-middle income countries (LMICs), including Nepal. The present study investigated the rate of nasal carriage of MRSA among the healthcare workers in a tertiary care hospital, in Kathmandu, Nepal with emphasis on inducible macrolide-lincosamide-streptogramin B (iMLSB) resistance. Material and method: The study was conducted at Star Hospital, Lalitpur, Nepal, from September 2022 to November 2022. Healthcare workers (HCWs) working at the different departments of the hospital were enrolled. Nasal swabs from both anterior nares of HCWs were collected aseptically and cultured on Mannitol Salt agar. S. aureus was identified by Gram stain and standard biochemical tests. Antibiotic susceptibility of S. aureus was performed by disc diffusion method. MRSA isolates were detected phenotypically by disc diffusion method using cefoxitin disc (30 µg), and inducible clindamycin resistance was detected phenotypically by the D-zone test. Results: Total 105 HCWs were enrolled in the study. Out of 105 HCWs, 14 (13.3%) were positive for S. aureus among which 6 (5.7%) were MRSA carriers. The nasal carriage of MRSA was highest among doctors (16.7%) and the HCWs of the post-operative department (14.3%). All the isolated MRSA were susceptible to chloramphenicol and vancomycin. Inducible MLSB resistance was detected in 33.3% MRSA while the rate was 21.4% in all isolated S. aureus. Conclusion: The study demonstrated that HCWs could be the potential source of nosocomial infection by methicillin and inducible clindamycin resistant S. aureus. Thus, preventive measures should be initiated to mitigate the risk of its spread and the test for detection of inducible clindamycin resistance should be incorporated into the routine antibiotic susceptibility testing in hospital settings. IMC J Med Sci. 2024; 18(1):005. DOI: https://doi.org/10.55010/imcjms.18.005   *Correspondence: Gaurab Pandey, Non-Communicable Disease Laboratory, National Public Health Laboratory, Teku, Kathmandu, 44600, Nepal; E-mail: pandeygaurab67@gmail.com   Introduction Staphylococcus aureus is a Gram-positive coccus, arranged in clusters and is ubiquitously present as normal flora in humans and animals [1]. S. aureus is a highly infectious human pathogen that, despite being a normal component of the floral biota, has the potential to cause a wide variety of infections ranging from minor cutaneous symptoms to fatal sepsis [2]. Its adaptive versatility to alternating host and environmental conditions has rendered it a clinically important bacterium. Macrolide-lincosamide-streptogramin B (MLSB) antibiotics are commonly used for the management of infection by MRSA [5]. The category of antibiotics known as MLSB includes the macrolides (such as erythromycin, azithromycin, and spiramycin), lincosamides (such as clindamycin, and lincomycin), and streptogramin B (such as quinupristin). Clindamycin is a popular choice for various staphylococcal infections, notably skin and soft tissue infections, and it is an alternative for people who are allergic to penicillin. This has caused clinicians to become more interested in MLSB antibiotics to treat S. aureus infections rather than penicillin derivatives [6,7]. However, with time and overuse, S. aureus has also acquired resistance against MLSB antibiotics. Resistance to MLSB antibiotics is mediated by methylation of rRNA, active efflux and enzymatic inactivation [8]. The expression of the bacterial resistance to MLSB antibiotics may either be constitutive or inducible. Therefore, clinical failures may result if resistance to MLSB antibitics is not sufficiently investigated in the laboratory [6,8]. Hospital-acquired infections (HAIs) are a major problem in the world today and healthcare workers are an important reservoir of infectious agents. Undoubtedly, HAIs are an important interface between healthcare centers and the community [15,16]. HAIs due to MRSA is associated with significant morbidity, mortality and cost burden [15]. HCWs are more frequently viewed as vectors, rather than being the main source of MRSA transmission [17]. The commonest mode of MRSA transmission has been through the hands of HCWs contaminated with colonizer MRSA. Several case reports have documented symptomatic clinical MRSA infections among carrier HCWs [18]. This study examined the nasal carriage of MRSA in a tertiary care hospital in Kathmandu, Nepal, and studied their antibiotic susceptibility pattern with emphasis on inducible macrolide-lincosamide-streptogramin B (iMLSB) resistance. The findings of this project are aimed at bringing forth the importance of antimicrobial procedures and infection control strategies by and within healthcare workers. Materials and Methods 3.     Jevons MP. “Celbenin”-resistant Staphylococci. Br Med J. 1961;1(5219):124-125. 5.     Adaleti R, Nakipoglu Y, Ceran N, Tasdemir C, Kaya F, Tasdemir S. Prevalence of phenotypic resistance of Staphylococcus aureus isolates to macrolide, lincosamide, streptogramin B, ketolid and linezolid antibiotics in Turkey. Braz J Infect Dis. 2010; 14(1): 11-14. doi:10.1590/s1413-86702010000100003. 7.     Sathish JV, Janakiram K, Vijaya D. Inducible clindamycin resistance in Staphylococcus aureus: Reason for treatment failure. J Int Med Dentistry; 2015; 2(2): 97-103.doi: 10.18320/JIMD/201502.0297. 9.     Samia NI, Robicsek A, Heesterbeek H, Peterson LR. Methicillin-resistant Staphylococcus aureus nosocomial infection has a distinct epidemiological position and acts as a marker for overall hospital-acquired infection trends. Sci Rep. 2022; 12(1): 17007. doi:10.1038/s41598-022-21300-6. 11. Rongpharpi SR, Hazarika NK, Kalita H. The prevalence of nasal carriage of Staphylococcus aureus among healthcare workers at a tertiary care hospital in Assam with special reference to MRSA. J Clin Diagn Res. 2013; 7(2): p.257. doi:10.7860/JCDR/2013/4320.2741. 13.  Khanal LK, Jha BK. Prevalence of methicillin resistant Staphylococcus aureus (MRSA) among skin infection cases at a hospital in Chitwan, Nepal. Nepal Med Coll J. 2010; 12(4): 224-228. 15.  Kandel SN, Adhikari N, Dhungel B, Shrestha UT, Angbuhang KB, Karki G, et al. Characteristics of Staphylococcus aureus isolated from clinical specimens in a tertiary care hospital, Kathmandu, Nepal. Microbiol Insights. 2020; 13:1178636120972695. doi:10.1177/1178636120972695. 17.  Albrich WC, Harbarth S. Health-care workers: source, vector, or victim of MRSA? Lancet Infect Dis. 2008; 8(5): 289-301. doi:10.1016/S1473-3099(08)70097-5. 23.  Giri N, Maharjan S, Thapa TB, Pokhrel S, Joshi G, Shrestha O, et al. Nasal Carriage of Methicillin-Resistant Staphylococcus aureus among Healthcare Workers in a Tertiary Care Hospital, Kathmandu, Nepal. Int J Microbiol. 2021;2021:8825746. doi:10.1155/2021/8825746. 25.  Neupane R, Bhatt N, Poudyal A, Sharma A. Methicillin-resistant Staphylococcus aureus nasal carriers among laboratory technical staff of tertiary hospital in Eastern Nepal. Kathmandu Univ Med J (KUMJ). 2020; 18(69): p. 3-8. <![CDATA[Association between serum bilirubin and estimated glomerular filtration rate in diabetic patients with chronic kidney disease]]> Tanzia Tahfim Gazi Sharmin Sultana Mst. Hasnat Silvi Era Farjana Yesmin Rehana Afroze Ruma Laila Sultana https://imcjms.com/journal_full_text/499 2023-11-08 09:41:46 Original Article IMC J Med Sci. 2024; 18(1):006 Abstract Background and objectives: Hyperglycemia induces oxidative stress in diabetic patients by increasing reactive oxygen species production, which ultimately damage the cells and cause micro and macrovascular complications including diabetic nephropathy. Increased serum bilirubin level, within physiological range, can inhibit oxidative stress; thereby, preventing development of diabetic nephropathy. The aim of this study was to find out association between serum bilirubin and estimated glomerular filtration rate (eGFR) in diabetic patients with or without chronic kidney disease (CKD). Materials and method: Both male and female participants aged 30 to 60 years were enrolled in the study. Enrolled participants included healthy individuals (Group-1), diabetic patients without CKD (Group-2) and diabetic patients with CKD (Group-3). Clinical and biochemical parameters namely blood pressure, body  mass index (BMI), fasting blood glucose (FBG), HbA1c, eGFR, serum bilirubin and spot urine ACR were measured by appropriate methods. Pearson’s correlation coefficient, ANOVA and multiple linear regression models were used to analyze the data. Result: Total 189 respondents were enrolled in 3 study groups. Each group consisted of 63 cases. Of the 63 cases in Group-3, 49 and 14 belonged to CKD stage 3 and stage 4 respectively. The mean (± SD)  serum bilirubin levels of healthy individuals, diabetic patients without CKD and diabetic patients with CKD were 0.66 ± 0.31, 0.64 ± 0.21, 0.46±0.18 mg/dL respectively. Mean serum bilirubin was significantly low (p<0.001) in diabetic patients with CKD compared to healthy and diabetics without CKD. A Stepwise multiple regression analysis using eGFR as an objective variable adjusted for risk factors as explanatory variables, showed that serum bilirubin (β=0.323, p<0.001) was significantly associated with eGFR, in addition to age, BMI, HbA1c and urinary ACR. Conclusion: The study has demonstrated that low serum bilirubin level is associated with CKD in diabetic patients and it could be used as a simple marker for CKD in diabetics. IMC J Med Sci. 2024; 18(1):006. DOI: https://doi.org/10.55010/imcjms.18.006 *Correspondence: Tanzia Tahfim, Department of Biochemistry, Shaheed Monsur Ali, Medical College, Uttara, Dhaka-1230, Bangladesh. Email: tanzia.uamc@gmail.com   Introduction Chronic hyperglycemia in diabetes is associated with long term damage, dysfunction, and failure of different organs, especially the eyes, kidneys, nerves, heart, and blood vessels [1,2]. Chronic kidney disease (CKD) is a frequent long-term complication of diabetes. CKD is a leading cause of end-stage kidney disease in diabetics, accounting for 50% of cases [3]. It is characterized by persistently elevated urinary albumin excretion (albumin-to-creatine ratio [ACR] ≥ 30 mg/g) and/or low estimated glomerular filtration rate (eGFR < 60 mL/min/1.73 m2) in a person with diabetes [4]. Oxidative stress has been considered a pathogenic factor for the development of nephropathy in diabetic patients [5,6]. Bilirubin is a potent antioxidant and it largely protects cells against lipid peroxidation [7]. It is generated from biliverdin by biliverdin reductase. During its antioxidant activity, it is oxidized to biliverdin which is immediately reduced again by biliverdin reductase to bilirubin [8]. The precise nature of the relationship between serum bilirubin level and development of nephropathy in diabetic patients is unknown. But it is expected that increased serum bilirubin level within physiological range can inhibit oxidative stress and inflammation; thereby, preventing development of diabetic nephropathy [9]. Previous studies reported that low serum bilirubin level predicts the development of chronic kidney disease in patients with type 2 diabetes mellitus [10]. But with the best of our knowledge there is no study regarding the relationship of serum bilirubin and eGFR in diabetic patients with or without CKD in Bangladesh. So, this study aimed to find out association between serum bilirubin and eGFR in diabetic patients with or without CKD in our population.   Materials and method The study was conducted at the Department of Biochemistry and Molecular Biology, BIRDEM General Hospital over one year period.The study was approved by Institutional Review Board, BIRDEM. Informed written consent was obtained from each participant prior to the enrollment in the study. Both male and female  diabetic patients with and without CKD and between the age group of 30 to 60 years were selected from outpatient department of Medicine, BIRDEM General Hospital and enrolled in the study. Patients with jaundice, acute kidney injury, kidney disease with non-diabetic etiology or patients on renal replacement therapy were excluded. Also pregnant women, patients taking nephrotoxic or hepatotoxic drugs were also excluded. Detail clinical and biophysical characteristics of each participant were recorded in a structured questionnaire. Diabetes mellitus was diagnosed based on WHO criteria [11]. CKD was diagnosed on the basis of persistent albuminuria (>30mg/day or ACR>30mg/g) in at least two occasions within six months period and/or GFR less than 60 ml/min/1.73m2 for more than three months [12]. Estimated GFR was calculated by CKD-EPI method. Serum creatinine was measured in Jaffe’s method by Abbott ARCHITECT PLUS C 8000 Autoanalyzer. Serum bilirubin was measured by photometric method in Abbott ARCHITECT PLUS C 8000 Autoanalyzer. HbA1c was measured by High Performance Liquid Chromatography (HPLC) method by BIO-RAD Variant TM II Turbo. Spot urine microalbumin (mg/L) was measured in particle-enhanced turbidimetric inhibition immunoassay and urine creatinine (g/L) was measured by Jaffe’s method by SIMENS Dimension EXL 200. Urine microalbumin creatinine ratio (mg/g) was calculated. Hemoglobin was measured by Sodium lauryl sulphate method in SYSMEX XN-1000 Autoanalyzer. Pearson’s correlation coefficient, multiple linear regression analysis and ANOVA tests were done to determine the relation between serum bilirubin and eGFR. All statistical tests were considered at 5% level of significance. SPSS version 22 was used for data analysis.    Results A total of 189 respondents were included. Out of 189 cases, 63 were healthy individuals (Group-1), 63 were diabetic patients without CKD (Group-2) and 63 were diabetic patients with CKD (Group-3). Cases of Group-3 were further divided according to the stage of kidney disease.  Of the 63 Group-3 cases, 49 and 14 belonged to CKD stage 3 and stage 4 respectively. In Group-1, 2 and 3, 50.7%, 74.6% and 67.7% participants were male respectively. Table-1 shows the detail clinical and biochemical parameters of the three study groups. Age, systolic and diastolic blood pressure were significantly (p<0.05) higher in diabetic patients with CKD than other two groups. Mean BMI was significantly (p<0.05) higher in patients of Group-3 in comparison to Group-1 and 2. Mean hemoglobin was significantly lower (p<0.001) in Group-3 than Group-1 and 2. Fasting blood glucose and HbA1c of Group-3 patients were significantly (p<0.001) lower than those of other two groups (Group-1 and 2). Estimated GFR was significantly lower (p<0.001) in Group-3 cases than those of Group-1 and 2 cases (40.63±13.07, 96.30±18.60 and 78.14±14.51 ml/min/m2 respectively). Mean serum bilirubin was significantly lower (p<0.001) in diabetic patients with CKD (Group-3; 0.46±0.18 mg/dl) compared to healthy (Group-1, 0.64±0.21 mg/dL) and diabetic cases without CKD (Group-2, 0.46±0.19 mg/dL).   Table-1: Comparison of clinical and biochemical parameters of the three study groups   Table-2 shows the differences of clinical and biochemical parameters of Group-3 diabetic patients with stage 3 and stage 4 CKD. Mean eGFR was significantly lower (p<0.001) in stage 4 CKD patients than stage 3 CKD patients. Serum bilirubin was also found significantly lower (p=0.029) in stage 4 CKD patients (0.37±0.10 mg/dl) compared to those of stage 3 CKD patients (0.48±0.19 mg/dl).   Table-2: Comparison of clinical and biochemical parameters of diabetic patients with stage 3 and stage 4 CKD   Table-3 shows the relationship between participants’ characteristics and eGFR. Serum bilirubin (r= 0.447, p<0.001) along with BMI, systolic and diastolic blood pressure, hemoglobin, fasting plasma glucose, HbA1c and urinary ACR were significantly related with eGFR. Stepwise multiple regression analysis using eGFR as an objective variable adjusted for risk factors as explanatory variables, showed that serum bilirubin (β=0.323, p<0.001) was significantly associated with eGFR, in addition to age, BMI, HbA1c and urinary ACR.   Table-3: Relationship between various risk factors including serum bilirubin and estimated glomerular filtration rate in all study subjects (N=189)   Discussion The present study analyzed the relationship between serum bilirubin concentration and eGFR in healthy individuals and diabetic patients with or without CKD.The different clinical and biochemical profiles of the cases of our study groups were similar to the findings of other reported studies [13-15]. Serum bilirubin level was significantly lower in diabetic patients with CKD (p<0.001) than healthy individuals and diabetic patients without CKD. Similar findings were also found in other studies [13,14]. In our study, among the 63 diabetic patients with CKD, 49 were stage 3 CKD and 14 were stage 4 CKD patients. Serum bilirubin was also found significantly lower (p=0.029) in stage 4 CKD patients compared to stage 3 CKD patients (0.37±0.10 vs. 0.48±0.19 mg/dL) indicating that level of serum bilirubin was associated with decline of eGFR. Other studies also reported that bilirubin differed in different stages of CKD [16]. In this study, a stepwise multiple linear regression model using eGFR as an objective variable adjusted for risk factors for explanatory variables demonstrated that, serum bilirubin (β=0.323, p<0.001) was positively and independently associated with eGFR along with age (β=-0.185, p=0.001), BMI (β=-0.185,p=0.001), HbA1c (β=-0.238, p<0.001) and spot urine ACR (β=-0.322, p<0.001) in all study subjects. Katohet al., [10] detected positive association between serum bilirubin (β=0.11, p<0.001) with eGFR along with age (β=-0.29, p<0.001) in a cross-sectional study. The present study had some limitations. The study was conducted for a limited period of time with relatively small population and convenient sampling was used from a single center. Multicenter, longitudinal, population based study with a large sample size and longer duration is recommended for more accurate and reliable results. In this study, significantly lower serum bilirubin level was observed in diabetic patients with CKD in comparison with healthy individuals and diabetic patients without CKD. The results suggest that low serum bilirubin level may predict development and progression of CKD in diabetic patients. Therefore, it is concluded that proper glycemic control and screening of serum bilirubin in diabetic patients would be beneficial for early diagnosis and prevention of progression of CKD in diabetic patients.   Acknowledgements We are extremely thankful to, Prof. Dr. M A Muttalib, Professor and Ex Head, Department of Biochemistry and Molecular Biology, BIRDEM, for his supervision, valuable guidance, intellectual inputs and constructive criticism. We are grateful to Dr. Parvin Akter Khanom, Associate Professor, Department of Epidemiology and Biostatistics, BIRDEM General Hospital for her continuous suggestions on data and statistical analysis. We are also thankful to the staffs of BIRDEM General Laboratory and study participants for their continuous assistance and support.   Author’s contributions TT designed the protocol, collected patents’ data and samples, analyzed the data and wrote the manuscript; GSS supervised and coordinated the study and edited the manuscript. MHSE collected samples, performed biochemical tests and did the statistical analysis; LS collected sample and did biochemical tests; FY and RAR collected the data including history taking and physical examination.   Funding This research received no external funding.   Conflicts of Interest The author declares no conflict of interest.   References 1.     Pavithra D, Praveen D, Chowdary PR, Aanandhi MV. A review on role of Vitamin E supplementation in type 2 diabetes mellitus. Drug Invent Today. 2018; 10(2): 236-240. 2.     Halliwell B, Gutteridge JMC. Free Radicals in Biology and Medicine. 3rd ed. Oxford UK: Oxford University Press; 1999. 3.     Tuttle KR, Bakris GL, Bilous RW, Chiang JL, De Boer IH, Goldstein-Fuchs J, et al. Diabetic kidney disease: a report from an ADA Consensus Conference. Diabetes Care. 2014; 37(10): 2864-2883. doi:10.2337/dc14-1296. 4.     Levin A, Stevens PE, Bilous RW, Coresh J, De Francisco AL, De Jong PE, et al. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.KI Supplements. 2013; 3(1): 1-150. doi: https://doi.org/10.1038/kisup.2012.73. 5.     Forbes JM, Coughlan MT, Cooper ME. Oxidative stress as a major culprit in kidney disease in diabetes. Diabetes. 2008; 57(6): 1446-1454. doi:10.2337/db08-0057. 6.     Aouacheri O, Saka S, Krim M, Messaadia A, Maidi I. The investigation of the oxidative stress-related parameters in type 2 diabetes mellitus. Can J Diabetes. 2015; 39(1): 44-49. doi:10.1016/j.jcjd.2014.03.002. 7.     Stocker R, Yamamoto Y, McDonagh AF, Glazer AN, Ames BN. Bilirubin is an antioxidant of possible physiological importance. Science. 1987; 235(4792):1043-1046. doi:10.1126/science.3029864. 8.     Sedlak TW, Saleh M, Higginson DS, Paul BD, Juluri KR, Snyder SH. Bilirubin and glutathione have complementary antioxidant and cytoprotective roles. Proc Natl Acad Sci U S A. 2009; 106(13): 5171-5176. doi:10.1073/pnas.0813132106. 9.     Ahn KH, Kim SS, Kim WJ, Kim JH, Nam YJ, Park SB, et al. Low serum bilirubin level predicts the development of chronic kidney disease in patients with type 2 diabetes mellitus. Korean J Intern Med. 2017; 32(5): 875-882. doi:10.3904/kjim.2015.153. 10.  Katoh T, Kawamoto R, Kohara K, Miki T. Association between Serum Bilirubin and Estimated Glomerular Filtration Rate among Diabetic Patients. Int Sch Res Notices. 2015; 2015: 480418. doi:10.1155/2015/480418. 11.  Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med. 1998; 15(7): 539-553. doi:10.1002/(SICI)1096-9136(199807)15:7<539::AID-DIA668>3.0.CO;2-S 12.  Haneda M, Utsunomiya K, Koya D, Babazono T, Moriya T, Makino H, et al. A new classification of diabetic nephropathy 2014: a report from Joint Committee on Diabetic Nephropathy. Clin Exp Nephrol. 2015; 19(1): 1-5. doi: 10.1007/s10157-014-1057-z. 13.  Fan Y, Fei Y, Zheng L, Wang J, Xiao W, Wen J, et al. Expression of endothelial cell injury marker Cd146 correlates with disease severity and predicts the renal outcomes in patients with diabetic nephropathy. Cell Physiol Biochem. 2018; 48(1): 63-74. doi:10.1159/000491663. 14.  Chen F, Li YM, Yang LQ, Zhong CG, Zhuang ZX. Association of NOS2 and NOS3 gene polymorphisms with susceptibility to type 2 diabetes mellitus and diabetic nephropathy in the Chinese Han population. IUBMB Life. 2016; 68(7): 516-525. doi:10.1002/iub.1513. 15.  Tanaka M, Fukui M, Okada H, Senmaru T, Asano M, Akabame S, et al. Low serum bilirubin concentration is a predictor of chronic kidney disease. Atherosclerosis. 2014; 234(2): 421-425. doi: https://doi.org/10.1016/j.atherosclerosis.2014.03.015. 16.  Moolchandani K, Priyadarssini M, Rajappa M, Parameswaran S, Revathy G. Serum bilirubin: a simple routine surrogate marker of the progression of chronic kidney disease. Br J Biomed Sci. 2016; 73(4): 188-193. doi:10.1080/09674845.2016.1182674.   Cite this article as: Tahfim T, Sultana  GS, Era MHS, Yesmin F, Ruma RA, Sultana L. Association between serum bilirubin and estimated glomerular filtration rate in diabetic patients with chronic kidney disease. IMC J Med Sci. 2024; 18(1):006. DOI: https://doi.org/10.55010/imcjms.18.006 <![CDATA[Impact of COVID-19 pandemic on the physical, mental and social health of the suburban and rural adult population in Bangladesh]]> Nehlin Tomalika Rishad Mahzabeen Md Mohiuddin Tagar Sadya Afroz Naima Ahmed Masuda Mohsena Rashid-E-Mahbub MA Sayeed https://imcjms.com/journal_full_text/501 2023-12-03 09:23:13 Original Article IMC J Med Sci. 2024; 18(1):007 Abstract Background and objectives: The COVID-19 pandemic caused a significant impact on health worldwide. Adverse effect of COVID-19 on health-related quality of life is significant. This study aimed to find out the impact of COVID-19 on the physical, mental and social health of suburban and rural adult population in Bangladesh. Methods: A suburban and a rural community were purposively selected. The suburban and rural areas were located about 40 km and 130 km north and north-east of Dhaka city respectively. People aged ≥20 years in the selected communities were enrolled in the study. The investigation procedure included socio-demographic and clinical history, anthropometry, and clinical examination and laboratory investigations. Depression, Anxiety and Stress Scale-21 (DASS-21) and 36-Item Short Form Health Survey (SF-36) questionnaires were used for assessing mental and social health respectively. Knowledge, attitude and practice (KAP) regarding the prevention and transmission of COVID-19 was assessed by a validated questionnaire and interview. Results: Total 385 individuals (suburban=201, rural=184) were enrolled in the study. Out of 385, 116 and 269 were male and female, respectively. Out of total 385 participants, depression, anxiety and stress were present in 113 (29.4%), 144 (37.4%) and 70 (18.2%) respectively, while 210 (54.5%) were normal. Extremely severe depression, anxiety and stress were present in 3.6%, 6% and 0.5%, respectively. Depression and anxiety did not differ between suburban and rural populations, though stress was significantly higher among the suburban (p<0.05) population. Social functioning was limited in more than 50% as opposed to excellent (5.5%) or good (39.8%). Almost 60% of the participants had to cut-down schedule of heavy work. Moderate to minimal physical activities were less affected, though weakness and nervousness predominantly hindered socialization. About the prevention and transmission of COVID-19, awareness and attitude were found satisfactory (≥45%), though practice was neglected (<30%). Conclusions: This is the first study in Bangladesh to report the impact of the COVID-19 pandemic on the physical, mental, and social health of adult suburban and rural populations. Physical and mental disabilities were evident among the studied people. Social functioning was affected by COVID-19 equally in suburban and rural participants. A well-designed cohort study is needed to obtain a real picture of the impact of COVID-19 pandemic on human health and society. IMC J Med Sci. 2024; 18(1):007. DOI: https://doi.org/10.55010/imcjms.18.007 *Correspondence: MA Sayeed,  Department of Community Medicine and Public Health, Ibrahim Medical College,    1/A Ibrahim Sarani, Segunbagicha, Dhaka 1000, Bangladesh; Email: sayeed1950@gmail.com   Introduction A local outbreak of pneumonia of initially unknown cause was detected in Wuhan (Hubei, China) and first reported in December, 2019 [1]. The causative agent was quickly identified as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and became the cause of the pandemic of acute respiratory disease, called ‘coronavirus disease 2019’ (COVID-19).The outbreak rapidly engulfed many other countries and regions, affecting 70000 confirmed cases by February, 2020 [1-3]. This virus invades almost all organs of the body and upsets physical and mental health, affecting psychosocial behavior. The reported morbidity and mortality were enormous. In short, this pathogen had disastrous effects on mankind by making a pandemic health hazard. The fatality rate reached 14.1% in New York and also in some other countries [4].World-wide, regularly published reports on COVID-19 have been keeping us informed about the magnitude of the infection and fatality [1-5].Mental, physical and behavioral disorders are reported in both COVID-19 sufferers and general people during this pandemic in different countries, including Bangladesh [6-8]. There has been no comprehensive study on the effect of the COVID-19 pandemic on mental, physical and social functioning of the general Bangladeshi population. This study compared the impact of the COVID-19 pandemic on mental and physical health as well as the social functioning of rural and suburban people. The study also assessed the knowledge, attitude and practice (KAP) of those populations regarding the prevention and transmission of SARS-CoV-2.   Materials and methods The study was conducted in suburban and rural communities from November, 2022 to December, 2022 and in August, 2023 respectively. The protocol was duly approved by the Institutional Review Board. Informed consent was obtained from each participant prior to enrollment in the study. Study population and methods: The suburban community was selected from Savar Upazila (sub-district) under Dhaka district, about 40km north of Dhaka City. The rural villages were selected from Nandail Upazila (sub-district) under Mymensingh district, about 130 km north-east of Dhaka city. The sample size was arbitrarily estimated at 200 from suburban and 200 from rural sites. All people aged 20 years and above in the selected communities were invited to take part in the study. The local social, political and religious leaders were briefed about the objectives and procedural details of the study. The local school teachers and students were requested to volunteer and cooperate in the implementation of the study. The investigation team consisted of physicians, nurses and laboratory technicians. The participants (age ≥20y) were enlisted serially, and a designated physician recorded socio-demographic data and clinical history in a structured questionnaire. After obtaining the detailed history, each participant underwent anthropometry (height, weight, waist- and hip-girth → BMI, WHR). Then general examination was done (look/appearance, anemia, cyanosis, jaundice, edema, etc). Every participant was checked for obesity (BMI, WHR), hypertension (blood pressure), diabetes (blood glucose) and post-COVID sequels. The DASS-21 questionnaire was used to assess the state of depression, anxiety and stress due to COVID-19 pandemic situation [9].TheDASS-21 scoring system was applied to grade the depression, anxiety and stress states into normal, mild, moderate, severe and extremely severe degrees, as per Table-1.   Table-1: DASS-21 scoring system for categorization of depression, anxiety and stress into different grades     For assessment of social health and function the “36 SF Questionnaire” was used. This questionnaire contained 36 questions on general health, limitations of activities, physical health problems, emotional health problems, social activities, energy and emotions. Using a validated questionnaire, each participant was also interviewed in depth on his/her knowledge, attitude and practice (KAP) regarding the prevention and transmission of the virus causing COVID-19. Minor illnesses were treated and if any additional systemic diseases were found, the participant was referred to referral hospitals. About 5 ml blood was collected aseptically from each participant and random blood glucose (RBG), lipids, creatinine and SGPT were estimated according to the standard methods. Statistical analysis: The post-COVID effect was described mainly with descriptive statistics. Knowledge, attitude and practice (KAP) were tabulated. The data were presented in percentages according to every component of KAP. Likewise, each component of depression, anxiety and stress score (DASS) was presented in percentage. Chi-sq test was done for determining the association between DASS and geographical sites and other variables (rural and suburban). SPSS version 20 was employed. For the inferential statistics, significance level was accepted at p<0.05.   Results A total of 385 individuals volunteered the study. Of them, 201 were from suburban and 184 from rural communities. Out of 385, 116 and 269 were male and female respectively. No significant difference was observed between male and female participants residing in suburban and rural areas (Table-2).   Table-2: Gender distribution of the study population     The biophysical characteristics of all participants are shown in Table-3a. Table-3b displays the differences in characteristics between male and female participants. Significant differences were observed, as usual, in anthropometric measures. Likewise, some differences were found to be significant in comparisons between suburban and rural participants (Table-3c).   Table-3a: Biophysical parameters of all participants     Table-3c: Comparisons of biophysical parameters of suburban and rural study population     It may be noted that lipids (chol, TG, HDL, LDL) could not be compared as the suburban group had no data. Based on the DASS-21 scoring system, Table-4a shows the prevalence of depression, anxiety and stress among the suburban and rural population. Out of the total 385 enrolled participants, 210 (54.5%) had no depression, anxiety or stress, while 29.4%, 37.4% and 18.2% had depression, anxiety and stress respectively. Of 385, 51 (13.2%) had all three conditions. There was no significant difference for depression and anxiety (p>0.5) between the suburban and rural people, though ‘stress’ was significantly (p = 0.023) higher in the suburban (22.4%) than their rural counterparts (13.6%). The prevalence of total and different grades of depression, anxiety and stress according to the gender of the study population are shown in Table-4b. No significant differences were observed between the male and female participants regarding the different grades of depression, anxiety and stress. Of the total 385, “extremely severe” depression, anxiety and stress were present in 3.6%, 6% and 0.5%, respectively.   Table-4a: Prevalence of depression, anxiety and stress among the suburban and rural population (n=385)     Table-4b: Prevalence of graded depression, anxiety and stress according to gender (male=116, female=269) of the study population (n=385)     The prevalence of different grades of depression, anxiety and stress of suburban and rural population are shown in Table-4c. No significant (p > 0.05) difference was present in the occurrences of different grades of the above mental conditions between the suburban and rural people.   Table-5a: Assessment of social functioning of the study population (n=385)     42.3% rated no change in their health status, while less than 30% reported being better or somewhat better. Regarding the limitation of regular activities, over 60% of the participants experienced an impact on vigorous or strenuous work, while the influence on moderate to minimal physical activities was less, ranging from 40% to 70% (Table-5b). The components of physical, emotional and social health were shown in Table-5c through Table-5f. Almost >50% reported that they had to cut-down on their regular work (Table-5c). Similarly, more than half of the respondents had emotional health problems and 42.6% had to avoid social responsibilities (Table-5d, 5e].The vitality and energetic effort were also affected but not very discernible. Nervousness and unhappiness were reported in less than 30% of people (Table-5f). Knowledge, attitude and practice (KAP) regarding the prevention and transmission of COVID-19 are shown in Table-6a and 6b. Overall, there was fairly adequate awareness about COVID-19, ranging from 47% to 88% (Table-6a). For attitude, 65% agreed to abide by the advices of health personnel while fewer than 35% adhered to recommended practices (Table-6b).   Table-5b: Limitations of activities during COVID-19 period (n=385)   Table-5c: Physical health problems during COVID-19 period (n=385)     Table-5d: Emotional health problems during COVID-19 period (n=385)     Table-5e: Emotional problem affecting social activities during COVID-19 period (n=385)     Table-5f: Assessment of energy and emotions (n=385)     Table-6a: Assessment of knowledge on the COVID-19 pandemic (n=385)     Table-6b: Assessment of attitude and practice regarding control and preventive measures for the COVID-19 pandemic (n=385)     Discussions Different public health measures have been adopted for the mitigation of transmission and to reduce the detrimental effects of the COVID-19. Though such measures have many potential benefits, they also have negative short- and long-term consequences for mental health. Long-term quarantine may pose financial loss and socioeconomic distress and, consequently, be responsible for the emergence of psychological disorders. The existing prevalence of mental disorders is very high in Bangladesh [10]. According to the nationwide survey on mental health conducted in 2019 (pre-COVID-19 period), the prevalence of all mental disorders among the adult population is 18.7% and among the child population, it is 12.6% [11]. A study conducted in the early period of the COVID-19 pandemic revealed that 30.1% of adolescents were suffering from moderate to severe depressive symptoms, and females suffered more than males [12]. The current study was conducted when the dreadfulness of COVID-19 was declining, at least to some extent. It was observed that nearly one-third of study participants had both depression and anxiety. Moreover, stress was reported by almost one-fifth of the participants. In this study, the prevalence of anxiety was somewhat similar to a study conducted during the very first enactment of lockdown by Banna et al [13]. But compared to that study, the prevalence of depression and stress in our study was nearly half and one-third respectively. According to Banna et al, the prevalence of depression, anxiety and stress was 57.9%, 33.7%, and 59.7%, respectively. In a study conducted in China, the prevalence of depressive symptoms was 16.5% in the general population [14] and Ueda et al. [15] from Japan also reported a much lower prevalence of depression (11.4%) during the early part of the COVID-19 pandemic. Socio-economic conditions and poor healthcare systems may contribute to the disparities in these findings in our country. A few earlier studies have reported that low- and middle-income countries have a higher burden of mental disorders than economically developed countries [16,17]. The rise in the confidence levels of doctors, improved public satisfaction with health information, increased adherence to personal protective measures, reduced fatalities from subsequent SARS-CoV-2 strains, and most importantly, a higher perception of survival chances among the general population may have contributed to this phenomenon. In DASS comparisons, it was noted that a higher percentage of females suffered from depression and anxiety compared to males, though this finding was not statistically significant. The observation aligns with the results reported by Wang et al [14] from China. The lockdown situation might have led to an upsurge in domestic violence against women, and the unrest stemming from financial insecurity could be a contributing factor to these outcomes. Depression and anxiety were almost same in both our communities, though stress was significantly higher among suburban people. This is possibly due to more morbidity and mortality in urban communities. This is consistent with an interesting finding in China [7]. The finding was that nurses exposed to COVID-19 from Hubei, China had stress disorders despite their job satisfaction. The present study is unique as it encompassed two geographical sites. This gave the opportunity to compare the differences in perception of COVID-19 and related health issues between suburban and rural people. Comparisons of KAP showed no significant difference between the two communities (data not shown). Possibly, this happened due to the nationwide dissemination of health-related education with an emphasis on COVID-19 transmission. Mass media is available even in the remotest village communities in Bangladesh. Hence, there was no notable difference in both awareness and attitude components. The lower adherence to practices in villages was attributed to the paucity of detected infections among residents. The social functioning of the participants was found to be limited in the study, which is consistent with other investigations. In Kerala, around one-third of the patients (36.4%) had dyspnea on exertion, and 11.8% had dyspnea at rest [8]. Another study conducted among the Japanese and Swedish observed that of the 135 COVID-19 survivors among the 763 total participants, 37% (n = 50/135) had post-COVID stress [18]. This study found that more than 50% of participants had to cut down on their regular activities, which had also been reported in the Irish Cohort [19]. Again, others reported that patients with Long COVID sufferings had multisystem involvement and significant disability. Their seven months follow-up showed many patients did not recover (mainly from systemic and neurological / cognitive symptoms) and had not returned to previous levels of work and continued to experience significant symptom burden [20]. The disabilities of post-COVID systemic and neurologic manifestations were reported by many other studies [21-23]. Some limitations of our study may be noteworthy. All the suspected COVID-19 patients in rural communities were not diagnosed serologically. History taken by the interviewer was not consistent. There might have been some error in recollecting and comparing the pre- and post-COVID statements.   Conclusions The study is the first of its kind to report on the impact of COVID-19 by comparing the biophysical characteristics, KAP, DASS and social functioning of rural vs. urban population. Long-lasting disabilities in physical and mental health were evident and consistent with other studies. Social health and functioning were affected by COVID-19, both in suburban and rural participants. More studies, specifically cohort studies, are needed to get a real picture of the COVID-19 impact on the general population with different socio-economic and health statuses.   Authors’ contribution NT: data collection, data analysis and draft manuscript writing; MMT, SA, NA: data collection; RM: tool development and data collection; MM: planning, data collection and manuscript writing; MAS: protocol design, data analysis and manuscript writing; RM: idea and concept.   Fund The study was funded by Ibrahim Medical College.   References 1.     Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect. Dis. 2020; 20(5): 533–534. doi: 10.1016/S1473-3099(20)30120-1. 2.     World Health Organization. Coronavirus disease (COVID-2019) situation reports. Geneva: World Health Organization; 2020. 3.     World Health Organization. 2019-nCoV outbreak is an emergency of international concern. Geneva: World Health Organization; 2020. 4.     An official website of the United States Government, Quick Facts. New York city, New York. 5.     Survey conducted by USAID. Covid-19 impacts in Bangladesh. Nationwide survey on livelihoods, nutrition, education and health. 2022. 6.     Islam MS, Sujan MSH, Tasnim R, Sikder MT, Potenza MN, van Os J. Psychological responses during the COVID-19 outbreak among university students in Bangladesh. PLoS One. 2020; 15(12): e0245083. doi: https://doi.org/10.1371/journal.pone.0245083. 7.     Wang YX, Guo HT, Du XW, Song W, Lu C, Hao WN. Factors associated with post-traumatic stress disorder of nurses exposed to corona virus disease 2019 in China. Medicine (Baltimore). 2020; 99(26): e20965. doi:10.1097/MD.0000000000020965. 8.     Raj SVA, Jacob A, Ambu V, Wilson T, Renuka R. Post COVID-19 clinical manifestations and its risk factors among patients in a Northern District in Kerala, India. J Family Med Prim Care. 2022; 11(9): 5312-5319. doi: 10.4103/jfmpc.jfmpc_131_22. 9.     Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales.2nd. Eds. Sydney: Psychology Foundation of Australia, Sydney, N.S.W; 1995. 10.  Hasan MT, Anwar T, Christopher E, Hossain S, Hossain MM, Koly KN, et al. The current state of mental healthcare in Bangladesh: part 1-an updated country profile. BJPsych Int. 2021; 18(4):78-82. doi:10.1192/bji.2021.41. 11.  National Institute of Mental Health. National Mental Health Survey of Bangladesh 2018–19: Provisional Fact Sheet. NIMH, 2019 (https://www.who.int/docs/default-source/searo/ bangladesh/pdf-reports/cat-2/nimh-fact-sheet-5-11-19.pdf? sfvrsn=3e62d4b0_2. 12.  Anjum A, Hossain S, Hasan MT, Alin SI, Uddin ME, Sikder MT. Depressive symptom and associated factors among school adolescents of urban, semi-urban and rural areas in Bangladesh: a scenario prior to COVID-19. Front Psychiatry. 2021; 12:708909. doi: 10.3389/fpsyt.2021.708909. 13.  Banna MHA, Sayeed A, Kundu S, Christopher E, Hasan MT, Begum MR, et al. The impact of the COVID-19 pandemic on the mental health of the adult population in Bangladesh: a nationwide cross-sectional study. Int J Environ Health Res. 2022; 32(4): 850-61. doi: 10.1080/09603123.2020.1802409. 14.  Wang C, Pan R, Wan X, Tan Y, Xu L, McIntyre RS, et al. A longitudinal study on the mental health of general population during the COVID-19 epidemic in China. Brain Behav Immun. 2020; 87:40-48. doi:10.1016/j.bbi.2020.04.028. 15.  Ueda M, Stickley A, Sueki H, Matsubayashi T. Mental health status of the general population in Japan during the COVID-19 pandemic. Psychiatry Clin Neurosci. 2020; 74(9):505-506. doi:10.1111/pcn.13105. 16.  Bass JK, Bornemann TH, Burkey M, Chehil S, Chen L, Copeland JRM, et al. A United Nations general assembly special session for mental, neurological, and substance use disorders: the time has come. PLoS Med. 2012; 9 (1): e1001159. doi: 10.1371/journal.pmed.1001159. 17.  Hock RS, Or F, Kolappa K, Burkey MD, Surkan PJ, Eaton WW: A new resolution for global mental health. Lancet. 2012; 379 (9824): 1367-1368. doi:10.1016/S0140-6736(12)60243-8. 18.  Matsumoto K, Hamatani S, Shimizu E, Käll A, Andersson G. Impact of post-COVID conditions on mental health: a cross-sectional study in Japan and Sweden. BMC Psychiatry. 2022; 22(1): 237. doi: 10.1186/s12888-022-03874-7. 19.  O’ Mahony L, Buwalda T, Blair M, Forde B, Lunjani N, Ambikan A, et al. Impact of Long COVID on health and quality of life. HRB Open Res. 2022; 5: 31. doi: 10.12688/hrbopenres.13516.1. 20.  Davis HE, Assaf GS, McCorkell L, Wei H, Low RJ, Re'em Y, et al. Characterizing long COVID in an international cohort: 7 months of symptoms and their impact. EClinicalMedicine.2021; 38: 101019. doi:10.1016/j.eclinm.2021.101019. 21.  Groff D, Sun A, Ssentongo AE, Ba DM, Parsons N, Poudel GR, et al. Short-term and long-term rates of post acute sequelae of SARS-CoV-2 infection: A systematic review. JAMA Network Open. 2021; 4(10):e2128568. doi: 10.1001/jamanetworkopen.2021.28568. 22.  Jafri MR, Zaheer A, Fatima S, Saleem T, Sohail A. Mental health status of COVID-19 survivors: a cross sectional study. Virol J. 2022; 19(1): 3. doi: 10.1186/s12985-021-01729-3. 23.  Hamano J, Tachikawa H, Takahashi S, Ekoyama S, Nagaoka H, Ozone S, et al. Exploration of the impact of the COVID-19 pandemic on the mental health of home health care workers in Japan: a multicenter cross-sectional web-based survey. BMC Prim Care. 2022; 23(1): 129. doi: 10.1186/s12875-022-01745-4.      Cite this article as: Tomalika N, Mahzabeen R, Tagar MM, Afroz S, Ahmed N, Mohsena M, Mahbub R, Sayeed MA. Impact of COVID-19 pandemic on the physical, mental and social health of the suburban and rural adult population in Bangladesh.  IMC J Med Sci. 2024; 18(1):007. DOI: https://doi.org/10.55010/imcjms.18.007 <![CDATA[Impaired polymorphonuclear neutrophil functions in diabetics]]> Tanzinah Nasrin* Nurun Nahar Faizunnesa Sraboni Mazumder https://imcjms.com/journal_full_text/502 2023-12-05 11:11:40 Original Article Med Sci. 2024; 18(1):008 Abstract Background and objectives: Polymorphonuclear neutrophils (PMN) are the first line of host resistance against infections. Diabetics are prone to both bacterial and fungal infections. The present study evaluated the phagocytic and killing activity of PMN in diabetics. Material and methods: Females aged 30 to 50 years with and without diabetes mellitus were enrolled. Functions of PMN were assessed by determining the phagocytic rate, phagocytic index and killing of C. albicans by PMN. Results: A total of 36 diabetic patients and 15 age matched non-diabetic healthy individuals were enrolled. Phagocytosis and killing of C. albicans by PMN were significantly (p<0.05) lower in patients with diabetes mellitus compared to non-diabetic healthy individuals (86.5±14.6 vs. 94.5±4.2; 56.7±23.8 vs. 81.5±24.2). Conclusion: Phagocytic and killing functions of PMN were significantly reduced in patients with diabetes mellitus. IMC J Med Sci. 2024; 18(1):008. DOI: https://doi.org/10.55010/imcjms.18.008 *Correspondence:Tanzinah Nasrin, Microbiologist, Quality Control Laboratory, Department of Fisheries, Ministry of Fisheries and Livestock, Dhaka, Bangladesh. Email: tanzinahn8@gmail.com   Introduction Polymorphonuclear neutrophils (PMN) are the first line of host resistance against bacterial infection. The main mechanisms that allow microbial killing are migration of PMNs to the site of infection, phagocytosis and killing by both oxygen-dependent and oxygen-independent mechanisms. In addition, activated PMNs produce chemokines and cytokines which recruit and activate other immune cells [1]. Finally, activated PMNs undergo apoptosis, resulting in phagocytosis by macrophage [2]. Diabetes mellitus (DM) is a chronic metabolic disorder that is characterized by chronic hyperglycemia and causes long-term complications like retinopathy, neuropathy, nephropathy and increased susceptibility to infections. It is becoming one of the largest emerging threats to public health in the 21st century [3]. Several immune alterations have been described in diabetes especially changes in polymorphonuclear cells, monocytes and lymphocytes [4]. Several studies have shown alterations in neutrophil function, an effect that contributes to the high incidence of infections in diabetic patients [5]. Studies with neutrophils of diabetic patients reveal decreased bactericidal activity, impaired phagocytosis and decreased release of lysosomal enzymes and reduced production of reactive oxygen species [6]. This reduction in leukocyte phagocytosis and bactericidal activity is correlated with increase in blood glucose levels [7]. In poorly controlled diabetic patients abnormalities in granulocyte chemotaxis, phagocytosis and microbicidal activity have been described by several groups [8]. Candida albicans is a part of the normal flora and is in the normal state kept under control by host defense mechanisms [9]. DM predisposes individuals to candidal infection. Several factors have influence on the balance between host and C. albicans, favoring the transition of C. albicans from commensal to pathogen and causing infection [10]. The main reason for this infection could be because of altered functions of the immune system in diabetic patients due to poor glycemic control [11]. Therefore, the present study evaluated the phagocytic functions of PMN in diabetics.   Materials and methods The study protocol was approved by the Institutional Ethical Review Committee of Diabetic Association of Bangladesh. Informed written consent was obtained from all study participants prior to the enrollment in the study. Study population and sample collection: Diabetic females aged 30 to 50 years with body mass index (BMI) 22-27, fasting plasma glucose 8-12mmol/L, on oral hypoglycemic agent (OHA) and free from diabetic complication(s) or systemic illness or pregnancy were enrolled. All diabetic cases were within normal limit of serum creatinine and C-reactive protein. Cases with hyperlipidemia and hypertension were excluded. Age matched healthy non-diabetic females were included as control. About 10 ml of venous blood was collected from each individual with aseptic precautions. Six milliliter of blood was taken in heparinized tube and 4 ml of blood was kept in a glass test tube for autologous serum and biochemical tests. AB serum was prepared from blood of AB positive healthy individual. The serum was separated and stored at -200C until used. Assessment of PMN functions: Functions of PMN were assessed by determining the rate of uptake and killing of C. albicans by PMN as described earlier [12]. Yeast form of C. albicans was prepared by culturing C. albicans on Sabouraud dextrose agar media for 24 hours at 370C. Yeast cells were harvested and a suspension of 1x106/ml and 4x106/ml yeast cells were made in Hanks’ balanced salt solution (HBSS, pH 7.4) for candidacidal and phagocytic assays respectively. Viability of yeast cells was checked by methylene blue dye-exclusion test. PMNs were isolated from heparinized venous blood by Ficoll-Hypaque (MP Biomedicals) density gradient centrifugations. PMN purity was >95%, as determined by Giemsa staining and microscopy, while the cell viability was >98%, as determined by trypan blue exclusion test [13]. The PMNs were washed twice with HBSS and suspended in HBSS to a final concentration of 1x106 cell/ml. For assessing PMN phagocytic function, a suspension of PMN and C. albicans was prepared at a ratio of 1:4 for PMN to C. albicans. Volumes of 100 µl of PMN suspension (1x105/100 µl), 100 µl C. albicans (4x105/100 µl), 100 µl autologous serum and 100 µl HBSS were made up to a final total volume of 400 µl in 1.5 ml microcentrifuge tube. A parallel assay in AB serum and appropriate controls without PMN were set up. The tubes were incubated at 370C for 2 hours with rotation. After 2 hours, the mixture was centrifuged at 3000g for 1 minute. Then 200 µl of supernatant was removed. The remaining mixture was shaken gently and smear was made on glass slide. The slide was fixed in absolute alcohol and stained with Leishman stain. At least 200 PMN cells were counted. The percentage of PMN with phagocytosed C. albicans was calculated by: {(Number of PMN with phagocytosed C. albicans ÷ Total PMN counted) × 100}. The phagocytic index per PMN was estimated by the formula: (Total number of intracellular C. albicans ÷ Total PMN with phagocytosed C. albicans counted). For neutrophil candidacidal assay, 100 µl PMN (1x105/100 µl), 100 µl C. albicans (1x105/100 µl), 100 µl autologous serum and 100 µl HBSS were made up to a final total volume of 400 µl in a 1.5 ml microcentrifuge tube. A parallel assay in AB serum and appropriate controls without PMN were set up. The tubes were incubated at 370C for 2 hours with rotation. Then the mixture was centrifuged at 3000g for 1 minute and 200 µl of supernatant was removed. After mixing thoroughly, 50 µl of the mixture was taken in another microcentrifuge tube where 50 µl of 0.1% ice cold methylene blue solution was added. After 20 minutes, 1 drop of the mixture was taken on a glass slide and covered with a cover slip. The wet film was examined under microscope and 200 yeast cells within PMN were counted. The percent of C. albicansstained blue (i.e. % kill) was scored. Optimization of neutrophil phagocytic assay and candidacidal assay: Uptake and killing of C. albicans by PMN were optimized in diabetics and healthy individuals. Ability of uptake and killing of C. albicans by PMN was observed at different time points namely 5, 30, 60, 90 and 120 minutes. Maximum uptake, phagocytic index and killing of C. albicans by PMN from both diabetic and healthy individuals were observed at 120 minutes.   Results A total of 36 diabetic patients and 15 age matched non-diabetic healthy individuals were enrolled. Biochemical profile of study participants are shown in Table-1. Table-2 shows the comparative rate of phagocytosis and killing of C. albicans by PMN from study population. There was significant difference (p=0.043) in the rate of phagocytosis of C. albicans by PMN between diabetic and non-diabetic healthy controls (86.5±14.6 vs. 94.5±4.2). Significantly (p=0.006) lower phagocytic index of PMN was observed in diabetic cases compared to non-diabetic controls (5.2±2.8 vs. 7.8±2.8). The candidacidal activity of PMN was significantly (p=0.001) higher in non-diabetic healthy controls than that of diabetic cases (81.5±24.2 vs. 56.7±23.8).   Table-1: Biochemical profile of study population     Table-2: Comparison of rate of phagocytosis and killing of C. albicans by PMN from diabetic and non-diabetic healthy individuals     Discussion Diabetes is a major risk factor associated with candidiasis. One simple explanation for this is that PMN functions are altered in diabetic patients [9]. In our study, PMNs from diabetic cases exhibited reduced phagocytosis of C. albicans. A similar finding has been reported for patients with poor glycemic control who showed impaired PMN phagocytosis of virulent K1/K2 Klebsiella pneumoniae compared with patients with good glycemic control and healthy volunteers [14]. Also, PMN from diabetics displayed reduced uptake of Burkholderia pseudomallei compared to that of by PMNs from healthy controls [13]. Also, neutrophil candidacidal assay revealed reduced killing of C. albicans by PMNs from diabetic patients. In the present study, killing of C. albicans was significantly reduced in diabetic than non-diabetic population. Previous studies have documented similar results; for example, PMN from DM subjects with poor glycemic control displayed lower killing rate of B. pseudomallei than PMN from healthy individuals [13]. Again, Mazade et al., found impairment of group B Streptococcus killing by neutrophils in diabetics [15]. For phagocytosis or killing of microbes, neutrophil requires energy. Metabolic changes are involved in the reduction of neutrophil function observed in DM [8]. Intracellular killing activity of PMN involves production H2O2, superoxide anion, molecular oxygen and nitric oxide [16]. The generation of these substances is dependent on activation of the pentose phosphate pathway of glucose utilization. Killing activity of PMN is thus closely connected with carbohydrate metabolism. PMN of diabetic persons may have decreased glucose consumption, disturbances of glycolytic processes, and decreased glycogen synthesis. Insulin improves carbohydrate metabolism in PMNs of diabetics [17]. Our results suggest that PMNs of diabetics are defective in resisting infection due to impaired phagocytic and killing functions.   References 1.     Theilgaard-Monch K, Porse BT, Borregaard N. Systems biology of neutrophil differentiation and immune response. Curr Opin Immunol. 2006; 18: 54-60. doi:10.1016/j.coi.2005.11.010. 2.     Kobayashi SD, Braughton KR, Whitney AR, Voyich JM, Schwan TG, Musser JM, et al. Bacterial pathogens modulate an apoptosis differentiation program in human neutrophils. PNAS. 2003; 100(9): 10948-10953. doi:10.1073/pnas.1833375100. 3.     Karaa A, Goldstein A. The spectrum of clinical presentation, diagnosis, and management of mitochondrial forms of diabetes. Pediatr Diabetes. 2015; 16: 1-9. doi:10.1111/pedi.12223. 4.     Calvet HM, Yoshikawa TT. Infections in diabetes. Infect Dis Clin N Am. 2001; 15(2): 407-421, viii. doi:10.1016/s0891-5520(05)70153-7. 6.     Nielson CP, Hindson DA. Inhibition of polymorphonuclear leukocyte respiratory burst by elevated glucose concentrations in vitro. Diabetes. 1989; 38(8): 1031-1035. doi:10.2337/diab.38.8.1031. 8.     Alba-Loureiro TC, Munhoz CD, Martins JO, Cerchiaro GA, Scavone C, Curi R, et al. Neutrophil function and metabolism in individuals with diabetes mellitus. Braz J Med Biol Res. 2007; 40(8): 1037–1044. doi:10.1590/s0100-879x2006005000143. 10.  Rodrigues CF, Rodrigues ME, Henriques M. Candida sp. infections in patients with diabetes mellitus. J Clin Med. 2019; 8(1): 76. doi:10.3390/jcm8010076. 12.  Wood SM, White AG. A micro method for the estimation of killing and phagocytosis of Candida albicans by human leucocytes. J Immunol Methods. 1978; 20: 43-52. doi:10.1016/0022-1759(78)90243-0. <![CDATA[Preferences and perceptions of MBBS students towards blended learning in medical education]]> Mohd. Yasir Zubair* Absar Ahmad Sameena Ahmad Saira Mehnaz Uzma Eram Ragul Jayaprakasam Satyamoorthy Zeeshan Ahmad https://imcjms.com/journal_full_text/506 2023-12-23 11:34:40 Original Article IMC J Med Sci. 2024; 18(1):009 Abstract Introduction: With the advent of COVID-19 pandemic there has been a rapid shift in the mode of delivering education. A swift transition from place-based offline classes to virtual online learning platforms has emerged during the pandemic. The present study explored the acceptance, perceptions and preferences of blended learning among medical undergraduate students. Methods: MBBS undergraduate students of second and final professional (Part I & II) phases from Jawaharlal Nehru Medical College, AMU, Aligarh, UP were enrolled in the study. We studied acceptance, perception and preferences regarding blended mode of learning of MBBS students using online Google Form. Semi structured questionnaire was drafted by the research team, based on thorough and critical review of pertinent literature and other similar survey tools. Each item was discussed separately and changes were made where required. Then, it was transformed to an online form through Google Forms. Results: Out of a total of 432 students, more than 3/4th of students (78.2%) believed that combined approach would lead to improvement in learning. Around half (53.6%) of the female students were relying predominantly on offline learning compared to 37.0% of male students (p = 0.004). Flexible schedule and personal convenience was reported as the most common benefit of online learning while lack of interaction with peers and connectivity issues were found to be the major disadvantages. Conclusion: Majority of the students echoed a positive attitude towards blended mode of teaching and learning. Medical education is largely demonstration and application based for acquiring skills. Therefore, a combined approach where the theoretical aspect of the curriculum is made online, might offer a more convenient, flexible and effective alternative way of teaching and learning. IMC J Med Sci. 2024; 18(1):009. DOI: https://doi.org/10.55010/imcjms.18.009 *Correspondence: Mohd. Yasir Zubair, Department of Community Medicine, Jawaharlal Nehru Medical College,   AMU, Aligarh, Uttar Pradesh, India. Email: yasmuhsin@gmail.com   Introduction As we recover from the COVID-19 pandemic and its after-effects and plan to restructure the way we approach our day-to-day lives, there has been a rapid shift in the way we do and approach certain things. One such thing that has undergone profound change is the mode of delivering education. The traditional mode of offline education could not be carried out after enforcement of the lockdown. Thus, an increasing trend in E-Learning activities was observed during the pandemic, making a swift transition from place-based offline classes to virtual online learning platforms [1]. This led to innovation as well as familiarity with various platforms of online education. As the pandemic has eased-off, we have slowly returned to the traditional classroom teaching. However, it is intuitive to utilize the advantage of familiarity of online platforms that we have gained during this period and one wonders whether a combined online and offline approach will enhance learning and improve its outcome. In fact, today we are already witnessing the age of blended or hybrid education [2]. Blended learning is defined as any combination of face-to-face teaching with technology-mediated teaching, where all participants in the learning process are separated some of the time by distance [3]. Studies have reported that blended system may increase education levels and stimulate learning for health professionals [4,5]. Even though hybrid mode of learning is not a new concept, it has taken the centre stage in post COVID-19 pandemic period. Blended learning is promising for medical education curriculum because of its advantages over traditional learning at least in certain domains. Like other disciplines, better outcomes in medical education have been obtained through blended approach compared to traditional offline approach [6]. In this study we have explored the acceptance, perceptions and preferences of blended learning among medical undergraduate students. This would help in developing an acceptable and effective blended learning curriculum in medical undergraduate education.   Methods MBBS undergraduate students of second and final professional (Part I & II) from Jawaharlal Nehru Medical College, AMU, Aligarh, UP, were enrolled as respondents for this study. These were the students who had experienced online teaching during the lockdown and have now returned for on-campus classes. Semi structured questionnaire was drafted by the research team, based on thorough and critical review of pertinent literature and other similar survey tools. Each item was discussed separately and changes were made where required. Then, it was transformed to an online form through Google Forms. The initial questionnaire was administered to 40 students on a pilot basis and the questionnaire was accordingly modified and refined based on the feedback from those respondents regarding feasibility and minimizing the ambiguity. Batch wise WhatsApp group of students was created and the final Google Form questionnaire link was shared. The purpose of the study was explained to students and confidentiality was assured, following which they were asked for their voluntary participation. The link was disabled after 10 days of circulating the Google form. Data were collected regarding demographic variables, acceptance, preferences, perception, pros and cons, limitations and suggestions for online teaching. Offline learning was defined as classroom based traditional mode of learning by the students where students and teacher both physically remain present. It also included students’ self-study where they use books and other printed/hand written materials for study. Online learning was defined as use of virtual mode where the teacher and student need not be physically present; teaching was delivered by employing any of virtual networks such as Zoom, Google Classroom, etc. This also included students’ self-study where they use online coaching platforms for their study. The data from Google forms was imported as MS excel (2010) sheet and then transferred to IBM SPSS Version 20.0 for analysis. Frequency and percentage were calculated for most of the responses to summarize the data and presented in the form of tables and graphs. Chi square test was used to find the association of categorical outcomes. Ethical clearance: The study was approved by the Institutional Ethics Committee, Jawaharlal Nehru Medical College and Hospital (JNMCH), Aligarh Muslim University (AMU), Aligarh-IECJNMC/1065.   Results A total of 450 students were shared the questionnaire out of which 432 responses were received. Demographic details of participants: Out of total 432 students, 292 (66.4%) were males and 140 (33.6%) were females. The mean age of respondents was 21.36 ± 1.52 years. Around 3/4th (n=327, 75.7%) of the participants were hostellers and the remaining (n=105, 24.3%) were day scholars. Mode of learning: All the students had previous exposure to online learning platform. More than half of the students (n= 239, 55.3%) were already using combined mode in their routine learning activities, 42.4% (n=183) were practicing predominantly traditional offline learning and only 10 students (2.3%) were predominantly using online approach. Around half (n= 232, 53.6%) of the female students were relying predominantly on offline learning compared to 37.0% (n=160) of male students (p= 0.004) [Table-1].   Table-1: Association between gender and preferred mode of learning     Close to 3/4th of the respondents (n= 338, 78.2%) believed that blended mode of teaching would lead to improvement in medical education (Table-2).   Table-2: Distribution of the respondents regarding the perception of combined mode of teaching in medical education     Students’ preference for combined learning: The devices used by the students for attending online classes were smart phone (n=228, 51.5%), tablet (n=156, 36.1%), laptop (n= 40, 9.1%) and desktop (n= 14, 3.3%). An overwhelming majority (n= 394, 91.2%) of students said that they would prefer WhatsApp for communication regarding class updates (Table-3). Wi-Fi is the preferred source of internet for 60.2%(n= 262) of students and remaining 39.8%(n=172) predominantly use mobile data for attending online classes.   Table-3: Preferred platform for receiving class updates     Framework of blended learning: Live classes that can be recorded was the most preferred (n =248, 57.4%) format for online class. Around 1/5th of the students preferred recorded classes and live online classes (n= 88, 20.4% each) and only 1.8% (n=8) of the students preferred reading material only (Table-4). With regards to content of class, 88.7% (n= 383) of the students preferred video with supplementary reading material, 9.0%(n=39) preferred video content only and 12.3% (n= 53) preferred reading material only.   Table-4: Students’ response regarding their preferred format for online class     With regards to delivery of content in an online class, majority (n=268, 62.0%) of the students favoured both Power Point alongside white board teaching, 19.2% (n=83) students preferred white board teaching only, 17.6% (n=76) preferred only Power Point teaching while only 1.2% (n=5) students desired lecture only (Table-5).   Table-5: Responses with regards to mode of delivery of contents in an online class     Addressing the queries: Preferred methods for clarification of doubts by the students were: separate offline session (n=166, 38.4%), WhatsApp (n=125, 28.9%), separate online live session (n=124, 28.7%), and email (n=13, 3.0%) [Table-6]. A little over one-third of respondents (n=157, 36.3%) said that queries should preferably be clarified before the next class, 25.7% (n=111) said that it should be addressed within a day, 22% (n=95) thought that within 2-3 days is fine, and 16% (n=70) wanted this done within few hours.   Table-6: Preferred modality for clarification of queries     Methods to improve learning: Out of 432 respondents, 356(82.4%) believed that including a quiz session of 5-10 minutes during each class would improve learning while the majority (n= 184, 42.6%) disagreed that assignment at the conclusion of each class would lead to better learning. Most of the respondents (n=287, 66.4%) believed that assignment at the completion of each unit would lead to reinforcement in learning. Benefits and challenges: Flexible scheduling and personal convenience was the most common listed item by 86% (n= 372) of the respondents when asked about benefits of combined learning. More comfortable environment and greater ability to concentrate were other advantages listed by 55.1% (n=238) and 27.8% (n=120) of respondents respectively while 22.7% (n=98) thought that it would lead to improvement in technical skills and 20.4% (n=88) believed that it might also lead to improved self-discipline (Table-7).   Table-7: Benefits of combined learning as perceived by students     With regards to challenges, connectivity issues (due to inadequate/interruption of internet services) and daily data limitation were identified by 74.3% (n=21) and 57.9% (n=250) of students respectively while 53.5% (n=251) admitted that little or no face-to-face interaction is also a significant limitation. Intense requirement of self-discipline (sticking to a fixed time schedule to attend classes in the absence of attendance pressure) and poor learning environment (formal classroom environment that offline mode provides is not available at home and in hostels) were reported by 41.0% (n=177) and 26.4% (n=114) respectively. When asked about the limitation of online theory class, responses varied from lack of interaction with friends and colleagues (n=130, 30.1%), connectivity issues (n=107, 24.8%), to intense requirement of self-discipline (n=60, 14.0%). Other responses included little/no face-to-face interaction (n=50, 11.6%), daily data limit (n=48, 11.1%) and poor learning environment (n=35, 8.2%) [Table-8]. There was no significant difference between hostel students and day scholars in this regard (p= 0.22). The responses of males and females were also similar (p= 0.41).   Table-8: Challenges of combined learning as perceived by students     Discussion Over the last few decades, an increasing number of educational courses in the health sciences, as well as courses across schools, colleges and universities, have introduced online curriculums. Improvements in performance of students have also been reported with blended approach of teaching and learning [7]. With the introduction of lockdown during the COVID-19 pandemic, online education became a necessity thus exposing every student to an online learning experience. In this study, we investigated students’ experiences, opinions and acceptance of online education combined with on-campus offline education. Although online platform is not an official part of the current medical education curriculum, 57.6% of the students in our study were already employing online platforms at personal learning. This point towards the emergence of alternative online learning platforms and the fact that majority of the students are finding it attractive, accessible and beneficial. Smart phones and Tablets were commonest devices used by students for their online learning. These devices are handy, can be carried along easily and can be accessed anywhere. Wi-Fi was the preferred source of internet connection for majority (62.5%) of students and these were the students who reported lesser connectivity issues compared to others who used mobile data. Any official shift to online platform would also need to ensure availability of Wi-Fi facility for students to ensure smoother implementation. With respect to framework, our study revealed that live classes that could be recorded as the most preferred (57.4%) format for online class followed by recorded classes and live online classes (20.4% each) and only 1.8% of the students preferred reading material only. Similar finding were reported by Muthuprasad et al [8] where classes uploaded at the university website/YouTube or any other accessible platform was the most preferred format (54.4%), followed by recordable live classes (27.04%) and live classes alone (17.9%). Only 0.65% wanted reading materials. Recorded lectures allow students to review electronic learning materials at their own pace as often as necessary and this likely enhances their learning outcome. Rawat et al[9] in their study reported that 43.7% of their study participants felt that the online method of teaching was convenient and most of the students in the study agreed that it provide better learning and improve retention of the topics. Al-Balas et al [10] found that 63.8% of their students reported flexibility of time as one of the major advantages of online learning. With regards to content of the class, majority of the students preferred video with supplementary reading material [11,12]. To summarize the students’ responses with regards to framework of the online class, it was found that apt content, smooth connectivity, recorded learning materials along with proper timely follow up makes online classes as good as the traditional classroom situation. Most of the responses from the students in our study reiterated these points. Thus, online mode of delivering education allows institutions and teachers to reach their learners virtually, enhances convenience and opens educational opportunities and these points have been reiterated across many studies in the past [11,13,14]. When asked about methods to improve learning, more than three quarter of students (79.7%) believed that including a quiz of 5-10 minutes during each class would improve learning. Quizzes as effective means to improve online learning is amply supported by data from previous studies [15,16]. Flexible scheduling and personal convenience were the common listed items by 85.1% of respondents when asked about benefits of hybrid learning. Similar findings were reported by others [8]. Studies indicated that unlike the traditional classroom learning, it was convenient for the students to do an online course in collaborative groups without the need for rearranging the schedule for everyone [17]. Also in online setup, resources are often accessed easily from home computers by the students [18]. Therefore, care needs be taken to schedule the online classes as per the learner’s conveniences and it will only help if recorded videos are uploaded at an accessible platform so that the videos may be accessed as per the convenience. However, it has also been reported that students who are not committed to strict discipline often procrastinate which leads to poor performance [19]. With regards to challenges, connectivity issues and little/no face-to-face interactions were identified by 74.7% and 53.9% of students respectively. Gautam in her article also reported similar concerns [20]. While connectivity issues can be addressed over the due course of time in our country, advantages lost due to lack of face-to-face interaction among colleagues will remain a concern. This is another case for blended approach where students will be benefitted from the advantages that both modes offer while also overcoming the disadvantages. Undergraduate medical education may turn to a hybrid/blended mode where the theory classes are conducted online while demonstration based and clinical classes are conducted offline. The findings from our study can be very helpful in designing the content, structure as well as in choosing the appropriate modes for the online classes. We limited our study only to undergraduate students and excluded the teachers and instructors which could have offered more insights. The findings of our study indicated that majority of the students echoed a positive attitude towards online classes. The online platform was found to be advantageous as it provides flexibility and convenience to the learners. Students preferred structured content with recorded videos uploaded timely at accessible platforms. They also indicated the need for interactive sessions with quizzes and assignments at the end of each unit to optimize and enhance their learning process and learning outcome. Thus, all these factors and preferences should be considered while developing an online curriculum to make it more acceptable, effective and productive for the students. Thus, familiarity with online platforms gained during COVID-19 pandemic may be utilized to design a more robust medical education curriculum involving both online and offline modes thus benefitting the students with advantages that each mode offers.   Acknowledgement We wholeheartedly thank all the participants for spending their valuable time on responding to our questionnaire.   Conflict of Interest: None   Funding: None   References 1.     Murphy MPA. COVID-19 and emergency eLearning: Consequences of the securitization of higher education for post-pandemic pedagogy. Contemp Secur Policy. 2020; 41(3): 492–505. doi: https://doi.org/10.1080/13523260.2020.1761749. 2.     ET Contributors. The age of hybrid education. 2022 Aug; Available from: Hybrid Education: The age of hybrid education - The Economic Times (indiatimes.com). [Accessed on: 10th October, 2023] 3.     Siemens G, Gasevic G, Dawson S. Preparing for the digital university: a review of the history and current state of distance, blended, and online learning. 2015; Bill and Melinda Gates Foundation.https://research.monash.edu/files/256525723/256524746_oa.pdf. 4.     Westerlaken M, Christiaans-Dingelhoff I, Filius RM, De Vries B, De Bruijne M, Van Dam M. Blended learning for postgraduates; An interactive experience. BMC Med Educ. 2019; 19(1): 289. doi: 10.1186/s12909-019-1717-5. 5.     Varthis S, Anderson OR. Students’ perceptions of a blended learning experience in dental education. Eur J Dent Educ. 2018; 22(1): e35–41. doi: 10.1111/eje.12253. 6.     Vallée A, Blacher J, Cariou A, Sorbets E. Blended learning compared to traditional learning in medical education: systematic review and meta-analysis. J Med Internet Res. 2020; 22(8): e16504. doi: 10.2196/16504. 7.     Kiviniemi MT. Effects of a blended learning approach on student outcomes in a graduate-level public health course. BMC Med Educ. 2014. 14(47). doi: https://doi.org/10.1186/1472-6920-14-47. 8.     Muthuprasad T, Aiswarya S, Aditya KS, Jha GK. Students’ perception and preference for online education in India during COVID -19 pandemic. Soc Sci Humanit Open. 2021; 3(1): 100101. doi: 10.1016/j.ssaho.2020.100101. 9.     Rawat R, Singh P. A comparative study between traditional and online teaching-learning: medical students’ perspective in the wake of corona pandemic. Natl J Community Med. 2020; 11(09): 341–5. doi: https://doi.org/10.5455/njcm.20200902070715. 10.  Al-Balas M, Al-Balas HI, Jaber HM, Obeidat K, Al-Balas H, Aborajooh EA, et al. Distance learning in clinical medical education amid COVID-19 pandemic in Jordan: current situation, challenges, and perspectives. BMC Med Educ. 2020; 20(1): 341. doi: 10.1186/s12909-020-02428-3. 11.  Hofmann DW. Internet-based distance learning in higher education. Tech Directions. 2002; 62(1): 28–32. doi: https://www.learntechlib.org/p/95322/. 12.  Rourke JR. Online learning: fad or fate? Principal Leadership. 2001; 1(9): 8-14. 13.  Bourne JR, McMaster E, Rieger J, Campbell O.Paradigms for on-line learning: a case study in the design and implementation of an asynchronous learning networks (ALN) course. Online Learn J. 1997; b(2). doi: https://doi.org/10.24059/olj.v1i2.1932. 14.  Hill JR. Overcoming obstacles and creating connections: community building in web-based learning environments. J Comput High Educ. 2002; 14: 67-86. doi: https://doi.org/10.1007/BF02940951. 15.  Spanjers IAE, Könings KD, Leppink J, Verstegen DML, de Jong N, Czabanowska K, et al. The promised land of blended learning: quizzes as a moderator. Educ Res Rev. 2015; 15: 59–74. doi: http://dx.doi.org/10.1016/j.edurev.2015.05.001. 16.  Cohen D, Sasson I. Online quizzes in a virtual learning environment as a tool for formative assessment. J Technol Sci Educ. 2016; 6(3): 188–208. doi: http://dx.doi.org/10.3926/jotse.217. 17.  Petrides LA. Web-based technologies for distributed (or distance) learning: creating learning-centered educational experiences in the higher education classroom. Int J Instr Media. 2002; 29(1): 69-77. doi: https://www.learntechlib.org/p/64241/. 18.  Poole DM. Student participation in a discussion-oriented online course. Journal of Research on Computing in Education (JRCE). 2000; 33(2): 162–77. doi: https://doi.org/10.1080/08886504.2000.10782307. 19.  Ucar H, Bozkurt A, Zawacki-Richter O. Academic procrastination and performance in distance education: a causal-comparative study in an online learning environment. Turk Online J Distance Educ. 2021; 22(4/2): 13-23. 20.  Gautam P. Advantages and disadvantages of online learning. 2020. Available from: https://elearningindustry.com/advantages-and-disadvantages-online-learning. [Accessed on 10thOctober, 2023]     Cite this article as: Zubair MY, Ahmad A, Ahmad S, Mehnaz S, Eram U, Satyamoorthy RJ, Ahmad Z. Preferences and perceptions of MBBS students towards blended learning in medical education. IMC J Med Sci. 2024; 18(1):009. DOI: https://doi.org/10.55010/imcjms.18.009 <![CDATA[Species distribution and antimicrobial susceptibility pattern of coagulase-negative staphylococci isolated from clinical specimens at a tertiary care hospital]]> Sabiha S Tamboli Saleem B Tamboli https://imcjms.com/journal_full_text/507 2023-12-31 12:46:13 Original Article IMC J Med Sci. 2024; 18(1):010 Abstract Background and objectives: Coagulase-negative staphylococci (CoNS) are considered important causative agents of hospital acquired infection. These organisms are found in various clinical specimens from hospitalized patients. Present study was carried out to determine the species distribution and antimicrobial susceptibility pattern of CoNS isolated from clinical specimens at a tertiary care hospital. Materials and methods: CoNS isolated from various clinical samples were included in this study. The isolates were identified by colony morphology, Gram’s staining, catalase and coagulase tests. Further differentiation of species was performed by susceptibility to novobiocin, urease activity and ornithine decarboxylase test. Antibiotic susceptibility testing was performed according to the Clinical and Laboratory Standard Institute (CLSI) guidelines. Results: Total 108 isolates of CoNS were included and analysed. Out of 108 CoNS, S. epidermidis was the most common species (36.1%) followed by S. saprophyticus (23.1%), S. hemolyticus  (17.6%), S. hominis (13%) and S. lugdunensis (10.2%). Most of the isolates showed resistance to penicillin, oxacillin, amoxycillin, erythromycin, ciprofloxacin and ofloxacin. All the isolates were sensitive to vancomycin. Conclusions: CoNS emerged as an important nosocomial pathogen and should not be neglected as contaminant. High rate of antimicrobial resistance warrants susceptibility testing prior to the treatment of CoNS. IMC J Med Sci. 2024; 18(1):010. DOI: https://doi.org/10.55010/imcjms.18.010 *Correspondence: Sabiha S Tamboli, Department of Microbiology, Parbhani Medical College and RP Hospital Research Institute, Pathri Road, Parbhani, Maharashtra, India. Email: sabihatamboli77@gmail.com   Introduction Coagulase-negative staphylococci (CoNS) are part of normal flora of skin [1]. Previously, they were considered non-pathogenic with low virulence. But since 1950, cases of CoNS associated infections have been reported with increased frequencies. The predisposing factors for CoNS infections are patients with catheter, prosthetic implants, dialysis, oncological diseases, compromised immunity and neonatal state [2]. CoNS survive on synthetic medical devices and equipment such as intravenous catheters, prosthetic heart valves and various implants [3]. Currently more than fifty different CoNS species have been described. Out of this, S. epidermidis, S. saprophyticus, S. hemolyticus, S. hominis and S. lugdunensis have higher clinical significance [4]. The main challenge in the diagnosis is to correctly identify the cases in which CoNS are causative agents for infection rather than contaminants. This leads to under treatment (i.e., delayed or withheld antibiotics) and thereby contributing to increased morbidity and mortality [5]. Due to increasing clinical significance of CoNS infection, accurate species identification and determination of antibiotic resistance are of paramount importance to treat CoNS infections. The aim of the study was to investigate species distribution and antimicrobial resistance pattern of CoNS isolated from clinical specimens at a tertiary care centre.   Material and method The study was conducted at the Department of Microbiology in a tertiary care teaching hospital of Marathwada region of Maharashtra state, India. Study was done over a period of one year from January 2015 to December 2015. The study was approved by the institutional ethical committee. CoNS isolated from different clinical samples such as pus, urine, blood, sputum, vaginal swab, wound swab, suction tip, pleural fluid and nasal swab were included. Same strain of CoNS isolated twice in pure culture from an infected site or body fluid was considered clinically significant. Samples were cultured on nutrient and blood agar plates for bacterial isolation. Plates were incubated aerobically overnight at 37°C for 48 hours [6]. Isolates were identified by colony morphology, Gram’s stain, catalase and coagulase tests. Bacitracin susceptibility was performed to exclude micrococci and Stomatococcus species [7]. The speciation of CoNS was done by ornithine decarboxylase, urease, mannose fermentation and novobiocin (5 µg) sensitivity tests [8,9]. The antimicrobial susceptibility of all the isolates was performed by Kirby-Bauer disc diffusion method using Muller-Hinton agar plates as per the recommendation of Clinical Laboratory Standard Institute guidelines [10]. S. aureus ATCC 25923 was used as a standard control strain for antimicrobial susceptibility testing. Antimicrobial discs used were penicillin (10 µg), amoxicillin-clavulanic acid (20/10 µg), oxacillin (1 µg), erythromycin (15 µg), linezolid (30 µg), gentamicin (10 µg), and vancomycin (30 µg). The various antibiotic discs used were purchased from HiMedia Laboratories Private Limited, India.    Results A total of 108 CoNS isolates were included in the study. Out of 108 isolates, 65 (60.2%) and 43 (39.8%) were from male and female patients respectively. Maximum numbers of isolates (44.4%) were from age group 21-40 years followed by 18.5% from age group 41-60 years [Table-1].   Table-1: Age and sex distribution (n=108)     Majority of CoNS were from pus sample (44.4%) followed by urine (23.1%), blood (9.3%), suction tip (6.5%), sputum (4.6%), vaginal swab (3.7%) and, 2.8% each from wound swab, nasal swab and pleural fluid [Table-2]. The commonest CoNS species isolated was S. epidermidis 39 (36.1%) followed by S. saprophyticus 25 (23.1%), S. hemolyticus 19 (17.6%), S. hominis 14 (13%) and S. lugdunensis 11 (10.2%) [Table-2]. Antimicrobial sensitivity test of the isolates showed maximum resistance to oxacillin (88%), ciprofloxacin (80%), penicillin (78.7%), amoxicillin-clavulanic acid (75%), erythromycin (60.2%) and  ofloxacin (60.2%). None of the CoNS species showed resistance to vancomycin while only 9.3% were resistant to linezolid [Table-3].   Table-2: Distribution of CoNS and their species in different clinical samples (n=108)     Table-3: Species wise antibiotic resistance pattern of isolated CoNS     Discussion CoNS formerly considered as contaminant bacteria have now emerged as a major cause of nosocomial infections. CoNS are the common agents of nosocomial bloodstream infections as well as other type of infections. Factors helpful in identification of true infections by CoNS include repeated isolation of same strain of CoNS in pure culture from infected site or specimen over the course of an infection plus presence of clinical evidence of infection [11,12]. Recent studies have shown that CoNS are one of the important causative agents of human infection, especially in immunocompromised patients, premature newborns and patients with indwelling medical devices [13]. In our study, majority of CoNS were isolated from male patients (60.2%). Similar findings are also reported by Usha et al and Asangi et al [14,15]. On the other hand, Goudarzi M et al found maximum number of CoNS from female patients [16]. In this study, out of 108 isolates, most of the isolates were from pus (44.4%) and urine (23.2%). The results differ from studies by Bhatt P et al and Parashar [17,18]. In their studies maximum numbers of CoNS were isolated from blood samples. This difference could be due to types of patients and hospital settings. In the laboratory, staphylococci other than S. aureus are reported as CoNS without speciation. As various species of CoNS are associated with different diseases, CoNS should be identified to the species level by simple, reliable and inexpensive method [19]. In the present study we have identified CoNS species by slide and tube coagulase, ornithine decarboxylase, urease, mannose fermentation and novobiocin sensitivity tests. These tests are inexpensive and affordable and can be practiced in most of the diagnostic laboratories. In the present study, S. epidermidis constituted the predominant species (36.1%) followed by S. saprophyticus, S. hemolyticus , S. hominis and S. lugdunensis. This is in concurrence with other reported studies from India and adjoining region [20-22]. Those studies have reported S. epidermidis as the most common species (41% - 46.84%) among the isolated CoNS. The second most common species in our study was S. saprophyticus which is similar to other studies who also found S. saprophyticus as second most common species [7,23]. In the present study, majority of the isolates showed resistance to oxacillin, ciprofloxacin, amoxicillin-clavulanic acid, penicillin, erythromycin and ofloxacin. So, these antibiotics could not be recommended for empiric treatment of CoNS. All the isolates in our study were sensitive to vancomycin and only 9.3% were resistant to linezolid. Similar results were also observed by others [24-26]. Vancomycin and linezolid are the most effective drugs in treating infections caused by CoNS species. Prolonged hospital stays, widespread antibiotic use and the ability of CoNS to form multi-layered bio-films on artificial surfaces are the potential causes of high resistance rate to multiple antimicrobial agents especially for the species that are isolated from catheter tips and blood cultures. This high resistance to multiple antimicrobial agents poses a significant challenge in the clinical management of infections caused by CoNS. Therefore, continued surveillance, prudent use of antibiotics and emphasis on infection prevention measures in hospitals are imperative in curbing the rise of antibiotic resistant CoNS strains. In addition to increased vigilance, advanced diagnostic approaches and an understanding of the antibiogram profiles are essential for effective clinical management and the prevention of CoNS associated infections in healthcare settings.   Conflict of interest: The author declares no conflict of interest.   Funding: None   References 1.     Hall KK, Lyman JA. Updated review of blood culture contamination.ClinMicrobiol Rev. 2006; 19(4): 788–802. doi:10.1128/CMR.00062-05. 2.     Michalik M, Samet A, Podbielska-Kubera A, Savini V, Międzobrodzki J, Kosecka-Strojek M. Coagulase negative Staphylococci (CoNS) as a significant etiological factor of laryngological infections: a review. Ann Clin Microbiol Antimicrob. 2020; 19(26). doi: 10.1186/s12941-020-00367-x. 3.     Sharma V, Jindal N, Devi P. Prevalence of methicillin resistant coagulase negative staphylococci in a tertiary care hospital. Iran J Microbiol.2010; 2(4): 185-188. 4.     Becker K, Both A, Weißelberg S, Heilmann C, Rohde H. Emergence of coagulase-negative staphylococci. Expert Rev Anti Infect Ther. 2020; 18(4): 349–366. doi: 10.1080/14787210.2020.1730813. 5.     Taylor SP, Anderson WE, Beam K, Taylor B, Ellerman J, Kowalkowski MA. The association between antibiotic delay intervals and hospital mortality among patients treated in the emergency department for suspected sepsis. Crit Care Med. 2021; 49(5): 741-747. doi: 10.1186/s13054-021-03736-w. 6.     Winn WS, Allen SD, Janda WM, Koneman EW, Procop GW, Schreckenberger PC, et al. Charts. In: Darcy P, Peterson N, Montalbano J, Editors. Koneman’s Color Atlas and Textbook of Diagnostic Microbiology. 6th Eds. Philadelphia: Lippincott; 1997; 1442-1535. doi: 10.1097/01.prs.0000358868.74684.60. 7.     Singh S, Banerjee G, Agarwal SK, Kumar M, Singh RK. Simple method for speciation of clinically significant coagulase negative staphylococci and its antibiotic sensitivity/ resistant pattern in NICU of tertiary care centre. Biomed Res. 2008; 19(2): 97-101. 8.     De Paulis AN, Predari SC, Chazarreta CD, Santoianni JE. Five test simple scheme for the species level identification of clinically significant coagulase negative staphylococci. J Clin Microbiol. 2003; 41(3): 1219-24. doi: 10.1128/JCM.41.3.1219-1224.2003. 9.     Baird D. Staphylococcus: cluster forming Gram-positive cocci. In: Colle JG, Fraser AG, Marimom BP, Simmons A, editors. Mackie and McCartney Practical Medical Microbiology. 14th eds. New York: Churchill Living Stone; 1996; 245-261. 10.  Performance Standards for Antimicrobial Susceptibility Testing; Twenty-Fourth Informational Supplement. CLSI M100-S24. Wayne, PA: Clinical and Laboratory Standards Institute; 2014. 11.  Kloos WE, Bannerman TL. Update on clinical significance of coagulase-negative staphylococci. Clin Microbiol Rev. 1994; 7(1): 117–140. doi: 10.1128/CMR.7.1.117. 12.  Beekmann SE, Diekema DJ, Doern GV. Determining the clinical significance of coagulase-negative staphylococci isolated from blood cultures. Infect Control Hosp Epidemiol. 2005; 26(6): 559–566. doi: 10.1086/502584. 13.  Nzeako BC, Al Rusheidi S, Neilson F, Al-Balkhair A. Types of bacteria on some medical devices used in Sultan Qaboos University hospital wards. Middle-East J SciRes. 2010; 5(6): 449– 53. 14.  Usha MG, Shwetha DC, Vishwanath G. Speciation of coagulase negative Staphylococcal isolates from clinically significant specimens and their antibiogram. Indian J Pathol Microbiol. 2013; 56(3): 258-260. doi:10.4103/0377-4929.120383. 15.  Asangi SY, Mariraj J, Sathyanarayan MS, Nagabhushan R. Speciation of clinically significant coagulase negative staphylococci and their antibiotic resistant pattern in a tertiary care hospital. Int J Biol Med Res. 2011; 2(3): 735-9. 16.  Goudarzi M, Seyedjavadi SS, Goudarzi H, Boromandi S, Ghazi M, Azad M, et al. Characterization of coagulase-negative staphylococci isolated from hospitalized patients in Tehran, Iran. J Paramedical Sci. 2014; 5(2): 44–50. https://doi.org/10.22037/jps.v5i2.5841. 17.  Bhatt P, Tandel K, Singh A, Mugunthan M, Grover N, Sahni AK. Species distribution and antimicrobial resistance pattern of coagulase-negative staphylococci at a tertiary care centre. Med J Armed Forces India. 2016; 72(1): 71-74. doi: 10.1016/j.mjafi.2014.12.007. 18.  Parashar S. Significan ce of coagulase negative staphylococci with special reference to species differentiation and antibiogram. Ind Med Gaz. 2014; CXLVII(7): 255-258. 19.  Ieven M, Verhoeven J, Pattyn SR, Goossens H. Rapid and economical method for species identification of clinically significant coagulase-negative staphylococci. J Clin Microbiol.1995; 33(5): 1060-3. doi: 10.1128/jcm.33.5.1060-1063.1995. 20.  Kavitha Y, Shaik KM. Speciation and antibiogram of clinically significant coagulase negative staphylococci. Int J Health Sci Res. 2014; 4(12): 157-161. 21.  Goyal R, Singh NP, Kumar A, Kaur I, Singh M, Sunita N, et al. Simple and economical method for speciation and resistotyping of clinically significant coagulase negative staphylococci. Indian J Med Microbiol. 2006; 24(3): 201-4. https://doi.org/10.1016/S0255-0857(21)02350-1. 22.  Sheikh AF, Mehdinejad M. Identification and determination of coagulase-negative staphylococci species and antimicrobial susceptibility pattern of isolates from clinical specimens. Afr J Microbiol Res. 2012; 6(8): 1669–1674. doi: 10.5897/AJMR11.076. 23.  Singh S, Banerjee G, Agarwal SK, Rajput A, Tripathi P, Kumar M, et al. Prevalence of MecA gene positive coagulase negative staphylococci in NICU of a tertiary care hospital. Biomed Res. 2009; 20(2): 94-8. 24.  Al Tayyar IA, Al-Zoubi MS, Hussein E, Khudairat S, Sarosiekf K. Prevalence and antimicrobial susceptibility pattern of coagulase negative staphylococci (CoNS) isolated from clinical specimens in Northern of Jordan. Iran J Microbiol. 2015; 7(6): 294–301. 25.  Asaad AM, Qureshi MA, Hasan SM. Clinical significance of coagulase-negative staphylococci isolates from nosocomial bloodstream infections. Infect Dis (Lond). 2016; 48(5): 356–360. doi: 10.3109/23744235.2015.1122833. 26.  Pedroso SHSP, Sandes SHC, Filho RAT, Nunes AC, Serufo JC, Farias LM, et al. Coagulase-negative staphylococci isolated from human bloodstream infections showed multidrug resistance profile. Microb Drug Resist. 2018; 24(5): 635–47. doi: 10.1089/mdr.2017.0309.       Cite this article as: Tamboli SS, Tamboli SB, Species distribution and antimicrobial susceptibility pattern of coagulase-negative staphylococci isolated from clinical specimens at a tertiary care hospital. IMC J Med Sci. 2024; 18(1):010. DOI: https://doi.org/10.55010/imcjms.18.010 <![CDATA[Modified MacConkey agar: a simple selective medium for isolation of Burkholderia pseudomallei from soil]]> Salvinaz Islam Moutusy Saika Farook Sraboni Mazumder Lovely Barai K.M. Shahidul Islam Md. Shariful Alam Jilani* https://imcjms.com/journal_full_text/508 2024-01-15 10:04:56 Original Article IMC J Med Sci. 2024; 18(1):011 Background and objectives:A selective medium is required for isolation of Burkholderia pseudomallei from soil. The present study aimed to develop an easy to prepare selective media by modifying MacConkey agar medium for improved isolation of B. pseudomallei from soil. Results: Culture of supernatant from spiked sterile soil after enrichment showed equivalent isolation of B. pseudomallei on MMB and Ashdown’s media and there was 100% inhibition of Klebsiella pneumoniae, Escherichia coli and Pseudomonas aeruginosa on MMB medium. Almost similar inhibition of Comamonas testosteroni, Aeromonas salmonicida and Burkholderia cepacia was observed on both MMB and Ashdown’s media. Culture of sterile soil seeded with different concentrations of P. aeruginosa showed no growth in MMB media. But there was growth of P. aeruginosa when sterile soil samples spiked with 1x106 to 1x103 CFU of P. aeruginosa were cultured in Ashdown media. When unsterile soil was seeded with graded concentration of B. pseudomallei, the colony count of this bacterium gradually declined in all three medium with decreased spiking concentrations. Growth of other soil organisms was less in MMB media compared to other two media. IMC J Med Sci. 2024; 18(1):011. DOI: https://doi.org/10.55010/imcjms.18.011 *Correspondence:Md. Shariful Alam Jilani, Department of Microbiology, Ibrahim Medical College, 1/A Ibrahim Sarani, Segun Bagicha, Dhaka-1000, Bangladesh. Email: jilanimsa@gmail.com   Introduction Melioidosis, caused by a facultative β-proteobacterium, Burkholderia pseudomallei, is endemic in over 46 countries including Bangladesh [1-4]. B. pseudomallei is a saprophytic environmental organism found mainly in plant rhizosphere and distributed in many different environmental niches especially paddy field, stagnant surface water, water holes and sea water [5]. Detection of B. pseudomallei in clinical and environmental samples is fundamental to determine the source and geographical distribution of this organism [6]. The present standard for detection of B. pseudomallei in soil is culture. However, isolation of B. pseudomallei is difficult from soil samples due to the abundant presence of other non-fermentative Gram-negative species that morphologically resemble B. pseudomallei. Although B. pseudomallei grows in many ordinary media including nutrient agar, blood agar or MacConkey agar, a selective media is required for its isolation from heavily contaminated unsterile environmental samples. Currently Ashdown selective agar is the favored media for isolation and identification of B. pseudomallei in areas where melioidosis is endemic [7]. Ashdown media performs well as a selective agar, but this media is not readily available in laboratories of many melioidosis endemic areas like Bangladesh. Apart from Ashdown media, B. pseudomallei selective agar (BPSA) medium, B. cepacia media were reported to yield improved recovery of B. pseudomallei; however, these media are not also commercially available. A clinical comparison of BPSA, Ashdown and B. cepacia media demonstrated equivalent sensitivity but lower selectivity of BPSA than the other two media [8,9]. Development of a selective, readily available and inexpensive culture media is very much essential for specific isolation of B. pseudomallei from various unsterile clinical and environmental samples. Therefore, the present study was undertaken to develop a cheap and easy to prepare selective medium by modifying the easily available MacConkey agar medium for isolation of B. pseudomallei from spiked soil.   Materials and methods MacConkey agar media was modified and compared with Ashdown agar medium for better isolation of the B. pseudomallei from spiked soil samples. The study was approved by the Institutional Review Board of Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) General Hospital, Dhaka, Bangladesh. Bacterial strains used in the study: B. pseudomallei reference strain from Universiti Sains Malaysia (USM) and a total of ten local strains of B. pseudomallei from clinical specimens confirmed by colony characteristics, biochemical tests, monoclonal antibody based latex agglutination test (Melioidosis Research Center, Khon Kaen, Thailand) and polymerase chain reaction, were selected for the study [10,11]. One strain of B. pseudomallei from above mentioned local strains from clinical specimen was randomly selected for further laboratory work of this study. As control, the following strains were used in this experiment: Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa isolated from clinical specimens and Comamonas testosteroni, Aeromonas salmonicida and Burkholderia cepacia isolated from environmental samples. Preparation of modified MacConkey agar medium: Modified MacConkey agar medium was prepared by adding glycerol and four antimicrobial agents to MacConkey agar medium and termed as ‘Modified MacConkey agar for Burkholderia (MMB media)’. Four percent (4%) glycerol (40 mL/L) was added as previously described by Ashdown et al [7]. Four antimicrobial agents, namely vancomycin (2.5 mg/L), amphotericin B (1 mg/L), gentamicin (5 mg/L) and colistin (50 mg/L) were added into 51.5 gm/L of MacConkey agar medium. Vancomycin and amphotericin B were added to inhibit the growth of Gram positive bacterial and fungal species. The concentrations of gentamicin and colistin added were determined in accordance with minimum inhibitory concentrations (MIC) of selected B. pseudomallei strains. Following determination of MIC of the two antimicrobial drugs, two different concentrations of gentamicin and colistin were added to detect the optimum growth of B. pseudomallei in the MMB medium. The MIC of gentamicin and colistin for all the test strains of B. pseudomallei were > 1024 µg/mL. Consequently, the two concentrations selected for colistin and gentamicin were well below the MIC, anticipating that when added together, they might have a synergistic inhibitory effect on the growth of B. pseudomallei [12]. Optimization of antimicrobial concentrations: MMB media was prepared with two different concentrations of gentamicin and colistin to determine the maximum growth of B. pseudomallei and maximum inhibition of other organisms. In one set of MMB media, gentamicin and colistin were added at a concentration of 5 mg/L and 50 mg/L respectively and in another set, 10 mg/L and 500 mg/L respectively. MMB media with the different concentrations of gentamicin and colistin were separately inoculated with 10 µl of 1 × 104 colony forming unit (CFU)/ mL (100 CFU) of B. pseudomallei, Escherichia coli ATCC 25922, Pseudomonas aeruginosa ATCC 23853 and Staphylococcus aureus ATCC 25923. For each of the bacterial species, ten MMB plates were inoculated. The media were incubated at 370C aerobically for 72 hours. The number of colonies of each organism in MMB media with specific gentamicin and colistin concentrations was counted and expressed as the mean CFU. Determination of inhibitory effect of antimicrobial agents in MMB media: To determine the inhibitory effect of multiple antimicrobials incorporated in MMB medium on B. pseudomallei, 10 µl of 1 × 104 colony forming unit (CFU)/ mL (100 CFU) of B. pseudomallei was inoculated in each of ten blood agar media, MacConkey agar, MMB and Ashdown agar media. All media were incubated at 370C aerobically for 72 hours. After 72 hours, the colonies of B. pseudomallei were counted on each set of three different media and the mean colony count recorded. The percentage of inhibition of bacterial growth was calculated by: [{(Total CFU in blood agar media – Total CFU in MMB media) ÷ Total CFU in blood agar media} x 100]. Evaluation of the MMB media using spiked soil samples: After initial trial, MMB medium having best combinations and concentrations of antimicrobials was selected to evaluate the culture of B. pseudomallei from spiked soil samples. The modified Ashdown broth as described previously, was used for the enrichment of all soil samples [9,13]. Soil samples were collected in two sterile plastic bags, sealed with rubber bands and transported to the laboratory. One set of soil samples was kept unsterile at room temperature and another set was sterilized by autoclaving at 1210C for 15 minutes. Sterility of the soil was checked following enrichment in trypticase soy broth (TSB) for 48 hours and inoculating the soil samples in blood agar media. No growth was observed in the sterile soil samples. Suspension of 1.5 × 108 CFU/mL of B. pseudomallei was prepared with sterile normal saline and serial 10-fold dilutions were made starting from 1 × 106 to 1 × 101 CFU/mL in 6 test tubes. One set of 6 tubes containing 3 gm of sterile soil and another set of 6 tubes containing 3 gm of unsterile soil were prepared. Six tubes of each set of soil were then spiked with B. pseudomallei with 1 × 106 CFU/gm to 1 × 101 CFU/gm of soil. Nine milliliter (9 mL) of modified Ashdown enrichment broth was added to each test tube containing 3 gm of soil. The tubes were vortexed for 30 seconds and incubated at 370C for 48 hours. After 48 hours, 20 µl of undisturbed supernatant from each dilution was inoculated in MMB, Ashdown and MacConkey agar media and incubated at 370C for 72 hours. As control, Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa isolated from clinical specimens and Comamonas testosteroni, Aeromonas salmonicida and Burkholderia cepacia isolated from environmental samples were used. The organisms were diluted and spiked in tubes containing sterile soil in the same concentrations as that of B. pseudomallei as described previously. TSB (9 ml) was added to each test tube for enrichment and incubated at 370C for 48 hours. After 48 hours, 20 µl of undisturbed supernatant from each dilution was inoculated in MMB media, Ashdown agar and MacConkey agar media and incubated at 370C for 72 hours.   Results Optimization of antimicrobial concentrations: Optimized concentrations of gentamicin and colistin were determined to detect their ability to inhibit growth of both Gram positive and Gram negative bacteria as well as to support maximum growth of B. pseudomallei. Table-1 shows the effect of different concentrations of gentamicin and colistin on the growth of B. pseudomallei in our MMB medium. Growth of B. pseudomallei colonies was significantly (p<0.05) less in MMB media containing higher concentrations of gentamicin and colistin (Mean CFU/plate: 56.7 ± 0.6) compared to MMB media containing lower concentrations of gentamicin and colistin (Mean CFU/plate: 76.6 ± 1.2). Mean percentage inhibition of B. pseudomallei colonies was significantly (p<0.05) more in MMB containing higher concentration of gentamicin and colistin compared to media containing lower concentrations of gentamicin and colistin (43.3 ± 0.6 vs. 24.7 ± 1.20).   Table-1: Effect of different concentrations of gentamicin and colistin on the growth of B. pseudomallei in MMB media     No growth of E. coli ATCC 25922, P. aeruginosa ATCC 23853 and S. aureus ATCC 25923 was observed in MMB media containing either concentrations of gentamicin and colistin. Therefore, gentamicin 5 mg/L and colistin 50 mg/L plus vancomycin 2.5 mg/L and amphotericin B 1 mg/L concentration were selected for preparation of MMB media for subsequent use in this study.  Growth of B. pseudomallei in MMB medium: Table-2 shows the growth of B. pseudomallei in MacConkey, Ashdown and MMB media compared to blood agar media inoculated with   (100 CFU/plate). The mean numbers of colony of B. pseudomallei in each of ten MacConkey (78.7 ± 1.5 CFU), Ashdown (77 ± 1 CFU) and MMB agar plates (76.7 ± 1.5 CFU) were significantly less (p< 0.05) than that in blood agar media (92.3 ± 2.5 CFU). However, there was no significant (p>0.05) difference of mean number of B. pseudomallei colonies in the MMB, MacConkey agar and Ashdown media. The colony morphology of B. pseudomallei after 48 hours of incubation at 420C aerobically was pink and centrally depressed in all three media in while colonies were dry and wrinkle in Ashdown media (Figure-1).   Table-2: Comparison of growth of B. pseudomallei in blood, MacConkey agar, Ashdown and MMB media (100 CFU/plate)         Figure-1: Colony characteristics of B. pseudomallei after 48 hours of incubation at 420C aerobically on (a) MacConkey agar media, (b) MMB media and (c) Ashdown media.   Evaluation of MMB media by culturing spiked sterile soil samples: Table-3 shows the results of culture of sterile soil spiked with graded concentration of B. pseudomallei and six other Gram negative bacilli in MMB media.   Table-3: Comparison of growth of B. pseudomallei and other Gram negative bacteria from spiked sterile soil in MMB, MacConkey and Ashdown media     The growth of B. pseudomallei in MacConkey, Ashdown and MMB media was numerous from sterile soil spiked with B. pseudomallei with 1 × 106 CFU/gm of sterile soil. B. pseudomallei colony count was possible in Ashdown and MMB media when per gram of sterile soil was spiked with 1 × 105 to 1 × 102 CFU B. pseudomallei. None of the seven test bacteria grew in any of the 3 media when soil samples were spiked with 1 × 101 CFU of bacteria. There was 100% inhibition of K. pneumoniae and E. coli in both MMB and Ashdown media from culture of sterile soil seeded with all graded concentrations as compared to MacConkey agar media. Also, P. aeruginosa did not grow in MMB media at all bacterial concentration whereas in Ashdown media, growth of P. aeruginosa was observed at bacterial concentration from 1 × 106 to 1 × 103 CFU/gm of spiked soil. All other six types of bacteria grew in MacConkey agar media from culture of sterile soil seeded with all concentrations, except at spiking concentration of 1 × 102 and 1 × 101 CFU/gm of sterile soil. Growth of C. testosteroni, A. salmonicida and B. cepacia was found in all three media at bacterial concentration from 1 × 106 to 1 × 103 CFU/gm of sterile soil. Evaluation of MMB media by culturing spiked unsterile soil samples: Table-4 shows the growth of bacteria from culture of unsterile soil samples seeded with graded concentration of B. pseudomallei. The growth of bacteria in MacConkey agar media, Ashdown agar and MMB media was numerous, uncountable and could not be differentiated into specific types of bacteria from unsterile soil seeded with B. pseudomallei with 1 × 106 CFU/gm of unsterile soil.   Table-4: Comparison of growth of B. pseudomallei from unsterile soil seeded with graded concentration of B. pseudomallei     Colony count of B. pseudomallei and other types of bacteria was possible in Ashdown and MMB media from unsterile soil samples seeded with 1 × 105 – 1 × 102 CFU of B. pseudomallei/gm soil. The colony counts of other types of bacteria was 26 – 30 CFU/plate in MMB media compared to 40 CFU/plate and 66 – 70 CFU/plate in Ashdown and MacConkey agar media respectively. The colony count of B. pseudomallei gradually declined in all three media with decrease of spiking concentrations of B. pseudomallei in unsterile soil. B. pseudomallei did not grow from unsterile soil seeded with B. pseudomallei with 1 × 101 CFU/gm of unsterile soil.   Discussion Culture is the gold standard for diagnosis of melioidosis. Ashdown media is the currently used selective medium for isolation of B. pseudomallei from environmental and clinical samples [7]. However, overgrowth of other soil bacteria and fungi on Ashdown agar plates is common [9]. The media is also not readily available in prepared form in melioidosis endemic area like Bangladesh. So, a readily available selective media is needed for culture and isolation of B. pseudomallei for environmental survey. In this study, commercially available MacConkey agar media was modified by addition of specific antimicrobials and glycerol to suppress the growth of soil flora while still allowing the growth of B. pseudomallei. The modified MacConkey media was termed as ‘Modified MacConkey agar for Burkholderia (MMB media)’. Gentamicin and colistin were chosen because of their previous use in B. pseudomallei selective media [7,15] and intrinsic resistance of B. pseudomallei to those antimicrobials [16,17]. Minimum inhibitory concentration (MIC) of gentamicin and colistin of ten local B. pseudomallei isolates was determined by agar dilution method. MIC values of both gentamicin and colistin of all ten local isolates were > 1024 µg/mL. This indicates that using these antimicrobials at a lower concentration will allow the growth of B. pseudomallei, but will suppress growth of other microbial flora in the sample. Initially, we tried two combinations of gentamicin and colistin concentrations. Although, the higher concentrations of gentamicin and colistin (10 mg/L + 500 mg/L) had greater ability to suppress soil flora, they caused diminished growth rate of B. pseudomallei. So, finally the lower concentration of gentamicin and colisitin (5 mg/L + 50 mg/L) was selected. Vancomycin 2.5 mg/L and amphotericin B 1 mg/L were added in MMB media to inhibit Gram positive organism and fungus present in soil. The MMB media with the combination of four antimicrobials was highly selective against a variety of Gram positive and Gram negative bacterial species. There was no growth of E. coli ATCC 25922, P. aeruginosa ATCC 23853 and S. aureus ATCC 25923 on MMB media. MMB media was also enriched with glycerol at a concentration of 40 ml/L to prevent the moisture loss during prolonged incubation and for production of characteristic colony of B. pseudomallei as used by Ashdown [7]. Our new MMB was evaluated for its capability to support the growth and easy recognition of B. pseudomallei in comparison to selective Ashdown and MacConkey media. Equally good growth of B. pseudomallei was present in MMB, MacConkey and Ashdown media. In MMB media, B. pseudomallei produced characteristic pink and centrally depressed colonies. The assessment of newly modified MMB media for the isolation of B. pseudomallei in spiked positive soil samples showed that the MMB media has sensitivity similar to Ashdown media. During evaluation of the media by culturing sterile soil spiked with B. pseudomallei, it was seen that, there was no significant difference in colony counts between MMB media and Ashdown media. There was 100% inhibition of common Gram negative soil bacteria namely K. pneumoniae, E. coli and P. aeruginosa in MMB media while in Ashdown media, growth of P. aeruginosa was observed when sterile soil seeded with 1 × 106 to 1 × 103 CFU of P. aeruginosa /gm was cultured. There were no growth of any of the bacteria at a concentration of 1×102 and 1×101 CFU/gm of sterile soil in MacConkey, Ashdown media and MMB media. This could be due to either very low number of bacteria inoculated to grow or due to presence of some unknown substances in soil which might have inhibited the growth of bacteria in culture [18]. When B. pseudomallei was spiked into natural unsterile soil, the inhibition of other bacterial flora of soil was found significantly high in MMB media in comparison to Ashdown and MacConkey agar media. There was apparent decrease in colony count of gentamicin and colistin resistant soil bacteria on MMB media. Growth of other soil bacteria was 30-26 CFU/plate on MMB media compared to 40 CFU/plate and 66-70 CFU/plate on Ashdown and MacConkey media respectively. So, it was easy to identify B. pseudomallei colonies in MMB media by inhibiting other soil bacteria. The present study has some limitations. The newly devised MMB media could not be evaluated at the field level for the detection of B. pseudomallei from soil and other environmental samples from different locations of the country. Also, the efficacy of MMB media needs to be assessed for better isolation of B. pseudomallei with clinical samples from unsterile sites.  The newly devised MMB medium can be prepared in small laboratories located in melioidosis endemic areas for isolation of B. pseudomallei from environmental and clinical samples from unsterile sites. Also in resource limited settings, this inexpensive and easy to prepare selective media can serve as a tool for large scale epidemiological surveys for detection of B. pseudomallei.   Conflict of interest: The authors declare no conflict of interest.   Funding: None   References 1.     Gassiep I, Armstrong M, Norton R. Human Melioidosis. Clin Microbiol Rev. 2020; 33(2): e00006-19. doi:10.1128/CMR.00006-19. 2.     Currie BJ, Dance DAB, Cheng AC. The global distribution of Burkholderia pseudomallei and melioidosis: an update. Trans R Soc Trop Med Hyg. 2008; 102 Suppl 1: S1-S4. doi:10.1016/S0035-9203(08)70002-6. 3.     Jilani MSA, Robayet JAM, Mohiuddin M, Hasan MR, Ahsan CR, Haq JA. Burkholderia pseudomallei: its detection in soil and seroprevalence in Bangladesh. PLoS Negl Trop Dis. 2016; 10(1): e0004301. doi:10.1371/journal.pntd.0004301. 4.     Barai L, Jilani MSA, Haq JA. Melioidosis - case reports and review of cases recorded among Bangladeshi population from 1988-2014. Ibrahim Med Coll J. 2014; 8(1): 25-31. doi: http://dx.doi.org/10.3329/imcj.v8i1.22985. 5.     Cheng AC, Currie BJ. Melioidosis: epidemiology, pathophysiology and management. Clin Microbiol Rev. 2005; 18(2): 383-416. doi: 10.1128/CMR.18.2.383-416.2005. 6.     Kaestli M, Mayo M, Harrington G, Ward L, Watt F, Hill JV, et al. Landscape changes influence the occurrence of the melioidosis bacterium Burkholderia pseudomallei in soil in northern Australia. PLoS Negl Trop Dis. 2009; 3(1): e364. doi: 10.1371/journal.pntd.0000364. 7.     Ashdown LR. An improved screening technique for isolation of Pseudomonas pseudomallei from clinical specimens. Pathology. 1979; 11(2): 293-297. doi:10.3109/00313027909061954. 8.     Howard K, Inglis TJJ. Novel selective medium for isolation of Burkholderia pseudomallei. J Clin Microbiol. 2003; 41(7): 3312-3316. doi:10.1128/JCM.41.7.3312-3316.2003. 9.     Peacock SJ, Chieng G, Cheng AC, Dance DAB, Amornchai P, Wongsuvan G, et al. Comparison of Ashdown's medium, Burkholderia cepacia medium, and Burkholderia pseudomallei selective agar for clinical isolation of Burkholderia pseudomallei. J Clin Microbiol. 2005; 43(10): 5359-5361. doi:10.1128/JCM.43.10.5359-5361.2005. 10.  Washington JAH. Susceptibility tests: agar dilution. In: Lennette EH, Balows A, Hausler WJ, Shadomy HJ, editors. Manual of clinical microbiology. 4th eds. Washington DC: American Society for Microbiology; 1985; p. 967-971. 11.  Wuthiekanun V, Amornchai P, Saiprom N, Chantratita N, Chierakul W, Koh GCKW, et al. Survey of antimicrobial resistance in clinical Burkholderia pseudomallei isolates over two decades in Northeast Thailand. Antimicrob Agents Chemother. 2011; 55(11): 5388-5391. doi:10.1128/AAC.05517-11. 12.  Brook MD, Currie B, Desmarchelier PM. Isolation and identification of Burkholderia pseudomallei from soil using selective culture techniques and the polymerase chain reaction. J Appl Microbiol. 1997; 82(5): 589–596. 13.  Wuthiekanun V, Dance DA, Wattanagoon Y, Supputtamongkol Y, Chaowagul W, White NJ. The use of selective media for the isolation of Pseudomonas pseudomallei in clinical practice. J Med Microbiol. 1990; 33(2): 121-126. doi:10.1099/00222615-33-2-121. 14.  Ashdown LR, Clarke SG. Evaluation of culture techniques for isolation of Pseudomonas pseudomallei from soil. Appl Environ Microbiol. 1992; 58(12): 4011-4015. doi:10.1128/aem.58.12.4011-4015.1992. 15.  Limmathurotsakul D, Kanoksil M, Wuthiekanun V, Kitphati R, deStavola B, Day NPJ, et al. Activities of daily living associated with acquisition of melioidosis in northeast Thailand: A matched case-control study. PLoS Negl Trop Dis. 2013; 7(2): e2072. doi:10.1371/journal.pntd.0002072. 16.  Moore RA, DeShazer D, Reckseidler-Zenteno S, Weissman A, Woods DE. Efflux-mediated aminoglycoside and macrolide resistance in Burkholderia pseudomallei. Antimicrob Agents Chemother. 1999; 43(3): 465-470. doi:10.1128/AAC.43.3.465. 17.  Burtnick MN, Woods DE. Isolation of polymixin B-susceptible mutants of Burkholderia pseudomallei and molecular characterization of genetic loci involved in polymixin B resistance. Antimicrob Agents Chemother. 1999; 43(11): 2648-2656. doi:10.1128/AAC.43.11.2648. 18.  Fujimura Y, Katayama A, Kuwatsuka S. Inhibitory action of dissolved humic substances on the growth of soil bacteria degrading DDT. Soil Sci Plant Nutr. 1994; 40(3): 525-530. doi:10.1080/00380768.1994.10413330.        Cite this article as: Moutusy SI, Farook S, Mazumder S, Barai, L, Islam KMS, Jilani MSA. Modified MacConkey agar: a simple selective medium for isolation of Burkholderia pseudomallei from soil. IMC J Med Sci. 2024; 18(1):011. DOI: https://doi.org/10.55010/imcjms.18.011 <![CDATA[How fatal can untreated constipation be?]]> Salih Karakoyun Yasin Haydar Yartaşı Mehmet Cihat DEMIR Mustafa BOĞAN https://imcjms.com/journal_full_text/476 2023-08-21 09:54:42 Clinical Case Report IMC J Med Sci. 2024; 18(1):001 Abstract This case report discusses a patient who presented with dyspnea and presyncope following the Valsalva maneuver. The patient had a history of chronic constipation and experienced difficulty defecating, leading to vigorous straining. Upon arrival at the emergency department, the patient exhibited signs of cardiac tamponade and computed tomography(CT) scan revealed high-density pericardial hemorrhagic effusion. Pericardiocentesis and surgical decompression were performed to manage the tamponade. The patient's symptoms improved and discharged in stable condition. This case highlights the potential fatal complications of constipation, emphasizing the need for a holistic approach in cardiovascular care. IMC J Med Sci. 2024; 18(1):001. DOI: https://doi.org/10.55010/imcjms.18.001 *Correspondence: Mustafa BOĞAN, Emergency Department, School of Medicine, Düzce University, Düzce, Turkey, Posta code: 81620;  Email: mustafabogan@hotmail.com;  ORCID: 0000-0002-3238-1827   Introduction Pericardial effusion is defined as an increased accumulation of fluid within the pericardial cavity, either acutely or chronically. Physiologically, the amount of pericardial fluid ranges between 10-50 milliliter [1,2]. Various pathophysiological changes play a role in the increase of this fluid. Increased pericardial fluid can be attributed to pericardial inflammation [1,2], reduced reabsorption due to increased systemic venous pressure [1,2], progressive fluid accumulation as a result of surgical intervention [1-3], impairment of pericardial characteristics and thickness due to severe or recurrent inflammation [4], obstruction of venous return and ventricular diastolic filling due to compression of cardiac chambers [3,4], increased ventricular diastolic pressure [3,4], and systemic congestion [3,4]. These are known as the leading causes of pericardial effusion. Pericardial effusion can be incidentally detected in asymptomatic individuals. However, pericardial fluid can lead to a life-threatening condition known as cardiac tamponade, which can result in death [5]. Cardiac tamponade is a clinical syndrome characterized by the accumulation of fluid in the pericardial cavity, leading to impaired ventricular filling and cardiac output [1,3]. Pericardial effusion can cause symptoms such as dyspnea, orthopnea at advanced stages, chest pain, tachypnea, cough, dysphagia, and nausea in patients [1-4]. In cardiac tamponade, additional features may include hypotension, pulsus paradoxus, increased jugular venous pressure, and muffled heart sounds [1-4]. Physical examination may reveal Beck's triad (hypotension, muffled heart sounds, distended jugular veins), tachycardia, tachypnea, fever, and pulsus paradoxus. The diagnosis of pericardial tamponade is confirmed by echocardiography, which is complemented by electrocardiography (ECG), X-ray, and computed tomography (CT). Pericardial effusion can occur due to inflammatory or non-inflammatory processes [5]. Inflammatory causes include viral, bacterial, fungal, protozoal, secondary to uremia, and drug hypersensitivity-related pericarditis. In the United States and Western Europe, the most common etiology of inflammation-related pericardial effusion is post-viral idiopathic pericarditis [5]. Non-inflammatory causes include malignancy, metabolic factors, trauma, and conditions associated with decreased lymphatic drainage [5]. Pericardial fluid can possess the qualities of transudate (hydropericardium), exudate, purulence (pyopericardium), or blood (hemopericardium) [1,3]. The most common causes of cardiac tamponade include acute pericarditis, tuberculosis, iatrogenic injury, blunt chest trauma, and malignancy [1,3]. Rare causes may include collagen vascular diseases (such as systemic lupus erythematosus, rheumatoid arthritis, scleroderma), myocardial infarction, uremia, aortic diseases, bacterial infection, and sequelae of radiotherapy [1]. The treatment of pericardial effusion primarily focuses on addressing the underlying cause. The primary approach is to remove and halt the accumulation of pericardial fluid that contributes to the patient's clinical presentation and symptoms. Pericardiocentesis and drainage are methods used to accomplish this, with pericardiotomy and pericardiectomy being options in cases where pericardiocentesis and drainage are insufficient or for patients with recurrent effusion [1]. In cases of isolated pericardial effusion, additional medical therapy is not necessary; however, if systemic inflammation is present, conditions such as acute pericarditis should be treated. This may involve the use of aspirin, non-steroidal anti-inflammatory drugs, and colchicine [1,3]. Here, we describe a patient who presented with cardiac tamponade following Valsalva maneuver due to chronic constipation.   Case Presentation A 53-year-old male patient was brought to the Emergency Service (ES) by ambulance. It was learned that the patient had excessive difficulty defecating in the early hours of the morning and inserted his finger into the rectum because he could not remove the stool. Subsequently, he experienced lightheadedness, blurred vision, dyspnea, and numbness radiating to his left arm, prompting him to call for an ambulance. Upon arrival at the emergency department, the patient's general condition was moderate, agitated but oriented and cooperative. Vital signs were as follows: blood pressure 69/39 mm Hg, heart rate 130 beats/min, respiratory rate 22 breaths/min, oxygen saturation 82%, and body temperature 36.8°C. Physical examination revealed cachexia and jugular venous distension. Neurological examination was unremarkable, and abdominal examination showed no pathology. No murmurs were heard on cardiac examination, and both lungs had equal breath sounds. The patient had no known medical history other than hypertension and chronic constipation. The ECG taken during the emergency department visit showed 1.5 mm ST depressions in leads D2, D3, AVF, V3, and V6, and 1 mm ST elevation in leads AVR and V1. Despite hydration, the patient continued to have hypotension, and intravenous norepinephrine support was initiated. To exclude possible cardiovascular and aortic pathologies, thoracoabdominal aorta CT angiography was performed. No pathology related to the aorta was detected, but a high-density hemorrhagic effusion measuring 19 mm in the thickest part of the pericardial cavity was observed (Figure-1).     Figure-1: CT angiograph showing high-density hemorrhagic effusion in the pericardial cavity   Blood tests revealed elevated levels of conventional troponin (2.41 ng/ml; reference range: 0-0.16) and CRP (7.44 mg/dl; reference range: 0-0.5), while liver and kidney function tests were normal. Coronary angiography was performed to evaluate acute coronary syndrome as a possible etiology of cardiac tamponade. But, coronary angiography did not reveal any vascular contrast leakage. As a result, the patient was diagnosed as a case of cardiac tamponade with pericardial effusion on the CT scan, and the patient was referred to the cardiology department for consultation. Attempted therapeutic pericardiocentesis by the cardiology team was unsuccessful because the aspirated fluid had a dense clotting property. Due to the patient's unstable vital signs, indicating the need for surgical decompression of tamponade, the case was transferred to cardiovascular surgery (CVS). Diagnostic and therapeutic total median sternotomy was performed by the CVS team. During the procedure, organized encapsulated clotting material was observed within the pericardium and was removed. No significant macroscopic pathology causing hemopericardium was detected. Based on the above, the patient was finally diagnosed as a case of cardiac tamponade due to hemopericardium following straining (Valsalva) during defecation for chronic constipation. The patient's clinical and vital signs remained normal during the follow-up, and the symptoms improved. The patient was discharged in stable condition after three days.   Discussion ST segment elevation/depression on an ECG can be seen due to various causes. These include acute myocardial infarction, early repolarization, coronary vasospasm (Prinzmetal's angina), pericarditis, left bundle branch block, left ventricular hypertrophy, ventricular aneurysm, Brugada syndrome, increased intracranial pressure, Takotsubo cardiomyopathy, pulmonary thromboembolism, pneumothorax, cardiac contusion, hypothermia, and hyperkalemia, etc [6-9]. In our case, acute coronary syndrome was ruled out, and no significant pathology was observed apart from hemopericardium. Hemopericardium can be caused by trauma, misplaced central catheter, bleeding diathesis, ventricular rupture following myocardial infarction, chest trauma, over dose of anticoagulants, rupture of sinus of Valsalva aneurysm, and rupture of aortic arch aneurysms, among others [10-12]. In this case, no significant pathology was present that could cause the observed hemopericardium. The main factor worsening the patient's clinical condition in this case was the Valsalva maneuver, which occured primarily as a result of expiratory effort against a closed airway, following increased intrathoracic and intra-abdominal pressure [13]. The side effects and complications of the Valsalva maneuver are actually quite rare [13]. In patients, especially those with a history of coronary artery or cerebrovascular disease - chest pain, syncope, arrhythmia, and cerebral stroke may occur after the maneuver [13]. Temporary ventricular arrest and even sudden death have been reported due to decreased left ventricular stroke volume and inadequate autonomic regulation [13]. Headache, dizziness, nausea, altered mental status, and increased intraocular pressure leading to retinal or macular hemorrhage are also reported side effects [13]. Although these side effects have been reported in various case series, no complications were encountered in autonomic testing studies, including 20,000 Valsalva maneuvers conducted by Low in 1993, and studies conducted by the American Academy of Neurology in 1996 [14, 15]. Constipation, due to its disruption of the gut flora, can lead to increased atherosclerosis and elevated blood pressure, exacerbating the course of cardiovascular events [16]. Straining behavior raises blood pressure and can trigger cardiovascular events such as arrhythmia, congestive heart failure, acute coronary syndrome, aortic dissection, and stroke [16]. In this patient, excessive straining due to constipation led to cardiac tamponade following development of hemopericardium.   Conclusion Physicians tend to focus solely on resolving the pathology that concerns them during the treatment and follow-up process of pericardial effusion. In our case, where the patient progressed to cardiac tamponade after straining, this becomes even more strikingly dramatic. It is true that with advancing technology, we have made ground breaking achievements in scientific endeavors. Specialization in every field has led to remarkable successes. However, there is something we have forgotten: the holistic approach. This case serves as a reminder that cardiovascular pathologies can develop or worsen following constipation.   Declaration of conflicting interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.   Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.   Informed consent Written consent was obtained from the patient.   Human rights Authors declare that human rights were respected according to Declaration of Helsinki.   References 1.     Adler Y, Charron P, Imazio M, Badano L, Barón-Esquivias G, Bogaert J, Brucato A, Gueret P, Klingel K, Lionis C, Maisch B, Mayosi B, Pavie A, Ristic AD, Sabaté Tenas M, Seferovic P, Swedberg K, Tomkowski W; ESC Scientific Document Group. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC) Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2015 Nov 7; 36(42): 2921-2964. doi: 10.1093/eurheartj/ehv318. 2.     Imazio M, Adler Y. Management of pericardial effusion. Eur Heart J. 2013 Apr; 34(16): 1186-1197. 3.     Seferović PM, Ristić AD, Maksimović R, Simeunović DS, Milinković I, Seferović Mitrović JP, et al. Pericardial syndromes: an update after the ESC guidelines 2004. Heart Fail Rev. 2013 May; 18(3): 255-266. doi: 10.1007/s10741-012-9335-x. 4.     Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK.. Pericardial disease: diagnosis and management. Mayo Clin Proc. 2010 Jun; 85(6): 572-593. doi: 10.4065/mcp.2010.0046. 5.     Vakamudi S, Ho N, Cremer PC. Pericardial Effusions: Causes, diagnosis, and management. Prog Cardiovasc Dis. 2017 Jul-Aug; 59(1): 380-388. doi: 10.1016/j.pcad.2016.12.009. 6.     Edhouse J, Brady WJ, Morris F. ABC of clinical electrocardiography: Acute myocardial infarction-Part II. BMJ. 2002 Apr 20; 324(7343): 963-966. doi: 10.1136/bmj.324.7343.963. 7.     Smith SW. T/QRS ratio best distinguishes ventricular aneurysm from anterior myocardial infarction. Am J Emerg Med. 2005 May; 23(3): 279-287. doi: 10.1016/j.ajem.2005.01.003. 8.     Kashou AH, Basit H, Malik A. ST Segment. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. 9.     Karakoyun S, Boran M, Saritaş A, Boran E. ECG evaluation in patients with pneumothorax admitted to the emergency department: a three years analysis. Konuralp Medical Journal. 2021; 13(3): 634-639. 10.  Krejci CS, Blackmore CC, Nathens A. Hemopericardium: an emergent finding in a case of blunt cardiac injury. AJR Am J Roentgenol. 2000 Jul; 175(1): 250. doi: 10.2214/ajr.175.1.1750250. 11.  Katis P. Atraumatic hemopericardium in a patient receiving warfarin therapy for a pulmonary embolus. Can J Emerg Med. 2005 May; 7(3): 168-170.              doi: 10.1017/s148180350001321 12.  Hong YC, Chen YG, Hsiao CT, Kuan JT, Chiu TF, Chen JC. Cardiac tamponade secondary to haemopericardium in a patient on warfarin. Emerg Med J. 2007 Sep; 24(9): 679-680. doi: 10.1136/emj.2007.049643. 13.  Pstras L, Thomaseth K, Waniewski J, Balzani I, Bellavere F. The Valsalva manoeuvre: physiology and clinical examples. Acta Physiol (Oxf). 2016 Feb; 217(2): 103-119. doi: 10.1111/apha.12639. 14.  Low PA. Autonomic nervous system function. J Clin Neurophysiol. 1993 Jan; 10(1): 14-27. doi: 10.1097/00004691-199301000-00003. 15.  American Academy of Neurology. Assessment: clinical autonomic testing report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 1996 Mar; 46(3): 873-880. 16.  Ishiyama Y, Hoshide S, Mizuno H, Kario K. Constipation-induced pressor effects as triggers for cardiovascular events. J Clin Hypertens (Greenwich). 2019 Mar; 21(3): 421-425. doi: 10.1111/jch.13489.     Cite this article as: Karakoyun S, Yartaşı YH, Demir MC, Boğan M. How fatal can untreated constipation be? IMC J Med Sci. 2024; 18(1):001. DOI: https://doi.org/10.55010/imcjms.18.001 <![CDATA[Hall technique for the management of carious primary molar teeth among African children - a review]]> Obehi. O Osadolor https://imcjms.com/journal_full_text/480 2023-09-05 12:00:18 Review IMC J Med Sci. 2024; 18(1):003 Abstract Background: Hall technique involves cementing preformed metal crowns or stainless steel crowns on the tooth with the use of luting glass ionomer cements, without the use of local anaesthesia, caries removal and tooth preparation of any kind. It can be an intervention to stop the progression of active untreated carious lesion in primary molar teeth among African children. This article reviews the available studies on Hall technique used for the management of carious primary molar teeth among African children. Method: An electronic literature search in Web of science, Scopus, PubMed, Google Scholar, African journals online, ResearchGate and Google was conducted in June, 2023 using the Population-Concept-Context framework. Search terms and keywords were combined by Boolean operators. Three independent investigators (research assistants) screened titles, abstracts and full text of publications. The inclusion criteria were original research articles, case report, case series related to Hall technique for the management of carious primary molar teeth studies conducted in African continent, published in English language and in electronic databases. Results: Four articles were included as they were assessed to meet the aim of the review. The study design of the articles was three randomised controlled clinical trial and one case report. One study was identified each from Egypt, Morocco, Nigeria and Sudan respectively. All the identified studies in African continent were hospital based. Conclusion: Hall technique can be an intervention for management of carious primary molar teeth in resource poor locality in Africa and globally. Studies on Hall technique for the management of carious primary molar teeth identified in Africa were few and restricted to few countries. IMC J Med Sci. 2024; 18(1):003. DOI: https://doi.org/10.55010/imcjms.18.003 *Correspondence:Obehi. O Osadolor, University of Nigeria Teaching Hospital, Ituku- ozalla, Enugu State, Nigeria.  E-mail: osadolorobehi@yahoo.com   Introduction There are many techniques for managing carious primary teeth among children. Hall technique is one of the non-invasive methods of managing carious primary molars [1]. The technique involves the removal of food debris by use of hand instruments, without any use of local anaesthesia, caries removal and tooth preparation of any kind, and cementing preformed metal crowns or stainless steel crowns on the tooth with the use of luting glass ionomer cements [2]. In Hall technique for managing carious primary molar teeth, dental caries in tooth/teeth is sealed under preformed metal crowns [1]. Hall technique is not suitable for every child and every carious primary molar tooth. There are selection criteria that should be assessed before considering or recommending the technique to a child, parent or caregiver. Orthodontic elastic separators are placed between the tight contact point of the primary molar using two pieces of dental floss or an elastic separator placing pliers [3]. The elastic separators are left in place for about five to seven days. The use of Hall technique for managing carious primary molar teeth in resource poor settings requires minimal training, simple armamentarium and minimal support. The aim of this article is to review the available studies on Hall technique for the management of carious primary molar teeth among African children. The success rate, minor and major failures rate of preformed metal crowns placed using Hall technique is also reviewed among the identified studies in Africa continent.   Materials and methods The review focused on published primary articles on Hall technique for the management of carious primary molar teeth in children and conducted in African region. Literature search method: An electronic literature search in Web of science, Scopus, PubMed, Google Scholar, African journals online, ResearchGate and Google was conducted in June, 2023 using the Population-Concept-Context framework [4]. Framework included: (a) population: children, pre-school children, (b) concept: Hall technique for the management of carious primary molar teeth, and (c) context: studies carried out in Africa continent, published in English language and in electronic databases. The keywords used were Hall technique, carious teeth, deciduous molars, primary teeth, primary molars, Africa countries, sub-Saharan Africa, deciduous teeth, African region, Africa continent, African population, African people, sub-Saharan countries, African children, Oral health practitioner, African Dentist and Africa. Search terms and keywords were combined by Boolean operators. Three independent investigators (research assistants) screened titles and abstracts of publications on Hall technique for the management of carious primary molar teeth studies, and potential references to identify which studies met the inclusion criteria of this review. Information was extracted from the full texts of articles regarding the location of the research and the main content. The inclusion criteria were original research articles, case report, case series related to Hall technique for the management of carious primary molar teeth conducted in African region, published in English language and in electronic databases. Review articles, systematic reviews, viewpoints, books, letters, editorials, book chapters, perspectives, and news related to Hall technique for the management of carious primary molar teeth were excluded. Study data of the included articles were extracted and collated in a table, including study details, author(s), year of publication, study population, study location or country, study objectives and design. Sample size, success rate, minor and major failure rate and period of assessment were also extracted from identified studies and collated in a table. All identified studies in Africa were included and if relevant data were missing, the authors of the articles were contacted for additional information via e-mail. No specified time frame was used during the search, any additional studies in African region identified from the reference lists of published papers were retrieved from the web using Google scholar and Google search engines.   Results Seventy six articles were identified; fifty duplicates were removed during screening. Abstracts and full texts were screened using inclusion criteria by three independent research assistants. Twenty two articles were excluded because they did not meet the inclusion criteria. Four articles were finally included as they were assessed to meet the aim of the review. Four articles included were three randomised controlled clinical trial and one case report (Figure-1). One study was conducted in Egypt, Morocco, Nigeria, and Sudan respectively among the articles eligible for review. Summary of identified studies conducted in African countries for management of carious primary molar teeth using Hall technique is shown in Table-1.     Figure-1: Flow chart showing inclusion and exclusion of studies Table-1: Summary of identified studies on Hall technique for management of carious primary molar teeth conducted in African countries     All the identified studies included in this review used defined criteria for success and failure of Hall technique for the management of carious primary molar teeth among African children. Table-2 summarized the criteria used to assess the success and failures of the Hall technique in the identified studies.   Table-2: Criteria for success, major and minor failures of preformed metal crowns placed using Hall technique for the management of carious primary molar teeth in the identified studies     In Sudan, the survival rate was 94.5% at 12 months and 93.6% at 24 months follow up. Overall failure rate was 9.2 % and success rate was 90.8% at 24 months follow up, while the dropout rate was 3.7%, 4.6%, 12.8% and 22.9% at 6 12, 18  and 24 months follow-ups respectively. In Egypt, the success rate was 94.2% and failure rate was 5.8% at 6 and 12 months follow up respectively, while in Nigeria, the failure rate was 0% and success rate was 100% at 12 months follow-up (Table-3).   Table-3: Summary of success and failure rates of preformed metal crowns placed using Hall technique for management of carious primary molar teeth among African children in the identified studies     Discussion The level of untreated dental caries in primary teeth among African children is high [8]. Hall technique with preformed metal crowns can be an intervention for preventing the progression of active carious lesion in primary molar teeth. The selected teeth for this technique are single surface or multi-surface enamel or dentine caries that are symptomless, non-mobile, cavitated or non-cavitated carious lesion, with no clinical or radiographic signs of pulpal pathology [3,5-7]. The use of the technique might not be common in low income countries or resource limited environment in Africa and globally, because of non-availability of preformed metal crowns or stainless steel crowns, level of training, need for training and need for patient co-operation [6]. This review identified studies on Hall technique for carious primary molar teeth from four countries [3,5-7] in African region. All of them were hospital based studies though this technique can be carried out in community based setting with simple armamentarium. The success rate, minor and major failures rate of preformed metal crowns placed using Hall technique was also reviewed among the identified studies in African continent. In Egypt, the success rate was 94.2%, failure rate was 5.8% at 6 and 12 months follow up respectively [7]. In Nigeria, the success rate was 100% and 0% failure rate at 12 months follow up [3]. In Sudan, the criteria for assessment used were minor failures when there was dislodgement or perforation of the preformed metal crown without pain while major failures were associated with pain and needed pulp therapy or extraction. Success was considered when there was absence of minor and major failures [6]. The success rate was 90.8% and failure rate was 9.2% in Sudan at 24 months review [6]. The calculated mean cost per unit was cheaper in Hall technique than the conventional stainless steel crown technique. Preformed metal crowns placed by Hall technique were more cost-effective than the conventional stainless steel crown technique [6]. The mean procedure time in Hall technique was also shorter than the conventional stainless steel crown technique [3,6-7]. Hall technique had been shown to be more advantageous in term of time and cost [3,6], but some dentists from general dental practice did not routinely use preformed metal crown for managing carious primary molars because of lack of training, perceived lack of cost-effectiveness in general practice, and need for patient cooperation [6]. Four studies analysed in this review might not reflect the diverse ethnic population and situation in Africa. Some parents and children in Africa might have concerns on the aesthetic appearance of the preformed metal crowns. More studies on use of Hall technique from various countries and ethnic groups in Africa are required to fill the existing knowledge gaps of the dental caregivers.   Conclusion The armamentarium for Hall technique is simple and it could be used in underserved and un-served African children population with active carious lesions in primary molar teeth. The studies identified in Africa continent were few. More studies from other African countries are needed to add to the existing knowledge and literature.   Financial support and sponsorship None. Conflicts of interest No competing interest/conflict of interest.   Acknowledgements Author wishes to thank all the colleagues who helped in searching and screening of articles.   References 1.     Altoukhi DH, El-Housseiny AA. Hall technique for carious primary molars: a review of the literature. Dent J (Basel). 2020 17; 8(1): 11. doi: 10.3390/dj8010011. 2.     Innes NP, Evans DJ, Bonifacio CC, Geneser M, Hesse D, Heimer M, et al. The Hall Technique 10 years on: questions and answers. Br Dent J. 2017; 222(6): 478-483. doi: 10.1038/sj.bdj.2017.273. 3.     Ayedun OS, Oredugba FA, Sote EO. Comparison of the treatment outcomes of the conventional stainless steel crown restorations and the Hall technique in the treatment of carious primary molars. Niger J Clin Pract. 2021; 24: 584-594. doi: 10.4103/njcp.njcp_460_20. 4.     Glonti K, Cauchi D, Cobo E, Boutron I, Moher D, Hren D. A scoping review protocol on the roles and tasks of peer reviewers in the manuscript review process in biomedical journals. BMJ Open. 2017; 7: e017468. doi:10.1136/bmjopen-2017-017468. 5.     Hariri M, Ramdi H, El Alloussi M, Chhoul H. The Hall technique: a non-conventional method for managing carious primary molars. Dentistry. 2016; 6(7): 385. doi: 10.4172/2161-1122.1000385. 6.     Elamin F, Abdelazeem N, Salah I, Mirghani Y, Wong F. A randomized clinical trial comparing Hall vs. conventional technique in placing preformed metal crowns from Sudan. PLoS One. 2019; 14(6): e0217740. doi: 10.1371/journal.pone.0217740. 7.     Sharaf DA, Dowidar K, Habashy LM, Hamed H. Hall technique versus the conventional stainless steel crowns restoring carious primary molar teeth: a randomized controlled clinical trial. Alex Dent J. 2021; 46(3): 174-180. doi: 10.21608/adjalexu.2021.47605.1117. 8.     Osadolor OO. Dental caries and access to oral health services among children and adolescents. Janaki Med Coll J Med Sci. 2022; 10 (3): 64-70.      Cite this article as: Osadolor OO. Hall technique for the management of carious primary molar teeth among African children - a review. IMC J Med Sci. 2024; 18(1):003. DOI: https://doi.org/10.55010/imcjms.18.003 <![CDATA[Dengue in Bangladesh and neighboring countries: an overview of epidemiology, transmission, control, and prevention]]> M. S. Zaman* Amal K. Mitra https://imcjms.com/journal_full_text/511 2024-01-27 09:51:23 Review IMC J Med Sci. 2024; 18(1):012 Abstract Background and Objectives: Dengue fever, caused by four serotypes of the dengue virus (DENV), is a global health threat, affecting millions of people annually, with a significant burden in Asian countries. Bangladesh, where dengue was first documented in the 1960s, has witnessed an escalation of cases in recent years. The aim of this review is to provide an overview on dengue covering dengue epidemiology in Bangladesh and neighboring countries, efficacy of available vaccines, diagnostic tests and preventive measures. Materials and Methods: A narrative review was conducted using the keywords such as dengue in Bangladesh, dengue in South and Southeast Asia, epidemiology, genomic structure, transmission, diagnosis, vaccines and prevention. The information and data of this article were drawn from extensively reviewed scientific journals and pertinent authoritative sources. The data search was limited from year 2000 to 2023. Results: Magnitude of dengue infection in Bangladesh and neighboring countries was assessed. The usefulness of diagnostic tests as well as the prospect of available vaccines was reviewed. Control and preventive measures to mitigate spread and transmission of the disease were also discussed. Conclusion: Effective prevention and control of dengue needs coordinated efforts in surveillance, research, control and preventive measures. This holistic approach is necessary to mitigate detrimental consequences of dengue on public health and economies worldwide. IMC J Med Sci. 2024; 18(1):012. DOI: https://doi.org/10.55010/imcjms.18.012 *Correspondence: M. S. Zaman, Department of Biological Sciences, Alcorn State University, Lorman, Mississippi, USA. Email: zaman@alcorn.edu; mzaman@southtexascollege.edu   Introduction  Dengue fever, a mosquito-borne viral disease, has profound global impacts, affecting millions of people each year. This disease is transmitted through the bite of virus-infected mosquitoes, with the primary vectors being female Aedes aegypti, followed by Aedes albopictus. The virus is characterized by four antigenically distinct serotypes: DENV-1, DENV-2, DENV-3, and DENV-4 [1]. However, a fifth serotype (DENV-5) was reported in Malaysia in 2013 [2]. Although most dengue cases are not fatal, dengue can lead to severe illness, known as dengue hemorrhagic fever and dengue shock syndrome, which often require hospitalization and intensive care. Dengue is a prevalent endemic illness found in more than 100 countries, primarily in tropical and subtropical regions worldwide [3].The surge in dengue cases strains healthcare resources in many countries, especially in regions where the disease is endemic. Dengue has had a significant and concerning impact in Bangladesh, with frequent outbreaks causing substantial public health challenges. The country faces a recurring cycle of dengue epidemics, especially during the monsoon season when mosquito breeding sites are abundant. Most dengue cases are not fatal; however, disease outbreaks strain the healthcare system, with hospitals and clinics overwhelmed by dengue cases. The demand for medical care often exceeds the available resources, leading to difficulties in timely diagnosis and treatment. Furthermore, the economic impact of dengue in Bangladesh is noteworthy, as families often struggle to meet the healthcare costs associated with the disease [4]. In Bangladesh and other dengue endemic countries, the outbreak of dengue diverts resources away from other healthcare priorities, impacting the overall quality and accessibility of healthcare services. The burden on the healthcare system, combined with the economic costs of dengue treatment, aggravates the healthcare crisis. The aim of this brief review is to provide an understanding on dengue epidemiology in Bangladesh and neighboring countries, efficacy of available vaccines, diagnostic tests and preventive measures.   Materials and methods The search strategy for this narrative review included keywords such as “dengue fever”, “dengue hemorrhagic fever”, “epidemiology”, “genomic structure”, “transmission”, “diagnosis”, “serologic tests”, “molecular test”, “vaccines”, “dengue in Bangladesh”, “dengue in South and Southeast Asia”, and “epidemic”. The search engines included Google Scholar, Pubmed, Scopus, MEDLINE, CDC, and WHO websites. The data search was limited from 2000 to 2023. The inclusion criteria were: (1) articles describing the epidemiology, viral genotypes and serotypes, risk factors, and prevention. The exclusion criteria were: (1) articles published before 2000; (2) non-English articles; and (3) articles not having the full text. The researchers independently searched for articles and performed the quality appraisal for further inclusion in the review by reading the full text of the articles.   Structure of dengue virus Dengue virus is a single-stranded positive-sense enveloped RNA virus belonging to the Flaviviridae family. The dengue virus is roughly spherical with a diameter of approximately 50 nanometers. The viral envelope is a lipid bilayer that encapsulates the nucleocapsid. The envelope contains E and M proteins across the surface. The virus can assume different conformations during the maturation and infection stages due to the flexibility of the envelop proteins. E-protein serves as the primary antigen causing antibody responses during infection and is essential for the initial attachment of the virus to the host cells. The amino acid sequence of E-protein among the different serotypes of DENV bears 60-70% similarity. The core of the virus is composed of the viral RNA and C proteins [1,5]. The genome of the dengue virus (Figure-1) comprises of a single-stranded positive-sense RNA. It is composed of ten genes, which are translated into three structural proteins: (1) capsid C – which plays a crucial role in encapsulating the viral RNA genome, (2) membrane M having a membrane precursor M (prM) – which is associated with the organization and maturation of the dengue virus, and (3) Envelope E – which is located on the viral surface, is essential for the initial attachment of the virus to host cells, and seven nonstructural proteins: NS1, NS2A, NS2B, NS3, NS4A, NS4B, and NS5 that are involved in viral replication and assembly processes [1,5].     Figure-1: Genome structure of dengue virus [1].     Epidemiology of dengue infection Dengue is a viral infection transmitted to humans through the bites of infected mosquitoes, predominantly in tropical and subtropical regions worldwide, especially in urban and semi-urban environments. The primary vectors responsible for transmitting dengue to humans are Aedes aegypti mosquitoes and, to a lesser extent, Aedes albopictus. Dengue virus is comprised of four distinct serotypes (DENV-1, DENV-2, DENV-3, DENV-4), and individuals are susceptible to infection by any of these serotypes. Infection with a specific serotype confers lasting immunity against that serotype but does not protect from the others. Subsequent infections may increase the risk of developing severe dengue. Dengue is a prevalent endemic illness found in more than 100 countries, primarily in tropical and subtropical regions worldwide, causing 20,000 to 25,000 deaths annually, mostly in children [3]. Approximately 390 million cases of dengue virus infections are reported annually across 128 countries, with Asian countries accounting for 70% of these infections. Out of the total 390 million cases, approximately 96 million are classified as clinical cases [3]. Age-standardized incidence rate (ASR) of dengue increased from 1990 to 2011 with a subsequent decrease per year from 2011 to 2019 [6]. The greatest risk for contracting dengue infection is in the Indian subcontinent; Southern China; Southeast Asia; Taiwan; the Pacific Islands; Mexico; Africa; the Caribbean (except for the Cayman Islands or Cuba); Central and South America, (except for Paraguay, Chile, and Argentina); Hawaii; areas along the Texas-Mexico border; and Key West, Florida.   Dengue in Bangladesh and neighboring countries Bangladesh has a subtropical monsoon climate characterized by wide seasonal variations in rainfall. A warm and humid climate and stagnant rainwater create favorable breeding grounds for mosquitoes. This provides a suitable environment for the Aedes mosquitoes, the primary vectors for dengue. Furthermore, rapid urbanization in Bangladesh has led to densely populated cities, which provide ample breeding sites for Aedes mosquitoes in water containers, discarded tires, various other containers, and ditches that collect rainwater.In Bangladesh, dengue was initially documented in the 1960s and was colloquially referred to as "Dacca fever" [7].The abundance of the Aedes aegypti mosquito vector and its urban transmission cycles has established dengue as an endemic disease in Bangladesh. According to multiple sources, several epidemics of dengue fever affected Bangladesh in recent years – two major epidemics occurred in 2019 and 2023 [7-11]. The 2019 dengue epidemic had 101,354 confirmed cases and 164 deaths, with a case-fatality rate (CFR) of 0.16%, whereas the country witnessed the most devastating epidemic in 2023, which resulted in 320,945confirmed dengue cases and 1701 deaths (CFR, 0.53%), as reported by the Bangladesh Directorate General of Health Services [11]. Table-1 shows the number of dengue cases, deaths and case fatality rate in Bangladesh from 2016 to 2023.     Table-1: Number of dengue cases and deaths in Bangladesh from 2016 to 2023 [7-11].     The dengue cases were reported from all the 64 districts of Bangladesh, with a higher number of cases in males than females (62% vs. 58%, respectively). However, the overall CFR was higher in females than in males (0.72% vs. 0.32%, respectively). Adults aged 30 years and older accounted for 38% of cases and 64% of all deaths in 2023. In contrast, a previous study of an outbreak in 2022 had a total of 62,382 cases and 281 fatalities, with a CFR of 0.45%. Dhaka and Chittagong were the hardest hit cities in the country [7-11]. An earlier cross-sectional survey of 1,176 households in 2019 reported a higher prevalence of dengue among adults aged 19 to 50 years and in females [7-9]. Although DENV3 was detected more frequently in recent past outbreaks, DENV2 was the predominant serotype isolated during this outbreak [9].The distribution of dengue cases and deaths by location in Bangladesh is shown in Figure-2 [11]     Figure-2: Distribution of confirmed dengue cases and number of dengue-related deaths by location in Bangladesh in 2023 [11].   According to the report compiled by National Center for Vector Borne Diseases Control in India [12], from January 2018 to September 2023, among the 28 states and 8 Union territories, the most dengue hit places (with number of dengue cases) in 2023 were: Kerala (9779), Karnataka (9185), Maharashtra (8496), Odisha (6563), Uttar Pradesh (5742), and Assam (5604). Data from West Bengal was not reported in the previously mentioned source. However, Hindustan Times (a daily newspaper in India) reported the highest number of dengue cases (over 76,000) in West Bengal as of November 1, 2023 [13]. According to World Health Organization (WHO), dengue cases in Southeast Asia regions increased by 46% (from 451,442 to 658,301) and deaths decreased by 2% (from 1,584 to 1.555) from 2015 to 2019. Tian and colleagues reviewed dengue incidence and used disability-adjusted life years (DALY) to measure the disease burden of dengue fever in the endemic countries in Southeast Asia [15]. The age-standardized rate increased by 33% from 557.15 (95% CI 243.32 to 1212.53) per 100,000 in 1990 to 740.4 (95% CI 478.2 to 1323.1) per 100,000 in 2019 in these countries. Six countries including Bangladesh, India, Indonesia, Myanmar, Sri Lanka, and Thailand are among the high-endemic countries in the world [14]. An increase of dengue mosquito vector and viruses due to increased population density, increased migration in urban areas, inadequate water supply, poor waste management systems, and global warming are among the reasons for the dengue upsurge over time.   Transmission Dengue transmission is primarily carried out by two mosquito species, Aedes aegypti and Aedes albopictus. However, Aedes aegypti plays a primary role because this mosquito species can adapt to various environments. They breed in water collected in small containers, flowerpots, tires, and any stagnant water, adapting to all types of surroundings. Dengue transmission pathways involve a complex interaction involving the virus, mosquitoes (vectors), and humans (hosts). The process is outlined in Figure-3.      Figure-3: The pathways involved in the transmission of dengue virus [16-18].   Apart from symptomatic dengue cases, asymptomatic infections play a significant role in the transmission of dengue infection. Estimated overall global prevalence of asymptomatic dengue infection has been reported as 59.3% with 65.5% and 30.8% during outbreaks and non-outbreak periods respectively [19-21]. However, WHO reports that around 80% of dengue cases do not show any symptom [3]. Therefore, detection of asymptomatic dengue is crucial to prevent spread of dengue in a community.   Diagnostic tests The primary focus in diagnosing dengue should be on the detection of the virus or the viral components. During the acute stage of the infection, diagnosis can be made by detection of the virus, or its nucleic acids or antigens. Typically, within the first 4 to 5 days of the onset of the disease, the virus can be detected in plasma, blood cells, and various tissues [22]. For patients seeking medical attention within the five days of the onset of fever, diagnostic assessment should include rRT-PCR (testing for viral RNA) or NS1 antigen test. NS1 antigen test detects the non-structural protein NS1 of dengue virus. This protein is secreted into the blood during dengue infection. NS1 has shown to produce positive results for up to 12 days after the onset of fever. In addition, Immunoglobulin M (IgM) antibodies to viral antigen also start to appear around 3-7 days following the onset of symptoms. During the post-acute stage, serology is the method of choice for diagnosis which detects IgM or IgG antibodies. First-time (primary) dengue virus infections typically show a stronger IgM response; however, subsequent (secondary) infections show a weaker IgM response but a stronger IgG response [22]. For patients with more than one week after the onset of fever, IgM detection is the most effective diagnostic method [23]. IgM antibodies become detectable 3 to 7 days following infection and could remain detectable for 6 months or longer [23]. It takes approximately 5 to 7 days following the onset of symptoms for immunoglobulin G (IgG) antibodies to become detectable, and these levels may remain elevated for years [22].  In 2023, Luvira et al reported serum concentration by the ultrafiltration method as a simple and applicable technique to improve the diagnostic sensitivity and specificity of NS1 antigen test [24]. Dengue NS1 detection by enzyme-linked immunosorbent assay (ELISA) had the highest sensitivity of 82.4% (and 94.3% specificity), while NS1 by rapid diagnostic test (RDT) had 76.5% sensitivity, when compared with the viral detection by polymerase chain reaction (PCR). Serum concentrated three times with the ultrafiltration method using a 10 kDa molecular weight cut-off membrane increased the sensitivity of RDT-NS1 detection from 76.5% to 80.4%, with 100% specificity. Combining NS1 and IgM detection, the concentration method further increased the RDT sensitivity to 82.4% with 100% specificity.   Prevention Mosquito control: Mosquito control efforts rely on eradicating mosquito breeding sites, as mosquitoes lay their eggs in stagnant water. Regular inspections and removal of potential breeding sites like discarded tires, flowerpots, containers, and puddles where water accumulates are essential. Furthermore, the use of larvicides can help eliminate mosquito larvae in stagnant water, while using mosquito screens or nets can prevent mosquitoes from infiltrating living spaces. In addition to various mosquito control measures, studies indicate that Bacillus thuringiensis, often referred to as “Bt,” can serve as a successful larvicide against mosquito larvae. The Sterile Insect Technique (SIT) has proven effective in numerous nations for managing mosquito populations, although its ecological consequences are not clearly understood [25]. Furthermore, scientists are exploring the potential of Wolbachia, a bacterium that naturally occurs in mosquitoes and various insects, as a means to manage mosquito populations. The concept involves releasing male mosquitoes containing Wolbachia into selected regions. These Wolbachia-infected male mosquitoes subsequently mate with indigenous wild female mosquitoes. This mating process results in unhatched eggs, consequently decreasing the population of Aedes aegypti mosquitoes, which are the primary carriers of the dengue virus [26]. Protective measures: Wearing long-sleeved shirts, long pants, socks, and shoes in areas where mosquito activity is high, especially during dawn and dusk, could protect from mosquito bites. Using mosquito repellent on exposed skin and clothing, seeking shelters in screened areas, and using mosquito nets could also provide protection against mosquito bites. Community and public health initiatives: Identifying and cleaning up potential mosquito breeding sites in the community, campaigning and raising awareness about dengue prevention and control, educating students about dengue prevention through school programs, and implementing travel restrictions to and from dengue-infected areas, could play a significant role in dengue prevention. Dengue Vaccines: There are several challenges in developing an effective dengue vaccine – simply because of the complexities of formulating a tetravalent vaccine, and in conducting an efficacy trial against all four serotypes. At least seven DENV vaccines have undergone different phases of clinical trials; they include: (1) tetravalent, live-attenuated vaccines, (2) chimeric live attenuated vaccines, (3) inactivated vaccines, (4) subunit vaccines, and (5) nucleic acid-based vaccines. However, only three of them (Dengvaxia®, Odenga or TAK-003, and TV003/005) have showed promising results in several studies [27-29]. Table-2 summarizes the three vaccines with promising efficacy against dengue infection.   Table-2: Comparison of available vaccines for dengue [27-29]     Dengvaxia® is a tetravalent live-attenuated dengue vaccine (LATV), which received authorization in 2022 for use in children, aged 9 to 16 with a confirmed history of dengue infection and living in dengue-endemic regions [27]. This vaccine is only for individuals with prior dengue infections. If given to individuals without a previous infection who later contract the virus, the risk of severe dengue is high. The vaccine’s effectiveness is achieved through a three-dose regimen, with each dose spaced 6 months apart. Until now, among all the available vaccines, Dengvaxia protects children from dengue illness, hospitalizations, and severe dengue 8 out of 10 times (80%) in children who had dengue before vaccination. The vaccine protects against all four dengue virus serotypes [29]. Qdenga (TAK-003), a dengue tetravalent vaccine, is recommended by the World Health Organization (WHO) for children aged 6 to 16, irrespective of their previous dengue infection history. Therefore, a laboratory-confirmed dengue infection is not a prerequisite. This vaccine is administered as a two-shot series with a 3-month interval [29]. TV003/TV005 is a tetravalent live-attenuated dengue vaccine. It is produced by the National Institute of Allergy and Infectious Diseases (NIAID) of the United States and the Butantan Institute in Brazil. Of the five LATV formulations that were evaluated, TV003 and TV005 induced the most balanced neutralizing antibody responses [29]. TV005 is an improved version of TV003; it significantly increases seroconversion and antibody titers against DENV2. A recent clinical trial of TV005 focusing on safety and immunogenicity has been successfully carried out in Bangladesh [30]. The study demonstrated that by 180 days post vaccination, 83%, 99%, 96%, 87% vaccine recipient were found seropositive to DENV1, DENV2, DENV3 and DENV4 respectively. Antibody titers to all serotypes remained stable in 63-86% adults after 3 years of follow-up. However, the antibody titters declined in individuals without past exposure to dengue by 3 years. However, it's essential to recognize that the dengue vaccine can have specific side effects, including soreness, itching, headaches, fatigue, and general discomfort. In rare instances, individuals may experience fainting after vaccination, and there is a minimal risk of a severe allergic reaction triggered by the vaccine [30]. It is advisable to consult with a healthcare professional before considering vaccination.   Discussion Dengue is an endemic disease in many countries. While cases can crop up anywhere, they typically occur in tropical and subtropical regions where rainfall and humidity are high. Dengue fever is primarily prevalent during the rainy season. There are an estimated 400 million dengue cases that occur throughout the world each year. Of those, approximately one in four, or 96 million, results in illness [8,14]. It is considered a significant public health issue, and its impact is felt worldwide.In Bangladesh, dengue is an endemic disease that primarily surfaces during the monsoon season. In recent years dengue infection in Bangladesh has been significantly high, creating significant pressure on the healthcare system which is not fully prepared to tackle this added stress. Since the vector carrying the virus is a mosquito, it is easily comprehendible that the eradication of mosquito breeding sites would produce significant progress in dengue prevention and control in Bangladesh. Due to the high population density and rapid urbanization, the risk of re-infection from dengue remains a formidable challenge in Bangladesh, and controlling the situation remains a concern. The climatic conditions in Bangladesh are progressively becoming more conducive to the transmission of dengue and other vector-borne diseases such as malaria and chikungunya. This change is attributed to factors like excessive rainfall, water logging, flooding, rising temperatures, and significant alterations in the country’s traditional seasonal patterns [8]. In Bangladesh, the dengue situation in 2023 is cause for serious concern, with a significant increase in both the number of dengue cases and related fatalities compared to the past five years. The dengue virus has affected all 64 districts of Bangladesh. The surge in dengue cases began in May 2023 and has persisted since then [9,10,11]. However, because of possibility of under reporting, it is assumed that the actual figures for both cases and fatalities may be considerably higher than the reported numbers. Based on a survey run by the Directorate General of Health Services (DGHS), in the earlier part of 2022 (pre-monsoon), there was an increased concentration of Aedes mosquitoes in Dhaka, exceeding the levels recorded in 2021. Experts in the Communicable Disease Control (CDC) unit of the DGHS had foreseen a deteriorating dengue situation in Dhaka city for this year unless proactive measures were implemented. A follow-up survey, (monsoon) produced in September, indicated that the mosquito population in Dhaka city doubled compared to the pre-monsoon assessment [[9,10,11]. Therefore, this current outbreak could have been predicted. The reports from the CDC should have been treated with utmost seriousness, and prompt, well-targeted measures from the relevant agencies could have played a crucial role in alleviating the ongoing crisis. The fundamental aspect of dengue prevention is safeguarding the population from dengue virus transmission. There is no alternative to individual and social awareness and governmental engagement for dengue control. Mosquito and larva eradication efforts must be undertaken at both the government and private levels. The examples of school, college, and community-based voluntary initiatives are not new in Bangladesh. Social and political organizations must take a proactive role. Additionally, using mosquito nets and mosquito repellent creams at home could provide essential avoidance from mosquitoes. This review is limited by the fact that a literature review of similar nature is prone to bias, which could be reduced by a systematic review. Since this study did not follow a systematic review methodology, the search strategies did not warrant a comprehensive review. Further, this study included data for about 22 years, primarily using the outbreaks reported from Bangladesh. In addition, the review did not use a systematic method of reducing the risk of bias assessment by meta-analysis of the data.   Conclusions Dengue prevention and control in Bangladesh and other dengue endemic countries of the region require a dedicated multi-pronged approach involving individual, social, and government efforts. Additionally, the global impacts of dengue also highlight the need for coordinated efforts in surveillance, research, and preventive measures to combat the spread of the disease and its detrimental consequences on public health and economies worldwide.   Competing interest No competing interest/conflict of interest.   References 1.     Aryal, S. (Editor). Dengue and dengue virus – An overview.  Microbe Notes. 2021. Available at: https://microbenotes.com/dengue/ [Accessed 12 December 2023]. 2.     Mustafa MS, Rasotgi V, Jain S, Gupta V. Discovery of fifth serotype of dengue virus (DENV-5): A new public health dilemma in dengue control. Med J Armed Forces India. 2015; 71(1): 67-70. doi: 10.1016/j.mjafi.2014.09.011. 3.     World Health Organization (21 December 2023). Disease Outbreak News; Dengue – Global situation Available at: https://www.who.int/emergencies/disease-outbreak-news/item/2023-DON498. [Accessed 30  December 2023] 4.     Sarker AR, Paul S, Zohara F, Hossain Z, Zabeen I, Chowdhury SMZI, et al.  Economic burden of dengue in urban Bangladesh: A societal perspective. PLoS Negl Trop Dis. 2023; 17(12): e0011820. doi:10.1371/journal.pntd.0011820 5.     Beasley DWC, Barrett ADT. The Infectious Agent. In: Pasvol G, Hoffman SL, editors. Dengue. Vol. 5. Covent Garden, London, UK: Imperial College Press; 2008. p. 29–73. 6.     Du M, Jing W, Liu M, Liu J. The Global Trends and Regional Differences in Incidence of Dengue Infection from 1990 to 2019: An Analysis from the Global Burden of Disease Study 2019. Infect Dis Ther. 2021; 10(3): 1625-1643. doi:10.1007/s40121-021-00470-2. 7.     World Health Organization (11 August 2023). Disease Outbreak News; Dengue in Bangladesh. Available at: https://www.who.int/emergencies/disease-outbreak-news/item/2023-DON481. 8.     World Health Organization (17 March 2023). Dengue and severe dengue. Available at: https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue [Accessed 13 December 2023]. 9.     UNICEF. Bangladesh Dengue Outbreak. Situation Report #6 15th December 2023. Available at: https://www.unicef.org/media/150136/file/Bangladesh%20Humanitarian%20Situation%20Report%20No.%206%20(Dengue%20Outbreak)%2015%20December%202023.pdf [Accessed 30 December 2023] 10.  Bhowmik KK, Ferdous J, Baral PK, Islam MS. Recent outbreak of dengue in Bangladesh: A threat to public health. Health Sci Rep. 2023; 6(4): e1210. doi: 10.1002/hsr2.1210. 11.  Directorate General Health Services (DGHS), Bangladesh. Bangladesh 2023 dengue outbreak.  ACAPS Briefing Notes. 26 September 2023. Available at: https://www.acaps.org/fileadmin/Data_Product/Main_media/20230926_ACAPS_briefing_note_Bangladesh_2023_dengue_outbreak.pdf [accessed 30 December 2023]. 12.  National Center for Vector Borne Diseases Control, Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India. Dengue Situation in India: Dengue cases and deaths in the country since 2018. Available at: https://ncvbdc.mohfw.gov.in/index4.php?lang=1&level=0&linkid=431&lid=3715[Accessed 14 December 2023]. 13.  Hindustan Times (December 14, 2023). West Bengal records over 76,000 dengue cases in 2023, nearly 10,000 more than 2022. Available at: https://www.hindustantimes.com/cities/kolkata-news/west-bengal-records-over-76-000-dengue-cases-in-2023-nearly-10-000-more-than-2022-101698810081173.html[Accessed 14 December 2023]. 14.  World Health Organization. Health topics: Dengue in South-East Asia. Available at: https://www.who.int/southeastasia/health-topics/dengue-and-severe-dengue [Accessed 14 December 2023]. 15.  Tian N, Zheng JX, Guo ZY, et al. Dengue Incidence Trends and Its Burden in Major Endemic Regions from 1990 to 2019. Trop Med Infect Dis. 2022; 7(8): 180. doi:10.3390/tropicalmed7080180 16.  Kraemer MU, Sinka ME, Duda KA, Mylne AQ, Shearer FM, Barker CM, et al. The global distribution of the arbovirus vectors Aedes aegypti and Ae. albopictus. Elife. 2015; 4: e08347. doi: 10.7554/eLife.08347. 17.  Mukherjee D, Das S, Begum F, Mal S, Ray U. The mosquito immune system and the life of dengue virus: What we know and do not know. Pathogens. 2019; 8(2):77. doi: 10.3390/pathogens8020077. 18.  Novelo M, Hall MD, Pak D, Young PR, Holmes EC, McGraw EA. Intra-host growth kinetics of dengue virus in the mosquito Aedes aegypti. PLoS Pathog. 2019; 15(12): e1008218. doi: 10.1371/journal.ppat.1008218.  19. Asish PR, Dasgupta S, Rachel G, Bagepally BS, Girish Kumar CP. Global prevalence of asymptomatic dengue infections - a systematic review and meta-analysis. Int J Infect Dis. 2023; 134: 292-298. doi:10.1016/j.ijid.2023.07.010 20.  Duong V, Lambrechts L, Paul RE, Ly S, Lay RS, Long KC, et al. Asymptomatic humans transmit dengue virus to mosquitoes. Proc Natl Acad Sci U S A. 2015; 112(47): 14688-14693. doi:10.1073/pnas.1508114112. 21.  ten Bosch QA, Clapham HE, Lambrechts L, Duong V, Buchy P, Althouse BM, et al. Contributions from the silent majority dominate dengue virus transmission. PLoS Pathog. 2018; 14(5): e1006965. doi:10.1371/journal.ppat.1006965. 22.  Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control: New Edition. Geneva: World Health Organization; 2009.  23. CDC (3 May 2019). Testing for dengue virus. Available at: https://www.cdc.gov/dengue/healthcare-providers/testing/index.html [Accessed 13 December 2023]. 24.  Luvira V, Thawornkuno C, Lawpoolsri S, Thippornchai N, Duangdee C, Ngamprasertchai T, et al. Diagnostic Performance of Dengue NS1 and Antibodies by Serum Concentration Technique. Trop Med Infect Dis. 2023; 14; 8(2): 117. doi: 10.3390/tropicalmed8020117. 25.  World Health Organization (14 November 2019). Mosquito sterilization offers new opportunity to control chikungunya, dengue, and Zika. Available at: https://www.who.int/news/item/14-11-2019-mosquito-sterilization-offers-new-opportunity-to-control-chikungunya-dengue-and-zika#:~:text=A%20technique%20that%20sterilizes%20male,form%20of%20insect%20birth%20control [Accessed 13 December 2023]. 26.  CDC (15 July 2022). Mosquitoes with Wolbachia for reducing numbers of Aedes aegypti mosquitoes. Available at: https://www.cdc.gov/mosquitoes/mosquito-control/community/emerging-methods/wolbachia.html [Accessed 13 December 2023]. 27.  Torres-Flores JM, Reyes-Sandoval A, Salazar MI. Dengue Vaccines: An Update. Bio Drugs. 2022; 36(3): 325-336. doi: 10.1007/s40259-022-00531-z.  28.  Chen Y, Huang A, Sui Y, Tong X, Yu F. Progress and development of three types of live attenuated vaccines for dengue fever. Highl Sci Eng Tech 2022; 8: 497-504. doi: doi.org/10.54097/hset.v8i.1204 29.  CDC. Dengue Vaccination: What Everyone Should Know. Center for Disease Control and Prevention. 2023. Available at: https://www.cdc.gov/vaccines/vpd/dengue/public/index.html [Accessed 12 December 2023]. 30.  Walsh MR, Alam MS, Pierce KK, Carmolli M, Alam M, Dickson DM, et al. Safety and durable immunogenicity of the TV005 tetravalent dengue vaccine, across serotypes and age groups, in dengue-endemic Bangladesh: a randomised, controlled trial. Lancet Infect Dis. 2023: S1473-3099(23)00520-0. doi: 10.1016/S1473-3099(23)00520-0.     Cite this article as: Zaman MS, Mitra AK. Dengue in Bangladesh and neighboring countries: an overview of epidemiology, transmission, control, and prevention. IMC J Med Sci. 2024; 18(1):012.  DOI: https://doi.org/10.55010/imcjms.18.012 <![CDATA[Vitamin D levels in seven non-identical occupational groups entail redefining of existing vitamin D deficiency diagnostic cut off level for native Bangladeshi population]]> Tahniyah Haq Nehlin Tomalika Masuda Mohsena Hasina Momtaz Akhter Banu Mohammad Mainul Hasan Chowdhury Kazi Natasha Hashem Md Mohiuddin Tagar Md. Shahed Morshed MA Sayeed https://imcjms.com/journal_full_text/453 2023-03-12 10:43:30 Original Article IMC J Med Sci. 2023; 17(2):001. DOI: https://doi.org/10.55010/imcjms.17.011 Abstract Background and objectives: Recent publications have reported alarming prevalence of hypovitaminosis D in South Asian countries including Bangladesh. But, data on vitamin D levels in different occupational groups are lacking. This study addressed the prevalence of hypovitaminosis D in different occupational groups of Bangladesh. Additionally, the study estimated parathyroid hormone, phosphate, calcium and metabolic syndrome in these groups to see the effect of hypovitaminosis D on these parameters. Materials and method: Seven diverse occupational groups (agrarian workers, rickshaw-pullers, young cricketers and footballers, fishermen, dry fish industry workers, garment-workers and medical students) of Bangladesh were selected based on grade of physical activity and level of sun exposure. Blood was collected for the estimation of 25(OH) vitamin D, fasting glucose,lipid profiles, calcium, phosphate, magnesium and intact parathyroid (iPTH) hormone. Multiple comparisons of these variables among the 7 groups were estimated by ANOVA. Results: A total of 785 (m / f = 359 / 426) participants volunteered. Of them, 54.2% had vitamin D deficiency. Metabolic syndrome was 5% and showed no significant association with hypovitaminosis D (x2 = 0.9, p=0.43). For biophysical characteristics, the mean (±SD) values of age, body mass index, waist to hip ratio and waist to height ratio were – 33.8±16.3y, 22.3±4.1 kg/m2, 0.87±0.06 and 0.39±0.16, respectively. The values for vitamin D (ng/ml), calcium (mg/dl), iPTH (pgm/ml) and phosphate (mg/dl) were 20.25±13.1, 9.57±1.85, 38.22±24.54 and 4.18±0.81, respectively. The comparisons of vitamin D and other related variables among the groups (ANOVA) showed vitamin D level in the garments worker was significantly (p<0.01) higher from other 6 groups. Likewise, compared with other six, rickshaw-pullers had significantly higher calcium level. Calcium, phosphate and parathyroid hormone did not show any change with decreasing vitamin D level (high to low quartile: Q4→Q1), though parathyroid hormone increased significantly at the lowest vitamin D level (Q1:<11.8ng/ml: p=0.002). Conclusion: The prevalence of hypovitaminosis D was high irrespective of occupations, site (rural/urban), social class and sun-exposure. Overall, vitamin D level was low though varied among the groups. Despite minimum and maximum sun-exposure, the garments workers had the highest and the fishermen had the lowest vitamin D levels, respectively. Calcium level was normal in all groups. Calcium, phosphate and parathyroid hormone did not show any changes with decreasing vitamin D, though parathyroid hormone increased significantly when vitamin D decreased to the lowest quartile. The findings indicate that the specific cut off value for vitamin D deficiency needs to be determined for population of a given geographic area. IMC J Med Sci. 2023; 17(2):001. DOI: https://doi.org/10.55010/imcjms.17.011 *Correspondence: M Abu Sayeed, Department of Community Medicine, Ibrahim Medical College, 1/A, Ibrahim Sarani, Segunbagicha, Dhaka 1000, Bangladesh. Email: sayeed1950@gmail.com   Introduction Vitamin D deficiency (hypovitaminosis D) has become a pandemic with the concerned implications in both skeletal and extra-skeletal health. It is common in South Asian countries and Bangladesh ranks second in the prevalence of vitamin D deficiency. Around 67% of Bangladeshi adults were reported vitamin D deficient [1,2]. In Bangladesh, vitamin D deficiency is common in all age-groups and higher in females [1]. A recent study reported vitamin D deficiency was 71% among adequately sunlight exposed coastal fisherman of Bangladesh [3]. Despite abundant sunshine, the high prevalence of vitamin D deficiency is a mystery in a subtropical country like Bangladesh. Genetic factors affecting dermal synthesis and sun avoiding behavior may be an explanation [4]. Also, all these reported level of vitamin D at which deficiency has been defined is according to the cut off values recommended by the different international bodies. Synthesis of vitamin D is affected by many factors including geographical location, season, environmental pollution, sunlight exposure time, exposed body surface and skin color [5]. Several factors including lack of knowledge, inadequate sunlight exposure and low intake of vitamin D rich food and disease conditions were identified as risk factors of vitamin D deficiency in Bangladeshi people [1]. Apart from these, different socio-demographic factors such as old age, female sex, low socio-economic status, urban residence and indoor occupation may be responsible for the low vitamin D level in our population [1,6,7]. The level of vitamin D at which deficiency has been defined is still a debatable issue. The optimal cut-off of vitamin D was determined by several factors including suppression of parathyroid hormone, calcium absorption, markers of bone formation and resorption, bone mineral density, osteomalacia and rickets. The Institute of Medicine (IOM) proposed 20 ng/ml is an optimal cut off level for vitamin D deficiency [8]. Evaluation of bone markers also showed similar cut-off [9]. However, several societies suggest ≤30 ng/ml as an optimal level of risk for vitamin D deficiency [10,11].The plateau of parathyroid hormone is reached at various Vit D levels. Some studies failed to find a relation between parathyroid hormone and vitamin D [9]. Similarly, two studies conducted among Bangladeshi adults found 15.2 ng/ml in female garment workers and 30.1 ng/ml in apparently healthy population, as the minimum Vitamin D level required for suppressing parathyroid hormone [12,13]. There are several studies on vitamin D with conflicting results, especially regarding the optimum level of vitamin D that is required to maintain bone health. Limited data are available regarding vitamin D status with its association with calcium and parathyroid hormone in different occupational groups of Bangladesh. Therefore, this study was undertaken to measure vitamin D, parathyroid hormone and calcium levels in different occupational groups of Bangladesh and to see the relation between them.   Materials and methods The study was approved by the Institutional Ethical Review Board and conducted from May 2018 to July 2021. Study design: Seven occupational groups / workers were selected. The selection was based on grading of (a) physical activities ranging from sedentary to streneous, and (b) exposure to sun from none to heavy. Thus, seven occupations cosidered were: agrarian workers and rickshaw-pullers (moderate sun-exposure with moderate to heavy physical activites, one was rural and the other was urban), garment-workers, and medical students (both sedentary and least sun-exposure and urban), young cricketers and footballers (YCF) from a training institute for athletics and sports (moderate to heavy sun-exposure and physical activities), fishermen and dry fish industry workers (DFIW) both groups had sun-exposure of 4 to 8 hours everyday with moderate to heavy physical activities. For the agrarian workers, five villages were purposively selected in Nandail sub-district of Mymensingh district about 100 Km north-east of Dhaka city. Gament-workers and rickshaw-pullers were selected from Dhaka City. The medical students of Ibrahim medical college (IMC) in Dhaka City actively participated when they were briefed about the objectives of the protocol. The young cricketers and footballers (YCF) from Bangladesh Krira Shikkha Protistan (BKSP), an athlete and sports training institute in Dhaka volunteered. Likewise, the fishermen and dry fish industry workers agreed to volunteer when discussed with the fishermen’s (motsojibi) union of the area. The investigations included - a) socio-economic history, b) clinical history, c) anthropometry (height, weight) d) and estimation of 25-hydroxyvitamin D [25(OH)D] and other biochemical tests namely fasting blood glucose (FBG), lipid profiles, intact parathyroid hormone (iPTH), calcium, phosphate, magnesium, alkaline phosphatase as mentioned in the Figure-1. Algorithm of the study protocol is shown in Figure-1.     Figure-1: Algorithm of the study protocol. FBG: fasting blood glucose, iPTH: intact parathyroid hormone   For each occupational group the willing participants were enlisted on the day before investigation and were informed about the objectives and procedural details of the study. They were advised to attend an investigation site at 8 AM in the next morning with an overnight fast. On the investigation day, each participant was interviewed on socio-economic and clinical history. Height, weight and blood pressure were measured by standard procedures. Body mass index was calculated with the formula (BMI= weight in kg ÷ height in meter2). About 5 ml of blood was collected aseptically from each participant. Collected blood samples were centrifuged and sera were separated in different aliquots, which were frozen locally and transported in coldbox to biochemistry laboratory for analysis. The measurements of plasma glucose were done by glucose oxidase- peroxidase method using Technicon M-II auto analyzer. Lipids namely triglyceride, (TG), cholesterol (Chol), high density lipid (HDL) and low density lipid (LDL) were estimated by Hitachi-704 auto-analyzer using enzymatic method. LDL-cholesterol was measured using formula: LDL-C = 0.9 TC- (0.9 TG/5)-28 [14]. Serum 25-hydroxyvitamin D [25(OH)D] was measured by enzyme linked immunosorbent assay (ELISA). Serum iPTH, calcium, albumin, phosphate and magnesium were measured by chemiluminescent enzyme-labeled immunometric assay with Immulite 2000 systems Siemens, USA analyzer. Corrected calcium was calculated from fasting calcium and albumin by using correction formula {corrected calcium (mg/dl) = measured calcium (mg/dl) + 0.8 × (4 –measured albumin in gm/ dl)}. Diagnostic criteria: Diagnostic cut-off for hypovitaminosis D (or vitamin D deficiency) was <20 ng/ml [8,9] and metabolic syndrome was a constellation of BMI >22.3, SBP >114mmHg, FBG >5.5 mmol/l and TG >165 mg/dl [15]. Statistical analysis: The biophysical characteristics of the seven occupational groups were depicted in mean with standard deviation (SD) and 95% confidence interval (CI). The prevalence rates of vitamin D deficiency of the seven study groups by sex were given in percentages. The characteristics of participants were compared between with and without vitamin D deficiency (vitamin D<20 vs. ≥20 ng/ml) and were estimated by unpaired t-test. Multiple comparisons of variables among different groups were estimated by ANOVA with Scheffe’s Post hoc test.   Results A total of 785 (m / f = 359 / 426) individuals were enrolled in the study (Table-1a). Of the total 785 participants, 424 (54%) had vitamin D deficiency. Compared to males, females had significantly higher prevalence of hypovitaminosis D (m / f = 43.7% / 62.8%, x2 = 28.1, p<0.001). The overall prevalence of metabolic syndrome (MetS) was 5% and not related to hypovitaminosis D (x2 = 0.9, p=0.43 NS; Table 1b). Prevalence of metabolic syndrome was highest in fishermen (12.2%) and lowest in DFI workers [0%; (Table-1c)]. Of them, 45% were non-affluent and 40% were illiterate (data not shown). Regular sun-exposure was found in 41.5%. Agrarian workers, fishermen and young cricketers/footballers had the highest rates of frequent and regular sun exposure.   Table-1a: Prevalence of hypovitaminosis D (Vitamin D <20ng/ml) by gender of the participants (N=785)     Table-1b: Prevalence of metabolic syndrome among the study population having normal (≥20 ng/ml) and deficient (<20ng/ml) vitamin D levels     Table-1c: Prevalence of metabolic syndrome by occupations (N=785)     The characteristics of the study participants are shown in Table 2a, 2b, 2c and 2d. The mean values (±SD) and 95% CI of age, BMI, waist to hip ratio (WHR), waist to height ratio (WHtR) are shown in Table-2a; systolic and diastolic blood pressure (SBP, DBP) and FBG inTable-2b, lipids in Table-2c and vitamin D, iPTH, calcium, ALP, Mg in Table-2d.The mean (±SD) of age, BMI, WHR, SBP, FBG, Chol and HDL were 33.8 (±16.3)y, 22.3 (±4.1) kg/m2, 0.87 (±0.06), 113.6 (±18.2) mmHg, 5.5 (±1.7) mmol/L, 158 (±43.8) mg/dl and 49.1(±8.5) mg/dl, respectively. The mean (±SD) of vitamin D was 20.25 (±13.1) ng/ml) and iPTH was 38.22 (±24.5)  pg/ml), calcium 9.57 (±1.85) mg/dl), phosphate 4.18 (±0.81) mg/dl and magnesium 1.82 (±0.88) mg/dl.   Table-2a: Mean (±SD and 95% CI) values of biophysical characteristics (age, BMI, WHR and WHtR) of the seven occupational groups.     Table-2b: Mean (± SD and 95% CI) values of biophysical and biochemical characteristics (SBP, DBP and FBG) of the seven occupational groups.   Table-2c: Mean (±SD and 95% CI) values of biochemical characteristics (chol, HDL, LDL and TG) of the seven occupational groups.     Table-2d: Mean (±SD and 95% CI) values of Vitamin D, serum calcium, iPTH, phosphate, ALP and magnesium level of the seven occupational groups.     The prevalence of hypovitaminosis D (<20ng/ml) according to occupational groups is shown in Table-3a. Regarding occupation, highest prevalence of hypovitaminosis D was found in DFIW (77%) followed by medical students (72.9%), fishermen (71.6%), YCF (69.9%), rickshaw-puller (42.5%) and lowest in garment workers (23.0%).   Table-3a: Prevalence of hypovitaminosis D (vitamin D <20ng/ml) according to occupational groups     Table-3b depicts prevalence of hypovitaminosis D (<20ng/ml) among the male and female of different occupational groups. Prevalence of hypovitaminosis D was significantly (p<0.05) high among the females compared to males of all occupational groups except medical students (male vs. female: 44.3% vs. 55.7%).   Table-3b: The prevalence of vitamin D deficiency (<20ng/dl) according to gender among different occupational groups     Multiple comparisons of mean (±SD) of vitamin D and calcium levels among the seven occupational groups were estimated by One-Way ANOVA and Post-Hoc tests (Table-4a and 4b). The observed estimated figures are self-explanatory. The source ‘I” denotes an occupation to which other six occupations “J” are compared. As shown in Table 4a, the agrarian workers (I) had significantly lower vitamin D level than garment workers (J), (p =0.002); whereas significantly higher than YCF (p=0.014), fishermen and DFIW (both p = 0.002).   Table-4a: Multiple comparisons of means of vitamin D levels among the seven occupational groups using One-way ANOVA: Post hoc Scheffe tests. The occupational group [‘I’] is compared with the others [‘J’]     Table-4b: Multiple Comparisons of vitamin D and serum calcium levels among the seven occupational groups using One-way ANOVA: Post hoc Scheffe tests. The occupational group [‘I’] is compared with the others [‘J’]   Figure-2 shows the comparisons of vitamin D related variables (calcium and iPTH) among the three occupational groups. Vitamin D and iPTH varied strikingly but calcium did not, rather maintained a consistent level.     Figure-2: Comparative mean (±SE) values of vitamin D (Vit D), calcium (Cal) and parathyroid hormone (iPTH) of agrarian workers (AW), rickshaw-pullers (RP) and medical students (MS).   A line graph (Figure-3) was constructed according to quartiles of vitamin D (Q1 - 4) to determine whether the mean values of iPTH, calcium, phosphate and alkaline phosphatase show any variation with increasing quartile of vitamin D levels and estimated by ANOVA . Serum calcium and phosphate showed no change with the changed vitamin D levels. Only iPTH showed significant difference between Q1 and Q4 of Vitamin D (48.0 vs. 27.7 ng/ml, p=0.002), higher being in the lowest than in the highest quartile. PTH showed significant increase when vitamin D decreased extremely (<11.8 ng/ml: p=0.002). There was a significant weak negative correlation between vitamin D and iPTH. Simple linear regression with iPTH as dependent variable showed a significant association with vitamin D (β=-0.608, p<0.001, 95% CI -0.902 to -0.295, R2=7.1). When vitamin D decreased by 1 ng/ml, iPTH increased by 0.608 pg/ml.     Figure-3: The mean values of iPTH, calcium, phosphate and alkaline phosphatase are shown according to quartiles of vitamin D (Q1<11.8, Q2 11.8 – 17.9, Q3 18 – 24.9 and Q4>25.0 ng/ml), estimated by ANOVA.   Discussion This study was unique considering the inclusions of several occupations that are distinctively different from one another, each with their own entity and characteristics. For example, at one hand there was the non-affluent rickshaw-pullers who were urban dwellers and heavily exposed to the sun doing strenuous physical activities (BMI=19.0); and on the other hand there was the affluent medical students who were also urban, but rarely exposed to the sun and doing minimum physical activities (BMI=25.5). Thus, each group differed from the other with respect to site (urban/ rural), social class (affluent/non-affluent), grading of sun-exposure (maximum/moderate/minimum) and physical activity (strenuous/moderate/sedentary).The observed biophysical characteristics of different groups (Table 2a-2d) also proved such differences. There was a high rate of vitamin D deficiency in the study population, with no association with metabolic syndrome. Surprisingly, the highest rate of vitamin D deficiency was seen in occupations with maximum sun exposure. Despite the low levels of vitamin D, iPTH, calcium and phosphate were in the normal range. There was a weak inverse relation between vitamin D and iPTH, which became more apparent below a vitamin D level of 11 ng/ml. Several studies opined in favor of “association between hypovitaminosis D and the metabolic syndrome, its component factors, cardiovascular disease (CVD) and mortality” [16,17]. However, we found no association between vitamin D deficiency and metabolic syndrome (Table-1b), nor was there any correlation with component factors (correlation matrix not shown). Overall, more than half of the participants had hypovitaminosis D, which is consistent with other South Asian studies [1,-3,7,12,18]. Some unexpected findings were encountered. It is expected that individuals with maximum sun-exposed occupations should have the lowest prevalence of vitamin D deficiency. On the contrary, the garment workers who had minimum sun-exposure had the lowest prevalence (23%) of vitamin D deficiency compared to maximum sun exposed (≥8h/d) occupations – DFIW (77%) and fishermen (71%) (Table3a). Furthermore, the least sun-exposed (garments workers) had the highest vitamin D level, which differed significantly from other groups (Table -4a).Vitamin D level depends on genetic, epigenetic and environmental factors [4]. As the population belonged to low socioeconomic class, poor nutrition may have contributed to the low levels. Bangladesh is a tropical country with abundant sunlight (23.6850° N, 90.3563° E). Lowest level of vitamin D (13.7±7.8ng/ml) was observed in fishermen despite abundant sun exposure. A study in Hawaii also showed that 51% of the population with mean sun exposure of 28.9 hours/week had vitamin D deficiency [18]. Sun exposure does not increase vitamin D above 60 ng/ml. Authors believe that the skin may restrict production of vitamin D in response to excess sun exposure [19]. Possible mechanisms include decreased production, enhanced breakdown, decreased transport of vitamin D in the skin and increased melanin production [18]. In addition to environmental factors, there is an influence of genetic polymorphism on serum 25(OH)D and 1,25(OH) vitamin D levels. Several steps of vitamin D metabolism are under genetic control [4]. Although the genetic influence of vitamin D is still poorly understood, family studies in different populations have found that genetic factors contribute to 70% of the variation in serum vitamin D level [20]. Genetic polymorphisms arising from evolutionary responses to the environment may explain different levels of vitamin D in different populations. The other uncommon finding – despite low vitamin D level, serum iPTH, calcium and phosphate levels were in the normal range. Usually, iPTH maintains inverse association with vitamin D. In this study, inverse relation was found only at extremely low vitamin D level (<11.8ng/ml), when iPTH increased significantly [Figure-3]., We found iPTH did not increase with decreasing vitamin D till it reached <11.8ng/ml, after which iPTH increased significantly. Possibly, this rise was inevitable to maintain dynamic calcium-phosphate homeostasis. There are many studies looking at the relationship between vitamin D and parathyroid hormone. However, they had controversial results. Not all studies found a definite level of vitamin D at which iPTH level increased [9]. However, some of them demonstrated that iPTH reached a plateau below a vitamin D of 30 ng/ml [5,21]. The threshold of vitamin D below which markers of bone resorption and formation start to increase was only 18 ng/dl [9]. A study on 200 young Bangladeshi female garments workers found that iPTH level increased below a vitamin D cut off of 15.22 ng/ml [12]. Another similar study in 130 healthy Bangladeshi adults with a mean age of 37 years showed a cut off of 27.55 ng/ml [13]. Reciprocal association between vitamin D and iPTH may not be simple. Some unexplored determinants might influence calcium-phosphate-magnesium homeostasis. Phosphate homeostasis is under direct influence of calcitriol, iPTH, and phosphatonins, including fibroblast growth factor 23 (FGF-23). Receptors of vitamin D, FGF-23, iPTH, and calcium-sensing receptor (CaSR) also play an important role in phosphate homeostasis [17,22]. It is now clear that there is interplay of FGF-23, Klotho and parathyroid hormone on the calcium and phosphate homeostasis [23,24]. Regarding limitations of the study, we could not ascertain drug history (anyone taking vitamin D or other micronutrients), dietary habits (fat-deficient), steatorrhea and presence of inflammatory bowel syndrome (IBS). Had there been dual energy X-ray absorptiometry (DEXA scan) we could have shown association between vitamin D deficiency and osteopenia. We could not also investigate iPTH, phosphate, and magnesium for all participants.   Conclusions We conclude that the prevalence of hypovitaminosis D in the study population was high and was not related to metabolic syndrome (obesity, hyperglycemia, hypertension, dyslipidemia). It was also revealed that sun-exposure had insignificant effect on vitamin D level. Calcium and phosphate showed no association with vitamin D. Also, parathyroid hormone and vitamin D levels showed no significant association except at the lowest quartile of the vitamin D level. Despite very low vitamin D level, the participants were found physically active and mentally healthy with respect to their occupations. We may assume ‘hypovitaminosis D’ is not the only player in maintaining electrolytes and health. So, our findings reasonably demand a careful evaluation of the existing cut-offs values for hypovitaminosis D based on and including other regulatory substances or secretions namely FGF-23, Klotho, osteocalcin and phosphatonins.   Acknowledgments   We shall remain obliged to the Government of the People’s Republic of Bangladesh, Ministry Of Education and Bangladesh Bureau of Educational Information & Statistics (BANBEIS) for funding the project.   Author’s contributions TH: designing of the study, wrote the manuscript and analyzed the data; MSM: wrote the introduction of the manuscript; NT, MM, HM, AB, MMHC, KNH, MMT: involved in designing of the study, data collection, organization, computing, editing, and assisting reviewing literatures and laboratory assay; MAS: involved in designing of the study, data collection, data analysis and editing manuscript,   Competing interest The authors declare no conflict of interest.   References 1.     Islam MZ, Bhuiyan NH, Akhtaruzzaman M, Allardt CL, Fogelholm M. Vitamin D deficiency in Bangladesh: A review of prevalence, causes and recommendations for mitigation. Asia Pac J Clin Nutr. 2022; 31(2): 167-180. doi: 10.6133/apjcn.202206_31(2).0002. 2.     Siddiqee MH, Bhattacharjee B, Siddiqi UR, Rahman MM. High prevalence of Vit D deficiency among the South Asian adults: a systematic review and meta-analysis. BMC Public Health. 2021; 21(1): 1823. doi: 10.1186/s12889-021-11888-1. 3.     Haque WMMU, Pathan MF, Sayeed M. Vitamin D status of healthy coastal fishermen of Bangladesh. IMC J Med Sci. 2020; 13(2): 35-9. 4.     Bahrami A, Sadeghnia HR, Tabatabaeizadeh SA, Bahrami-Taghanaki H, Behboodi N, Esmaeili H, et al. Genetic and epigenetic factors influencing Vit D status. J Cell Physiol. 2018; 233(5): 4033-4043. doi: 10.1002/jcp.26216. 5.     Holick MF. Vitamin D deficiency. N Engl J Med. 2007; 357(3): 266-281. doi: 10.1056/NEJMra070553. 6.     Mahmood S, Rahman M, Biswas SK, Saqueeb SN, Zaman S, Manirujjaman M, et al. Vitamin D and parathyroid hormone status in female garment workers: a case-control study in Bangladesh. Biomed Res Int. 2017; 2017: 4105375. doi: 10.1155/2017/4105375. 7.     Acherjya GK, Ali M, Tarafder K, Akhter N, Chowdhury MK, Islam DU, et al. Study of vitamin D deficiency among the apparently healthy population in Jashore, Bangladesh. Mymensingh Med J. 2019; 28(1): 214-221. 8.     Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium. Dietary reference intakes for calcium and Vit D. Ross AC, Taylor CL, Yaktine AL, Del Valle HB, editors. Washington (DC): National Academies Press (US); 2011. Available at: https://www.ncbi.nlm.nih.gov/ books/NBK56070/. doi: 10.17226/13050. 9.     Sai AJ, Walters RW, Fang X, Gallagher JC. Relationship between vitamin D, parathyroid hormone and bone health. J Clin Endocrinol Metab. 2011; 96(3): E436-46. doi: 10.1210/jc.2010-1886. 10   Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011; 96(7): 1911-30. doi: 10.1210/jc.2011-0385. 11.  American Geriatrics Society Workgroup on Vitamin D Supplementation for Older Adults. Recommendations abstracted from the American Geriatrics Society Consensus Statement on Vitamin D for prevention of falls and their consequences. J Am Geriatr Soc. 2014; 62(1): 147-52. doi: 10.1111/jgs.12631. 12.  Islam MZ, Shamim AA, Kemi V, Nevanlinna A, Akhtaruzzaman M, Laaksonen M, et al. Vitamin D deficiency and low bone status in adult female garment factory workers in Bangladesh. Br J Nutr. 2008; 99(6): 1322-9. doi: 10.1017/S0007114508894445. 13.  Yadav A, Selim S, Haq T, Shah AK, Morshed MS, Ghani MH, Faisal I, khan MA, Mustari M, Rajib MH, Hossain MF, Hasanat M, Fariduddin M. Vitamin D level in healthy Bangladeshi adults- a pilot study. J Medicine. 2022; 23(2): 139-45. 14.  Anandaraja S, Narang R, Godeswar R, Laksmy R, Talwar KK. Low density lipoprotein cholesterol estimation by a new formula in Indian population. Int J Cardiol. 2005; 102(1): 117–120. 15.  Kassi E, Pervanidou P, Kaltsas G, Chrousos G. Metabolic syndrome: definitions and controversies. BMC Med. 2011; 9: 48. doi: https://doi.org/10.1186/1741-7015-9-48. 16.  Parker J, Hashmi O, Dutton D, Mavrodaris A, Stranges S, Kandala NB, Clarke A, et al. Levels of vitamin D and cardiometabolic disorders: systematic review and meta-analysis. Maturitas. 2010; 65: 225–236. 17.  Strange RC, Shipman KE, and Ramachandran S. Metabolic syndrome: A review of the role of vitamin D in mediating susceptibility and outcome. World J Diabetes. 2015 Jul 10; 6(7): 896–911. doi: 10.4239/wjd.v6.i7.896 18.  Binkley N, Novotny R, Krueger D, Kawahara T, Daida YG, Lensmeyer G, et al. Low vitamin D status despite abundant sun exposure. J Clin Endocrinol Metab. 2007; 92(6): 2130–2135. doi: https://doi.org/10.1210/jc.2006-2250. 19.  Holick MF, MacLaughlin JA, Doppelt SH. Regulation of cutaneous previtamin D3 photosynthesis in man: skin pigment is not an essential regulator. Science. 1981; 211: 590-593. 20.  Karohl C, Su S, Kumari M, Tangpricha V, Veledar E, Vaccarino V, Raggi P. Heritability and seasonal variability of vitamin D concentrations in male twins. Am J Clin Nutr. 2010; 92(6): 1393-1398. 21.  Dawson-Hughes B, Heaney RP, Holick MF, Lips P, Meunier PJ, Vieth R. Estimates of optimal vitamin D status. Osteoporos Int. 2005; 16: 713–716. 22.  Goyal R, Jialal I. Hyperphosphatemia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. 2022 Jun 21. 23.  Gayan-Ramirez G, Janssens W.Vitamin D Actions: The Lung Is a Major Target for Vitamin D, FGF23, and Klotho. JBMR Plus. 2021 Nov 18; 5(12): e10569. doi: 10.1002/jbm4.10569. 24.  Noriko Ide, Rui Ye, Gourbebaisse M, Olauson H, Densmore MJ, Larsson TE et al. In vivo evidence for interplay of FGF23/Klotho/PTH axis on the phosphate handling in renal proximal tubules. Am J Physiol Renal Physiol. 2018 Nov 1; 315(5): F1261-F1270. doi: 10.1152/ajprenal.00650.2017       Cite this article as:  HaqT, TomalikaN, MohsenaM, MomtazH, BanuA, ChowdhuryMMH, HashemKN, TagarMM, MorshedMS, SayeedMA. Vitamin D levels in seven non-identical occupational groups entail redefining of existing vitamin D deficiency diagnostic cut off level for native Bangladeshi population. IMC J Med Sci. 2023; 17(2): 001. DOI: https://doi.org/10.55010/imcjms.17.011 <![CDATA[Trends in HIV/AIDS incidence rate in Mississippi, 2008-2019]]> Adetoun F. Asala Azad R. Bhuiyan Amal K. Mitra Vincent L. Mendy Anthony R. Mawson Luma Akil https://imcjms.com/journal_full_text/454 2023-03-14 12:03:34 Original Article IMC J Med Sci. 2023; 17(2):002 Abstract Background and objectives: Despite the decline in new HIV infection across the United States, Mississippi is still experiencing high rates of new HIV infections. Reports highlighted significant variations by geographical locations and socio-demographic factors. This study examined trends of HIV/AIDS incidence rates in Mississippi from 2008 to 2019. Materials and methods: Data on HIV/AIDS diagnosis were extracted from Mississippi Enhanced HIV/AIDS Reporting System database. Data were cleaned and de-identified using Microsoft Excel and SAS 9.4. Overall and annual age-adjusted HIV and AIDS incidence rates were calculated by sex, race, and age using 2000 US population. Annual Percentage Change (APC) and Average Annual Percentage Change (AAPC) were analyzed using Joinpoint regression models. Results: Overall, HIV incidence rate declined from 25.0 in 2008 to 18.79 per 100,000 population in 2019 (24.8% decrease) while AIDS incidence increased from 6.4 in 2008 to 8.2 per 100,000 population in 2019 (28.1% increase). Comparison between sexes of all age groups showed a downward trend of new HIV infection (AAPC: Male:-1.50, Female:-5.17) and an upward trend of AIDS incidence (AAPC: Male: 1.90, Female: 3.70). Age adjusted HIV incidence declined by 26.8% and 12.4% among blacks and whites respectively (AAPC: Blacks: -2.8, Whites:-1.0) but there was no significant change in age-adjusted AIDS incidence among both races from 2008-2019. Conclusion: This study indicated that age-adjusted HIV incidence rate is declining in Mississippi but trends differ by race, gender, and age. More interventions aimed at ensuring early diagnosis, proper linkage to care and preventing the progression of HIV to AIDS particularly among at-risk population are needed in Mississippi. IMC J Med Sci. 2023; 17(2):002. DOI: https://doi.org/10.55010/imcjms.17.012 *Correspondence: Adetoun F. Asala, Department of Epidemiology and Biostatistics, School of Public Health, 350 W Woodrow Wilson Dr, Jackson, MS 39213. Email: adetoun.f.asala@students.jsums.edu   Introduction Human immunodeficiency virus (HIV) still poses a significant threat to public health globally despite improved antiretroviral therapies (ART) [1]. About 50,000 new HIV infections have been reported annually over the past decade in the United States. In 2015, Mississippi ranked seventh highest in the rate of new HIV infections (19.2) and the city of Jackson ranked fourth highest HIV infection rate in the nation. Also, Mississippi has one of the highest numbers of AIDS-related deaths in the nation [2,3]. New HIV infection patterns and distribution highlight that high-risk groups, some geographical locations, and racial and ethnic minorities are disproportionately affected by HIV/AIDS [4,5]. The Centers for Disease Control and Prevention CDC, (2018) reported 37,968 new HIV diagnoses; gay and bisexual men accounted for 69%, while heterosexuals and injection drug users (IDUs) accounted for 24% and 7% respectively; these groups represent the largest proportion of new HIV diagnoses. In addition, the incidence of new HIV infections is commonest among adolescents and adults between ages 13-34 [6]. Various epidemiological studies reported that new HIV infection in the United States has declined by 9% in recent years; this decline varies by gender, ethnicity/race, and geographical location [7,8]. Mississippi still has high rates of new HIV infection [9]. Annual incidence rates of HIV infection in Mississippi vary significantly and range from 5 to 19.1 per 100,000 persons depending on the region and location. The city of Jackson and Mississippi Delta region has the highest rates of HIV infection in the state [10,11]. Examining trends of HIV/AIDS incidence rates by age, gender, ethnicity/race is important and would be informative for statewide policymakers to design and implement effective interventions to protect vulnerable populations and prevent new infections. Despite its public health importance, limited studies have been conducted to examine trends and annual changes in HIV/AIDS incidence rates in Mississippi. To address this gap, an in-depth study was undertaken to explore the annual percentage change, and average annual percentage change in age-adjusted HIV/AIDS infection among Mississippians from 2008 to 2019.   Materials and Methods Data collection and analyses Data was extracted from Mississippi Enhanced HIV/AIDS Reporting System (eHARS). eHARS is a secure relational database with web-based data system and a SQL-server back-end which is designed and provided by CDC to all jurisdictions in United States to collect HIV surveillance data. Like other jurisdictions, Mississippi maintains HIV surveillance data in eHARS and submits de-identified data to CDC’s national database monthly through a secure data network. SAS versions 9.3 and 9.4 were used to preprocess data from eHARS into a standardized format [12]. Data of newly diagnosed HIV/AIDS infection between 2008 and 2019 in Mississippi were collected. Age adjustment was done using direct method and the 2000 US standard projected population [13]. The US census estimates for Mississippi population for each year from 2008 to 2019 were used to calculate crude and age-adjusted incidence rates, as well as standard errors for the overall population. Stratified analyses were done by age groups (0-14, 15-44, 45-64, ³65 years), race (white or black), and gender (male or female) for each year. Analyses for racial groups were restricted to non-Hispanic black and non-Hispanic white groups because these groups accounted for 96.9% of the entire Mississippi population in 2019 [14].   Formulae used: The standard error represents a measure of precision of the estimates calculated. Age-adjusted standard error for incidence, prevalence, and deaths for each year from 2008-2019 was computed by gender and race/ethnicity using the formula below: Age adjusted standard error = Total number of cases each Year by specified age groups / (Total population of the specified age groups each Year)2 X (Weight of specified age group)2   Statistical Analysis The data were analyzed using SAS 9.4 (SAS Institute Inc). PROC FREQ procedure was used for frequency analysis to count the proportions of new HIV and AIDS cases for each year from 2008 to 2019. Crude- and age-adjusted HIV/AIDS incidence rates were calculated using excel spreadsheet for new cases, total number of cases as numerators and the corresponding overall and strata-specific population estimates as the denominator. All stratified age-adjusted rates and standard errors were calculated to estimate respective yearly rates. Age at diagnosis were categorized into age groups (0-14, 15-44, 45-64, and 65 and above) of the 2000 US standard population and weights for these age groups were calculated [13]. Then, we exported the computed age-adjusted rates and standard errors to the US Surveillance, Epidemiology, and End Results (SEER) Joinpoint regression program version 4.9.0.1.0 [15] to calculate Annual Percentage Change (APC) and Average Annual Percentage Change (AAPC) of HIV/AIDS incidence rates in Mississippi by age, sex, and race. Joinpoint regression analysis is one of the widely applied methods for examining trends of disease incidence rates, death rates or survival rates. Joinpoint regression fits linear regression and describes trend in each time segment and these trends could significantly change between segments thus identifying change points of trend over time. Joinpoint regression analysis identifies points where there were significant changes in a trend and pinpoints periods with distinct log-linear trends in HIV/AIDS incidence rates. The Bayesian information criterion was used to select parsimonious model with the best fit and a maximum of 3 Joinpoints were specified; using Monte Carlo Permutation method, the test for significance finds the best fit line for each segment [16]. Slopes of the model were used to calculate APC for each trend segment as well as AAPC, 95% confidence intervals were calculated for each AAPC with significant P-values set at <0.05.   Results From 2008 to 2019, Mississippi recorded a total of 7,322 new cases of HIV and 3,044 new cases of AIDS. The source population for which incidence rates were estimated from 2008 to 2019 was obtained from Mississippi vital statistics. Most cases were reported among males (77.4% HIV, 76.91% AIDS), blacks, (77.4% HIV, 78% AIDS), age group 15-44 (78.2% HIV, 71.9% AIDS), and MSMs (50.1% HIV, 46.04 % AIDS) (Table-1).   Table-1: Number of new HIV/AIDS cases reported, 2008-2019     The overall age-adjusted HIV incidence rate declined from 25 cases per 100,000 population in 2008 to 18.8 cases in 2019 (-24.8% decrease) whereas age-adjusted AIDS incidence rate increased from 6.4 cases per 100,000 population in 2008 to 8.2 cases in 2019 (28.1% increase) (Figure-1).     Figure-1: Overall age-adjusted HIV/AIDS Incidence rate per 100,000 population in Mississippi, 2008-2019   HIV Incidence Rates by Gender From 2008 - 2019, among females age-adjusted HIV incidence rate declined by 50% (14.2 cases per 100,000 to 7.1 cases per 100,000), with an average annual decline of -5.2% (AAPC, -5.2%, 95% CI, -7.9% to -2.5%). However, there was no significant decline among males during this period (50% decline; 36.1 cases per 100,000 to 30.7 cases per 100,000; AAPC, -1.5%, 95% CI, -3.8% to 0.9%). The trends in males consisted of 2 segments; a nonsignificant APC of 1.4% (95% CI, -7.2% to 10.9%) during the first segment (2008-2011) and a significant APC of -2.6% (95% CI, -4.6% to -0.6%) in the second segment (2011-2019). In addition, trends in females consisted of 2 segments; a significant APC of -10.8% (95% CI, - 16.8% to -4.3%) during the first segment (2008-2012) and a nonsignificant APC of - 1.9% (95% CI, -5.5% to 1.7%) in the second segment (2012-2019). In addition, trends in females consisted of 2 segments; a significant APC of -10.8% (95% CI, - 16.8% to -4.3%) during the first segment (2008-2012) and a nonsignificant APC of - 1.9% (95% CI, -5.5% to 1.7%) in the second segment (2012-2019). See Table-2 and Figure-2.     Figure-2: Age-adjusted HIV incidence rates per 100,000 population in Mississippi. By gender, 2008-2019   Incidence Rates by Race From 2008- 2019, among blacks age-adjusted HIV incidence rate declined by 26.8% (47.8 per 100,000 population to 35.0 per 100,000) with an average annual decline of -2.8% (AAPC, -2.8% 95% CI, -5.1% to -0.4%). However, there was no significant decline among whites during this period (a relative decline of 12.4%; 8.9 per 100,000 population to 7.8 per 100,000) with an average annual decline of -1.0% (AAPC, -1.0%, 95% CI, -3.4% to 1.5%). The trend among whites consisted of 2 segments; a significant APC of -2.9% (95% CI, -4.8% to -1.0%) during the first segment between 2008 and 2016 and a nonsignificant APC 4.5% (95% CI, -5.0% to 15.0%) in the second segment (2016-2019) whereas trend among blacks consisted of 2 nonsignificant segments; an APC of -2.4% (95% CI, -4.9% to 0.2%) during the first segment (2008-2015) and -3.5% (95% CI, -9.7% to 3.1%) in the second segment (2015-2019). See Table- 2 and Figure-3.   Table-2: Trends in HIV Incidence in Mississippi, 2008-2019         Figure-3: Age-adjusted HIV incidence rates per 100,000 population in Mississippi. By race, 2008-2019   HIV Incidence Rates by Age Among children aged 0 to 14 years, new HIV infection declined from 2 per 100,000 population in 2008 to 0 per 100,000 population in 2019. Among people aged 15 to 44 years, new HIV infection declined from 550 per 100,000 population in 2008 to 407 per 100,000 population in 2019, a relative decline of -26% and a significant AAPC decline of -2.2% (95% CI, -4.4% to -0.2%). The trend among this age group consisted of 2 segments; an APC of -1.6% (95% CI, -3.8% to 0.7%) during the first segment (2008-2015) and -3.4% (95% CI, -9.1% to 2.6%) in the second segment (2015-2019). Among adults aged 44 to 65 years, new HIV infection declined from 156 per 100,000 population in 2008 to 108 per 100,000 population in 2019, a relative decline of -30.8% and an AAPC decline of -3.6% (95% CI, -7.1% to 0.1%). In this age group, the trend consisted of 2 segments; a significant APC of -6.6% (95% CI, -9.2% to -3.9%) during the first segment (2008-2016) and a nonsignificant APC 4.9% (95% CI, -9.3% to 21.3%) in the second segment (2016-2019). Among adults aged 65 years and above, new HIV infection increased from 6 per 100,000 population in 2008 to 11 per 100,000 population in 2019, a relative increase of 83.3% and an AAPC of 12.3% (95% CI, -22.7% to 63.0%). The trend among this age group consisted of 2 segments; an APC of 81.4% (95% CI, -64.0% to 814.4%) during the first segment (2008-2011) and -6.2% (95% CI, -16.8% to 5.7%) in the second segment (2011-2019). See Table-2.   AIDS Incidence Rates by Gender From 2008- 2019, among males age-adjusted AIDS incidence rate increased by 30% (10 cases per 100,000 to 13 cases per 100,000), with an average annual increase of 1.9% (AAPC, 1.9%, 95% CI, -0.6% to 4.4%). Also, there was an increase among females during this period (12.9% increase; 3.1 cases per 100,000 to 3.5 cases per 100,000; AAPC, 3.7%, 95% CI, -4.3% to 12.4%). The trends in males consisted of 2 significant segments; an APC of 15.8% (95% CI, -5.9% to 26.6%) during the first segment (2008-2011) and -2.9% (95% CI, -0.5% to 2.9%) during the second segment (2011-2019). However, trends in females consisted of 2 segments which were not significant; an APC of 13.7% (95% CI, - 31.2% to 87.9%) during the first segment (2008-2010) and 1.6% (95% CI, -2.3% to 5.7%) in the second segment (2010-2019). See Table-3 and Figure-4.     Figure 4: Age-adjusted AIDS incidence rates per 100,000 population in Mississippi. By gender, 2008-2019   Table-3: Trends in AIDS Incidence in Mississippi, 2008-2019     AIDS Incidence Rates by Race From 2008- 2019, there was no significant change in age-adjusted AIDS incidence rate among whites and blacks. The age-adjusted AIDS incidence rate among blacks increased by 45% (11.1 per 100,000 population to 16.1 per 100,000) with an average annual increase of 3.7% (AAPC, 3.7% 95% CI, -6.2% to 14.8%). Among whites, the age-adjusted AIDS' incidence rate declined slightly by 3.4% (2.9 per 100,000 population to 2.8 per 100,000) with an average annual decline of 0.3% (AAPC, -0.3%, 95% CI, -5.5% to 5.8%). The trend among blacks consisted of 2 non-significant segments; an APC of 28.5% (95% CI, -31.7% to 141.9%) during the first segment (2008-2010) and -1.1% (95% CI, -5.9% to 3.9%) in the second segment (2010-2019). Also, trend among whites consisted of 2 non-significant segments; an APC of 8.6% (95% CI, -13.0% to 35.6%) during the first segment (2008-2011) and -3.5% (95% CI, -7.6% to 0.9%) in the second segment (2011-2019). See Table-3 and Figure-5.     Figure-5: Age-adjusted AIDS incidence rates per 100,000 population in Mississippi. By race, 2008-2019   AIDS Incidence Rates by Age Among children aged 0 to 14 years, AIDS diagnosis decreased from 1 case per 100,000 population in 2008 to 0 per 100,000 population in 2019. Among people aged 15 to 44 years, AIDS diagnosis increased from 115 per 100,000 population in 2008 to 164 per 100,000 population in 2019, a relative increase of 42.6% and an AAPC of 3.9% (95% CI, -0.4% to 8.5%). The trend among this age group consisted of 2 significant segments; an APC of 23.8% (95% CI, 3.8% to 47.7%) during the first segment (2008-2011) and -2.7% (95% CI, -5.1% to -0.2%) in the second segment (2011-2019). Among adults aged 44 to 65 years, AIDS diagnosis declined from 71 per 100,000 population in 2008 to 65 per 100,000 population in 2019, a relative decline of -8.5% and an AAPC decline of -2.1% (95% CI, -4.9% to 0.8%). In this age group, the trend consisted of 2 segments; an APC of -7.1% (95% CI, -14.1% to 0.4%) during the first segment (2008-2012) and 0.9% (95% CI, -2.3% to 4.2%) in the second segment (2012-2019). Among adults aged 65 years and above, AIDS diagnosis increased from 2 per 100,000 population in 2008 to 4 per 100,000 population in 2019, a relative increase of 100% and a significant AAPC of 6.0% (95% CI, -8.5% to 22.8%). The trend among this age group consisted of 2 segments; a significant APC of 21.8% (95% CI, 4.3% to 42.2) during the first segment (2008-2015) and a nonsignificant APC of -16.9% (95% CI, -44.7% to 24.7%) in the second segment (2015-2019; Table 3).   Discussion In Mississippi across all age groups, age-adjusted HIV incidence rate declined by 24.8% between 2008 and 2019; however, the timing and magnitude of decline differed by gender, race, and age group. Our finding of declining age-adjusted HIV incidence rates is consistent with findings on national trends of new HIV infection reported in 2017 (17) where an annual decline of 4.0% was reported. Various reasons have been documented for the decline in HIV incidence, which includes improved care and prevention services, increased HIV counseling and testing, advanced ART, estimated recency of infection, and reducing HIV incidence among MSMs and other high-risk groups [17,18]. Furthermore, data from CDC highlighted a significant decline of 8% in HIV incidence rate between 2016-2019, however, decline was highest among women, whites, and adults 55 years and above [19, 20, 21]. Reports showed that Mississippi has made considerable progress in reducing new HIV infection and improving diagnosis/testing, as well as quick linkage to care. Knowledge of HIV status is important for an individual to gain access to quality medical care which in turn can improve quality of life, modify health behaviors that could prevent HIV transmission to others, improve quality of life, and extend life expectancy [22]. Unfortunately, about 15% of HIV-positive individuals are not aware of their HIV status [23]. In addition, HIV incidence among Mississippians changed between 2008-2019, age-adjusted HIV incidence rate decreased across all age groups, races, and gender categories. Many studies have reported that the number of new HIV infections in the US has leveled off which could be due to increased awareness about HIV counseling and testing as well as achievement of viral load suppression thus resulting in undetectable and untransmissible viral load [22,24,25,26,27,28]. Also, the new HIV infection was higher among males and blacks when compared to their respective counterparts of the same age group. Adolescents and adults between age 15- 44 years had the highest age-adjusted HIV incidence rates. The lowest rate was observed among females and adults aged 65 years and above. Of the mode of transmission or risk factors category, the highest number of new cases reported between 2008-2019 were among MSM (3,971), followed by heterosexual contact with PWA (1,248), and heterosexual contact with person not HIV positive (1,202). These findings are in line with a national report from 2009- 2018 which indicated considerable progress, an overall decline in new HIV incidence [29]. Similarly, despite overall decline some reports also highlighted disparities in new HIV incidence with blacks, MSMs, adult females who have heterosexual contacts, and age group 25-34 years bearing the highest burdens which are even more prominent in the southern states and the District of Columbia [29,30,31]. The decline in HIV incidence rate reported nationally can be attributed to proven effective HIV prevention interventions some of which include increased HIV testing, quick linkage to care, ART, viral load suppression, increased access to condoms and sterile syringes, increased access to PREP and PEP, education of PWA targeted at reducing risk behaviors and transmission from person to person, education and prevention program to high risk groups, proper screening of blood and body fluids before transfusion, substance abuse treatment, as well as testing and treatment for other sexually transmitted infections. The strategies have averted over 350,000 new HIV infection in the US [2,32]. This decline in HIV incidence rate in Mississippi can also be attributed to increased funding of CDC through Ending HIV Epidemic (EHE). This highlights an improvement in Mississippi’s efforts to reducing new HIV infection which not only targets increasing HIV screenings and testing sites but also includes increase access of Mississippians to pre-exposure prophylaxis (PREPs), condoms, providers/ healthcare workers training, HIV information, education, and communication (IEC) materials, community outreaches. Contrastingly, this study findings also indicated that overall age-adjusted AIDS incidence and death rate increased significantly by 28.1% and 190% respectively. Age adjusted AIDS incidence was highest among males and people between age 15 to 44 years. The upward trend of AIDS incidence highlighted that Mississippi needs to more efforts to create awareness and educate Mississippians about the management of HIV infection to slow disease progression. Males, African Americans, gays, MSMs, adolescents and adults between age 14-44 years were mostly affected by HIV/AIDS in Mississippi. Researchers and medical practitioners have attributed systemic poverty, homophobia and transphobia, late diagnosis and late linkage to care, lost in care or loss to follow up, nonadherence to ART medications, lack of insurance, stigmatization, and unavailability of support group as factors which increase AIDS incidence and death rates [33,34]. In 2013, President Obama signed an executive order giving directives to all federal agencies to prioritize and support HIV Care Continuum Initiative. The initiative which all states including Mississippi benefitted from aimed at accelerating efforts to improve the number of people living with HIV (PLWHIV) to move from testing to treatment and ultimately to achieve viral (The White House [35]. Also, efforts to collectively combat HIV/AIDS in the U.S. recorded progress. For example, in 2013, CDC launched a national bilingual campaign tagged “Reasons/Razones” to encourage bisexual and Latino gay men to get tested for HIV and consider their reasons for getting tested. In addition, in 2017, communities and religious bodies garnered more support, the first national Faith HIV & AIDS Awareness Day which involved collaborations from Christians, Muslims, Jewish, Hindu, Sikh, Buddhist, and Baha’i was launched. The main goal of the organization was to publicly take a stand against stigma within their respective congregations and to create HIV/AIDS awareness in their communities [36]. These collective efforts have significantly contributed to reducing HIV nationally and regionally. Mississippi’s integrated HIV prevention and care plan implemented similar intervention strategies to curb new HIV infection and notable improvement has been reported so far in Mississippi especially with prevention of mother-to-child transmission recording the most successful based on this study findings. Furthermore, findings from this study indicated a 100% decline in pediatric HIV/AIDS incidence between 2008-2019 and no HIV/AIDS related deaths were recorded during this period [37,38]. In 2020, Mississippi received a federal grant to aid the state’s effort of fighting HIV epidemic. One of the goals of the Office of National AIDS policy was to reduce disparities in new HIV diagnoses by at least 15% by year 2020, however, this goal was not met, the disparity ratio increased rather than decrease [39]. It is worthy to note that more interventions targeting AIDS is urgently needed. Mississippi needs comprehensive collective efforts to improve HIV prognosis and reduce AIDS incidence, frequency of testing and counseling in at-risk communities is very paramount. This study has some limitations. First, only people with confirmed HIV diagnosis in the state of Mississippi were included which may have left out individuals who are positive but unaware of their current HIV status. Second, given the nature of the study, there is limited capacity to measure association. Information for some variables collected from eHARS were self-reported, therefore it may be subjected to recall bias as well as under-reporting and over-reporting. Third, some variables in the dataset like education and marital status, had too much missing information which may affect the final interpretation of the results. The major strength of this study was its use of statewide HIV/AIDS surveillance data. Also, the study analyzed trends and observed changes over time. Reliability is the ability of an instrument to consistently measure the variable of interest. All variables measured and reported including lab reports in the eHARS database are reliable and consistent not only in the U.S. but globally. The algorithm for HIV/AIDS case definition is consistent with national and global standards. Generalizability, the result of this analysis can be generalized to all PLWHA in Mississippi and the southern states. Conclusions From 2008-2019, the overall age-adjusted HIV incidence rate declined significantly but the magnitude and timing of the recorded decline varied by age, race, and sex. HIV incidence rates increased significantly among males, MSMs, and blacks; AIDS incidence rates increased significantly among males and people between age 15 to 44 years; HIV/AIDS death rates increased significantly among men from year 2008 to 2014 and among women from 2008 to 2017. Also, overall age-adjusted death rate was highest among people ages 15 to 44 years.   Author contributions: AFA, VLM, ARB, AKM, LA and ARM: conceptualization and methodology; AFA and VLM: data analysis; AFA: writing—original draft preparation;, ARB, VLM, AKM, LA and ARM: review and editing. All authors have read and agreed to the published version of the manuscript.   Funding: This research received no external funding.   Ethical approval: This study was approved by Jackson State University Institutional Review Board and Mississippi Department of Health (4091D15AA246469D9658C323E43BD888).   Data availability statement: Data used is not publicly available but can be requested from Mississippi data governance office and STD/HIV Office at Mississippi State Department of Health.   Acknowledgments: We thank Mississippi State Department of Health. We did not receive financial support for this work and no copyrighted materials, surveys, tools, or instruments were used.   Conflicts of interest: The authors declare no conflict of interest.   References 1.     Maartens G, Celum C, Lewin SR. HIV infection: epidemiology, pathogenesis, treatment, and prevention. The Lancet. 2014; (9939): 258-71. 2.     Centers for Disease Control and Prevention. Diagnoses of HIV infection in the United States and dependent areas, 2018. HIV surveillance report. 2019; 31. 3.     HrostowskiS, Camp A. The unchecked HIV/AIDS crisis in Mississippi. Soc Work Health Care. 2015; 54(5): 474-83. 4.     Hanna DB, Selik RM, Tang T, Gange SJ. Disparities among states in HIV-related mortality in persons with HIV infection, 37 US States, 2001–2007. AIDS (London, England). 2012; 26(1): 95. 5.     Huang MB, Ye L, Liang BY, Ning CY, Roth WW, Jiang JJ, et al. Characterizing the HIV/AIDS epidemic in the United States and China. Int J Environ Res Public Health. 2016; 13(1): 30. 6.     Center for Disease Control and Prevention, CDC Fact Sheet–HIV in the United States: At aglance.2018. https://www.cdc.gov/hiv/statistics/overview/ataglance.html 64 Accessed Mar 7, 2021. 7.     Sidibé M, Loures L, Samb B. The UNAIDS 90–90–90 target: a clear choice for ending AIDS and for sustainable health and development. J Int AIDS Soc. 2016; 19(1). 8.     Parashar S, Collins AB, Montaner JS, Hogg RS, Milloy MJ. Reducing rates of preventable HIV/AIDS-associated mortality among people living with HIV who inject drugs. Curr Opin HIV AIDS. 2016; 11(5): 507. 9.     Barnes A, Nunn A, Karakala S, Sunesara I, Johnson K, Parham J, et al. State of the ART: characteristics of HIV infected patients receiving care in Mississippi (MS), USA from the medical monitoring project, 2009–2010. J Miss State Med. 2015; 56(12): 376. 10.  Johnson K, Dobbs T. Late Diagnoses of HIV Infection in Mississippi: Implications for Improved Testing Strategies and Treatment. J Miss State Med. 2015; 56(6): 162-5. 11.  Sison N, Yolken A, Poceta J, Mena L, Chan PA, Barnes A, et al. Healthcare provider attitudes, practices, and recommendations for enhancing routine HIV testing and linkage to care in the Mississippi Delta region. AIDS Patient Care STDs. 2013; 27(9): 511-7. 12.  Ocampo JM, Smart JC, Allston A, Bhattacharjee R, Boggavarapu S, Carter S, et al. Improving HIV surveillance data for public health action in Washington, DC: a novel multiorganizational data-sharing method. JMIR Public Health Surveillance. 2016; 2(1): e5317. 13.  Klein RJ. Age adjustment using the 2000 projected US population. Department of Health & Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2001. 14.  Mississippi Vital Statistics. 2021. The Mississippi Statistically Automated Health Resource System (MSTAHRS).  https://mstahrs.msdh.ms.gov. Accessed February 18, 2022. 15.  Kim HJ, Fay MP, Feuer EJ, Midthune DN. Permutation tests for joinpoint regression with applications to cancer rates. Stat Med. 2000; 19(3): 335-51. 16.  Zhang NR, Siegmund DO. A modified Bayes information criterion with applications to the analysis of comparative genomic hybridization data. Biometrics. 2007; 63(1): 22-32. 17.  Hall HI, Song R, Tang T, An Q, Prejean J, Dietz P, et al. HIV trends in the United States: diagnoses and estimated incidence. JMIR Public Health Surveillance, 2017; 3(1), p.e7051. 18.  Bertozzi S, Padian NS, Wegbreit J, DeMaria LM, Feldman B, Gayle H, et al. HIV/AIDS prevention and treatment. DCP1, 2006;2, pp.331-370. 19.  CDC. HIV Diagnoses. HIV. https://www.cdc.gov/hiv/statistics/overview/in-us/diagnoses.html. Accessed Dec 7, 2022 20.  Linley L, Johnson AS, Song R, Hu S, Wu B, Hall HI, et al. Estimated HIV incidence and prevalence in the United States 2010–2019. 21.  Krueger A, Dietz P, Van Handel M, Belcher L, Johnson AS. Estimates of CDC-funded and national HIV diagnoses: a comparison by demographic and HIV-related factors. AIDS Behav. 2016; 20(12): 2961-5. 22.  Patel D, Johnson CH, Krueger A, Maciak B, Belcher L, Harris N, et al. Trends in HIV testing among US adults, aged 18–64 years, 2011–2017. AIDS Behav. 2020; 24(2), pp.532-539. 23.  Centers for Disease Control and Prevention, HIV Statistics Overview. 2020.  https://www.cdc.gov/hiv/statistics/overview/index.html Accessed Apr 10, 2022. 24.  Guilamo-Ramos V, Thimm-Kaiser M, Benzekri A, Futterman D. Youth at risk of HIV: the overlooked US HIV prevention crisis. The Lancet HIV. 2019; 6(5), pp.e275-e278. 25.  Hess  KL, Johnson AS, Hu X, Li J, Wu B, Yu C, et al. 2017. Diagnoses of HIV infection in the United States and dependent areas, 2016. Centers for Disease Control and Prevention. HIV Surveillance Report, 2016; vol. 28. 26.  HIV.gov. HIV National Strategic Plan (2021-2025). 2021. https://www.hiv.gov/federal-response/hiv-national-strategic-plan/hiv-plan-2021-2025 Accessed Jan 20, 2022  27.  Bain LE, Nkoke C, Noubiap JJN. UNAIDS 90–90–90 targets to end the AIDS epidemic by 2020 are not realistic: comment on “Can the UNAIDS 90–90–90 target be achieved? A systematic analysis of national HIV treatment cascades”. BMJ Glob Health. 2017; 2(2), p.e000227. 28.  Joint United Nations Programme on HIV/AIDS. Joint United Nations Programme on HIV/AIDS: 90-90-90: An ambitious treatment target to help end the AIDS epidemic. 2014. Geneva: UNAIDS. 29.  Sullivan PS, Johnson AS, Pembleton ES, Stephenson R, Justice AC, Althoff KN, et al. Epidemiology of HIV in the USA: epidemic burden, inequities, contexts, and responses. The Lancet. 2021; 397(10279): 1095-106. 30.  Mayer KH, Nelson L, Hightow-Weidman L, Mimiaga MJ, Mena L, Reisner S, et al. The persistent and evolving HIV epidemic in American men who have sex with men. The Lancet. 2021; 397(10279): 1116-26. 31.  Beyrer C, Sullivan PS, Sanchez J, Dowdy D, Altman D, Trapence G, et al. A call to action for comprehensive HIV services for men who have sex with men. The Lancet. 2012; 380(9839): 424-38. 32.  Centers for Disease Control and Prevention. HIV prevention works. 2020. https://www.cdc.gov/hiv/policies/hip/works/html Accessed Feb 2, 2022. 33.  Beer L, Valverde EE, Raiford JL, Weiser J, White BL, Skarbinski J. Clinician perspectives on delaying initiation of antiretroviral therapy for clinically eligible HIV-infected patients. J Int Assoc Provid AIDS Care. 2015; 14(3): 245-54. 34.  Ingabire PM, Semitala F, Kamya MR, Nakanjako D. Delayed antiretroviral therapy (ART) initiation among hospitalized adults in a resource-limited settings: a challenge to the global target of art for 90 of hiv-infected individuals. AIDS Res Treat. 2019; 2019. 35.  The White House. Executive Order-HIV Care Continuum Initiative. 2013. The Press Office. https://obamawhitehouse.archives.gov/the-press- office/2013/07/15/executive-order-hiv-care-continuum-initiative Accessed Jun 1, 2022. 36.  HIV.gov. National Faith HIV/AIDS Awareness Day. HIV.Gov.N.D. https://www.hiv.gov/events/awareness/faith Accessed May 4, 2022. 37.  Centers for Disease Control and Prevention. HIV Prevention: Mississippi- CDC. 2021. https://www.cdc.gov/hiv/pdf/policies/profiles/cdc-hiv-mississippi- PrEP.pdf  Accessed Dec 5, 2021. 38.  Mississippi State Department of Health. 2017-2021Integragted HIV Prevention and Care Plan. 2016.http://www.msdh.state.ms.us/msdhsite/index.cfm/14,7022,150,pdf/7022.pdf Accessed Jun 1, 2022. 39. Zalla LC, Edwards JK, Cole SR, Rudolph JE, Breger TL, Virkud A, et al. Demographic Trends in US HIV Diagnoses, 2008–2017: Data Movies. Am J Public Health. 2021; 111(4): 529-32.       Cite this article as: Asala AF, Bhuiyan AR, Mitra AK, Mendy VL, Mawson AR, Akil L. Trends in HIV/AIDS incidence rate in Mississippi, 2008-2019. IMC J Med Sci. 2023; 17(2):002. DOI: https://doi.org/10.55010/imcjms.17.012 <![CDATA[Clinical profile, surgical management and outcome of bronchial carcinoids - a single centre experience]]> Farooq Ahmad Ganie Shahbaz Bashir Dar Masarat-ul Gani Hakeem Zubair Ashraf Ghulam Nabi Lone Mudasir Hamid Bhat Iqra Nazir Naqash https://imcjms.com/journal_full_text/455 2023-03-15 13:04:20 Original Article IMC J Med Sci. 2023; 17(2):003 Abstract Background and objectives: Bronchial carcinoid tumors are neuroendocrine neoplasms that range from low-grade typical carcinoids to more aggressive atypical carcinoids and, therefore demonstrate a wide spectrum of clinical behaviors, histologic features and outcome. The aim of the present study was to investigate the clinical profile, surgical management and outcome of bronchial carcinoids at a single centre over two years period. Materials and methods: Patients with a final histologic diagnosis of bronchial carcinoid tumor were included in the study. Evaluation comprised of clinical history and physical examination, postero-anterior and lateral chest radiographs, and computed tomographic (CT) scans of the chest and upper abdomen (including liver and adrenal glands). Performance status was assessed by the Karnofsky scale. Pulmonary function tests were performed routinely. Results: A total of 18 patients were included in the study. Out of 18 cases, 10 (55.6%) were female and 8 (44.4%) were males. Sixteen (88.9%) patients had typical carcinoid tumor and 2 (11.1%) had atypical carcinoid tumor. The tumor was located in the right lung in 11 (61.1%) and in the left lung in 7 patients (38.9%). Surgeries included 15 standard lobectomies and 3 bronchial sleeve resection. At one month post surgery, there was 13-22% increase in post operative FEV1 in patients who underwent bronchial sleeve resection while in patients who underwent lobectomy, the post operative FEV1 was 84% of pre-operative FEV1. Post surgery, all patients were in group A as per Karnofsky performance status. Conclusion: Standard care of bronchial carcinoid tumors is surgical resection, and the surgical approach should depend on tumor’s size, location and histology. IMC J Med Sci. 2023; 17(2):003. DOI: https://doi.org/10.55010/imcjms.17.013 *Correspondence: Farooq Ahmad Ganie, Department of Cardiovascular and Thoracic Surgery, SKIMS, Soura, Srinagar, Kashmir, India. Email: farooq.ganie@ymail.com   Introduction Bronchial carcinoid tumors are neuroendocrine neoplasms that range from low-grade typical carcinoids to more aggressive atypical carcinoids and therefore demonstrate a wide spectrum of clinical behaviors and histologic features [1]. Typical and atypical bronchial carcinoids have similar imaging features. Because most bronchial carcinoids are located in central airways, radiologic findings are usually related to bronchial obstruction. Central bronchial carcinoids manifest as an endobronchial nodule, hilar or perihilar mass with a close anatomic relationship to the bronchus [1]. The mass is usually a well-defined, round or ovoid lesion and may be slightly lobulated at radiography and computed tomography (CT). Associated atelectasis, air trapping, obstructing pneumonitis, and mucoid impaction may also be seen. Peripheral bronchial carcinoids appear as solitary nodules. Calcification is common and is easily visualized at CT. Bronchial carcinoids demonstrate high signal intensity on T2-weighted and short-inversion-time inversion recovery magnetic resonance images. Prognosis of bronchial carcinoids is highly dependent on histologic findings. Typical bronchial carcinoids generally have an excellent prognosis, whereas atypical bronchial carcinoids have a worse prognosis. Therefore, understanding the histologic, clinical, and radiologic features of bronchial carcinoids facilitates accurate diagnosis and helps optimize surgical planning [2]. Standard care of bronchial carcinoid tumors is surgical resection. Surgical approach depends on tumor’s size, location and histology. Pneumonectomy, while effective at removing lung tumors, can carry high morbidity and mortality by removing an entire half of a person's lung volume. Pulmonary resection techniques are varied and categorized by the extent of lung resected. Bronchial sleeve resection with complete pulmonary preservation (BSRCPP) is a classic surgical method for the treatment of benign or low-grade bronchial tumors [3]. For elderly patients and patients with poor cardiopulmonary function, BSRCPP is particularly advantageous because some of these patients may not tolerate lobectomy or pneumonectomy. The use of bronchial and arterial sleeve resections for the treatment of centrally-located lung cancers, when available, has become the option of choice in comparison with pneumonectomy (PN) or lobectomy. The present study evaluated the clinical profile, surgical management and outcome of bronchial carcinoids at a single center over two years period.   Materials and methods The study was conducted in the Department of Cardiovascular and Thoracic Surgery, SKIMS Srinagar Kashmir from January 2020-January 2022. After local ethical clearance, patients with a final histologic diagnosis of bronchial carcinoid tumor were assessed for surgery and enrolled in the study. Evaluation comprised history and physical examination, posteroanterior and lateral chest radiographs, and computed tomographic (CT) scans of the chest and upper abdomen (including liver and adrenal glands). Pulmonary function tests were performed routinely. All patients had a preoperative examination with a fiberoptic bronchoscope, and in all cases endoscopic biopsy was performed. At surgery, all specimens resected, including hilar and mediastinal lymph nodes were sent for histologic examination. Tumors were classified according to the current WHO/IASLC criteria for neuroendocrine tumors. Typical carcinoids were defined as tumors greater than 5 mm in diameter, with carcinoid morphology and less than 2 mitoses per 2 mm2, and lacking necrosis. Tumors with a mitosis rate of 2-10 per 2 mm2, with focal necrosis or limited necrosis, were classified as atypical carcinoid tumors [4]. All patients underwent complete blood count, fasting blood sugar, kidney and liver function tests. Performance status of the patients was assessed by the Karnofsky Performance scale (KPS) [5]. KPS describes a patient’s functional status as a comprehensive 11-point scale correlating to percentage values ranging from 100% (no evidence of disease, no symptoms) to 0% (death) and classified patients into following three groups: A: Able to carry on normal activity and to work. No special care is needed. B: Unable to work. Able to stay at home and take care of most personal needs. A varying degree of assistance is needed. C: Unable to care for self. Requires equivalent of institutional or hospital care. Disease may be progressing rapidly.   Results The study group comprised of 18 patients, with 10 (55.6%) female and 8 (44.4%) male patients. Age at presentation ranged from 12 to 55 years (mean: 42 years). Out of 18 cases, 16 (88.9%) patients had typical carcinoid tumor and 2 (11.1%) had atypical carcinoid tumor. Both patients with atypical carcinoid were aged more than 45 years. Symptoms were present in 16 patients: cough (n= 15), fever (n=12), wheezing (n=9), hemoptysis (n=7) dyspnea (n=7) and recurrent pulmonary infections (n=5). Two patients were asymptomatic and bronchial carcinoid tumor was incidentally detected during post Covid-19 illness checkup. General profile and presenting clinical features of the study population are shown in Table-1.   Table-1: General profile and presenting clinical features of the study population (n=18)     Location and types of the tumors: The tumor was located in the right lung in 11 patients (61.1%) and in the left lung in 7 patients (38.9%). Features of typical carcinoid lung tumor included: tumor size > 5 mm in diameter, with carcinoid morphology and less than 2 mitoses per 2 mm2. Atypical carcinoid tumor had a mitosis rate of 2 to 10 per 2 mm2, with focal necrosis or limited necrosis. Surgery and postoperative course: Surgeries included 15 standard lobectomies (5 right inferior, 3 right superior, 2 right middle, 3 left superior and 2 left inferior) and 3 bronchial sleeve resection ( 2 left and 1 right). The patients who underwent lobectomy were discharged 9 to 14 days after surgery (mean duration: 12 days) and the patients who underwent bronchial sleeve resection were discharged 7 to 11 days after surgery (mean duration: 9 days). There was a complete resolution of symptoms immediately in all patients, however, 2 out of 15 patients who underwent lobectomy felt dyspnea on exertion at 15 day follow up which gradually improved. At one month, there was 13-22 % increase in post operative FEV1 in patients who underwent bronchial sleeve resection. In patients who underwent lobectomy, the post operative FEV1 was 84% of pre-operative FEV1 at one month. Post surgery, all patients were in group A (able to carry on normal activity and to work, no special care is needed) as per Karnofsky performance status.   Discussion Carcinoid tumors are a unique type of malignant pulmonary disease. They are rare, comprising less than 2% of all primary pulmonary neoplasms [6]. The prevalence of bronchial carcinoid tumors is slightly higher in females [7]. The mean age of our patients at presentation was 42 years (range 12 to 55 years), which is in line with literature. Patients having atypical carcinoid tumors were significantly older at presentation than patients with typical carcinoid tumors, as mentioned in various studies [8]. Bronchoscopy plays a big role in the diagnosis of carcinoids. In majority of our cases the tumors were centrally located and visible at endoscopic evaluation, as described by others [9]. Some authors found bleeding to occur in two thirds of their patients and some advised against biopsy when carcinoid was suspected. However, others disagreed, maintaining that bronchoscopic biopsy significantly increases the diagnostic yield without adding morbidity. In our experience, no troublesome bleeding was reported after endoscopic biopsy.  Preoperative radiologic evaluation and histologic typing are mandatory in selecting the extent of surgical resection. Newer modalities of investigation for staging bronchial carcinoid tumors that have recently been introduced include positron emission tomography and octreotide scintigraphy. Positron emission tomographic imaging of bronchial carcinoid tumors demonstrates lower uptake than non–small cell lung cancers, suggesting that the process is benign and that staging of regional lymph nodes might be unreliable [10]. Scintigraphy with 111In-octreotide has demonstrated reliable uptake in primary tumors and the ability to detect early recurrences and metastases even in asymptomatic patients, suggesting that it would be a useful tool for routine staging in the future [11]. At present, however, decisions regarding appropriate therapy for patients with bronchial carcinoid tumors are made on the basis of histologic features and clinical staging of the tumor by bronchoscopy and CT scan. The success of current surgical management of bronchial carcinoids is influenced by the recurrence rates and survival patterns. In patients with centrally located typical carcinoid tumor of the lung, we think that bronchial sleeve resection or sleeve lobectomy should be considered, when possible, because local recurrence is rare and survival is excellent. Despite the low local recurrence rate, early-stage typical carcinoids should be considered as low-malignancy neoplasms and should be managed by an anatomic resection to secure the least risk of recurrence. On the other hand, local recurrence rate and long-term survival are both unfavorably affected by the finding of atypical subtype. If this histologic subtype is identified, a more extensive surgical approach such as lobectomy or pneumonectomy associated with lymph node dissection is mandatory. Standard care of bronchial carcinoid tumors is surgical resection, with the surgical approach depending on tumor’s size, location and histology. Pneumonectomy, while effective at removing lung tumors, can carry high morbidity and mortality by removing an entire half of a person's lung volume. Pulmonary resection techniques are varied and categorized by the extent of lung resected. Bronchial sleeve resection with complete pulmonary preservation (BSRCPP) is a classic surgical method for the treatment of benign or low-grade bronchial tumors.   Funding: This research received no internal or external funding.   Conflicts of interest: The authors declare no conflict of interest.   References 1.     Chughtai TS, Morin JE, Sheiner NM, Wilson JA, Mulder DS. Bronchial carcinoid--twenty years' experience defines a selective surgical approach. Surgery. 1997; 122(4): 801-8. doi: 10.1016/s0039-6060(97)90090-8. 2.     Maurizi G, Ibrahim M, Andreetti C, D'Andrilli A, Ciccone AM, Pomes LM, et al. Long-term results after resection of bronchial carcinoid tumour: evaluation of survival and prognostic factors. Interact Cardiovasc Thorac Surg. 2014; 19(2): 239-44. doi: 10.1093/icvts/ivu109. 3.     Van Schil P, Knaepen P, Brutel de la Rivière A, van Swieten H, Schreurs A, Vanderschueren R. Sleeve resection for bronchial carcinoid tumors: results in 13 patients with an average follow-up of 6 years. Acta Chir Belg. 1991; 91(3): 131-5. Dutch. 4.     Travis WD, Rush W, Flieder DB, Falk R, Fleming MV, Gal AA, et al. Survival analysis of 200 pulmonary neuroendocrine tumors with clarification of criteria for atypical carcinoid and its separation from typical carcinoid. Am J Surg Pathol. 1998; 22(8): 934-944. doi: 10.1097/00000478-199808000-00003. 5.     Péus D, Newcomb N, Hofer S. Appraisal of the Karnofsky Performance Status and proposal of a simple algorithmic system for its evaluation. BMC Med Inform Decis Mak. 2013; 13: 72. doi:10.1186/1472-6947-13-72. 6.     Chughtai TS, Morin JE, Sheiner NM, Wilson JA, Mulder DS. Bronchial carcinoid--twenty years' experience defines a selective surgical approach. Surgery. 1997; 122(4): 801-8. doi: 10.1016/s0039-6060(97)90090-8. 7.     Okike N, Bernatz PE, Woolner LB. Carcinoid tumors of the lung. Ann Thorac Oncol. 1976; 22: 270–277. 8.     El Jamal M, Nicholson AG, Goldstraw P. The feasibility of conservative resection for carcinoid tumours: is pneumonectomy ever necessary for uncomplicated cases? Eur J Cardiothorac Surg. 2000; 18(3): 301-6. doi: 10.1016/s1010-7940(00)00519-4. 9.     Rea F, Binda R, Spreafico G, Calabrò F, Bonavina L, Cipriani A, et al. Bronchial carcinoids: a review of 60 patients. Ann Thorac Surg. 1989; 47(3): 412-414. doi: 10.1016/0003-4975(89)90383-4. 10.  Erasmus JJ, McAdams HP, Patz EF Jr, Coleman RE, Ahuja V, Goodman PC. Evaluation of primary pulmonary carcinoid tumors using FDG PET. AJR Am J Roentgenol. 1998; 170(5): 1369-1373. doi: 10.2214/ajr.170.5.9574618. 11.  Musi M, Carbone RG, Bertocchi C, Cantalupi DP, Michetti G, Pugliese C, et al. Bronchial carcinoid tumours: a study on clinicopathological features and role of octreotide scintigraphy. Lung Cancer. 1998; 22(2): 97-102. doi: 10.1016/s0169-5002(98)00075-0.       Cite this article as: Ganie FA, Dar SB, Gani M, Ashraf HZ, Lone GN, Bhat MH, Naqash IN. Clinical profile, surgical management and outcome of bronchial carcinoids - a single centre experience. IMC J Med Sci. 2023; 17(2): 003. DOI: https://doi.org/10.55010/imcjms.17.013   <![CDATA[Antimicrobial susceptibility pattern of enterococci isolated from various clinical samples in a tertiary care hospital in India]]> Sameena Khan Hardik Bansal Nageswari Gandham Shahzad Mirza Chanda Vyawahare Rajashri Patil Sahjid Mukhida Nikunja Kumar Das https://imcjms.com/journal_full_text/456 2023-03-19 10:12:39 Original Article IMC J Med Sci. 2023; 17(2):004 Abstract Background and objectives: Enterococci are significant human pathogens that are capable of causing various nosocomial infections. This study determined the antibiotic susceptibility pattern of enterococcal species isolated from various clinical specimens with special reference to vancomycin-resistant enterococci. Material and methods: The study was carried out for 6 months on enterococci isolated from various clinical specimens at a tertiary care hospital. Organisms were identified by standard procedures, and subjected to antimicrobial testing as per the standard guidelines. Results: Total 116 enterococci were isolated from various clinical samples. Of the total isolates, 56.9%, 30.2% and 12.9% were isolated from indoor, intensive care unit and non-hosptalized (outdoor) patients respectively.The most common Enterococcus species from blood was E. faecium (72%) followed by E. faecalis (12%) and E. galinarrium (9.4%). Out of 116 enterococci isolates, 31 (26.7%) were resistant to vancomycin and only 1 (0.9%) was resistant to linezolid. Conclusion:The study demonstrated high prevalence of multidrug-resistant enterococci in our hospital setting, thus posing a serious therapeutic challenge. The result would be useful in monitoring the future trends of antimicrobial susceptibility of enterococci in this region. *Correspondence: Dr. Nikunja Kumar Das, Department of Microbiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India-411018. E-mail: nikunjdas3085@gmail.com IMC J Med Sci. 2023; 17(2):004. DOI: https://doi.org/10.55010/imcjms.17.014      Introduction Enterococci are inhabitants of normal human intestinal flora which were thought to be harmless. But over the past few decades, it has emerged as an agent of serious nosocomial infection with a dramatic increase in patient morbidity and mortality, thus causing increasing associated costs of healthcare in such patients [1]. Enterococci species cause variety of infections and the most common species that account for 90% of clinical isolates are Enterococcus faecalis and Enterococcus faecium [2,3]. Traditionally, enterococcal infections are treated with cell wall active agents namely penicillin or ampicillin. However, Enterococcus species are intrinsically resistant to many antimicrobial agents, including cephalosporins, clindamycin, cotrimoxazole and aminoglycosides, with the capacity to acquire resistance genes and mutations [4]. The rapid increase in resistance to vancomycin as well as high-level aminoglycosides resistance is of particular concern as the treatment options for vancomycin-resistant enterococci (VRE) is limited. Nosocomial VRE infections can develop either endogenously, where colonization in critically ill patients is followed by invasive infection, or exogenously, in which the bacteria are transmitted via healthcare workers or contact with contaminated instruments and inanimate surfaces [5]. Prompt and accurate identification of antibiotic-susceptible and resistant enterococci is essential to establish diagnosis, selecting effective therapy, and instituting infection control measures [5,6]. The main aim of the study was to find out the prevalence of enterococci in various clinical samples and their antimicrobial susceptibility patterns with special reference to vancomycin resistance in a tertiary care Hospital.   Materials and method The study was carried out over six month period from May 2021 to October 2021 and approved by the institutional ethical committee (Ethical approval letter No. Micro/DPU/2021/148). All enterococcal species isolated from various clinical specimens were included in the study. Specimens were cultured on blood agar, MacConkey Agar, Cystine-Lactose-Electrolytes-Deficient (CLED) agar by streaking methods and incubate at 37°C for 18-24 hours. Blood specimens were collected in BacTec bottle and loaded in BacT/ Alert automation system for incubation at 37°C for 5 days. After receiving positive signal flag, bottles were removed and subcultured on blood agar and MacConkey agar plates and incubated at 37°C for 18-24 hours.Next day growth was observed and suspected enterococcus colonies were further identiﬁed to the species level with the help of conventional phenotypic methods which included Gram stain, colony morphology, catalase test, bile -esculin test, growth in 6.5% NaCl, mannitol fermentation, and pyruvate fermentation tests [7]. All Enterococcal isolates were tested for their susceptibility to various antibiotics by the Kirby-Bauer disc diffusion method. The antibiotics tested were penicillin (10 units), ampicillin (10 mcg), ciprofloxacin (5 mcg), erythromycin (15 mcg), and linezolid (30 mcg) and vancomycin (30 mcg). Vancomycin susceptibility was checked by the disk diffusion as well as by automated Vitek-2C system (Bio-Merieux, France). Enterococcus isolates from urine were tested for their susceptibility to nitrofurantoin and nalidixic acid additionally. The test was performed on Mueller-Hilton agar and interpreted as per the current CLSI guidelines after 18-24 h of incubation at 37°C [8]. Enterococcus isolated from blood were tested for speciation and antibiotic susceptibility by Vitek 2C automation system as per institutional policy. Enterococcus faecalis ATCC 29212 and Enterococcus casseliflavus ATCC 700327 were used as control strains.   Results During the study period, a total of 116 enterococci were isolated from various clinical specimens. Out of them, 53.5% and 46.6% were from male and female patients respectively. Of the total enterococci, 33.6%, 28.7% and 27.6% were isolated from samples from 41-60, 18-40 and > 60 years age group cases respectively (Table-1). Of the total isolates, 56.9%, 30.2% and 12.9% were isolated from indoor, intensive care unit and non-hosptalized (out door) patients respectively. Most of the enterococcal isolates were from urine (53.5%) followed by blood (27.6%). Ten (10) enterococci were isolated from body fluids which include: ascetic/peritoneal fluid - 6, pleural fluid- 2 and bile -2. Antimicrobial resistance pattern of isolated enterococci from different clinical specimens is shown in Table-2. Overall, 31 (26.7%) enterococcal isolates were resistant to vancomycin. Vancomycin resistance rate of isolated enterococci was 16.7% to 40.6% in different clinical samples. All vancomycin resistant enterococci (VRE) were resistant to penicillin, ciprofloxacin, and erythromycin too. Except 1 (1.2%), all the enterococci were sensitive to linezolid. Out of 116 isolates, 65.5% and 81% were resistant to ampicillin and erythromycin respectively. Enterococci isolated from the urine specimen showed 96.8% and 38.7% resistance to nalidixic acid and nitrofurantoin respectively by disk diffusion method. Susceptibility to tigecycline and levofloxacin was tested only in blood isolates by automation. All the 32 (100%) blood isolates were sensitive to tigecycline and 29 (90.6%) were resistant to levofloxacin.   Table-1: Source of the isolated enterococci (N=116)     Table-2: Antimicrobial susceptibility pattern of entrococci isolated from different clinical speciemens     Resistance pattern of enterococci isolated from samples from different locations is shown in Table-3. Overall, the resistance rate of isolated enterococci from outdoor cases were low compared to indoor and ICU cases. Speciation was done only for enetrococci isolated from blood. The most common enterococcus species isolated was E. faecium (72%) followed by E. faecalis (12%) and E. galinarrium (9.4%). Other species were E. avium and E. rafinosus (Table-4). Resistance rates to different antimicrobials were higher among the E. faecium compared to other species.   Table-3: Antimicrobial susceptibility pattern of entrococci isolated from speciemens from different locations.     Table-4: Distribution of enterococcal species from blood sample and their antimicrobial susceptibility pattern (N=32)     Discussion Enterococci contribute significantly to hospital-associated infections. In our study, isolation of the enterococcal species was found to be more in males (53.5%) as compared to females. Similar results have been shown in studies by Yielma et al (54.3%) and Jada S et al (55.6%) [9,10]. In the current study, we found that the majority of the enterococcal species were isolated from adults and geriatric age groups (33.6% and 27.6%).This is in accordance with the study done by Jada et al. [10] who isolated most of the enterococcus from the adult age group (35.8%) and geriatric pateints (39.9%). This is contrary to the findings of Yielma et al [9] who reported 54.2% isolates from the pediatric age group in Ethiopia.This difference could be due to variation in the clinical specimens as their study was on urine specimens while our study included various clinical specimens. Isolation of the enterococcus in hospitalized patients is common. In the present study, 87.1% of enterococci were isolated from hospitalized patients which included indoor and ICU patients. Similar rate (83.3%) of isolation of eneterococci was reported from hospitalized patients by Yielma et al. [9]. Several studiess have reported high isolation of enterococci (40.3%,-46.6%) from urine samples [9,10,12]. Our study also showed similar results (53.4%). However, Sreeja S et al [11] reported that majority of their isolates were from pus specimens (55.4%). The prevalence of the enterococcal species can vary depending on the region of the study. Studies from India [11,12] reported E. faecalis as the most common species (58 - 76%) whereas, in the current study, we found only 12% E. faecalis. On the contrary, we found 72% of the enterococci as E. faecium while the other studies reported 24% - 42% [12-14]. This variation could be due to types of clinical samples and patients.Uroisolate enterococcal species were tested for nitrofurantoin susceptibility. In the present study, we found 38.7% enterococci resistant to nitrofurantoin which was higher (11.7% - 14.2%) than other reported studies [12,13]. Beta lactam antibiotics were effective in infection by enterococcus. But recently, resistance against penicillin is emerging among enterococci. In the present study, 65.5% enterococci were resistant to either penicillin or ampicillin. Similar high prevalence of penicillin resistance was reported by others [9,10]. Similarly, most of our enterococci were resistant to macrolides. VRE is one of the major issues in-hospital care setups all over the world. In the current study, we found 26.7% VRE among all isolated enetrococci. However, the rate was lower than those reported from Ethiopian (41.7%), Nigerian (42.9%), Serbian (54.1%), and Iraq (71.4%) [9,15,16,17]. This variations in the prevalence of VRE could be due to variation of the specimen, study duration, use of antimicrobial agents and types of patients. Ethiopian and Iraq study evaluated only urine specimens while the Serbian study evaluated enetrococci isolated only from blood. Only, Rudy et al [13] reported 100% susceptibility of their enterococci to vancomycin. All species of enetrococci in our study were found sensitive to linezolid except one isolate which was isolated from urine. This study was conducted only for a short period (6 months) of time and the sample size was small. Hence, a multicentric study with large number of samples and of longer duration would give a better perspective of the prevalence of enterococcal species and their antimicrobial susceptibility pattern in our region. Also, we did not test the enterococcal isolates for high-level resistance to aminoglycosides as per institutional policy. Also, minimum inhibitory concentration (MIC) of vancomycin was not determined. Enterococcus sp is one of the major organisms responsible for hospital acquired infection. The current study has demonstrated high prevalence of vancomycin resistant enterococci in our hospital setting. Therefore, regular monitoring of the antimicrobial susceptibility pattern of enterococci would be useful to control its spread within the hospital and in the community.   Acknowledgement The authors would like to acknowledge the contributions of staff and laboratory personnel of the Department of Microbiology, Dr. D.Y. Patil Medical College, Hospital and Research Center, Pimpri, Pune, India.   Conflict of interest None of the authors have declared any conflict of interest   Fund All the tests and procedures were carried out from institutional funds. Funds were not received from any external agency.   Ethical Approval Ethical clearance was taken from the institutional sub-ethical committee before the study was conducted. Ethical approval letter No. Micro/DPU/2021/148.   References 1.     Chacko B, Thomas K, David T, Paul H, Jeyaseelan L, Peter JV. Attributable cost of a nosocomial infection in the intensive care unit: A prospective cohort study. World J Crit Care Med. 2017; 6(1): 79-84. 2.     Cetinkaya Y, Falk P, Mayhall CG. Vancomycin-resistant enterococci. Clin Microbiol Rev. 2000; 13(4): 686-707. doi: 10.1128/CMR.13.4.686. 3.     Treitman AN, Yarnold PR, Warren J, Noskin GA. Emerging incidence of Enterococcus faecium among hospital isolates (1993 to 2002). J Clin Microbiol. 2005; 43(1): 462-463. 4.     Bhatt P, Patel A, Sahni AK, Praharaj AK, Grover N, Chaudhari CN, Das NK, Kulkarni M. Emergence of multidrug resistant enterococci at a tertiary care centre. Med J Armed Forces India. 2015; 71(2): 139-144. 5.     Nimer NA. Nosocomial infection and antibiotic-resistant threat in the Middle East. Infect Drug Resist. 2022; 15: 631-639 6.     Faron ML, Ledeboer NA, Buchan BW. Resistance mechanisms, epidemiology, and approaches to screening for vancomycin-resistant enterococcus in the health care setting. J Clin Microbiol. 2016; 54(10): 2436-2447. 7.     Collee J.G., Miles R.S. and Watt, B. Tests for the Identification of Bacteria. In: Collee, J.G., Marmion, B.P., Fraser, A.G. and Simmons, A., Eds., Mackie & McCartney Practical Medical Microbiology, 1996, 14th Edition, Churchill Livingstone, New York, 131-151. 8.     CLSI. Performance Standards for Antimicrobial Susceptibility Testing. 31st Ed. CLSI Supplement M100. Clinical Laboratory Standard Institute; 2021. 9.     Yilema A, Moges F, Tadele S, Endris M, Kassu A, Abebe W, Ayalew G. Isolation of Enterococci, their antimicrobial susceptibility patterns and associated factors among patients attending at the University of Gondar Teaching Hospital. BMC Infect Dis 2017; 17: 276. 10.  Jada S & Jayakumar K. Prevalence of Enterococcus species from various clinical specimens in Shri Sathya Sai Medical College and Research Institute with special reference to speciation & their resistance to vancomycin. Int J Med Clin Res. 2012; 3(4): 154-160 11.  Sreeja S, Babu P R S, Prathab AG. The prevalence and the characterization of the Enterococcus species from various clinical samples in a tertiary care hospital. J Clin Diagn Res. 2012; 6(9): 1486-1488. 12.  Shridhar S, Dhanashree B. Antibiotic susceptibility pattern and biofilm formation in clinical isolates of Enterococcus spp. Interdiscip Perspect Infect Dis. 2019; Article ID 7854968. Doi: https://doi.org/10.1155/2019/7854968. 13.  Rudy M, Nowakowska M, Wiechuła B, Zientara M, Radosz-Komoniewska H. Analiza. [Antibiotic susceptibility analysis of Enterococcus spp. isolated from urine]. Przegl Lek. 2004; 61(5): 473-6. Polish. 14.  Prakash VP, Rao SR, Parija SC. The emergence of unusual species of Enterococci causing infections, South India. BMC Infect Dis. 2005; 5: 14. 15.  Olawale KO, Fadiora SO, Taiwo SS. Prevalence of hospital-acquired enterococci infections in two primary-care hospitals in Osogbo, Southwestern Nigeria. Afr J Infect Dis. 2011; 5(2): 40–46. 16.  Mira MU, Deana M, Zora J, Vera, Biljana M, Biljana R. Prevalence of different enterococcal species isolated from blood and their susceptibility to antimicrobial drugs in Vojvodina, Serbia, 2011-2013. Afr J Microbiol Res. 2014; 8(8): 819–824. 17.  Chabuck ZA, Al-Charrakh AH, Al-Saadi MAK. Prevalence of vancomycin resistant enterococci in Hilla city,Iraq. Med J Babylon. 2011; 8(3): 326–340.       Cite this article as: Khan S, Bansal H, Gandham N, Mirza S, Vyawahare C, Patil R, Mukhida S, Das NK. Antimicrobial susceptibility pattern of enterococci isolated from various clinical samples in a tertiary care hospital in India. IMC J Med Sci. 2023; 17(2):004. DOI: https://doi.org/10.55010/imcjms.17.014 <![CDATA[Estimated glucose disposal rate (eGDR) in rural Bangladeshi population and its correlation with cardiometabolic risks]]> Nehlin Tomalika Md Mohiuddin Tagar Sadya Afroz Masuda Mohsena MA Sayeed https://imcjms.com/journal_full_text/457 2023-03-23 12:08:13 Original Article IMC J Med Sci. 2023; 17(2):005 Abstract Background and objectives: For decades type 2 diabetes mellitus (T2DM) and insulin resistance (IR) are increasingly gaining importance as an underlying mechanism for increased risk of cardiovascular diseases (CVD). IR is related to various cardiometabolic adverse effects. Hyperinsulinemic-euglycemic clamp technique, the gold standard method for measuring IR, is an invasive and complex procedure. Estimation of glucose disposal rate (eGDR) is an easy alternative tool for measuring IR. There is no known study on eGDR level in Bangladeshi native population. Therefore, this study was undertaken to determine the eGDR values in a healthy working rural Bangladeshi population. Materials and methods: Six villages were selected purposively as the study sites. All healthy working people aged ≥20 years in selected rural community were considered eligible. Those who consented to participate in the study were enrolled. Investigations included a) interviewing for social and clinical history, b) anthropometry and measurement of blood pressure and d) estimation of HbA1c and biochemical indices. The eGDR (mg/kg/min) was calculated using formula: eGDR = 21.158 − (0.09 * WC) − (3.407 * HT) − (0.551 * HbA1c); where WC = waist circumference in cm, HT = hypertension (yes = 1/no = 0), and HbA1c = HbA1c (%). Results: A total of 93 (m/w = 29/64) participants were enrolled in the study. The prevalence rates of hypertension, diabetes and metabolic syndrome (MSyn) were 34%, 31.1% and 16.1%, respectively. The mean eGDR value was 9.9 (±0.149; 95% CI: 9.62–10.2) mg/kg/min. Most of the values of biophysical characteristics were normal. The comparison between participants with and without MSyn showed that the former had significantly lower eGDR (9.05±1.24 vs.10.10±1.37, p<0.01). Inverse correlations of eGDR with the obesity, glycemia and lipidemia (weight, waist, FBG, T-chol, and TG) were significant. Declining eGDR were significant with rising WHR, WHtR, TG/HDLR and T-chol/HDLR (for all, p<0.05). Conclusions: The study revealed the level of eGDR in a healthy working people of a rural community of Bangladesh. Moreover, eGDR was found to decrease significantly with the increasing cardiometabolic risks. The study revealed a higher prevalence of hypertension, diabetes and metabolic syndrome in apparently healthy working people highlighting susceptibility of Bangladeshi natives to non-communicable diseases. IMC J Med Sci. 2023; 17(2):005. DOI: https://doi.org/10.55010/imcjms.17.015 *Correspondence: M Abu Sayeed, Department of Community Medicine, Ibrahim Medical College, 1/A, Ibrahim Sarani, Segunbagicha, Dhaka 1000, Bangladesh. Email: sayeed1950@gmail.com   Introduction A substantial number of the recent studies emphasize the importance of estimated glucose disposal rate (eGDR) for predicting cardio-cerebrovascular events, which indirectly measure the insulin resistance and overall metabolic dysfunctions [1-3]. It was reported that an eGDR level less than 8.77 mg/kg/minshowed 100% sensitivity and 85.2% specificity for the diagnosis of metabolic syndrome [4,5]. Additionally, lower eGDR is related to micro-vascular complications like retinopathy, nephropathy and neuropathy [6]. Apart from micro- and macro- vascular complications, events like acute coronary syndrome are related to abnormal eGDR [7]. Also, individuals with type 1 diabetes mellitus (T1DM) and low eGDR have altered cholesterol and triglycerides [8]. These studies substantiate the significance of eGDR as an easy alternative tool for determining insulin resistance and to predict metabolic dysfunctions in a large population. To date, no study has yet been done on eGDR on Bangladeshi population. Therefore, this study was designed to measure the eGDR values in an apparently healthy working people of rural community of Bangladesh. Some other known metabolic variables related to metabolic syndrome (obesity, blood pressure, blood glucose, lipids) were also investigated to determine their associations with eGDR.   Materials and methods The study was approved by Institutional Ethical Review Committee and conducted over 4 months period from September 2022 to December 2022. Geographical site and participants: Six villages inhabited by mostly lower and middle class families were purposively selected. Occupationally these people were engaged in pottery, pottery-art and clay-modeling; some had mixed occupations like agriculture, teaching, and small-scale business. The study area is situated at a distance of about 38 km north of Dhaka City. The village social leaders and school teachers were discussed about the objectives and procedural details of the expected investigation. After obtaining the consent, the medical students of Ibrahim Medical College (Batch-19) prepared the participants’ list by house to house visit. The local volunteers helped them to access the participants’ house. A pretested questionnaire detailing social and clinical history was filled up following face to face interview. Each participant was requested to attend the local Gonoshasthya Kendra Hospital (GKH) in the next morning with overnight fast for further investigations. Investigations: At GKH, height, weight, waist-girth, and hip-girth were measured. Blood pressure was measured after rest for 10 minutes. Maintaining aseptic measure, 5ml venous blood was taken. HbA1c was measured from a drop of whole blood by the hemoglobinA1c analyzer (Glycohemoglobin analyzer). Blood sample was centrifuged. Serum was separated and kept in 2 aliquots, frozen and transported to IMC Biochemistry Laboratory for estimation of fasting blood glucose (FBG), total cholesterol (T-chol), triglycerides (TG), high density lipid (HDL), low density lipid (LDL), serum glutamate pyruvate transaminase (SGPT) and creatinine. The eGDR (mg/kg/min) was calculated using formula: eGDR = 21.158 − (0.09 * WC) − (3.407 * HT) − (0.551 * HbA1c); where WC = waist circumference in cm, HT = hypertension (yes = 1/no = 0), and HbA1c = HbA1c (%) [1]. Participants diagnosed as having DM, HTN and MSyn for the first time were registered at non-communicable disease (NCD) corner of GKH for management and follow-up.  Statistical analysis: The prevalence rates were shown in percentages. The bio-physical characteristics and cardio-metabolic risk variables were expressed in mean (±SD) and 95% confidence interval (CI). Comparison between groups (men vs. women) and Msyn (with vs. without) were tested by independent t-test). The rising or declining trend of mean values of risk variables with quartiles of eGDR were estimated by ANOVA. Correlations of eGDR with different biophysical variables were assessed by Pearson’s Correlation coefficient (r) adjusted for sex only and also for age and sex. Level of significance was accepted at less 0.05. SPSS was used for all analyses.   Results A total of 93 (m/w = 29/64) participants volunteered the study. Table-1 illustrates the bio-physical characteristics and eGDR values of the participants as mean and 95% CI. The mean eGDR was 9.9±0.15 (95% CI: 9.62-10.2) mg/kg/min. Most of the other values were found to be normal.   Table-1: Characteristics of the participants (n=93)     The comparisons between men and women (Table-2) showed that men were significantly older (age, p=0.002), obese (BMI, p=0.006) and hyperglycemic (FBG, p=0.009; HbA1c, p<0.001) than the female participants. Men compared to women had significantly (p=0.009) lower eGDR (men: 9.3713 vs. 10.1999).   Table-2: Comparison of characteristics between men and women (m/w = 29/64)     The prevalence of systolic hypertension, diabetes and metabolic syndrome were 34.1%, 31.1% and 16.1% respectively as shown in (Table-3). Men and women did not show any significant differences.   Table-3: Prevalence of hypertension, diabetes and metabolic syndrome by gender     Comparison between participants with and without MSyn (Table-4) showed that the cardio-metabolic risks were significantly higher among those with than those without MSyn. Thus, BMI, SBP, TG, were all significantly higher among the MSyn group (for all p <0.05). As expected, the mean (±SD) values of eGDR was significantly lower among those who had MSyn compared to those who had no MSyn (eGDR, mg/kg/min: 9.05±1.24 vs.10.10±1.37, p<0.01).   Table-4: Comparison of characteristics between participants with (n=15) and without (n=78) metabolic syndrome (MSyn)     Correlation matrices controlling for sex and controlling for age and sex are shown in Table-5 and 6 respectively. Correlations of eGDR with the biophysical characteristic - height, weight, waist, FBG, T-chol, and TG were found negatively significant (first row, Table-5). Thus, the findings showed inverse associations – indicating that higher the obesity, glycemia, lipidemia lower the eGDR. These significant inverse correlations of eGDR with cardiometabolic risks factors namely BMI, WHtR in column 4, and FBG, TG, T-chol in row 4 of Table-6 were maintained even when adjusted for age and sex.   Table-5: Correlations (‘r’) of eGDR with bio-physical characteristics controlling for sex     Table-6: Correlations (‘r’) of eGDR with cardiometabolic risks controlling for age and sex     ANOVA was employed to test whether decreasing quartile of eGDR (Q4→Q3→Q2→Q1) with increasing level of bio-physical risk variables were significant (Figure-1 and 2). Inverse associations were significant with central obesity (WST , p<0.001) and TG (p<0.001) though weight (wt), systolic blood pressure (sbp) and T-chol were found not significant (Figure-1). Likewise, cardiometabolic risks were found to increase significantly with declining eGDR (Figure-2). Inverse trends of declining eGDR were significant with the rise of WHR, WHtR, TG/HDLR and T-chol/HDLR (for all p<0.05).     Figure-1: ANOVA determined the mean values of WST (cm), WT (kg), SBP (mm), TG (mg/dl), T-chol (mg/dl) according to quartiles (Q1:≤8.8, Q2:8.9 – 9.9, Q3:9.10 – 10.7, Q4: ≥10.8 ) of eGDR     Figure-2: ANOVA estimated the mean values of WHR, WHtR, FBG (mmol/L), TG/HDL Ratio, T-chol/HDL Ratio according to quartiles (Q1:≤8.8, Q2:8.9 – 9.9, Q3:9.10 – 10.7, Q4: ≥10.8) of eGDR   Discussions As mentioned, there was no published report to date on eGDR on Bangladeshi population. There are many studies which investigated the status of eGDR on the patients suffering from diabetes (type1 & type2) with macro- [1-5,7-10] and micro-angiopathy [6]. Thus, the present study was unique, as it was conducted on working apparently healthy rural people. It is difficult to compare this study findings with other studies. Very important outcome of this study is that we could determine the level of eGDR in healthy community population (95%CI, 9.62 – 10.2 mg/kg/min). This range of eGDR value may be used as reference one until we get a value level based on well-designed study with larger number of samples. Other outcomes are also important like the prevalence of hypertension (34.1%), T2DM (31.1%) and MSyn (16.1%) in a rural community of Bangladesh. The prevalence of hypertension (34.1%) is consistent, though higher than that reported by Kibria et al [11]. Prevalence rates for T2DM and MSyn are consistent with Talukder et al [12] and Chowdhury et al [13], respectively. One striking observation was that the HDL level was significantly higher among the MSyn group than the non-MSyn group. This was a contradiction to the overall cardiometabolic standards, remained unexplained and unclear. Possibly, the guideline as proposed by National Cholesterol Education Program III Guidelines is not applicable on Bangladeshi people with MSyn. Bangladesh including south Asian population needs own guideline for MSyn as we proposed earlier in 2008 [14].   Conclusion The study revealed the range of eGDR values in apparently healthy rural population of Bangladesh. The significance of correlations of eGDR with cardiometabolic risks (obesity, hypertension, hyperglycemia, and hyperlipidemia) was also projected. In addition, the study revealed a higher prevalence of hypertension, diabetes and metabolic syndrome in apparently healthy rural working people highlighting susceptibility of Bangladeshi natives to NCDs. These findings demand health screening at regular interval. The findings are baseline and suitable for an excellent cohort to assess the natural course of different eGDR-quartiles in a Bangladeshi population in future.   Acknowledgements We acknowledge the contribution of Ibrahim Medical College for financing the study. We are obliged to the potters’ community for their active cooperation in every step of investigations. We are thankful to the workers of all grades, staff and authority of Gonoshasthya Kendra for providing food and lodging. We are also grateful to the physicians, nurses, paramedics, and the technicians of biochemistry, imaging and electrocardiography. The medical students of Ibrahim Medical College (IMC –batch 19) showed their capabilities in conducting such an innovative epidemiological study.   Fund The study was funded by Ibrahim Medical College.   Competing interest The authors declare no conflict of interest.   References 1.     Zabala A, Darsalia V, Lind M, Svensson AM, Franzén S, Eliasson B, et al. Estimated glucose disposal rate and risk of stroke and mortality in type 2 diabetes: a nationwide cohort study. Cardiovasc Diabetol. 2021; 20(1): 202. doi: 10.1186/s12933-021-01394-4. 2.     Williams KV, Erbey JR, Becker D, Arslanian S, Orchard TJ. Can clinical factors estimate insulin resistance in type 1 diabetes? Diabetes.2000; 49(4): 626–632. doi: 10.2337/diabetes.49.4.626. 3.     Zheng X, Han L, Shen S. Hypertension, remnant cholesterol and cardiovascular disease: evidence from the China health and retirement longitudinal study. J Hypertens. 2022; 40(11): 2292-2298. doi: 10.1097/HJH.0000000000003259. 4.     Ren X, Jiang M, Han L, Zheng X. Estimated glucose disposal rate and risk of cardiovascular disease: evidence from the China Health and Retirement Longitudinal Study. BMC Geriatr. 2022; 22(1): 968. doi: 10.1186/s12877-022-03689-x. 5.     Xuan J, Juan D, Yuyu N, Anjing J. Impact of estimated glucose disposal rate for identifying prevalent ischemic heart disease: findings from a cross-sectional study. BMC Cardiovasc Disord. 2022; 22(1): 378. doi: 10.1186/s12872-022-02817-0. 6.     Chillarón JJ, Goday A, Flores-Le-Roux JA, Benaiges D, Carrera MJ, Puig J, et al. Estimated glucose disposal rate in assessment of the metabolic syndrome and microvascular complications in patients with type 1 diabetes. J Clin Endocrinol Metab. 2009; 94(9): 3530-3534. doi: 10.1210/jc.2009-0960. 7.     Liu C, Zhao Q, Zhao Z, Ma X, Xia Y, Sun Y, et al. Correlation between estimated glucose disposal rate and in-stent restenosis following percutaneous coronary intervention in individuals with non-ST-segment elevation acute coronary syndrome. Front Endocrinol (Lausanne). 2022; 13: 1033354. doi: 10.3389/fendo.2022.1033354. 8.     Nishtala R, Kietsiriroje N, Karam M, Ajjan RA, Pearson S. Estimated glucose disposal rate demographics and clinical characteristics of young adults with type 1 diabetes mellitus: a cross-sectional pilot study. Diab Vasc Dis Res. 2020; 17(5): 1479164120952321. doi: 10.1177/1479164120952321. 9.     Shi W, Qin M, Wu S, Xu K, Zheng Q, Liu X. Value of estimated glucose disposal rate to detect prevalent left ventricular hypertrophy: implications from a general population. Postgrad Med. 2023; 135(1): 58-66. doi: 10.1080/00325481.2022.2131153. 10.  Liu Y, Xu K, Wu S, Qin M, Liu X. Value of estimated pulse wave velocity to identify left ventricular hypertrophy prevalence: insights from a general population. BMC Cardiovasc Disord. 2022; 22(1): 157. doi: 10.1186/s12872-022-02541-9. 11.  Kibria GMA, Muhammed G, Gupta RD, Nayeem J. Prevalence, awareness, and control of hypertension among Bangladeshi adults: an analysis of demographic and health survey 2017–18. Clin Hypertens. 2021; 27(1): 17. doi: 10.1186/s40885-021-00174-2. 12.  Talukder A, Hossain MZ. Prevalence of diabetes mellitus and its associated factors in Bangladesh: application of two-level logistic regression model. Sci Rep. 2020; 10(1): 10237. doi: 10.1038/s41598-020-66084-9. 13.  Chowdhury MZI, Anik AM, Farhana Z, Bristi PD, Abu Al Mamun BM, Uddin MJ, et al. Prevalence of metabolic syndrome in Bangladesh: a systematic review and meta-analysis of the studies. BMC Public Health. 2018; 18(1): 308. doi: 10.1186/s12889-018-5209-z. 14.  Sayeed S, Banu A, Khanam PA, Alauddin S, Begum T, Mahtab H, et al. Prevalence of metabolic syndrome in three urban communities of Dhaka City. Ibrahim Med Coll J. 2008; 2(2): 44-48. doi: 10.3329/imcj.v2i2.2936.         Cite this article as: Tomalika N, Tagar MM, Afroz S, Mohsena M, Sayeed MA. Estimated glucose disposal rate (eGDR) in rural Bangladeshi population and its correlation with cardiometabolic risks. IMC J Med Sci. 2023; 17(2):005. DOI: https://doi.org/10.55010/imcjms.17.015 <![CDATA[Bacterial co-infection in Covid-19 patients visiting a tertiary care hospital in Maharashtra]]> Rajashri Patil Rakshit Pandey Nageswari Gandham Shahzad Mirza Chanda Vyawahare Sameena Khan Jyoti Ajagunde Nikunja Kumar Das Sahjid Mukhida https://imcjms.com/journal_full_text/458 2023-04-12 12:58:28 Original Article IMC J Med Sci. 2023; 17(2):006 Abstract Background and objectives: Several patients with SARS-CoV-2 infection presents with bacterial co-infection. The aim of the present study was to determine the bacteria responsible for co-infection in Covid-19 infected patients visiting a tertiary care hospital of Maharashtra, India. Material and methods: A cross sectional study was conducted for 3 months at tertiary care center. Covid-19 patients attending the hospital were included in the study. All the specimens were collected either at the time of admission at outdoor or within 24-48 hours of admission. All the specimens were processed for culture and antibiotic susceptibility testing as per institutional policy and standard methods. Results: Total 200 samples were collected out of which 98 (49%) patients were diagnosed with bacterial co-infection. Majority of cases with bacterial co-infection were above 21 years of age. Culture was positive in 80%, 66.7%, 49.2% and 38.8% of tracheal aspirate, pus, blood and urine samples respectively. Out of 98 cases of bacterial co-infection, 62.2% and 37.8% had infection with Gram negative and positive bacteria respectively. Most common organism isolated was Klebsiella pneumoniae (20.4%) followed by Enterococcus species (14.3%). Over 70% of Klebsiella pneumoniae isolates were resistant to aminoglycosides, cephalosporins, fluroquinolones and carbapenems while 100% Acinetobacter was resistant to all antimicrobials tested. Among 57 Of the Gram negative isolates, 5 and 24 isolates were positive for ESBL carbapenemase respectively. Conclusion: The study revealed that bacterial co-infection was present in considerable proportion of Covid-19 patients and the organisms responsible were resistant to several antimicrobial agents. IMC J Med Sci. 2023; 17(2):006. DOI: https://doi.org/10.55010/imcjms.17.016 *Correspondence: Sahjid Mukhida, Department of Microbiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India-411018. E-mail: drssmukhida@rediffmail.com   Introduction The novel coronavirus first emerged in Wuhan, China, in December 2019 and has led to a global pandemic and as of May, 2022, about 500 million cases and more than 6 million deaths have been recorded around the world [1]. People with underlying morbidities are more susceptible to complications [2]. However, healthy individuals experience a mild flu-like illness or may be asymptomatic, recuperating from the infection even without any particular intervention [3]. Multiple studies have reported a correlation between SARS-CoV-2 infection and bacterial co-infections/superinfections [4-8]. About 20% of patients with SARS-CoV-2 are presented with co-infection, while 41% of superinfections were found among the ICU patients [7]. Therefore, antimicrobial agents are frequently used in cases of Covid-19 disease. The availability of bacterial and antimicrobial resistance profiles is important for rational prescription of antibiotics to treat Covid-19 patients effectively. However, data regarding types of bacteria causing co-infections and their antimicrobial resistance profiles are lacking. So, the present study was undertaken to determine the bacteria responsible for co-infection in Covid-19 patients visiting a tertiary care hospital in Maharashtra, India.   Material and methods This cross sectional study was conducted for 3 months from January to March 2022 at a tertiary care hospital of western Maharashtra. The study was approved by the institutional ethical committee prior to the initiation of the study (Ethical approval letter No. I.E.S.C./31/2022). Study population and sample collection: Covid-19 patient attending the outpatient department or admitted in the hospital were included in the study. Covid-19 was defined if a case was positive for SARS-CoV-2 either by RT-PCR or rapid antigen test or both. Detailed history regarding age, sex, associated conditions, and antibiotic, steroid, or antiviral therapies was taken from the enrolled patients. All the specimens were collected within 24-48 hours of admission. None of the sample was collected after 48 hours of hospital admission to exclude patient with hospital acquired infection in our current study sample. Samples from patients attending the outpatient were collected at the time of visit or admission of the patients. Samples for the culture were collected aseptically only from those who had suspected co-infection(s). Sample processing: All the collected specimens were processed for culture as per institutional policy and standard methods. Specimens were cultured on blood agar, MacConkey agar, Cystine-Lactose-Electrolytes-Deficient (CLED) agar by streaking methods and incubated at 37°C for 18-24 hours. Blood specimen was collected in automated BacT/Alert blood culture bottle and incubated at 370C for up to 7 days. Positive sample was sub-cultured on blood agar, MacConkey agar and incubate for 18 -24 hours. Suspected colonies were identified by Gram stain, motility, catalase, oxidase, coagulase and other standard biochemical tests [9]. All bacterial isolates were tested for antibiotic susceptibility using Kirby Bauer disc diffusion method on Mueller-Hinton agar plates. Isolated colonies were inoculated by lawn culture and antibiotic discs were placed on the surface and the plates were kept for incubation for 18-24 hours. The zone of inhibition was interpreted following the CLSI 2022 guidelines [10]. Automated Vitek 2C was used for identification of organism and antibiotic susceptibility testing as and when required. Extended spectrum Beta lactamase (ESBL) and carbapenemase production were detected by double disc diffusion method and modified Hodge test respectively [11,12].   Results Total 200 samples were collected and out of which 98 (49%) specimens yielded bacterial growth. Out of 200 cases, Gram negative and positive bacteria were isolated from 61 (30.5%) and 37 (18.5%) cases respectively and 86 (43%) had infection in single site and in 12 (6%) cases bacteria were isolated from more than one anatomical sites. The rate of culture positivity was 45.9% and 55.4% in male and female patients respectively while the rates ranged from 55.7% - 37.7% in samples collected from outdoor, indoor and ICU. Majority of cases belonged to 21 years to above 60 years of age. Culture was positive in 80%, 66.7%, 49.2% and 38.8% of tracheal aspirate, pus, blood and urine samples respectively. Only 30 (15%) patients had comorbidities and of them 6 (20%) had co-infection (Table-1).   Table-1: Detail characteristics of the study population (N=200)     Table-2 shows the pattern of bacteria isolated from different samples of Covid-19 patients. Overall, out of 98 cases of bacterial co-infection, 61 (61/98=62.2%) had infection with Gram negative bacteria while 37 (37/98=37.8%) was infected with Gram positive bacteria. Except pus, other specimens yielded mostly (55%-100%) growth of Gram negative organisms. Out of 14 pus samples, 9 (64.3%) showed growth of Gram positive bacteria. Most common organism isolated from the covid-19 patients was Klebsiella pneumoniae (20.4%) followed by Enterococcus species (14.3%), Staphylococcus aureus and Pseudomonas sp (each 12.2%) Less common isolates were Proteus sp, Elizabethkingia meningoseptica and Aerococcus viridans.   Table-2: Pattern of bacteria isolated from different specimens of Covid-19 patients     Table-3 shows the detail antimicrobial resistance profile of Gram-negative bacteria isolated from Covid-19 patients. As per the antibiotic susceptibility testing, more than 70% of Klebsiella pneumoniae isolates were resistant to aminoglycosides, cephalosporins, fluroquinolones and carbapenems. All (100%) the Acinetobacter sp, Proteus sp and E. meningoseptica were resistant to all antimicrobials tested. Among the gram-positive isolates, major drug resistance was noted against the fluroquinolones, macrolides and ampicillin (Table-4). None of the isolate was resistant to vancomycin and linezolid.   Table-3: Antimicrobial resistance patterns of isolated Gram-negative bacteria     Table-4: Antimicrobial resistance patterns of isolated Gram-positive bacteria.     Among 61 Gram negative isolates, 57 isolates were tested for ESBL and carbapenemase production. Out of 57 isolates 5 (8.8%) and 24 (42.1%) were positive for ESBL and carbapenemase respectively (Table-5). Highest (58.3%) carbapenemase production was detected in Pseudomonas sp.   Table-5: Rate of ESBL and carbapenemase producing bacteria     Discussion In the present study, bacterial co-infection was found in 49% patient. The rate was higher than many reported studies [13-18]. Those studies reported bacterial co-infection from 4% to 20% in Covid-19 patients. However on the contrary, Alshrefy et al [19] and Sreenath et al [20] reported almost similar rate of bacterial co-infection (42.4% and 47.1%) like ours. Covind-19 affects all age group patients which include from pediatric to geriatric age groups but older age group patient is infected more compared to other age group. In the present study, there was no significant increase of bacterial isolation rate with the increase of age. Mean age of the Covid-19 patients in current study was 47.13 years which was lower compared to various studies done on bacterial co-infection in Covid-19 admitted patients. The reported mean age of patients in other studies ranged from 56 to 74 years [14,16,17,21-24]. Majority of the Covid-19 patients need ventilator support as well as urinary catheterization during their ICU stay. Due to use of various immunosuppressive drugs, ICU patients have more chance to develop the bacterial infections. Several studies reported 28% to 83% bacterial infection in ICU admitted Covid-19 patients [14,15,21]. In the present study, 37.7% specimens from ICU patients had positive bacterial growth. Several studies reported Gram negative bacteria as predominant infecting agents in Covid-19 patients. Bacterial co-infection in Covid-19 patients due to Gram negative organism varied from 75% to about over 90% [22,16,15] while it was around 40% by Gram positive bacteria [16,22]. Similarly, in the current study we also found Gram negative bacteria as the predominant (62.2%) offending agents for causing co-infection in our Covid-19 cases. Only, 37.4% cases were infected by Gram positive bacteria. Among the Gram negative bacteria, K. pneumoniae was the most commonly isolated bacteria followed by Pseudomonas and Acinetobacter species. Same types of bacteria were most commonly isolated from Covid-19 cases by others [15,16,19,24]. As found by other studies [16,20], we also observed enterococci and S. aureus as the most commonly isolated Gram positive bacteria. Resistance against antimicrobial agents is a global health burden in current time. With the extensive use of antimicrobials, multi-drug resistant isolates have arisen globally. During the covid-19 pandemic, antibiotics are extensively used by the clinicians. Over 70% of Klebsiella pneumonia, the most commonly isolated bacteria in our series, was resistant to all the antimicrobial agents tested. Similar high rate of resistance was exhibited by our isolated Acinetobacter sp and Gram positive bacteria to several antibiotics tested. This could be due to prevalence of such drug resistant bacteria in the local community. The increasing exposure to healthcare environments and invasive procedures, as well as increased antibiotic usage, raises the potential for emergence of multidrug resistant bacteria [15,22,24]. The present study had some limitations. The study was conducted at a single center over a short period and the sample size was small. The present study has demonstrated that about half of the Covid-19 cases suffer from bacterial co-infections and many of those are caused by multidrug resistant bacteria. However, it is still unclear what exact roles co-infections and/or super infections play in patients with COVID-19 cases. Accurate and quick detection of bacterial co-infection with antibiotic susceptibility testing, particularly for severe infections, can assist clinicians to effectively treat Covid-19 patients with better clinical outcomes.   Acknowledgement The authors would like to acknowledge the contributions of staff and laboratory personnel of the Department of Microbiology, Dr. D.Y. Patil Medical College, Hospital and Research Center, Pimpri, Pune, India.   Source of Funding All the tests and procedures were carried out from institutional funds. Funds were not received from any external agency.   Conflict of Interest None of the author has any conflict of interest.   References 1.     World Health Organization. WHO Coronavirus (COVID-19) Dashboard. Geneva: World Health Organization; 2022. 2.     Silva D, Lima C, Magalhães V, Baltazar L. Peres N, Caligiorne R, et al. Fungal and bacterial coinfections increase mortality of severely ill COVID-19 patients. J Hosp Infect. 2021; 113: 145–154.  3.    Jose M, Desai K. Fatal superimposed bacterial sepsis in a healthy Coronavirus (COVID-19) patient. Cureus. 2020; 12(5): e8350. Doi: 10.7759/cureus.8350. 4.     Phua J, Weng L, Ling L, Egi M, Lim CM, Divatia JV, et al. Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations. Lancet Respir Med. 2020; 8: 506–517. doi: 10.1016/S2213-2600(20)30161-2. 5.     Elabbadi A, Turpin M, Gerotziafas GT, Teulier M, Voiriot G, Fartoukh M. Bacterial coinfection in critically ill COVID-19 patients with severe pneumonia. Infection. 2021; 49: 559–562. doi: 10.1007/s15010-020-01553-x. 6.     Garcia-Vidal C, Sanjuan G, Moreno-García E, Puerta-Alcalde P, Garcia-Pouton N, Chumbita M, et al. Incidence of co-infections and superinfections in hospitalized patients with COVID-19: a retrospective cohort study. Clin Microbiol Infect. 2020; 27: 83–88. doi: 10.1016/j.cmi.2020.07.041. 7.     Musuuza JS, Watson L, Parmasad V, Putman-Buehler N, Christensen L, Safdar N. Prevalence and outcomes of co-infection and superinfection with SARS-CoV-2 and other pathogens: a systematic review and meta-analysis. PLoS ONE. 2021; 16: e0251170. doi: org/10.1371/journal.pone.0251170. 8.     He S, Liu W, Jiang M, Huang P, Xiang Z, Deng D, et al. Clinical characteristics of COVID-19 patients with clinically diagnosed bacterial co-infection: a multi-center study. PloS ONE. 2021; 16: e0249668. doi.org/10.1371/journal.pone.0249668.  9.    Winn W, Allen S, Janda W, Koneman E, Procop G, Schreckenberger P, Woods, G. Koneman’s Color Atlas And Textbook Of Diagnostic Microbiology. 7th Edition, Lippincott Williams and Wilkins, New York. 2016; 804-807. 10.  Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing. 32nd Ed. CLSI Supplement M100. Wayne, PA: Clinical Laboratory Standard Institute; 2022. 11.  Clinical and Laboratory Standards Institute. 2012. Performance standards for antimicrobial susceptibility testing. Twenty second informational supplement update. CLSI document M100-S22 U. Wayne, PA: Clinical and Laboratory Standards Institute; 2012. 12.  Clinical and Laboratory Standards Institute. Screening and confirmatory tests for suspected carbapenemases production. 20 supplemental table 2A-S2. Wayne, PA:Clinical Laboratory Standard Institute;2010. 13.  Westblade LF, Simon MS, Satlin MJ. Bacterial coinfections in Coronavirus Disease 2019. Trends Microbiol. 2021; 29(10): 930-941. Doi: 10.1016/j.tim.2021.03.018. 14.  Russell CD, Fairfield CJ, Drake TM, Turtle L, Seaton RA, Wootton DG, et al. Co-infections, secondary infections, and antimicrobial use in patients hospitalised with COVID-19 during the first pandemic wave from the ISARIC WHO CCP-UK study: a multicentre, prospective cohort study. The Lancet Microbe. 2021; 2(8): E354-E365. doi.org/10.1016/S2666-5247(21)00090-2. 15.  Pourajam S, Kalantari E, Talebzadeh H, Mellali H, Sami R, Soltaninejad F, et al. Secondary bacterial infection and clinical characteristics in patients with COVID-19 admitted to two intensive care units of an academic hospital in Iran during the first wave of the pandemic. Front Cell Infect Microbiol. 2022; 12: 784130. doi: 10.3389/fcimb.2022.784130. 16.  Shafran N, Shafran I, Ben-Zvi H, Sofer S, Sheena L, Krause I, et al. Secondary bacterial infection in COVID-19 patients is a stronger predictor for death compared to influenza patients. Sci Rep. 2021; 11(1): 12703. doi.org/10.1038/s41598-021-92220-0. 17.  d’Humières C, Patrier J, Lortat-Jacob B, Tran-dinh A, Chemali L, Maataoui N, et al. Two original observations concerning bacterial infections in COVID-19 patients hospitalized in intensive care units during the first wave of the epidemic in France. PloS ONE. 2021; 16(4): e0250728. doi.org/10.1371/journal.pone.0250728. 18.  Soltani S, Faramarzi S, Zandi M, Shahbahrami R, Jafarpour A, AkhavanRezayat S, et al. Bacterial coinfection among coronavirus disease 2019 patient groups: an updated systematic review and meta-analysis. New Microbes New Infect. 2021; 43:100910. doi: 10.1016/j.nmni.2021.100910. 19.  Alshrefy AJ, Alwohaibi RN, Alhazzaa SA, Almaimoni RA, AlMusailet LI, AlQahtani SY, Alshahrani MS. Incidence of bacterial and fungal secondary infections in COVID-19 patients admitted to the ICU. Int J Gen Med. 2022; 15: 7475-7485. doi.org/10.2147/IJGM.S382687. 20.  Sreenath K, Batra P, Vinayaraj EV, Bhatia R, SaiKiran K, Singh V, et al. Coinfections with other respiratory pathogens among patients with COVID-19. Microbiol Spectr. 2021; 9(1): e0016321. doi: 10.1128/Spectrum.00163-21. 21.  Bazaid AS, Barnawi H, Qanash H, Alsaif G, Aldarhami A, Gattan H, et al. Bacterial coinfection and antibiotic resistance profiles among hospitalised COVID-19 patients. Microorganisms. 2022; 10(3): 495. doi.org/10.3390/microorganisms10030495. 22.  Saeed NK, Al-Khawaja S, Alsalman, J, Almusawi S, Albalooshi NA, Al-Biltagi M. Bacterial co-infection in patients with SARS-CoV-2 in the Kingdom of Bahrain. World J Virol. 2021; 10: 168–181. 23.  Moreno-García E, Puerta-Alcalde P, Letona L, Meira F, Dueñas G, Chumbita M, et al. Bacterial co-infection at hospital admission in patients with COVID-19. Int J Infect Dis. 2022; 118: 197-202. doi: 10.1016/j.ijid.2022.03.003. 24.  Li J, Wang J, Yang Y, Cai P, Cao J, Cai X, Zhang Y. Etiology and antimicrobial resistance of secondary bacterial infections in patients hospitalized with COVID-19 in Wuhan, China: a retrospective analysis. Antimicrob Resist Infect Control. 2020; 9(1): 153. doi: 10.1186/s13756-020-00819-1          Cite this article as: Patil R, Pandey R, Gandham N, Mirza S, Vyawahare C, Khan S, Ajagunde J, Das NK, Mukhida S. Bacterial co-infection in Covid-19  patients visiting a tertiary care hospital in Maharashtra. IMC J Med Sci. 2023; 17(2): 006. DOI: https://doi.org/10.55010/imcjms.17.016 <![CDATA[Seroprevalence of hepatitis B virus infection in pre-mass vaccination era among children residing in a rural area of Bangladesh]]> Masuda Mohsena Amal K Mitra MA Sayeed Akhter Banu J Ashraful Haq https://imcjms.com/journal_full_text/465 2023-05-23 09:38:21 Original Article IMC J Med Sci. 2023; 17(2):007 Abstract Background and objectives: There are few details available regarding the prevalence of hepatitis B virus (HBV) infection in the general Bangladeshi population. There is a dearth of data on prevalence of HBV infection in children and adolescents who were born before the hepatitis B vaccine was introduced in the Expanded Program on Immunization (EPI). The objective of the current study was to use archived data to describe the seroepidemiology of HBV infection (HBsAg and anti-HBc Antibody) among school children in a particular rural area of Bangladesh. Also, the study correlated serum vitamin A level with the HBV infection status among a subset of children. Materials and method: The study analyzed the archived data of a study conducted in 2003 and 2004. The samples were collected from 1995 children, aged 5 to 15 years, from a purposively selected rural area located about 100 km north-east of capital Dhaka. HBsAg (HBV surface antigen) and anti-HBc antibody were determined by ELISA method. Vitamin A (retinol) in blood was assayed by HPLC technique. The prevalence rates of HBsAg and anti-HBc antibody was determined by simple percentages. All associations between different characteristics were tested by Chi square test. Results: Of the total 1995 children, 988 (49.5%) and 1007 (50.5%) were male and female respectively. Among them, 23 (1.2%) were HBsAg positive or HBV carriers and 79 (8.1%) were anti-HBc antibody positive. Neither HBsAg nor anti-HBc antibody positivity rate showed any difference in male and female children. There was also no significant difference of HBsAg positivity rate amongst children of different age groups; whereas, anti-HBc antibody positivity rate increased significantly (p <0.005) with increase of age. Serum vitamin A was estimated in a subset of children. The mean serum vitamin A concentration was found significantly (p<0.05) lower among HBsAg positive children compared to their age and sex matched healthy control group. Conclusion: This study has demonstrated that rural children are in risk of exposure to HBV infection. Increasing HBV seropositivity with age emphasizes the need for devising prevention strategies and to create awareness among the rural children. Further studies are necessary to find out the hitherto undetected sources namely occult hepatitis B cases and the ways of spread of HBV in the community. IMC J Med Sci. 2023; 17(2):007. DOI: https://doi.org/10.55010/imcjms.17.017 *Correspondence: M Abu Sayeed, Department of Community Medicine, Ibrahim Medical College, 1/A, Ibrahim Sarani, Segunbagicha, Dhaka 1000, Bangladesh; Email: sayeed1950@gmail.com; J. Ashraful Haq, Department of Microbiology, Ibrahim Medical College, Segunbagicha, Dhaka, Bangladesh; Email: jahaq54@yahoo.com   Introduction Hepatitis B virus (HBV) infection is a global health problem; it is estimated that two billion people worldwide are infected with HBV and that more than 350 million people have chronic hepatitis B infection [1].  There are few details available about the prevalence of HBV infection in Bangladeshi general population, and so far no national-level research has been carried out on seroepidemiology of HBV. HBsAg (Hepatitis B surface antigen) seroprevalence in Bangladeshi adults was found to be 8.6%, 6.4%, 5.5%, and 6.5%, respectively, in studies done in 1991, 1997, 2008, and 2011[2]. Bangladesh is not an exception to the global lack of data on HBV infection in children and adolescents. In Bangladesh, the Expanded Program on Immunization (EPI) schedule included the hepatitis B vaccine in a phased manner between 2003 and 2005 [3]. Very little information regarding HBV infection is available among children and adolescents who were born before the program's launch. In terms of hepatitis B care, le et al [4] referred them as the "missing generation" and voiced concern about the fact that they are in the age bracket with a tendency of risky behavior, increasing their risk of HBV exposure. Therefore, it is useful to study the prevailing situation against which this vaccination program was implemented. It has long been established that vitamin A has a protective role against a number of infectious diseases. This vitamin has essential roles in immunity, cellular differentiation, maintaining epithelial surfaces, growth, reproduction and vision [5]. In children, severity of measles, pneumonia, and diarrhea have all been linked to vitamin A deficiency [6–8]. Vitamin A storage and metabolism takes place in liver. Hepatitis B virus causes inflammation and damages the liver over time, so there may be a relationship between HBV biomarkers and vitamins A concentrations in humans [9]. The objective of the current study was to use archived data to describe the seroepidemiology of HBV infection (HBsAg and anti-HBc Antibody) among school children in a particular rural area of Bangladesh. These findings may be used to establish baseline estimates of pediatric chronic HBV infection and determine whether Bangladesh is on track to meet regional and global targets for the eradication of HBV. Also, the study correlated serum vitamin A level with the HBVinfection status among a subset of children.   Material and methods The study analyzed the archived data of a study conducted in 2003 and 2004 to find out the prevalence of HBV carrier and exposure rate to the virus amongst rural children. At that time, HBV vaccination was not included in EPI schedule in that area. Information on all data, test methods and results were retrieved from the stored data sheets. A structured data sheet was used to record the age, gender, comorbid condition and test results. Approval of the Institutional Review Board was obtained for analysis of the archived data. The study was conducted at a purposively selected rural area located about 100 km north-east of capital Dhaka. The area covered 19 villages with a population of 16,400 above one year age. Apparently healthy children between 5 to 15 years of age were selected randomly from the entire population. Each participant and their guardians were informed about the objectives and the procedural details of the investigation. Informed consent and assent were obtained from the participants and the guardians, respectively. Participants were informed about the results of the tests and advised accordingly. At the time of enrollment in the study 2 ml of venous blood was collected aseptically from all participants. A second sample of blood (2ml) was collected 12 months after the first sample from those who were HBsAg positive. Immediately, serum was separated from collected blood samples and transported to laboratory by maintaining a cold chain for detection of HBsAg and anti-HBc antibody and estimation of serum vitamin A concentration. Serum vitamin A was measured among HBsAg positive cases and in age and sex matched healthy HBsAg negative children (controls). HBsAg and anti-HBc antibody were determined by ELISA method. Any child who had HBsAg in serum for more than 6 months with no clinical symptoms was considered as HBV carrier [10]. Any child who was positive for anti-HBc antibody but HBsAg negative was considered exposed to hepatitis B virus [11]. Vitamin A (retinol) in blood was assayed by HPLC technique [12]. The HPLC was carried out using Shimadzu HPLC system (Tokyo, Japan). All data were analyzed by using SPSS (version 22.0). The prevalence rates of HBsAg and anti-HBc antibody was determined by simple percentages. All associations between different characteristics were tested by Chi square test.   Result A total of 1995 children aged 5 to 15 years were included in the analysis. Of the total, 988 (49.5%) and 1007 (50.5%) were male and female children, respectively. Mean age of the study population was 9.62 ± 3.19 years. Detail age groups and gender distribution of the study population is shown in Table-1. Out of 1995 enrolled children, 23 (1.2%) were HBsAg positive or HBV carriers (Table-2). The rate of positivity of HBsAg in male and female children was not significantly different (1.4% vs 0.9%; p < 0.05). There was also no significant difference of HBsAg positivity rate amongst children of different age groups.   Table-1: Age and gender distribution of the study population (n=1995)     Table-2: Distribution of HBsAg positive (HBV carrier) cases according to the gender and age groups (n=1995)     Table-3 shows the exposure rate to HBV among the study children. Out of 1995 children, anti-HBc antibody was determined in 973 children of which 485 and 488 were male and female respectively. Overall anti-HBc antibody was positive in 79 (8.1%) children, of which 40 (8.2%) and 39 (8%) were male and female, respectively (p > 0.05). Among the children, anti-HBc antibody positivity rate increased significantly (p <0.05) with increase of age. Age group 11-12 and 13-15 years had significantly (p <0.05) higher anti-HBc antibody positivity rate compared to age 5-6 and 7-10 years age groups (13.7% and 9.5% vs. 5.8% and 4.7%).   Table-3: Anti-HBc antibody positivity rate according to the gender and age groups (N=973)     Serum vitamin A was estimated in 18 HBsAg positive children and in 118 age and sex matched HBsAg negative apparently healthy children (Table-4). The mean serum vitamin A concentration was significantly (p < 0.05) less in HBsAg positive children (20.43 ± 2.15 mg/dl) compared to healthy children (24.89 ± 0.68 mg/dl).   Table-4: Comparison of vitamin A levels of HBsAg positive (HBV carrier) and negative children     Discussion The HBsAg prevalence among pre-mass vaccination era children, aged 5-15 years was found to be 1.2%, which was lower than the findings from previous small-scale studies in Bangladesh conducted before the introduction of hepatitis B vaccine. The majority of earlier investigations, however, involved either high-risk populations or hospital patients, or participants from particular urban regions. Children under the age of 10 were found to have a 5.4% HBsAg prevalence in a study conducted in 1997–1998 among participants in a hospital’s outpatient department for pre-vaccination HBsAg screening[13]. In another study, conducted in 2005–2006 among under-five children in an impoverished area of Dhaka, known for its high burden of infectious diseases, HBsAg prevalence was found to be 12.5% [14]. However, a different study carried out in 1995 in Dhaka among school children aged 6 to 15 found a lower rate (0.8%) [15]. Because of the difference in sample selection methodology, these findings might not be comparable to the current study findings. Since the discovery of HBsAg, it has been known that males typically have a higher prevalence of HBV than females [16]. This finding is supported by almost all reports on the prevalence of HBV in Bangladesh that included gender-specific data, and in the majority of cases, the differences were statistically significant [17]. On the other hand, the current study revealed no discernible variation in anti-HBc antibody prevalence across the gender categories. According to the results of the age-group analysis, children between the ages of 11 and 15 had a significantly higher anti-HBc antibody prevalence rate than those between 5 and 10 years old. From the data available, it was not possible to draw any firm conclusions about the reason of this finding. In Bangladesh, vertical transmission is one of the most common ways for HBV to spread, but present study was unable to assess this since it excluded children under the age of 5. Additionally, serological markers of other household members were not evaluated, and therefore it was not possible to estimate the risk of HBV transmission at the household level. As indicated earlier, le et al. [4] stated that teenagers and young adults tend to engage in risky behavior, which may increase their risk of being exposed to HBV. However, more thorough studies are required to fully comprehend the dynamics of HBV infection transmission and risk factors in Bangladeshi children. Vitamin A level was measured in a subset of sample and it was found that HBV seronegative children had significantly higher levels of vitamin A than seropositive children. For a long time, vitamin A has been referred to as "the anti-infective vitamin” [18], but scientific interest in vitamin A as "anti-infective" therapy has declined due to recent developments in antibiotics. Recent clinical trials and systematic reviews, however, demonstrate that regular vitamin A administration can reduce mortality and morbidity of HIV-infected children [19]. According to Sinopoli et al. [20], vitamin A supplemented individuals had a better prognosis and outcomes in several diseases like clearing up of HPV lesions or fewer complications from the measles. A previous study demonstrated that having a positive HBsAg test result was a strong independent predictor of low vitamin A concentration and that those who were HBsAg- positive were almost 6 times as likely to have low vitamin A concentration as those who were HBsAg-negative [9]. Recent studies have demonstrated that vitamin A is more effective to enhance recovery from infection than to prevent infection in first place [21]. It would have been preferable if the current study had done a follow-up to evaluate the HBV markers after supplementing vitamin A in the seropositive subjects. In conclusion, this study has demonstrated that rural children are in risk of exposure to HBV infection. Increasing HBV seropositivity with age emphasizes the need for devising prevention strategies and to create awareness among the rural children. Further studies are necessary to find out the hitherto undetected sources namely occult hepatitis B cases and the ways of spread of HBV in the community.   Acknowledgement Authors acknowledge the support of the participants and their guardians in materializing the study.   Conflict of interest The authors declared no conflict of interest.   Fund Cost of the laboratory test of the original study was funded by Faculty Summer Research Program of the University of Southern Mississippi, Hattiesburg, MS, USA.   Reference 1.     Hou J, Liu Z, Gu F. Epidemiology and prevention of hepatitis B virus infection. Int J Med Sci. 2005; 2(1): 50-57. doi: 10.7150/ijms.2.50. 2.     Banik S, Datta A, Ghosh A, Ghosh KY, Debi H. The prevalence of hepatitis B virus infection in Bangladesh: a systematic review and meta-analysis. Epidemiol Infect. 2022 Feb 14; 150: e47. doi: 10.1017/S0950268822000061. 3.     Paul RC, Rahman M, Wiesen E, Patel M, Banik KC, Sharif AR, et al. Hepatitis B surface antigen seroprevalence among prevaccine and vaccine era childhood in Bangladesh. Am J Trop Med Hyg. 2018 Sep; 99(3): 764-771. doi: 10.4269/ajtmh.17-0721. 4.     Ie SI, Turyadi, Sidarta E, Sadhewa A, Purnomo GA, Soedarmono YS, et al. High prevalence of hepatitis B virus infection in young adults in Ternate, Eastern Indonesia. Am J Trop Med Hyg. 2015 Dec; 93(6): 1349-1355. doi: 10.4269/ajtmh.15-0331. 5.     Semba RD, Vitamin A, immunity and infection. Clin Infect Dis. 1994; 19(3): 489-499. 6.     Markowitz L, Nzilambi N, Driskell WJ, Sension MG, Rovira EZ, Nieburg P, et al. Vitamin A levels and morality among hospitalized measles patients, Kinshasa. Zaire J Trop Pediatr. 1989; 35(3): 109-112. doi: 10.1093/tropej/35.3.109. 7.     Sommer A, Katz J, Tarwotjo I. Increased risk of respiratory disease and diarrhea in children with preexisting mild vitamin A deficiency. Am J Clin Nutr. 1984; 40(5): 1090-1095. doi:10.1093/ajcn/40.5.1090. 8.     Semba RD. Vitamin A and immunity to viral, bacterial and protozoan infections. Proc Nutr Soc. 1999; 58(3): 719-727. doi: 10.1017/s0029665199000944 9.     Obuseh FA, Jolly PE, Jiang Y, Shuaib FM, Waterbor J, Ellis WO, et al. Allflatoxin B1 albumin adducts in plasma and aflatoxin M1 in urine are associated with plasma concentrations of vitamins A and E. Int J Vitam Nutr Res. 2010 Dec; 80(6): 355-368. doi: 10.1024/0300-9831/a000021. 10.  Hoofnagle JH, Shafritz DA, Popper H. Chronic type B hepatitis and the healthy HBsAg carrier state. Hepatology. 1987; 7(4): 758-763. doi: 10.1002/hep.1840070424 11.  Centers for Disease Control and Prevention. Viral hepatitis: interpretation of hepatitis B serologic test results. USA: Centers for Disease Control and Prevention; Jan 2023. USA. 12.  Driskell W, Neess JW, Bryant CC, Bashor MM. Measurement of vitamin A and vitamin E in human serum by HPLC. J Chromatogr. 1982; 231(2): 439-444. doi: 10.1016/s0378-4347(00)81869-1. 13.  Zaki H, Darmstadt GL, Baten A, Ahsan CR, Saha SK. Seroepidemiology of hepatitis B and delta virus infections in Bangladesh. J Trop Pediatr. 2003; 49(6): 371-374. doi: 10.1093/tropej/49.6.371. 14.  Ashraf H, Alam NH, Rothermundt C, Brooks A, Bardhan P, Hossain L, et al. Prevalence and risk factors of hepatitis B and C virus infections in an impoverished urban community in Dhaka, Bangladesh. BMC Infect Dis. 2010 Jul; 10: 208. doi:10.1186/1471-2334-10-208. 15.  Laskar MS, Harada N, Khan F. Prevalence of hepatitis B surface antigen (HBsAg) in Viqarunnessa noon girls' school children in Dhaka, Bangladesh. Cent Eur J Public Health. 1997; 5(4): 202-204. 16.  Blumberg BS. Sex differences in response to hepatitis B virus. I. History. Arthritis Rheum. 1979 Nov; 22(11): 1261-1266. doi:10.1002/art.1780221114. 17.  Uz-Zaman MH, Rahman A, Yasmin M. Epidemiology of Hepatitis B Virus Infection in Bangladesh: Prevalence among General Population, Risk Groups and Genotype Distribution. Genes (Basel). 2018; 9(11): 541. doi: 10.3390/genes9110541. 18.  Semba RD, Vitamin A as “Anti-Infective” Therapy, 1920–1940. J Nutr. 1999; 129 (4): 783–791. doi: 10.1093/jn/129.4.783. 19.  Semba RD, Ndugwa C, Perry RT, Clark TD, Jackson JB, Melikian G, et al. Effect of periodic vitamin A supplementation on mortality and morbidity of human immunodeficiency virus-infected children in Uganda: A controlled clinical trial. Nutrition. 2005; 21(1):25-31. doi: 10.1016/j.nut.2004.10.004. Erratum in: Nutrition. 2005 Feb; 21(2): 287. 20.  Sinopoli A, Caminada S, Isonne C, Santoro MM, Baccolini V. What Are the Effects of Vitamin A oral supplementation in the prevention and management of viral infections? A systematic review of randomized clinical trials. Nutrients. 2022; 14(19): 4081. doi: 10.3390/nu14194081. 21.  Villamor E, Fawzi WW. Effects of vitamin a supplementation on immune responses and correlation with clinical outcomes. Clin Microbiol Rev. 2005; 18(3): 446-464. doi: 10.1128/CMR.18.3.446-464.2005.       Cite this article as: Mohsena M, Mitra AK, Sayeed MA, Banu, A, Haq JA. Seroprevalence of hepatitis B virus infection in pre-mass vaccination era among children residing in a rural area of Bangladesh. IMC J Med Sci. 2023; 17(2): 007. DOI:https://doi.org/10.55010/imcjms.17.017 <![CDATA[Prevalence and antimicrobial susceptibility of high-level gentamicin resistant enterococci isolated from urine at a hospital in Pune, India]]> Nageswari R. Gandham Shahzad Mirza Chanda Vyawahare Rajashri Patil Sahjid Mukhida Sriram Kannuri Shalini Bhaumik https://imcjms.com/journal_full_text/466 2023-05-25 11:35:19 Original Article IMC J Med Sci. 2023; 17(2):008 Abstract Introduction: Enterococci are one of the common organisms isolated from hospitalized patients with urinary tract infections. Guidelines recommend testing enterococcifor susceptibility to high-level gentamicin (HLG) and streptomycin. The present study was planned to determine the susceptibility of uropathogenic enterococci to high-level gentamicin in a tertiary care hospital. Materials and Methods: Prospective observational research was carried out at a tertiary care hospital for two years on all isolated enterococci from urine specimens. Identification and antibiotic susceptibility were performed as per standard methods. All the isolated enterococci were tested for high level gentamicin ((120µg) resistance and susceptibility to other recommended antimicrobial agents by standard methods. Results: A total of 320 uropathogenic enterococci were isolated and tested for antibiotic susceptibility. The majority of enterococci were isolated from elderly (34.06%) and admitted patients (69.06%). A total of 68.4% isolated enterococci were HLG resistant. HLG resistant enterococci were highly resistant to erythromycin (96.3%), ciprofloxacin (96.8%) and nalidixic acid (97.7%). Enterococci sensitive to HLG were significantly (p <0.05) less resistant to the other antimicrobial agents except nalidixic acid. Only 20.5% isolated Enterococci were resistant to vancomycin. All isolated enterococci were susceptible to linezolid. Conclusion: The study demonstrated high prevalence of HLG resistant enterococci causing UTI in our hospital setting. Compared to HLG sensitive enterococci, HLG resistant enterococci were more resistant to other antimicrobial agents tested. The findings highlight the need for mandatory testing of enterococci for HLG resistance to determine effective antimicrobials for treatment. IMC J Med Sci. 2023; 17(2):008. DOI: https://doi.org/10.55010/imcjms.17.018 *Correspondence: Dr. Sahjid Mukhida, Department of Microbiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India. E-mail: drssmukhida@rediffmail.com   Introduction Enterococci, a Gram-positive facultative anaerobic catalase-negative cocci, are one of the common organisms responsible for hospital-associated infections (HAI) in healthcare settings [1,2]. The majority of enterococci are isolated from individuals with bacteremia, urinary tract infection (UTI), infective endocarditis, and occasionally meningitis [3]. Enterococci are capable of producing biofilm, enhancing adhesion in urinary catheters, artificial heart valves, and dental prostheses [4]. Among all uropathogens identified from urine specimens, enterococci are the second most common [5]. Isolation of organisms from clinical specimens is pointless unless antibiotic susceptibility is performed. Clinical Laboratory Standard Institute (CLSI) guideline is useful for assessing antibiotic susceptibility in enterococcus [6]. Beta-lactam, macrolides, fluoroquinolones, glycolipopeptides, and linezolid are commonly used antibiotics for enterococci. Few drugs namely aminoglycosides, cephalosporins, cotrimoxazole, and clindamycin though effective on gram-positive organisms are not effective on enterococcus because enterococci are intrinsically resistant to them [6]. However, aminoglycosides can be used in combination with bacterial cell wall biosynthesis inhibitor drugs such as penicillin, ampicillin or vancomycin [7]. Only gentamicin and streptomycin are recommended for combination use in enterococcal infection to have the synergistic effects while other aminoglycosides are not used in this application [8,9]. CLSI guidelines recommend testing enterococcal species for susceptibility to high-level gentamicin (HLG) and streptomycin from the aminoglycoside group because their mechanisms of action differ from other aminoglycosides and are effective drugs in combination with other drugs or alone at higher doses than the standard therapeutic dose [4]. Several studies reported high prevalence of enterococci in urinary tract infections [9-12]. The present study investigated the susceptibility of uropathogenic enterococci to high-level gentamicin at a tertiary care hospital. Also, the study evaluated susceptibility patterns of various antibiotics in the context of high-level gentamicin resistance in enterococci.   Materials and method Prospective observational research was carried out at a tertiary care medical college hospital for two years, from December 2020 to November 2022. The study included all urine specimens with significant (105 CFU/ml) growth of enterococci from patients with features of urinary tract infection. Other specimens and uropathogens were not included in the investigation. The study was approved by the institutional Ethical sub-committee before the study was initiated. Approval was granted by letter no: I.E.S.C./154/2022 dated 12 November 2022. Written informed consent was taken from patients or their attendants regarding sample testing, their results, and further use of results for research purposes. Samples were inoculated on Cystine Lactose Electrolyte Deficient (CLED) agar plate with a calibrated single-loop wire. Culture plates were incubated at 37oC for 18-24 hours. Following incubation, culture plates were examined for growth of enterococci. Only significant colony-forming units (105/ml or more) were considered pathogenic. Suspected colonies were confirmed using a Gram stain smear and other standard biochemical tests. Catalase and bile esculin tests were performed for identification of enterococci [13]. Antibiotic susceptibility testing was performed on cation-adjusted Muller Hilton agar by Kirby Bauer disc diffusion method. Following discs were used: erythromycin (15µg), ciprofloxacin (5µg), vancomycin (10µg), linezolid (30µg), ampicillin (10µg), and gentamicin (120µg). Lawn culture was performed and the above discs were placed on a lawn-cultured plate. Culture plates were incubated at 37ºC for 18-24 hours. Antibiotic susceptibility was interpreted using current CLSI guidelines M-100 (2021 and 2022) [6,14]. Enterococcus faecalis ATCC 29212 and Enterococcus casseliflavis ATCC 700327 were used as the quality control strains. From time-to-time QC strain was checked by disc diffusion as well as automation to maintain the quality of the test and study.   Results During the study period, a total of 320 enterococci were isolated and tested for HLG susceptibility by the Kirby Bauer disc diffusion method. Out of 320 isolates, 68.4% were resistant to HLG. Of the total isolates, 158 (49.37%) were from male and 162 (50.6%) were female patients. The highest numbers of enterococci were isolated from 41-60 years age group (34.1%) followed by the 21-40 years (29.1%) and above 60 years (24.4%) age groups (Table-1).   Table-1: Distribution of high level gentamicin (HLG) resistant and susceptible enterococci according to the gender, age, location and speciality (n=320)     During the study period, specimens were received from out and in patients departments and ICU. The highest number of specimens was received from admitted patients (69.1%) but the highest HLG resistant enterococci were found in samples from ICU-admitted patients (78.5%). Among all the patients, the majority of the specimens were received from the medicine department (34.7%) followed by urology department (22.8%). However, the highest HLG resistant enterococci were isolated in samples from patients of pediatric ward (85.2%) followed by patients from surgery (76.2%) and critical care medicine (76%). Details are shown in Table-1. Table-2 shows the susceptibility of HLG resistant and sensitive enterococci isolates to several antimicrobial agents tested. Except resistance to nalidixic acid, HLG resistant enterococci were significantly (p< 0.05) more resistant to ampicillin, erythromycin, nitrofurantoin and vancomycin compared HLG sensitive isolates. Overall, 15% enterococci were resistant to vancomycin. All the isolated enterococci were sensitive to linezolid.   Table-2: Susceptibility of HLG resistant and sensitive enterococci isolates to antimicrobial agents tested     Discussion Drug-resistant enterococci play a significant role in hospital acquired infections. Detection of HLG resistance in enterococci is important for successful management of infection. With this background, the current study was planned. In the present study, there was no significant difference of isolation rate of enterococci from urine samples of male and female cases. Several Indian and international studies also reported almost similar rates (52.3% to 59.7%) of enterococcal infection in male and female patients [15-19]. However, these studies were conducted with blood, urine and others clinical specimens while the current study was conducted only on urine specimens. In the current study, 89.4% of isolates were from the admitted patients which include 69.1% from wards and 20.3% from ICU admitted patients and the findings were comparable to other reported studies [15,20,21]. Age can play a major role in causing urinary infections. Elderly patients are more prone to acquire UTIs. In the current study more than half of the UTI patients (55.8%) with enterococcal was above the age of 40 years. Other studies also reported similar rates [15,19]. Several studies investigated the magnitude of HLG resistance in enterococci isolated from different clinical samples. In our study 68.4% enterococcal isolates from urine was HLG-resistant. Studies from different regions of India and other countries also reported the rates from 41% to 86.2% [6,8,12,13,16,17,20-25]. In our study, resistance against other commonly used antibiotics was found significantly higher in HLG resistant enterococci compared HLG sensitive isolates. Similar results were also reported by Dadfarma N et al, specifically for penicillin, ciprofloxacin, and erythromycin [11]. Overall, the resistance against ampicillin, quinolones, macrolides and nitrofurantoin was high in our isolates. Several other studies also reported almost similar resistance rate in enterococci [12,16-20,22-24,26,27]. Vancomycin is used to treat infections due to methicillin resistant S. aureus (MRSA) and enterococci. In our series, overall 15% of the enterococci was resistant to vancomycin, but the rate was significantly higher in HLG resistant than that of sensitive enterococci (20.5% vs. 2.9%). Several earlier studies reported the resistance to vancomycin from 12% to about 37% [12,19,20,23,24,26]. Linezolid is increasingly used to treat infections due to vancomycin resistant and sensitive enterococci. Recently, resistance to linezolid has been reported by many studies. The reported resistance to linezolid varied from 0.5% to 4% [12,19,23,24]. However, in the current study, all the enterococci isolates were susceptible to linezolid. The present study had some limitations. The organism could not be identified up to the species level and minimum inhibitory concentrations (MIC) for the tested antibiotics were not done due to limited resources. Occurrence of high rates (68%) of HLG resistant enterococci in the present study highlights the need for testing and reporting enterococci for HLG resistance.   Acknowledgement The authors would like to thank Dr. S. L. Jadhav, Professor and his PG Resident Dr. Deepu Palal, Department of Community Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India for helping in statistical analysis of the work.   Conflict of interest None of the author has conflict of interest.   Fund The study did not receive any grant from any funding agencies.   References 1.     Goel V, Kumar D, Kumar R, Mathur P, Singh S. Community acquired enterococcal urinary tract infections and antibiotic resistance profile in North India. J Lab Physicians. 2016; 8: 50-54. 2.     Angadi K, Jadhav S, Misra RN, Mirza SB, Desai D. Incidence and antimicrobial susceptibility of enterococcal infections in tertiary care hospital. Int J Microbiol Res. 2018; 10(4): 1135-38. 3.     Hashem YA, Amin HM, Essam TM, Yassin AS, Aziz RK. Biofilm formation in Enterococci: genotype-phenotype correlations and inhibition by vancomycin. Sci Rep. 2017; 7(1): 5733. Doi: 10.1038/s41598-017-05901-0. 4.     Emaneini M, Khoramian B, Jabalameli F, Beigverdi R, Asadollahi K, Taherikalani M, et al. Prevalence of high-level gentamicin-resistant Enterococcus faecalis and Enterococcus faecium in an Iranian hospital. J Prev Med Hyg. 2016; 57(4): E197-E200. 5.     Naruka HS, Chand AE, Meena H. Prevalence of various enterococcus species and their antibiotic resistance pattern among urinary isolates in tertiary care center in South Eastern Rajasthan. IP Int J Med Microbiol Trop Dis. 2019; 5(1): 18-22. 6.     CLSI, Performance Standards for Antimicrobial Susceptibility Testing; 31st edition. CLSI Supplement M100. Clinical Laboratory Standard Institute, Wayne, PA: CLSI; 2021. 7.     Nishimoto Y, Kobayashi N, Alam MM, Ishino M, Uehara N, Watanabe N. Analysis of the prevalence of tetracycline resistance genes in clinical isolates of Enterococcus faecalis and Enterococcus faecium in a Japanese hospital. Microb Drug Resist. 2005; 11: 146–153. 8.     del Campo R, Tenorio C, Rubio C, Castillo J, Torres C, Gómez-Lus R. Aminoglycoside-modifying enzymes in high-level streptomycin and gentamicin resistant Enterococcus spp. in Spain. Int J Antimicrob Agents. 2000; 15(3): 221-6. Doi: 10.1016/s0924-8579(00)00169-2. 9.     Shete V, Grover N, Kumar M. Analysis of aminoglycoside modifying enzyme genes responsible for high-level aminoglycoside resistance among enterococcal isolates. J Pathog. 2017; 2017: 3256952. Doi: 10.1155/2017/3256952. 10.  Mathur P, Kapil A, Chandra R, Sharma P, Das B. Antimicrobial resistance in Enterococcus faecalis at a tertiary care centre of northern India. Indian J Med Res. 2003; 118:25–28. 11.  Dadfarma N, Fooladi AAI, Oskoui M, Hosseini HM, High level of gentamicin resistance (HLGR) among enterococcus strains isolated from clinical specimens. J Infect Public Health. 2013; 6(3): 202-208. 12.  Das AK, Dudeja M, Kohli S, Ray P, Nandy S. High-level gentamicin resistance mediated by Aac(6′)-Ie-aph(2”)-Ia gene in Enterococcus species isolated from clinical samples in Northern India. Indian J Pharmacol. 2022; 54: 171-176. 13.  CLSI, Performance Standards for Antimicrobial Susceptibility Testing; 32nd edition. CLSI Supplement M100. Clinical Laboratory Standard Institute, Wayne, PA: CLSI; 2022. 14.  Winn, W., Allen, S., Janda, W., Koneman, E., Procop, G., Schreckenberger, P. and Woods, G. Koneman’sColor Atlas and Textbook of Diagnostic Microbiology. 7th Edition, Lippincott Williams and Wilkins, New York. 2016. 15.  Georges M, Odoyo E, Matano D, Tiria F, Kyany’a C, Mbwika D, et al. Determination of Enterococcus faecalis and Enterococcus faecium antimicrobial resistance and virulence factors and their association with clinical and demographic factors in Kenya. J Pathog. 2022; 2022: 3129439. Doi: 10.1155/2022/3129439. 16.  Adesida SA, Ezenta CC, Adagbada AO, Aladesokan AA, Coker AO. Carriage of multidrug resistant Enterococcus faecium and Enterococcus faecalis among apparently healthy humans. Afr J Infect Dis. 2017; 11(2): 83-89. Doi: 10.21010/ajid.v11i2.11. 17.  Sumangala B, Sharlee R, Sahana Shetty N S. Identification of Enterococcus faecalis and E faecium among enterococci isolated from clinical samples in a teaching hospital Mandya Institute of Medical Sciences, Mandya. Indian J Microbiol Res. 2020; 7(3): 284-287. 18.  Ahmad S, Alotaibi H, Alkhaibari S, Alshahrani B. Enterococcal urinary tract infection in newborns at a Pediatric Hospital in Saudi Arabia. Dhaka Univ J Pharm Sci. 2020; 19: 119-124. 19.  Rana D, Sande S. Study of prevalence and antimicrobial susceptibility pattern of Enterococci isolated from clinically relevant samples with special reference to high Level aminoglycoside resistance (HLAR) in a rural tertiary care hospital. J Evolution Med Dent Sci. 2020; 9(34): 2472-2478. DOI: 10.14260/jemds/2020/537. 20.  Meena S, Mohapatra S, Sood S, Dhawan B, Das BK, Kapil A. Revisiting nitrofurantoin for vancomycin resistant enterococci. J Clin of Diagn Res. 2017; 11(6): DC19-DC22. doi.org/10.7860/JCDR/2017/25140/10140. 21.  Billington EO, Phang SH, Gregson DB, Pitout JD, Ross T, Church DL, et al. Incidence, risk factors, and outcomes for Enterococcus spp. blood stream infections: a population-based study. Int J Infect Dis. 2014; 26: 76-82. Doi: 10.1016/j.ijid.2014.02.012. 22.  El-Mahdy R, Mostafa A, El-Kannishy G. High-level aminoglycoside resistant enterococci in hospital-acquired urinary tract infections in Mansoura, Egypt. Germs. 2018; 8(4): 186-190. Doi: 10.18683/germs.2018.1145. 23.  Bhatt P, Patel A, Sahni AK, Praharaj AK, Grover N, Chaudhari CN, Das NK, Kulkarni M. Emergence of multidrug-resistant enterococci at a tertiary care centre. Med J Armed Forces India. 2015; 71(2): 139-144. 24.  Moussa AA, Md Nordin AF, Hamat RA, Jasni AS. High level aminoglycoside resistance and distribution of the resistance genes in Enterococcus faecalis and Enterococcus faecium from teaching hospital in Malaysia. Infect Drug Resist. 2019; 12: 3269-3274. Doi: 10.2147/IDR.S219544. 25.  Mittal S, Singla P, Deep A, Bala K, Sikka R, Garg M, et al. Vancomycin and high-level aminoglycoside resistance in Enterococcus spp. In a tertiary health care centre: A therapeutic concern. J Pathog. 2016; 2016: 8262561. 26.  Purohit G, Gaind R, Dawar R, Verma PK, Aggarwal KC, Sardana R, et al. Characterization of vancomycin-resistant Enterococci in hospitalized patients and role of gut colonization. J Clin Diagn Res. 2017; 11: C01-5. 27.  Rezaee MA, Abdinia B. Etiology and antimicrobial susceptibility pattern of pathogenic bacteria in children subjected to UTI: a referral hospital-based study in Northwest of Iran. Medicine (Baltimore). 2015; 94(39): e1606. Doi: 10.1097/MD.0000000000001606.      Cite this article as: Gandham NR, Mirza S, Vyawahare C, Patil R, Mukhida S, Kannuri S, BhaumikS. Prevalence and antimicrobial susceptibility of high-level gentamicin resistant enterococci isolated from urine at a hospital in Pune, India. IMC J Med Sci. 2023; 17(2):008. DOI: https://doi.org/10.55010/imcjms.17.018 <![CDATA[Serum adiponectin profile in obese Bangladeshi children attending an obesity clinic]]> Palash Chandra Sutradhar Tahniyah Haq Md. Kabir Hossain Marufa Mustari M A Hasanat Md. Farid Uddin https://imcjms.com/journal_full_text/468 2023-06-14 10:02:52 Original Article IMC J Med Sci. 2023; 17(2):009 Abstract Background and objective: Childhood obesity plays major role in the pathogenesis of various cardiovascular and metabolic diseases. Serum adiponectin has been found to be associated with several cardiometabolic risk factors. The study investigated the serum adiponectin levels and its relationship with obesity and cardiometabolic risk factors in Bangladeshi obese children. Material and methods: Overweight or obese children, between 6-18 years of age, attending the obesity clinic of the Department of Endocrinology, BSMMU were enrolled. Waist circumference (WC) and blood pressure (BP) were measured and blood samples were taken for estimation of glucose, insulin, lipid profile and adiponectin. Fasting plasma glucose (FPG), serum insulin and lipid profile were estimated by automated analyzer. Insulin resistance (HOMA-IR) was calculated from fasting insulin and fasting plasma glucose values. Serum adiponectin (total) was measured by ELISA method using DRG ELISA kit, Germany. Results:A total of 78 overweight or obese children of 6-18-year of age were enrolled. The mean (±SD) age of the study population was 12.22 ± 2.56 years and the mean BMI was 28.79 ± 4.54 kg/m2. Mean (±SD) serum adiponectin was 36.93 ± 17.85 µg/ml in 78 overweight/obese children. One way ANOVA showed no significant (P= 0.582) difference of adiponectin levels among children with overweight and different grades of obesity. There was no significant correlation between adiponectin and measures of generalized (r=0.035, p=0.763) or central (r=0.098, p=0.392) obesity. Also, no significant correlation was found between serum adiponectin level and any of cardiovascular risk factors of obesity or metabolic health. Conclusion: The study showed high serum adiponectin level in obese Bangladeshi children. Also, no association was found between serum adiponectin levels with grades of obesity and cardiometabolic risk factors among obese children of Bangladesh.   IMC J Med Sci. 2023; 17(2):009. DOI: https://doi.org/10.55010/imcjms.17.019 Correspondence: Palash Chandra Sutradhar, Department of Medicine, Sir Salimullah Medical College Mitford Hospital, Kotwali, Dhaka-1000, Bangladesh. Email: palashdmc@gmail.com   Introduction Obesity, a worldwide pandemic, affects not only adults, but also children [1]. According to report of WHO in 2018, over 381 million children and adolescents (5-19yrs) were overweight/obese [2]. A countrywide epidemiological study in Bangladesh reported that 3.5% and 9.5% of 6–15-year-old children were obese and overweight respectively [3]. Childhood obesity plays major role in the pathogenesis of various cardiovascular and metabolic diseases. It increases the risk of glucose intolerance, atherogenic dyslipidemia and atherosclerosis, hypertension, metabolic syndrome, non-alcoholic fatty liver disease, and polycystic ovarian syndrome, etc [4,5]. In obesity, adipose tissue has been proved to be the site of secretion of metabolically active mediators (adipokines) including adiponectin [6]. Adiponectin, having variety of protective roles: anti-inflammatory, anti-atherogenic, cardio-protective, vasculo-protective and insulin sensitizing properties, is dysregulated in expression in obesity [7]. Serum adiponectin has been observed to be decreased in childhood obesity [8-11]. Serum adiponectin has been found inversely correlated with insulin resistance, TC and TG, but positively correlated with HDL-C, insignificant or no association with LDL-C and blood pressure [9,11-17]. In Bangladesh, very few studies have been done to observe the association between adiponectin and obesity and its cardiometabolic risk factors. One recent study conducted in adults showed that serum adiponectin was decreased in metabolically unhealthy adults (both normal weight and overweight/obese) [18]. However, correlation was not significant between obesity phenotypes and adiponectin. Serum adiponectin has not yet been investigated adequately on children in Bangladesh. So, the present study was conducted to find out the profile of serum adiponectin and its relationship with obesity and cardiometabolic risk factors in overweight/obese children.   Material and Methods This cross-sectional study was conducted at the Department of Endocrinology, BSMMU from March 2019 to August 2020.The protocol was duly approved by the Institutional Review Board (IRB) of BSMMU before the initiation of the study. Informed written consent or assent was obtained from the participants and their guardians prior to the enrollment in the study. Study population and anthropometry: Overweight or obese children between 6-18 years of age attending obesity clinic of the department were enrolled. Overweight and obese children having secondary causes of obesity were excluded. Standing height was measured by using a portable stadiometer in standing upright position on a flat surface without shoes. Weight was measured using a digital weighing machine. Height and weight were recorded to the nearest 0.1kg. Waist circumference (WC) for central obesity and blood pressure (BP) of each participant were measured. WC was measured by using a non-extensible and non-elastic measuring tape in mid respiration. BMI (kilograms per square meter) was calculated from height and weight measurements and was plotted on the CDC age and sex specific growth chart to determine the BMI-per-age percentile. Collection of blood samples and biochemical analysis: About 5 ml of fasting blood sample was collected aseptically from each child by venipuncture for estimation of adiponectin and other biochemical investigations. Serum was immediately separated and preserved in -700C freezer until tested. Blood glucose, insulin and lipid profile were analyzed by automated analyzer using glucose oxidase, chemiluminescent immunoassay and glycerol phosphate oxidase methods respectively. Serum adiponectin (total) was measured by sandwich ELISA method using DRG ELISA kit, Germany. Categorization of study population: Based on BMI percentile, children were classified into normal, overweight, grade-I, grade-II and grade-III obese as follows: normal - < 85th percentile, overweight - 85th to less than 95th, obese – equal to or greater than 95th, Grade I obesity - ≥ 95th percentile to < 120% of the 95th percentile, Grade II obesity - ≥ 120% to < 140% of the 95th percentile and Grade III obesity - ≥ 140% of the 95th percentile [19]. Central obesity was classified by waist circumference into: normal - 5th to < 90th percentile and increased (central obesity present) - equal to or greater than the 95th percentile [20]. Systolic and/or diastolic blood pressure was categorized into normal, pre-hypertension (elevated blood pressure), and stage 1 and 2 hypertension) for age (1-13 and ≥ 13 years), gender and height according to the “Fourth Report on Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents” (Table-1) [21,22].   Table-1: Categories of systolic and/or diastolic blood pressure for children aged 1-13 and ≥ 13 years     Homeostasis model assessment for insulin resistance (HOMA-IR) was employed to measure the insulin resistance [23]. Formula used was - HOMA-IR = Fasting plasma insulin (μU/ml) × fasting plasma glucose (mmol/L)/22.5. HOMA-IR value above 3 was considered to be insulin resistance in children (corresponds to the 95th percentile healthy reference children) [24]. Impaired fasting glycemia (IFG) and diabetes mellitus (DM) were defined as fasting plasma glucose (FPG) levels between 5.6 to 6.9 mmol/l and FPG ≥7 mmol/l respectively [25]. Dyslipidemia in children and adolescents was defined as at least one abnormal value for HDL, LDL, total cholesterol, or triglyceride [26,27]. Abnormal cutoffs value of individual blood lipids in children is shown in Table-2.   Table-2: Plasma lipid ranges for children and adolescents [27]     According to the International Diabetes Federation (IDF) metabolic syndrome was defined as abdominal obesity (waist circumference ≥ 90th percentile for age and sex) plus at least two of the following parameters: high triglyceride (TG) and/or low HDL-cholesterol, elevated blood pressure or hypertension, and impaired glucose tolerance or type 2 diabetes mellitus [28].   Data analysis Data obtained from the study were analyzed using computer-based IBM SPSS Statistics software program version 26. The data distribution was assessed by Shapiro–Wilk test. Skewed continuous variables were log-transformed when necessary. Results were described in frequencies or percentages for qualitative values and mean (± SD/SE) for quantitative values with normal distribution. Subgroups made based on obesity and metabolic findings were compared by one way ANOVA or, unpaired independent t-test as applicable. Correlation between variables was analyzed by Pearson correlation coefficient test or Spearman rho correlation coefficient test as appropriate. P values ≤ 0.05 was considered statistically significant.   Results A total of 78 overweight or obese children of 6-18-year of age were enrolled. The mean (±SD) age of the study population was 12.22 ± 2.56 years and the mean BMI was 28.79 ± 4.54 kg/m2.The characteristics of the study population are depicted in Table-3.   Table-3: Characteristics of the study population (n=78)     Of the total participants, 53 (67.9%) were male and 71 (91%) were obese of which 51.3% and 32.1% had grade I and II obesity respectively. Majority (92.3%) had high waist circumference. Though the majority was normotensive (62.8%) and normoglycemic (87.2%), 97.5% of the population had dyslipidemia. The frequencies of baseline characteristics of study population are depicted in Table-4.   Table-4: Baseline clinical characteristics of the study population (n=78)     More than half (51/65.4%) of the study population was metabolically healthy obese whereas only 20.5% of the study population was metabolically unhealthy obese. The frequency of metabolic health categories is shown in Table-5.   Table-5: Distribution of study population according to the different metabolic health categories (n=78)     The mean (±SD) serum adiponectin level in children and adolescents with overweight and obesity was 36.93 ± 17.85 µg/ml. Details of the distribution of serum adiponectin are shown in Table-6. There was no significant (p=0.676) difference of serum adiponectin between male (36.34 ± 16.55 µg/ml) and female (38.17 ± 20.65 µg/ml) children.   Table-6: Statistical measures of serum adiponectin (n=78)     One way ANOVA showed no significant (P= 0.582) difference of adiponectin levels among children with different grades of overweight and obesity (Table-7). Although serum adiponectin level was higher in those with high waist circumference, the difference was not statistically significant (P=0.408) There was also no significant difference of serum adiponectin level between children with and without cardiometabolic risk factors or metabolic syndrome (Table-8). There was also no significant difference of adiponectin levels among various metabolic health categories.   Table-7: Serum adiponectin levels of study population with different grades of obesity (n=78)     Table-8: Comparison of serum adiponectin levels between patients with and without cardiometabolic risk factors (n=78)     No significant correlation between adiponectin level and measures of generalized or central obesity was observed (Table-9). Similarly, there was no significant correlation between adiponectin level and cardiovascular risk factors of obesity or metabolic health status.   Table-9: Relationship of serum adiponectin with measures of obesity (generalized and central), cardiometabolic risk factors and metabolic health (n=78)     Discussion This cross-sectional study was designed to study the serum adiponectin levels and its relationship with obesity and cardiometabolic risk factors among Bangladeshi obese children and adolescents. There was no association between serum adiponectin level and obesity (generalized and central) or cardiometabolic risk factors. In the present study, serum adiponectin was paradoxically high, instead of low, irrespective of metabolic health status in comparison to reference range of adiponectin i.e. 4.58−8.30 µg/ml [29]. However, in most previous studies, serum adiponectin was found to be decreased in overweight/obese children compared to normal weight children [8-11]. A recent study conducted in Bangladeshi individuals less than 30 years of age with diabetes mellitus also found high adiponectin levels compared to healthy individuals [30]. High serum adiponectin, as found in this study, might be due to inherent high adiponectin in Bangladeshi children, which however may be confirmed by further studies. Other plausible causes of high adiponectin in this study could be due to calorie restriction and physical exercise undertaken by the study children prior to enrollment in study. In addition, most of the study population were healthy obese, as only 20.5% had metabolic syndrome. A higher percentage of metabolically healthy obese children might have contributed to observed higher adiponectin concentration. In this study, there was no significant association found between adiponectin and generalized or central obesity. Most previous studies found a negative association between serum adiponectin and obesity (generalized and central) in children [8-11]. There were only few studies that contradicted these findings. In a study in non-diabetic Asian Indian teenagers, no correlation was found between adiponectin level and BMI and WC [31]. Plausible causes might be ethnic variation, unreported weight loss, and use of indirect and less sensitive measures of adiposity (BMI and WC). In this study, no significant correlation was found between serum adiponectin and cardiometabolic risk factors or metabolic health status. Similar insignificant or no association of serum adiponectin with LDL-C was reported earlier [17]. Also, no correlation between adiponectin and HDL-C, TC or TG was found in children [21]. Numerous studies were thoroughly reviewed to find out the association of serum adiponectin with insulin resistance. Many studies reported inverse correlation between serum adiponectin with insulin resistance [9,11-14]. However, similar to this study only a few studies found no association between adiponectin and insulin resistance in children [10,15,31]. Relation of adiponectin with blood pressure is yet conflicting and unresolved. Similar to this study, no correlation between plasma adiponectin and blood pressure was observed in most studies in children [14,15,31]. In contrast to this study, in majority of studies adiponectin was positively correlated with HDL-C and inversely correlated with TC and TG in children [15-17]. Findings in the present study about adiponectin levels related to cardiometabolic risk factors could also be due to less number of children with metabolic syndrome and more metabolically healthy obese children. However, the present study had some limitations. We did not measure the serum adiponectin levels of healthy age and sex matched non-obese children. In conclusion, the study has provided a profile of serum adiponectin levels in obese children of Bangladesh. Also, the study has demonstrated no association between serum adiponectin levels and obesity or cardiometabolic risk factors in obese children.   Acknowledgements The authors express their sincere gratitude to the hospital administration, treating physicians, supporting staff and the patients for their generous support. We acknowledge the contribution of the Departments of Microbiology & Immunology and Biochemistry & Molecular Biology, BSMMU for biochemical analyses.   Conflict of interests None of the author has conflict of interest.   Funding The work was supported by grant from Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh.   References 1.     James PT, Leach R, KalamaraE, Shayeghi M. The worldwide obesity epidemic. Obes Res. 2001; 9: 228-233. doi: 10.1038/oby.2001.123 2.     World Health Organization (WHO). Obesity and overweight. June 2021. (Accessed date 18th February, 2018). Available at: http://www.who.int/news-room/ fact-sheets/detail/obesity-and-overweight. 3.     Bulbul T and Hoque M. Prevalence of childhood obesity and overweight in Bangladesh: finding from a countrywide epidemiological study. BMC Pediatrics. 2014; vol. 14: 86. 4.     Maggio AB, Martin XE, Grasser CS, Gal-duding C, Beghetti M, Farpour-Lambert NJ, et al. Medical and non-medical complications among children and adolescents with excessive body weight. BMC Pediarics. 2014; 14: 232. doi: 10.1186/1471-2431-14-232. 5.     Rahman MH. Childhood obesity; effects and prevention. Bangladesh J Child Health. 2017; 41(2): 74-76. doi: 10.3329/bjch.v41i2.36101 6.     Nigro E, Scudiero O, Monaco ML, Palmieri A, Mazzarella G, Costagliola C, et al. New insight into adiponectin role in obesity and obesity-related diseases. BioMed Res Int. 2014; 2014: 658913. doi: 10.1155/2014/658913. 7.     Antoniades C, Antonopoulos AS, Tousoulis D and Stefandis C. Adiponectin: from obesity to cardiovascular disease. Obes Rev. 2009; 10(3): 269-279. doi: 10.1111/j.1467-789X.2009.00571.x. 8.   AritaY, Kihara S, Ouchi N, Takahashi M, Maeda K, Miyagawa JI, et al. Paradoxical decrease of an adipose-specific protein, adiponectin, in obesity. Biochem Biophys Res Commun. 1999; vol. 257: 79-83. doi: 10.1006/bbrc.1999.0255 9.     Stefan N, Bunt JC, Salbe AD, Funahashi T, Matsuzawa Y, Tataranni P. Plasma adiponectin concentrations in children: relationships with obesity and insulinemia. J Clin Endocrinol Metab. 2002; 87: 4652-4656. doi: 10.1210/jc.2002-020694 10.  Nemet D, Wang P, Funahashi T, Matsuzawa Y, Tanaka S, Engelman L, et al. Adipocytokines, body composition, and fitness in children. Pediatric Research. 2003; 53: 148-152. doi: 10.1203/00006450-200301000-00025 11.  Alikasifoglu A, Gönç EN, Özön ZA, Sen Y, Kandemir N. The relationship between serum adiponectin, tumor necrosis factor-alpha, leptin levels and insulin sensitivity in childhood and adolescent obesity: adiponectin is a marker of metabolic syndrome. J Clin Res Pediatr Endocrinol. 2009; 1: 233-239. doi: 10.4274/jcrpe.v1i5.233 12.  Vikram NK, Misra A, Pandey RM, Dwivedi M and Luthra L. Adiponectin, insulin resistance, and C-reactive protein in post-pubertal Asian adolescents. Metabolism. 2004; 53: 1336-1341. doi: 10.1016/j.metabol.2004.05.010 13.  Chu NF, Shen MH, Wu DM, Lai CJ. Relationship between plasma adiponectin levels and metabolic risk profiles in Taiwanese children. Obes Res. 2005; 13(11): 2014-20. doi: 10.1038/oby.2005.247. 14.  Riestra P, Garcia-Anguita A, Lasuncion MA, Cano B, Oya MD, Garces C. Relationship of adiponectin with metabolic syndrome components in pubertal children. Atherosclerosis. 2011; 216: 467-470. doi: 10.1016/j.atherosclerosis.2011.02.031 15.  Kettaneh A, Heude B, Oppert J, Scherer P, Meyre D, Borys J, et al. Serum adiponectin is related to plasma high-density lipoprotein cholesterol but not to plasma insulin-concentration in healthy children: the FLVS II study. Metabolism. 2006; 55: 1171-1176. doi: 10.1016/j.metabol.2006.04.015 16.  Guenther M, James R, Marks J, Zhao S, Szabo A, Kidambi S. Adiposity distribution influences circulating adiponectin levels. Transl Res. 2014; 164(4): 270-277. doi: 10.1016/j.trsl.2014.04.008. 17.  Yanai H, Yoshida H. Beneficial effects of adiponectin on glucose and lipid metabolism and atherosclerotic progression: mechanisms and perspectives. Int J Mol Sci. 2019; 20: 155-179. doi: 10.3390/ijms20051190 18.  Naher S and Hoque N. Metabolic phenotyping: A new concept. Bangladesh J Med Biochem, 2018; 11: iii-iv. 19.  Skinner AC and Skelton JA. Prevalence and trends in obesity and severe obesity among children in the United States, 1999-2012. JAMA Pediatrics. 2014; 168: 561-566. doi: 10.1001/jamapediatrics.2014.21 20.  Xi B, Zong X, Kelishadi R, Litwin M, Hong YM, Poh BK, et al. International waist circumference percentile cutoffs for central obesity in children and adolescents aged 6 to 18 years. J Clin Endocrinol Metab. 2020; 105(4): e1569–83. doi: 10.1210/clinem/dgz195. 21.  Yan W, Liu F, Li X, Wu L, Zhang Y, Cheng Y, Zhou W, Huang G. Blood pressure percentiles by age and height for non-overweight Chinese children and adolescents: analysis of the China Health and Nutrition Surveys 1991-2009. BMC Pediatr. 2013; 13: 195. doi: 10.1186/1471-2431-13-195.. 22.  Falkner B, Daniels SR. Summary of the fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Hypertension.2004; 44: 387–388. doi: 10.1161/01.HYP.0000143545.54637.af 23.  Matthews DR, Hoske JP, Rudenski AS, Naylor BA, Treacher DF and Turner RC. Homeostasis model assessment: insulin resistance and B-cell function from fasting plasma glucose and insulin concentration in man. Diabetologia. 1985; 28: 412-419. 24.  Yin J, Li M, Xu L, Wang Y, Cheng H, Zhao X, et al. Insulin resistance determined by Homeostasis Model Assessment (HOMA) and associations with metabolic syndrome among Chinese children and teenagers. Diabetol Metab Syndr. 2013; 5(1): 71. doi: 10.1186/1758-5996-5-71. 25.  Expert Committee on the Diagnosis and Classiﬁcation of Diabetes Mellitus. Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care, 2003; 26: 3160–3167. doi: 10.2337/diacare.26.11.3160   26. Gröber-Grätz D, Widhalm K, de Zwaan M, Reinehr T, Blüher S, Schwab KO, et al. Body mass index or waist circumference: which is the better predictor for hypertension and dyslipidemia in overweight/obese children and adolescents? Association of cardiovascular risk related to body mass index or waist circumference. Horm Res Paediatr. 2013; 80(3): 170-8. doi: 10.1159/000354224. 27. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011; 128 Suppl 5(Suppl 5): S213-56. doi: 10.1542/peds.2009-2107C. 28.  Zimmet P, Alberti KG, Kaufman F, Tajima N, Silink M, Arslanian S, et al. The metabolic syndrome in children and adolescents: an IDF consensus report. Pediatric Diabetes. 2007; 8(5): 299-306. doi: 10.1111/j.1399-5448.2007.00271.x. 29. Chang C, Jian D,Lin M, Zhao J, Ho L, Juan C. Evidence in obese children: contribution of hyperlipidemia, obesity-inflamation, and insulin sensivity. PLoS One. 2015 26; 10(5): e0125935. doi: 10.1371/journal.pone.0125935. 30.  Roy I. Adiponectin, leptin levels and leptin/adiponectin ratio as a marker of insulin resistance in young diabetic subjects. Thesis (MD). 2019; BSMMU, Dhaka. 31.  Snehalatha C, Yamuna A, Ramachandran A. Plasma adiponectin does not correlate with insulin resistance and cardiometabolic variables in nondiabetic Asian Indian teenagers. Diabetes Care. 2008; 31: 2374-2379. doi: 10.2337/dc08-1083.      Cite this article as: Sutradhar PC, Haq T, Hossain MK, Mustari M, Hasanat MA, Farid Uddin M. Serum adiponectin profile in obese Bangladeshi children attending an obesity clinic. IMC J Med Sci. 2023; 17(2):009. DOI: https://doi.org/10.55010/imcjms.17.019 <![CDATA[Knowledge, attitude and practice regarding breast and cervical cancer among women of reproductive age residing in a rural area of West Bengal, India]]> Kuntala Ray Vanlaldiki Chhakchhuak Mausumi Basu Vineeta Shukla https://imcjms.com/journal_full_text/473 2023-07-18 11:54:35 Original Article IMC J Med Sci. 2023; 17(2):011 Abstract Background and objectives: Developing screening programmes to lower breast and cervical cancer morbidity and mortality requires a better knowledge of psychological, socioeconomic, and environmental variables that may affect screening behaviours. This study was conducted to assess the knowledge, attitude and practices regarding breast and cervical cancer among women of reproductive age group in a village in West Bengal, India. Materials and methods: A descriptive type of observational study was conducted in village Muchisa of Budge-Budge II block, West Bengal among 300 women from January to June 2022 using a pre-designed, pre-tested, structured schedule by face-to-face interview method. Data were analyzed using SPSS version 25.0 using suitable descriptive and inferential statistics. Results: The mean age of the study participants was 31.6 ± 7.4 years. Out of 300 women, 41.7% and 41.3% had adequate knowledge on breast and cervical cancer respectively. Regarding attitude, 57.3% and 75.3% had highly favourable attitude on breast and cervical cancer respectively. Only 38 (12.7%) had performed breast self-examination at least once whereas only 5.3% had undergone Pap smear test at least once before the survey. Socio-demographic and economic factors of the respondents were significantly (p<0.05) associated with knowledge on breast cancer while none of these factors were found to have statistically significant association with knowledge on cervical cancer. Conclusion: Most of the study population did not have adequate knowledge of breast and cervical cancer, their risk factors and symptoms. Their attitude was positive but practice related to screening was very unsatisfactory. IMC J Med Sci. 2023; 17(2):011. DOI: https://doi.org/10.55010/imcjms.17.021 *Correspondence: Vineeta Shukla, Senior Resident, Department of Community Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, India; Email: vineeta1992@gmail.com   Introduction Globally, breast and cervical cancers are the most common cancer among women. There were about 2.3 million new cases of breast cancer worldwide and about 685 000 deaths from this disease in 2020 [1]. The burden of breast cancer is expected to increase to over 3 million new cases, and 1 million deaths every year by 2040. Likewise, there were about 570,000 new cases and 311,000 deaths of women from cervical cancer globally in 2018 [2]. It is evidenced that, approximately 83% of the world’s new cases and 85% of all cervical cancer deaths reported are from developing countries [3]. Age standardized incidence rate of breast cancer in India is about 25.8 per 100,000 women that means roughly 1 in 4000 females are affected [4]. According to Globocan data 2020, breast cancer accounted for 10.6% (90,408) of all fatalities in India and 13.5% (1,78,361) of all cancer cases, with a cumulative risk of 2.81[5]. The mortality rate is lower in developed countries compared to developing countries due to availability of early cancer screening programmes. The established risk factors for breast cancer include early menarche, late menopause, late pregnancy, oral contraceptives, and hormone therapy for menopause. The main risk factors for the human papillomavirus (HPV), which causes cervical cancer, include being single, being illiterate, having antibodies against the herpes simplex virus (HSV), smoking, parity and having several sex partners [6]. Breast cancer unlike other type of cancers, is an easily screenable cancer, affects an easily visible organ and has an effective treatment. One of the major causes of low survival rate among breast cancer patients in developing countries is late diagnosis, and delay in initiation of effective treatment. Early diagnosis is aided by early reporting of patients to the health care set-up which can only be possible by creating awareness about the early detection of clinical symptoms and signs. Breast self-examination (BSE) helps in early detection of breast cancer. But, several studies have reported low or inadequate knowledge and practice of BSE among women of developing countries [7-12]. Similarly, several studies have reported low state of knowledge on cervical cancer as well as practice of cervical cancer screening among rural and tribal women in India [13,14]. Improving understanding of psychological, socio-economic, and environmental factors that may influence screening behaviour is a critical element of developing screening programs to reduce breast and cervical cancer morbidity and mortality. The success and benefits of screening to control and prevent breast and cervical cancer depend to a great extent on the level of awareness of the women of reproductive age group. With this background, the present study was conducted to assess the knowledge, attitude, and practice regarding breast cancer and cervical among women of reproductive age residing in a village of Budge-Budge II block, West Bengal, India. The study also attempted to find out the association (if any) between knowledge of breast and cervical cancers and socio-demographic and other epidemiological factors.   Materials and methods This descriptive type of observational study with cross sectional design was conducted among women of reproductive age residing in Muchisa village of Budge-Budge II block, West Bengal which is the rural field practice area of Institute of Post Graduate Medical Education and Research, Kolkata. The study period was from January to June 2022 (6 months). The study was initiated after approval from the institutional Ethics Committee (Approval letter no. IPGME&R/IEC/2022/244 dated 18.04.2022). Women of reproductive age, aged 15-49 years, who were permanent resident of that area for more than 1 year, were selected as study population. Women who did not give informed written consent were excluded from the study. Sample size was calculated using the following formula: n=(Z² *pq)/d2, where n=sample size, Z=1.96 (for Confidence interval = 95%), p=58% (prevalence of adequate knowledge regarding breast cancer from Singh et al. study)[8], q=1-p, d=relative error 10% and Non-Response=10% Hence, putting the values in the equation: n=278 + 10% of 278 = 306 The study participants were selected from the list maintained at the sub-centre by simple random sampling. The schedule had the following sections: 1.   Socio-demographic information of the respondents, 2.   Information on the knowledge, attitude, and practice regarding breast and cervical cancer. The schedule was prepared in English and later translated into Bengali (local language) by a language expert and retranslated by an independent expert. It was then pretested among 20 randomly selected women from the same setting to assess its clarity, validity, and reliability. After some minor modifications, the schedule was revaluated by the experts. The participants who were included in pretesting were excluded in the final study sample. After a brief introduction about the study and its importance, informed written consent was obtained. Data were then collected by face-to-face interview method. Investigator assured the participants that their identity and the information they provided would be treated as confidential. A maximum of 3 visits were made to every house to minimize drop out. The study variables were broadly dependent variables (knowledge, attitude and practice regarding breast and cervical cancers) and independent variables (socio-demographic characteristics such as age, religion, level of education, occupation, socio-economic status as per Modified BG Prasad Scale 2022 [15], type of family, etc). The forms were checked for completeness. Knowledge of breast cancer was assessed on 7 questions. Each correct response was scored one while incorrect/do not know was scored zero. Range of knowledge scores was zero to seven. The 75th percentile score (4) was taken as cut off. Those scoring 4 and above were categorized as having adequate knowledge. Attitude on breast cancer was assessed on 4 items on a 5-point Likert scale (responses ranging from strongly willing to strongly unwilling). The range of scores was 4 to 20. Respondents scoring 17 (Median) and above were said to have highly favourable attitude. The study participants were asked if they had undergone breast self-examination ever. Those who responded “yes” were said to have satisfactory practice. Seven questions were used to assess knowledge on cervical cancer. Each accurate response was given a score of 1, while wrong or do not know responses were scored 0. Scores on knowledge ranged from 0 to 7. The cut off was set at the 75th percentile score (3). Those who received a score of 3 or higher were considered to have adequate knowledge. Four items on a 5-point Likert scale measuring attitude towards cervical cancer were employed (responses ranged from highly willing to strongly unwilling). Scores ranged from 4 to 20. Respondents who received a score of 16 or higher were considered to have a highly favourable attitude. The study participants were questioned if they had ever undergone a Pap smear test. Those who replied "yes" were considered to have satisfactory practice. Data were tabulated into Microsoft Excel 2019 (Microsoft Corp, Redmond, WA, USA) and then imported to Statistical Package for the Social Sciences (SPSS for Windows, version 25.0, SPSS Inc., Chicago, USA) for interpretation and analysis. Descriptive and inferential statistics for study variables were performed. Pearson’s Chi square test was applied to test association between knowledge of breast and cervical cancer and socio-demographic variables. A p value of less than 0.05 was considered statistically significant.   Results The study was conducted among women of reproductive age group between 15-49 yrs of age Among the 306 participants contacted at their homes; data was available from 300 participants with 98% response rate. The mean age of the study participants was 31.6 ± 7.4 years and 87.3% were Hindus. Out of the total study participants, 92% were married and 81.3% were homemakers. Of the total, 29% and 26.7% had completed higher secondary and secondary level education respectively. About 45% belonged to lower middle socio-economic class according to Modified BG Prasad Scale 2022 and most of them were living in joint families (67.7%). Only 8.7% of the study participants were having past or family history of breast cancer. All the study participants had heard the terms breast cancer and cervical cancer. A large percentage of subjects (77.3%) were aware that breast cancer is one of the most prevalent cancers in women but only 30% could correctly coin that its occurrence increases with increasing age, 33% women said that breast cancer exhibits a hereditary pattern and 71.7% of them said that it is curable if detected early (Table-1). A mixed result was found in knowledge regarding breast self-examination. Only 17.3% respondents had knowledge of BSE and only 38 (12.7%) had performed BSE beforehand. Interestingly, friends and relatives were the most common source (31) of knowledge about BSE. Only 14 women got knowledge from health workers (Table-1). About 81% of the women were willing to know more about breast cancer, 46.3% were strongly willing to visit a doctor if they felt any lump in their breast, all (100%) were willing to do BSE regularly if they were shown how to do it and all of them were willing to share this knowledge with their friends of similar age (Table-1).   Table-1: Distribution of the study population according to their knowledge, attitude, and practice regarding breast cancer (n=300)     Out of 300 participations, 133 (44.3%) could correctly point out at least one symptom of breast cancer and 132 (99.2%) respondents indicated presence of any lump or tumor in the breast as a symptom of breast cancer. However, there was less knowledge regarding any risk factors for breast cancer as only 25.3% (76/300) could correctly name one of them. The knowledge regarding risk factors of breast cancer among the study-population was maximum for tobacco/smoking (58, 76.3%), followed by alcohol (56, 73.7%) and least for exposure to radiation (6, 7.9%) (Table-2).   Table-2: Distribution of the study population according to their knowledge on symptoms and risk factors of breast cancer     The risk factors of breast cancer currently present among the study participants were long term use of OCPs (9.3%), followed by obesity (BMI >30.0) (4%). Only 2 had history of exposure to radiation (Table-3).   Table-3: Distribution of the study population currently having risk factors of breast cancer (n=300)*     It was found that nearly half (49.0%) of the study participants recognised cervical cancer as a major public health problem. Only 33 (11%) could name at least one symptom correctly, 35 (11.7%) could say at least one risk factor and 13.3% responded ‘yes’ when asked if HPV was a causative agent of cervical cancer. More than half (56.7%) said that cervical cancer was preventable and 64% said that it could be cured if detected early (Table-4). Only 25 (8.3%) had knowledge about Pap smear and only 5.3% had undergone the test, at least once, on their own. Out those who knew about Pap smear test, most of them heard it from health care workers (19/25), followed by friends and relatives (8/25). About 87.3% were willing to know more about cervical cancer and 66% were inclined towards visiting a doctor if they noticed any post-menopausal bleeding or abnormal vaginal discharge. Around 60% were willing to undergo Pap smear test but the rest 40% were not sure (Table-4).   Table-4: Distribution of the study population according to their knowledge, attitude, and practice regarding cervical cancer (n=300)     The knowledge regarding symptoms of cervical cancer depicted by the study population was bleeding after menopause (32), persistent blood-tinged vaginal discharge (31) and foul-smelling vaginal discharge (28). None of the study participants were having any symptoms pertinent to cervical cancer. Out of the 35 participants who could name the risk factors of cervical cancer, 35, 30 and 24 respondents identified multiple sexual partners, sexually transmitted diseases and family history of cancer respectively as the (24) (Table-5).   Table-5: Distribution of the study population according to their knowledge on symptoms and risk factors of cervical cancer     The mean knowledge score on breast cancer was 2.99 ± 1.63, median score was 3 and 75th percentile score was 4. About 41.7% of the study population had adequate knowledge on breast cancer. The mean attitude score on breast cancer was 16.65 ± 0.62 and median score was 17. About 57.3% had highly favourable attitude (Table-6 and 7).   Table-6: Range of scores and central tendency measures of knowledge, attitude, and practice regarding breast and cervical cancer among the study population (n=300)     The mean knowledge score on cervical cancer was 2.14 ± 1.54, median score was 2 and 75th percentile score was 3. About 41.3%% of the study population had adequate knowledge on cervical cancer. The mean attitude score on cervical cancer was 16.07 ± 0.79 and median score was 16. About 75.3% had highly favourable attitude (Table-6 and 7).   Table-7: Distribution of the study population according to their knowledge, attitude, and practice regarding breast and cervical cancer (n=300)     Age group, marital status, occupation and socio-economic status of the respondent were significantly associated with knowledge on breast cancer (Table-8). None of the socio-demographic factors were found to have statistically significant association with knowledge on cervical cancer (Table-9).   Table-8: Association between knowledge regarding breast cancer and socio-demographic variables (n=300)     Table-9: Association between knowledge regarding cervical cancer and socio-demographic variables (n=300)     Discussion Most cancer patients in India usually seek medical advice when the disease is in an advanced stage. This may be attributed to lack of awareness on various screening programmes. This study attempted to assess the knowledge and attitude of reproductive age group women on breast and cervical cancer as these two are the commonest cancers occurring amongst Indian women. Along with this, presence of various self-reported risk factors was also documented. Gangane et al. from their study from Wardha district in rural Maharashtra reported that about 63% of the study participants were aware of breast cancer [14]. This was greater than the present study findings where 41.7% had adequate knowledge on breast cancer. Very high proportions (89%) of women were reported aware of breast cancer in Trichy, Tamil Nadu India [9]. BSE is an inexpensive, simple, noninvasive method for early detection of breast tumors. Thus, knowledge about this procedure and consistent practice can impede severe morbidity and mortality due to breast cancer. Only 52 (17.3%) of the study participants in the current study knew of BSE which was strikingly unusual and was a matter of concern. In Prathipadhu, Guntur, Andhra Pradesh almost 70% of the respondents had not heard of BSE [10]. Around 62.5% of the women did not have any idea of the procedure of BSE in Trichy, Tamil Nadu [9]. On the contrary, Baburajan et al [11] in their study in rural Ramanagara district in Karnataka reported that 85.1% of respondents had never heard of BSE which is a significantly lower proportion that the current study. In the present study, only 38 (12.7%) women responded that they perform BSE. In Tamil Nadu, BSE was practiced by 18% women and out of them, only 5% participants practiced it regularly every month [9]. In Karnataka study, less than 10% of women had ever performed BSE [11]. A very small proportion of the participants reported practicing BSE at least once in Maharashtra study (3.45%) [12]. About 97.5% were willing to approach a doctor in case of presence of lump/abnormality in their breast in Trichy as reported by Kumarasamy et al [11] which was lower than this study (100%). In the present study, all of the study participants were willing to do BSE regularly if they were taught about the technique while the response was 83% in Tamil Nadu study [9]. Oral contraceptive pill usage was found as the most prevalent risk factor for breast cancer in the present study. However, other similar studies on breast cancer mentioned only about the awareness of risk factors among the study participants and not regarding the presence of risk factors. Over 99% had not heard about Pap smear in a study in Tripura, India by Banik et al [13]. In the present study, 91.7% had never heard Pap smear test before. The respondents in Tripura did not undergo any screening test for cervical cancer citing absence of symptoms as the main reason. About 5.3% of the women in this study reported undergoing Pap smear test. According to Ghosh et al [14] in a study among tribal women in Karnataka, 82.9% of the participants said they had heard of cervical cancer, only 2.3% were aware that it could be detected early and only 51% knew that it could be prevented. However, 99.9% were in favour of cervical cancer screening. None of them had undergone screening for cervical cancer.   Limitations The study was conducted in only one village of a large block thus limiting the generalization of the findings. Also, some of the respondents may have given socially favourable answers. Inclusion of a health education intervention followed by post test among the study participants would have been better.   Conclusion Most of the study participants did not have adequate knowledge of breast cancer and cervical cancer,its risk factors and symptoms. Their attitude was positive but practice related to screening was very unsatisfactory. Knowledge and practice regarding breast self-examination and Pap smear test were poor. Age group of the study population, occupation and family history of cancer were found to have statistically significant association with knowledge on breast cancer. More awareness programmes stressing on screening methods including availability of HPV vaccine should be carried out, especially in rural areas.   Acknowledgement The authors would like to thank the Block Medical Officer, Auxiliary Nurse Midwife (ANM) of Muchisa Health and Wellness centre and all the respondents for their active participation and support in the study.   Authors’ contribution KR, VC, MB and VS equally involved in Concept devlopment and design of the study, analysis and interpretation of data, drafting and revising and final approval of the manuscript.   Financial support Nil   Conflict of interest There are no conflicts of interest.   References 1.     Arnold M, Morgan E, Rumgay H, Mafra A, Singh D, Laversanne M, et al. Current and future burden of breast cancer: global statistics for 2020 and 2040. Breast. 2022 Dec; 66: 15-23. doi: 10.1016/j.breast.2022.08.010. 2.     Arbyn M, Weiderpass E, Bruni L, de Sanjosé S, Saraiya M, Ferlay J, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. Lancet Glob Health. 2020; 8(2): e191–203. https://doi.org/10.1016/S2214-109X(19)30482-6. 3.     World Health Organization. Comprehensive Cervical Cancer Control. A guide to essential practice. Geneva: WHO; 2006. 4.     Malvia S, Bagadi SA, Dubey US, Saxena S. Epidemiology of breast cancer in Indian women. Asia Pac J Clin Oncol. 2017; 13(4): 289-295. doi: 10.1111/ajco.12661. 5.     International Agency for Research on Cancer. India. Source: Globocan 2020 [Internet]. Availablefrom: https://gco.iarc.fr/today/data/factsheets/populations/356-india-fact-sheets.pdf. [Accessed on 17 May 2023] 6.     Kolawole A. Cervical cancer prevention in Nigeria: issues arising. Int J Genomics Proteomics. 2012; 6(2). 7.     Taşçı A, Usta YY. Comparison of knowledge and practices of breast self examination (BSE): a pilot study in Turkey. Asian Pac J Cancer Prev. 2010; 11(5): 1417-1420. 8.     Singh R, Turuk A. A study to assess the  knowledge regarding breast cancer and practices of breast self-examination among women in urban area. Int J Community Med Public Health. 2017; 4: 4341–4347. DOI: https://doi.org/10.18203/2394-6040.ijcmph20174856 9.     Kumarasamy H, Veerakumar AM, Subhathra S, Suga Y, Murugaraj R. Determinants of awareness and practice of breast self examination among rural women in Trichy, Tamil Nadu. J Mid-life Health. 2017; 8: 84-88. doi: 10.4103/jmh.JMH_79_16 10.  Yerpude PN, Jogdand KS. Knowledge and practice of breast self-examination (BSE) among females in a rural area of South India. Natl J Community Med [Internet]. 2013; 4(02): 329-332. doi: 10.4081/jphia.2019.805 11.  Baburajan C, Pushparani MS, Lawenya M, Lukose L, Johnson AR. Are rural women aware of breast cancer and do they practice breast self-examination? A cross-sectional study in a rural hospital in South India. Indian J Cancer. 2022; 59: 354-359. doi: 10.4103/ijc.IJC_799_19 12.  Gangane N, Nawi N, Sebastian MS. Women's knowledge, attitudes, and practices about breast cancer in a rural district of central India. Asian Pac J Cancer Prev. 2015; 16(16): 6863-6870. doi: 10.7314/apjcp.2015.16.16.6863. 13.  Banik S, Sahu DP, Bhattacharjya H. Knowledge and practice regarding cervical cancer prevention among women in a rural area of Tripura, India. Int J Community Med Public Health. 2022; 9: 763-766. doi:10.18203/2394-6040.ijcmph20220236 14.  Ghosh S, Mallya SD, Shetty RS, Pattanshetty SM, Pandey D, Kabekkodu SP, et al. Knowledge, attitude and practices towards cervical cancer and its screening among women from tribal population: a community-based study from southern India. J Racial Ethn Health Disparities. 2021; 8: 88-93. doi: 10.1007/s40615-020-00760-4 15.  Pentapati SSK, Debnath DJ. Updated BG Prasad's classification for the year 2022. J Family Med Prim Care. 2023; 12: 189-190.       Cite this article as: Ray K, Chhakchhuak V, Basu M, Shukla V. Knowledge, attitude and practice regarding breast and cervical cancer among women of reproductive age residing in a rural area of West Bengal, India. IMC J Med Sci. 2023; 17(2):011. DOI: https://doi.org/10.55010/imcjms.17.021 <![CDATA[Probiotics in gastroenteritis in children: A systematic review]]> Elizabeth A.K. Jones Amal K. Mitra Anamika Bisht Precious Patrick Edet Faith Iseguede Ebele Okoye https://imcjms.com/journal_full_text/469 2023-06-22 10:13:29 Review Abstract Background and objectives: Gastroenteritis is the second leading cause of death among children worldwide. It is a preventable and treatable disease, yet it affects 3 to 5 million children and is the cause of approximately 10% of hospitalizations globally. This systematic review aims to identify the effectiveness of probiotics in treating acute gastroenteritis in children globally and also to provide results of quality research to healthcare-related communities about possible therapies of the condition. Methods: This study follows the PRISMA guidelines for systematic reviews of 29 quantitative studies conducted between 2014-2023. A quality appraisal of the selected studies was conducted using CADIMA and a rating scale of 0 to 3 based on a few predetermined criteria. Results: Sample sizes varied from 29 to 1811, with a median of 200. Globally, there are mixed findings about the roles and benefits of probiotics to treat acute gastroenteritis in children. This is possibly due to the type of probiotic, the type of disease, and treatment adherence. Conclusions: Findings from this systematic review suggest that probiotics play a crucial role in improving children’s health outcomes. Therefore, it is important to promote and implement the use of probiotic therapies in the treatment of acute gastroenteritis conditions in children. IMC J Med Sci. 2023; 17(2):010. DOI: https://doi.org/10.55010/imcjms.17.020 *Correspondence: Amal K. Mitra, Department of Epidemiology & Biostatistics, Jackson State University, 350 W. Woodrow Wilson Drive, Room 216 Jackson, MS 39213, USA. E-mail: amal.k.mitra@jsums.edu   Introduction Acute gastroenteritis is a serious illness prevalent among infants and children globally. Despite being a preventable and treatable disease, acute gastroenteritis remains a major cause of pediatric morbidity and mortality, especially in developing countries. Every year, around 3 to 5 billion children worldwide suffer from acute gastroenteritis resulting in approximately 12% of death in children aged 5 years or younger [1]. In addition, an estimated 10% of hospitalizations in children under 5 years were attributed to acute gastroenteritis globally [2]. Gastroenteritis causes a tremendous economic burden, and the cost of care could weigh heavily on affected families. According to Papadopoulos et al. [3], the five-year economic burden of acute gastroenteritis in Belgium was estimated to be €112 million in direct cost and €927 million (90% of the total costs) in indirect cost, totaling an average cost of €103 per case and €94 per person. Gastroenteritis in children is mostly caused by rotavirus and norovirus [4]. Both pathogens account for about 58% of all acute gastroenteritis cases in the United States [5]. Due to the high rates of acute gastroenteritis and severe outcomes associated with the illness, it is imperative to identify effective treatment therapies to improve health outcomes in children with acute gastroenteritis.  Globally, the use of probiotics in treating acute gastroenteritis has been extensively studied by researchers. This has caused controversy and prompted questions about whether or not to use probiotics for treating gastroenteritis. Two clinical trials by Erdoğan et al. [6] and LaMont [7], conducted in Turkey and Europe, respectively, showed better health outcomes from probiotic use in gastroenteritis. Erdoğan et al. [6] reported that Saccharomyces boulardii and Bifidobacterium lactis probiotics had an efficacious effect in treating gastroenteritis in children. Furthermore, Lamont [7] tested the effectiveness of probiotics in the treatment of acute gastroenteritis in children and revealed beneficial effects in the hosts or patients. Results from these clinical trials [6,7] suggest the use of probiotics as an important aspect of gastroenteritis research in treating severe outcomes associated with the condition. These outcomes include death, severe dehydration, etc. In contrast, Hojsak [8], a Croatian researcher, argued that “not all probiotic strains have the same efficacy for all clinical indications, therefore, only strains with proven efficacy and safety should be recommended”. This contradictory finding indicates a need for further investigation into the issue of probiotic use in treating gastroenteritis in children. Gastroenteritis among children is the second-leading cause of death worldwide [5]. Due to the poor outcomes associated with gastroenteritis in children, it is crucial to review the effectiveness of probiotics in treating acute gastroenteritis in children. It is also vital to identify new or effective therapies to improve the health outcomes of children afflicted with gastroenteritis. Furthermore, improving children's health, safety, and well-being, a goal that aligns with Healthy People 2030 in the United States, can be achieved by providing adequate medications for children afflicted by diseases such as acute gastroenteritis [9,10]. We hypothesize that probiotics are able to treat acute gastroenteritis in children. The aim of the systematic review was to assess the effectiveness of probiotics in treating acute gastroenteritis conditions in children and to provide quality research data to healthcare-related communities about use of probiotics as a possible treatment option in childhood gastroenteritis.   Materials and methods The systematic review included studies following the PRISMA guidelines [11]. The study focused on published primary articles associated with the impact of probiotics on acute gastroenteritis outcomes in children. Table-1 shows the inclusions and exclusions of the review.   Table-1: Inclusion and exclusion criteria.     Search Guidelines The primary search engines used to identify articles included in EBSCOhost, MEDLINE, APA PsychoInfo, APA Psych, Socindex, Google Scholar, and CINAHL. The studies were chosen for the review based on inclusion criteria, such as (1) articles being written in English; (2) being quantitative studies; (3) being scholarly papers; (4) using human participants between the ages of 0-17 years; (5) being associated with acute gastroenteritis; and (6) being associated with probiotics. The search was performed on 25 January 2023. The time limit for the studies was from 2008–2023. Table-2 shows the search string.   Table-2: Research thread for all databases     Screening guidelines The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines (2009) were used as a guide to record the review process [11]. Selected abstracts were reviewed to ensure eligibility. Full-text articles of eligible abstracts were retrieved and assessed on whether they answered the research questions and fulfilled the inclusion criteria. Studies were included if a consensus was reached by the researchers.  Research Information System (RIS) formatted references were exported from the databases, where studies were automatically screened based on the inclusion criteria and then imported into CADIMA. Total studies imported into CADIMA were accessed based on title and abstracts. The researchers assessed the studies twice before discussing if the studies should be chosen for full-text review. Conflicts were managed by group discussions between the researchers of the study. After the initial discussion, the researchers agreed that 104 studies should be selected for further screening using the inclusion criteria. During this second phase of screening for excluding review articles, the researchers independently screened the 104 articles twice for the second time. Conflicts were managed by group discussions. After discussion, 72 more articles were excluded because they were review articles, and 3 more articles were excluded because the articles were duplicated between the primary search engines and finally 29 articles were selected to be included in the systematic review. The PRISMA flow chart (Figure-1) depicts the search and inclusion process for the systematic review.   Figure-1: PRISMA flow chart showing inclusion and exclusion of studies [11]   Quality Appraisal Studies were appraised for quality using CADIMA. Through CADIMA, standards for critical appraisal and the rating scale were defined. We followed the critical appraisal tools for systematic reviews developed by the University of Adelaide, South Australia [12]. A rating scale from 0 to 3 was based on the following criteria: (1) Study design—cross-sectional, case–control, or cohort study = 1, otherwise = 0; (2) Sample size—large = 1, small = 0; (3) Selection of participants—random selection or lack of bias = 1, non-random sample or convenience sample or presence of bias = 0 points. Based on the above-mentioned criteria, the researchers rated each of the 29 studies independently from a range of 0 to 3. Due to having no major inter-observer variations in the evaluation of the quality of the studies, an average of the three scores was presented in Table-3 under the quality appraisal section.    Results A summary of the methodology, characteristics of findings, the impact of probiotics on acute gastroenteritis outcomes in children, quality appraisal, and the countries of the studies are presented in Table-3. Of the 29 studies reviewed, 5 were conducted in the United States, and Iran, 3 were conducted in Europe, 2 were conducted in Canada, India and Poland, and 1 each in Belgium, Romania, Turkey, Bangladesh, China, Uganda, Botswana, Mexico, Korea, and Canada/United States. All 29 studies were clinical trials [13-41]. All of the selected studies were conducted among children, ranging from infancy to adolescents/ teenagers. The total sample size used in studies ranged from 29 to 1811, having a median sample size of 200 (Quartile-1 = 92 and Quartile-3 = 816); 3 out of 29 (10.3%) had sample sizes of more than 1000. In terms of standardized tools, all studies (100%) used standardized assessment tools. An average score of 3 out of 3, meant excellent in 3 studies (10.3%), 2 meant moderate/good in 25 studies (86.2%), and 0-1 meant poor in one study (3.4%).    Benefits of probiotics in the treatment of acute gastroenteritis in children Of the 29 studies, 19 (65.5%) showed the benefits of probiotics in gastroenteritis treatment. Five studies supported the notion that probiotics improved acute gastroenteritis conditions in children [13-15, 26, 30]. Nocerino et al. found that probiotics lowered acute gastroenteritis in children [13]. Hesaraki et al. concluded that probiotics improved acute gastroenteritis conditions by improving recovery, reducing disease severity, and improving vital signs [14]. Lopetuso et al. have found probiotics to be effective in treating acute gastroenteritis [15]. Schnadower et al. showed the benefits of adherence to probiotic treatments when treating acute gastroenteritis in children, which resulted in better outcomes [26]. Mosaddek et al. also found improved outcomes for children with acute gastroenteritis after being prescribed probiotics [30]. Two studies by Schnadower et al. and Mosaddek et al. revealed that the use of probiotics in the treatment of gastroenteritis in children resulted in better outcomes in ambulatory settings and quicker recovery times [27, 30]. Eight studies also determined that probiotics reduced acute gastroenteritis in children [18, 25,28-29, 32, 35, 37, 40]. Three studies have shown that the use of probiotics reduced hospitalization rates for children with acute gastroenteritis [29, 32, 33, 38]. One study reported that probiotics significantly reduced the duration of rotaviral diarrhoea [20]. Two studies also concluded that probiotics improved outcomes for children diagnosed with special conditions associated with acute gastroenteritis, such as nosocomial infections [39] and hyperbilirubinemia [36].    Lack of benefits of probiotics in the treatment of acute gastroenteritis in children Of the 29 studies, 8 (27.6%) failed to validate the benefits of probiotics in gastroenteritis in children. Those studies found no benefit or improvement in treating acute gastroenteritis in children with probiotics [17,19,21-24,31,41,]. One study by Ahmadipour et al. [31] even emphasized that zinc supplementation was more effective than probiotics in treating acute diarrhea. Another study by Freedman et al. [22] revealed that probiotics had no effect on immunoglobulin A modulation, which is the antibody that helps the body to fight infections. A study by Olek et al. [41] determined that probiotics had no impact on improving acute gastroenteritis symptoms, including diarrhea frequency or abdominal symptoms.   Mixed results in treatment of acute gastroenteritis in children Of the 29 studies, 2 (6.9%) reported mixed results. One study by Szymanski and Szajewska [16] found that probiotics reduced hospitalizations from acute gastroenteritis but not the diarrheal symptoms. Another study by Bhat et al. [38] observed that probiotics reduced diarrheal output in patients receiving outpatient treatment for gastroenteritis but not in hospitalized patients.   Table-3: Impact of Probiotics on Acute Gastroenteritis Outcomes in Children   Treatment Impact of Probiotics on Acute GE in Children (Out of 3) Country of Study Nocerino et al. [13] n = 377; The proportion of children with acute gastroenteritis was lower in group A (13%) for children given daily cow’s milk and for group B (19.5%), who were given a probiotic (Lactobacillus paracasei) Positive 2-good Europe Hesaraki et al. [14] n = 84; Probiotic (kidilact) improved recovery, reduced disease severity, and improved vital signs in children with acute gastroenteritis Positive 2-good Iran Lopetuso et al. [15] n = 1811; Gelatin tannate and tyndallized probiotics were highly effective in the treatment of acute gastroenteritis Positive 3-excellent Canada & United States Refeey et al. [18] n = 160; Probiotic (L. acidophilus) reduced the severity of acute diarrhea associated with acute gastroenteritis in children Positive 2-good Iran Freedman et al. [19] n = 886; Probiotics (Lactobacilli) did not prevent the development of moderate to severe acute gastroenteritis within the 14 days of the study’s enrollment No 2-good Canada Lee et al. [20] n = 29; Probiotic (L. acidophilus) was an effective treatment for acute rotaviral gastroenteritis Positive 2-good Korea Freedman et al. [21] n = 816; No evidence supported the benefits of routine probiotic administration to children with acute gastroenteritis regardless of infecting virus No 2-good United States Freedman et al. [22] n = 133; Probiotic had no effect on immunoglobulin A modulation in children with acute gastroenteritis No 2-good Canada Schnadower et al. [23] n = 813; Probiotic L. rhamnosis GG (LGG) did not improve outcomes in children with acute gastroenteritis No 2-good United States Schnadower et al. [24] n = 971; a 5-day course of L. rhamnosis GG did not lead to better outcomes among preschool children with acute gastroenteritis No 2-good United States Kluijfhout et al. [25] n = 46; Use of probiotics normalized stool consistency significantly or improved diarrhea-related acute gastroenteritis symptoms Positive 2-good Belgium Schnadower et al. [26] n = 971; Adherence to probiotic treatment for acute gastroenteritis resulted in better outcomes Positive 2-good United States Schnadower et al. [27] n = 970; there were benefits associated with probiotic (LGG) administration in ambulatory children presented to the emergency department with acute gastroenteritis Positive 2-good United States Condratovici et al. [28] n = 36; The use of xyloglucan (probiotic) resulted in faster onset of action and improvement of diarrheal symptoms associated with acute gastroenteritis Positive 2-good Romania Dinleyici et al. [29] n = 1200; Probiotics led to reduced rates of hospitalization and reduced diarrhea for children with acute gastroenteritis Positive Bangladesh Ahmadipour et al. [31] n = 146; Zinc was more effective than probiotics in treating viral diarrhea associated with acute gastroenteritis in children No 2-good Iran Sudha et al. [32] n = 200; Probiotic (B. clausii) reduced diarrhea associated with acute gastroenteritis in children Positive 2-good India Chen et al. [33] n = 194; 3 probiotic strains (Bifidobacterium lactis Bi07, Lactobacillus rhamnosus HN001, and Lactobacillus acidophilus NCFM) resulted in shorter durations of diarrhea, hospitalizations, and improved health outcomes among children with acute gastroenteritis Positive 2-good China Grenov et al. [34] n = 400; Probiotics had no effect on diarrhea in children with acute gastroenteritis conditions that were associated with severe acute malnourishment duringhospitalization, but probiotics did reduce the number of days with diarrhea in children receiving outpatient treatment Positive/No 2-good Uganda Gutierrez-Castrellon et al. [35] n = 336; Probiotic reduced the frequency and duration of episodic diarrhea in children with acute gastroenteritis conditions Positive 2-good Mexico Torkamen et al. [36] n = 92; Probiotics were beneficial in the treatment of infants with hyperbilirubinemia associated with acute gastroenteritis Positive 2-good Iran Sharif et al. [37] n=200; Probiotics resulted in significantly lower days of diarrhea among children with acute gastroenteritis outcomes Positive 2-good Iran Bhat et al. [38] n = 120; The probiotic was effective in the reduction of diarrhea and hospitalizations in children with acute gastroenteritis Positive 2-good India Bruzzese et al. [39] n = 90; Probiotic (Lactobacillus GG) reduced the incidence of nosocomial infections associated with acute gastroenteritis in children Positive 2-good Europe Pernica et al. [40] n = 76; Probiotic resulted in lower odds of diarrhea from acute gastroenteritis conditions Positive 2-good <![CDATA[Better cardioprotection in atrial septal defect patients treated with cardiopulmonary bypass beating heart technique without the application of aortic cross clamp]]> Feroze Mohammad Ganai Abdul Majeed Dar Ghulam Nabi Lone Dil Afroze https://imcjms.com/journal_full_text/425 2022-08-28 11:53:28 Original Article IMC J Med Sci. 2023; 17(1): 001 Abstract Background and objectives: Creatine phosphokinase-myocardial band fraction (CPK-MB) and cardiac troponin I (cTnI) are cardiac specific biochemical markers which are raised in myocardial ischemia. The aim of this study was to determine cardiac injury by comparing the levels of cardiac enzymes CPK-MB and cTnI in atrial septal defect (ASD) patients whose operative repair was done under cardiopulmonary bypass (CPB) using beating heart technique with and without the application of aortic cross clamp. Materials and Methods: This study was carried out in the Department of Cardiothoracic and Vascular Surgery in a Tertiary Care Hospital over a period of 2 years. A total of 60 atrial septal defect (ASD) patients were operated and repair of the defect was done under the CPB using beating heart technique. Aortic cross clamp was applied in 22 patients (Group-A) while 38 patients were operated without cross clamp (Group-B) during the procedure. Blood samples were collected 24 hours prior and 12 hours post procedure for the estimation of CPK MB and cTnI levels. Results: Mean age of the atrial septal defect patients was 23.83±10.97 years and 60% and 40% of the patients were females and children (age < 18 years) respectively. Serum CPK-MB and cTnI l levels were in the normal range in all the patients before surgery and increased significantly post procedure. Twelve hours after surgery, the mean CPK-MB and cTnI levels were significantly low in Group-B patients compared to Group-A patients (CPK-MB: 56.39±23.55 U/L vs. 34.38±15.97U/L , p= 0.0004; cTnI: 9.37±4.97 ng/ml vs. 5.92±4.17ng/ml, p = 0.009). Conclusion: Post surgery CPK-MB and cTnI levels were significantly higher in ASD patients who underwent CPB surgery with aortic cross clamp compared to those in whom aortic cross clamp was not applied. Therefore, application of aortic cross clamp during the procedure induces greater levels of ischemic injury to the heart. IMC J Med Sci. 2023; 17(1): 001. DOI: https://doi.org/10.55010/imcjms.17.001 *Correspondence: Feroze Mohammad Ganai, Department of CVTS, Superspeciality Hospital, Shireen Bagh, Srinagar, Jammu and Kashmir, India. Email address: ferose999@yahoo.com   Introduction Atrial septal defect (ASD) is the third most common congenital heart disease [1]. ASDs comprise 30 to 40% of all congenital heart diseases in adults [2]. MSX1 gene has been found strongly associated with the development of ASD [3]. Normally, an interatrial septum separates the upper chambers of the heart namely right and left atrium. ASD occurs because of the failure of closure of communication between the right and left atria [4]. ASDs are classified into various types based on the location of the defect in interatrial septum [5]. Most common type is the ostium secundum ASD which is due to enlarged foramen ovale or septum secundum not completely formed. Ostium primum type of ASD is usually associated with AV canal defects. A sinus venosus ASD occurs in the inflow portion of superior and inferior vena cava. It is usually associated with anomalous pulmonary venous drainage into the right atrium [6]. Surgical repair of ASD is safe and effective with minimal morbidity and mortality [7]. It involves closure of the septal defect under CPB. In beating heart technique aortic cross clamp may or may not be applied during the procedure. Advantage of using beating heart technique is to prevent or minimize ischemic-reperfusion injury to myocardium [8]. Ischemic myocardial injury during cardiac surgery may cause cardiac stunning and dysfunction which is one of the consequences and can cause delay in the postoperative recovery. CPK-MB and cTnI are cardiac specific markers and their levels increase during myocardial ischemia. CPK-MB levels rise within 4 to 8 hours of ischemia or acute myocardial infarction and return to normal in 48 to 72 hours. Biological reference interval is <4.88 U/L. cTnI is a cardiac-specific protein and is a highly sensitive marker of myocardial ischemic damage. Its levels rise in serum within 3 to 4 hours of myocardial ischemia and remain elevated up to 10 days. Its biological reference interval is <0.040 ng/ml. Some ischemic myocardial injury does occur even in the beating heart surgery despite continuous warm blood perfusion to the coronary arteries and is manifested in the form of rise in the levels of CPK-MB and cTnI. The aim of the study was to determine cardiac injury by comparing the levels of cardiac biomarkers CPK-MB and cTnI in ASD patients in whom operative repair was done under CPB using beating heart technique with continuous normothermic perfusion with and without the application of aortic cross clamp.   Material and methods This prospective study was carried out in the Department of Cardiothoracic and Vascular Surgery, Sheri Kashmir Institute of Medical Sciences (SKIMS), Srinagar- a Tertiary Care Hospital in collaboration with the Department of Immunology and Molecular Medicine, SKIMS. The study was conducted over a period of 2 years from June 2016 to May 2018 and was approved by the Institutional Ethical Committee of SKIMS. Informed verbal consent was obtained from all individual participants included in the study. In case of children (≤18 years of age), consent was obtained from the parents/guardians. Study population and surgical procedure: ASD patients of both genders were included in the study. Patients were properly evaluated. Coronary angiography was performed in patients above 40 years of age with complaints of chest pain or having risk factors for coronary artery disease. Patients with coronary artery disease, recent myocardial infarction were excluded from the study. Enrolled patients were randomly assigned to Group-A and Group-B. Surgical repair of the defect was performed in all patients under CPB using beating heart technique. Aortic cross clamp was applied to the aorta in Group-A patients. In Group-B patients, ASD repair was performed without applying aortic cross clamp. The main aim of using the beating heart technique was to minimize ischemic-reperfusion injury to the myocardium. Approach was standard midline sternotomy. After heparinization, total CPB was instituted by cannulating ascending aorta and both venae cavae. An antegrade high flow cannula was inserted into the ascending aorta to facilitate high flow perfusion during the procedure. Continuous normothermic perfusion to coronaries was provided through aortic root cannula with a 5 ml/kg/min normothermic oxygenated blood continuously in patients of both groups. Left atrium was kept filled with the blood to prevent air embolism from occurring. Cardioplegia was not administered in any of the patients. Primary repair was done in patients with small atrial septal defects while in larger defects a patch repair was done either with pericardium or prosthetic materials. General anesthesia was similar in both groups with routine systemic arterial and central venous pressure monitoring. Same cardiopulmonary bypass machine with a roller pump and CPB circuit with membrane oxygenator from the same manufacturer was used in all patients. Electrocardiographic changes were monitored and recorded throughout the procedure. Estimation of CPK-MB and cTnI: Twenty four hours before surgery, two samples of 3ml arterial blood were collected in two separate specialized tubes and were sent for estimation of CPK-MB and cTnI levels by CLIA (chemiluminescence immunoassay) method. Similarly, 12 hours after surgery, two samples of 3ml arterial blood were collected again for estimation of CPK-MB and cTnI levels by CLIA method. Data Analysis: Microsoft Excel and SPSS 20 were used for data analysis. Student’s t-test and ANOVA were used for p value determination. p value ≤0.05 was considered significant.   Results Beating heart ASD repair was done in 60 patients over a period of 2 years. This included 24 children (age ≤ 18 years; mean age 13±4.18 years) and comprised 40% of the total patient population. Of the total cases, 60% of patients were females. Group-A and B consisted of 22 (36.6%) and 38(63.3%) patients respectively. Ages varied from 5 to 45 years. Predominant age groups were 10-19 (33.3%) and 30-39 (26.7%) years. Mean age of the Group-A and B patients was 21.77±10.75 and 25.02±11.05 years respectively (Table-1).   Table-1: Age distribution of study patients (n=60)   Primary repair was done in 34 (56.6%) atrial septal defect cases which mainly included small defects ≤20 mm. Although this also included 15 cases with defect sizes in between 20 to 30 mm. Patch repair was done in larger defects either with pericardium or synthetic material (PTFE). Pericardial patch repair was done in 15 (25%) and PTFE patch repair in 11 (18.3%) patients. Table-2 shows levels of CPK-MB and cTnI post surgery in patients with different sizes of atrial septal defects. Levels of these biomarkers did not correlate with the sizes of the defects and were not significantly (p>0.05) different.   Table-2: Post surgery serum CPK-MB and cTnI levels in patients with different sizes of atrial septal defects (n=60)     Table-3 shows the serum CPK-MB and cTnI level in Group-A and Group-B patients before and after ASD repair surgery. Twenty four hours prior to surgery serum CPK-MB and cTnI levels were in normal range in all (both Group-A and B) the patients. Twelve hours post surgery, both serum CPK-MB and cTnI levels were raised in all the patients of both groups. Group-A patients in whom aortic cross clamp was applied had significantly more mean serum CPK-MB and cTnI levels compared to Group-B patients who were operated without aortic cross clamp (CPK-MB: 56.39±23.55 vs. 34.38±15.97 U/L, p=0.0004; cTnI: 9.37±4.97 vs. 5.92±4.17 ng/mL, p=0.009 respectively; Table-3).   Table-3: Serum CPK-MB and cTnI levels in ASD cases before and after the operation with and without the application of aortic cross clamp       Discussion Beating heart surgery on CPB is safest and one of the best forms of myocardial protection. Main advantage of using the beating heart technique in ASD repair is to minimize ischemic injury to the myocardium [8]. In conventional heart surgery cardioplegic solutions used to arrest the heart lead to ischemic-reperfusion myocardial injury and cardiac stunning. Some myocardial damage does occur even in beating heart surgery despite no use of cardioplegic solutions and use of continuous warm blood perfusion. Rise in the levels of cardiac biochemical markers such as CPK-MB and cTnI in beating heart surgery does suggest some myocardial injury as a result of ischemia. The results in this study showed a rise in the levels of both CPK-MB and cTnI post surgery in the patients of ASD repair. Average levels of these cardiac markers were significantly more in the patients in whom aortic cross clamp was applied during the procedure than those patients in whom aortic cross clamp was not applied. It may be inferred from this study that myocardial protection is better in ASD patients undergoing beating heart ASD repair without aortic cross clamp. Application of aortic cross clamp appears to increase myocardial ischemic injury. Siaplaouras and colleagues [9] studied perioperative myocardial damage by measuring cTnI levels serially before and after surgery in the pediatric population undergoing elective cardiac surgeries for congenital heart defects. The study demonstrated that it was an important determinant for postoperative cardiac function and recovery. A study by Swaanenburg et al. [10] estimated CPK-MB and cTnI levels postoperatively to determine the myocardial injury and found that the levels of cardiac biochemical markers depend upon the type of cardiac surgery and duration. There are similar studies which correlate increased postoperative CPK-MB and cTnI levels with the adverse effect and postoperative recovery [11,12,13]. CPK-MB and cTnI levels can increase many fold compared to baseline levels depending on the duration of the procedure [10,15]. Cardiac troponin I was found very useful in predicting the postoperative course in terms of length of ICU and postoperative hospital stay of the patients undergoing mitral valve surgery [16]. The levels of cardiac biomarkers namely CPK-MB and cTnI in CPB surgery significantly correlated with the type of cardiac surgery and also upon the cross clamp time [14,17]. Also, beating heart technique in ASD repair offers early extubation and discharge from the hospital [18]. Using aortic cross clamp during ASD repair done under CPB and beating heart technique seems to increase myocardial ischemic injury as is evident from the high levels of cardiac biomarker levels in this study. There were certain limitations of this study. First, sample size was small and second it was a single centre study and might not reflect the experience in other centers. Also, the effect of duration of surgery on biochemical marker levels was not taken into consideration. ASD patients in whom operative repair was done under CPB using beating heart technique without the application of aortic cross clamp suffer significantly less myocardial injury as was evident by the lower levels of cardiac biochemical markers namely CPK-MB and cTnI 12 hours post surgery compared to ASD repair with aortic cross clamp. However, some degree of ischemic injury to myocardium does occur in both techniques.   Funding: Nil   Conflict of interest: None   References 1.     Geva T, Martins JD, Wald RM. Atrial septal defects. The Lancet. 2014; 383(9932): 1921-1932. 2.     Menillo AM, Lee LS, Pearson-Shaver AL. Atrial septal defect. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021. 3.     Kaplan S. Natural and postoperative history across age groups. Cardiol Clin. 1993; 11(4): 543–556. 4.     Rhodes. ‘Hole in the heart’ disease gene discovered by Manchester researchers could curb childhood deaths. Mancunian Matters. 2013. 5.     Lindsey J, Hollis L. Clinical update: atrial septal defect in adults. The Lancet. 2007; 369(9569): 1244-1246. 6.     Davia J, Cheitlin M, Bedynek J. Sinus venosus atrial septal defect: analysis of fifty cases. Am Heart J. 1973; 85(2): 177–185. 7.     Liava M, Kalfa D. Surgical closure of atrial septal defects. J Thorac Dis. 2018; 10 Suppl 24: S2931. 8.     Thapmongkol S, Sayasathid J, Methrujpanont J, Namchaisiri J. Beating heart as an alternative for closure of secundum atrial septal defect. Asian Cardiovas Thorac Ann. 2012; 20(2): 141-145. 9.     Siaplaouras J, Thul J, Will JC, Bauer J, Kreuder J, Valeske K, et al. Cardiac troponin I after heart surgery corrective operation in infancy and childhood. Z Kardiol. 2001; 90(6): 408-413. 10.  Swaanenburg JC, Loef BG, Volmer M, Boonstra PW, Grandjean JG, Mariani MA, et al. Creatine kinase MB, troponin I, and troponin T release patterns after coronary artery bypass grafting with or without cardiopulmonary bypass and after aortic and mitral valve surgery. Clin Chem. 2001; 47(3): 584-587. 11.  Andres J, Stepień E, Szajna-Zych M, Drwiła R, Zietkiewicz M, Sadowski J, et al. Levels of troponin I, tropoinin T, isoenzyme MB creatine kinase and myoglobins in blood serum for perioperative diagnosis of myocardial infarction in patients after coronary artery bypass graft surgery with extracorporeal circulation. Folia Med Cracov. 2001; 42(4): 263-271. 12.  Fransen EJ, Diris JH, Maessen JG, Hermens WT, Van MP. Evaluation of “new” cardiac markers for ruling out myocardial infarction after coronary artery bypass grafting. Chest. 2002; 122: 1316–1321. 13.  Januzzi JL, Lewandrowski K, MacGillivray TE, Newell JB, Kathiresan S, Servoss SJ, et al. A comparison of cardiac troponin T and creatine kinase-MB for patient evaluation after cardiac surgery. J Am Coll Cardiol. 2002; 39(9): 1518-1523. 14.  Salerno PR, Jatene FB, Figueiredo PE, Bosisio LJ, Jatene MB, Santos MA, et al. The behavior of Troponin I and CK MB mass in children who underwent surgical correction of congenital heart malformations. Rev Bras Cir Cardiovasc. 2003; 18(3): 235-241. 15.  Mohiti J, Behjati M, Soltani MH, Babaei A. The significance of troponin T and CK-MB release in coronary artery bypass surgery. Indian J Clin Biochem. 2004; 19(1): 113-117. 16.  Oshima K, Kunimoto F, Takahashi T, Mohara J, Takeyoshi I, Hinohara H, et al. Postoperative cardiac troponin I (cTnI) level and its prognostic value for patients undergoing mitral valve surgery. Int Heart J. 2010; 51(3): 166-169. 17.  Mastro F, Guida P, Scrascia G, Rotunno C, Amorese L, Carrozzo A, et al. Cardiac troponin I and creatine kinase-MB release after different cardiac surgeries. J Cardiovasc Med. 2015; 16(6): 456-464. 18.  Pendse N, Gupta S, Geelani MA, Minhas HS, Agarwal S, Tomar A, et al. Repair of atrial septal defects on the perfused beating heart. Tex Heart Inst J. 2009; 36(5): 425–427.     Cite this article as: Ganai FM, Dar AM, Lone GN, Afroze D. Better cardioprotection in atrial septal defect patients treated with cardiopulmonary bypass beating heart technique without the application of aortic cross clamp. IMC J Med Sci. 2023; 17(1): 001. DOI: https://doi.org/10.55010/imcjms.17.001 <![CDATA[Do obesity, hypertension and dyslipidemia pose significant risks for coronary artery disease among Bangladeshi diabetics?]]> Akhter Banu Fazlul Hoque Khandoker Abul Ahsan M Abu Sayeed https://imcjms.com/journal_full_text/426 2022-09-07 13:24:09 Original Article IMC J Med Sci. 2023; 17(1): 002 Abstract Background and objectives: For decades the global population has been experiencing diabetic epidemic. The risks related to obesity, diabetes mellitus (DM) and coronary artery diseases (CAD) are well known. This study aimed to assess the prevalence of coronary artery disease (CAD) and its related risks in Bangladeshi diabetics. Materials and methods: The study was conducted at Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), a largest referral center for diabetes in Bangladesh. Socio-demographic and clinical history including biochemical investigation report were collected from the BIRDEM registry. The eligible criteria of study participants were: age 30 – 60 year, having DM, non-smoker, free from retinopathy, nephropathy and neuropathy. The prevalence of CAD, systolic hypertension (SHTN) and diastolic hypertension (DHTN) in the registered diabetic patients were estimated. Additionally, the study addressed the risk and predictors of CAD among those with DM. Investigations included – anthropometry, blood pressure, blood glucose, serum lipids and electrocardiogram (ECG). CAD was diagnosed on: (a) history of angina plus positive ECG - either on rest or on stress, post-myocardial infarction (MI) with Q-wave MI or non-Q-MI or echocardiographic evidences. Lipids namely triglycerides (TG), total cholesterol (T-Chol), high density lipoproteins (HDL) and low-density lipoproteins (LDL) were estimated by Hitachi-704 auto-analyzer using enzymatic method. Results: A total of 693 (M /W =295/398) participants volunteered. The prevalence of CAD, SHTN, DHTN and mean arterial hypertension (MAH) were 18.6%, 23.2%, 13.6% and 17.7%, respectively. Their mean (±SD) values of age, body mass index (BMI - kg/m2), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR) and mean arterial pressure (MAP) were 47 (8.6) years, 24.6 (3.5), 0.98(0.05), 0.56(0.06) and 101(11.3) mmHg, respectively. The mean (±SD) of FBG (mmol/L), T-Chol, TG and HDL (mg/dl) were 10.2 ± 4.0, 206 ± 44, 218 ± 86 and 47.5 ± 9.3 respectively. The women had significantly higher BMI (p<0.001), WHtR (p<0.001), SBP (<0.001), MAP (p<0.001), T-Chol (p<0.001) and TG (p=0.043) than men. The risk variables were categorized into quartiles and Chi-sq trend determined whether the increasing prevalence of CAD were significant. Higher quartile of age was found consistently significant (p<0.001). Of the obesity indices, only higher quartile of WHtR was significant (p< 0.05). For BP measures, higher MAP quartiles showed the trend significant (p<0.001). Likewise, for lipids, higher quartiles of TG (p<0.001) and lower quartile of HDL (p<0.001) were significant. Finally, logistic regression estimated the risk related to CAD. The highest age-quintile (>55y: 95% CI: 1.09 - 43.7) and highest TG-quintile (281mg/dl: 95% CI: 1.45-59.7) were proved to be significant predictor of CAD and HDL highest quintile (>54mg/dl) was proved to be significant protecting factor for CAD (95% CI: 0.005-0.583). Conclusion: The study observed the importance of MAP, TG, HDL, T-Chol/HDLR (T-Chol -to HDL ratio) and TG/HDLR (triglycerides-to HDL ratio) as risks for CAD among diabetics. Further study with investigations of echocardiogram, ETT, coronary angiogram and coronary calcium scoring would be helpful in confirming these findings related to CAD risks. IMC J Med Sci. 2023; 17(1): 002.  DOI: https://doi.org/10.55010/imcjms.17.002 *Correspondence:M Abu Sayeed, Department of Community Medicine, Ibrahim Medical College, 1/A, Ibrahim Sarani, Segunbagicha, Dhaka 1000, Bangladesh. Email: sayeed1950@gmail.com   Introduction According to World Health Organization (WHO) cardiovascular diseases (CVDs) are the leading cause of death, taking approximately 18 million lives annually globally [1]. There have been many newer published reports highlighting high arterial pressure and dyslipidemia as important risk for coronary artery disease (CAD) [2,3]. Four out of five CVD deaths are due to heart attacks and strokes [1]. One third of these deaths occur prematurely below (<70y). Several risk factors are shared between Type2 diabetes (T2D) and CAD, including obesity, insulin resistance and dyslipidemia [4,5]. CAD can precede type 2 diabetes (T2D), which is a major risk factor for CVD [6]. It may be recalled that 1in 10 adults of the world are now living with diabetes [7]. For Bangladeshi diabetic population the findings of coronary risks were reported mainly on age, sex, geographical site, occupation, obesity, hypertension, and glycemic control [8]. This study revisited the published report comparing the risk of CAD related to obesity, elevated mean arterial hypertension and dyslipidemia. It also showed the effect of high total cholesterol (T-Chol), high triglyceride (TG) and low high-density lipoprotein (HDL) on CAD separately. Additionally, it demonstrated the effect of T-Chol-to-HDL ration (T-Chol/ HDLR) and TG-to-HDL ratio (TG/HDLR) on CAD.   Materials and methods Study design: Subjects and methods have been detailed in the previous published report [8]. Briefly the selection procedure is elaborated in the Figure-1. The duration of diabetes (mean ±S.D.) was 13.6 ± 3.6 (range 2–18) months. Informed consent was taken and they were interviewed for the clinical history related to initial investigations and diagnosis, smoking habits, family history of diabetes, HTN and atherosclerotic cardiovascular events and their drug history (if any). They were also interviewed for past illness about HTN and CAD followed by general and systemic examination.     Figure-1: Selection of study participants from the BIRDEM diabetes registry. CAD-coronary artery disease; SHTN-systolic hypertension; DHTN-diastolic hypertension; MAH-mean arterial hypertension (MAP >110mmHg)   Then, based on clinical findings, relevant investigations were undertaken in BIRDEM for confirmation ofthe diagnosis. The subjects with secondary HTN, cerebrovascular stroke, foot ulcer, nephropathy and retinopathy were excluded from the study. Those who were using corticosteroid and contraceptive pills were also excluded. Anthropometric assessment included body mass index (BMI), waist-to-hip ration (WHR) and waist-to-height ration (WHtR). Mean arterial pressure (MAP) was estimated as (MAP = dbp + 1/3(sbp – dbp) [9]. For this study elevated (>110mmHg) MAP was considered. Systolic (SHTN) and diastolic (DHTN) hypertension were taken as SBP ≥140 and DBP ≥90 mmHg, respectively. Hypertensive subjects previously diagnosed were also included. Their BP was taken 2 days after cessation of anti-hypertensive drugs. World Health Organization (WHO) diagnostic criteria were used to diagnose diabetes mellitus. The measurements of plasma glucose were done by glucose-oxydase peroxydase method using Technicon M-II autoanalyzer. All subjects underwent ECG-tracing except those with recent ECG reports. The diagnosis of CAD was based on: (a) history of angina plus positive ECG either on rest or on stress, post-myocardial infarction (MI) with Q-wave MI or non-Q-MI in echocardigraphic evidences. Lipids (TG, Chol, HDL, LDL) were estimated by Hitachi-704 auto-analyzer using enzymatic method. LDL-cholesterol (LDL) was measured using formula: LDL-C = 0.9 TC- (0.9 TG/5)-28 [18]. Statistical analysis: The prevalence rates (qualitative variables) were given in percentages. The quantitative variables were presented in means with standard deviation (SD). The comparisons between groups were estimated by unpaired t-test. The associations between anthropometrics and lipid fractions were estimated by Pearson’s correlations co-efficient. The prevalence trends (increasing / decreasing) were estimated by Chi-sq. Binary logistic regression analysis showed the effects of independent variables (obesity, blood pressure, lipids) on the dependent variables CAD. The significance levels of all statistical tests were taken at 0.05.   Results A total of 693 (M=295, F=398) registered diabetic patients of age 30 – 60 year volunteered the study (Figure1). The prevalence of CAD was 18.6% (men vs. women = 16.6 vs. 20.2%; p = 0.139). The prevalence of systolic hypertension (SHTN) was 23.2% (men vs. women = 19.3 vs. 26.1%, p<0.05) and prevalence of diastolic hypertension (DHTN) was 13.6% (men vs. women = 11.2 vs. 15.3%, p =0.07). The prevalence of mean arterial hypertension (MAH) was 17.7% (men vs. women = 14.9 vs. 19.8, p = 0.058). The biophysical characteristics of all participants were shown in Table-1a. The comparisons of these characteristics between men and women were shown in Table-1b. The comparison between age-matched 295 men and 398 women showed that the women had significantly higher BMI (p<0.001), WHtR (p<0.001), SBP (p<0.001), MAP (p = 0.002), T-Chol (p<0.001) and TG (p<0.05) than their male counterpart. Thus, most of the obesity and blood pressure related variables were higher in women than men, except WHR, which was significantly higher (p<0.001) in men.   Table-1a: Biophysical characteristics of the total participants     Table-1b: Comparison of biophysical characteristics between men and women     The Pearson’s correlation test, controlling age and sex, was used to determine the associations between obesity related variables (BMI, WHR, WHtR) and lipid fractions (T-Chol, TG, HDL, LDL) [Table-2]. Significant correlations of lipid-fractions were neither found with general (BMI) nor with central obesity (WHR, WHtR). The correlations of lipid fractions with BP measures (SBP, DBP and MAP) were shown in Table-3. Of the lipids, TG showed significant positive and HDL significant negative correlations with all BP measures though these correlations with T-Chol and LDL were not significant.   Table-2: Correlations (controlling for age and sex) between obesity and lipids related variables     Table-3: Correlations of lipid related variables (T-Chol, TG, HDL, LDL) with SBP, DBP and MAP (controlling for age and sex).     Table-4 depicted correlations (controlling for age and sex) between blood pressure and metabolic variables (T-Chol, TG, HDL, LDL, FBG). All BP measures (SBP, DBP and MAP) correlated significantly with T-Chol/HDLR and TG/HDLR, but not with FBG.   Table-4: Correlations of BP measures with metabolic variables like ratios of lipid fractions (CHOL/HDLR, TG/HDLR) and FBG.     Whether the prevalence of CAD was related to advancing age, increasing mean arterial pressure (MAP), TG and decreasing with increasing HDL level are shown in Figure-2. The prevalence of CAD according to quartiles of age, MAP, TG and HDL were estimated by chi-sq trend with level of significance (chi-sq, p). The trends were significant for the quartiles of age (33.6, <0.001), (MAP: 75.7, p<0.0001), TG (23.5, <0.001). As expected, HDL had inverse association with CAD prevalence (20.2, <0.001), which indicated that low HDL level had higher risk of developing CAD.     Figure-2:Prevalence (%) of CAD according to quartiles (Q1, Q2, Q3, Q4) of age, MAP, TG and HDL. Age (y): Q1<40, Q2 41- 47, Q3 48-55, Q4 >55; HDL mg /dl: Q1 <41, Q2 41-48, Q3  48-53, Q4 >53; MAP mmHg: Q1 <93, Q2 94-100, Q3 101- 106, Q4 >106.   The trend of CAD prevalence according to the quartiles of TG, HDL, T-Chol/HDLR and TG/HDLR are shown in Figure-3 for comparison. Very high prevalence of CAD was found in the highest quartile of TG and lowest quartile of HDL (for both, p<0.001). Importantly, the increasing quartiles of T-Chol / HDL ratio and TG / HDL ratio showed significant increasing trend of CAD prevalence. The trend of CAD prevalence with increasing obesity (quartiles of BMI, WHR, WHtR) is shown in Figure-4. The trends were not significant for BMI and WHR. The highest quartile of WHtR (Q4 >0.6) was found significant (p = 0.02).     Figure-3: Prevalence (%) of CAD according to quartiles (Q1, Q2, Q3, Q4) of TG, HDL, T-Chol / HDL ratio and TG / HDL ratio. The trends were significant (chi Sq, P) for increasing quartiles of TG (23.5, <0.001) and decreasing HDL (20.2, <0.001), T-Chol/HDL ratio (30.7<0.001) and TG/HDL ratio (30.7, <0.001). Quartile values of TG, mg / dl: Q1 <153, Q2 154 - 201, Q3 202 - 280, Q4 >280; Quartile values of HDL mg / dl: Q1 <41, Q2 41 - 48, Q3 48 - 53, Q4 >53; Quartile values of TG/HDL; Q1 <3.03, Q2 3.04 - 4.23, Q3 4.24 - 6.77, Q4 >6.77; and Quartile values of T-Chol/HDL ratio: Q1 <3.75, Q2 3.76-4.83, Q3 4.84-5.63 and Q4 >5.63. * Values for HDL, cholesterol and TG, and ratios were estimated in mg/dL.     Figure-4: Prevalence (%) of CAD according to quartiles (Q1, Q2, Q3, Q4) of BMI, WHR and WHtR.. Quartile values of BMI: Q1 <22.2, Q2 22.3 - 24.3, Q3 24.4 - 26.5, Q4 >26.5; Quartile values of WHR: Q1 <0.95, Q2 0.96 - 0.98, Q3 0.99 -1.01, Q4 >1.01; Quartile values of WHtR Q1 <0.52, Q2 0.53 - 0.55, Q3 0.56 - 0.6, Q4 >0.6.   Some inconsistent findings emerged when we tried to determine the risks related to CAD among the our diabetic study population. The investigated variables were age, sex, sites (urban/rural), family history of NCDs, obesity, blood pressures and lipids. Of these risk factors, which were more significant remained unclear. We used binary logistic regression taking the risk factors as independent and CAD as dependent variable. Of the independent variables (sex, area, age, BMI, WHR, WHtR) only higher age quartile (Q3 and Q4) was proved to be a significant risk for CAD [Table-5]. In Table-6, the independent variables were sex, age and lipid fractions. The highest quartile of age and TG, and the lowest quartile of HDL were found significant risk for CAD.   Table-5: Binary logistic regression taking coronary artery disease (no =0, yes =1) as a dependent variable; and sex, area, age, BMI, WHR, WHtR as independent variables. The categorical variables are depicted below     Table-6: Binary logistic regression taking coronary artery disease (no =0, yes =1) as a dependent variable and sex, age, cholesterol, TG, HDL as independent variables. The categorical variables are depicted below.       Discussions The study was conducted on purposively selected registered diabetic patients of a referral center, BIRDEM. The prevalence of CAD was 18.6% [Figure-1], which was more or less consistent with the findings of the systemic review report published earlier [9]. In the review, 21.2% had coronary heart disease (42 articles, N = 3,833,200). Higher prevalence of cardiovascular disease in patients with type 2 DM was 37.4% (95% CI: 31.4-43.8) in Iran [10]. Another study from Bangladesh reported the prevalence of CAD as 17.2% [11]. The study found that it had no significant difference between gender and CAD. The present study observed higher prevalence of CAD in women than men (20.2% vs. 16.6 %) though not significant. Interestingly, the age matched women had significantly higher BMI (p<0.001), WHtR (p<0.001), SBP (p<0.001), MAP (p = 0.002), T-Chol (p<0.001) and TG (p<0.05) than men. Only, WHR was significantly higher in men than women (p<0.001). The measures of obesity (BMI, WHtR), blood pressure (SBP, DBP, MAP) and TG were higher in women than men and consistent with the higher prevalence of CAD in women, though the difference was not significant. Most of the cited studies reported higher CAD prevalence in men than women [5,7,10,11]. This contradictory finding could have been explained if in the study there were equal numbers of female participants from rural population. The BIRDEM diabetes registry revealed that more than 30% of women were occupationally urban housewives and they lack physical activity resulting obesity with dyslipidemia. The associations between variables of obesity and lipids (Table-2), and lipids and blood pressures (Table-3) revealed that none of lipid fractions correlated with obesity significantly. Of the lipid fractions, TG and HDL (and not T-Chol and LDL) showed very significant association with SBP, DBP and MAP. This indicated that T-Chol and LDL were not related to blood pressure. These findings could not be compared with any published data that studied lipid fractions separately in relation to SBP, DBP and MAP. Anika et al showed significant correlation between total cholesterol and systolic blood pressure, also between triglyceride and diastolic blood pressure [12]. Other studies found total cholesterol was positively associated with IHD mortality in both middle and old age [13,14]. Interestingly, this study revealed that T-Chol/HDLR and TG/HDLR correlated with all types of BP measures (Table-4 and Figure-3). This observation is very much consistent with other Bangladeshi report [15]. Of the obesity indices only WHtR proved to have significant risk at Q4 (>0.6). This study proved WHtR to be a better obesity index for CAD. The highest quartile of mean arterial pressure (MAP >106mmHg) was found to be a significant risk for CAD. The importance of MAP was also emphasized by Gao et al [2]. The study showed the importance of T-Chol/HDLR and TG/HDLR for predicting CAD in diabetic population. This observation is very much consistent with the findings of other studies. [15-17]. The study had some limitations. Firstly, glycemic control could not be monitored for the follow-up period after registration. Secondly, the number of women was not proportionate to the geographical sites (urban/rural). Thirdly, physical activity of the study participants could not be graded. Lastly, the diagnosis of CAD was based on only on ECG findings.   Conclusions The study revealed the prevalence of coronary artery disease (CAD), systolic hypertension and diastolic hypertension in the registered Bangladeshi diabetic patients. It identified the risk factors for developing CAD. Additionally, the study addressed the possible predictors of CAD among those with DM. The study observed the importance of MAP, TG, HDL, T-Chol/HDLR and TG/HDLR as predictors of CAD. Further study along with the investigation of echocardiography, ETT, coronary angiogram and coronary calcium scoring would be helpful in confirming these findings related to CAD risks.   Acknowledgements – We are grateful to those participants who actively volunteered the study. We are also indebted to the doctors and other official staff of BIRDEM-OPD. The BIRDEM registry office helped in obtaining the records of the newly registered patients with the “REFERECE No” and laboratory technician with biochemical reports. We would like to convey our gratitude to the departed souls of Dr. Fazlul Hoque and Dr. Khandoker Abul Ahsan. We commemorate both of them for their whole hearted cooperation to get the study complete.   References 1.     World Health Organization. (Accessed date 20 Dec 2021). Available from: https://www.who.int/ health-topics/cardiovascular-diseases. 2.     Gao Y, Wang Q, Li J, Zhang J, Li R, Sun L, et al. Impact of mean arterial pressure fluctuation on mortality in critically ill patients. Crit Care Med. 2018; 46(12): e1167-e1174. 3.     Pires A, Sena C, Seiça C. Dyslipidemia and cardiovascular changes in children. Curr Opin Cardiol. 2016; 31(1): 95-100. 4.     Laakso M, Kuusisto J. Insulin resistance and hyperglycaemia in cardiovascular disease development. Nat Rev Endocrinol. 2014; 10(5): 293-302. 5.     Silva LF, Vangipurapu J, Laakso M. The "Common Soil Hypothesis" revisited- risk factors for type 2 diabetes and cardiovascular disease. Metabolites. 2021; 11(10): 691. 6.     International Diabetes Federation. (accessed on 20 Dec 2021). Available from: https://www.idf.org/ 7.     Pursnani S, Merchant M. South Asian ethnicity as a risk factor for coronary heart disease. Atherosclerosis. 2020; 315: 126-130. 8.     Sayeed MA, Banu A, Malek MA, Khan AKA. Blood pressure and coronary heart disease in NIDDM subjects at diagnosis: prevalence and risks in a Bangladeshi population. Diab Res Clin Pract. 1998; 39: 147-155. 9.     Einarson TR, Acs A, Ludwig C, Panton UH. Prevalence of cardiovascular disease in type 2 diabetes: a systematic literature review of scientific evidence from across the world in 2007–2017. Cardiovasc Diabetol. 2018; 17(1): 1-9. 10.  Kazeminia M, Salari N, Mohammadi M. Prevalence of cardiovascular disease in patients with type 2 diabetes mellitus in Iran: a systematic review and meta-analysis. J Diabetes Res. 2020; 2020.  11.  Hanif AAM, Hasan M, Khan MSA, Hossain MM, Shamim AA, Hossaine M, et al. Ten-years cardiovascular risk among Bangladeshi population using non-laboratory-based risk chart of the World Health Organization: findings from a nationally representative survey. PLoS One. 2021; 16(5): e0251967. 12.  Anika UL, Pintaningrum Y, Syamsun A. Correlation between serum lipid profile and blood pressure in NTB general hospital. J Hypertens. 2015; 33: e32. 13.  Wong ND, Lopez VA, Roberts CS, Solomon HA, Burke GL, Kuller L, et al. Combined association of lipids and blood pressure in relation to incident cardiovascular disease in the elderly: the cardiovascular health study. Am J Hypertens; 2010; 23(2): 161–167. 14.  Prospective Studies Collaboration, Lewington S, Whitlock G, Clarke R, Sherliker P, Emberson J, et al. Blood cholesterol and vascular mortality by age, sex, and blood pressure: a meta-analysis of individual data from 61 prospective studies with 55,000 vascular deaths. Lancet. 2007; 370(9602): 1829-1839. 15.  Amin MR, Rahman MA, Alam N, Hasan MN, Hasan GS. Relationship between triglyceride HDL-cholesterol ratio and severity of coronary artery disease in patient with acute coronary syndrome. Bangladesh Med J. 2014; 43(3): 157–161. 16.  Calling S, Johansson SE, Wolff M, Sundquist J, Sundquist K. Total cholesterol/HDL-C ratio versus non-HDL-C as predictors for ischemic heart disease: a 17-year follow-up study of women in southern Sweden. BMC Cardiovasc Disord. 2021; 21(1): 1-9. 17.  Holman RR, Coleman RL, Shine BS, Stevens RJ. Non-HDL cholesterol is less informative than the total-to-HDL cholesterol ratio in predicting cardiovascular risk in type 2 diabetes. Diabetes Care. 2005; 28(7): 1796–1797. 18.  Anandaraja S, Narang R, Godeswar R, Laksmy R, Talwar KK. Low density lipoprotein cholesterol estimation by a new formula in Indian population. Int J Cardiol. 2005; 102(1): 117–120.     Cite this article as: Banu A, Hoque F, Ahsan KA, Sayeed MA. Do obesity, hypertension and dyslipidemia pose significant risks for coronary artery disease among Bangladeshi diabetics? IMC J Med Sci. 2023; 17(1): 002. DOI: https://doi.org/10.55010/imcjms.17.002 <![CDATA[Histopathologic and clinical features of diabetic nephropathy alone and with concomitant nondiabetic renal diseases]]> Sk Md Jaynul Islam Shamoli Yasmin Ishtyiaque Ahmed Wasim Md Mohosinul Haque https://imcjms.com/journal_full_text/431 2022-09-29 11:19:36 Original Article IMC J Med Sci. 2023; 17(1): 003 Abstract Background and objective: Diabetic nephropathy (DN) is a major complication of diabetes mellitus (DM) and one of the leading causes of end-stage kidney disease. The aim of the present study was to evaluate the histomorphological and clinical profiles of DN and associated non-diabetic renal dieases (NDRD) in diabetic patients. Materials and methods: The study was carried out at the Department of Histopathology, Armed Forces Institute of Pathology (AFIP), Dhaka, from July 2019 to December 2020. Renal biopsy samples from known diabetic patients were included in the study. The formalin-fixed tissues were stained with haematoxylene & eosin (H&E), Periodic acid Schiff (PAS), Masson Trichrome (MT) and Jones Methanamine Silver (JMS) stains. Tissues were stained for IgG, IgA, IgM, C3, C1q, kappa and lambda for direct immunofluorescence (DIF) study. DN was histologically classified according to Tervaert classification system. Interstitial fibrosis and tubular atrophy (IFTA) as well as arteriolar hyalinization scoring was also done. Clinical information was retrieved from the patient’s information sheet. Results: Total 46 biopsy samples from DN cases were included in the study. The mean age of the cases was 46.76+10.63 years, including 36 males and 10 females. The most common clinical presentation was nephritic range proteinuria (n=32, 69.56%). Among all, 27 (58.69%) patients had haematuria. The mean serum creatinine level was 4.28+2.61 mg/dl, and 80.43% had serum creatinine levels >1.5 mg/dl. Histopathologic examinatiom revealed type III DN in 26 (56.5%) and type IV DN in 11 (23.9%) cases. IFTA score 1 (<25%) was seen in 20 (43.5%), score 2 (25-50%) in 19 (41.3%) and score 3 (>50%) in 7 (15.2%). Vascular hyalinization score-2 in 25 (54.3%), score-1 in 14 (30.4%) and score-0 in 7 (15.2%). DN class II, III and IV were associated with high urinary total protein (UTP) and serum creatinine levels. Among the histologic changes, percentage of glomerular sclerosis, the mean IFTA score and vascular hyalinization score were found to be highest in class IV DN, and all were significantly associated with histologic glomerular DN classes (p= <0.05). Of the total cases, 21 (45.65%) were found with nondiabetic renal diseases (NDRD), the most common feature was focal segmental glomerulosclerosis (FSGS) (26.57%), followed by IgA nephropathy and post-infectious glomerulonephritis (PIGN). Among 46 cases, one post-transplant biopsy was included, which revealed class II DN along with features of calcineurin inhibitor toxicity. Conclusion: Tervaert’s histologic classification of our cases revealed class III DN lesions as the predominant one, and the classes had a significant association with age of the patient, serum creatinine level, mean IFTA, arteriolar hyalinization and NDRD. Among the NDRD, FSGS was the most common pathology. IMC J Med Sci. 2023; 17(1): 003. DOI: https://doi.org/10.55010/imcjms.17.003 *Correspondence: Sk Md Jaynul Islam, Department of Histopathology, Armed Forces Institute of Pathology, Dhaka Cantonment, Dhaka, Bangladesh.  Email: jaynul.islam@gmail.com   Introduction Diabetic nephropathy (DN) is a major complication of diabetes mellitus (DM) and one of the leading causes of end-stage kidney disease [1]. DN develops in 30% of patients with insulin-dependent DM (type-1) and in 40% with non-insulin-dependent type-2 DM [2]. DN is a clinical syndrome characterized by persistent albuminuria and progressive decline in renal function, and the term refers to the presence of a typical pattern of glomerular disease. DN is reported to occur in 20% to 50% of those with diabetes and is the commonest cause of end-stage kidney disease (ESKD) in different populations, accounting for 28% of those commencing renal replacement therapy (RRT) in the United Kingdom, with corresponding figures of 44% in the United States and 38% in Australia [3,4]. Diagnosis of DN is commonly made by clinical findings. Kidney biopsies are performed less frequently in patients with DM than in other patients with proteinuria and are generally carried out in patients with atypical clinical and laboratory features. Indications for kidney biopsy in patients with diabetes are mostly determined by the attending physician and policies of the country or the institution [5]. The natural course of DN has traditionally been initial glomerular hyperperfusion followed by microalbuminuria, overt proteinuria, and eventually progressive renal dysfunction. Isolated proteinuria, which is likely to be caused by DN, is not an indication for renal biopsy, as pathological confirmation of DN rarely provides additional information regarding the management of patients. However, several studies have suggested that non-diabetic renal disease is common in diabetic patients, ranging from 27% to 79% among patients undergoing renal biopsy [6-10]. According to the International Diabetes Federation (IDF) Diabetes Atlas, there are an estimated 8.4 million people with diabetes in Bangladesh. The IDF projected that the number of people with diabetes will increase to 16.8 million by 2030, placing Bangladesh among the top ten countries globally [11]. Several recent studies have reported DN as a major complication of DM, ranging from 6.4% to 8.6% [12,13]. Most of these studies on DN carried out in Bangladesh focused on clinical parameters and the impact of different risk factors [14, 15]. So far, no study has been reported from Bangladesh on renal biopsy findings of DN cases. In the present study, we evaluated the histomorphological and clinical profiles of of DN cases and associated non-diabetic renal diseases.   Materials and methods This cross-sectional study was carried out at the Department of Histopathology, Armed Forces Institute of Pathology, Dhaka, a referral diagnostic center of Bangladesh, from July 2019 to December 2020. The study was approved by the concerned authority. Renal biopsy samples of known diabetic patients received during the period with a history of proteinuria, haematuria/renal dysfunction were included in the study. For each patient, two samples of the renal core biopsy were received, one in 10% formalin for histopathological examination and another one in cold normal saline/Michel’s transport medium for direct immunofluorescence (DIF) study. The formalin-fixed tissues underwent routine tissue processing followed by paraffin block preparation. Tissues were stained with haematoxylene & eosin (H&E), Periodic acid Schiff (PAS), Masson Trichrome (MT) and Jones Methanamine Silver (JMS) stains. In certain suspected cases, Congo red staining was done. For the DIF study, tissue from each sample was stained for IgG, IgA, IgM, C3, C1q, Kappa and Lambda. Clinical presentation and investigation findings were retrieved from the patient’s information sheet accompanying the respective sample. Two competent histopathologists made the final histological diagnosis after meticulous observation of all the stained histopathology slides, DIF study and consideration of clinical presentations and laboratory investigations. The suboptimal number of the glomerulus in the paraffin section and/or no glomerulus in the DIF study were considered as inadequate specimens. DN has been histologically classified into four glomerular classes, class I to IV according to Tervaert classification (Table-1) [16]. Interstitial fibrosis and tubular atrophy (IFTA) scoring was done as, No IFTA= 0, IFTA <25%=1, IFTA 26-50%= 2, IFTA >50%=3. Similarly, vascular hyalinization scoring was done as no hyalinization= 0, single arteriolar involvement=1, more than one arteriolar involvement=2.   Table-1: Histologic glomerular classes according to Tervaert classification [16]     Statistical analysis was performed using the statistical package for social studies (SPSS) version 26 (IBM, USA). p<0.05 was considered as significant.   Results Excluding the inadequate specimens, total DN samples were 46, which was 4.89% of the total renal biopsy samples received at AFIP during the stipulated period. Detail demographic and clinical characteristics of the study patients are shown in Table-2. The mean age of the cases was 46.76+10.63 years, ranging from 23 years to 82 years. Among all, 36 were male, and 10 were female.   Table-2: Demographic and clinical characteristics of DN patients (n=46)     Among 46 cases, 32 cases (69.56%) presented with nephrotic range proteinuria, 27 (58.69%) patients had some form of haematuria, which included gross haematuria (>20/HPF) in 13 (28.26%) cases. Mean serum creatinine level was 4.28+2.61 mg/dl, ranging from 0.3 mg/dl to 6.8 mg/dl and 80.43% had serum creatinine level >1.5 mg/dl. Only one (2.2%) patient had retinopathy. Among all the cases, the predominant histologic glomerular class was type III DN in 26 (56.5%) patients, followed by type IV DN in 11 (23.9%) [Table-3]. Only, one class I DN was found in a 82 yrs old patient who presented with nephrotic syndrome with slightly raised serum creatinine level. It was found with acute tubular injury and associated non-diabetic changes. IFTA score 1 (<25%) in 20 (43.5%) cases followed by IFTA score 2 (25-50%) in 19 (41.3%) cases and score 3 (>50%) in 7 (15.2%) cases. Vascular hyalinization score-2 was seen in 25 (54.3%) cases followed by hyalinization score-1 in 14 (30.4%) cases and score-0 in 7 (15.2%) cases.   Table-3: Histopathologic classes of DN cases (n=46)     Clinico-pathological characteristics of different glomerular classes of DN are shown in Table-4. Different histologic classes of DN were significantly associated with the age of the patient (p=0.041) and with nondiabetic histologic changes (p=0.010). UTP was high in class III DN in comparison to class IV, while serum creatinine level sequentially increased in class II, Class III and highest in class IV. Among the histologic changes percentage of glomerular sclerosis, the mean IFTA score and vascular hyalinization score were found to be highest in class IV DN, and all were significantly associated with histologic glomerular DN classes (p= <0.05). NDRD was present in 87.5% of DN class II cases.   Table- 4: Clinico-pathological characteristics of cases with different glomerular classes of DN     Among all the cases, 21 (45.65%) biopsy samples had associated nondiabetic renal diseases (NDRD; Table-5). Among the 21 NDRD cases, the most common was focal segmental glomerulosclerosis (FSGS, 28.6%), followed by IgA nephropathy (14.3%) and post-infectious glomerulonephritis (14.3%). Anti-neutrophil cytoplasmic antibody (ANCA) mediated pauci-immune glomerulonephritis, and acute tubular injury were found in 2 (4.3%) cases each.   Table-5: Pattern of associated non-diabetic renal diseases (NDRD) in study population (n=21)     Crystal nephropathy, immune complex-mediated membranoproliferative glomerulonephritis (IC-MPGN), membranous nephropathy (MN) and renal cortical necrosis (RCN) were other NDRD. Among 46 cases, one post-transplant biopsy was included, revealing class II DN and features of calcineurin inhibitor toxicity.   Discussion In this study, we investigated 46 cases of diabetic nephropathy diagnosed on renal biopsy during the 1.5 years of study period, accounting for 4.89% of the total 940 renal biopsy samples. The common affected age group was the 4th decade in our study with a mean age of 46.76 + 10.63 yrs, and males were predominantly affected. Lee YH et al also reported male aged more than 50 years as the commonly affected group [17]. In contrast, a study from Turkey reported female as the predominantly affected group [18]. In our study, 69.56% cases had nephrotic range proteinuria and only one case had retinopathy. Therefore, it seems that the most pertinent indication for renal biopsy in DN cases is nephritic range proteinuria. Artan et al also reported proteinuria without retinopathy as the commonest indication of renal biopsy in their cohort [3]. In our cohort, 80.43% had raised serum creatinine levels with mean serum creatinine of 4.28+2.61 mg/dl, which was quite high in comparison to other similar studies [3,17,18]. The mean UTP level was in our cases was 6.44+3.15 g/24 hrs and 58.69% of cases had some form of haematuria. Sharma et al in their study, reported a median UTP of 5.0 g/24 hrs and haematuria in 27.8% to 33.6% of cases [19]. In our study, we found Class III DN as the most prevalent glomerular histological class comprising 56.52% followed by class-IV, 23.91%. All the class II lesions were of class IIb type, which was 17.39%. Wang J et al also found Class III DN as the most common DN histologic type (45.71%), but their second common histologic classwas class II DN (32.70%)[18] instead of class IV as found in our series. Different histologic classes of DN were significantly associated with the age of the patient (p=0.041) and nondiabetic histologic changes (p=0.010). UTP was high in class III DN in comparison to class IV, while serum creatinine level sequentially increased in class II, Class III and highest in class IV DN. Among the histologic changes percentage of glomerular sclerosis, the mean IFTA score and vascular hyalinization score were highest in class IV DN, and all were significantly associated with histologic glomerular DN classes (p= <0.05). Afroz et al also reported a significant association with mean age and sequential increasing mean serum creatinine level, mean IFTA score and mean vascular hyalinization score with diabetic glomerular classes [20). Sahay et al observed higher degree of proteinuria among cases with higher histologic classes [21]. This study found 45.65% cases of NDRD along with DN. In our study, lower glomerular classes had an increasing association with NDRD. The most common NDRD was FSGS (26.57%), followed by IgA nephropathy and PIGN (14.21%). Similar rate of associated NDRD in DN cases have also been reported by others [22,23]. Sanghavi et al [24] and Sharma et al [19] also reported FSGS as the predominant NDRD in their studies. While Lee et al [17] reported MN as the predominant NDRD and several studies in China [22,23,25] observed IgA nephropathy as the most prevalent NDRD. In this study, one post-transplant calcineurin inhibitor toxicity was identified along with DN. Diabetic nephropathy has become a leading cause of end-stage renal failure, which ultimately needs renal replacement therapy. Renal biopsy is performed only in some selected cases mostly to find out the presence of other underlying causes other than diabetic changes. In our study, as about half of the cases had NDRD along with DN. Tervaert’s histologic classification of our cases revealed class III DN lesions as the predominant one and had a significant association with age of the patient, serum creatinine level, IFTA, arteriolar hyalinization and NDRD. However, the study was conducted on limited number of DN cases. A countrywide study with larger number cases would provide more detail information regarding the state of DN, its classes and progression indicators in Bangladeshi diabetic patients.   Conflict of Interest: Nothing to declare.   Fund: None   References 1.     Afkarian M, Zelnick LR, Hall YN, Heagerty PJ, Tuttle K, Weiss NS, et al. Clinical manifestations of kidney disease among US adults with diabetes, 1988-2014. JAMA. 2016; 316(6): 602-610. 2.     USRDS: United States Renal Data System Annual Data Report. Epidemiology of kidney disease in the United States. National Institute of Diabetes and Digestive and Kidney Diseases; 2015. 3.     Byrne C, Caskey F, Castledine C, Davenport A, Dawnay A, Fraser S, et al. UK Renal Registry: 20th annual report of the Renal Association. Nephron. 2018; 139 Suppl 1: S24-35. 4.     Koye DN, Shaw JE, Reid CM, Atkins RC, Reutens AT, Magliano DJ. Incidence of chronic kidney disease among people with diabetes: a systematic review of observational studies. Diabet Med. 2017; 34(7): 887-901. 5.     Artan AS, Gürsu M, Çoban G, Elçioğlu ÖC, Kazancıoğlu R. Renal biopsy in patients with diabetes: indications, results, and clinical predictors of diabetic kidney disease. Turk J Nephrol. 2021; 30(1): 2-8. 6.     Byun JM, Lee CH, Lee SR, Moon JY, Lee SH, Lee TW, et al. Renal outcomes and clinical course of nondiabetic renal diseases in patients with type 2 diabetes. Korean J Intern Med. 2013; 28(5): 565–72. 7.     Chang TI, Park JT, Kim JK, Kim SJ, Oh HJ, Yoo DE, et al. Renal outcomes in patients with type 2diabetes with or without coexisting nondiabetic renal disease. Diabetes Res Clin Pract. 2011; 92(2): 198–204. 8.     Chong YB, Keng TC, Tan LP, Ng KP, Kong WY, Wong CM, et al. Clinical predictors of nondiabetic renal disease and role of renal biopsy in diabetic patients with renal involvement: a single centre review. Ren Fail. 2012; 34(3): 323–328. 9.     Lee EY, Chung CH, Choi SO. Nondiabetic renal disease in patients with non-insulin dependent diabetes mellitus. Yonsei Med J. 1999; 40(4): 321–326. 10.  Mazzucco G, Bertani T, Fortunato M, Bernardi M, Leutner M, Boldorini R, et al. Different patterns of renal damage in type 2 diabetes mellitus: a multicentric study on 393 biopsies. Am J Kidney Dis. 2002; 39(4): 713–720. 11.  International Diabetes Federation. IDF Diabetes Atlas. 6th ed. Brussels, Belgium: International Diabetes Federation; 2013. 12.  Kibriya MG, Mahtab H. Micro-vascular complications in type-2 diabetes in Bangladesh: the Diabcare-Asia, Bangladesh project. Diabetes Res Clin Pract. 2000; 50: 135-136. 13.  Latif ZA, Jain A, Rahman MM. Evaluation of management, control, complications and psychosocial aspects of diabetics in Bangladesh: DiabCare Bangladesh 2008. Bangladesh Med Res Counc Bull. 2011; 37(1): 11-16. 14.  Islam SM, Islam MS, Rawal LB, Mainuddin A, Wahiduzzaman M, Niessen LW. Clinical profile of patients with diabetic nephropathy in a tertiary level hospital in Dhaka, Bangladesh. Arch Med Health Sci. 2015; 3(2): 191-197. 15.  Rahim MA, Zaman S, Habib SH, Afsana F, Haque WMMU, Iqbal S. Evaluation of risk factors for diabetic nephropathy among newly diagnosed type 2 diabetic subjects: preliminary report from a tertiary care hospital of Bangladesh. BIRDEM Med J. 2020; 10(2): 88-91. 16.  Tervaert TWC, Mooyaart AL, Amann K, Cohen AH, Cook HT, Drachenberg CB, et al. Pathologic classification of diabetic nephropathy. J Am Soc Nephrol. 2010; 21(4): 556–563. 17.  Lee YH, Kim KP, Kim YG, Moon JY, Jung SW, Park E, et al. Clinicopathological features of diabetic and nondiabetic renal diseases in type 2 diabetic patients with nephrotic-range proteinuria. Medicine. 2017; 96(36): e8047. 18.  Wang J, Zhao L, Zhang J, Wang Y, Wu Y, Han Q, et al. Clinicopathological features and prognosis of type 2 Diabetes Mellitus and diabetic nephropathy in different age group: more attention to younger patients. Endocr Prac. 2020; 26(1): 51-57. 19.  Sharma SG, Bomback AS, Radhakrishnan J, Herlitz LC, Stokes MB, Markowitz GS, et al. The modern spectrum of renal biopsy findings in patients with diabetes. Clin J Am Soc Nephrol. 2013; 8(10): 1718–1724. 20.  Afroz T, Sagar R, Reddy S, Gandhe S, Rajaram KG. Clinical and histological correlation of diabetic nephropathy. Saudi J Kidney Dis Transpl. 2017; 28(4): 836-841. 21.  Sahay M, Mahankali RK, Ismal K, Vali PS, Sahay RK, Swarnalata G. Renal histology in diabetic nephropathy: a novel perspective. Indian J Nephrol. 2014; 24(4): 226–231. 22.  Zhou J, Chen X, Xie Y, Li J, Yamanaka N, Tong X. A differential diagnostic model of diabetic nephropathy and nondiabetic renal diseases. Nephrol Dial Transplant. 2008; 23(6): 1940–1945. 23.  Bi H, Chen N, Ling G, Yuan S, Huang G, Liu R. Nondiabetic renal disease in type 2 diabetic patients: a review of our experience in 220 cases. Ren Fail. 2011; 33(1): 26–30. 24.  Sanghavi SF, Roark T, Zelnick LR, Nazafian B, Andeen NK, Alpers CE, et al. Histopathologic and clinical features in patients with diabetes and kidney disease. Kidney 360. 1(11): 1217–1225. 25.  Mou S, Wang Q, Liu J, Che X, Zhang M, Cao L, et al. Prevalence of nondiabetic renal disease in patients with type 2 diabetes. Diabetes Res Clin Pract. 2010; 87(3): 354–359.       Cite this article as: Islam SMJ, Yasmin S, Ahmed I, Haque WMM. Histopathologic and clinical features of diabetic nephropathy alone and with concomitant nondiabetic renal diseases.  IMC J Med Sci. 2023; 17(1): 003.  DOI: https://doi.org/10.55010/imcjms.17.003 <![CDATA[Grade of liver siderosis in beta-thalassaemia major patients receiving different amount of blood transfusion]]> Souvik Basak Kashinath Das https://imcjms.com/journal_full_text/432 2022-10-13 11:05:26 Original Article IMC J Med Sci. 2023. 17(1): 004 Abstract Background and objectives: A progressive accumulation of body iron easily occurs as a result of long-term transfusions in patients with anaemia of genetic disorders such as thalassaemia. Iron deposit in liver biopsy sections was studied in beta-thalassaemia major patients to assess the grade of liver siderosis and to correlate the grade with amount of blood transfused. Materials and methods: Beta-thalassaemia major patients having splenomegaly and selected for splenectomy were enrolled. Liver biopsy was taken from every patient during the splenectomy. Liver tissue was sectioned and stained with Perls’ prussian blue method for the presence of iron deposition. The degree of iron deposition was expressed as grades of siderosis from 0 to 4. Results: A total of 30 beta-thalassemia patients were enrolled in the study. Out of 30 patients, 7 were males (23.3%) and 23 females (76.7%). The mean age of patients was 15.2 ± 1.4 years. The mean serum iron and ferritin levels of the study cases were above the normal range. Blood received by all patients was 51.5 ± 11.6 units (range 31 to 88 units). Out of 30 patients, grade 1, 2, 3 and 4 liver siderosis was present in 1, 3, 9 and 17 patients respectively. Serum ferritin level of patients with grade 4 siderosis was significantly higher (p = 0.03) compared to grade 3 cases. Pearson’s correlation coefficient test revealed significant positive correlation between grades of liver siderosis and amount of blood transfusion received (0.626, p < 0.01). Conclusion: Grade of liver siderosis is associated with increased units of blood transfusion and is a good indicator for transfusional iron overload in beta-thalassaemia major patients. IMC J Med Sci. 2023. 17(1): 004. DOI: https://doi.org/10.55010/imcjms.17.004 *Correspondence: Dr. Souvik Basak, Department of General Surgery, Medical College, Kolkata, West Bengal, India.  Email: sb009cmc@gmail.com   Introduction The total amount of body iron is approximately 3–4 g, two-thirds of which is composed of red blood cell (RBC) iron and recycled iron by RBC destruction. The remainder is stored as ferritin/hemosiderin, while only 1–2 mg of iron is absorbed in the intestinal tract and circulated in the blood. In the circulation, iron is usually bound to transferrin, and most of the transferrin bound iron is utilized for bone marrow erythropoiesis [1,2]. As there is no active mechanism to excrete iron from the body, a progressive accumulation of body iron easily occurs as a result of long-term transfusions in patients with anaemia of genetic disorders such as thalassaemia. Hepatic iron overload resulting from multiple red cell transfusions over a long period of time is a complication of thalassaemia major and other congenital anaemia. Liver parenchymal iron overload is usually the result of excessive iron absorption by the enteral route, such as in hereditary hemochromatosis (HHC) and anaemia with ineffective erythropoiesis (iron loading anaemia), but may also reflect enhanced internal redistribution of transfused erythrocyte iron recycled from the reticuloendothelial (RE) cells, as observed in the more advanced stage of transfusional iron overload [3-6]. Organ damage is related to the amount of iron present in the parenchymal cells, whereas iron within RE cells appears to be relatively innocuous [3,6]. The purpose of this study was to assess grades of liver siderosis in beta-thalassaemia major patients and to correlate the grades with number of units of blood transfused.   Material and methods Study place and population: The study was an institution-based study conducted in the Department of Surgery, Medical College, Kolkata, India from January 2013 to June 2014 after obtaining approval from Institutional Ethical Committee and informed consent from the patients. The study enrolled already diagnosed patients of beta-thalassaemia major who were having splenomegaly and being planned for splenectomy. The inclusion criteria were beta-thalassaemia major patients a) requiring repeated blood transfusions (at least 2 per month), b) did not undergone chelation therapy, and c) were more than 12 years of age. Patients having any congenital or acquired liver disease, chronic hepatitis B or hepatitis C infection, malignancy, disease causing splenomegaly, and who refused to be part of the study were excluded. Each enrolled case was clinically examined and detail clinical history was taken using a structured questionnaire. Detail transfusion history and the amount of transfusion received by each patient were recorded. Determination of liver siderosis: Liver biopsy was taken during splenectomy. Liver biopsy sections were stained with Perls’ prussian blue method for iron deposition. The degree of iron deposition/siderosis was expressed as grades. Grade 0 being negative and grades 1, 2, 3 and 4 represent increasing amounts of stainable iron [7]. Deposits were heaviest in the periphery of the lobule with a concentration gradient toward the centre of the lobule. Data analysis: Data were analysed with SPSS® software version 26 for Windows 11 (SPSS, Chicago, IL, USA). Apart from descriptive statistics nonparametric Kruskal-Wallis test was performed to compare among the different groups. Pearson’s correlation coefficient was performed to test the relationship between the grade of siderosis and amount of blood transfused.   Results In this study, 30 beta-thalassaemia major patients were included. Out of 30 patients, 7 were males (23%) and 23 females (77%). The mean age of patients was 15.2 ± 1.4 years (Table-1). Detail results of MCV, MCH, MCHC, serum iron and ferritin of the study population are shown in Table-1. The mean serum iron and ferritin levels of the study cases were above the normal range.   Table-1: Baseline blood parameters of study population (n = 30)   Out of 30 patients, one patient had grade 1 liver siderosis and grade 2, 3 and 4 liver siderosis was present in 3, 9 and 17 patients respectively (Table-2). The mean age of patients having grade 1, 2, 3 and 4 liver siderosis were 16, 15.3 ± 2.3, 14.8 ± 1.2 and 15.4 ± 1.5 years respectively. There was no significant difference of age of the patients belonging to four grades. There were no significant differences in MCV, MCH, MCHC, serum iron and TIBC among patients having different grades of liver siderosis. Serum ferritin was more than the normal range in patients with grade 1 to 4 siderosis. Serum ferritin level of patients having grade 4 siderosis was significantly higher (p = 0.03) compared to grade 3 cases. However, serum ferritin levels of patients having grade 1, 2 and 3 were not significantly different from each other (p > 0.05). Table-2: Comparison of blood parameters and iron studies of patients with different grades of liver siderosis     Table-3 shows the unit of blood transfusion received by patients with different grades of liver siderosis. Total 51.5 ± 11.6 units of blood were received by all patients (range 31 to 88 units). Recipient of more units of blood transfusion had higher grade of liver siderosis. Patients having grade 4 siderosis received significantly more units of blood transfusion compared to patients of other grades. Pearson’s correlation coefficient test revealed that there was significant positive correlation between grades of liver siderosis and amount of transfusion received (r = 0.626, p < 0.01; Figure-1).   Table-3: Unit of blood transfusion received by patients having different grades of liver siderosis         Figure-1: Pearson correlation between amount of transfusion units and grades of siderosis   Discussion In our study, 30 beta-thalassaemia major patients, fulfilling the selection criteria, were studied for the presence of liver siderosis and were correlated with the amount of blood transfusion received by them. In our study, the values of MCV, MCH and MCHC were below their normal values which were expected findings in these patients as these RBC indices decrease in microcytic hypochromic anaemia like thalassaemia. There were no significant differences in MCV, MCH, MCHC, serum iron and TIBC values among patients having differing grades of liver siderosis. However, serum ferritin was high in all the cases with different grades of liver siderosis. This finding is consistent with the findings of Takatoku et al [8]. However, the level of serum ferritin is also affected by acute and chronic inflammation and infections. Other clinical conditions such as inflammation and malignancy should be excluded for appropriate interpretation of the values of serum ferritin for the assessment of body iron status when serum ferritin is used as a biological marker for evaluation of body iron stores [9]. In beta-thalassaemia major, abnormalities in haemoglobin decrease erythrocyte life span and the pool of erythrocyte precursors is markedly expanded, leading to increased enteral absorption of dietary iron [4,6,10]. Aggressive transfusion therapy suppresses endogenous erythropoiesis and corrects the severe anaemia, but leads to its own complications, the worst of which is iron overload [11,12]. In the present study, majority cases had grade 4 liver siderosis. It could be due to their late presentation which was evident by high serum ferritin level and repeated monthly blood transfusions (> 2). Repeated transfusion increases iron deposition in liver resulting into increased grade of liver siderosis. Increasing the awareness of both patients and their first points of contact like primary health workers must be done to minimize irreversible organ damage and subsequent complications. Non-invasive methods for the assessment of hemosiderosis should be considered to detect early deposition of iron in liver to prevent lasting organ damage. Blood chelating agents should be started at appropriate time so that the chances of patients ending up for surgery can be minimized. According to Deugnier et al, patients of hereditary hemochromatosis have an estimated 240-fold increased relative risk of developing hepatocellular carcinoma, with the degree of risk correlating with the amount and duration of iron overload and degree of fibrosis [13]. Though mechanism of hemosiderosis is different in thalassaemia and hereditary hemochromatosis it cannot be ignored that iron deposition per se can have several liver related complications, even life-threatening ones and further research is necessary in this regard. So, grade of liver siderosis can be a good indicator for transfusional iron overload in beta-thalassaemia major patients. Further research is necessary with regard to iron deposition in non-hepatic organs to properly assess the progress of disease and to determine timing for aggressive therapy.   Acknowledgement: The authors take this opportunity to thank Dr. Dhritiman Maitra, Assistant Professor, Department of Surgery and Dr. Nirmal Kumar Bhattacharya, Associate Professor, Department of Pathology for their whole hearted support for this study.   Author’s contribution: Concept, design of the study, interpretation of the results, literature review and manuscript preparation. KD – Concept and design of the study and revision of the manuscript.   Ethical approval: Ethical approval was obtained from Institutional Ethics Committee, Medical College, Kolkata. Conflict of interest: None   Source of funding: None   References 1.     Kumar V, Abbas AK, Fausto N, Aster J. Robbins & Cotran Pathologic basis of disease. 8th ed. Philadelphia: Saunders; 2010. 2.     Andrews NC. Disorders of iron metabolism. N Engl J Med. 1999; 341(26): 1986-1995. 3.     Finch C, Huebers H. Perspectives in iron metabolism. N Engl J Med. 1982; 306(25): 1520-1528. 4.     Halliday J, Powell L. Iron overload. Semin Hematol. 1982; 19: 42-53. 5.     Powell L, Jazwinska E, Halliday J. Primary iron overload. In: Brock, Halliday, Pippard and Powell, editors. Iron metabolism in health and disease. London: Saunders; 1994. p. 227-270. 6.     Pootrakul P, Kitcharoen K, Yansukon P, Wasi P, Fucharoen S, Charoenlarp P, et al. The effect of erythroid hyperplasia on iron balance. Blood. 1988; 71(4): 1124-1129. 7.     Scheuer PJ, Williams R, Muir AR. Hepatic pathology in relatives of patients with hemochromatosis. J Pathol Bacteriol. 1962; 84: 53-64. 8.     Takatoku M, Uchiyama T, Okamoto S, Kanakura Y, Sawada K, Tomonaga M, et al. Retrospective nationwide survey of Japanese patients with transfusion-dependent MDS and aplastic anemia highlights the negative impact of iron overload on morbidity/mortality. Eur J Haematol. 2007; 78(6): 487-494. 9.     Kohgo Y, Ikuta K, Ohtake T, Torimoto Y, Kato J. Body iron metabolism and pathophysiology of iron overload. Int J Hematol. 2008; 88(1): 7-15. 10.  Bacon B. Causes of iron overload. N Engl J Med. 1992; 326(2): 126-127. 11.  Olivieri N, Brittenham G. Iron-chelating therapy and the treatment of thalassemia. Blood. 1997; 89(3): 739-761. 12.  Baer D. Hereditary iron overload in African Americans. Am J Med. 1996; 101(1): 5-8. 13.  Deugnier YM, Guyader D, Crantock L, Lopez JM, Turlin B, Yaouanq J, et al. Primary liver cancer in genetic hemochromatosis: a clinical, pathological, and pathogenetic study of 54 cases. Gastroenterology. 1993; 104(1): 228-234.       Cite this article as: Basak S, Das K. Grade of liver siderosis in beta-thalassaemia major patients receiving different amount of blood transfusion.IMC J Med Sci. 2023. 17(1): 004.  DOI: https://doi.org/10.55010/imcjms.17.004 <![CDATA[Correlation of serum magnesium with HbA1c in patients with diabetes mellitus]]> Farzana Ahmed Nasima Sultana Taslima Akter https://imcjms.com/journal_full_text/433 2022-10-18 09:37:25 Original Article IMC J Med Sci. 2023. 17(1): 005 Abstract Background and objectives: Diabetes mellitus (DM) is a leading cause of death and disability world wide. Magnesium acts as a cofactor in glucose metabolism and its decreased level causes insulin resistance and many complications in diabetic patients. The present study evaluated the correlation of serum magnesium with HbA1c in DM patients. Materials and methods: This cross sectional study was conducted in the Department of Biochemistry, Dhaka Medical College, Dhaka from July 2016 to June 2017. A total number of 100 individuals with and without diabetes mellitus were included in the study. HbA1c was measured by high performance liquid chromatography and estimation of serum magnesium was done by automatic biochemistry analyzer. Results: Out of 100 enrolled participants, 50 were diagnosed patients of DM (Group-A) and 50 were age and sex matched apparently healthy individuals (Group-B). The mean age of Group-A and B individuals was 50.5 ± 6.0 and 50.4 ± 5.1 years respectively. Group-A had significantly (p < 0.001) lower serum magnesium concentration compared to Group-B (1.5 ± 0.6 mg/dl vs 2.3 ± 0.5 mg/dl). Serum magnesium levels showed significant negative correlations with HbA1c (r = -0.511, p < 0.001). Conclusion: DM patients showed significant negative correlation of serum magnesium with HbA1c level. Routine screening for serum magnesium status would be helpful for the better management of diabetic cases. IMC J Med Sci. 2023. 17(1): 005. DOI: https://doi.org/10.55010/imcjms.17.005 *Correspondence: Farzana  Ahmed, Department of Biochemistry, Ibrahim Medical College, 1/A Ibrahim Sarani, Shegunbagicha, Dhaka, Bangladesh. Email: tanvy1108@gmail.com   Introduction World Health Organization (WHO) has reported alarming increase of diabetes mellitus (DM) globally. It has increased from 180 million in 1980 to 422 million in 2014 and during this period the prevalence of diabetes has almost doubled from 4.7% to 8.5% [1-3]. In diabetes mellitus, the metabolism of several minerals is altered resulting into various organ dysfunctions leading to increased morbidity and mortality of the diabetic patients. Trace elements like magnesium, zinc and copper are important for the normal growth and biological functions of the human body. In recent years the role of these minerals has been studied extensively in diabetes, autoimmune, neurological and psychiatric disorders [4-9]. Among the trace elements, magnesium (Mg) acts as a cofactor in the glucose transport mechanism of the cell and also plays an important role in glucose metabolism by acting as a cofactor of various enzymes involved at multiple steps in insulin secretion, binding and activity [10]. Magnesium deficiency decreases insulin sensitivity via alteration of the insulin receptor associated tyrosine kinase in type 2 DM patients [11]. Deficiency of magnesium has been implicated in insulin resistance, carbohydrate intolerance, dyslipidaemia and complications of DM [12]. Low serum magnesium levels may contribute to the development of diabetic complications such as retinopathy, abnormal platelet function, cardiovascular disease and hypertension via reduction of inositol transport rate and subsequent intracellular depletion. Hypomagnesaemia may occur following insulin therapy for diabetic ketoacidosis and may be related to the anabolic effects of insulin driving magnesium back into cells [10]. The reasons for high prevalence of Mg deficiency in diabetes are not clear, but may include increased urinary loss, lower dietary intake or impaired absorption of magnesium compared to healthy individuals. Increased urinary magnesium excretion due to hyperglycemia and osmotic diuresis may contribute to hypomagnesaemia in diabetes [13]. Therefore, the present study was aimed to determine the serum magnesium level and correlate it with HbA1c in DM patients.   Material and methods Study population and place: This cross sectional study was conducted from July 2016 to June 2017 at the Department of Biochemistry, Dhaka Medical College, Dhaka. The study was approved by the Institutional Review Board. Informed written consents were obtained from all enrolled participants. By convenient and purposive sampling technique, a total of 100 individuals were enrolled according to the selection criteria. Out of 100 participants, 50 were diagnosed patients of DM (Group-A) attending the outpatient department of Endocrinology and Metabolism, Dhaka Medical College Hospital. Same number of age and sex matched apparently healthy individuals weas selected as control for comparison (Group-B). DM was defined as a condition of progressive pancreatic beta cell dysfunction having HbA1c level ≥ 6.5% or fasting plasma glucose (FPG) ≥ 7.0 mmol/l or two-hour plasma glucose ≥ 11.1 mmol/l during an oral glucose tolerance test (OGTT) or a random plasma glucose of ≥ 11.1 mmol/l in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis [14]. Known cases of type 1 diabetes mellitus, DM with acute complications, hypertension, malignancy, chronic liver disease, chronic kidney disease, acute illness, pregnant and lactating women, recent history of acute infection and diarrheal disease were excluded.All data were recorded in a predesigned data collection sheet. Collection of blood samples and tests: Blood samples were collected from each individual in designated sterile tubes with aseptic precautions.Fasting plasma glucose was estimated enzymatically by glucose oxidase method. Plasma HbA1c was measured by high performance liquid chromatography. Values for HbA1c were: <5.7% normal, 5.7–6.4% pre-diabetes and ≥ 6.5% diabetes mellitus [15]. Quantitative serum magnesium was determined by colorimetric dye-complexing method using Evolution-3000 flow cell semi-auto- analyzer. Normal level of serum magnesium is 1.8-3.6 mg/dl [16]. Data analysis: Continuous variables were expressed as mean ± SD and were compared between groups of patients by unpaired Student’s t test. Categorical variables were compared using chi-square test. Pearson’s correlation coefficient was used to test the relationship between the parameters. The quantitative observations were indicated by absolute frequencies. The result was considered as statistically significant when p value was less than 0.05.   Results The study was aimed to correlate serum Mg levels with HbA1c of DM patients. Table-1 shows the baseline parameters of the study population. There was no significant difference of age, sex, systolic blood pressure (BP), diastolic BP and body mass index (BMI) between Group-A and B cases. Out of 50 Group-A cases, 43 (86%) had serum magnesium below the normal reference range (< 1.8 mg/dl) while all the Group A cases were within the normal range.   Table-1: Baseline parameters of the Group-A and B study population (N = 100)     Table-2 shows the serum magnesium and HbA1c levels of the study subjects of both groups. Fasting plasma glucose and HbA1c levels were significantly (p < 0.001) higher in DM patients (Group-A) than healthy individuals (Group-B) while serum magnesium levels were significantly (p < 0.001) low in DM patients compared to healthy individuals.   Table-2: Serum magnesium and HbA1c levels of the study population (N = 100)     Pearson’s correlation coefficient test revealed that there was significant negative correlation between serum magnesium with HbA1c (r= -0.511, p<0.001; Figure-1).     Figure-1: Correlation of HbA1c with serum magnesium in Group A   Discussion This cross sectional study investigated the level of serum magnesium in DM patients and in age and sex matched healthy individuals. We also evaluated the correlation of serum magnesium with HbA1c. Serum magnesium concentration was significantly lower in DM patients (p < 0.001) compared to healthy individuals.The finding of our study is in agreement with other reported studies [9,17] who also found significantly decreased level of serum magnesium in diabetic patients. The possible explanation of such hypomagnesaemia in DM cases could be due to higher urinary losses or impaired absorption of magnesium [9,10]. Correlation of serum magnesium with HbA1c was done. In the present study, we found negative correlation of serum magnesium levels with HbA1C (r = -0.511 and p < 0.001) in DM cases. Similar negative correlation of serum magnesium with HbA1c in diabetic cases has been reported by other studies [18]. The findings indicate that uncontrolled glycemia is associated with low serum magnesium status in DM cases. Therefore, it is concluded that regular assessment of serum magnesium would be helpful to prevent the complications related to hypomagnesaemia among DM patients.   Acknowledgement The authors are grateful to the study participants for their participation and their kind cooperation throughout the study.   Conflict of interest The authors declare no conflict of interest.   References 1.     World Health Organization. Global report on diabetes. Geneva: World Health Organization; 2016. 2.     Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004; 27(5): 1047-1053. 3.     Divers J, Mayer-Davis EJ, Lawrence JM, Isom S, Dabelea D, Dolan L, et al. Trends in incidence of type 1 and type 2 diabetes among youths - selected Counties and Indian Reservations, United States, 2002–2015. MMWR Morb Mortal Wkly Rep. 2020; 69(6): 161-165. 4.     Sanna A, Firinu D, Zavattari P, Valera P. Zinc status and autoimmunity: a systematic review and meta-analysis. Nutrients. 2018; 10(1): 68. 5.     Yanik M, Kocyigit A, Tutkun H, Vural H, Harken H. Plasma manganese, selenium, zinc, copper, and iron concentrations in patients with schizophrenia. Biol Trace Elem Res. 2004; 98: 109-117. 6.     Kirkland AE, Sarlo GL, Holton KF. The role of magnesium in neurological disorders. Nutrients. 2018; 10(6): 730. 7.     Ferdousi S, Mollah FH, Mia MAR. Serum levels of zinc and magnesium in newly diagnosed type 2 diabetic subjects. Bangladesh J Med Sci. 2010; 3(2): 46-49. 8.     Mahdizadeh R, Shirali S, Ebadi P. Investigation of imbalance of trace elements in patients with type 2 diabetes mellitus. J Acad Applied Studies. 2014; 4(9): 11-21. 9.     Pujar S, Pujar LL, Ganiger A, Hiremath K, Mannangi N, Bhuthal M. Correlation of serum zinc, magnesium and copper with HbA1c in type 2 diabetes mellitus patients among Bagalkot population - a case control study. Medica Innovatica. 2014; 3(2): 4-8. 10.  Puri M, Gujral U, Nayyar SB. Comparative study of serum zinc, magnesium and copper levels among patients of type 2 diabetes mellitus with and without microangiopathic complications. Innovative J Medical Health Science. 2013; 3: 274-278. 11.  Supriya, Mohanty S, Pinnelli VB, Murgod R, DS R. Evaluation of serum copper, magnesium and glycated haemoglobin in type 2 diabetes mellitus. Asian J Pharm Clin Res. 2013; 6(2): 188-190. 12.  Saha-Roy S, Bera S, Choudhury KM, Pal S, Bhattacharya A, Sen G, et al. Status of serum magnesium, zinc and copper in patients suffering from type 2 diabetes mellitus. J Drug Delivery Therapeutics. 2014; 4(1): 70-72. 13.  Monika KW, Michael BZ, Giatgen AS, Richard FH. Low plasma magnesium in type 2 diabetes. Swiss Med Wkly. 2003; 133: 289-292. 14.  American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2010; 33(1): 62-69. 15.  American Diabetes Association. Standards of medical care in diabetes-2016. Diabetes Care. 2016; 39(1): 1-106. 16.  U.S. Food and Drug Administration. Investigations operations Manual 2017. Maryland: US Food and Drug Administration; 2017. 468 p. 17.  Farid SM, Abulfaraj TG. Trace mineral status related to levels of glycated hemoglobin of type 2 diabetic subjects in Jeddah, Saudi Arabia. Med J Islamic World Acad Sci. 2013; 21(2): 47-56. 18.  Jyothirmayi B, Vasantha M. Study of zinc and glycated Hb levels in diabetic complications. Int J Pharm Clin Res. 2015; 7(5): 360-363.       Cite this article as: <![CDATA[Assessment of anemia among rural children in Kaduna State, Nigeria by determining hemoglobin and serum ferritin levels]]> Andrew Nuhu Yashim Dorcas Yetunde Obazee Michael Olugbamila Dada Azeezat Abimbola Oyewande Bolanle Yemisi Alabi Ajani Olumide Faith Ishata Conteh Felix Olaniyi Sanni Olaiya Paul Abiodun Ochonye Boniface Bartholomew Tolu Adaran Zachary Terna Gwa Olaide Lateef Afelumo Innocent Okwose https://imcjms.com/journal_full_text/434 2022-10-23 10:27:05 Original Article IMC J Med Sci. 2023. 17(1): 006 Abstract Background and objective: Children in the developing world are vulnerable to iron deficiency (ID) and iron deficiency anemia (IDA) because they grow fast and consume diets low in iron. Thus, this study assessed anemia in children aged 6 - 12 years in rural Nigeria, using hematological indices and serum ferritin as diagnostic tools. Materials and methods: This cross-sectional study was carried out in two primary schools in Kumin Masara Kataf village in Kaduna state, Nigeria. School children aged 6 - 12 years were enrolled. Personal information and laboratory data were collected. Hemoglobin and serum ferritin concentration was estimated to determine anemia and iron status. Data analysis was done using IBM-SPSS Inc., Chicago, IL, USA, version-25.0. Results: A total of 191 school-age children aged 6 - 12 years were enrolled in the study. The overall serum ferritin was 16.51±5.20 mg/L, but the children aged 6 - 9 years had significantly (p<0.05) higher serum ferritin (17.23±5.57 mg/L), compared to children aged 10-12 years (15.62±4.62). The mean hemoglobin concentration and serum ferritin were significantly (p<0.05) more elevated among males (11.17±2.53g/dl and 19.01±5.06 mg/L, respectively) than females (10.18±2.46 g/dl and 14.03±4.02 mg/L respectively).The overall rate of anemia was 51.3%, while IDA was 70.4% (69/98). Iron deficiency was present in 47.3% (44/93) children. Also, anemia was significantly (p<0.001) more prevalent among females (66.7%), than males (35.8%), and a higher proportion of females (87.5%) than males (26.2%) were iron deficient (p<0.05), but more males (44.1%) had IDA, p<0.05. Conclusion: This study found a high prevalence of IDA and ID among rural school children in Nigeria. It is recommended that healthcare providers focus more on preventing IDA right before childhood. IMC J Med Sci. 2023. 17(1): 006. DOI: https://doi.org/10.55010/imcjms.17.006 *Correspondence: Andrew Nuhu Yashim, Haematology and Blood Transfusion Department, National Hospital, Abuja, Nigeria. Email:  yashimnuhuandrew@gmail.com   Introduction Anemia is one of the significant public health issues across the world. According to the World Health Organization (WHO), children and non-pregnant women have the highest prevalence of anemia worldwide at 42.6% and 29.0%, respectively [1]. Anemia is defined as a condition in which the number of red blood cells (RBC) or the hemoglobin (Hb) concentration is lower than what is expected for age, sex and geographical location or inadequate to meet the physiological needs of an individual [1,2]. Hemoglobin is required to transport oxygen in the body system. But, if the RBC is abnormal or too few, or the hemoglobin level is insufficient, it will be difficult for blood to transport oxygen to the body tissues, which usually leads to fatigue, weakness, dizziness, shortness of breath, etc.[1]. The most common micronutrient deficiency and commonest anemia worldwide are iron deficiency and iron deficiency anemia [3-5]. Children in the developing world are highly vulnerable to ID because they are growing fast and consume diets low in iron [6,7]. Africa and Asia have extreme public health significance of anemia, with an estimated 67.6% of children below five years suffering from anemia in Africa and 65.5% in Southeast Asia [8]. The results of studies on the prevalence of anemia among Nigerian children vary. A recent data from Nigeria Demographic and Health Surveys showed that 67.01% of children aged 6-59 months were anemic [9], whereas a study conducted in rural Nigeria among school children aged 6-15 years found a higher prevalence of 85.5% [10]. Another study conducted in South-East Nigeria found a prevalence of 49.2% among children below five years old [11]. However, among 87 pre-school children in Lagos, South-West Nigeria, the prevalence of iron deficiency anemia was reported as 10.11% [12]. There are three sequences of events in iron deficiency anemia. The first stage is iron depletion, also called the "decrease in iron stores," and can be caused by insufficient serum ferritin concentration [13,14]. The second stage is an iron deficiency, when the absorption of iron in the body is inadequate to meet up with depleted iron stores; this also implies that the hemoglobin concentration reduces due to impaired synthesis [11,15]. This stage can be determined by decreased serum ferritin, mean corpuscular volume (MCV), and mean corpuscular hemoglobin (MCH). The third and most severe of the three stages is iron deficiency anemia, which reduces iron in the red blood cells [3,16,17]. This stage can also be measured by serum ferritin decline, MCV, MCH, and hemoglobin levels [12]. Study area and population: This cross-sectional study was carried out from February to August 2020. The study population comprised of primary school pupils from two schools in rural Masara Kataf village in Kaduna State, Nigeria. The school-age children involved male and female pupils aged 6 to 12 years. A total of 191 school-age children were recruited as the study participants. Children with hematological problems (infection, inflammation, malignancy) or chronic diseases that could significantly affect the analyzed parameters were excluded from the study. The exclusion was based on their hematological history. Also, children with a history of blood transfusion within three months before the study were excluded, and those who received iron therapy or had raised high-sensitivity C-reactive protein. Sample size calculation: Based on the 85.5% prevalence of anemia among children aged 6-15 years in Nigeria [10], the sample size was calculated using the formula:    where: n is the initial sample size, Z= 1.96 for a 95% confidence level. p is the prevalence of anemia (85.5% = 0.855), and q = 1-p (1-0.855) = 0.145; d is the accepted bias for p in the sample, and it equals 0.05. n =                         = 190.50 = 191 Therefore, total sample size was 191. Sample and data collection: Five milliliters of venous blood samples were collected aseptically from each child after taking their history for the estimation of hemoglobin and serum ferritin. Iron deficiency anemia was determined using WHO standards of a low hemoglobin concentration based on age: Hb <11.5 g/dL for age 6-9 years and <12.0 g/dL for 10-12 years [10,21] with ferritin <15 mg/L [22]. Iron deficiency without anemia was described as normal hemoglobin concentration according to age and serum ferritin <15 mg/L [10,22] while iron depletion - serum ferritin 15 - <20mg/L with normal Hb [12]. Normal hemoglobin concentration was taken as ≥11.5 g/dL. Hemoglobin concentration of 10.0 - 11.4, 7- 9.9 and < 7.0 g/dL was considered as mild, moderate and severe anemia respectively [10]. Statistical analysis: Data were analyzed using IBM- Statistical Package for the Social Sciences (SPSS) version 25.0 for Windows. The Chi-square test was used to establish the association between categorical variables. An independent t-test was conducted to determine the mean values of hematological parameters and serum ferritin of children based on age and gender. A p-value of less than 0.05 was considered statistically significant.   Results The study comprised of 191 school children from two different primary schools aged 6-12 years. The mean age of the study subjects was 9.04 ± 2.07 years, including 95 (49.7%) males and 96 (50.3%) females; the majority, 105 (55.0%),were within the age group 6-9 years and 86 (45.0%) were between 10-12 years. The mean hemoglobin concentration of the study subjects was 10.67 ± 2.54 g/dL with a significantly higher value among children aged 6-9 years (11.03 ± 2.63 g/dL) than 10-12 years (10.24 ± 2.37 g/dL; p<0.05). The overall serum ferritin was 16.51 ± 5.20 mg/L but the children aged 6-9 years had significantly higher serum ferritin (17.23 ± 5.57 mg/L) than 10-12 years (15.62 ± 4.62 mg/L; p<0.05). The results show that mild and severe anemia was more prevalent among children aged 10-12 years (16.3% and 9.3%) than 3.8% and 6.7% among children aged 6 - 9 years. On the other hand, a higher proportion of those aged 6-9 years had moderate anemia (45.7%, p<0.001). A total of 98 (51.3%) had anemia; IDA was more prevalent among 10-12 years, 82.1% (32/39), than 62.7% (37/59) of children aged 6-9 years (p<0.001). Similarly, among the 93 children without anemia, 47.3% had iron deficiency, mostly among children aged 10-12, (63.8%, 30/47) than age 6-9 (30.4%,14/46; p<0.001 (Table-1).   Table-1: Hemoglobin, serum ferritin and anemia status of the study population according to age groups     As shown in Table-2, the mean hemoglobin concentration and serum ferritin were significantly higher among males (11.17±2.53g/dl and 19.01±5.06) than females (p<0.05). Anemia was significantly (p<0.001) more prevalent among females (66.7%) than males (35.8%), with an overall anemia prevalence of 51.3%. However, a higher proportion of males, 44.1% (15/34) had anemia with iron deficiency than females, 21.9% (14/64), p<0.05. On the other hand, a higher proportion of females without anemia were iron deficient, 87.5% (28/32), than males, 26.2% (16), p<0.001, with an overall iron deficiency of 47.3%.   Table-2: Hemoglobin concentration, serum ferritin and anemia status of the study population according to the gender     The mean hemoglobin and serum ferritin concentration of the male study children aged 6-9 and 10-12 years were not significantly (p>0.05) different (Table-3). The results show that normal and severe anemia were more prevalent among male children aged 10 -12 years (75% and 11.1%) than 57.6% and 5.1% among male children aged 6 - 9, p>0.001. A total of 34 (35.8%) male children had anemia; There was no significant difference of prevalence of IDA in male children between aged 6-9 and 10-12 years (56% vs. 55.6%; p=0.982) while ID was significantly (p=0.004) more among the male children aged 10-12 (44.4%) compared to those aged 6-9 years (11.8%, Table-3).   Table-3: Hemoglobin, serum ferritin and anemia status in male children of different age groups     As shown in Table-4, the mean hemoglobin and serum ferritin concentration of the female study children aged 6-9 and 10-12 years were not significantly (p>0.05) different. The results show that normal and mild anemia were significantly (p<0.005) more prevalent among female children aged 10-12 years (40% and 26%) than 26.1% and 4.3% among female children aged 6-9 years. IDA was significantly (p=0.031) more prevalent among female children aged 10-12 years, than children aged 6-9 years (90% vs. 67.6%). No significant difference was observed regarding ID in two groups.   Table-4: Hemoglobin, serum ferritin and anemia status in female pupils of different age groups     Discussion Iron deficiency anemia and iron deficiency without anemia are common nutritional problems among different age groups worldwide. The overall prevalence of anemia in this study was 51.3%, which was similar to 50% obtained among children aged 6 to 59 months in Kaduna [23] but lower than the findings from similar studies in Anambra (66,7%) and Enugu (57.1%) in the Eastern parts of Nigeria [24,25]. However, this study's overall prevalence of anemia was higher than another study conducted among children in Sokoto, North-Western Nigeria (34.8%) [26]. Studies in other countries have also shown varying rates of the prevalence of anemia. It is13.0% in Indonesia [21], 11.8% among six months old children in Beijing, China [27], 30.61% in Chittagong, Bangladesh [28], 66.6% among children 6 to 23 months old in Northeast Ethiopia [8], and 18.7% in Pakistan [16]. The high prevalence of anemia in our study is not unusual because Nigeria was declared an anemic nation by the WHO [1], with a higher prevalence of anemia among children in Northern Nigeria, ranging from 66% in North Central to 71% in North East [23]. The issue of concern is that the situation remains unchanged, which calls for interventions to save our children from the effects of malnutrition. The mean hemoglobin concentration of our study children (10.67 ± 2.54 g/dL) was comparatively lower than the WHO standard [29]. The overall anemia in our study was not significantly associated with age though severe anemia was more prevalent among those aged 10-12 years; this finding supports a previous report that age is not a determinant of anemia [13]. However, a study conducted in south-east Nigeria reported that younger ages were more likely to be anemic due to malaria infection, poor complementary feeding practices in body demand due to rapid growth, and increased activity due to achieved motor milestones [11]. This might be why over 50% of children aged 6 to 9 years in our study were anemic compared to 45% of those aged 10 to 12 years. It has been reported that anemia is more prevalent among children in the vulnerable age groups of newborns to 15 years [26]. This study's overall anemia for male children was 35.8% and 66.7% for female children. This shows that anemia was more prevalent among female children than male children. This was similar to a the findings of a study undertaken in Brazil which found a higher prevalence of anemia among female children than in male in a hospital in Recife, Brazil [30]. Nevertheless, a study in Haiti showed a contrary result in which male children had a higher prevalence than female children [31]. There have been various reports on the association between anemia and gender [24,32]. Our study showed that females were more anemic than males, which might be attributed to growth, diet and menstruation. It has been reported that the onset of menstruation imposes additional iron needs on females, which may be challenging to meet with low consumption of iron-rich foods [32]. However, the high prevalence of anemia among females might not be due to the low consumption of iron-rich foods or menstruation alone since many study participants were below the age for onset of menstruation. Instead, it may be due to inadequate dietary intake and parasitic infections that The Federal Ministry of Health has identified as significant causes of iron deficiency anemia in Nigeria [33]. The finding from this study showed that overall ID among male children was 26.2% and IDA (55.9%) while the female children had ID of 87.5% and IDA of 78.1%.. This was contrary to the findings, regarding the burden of iron deficiency on African children [34]. The study reported that male infants were more iron deficient than female infants for each of the different measures of iron status. Other studies also reported similar findings [35-37]. Also, a study among school children in Morocco found that iron deficiency anemia was more prevalent among boys than girls [38]. Before developing anemia, the sequences of events leading to iron deficiency anemia includes iron depletion and iron deficiency [22]. Early detection of ID to prevent unwanted complications is vital since all these stages can lead to permanent problems, particularly growth and development [3,17,21]. ID and IDA were higher among females than males and children between 6-9 years old. Studies have shown that girls, particularly adolescent girls, are more prone to iron deficiency anemia because, unlike male children, they are more prone to iron loss [2,33]. The higher IDA and ID found among children aged 6-9 years in our study might be due to more subjects in this age group than those aged 10-12 years (105 vs 86). It may also be due to insufficient iron in mothers during pregnancy. We only assessed iron deficiency as a cause of anemia, while other factors such as malaria, helminthic infection, thalassemia trait, gastritis, and duodenitis were not considered. Although iron deficiency is the most common cause of anemia, other studies have significantly associated these factors with anemia [10-12,39-41].This study was conducted in the village among school children with low socioeconomic status. Studies have established that low socioeconomic condition is a risk factor for ID and IDA [7,12,21,33]. Since our research focuses on hemoglobin and iron ferritin as determinants of anemia in children, further studies can be conducted to determine other factors associated with anemia among primary school children. The limitation of this study was that other causes of anemia apart from iron deficiency were not assessed. Besides, the study was conducted in a rural area among children of low socioeconomic status only. Further studies may be needed to compare children of high socioeconomic status with that of low status or compare children aged 6-12 years and adolescents up to 18 years.   Acknowledgement Nil Authors’ contributions ANY: study conception and design; OLA and IO: definition of intellectual content; DYO, AAO and AOF: literature search and data collection; FOS and OBB: data and statistical analysis; BYA and MOD: manuscript preparation; TA, ZTG, IO and IC: experimental studies.   Competing interests The authors have declared that no competing interests exist.   Ethical consideration Written consent was obtained from the children, parents, teachers, or guardians. The research ethics committee also approved this research of the National Hospital, Abuja, Nigeria, with approval number NHA/PER/0412/V.1/137.   Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.   References 1.     World Health Organization. The Global Prevalence of Anaemia in 2011. Geneva: World Health Organization; 2015. 2.     Chaparro CM, Suchdev PS. Anemia epidemiology, pathophysiology, and etiology in low- and middle-income countries. Ann N Y Acad Sci. 2019; 1450(1): 15–31. 3.     Andriastuti M, Adiwidjaja M, Satari HI. Diagnosis of iron deficiency and iron deficiency anemia with reticulocyte hemoglobin content among children aged 6-18 years. Iran J Blood Cancer. 2019; 11(4): 127–132. 4.     Baker RD, Greer FR, Bhatia JJS, Abrams SA, Daniels SR, Schneider MB, et al. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics. 2010; 126(5): 1040–1050. 5.     Lopez A, Cacoub P, Macdougall IC, Peyrin-Biroulet L. Iron deficiency anaemia. Lancet. 2016; 387(10021): 907–916. 6.     Domellöf M, Braegger C, Campoy C, Colomb V, Decsi T, Fewtrell M, et al. Iron requirements of infants and toddlers. J Pediatr Gastroenterol Nutr. 2014; 58(1): 119–129. 7.     Rothman M, Faber M, Covic N, Matsungo TM, Cockeran M, Kvalsvig JD, et al. Infant development at the age of 6 months in relation to feeding practices, iron status, and growth in a peri-urban community of South Africa. Nutrients. 2018; 10(1): 73. 8.     Woldie H, Kebede Y, Tariku A. Factors associated with anemia among children aged 6-23 months attending growth monitoring at Tsitsika Health Center, Wag-Himra Zone, Northeast Ethiopia. J Nutr Metab. 2015; 2015. 9.     Ogunsakin RE, Babalola BT, Akinyemi O. Statistical modeling of determinants of anemia prevalence among children aged 6-59 months in Nigeria: a cross-sectional study. Anemia. 2020; 2020. 10. Ayogu RNB, Okafor AM, Ene-Obong HN. Iron status of school children (6-15 years) and associated factors in rural Nigeria. Food Nutr Res. 2015; 59(1): 26223. 11. Ughasoro MD, Emodi IJ, Okafor HU, Ibe BC. Prevalence and risk factors of anaemia in paediatric patients in South-East Nigeria. South African J Child Heal. 2015; 9(1): 14–17. 12. Akodu OS, Disu EA, Njokanma OF, Kehinde OA. Iron deficiency anaemia among apparently healthy pre-school children in Lagos, Nigeria. Afr Health Sci. 2016; 16(1): 61–68. 13. Khan AS, Shah SA. Iron deficient children and significance of serum ferritin. J Pak Med Assoc. 2005; 55(10): 420–423. 14. Oatley H, Borkhoff CM, Chen S, Macarthur C, Persaud N, Birken CS, et al. Screening for iron deficiency in early childhood using serum ferritin in the primary care setting. Pediatrics. 2018; 142(6): e20182095. 15. World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Geneva: World Health Organization; 2011. 16. Ahmad MS, Farooq H, Maham SN, Qayyum Z, Waheed A, Nasir W. Frequency of anemia and iron deficiency among children starting first year of school life and their association with weight and height. Anemia. 2018; 2018. 17. Kazmi A, Mansoor R, Almani MIK, Zafar H. Open access estimation of serum ferritin level to detect iron deficiency anemia in children less than 5 years of age. J Islam Med Dent Coll. 2017; 6(4): 259–262. 18. Özdemir N. Iron deficiency anemia from diagnosis to treatment in children. Turk Pediatr Ars. 2015; 50(1): 11–19. 19. Tamura T, Goldenberg RL, Hou J, Johnston KE, Cliver SP, Ramey SL, et al. Cord serum ferritin concentrations and mental and psychomotor development of children at five years of age. J Pediatr. 2002; 140(2): 165–170. 20. Jain M, Chandra S. Correlation between haematological and cognitive profile of anaemic and non anaemic school age girls. Curr Pediatr Res. 2012; 16(2): 145–149. 21. Andriastuti M, Ilmana G, Nawangwulan SA, Kosasih KA. Prevalence of anemia and iron profile among children and adolescent with low socioeconomic status. Int J Pediatr Adolesc Med. 2020; 7(2): 88–92. 22. World Health Organization. Serum ferritin concentrations for the assessment of iron status and iron deficiency in populations. Vitamin and Mineral Nutrition Information System. Geneva: World Health Organization; 2011. 23. Edomwonyi P, Walters SJ, Jacques R, Khatab K. Individual, household and area predictors of anaemia among children aged 6 – 59 months in Nigeria. Public Heal Pract. 2022; 3: 100229. 24. Chukwuka JO, Chukwuka UB. The prevalence of anaemia in rural primary school children in Ekwusigo local government area, Anambra state, Nigeria. Orient J Med. 2014; 26(3-4): 122–127. 25. Ekwochi U, Osuorah D, Odetunde O, Egbonu I, Ezechukwu C. Prevalence of iron deficiency anaemia in anaemic under-5 children in Enugu South East Nigeria. Niger J Paediatr. 2014; 41(2): 129-132. 26. Mainasara AS, Ibrahim KK, Uko EU, Jiya NM, Erhabor O, Umar A, et al. Prevalence of anaemia among children attending paediatrics department of UDUTH, Sokoto, North-western Nigeria. Int Blood Res  Rev. 2017; 7(1): 1–10. 27. Li Q, Liang F, Liang W, Shi W, Han Y. Prevalence of anemia and its associated risk factors among 6-months-old infants in Beijing. Front Pediatr. 2019; 7: 286. 28. Mujib ASM, Mahmud ASM, Halder M, Hasan CMM. Study of hematological parameters in children suffering from iron deficiency anaemia in Chattagram Maa-o-Shishu general hospital, Chittagong, Bangladesh. Anemia. 2014; 2014. 29. World Health Organization. Guideline: daily iron supplementation in infants and children. Geneva: World Health Organization; 2016. 30. dos Santos RF, Gonzalez ESC, de Albuquerque EC, Arruda IK, Diniz AD, Figueroa JN, et al. Prevalence of anemia in under five-year-old children in a children's hospital in Recife, Brazil. Rev Bras Hematol Hemoter. 2011; 33(2): 100–104. 31. Ayoya MA, Ngnie-Teta I, Séraphin MN, Ayoya MA, Ngnie-Teta I, Séraphin MN, et al. Prevalence and risk factors of anemia among children 6-59 months old in Haiti. Anemia. 2013; 2013. 32. Ayogu RNB, Nnam NM, Ibemesi O, Okechukwu F. Prevalence and factors associated with anthropometric failure, vitamin A and iron deficiency among adolescents in a Nigerian urban community. Afr Health Sci. 2016; 16(2): 389–398. 33. Vir SC, Kotecha PV. Iron deficiency and iron deficiency anemia in young children. In: Vir SC, editor. Public Health & Nutrition in Developing Countries. India: WPI Publishing; 2015; p638–662. 34. Muriuki JM, Mentzer AJ, Webb EL, Morovat A, Kimita W, Ndungu FM, et al. Estimating the burden of iron deficiency among African children. BMC Med. 2020; 18(1): 1–14. 35. Domellöf M, Lönnerdal B, Dewey KG, Cohen RJ, Landa Rivera L, Hernell O. Sex differences in iron status during infancy. Pediatrics. 2002; 110(3): 545–552. 36. Jaeggi T, Moretti D, Kvalsvig J, Holding PA, Tjalsma H, Kortman GA, et al. Iron status and systemic inflammation, but not gut inflammation, strongly predict gender-specific concentrations of serum hepcidin in infants in rural Kenya. PLoS One. 2013; 8(2): e57513. 37. Ziegler EE, Nelson SE, Jeter JM. Iron stores of breastfed infants during the first year of life. Nutrients. 2014; 6(5): 2023–2034. 38. Achouri I, Aboussaleh Y, Sbaibi R, Ahami A, Hioui ME. Prevalence of iron deficiency anaemia among school children in Kenitra, Northwest of Morocco. Pakistan J Biol Sci. 2015; 18(4): 191–195. 39. Nambiema A, Robert A, Yaya I. Prevalence and risk factors of anemia in children aged from 6 to 59 months in Togo: analysis from Togo demographic and health survey data, 2013–2014. BMC Public Health. 2019; 19(1): 1–9. 40. National Beareu of Statistics (NBS). National Nutrition and health Survey. Nigeria: National Beareu of Statistics; 2018. 161 p. 41. Husna N, Arif A Al, Putri C, Leonard E, Handayani NSN. Prevalence and distribution of thalassemia trait screening. J Med Sci. 2017; 49(3): 106–113.     Cite this article as: Yashim AN,  Obazee DY, Dada MO, Oyewande AA, Alabi BY, Faith AO, Conteh I, Sanni FO, Abiodun OP, Bartholomew OB, Adaran T, Gwa ZT, Afelumo OL, Okwose I. Assessment of anemia among rural children in Kaduna State, Nigeria by determining hemoglobin and serum ferritin levels. IMC J Med Sci. 2023. 17(1): 006. DOI:https://doi.org/10.55010/imcjms.17.006 <![CDATA[Effect of smoking on vital hemodynamic parameters and lipid profile of young smokers]]> Bhupendra Kumar Jain Ashwin Songara U Maheshwar Chandrakantham Jyoti Nagwanshi https://imcjms.com/journal_full_text/436 2022-11-21 12:25:58 Original Article IMC J Med Sci. 2023. 17(1): 007 Abstract Background and objectives: Tobacco use is associated with cardiovascular, respiratory and peripheral vascular diseases. The short term effects of tobacco smoking on vital hemodynamic parameters and lipid profile of young smoker with increased quantity of smoking is still debatable. The objective of this study was to evaluate the effect of smoking on vital hemodynamic parameters and lipid profile of young smokers. Materials and methods: The current study was an observational cross sectional study conducted in a tertiary care hospital over a period of 18 months and included smokers and non-smokers. Data on vital hemodynamic parameters like blood pressure, heart rate, oxygen saturation (SPO2) and lipid profile were collected. Chi-square and analysis of variance (ANOVA) tests were used to analyze the data. Results: A total of 80 smokers and 80 non-smokers were enrolled in the study. Blood pressure, heart rate and mean SpO2 were significantly (p<0.001) lower in non-smokers compared to smokers. Breath holding time (BHT) and single breath count (SBC) were higher in non-smokers. Mean values of total cholesterol (T-chol), low density lipoprotein (LDL) and triglyceride (TG) were significantly (p<0.001) higher in smokers than non-smokers, while high density lipoprotein (HDL) was significantly low in smokers. SBP, T -chol and TG significantly (p<0.05) increased as the quantity of smoking increased. Conclusion: Smoking is associated with derangement of vital hemodynamic parameters and lipid profile across the age. Anti-smoking campaign should be organized to discourage both personal smoking and smoking in public places. IMC J Med Sci. 2023. 17(1): 007. DOI : https://doi.org/10.55010/imcjms.17.007 *Correspondence: Bhupendra Kumar Jain, Department of Pulmonary Medicine, School of Chhindwara Institute Of Medical Sciences, Jabalpur Medical University, Chhindwara, Madhya Pradesh, India. Email: drbhupendrakjain@gmail.com   Introduction The tobacco epidemic is one of the biggest public health issue that the world that has ever faced. It kills about 8 million people each year around the world [1]. Over 80% of the 1.3 billion tobacco users worldwide live in low- and middle-income countries. Cigarette smoking is the most common form of tobacco use worldwide. .Smoking is causally associated with lower body mass index (BMI), higher level of adiposity and is strongly associated with elevated blood pressure and is also considered a major risk factor for cardiovascular diseases [2-4]. Smoking tobacco is linked to early onset atherosclerosis, increased risk of acute myocardial infarction (AMI), stroke, peripheral artery disease, aortic aneurysm and sudden death [5,6]. The main objective of this study was to evaluate cumulative effect of smoking on vital hemodynamic parameter and lipid profile of young smokers.   Material and methods The current study was an observational cross sectional study conducted at the Department of Respiratory Medicine and Medicine at Sri Aurobindo Medical College and Postgraduate Institute, Indore over a period of 18 months from January 2015 to June 2016. All protocols and procedures were approved by the institutional ethics and scientific committee. Written informed consent was obtained from all participants. The study included non-smokers and smokers. Inclusion criteria of smokers for enrollment in the study were informed and willing young smokers with no prior history of any chronic disease, age between 20-50 years, body mass index (BMI) of 18-25 kg/m2 and smoking history of 1-20 pack years. Non-smoker persons attending executive health checkup for yearly routine self-care were enrolled as non-smoker control group. Individuals with comorbidities like diabetes mellitus, hypertension, coronary artery disease or other systemic illness, smoker for > 20 pack year, smoker less than 20 years of age or more than 50 years of age, and alcohol dependence were excluded from study. Both smoker and non-smoker were divided into two age groups namely 20 to 35 years (Group-1) and 36 to 50 years (Group-2). Smokers were divided into 4 groups according to the number of pack years (py) they used to smoke. Groups were: group-A (1-5 spy), group-B (5-10 spy), group-C (10-15 spy) and group-D (15-20 spy). The study tools used for collecting data were history, physical examination, body mass index, pulmonary function test, vital hemodynamic parameter measurements like - blood pressure, pulse rate, oxygen saturation (SPO2) and lipid profile. Weight (kg) of the participants was measured with a calibrated electronic scale and standing height (cm) was measured with a fixed stadiometer. Blood pressure (systolic and diastolic) was measured using a standard mercury sphygmomanometer in the right arm in a sitting position. Resting heart rate (HR) and percentage oxygen saturation (% SpO2) were measured by a pulse oximeter type SMART CARE model SC 500 B. All the individuals were first explained and demonstrated the methods to perform BHT and SBC. The breath-holding test was carried out as described previously [7]. Individuals were asked to inspire deeply and to stop breathing at the end of inspiration. The counting of the duration of the breath-holding was made by a stopwatch from the beginning of the inspiration to the appearance of reflex contractions of the diaphragm. Single breath count (SBC) was the measurement of how far an individual could count in a normal speaking voice after a maximal effort inhalation [8]. The smoking was quantified by pack-year. It is a unit for measuring the amount a person has smoked over a long period of time. It was calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person smoking. Lipid profile data were collected from the Pathology Laboratory of SAMC and PG Institute. Kit method was used for the estimation of lipids. The means and standard deviations for the linear groups were calculated and compared using Chi square test. The means across more than two groups were compared using the Analysis of Variance (ANOVA) and p value <0.05 is statistically significant.   Result A total of 80 smokers and 80 non-smokers were enrolled in the study. Table-1 shows the general characteristics of smokers and non smokers. Age, height, weight and BMI of smokers were not significantly different from that of and non-smokers. Among the smokers, there were 42 (52.5%) and 38 (47.5%) individuals belonged to 20-35 years (Group-1) and 36-50 years (Group-2) age groups respectively while it was 43 (53.75%) and 37 (46.25%) individuals among the non-smokers. Detail age-group specific general characteristics of the enrolled study population are shown in Table-2. The mean weight of smokers aged 36-50 years was significantly (p<0.05) more compared to other groups while there was no differences in other variables. Quantity of smoking was significantly (p=0.0004) more among the individuals aged 36-50 years compared to that of 20-35 years.   Table-1: General characteristics of the total study population (N=160)     Table-2: Age group specific general characteristics of the study population (N=160)     Table-3 shows the difference in the hemodynamic and lipid parameters of smokers and non-smokers. Blood pressure, heart rate and mean SpO2 in non-smokers were significantly (p<0.001) lower than that of smokers. Also, the breath holding time and single breath count were higher in non-smokers. Mean values of T-chol, LDL and TG were significantly (p<0.001) higher in smokers than non-smokers, while HDL was significantly low in smokers compared to non-smokers (40.28±6.79 vs. 45.17±6.84 mg/dl).   Table-3: Hemodynamic parameters and lipid profile of smokers and non smokers     Table-4 shows the age-group specific hemodynamic and lipid profiles of smokers and non-smokers study participants. SBP was significantly higher in smokers of both age groups compared to non-smokers. Smokers of age group 36-50 years had also significantly higher SBP compared to smokers of 20-35 years age group indicating that both smoking and increasing age was a risk factor for increased systolic blood pressure. Diastolic blood pressure was almost same in smokers of both age groups. Baseline heart rate was same in smokers while more in case of non-smokers of age group-2 when compared with non-smokers of group-1. Mean SpO2 had least value in smokers of age group-2 indicating decrease in mean SpO2 value with increase in duration and intensity of smoking. There was statistically significant difference (p= 0.03) in breath holding time of smokers in two age groups. BHT was almost same for non-smokers of both groups while it was least for smokers in age group-2 which could be due to increased age as well as increased number of pack years of smoking. Smokers of both age groups had significantly low SBC compared to non-smokers of both groups. The mean values of T-chol, LDL and TG were significantly high in smokers than age matched controls of non-smoker group. The mean values of T-chol, LDL and TG were higher in smokers of age group 36-50 years. HDL was significantly higher in non-smokers compared to smokers of both age groups.   Table-4: Age group specific hemodynamic and lipid profiles of smokers and non smokers (N=160)     The Table-5 shows the comparison of hemodynamic and lipid profile according to the quantity of smoking in terms of number of pack year. ANOVA test revealed that as the number of pack years increases, the mean value of SBP, T -chol and TG significantly (p<0.05) increased while the mean value of HDL decreased. There was no significant (p=0.355)difference in LDL with increase in pack years of smoking.Table-5: Hemodynamic and lipid profiles of smokers according to the quantity of smoking (n=80)   Discussion Cigarette smoking produces a chronic inflammatory state that contributes to the atherogenic disease processes and elevates the levels of biomarkers of inflammation [9,10,]. In our study, there was no significant difference in the mean anthropometric parameters like age, height, weight, body mass index the smokers and non-smokers. Cigarette smokers in our study usually smoked non-filter cigarettes which are cheap and easily available. In our study, the blood pressure and heart rate was higher in smokers than in non-smokers. The rise in blood pressure could be due to an increase in cardiac output and total peripheral vascular resistance [10]. Cigarette smoking has an acute hypertensive effect mediated by the stimulation of the sympathetic nervous system [11]. Saladini et al. investigated the effect of smoking on peripheral and central blood pressure in a group of young stage I hypertensive individuals [12]. Central systolic blood pressure and pulse pressure were higher in smokers than in non-smokers, thus implying a predominant effect of smoking on central blood pressure. Also, other studies reported significantly higher blood pressure and heart rates in smokers compared to non-smokers [12-14]. However, Saafan A Al-Safi reported that smoking had statistically non-significant effects on heart rate in females while heart rate values were significantly higher in male smokers than in non-smokers [14]. In our study, we have found that as the number of pack years of smoking increases, systolic blood pressure increases, while there were very minimal changes in diastolic blood pressure and even DBP is lesser for heavy smokers group like group C and D. We found increased heart rate and decreased SpO2 with increase in number of pack years. We have found that severity of smoking decreases the baseline SpO2 value in smokers despite of the group to which they belong. On the contrary, Chandra et al reported no significant difference in pulse oximetric (SpO2) values in subjects with a smoking history of <10 pack years compared to subjects with a smoking history of >10 pack years (p>0.05) [15]. It has been suggested that smoking, even of short duration and moderate consumption of cigarettes, is associated with adverse lipoprotein profiles [16]. In our study, mean values of T-chol, LDL and TGs were significantly (p<0.05) higher in smokers than non-smokers, while HDL was lower in smokers indicating derangement of lipid profiles in smokers. Duration and intensity of smoking are correlated with lipid profile. In our study we found that as the smoking pack years increases, mean value of T-chol, LDL and TG increases while that of HDL decreases. The difference was found to be statistically significant. Almost similar results were observed by other authors for cholesterol and triglycerides in smokers. Meenakshisundaram et al. [17] in their study on 274 asymptomatic male smokers showed that number of smoking pack years was directly proportional to the derangements in lipid profile variables. Previous studies by Neki [18] and Venkatesan et al [19] have demonstrated a rise in T-chol, TG, LDL and Apo-B, and a fall in HDL and Apo-A in smokers; and this association was dose dependent. Serum HDL concentration has an inverse relationship with smoking. In our study, serum HDL gradually decreased as the duration and intensity of smoking increased from group A to Group D, thus increasing atherogenic risk. Maximum prevalence of dyslipidemia was found in higher age smokers (age group-2). Though the mean values were within normal range for both smokers and non-smokers but they were close to upper reference range in smokers. It was also affected by number of cigarettes smoked. Amongst the two groups of smokers based on age, the smokers of higher age group had higher values of T-chol, TG and LDL, while lower values of HDL. Thus, the present study shows that smoking has an adverse effect on lipid profile and vital hemodynamic parameters of young smokers. Smoking induces hypertension and reduces lung oxygenation capacity. Therefore, young individuals should be strongly advised to stop smoking and policy makers should take necessary measures to prohibit smoking.   Authors’ contributions BKJ: study conception, design, literature search, manuscript preparation, editing and review; AS: study conception, design, literature search, data collection, data analysis, manuscript preparation, editing and review; UMC and JN: study conception, design, manuscript preparation, editing and review.   Conflict of Interest: Nothing to declare.   Fund: None   References 2.     Freathy RM, Kazeem GR, Morris RW, Johnson PC, Paternoster L, Ebrahim S, et al. Genetic variation at CHRNA5-CHRNA3-CHRNB4 interacts with smoking status to influence body mass index. Int J Epidemiol. 2011; 40: 1617–1628. 4.     Seven E, Husemoen LL, Wachtell K, Ibsen H, Linneberg A, Jeppesen JL. Five-year weight changes associate with blood pressure alterations independent of changes in serum insulin. J Hypertens. 2014; 32(11): 2231–2237. 6.     Frey PF, Ganz P, Hsue PY, Benowitz NL, Glantz SA, Balmes JR, et al. The exposure-dependent effects of aged second hand smoke on endothelial function. J Am Coll Cardiol. 2012; 59: 1908-1913. 8.     Bartfield JM, Ushkow BS, Rosen JM, Dylong K. Single breathcounting in the assessment of pulmonary function. Ann Emerg Med. 1994; 24: 256–259. 10.  Cryer PE, Haymond MW, Santiago JV, Shah SD. Norepinephrine and epinephrine release and adrenergic mediation of smoking-associated hemodynamic and metabolic events. N Engl J Med. 1976; 295(11): 573–577. 12.  Saladini F, Benetti E, Fania C, Mos L, Casiglia E, Palatini P. Effects of smoking on central blood pressure and pressure amplification in hypertension of the young. Vasc Med. 2016; 21(5): 422-428. 14.  Al-Safi SA. Does smoking affect blood pressure and heart rate? Eur J Cardiovasc Nurs 2005; 4: 286-9. 16.  Raftopoulos CBM, Steinbeck KS: Coronary heart disease risk factors in male adolescents with particular reference to smoking and blood lipids. J Adolesc Health. 1999; 25(1): 68-74. 18.  Neki NS. Lipid profile in chronic smokers - a clinical study. JIACM. 2002; 3: 51-54.   <![CDATA[Fosfomycin susceptibility among Escherichia coli causing urinary tract infection in a tertiary care centre in Western Maharashtra]]> Yash Lohariwal Nikunja Kumar Das Shahzad Mirza Nageswari Gandham Rajashri Patil Sahjid Mukhida Heer Shah Sameena Khan https://imcjms.com/journal_full_text/437 2022-12-03 12:11:04 Original Article IMC J Med Sci. 2023; 17(1): 008 Abstract Background and objective: Urinary tract infection(UTI) is one of the most common bacterial infections encountered in clinical practice. UTIs caused by extended-spectrum beta-lactamase (ESBL) AmpC and metallo-beta-lactamase (MBL) producing Escherichia coli (E. coli) are difficult to treat. Fosfomycin is an old antibiotic that has excellent bactericidal activity against a wide range of bacteria. This study aimed to determine the fosfomycin susceptibility of E. coli causing UTI  in a tertiary care hospital in Western Maharashtra, India. Material and methods: The study was conducted at a tertiary care center in Pune, a city of Western Maharashtra, India. Urine samples from UTI cases yielding significant (> 1x 105 cfu/ml) growth of E. coli were included in study. E. coli isolates were tested for susceptibility to fosfomycin and a panel of antimicrobial agents by Kirby Bauer disc diffusion method. All the isolates were tested for production of ESBL, AmpC and MBL. Result: A total of 88 E. coli were isolated of which, 47 (53.40%) and 41 (46.59%) were from male and female patients respectively. Of the total E. coli isolates, 58 (65.9%) were from in-patient cases. Multi-drug resistance was found in 69 (78.40%) isolates and remaining 19 (21.6%) were resistant to different antimicrobials tested. All (100%) the MDR and non-MDR isolates were sensitive to fosfomycin. Highest resistance was present against nalidixic acid (93.8%) while resistance was least against nitrofurantoin (15.91%), piperacillin/tazobactam (17.1%) and meropenem (18.18%). Of the total, 35 (50.72%) isolates were both AmpC and ESBL producers while 11 (15.94%) and 8 (11.59%) were only AmpC and ESBL producers respectively. MBL was positive in 15 (21.73%) of E. coli isolates. All those isolates tested sensitive to fosfomycin. Conclusion: The study revealed that fosfomycin had excellent activity against MDR E. coli causing UTI in our area. IMC J Med Sci. 2023; 17(1): 008. DOI: https://doi.org/10.55010/imcjms.17.008 *Correspondence: Dr. Sameena Khan, Department of Microbiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India. E-mail: sameenak27@gmail.com   Introduction Urinary tract infection(UTI) is a common bacterial infection of urinary system and requires antibiotics for treatment [1]. Beta-lactams, co-trimoxazole, fluoroquinolones and other antimicrobial agents have been used for many years in the treatment of UTI. But UTI caused by emerging multi-drug resistant and extended-spectrum beta-lactamases (ESBLs), AmpC and metallo-beta-lactamase (MBL) producing organisms has made treatment of UTI difficult and expensive. Fosfomycin is an old bactericidal agent which has a good in vivo and in vitro activity against a wide range of bacteria and thus making it a good option for the treatment of UTI [2-4]. Fosfomycin also shows very good activity in penetrating biofilms of Gram-negative bacteria in monotherapy as well as in combined therapy and has very good eradication activity [5]. The main mechanism by which fosfomycin acts is by irreversibly inhibiting the bacterial cell wall biosynthesis. After entering into cytoplasm of bacteria, fosfomycin binds with MurA enzyme and inhibits peptidoglycan biosynthesis [3,6]. Apart from being effective, fosfomycin formulations have less adverse effects than other antimicrobial agents. Mild gastro intestinal distress is the most commonly reported adverse effect [7]. Therefore, this study was undertaken to assess the fosfomycin susceptibility of Escherichia coli causing UTI in a tertiary care center in Western Maharashtra, India. Results of the study would help in guiding treatment of UTIs due to sensitive as well as multi-drug resistant (MDR) pathogens.   Material and Methods The study was carried out at a tertiary care center based in Pune, a city of Western Maharashtra, India. It was approved by the Institutional Ethical Sub-committee (Letter number: IESC/30/2022 dated: 17 February 2022). Urine samples from in and out patient departments having clinical features of UTI were collected and included in the study. Samples yielding significant (> 1x 105 cfu/ml) [8] growth of E. coli were included in study for further analysis. Any urine sample which yielded a non-significant count and organisms other than E. coli was excluded from the study. Relevant patient-related demographic information was collected in a pre-designed data sheet. Standard procedures were followed for the collection, transport, processing, and culture of the urine samples. Samples once collected were sent to the laboratory immediately. From urine container, 0.01ml urine sample was inoculated immediately on a Cysteine Lactose Electrolyte Deficient (CLED)  agar plate with the help of a calibrated double loop inoculator (Himedia, India). Plates were then incubated for 18-24 hours in an incubator at 37ºC. E. coli was identified by motility, sugar fermentation, methyl red, Voges Proskeuer, indole, citrate, urease, hydrogen sulfide formation, and oxidase tests [9]. E. coli isolates were tested for antibiotic susceptibility by Kirby Bauer disc diffusion method. Antibiotic discs used were gentamicin-10µg, amikacin-30µg, ampicillin-10µg, amoxicillin/clavulanic acid-20/10µg, ceftazidime-30µg, ceftriaxone-30µg, meropenem-10µg, piperacillin/tazobactam-100/10µg, nalidixic acid-30µg, norfloxacin-10µg, co-trimoxazole- 1.25/ 23.75µ, nitrofurantoin-300µg and fosfomycin-200 µg. The result was interpreted according to CLSI 2021 guidelines. For fosfomycin, the inhibition zone of >16mm, 13-15mm and <12mm was interpreted as sensitive, intermediate sensitive and resistant respectively according to CLSI 2021 guideline [10]. MDR was defined as resistance to a minimum one drug of three or more groups of antibiotics [11]. ESBL production in E. coli was detected by double disc synergy test (DDST) as described earlier [12]. Mueller Hinton agar was inoculated with standardized inoculums (corresponding to 0.5 McFarland tube) of test organism. An amoxicillin/clavulanic acid disc 20/10 μg was placed in the center of the plate and test discs of 3rd generation cephalosporins (ceftazidime- CAZ 30μg, ceftriaxone-CRO 30μg, cefotaxime-CTX 30μg) discs were placed at 20 mm distance (center to center) from the amoxicillin-clavulanic acid disc. The plate was incubated overnight at 35°C. Enhancement of the zone of inhibition of any one of the three drug discs toward amoxicillin-clavulanic acid suggested the presence of ESBLs. AmpC producers were detected by the cefoxitin-oxacillin disk diffusion test [13]. MBL detection was done by a combined disc test, in which imipenem and imipenem plus EDTA disc was used [14].   Results During the study period, 88 E. coli were isolated. Out of them, 47 (53.40%) were from male patients and 41 (46.59%) were from female patients. Of the total samples, 30 (34.1%), 26 (29.55%) and 25 (28.41%) were from patients above 60, 18-40 and 41-60 years age group respectively. Out of 88 E. coli isolates, 58 (65.9%) were from in-patient cases (Table-1). Out of 58 urine samples from in-patient departments, only 4 were from intensive care unit (ICU).   Table-1: Distribution of gender, age and source of study cases (N=88)     Susceptibility of isolated E. coli to different antimicrobial agents is shown in Table-2. Highest resistance of E. coli was noted against nalidixic acid (93.8%) followed by ampicillin (81.82%), cephalosporins (77.27%) and norfloxacin (72.73%). Rate of resistance was low for nitrofurantoin (15.91%), piperacillin/tazobactam (17.05%), meropenem (18.18%), amoxycillin+ clavulanic acid (25%) and amikacin (23.86%). All the 88 (100%) isolated E. coli was sensitive to fosfomycin. Out of total E. coli, 78.4% was MDR strains.   Table-2: Susceptibility of isolated E. coli to fosfomycin and other antimicrobial agents (N=88)     Table-3 shows that out of 88 E. coli tested, 35 (39.8%) isolates were both AmpC and ESBLs producers, while 11 (12.5%) and 8 (9.1%) were only ESBL and AmpC producers respectively. MBL was positive in 15 (17%) E. coli isolates. All 69 ESBL, AmpC and MBL positive E. coli isolates were sensitive to fosfomycin.   Table-3: Distribution of ESBL, AmpC and MBL positive E. coli and their susceptibility to fosfomycin     Discussion Urinary tract infection is a common problem in clinical practice. The study was conducted in a tertiary care setting in western Maharashtra, India to find out the prevalence of fosfomycin resistance among E. coli isolated from patients with UTI. UTI caused by a multi-drug resistant strain pose a serious challenge for the physician and also is a burden on the patient. Multidrug-resistant (MDR) isolates have emerged worldwide with the widespread use of cephalosporins and fluoroquinolones [15,16]. As a result, use of carbapenems has increased over the last 20 years, resulting into dramatic spread of carbapenem resistance [17,18]. Fosfomycin, discovered more than 40 years ago, is active against a wide range of organisms, including MDR Enterobacteriaceae [3,19,20]. Studies with fosfomycin are limited though, it is available for intravenous and oral use [19,21]. Recently, it has been shown to be non-inferior to piperacillin-tazobactam for the treatment of complicated urinary tract infections [22]. It is also been shown non-inferior to comparators for the treatment of bacteremic urinary tract infections due to MDR E coli [23]. In our study, a total of 88 isolates of E. coli were collected and analyzed. The majority of the urine samples were from male patients. Most isolates of E. coli were from UTI cases aged 60 and above and were from hospitalized patients (61%). About 78.4% of our E. coli isolates were MDR strains and positive for ESBL, AmpC or MBL. Niranjan et al found 38% of his E. coli isolates from UTIs were from in-patients and 76.5% of the isolates were MDR [24]. Hasan et al found 53% of E. coli from UTI cases as MDR strains [25]. Paul et al from Assam, India reported 26.2% ESBL and 12.6% carbapenemase producing E. coli from UTI cases [26]. All our E. coli isolates tested were sensitive to fosfomycin (100%). There was no difference in fosfomycin sensitivity between sensitive and MDR strains. Similar to our findings, Sabharwal et al in their study found 97% sensitivity to fosfomycin in E. coli isolated from UTI cases [27]. Our study has demonstrated that fosfomycin has excellent activity against MDR E. coli causing UTI in our area. Thus, the finding would help in formulating antibiotic treatment guideline for UTIs due to multi-resistant E. coli. However, our study had some limitations. This study was conducted only for a short period of time with 88 E. coli isolates at a single center and minimum inhibitory concentration (MIC) of fosfomycin for those was not determined. Hence, multicenter studies with large sample size would provide a better perspective of the resistance pattern of uropathogenic E. coli to fosfomycin and other drugs in western part of Maharashtra.   Acknowledgement The authors would also like to acknowledge the contributions of staff and laboratory personnel of the Department of Microbiology, Dr. D.Y. Patil Medical College, hospital and research center, Pimpri, Pune.   Conflict of interest: The authors have no conflict of interests to declare.   Fund: None   References 1.     Bono MJ, Leslie SW, Reygaert WC. Urinary tract infection. [Updated 2022 Jun 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470195/ 2.     Maraki S, Samonis G, Rafailid is PI, Vouloumanou EK, Mavromanolakis E, Falagas ME. Susceptibility of urinary tract bacteria to fosfomycin. Antimicrob Agents Chemother. 2009; 53(10): 4508-4510. 3.     Dijkmans AC, Zacarías NVO, Burggraaf J, Mouton JW, Wilms EB, van Nieuwkoop C, et al. Fosfomycin: Pharmacological, Clinical and Future Perspectives. Antibiotics (Basel). 2017 Oct 31; 6(4): 24. 4.     Sreenivasan S, Kali A, Pravin Charles MV, Kunigal S. Evaluation of in vitro susceptibility of fosfomycin among Enterobacteriaceae isolates from urine cultures: A study from Puducherry. J Lab physicians. 2019; 11(3): 249-252. 5.     Ruiz Ramos J, Salavert Lletí M. Fosfomycin in infections caused by multidrug-resistant Gram-negative pathogens. Rev Esp QuiMioter. 2019; 32(Suppl 1): 45-54. 6.     Brown ED, Vivas EI, Walsh CT, Kolter R. MurA (MurZ), the enzyme that catalyzes the first committed step in peptidoglycan biosynthesis, is essential in Escherichia coli. J Bacteriol. 1995; 177(14): 4194-7. 7.     Reffert JL, Smith WJ. Fosfomycin for the treatment of resistant Gram-negative bacterial infections. Insights from the society of infectious diseases pharmacists. Pharmacotherapy. 2014; 34(8): 845-857. 8.     Collee JG, Duguid JP Fraser AG, Marmion BP, Simmons A. Laboratory strategy in the diagnosis of infective syndromes. In: Collee JG, Fraser AG, Marmion BP, Simmons A, editors. Mackie & McCartney Practical Medical Microbiology. 14th ed. India; Churchill Livingstone: 2011. 9.     Winn, W., Allen, S., Janda, W., Koneman, E., Procop, G., Schreckenberger, P. and Woods, G. Koneman’s Color Atlas and Textbook of Diagnostic Microbiology. 7th Edition, Lippincott Williams and Wilkins, New York. 2016; Page 225-255. 10.  CLSI, Performance standards for antimicrobial susceptibility testing; 31st edition. CLSI Supplement M100. Clinical Laboratory Standard Institute 2021. 11.  Magiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect. 2012; 18(3): 268-281. 12.  Banerjee S, Sengupta M, Sarker TS. Fosfomycin susceptibility among multidrug-resistant, extended-spectrum beta-lactamase-producing, carbapenem-resistant uropathogens. Indian J Urol.2017; 33(2): 149-54. 13.  Gopichand P, Agarwal G, Natarajan M, Mandal J, Deepanjali S, Parameswaran S, Dorairajan LN. In vitro effect of fosfomycin on multi-drug resistant gram-negative bacteria causing urinary tract infections. Infect Drug Resist. 2019 Jul 9; 12: 2005-2013. 14.  Das NK, Grover N, Sriram R, Kumar M, Dudhat VL, Sarangan P. Prevalence of carbapenem resistance and comparison between different phenotypic methods for detection of metallo-beta-lactamases in Gram-negative non-fermentative bacteria in the acute wards of a tertiary care centre. Int J Curr Microbiol Appl Sci. 2016; 5(5): 109-119. 15.  Rodríguez-Baño J, Pascual A. Clinical significance of extended-spectrum beta-lactamases. Expert Rev Anti Infect Ther. 2008; 6(5): 671-683. 16.  Holland MS, Nobrega D, Peirano G, Naugler C, Church DL, Pitout JDD. Molecular epidemiology of Escherichia coli causing bloodstream infections in a centralized Canadian region: a population-based surveillance study. Clin Microbiol Infect. 2020; 26(11): 1554.e1-1554.e8. 17.  Klein EY, Van Boeckel TP, Martinez EM, et al. Global increase and geographic convergence in antibiotic consumption between 2000 and 2015. Proc Natl Acad Sci U S A. 2018; 115(15): E3463-E3470. 18.  Tzouvelekis LS, Markogiannakis A, Psichogiou M, Tassios PT, Daikos GL. Carbapenemases in Klebsiella pneumoniae and other Enterobacteriaceae: an evolving crisis of global dimensions. Clin Microbiol Rev. 2012; 25(4): 682-707. 19.  Falagas ME, Vouloumanou EK, Samonis G, Vardakas KZ. Fosfomycin. Clin Microbiol Rev. 2016; 29(2): 321-347. 20.  Falagas ME, Kastoris AC, Kapaskelis AM, Karageorgopoulos DE. Fosfomycin for the treatment of multidrug-resistant, including extended-spectrum beta-lactamase producing, Enterobacteriaceae infections: a systematic review. Lancet Infect Dis. 2010; 10(1): 43-50. 21.  Grabein B, Graninger W, Rodríguez Baño J, Dinh A, Liesenfeld DB. Intravenous fosfomycin-back to the future: systematic review and meta-analysis of the clinical literature. Clin Microbiol Infect. 2017; 23(6): 363-372. 22.  Kaye KS, Rice LB, Dane AL, et al. Fosfomycin for injection (ZTI-01) versus piperacillin-tazobactam for the treatment of complicated urinary tract infection including acute pyelonephritis: ZEUS, a phase 2/3 randomized trial. Clin Infect Dis. 2019; 69(12): 2045-2056. 23.  Sojo-Dorado J, López-Hernández I , Rosso-Fernandez C, Morales IM, Palacios-Baena ZR, Hernández-Torres A, et al. Effectiveness of fosfomycin for multidrug-resistant urinary tract infections from E coli. JAMA Network Open. 2022; 5(1): e2137277. 24.  Niranjan V, Malini A. Antimicrobial resistance pattern in Escherichia coli causing urinary tract infection among inpatients. Indian J Med Res. 2014; 139(6): 945-8. 25.  Hasan AS, Nair D, Kaur J, Baweja G, Deb M, Aggarwal P. Resistance patterns of urinary isolates in a tertiary Indian hospital. J Ayub Med Coll Abbottabad. 2007; 19: 39–41.  26. Paul D, Anto N, Bhardwaj M, Prendiville A, Elangovan R, Bachmann TT, et al. Antimicrobial resistance in patients with suspected urinary tract infections in primary care in Assam, India. JAC-Antimicrobial Resistance. 2021; 3(4): dlab164. 27.  Sabharwal ER, Sharma R. Fosfomycin: an alternative therapy for the treatment of UTI amidst escalating antimicrobial resistance. J Clin Diagn Res. 2015; 9(12): DC06-9.     Cite this article as: Lohariwal Y, Das NK, Mirza S, Gandham N, Patil R, Mukhida, S, et al. Fosfomycin susceptibility among Escherichia coli causing urinary tract infection in a tertiary care centre in Western Maharashtra. IMC J Med Sci. 2023; 17(1): 008. DOI: https://doi.org/10.55010/imcjms.17.008 <![CDATA[Antibody response to receptor-binding domain of SARS-CoV-2 spike protein following vaccination and natural infection with SARS-CoV-2]]> Fahmida Rahman Sraboni Mazumder Saika Farook Paroma Deb Supti Prava Saha Farjana Akter Md Shariful Alam Jilani Jalaluddin Ashraful Haq https://imcjms.com/journal_full_text/438 2022-12-07 12:38:07 Original Article IMC J Med Sci. 2023; 17(1): 009 Abstract Background and objectives: Antibody to SARS-CoV-2 develops both after natural infection with SARS-CoV-2 and vaccination. This study was undertaken to determine the antibody response to SARS-CoV-2 among population after natural SARS-CoV-2 infection and vaccination. Material and methods: The study was carried out on adults aged 18 years and above. Study population consisted of four groups. Group-1 (control): healthy and history of no prior SARS-CoV-2 infection and vaccination, Group-2: had past SARS-CoV-2 infection and no vaccination, Group-3: received two doses of recombinant adenoviral vector vaccine ChAdOx1 (Oxford–AstraZeneca) without past SARS-CoV-2 infection, and Group-4: had past SARS-CoV-2 infection and received 2 doses of ChAdOx1 vaccination. Blood was collected 1 and 7 months after the second dose of vaccination from Group-3 and 4 individuals. Single blood sample was collected from participants of Gr-1 and 2 at the time of enrolment. Immunoglobulin G (IgG) antibodies to receptor-binding domain (RBD) of SARS-CoV-2 spike protein S1 (anti-RBDS1 IgG) was determined in serum by ELISA method. Results: Total 176 participants aged 18 years and above were enrolled. Anti-RBDS1 IgG positivity rates were 51.9%, 66.7%, 96.8% and 100% in individuals of Group-1, 2, 3 and 4 respectively. Gr-4 had significantly (p < 0.05) mean higher anti-RBDS1 IgG antibody level (120.8 ± 31.9 DU/ml) compared to other groups 1 month after 2nd dose of vaccination. No significant differences in antibody response were found among the individuals of four groups across gender and comorbidities. Seven months after the 2nd dose of vaccines, the antibody concentration declined in 85.3% (112.1 ± 30.4 DU/ml to 75.9 ± 48.7 DU/ml) and 81.5% (127.3 ± 20.4 DU/ml to 92.5 ± 43.6 DU/ml) individuals of Group-3 and Group-4 respectively. Decline of antibody was 40.6% and 34.7% in 7 months, but all remained positive except 1 in Group-3. Fever (34.4%) and headache (24.8%) were the most common adverse effects noted after vaccination. Conclusion: The study revealed that ChAdOx1 nCoV-19 vaccine induces high concentration of persisting anti-RBDS1 IgG antibody after 2nd dose and previous infection with SARS-CoV-2 acts as immune priming. Therefore, antibody screening test prior to booster dose could be a good option to maximize coverage of vaccination. IMC J Med Sci. 2023; 17(1): 009. DOI: https://doi.org/10.55010/imcjms.17.009 *Correspondence: J. Ashraful Haq, Department of Microbiology, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka, Bangladesh. Email: jahaq54@yahoo.com   Introduction The world is currently facing pandemic due to severe acute respiratory syndrome corona virus–2 (SARS-CoV-2) since its origin in December, 2019 in Wuhan, China [1]. As of 3rd May, 2022, around 511,965,711 cases and 6,240,619 deaths have been recorded around the world [2]. Development of immunity to SARS-CoV-2 is important for the containment of the disease. Antibody to SARS-CoV-2 develops both after natural SARS-CoV-2 infection and vaccination. Several studies have reported that almost 100% of naturally SARS-CoV-2 infected individuals develop IgG antibodies to virus by day 30 [3-5]. Wei et al., determined antibody response after SARS-CoV-2 infection in 7,256 general populations in UK and found 24% of the participants as ‘non-responder’ meaning that they did not develop anti-spike antibodies [6]. The non-responders were older and had lower viral burden. Studies have reported that IgG antibodies to SARS-CoV-2 persist for several months in patients recovering from SARS-CoV-2 infection [5,7]. In a linear mixed model analysis, using data from 4553 participants ofTexas antibody response survey, Swartz et al., has showed that expected antibody response increases for 100 days post SARS-CoV-2 infection and may remain positive beyond 500 days from the time of infection depending on age, body mass index and disease severity [8]. Antibody response following vaccination against SARS-CoV-2 varies depending on the types of vaccines and doses. Antibody level against the SARS-CoV-2 nucleocapsid protein following 2 doses of the SARS-CoV-2 messenger RNA (mRNA) vaccine (mRNA-1273, Moderna) was found 3836 U/ml whereas the antibody response following 2 doses of BNT162b2 mRNA vaccine (Pfizer-BioNTech) was 1444 U/ml [9]. Whole inactivated virus COVID-19 BIBP vaccine (Sinopharm) induced a median anti-spike antibody level of 52.15 RU/ml (equivalent to 166.88 BAU/ml) one month following 2 doses of vaccine among 95.7% individuals [10]. For a recombinant adenoviral vector vaccine ChAdOx1 nCoV-19 (Oxford–AstraZeneca), median spike antibody level of 1201 U/ml was observed at 0-20 days [11]. The recombinant adenoviral vector vaccine Ad5-nCoV (CanSino Biologics Inc) induced neutralizing antibodies against SARS-CoV-2 among 92.6% of individuals without prior COVID-19 disease following 21-25 days of vaccination [12]. Townsend et al., estimated the durability of anti-spike IgG antibody levels following vaccination by BNT162b2, mRNA-1273, ChAdOx1, and recombinant adenoviral vector vaccine Ad26.COV2.S (Johnson & Johnson/Janssen) by applying comparative evolutionary framework [13]. Messenger RNA vaccines (BNT162b2 and mRNA-1273) were predicted to yield protection against breakthrough infections for median time of 29.6 months whereas the expected median time of breakthrough infection following vector vaccination with ChAdOx1 and Ad26.COV2.S as 22.4 and 20.5 months respectively. Bangladesh initiated mass vaccination with ChAdOx1 (Oxford–AstraZeneca) in January 2021 [14]. This study was designed to determine the IgG antibody response to RBD (receptor binding domain) of SARS-CoV-2 spike protein S1 in individuals suffered from SARS-CoV-2 infection and in those vaccinated with ChAdOx1 vaccine. Persistence of antibody after a defined period was also determined in those individuals.   Material and methods The study was approved by the Institutional Research Review Board of Ibrahim Medical College. Informed consent was obtained from all participants after explaining the nature and purpose of the study. The laboratory work was conducted at K.A. Monsur Research Laboratory at the Department of Microbiology, Ibrahim Medical College. Study population: This study was carried out on adults aged 18 years and above. Study population consisted of four groups. Group-1 (control): healthy and history of no prior SARS-CoV-2 infection and vaccination, Group-2: had past SARS-CoV-2 infection (RT-PCR positive) within 1-10 months of enrolment in the study and no vaccination, Group-3: received two doses of recombinant adenoviral vector vaccine ChAdOx1 (Oxford–AstraZeneca) without past SARS-CoV-2 infection, and Group-4: past SARS-CoV-2 infection within 1-10 months plus received 2 doses of recombinant adenoviral vector vaccine ChAdOx1 (Oxford–AstraZeneca) vaccination. ChAdOx1 vaccine was a replication-deficient adenoviral vector vaccine manufactured by Oxford–AstraZeneca. A pre-tested structured questionnaire (closed ended) was used to record the age, gender, co-morbid condition and adverse effects of vaccination. Collection of blood sample: Single blood sample from participants of Gr-1 was collected at the time of enrolment. Sample from Gr-2 participants were collected within 1-10 months of recovery from SARS-Cov-2 infection (COVID-19). Two blood samples were collected from Gr-3 and Gr-4 individuals. First blood samples from Gr-3 cases were collected 1 month after the 2nd dose of vaccination. First blood samples from Gr-4 individuals were collected 1 month after the 2nd dose of vaccination and within 1-10 months of recovery from SARS-Cov-2 infection (COVID-19). Second blood samples from Gr-3 and Gr-4 individuals were collected 7 month after the 2nd dose of vaccination having antibody level of >30 DU/ml. About 5 ml of blood was collected aseptically from each participant by venipuncture. After collection, blood was kept at room temperature for at least half an hour followed by centrifugation at 1500 rpm for 10 minutes. Then the serum was separated and stored at –200C until tested. Estimation of IgG antibodies to receptor binding domain (RBD) of SARS-CoV-2 spike protein S1: IgG antibodies to RBD of SARS-CoV-2 spike protein S1 (anti-RBDS1 IgG) was determined in serum by ELISA using DRG ELISA kit (EIA-6150; Marburg, Germany). ELISA test was performed according to manufacturer’s instruction. Concentration of anti RBDS1 IgG antibody was expressed in DU/ml. Any sample showing antibody concentration above the cut off value of 5.4 DU/ml (1DU/ml=5.15IU/ml) was considered as positive.   Results Total 176 participants were enrolled of which Group-1, 2, 3 and 4 consisted of 27, 24, 93 and 32 individuals respectively. The age range of the participants was 18-85 years. Of the total, male and female were 111 (63.1%) and 65 (36.9%) respectively. About one-third of participants (30.1%) had comorbid condition which included diabetes, hypertension, asthma and cancer (Table-1).   Table-1: Distribution of groups, gender and co-morbid condition of study population (N = 176)     Table-2 shows the anti-RBDS1 IgG antibodies of participants belonging to four groups. Anti-RBDS1 IgG was positive in 51.9%, 66.7%, 96.8% and 100% participants of Group-1, 2, 3 and 4 respectively and the mean antibody concentrations of the positive participants were 16.5 ± 10.6, 39.9 ± 39.8, 97.7 ± 42.1 and 120.8 ± 31.9 DU/ml respectively. Seropositivity rate was significantly (p<0.001) higher in Group-3 and 4 individuals compared to that of Gr-1 and 2. No significant (p=0.284) difference in seropositivity rate was found between healthy control and individuals with past SARS-CoV-2 infection (Gr-1 vs Gr-2). Individuals who were previously infected and vaccinated (Gr-4) had significantly higher (p<0.05) anti-RBDS1 IgG antibody level (120.8 ± 31.9 DU/ml) compared to participants who were naturally infected but not vaccinated (Gr-2, 39.9 ± 39.8 DU/ml) as well as those who were vaccinated without prior infection (Gr-3, 97.7 ± 42.1 DU/ml). There were no significant differences in positivity rate and antibody levels between male and female individuals of any groups (Table-3). No significant (p>0.05) difference of anti-RBDS1 IgG antibody level was found between individuals with and without co-morbidity of any four groups (Table-4). Comorbid conditions included diabetes, hypertension, asthma and cancer.   Table-2: Anti-RBDS1 IgG antibody response in different groups of study population (N = 176)     Table-3: Anti-RBDS1 IgG antibody response in male and female participants of study population (N = 176)     Table-4: Anti-RBDS1 IgG antibody concentration in study population with and without comorbidities (N = 176)     Seven months after the 2nd dose of vaccination blood samples were collected from 61 and 22 individuals of Group- 3 and 4 respectively having > 30 DU/ml anti-RBDS1 IgG antibodies. Seven months after receiving the 2nd dose of vaccines, the antibody concentration declined in 85.3% and 81.5% of individuals of Group-3 and Group-4 respectively. Mean antibody concentration declined significantly (p≤0.05) from 112.1 ± 30.4 DU/ml to 75.9 ± 48.7 DU/ml and from 127.3 ± 20.4 DU/ml to 92.5 ± 43.6 DU/ml in Group-3 and Group-4 individuals respectively seven months after receiving the 2nd dose of vaccines (Table-5). Decline of antibody was 40.6% and 34.7% in 7 months. Only 1 (2.9%) out of 63 cases of Group-3 became negative (level <5.4 DU/ml). Out of total 176 participants, 103 reported adverse events following second dose of vaccination. Fever was the most common systemic adverse effect (41.7%) followed by headache (30.1%), myalgia (21.4%) and anorexia (6.8%) among the reported adverse events (Table-6).   Table-5:Anti-RBDS1 IgG levels of Group-3 and Group-4 individuals 1 and 7 months after 2nd dose of vaccination (N = 83)     Table-6: Adverse effects after 2nd dose of vaccination among participants (N = 103)     Discussion In this study, we report antibody response in adults who contracted SARS-CoV-2 and who were vaccinated with ChAdOx1 nCoV-19 vaccine and both. The antibody response of those participants was compared with that of a control group of adults who were not previously infected with SARS-CoV-2 or vaccinated. Our results show that after 2 doses of ChAdOx1 nCoV-19 vaccine the antibody concentration increased substantially with seropositivity rate over 96%. Antibody positivity is only one measure of a multifaceted immune response. SARS-CoV-2 vaccines have been shown to induce a Th1-dominated T cell response, which persists for at least 6-8 months and continues to mature [15]. B cell-mediated immunity can sustain at least for 12 months after initial infection [16,17]. In our study, the concentration of antibodies was significantly higher in response to the vaccine than after natural infection. These results are in agreement with the previous studies [18,19]. This finding may be related to heterogeneity within the COVID-19 recovered persons including variations in timing and severity of prior illness. In our study, significantly higher antibody response to the vaccine was noted in previously SARS-CoV-2 infected individuals than in infection-naïve individuals. This observation is similar with previous studies [20,21]. In naturally infected individuals subsequent vaccination serves as booster. This aspect is important to preserve vaccine in the context of scarcity. The serological data suggests a potential approach is to include antibody screening at or before the time of booster to prioritize the use of booster doses for individuals with no previous infection. This would help in maximizing the use of vaccine. In the present study, among 27 participants of the control group who had no history of natural infection with SARS-CoV-2 and vaccination, 14 (51.9%) were found positive for anti-RBD IgGS1 antibodies though the level of antibody concentration was low. The reason behind their positivity might be due to the presence of cross-reactive antibodies against other prevalent corona viruses than SARS-CoV-2. In fact a study in 2019 in Dhaka found that 4.57% of viral respiratory tract infections were due to corona viruses other than SARS-CoV-2 (corona virus 229E, corona virus NL63) [22]. However, in addition our Gr-1 population could have asymptomatic SARS-CoV-2 infection in this pandemic period. We found no differences in antibody level between male and female which was in agreement with previous study [23]. However, this is in contrast to the results of some reports where female showed higher antibody response than male to a range of vaccines [24]. Our findings showed that the antibody responses of naturally infected persons, infection-naïve vaccinees and previously infected vaccinees with comorbidities were similar to those without the comorbidities. The findings indicate that the recombinant adenoviral vector vaccine ChAdOx1 nCoV-19 is capable of inducing antibody response irrespective of gender and presence of comorbidities. Although our study found significant decrease in antibody level 7 months after 2nd dose of vaccine, the persisting antibody level was still high. This presence of persisting antibody to SARS-CoV-2 suggest antibody screening test prior to booster dose to maximize coverage and impact. For example, estimation of antibody titer is recommended before giving booster dose against hepatitis B virus. If the titer is found below the protection level of 10mIU/ml, only then booster dose is recommended [25]. The implications of detectable antibodies to SARS-CoV-2 are not yet well understood. Presence of high antibody concentration does not necessarily mean protection from infection, just as a negative result does not correlate susceptibility to infection. Cavanaugh et al., studied individuals infected with SARS-CoV-2 during April-December, 2020 and subsequently re-infected during May-June, 2021 [26]. They have found 20.3% had two doses of vaccination between first and second infection which implies re-infection is possible in spite of having high titer of antibody after natural infection and vaccination. In our study population, no serious adverse effect was noted after vaccination that warranted hospitalization. Mild constitutional symptoms recorded were similar to reported study [23]. The limitation of our study was that we could not assess the persistence of antibody to SARS-CoV-2 over a longer period of time. Also, we could not determine the neutralizing antibody and cell-mediated immune response and our sample size was small. Our study revealed that ChAdOx1 nCoV-19 vaccine induces high concentration of persisting anti-RBDS1 IgG antibody after second dose irrespective of gender and comorbidities. Previous infection with SARS-CoV-2 acts as immune priming and subsequent vaccination serves as booster. Therefore, antibody screening test prior to booster dose could be a good option to maximize coverage of vaccination.   Competing interest The authors declare no competing interests.   Funding The study was funded by grant from Ibrahim Medical College.   References 1.     Liu W, Liu L, Kou G, Zheng Y, Ding Y, Ni W, et al. Evaluation of nucleocapsid and spike protein based ELISAs for detecting antibodies against SARS-CoV-2. J Clin Microbiol. 2020; 58(6): e00461-20. 2.     World Health Organization. WHO Coronavirus (COVID-19) Dashboard. Geneva: World Health Organization; 2022. 3.     Shirin T, Bhuiyan TR, Charles RC, Amin S, Bhuiyan I, Kawser Z, et al. Antibody responses after COVID-19 infection in patients who are mildly symptomatic or asymptomatic in Bangladesh. Int J Infect Dis. 2020; 101: 220-225. 4.     Long QX, Liu BZ, Deng HJ, Wu GC, Deng K, Chen YK, et al. Antibody responses to SARS-CoV-2 in patients with COVID-19. Nat Med. 2020; 26(6): 845-848. 5.     Arkhipova-Jenkins I, Helfand M, Armstrong C, Gean E, Anderson J, Paynter RA, et al. Antibody response after SARS-CoV-2 infection and implications for immunity: a rapid living review. Ann Intern Med. 2021; 174(6): 811-821. 6.     Wei J, Matthews PC, Stoesser N, Maddox T, Lorenzi L, Studley R, et al. Anti-spike antibody response to natural SARS-CoV-2 infection in the general population. Nat Commun. 2021; 12(1): 6250. 7.     Zhang S, Xu K, Li C, Zhou L, Kong X, Peng J, et al. Long-Term kinetics of SARS-CoV-2 antibodies and impact of inactivated vaccine on SARS-CoV-2 antibodies based on a COVID-19 patients cohort. Front Immunol. 2022; 13: 829665. 8.     Swartz MD, DeSantis SM, Yaseen A, Brito FA, Valerio-Shewmaker MA, Messiah SE, et al. Antibody duration after infection from SARS-CoV-2 in the Texas coronavirus antibody response survey. J Infect Dis. 2022; jiac167. 9.     Steensels D, Pierlet N, Penders J, Mesotten D, Heylen L. Comparison of SARS-CoV-2 antibody response following vaccination with BNT162b2 and mRNA-1273. JAMA. 2021; 326(15): 1533-1535. 10.  Omran EA, Habashy RE, EzzElarab LA, Hashish MH, El-Barrawy MA, Abdelwahab IA, et al. Anti-spike and neutralizing antibodies after two doses of COVID-19 Sinopharm/BIBP vaccine. Vaccines. 2022; 10(8): 1340. 11.  Shrotri M, Navaratnam AMD, Nguyen V, Byrne T, Geismar C, Fragaszy E, et al. Virus watch collaborative. Spike-antibody waning after second dose of BNT162b2 or ChAdOx1. Lancet. 2021; 398(10298): 385-387. 12.  Hernández-Bello J, Morales-Núñez JJ, Machado-Sulbarán AC, Díaz-Pérez SA, Torres-Hernández PC, Balcázar-Félix P, et al. Neutralizing antibodies against SARS-CoV-2, anti-Ad5 antibodies, and reactogenicity in response to Ad5-nCoV (CanSino Biologics) vaccine in individuals with and without prior SARS-CoV-2. Vaccines. 2021; 9(9): 1047. 13.  Townsend JP, Hassler HB, Sah P, Galvani AP, Dornburg A. The durability of natural infection and vaccine-induced immunity against future infection by SARS-CoV-2. Proc Natl Acad Sci. 2022; 119(31): e2204336119. 14.  World Health Organization: WHO. Bangladesh COVID-19 reported to WHO [Internet]; 2021. Available from: https://covid19.who.int/region/searo/country/bd. 15.  Swanson PA 2nd, Padilla M, Hoyland W, McGlinchey K, Fields PA, Bibi S, et al. AZD1222/ ChAdOx1 nCoV-19 vaccination induces a polyfunctional spike protein-specific TH1 response with a diverse TCR repertoire. Sci Transl Med. 2021; 13(620): eabj7211. 16.  Guerrera G, Picozza M, D'Orso S, Placido R, Pirronello M, Verdiani A, et al. BNT162b2 vaccination induces durable SARS-CoV-2-specific T cells with a stem cell memory phenotype. Sci Immunol. 2021; 6(66): eabl5344. 17.  Turner JS, Kim W, Kalaidina E, Goss CW, Rauseo AM, Schmitz AJ, et al. SARS-CoV-2 infection induces long-lived bone marrow plasma cells in humans. Nature. 2021; 595(7867): 421-425. 18.  Gobbi F, Buonfrate D, Moro L, Rodari P, Piubelli C, Caldrer S, et al. Antibody Response to the BNT162b2 mRNA COVID-19 Vaccine in subjects with prior SARS-CoV-2 infection. Viruses. 2021; 13(3): 422. 19.  Ebinger JE, Fert-Bober J, Printsev I, Wu M, Sun N, Figueiredo JC, et al. Prior COVID-19 infection and antibody response to single versus double dose mRNA SARS-CoV-2 vaccination. medRxiv [Preprint]. 2021; 2021.02.23.21252230. 20.  Prendecki M, Clarke C, Brown J, Cox A, Gleeson S, Guckian M, et al. Effect of previous SARS-CoV-2 infection on humoral and T-cell responses to single-dose BNT162b2 vaccine. Lancet. 2021; 397(10280): 1178-1181. 21.  Manisty C, Otter AD, Treibel TA, McKnight Á, Altmann DM, Brooks T, et al. Antibody response to first BNT162b2 dose in previously SARS-CoV-2-infected individuals. Lancet. 2021; 397(10279): 1057-1058. 22.  Ghosh AK. Development and evaluation of an in-house multiplex PCR assay for detection of common respiratory viruses. Bangabandhu Sheikh Mujib Medical University. Thesis. 2020. 23.  Hoque A, Barshan AD, Chowdhury FUH, Fardous J, Hasan MJ, Khan MAS, et al. Antibody response to ChAdOx1-nCoV-19 vaccine among recipients in Bangladesh: a prospective observational study. Infect Drug Resist. 2021; 14: 5491-5500. 24.  Poland GA, Ovsyannikova IG, Kennedy RB. Personalized vaccinology: a review. Vaccine. 2018; 36(36): 5350-5357. 25.  World Health Organization‎. Hepatitis B. Geneva: World Health Organization; 2002. 76 p. 26.  Cavanaugh AM, Spicer KB, Thoroughman D, Glick C, Winter K. Reduced risk of reinfection with SARS-CoV-2 after COVID-19 vaccination - Kentucky, May-June 2021. MMWR Morb Mortal Wkly Rep. 2021; 70(32): 1081-1083.       Cite this article as: Rahman F, Mazumder S, Farook S, Deb P, Saha SP, Akter, et al. Antibody response to receptor-binding domain of SARS-CoV-2 spike protein following vaccination and natural infection with SARS-CoV-2. IMC J Med Sci. 2023; 17(1): 009.  DOI: https://doi.org/10.55010/imcjms.17.009 <![CDATA[Repeated episodes of seizures in an infant following accidental administration of tramadol suppository: a case report]]> Israt Zahan Ima Md Abdul Baki Jebun Nahar https://imcjms.com/journal_full_text/444 2022-12-18 10:31:04 Clinical Case Report IMC J Med Sci. 2023; 17(1): 010 Abstract Tramadol has become a popular analgesic in last few years. Number of studies has reported tramadol poisoning in children. Here, we report a case of tramadol poisoning in a one and half month old infant who presented with repeated seizures and apnea following accidental administration of tramadol suppository. IMC J Med Sci. 2023; 17(1): 010. DOI: https://doi.org/10.55010/imcjms.17.010 *Correspondence: Israt Zahan Ima, Department of Pediatrics, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), 1/A Ibrahim Sarani, Segunbagicha, Dhaka, Bangladesh.   Email: imaisratzahan@gmail.com   Introduction Tramadol, an analogue of codeine, is an analgesic that acts upon central nervous system (CNS). Tramadol is an agonist of the opioid (mainly μ-opioid) and gamma-aminobutyric acid (GABA) receptors and inhibits the reuptake of serotonin (SSRI) and norepinephrine (SNRI) in CNS [1]. Classic features of intoxication are bradypnea or apnea, CNS depression and meiosis [2]. Other features are seizures, confusion, hemodynamic instability, blood glucose abnormality, hepatic injury and anaphylaxis [3-5]. Seizure occurs within first 6 hours of tramadol poisoning [6-8]. Naloxonehas been used as a specific antidote for opioid poisoning [9]. Tramadol is not usually prescribed for children and tramadol intoxication may occur in younger children due to its accidental use [10-13]. Two recent studies from Bangladesh reported tramadol related intoxication and deaths in infants [14,15]. Here, we report an infant of 1 month 21 days of age with tramadol poisoning who presented with repeated seizures. This report would help to create awareness to keep medicines of children and adult separately and at a safe place at home.   Case history A one month 21 days old female infant was admitted to Pediatric department of BIRDEM General Hospital with repeated episodes of convulsions over 2 hours. Each episode of convulsion was manifested as generalized tonic, in nature and rolling of eye balls, that persisted for 1 to 2 minutes and following convulsion she became drowsy. There was no history of fever, vomiting, respiratory distress, head trauma, diarrhea or inadequate feeding before convulsion. She had history of irregular bowel movement. The baby usually passed stool at every 3 or 4 days interval for which mother sometimes used to administer glycerin suppository for bowel movement. On the day of admission, mother administered her tramadol suppository of 100 mg instead of glycerin suppository one hour before starting of convulsion. She was absolutely well and had no history of convulsion before this event. The baby was delivered by lower uterine segment Cesarean section (LUCS) at term with average (2500gm) weight. She had no history of asphyxia, jaundice, convulsion at perinatal period. Developmentally she was age appropriate. On examination the baby was stiff, cyanosed and drowsy, fontanelles were not bulged, anthropomorphically she was age appropriate [length: 54 cm (10th percentile), weight: 3.6 kg (5th percentile), occipital frontal circumference (OFC): 37 cm (25th percentile)]. She was afebrile, bradypnoeic (respiratory rate: 28 breaths/minute, pattern of respiration was shallow), heart rate was 110 beats/minute, blood pressure was 80/50 mmHg (25th - 50th centile), capillary refilling time (CRT): < 2 second, SpO2: 78%, capillary blood glucose: 6.8 mmol/L, muscle tone was increased. Other systems revealed normal findings. Her complete blood count (total and differential), peripheral blood film, liver enzymes, serum electrolyte, random blood glucose and chest X-ray were normal. Arterial blood gas (ABG) report showed respiratory acidosis. The patient was diagnosed as a case of accidental tramadol poisoning. The baby was managed with oxygen inhalation and injectable phenobarbitone. But after 2 hours, she again developed generalized tonic convulsion followed by apnea. The baby was shifted to intensive care unit and was put into IMV (Intermittent mandatory ventilation) mode of ventilation. A single dose of injection naloxone (0.1 mg/kg/dose) was given intravenously. Gradually, the patient’s condition improved. On 5th day she was discharged with advice to come for follow up. On follow up visit, the baby was well and had no neurologic deficit.   Discussion Food and Drug Administration (FDA) has not approved the use of tramadol in children less than 12 years of age [16]. The recommended therapeutic dose in children is 1-2 mg/kg every 6 hours [1]. In this case, the baby received a tramadol suppository of 100 mg accidentally. Clinical features of tramadol poisoning of this baby were convulsion, apnea, stiffness and cyanosis. A study done at the Pediatrics department of our hospital from 2014 to 2019 recorded decreased level of consciousness (100%), seizure (80%), meiosis (80%) and apnea (50%) as the main clinical features among 10 infants admitted with tramadol poisoning [15]. Another study with 11 infant of tramadol poisoning, observed seizure in 2 (18%) cases, apnea in 2 (18%) cases, shallow respiration in 2 (18%) cases and hypertonicity in 2 (18%) cases [14]. In our case, the baby was given accidentally 100 mg tramadol suppository instead of glycerin suppository. In the study by Nahar et al, 80% of cases received tramadol suppository accidentally instead glycerin/paracetamol suppositories [15]. Similarly, Rahman et al reported accidental administration of tramadol suppository instead of paracetamol and glycerin suppository in 18% and 82% cases respectively [14]. The study noted that similarities of those suppositories’ size, shape and color and keeping the drugs in same container as the causes of mistaken administration of tramadol suppository. Our case was managed successfully due to early diagnosis, availability of intensive care support and by use of naloxone. Naloxone has been successfully used in the management of 85-100% cases of tramadol intoxication [12,15]. Prolonged apnea or severe respiratory depression in tramadol intoxication needs intubation and mechanical ventilation. Our case required hospitalization for 108 hours. The average duration of hospital stay of such tramadol intoxication cases was between 46 to 89 hours [14,15]. Meticulous history taking, early diagnoses helped us to manage this case promptly.   Conclusion This case report highlights the occurrence of life threatening repeated episodes of seizures in young infants due to accidental administration of tramadol suppository. Medicines for children of similar packaging and appearance should be kept in separate containers. Parents should be educated about checking the name of medication properly prior to administration to children.   References 1.     Grond S, Sablotzki A. Clinical pharmacology of tramadol. Clin Pharmacokinet. 2004; 43(13): 879–923. 2.     Zamani N, Sanaei-Zadeh H, Mostafazadeh B. Hallmarks of opium poisoning in infants and toddlers. Trop Doct. 2010; 40(4): 220-222. 3.     Nakhaee S, Hoyte, C, Dart RC, Askari M, Lamarin, RJ, Mehrpour O. A review on tramadol toxicity: mechanism of action, clinical presentation, and treatment. Forensic Toxicol. 2021; 39(2): 293-310. 4.     Ahmed S, Sundari S. Hypoglycaemia in a child with tramadol poisoning. Eur J Mol Clin Med. 2020; 7(7): 6055–6057. 5.     Mori F, Barni S, Manfredi M, Sarti L, Pecorari L, Pucci N, et al. Anaphylaxis to intravenous tramadol in a child. Pharmacol. 2015; 96(5-6): 256–8. 6.     Sadove MS, Balagot RC, Hatano S, Gobgen EA. Antagonist--N-allyl-noroxymorphone. JAMA. 1963; 183: 666-668. 7.     Talaie H, Panahandeh R, Fayaznouri MR, Asadi Z, Abdollahi M. Dose-independent occurrence of seizure with tramadol. J Med Toxicol. 2009; 5: 63–67 8.     Marquardt KA, Alsop JA, Albertson TE. Tramadol exposures reported to statewide poison control system. Ann Pharmacother. 2005; 39(6): 1039-1044. 9.     Clarot F, Goulle J, Vaz E, Proust B. Fatal overdoses of tramadol: is benzodiazepine a risk factor of lethality? Forensic Sci Int. 2003; 134: 57-61. 10.  De Decker K, Cordonnier J, Jacobs W, Coucke V, Schepens P, Jorens PG. Fatal intoxication due to tramadol alone: case report and review of the literature. Forensic Sci Int. 2008; 175(1): 79-82. 11.  Sruthi V, Narendra A. Accidental tramadol ingestion in children admitted in a tertiary care centre. Int J Basic Clin Pharmacol. 2019; 8: 2661-2664.  12. Hassanian-Moghaddam H, Farnaghi F, Rahimi M. Tramadol overdose and apnea in hospitalized children, a review of 20 cases. Res Pharm Sci. 2015; 10(6): 544-552.  13. Tanné C, Javouhey J, Millet A, Bordet F. Severe tramadol overdoses in children: a case series admitted to paediatric intensive care unit. J Clin Toxicol. 2016; 6: 1-5. 14.  Rahman M, Chowdhury MA, Haque MM, Hossian MM, Suman GM. Tramadol suppository poisoning in children of Bangladesh. Bangladesh J Child Health. 2019; 43(3): 157-160. 15.  Nahar J, Begum N, Islam N, Sultana N, Yasmin F, Mohsin F, et al. Tramadol intoxication in infants: experience at a tertiary care hospital in Dhaka, Bangladesh. BIRDEM Med J. 2021; 11(3): 197-201. 16.  Jin J. Risks of codeine and tramadol in children. JAMA. 2017; 318(15): 1514.       Cite this article as:  Ima, IZ, Baki MA, Nahar J. Repeated episodes of seizures in an infant following accidental administration of tramadol suppository: a case report. IMC J Med Sci. 2023; 17(1): 010. DOI: https://doi.org/10.55010/imcjms.17.010 <![CDATA[Role of breakfast skipping, depression, and other risk factors for obesity: The Youth Risk Behavior Surveillance System]]> Azad R. Bhuiyan Amal K. Mitra Marinelle Payton Paul B. Tchounwou https://imcjms.com/journal_full_text/408 2022-02-23 12:09:31 Original Article IMC J Med Sci 2022; 16(2): 001 Abstract Background and objectives: Obesity among adolescents is a significant public health concern in the United States. The prevalence of obesity has increased from 13.0% in 2011 to 15.5% in 2019. The association between breakfast skipping and obesity is still controversial, and a mediator role of depression in this association is limited. The purpose of this study was to investigate the independent association between breakfast skipping and obesity and to investigate the mediator role of depressive symptomology between breakfast skipping and obesity prevalence. Materials and methods: In this cross-sectional study, data were extracted from the CDC's Youth Risk Behavior Surveillance System (YRBSS) for 9th to 12th graders from 2011 through 2020. SAS version 9.4 was used to analyze the data using proc survey frequency and proc survey logistic regression models. The adjusted odds ratios (aORs) with 95% confidence intervals (CI) were estimated. The Sobel test also was performed to test the mediator role of self-reported depression. Results: Of the 56,320 adolescents, 13.7% did not eat breakfast, 14.1% were obese, and 15.1% had depressive symptomology. Breakfast non-eaters was associated with a 24% increased odds of obesity (aOR: 1.24; 95% CI: 1.14 to 1.36) after adjusting for race/ethnicity, gender, grade level, and behavioral risk factors. A mediator role of self-reported depression was noted using the regression model and Sobel test (z = 3.90, S.E. = 0.02, p< 0.0001) between breakfast skipping and obesity. Conclusions: Breakfast skipping was independently associated with obesity. Self-reported depression was identified as a mediator factor. Therefore, the mental health condition also needs to be addressed in the prevention of obesity among adolescents. IMC J Med Sci 2022; 16(2): 001. DOI: https://doi.org/10.55010/imcjms.16.11 *Correspondence: Azad R. Bhuiyan, Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Jackson State University, Jackson, MS 39213, USA. Email:  azad.r.bhuiyan@jsums.edu   Introduction Breakfast is an important first meal of the day that impacts behavior, academic performance, and physical and mental well-being [7-11]. Adolescence is a critical transition period from childhood to adulthood as it represents the vulnerable phase of human development to physical, mental, and social maturity [12]. Although breakfast impacts both short- and long-term health and wellbeing of adolescents, the barrier to eating breakfast prevail among adolescents, especially in minority population having several risk factors such as lower family income, lower education, physical inactivity, watching television, and alcohol consumption [6,12-15]. However, controversy remains in the relationship between breakfast skipping and obesity prevalence among adolescents in the U.S., mainly because of inadequate adjustment of confounding variables. For example, conflicting results within four U.S. studies are notable –breakfast skipping was associated with obesity among adolescents in study of Kentucky adolescents and in a national study [15,16]. On the other hand, the National Heart, Lung, and Blood Institute Growth and Health Study found no association of breakfast skipping with obesity measures used after controlling for race, age, parental education, energy intake [13,14]. According to the Centers for Disease Control and Prevention (CDC), the rate of breakfast non-eaters increased from 13.1% to 16.7% and obesity rates increased from 13.0% to 15.5% among adolescents during the 2011-2012 survey period to the 2019-2020 survey period [17]. <![CDATA[A retrospective analysis of the skull base fractures: demographic characteristics, causes and imaging findings]]> Hüseyin Kafadar Safiye Kafadar ŞeyhoCem Yücetaş Hakan Kaya https://imcjms.com/journal_full_text/411 2022-03-23 11:23:40 Original Article IMC J Med Sci 2022; 16(2): 002 Abstract Background and objectives: Skull base fractures have high mortality and morbidity rates and constitute a significant medical issue. The aim of the present study was to review the demographic characteristics, common locations and causes of the skull base fractures retrospectively. Methods: This retrospective study was conducted on patients who attended the Intensive Care Unit/Radiology Clinic of Adiyaman University Training and Research Hospital between 2015 and 2018 and were found to have skull base fractures. The data were accessed via PACS system of the hospital database. Age, gender, cause of the trauma, type of the skull base fracture, imaging findings and outcome of the enrolled patients were analyzed. Results: Total 138 cases who met the study criteria were enrolled in the study. The causes of the skull base fracture were as follows: fall 52.2%, traffic accident 36.2%, pounding 3.6%, firearm injury 0.7%, sharp object injury 0.7%, and other causes 6.5%. There was a statistically significant (p<0.001) difference in rate of skull base fracture caused by traffic accident between the ≤18-year group and 19-45 age group. The difference between the types of epidural hematoma was not significant in all age groups (p= 0.156); however, there was a statistically significant difference for gender (female vs. male 26.1%73.9%, p=0.025). Conclusion: Skull base fractures were more common in fall from height and traffic accidents. In order to reduce skull base fractures, it is recommended to take preventive precautions for falls from height and traffic accidents. IMC J Med Sci 2022; 16(2): 002. DOI:https://doi.org/10.55010/imcjms.16.012 *Correspondence: Safiye Kafadar, Department of Radiology, Adiyaman University Education and Research Hospital, Adiyaman, Turkey. Email: safiyekafadar@gmail.com, ORCID: 0000-0003-4070-9615   Introduction Skull base fractures are defined as fracture of any bones that consist of the skull base due to any reason. Since skull base fractures have high mortality and morbidity rates, they constitute a significant public health issue [1]. It is recognized that skull base fractures appear in approximately 25% of the head trauma cases [2]. Almost 90% of these fractures occur due to closed head trauma whereas approximately 10% of the cases appear in the form of penetrating injuries [3]. In skull base fractures, severe complications may occur as a result of injury to the blood vessels and nerves. Mortality is high, and therefore diagnosis and treatment require urgent intervention. The most important factors that affect the mortality include trauma severity, cerebral hemorrhage and cerebral damage concomitant to skull base fractures [4]. A destructive neurological pathology or possibly fatal vascular injuries accompany the clinical presentation in approximately 50% of the patients with skull base fracture [5]. Cranial computed tomography (CT) is used as a sensitive imaging method to diagnose skull base fracture and to determine concomitant cerebral hemorrhages [6]. Although skull base fractures commonly involve the temporal bone, fractures of the occipital, sphenoid, ethmoid and frontal bones may also be detected [7]. The aim of the present study was to analyze the demographic characteristics, the events that caused fracture (i.e. traffic accident, falling, pounding, firearm injury), types of skull base fracture, imaging findings and outcome of the enrolled patients.   Methods This retrospective study was approved by the Clinical / Human Research Ethics Committee (2019/7-4) of Medical Faculty, Adiyaman University. Helsinki Declaration rules were followed to conduct the study. Patients who attended the Intensive Care Unit/Radiology Clinic of Adiyaman University Training and Research Hospital between June 1, 2015 and June 30, 2018 and were found to have skull base fractures were included in the study. The data were accessed via PACS system of the hospital database. The enrolled patients with skull base fracture were reviewed for age, gender, the event that caused fracture (i.e. traffic accident, falling, pounding), type of the skull fracture on the imaging studies (i.e. direct X-ray, computed tomography and magnetic resonance imaging), hospitalization period, clinical features and the outcome. Statistical analysis: Analysis of the variables was performed through SPSS 25.0 (IBM Corporation, Armonk, New York, United States) program. Pearson's Chi-Square and Fisher's exact tests were used to compare categorical variables with each other; results of the exact test were used for Fisher-Freeman-Holton test and Monte Carlo simulation technique; column ratios were compared with each other, and the values were expressed according to Benjamini-Hochberg corrected p value. The odds ratio was used along with confidence interval of 95% to demonstrate the number of the patients with or without a risk factor. Quantitative variables were expressed in mean ± SD (standard deviation) and median (minimum / maximum); categorical variables were demonstrated as number (n) and percent (%). The variables were reviewed at a confidence interval of 95%, and a p value smaller than 0.05 was accepted as significant.   Results Total 138 patients with skull base fracture were enrolled in the study. The cases were reviewed in four groups namely ≤18, 19-45, 45-65 and ≥66 years. Furthermore, a comparison was performed by gender. Of the total cases, 26.1% were female and 73.9% were male with a mean age of 25.4 years. The comparisons according to the months within the year revealed no statistically significant (p>0.05) difference between gender and age groups for skull base fractures (Table-1).   Table-1: Month wise incidence of skull base fractures according to age groups and gender of the study patients (n=138)     Skull base fracture according to the causes of the incidents is shown in Table-2. The causes of the skull base fracture were by traffic accident 36.2%, fall 52.2%, firearm injury 0.7%, pounding 3.6%, sharp object injury 0.7%, and other causes 6.5%. Fall as the cause for skull base fractures was detected more in the ≤18 years of age (76.5%) and female gender (p<0.001). The skull base fractures due to traffic accidents were observed more in the 19-45 and 46-65 age groups than in the ≤ 18 years group, and in male than female gender (p<0.001).   Table-2: Causes of the skull base fracture according to age and gender groups (n=138)     Out of total fracture cases, 44.2% of skull base fractures were on single site whereas 55.8% of them were on multiple sites. In addition to the skull base fracture, 22.5% of the cases had cerebral edema, and contusion was detected in 19.6% of the cases. It was detected that cerebral contusion together with skull base fracture was more in 19-45 age group than ≤18 age group, and the fractures without contusion were more in the 19-45 age group than ≤18 age group (p=0.003). Epidural, subdural and intracranial hematomas were present in 31.9%, 14.5%, and 6.5% cases respectively. Subarachnoid hemorrhage was found in 24.6%, patients (Table-3). Anatomic locations of the skull base fractures were detected on the following locations: right frontal region 7.9%, left frontal region 6.9%, right temporal region 11.5%, left temporal region 19.6%, right occipital region 33.1%, left occipital region 4%, sphenoidal region 7.4%, and ethmoidal region 9.5%. Only 4 patients died in the present study. It was concluded that deaths occurred at the scene of occurrence or before arrival to the hospital, and for this reason, all deaths might not have been registered in the hospital records (Table-3). There was no statistically significant difference between other traumatic causes and mortality, fracture types, anatomic region and edema. Review of hematoma and hemorrhages that accompanied skull base fractures revealed no significant association between the age groups, but it was more in male patients than females (p=0.025). There was no significant association between gender and the age groups for subdural and intracranial hematoma (p>0.05). Subarachnoid bleeding was more common in the ≤18 age group than other age groups (p=0.003), and more prevalent in male patients than female patients (p=0.004; Table -3).   Table-3: Analysis of imaging findings and outcome of the patients with skull base fractures (n=138)     Discussion Skull base fractures are evaluated as basic fractures that are present at the skull base including temporal, occipital, sphenoid or ethmoid bones [1-3]. Such fractures may cause rupture of the meninges and leakage of cerebrospinal fluid (CSF) [8]. The leaked CSF may accumulate in the middle ear space and may cause neurological and hearing loss [9]. Direct X-ray has limited value for confirmation of the skull base fractures, and CT or MRI is required for final diagnosis [10]. In the present study, 138 patients who presented with skull base fracture due to different reasons were reviewed with justification of the diagnosis by X ray, CT and MRI. A previous study reported that 78.6% of the cases with skull base fracture were male with a male to female ratio of 3.6 to 1 [11]. We also detected in our group that the male patients with skull base fracture was relatively higher than female patients. Our results comply with the literature information that skull base fractures usually occur on males. The cause for higher number of male cases may be the vulnerability of men to severe traumas due to working in hazardous professions. Approximately 30% of skull base fractures are known to be caused by motor vehicle accidents, fall, physical assaults and close contact sports. The prevalence of skull base fractures in the patients with head injury was reported from 3.5% to 24.0% [12]. Basillary skull fractures are more common in younger individuals due to their tendency to perform risky activities [13]. A previous study demonstrated that 64.7% cases of skull base fractures had injury to the anterior fossa of the skull [14]. An earlier study reported that the most common causes of skull injuries were traffic accidents (59%), fall (13%) and bicycle accident (12%) [15]. It is a noticeable assessment that motor vehicle accidents are the most common cause of skull base fractures, and majority of these cases are pedestrians [12]. In the present study, we observed that fall (52.2%) were the most common cause of skull base fractures followed by traffic accidents (36.2%). In the present study, the correlation between skull base fractures and intracranial lesions were evaluated. Intracranial hemorrhages in skull base fractures occur due to linear breakage of the skull convexity [16]. It was also demonstrated that linear fractures may cause cerebral contusion or intracranial hemorrhage [17]. It was detected that skull base fractures were anatomically on a single site in 44.2% of the cases, on multiple sites in 55.8% of the cases; no edema was detected in 77.5% of the patients; contusion was observed in 19.6% of the cases; epidural hematoma, subdural hematoma, subarachnoid bleeding and intracranial hematoma were detected in 31.9%, 14.5%, 24.6% and 6.5% of the cases respectively. A previous research on skull base fracture reported higher incidence of intracranial hemorrhage in the moderate head injury group than mild and severe head injury groups [14]. It was found in the same study that skull base fractures appeared on the anterior fossa were more likely to cause single lesion of traumatic intracranial hemorrhage when compared with other groups. Furthermore, subdural hemorrhages were reported to be higher than cerebral, subarachnoid and extradural hemorrhages in multiple lesions. In the present study, there was no significant association between the age groups and skull base fractures caused by trauma for the cases without epidural hematoma; however, number of male patients was higher than females. A statistically significant association was not detected for age and gender in the patients with and without subdural and intracranial hematoma. Subarachnoid hemorrhage in patients with skull base fracture was found lower in ≤18 year’s age group than other groups, and in men than women. We observed contusion in 19.6% cases. These contusions have the potential to progress to cerebral bleeding, subdural, subarachnoid hemorrhage or intraventricular hemorrhages. The limitations of the study were that the study had small number of cases (total 138 cases), conducted in a single center and the lack of late-period follow up findings of the patients (after 2 years). We believe that this study on skull base fracture would raise the awareness of the healthcare providers about the approach to the patients. It was also observed that skull base fractures were strongly correlated with traumatic intracranial lesions, while age gender had positive or negative effect.   Conflict of interest All authors declare no conflicts of interest.   Financial disclosure No funding or financial support was received.   References 1.     Yates PJ, Williams WH, Harris A, Round A, Jenkins R. An epidemiological study of head injuries in a UK population attending an emergency department. J Neurol Neurosurg Psychiatry. 2006; 77(5): 699-701. 2.     Yellinek S, Cohen A, Merkin V, Shelef I, Benifla M. Clinical significance of skull base fracture in patients after traumatic brain injury. J Clin Neurosci. 2016; 25: 111-115. 3.     Wani AA, Ramzan AU, Raina T, Malik NK, Nizami FA, Qayoom A, et al. Skull base fractures: An institutional experience with review of literature. Indian J Neurotrauma. 2013; 10(2): 120-126. 4.     Liu CC, Wang CY, Shih HC, Wen YS, Wu JJK, Huang CI, et al. Prognostic factors for mortality following falls from height. Injury. 2009; 40(6): 595-597. 5.     Yildirim A, Gurelik M, Gumus C, Kunt T. Fracture of skull base with delayed multiple cranial nerve palsies. Pediatr Emerg Care. 2005;21(7):440-442. 6.     Ringl H, Schernthaner RE, Schueller G, Balassy C, Kienzl D, Botosaneanu A, et al. The skull unfolded: a cranial CT visualization algorithm for fast and easy detection of skull fractures. Radiology. 2010; 255(2): 553-562. 7.     Katzen JT, Jarrahy R, Eby JB, Mathiasen RA, Margulies DR, Shahinian HK. Craniofacial and skull base trauma. J Trauma. 2003; 54(5): 1026-1034. 8.     Arlı C, Özkan M, Karakuş A. Incidence, etiology, and patterns of maxillofacial traumas in Syrian patients in Hatay, Turkey: A 3 year retrospective study. Ulus Travma Acil Cerrahi Derg. 2019; 25: 29-33. 9.     Samad S., Sjamsudin E. TA. Characteristics of maxillofacial fracture and head injury due to motor vehicle accidents in hasan Sadikin hospital, Bandung, Indonesia. Int J Sci Res. 2018; 7: 574-577. 10.  Faried A, Satriawan FC, Arifin MZ. Feasibility of online traumatic brain injury prognostic corticosteroids randomisation after significant head injury (crash) model as a predictor of mortality. World Neurosurg. 2018; 116: e239-e245. 11.  Faried A, Bachani AM, Sendjaja AN, Hung YW, Arifin MZ. Characteristics of moderate and severe traumatic brain injury of motorcycle crashes in Bandung, Indonesia. World Neurosurg. 2017; 100: 195-200. 12.  Saadat S, Rashidi-Ranjbar N, Rasouli MR, Rahimi-Movaghar V. Pattern of skull fracture in Iran: Report of the Iran national trauma project. Ulus Travma ve Acil Cerrahi Derg. 2011; 17(2): 149-151. 13.  Faried A, Halim D, Widjaya IA, Badri RF, Sulaiman SF, Arifin MZ. Correlation between the skull base fracture and the incidence of intracranial hemorrhage in patients with traumatic brain injury. Chinese J Traumatol. 2019; 22(5): 286-289. 14.  Akay AM, Gürbüz N, Yayla D, Elemen EL, Ekingen Yıldız G, Kahraman Esen H,et al. Acil Servise Başvuran Pediyatrik Travma Olgularının Değerlendirilmesi Evaluation of Pediatric Trauma Cases Applied to Emergency Department. Medical Journal of Kocaeli 2013; 3: 1-5. [Turkish] 15.  Graham DI, Gennareli TA. Pathology of brain damage after head injury. In: Cooper P, Golfinos G, editors. Head Injury. 4th Ed. Morgan Hill; New York: 2000. 16.  Chan KH, Mann KS, Yue CP, Fan YW, Cheung M. The significance of skull fracture in acute traumatic intracranial hematomas in adolescents: A prospective study. J Neurosurg. 1990; 72(2): 189-194. 17.  Chen W, Lv H, Liu S, Liu B, Zhu Y, Chen X, et al. National incidence of traumatic fractures in China: a retrospective survey of 512 187 individuals. Lancet Glob Health. 2017; 5(8): e807-e817.     Cite this article as: Kafadar H, Kafadar S, Yücetaş S, Kaya H. A retrospective analysis of the skull base fractures: demographic characteristics, causes and imaging findings. IMC J Med Sci. 2022; 16(2):002. DOI: https://doi.org/10.55010/imcjms.16.012 <![CDATA[Asymptomatic Helicobacter pylori infection among rural children and adolescents in Bangladesh]]> Sraboni Mazumder Fahmida Rahman Farjana Akter Rehana Khatun Shahida Akter Supti Prava Saha Md. Shariful Alam Jilani Mohammad Abu Sayeed Jalaluddin Ashraful Haq https://imcjms.com/journal_full_text/415 2022-05-26 10:04:23 Original Article IMC J Med Sci 2022; 16(2): 007 Abstract Background and objectives: The Helicobacter pylori infection rate varies according to the age, location of the residence and socioeconomic status. The aim of the present study was to investigate the status of H. pylori infection among the asymptomatic Bangladeshi rural children and adolescents. Material and methods: This cross-sectional study was carried out in a rural area under Pabna district about 150 km north-west of capital Dhaka. Asymptomatic and apparently healthy rural children and adolescents aged 6 to 18 years were enrolled in the study. A structured questionnaire was used to record the socio-demographic and clinical information. The rate of H. pylori infection was determined by the presence of H. pylori antigen in faeces and/or anti-H. pylori IgG and/or IgA antibodies in blood. H. pylori stool antigen was detected by lateral flow chromatographic immunoassay and serum anti-H. pylori IgG and IgA antibodies were estimated by ELISA method. Results: A total number of 185 asymptomatic and apparently healthy children and adolescents were enrolled of which 34, 131 and 20 were in 6-10, 11-15 and 16-18 years age groups respectively. The overall H. pylori infection rate was 79.5% (95% CI: 0.729, 0.85) by positive stool antigen or by the presence of serum anti-H. pylori IgG/IgA antibodies. The rate of H. pylori infection significantly (p=0.05) increased with progress of age. H. pylori infection rate was 67.6%, 80.2% and 95% in 6-10, 11-15 and 16-18 years age groups respectively. The concentration of serum anti-H. pylori IgG/IgA antibodies did not differ across the age groups. The infection rate was significantly (p<0.05) higher among the children of illiterate parents compared to the children of literate parents. Conclusion: The study demonstrated a high prevalence of H. pylori infection among children and adolescents in a rural setting. Gender and family history did not affect H. pylori prevalence but increasing age and poor educational status of parents were associated with a higher H. pylori prevalence. IMC J Med Sci 2022; 16(2): 007. DOI: https://doi.org/10.55010/imcjms.16.017 *Correspondence: J. Ashraful Haq, Department of Microbiology, Ibrahim Medical College, 1/A, Ibrahim Sarani, Segunbagicha, Dhaka 1000, Bangladesh. Email: jahaq54@yahoo.com   Introduction Helicobacter pylori infection is one of the most chronic infections in humans [1]. It is associated with gastric diseases such as peptic ulcer, chronic gastritis, gastric adenocarcinoma and mucosa associated lymphoid tissue (MALT) lymphomas [2,3]. In addition, the infection has been associated with chronic diarrhea and malnutrition among infants and children [4,5]. In a meta-analysis, the overall global prevalence of H. pylori infection has been found as 44.3%, while it is 50.8% in developing countries and 34.7% in developed countries [6]. Previously, we reported low prevalence (38.9%, CI: 32.1, 46.2) of H. pylori infection in asymptomatic rural adults of Bangladesh [7]. H. pylori is most likely acquired in childhood [8-10]. In developed countries, the prevalence of H. pylori infection in children ranges from 10%–16.7% whereas it is 9%–78.6% in school children of developing countries [11-14]. In Bangladesh, the prevalence of H. pylori infection in peri-urban children has been reported as 82% [15]. However, the age group at greatest risk of infection is not clear yet [16]. Though the infection is clustered in families, it is not confirmed yet whether it is because of acquisition from person-to-person transmission or from common environmental source(s) [17-19]. Identifying the age group at greatest risk of H. pylori infection would be useful in determining the specific risk factors for infection and to plan preventive measure. No previous study investigated the prevalence in rural children and adolescents in our country. Therefore, the primary aim of the present study was to find out the seroprevalence of H. pylori infection among asymptomatic rural children and adolescents in Bangladesh.   Materials and methods The study was approved by the Institutional Research Review Board of Ibrahim Medical College and written informed consent was obtained from all adult participants and from the guardians of the children after explaining the nature and purpose of the study. Laboratory work was conducted at KA Monsur Research Laboratory at the Department of Microbiology, Ibrahim Medical College. Study place and population: This cross-sectional study was carried out at Bhulbaria rural area of Santhia Upazilla (sub-district) under Pabna district in 2019. It is located about 150 km north-west of capital Dhaka. Apparently healthy rural school children and adolescents aged 6 to 18 years having no gastrointestinal symptoms, systemic infection, and malnutrition were enrolled in this study. A structured questionnaire (closed ended) was developed and used to record the socio-demographic information and clinical history. It was pretested and checked for applicability before it was finally launched at the field to interview for data collection from the respondents. Definition of asymptomatic H. pylori infection: Asymptomatic H. pylori infection was defined if an apparently healthy individual was found positive for H. pylori stool antigen and or anti-H.pylori IgG and or IgA antibodies in blood without having any gastrointestinal symptoms. Sample collection and preparation: Blood sample (about 2.5 ml) was collected aseptically from each participant by peripheral venipuncture. After collection, the serum was separated, aliquoted, refrigerated at 40C and then transported to the microbiology laboratory in a cold box and stored at -200C until tested. For stool antigen test, participants were asked to bring freshly passed stool (about 3-4 gm) in a sterile container and stored at 40C until tested. Stool antigen test was performed within 3/4 hours of collection of stool. Detection of H. pylori stool antigen: Stool samples were analyzed for H. pylori stool antigen using one step rapid lateral flow chromatographic immunoassay (ABON, Inverness Medical Innovation Hong Kong Limited). The test was performed as per manufacturer’s instruction. Small portions of stool from different parts of the collected stool were thoroughly mixed with extraction buffer and then vigorously agitated. Two drops of mixture were then put into the round window of the test cassette. Reading was made after 10 minutes of incubation at room temperature. Appearance of control (C) and test (T) lines across the central window of the cassette indicated positive test. Only one C line indicated negative result. The test was considered invalid if no line appeared in C line region. Detection of serum anti-H. pylori IgG and IgA antibodies by ELISA: Serum samples were tested for the presence of anti-H. pylori IgG and IgA antibodies by ELISA method using DRG H. pylori IgG and IgA ELISA kit (DRG International Inc., USA). The test was performed according to the manufacturer’s instruction. The antibody concentration was expressed in optical density (OD) of the reactants. Treatment of H. pylori stool antigen positive cases: H. pylori stool antigen positive individuals were treated with a proton pump inhibitor (PPI) and two antibiotics namely amoxicillin and metronidazole for 14 days for eradication of H. pylori according to the recommended dose schedule [20,21]. Stool samples were collected again and re-tested for H. pylori antigen one month after the completion of the treatment.   Results A total number of 185 apparently healthy asymptomatic children and adolescents were enrolled in the study of which 34, 131 and 20 were in 6-10, 11-15 and 16-18 years age groups respectively. Socio-demographic variables of the participants are shown in Table-1. Almost equal number of male (51.4%) and female (48.6%) participated in the study. All were from middle socio-economic class. Of the enrolled children, 35.1% and 24.3% of their fathers and mothers were illiterate while remaining had access to academic education. Almost all (98.9%) used tube well water for drinking. Most of the participants (87%) used slab latrine. Though 81.6% washed hand with soap after defecation, only 37.3% washed hand with soap before meal. Around 48.1% had family history of gastritis whereas 51.9% had no such history. More than two third of individuals (71.4%) provided history of eating less spicy food. Most of the participants (96.8%) had no history of smoking.   Table-1: Socio-demographic characteristics of the study population (N=185)   Out of total 185 study population, 147 (79.5%; (95% CI: 0.729, 0.85) participants were positive for H. pylori infection either by positive stool antigen or by the presence of serum anti-H-pylori IgG/IgA antibodies (Table-2). Stool antigen, anti-H. pylori IgG and IgA antibody were positive in 24.9%, 64.9% and 55.1% participants respectively. The rate of H. pylori infection significantly (p=0.05) increased with the progress of age. H. pylori infection rate was 67.6%, 80.2% and 95% in 6-10, 11-15 and 16-18 years age groups respectively. Concentrations of anti-H. pylori IgG and IgA antibodies in different age groups were not significantly different as measured by OD (Table-3).   Table-2: Rate of H. pylori infection in different age groups of study population as determined by presence of stool antigen and serum anti-H. pylori IgG/IgA antibodies     Table-3: Anti-H. pylori IgG and IgA antibody concentration in different age groups of study population (N=185)     Significantly higher numbers of individuals were positive for anti-H. pylori IgG and IgA antibodies among stool antigen positive individuals compared to those who were stool antigen negative (p<0.001, 0.02 and p<0.009). Out of 46 H. pylori stool antigen positive cases, 91.3% were positive for IgG and/or IgA while out of 139 stool antigen negative individuals, 72.7% were also positive for anti-H. pylori IgG and/or IgA (Table-4).   Table-4: Comparison of stool antigen with the presence of serum anti-H. pylori IgG and IgA antibodies     No significant (p>0.05) association of H. pylori infection was observed with gender and family history of gastritis. The infection rate was significantly (p<0.05) higher among the children of illiterate parents than the children of parents having access to school (Table-5). Out of 46 stool antigen positive individuals, 34 (73.9%) became negative for H. pylori stool antigen when tested one month after the completion of scheduled treatment.   Table-5: Status of H. pylori infection according to the socio-demographic characteristics of the study population (N=185)     Discussion This is the first study describing the H. pylori infection rate in rural children and adolescents in Bangladesh. In this study, H. pylori infection in an individual was defined as positive stool antigen and/or positive serum anti-H. pylori IgG and/or IgA antibodies. In the present study, we found the overall positivity rate as 79.5%; 67.6%, 80.2% and 95% in 6-10, 11-15 and 16-18 years age groups respectively. We found an increasing prevalence with age. This finding is comparable with other studies [22-24]. A plausible explanation might be increasing chance of exposure to H. pylori with advance of age due to consumption of H. pylori contaminated food/drinks from street vendors with poor hygienic condition. Children of lower age groups frequently consume antibiotics for other infections which might indirectly prevent infection by H. pylori infection [25]. Our study showed H. pylori IgG positivity rate of 64.9% in children and adolescents. In another developing country Benin, the rate was 68.3% in rural children [26]. In addition, in Vietnam, it was 41.4% in rural children [27]. On the other hand, the prevalence of H. pylori IgG antibodies in urban children of Benin was 78.3%. The lower rate of H. pylori infection in rural than urban population might be due to crowded accommodation, poor sanitation and exposure to unhygienic foods [26]. In the current study, the prevalence of H. pylori stool antigen in asymptomatic rural children and adolescents was 24.9%. It was 14.2% in African rural children [28]. Positive H. pylori stool antigen means active infection or individual is harboring the organism whereas positive H. pylori IgG antibodies represent current or previous H. pylori infection [29]. In our study, the H. pylori infection rate by serum anti-H. pylori IgG antibodies was 64.9% while the H. pylori stool antigen positivity rate was 24.9%. This difference suggests spontaneous resolution of infection in children. Auto-curability among black children aged 7-21 years in USA was 0.3% yearly and 5.5% per year in white children in the same cohort study [30]. Among Peruvian children, a spontaneous eradication of 7% monthly was reported [31]. The natural history of H. pylori infection in children continues to evolve. Further studies are needed to investigate whether re-infection or persistent infection occurs in antibody positives cases by detecting stool antigen or urea breath test or endoscopy. We found no significant gender difference in the prevalence of H. pylori infection. It could be due to both boys and girls were equally exposed to same environment or sources in school as well as residence. Similar finding was observed in a meta-analysis of 10 studies conducted over the last 20 years in different countries [32]. However, few other studies reported significantly higher infection rates in boys than that of girls [33,34]. Our findings showed a significant association between higher rates of H. pylori infection in children of illiterate parents. It indicates that children of illiterate parents might have less knowledge regarding personal hygiene and good life style and that ultimately poses greater risk to be infected with H. pylori. Our study revealed H. pylori infection was acquired in early childhood in rural Bangladeshi children. However, further study is necessary to understand the long term consequences of childhood H. pylori infection on the overall health of the population with the progress of age.   Acknowledgement Authors gratefully acknowledge the support of Square Pharmaceuticals Ltd. for providing the accommodation during the field work.   Authors’ contributions SM: sample/data collection, laboratory work, data entry and analysis and manuscript writing; FR: sample/data collection, laboratory work, data entry and analysis; FA: sample/data collection and data entry; RK and SA: sample/data collection; SPS: data entry; MSAJ: sample/data collection and data analysis; MAS and JAH: Idea generation, study design, data analysis and editing of manuscript.   Conflict of interest: The authors do not have any conflict of interest.   Financial support: The study was funded by research grant from Ibrahim Medical College, Dhaka, Bangladesh.   References 1.     Brown LM. Helicobacter pylori: epidemiology and routes of transmission. Epidemiol Rev. 2000; 22(2): 283–297. 2.     Salih BA. Helicobacter pylori infection in developing countries: the burden for how long? Saudi J Gastroenterol. 2009; 15(3): 201–207. 3.     Yamada T. Consensus development panel for Helicobacter pylori in peptic ulcer disease. JAMA. 1994; 272(1): 65–69. 4.     Naficy AB, Frenck RW, Abu-Elyazeed R, Kim Y, Rao MR, Savarino SJ, et al. Seroepidemiology of Helicobacter pylori infection in a population of Egyptian children. Int J Epidemiol. 2000; 29(5): 928–932. 5.     Adeniyi OF, Fajolu IB, Temiye E, Esezobor CI, Mabogunje CA. Helicobacter pylori infection in malnourished children in Lagos. Niger Med J. 2019; 60(4): 205–210. 6.     Hooi JKY, Lai WY, Ng WK, Suen MMY, Underwood FE, Tanyingoh D, et al. Global prevalence of Helicobacter pylori infection: systematic review and meta-analysis. Gastroenterology. 2017; 153(2): 420–429. 7.     Rhaman MM, Rahman F, Mazumder S, Sayeed MA, Haq JA. Helicobacter pylori infection in asymptomatic rural Bangladeshi population. IMC J Med Sci. 2021; 15(1): 007. 8.     Parsonnet J. Helicobacter pylori: the size of the problem. Gut. 1998; 43(Suppl 1): S6–S9. 9.     Banatvala N, Mayo K, Megraud F, Jennings R, Deeks JJ, Feldman RA. The cohort effect and Helicobacter pylori. J Infect Dis. 1993; 168: 219–221. 10.  Suerbaum S, Michetti P. Helicobacter pylori infection. N Engl J Med. 2002; 347: 1175–1186. 11.  O’Donohoe JM, Sullivan PB, Scott R, Rogers T, Brueton MJ, Barltrop D. Recurrent abdominal pain and Helicobacter pylori in a community-based sample of London children. Acta Paediatr. 1996; 85(8): 961–964. 12.  Yamashita Y, Fujisawa T, Kimura A, Kato H. Epidemiology of Helicobacter pylori infection in children: a serologic study of the Kyushu region in Japan. Pediatr Int. 2001; 43(1): 4–7. 13.  Malaty HM, Kim JG, Kim SD, Graham DY. Prevalence of Helicobacter pylori infection in Korean children: inverse relation to socioeconomic status despite a uniformly high prevalence in adults. Am J Epidemiol. 1996; 143(3): 257–262. 14.  Aguemon BD, Struelens MJ, Massougbodji A, Ouendo EM. Prevalence and risk-factors for Helicobacter pylori infection in urban and rural Beninese populations. Clin Microbiol Infect. 2005; 11(8): 611–617. 15.  Sarker SA, Naliar S, Rahman M, Bardhan PK, Nair GB, Beglinger C, et al. High prevalence of cagA and vacA seropositivity in asymptomatic Bangladeshi children with Helicobacter pylori infection. Acta Paediatr. 2004; 93(11): 1432–1436. 16.  Rowland M, Daly L, Vaughan M, Higgins A, Bourke B, Drumm B. Age-specific incidence of Helicobacter pylori. Gastroenterology. 2006; 130(1): 65–72. 17.  Drumm B, Perez-Perez GI, Blaser MJ, Sherman PM. Intrafamilial clustering of Helicobacter pylori infection. N Engl J Med. 1990; 322: 359–363. 18.  Malaty H, Graham DY, Klein P, Evans DG, Adam E, Evans DJ. Transmission of Helicobacter pylori infection. Studies in families of healthy individuals. Scand J Gastroenterol. 1991; 26: 927–932. 19.  Lu Y, Redlinger TE, Avitia R, Galindo A, Goodman K. Isolation and genotyping of Helicobacterpylori from untreated municipal waste water. Appl Environ Microbiol. 2002; 68: 1436–1439. 20.  Khurana R, Fischbach L, Chiba N, van Zanten SV, Sherman PM, George BA, et al. Meta-analysis: Helicobacter pylori eradication treatment efficacy in children. Aliment Pharmacol Ther. 2007; 25: 523–536. 21.  de Boer WA, Tytgat GN. Regular review: treatment of Helicobacter pylori infection. BMJ. 2000; 320(7226): 31–34. 22.  Nguyen TVH, Phan TTB, NguyenVBP, HoangTTH, Le TLA, Nguyen TTM, et al. Prevalence and risk factors of Helicobacter pylori infection in Muong children in Vietnam. Ann Clin Lab Sci. 2017; 5(1): 159. 23.  Ndip RN, Malange AE, Akoachere JF, MacKay WG, Titanji VP, Weaver LT. Helicobacter pylori antigens in the faeces of asymptomatic children in the Buea and Limbe health districts of Cameroon: a pilot study. Trop Med Int Health. 2004; 9(9): 1036–1040. 24.  Omar AA, Ibrahim NK, Sarkis NN, Ahmed SH. Prevalence and possible risk factors of Helicobacter pylori infection among children attending Damanhour Teaching Hospital. J Egypt Public Health Assoc. 2001; 76(5-6): 393–410. 25.  Opekun AR, Gilger MA, Denyes SM, Nirken MH, Philip SP, Osato MS, et al. Helicobacter pylori infection in children of Texas. J Pediatr Gastroenterol Nutr. 2000; 31(4): 405–410.  26.  Aguemon BD, Struelens MJ, Massougbodji A, Ouendo EM. Prevalence and risk-factors for Helicobacter pylori infection in urban and rural Beninese populations. Clin Microbiol Infect. 2005; 11(8): 611–617.  27.  Nguyen TH, Nguyen VB, Phan TT. Epidemiology of Helicobacter pylori infection in Tay children in Vietnam. Ann Clin Lab Res. 2016; 4: 4. 28.  Awuku YA, Simpong DL, Alhassan IK, Tuoyire DA, Afaa T, Adu P. Prevalence of Helicobacter pylori infection among children living in a rural setting in Sub-Saharan Africa. BMC Public Health. 2017; 17(1): 360. 29.  Khatun S, Rahman F, Shadia K, Dutta IK, Hoq MN, Akter F, et al. Evaluation of rapid stool antigen test for the diagnosis of Helicobacter pylori infection in patients with dyspepsia. IMC J Med Sci. 2017; 10(2): 39–44. 30.  Malaty HM, Graham DY, Wattigney WA, Srinivasan SR, Osato M, Berenson GS. Natural history of Helicobacter pylori infection in childhood: 12-year follow-up cohort study in a biracial community. Clin Infect Dis. 1999; 28(2): 279–282. 31.  Klein PD, Gilman RH, Leon-Barua R, Diaz F, Smith EO, Graham DY. The epidemiology of Helicobacter pylori in Peruvian children between 6 and 30 months of age. Am J Gastroenterol. 1994; 89(12): 2196–2200. 32.  de Martel C, Parsonnet J. Helicobacter pylori infection and gender: a meta-analysis of population-based prevalence surveys. Dig Dis Sci. 2006; 51(12): 2292–2301. 33.  Hestvik E, Tylleskar T, Kaddu-Mulindwa DH, Ndeezi G, Grahnquist L, Olafsdottir E, et al. Helicobacter pylori in apparently healthy children aged 0-12 years in urban Kampala, Uganda: a community-based cross sectional survey. BMC Gastroenterol. 2010; 10: 62. 34.  Lin SK, Lambert JR, Nicholson L. Prevalence of Helicobacter pylori in a representative Anglo-Celtic population of urban Melbourne. J Gastroenterol Hepatol. 1998; 13: 505–510.     Cite this article as: Mazumder S, Rahman F, Akter F, Khatun R, Akter S, Saha SP, et al. Asymptomatic Helicobacter pylori infection among rural children and adolescents in Bangladesh. IMC J Med Sci. 2022; 16(2): 007. DOI: https://doi.org/10.55010/imcjms.16.017 <![CDATA[Serum ferritin level in type 2 diabetic patients with renal dysfunction]]> Prashanth Kumar Goudappala Jasneet Kaur Sandhu Vinay Kumar Krishnaiah Siva Prasad Palem https://imcjms.com/journal_full_text/416 2022-06-02 11:19:10 Original Article IMC J Med Sci 2022; 16(2): 008 Abstract Background and objective: Nephropathy is the major cause of end-stage renal disease (ESRD) in type 2 diabetes mellitus (T2DM). Delay in identification and management of nephropathy in T2DM may cause development of ESRD. An increased level of serum ferritin plays a role in the pathogenesis of chronic kidney disease (CKD) in T2DM. Hence, the present study intended to assess the level of serum ferritin in renal dysfunction in patients with T2DM. Material and methods: This was a retrospective study with 81 T2DM patients with and without nephropathy. They were categorized into two groups. Group-1 consisted of 46 T2DM cases without nephropathy and remaining 35 with nephropathy.The clinical and biochemical parameters such as blood glucose, urea, creatinine, iron, ferritin, transferrin, total iron binding capacity (TIBC), and haemoglobin were measured by standard methods, and estimated glomerular filtration rate (eGFR) by MDRD formula. Results: Significantly (p<0.05) elevated level of serum ferritin along with urea and creatinine was found in patients with T2DM with nephropathy.A significant positive correlation (r = 0.37) of serum ferritin and negative correlation (r = - 0.852) of eGFR with creatinine were found. It indicated that ferritin could be a good marker to monitor kidney function in T2DM. Conclusion: Apart from eGFR and serum creatinine, raised serum ferritin level was a good indicator of renal dysfunction in T2DM patients and might play an important role in renal dysfunction in early stage diabetic nephropathy. IMC J Med Sci 2022; 16(2): 008. DOI: https://doi.org/10.55010/imcjms.16.018 *Correspondence: Dr. Siva Prasad Palem., M.Sc., Ph.D., Department of Biochemistry, Faculty of Medicine, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar-505001, Telangana, India. Affiliated with Kaloji Narayana Rao University of Health Sciences (KNRUHS), Warangal, Telangana, India. E-mail: sp.biocom@yahoo.co.in.   Introduction Chronic kidney disease (CKD) is a global health problem. Patients with type 2 diabetes mellitus (T2DM) are in increased risk of developing chronic kidney disease. Globally, the prevalence of CKD among T2DM patients varied from 6.0% to 39.3% [1-3]. Also, diabetes-related chronic kidney disease (CKD) is the leading cause of end-stage kidney disease (ESKD) in T2DM patients worldwide [4,5]. Ferritin is an evolutionarily preserved intracellular iron storage protein that control ironmetabolism[6].Serum ferritin is considered as a malignancy marker, namely in neuroblastoma, renal cell carcinoma, or Hodgkin's lymphoma. Hyperferritinemia is also related with hepatic dysfunction, usually because liver is the main organ to eliminate moving ferritin molecules. In addition, T2DM is often related with increased levels of serum ferritin. A relation between concentration of high serum ferritin, insulin resistance and glucose intolerance in healthy individuals has also been reported [7]. Moreover, a reduction in glucose resistance has been recognized after depletion of iron in T2DM subjects [8]. High levels of ferritin have been observed in subjects who had CKD with proteinuria and glomerular disease [9].The present study was carried out to find whether serum ferritin can be an independent marker of kidney dysfunction in patients with T2DM.   Materials and methods This study was conducted at the Clinical Biochemistry laboratory of Chalmeda Anand Rao Institute of Medical Sciences & Hospital, Karimnagar, Telangana, India. The study comprised of two groups aged between 34 to 53 years. Group-1 participants consisted of T2DM patients without CKD (n =46)while Group-2comprised of T2DM patients with chronic kidney dysfunction (n =35).T2DM patients having the serum creatinine higher than 1.4 mg/dl levels were considered to have chronic kidney dysfunction. T2DM patients with serum creatinine less than 1.4 mg/dl were considered to have normal kidney function. Data of the patients were collected from the records of Clinical Biochemistry laboratory from September 2020 to December 2020. The requirement of written informed consent was waived owing to the retrospective nature of the study. Blood glucose, urea, creatinine, hemoglonin, iron, transferrin, ferritin, total iron binding capacity (TIBC) were analysed in Randox Imola auto-analyser.eGFR was estimated based on serum creatinine using online MDRD (modification of Diet in Renal Disease) formula. The mean value and standard deviation were measured for each parameter. Mean values were compared by independent t test.Pearson's correlation coefficient test was used to measure association between variables. The analysis was carried out by using Sigma Plot 13 (Systat software USA).   Results A total of 81 T2DM patients were included in the study of which 46 had T2DM without CKD (Group-1) while 35 had T2DM with CKD (Group-2). Table-1 shows the detail characteristics of the Group-1 and Group-2 study population. The mean age of the Group-1 study population (35.50±1.1 years) was significantly (p<0.001) less than that of Group-2 cases (49.29±4.15 years). Ingenderwise distribution, Group-1had 28 males and 18 females, while Group-2had 26 males and 9 females. The biochemical parameters likeurea, creatinine and serum ferritin values were significantly (p<0.001) elevated in diabetic subjects with renal dysfunction compared to diabetic subjects without renal dysfunction. However, no significant difference was observed in the level of iron, TIBC, transferrin and haemoglobin between the two study groups.   Table-1: Clinical parameters of Group-1and Gruup-2 study population (n = 81)     Figure-1 illustrates that serum creatinine had significant positive correlation with age (r = 0.668), urea (r = 0.816) and serum ferritin (r = 0.37) in all study subjects. In addition to that creatinine was negatively correlated with TIBC and transferrin, but statistically insignificant. However, no significant correlation of creatinine with RBG, iron and haemoglobin was found in the study subjects. Figure-1: Correlation of creatinine with other parameters in all study subjects. RBS: Random blood glucose, TIBC: Total iron binding capacity, eGFR: estimated glomerular filtration rate.     Discussion Creatinine, urea and eGFR are clinically established diagnostic markers for renal disease. The anhydrous form of creatinine gets filtered by the glomerulus and thus serum creatinine is considered as an indirect estimation of glomerular filtration capacity. The diminished glomerular filtration rate leads to rise in creatinine and urea levels in the serum [10,11]. Furthermore, estimation of albuminuria, serum creatinine and eGFR are predictors of renal disease progression in T2DM [12]. In the present study significant positive co-relation of creatinine was found with raised serum ferritin level in study population. Serum iron, TIBC, transferrin and haemoglobin levels were though higher in diabetic patients with no kidney dysfunction but the differences were not statistically significant than those with CKD. Overall, we found that TIBC, transferrin, haemoglobin and eGFR were negatively correlated with creatinine.Recently it has been reported that raised levels of serum ferritin may play a role in the pathogenesis leading to the development of CKD in T2DM [13]. Also, serum ferritin level has been found as a prognostic marker for predicting renal recovery in acute kidney injury [14]. Therefore, elevated serum ferritin may be considered as a marker for kidney dysfunction in patients with T2DM.The serum ferritin could be used as laboratory parameter for the diagnosis of kidney dysfunction because of its easy availability and low cost.For clinical practice, serum ferritin marker may also be one of the recommended assays for identifying and monitoring the chronic kidney dysfunction in patient with T2DM. Conflict of interest The authors declare that they have no conflict of interest for this study.   Fund: Nil   References 1.     Wagnew F, Eshetie S, Kibret GD, Zegeye A, Dessie G, Mulugeta H, et al. Diabetic nephropathy and hypertension in diabetes patients of sub-Saharan countries: a systematic review and meta-analysis. BMC Res Notes. 2018; 11: 565. 2.     Bailey RA, Wang Y, Zhu V, Rupnow MF. Chronic kidney disease in US adults with type 2 diabetes: an updated national estimate of prevalence based on kidney disease: Improving Global Outcomes (KDIGO) staging. BMC Res Notes. 2014; 7: 415. 3.     Jitraknatee J, Ruengorn C, Nochaiwong S. Prevalence and risk factors of chronic kidney disease among type 2 diabetes patients: a cross-sectional study in primary care practice. Sci Rep. 2020; 10: 6205. 4.     Tuttle KR, Bakris GL, Bilous RW, Chiang JL, de Boer IH, Goldstein-Fuchs J, et al. Diabetic Kidney Disease: a report from an ADA Consensus Conference. Diabetes Care. 2014; 37(10): 2864–2883. 5.     Saran R, Robinson B, Abbott KC, Agodoa LYC, Bragg-Gresham J, Balkrishnan R, et al. US Renal Data System 2018 Annual Data Report: epidemiology of kidney disease in the United States. Am J Kidney Dis. 2019; 73(3 Suppl 1): A7-A8. 6.     Knovich MA, Storey JA, Coffman LG, Torti SV, Torti FM. Ferritin for the clinician. Blood Rev. 2009; 23(3): 95-104. 7.     Kim NH, Oh JH, Choi KM, Kim YH, Baik SH, Choi DS, et al. Serum ferritin in healthy subjects and type 2 diabetic patients. Yonsei Med J. 2000; 41(3): 387-392. 8.     Wanner C, Lachin JM, Inzucchi SE, Fitchett D, Mattheus M, George J, et al. Empagliflozin and clinical outcomes in patients with type 2 diabetes mellitus, established cardiovascular disease, and chronic kidney disease. Circulation. 2018; 137:119-129. 9.     Saidi T, Zaim O, Moufid M, El Bari N, Ionescu R, Bouchikhi B. Exhaled breath analysis using electronic nose and gas chromatography–mass spectrometry for non-invasive diagnosis of chronic kidney disease, diabetes mellitus and healthy subjects. Sens Actuators B: Chem. 2018; 257:178-188. 10.  Anders HJ, Huber TB, Isermann B, Schiffer M. CKD in diabetes: diabetic kidney disease versus nondiabetic kidney disease. Nat Rev Nephrol. 2018; 14:361-377. 11.  Ray AS, Kare PK, Makwane HS, Saxena T, Garg C. Estimation of serum creatinine, serum urea, glomerular filtration rate and proteinuria among apparently healthy adults to assess the renal impairment and its association with body mass index: an observational hospital-based study. Int J Med Res Rev. 2020; 8(2): 183-188. 12.  Norris KC, Smoyer KE, Rolland C, Van der Vaart J, Grubb EB. Albuminuria, serum creatinine, and estimated glomerular filtration rate as predictors of cardio-renal outcomes in patients with type 2 diabetes mellitus and kidney disease: a systematic literature review. BMC nephrol. 2018; 19(1): 1-3. 13.  Wu YH, Wang SY, Li MX, He H, Yin WJ, Guo YH, et al. Serum ferritin independently predicts the incidence of chronic kidney disease in patients with type 2 diabetes mellitus. Diabetes Metab Syndr Obes. 2020; 13: 99-105. 14.  Dimitrijevic ZM, Salinger-Martinovic SS, Jankovic RJ, Mitic BP. Elevated serum ferritin levels are predictive of renal function recovery among patients with acute kidney injury. Tohoku J Exp Med. 2019; 248(2): 63-71.     Cite this article as: Goudappala PK, Sandhu JK, Krishnaiah VK, Palem SP. Serum ferritin level in type 2 diabetic patients with renal dysfunction. IMC J Med Sci. 2022; 16(2): 008. DOI: https://doi.org/10.55010/imcjms.16.018 <![CDATA[Anti-ulcer effects of natural honey against indomethacin induced gastric ulcer in rats]]> Md. Faizul Ahasan Md. Ismail Khan Eliza Omar Eva Rukhsana Quadir Masuma Khanom Syful Islam Shumona Haque https://imcjms.com/journal_full_text/423 2022-06-22 16:12:25 Original Article Abstract Background and objectives: Non-steroidal anti-inflammatory drugs (NSAIDs) are the leading cause of peptic ulcer disease (PUD). Drug such as proton pump inhibitors or cytoprotective agents used to treat PUD have several adverse effects. Therefore, interest in alternative therapies like honey has increased due to fewer side effects, ease of accessibility and affordability. This study determined the anti-ulcer effect of natural honey against indomethacin induced ulcer in rats. Materials and Methods: This experimental study was conducted on albino rats. Rats were assigned to four groups (Group1 to 4) and each group consisted of six rats. Gr1 received indomethacin (60 mg/kg) only and Gr2, 3 and 4 were pre-treated with assigned doses of sucralfate, honey, and honey + sucralfate respectively for 7 days. The effects of experimental agents were assessed by ulcer score, ulcer index (UI), percentage protective ratio (PPR). Effect of honey, sucralfate and honey plus sucralfate mixture was compared against high dose indomethacin induced gastric ulcer in rats. Results: UI significantly (p < 0.001) reduced in sucralfate, (0.67 ± 0.82), honey (0.83 ± 0.98) and honey + sucralfate (0.17 ± 0.41) treated group compared to only indomethacin treated group (4 ± 0.63).The PPR of sucralfate, honey and honey + sucralfate was 83.25%, 79.25% and 95.75%, respectively. Conclusions: The study showed that honey had anti-ulcer properties against the indomethacin-induced gastric ulcers and the effect is potentiated when used with sucralfate. Honey may be used to protect the gastric mucosa against NSAIDs. IMC J Med Sci 2022; 16(2): 009. DOI: https://doi.org/10.55010/imcjms.16.019 *Correspondence: Md. Faizul Ahasan, Department of Pharmacology, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka 1000, Bangladesh. Email: arronnoo_shuvro@live.com   Introduction Peptic ulcer disease (PUD) is one of the most common gastrointestinal diseases with a worldwide prevalence of nearly 11-14% in men and 8-11% in women [1]. The typical causes include infection with Helicobacter pylori (H. pylori), consumption of non-steroidal anti-inflammatory drugs (NSAIDs) and medications like steroids, iron preparations and selective serotonin reuptake inhibitors (SSRIs) [2,3]. Gastric injury following indomethacin ingestion is mediated by interference to prostaglandins production and their physiological actions. Consequently, gastric mucosal blood flow reduces, and there is a drop in mucin levels with decreased bicarbonate release with the upturn in leukocyte activation. Additionally, alteration in the production of inflammatory and pro-inflammatory mediators, acid secretion, vasoconstriction and leucocyte adhesion to vascular endothelium gets upper hand, ultimately causing release of free radicals that produce gastric mucosal damage [4]. Misoprostol and sucralfate, used for the treatment of NSAID induced peptic ulcer are associated with several adverse effects. Misoprostol may cause diarrhoea, abdominal pain, headache, uterine cramps, menstrual disorder, fatigue, and muscle cramps [5] while sucralfate may cause constipation, dry mouth, nausea, vomiting, headache, urticaria and rashes [6]. Honey as a medicinal natural product has been studied throughout the last decade. Honey is recognized not only as a sweetener but also as a component of traditional folk medicine around the world. It is the by-product of flower nectar and upper aero-digestive tract secretion of the honeybee, concentrated through a dehydration process inside the beehive. It is principally composed of sugar, water, antioxidant, vitamin, catalase, superoxide dismutase, reduced glutathione, Millard reaction products and peptides, phenolic acids, and flavonoids [7,8]. Honey stimulates the sensory nerve endings of the stomach (capsaicin responding), releases vasodilatory peptides and produce nitric oxide thereby increasing blood supply and protecting the gastric mucosa [9]. It augments levels of non-protein sulfhydryl (NP-SH) groups which prevent oxidative damage, thereby blocking free radical derived self-amplifying inflammatory response [8]. Their anti-inflammatory action reduces the features of inflammation and stimulates the formation of granulation tissue [10]. The objective of this study was to assess the anti-ulcer effects of honey alone and in combination with sucralfate against indomethacin-induced ulcer in rats.   Material and Methods The study assessed the anti-ulcer effect of honey against experimentally induced gastric ulcers with high dose (60 mg/kg)of indomethacin in albino rats. The study was conducted at the Department of Pharmacology of Dhaka Medical College and was approved by the Institutional Research Review Board. Experimental animal: Albino rats (150-200 g) of either sex were used. Rats were kept at standard housing condition and fed with standard diet and water during the experiments. Honey and drugs: The honey used in this study was pure, unprocessed, unboiled and procured from the National Institute of Apiculture, Dhaka, Bangladesh. The dose of honey administered was 1.2 g/kg/day (0.84 ml/kg) body weight. [11]. According to the Density Database Version 2.0 - FAO, 1g honey is equivalent to 0.696 ml. Indomethacin, and sucralfate used in the study were obtained from Beximco Pharmaceutical Ltd, Bangladesh. Indomethacin was used to induce gastric lesion. Sucralfate was used as standard gastro- protective drug to compare with the effects of honey. The dose of indomethacin was 60 mg/kg given once on day 7 while the dose of sucralfate was 250 mg/kg body weight per day [11,15]. Dose was calculated for individual rat according to the body weight and stock solution was prepared just before the daily administration. The entire calculated amount was dissolved in distilled water and administered orally through nasogastric tube at a volume of 1 ml/100 g body weight [16]. Study design: Protective effect of honey alone and in combination with sucralfate was assessed on indomethacin induced gastric ulcer in rats. Anti-ulcer effect of honey alone was also compared with that of sucralfate. Rats were assigned to four groups (Group1 to 4) and each group consisted of six rats and received the treatment as described in Table-1. Group-1 received indomethacin on day 7 only and served as positive control. Group-2, 3 and 4 received pre-treatment with sucralfate, honey and sucralfate plus honey respectively for 7 days and indomethacin on day 7.Thirty minutes after the last (on day 7) daily administration of respective agents, rats of all groups were administered indomethacin (60 mg/kg, orally) suspended in distilled water. Thereafter, all rats were fasted for 24 hours but were given free access to water and were kept in separate cages to prevent coprophagy.   Table-1: Experimental design: drugs, dose schedule pre-treatment duration and indomethacin treatment     Sacrifice of rats and collection of the stomach: The rats were sacrificed, and stomachs were collected on 8th day. Stomachs were opened along their greater curvature and gently rinsed under running tap water and were spread on paraffin plate. Measurement of gastric lesions: Lesions were observed with the help of dissecting microscope grossly (10x) with a square grid eyepiece to assess the gastric lesions. Gastric lesion was expressed as ulcer score, ulcer index (UI) and percentage protection ratio (PPR) as described earlier [17]. Macroscopic ulcer score was assessed and scored as 0 = no lesion, 1 = mucosal edema and petechiae, 2 = one to five small lesions (1-2mm), 3 = more than five small lesions or one intermediate lesion (3-4 mm), 4 = two to more intermediate lesions or one gross lesion (>4 mm), and 5 = perforated ulcers. Ulcer index and PPR were calculated by the following formula: Ulcer index (UI) = Total ulcer score/Number of animals ulcerated. Percentage protection ration = [(UI of ulcerogen treated group/UI of ulcerogen treated) – (UI of drug pretreated group/ UI of ulcerogen treated)] x100 Statistical analysis: All relevant data for each rat were recorded and analyzed using Statistical Package for the Social Sciences (SPSS).   Results Table-2 shows the ulcer scores of the Group 1 to 4 of the study groups. Ulcer scores were between 3-5 (score 4 - 66.7% and score 3 and 5 - 16.7% each) of Gr1 rats receiving high dose of indomethacin. Rats of Gr2, Gr3 and Gr4 had ulcer scores from 0 to 2. In Gr4, 83.3% rats pre-treated with mixture of honey and sucralfate had ulcer score of 0. None of the rats in Gr2, 3 and 4 had ulcer score 3-5. Ulcer index of rats receiving sucralfate (Gr2), honey (Gr3) and sucralfate + honey (Gr4) was significantly (p< 0.001) less compared to that of indomethacin group (Gr1) (Table-3). However, no significant difference of ulcer index was observed among the rats of Gr2, 3 and 4. PPRs were 83.25%, 79.25% and 95.75% against high dose indomethacin induced ulcer in sucralfate, honey and sucralfate + honey pre-treated groups respectively. PPRs of different groups were not significantly different from each other (p>0.05).   Table-2: Ulcer score of rat stomachs treated with high dose indomethacin, sucralfate, honey and mixture of honey and sucralfate.     Table-3: Ulcer index and percentage protection ratio of rats treated with high dose indomethacin, sucralfate, honey and mixture of honey and sucralfate     Discussion This study demonstrates that honey alone, or in combination with sucralfate is an effective anti-ulcerogenic agent against indomethacin induced gastric lesions. Pre-treatment with sucralfate, honey and combination of sucralfate and honey significantly reduced the UI in rats treated with high dose of indomethacin (p < 0.001). Honey and sucralfate mixture had higher UI lowering ability compared to honey or sucralfate alone. The protection ratio was though maximum in honey sucralfate combination group, but not significantly different from other two groups against high dose indomethacin induced gastric lesions. In accordance with these results several authors reported that honey possesses a gastro-protective role in NSAIDs induced peptic ulcer disease [18-20]. Several mechanisms for this have been proposed. Stimulation of sensory nerves, release of vasodilatory peptides and nitric oxide, increased blood supply, augmentation of non-protein sulfhydryl (NP-SH) levels, inhibition of free radical derived self-amplifying inflammatory response reduce the feature of inflammation and promote healing of the damaged gastric tissue [8,11]. In conclusion, our study demonstrated that pre-treatment with honey alone or in combination with sucralfate can prevent or reduce mucosal lesions induced by indomethacin. However, the current study was basically a pharmacological study where both the modern drug and herbal product were used to influence the biological system in a rat model. Biological system is affected by individual variations. Therefore, further study is needed to assess the degree of anti-ulcer effects of natural honey in human. Comparing the findings observed in different groups of rats, it was obvious that honey had protective ability against indomethacin induced gastric ulcer and the effect was potentiated in combination with sucralfate. Therefore, honey may be used to protect the gastric mucosa against NSAIDs.   Conflict of interest: The authors do not have any conflict of interest.   Financial support: Nil.   References 1.     Malfertheiner P, Chan FK, Mccoll KE. Peptic ulcer disease. Lancet. 2009; 374(9699): 1449-1461. 2.     Rosenstock S, Jørgensen T, Bonnevie O, Andersen L. Risk factors for peptic ulcer disease: a population based prospective cohort study comprising 2416 Danish adults. Gut. 2003 Feb 1; 52(2): 186-93. 3.     Yuan Y, Padol IT, Hunt RH. Peptic ulcer disease today. Nat Clin Pract Gastroenterol Hepatol. 2006; 3(2): 80-89. 4.     Suleyman H, Albayrak A, Bilici M, Cadirci E, Halici Z. Different mechanisms in formation and prevention of indomethacin-induced gastric ulcers. Inflammation. 2010; 33(4): 224-234. 5.     Monk JP, Clissold SP. Misoprostol. Drugs. 1987; 33(1): 1-30. 6.     McCarthy DM. Sucralfate. New Eng J Med. 1991 Oct 3; 325(14): 1017-1025. 7.     Eteraf-Oskouei T, Najafi M. Traditional and modern uses of honey in human diseases: a review. Iran. J. Basic Med. Sci. 2013; 16(6): 731. 8.     Erejuwa OO, Sulaiman SA, Ab Wahab MS. Honey: a novel anti-oxidant. Molecules. 2012; 17(4): 4400-4423. 9.     Calatayud S, Sanz MJ, Canet A, Bello R, de Rojas FD, Esplugues JV. Mechanisms of gastroprotection by transdermal nitroglycerin in the rat. Br J Pharmacol. 1999; 127(5): 1111-1118. 10. Yaghoobi R, Kazerouni A. Evidence for clinical use of honey in wound healing as an anti-bacterial, anti-inflammatory anti-oxidant and anti-viral agent: A review. Jundishapur J. Nat. Pharm. Prod. 2013; 8(3): 100. 11.  Nasuti C, Gabbianelli R, Falcioni G, Cantalamessa F. Antioxidative and gastroprotective activities of anti-inflammatory formulations derived from chestnut honey in rats. NutrRes. 2006 Mar 1; 26(3): 130-137. 12.  Charrondiere UR, Haytowitz D, Stadlmayr B. FAO/INFOODS density database, version 2.0. InFood and agriculture organization of the United Nations technical workshop report 2012. 13.  Gharzouli K, Gharzouli A, Amira S, Khennouf S. Protective effect of mannitol, glucose-fructose-sucrose-maltose mixture, and honey hyperosmolar solutions against ethanol-induced gastric mucosal damage in rats. Exp. Toxicol. Pathol. 2001 Jan 1; 53(2-3): 175-180. 14.  Izzettin FV, Sancar M, Okuyan B, Apikoglu-Rabus S, Cevikbas U. Comparison of the protective effects of various antiulcer agents alone or in combination on indomethacin-induced gastric ulcers in rats. Exp. Toxicol. Pathol. 2012 May 1; 64(4): 339-343. 15.  Ali A, Al OS. Honey potentiates the gastric protective effects of sucralfate against ammonia-induced gastric lesions in rats. Saudi J Gastroenterol. 2003; 9(3): 117-123. 16.  Erhirhie EO, Ekene NE, Ajaghaku DL. Guidelines on dosage calculation and stock solution preparation in experimental animals' studies. J. Nat. Sci. Res. 2014; 4(18): 100-106. 17.  Adinortey MB, Ansah C, Galyuon I, Nyarko A. In vivo models used for evaluation of potential antigastroduodenal ulcer agents. Ulcers. 2013; 2013: 1–12. 18.  Gharzouli K, Amira S, Gharzouli A, Khennouf S. Gastroprotective effects of honey and glucose-fructose-sucrose-maltose mixture against ethanol-, indomethacin-, and acidified aspirin-induced lesions in the rat. Exp. Toxicol. Pathol. 2002; 54(3): 217-221. 19.  Lychkova AE, Kasyanenko VI, Puzikov AM. Gastroprotective effect of honey and bee pollen. Clin. Exp. Gastroenterol. 2014; 1(9): 72-74. 20.  Header E, Hashish AE, ElSawy N, Al-Kushi A, El-Boshy M. Gastroprotective effects of dietary honey against acetylsalicylate induced experimental gastric ulcer in albino rats. Life Sci. 2016; 13(1): 42-47.    Cite this article as: Ahasan MF, Khan MI, Eva EO, Quadir R, Khanom M, Islam S, Haque S. Anti-ulcer effect of natural honey against indomethacin induced gastric ulcer in rats. IMC J Med Sci 2022; 16(2): 009. DOI: https://doi.org/10.55010/imcjms.16.019 <![CDATA[Prevalence of rotavirus infection among children under five years at a tertiary institution in Nigeria]]> Felix Olaniyi Sanni Ochonye Boniface Bartholomew Ishata Conteh Zachary Gwa Azeezat Abimbola Oyewande Olumide Faith Ajani Michael Olugbamila Dada Paul Olaiya Abiodun Andrew Nuhu Yashim Michael Olabode Tomori Olaide Lateef Afelumo Innocent Okwose Ahmed Mamuda Bello Abimbola Oluseyi Ariyo https://imcjms.com/journal_full_text/424 2022-08-27 10:58:49 Original Article J Med Sci. 2022; 16(2): 010 Abstract Background and objectives: Rotavirus is a significant cause of nonbacterial diarrhea, especially in infants and young children worldwide. This study evaluated the pattern of rotavirus infection in children under five years presenting with acute diarrhea in Abuja Teaching Hospital, Gwagwalada, Nigeria. Methodology: It was a cross-sectional descriptive study to describe the prevalence of rotavirus infection among children. The study enrolled children 1 to 59 months old with acute diarrhea attending General Paediatric Outpatient clinic and hospitalized in the Emergency Paediatric Unit of University of Abuja Teaching Hospital (UATH), Gwagwalada, Nigeria. Rotavirus antigen was detected in the stool by qualitative enzyme-linked immunosorbent assay (ELISA). Data were analyzed using IBM-SPSS version 25.0. Results: The study comprised of 414 diarrhoeal children aged 1–59 months, of which 226 (54.6%) were male and the mean age was 12.1 months. The overall rate of rotavirus infection was 43.0% (178/ 414). The rotavirus infection was slightly higher among females than in males (46.8% vs 39.8%; p=0.153). Children from upper and middle social classes were at 1.95 [CI=1.17–3.26] and 3.08[CI=1.77–5.34] times higher risks of rotavirus induced diarrhea than the children from the lower social class (p<0.005). Children whose mothers had post-secondary education were three times more at risk of rotavirus diarrhea [OR=3.70; CI=1.46–9.36] than those with primary or no formal education (p<0.05). Children who had never been vaccinated against rotavirus were four times more likely to suffer rotavirus infection than those who had been vaccinated [OR=3.96; 95%CI=1.13–13.89, p=0.032]. Conclusion: This study found that rotavirus was an important causative agent of diarrhea in children in Gwagwalada, Abuja. Due to low rotavirus vaccination status in children, rotavirus screening tests are necessary for children with acute diarrheal disease. J Med Sci. 2022; 16(2): 010.  DOI: https://doi.org/10.55010/imcjms.16.020 *Correspondence: Felix Olaniyi Sanni, Department of Public Health, Fescosof Data Solutions, Ogun, Nigeria. Email: fescosofanalysis@gmail.com   Introduction Diarrhea is one of the leading causes of childhood morbidity and mortality globally [1]. It is responsible for nine percent of all deaths among children under five years of age worldwide [1-3]. Most of these deaths occur in developing countries of Africa and South Asia [4]. The leading cause of death in acute diarrhea is dehydration, which results from excessive loss of fluid and electrolytes in diarrhea stools [5]. The etiology of diarrhea in children can be viral, bacterial, parasitic, nutritional, or other systemic illnesses [6]. Rapid population increase and deteriorating economic situations stretch the country’s available (albeit inadequate) health facilities, negatively impacting the population’s health, especially children under five years. More local studies are needed to reflect the true prevalence of rotavirus and determine the clinical severity of rotavirus diarrhea in North Central Nigeria. This study is designed to provide information and insight into the prevalence of rotavirus disease in Abuja’s Federal Capital Territory. The study has shown that rotavirus is an important causative agent of childhood diarrhoea at the General Paediatric Out-patient Clinic and the Emergency Paediatric Unit of UATH Gwagwalada. The prevalence of rotavirus infection was 43.0%, and more than 90% of rotavirus infections occur in children aged 24 months and below. Due to low rotavirus vaccination status in the community, rotavirus screening tests are necessary for children with acute diarrheal disease. 2.     Bhutta ZA. Acute gastroenteritis in children. In: Kliegman RM, Stanton BF, St Geme III JW, Schor NF, Behrman RE, editors. Nelson Textbook of Pediatrics. 20th ed. Philadelphia: Elsevier; 2015. p. 1854–1875. 4.     Parashar UD, Hummelman EG, Bresee JS, Miller MA, Glass RI. Global illness and deaths caused by rotavirus disease in children. Emerg Infect Dis. 2003; 9(5): 565–572. 6.     Imade PE, Eghafona NO. Viral agents of diarrhea in young children in two Primary Health Centers in Edo State, Nigeria. Int J Microbiol. 2015; 2015: 1–5. 8.     Dennehy PH. Rotavirus Vaccines : an overview.ClinMicrobiol Rev. 2008; 21(1): 198-208. 10.  National Bureau of Statistics (NBS). National Nutrition and Health Survey (NNHS) 2018. National Bureau of Statistics, UNICEF; 2018. 12.  Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine preventable diseases. 13th ed. Washington D.C.: Public Health Foundation; 2015. 14.  Vesikari T, Karvonen A, Prymula R, Schuster V, Tejedor J, Cohen R, et al. Efficacy of human rotavirus vaccine against rotavirus gastroenteritis during the first 2 years of life in European infants: randomized, double-blind controlled study. Lancet. 2007; 370(9601): 1757–1763. 16.  Page N, Mapuroma F, Seheri M, Kruger T, Peenze I, Walaza S. Rotavirus surveillance report, South Africa, 2013. Commun Dis Surveill Bull. 2014; 12(4): 130–135. 18.  Mwenda JM, Ntoto KM, Abebe A, Enweronu-laryea C, Amina I, Mchomvu J, et al. Burden and Epidemiology of Rotavirus Diarrhea in Selected African Countries : Preliminary Results from the African Rotavirus Surveillance Network. J Infect Dis. 2010; 202 Suppl 1: S5-11. 20.  Iyoha O, Abiodun PO. Human rotavirus genotypes causing acute watery diarrhea among under‑five children in Benin City, Nigeria. Niger J Clin Pract. 2015; 18: 48–51. 22.  Tagbo BN, Mwenda JM, Armah G, Obidike EO, Okafor UH, Oguonu T, et al. Epidemiology of Rotavirus Diarrhea among Children Younger than 5 years in Enugu, South East, Nigeria. Pediatr Infect Dis J. 2014; 33 Suppl: S19–22. 24.  Federal Republic of Nigeria. Priority Table III: Population distribution by sex, State, LGA and Senatorial District. Abuja: National Population Commission; 2010. 64 p. 26.  Araoye MO. Research Methodology with Statistics for Health and Social Sciences. Ilorin: Nathadex; 2003. p. 115–129. 28.  Records and Information Department, University of Abuja Teaching Hospital, Gwagwalada, Federal Capital Territory 2016. 30.  Udeani TK, Ohiri UC, Onwukwe OS, Chinedu C. Prevalence and Genotypes of Rotavirus Infection among Children with Gastroenteritis in Abuja, Nigeria. Res J Microbiol. 2018; 13(2): 84–92. 32.  Junaid SA, Umeh C, Olabode AO, Banda JM. Incidence of rotavirus infection in children with gastroenteritis attending Jos university teaching hospital, Nigeria. Virol J. 2011; 8(1): 1-8. 34.  Abiodun PO. Incidence of rotavirus in acute diarrhea in the University of Benin Teaching Hospital, Benin. Niger J Paediatr. 1989; 16: 31–34. 36.  Aminu M, Esona MD, Geyer A, Steele AD. Epidemiology of rotavirus and astrovirus infections in children in northwestern Nigeria. Ann Afr Med. 2008; 7(4): 168–174. 38.  Mwenda JM, Tate JE, Parashar UD, Mihigo R, Agócs M, Serhan F, et al. African rotavirus surveillance network: A brief overview. Pediatr Infect Dis J. 2014; 33 Suppl: S6–8. 40.  Bonkoungou IJO, Sanou I, Bon F, Benon B, Coulibaly SO, Haukka K, et al. Epidemiology of rotavirus infection among young children with acute diarrhea in Burkina Faso. BMC Pediatr. 2010; 10(1): 1–6. 42.  Fischer TK, Valentiner-Branth P, Steinsland H, Perch M, Santos G, Aaby P, et al. Protective immunity after natural rotavirus infection: A community cohort study of newborn children in Guinea-Bissau, West Africa. J Infect Dis. 2002; 186(5): 593–597. 44. Muendo C, Laving A, Kumar R, Osano B, Egondi T, Njuguna P. Prevalence of rotavirus infection among children with acute diarrhea after rotavirus vaccine introduction in Kenya. BMC Pediatr. 2018; 18(1): 1–9. 46.  Zarnani AH, Modarres S, Jadali F, Sabahi F, Moazenni SM, Vazirian F. Role of rotaviruses in children with acute diarrhea in Tehran, Iran. J Clin Virol. 2004; 29(3): 189–193. 48.  Wilking H, Höhle M, Velasco E, Suckau M, Eckmanns T. Ecological analysis of social risk factors for Rotavirus infections in Berlin, Germany, 2007-2009. Int J Health Geogr. 2012; 11(1): 1-12.   Cite this article as: Sani FO, Bartholomew OB, Conteh I, Gwa Z, Oyewande AB, Ajani OF, et al. Prevalence of rotavirus infection among children under five years at a tertiary institution in Nigeria. IMC J Med Sci. 2022; 16(2): 010. DOI: https://doi.org/10.55010/imcjms.16.020 <![CDATA[Localization and management of mediastinal parathyroid adenoma – a case report]]> Nusrat Sultana Amrit Rijal Hurjahan Banu Sharmin Jahan M Fariduddin Bishnu Pada Dey MA Hasanat https://imcjms.com/journal_full_text/412 2022-04-03 10:20:14 Clinical Case Report IMC J Med Sci 2022; 16(2): 003 Abstract Ectopic parathyroid adenoma sometimes poses diagnostic challenge and can be a cause of persistent and recurrent primary hyperparathyroidism. Anterior mediastinum is one of the locations for ectopic parathyroid adenoma. Surgical excision is the only cure and for successful surgery, pre-operative localization is crucial. Chance of failed surgery is being increased without prior localization of the ectopic gland. The combination of single photon emission computed tomography (SPECT) and computed tomography (CT) has got high sensitivity for accurate localization of ectopic parathyroid. On the other hand, with accurate localization surgical outcome is excellent. Here we report, successful localization and management of a case of primary hyperparathyroidism due to adenoma in anterior mediastinum in 47-year-old man. IMC J Med Sci 2022; 16(2): 003. DOI: https://doi.org/10.55010/imcjms.16.013 *Correspondence: Dr. Nusrat Sultana, Room no-1620, Block-D, 15th floor, Department of Endocrinology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh. Email: nusrat_sultana@bsmmu.edu.bd   Introduction Primary hyperparathyroidism results from excessive parathyroid hormone (PTH) secretion from parathyroid glands and is mostly due to the presence of one (75 to 80%) or more parathyroid adenoma (5%) [1]. The prevalence of ectopic parathyroid adenoma (EPA) is approximately 20% with primary hyperparathyroidism, but it is as high as 66% when repeat surgery is being done for recurrent or persistent hyperparathyroidism [2]. In a study over 1,500 patients of primary hyperparathyroidism who underwent surgery, ectopic parathyroid glands were found in 22% cases and were predominantly located in the thymus (38%) followed by 31% in the retro-esophageal region and 18% intra-thyroidal [3]. Among the various ectopic locations, mediastinal ectopic parathyroid adenomas constitute 1–2% [4]. For diagnosis of primary hyperparathyroidism, a combination of clinical features and laboratory findings of elevated serum calcium level with non-suppressed PTH is required [1,5]. The first line imaging studies are neck ultrasound and technetium 99 sestamibi (99mTc) scan though sensitivity of these methods is relatively low. However, combination of single photon emission computed tomography and computed tomography (SPECT-CT) increases sensitivity [2,6]. 4D-CT is superior to sestamibi scan in localizing hyperfunctioning parathyroid gland/adenoma or in case of multi gland disease [7]. Surgery is curative in case of primary hyperparathyroidism. EPA often poses diagnostic challenge and responsible for persistent or recurrent hyperparathyroidism [2]. But it can also be treated successfully by surgery with help of an accurate preoperative localization [4]. Thus the main challenge in managing EPA remains with proper localization and selection of surgical procedure. Here, we describe a case of mediastinal parathyroid adenoma detected successfully by SPECT-CT in a middle aged male patient who presented with features of hyperparathyroidism.   Case report A 47-year-old man presented to Endocrinology outpatient department of Bangabandhu Sheikh Mujib Medical University (BSMMU) in March 2021 with the history of recurrent renal stones for last three years which was managed by urologist conservatively as the size of the stones were small. During evaluation he was found to have raised serum calcium level 11.8 mg/dl, high serum intact parathyroid hormone (S-iPTH) 221.10 pg/ml and low inorganic phosphate (iPO4) 1.7 mg/dl. He had complaints of anorexia, dyspepsia, fatigability, insomnia and some neuropsychiatric manifestations like depression, anxiety and burning sensation of whole body. On examination he was found mildly anemic, otherwise examination findings were unremarkable. Other laboratory reports showed low vitamin-D level [25(OH)D] 12.20 ng/dl, normal renal function and serum alkaline phosphatase level was within normal range. His bone mineral density (BMD) showed low T score in lumbar vertebrae and in both femoral neck, ─3.2, ─2.7 and ─2.9 respectively. Ultrasonogram (USG) of the abdomen revealed nephrocalcinosis and plain X-ray abdomen showed presence of left renal calculi. USG of the neck was done to find out the source of high PTH, which suggested mild thyromegaly only. The patient was then advised to perform fused SPECT-CT fusion imaging of neck and upper thorax. It showed the presence of parathyroid adenoma within the anterior mediastinum (Figure-1). Based on the above, the patient was diagnosed of having mediastinal parathyroid adenoma. Subsequently he was referred to the Department of Cardiothoracic surgery of BSMMU and an extended thymectomy with excision of ectopic parathyroid adenoma was carried out. Intra-operative blood sample for iPTH revealed a result of 18.5 pg/ml which was 221.10 pg/ml prior to surgery. Serum calcium was reduced to normal level (9.7 mg/dl) within one month. Histopathology confirmed the excised tissue as parathyroid adenoma (Figure-2).     Figure-1: SPECT-CT image of neck and upper thorax shows focal area of increased radiotracer concentration within the anterior mediastinum at the level of D3-D4.     Figure-2: H&E 100x: Section shows a parathyroid neoplasm composed of mostly chief cells with thin fibrous capsule. These cells have round nucleus with scanty granular cytoplasm. Follicle formation is present. Stromal adipocytes are absent. Not much of atypia or mitosis is seen. No capsular or vascular invasion is seen.   The patient was discharged with vitamin-D supplementation with colecalciferol 1000 IU daily as maintenance dose. He was also prescribed bisphosphonate alendronate 70 mg on a weekly schedule until follow-up with repeat DEXA scan of bone after 2 years. The periodic follow-up over the next six months ensured successful excision of adenoma as evidenced by persistence of normal S-calcium and i-PTH levels. There was symptomatic improvement as well, though some features like burning sensation of body and sleep disturbance persisted to some extent initially. Finally, the patient became completely symptom free after six months of surgery and there was no more occurrence of new renal stone.   Discussion This case report underlines the diagnostic workup and management of primary hyperparathyroidism (PHPT) due to ectopic parathyroid adenoma (EPA) located in anterior mediastinum. The classical presentations of PHPT which is commonly known as "bones, stones, abdominal groans, and psychic moans" are uncommon in the developed world but in a resource-limited country it is still the initial presentation [8]. In Western countries, asymptomatic patients of primary PHPT are detected during routine testing for serum calcium. They usually have mild hypercalcemia and serum calcium is usually below 11.5 mg/dl [9,10]. In course of time, approximately 30% of patients may develop classical manifestations like renal stone, nephrocalcinosis or skeletal manifestations [11]. Our patient was never being screened for calcium level before rather he was found to be hypercalcemic when he already had developed recurrent renal stone, nephrocalcinosis and some form of skeletal involvement. History of previous illness revealed that he had nonspecific symptoms like fatigability, anorexia, dyspepsia, depression, anxiety long before manifestation of renal stone. It has been reported in literature that patients in asymptomatic stage might actually have nonspecific symptoms [12]. Curative treatment of primary hyperparathyroidism involves surgical removal of the parathyroid adenomas whether the diseased gland is located in eutopic or ectopic position. Though preoperative localization of the gland is not obligatory in first time surgery but it helps to successfully carry out minimally invasive surgery [1]. But, in case of ectopically located gland, chance of failed surgery is high without prior localization. A number of localization techniques, both invasive and non-invasive procedures are available. In this case we tried to locate the source at first by ultrasound but it was unrevealing. Later on, without going for sestamibi scan alone we went for SPECT-CT fusion image of neck and upper thorax and the adenoma was spotted within the anterior mediastinum. For mediastinal parathyroid adenomas without prior imaging there is a reported failure rate of 30–36% [13]. The presence of EPA can be elusive sometimes. Various imaging modalities including ultrasonography, CT scan, magnetic resonance imaging (MRI), positron emission tomography (PET), Tc99m-Sestamibi scan, SPECT-CT fusion image of parathyroid are being utilized with variable sensitivity. Among these, ultrasound is the most widely used modality due to its low cost and easy availability and is good at locating adenomas in thyroid region, but it tends to miss ectopically located gland [4,14]. Tc99m-sestamibi scan is increasingly being utilized for the locating EPA with good sensitivity of up to 90% [15]. Moreover, SPECT combined with sestamibi scintigraphy which is a multiplane imaging provide three-dimensional image and thus further increase the sensitivity of detecting mediastinal adenoma [4]. A meta-analysis of 24 studies has demonstrated that SPECT-CT image is superior to planar and SPECT techniques alone in localizing EPAs [16]. CT alone has low sensitivity (45–55%) for parathyroid disease, but it is slightly better in detecting mediastinal parathyroid disease. The overall sensitivity of MRI is 78% and it goes up to 88% in mediastinal parathyroid glands. Invasive procedures like selective venous PTH sampling and selective angiography are seldom used because of its invasive nature [17]. In a case series on 16 patients by Akram et al. has reported that combination of SPECT-CT image of neck identified 39% more lesions compared with SPECT imaging alone [18]. This combination technique is used increasingly for routine preoperative localization of ectopic parathyroid adenomas [19]. Successful surgical outcome can be achieved by proper pre-surgical localization of the EPA. Removal of EPA routinely requires alternative surgical approaches than usual procedure for eutopic adenomas. Cervical approach is often not appropriate to reach mediastinal adenoma and sometimes parathyroid adenoma may be located deep in the mediastinum requiring thoracotomy or sternotomy [20]. In our case, surgical excision was done by approaching through sternotomy with successful outcome.   Conclusion EPA can be treated successfully by surgical excision with pre-operative accurate localization. Though localization is often difficult, combination of SPECT-CT is an excellent tool for localizing mediastinal parathyroid adenoma. This case report demonstrated that SPECT-CT imaging of neck and upper thorax is an important diagnostic procedure for localization of an EPA.   Acknowledgement: The authors gratefully acknowledge the team of Cardiothoracic Surgery of BSMMU for the surgical maneuver.   Conflict of interest: Nothing to declare.   Informed consent: The patient has given consent for publication.   Funding source: None   References 1.     Melmed S, Koenig R, Rosen C, Auchus R, Goldfine A. Williams Textbook of Endocrinology. 14th ed. Philadelphia: Elsevier; 2020. 2.     Moron Fe, Parikh AM, Suliburk JW. Imaging Ectopic parathyroid adenoma. A literature review. Rev Colomb Radiol. 2019; 30(1): 5069-5080. 3.     Roy M, Mazeh H, Chen H, Sippel RS. Incidence and localization of ectopic parathyroid adenomas in previously unexplored patients. World J Surg. 2013; 37(1): 102-106. 4.     Zhou W, Chen M. A case report of mediastinal ectopic parathyroid adenoma presented as parathyroid crisis localized by SPECT/CT. Medicine (Baltimore). 2016; 95(41): e5157. 5.     Wilhelm SM, Wang TS, Ruan DT, Lee JA, Asa SL, Duh QY, et al. The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism. JAMA Surg. 2016; 151(10): 959-968. 6.     Noussios G, Anagnostis P, Natsis K. Ectopic parathyroid glands and their anatomical, clinical and surgical implications. Exp Clin Endocrinol Diabetes. 2012; 120(10): 604e610. 7.     Minhas P, Jadhav R, Singh J, Virmani S, Gupta K. Diagnostic performance of 4D-CT in cases of primary hyperparathyroidism with negative SPECT 99mTc Sestamibi scan. J Nucl Med. 2020; 61(supplement 1): 1162. 8.     Lazaretti-Castro M. The diagnosis of primary hyperparathyroidism in developing countries remains in the past century: still with bones, stone and groans. Arch Endocrinol Metab. 2020; 64(2): 101. 9.     Silverberg SJ, Clarke BL, Peacock M, Bandeira F, Boutroy S, Cusano NE et al. Current issues in the presentation of asymptomatic primary hyperparathyroidism: Proceedings of the Fourth International Workshop. J Clin endocrinol Metab. 2014; 99: 3580. 10.  Bilezikian JP, Silverberg SJ. Clinical practice. Asymptomatic primary hyperparathyroidism. N Engl J Med. 2004; 350(17): 1746-1751. 11.  Yu N, Leese GP, Smith D, Donnan PT. The natural history of treated and untreated primary hyperparathyroidism: the parathyroid epidemiology and audit research study. QJM. 2011; 104(6): 513-521. 12.  Trombetti A, Christ ER, Henzen C, Gold G, Blandle M, Hermann FR, et al. Clinical presentation and management of patients with primary hyperparathyroidism of the Swiss Primary Hyperparathyroidism Cohort: a focus on neuro-behavioral and cognitive symptoms. J Endocrinol Invest. 2016; 39(5): 567-576. 13.  Wang C, Gaz RD, Moncure AC. Mediastinal parathyroid exploration: a clinical and pathologic study of 47 cases. World J Surg. 1986; 10(4): 687–695. 14.  Fatimi SH, Inama H, Chaganb FK, Choudryc UK. Management of mediastinal parathyroid adenoma via minimally invasive thoracoscopic surgery: Case report. Int J Surg Case Rep. 2017; 40: 120-123. 15.  Krausz Y, L. Bettman L, Guralnik L, Yosilevsky G, keidar Z, Bar-Shalom R, et al. Technetium-99m-MIBI SPECT/CT in primary hyperparathyroidism. World J Surg. 2006; 30(1): 76-83. 16.  Wong KK, Fig LM, Gross MD, Dwamena BA. Parathyroid adenoma localization with 99mTc-sestamibi SPECT/CT: a meta-analysis. Nucl Med Commun. 2015; 36(4): 363-375. 17.  Shen W, Düren M, Morita E, Higgins C, Duh Q-Y, Siperstein AE, et al. Reoperation for persistent or recurrent primary hyperparathyroidism. Arch Surg. 1996; 131: 861–869. 18.  Akram K, Parker JA, Donohoe K, Kolodny G. Role of single photon emission computed tomography/computed tomography in localization of ectopic parathyroid adenoma: a pictorial case series and review of the current literature. Clin Nucl Med. 2009; 34: 500–502. 19.  Elaraj DM, Sippel RS, Lindsay S. Are additional localization studies and referral indicated for patients with primary hyperparathyroidism who have negative sestamibi scan results? Arch Surg. 2010; 145: 578–581. 20.  Kitada M, Yasuda S, Nana T, Ishibashi K, Hayashi S, Okazaki S, et al. Surgical treatment for mediastinal parathyroid adenoma causing primary hyperparathyroidism. J Cardiothorac Surg. 2016; 11: 44.     Cite this article as: Sultana N, Rijal A, Banu H, Jahan S, Fariduddin M, Dey BP, Hasanat MA. Localization and management of mediastinal parathyroid adenoma - a case report. IMC J Med Sci. 2022; 16(2): 003. DOI: https://doi.org/10.55010/imcjms.16.013 <![CDATA[A case of Sjogren’s syndrome presenting with recurrent hypokalemia]]> Shapur Ikhtaire Nishat Nayla Aurpa Nuzaira Nahid Syeda Kimia Shahdaty Tahniyah Haq Khaled Mahbub Murshed Mohammad Ferdous Ur Rahaman Md. Abul Kalam Azad https://imcjms.com/journal_full_text/413 2022-05-16 10:10:53 Clinical Case Report IMC J Med Sci 2022; 16(2): 004 Abstract We report a case of a 26-year old lady who presented with a history of several episodes of limb weakness requiring repeated hospitalization over the last 12 years and about 6 years back, she also developed features of sicca complex. Further investigations revealed hypokalemia, distal renal tubular acidosis and bilateral extensive nephrocalcinosis. Finally, a diagnosis of Sjogren’s syndrome was made. Hypokalemia may be the presenting feature of Sjogren’s syndrome. Sjogren’s syndrome may be suspected in patients with recurrent hypokalemia and renal tubular acidosis. IMC J Med Sci 2022; 16(2): 004. DOI: https://doi.org/10.55010/imcjms.16.014 *Correspondence: Shapur Ikhtaire, Department of Internal Medicine, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka 1000, Bangladesh. Email: shapur17@gmail.com   Introduction Sjogren’s syndrome is a rare systemic autoimmune condition with chronic inflammation of exocrine glands. It typically involves the lacrimal and salivary glands, causing dry eyes and dry mouth respectively [1]. In this disorder, kidneys are also involved due to autoimmune tubulointerstitial nephritis and distal renal tubular acidosis (RTA) [2]. Distal RTA is characterized by inability to acidify the urine in the distal parts of the nephron [3]. Though distal RTA is common in Sjogren’s syndrome, it usually remains asymptomatic [4]. However, left untreated, it can lead to marked acid-base abnormalities like hyperchloremic metabolic acidosis and severe hypokalemia [3]. Hypokalemia is the most common electrolyte abnormality in distal RTA and may present earlier than typical glandular symptoms [5]. Here, we present a case of young lady with several episodes of weakness due to hypokalemia, who was subsequently diagnosed with primary Sjogren’s syndrome. Though, Sjogren’s syndrome is a recognized cause of distal RTA, its presentation as hypokalemic paralysis has not been widely reported in clinical practice.   Case report A 26-year-old woman with a 12 year history of recurrent limb weakness presented to our institution with epigastric pain, vomiting and profound weakness for 5 days. Soon after admission, pain and vomiting subsided with conservative treatment but the weakness persisted. On query, she gave history of several episodes of limb weakness requiring repeated hospitalization over the last 12 years. Each episode resolved after potassium supplementation. She was labeled as a case of hypokalemic periodic paralysis and precluded further work up in primary health care centre. During review of her symptoms, she mentioned dry mouth with oral ulceration, dry eyes, dyspareunia, hair fall and multiple inflammatory small joint pain for the last 6 years. For the last two years she noticed marked tooth erosion (Figure-1) and unintentional weight loss. There was no significant family history of note.     Figure-1: Photograph showing presence of dental erosion   On examination, there was xerosis of eyes and mouth, dental erosions and a positive Schirmer’s test (<10mm of wetting in 5min). She was mildly anemic and had an enlarged (1x1 cm), non-tender, firm right supraclavicular lymph node. Nervous system examination revealed 3/5 muscle weakness, flaccid reflexes, flexor planters and no sensory deficit. Examination of all other systems was unremarkable. Based on her clinical presentation, she was evaluated to find out the cause of recurrent hypokalemia. Laboratory investigations are shown in Table-1. Investigations revealed hypokalemia, normal anion gap metabolic acidosis and raised urine pH. Urine pH remained high (>5.3) after acid load test. These findings were consistent with distal RTA. She had evidence of microcytic hypochromic anemia with normal iron profile. Hemoglobin (Hb) electrophoresis showed evidence of beta-thalassemia trait. Liver function, renal function and calcium profile were normal. Her autoantibody screen revealed positive anti-nuclear (ANA), anti-Sjogren’s syndrome type A (anti SS-A) and anti-Sjogren’s syndrome type B (anti SS-B) antibodies. All other autoantibodies including anti-double stranded DNA, anti-Scl 70 (topoisomerase I), anti –ribonucleoproteins (anti-RNP), anti-Jo 1, anti-smooth muscle (anti- Sm) were negative. Imaging of the abdomen showed extensive bilateral nephrocalcinosis (Figure-2). Excision biopsy of the supraclavicular lymph node showed reactive lymphadenitis.     Figure-2: Imaging of the abdomen showing extensive bilateral nephrocalcinosis   Table-1: Investigation results of the patient     A presumptive diagnosis of primary Sjogren’s syndrome was made based on the presence of three (classic sicca symptoms, positive Schirmer’s test, positive anti-Sjogren’s syndrome antibodies) out of six American-European Consensus classification criteria. [1]. Renal complications included distal RTA and nephrocalcinosis. Accordingly, she was prescribed six cycles of pulse cyclophosphamide and prednisolone to treat the primary disease and halt further renal progression. Potassium, spironolactone and sodium bicarbonate were given for RTA. She was discharged in apparently good health and advised for regular follow up.   Discussion Sjogren’s syndrome is a rare autoimmune condition with chronic inflammation of exocrine organs such as lacrimal and salivary glands typically resulting in the characteristic symptoms of dry eyes and dry mouth. Extraglandular manifestations of this immune process can affect the kidneys, liver, lungs, pancreas, nervous system and skin [5]. Though renal involvement in Sjogren’s syndrome is rare, it is one of the most commonly confronted extraglomerular manifestations. Whilst tubulointerstitial nephritis (TIN) is the most common histological finding in Sjogren’s syndrome [6], distal RTA presenting as hypokalemia has been scarcely reported to date. Renal involvement is uncommon in Sjogren’s syndrome. When present, it is mainly due to TIN [6] and manifests as isolated hypokalemia, isolated acidosis, both proximal and distal RTA and nephrocalcinosis [7]. A study done by Ren et al on 130 patients with primary Sjogren’s showed that distal RTA was present in as many as 70% of the patients [8]. Although RTA is associated with Sjogren’s syndrome, hypokalemia due to RTA is rarely the main and sole presenting feature of this disorder. Furthermore, RTA is usually asymptomatic in patients with Sjogren’s syndrome [3]. A case report published by Rajput et al showed that nephrocalcinosis can also be the rare presenting manifestation of Sjogren’s syndrome [2]. Our patient presented with a long history of recurrent hypokalemic paralysis, which preceded typical symptoms of Sjogren’s syndrome. She also had nephrocalcinosis. Despite these renal involvements, her serum creatinine level was normal. She was finally diagnosed with primary Sjogren’s syndrome based on the presence of sicca symptoms and antibodies, which developed six years after her initial presentation with hypokalemia. This case demonstrates that symptomatic hypokalemia due to RTA can be a presenting feature of Sjogren’s syndrome, even before the appearance of typical sicca syndrome. To date the association between hypokalemic RTA and Sjogren’s syndrome has not been emphasized enough. Since renal involvement is rare and not included in the diagnostic criteria; and majority of patients present with typical sicca symptoms, diagnosis of Sjogren’s syndrome in patients presenting with RTA may be missed. Thus individuals with RTA should be investigated for Sjogren’s syndrome.   Author contributions SI, NN, SKS, MFUR, KMM and MAKA diagnosed and managed the case. SI, NNA and TH wrote the manuscript. TH and MAKA edited the manuscript.   Informed consent: Patient provided consent for publication.   Conflict of interest: The authors did not have any conflict of interest.   Financial support: Nil.   References 1.     Vitali C, Bombardieri S, Jonsson R, Moutsopoulos HM, Alexander EL, Carsons SE, et al. Classification criteria for Sjögren’s syndrome: a revised version of the European criteria proposed by the American-European Consensus Group. Ann Rheum Dis. 2002; 61: 554–558. 2.     Rajput R, Sehgal A, Jain D, Sen R, Saini O. Nephrocalcinosis: a rare presenting manifestation of primary Sjögren’s syndrome. Mod Rheumatol. 2012; 22(3): 479-482. 3.     Vasquez-Rios G, Westrich D, Philip I, Edwards J, Shieh S. Distal renal tubular acidosis and severe hypokalemia: a case report and review of the literature. J Med Case Rep. 2019; 13(1): 103. 4.     Shahbaz A, Shahid M, Saleem H, Malik Z, Sachmechi I. Hypokalemic paralysis secondary to renal tubular acidosis revealing underlying Sjogren's Syndrome. Cureus. 2018; 10(8): e3128. 5.     Shioji R, Furuyama T, Onodera S, Saito H, Ito H, Sasaki Y. Sjögren’s syndrome and renal tubular acidosis. Am J Med. 1970; 48(4): 456-463. 6.     Ho K, Dokouhaki P, McIsaac M, Prasad B. Renal tubular acidosis as the initial presentation of Sjögren’s syndrome. BMJ Case Rep. 2019; 12: e230402. 7.     Jasiek M, Karras A, Le Guern V, Krastinova E, Mesbah R, Faguer S, et al. A multicentre study of 95 biopsy-proven cases of renal disease in primary Sjögren’s syndrome. Rheumatology (Oxford). 2017; 56(3): 362–370. 8.     Ren H, Wang WM, Chen XN, Zhang W, Pan XX, Wang XL, et al. Renal involvement and followup of 130 patients with primary Sjögren's syndrome. J Rheumatol. 2008 Feb; 35(2): 278-84.     Cite this article as: Ikhtaire S, Aurpa NN, Nahid N, Shahdaty SK, Haq T, Murshed KM, et al.  A case of Sjogren’s syndrome presenting with recurrent hypokalemia. IMC J Med Sci. 2022; 16(2): 004. DOI: https://doi.org/10.55010/imcjms.16.014 <![CDATA[A case of severe subglottic stenosis masking as bronchial asthma]]> Bhupendra Kumar Jain Umamaheswar Chandrakantham https://imcjms.com/journal_full_text/414 2022-05-16 10:21:56 Clinical Case Report IMC J Med Sci 2022; 16(2): 005 Abstract Tracheal stenosis is an uncommon and dangerous complication after intubation and tracheostomy and its clinical presentation may be misinterpreted as bronchial asthma. A careful vigilant clinical history and examination is required for the diagnosis of such tracheal stenosis. Here, we describe a case of post intubation subglottic tracheal stenosis in a young male who presented with features mimicking bronchial asthma. IMC J Med Sci 2022; 16(2): 005. DOI: https://doi.org/10.55010/imcjms.16.015 *Correspondence: Bhupendra Kumar Jain, Department of Pulmonary Medicine, Chhindwara Institute of Medical Sciences,  Chhindwara,  Jabalpur Medical University, Madhya Pradesh , India; ORCID : 0000-0002-6619- 8596;Email: drbhupendrakjain@gmail.com   Introduction Airway stenosis is partial or complete narrowing of the central airway passages. Tracheal stenosis is a dangerous complication resulting from numerous different causes. The disease may be caused by trauma (prolonged tracheostomy or intubation), systemic inflammatory diseases (e.g., Wegener disease, relapsing polychondritis or infectious disease like tuberculosis), malignancy (primary or metastatic). If an underlying etiology is unknown, the condition is termed idiopathic tracheal stenosis. Subglottic stenosis, a subtype of laryngo-tracheo stenosis, is characterized by fibrosis and narrowing of the subglottic space, which extends from the inferior margin of the vocal cords to the cricoid cartilage. Iatrogenic injury from endotracheal intubation and tracheostomy remains the most common cause [1]. Depending on the site of the lesion and severity of the tracheal narrowing, the stenosis may cause symptoms of persistent cough, dyspnoea on exertion, stridor, wheeze, irritable cough, or recurrent respiratory tract infections. The reported incidence of tracheal stenosis after tracheostomy and prolonged intubation varies between 0.6% to 21% and 6% to 21%, respectively [2]. The simple stenoses includes granulomas, web-like and concentrical scarring stenosis (<1cm) with the absence of tracheomalacia or loss of cartilaginous support. The complex stenosis has long lesion (greater than 1 cm) with tracheomalacia [3]. Here, we describe a case of severe tracheal stenosis, who presented initially with features of bronchial asthma.   Case report A 22 years old male presented with persistent cough, shortness of breath following thick sputum being stuck in the throat mimicking as bronchial asthma. The patient had severe dyspnoea which was partially relieved after spitting out thick sputum stuck in the throat. But, he had no stridor. The patient was a chronic tobacco chewer with no other addiction. In addition to symptoms like bronchial asthma, his past medical history was not notable for tuberculosis, hypothyroidism, congestive heart failure or coronary artery disease. After deep interrogation patient provided history of admission at another hospital 20 days back for ingestion of unknown poison with intubation for five days. On admission, physical examination revealed a pulse rate of 106 beats / minutes, blood pressure of 132/80 mm Hg, and oxygen saturation of 96% on room air. No gallops, murmurs, or rubs were audible. Routine investigations including complete blood counts, renal and liver function tests, and urine examination were within the normal range. Sputum smears for acid-fast bacilli, and smears and cultures for pyogenic organisms and fungi were also negative. After admission in our centre, the patient was started on inhalation bronchodilator and systemic steroids. But patient did not improve and his CT scan of thorax was planned which was normal. The flow-volume curve was consistent with fixed airway obstruction with a functional vital capacity (FVC) of 2.72 L and 1-second forced expiratory volume (FEV1) of 1.10 L (FEV1/FVC: 40.4%). Contrast Enhanced Computed Tomography (CECT) examination of the neck was performed which revealed moderate focal subglottic tracheal stenosis 2.0 cm below the vocal cords with a transverse luminal diameter of less than 2.0 mm (Figure-1). The antero-posterior luminal diameter was 9 mm at the level of stenosis. Flexible fibreoptic bronchoscopy revealed normal vocal cords and subglottic tracheal stenosis with luminal opening of 1.5-1.8 mm with a thickened trachea around the small opening. Even, scope of 2.2 mm diameter could not be negotiated through small tracheal opening (Figure-2). Endotracheal biopsy was taken from around the thickened tracheal luminal opening which revealed fragments of stratified squamous epithelium revealing acanthosis, exocytosis and neutrophils showing mild to moderate reactive atypia.     Figure-1: CECT of neck showing moderate focal subglottic stenosis 2.0 cm below the vocal cords     Figure-2:  Subglottic stenosis 2 cm below the vocal cords with narrow tracheal lumen 1.8 mm in size.   Therapeutic flexible bronchoscopy was performed under local/general anesthesia in the operation theatre. Initially, an electocautery probe was passed through the suction channel of the fibreoptic bronchoscope under 35-40% oxygen supplementation. Linear cuts were given using the “blend” mode on the electrocautery unit which allows tissue cutting and coagulation simultaneously. The electrocautery knife created 1 to 2 mm incisions at targeted points and the balloon dilated the airway. Continuous suction was applied so that the target area remained free of blood and mucus and smoke was evacuated. The linear cuts were made on the walls of the stricture at 12 o’clock, 3 o’clock and 9 o’clock position. During inflation, a balloon inflation device with pressure gauge monitor (Boston Scientific) was used to inflate the balloon (Figure-3). The balloon was initially inflated in the stenosed segment with pressure of 2–3 atm for 15 seconds, and this procedure was repeated thrice. The patient was provided 70% oxygen inhalation before and after the balloon dilatation. Later on, topical spray with mitomycin C was given to prevent re-stenosis. Check bronchoscopy after one week revealed good dilatation of subglottic stenosis.     Figure-3:  Incision of  stenosis at  3 o’clock  position  and  dilated with  Boston  balloon   Discussion This case report manifests the importance of early diagnosis and management of an uncommon and dangerous complication of intubation, which may be misinterpreted as a case of bronchial asthma. High suspicion, careful physical examination with characteristic spirometric flow volume loops and evaluation by fibreoptic bronchoscopy/3D CT scan of neck enabled early identification of this condition. Tracheal stenosis is most commonly acquired from prolonged intubations in which the endotracheal cuff pressure exceeded the mean capillary pressure of the tracheal mucosa (> 30 mm Hg). The excessive pressure leads to ischemia, granulation tissue formation, and scarring with lumen stricture [4]. Even when high volume, low pressure cuffed tubes are used, airway stenosis may occur in up to 11% of intubated or tracheostomy patients, even after less than 24 hours of intubation [5,6]. A second common cause of tracheal stenosis is via tracheostomy damage. The injury may involve fractured cartilage from mechanical leverage of the ventilator tubing on the tracheal tube, incorrect sizing of the tracheostomy, fracture during percutaneous tracheostomy tube placement, and excess granulation tissue from infection and abnormal healing [7]. Three-dimensional CT is a useful noninvasive evaluation for tracheo-bronchial stenosis. It allows preoperative determination of balloon size and length, especially when the bronchoscope cannot be passed through the obstruction. It can allow an accurate determination of the degree and length of stenosis and an evaluation of the airway distal to the stenosis and shows the presence of multiple stenoses as well as the relationships with mediastinal structures [8]. Flexible endoscopy is the invasive gold standard procedure for diagnosing endoluminal lesions. But nowadays, the availability of non invasive virtual chest CT (virtual bronchoscopy) is increasing, and it has a diagnostic sensitivity of 94% to 100% for identifying airway stenosis [9,10]. In our case, at the narrowest point of stenosis, there was an approximate cross-sectional obstruction of 90%, which was consistent with a grade 3 obstruction according to the Myer-Cotton classification [11]. Myer-Cotton system primarily addresses circumferential stenosis confined to the subglottic region. Endoscopic procedures currently used include balloon dilatation, excision of granulation tissue by electrocautery, laser, or sharp incision with balloon dilatation, and topical application of steroids or mitomycin C and silicone or metallic stenting. These treatments are the primary choice for elderly or very ill patients for whom open surgery would be difficult. Brichet, et al has designed a treatment algorithm utilizing a multidisciplinary approach to tracheal stenosis management [12]. Rigid bronchoscopy with neodymium±yttrium aluminium garnet (Nd-YAG) laser resection or stent implantation (removable stent) is proposed as first-line treatment, depending on the type of stenosis (web-like versus complex stenosis). In patients with web-like stenosis, sleeve resection was proposed when laser treatment (up to three sessions) fails. In patients with complex stenosis, operability is assessed 6 months after stent implantation. If the patient is judged operable, the stent is removed and the patient undergoes surgery if the stenosis recurred [12]. Galluccio et al suggest that rigid endoscopy using laser assisted mechanical dilatation (LAMD) and, eventually, stent placement as the treatment of choice for simple stenosis with 96% success rate and referred the patient to surgery in case of failure [3]. In complex stenosis with stenotic lesion >1cm with the scarring contracture of tracheal wall surgery is the first option and endoscopy should be performed in order to obtain the correct information about the tracheal lesion and decide together with the surgeon the best therapeutic option [3]. Complications associated with balloon dilatation are tearing of the bronchial wall due to excessive stretching, resulting in pneumothorax, pneumomediastinum, and subcutaneous emphysema. These complications can be avoided using Nd- YAG laser for cutting open the fibrotic stricture prior to balloon dilatation, as it avoids the need for excessively high pressure for dilating the balloon [13]. Both electrocautery and argon plasma photocoagulation (APC) offer advantage of ease and lower cost as compared with laser therapy [14]. Boxem and colleagues documented that the amount of mucosal damage visualized after electrocautery has good correlation with histologic tissue damage [15]. In our case also web like subglottic stenosis less than 1 cm length was initially subjected to electrocautery incisions at targeted points and the Boston balloon was used to inflate the stenosed segment under controlled pressure. Later on, topical spray with mitomycin C was given to prevent re-stenosis. For web-like stenoses, a recommended mucosal sparring technique with radial incisions followed by airway dilatation using balloon bronchoplasty was described by Mehta [16]. Bronchoscopic tools such as balloon bronchoplasty and electrocautery incisions are safe and rapid treatments that can also be performed during diagnostic bronchoscopy and can limit the need for more invasive surgical procedures [17]. The topical application of mitomycin C following endoscopic electrosurgery can be used for treatment of post intubation tracheal stenosis. Bronchoscopic therapy and topical application of mitomycin C suggest that this intervention works better as a bridge to definitive surgery rather than as a stand-alone therapy [18]. Central airway stenosis is a life-threatening upper airway obstruction and can be mistaken as bronchial asthma. A multidisciplinary approach including electrocautery or laser with balloon dilatation, stent placement or surgery is needed for treatment of tracheo-bronchial stenoses depending on the type and length of stenosis. A careful vigilant clinical examination of patient with history of past intubation or tracheostomy procedure is necessary for diagnosis of tracheal stenosis.   Consent: Informed consent for participation and publication was obtained from the patient.   Conflict of interest: The authors do not have any conflict of interest.   Financial support: Nil.   References 1.     D’Andrilli A, Venuta F, Rendina EA. Subglottic tracheal stenosis. J Thorac Dis. 2016; 8: S140–147. 2.     Farzanegan R, Farzanegan B, Zangi M, Golestani Eraghi M, Noorbakhsh S, Doozandeh Tabarestani N, et al. Incidence Rate of Post-Intubation Tracheal Stenosis in Patients Admitted to Five Intensive Care Units in Iran. Iran Red Crescent Med J. 2016 Aug 2; 18(9): e37574. 3.     Galluccio G, Lucantoni G, Battistoni P, Paone G, Batzella S, Lucifora V, et al. Interventional endoscopy in the management of benign tracheal stenoses: definitive treatment at long-term follow-up. Eur J Cardiothorac Surg. 2009 Mar; 35(3): 429-433. 4.     Melkane AE, Matar NE, Haddad AC, Nassar MN, Almoutran HG, Rohayem Z, et al. Management of postintubation tracheal stenosis: appropriate indications make outcome differences, Respiration, 2010; 79(5): 395-401. 5.     De S, De S. Post intubation tracheal stenosis. Indian J Crit Care Med. 2008; 12(4): 194-197. 6.     Grillo HC, Donahue DM, Mathisen DJ, Wain JC, Wright CD. Postintubation tracheal stenosis. Treatment and results. J Thorac Cardiovasc Surg. 1995 Mar; 109(3): 486-492. 7.     Sarper A, Ayten A, Eser I, Demircan A, Isin E. Review of posttracheostomy and postintubation tracheal stenosis with special regard to etiology and treatment. Internet J Thorac Cardiovasc Surg. 2002; 6: 1524-0724. 8.     Rooney CP, Ferguson JS, Barnhart W, Cook-Granroth J, Ross A, Hoffman EA, et al. Use of 3-dimensional computed tomography reconstruction studies in the preoperative assessment of patients undergoing balloon dilatation for tracheobronchial stenosis. Respiration. 2005; 72(6): 579-586. 9.     Finkelstein SE, Summers RM, Nguyen DM, Stewart JH 4th, Tretler JA, Schrump DS. Virtual bronchoscopy for evaluation of malignant tumors of the thorax. J Thorac Cardiovasc Surg. 2002; 123: 967–972. 10.  Hoppe H, Walder B, Sonnenschein M, Vock P, Dinkel HP. Multidetector CT virtual bronchoscopy to grade tracheobronchial stenosis. AJR Am J Roentgenol. 2002; 178: 1195–1200. 11.  Myer CM 3rd, O'Connor DM, Cotton RT. Proposed grading system for subglottic stenosis based on endotracheal tube sizes. Ann Otol Rhinol Laryngol. 1994; 103(4 Pt 1): 319-323. 12.  Brichet A, Verkindre C, Dupont J, Carlier ML, Darras J, Wurtz A. Multidisciplinary approach to management of postintubation tracheal stenosis. Eur Respir J. 1999 Apr; 13(4): 888-93. 13.  Kwon Ys, Kim H, Kang KW, Koh WJ, Suh GY, Chung MP, et al. The role of ballooning in patients with post tuberculosis bronchial stenosis. Tuberc Respir Dis 2009; 66: 431-436. 14.  Puchalski J, Musani AI. Tracheobronchial stenosis causes and advances in management. Clin Chest Med. 2013; 34: 557–5 67. 15.  van Boxem TJ, Westerga J, Venmans BJ, Postmus PE, Sutedja TG. Tissue effects of bronchoscopic electrocautery: bronchoscopic appearance and histologic changes of bronchial wall after electrocautery. Chest. 2000; 117(3): 887-891. 16.  Mehta AC, Lee FY, Cordasco EM, Kirby T, Eliachar I, De Boer G. Concentric tracheal and subglottic stenosis. Management using the Nd-YAG laser for mucosal sparing followed by gentle dilatation. Chest. 1993; 104: 673–677. 17.  Solly WR, O’Connell RJ, Lee HJ, Sterman DH, Haas AR. Diagnosis of idiopathic tracheal stenosis and treatment with papillotome electrocautery and balloon bronchoplasty. Respiratory Care. 2011; 56: 1617-1620. 18.  Fuller A, Sigler M, Kambali S, Alalawi R. Successful treatment of post-intubation tracheal stenosis with balloon dilation, argon plasma coagulation, electrocautery and application of mitomycin C. Southwest Respir Crit Care chron. 2015; 3(9): 14-18.     Cite this article as: Jain BK, ChandrakanthamU.  A case of severe subglottic stenosis masking as bronchial asthma. IMC J Med Sci. 2022; 16(2):005. DOI: https://doi.org/10.55010/imcjms.16.015 <![CDATA[Management strategy for control and prevention of SARS-CoV-2 infection in hospital settings - a brief review]]> Ishrat Binte Aftab Akash Ahmed Sinthia Kabir Mumu M Mahboob Hossain https://imcjms.com/journal_full_text/410 2022-03-16 14:25:26 Review IMC J Med Sci 2022; 16(2): 006 Abstract The current pandemic of COVID-19 has spread worldwide rapidly. Many countries are struggling with the third pandemic wave despite having the vaccine distribution to frontline workers and people at high risk. Several studies have suggested a high possibility of hospital-acquired COVID-19. Therefore, it is vital to have proper recommendations and guidelines to prevent COVID-19 transmission in hospitals. Eliminating hospital-acquired infection is impossible, but reducing the rate and severity is possible by following appropriate guidelines. This paper reviews the strategies and recommendations that can be helpful for a hospital authority to control and prevent SARS-CoV-2 infection among the patients and healthcare workers. IMC J Med Sci 2022; 16(2): 006. DOI: https://doi.org/10.55010/imcjms.16.016 *Correspondence: Akash Ahmed, Department of Mathematics & Natural Sciences, BRAC University, Dhaka, Bangladesh. Email: akash.ahmed@bracu.ac.bd   Introduction Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread worldwide at an exponential rate since its detection in Wuhan, China in December 2019. By March 2022, about 500 million people around the world had COVID-19 and among them, there were 6.2 million deaths [1]. Globally, vaccines are distributed yet the cases and death continue to exist. Leaders and policymakers are already claiming to have scarcity of intensive care units and other healthcare facilities even in developed countries. Even though there is not enough empirical evidence suggesting hospital as a transmission spot for COVID-19, there are case study analyses that show evidence of hospital acquired Covid-19. Marago and colleagues [2] conducted a retrospective case analysis in the General District Hospital in the North West of England and found the prevalence of hospital-acquired COVID-19 up to 16.2%. In a meta-analysis of cases from China-based databases, Zhou et al. showed [3] that the proportion of COVID-19 acquired in a hospital setting was 44%. The majority of the infected person was healthcare workers [3]. In another retrospective study performed by Rickman et al. [4] at a University Hospital London, 11% (47/435) Covid-19 cases were confirmed hospital-acquired and among them, the mortality rate was 36%. An observational study with COVID-19 cases showed among 1564 patients admitted, 12.5% were hospital-acquired where the mortality rate was 27% [5]. Even though these studies have few limitations, it is evident from the official data that 12-15% COVID-19 cases were nosocomial in origin [6]. Therefore, to prevent the transmission of COVID-19 among the hospital patients and healthcare workers, hospitals all over the world have taken different measures based on their local resources. The WHO (World Health Organization) and CDC (Centers for Disease Control and Prevention) have published recommendations on control of SARS-CoV-2 infection. Unfortunately, most of the recommendations are based on previous SARS (Severe Acute Respiratory Syndrome) and MERS (Middle East Respiratory Syndrome) outbreaks. However, specialists, scientists, front-line doctors working with COVID-19 patients have made recommendations to prevent spread of COVID-19 in hospital settings. The aim of this paper is to review the available recommendations and information that can help preventing hospital-acquired COVID-19 transmission.   Methods A thorough search was conducted on Google scholar and MEDLINE through specific keywords, e.g. “hospital management during COVID-19”, “infection control in hospital during COVID-19”, “COVID-19 transmission in hospital”, “lab considerations during corona outbreak”, “healthcare worker safety in COVID-19”. Papers were also handpicked from references.   Administrative control In a healthcare facility, it is important to have a strong administrative control to keep the workflow uninterrupted and modify if and when necessary. It is the most essential level of hierarchy to reduce the COVID-19 exposure to uninfected people [7]. Its responsibility includes, reminding staff to take necessary precaution and monitoring them when they are on duty [8]. Some hospitals have established real time monitoring where the monitoring is done on computer screen in a separate room [9]. Lai et al [7] suggest, in the time of COVID-19, it is crucial for administrators to reduce the patient attendance as much as possible and suspend the elective clinical services to avoid viral transmission. It is also essential for keeping the resources available such as inpatient beds, staff and medical equipment to fight against emergency outbreak [7]. In addition, unique shifting system such as, working at different time and location, doing long shifts and keeping backup staff ready can limit exposure, save protective equipment and keep workflow uninterrupted [10-12]. All medical documents such as, physicians’ order, medical records, consent form, lab results and nursing materials is better to make paperless, as explained by Huang et al [9].   Screening and zoning In order to keep the health workers and uninfected patients safe, a thorough screening process is important. A triage station should be set up to identify fever patients before they enter the clinical area or outpatient gateway [7,12]. Patients or hospital staff entering the hospital should be screened for fever using infra-red thermometers [7]. The clinical area of important department should be divided into clean, semi-contaminated and contaminated zones depending on the patient occupancy time, ventilation condition and risk of exposure [12].   Safety of health workers Health workers are the most important asset in COVID-19 pandemic and during any disease outbreak or epidemic [8,13]. Therefore, it is crucial to protect them first from acquiring infection for the greater benefit of whole population. It is recommended that healthcare worker should report any symptoms that may be associated with COVID-19 and their travel history after returning from vacation [7]. A large tertiary hospital of Singapore measures and records electronically the body temperature of their medical staff twice a day [14]. Huang et al. [8] believe education regarding infection control and personal safety should reach every medical personnel. The safety information includes use of personal protective equipment (PPE), hand hygiene, ward disinfection, medical waste management, and sterilization of patient-care devices and management of occupational exposure [9]. The Joint Task Force of the Chinese Society of Anesthesiology and the Chinese Association of Anesthesiologists mention in their recommendation that highest level of personal precautions includes a disposable surgical cap, test-fit N95 masks or respirators, gloves, goggles or face shield, gown, and fluid-resistant shoe covers [13]. The key element of this precaution is the full coverage of the head and facial skin. However, Bourouiba [15] in his article suggests that mask and other protective equipment should be able to withstand high-momentum multi-phase turbulent gas cloud ejected with a sneeze or a cough where the virus is trapped. A surgical mask along with N95 in addition with goggles and face shield works well as protection [8,13]. Some clinicians made the suggestion of using powdered air-purifying respirator (PAPRs) in aerosol generating conditions, although poses limited evidence and logistical challenges [16]. Even though laboratory study shows that N95 mask gives higher protection than FFP2 and FFP3 (filtering facepiece), a recent meta-analysis shows no significant difference [17]. It is advisable to use double-gloving as a standard practice to minimize spread through fomite after intubation [18]. There is a potential risk of contamination during the donning (putting on) and doffing (removing) of PPE, thus, requires thorough training (using teaching video, infographic etc.), as explained by Phua and colleagues [16]. Health worker who are pregnant should have special attention and work in a clean zone [8,10].   Infection control in hospital Anesthesia and operating room (OR) management of a hospital play a big role in the infection control procedure during an airborne viral pandemic like COVID-19. Multiple studies have confirmed that COVID-19 transmission occurs through air droplets; therefore, all aerosol-generating procedures should take place in airborne infection isolation room [18]. Aerosol generation typically occurs in operating room during tracheal intubation, noninvasive ventilation (NIV), high-flow nasal oxygen (HFNO) procedures, bronchial suctioning, airway manipulation, open airway suctioning, bronchoscopy and sputum induction [17,19]. Coccolini [19] suggests that during a general anesthesia, a HEPA (high-efficiency particulate air) filter to connect to the patient end of breathing circuit and another one between expiratory limb and anesthetic machine. Also, regional anesthesia is preferable over general one. Even though not possible during the time of pandemic, it is not advisable to take the patient to the post anesthesia care unit because it may induce contamination, rather they should recover in the room where they had surgery [11]. Awake intubation should be avoided as it has risk of patient coughing or vomiting which is a potential source of infection for healthcare workers [19]. Cheung and his team [18] recommend avoiding bag mask ventilation as it generates aerosol. They recommend using methods like bed-up-head-elevated position, airway adjunct or positive end expiratory pressure valve. However, if bag masking is unavoidable, they advise to use supraglottic device rather than bag mask ventilation, although no robust evidence is available for this recommendation but this process is easy and requires less medical staff. On the other hand, Coccolini [19] suggests using rapid sequence intubation (RSI) in order to avoid manual ventilation. In addition, turning off the gas flow and clamping the endotracheal tube using forceps during the switching between portable device and ventilator may reduce aerosolization. For COVID-19 patients, a negative pressure environment for operating room (OR) is recommended to reduce the spread of virus outside the room [19]. An evidence-based study by Dexter and colleagues [11] suggest that typical hand hygiene is insufficient to control infection in operating room. They also suggest that a multilayered approach such as improved hand hygiene, environmental cleaning, vascular care, patient decolonization, and surveillance optimization can minimize perioperative infection for bacterial and viral pathogens. In addition to that, high air exchange cycle rate (25 cycles/h) can significantly downscale the viral load within ORs. After the surgery, patient is advised to recover in the OR so that the contamination stays in one room; however, during this pandemic it may not be possible to institute such measure in all hospitals. To eliminate the risk of circuit contamination, the anesthetic breathing circuit and the canister of soda lime needs to be discarded after completion of surgery [19]. Along with the aforementioned procedures, there are other aerosol generating processes in the ICU such as, administration of nebulized treatment, endotracheal intubation, disconnecting the patient from the ventilator, non-invasive positive pressure ventilation, tracheostomy, and cardiopulmonary resuscitation (CPR) [20]. Recent reports show that acute cardiac injury can happen in 7% patients with COVID-19 [21]. Also, their treatment poses infection risk. Active CPR may generate aerosols of respiratory secretions that may result in spread of infection. Therefore, Alhazzani and colleagues have suggested considering WHO recommendation of using negative pressure rooms with 12 air changes minimum per hour or at least 160 L/ second/patient in facilities with natural ventilation. Furthermore, they suggest doing the endotracheal intubation by experienced personnel to reduce the risk of infection by minimizing the number of attempts [18,20]. Restriction on ICU visits is important, and in case of emergency, video calling is preferable. Radiology department plays a significant role in the management of COVID-19 patients during this pandemic. Therefore, contamination in this area has larger consequences in viral spread in hospital. In order to reduce the hospital spread of SARS-CoV-2, radiology department may be divided into four zones namely contaminated, semi-contaminated, buffer and clean zones and each zone should be separated from each other [8]. A provision for negative pressure CT room is also recommended [10].   Immuno -suppressed patients Immuno-compromised patients are in increased risk of acquiring SARS-Cov-2 infection during their visit and stay in hospitals. Shamsi et al. [22] states that cancer patients are considered as immune-suppressed, however, there are limited data available related to cancer survivors and COVID-19 infection. They suggest, for some selective patients, delaying elective surgery will be appropriate for early asymptomatic small breast cancer tumors detected on routine screening mammograms. It is recommended to defer breast surgery for 3 months in case it is for atypia, prophylactic/risk-reducing surgery, reconstruction, or benign conditions [23]. They further recommend that all uncomplicated, elective and early-stage cancer surgery should be deferred. However, delaying elective surgery is complex idea depending on the fact that every cancer has different disease pattern each of which requires unique oncological multidisciplinary approach and decision [22]. Therefore, even if there are recommendations available, decisions on surgery should be made on case-by-case basis. Elective surgeries in patients with type-2 diabetes are advised to be deferred in COVID-19 pandemic situation [24]. Type-2 diabetic and obese patients are at high risk of COVID-19 complications due to the surgical stress in recovery period. In a retrospective study, Cao and colleagues [25] explain, pregnant women are more susceptible to respiratory pathogens due to maternal physiologic changes and immune suppression. Therefore, it is important to screen pregnant women for SARS-CoV-2 before admission to reduce the transmission of virus among the hospital staff and other patients [17,25]. Furthermore, during labor, increased ventilation may accelerate airborne transmission, especially if the pregnant woman has symptoms of COVID-19 lung sequelae [17]. Limited data suggest that transplacental transmission is unlikely in women with COVID-19, therefore, neonates are considered safe. However, to remain safe, early cord clamping and temporary separation of the mother and newborn for minimum of 2 weeks is recommended to reduce transmission of COVID-19 from infected mother to the newborn. Also, breast feeding is not recommended if the mother is infected, instead, pumped breast milk can be given [26].   Laboratory considerations In an early experience of managing emerging COVID-19 in Singapore’s tertiary institution, Tan et al. [27] have stated that laboratory specimens should neither be delivered by hand nor sent through pneumatic tube as it has the risk of spillage. They have suggested the use of universal transport medium for nasopharyngeal and oropharyngeal swabs where the swabs are dipped within 3ml of fluid. Furthermore, they have also recommended transporting tightly capped specimens in biohazard zip-lock bags, within a cryobox (leak-proof) which is labeled clearly as biohazard. They have also made the recommendation of adopting WHO guidelines of “triple packaging system” during the pandemic to prevent the transmission. This packaging system includes a receptacle, a watertight and leak-proof packaging to protect the receptacle and an outer layer to reduce physical damage in transit [27].   Environment and equipment cleaning Environment and equipment cleaning are of paramount importance, especially in places where immune-suppressed patients are handled, e.g. ICU, radiotherapy unit, OR, etc. Improved cleaning of environment and equipment using surface disinfection and UV-C approach is recommended as use of UV-C only may result in shadowing [11]. Huang and colleagues [8] recommend disinfecting object surface with 1,000 mg/L chlorine-containing disinfectant and wiping twice with 75% ethanol for non-corrosion resistant surface, once in every 4 hours. For disinfecting equipment, they suggest to use 2,000 mg/L chlorine-containing disinfectant. For disinfection of room air, in general air condition is advised to turn off to reduce transmission. When the room is suspected of being contaminated, they recommend ventilating it well once in 4 hours. Also, their radiotherapy department uses the spraying of ambient air with 1,000 mg/L chlorine-containing disinfectants. Ground disinfection is done with 1,000 mg/L chlorine-containing disinfectant, once every 4 hours. Catheterization laboratory, OR and every other area exposed to COVID-19 patient are recommended to follow terminal cleaning after each use [11,12]. Electro-medical equipment such as ventilator and different radiological equipment must be cleaned (rinsed and dried) with 0.1% chlorine-based solution [19]. After an operation, OR utensils should be cleaned with sodium hypochlorite 1000 ppm and hydrogen peroxide vaporization or UV-C irradiation. Hydrogen peroxide vaporization is effective against various viruses including transmissible gastroenteritis coronavirus of pigs and UV-C irradiation kills or inactivates aerosolized viruses [19].   Hospital waste management About 87% of a hospital's total waste is infectious [28]. Therefore, proper technologies should be used when managing hospital waste and waste water, especially during a pandemic. Some of the common infectious wastes in the hospital are the feces, vomit, and urine of the infected patients. The feces of COVID-19 infected patients have been confirmed to contain the RNA strands of the virus and it is believed that the fomites of the infected container to be a source of transmission [29]. Wang and his team [28] suggest that the waste water discharged from hospitals treating COVID-19 patients also needs to be regulated as it can contaminate the entire drainage system and even cause aerial transmissions. The large amount of waste produced by the hospitals must be disinfected according to strict procedures to prevent new infections among medical staffs and patients. Any sort of waste that may have been in contact with infected patients should be placed in easily identifiable containers for infectious-risk health waste (IRHW). The containers must be closed and sealed before transferring them to inactivation points. Medical staffs handling these containers should wear personal protection equipment all times. The process of inactivation of SARS-CoV-2 is still a relatively less studied topic. In this case, the best action would be to adhere to the techniques used during the SARS epidemic since the COVID-19 share significant similarities with the SARS-CoV-1. An effective method for the inactivation of any SARS virus is the use of more than 0.5 mg/L residual free chlorine or 2.19 mg/L residual chlorine dioxide. Chlorine and UV-C irradiation were found as the most effective disinfectant for SARS virus. Methods involving chlorine dioxide were second in term of performance. These findings are in line with the recommendation made by the Ministry of Ecology and Environment of China for treating the waste water of hospitals built for COVID-19 patients. Chlorine base disinfectants such as liquid chlorine, chlorine dioxide and sodium hypo-chloride with about 50mg/L of chlorine were suggested for disinfection process. Disinfectants containing 20g/L chlorine should be used for up to two hours to avoid all sorts of transmissions. Pharmaceutical and chemical wastes need to be incinerated. The choice of disinfectant and procedures will depend on the economic and feasible factors such as amount of wastewater, existing infrastructure, cost of operation, scope of investment and availability of the disinfectants [28].   Limitations of the study All the papers included in this review are not peer-reviewed due to COVID-19 situation. Additionally, safety recommendations are changing frequently as this is an ongoing pandemic. Therefore, consistency in the information may differ with time.   Conclusion There is no fixed precaution that can eliminate the possibility of hospital-acquired COVID-19. However, many recommendations can be adopted to reduce the transmission. Despite all the recommendations mentioned in this review, it is advisable to formulate and modify the hospital management system according to the hospital’s infrastructure, budget, available manpower, and area of location. The rate of hospital-acquired COVID-19 is not only distressing, but it is also posing a big threat to the healthcare system and healthcare-seeking behavior of mass people. The scenario will soon be out of hand if appropriate procedures are not practiced.   Authors' contributions ABM and SKM: Wrote the original draft. AA: Idea of the review and supervision, MMH: Edited and finalized the manuscript.   Conflicts of interest/Competing interests All the authors state that there is no conflict of interest.   Funding: Nil   References 1.     COVID-19 Map. Johns Hopkins Coronavirus Resource Center. Available at: https://coronavirus.jhu.edu/map.html (accessed on 30 April, 2022). 2.     Marago I, Minen I. Hospital-Acquired COVID-19 Infection – The magnitude of the problem. SSRN Electron J. 2020. doi: org/10.2139/ssrn.3622387. 3.     Zhou Q, Gao Y, Wang X, Liu R, Du P, Wang X, et al. Nosocomial infections among patients with COVID-19, SARS and MERS: a rapid review and meta-analysis. Ann Transl Med. 2020; 8(10): 1-14. 4.     Rickman HM, Rampling T, Shaw K, Martinez-Garcia G, Hail L, Coen P, et al. Nosocomial transmission of coronavirus disease 2019: a retrospective study of 66 hospital-acquired cases in a London teaching hospital. Clin Infect Dis. 2021; 72(4): 690-693. 5.     Carter B, Collins JT, Barlow-Pay F, Rickard F, Bruce E, Verduri A, et al. Nosocomial COVID-19 infection: examining the risk of mortality. The COPE-Nosocomial Study (COVID in Older People). J Hosp Infect. 2020; 106(2): 376-384. 6.     Barranco R, Vallega BDTL, Ventura F. Hospital-acquired SARS-Cov-2 infections in patients: inevitable conditions or medical malpractice?. Int J Environ Res Public Health. 2021; 18(2): 489-498. 7.     Lai TH, Tang EW, Chau SK, Fung KS, Li KK. Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong. Graefe’s Arch Clin Exp Ophthalmol. 2020; 258(5): 1049-1055. 8.     Huang Z, Zhao S, Li Z, Chen W, Zhao L, Deng L, et al. The battle against coronavirus disease 2019 (COVID-19): emergency management and infection control in a radiology department. J Am Coll Radiol. 2020; 17(6): 710-716. 9.     Huang L, Lin G, Tang L, Yu L, Zhou Z. Special attention to nurses’ protection during the COVID-19 epidemic. Crit Care. 2020; 24(1): 1-3. 10.  Cheng LT, Chan LP, Tan BH, Chen RC, Tay KH, Ling ML, et al. How the severe acute respiratory syndrome experience influenced a Singapore radiology department's response to the coronavirus disease (COVID-19) epidemic. Am J Roentgenol. 2020; 214(6): 1206-1210. 11.  Dexter F, Parra MC, Brown JR, Loftus RW. Perioperative COVID-19 defense: an evidence-based approach for optimization of infection control and operating room management. Anesth Analg. 2020; 131(1): 37–42. 12.  Wei W, Zheng D, Lei Y, Wu S, Verma V, Liu Y, et al. Radiotherapy workflow and protection procedures during the Coronavirus Disease 2019 (COVID-19) outbreak: Experience of the Hubei Cancer Hospital in Wuhan, China. Radiother Oncol. 2020; 148: 203-210. 13.  Chen W, Huang Y. To protect health care workers better, to save more lives with COVID-19. Anesth Analg. 2020; 131(1): 97–101. 14.  Wong J, Goh QY, Tan Z, Lie SA, Tay YC, Ng SY, et al. Preparing for a COVID-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in Singapore. Can J Anesth. 2020; 67(6): 732-745. 15.  Bourouiba L. Turbulent gas clouds and respiratory pathogen emissions: potential implications for reducing transmission of COVID-19. J Am Med Assoc. 2020; 323(18): 1837-1838. 16.  Phua J, Weng L, Ling L, Egi M, Lim CM, Divatia JV, et al. Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations. Lancet Respir Med. 2020; 8(5): 506-517. 17.  Odor PM, Neun M, Bampoe S, Clark S, Heaton D, Hoogenboom EM, et al. Anaesthesia and COVID-19: infection control. Br J Anaesth. 2020; 125(1): 16-24. 18.  Cheung JC, Ho LT, Cheng JV, Cham EY, Lam KN. Staff safety during emergency airway management for COVID-19 in Hong Kong. Lancet Respir Med. 2020; 8(4): e19. 19.  Coccolini F, Perrone G, Chiarugi M, Di Marzo F, Ansaloni L, Scandroglio I, et al. Surgery in COVID-19 patients: operational directives. World J Emerg Surg. 2020; 15(1): 1-7. 20.  Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, et al. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Crit Care Med. 2020; 46(5): 854-887. 21.  Welt FG, Shah PB, Aronow HD, Bortnick AE, Henry TD, Sherwood MW, et al. Catheterization laboratory considerations during the coronavirus (COVID-19) pandemic: from the ACC’s Interventional Council and SCAI. J Am Coll Cardiol. 2020; 75(18): 2372-2375. 22.  Al‐Shamsi HO, Alhazzani W, Alhuraiji A, Coomes EA, Chemaly RF, Almuhanna M, et al. A practical approach to the management of cancer patients during the novel coronavirus disease 2019 (COVID‐19) pandemic: an international collaborative group. Oncologist. 2020; 25(6): e936-945. 23.  Bartlett DL, Howe JR, Chang G, Crago A, Hogg M, Karakousis G, et al. Management of cancer surgery cases during the COVID-19 pandemic: considerations. Ann Surg Oncol. 2020; 27(6): 1717-1720. 24.  Bornstein SR, Rubino F, Khunti K, Mingrone G, Hopkins D, Birkenfeld AL, et al. Practical recommendations for the management of diabetes in patients with COVID-19. Lancet Diabetes Endocrinol. 2020; 8(6): 546-550. 25.  Cao D, Yin H, Chen J, Tang F, Peng M, Li R, et al. Clinical analysis of ten pregnant women with COVID-19 in Wuhan, China: A retrospective study. Int J Infect Dis. 2020; 95: 294-300. 26.  Liang H, Acharya G. Novel corona virus disease (COVID-19) in pregnancy: What clinical recommendations to follow? Acta Obstet Gynecol Scand. 2020; 99: 439–442. 27.  Tan SS, Yan B, Saw S, Lee CK, Chong AT, Jureen R, et al. Practical laboratory considerations amidst the COVID-19 outbreak: early experience from Singapore. J Clin Pathol. 2021; 74(4): 257-260. 28.  Wang J, Shen J, Ye D, Yan X, Zhang Y, Yang W, et al. Disinfection technology of hospital wastes and waste water: Suggestions for disinfection strategy during coronavirus Disease 2019 (COVID-19) pandemic in China. Environ Pollut. 2020; 262: 114665. 29.  Ong SW, Tan YK, Chia PY, Lee TH, Ng OT, Wong MS, et al. Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a symptomatic patient. J Am Med Assoc. 2020; 323(16): 1610-1612.       Cite this article as: Aftab IB, Ahmed A, Mumu SK, Hossain MM. Management and prevention of hospital acquired SARS-CoV-2 infection. IMC J Med Sci. 2022; 16(2): 006. DOI: https://doi.org/10.55010/imcjms.16.016 <![CDATA[The diagnostic value of neutrophil to lymphocyte ratio in determining the severity of COVID-19]]> Mehmet Ozdin Hakan Kaya Umut Gulacti Uğur Lok Hüseyin Kafadar Cem Yucetas https://imcjms.com/journal_full_text/390 2021-09-22 13:26:13 Original Article IMC J Med Sci 2022; 16(1): 001 Abstract Background: Changes in hematological parameters play a role in the pathogenesis of coronavirus disease 2019 (COVID-19). We aimed to investigate the significance of neutrophil-lymphocyte ratio (NLR) and hematologic parameters in determining the severity of COVID-19. Methods: This retrospective cross-sectional study was conducted on adult patients diagnosed with COVID-19 in two pandemic hospitals between 01, April, and 01, July 2020. Using the COVID-19 diagnostic criteria of the world health organization (WHO), the patients were divided into two groups as severe and non-severe. Demographic and clinical characteristics, white blood cell (WBC), neutrophil, lymphocyte and platelet counts, and NLR of all patients were examined at the first admission. Multivariate analyzes were performed to determine the independent predictive data and ROC analysis to test the diagnostic accuracy of the hematological parameters. Results: Of the 381 patients included in the study, 42 (11%) had severe COVID-19 infection. While the mean NLR was 7.61±7.48 in patients with severe COVID-19, the mean NLR of non-severe patients was 2.97±2.37 (95% CI: 2.294 to 6.984, p<0.001). Long duration of hospital stay, elevated NLR ratio, female gender were predictive variables of severe COVID-19 cases (OR =0.833, 95% CI: 0.744 to 0.934, p=0.002; OR=0.195, 95% CI: 0.057 to 0.6731, p=0.010; OR=0.664, 95% CI: 0.501 to 0.881, p=0.005, respectively). In ROC analysis, NLR ratio had 2.625 optimum cut-off value, 60% specificity (95% CI: 54.7 to 65.4), 86% sensitivity (95% CI: 71.5 to 94.6), positive likelihood ratio (PLR) of 4.2 (95% CI: 2.0 to 8.9) and negative likelihood ratio (NLR) of 0.46 (95% CI: 0.4 to 0.6) for severe COVID-19 cases. Conclusion: The results of this study revealed that there might be a relationship between elevated NLR and severity in COVID-19 cases. IMC J Med Sci 2022; 16(1): 001. DOI: https://doi.org/10.55010/imcjms.16.001 *Correspondence: Dr. Umut Gulacti, Adiyaman University Training and Research Hospital, Emergency Medicine, Adiyaman, Turkey. E-mail: umutgulacti@gmail.com   Introduction Coronavirus disease 2019 (COVID-19) may lead to severe acute respiratory syndrome. COVID-19 first appeared in Wuhan, China, and spread from there, causing an epidemic across China and then a pandemic around the world [1-3]. A large number of infected patients were seen due to a lack of immunity to COVID-19, and complications that occur during this viral disease. It usually manifests itself with fever (>80%), cough (>60%), and myalgia or fatigue (>40%) in patients [3]. About 60% of male cases in the middle age are affected around the age of 50 [4]. Clinical manifestations can be asymptomatic, and vary from very mild to severe disease to sepsis and death. Looking at the available data, most of the COVID-19 diseases are mild, while 16% of cases were severe [5]. In clinically severe cases, infection-related complications were reported to activate systemic coagulation and inflammatory responses, which are vital for patients' defense but can cause DIC [6-10]. Neutrophilia is a parameter that indicates a response to systemic inflammation, while lymphopenia, in general, indicates that cellular immunity is weak. The ratio of these two parameters indicates the adequacy of the cellular immune response against this inflammatory state by the size of the systemic inflammation. Neutrophil lymphocyte ratio (NLR) is an indicator of ability to generate immune responses and subclinical inflammation. NLR is an economical, easy and repeatable measurement parameter. The reason NLR shows a poor prognosis is that neutrophils are dominant, which can suppress cytotoxic T cells. NLR increases in the presence of infection, especially sepsis, and also in the increased severity of these clinical conditions [9-11]. New studies on the characteristics and treatment of the virus and the disease are added everyday to the literature since the emergence of COVID-19 in China. However, despite the large number of scientific studies included in the literature from day to day, there is not yet sufficient and accurate information about COVID-19 and its treatment. Considering the pathogenesis of the disease, the clinical manifestation, and test results in patients, it is observed that hematological parameters, especially neutrophil and lymphocyte counts are affected in this infection. In the literature, few publications examined hematological parameters in relation to severity of COVID-19 [12,13]. Thus, this study aimed to investigate the neutrophil-to-lymphocyte ratio (NLR) and other hematological parameters for the diagnosis of severe COVID-19 patients.   Methods Study settings and protocol: This hospital-based retrospective cross-sectional study was conducted by investigating the files of COVID-19 patients who were brought to Adıyaman Training and Research Hospital and Sakarya University Training and Research Hospital between April 2020 and July 2020. Both hospitals were among the hospitals designated as COVID-19 pandemic hospitals in Turkey. Before starting the study, approvals of the Ministry of Health and the local ethics committee were obtained and, the Declaration of Helsinki was followed.   Participants: Patients over the age of 18 years admitted to the hospital with a definitive diagnosis of COVID-19 were included in the study. Patients under the age of 18 years, pregnant women, patients with missing data in hospital records, patients with the hematological disease were excluded from the study. Patients definitively diagnosed with COVID-19 based on typical CT image of COVID-19 viral pneumonia and/or with a positive result of RT-PCR for SARS-CoV-2 RNA were divided into two groups as severe and non-severe patients. Based on the COVID-19 Infection Diagnosis and Treatment Guideline [13], the World Health Organization (WHO) defines severe patients as the patients with clinical signs of pneumonia (fever, cough, dyspnea, rapid breathing) with at least one of the following criteria (respiratory rate ≥ 30 times/min, severe respiratory distress, oxygen saturation (room air) ≤ 93%). White blood cell (WBC), neutrophil, lymphocyte and platelet counts, and NLR of the patients were examined at the first admission to the COVID-19 pandemic service of the emergency clinic of hospitals. An experienced researcher confirmed the severity of the patients.   Data collection and laboratory investigations: Data regarding age, gender, present diseases and comorbidities, length of stay (day) in hospital, and laboratory investigation of each patient were obtained from hospital records. Two researchers independently examined the accuracy of the patient data and COVID-19 diagnosis. The venous blood samples used for laboratory analysis were collected in hemogram tubes containing ethylenediaminetetraacetic acid (EDTA). WBC, neutrophil, lymphocyte, and platelet count were studied in CELLDYN 3700 device (Abbott, USA) within one hour of collection of blood samples. The reference values for total WBC, neutrophil, lymphocyte and platelet were 4.6 to 10.2 x 109/L, 2.0 to 6.9 x 109/L, 0.60 to 3.40 x 109/L and 140 to 424 x 109/L respectively. Throat and nasal swab samples for SARS-CoV-2 diagnosis were analyzed with the qRT-PCR kit as per the WHO guidelines (BioGerm, Shanghai, China).   Statistical analysis: Data analysis was performed using the Statistical Package for Social Sciences for Windows software, version 17 (SPSS Inc., Chicago, IL, United States) and Medcalc version 12.7.0.0. Data were expressed as mean ± SD for continuous variables and frequencies and proportions for categorical variables. Student’s t-test was used to analyze mean differences between groups. Categorical data were analyzed using Pearson’s chi-square test. Determining the best predictors that affect severity was evaluated by multiple logistic regression analysis. Any variable having a significant univariate test along with all other variables of known clinical importance were selected as candidates for the multivariate analysis. Odds ratios and 95% confidence intervals (CI) for each independent variable were calculated. For the cut-off points of each clinical variable, severe and non-severe patient were evaluated by receiver operating characteristic (ROC) analyses, a calculating area under the curve (AUC) as giving the maximum sum of sensitivity and specificity for the relevant test. Sensitivity, specificity, and positive and negative likelihood values were also calculated at the best cut-off point for each clinical variable and presented with 95% CI. A p-value of <0.05 was considered statistically significant.   Results Medical records of 462 COVID-19 patients were examined. However, 81 patients whose data could not be reached were excluded from the study. Finally, a total of 381 COVID-19 patients who met the research criteria were included in the study. Of these patients, 42 (11.02%) were severe COVID-19 patients, and 339 were non-severe COVID-19 patients. Mean age of the severe and non-severe patients was 67.33±16.46 and 48.81±18.48 years respectively (95% CI: 13.05 to 23.99, p<0.001). In the comparison of severe and non-severe patients, female gender (59.5% vs. 43.1%, p=0.043), hypertension (30.8% vs. 16.2%; 95% CI: 0.029 to 0.026, p=0.024), presence of coronary artery disease (33.3 vs. 16.8; 95% CI: 0.017 to 0.015, p=0.012), mean number of days hospitalized (10.96±5.68 vs. 5.79±3.49; 95% CI: 2.89 to 7.458, p<0.001) and mean NLR (7.61±7.48 vs. 2.97±2.37 95% CI: 2.294 to 6.984, p<0.001) were found to be higher in severe patients. The demographic and clinical characteristics of the patients are shown in Table-1.     Table-1: Demographic and clinical characteristics of COVID-19 patients     In multiple logistic regression analysis, predictive variables that differed between severe and non-severe cases were identified as gender, the number of days of hospitalization, and NLR (Table-2).   Table-2: The results of multiple logistic regression analysis     ROC analysis of NLR and WBC and platelet count was performed to evaluate the use of optimal limit values in laboratory results to distinguish non-severe COVID-19 infection. The area below the ROC curve was found to be statistically significant for the NLR in determining severe COVID-19 patients (AUC: 0.770, 95% CI: 0.725 to 0.812, p<0.001). In distinguishing the two groups from each other, the NLR had 2.625 optimum cut-off value, 60% specificity (95% CI: 54.7 to 65.4), 86% sensitivity (95% CI: 71.5 to 94.6), positive likelihood ratio (PLR) of 4.2 (95% CI: 2.0 to 8.9) and negative likelihood ratio (NLR) of 0.46 (95% CI: 0.4 to 0.6). AUC (Area under the curve) values were not statistically significant in distinguishing the two groups in the ROC analysis performed to determine diagnostic values of lymphocytes, neutrophils, and platelets (p>0.05) (Figure-1).     Figure-1: Lymphocyte, neutrophil and neutrophil-lymphocyte ratio (NLR) ROC curve   Discussion COVID-19 infection affects the respiratory tract, causing a wide range of clinical manifestations ranging from mild viral pneumonia to severe respiratory failure and death [10,12]. Alteration of many hematological and biochemical parameters related to inflammation, coagulation and tissue damage were found to be associated with the course of COVID-19 infection and mortality [14]. NLR correlates with the prognosis of systemic inflammatory diseases. Therefore, NLR levels were also investigated especially in diseases other than COVID-19 [15-19]. Besides, indices such as NLR were found to be significant in prognostic monitoring of diseases such as ulcerative colitis, obstructive sleep apnea, Sjogren’s syndrome and systemic lupus erythematosus, where the inflammatory activity is dominant [19-21]. Studies in patients with squamous cell carcinoma of the esophagus and diseases accompanied by inflammation showed a significant association of the condition with NLR value [22,23]. A study conducted in patients with rheumatoid arthritis found NLR values as significantly higher in the patient group compared to the healthy control group [24]. Studies conducted in patients with cardiovascular disease have found that increase in mortality was correlated with the elevated NLR values [25,26]. In COVID-19 cases, a study conducted by Yang et al. found that among the hematological and inflammation biomarkers, increased NLR was associated with poor prognosis, duration of hospital stay, and clinical course [9]. A study that analyzed 548 COVID-19 cases reported an increase in neutrophil count and NLR in critically ill and terminal cases [13]. Similarly, increased NLR has been shown to be associated with increased severity and mortality in COVID-19 cases [27]. In our study of COVID-19 patients, when we compared the NLR values of severe patients with non-severe patients, we found a statistically significant high NLR values in severe cases. Published studies have reported different efficacy and power of the diagnostic value of NLR in determining the severity of COVID-19. While its diagnostic efficiency was high in some studies, it was low in others. A study examining NLR to predict all-cause mortality in COVID-19 patients found that NLR had 84% specificity and 100% sensitivity [28]. A study involving 1579 patients reported the sensitivity and specificity as 0.78 (95% CI: 0.70 to 0.84) and 0.78 (95% CI: 0.73 to 0.83) respectively for the predictive value of NLR on disease severity [29]. In our study, NLR had 60% specificity (95% CI: 54.7 to 65.4) and 86% sensitivity (95% CI: 71.5 to 94.6) in distinguishing severe COVID-19 cases. <![CDATA[Prevalence and incidence of micro- and macro-vascular complications in a diabetic population of Bangladesh: a retrospective cohort study]]> M Abu Sayeed Akhter Banu Parvin Akter Khanam Tanjima Begum https://imcjms.com/journal_full_text/391 2021-09-28 11:00:24 Original Article IMC J Med Sci 2022; 16(1): 002 Abstract Background and objectives: Diabetes mellitus (DM) is a major health problem in South Asian Region including Bangladesh. Increasing prevalence of DM is likely to cause higher morbidity and mortality. The objective of this study was to find out the prevalence and incidence of diabetic complications in a Bangladeshi diabetic cohort attending BIRDEM, a largest referral center in Bangladesh for endocrine and metabolic diseases. Methodology: The study was conducted in BIRDEM-OPD (outpatient department) from 1 January to 31 December of 1995 and analyzed the data of diabetic cases preserved in BIRDEM registry since 1956. Up to 31 December 1985, the REFERENCE NUMBER (Ref No) of last case was ‘49,510’. Therefore, this retrospective cohort comprised of all those patients having Ref No 49,510 or less and attending BIRDEM-OPD for follow-up. In the year 1995, the cohort had follow-up for at least ten years. The duration of follow-up was 39 years (1956 to 1995).  The study also retrieved follow-up data from the guidebook of each registered diabetic patient. All data regarding clinical, anthropometric and biochemical investigations preserved in BIRDEM registry and in the patient's guidebook were retrieved and analyzed. The cohort was categorized into three groups (Gr1, 2 and 3) based on follow-up duration: >15, 10-15 and <10years, respectively. Results: Micro-vascular complications (retinopathy and nephropathy) were the highest among both Gr1 with follow-up >15y and Gr2 with follow-up 10-15y. Compared with the Gr2, retinopathy (34.4 vs. 48.5 %: c2 =11.5, p <0.001) and nephropathy (24.0 vs. 39.2 %: c2 = 15.6, p<0.001) were significantly higher in the Gr1. In contrast, HTN, skin-lesion and periodontal diseases were significantly higher in the Gr2 than in Gr1. All types of complications were found increasing with the duration of follow-up. For Gr1, the increasing trend of cerebrovascular accident (CVD/ stroke) and CHD was significant (p<0.01 and p<0.001). Mean blood glucose of study population revealed moderate to severe hyperglycemia in successive follow-up visits. The comparison between patients with and without severe hyperglycemia (2hPG: <10.0 vs. ³10.0 mmol/l) showed very little difference of complications. The increasing age over 40 years showed significant risk for CHD and hypertension. Conclusion: CHD, stroke and PVD were less frequent compared to those with retinopathy and nephropathy. Compared to microvascular complications the macrovascular events resulted in either early death or complete disability to pursue long-term follow-up. The most important and consistent predictors were female gender and duration of diabetes.  IMC J Med Sci 2022; 16(1): 002. DOI: https://doi.org/10.55010/imcjms.16.002 *Correspondence: M. Abu Sayeed, Department of Community Medicine, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka-1000. email: sayeed@imc.ac.bd; sayeed1950@gmail.com   Introduction It has been proved that maintenance of normal blood glucose unequivocally reduces mortality from acute events (or complications) in diabetic population [1,2]. It has also been unanimous among diabetologists that normoglycemia is always desirable for wellbeing of the diabetic subjects [1]. The most common chronic complications were the development of either micro- or macro-vascular complications. The microvascular lesions encompass retinopathy, nephropathy and neuropathy. The macrovascular complications are related to atherosclerosis and include mainly coronary artery disease (CAD), peripheral vascular disease (PVD) and cerebrovascular disease (CVD or stroke). Three most world famous prospective studies – Diabetes Complication Control Trial (DCCT) [2], United Kingdom Prospective Diabetes Study (UKPDS) [3] and Minnesota study [4] concluded that strict monitoring and maintenance of normal blood glucose certainly prevents microvascular complications. In contrast, both the studies could not confirm whether and not ‘strict control of blood glucose’ effectively prevents macrovascular complications and prevents atherosclerotic mortality [3,5]. However, there have been a very few cohort studies to assess the diabetes complications in the south-east Asian region. This cohort study addressed to determine the prevalence and incidence of micro- and macro-vascular complications in a diabetes population of Bangladesh.   Study design The study basically analyzed retrospective data of a cohort of diabetic patients who were registered in the past at Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM). BIRDEM is the largest national referral center for diabetes and endocrine diseases in Bangladesh. BIRDEM started registration and follow-up of diabetic patients since 28 February 1956. The diabetic patients from all areas of the country are usually referred to this center. The patients are registered after confirmation of diagnosis. Once registered, they get a unique ‘Reference Number’ (Ref No) printed on the guidebook for follow-up care throughout life. Baseline information of all registered patients is stored in the center. Follow- up care records are maintained in the BIRDEM registry and also written in the guidebook of the patient. The first registration was started on the 28 February 1956 with Ref No 00001. This study cohort included all registered diabetic patients from the first Ref No 00001 (28February 1956) to the last Ref No 49,510 registered on the 31 December 1985. A total of 49,510 diabetic subjects were registered during this period. The selection criteria of the cohort was, therefore, all diabetes patients registered at BIRDEM during this period and attending BIDEM-OPD with their guidebooks for regular follow-up visits. The data collection period was one year, starting from the first January to the 31December 1995. Prior to the study, the doctors and health staff of BIRDEM-OPD were discussed about the study protocol. It was decided that whoever attends with reference number £49,510 would be received in a special counter designed for this cohort study (Figure-1). The guide-books were photocopied for retrieval of data. The BIRDEM history-sheet and guide book were the sources of data.     Figure-1: Steps for collecting data from the patient’s guidebook and from the newly generated investigations’ reports. BP – blood pressure; ECG – electrocardiogram; CCR – creatinine clearance; GB – guidebook   The baseline information included socioeconomic status, smoking habits, and family history of diabetes, hypertension, coronary heart disease, peripheral vascular disease and foot ulcer. The clinical and anthropometric examination included age, height, weight and calculated body mass index. In addition, measurements of blood pressure (for hypertension), peripheral arterial pulse for peripheral arterial disease (PAD), peripheral sensation (for neuropathy), electrocardiogram (for CHD), ophthalmoscopy (for retinopathy) and urinary albumin (for nephropathy) were taken. Similarly, for the assessment of biochemical risk factors for micro- and macro-vascular organic lesion some biochemical investigations were also included. These were plasma glucose, blood lipids, urea, creatinine, electrolytes and total urinary protein. The duration of study cohort was 39 years ranged from 1956 to 1995. We categorized the cohort into three groups: Gr1 with >15 years follow-up, Gr2 with 10-15 years and Gr3 with <10 years. Gr3 was included in the study as the reference for comparative analysis between the recent and the older subjects with varying duration of follow-ups. The biophysical (BMI, BP, 2hPG) characteristics of the patients with shorter duration were compared with the longer duration. Statistical analyses: The prevalence of complications was shown in percentages. Comparison between groups (men vs. women, rural vs. urban, Gr1 vs. Gr2) were estimated by unpaired t-test. Chi-sq test was used to determine the associations between variables. Chi-sq trend test estimated the trend of complications with increasing duration. The level of significance was accepted p<0.05. SPSS Window 19.0 Version was used for all these analyses.   Results According BIRDEM registry 26,349 diabetic patients were registered up to 31 December 1980. This was Gr1 cohort. Of the total 26,349, only 171 (0.7%) were found attending BIRDEM-OPD for follow up. The baseline and follow up data (complications, hospitalization and other investigations) of these 171 patents were retrieved either from their guidebooks or from the BIRDEM registry. The Gr2 cohort comprised 23,161 patients registered from 1 January 1981 to 31 December 1985. Of them, 625 (2.7%) were found attending BIRDEM-OPD for follow up. The Gr3 consisted of only 110 diabetic patients, supposedly, with fewer complications. They were registered from January 1986 through December 1990. The socio-demographic characteristics of Gr1 and Gr2 are shown in Table-1 and 2. The tables also depicted the number of patents attended follow up in successive 5 years interval. Both the groups showed urban predominance than the rural plus suburban. The predominance of female was found in Gr2 but of male in Gr1.   Table-1: Area and sex distribution of the study population, registered up to December 1980 (Gr1), and according to successive 5-year follow-up (n = 171).     Table-2: Area and sex distribution of the study population, registered from Jan 1981 through December 1985 (Gr2), and according to successive 5-year follow-up (n = 625).     Table-3: Mean post-prandial plasma glucose level of study population observed at registration and in the successive 5-year follow-up for ³15-year follow-up study (male + female, n=171, Gr1).     Table-4: Comparison of mean post-prandial plasma glucose level of the study population observed between at registration and last 5-year follow-up period for male and female     Table-5: The prevalence of macrovascular complications among the diabetic patients (n=171) who had ³15 years follow-up.     Table-6: The prevalence of microvascular complications among the diabetic patients (n=171, older group) who had ³15 years follow-up at BIRDEM-OPD.     The trend of 2h post-prandial glucose (2hBG) level of Gr1 is shown at registration and in the subsequent 5 year follow-up period in Table-3. The values of 2hBG were increasing significantly in every 5 years. This indicated that glycemic control target (≤7.8mmol/l) could not be maintained over the years. The significant increasing trend was observed in both male and female cases (Table-4). <![CDATA[Role of tranexamic acid in reducing perioperative blood loss in transthoracic esophagectomy]]> Farooq Ahmad Ganie Syed Mohsin Manzoor Masarat-ul Gani Mohd Yaqoob Khan G N lone Mudasir Hamid Bhat Iqra Nazir Naqash https://imcjms.com/journal_full_text/392 2021-10-05 12:08:17 Original Article IMC J Med Sci 2022; 16(1): 003 Abstract Background and objectives: Transthoracic esophagectomy is usually associated with significant perioperative bleeding and blood loss. The present study investigated the role of prophylactic tranexamic acid on intra- and postoperative blood loss and the need for blood transfusion in transthoracic esophagectomy (Ivor Lewis esophagectomy). Materials and Methods: Patients who underwent laparotomy and right thoracotomy with intrathoracic anastomosis for esophageal malignancy were enrolled in the study. The enrolled cases were divided into two groups namely Group A and B. Informed consents were obtained from all the enrolled patients. Group A patients received a standard dose of 1 gram of intravenous tranexamic acid one hour before the beginning of surgery while Group B patients did not receive any tranexamic acid before or after the surgery. Peroperative blood loss was estimated and noted. Post-operative blood loss was assessed from the surgical drains. Results: A total of 55 cases were included in the study. Group A and B had 27 and 28 cases respectively. The mean age of the Group A and Group B patients was 60.1 ± 6.2 and 60 ± 6.9 years respectively. Out of 27 cases in Group A, 7 (25%) patients had a postoperative haemorrhage (blood loss) up to 300 ml and among the remaining 20, only 2 (7%) patients required blood transfusion as hematocrit fell below 20%. Compared to Group A, patients in Group B who did not receive preoperative tranexamic acid, 21(75%) patients had postoperative haemorrhage up to 300 ml (Group A vs. Group B: p=0.0002). Regarding intraoperative blood loss no significant (p >0.05) difference was observed among the cases in two groups. Conclusion: The study revealed that administration of prophylactic tranexamic acid resulted into fewer postoperative blood loss in transthoracic esophagectomy. IMC J Med Sci 2022; 16(1): 003. DOI: https://doi.org/10.55010/imcjms.16.003 *Correspondence: Farooq Ahmad Ganie, Department of Cardiovascular and Thoracic Surgery, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar -190011, J & K, India. E-mail: farooq.ganie@yamil.com   Introduction Esophageal cancer continues to represent a formidable challenge for both patients and clinicians. Surgical treatment remains a fundamental component of the treatment of localized esophageal carcinoma. Multiple approaches have been described for esophagectomy but the transthoracic approach is widely practised [1,2].The radical surgical procedures are associated with excessive perioperative blood loss and necessitate blood transfusion in the absence of blood conservation strategies. The intra-thoracic oesophagus lies in close vicinity to major vessels such as the aorta, azygous vein and pulmonary vessels and is supplied mainly by small branches from the aorta. The risk may be higher in patients with bulky esophageal tumors in close relation with the major vessels and in patients who have received preoperative chemotherapy or radiotherapy [3]. Surgery affects the coagulation systems and the fibrinolytic system shuts down due to increased release of plasminogen activator inhibitor [2]. Tranexamic acid is a synthetic lysine-analogue with anti-fibrinolytic activity that competitively inhibits the activation of plasminogen to plasmin, and is a well-documented blood sparing agent. Tranexamic acid has roughly eight times antifibrinolytic activity of an older analogue epsilon-aminocaproic acid [4]. The drug interfere with the formation of the fibrinolytic enzyme plasmin from its precursor plasminogen by plasminogen activators (primarily t-PA and u-PA) which takes place mainly in lysine rich areas on the surface of fibrin. The drug blocks the binding sites of the enzymes or plasminogen and thus stop plasmin formation. The administration of tranexamic acid preoperatively significantly reduces blood loss in the first 24 hours in patients undergoing major surgeries for hip and femoral fractures as well it causes a significant reduction in postoperative anaemia and need for transfusion among these patients [5]. This would in turn, help avoid complications related to transfusion of blood and blood products. Also, preoperative administration of single bolus dose of tranexamic acid (20 mg/kg) significantly reduces blood loss in major surgeries of head and neck and other surgeries [6,7]. Thus, it reduces eventual need for blood transfusion. Tranexamic acid demonstrated a significantly lower risk of bleeding complications and transfusion requirements compared to placebo in patients undergoing coronary artery surgery without any significant increase in the risk of death or thrombotic complications [8]. A prospective double blind study reported that single intravenous bolus plus perioperative continuous infusion of tranexamic acid significantly reduce blood loss in abdominal oncosurgical procedures [9]. Transthoracicesophagectomy is a major surgery and hence there is always a significant risk of both intra- as well as postoperative bleeding and blood loss. There is a paucity of information on the efficacy of tranexamic acid in reducing the blood loss in major surgery like transthoracic esophagectomy. With these considerations, we investigated the prophylactic role of tranexamic acid on the bleeding spectrum in transthoracic esophagectomy.   Material and Methods Patients with esophageal malignancy undergoing laparotomy and right thoracotomy with intrathoracic anastomosis (Ivor Lewis esophagectomy) for esophageal malignancy were enrolled in the study. The study was conducted from January 2018 to January 2020 at the Department of Cardiovascular and Thoracic Surgery, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, India. The study was approved by the institutional ethical board. Informed consent was obtained from all the cases prior to enrolment in the study. The enrolled cases were divided into Group A and B. All the patients were of same race and were operated by the same team of surgeons. Group A patients received a standard dose of 1 gram of intravenous tranexamic acid one hour before the beginning of surgery while Group B patients did not receive any tranexamic acid before or after the surgery. Per-operative co-administration of procoagulant like fresh frozen plasma (FFP), platelet rich plasma (PRP), platelet concentrate (PC) was avoided. Patients havingco-morbidities, any coagulation disorder or using any anticoagulants or antiplatelet drugs was not included in study. The peroperative blood loss was estimated and noted. Postoperative blood loss was assessed from the surgical drains. The serial hematocrit and the need and number of postoperative blood transfusions were recorded in both the groups. The indication for transfusion in our study was based on intra-operative and post operative hematocrit value. Blood transfusion was given if the hematocrit value became less than 20%.   Results The mean age of Group A and B patients was 60.1 ± 6.2 and 60.0 ± 6.9 years respectively. In Group A, only 3 (11.1%) patients had an estimated intra-operative blood loss of 200 ml while as remaining 24 (88.9%) patients had less than 200 ml intraoperative bleed compared to 9 (32.1%) and 19 (67.9%) cases respectively in Group B (p = 0.06). After shifting to the ward, out of 27 cases in Group A, 7 (25%) patients had a postoperative bleeding up to 300 ml and among the remaining 20, only 2 (7%) patients required blood transfusion as hematocrit fell below 20%. Compared to Group A, patients in Group B who did not receive preoperative tranexamic acid, 21(75%) patients had postoperative haemorrhage up to 300 ml (Group A vs. Group B: p=0.0002). No significant (p = 0.14) differences were observed between the groups regarding the requirement for blood transfusion. Details are shown in Table-1.   Table-1: Comparison of perioperative blood loss in patients undergoing transthoracic esophagectomy with and without prophylactic tranexamic acid (N=55)     Discussion For many years, tranexamic acid has been used in different types of surgical procedures to reduce blood loss during intra- and in post operative period to avoid eventual need for blood transfusion in surgical patients. Tranexamic acid has been extensively studied to reduce blood loss in orthopaedic [2,5], gynaecological [7,10], cardiac [8] and spine surgeries [8,11]. The treatment effect of tranexamic acid varies somewhat according to the type of surgery, but the result is overall beneficial in terms of reduction of blood loss during and after surgery. However, evidence-based studies regarding its optimal perioperative haemostatic dose regimen in abdominal and abdomino-thoracic surgeries are still lacking. Different doses of the drug are being used in perioperative period which ranged from 10 mg/kg to 20 mg/kg, all showing variable effects on perioperative blood loss [9, 11]. In our study, in patients with transthoracic esophagectomy, significantly (p=0.0002) fewer patients had post operative blood loss of up to 300ml with prophylactic tranexamic acid (1 gram) compared to the control group. However, there was no significant difference between the groups with regard to intra-operative blood loss and need for blood transfusion possibly could be due to low number of cases. Therefore, our encouraging result of low bleeding tendency during postoperative period is useful for preoperative prophylactic application of tranexamic acid in patients undergoing transthoracic esophagectomy. However due to small size of the study population, the validity of the efficacy of tranexamic acid in reducing perioperative blood loss in transthoracic esophagectomy needs further elaborative study.   Conflict of interest: None   References 1.     Barreto JC, Posner MC. Transhiatal versus transthoracic esophagectomy for esophageal cancer. World J Gastroenterol. 2010; 16(30): 3804-3810. 2.     Gupta K, Rastogi B, Krishan A, Gupta A, Singh VP, Agarwal S. The prophylactic role of tranexamic acid to reduce blood loss during radical surgery: A prospective study. Anesth Essays Res. 2012; 6(1): 70-73. 3.     Javed A, Pal S, Chaubal GN, Sahni P, Chattopadhyay TK. Management and outcome of intrathoracic bleeding due to vascular injury during transhiatal esophagectomy. J Gastrointest Surg. 2011; 15(2): 262-266. 4.     Alajmi T, Saeed H, Alfaryan K, Alakeel A, Alfaryan T. Efficacy of tranexamic acid in reducing blood loss and blood transfusion in idiopathic scoliosis: a systematic review and meta-analysis. J Spine Surg. 2017; 3(4): 531-540. 5.     Vijay BS, Bedi V, Mitra S, Das B. Role of tranexamic acid in reducing postoperative blood loss and transfusion requirement in patients undergoing hip and femoral surgeries. Saudi J Anaesth. 2013; 7(1): 29-32. 6.     Das A, Chattopadhyay S, Mandal D, Chhaule S, Mitra T, Mukherjee A, Mandal SK, Chattopadhyay S. Does the preoperative administration of tranexamic acid reduce perioperative blood loss and transfusion requirements after head neck cancer surgery? A randomized, controlled trial. Anesth Essays Res. 2015; 9(3): 384-90.  7.    Ker K, Edwards P, Perel P, Shakur H, Roberts I. Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis, BMJ. 2012; 344: e3054.  8.    Myles PS, Smith JA, Forbes A, Silbert B, Jayarajah M, Painter T, et al., ATACAS Investigators of the ANZCA Clinical Trials Network. Tranexamic acid in patients undergoing coronary-artery surgery. N Engl J Med. 2017; 376(2): 136-148. 9.     Prasad R, Patki A, Padhy S, Ramchandran G. Single intravenous bolus versus perioperative continuous infusion of tranexamic acid to reduce blood loss in abdominal oncosurgical procedures: A prospective randomized double-blind clinical study. J Anaesthesiol Clin Pharmacol. 2018; 34(4): 529-534. 10.  Lundin ES, Johansson T, Zachrisson H, Leandersson U, Bäckman F, Falknäs L, Kjølhede P. Single-dose tranexamic acid in advanced ovarian cancer surgery reduces blood loss and transfusions: double-blind placebo-controlled randomized multicenter study. Acta Obstet Gynecol Scand. 2014; 93(4): 335-44. 11.  Zhang F, Wang K, Li FN, Huang X, Li Q, Chen Z, et al. Effectiveness of tranexamic acid in reducing blood loss in spinal surgery: a meta-analysis. BMC Musculoskelet Disord. 2014; 15: 448. <![CDATA[Antimicrobial susceptibility patterns of bacterial isolates from routine clinical specimens of a tertiary hospital in Bangladesh]]> Md. Anwar Hossain M. Mahboob Hossain Nilufar Begum https://imcjms.com/journal_full_text/400 2021-11-14 13:02:47 Original Article IMC J Med Sci 2022; 16(1): 005 Abstract Background and objectives: To prevent the emergence and spreading of antimicrobial resistance, especially multidrug resistance in pathogenic bacteria, the selection of appropriate antibiotics is a prerequisite for the effective treatment of infection.This study aimed to analyze the prevalence and antimicrobial resistance patterns of bacterial isolates from various clinical samples in a tertiary care hospital. Methods: This study was conducted at a teaching hospital of Dhaka city, Bangladesh from January 2020 to March 2021. The results of culture and antimicrobial susceptibility of bacterial isolates from various clinical samples were collected and analysed. Identification of bacteria and antimicrobial susceptibility test were performed according to the standard methods. Results: A total of 1277 bacterial isolates was analyzed. Of them, 1072 (83.95%) were Gram-negative, and 205 (16.05%) were Gram-positive bacteria. Among the isolates, Escherichia coli (n=576), Enterobacter spp. (n=150), Klebsiella spp. (n=140), and Staphylococcus aureus (n=117) were predominant.The Enterobacteriaceae showed higher resistance to cephradine (94.3%) and cefuroxime (76.7%), whereas least resistant to imipenem (10.1%) and meropenem (14.8%).  <![CDATA[Use of infrared thermal camera in acute scrotal pain: a prospective study]]> Erdal Yavuz Hakan Kürümlüoğlu Suat Zengin Şevki Hakan Eren Esat Karaduman Cuma Önder Yeşildağ Behçet Al Cuma Yıldırım https://imcjms.com/journal_full_text/402 2021-11-25 12:22:09 Original Article IMC J Med Sci 2022; 16(1): 007 Abstract Background and objectives: Infrared thermal (IR) camera is used to assess various clinical conditions such as diabetic foot, carotid artery stenosis, and superficial infection. The present study was designed to determine the usefulness of IR thermal camera in scrotal temperature measurement before color Doppler ultrasonography (CDUS) in patients admitted to the emergency department with acute scrotal pain. Method: This study was prospectively conducted on 49 patients with acute scrotal pain and 30 control participants. The findings of CDUS and scrotal temperature measurements by an IR camera were separately evaluated by different physicians. In all patients, temperature measurements with IR camera were made under the same environmental conditions. Results: Of the 49 patients included in the study, four were diagnosed with torsion, 12 with epididymitis, 4 with orchitis, 3 with epididymo-orchitis, and 2 with varicocele. A significant difference was observed between the scrotal temperature of the patients with scrotal pain and the mean testicular temperature of the control group based on the IR camera measurement (p<0.05). IR camera did not detect any difference between the two testicles of the same person in the patient group (p=0.615). Although the lowest temperature was in testicular torsion, the patients’ scrotal temperature did not significantly differ according to their diagnoses (p=0.087). Conclusion: Testicular temperature measured by IR device was lower in patients presenting with scrotal pain compared to normal individuals. Although not statistically significant, the lowest temperature was found in cases of testicular torsion. IR camera may be useful in triage when used in conjunction with physical examination in patients presenting with acute scrotal pain. IMC J Med Sci 2022; 16(1): 007. DOI: https://doi.org/10.55010/imcjms.16.005 *Correspondence: Erdal Yavuz, Department of Emergency Medicine, Faculty of Medicine, Adiyaman University, Adiyaman, Turkey. Email: erdal_yavuz15@hotmail.com, Orcid: 0000-0002-3168-6469   Introduction Scrotal pain can be primary or reflective. The differential diagnosis of acute scrotal pain includes testicular torsion, torsion of the testicular extensions, epididymitis, orchitis, incarcerated hernia, trauma and vasculitis. Testicular torsion should be considered first in acute scrotal pain due to potential infarction and infertility. Delays in the diagnosis of testicular torsion can cause testicular necrosis and testicular loss. It is important to diagnose patients presenting to the emergency department with acute scrotal pain promptly since emergency surgery is indicated in the presence of testicular torsion [1]. In case of acute scrotal pain, laboratory investigations and imaging methods are used along with a physical examination for diagnostic purpose. For the detection of testicular pathologies, the most used and beneficial imaging method is Doppler ultrasonography, but this procedure requires experienced personnel. Radiology physicians are not always available in the hospital, and there may be concerns of emergency physicians about requesting ultrasonography. Also, ultrasonography may not be available in every healthcare institutions in low economic countries [2,3]. The infrared (IR) thermal camera, which has been introduced to the field of medicine, assists in the early diagnosis of various clinical conditions. It is used in various clinical conditions such as diabetic foot, carotid artery stenosis, and superficial infection. In case of vascular stenosis or skin infection, temperature changes can occur in the skin. While the temperature increase is less in stenosis cases, it is higher in cases of infection. It is possible to detect these changes using an IR thermal imager at low cost [4-6]. This study aimed to examine the diagnostic value of IR thermal camera images of patients presenting with acute scrotal pain by comparing them with color Doppler ultrasonography (CDUS). We hypothesized that the temperature measurements by an IR thermal imager would low in case of testicular torsion and high in the presence of infection. We assume that IR thermal camera can help physicians in healthcare settings lacking facility for CDUS.   Methods Study design and setting: This prospective controlled study was conducted at the Emergency Department of University Adiyaman Research and Education Hospital. The study was approved by the ethics committee of the hospital (ethics committee decision number: 2016/185, date: 26.09.2016). Informed consent was obtained from the each participant. The study protocol was carried out in accordance with the principles of the Declaration of Helsinki. Selection of participants: The study population consisted of all patients over 16 years of age that presented to the emergency department with acute onset of scrotal pain. The suitability of the patients was determined by the emergency physician. Physicians participating in the study were trained on the use of CDUS and IR camera. For the control group, volunteers over the age of 16 years, who did not have any comorbidities, testicular pain, increased temperature, or swelling, were selected. Patients younger than 16 years of age and those that did not agree to participate in the study, as well as those with any additional organic pathology were not included in the study. Study procedures: The cases included in the study were taken to a room in the emergency department equipped for ultrasonography and thermal imaging. The room where the imaging was performed was not exposed to direct sunlight and did not contain any heat source or lighting equipment that could cause errors in thermal imaging. Three teams were involved in the imaging process: one for recording the thermal image, one for performing CDUS and one for reviewing the data. The data obtained from these teams were provided that each was blinded to the others’ evaluation. All patients and controls were kept in the room prepared for the study with their scrotum uncovered for 5 minutes in order to minimize the temperature differences that could be caused by the clothes and ambient temperature. While the patient was in the supine position, a thermal camera was focused from a distance of approximately 50 cm and three consecutive images of the scrotum were taken for both sides. After taking the thermal images CDUS was performed on the patient and control groups. Methods of measurements: Using software, background temperatures were completely removed from the thermal images to increase sensitivity, and thus pure testicular temperatures were obtained. In addition, two testes were separated independently by creating separate heat vectors. The generated heat vectors were used in the statistical asymmetry analysis of the diseased and intact testes. In this analysis, mean, median, standard deviation, variance, kurtosis, skewness and entropy values were calculated to allow for a completely objective evaluation in distinguishing the presence of a disease. Images taken from the patients with a thermal camera were evaluated to make a diagnosis using various image processing techniques and statistical calculations. The Logiq P6 (General Electric Healthcare, 2008, Germany) ultrasonography device with 12 MHz linear and 5 MHz convex probes were used for the CDUS examinations. The Testo 875-I (Testo SE & Co, UK) thermal imager was used for thermal imaging. This camera has a 160×120 pixel detector and can record images at a resolution of up to 320×240 pixels with its super resolution feature and detect a temperature difference of 0.05 °C (Figure 1).     Figure-1: The samples showing measurement with IR device   Statistical analysis: The distribution analysis of the data obtained from this study was performed using the Kolmogorov-Smirnov test. The independent-samples t-test was used for the binary comparisons of independent and normally distributed data while the Mann-Whitney U test was conducted for the binary comparisons of independent and non-normally distributed data. The results of the nominal value groups were analyzed using the chi-square test. The results were expressed as mean ± standard deviation. For statistical analyses, SPSS v. 18.0 was used. P <0.05 was considered to be statistically significant in all comparisons.   Results During the study period, 70 patients with scrotal pain were evaluated, of these patients, 21 (30%) were excluded based on exclusion criteria. Finally, a total of 49 patients with scrotal pain were included in the study. Thirty individuals were recruited for the control group (Figure-2). The mean age was 28.5 ± 11.7 years for the patient group and 27.8 ± 11.4 years for the control group.     Figure-2: Flow chart showing the enrollment of the study population   According to the reports of the CDUS, epididymitis was present in 24.5% of the patients, orchitis in 8.2%, epididymo-orchitis in 6.1%, torsion in 8.2%, varicocele in 4.1%, and normal findings in 49% cases (Table-1). The physical examination findings of the patients varied depending on their diagnoses. There were differences in relation to the cremaster reflex and Prehn’s sign according to the diagnoses. These findings were negative in all patients with torsion while they were positive in most of the cases with normal findings (Table-2).   Table-1: Doppler ultrasonography results of patients (n=49)     Table-2: Analysis of the cremaster reflex and Prehn’s sign according to the diagnoses (n=49)     There was a statistically significant (p <0.001) difference between the mean testicular temperature of the group with scrotal pain and the control group based on the IR camera measurements (Table-3). The mean testicular temperature of the group with scrotal pain was 33.06 ± 1.21°C, while the mean testicular temperature of the control group was 34.09 ± 0.73°C. Temperatures of the diseased and intact testicles of the patients were also evaluated with IR camera and no significant difference was found (p=0.615) (Table-3). When the IR measurements were evaluated according to the diagnoses, the lowest temperature was in testicular torsion (31.93 ± 0.56 °C). The highest temperature was recorded in epididymitis (33.40 ± 1.34 °C). However, the mean testicular temperature did not significantly differ according to the types of diagnosis (p = 0.087) in patient group (Table-3).   Table-3: Scrotal temperature according to the diagnoses as measured by IR camera     Discussion There are only a few human studies on the use of an IR thermal imager for testicular pathologies. Most of the studies involving scrotal pathology were conducted on animal models. Arumalla conducted a study on testicular torsion in sheep and skin infection in humans in order to investigate the effectiveness of thermal cameras [7]. The aim of the author in that study was to show the temperature decrease due to decreased blood circulation in testicular torsion of sheep, and the increase in temperature due to inflammation in skin infections (abscess, cellulite, etc.) with a thermal camera. The authors concluded that infrared thermal camera were effective in detecting skin infection and testicular torsion and therefore, could be used in humans. Another study conducted by Yanmaz et al [8] on the extremity diseases of horses, reported that thermography could be used in routine clinical practice as an auxiliary diagnostic method to identify and diagnose lesions of soft and hard tissues of the horse extremity. A study conducted on pigs reported that IR thermal imager could effectively detect decreased surface temperature following arterial and venous thrombosis [9], In human, Saxena et al [4] reported that IR camera measurements performed on the skin were significantly lower in patients with carotid artery stenosis. In another study, Doremalen et al [5] suggested that an IR camera was a good screening device for assessing diabetic foot. A study that monitored surface temperature by IR thermal camera in the postoperative management of free tissue transfers showed lower surface temperature in flaps with thrombosis than normal flaps [10]. Earlier, few studies on human reported elevated scrotal temperature in patients with varicocele when assessed by IR thermal camera [11,12]. In our study, a significant difference was observed when the temperature of the testicles of individuals in the scrotal pain group and the control group were compared. Temperature was lower in the scrotal pain group. In our study, the lowest scrotal temperature is in torsion patients. But there was no significant difference between patient diagnoses and body temperature which could be due to the low number of patients. However, there was no significant difference between the temperatures of the diseased and intact testicles measured by an IR thermal camera in the same individuals. This could be due the proximity of the diseased and intact testes affected the temperatures. There was some limitation in our study. The study had small number of cases. But this study may be valuable as it examined for the first time the testicular temperature in humans by an IR camera in variety of scrotal pathology. Differences in temperature values of disease groups according to diagnoses and comparison with values in normal individuals could not be examined. Further studies are needed for comparisons with larger number of cases. In this study, a lower temperature is significant in acute scrotal pain. The management of acute scrotal pain in the emergency department requires the evaluation of patient by physical examination and imaging findings together. Imaging or physical examination alone is not sufficient for a diagnosis. Testicular temperature measured by IR device was lower in patients presenting with scrotal pain compared to normal individuals. An IR camera could not replace CDUS in acute scrotal pathologies; however, it may be beneficial in triage when used together with the physical examination of patients presenting with acute scrotal pain. We think that IR thermal camera can help physicians in low economic settings and in healthcare facilities where opportunities for CDUS are limited.   Authorship: EY, SZ and HK contributed to conception and design, supervision; BA, CY and CÖY contributed to data collection and processing; EY, ŞHE contributed to analysis and interpretation; SZ, HK and EK contributed to literature review; EY, HK contributed to writing; and SZ contributed to critical review.   Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.   Conflict of interest: The authors declare that they have no conflict of interest. Human rights: Authors declare that human rights were respected according to Declaration of Helsinki.   References 1.     Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013; 88(12): 835-840. 2.     Hazeltine M, Panza A. Testicular torsion: current evaluation and management. Urol Nurs. 2017; 37(2): 61-93. 3.     Nakayama A, Ide H, Osaka A, Yasuyuki I, Yukihito, S, Toshiyuki I, et al. The diagnostic accuracy of testicular torsion by doctors on duty using sonographic evaluation with color doppler. Am J Mens Health. 2020; 14(5): 1-6. 4.     Saxena A, Eddie YK, Wee NG, Lim ST. Infrared (IR) thermography as a potential screening modality for carotid artery stenosis. Comput Biol Med. 2019; 113: 1-11. 5.     Van Doremalen RF, Van Netten JJ, Van Baal JG, Vollenbroek-Hutten MM, van der Heijden F. Validation of low-cost smartphone-based thermal camera for diabetic foot assessment. Diabetes Res Clin Pract. 2019; 149: 132-9. 6.     Capraro GA, Nathanson BH, Jasienowski S, Reiser M, Blank FS. Can the heat of localized soft tissue infections be quantified non-invasively using an infrared thermography camera? Ann Emerg Med. 2008; 52(4): 157. 7.     Arumalla RR. Medical infrared image analysis for detecting skin temperature disparities [Thesis]. Amherst, Masachusetts: University of Masachusetts Amherst. February, 2009. 8.     Yanmaz LE, Okumus Z, Dogan E. Instrumentation of thermography and its applications in horses. J Anim Vet Adv. 2007; 6(7): 858-62. 9.     Perng CK, Ma H, Chiu YJ, Lin PH, Tsai CH. Detection of free flap pedicle thrombosis by infrared surface temperature imaging. J Surg Res. 2018; 229: 169-76. 10.  Papillion P, Wong L, Waldrop J, Sargent L, Brzezienski M, Kennedy W, et al. Infrared surface temperature monitoring in the postoperative management of free tissue transfers. Can J Plast Surg. 2009; 17(3): 97-101. 11.  Dadpay M, Ghayoumi Zadeh H, Danaeian M, Namdari F, Rezakhaniha B. Evaluation of thermal ımaging system of the scrotum in patients with varicocele. Iran J Public Health. 2017 Dec; 46(12): 1742-1743. 12.  Kulis T, Knezevic M, Karlovic K, Kolaric D, Antonini S, Kastelan Z. Infrared digital thermography of scrotum in early selection of progressive varicocele. Med Hypotheses. 2013 Oct; 81(4): 544-6. <![CDATA[Comparison of clinicopathological and preoperative computed tomography findings of sinonasal masses]]> Namrata Sasidharan Abdunnasar Moodem Pilakkal Santhi Thankappan Pillai https://imcjms.com/journal_full_text/403 2021-12-07 11:50:53 Original Article IMC J Med Sci 2022; 16(1): 008 Abstract Background and objectives: Computerized tomography (CT) scan with contrast can delineate soft tissue pathologies and is now the first choice in diagnosing sinonasal malignancy and inflammatory lesions. The present study compared the diagnostic nasal endoscopy (DNE) and CT scan to diagnose cases presented with sinonasal mass. Materials and methods: This was a descriptive study conducted on patients with sinonasal masses attending at Government TD Medical College, Alappuzha, Kerala from 1/1/2014 to 30/6/2015. Each patient was examined by diagnostic nasal endoscopy and had undergone preoperative CT scan. Histopathological examination of the specimens was carried out and compared with the findings of DNE and CT scan. Results: A total of 72 cases were enrolled in the study. Age group was from 13-85 years with a male to female ratio of 1.3:1. Nasal obstruction was the commonest symptom. Among the 72 cases, 59 belonged to the non-neoplastic group and 13 to the neoplastic group. Sinonasal polyps (65.3%) formed the majority of the non-neoplastic lesions. Vascular lesions (6.9%) were the commonest benign neoplastic mass and malignancy was seen in 6.9% of cases. Diagnosis by DNE and CT scan was same except in 3 cases. Histopathology and radiological scan result correlated well except in 3 cases. Conclusion: Histopathology still remains the gold standard in the diagnosis of sinonasal masses. Clinical, CT scan and histopathology diagnoses were complementary with each other. However, CT scan is indispensible in studying the anatomical variants and providing the route map prior to and during endoscopic sinus surgeries. IMC J Med Sci 2022; 16(1): 008. DOI: https://doi.org/10.55010/imcjms.16.006 *Correspondence: Santhi Thankappan Pillai, Department of Otorhinolaryngology, Government TD Medical College, Vandanam, Alappuzha, Kerala 688005, India. Email: sttpillai@gmail.com   Introduction Sinonasal masses are often diagnosed as nasal polyp which is a pedunculated prolapsed mucosa that projects from the normal mucosal surface [1,2]. These originate from the epithelial mucosa, mucous gland, bony structures, minor salivary glands, neural tissue and lymphatics [3]. Diagnostic nasal endoscopy (DNE) is used to understand the gross nature of nasal masses, nasal discharge, structures on the lateral nasal wall and the various anatomic variations [4]. Computerized tomography (CT) scan with contrast can delineate soft tissue pathologies and is now the first choice in diagnosing sinonasal malignancy and inflammatory lesions [5,6]. Patients with significant pathology are planned for surgery. CT scan with fine coronal sections at the level of osteomeatal complex is an excellent technique in assessing bony detail, extent of the disease, hyperdensities and anatomical variations of sinonasal diseases [7]. CT scan can also reveal mucosal thickening and secretions in the sinuses, but the mucosal thickening cannot be interpreted specifically for sinusitis [8]. So at least 4-6 weeks of aggressive medical therapy should be given prior to CT scan so that the extent of the disease can be delineated amidst irreversible mucosal or bony changes, as around 40% of the asymptomatic population has mucosal changes in the CT [9]. However, for patients being considered for endoscopic sinus surgery, the CT should be carefully interpreted before beginning surgery and should be available for review during the procedure. But, if CT findings are not interpreted in the light of the clinical findings, many people who have incidental changes may be labeled as having sinus disease and would undergo unnecessary surgery [10]. The combination of DNE with conventional CT scan has proven to be the ideal method for the examination of inflammatory disease of the paranasal sinuses. Also, histopathology of the surgical specimen is necessary as neoplasms of the sinuses and nasal cavity account for 0.2–0.8 % of all carcinomas [11]. Objective of this study was to compare the DNE features of the sinonasal masses with the findings of preoperative CT scans for an accurate diagnosis and proper management of the condition.   Materials and methods Study population and design: This descriptive study was conducted on patients with sinonasal masses who attended the ENT (ear, nose and throat) outpatient department (OPD) at Government TD Medical College, Alappuzha, Kerala during 1st January, 2014 to 30th June 2015. Ethical clearance and approval of the protocol from the Institutional Review Committee (approval number No.B3/1573/2010/TDMCA/EC 9/2013) was obtained prior to initiation of the study. With informed consent, patients were clinically evaluated. The study variables were age, sex, symptomatology, duration, laterality, findings of DNE, CT scan and histopathology. DNE was performed and the patients with sinonasal masses were sent for preoperative CT scan. Coronal and axial cuts of CT of nose and paranasal sinuses with contrast were done. Nature and extent of the lesion, involvement of the osteomeatal complex and paranasal sinuses, mucosal thickening, bone involvement and anatomical variants were studied radiologically. Patients were operated and histopathological examination of the specimens was carried out. All details were systematically recorded in predesigned data sheet. Inclusion criteria: Both males and females patients above 12 years of age with clinically diagnosed sinonasal masses and willing to do CT scan of the nose and paranasal sinuses were included in the study. Exclusion criteria: Cases excluded from the study were: (i) patients below 12 years of age to avoid radiation exposure during CT scan and above 85 years due to associated comorbidities where CT scan with contrast is contraindicated, (ii) patients with congenital nasal masses, (iii) patients with lesions arising from the nasopharynx and (iv) patients who have been previously operated for sinonasal masses. Study procedure: DNE was performed using a 0 degree adult nasal endoscope under local anesthesia followed by CT scans with contrast of the nose and paranasal sinuses. A provisional diagnosis was made after correlating clinical assessment with radiological investigation findings. Endoscopic sinus surgery was performed and surgical specimens were sent for histopathology. Clinical and radiological findings were compared with the histopathological findings and the results were analyzed. Data obtained was analyzed with SPSS 16.0. Percentages and proportions were used for qualitative variables and appropriate statistical tests were employed to determine significant difference of findings by the different methods.   Results A total of 72 patients with sinonasal masses were enrolled in this study. The age distribution of the patients ranged from 13-85 years and majority (51.7%) belonged to 41-60 years age group (Table-1). Male to female ratio was 1.3:1. The commonest symptoms were nasal obstruction (81.9%), nasal discharge (61.1%) and headache (58.3%). Frequency of the symptoms is shown in Figure-1.   Table-1: Age distribution of the study population (n=72)         Figure-1: Symptoms of study population (n=72)   On clinical examination by DNE, 48 patients (66.7%) had bilateral and 24 (33.3%) had unilateral nasal masses (Table-2). Among the 48 patients with bilateral nasal masses, clinically 46 (95.8%) had non-neoplastic and 2 (4.2%) had neoplastic masses. Among the unilateral masses, 11 (45.8%) and 13 (54.2%) had neoplastic and non-neoplastic type lesions respectively. Among the 72 patients, 59 patients (81.9%) were clinically diagnosed as non-neoplastic while 13 patients (18.1%) were diagnosed as having neoplastic lesions. Among the 13 neoplastic cases, 8 were diagnosed clinically as benign and 5 as malignant lesions.   Table-2: Relation between laterality and type of sinonasal mass (n=72)     Comparative diagnosis by DNE and CT scan is shown in Table-3. Clinically sinonasal polyposis was the commonest diagnosis in 47 patients (65.3%), others being fungal sinusitis in 10 patients (13.9%), malignancy and vascular lesions in 5 patients each (6.9% each), inverted papilloma in 3 patients (4.2%) and frontoethmoid mucocele in 2 patients (2.8%). According to the CT scan, 49 patients (68.1%) had sinonasal polyps, 8 patients (11.1%) had malignancy, fungal disease in 7 patients (9.7%), vascular lesion in 4 patients (5.6%), mucocele and inverted papilloma in 2 patients (2.8%) each. No significant (p>0.05) difference in diagnosis of sinonasal masses was observed between DNE and CT scan.   Table-3: Diagnosis of sinonasal masses by diagnostic nasal endoscopy (DNE) and CT scan (n=72)     Detail histopathological diagnosis of sinonasal masses is shown in Table-4. Histopathology examination revealed that 31 (43.1%) cases of the polyps as inflammatory, while 16 (22.2 %) cases were allergic in nature making a total of 47 cases of sinonasal polyps. Other non-neoplastic lesions were aspergillosis (8 cases, 11.1%), mucormycosis (3 cases, 4.2%) and mucocele (2 cases, 2.8%). Among the benign neoplastic lesions, hemangiomatous lesions were the commonest (5 cases, 6.9) followed by inverted papilloma (3 cases, 4.2%). Histopathologically, squamous cell carcinoma and angiosarcoma were detected in 3 (4.2%) and 1 cases (1.4%) respectively. Histopathology report correlated well with clinical diagnosis by DNE and CT scan in 71 patients with the exception of one patient.   Table-4: Diagnosis of sinonasal masses by histopathology     Discussion Sinonasal masses constitute a heterogeneous group of lesions with a broad spectrum of histopathological features [12]. Commonly presenting as nasal polyps, at times it is difficult to differentiate neoplastic lesions from non-neoplastic lesions and benign from malignant lesions clinically [13].Hence, this study was conducted to determine the correlation of the clinical and radiological diagnosis with the histopathology of the sinonasal masses. In our study, the mean age of presentation was 42.75 years and the male to female ratio was 1.3:1. The most common presenting symptoms in patients with sinonasal masses were nasal obstruction, nasal discharge and headache while the presence of polyp was the predominant nasal endoscopic feature which were comparable to the findings by similar studies [1,14,15]. Eye symptoms were seen in 10 (13.9%) cases.Eye symptoms were more in non-neoplastic lesions (11.1%) which were similar to the study by Rawat et al. [14]. According to this study, 33.3% of sinonasal masses were unilateral and 66.7% were bilateral. Bone erosion was seen in 25% of the cases on CT. This was either due to malignancy or invasive fungal sinusitis and was similar to another study [16]. Though CT scan helps in diagnosis and tumour staging, it is not totally reliable in assessing the extent of the sinonasal mass lesions as retained/inspissated secretions and thickened mucosa within the paranasal sinuses can be misinterpreted as extension of the malignancy [15]. In such cases, investigation like MRI may be needed to differentiate true disease infiltration from obstruction of the draining ostia [17]. Majority (81.9%) of our cases with sinonasal masses had non-neoplastic lesions. Similar preponderance of non-neoplastic sinonasal masses were reported by others [1,14,15]. Lobular capillary hemangioma was the commonest benign lesion diagnosed in 6.9% of patients (5 cases) which was similar to the study by Lathi et al. [1] while inverted papilloma formed 4.2% of the benign neoplasms in our study but 36.8% in the study by Lathi et al. [1]. In the study by Bist et al. [15], 56.4% cases were non-neoplastic lesions, 19.8% were benign and 23.7% were of malignant nature. Angiofibroma formed 35% of the benign cases and carcinoma of the nasal cavity was present in 45.83% out of which squamous cell carcinoma was the commonest histopathological diagnosis in 33.3% cases. Among the malignant lesions, malignancy of maxilla was the commonest lesion seen in 4.2% of patients in our study. Squamous cell carcinoma (SCC) was diagnosed in 3 out of the total 4 patients with neoplastic malignant lesions. The results were partly in accordance with the study by Bist et al. [15] where nasal polyps, angiofibroma, and SCC were the commonest non-neoplastic, benign, and malignant lesions respectively. The variation noted between CT diagnosis and histopathology was 4.16% in the current study (3 patients). This was in accordance with a similar study of sinonasal masses, which showed variation in 3.63% of the cases [15] and 3.62% in another study by Somani et al. [17]. One of the limitations was that other radiological investigation like MRI was not done in this study of sinonasal pathologies. In our study histopathology and clinical diagnosis did not correlate in only one case (1.38%). Diamantopoulos et al. reported different histopathological findings from the clinical diagnosis in 1.1% of patients who presented with sinonasal masses [18]. Two other studies also reported that only 0.3% of their patients had histopathological findings different from clinical diagnosis [16,19]. It appears that histopathology remains the gold standard for the accurate diagnosis and further management of cases with sinonasal mass. Though histopathology is considered as the gold standard in diagnosis of sinonasal lesions, CT scan as an imaging modality should be done following diagnostic nasal endoscopy to understand the nature and extent of the disease and planning surgical management. It is essential to correlate clinical, radiological and pathological findings in the management of sinonasal masses, as these modalities are complementary to each other.   Authors’ contributions NS, ABMP and STP designed the study protocol. NS and ABMP collected the data; NS, ABMP and STP did the statistical analysis; NS, ABMP and STP prepared the manuscript. ABMP and STP supervised and coordinated the study and edited the manuscript.   Competing interests None of the authors have any conflict of interest to declare.   Ethics approval and consent to participate and publish Prior to commencement, the research protocol was approved by the Institutional Review (IRC) of Govt TD Medical college (No.B3/1573/2010/TDMCA/EC 9/2013). Informed written consent was taken from all participants to participate in the study and publish the study findings.   References 1.     Lathi A, Syed MM, Kalakoti P, Qutub D, Kishve SP. Clinico-pathological profile of sinonasal masses: a study from a tertiary care hospital of India. Acta Otorhinolaryngol Ital. 2011; 31(6): 372-377. 2.     Dasgupta A, Ghosh RN, Mukherjee C. Nasal polyps - histopathologic spectrum. Indian J Otolaryngol Head Neck Surg. 1997; 49(1): 32-37. 3.     Groves J, Gray RF. Tumours and cysts of the nose, paranasal sinuses and jaws. In: A Synopsis of Otolaryngology. 4th ed. Bristol: Wright. 1985; p215-226. 4.     K Maru Y, Gupta Y. Nasal endoscopy versus other diagnostic tools in sinonasal diseases. Indian J Otolaryngol Head Neck Surg. 2016; 68(2): 202-206. 5.     Sonkens JW, Harnsberger HR, Blanch GM, Babbel RW, Hunt S. The impact of screening sinus CT on the planning of functional endoscopic sinus surgery. Otolaryngol Head Neck Surg. 1991; 105(6): 802-813. 6.     Varshney H, Varshney J, Biswas S, Ghosh SK. Importance of CT scan of paranasal sinuses in the evaluation of the anatomical findings in patients suffering from sinonasal polyposis. Indian J Otolaryngol Head Neck Surg. 2016; 68(2): 167-172. 7.     Kanwar SS, Mital M, Gupta PK, Saran S, Parashar N, Singh A. Evaluation of paranasal sinus diseases by computed tomography and its histopathological correlation. J Oral Maxillofac Radiol. 2017; 5: 46-52. 8.     Okuyemi KS, Tsue TT. Radiologic imaging in the management of sinusitis. Am Fam Physician. 2002; 66(10): 1882-1886. 9.     Leung RS, Katial R. The diagnosis and management of acute and chronic sinusitis. Prim Care. 2008; 35(1): 11-24, v-vi. 10.  Jones NS. CT of the paranasal sinuses: a review of the correlation with clinical, surgical and histopathological findings. Clin Otolaryngol Allied Sci. 2002; 27(1): 11-7. 11.  Kazi M, Awan S, Junaid M, Qadeer S, Hassan NH. Management of sinonasal tumors: prognostic factors and outcomes: a 10 year experience at a tertiary care hospital. Indian J Otolaryngol Head Neck Surg. 2013; 65(Suppl 1): 155-159. 12.  Shirazi N, Bist SS, Selvi TN, Harsh M. Spectrum of sinonasal tumors: A 10-year experience at a tertiary care hospital in North India. Oman Med J. 2015; 30(6): 435-440. 13.  Garg D, Mathur K. Clinico-pathological study of space occupying lesions of nasal cavity, paranasal sinuses and nasopharynx. J Clin Diagn Res. 2014; 8(11): FC04-7. 14.  Rawat DS, Chadha V, Grover M, Ojha T, Verma PC. Clinico-pathological profile and management of sino-nasal masses: A prospective study. Indian J Otolaryngol Head Neck Surg. 2013; 65(Suppl 2): 388-393. 15.  Bist SS, Varshney S, Baunthiyal V, Bhagat S, Kusum A. Clinico-pathological profile of sinonasal masses: An experience in tertiary care hospital of Uttarakhand. Natl J Maxillofac Surg. 2012; 3(2): 180-186. 16.  Kale SU, Mohite U, Rowlands D, Drake-Lee AB. Clinical and histopathological correlation of nasal polyps: are there any surprises? Clin Otolaryngol Allied Sci. 2001; 26(4): 321-3. 17.  Somani S, Kamble P, Khadkear S. Mischievous presentation of nasal masses in rural areas. Asian J Ear Nose Throat. 2004; 2: 9-17. 18.  Diamantopoulos II, Jones NS, Lowe J. All nasal polyps need histological examination: an audit-based appraisal of clinical practice. J Laryngol Otol. 2000; 114(10): 755-759. 19.  Garavello W, Gaini RM. Histopathology of routine nasal polypectomy specimens: a review of 2,147 cases. Laryngoscope. 2005; 115(10): 1866-1868. <![CDATA[Comparison of paracetamol and hyoscine-N-butylbromide in the treatment of abdominal pain and cramps due to acute gastroenteritis]]> Hasan Sultanoğlu Yılmaz Safi Mustafa Enes Demirel Mehmet Cihat Demir Hasan Baki Altinsoy Mustafa Boğan Hasan Gümüşboğa https://imcjms.com/journal_full_text/404 2021-12-11 13:29:55 Original Article IMC J Med Sci 2022; 16(1): 009 Abstract Background and objective: Hyoscine-N-butyl bromide (HBB) and paracetamol (acetaminophen)are widely used in emergency departments for abdominal pain and cramps. However, there is not enough data on the efficacy, safety, and superiority of each other in treating acute gastroenteritis (AGE) related abdominal pain and cramps. In this study HBB and paracetamol were compared for the treatment of abdominal pain and cramps related to acute gastroenteritis. Materials and methods: The study was conducted in a tertiary university hospital emergency department as a prospective, randomized-controlled, and double-blind study. Intravenous (IV) 1000 mg paracetamol and IV 20 mg hyoscine-N-butyl bromide (HBB) were used to treat abdominal pain and cramps related to AGE. Visual analogue scale (VAS) was used to evaluate the degree of abdominal pain before and after treatment. Results: HBB and paracetamol groups consisted of 123 and 158 cases respectively. In both groups, it was observed that the VAS score gradually decreased from the 0th hour to the 1st and 2nd hours (p<0.001).When comparing each time within itself, it was observed that HBB and paracetamol measurements had similar values (p>0.05). No severe side effects were observed in any of the patients. Conclusion: HBB and paracetamol were used for symptomatic treatment in AGE patients presenting with abdominal pain and cramps. A significant reduction in pain and cramps was achieved in both patient groups. There was no difference between the two drugs in terms of treatment efficacy and side effects. IMC J Med Sci 2022; 16(1): 009. DOI: https://doi.org/10.55010/imcjms.16.007 *Correspondence: Hasan Gümüşboğa, Department of Emergency, Şehitkamil State Hospital, Gaziantep, Turkey, Posta code: 27500; Email: profhasan@hotmail.com; ORCID:0000-0003-2097-7102.   Introduction Acute gastroenteritis (AGE) is a generally self-limiting acute inflammatory condition of the gastrointestinal tract due to infectious or non-infectious causes [1]. Diarrhea is the main finding and may be accompanied by nausea, vomiting, fever, abdominal pain and cramps, bloating, gas, bloody stool, tenesmus, and urgency to defecate [1,2]. Visceral pain, associated with smooth muscle spasm, is a common symptom observed in gastrointestinal pathologies [3]. Although antispasmodic agents are widely used in the symptomatic treatment of abdominal pain and cramps, there is insufficient data on their efficacy and safety and is not included in the guidelines [5-7]. Hyoscine N-butylbromide (HBB), frequently used in symptomatic treatment, is a quaternary ammonium derivative that reduces abdominal cramps and pain by reducing smooth muscle tone [5]. On the other hand, paracetamol (acetaminophen), a weak prostaglandin synthesis inhibitor, has been used for many years as an analgesic and antipyretic [8]. Both drugs are widely used in emergency departments and are effective in abdominal pain and cramps [5,6]. However, there is not enough data on the efficacy, safety, and superiority of each other in treating AGE-related symptoms. In this study, intravenous 1000 mg paracetamol and IV 20 mg HBB were used to treat abdominal pain and cramps related to AGE. The effectiveness of drugs, their superiority to each other, and their side effects were compared to find the safest and most effective treatment method that can be used in the emergency room.   Materials and Methods Ethics committee approval was obtained from Bolu Abant İzzet Baysal University for the study (Decision no: 2020/268; Date: 24/11/2020). The study was conducted in a tertiary university hospital emergency department as a prospective, randomized-controlled, and double-blind study. The emergency department receives approximately 75,000 patient admissions per year. Written informed consent was obtained from all participants prior to the enrollement in the study. Study population, inclusion and exclusion criteria: Patients aged 18 years and over who presented to the emergency department with symptoms of AGE and had abdominal pain and cramps were included in the study. Patients who were allergic to the drugs to be given, had acute surgical abdominal findings in physical and radiological examinations, known to have GIS disease (liver dysfunction, mega colon, gastrointestinal ulceration, history of chronic inflammatory bowel disease), renal dysfunction, history of bleeding diathesis, with a heart rate of more than 120/minute, systolic blood pressure below 90 mmHg, use of analgesics or antispasmotic in the last 24 hours, and who were pregnant were not included in the study. Randomization and blinding: Anamnesis was taken from the patients in the triage room, and after written informed consent was obtained, they were sent to the examination room. Patients were informed about both treatments to be given. Consecutive numbers were given for each treatment with a simple randomization program (https://tr.rakko.tools). The researchers who administered the treatment and the researchers who filled the form were different. Patients and researchers who filled out the forms were unaware of the treatment the patient was receiving. Intervention and measurement: Before the treatment, direct abdominal X-rays and abdominal ultra sonogram (USG) were performed in all patients. Patients with acute surgical abdominal findings in the physical and radiological examinations were excluded from the study. Visual Analogue Scale (VAS) was used to evaluate the degree of abdominal pain before treatment. "Little pain" and "more pain" were written on both ends of a 10 cm line, and the patient was asked to mark where his condition was appropriate on this line (1-10). After keeping the patient's VAS score before the treatment (0 h), a non-working nurse began administering the treatment. Two different patient groups were formed. One group was called HBB, and the other group was called the paracetamol group. In the HBB group, 20 mg HBB in 100 ml 0.9% NaCl was administered by slow infusion over 15 minutes. One gram (1g) of paracetamol in 100 ml 0.9% NaCl package was administered to the paracetamol group by slow infusion within 15 minutes (there are 1g vials of paracetamol in our country). However, to double-blind the study, the drugs in the vials were applied in 100 ml 0.9% NaCl packages. After the treatment, the patients were asked to mark the 1st and 2nd-hour VAS scores again. Patients' age, gender, first presentation symptoms, first admission examination findings, comorbidities, vital signs [fever (high fever >380 C was accepted), systolic and diastolic pressure], VAS scores at 0,1 and 2 hours, and side effects if developed were recorded. Post-treatment follow-up: All patients were informed that they should inform again or call the phone number given to them if their pain increased or changed in character. All patients were called back 24 hours after the treatment, and the presence and nature of pain were questioned. Patients with severe abdominal pain and suspected acute abdomen were called to the hospital. After treatment, 22 patients were re-evaluated in the first 24 hours. No acute surgical abdomen was detected in any of them. Calculating sample size: In proportional data where the sample universe is unknown, the minimum sample size required for the research was determined by power analysis. Accordingly,a minimum of 255 samples was found with an effect size of 0.5, an error level of 0.05, and a confidence interval of 0.95. Statistical analysis: The conformity of the data to the normal distribution was tested with Shapiro Wilks, and Student's t-test was used to compare the customarily distributed features in two independent groups. Mann Whitney U test was used to compare the non-normally distributed features in 2 separate groups. Two-way Repeated ANOVA and Bonferroni post hoc test was used to examine the pain measurements of the paracetamol and HBB groups, which had normal distribution at recurrent times. As descriptive statistics, mean ± standard deviation, median, min-max for numerical variables, and number and % values for categorical variables are given. SPSS Windows version 23.0 package program was used for statistical analysis, and p<0.05 was considered statistically significant.   Results A total of 281 cases were enrolled in the study of which 123 were in HBB and 158 were in paracetamol group. Gender distribution, age and comorborbidities of HBB and paracetamol groups were not different (p>0.05) from each other (Table-1). Systolic and diastolic pressures, complaints in first presentation, physical examination findings and post-treatment side effects were not different from each other in both groups (p>0.05) (Table-2). It was observed that patients with high fever were more common in the paracetamol group [n= 35 (22.2%); p=0.018].   Table-1:Distribution of age, gender and comorbitities of study population     Table-2: Clinical findings and post treatment adverse effects observed in HBB and paracetamol groups     In both groups, VAS score gradually decreased from the 0th hour to the 1st and 2nd hours (p<0.001). Although the initial VAS score of the HBB group was higher than the paracetamol group and the 2nd-hour VAS score was lower than the paracetamol group, no significant difference was found when the groups' VAS scores at 0, 1 and 2 hours were compared (p>0.05; Table-3). When comparing each time within itself, it was observed that HBB and paracetamol measurements had similar values (p>0.05) (Figure-1).   Table-3: Comparison of VAS scores of HBB and paracetamol Groups       Figure-1: Variation of VAS scores over time. Buscopan –HBB, Parol - paracetamol     Discussion HBB is a frequently preferred agent, especially in pain and cramps of gastrointestinal and genitourinary systems (GUS). It is known that smooth muscles reduce the frequency and severity of pain by lowering tone and mobility [3,5]. Paracetamol. which has a weak anti-inflammatory effect, is considered a safer choice and is frequently used for similar conditions [5,6,8]. It has been shown that 20 mg IV HBB reduces smooth muscle mechanical motility index by 50.9% and electrical motility by 36.5% [9]. It has been observed that HBB reduces pain after 30 minutes in 90% of patients with renal colic and similarly a pain reduction of 42-78% was observed in patients with biliary colic [6]. In the study where Kumar et al. compared the effects of diclofenac and HBB on colic pain, a reduction in pain was found in 69.4% of the patients who used HBB [10]. In their study with 132 patients, Remington-Hobbs et al. showed that oral paracetamol was at least as effective as IV HBB or paracetamol-HBB combination in treating abdominal pain [11]. While similar analgesia levels were observed in all groups at the 30th minute, it was observed that at the 60th minute, the pain scores of the patients who took oral paracetamol decreased more than those who received IV paracetamol + HBB In the study conducted by Poonai et al in 236 patients aged 8-17 years with nonspecific colic pain, no significant difference was found between HBB and paracetamol regarding pain reduction and side effects [12]. In the study of Mueller-Lissner et al., 1637 patients with recurrent cramps and abdominal pain were treated with HBB, paracetamol and HBB-paracetamol combination. A significant reduction in pain intensity and pain frequency was achieved in intervention groups compared to placebo [5].. In the study of Schäfer et al which included 712 patients with irritable bowel syndrome, were given HBB+paracetamol, HBB, paracetamol,or placebo. After four weeks of treatment, pain relief was detected in more than 75% of the patients in the HBB groups [8]. Esmaeili et al used HBB in acute appendicitis in a study of 70 patients; they found a significant decrease in pain and sensitivity [13]. Mousavi et al compared paracetamol and placebo in 107 patients diagnosed with acute appendicitis and found that the pain was significantly lower in the paracetamol group at 30 minutes, 1 hour, and 4 hours compared to placebo [14]. In our study, a significant reduction in pain and cramps was detected in both patient groups. It has been found that both drugs have a similar effect on reducing pain. While the initial (0 hour) median pain score of both groups was 7, the second-hour median pain score was lower in the HBB group, but this was not statistically significant (p=0.064). This p-value may give us an idea that HBB may provide a more effective reduction of pain in many patients. Anticholinergic side effects such as nausea, blurred vision, palpitations, dry mouth, and urinary retention may be observed after HBB treatment [15]. Intravenous paracetamol is almost as tolerable as a placebo. During treatment, adverse effects like discomfort, hypersensitivity, hypotension, increase in liver enzymes and thrombocytopenia can rarely be seen [16]. A previous study reported adverse effects in 16% (0.2% severe side effects) cases in the HBB group and 14% (0.7% severe side effects) in the paracetamol group [5]. In the study of Schäfer et al. conducted with HBB, HBB + paracetamol, paracetamol, and placebo, no difference was observed among the groups in terms of side effects [8]. Poonai et al [12] reported no significant difference of adverse effects between HBB and paracetamol groups ( 27.6% in the HBB group vs. 24.3% in the paracetamol group). In our study, side effects were observed in 3 (2.4%) patients in the HBB group and 2 (1.3%) patients in the paracetamol group. There was no significant difference between the groups in terms of side effects. No severe side effects were observed in any of the patients.   Conclusion HBB and paracetamol were used for symptomatic treatment in AGE patients presenting with abdominal pain and cramps. A significant reduction in pain and cramps was achieved in both patient groups. There was no difference between the two drugs in terms of treatment efficacy and side effects. No severe side effects were observed in any of the patients in either group. These showed that both drugs are effective in the symptomatic treatment of AGE patients with abdominal pain and cramp and can be used safely with a 15-minute IV infusion.   Authors’ contributions HS, MB: Conceptualization, methodology, software; HS, MB, YS: Data curation, writing- original draft preparation; HS,MED: Visualization, investigation; MB, HBA: Supervision; MB, MCD: Validation, formal analysis; HS, MB,MED: Writing, reviewing and editing MED: Project administration.    Declaration of conflicting interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.   Funding: The authors received no financial support for the research, authorship, and/or publication of this article.   References 1.     Tam CC, O'Brien SJ, Tompkins DS, Bolton FJ, Berry L, Dodds J, et al. Changes in causes of acutegastroenteritis in the United Kingdom over 15 years: microbiologic findings from 2 prospective, population-based studies of infectious intestinal disease. Clin Infect Dis. 2012; 54(9): 1275-1286. 2.     Bányai K. Estes MK. Martella V. Parashar UD. Viral gastroenteritis. Lancet. 2018; 392(10142): 175-186. 3.     Abdo-Francis JM. Martínez-Juárez A. Pineda-Corona B. Bernal-Sahagún F. Un nuevo esquema terapéutico en el manejo del dolor abdominal de tipo cólico. Rev Med Hosp Gen Mex. 2003; 66(3): 142 – 146. [Spanish] 4.     Pickering LK. Snyder JD. Gastroenteritis. In: Behrman RE. Kliegman RM. Jenson HB. editors. Textbook of Pediatrics. 17th ed. Philadelphia:Saunders. 2004; 1272- 1276. 5.     Mueller‐Lissner S.Tytgat GN. Paulo LG. Quigley EMM. Bubeck J. Peil H. et al. Placebo- and paracetamol-controlled study on the efficacy and tolerability of hyoscine butylbromide in the treatment of patients with recurrent crampy abdominal pain. Aliment Pharmacol Ther. 2006; 23(12): 1741-1748. 6.     Tytgat GN. Hyoscinebutylbromide - a review on its parenteral use in acute abdominal spasm and as an aid in abdominal diagnostic and therapeutic procedures. Curr Med Res Opin. 2008; 24(11): 3159-3173. 7.     Riddle MS. DuPont HL. Connor BA. ACG ClinicalGuideline: Diagnosis. Treatment. andPrevention of AcuteDiarrhealInfections in Adults. Am J Gastroenterol. 2016; 111(5): 602-622. 8.     Schäfer E, Ewe K. Behandlung des Colon irritabile. Wirksamkeit und Verträglichkeit von Buscopan plus, Buscopan, Paracetamol und Plazebo bei ambulanten Patienten mit Colon irritabile [The treatment of irritable colon. Efficacy and tolerance of buscopan plus, buscopan, paracetamol and placebo in ambulatory patients with irritable colon]. Fortschr Med. 1990 Aug 30; 108(25): 488-492. [German]. 9.     Américo MF. Miranda JR. Corá LA. Romeiro FG. Electrical and mechanical effects of hyoscinebutylbromide on the human stomach: a non-invasive approach. Physiol Meas. 2009; 30(4): 363-370. 10.  Kumar A. Deed JS. Bhasin B. Kumar A. Thomas S. Comparison of the effect of diclofenac with hyoscine-N-butylbromide in the symptomatic treatment of acute biliary colic. ANZ J Surg. 2004; 74(7): 573-576. 11.  Remington-Hobbs J. Petts G. Harris T. Emergency department management of undifferentiated abdominal pain with hyoscine butylbromide and paracetamol: a randomised control trial. Emerg Med J. 2012; 29(12): 989-994. 12.  Poonai N. Kumar K. Coriolano K. Thompson G. Brahmbhatt S. Dzongowski E. et al. Hyoscine butylbromide versus acetaminophen for nonspecific colicky abdominal pain in children: a randomized controlled trial. CMAJ. 2020; 192(48): E1612-E1619.  13.Esmaeili A. Salimi V. Mohammad Karimi N. Hajimaghsoudi M. Vakili M. Zarepur E. The effect of hyoscine on pain. tenderness. and rebound tenderness in patients with appendicitis: quasi-ınterventional study. Bull Emerg Trauma. 2018; 6(4): 300-305. 14.  Mousavi SM. Paydar S. Tahmasebi S. Ghahramani L. The effects of ıntravenous acetaminophen on pain and clinical findings of patients with acute appendicitis; a randomized clinical trial. Bull Emerg Trauma. 2014; 2(1): 22-26. 15.  Tytgat GN. Hyoscine butylbromide: a review of itsuse in the treatment of abdominal cramping and pain. Drugs. 2007; 67(9): 1343-1357. 16.  Duggan ST. Scott LJ. Intravenous paracetamol (acetaminophen). Drugs. 2009; 69(1): 101-113. <![CDATA[Preferences and perceptions of teaching and learning methods of preclinical medical students]]> Rashmi Chandel Garima Shivhare Archana Goel https://imcjms.com/journal_full_text/407 2022-01-26 11:52:23 Original Article IMC J Med Sci 2022; 16(1): 010 Abstract Background and objectives: Teaching methods used in medical education should be evaluated from time to time to improve the quality of future doctors. So, this study was conducted to know the preclinical student’s preferences and perception about the current teaching and learning process. Methods: The present study was conducted at Adesh Medical College and Hospital, Shahabad among 150 students of second year MBBS course. A predesigned and prevalidated questionnaire was used to assess students’ preferences and perception of teaching, learning and assessment methods. Students’ opinion about the quality of a good teacher was also sought. Results: Out of 150 students, 54% and 62% chose lecture and chalk and board combined with power point presentation (PPT) respectively as the most preferred teaching method and aid. About half (53%) of the students chose written assessments as the most preferred assessment method. Very few students (6%) expressed that ability to generate curiosity in students as a quality of a good teacher. Conclusion: The present study suggested that lectures by chalk and board supported by PPT and written assessment were the most preferred teaching learning and assessment methods. IMC J Med Sci 2022; 16(1): 010. DOI: https://doi.org/10.55010/imcjms.16.008 *Correspondence: Rashmi Chandel, Department of Physiology, Adesh Medical College and Hospital, Shahabad, India. Email: unique_ras@rediffmail.com   Introduction In India medical education has a goal to make competent Indian medical graduate. In order to achieve this goal, medical teacher has to introduce various methods of teaching. Gaining this medical knowledge of teacher by the students help the students to learn the necessary skills and attitudes related to medical practice [1]. During MBBS course, a number of teaching learning methods are used to increase student’s participation and involvement in lectures as well as in practical classes [2]. The quality of medical education depends on these teaching learning methods used in medical colleges [3]. To improve the quality and competency of future doctors, methods used in medical education should be evaluated from time to time. With passing generations, the needs and understanding level of students are changing. Also, the students in a medical college differ in their age, place, learning styles, understanding level and memorizing skills [4]. So, it is very important for a medical teacher to know the educational needs of students for delivering his/her knowledge to students in a more efficient, retainable way which is only possible by taking feedback from students regarding teaching learning methods. Another problem faced in medical education is to plan a lecture in such a way that students can retain maximum knowledge in a short span of time [5]. Therefore, it is very important to obtain students’ feedback on teaching learning methods used to teach them. This would help to improve their understanding of the subject and skills. Improved learning process is necessary to enhance the academic performance and to make the life easier, stress free and interesting in medical college. In this way, the goal of making a competent Indian medical graduate is achieved. The aim of this study was to know the preclinical students’ preferences and perception about current teaching-learning methods, teaching aids and assessment methods used by faculty at Adesh medical college and hospital. Students’ opinion about the quality of a good teacher and the obstacles faced during the learning process were also sought.   Material and methods The present study was conducted at Adesh Medical College and Hospital, Shahabad among 150 students of second year MBBS course (Batch 2017-2018). A total of 11 systems in physiology were taught by lectures (165 hours), seminars (60 hours) and small group discussions (25 hours) during the first year MBBS course. These lectures were taken using different teaching aids like chalk and board along with power point presentation (PPT), only chalk and board, only PPT, smart boards and videos and animation. Out of total 39 assessments taken (including formative and summative), 14 were written assessment, 14 were oral assessments and 11 were tutorials. Questionnaire was prepared keeping in view the teaching learning and assessment methods used in this college. This predesigned and prevalidated questionnaire was given to second year students to know their perception and preferences about teaching learning methods, teaching aids and assessment methods used in teaching physiology curriculum during the first year MBBS course (Figure-1)     Figure-1: Study outline   They were also asked to identify the common obstacle(s) they experience during physiology theory lectures. Their opinion about a good teacher was also sought. They were also told to give their suggestions to improve current teaching learning methods. Prior written informed consent was taken from all the students. They were assured that their identity would not be disclosed and their responses would be kept confidential. Students were informed that this information would be used only for research purpose and to improve current teaching learning process. The study was approved by the institutional ethical committee. The data collected was analyzed in percentages.   Results In our study, 81(54%) students found lectures to be the most preferred teaching learning method followed by small group discussion (31%) and seminar (15%) as shown in Table 1. When asked about teaching aid, then out of 150 students, 93 (62%) students chose combination of chalk and board and PPT as the most preferred teaching aid and smartboards were chosen by 4 (2.7%) students making it least preferred teaching aid. Only PPT was preferred by 24 (16%) students, only chalk and board was preferred by 19 (12.7%), and videos and animation was preferred by 10 (6.7%) students. Written assessments were found to be most preferred assessment method as chosen by 79 (52.7%) students and oral assessment was chosen by 22 (14.7%) students which made it least preferred assessment method.   Table-1: Students’ preference of teaching-learning and assessment methods     Regarding the satisfaction of the students about current teaching learning methods, 18 (12%) students were strongly satisfied, 92 (61.3%) were satisfied, while 25 (16.7%) and 15 (10%) students were unsatisfied and strongly unsatisfied respectively (Table-2). Students’ perception about the quality of a good teacher is shown in Table-3. Of the total students, 41 (27.3%) students stated that a good teacher should be knowledgeable while 31 (20.7%) students expressed that the teacher should have good understanding of subject. Twenty five (16.7%) students wanted that teacher should be audible and should have clear speech while 10% students want that teacher should be easy to approach and interactive with students. Very few students 9 (6%) expressed that ability to generate curiosity in students as a quality of a good teacher.   Table-2: Level of satisfaction of the students about current teaching-learning methods     Table-3: Students’ perception about quality of a good teacher     Common obstacles faced by the students in theory class are shown in Table-4. Out of total 150 students, 63 (42%), 43 (28.7%) and 29 (19.3%) students stated lack of clarity of speech, length of lecture and speed of teaching respectively were the most common obstacles they faced during the theory class. Only 2.7% students found student teacher ratio as an obstacle during theory class.   Table-4: Common obstacles faced by the students in theory class     Discussion Medical education is the most exigent field of study in today’s time. Medical educator has the responsibility to make medical education a joyful and stress free experience for young students. It is very important to review teaching learning methods used so that any changes, if required according to changing needs of students could be made. This is necessary for efficient learning in a congenial atmosphere in a medical college. This will help to produce competent doctors and thus shall benefit society also. The present study was conducted at Adesh Medical College and Hospital, Shahabad among 150 students of second year MBBS course. In this study, it was found that lectures were the most preferred teaching method among students. Similar findings were observed by others [6-10]. In lecture, a topic could be conveniently taught to a large group of students. Seminar was chosen as the least preferred teaching learning method which was consistent with the findings of previously reported study [11]. In a seminar there is no active participation of the whole class. Lectures can be made more interactive using various teaching aids. In this study students chose combination of chalk and board and PPT as the best teaching aid. The present study is consistent with previous studies [12-14]. Combination of teaching aids should be used to meet the needs of different segments of learners [15]. Didactic lectures with chalk and board supported by diagrams in PPT helped students to make lectures more interesting and easy to understand. With chalk and board they get time to understand the topic and with diagrams, videos and animations incorporated in PPT they can have clear perception of topic. This also helps to retain and interpret topic in a better way. Teaching with PPT combined with chalk and board breaks the monotony of lecture and improves the attention span of students. The best assessment method found by the students was written assessments and oral assessments were chosen as the least preferred assessment method. This is consistent with other studies [11]. The students come to know about their shortcomings by written assessments and that eventually help them to overcome their weakness and knowledge gaps. Students do have perception of a good teacher. In our study, most of the students feel that personality of a teacher doesn’t matter much in their learning but he/she should have knowledge and understanding of the subject. He/she should be easy to approach so that they can discuss their problems easily. They feel that teacher should be interactive with students so that they can remain attentive in class. They also feel that teacher should make topic easy for them as the curriculum is very vast and a good teacher can guide students how to understand and retain a topic in a short span of time. This coincided with the findings of previous study [3]. In the present study, very few students (9%) regarded generating curiosity in the minds of students as a quality of a good teacher. This finding indicates that most of the medical students lack interest in creative thinking. The present study suggested that interactive lectures using chalk and board supported by PPT and regular written assessment were the most preferred teaching-learning and assessment methods. Further study is needed to find out why medical students lack interest in creative thinking.   Acknowledgement: All the participants who participated in this study   Funding and support: Nil   Conflict of interest: Nil   References 1.     Sheikh NA, Nirgude AS, Ramanaiah TV, Naik PR. Medical students perceptions of teachers evaluation in a private medical college of south India. Int J Dev Res. 2014; 4(8): 1705-1708. 2.     Gupta SS, Rathod AD. A study on preferences of I M.B.B.S students about teaching-learning methods. J Edu Tech Health Sci. 2016; 3(1):20-22. 3.     Khane RS, Joshi AA. A questionnaire based survey from first year M.B.B.S. students about teaching learning methods of physiology in private medical college. Ind J Res. 2014; 3(2): 223-225. 4.     Gade S, Chari S, Gupta DS. Perception of the medical students of a private medical college on their future career. Ind J App Res. 2013; 3(10): 1-4. 5.     Patil U, Vaidya S, Jore S, Parekh M, Patwardhan MS. Study of student’s feedback on present teaching and learning patterns. Int J Recent Trends Sci Tech. 2012; 4(1): 34-35. 6.     Skandhan KP, Dileep D, Sankar A. Teaching physiology: under graduates’ perspective. IOSR- J Res Meth Edu. 2015; 5(3): 82- 85. 7.     Gupta S, Ashwani K, Kaur H, Verma M, Singh K. An assessment of students preference for lecture delivery methods in medical education. J Res Med Edu Ethics. 2014; 4: 36-40. 8.     Tabish A, Sanat S, Syed AS, Raj S, Mahendra J. Assessment of effectiveness of different teaching methodologies in pharmacology for undergraduates at a rural medical college of Bastar region. Int J Biomed Res. 2015; 6: 512-517. 9.     Bakhsh AR, Kusangaya RS, Siddiqui HT, Syed H, Khan S, Bilal I. Learning styles and teaching/learning preferences of pre-clinical medical students in Ajman, U.A.E. Gulf Med J. 2014; 3: S106-113 10.  Sekhri K. Teaching methodologies in pharmacology: A survey of students’ perceptions and experiences. J Educ Ethics Dent. 2012; 2: 40-44. 11.  Amin TT, Kaliyadan F, Muhaidib A. Medical students’ assessment preferences at King Faisal University, Saudi Arabia. Adv Med Educ Pract. 2011; 2: 95-103. 12.  Mohan L, Ravi Shankar P, Kamath A, Manish MS, Eesha BR. Students' attitudes towards the use of audio visual aids during didactic lectures in pharmacology. J Clin Diagn Res. 2010; 4: 3363-3368. 13.  Banerjee I, Jauhari AC, Bista D, Johorey AC, Roy B, Sathian B. Medical students view about integrated MBBS course: a questionnaire based cross sectional survey from a medical college of Kathmandu vally. Nepal J Epidemiol. 2011; 1(3): 95-100. 14.  Williams S, Sa B, Nunes P, Stevenson K. Communicating with first year medical students to improve communication skills teaching in the university of the West Indies. Int J Med Edu. 2010; 1: 5-9. 15.  Urval RP, Kamath A, Ullal S, Shenoy AK, Shenoy N, Udupa LA. Assessment of learning styles of undergraduate medical students using the VARK questionnaire and the influence of sex and academic performance. Adv Physiol Educ. 2014; 38: 216-220. <![CDATA[Unilesional mycosis fungoides: a case report and review of literature]]> Wasim Selimul Haque Shakibul Alam Humayun Kabir Al-Amin Chowdhury https://imcjms.com/journal_full_text/401 2021-11-20 13:26:28 Clinical Case Report IMC J Med Sci 2022; 16(1): 006 Abstract Mycosis fungoides (MF) is the commonest primary cutaneous T-cell lymphoma (CTCL). Classically MF is presented clinically as multilesional disease but occurrence of solitary lesion, though quite rare, is on the record. This rare variant of MF is clinically and histopathologically indistinguishable from classic MF. Due to the rarity of the presentation the clinician may miss the diagnosis and the pathologist may also be in diagnostic dilemma specially if not clinically oriented. Here we describe a case of unilesional/solitary MF (UMF) in a 59 years old male who was initially clinically diagnosed as inflammatory dermatosis and was treated accordingly without any appreciable clinical response for over 4 years. Unresponsiveness to empirical treatment led to biopsy which finally proved it to be UMF. The clinical, light microscopic and immunohistochemical features of UMF are briefly reviewed to create awareness among the clinicians and pathologists about this rare variant of MF. IMC J Med Sci 2022; 16(1): 006. DOI: https://doi.org/10.55010/imcjms.16.009 *Correspondence: Wasim Selimul Haque, Head, Department of Histopathology and Cytopathology, Jaber Al-Ahmed Armed Forces Hospital, Kuwait Armed, Forces, Subhan Cantonment, Kuwait. Email: audrirodelawasim@gmail.com   Introduction Mycosis fungoides is the most common CTCL, accounting for almost 50% of all primary cutaneous lymphomas. The diagnosis is based on clinical evaluation and correlation of clinical features with histopathological findings [1]. Described for the first time in 1806 by the French dermatologist Jean Louis Alibert [2], conventional MF presents with multiple erythematous polymorphic patches and/or plaques that may progress to tumors [3]. The solitary lesions, first described in 1981 by Russel-Jones and Chu, are clinically and histopathologically indistinguishable from classic mycosis fungoides [4]. Since its first description some well documented cases have been published in the literature [5-15].They are reported to have excellent prognosis. Because of its rarity, solitary MF may pose a diagnostic challenge both to the clinicians and pathologists. Here we describe a case of UMF and has briefly reviewed the clinical, light microscopic and immunohistochemical features of this rare variant of MF.   Case Report A 59 year‐old male of Arab ethnicity presented with erythematous, non-itchy, painless plaque over right thigh for over 4 years. On examination a solitary erythematous plaque having irregular border with fine scales over it was noted (Fig-1). No mark of excoriation was identified. Lymphadenopathy was absent. The patient was treated with multiple topical modalities of treatment considering the condition as eczema and psoriasis vulgaris without clinical response for last 4 years. He had diabetes mellitus (DM), hypertension (HTN), dyslipidemia and nodular prostatic hyperplasia as comorbidities. He was treated with dulaglutide, glicazide, empagliflozin, metformin and insulin glargine for DM. Amlodipine and telmisartan were given for HTN and atorvastatin for dyslipidemia. His complete blood picture was within normal ranges. Routine biochemical tests which included plasma glucose, serum urea, creatinine, uric acid, bilirubin, AST, ALT, ALP, gamma GT, protein profile and lipid profile were all within normal limits.     Figure-1: The solitary erythematous plaque on the medial aspect of thigh having irregular border with fine scales. The suture indicates site of biopsy (photograph taken after biopsy was performed).   Histopathology of the biopsied sample revealed epidermal atrophy with flattening of rete ridges. There was lichenoid infiltrates of lymphocytes confined within the papillary dermis (Fig-2a).The lymphocytes displayed prominent epidermotropism (Fig-2b).The epidermotropic lymphocytes displayed basilar regimentation (Fig-2c) as well as Pautrier micro-abscess formation (Fig-2d). The lymphocytes were of small size but some of them exhibited hyperconvoluted nuclei (Fig-3).     Figure-2: H&E stained sections of the skin biopsy, showing- 2a: epidermal atrophy and lichenoid lymphoid infiltrates in papillary dermis (x40). 2b: epidermotropic lymphocytes (black arrow) infiltrating the epidermis (x100). 2c: basilar regimentation of epidermotropic lymphocytes (black arrows) (x200).2d: Pautrier microabscess (x200).     Figure-3: H&E stained sections showing some atypical lymphocytes having hyperconvoluted nuclei (black arrow) both in dermis and epidermis (x1000).   Immunohistochemistry (IHC) for CD3, CD20, CD2, CD5, CD7, CD4, CD8, PD-1 and CD56 was performed. The lymphocytes were CD3+, CD4+ T cells (Fig-4a and 4c). CD8+ cells were virtually absent in the epidermal component and even in the dermis, only a few of them were found scattered among overwhelming population of CD4+ T cells (Fig-4d). The CD4:CD8 ratio was estimated to be 10:1. The CD2, CD5 and CD7 lymphocytes dropped at varying proportions (Fig-5a, b and c). Dermal/epidermal discordance was pronounced - all these 3 markers were markedly reduced in epidermal component. CD5+ and CD7+ cells were virtually not found in epidermal component. Most of the epidermal CD2+ lymphocytes also dropped. The cells were PD-1 negative and also they were negative for CD56. Only scattered CD20 positive B cells were present in the infiltrates (Fig.-4b). Therefore, based on clinical feature i.e. solitary erythematous plaque in non-sun exposed area for over 4 years not responding to topical therapy coupled with typical histology and immunophenotype of lymphoid infiltrates the case was diagnosed as mycosis fungoides (unilesional) and the patient was assessed clinically to be in patch phase of the disease.     Figure-4: Photographs of immunohistochemistry of CD3, CD20, CD4 and CD8. 4a: both epidermal and dermal lymphocytes are CD3+. 4b: only very occasional CD20 positive B cells are present in the dermis. 4c: both epidermal and dermal lymphocytes are CD4+. 4d: only a few scattered CD8+ cells are present in the dermal component. Virtually no CD8+ cell is present in the epidermal component.     Figure-5: Photographs of immunohistochemistry of CD2, CD5 and CD7. 5a: More that 50% of both epidermal lymphocytes have dropped CD2. 5b: Epidermal lymphocytes are virtually negative for CD5. 5c: both epidermal and dermal lymphocytes have lost CD7 to great extent. Epidermis is virtually devoid of CD7 positive lymphocytes. In the dermal component only about 10% cells have retained CD7.   The peripheral blood film examination of the patient revealed no abnormal lymphocytes having hyperconvoluted nuclei. CT scan of abdomen revealed no evidence of abdomino-pelvic lymphadenopathy. Spleen and liver were also unremarkable. Considering solitary lesion in the form of skin patch confined to thigh, the absence of lymphadenopathy, no evidence of organ involvement and absence of abnormal lymphocytes in the peripheral blood film he was considered to be in Stage T1a, N0, M0, B0 according to the International Society for Cutaneous Lymphomas (ISCL) and the European Organization for Research and Treatment of Cancer (EORTC) staging of mycosis fungoides and Sezary syndrome. The patient is being treated with application of topical clobetasol twice daily and narrow band ultraviolet B (UVB) twice weekly. There was appreciable clinical improvement with topical clobetasol and after completion of 4 cycles of narrow band UVB therapy.   Discussion MF is relatively rare, contributing less than 1% of non-Hodgkin lymphomas; however, of primary CTCL, it represents the commonest entity [16]. MF is clonal expansion of epidermotropic T cells presenting clinically with noncontiguous cutaneous lesions. Skin homing of mature T cells is postulated to be normal counterpart of these neoplastic cells, which are mostly CD4 positive [17]. Classic MF initially goes through a nonspecific phase and presents clinically with multiple polymorphic patches, commonly confined to sun-protected areas, with or without plaques which often persist for years; subsequently patients develop plaques and later on tumors in some cases. Clinicopathological correlation coupled with immunophenotypic characterization of the lymphoid infiltrates is the mainstay of diagnosis and is sufficient for vast majority of cases [17]. T cell receptor (TCR) gene analysis may be of help in difficult situations. However, it should be remembered that diagnosis of early MF is a challenge to dermatologists and histopathologists and IHC and/or molecular testing even may not be of help in reaching at the diagnosis [18]. In recent decades a good many clinical and histopathologic variants of MF have been published in the literature. There are clinical variants which present with distinctive clinical features but having histopathologic features similar to classic MF, namely erythrodermic, hypo/hyper pigmented, bullous/vesicular, unilesional and even invisible MF. Again there are histopathologic variants which require biopsy to distinguish them from classic MF, viz. poikilodermatous, folliculotropic and syringotropic MF among many others. There are, in addition, clinicopathologic variants which have distinctive clinicopathologic features e.g. granulomatous MF or MF with large cell transformation [2,19,20]. Most of these variants have a clinical behavior similar to that of classic MF, thus in recent classifications they are not classified separately. In the WHO European Organization of Research and Treatment of Cancer (WHO-EORTC) classification and in the revised 2017 WHO classification, only folliculotropic (FMF), pagetoid reticulosis (PR) and granulomatous slack skin are recognized as distinct variants of MF as they display distinctive clinicopathologic features, clinical behavior, and/or prognosis [3,17]. Solitary or unilesional mycosis fungoides is a clinical variant of classic MF which presents with solitary lesion but histologically identical to classic MF. In 1939, Woringer and Kolopp reported the first case of solitary MF, now known as PR, characterized by an acral, hyperkeratotic plaque with massive epidermotropism of large atypical cells, but having no or occasional atypical cells in the dermis [10]. As discussed before this entity is now classified as a distinct variant of MF by WHO and WHO-EORTIC. It is not included as UMF which is distinct from PR both clinically and histologically. In 1972 in a societal proceeding of Irish Dermatology Society Dr. Mitchell described the first case of MF, which clinically presented as a solitary tumor mass in the scalp [21]. Russel-Jones and Chu in 1981 reported the first case of solitary MF where the patient presented with an erythematous scaly lesion on the forearm for 14 yrs and histologically showing typical features of MF. They compared this case with a case of PR and described UMF as histologically distinct from PR [4]. Since 1981, approximately 180 solitary cases of MF have been described, included among these are some cases of FMF, a few cases of syringotropic MF and a very rare case of solitary hemorrhagic MF with angiocentric (angiodestructive) features [11]. Widely accepted criteria for solitary MF are lacking. Some authors coin it for lesions that clinically present as a solitary lesion but are histopathologically similar to classic MF [7]. Others designate it as MF involving a single area that covers less than 5% of the body surface [12]. Histopathologic features of solitary MF mirror those of patch and plaque-stage of typical MF. Both present with superficial lichenoid infiltrates of lymphocytes admixed with histiocytes. The atypical lymphoid cells have highly indented nuclei termed as ‘cerebriform’ nuclei which are often hyperchromatic also, but in early patch stage they may be very few (or even absent) and are confined to the epidermis, characteristically colonizing the basal layer as single cells, or in a linear fashion. The epidermotropic neoplastic cells may show halo around them. They may also form intraepidermal collections of lymphocytes called ‘Pautrier micro-abscess’- though highly characteristic it is identified only in minority of cases [1,18]. Routine dermatopathology practice of diagnosing classic MF involves multiple biopsies, preferably shave biopsies [22] (which provides more tissue for microscopic examination), submitted with MF as a clinical differential diagnosis [18]. Histopathologic diagnosis may be quite demanding as microscopic features may vary and again they may overlap with quite a good number of inflammatory dermatoses, namely- lymphomatoid contact dermatitis [6], actinic reticuloid [6,23], arthropod reaction [6], lymphomatoid keratosis [4], drug eruption [4,23], secondary syphilis [23], lichenoid purpura [23], lichen striatus [23] and atrophic lichen planus [23] among many others. The scenario may become much more complicated for UMF as clinicians may altogether fail to consider it in their differential diagnosis on one hand and, on the other hand pathologists may be faced with real difficulty in determining whether an infiltrate is neoplastic or reactive because of absence of multiple lesions. It has been suggested that while evaluating a skin sample if a pathologist is confronted with one of the following three patterns in histology section he/she should actively consider MF in differential diagnosis, viz. i) psoriasiform lichenoid pattern characterized by combination of elongated rete ridges with rounded bases and band like lymphocytic infiltrates, ii) spongiotic psoriasiform lichenoid patternif spongiosis is superimposed on first pattern and iii) atrophic lichenoid pattern, when epidermis is atrophied, becomes thin and flat based [18,23]. Once pathologist is convinced that he/she may be dealing with MF piercing evaluation of constellation of following histologic features helps to discriminate MF from its inflammatory mimics namely Pautrier microabscesses, haloed epidermotropic lymphocytes, disproportionate epidermotropism (epidermotropism disproportionately more to the degree of spongiosis), epidermal lymphocytes larger to dermal lymphocytes, absence of dyskeratosis, hyperconvoluted dermal and epidermal lymphocytes, and papillary dermal fibrosis [1,18]. Rarity of eosinophils and absence of necrotic keratinocytes also favors MF [22]. Our case presented with atrophic lichenoid pattern. They also displayed atypical lymphocytes having hyperconvoluted nuclei. Haloed epidermotropic lymphocytes in our case also found to have colonized basal layer in a linear formation and they also formed Pautrier microabscess. Immunohistochemistry (IHC) may play an important adjunct role in diagnosis of MF. As expected, immunophenotypic characterization of UMF mirrors that of classic MF [5]. The neoplastic cells in MF are classically CD3+, CD4+ and CD8- memory T cell phenotype but a minority of cases may show a CD4–, CD8+ cytotoxic T-cell phenotype or, even more uncommonly, a CD4−, CD8− or CD4+, CD8+ T-cell phenotype [19]. Neoplastic T cells tend to drop one or more of the pan-T markers i.e. CD2, CD3, CD5 or CD7. Shedding by lymphocytes of pan T cell markers in a lymphoid infiltrates may be highly indicative of a neoplastic process but the finding is neither specific nor sensitive for MF. Benign lymphoid infiltrates may also show loss of these markers [7]. This loss may involve the epidermotropic lymphocytes only (termed as ‘discordance’) and may involve total cutaneous infiltrate [18]. For total lesional infiltrates, CD2, CD3, and CD5 expression by less than 50% of T cells is virtually 100% specific for T-cell lymphoma but regrettably for MF the sensitivity is only about 10%. This is also true for epidermal/dermal discordance for these pan T cell markers. CD7 expression of less than 10% has been reported to be 41% sensitive and 100% specific for MF [24]. Increased CD4/CD8 ratio (ratio more that 2-3:1) by IHC may also be a useful aide for the diagnosis of MF in appropriate clinicopathological context [25,26]. The CD4/CD8 ratio ≥ 9:1 is virtually diagnostic for MF [25].The assessment should be carefully done as CD4 not only marks lymphocytes but also dermal and intraepidermal Langerhans cells, which may also be increased in spongiotic dermatoses [25]. Before concluding the discussion of role of IHC in diagnosing MF it is to be remembered that loss of pan T cell markers as an evidence to a neoplastic process occurs in plaque and tumor stage, when histologic diagnosis is less exacting [1]. The real challenge is diagnosing in early patch stage of the disease. T cell receptor (TCR) gene rearrangement analysis can be performed to assess clonality of the T cells in lymphoid infiltrates with a sensitivity of 50% to about 80% of patch and plaque stage of disease [1].It is to be remembered that clonality assessment does not confirm a cases as neoplastic proliferation; some benign lesions like lichen planus, pityriasis lichenoides, lichen sclerosus, and chronic eczema may also show clonality [18]. UMF need to be differentiated from other CTCL that generally presents as solitary disease, viz. Pagetoid reticulosis (PR), primary cutaneous acral CD8+ T cell lymphoma (PCATCL) and primary cutaneous CD4+ small/medium pleomorphic T-cell lymphoproliferative disorder (SMPTCLD). Typically PR clinically presents as a single, well circumscribed, psoriasiform, scaly and crusty patch or plaque that grows slowly and affects acral site. Histologically it is characterized by massive epidermal infiltrates of medium to large sized atypical cerebriform T lymphocytes showing ‘pagetoid’ pattern of growth which are typically CD8+ with dermis infiltrated with reactive lymphocytes but contain very few, if any, neoplastic cell that are seen in epidermis [17,19]. SMPTCLD presents with solitary plaque or tumor on the face, neck, or upper trunk. Histologically it is characterized by dense dermal infiltrates of neoplastic lymphocytes that tend to extend to subcutis with no or only focal epidermotropism. The neoplastic cells are CD4+ T lymphocytes showing follicular helper cell phenotype and as such show variable positivity for PD-1, BCL6, CXCL13 and ICOS though CD10 is usually negative. A good number of reactive B lymphocytes are often found admixed with neoplastic T cells [17]. PCATCL commonly presents as solitary erythematous papules or nodules in the ear or less commonly nose and rarely distal extremity. Histologically characterized by dense dermal infiltrates of medium sized atypical lymphocytes and maintain Grenz zone with epidermis though focal epidermotropism and even Pautrier microabscess formation may occur. The cells are by definition CD8+ T lymphocytes. Reactive B cell aggregates/ follicles may be present in the tumor [17]. As expected UMF shows excellent prognosis as it corresponds to early stage of MF (stage T1) knowing that classical limited stage MF patients generally have an excellent prognosis with survival rate similar to general population [17]. Only three among the reported cases of UMF in the literature has progressed to large cell transformation [11]. A few cases of recurrences, both at the same site or at new site, are recorded but are generally amenable to treatment [5,10]. As the disease is localized, curative rather than palliative treatment is advocated by many studies and have recommended curative radiotherapy [4,27]. The other means of curative therapy include surgical excision, photodynamic therapy and topical treatment which includes potent corticosteroids, imiquimod, calcineurin inhibitors, carmustine, and nitrogen mustards [9,15].   Conclusion Unilesional MF, a rarely described clinical variant in the literature, can be viewed as localized form of early stage MF and thus entailing management of the patient focused to early diagnosis and curative treatment. Diagnosis may be delayed due to rarity of presentation. Clinically a typical lesion, even if it is solitary, if not responding to topical treatment targeted to inflammatory dermatoses should prompt the clinician to biopsy the lesion to exclude MF. Ancillary techniques like immunohistochemistry and/or TCR gene rearrangement analysis may be of help in difficult situation but gold standard of diagnosis rests on clinicopathologic correlation.   Conflict of interest: There are no conflicts of interest.   Informed consent: Patient provided informed written consent for publication of the case.   Financial support and sponsorship: Nil   References 1.     Naraghi ZS, Seirafi H, Valikhani M, Farnaghi F, Kavusi S, Dowlati Y. Assessment of histologic criteria in the diagnosis of mycosis fungoides. Int J Dermatol. 2003; 42(1): 45-52. 2.     Muñoz-González H, Molina-Ruiz AM, Requena L. Clinicopathologic variants of Mycosis Fungoides. Actas Dermosifiliogr. 2017; 108(3): 192-208. 3.     Willemze R, Jaffe ES, Burg G, Cerroni L, Berti E, Swerdlow SH et al. WHO-EORTC classification for cutaneous lymphomas. Blood. 2005; 105(10): 3768-85. 4.     Jones RR, Chu A. Pagetoid reticulosis and solitary mycosis fungoides. Distinct clinicopathological entities. J Cutan Pathol. 1981; 8(1): 40-51. 5.     Ally MS, Pawade J, Tanaka M, Morris S, Mitchell T, Child F, Wain M, Whittaker S, Robson A. Solitary mycosis fungoides: a distinct clinicopathologic entity with a good prognosis: a series of 15 cases and literature review. J Am Acad Dermatol. 2012; 67(4): 736-44. 6.     Oliver GF, Winkelmann RK. Unilesional mycosis fungoides: a distinct entity. J Am Acad Dermatol. 1989; 20(1): 63-70. 7.     Oliver GF, Winkelmann RK. Unilesional mycosis fungoides: a distinct entity. J Am Acad Dermatol. 1989; 20(1): 63-70. 8.     Hodak E, Phenig E, Amichai B, Feinmesser M, Kuten A, Maron L et al. Unilesional mycosis fungoides: a study of seven cases. Dermatology. 2000; 201(4): 300-6. 9.     Otero Rivas MM, Sánchez Sambucety P, ValladaresNarganes LM, Rodríguez Prieto MÁ. Unilesional mycosis fungoides: 3 different clinical presentations. Actas Dermosifiliogr. 2014; 105(4): 420-4. 10.  Amitay-Laish I, Feinmesser M, Ben-Amitai D, Fenig E, Sorin D, Hodak E. Unilesional folliculotropic mycosis fungoides: a unique variant of cutaneous lymphoma. J Eur Acad Dermatol Venereol. 2016; 30(1): 25-9. 11.  Belousova IE, Samtsov AV, Kazakov DV. A Rare Case of Solitary hemorrhagic Mycosis Fungoides with angiocentric features. Am J Dermatopathol. 2017; 39(4):313-315. 12.  Magro CM, Telang GH, Momtahen S. Unilesional follicular mycosis fungoides: report of 6 cases and review of the literature. Am J Dermatopathol. 2018; 40(5): 329-336. 13.  Jang MS, Jang JY, Park JB, Kang DY, Lee JW, Lee TG et al. Folliculotropic mycosis fungoides in 20 Korean cases: clinical and histopathologic features and response to ultraviolet A-1 and/or photodynamic therapy. Ann Dermatol. 2018; 30(2):192-201. Erratum in: Ann Dermatol. 2018 Aug; 30(4): 510. 14.  Evans MS, Burkhart CN, Bowers EV, Culpepper KS, Googe PB, Magro CM. Solitary plaque on the leg of a child: A report of two cases and a brief review of acral pseudolymphomatous angiokeratoma of children and unilesional mycosis fungoides. Pediatr Dermatol. 2018; 00: 1–5. 15.  Jedee P, Rattanakaemakorn P, Rajatanavin N. Solitary mycosis fungoides treated with photochemotherapy: A case report. Thai J Dermatol. 2019; 35(4): 171-5. 16.  Murphy FG, Schwarting R. Cutaneous Lymphomas and Leukemias. In: Elder DE, Elenitsas R, Johnson BL, Murphy GF, editors. Lever’s Histopathology of the Skin. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 951 17.  Elder DE, Massi D, Scolyer RA, Willemze R, editors. WHO classification of Skin tumours. 4th ed. Lyon, France: IARC Press; 2018. p. 226-253.  18.Harvey NT, Spagnolo DV, Wood BA. ‘Could it be mycosis fungoides?’: an approach to diagnosing patch stage mycosis fungoides. J Hematopathol. 2015; 8: 209–223. 19.  Willemze R. Mycosis fungoides variants-clinicopathologic features, differential diagnosis, and treatment. SeminCutan Med Surg. 2018; 37(1): 11-17. 20.  Virmani P, Myskowski PL, Pulitzer M. Unusual variants of mycosis fungoides. Diagn Histopathol (Oxf). 2016; 22(4): 142-151. 21.  Mitchell D. Mycosis fungoides presenting as a solitary tumour. Br J Dermatol 1972; 87: 514 22.  DiCaudoDJ. Cutaneous T-cell lymphoma, NK-cell lymphoma, and myeloid leukemia. In: Elston DM, Tammie Ferringer T, Ko CJ, Peckham S, High WA, DiCaudo DJ, Bhuta S, editors. Dermatopathology. 3rd ed. Philadelphia: Elsevier; 2019. p. 981. 23.  Jaffe ES, Arber DA, Campo E, Harris NL, Quintanilla-Martinez L. Hematopathology. 2nd ed. Philadelphia: Elsevier; 2017. Chapter 39, Mycosis Fungoides and Sézary Syndrome; p.715‐717. 24.  Pimpinelli N, Olsen EA, Santucci M, Vonderheid E, Haeffner AC, Stevens S et al. International Society for Cutaneous Lymphoma. Defining early mycosis fungoides. J Am Acad Dermatol. 2005; 53(6): 1053-63. 25.  Florell SR, Cessna M, Lundell RB, Boucher KM, Bowen GM, Harris RM et al. Usefulness (or lack thereof) of immunophenotyping in atypical cutaneous T-cell infiltrates. Am J Clin Pathol. 2006; 125(5): 727-36. 26.  Nuckols JD, Shea CR, Horenstein MG, Burchette JL, Prieto VG. Quantitation of intraepidermal T-cell subsets in formalin-fixed, paraffin-embedded tissue helps in the diagnosis of mycosis fungoides. J Cutan Pathol. 1999; 26(4): 169-75. 27.  Micaily B, Miyamoto C, Kantor G, Lessin S, Rook A, Brady L et al. Radiotherapy for unilesional mycosis fungoides. Int J Radiat Oncol Biol Phys. 1998; 42(2): 361-4. <![CDATA[Molecular pathogenesis of Rocky Mountain spotted fever: a brief review]]> Peter Uteh Upla Bashiru Sani Naja’atu Shehu Hadi Fatima Yusuf Al-Mustapha Kabiru Shuaibu https://imcjms.com/journal_full_text/396 2021-10-27 13:27:52 Review IMC J Med Sci 2022; 16(1): 004 Abstract Rocky Mountain spotted fever (RMSF) is a bacterial infection caused by Rickettsia, a diverse group of small Gram-negative rod-shaped α-proteobacteria, and obligates intracellular pathogens, which are free-living in hosts' cell cytoplasm and are transmitted to humans by arthropod vectors. It is the most acute rickettsial diseases known to human, with significant death rates of over 20–30%. They are distinguished by a strictly intracellular position which has, for long, delayed their comprehensive study. This article attempts primarily to focus on the mechanisms of Rickettsia-host cell interactions and the underlying molecular pathogenesis of RMSF. IMC J Med Sci 2022; 16(1): 004. DOI: https://doi.org/10.55010/imcjms.16.010 *Correspondence: Bashiru Sani, Department of Microbiology, Federal University of Lafia, Nasarawa State, Nigeria. Email: bashmodulus@gmail.com   Introduction Rickettsia are a diverse group of small Gram-negative rod-shaped α-proteobacteria, usually 0.3 by 0.1μm and obligate intracellular pathogens, that lives free in the host cell cytoplasm, and are transmitted by arthropod vectors to humans [1]. Rickettsia species have a small size of approximately 1.1-1.5Mbp genome and gene content of 900-1,500 genes [2]. They are parasites of arthropods infecting insects and ticks (fleas and lice) [3,4], in which they are assumed to be able to be maintained in the population and can as well be transmitted vertically. In contact with the faeces or through the bites of the vectors, the parasites can infect mammals, thereby making it easy to become the source for the next lines of infected vectors [5]. The genus Rickettsia causes RMSF and Mediterranean spotted fever (MSF) by Rickettsia rickettsii and Rickettsia conorii respectively. At the same time, the typhus syndromes are made up of epidemic and endemic typhus due to infection with Rickettsia prowazekii and Rickettsia typhi respectively [6]. Rickettsial diseases have well-established reputation as critical human infectious diseases, leading to disability, deaths, and “scourge of armies” during World Wars I and II [6]. Although Rickettsia sp. have traditionally been separated into different groups, the spotted fever and typhus groups, a modern classification based on whole-genome put forward by Gillespie et al. has now categorised over 20 species of the genus Rickettsia into four groups [7], including the ancestral group that is made up of R. Canadensis and R. bellii which are affiliated with ticks. The typhus group consisting of R. Prowazekii and R. typhi which are affiliated with fleas and lice, the spotted fever group consisting of R. africae, R. heilongjiangensis, R. helvetica, R. slovaca, R. honei, R. japonica, R. aeschlimanii, R. massiliae, R. montanensis, R. parkeri, R. peacockii, R. rhipicephali, R. rickettsii, R. Sibirica and R. conorii which are affiliated with ticks and a transitional group consisting of R. felis, R. australis and R. akari which are affiliated with mites, fleas and ticks [7]. RMSF is the most critical rickettsial diseases known to human, with significant death rates of over 20–30% [6]. This article attempts to focus on the mechanisms underlying host pathogen interactions and the molecular pathogenesis of RMSF.   Rocky Mountain spotted fever Rocky Mountain spotted fever caused by R. Rickettsii, is attributed as the most critical rickettsial diseases known to human, with significant death rates of over 20–30%, unless treated with an appropriate antibiotic at the appropriate time [6]. The death rate and severity of the infection are more significant for men, especially black men, and older adults, when there is deficiency in glucose-6-phosphate dehydrogenase [8]. Despite the fact that RMSF was first identified over 100 years ago, diagnosing the disease remains difficult because a rash is not noticeable up to three days into the illness and the petechial rash does not manifest until later in the course [9]. As a potentially deadly tick-borne infection to human-kind, RMSF is an infection notifiable to the Centre for Disease Control and Prevention (CDC) in the United States of America. In the United States between 2000 and 2007, the reported annual incidence of RMSF rose from less than two to over seven cases per million people, but there is a decline in death rate in the post antibiotic era [9]. In the central and southern part of America, RMSF is continually present in various urban, coastal deep forest and suburban regions of Argentina, Brazil, Costa Rica, Colombia, Panama and Mexico [6]. Apart from RMSF, Mediterranean spotted fever caused by R. conorii is continually present in the Mediterranean basin and is considered a milder disease than the RMSF; however, it has been reported that the death rates in adults are as high as 21% [10]. Another significant characteristic of R. conorii transmission to humans is the existence of a tache-noir called 'eschar' seen at the tick bite site [4,11]. In addition, the potential of some other spotted fever species such as R. helvetica, R. aeschlimanii, R. slovaca and R. massiliae, which were believed to be non-pathogenic in nature, is also being acknowledged. Lastly, there is every likelihood that previously unsuspected arthropod vectors can transmit rickettsiae in the area that have very low prevalence of human rickettsioses, which suggests the pathogens’ exploitation of mechanisms to adjust to new ecological niches, while maintaining their virulence [12].   Contributions of genome sequencing to understanding rickettsiae The genomes of Rickettsia are greatly conserved, with the same gene content and synteny [13]. Their tiny genomes have evolved from gene decay, with plenty of non-functional genes and a high proportion of non-coding DNA. Their cytosolic niche, rich in amino acids, nucleotides and nutrients, has enabled Rickettsia to drop the genes that encode enzymes for sugar metabolism and for nucleotide, amino acid, and lipids, a feature likely to be responsible for inability to grow them in cell-free medium in the laboratory [13]. They contain proteins with 3 domains, passenger sequence, 5 autotransporters, a leader sequence that mediates transport across the cell membrane, and a transporter sequence that is inserted as a β-barrel into the outer envelope to carry the passenger sequence to the surface of the cell wall. Amid the autotransporters, outer membrane protein "OmpA" is found only in the spotted fever group, while the OmpB is found in all Rickettsia species. Sca 1, Sca2, and Sca 3 are involved in the adhesion process and exist as split genes [9,13].   Rickettsia-host cell interaction For the parasite to survive, proliferate and successfully transmit infection, the parasite needs to attach to and capture target host cells. Early study of adhesion-invasion mechanisms shows that drug-induced modifications of host cell or inactivation of rickettsiae have harmful effects on their entry into host cells, and due to the certainty that viability of the target bacteria and metabolic activity of the host cell were determined as the criteria for intracellular uptake of rickettsiae, the process was known as ‘induced phagocytosis’. The spotted fever group rickettsiae adhere to the host cell receptor Ku70 thereby employing surface protein, OmpB (they also use OmpA, Sca (surface cell antigens)1, and Sca 2 as adhesion proteins) [16]. Once the OmpB is attached to the host membrane protein Ku70, it enhances the recruitment of more cell receptor Ku70 molecules to the cell membrane, for further binding of OmpB. Ubiquitin ligase (a protein that recruits an E2 ubiquitin) is also recruited for subsequent rickettsial entry site where Ku70 is ubiquitinated, which then signal transduction phenomenon leading to the recruitment of Arp2/3 complex. A small guanidine triphosphatase (Cdc42), phosphoinositide 3-kinase, Src-family kinase, and protein tyrosine kinase activate Arp2/3, leading to phagocytosis of the adhered Rickettsia. There is a zipper-like structure formation as a consequence of cytoskeletal actin modification at the point of entry [17]. An additional rickettsial protein known as RickA (a group of proteins found in the spotted fever group but are not found in the typhus group), induces Arp2/3, as expressed on the rickettsial surface, thereby initiating polymerization of host cell actin [18,19]. The actin filament helps to push the Rickettsia to the host cell's surface, where the host cell membrane is disfigured from the outside and turned inward into the adjacent cell. As the host cell membrane is disrupted or disfigured from both outward and inward, Rickettsia can gain access into the adjoining cell without the Rickettsia being exposed to the extracellular environment. In the process, some rickettsiae are released through the inner open cavity or surface of blood vessels straight to the bloodstream [18,20]. To avoid death and phagolysosomal fusion, the parasite enters the host cell's cytosol where there is availability of amino acids, adenosine triphosphate (ATP), nutrients and nucleotides [21]. They secrete hemolysin C and phospholipase D, which helps to disrupt the phagosomal membrane thereby enabling the quick break free of the rickettsiae.   Pathogenesis The pathophysiological outcome of rickettsial infections is the increase in microvascular permeability due to the disruption of adherens junctions that involves development of inter endothelial gaps, conversion of the shape of endothelial cells from polygons to large spindles, and formation of stress fibres [22]. Based on the current belief, the mechanism of injury of Rickettsia-infected endothelial cells occurs as a result of oxidative stress, which causes lipid peroxidative damage to the host cell membranes [23]. Despite proof that suggests rickettsial infection causes oxidative stress in infected animals, it is yet to be determined how the spotted fever group rickettsioses causes other pathogenic mechanisms involving cytotoxic T cells or cytokines [24]. Once the parasite is introduced through the skin, it proliferates in the lymphatics and blood vessels. The parasite adheres to and then enters the vascular endothelium and vascular smooth muscle cells via surface exposed protein as well as rickettsial phospholipase [25,26]. Rickettsia target and proliferate inside the endothelial muscle cells of blood vessels [27,28].It then induces nuclear factorkappa B (NF-kB), which hinders apoptosis thereby mediating the production of proinflammatory cytokines like interleukin (IL)-1α, resulting in up-regulation of E-selectin [29]. This enables increase attachment of polymorphs to the vasculature. Once the endothelial cells are infected, it produces IL-6, IL-8, and monocyte chemoattractant protein 1. The pathological state of the endothelial cells gives rise to the activation of clotting factors, reduced perfusion of tissue, and the extravasation of fluids [9].A great expression of the endothelial cell injury is accompanied with increase microvascular permeability resulting in pulmonary oedema, hypotension, hypoalbuminemia, and hypovolemia [30].   Immune response Amid the most fascinating features of the pathogenesis of rickettsial infections are the host defence mechanisms. Studies carried out on murine models of spotted fever rickettsioses have recognized new mechanisms of immunity, which include cytokine- mediated activation of endothelial cell bactericidal control of intracellular infection and the role of autophagy in rickettsial killing. Once TNF-α and IFN-γ activate the murine endothelial cells, it then produces rickettsicidal nitric oxide by inducible nitric oxide synthetase [31]. Upon rickettsial infections, natural killer cells are activated and inhibit growth of rickettsiae in line with the production of IFN-γ. The cytotoxic CD8+ T cells are employed to clear off rickettsiae thereby eliminating the infected endothelial cells via activation of apoptosis determined by a perforin-mediated mechanism. Antibodies against rickettsial OmpA and OmpB stands to protect the host cells against re- infection [32,33]. However, antibodies to OmpA and OmpB proteins are not visible until the control of infection and recovery. Human endothelial cells activated by TNF-α, IFN-γ, IL-1β, including RANTES, kill intracellular rickettsiae via two bactericidal mechanisms: hydrogen peroxide production and nitric oxide production [31]. Human macrophages, a small target of rickettsial infections, eliminates intracellular rickettsiae after the activation via TNF-α, IFN-β as well as IL-1b through the production of hydrogen peroxide and tryptophan starvation of rickettsiae in line with degradation of tryptophan by indoleamine-2,3-deoxygenase [31].   Future prospect and conclusion Although RMSF was identified over 100 years ago, the mechanisms by which it escape phagosome and initiate a successful intracellular infection are yet to be fully elucidated. Diagnosing the disease still remains difficult because a rash is not visible three days into the illness and does not manifest as petechial rash until later in the course. Nevertheless, with the advances in the understanding of Rickettsia host pathogen interaction, virulence mechanisms, structures of bacterial effectors proteins, target cells, including signal transduction systems and signalling pathways, apoptotic clearance of infected cells, as well as immunopathological basis of clinical manifestation is helping in providing current target for treatment/remedy to obstruct pathogen virulence mechanism including host pathogen interaction. In recent years, molecular approaches for rickettsial disease detection and diagnosis have substantially improved diagnostic capacities. These methods are rapid and highly standardized. Combination of qPCR with eschar swabbing has allowed for more rapid and robust detection of rickettsial diseases than traditional skin biopsy. Whole-genome sequencing (WGS) has also been used to reveal unbeknownst knowledge regarding the evolutionary and physiological characteristics of rickettsiae, its proteins, secretion systems and virulence factors leading to the development of novel rickettsia detection and control strategies. It is now imperative and necessary to continuously develop cost-effective and more rapid molecular and serological diagnostic methods – especially due to extensive human migration and varying and wide range of habitats that rickettsial vector can inhabit and survive. To improve present diagnostic capacities and safeguard citizens from severe rickettsial/oriental disease, the development of such diagnostic instruments will be critical. This updated approach will be valuable not just in surveillance studies, but also in clinical circumstances where biopsies are not possible.   Conflict of interest: None.   Financial disclosure: The authors declared that this study has received no external financial support.   References 1.     Mansueto P, Vitale G, Cascio A, Seidita A, Pepe I, Carroccio A, et al. New insight into immunity and immunopathology of Rickettsial diseases. Clin Dev Immunol. 2012; 2012: 967852. 2.     Andersson SGE, Zomorodipour A, Andersson JO, Sicheritz-Pontén T, Alsmark UCM, Podowski RM, et al. The genome sequence of Rickettsia prowazekii and the origin of mitochondria. Nature. 1998; 396: 133–140. 3.     Azad AF, Beard CB. Rickettsial pathogens and their arthropod vectors. Emerg Infect Dis. 1998; 4: 179–186. 4.     Raoult D, Roux V. Rickettsioses as paradigms of new or emerging infectious diseases. Clin Microbiol Rev. 1997; 10: 694–719. 5.     Blanc G, Ogata H, Robert C, Audic S, Suhre K, Vestris G, et al. Reductive genome evolution from the mother of Rickettsia. PLoS Genet. 2007; 3(1):  e14. 6.     Sahni SK, Narra HP, Sahni A, Walker DH. Recent molecular insights into rickettsial pathogenesis and immunity. Future Microbiol. 2013; 8: 1265–1288. 7.     Gillespie JJ, Beier MS, Rahman MS, Ammerman NC, Shallom JM, Purkayastha A, et al. Plasmids and Rickettsial evolution: Insight from Rickettsia felis. PLoS One. 2007; 2: e266. 8.     Walker DH. Rickettsia. In:Cockerham WC, Quah SR, editors. International Encyclopedia of Public Health, 2nd eds. Massachusetts: Academic Press; 2016; p370-377. 9.     Thorner AR, Walker DH, Petri WA. Rocky mountain spotted fever. Clin Infect Dis. 1998; 27: 1353–1360. 10.  Argüello AP, Hun L, Rivera P, Taylor L. Case report: A fatal urban case of Rocky Mountain spotted fever presenting an eschar in San José, Costa Rica. Am J Trop Med Hyg. 2012; 87:   345–348. 11.  Walker DH, Occhino C, Tringali GR, Rosa S Di, Mansueto S. Pathogenesis of rickettsial eschars: The tache noire of boutonneuse fever. Hum Pathol. 1988; 19: 1449–1454. 12.  Dumler JS, Walker DH. Rocky Mountain Spotted Fever — Changing ecology and persisting virulence. 2005; 353: 551–553. 13.  McLeod MP, Qin X, Karpathy SE, Gioia J, Highlander SK, Fox GE, et al. Complete genome sequence of Rickettsia typhi and comparison with sequences of other rickettsiae. J Bacteriol. 2004; 186: 5842–5855. 14.  Walker TS, Winkler HH. Penetration of cultured mouse fibroblasts (L cells) by Rickettsia prowazeki. Infect Immun. 1978; 22: 200–208. 15.  Walker TS. Rickettsial interactions with human endothelial cells in vitro: Adherence and entry. Infect Immun. 1984; 44: 205–210. 16.  Martinez JJ, Seveau S, Veiga E, Matsuyama S, Cossart P. Ku70, a component of DNA-dependent protein kinase, is a mammalian receptor for Rickettsia conorii. Cell. 2005; 123: 1013–1023. 17.  Martinez JJ, Cossart P. Early signaling events involved in the entry of Rickettsia conorii into mammalian cells. J Cell Sci. 2004; 117: 5097–5106. 18.  Gouin E, Egile C, Dehoux P, Villiers V, Adams J, Gertler F, et al. The RickA protein of Rickettsia conorii activates the Arp2/3 complex. Nature. 2004; 427: 457–461. 19.  Jeng RL, Goley ED, D’Alessio JA, Chaga OY, Svitkina TM, Borisy GG, et al. A Rickettsia WASP-like protein activates the Arp2/3 complex and mediates actin-based motility. Cell Microbiol. 2004; 6: 761–769. 20.  Gouin E, Gantelet H, Egile C, Lasa I, Ohayon H, Villiers V, et al. A comparative study of the actin-based motilities of the pathogenic bacteria Listeria monocytogenes, Shigella flexneri and Rickettsia conorii. J Cell Sci. 1999; 112: 1697–1708. 21.  Whitworth T, Popov VL, Yu XJ, Walker DH, Bouyer DH. Expression of the Rickettsia prowazekii pld or tlyC gene in Salmonella enterica serovar typhimurium mediates phagosomal escape. Infect Immun. 2005; 73: 6668–6673. 22.  Valbuena G, Walker DH. Changes in the adherens junctions of human endothelial cells infected with spotted fever group rickettsiae. Virchows Arch. 2005; 446: 379–382. 23.  Walker DH. Rickettsiae and rickettsial infections: The current state of knowledge. Clin Infect Dis. 2007; 45 (Supplement 1): S39–S44. 24.  Rydkina E, Sahni SK, Santucci LA, Turpin LC, Baggs RB, Silverman DJ. Selective modulation of antioxidant enzyme activities in host tissues during Rickettsia conorii infection. Microb Pathog. 2004; 36: 293–301. 25.  Silverman DJ, Santucci LA, Meyers N, Sekeyova Z. Penetration of host cells by Rickettsia rickettsii appears to be mediated by a phospholipase of rickettsial origin. Infect Immun. 1992; 60: 2733–40. 26.  Walker DH, Lane TW. Rocky Mountain spotted fever: Clinical signs, symptoms, and pathophysiology. In: Walker DH, editor. Biol. Ricketts. Dis., Boca Raton: CRC Press; 1988, p. 63–78. 27.  Walker D., Cain B. The rickettsial plaque. Evidence for direct cytopathic effect of Rickettsia rickettsii. Lab Investig. 1980; 43: 388–396. 28.  Walker DH, Firth WT, Edgell CJS. Human endothelial cell culture plaques induced by Rickettsia rickettsii. Infect Immun. 1982; 37: 301–306. 29.  Joshi SG, Francis CW, Silverman DJ, Sahni SK. NF-κB activation suppresses host cell apoptosis during Rickettsia rickettsii infection via regulatory effects on intracellular localization or levels of apoptogenic and anti-apoptotic proteins. FEMS Microbiol Lett. 2004; 234: 333–341. 30.  Walker DH, Raoult D. Rickettsia rickettsii and other spotted fever group rickettsiae (Rocky Mountain spotted fever and other spotted fevers). In: Mandell G, Bennett J, Dolin R, editors. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 6th ed. Philadelphia: Churchill Livingstone; 2005, p.729. 31.  Valbuena G, Feng HM, Walker DH. Mechanisms of immunity against rickettsiae. New perspectives and opportunities offered by unusual intracellular parasites. Microbes Infect. 2002; 4: 625–33. 32.  Feng HM, Whitworth T, Popov V, Walker DH. Effect of antibody on the Rickettsia-host cell interaction. Infect Immun. 2004; 72: 3524–3530. 33.  Feng HM, Whitworth T, Olano JP, Popov VL, Walker DH. Fc-Dependent polyclonal antibodies and antibodies to outer membrane proteins A and B, but not to lipopolysaccharide, protect SCID mice against fatal Rickettsia conorii infection. Infect Immun. 2004; 72: 2222–2228. <![CDATA[Effects of metformin on polycystic ovary syndrome: a randomized, double-blind, placebo-controlled study]]> Nazma-Akhtar Hurjahan-Banu Md. Shahed-Morshed Tania-Sultana Afroza-Begum MA Hasanat https://imcjms.com/journal_full_text/382 2021-07-13 23:00:31 Original Article IMC J Med Sci 2021; 15(2): 001 Abstract Background and objectives: Metformin improves manifestations of polycystic ovary syndrome (PCOS) by reducing insulin resistance. The objective of this study was to determine how metformin, in combination with lifestyle changes, affects the clinical manifestations of PCOS. Materials and Methods: Patients with PCOS attending the outpatient of a tertiary care hospital were enrolled in the study. Revised Rotterdam Consensus 2003 criteria were used to diagnose cases of PCOS. Clinical information, anthropometric measurement, serum progesterone and polycystic ovarian morphology (PCOM) of each subject were recorded in a prescribed data sheet at baseline and after a period of nine months. Randomized placebo controlled double blind design was used to assign participants in respective groups. Participants were randomly assigned to receive 9 month course of either metformin (1500 mg/day) or placebo. Both groups were advised regarding schedule of lifestyle modification. Outcome variables were clinical manifestations related to metabolic, reproductive and androgenic status of PCOS. Results: Out of 80 enrolled PCOS cases, 49 completed the study (metformin=26, placebo=23). The mean age of the study participants of metformin and placebo groups was 23.52±5.18 and 22.09±3.58 years respectively (p=0.262). Menstrual cycle significantly improved in both the study groups (before vs. after - metformin: 19.2% vs. 76.9%, p=0.003; placebo: 19.2% vs. 47.8%, p=0.02) after 9 months, but compared to placebo group no such significant (p=0.12) improvement occurred in metformin group. Severity of hirsutism, presence of acne, serum progesterone level and ovulatory status improved significantly in both groups after completion of the study. Except acanthosis nigricans, other metabolic manifestations did not significantly improve in metformin compared to placebo group after the intervention. While comparing the percentage changes, body mass index (BMI) and waist circumference (WC) reduced significantly in metformin than placebo group (BMI in kg/m2- metformin vs. placebo: -3.63±8.22 vs. +1.42±6.67, p= 0.024; WC in cm - 2.81±7.74 vs. +1.68±7.89, p= 0.05). No significant adverse event was observed in metformin group. Conclusion: Metformin, in conjunction with lifestyle modifications, has favorable impacts on clinical manifestations of PCOS. IMC J Med Sci 2021; 15(2): 001. DOI: https://doi.org/10.3329/imcjms.v15i2.55808 *Correspondence: Dr. Nazma-Akhtar, Shahid Tajuddin Ahmad Medical College, Gazipur, Bangladesh. Email: nazma.akhtar@ymail.com   Introduction Materials and methods <![CDATA[Comparison of the outcome of transverse and circumferential capitonnage in surgical treatment of pulmonary hydatid cyst - a single centre study]]> Farooq Ahmad Ganie Masarat-ul Gani Khan M Yaqoob Syed Mohsin Manzoor G N Lone Abdual Majeed Dar Mohd Akbar Bhat Mudasir Hamid Bhat https://imcjms.com/journal_full_text/383 2021-07-13 23:14:02 Original Article IMC J Med Sci 2021; 15(2): 002 Abstract Background and objectives: The enucleation of the pulmonary hydatid cyst is followed by individual closure of bronchial air leaks and obliteration of the residual pericystic cavity by capitonnage, either by circumferential or interrupted transverse suture. The objective of the study was to compare the surgical outcome of transverse and circumferential capitonnage in terms of postoperative recovery course, residual cavitations, air leaks, cavitatory or pleural collections and the recurrence of primary disease after enucleation of the pulmonary hydatid cyst. Methods: Patients with pulmonary hydatid cyst were included in the study and divided into two groups. Each group consisted of 30 patients. Patients of Group-1 underwent enucleation of the hydatid cyst followed by closure of bronchial air leaks with classical circumferential closure of the cavity and patients of Group-2 had enucleation of the hydatid cyst and closure of the cavity by transverse capitonnage. Results: Ten cases (33.33%) of Group-1 had hospital stay for more than 5 days compared to 4(13.33%) in Group-2 (p=0.03). Out of 30 patients who had undergone circumferential closure of the hydatid cavity, 5 (16.67%) patients had residual cavitatory fluid collection while there was none in the other group. In Group-1, 7 (23.3%) cases had reactionary intrapleural fluid collection compared to 2 (6.6%) in Group-2 (p=0.035). After 3 months of follow-up, 4 patients in circumferential capitonnage had mild haemoptysis and 1 had aspergilloma while no such complication occurred in any patient in the transverse capitonnage group. No recurrence of cyst occurred in any case in both groups. Conclusion: There was a considerable advantage of transverse capitonnage of the hydatid lung cavity after enucleation in terms of short hospital stay, minimal or no reactionary intrapleural or intra cavitatory collections and less air leaks. IMC J Med Sci 2021; 15(2): 002. DOI: https://doi.org/10.3329/imcjms.v15i2.55809 *Correspondence: Farooq Ahmad Ganie, Department of Cardiovascular and Thoracic Surgery, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar -190011, J & K, India. E-mail: farooq.ganie@yamil.com   Introduction Four species of Echinococcus produce infection in humans. E. granulosus and E. multilocularis are the most common, causing cystic echinococcosis and alveolar echinococcosis respectively [4,2]. The two other species, E. vogeli and E. oligarthrus, cause polycystic echinococcosis but have only rarely been associated with human infection [6]. The geographic distribution and animal host species vary by Echinococcus species, and mixed infections involving more than one species have been reported. In addition, different strains within an Echinococcus species may have variable morphology, genetic characteristics, infectivity to humans, and pathogenecity [6]. In endemic rural areas, prevalence rates of 2 to 6 percent or higher have been recorded [4,7]. New echinococcal infections continue to occur throughout life and increases with age [1,6]. <![CDATA[Evaluation of the effectiveness of handwashing training given to paramedic students remotely]]> Mehmet Murat Oktay Mustafa Boğan Mustafa Sabak Hasan Gümüşboğa https://imcjms.com/journal_full_text/384 2021-08-05 00:20:03 Original Article IMC J Med Sci 2021; 15(2): 003 Abstract Background and objectives: The COVID-19 pandemic has affected face to face medical education and training activities around the world. The aim of this study was to provide remote practical handwashing training to health sciences students and to measure the effectiveness of the training provided and to create a feedback model. Methods: Students of the Paramedic department were included in the study. Two virtual classrooms were created via Zoom Video Communication system. An 11-step handwashing algorithm was developed. Two hours of remote handwashing training was given. Participants were asked to apply the handwashing application they learned at their own location and to record videos. Application videos were evaluated and scored. Results: A total of 135 Term-1 and Term 2 students of the Paramedic department participated in the study. The duration of the evaluated videos was on average 57.67 ± 12.69 (34-95) seconds. Fifty five (40.7%) of the participants successfully completed all the steps and their average success score was 10.3 ± 0.67 (8-11). The most failure (33.3%) in the process steps was the 9th step in which the wrists are rubbed with soap. Conclusion: Suitable teaching and feedback methods are required for medical and health science students who receive education and practical training remotely from home. IMC J Med Sci 2021; 15(2): 003. DOI: https://doi.org/10.3329/imcjms.v15i2.55810 *Correspondence: Hasan Gümüşboğa, Emergency Department of Sehitkamil State Hospital, Pirsultan, Cetin Emec cad. 27500, Sehitkamil/Gaziantep, Turkey. E-mail: profhasan@hotmail.com   Introduction The COVID-19 pandemic has deeply affected education and training activities around the world. In Turkey, education and internship program have been stopped within the scope of health measures and all kinds of patient contact are prohibited. However, some countries have graduated their medical students early to meet the increasing need for service [1,2].This new situation has created the risk of inadequate education in the field of health sciences where applied education is compulsory. University administrations had to make new decisions regarding the education of health sciences students [3]. Models such as virtual classroom creation, online learning and hybrid education models have been rapidly implemented. However, this situation has created new problems for applied trainings. The most important of these problems is the measurement of the effectiveness of the training provided. Hand hygiene is an important element in combating infectious diseases and hospital infection. Hand hygiene education is an element that increases the theoretical knowledge of students, predicts their practice and contributes to the fight against pandemic. One of the main recommendations published by the World Health Organization (WHO) for the public is to wash hands frequently and correctly to prevent SARS-CoV-2 infection [4]. During this period when the importance of hand hygiene education and distance education models are discussed, the fact that it is difficult to manage practical trainings remotely [5].The aim of this study was to provide handwashing training to health sciences students whose practical training was interrupted, to measure the effectiveness of the training provided, and to create a feedback model for remote practical training.   Materials and methods The study was approved by the institutional ethics committee. The study was conducted with first and second year paramedic students. No pre-test was applied as none of the participants had received handwashing training before. Workflow First step: Training content and plan were determined. The training plan included: a. learning the indications of handwashing b. correct handwashing application - Using the hand hygiene guide recommended by WHO [6] and the handwashing algorithm recommended by the Turkish Republic (TR) Ministry of Health [7], an 11-step handwashing algorithm of Hasan Kalyoncu University was created (Image-1), and c. Wrong applications during handwashing Second Step: Learning resources were determined and training materials were produced. At this stage, Power Point presentation, visual and written resources were prepared in accordance with the learning objectives and training content. Learning materials were created based on videos and brochures prepared by WHO and Turkish Ministry of Health. Using these guides, a 60-second implementation video was shot. The video and the prepared algorithm were sent to the groups in which the participants were included via the WhatsApp Messenger application. Third step: Two virtual classrooms consisting of first and second year students of the paramedic department were established over the Zoom Video Communications system. During the study, two hours of remote handwashing training was given to both groups separately by the coordinators of the study. In these presentations, handwashing skill was explained to the participants in practice. Participants were able to present instant questions and contribute during the presentation. Fourth step: It was aimed to provide feedback of the participants. Participants were asked to apply the handwashing application they learned at their own location and to record videos during the application. Participants were notified beforehand that recordings were limited to <100 seconds. The recorded images were sent to the study directors via e-mail within a period of 15 days. Fifth step: Application videos were evaluated. First of all, video quality was evaluated with the Global Quality Score (Table-1). Videos with a Global Quality Score of 4 and 5 were evaluated in terms of content. The application stages were scored separately according to the Hasan Kalyoncu University handwashing algorithm (Image-1). While evaluating the videos, "1 point" was given for each correct step of the participant and "0 point" for incorrect step. Each participant received a minimum of "0" and a maximum of "11" points from the applications. The participant who secured full 11 points from one application was deemed successful; the participant with less than 11 points was termed as failed. The videos were scored individually by two independent observers (two emergency medicine specialists with at least 5 years of experience) using a rubric. Participants who did not want to participate in the study, who wanted to leave the study, who did not submit their video recording on time, who had a Global video quality score of <4 and a video duration of <15 seconds were excluded from the study.   <![CDATA[Red blood cell profile in patients with mild, moderate and severe COVID-19]]> Khushbhun Nahar Layla Shahanara Yeasmin Afrina Binte Azad Masba Uddin Chowdhury Nasrin Sultana Abul Fazal Shah Muhammad Shazedur Rahman Mohammad Mostafizur Rahman Rukaia Labiba Rafa https://imcjms.com/journal_full_text/385 2021-08-05 02:02:40 Original Article IMC J Med Sci 2021; 15(2): 004 Abstract Background and objectives: Coronavirus disease 2019 (COVID-19) pandemic has affected millions of people world-wide. It is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Increasing evidence has shown abnormalities of different hematological parameters with the severity of the diseases. The present study was undertaken to determine the red blood cell (RBC) profile in different categories of COVID-19 patients. Materials and methods: The study was conducted from January 2020 to December 2020. Reverse transcriptase-polymerase chain reaction (RT-PCR) positive COVID-19 patients were enrolled. Patients were categorized into mild, moderate and severe COVID-19 cases. Blood samples were analyzed by Automated Hematology Analyzer for hemoglobin concentration, total erythrocyte count and RBC indices. ANOVA followed by Bonferroni test, Chi square test, Spearman’s rho correlation coefficient test were performed as applicable using SPSS version 25.0. Results: A total of 100 RT-PCR positive COVID-19 patients were included in the study. There were 25, 38 and 37 mild, moderate and severe cases respectively. The mean age of the study participants was 44.68 + 13.16 years (range: 18 to 65 years). There were 67 (67%) males and 33 (33%) females. No significant difference in hemoglobin (Hb), hematocrit (HCT), total RBC count, red blood cell distribution width (CDW) was observed among the three groups. Significant negative correlation of mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH); rs-0.362 & -0.255 respectively) was observed with disease severity. Conclusion: The study showed low MCV and MCH were significantly related with the severity of the COVID-19 illness. Therefore, comprehensive analysis of the RBC profile would be helpful to understand the disease course. IMC J Med Sci 2021; 15(2): 004. DOI: https://doi.org/10.3329/imcjms.v15i2.55811 *Correspondence: Khushbhun Nahar Layla, Department of Physiology, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka 1000, Bangladesh. Email: laylaluna7671@gmail.com   Introduction Coronavirus disease -19 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first appeared in Wuhan, China in December 2019 [1]. Since then millions of people are infected with SARS-CoV-2 causing thousands of death in more than 200 countries and regions around the world [2-4]. First case of COVID-19 was detected in Bangladesh on March, 2020 [5]. SARS-CoV-2 enters the pulmonary alveolar epithelial cells through angiotensin converting enzyme 2 (ACE2) receptor [2,6]. The main mechanism of inflammation and organ damage by SARS-CoV-2 is due to cytokines storm, especially in pulmonary vascular endothelial cells, with production of increased inflammatory cytokines such as IL-1B, IL-6, IL-12, IL-10, INF and MCP-1 [7]. This virus initially undergoes replication in the respiratory tract and then spread to other organs and tissues. At the bone marrow level, the virus causes cellular apoptosis resulting in reduction in hematopoiesis [8-10]. The cytokines act on progenitor cells of bone marrow and cause inactivation of platelets and leukocytes [9]. The inflammation alters hematological parameters in mild, moderate and severe COVID-19 patients [11-13]. Therefore, the present study examined the RBC profiles in different categories of COVID-19 patients.   Materials and methods Place of study and study population: This cross sectional study was conducted at the Department of Physiology, Dhaka Medical College, from January 2020 to December 2020. The study was approved by the Institutional Review Board. Informed consent was obtained from each participant prior to enrollment in the study. RT-PCRpositive COVID-19 patients attending Dhaka Medical College Hospital were enrolled. Based on COVID-19 interim guidance by World Health Organization [14], the cases were categorized asmild, moderate and severe COVID-19 cases as stated below: Mild: The clinical symptoms were mild, and there was no sign of pneumonia on imaging. Symptoms may be fever, cough, sore throat, malaise, headache, muscle pain and no shortness of breath. Moderate: Fever and respiratory symptoms with radiological findings of pneumonia. Respiratory distress with <30 breaths/min, pulse oximetry showing saturation >93% at ambient air. Severe: Respiratory distress (≥30 breaths/min) or finger oxygen saturation≤93% at rest or arterial partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2)≤300mmHg. Demographic, clinical and laboratory data were recorded in a pre-designed structured data collection form.   Collection of blood sample and tests: About 5-6 ml of venous blood was collected aseptically from ante-cubital vein in a sterile EDTA tube. Blood samples were analyzed by Automated Hematology Analyzer for hemoglobin concentration, total RBC count and RBC indices.   Data analysis: ANOVA followed by Bonferroni test, Chi square test, Spearman’s Rho correlation coefficient test were performed as applicable using SPSS version 25.0.   Results A total of 100 RT-PCR positive COVID-19 patients were included in this study. There were 25, 38 and 37 mild, moderate and severe cases respectively. The mean age of the study participants was 44.68 + 13.16 years (range: 18 to 65 years). The mean age of the mild, moderate and severe COVID cases were 41.52 ± 13.48 (range: 18-61), 47.32 ± 12.10 m(range: 23-65) and 45.24 ± 13.97 (range: 18-65) years respectively (p=0.236; calculated by ANOVA). Out of 100 cases, there were 67 (67%) males and 33 (33%) females and no significant difference in gender distribution (p = 0.702) was found among the mild, moderate and severe cases (Table-1).   Table-1: Age and gender distribution of mild, moderate and severe COVID-19 patients (N=100)     Detail RBC profile of mild, moderate and severe COVID-19 patients is shown in Table-2a. No significant difference in hemoglobin, hematocrit (HCT), total RBC count, red blood cell distribution width (CDW-cv) was observed among the three groups.  Mean corpuscular volume (MCV) values of RBC was significantly less in severe COVID-19 cases compared to mild (p=0.04) and moderate cases (p=0.001) (Table-2a and 2b) while MCH was significantly (p=0,025) less in severe compared to moderate cases. Spearman’s correlation revealed (Table-3, Fig-1a and 1b) statistically significant negative correlation (rs = -0.362 and -0.255 respectively) of MCV and MCH with increasing disease severity.   Table-2a: RBC profile of mild, moderate and severe COVID-19 patients (N=100)     Table-2b: Bonferroni test for RBC indices     Table-3: Correlation of RBC indices with mild, moderate and severe COVID-19 patients       Figure-1a: Correlation of MCV with mild, moderate and severe COVID-19 patients     Figure-1b: Correlation of MCH with mild, moderate and severe COVID-19 patients   Discussion The present study was undertaken to assess the changes of RBC indices of mild, moderate and severe COVID-19 patients. In the present study most of the RBC indices were similar in all three groups except for MCV and MCH. In our study, the mean hemoglobin concentration in mild, moderate and severe COVID-19 cases were not statistically significant (p =0.432).This finding was in agreement with the study done by Lippi and Plebani [11]). On the contrary, other studies reported significant association of COVID severity and hemoglobin level [4, 15]. Hemoglobin concentrations showed negative correlation (r = -0.173) with severity of disease but is not statistically significant (p = 0.086). Anemia is not a common finding in patients suffering from COVID-19 [16-18]. Hemoglobin production may be impaired due to direct infection of precursor cells by the virus itself [19] and due to inflammation of mature erythrocyte [20]. Autoimmune hemolytic anemia is reported due to development of cytokine storm syndrome [21]. Anemia could be the result of iron-restricted erythropoiesis arising from alterations in iron metabolism [22]. In the present study, though we found lower hemoglobin level and higher RDW-CV in severe group in comparison to mild and moderate groups, but the differences were not statistically significant. However, other study reported significant higher level of RDW-CV and lower level of hemoglobin, HCT in severe group [23,24]. In this study we found significant lower MCV and MCH values in severe group compared to mild and moderate cases. Similar findings were also reported by others [25]. RBC anisocytosis in COVID-19 occurs due to direct cytopathic injury to circulating erythrocyte and bone marrow precursors and indirect erythrocyte damage consequent to hemolytic anemia or intravascular coagulopathy, and disturbance of iron metabolism due to ongoing inflammatory response [23]. SARS-CoV-2 infection generates important structural change in membrane of circulating red blood cells, both in protein and lipid level [26]. SARS-C0V-2 causes oxidative damages and consequent fragmentation of protein. SARS-CoV-2 infection may be associated with hemophagocytic phenomena characterized by macrophage engulfment of both mature erythrocytes and erythroblasts [27]. A coexistent indirect injury like molecular mimicry between spike protein of SARS-CoV-2 and the protein ankyrin 1 may also explain the disturbance of RBC biology in patients with SARS-CoV-2 infection [28]. Intravascular coagulopathy is also common in severe COVID-19 patients [29]. Erythrocyte injury occurs due to development of both macro and micro thrombi in many blood vessels, which could contribute morphological abnormalities of erythrocyte [30]. Our study had some limitations. The number of samples in each category of illness was small and multiple blood samples were not taken at different time points of the disease course to see the status of RBC profiles. This study showed that low MCV and MCH were significantly associated with the severity of the illness. So, comprehensive analysis of the RBC parameters would be helpful for early identification and better management of severe COVID-19 disease.   Conflict of interest: None   Reference 1.     Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med. 2020; 382: 727-733. 2.     Jiang F, Deng L, Zhang L, Cai Y, Cheung CW, Xia Z. Review of the clinical characteristics of coronavirus disease 2019 (COVID-19). J Gen Intern Med. 2020; 35(5): 1545-1549. 3.     Peeri NC, Shrestha N, Rahman MS, Zaki R, Tan Z, Bibi S, et al. The SARS, MERS and novel coronavirus (COVID-19) epidemics, the newest and biggest global health threats: what lessons have we learned? Intern J Epidemiol. 2020; 49(3): 717-726. 4.     Yuan X, Huang W, Ye B, Chen C, Huang R, Wu F, et al. Changes of hematological and immunological parameters in COVID-19 patients. Intern J Hematol. 2020; 112(4): 553-559. 5.     Bhuiyan MN, Giti S, Hossen MS, Rahman MM, Zannat MN, Chokroborty S. Haematologic profile abnormalities and coagulopathy associated with Covid-19: A prospective study of 100 patients. J Bangladesh Coll Phys Surg. 2020; 3: 61-66. 6.     Wan S, Xiang YI, Fang W, Zheng Y, Li B, Hu Y, et al. Clinical features and treatment of COVID‐19 patients in northeast Chongqing. J Med Virol. 2020; 92(7): 797-806. 7.     Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020; 395(10223): 497-506. 8.     Xu P, Zhou Q, Xu J. Mechanism of thrombocytopenia in COVID-19 patients. Ann Hematol. 2020; 99(6): 1205-1208. 9.     Cascella M, Rajnik M, Aleem A, Dulebohn S, Di Napoli R. Features, evaluation, and treatment of coronavirus (COVID-19). Stat Pearls. 2020; 52(171): 1-7 10.  Amgalan A, Othman M. Exploring possible mechanisms for COVID‐19 induced thrombocytopenia: Unanswered questions. J Thromb Haemost. 2020; 18(6): 1514-1516. 11.  Lippi G, Plebani M. Laboratory abnormalities in patients with COVID-2019 infection. Clin Chem Lab Med (CCLM). 2020; 58(7): 1131-1134. 12.  Sardu C, Gambardella J, Morelli MB, Wang X, Marfella R, Santulli G. Hypertension, thrombosis, kidney failure, and diabetes:Is COVID-19 an endothelial disease? A comprehensive evaluation of clinical and basic evidence. J Clin Med.2020; 9(5): 1417. 13.  Magro C, Mulvey JJ, Berlin D, Nuovo G, Salvatore S, Harp J, et al. Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: a report of five cases. Transl Res. 2020; 220: 1-13. 14.  World Health Organization. Clinical management of COVID-19: interim guidance, 27 May 2020. Geneva: World Health Organization; 2020. 62 p. Report No.: WHO/2019-nCoV/clinical/2020.5. 15.  Wang C, Deng R, Gou L, Fu Z, Zhang X, Shao F, et al. Preliminary study to identify severe from moderate cases of COVID-19 using combined hematology parameters. Ann Transl Med. 2020; 8(9): 593. 16.  Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020; 382(18): 1708-1720. 17.  Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020; 395(10223): 507-513. 18.  Xu XW, Wu XX, Jiang XG, Xu KJ, Ying LJ, Ma CL, et al. Clinical findings in a group of patients infected with the 2019 novel coronavirus (SARS-Cov-2) outside of Wuhan, China: retrospective case series. BMJ. 2020; 368: 1-7. 19.  Yang M, Li CK, Li K, Hon KL, Ng MH, Chan PK, et al. Hematological findings in SARS patients and possible mechanisms. Intern J Mol Med. 2004; 14(2): 311-315. 20.  McCranor BJ, Kim MJ, Cruz NM, Xue QL, Berger AE, Walston JD, Civin CI, Roy CN. Interleukin-6 directly impairs the erythroid development of human TF-1 erythroleukemic cells. Blood Cells Mol Dis. 2014; 52(2-3): 126-133. 21.  Lazarian G, Quinquenel A, Bellal M, Siavellis J, Jacquy C, Re D,  et al. Autoimmune haemolytic anaemia associated with COVID‐19 infection. Br J Haematol. 2020; 190(1): 29-31. 22.  Taneri PE, Gómez-Ochoa SA, Llanaj E, Raguindin PF, Rojas LZ, Roa-Díaz ZM, et al. Anemia and iron metabolism in COVID-19: a systematic review and meta-analysis. Eur J Epidemiol. 2020; 35(8): 763-773. 23.  Henry BM, Benoit JL, Benoit S, Pulvino C, Berger BA, Olivera MHS, et al. Red Blood Cell Distribution Width (RDW) predicts COVID-19 severity: a prospective, observational study from the Cincinnati SARS-CoV-2 emergency department cohort. Diagnostics, 2020; 10(90): 618-622. 24.  Pouladzadeh M, Safdarian M, Choghakabodi PM, Amini F, Sokooti A. Validation of red cell distribution width as a COVID-19 severity screening tool. Future Sci OA. 2021; 7(7): 1-13. 25.  Khartabil TA, Russcher H, van der Ven A, De Rijke YB. A summary of the diagnostic and prognostic value of hemocytometry markers in COVID-19 patients. Crit Rev Clin Lab Sci. 2020; 57(6): 415-431. 26.  Thomas T, Stefanoni D, Dzieciatkowska M, Issaian A, Nemkov T,  Hill RC, et al.  Evidence of structural protein damage and membrane lipid remodeling in red blood cells from COVID-19 patients. J Proteome Res. 2020; 19(11): 4455-4469. 27.  Prieto-Pérez L, Fortes J, Soto C, Vidal-González Á, Alonso-Riaño M, Lafarga M, Cortti MJ, et al. Histiocytic hyperplasia with hemophagocytosis and acute alveolar damage in COVID-19 infection. Mod Pathol. 2020;  3: 1-8. 28.  Angileri F, Légaré S, Marino Gammazza A, Conway de Macario E, Macario AJ, Cappello F. Is molecular mimicry the culprit in the autoimmune haemolytic anaemia affecting patients with COVID‐19?. Br J Haematol. 2020; 190(2): 92-93. 29.  Lippi G, Sanchis-Gomar F, Henry BM. Coronavirus disease 2019 (COVID-19): the portrait of a perfect storm. Ann Transl Med.2020; 8(7): 1-7. 30.  Martinelli N, Montagnana M, Pizzolo F, Friso S, Salvagno GL, Forni GL, et al. A relative ADAMTS13 deficiency supports the presence of a secondary microangiopathy in COVID 19. Thromb Res. 2020; 193: 170-172. <![CDATA[Analysis of genitourinary trauma patients admitted to the emergency department]]> İrfan Aydın Erdal Yavuz https://imcjms.com/journal_full_text/386 2021-08-06 23:38:48 Original Article IMC J Med Sci 2021; 15(2): 005 Abstract Background and objective: Genitourinary injuries are commonly encountered in the emergency department but may be over looked in case of multi-trauma. Determining the clinical features of genitourinary injuries will help physicians in the management of genitourinary trauma. Methods: The study was conducted in a tertiary hospital. Patients of all ages, admitted in the emergency department, with trauma between 2015 and 2020 were included and analyzed. The cause of genitourinary trauma, affected organs, any accompanying injury, treatments, mortality status, and laboratory tests related to mortality were obtained from the hospital records and analyzed. Results: During the study period, 87 patients admitted to the emergency department with genitourinary trauma were included in the study. The majority of these patients (n=79) were male. Of the patients, 9.2% died. All the patients in the mortality group had additional injuries. The most frequently injured organ was determined as the kidney (51.7%), followed by the scrotum (25.3%) and penis (8.1%). Additional injuries were observed in 81.6% of the patients. Intra-abdominal organ injuries (19.5%) were the most common accompanying injuries. White blood cell count (WBC), aspartate aminotransferase (AST), alanine aminotransferase ( ALT), blood glucose and creatinine values measured at the time of admission to the emergency department were found to be higher in the non-survivor group. The majority of the patients (81%) were discharged with conservative treatment and follow-up. Conclusion: It was determined that genitourinary injuries were frequently seen with additional injuries. Genitourinary injury should be evaluated carefully, especially in the presence of intra-abdominal organ injuries. IMC J Med Sci 2021; 15(2): 005. DOI: https://doi.org/10.3329/imcjms.v15i2.55807 *Correspondence: Erdal Yavuz, MD, Department of Emergency Medicine, Adıyaman University, 02200, Adıyaman, Turkey. Email: erdal_yavuz15@hotmail.com   Introduction Traumas constitute a general public health problem and an important cause of mortality and morbidity. Genitourinary injuries occur in approximately 10-20% of multi-trauma cases and are more common in young men. They usually occur with other life-threatening injuries that require immediate intervention [1]. The most common causes of genitourinary injuries are traffic accidents, falls, sexual assaults, gunshot wounds, and penetrating stab wounds. Pelvic fractures and abdominal organ damage are the most common injuries accompanied by genitourinary injuries. The most frequently injured organ in genitourinary injuries is the kidney [2]. Evaluation of genital organ damage in trauma patients is performed in a secondary examination. Genitourinary injuries can sometimes be asymptomatic or of secondary importance in case of multi-trauma. Although the mortality rate is low in genitourinary trauma, they are important in terms of their possibility to cause sexual dysfunction and permanent kidney damage. Early diagnosis and treatment of genitourinary injuries are important in preventing or minimizing complications, such as mortality and renal dysfunction, urinary incontinence and sexual dysfunction [3]. As in all trauma cases, in patients with genitourinary injuries, the airway should be protected first, and then external bleeding and hemodynamic shock should be controlled. After evaluating possible causes of fatal trauma, a genitourinary evaluation should be performed in the early period [4]. Thereore, the main purpose of this study was to evaluate genitourinary injuries in trauma patients, discuss them in light of the literature, and draw the attention of emergency physicians to these injuries.   Methods Study design and study population: The study was initiated after obtaining approval from the Clinical Research Ethics Committee of Adiyaman university (ethics committee number: 2020/07-34). Informed consent was waived due to the retrospective nature of the study. In this study, patients from all age groups who presented to our emergency department due to trauma between 2015 and 2020 were examined. Patients with injuries caused by traffic accidents, falls, battery, and sports activities were identified from the hospital archive. The epicrisis reports of these patients were examined, and the patients with genitourinary trauma were recorded. The patients’ age, gender, cause of trauma, time of trauma, injured organ, accompanying additional injury, conclusion time of consultation, length of hospital stay, clinical outcomes, and the values of laboratory investigations/tests at the time of admission to the emergency department were recorded in prepared forms. The obtained values were analyzed and compared between the non-survivor and survivor groups . Patients without genitourinary trauma and those with missing data in the hospital archive were not included in the study. Statistical Analysis: SPSS software package version 17 was used in the study. The suitability of continuous data to normal distribution was investigated with the Kolmogorov-Smirnov test. Data conforming to normal distribution were analyzed using Student’s t-test, and those that were not normally distributed were analyzed with the Mann-Whitney U test. The chi-square test was used to compare qualitative data. Numerical data conforming to normal distribution were shown as mean ± standard deviation, and those that were not normally distributed were presented as median (minimum-maximum) values. Categorical variables were expressed as numbers and percentages. P values of <0.05 were considered statistically significant.   Results During the study period, a total of 87 patients, 79 (90.8 %) male and 8 (9.2%) female, presented to the emergency department with genitourinary injuries (Table-1). Concerning age, 36.7% of the patients consisted of young males aged 21-40 years. The injuries most frequently occurred in the time zone between 16:00 and 23:59 (49.4%), and when the trauma type was considered, it was most frequently related to traffic accidents (48.3%). <![CDATA[Views of emergency medicine congress participants' on congress presentations]]> Mustafa Boğan Mustafa sabak Mehmet Karadağ Fatma Boğan Hasan Gümüşboğa Mehmet Murat Oktay Behçet Al https://imcjms.com/journal_full_text/376 2021-06-03 04:12:34 Original Article IMC J Med Sci 2021; 15(2): 007 Abstract Background and objectives: Science congresses have begun to be recognized as a tourism model that named as congress tourism. The hotels where the National Emergency Medicine Congresses are hosted, which are held once a year, contribute to congress tourism.The aim of this study is to find out views of attendees of emergency medicine congresses about the congress and presentations. Methods: A survey form consisting of 16 questions (without demographic question) was shared with participants attending the 14th National Emergency Medicine Congress of the Association of Emergency Medicine Specialists (EPAT) by SMS, e-mail, and social media messenger programs (WhatsApp, etc.). Results: A total of 238 participants took part in the study of whcih73.9% (n = 176) were male. The age of the majority (68, 28.6%) participants was between 35 to 39 years. Maximum participants (n = 95, 39.9%) were specialist titleholders and the majority's (n = 81, 34.0%) length of service was 6-10 years. Of the total particinats, 73.1% and 65% expressed that curiosity about the scientific content and refreshing the knowledge respectively were the reasons for attending the conferences. Conclusion: Even if congresses are held in holiday hotels, participants are more interested in scientific content. Paramedical activities and visuals used in presentations are viewed positively. Although there are very intense programs in the congress, the majority of the participants stated that they would listen to eight presentations most efficiently. IMC J Med Sci 2021; 15(2): 007. DOI: https://doi.org/10.3329/imcjms.v15i2.55879 *Correspondence: Mustafa Boğan, Emergency Department, School of Medicine, Düzce University, Postacode: 81620. Turkey. Email: mustafabogan@hotmail.com   Introduction Congresses are formal gatherings of people with similar businesses or interests that span a few days and allow them to express their ideas [1]. For academics, congresses are not just a scientific or business opportunity, but also a chance to travel [2]. In recent years, congresses have begun to be recognized as a tourist model, and this phenomenon, known as congress tourism, has begun to appeal to attendees in terms of entertainment, lodging, and vacation [3]. The hotels where the National Emergency Medicine Congresses are hosted, which are held once a year, contribute to congress tourism. Even though subject, hall, and time standardize scientific material, the attendees' overall impressions of the congresses are not reported. The purpose of this study is to find out what attendees of emergency medicine congresses think about the motivations for attending the events and what they think about the congress presentations.   Methodology Hasan Kalyoncu University's ethics committee granted authorization for the study (Date: 20/11/2018 Decision number: 2018/32). The survey study began on April 19, 2019, on the first day of the 14th National Emergency Medicine Congress of the Association of Emergency Medicine Specialists (EPAT), and lasted for 6 (six) months. Gender, age, academic title, and length of service, followed by demographic questions, were all included in the Google Forms survey. There were 16 questions, each with five options, about congress experiences. Participants received surveys via SMS, e-mail, and social media messenger programs (WhatsApp, etc.). On the first page, the participant was asked whether they wanted to take part in the survey. Those who agreed to take part were brought to a page with questions. EPAT provided contact information for the participants. Participants who had attended at least one congress were asked to complete surveys. Statistical analysis: Exact and Pearson Chi-square tests were used to examine the relationships between the independent variables at the categorical measurement level. Categorical variables were given numerical and percentage values as descriptive statistics. For statistical analysis, the SPSS Windows version 24.0-package program was used, and p ≤ 0.05 was considered statistically significant.   Results In total, 238 participants took part in the study. Of the total participants, 73.9% (n = 176) were male; the majority of the participants (n = 68, 28.6 %) were between the ages of 35 and 39. Participation was most common with the title of specialist (n = 95, 39.9%). Majority's length of service/job was 6-10 years (n = 81, 34.0%). The academic title and gender of the participants had no relationship (p = 0.084). The academic title advanced with the age and duration of the service (p < 0.05). Gender, age group, or length of service had no differences (p> 0.05). Detail is shown in Table-1.   Table-1: Descriptive data of the participants (N=238)     Table-2: Shows the responses of the participants to the questions. Question-1: What is the most important factor that determines the presentations you entered in the congress? a) The speaker or session chair is your friend/teacher. b) The academic title/career of the speaker. c) The speaker is of foreign nationality. d) Curiosity about the scientific content. e) Other. In this question, the option (d) was marked by 73.1% participants. Among the different academic titleholders, 94.1% associate professor and those who did not specify marked option (d) while option (a) was marked most (25.3%) by specialist physicians (p <0.05). Question-2: What is your purpose for attending the congress? a) Refreshing my knowledge. b) Meeting with your friends. c) Taking a vacation. d) Meeting new local/foreign people. e) Other. In this question, option (a) was marked most (65.0%). A significant difference was observed between the purpose of attending the congress and the academic title (p = 0.001). Associate professors were the ones who pointed the option (b) the most, while the specialist physicians marked the option (d) the most. Question-3: What should be the ideal starting time for the presentations in the congress? a) 8:00 am, b) 8:30 am, c) 09:00 am, d) 09:30 am, e) Other. In this question, the (c) option was marked the most (54.2%). There were statistically significant (p = 0.001) differences regarding the ideal starting hour of the presentations at the congress among the participants having different academic titles. General practitioners, specialists, physician faculty members, and associate professors had a higher rate of opinion compared to the other titleholders about the starting time of 09:00 am. Question-4: What is the most disturbing situation for you in the presentations at the congress? a) Not paying attention to the spelling rules. b) Font size is too small / too large to be seen. c) Written content containing more than half of a slide. d) The number of slides exceeding the number of minutes given. e) Other. In this question, 48.3% participants marked the option (d). A statistically significant difference was found among the academic titleholders and the answers given (p = 0.003). Associate professors marked (c), general practitioners and research assistants marked (d) at a higher rate compared to other titleholders. Question-5: How many presentations can you listen to efficiently and carefully in a day at the congress? a) 1-4, b) 5-8, c) 9-12, d) 13-16, e) Other. In this question, the most preferred (47.9%) option was (b). There was no statistically significant difference among the academic titleholders and the answers given (p = 0.106). Question-6: How many slides in a presentation would allow you to listen more carefully? a) 5-10, b) 11-15, c) 16-20, d) 21-25, e) Other. In this question, option (c) was marked the most (39.1%). A statistically significant difference was found between the academic title and the answers given (p = 0.001). Associate professors marked (d), general practitioners marked (c), and research assistants marked (b), at a higher rate compared to other titleholders. Question-7: Which of the following expresses your thoughts about paramedical video, photographs, quotations, etc. in congress presentations? a) I think it distracts me. b) I think it enriches the presentation. c) I consider it an unwarranted action. d) I think it allows the audience to rest in the presentation. e) Other. In this question, the most preferred (45.4%) option was (b). There was no statistically significant difference between the academic titleholders and the answers given (p = 0.194). Question-8: Which of the following expresses your thoughts about medical videos, photographs, quotations, etc. in congress presentations? a) I think it distracts me. b) I think it enriches the presentation. c) I consider it an unwarranted action. d) I think it allows the audience to be heard in the presentation. e) Other. In this question, (b) was the most preferred option (68.1%). A statistically significant difference was found between the academic titleholders and the answers given (p = 0.003). Doctor faculty members and those whose title was not specified marked option (b) at a higher rate compared to the other titleholders. Question-9: Which of the following expresses you best about your speaker preferences at the congress? a) I prefer to listen to speakers with higher academic titles (professor, associate professor). b) I prefer to listen to foreign speakers. c) I prefer to listen if I find the speakers more dynamic. d) I prefer to listen to speakers from different departments. e) Other. In this question, the most preferred option was (a) and marked by 30.7% participants. There were statistically significant differences between the academic title and the answers given (p = 0.001). Associate professors and general practitioners marked option (a) at a higher rate compared to other titleholders. Question-10: Which of the following expresses your opinion about the Turkish presentations, presentations in English, and oral presentations in many halls at the same time in the congress? a) Having a conversation in several halls at the same time distracts me. b) Speaking in several halls at the same time increases the efficiency of the congress. c) Having a conversation in several halls at the same time causes me to miss important topics and speakers. d) Having a speech in several halls at the same time allows me to switch from one presentation to another in a short time. e) Other. In this question, 62.6% participants marked the option (c). A statistically significant relationship was observed between the academic title and the answers given (p = 0.001). Researchers, specialists, and those whose title was not specified marked (c) at a higher rate compared to other titleholders. Question-11: From which sources do you think the presentations at the congress should be prepared? a) I prefer the presentations to be consisted from classical book information. b) I prefer the presentations to be compiled from classical book information as well as current research. c) I prefer the presentations to be comprised of current research and information rather than classical book information. d) I prefer the presentations to be compiled from the works and experiences of the speaker on the relevant subject, together with current research and information. e) Other. In this question, the (d) option was marked most (41.2%). There was no statistically significant difference between the academic title and the answers given (p = 0.174). Question-12: Which one of the following expresses your opinions if the presentation exceeds the given time? a) If the presentation content is of good quality, it does not distract me from exceeding the time. b) Even if the presentation content is of good quality, it distracts me if the time is exceeded. c) If the presentation time is exceeded, I will consider leaving the hall. d) I think that the speaker is not well prepared if the presentation time exceeds. e) Other. In this question, option (a) was marked by 57.1% participants. A statistically significant relationship was observed among the different academic titleholders (p = 0.001). General practitioners, research assistants, specialists, and physician faculty members marked option (a) at a higher rate compared to other titleholders. Question-13: In your opinion, what is the ideal place/time to ask questions to speaker about the presentation? a) Immediately after the presentation. b) At the end of all presentations in the session. c) Questions should be taken during the coffee break, not during the session. d) Questions should be given in writing, not verbally. It should be included in the abstract book with its answers. e) Other. In this question, option (a) was marked most (71%). A statistically significant relationship was observed between the academic titleholders and the answers given (p = 0.001). Associate professors, research assistants, and physician faculty members marked option (a) at a higher rate compared to other titleholders. Question-14: In your opinion, which of the following factors is the most responsible for the prolongation of the presentations in the congress? a) The speaker comes unprepared. b) The speaker's slides are long. c) Too many questions on the subject. d) The chairperson of the session is not sensitive about the time. e) Other. In this question, the most preferred (51.3%) option was (b). A statistically significant relationship was observed between the academic title and the answers given (p = 0.001). General practitioners have indicated option (d). Associate professors, research assistants, and specialist physicians marked option (b) at a higher rate compared to other titleholders. Question-15: Which of the following best expresses your opinions about not only medical but also paramedical issues and competitions in congress presentations? a) Paramedical issues and competitions do not interest me. b) I think paramedical subjects and competitions will color the congress. c) I believe that paramedical subjects and competitions reduce the level of the congress. d) I think that paramedical topics and competitions increase cohesion between participants. e) Other. In this question, the most preferred (47.9%) option was (b). A statistically significant relationship was observed between the academic title and the answers given (p = 0.001). Research assistants and specialist physicians marked option (b) at a higher rate compared to other titleholders. Question-16: How many minutes do you think should be the ideal time for a presentation? Options: a) 5, b) 10, c) 15, d) 20, e) 25 minutes. In this question, the option (d) was marked most (43.3%). A statistically significant relationship was observed between the academic titleholders and the answers given (p = 0.001). General practitioners, physician faculty members, associate professors, and those whose title was not specified marked (d) at a higher rate compared to other titleholders. There was no difference between gender and the answers given to the questionnaire (p> 0.05).   Table-2: Survey questions and answers given by the participants (N=238)     Discussion As in many sectors, meetings (congresses, symposiums, conferences, etc.) are organized in the field of medicine/emergency medicine. However, there is not enough data regarding the opinions of the participants in these congresses on the contents of the congresses. Although the number and cost of these meetings, which have an important place in many medical disciplines, are unclear, an estimate of more than 100 000 medical meetings per year might not be unrealistic, [4]. Although the format of medical conferences has not changed for a long time, there is a lot that participants can do, such as expanding their knowledge, seeking new ideas, meeting new people, participating in social events, dealing with catering and promotions in the exhibition and stand areas [5]. In a medical meeting, which is an effective training method in professional development and maturation, professionals can receive experience transfer from their peers and seniors [6]. At the national and international congresses organized by EPAT every year, there are participants and speakers from many countries [7,8]. It has been determined that the majority of the participants in these congresses, which are enriched with social activities as well as scientific content and held in holiday-concept hotels, are more interested in scientific content than holidays. Although many medical meetings are enjoyable, they often distract attention because of tiring and busy schedule [7,8]. For example, at the 15th National Emergency Medicine Congress organized by EPAT, there was an intense program in 4 halls, from morning to evening and also included 16-20 presentations daily in each hall, and each presentation lasted approximately 20 minutes [7]. The 16th National Congress was similar, additionally, oral presentations were made in different halls in both congresses [7,8]. Similarly, congresses organized by the American College of Emergency Physicians (ACEP) are full of lectures, courses, panels, and activities that start in more than one field at the same time continue from the early morning until the evening [9]. Unlike congresses with intensive programs, the majority of the participants do not seem to embrace this intensity much. While most of the participants (n = 114, 47.9%) stated that they would listen to 5-8 presentations in a day efficiently, the number of those saying they could listen to 1-4 presentations efficiently, was quite high (n = 90, 37.8%). About 62.6% of the participants stated that having activities and lessons in more than one field at the same time would cause them to miss important topics and speakers. Although it is for medical purposes, these meetings may include programs aimed at paramedical activities and socialization [7-9]. These activities can be in the form of knowledge competitions, sports tournaments, or music concerts [8, 9]. In our study, 47.9% of the participants expressed a positive opinion that such activities will color the congress. It has been argued that visuals such as photographs, graphics, etc. which are less relevant and unrelated to the subject used in the preparation of the presentation attract the attention of the audience and make the presentation more effective [10,11]. In our study, 68.1% to 45.4% of the participants stated that the visuals with medical and paramedical content respectively enrich the presentations.   Conclusion Even if congresses are held in holiday hotels, participants are more interested in scientific content. Paramedical activities and visuals used in presentations are viewed positively. Although there are very intense programs in the congress, the majority of the participants stated that they would listen to 8 presentations most efficiently. It is recommended to utilize these data while organizing congresses or preparing presentations.   Conflict of interest: None   References 1.     Conference. Oxford Learner’s Dictionaries. (Accesseddate 10Sep2020) Available from: https://www.oxfordlearnersdictionaries.com/definition/american_english/conference. 2.     Kocabulut Ö. [Determination of the academics’ participation motivation to ınternatıonal congresses]. Seyahat ve Otel İşletmeciliği Dergisi. 2017; 14(1): 48-58. Turkish 3.     Çelik Yetim A. [A research on experientıal values for congress events]. Seyahat ve Otel İşletmeciliği Dergisi. 2015; 12(2). 57-72. Turkish 4.     Ioannidis JPA. Are medical conferences useful? And for whom? JAMA. 2012; 307(12): 1257–1258. 5.     Wiffen P. What's in a congress? Eur J Hosp Pharm. 2015; 22:63. 6.     Elhassan M. Success and survival conference: a novel idea to resonate an under utilized concept in medical education. Int J Med Educ. 2017; 8: 273-275. 7.     15. Ulusal Acil Tıp Kongresi. (2019). (Accessed date 13Sep 2020), Available from: http://www.atuder.org.tr/atuderData/Document/252019214037-15-acil-tip-PROGRAMson.pdf 8.     14. Ulusal Acil Tıp Kongresi. (2018). (Accesseddate 13 Sep 2020), Available from: https://www.atuder.org.tr/atuderData/Document/25420181507-14-acil-tip-PROGRAM-2.pdf 9.     ACEP’s 50th Anniversary, San Diego (2018). (Accessed date 13 Sep 2020), Available from:https://www.acep.org/static/globalassets/resources/documents/sa-documents/acep18brochure.pdf 10.  Doğan NÖ. Kongre Sunumu Yapmak (Accessed date 10Sep 2020), Available from: https://acilci.net/kongrede-sunum-yapmak/  11. Tatar H. İyi Bir Sunum Nasıl Hazırlanır? (Accessed date 10 Sep 2020), Available from: https://www.youtube.com/watch?v=QG6_qKIxcxY <![CDATA[Immunoglobulin G4 related disease: an overview]]> Saika Farook Abdullah Ahmed Solaiman Md. Shariful Alam Jilani https://imcjms.com/journal_full_text/387 2021-08-10 01:17:07 Review IMC J Med Sci 2021; 15(2): 006 Abstract Immunoglobulin G4 related disease (IgG4-RD) is a recently perceived fibroinflammatory condition, identified as a systemic illness for the first time in the early 2000. It can involve virtually every organ of the body, commonly presenting as lymphadenopathy, retroperitoneal fibrosis, autoimmune pancreatitis, tubulointerstitial nephritis, parotid or lacrimal gland enlargement. The diagnosis is confirmed by histopathological analysis and is often, but not always accompanied by an increased level of serum IgG4 concentration. In fact, the name addressing this autoimmune fibroinflammatory condition may be considered a misnomer, as the role of the non-inflammatory immunoglobulin IgG4 in the immune mechanism of IgG4-RD remains to be elucidated. IMC J Med Sci 2021; 15(2): 006. DOI: https://doi.org/10.3329/imcjms.v15i2.55878 *Correspondence: Saika Farook, Department of Microbiology, Molecular and Flow Cytometry, DMFR Molecular Lab & Diagnostics BD LTD, Dhaka, Bangladesh. Email: sairana15@yahoo.com   Introduction An International symposium held in 2011 provided a set of guidelines for the diagnosis of IgG4-RD. Even the nomenclature of this newly discovered condition continues to evolve and the term IgG4-related disease has recently been elected in preference to alternatives such as IgG4-related systemic disease, IgG4-related sclerosing disease, and IgG4-related multi-organ lymphoproliferative syndrome [4]. Epidemiology   Since the establishment of the disease entity, several studies have been conducted to elucidate the immunopathogenesis of IgG4-RD. The immunoglobulin IgG4 has restricted ability to bind complement and to interact with activating Fc receptors for which it is considered as a non-inflammatory immunoglobulin [9]. Hence, whether IgG4 play an active role in the autoimmune mechanism of the disease is still questionable. Recent studies claim, interactions among clonally expanded CD4+ cytotoxic T-lymphocytes (CD4+CTL), T follicular helper (TFH) cells, and B cells play a major role in the immunopathogenesis of IgG4-RD [13]. Annexin A11 and galactin-3 have been implicated to be the causative autoantigens [14]. The plasmablasts or activated B cells in patients with IgG4-RD are specific for these autoantigens and are oligoclonally restricted, resulting in clonal expansion of CD4+ CTL in tissue sites [13]. CD4+ CTLs are a unique CD4+ T cells with cytolytic capabilities, especially found associated with chronic viral infections and malignancies [15]. In IgG4-RD, CD4+ CTLs in affected tissues, secrete profibrotic cytokines including interleukin (IL)-1β, transforming growth factor β1 (TGF-β1), and interferon γ (IFN-γ) as well as cytolytic molecules such as perforin and granzymes A and B, responsible for killing target cells. Furthermore, IL-4-secreting TFH cells are also expanded in blood and tissue sites, which are essentially responsible for germinal center formation, affinity maturation, class switching to IgG isotypes including IgG4 and the development of most high affinity memory B cells [13, 16].   Risk factors Several immune mediated mechanisms are thought to play a role in the fibroinflammatory process of IgG4-RD. Since the condition is relatively new, these factors are not well established and further extensive studies are essential to confirm their contributions.   Genetic factors:Genetic studies revealed that the HLA serotypes DRB1*0405 and DQB1*0401 are associated with increased susceptibility to IgG4-related disease in Japanese populations, whereas DQβ1-57 without aspartic acid is related to disease relapse in Korean populations [17, 18].       IgG4-RD can affect any organ of the body and can present with varied clinical features. Presentation is usually subacute; fever and elevation of C-reactive protein levels are unusual. The disorder is often diagnosed incidentally through radiologic findings or unpredictably in pathological specimens [26]. However, patients with multi-organ involvement may suffer from weight loss - about 9 to14 kgs over a period of few weeks to months before reaching the correct diagnosis [26]. IgG4-RD is relatively new in Bangladesh and cases have not been reported widely. Till now, a single case of IgG4-related peri-aortitis has been reported in 2018, suggesting that although the incidence of the disease exists in Bangladesh, cases are not being unmasked extensively [35]. This is possibly due to a lack of awareness as well as adequate diagnostic facilities. Clinicians should remain concerned to the possibility that IgG4-RD often presents with features of malignancy and may mimic some autoimmune rheumatic diseases such as Sjögren's syndrome, systemic lupus erythematosus (SLE), and granulomatosis with polyangiitis [36]. Diagnosis       Although IgG4 level reduces in patients whose serum IgG4 concentration was raised at baseline following treatment with glucocorticoids, they may remain above normal values in certain patients [41]. Interestingly, a study conducted in Japan revealed that IgG4 concentration was not reduced to normal level in 115 out of 182 (63%) patients treated with glucocorticoids [44]. Therefore, the diagnosis of IgG4-RD is determined by the combination of clinical, imaging, serological and histological criteria. A summary diagnostic scheme of IgG4-RD is shown in Figure-1.     Figure-1: Diagnostic scheme of IgG4-RD. Serum IgG4 - normal up to 1.35 g\L. HPF: high power field (400x); +ve: positive.   Treatment 6.     Umehara H, Okazaki K, Masaki Y, Kawano M, Yamamoto M, Saeki T, et al. Comprehensive diagnostic criteria for IgG4-related disease (IgG4-RD). Mod Rheumatol. 2012; 22(1): 21-30. 7.     Comai G, Cuna V, Fabbrizio B, Sabattini E, Leone O, Tondolo F, et al. A case report of IgG4-related disease: an insidious path to the diagnosis through kidney, heart and brain. BMC Nephrol. 2019; 20(1): 1-7. 8.     Karim F, Loeffen J, Bramer W, Westenberg L, Verdijk R, van Hagen M, et al. IgG4-related disease: a systematic review of this unrecognized disease in pediatrics. Pediatr Rheumatol. 2016; 14(1): 1-9. 9.     Bruhns P, Iannascoli B, England P, Mancardi DA, Fernandez N, Jorieux S, et al. Specificity and affinity of human Fc gamma receptors and their polymorphic variants for human IgG subclasses. Blood. 2009; 113(16): 3716–25. 12.  Mavragani CP, Fragoulis GE, Rontogianni D, Kanariou M, Moutsopoulos HM. Elevated IgG4 serum levels among primary Sjogren’s Syndrome patients: Do they unmask underlying IgG4-Related disease? Arthritis Care Res. 2014; 66(5): 773-777. 14.  Hubers LM, Vos H, Schuurman AR, Erken R, Elferink RPO, Burgering B, et al. Annexin A11 is targeted by IgG4 and IgG1 autoantibodies in IgG4-related disease. Gut. 2018; 67(4): 728-735. 16.  Crotty S. Follicular helper CD4 T cells (TFH). Annu Rev Immunol. 2011; 29: 621- 663. 18.  Park DH, Kim MH, Oh HB, Kwon OJ, Choi YJ, Lee SS, et al. Substitution of aspartic acid at position 57 of the DQbeta1 affects relapse of autoimmune pancreatitis. Gastroenterology. 2008; 134(2): 440-446. 20.  Frulloni L, Lunardi C, Simone R, Dolcino M, Scattolini C, Falconi M, et al. Identification of a novel antibody associated with autoimmune pancreatitis. N Engl J Med. 2009; 361(22): 2135-42. 22.  Aparisi L, Farre A, Gomez-Cambronero L, Martinez J, Heras GDL, Corts J, et al. Antibodies to carbonic anhydrase and IgG4 levels in idiopathic chronic pancreatitis: relevance for diagnosis of autoimmune pancreatitis. Gut. 2005; 54(5): 703-9.  24. Lohr JM, Faissner R, Koczan D, Bewerunge P, Bassi C, Brors B, et al. Autoantibodies against the exocrine pancreas in autoimmune pancreatitis: gene and protein expression profiling and immunoassays identify pancreatic enzymes as a major target of the inflammatory process. Am J Gastroenterol. 2010; 105(9): 2060-71. 26.  Stone JH, Khosroshahi A, Deshpande V, Chan JK, Heathcote JG, Aalberse R, et al. IgG4-related disease: recommendations for the nomenclature of this condition and its individual organ system manifestations. Arthritis Rheum. 2012; 64(10): 3061-7. 28.  Dahlgren M, Khosroshahi A, Nielsen GP, Deshpande V, Stone JH. Riedel’s thyroiditis and multifocal fibrosclerosis are part of the IgG4-related systemic disease spectrum. Arthritis Care Res. 2010; 62(9): 1312-8. 30.  Kamisawa T, Anjiki H, Egawa N, Kubota N. Allergic manifestations in autoimmune pancreatitis. Eur J Gastroenterol Hepatol. 2009; 21(10): 1136-9. 32.  Stone JH, Khosroshahi A, Deshpande V, Stone JR. IgG4-related systemic disease accounts for a significant proportion of thoracic lymphoplasmacytic aortitis cases. Arthritis Care Res. 2010; 62(3): 316-22. 34.  Raissian Y, Nasr SH, Larsen CP, Colvin RB, Smyrk TC, Takahashi N, et al. Diagnosis of IgG4-related tubulointerstitial nephritis. J Am Soc Nephrol. 2011; 22(7): 1343-52. 36.  Moutsopoulos HM, Fragoulis GE, Stone JH. Pathogenesis and clinical manifestations of IgG4-related disease. Up To Date. 2019. 38.  Dhall D, Suriawinata AA, Tang LH, Shia J, Klimstra DS. Use of immunohistochemistry for IgG4 in the distinction of autoimmune pancreatitis from peritumoral pancreatitis. Hum Pathol. 2010; 41(5): 643-52. 40.  Takahashi N, Kawashima A, Fletcher JG, Chari ST. Renal involvement in patients with autoimmune pancreatitis: CT and MR imaging findings. Radiology; 2007; 242(3): 791-801. 42.  Boonstra K, Culver EL, de Buy Wenniger LM, van Heerde MJ, van Erpecum KJ, Poen AC, et al. Serum immunoglobulin G4 and immunoglobulin G1 for distinguishing immunoglobulin G4‐associated cholangitis from primary sclerosing cholangitis. Hepatology. 2014; 59(5): 1954-63. 44.  Kamisawa T, Shimosegawa T, Okazaki K, Nishino T, Watanabe H, Kanno A, et al. Standard steroid treatment for autoimmune pancreatitis. Gut. 2009; 58(11): 1504-7. 46.  Aalberse RC, Stapel SO, Schuurman J, Rispens T. Immunoglobulin G4: an odd antibody. Clin Exp Allergy. 2009; 39(4): 469-77. 48.  Kamisawa T, Okazaki K, Kawa S, Shimosegawa T, Tanaka M. Japanese consensus guidelines for management of autoimmune pancreatitis. III. Treatment and prognosis of AIP. J Gastroenterol. 2010; 45(5): 471-7. 50.  Brito-Zerón P, Kostov B, Bosch X, Acar-Denizli N, Ramos-Casals M, Stone JH. Therapeutic approach to IgG4-related disease: a systematic review. Medicine. 2016; 95(26): e4002. 52.  Ebbo M, Grados A, Samson M, Groh M, Loundou A, Rigolet A, Terrier B, Guillaud C, Carra-Dallière C, Renou F, Pozdzik A. Long-term efficacy and safety of rituximab in IgG4-related disease: data from a French nationwide study of thirty-three patients. PLOS One. 2017; 12(9): e0183844. <![CDATA[Perspective and a brief overview of genome-wide association studies in moderate to severe asthma]]> Md Monirul Hoque https://imcjms.com/journal_full_text/389 2021-08-22 01:44:03 Review Abstract Asthma is a common chronic respiratory disease that shares phenotypic heritability and shows clusters of symptoms among the relatives. A large number of studies have been conducted to examine the genetic susceptibility of asthma over the past three decades. In the last decade, genome-wide association studies (GWAS) have readdressed the perspective of viewing asthma and have identified some novel genes associated with the susceptibility of asthma. However, few genetic studies have been conducted focusing the moderate to severe asthma, and the molecular targets explain a small proportion of asthma heritability. This review focuses on the principal findings of the genomic studies investigating the genome-wide association of moderate to severe asthma and how it is transitioning the phenotype-based approach towards the fundamental genomic studies. It further illustrates the integrative perspectives aimed towards the translation of the findings in precision medicine. Therefore, a better understanding of asthma pathogenesis would focus the individual at the center of asthma care. IMC J Med Sci 2021; 15(2): 008. DOI: https://doi.org/10.3329/imcjms.v15i2.55880 *Correspondence: Md Monirul Hoque, Department of Pathobiology, College of Veterinary Medicine, Auburn University, Alabama, USA. Email: hoquemonir@yahoo.com   Introduction Asthma is a complex, non-communicable disease of the airways characterized by recurrent episodes of shortness of breath, cough, wheezing, reversible airflow obstruction, bronchial hyper-responsiveness, mucus overproduction, and abnormal inflammation of the respiratory mucosa. According to the WHO report, 262 million people suffered from asthma in 2019 worldwide. There were 383,000 deaths due to asthma in 2015 and this death toll jumped to 461,000 in 2019, most of which occurred in low and lower-middle income countries. Asthma is a common disease among children and cases are increasing at a rate of 50 percent every ten years [1]. An increase in the incidence of asthma has been associated with urbanization. Recurrent attacks of asthma symptoms are responsible for frequent sleeplessness, daytime fatigue, reduced activity, and absenteeism from school and work. Moreover, in some patients, airflow may be intractably compromised and the airway may be remodeled irreversibly making them refractory to the conventional treatment options with high dose inhaled corticosteroids (ICS) and long-acting β2-adrenergic receptor agonists (LABA) [2]. This subgroup of patients requires a different management approach for their treatment. Researches on the genetic basis of asthma have been evidenced as a promising field of study to develop newer treatment modalities as well as novel preventive protocols for severe asthmatic patients. There are significant differences in asthma prevalence not only among different countries and populations but also among different ethnic groups within the same country. Complex interactions among genetic and environmental factors are responsible for these variations, where genetic factors are assumed to contribute to 35-95% of the susceptibility to develop asthma [3]. Active researches are going on to find out the fundamental causes and underlying pathobiological pathways responsible for the development of asthma. Several genomic approximations have been done to find out the genes underlying the pathogenesis of asthma. The expedition started with linkage analysis studies followed by positional cloning and later by candidate-gene association studies. High-throughput polymorphism genotyping led to the development of methods for much denser genomic scans and initiated the era of genome-wide association studies (GWAS) [4]. Moffatt MF et al. conducted the first GWAS of asthma in 2007 [5]. Ninety three papers were found reported in the GWAS catalog (https://www.ebi.ac.uk/gwas/) till June 1, 2021, on 51 asthma or asthma-related traits. Among them, 9 are GWASs of severe asthma or asthma exacerbations. Validation of the genomic findings from GWAS through the studies of biological mechanistic pathways is opening up the prospect of discovery of potential targets and newer biological drugs, which can modify the progression of disease and prevent the development of severe diseases. This will lead to a paradigm shift in the management approach of asthma that will prioritize the endotype than the phenotype of the disease. It will ultimately lead to a better understanding of asthma heterogeneity and progression, and will help to develop new targeted treatments.   Phenotypic view of asthma Asthma has long been managed conventionally based on the phenotypic characteristics which are diagnosed by different clinical parameters, such as, history of the patient, lung function test, spirometry, FEV1 (forced expiratory volume) and chest X-ray. Different studies have been conducted to precisely classify asthma so that management protocol can be tailored according to the requirement of the patient cohort. Moore et al. studied asthmatic patients of over 12 years old (726 patients), registered with the Severe Asthma Research Program (SARP) of National Heart Lung and Blood Institute (NHLBI). They conducted cluster analysis using different respiratory function tests and other parameters and categorized the asthmatic patients into 5 clusters emphasizing the clinical course and treatment response for better compliance and greater outcome. Although their algorithm was used for the differential diagnoses of asthma in research studies, it could not be applied in different levels of asthma severity [6,7]. Even though newer drugs are being discovered to combat asthma, the mainstay of treatment remains the inhaled corticosteroids, β2-adrenoceptor agonists, and cholinergic antagonists. None of these drugs prevents or cure asthma, though patients get some level of symptomatic relief but a large proportion continues to suffer [8,9]. A genetic basis can explain this discrepancy of response to the drugs. Asthma susceptibility genes cause mild or intermittent asthma by interacting with environmental factors. Later, different genes lead to disease progression by interacting with other environmental exposures. Thus genetic profiles combined with environmental factors create the platform of different pathophysiological abnormalities and lead to varied clinical asthma patterns. So, a prospective approach is required to categorize the severity of asthma and improve asthma control by personalization of asthma management and identifying the patients at risk for adverse outcomes [5].   Insight into the genetic epidemiology of asthma and associated contributing factors Asthma is not merely a single disease rather it is an umbrella for multiple diseases with similar clinical features. It has different genetic and environmental contributors. The risk of developing asthma in a person depends not only on his/her degree of genetic relatedness to his/her relative with the disease but also on the severity and the age of onset of asthma in that relative. There is more chance of the development of asthma among the offspring of the asthmatic parents. This supports the genetic predisposition of asthma. The risk of developing asthma in children is 25% if one parent is affected, but it becomes 50% if both parents are affected. Studies on twin further support the genetic basis of asthma. The recurrence risk of asthma is much higher among monozygotic twins than in dizygotic twins [10,11]. However, the concordance of asthma in monozygotic twins is 75% rather than 100%. Even though the monozygotic twins share all their genes, this discordance of asthma among them points out that not only the genetic factors but also environmental risk factors play an important role in asthma [10]. Hence, although family background plays an important role in the development of asthma, the phenotypic expression of asthma may be influenced by environmental and other genetic factors. A small number of genes are responsible for setting the individual risk background which is then acted upon by another set of modifying genes and environmental factors. Markus J. Ege et al. conducted a genome-wide interaction analysis for candidate genes of asthma and atopy in a farming environment and they found 5 SNPs (Single Nucleotide Polymorphism) interact with farm-related exposures [12]. This indicates the presence of a potential interaction between the genotype and the environmental factors. Classic GWASs without considering the environmental exposures may not detect the involved SNPs. However, gene-environment interaction provides the opportunity to unravel genetic effects masked by environmental exposures. Moreover, the non-linear expression of the asthma phenotypes makes it even more variable. This adds more difficulty in the prediction of asthma status for a genotype or combination of genotypes. Asthma is more prevalent in the Western population (up to 20%) whereas it is around 1% in the developing world [13]. People in urban areas suffer more from asthma than rural people. Occurrence of symptom frequency, degree of airway responsiveness, level of lung function, and airway inflammation has been found to aggregate within families. So, a person is prone to develop severe asthma if he has a positive family history of severe asthma. A better understanding of the causative factors for the variation of diseases along with the host-related differences in genetic makeup would facilitate the personalized treatment [14].   Approaches for discovering asthma genes: the study of molecular genetics Over a hundred genes have been found associated with the development of asthma and the list is still growing. Different experimental approaches have been used to unravel the genetic determinants of asthma. Technology has continuously evolved over the time to overcome the limitation of existing techniques to reach the desires goal. The candidate gene approach and genome-wide approaches are the principal approaches. Candidate gene association study is conducted in a case-control manner and enrichment of a marker allele (SNP) or haplotype (the group of alleles) are compared among the cases and controls. Another approach is the candidate gene analysis where course of the disease is investigated in the cohort and cross-sectional study designs. Candidate genes are selected based on their known function and the role they play in pathogenesis. As a result, these studies become biased towards studies of immune-related genes and they are unable to discover novel genes or pathways by themselves. These approaches are confined to what we already know or what we think we know about disease pathogenesis and gene functions [15,16]. To overcome the drawback of the candidate gene analysis study, the genome-wide approach was adopted. In this gene discovery approach, the whole genome is taken into consideration without any prior hypotheses about the location of the most important genetic contributors to disease risk. So this approach is called the “hypothesis-free” or “hypothesis-generating” approach. Genome-wide approaches can discover novel genes and pathways involved in the pathogenesis of the disease. Thus this approach introduces new targets and potential pathways for further exploration of the diseases process. Genome-wide linkage study and genome-wide association study (GWAS) are the two methods of genome-wide approach. Genome-wide linkage studies require the availability of families with at least two affected relatives (affected sibling pairs) where the disease locus co-segregates within the families. The susceptibility loci are also shared among affected relatives more often than expected by chance. This linkage disequilibrium (LD) is utilized in such studies. Linkage studies require relatively few genetic markers and they reveal multiple rare alleles that confer risk for disease, even if the specific variant differs among families. However, they identify very broad regions that contain hundreds of genes and this limits the resolution of the method. Moreover, these studies have low power to detect risk variants with modest effect sizes on disease risk [15]. The next approach that came into play to deal with the shortcomings of linkage studies is GWAS. GWAS has excellent resolution and good power to detect risk variants with modest effect sizes. It does not need to study families for linkage analysis. It extends the candidate gene approach to include markers that tag all common variations in the genome. GWAS can test for associations with more than a million Single Nucleotide Polymorphisms (SNPs). To achieve genome-wide levels of significance, very large sample sizes and very stringent thresholds of significance (typically with p<10-7) are required to deal with the statistical issues while performing millions of SNP association analyses. To fulfill the criteria researchers collaborate at national and international levels, combine different smaller GWASs and conduct meta-analysis to increase the power of the study [15]. Several GWASs have been conducted to find out the genetic basis of severe asthma.   Perspectives of genome-wide association studies GWAS is a form of genetic association study where hundreds of thousands of SNPs are assessed in a large group of subjects (in a case-control manner) for relationships to a specific phenotype (such as asthma) or a disease-related phenotype (such as IgE level). Unbiased interrogation of the whole genome is the main driving power of GWAS. It is viewed in the context of the Human Genome Project as a whole [17]. The GWASs enable the detection of previously un-described and un-suspected genetic components. But, variants detected as significantly associated in a GWAS do not certify that they are pathogenic. These variants might be in linkage disequilibrium with other rarer and untyped variants [18]. Moreover, the relationship between the genotype and disease is moderated by early environmental exposures, including tobacco smoke, respiratory infection [19], and place of residence. In particular, gene-environment interaction in childhood may determine the platform of risk factors so that associations become apparent only in the exposed individuals. Such gene-environment interactions are common in asthma, and they are very difficult to detect in a GWAS. Thirty eight loci have been found associated with asthma with a threshold of the genome-wide significance level. Among these loci, the cluster of genes on chromosome 17q12-21 is the most consistently replicated locus among the childhood-onset disease across a diverse range of ethnic backgrounds [20]. Variation at this locus is not associated with atopy, indicating that it is an asthma susceptibility locus and it acts through non-atopic pathways (non-IgE-mediated) [15]. Thus, GWASs are redefining the conventional view of looking at the disease and treatment by identifying novel findings. Genome-wide association studies perform genotyping arrays with up to millions of SNP markers in an unbiased manner throughout the genome to detect the underlying genetic variants responsible for the disease. It requires a very large sample size to maximize the statistical power to detect risk alleles with modest size effects. This requirement is achieved by pooling the samples from multiple independent investigations where the participating members get the chance to agree on standard methods of analysis. A well-developed plan for a large meta-analysis provides the platform for examining genetic factors that are common to or variable between various studies [21]. Meta-analyses of asthma GWASs have been conducted by the GABRIEL (A Multidisciplinary Study to Identify the Genetic and Environmental Causes of Asthma in the European Community) and the EVE (a collection of US-based investigators assembled to investigate asthma-susceptibility genes in ethnically diverse populations) consortiums. Subjects only from European ancestry were included in GABRIEL meta-analysis, whereas the EVE study included racially and ethnically diverse subjects from the U.S. and Mexico. The combined results of these two large studies showed highly replicable ethnic or race-specific as well as ethnically diverse associations with asthma [15]. Novel genetic variants, as well as new biological pathways, came under the focus of study. Rose Du et al. conducted the first genome-wide association study of severe or exacerbated asthma among non-Hispanic white children in 2011 [22]. They found that the class I MHC-restricted T cell-associated molecule gene (CRTAM) expression (in the activated CD8+ and NK-T cells) was associated with asthma exacerbation at a low level of vitamin D. This study referred to the importance of maintenance of an adequate level of vitamin D in the high-risk asthmatic patients. Another study to determine the genetic determinants of severe asthma found the role of ORMDL3/GSDMB locus on chromosome 17q12-21, which was identified as associated with mild to moderate asthma. Proper study design, control of the population heterogeneity with adequate sample size might discover variants responsible for severe asthma masked as a variant of mild asthma. This study found another two novel genes PRPS1L1 and intergenic associated with severe asthma [2]. These genes play biological roles in the pathogenic inflammation of asthma through dendritic cells or Th2 cytokines. Genetic variants identified underlying moderate to severe asthma are summarized in Table-1. All these variants are related to the biological pathways of asthma at different levels of pathogenesis. They will reveal fundamental information regarding severe asthma pathogenesis through a multi-dimensional approach.   Table-1: Genome-wide association studies identifying moderate to severe asthma risk variants*     The largest GWAS conducted among European ancestry for moderate to severe asthma was published in 2019. It identified 3 novel genes expressed in airway epithelium and in the blood eosinophil [21]. SEMA3D gene codes for a signaling protein for endothelial cell migration and angiogenesis which is responsible for airway remodeling and asthma exacerbation. It causes immune cell recruitment during inflammation. CTNNA3 plays a role in muscle cell coherence, which has brought bronchial smooth muscle under study for insight into its possible role in asthma exacerbation [24]. Target genes of asthma risk variants and functional study The aim of asthma GWAS is to identify genetic variants (or another variant in strong linkage disequilibrium) associated with disease risk which affects the protein sequence or the transcription patterns of a gene (target gene) that ultimately plays a role in disease pathophysiology. Disease risk-associated variants highlight specific genes and molecular pathways which are dysregulated in asthma and they help understand the underlying cause of the development of asthma. There are at least 24 genes that are likely targets of severe asthma risk variants. Target genes of risk variants can be identified in two ways. Based on the published risk variants or variants in strong LD with them, a statistical approach, such as ANNOVAR is used to see if these variants are non-synonymous coding variants. Assessment of the variants for a reproducible association with asthma in the UK Biobank study can be performed. This approach identified 8 likely (non-synonymous variants) target genes: GSDMA, GSDMB, HLA-DQA1, HLA-DQB1, IL1RL1, IL6R, TLR1, and ZPBP2 in asthma risk variants [26]. <![CDATA[A distance education experience on assessment of airway maneuvers during COVID-19 pandemic]]> M. Murat Oktay Mustafa Boğan Mustafa Sabak Hasan Gümüşboğa İbrahim Bilir Mehmet Cihat Demir Hüseyin Narcı https://imcjms.com/journal_full_text/362 2021-01-29 03:00:56 Original Article MC J Med Sci 2021; 15(1): 001 Abstract Background and objectives: The coronavirus disease 2019 (COVID-19) pandemic has necessitated the switch to distance education by abandoning face-to-face education worldwide. This study aimed to investigate whether it is possible for practical education and performance measurements through distance education. Methods: The application video and the application steps were sent to the participants through their smartphone by WhatsApp messenger. Grade 1 students in the Physiotherapy Section (Group A) and Grade 1 students in the Paramedic Section (Group B) voluntarily participated in the study. The participants were asked to apply simulation applications and record the simulation applications' video clips with their smartphones. Results: The mean age of the 123 participants was 20.11 ± 2.03 (18-33) years, and 56 (45.5%) were in Group A, and 67 (54.5%) were in Group B. While the participants in Group A were successful at a rate of 35.7% (n = 20) in the head tilt-chin lift maneuver, this rate was 65.7% (n = 44) for Group B (p = 0.001). For the jaw thrust maneuver, the success rate was 21.4% (n = 12) for Group A and 31.3% (n = 21) for Group B. Conclusion: In this study, the participants used family members as a live simulation model in our research. The participants who were given face-to-face education before were more successful on head tilt chin lift maneuver. Jaw thrust maneuver was more challenging to learn and practice by distance education. The academicians interested in medical education should keep in mind that the outcomes of the COVID-19 pandemic have permanent effects on education systems. IMC J Med Sci 2021; 15(1): 001. DOI: https://doi.org/10.3329/imcjms.v15i1.54195 *Correspondence: Mustafa Boğan, Emergency Department, Health Research and Application Hospital, Düzce University, Düzce, Turkey, Posta code: 81620.  Email: mustafabogan@hotmail.com   Introduction The coronavirus disease 2019 (COVID-19) pandemic has necessitated the switch to distance education through abandoning face-to-face education worldwide [1-2]. Distance education models have been used in medical education during the recent 30 years; distance practical education is still a problem [3-7]. On the other hand, useful and reliable methods could not be developed to evaluate distance education efficiency [7]. Basic Life Support (BLS) is among the most common practical education by using technological items [8-10]. In didactic medical education models, airway maneuvers are taught on models by an experienced instructor, in addition to theoretical educations [11]. Practical education is the main difficulty of distance education systems.In this study, we aimed to teach the airway maneuvers [the head tilt-chin lift (HTCL) maneuver and the jaw thrust (JT) maneuver] by distance education, and to evaluate by video clips which content practical application of the participants on a family member. It was also aimed at integrated simulation education to distance education in accordance with the education needs that have changed abruptly during the COVID-19 pandemic.   Methods Table-1: Global Quality score   The application steps were scored separately (Table-2 and Table-3). While evaluating the videos, each application step was scored as "1 point" if it was done correctly and "0 points" if it was not done correctly. Both applications were evaluated in 8 sub-steps. Each participant received a minimum of "0" and a maximum of "8" points from the applications. The participant who got eight full points from an application was considered successful; the participant who got < 8 points was unsuccessful. The videos were scored separately by two independent observers (two emergency medicine specialists with a minimum of 5 years of experience) using a rubric. Pearson Correlation test was used to determine rater reliability, which shows consistency between raters. Analysis results showed a high correlation between raters (r = 0.90; p < 0.05). The two groups were compared according to gender, duration of the videos, HTCL and JT score, success level of HTCL and JT.   Table-2: Head tilt chin lift assessment steps   Table-3: Jaw thrust assessment steps     Statistical Analysis The normality distribution of the data was evaluated with the Shapiro Wilk test. The Student’s t test was used for comparison of two independent normally distributed groups and the Mann Whitney U test was used for comparison of two independent non-normally distributed groups. The associations between categorical variables were analyzed with the Pearson and exact chi-square tests.Pearson Correlation test was used to determine rater reliability, which shows consistency between raters. For the descriptive statistics, the mean ± standard deviation was used for the numerical variables, and numbers and percentages were used for the categorical variables. Statistical analyses were carried out using the SPSS Windows version 24.0 package program and a p level of < 0.05 was accepted as statistically significant.   Results     Discussion Studies have reported that some methodological innovations are required for to develop the students’ knowledge and skills in distance education environments [13-17]. The studies toward developing novel education paradigms are mostly based on comparison of didactic education systems and distance education systems. Gallagher et al. determined that students who received web-based distance education demonstrated better attendance and motivation [18]. In the study of Sarıhan et al. comparing two emergency medicine resident groups who had received traditional and video-assisted education, no significant difference was found between the groups concerning pre-test and post-test scores [19]. Bernard et al. evaluated the studies investigating learning methods between 1985 and 2002 and found that distance education models achieved better learning [20]. However, some education models, which use both didactic education systems and distance education systems, are also available [21,22]. Our study compares distance education procedures (Group A) and blended education procedures (Group B). In our research, while there was no difference between the groups about the JT maneuver, Group B, the complex education group, yielded better results for the HTCL maneuver. In this regard, our study results are consistent with those of studies proposing that complex education systems that integrate didactic learning models and distance education systems positively influence learning [22,23]. One of the most critical distance education problems is feedback and testing of lesson elements [7,24]. Assessments of the performance were mostly made with traditional methods in many studies comparing e-education models and traditional education models. Our study, the participants recorded their applications on videos through cell phones, and their learning performances were evaluated through these videos. Hence, we could show that a performance assessment criterion could be developed for distance education by assessing videos recorded by the participants. It is possible to state that although simple, this is a methodological innovation type under pandemic conditions, and it is one of the unique aspects of our study. On the other hand, this was mandatory for us under pandemic conditions despite limited evidence about the effectiveness of offline video applications on e-learning [25]. However, it should be stated that the duration of the application videos recorded by the researchers and participants were shorter than the 5-7 min reported in the literature [24]. Barsuk et al. showed that the medical student group which received practical education through a simulator was more successful in airway management [30]. Birt et al. did not detect a difference between the two groups of paramedic students, one of which received a classical education for removing foreign bodies in the airway and another received distance education with telephone and plastic laryngoscopes obtained with a 3D printer [31]. In our study, which yielded practice training through live models, the finding of similar results in the two groups about the JT maneuver is consistent with the studies that have proposed that learning through e-education only is an effective way of learning [32]. The participants in both groups mostly made errors in the 6th step of the JT maneuver. This is the step that is frequently taken incorrectly by the participants, also during face-to-face training. The subject should repeat the procedure several times; besides, he/she needs to be instructed individually. Studies propose that formal assessment systems are insufficient in medical education [33]. We suggest that it is an advantageous method in hands-on training as it is possible to monitor learning, provide feedback to the student, and provide assessment data for the teacher. Studies are proposing that online lessons of the formal assessment methods are also possible [33-35]. We could not apply formal methods individually online due to the pandemic’s restricted time. We suggest that this is a factor that plays a role in the low (< 30%) success rates in both groups. Due to the restricted time, the steps that were misapplied by the participants could only be discussed with them individually online. Not asking for a second video after the application has led to a limitation concerning performance assessment. Furthermore, the satisfaction of the participants could not be evaluated. The academicians interested in medical education should keep in mind that the outcomes of the COVID-19 pandemic have permanent effects on education systems. The COVID-19 pandemic has necessitated the development of a novel education paradigm based on information technologies. The need for integration of simulation education with distance education has also emerged during this process. Although our study indicates that distance hands-on training may be practical, it is also an example of assessing this education. We consider that virtual reality applications could contribute to medical education, and further studies should be conducted on this issue. References 1.     Srinivasan DK. Medical students’ perceptions and an anatomy teacher's personal experience using an e‐learning platform for tutorials during the Covid‐19 crisis. Anat Sci Edu. 2020; 13(3): 318–319. <![CDATA[Lead poisoning prevention: A community-based participatory research program in Mississippi]]> Amal K. Mitra Charkarra Anderson-Lewis https://imcjms.com/journal_full_text/367 2021-03-24 23:55:49 Original Article IMC J Med Sci 2021; 15(1): 002 Abstract Background and objectives: Lead poisoning is a preventable environmental health hazard. Although the prevalence of lead poisoning is declining, the rates are disproportionately high in selected communities. This community-based participatory research (CBPR) program aimed to enhance people’s awareness on lead poisoning prevention through community outreach and educational interventions in Mississippi. Methods: Secondary data of 42,372 children obtained from the Mississippi State Department of Health were analyzed to identify the most affected communities in Mississippi. Community-based outreach and education activities were carried out in the most affected areas to increase population awareness on lead poisonig prevention. Results: Hands-on training was offered to 25 participants at homebuilding retail stores. Of them, 23 (92%) reported the hands-on training was very useful or useful. Among 91 home-buyers and rental home owners who attended workshops offered by the Neighborhood Association, 90% mentioned that the training was useful or very useful. An online visual training was given to 220 realtors, and 75 inspectors, contractors, and Do-It-Yourself (DIY) workers. At posttest, 59.4%, 67.9%, 65.1% of the realtors, inspectors, contractors and DIY workers (n = 295) identified soil, car batteries and paint as sources of lead in the environment, respectively. A total of 62.3%, 48.1% and 58.5%, at posttest, identified three complications - behavioral, physical and psychological, respectively. The mean posttest score was significantly higher than the pretest scores (7.47 ± 2.07 vs. 6.60 ± 1.68, p = 0.04, respectively). Conclusion: These outreach activities were successful in improving the knowledge of the community people on lead poisoning prevention. IMC J Med Sci 2021; 15(1): 002. DOI: https://doi.org/10.3329/imcjms.v15i1.54197 *Correspondence: Amal K. Mitra, Department of Epidemiology and Biostatistics, College of Health Sciences, School of Public Health, Jackson, Mississippi, USA. Email: amal.k.mitra@jsums.edu.   Introduction In 2012, the Centers for Disease Control and Prevention (CDC) had lowered the cutoff point of blood lead levels (BLLs) from 10 µg/dL to 5 µg/dL, in order to identify children as having lead exposure earlier and parents, doctors, public health officials, and communities to take action sooner [1]. The National Childhood Blood Lead Surveillance Data shows that BLLs remained low, ranging from 2.0% to 2.4% from 2012 to 2016, with a slight increase of the rate to 3.0% in 2017 in the United States [2]. However, based on the prevalence rate, approximately 535,000 of U.S. children are still suffering from lead poisoning [3]. Because of the increased risk of lead poisoning among the people who are exposed to household dust and paint as the source of the lead, living in older homes are potentially at a higher risk of lead contamination [3]. Minority children who reside in pre-1978 housing are at greatest risk for exposure, because older housing may contain paint with higher lead content [3]. According to the U.S. Department of Housing and Urban Development (HUD), there are approximately 3.8 million houses or buildings that have children living in them who are potentially being exposed to lead [4]. Nearly half a million U.S. children ages 1 to 5 have BLLs at or above 5 µg/dL, at which the CDC recommends public health actions be taken [5]. Exposure to lead is associated with toxicity that affects almost every organ system of the human body [6]. Long-term exposure to lead can seriously harm a child’s health and cause well-documented adverse effects including neurological damage [7], retarded growth and development [8], learning and behavioral abnormalities [9,10], hearing and speech problems [10,11], deficits in cognitive function [12], sleep deficits [13], attention deficiencies, and underperformance in school [13]. Some of the symptoms of lead poisoning, such as cognitive deficits, attention deficiencies, behavioral abnormalities, learning difficulties, and speech-language pathologies mimic autism spectrum disorders (ASD), which can create diagnostic challenges and management difficulties of such children [10]. The proposed Healthy People 2030 objectives [14] established the nation’s strategy for improving the health and well-being of all citizens, and emphasized to reduce blood lead level in children aged 1–5 years. Because of having no safe level of lead, CDC recommends an urgent need of preventing childhood exposures to lead [5]. Culturally appropriate community based programs are needed for the primary prevention of lead poisoning in “high-risk” communities [15]. To provide a comprehensive effort to educating community people on childhood exposure to lead and lead prevention, we developed a Community-Based Participatory Research (CBPR) program called Community Lead Awareness Partnership (CLAP) for Healthy Kids in Mississippi. The aims of the program were two-fold: (1) Conduct outreach activities for childhood lead poisoning prevention in “high-risk” areas in Mississippi; and (2) Evaluate effectiveness of a comprehensive lead education and training program in awareness building and practices of the people on lead prevention.   Materials and methods Selection of the study population: In order to focus our efforts in the area with the greatest need, we analyzed 42,372 records of children aged < 5 years in Mississippi. The data were obtained from the Mississippi State Department of Health’s Lead Poisoning Prevention and Healthy Homes Program (LPPHHP). Nine out of 82 counties in Mississippi reported 12% or more of the children tested having high BLL. Those nine “high risk” counties, in order of the highest to the lowest levels of BLL included: Forrest, Oktibbeha, Covington, Coahoma, Greene, Grenada, Pike, Jones, and Yazoo County. The City of Hattiesburg, Mississippi is the largest city in Forrest County which was found to have the highest proportion (ranging from 20% to 27%) of children with high BLL. Therefore, our study was undertaken in the Forrest County. The CLAP for Healthy Kids project activities targeted the population living in the areas of low-income residences of Forrest County. Fig. 1 shows a map of the census tracts within the City of Hattiesburg and the percentage of low-income residents within those areas. Our project concentrated its activities in those areas with the percentage of low-income residents being 55% or greater.   Fig.1: Distribution of low income areas in the City of Hattiesburg, Mississippi   Selection of community partners: The CLAP for Healthy Kids Project developed partnership with a number of community organizations and stakeholders in Mississippi. From the very beginning of the study, the community partners were involved in the concept building of the research, in identifiying the community needs, and in developing strategies for the project. The partners included Mississippi State Department of Health, the National Paint and Coatings Association, a local Community Housing Development Organization, Hattiesburg City Government, the Head Start Program, community and faith-based organizations, public schools, kindergartens, home buyers, local contractors and realtors. Representatives from all the partners participated in a Community Advisory Board (CAD). CADs met quarterly to discuss the study activities, the study progress and any problems encountered. CADs also served as an external body to evaluate the project, and at the same time to serve as the liaison between the researchers and the community so that the community needs are reflected effectively in the study protocol.   Ethical procedures: The study was approved by the Institutional Review Board (IRB) of The University of Southern Mississippi, Hattiesburg, Mississippi. The study was conducted according to the guidelines of the Declaration of Helsinki. Informed consent was obtained from all subjects before they were enrolled in the study. In addition, written approval was obtained from the school authorities for the educational classes offered in schools.   Project goals, activities, and measurable outcomes: The primary goals of the research included: 1) Encourage health promotion by conducting community-based outreach (such as health fairs, distribution of educational materials, and public appearances) concerning childhood lead poisoning prevention; and 2) Encourage health promotion by conducting community-based educational andtraining activities (such as seminars, workshops, and classroom or online training) on childhood lead poisoning prevention. The project activities, the specific project outputs, and the measureable outcomes for each activity are narrated in Table-1.   Results Population at-risk of lead poisoning: secondary data Racial difference: Among the 42,372 children who had BLL measured, African-Americans outnumbered the whites (84% vs. 16%, respectively, p < 0.001). The proportion of African-Americans with elevated levels of blood lead was also higher than that of whites (5.6% vs. 3.1%, p < 0.001). According to the 2000 census, African-Americans comprise 47% of the Hattiesburg population.   Table-1: Project goals, activities, and measureable outcomes   Table-2: Outcome of outreach and training activities offered by the CLAP for Healthy Kids program   Relation between BLL and pre-1978 housing: The 2000 census data was used to calculate the percent of pre-1978 housing units in each county in the state. There was a statistically significant correlation between BLL and percent of housing units > 50 years old, although the correlation was very weak (r = 0.10, p < 0.001). In Hattiesburg, Mississippi, 60% of residential structures were built prior to 1978. Members of racial minority groups reside in the majority of these pre-1978 housing structures. Relation between BLL and income: Again, the 2000 census data at the county level has indicated that the median household income was inversely but weakly correlated with BLL (r = -0.12, p < 0.001). Similarly, BLL was inversely correlated with the median rent (r = -0.086, p < 0.001) and median value of the house (r = -0.091, p < 0.001), meaning the poor were at higher risk of lead poisoning. On average, 26% of Mississippi children live below the national poverty level.   Training activities and outcomes A list of the target population, a summary of the training activities and training materials used, and the outcomes are presented in Table-2. The assessment instruments were: (1) Exit survey for participants for hands-on training at home builder retail stores—10 questions on a scale from 0 to 10; (2) Follow-up survey for HUD’s Online Training for Realtors—6 questions on a scale from 0 to 10; (3) Pre- and posttest of training of home buyers—5 questions; and (4) HUD Curriculum for Inspectors, Contractors, DIY Workers—8 questions.   Impact of online visual training Environment Protection Agency/U.S. Department of Housing and Urban Development (EPA/HUD)’s online visual training [18] was given to 220 realtors, and 75 inspectors, contractors, and Do-It-Yourself (DIY) workers. Fig. 2 shows that at posttest, 59.4%, 67.9%, 65.1% of the realtors, inspectors, contractors and DIY workers (n = 295) identified soil, car batteries and paint as sources of lead in the environment, respectively. Nearly 70% identified lead as a poison in the environment while 77.5% and 47.2% of those surveyed demonstrated two behaviors (such as wash hands frequently and clean dusty areas), which will help prevent lead poisoning. A total of 62.3%, 48.1% and 58.5%, at posttest, identified three complications - behavioral, physical and psychological, respectively. The mean posttest score was significantly higher than the pretest scores (7.47 ± 2.07 vs. 6.60 ± 1.68, p = 0.04, respectively).   Fig.2: Sources and complications of lead, as idenfied correctly by workers after an online training   All the participants on HUD online training participated at a 2-month follow-up survey. They reported that they actually implemented what they had learned during the training on HUD curriculum on lead poisoning prevention. The outcome measurements of home-buyer workshops were not significantly different from those of the online training.   Discussion Based on the secondary data analysis, this study identified a few areas in Mississippi where 20% to 27% of children from low-income (Medicaid eligible) families were found with increased BLLs. The CDC guidelines define an area in the United States as being at high-risk if 12% or more of the children tested are found with high BLLs [19]. Based on the guideline of the CDC [19], the observed BLLs in children in certain areas of Mississippi put them and the areas they reside at “high-risk”. When the Mississippi data are compared with another large cross-sectional study conducted in Bangladesh by Mitra and colleagues [20], the situation of Bangladesh was much worse. Several areas in Dhaka and its neighborhood, especially school-children from Tongi industrial area (99% with high BLLs) and from Tannery industrial area in Zigatola, Dhaka (91% with high BLLs) were identified having alarmingly high risk of lead poisoning in Bangladesh. Although the risk of lead poisoning in the United States is mainly from sources such as lead-based paint and dust [3], multiple potential sources of lead poisoning in Bangladesh were identified, including environmental contamination due to industries, discharges from brick kiln factories, hazardous waste dumping in open garbage disposal places in the city, environmental contamination by discharges from tannery industries, air pollution from car repair shops, the use of lead-based paints in potteries and houses, and the use lead-containing indigenous (kabiraji and homeopathic) medicinal treatments [20]. Another recent study reported a dangerously high level of lead in turmeric which was adulterated with lead based paint (which is yellow) to make them more attractive before they are sold in retail markets in Bangladesh [21]. Immediate steps are needed to regulate and stop human-made lead contaminations of the environment and adulteration of food in Bangladesh and other developing countries. The CBPR project, CLAP for Healthy Kids, achieved its goal in improving people’s awareness and practices in lead prevention in Mississippi through a comprehensive approach of outreach and training activities. A total of 1,588 participants were involved in the outreach and training activities through the project including health fairs, community events, kindergarten school-based training, HUD’s online free Lead-Based Paint Visual Assessment Training [18], hands-on training, workshops, and public presentations. EPA’s Renovation, Repair, and Painting (RRP) Rule requires that firms performing renovation, repair, and painting projects use certified renovators who are trained by EPA-approved training providers and follow lead-safe work practices [22]. The training programs of this project were, therefore, in alignment with the EPA/HUDS’s objective of encouraging sustainable infrastructure development programs for the prevention of childhood lead poisoning. Although the outreach programs and trainings were attended by a large number of people, the number of participants at home-building retail stores was not satisfactory. This is a lesson learned that the training programs offered through retail stores such as Lowe’s and Home Depot may not be suitable because of people’s busy schedules and limited time in spending for hands-on training during shopping. One of the most successful of all programs was the EPA/HUD’s online free Lead-Based Paint Visual Assessment Training [18]. The reason of success of this program was probably because people had flexibility of scheduling their time for the online training. It is noteworthy that the outcome measurements of home-buyer face-to-face workshops were not significantly different from those of the online training. One of the strengths of this study was the community engagement from the beginning of the study in the planning, goal setting, project activities, and project evaluation. The project activities were boost up by the proclamation of the Honorable Mayor of The City of Hattiesburg. CBPR and engagement of the community people have been emphasized in many studies for the success of a community-based program [23]. The project also helped in the sustainability of the lead prevention program in the City by providing training of the home inspectors, DIY workers, realtors, home buyers, and the general people. Similar success stories of educational programs were reported from another community-participatory research in Philadelphia involving 1200 children and 900 adults [24]. In the later study, community-developed strategies were created for this project with resident leaders from the community and grassroots agencies serving the community. The grassroots agencies included the Philadelphia Housing Authority Tenant Councils for Norris Homes and Apartments and Fairhill Apartments; the Village of the Arts and Humanities, an organization devoted to introducing the arts and humanities to all socioeconomic groups; the Philadelphia Parent Child Center; the Neighborhood Action Bureau, an economic development corporation; and the Salvation Army. Another community-based Tribal Efforts Against Lead (TEAL) project used a lay health advisor model to build capacity in a Native American community to reduce lead exposure in a mining area in northeastern Oklahoma [25]. In the TEAL project, approximately 40 tribal members were recruited from area tribes and trained on lead poisoning and its prevention. For a 2-year period, they educated members of their social networks and worked to implement change in their community to reduce exposure to lead. One of the limitations of the present study was that it focused on health education only. Although several studies have shown successes in improving education of the people, education alone has a limited effectiveness in alleviating the burden of lead poisoning, especially if it is not combined with resources to actually correct lead-based paint hazards in housing or take remedial measures for other sources of lead poisoning. Studies that evaluated the effectiveness of parents’ education alone have failed to show significant reductions in childhood BLLs [26]. Studies are needed to focus on reducing the sources of childhood lead exposures rather than identifying children who have already been unduly exposed or attempting to ameliorate the toxic effects of lead exposure.   Conclusion This CBPR was successful in improving people’s knowledge in identifying sources of lead, complications, and prevention of lead. The involvement of kindergarten students in learning about lead and its prevention using Sesame Street Lead Away videos [16] was exemplary, and easy-to-adopt in other programs. Free online HUD visual lead training programs [18] can be adopted in lead abatement programs in Bangladesh. Countries like Bangladesh should adopt policies following the CDC guidelines for mandatory lead screening of all children under 6 years of age before they are entered to the school. More innovative methods of interventions are needed addressing the needs of high-risk populations and local communities for alleviating the risk of lead poisoning in the community.   Acknowledgments: The authors are indebted to Joel Downey, a Home Specialist and a certified home owner instructor for Housing Alternatives in Hattiesburg, Inc. (HAH) for his contribution in identifying community partners, and in providing support in outreach activities of the project.   Funding: This research was funded by the National community-based lead outreach and training grant, Environmental Protection Agency, Award No. EPA-OPPT-08-003.   Conflicts of interest: The authors declare no conflict of interest. References 1.     Centers for Disease Control and Prevention. Blood lead levels in children. Available online: https://www.cdc.gov/nceh/lead/docs/lead-levels-in-children-fact-sheet-508.pdf (accessed on January 1, 2021). 2.     Centers for Disease Control and Prevention. CDC national childhood blood lead surveillance data. Available online: https://www.cdc.gov/nceh/lead/data/national.htm (accessed on January 1, 2021). 3.     Agency for Toxic Substances & Disease Registry. Lead toxicity. Who is at risk of lead exposure? Available online: https://www.atsdr.cdc.gov/csem/csem.asp?csem=34&po=7 (accessed on January 1, 2021). 4.     U.S. Department of Housing and Urban Development. American healthy homes survey—lead and arsenic findings. Available online: https://www.hud.gov/sites/documents/AHHS_REPORT.PDF (accessed on 22 December 2020). 5.     Centers for Disease Control and Prevention. Preventing lead poisoning in young children; CDC: Atlanta, GA, USA, 2005. Available online: www.cdc.gov/nceh/lead/publications/PrevLeadPoisoning.pdf (accessed on 12 December 2020). 6.     Agency for Toxic Substances & Disease Registry. Toxicological profile for lead. Available online: https://www.atsdr.cdc.gov/ToxProfiles/tp.asp?id=96&tid=22 (accessed on 22 December 2020). 7.     Greig J, Thurtle N, Cooney L, Ariti C, Ahmed AO, Ashagre T, Meredith C. Association of blood lead level with neurological features in 972 children affected by an acute severe lead poisoning outbreak in Zamfara State, Northern Nigeria. PLoS ONE. 2014; 9: e93716. 8.     Kuang W, Chen Z, Shi K, Sun H, Li H, Huang L, Bi J. Adverse health effects of lead exposure on physical growth, erythrocyte parameters and school performances for school-aged children in eastern China. Environ In. 2020; 145: 106130. 9.     Geier DA, Kern JK, Geier MR. Blood lead levels and learning disabilities: A cross-sectional study of the 2003–2004 National Health and Nutrition Examination Survey (NHANES). Int J Environ Res Public Health. 2017; 14: 1202. 10.  Hauptman M, Stierman B, Woolfe AD. Children with autism spectrum disorder and lead poisoning: diagnostic challenges and management complexities. Clin Pediatr. 2019; 58: 605–612. 11.  Zimmerman E, Borkowski C, Clark S, Brown P. Educating speech-language pathologists working in early intervention on environmental health. BMC Med Educ. 2018; 18: 155. 12.  Santa Maria MP, Hill BD, Kline J. Lead (Pb) neurotoxicology and cognition. Appl Neuropsychol Child. 2019; 8: 272–293. 13.  Mitra AK, Haque A, Islam M, Bashar S. Lead poisoning: an alarming public health problem in Bangladesh. Int J Environ Res Public Health. 2009; 6: 84–95. 14.  U.S. Department of Health and Human Services. Office of disease prevention and health promotion. Healthy people 2030. Available online: https://health.gov/healthypeople (accessed on 13 December 2020). 15.  Mitra AK, Anderson-Lewis C. Community engagement and outreach programs for lead prevention in Mississippi. Int J Environ Res Public Health. 2021; 18: 202. 16.  Prudential Foundation. Sesame street lead away video. Available online: https://video.search.yahoo.com/yhs/search? fr=yhs-avast-securebrowser&hsimp=yhs-securebrowser&hspart=avast&p=Sesame+Street+Lead+Away+Video#id=1&vid=fa96193dfd221faac764df6ffb47eda2&action=click (accessed on 13 December 2020). 17.  University of Connecticut; Cooperative Extension System; College of Agriculture and Natural Resources. A teacher’s guide to how mother bear taught the children about lead. Available online: https://kids.niehs.nih.gov/assets/docs/teachers_guide_508.pdf#:~:text=How%20Mother%20Bear%20Taught%20the%20Children%20about%20Lead%3A,individually%2C%20in%20small%20groups%2C%20or%20as%20a%20class (accessed on 13 December 2020). 18.  U.S. Department of Housing and Urban Development (HUD). Lead based paint visual assessment training course. Available online: https://apps.hud.gov/offices/lead/training/visualassessment/h00101.htm (accessed on 10 December 2020). 19.  Screening for elevated blood lead levels. American Academy of Pediatrics Committee on Environmental Health. Pediatrics. 1998; 101(6): 1072–1078. 20.  Mitra AK, Ahua E, Saha P. Prevalence and risk factors for lead poisoning among young children in Bangladesh. J Health Pop Nutr. 2012; 30(4): 404–409. 21.  Forsyth JE, Nurun Nahar S, Islam SS, Baker M, Yeasmin D, Islam MS, et al. Turmeric means “yellow” in Bengali: lead chromate pigments added to turmeric threaten public health across Bangladesh. Environ Res. 2019; 179 (Part A). 22.  Environment Protection Agency. Lead Outreach, Partnerships and Grants. Lead Renovation, Repair and Painting (RRP) Rule. Available online: https://archive.epa.gov/epa/lead/lead-outreach-partnerships-and-grants.html (accessed on 13 December 2020). 23.  Lasker RD, Weiss ES. Broadening participation in community problem solving: A multidisciplinary model to support collaborative practice and research. J Urban Health 2003; 80: 14–60. 24.  Rothman NL, Lourie RJ, Gaughan J. Lead awareness: North Philly style grant team. Am J Public Health. 2002; 92:739–741. 25.  Kegler MC, Malcoe LH, Lynch R, Whitecrow-Ollis S. A community-based intervention to reduce lead exposure among Native American children. Environ. Epidem Toxicol. 2000; 2: 121–132. 26.  American Academy of Pediatrics. Prevention of childhood lead toxicity. Pediatrics. 2016; 138: e20161493. <![CDATA[Management of intra-operative tracheal injuries during transhiatal esophagectomy]]> Farooq Ahmad Ganie Ghulam Nabi Lone Syed Mohsin Manzoor Hakeem Zubair Ashraf Nadeem-ul Nazir Kawoosa Rouf Gul https://imcjms.com/journal_full_text/368 2021-04-01 02:20:23 Original Article IMC J Med Sci 2021; 15(1): 003 Background and objective: In transhiatal esophagectomy, iatrogenic injuries to trachea are very uncommon but when it happens it is potentially lethal and has high morbidity. This study aimed to investigate the incidence and outcome of tracheal injuries during transhiatal esophagectomy. Methods: The medical records of 608 patients who underwent transhiatal esophagectomy for esophageal cancer from January 2000 to January 2019 were analyzed. Results: Out of 608 transhiatal esophagectomy, four (0.66%) patients sustained injuries to major airway. Three injuries occurred during transhiatal and one injury during transcervical part of dissection. All the injuries occurred in trachea proximal to carina. All four injuries were closed primarily, re-enforced by muscle and fascial pledgets. Conclusion: Tracheobronchial injury is a rare complication of transhiatal esophagectomy, mostly seen in patients who receive neo-adjuvant therapy or have locally advanced growth with dense adhesions. Its immediate recognition and closure decreases the mortality and morbidity associated with this rare but fatal intra-operative complication. It can be managed effectively by primary closure, with or without muscle and fascial pledget reinforcement. IMC J Med Sci 2021; 15(1): 003.  OPEN ACCESS. DOI: https://doi.org/10.3329/imcjms.v15i1.54198 *Correspondence: Farooq Ahmad Gganie, Department of Cardiovascular and Thoracic Surgery, Sheri-I-Kashmir Institute of Medical Sciences (SKIMS), Soura, Srinagar, Kashmir, India. Email ID: farooq.ganie@ymail.com   Introduction The squamous cell cancer of esophagus is common in Asian countries of esophageal cancer belt, stretching from eastern Turkey to northern China and India. It is relatively uncommon in United States, Canada and Europe where adenocarcinoma of the lower esophagus and cardia predominate [1]. The predominant risk factors for squamous cell carcinoma are smoking and alcohol consumption and for adenocarcinoma it is gastro-esophageal reflux and Barrett’s esophagus [2]. The most common surgical procedure performed for esophageal cancers is transhiatal esophagectomy. Other options are Ivor-Lewis, McKeown procedure and pharyngo-laryngo-esophagectomy (PLE) for hypopharyngeal and upper cervical esophageal lesions. The rationale for transhiatal esophagectomy is to avoid thoracotomy and its complications. Fashioning of cervical anastomosis is to minimize clinical consequences of anastomotic leak. The common complications include anastomotic leak/stricture, recurrent laryngeal nerve injury, bleeding, and chyle leak. There is a risk of injury to azygous vein, trachea and cardiac instability. Injury to major airway is a rare but potentially fatal complication of transhiatal esophagectomy that needs prompt recognition, isolation and repair [3]. This study aimed to investigate the incidence and outcome of tracheal injuries during transhiatal esophagectomy.   Materials and methods       The tracheal rent was sutured with interrupted polypropylene (4.0) suture using long instruments from distal to proximal. The sutures were buttressed with muscle and fascial pledgets. Care was taken not to puncture the endotracheal tube. At the end of tracheal repair the endotracheal tube was withdrawn to ensure there was no inadvertent suturing of the airway tube. The gastric tube was advanced into the neck, anastomosed to esophageal stump and the procedure completed. Trans-thoracic approach was used in patients with longer tear (> 5 cm) in the trachea. Right postero-lateral thoracotomy through 5th intercostals space was performed. The trachea was dissected from surrounding structures and the tear was sutured with interrupted (40) polypropylene sutures and then the gastric tube was advanced to neck for anastomosis with the proximal esophageal stump. Thoracotomy was closed after placing one intercostal tube drain (32 F) in the pleural cavity.   Out of 608 transhiatal esophagectomies, four patients (0.66%) sustained injuries to major airway. Three injuries occurred during transhiatal and one injury during transcervical part of dissection. All the injuries occurred in trachea proximal to carina. All four injuries were closed primarily, re-enforced by muscle and fascial pledgets. In two patients the trachea was repaired through right thoracotomy and in two patients by the cervical incision that was utilized for mobilization of esophagus in the neck and provided adequate exposure for repair of the trachea. Two patients who sustained intra-operative airway injury received pre-operative chemo-radiation for advanced growth. Discussion In patients with carcinoma esophagus having dense peri-esophageal adhesions after neo-adjuvant chemo-radiation and difficult transhiatal esophageal dissection due to adherent growth, threshold for conversion to trans-thoracic approach (and sharp dissection under vision) should be low. Injury during trans-cervical part of esophageal dissection can be managed through the same incision and injuries as low as carina can be successfully managed without any additional morbidity. The crux of uncomplicated repair of tracheal injuries in transhiatal esophagectomy is immediate recognition, proper exposure, interrupted suture technique, suture reinforcement and proper post-operative care.   1.     Samarasam I. Esophageal cancer in India: current status and future perspectives. Int J Adv Med Health Res. 2017; 4: 5–10.3.     Harney TJ, Condon ET, Lowe D, McAnena OJ. A novel technique for repair of iatrogenic tracheal tear complicating three stage oesophagectomy. Ir J Med Sci. 2009; 178(3): 337–338. 4.     LA Gorenstein, JG Abel and GA Patterson. Pericardial repair of a tracheal laceration during transhiatal esophagectomy. Ann Thorac Surg. 1992; 54(4): 784–786. 5.     Foroulis CN, Simeoforidou M, Michaloudis D, Hatzitheofilou K. Pericardial patch repair of an extensive longitudinal iatrogenic rupture of the intrathoracic membranous trachea. Interact Cardiovasc Thorac Surg. 2003; 2(4): 595–597. 6.     Gupta V, Gupta R, Thingnam SKS, Singh RS, Gupta AK, Kuthe S, et al.Major airway injury during esophagectomy: experience at a tertiary care center. J Gastrointest Surg. 2009; 13: 438–441. 7.     Hulscher JB, Hofstede E, Kloek J, Obertop H, de Haan P, van Lanschot JJB. Injury to the major airways during subtotal esophagectomy: incidence, management, and sequelae. J Thorac Cardiovasc Surg. 2000; 120: 1093–1096. 8.     Nunez JAF, Merino MCU, Escudero JA, Landeira JMV. Tracheal injury during transhiatal esophagectomy without thoracotomy: anesthesiologic management. Rev Esp Anestesiol Reanim. 1990; 37: 32–36. <![CDATA[Analysis of the contents of consultations requested by the emergency department]]> Mustafa Boğan Hasan Sultanoğlu Mehmet Cihat Demir Mehmet Karadağ Hasan Baki Altınsoy https://imcjms.com/journal_full_text/363 2021-01-29 04:01:49 Original Article IMC J Med Sci 2021; 15(1): 004 Abstract Background and objectives: Every year several thousand patients attend the hospital emergency department (ED). The aim of the present study was to evaluate the content of the consultations requested from the emergency department. Methods: The patients who had presented to the adult emergency department between January 1, 2020 and January 31, 2020, and who had undergone consultation by at least one clinic were included in the study. Age, gender, the number of consultation required at the same admission, the clinic from which the consultation sought, time required to respond to the request and the outcomes of the consultations were analyzed. Results: The total number of emergency department presentations was 8930 patients and at least one consultation had been requested for 6.64% (n = 593) patients. The mean duration of answering the consultation was 85.76 ± 90.33 minutes. Consultations were requested from the cardiology most frequently (n = 188, 19%), followed by the pulmonology department (n = 181, 18.3%). Discharge was recommended with prescription in 235 (39.6%) consultations. Internal medicine was the clinic, which recommended treatment at the emergency room most frequently (n = 45, 22.4%) and the most commonly recommended treatment was erythrocyte suspension replacement (n = 7). The clinic that demanded additional tests most commonly was determined to be the pulmonology department (n = 41, 22.9%) and arterial blood gases analysis was the most commonly demanded test (n = 16). Conclusion: In our study, the rate of consultations requested was seen to be lower and the rate of cases that required hospitalization was seen to be higher. The duration of answering consultations was found to be longer than desired and institutional protocols should be developed for shortening this duration. IMC J Med Sci 2021; 15(1): 004.  OPEN ACCESS. DOI: https://doi.org/10.3329/imcjms.v15i1.54196 *Correspondence: Mustafa Boğan, Emergency Department, Health Research and Application Hospital, Düzce University, Düzce, Turkey, Posta code: 81620.  Email: mustafabogan@hotmail.com   Background Every year, there are millions of admissions in the emergency departments of our country. A multi-disciplinary approach is required for the care of some patients. In such a case, consultation is requested from other departments. Although the regulations specify the rules of requesting consultations failures are sometimes experienced [1]. The problems during the consultation process reduce the patients’ satisfaction and also prolong the length of stay in the emergency department [2]. According to our observations, many clinics request additional tests, treatments and consultations from other clinics for patients for whom consultation is requested from the emergency department and requires a re-consultation when the test results are completed. The aim of the present study was to evaluate the content of the consultations requested from the emergency department (ED).   Methods The ethics committee approval was obtained from Düzce University prior to the study (date: 02.03.2020, decision number: 2020/25). The ED, where the study was conducted, is a part of Düzce University hospital. Therefore, intern, resident, specialist and academic staff of medical school also work at the ED. Between February 1, 2019 and January 31, 2020, a total of 56236 patients were admitted in our ED. During this time, at least one consultation was requested for 8539 (annually 15.18%) patients. The patients who had presented to the ED between January 1, 2020 and January 31, 2020, and who had undergone consultation by at least one clinic were included in the study. Age, gender, the number and name of the clinics the consultations was requested from, and the outcomes of the consultations were recorded. The consultations requested from obstetrics clinic for pregnancy follow-up were excluded. The consultations which were not ended by related clinic because of an emergency status (such as emergency operation, percutaneous coronary intervention) were excluded from the study.   Process of the consultation at the ED - The patients were examined by an emergency doctor (intern, resident) at first admission. - The findings and patients were re-evaluated by responsible specialist or assistant professor (doctor). - If any test (laboratory, radiological, etc) requested, the results were obtained in 1-3 hours. - After results obtained, if it was needed, a consultation was requested from other clinics. - A digital consultation form was created at hospital information system and related clinics were alerted by a phone call. - The respective clinic requested for consultations were required to answer in 30 minutes according to in hospital procedures. - The treatment of patients was administered according to result of consultation and decision of responsible physician of ED.   The consultation of the respective clinic was analyzed based on the following criteria: - The duration of completing the consultation (the time between creating a digital consultation form and accomplishment of the consultation). - Recommendation for an additional test at the emergency department. - Recommendation for an additional treatment at the emergency department. - Recommendation for an additional consultation from another clinic. - Recommendation for re-consultation following the demanded procedures. - Outcome of the patients. Outcomes were categorized into three groups such as (a) needed hospitalization (hospitalization at the clinic, exitus in ED, recommendation for follow-up at intensive care unit), (b) discharged (discharge after treatment at emergency room, recommendation for outpatient clinic admission after prescription) and (c) others (such as treatment rejection, leave without permission of doctors). The consultations were analyzed for the content detailed above and the obtained data were evaluated. Statistical method: For the descriptive statistics, the mean ± standard deviation, median, first quartile (Q1) and the third quartile (Q3), minimum and the maximum values were given for numerical variables, and numbers and percentages were given for the categorical variables. The Kruskal-Wallis test was used for comparison of the durations of the departments from which consultation was requested. Statistical analyses were carried out using the SPSS Windows version 23.0 package program and a p level of <0.05 was accepted as statistically significant.   Results The total number of emergency department presentations was 8930 patients and at least one consultation had been requested for 6.64% (n = 593) patients. The mean age of these patients was 60.05 ± 21.37 years and 328 (55.3%) were males. A total of 987 consultations were requested for these patients and 389 (65.6%) patients had been consulted by a single clinic. Most of the patients (n = 330, 55.6%) needed hospitalization (Table-1). Table-1: Descriptive data of the patients     Consultations were requested most frequently from cardiology department (n = 188, 19%), followed by the pulmonology department (n = 181, 18.3%). Additional treatment and tests were recommended for 201 (20.4%) and 179 (18.1%) cases respectively at the emergency department. A total of 242 (24.5%) consultations were requested from another department and there were 146 (14.8%) request/demand for re-consultation by the clinicians following the planned procedure (Table-2). The mean duration of answering the consultation was 85.76 ± 90.33 minutes. The department of cardio-vascular surgery (CVS) needed the maximum time (581.67 min) to answer/respond the consultation request. When the procedures carried out for the patients were analyzed, a total of 3 patients were determined to have been consulted by the CVS clinic, and of these, one had undergone an urgent operation, and another was hospitalized at the 77th min of consultation. Hence, it was found that consultation was completed after the urgent procedures had been accomplished and thereby, the duration of answering the question seemed prolonged (Table-3). Table-2: Descriptive data of consultations     Internal medicine was the clinic, which recommended additional treatment at the emergency room most frequently (n = 45, 22.4%) and the most commonly recommended treatment was erythrocyte suspension replacement (n = 7). The clinic that demanded additional tests most commonly was the Pulmonology department (n = 41, 22.9%) and arterial blood gases analysis was the most commonly demanded test (n = 16). Internal medicine was found to recommend highest additional consultation from another clinic (n = 54, 22.3%) and pulmonology was the clinic that was most commonly recommended (n = 14). Pulmonology was the clinic that demanded re-consultation most frequently (n = 30, 20.5%). Table-4 shows the details of the contents of the consultations by different departments. Table-4: Contents of the consultations answered by the clinics   Some of the patients who present to the emergency department may need to be evaluated by different clinics. In such situations, the process of the consultations has an important role in the operation of the emergency room. In the one-month analysis in our study, 6.64% of the patients were seen to have undergone consultation by at least one clinic. This rate reaches 10.89% when pregnant women undergoing consultation by the obstetrics clinic are also included (also annually 15.18%). Dönmez et al. determined that 21.6% of the patients presenting to the emergency room had undergone consultation by other clinics [3]. In the analysis of emergency room presentations during 2 months by Aygencel et al., 30% of the patients were determined to have undergone consultations by at least one clinic [4]. In a review by Lee et al., the rate of consultations from the emergency room to the other clinics was 20-40% [5]. In our study, the rate of consultations was lower because our center is located in a small city that has approximately 300,000 populations and there are three hospitals (this center, a state hospital, and a special hospital) around. Our center is tertiary educational hospital and all patients were discussed by ED doctors that included emergency resident, emergency specialist and lecturers before consultations. This might have contributed to reduce the rate of consultations. However, this might be associated with legal risks. In the present study, the mean duration of answering consultations was 85.7 ± 90.3 minutes. The longest duration belonged to the CVS clinic (581.67 min); however, when the files of the patients consulted by the CVS clinic were analyzed, the patients who had undergone consultation whose final reports had not been written for a long time were determined to have undergone urgent operations or transferred to the intensive care unit hours before. The clinics from which the consultations had been requested most by the emergency department were seen to have an answering time longer than the mean; this duration was 84.08 min for the cardiology and 88.71 min for the pulmonology clinics. Karakaya et al. reported the mean duration of answering consultations as 22.33 ± 25.04 min [2]. Dönmez et al. reported the nephrology clinic required the longest time (mean 306 ± 393 min) to respond to request for consultation while it was 212 ± 182 min for the pulmonology clinic and 186 ± 152 min for the cardiology clinic [3]. A prolonged time of answering consultations means prolonged stay in emergency room and thereby increased mortality and morbidity [7,8] . In our country, the legal time for answering emergency room consultations has been specified as 30 minutes [1]. We consider that the reasons for the long consultation time are the additional tests, the hierarchical patient counseling habit and requesting more than one consultation during the same period, particularly at busy hours. Physical conditions of the hospital building can have effect on the consultation time. Other departments are located far away from the ED in our center (approximately 20 minutes by walking). We think the hierarchical patient counseling habit and long distance to ED are some of causes of long consultation time. This may be solved by some innovative approach such as telemedicine and use of small vehicles to travel the distance fast. In our study, we found that 55.6% cases required hospitalization. Almost similar rate (49%) of hospitalization was reported by others [4,6]. This comparatively higher rate of hospitalization in our center could be due to the fact that many patients with serious ailments prefer to come to our center as ours is a tertiary care hospital that perform many specialized procedures. The rate of consultations requested was seen to be lower and the rate of cases that required hospitalization was seen to be higher in our study. The duration of answering consultations was seen to be longer than desired. The hierarchical patient counseling habit, long distance of ED from other clinics, and being a tertiary hospital are the reasons of this condition. These problems could be solved by telemedicine and right hospital consultation policy.   Declaration of conflicting interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.   Funding: The authors received no financial support for the research, authorship, and/or publication of this article.   Ethical approval: Ethics committee approval was obtained from Düzce University.   Human rights: Authors declare that human rights were respected according to the Declaration of Helsinki. References 2.     Karakaya Z, Gökel Y, Açıkalın A, Karakaya O. Evaluation of the process and effectiveness of consultation system in the Department of Emergency Medicine. Turkish Journal of Trauma & Emergency Surgery. 2009; 15(3), 210-216. <![CDATA[Prevalence of morbidity and mortality of diabetes mellitus in a rural community cohort]]> M Abu Sayeed Parvin Akter Khanam Akhter Banu Khandaker Abul Ahsan Fazlul Haq https://imcjms.com/journal_full_text/369 2021-04-27 00:32:35 Original Article IMC J Med Sci 2021; 15(1): 005 Abstract Background and objectives: The developing countries are facing the double burden of the communicable (CD) and non-communicable (NCD) diseases. The initiation of primary health care (PHC) adopted in the past century, which included sanitation and immunization, remarkably reduced the load of CDs in the least developing nations. The burden of NCDs remained the same or showed an increasing trend. Of the NCDs, diabetes has become a serious threat to human health and the related morbidity and mortalities are affecting the younger people. As a consequence, the disease complications render huge number of people to disabilities and unusual enormous health expenditures. Very few studies addressed the prevalence of complications among the diabetes patients in a rural community. This study aimed to determine the prevalence of sequels (morbidity and mortality) among the diabetic cases eight years after the initial diagnosis of diabetes in a rural community cohort Subjects and Methods: A rural community survey in 10 villages was conducted in 1993. The survey screened 1319 (797 men, 522 women) for diabetes mellitus (DM) and impaired glucose tolerance (IGT). Those who were diagnosed DM and IGT referred to a referral center (BIRDEM) for registration. A retrospective cohort was designed in 2001. The addresses of the patients were retrieved from the BIRDEM registry. These registered patients, both survivors and non-survivors, were traced in ten villages. The survivors were investigated (anthropometry, glycemia, fundoscopy, urine protein etc.). A verbal autopsy was performed to determine the cause(s) of death in the non-survivors. Results: Of the188 registered cases, 79 were found and located (survivors 43 (54.4%, non-survivors 36 (45.6%). Of the survivors, 44.2% developed complications. The observed complications were sensory neuropathy 16.3%, CAD 9.3%, retinopathy 7% and nephropathy 4.7%. Among the non-survivors, 19.4% were found to have nephropathy leading to end-stage renal disease. Conclusions: The study cohort revealed that more than one-third of the people with diabetes died in less than ten years after being diagnosed. The cohort also revealed that diabetic nephropathy (end-stage renal disease) and dearth of dialysis facilities contributed to early death in the rural community. Among the complications, most frequent incidence was neuropathy and neuro-psychiatric disorders. IMC J Med Sci 2021; 15(1): 005. DOI: https://doi.org/10.3329/imcjms.v15i1.54199 *Correspondence: M. Abu Sayeed, Department of Community Medicine, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka-1000. email: sayeed@imc.ac.bd   Introduction In a recent report, World Health Organization (WHO) emphasized the alarming increasing trend of diabetes – rising from 180 million in 1980 to 422 million in 2014 [1]. During this time period, the prevalence of diabetes almost doubled from 4.7% to 8.5% in adult population [1-3]. The WHO also observed that premature death due to diabetes increased 5% from 2000 to 2016 affecting mostly the low and middle income countries. A substantial number of studies observed various organ dysfunctions leading to morbidity and mortality of the diabetic patients. These findings were mostly based on the patients on regular follow-up either at the outpatient or the inpatient departments of the hospitals. Very few published reports are available regarding organ dysfunction or sequels among those who are diagnosed of having diabetes at population-based screening for diabetes in rural community. This study assessed the morbidity and mortality of diabetes in a rural community cohort eight years after the initial diagnosis.   Materials and methods Ten villages of Kharua Union in Nandail sub-district under Mymensingh district, Bangladesh were surveyed in February and March 1993 to assess the prevalence of diabetes mellitus (DM). A total of 1319 subjects aged 18 years or more were screened for diabetes. Oral glucose tolerance test (OGTT) with 75g glucose drink was used [4, 5] to diagnose diabetes. All newly detected DM and IGT subjects were referred to a referral center, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM). The participants were registered and given a unique REFERENCE number. A second OGTT was done to confirm the diagnosis during registration. At registration, they were clinically examined, investigated and advised accordingly. Each participant was given special counseling for self-management of diabetes in a rural setting. They were encouraged to attend BIRDEM OPD, if necessary, and also for regular follow-up. An investigator maintained the communication with those registered patients. After an interval of eight years in 2001, the REFERENCE numbers of those diabetic cases were retrieved from the BIRDEM registry. The addresses of the registered cases were collected and the cases were traced in the community. Some houses were missing or lost. The houses were missed or lost due to natural disaster like flood, river erosions, cyclone and migration to other areas. We interviewed the neighbors and the people of adjacent houses to locate his/her present migrant destination. Every effort was made to contact the registered diabetics, whether living or dead. For the dead individuals, we conducted a verbal autopsy using “2012 WHO verbal autopsy [form 3] death of a person aged 15 years and above” though some irrelevant questions were excluded or skipped. After locating them we investigated each individual for fasting plasma glucose, fundoscopy, urinary albumin, vibration and monofilament (10g) tests and ECG to determine the presence of diabetes related sequels/complications. Any case, which had diabetes related complication(s) at the time of registration in 1993 were excluded from the follow up study of 2001.   Results A total of 1319 participants (797 men, 522 women) took part in the rural community survey in 1993. The methods and results were published [5]. The screening of participating population in 1993 detected 143 and 51 cases (total 194) of impaired glucose tolerance (IGT) and DM respectively using OGTT criteria of WHO. Of them, 188 subjects were registered in BIRDEM (Figure-1). We could locate only 79 (42.0%) out of 188 cases. The survivors among them were 43 (54.4%) and the non-survivors were 36 (45.6%). The biophysical characteristics of both men and women including comparisons between men and women are shown in Table-1. The men had significantly higher age (p = 0.009), height (p<0.001) and serum creatinine (p = 0.033). In contrast, the women had higher BMI (p = 0.003). Table-2 depicted the possible causes of death in non-survivors and the clinical status of survivors of the diabetic cohort traced in 2001 after the initial diagnosis in 1993. Most deaths were reported to be due to diabetic nephropathy leading to end stage renal disease (19.4%).The verbal communication indicated most of them were advised regular dialysis or kidney transplant. Neither regular dialysis nor kidney transplant was feasible or accessible to the families. The second most common cause was stroke (16.7%). It was easy to clinch diagnosis as their deaths ensued after long sufferings with hemiplegia. Sudden death occurred in 13.0%. These deaths appeared to be due to coronary artery disease (CAD) as described by the nearest relatives. Obesity, antihypertensive medication, smoking, sedentary habit and not complying the advices of treating physician were the main features of diagnosing CAD. Even after extensive interviewing and searching, cause(s) of death could not be identified in 19.4% of deaths. Of these cases, the nearest family members believed that the deaths were natural (extreme old age, bed-ridden for months or even years). One death was reported as paranormal (due to bad air). The apparently healthy person was found dead, while working in the nearest garden. One death occurred unattended when no relative or family member was present.   Fig-1: Algorithm for participants who were first diagnosed as having impaired glucose tolerance <![CDATA[Radiofrequency ablation of varicose veins: experience at a tertiary hospital]]> Farooq A. Ganie Ghulam Nabi Lone Mohd Yaqoob Khan Syed Mohsin Manzoor Mudasir Hamid Bhat Syed Nisar Ahmad https://imcjms.com/journal_full_text/370 2021-05-06 01:30:51 Original Article IMC J Med Sci 2021; 15(1): 006 Abstract Background and objectives: Radiofrequency ablation (RFA) is a recent modality of treatment of the affected varicose vein. In the present study, the outcome of great saphenous varicose vein disease treated byradiofrequency ablation technique was analyzed. Methods: Patients with varicosities of the lower limb affecting mainly the great saphenous vein were (GSV) included. The procedures were carried out under spinal anesthesia. The target varicose vein was accessed by Seldinger technique and the RFA catheter advanced 2 to 3 cm below sapheno-femoral junction under ultrasonography (USG) guidance. A tumescent anesthetic infiltration was given in a solution of normal saline and sodium bicarbonate before the vein being ablated. Results: The success rate of RFA was 97.5 % (39 out of 40). One patient showed episodic recanalisation of vein at one year duplex colour scan. Though the complications related to procedure were negligible, one patient developed endovenous heat induced thrombosis (EHIT) and non-fatal pulmonary thromboembolism (PTE) which was managed adequately. Conclusion: Endovenous RFA is a useful treatment modality for varicose vein disease primarily due to great saphenous insufficiency with marked symptomatic improvement and least recurrence. Although the complications are minimal, EHIT is a potential and serious complication of heat ablation. IMC J Med Sci 2021; 15(1): 006. DOI: https://doi.org/10.3329/imcjms.v15i1.54200 *Correspondence: Farooq Ahmad Gganie, Department of Cardiovascular and Thoracic Surgery, Sheri-I-Kashmir Institute of Medical Sciences (SKIMS), Soura, Srinagar, Kashmir, India. Email ID: farooq.ganie@ymail.com   Introduction Varicose veins are large, swollen veins that often appear on the legs and feet. Varicose veins are generally benign. The cause of this condition is not known precisely, however some risk factors are attributed to occupations with long standing and hormonal imbalance. The spectrum of symptoms is diverse ranging from asymptomatic engorged veins to aching pain and discomfort or skin ulceration and bleeding signaling an underlying circulatory problem. Treatment modalities involve compression stockings, specific exercises or operative procedures to remove or obliterate the affected veins. Available operative modalities include saphenous venous ligation and stripping, phlebectomy, endovenous laser therapy and radiofrequency ablation. Radiofrequency ablation is the newest of these technologies [1]. Conventional venous stripping is an invasive procedure and inflicts tremendous surgical trauma to patients [2]. The blood loss is also considerable in some cases. Though laser and cryo-ablation are alternative options gaining widespread popularity but the cost consideration remain the main limiting factor for universal application in our set up. In the present study, we employed radio-frequency ablation technique to selected strata of patients with great saphenous varicose vein disease and analyzed our experience.   Material and methods <![CDATA[Helicobacter pylori infection in asymptomatic rural Bangladeshi population]]> Mir Masudur Rhaman Fahmida Rahman Sraboni Mazumder M. Abu Sayeed Jalaluddin Ashraful Haq https://imcjms.com/journal_full_text/374 2021-05-19 22:08:06 Original Article IMC J Med Sci 2021; 15(1): 007 Abstract Background and objectives: The prevalence of Helicobacter pylori infection differs in urban and rural population. In our country, no previous study investigated the H. pylori infection in rural population. The aim of the present study was to find out the status of H. pylori infection among the Bangladeshi asymptomatic rural adult population. Material and Methods: This cross-sectional study was carried out in a rural area located about 40 km north-east of capital Dhaka. Apparently healthy non-diabetic, pre-diabetic and diabetic adults (18 years and above) were enrolled in this study. A structured questionnaire was developed to record the socio-demographic and clinical information. H. pylori infection status was determined by the presence of anti- H. pylori IgG antibody in blood. Serum anti-H.pylori IgG antibodies were determined by immunochromatographic test (ICT) method. Results: A total number of 180 apparently healthy adult individuals were enrolled of which 112, 40 and 28 were non-diabetic, pre-diabetic and diabetic respectively. Out of 180 individuals, anti- H. pylori IgG was present in 70 (38.9%, CI: 32.1, 46.2) cases. Infection rate was 50%, 27.5% and 43.5% in 19-30, 31-50 and >50 years age group respectively. Infection rate was significantly (p< 0.05) low in 31-50 years age group compared to 19-30 and > 50 years age groups. H. pylori infection rates in male and female were 42.6% (CI: 29.2, 56.8) and 37.3% (CI: 28.9, 46.4) respectively (p=0.50). There was no significant (p>0.05) association of H. pylori infection with economic status, education level, occupation and tobacco consumption of the study population. The rate of H. pylori infection in non-diabetic, pre-diabetic and diabetic individuals were not significantly different from each other. Conclusion: The study revealed a low prevalence of H. pylori infection in rural population of Bangladesh. There was no significant association of H. pylori infection with several sociodemographic status and diabetes. IMC J Med Sci 2021; 15(1): 007.  OPEN ACCESS. DOI: https://doi.org/10.3329/imcjms.v15i1.54201 *Correspondence: Jalaluddin Ashraful Haq, Department of Microbiology, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka 1000, Bangladesh. Email: jahaq54@yahoo.com   Introduction H. pylori, a gastroduodenal pathogen, causes chronic gastritis and peptic ulcer disease and is associated with gastric cancer [1]. The prevalence of H. pylori infection is more in developing countries. Poverty-related factors including overcrowding, poor sanitation, unclean water and low education level are the main risk factors of acquiring H. Pylori [2]. The infection tends to become chronic unless it is treated with antimicrobials [3]. In developed countries, the prevalence ranges from 11-32% in adults [4,5] and 10-16.7% in children [6,7]. On the hand, in developing countries, it ranges from 49-87% in adults [8,9] and 9-78.6% in schoolchildren [10,11]. However, in some developing countries, the prevalence is decreasing. For example, in South Korea, a significant decrease in prevalence was observed from 1998 (66.9%) to 2005 (59.6%) [12]. Bangladesh is one of the developing countries having peptic ulcer disease as a common health problem. The seroprevalence was reported 92% in 1997 [13] and 71.1% in 2008 [14] among the asymptomatic adults. In children, the prevalence was reported as 58% (0-4 years) to 82% (8-9 years) in Bangladesh [15,16]. The prevalence differs in urban and rural settings. In Vietnam, significantly higher prevalence of H. pylori infection was observed in urban area than in rural area. In the rural population of Vietnam, the risk for acquiring infection was 40% less than in the urban people [17]. In our country, no previous study investigated the H. pylori infection in asymptomatic rural population. Therefore, the primary aim of the present study was to find out the current prevalence status of H. pylori infection among the Bangladeshi asymptomatic adult rural population.   Materials and Methods Study place and population: This cross-sectional study was carried out in a rural area named Sreepur under Gazipur district. The rural area is located about 40 km north-east of capital Dhaka. Apparently healthy non-diabetic, pre-diabetic and diabetic adults (18 years and above) were enrolled in this study. Diabetes mellitus (DM) and pre-diabetes were defined according to the criteria of American Diabetes Association [18]. Informed written consent was obtained from all the participants after explaining the nature and purpose of the study. A structured questionnaire (close ended) was developed and used to record the socio-demographic information and clinical history. It was pretested and checked for applicability before it was finally launched at the field to interview for data collection from the respondents. Collection of blood and estimation of anti- H.pylori IgG antibody: H. pylori infection status was determined by the presence of anti- H. pylori IgG antibody in blood. Blood samples (2.5 mL) were collected aseptically from each participant by peripheral venipuncture under aseptic conditions. After collection, the serum was separated, aliquoted, refrigerated at 40C and then transported to the microbiology laboratory in a cold box. Serum anti- H. pylori IgG antibodies were determined by ICT (immunochromatographic test) method using AimStep™ H. Pylori Rapid Cassette test device (Germaine® Laboratories, Inc, USA). The test was performed and interpreted according to the manufacturer’s instruction.   Result A total number of 180 apparently healthy adult individuals were enrolled of which 112, 40 and 28 were non-diabetic, pre-diabetic and diabetic respectively. Out of 180 individuals, IgG antibody for H. pylori was present in 70 (38.9%; CI: 32.1, 46.2) cases.Table-1 shows the H. pylori infection status by age and gender. Infection rate was 50%, 27.5% and 43.5% in 19-30, 31-50 and >50 years age group respectively. Infection rate was significantly (p< 0.05) low in 31-50 years age group compared to 19-30 and > 50 years age groups. There was no significant (p=0.5) difference of infection in the 19-30 and >50 years age groups. The infection rates in male and female were 42.6% (CI: 29.2, 56.8) and 37.3% (CI: 28.9, 46.4) respectively. No significant association of H. pylori infection was observed with economic status, education level, occupation and tobacco consumption of the study population (Table-2).The rate of H. pylori infection in non-diabetic, pre-diabetic and diabetic individuals were 39.3%, 42.5% and 32.1% respectively. The rates were not significantly different from each other (Table-3).   Table-1: H. pylori infection according to age and gender of the study population     Table-2: H. pylori infection according to socio-demographic characteristics of the study population     Table-3: H. pylori infection according to diabetes status     Discussion The present study, using ICT, found a low prevalence of H. pylori infection (38.9%) in asymptomatic adult Bangladeshi rural population. Previously in 1997 and 2008, the seroprevalence rate of ˃90% and ˃70% were reported respectively in asymptomatic urban people from Bangladesh [13,14]. Similar decreasing trend was observed in South Korea [12]. Similar observation was made previously in Nepal where the infection rate in urban was 67.2% compared to 41.5% in rural population [19]. An Ethiopian study found a two-fold higher prevalence in an urban population than rural [20]. The explanation behind this difference might be increasing migration of people from rural to urban area causing higher urban density with crowded accommodation and poor living condition [21]. The low prevalence found in our study might be due to the improvement in socioeconomic standard of the local people and improved sanitation, hygiene or water supply in rural areas. Also, there could be some other unidentified factors that might inhibit H. pylori infection in our rural population. Though H. pylori has no known environmental reservoir, in Peru, the infection rate was lower in people using water from private wells than from municipal supply [22]. Also, exceptionally low (7.0%) prevalence of H. pylori infection was reported among Malay peptic ulcer patients in north-eastern peninsular Malaysia [23]. Also, studies found that use of local strain to detect antibodies to H. pylori yielded a significantly improved sensitivity and specificity [17,24,25]. In our study, the maximum infection rate was found in ≤30 years of age group. People mostly acquire H. pylori during young age of life through feco-oral, oro-oral or gastro-oral transmission. The rate of infection becomes lower during later age due to lower exposure risk and decrease in susceptible individuals [3]. No significant difference between male and female was demonstrated in this study. Many previous studies reported similar finding [26,27] whereas significantly higher prevalence of infection among men was also found in other studies [28,29]. The study did not find any significant association of economic status, education and occupation with H. pylori infection suggesting that other risk factors likely exist which were not assessed in the current study. Additionally, the present study was conducted on a small number of relatively homogenous populations. We did not find any significant difference in H. pylori infection among non-diabetic, pre-diabetic and diabetic population having no symptom of gastritis or peptic ulcer disease. Also, in our previous study we did not find any significant difference in H. pylori infection in peptic ulcer patients with and without diabetes mellitus [30]. Thus, it appeared that diabetes was not a predisposing factor for H. pylori infection. In conclusion, our study has shown a low prevalence of H. pylori infection in adult rural population of Bangladesh. Further large scale studies covering additional possible risk factors and by using indigenous H. pylori strain derived antigen(s) are needed to determine the exact prevalence of H. pylori infection in urban and rural population of Bangladesh.   References 1.       Suerbaum S, Michetti P. Helicobacter pylori infection. N Engl J Med. 2002; 347: 1175-1186. 2.       Windle HJ, Kelleher D, Crabtree JE. Childhood Helicobacter pylori infection and growth impairment in developing countries: a vicious cycle? Pediatrics. 2007; 119(3): e754-759. 3.       Miranda ACP, Machado RS, Koga da Silva EM, Kawakami E. Seroprevalence of Helicobacter pylori infection among children of low socioeconomic level in São Paulo. Sao Paulo Med J. 2010; 128(4): 187-191. 4.       Kruszon-Moran D, McQuillan GM. Seroprevalence of six infectious diseases among adults in the United States by race/ethnicity: data from the third national health and nutrition examination survey, 1988--94. Adv Data. 2005; (352): 1-9. 5.       Thjodleifsson B, Asbjörnsdottir H, Sigurjonsdottir RB, Gíslason D, Olafsson I, Cook E, et al. Seroprevalence of Helicobacter pylori and cagA antibodies in Iceland, Estonia and Sweden. Scand J Infect Dis. 2007; 39(8): 683-689. 6.       O’Donohoe JM, Sullivan PB, Scott R,Rogers T, Brueton MJ, Barltrop D. Recurrent abdominal pain and Helicobacter pylori in a community-based sample of London children. Acta Paediatr. 1996; 85(8): 961-964. 7.       Yamashita Y, Fujisawa T, Kimura A, Kato H. Epidemiology of Helicobacter pylori infection in children: a serologic study of the Kyushu region in Japan. Pediatr Int. 2001; 43(1): 4-7. 8.       Olmos JA, Ríos H, Higa R. Prevalence of Helicobacter pylori infection in Argentina: results of a nationwide epidemiologic study. Argentinean Hp epidemiologic study group. J Clin Gastroenterol. 2000; 31(1): 33-37. 9.       Newton R, Ziegler JL, Casabonne D, Carpenter L, Gold BD, Owens M,et al. Helicobacter pylori and cancer among adults in Uganda. Infect Agent Cancer. 2006; 1: 5. 10.    Malaty HM, Kim JG, Kim SD, Graham DY. Prevalence of Helicobacter pylori infection in Korean children: inverse relation to socioeconomic status despite a uniformly high prevalence in adults. Am J Epidemiol. 1996; 143(3): 257-262. 11.    Aguemon BD, Struelens MJ, Massougbodji A, Ouendo EM. Prevalence and risk-factors for Helicobacter pylori infection in urban and rural Beninese populations. Clin Microbiol Infect. 2005; 11(8): 611-617. 12.    Yim JY, Kim N, Choi SH, Kim YS, Cho KR, Kim SS, et al. Seroprevalence of Helicobacter pylori in South Korea. Helicobacter. 2007; 12(4): 333-340. 13.    Ahmad MM, Rahman M, Rumi AK, Islam S, Huq F, Chowdhury MF, et al. Prevalence of Helicobacter pylori in asymptomatic population--a pilot serological study in Bangladesh. J Epidemiol.1997; 7(4): 251-254. 14.    Sumona AA, Hossain MA, Shamsuzzaman AKM, Musa AKM, Mahmud MC, Ali MS, et al. Anti-Helicobacter pylori IgG in asymptomatic population. Bangladesh J Med Microbiol. 2008; 2(02): 31-34. 15.    Mahalanabis D, Rahman MM, Sarker SA, Bardhan PK, Hildebrand P, Beglinger C, et al. Helicobacter pylori infection in the young in Bangladesh: prevalence, socioeconomic and nutritional aspects. Int J Epidemiol. 1996; 25(4): 894-898. 16.    Sarker SS, Rahman MM, Mahalanabis D, Bardhan PK, Hildebrand P, Beglinger C, et al. Prevalence of Helicobacter pylori infection in infants and family contacts in a poor Bangladesh community. Dig Dis Sci. 1995; 40(12): 2669-2672. 17.    Hoang TTH, Bengtsson C, Phung DC, Sörberg M, Granström M. Seroprevalence of Helicobacter pylori infection in urban and rural Vietnam. Clin Diagn Lab Immunol. 2005; 12(1): 81-85. 18.    American Diabetes Association. Classification and diagnosis of diabetes mellitus. Diabetes Care. 2017; 34(1): 2–7. 19.    Kawasaki, M, Kawasaki T, Ogaki T, Itoh K, Kobayashi S, Yoshimizu Y, et al. Seroprevalence of Helicobacter pylori infection in Nepal: low prevalence in an isolated rural village. Eur J Gastroenterol. 1998; 10: 47–49. 20.    Lindkvist P, Enquselassie F, Asrat D, Nilsson I, Muhe L, Giesecke J. Risk factors for infection with Helicobacter pylori: a study of children in rural Ethiopia. Scand J Infect Dis. 1998; 30: 371–376. 21.    Aguemon BD, Struelens MJ, Massougbodji A, Ouendo EM. Prevalence and risk-factors for Helicobacter pylori infection in urban and rural Beninese populations. Clin Microbiol Infect. 2005; 11(8): 611-617. 22.    Klein PD, Graham DY, Gaillour A, Opekun AR, Smith E. Water source as risk factor for Helicobacter pylori infection in Peruvian children. Lancet. 1991; 337: 1503-1506. 23.    Raj SM, Yap K, Haq JA, Singh S, Hamid A. Further evidence of exceptionally low prevalence of Helicobacter pylori infection among peptic ulcer patients in north-eastern peninsular Malaysia. Trans R Soc Trop Med Hyg. 2001; 95(1): 24-27. 24.    Hoang TTH, Wheeldon TU, Bengtsson C, Phung DC, SörbergM, Granström M. Enzyme-linked immunosorbent assay for Helicobacter pylori needs adjustment for the population investigated. J Clin Microbiol. 2004; 42: 627-630. 25.    Romero-Gallo J, Perez-Perez GI, Novick RP, Kamath P, Norbu T, Blaser MJ. Responses of endoscopy patient in Ladakh, India, to Helicobacter pylori whole-cell and CagA antigens. Clin Diagn Lab Immunol. 2002; 9: 1313-1317. 26.    Jimenez-Guerra F, Shetty P, Kurpad A. Prevalence of and risk factors for Helicobacter pylori infection in school children in Mexico. Ann Epidemiol. 2000; 10: 474. 27.    Rothenbacher D, Bode G, Pesch F. Active infection with Helicobacter pylori in an asymptomatic population of middle aged to elderly people. Epidemiol Infect. 1998; 120: 297-303. 28.    Liberato SVL, Galindo MH, Alvarez LT, Miramón FS, Ciriza SEL, Abadía AG,et al. Helicobacter pylori infection in the child population in Spain: Prevalence, related factors and influence on growth. An Pediatr (Barc). 2005; 63(6): 489-494. 29.    Murray LJ, McCrum EE, Evans AE. Epidemiology of Helicobacter pylori infection among 4742 randomly selected subjects from Northern Ireland. Int J Epidemiol. 1997; 26: 880-887. 30.    Khatun S, Shadia K, Mahmud M, Mazumder S, Dutta IK, Rahman F, et al. Helicobacter pylori infection in diabetes mellitus patients with peptic ulcer disease. IMC J Med Sci. 2020; 14(2): 006. <![CDATA[Endocrinopathies in thalassemia - a review]]> Tahniyah Haq Shapur Ikhtaire Farzana Rahman Nishat Nayla Aurpa https://imcjms.com/journal_full_text/375 2021-05-22 02:46:04 Review IMC J Med Sci 2021; 15(1): 008 Abstract Improved treatment has increased survival of patients with thalassemia. However, they still suffer from several endocrine complications mainly as a result of iron overload from multiple transfusions. Endocrinopathies manifest as early as the first decade of life, affecting growth, puberty, psychological development and quality of life. The presence of concomitant anemia, chronic liver disease and cardiomyopathy affect the development and treatment of endocrine disorders, making endocrinopathies in thalassemia a complex disorder.  This review focuses on the pathogenesis, diagnosis and treatment of endocrinopathies in transfusion and non transfusion dependent thalassemia. The main points that should be considered in the management of endocrine disorders in a patient with thalassemia are highlighted in this review. IMC J Med Sci 2021; 15(1): 008.  OPEN ACCESS. DOI: https://doi.org/10.3329/imcjms.v15i1.54202 *Correspondence: Tahniyah Haq, Department of Endocrinology, Room 1620, 15th Floor, Block D, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka 1000, Bangladesh. Email: tahniyah81@gmail.com   Introduction Thalassemia can be classified depending on the need for transfusion. Non-deletional HbH, β – thalassemia major and severe HbE/β-thalassemia  require regular blood transfusions and are classified as transfusion dependent thalassemia (TDT) [3]. Patients with TDT suffer from iron overload and require aggressive chelation therapy. Endocrine complications are more prevalent and serious in these individuals. On the other end of the spectrum are the non-transfusion dependent thalassemia (NTDT) (α –thalassemia trait, β –thalassemia minor, mild and moderate HbE/β –thalassemia, HbC/β-thalassemia and deletional HbH disease) [3]. Since they have mild disease and do not require regular transfusions, there is less organ damage due to iron deposition. However, endocrinopathies can still occur in NTDT and regular screening is advised. Although endocrinopathies are the third most common cause of death in patients with TM [4], only a half of them consult an endocrinologist [5]. Treatment of endocrinopathies in thalassemia is complex due to multisystem involvement and lack of appropriate guidelines. Collaboration between hematologist, endocrinologist, hepatologist, cardiologist and gynecologist is therefore central to the management of this disorder. In this review, we describe the pathogenesis, diagnosis and treatment of endocrinopathies in thalassemia, with emphasis on TDT.   Pathogenesis In thalassemia, similar to other organs such as liver and heart, iron overload damages endocrine glands. Excess iron accumulation results from repeated blood transfusions and increased iron absorption due to ineffective erythropoesis. This leads to increased intracellular and extracellular iron deposition, which trigger a cascade of events culminating in cell damage primarily through generation of reactive oxygen species (Figure-1) [3,6-8].As a consequence, several endocrine glands are affected resulting in different types of endocrinopathies. Figure-2 briefly depicts the different endocrinopathies in thalassemia, their important contributing factors and parameters for assessment.   Figure-1: Pathogenesis of iron toxicity in thalassemia. GDF 15 - growth differentiation factor 15, NTBI - non-transferring bound iron, IL -  interleukin, TNF - tissue necrosis factor [3,6-8].   There are a multitude of endocrine disorders in TDT, with pituitary disorders being the most common. Severe pathology coupled with frequent transfusions and aggressive chelation make endocrine glands more susceptible to damage in TDT. Each disorder is described below along with a table (Table-1) outlining the key points of each endocrinopathy in TDT. 9.     De Sanctis V, Soliman A, Elsedfy H, Di Maio S, Canatan D, Soliman N et al. Gonadal dysfunction in adult male patients with thalassemia major: an update for clinicians caring for thalassemia. Expert Rev Hematol. 2017; 10(12): 1095-1106. 10.  Shalitin S, Carmi D, Weintrob N, Phillip M, Miskin H, Kornreich L, Zilber R, Yaniv I, Tamary H. Serum ferritin level as a predictor of impaired growth and puberty in thalassemia major patients. Eur J Haematol. 2005; 74: 93-100. 11.  Gardner DG, Shoback D, Greenspan’s Basic and Clinical Endocrinology. 10th ed. New York: McGraw-Hill Education; 2018 12.  Lazzerini M, Bramuzzo M, Martelossi S, Magazzù G, Pellegrino S, Ventura A. Amenorrhea in Women Treated with   Thalidomide. Inflamm Bowel Dis. 2013; 19(1): E10-E11. 13.  He L, Chen W, Yang Y, Xie Y, Xiong Z, Chen D et al. Elevated Prevalence of Abnormal Glucose Metabolism and Other Endocrine Disorders in Patients with β-Thalassemia Major: A Meta-Analysis. Biomed Res Int. 2019; 2019: 1-13. 14.  De Sanctis V. Endocrine complications. Thalassemia Reports. 2018; 8(1). 15.  Tangngam H, Mahachoklertwattana P, Poomthavorn P, Chuansumrit A, Sirachainan N, Chailurkit L et al. Under-recognized  Hypoparathyroidism in Thalassemia. J Clin Res Pediatr Endocrinol. 2018; 10(4): 324–330 <![CDATA[Regional differences in COVID-19 attack and case fatality rates in the first quarter of 2020: a comparative study]]> Most. Zannatul Ferdous Lakshmi Rani Kundu Marjia Sultana Sheikh Jafia Jafrin https://imcjms.com/journal_full_text/352 2020-08-16 23:52:26 Original Article IMC J Med Sci 2020; 14(2): 001 Abstract Background and Objective: The COVID-19 (Coronavirus disease 2019) outbreak has become a public health threat all over the world. From December 31, 2019 to March 19, 2020, 146 countries were affected. Evidence on the management approaches of current COVID-19 pandemic is still limited though the numbers of affected countries are increasing as the days go by. This study was aimed at determining the attack rate (AR) and case fatality rate (CFR) of Covid-19 in six different regions around the world in the first quarter of 2020. An attempt was also made to provide an overview of the ongoing situation of COVID-19. Methods: The design of the study was mixed approach where a retrospective analysis of surveillance data of six different regions around the world were collected from COVID-19 dashboard of World Health organization, between 31 December 2019 to 19 March 2020 (Time: 2:00 pm. BST [CET: 9 am]). Besides, other different validated sources (example: Worldometer, Center for Disease Control and Prevention) were used to assess the ongoing situation regarding COVID-19. A statistical software SPSS version 26 was used to analyze the data. Results: There were a total of 207,860 confirmed cases and 8779 deaths across six different regions around the world from 31 December 2019 to 19 March 2020, with the highest AR of 9.92/100,000 population in Europe region, followed by Asia (2.7/ 100,000), Australia (1.75/100,000), North America (1.42/100,000), South America (0.23/100,000) and Africa (0.06/100,000) regions. Study results revealed statistically significant association between attack rates and the six regions of the world (p=0.002), meaning that AR varied in the regions around the world. The CFR was high in Europe region (4.81%), followed by Asia (4.06%), Africa (2.72%), South America (1.41%), Australia (1.12%), and North America (0.69%) regions. Data reviewed from different countries revealed that the highest number of cases was confirmed in the United States, followed by Spain and Italy. The findings revealed that the reported confirmed cases varied widely in different regions of the world. Conclusion: The severity and variation in -geographical distribution of COVID-19 cases and deaths suggest that urgent response from various government and public health authorities should be taken and research regarding underlying factors determining this severity should be sought for. IMC J Med Sci 2020; 14(2): 001. EPub date: 16 August 2020. DOI: https://doi.org/10.3329/imcjms.v14i2.52825 *Correspondence: Most. Zannatul Ferdous, Department of Public Health and Informatics, Jahangirnagar University, Savar, Dhaka-1342, Bangladesh. Email: m.zannatul.ferdous@juniv.edu   Introduction Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) [1]. It is a positive-sense single-stranded RNA virus. SARS-CoV-2 is a member of the subgenus Sarbecovirus (beta-CoV lineage B) [2-4]. The earliest case of COVID-19 infection is thought to have been found on 17 November 2019 in Wuhan, Hubei, China [5]. On 7 January 2020, the COVID-19 was identified as the causative virus by Chinese authorities. Subsequently, the virus spread to all provinces of China and to more than hundreds of other countries in Asia, Europe, North America, South America, Africa, and Oceania [6]. Among the WHO South East Asia region, the number of confirmed cases is showing increasing trend, especially in Bangladesh and in India [7]. In 17 May 2020, the Institute of Epidemiology, Disease Control and Research (IEDCR), reported a total of 22,268 confirmed cases, with 4,373 recoveries and 328 deaths of COVID-19 in Bangladesh, since the first case was reported on the 8th of March 2020 [8]. World health Organization reported that the number of confirmed cases and deaths increased as days go by. The virus causes serious illness mostly among aged people and those with co-morbid conditions [7]. Human-to-human transmission of the virus has been confirmed in all of these regions [9,10]. Fever, cough, and shortness of breath are included as common symptoms of this disease [11]. As of March 25, 2020, the overall rate of deaths per number of diagnosed cases was 4.5 percent; ranging from 0.2 percent to 15 percent according to age group or different co-morbid conditions [12]. SARS-CoV-2 was announced as a Public Health Emergency of International Concern by the WHO on 30 January 2020 [13,14] and on 11 March 2020 the WHO declared it as a pandemic [15]. Literature from previous epidemic studies has revealed that the spreading capacity of COVID-19 virus is much wider than SARS or MERS [16]. The case fatality rates (CFR) for other Corona virus diseases, e.g. SARS- CoV and MERS-CoV were much higher, 10% and 34% respectively, whereas the CFR of US seasonal flu was approximately 0.1%, which is much lower than the current CFR for the COVID-19 [17]. Currently, stopping this deadly epidemic of COVID-19 is the highest priority for the global public health community [18]. Till now no vaccine has been developed for COVID-19. However, early care and proper treatment in time by the healthcare providers can significantly reduce the morbidity and mortality. So, surveillance of the disease is now the highest priority to detect the regular confirmed cases and deaths. Besides, two epidemiological measurements estimating the CFR and AR for COVID-19 in real time during its epidemic are important. These rates would help to guide the response from various government and public health authorities’ worldwide [19]. Thus, this study was undertaken to provide a comparative analysis of the AR and CFR of COVID-19 in six different regions of the world in the first quarter of 2020 with an overview of the ongoing situation of COVID-19 pandemic.   Methods Study design, period, and setting: This study was a retrospective analysis of secondary surveillance data spanning from 31 December 2019 to 19 March, 2020. During this period, six regions affected by the outbreak were Asia region (33 countries and 1 territory), African region (33 countries and 2 territories), European region (50 countries and 4 territories), Australia region (2 countries and 2 territories), North American region (12 countries and 1 territory), South American region (16 countries and 10 territories) and 1 International Conveyance (Cruise Ship).   Data source and management: Data of COVID-19, both on confirmed cases and deaths in the above mentioned regions were collected from coronavirus disease situation dashboard/database namely Worldometer, World Health Organization and European Center for Disease Control [20-23]. Data was first imported in MS Excel and then exported in SPSS version 26 for analysis. The processes for selecting the final dataset are shown in Figure-1.   Fig-1: The selection process of data, 31 December 2019 - 19 March 2020; *[20-23].   Study population, and definition of key variable: The study population comprised of people identified as COVID-19 cases during the outbreak period. In accordance with the European Center for Disease Control guidelines for preparedness and response to COVID-19 outbreak, a COVID-19 case was defined as a person with laboratory confirmation of virus causing COVID-19 infection, irrespective of clinical signs and symptoms [22].   Statistical analyses: All statistical analysis was performed in SPSS version 26. Case fatality rate was expressed as percentage. Fisher-exact test was used to show the differences of attack rates in the selected regions around the world. A p-value of less than 0.05 was considered statistically significant. As the data includes only the printed and published information, no formal ethical clearance was needed.   Results Thirty four countries and 1 territory in Asia region, 33 countries and 2 territories in African region, 50 countries and 4 territories in European region, 2 countries and 2 territories in Australia region, 16 countries and 10 territories in North America, 12 countries and 1 territory in South American region and 1 International Conveyance (Diamond Princess Cruise Ship) have been affected by the COVID-19 outbreak, resulting in a total of 207,860 cases and 8779 deaths till 19 March 2020. Table 1a highlights the reported coronavirus cases and deaths by region till 19 March 2020.The outbreak was divided by six regions and a Cruise ship called the Diamond Princess. Notably, the majority of coronavirus cases occurred in Asia region with a peak at 112,021 cases and 4,546 deaths with an AR of 2.57/100,000 population and a CFR of 4.06%. Though the number of cases were more in Asia both AR and CFR were highest in Europe among the six regions. The second highest numbers were reported in Europe with 84,968 cases and 4,084 deaths. The lowest numbers were reported in Australia with 538 cases and 6 deaths. The second lowest numbers were found in Africa with an AR of 0.06/100000 population but showed an alarming CFR of 2.72% (Table-1a).   Table-1a: Distribution of COVID-19 cases showing AR and CFR by regions from 31 December 2019 to 19 March 2020     The highest number of deaths (3,242) was recorded in China with an attack rate of 5.64/100,000 population and a case fatality rate of 3.99% in Asia region during the study period. In Europe, the most affected country was Italy with 35,713 cases and 2,978 deaths (Table-1b). The Diamond Princess Cruise ship was affected immensely; there were 712 cases and 7 deaths out of 3,711 passengers and crew members.   Table-1b: Distribution of COVID-19 cases in countries having cases more than 1000 from 31 December 2019 to 19 March 2020     Figure-2, presents the cumulative cases of novel coronavirus diseases by date. The graph shows an increasing trend; on 25th January there were 1.3 thousand cases, which enhanced to 7.8 thousand cases by 30th January. In February, total case number became 85.6 thousand. In middle of March it increased sharply to 153.6 thousand cases.   Fig-2:Time series of novel coronavirus (COVID-19) situation   Primary outcomes included AR and CFR and were presented in accordance to regions in Table 2. Coronavirus AR (per 100,000) was less than 1 person among 55.9% countries in the Asia region. It lies between 1 to 4.99 persons among 20.6% countries in that region. Attack rate of more than 20 people were reported in 2.9% countries in this region. In African region, less than 1 person was affected with COVID-19 among 80% of the countries. In South America, 76.9% countries attack rate was less than 1, no countries reported attack rate of ≥5.00 people per 100,000. Data in Table-2 revealed that the attack rates differed significantly in different regions of the world (p <0.005).   Table-2: Association between Regions and Attack rate     This section provides an overview of the ongoing pandemic of COVID-19 in selected American, European and South East Asian countries. Data and literature review suggested that the number of confirmed cases and deaths were increasing in countries of different regions all over the world (Figure-3a and 3b). The highest numbers of confirmed cases were found in the United States, followed by Spain, and Italy (Figure-3a). Figure-3b revealed that during the study period the highest and lowest numbers of deaths were in the United States (91,593) and in China (4634) respectively among the affected countries.   Fig-3a: Cumulative number of cases by number of days [20]     Fig-3b: Cumulative number of deaths [20]   Figure-4a shows the growth of COVID-19 confirmed cases in the selected South East Asian countries starting from the day they reported 100 confirmed cases. In Figure-4b, the distribution of the number of confirmed cases and deaths of COVID-19 in Bangladesh were presented, it was observed that by the end of first week of May, 2020 the total active cases, deaths and recoveries were 12,550, 239, and 2902 were respectively. Surprisingly, among the countries in South East Asian region, infection rate in Bangladesh stayed low until the end of March (first case identified 8 March, 2020) but a steep rise was seen afterwards. By April 9, the case number reached to 100 and within next two days the number had doubled (case doubling time).   Fig-4a: The growth of COVID-19 confirmed cases in selected South East Asian countries [23]   Fig-4b: The figures showing the daily distribution of reported confirmed COVID-19 cases, total deaths and recoveries, Bangladesh [23]   Discussion COVID-19 was first reported in December, 2019, in Wuhan, in the Hubei province of China, and spread very rapidly to all other places in Hubei, as well as all other provinces, autonomous regions, municipalities, and special administrative regions of China. Then it spread not only within China but also broke out all over the world. During any epidemic, it is very difficult to estimate CFR. However, this measurement is helpful for guiding responsible authorities to take necessary preventive measures. Besides estimating CFR, attack rate and secondary attack rate (SAR) are also important pieces of data that help to guide in getting the necessary response from various government and public health authorities worldwide. This study was carried out to provide a comparative description of COVID-19 AR and CFR among six WHO regions. The reported confirmed cases are increasing day by day all over the world. On 25th January there were 1.3 thousand cases but after 3 weeks (on February 15) it increased to 67.2 thousand cases. On March 15, it became 153.6 thousand cases. As of 19 March 2020, there were 207.8 thousand confirmed cases in six regions [21]. The report showed that 66% countries in Asia region, 61% countries in Africa region, 98% countries in Europe region, 14.29% in Australia region, 69.57% in North America region and 100% countries in South America region have been affected by this pandemic. As of March 19, 2020, there have been 207,860 confirmed cases and 8779 deaths in those regions. A total of 146 countries and 20 territories in six regions and 1 International Conveyance (Diamond Princess Cruise Ship) have been affected by the COVID-19. Thus worldwide, this new disease has brought tremendous pressure and terrible consequences on the public health and medical systems of the affected countries. Current estimates of CFR for COVID-19 vary depending on the datasets and time periods examined. A previous study on nearly 1100 patients from China suggested a CFR of 1-4% [24]. The present study during the study period (31 December 2019 to19 March 2020) observed the CFR and AR in China as 3.99% and 5.64% respectively. The highest CFR was in Italy (8.34%), followed by Spain (6.54%) and Iran (4.36%). Among the six WHO regions highest CFR was found in Europe region (4.81%), followed by Asia (4.06%) and Africa region (2.72%) during that time period. From a previous dataset of 44,672 confirmed cases in China, a report from the Chinese Center for Disease Control and Prevention (CDC) estimated an overall CFR of 2-3%. Nevertheless, the study pointed out that the rate varied by location and intensity of transmission (for example, 2-9% in Hubei vs. 0-4% in other areas of China), in different phases of the outbreak (for example,4-14.0% before Dec 31, 6-15.0% for Jan 1–10, 5-7% for Jan 11–20, 1-9.0% Jan for 21-31, and 0-8% after Feb 1), as well as by sex (2-8% for males vs.1-7% for females) [19,25]. Estimates of CFR differ from one country to another because of differences in implementation of preventive, control, and mitigation measures. Also, the preparedness and availability of health care facilities substantially affects the CFR. Besides, previously published studies identified delay in detection of infected cases as one of the key factors of spreading the virus and worse outcome of the disease [26]. Considering another objective of the study, we searched for data of ongoing situation of COVID-19. The data reviewed suggests that the number of confirmed cases and deaths had increased in America and Europe. However, the AR and CFR were less in some regions during the period of the study as the number of affected countries and confirmed cases was low. During the selected period of the study, a slow increasing rate of the confirmed cases and deaths in Asia region especially in Bangladesh was observed. However, from the time between preparation of the paper and submission, the number of confirmed cases and death were found to have been increased in different regions mainly in India and Bangladesh [20]. Our study has limitations. First, this study used secondary data sets which varied with time. Second, we did not report the CFR according to different age groups. Third, CFR differs with delay in detection of case, transmission rate of infection, prevention and mitigation strategies of a country, all of which were not adjusted in this study. Fourth, only two indicators were analyzed. Thus, interpretation of the findings is limited. Fifth, the death from COVID-19 with comorbid conditions were not excluded, influencing the CFR. Sixth, the reasons in the differences in the number of confirmed cases and deaths in six regions were not explored. Finally, the reviewed data did not provide a representative picture of the country-wise differences of the number of cases and deaths and the management options taken by the respective country. So, further situation analysis is needed to understand the overall dynamics of the COVID-19 pandemic. In summary, this study found that the case fatality rate and attack rate varied across different regions of the world. As there is no specific treatment against COVID-19 yet, the only solution is to keep the infected cases as low as possible. However, cases are still increasing all over the world. So, all the concerned authorities and public should come forward and work united to get rid of this COVID-19 and to ensure a pandemic free world.   Conflict of interest The authors declare that they have no potential conflict of interest for the publication of this article.   Author contributions MZF and LRK: Conceptualization, methods, data searching, writing-original draft, editing, and validation. MS: Editing. SJJ: Writing-original draft.   References 1.     World Health Organization. Naming the coronavirus disease (COVID-19) and the virus that causes it. Geneva: World Health Organization; 2020. 2.     Hui DS, Azhar EI, Madani TA, Ntoumi F, Kock R, Dar O, et al. The continuing 2019-nCoV epidemic threat of novel coronaviruses to global health — The latest 2019 novel coronavirus outbreak in Wuhan, China. Int J Infect Dis. 2020; 91: 264-266. [Editorial]. 3.     Gorbalenya AE, Baker SC, Baric RS, de Groot RJ, Drosten C, Gulyaeva AA, et al. The species of severe acute respiratory syndrome-related Coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2. Nature Microbiology. 2020; 5(4): 536-544. 4.     Wong ACP, Li X, Lau SKP, Woo PCY. Global epidemiology of bat coronaviruses. Viruses. 2019; 11(2): 174. 5.     Josephine M. Coronavirus: China’s first confirmed Covid-19 case traced back to November 17. South China Morning Post. 2020. 6.     Johns Hopkins CSSE. Coronavirus COVID-19 Global Cases by Johns Hopkins CSSE 1. Johns Hopkins University. 2020. 7.     World Health Organization. COVID-19 situation. Bangladesh: World Health Organization; 2020. Report No.: 9. 8.     Institute of Epidemiology, Disease Control and Research (IEDCR), Dhaka, Bangladesh. Corona Info. corona.gov.bd (in Bengali). Retrieved 3 May2020. 9.     Chan JFW, Yuan S, Kok KH, To KKW, Chu H, Yang J, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet. 2020; 395: 514-523. 10.  Rothe C, Schunk M, Sothmann P, Bretzel G, Froeschl G, Wallrauch C, et al. Transmission of 2019-NCOV infection from an asymptomatic contact in Germany. N Engl J Med. 2020; 382(10): 970-971. 11.  Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19). CDC Online Newsroom. CDC; 2020. 12.  Wikipedia. 2019–20 coronavirus pandemic in mainland China. Wikipedia; 2020. 13.  World Health Organization. Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV). Geneva: World Health Organization; 2005. 14.  Mahtani S, Berger M, O’Grady S, Iati M. Hundreds of evacuees to be held on bases in California; Hong Kong and Taiwan restrict travel from mainland China – The Washington Post. The Washington Post; 2020. 15.  World Health Organization. WHO Director-General’s opening remarks at the media briefing on COVID-19 - 15 April 2020. 2020. 16.  Petrosillo N, Viceconte G, Ergonul O, Ippolito G, Petersen E. COVID-19, SARS and MERS: are they closely related? Eur J Clin Microbiol Infect Dis. 2020; 26(6): 729-734. 17.  Lei S, Jiang F, Su W, Chen C, Chen J, Mei W, et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. E Clinical Medicine. 2020; 21:100331 18.  Sohrabi C, Alsafi Z, O’Neill N, Khan M, Kerwan A, Al-Jabir A, et al. World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). Int J Surg. 2020; 76: 71-76. 19.  Ruan S. Likelihood of survival of coronavirus disease 2019. Lancet Infect Dis. 2020; 20(6): 630-631. 20.  Worldometer. Population by country (2020) - Worldometer. 2020. 21.  World Health Organization. WHO COVID-19 Dashboard. 2020; 1–1. 22.  European Center for Disease Control. Case definition and European surveillance for COVID-19, as of 2 March 2020. 2020. 23.  World Health Organization. COVID-19 situation. Bangladesh: World Health Organization; 2020. Report No.: 11 24.  Liu Y, Eggo RM, Kucharskia AJ. Secondary attack rate and superspreading events for SARS-CoV-2. Lancet. 2020; 395(10227): e47. 25.  Guan W, Ni Z, Hu Y, Liang W, Ou C, He J, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020; 382: 1708-1720. 26.  Verity R, Okell LC, Dorigatti I, Winskill P, Whittaker C, Imai N, et al. Estimates of the severity of coronavirus disease 2019: a model-based analysis. Lancet Infect Dis. 2020; 20(6): 669-677. <![CDATA[Outcome of ivermectin treated mild to moderate COVID-19 cases: a single-centre, open-label, randomised controlled study]]> Chinmay Saha Podder Nandini Chowdhury Mohim Ibne Sina Wasim Md Mohosin Ul Haque https://imcjms.com/journal_full_text/353 2020-09-03 00:05:06 Original Article IMC J Med Sci 2020; 14(2): 002 Abstract Background and objectives: Various existing non-antiviral drugs are being used to treat severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection based mostly on existing data from previous coronavirus outbreaks. Ivermectin is one of such agents being widely used to treat early-stage of COVID-19. This study evaluated the outcome of ivermectin treated mild to moderate COVID-19 cases compared to usual care. Methods: This open-label randomised controlled study was conducted at a sub-district (Upazila) health complex from 1st May 2020 to the end of July 2020. Consecutive RT-PCR positive eligible COVID-19 patients were randomised into control and intervention arms. In the intervention arm, ivermectin 200 micrograms/kg single dose was administered orally in addition to usual care and was followed up till recovery. Repeat RT-PCR was done on day ten since the first positive result. The end point with regard to treatment outcome was time required for the resolution of symptoms from the onset of the symptoms and following enrollement in the study. Results: A total of 62 mild to moderate COVID-19 patients were enrolled in the study. There were 30 patients in the control arm and 32 patients in the intervention arm. Total recovery time from the onset of symptoms to complete resolution of symptoms of the patients in the intervention arm was 10.09 ± 3.236 days, compared to 11.50 ± 5.32 days in the control arm (95% CI -0.860,3.627, p>. 05) and was not significantly different. The mean recovery time after enrolment in the intervention arm was 5.31 ± 2.48 days, which also did not differ significantly from the control arm of 6.33 ± 4.23 days (95% CI – 0.766, 2.808, p> 0.05). Results of negative repeat RT- PCR were not significantly different between control and intervention arms (control 90% vs intervention 95%, p>.05). Conclusion: Ivermectin had no beneficial effect on the disease course over usual care in mild to moderate COVID-19 cases. IMC J Med Sci 2020; 14(2): 002. EPub date: 03 September 2020. DOI: https://doi.org/10.3329/imcjms.v14i2.52826 *Correspondence: Wasim Md Mohosin Ul Haque, Department of Nephrology, BIRDEM General Hospital, 122 Kazi Nazrul Islam Avenue, Dhaka 1000, Bangladesh. Email: wmmhaque@live.com   Introduction Coronavirus disease (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which was first identified during an outbreak of a respiratory illness in Wuhan City, Hubei Province, China, in December 2019 [1]. On March 11, WHO declared COVID-19 a global pandemic [2]. To date (August 11, 2020), approximately 20 million people worldwide have been infected, and about 0.75 million patients died of COVID-19. Currently, no drug is clearly found effective in the treatment of COVID-19. Based on experience from previous coronavirus outbreak, some antiviral agents namely remdesivir and favipiravir, have shown some promise in the treatment of COVID-19. However, these are very expensive and are reserved for severe cases only [3,4]. Treatment for patients with mild to moderate disease is not well established [5,6]. Several national and international observational studies have reported encouraging results of ivermectin in the treatment of COVID-19 patients with a mild degree of severity [7]. Ivermectin has been a popular anti-parasitic drug since the late 1970s. This drug stimulates gamma-aminobutyric acid-controlled chloride channels, which leads to hyperpolarisation and paralysis of the affected organism. The antiviral function of ivermectin has been discovered in recent years and is fascinating. This drug has a wide range of antiviral activities, both in vivo and in vitro, against various RNA and DNA viruses [8,9]. Efficacy against specific flaviviruses (dengue, Japanese encephalitis, and tick-borne encephalitis virus) and the chikungunya virus have been demonstrated in-vitro [10,11]. In a study by Caly et al has demonstrated that Vero/hSLAM cells infected with SARS-CoV-2 when treated with ivermectin resulted in a 5,000-fold reduction in viral RNA after 48 hours [12]. The exact mechanism of this effect is not yet known. However, the possible mechanism is inhibition of importin α / β1 mediated transport of viral proteins in and out of the nucleus [13]. The promising result of the in-vitro study mentioned above has led clinicians in many countries to use ivermectin to treat COVID-19 patients. A retrospective cohort study in hospitalised patients with confirmed SARS-CoV-2 infection in four hospitals in Florida showed significantly lower mortality rates among those who received ivermectin compared to the usual treatment [14]. The mortality rate was also significantly lower in ivermectin-treated patients with severe lung disease, although the rate of successful extubation was not significantly different [14]. In an observational study in Bangladesh, involving 100 COVID-19 patients treated with a combination of ivermectin and doxycycline showed adequate viral clearance in mild and moderately ill patients [7]. A recently published randomised controlled trial in Bangladesh found that a combination of ivermectin and doxycycline was safe and effective in patients infected with SARS-CoV-2, and showed no significant adverse events and had an improved tolerance compared to a combination of 'hydroxychloroquine and azithromycin [15]. However, there was no control (usual care) group in this study. The available pharmacokinetic data suggest that plasma concentrations of ivermectin with significant activity against SARS-CoV-2 could not be achieved without potentially toxic doses of ivermectin in humans [13]. Therefore, use of ivermectin warrants rapid implementation of controlled clinical trials to assess the efficacy against SARS-CoV-2 [16]. Although observational data suggest a beneficial effect of ivermectin in the treatment of COVID-19, there has been no randomised controlled trial (RCT) with ivermectin compared to the usual care in patients with mild to moderate COVID-19. Therefore, it is essential to conduct a clinical trial with ivermectin in patients with COVID-19 to evaluate the effectiveness of this drug in treating mild to moderate COVID-19 patients. This study was designed to evaluate the benefit of, if any, adding ivermectin to usual care, compared to usual care alone in the treatment of COVID-19 cases at a semi-rural settings.   Methods Study design, randomisation and intervention This study was an intention to treat prospective randomised controlled trial conducted at Debidwar Upazila (sub-district) Health Complex, Debidwar, Comilla. Patients were enrolled from the outpatient department of the health center from the beginning of May 2020 to the end of July 2020. All COVID-19 suspected cases were advised for RT-PCR test. Consecutive RT-PCR positive eligible mild to moderate COVID-19 cases of more than 18 years of age, of both sexes, were enrolled and randomised into control and intervention arms and followed till recovery. Randomisation was done using an odd-even methodology applied to registration numbers, in a consecutive fashion of 1:1 ratio. Patients with known pre-existing hypersensitivity to Ivermectin, pregnant and lactating mothers, and patients taking other antimicrobials or hydroxychloroquine were excluded from the study. Mild to moderate diseases were defined according to WHO COVID-19 disease severity classification. Symptomatic patients without evidence of viral pneumonia or hypoxia (SpO2 >93% on room air) were considered as a mild disease and patients with clinical signs of pneumonia (fever, cough, dyspnoea, fast breathing) but no signs of severe pneumonia, including SpO2≥ 90% on room air were considered as a moderate disease [6]. Upon enrollment, all COVID-19 cases received symptomatic treatment which included antipyretics, cough suppressants, and capsule doxycycline (100 mg every 12 hours for seven days) to treat possible community-acquired pneumonia as part of the local working protocol and this treatment schedule was termed as ‘usual care’. The control arm continued to receive the ‘usual care’, and the intervention arm in addition to usual care, received single dose of ivermectin 200 micrograms/kg on the day 1 of randomisation. Procedure for enrollement of cases is shown in Figure-1. The selected cases were treated on an OPD basis.   Fig-1: Sample selection flow chart   Repeat RT-PCR was performed on day 10 after the first positive test result. Data were collected in a semi-structured questionnaire devised for the study by the research team. Both face-to-face and telephonic communication were used for follow-up and data collection.   Outcome measures The outcome end point was the time needed for resolution of fever, cough, shortness of breath and finally, full recovery from all symptoms and the negative result of repeat RT-PCR on day 10. Recovery time was defined as time required for the resolution of symptom(s) from the date of enrolment in the study as well as from the onset of initial illness.   Ethics and statistical analysis Permission was taken from the head of the health centre. Informed written consent from the patients was obtained before enrolment. After collection, data editing and clearing were done manually and prepared for data entry and analysis by using SPSS version 20. The data was checked for any omissions, irrelevance, and inconsistencies. The omissions were corrected by repeating history. Irrelevant and inconsistent data were discarded. Finally, 62 patients were included in the intention-to-treat analysis. The unpaired t-test was used to compare the means between control and intervention arms. Crosstab and chi-square tests were used to compare demographic parameters between control and intervention arms. P-value of less than 0.05 was taken as significant.   Results Initially, 82 patients were recruited; of these, 62 patients who presented within seven days of onset of symptoms were finally selected for analysis. Twenty patients were excluded as 18 had symptoms for more than seven days at the time of enrollment and two other patients had insufficient data. There were 30 patients in the control arm, and 32 patients were in the intervention arm. The mean age of the all enrolled cases was 39.16±12.07 years. The mean age of cases in control and intervention arms were not significantly different (39.97±13.24 versus 38.41±11.02 years; p>0.05). Out of 62 cases, 44 (71.0%) were male and 18 (29.0%) were female. With regard to category, 50 (80.6%) and 12 (19.4%) were mild and moderate COVID-19 cases respectively. The predominant symptoms of the study population were fever (50, 80.6%), followed by cough (42, 67.7%). There was no statistically significant differences in baseline demographic and clinical parameters between control and intervention arms except sore throat (Table-1).   Table-1: Demographic and clinical characteristics of the patients at the time of enrolment in the study (n=62)   Table-2 shows the duration of different symptoms of the study participants at the time of enrolment. Mean duration of different symptoms of the cases in both control and intervention arm was not significantly different (p>0.05) at the time of enrolment.   Table-2: Duration of symptoms of patients in intervention and control arms at the time of enrolment (n=62).   There were no significant differences with regard to recovery time for fever, cough, shortness of breath and complete resolution of all symptoms between control and intervention arms either from the date of enrolement or from the onset of illness (Table-3 and Table-4). Therefore, the duration of the illness from onset to recovery was not significantly different among the of COVID-19 cases in two study arms.   Table-3: Time required for the resolution of symptoms of cases in control and intervention arms from the date of enrolment in the study   Table-4: Time required for the resolution of symptoms of cases in control and intervention arms from the date of onset of illness   Repeat RT-PCR was done in 40 patients on day ten since the first positive RT-PCR. Repeat RT-PCR for SARS-CoV-2 was negative in 37 (92.5%) patients. Results of repeat RT- PCR were not significantly different between control and intervention arms (Table-5).   Table-5: Result of repeat RT-PCR on 10th day (n=40)     Discussion In this open-label, single-centre, intention-to-treat randomised controlled study involving mild to moderate RT-PCR confirmed COVID-19 patients, a 200 micrograms/kg single dose of ivermectin added to usual care did not provide better clinical outcomes in terms of duration of symptomatic recovery and rate of repeat RT-PCR negativity. The COVID-19 pandemic has caused a tremendous burden on healthcare facilities around the world, due to its rapid spread with devastating consequences. Currently, no medication is recommended for mild to moderate COVID-19. The development of a whole new molecule takes time, so researchers are also trying to explore the effectiveness of existing drugs against SARS-CoV-2, which have already been shown to be effective in treating similar viruses. Several of these drugs are currently in use without having apparent benefits. Hydroxychloroquine and chloroquine were the most widely used drugs. Initial observational studies showed significant benefit of these drugs against COVID-19 [17,18]. However, later in RCTs, these presumed benefits were negated [19,20]. Ivermectin is also one of these drugs, widely used as a treatment for the early stage of COVID-19. This drug has shown its in-vitro activities against SARS-CoV-2 [12]. Initial observational studies have also shown benefits, but no RCTs have been published yet to prove its benefit over usual care in the management of mild to moderate COVID-19 cases. In this study most of the patients were men; also, in other Bangladeshi studies, men were found more affected than women [7,15,21,22] though internationally, no gender difference was found in COVID-19 [23]. The predominant symptoms found in the study was fever followed by cough were typical of the presentation of COVID-19 [15,24]. There was no significant difference in age, sex, and disease severity at presentation between the cases of control and intervention arms and thus eliminated the selection bias. However, one of the limitation of our study was that we could not perform detail biochemical and hemotological investigations of the study participants. It was due the fact that the study was carried out at a primary health care center at a semi-rural settings. Thus, we were unable to determine the effect of ivermectin (if any) on the biochemical and haematological parameters of the COVID-19 cases. However, the study emphasis was on the clinical outcome following ivermectin treatment. A recent RCT in Bangladesh, reported ivermectin-doxycycline combination superior to hydroxychloroquine-azithromycin combination therapy in mild to moderate COVID-19 cases [21]. However, the time difference to become symptom-free and the time difference for negative RT-PCR were not statistically significant (consecutively p=0.071 and p= 0.2314). The mean duration of symptomatic recovery was 5.93 days (5 to 10 days) in the ivermectin group and 6.99 days (4 to12 days) in the hydroxychloroquine group.In our study, the mean duration of symptomatic recovery was not different between the control and intervention arms. Another study compared the viral clearance by ivermectin+doxycycline with hydroxychloroquine plus azithromycin in patients with COVID-19 [15]. In this study, Rahman M et al. compared the benefits of viral clearance between the groups mentioned above and found better viral clearance in the ivermectin group. However, the results of the two groups were assessed at different time frames, making comparisons disputed and was criticised in an editorial comment in the same issue of the journal [25]. The ineffectiveness of ivermectin on the overall COVID-19 outcome is not unexpected. Available pharmacokinetic data from clinically relevant and excessive dose studies suggest that the ivermectin concentration required to inhibit SARS-CoV-2 in humans is unlikely to be attainable in serum and tissue with known dosing regimens [13]. In a brief review of ivermectin and COVID-19, Chaccour et al. concluded that ivermectin is incorrectly used to treat COVID-19 without scientific evidence of demonstrable efficacy and safety [16]. In conclusion, adding ivermectin to usual care in the management of mild to moderate COVID-19 patients did not show any benefit. However, since the sample size was small, future multicentre studies with a larger sample size could be conducted to confirm the outcome.   Author’s contributions CSP was involved in study planning, patient recruitment and data collection; NC was involved in patient recruitment, data collection, data entry; MIS did patient recruitment, data entry; WMMH did study planning, data analysis and manuscript writing.   Conflict of Interest The authors declare no conflict of interest.   Funding This study was self-financed.   References 1.     Zheng J. SARS-CoV-2: an Emerging Coronavirus that Causes a Global Threat. Int J Biol Sci. 2020; 16(10): 1678-85. 2.     Cucinotta D, Vanelli M. WHO Declares COVID-19 a Pandemic. Acta bio-medica: Atenei Parmensis [Internet]. 2020; 91(1): 157-160. 3.     Li G, De Clercq E. Therapeutic options for the 2019 novel coronavirus (2019-nCoV). Nat Rev Drug Discov. 2020; 19(3): 149-50. 4.     De Clercq E. Potential antivirals and antiviral strategies against SARS coronavirus infections. Expert Rev Anti Infect Ther. 2006; 4(2): 291-302. 5.     Disease Control Division. Directorate General of Health Services. Ministry of Health & Family Welfare. Government of the People’s Republic of Bangladesh. National Guidelines on Clinical Management of Coronavirus Disease 2019 (COVID-19). Version 7.0. Published, 28 May 2020. 6.     World Health Organization. Clinical management of COVID-19: interim guidance, 27 May 2020. World Health Organization; 2020. 7.     Alom M, Murshed R, Bhiuyan E, Saber S, Alam R, Robin R. A Case Series of 100 COVID-19 Positive Patients Treated with Combination of Ivermectin and Doxycycline. J Bangladesh Coll Phys Surg. 2020; 38(Supplement Issue): 10-15. 8.     Sharun K, Dhama K, Patel SK, Pathak M, Tiwari R, Singh BR, et al. Ivermectin, a new candidate therapeutic against SARS-CoV-2/COVID-19. Ann Clin Microbiol Antimicrob. 2020; 19(1): 23. 9.     Heidary F, Gharebaghi R. Ivermectin: a systematic review from antiviral effects to COVID-19 complementary regimen. J Antibiot (Tokyo). 2020; 73(9): 593-602. 10.  Mastrangelo E, Pezzullo M, De Burghgraeve T, Kaptein S, Pastorino B, Dallmeier K, et al. Ivermectin is a potent inhibitor of flavivirus replication specifically targeting NS3 helicase activity: new prospects for an old drug. J Antimicrob Chemother. 2012; 67(8): 1884-1894. 11.  Varghese FS, Kaukinen P, Gläsker S, Bespalov M, Hanski L, Wennerberg K, et al. Discovery of berberine, abamectin and ivermectin as antivirals against chikungunya and other alphaviruses. Antiviral Res. 2016; 126: 117-124. 12.  Caly L, Druce JD, Catton MG, Jans DA, Wagstaff KM. The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro. Antiviral Res. 2020; 178: 104787. 13.  Momekov G, Momekova D. Ivermectin as a potential COVID-19 treatment from the pharmacokinetic point of view: antiviral levels are not likely attainable with known dosing regimens. Biotechnol Biotechnol Equip. 2020; 34(1): 469-74. 14.  Rajter JC, Sherman M, Fatteh N, Vogel F, Sacks J, Rajter J-J. ICON (Ivermectin in COvid Nineteen) study: Use of Ivermectin is Associated with Lower Mortality in Hospitalized Patients with COVID19. medRxiv. 2020:2020.06.06.20124461. 15.  Rahman M, Iqbal S, Islam M, Niaz M, Hussain T, Siddiquee T. Comparison of Viral Clearance between Ivermectin with Doxycycline and Hydroxychloroquine with Azithromycin in COVID-19 Patients. J Bangladesh Coll Phys Surg. 2020; 38(Supplement Issue): 5-9. 16.  Chaccour C, Hammann F, Ramón-García S, Rabinovich NR. Ivermectin and COVID-19: Keeping Rigor in Times of Urgency. Am J Trop Med Hyg. 2020; 102(6): 1156-7. 17.  Gautret P, Lagier J-C, Parola P, Hoang VT, Meddeb L, Mailhe M, et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. Int J Antimicrob Agents. 2020; 56(1): 105949-. 18.  Arshad S, Kilgore P, Chaudhry ZS, Jacobsen G, Wang DD, Huitsing K, et al. Treatment with hydroxychloroquine, azithromycin, and combination in patients hospitalized with COVID-19. Int J Infect Dis. 2020; 97: 396-403. 19.  Borba MGS, Val FFA, Sampaio VS, Alexandre MAA, Melo GC, Brito M, et al. Effect of High vs Low Doses of Chloroquine Diphosphate as Adjunctive Therapy for Patients Hospitalized With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection: A Randomized Clinical Trial. JAMA Netw Open. 2020; 3(4): e208857-e. 20.  Cavalcanti AB, Zampieri FG, Rosa RG, Azevedo LCP, Veiga VC, Avezum A, et al. Hydroxychloroquine with or without Azithromycin in Mild-to-Moderate Covid-19. N Engl J Med. 2020. 21.  Chowdhury ATMM, Shahbaz M, Karim MR, Islam J, Guo D, He S. A Randomized Trial of Ivermectin-Doxycycline and Hydroxychloroquine-Azithromycin therapy on COVID19 patients. Research Square; 2020. 22.  Bhuyan MA, Al Mahtab M, Ashab E, Haque MJ, Hoque SMM, Faizul Huq A, et al. Treatment of COVID-19 Patients at a Medical College Hospital in Bangladesh. Euroasian J Hepatogastroenterol. 2020; 10(1): 27-30. 23.  Spagnolo PA, Manson JE, Joffe H. Sex and Gender Differences in Health: What the COVID-19 Pandemic Can Teach Us. Ann Intern Med. 2020. 24.  Zhu J, Ji P, Pang J, Zhong Z, Li H, He C, et al. Clinical characteristics of 3062 COVID-19 patients: A meta-analysis. J Med Virol. 2020. 25.  Rahim M, Mostafi M. Re-purposive Use of Drugs in COVID-19: A Wake-up Call. J Bangladesh Coll Phys Surg. 2020; 38(Supplement Issue): 3-4. <![CDATA[Neonatal sepsis due to non-albicans Candida species and their susceptibility to antifungal agents: first report from Bangladesh]]> Rafia Afreen Jalil K.M. Shahidul Islam Lovely Barai Shahida Akhter https://imcjms.com/journal_full_text/358 2021-01-13 01:49:02 Original Article IMC J Med Sci 2020; 14(2): 005 Abstract Background and objectives: Frequency of neonatal sepsis in Neonatal Intensive Care Units (NICU) has been increasing worldwide over the last decades. The emergence of non-albicans Candida (NAC) species and their resistance to common antifungal agents become an important preventive and therapeutic issue. The present study was undertaken to find out the role of NAC species in neonatal sepsis/candidemia in the NICUs of hospitals of Dhaka city. The susceptibility pattern of NAC species to antifungal agents was also determined. Materials and methods: Suspected cases of neonatal sepsis admitted in NICU of four tertiary care hospitals of Dhaka city, from March to December 2018 were enrolled. In this cross sectional study, blood samples were collected from neonates with suspected sepsis for culture.Identification of Candidaspecies was done by carbohydrate (CHO) assimilation tests using swab auxanographic technique, CHO impregnated yeast nitrogen base plate method (YNB), microtiter plate based miniaturized method and by HiCromeTM Candida Differential Media. Susceptibility of the isolated Candida species to antifungal agents was determined by disk diffusion (DD) and by minimum inhibitory concentration (MIC) methods. MIC was determined by broth microdilution method using RPMI 1640 and trypticase soy broth (TSB). Results: In the present study, NAC species were isolated from 39.7% neonates. C. tropicalis was the predominant species (81.0%) followed by C. parapsilosis (12.1%), C. auris (5.2%) and C. dubliniensis (1.7%).Isolated NAC species were 98.3% sensitive to voriconazole. Sensitivity to fluconazole, ketoconazole, itraconazole, and clotrimazole was 3.5%, 15.5%, 86.2% and 56.9% respectively by DD method. All the isolates (100%) were sensitive to miconazole and nystatin. All the C. tropicalis, C. auris and C. dubliniensis were sensitive to amphotericin B and anidulafungin. One and four C. parapsilosis were found resistant to amphotericin B and anidulafungin respectively. The MIC results obtained by using RPMI 1640 and TSB as growth medium were concordant suggesting that TSB media was a good alternative to expensive RPMI 1640. Conclusion: The advent of NAC species merits attention as they are highly resistant to most of the azoles. Therefore, speciation of Candida in neonatal candidemia is essential to institute appropriate antifungal therapy. IMC J Med Sci 2020; 14(2): 005. EPub date: 13 January 2021. DOI: https://doi.org/10.3329/imcjms.v14i2.52827 *Correspondence: Rafia Afreen Jalil, Department of Microbiology, Green Life Medical College, Green Road, Dhaka, Bangladesh. Email: rafiaafreen133@gmail.com   Introduction Over the last two decades, blood stream infection (BSI) by Candida species has become a significant issue in neonatal intensive care units (NICUs). Candidemia is the third most common cause of late onset sepsis in neonates. It is responsible for 9-13% of BSI in neonates and is associated with high crude and attributable mortality rates [1]. Among the Candida species, C. albicans is the most commonly isolated organism. But recently non-albicans Candida (NAC) species have emerged as potential pathogens, particularly C. tropicalis, C. parapsilosis, C. krusei, C. glabrata and C. auris [2-4]. Various factors such as broad spectrum antibiotics, indwelling devices, prematurity, low birth weight (LBW), total parenteral nutrition (TPN), artificial ventilation and gastrointestinal surgery contribute to the risk of fungal colonization and infection. Also, fungal colonization is associated with overcrowding in the NICU, inadequate nurse-to-patient ratio and poor hygiene practices. Approximately 10% of the newborns are colonized during the first week of life and up to 64% of them get colonized by 4 weeks stay in hospital [5-6]. Candida species may spread via vertical transmission from the maternal flora or by horizontal transmission from the healthcare workers (HCW) hands [7-8]. Majority of the Candida species become resistant to the antifungal agents, mainly to triazole compounds, by the expression of efflux pumps that minimize drug accumulation, altering the structure or concentration of antifungal target proteins and modification of membrane sterol composition [9,10]. Some NAC species are intrinsically resistant to fluconazole and newer triazoles. Therefore, speciation and antifungal susceptibility of all the yeast isolates are essential. Owing to significant regional heterogeneity, local epidemiological data is crucial in the prevention and management of invasive candidiasis. No study has yet been carried out in Bangladesh on the frequency and the types of NAC species responsible for sepsis in neonates admitted at the NICUs of different hospitals. The present study was undertaken to determine the NAC species and their antifungal susceptibility pattern causing neonatal sepsis in the NICUs of four tertiary care hospitals of Dhaka city.   Materials and methods This cross sectional hospital based study was carried out in the Department of Microbiology, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) in collaboration with Department of Neonatology of four tertiary care hospitals of Dhaka city. The study period was from March, 2018 to December, 2018. The study was approved by the Institutional Ethical Committee of each institution and written informed consents from patients’ guardian were obtained prior to collection of samples.   Study population and collection of blood samples: Neonates admitted in respective NICUs with suspected septicemia were included in the study. About 1-2 ml of peripheral venous blood samples were collected aseptically from enrolled neonates. Immediately, 0.5-1 ml of blood was inoculated in BacT/Alert PF plus bottle and remaining 0.5-1 ml blood inoculated in the lytic blood culture tube. The specimens were transported immediately to microbiology laboratory of BIRDEM. Since Candida could be part of skin flora of neonates admitted in hospital, its isolation from blood culture might reflect contamination from skin flora. To rule out this contamination, a second blood sample was collected from the culture positive cases. Candidemia was diagnosed by isolation of Candida species from at least two consecutive blood samples with clinical features of septicemia.   Isolation and identification of NAC species: Culture was performed using standard microbiological techniques [11,12]. Candida was identified by colony morphology, wet film and Gram stain. Species identification was done by germ tube test, carbohydrate (CHO) assimilation tests using swab auxanographic technique, carbohydrate impregnated yeast nitrogen base plate method and microtitre plate based miniaturized method, modified enrichment broth growth assay and HiCromeTM Candida Differential Media [13-16]. Yeast nitrogen base, bromocresol purple and eleven types of carbohydrates were used in all the three methods of CHO assimilation tests. In swab auxanographic method, carbohydrate was incorporated in individual discs. In the mictotitre plate and CHO impregnated YNB plate methods, the carbohydrates were incorporated in the media. Growth in the media and turning the bromocresol purple to yellow indicated utilization of particular carbohydrate. C. auris was further confirmed by modified enrichment broth growth assay with salt yeast nitrogen base broth.Growth at 420C and development of a yellow colour in the medium indicated C. auris. The Candida isolates were inoculated on HiCromeTM Candida Differential Media and incubated at 370C for 24 hours and the species were identified by colour of the colonies as per manufacturer’s instructions.   Antifungal susceptibility tests: Antifungal susceptibility test was performed by disk diffusion method using Mueller-Hinton agar supplemented with 2% glucose and 0.5 µg/ml methylene blue dye. Inhibition zones for fluconazole and voriconazole were interpreted according to validated CLSI (M44-A) [17], while for other drugs the inhibition zones were adopted from published studies [18-20]. Broth microdilution was done to determine minimum inhibitory concentration (MIC) of fluconazole, amphotericin B and anidulafungin as per NCCLs M27-A2 and EUCAST v 7.3.1 [21,22] using both RPMI 1640 and trypticase soy broth as growth medium. For determination of minimal fungicidal concentration (MFC), 2 µl of broth was withdrawn from the optically clear MIC well of respective antifungal agent (concentrations above the MIC) and plated on Sabouraud dextrose agar plate and incubated at 350C for 72 hrs. MFC was defined as the lowest drug concentration that yielded less than three colonies, a killing activity of ~ 99% [23].   Results A total of 146 neonates with suspected sepsis were enrolled in the study. Out of 146 suspected cases of neonatal sepsis, 91 (62.3%) yielded positive blood culture. NAC species was isolated from 58 (39.7%) cases and remaining 33 (22.6%) yielded growth of bacteria (Table-1). Detail rate of isolation of NAC species from different categories of study population is shown in Table-1. Rate of isolation of NAC species from term and preterm babies were 19.1% and 43.2% respectively. Fungal culture positivity among normal birth weight (NBW), low birth weight (LBW) and very low birth weight (VLBW) babies were 26.3%, 46.8% and 33.3% respectively. Of the 58 NAC species isolated, 3 were from neonates with early-onset sepsis and the rest 55 were from cases with late-onset sepsis. The ratio of isolation of NAC species in neonates of diabetic and non diabetic mother was 2:1. Table-2 shows that C. tropicalis was the predominant species (81.0%) followed by C. parapsilosis (12.1%), C. auris (5.2%) and C. dubliniensis (1.7%).   Table-1: Rate of isolation of NAC species and bacteria from different category of study population   Susceptibility of NAC species to fluconazole, ketoconazole, itraconazole, clotrimazole and nystatin by disc diffusion method is shown in Table-3. Out of 58 NAC isolates, 96.6%, 84.5%, 13.8% and 43.1% were resistant to fluconazole, ketoconazole, itraconazole and clotrimazole respectively. Except one C. parapsilosis isolate, none was resistant to voriconazole. None of the isolated NAC species was resistant to miconazole and nystatin.   Table-2: Types of NAC species isolated from study population (n=58)   Table-3: Antifungal susceptibility pattern of the isolated NAC species by disk diffusion method   Table-4 shows the resistance pattern of isolated NAC species to fluconazole, amphotericin B and anidulafungin by MIC method. Among the 47 C. tropicalis, 44 (93.6%) were resistant to fluconazole. C. parapsilosis, C. auris and C. dubliniensis were 100% resistant to fluconazole by both disc diffusion and MIC methods. All the C. tropicalis, C. auris and C. dubliniensis were sensitive to amphotericin B and anidulafungin. Out of 7 C. parapsilosis, 1 (14.3%) and 4 (57.1%) were found resistant to amphotericin B and anidulafungin respectively. The MIC results obtained by using RPMI 1640 and TSB as growth medium were concordant suggesting that TSB media could be a good alternative to expensive RPMI 1640.   Table-4: Antifungal susceptibility pattern of isolated NAC species to fluconazole, amphotericin B and anidulafungin by MIC method   Table-5 shows the MIC50 and MIC90 of fluconazole, amphotericin B and anidulafungin of isolated NAC species. MIC50 value of fluconazole for all the NAC isolates were in the resistant range. MIC50 of amphotericin B for C. tropicalis, C. parapsilosis, C. auris and C. dubliniensis were 0.5 µg/ml, 1 µg/ml, 1 µg/ml and 0.25 µg/ml respectively and these values were all within the sensitive range. Only MIC90 of amphotericin B for C. parapsilosis was 2 µg/ml which was in the resistant range. MIC50 of anidulafungin for C. parapsilosis was 4 µg/ml and was in the resistant range. Both MIC50 and MIC90 of anidulafungin for rest of the Candida species were within the sensitive range. The lowest drug concentration required to inhibit the growth of 50% of organisms (MIC50) and minimum concentration required to kill 50% of viable organisms (MFC50) of the antifungal drugs for all the Candida species were calculated and shown in Table-6. MFC50 was 2 fold higher than MIC50 for fluconazole, amphotericin B and anidulafungin for all the NAC species.   Table-5: MIC50 and MIC90 of fluconazole, amphotericin B and anidulafungin of isolated NAC species   Table-6: MIC50 versus MFC50 of fluconazole, amphotericin B and anidulafungin for all NAC species   Discussion The present study has for the first time demonstrated the distribution of different non-albicans Candida species responsible for sepsis among neonates admitted in the NICUs of different hospitals in Dhaka city. In the current study 39.7% neonates were culture positive for NAC species. ARTEMIS Antifungal Surveillance study conducted between June 1997 and December 2007 in 41 countries reported a declining trend in isolation of C. albicans from 70.9% to 65.9% [24]. A similar trend of emergence of NAC speciesin bloodstream infection has also been documented in a number of studies [25-31]. In this study, prematurity, LBW, VLBW, antibiotic prophylaxis and extended hospital stay could be the important reasons for high isolation of NAC species. Long-term use of broad-spectrum antibiotics in routine empiric therapy also contributes to an overgrowth of opportunistic Candida by reducing the competitive pressure imparted by normal bacterial flora [32]. Also, increased use of azole antifungal agents, particularly fluconazole, leads to an increase in the distribution of NAC species and a decrease in C. albicans [33]. In the present study, among NAC species, C. tropicalis was the most common species (81.0%). Various other studies have also reported C. tropicalis to be the most common isolate [3,30,31].Pressure of fluconazole prophylaxis could be the reason behind this high rate of isolation of C. tropicalis in this study. The isolated NAC species were 98.3% sensitive to voriconazole and this finding is similar to the results published by other studies [35,36]. In the present study, resistant rate to fluconazole by the Candida isolates was 87.9% by disk diffusion and 94.8% by MIC method. All the C. parapsilosis and C. auris were resistant to fluconazole while C. tropicalis isolates were 93.6% resistant. These findings were in agreement with Pandita et al. and Yadav et al [37,38]. All the C. tropicalis, C. auris and C. dubliniensis were sensitive to amphotericin B and anidulafungin. Out of 7, only 1 (14.3%) C. parapsilosis was found resistant to amphotericin B and 4 (57.1%) were resistant to anidulafungin. Therefore, it appeared that amphotericin B and anidulafungin could be used against NAC species when the organisms become resistant to other antifungal agents. There are only few literaturesavailable regarding the use of echinocandin particularly anidulafungin in the pediatric ICU. Anidulafungin might be used as an alternative drug in neonates particularly when the local Candida strains are resistant to azoles. However, since the first introduction of echinocandins, these antifungal agents have exhibited higher minimum inhibitory concentrations against C. parapsilosis. Compared to other species of Candida, C. parapsilosis demonstrates higher in vitro MICs to echinocandin, and treatment failures with these antifungal agents have been reported for C. parapsilosis infections [39,40]. Antifungal susceptibility was done by disk-diffusion and MIC broth microdilution methods. RPMI 1640 is the proposed medium for carrying out micro broth dilution by EUCAST and NCCLs (M27-A2). However, RPMI 1640 is very expensive and not easily available in many laboratories. So, MIC of fluconazole and amphotericin B for Candida species were done using both TSB and RPMI 1640 medium and the results were compared. The MIC results obtained by both the media were concordant suggesting that TSB broth media could be a good alternative to RPMI 1640. In our study, we observed the minimum fungicidal concentrations (MFC) of fluconazole, amphotericin B and anidulafungin as 2 fold higher than the MIC. Very little is known regarding the role of differences between MIC and MFC in treatment failure, and further studies are required. The present study provided evidence of colossal burden of NAC species as an important cause of neonatal sepsis in our NICUs. The isolated NAC species were found highly resistant to widely used fluconazole whereas amphotericin B, voriconazole and anidulafungin were the most effective agents. The results of our study could be used as a template for the establishment of local guidelines for the effective treatment and prevention of neonatal candidemia.   Competing interest The authors declared no competing interests.   Funding None   References 1.     Benjamin DK, Stoll BJ, Fanaroff AA, McDonald SA, Oh W, Higgins RD, et al. Neonatal candidiasis among extremely low birth weight infants: risk factors, mortality rates, and neurodevelopmental outcomes at 18 to 22 months. Pediatrics. 2006; 117(1): 84-92. 2.     Oberoi JK, Wattal C, Goel N, Raveendran R, Datta S, Prasad K. Non-albicans Candida species in blood stream infections in a tertiary care hospital at New Delhi, India. Indian J Med Res. 2012; 136(6): 997-1003. 3.     Goel N, Ranjan PK, Aggarwal R, Chaudhary U, Sanjeev N. Emergence of non-albicans Candida in neonatal septicemia and antifungal susceptibility: experience from a tertiary care center. J Lab Physicians. 2009; 1(2): 53-55. 4.     Warris A. Candida auris, what do paediatricians need to know? Arch Dis Child. 2018; 103(9): 891-894. 5.     Singhi S, Rao DS, Chakrabarti A. Candida colonization and candidemia in a pediatric intensive care unit. Pediatr Crit Care Med. 2008; 9(1): 91-95. 6.     Rao S, Ali U. Systemic fungal infections in neonates. J Postgrad Med. 2005; 51 Suppl 1: S27-29. 7.     Ariff S, Saleem AF, Soofi SB, Sajjad R. Clinical spectrum and outcomes of neonatal candidiasis in a tertiary care hospital in Karachi, Pakistan. J Infect Dev Ctries. 2011; 5(03): 216-223. 8.     Adib SM, Bared EE, Fanous R, Kyriacos S. Practices of Lebanese gynecologists regarding treatment of recurrent vulvovaginal candidiasis. N Am Med Sci. 2011; 3(9): 406-410. 9.     Sanglard D, Odds FC. Resistance of Candida species to antifungal agents: molecular mechanisms and clinical consequences. Lancet Infect Dis. 2002; 2(2): 73-85. 10.  Magill SS, Shields C, Sears CL, Choti M, Merz WG. Triazole cross-resistance among Candida spp.: case report, occurrence among bloodstream isolates, and implications for antifungal therapy. J Clin Microbiol. 2006; 44(2): 529-535. 11.  Cheesbrough M. District laboratory practice in tropical countries, part 2. Cambridge University Press; 2005. 12.  Tarrand JJ, Guillot C, Wenglar M, Jackson J, Lajeunesse JD, Rolston KV. Clinical comparison of the resin-containing BACTEC 26 Plus and the Isolator 10 blood culturing systems. J Clin Microbiol. 1991; 29(10): 2245-2249. 13.  McGinnis MR. Laboratory handbook of medical mycology. Michigan: Michigan University Press; 1980. p. 661. 14.  Land GA, Vinton EC, Adcock GB, Hopkins JM. Improved auxanographic method for yeast assimilations: a comparison with other approaches. J Clin Microbiol. 1975; 2(3): 206-217. 15.  Devadas SM, Ballal M, Prakash PY, Hande MH, Bhat GV, Mohandas V. Auxanographic carbohydrate assimilation method for large scale yeast identification. J Clin Diagn Res. 2017; 11(4): DC01-DC03. 16.  Welsh RM, Bentz ML, Shams A, Houston H, Lyons A, Rose LJ, et al. Survival, persistence, and isolation of the emerging multidrug-resistant pathogenic yeast Candida auris on a plastic health care surface. J Clin Microbiol. 2017; 55(10): 2996-3005. 17.  Clinical and Laboratory Standards Institute. Methods for antifungal disk diffusion susceptibility testing of yeasts; Approved Guideline M44-A, Vol. 24, Number 15. 2nd ed. Wayne, USA: Clinical and Laboratory Standards Institute; 2004. 18.  Pam VK, Akpan JU, Oduyebo OO, Nwaokorie FO, Fowora MA, Oladele RO, et al. Fluconazole susceptibility and ERG11 gene expression in vaginal Candida species isolated from Lagos Nigeria. Int J Mol Epidemiol Genet. 2012; 3(1): 84-90. 19.  Dota KF, Freitas AR, Consolaro ME, Svidzinski TI. A challenge for clinical laboratories: detection of antifungal resistance in Candida species causing vulvovaginal candidiasis. Lab Med. 2011; 42(2): 87-93. 20.  Vandeputte P, Larcher G, Bergès T, Renier G, Chabasse D, Bouchara JP. Mechanisms of azole resistance in a clinical isolate of Candida tropicalis. Antimicrob Agents Chemother. 2005; 49(11): 4608-4615. 21.  Clinical and Laboratory Standards Institute. Reference method for broth dilution antifungal susceptibility testing of yeasts M27-A2, Vol. 22, Number15. 2nd ed. Wayne, USA: Clinical and Laboratory Standards Institute; 2002. 22.  European Society of Clinical Microbiology and Infectious Diseases. Method for the determination of broth dilution minimum inhibitory concentrations of antifungal agents for yeasts. EUCAST Definitive Document E.DEF 7.3. Copenhagen: European Society of Clinical Microbiology and Infectious Diseases; 2015. 23.  Torres-Rodríguez JM, Alvarado-Ramírez E, Murciano F, Sellart M. MICs and minimum fungicidal concentrations of posaconazole, voriconazole and fluconazole for Cryptococcus neoformans and Cryptococcus gattii. J. Antimicrob Chemother. 2008; 62(1): 205-206. 24.  Pfaller MA, Diekema DJ, Gibbs DL, Newell VA, Ellis D, Tullio V, et al. Results from the ARTEMIS DISK Global Antifungal Surveillance Study, 1997 to 2007: a 10.5-year analysis of susceptibilities of Candida species to fluconazole and voriconazole as determined by CLSI standardized disk diffusion. J Clin Microbiol. 2010; 48(4): 1366-1377. 25.  Kossoff EH, Buescher ES, Karlowicz MG. Candidemia in a neonatal intensive care unit: trends during fifteen years and clinical features of 111 cases. Pediatr Infect Dis J. 1998; 17(6): 504-508. 26.  Sardana V, Pandey A, Madan M, Goel SP, Asthana AK. Neonatal candidemia: a changing trend. Indian J Pathol Microbiol. 2012; 55(1): 132-133. 27.  Rani R, Mohapatra NP, Mehta G, Randhawa VS. Changing trends of Candida species in neonatal septicaemia in a tertiary North Indian hospital. Indian J Med Microbiol. 2002; 20(1): 42-44. 28.  Femitha P, Joy R, Adhisivam B, Bhat V, Prasad K, Gane BD, Singh R. Candidemia in neonatal ICU-experience from a tertiary care hospital. Skin. 2013; 5: 13-19. 29.  Shrivastava G, Bajpai T, Bhatambare GS, Chitnis V, Deshmukh AB. Neonatal candidemia: Clinical importance of species identification. Sifa Med J. 2015; 2(2): 37. 30.  Capoor MR, Nair D, Deb M, Verma PK, Srivastava L, Aggarwal P. Emergence of non-albicans Candida species and antifungal resistance in a tertiary care hospital. Jpn J Infect Dis. 2005; 58(6): 344-348. 31.  Agarwal J, Bansal S, Malik GK, Jain A. Trends in neonatal septicemia: emergence of non-albicans Candida. Indian pediatrics. 2004; 41(7): 712-715. 32.  Benjamin DK, Stoll BJ, Gantz MG, Walsh MC, Sánchez PJ, Das A, et al. Neonatal candidiasis: epidemiology, risk factors, and clinical judgment. Pediatrics. 2010; 126(4): e865-e873. 33.  Filioti J, Spiroglou K, Roilides E. Invasive candidiasis in pediatric intensive care patients: epidemiology, risk factors, management, and outcome. Intensive Care Med. 2007; 33(7): 1272-1283. 34.  Sopian IL, Sa’adiah Shahabudin MA, Lung LT, Sandai D. Yeast infection and diabetes mellitus among pregnant mother in Malaysia. Malays J Med Sci. 2016; 23(1): 27-34. 35.  Kavitha H, Anuradha K, Venkatesha D. Comparison of susceptibility of various Candida species isolated from neonatal septicaemia to voriconazole and fluconazole. IOSR J Pharm Biol Sci. 2014; 9(02): 78-81. 36.  Nazir A. Non-albicans Candida in neonatal septicemia: an emerging clinical entity. Int J Biomed Res. 2016; 7(2): 47-50. 37.  Pandita N, Peshin C, Wasim S, Bhat NK, Gupta A. Profile of fungal septicaemia in new born at a tertiary care hospital in North India. Int J Contemp Pediatr. 2017; 4(2): 455-459. 38.  Yadav S, Dahiya S, Budhani D. Candidemia in neonatal intensive care unit: a cause of concern. Int J Res Med Sci. 2017; 5(5): 2165-2167. 39.  Arendrup MC, Perlin DS. Echinocandin resistance: an emerging clinical problem? Curr Opin Infect Dis. 2014; 27(6): 484-492. 40.  Perlin DS. Echinocandin resistance, susceptibility testing and prophylaxis: implications for patient management. Drugs. 2014; 74(14): 1573-1585. <![CDATA[Helicobacter pylori infection in diabetes mellitus patients with peptic ulcer disease]]> Salma Khatun Khandaker Shadia Mafruha Mahmud Sraboni Mazumder Indrajit Kumar Dutta Fahmida Rahman Md. Shariful Alam Jilani Jalaluddin Ashraful Haq https://imcjms.com/journal_full_text/359 2021-01-19 00:01:20 Original Article IMC J Med Sci 2020; 14(2): 006 Abstract Background and objectives: Helicobacter pylori infection is suspected to be associated with extra-gastrointestinal disorders such as diabetes mellitus (DM). It is still a subject of investigation whether H. pylori has a pathogenic role on DM or diabetic patients have an increased susceptibility to H. pylori infection. The aim of the present study was to find out the rate of H. pylori infection in individuals with and without DM. Materials and methods: The study was conducted on 72 diabetic and 19 non-diabetic adult individuals with dyspeptic symptoms attending the BIRDEM General Hospital for diagnostic endoscopy. All cases were tested for H. pylori stool antigen by rapid immunochromatographic test (ICT), urease production in biopsy samples by rapid urease test (RUT), and serum anti-H. pylori IgA and anti-CagA IgG antibodies by enzyme-linked immunosorbent assay (ELISA). Any case that had peptic ulcer/erosion and was positive for H. pylori stool antigen or rapid urease test (RUT) was defined as H. pylori positive case. Results: There was no significant (p=0.095) difference in H. pylori infection between diabetics and non-diabetics (68.1% vs 47.4%). Presence of ulcer and erosion were not significantly different among diabetics and non-diabetics. Anti-H. pylori IgA positivity rate in H. pylori positive diabetic and non-diabetic cases were 65.3% and 55.6% (p=0.575) respectively while anti-CagA IgG rate in those cases were 46.9% and 66.7% (p=0.276) respectively. Conclusion: The present study did not reveal any significant difference in H. pylori infection between individuals with and without DM having peptic ulcer/erosion. IMC J Med Sci 2020; 14(2): 006. EPub date: 17 January 2021.  DOI: https://doi.org/10.3329/imcjms.v14i2.52832 *Correspondence: J. Ashraful Haq, Department of Microbiology, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka 1000, Bangladesh. Email: jahaq54@yahoo.com   Introduction Helicobacter pylori, a gram-negative bacterium, is associated with chronic gastritis, gastric and duodenal ulcers, and in rare occasion gastric cancer and lymphoma [1]. H. pylori infection is more frequent in developing countries and an estimated 4.4 billion individuals are reported infected with H. pylori worldwide [2]. Besides gastroduodenal involvement, H. pylori is suspected to be associated with extra-gastrointestinal disorders such as diabetes mellitus (DM), cardiovascular diseases, and glaucoma [3]. Today, DM is a major public health concern worldwide. In 2015, it was estimated that there were 415 million people with DM aged 20-79 years, 5 million deaths attributable to DM and the total global health expenditure due to DM was estimated at 673 billion dollars [2]. If a causal relationship between H. pylori and DM becomes clear, it will lead to new preventive and therapeutic strategies for DM and the impact will be significant because of the large number of patients of both diseases [2]. Many studies have addressed the relationship between H. pylori infection and DM. However, the findings are conflicting. Several case-control studies have revealed higher prevalence of H. pylori infection in patients with DM [4]. Moreover, a meta-analysis carried out by Zhou et al. suggested a trend toward more frequent H. pylori infection in DM patients [5]. However, Tamura et al. found a significantly higher DM prevalence among individuals with H. pylori infection than those without [6]. Some studies reported no significant difference in the prevalence of H. pylori infection between diabetics and non-diabetics [7,8]. It is still debated whether H. pylori has a pathogenic role on DM or whether diabetic patients have an increased susceptibility to H. pylori infection [9]. No previous study has yet examined the H. pylori infection patients with DM in Bangladesh. Therefore, the aim of the study was to examine the rate of H. pylori infection in dyspeptic individuals with and without DM.   Materials and methods Study population and case definition: The study was conducted on diabetic and non-diabetic adult individuals with dyspeptic symptoms attending the BIRDEM General Hospital for diagnostic endoscopy. Diabetes mellitus (DM) was defined as a condition of progressive pancreatic beta cell dysfunction having HbA1c level ≥6.5% or fasting plasma glucose (FPG) ≥7.0 mmol/l or two-hour plasma glucose ≥11.1 mmol/l during an OGTT or a random plasma glucose of ≥11.1 mmol/l in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis [10]. All participants were tested for peptic ulcer/erosion by endoscopy, H. pylori stool antigen, urease production in biopsy samples, and serum anti-H. pylori IgA and anti-CagA IgG and antibodies. Any case that had peptic ulcer/erosion and was positive for either H. pylori stool antigen or rapid urease test (RUT) was defined as H. pylori positive case. Participants taking any antibiotics, colloidal bismuth compounds, proton pump inhibitors (PPI) or H2 blocker within the last four weeks were excluded. The study was approved by the Institutional Ethical Committee and written informed consent was obtained from all patients. Sample collection: Twenty to thirty gram stool was collected from each individual for H. pylori stool antigen test. The test was carried out within 6 hours of collection of fecal sample. During endoscopy gastric biopsy specimen(s) was taken to detect H. pylori by rapid urease test (RUT). Blood (2.5 ml) sample was collected from each patient for the detection of anti-H. pylori IgA and anti-CagA IgG antibodies. Serum was separated and stored at –200C until tested. H. pylori stool antigen assay: H. pylori stool antigen was detected by ICT test using ABON one step H. pylori antigen ICT test device (Inverness Medical Innovation Hong Kong Limited). After taking about 50 mg of stool from 3 different sites of collected stool, it was mixed with supplied extraction solution using vortex mixer. Then the tube was centrifuged for 5 minutes at 4000 rpm. Two drops of the supernatant was added to the sample well of the test kit.When a purple-pink line (test line) appeared in addition to the control line, the sample was considered positive. Rapid urease test (RUT): The biopsy specimen was inoculated in the rapid urease test media and incubated for 4 hours at 370C. The sample was considered positive if the medium became pink in color. Anti-H. pylori IgA and anti-CagA IgG detection by ELISA: Serum anti-H. pylori IgA and anti- CagA IgG antibodies were determined by ELISA using kit from DRG International Inc. USA. The test was performed and interpreted according to the manufacturer’s instruction.   Results A total of 72 diabetic and 19 non-diabetic adult individuals with dyspeptic symptoms were included in this study. The mean age of diabetics and non-diabetics was 56 ± 11.9 and 43 ± 15.4 years respectively (Table-1). Out of 72 diabetic cases, 84.7% and 15.3% had erosion and ulcer respectively while the rates were 68.4% and 31.6% among the non-diabetic individual. Table-2 shows the H. pylori infection among the individuals with and without DM. The rate of H. pylori infection in individuals with and without DM was 68.1% and 47.4% (p=0.095) respectively by stool antigen/RUT tests. The rate of H. pylori infection was not significantly (p>0.05) different in two groups either by stool antigen or by RUT tests separately. Table-3 shows that anti-H. pylori IgA positivity rate in H. pylori positive diabetic and non-diabetic cases were 65.3% and 55.6% (p=0.575) respectively while anti-CagA IgG rate in those cases were 46.9% and 66.7% (p=0.276) respectively. Mean OD values of anti-H. pylori IgA and anti-CagA IgG antibodies of H. pylori infected DM cases were not significantly different from that of non-diabetics.   Table-1: Age of study population and distribution of gastroduodenal lesions among them   Table-2: Rate of H. pylori infection in diabetics and non-diabetics   Table-3: Anti-H. pylori IgA and anti-CagA IgG antibodies in H. pylori positive cases     Discussion The role of H. pylori infection in type 2 DM (T2DM) is unclear and it is still debated whether H. pylori has a pathogenic role in the development of diabetes or whether diabetic patients have an increased susceptibility to H. pylori infection. Impairment of cellular and humoral immunity in diabetic patients could enhance an individual’s susceptibility to acquire H. pylori infection and altered glucose metabolism might facilitate H. pylori colonization in the gastric mucosa. Also, diabetes induced reduction of gastrointestinal motility and acid secretion may further promote bacterial colonization and infection rate in the gut [9]. H. pylori infection may also contribute to the development of diabetes as the infection is associated with chronic low-grade inflammation with up-regulation of cytokines such as C-reactive protein, tumor necrosis factor and interleukin 1β, which may influence pancreatic β cell secretion and thus function of insulin. In addition, H. pylori induced gastritis affects the secretion of gastric hormones, including leptin, ghrelin, gastrin, and somatostatin, which could affect insulin sensitivity and glucose homeostasis [11,12]. A prospective study showed that those who were sero-positive for H. pylori infection at the enrolment were 2.7 times more likely to develop T2DM compared to sero-negative individuals at any given time [13]. It was reported that T2DM patients with H. pylori infection required higher levels of serum insulin to reach the same degree of glycemic control compared to T2DM patients without H. pylori infection [14]. Another study reported that the level of HbA1c tended to improve after eradication of H. pylori infection [15]. Also, It was observed that the eradication rate of H. pylori infection in T2DM patients was lower [16]. In this study, we assessed the association of H. pylori infection with DM. To our knowledge, this is the only study in Bangladesh that addressed the association between H. pylori infection and DM. We did not find any significant difference in the rate of H. pylori infection between individuals with and without DM. Also, we did not find any significant difference in the incidence of ulcer and erosion between diabetics and non-diabetics. Previous studies that investigated the association between H. pylori infection and DM reported conflicting results. Some studies demonstrated significant positive association [17-21] while others reported no such association [22-27]. Prevalence of H. pylori infection in diabetics and non-diabetics were reported as 28.1% vs. 29.25% [25], 37.3% vs. 35.2% [26], and 50.8% vs. 56.4% [27] respectively. 2.     Kato M, Toda A, Yamamoto-Honda R, Arase Y, Sone H. Association between Helicobacter pylori infection, eradication and diabetes mellitus. J Diabetes Investig. 2019; 10: 1341–1346. 4.     Kayar Y, Pamukçu O, Eroğlu H, KalkanErol K, Ilhan A, Kocaman O. Relationship between Helicobacter pylori infections in diabetic patients and inflammations, metabolic syndrome, and complications. Int J Chronic Dis. 2015; 2015: 290128. 6.     Tamura T, Morita E, Kawai S, Sasakabe T, Sugimoto Y, Fukuda N, et al. No association between Helicobacter pylori infection and diabetes mellitus among a general Japanese population: a cross-sectional study. Springerplus. 2015; 4: 602. 8      .Sotuneh N, Hosseini SR, Shokri-Shirvani J, Bijani A, Ghadimi R. Helicobacter pylori infection and metabolic parameters: is there an association in elderly population? Int J Prev Med. 2014; 5(12): 1537–1542. 10.  American Diabetes Association. Classification and diagnosis of diabetes mellitus. Diabetes Care. 2017; 34(1): 2–7. 12.  Roper J, Francois F, Shue PL, Mourad MS, Pei Z, Olivares de Perez AZ, et al. Leptin and ghrelin in relation to Helicobacter pylori status in adult males. J Clin Endocrinol Metab. 2008; 93(6): 2350–2357. 14.  Vafaeimanesh J, Bagherzadeh M, Heidari A, Motii F, Parham M. Diabetic patients infected with Helicobacter pylori have a higher insulin resistance degree. Caspian J Intern Med. 2014; 5(3): 137–142. 16.  Horikawa C, Kodama S, Fujihara K, Hirasawa R, Yachi Y, Suzuki A, et al. High risk of failing eradication of Helicobacter pylori in patients with diabetes: a meta-analysis. Diabetes Res Clin Pract. 2014; 106(1): 81–87. 18.  Bener A, Micallef R, Afifi M, Derbala M, Al-Mulla HM, Usmani MA. Association between type 2 diabetes mellitus and Helicobacter pylori infection. Turk J Gastroenterol. 2007; 18(4): 225–229. 20.  Bajaj S, Rekwal L, Misra SP, Misra V, Yadav RK, Srivastava A. Association of Helicobacter pylori infection with type 2 diabetes. Indian J Endocrinol Metab. 2014; 18(5): 694–699. 22.  Demir M, Gokturk HS, Ozturk NA, Kulaksizoglu M, Serin E, Yilmaz U. Helicobacter pylori prevalence in diabetes mellitus patients with dyspeptic symptoms and its relationship to glycemic control and late complications. Dig Dis Sci. 2008; 53(10): 2646–2649. 24.  Wang F, Liu J, Lv ZS. Association of Helicobacter pylori infection with diabetes mellitus and diabetic nephropathy: A meta-analysis of 39 studies involving more than 20,000 participants. Scand J Infect Dis. 2013; 45(12): 930–938. 26.  Anastasios R, Goritsas C, Papamihail C, Trigidou R,   Garzonis   P,   Ferti   A.   Helicobacter   pylori infection in diabetic patients: Prevalence and endoscopic findings. Eur J Intern Med. 2002; 13: 377. <![CDATA[A profile of illnesses prevailing in the secondary schools of rural communities of Bangladesh]]> Tanjima Begum Parvin Akter Khanam Mir Masudur Rhaman M. Abu Sayeed https://imcjms.com/journal_full_text/364 2021-03-06 01:07:19 Original Article IMC J Med Sci 2020; 14(2): 007 Abstract Background and objectives: The childhood population in Bangladesh is ~20% of the 166.5 million. The rural population comprises almost 70%. Approximately, Bangladesh has more than 23,500 high schools. There has been no published data on the profile of illness commonly observed among the high school children. The aims of the study were a) to determine a profile of common illness among the students of rural high schools; b) to assess the nutrition status related to socio-economic class and c) to find out the correlations between anthropometry and blood pressure and between anthropometry and blood glucose status. Methods: The study was conducted in purposively selected high schools in Santhia thana under the district of Pabna. Local leaders and the school teachers volunteered to communicate the study objectives and investigation details to the eligible students. The teachers prepared the list of participants. All the willing participants were advised to attend the investigation site in the morning in a fasting state. Each participant was interviewed. Socio-demographic and clinical history was taken. Investigations included anthropometry – height (ht), weight (wt), waist- and hip-circumference (waist, hip). Adiposity indices namely body mass index (BMI – wt in kg/ht in met. sq.), waist/hip ratio (WHR) and waist/ht ratio (WHtR) were calculated. Resting blood pressure was taken. Clinical examination (general and systemic) was done. Fasting blood glucose (FBG) was estimated using glucometer strip and blood grouping by test kit. Test kit was also used for detection of urinary protein. Results: From six schools, 1069 students (boys/girls = 392/677) of age 10 to 19 years participated in the study. The participants from middle class family were 52.7% and upper were 14.4%. Their mothers were mostly housewives (95.5%) and only 16% had academic education of ten years or more. The mean (± SD) values of BMI, WHR, WHtR and FBG were 18.2 (± 2.9), 0.81 (± 0.07), 0.43 (± 0.05) and 5.26 (± 0.45) mmol/L respectively. Adiposity was significantly higher in upper socio-economic class than the middle and lower class, though no differences were observed in blood pressure and blood glucose level. Of the illnesses, the most common were sinusitis (21.4%), tonsillitis (13.3%) and toothache plus dental caries (10.7%). Conclusions: The most common illnesses were sinusitis, tonsillitis and dental caries. Anthropometric measures indicated that adiposity was not uncommon in rural children. Though adiposity was found higher among the upper than the lower socio-economic class, blood pressure and blood glucose level showed no difference indicating equal risk of non-communicable diseases (NCDs) irrespective of socio-economic class. These findings envisage that the existing status of child health might lead to NCDs in adult life. We suggest adiposity, blood pressure and blood glucose status of a high school cohort may be prospectively followed for eventual future health events. IMC J Med Sci 2020; 14(2): 007. EPub date: 07 March 2021.  DOI: https://doi.org/10.3329/imcjms.v14i2.52828 *Correspondence: Tanjima Begum, Department of Epidemiology and Biostatistics, BIRDEM General Hospital, Shabhag, Dhaka, Bangladesh. Email: tanjima1982@gmail.com   Introduction There were substantial number of studies that addressed health of children, adolescents and adults [1–5]. Some observed nutritional trend from 1975 to 2016 [1] and some found the childhood adiposity [3,6]. But there are very few studies conducted on illness commonly encountered by school children in rural communities of Bangladesh. There has been no published data neither in rural nor even in the urban communities on illness nature of secondary schools. This study was taken to determine the nature and extent of illnesses commonly affecting rural school children. Additionally, the study investigated the association between a) nutrition (adiposity) and socio-economic class, b) adiposity (BMI, WHR, WHtR) and fasting blood glucose (FBG) status and c) adiposity and blood pressure (SBP - systolic blood pressure, DBP - diastolic blood pressure).   Methods The protocol was approved by the Ethical Review Committee of Bangladesh Diabetes Somity (BADAS). Site selection: The study was purposively conducted at six selected schools of Santhia thana under Pabna district. These schools enroll the children from remote villages not connected with roads. Most of the children attend school on foot and in groups. The local elected body of Vulbaria Union Council (UC) under Santhia was communicated. The UC members agreed to cooperate. They suggested the names of schools. The study team discussed the study procedure (clinical history, anthropometry, blood pressure, clinical examination, fasting blood glucose) in detail with the school teachers. The teachers agreed to volunteer to communicate with the students and informed them the procedural details. The students who showed their interest to participate in the study were enlisted by the respective class teachers. Enlistment of participants: The school teachers made the list of willing participants. The students of class five to class ten were considered eligible. The study team discussed with the participants about the objectives and stepwise investigation procedure before the day of investigation. The printed questionnaire sheet was explained to the participants. They were advised to attend the school campus in the next morning in fasting condition. Investigations: Investigations included interviewing, anthropometry, blood pressure measurement, clinical examination, estimation of blood glucose, determination of blood grouping and proteinuria. Each participant was interviewed with the help of the class teacher on: a) clinical history (present illness, medication if any, past illness and treatment); b) mothers’ education and occupation; c) family income and number of family members for assessment of social-economic class. After completion of the interviewing session each student was investigated for a) anthropometry (height, weight, waist- and hip-circumference; b) blood pressure (SBP, DBP); c) fasting blood glucose using glucometer. The anthropometry measurements, blood pressure and fasting blood glucose were determined as cited in the previous study [7]. Finally, blood grouping was done using blood grouping test kit and a semi-quantitative dipstick test kit was used for detection of proteinuria. Then every participant was examined clinically. Both general and systemic examinations were done by the two physicians of the team. General examination determined any gross deformity, anemia, jaundice and edema. Systemic examination included alimentary, respiratory, cardiovascular and musculoskeletal system. Presence of abnormalities of vision (finger count and color), ear (discharge), nose (polyp, septal deviation), throat (tonsils), oral cavity (ulcer, spongy gum), teeth (decay/caries) and skin (scabies, ringworm, pigmentation) were sought. Statistical analyses: The socio-demographic data were presented in percentages. The illness prevalence data were also presented in percentages. Unpaired t-test was applied to compare the characteristics between boys and girls. All the quantitative variables were shown as – a) mean with standard deviation, b) mean with 95% confidence interval (CI). Comparisons of BMI, WHR, WHtR, SBP, DBP and FBG are shown according to social class using ANOVA.   Results A total of 1069 students (boys/girls = 392/677) volunteered the study. The mean age of participants was 13.5 ± 1.47 years. Socio-demographic variables of the participating students are shown in Table-1. More than half of the participants were from the middle and less than a third were from the upper socio-economic class. Almost a third of their mothers were illiterate. More than a half of the mothers had no access to academic education though they knew how to put their signature. Only 3.4% mothers had graduation equivalent to 12 or more years of schooling. As regards mothers’ occupation, almost all were housewives (95.5%). Very few had employment at local rural non-government organization (NGOs). The mean family size of the children was 4.7 (95% CI: 4.63, 4.79).   Table-1: Socio-demographic characteristics of the participants (n = 1069) of school children   Table-2 illustrates the biophysical characteristics of all participants and compares these variables between boys and girls. They were the students of academic class from VI (6th) to X (10th). The mean (± SD) of age was 13.5 (± 1.47) (y); and their height, weight, waist-girth and hip-girth were 153 (± 8.96) cm, 43.2 (± 9.10) kg, 65.3 (± 7.78) cm and 80.4 (± 7.76) cm, respectively. The comparisons between boys and girls showed, despite significantly higher age in the boys, the girls had significantly higher BMI, SBP and DBP; whereas, the boys had significantly higher WHR and FBG.   Table-2: Characteristics of total participants (n = 1069) including comparisons between boys and girls Table-3: Correlations among biophysical variables controlling for age and sex   The investigated biophysical characteristics (age, height, weight, waist, hip, BMI, WHR, WHtR, pulse, SBP, DBP, FBG) were put on view according to sex for each academic class in Table-4a, 4b and 4c. The values were displayed in mean with 95% confidence interval (CI).   Table-4a: The biophysical characteristics are shown according to sex by academic class (mean with 95% CI) Table-4b: The biophysical characteristics are shown according to sex by academic class (mean with 95% CI)   Table-4c: The biophysical characteristics are shown according to sex by academic class (mean with 95% CI)   Table-5 demonstrates the values of the anthropometry at 15th, 85th and 95th levels for possible lower and upper limits of nutrition and adiposity. Likewise, the values of SBP, DBP and FBG at the same levels (15th, 85th and 95th) may be used to assess the trend of metabolic outcomes related to non-communicable diseases.   Table-5: Anthropometric measures, blood pressure and fasting blood glucose levels at 15th, 85th, 95th percentiles are shown separately for male and female students   The complaints or illnesses presented or observed are shown in Table-6. Of the otolaryngologic (ear, nose and throat) illnesses, sinusitis and tonsillitis were the most common complaints or illnesses. Alimentary system including orodental hygiene, though thought to be the most common, only a total of 18% were observed; and of these, tooth decay (dental caries) was the highest (10.7%). Only 711 participants were tested for the presence of proteinuria. Gross proteinuria (3+) was found in 0.4%. For the musculoskeletal system, history of fracture and plaster was observed in 9.3% though there was no deformity. Bone deformity following fracture was found in 1.3%. Testing of blood group revealed that the most common group was B+ve (33.4%), followed by O+ve (27.0%) and A+ve (24.3%).   <![CDATA[Clinical characteristics and factors influencing the outcome of hospitalised COVID-19 patients in a semi-urban primary healthcare center]]> Wasim Md Mohosin Ul Haque Chinmay Saha Podder Nandini Chowdhury Md. Mohim Ibne Sina S.K.M Shameem Kawser Ahammed Kabir Robiul Hasan Md. Arifur Rahman Munshi Asma Akter Arjun Saha Lima Saha Sohel Rana https://imcjms.com/journal_full_text/366 2021-03-18 00:39:19 Original Article IMC J Med Sci 2020; 14(2): 009 Abstract Background and objectives: Various new manifestations and risk factors for COVID-19 have been unveiled in the course of the current pandemic. Understanding the clinical spectrums as well as the risk factors associated with the adverse outcome of the disease is critical to combat this pandemic. This study was conducted to identify the clinical features, overall outcome and the factors associated with adverse outcome of the hospitalised COVID-19 patients in a semi-urban healthcare setting. Methods: This study was conducted at Debidwar Upazila (sub-district) Health Complex under the Cumilla district from April 2020 to October 2020. Reverse transcriptase-polymerase chain reaction (RT-PCR) positive COVID-19 patients, aged 18 years and above, admitted at the Health Complex were enrolled in the study. All patients were followed till their recovery, referral or death. The data were collected in a pre-designed semi-structured questionnaire that included demographic, epidemiological, clinical and laboratory parameters. Result: Out of 50 RT-PCR positiveCOVID-19 adult participants, 30 (60%) were males and 20 (40%) were females. Twenty-four percent, 36%, and 40% of the patients had mild, moderate and severe disease respectively. The most common clinical symptom was fever (96%), followed by cough (86%) and shortness of breath (60%). Hypertension (54%), diabetes mellitus (40%), bronchial asthma (20%) and chronic obstructive pulmonary disease (COPD, 14%) were the major co-morbid conditions. Of the total cases, 2 (4%) died and 8 (16%) required referral to tertiary care hospital while 40 (80%) recovered. COPD was associated with poor outcome (OR 19; 95% CI: 2.88, 125.31; p < 0.05). Smokers were 7 times more likely to exhibit the negative outcome than non-smokers (95% CI: 1.52, 32.33; p < 0.05). Conclusion: In this study, COPD was associated with a negative outcome. Further study with larger sample should be carried out to determine the spectrum of risk factors. IMC J Med Sci 2020; 14(2): 009. DOI: https://doi.org/10.3329/imcjms.v14i2.52829 Co-first author - contributed equally. *Correspondence: Wasim Md Mohosin Ul Haque, Department of Nephrology, BIRDEM General Hospital, 122 Kazi Nazrul Islam Avenue, Dhaka 1000, Bangladesh. Email: wmmhaque@live.com   Introduction Coronavirus disease-19 (COVID-19) is caused by an infection from SARS-CoV-2. With the disease spreading rapidly across continents; the World Health Organization declared it a pandemic on March 11, 2020 [1]. Till 12 January 2021, there have been over 88 million reported cases and over 1.9 million deaths globally since the start of the pandemic [2]. In Bangladesh, about over half a million cases and 8,094 deaths have been reported till the middle of January 2021 [3]. The viral virulence and the clinical spectrum of the disease are changing over time and vary from region to region [4,5]. The clinical outcome depends on various factors namely age, male gender, smoking, and presence of underlying medical conditions such as hypertension, coronary artery disease, chronic obstructive pulmonary disease (COPD), diabetes, obesity and cancer [6-8]. Compared to Germany and South Korea, the case fatality rate was significantly higher in the United States and Italy [5]. Potentially more transmissible variants of SARS-CoV-2 and various new presentations, namely cognitive defect, various skin manifestations, post-COVID inflammatory disorders have been unveiled as the pandemic progresses [9-13]. A full and thorough understanding of the epidemiological and clinical features of COVID-19 is essential to bring the pandemic under control. The current study aimed to find out the spectrum of clinical features, overall outcome and also to identify the potential risk factor(s) for the adverse outcome of the hospitalized COVID-19 patients in a semi-urban healthcare center.   Materials and methods Place of study: The study was conducted at Debidwar Upazila (sub-district) Health Complex (UHC) under the Cumilla district from April 2020 to October 2020. This health complex provides healthcare services to over 430,000 residents of Debidwar Upazila. The study was duly approved by the UHC authority. Informed consent was obtained from each participant prior to the enrollment in the study.   Study design and participants: The study was a prospective observational study conducted on hospitalised reverse transcriptase-polymerase chain reaction (RT-PCR) positive COVID-19 patients aged 18 years and above. Patients who died or were referred to the higher were also included.   Data collection and investigations: The data were collected in a pre-designed semi-structured questionnaire that included demographic, epidemiological, clinical and laboratory parameters. All investigations were conducted on the day of admission or the within one day after admission and were recorded. The repeat RT-PCR was performed 10 days after the first positive RT-PCR test. The patients were examined daily and as needed. All data were entered into the SPSS data sheet.   Admission criteria: Admission criteria included dyspnea with oxygen saturation of less than 94%, presence of multiple co-morbidities, requiring intravenous medication, enoxaparin (anti-coagulants) and isolation. Criteria for cure or recovery from illness were (a) oxygen saturation over 94% for three consecutive days, (b) resolution of fever and afebrile state for at least three days without antipyretics and (c) optimisation of treatment of co-morbidities. Patients who fulfilled the above criteria were discharged from the hospital. Criteria for referral to a higher center included refractory hypoxemia, acute respiratory distress syndrome (ARDS), thromboembolic complications or septic shock.   Case definition: COVID-19 was defined and classified based on clinical management of COVID-19: interim guidance by WHO [14] and national guideline [15]. The cases were categorized as: •  Mild: The clinical symptoms were mild, and there was no sign of pneumonia on imaging. •  Moderate: Fever and respiratory symptoms with radiological findings of pneumonia. Respiratory distress with < 30 breaths/min, pulse oximetry showing saturation > 93% at ambient air. •  Severe: Respiratory distress (≥ 30 breaths/min) or finger oxygen saturation ≤ 93% at rest or arterial partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) ≤ 300 mmHg. •  Critical: Respiratory failures and requiring mechanical ventilation or presence of shock with organ failures that require intensive care unit (ICU) care.   Study outcomes: The primary endpoint of the study was defined as "discharge after recovery" or death/referral to higher center. The secondary endpoint was the duration of hospital stay of the recovered patients. Discharge after recovery was considered a positive outcome whereas death/referral was considered a negative outcome.   Statistical analysis: Continuous variables were expressed as the mean ± standard deviation (SD) for the normally distributed data or the median for the skewed data. Similarly, the independent t-test and Mann-Whitney U-test were used to determine the difference between the groups. Categorical variables were described as number (%). Binary logistic regression was performed to determine the potential risk factors associated with the endpoint. The statistical significance was defined as p < 0.05. Result     Table-2: Pattern of co-morbidities of the study population       Table-4: Duration of illness at the time of admission (in days)       Table-6: Findings of the X-Ray chest P/A view (n=50)     Of the 34 patients re-tested, nearly all (82.4%) became RT-PCR negative for the virus by 10 days (Table-8). The median time of hospital stay was 6 days with a minimum of 1 day and a maximum of 40 days. Forty patients (80%) had recovered and were discharged after a median time of 7 days (Table-9), two patients died, and rest of the 8 patients were transferred to higher centers for respiratory support. The patients who died or were transferred to the higher center had significantly lower hospital stay time (mean 2.82 ± 2.9 days, minimum of 1 day to maximum 9 days with a median of 1 day) than those who discharged (mean 8.87 ± 6.9 days, minimum 3 days to maximum 40 days with a median of 7 days; 95% CI: 2.259, 11.091; p < 0.05). Based on median hospitalisation time, 15 (37.5%) patients who recovered had extended hospital stay of more than 7 days. Table-9: Outcome of the patients at the end of follow-up     Table-10: Univariate logistic regression analysis showing impact of risk factors on outcome (death/referral)   Table-11: Logistic regression analysis showing the influence of age and sex on outcome   Table-12: Multivariate logistic regression analysis showing the impact of the individual risk factor     Table-13: Univariate logistic regression showing impact of clinical parameters at admission on outcome (death/referral)   Discussion This study was conducted at a resource constraint rural healthcare center. However, all the COVID-19 patients who were included in the study were prospectively followed up to the endpoint, and relevant data were recorded systematically. The patients were closely monitored and treated following the national guideline. We documented the range of presentations and try to ascertain the probable risk factor(s) for unfavourable outcomes. Most of the COVID-19 cases in this study were male. Although the gender distribution for COVID-19 infection is conflicting [16], other Bangladeshi studies and studies from neighbouring countries show strong male predilection [17-27]. In a recent meta-analysis of 1994 COVID-19 patients, 60% (95% CI: 0.54, 0.65) were male [23], but in another meta-analysis, this deference was only minimal; the ratio of men to women was 1:0.9 [28]. The higher infection rate in male was explained by a higher expression of the angiotensin-converting enzyme 2 (ACE2) receptor in men [29]. Nevertheless, this issue is still controversial [30]. Other factors namely, less outdoor activity and less chance of contact of women with an infected person in this part of the world might contribute in lower rates of infection among women [23]. Women show more robust innate and humoral immune responses, and this may be another contributing factor to the lower infection rate in women [31]. Also, hygiene practices and compliance with the rules of personal protection and social distancing are more common among women [30,32]. Male patients in our study had a significantly worse outcome than women, which is a recognised finding of the COVID-19 outcome globally [23,28,30,33]. It is unclear why men are more prone to developing serious diseases, but immunological status can contribute to poorer outcomes in male patients. Men and women show a clear difference in the reactions of the immune system, with women producing more robust immune responses to pathogens [31,34]. This difference in immune response can make a significant contribution to viral load, disease severity and mortality [33]. Differences in the sex hormones could also be a determinant of viral infections since oestrogen has immune-stimulatory effects while testosterone has immunosuppressive effects [35]. Another critical factor is the higher prevalence of smoking in men which could adversely affect the respiratory system and influence the outcome with SARS-CoV-2 infections [36]. Most of our participants were middle-aged, which correlates with other Bangladeshi studies as well as studies from other Asian countries [18,21,22,37,38]. However, in Western countries, due to the large number of elderly people, the average age of COVID-19 cases is relatively higher [39,40]. Age is a major contributor to poor outcomes in patients with COVID-19 [41-44]. In our study, however, we found no significant influence of age on disease severity or mortality. In a meta-analysis of 12 studies focused on quantifying the isolated influence of age on severe COVID-19 outcomes, Starke et al. found a 2.7% increase in the risk of disease severity per year and almost no risk of age-related death. It seems that age-related co-morbidities carry more weight than age itself [45]. Diabetes and hypertension were the two most common co-morbidities in our study population, which correlates with the results of other studies [46,47]. In a meta-analysis of 10 Chinese studies, Singh et al. found that almost 21% of the study population had HTN and 11% had diabetes. In this study, they found increased mortality with these co-morbidities in patients with COVID-19 [47]. In another meta-analysis by de Almeida-Pititto et al. found that diabetes mellitus and hypertension were moderately associated with severity and mortality in COVID-19 (diabetes: OR 2.35; 95% CI: 1.80, 3.06 and OR 2.50; 95% CI: 1.74, 3.59; hypertension: OR 2.98; 95% CI: 2.37, 3.75 and OR 2.88; 95% CI: 2.22, 3.74) [48]. Parveen et al. in a systematic literature review and exploratory meta-analysis also concluded the same [49]. However, in our study, we found no association between the adverse outcomes and diabetes or hypertension, which so far was unexplained. Within the critical co-morbidities, COPD had a significantly negative impact on the outcome in our cohort, which correlates with other national and international studies [50-52]. In a systematic review and meta-analysis, Zhao et al. have shown that the presence of COPD is associated with a nearly fourfold higher risk of developing severe COVID‐19 (OR 4.38; 95% CI: 2.34, 8.2) and OR of COPD for death was 1.93 (95%CI: 0.59, 7.43) [53]. In our study, significantly higher proportion of smokers had to be transferred to the higher center or succumbed to the disease. Smoking has been reported as one of the most important causes of adverse COVID-19 outcome [54,55]. It was found in a meta-analysis by Zhao et al. that smoking doubled the risk of severe COVID-19 (OR 1.98; 95% CI: 1.29, 3.05) [53]. In another meta-analysis of 19 peer-reviewed articles covering 11,590 COVID-19 patients, Patanavanich et al. found a significant association between smoking and the progression of COVID-19 (OR 1.91; 95% CI: 1.42, 2.59; p = 0.001) [54]. Smoking upregulates the ACE2 receptor; a potential adhesion site for the SARS-CoV-2 and might be responsible for severe disease in smokers and patients with COPD [56]. Contrary to general agreements, few studies have not found a detrimental effect of current smoking on the outcome of COVID-19 [38,57-59], this may be due to misclassification of smoking, or due to the under-reporting of smoking in these cohorts [60]. In our study, after adjusting the impact of COPD and other risk factors, the significance of smoking on the outcome disappeared. COPD is a well-known consequence of long-term smoking. All of the COPD patients in this study were smokers. Therefore, it was not clear whether the negative outcome of COVID-19 patients was due to the effects of current smoking or due to the sequelae of long-term smoking. In any case, smoking, at present or in the past, is a risk factor and should be considered in evaluating COVID-19 pateints. Finally, Mahabee-Gittens et al. raised concern about the transmission of SARS-CoV-2 through vapour and smoke and urged to quit both indoor smoking and vaping [61]. We did not found any association between other co-morbidities and COVID-19 outcome. In this cohort, fever was the most common symptom as in the other cohorts [22,46]. Most patients have had severe disease, but this does not reflect the true picture of the severity of the disease in the community as patients with milder disease usually do not require hospitalisation [15]. Patients sought hospitalisation at the end of the first week of symptom onset in our study, which correlated with the timing of symptom worsening if they had not already recovered. However, from the onset of symptoms to hospitalisation time was shorter in the early stages of the pandemic, in a study in Shanghai, between January 2020 and February 2020, the time between the onset of symptoms and hospitalisation in symptomatic patients was 4 days (2-7 days) [62]. In our cohort, two patients had an altered level of consciousness; a recent study found that altered mental state may be the first manifestation of COVID-19 in elderly patients [63]. However, in our cases, an altered level of consciousness could be due to hypoxia [64,65]. Respiratory rate and SpO2 at admission had a significant impact on the outcome; higher respiratory rate and lower SpO2 were associated with increased death and referral to a higher center in our cohort. In a retrospective study of 6,493 hospitalised COVID-19 patients, Mikami et al. found a respiratory rate greater than 24 per minute and peripheral oxygen saturation less than 92% were associated with about two times increased in mortality (HR 1.43; 95% CI: 1.13, 1.83; HR 2.12, 95% CI: 1.56, 2.88) [66]. In an American cohort of 1,461 hospitalised COVID-19 patients, Bahl et al. found a similar picture, in multivariable analysis. Low oxygen saturation and elevated respiratory rate on admission were associated with increased in-hospital mortality [67]. We did not found any association between other clinical and laboratory parameters and COVID-19 outcome. The study had some limitations. The study was conducted at a resource-poor setup on small number of patients and not all necessary investigations were conducted. Post transfer data of the referred patients’ could not be collected and also no detailed smoking history of every case was available. In this study, COPD was associated with a negative outcome. However, we did not find any association between many established risk factors (age, DM, HTN) and adverse COVID-19 outcome in our study. Extensive prospective studies should be carried out to identify the risk factors influencing the outcome of COVID-19 in our population at different health care settings.   Author’s contribution: WMMH – study planning, data analysis, manuscript writing; CSP – study planning, patient recruitment and management, data collection; NC – data collection and entry, patient management; MMIS – patient management, data entry; SKMSK – patient management, data collection; AK – overall supervision of isolation unit; RH, MARM, AA, AS, LS, SR – patient management.   Conflict of interest: none   References 1.     World Health Organisation. WHO Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020. Geneva: World Health Organisation; 2020. 2.     World Health Organisation. COVID-19 weekly epidemiological update, 12 January 2021. Geneva: World Health Organisation; 2021. 3.     Worldometer. COVID-19 coronavirus pandemic. United States of America: Worldometer; 2021. 4.     Noor AU, Maqbool F, Bhatti ZA, Khan AU. Epidemiology of CoViD-19 pandemic: Recovery and mortality ratio around the globe. Pak J Med Sci. 2020; 36(COVID19-S4): S79-S84. 5.     Khafaie MA, Rahim F. Cross-country comparison of case fatality rates of COVID-19/SARS-COV-2. Osong Public Health Res Perspect. 2020; 11(2): 74-80. 6.     Onder G, Rezza G, Brusaferro S. Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy. JAMA. 2020; 323(18): 1775-1776. 7.     Cao Y, Hiyoshi A, Montgomery S. COVID-19 case-fatality rate and demographic and socioeconomic influencers: worldwide spatial regression analysis based on country-level data. BMJ Open. 2020; 10(11): e043560. 8.     Islam MZ, Riaz BK, Islam ANMS, Khanam F, Akhter J, Choudhury R, et al. Risk factors associated with morbidity and mortality outcomes of COVID-19 patients on the 28th day of the disease course: a retrospective cohort study in Bangladesh. Epidemiol Infect. 2020; 148: e263. 9.     Datta SD, Talwar A, Lee JT. A proposed framework and timeline of the spectrum of disease due to SARS-CoV-2 infection: illness beyond acute infection and public health implications. JAMA. 2020; 324(22): 2251-2252. 10.  Wise J. Covid-19: new coronavirus variant is identified in UK. BMJ. 2020; 371: m4857. 11.  Mahase E. Covid-19: what have we learnt about the new variant in the UK? BMJ. 2020; 371: m4944. 12.  Alonso-Lana S, Marquié M, Ruiz A, Boada M. Cognitive and neuropsychiatric manifestations of COVID-19 and effects on elderly individuals with dementia. Front Aging Neurosci. 2020; 12: 588872. 13.  Genovese G, Moltrasio C, Berti E, Marzano AV. Skin manifestations associated with COVID-19: current knowledge and future perspectives. Dermatology. 2021; 237(1): 1-12. 14   .World Health Organization. Clinical management of COVID-19: interim guidance, 27 May 2020. Geneva: World Health Organisation; 2020. 62 p. Report No.: WHO/2019-nCoV/clinical/2020.5. 15.  Disease Control Division. Directorate General of Health Services. Ministry of Health & Family Welfare. Government of the People’s Republic of Bangladesh. National Guidelines on clinical management of coronavirus disease 2019 (COVID-19). Bangladesh: Directorate General of Health Services, Ministry of Health & Family Welfare; 2020. Version 7.0. 16.  Kopel J, Perisetti A, Roghani A, Aziz M, Gajendran M, Goyal H. Racial and gender-based differences in COVID-19. Front Public Health. 2020; 8: 418. 17.  FaizulHuq A, Rahman MF, Islam MA, Iqbal SA, Rahman A, Abdullah SAHM, et al. Real-life management strategy of COVID-19 patients in Bangladesh with no death: an observational and cohort study. Euroasian J Hepatogastroenterol. 2020; 10(1): 31-35. 18.  Asghar MS, Kazmi SJH, Khan NA, Akram M, Khan SA, Rasheed U, et al. Clinical profiles, characteristics, and outcomes of the first 100 admitted COVID-19 patients in Pakistan: a single-center retrospective study in a tertiary care hospital of Karachi. Cureus. 2020; 12(6): e8712. 19.  Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020; 382(18): 1708-1720. 20.  Siam MHB, Hasan MM, Tashrif SM, Khan MHR, Raheem E, Hossain MS. Insights into the first seven-months of COVID-19 pandemic in Bangladesh: lessons learned from a high-risk country. Research Square; 2020. 21.  Mowla S, Azad K, Kabir A, Biswas S, Islam MR, Banik G, et al. Clinical profile of 100 confirmed COVID-19 patients admitted in Dhaka Medical College Hospital, Dhaka, Bangladesh. J Bangladesh Coll Phys Surg. 2020; 38: 29-36. 22.  Hossain HT, Chowdhury T, Majumder MI, Ava AR, Rahman QAA, Zahiruddin M, et al. Demographic and clinical profile of 190 COVID-19 patients in a tertiary care private hospital of Dhaka, Bangladesh: an observational study. J Medicine. 2020; 21(2): 82-88. 23.  Li LQ, Huang T, Wang YQ, Wang ZP, Liang Y, Huang TB, et al. COVID-19 patients' clinical characteristics, discharge rate, and fatality rate of meta-analysis. J Med Virol. 2020; 92(6): 577-583. 24.  Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020; 395(10223): 497-506. 25.  Guan WJ, Liang WH, Zhao Y, Liang HR, Chen ZS, Li YM, et al. Comorbidity and its impact on 1590 patients with COVID-19 in China: a nationwide analysis. Eur Respir J. 2020; 55(5): 2000547. 26.  Gupta N, Agrawal S, Ish P, Mishra S, Gaind R, Usha G, et al. Clinical and epidemiologic profile of the initial COVID-19 patients at a tertiary care centre in India. Monaldi Arch Chest Dis. 2020; 90(1). 27.  Haque H, Ahmed A, Habib S, Sulzana M, Ghosh R, Shreya P, et al. Clinical and laboratory parameters of confirmed and probable COVID-19 patients: experience from a tertiary care hospital of Bangladesh. BIRDEM Med J. 2020; 10(COVID Supplement): 6-11. 28.  Ortolan A, Lorenzin M, Felicetti M, Doria A, Ramonda R. Does gender influence clinical expression and disease outcomes in COVID-19? A systematic review and meta-analysis. Int J Infect Dis.2020; 99: 496-504. 29.  Zhao Y, Zhao Z, Wang Y, Zhou Y, Ma Y, Zuo W. Single-cell RNA expression profiling of ACE2, the receptor of SARS-CoV-2. Am J Respir Crit Care Med. 2020; 202(5): 756-759. 30.  Ahmed SB, Dumanski SM. Sex, gender and COVID-19: a call to action. Can J Public Health. 2020; 111(6): 980-983. 31.  Schurz H, Salie M, Tromp G, Hoal EG, Kinnear CJ, Möller M. The X chromosome and sex-specific effects in infectious disease susceptibility. Hum Genomics. 2019; 13(1): 2. 32.  Guzek D, Skolmowska D, Głąbska D. Analysis of gender-dependent personal protective behaviors in a national sample: Polish adolescents' COVID-19 experience (PLACE-19) study. Int J Environ Res Public Health. 2020; 17(16): 5770. 33.  Pradhan A, Olsson PE. Sex differences in severity and mortality from COVID-19: are males more vulnerable? Biol Sex Differ. 2020; 11(1): 53. 34.  Klein SL, Flanagan KL. Sex differences in immune responses. Nat Rev Immunol. 2016; 16(10): 626-638. 35.  Taneja V. Sex hormones determine immune response. Front Immunol. 2018; 9: 1931. 36.  Pampel FC. Global patterns and determinants of sex differences in smoking. Int J Comp Sociol. 2006; 47(6): 466-487. 37.  Qian GQ, Yang NB, Ding F, Ma AHY, Wang ZY, Shen YF, et al. Epidemiologic and clinical characteristics of 91 hospitalized patients with COVID-19 in Zhejiang, China: a retrospective, multi-centre case series. QJM. 2020; 113(7): 474-481. 38.  Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020; 382(18): 1708-1720. 39.  Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA. 2020; 323(20): 2052-2059. 40.  Colaneri M, Sacchi P, Zuccaro V, Biscarini S, Sachs M, Roda S, et al. Clinical characteristics of coronavirus disease (COVID-19) early findings from a teaching hospital in Pavia, North Italy, 21 to 28 February2020. Euro Surveill. 2020; 25(16): 2000460. 41.  Chen T, Dai Z, Mo P, Li X, Ma Z, Song S, et al. Clinical characteristics and outcomes of older patients with coronavirus disease 2019 (COVID-19) in Wuhan, China: A single-centered, retrospective study. J Gerontol A Biol Sci Med Sci. 2020; 75(9): 1788-1795. 42.  Chen T, Wu D, Chen H, Yan W, Yang D, Chen G, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ. 2020; 368: m1091. 43.  Dudley JP, Lee NT. Disparities in age-specific morbidity and mortality from SARS-CoV-2 in China and the Republic of Korea. Clin Infect Dis. 2020; 71(15): 863-865. 44.  Verity R, Okell LC, Dorigatti I, Winskill P, Whittaker C, Imai N, et al. Estimates of the severity of coronavirus disease 2019: a model-based analysis. Lancet Infect Dis. 2020; 20(6): 669-677. 45.  Starke KR, Petereit-Haack G, Schubert M, Kämpf D, Schliebner A, Hegewald J, et al. The age-related risk of severe outcomes due to COVID-19 infection: a rapid review, meta-analysis, and meta-regression. Int J Environ Res Public Health. 2020; 17(16): 5974. 46.  Mowla SGM, Azad KAK, Kabir A, Biswas S, Islam MR, Banik GC, et al. Clinical profile of 100 confirmed COVID-19 patients admitted in Dhaka Medical College Hospital, Dhaka, Bangladesh. J Bangladesh Coll Phys Surg. 2020; 38: 29-36. 47.  Singh AK, Gupta R, Misra A. Comorbidities inCOVID-19: outcomes in hypertensive cohort and controversies with renin angiotensin system blockers. Diabetes Metab Syndr. 2020; 14(4): 283-287. 48.  de Almeida-Pititto B, Dualib PM, Zajdenverg L, Dantas JR, de Souza FD, Rodacki M, et al. Severity and mortality of COVID 19 in patients with diabetes, hypertension and cardiovascular disease: a meta-analysis. Diabetol Metab Syndr. 2020; 12(1): 75. 49.  Parveen R, Sehar N, Bajpai R, Agarwal NB. Association of diabetes and hypertension with disease severity in covid-19 patients: a systematic literature review and exploratory meta-analysis. Diabetes Res Clin Pract. 2020; 166: 108295. 50.  Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020; 395(10229): 1054-1062. 51.  Wang K, Zuo P, Liu Y, Zhang M, Zhao X, Xie S, et al. Clinical and laboratory predictors of in-hospital mortality in patients with coronavirus disease-2019: a cohort study in Wuhan, China. Clin Infect Dis. 2020; 71(16): 2079-2088. 52.  Yang X, Yu Y, Xu J, Shu H, Xia Ja, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020; 8(5): 475-481. 53.  Zhao Q, Meng M, Kumar R, Wu Y, Huang J, Lian N, et al. The impact of COPD and smoking history on the severity of COVID-19: a systemic review and meta-analysis. J Med Virol. 2020; 92(10): 1915-1921. 54.  Patanavanich R, Glantz SA. Smoking is associated with COVID-19 progression: a meta-analysis. Nicotine Tob Res. 2020; 22(9): 1653-1656. 55.  Gülsen A, Yigitbas BA, Uslu B, Drömann D, Kilinc O. The effect of smoking on COVID-19 symptom severity: systematic review and meta-analysis. Pulm Med. 2020; 2020: 7590207. 56.  Brake SJ, Barnsley K, Lu W, McAlinden KD, Eapen MS, Sohal SS. Smoking upregulates angiotensin-converting enzyme-2 receptor: a potential adhesion site for novel coronavirus SARS-CoV-2 (Covid-19). J Clin Med. 2020; 9(3): 841.  57.  Rossato M, Russo L, Mazzocut S, Di Vincenzo A, Fioretto P, Vettor R. Current smoking is not associated with COVID-19. Eur Respir J. 2020; 55(6): 2001290. 58.  Guan WJ, Liang WH, Zhao Y, Liang HR, Chen ZS, Li YM, et al. Comorbidity and its impact on 1590 patients with Covid-19 in China: a nationwide analysis. Eur Respir J. 2020; 55(5): 2000547. 59.  Lippi G, Henry BM. Active smoking is not associated with severity of coronavirus disease 2019 (COVID-19). Eur J Intern Med. 2020; 75: 107-108. 60.  Leung JM, Yang CX, Sin DD. Reply to: “Current smoking is not associated with COVID-19”. Eur Respir J. 2020; 55(6): 2001340. 61.  Mahabee-Gittens EM, Merianos AL, Matt GE. Letter to the Editor regarding: “An imperative need for research on the role of environmental factors in transmission of novel coronavirus (COVID-19)” — secondhand and thirdhand smoke as potential sources of COVID-19. Environ Sci Technol. 2020; 54(9): 5309-5310. 62.  Chen J, Qi T, Liu L, Ling Y, Qian Z, Li T, et al. Clinical progression of patients with COVID-19 in Shanghai, China. J Infect. 2020; 80(5): e1-e6. 63.  Ward CF, Figiel GS, McDonald WM. Altered mental status as a novel initial clinical presentation for COVID-19 infection in the elderly. Am J Geriatr Psychiatry. 2020; 28(8): 808-811. 64.  Goodall S, Twomey R, Amann M. Acute and chronic hypoxia: implications for cerebral function and exercise tolerance. Fatigue. 2014; 2(2): 73-92. 65.  Garg RK, Paliwal VK, Gupta A. Encephalopathy in patients with COVID-19: a review. J Med Virol. 2021; 93(1): 206-222. 66.  Mikami T, Miyashita H, Yamada T, Harrington M, Steinberg D, Dunn A, et al. Risk factors for mortality in patients with COVID-19 in New York City. J Gen Intern Med. 2021; 36(1): 17-26.  67.  Bahl A, Van Baalen MN, Ortiz L, Chen NW, Todd C, Milad M, et al. Early predictors of in-hospital mortality in patients with COVID-19 in a large American cohort. Intern Emerg Med. 2020; 15(8): 1485-1499. <![CDATA[Melioidosis by aminoglycoside susceptible Burkholderia pseudomallei: First case in Bangladesh]]> Saika Farook Md. Shariful Alam Jilani Alpona Akhter J. Ashraful Haq https://imcjms.com/journal_full_text/354 2020-10-18 23:02:50 Clinical Case Report IMC J Med Sci 2020; 14(2): 003 Abstract Burkholderia pseudomallei is the etiological agent of melioidosis. It is a gram-negative bacillus present in environment and intrinsically resistant to many antibiotics including aminoglycosides. However, recently aminoglycoside susceptible B. pseudomallei has been isolated from melioidosis cases and reported from some countries of the world. But, such aminoglycoside susceptible B. pseudomallei has never been detected in Bangladesh either from melioidosis cases or from environment. All the B. pseudomallei isolated so far in Bangladesh were resistant to gentamicin and other aminoglycosides.  Here, we describe a disseminated case of melioidosis caused by aminoglycoside susceptible B. pseudomallei in a 55 years old Bengali male patient. This is the first case of melioidosis due to aminoglycoside susceptible B. pseudomallei in Bangladesh. IMC J Med Sci 2020; 14(2): 003. EPub date: 19 October 2020. DOI: https://doi.org/10.3329/imcjms.v14i2.52830 *Correspondence: Md. Shariful Alam Jilani, Department of Microbiology, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka 1000, Bangladesh. e-mail: jilanimsa@gmail.com   Introduction   Case Summary A 55 years old smoker, non-diabetic male presented with a 3 month history of high grade fever, non productive cough and weight loss. About a year back, he developed intermittent to high grade fever, cough and loss of appetite and was diagnosed as a smear negative pulmonary tuberculosis case and treated accordingly in a local hospital. Initially, his symptoms improved, but about 3 months back he gradually developed high grade fever again, the highest recorded temperature being 1040F. With deteriorating symptoms he was admitted to Medicine unit of Dhaka Medical College Hospital. Four days after admission he developed pain and swelling on the left elbow. About 1 month following admission, the patient developed sudden, severe headache along with a single episode of vomiting followed by restlessness and disorientation. He had 5 episodes of seizures in 2 days with loss of consciousness (Glasgow Coma Scale was 3/15). On general examination, patient was mildly anemic, dyspneic and the temperature was 1030F. Respiratory system examination revealed features suggestive of consolidation. The left elbow joint was erythematous, swollen (4cm×4cm), tender without any discharge or regional lymphadenopathy. Liver was just palpable. Blood analysis yielded haemoglobin 9.6 g/dl, ESR 70 mm at first hour, total white cell count 6.8x109/L, platelets 70x109/L, SGPT 80 U/L and SGOT 173 U/L. HbsAg and anti HBc IgM was positive. Chest radiograph showed patchy and in-homogenous opacities in both upper, mid and right lower zone of both lungs (Fig-1).  Blood, sputum, urine and cerebrospinal fluid (CSF) culture yielded no growth. Sputum for acid fast bacilli (AFB) and Mycobacterium tuberculosis by Ziehl–Neelsenstain and MTB/RIF-GeneXpert test was negative respectively. Ultrasonography of whole abdomen revealed mild hepatosplenomegaly and grossly enlarged prostate. Magnetic resonance imaging (MRI) of brain exhibited features suggestive of venous infarct due to suspected venous thrombosis involving superior sagittal sinus.   Fig.1: Chest X-Ray P/A view showing patchy opacities in upper, middle and lower zone of lungs   Pus was aspirated from the left elbow joint swelling using a sterile syringe. Gram stain of the pus showed gram-negative bacilli arranged in bipolar ‘safety pin’ pattern. Culture of the pus yielded growth of gram-negative and oxidase positive bacilli in Blood and MacConkey agar media, but no growth was detected on modified Ashdown’s selective media containing gentamicin 5µg/ml. The isolate was identified as B. pseudomallei by colony morphology and biochemical tests [8]. The isolate was further confirmed by monoclonal antibody based latex agglutination test for B. pseudomallei(Melioidosis Research Center, Khon Kaen, Thailand). Polymerase Chain Reaction (PCR) and Loop Mediated Isothermal Amplification based assay (LAMP) using B. pseudomallei specific primers (Table-1) were also performed for further confirmation of the isolate. Both PCR and LAMP tests confirmed the isolate as B. pseudomallei (Fig-2 and Fig-3). The isolate was sensitive to ceftazidime, meropenem, amoxicillin+clavulinic acid, piperacillin+ tazobactem and aminoglycosides namely gentamicin, amikacin and netilmicin (Table-2) and resistant to trimethoprim- sulphamethoxazole (TMP-SMX) and colistin. Since aminoglycoside susceptible B. pseudomallei was never been detected in Bangladesh further enquiry was made to track the possible source of the organism. On enquiry, it was found that he had been a construction worker in Malacca, Malaysia for the past 10 years where he developed high grade intermittent fever, cough and loss of appetite about a year ago and then he returned to Bangladesh. Based on the above, the patient was finally diagnosed as a case of disseminated melioidosis by aminoglycoside susceptible B. pseudomallei. Probably, the patient could have acquired the infection while in Malaysia because such aminoglycoside susceptible B. pseudomallei strains are prevalent there. The patient was successfully treated with standard antibiotic regimen for melioidosis and discharged with improved general condition.     Table-1: Primers targeting TTS1 gene used in conventional PCR [9] and in-house LAMP [10]     Table-2: Results of disc diffusion and MIC tests of isolated B. pseudomallei     Discussion In Bangladesh, the first case of melioidosis was reported in 1988 [12]. Since then, about 54 human melioidosis cases from different districts of Bangladesh have been recorded till 2018 [13]. In addition, B. pseudomallei was isolated from soil samples of Gazipur district [14], rendering Bangladesh as a ‘definite’ melioidosis endemic country. B. pseudomallei is known to be intrinsically resistant to aminoglycosides [2]. Resistance to aminoglycosides and colistin is an important identification criterion for B. pseudomallei. All B. pseudomallei that have been isolated in Bangladesh till now were resistant to amikacin and gentamicin by both Kirby-Bauer disk diffusion and MIC method [7]. However, aminoglycoside sensitive B. pseudomallei have been isolated in certain regions of Southeast Asia and Australia [3-6]. There have been reports of rare cases of melioidosis due to aminoglycoside susceptible strains (0.1%) in Thailand [5] and in Australia [6]. On the contrary, 86% of B. pseudomallei isolates in Sarawak, Malaysian Borneo were found sensitive to Gentamicin [3]. However, in Kedah, Malaysia, about 21% and 6% of isolates were susceptible to gentamicin and amikacin respectively [4].  Resistance to aminoglycosides in B. pseudomallei is due to amrAB-oprA-mediated efflux [5,15]. Studies comprising of genome sequencing have revealed that a mutation or absence of amr-B transcripts that encodes for the multidrug efflux system accounts for the susceptibility to aminoglycosides as well as macrolides in the aforementioned isolates [3-4]. Apparently, our patient with disseminated melioidosis was residing in Malacca, Malaysia for the past 10 years. So, it could be reasonably assumed that this particular strain could be acquired in Malaysia where aminoglycoside susceptible strains had previously been detected. However, we should not dismiss the possibility of presence of such aminoglycoside susceptible strains indigenously in Bangladesh. True origin of our aminoglycoside susceptible isolate could be determined if we could do sequence analysis or multilocus sequence typing. In a resource limited country like ours, culture of B. pseudomallei constitutes the diagnostic gold standard. Intrinsic resistance of B. pseudomallei to aminoglycosides is used for the development of selective media for its isolation from samples like sputum or soil that contain other organisms. This particular case demonstrates that the use of gentamicin incorporated selective media might fail to detect such susceptible strains and would undermine the true extent of its presence in environment and clinical samples.   Author contributions SF did the experiments and wrote the manuscript; MSAJ supervised the work and contributed in writing the manuscript; AA collected the clinical data and involved in the management of the patient; JAHcontributed in writing and editing the manuscript.   Conflict of interest The authors hereby, declare that no conflict of interest exists   Ethical statement Written consent was obtained from the patient for publication of the case.   Funding This study was partly funded by Ibrahim Medical College   References 1.     Jenney AW, Lum G, Fisher DA, Currie BJ. Antibiotic susceptibility of Burkholderia pseudomallei from tropical northern Australia and implications for therapy of melioidosis. Int J  Antimicrob Agents. 2001; 17(2): 109-13. 2.     Dance DA, Wuthiekanun V, Naigowit P, White NJ. Identification of Pseudomonas pseudomallei in clinical practice: use of simple screening tests and API 20NE. J Clin Pathol. 1989; 42(6): 645-8. 3.     Podin Y, Sarovich DS, Price EP, Kaestli M, Mayo M, Hii K, Ngian H, Wong S, Wong I, Wong J, Mohan A. Burkholderia pseudomallei isolates from Sarawak, Malaysian Borneo, are predominantly susceptible to aminoglycosides and macrolides. Antimicrob Agents Chemother. 2014; 58(1): 162-6. 4.     Hassan MR, Vijayalakshmi N, Pani SP, Peng NP, Mehenderkar R, Voralu K, Michael E. Antimicrobial susceptibility patterns of Burkholderia pseudomallei among melioidosis cases in Kedah, Malaysia. Southeast Asian J Trop Med Public Health. 2014; 45(3): 680. 5.     Trunck LA, Propst KL, Wuthiekanun V, Tuanyok A, Beckstrom-Sternberg SM, Beckstrom-Sternberg JS, Peacock SJ, Keim P, Dow SW, Schweizer HP. Molecular basis of rare aminoglycoside susceptibility and pathogenesis of Burkholderia pseudomallei clinical isolates from Thailand. PLOS Negl Trop Dis. 2009; 3(9): 519. 6.     Price EP, Sarovich DS, Mayo M, Tuanyok A, Drees KP, Kaestli M, Beckstrom-Sternberg SM, Babic-Sternberg JS, Kidd TJ, Bell SC, Keim P. Within-host evolution of Burkholderia pseudomallei over a twelve-year chronic carriage infection. mBio. 2013; 4(4). 7.     Dutta S, Haq S, Hasan MR, Haq JA. Antimicrobial susceptibility pattern of clinical isolates of Burkholderia pseudomallei in Bangladesh. BMC Res Notes. 2017; 10(1): 1-5. 9.     Novak RT, Glass MB, Gee JE, Gal D, Mayo MJ, Currie BJ, Wilkins PP. Development and evaluation of a real-time PCR assay targeting the type III secretion system of Burkholderia pseudomallei. J Clin Microbiol. 2006; 44(1): 85-90. 10.  Farook S. Development of Loop Mediated Isothermal Amplification based assay for the rapid detection of Burkholderia pseudomallei [Thesis]. Dhaka, Bangladesh: Bangabandhu Sheikh  Mujib Medical University. July, 2020. 11.  Performance standards for antimicrobial susceptibility testing M100. Thirtieth Informational Supplement, vol. 39. Wayne: Clinical and Laboratory Standards Institute; 2020. 12.  Struelens MJ, Mondol G, Bennish M, Dance DA. Melioidosis in Bangladesh: a case report. Trans R Soc of Trop Med Hyg. 1988; 82(5): 777-8. 13.  Chowdhury FR, Jilani M, Alam S, Barai L, Rahman T, Saha MR, Amin M, Fatema K, Islam KM, Faiz MA, Dunachie SJ. Melioidosis in Bangladesh: a clinical and epidemiological analysis of culture-confirmed cases. Trop Med Infect Dis. 2018; 3(2): 40. 14.  Jilani MS, Robayet JA, Mohiuddin M, Hasan MR, Ahsan CR, Haq JA. Burkholderia pseudomallei: its detection in soil and seroprevalence in Bangladesh. PLOS Negl Trop Dis. 2016; 10(1): e0004301. 15. Moore RA, DeShazer D, Reckseidler S, Weissman A, Woods DE. Efflux-mediated aminoglycoside and macrolide resistance in Burkholderia pseudomallei. Antimicrob. Agents Chemother. 1999; 43:465-470. <![CDATA[Diagnostic tests for SARS-CoV-2: current status and issues]]> Sraboni Mazumder Md Monirul Hoque https://imcjms.com/journal_full_text/355 2020-10-24 01:01:32 Review IMC J Med Sci 2020; 14(2): 004 Abstract The current coronavirus disease 2019 (COVID-19) pandemic has affected the whole world. Accurate, rapid and affordable diagnostic testing for COVID-19 is crucial to prevent and control this global pandemic. This paper reviews the current status and issues related to diagnostic tests for COVID-19. IMC J Med Sci 2020; 14(2): 004. EPub date: 24 October 2020. DOI: https://doi.org/10.3329/imcjms.v14i2.52831 *Correspondence: Sraboni Mazumder, Department of Microbiology, Ibrahim Medical College, 1/A Ibrahim Sarani, Shegun Bagicha, Dhaka, Bangladesh. Email: mazumder.sraboni@gmail.com   Introduction The current outbreak of coronavirus disease 2019 (COVID-19) which emerged in Wuhan, China, is caused by a novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1]. World Health Organization (WHO) declared SARS-CoV-2 a pandemic on March 11, 2020 [2]. Accurate, rapid and affordable diagnostic testing for COVID-19 is crucial to prevent and control this global pandemic. The global approach to SARS-CoV-2 testing has been non-uniform. In South Korea, individuals with respiratory illness and any contacts with COVID-19 are tested whereas Spain initially limited testing to individuals with severe symptoms or those at high risk of developing them [3]. The vital role of highly sensitive and specific diagnostic assay in the control of infectious epidemic was evidenced around two decades back, in 2002/2003, when SARS-CoV emerged in Southeast Asia and when MERS-CoV emerged in Middle East back in 2012. The concerted efforts of public health authorities by means of rapid testing of suspected cases interrupted the chain of transmission and helped contain the outbreak. Moreover, valid, rapid, sensitive and specific laboratory diagnostic tools are essential for proper case identification, timely management of the patients, contact tracing, animal source finding, and rationalization of infection control measures in COVID-19 [4]. Several approaches have been used to devise rapid and affordable test(s) to detect COVID-19 cases efficiently and as early as possible to prevent and control this highly transmissible disease. The tests include virus culture, molecular technique for detection of viral nucleic acid and immunoassays.   Virus culture Diagnosis using viral culture is not useful, as it takes at least 3-6 days for SARS-CoV-2 to cause apparent cytopathic effects in selected cell lines, such as VeroE6 cells. Moreover, isolation of the virus requires highly skilled manpower; expensive equipment and biosafety level 3 facilities, which are not available in most health care institutions [5].   Molecular assays A real-time RT-PCR (reverse transcriptase polymerase chain reaction) method is recommended for detecting SARS-CoV-2 during the period of viral shedding in acute phase of COVID-19, till date. However, this method, when used alone, has limitation in the detection of the virus during different phases of the illness as the viral load of SARS-CoV-2 is very high when symptoms appear (overall >1 × 10⁶ copies/mL) among different clinical specimens [6] and declines steadily [7,8]. Another pressing issue regarding using RT-PCR to detect COVID-19 case is the false-negative and false-positive results. Wang et al. reported the failure to diagnose many suspected cases having conventional clinical COVID-19 features including specific computed tomography (CT) images led to inefficient separation of many potential cases and hindered the control strategy [9]. Following infection, SARS-CoV-2 undergoes immunologic pressure in humans and accumulate mutations, which may affect not only its transmissibility and virulence but also its detectability with the same RT-PCR kit overtime [10]. One study detected 93 mutations among 86 complete or near complete genome of SARS-CoV-2 [11]. Similarly, mutations in the primer and probe target regions of the SARS-CoV-2 genome for RT-PCR may produce false-negative results. Although, in order to mitigate this problem, several types of SARS-CoV-2 RT-qPCR kit have been devised targeting the conserved regions of the viral genome and targeting multiple target gene amplification. However, variability resulting in mismatches between the primers and probes and the target sequences might reduce the assay performance. Moreover, the viral load of SARS-CoV-2 in different anatomic sites, sampling timing, sampling procedures and stage of the disease play important roles in producing false-negative results [12]. Specimens are generally collected from both theupper respiratory tract (URT; nasopharynx and oropharynx) and lower respiratory tract (LRT; expectorated sputum, endotracheal aspirate, or bronchoalveolar lavage) for COVID-19 testing by RT-PCR. The virus is also detected in fecal and blood specimens [13]. The sensitivity/positivity rate of RT-PCR in various biological samples of COVID-19 patients is shown in Table-1. The sensitivity/ positivity rate varies from 3.03% to 93% in various clinicalsamples. A study observed strong correlation of viraemia with the disease severity [14]. SARS-CoV-2 quantification in plasma/serum could also represent a potentially useful early diagnostic and prognostic tool [15]. According to Guangzhou CDC, virus can be detected in upper respiratory samples 1-2 days prior to symptom onset and persists for 7-12 days in moderate cases and up to 2 weeks in severe cases [13]. Prolonged viral shedding from nasopharyngeal aspirates – up to at least 24 days after symptom onset – was reported among COVID-19 patients in Singapore [16]. Viral RNA has been detected in feces in up to 30% of patients from day 5 following onset of symptoms and has been noted for up to 4-5 weeks in moderate cases [13]. Fang et al. found first RT-PCR test positive in 71% cases after studied on first throat swab or sputum samples from 51 patients. In second RT-PCR, another 23% cases became positive who were initially negative. In third and fourth RT-PCR, another 4% and 2% cases became positive [17]. Another study conducting serial RT-PCR testing showed the mean time from an initial negative RT-PCR to subsequent positive RT-PCR was 5.1 days (± 1.5 days) [18]. Regarding asymptomatic patients, Arons et al. reported that more than half of subjects with positive test results were asymptomatic at the time of testing [19]. Zou et al. reported that the viral load of asymptomatic patients was similar to symptomatic patients, indicating a transmission potential of asymptomatic or pre-symptomatic patients. The study reported that patients with few or no symptoms had modest levels of detectable viral RNA in the oropharynx for at least 5 days [20].   Table-1: The sensitivity/positivity rate of RT-PCR in different specimens during acute phase of COVID-19 patients     RT-PCR assay targets the open reading frames (ORF1a and ORF1b), non-structural protein (nsp14), RNA-dependent RNA polymerase (RdRp), envelope glycoproteins spike (S), envelope (E), nucleocapsid (N), or helicase (Hel) gene of SARS-CoV-2. To avoid potential cross-reaction with other endemic coronaviruses as well as potential genetic drift of SARS-CoV-2, at least two molecular targets should be included in the assay. Various investigators in different countries have used a number of these molecular targets for real-time RT-PCR assays [27]. In the United States, the US Centers for Disease Control and Prevention (CDC) recommends two nucleocapsid protein targets (N1 and N2) [28] while WHO recommends first line screening with the E gene assay followed by a confirmatory assay using the RdRp gene [29]. Another study in Hong Kong, China used two targets for their RT-PCR assay; the first used the nucleocapsid for screening followed by confirmation by the open reading frame 1b [30]. Chan et al. developed and compared the performance of three novel real-time RT-PCR assays targeting the RdRp/Hel, S, and N genes of SARS-CoV-2. Among them, the COVID-19-RdRp/Hel assay had the lowest limit of detection in vitro and higher sensitivity and specificity [31]. The analytical sensitivity of different RT-PCR test kits varies from 0.15 to 100 copy/μL [32].The US CDC recommends that negative results of real time RT-PCR testing for SARS-CoV-2 from at least two sequential respiratory tract specimens collected at least 24 hours apart can be considered to discontinue transmission-based precautions [33].   Immunoassays Success of PCR-based diagnostics relies on timing and technique of sampling, stage of the infection, type of sample, the kinetics of viraemia and shedding of virus throughout the course of infection. Moreover, inadequate access to reagents, expensive equipment and bio-safety facilities have resulted in low efficiency in handling large number of samples in-time delivery of reports. Therefore, serological testing is crucial to complement the RT-qPCR. In addition, serology is used as an important tool to monitor the evolution of an outbreak, retrospective studies of asymptomatic and mild cases and animal reservoir identification [34,35]. However, devising serologic assays targeting immunogenic proteins is difficult because closely related viruses may share common epitopes that elicit cross-reactive and cross-neutralizing antibodies. Within a genus, antibodies against other coronaviruses might cross-react and such cross-reactive conserved viral proteins limit the use of whole virus–based assays, for example, immunofluorescence assay (IFA) [7]. Also whole virus based assays primarily require viral culture which is difficult to establish. Several immunoassays have been developed for rapid detection of SARS-CoV-2 antigens or antibodies to overcome this hurdle. Immunoassays tests include rapid lateral flow assays, ELISA and chemiluminescence. These serological tests provide the advantage of fast and low-cost detection of SARS-CoV-2 but are likely to suffer from poor sensitivity during acute phase of the disease [27]. According to recent studies, serological testing identifies convalescent cases or people with milder disease or patients who present late with a very low viral load, below the detection limit of RT-PCR assays. One study evaluated two recombinant SARS-CoV-2 nucleocapsid protein (rN) and spike protein (rS) based ELISA kits for detection of IgM and IgG antibodies. They found high sensitivity in samples collected from patients 10 days post-disease onset. They observed that IgM and IgG positivity rate increased with increasing interval of days following onset of disease [1]. Serum IgG was found to rise at the same time or earlier than those of IgM against SARS-CoV-2. It was reported that a higher proportion of patients had earlier IgG than IgM seroconversion probably due to lower sensitivity of the IgM ELISA [8]. CDC’s serologic test designed to detect antibodies against SARS-CoV-2 spike protein antigen has a specificity of greater than 99% and a sensitivity of 96%. It can be used to identify past SARS-CoV-2 infection in people who were infected at least 1 to 3 weeks previously [36]. Different antibody detection assays have been approved in different countries for diagnostic and/or research use. The sensitivity and specificity of those methods are shown in Table-2. Several antigens mainly spike and nucleocapsid proteins have been used as capture-antigen in ELISA and lateral flow assay/rapid diagnostic test (RDT) to diagnose IgG and/or IgM against SARS-CoV-2 [37]. Nevertheless, cross-reactivity of antibodies to closely related viruses is a potential issue to interpret the serological test results. A South Korean antigen detection kit reported 84.38% and 100% sensitivity and specificity respectively using nasopharyngeal swabs from 202 symptomatic patients for detection of SARS-CoV-2 antigen [38]. Quidel Sofia, USA SARS antigen test kit has been reported to detect antigen targeting nucleocapsid protein from SARS-CoV-2 with 96.7% sensitivity within five days of the onset of symptoms. The kit detects viral antigen in nasopharyngeal or nasal swab using immunofluorescence-based lateral flow technology [39]. Another antigen detection kit developed in Japan that detects neucleocapsid protein antigen of SARS-CoV-2 in nasopharyngeal swab using immunochromatographic assay has almost similar sensitivity and specificity [40].   Table-2: Sensitivity and specificity of antibody detection assays for COVID-19 [37]     Transformation of the script of laboratory based diagnostic approach into a self-conducted, non-invasive, rapid, convenient, cheap and available over-the-counter diagnostic test, be it less sensitive than the current RT-PCR or serology assay, would enable mass people detect themselves as suspected cases. Thus they could self-isolate far ahead of time than if they were to be diagnosed by the conventional laboratory tests. As long as these people stay home, it would provide a kind of artificial herd immunity which will interrupt the chain of transmission to impede the pandemic. Moreover, these suspected cases would be able to confirm the infection status later by the more specific laboratory tests. The most important issue is that, this strategy would best utilize the minimal resources and the narrow window of time that is not achievable with more sensitive but expensive and time consuming PCR tests. Sherlock Biosciences of Harvard’s Wyss Institute for Biologically Inspired Engineering and E25Bio-rooting from Massachusetts Institute of Technology (MIT) and Harvard have developed an inexpensive paper-based test which can be conducted at home with saliva or nasal mucous, just like doing at-home pregnancy test [41].   Symptom-based diagnosis A simple and technology independent diagnostic tool, if available, would be immensely valuable to handle the present COVID-19 pandemic. Historically, after initial detection and confirmation of the offending microbe, many previous epidemics were combated without laboratory testing of every case. Subsequently, the cases were detected and managed by typical clinical features of the disease. Therefore, clinical symptom and sign based diagnostic approach may also be a valuable and useful instrument to diagnose COVID-19 in places where RT-PCR or other serological tests are not easily available. There is paucity of studies with regard to the sensitivity and specificity of such symptom based diagnosis of COVID-19. Few studies that considered symptoms based diagnosis of COVID-19 assessed symptoms alone. A Cochrane systematic review reported that till the end of April 2020 no study assessed combinations of different signs and symptoms to diagnose a case of COVID-19. The review revealed a sensitivity of 50% and specificity of 90% when six symptoms (cough, sore throat, fever, myalgia or arthralgia, fatigue, and headache) were considered [42]. The symptom of “sudden smell loss” has been associated with 97% specificity and a sensitivity of 65% with positive and negative predictive values of 63% and 97% respectively for COVID-19 [43]. Therefore, combined symptoms and signs (may be including imaging characteristics) based diagnostic tool for COVID-19 should be developed and tested for sensitivity and specificity in different areas and healthcare settings. Such technology independent tool might help in primary care, emergency or in telemedicine services in resource poor countries/regions to identify COVID-19 patients at low cost and thus would minimize its spread. Moreover, it would reduce the cost of diagnosing COVID-19 even in hospitals with all facilities by avoiding expensive RT-PCR test in every case. Conclusion The pandemic of SARS-CoV-2 infection has emphasized the importance of simple, fast and affordable high quality diagnostic tools to limit the spread as well as to appropriately treat the COVID-19 patients. Further studies are needed to develop easy to use assays of similar sensitivity and specificity of RT-PCR. Symptom/sign based technology independent diagnostic tool for detection of COVID-19 deserves further attention because that can be used at all levels of healthcare facilities.   Acknowledgement We acknowledge the idea and advice of Prof. J. Ashraful Haq, Department of Microbiology, Ibrahim Medical College, Dhaka, Bangladesh.   References 1.     Liu W, Liu L, Kou G, Zheng Y, Ding Y, Ni W, et al. Evaluation of nucleocapsid and spike protein-based ELISAs for detecting antibodies against SARS-CoV-2. J Clin Microbiol. 2020; 58(6): e00461-20. 2.     World Health Organization. Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020. Geneva: World Health Organization; 2020. 3.     Black JRM, Bailey C, Swanton C. COVID-19: the case for health-care worker screening to prevent hospital transmission. Lancet. 2020; 395(10234): 1418-1420. 4.     Meyer B, Drosten C, Müller MA. Serological assays for emerging coronaviruses: challenges and pitfalls. Virus Res. 2014; 194: 175-183. 5.     Chan JF, Yip CC, To KK, Tang TH, Wong SC, Leung KH, et al. Improved molecular diagnosis of COVID-19 by the novel, highly sensitive and specific COVID-19-RdRp/Hel real-time reverse transcription-PCR assay validated in vitro and with clinical specimens. J Clin Microbiol. 2020; 58(5). 6.     Pan Y, Zhang D, Yang P, Poon LLM, Wang Q. Viral load of SARS-CoV-2 in clinical samples. Lancet Infect Dis. 2020; 20(4): 411-412. 7.     Yong SEF, Anderson DE, Wei WE, Pang J, Chia WN, Tan CW, et al. Connecting clusters of COVID-19: an epidemiological and serological investigation. Lancet Infect Dis. 2020; 20(7): 809-815. 8.     To KK, Tsang OT, Leung WS, Tam AR, Wu TC, Lung DC, et al. Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study. Lancet Infect Dis. 2020; 20(5): 565-574. 9.     Wang Y, Kang H, Liu X, Tong Z. Combination of RT-QPCR testing and clinical features for diagnosis of COVID-19 facilitates management of SARS-CoV-2 outbreak. J Med Virol. 2020; 92(6): 538-539. 10.  Shen Z, Xiao Y, Kang L, Ma W, Shi L, Zhang L, et al. Genomic diversity of severe acute respiratory syndrome-coronavirus 2 in patients with coronavirus disease 2019. Clin Infect Dis. 2020; 71(15): 713-720. 11.  Tung P. Genetic diversity and evolution of SARS-CoV-2. Infect Genet Evol. 2020; 81: 104260. 12.  Alireza T, Ardebili A. Real-Time RT-PCR in COVID-19 detection: issues affecting the results. Expert Rev Mol Diagn. 2020; 20(5): 453-454. 13.  World Health Organization. Report of the WHO-China joint mission on coronavirus disease 2019 (COVID-19). Geneva: World Health Organization; 2020. 40 p. 14.  Chen W, Lan Y, Yuan X, Deng X, Li Y, Cai X, et al. Detectable 2019-nCoV viral RNA in blood is a strong indicator for the further clinical severity. Emerg Microbes Infect. 2020; 9(1): 469-473. 15.  Yan Y, Chang L, Wang L. Laboratory testing of SARS-CoV, MERS-CoV, and SARS-CoV-2 (2019-nCoV): current status, challenges, and countermeasures. Rev Med Virol. 2020; 30(3): e2106. 16.  Young BE, Ong SWX, Kalimuddin S, Low JG, Tan SY, Loh J, et al. Epidemiologic features and clinical course of patients infected with SARS-CoV-2 in Singapore. JAMA. 2020; 323(15): 1488-1494. 17.  Fang Y, Zhang H, Xie J, Lin M, Ying L, Pang P, et al. Sensitivity of chest CT for COVID-19: comparison to RT-PCR. Radiology. 2020; 296(2): E115-E117. 18.  Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W, et al. Correlation of chest CT and RT-PCR testing for coronavirus disease 2019 (COVID-19) in China: A Report of 1014 Cases. Radiology. 2020; 296(2): E32-E40. 19.  Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR, et al. Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility. N Engl J Med. 2020; 382(22): 2081-2090. 20.  Zou L, Ruan F, Huang M, Liang L, Huang H, Hong Z, et al. SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med. 2020; 382(12): 1177-1179. 21.  Wang W, Xu Y, Gao R, Lu R, Han K, Wu G, et al. Detection of SARS-CoV-2 in different types of clinical specimens. JAMA. 2020; 323(18): 1843-1844. 22.  Jamal AJ, Mozafarihashjin M, Coomes E, Powis J, Li AX, Paterson A, et al. Sensitivity of nasopharyngeal swabs and saliva for the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Clin Infect Dis. 2020; 25: ciaa848. 23.  Centers for Disease Control and Prevention. Performance of oropharyngeal swab testing compared with nasopharyngeal swab testing for diagnosis of coronavirus disease 2019—United States, January 2020–February 2020. United States: Oxford University Press for the Infectious Diseases Society of America; 2020. 4 p. 24.  Wu J, Liu J, Li S, Peng Z, Xiao Z, Wang X, et al. Detection and analysis of nucleic acid in various biological samples of COVID-19 patients. Travel Med Infect Dis. 2020; 18: 101673. 25.  Chang L, Yan Y, Wang L. Coronavirus disease 2019: coronaviruses and blood safety. Transfus Med Rev. 2020; 34(2): 75-80. 26.  Lin W, Xie Z, Li Y, Li L, Wen C, Cao Y, et al. Association between detectable SARS-COV-2 RNA in anal swabs and disease severity in patients with coronavirus disease 2019. J Med Virol. 2020; 10. 27.  Tang YW, Schmitz JE, Persing DH, Stratton CW. The laboratory diagnosis of COVID-19 infection: current issues and challenges. J Clin Microbiol. 2020; 58(6): e00512-20. 28.  Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, et al. First case of 2019 novel coronavirus in the United States. N Engl J Med. 2020; 382: 929-936. 29.  Corman VM, Landt O, Kaiser M, Molenkamp R, Meijer A, Chu DKW, et al. Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR. Euro Surveill. 2020; 25(3). 30.  Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet. 2020; 395: 514-523. 31.  Chan JF, Yip CC, To KK, Tang TH, Wong SC, Leung KH, et al. Improved molecular diagnosis of COVID-19 by the novel, highly sensitive and specific COVID-19-RdRp/Hel real-time reverse transcription-polymerase chain reaction assay validated in vitro and with clinical specimens. J Clin Microbiol. 2020; 4: 310-320. 32.  Giri B, Pandey S, Shrestha R, Pokharel K, Ligler FS, Neupane BB. Review of analytical performance of COVID-19 detection methods. Anal Bioanal Chem. 2020; 18: 1-14. 33.  Centers for Disease Control and Prevention. Interim guidance for discontinuation of transmission-based precautions and disposition of hospitalized patients with COVID-19. United States of America: Centers for Disease Control and Prevention; 2020. 34.  Chen W, Xu Z, Mu J, Yang L, Gan H, Mu F, et al. Antibody response and viraemia during the course of severe acute respiratory syndrome (SARS)-associated coronavirus infection. J Med Microbiol. 2004; 53(Pt 5): 435-438. 35.  Guan Y, Zheng BJ, He YQ, Liu XL, Zhuang ZX, Cheung CL, et al. Isolation and characterization of viruses related to the SARS coronavirus from animals in Southern China. Science. 2003; 10; 302(5643): 276-278. 36.  Centers for Disease Control and Prevention. Serology testing for COVID-19. United States of America: Centers for Disease Control and Prevention; 2020. 37.  Johns Hopkins Bloomberg School of Public Health. Serology-based tests for COVID-19: United States: Johns Hopkins University; 2020. 38.  SD BIOSENSOR. Standard Q COVID-19 Ag. Korea: SD BIOSENSOR; 2020. 39.  Quidel. Sofia SARS Antigen FIA. USA: Quidel; 2020. 40.  Fujirebio. ESPLINE® SARS-CoV-2. Japan: Fujirebio; 2020. 41. Powell A. Cheap, frequent COVID tests could be ‘akin to vaccine,’ professor says. The Harvard Gazette. Harvard University; 2020. 42.  Struyf T, Deeks JJ, Dinnes J, Takwoingi Y, Davenport C, Leeflang MMG, et al. Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID-19 disease. Cochrane Database Syst Rev. 2020; 7(7): CD013665. 43.  Haehner A, Draf J, Dräger S, de With K, Hummel T. Predictive value of sudden olfactory loss in the diagnosis of COVID-19. ORL J Otorhinolaryngol Relat Spec. 2020; 82(4): 175-180. <![CDATA[Commentary about open-label randomized controlled study of ivermectin in mild to moderate COVID-19]]> Eduardo Ortega-Guillén Giovanni Meneses https://imcjms.com/journal_full_text/357 2021-01-03 01:26:21 Others To the Editor: We have carefully read the article from Podder et al. [1] published on July 2020 at this journal (volume 14, issue 2). In this regard, the authors mentioned approval of their study by the director of the health center, but not a methodological and ethical evaluation by an institutional board. We noted that the trial is not registered in ClinicalTrials.gov, unlike the trial of e.g. Chowdhury et al. [2] from the same country (cited in the article). A board would have questioned the low statistical power of the design, as it only had 62 subjects. We consider inappropriate the choice of a negative outcome of 10-day RT-PCR test as a result in outpatients, since it already was not recommended by the WHO in June 2020 [3]. The authors excluded subjects taking hydroxychloroquine or antimicrobials other than doxycycline, which could introduce considerable selection bias because it ruled out 80% of patients with a positive RT-PCR test. Lack of concealment of the randomization sequence and systematic allocation were additional factors of bias when distributing patients to the study groups. On the other hand, the lack of blinding increased the risk of information bias, since the outcome is the absence of symptoms. But the most objectionable methodological element was the exclusion of 20 subjects after allocation, based on criteria of lack of information and time of symptoms greater than seven days, not previously defined as study exclusion criteria. We consider inadequate that the authors combined mild and moderate cases of the disease and managed both categories in a single study of outpatients, when moderate cases probably must be hospitalized or receive stricter monitoring. Since May 2020, WHO advised against the decision to administer antibiotics (e.g. doxycycline) to patients without evidence of bacterial pneumonia [4]. When calculating the coefficients of variation of the times until the patients’ recovery, high variability is found in almost all described symptoms durations. We would recommend to the authors to perform a normality contrast test (e.g. Shapiro-Wilk) to check the relevance of the t-test, due to a possible lack of a normal distribution of the data. Even for smaller subgroups (about 6 patients per group with dyspnea or fatigue) the potential utility of a test of difference of medians (e.g. Mann-Whitney U test) had to be evaluated.   References 1.     Podder CS, Chowdhury N, Sina MI, Haque WMMU. Outcome of ivermectin treated mild to moderate COVID-19 cases: a single-centre, open-label, randomised controlled study. IMC J Med Sci. 2020; 14(2). 2.     Chowdhury ATMM, Shahbaz M, Karim MR, Islam J, Guo D, He S. A randomized trial of ivermectin-doxycycline and hydroxychloroquine- azithromycin therapy on COVID19 patients. Research Square; 2020. 3.     World Health Organization. Criteria for releasing COVID-19 patients from isolation: scientific brief: June 17, 2020. Geneva: World Health Organization; 2020. 5 p. Report No.: WHO/2019-nCoV/Sci_Brief/Discharge_From_Isolation/2020.1. 4.     World Health Organization. Clinical management of COVID-19: interim guidance, 27 May 2020. Geneva: World Health Organization; 2020. 62 p. Report No.: WHO/2019-nCoV/clinical/2020.5.   Eduardo Ortega-Guillén, MSc Hospital Nacional Alberto Sabogal Sologuren-EsSalud, Callao, Peru Universidad Nacional Mayor de San Marcos, Lima, Peru.   Giovanni Meneses*, PhD Hospital San Juan de Lurigancho, San Juan de Lurigancho, Lima, Peru Universidad Nacional Mayor de San Marcos, Lima, Peru.   *Corresponding author: Giovanni Meneses, Departamento Académico de Medicina Preventivay Salud Pública, Facultad de Medicina, Universidad Nacional Mayor de San Marcos, Lima, Peru. ZIP Code: 15307. E-mail: gmenesesf@unmsm.edu.pe     [Editor’s note: Reference # 5 is deleted as the reference is missing/not cited within the text.]     Authors’ reply We appreciate Eduardo Ortega-Guillén, MSc and Giovanni Meneses, PhD for the issues they raised about our study. With all admiration to their concerns, our responses to disavow most of the claims are that the study was performed in a resource-limited primary healthcare setting, where a well-organized institutional review board is not a reality. The local health complex authority consisting of Head of the Upazila health complex and other senior consultants decide and approve conduction of any study at the center. The authority assesses the scientific and ethical aspects of the study(s).  This study was also approved by the same body. Though not mandatory – it would have been better if the study was registered in ClinicalTrials.gov site. At the beginning of the study repeat RT-PCR for end of isolation was recommended [1]. We excluded subjects taking hydroxychloroquine or antimicrobials other than doxycycline to eliminate confounders and determine the optimum benefit of ivermectin over the usual care. We also excluded the patients presented after one week or more as ivermectin was presumed to be effective if initiated early in the disease. Though antibiotics are not recommended in COVID management if there is no bacterial infection suspected; it was the centre's protocol to treat every suspected patient of pneumonia with doxycycline at presentation as there were not sufficient investigation facilities to exclude community-acquired pneumonia. In our national and WHO interim guidelines, patients with the mild and moderate disease are advised to be managed at home [1,2]. In some cases, mild and moderate cases are clinically overlapped, so we managed these patients on outdoor patient department (OPD) basis, preserving the valuable hospital beds for more severe cases. Regarding the relevance of t-test, yes, we agree with Eduardo Ortega-Guillén and Giovanni Meneses that it would have been better if we used a nonparametric test for some cases to find out the differences of medians. As suggested, we have re-analyzed our data by Shapiro-Wilk and Mann-Whitney tests, but the results remained as before and there was no change of significance. Also, similar to our observations, several studies showed no conclusive benefits after ivermectin use [3].     References 1.     World Health Organization. Clinical management of COVID-19: interim guidance, 27 May 2020. Geneva: World Health Organization; 2020. 62 p. Report No.: WHO/2019-nCoV/clinical/2020.5. 2.     Disease Control Division. Directorate General of Health Services. Ministry of Health & Family Welfare. Government of the People’s Republic of Bangladesh. National Guidelines on clinical management of coronavirus disease 2019 (COVID-19). Bangladesh: Directorate General of Health Services, Ministry of Health & Family Welfare; 2020. Version 7.0. 3.     National Institutes of Health. COVID-19 treatment guidelines panel. Coronavirus disease 2019 (COVID-19) treatment guidelines. [accessed on February 25, 2021]; Available from: https://www.covid19treatmentguidelines.nih.gov/.   Wasim Md Mohosin Ul Haque* Department of Nephrology, BIRDEM General Hospital 122 Kazi Nazrul Islam Avenue, Dhaka 1000, Bangladesh; Email: wmmhaque@live.com   Chinmay Saha Podder Debidwar Upazila Health Complex Debidwar, Cumilla, Bangladesh.   *Corresponding author <![CDATA[Response to short course androgenisation in late reported cases with micropenis]]> Mahmudul Huque Tania Tofail Tofail Ahmed https://imcjms.com/journal_full_text/334 2020-01-20 01:58:47 Original Article IMC J Med Sci 2020; 14(1): 001 Abstract Background and objectives: Micropenis is an abnormally short penis and its treatment should begin in infancy or in very early childhood. The present study investigated the response of short term testosterone therapy in late reported cases of micropenis. Methods: A total of 17 cases of micropenis between the age of 8 and 15 years were included in the study. Standard criteria for the diagnosis of micropenis were followed. All cases were treated with intramuscular testosterone 50 to 75 mg once every 21 days. Response to testosterone treatment was measured by the absolute and percent increment in stretched penile length (SPL). Response was considered adequate if final SPL crosses the average SPL for age. We also compared the response of treatment of cases reported before and after 11 years of age. Result: A total of 17 micropenis cases were included in the study. Out of total 17 boys, 10 were between 8 to 11 years (Group 1) and 7 were between 12 to 15 years (Group 2) of age. The mean pre-treatment SPL of 17 micropenis cases was 3.1±0.2 cm (CI: 2.83, 3.43 cm). The mean initial SPL of Gr1 and Gr2 was not significantly different (3.2±0.3 cm vs 3.0±0.1 cm; p>0.248). The mean post treatment SPL of 17 cases increased significantly (p<0.001) compared to their initial SPL. The range of percentage increment in SPL was 100%-400%. Higher testosterone doses were required in Gr2 cases compared to Gr1 (360±20.8 mg vs 260.7±38.5 mg). Conclusion: Micropenis in boys with palpable gonads responded to short term testosterone treatment in late reported cases and we termed these cases as simple micropenis. IMC J Med Sci 2020; 14(1): 001. EPub date: 21 January 2020. DOI: https://doi.org/10.3329/imcjms.v14i1.47381 Address for Correspondence: Dr. Tofail Ahmed, Professor, Department of Endocrinology, BIRDEM General Hospital, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka, Bangladesh. Email: tofail.ahmed@yahoo.com   Introduction Micropenis is an abnormally short penis and is defined as stretched penile length (SPL) of < 2.5 standard deviations below the mean SPL for age [1,2]. Micropenis should be treated shortly after birth to prevent its consequences. Appropriate evaluation is required to exclude few potentially serious diseases like panhypopituitarism, isolated growth hormone deficiency, androgen insensitivity states, congenital adrenal hyperplasia (CAH) in a girl or developmental anomaly [1,2]. The cases with palpable testes are likely to have intraabdominal sex organs and are of male pattern and most of them respond well to short term androgenisation therapy [3,4]. It is important that treatment of these cases should begin in infancy or in very early childhood. But in practice, we come across such cases who seek treatment late. In this paper, we present our experience of 17 cases of micropenis who sought treatment from 8 to 15 years of age.   Material and method Cases of micropenis reporting to the outpatient department after their 8th birthday from January 2015 to December 2018 were enrolled in the study. Diagnosis of micropenis was made by measurement of SPL which was either equal or less than that for his age by using table described by Custer & Rau [1]. Exclusion criteria included hypothyroid, suspected hypopituitarism, growth hormone deficiency, any syndrome related to microphallus or developmental anomaly, family history of androgen insensitivity, bilateral cryptoorchids and one or both testicular volume > 4 ml [1,2]. All cases were treated with intramuscular testosterone 50 to 75 mg once every 21 days until SPL reaches or cross the average SPL for his age up to the age of 11 and for age 11 thereafter or total 6 times which ever came first. Total increment and percent increment were calculated by formula (Last SPL – Initial SPL) and [(Last SPL – Initial SPL)/ Initial SPL] x100 respectably. The response of treatment was considered adequate if last SPL of the case reached or crossed the average SPL for his age up to age of 11 years and for age 11 years thereafter. To assess obesity we used BMI-for-age by calculating BMI Percentile Calculator for Child and Teen [5]. Statistical analysis was done with IBM SPSS package version 24.   Result A total of 17 micropenis cases were included in the study. Out of total 17 boys, 10 were between 8 to 11 years (Group 1) and 7 were between 12 to 15 years (Group 2) of age. All the 17 boys were treated with injection testosterone. Their pre and post treatment detail profile namely age, height, weight, BMI, puberty stage, testosterone dose and SPL are shown in Table-1. Age adjusted % BMI showed 10 (59%) were obese; 3 (17.5%) over weight and 4 (23.5%) were of normal weight. The mean (±SE) BMI of 17 cases was 22.6±1 Kg/m2. Mean BMI of Gr1 and Gr2 cases was 23.9±1.3 Kg/m2 and 20.8±1.7 Kg/m2 respectively (p=0.08). Their pubertal parameters were compatible with Tanner’s stage I: testicular volume (TV) range: (1–4 ml) and pubic hair (PH) stage 1 and serum testosterone level were < 20 ng/dl (Table-1). The SPL increased in all cases after testosterone treatment compared to pre-treatment length. The mean post treatment SPL of 17 cases increased significantly (p<0.001) compared to initial SPL (Table-2). The mean increase of SPL of younger boys (Gr1) was significantly more (p=0.008) compared to that of older boys (Gr2; Table-2). The range of percentage increment in SPL was 100%-400%. No significant (p=0.139) difference in percentage increment of SPL occurred between Gr1 and Gr2 cases. Higher testosterone doses were required in Gr2 cases compared to Gr1 (360±20.8 mg vs. 260.7±38.5 mg). Table-3 shows the change of height and weight of micropenis cases following testosterone treatment.   Table-1: Profile of study population and change of stretched penile length (SPL) and other parameters before and after testosterone therapy     Table-2: Change of SPL and percent increment of SPL following testosterone treatment of micropenis cases     Table-3: Change of height and weight of micropenis cases following testosterone treatment       Discussion Micropenis means abnormally small penis and is defined by stretched penile length less than 2.5 standard deviations below the average stretched length for their age [1,2]. Micropenis has psychological stress to both family and individual and also has medical challenges. The condition may be a presenting feature for underlying hormonal disorders like panhypopituitarism, isolated growth hormone deficiency, hypogonadism, hypothyroidism, testosterone insensitivity in boys or CAH in girls or of a part of syndrome like Prader-Willi syndrome and Laurence-Moon syndrome [1,2]. Usually a person with micropenis has internal genitalia and normal testicles. Testosterone treatments can often help the penis to grow. Applying testosterone cream to the genitals during infancy was tried with variable response but intramuscular testosterone injections are very effective [6-8]. It is advocated to treat early and at least before the age of onset of puberty e.g. before 8th birth day. In practice, some cases report late and clinician has to offer testosterone therapy. Our study is with 17 cases between their 8th and 15th birthday and 10 of them are after their 10th birthday. We administered 50 to 75 mg of testosterone at an interval of 3 weeks until target SPL was achieved or total dose of 450 mg was administered. In literature, a good response to testosterone treatment has been described as 100 percent increase in the SPL while an adequate response as a 3.5 cm increase in length [3,4,9]. All our cases attained the normal SPL for that age after testosterone treatment. We were also able to assess the amount of testosterone required to reach the mean SPL for age. All our cases had bilateral palpable gonad which means their karyotype was likely to be of male pattern (XY) and the response to such a dose of testosterone apparently excluded them as cases of androgen insensitivity syndromes (AIS). We, therefore, term this condition as simple micropenis. It is characterized by a) SPL < 2.5 SD below the mean for age, b) bilateral palpable gonads and c) response to testosterone treatment. All our cases were in per pubertal stage and during treatment there was no change in TV and PH. Out of 17 cases, 13 (76.5%) cases were either obese or overweight and that might have delayed the diagnosis of micropenis by failing to differentiate them from buried penis. The study emphasizes that physicians should be made aware that micropenis is a treatable condition with good outcome even if diagnosed late.   References 1.     Custer JW, Rau RE. The Harriet Lane handbook. 18th ed. Mosby; 2008. p 269-300. 2.     Kronenberg HM, Melmed S, Polonsky KS, Larsen PR. Williams textbook of endocrinology. 11th ed. Philadelphia: Saunders Elsevier; 2008. 3.     Massa GG, Langenhorst V, Oostdijk W, Wit JM. Micropenis in children: etiology, diagnosis and therapy. Ned Tijdschr Geneeskd. 1997; 141(11): 511–515. 4.     Hatipoğlu N, Kurtoğlu S. Micropenis: etiology, diagnosis and treatment approaches. J Clin Res Pediatr Endocrinol. 2013; 5(4): 217–223. 5.     BMI calculator for child and teen. https://www.cdc.gov/healthyweight/bmi/calculator.html. 6.     Smith DW. Micropenis and its management. Birth Defects Orig Artic Ser. 1977; 13(2): 147–154. 7.     Becker D, Wain LM, Chong YH, Gosai SJ, Henderson NK, Milburn J, et al. Topical dihydrotestosterone to treat micropenis secondary to partial androgen insensitivity syndrome (PAIS) before, during, and after puberty - a case series. J Pediatr Endocrinol Metab. 2016; 29(2): 173–177. 8.     Choi SK, Han SW, Kim DH, de Lignieres B. Transdermal dihydrotestosterone therapy and its effects on patients with microphallus. J Urol. 1993; 150(2 Pt 2): 657–660. 9.     Cimador M, Catalano P, Ortolano R, Giuffrè M. The inconspicuous penis in children. Nat Rev Urol. 2015; 12(4): 205–215. <![CDATA[Association of visceral adiposity index with insulin resistance in adults with diabetes mellitus]]> Sultana Parveen Tohfa-E-Ayub Tahniyah Haq Nazmun Nahar Naureen Manbub Fahmida Islam Farjana Aktar Murshida Aziz https://imcjms.com/journal_full_text/335 2020-02-11 00:39:05 Original Article IMC J Med Sci 2020; 14(1): 002 Abstract Background and objectives: Visceral adiposity is linked to excess morbidity and mortality and positively correlates with the risk of insulin resistance, type-2 diabetes mellitus, cardiovascular disease and premature death. The study was conducted to find out the relationship between visceral adiposity index (VAI) and homeostatic model assessment insulin resistance (HOMA-IR) in diabetes mellitus (DM). Materials and methods: This cross sectional study was carried out on adult population with and without DM. Waist circumference (WC) and body mass index (BMI) were measured. BMI of 25-29.9 kg/m2 and ≥30 kg/m2 was defined as overweight and obese respectively. HOMA-IR method was used to calculate insulin resistance (IR). Standard formula using BMI, WC, triglyceride (TG) and high density lipoprotein cholesterol (HDL-c) was used to calculate VAI. Blood was analyzed for fasting blood glucose (FBS), TG, HDL-c and insulin level. Results: A total of 439 individuals were included in the study of which 269 had DM and 170 were healthy volunteers and the mean age was 41.47±6.82 and 36.16±7.44 years respectively. Compared to healthy controls, a greater number of diabetics had high VAI (86.5% vs. 98.9%) and high IR (43.5% vs. 85.1%). We found the highest sensitivity and specificity at a cut-off of 2.23 of VAI while at 3.65 had the highest specificity. Insulin resistance was observed significantly higher in those with diabetes compared to control, both in case of normal and high VAI at all cut-offs of VAI. Among anthropometric parameters (WC, BMI and VAI), VAI had positive (r=0.21, p<0.001) correlation with HOMA-IR than WC (r=0.10, p=0.043). Visceralfat was linearly related with insulin resistance (ß=0.18, p<0.001). Area under the curve (AUC) (0.66) showed that VAI can discriminate HOMA-IR. Conclusion: There was a high rate of raised VAI in cases with DM. VAI had positive association with HOMA-IR in diabetes mellitus. Although weak, there was an acceptable discrimination between them. IMC J Med Sci 2020; 14(1): 002. EPub date: 11 February 2020. DOI: https://doi.org/10.3329/imcjms.v14i1.47382 Address for Correspondence: Dr. Sultana Parveen. Professor, Department of Biochemistry, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka-100, Bangladesh, 8th floor, Room: 906. Email: bioheadimc@gmail.com   Introduction Visceral adiposity has become a major concern in public health due to its significant role in obesity associated diseases. Abnormally increased deposition of visceral adipose tissue surrounding intra-abdominal organs is known as visceral obesity [1]. Previous studies have reported that individuals with high visceral adiposity are at increased risk of insulin resistance and metabolic disorders, and are more likely to develop diabetes [2-4]. Major metabolic abnormality behind type-2 diabetes mellitus is insulin resistance and the compensatory hyperinsulinemia [5]. Adipose tissue is a main source of reactive oxygen species, which may contribute to obesity-associated insulin resistance and cause type-2 diabetes mellitus as a consequence [6]. It secretes adipocytokines that impair insulin sensitivity in tissues such as liver and muscle. Release of inflammatory cytokines by macrophages in visceral adipose tissue also impairs insulin sensitivity [7].  The classical parameters for measuring obesity namely waist circumference (WC) and body mass index (BMI) alone cannot help to distinguish between subcutaneous and visceral fat [8]. Magnetic resonance imaging (MRI) and computed tomography (CT) are considered as the gold standards for measuring the body fat distribution [9]. However, they are expensive and not suitable for daily clinical practice. Moreover, adipocytokines assessment for evaluating visceral adipose dysfunction is not feasible due to the complex function of the ‘adipose endocrine organ’ [10] and high costs [11]. A novel and feasible sex-specific index called visceral adiposity index (VAI) based on WC, BMI, triglyceride (TG) and high density lipoprotein cholesterol (HDL-c) has been introduced by Amato et al [12]. As VAI includes both physical and clinical parameters, it provides an estimation of both fat distribution and function. Moreover, it reflects altered production of adipocytokines, increased lipolysis and plasma free fatty acids [12]. Bangladesh has the second highest prevalence of diabetes in South-East Asian region in 2017 (prevalence of diabetes 10%) [13,14]. VAI could be a simple clinical marker to identify adipose tissue dysfunction or indirectly the risk of insulin resistance. Therefore, our study was conducted to determine VAI and insulin resistance in adult people with diabetes mellitus and to assess the association between them.   Methodology This cross sectional study was conducted on adult participants with and without DM. DM cases were selected from outpatient department of BIRDEM General Hospital over a period of 2 years. DM was diagnosed according to WHO criteria, 2006 [15]. Diabetes mellitus with cardiovascular complications, pregnant women, women taking oral contraceptive pill and patients taking lipid lowering agents were excluded from the study. Healthy adult volunteers without DM served as control group. The study was approved by the ethical committee of BADAS and written informed consent was taken from each participant.   Study procedure Participants were asked to fill up a questionnaire focusing on socio-demographic attributes and background characteristics of diabetes including duration, mode of treatment and presence of any complications. A digital scale was used to measure body weight (BW). Height was measured using a commercial stadiometer. Body mass index (BMI) was calculated as body weight in kg divided by square of the height in meter (m2). Waist circumference (WC) was measured in the standing position at the midpoint between lower rib margin and the iliac crest [16]. Based on the International Obesity Task Force, an individual with BMI of 25-29.9 kg/m2 and ≥30 kg/m2 were defined as overweight and obese respectively [17]. To determine the extent of central adiposity, waist circumference cut off points of ≥90 cm in men and ≥80 cm in women were taken [18]. Venous blood samples were drawn for biochemical tests following a 12-hour overnight fast. Collected blood was allowed to clot, centrifuged, appropriately labeled and stored at -200C. Serum TG was measured by glycerol phosphate dehydrogenase-peroxidase (GPO-POD) method and HDL-c was by precipitating method using the total cholesterol enzymatic reagent [19]. Blood glucose was measured by glucose oxidase method. Serum insulin was measured by ELISA.   Operational definition HOMA-IR: Homeostatic model assessment for insulin resistance (HOMA-IR) is a method to calculate insulin resistance based on the degree of fasting hyperglycemia which is determined by the combination of ß-cell deficiency and insulin resistance. The formula to calculate HOMA-IR is HOMA-IR = fasting insulin [mIU/L] x fasting glucose [mmol/L] / 22.5 [20]. HOMA-IR cut-off of 2.6 has been found to indicate presence of insulin resistance in Bangladeshi population [21].   VAI: VAI is a simple sex-specific index based on physical and biochemical measures to reflect regional fat. BMI, WC, TG (mmol/L) and HDL-c (mmol/L) levels are used in the formula [12]. Male: VAI = {WC/39.68 + (1.88×BMI)} × (TG/1.03) × (1.31/HDL) Female: VAI = {WC/36.58 + (1.89×BMI)} × (TG/0.81) × (1.52/HDL) VAI of 1 is considered normal, i.e., normal adipose tissue distribution and normal TG and HDL cholesterol levels [12].   Statistical analysis Data were expressed as mean±SD or frequency with percentage; independent student’s t test and Chi square test were used to compare VAI between groups with and without insulin resistance. Control and diabetic populations were classified into normal and high VAI after considering cut-off at 1.0, 2.23 and 3.65 for VAI. Pearson’s correlation analysis was done to determine the correlation between VAI and HOMA-IR. Linear regression analysis was done using HOMA-IR as dependent variable and BMI, WC and VAI as independent variables. A receiver operating characteristic (ROC) curve analysis was performed for VAI to observe its ability to discriminate HOMA-IR. Area under the curve was used to determine highest cut-off of VAI for our population.   Results A total of 439 individuals were included in the study of which 269 had DM and 170 were healthy volunteers. The mean age of patients with DM and without DM (control group) was 41.47±6.82 and 36.16±7.44 years respectively. The clinical and biochemical profiles of the study population are shown in Table-1. Except WC and BMI, the average values of TG, FBS, insulin resistance and VAI were significantly higher in DM than that of control cases (Table-1). More participants from control group had central obesity (60.6% vs 58.7%). A greater number of participants with DM had high VAI (86.5% vs 98.9%) and high IR (43.5% vs 85.1%; Table-2). Out of 439 cases, 136 had normal HOMA-IR and 303 cases had raised HOMA-IR. VAI was found significantly higher in individuals with raised HOMA-IR compared to those with normal levels (2.7±2.21 vs. 3.6±2.28, p<0.001) (Table-3).   Table-1: Clinical and biochemical characteristics of study population (n=439)   Table-2: Frequency of clinical and biochemical characteristics of study population (n=439)   Table-3: VAI in total population with normal and high HOMA-IR (n=439)   Three cut-off points of VAI (1, 2.23 and 3.65) were used to show association with HOMA-IR in Table-4a, 4b and 4c. VAI 1 was considered normal [12]. We used cut-off of 2.23 to classify individuals with high VAI, as this level had both the highest sensitivity and specificity. Cut-off of 3.65 had the highest specificity. Total population was divided into four groups (group 1=DM with normal VAI, 2=DM with high VAI, 3=control with normal VAI and 4=control with high VAI). Insulin resistance was significantly higher in those with diabetes compared to control, both in case of normal and high VAI. Though significantly higher HOMA-IR was seen in diabetic patients with high VAI, this was not found in the control group. This observation was seen at all cut-offs of VAI.   Table-4a: Association between HOMA-IR and VAI in the study population (n=439) using VAI cut-off of 1   Table-4b: Association between HOMA-IR and VAI in the study population (n=439) using VAI cut-off of 2.23   Table-4c: Association between HOMA-IR and VAI in the study population (n=439) using VAI cut-off of 3.65   Individuals with a high VAI had high HOMA-IR and the difference was statistically significant. HOMA-IR also had significant association with VAI at cut-off of 2.23. But significant insulin resistance was found at a 3.65 cut-off in normal VAI (Table-5). Pearson’s correlation analysis was used to determine the correlations of anthropometric indices (BMI, WC and VAI) with HOMA-IR. Among anthropometric parameters VAI had positive (r=0.21, p<0.001) correlation with HOMA-IR than WC (r=0.10, p=0.043) (Table-6).   Table-5: Insulin resistance in total population with normal and high VAI (n=439)   Table-6: Correlation of anthropometric variables with HOMA-IR (n=439)   Visceral fat was linearly related with insulin resistance. When VAI increased by 1 unit, HOMA-IR increased by 0.18 units (ß=0.18, p<0.001) (Table-7). Area under curve was 0.66 which was an acceptable discrimination for insulin resistance. At VAI of 1, sensitivity was 95.7% and specificity was only 9.6%.The cut-off point at which VAI had both greatest sensitivity (70%) and specificity (54.4%) to predict HOMA-IR was 2.23. VAI of 3.65 had the highest specificity of 80%, but sensitivity of only 40% in predicting insulin resistance (Figure 1).   Table-7: Multiple linear regression with HOMA-IR as dependent variable (n=439)     Fig-1: ROC analysis of VAI to predict HOMA-IR.   Discussion This study looked at the association between VAI and insulin resistance in this population. We found a high rate of raised VAI (98.9%) in people with diabetes mellitus and an association with insulin resistance in whole population but not in between control and DM groups. In this observational study, we found that Bangladeshi adults with diabetes mellitus had high rate of VAI. A cross sectional analysis on Chinese adults showed similarly high VAI values (90%) among people with diabetes [22]. High VAI observed in people with diabetes may be due to the fact that hypertriglyceridemia and low HDL-c (two of the measures included in calculating VAI) characteristically occur in diabetes [23]. To the best of our knowledge, this is the only study to show the association of VAI with HOMA-IR in diabetes mellitus. Patients with diabetes mellitus who had increased insulin resistance had significantly higher VAI (Table-3). Chen et al. found that there was 2.55 fold risk of diabetes mellitus in the group with highest VAI but they did not examine association of VAI with IR [24]. Few studies confirmed the association of VAI with insulin resistance in young women with polycystic ovary syndrome (PCOS) [25] and in those with arterial stiffness [26]. Control and diabetic populations were classified into normal and high VAI after considering cut-off at 1.0, 2.23 and 3.65 for VAI. Interestingly, analysis showed significant association of HOMA-IR with VAI in diabetic population, but not in control (Table-4a, b, c). Amato et al. also reported VAI cut-off 2.23 for the age group of 30-41 years [12]. At 3.65 we got 80% specificity, but for young Korean women with PCOS optimal cut-off was determined at 1.79 (specificity 84.7%, sensitivity 82.6%) [25]. Possible explanation may be the inclusion of male participants in our study. Further study is required to identify age and sex-specific cut-off points in Bangladeshi population. We showed insulin resistance was linearly associated with VAI in univariate and multivariate analysis (Table-7). Du et al. also found significant linear association of VAI with HOMA-IR (p=0.034 in men, p=0.042 in women) [27]. VAI includes measurement of WC and biochemical metabolic parameters which are markers of central adiposity. Furthermore, VAI has been shown to correlate well with visceral fat [24]. Central and visceral adiposity predispose to insulin resistance. Moreover, insulin resistance leads to hypertriglyceridemia and low HDL-c [23]. This may explain the association found between VAI and HOMA-IR. AUC (0.66) showed that VAI can discriminate HOMA-IR, also reported 0.62 by Chen and by Du et al. (0.695 in men and 0.682 in women) [24,27]. Therefore VAI has been suggested as a useful, convenient and applicable surrogate marker for visceral fat distribution and function [26]. In previous studies, visceral adiposity measurement by MRI and CT was done for confirming the association of visceral adiposity with insulin resistance [2,3]. But these gold standards for visceral adipose tissue measurement are not suitable for large epidemiological studies due to their high cost and inconvenience. Simple measures such as WC and BMI cannot reflect the difference between subcutaneous and visceral fat [22]. Since VAI includes anthropometric (BMI and WC) and metabolic (TG and HDL-c) parameters, it indicates both fat distribution and function [24]. VAI correlates with visceral adiposity measured by MRI. In addition, association of visceral obesity with atherogenic lipoprotein (high serum triglyceride) was confirmed by other study [28]. The small number of men and women assessed in this study may limit the interpretation and extrapolation in other populations. Also, it was not possible to use the gold standard euglycaemic clamp method for measurement of insulin resistance. For control oral glucose tolerance test was not done due to technical difficulties. But participants with DM and prediabetes were excluded from control group for better outcome.   Conclusion There was a high rate of raised VAI in type-2 diabetes mellitus. VAI had positive association with HOMA-IR in diabetes mellitus. Although weak, VAI could discriminate insulin resistance.   Author’s contributions SP developed the concept and supervised the study; TA collected the samples, entered and analyzed the data and contributed to the drafting of manuscript; TH reviewed data analysis, contributed to discussion and drafting and revision of the manuscript; NN drafted the protocol and helped in data collection; NM collected and organized the data; FI, FA and MA Aziz helped in sample collection and clinical management of the volunteers.   Conflict of Interest The authors declare no conflict of interest.   Funding This study was funded by Ibrahim Medical College.   References 1.     Shuster A, Patlao M, Pinthus JH, Mourtzakis M. The clinical importance of visceral adiposity: a critical review of methods for visceral adipose tissue analysis. Br J Radiol. 2012; 85(1009): 1-10. 2.     Fox CS, Massaro JM, Hoffmann U, Pou KM, Maurovich-Horvat P, Liu CY, et al. Abdominal visceral and subcutaneous adipose tissue compartments: association with metabolic risk factors in the Framingham Heart Study. Circulation. 2007; 116(1): 39–48. 3.     DeNino WF, Tchernof A, Dionne IJ, Toth MJ, Ades PA, Sites CK, Poehlman ET. Contribution of abdominal adiposity to age-related differences in insulin sensitivity and plasma lipids in healthy nonobese women. Diabetes Care. 2001; 24: 925–932. 4.     Bu J, Zhang Y, Chen H, Liang YP, Huang JL. Relationship between visceral fat volume by CT and insulin resistance in type 2 diabetes [Article in Chinese]. Shi Yong Yi XueZaZhi. 2009; 25: 2278–2279. 5.     Lillioja S., Mott MD, Spraul M, Ferraro R, Foley JE, Ravussin E, et al. Insulin resistance and insulin secretory dysfunction as precursors of NIDDM, prospective study of Pima Indians. N Engl J Med. 1993; 329: 1988-1992. 6.     Matsuda M, Shimomura I. Increased oxidative stress in obesity: implications for metabolic syndrome, diabetes, hypertension, dyslipidemia, atherosclerosis, and cancer. Obes Res Clin Pract. 2013; 7: e330–e341. 7.     Hardy OT, Czech MP, Corvera S. What causes the insulin resistance underlying obesity? Curr Opin Endocrinol Diabetes Obes. 2012; 19(2): 81-87. 8.     Pouliot MC, Despres JP, Lemieux S, Moorjani S, Bouchard C, Tremblay A, et al. WC and abdominal saggital diameter: best simple anthropometric indices of abdominal visceral adipose tissue accumulation and related cardiovascular risk in men and women. American Journal Cardiol. 1994; 73: 460-468. 9.     Despres JP. Is visceral obesity the cause of metabolic syndrome? Annual Medicine. 2006; 38: 52-63. 10.  Kershaw EE, Flier JS. Adipose tissue as an endocrine organ. J Clin EndocrinolMetab.2004; 89: 2548-2556. 11.  Amato MC, Giordano C, Pitrone M, Galluzzo A. Cut-off points of the VAI identifying a visceral adipose dysfunction associated with cardiometabolic risk in a Caucasian Sicilian population. Lipids Health Dis. 2011; 10:183. 12.  Amato MC, Giordano C, Galia M, Criscimanna A, Vitabile S, Midiri M, et al. Visceral adiposity index: a reliable indicator of visceral fat function associated with cardiometabolic risk. Diabetes Care. 2010; 33(4): 920-922. 13.  Shamima A, Mizanur RM, Sarah AK, Papia S. Prevalence of diabetes & prediabetes and their risk factors among Bangladeshi adults: a nationwide survey. Bulletin of WHO. 2014; 92: 204-213. 14.  IDF Diabetes Atlas, 8th edition. 2017. Available from: https://www.idf.org. 15.  World Health Organization. Definition and diagnosis of Diabetes mellitus and intermediate hyperglycemia: Report of a WHO/IDF consultation; 2006. 16.  Dahlen EM, Bjarnergard N, Lanne T, Nystorm FH, Ostgren CJ. Sagital abdominal diameter is a more independent measure compared with waist circumference to predict arterial stiffness in subjects with type 2 diabetes-a prospective observational cohort study. Cardivasc Diabetol. 2013; 12: 55. 17.  Cole TJ, Lobstein T. Extended international (IOTF) body mass index cut-offs for thinness, overweight and obesity. Pediatric Obesity. 2012; 7(4): 284-294. 18.  Amato MC, Giordano C, Galia M, Criscimanna A, Vitabile S, Midiri M, et al. Visceral Adiposity Index. Diabetes Care. 2010; 33(4): 920-922. 19.  Kaplan A, Glucose K. Clin Chem. The C.V. Mosby Co. St Louis. Toronto. Princeton 1984; p. 436. 20.  Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher BF, Turner RC. Homeostasis model assessment: insulin resistance and b-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia. 1985; 28: 412–419. 21.  Bhowmik B, Siddiquee T, Mujumder A, Rajib MMR., Das CK, Khan MI, et al. Identifying insulin resistance by fasting blood samples in Bangladeshi population with normal blood glucose. J Diabetol. 2016; 7(3): 4. 22.  Liu PJ, Ma F, Lou HP, Chen Y. VAI Is Associated with Pre-diabetes and Diabetes Mellitus in Chinese Adults Aged 20-50. Ann Nutr Metab. 2016; 68(4): 235-243. 23.  Holt RIG, Cockram CS, Flyvbjerg A, Goldstein BJ. Textbook of Diabetes. 4th ed. UK: Wiley –Blackwell; 2011. 24.  Chen C, Yan X, Zhi-rong G, Jie Y, Ming W, Xia-shu H. The application of VAI in identifying type 2 diabetes risks based on a prospective cohort in China. Lipids Health Dis. 2014; 13: 108. 25.  Oh JY, Sung YA, Lee HJ. The visceral adiposity index as a predictor of insulin resistance in young women with polycystic ovary syndrome. Obesity. 2013; 21(8): 1690-1694. 26.  Yang F, Wang G, Wang Z, Sun M, Cao M, Zhu Z, et al. Visceral adiposity index may be a surrogate marker for the assessment of the effects of obesity on arterial stiffness. PLoS ONE. 2014; 9(8): e 104365. 27.  Du T, Gang Y, Muxun Z, Xingrong Z, Xingxing S, Xuefeng Y. Clinical usefulness of lipid ratios, visceral adiposity indicators and the triglycerides and glucose index as risk markers of insulin resistance. Cardiovasc Diabetol. 2014; 13: 46. 28.  Nieves DJ, Cnop M, Retzlaff B, Walden CE, Brunzell JD, Knopp RH, et al. The Atherogenic Lipoprotein Profile Associated With Obesity and Insulin Resistance Is Largely Attributable to Intra-Abdominal Fat. Diabetes. 2003; 52: 172-179. <![CDATA[Lipid profile in an urban healthy adult Bangladeshi population]]> Taslima Akter Elisha Khandker Zinat Ara Polly Fatima Khanam https://imcjms.com/journal_full_text/336 2020-02-19 23:34:51 Original Article IMC J Med Sci 2020; 14(1): 003 Abstract Background and objectives: The prevalence of ischemic heart disease (IHD) has increased in most of the developing countries, including Bangladesh. An important marker of IHD is dyslipidemia which includes high levels of triglyceride (TG), total cholesterol (T-cholesterol), low density lipoprotein cholesterol (LDL-c) and low level of high density lipoprotein cholesterol (HDL-c). So it is very important to know the lipid levels of a particular population for early intervention and prevention of IHD. The present study investigated the lipid levels of healthy urban adult Bangladeshi population. Methods: The cross sectional study was carried out over a period of one year at the Department of Physiology of Ibrahim Medical College, Dhaka, Bangladesh. A total number of 286 apparently healthy individuals were included in this study. Blood sample following overnight fast was collected for determination of serum TG, T-cholesterol, LDL-c and HDL-c. For all four lipid components, 95th percentile value was calculated and compared with values recommended by World Health Organization (WHO). Results: A total number of 286 adult individuals were enrolled of which 130 (45.5%) and 156 (54.5%) were male and female respectively. The mean levels of TG (122±56 mg/dl) and T-cholesterol (178±25 mg/dl) of male participants were significantly (p=0.001, p=0.008) higher than that of females (79.3±35.6 and 170±26 mg/dl). The level of serum HDL-c was significantly (p=0.001) higher in females (46.1±7.8 mg/dl)) compared to the males (39.7±8.6 mg/dl). The 95th percentile values of TG, T-cholesterol and LDL-c were higher than that of values recommended by WHO. Of the total participants, 17.1% to 24.1% had TG, T-cholesterol and LDL-c levels higher than the WHO recommended range. Conclusion: It is concluded that a proportion of our urban healthy young adult population had lipid profiles different from that recommended by WHO. IMC J Med Sci 2020; 14(1): 003. EPub date: 20 February 2020. DOI: https://doi.org/10.3329/imcjms.v14i1.47383 Address for Correspondence: Dr. Fatima Khanam. Professor, Department of Physiology, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka-100, Bangladesh, 8th floor, Room: 906. Email: fatimakhanam37@yahoo.com   Introduction Metabolic abnormality is affecting the human health at an increased rate all over the world. Major characteristic features of the metabolic abnormalities include obesity, dyslipidemia, hypertension and insulin resistance. This cluster of conditions has been termed as metabolic syndrome (MS) [1]. Hypertriglyceridemia, low HDL-c and high LDL-c have been found to have strong correlation with obesity parameters like body mass index (BMI), fasting glucose, atherosclerotic disease and coronary heart disease [2-5]. The prevalence of ischemic heart disease (IHD) has increased in most of the developed countries and is gradually increasing in developing countries, including Ban00gladesh [6,7]. Ischemic heart disease is the major cause of death in developed countries as well as in developing countries. Coronary heart disease and stroke are the leading causes of death in South Asian population living in UK. The rates are higher than the white population of UK [8]. The major cardiovascular risk factors are hypertension, diabetes mellitus and dyslipidemia [9,10]. Lipids and lipoproteins are well known risk factors for IHD. Elevated levels of triglyceride and total cholesterol and LDL-c are documented as risk factors for atherogenesis [11,12]. Considering this fact, World Health Organization (WHO) has already set a low cut-off value for BMI (23 kg/m² for both sex) and waist to height ratio (WHtR; 0.88 and 0.81 for men and women respectively) for Asian population [13]. American Heart Association (AHA) has set up cut-off values for lipid profile (cholesterol - upto 200 mg/dl; TG<180 mg/dl; HDL - 30-60 mg/dl; LDL - 100-190 mg/dl) and blood pressure (systolic - 110-130 mm of Hg and diastolic - 60-90 mm of Hg) for their communities [14]. WHtR has been proved as a valuable obesity index for predicting diabetes, hypertension and dyslipidemia [15]. Different national and international bodies have proposed a cut-off value for the different lipid components. Among these, the reference value proposed by WHO is accepted worldwide. But these values may not reflect the normal lipid levels of diverse ethnic population living in different geographic regions having different life style. The present study was aimed to determine the lipid levels in an urban healthy adult Bangladeshi population.   Methodology Study population and place: The cross sectional study was carried out over a period of one year at the Department of Physiology of Ibrahim Medical College, Dhaka, Bangladesh. Apparently healthy adult individuals aged 18 to 30 years living in Dhaka city were enrolled. The participants represented young urban affluent community. Anyone having diabetes, hypertension, pregnancy, taking oral contraceptives or lipid lowering agents were excluded. Informed written consent was obtained from all the participants after explaining the nature and purpose of the study. Detail family and medical history, anthropometric measurement and blood pressure were recorded in a predesigned data sheet. Collection of blood and estimation of lipid profile: About 5 ml of blood was collected aseptically from each participant after overnight fasting for estimation of TG, T-cholesterol, LDL-c and HDL-c. Biochemical analysis were carried out using auto-analyzer. Normal ranges for lipid profile were taken as: TG<150 mg/dl; TC<200 mg/dl; HDL>60 mg/dl and LDL<130 mg/dl [16]. Data analysis: Data were expressed as Mean± SD, number (percentage), range and 95% confidence interval. 95th percentile {K=k(n+1)/100, here, k=desired percentile, n=number of values} was calculated to work out the range of lipid components of the study participants.   Result   Table-1: Lipid profile of study population     Table-2: Ninety fifth (95th) percentile values of four lipid components for male, female and all volunteers     Table-3: Distribution of individuals with lipid values above the 95th percentile and WHO recommended range for lipids   Discussion The present study has investigated the lipid profile of affluent urban healthy Bangladeshi adults to find out the normal as well as the status of lipid levels in this population group. The levels of TG, T-cholesterol and LDL-c were significantly higher in males compared to females. The HDL-c levels in male and female was significantly below the WHO recommended levels. Similar observations have been reported from studies conducted in Caribbean island, Iran and Brazil [17-19]. A significant proportion of participants in our study had lipid levels higher than those recommended by WHO. Also, the 95th percentile values of TG, T-cholesterol and LDL-c of our study population were higher than those recommended by WHO. Similarly, the 95th percentile value of HDL-c was less than that of WHO recommended value. These high values for lipids may be due to ethno-geographic differences and specific life style. Considering this, the cut-off values for different lipid profile parameters should also be different for different ethnic groups. The gender variation should also be taken into consideration. Primary causes of dyslipidemia involve gene mutations that cause the body to produce too much LDL-c or triglycerides or to fail to remove those substances. Primary causes tend to be inherited and thus to run in families. The secondary causes of dyslipidemia include consuming a diet high in saturated fats, trans-fats, and cholesterol and physical inactivity. The high value of TG in Asian countries is probably due to the food habit i.e., consumption of high carbohydrate content food. Therefore, it will be interesting to study whether such lipid profiles in different ethnic population having different food habits, genetic make-up and life style have adverse impact on health or contribute to increase cardiovascular diseases [20]. If it does not affect the health adversely, then one should consider recommending different normal lipid range for different ethnic or regional population. In the present study, dyslipidemia appeared to be markedly high in both male and female study population. To conclusively comment regarding the normal lipid levels, the number of participants needs to be expanded involving multicenter/region approach to circumvent the bias in enrollment of volunteers.   Acknowledgement The authors acknowledge Department of Biochemistry and Molecular biology and laboratory medicine of BIRDEM General Hospital, Dhaka for their cooperation in sample collection and analysis.   Conflict of interest: None   Reference 1.     Huang PL. A comprehensive definition for metabolic syndrome. Dis Model Mech. 2009. 2(5-6): 231-237. 3.     Sayeed MA, Mahtab H, Sayeed S, Begum T, Khanam PA, Banu A. Prevalence and risk factors of coronary heart disease in a rural population of Bangladesh. IMC J Med Sci. 2010; 4(2): 37-43. 5.     Khoo KL, Tan H, Liew Y-M. Serum lipid and their relationship with other coronary risk factors in healthy subject in city clinic. Med J Malaysia. 1997; 52(1): 38-52. 7.     Ahsan SA, Haque KS, Salman M, Bari AS, Nahar H, Ahmed MK, et al. Detection of ischemic heart disease with risk factors in different categories of employees of university Grants Commission. University Heart J. 2009; 5(1): 20-23. 9.     Kannel WB, Macgee D, Gorton T. A general cardiovascular risk profile: the Framinghan Study. Am J Cardiol. 1976; 38(1): 46-51. 11.  Witztum JL, Steinberg D. Role of oxidized low density lipoprotein in atherogenesis. J Clin Invest. 1991; 88(6): 1785-1792. 12.  Palinski W, Rosenfeld ME, Herttuala SY, Gurtner GC, Socher SS, Butler SW, et al. Low density lipoprotein undergoes oxidative modification in vivo. Proc Natl Acad Sci USA. 1989; 86(4): 1372-1376. 13.  Chamukuttan S, Vijay V, Ambay R. Cut off values for normal anthropometric variables in Asian Indian adults. Diabetes Care. 2003; 26(5): 1380-1384. 14.  Lipid research clinic program, the lipid research clinic coronary primary prevention trial result 11. J Am Med Assoc. 1984; 251(3): 351-364. 15.  Sayeed MA, Mahtab H, Latif ZA, khanam PA, Ahsan KA, Banu A, et al. Waist to height ratio is a better obesity index than body mass index and waist to hip ratio for predicting diabetes, Hypertension and Lipidemia. Bangladesh Med Res Conc Bull. 2003; 29(1): 1-10. 16.  World Health Organization. Diagnosis and classification of diabetes mellitus. Geneva: World Health Organization; 1999. Report series no. 727. 17.  Foucan L, Kangambega P, Koumavi DE, Rozet JE, Brédent BJ. Lipid profile in an adult population in Guadeloupe. Diabetes Metab (Paris). 2000; 26(6): 473-480. 18.  Azizi F, Rahmani M, Ghanbarian A, Emami M, Salehi P, Mirmiran P, et al. Serum lipid levels in an Iranian adults population: Tehran lipid and glucose study. Eur J Epidemiol. 2003; 18(4): 311-319.  19.Freitas RWJF,Araújo MFM,Lima ACS, Pereira DCR, et al. Study of Lipid profile in a population of university students. Rev Lat Am Enfermagem. 2013; 21(5): 1151-1158. 20. Nelson RH. Hyperlipidemia as a Risk Factor for Cardiovascular Disease. Prim Care. 2013; 40(1): 195-211. <![CDATA[Comparative evaluation of rapid Salmonella Typhi IgM/IgG and Widal test for the diagnosis of enteric fever]]> Farjana Akter Mahmuda Yeasmin Md. Zahangir Alam Md. Rokibul Hasan Fahmida Rahman Elisha Khandker Md. Monirul Hoque Lovely Barai Md. Mohiuddin Md. Shariful Alam Jilani https://imcjms.com/journal_full_text/337 2020-02-29 00:24:34 Original Article IMC J Med Sci 2020; 14(1): 004 Abstract Background: Accurate and early diagnosis of enteric fever is a diagnostic challenge where facility for blood culture is not available. As a result, Widal test is still used widely in resource limited settings. Recently, user-friendly rapid immunochromatographic tests (ICT) have been introduced for quick diagnosis of enteric fever. So, we evaluated sensitivity and specificity of an immunochromatography based Salmonella Typhi IgM/IgG test kit and Widal test compared to blood culture for the diagnosis of enteric fever. Method: The study was conducted in the Department of Microbiology, Ibrahim Medical College (IMC) and Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) from June 2017 to September 2017. Clinically suspected enteric fever cases were included. Blood culture, Widal and Salmonella Typhi IgM/IgG detecting ICT were employed for the diagnosis of enteric fever. Results: Out of 71 suspected cases of enteric fever, blood culture was positive in 36 cases (50.7%) while 42 (59.15%) and 35 (49.29%) cases were positive by Widal test and ICT respectively. Widal and ICT had sensitivity and specificity of 100% and 89.9% and 82.9% & 91.4% respectively. Conclusion: Findings of the study suggest that both Widal and immunochromatographic tests can be used interchangeably for rapid diagnosis of enteric fever. IMC J Med Sci 2020; 14(1): 004. EPub date: 29 February 2020. DOI: https://doi.org/10.3329/imcjms.v14i1.47452 Address for Correspondence: Dr. Farjana Akter. Lecturer, Department of Microbiology, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka-1000, Bangladesh, 10th floor, Room: 1118. Email: farjana73mail@yahoo.com   Introduction Enteric fever is a multisystem disease and its outcome can be fatal if not properly diagnosed and treated [1]. It is predominantly caused by Salmonella enterica serotype Typhi and less frequently by Salmonella enterica serotype Paratyphi A and B [2]. Lack of access to safe drinking water, unhygienic sanitation, and overcrowded population of underdeveloped countries may accelerate its feco-oral transmission [3]. Physicians often experience diagnostic dilemma due to its protean clinical presentation which is quite similar to other febrile illness like dengue, malaria, chikungunya etc. in endemic area [4]. Prompt and accurate diagnosis of enteric fever is a pressing need albeit no such diagnostic test is currently available that can provide 100% sensitivity and accuracy. Diagnosis at an early stage can reduce indiscriminate antibiotic use; prevent unwanted life threatening complications and chronic carrier state [5]. Amidst available diagnostic test, isolation of organisms from blood, bone marrow, urine and stool is considered gold standard for diagnosis of enteric fever [6,7]. Culturing of organism from blood is frequently done in clinical setting which is insufficiently sensitive, laborious and time consuming and bone marrow culture, although more sensitive is not done routinely due to its high technical demand [8,9]. In spite of considering blood culture as a gold standard test, it is not available in every primary health care setting. Moreover, its turnaround time is longer, usually 2-3 days. As a result, diagnosis of enteric fever overlooked or delayed and based on clinical features, clinicians often provide unnecessary antimicrobial therapy or undertreat the patients when other differentials are considered [10,11]. Therefore, rapid, simple, convenient, easy to perform, sensitive serological test to identify Salmonella Typhi and Paratyphi is often considered as the only diagnostic tool that can guide clinicians [12]. Most routinely performed serological test is Widal which was developed by Georges Fernand Widal in 1890 based on the demonstration of agglutinating antibodies against lipopolysaccharide (LPS; O) and ﬂagella (H) antigens of Salmonella Typhi and Paratyphi A and B. This test became obsolete in many developed countries due to its unsatisfactory results, low prevalence of enteric fever and availability of more sophisticated diagnostic tools [13]. Variable sensitivity and specificity of Widal test was documented in different studies and its role as a diagnostic tool is still debatable. However, some studies conducted in Tanzania, Vietnam, Bangladesh, India during different periods of time stated that Widal test could be relevant as a diagnostic tool and could be an alternative to blood culture [14-17]. On the other hand, findings of other studies conducted in Pakistan, Nepal, South Africa, Tanzania, and Ethiopia indicated that Widal test alone might not be suitable to diagnose enteric fever as it could produce false positive results [18]. But scenario is quite different in developing countries like Bangladesh where Widal test is still used widely as facility of culturing organism is limited to only in tertiary care hospitals, lack of trained personnel and prohibitively high cost of culture compared to serological test [16]. User friendly rapid diagnostic tests (RDT) for diagnosis of Salmonella Typhi are available commercially in different methods and formats like ELISA or immunochromatography based tests (ICT) which can directly detect IgM and/or IgG antibodies against specific antigen of Salmonella Typhi [19]. It can also detect antibodies within 4-5 days of appearance of fever and ICT can provide results within 15-30 minutes. ICT is user-oriented, time saving and does not require highly skilled personnel to perform the test and to interpret the result which makes it an excellent choice for point of care service [20]. But these kits are still not widely acceptable due to its inconsistent sensitivity (73-95%) and specificity (68-95%) which have been documented in different studies conducted preliminarily in different Asian countries [21-25]. Therefore, the aim of the current study was to evaluate the sensitivity and specificity of both Widal test and rapid Salmonella Typhi IgM/IgG immunochromatographic test in comparison to blood culture for quick and accurate diagnosis of typhoid fever.   Materials & Methods Study population, place and samples collection: This study was conducted in the Department of Microbiology, Ibrahim Medical College (IMC) and Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) from June 2017 to September 2017. Total 71 blood samples were collected from suspected cases of enteric fever for blood culture, Widal test and Salmonella Typhi IgM/IgG immunochromatographic test. From each patient 10 ml of venous blood was collected aseptically for blood culture and serological tests. Informed written consent was obtained from each patient prior to collection of blood. Blood culture: An aliquot (8 ml for adult and 1.5 ml for children) of fresh blood was immediately processed for culture. Blood culture was done by lysis centrifugation method and inoculated on blood agar and MacConkey agar media and incubated for 48 hours at 370C [25,26]. Suspected bacterial colony was identified by Gram staining and standard biochemical tests [25,27]. Serotype of Salmonella spp. was identified by slide agglutination test by specific ‘O’ (lipopolysaccharide), ‘H’ (flagella) anti-sera [27]. Widal test and Salmonella IgM/IgG ICT: Widal test was carried out by slide method using HiPer® Widal Test Teaching Kit (HiMedia Laboratories Pvt. Limited, India) according to the manufacturer’s instruction. Test results were interpreted visually by demonstrating agglutinating antibody titres against ‘O’ (lipopolysaccharide) and ‘H’ antigen (flagella) of Salmonella spp. An antibody titre of 1:80 or more against ‘O’ and ‘H’ antigen was considered positive [28]. Enteroscreen-WB ICT kit Typhi manufactured by Zephyr Biomedical (Verna Industrial Estate, Verna, Goa, India) was used to detect Salmonella IgM/IgG antibodies against an outer membrane protein of Salmonella Typhi. Test was carried out as per manufacturer’s instruction and reading was taken after 15-30 minutes based on appearance of coloured band in the control region and test region. The band in test region represented presence of either anti-Salmonella IgM or IgG. ICT was considered positive if any anti-Salmonella IgM, IgG or IgM+IgG band appeared positive in any sample. The result was compared with blood culture and Widal test.   Results Total 71 suspected cases of enteric fever were included in the study. Out of 71 cases, blood culture, Widal and ICT were positive in 36 (50.7%), 42 (59.2%) and 35 (49.3%) cases respectively (Table-1). Out of 36 blood culture positive cases, Salmonella Typhi was isolated from 32 cases and Salmonella Paratyphi A was present in 4 cases (Table-2).   Table-1: Results of blood culture, Widal and Salmonella-IgM/IgG ICT tests (n=71)   Widal test was positive in all S. Typhi and S. Paratyphi A positive cases. Out of 35 culture negative cases, 6 cases were Widal test positive as well. Widal test showed more than 1:80 titre of TO/TH in all S. Typhi culture positive cases and higher titre of ‘AO’/‘AH’ was observed in all S. Paratyphi A cases. Although TO/TH is specific to S. Typhi, higher titre was also observed in all culture positive cases of S. Paratyphi A and at the same time titre of AO/AH which was specific to S. Paratyphi A was raised in 11 cases of S. Typhi. ICT for Salmonella IgM/IgG was performed in all 71 cases. ICT was positive in total 32 (88.9%) out of 36 blood culture positive cases. Out of 32 S. Typhi positive cases, 29 cases were positive by ICT and 3 were negative by ICT. On the other hand among 4 S. Paratyphi A positive cases, 3 showed positive result in ICT (Table-2).   Table-2: Comparative results of blood culture, Widal test and Salmonella-IgM/IgG ICT (n=71)     Only anti-Salmonella IgM, IgG and both IgM and IgG were positive in 3 (4.2%), 18 (25.4%) and 14 (19.7%) cases respectively (Table-3). Total 32 cases (45.1%) were IgG positive, 17 (23.9%) were IgM positive and 14 (29.17%) were both IgM and IgG positive (Table-3). The sensitivity and specificity of Widal and Salmonella IgM/IgG ICT are shown in Table-4. The sensitivity and specificity of Widal test were 100% and 82.9% respectively while these were 88.9% and 91.4% for Salmonella IgM/IgG ICT. Salmonella IgM/IgG test had higher (91.4%) positive predictive value (PPV) compared to Widal test (85.7%). Table-3: Rate and pattern of Salmonella IgM/IgG antibodies by ICT in study cases (n=71)     Table-4: Sensitivity, specificity, PPV and NPV of Widal and Salmonella IgM/IgG tests     Discussion Isolation of Salmonella Typhi and Paratyphi A and B from blood for diagnosis of enteric fever is the current recommendation of WHO and considered as a reference while evaluating other tests [29]. Blood culture is highly specific but its suboptimal sensitivity after the first week of illness leads to the diagnostic difficulty and sensitivity [30]. In this study, it has been observed that blood culture for Salmonella enterica serotype Typhi and Paratyphi A was found to be positive in 50.7% cases which is quite similar to other study findings where 40-70% of presumptive cases were found culture positive [7,31-35]. In contrast to these study findings, rate of isolation of Salmonella spp. was found much lower ranging from 8.9-43% in many well documented studies [36-39]. This low rate of isolation may be attributed to negligence of seeking health care services at an early stage of fever, inappropriate use of antibiotic before blood culture and collection of inadequate amount of blood especially in case of children [40]. In this current series, both Widal test and ICT (Enteroscreen-WB) were performed in 71 clinically suspected cases of enteric fever to evaluate their sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) compared to blood culture. Out of 42 Widal positive cases 36 cases were blood culture positive and 6 cases were blood culture negative. Sensitivity, specificity, PPV and NPV of Widal were noted as 100%, 82.9%, 85.7% and 100% respectively. In this study, the sensitivity of Widal was found higher though specificity was slightly reduced and was in accordance with the reported results of blood culture. Gopala kirshnan et al. [41] in 2002 reported sensitivity and specificity of Widal test as 98% and 76% respectively which closely resemble our study findings. Another study reported the sensitivity and specificity of Widal test as 71% and 62% [17]. In 2016, a study from Bangladesh reported the sensitivity, specificity, PPV and NPV of Widal test as 83.3%, 80%, 86.2%, and 76.2% respectively [42]. These study findings revealed fairly good diagnostic accuracy of Widal test for diagnosis of enteric fever. In the present study raised titre of TO/TH of more than 1:80 was observed in all Salmonella Paratyphi A positive cases and AO/AH in 11 Salmonella Typhi positive cases. This may be due to cross reacting antigen between these serotypes. Moreover, lipopolysaccharide ‘O’ antigen also shared by other Enterobacteriaceae which results in false positive Widal test making the test less specific to detect Salmonella spp. Several studies have claimed that rapid diagnostic tests (RDT) provide better valid results than Widal test with regard to sensitivity and specificity [22, 43]. In our study with lateral flow rapid Salmonella IgM/IgG ICT, the sensitivity, specificity, PPV and NPV were recorded as 88.89%, 91.43%, 91.43% and 88.89% respectively. According to a study done by Sanjeev et al. [44], Typhi-dot performed better than Widal test and they found sensitivity and specificity of Widal and Typhi-dot as 100% and 76% and 78.78% and 58.82% respectively. They suggested that rather than using Widal test it might be more useful to use rapid test like Typhi-dot in routine diagnostic service besides blood culture. Studies from Bangladesh reported similar rate of sensitivity and specificity of a rapid ICT (SD Bioline) and TUBEX® for the diagnosis of typhoid fever [45,46]. This is in agreement with our findings. In contrary to these findings, Neheed et al. demonstrated suboptimal performance of Typhi-dot and TUBEX® to diagnose typhoid fever among community populations [47]. Dissimilarity regarding the sensitivity and specificity observed in different studies could be due to the use of different format of rapid diagnostic test kit from different manufacturers. In addition, time elapsed from onset of symptoms and performance of test may affect sensitivity and specificity of ICT. Among the available different RDT kit, diagnostic accuracy of Typhi-dot and TUBEX® were largely studied. Very limited studies were conducted where performance of Enteroscreen ICT (Bioline) was analysed. Prasad et al. included 2699 patients in their study to compare the diagnostic validity of two rapid Salmonella IgM tests with regard to blood culture [48]. Sensitivity, specificity, PPV and NPV of Typhi-dot and Enteroscreen were recorded as 97.29%, 97.40%, 98.18% and 96.15% and 88.13%, 87.83%, 92.03% and 82.27% respectively. Though Enteroscreen performed poorly in comparison to Typhi-dot, they recommend Enteroscreen during emergency situation due to its acceptable PPV and it takes less time to provide results [48]. Our data matched well with these values. On the other hand, another study mentioned sensitivity, specificity, PPV and NPV of Enteroscreen ICT in comparison to Widal as gold standard test as 50%, 96%, 66.66% and 92.30% respectively. Specificity and NPV of ICT were similar to our study while they found poor sensitivity and PPV of this particular ICT kit [49]. Although this ICT kit is meant to detect S. Typhi only, but in this study we observed that out of 4 S. Paratyphi A cases, 3 (75%) were positive by this kit. This could be attributed to cross reactivity between outer membrane protein of both Salmonella spp. Prasad et al. (2015) noted Enteroscreen ICT positive results in 22 cases of 46 blood culture positive S. Paratyphi cases and sensitivity was 47.83% in their study [48]. This cross reactivity provides extra advantages of diagnosing paratyphoid fever by Enteroscreen ICT kit. The ICT kit that we have used is able to differentiate between IgM and IgG antibodies. This study demonstrated that only IgM became positive in 4.2% cases, only IgG in 25.4% cases and both IgM and IgG was found positive in 19.7% cases. Only IgM (early phase) or both IgM and IgG positive (middle phase) indicates current infection and IgG without IgM usually denotes past, reinfection or late stage disease when sero-conversion has already been occurred. In this study we observed the percentages of IgG positive cases among culture positive group was high, but in other studies conducted through different ICT kit found more IgM positive cases [45]. This could be explained by the disappearance of IgM in the late stage of disease or masking of IgM by IgG [50]. In our study, Enteroscreen Salmonella IgM/IgG rapid test showed satisfactory results in terms of sensitivity and specificity compared to Widal test. Our results differ to some extent from above mentioned studies and this might be due to small sample size and collection of blood at different stage of fever. So, these serological tests may be used interchangeably with Widal test in suspected enteric fever where an adequate laboratory facility for blood culture is not available. Development of convenient, rapid, highly sensitive, specific and robust diagnostic tool is a long felt need to diagnose enteric fever accurately at an early stage of disease. In this regard, rapid serological diagnostic tests in ICT format with considerable sensitivity and specificity can play a fundamental role, especially in resource-constrained rural settings of Bangladesh. At the same time, usefulness of Widal test in area with limited microbiology laboratory facilities cannot be ignored. Although clinical implication of Widal test is reducing day by day, but in some areas, it is the only available test in which clinicians have to rely to reach a diagnosis of enteric fever. Our work has led us to conclude that Widal test is justifiable as long as the results are interpreted in accordance with the clinical history indicative of enteric fever and background level of antibody titres of local populations are considered. At the same time introduction of ICT might be an important addition to serological test for more rapid and reliable diagnosis of enteric fever.   Acknowledgement We are grateful to Tradesworth Ltd. Bangladesh for providing Enteroscreen-WB ICT kit. References 1.     Nasrallah SM, Nassar VH. Enteric fever: a clinicopathologic study of 104 cases. Am J Gastroenterol.1978; 69(1): 63-69. 2.     Joshi S. Antibiogram of S. enterica serovar typhi and S. enterica serovar paratyphi A: a multi-centre study from India. WHO South East Asia J Public health. 2012; 1(2): 182-183. 3.     Corner RJ, Dewan AM, Hashizume M. Modelling typhoid risk in Dhaka metropolitan area of Bangladesh: the role of socio-economic and environmental factors.Int J Health Geogr. 2013; 12: 13. 4.     Bhutta ZA, Dewraj HL. Current concepts in the diagnosis and treatment of typhoid fever. BMJ. 2006; 333(7558): 78-82. 5.     Baker S, Favorov M, Dougan G. Searching for the elusive typhoid diagnostic. BMC Infect Dis. 2010; 10: 45. 6.     Gasem MH, Dolmans WM, Isbandrio B, Wahyono H, Keuter M, Djokomoeljanto R. Culture of Salmonella Typhi and Salmonella Paratyphi from blood and bone marrow in suspected typhoid fever. Trop Geogr Med. 1995; 47(4): 164-167. 7.     Gilman RH, Terminel M, Levine MM, Hernandez-Menodoze P, Hornick Rb. Relative efficacy of blood, urine, rectal swab, bone marrow and rose spot cultures for recovery of Salmonella Typhi in typhoid fever. Lancet. 1975; B(7918): 1211-1213. 8.     Hoffman SL, Edman DC, Punjabi NH, Lesmana M, Cholid A, Sundah S, et al. Bone marrow aspirate culture superior to streptokinase clot culture and 8 ml 1: 10 blood-to-broth ratio blood culture for diagnosis of typhoid fever. Am J Trop Med Hyg. 1986; 35(4): 836-839. 9.     Parry CM, Wijedoru L, Arjyal A, Baker S. The utility of diagnostic tests for enteric fever in endemic locations.Expert Rev Anti Infect Ther. 2011; 9(6): 711-725. 10.  Ross IN, Abraham T. Predicting enteric fever without bacteriological culture results. Trans R Soc Trop Med Hyg. 1987; 81(3): 374-377. 11.  Archibald LK, Reller LB. Clinical microbiology in developing countries. Emerg Infect Dis. 2011; 7: 302-305. 12.  House D, Wain J, Ho VA, Diep TS, Chinh NT, Bay PV, et al. Serology of typhoid fever in an area of endemicity and its relevance to diagnosis. J Clin Microbiol. 2001; 39(3): 1002-1007. 13.  Olopoenia LA, King AL. Widal agglutination test − 100 years later: still plagued by controversy.Postgrad Med J. 2000; 76(892): 80-84. 14.  Ley B, Mtove G, Thriemer K, Amos B, Von Seidlein L, Hendriksen I, et al. Evaluation of the Widal tube agglutination test for the diagnosis of typhoid fever among children admitted to a rural hospital in Tanzania and a comparison with previous studies. BMC Infect. Dis. 2010; 10(1): 180. 15.  Parry CM, Hoa NT, Diep TS, Wain J, Chinh NT, Vinh H, et al. Value of a single-tube Widal test in diagnosis of typhoid fever in Vietnam.J Clin Microbiol. 1999; 37(9): 2882-2886. 16.  Alam AS, Rupam FA, Chaiti F. Utility of a single Widal test in the diagnosis of typhoid fever. Bangladesh J Child Health. 2011; 35(2): 53-58. 17.  Aziz T, Haque SS. Role of Widal test in the diagnosis of typhoid fever in context to other test. Am J Biochem. 2012; 2(1): 16-18. 18.  Mengist HM, Tilahun K. Diagnostic value of Widal test in the diagnosis of typhoid fever: a systematic review. J Med Microbiol Diagn. 2017; 6: 248. 19.  Prasad KJ, Oberoi JK, Goel N, Wattal C. Comparative evaluation of two rapid Salmonella-IgM tests and blood culture in the diagnosis of enteric fever. Indian J Med Microbiol. 2015; 33(2): 237-242. [Letter] 20.  Wijedoru L, Mallett S, Parry CM. Rapid diagnostic tests for typhoid and paratyphoid (enteric) fever. Cochrane Database Syst Rev. 2017; 5: CD008892. 21.  Sherwal BL, Dhamija RK, Randhawa VS, Jais M, Kaintura A, Kumar M. A comparative study of Typhidot M and Widal test in patients of typhoid fever. J Indian Acad Clin Med. 2004; 5(3): 244-260. 22.  Jesudason MV, Sivakumar S. Prospective evaluation of a rapid diagnostic test Typhidot for typhoid fever. Indian J Med Res 2006; 123(4): 513-516. 23.  Choo KE, Davis TM, Ismail A, Ibrahim TA, Ghazali WN. Rapid and reliable serological diagnosis of enteric fever: Comparative sensitivity and specifcity of Typhidot and Typhidot-M tests in febrile Malaysian children. Acta Trop. 1999; 72: 175-183. 24.  Bhutta ZA, Mansurrali N. Rapid serologic diagnosis of pediatric typhoid fever in an endemic area: A prospective comparative evaluation of two dot enzyme immunoassay and the Widal test. Am J Trop Med Hyg. 1999; 61(4): 654-657. 25.  Cheesbrough M. District Laboratory Practice in Tropical Countries. 2nd ed. India: Cambridge University Press; 2012. p. 184-186. 26.  Sultana S, Hossain MA, Al Maruf MA, Gani MA. Comparison of the lytic blood culture method with the conventional blood culture method in cases of enteric fever in a tertiary care hospital. Bangladesh J Infect Dis. 2016; 3(1): 6-10. 27.  Baron E. Specimen collection, transport and processing: Bacteriology. In: Jorgensen JH,  Pfaller MA, Carroll KC, Funke G,  Landry ML, Richter SS, Warnock DW, editors. Manual of Clinical Microbiology. 11th eds. Washington, DC: ASM Press; 2007; p310. 28.  Khan A, Ashher F, Khanam F, Rahman MM, Khan M, Paul SK, Hossain MA. Baseline Widal titer among healthy adult males from the greater Mymensingh division of Bangladesh. Infect Disord Drug Targets. 2018; 18(3): 233-240. 29.  World Health Organisation. The diagnosis, treatment and prevention of typhoid fever; Communicable disease surveillance and response vaccine and biologicals. Geneva: World Health Organisation; 2003. 38p. 30.  Buckle GC, Walker CLF, Black RE. Typhoid fever and paratyphoid fever: Systematic review to estimate global morbidity and mortality for 2010. J Glob Health. 2012; 2(1):010401. 31.  Farooqui BJ, Khurshid M, Ashfaq MK, Khan MA. Comparative yield of Salmonella Typhi from blood and bone marrow cultures in patients with fever of unknown origin. J Clin Pathol. 1991; 44(3): 258-259. 32.  Ochiai RL, Acosta CJ, Danovaro-Holliday M, Baiqing D, Bhattacharya SK, Agtini MD, et al. A study of typhoid fever in five Asian countries: disease burden and implications for controls.Bull World Health Organ.2008; 86: 260-268. 33.  Crump JA, Luby SP, Mintz ED. The global burden of typhoid fever. Bull World Health Organ. 2004; 82: 346-353. 34.  Abdoel TH, Pastoor R, Smits HL, Hatta M. Laboratory evaluation of a simple and rapid latex agglutination assay for the serodiagnosis of typhoid fever. Trans R Soc Trop Med Hyg. 2007; 101(10): 1032-1038. 35.  Krishnan P, Stalin M, Balasubramanian S. Changing trends in antimicrobial resistance of Salmonella enterica serovar typhi and Salmonella enterica serovar paratyphi A in Chennai.Indian J Pathol Microbiol. 2009; 52(4): 505. 36.  Narayanappa D, Sripathi R, Jagdishkumar K, Rajani HS. Comparative study of dot enzyme immunoassay (Typhidot-M) and Widal test in the diagnosis of typhoid fever. Indian Pediatr. 2010; 47(4): 331-333. 37.  Abucejo PE, Capeding MR, Lupisan SP, Arcay J, Sombrero LT, Ruutu P, Herva E. Blood culture confirmed typhoid fever in a provincial hospital in the Philippines. Southeast Asian J Trop Med Public Health. 2001; 32(3): 531-536. 38.  Wain J, Hosoglu S. The laboratory diagnosis of enteric fever.J Infect Dev Ctries.2008; 2(06): 421-425. 39.  Akoh JA. Relative sensitivity of blood and bone marrow cultures in typhoid fever.Trop Doct. 1991; 21(4): 174-176. 40.  Mogasale V, Ramani E, Mogasale VV, Park J. What proportion of Salmonella Typhi cases are detected by blood culture? A systematic literature review. Ann Clin Microbiol Antimicrob. 2016; 15(1): 32. 41.  Gopalakrishnan V, Sekhar WY, Soo EH, Vinsent RA, Devi S. Typhoid fever in Kuala Lumpur and a comparative evaluation of two commercial diagnostic kits for the detection of antibodies to Salmonella Typhi. Singapore Med J. 2002; 43(7): 354-358. 42.  Islam K, Sayeed MA, Hossen E, Khanam F, Charles RC, Andrews J, et al. Comparison of the performance of the TPTest, tubex, typhidot and Widal immunodiagnostic assays and blood cultures in detecting patients with typhoid fever in Bangladesh, including using a Bayesian latent class modelling approach. PLoS Negl Trop Dis. 2016; 10: e0004558. 43.  Anusha R, Ganesh R, Lalitha J. Comparison of a rapid commercial test, Enterocheck WB®, with automated blood culture for diagnosis of typhoid fever. Ann Trop Paediatr. 2011; 31(3): 231-234. 44.  Sanjeev H, Nayak S, Asha PK, Rekha R, Karnaker V, Ganesh HR. A systematic evaluation of rapid dot-EIA, blood culture and Widal test in the diagnosis of typhoid fever. Nitte University J Health Science. 2013; 3(1): 21. 45.  Choudhury Z, Karim MR, Samad R, Islam S. Validity of immunochromatographic test for antibody in diagnosis of typhoid fever in children admitted in a tertiary care hospital. Chattagram Maa-O-Shishu Hosp Med Coll J. 2017; 16(2): 20-24. 46.  Rahman M, Siddique AK, Tam FCH, Sharmin S, Rashid H, Iqbal A, et al. Rapid detection of early typhoid fever in endemic community children by the TUBEX® O9-antibody test.Diagn Microbiol Infect Dis.2007; 58(3): 275-281. 47.  Naheed A, Ram PK, Brooks WA, Mintz ED, Hossain MA, Parsons MM, et al. Clinical value of Tubex™ and Typhidot® rapid diagnostic tests for typhoid fever in an urban community clinic in Bangladesh. Diagn Microbiol Infect Dis.2008; 61(4): 381-386. 48.  Prasad KJ, Oberoi JK, Goel N, Wattal C. Comparative evaluation of two rapid Salmonella-IgM tests and blood culture in the diagnosis of enteric fever. Indian J Med Microbiol. 2015; 33(2): 237. 49.  Parveen S, Verma P, Dubey K, Verma MK. Comparative evaluation of ENTEROSCREEN-WBTM and Widal test in suspected cases of enteric fever. Int J Life Sci Scienti Res. 2015; 1(2): 84-88. 50.  Ismail A. New advances in the diagnosis of typhoid and detection of typhoid carriers. Malays J Med Sci. 2000; 7(2): 3. <![CDATA[Knowledge about informed consent among doctors in postgraduate courses in Bangladesh]]> Kazi Taib Mamun Nabeela Mahboob Mohammad Abdullah Al Mahmud K. Zaman https://imcjms.com/journal_full_text/338 2020-03-07 01:01:59 Original Article IMC J Med Sci 2020; 14(1): 005 Abstract Background and objectives: Informed consent is now accepted as the cornerstone of medical practice and research. Concept of consent is an endeavor by which the patient can take part in clinical judgment concerning their treatment and protects patient and doctors against any litigation. However, in research informed consent is not merely a form that is signed, but is a process in which the participant has an understanding of the research and its risks. In view of this, the objective of the study was to assess the knowledge regarding informed consent among the doctors pursuing postgraduate courses in a medical institute in Bangladesh. Methodology: A descriptive cross sectional study was carried out among 160 postgraduate medical students in Dhaka city. A self-administered structured questionnaire consisting of 36 questions was used to assess their knowledge regarding informed consent. The response format was based on a 3-point Likert scale. Frequency distribution was used for statistical analysis. Results: The age range of the participants was from 25-40 years. Of the total participants, 48% were males and 42% were females. Majority of the respondents acknowledged the importance of an informed consent and 86.3% of the doctors agreed that only verbal consent was not adequate. Only 66.2% agreed that consent for participation in research should always be voluntary and informed. Majority (76.9%) agreed not to recruit individuals with mental or behavioral disorders not capable of giving adequately informed consent. Only 27.5% were aware that assent should be taken from children participating in a research. Out of total participants, 71.2% and 81.2% agreed that the participants should be informed about the laboratory test results. Management/referral must be ensured in case of abnormal test results respectively. For genetic research, 88.1% and 81.3% agreed for pre- and post-counseling respectively. Conclusion: There is need to initiate further educational programs to aware the doctors of the importance of informed consent in research, clinical practice and patient care. IMC J Med Sci 2020; 14(1): 005. EPub date: 07 March 2020. DOI: https://doi.org/10.3329/imcjms.v14i1.47451 Address for Correspondence: Dr. Nabeela Mahboob, Assistant Professor, Department of Microbiology, Popular Medical College, Dhanmondi, Dhaka, Bangladesh. Email: nabeela.islam311@gmail.com, Contact no: 01769050442   Introduction Medical research has increased greatly in many developing countries during the recent decade, motivated by the need to improve health in these countries [1]. Since medical research involves human participants, such research needs to be guided by fundamental ethical principles to ensure the protection of their rights and welfare. Furthermore, international standards mandate the review of research by research ethics committees (RECs) [2,3]. Ethical code within medicine has evolved overtime. In the past, a “doctor knows best” attitude was adopted by patients before any procedure as universal acceptance of the physician’s procedure. It was in the last few centuries that pressure began to mount on physicians for information about diseases and treatment options by patients [7]. The Nuremberg Trials of 1947 are regarded as the basis for the development of medical consent [8]. The Nuremberg Code of 1948 laid out the principle that “voluntary consent of the human subject is absolutely essential” [9]. Informed consent eventually emerged as legal and a right in 1972. This was as a result of series of legal cases in California in the 1950s [10] and in response to public outcry concerning unethical practices in the Tuskegee research [7]. Informed consent is a legal term that is supported by jurisdiction and international laws. It is defined as “voluntary agreement given by a person or a patient’s responsible proxy for participation in a study, immunization program, treatment regimen, invasive procedure, etc., after being informed of the purpose, methods, procedures, benefits and risks’’ [11]. A descriptive cross-sectional study was conducted among postgraduate medical doctors over a three months’ period from January 2018 to March 2018. The study was conducted in a single Postgraduate Medical Institute. All doctors of different disciplines studying in 2nd year and thesis part of postgraduate courses were approached to take part in the present study. Only 160 doctors agreed to take part and after obtaining consent a self-administered structured questionnaire was distributed. The questionnaire was developed and tested among them, and interviewed to obtain feedback on the overall acceptability of the questionnaire in terms of length and language clarity. Based on their feedback, the questionnaire did not require any corrections. The questionnaire designed to obtain knowledge towards informed consent, consisted of four sections. Section I solicited general demographic and professional background information. Section II had integrated 24 questions to collect information about knowledge regarding informed consent, section III had integrated 8 questions about knowledge regarding informed assent and section IV had integrated 4 questions about knowledge towards genetic studies. Before giving the questionnaires the participants were clearly explained about the research procedure and purpose. The anonymity was maintained. They were approached individually and requested to complete the forms. The participant’s responses for all sections other than section I were recorded using a 3-point Likert scale. Questionnaires were coded and excel sheet was created for data entry. The data were analyzed using SPSS version 20 (SPSS Inc., Chicago, IL, USA). Frequency distribution was calculated for proportion. In the present study, more than 80% of the participants agreed that for genetic studies, participants should be informed about the nature, outcome and consequences of the study findings, test results must be revealed and clarified, provisions for pre- and post-counseling must be ensured. Because of the complex issues and implications surrounding genetic testing, genetic counseling is often provided in the way of education, guidance, and pre- and post-test information about the risks, benefits, limitations, and implications of tests, as well as data storage and data usage (e.g., use in quality control or research) [26,27]. This approach facilitates patient consent to genetic testing and is viewed as a positive ethical feature. Indeed, evidence suggests genetic counseling improves knowledge and decreases anxiety, distress and depression [28]. Even so, concern remains about the lack of feasibility, applicability, or benefit to patients of receiving all of this information during the consent process. This is true for genetic testing in general, but especially relevant to broader genome analysis [29,30]. Others have gone further, and argued that too much detailed information can overload patient understanding [31,32] and undermine autonomous choice [33]. Though in our study, only 88.1% and 81.3% agreed for pre- and post-counseling respectively, but all genetic research must have provision for proper pre- and post-counseling. This study has concluded that informed consent is deemed as an integral part of the doctor and patient rapport. Knowledge and attitude should always run in a parallel way; once knowledge gets better, attitude will automatically improve. Although there is fair knowledge among postgraduate students; there is further need to initiate educational events to increase knowledge, awareness and acceptance of principles of research ethics among researchers. Faculty or students should be educated by holding seminars, workshops and continuing educational programs. The curriculum for students needs to be more detailed concerning research ethics. Thus, such initiative would further reduce the gaps of knowledge regarding informed consent and that may help in building constructive attitude towards necessity of consent process. Conflicts of interest The authors declare that there is no conflict of interests regarding the publication of this article.   Acknowledgments The authors are grateful to the study participants for their participation and kind cooperation throughout the study.   References 2.     Zimmerman C, Watts C. WHO ethical and safety recommendations for interviewing trafficked women. Geneva: World Health Organization; 2003. 4.     Khare A, Saxena V, Jain M, Sharva V, Singh P, Dayma A. Knowledge and attitude toward informed consent in medical and dental practitioners, of Bhopal city, India. J Dent Res Rev. 2017; 4(1): 17. 6.     Irving DN. What is bioethics? In: Koterski JW. Life and learning X: proceedings of the tenth university faculty for life conference. Washington, DC: University Faculty for Life; 2002. p. 1-84. 8.     Extended Project Dissertation; Can the lack of medical consent ever be justified? Available from: www.edexcel.com/.Medical20Consent-Feb. <![CDATA[Helicobacter pylori CagA seropositivity in adult Bangladeshi patients with peptic ulcer and erosion]]> Fahmida Rahman Khandaker Shadia Salma Khatun Mafruha Mahmud Indrajit Kumar Dutta Jalaluddin Ashraful Haq https://imcjms.com/journal_full_text/339 2020-04-05 00:47:41 Original Article IMC J Med Sci 2020; 14(1): 006 Abstract Background: CagA IgG antibody in sera might indicate presence of virulent Helicobacter pylori in patients with peptic ulcer disease. Present study was performed to find out the prevalence of CagA IgG antibody in patients with peptic ulcer/erosion. Methods: Any case that had peptic ulcer/erosion, plus positive for rapid urease test (RUT) or H. pylori stool antigen (HpSAg) or serum anti-H. pylori IgG/IgA were included in the study and named as H. pylori positive case. H. pylori positive cases were tested for CagA IgG antibody. Anti-H. pylori IgG, IgA and CagA IgG antibodies were determined by enzyme-linked immunosorbent assay (ELISA) and stool antigen by rapid immunochromatographic test (ICT). Urease production in biopsy sample was detected by RUT. Results: Total 86 H. pylori positive patients were included in the study. Out of 86 patients, CagA IgG was positive in 34 (39.5%; 95% CI: 0.30,0.50) cases. CagA seropositivity rate in ulcer and erosion cases were 58.8% (95% CI: 0.36,0.78) and 34.8% (95% CI: 0.25,0.47) respectively. H. pylori stool antigen and IgA antibodies were positive in all (100%) CagA antibody positive ulcer cases while the rates were significantly less among the CagA antibody negative cases (42.8% and 28.6%; p<0.05). However, in CagA antibody positive erosion cases, the rates were not significantly different from CagA antibody negative cases. Conclusion: The study has demonstrated that the CagA positive strain is less prevalent in erosion than ulcer cases. IMC J Med Sci 2020; 14(1): 006. EPub date: 05 April 2020. DOI: https://doi.org/10.3329/imcjms.v14i1.47453 *Correspondence: J. Ashraful Haq, Department of Microbiology, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka 1000, Bangladesh. Email: jahaq54@yahoo.com ; 2a: present address   Introduction Helicobacter pylori infects about half of the world population, but only a small percentage develops clinical diseases. Outcome of infection is determined by the host factors, environment, virulence and genetic heterogeneity of H. pylori [1]. Now-a-days several virulence associated genes have been identified in the genome of H. pylori [2,3]. Vacuolating cytotoxin (vacA) gene is present in all H. pylori strains and encodes a vacuolating cytotoxin. Cytotoxin associated gene (cagA) is not present in all H pylori strains, and is considered as a marker for the presence of a pathogenicity island of 35–40 kbp in the bacterial genome. This island contains a number of genes, whose products are associated with increased pathogenicity of H. pylori. It can induce local epithelial cells to release cytokines namely interleukin-8 and 6 and tumor necrosis factor-α (TNF-α). This may be the reason why cagA positive strains are more prevalent in patients with peptic ulcers compared with patients with gastritis only [4-6]. Study has reported that the occurrence of CagA positive H. pylori is higher among peptic ulcer disease (93.4%) than functional dyspepsia (64.6%) [7]. In the present study, H. pylori CagA seropositivity has been evaluated in adult patients with peptic ulcer and erosion.   Materials and methods Study population and case definition: Adult patients with dyspeptic symptoms attending the BIRDEM General Hospital for diagnostic endoscopy were enrolled in the study and screened for peptic ulcer/erosion, urease production in biopsy samples, H. pylori stool antigen and serum IgG/IgA. Any case that had peptic ulcer/erosion and positive for rapid urease test (RUT) or H. pylori stool antigen or serum anti- H. pylori IgG/IgA was included in the study and designated as H. pylori positive case. Patients treated with any antibiotics, colloidal bismuth compounds, proton pump inhibitors (PPI) or H2 blocker within the last four weeks were excluded from the study. Patients were diagnosed as ulcer or erosion by endoscopy. The study was approved by the Institutional Review Board and written informed consent was obtained from all cases. The study period was from July 2012 to February 2014.   Sample collection: Gastric biopsy specimen(s) was obtained during endoscopy for detection of H. pylori infection by rapid urease test (RUT). Stool (20-30 gm) and blood (2.5 ml) samples were collected from each patient. Stool samples were tested for H. pylori antigen within 6 hours of collection. Blood was used for the detection of H. pylori IgG and IgA and CagA IgG antibodies. Serum was separated and stored at –200C until used.   H.pyloristoolantigenassay: H.pylori stool antigen was detected by ABON one step H. pylori antigen ICT test device (Inverness Medical Innovation Hong Kong Limited). The test was performed as per instruction of the manufacturer. About 50 mg of feces was taken from three different sites of collected stool and mixed with extraction solution. The tube was shaken vigorously using vortex mixer and then centrifuged for 5 minutes at 4000 rpm. The supernatant was used for the assay. Two drops of extracted stool sample was added to the sample well of the test kit. The result was read 10 minutes after dispensing the sample. A test was considered positive when a purple-pink line (test line) appeared in addition to the control line and was considered negative when only the control line appeared. Lack of control line indicated invalid result.   H. pylori IgG, IgA and CagA IgG detection by ELISA: Serum samples were tested for the presence of anti-H. pylori IgG, IgA and CagA IgG antibodies by ELISA kit from DRG International Inc. USA. The test was performed and interpreted according to the manufacturer’s instruction.   Rapid urease test (RUT): The biopsy specimen was inoculated in the rapid urease test media. The test was considered positive if the colour of the medium changed from yellow to pink after 4 hours of incubation at 370C.   Results A total of 86 H. pylori positive cases with either peptic ulcer or erosion were included in the study. Of 86 patients, 17 (19.8%) and 69 (80.2%) had peptic ulcer and erosion respectively. Out of 86 cases, H. pylori CagA antibody was present in 34 (39.5%) cases (Table-1). Among ulcer, the CagA antibody was positive in 58.8% (95% CI: 0.36,0.78) cases compared to 34.8% (95% CI: 0.25,0.47) in erosion case. Higher positive rate of CagA antibody was significantly (p=0.03) associated with the presence of ulcer. The mean optical density (OD) values for CagA antibody in ulcer and erosion cases were not significantly different (p=0.89; Table-1). H. pylori stool antigen and IgA antibodies were positive in all (100% in both) CagA antibody positive ulcer cases while the rates were significantly (p<0.05) less among the CagA antibody negative cases (42.8% and 28.6%; Table-2). Among the CagA positive erosion cases, the stool antigen and serum IgA were positive in 66.7% and 70.8% cases respectively compared to 55.6% and 53.3% cases in CagA negative cases (p>0.05, p>0.05). H. pylori stool antigen was present in significantly (p=0.04) higher proportion of CagA antibody positive ulcer cases compared to erosion cases (100% vs. 66.7%). No significant difference was observed for IgA in CagA positive ulcer and erosion cases. Serum H. pylori IgG was present in almost equal proportion in both ulcer and erosion cases with and without positive CagA antibodies (Table-2).   Table-1: H. pylori CagA antibody in ulcer and erosion cases     Table-2: Presence of H. pylori stool antigen, IgA and IgG antibodies in relation to CagA antibody status in ulcer and erosion cases     Discussion Prevalence studies have indicated that H. pylori infection is extremely common in Bangladesh as in other developing countries [8]. The reported seroprevalence of H. pylori in the hospitalized Bangladeshi population has been reported as 77.4% and CagA antibodies detected in 86% of those [9]. A high association of H. pylori with peptic ulcer (77%) and gastritis (74%) was observed [10]. In our previous study, we found that 83.5% of dyspeptic cases were positive for H. pylori infection either by stool antigen or serum anti-H. pylori IgA [11]. In the present study, we attempted to find out the anti-CagA IgG status in dyspeptic patients. We found that only 39.5% dyspeptic patients were CagA IgG positive although 58.8% ulcer patients were CagA IgG positive compared to 34.8% in erosion cases. However, a high prevalence of cagA positive strains (75%) was reported in Bangladeshi patients with peptic ulcer diseases compared to strains from patients with non-ulcerated diseases (55%) by PCR [12]. Another study analyzed cagA and vacA subtypes and their association with severe histology phenotypes among Bangladeshi population and found 73.2% of isolated H. pylori carried cagA. They also observed that patients who were infected with cagA positive strains had more severe histological scores than patients infected with cagA negative strains [13]. Also, an earlier study showed that persons carrying cagA positive strains had greater degrees of gastric inflammation and epithelial cell damage than those who had cagA negative strains [14]. Therefore, CagA antibody could be a good marker to identify patients with a risk of developing future complications. Infection with CagA-positive strains is associated with increased gastric cancer [15].Low rate of CagA positivity observed in our study population could be due to the fact that we had more erosion cases than that of ulcer indicating milder form of disease. Frequency of CagA seropositivity has been variable in different countries: 50% in Turkey, 35.6% in Iran and 86.1% in Italy [16-18]. We also found that all CagA IgG positive ulcer cases were also positive for RUT, H. pylori stool antigen, H. pylori IgG and IgA antibodies. The study has shown that in our population less CagA positive strain is associated with erosion than ulcer cases and further prospective study is necessary to find out its implication in disease process.   Conflicts of interest The authors declare that there was no conflict of interests.   Funding The study was funded by the grant from Ibrahim Medical College.   References 1.     Dunn BE, Cohen H, Blaser MJ. Helicobacter pylori. Clin Microbiol Rev. 1997; 10: 720-741. 2.     Blaser MJ. Intrastrain differences in Helicobacter pylori. A key question in mucosal damage? Ann Med. 1995; 27: 559-563. 3.     Van Doorn LJ, Figueiredo C, Sanna R, Plaisier A, Schneeberger P, de Boer W, et al. Clinical relevance of the cagA, vacA, and iceA status of Helicobacter pylori. Gastroenterology. 1998; 115: 58-66. 4.     Kuipers EJ, Perez-Perez GI, Meuwissen SG, Blaser MJ. Helicobacter pylori and atrophic gastritis: importance of the cagA status. J Natl Cancer Inst. 1995; 87: 1777-1780. 5.     Maeda S, Ogura K, Yoshida H, Kanai F, Ikenoue T, Kato N, et al. Major virulence factors, VacA and CagA are commonly positive in Helicobacter pylori isolates in Japan. Gut. 1998; 42: 338-343. 6.     Yamaoka Y, Kita M, Kodama T, Sawai N, Kashima K, Imanishi J. Induction of various cytokines and development of severe mucosal inflammation by cagA gene positive Helicobacter pylori strains. Gut. 1997; 41: 442-451. 7.     Weel JF, van der Hulst RW, Gerrits Y, Roorda P, Feller M, Dankert J, et al. The interrelationship between cytotoxin-associated gene A, vacuolating cytotoxin, and Helicobacter pylori-related diseases. J Infect Dis. 1996; 173: 1171-1175. 8.     Mahalanabis D, Rahman MM, Sarker SA, Bardhan PK, Hildebrand P, Beglinger C, et al. Helicobacter pylori infection in the young in Bangladesh: prevalence, socioeconomic and nutritional aspects. Int J Epidemiol. 1996; 25: 894-898. 9.     Nessa, J, Chart H, Owen RJ, Drasar B. Human serum antibody response to Helicobacter pylori whole cell antigen in an institutionalized Bangladeshi population. J Appl Microbiol. 2001; 90: 68-72. 10.  Haque M, Rahman KM, Khan AA, Hasan M, Miah MRA, Rahman T, et al. Isolation and characterization of Helicobacter pylori strains from peptic ulcer patients in Dhaka, Bangladesh. Indian J Gastroenterol. 1995; 14: 128-130. 11.  Khatun S, Rahman F, Shadia K, Dutta IK, Hoq MN, Akter F, et al. Evaluation of rapid stool antigen test for the diagnosis of Helicobacter pylori infection in patients with dyspepsia. IMC J Med Sci. 2016; 10(2): 39-44. 12.  Rahman M, Mukhopadhyay AK, Nahar S, Datta S, Ahmad MM, Sarker S, et al. DNA-level characterization of Helicobacter pylori strains from patients with overt disease and with benign infections in Bangladesh. J clin Microbiol. 2003; 41(5): 2008-2014. 13.  Aftab H, Miftahussurur M, Subsomwong P, Ahmed F, Khan AKA, Matsumoto T, et al. Two populations of less-virulent Helicobacter pylori genotypes in Bangladesh. PLOS ONE. 2017; 12(8): e0182947. 14.  Peek RM Jr, Miller GG, Tham KT, Perez-Perez GI, Zhao X, Atherton JC, et al. Heightened inflammatory response and cytokine expression to cagA+ Helicobacter pylori strains. Lab Invest. 1995; 73: 760-770. 15.  Huang JQ, Zheng GF, Sumanac K, Irvine EJ, Hunt RH. Meta-analysis of the relationship between cagA seropositivity and gastric cancer. Gastroenterology. 2003; 125:1636-1644. 16.  Nazime OY, Ahmet S, Ali K, Iikay S. Detection of H. pylori infection by ELISA and western blot techniques and evaluation of anti-CagA seropositivity in adult Turkisk dyspeptic patients. World Gastroenterol. 2006; 12(33): 5375-5378. 17.  Bonyadi M, Babaloo Z, Fattahi E, Khoshbaten M, Abbasalizade F, Poozesh S. Detection of H. pylori infection and cagA strains seropositivity in adult dyspeptic patients in east Azerbaijan, northwest of Iran. Iran J Clin Infect Dis. 2010; 5(4): 228-230. 18.  Orsini B, Ciancio G, Surrenti E, Macrí G, Biagini MR, Milani S, et al. Serologic detection of cagA positive Helicobacter pylori infection in a northern Italian population. Helicobacter. 1998; 3(1): 15-20. <![CDATA[Hypothyroidism and hyperprolactinemia in women with primary and secondary infertility]]> Shamima Bari Rokeya Begum Qazi Shamima Akter https://imcjms.com/journal_full_text/344 2020-05-10 23:54:22 Original Article IMC J Med Sci 2020; 14(1): 009 Abstract Background and objectives: Infertility is a global health problem including Bangladesh. Altered thyroid and prolactin levels have been implicated as a cause of infertility. The study was undertaken to find out the serum thyroid hormones and prolactin status in women with primary and secondary infertility. Methods: Women with primary and secondary infertility were enrolled. Fertile age-matched women were included as control. The anthropometric details (age, height and weight) were recorded. Overnight fasting blood sample was collected on 2nd day of menstrual cycle of the follicular phase. Serum thyroid stimulating hormone (TSH), free tri-iodothyronine (FT3) and free thyroxine(FT4) were measured by enzyme-linked immunosorbent assay (ELISA). Serum prolactin (PRL) was estimated by radioimmunoassay.  Results: A total of 150 women were enrolled in the study. Out of 150 women, 50 had primary and 50 had secondary infertility while 50 women were age-matched fertile women as control. The mean TSH levels of both infertility groups were significantly higher than that of fertile women. Regarding thyroid function, 24% and 28% of women with primary and secondary infertility had hypothyroidism respectively. The serum prolactin level was high in 42.9% and 50% of hypothyroid cases in primary and secondary infertility groups respectively. Conclusion: The study has demonstrated high occurrence of hypothyroidism with raised serum prolactin levels among infertile females emphasizing the importance of estimating both serum TSH and prolactin in infertility. IMC J Med Sci 2020; 14(1): 009. EPub date: 11 May 2020. DOI: https://doi.org/10.3329/imcjms.v14i1.47454 *Correspondence: Shamima Bari, Department of Physiology, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka 1000, Bangladesh. Email: shamima.bari@yahoo.com   Introduction Infertility is an important health problem in Bangladesh. In Bangladesh, the rate of infertility has been reported as 4% to 15% [1-4]. The alteration of thyroid functions is associated with infertility [5-13]. Thyroid hormones, especially thyroid stimulating hormone (TSH), have been considered as an important component of infertility. Women with hyperprolactinemia have been found to have primary hypothyroidism. Thyroid dysfunctions interfere with numerous aspects of reproduction and pregnancy. Several articles have highlighted the association of hypothyroidism or hyperthyroidism with menstrual disturbance, anovulatory cycles, decreased productiveness and increased morbidity during pregnancy [8-10,14,15]. Hypothyroidism itself may contribute to infertility since thyroid hormones are necessary for the maximum production of both estradiol and progesterone [12,13]. Hence, it is necessary to screen serum thyroid hormones along with prolactin in women with infertility problems. Therefore, the present study was undertaken to determine the status of thyroid function in women with infertility.   Methods Study design: Women with primary and secondary infertility were included in the study. Equal number of age-matched apparently healthy fertile women was enrolled as control. Primary infertility denoted those women who had never conceived. Secondary infertility was defined as the same condition developing after initial phase of fertility that means the woman conceived previously but failed to conceive subsequently [12]. The fertility was defined as the capacity to conceive. Infertile women having husbands with normal semen analysis and those women with normal genitalia, uterus and adnexa were included. Women with tubal factor, congenital anomaly of urogenital tract and any obvious organic lesion or pelvic inflammatory diseases, and lactating women and also infertile women with subclinical hypothyroidism, secondary hypothyroidism were and subclinical hyperthyroidism, secondary hyperthyroidism were excluded from this study; only primary hypothyroidism and primary hyperthyroidism were included. The purpose and benefits of the study were explained to each participant and informed written consent was taken from each of them. A detailed medical, drug, personal, family, socio-economic histories were recorded in a predesigned questionnaire. The study was approved by the Institutional Ethical Review Committee. Collection of blood and estimation of biochemical parameters: Aseptically 5 milliliter of blood was collected from cubital vein of each participant. Blood was allowed to clot for 30-60 minutes at room temperature and then centrifuged at 3000 rpm for 5-10 minutes. The serum was separated and preserved at -20°C for estimation of serum TSH, FT4, FT3 and prolactin. The thyroid hormones were measured by enzyme-linked immunosorbent assay (ELISA) and serum prolactin was estimated by radioimmunoassay. The analysis was done within 2 weeks of blood collection. The normal range of serum, TSH, FT4, FT3 and prolactin were 0.3-4.0 mIU/L, 10.3-24.5 pmol/L, 2.3-6.3 pmol/L and 2-25 ng/ml respectively. Operational definition: The study population was categorized as (a) euthyroidism when the values of TSH and FT4 were within the normal range, (b) hypothyroidism when the TSH value exceeded 4.0 mIU/L and the FT4 value was normal or low, and (c) hyperthyroidism when the TSH value was <0.1 mIU/L or undetectable and normal or elevated FT3 or FT4 value [16,17]. Statistical Analysis: The data were analyzed by appropriate statistical tests namely, one way ANOVA, Tukey’s HSD post-hoc test and unpaired student’s t test and Z test.   Results A total of 150 women were included in the study. Out of 150 enrolled participants, 50 had primary (Group A) and another 50 had secondary infertility (Group B). Fifty age-matched apparently healthy fertile women were enrolled as control (Group C). The age range of the study population was from 23 years to 34 years and the mean age of different groups was almost similar and no statistically significant difference was observed. There was no significant difference of mean body mass index (BMI) between Group A and B. The mean serum levels of TSH, FT4, FT3 and prolactin of Group A, B and C are shown in Table-1. The mean serum TSH levels of women with primary (4.83±0.54 mIU/L)and secondary (6.40 ±0.59 mIU/L) infertility were significantly (p<0.001) higher than that of women with normal fertility (1.98±0.18 mIU/). The mean serum FT4 levels of women with primary (10.54±0.66 pmol/L) and secondary (7.64±0.44 pmol/L) infertility were significantly (p<0.005) lower than that of women with normal fertility (14.48±0.64 pmol/L). The mean serum FT3 levels of women with primary (4.12±0.32 pmol/L) and secondary infertility (3.9±0.23 pmol/L) were significantly (p=0.03 and p=0.001) lower than that of women with normal fertility (4.93±0.20 pmol/L). There was no significant difference of serum FT3 between Group A and B. Mean serum prolactin levels of women with primary (14.54±1.23 ng/ml) and secondary (15.36±1.02 ng/ml) infertility were significantly (p<0.05) higher than that of women with normal fertility (10.58±0.71 ng/ml). However, no significant difference was observed between women with primary and secondary infertility.   Table-1: Serum TSH, FT4, FT3 and prolactin levels of study population     According to the thyroid function status, 70% and 72% of the women having primary and secondary infertility were euthyroid respectively while 28% and 24% were suffering from hypothyroidism (Table-2). All the women in control group were euthyroid. Primary hyperthyroidism was present in 2% and 4% women with primary and secondary infertility (Table-2). The mean serum TSH level of hypothyroidism cases (7.97±0.72 mIU/L) of secondary infertility was significantly higher (p=0.02) compared to hypothyroidism cases of primary infertility group (5.14 ±0.85 mIU/L). High serum prolactin level was observed in 42.9% and 50% cases with hypothyroidism of women with primary and secondary infertility.   Table-2: Thyroid function status and prolactin levels in women with primary and secondary infertility     The Pearson’s correlation coefficient was calculated for serum TSH and prolactin in primary and secondary infertile women. In primary infertile women serum prolactin levels were significantly positively correlated with corresponding TSH levels (r =0.941, p <0.001; Figure-1). In secondary infertile women, serum prolactin levels also showed significantly positive correlation with serum TSH levels (r=0.915, p< 0.001, Figure-2). Hence, there was a strong association observed in primary and secondary infertile women with hyperprolactinemia and hypothyroidism.   Figure-1: Correlation of serum prolactin with TSH in primary infertile women     Figure-2: Correlation of serum prolactin with TSH in secondary infertile women     Discussion Thyroid dysfunction and alteration of prolactin levels have been reported as the cause of female infertility [8-10,15,18-23]. In the present study, hypothyroidism was found in 24%-28% women with primary and secondary infertility. Such pattern of thyroid dysfunction was also reported by several studies [8-15,18,20-22,24]. In hypothyroidism, increased thyrotropin-releasing hormone (TRH) production stimulates both TSH and prolactin secretion [23] and that leads to hyperprolactinemia and altered gonadotropin-releasing hormone (GnRH) secretion. This leads to a delay in luteinizing hormone (LH) response and inadequate corpus luteum leading to abnormal follicular development and ovulation [8-15,18,20-24]. 2.     Farely TMM, Baisey EM. The prevalence of an etiology of infertility. Proceedings of the 1st African Population Conference. 28 November 1998; Senegal, Dakar; 1998 4.     Vaessen M. Childlessness and infecundity. WFS Comparative Studies, Series 31. Voorburg, The Netherlands: Cross National Summaries, 1984. 6.     Roupa Z, Polikandrioti M, Sotiropoulou P, Faros E, Koulouri A, Wozniak G. Causes of infertility in women at reproductive age. Health Sci J. 2009; 3: 80-87. 8.     Akhter N, Hassan, MA. Subclinical hypothyroidism and hyperprolactinaemia in infertile women: Bangladesh perspective after universal salt iodinisation. The internet J Endocrinol. 2009; 5(1): 1-5. 10.  Tasneem A, Fatima I, Ali A, Mehmood N, Amin MK. The incidence of hyperprolactinaemia and associated hypothyroidism: local experience from Lahore. Pak J Nuclear Med. 2011; 1: 49-55. 12.  Doufas AG, Mastorakos G. The hypothalamic-pituitary-thyroid axis and the female reproductive system. Ann N Y Acad Sci. 2000; 900(1): 65-76. 14.  Iris A, Kawuwa MB, Habu SA, Adebayo A. Prolactin levels among infertile women in Maiduguri, Nigeria. Trop J Obs Gyn. 2003; 20: 97-100. 17.  Jameson J. Disorders of the thyroid gland. In: Fauci A, Braunwald E, Kasper D, Houser S, Longo D, Jameson J, editors. Harrison's Principles of Internal Medicine. New York: McGraw-Hill; 2008. pp. 2224-2246. 19.  Choudhary SD, Goswami A. Hyperprolactinemia and reproductive disorders – a profile from north east. J Assoc Phy India. 1995; 43: 617-618. 21.  Pratibha D, Govardhani M, Krihna PT. Prolactin levels in infertility and bromocriptine therapy in hyperprolactinemia. J Indian Med Assoc. 1994; 92(12): 397-399. 23.  Mancini T, Casanueva FF, Giustina A. Hyperprolactinemia and prolactinomas. Endocrinol Metab Clin North Am. 2008; 37(1): 67-69. 25.  Elahi S, Tasneem A, Nazir I, Nagra SA, Hyder SW. Thyroid dysfunction in infertile women. J Coll Physicians Surg Pak. 2007; 17(4): 191-194. 27.  Armada-Dias L, Carvalho JJ, Breitenbach MM, Franci CR, Moura EG. Is the infertility in hypothyroidism mainly due to ovarian or pituitary functional changes? Braz J Med Biol Res. 2001; 34 (9): 1209. 29.  Goswami B, Patel S, Chatterjee M, Koner BC, Saxena A. Correlation of prolactin and thyroid hormone concentration with menstrual patterns in infertile women. J Reprod Infertil. 2009; 10(3): 207-212. 31.  Verma I, Sood R, Juneja S, Kaur S. Prevalence of hypothyroidism in infertile women and evaluation of response of treatment for hypothyroidism on infertility. Int J Appl Basic Med Res. 2012; 2(1): 17-19. <![CDATA[Detection of antibodies to recombinant truncated flagellin and sonicated whole cell antigen of Burkholderia pseudomallei in acute melioidosis and in healthy Bangladeshi individuals]]> Md. Shariful Alam Jilani Tang Thean Hock Sraboni Mazumder Fahmida Rahman Md. Mohiuddin Chowdhury Rafiqul Ahsan Jalaluddin Ashraful Haq https://imcjms.com/journal_full_text/348 2020-05-29 23:26:11 Original Article IMC J Med Sci 2020; 14(1): 010 Abstract Background and objectives: Several types of Burkholderia pseudomallei antigens have been used to determine the antibody response in acute and asymptomatic cases. In the present study, we have detected immunoglobulin G (IgG) antibody to recombinant truncated flagellin antigen (RTFA) of B. pseudomallei in the sera of acute melioidosis cases and healthy individuals from melioidosis endemic areas of Bangladesh by indirect enzyme-linked immunosorbent assay (ELISA). In parallel, IgG antibody to sonicated whole cell antigen (SWCA) of B. pseudomallei was determined to compare with anti-RTFA antibody. Methodology: Serum samples from culture confirmed melioidosis cases and from healthy individuals aged 21 years and above residing in melioidosis endemic rural areas were included in the study. Serum IgG antibody to RTFA and SWCA of B. pseudomallei was determined by indirect ELISA. Results: Out of 8 culture confirmed acute melioidosis cases, 7 (87.5%) and 8 (100%) were positive for anti-B. pseudomallei IgG antibodies by RTFA and SWCA methods respectively. Among 361 healthy individuals, the rate of seropositivity by RTFA-ELISA was significantly less than that of SWCA-ELISA (16.1% versus 26.8%; p = 0.001). The mean optical density (OD) of RTFA-ELISA of positive cases was significantly less than that of SWCA-ELISA in both melioidosis and healthy individuals (0.79±0.11 versus 2.4±0.08, p = 0.0001; 0.67±0.01 versus 1.27±0.02, p = 0.0001). The sensitivity and specificity of RTFA-ELISA were 88.9% and 100% respectively. Conclusion: Findings of the study suggest that multiple or combination of antigens should be used to study the seroprevalence of B. pseudomalleiinfection in a community. Also, prospective study is necessary to find out the duration of persistence of antibodies to different antigenic components of B. pseudomallei after exposure. IMC J Med Sci 2020; 14(1): 010. EPub date: 31 May 2020. DOI: https://doi.org/10.3329/imcjms.v14i1.47455 *Correspondence: J. Ashraful Haq, Department of Microbiology, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka 1000, Bangladesh. Email: jahaq54@yahoo.com   Introduction Burkholderia pseudomallei is a gram negative bacillus and the causative agent of melioidosis. The organism is found in the soil and surface water of endemic areas and infects human by direct contact. Clinical disease includes localized or septicemia infection. But asymptomatic infection is also common [1]. The bacterium is able to remain quiescent or latent in the host for decades following primary infection while maintaining the potential to relapse to cause acute and fulminating disease after many years [2,3]. So, once considered as obscurity, melioidosis is now recognized as an emerging disease of global importance. It is largely restricted to the Southeast Asia and Northern Australia, however, the disease has been increasingly reported in countries outside the Asia-Pacific region including Bangladesh [4,5]. It was first reported in Bangladesh in 1964 [6]. Subsequently, substantial increase in sporadic cases were reported after 1988 [4,7,8]. Several serological methods have been developed to diagnose the infection by B. pseudomallei in acute cases as well as to determine the status and magnitude of exposure to the organism in healthy individuals. The most commonly used serological method – the indirect hemagglutination test (IHA) has limited clinical value in regions of endemicity due to the high background antibody titers in healthy individuals, most likely the result of repeated environmental exposure to B. pseudomallei [9]. A critical limitation of this assay is the lack of standardization between laboratories with respect to the antigens used; the antigens remain poorly characterized and are likely to be variable between isolates [10]. The indirect immunofluorescence antibody test (IFAT) using whole B. pseudomallei cells as antigen was found to be sensitive and superior to IHA and requires only a day to obtain the results [11]. The only drawback is that IFAT requires a fluorescence microscope and skilled personnel which might not be readily available in rural endemic regions of South and Southeast Asia. ELISA is being considered more favorably as a rapid and reliable tool for detection of B. pseudomallei infection [12]. Various antigen preparations such as crude and purified exopolysaccharide (EPS) and lipopolysaccharide (LPS) outer membrane proteins (Omps) and Bip components of B. pseudomallei type III secretion system (TTSS-3) have been reported as potential candidate antigens to detect antibodies in infection by B. pseudomallei in an ELISA format [12,13]. However, crude or uncharacterized antigens of B. pseudomallei cross-react with antibodies induced by other bacterial infection, making the methods less specific. To avoid the cross reactivity, a recombinant truncated flagellin antigen was developed to identify B. pseudomallei-specific antibodies [14]. The truncated flagellin protein of B. pseudomallei was supposed to be devoid of cross reactive epitopes and would elicit specific antibodies. The present study was undertaken to detect IgG antibody to recombinant truncated flagellin antigen (RTFA) and sonicated whole cell antigen (SWCA) of B. pseudomallei in the sera of acute melioidosis cases and healthy individuals from melioidosis endemic areas of Bangladesh by ELISA. The presence of IgG antibody to RFTA and SWCA in healthy individuals would provide evidence for extent of exposure of individuals to B. pseudomallei.   Materials and methods The present study was carried out to determine the presence of anti-B. pseudomallei IgG antibody in acute melioidosis cases and in endemic healthy individuals. Serum IgG antibody to B. pseudomallei was determined by ELISA using RTFA and SWCA. Details of the methods are described below. The Ethical Review Committee (ERC) of the Diabetic Association of Bangladesh (BADAS) approved the study. Informed written consent was obtained from all participants prior to collection of blood samples. Serum samples: Serum samples in this study were collected from 361 healthy individuals aged 21 years and above residing in rural areas of two melioidosis endemic districts of Bangladesh. Eight serum samples from culture confirmed acute melioidosis cases admitted at BIRDEM General Hospital were included. Sera from 35 healthy newborn babies of Dhaka city who were presumed not to be exposed to B. pseudomallei were enrolled as negative control. About 2 ml of venous blood was collected from each individual with proper aseptic technique. Expression and preparation of recombinant flagellin: Plasmid pGEX4Y-2 containing recombinant flagellin protein of B. pseudomallei used for the study was kindly provided by Ya-Lei Chen, Department of Medical Technology, Fooyin University, Kaohsi-ung 83101, Taiwan, Republic of China [14]. Flagellia protein was over expressed from the plasmid pGEX4T-2 cloned with flagellin gene of B. pseudomallei and transformed into E. coli BL21 strain. For protein purification, positive clone chosen was inoculated into 100 ml Luria Broth (LB) cultures and allowed to grow at 370C until the OD600 reached about 0.5 to 0.6, induced with 1.0 mM isopropyl-b-D-thiogalactopyranoside (IPTG) for about 4 hours. Cell pellet was resuspended in 10 ml of ice cool lysis buffer (50 mM Tris-HCl, pH 7.5, 300 mM NaCl, 10% glycerol, 1% Triton X-100) and subjected to sonication on the ice bath. The cell lysate was then centrifuged at 4000g for 20 minutes at 40C and supernatant was discarded. 400 mL of Ni2+-NTA resin (Qiagen, GmbH) was added to the supernatant and mixed at 40C for 2 hours on a rotator. Bound recombinant protein was collected from the resin by adding 10 mM reduced glutathione. The purified antigen was reconstituted with sterile distilled water to make up to a concentration of 1 mg/ml and aliquoted for further use. Preparation of SWCA: To prepare SWCA, 50 ml of Trypticase Soya Broth (TSB) was inoculated with pure colonies of B. pseudomallei USM strain and incubated overnight at 370C. Organisms were harvested by centrifugation for 30 minutes at 4000g at 100C. Pellets were suspended with 3 ml of 25 mM Tris-HCL (pH 7.4) and washed three times with Tris-HCL for 30 minutes at 4000g at 100C. Deposited pellet, suspended in 5 ml of ice-cold Tris-HCL, was sonicated at 40W for 8 minutes in each pulse inside the assigned biosafety cabinet. Sonicated bacterial suspension was then centrifuged at 5000xg at 100C for 30 minutes. After centrifugation, the supernatant containing the bacterial proteins was collected and its protein concentration was determined. Determination of anti-B. pseudomallei IgG antibody by ELISA: Serum anti-B. pseudomallei IgG antibody was determined by an indirect ELISA as described by Voller et al [15]. The 96 well ELISA plate (Linbro, USA) was coated with 2.5 µg/ml of RTFA or 10 µg/ml of SWCA in 0.5 M carbonate/ bicarbonate buffer (pH 9.6). To each well 100 µl volume of coating buffer was added and incubated overnight at 40C. The plate was washed three times with phosphate buffered saline-0.05% Tween 20 (PBS-T, pH 7.4) and blocked by incubating for 2 hours with PBS-T containing 2% bovine serum albumin (BSA) at 370C. The plate was then washed three times with PBS-T. A volume of 100 µl serum (1:400 dilution for RTFA and 1:1600 dilution for SWCA) samples was added into each well and incubated for 4 hours at 370C. After washing with PBS-T three times, 100 µl of horseradish peroxydase conjugated anti-human IgG antibodies (MP Biomedicals, USA) (1:4000 dilution) was added and incubated at 370C for 2 hours. After washing three times with PBS-T, 50 µl of tetramethylbenzidine (TMB) substrate was added to each well and incubated at room temperature for 30 minutes in dark. Then 50 µl of 1 M sulfuric acid was added in each well. The colour developed was measured by ELISA plate reader (Human ELISA Reader) at 450 nm. Optimum concentration of the antigen (2.5 µg/ml for RTFA and 10 µg/ml for SWCA) and serum dilution (1:400 dilution for RTFA and 1:1600 dilution for SWCA) were predetermined by checkerboard titrations. Cut-off OD values for anti-B. pseudomallei IgG antibody against RTFA and SWCA were determined to designate B. pseudomallei seropositivity of the study population. ELISA was performed with sera from 35 healthy newborn babies of Dhaka city who were presumed not to be exposed to B. pseudomallei. The mean OD+3xSD of these sera was taken as cut-off OD value to designate the case as seropositive. Table-1 shows the calculated cut-off OD values for RTFA and SWCA based ELISA. Any sample showing OD above the cut-off OD value of more than 0.4 and 0.8 by respectively RTFA and SWCA based ELISA was considered positive and referred to as exposed to B. pseudomallei infection.   Table-1: Calculated cut-off OD values for ELISA using RTFA and SWCA     Results Total 8 serum samples from culture confirmed melioidosis cases and 361 serum samples from healthy individuals aged 21 years and above residing in melioidosis endemic rural areas were included in the study. Out of 8 culture confirmed acute melioidosis cases, 7 (87.5%) and 8 (100%) were positive for anti-B. pseudomallei IgG antibodies by RTFA and SWCA methods respectively (Table-2). The mean OD of RTFA based ELISA of positive cases was significantly less than that of SWCA-ELISA (0.79±0.11 vs. 2.4±0.08; p = 0.0001).   Table-2: Detection of anti-B. pseudomallei antibodies in melioidosis cases and in endemic healthy individuals by ELISA using RTFA and SWCA     Out of total 361 healthy individuals, 58 (16.1%; 95% CI: 0.125, 0.203) and 97 (26.87%; 95% CI: 0.224, 0.318) individuals were positive for anti-B. pseudomallei IgG antibody by RTFA and SWCA based ELISA respectively. The rate of seropositivity by RTFA-ELISA was significantly less (p = 0.001) than that of SWCA-ELISA (Table-2).The mean OD values of RTFA and SWCA based ELISA were 0.67±0.01 and 1.27±0.02 respectively (p=0.0001). The sensitivity and specificity of RTFA-ELISA, when calculated, were 88.9% and 100% respectively and for SWCA-ELISA it was 100% and 97.9%.   Discussion Infection by B. pseudomallei can be detected by either culture, molecular or serological methods. These methods are usually employed to diagnose acute melioidosis cases. Apart from diagnosis of acute infection, serology is employed to assess the extent of exposure to particular organism in a community. Several antigens of B. pseudomallei have been employed for serodiagnosis of acute and past infection with varying results. A previous study evaluated 4 purified B. pseudomallei recombinant proteins (TssD-5, Omp3, smBpF4 and Omp85) using ELISA as potential diagnostic agents for melioidosis. TssD-5 demonstrated the highest sensitivity of 71% followed by Omp3 (59%), smBpF4 (41%) and Omp85 (19%). All 4 antigens showed equally high specificity (89-96%). A combination of four antigens provided improved sensitivity of 88.2% and good specificity (96%) [13]. Anuntagool et al. evaluated five different B. pseudomallei antigens including a 19.5-kDa antigen, a crude cell extract, a veronal extract, a 39.0-kDa antigen, and an immunoaffinity-purified antigen by indirect ELISA. The 19.5-kDa antigen exhibited the most satisfactory results, with 92% sensitivity and 91% specificity [16]. We determined anti-B. pseudomallei IgG antibody in culture confirmed melioidosis cases and in healthy population residing in melioidosis endemic rural area of Bangladesh, by ELISA using RTFA and SWCA of B. pseudomallei in an in-house indirect ELISA. The rate of positive cases by RTFA-ELISA was significantly less (16.1% versus 26.87%) compared to cases by SWCA-ELISA among the healthy people from melioidosis endemic area. Also, we observed lower mean OD values in both acute melioidosis and healthy cases by RTFA-ELISA than SWCA-ELISA indicating presence of less concentration of antibodies or reactants in serum against RTFA than SWCA. Similar low OD or absorbance (mean OD ~ 0.4) was observed in culture confirmed melioidosis cases against truncated flagellin fragment [17]. We also presume that the antibody to RTFA might decline earlier overtime following exposure to B. pseudomallei. Also RTFA-ELISA detected antibody produced only against flagellar proteins instead of proteins from whole cell. But in case of SWCA, the antibodies detected were a mixture of antibodies against several antigenic components of the B. pseudomallei some of which might be long persisting against specific proteins. It appears that the rate of positivity of anti-B. pseudomallei antibody might vary depending on the assay method and antigen used in the serological assays. Therefore, prospective study should be undertaken to find out the duration of persistence of antibodies to B. pseudomallei flagellar proteins as well as to other cellular components following exposure. High seropositivity rate in healthy population has been reported from other countries of the region. The seroprevalence rate of B. pseudomalleiamong the healthy people in Haiti was found as 9.8% by lipopolysaccharide based ELISA [18]. Another study reported 29% seropositivity among the adults in coastal areas in Southwestern India by indirect hemagglutination assay (IHA) using polysaccharide antigens of B. pseudomallei [19]. In a previous study conducted on more than 900 people in 2016, we found 21.5% of the study population as positive for anti-B. pseudomallei antibody by SWCA-ELISA [8]. The sensitivity and specificity of our RTFA-ELISA were 88.9% and 100% respectively. Similar range of sensitivity and specificity of flagellar protein based ELISA was reported by other studies [14,17]. The findings of the present study indicate that multiple or combination of antigens should be used to determine the actual presence of antibody to B. pseudomallei in seroprevalence study in a community.   Acknowledgment We are thankful to Dr. Ya-Lei Chen, Department of Medical Technology, Fooyin University, Kaohsi-ung 83101, Taiwan, Republic of China, for kindly providing the Plasmid pGEX4Y-2 containing recombinant flagellin protein of B. pseudomallei.   Competing interest The authors hereby, declare that no conflict of interest exists.   Funding The study was partly funded by Ibrahim Medical College.   References1. Cheng AC, Currie BJ. Melioidosis: epidemiology, pathophysiology, and management. Clin Microbiol Rev. 2005; 18(2): 383-416. 2. Ngauy V, Lemeshev Y, Sadkowski L, Crawford G. Cutaneous melioidosis in a man who was taken as a prisoner of war by the Japanese during world war II. J Clin Microbiol. 2005; 43(2): 970-972. 3.  Puthucheary SD, Nathan SA. Comparison by electron microscopy of intracellular events and survival of Burkholderia pseudomallei in monocytes from normal subjects and patients with melioidosis. Singapore Med J 2006; 47: 697-703. 4.  Barai L, Jilani MSA, Haq JA. Melioidosis – case reports and review of cases recorded among Bangladeshi population from 1988-2014. IMC J Med Sci. 2014; 8(1): 25-31. 5.  Jilani MSA, Haq JA. Melioidosis in Bangladesh – a disease yet to be explored. IMC J Med Sci. 2010; 4(1): i-ii. 6.  Maegraith BG, Leithead CS. Melioidosis: A case-report. Lancet. 1964; 1: 862-863. 7.  Struelens MJ, Mondol G, Bennish M, Dance DA. Melioidosis in Bangladesh: A case report. Trans R Soc Trop Med Hyg. 1988; 82: 777-778. 8.  Jilani MSA, Robayet JA, Mohiuddin M, Hasan MR, Ahsan CR, Haq JA. Burkholderia pseudomallei: Its detection in soil and seroprevalence in Bangladesh. PLOS Negl Trop Dis. 2016; 10: e0004301. 9.  Zysk G, Splettstosser WD, Neubauer H. A review on melioidosis with special respect on molecular and immunological diagnostic techniques. Clin Lab. 2000; 46(3-4): 119-130. 10.  Anuntagool N, Naigowit P, Petkanchanapong V, Aramsri P, Panichakul T, Sirisinha S. Monoclonal antibody-based rapid identification of Burkholderia pseudomallei in blood culture fluid from patients with community-acquired septicaemia. J Med Microbiol. 2000, 49(12): 1075-1078. 11.  Vadivelu J, Puthucheary SD, Gendeh GS, Parasakthi N. Serodiagnosis of melioidosis in Malaysia. Singapore Med J. 1995; 36(3): 299-302. 12.  Druar C, Yu F, Barnes JL, Okinaka RT, Chantratita N, Beg S, et al. Evaluating Burkholderia pseudomallei Bip proteins as vaccines and Bip antibodies as detection agents. FEMS Immunol Med Microbiol. 2008; 52(1): 78-87. 13.  Hara Y, Chin CY, Mohamed R, Puthucheary SD, Nathan S. Multiple-antigen ELISA for melioidosis – a novel approach to the improved serodiagnosis of melioidosis. BMC Infectious Diseases. 2013; 13:165. 14.  Chen YS, Shiuan D, Chen SC, Chye SM, Chen YL. Recombinant truncated flagellin of Burkholderia pseudomallei as a molecular probe for diagnosis of melioidosis. Clin Diagn Lab Immunol. 2003; 10(3): 423-425. 15.  Voller A, Bartlett A, Bidwell DE. Enzyme immunoassays with special reference to ELISA techniques. J Clin Pathol. 1978; 31(6): 507-520. 16.  Anuntagool N, Rugdech P, Sirisinha S. Identification of specific antigens of Pseudomonas pseudomallei and evaluation of their efficacies for diagnosis of melioidosis. J Clin Microbiol. 1993; 31: 1232-1236. 17.  Wajanarogana S, Kritsiriwuthinan K. Efficacy of indirect ELISA for serodiagnosis of melioidosis using immunodominant antigens from non-pathogenic Burkholderia thailandensis. Springer Plus. 2016; 5: 1814. 18.  Weppelmann TA, Norris MH, von Fricken ME, Khan MSR, Okech BA, Cannella AP, et al. Seroepidemiology of Burkholderia pseudomallei, etiologic agent of melioidosis, in the Ouest and Sud-Est Departments of Haiti. Am J Trop Med Hyg. 2018; 99(5): 1222-1228. 19. Vandana KE, Mukhopadhyay C, Tellapragada C, Kamath A, Tipre M, Bhat V, et al. Seroprevalence of Burkholderia pseudomallei among adults in coastal areas in Southwestern India. PLOS Negl Trop Dis. 2016; 10(4): e0004610. <![CDATA[Elimination of measles by 2024: achievements and challenges]]> Sabrina Afrin Kazi Taib Mamun Nabeela Mahboob Hasina Iqbal Hasnatul Jannat https://imcjms.com/journal_full_text/340 2020-04-05 10:22:00 Review IMC J Med Sci 2020; 14(1): 007 Abstract Measles is an infectious agent of viral origin with exceedingly high rate of transmissibility contributing to very high morbidity and mortality rates especially among children. Although measles is extremely infectious, control strategies of this virus used to be recognized as one of the most successful public health interventions ever undertaken. However, despite being vaccine-preventable disease measles has encountered an enormous resurgence as the rate of measles vaccination has declined and in many countries vaccination targets remain unmet and measles continues to claim hundreds of thousands of lives each year. This review discusses the reasons of the re-emergence of measles, the present global and Bangladesh situation and strategies that have been undertaken to combat this killer disease to eliminate measles globally by the year 2024. IMC J Med Sci 2020; 14(1): 007. EPub date: 05 April 2020. DOI: https://doi.org/10.3329/imcjms.v14i1.47456 *Correspondence: Sabrina Afrin, Department of Microbiology, Popular Medical College, Dhaka, Bangladesh, Email: sabrinaafrin19@gmail.com   Introduction Measles is a highly contagious virus that can affect people of all ages although it is considered primarily as a childhood illness. Being a killer virus in the pre-vaccine era measles used to kill 2 to 3 million people annually worldwide [1]. The incidences of devastating complications and sequelae of the pre-vaccine era have been plummeted by the collaborative global vaccination initiatives. However, in spite of the availability of the safe, potent and cost-effective vaccine, the hard fought gains against measles are threatened now and the number of measles cases has soared in recent years. The causes of the outbreaks vary but the sub-optimal vaccine delivery is at the root of them as eliminating the last pockets of the unvaccinated residents is the hardest. In view of the resurgence of measles in many countries of the world, the cardinal question asked by many is whether it will be really possible to eliminate this disease globally by the year 2024. This review discusses the clinical spectrum of measles, global elimination strategy and the likelihood of the worldwide elimination of this disease.   The virus Measles virus a highly contagious member of the Morbillivirus genus within the Paramyxoviridae family, is a spherical shaped, enveloped virus studded with virus-coded glycoproteins. The 15 kilobase encapsidated negative-sense single-stranded genomic RNA contains approximately 15,894 nucleotides [2,3]. The genome encodes eight proteins, two of which (V and C) are nonstructural proteins. Among the six structural proteins, phosphoprotein (P), large protein (L), and nucleoprotein (N) form the nucleocapsid whereas, the hemagglutinin protein (H), fusion protein (F), and matrix protein (M), together with lipids from the host cell membrane, form the viral envelope. The hemagglutinin (H) establishes initial contact with a cellular receptor mediating receptor binding and the fusion protein (F) is one of the important components of the measles virus fusion machinery [4]. Membrane fusion is not only required for virus-to-cell entry but also executes multinucleated giant cell formation [5]. Although measles virus is serologically monotypic and antigenically stable, by analysis of the sequences of the nucleoprotein (N) and hemagglutinin (H) genes 8 clades of measles virus (designated A through H) have been identified and these have been divided into 22 genotypes and one proposed genotype. Clades B, C, D, G and H each contain multiple genotypes (B1 – 3, C1 – 2, D1 – 10, G1 – 3, H1 – 2). Clades A, E and F each contain a single genotype (A, E, F). Infection by any genotype induces life-long immunity against all genotypes. Notably, there are no known biological differences between viruses of different genotypes and no genotype has been associated with variability in transmissibility, greater virulence or persistence, likelihood of developing severe sequelae, sensitivity of laboratory diagnosis. However, some genotypes may be associated with specific geographic regions [6]. New genotypes are likely to be identified with the assistance of molecular epidemiological investigation of measles outbreaks globally. This enhanced surveillance may allow us to observe the change in virus genotypes over time in a particular region establishing epidemiological links between cases in geographically distinct clusters [7]. In addition, molecular characterization of measles virus is an important component for assessing the effectiveness of vaccination programs and surveillance systems designed to achieve the elimination of measles [8,9].   Clinical spectrum and complications of measles After an incubation period of 8–12 days, measles begins with increasing fever (39°C-40.5°C), cough, coryza, and conjunctivitis. However, unlike other features of prodromal stage the Koplik’s spot is considered to be pathognomic for measles.Discrete maculopapular rash which begins from face and spreads gradually to chest, trunk and limbs is another significant clinical feature of acute measles infection. A leading cause of childhood morbidity and mortality is the development of secondary infections after acute measles infection globally. The most devastating complications of measles include respiratory and central nervous systems. Measles virus is associated with pneumonia due to the virus itself, pneumonia due to secondary bacterial infection and giant cell pneumonia. Most importantly, four types of measles-induced encephalitis namely primary measles encephalitis, acute post-measles encephalitis, measles inclusion body encephalitis and subacute sclerosing panencephalitis endanger the people who have suffered from measles infection. Primary measles encephalitis is concurrent with measles infection which approximately affects 1–3/1000 patients with measles infection. Although considerable gaps remain in the knowledge of the underlying mechanism of it, primary viral invasion of neurological cells followed by chemokine induction and lymphocytic infiltration might be a possible mechanism [10]. Mortality rate as high as 10–15% has been reported. In addition, permanent neurological damage lasts in 25% of patients [11]. The most frequent central nervous system (CNS) complication of measles virus is acute post-measles encephalomyelitis [12]. Being an autoimmune disease it is developed by molecular mimicry where a cross reactive myelin antibody induces the CNS dysfunction. About 1 child out of every 1,000 who get measles can develop acute post-measles encephalomyelitis [11]. Measles inclusion body encephalitis is a disease of the immunocompromised hosts principally the children of around six years who contracted measles infection within one year. Although mortality rate is 75% only supportive treatment exists. In addition, subacute sclerosing panencephalitis (SSPE) is a very rare, but fatal central nervous system disorder which may occur 5-15 years after measles infection. The underlying mechanism could be the capability of measles virus to persist in neurons as a defective variant when the immune system fails to eliminate measles virus-infected cells completely from the CNS [13]. In addition, the complication rates are increased by immune deficiency disorders, malnutrition and vitamin A deficiency [14]. Measles infection in pregnant women is associated with several adverse events including increased risk of hospitalization and pneumonia [15]. In addition, there are significant risks to the fetus including miscarriage, stillbirth, low birth weight, preterm delivery [16]. In areas of ongoing outbreaks where there is sustained transmission in compact and overcrowded communities, serologic testing for measles IgG can be considered in pregnant women without documented immunity to measles. Pregnant women with suspected measles exposure but without immunity should receive intravenous immunoglobulin (IVIG) treatment within 6 days of measles exposure. If serologic testing and obtaining results are not available in a timely manner, and measles exposure is suspected in a non-immune pregnant woman, the patient should receive measles IVIG [17,18].   Strategies undertaken to eliminate measles   Global resurgence of measles After decades of progress in measles elimination efforts, the hard fought gains are being threatened by a 31% increase in the number of measles cases reported globally between 2016 and 2017 [24]. There have been many outbreaks in the United States since the elimination of endemic measles. In 2014, an outbreak of 383 cases was reported in Ohio; between 2014 and 2015, 147cases of measles were reported in California and in 2017, 75 cases were reported in Minnesota. From January 1 to November 7, 2019, 1261 individual cases of measles had been confirmed in 31 states of USA the largest number since 2000 [25]. In Europe, the number of reported cases in 2018 was triple than that in 2017 and 15 times that in 2016 [1]. In addition, it is likely that endemic measles has now been reestablished in several European countries where transmission had previously been interrupted [24]. Current outbreaks include the Democratic Republic of the Congo, Ethiopia, Georgia, Samoa, Ukraine, Kazakhstan, Kyrgyzstan, Madagascar, Myanmar, Philippines, Sudan, Thailand and Ukraine, causing many deaths – mostly among young children. WHO reported 117,075 measles cases and 1205 deaths in Madagascar between October 2018 and April 2019 [1]. An extensive outbreak ravaged in Democratic Republic of Congo in 2019 where close to a quarter of a million people had been infected and nearly 5,000 people died. WHO mentioned the outbreak as the world's largest and fastest-moving epidemic [26].   Measles infection: Bangladesh perspective Bangladesh initiated the Expanded Program of Immunization on 7th April, 1979. Single dose measles vaccine for children aged 9 months was introduced in immunization program in 1989 and second dose was administered at 15 months of age since 2012. In 2015, estimated measles routine vaccine national coverage increased up to 92% for first dose of measles vaccine and 81% for the second dose. Apart from high routine vaccine coverage nationwide, Bangladesh has implemented the strategy to provide a second opportunity for measles vaccination through supplementary immunization activities. Several other initiatives like strengthening the case-based surveillance system, developing and maintaining an accredited measles laboratory network to reach the goal of elimination of measles have been adopted. SIAs were carried out in 2005-2006, 2010, 2014 and 2019. After implementation of nationwide SIAs there was a drastic decline in the occurrence of the disease. In Bangladesh, incidence of measles cases decreased from 40 to 6 per million during 2000-2016 which constituted to a reduction up to 84%. In 2005-2006, confirmed measles cases dropped to 6 from 14,877 (2005). Unfortunately, the rate of occurrence of the disease was varying in the subsequent years. In 2016, measles cases increased to 972 confirmed cases in Bangladesh [27]. A program assessment was conducted using WHO Programmatic Risk Assessment Tool for measles in 2016 and it was found that 8 districts were at very high risk for measles transmission, 13 districts at high risk, 24 and 19 districts at medium risk and low risk respectively [28].   Challenges in global elimination of measles A multitude of factors pose challenges in achieving and maintaining the elimination of measles. It is primarily due to disinclination amongst parents to vaccinate their children, explosive outbreaks of measles in both developed and developing countries and international travelling especially to measles endemic areas [29]. The reason of disinclination amongst the parents to vaccinate their children is based on a conflicting vaccine-safety misinformation whicharose by an article published in Lancet demonstrating a link between measles–mumps–rubella (MMR) vaccine and the development of autism in children. Although several studies have now thoroughly debunked that work, it gained attention on some social media networks and continues to be enforced by a small group of anti-vaccine activists [30]. Consequently, there has been a sharp fall in vaccination rates. Another cause behind the growing number of unvaccinated individuals accounts to be the unfamiliarity alongside lack of dread for the outcome of measles infection [31]. In addition, regarding inter-individual transmission dynamics, the fact that one measles virus infected person can be the source to infect 12-18 peoples which makes super spreader part of the picture. Individuals who infect an especially large number of secondary contacts, as compared to most others, are known as super spreaders [32]. The epidemiological concept of the basic reproduction number, R nought (R0), an indicator of the transmissibility of infectious agents within a population has shed some light to identify people at high risk of contracting an infection and where an outbreak can be effectively intercepted. R0 is defined as the average number of secondary cases caused by a primary case in a fully susceptible population. Moreover, an important milestone in regard to R0is that the herd immunity threshold can be determined from it. As R0 increases, higher immunization coverage is required to achieve herd immunity. Thus the herd immunity threshold is critical to interrupt transmission in a population and also it can be used as a target for immunization programs to stop the spread of disease [33]. Determinants of R0 include the probability of transmission between an infectious individual and a susceptible individual, the type and frequency of contacts between individuals, and the duration of infectivity [34]. Public health researchers frequently use the measles R0 range as 12–18 making it the most contagious of common diseases [35]. Even measles can reappear among vaccinated populations and this finding is pursuant to the observation that in 1989, an explosive school-based outbreak in Finland resulted in 51 cases, several of whom had been previously vaccinated. One child alone infected 22 others. It was noted during this outbreak that when vaccinated siblings shared a bedroom with an infected sibling, seven out of nine became infected as well [36]. Despite measles is a vaccine-preventable disease, high transmissibility, propagated misinformation suggesting that the risk and consequences of measles are inconsequential and the measles vaccine phobia could be the reasons behind widening pockets of unvaccinated children which have created a pathway to the measles outbreaks hitting several countries around the world today.   Conclusion In the last couple of years, progress towards measles elimination has stalled and there have been explosive outbreaks around the world. Global resurgence of measles virus raises concerns for childhood mortality as well as lifelong disability ranging from brain damage and blindness to hearing loss. People living in urban slums or in remote rural areas, unregistered with health clinics and beyond the reach of health workers are mostly under-immunized and unvaccinated. Identifying and reaching the under-immunized population spans a sequence of essential steps like training health workers, maintaining the cold chain, collecting data and raising awareness of the benefits of vaccination. Precise planning, community-based training and a range of tailored approaches are required to maximize protection against measles infection. Enactment and enforcement of measles elimination initiatives by the governments and partners such as the Measles & Rubella Initiative, Gavi, the Vaccine Alliance, UNICEF and other organizations are must and thereby the success of vaccination can be back on track worldwide and measles could be the next virus to be wiped out globally.   References 1.     Paules CI, Marston HD, Fauci AS. Measles in 2019 – going backward. N Engl J. 2019; 380(23): 2185-2187. 2.     Plumet S, Duprex WP, Gerlier D. Dynamics of viral RNA synthesis during measles virus infection. J Virol. 2005; 79(11): 6900-6908. 3.     Udem SA, Cook KA. Isolation and characterization of measles virus intracellular nucleocapsid RNA. J Virol. 1984; 49(1): 57-65. 4.     Griffin DE. Measles virus‐induced suppression of immune responses. Immunol Rev. 2010; 236(1): 176-189. 5.     Plattet P, Alves L, Herren M, Aguilar HC. Measles virus fusion protein: structure, function and inhibition. Viruses. 2016; 8(4): 112-115. 6.     World Health Organization. Nomenclature for describing the genetic characteristics of wild-type measles viruses (update): Part I. Geneva: World Health Organization; 2001. 7.     Mosquera MM, de Ory F, Echevarría JE. Measles virus genotyping and circulating genotypes. Open Vaccine J. 2010; 3(1): 76-85. 8.     Riddell MA, Rota JS, Rota PA. Review of the temporal and geographical distribution of measles virus genotypes in the prevaccine and postvaccine eras. J Virol. 2005; 2(1): 87-92. 9.     Rota PA, Bellini WJ. Update on the global distribution of genotypes of wild type measles viruses. J Infect Dis. 2003; 187(1): 270-276. 10.  Patterson CE, Daley JK, Echols LA, Lane TE, Rall GF. Measles virus infection induces chemokine synthesis by neurons. J Immunol. 2003; 171(6): 3102-3109. 11.  Buchanan R, Bonthius DJ. Measles virus and associated central nervous system sequelae. Semin Pediatr Neurol. 2012; 19(3): 107-114. 12.  Nardone R, Golaszewski S, Trinka E, Tezzon F, Zuccoli G. Acute disseminated encephalomyelitis preceding measles exanthema. J Neurovirol. 2011; 26(12): 1590-1592. 13.  Schneider-Schaulies J, Niewiesk S, Schneider-Schaulies S, Meulen VT. Measles virus in the CNS: the role of viral and host factors for the establishment and maintenance of a persistent infection. J Neurovirol. 1999; B(6): 613-622. 14.  Perry RT, Halsey NA. The clinical significance of measles: a review. J Infec Dis. 2004; 189 Suppl 1: S4-16 15.  Atmar RL, Englund JA, Hammill H. Complications of measles during pregnancy. Clin Infect Dis. 1992; 14: 217-226. 16.  Manikkavasagan G, Ramsay M. The rationale for the use of measles post-exposure prophylaxis in pregnant women: a review. J Obstet Gynaecol. 2009; 29: 572-575. 17.  University of Washington. Measles and the MMR vaccine: recommendations around pregnancy, including the periconception and postpartum periods: Obstetric consensus statement. Washington: University of Washington; 2019. 18.  Centers for Disease Control and Prevention. Measles (rubeola): for healthcare professionals. Atlanta: Centers for Disease Control and Prevention; 2018. 19.  Odei MP. Measles is in the news yet again. J Family Med Prim Care. 2018; 7(6): 1166-1172. 20.  O'Connor P, Jankovic D, Muscat M, Ben-Mamou M, Reef S, Papania M, et al. Measles and rubella elimination in the WHO Region for Europe: progress and challenges. Clin Microbiol Infect. 2017; 23(8): 504-510. 21.  World Health Organization. Global eradication of measles: report by the Secretariat. Geneva: World Health Organization; 2010. 22.  World Health Organization. Measles elimination and rubella/congenital rubella syndrome control: Report of a regional consultation, Kathmandu, Nepal, 19-22 February 2013. India: World Health Organization; 2013. 23.  World Health Organization. Outbreak news: measles outbreaks in Europe. Geneva: World Health Organization; 2011. 24.  World Health Organization. Sustain accelerate innovate: measles elimination and rubella control in the WHO South-East Asia Region. Geneva: World Health Organization; 2018. 25.  Dabbagh A, Laws RL, Steulet C, Dumolard L, Mulders MN, Kretsinger K, et al. Progress toward regional measles elimination – worldwide, 2000–2017. Morb Mortal Wkly Rep. 2018; 67(47): 1323-1328. 26.  Boyd C. MailOnline, 22 November 2019, UK. 27.  Khanal S, Bohara R, Chacko S, Sharifuzzaman M, Shamsuzzaman M, Goodson JL, et al. Progress toward measles elimination Bangladesh, 2000–2016. Morb Mortal Wkly Rep. 2017; 66(28): 753-757. 28.  Lam E, Schluter WW, Masresha BG, Teleb N, Brav-Alcántara P, Shefer A, et al. Development of a district‐level programmatic assessment tool for risk of measles virus transmission. Risk Anal. 2017; 37(6): 1052-1062. 29.  Fiebelkorn AP, Redd SB, Gallagher K, Rota PA, Rota J, Bellini W, et al. Measles in the United States during the postelimination era. J Infect Dis. 2010; 202(10): 1520-1528. 30.  Taylor B, Miller E, Farrington C, Petropoulos MC, Favot-Mayaud I, Li J, et al. Autism and measles, mumps, and rubella vaccine: no epidemiological evidence for a causal association. Lancet. 1999; 353(9169): 2026-2029. 31.  McLaren Jr RA, Stein JL, Minkoff H. Measles: there is no vaccine against vaccine phobia. Am J Perinat. 2019; 15(8): 201-203. 32.  Stein RA. Super-spreaders in infectious diseases. Int J Infect Dis. 2011; 15(8): 510-513. 33.  Guerra FM, Bolotin S, Lim G, Heffernan J, Deeks SL, Li Y, et al. The basic reproduction number (R0) of measles: a systematic review. Lancet Infect Dis. 2017; 17(12): 420-428. 34.  Dietz K. The estimation of the basic reproduction number for infectious diseases. Stat Methods Med Res. 1993; 2(1): 23-41. 35.  Anderson RM, May RM. Directly transmitted infectious diseases: control by vaccination. Science. 1982; 215(4536): 1053-1060. 36.   Paunio M, Peltola H, Valle M, Davidkin I, Virtanen M, Heinonen OP. Explosive school-based measles outbreak: intense exposure may have resulted in high risk, even among revaccinees. Am J Epidemiol. 1998; 148(11): 1103-1110. <![CDATA[Tuberculosis – burden and serodiagnosis]]> Md. Mohiuddin https://imcjms.com/journal_full_text/341 2020-04-26 02:24:35 Review IMC J Med Sci 2020; 14(1): 008 Abstract Tuberculosis (TB) is one of the leading causes of death worldwide. Clinical features and demonstration of the organism by microscopy/culture are still the mainstay of diagnosis of tuberculosis. The present paper reviews the burden of TB and the role of serology in its diagnosis. IMC J Med Sci 2020; 14(1): 008. EPub date: 26 April 2020. DOI: https://doi.org/10.3329/imcjms.v14i1.47457 Correspondence: Md. Mohiuddin, Department of Microbiology, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka, Bangladesh, Email: mohicmc@gmail.com   Introduction Tuberculosis (TB) is one of the leading causes of death worldwide due to a single infectious agent, Mycobacterium tuberculosis. The present review examines the burden of tuberculosis in terms of its prevalence, incidence, and resistance to anti-tubercular drugs and role of serodiagnostic procedures.   Burden of tuberculosis: About one-third of the world’s population is latently infected with M. tuberculosis [1]. In 2016, an estimated 10.4 million people (10% people living with HIV) fell ill with TB and 1.3 million died among HIV-negative TB people and an additional 374,000 deaths occurred among HIV-positive people. Most of the estimated number of incidence cases in 2016 occurred in the World Health Organization (WHO) South-East Asia Region (45%), the WHO African Region (25%) and the WHO Western Pacific Region (17%); smaller proportions of cases occurred in the WHO Eastern Mediterranean Region (7%), the WHO European Region (3%) and the WHO Region of the Americas (3%). The top five countries with 56% of estimated cases were India, Indonesia, China, Philippines and Pakistan (in descending order). Global efforts to combat TB have saved an estimated 53 million lives since 2000 and reduced the TB mortality rate by 37%. Despite these achievements, the latest picture of TB is grimand TB remains the top infectious killer in 2016. In 2015, an estimated 1 million children became ill with TB and 170,000 children died of TB (excluding children with HIV). It is estimated that there is a large pool of undiagnosed drug resistant M. tuberculosis infection in children [1]. Banu et al. reported drug susceptibility pattern of 1,906 M. tuberculosis isolates from fourteen sentinel surveillance sites of seven divisions of Bangladesh and showed that 1,481 (77.7%) isolates were susceptible to all first-line anti-tuberculosis drugs. Resistance to streptomycin (SM) was 373 (19.6%), to isoniazid (INH) 145 (7.6%), to rifampicin (RMP) 74 (3.9%) and to ethambutol (EMB) 68 (3.6%). Monoresistance to SM, INH, RMP and EMB was 255 (13.4%), 20 (1.0%), 09 (0.5%) and 7 (0.4%) respectively. The multi-drug resistant-TB (MDR-TB) was 2.3% in new patients and 13.8% in previously treated patients. The overall MDR-TB among the urban population was 3.1% in new and 9.6% in previously treated patients, and among the rural population it was 3.2% in new and 22.9% in previously treated patients [2]. Mohiuddin M and Haq JA conducted a study on drug resistance pattern of isolated M. tuberculosis from newly detected (untreated) and previously treatedTB cases. Out of the total 192 M. tuberculosisisolates, 167 were from newly detected and 25 were from previously treated cases. Among the 167 newly detected cases 46.71% were resistant to any of the four first line anti-TB drugs and overall drug resistance pattern was INH 37 (22.15%), rifampicin 16 (9.58%), ethambutol 22 (13.17%), and streptomycin 37 (22.15%). Among the previously treated cases, 100% were resistant to any of the four first line anti-TB drugs and overall drug resistance pattern was INH 13 (52.0%), rifampicin 14 (56.0%), ethambutol 17 (68.0%) and streptomycin 13 (52.0%). The rate of MDR-TB in newly detected cases was 4.2% while it was 36.0% among the previously treated cases [3]. Sinha et al. from India reported the drug resistance pattern of 235 M. tuberculosis isolates. Out of 235 isolates, 71.1% was resistant to at least one anti-TB drug, whereas only 28.9% was found to be sensitive to all drugs. The rate of MDR-TB was 52.8%. Interestingly, MDR strain of M. tuberculosis was isolated from bone marrow sample of a patient without any treatment history [4].Sethi et al. in India also reported a high prevalence of MDR-TB in HIV cases. MDR-TB was observed in 17.4% isolates. MDR-TB was found to be associated with 9.9% and 27.6% newly and previously treated cases respectively. There was significantly higher association of MDR-TB (27.3%) with HIV seropositive patients as compared to HIV seronegative patients (15.4%) [5]. Current estimates reported the prevalence of primary and acquired MDR-TB in India as 3.5% and 20.5%, respectively [6]. WHO estimated that there were 600,000 new cases with resistance to rifampicin of which 490,000 were MDR-TB. Almost half (47%) of these cases were in India, China and Russian Federation [1]. Recently, the emergence and dissemination of extensively drug-resistant TB (XDR-TB) worldwide is of great threat to public health and tuberculosis control, raising concerns of a future epidemic of virtually untreatable tuberculosis [4]. XDR-TB is defined as MDR-TB with additional resistance to any fluoroquinolone and to at least one of the three injectable anti-tubercular drugs like capreomycin, kenamycin and amikacin [7]. In fact, the emergence of drug resistant M. tuberculosis has unfavorably affected the efforts of TB control being made by different countries with limited access to second-line anti-TB drugs [8]. A number of outbreaks of MDR-TB require the continuous surveillance of drug resistance for effective treatment of TB patients and also for initiating adequate public health assessment. The latest anti-TB drug resistance surveillance data (WHO MDR-TB update 2017) showed that 4.1% of new and 19% of previously treated TB cases in the world were estimated to have rifampicin or multidrug-resistant tuberculosis (RR/MDR-TB) and about 6.2% of MDR-TB cases in 2016 were XDR-TB. It was also reported that in 2016 an estimated 600,000 new cases of RR/MDR-TB emerged globally of which 240,000 died. Most of the cases and deaths occurred in Asia. In 2016, 8,000 cases of XDR-TB were reported worldwide. To date, 121 countries have reported at least one XDR-TB case [1]. A summary of TB, MDR-TB and RR-TB cases in different WHO regions for 2016 is shown in Table-1.   Table-1: TB, MDR-TB and RR-TB cases in different WHO regions for 2016 [1]     Tuberculosis may involve any organ or system in the body and is classified as pulmonary (PTB) and extra pulmonary tuberculosis (EPTB). Common sites of EPTB include lymph nodes, pleura, abdominal organs and osteo-articular areas [9]. Lymph node involvement is the commonest form of EPTB. In developing countries where the incidence of TB is high, tubercular lymphadenitis (TBL) is one of the most frequent causes (30-52%) of lymphadenopathy [9,10]. In Bangladesh, lymph node tuberculosis was found to be common (36.2%) among the EPTB [11]. Therefore, rapid and accurate diagnosis of TBL is of prime importance because delayed chemotherapeutic intervention is associated with poor prognosis [12,13]. Despite T and B cell mediated immunity against M. tuberculosis, approximately 90-95% infected individuals develop latent tuberculosis infection (LTBI) following primary infection. If LTBI is left untreated, there is a 10% life time risk of developing active tuberculosis, usually localized in the lungs [14]. In HIV infected patients, there is an even greater risk, 10% per year, with a higher incidence of disseminated infection [15]. Diagnosis of TB: Diagnosis of tuberculosis (TB) mainly depends on sputum smear microscopy, chest radiography and tuberculin skin test (TST). Microscopic examination of sputum and other specimens by Ziehl-Neelsen staining is the only rapid, relatively simple and inexpensive test for diagnosis of active pulmonary TB and EPTB. But, the reported sensitivity of Ziehl-Neelsen staining of unprocessed sputum smears from adults is only 40 to 70% because 5×103 to 5×104 organism/ml specimen is needed for the detection of bacilli [16]. Culture is also done for isolation and identification of M. tuberculosis but it is time consuming, bio-hazardous and needs bio-safety facilities. It needs an average time of 23.6 days in Lowenstein-Jensen media [17]. Sensitivity and specificity of this method are 48.9% and 100% respectively [18]. In newer liquid culture method like Microscopic Observation of Drug Susceptibility (MODS) assay, about nine days are required for culture and drug susceptibility and its sensitivity is 92% and specificity 94.4% [19,20]. But in this method, chance of contamination is more and skilled laboratory personnel are required and it is bio-hazardous also. The average turnaround time for other liquid based culture methods like mycobacterial growth indicator tube (MGIT) and automated systems like BACTEC is around 6.5 to 9 days with specificity between 80-00% [21]. Improved diagnostic tests like nucleic acid amplification tests are often too expensive and complex to be used as routine method in low-income settings. The GeneXpert MTB/RIF assay, being claimed as a major advance in TB diagnostics and endorsed by the WHO, provides simultaneous detection of M. tuberculosis and rifampicin resistance. However, high cost is a barrier for scaling-up this new technology in many resource poor areas where the need is most severe [22]. Role of serodiagnostic procedures for diagnosis of TB:Detection of antibodies or antigens, as serological marker, is being used in regular practice for the diagnosis of many viral and bacterial infections. Many M. tuberculosis cell wall components have antigenic properties. Following its infection different antibodies like IgG, IgM, IgA are reported to be produced against different cell wall antigens. Many serological tests have been used to detect M. tuberculosisantigens and antibodies. In comparison to microscopy, serological TB tests have the advantages of rapid diagnosis, technological simplicity, and modest training requirements. In addition, these tests could be performed at peripheral health facilities.  M. tuberculosisinfection can be categorized into three main stages: latent, reactivating, and active TB. Each stage represents differences in M. tuberculosisgene expression and hence antibody response to M. tuberculosis infection varies in different stages of M. tuberculosis infection due to stage specific antigens [23]. Antibody response to M. tuberculosis infection may also vary due to heterogeneity of the geographical background [24]. Hsp16.3 is secreted during the latent phase of mycobacterial growth and is an important component that facilitates the survival of M. tuberculosis during latent human infection [25]. Immune responses to M. tuberculosisantigens, ESAT6 (early secretory antigen target), CFP10 (culture filtrate protein) and Ag85B have been shown to be significantly higher in active TB than in latent TB [26]. Thus, it is rational to evaluate the M. tuberculosis-secreted antigens in serodiagnosis of active TB or latent TB infection. The proteins of M. tuberculosis induce a variable degree of humoral immune responses in infected person. The most studied secreted proteins of M. tuberculosis are ESAT-6, CFP-10, 38kDa, 16kDa and Ag85 complex.The ability of these proteins to elicit serological response has in fact made them to be utilized as the candidates for serodiagnosis. The other proteins eliciting humoral immune response are cell wall fraction (CWF) and lipoarabinomannan (LAM). Serological methods have been regarded as attractive tools for rapid diagnosis of tuberculosis due to their simplicity, rapidity and low cost. Serodiagnosis also does not require safety measures associated with handling of live bacilli as in culture and offers the possibility of detecting cases often missed by routine sputum smear microscopy. Many investigators assayed humoral immune response to tubercular antigens and evaluated different antigens as candidate for serodiagnostic test to detect active and latent tubercular infection. The success is so far variable. Previously, we determined antibody response to four mycobacterial antigens namely Ag85 complex, culture filtrate protein (CFP), cell wall fraction (CWF) and lipoarabinomannan (LAM) in the sera of 30 confirmed cases of tuberculosis and 30 healthy subjects. The sensitivity and specificity of anti-Ag85 complexes and anti-CFP IgM and IgG antibody ranged from 60% to over 95%. It appeared that IgM and IgG antibody response to Ag85 complex was better compared to that of CFP. Therefore, determination of IgM and IgG against Ag85 complex could be used as a serological marker for diagnosis of active tuberculosis in cases where other tests do not give conclusive information [27]. It is particularly applicable in children where they are unable to provide sputum samples for either staining or culture. Many authors investigated antibody response against Ag85 complex, CFP and LAM and found sensitivity and specificity similar to our findings [28-34]. Ag85 complex also showed immunodominant positivity in the studies conducted by Imaz et al. [35] and Sanchez-Rodriquez et al. [36]. However, Suraiya et al. found poor positivity to Ag85 complex [37]. This might be due to difference in stages of infection and heterogeneity of the geographical background [24]. Suraiya et al. conducted a study on 60 confirmed pulmonary tuberculosis patients to test the presence of IgG and IgA against M. tuberculosis proteins like ESAT6, SCWP (soluble cell wall protein), LAM (lipoarabinomannan), Ag85 and observed that the sensitivity of IgA ELISA was 81.7%, 83.3%, 11.7%, 53% and specificity was 96.6%, 93.3%, 100.0%, 96.6% respectively. The sensitivity of IgG ELISA was 71.0%, 71.0%, 71.0%, 21.7% and specificity was 93.3%, 96.6%, 96.6%, 100.0% respectively [37]. Currently, the antigens including 38kD, 16kD, ESAT-6, MPT63, 19kD, MPT64, MPT32, Rv1009, MTB48, MTB81, MTC28, Ag85B and KatG have been evaluated for their serodiagnostic potential.The use of any single M. tuberculosis antigen as a serodiagnostic marker generated false positive rate of 30-40%, but a combined use of multiple antigens improves the positive diagnostic rate. Some researchers reported that the detection of antibodies directed against multiple antigens could provide an improvement in sensitivity compared to single antigen in M. tuberculosis infection. Zhang et al. focused on the analysis and comparison of the four potential M. tuberculosis secreted proteins - ESAT6, CFP10, Ag85B, Hsp16.3 and the fusion protein Ag85B-Hsp16.3 as new markers in the serodiagnosis between active TB and LTBI. The result showed that in active TB the specificity for detecting M. tuberculosis antibody responses to antigens Ag85B-Hsp16.3, Ag85B, Hsp16.3, ESAT6 and CFP10 was 95.65%, 80.43%, 88.04%, 95.65% and 80.43% respectively and sensitivity was 61.67%, 63.33%, 63.33%, 96.67%, and 80.00% respectively. In case of LTBI, the serological responses to Ag85B-Hsp16.3, Ag85B, Hsp16.3, ESAT6 and CFP10 showed that the specificity was 73.91%, 97.83%, 88.04%, 84.78% and 69.57% respectively and the sensitivity was 60.00%, 53.33%, 53.33%, 60.00% and 73.33% respectively [38]. Burbelo et al. used luciferase immunoprecipitation system (LIPS) to screen antibody responses against seven potential M. tuberculosis antigens (PstS1, Rv0831c, FbpA, EspB, BfrB, HspX, and Ssb) for the diagnosis of pulmonary TB. LIPS mixture format of seven antigens showed 74-90% sensitivity and 96-100 % specificity [39]. A summary of the different studies regarding antibody detection tests for serodiagnosis of active tuberculosis is given in Table-2.   Table-2: Evaluation of antibody detection tests for serodiagnosis of active tuberculosis     Dai et al. detected M. tuberculosis antigens (ESAT-6, CFP-10, 38kD) by multi-target antibodies as capture antibodies and showed that the diagnostic performance was significant with sensitivity of 68% (95% CI – 53.3, 80.48) and specificity of 97.5% (95% CI – 86.84, 99.94) [42]. Attallah et al. detected 55kDa M. tuberculosis antigen in serum samples of pulmonary TB patients by dot-ELISA format with sensitivity of 87% and specificity of 93% [43]. Liu et al. conducted a study for detection of M. tuberculosis antigen peptides of CFP-10 and ESAT-6 by antibody labeled and energy focusing porous discoloidal silicon nanoparticles, NanoDisc-MS method and detected target peptides in 92.6% TB cases with 100% sensitivity in smear positive cases and 91% sensitivity in smear negative cases and no target peptides were detected in healthy controls [44]. Three systematic reviews were commissioned by the WHO Special Program for Research and Training in Tropical Diseases. Two reviews evaluated the performance of commercial serological tests for diagnosis of PTB and EPTB and one review evaluated the performance of non-commercial (in-house) serological tests for PTB. The reference standards were culture and/or smear microscopy and in addition, for EPTB, histopathological examination. The reviews of commercial serological tests for the diagnosis of PTB and EPTB found highly variable sensitivity and specificity. For the review of non-commercial (in house) tests for PTB, only purified antigens were included and purified protein derivative (PPD), culture filtrates or sonicated antigens were excluded. The review yielded 254 test evaluations (including 51 distinct single antigens and 30 distinct multiple antigens combinations) and found potential candidate antigens for inclusion in a serological test in both HIV uninfected and infected individuals. Multiple antigens provided higher sensitivity than single antigen. However, no antigen achieved sufficient sensitivity to replace smear microscopy [45]. The sensitivity and specificity of antigen detecting serological tests for the diagnosis of PTB and EPTB are summarized in Table-3 and 4.   Table-3: Evaluation of antigen detection tests for serodiagnosis of pulmonary tuberculosis     Table-4: Evaluation of antigen detection tests for diagnosis of extra pulmonary tuberculosis     In order to develop policy guidance concerning commercial serological TB tests, WHO commissioned an updated systematic review. The review included 67 studies (5,147 participants) in PTB group and 25 studies (1,809 participants) in EPTB group. The results demonstrated that serological tests for both PTB and EPTB provided inconsistent and imprecise sensitivity and specificity. Anda-TB IgG (Anda Biologicals, Strasbourg, France) yielded pooled sensitivities of 76% (95% CI – 63, 87) in studies of smear-positive and 59% (95% CI – 10, 96) in studies of smear negative patients; corresponding pooled specificities were 92% (95% CI – 74, 98) and 91% (95% CI – 79, 96) respectively. The key finding in the analysis regarding the popularity of serological tests was that – it met the perceived need among the private providers and the patients, though it showed the absence of an accurate, validated point of care test for TB [46]. In 2011, World Health Organization has issued policy statement that commercial serological tests for the diagnosis of MTB provides inconsistent and variable results for sensitivity and specificity, do not improve patient-important outcomes and adversely affect the patient safety [45,47]. In view of this, India and Cambodia imposed ban on import and sale of TB serological tests. The gamma interferon (IFN-γ) release assay (IGRA) is an in vitro test based on release of IFN-γ by foreign epitope-stimulated T cells. The promising antigens for use in such assays are the ESAT-6, CFP-10 and the TB7.7, which are absent from BCG strains and from most non-tuberculous mycobacteria. ESAT-6 and CFP-10 have been shown to elicit strong IFN-γ responses from the T cells of persons infected with M. tuberculosis but not from the T cells of those vaccinated with BCG or at low risk of infection. Tsiouris et al. evaluated the sensitivity of an “in-tube” gamma interferon release assay using TB-specific antigens in comparison to the tuberculin skin test (TST) and the sputum smear for acid fast bacilli (AFB) in TB cases in South Africa. Among 154 patients with a positive culture for M. tuberculosis, the sensitivity of the IGRA for the diagnosis of TB varied by clinical subgroup from 64% to 82%, that of the TST varied from 85% to 94%, and that of two sputum smears for AFB varied from 35% to 53%. The sensitivity of the IGRA in HIV-infected TB cases was 81%. HIV-infected TB patients were significantly more likely to have indeterminate IGRA results and produced quantitatively less gamma interferon in response to TB-specific antigens than HIV-negative TB patients. The combined sensitivities of the TST plus IGRA and TST plus a single sputum smear were 96% and 93%, respectively. The overall sensitivity of the IGRA was 75% in all the patients with pulmonary TB, which increased to 82% in new cases of pulmonary TB. A single sputum smear combined with the IGRA resulted in a sensitivity of 86% (95% CI- 79, 91) for culture-proven pulmonary TB. A single sputum smear combined with the TST resulted in a sensitivity of 93% (95% CI- 87, 96) for culture-positive pulmonary TB. The sensitivity of the IGRA for TB was considered a surrogate of sensitivity in LTBI [59]. Doan et al. performed the meta-analysis to evaluate the performance of TST and IGRA for LTBI diagnosis in various patient populations using Bayesian latent class modeling. A total of 157 studies were included in the analysis. In immunocompetent adults, the sensitivity of TST and QuantiFERON-TB Gold In-Tube (QFT-GIT) test were estimated to be 84% (95% credible interval [CrI] 82–85%) and 52% (50–53%), respectively. The specificity of QFT-GIT was 97% (96–97%) in non-BCG-vaccinated and 93% (92–94%) in BCG-vaccinated immunocompetent adults. The estimated figures for TST were 100% (99–100%) and 79% (76–82%), respectively. T-SPOT.TB had comparable specificity (97% for both tests) and better sensitivity (68% versus 52%) than QFT-GIT in immunocompetent adults. In immunocompromised adults, both TST and QFT-GIT displayed low sensitivity but high specificity. QFT-GIT and TST were equally specific (98% for both tests) in non-BCG-vaccinated children; however, QFT-GIT was more specific than TST (98% versus 82%) in BCG-vaccinated group. TST was more sensitive than QFT-GIT (82% versus 73%) in children [60]. In summary, the serological tests for diagnosis of PTB and EPTB demonstrate inconsistent and imprecise sensitivity and specificity. However, it may be useful in LTBI where specimens for diagnosis are not available. Serological tests in association with smear microscopy would provide better result. Determination of antibodies directed against multiple antigens might provide improved result compared to single antigen. Similarly, detection of multiple M. tuberculosis antigens rather than single antigen could increase the positive diagnostic rate.   Reference 13.  Claridge JE, Shawar RM, Shinnick TM, Plikaytis BB. Large-scale use of polymerase chain reaction for detection of Mycobacterium tuberculosis in a routine Mycobacteriology laboratory. J Clin Microbiol. 1993; 31(18): 2049-2056. 19.  Caviedes L, Lee TS, Gilman RH, Sheen P, Spellman E, Lee EH, et al. Rapid, efficient detection and drug susceptibility testing of Mycobacterium tuberculosis in sputum by microscopic observation of broth cultures. J Clin Microbiol. 2000; 38(3): 1203-1208. 24.  Hoff ST, Abebe M, Ravn P, Range N, Malenganisho W, Rodriques DS, et al. Evaluation of Mycobacterium tuberculosis–specific antibody responses in populations with different levels of exposure from Tanzania, Ethiopia, Brazil, and Denmark. Clin Infect Dis. 2007; 45(5): 575-582. 27.  Mohiuddin M, Haq JA. Humoral immune response to selective mycobacterial antigens and serodiagnosis of active tuberculosis in Bangladeshi patients. IMC J Med Sci. 2016; 10(2): 53-57. 28.  Kumar G, Dagur PK, Singh PK, Shankar H, Yadav VS, Daatoch VM, et al. Serodiagnostic efficacy of Mycobacterium tuberculosis 30/32—kDa mycolyl transferase complex, ESAT-6 and CFP-10 in patients with active tuberculosis. Arch Immunol Ther Exp (Warsz). 2010; 58(1): 57-65. 35.  Imaz MS, Schmelling MF, Kaempfer S, Spallek R, Singh M. Serodiagnosis of tuberculosis: specific detection of free and complex dissociated antibodies anti-Mycobacterium tuberculosis recombinant antigens. Braz J Infect Dis. 2008; 12(3): 234-244. 37.  Suraiya S, Musa M, Suppian R, Haq JA. Serological diagnosis for active tuberculosis in Malaysian population: Comparison of four protein candidate. Asian Pac J Trop Dis. 2012; 2(Sup 1): S312-S315. 39.  Burbelo PD, Keller J, Wagner J, Kilmavicz JS, Bayat A, Rhodes CS, et al. Serological diagnosis of pulmonary Mycobacterium tuberculosis infection by LIPS using a multiple antigen mixture. BMC Microbiol. 2015; 15: 205. 42.  Dai Z, Liu Z, Xiu B, Yang X, Zhao P, Zhang X, et al. A multiple-antigen detection assay for tuberculosis diagnosis based on broadly reactive polyclonal antibodies. Iran J Basic Med Sci. 2017; 20(4): 360-367. 44.  Liu C, Zhao Z, Fan J, Lyon CJ, WU HJ, Nedelkov D, et al. Quantification of circulating Mycobacterium tuberculosis antigen peptides allows rapid diagnosis of active disease and treatment monitoring. Proc Natl Acad Sci USA. 2017; 114(15): 3969-3974. 46.  Jarosławski S, Pai M. Why are inaccurate tuberculosis serological tests widely used in the Indian private healthcare sector? A root-cause analysis. J Epidemiol Glob Health. 2012; 2(1): 39-50. 48.  Chanteau S, Rasolofo V, Rasolonavalona T, Ramarokoto H, Horn C, Aurégan G, et al. 45/47 kilodalton (APA) antigen capture and antibody detection assays for the diagnosis of tuberculosis. Int J Tuberc Lung Dis. 2000; 4(4): 377-383. 52.  Rajan AN, Kashyap RS, Purohit HJ, Taori GM, Daginawala HF. Serodiagnosis of tuberculosis based on the analysis of the 65 kD heat shock protein of Mycobacterium tuberculosis. Int J Tuberc Lung Dis. 2007; 11(7): 792-797. 54.  Stavri D, Popescu C, Constantin S, Niculescu D, Stavri H, Fuiorea I. Specific antibodies and mycobacterial antigens in patient sera with pulmonary tuberculous and nontuberculous diseases. Note II Arch Roum Pathol Exp Microbiol. 1990; 49(4): 331-338. 57.  Shende N, Upadhye V, Kumar S, Harinath BC. A low molecular weight ES-20 protein released in vivo and in vitro with diagnostic potential in lymph node tuberculosis. Indian J Med Microbiol. 2008; 26(1): 29-33. 59.  Tsiouris SJ, Coetzee D, Toro PL, Austin J, Stein Z, El-Sadr W. Sensitivity analysis and potential uses of a novel gamma interferon release assay for diagnosis of tuberculosis. J Clin Microbiol. 2006; 44(8): 2844-2850. <![CDATA[Listerial contamination of raw beef and chevon in north-central Nigeria]]> Aleruchi Chuku Godwin Attah Obande Sani Bashir Eya https://imcjms.com/journal_full_text/316 2019-03-26 21:03:53 Original Article IMC J Med Sci 2019; 13(2): 001 Abstract Background and objective: Listeria sp. is a ubiquitous and frequently isolated foodborne pathogen. The prevalence of Listeria sp in raw beef and chevon sold in Lafia Nigeria, as well as their antibiotic susceptibility profile was evaluated. Methods: A total 104 samples comprising of 52 raw beef and 52 chevon were obtained from street vendors (hawkers), Shinge abattoir, Lafia old market and Lafia Modern Market. Isolation of Listeria sp. was performed on Listeria Selective Agar, following enrichment in supplemented Listeria Selective Broth. Identification of Listeria sp. was carried out by cultural and biochemical methods. Antimicrobial susceptibility of isolated L. monocytogenes was performed by standard disk diffusion method. Chi-square test was used to determine association between contamination levels at p=0.05. Results: Seven types of Listeria sp. were isolated. L. monocytogenes and L. ivanovii were the most frequently isolated contaminants in all meat types and from all sample sources. L. monocytogenes was isolated with a frequency of 64.4% (67/104) in the meat samples. Beef samples had the highest listerial contamination with a frequency of 58.2% (78/134) compared to chevon which had a listerial frequency of 41.8% (56/134). Resistance of L. monocytogenes to streptomycin and sparfloxacin was 58.2% and 55.2% respectively. Resistance to ampicillin (34.3%) and gentamicin (20.9%) was also observed. Resistances to multiple antimicrobials were detected in 11 L. monocytogenes isolates. Conclusion: The study demonstrated that the raw meat sold in Lafia was contaminated with several Listeria sp. L. monocytogenes showed high rate of resistance to several antimicrobial agents used for the treatment of listerial infection. Appropriate regulation and monitoring of livestock rearing and meat retailing practices are advocated to safeguard the health of consumers. IMC J Med Sci 2019; 13(2): 001. EPub date: 18 July 2019. DOI: https://doi.org/10.3329/imcjms.v13i2.45274 Address for Correspondence: Godwin Attah Obande, Department of Microbiology, Faculty of Science, Federal University Lafia, Nasarawa state, Nigeria. E-mail: obandegodwins@gmail.com; +2348039646924   Introduction Listeria monocytogenes is a facultative anaerobic bacterium which can grow and reproduce inside the host’s cells, making it one of the most virulent food-borne pathogens. Unlike most other food-borne pathogens it can grow and multiply at a very low temperatures [1,2]. L. monocytogenes has been typed into four serotypes of which only three (1/2a, 1/2b, 4b) are involved in 95% of all human listeriosis cases [3]. It belongs to the genus Listeria which is widely distributed in the environment. The genus currently includes a total of seven species namely L. monocytogenes, L. ivanovii, L. innocua, L. seeligeri, L. murrayi, L. grayi and L. welshimeri [4]. Of these species, L. monocytogenes and L. ivanovi are the only species found to be pathogenic to humans and other animals [5]. L. monocytogenes is a constant challenge for the food industry, health regulatory officials and consumers [6] since it remains as one of the most virulent foodborne pathogens for immunodeficient individuals. It has been extensively studied over the past few decades due to its high case/fatality rate (20-30%), chronic infection resulting in high healthcare cost and its ability to survive for longer periods under adverse environmental conditions than many other non-spore-forming bacteria [7]. In man, outbreaks usually occur following consumption of unpasteurized milk, contaminated cheeses and other dairy products. Reports of outbreaks have also followed ingestion of undercooked meat and poultry [8]. It is frequently present in the gut of cattle, poultry and pigs and can be transmitted through ready-to-eat (RTE) foods or raw meat products [9]. Listeria species are isolated from a diversity of environmental sources, including decaying vegetation, soil, water, effluents, variety of foods, and the faeces of humans and animals [10]. L. monocytogenes is a major contaminant of RTE food and food products. Packaged raw foods can represent a potential source of contamination, and listeriosis is associated with the consumption of such undercooked raw foods [11]. Major changes in food production, processing and distribution, increased use of refrigeration as a primary preservation method, changes in eating habits particularly towards ready-to-eat foods are suggested as possible reasons for the emergence of human food-borne listeriosis [12]. While several studies have reported antibiotic resistance in bacterial isolates from human beings, it is becoming evident that food produced from farm animals is no longer exempted from antibiotic resistant bacteria [13]. Thus, the food microflora is not separated from its human counterpart in cases of antibiotic resistance. The occurrence of infection by antibiotic resistant organisms makes treatment difficult and increases the period of recovery from illness [14]. This situation has been worsened by the indiscriminate use of common broad spectrum antibiotics as prophylaxis and growth promoters in animal feed, particularly in developing nations [14,15]. There has been a dearth of information on the epidemiology of listeriosis in most African countries, including Nigeria [16] with only few reports, when compared to other developed regions like Europe and United States of America [17]. This is because the organism seems not to have been given as much attention as is required [18,19]. Listeriosis is considered a serious health problem due to its high mortality rate and severity of symptoms. Despite the foregoing and the continuous observation of the emergence of antibiotic resistant strains of Listeria, there is little or no documented reports of its prevalence and its antibiotic susceptibility profile in Lafia of Nasarawa state of Nigeria.   Methods Study area and period: This study was conducted in Lafia, Nasarawa state which lies between latitude 8o25’ 40”N to 8o34’ 15”N and longitude 8o24’ 25”E to 8o38’ 19”E in the guinea savannah region of North-Central Nigeria. Lafia is a large town in Nasarawa state with an estimated population of 330, 712 [20]. The study was carried out from June to August which witnessed increased slaughtering of animals in commemoration of the Eid il-Fitr celebration in the month of July, 2016. Sample collection: Preliminary investigation identified the Shinge abattoir, open markets (Lafia old market and Modern market) and hawkers as major sources of retail fresh raw meat within Lafia.A total of 104 samples comprising of 52 raw beef samples and 52 raw chevon samples were collected randomly from the four identified sources in the morning hours to prevent effects of changing temperatures on microbial population. The meat samples were bought and packaged as they are sold to other consumers, appropriately labeled and transported within 90 minutes to the laboratory for analysis. Contamination of the meat samples by other materials or sources such as collector’s hand was avoided. Isolation of Listeria sp: Isolation of Listeria from the meat samples were based on the method described by Ndahi et al. [21] and Adikwu et al. [19] with some modifications. Aseptically, 10g of each sample was added to 90 ml Listeria Enrichment broth (Oxoid, Basingstoke, UK) containing Listeria Selective Enrichment Supplement. The mixture was homogenized for 2 minutes in a blender (MasterChef) at room temperature and incubated at 30°C for 24 hours. Listeria species were isolated on Listeria Selective Agar (Oxoid) using pour plate method, by transferring 1 ml of the overnight supplement culture into molten Listeria Selective agar and incubating for 48 hours at 37°C, after which the plates were examined for the presence of listeria-like growths. Identification of Listeria sp: Listeria was identified by standard methods as previously described [22,23]. Suspected colonies were identified by Gram stain, motility, catalase reaction, haemolysin production, indole, urease, CAMP (Christie, Atkins, and Munch-Peterson) and sugar fermentation (rhamnose, mannose, xylose and mannitol) tests. Antimicrobial susceptibility test: Antibiotic susceptibility of the isolated L. monocytogenes was determined by the Kirby-Bauer disk diffusion method on Mueller-Hinton Agar [19,25]. The antibiotics used include erythromycin (15µg), streptomycin (10µg), co-trimoxazole (1.25/23.75 µg), rifampicin (5µg), nalidixic acid (30µg), ciprofloxacin (5µg), ampicillin (10µg), gentamicin (10µg), chloramphenicol (30µg), sparfloxacin (5µg) and ofloxacin (5µg). A broth culture of at least 18 hours old was diluted using sterile distilled water and standardized to match 0.5 McFarland standards (approximately 108cfu/ml). The culture was inoculated onto dried Mueller-Hinton Agar (MHA, Oxoid) plate to create a lawn. Antibiotic discs were then placed on the seeded agar surfaces and the plates incubated for 24 hours at 37°C, after which the diameter (in mm) of the inhibition zone around each disk was measured and interpreted according to the Clinical Laboratory Standard Institute (CLSI) guidelines using the break points of Staphylococcus species [25]. Statistical analysis: IBM SPSS Statistics version 22.0 (IBM Corp., Armonk, NY, USA; 2013) was used to analyse results obtained. Pearson’s chi-square test was used to determine significance of associations between variables. A p-value less than 0.05 was considered statistically significant.   Results The prevalence of Listeria species isolated from 104 samples is shown in Table-1. L. monocytogenes had the highest prevalence rate of 64.4% (67/104) while L. grayi had the lowest rate of 2.9% (3/104). L. ivanovii was isolated from 21.2% samples. Mixed contamination with more than one species was observed in some samples. L. monocytogenes was isolated from 42 (80.8%) and 25 (48.1%) of beef and chevon samples respectively. Differences in L. monocytogenes contamination was statistically significant (p<0.01). Beef samples had the highest listerial presence of 58.2% (78/134) against 41.8% (56/134) in chevon samples.   Table-1: Types of Listeria species isolated from beef (n=52) and chevon samples (n=52)     Table-2 shows the distribution of Listeria spp isolated from raw beef samples collected from different locations. L. monocytogenes was most frequently isolated in sample sources, having a frequency of 76.9% (10/13) in both Shinge abattoir and Street hawker samples, and 86.4 % (11/13) in samples from Lafia old market and Lafia modern market. The second most isolated species from Shinge abattoir and Street hawker samples was L. ivanovii with frequencies of 38.5% (5/13) and 30.8% (4/13) respectively. L. inocua were the second most isolated species in both Lafia old market and Lafia modern market with frequencies of 23.1% (3/13) respectively. At most, only one Listeria spp type was absent from each sample source. L. monocytogenes, L. ivanovii and L. innocua were isolated from all the collection sites. Beef samples from Shinge abattoir had the highest number of listeria contaminants (28.2%; 22/78), followed by Lafia modern market and street vendors which had the same number of listeria contaminants (24.4%; 19/78). Lafia old market had the least number of listeria contaminants (23.1%; 18/78). Contamination rate in the respective sources were however, not different statistically (p>0.05).   Table-2: Distribution of Listeria species in raw beef samples collected from different locations     Table-3 shows the distribution of Listeria species in raw chevon samples from the different sample sources. Samples from Shinge abattoir had the highest number of listerial contaminants (51.8%; 29/56) while Lafia old market had the least (48.2%; 27/56). L. monocytogenes was most prevalent in both sources (46.2%; 12/26 and 50.0%; 13/26 respectively). No L. grayi was found in samples obtained from Shinge abattoir. L. welshimeri, L. grayi and L. murrayi were the least occurring species in samples from Lafia old market with a frequency of 3.8% (1/26) respectively. Differences in contamination rates were not statistically significant (p>0.05).   Table-3: Distribution of Listeria species in raw chevon samples collected from Shinge and Lafia old market     A total 67 L. monocytogenes isolates were tested for susceptibility to different antimicrobial agents. Resistance to nalidixic acid, co-trimoxazole and sparfloxacin was 100%, 58.2% and 55.2% respectively (Table-4). Susceptibility rate of 76.1%, 65.7%, 61.2% and 55.2% was observed with rifampicin, ampicillin, gentamicin and erythromycin respectively. Eleven L. monocytogenes strains showed resistance to more than one antibiotic.   Table-4: Susceptibility pattern of L. monocytogenes to selected antimicrobial agents (N=67)     Discussion Results of this study revealed a high prevalence of L. monocytogenes in raw beef and chevon sold in Lafia. The prevalence rate of Listeria species observed in this study was lower than the 95.8% prevalence rate reported in vegetable salads in Zaria, Kaduna state [24] but higher than the 39.6% and 7.8% observed in Sokoto [26] and in Makurdi, Benue state [19]. The high L. monocytogenes contamination observed in the raw meat samples was in concordance with an earlier report where 14 out of the 15 Listeria species isolated were L. monocytogenes [27]. Similarly, the high prevalence of L. monocytogenes in beef samples confirms an earlier report [17]. The present study appears to be the first investigation regarding presence of Listeria sp in retailed meat within Nasarawa state. The high prevalence of Listeria in the two widely consumed meats raises an issue of serious public health importance. It is possible that cases of listeriosis may have been misdiagnosed across health centers in the study area since they do not include investigations for listeria infection in clinical specimens. Some of the symptoms associated with the disease onset such as gastroenteritis, headache, fatigue, muscular and joint pain are similar to those of typhoid fever [28]. Moreover, not much appears to be known about this organism in Nigeria and most African countries [16]. The least common listeria isolate was L. grayi while the most observed was L. monocytogenes. This was in contrast with an earlier report [26]where L. seeligeri and L. innocua were the least and the most observed listerial contaminants respectively. Listerial contamination of beef was highest in samples from the Shinge abattoir. Contamination was higher in beef than chevon, an observation that was also reported by earlier studies [22,29]. Although not determined in this study, the difference in contamination between the two meat types might have been influenced by factors such as pH and water activity (aw). For instance, L. monocytogenes is known to survive at a pH of <4.3 and water activity of <0.930 [30]. The high rate of Listeria contaminants identified in beef samples from this source could be due to unhygienic practices such as slaughtering and preparing of meat on bare floor, poor drainage system, use of contaminated water, poor facility maintenance, illiteracy and lack of hygiene awareness by the handlers, as well as improper storage facilities. Vending of these meats is mostly done without any covering, thus exposing the meats to high rate of microbial contamination. Adoption of proper methods during slaughtering of animals have been suggested as a means of considerably reducing presence of listeria in meats [31,32]. Chevon samples from Lafia old market had less listerial contaminants than those from Shinge abattoir. This could be due to double-washing process practiced in Lafia old market; the meats are washed after slaughtering and before sales to butchers (retailers), unlike at Shinge abattoir where this is not practiced. The practice of repeated washing might have enhanced the removal of surface contaminants from the meat obtained from Lafia old market. Findings also showed that the isolated L. monocytogenes was either sensitive or intermediate sensitive to most of the antimicrobial agents tested. Susceptibility to some antibiotics and the multiple antimicrobial resistance observed in this study is similar to earlier reports [19,21,24]. Almost all the studied strains were susceptible to a wide range of antibiotics but completely resistant to nalidixic acid. This observation is in agreement with the earlier reports [33,34]. Resistance to nalidixic acid justifies addition of nalidixic acid into selective media for the isolation of L. monocytogenes. Susceptibility to ampicillin, erythromycin, chloramphenicol, co-trimoxazoleand gentamicin, observed in this study is similar to that reported by Troxiler et al. [35] and Hansen et al. [36]. Listeriosis is treated usually with β-lactam antibiotics like ampicillin or penicillin alone, or combined with an aminoglycoside (usually gentamicin) [37]. However, about 20-34% of the isolated L. monocytogenes were resistant to ampicillin, gentamicin and erythromycin in this study. This portends a serious public health issue. Around Lafia, meat is prepared by roasting, apart from boiling and frying; sometimes, this may not be enough to destroy deep listerial contaminants, leaving consumers of such products at risk of foodborne diseases. The resistance pattern observed in the present study could be attributed to the irrational use of the antibiotics in cattle and goat by the animal rearers or veterinary quacks [26]. Misuse of antibiotics as growth promoters can confer selective pressure on bacteria [38], making those increasingly resistant to conventional antibiotics. Although not determined experimentally, horizontal gene transfer among bacteria in the environment could also been responsible for antibiotic resistance as observed in this study [38,39].   Conclusion Listeria contamination of raw beef and chevon sold in Lafia is alarming. Unhygienic practices amongst meat handlers at the collection site could be the major source of contamination. Use of contaminated water, washing without addition of disinfectant, lack of awareness, improper storage facilities, poor equipment maintenance and dirty environment were factors believed to be the major causes and sources of listerial contamination observed in this study.   Authors’ contributions GAO conceived the idea of the study. AC, GAO and SBE designed the study. SBE and GAO conducted the study. GAO performed statistical analysis of data. AC, SBE and GAO wrote, reviewed and approved the final manuscript.   Conflict of interest The authors hereby, declare that no conflict of interest exists.   References 1.     Huss, HH, Reilly A, Embarek PKB. Prevention and control of hazards in seafood. Food Control. 2000; 11(2): 149-56. 2.     Jeyaletchumi P, Tunung R, Margaret SP, Son R, Farinazleen MG, Cheah YK. Review article: Detection of Listeria monocytogenes in foods. Int Food Res J. 2010; 17: 1-11. 3.     Wang W, Zhou X, Suo Y, Deng X, Cheng M, Shi C, Shi X. Prevalence, serotype diversity, biofilm-forming ability and eradication of Listeria monocytogenes isolated from diverse foods in Shanghai, China. Food Control. 2017; 73B: 1068–1073. 4.     Gebretsadik S, Kassa T, Alemayehu H, Huruy K, Kebede N. Isolation and characterization of Listeria monocytogenes and other Listeria species in foods of animal origin in Addis Abada, Ethiopia. J Infect Public Health. 2011; 4(1): 22- 29. 5. Robinson RK, Batt CA, Patel PD. (eds). Encyclopedia of Food Microbiology. San Diego, CA: Academic Press; 2000. 6.     Selby, TL, Berzins A, Gerrard DE, Corvalan CM, Grant AL, Linton RH. Microbial heat resistance of Listeria monocytogenes and the impact on ready-to-eat meat quality after post-package pasteurization. Meat Science. 2006; 74(3): 425-34. 7.     Fenlon DR. Listeria monocytogenes in the natural environment. In: Ryser ET, Marth EH, editors. Listeria, Listeriosis and food safety. New York: Marcel Dekker; 1999. pp. 21-37. 8.     Ryser ET, Arimi SM, Bunduki MM, Donnelly CW. Recovery of different Listeria ribotypes from naturally contaminated, raw refrigerated meat and poultry products with two primary enrichment media. Appl Environ Microbiol. 1996; 62: 1781-7. 9.     Jones AD, Seeliger HPR. The Genus Listeria. In: Balows A, Trüper HG, Dworkin M, Harder W, Schleifer KH, editors. Prokaryotes: a handbook on the biology of bacteria: Ecophysiology, isolation, identification, applications. 2nd Ed. New York, NY: Springer Verlag; 1992. pp. 1595-1616. 10.  Kuhn M, Goebel W. Molecular virulence determinants of Listeria monocytogenes. In: Ryser ET, Marth EH, editors. Listeria, listeriosis and food safety. Boca Raton: CRC Press Taylor and Francis Group; 2007. pp. 111-155. 11.  Centers for Disease Control and Prevention (CDC). National Listeria Surveillance Annual Summary, 2008. Atlanta, Georgia: US Department of Health and Human Services, CDC, 2011. 12.  Chodorowska M, Kuklinska D. Virulence factors of Listeria monocytogenes and pathogenesis, clinical symptoms and antibiotic therapy of listeriosis. Post Mikrobiol. 2002; 41: 37-49. 13.  Teuber M. Spread of antibiotic resistance with food borne pathogens. Cell Mol Life Sci. 1999; 56(9-10): 755-63. 14.  Harakeh S, Saleh I, Zouhairi O, Baydoun E, Barbour E, Alwan N. Antimicrobial resistance of Listeria monocytogenes isolated from dairy-based food products. Sci Total Environ. 2009; 407(13): 4022-7. 15.  Bondarianzadeh D. Food risk to babies listeriosis. Nutrition Today. 2007; 42: 236-9. 16.  Enurah LU, Aboaba OO, Nwachukwu SCU, Nwosuh CI. Antibiotic resistant profiles of food (fresh raw milk) and environmental (abattoir effluents) isolates of Listeria monocytogenes from the six zones of Nigeria. Afr J Microbiol Res. 2013; 7(34): 4373-8. 17.  Molla B, Yilma R, Alemayehu D. Listeria monocytogenes and other Listeria species in retail meat and milk products in Addis Ababa, Ethiopia. Ethiop J Health Dev. 2004; 18(3): 131-212. 18.  Ishola OO, Mosugu JI, Adesokan HK. Prevalence and antibiotic susceptibility profiles of Listeria monocytogenes contamination of chicken flocks and meat in Oyo State, south-western Nigeria: Public health implications. J Prev Med Hyg. 2016; 57(3): E157-E163. 19.  Adikwu Peter, E.U. Umeh, E.T. Azua and Godwin Attah Obande. Prevalence and Antimicrobial Susceptibility of Listeria monocytogenes Isolated from Beef, Pork and Chicken Sold in Makurdi Metropolis. Br Microbiol Res J. 2016; 14(5): 1-7. 20.  National Population Commission. Federal Republic of Nigeria Official Gazette Number 2. Volume 96, 2nd February 2009. 21.  Ndahi MD, Kwaga JKP, Bello M, Kabir J, Umoh VJ, Yakubu SE, Nok AJ. Prevalence and antimicrobial susceptibility of Listeria monocytogenes and methicillin-resistant Staphylococcus aureus strains from raw meat and meat products in Zaria, Nigeria. Lett App Microbiol. 2013; 58(3): 262-269. 22.  Al-Nabulsia AA, Osailia TM, Awada AA, Olaimatb AN, Shakera RR, Holley RA. Occurrence and antibiotic susceptibility of Listeria monocytogenes isolated from raw and processed meat products in Amman, Jordan. CYTA-J Food. 2015; 13(3): 346–352. 23.  Food and Agriculture Organization. Quality assurance for microbiology in feed analysis laboratories, by R.A. Cowie. Edited by Harinder P.S. Makkar. FAO Animal Production and Health Manual No. 16. Rome. 2013. 24.  Ieren II, Bello M, Kwaga JKP. Occurrence and antibiotic resistance profile of Listeria monocytogenes in salad vegetables and vegetable salads sold in Zaria, Nigeria. Afr J Food Sci. 2013; 7(9): 334-338. 25.  Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing; Twenty-Fourth Informational Supplement. CLSI document M100-S24. Wayne, PA. 2014. 26.  Yakubu Y, Salihu MD, Faleke OO, Abubakar MB, Junaidu AU, Magaji AA, Gulumbe ML, Aliyu RM. Prevalence and antibiotic susceptibility of Listeria monocytogenes in raw milk from cattle herds within Sokoto Metropolis, Nigeria. Sokoto J Vet Sci. 2012; 10(2): 13-17. 27.  Meti M, Govind V, Sundaresan G, Appa RV, Narendra BR. Isolation and detection of Listeria monocytogenes in chicken meat marketed in retail outlets by using simplex PCR. J Entomol Zool Stud. 2017; 5(5): 434-437. 28.  Liu D, Busse HJ. Listeria. In: Liu D, editor. Molecular detection of food-borne pathogens. United Kingdom: CRC Press; 2009. 29.  Islam MS, Husna AA, Islam MA, Khatun MM. Prevalence of Listeria monocytogenes in Beef, Chevon and Chicken in Bangladesh. Am J Food Sci Health. 2016; 2(4): 39-44. 30.  Vermeulen A, Gysemans KPM, Bernaets K, Geeraerd Ah, Van Impe JF, Debevere J, Devlieghere F. Influence of pH, water activity and acetic acid concentration on Listeria monocytogenes at 7°C: data collection for the development of a growth/no growth model. Int J Food Microbiol. 2007; 114(3): 332-341. 31.  Keeratipibul S, Techaruwichit P. Tracking sources of Listeria contamination in a cooked chicken meat factory by PCR-RAPD-based DNA fingerprinting. Food Control. 2012; 27(1): 64-72. 32.  Kurpas M, Wieczorek K, Osek J. Ready-to-eat meat products as a source of Listeria monocytogenes. J Vet Res. 2018; 62(1): 49-55. 34.  Ennaji H, Timinouni M, Ennaji M, Hassar M, Cohen N. Characterization and antibiotic susceptibility of Listeria monocytogenes isolated from poultry and red meat in Marocco. Infect Drug Resist. 2008; 1: 45-50. 34.  Marius EC, Lorena AM, Tatiana VD, Alexandru R, Alina MB. Antibiotic Susceptibility Profiles of Listeria monocytogenes strains isolated from food products and clinical samples. Rev Rom Med Lab. 2014; 22(2): 255-261. 35.  Troxler R, von Graevenitz A, Funke G, Wiedemann B, Stock I. Natural antibiotic susceptibility of Listeria species: L. grayi, L. innocua, L. ivanovii, L. monocytogenes, L. seeligeri and L. welshimeri strains. Clin Microbiol Infect. 2000; 6(10): 525-535. 36.  Hansen JM, Gerner-Smidt P, Bruun B. Antibiotic susceptibility of Listeria monocytogenes in Denmark, 1958-2001. APMIS. 2005; 113(1): 31-36. 37.  Ramaswamy V, Cresence VM, Rejitha J, Mohandas UL, Dharsana KS, Suryaprasad PP, Helan MV. Listeria: Review of epidemiology and pathogensis. J Microbiol Immunol Infect. 2007; 40(1): 4–13. 38.  Indrawattana N, Nidabbhasobon T, Sookrung N, Chongsa-Nguan M, Tungtrongchitr A, Makino S, Tungyong W, Chaicumpa W. Prevalence of Listeria monocytogenes in raw meats marketed in Bangkok and characterization of the isolates by phenotypic and molecular methods. J Health Popul Nutr. 2001; 29(1): 26–38. 39.  Charpentier E, Courvalin P. Antibiotic resistance in Listeria spp. Antimicrob Agents Chemother. 1999; 43(9): 2103–2108. <![CDATA[Prevalence of hypothyroidism in different occupational groups of Bangladeshi population]]> MA Sayeed Masuda Mohsena Tahniyah Haq AHG Morshed Sadya Afroz Nehlin Tomalika Hasina Momtaz M Mostafizur Rahaman https://imcjms.com/journal_full_text/327 2019-07-24 00:32:15 Original Article IMC J Med Sci 2019; 13(2): 002 Background and aims: Hypothyroidism is a common global endocrine disorder. The magnitude of hypothyroidism at community level in Bangladesh is unknown except some clinic-based studies. The present study was undertaken to determine the prevalence of hypothyroidism in different occupational groups of Bangladeshi population and to assess the risks related to it. Results: Overall, 626 (M/F=123 / 503) participants with a mean age of 35.9 (34.75 – 37.02) years volunteered. The mean values of all participant for TSH and FT4 were 2.08 (95%CI: 1.72 – 2.45) μiu/ml and 13.04 (95CI:12.86 – 13.22) pmol/L respectively. The third percentile of TSH ranged from 0.42 to 0.46 μiu/ml and 97th percentile ranged from 5.16 to 5.24 μiu/ml. For FT4, the 3rd and the 97th percentile were 10.3 and 16.41 pmol/L, respectively. The prevalence of hypothyroidism in both sexes was 7.0% (M/F=4.1/8.3%). Occupational groups, sex and increasing age, obesity, blood pressure, and lipids showed no association with hypothyroidism. Hyperglycemia was proved to be a significant risk for hypothyroidism (prevalence in diabetic vs. non-diabetic was12.9% vs. 5.5%, p = 0.04; FBG was correlated with TSH, r = 0.138, p <0.001). IMC J Med Sci 2019; 13(2): 002. EPub date: 24 July 2019. DOI: https://doi.org/10.3329/imcjms.v13i2.45275     We investigated the trend of prevalence of hypothyroidism according to quartiles (Q 01 through Q04) of age, BMI, WHtR, FBG in Figure-1. The measures of central tendencies and variability of thyroid stimulating hormone (TSH) and free thyroxin (FT4) are shown in Table-7. The prevalence did not increase significantly with increasing age, BMI, WHtR; whereas, the trend was significant for increasing level of FBG (p=0.04).   Fig-1: Trend of hypothyroidism prevalence according to quartiles of age, BMI, WHR, WHtR, FBG. The trends of prevalence (%) for age-quartile, BMI-quartile were not significant, whereas, FBG-quartile was found significant (p=.04). The quartiles of central obesity measures (WHR) were not significant (not shown in the figure).   Table-7: Statistics measures of central tendencies and variability of thyroid stimulating hormone (TSH) and free thyroxin (FT4)   Hypothyroidism is based only on the circulating blood level of TSH despite normal FT4 level, and the clinical manifestations are usually not evident. This study is unique in the sense that it addressed the prevalence of subclinical hypothyroidism at community level. Additionally, it investigated whether the risk factors, so far known, are associated with hypothyroidism in our population. Simultaneously, this study included different occupational groups for comparison of prevalence rates and the associated risk factors acting upon the occupational groups. The study could propose the values of TSH and FT4 at 3rd and 97th percentile (Table-1). This finding may help to compare or to determine future reference range of TSH and FT4. Regarding diabetes, the prevalence of hypothyroidism was significantly higher among the diabetic than among the non-diabetic group (Table-3). Correlation was also found significant between FBG and TSH (Table-5). Additionally, we found that the trend of hypothyroidism increased significantly with increasing fasting blood glucose (Figure-1). The associations between hypothyroidism and diabetes have been reported in other studies and in other forms of diabetes [6, 7, 18-22]. A study found a higher TSH level in patients with metabolic syndrome suggesting that hypothyroidism may be a risk factor for it [23]. In subclinical hypothyroidism, insulin resistance may result from diminished rate of insulin stimulated glucose transport caused by perturbed expression of glucose transporter type 2 genes (GLUT 2). There is also impaired insulin stimulated glucose utilization in peripheral tissues [24]. The study has some limitations. Had we clinically examine those who had high TSH level we could have identified the common signs or symptoms related to hypothyroidism which could help physician to look into clinical features cautiously. Secondly, we could have assayed free tri-iodothyronine (FT3), thyroid peroxidase antibody (anti-TPO) and reverse thyroxine (rt3) for more reliable thyroid dysfunction. <![CDATA[Detection of Candida auris and its antifungal susceptibility: first report from Bangladesh]]> Subarna Dutta Md. Hasibur Rahman Kazi Shakhawath Hossain Jalaluddin Ashraful Haq https://imcjms.com/journal_full_text/328 2019-08-04 03:00:35 Original Article IMC J Med Sci 2019; 13(2): 003 Abstract Background and objectives: Candida auris is an emerging multidrug-resistant fungal pathogen that has been associated with nosocomial infections with a high mortality. The organism has been reported from several countries of the world except Bangladesh. The present study describes the presence of C. auris in clinical samples obtained from a large hospital of Dhaka city, Bangladesh. Materials and methods: The A total of 100 Candida species isolated from different clinical samples were purposively included in the present study. Samples were obtained from patients attending a 750 bed hospital of Dhaka city. C. auris was identified by growth characteristics, biochemical and carbohydrate assimilation test and further confirmed by polymerase chain reaction and sequencing using ITS1 and ITS2 targeting the conserved regions of 5.8S rRNA. Antifungal susceptibility of identified C. auris was performed by disk diffusion and minimum inhibitory concentration (MIC) methods. Results: Out of 100 Candida sp. tested, 21 isolates were identified as C. auris. Of the 21 C. auris, 14 (66.7%) were isolated from blood samples and the remaining 7 (33.4%) were from urine. Most of the C. auris isolated were from patients admitted in intensive care units.  Out of 21 C. auris, 17 (81.0%), 7 (33.3%) and 3 (14.3%) were sensitive to amphotericin B, fluconazole and voriconazole respectively by disk diffusion method. Out of 14 fluconazole resistant isolates, 5 were susceptible dose-dependent (SS-D) by MIC method. Conclusion: The present study is the first report demonstrating the presence of C. auris in clinical samples obtained from a large hospital of Bangladesh. Majority of isolates showed resistance to fluconazole and variable susceptibility to other antifungal agents. Further study is suggested to find its true magnitude and its susceptibility pattern to a range of antifungal agents. IMC J Med Sci 2019; 13(2): 003. EPub date: 05 August 2019. DOI: https://doi.org/10.3329/imcjms.v13i2.45276 Address for Correspondence: Jalaluddin Ashraful Haq, Professor of Microbiology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka 1000, Bangladesh. Email: jahaq54@yahoo.com   Introduction Candida is now recognized as a major agent of hospital-acquired infection [1]. Although, most infections are attributed to C. albicans, the shift towards treatment resistant non-albicans Candida (NAC) species is increasingly evident in recent years [2,3]. C. auris is an emerging NAC species which is first reported in Japan in 2009 [4]. Studies from several countries have documented that C. auris is causing severe illness in hospitalized patients and difficult to control hospital outbreaks [5, 6]. The organism is extremely transmissible between patients, inter healthcare facilities and from contaminated environments [7-9]. Infection by C. auris requires proper attention as it shows resistance to many commonly used antifungal agents [10-12]. A study from India has reported that 90%, 15% and 8% of C. auris isolated between 2009 and 2017 were resistant to fluconazole, voriconazole and amphotericin B, respectively [12]. Identification of C. auris is not usually done in routine microbiology practice due to lack of awareness about the organism and limited laboratory facilities. Moreover, C. auris is often difficult to differentiate from other NAC species in laboratories with limited biochemical tests. No study has yet been done in Bangladesh with regard to the detection and antifungal susceptibility of C. auris. The present study investigated the presence of C. auris in different clinical samples obtained from patients attending a hospital of Dhaka city. Its susceptibility to common antifungal agents was also determined.   Materials and methods Study samples and place: The study was carried out at a 750 bed-hospital of Dhaka city over a period of one year. A total of 100 Candida species isolated from different clinical samples were purposively included in the present study for detail species identification. Clinical samples included urine, blood, sputum, pus, high vaginal swab and body fluid from patients admitted in wards, intensive care unit (ICU) and neonatal intensive care unit (NICU). Isolation and identification of C. auris: All clinical samples were inoculated on the Sabouraud Dextrose Agar (SDA) media. Phenotypic features of C. auris were identified by wet film, (oval or round shape yeast or budding yeast cell), Gram staining (Gram positive yeast cell), and incubation at 37-420C temperature [13,14,]. Carbohydrate assimilation test was performed as described earlier [15]. C. auris identified by growth characteristics, biochemical reactions and carbohydrate assimilation tests were further confirmed by polymerase chain reaction and sequencing using ITS1 and ITS2 targeting the conserved regions of 5.8S rRNA [16].The purified PCR product was sent to McLab, California, USA for sequencing. The sequence was used as probes in NCBI blast search database in order to retrieve similar sequences.   Determination of antifungal susceptibility a.   Disk diffusion method (DDM): The isolates were tested for susceptibility to amphotericin B (10μg), fluconazole (25μg) and voriconazole (1μg) by disk diffusion method as described in NCCLS manual M44-A, 2004 [17]. The zone of inhibition around the disc was recorded and interpreted as susceptible (S), susceptible -dose dependent (S-DD), and resistant (R) as mentioned in Table-1. All disks were obtained from HIMEDIA, India Ltd.   Table-1: Interpretative breakpoints for C. auris by disk diffusion and MICs (μg/mL) methods as per M44-A and M27-A3 CLSI documents     b.  Minimum inhibitory concentrations (MIC) method: MIC of amphotericin B, fluconazole and voriconazole against isolated C. auris was determined by broth dilution method following the NCCLS approved guideline M27-A3 [18]. All reading was visually taken between 24 and 48 h of incubation at 35 °C in aerobic condition and interpreted according to the values mentioned in Table-1. Each isolate was tested in duplicate by both disk diffusion and MIC methods.   Results Out of 100 Candida sp. tested, 21 isolates were identified as C. auris by growth characteristics and carbohydrate assimilation tests. Representative isolates of 21 C. auris, as identified by growth characteristics and carbohydrate assimilation tests were confirmed as C. auris by sequencing (5.8S rRNA gene sequences).  Sequence analysis of our isolates showed 99%-100% similarity with those of C. auris KP326583, KP131674 and MF167535 5.8S ribosomal RNA gene.  Out of 21 isolates, 8 and 13 were isolated from samples of adult and neonate patients respectively (Table-2). Of the 21 C. auris, 14 (66.6%) were isolated from blood samples and the remaining 7 (33.4%) were from urine samples of adult patients. Except one, all C. auris were isolated from blood of neonates admitted in intensive care unit.   Table-2: Rate of Isolation of C. auris according to samples and locations (n= 21)     The susceptibility pattern of C. auris to different antifungal agents by disc diffusion and MIC method is shown in Table-3. Out of 21 C. auris, 14 (66.7%) were resistant to fluconazole by disk diffusion method. However, out of these 14 resistant isolates 5 were found susceptible dose-dependent (SS-D) by MIC method (Table-3). Most of isolates were sensitive to amphotericin B by both disk diffusion (81.0%) and MIC (76.2%) methods. Out of total 21 C. auris tested, 18 (85.7%) was resistant to voriconazole. The detail MIC, MIC50 and MIC90 of all isolates are shown in Table-4.   Table-3: Susceptibility pattern of C. auris to amphotericin B, fluconazole and voriconazole by DD and MIC methods     Table-4: MIC of amphotericin B, fluconazole and voriconazole against isolated C. auris (n=21)     Discussion C. auris is an emerging fungus and has become a global nosocomial problem. It causes candidiasis ranging from superficial skin infection to severe invasive bloodstream and multi organs infections. It is variably resistant to multiple antifungal drugs commonly used to treat Candida infections. C. auris was first isolated from the ear canal of a 70-year-old Japanese woman in Japan in 2009 [4]. In 2011, the first three cases of disease-causing C. auris were reported from South Korea [19]. The first report of a C. auris outbreak in Europe was in 2016 [20]. Up till 2019, C. auris in clinical samples has been documented in more than 30 countries of the world [21]. This is the first study of C. auris in Bangladesh. The study has revealed the presence of C. auris infection in the hospitalized patients of Bangladesh. About 62% and 29% of C. auris were found in pediatric and ICU adult patients respectively and most frequently it is isolated from blood (67%). A recent study in USA documented 77 clinical cases of C. auris from seven states of which 45 were bloodstream isolates and the remaining were from urine (n=11), respiratory tract (n=8), bile fluid (4), wound (4), CVC tip (2), bone, ear and jejunal biopsy specimens [14]. Antifungal susceptibility of Candida species varies from place to place and species to species. Susceptibility of C. auris to fluconazole, voriconazole and amphotericin B found in the present study was similar to the findings of other studies reported from different countries of the world [11,12,21]. In the present study, 5 (23%) C. auris found resistant by disk diffusion method to fluconazole were actually dose dependent susceptible by MIC method. These C. auris isolates exhibited slightly hazy zone of growth within the zone of inhibition in disk diffusion method and were recorded as ‘resistant’ by disk diffusion test. Therefore, any strain showing hazy zone of growth within the zone of inhibition should be confirmed by MIC method as higher dose of fluconazole could be used to treat infection by such S-DD strains of C. auris. It is important because fluconazole is a cheaper drug compared to other more expensive and toxic antifungal agents.  In our study, almost all (20/21) C. auris were isolated from patients admitted either in adult or neonatal intensive care units of the hospital. The finding of the study emphasizes the need for quick detection of this organism in clinical samples to prevent its spread in the hospitals. So, special attentions are needed to quickly detect C. auris and its antifungal susceptibility for appropriate treatment and for the prevention of its nosocomial transmission. Present method of identifying C. auris by biochemical and sugar assimilation tests is time consuming and is often fraught with difficulties. Rapid technique is needed for quick diagnosis of C. auris infection to initiate timely and appropriate treatment. Further study is warranted to determine its true magnitude in the hospitals of Bangladesh. Also, measures should be taken to create awareness among the microbiologists and clinicians regarding the importance of C. auris infection in severely ill patients requiring long hospital stay or admission in intensive care units.   References 1.     Douglas LJ. Candida biofilms and their role in infection. Trends in Microbiol.2003; 11(1): 30-36. 2.     Richter SS, Galask RP, Messer SA, Hollis RJ, Diekema DJ and Pfaller MA. Antifungal susceptibilities of Candida species causing vulvo-vaginitis and epidemiology of recurrent cases. J Clin Microbiol. 2005; 43(5): 2155–2162. 3.     Deorukhkar S. Saini S. Non albicans Candida species: its isolation pattern, species distribution, virulence factors and antifungal susceptibility profile. Int J Med Sci Public Health. 2013; 2(3): 533–538. 4.     Satoh K, Makimura K, Hasumi Y, Nishiyama Y, Uchida K, Yamaguchi H. Candida auris sp. Nov., a novel ascomycetous yeast isolated from the external ear canal of an inpatient in a Japanese hospital. Microbiol Immunol. 2009; 53: 41-44. 5.     Jeffery-Smith A, Taori SK, Schelenz S, Jeffery K, Johnson EM, Borman A, Candida auris Incident Management Team, Rohini Manuel, Colin S. Brown. Candida auris: a review of the literature. Clin Microbiol Rev. 2018; 31(1): e00029-17. 6.     Osei Sekyere J. Candida auris: A systematic review and meta-analysis of current updates on an emerging multidrug-resistant pathogen. Microbiologyopen. 2018; 7(4): e00578. 7.     Calvo B, Melo AS, Perozo-Mena A, Hernandez M, Francisco EC, Hagen F, et al. First report of Candida auris in America: clinical and microbiological aspects of 18 episodes of candidemia. J Infect. 2016; 73(4): 369-74. 8.     Rozwadowski F, McAteer J, Chow NA, Skrobarcek K, Forsberg K, Barrett PM, et al. Prevalence and risk factors for Candida auris colonization among patients in a long term acute care hospital — New Jersey, 2017. Open Forum Infect Dis. 2018; 5(Suppl 1): S14. 9.     Chowdhary A, Sharma C, Duggal S, Agarwal K, Prakash A, Singh PK, et al. New clonal strain of Candida auris, Delhi, India. Emerg Infect Dis. 2013; 19(10): 1670-3. 10.  Ben-Ami R, Berman J, Novikov A, Bash E, Shachor-Meyouhas Y, Zakin S, et al. Multidrug-resistant Candida haemulonii and C. auris, Tel Aviv, Israel. Emerg Infect Dis. 2017; 23(1): 10. 11.  Chowdhary et al. Multidrug-resistant endemic clonal strain of Candida auris in India. Eur J Clin Microbiol Infect Dis. 2014; 33: 919–26. 12.  Lockhart SR, Etienne KA, Vallabhaneni S, Farooqi J, Chowdhary A, Govender NP, Colombo AL, Calvo B, Cuomo CA. Simultaneous emergence of multidrug-resistant Candida auris on 3 continents confirmed by whole-genome sequencing and epidemiological analyses. Clin Infect Dis. 2017; 64 (2): 134–140.  13.  Chowdhary A, Prakash A, Sharma C, Kordalewska M, Kumar A, Sarma S, et al. A multicentre study of antifungal susceptibility patterns among 350 Candida auris isolates (2009–17) in India: role of the ERG11 and FKS1 genes in azole and echinocandin resistance. J Antimicrob Chemother. 2018; 73: 891–899. 14.  Borman AM, Szekely A, Johnson EM. Comparative pathogenicity of United Kingdom isolates of the emerging pathogen Candida auris and other key pathogenic Candida species. mSphere 2016; 1(4):e00189-16. 15.  Adams ED, Cooper BH. Evaluation of a modified Wickerham medium for identifying medically important yeasts. Am J Med Technol. 1974; 40(9): 377–388. 16.  Fujita SI, Senda Y, Nakaguchi S, Hashimoto T. Multiplex PCR using internal transcribed spacer 1 and 2 regions for rapid detection and identification of yeast strains. J Clin Microbiol. 2001; 39 (10): 3617–3622. 17.  Methods for antifungal disk diffusion susceptibility testing of yeasts; Approved Guideline M44-A. Vol: 29, Number 17. 2nd ed. Wayne, PA: National Committee for Clinical Laboratory Standards; 2004. 18.  Reference method for broth dilution antifungal susceptibility testing of yeasts M27-A3. Vol: 28, Number. 14. 3rd ed. Wayne, PA: Clinical and Laboratory Standards Institute; 2008. 19.  Lee WG, Shin JH, Uh Y, Kang MG, Kim SH, Park KH, et al. First three reported cases of nosocomial fungemia caused by Candida auris. J Clin Microbiol. 2011; 49 (9): 3139–3142.  20.  Schelenz S, Hagen F, Rhodes JL, Abdolrasouli A, Chowdhary A, Hall A, et al. First hospital outbreak of the globally emerging Candida auris in a European hospital. Antimicrob Resist Infect Control. 2016; 5: 35. 21.  Tracking Candida auris, July 12, 2019. Center for Disease Control and Prevention, Atalanta, GA, USA. www.cdc.gov/fungal/candida-auris/tracking-c-auris.html <![CDATA[Effect of metformin on blood lipids in patients with diabetes mellitus]]> Tahniyah Haq Sabah Haq https://imcjms.com/journal_full_text/317 2019-04-25 09:20:22 Original Article Abstract Background and objectives: Metformin improves macrovascular complications in people with diabetes mellitus (DM). Although the exact mechanism is not known, metformin has beneficial effects on dyslipidaemia. The aim of the study was to find out if there was an effect of metformin on blood lipids in people with diabetes mellitus. Method: This was a cross-sectional study which included 80 patients with diabetes mellitus. They were divided into 2 groups – (a) Group 1: on metformin and (b) Group 2: without metformin medication. None of the patients were on any other anti-diabetic medication. All data were obtained from patients’ medical records. Individual blood lipids and lipid ratios were compared between two groups. Result: Group 1 included 42 patients with a mean HbA1c of 7.58 ± 0.24% taking an average dose of 820.83 ± 60.40 mg/day of metformin. Group 2 consisted of 38 patients with mean HbA1c of 7.58 ± 0.29%. There was no significant difference in individual plasma lipid levels, lipoprotein ratio or frequency of dyslipidaemia between patients taking and not taking metformin (p>0.05). Also, different doses of metformin had no significant effect on the plasma lipid levels. Conclusion: Metformin did not affect the lipid profile of patients with diabetes mellitus. IMC J Med Sci 2019; 13(2): 004. EPub date: 22 August 2019. DOI: https://doi.org/10.3329/imcjms.v13i2.45277 Address for Correspondence: Dr. Tahniyah Haq, Assistant Professor, Department of Endocrinology, Room 1620, 15th Floor, Block D, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka 1000, Bangladesh. Email: tahniyah81@gmail.com   Introduction There is a multitude of evidence from both observational and intervention studies that metformin improves long-term macrovascular complications in people with type 2 diabetes mellitus [1]. It is associated with a 39% reduction in the incidence of myocardial infarction in diabetes [2]. Although, it is known that this favourable cardiovascular effect is independent of its anti-diabetic action, the exact mechanism is still being studied [3]. Metformin has modest positive effects on dyslipidaemia, inflammation and thrombosis, benefiting vascular function [3]. Some studies have described that metformin lowers very low density cholesterol (VLDL), triglyceride, low density lipoprotein (LDL), plasminogen activator inhibitors, factor VIII, C-reactive protein, and increases high density lipoprotein (HDL), especially if abnormal [2]. It also stabilizes fibrin and platelets [2]. However, others show no significant effect on blood lipids [4]. There may be several reasons why we did not find any association between lipid profile and metformin use in our study. Studies have shown that metformin reduces intestinal lipoprotein synthesis when used in high doses, of approximately 2300 mg/day [5]. Therefore, an explanation for the lack of effect of metformin on lipid profile may be the low dose (less than 1700 mg/day) used by the patients in this study. Unfortunately, the duration of metformin use was not available from the database. So, we do not know if metformin had sufficient time to affect blood lipids. In randomized controlled trials to see effect of metformin on lipids, metformin was used for at least 6 weeks [12]. Some reports have indicated that the lipid lowering effect of metformin is more pronounced when baseline lipids are markedly elevated [4]. The baseline lipid levels were however not substantially elevated in this study. This may contribute to the lack of difference seen between the two groups. In case of near normal glycaemic control, metformin had no effect on triglycerides but still affected the total and LDL cholesterol [12]. The HbA1c level was near normal in our study population. This may explain why a difference in triglyceride level was not found. A limitation of this study is its cross-sectional nature with small number of DM cases in both arms. This did not allow us to rigorously control the study to see the effect of introducing metformin on lipid profile. Further prospective study involving larger study population and defined criteria is needed to ascertain the effect of metformin on plasma lipids in ethnic Bengali DM population. In conclusion, metformin had no effect on lipid profile and lipoprotein ratios in our study population.   Author’s contributions TH designed the study, collected samples, analyzed data, wrote and edited the manuscript. SH was involved in data entry and analysis.   Competing interest There is no conflict of interest.   References 1.     Campbell IW, Howlett HCS. Metformin and the heart. In: Campbell IW, Howlett HCS, Holman RR, Bailey CJ, editors. Metformin – 60 years of clinical experience. Germany: Wiley. 2017: 45-58. 2.     Grant PJ. Beneficial effects of metformin on haemostasis and vascular function in man. Diabetes Metab. 2003; 29: 6S44-52. 3.     Bailey CJ. Metformin: effects on micro and macrovascular complications in type 2 diabetes. Cardiovasc Drugs Ther. 2008; 22(3): 215-24. 4.     Bailey CJ, Krentz AJ. Oral Antidiabetic Agents Diabetic Peripheral Neuropathy. In: Holt R I G, Cockram C S, Flyvbjerg A, Goldstein B J, editors. Textbook of Diabetes. 4th ed. Singapore: Wiley Blackwell. 2010: 615-634. 5.     Jeppesen J, Zhou MY, Chen YD, Reaven GM. Effect of metformin on postprandial lipemia in patients with fairly to poorly controlled NIDDM. Diabetes Care. 1994; 17(10): 1093–9. 6.     Viollet B, Guigas B, Leclerc J, Hebrard S, Lantier L, Mounier R, Andreelli F, Foretz M. AMP-activated protein kinase in the regulation of hepatic energy metabolism: from physiology to therapeutic perspectives. Acta Physiol (Oxf). 2009; 196(1): 81–98. 7.     Huang X, Li R, Chen L, Dai W. Metformin reduces plasma triglycerides in ob/ob obese mice via inhibiting the hepatic apoA5 expression. Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2017; 42(12): 1389-1394. 8.     Sato D, Morino K, Nakagawa F, Murata K, Sekine O, Beppu F, Gotoh N, Ugi S, Maegawa H. Acute effect of metformin on postprandial hypertriglyceridemia through delayed gastric emptying. Int J Mol Sci. 2017; 18(6). E1282. 9.   He X, Chen X, Wang L, Wang W, Liang Q, Yi L, Wang Y, Gao Q. Metformin ameliorates Ox-LDL-induced foam cell formation in raw264.7 cells by promoting ABCG-1 mediated cholesterol efflux. Life Sci. 2019; 216: 67-74. 10.  American Diabetes Association. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2019. USA: Diabetes Care; 2019; 42(1): S103-123. 11.  Millán J, Pintó X, Muñoz A, Zúñiga M, Rubiés-Prat J, Pallardo LF et al.Lipoprotein ratios: Physiological significance and clinical usefulness in cardiovascular prevention. Vasc Health Risk Manag. 2009: 5:757–765. 12.  Wulffelé MG1, Kooy A, de Zeeuw D, Stehouwer CD, Gansevoort RT. The effect of metformin on blood pressure, plasma cholesterol and triglycerides in type 2 diabetes mellitus: a systematic review. J Intern Med. 2004; 256(1): 1-14. <![CDATA[Polymorphonuclear neutrophil response to Burkholderia pseudomallei in patients with diabetes mellitus]]> Sraboni Mazumder Lovely Barai Md. Shariful Alam Jilani K.M. Shahidul Islam Jalaluddin Ashraful Haq https://imcjms.com/journal_full_text/311 2019-01-08 11:57:01 Original Article IMC J Med Sci 2019; 13(2): 005 Abstract Background and objectives: Burkholderia pseudomallei is the causative agent of melioidosis, a potentially fatal disease endemic in Bangladesh. Diabetes mellitus (DM) is a risk factor for increased susceptibility to B. pseudomallei infection. A few studies have been conducted to identify the underlying immunological mechanism responsible for increased susceptibility of individuals with diabetes mellitus to B. pseudomallei infection. The present study investigated the polymorphonuclear neutrophil (PMN) response to B. pseudomallei in terms of phagocytosis and early respiratory burst in individuals with diabetes mellitus. Materials and Methods: A total of 5 cases of DM and 5 age and sex matched non-diabetic healthy individuals were enrolled in the study to determine the early respiratory burst and phagocytic ability of PMN to B. pseudomallei. The effect of B. pseudomallei on phagocytic ability and early respiratory burst of PMN was determined by phagocytic assay and nitroblue tetrazolium (NBT) test respectively. The response of PMN treated with B. pseudomallei was compared with that of Escherichia coli. Results: There was no significant (p>0.05) difference in phagocytosis of B. pseudomallei by PMN between diabetic and non-diabetic cases (21.8±4.64 percent vs 29.25±5.5 percent). But in both diabetic and non-diabetic cases, significantly (p˂0.05 and p˂0.01) reduced rate of phagocytosis of B. pseudomallei by PMN was observed compared to E. coli (21.8±4.64 vs 65±5.36; 29.25±5.5 vs 71.25±5.59). Similar results were obtained in terms of phagocytic index. Mean percentage of formazan positive PMN from diabetic cases was not significantly different (p>0.05) from non-diabetic healthy cases when cells were treated with B. pseudomallei or E. coli. In both diabetic and healthy individuals, mean percentage of formazan positive PMN treated by B. pseudomallei was not significantly different from that by E. coli. Conclusion: The observations revealed that B. pseudomallei was equally capable of inhibiting the phagocytic ability of PMN from both diabetic and non-diabetic individuals. This anti-phagocytic property might play an important role in the pathogenesis of melioidosis. IMC J Med Sci 2019; 13(2): 005. EPub date: 01 September 2019. DOI: https://doi.org/10.3329/imcjms.v13i2.45278 Address for Correspondence: Jalaluddin Ashraful Haq, Professor of Microbiology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka 1000, Bangladesh. Email: jahaq54@yahoo.com   Introduction Burkholderia pseudomallei, a motile gram-negative facultative intracellular bacterium, is the causative agent of melioidosis which ranges from asymptomatic infection, to localized or disseminated abscess to fatal septicemia [1]. The global burden of melioidosis is 165,000 human cases per year, of which 89,000 (54%) die. The bacterium is intrinsically resistant to a wide range of antibiotics and more than 70% of cases die due to treatment with ineffective antibiotics [2-3]. Bangladesh is an endemic country for melioidosis [4]. In Bangladesh, so far, 35 culture-confirmed melioidosis cases were identified from 2001 to 2016; however, true extent of the disease is unknown because of unfamiliarity of the organism to physicians and microbiologists of the country [4]. Human gets infection mainly via traumatic inoculation. After entry into the host, the organism enters into macrophage and may cause latent infection in immunocompetent host and reactivate in immunosuppressed condition [3, 5]. Understanding the pathogenesis of B. pseudomallei and the role of host immune response are essential to realize the course of the disease. Diabetes mellitus is the most common risk factor for melioidosis, and is a co-morbid condition in more than 50% of all melioidosis cases [3]. The risk of diabetic people getting melioidosis is exceedingly higher than the rest of the population [6-7]. Diabetic individuals with poor glycemic control have defects in immune responses against infections [8]. However, the effect of DM on immunopathogenesis of B. pseudomallei infection is not clear yet. In BALB/c mice, the virulence of B. pseudomallei isolates from DM patients is significantly lower than that of isolates from patients without any risk factor; suggesting immunopathological changes due to diabetes increases the susceptibility to otherwise innocuous strain of B. pseudomallei [9]. Diabetes mellitus, the primary predisposing condition for melioidosis, is associated with impaired chemotaxis, phagocytosis, oxidative burst, and killing activity of neutrophils [12]. Increased incidence of melioidosis is also noted in neutropenic patients [13], as well as patients with chronic granulomatous disease [14]. Interestingly, treatment of melioidosis with the neutrophil-differentiating cytokine granulocyte colony-stimulating factor (G-CSF) showed mixed results [15].  It has reported to reduce the mortality of melioidosis patients in Australia [15], but is only associated with prolonged survival in Thai patients [16]. Thus, all these in vivo reports suggest the important role of neutrophils in controlling B. psedomallei infection, but how B. pseudomallei affects neutrophil is not clear yet. In this study, we aimed to observe PMN responses to B. pseudomallei in Bangladeshi people with diabetes mellitus. This would help us to understand the role of innate immunity in the pathogenesis of B. pseudomallei.    Materials and methods Study population and sample collection: Cases of diabetes mellitus of different duration and age and sex matched apparently healthy non-diabetic individuals were enrolled in the study. All diabetic cases were on different oral hypoglycemic agents. Cases with chronic disease, known hematological disorders, acute infection, leucocytosis and fever in last one month were excluded. About 2-3 ml of blood was collected from each individual with aseptic precautions in a sterile heparin tube and kept in ice until used. All assays to measure the PMN response to B. pseudomallei and E. coli were done within 2-3 hrs of blood collection. Informed consent was obtained from all study population prior to collection of blood sample. The study was approved by the Ethic Review Board of Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM). Bacterial strains and cell preparation: B. pseudomallei strain (CS6887) isolated from a Bangladeshi melioidosis patient and Escherichia coli ATCC 25922 strain were used to measure the early respiratory burst and phagocytic function of PMN. The response of PMN to B. pseudomallei (CS6887) was compared to that of E. coli. The bacteria were stored in trypticase soya broth (TSB, HiMedia Laboratories Pvt. Ltd., India) with 15% glycerol at -200C until used.  A single colony of B. pseudomallei orE. coli  was suspended separately in 5 ml TSB in two tubes and incubated aerobically overnight at 370C to obtain a cell suspension of 3×108 colony forming units per ml (CFU/ml). Phagocytic assay: Phagocytic assay was performed as previously described [17]. Briefly, 20 µl of growth of either B. pseudomallei or E. coli in TSB (6×106 cells) was added to 500 µl of whole blood sample in two tubes  and mixed thoroughly by gentle shaking. The tubes were incubated aerobically at 370C for 30 minutes.After 30 minutes, the mixture was mixed with gentle shaking. Then, duplicate smears were made on two glass slides from each tube and air dried. Before making smear, the glass slides were soaked in xylene overnight and then washed with absolute ethanol and air dried for minimizing the clumping of neutrophils [18]. One slide was stained with Leishman stain and another one with 0.5% safranin stain. Smears were examined under the oil immersion lens and 200 neutrophils were counted (Figure-1a, 1b). The percentage of PMN with phagocytosed bacteria was calculated by: {(Number of PMN with phagocytosed bacteria ÷ Total PMN counted) x 100}. The phagocytic index per neutrophil was estimated by the formula: {Total number of intracellular bacteria ÷ Total PMN with phagocytosed bacteria counted} [17].   Fig-1. Photomicrographs showing PMN with phagocytosed bacteria (arrow); (a) Leishman stain (b) Safranin stain (× 1000)   Nitro blue tetrazolium (NBT) test: Early respiratory burst of PMN to B. pseudomallei was determined by NBT test as previously described [19-20]. Formation of formazan by reduction of NBT dye following antigenic stimulation of PMN indicates occurrence of early respiratory burst in the cell. Twenty microliter of either live B. pseudomallei or E. coli in TSB (6×106 cells) was added to 500 µl of whole blood sample in two tubes and mixed thoroughly by gentle shaking. E. coli was used to compare the response of PMN to B. pseudomalleiwhileTSB without any bacteria served as a negative control. The tubes were incubated aerobically at 370C for 30 minutes. Then 500 µl of 0.2% NBT solution was added to each of the above mentioned tubes and mixed thoroughly by gentle shaking. Solution of 0.2% NBT was prepared by dissolving 2 mg NBT dye (Abcam, UK) with 40 µl absolute ethanol; the dissolved solution was made up to 1 ml by adding 960 µl phosphate buffered saline (PBS). To dissolve completely, the solution was heated at 600C for 20 minutes. This solution was made freshly for each batch of test. The tubes were again incubated aerobically at 370C for 25 minutes after adding NBT solution. After 25 minutes, the tubes were mixed with gentle shaking. Then, duplicate smears were made on two glass slides from each tube and air dried. The glass slide was prepared as described above. One slide was stained with Leishman stain and another one with 0.5% safranin stain. Smears were examined under oil immersion lens and 200 neutrophils were counted. Neutrophils with a single, large, dense and deep-blue colored cytoplasmic deposit of formazan (reduced NBT, Figure-2a, 2b) were counted as “positive” cells. The PMN stained blue in Leishman stain while it was reddish in colour by safranin stain (Figure-2a, 2b). The formazan containing monocytes were not taken into account.  Safranin stain permitted easier identification of formazan positive PMN due to an excellent contrast between the color of PMN and formazan. The percentage of formazan positive PMN was calculated as: (Number of formazan positive PMN ÷ Total PMN counted) x 100   In oxygen dependent killing mechanism, NADPH-oxidase enzyme complex present in PMN is activated, transfers electron to oxygen molecule and forms superoxide. This superoxide kills bacteria. In this study, NBT dye was used to detect superoxide formation. NBT dye is reduced to insoluble deep-blue or purple colored deposit called formazan by transfer of electron by NADPH-oxidase enzyme complex. Therefore, formazan formation indicates superoxide formation in terms of early respiratory burst within PMN [21]. In the present study, the early respiratory burst in PMN following stimulation with either B. pseudomallei or E. coli was not significantly reduced in diabetic than non-diabetic population. Though there was no significant reduction of early respiratory burst in PMN from both diabetic and non-diabetic cases for B. pseudomallei and E. coli, we did not assess the actual killing of the ingested bacteria. It is important to know the actual killing capability of B. pseudomallei by PMN from both diabetic and non-diabetic cases because B. pseudomallei can quickly escape from the endosome/phagosome of host cells and persists within the cytoplasm of those cells. Therefore, B. pseudomallei can spread from cell to cell avoiding the host extracellular environment [27]. This might play an important role to in the pathogenesis of melioidosis among diabetics as their other immune parameters are compromised [28].  Also, it is needed to see if there is any alteration of oxygen independent killing of B. pseudomallei by PMN of diabetic patients. In the present study, the rate of phagocytosis, phagocytic index and early respiratory burst of PMN for both B. pseudomallei and E. coli were though less in diabetic than that of non-diabetic cases, these were not significant.  This could be due to low number of cases tested or because of short duration (around 5 years) of diabetes in our cases. Therefore, further study with large number of cases is needed to see the response of PMN to B. pseudomallei in diabetics.    References 1.     Chaowagul W, Suputtamongkol Y, Dance DA, Rajchanuvong A, Pattara-Arechachai J, White NJ. Relapse in melioidosis: incidence and risk factors. J Infect Dis. 1993; 168: 1181-1185. 2.     Limmathurotsakul D, Golding N, Dance DA, Messina JP, Pigott DM, Moyes CL, et al. Predicted global distribution of and burden of melioidosis. Nat Microbiol. 2016; 1(1): 15008. 3.     Cheng AC, Currie BJ. Melioidosis: epidemiology, pathophysiology, and management. Clin Microbiol Rev. 2005; 18: 383-416. 4.     Jilani MS, Robayet JA, Mohiuddin M, Hasan MR, Ahsan CR, Haq JA. Burkholderia pseudomallei: Its Detection in soil and seroprevalence in Bangladesh. PLoS Negl Trop Dis. 2016; 10: e0004301. 5.     Currie BJ, Fisher DA, Anstey NM, Jacups SP. Melioidosis: acute and chronic disease, relapse and re-activation. Trans R Soc Trop Med Hyg. 2000; 94: 301-304. 6.     Currie BJ, Jacups SP, Cheng AC, Fisher DA, Anstey NM, Huffam SE, et al. Melioidosis epidemiology and risk factors from a prospective whole population study in northern Australia. Trop Med Int Health. 2004; 9: 1167-1174. 7.     Limmathurotsakul D, Jamsen K, Arayawichanont A, Simpson JA, White LJ, Lee SJ, et al. Defining the true sensitivity of culture for the diagnosis of melioidosis using Bayesian latent class models. PLoS One. 2010; 5(8): e12485. 8.     Jacob A, Steinberg ML, Yang J, Dong W, Ji Y, Wang P. Sepsis-induced inflammation is exacerbated in an animal model of type 2 diabetes. Int J Clin Exp Med. 2008; 1: 22-31. 9.     Ulett GC, Currie BJ, Clair TW, Mayo M, Ketheesan N, Labrooy J, et al. Burkholderia pseudomallei virulence: definition, stability and association with clonality. Microbes Infect. 2001; 3: 621-631. 10.  Easton A, Haque A, Chu K, Lukaszewski R, Bancroft GJ. A critical role for neutrophils in resistance to experimental infection with Burkholderia pseudomallei. J Infect Dis. 2007; 195: 99-107. 11.  Breitbach K, Klocke S, Tschernig T, Van Rooijen N, Baumann U, Steinmetz I. Role of inducible nitric oxide synthase and NADPH oxidase in early control of Burkholderia pseudomallei infection in mice. Infect Immun. 2006; 74: 6300-6309. 12.  Deshazer D, Waag DM, Fritz DL, Woods DE. Identification of a Burkholderia mallei polysaccharide gene cluster by subtractive hybridization and demonstration that the encoded capsule is an essential virulence determinant. Microb Pathog. 2001; 30: 253-269. 13.  Mukhopadhyay C, Chawla K, Vandana KE, Krishna S, Saravu K. Pulmonary melioidosis in febrile neutropenia: the rare and deadly duet. Trop Doct. 2010; 40: 165-166. 14.  Dorman SE, Gill VJ, Gallin JI, Holland SM. Burkholderia pseudomallei infection in a Puerto Rican patient with chronic granulomatous disease: case report and review of occurrences in the Americas. Clin Infect Dis. 1998; 26: 889-894. 15.  Cheng AC, Stephens DP, Anstey NM, Currie BJ. Adjunctive granulocyte colony-stimulating factor for treatment of septic shock due to melioidosis. Clin Infect Dis. 2004; 38: 32-37. 16.  Cheng AC, Limmathurotsakul D, Chierakul W, Getchalarat N, Wuthiekanun V, Stephens DP, et al. A randomized controlled trial of granulocyte colony-stimulating factor for the treatment of severe sepsis due to melioidosis in Thailand. Clin Infect Dis. 2007; 45: 308-314. 17.  Wood SM, White AG. A micro method for the estimation of killing and phagocytosis of Candida albicans by human leucocytes. J Immunol Methods. 1978; 20: 43-52. 18.  Matula G, Paterson PY. Spontaneous in vitro reduction of nitrobluetetrazolium by neutrophils of adult patients with bacterial infection. N Engl J Med. 1971; 285: 311-317. 19.  Freeman R, King B. Technique for the performance of the nitro-blue tetrazolium (NBT) test. J Clin Pathol. 1972; 25: 912-914. 20.  Park BH, Fikrig SM, Smithwick EM. Infection and nitroblue-tetrazolium reduction by neutrophils. A diagnostic acid. Lancet. 1968; 2: 532-534. 21.  Berridge MV, Herst PM, Tan AS. Tetrazolium dyes as tools in cell biology: new insights into their cellular reduction. Biotechnol Annu Rev. 2005; 11: 127-152. 22.  Mulye M, Bechill MP, Grose W, Ferreira VP, Lafontaine ER, Wooten RM. Delineating the importance of serum opsonins and the bacterial capsule in affecting the uptake and killing of Burkholderia pseudomallei by murine neutrophils and macrophages. PLoS Negl Trop Dis. 2014; 8: e2988. 23.  Corbett D, Roberts IS. The role of microbial polysaccharides in host-pathogen interaction. F1000 Biol Rep. 2009; 1: 30. 24.  Taylor CM, Roberts IS. Capsular polysaccharides and their role in virulence. Contrib Microbiol. 2005; 2: 55-66. 25.  Chanchamroen S, Kewcharoenwong C, Susaengrat W, Ato M, Lertmemongkolchai G. Human polymorphonuclear neutrophil responses to Burkholderia pseudomallei in healthy and diabetic subjects. Infect Immun. 2009; 77: 456-463. 26   Lin JC, Siu LK, Fung CP, Tsou HH, Wang JJ, Chen CT, et al. Impaired phagocytosis of capsular serotypes K1 or K2 Klebsiella pneumoniae in type 2 diabetes mellitus patients with poor glycemic control. J Clin Endocrinol Metab. 2006; 91: 3084-3087. 27.  Harley VS, Dance DA, Tovey G, McCrossan MV, Drasar BS. An ultrastructural study of the phagocytosis of Burkholderia pseudomallei. Microbios. 1998; 94: 35-45. 28.  Alba-Loureiro TC, Hirabara SM, Mendonca JR, Curi R, Pithon-Curi TC. Diabetes causes marked changes in function and metabolism of rat neutrophils. J. Endocrinol. 2006; 188: 295-303. <![CDATA[Vitamin D status of healthy coastal fishermen of Bangladesh]]> Wasim Md Mohosin Ul Haque Md. Faruque Pathan MA Sayeed https://imcjms.com/journal_full_text/329 2019-09-20 22:38:52 Original Article IMC J Med Sci 2019; 13(2): 006 Abstract Background and objectives: Vitamin D deficiency is now a global concern. Industrialization, urbanization and the decreasing participation in outdoor activities, with consequent sunlight deprivation, are thought to be the key factors in the increasing prevalence of vitamin D deficiency among general population of many countries. It is presumed that healthy, adequately sun-exposed people should maintain adequate vitamin D levels. However, studies within this population are scarce. Hence, this study was conducted to find out the actual vitamin D status in healthy, adequately sun-exposed population living in coastal district of Bangladesh. Material and Methods: One hundred and forty healthy fishermen living in costal district of Cox’s Bazar (210 25' North, 910 59' East) of Bangladesh were enrolled in this study. Relevant data and blood samples were collected during August 2018, one of the months with lower zenith angle and higher UV index. Chemiluminescent micro-particle immunoassay (CMIA) was used to measure 25-hydroxy vitamin D3. Other relevant biochemical parameters measured were random blood glucose (RBG), serum creatinine, albumin, calcium, phosphate, alkaline phosphatase and intact parathyroid hormone (iPTH). Results: Mean vitamin D level of the study population was 27.04±7.20 ng/ml. Based on the cut off value of Endocrine Society, 70.7% of the study population had low vitamin D levels of which 26 (18.6%) and 73 (52.1%) were in vitamin D deficient (<20ng/ml) and insufficient (20 – 29.99 ng/ml) categories respectively. Vitamin D level was normal in 41 (29.3%) subjects. There was no significant difference in iPTH level between groups with low and normal vitamin D levels (p>.05, 95%CI= -5.68226, 1.21086). Conclusion: The unexpectedly high prevalence of vitamin D deficiency in this healthy and adequately sun-exposed population raises the question regarding the validity of the current cutoff value being used to assess the vitamin D status of Bangladeshi population. Future studies should be carried out to determine nation-specific, local cutoff values for vitamin D sufficiency. IMC J Med Sci 2019; 13(2): 006. EPub date: 21 September 2019. DOI: https://doi.org/10.3329/imcjms.v13i2.45279 Address for Correspondence: Dr. Wasim Md Mohosin Ul Haque, Associate Professor, Department of Nephrology, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka, Bangladesh; Email: wmmhaque@live.com   Introduction Human skin using sunlight produces vitamin D3, the cholecalciferol, which is further converted to 25-hydroxy vitamin D3 in the liver. This 25-hydroxy vitamin D3 is further converted in the kidneys to its active form 1, 25-dihydroxy vitamin D3 which is responsible for most of the biological effects of vitamin D [1]. We measure serum 25-hydroxy vitamin D3 to assess vitamin D status. Vitamin D is not merely a vitamin but also a hormone [2], and participates in a diverse pool of physiological activities. Thus, its deficiency can lead to numerous diseases and disabilities. Significance of sun deprivation and consequent vitamin D deficiency was first recognized in the early 17th century during the industrial revolution and urbanization in Europe. The urbanization created congested cities, air pollution due to coal dust and led to the outbreak of vitamin D deficiency disorders called rickets in children [3]. In modern days, new elements of sun deprivation have been added. Children often prefer to remain indoors rather than going outside and most of the workers work within the building from dawn to dusk. This change in life style with less outdoor activity, less sunlight exposure, and consequently less production of ultraviolet-B (UVB)-induced vitamin D in the skin, ultimately ended with the pandemic of vitamin D deficiency. About 50% of the people worldwide have vitamin D insufficiency, and approximately 1 billion people suffer from vitamin D deficiency [1]. The situation in Bangladesh is much worse. Several recent studies have reported that about 82% to 100% of the studied Bangladeshi population have low (insufficient or deficient) vitamin D levels [4-10]. In a study conducted within the working population, Mahmood et al found that 100% of the garments workers and 97% of agricultural/ construction workers had low vitamin D levels [5]. About 82% of postmenopausal women visiting general physicians had low vitamin D levels [6]. Surprisingly, 95% of the seemingly healthy population and 94.3% of Bangladeshi adult Muslim females had vitamin D levels lower than normal [8,9]. However, in these studies, health and sun exposure were not appropriately addressed. It is presumed that healthy individuals with adequate sun exposure should maintain optimal levels of vitamin D. However, study within this group of the population is scarce. Hence, this study was conducted to find out the actual vitamin D status in healthy, adequately sun-exposed Bangladeshi populations.   Materials and Methods Study population and sample collection: This was a cross-sectional study. A total of 140 healthy fishermen living in coastal district of Cox’s Bazar (21025' North, 91059' East) were enrolled in the study. Cox’s Bazar is a district of Bangladesh located about 306 km east of capital Dhaka city along the coast of Bay of Bengal. Fishermen who had at least 30 minutes of sun exposure between 11 am and 2 pm, three times a week for previous 6 months were enrolled. They were exposed to sunlight for an average of 6 to 8 hours spanning the recommended hours every day. The age range of the participants was between 19 to 65 years. Each participant was interviewed which included socio-demographic information, age, sex, family income, and education, as well as clinical history of present and past illness, medication. Individuals with chronic diseases, taking vitamin D, calcium or anti-epileptic drugs and those who refused to participate in the study were excluded. Anthropometric measures included height and weight and the body mass index (BMI) was calculated (weight in kg / height in meter2). Blood samples were collected aseptically after counseling and thorough clinical evaluation. Informed written consent was obtained from each participant prior to collection of blood sample. Specimens were preserved at -600C until analyzed.   Biochemical tests: Chemiluminescent micro-particle immunoassay (CMIA) was used to estimate 25-hydroxy vitamin D to measure the serum vitamin D level [11]. Vitamin D level was categorized into deficient, insufficient and adequate according to the Endocrine Society guideline [12]. Random blood glucose, serum creatinine, albumin, calcium, phosphate, alkaline phosphatase and iPTH were also estimated. Serum vitamin D level of our study population was compared with the reported vitamin D levels of other studies conducted previously on different Bangladeshi population. IBM SPSS version 25 with python plug-in software was used to analyze the data.   Results Mean age and body mass index (BMI) of the study population were 38.1±11.6 years (CI=35.3, 39.3) and 22.4±3.2kg/m² (CI=22.2, 23.7) respectively. Eight subjects were obese (BMI≥30kg/m²) based on WHO criteria. Table - 1 shows the relevant biochemical parameters of the study population. The parameters were within normal range in all the participants except in 2 participants who had random blood glucose (RBG) more than 11.1 mmol/L and 7 had alkaline phosphatase levels higher than the upper normal limit. Mean serum vitamin D level of the study population was 27.04±7.2 ng/ml (95% CI=25.84, 28.25). Based on Endocrine Society guideline [12], 99 (70.70%) participants had low vitamin D levels (Table-2). Mean vitamin D level of all our participants was significantly higher than the reported levels in other studies conducted previously on Bangladeshi population (Table-3). There was no significant difference in iPTH level, the surrogate marker of vitamin D deficiency, between groups with low and normal vitamin D levels (p>.05, 95%CI=-5.68226, 1.21086; Table-4).   Table-1: Biochemical parameters of the study population     Table-2: Serum vitamin D status of the study population based on Endocrine Society guideline [12]   Table-3: Serum vitamin D levels of Bangladeshi population reported in previous studies compared to current study  Table-4: Relevant serum biochemical markers related to vitamin D deficiency in population with low and normal vitamin D levels       Discussion Higher mean vitamin D level (27.04±7.21 ng/ml) found among the fishermen living in coastal areas compared to levels reported in other categories of people by previous Bangladeshi studies signifies the importance of sun exposure to maintain adequate concentration of serum vitamin D. In a similar study, Lee et al found that healthy fishermen who lived in a coastal city in South Korea had 1.7 times higher mean serum concentration of 25(OH)D compared to the general occupation group (23.74±8.88ng/mL and 13.60 ± 6.43, p<.001) [13]. Despite having an abundant exposure to the sun, 71% of our study population had low vitamin D in terms of levels mentioned in the guideline of Endocrine Society. Similarly, the South Korean study reported low vitamin D levels in 78% of healthy coastal fishermen despite adequate sun exposure [13]. In India, 84.9% of the healthy adult population of the coastal regions of Odisha had low vitamin D levels [14]. However, healthy individuals with reasonable sun exposure residing in an area between 350N and 350S should not have vitamin D deficiency, because this region has enough sun strength to maintain adequate vitamin D levels [15]. All the studies mentioned including the current one were carried out in highly sun exposed zone. It is an established fact that only 5 to 10 minutes of sun exposure can produce 3000 IU of cholecalciferol that is sufficient to satisfy vitamin D requirement [16]. Study in India found that 30 minutes of sun exposure between 11 am and 2 pm, three times a week was enough to maintain adequate serum vitamin D concentration [17]. So, this high prevalence of low serum D in our study population is quite unexpected. Moreover, Vitamin D deficiency is usually associated with a raised iPTH level which is a surrogate marker of vitamin D deficiency. In our study, no significant difference was found between the serum iPTH levels of low and normal vitamin D groups.   Acknowledgement We are thankful to Prof. J. Ashraful Haq, Department of Microbiology, Ibrahim Medical College for his help in editing the manuscript.   Conflict of interest: None   References 1.     Nair R, Maseeh A. Vitamin D: the "sunshine" vitamin. J Pharmacol Pharmacother. 2012; 3(2): 118-126. 2.     Reichrath J, Lehmann B, Carlberg C, Varani J, Zouboulis CJH, Research M. Vitamins as hormones. Horm Metab Res. 2007; 39(02): 71-84. 3.     Wacker M, Holick MF. Sunlight and Vitamin D: a global perspective for health. Dermatoendocrinol. 2013; 5(1): 51-108. 4.     Islam MZ, Shamim AA, Kemi V, Nevanlinna A, Akhtaruzzaman M, Laaksonen M, et al. Vitamin D deficiency and low bone status in adult female garment factory workers in Bangladesh. Br J Nutr. 2008; 99(6): 1322-1329. 5.     Mahmood S, Rahman M, Biswas SK, Saqueeb SN, Zaman S, Manirujjaman M, et al. Vitamin D and parathyroid hormone status in female garment workers: a case-control study in Bangladesh. Biomed Res Int. 2017; 2017: 4105375. 6.     Ahmed AS, Haque WMMU, Uddin KN, Abrar F, Afroz FA, Huque HF, et al. Vitamin D and bone mineral density status among postmenopausal Bangladeshi women. IMC J Med Sci. 2018; 12(2): 44-49. 7.     Hossain HT, Islam QT, Khandaker MAK, Ahasan HAMN. Study of serum vitamin D level in different socio-demographic population-a pilot study. J Medicine. 2018; 19(1): 22-29. 8.     Acherjya GK, Ali M, Tarafder K, Akhter N, Chowdhury MK, Islam DU, et al. Study of vitamin D deficiency among the apparently healthy population in Jashore, Bangladesh. Mymensingh Med J. 2019; 28(1): 214-221. 9.     Shefin SM, Qureshi NK, Nessa A, Latif ZAJBMJ. Vitamin D status among Bangladeshi adult muslim females having diabetes and using hijab. BIRDEM Med J. 2018; 8(3): 203-209. 10.  Khan AU, Hossain MA, Rahman MA, Rahman HW, Reza MA, Khan MK, et al. Estimation of vitamin D levels among physicians working in a tertiary Level hospital of Bangladesh. Mymensingh Med J. 2019; 28(2): 322-327. 11.  Hutchinson K, Healy M, Crowley V, Louw M, Rochev Y. Verification of Abbott 25-OH-vitamin D assay on the Architect system. Pract Lab Med. 2017; 7: 27-35. 12.  Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011; 96(7): 1911-1930. 13.  Lee DH, Park KS, Cho MC. Laboratory confirmation of the effect of occupational sun exposure on serum 25-hydroxyvitamin D concentration. Medicine (Baltimore). 2018; 97(27): e11419. 14.  Rattan R, Sahoo D, Mahapatra S. Prevalence of vitamin D deficiency in adults in the coastal regions of Odisha, India. J Pharm Biol Sci. 2016; 11(6): 49-52. 15.  Holick MF. Vitamin D: importance in the prevention of cancers, type 1 diabetes, heart disease, and osteoporosis. Am J Clin Nutr. 2004; 79(3): 362-371. 16.  Holick MF. Vitamin D deficiency. N Engl J Med. 2007; 357(3): 266-281. 17.  Harinarayan CV, Holick MF, Prasad UV, Vani PS, Himabindu G. Vitamin D status and sun exposure in India. Dermatoendocrinol. 2013; 5(1): 130-141. <![CDATA[Risk factors for peripheral neuropathy in patients with diabetes mellitus]]> Taslima Akter Qazi Shamima Akhter Zinat Ara Polly Smita Debsarma https://imcjms.com/journal_full_text/279 2018-03-29 12:12:14 Original Article IMC J Med Sci 2019; 13(2): 007 Abstract Background and Objectives: Peripheral neuropathy is a complication of diabetes mellitus (DM). Several risk factors may accelerate the development of peripheral neuropathy in DM. The objective of the current study was to determine the risk factors for development of peripheral neuropathy in patients with DM. Methods: The study was conducted from July 2014 to June 2015 in a large hospital of Dhaka city. A total of 150 diabetic patients of both sexes with and without peripheral neuropathy were enrolled. The investigations included interviewing on clinical history, anthropometry (height, weight, waist- and hip-circumference), blood pressure measurement, estimation of HbA1c, fasting blood glucose and lipids. Results: Duration of diabetes for more than 5 years was significantly (χ2=124.39, p <0.001) associated with peripheral neuropathy. Sequential logistic regression analysis revealed high BMI (> 25 Kg/m2; OR=8.8, p <0.001), HbA1c (>6.5%; OR=5.25, p<0.05) and higher total cholesterol level (> 200 mg/dl; OR=4.74, p <0.05) as the significant risk factors for peripheral neuropathy. Conclusion: Obesity, hyperglycemia and high total cholesterol were possible risk factors for development of diabetic peripheral neuropathy. Proper glycemic control and prevention of obesity and dyslipidemia could be helpful to avert progression to peripheral neuropathy in diabetic population. IMC J Med Sci 2019; 13(2): 007. EPub date: 23 November 2019. DOI: https://doi.org/10.3329/imcjms.v13i2.45285 Address for Correspondence: Dr. Taslima Akter, Assistant Professor, Department of Physiology, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka, Bangladesh. Email: taslimaakter783160@gmail.com   Introduction Diabetes mellitus (DM) is a clinical syndrome characterized by hyperglycemia due to relative or absolute deficiency of insulin in the body [1]. World Health Organization (WHO)) has defined the diagnostic criteria of DM as fasting plasma glucose ≥7.0 mmol/L, or ≥11.1mmol/L 2 hours after 75 gram of glucose load or HbA1c ≥6.5% [2]. In Bangladesh the prevalence of DM is about 5.5% [3]. Peripheral neuropathy is one of the most common complications in patients with type 2 diabetes mellitus [4]. In peripheral neuropathy, damage involves motor and sensory nerves in the peripheral nervous system, sparing neurons in the central nervous system [5]. Diabetic peripheral neuropathy has been defined as the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after exclusion of other causes. Diabetic peripheral neuropathy can affects 20%-50% of the population with diabetes [6]. A study has reported that the prevalence of diabetic peripheral neuropathy in Bangladesh is about 19.7% [7]. Several studies have suggested that hyperglycemia is an important risk factor for development of neuropathy and intensified metabolic control can prevent or delay the development of diabetic peripheral neuropathy [8]. Glycosylated hemoglobin act as an index of long term diabetes control and HbA1c ≤ 7.0% is considered as good glycemic control [8]. Several studies have suggested that obesity and hyperlipidemia as potential risk factors for diabetic peripheral neuropathy. Elevated triglyceride and obesity increase the risk for future development of peripheral neuropathy in diabetic patients [9,10]. However, Bansal et al has reported that obesity might not correlate with neuropathy in diabetic patients [11]. The study has found that BMI and waist circumference as same in diabetic patients with and without neuropathy. It has been observed that in Asian population, the co-morbidities of obesity occur at a lower BMI than in other ethnic groups of the world [12]. Also, the severity of diabetic peripheral neuropathy depends on the duration of the diabetes and the degree of glycemic control [13]. Therefore, it appears that uncontrolled glycemia, obesity, hyperlipidemia and longer duration of DM are possible risk factors for development of peripheral neuropathy among diabetic cases. However, limited research work has been conducted to assess the risk factors associated with peripheral neuropathy in Bangladeshi population. The aim of the present study was to find out the risk factors for peripheral neuropathy among Bengali diabetic patients.   Methods Study population and place: This cross sectional study was conducted over a period of one year from July 2014 to June 2015. The study was approved by Ethical review committee of Dhaka Medical College, Dhaka. The nature, purpose and benefits of the study were explained to each participant in details and informed written consent was obtained. Study population were selected from indoor and outpatients of BIRDEM General Hospital in Dhaka city. Study population consisted of 150 cases of DM of both sexes and divided into two groups namely Group A and Group B. Group A consisted of cases who had only DM without peripheral neuropathy and Group B had age-matched DM cases with peripheral neuropathy. Age, sex, duration of diabetes, history of hypertension and other co-morbidities were recorded. Diagnosis of DM was based on fasting plasma glucose ≥7.0 mmol /L or HbA1c ≥6.5% [2]. Peripheral neuropathy was diagnosed by clinical features ((numbness, burning and tingling sensation, fatigue and cramping pain) and by nerve conduction velocity test [7,9]. Anthropometry: Anthropometric measurements namely height, weight, waist and hip circumference were taken to assess the general and central obesity status. The waist circumference was measured in a standing position between the lower border of the 12th rib and the highest point of the iliac crest on mid-axillary line at the end of normal expiration. Body mass index (BMI) was calculated using weight in kilogram divided by height in meter and expressed as kg/m2. Waist-to-hip ratio (WHR) was calculated as waist measurement divided by hip circumference. BMI was used for determining the general obesity while the WHR indicated central obesity. Blood pressure of each participant was measured after ensuring at least ten minutes of rest. All the information was recorded systematically in a predesigned data sheet. Collection of blood and biochemical tests: With aseptic precaution, 5 ml of venous blood was collected from antecubital vein by a disposable plastic syringe from each participant for estimation of fasting blood glucose (FBS), HbA1c, triglyceride (TG) and total cholesterol (TC). Statistical analyses: All the parameters were expressed as mean ± SD. Chi square was done to find out association between variables and unpaired Student’s ‘t’ test was performed to compare means between the two groups. Sequential logistic regression analysis was carried out to determine risk factors for developing neuropathy; p value ˂0.05 was considered as level of significance. Estimates were reported as odds ratios (OR) with 95% confidence interval (CI). Statistical analysis were performed by using a computer based statistical program SPSS (version 23).   Results A total of 150 DM cases were enrolled of which Group-A had 75 DM cases without peripheral neuropathy and Group-B had 75 age matched DM cases with peripheral neuropathy. Age, blood pressure, anthropometric and biochemical parameters of Group-A population were significantly (p<0.05 or 0.001) less than that of Group-B (Table-1). Table-2 shows that there was no significant association of specific sex with the occurrence of peripheral neuropathy. But peripheral neuropathy was significantly (χ2= 124.39, p<0.001) higher in cases having diabetes for more than 5 years of duration than those who had diabetes for 1-5 years. Sequential logistic regression revealed that higher BMI (≥25.0 kg/m2), HbA1c (≥6.5%) and increased total cholesterol (> 200 mg/dl) were associated significantly with the occurrence of diabetic peripheral neuropathy. Diabetic cases with high BMI (≥25 kg/m2), HbA1c (≥6.5%) and higher total cholesterol (≥200 mg/dl) had almost 9 (OR - 8.8; CI-3.0,25.9; p<0.001), 5 (OR-5.25; CI- 1.75,15.78; p<0.05) and 5 (OR-4.74; CI- 1.81,12.4 ;p<0.05) times higher risk of developing diabetic peripheral neuropathy respectively (Table-3). Waist circumference and triglycerides were not found as risk factors for peripheral neuropathy.   Table-1: Comparative profiles of Group-A and Group-B study population     Table-2: Association of peripheral neuropathy with gender and duration of diabetes     Table-3: Association of risk factors with diabetic peripheral neuropathy     Discussion The present study investigated the possible anthropometric and biochemical risk factors related to development of peripheral neuropathy in ethnic Bengali diabetic patients. Gender was not found to be associated with development of peripheral neuropathy while we found its significant association with longer duration of diabetes (> 5 years) in our cases. Similar observation was reported with South Indian diabetic cases [14]. Sequential logistic regression analysis revealed that higher HbA1c was a significant (OR – 5.25, p<0.05) risk factor for developing peripheral neuropathy in our study population. Similar findings were reported earlier in studies conducted in Bangladeshi diabetic population [7]. The current study found that higher BMI in DM cases as a significant risk factor for peripheral neuropathy. Significant association of peripheral neuropathy with obesity has been reported by others [10,15,16]. We also observed higher level of total cholesterol as a significant risk factor for peripheral neuropathy as reported in other studies [9,10,17,18]. Reactive oxygen species induced by obesity and dyslipidemiamight be responsible for development of peripheral neuropathy [19,20]. This study concluded that higher BMI and elevated level of HbA1c and cholesterol can be the risk factors for the development of peripheral neuropathy in diabetes mellitus. Therefore, obesity management and maintaining normal glycemic status and cholesterol level can prevent or delay the development of peripheral neuropathy in diabetics.   References 1.     Frier BM, Fisher M. Diabetes mellitus. In: Nicki R, Brian R, Stuart H, editors. Davidson's Principle and Practice of Medicine. 21st ed. New Delhi. Elsevier; 2010. 735-833. 2.     Seino Y, Nanjo K, Tajima N, Kodawaki T, Kasiwagi A, Araki E. Report of the committee on the classification and diagnostic criteria of diabetes mellitus. J Diabetes Invest. 2010; 1(5): 212-28. 3.     IDF Diabetes Atlas. 6th ed. Brussels, Belgium: International Diabetic Federation; 2013. 4.     Kakrani AL, Gokhale VS, Vohra KV, Vohra KV, Chaudhary N. Clinical and nerve conduction study correlation in patients of diabetic neuropathy. J Assoc Physician India. 2014; 62: 24-27. 5.     Chaudhry V. Peripheral neuropathy. In Hauser SL, editor. Harrison’s Neurology in Clinical Medicine. 2nd ed. New Delhi: The McGraw-Hill 2010: 525-49. 6.     Boulton A. The diabetic foot: Epidemiology, risk factors and the status of care. Diabetes Voice. 2005; 50(Special Issue): 5-7. 7.     Morkrid K, Ali L, Hussain A. Risk factors and prevalence of diabetic peripheral neuropathy: A study of type 2 diabetic outpatients in Bangladesh. Int J Diabetic Dev. 2010; 30(1):  11-17. 8.     Booya F, Bandarian F, Larijani B, Pajouhi M, Nooraei M, Lotfi J. Potential risk factors for diabetic neuropathy: A case control study. BMC Neurol. 2005; 24(5): 2371-75. 9.     Wiggin TD, Sullivan KA, Pop-Busui R, Amato A, Sima AA, Feldman EL. Elevated triglycerides correlate with progression of diabetic neuropathy. Diabetes. 2009; 58: 1634-1640. 10.  Smith AG, Singleton JR. Obesity and hyperlipidaemia are risk factors for early diabetic neuropathy. J Diabetes Complication. 2013; 27(5): 436-442. 11.  Bansal D, Gudala K, Muthyala H, Esam HP, Nayakallu R, Bansali A. Prevalence and risk factors of development of peripheral diabetic neuropathy in type 2 diabetes mellitus in a tertiary care setting. J Diabetes Investig. 2014; 5(6): 714-21. 12.  Misra A, Khurana L. Obesity-related non-communicable diseases: South Asians vs White Caucasians. Intern J Obes. 2011; 35: 167-87. 13.  Salem K, Ammari F, Khader Y, et al. Elevated glycosylated hemoglobin is associated with subclinical neuropathy in neurologically asymptomatic diabetic patients: a prospective study. J Clin Neurophysiol. 2009; 26: 50-53. 14.  Ashok S, Ramu M, Deepa R, Mohan V. Prevalence of neuropathy in type 2 diabetic patients attending a diabetes centre in South India. J Assoc Physicians India. 2002; 50: 546-550. 15.  Ziegler D, Rathmann W, Dickhaus T, Meisinger C, Mielch A. Prevalence of polyneuropathy in pre-diabetes and diabetes is associated with abdominal obesity and macroangiopathy. Diabetes Care. 2008; 31: 464-69. 16.  Li L, Chen J, Wang J, et al. Prevalence and risk factors of diabetic peripheral neuropathy in type 2 diabetes mellitus patients with overweight/ obese in Guangdong province, China. Primary Care Diabetes. 2015; 9(3): 191-195. 17.  Pawde PP, Thampi RR, Renish RK, Resmi RU, Vivek RU. Prevalence and risk factors of diabetic peripheral neuropathy among type 2 diabetic patients presenting to SMIMS hospital, Tamil Nadu. Int J Med Sci Public Health. 2013; 2(1): 73-76. 18.  Al-Ani, Marwan S, Al-Nimer, et al. Dyslipidemia as a contributory factor in etiopathogenesis of diabetic neuropathy. Indian J Endocrinol Metab. 2011; 15(2): 110-14. 19.  Vincent, Taylor. Biomarkers and potential mechanisms of obesity-induced oxidant stress in humans. Int J Obes. 2006; 30: 400-18. 20.  Farmer KL, Li C, Dobrowsky RT. Diabetic peripheral neuropathy: should a chaperone accompany our therapeutic approach. Pharmacol Rev. 2012; 64(4): 880-900. <![CDATA[Levocarnitine in the management of fatigue in levothyroxine treated hypothyroid patients]]> Farjana Akhter Zesmin Fauzia Dewan M A Hasnat Selina Akhter https://imcjms.com/journal_full_text/332 2020-01-14 02:21:07 Original Article IMC J Med Sci 2019; 13(2): 008 Abstract Background and objectives: Hypothyroid patients often complain of fatigue even after effective treatment. Thyroid hormone plays an important role in carnitine-dependent long chain fatty acid transport for oxidation and ultimate formation of ATP. Deficiency of L-carnitine has been presumed to disrupt ATP formation leading to fatigue. Present study was designed to assess the role of L-carnitine as a supplement to manage the fatigue state of hypothyroid patients. Methods: Hypothyroid patients receiving levothyroxine (L-T4) and suffering from fatigue symptoms were enrolled. Patients were randomly divided into Group A (Control group, n=35) and Group B (Experimental group, n=36). Patients of Group A were treated with L-T4 only and Group B patients received L-carnitine 2 g/day in addition to L-T4 therapy for 8 weeks. Fatigue was assessed by fatigue severity scale (FSS), physical fatigue (PF) and mental fatigue (MF) scores. Data regarding fatigue status, serum thyroid stimulating hormone (TSH) and free thyroxine (FT4) were collected at the beginning and after 8 weeks of intervention. Result: The mean age of Group A and Group B patients was 33.5±8.1 and 35.4±7.5 years respectively (p>0.05); and the mean body weight was 61.5±9.6 kg and 62.5±8.2 kg respectively (p>0.05). The mean baseline values of different fatigue scores and the serum TSH and FT4 levels of patients of two groups were identical and not significantly different (p>0.05). In Group-A patients, the mean MF score improved significantly (5.2±1.5 vs 4.6±1.4; p=0.01) from baseline score after 8 weeks while the FSS and PF scores did not improve significantly (p>0.05). In Group-B patients, the mean FSS, PF and MF scores improved significantly (p<0.01) from baseline score after 8 weeks of treatment with L-carnitine along with L-LT4 treatment. FSS, PF and MF scores of Group-B patients reduced significantly (p<0.01) compared to Group-A patients after 8 weeks of treatment. FSS, PF and MF scores improved in 88.9%, 77.8% and 47.2% cases respectively in Group-B compared to 20%, 14.3% and 5.7% cases in Group-A. L-carnitine was well tolerated and no severe adverse event was recorded. Conclusion: The results suggest that, administration of L-carnitine along with L-T4 in hypothyroid patients significantly reduced physical and mental fatigue. IMC J Med Sci 2019; 13(2): 008. EPub date: 15 January 2020. DOI: https://doi.org/10.3329/imcjms.v13i2.45286 Address for Correspondence: Dr. Farjana Akhter, Assistant Professor, Department of Pharmacology, Green Life Medical College, 31 & 31/1 Bir Uttam K.M. Shafiullah Sarak (Green Road), Dhaka, Bangladesh. Email: polynoble@gmail.com   Introduction Hypothyroidism is one of the common endocrine abnormalities in Bangladesh and all over the world. Thyroid dysfunction, especially hypothyroidism affects a significant number of people in Bangladesh [1-3]. Diffuse goiter has the highest incidence of 7.35%, followed by subclinical (6.59% to 15%) and clinical hypothyroidism (4.97%) [4,5]. A recent study from Bangladesh has reported the prevalence of hypothyroidism as 7% in different occupational groups [6] and its rate is 48% among the entire thyroid disorders [7]. Therefore, a significant number of the population is suffering from hypothyroidism that requires thyroid hormone replacement therapy. However, many patients experience persistent fatigue and fatigue-related symptoms even after hormone replacement [8,9]. Fatigue causes reduced ability to conduct daily activities, feeling of tiredness due to physical and/or mental exhaustion which in severe cases may lead to chronic fatigue syndrome (CFS) and is not improved in spite of rest [10]. CFS affected people is unable to lead a healthy personal, familial and social life which ultimately leads to psychological stress [11]. It is said that significantly decreased biosynthesis of carnitine occurs due to deficiency of thyroid hormone in hypothyroidism contributes in fatigue [12-14]. L-carnitine synthesized in the human body from lysine and methionine appears to be an essential carrier for fatty acids to enter the cell [15-18]. L-carnitine transports long chain fatty acids into the mitochondria where ATP is synthesized. Thyroid hormone is involved in fatty acid oxidation and transfer of free fatty acids into the mitochondria [19,20]. Free fatty acids are converted into acyl-coA derivatives inside cells and needed to be transported into the inner mitochondrial membrane for the oxidation process. So, carriers are needed for this transport through the impermeable outer mitochondrial membrane. Lack of L-carnitine interrupts transport of long chain fatty acids into the mitochondria and less formation of ATP leads to deprivation of energy resulting in fatigue. This condition may be alleviated by exogenous administration of L-carnitine. Reports suggest that 53% of patients with chronic illness such as hypothyroidism, diabetes mellitus or malignancy suffer from L-carnitine deficiency which might predispose to chronic fatigue state [21,22]. It is apparent that fatigue related symptoms in hypothyroid patients are related to L-carnitine deficiency. When hypothyroid patient is treated with L-T4, it promotes carnitine synthesis and also accelerates mitochondrial fatty acid oxidation by utilizing carnitine. This may lead to relative carnitine deficiency which may be responsible for development of fatigue. L-carnitine administration has been found to produce potentially favorable effects on fatigue related symptoms in hypothyroid patients receiving thyroid hormone replacement [23]. The present study has therefore been designed to investigate the effect of L-carnitine supplementation on fatigue related symptoms in hypothyroid patients.   Materials and methods This randomized controlled trial was carried out in the Department of Pharmacology and Department of Endocrinology of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, from September 2016 to February, 2018. The study was approved by the Institutional Review Board (IRB). This study was also registered in ClinicalTrials.gov and the ID number was (NCT03372772). Written informed consent was obtained from all participants prior to enrollment in the study.   Study population: Participants were enrolled by following specific inclusion criteria: clinically diagnosed as primary hypothyroid patients having symptoms of fatigue with fatigue severity scale score ≥ 30, age 20-50 years of both sexes, receiving levothyroxine for last 6 months, and serum FT4 and TSH levels within normal reference range (FT4: l0.8-1.8 ng/dl and TSH: 0.35-5.5 µIU/mL). Patients with acute or chronic liver diseases, anaemia, diabetes mellitus, cardiovascular disease (such as heart failure, arrhythmia and uncontrolled hypertension), psychological disorders (such as depression, anxiety disorder, schizophrenia, alcoholism), fatigue disorder due to other systemic diseases, serious infections or terminal illness (such as tuberculosis, HIV or malignant tumor), autoimmune diseases (such as rheumatoid arthritis, SLE or multiple sclerosis), impaired renal function were excluded from the study. Pregnant women, nursing mothers and patients taking drugs such as corticosteroid, iron, calcium, amantadine, lithium, carbamazepine, phenobarbital, beta-blockers were also excluded. After enrollment, baseline information regarding age, sex, body weight, blood pressure and pulse rate were obtained and recorded in a data sheet. Blood collection and estimation of TSH and free T4 (FT4): About 6ml of blood was collected aseptically from each patient following overnight fasting for the measurement of serum TSH and FT4 at the initiation of study and again after 8 weeks of intervention. Serum TSH and FT4 levels were estimated by automated analyzer (Unicel DXI-600) in Department of Microbiology and Immunology of BSMMU.   Measurement of fatigue: Fatigue of clinical importance was measured by the following fatigue scale: Fatigue severity scale: The fatigue severity scale (FSS) is a 9-item self-report questionnaire scale developed in 1989 [24]. The FSS is a valid instrument and a specific questionnaire to assess and quantify fatigue for clinical and research purpose [25,26]. FSS score range is from 9 to 63. A lowered total score indicates less fatigue in everyday life. Wessely-Powell fatigue score: Wessely and Powell fatigue scale consists of two scales measuring physical fatigue (PF) and mental fatigue (MF). PF has eight items each having a score from 0 (no fatigue) to 2 (highest possible fatigue) with total score of 0 to 16 and MF has five item each having a score from 0 (no fatigue) to 2 (highest possible fatigue) with total score of 0-10 [27]. Modified Bengali version of FSS and Wessly-Powell fatigue score: For linguistic, cultural variation and easy understanding, ‘Fatigue severity scale’ and ‘Wessly-Powell fatigue score’ questionnaires were translated into Bengali.   Piloting of questionnaire: A pilot study was conducted in ten hypothyroid patients at the outpatient department of Endocrinology, BSMMU to identify problem with the wording, answering the questions or any difficulties in filling the form. They were asked to comment on any difficulties to understand the question. Only minor changes in questionnaire were done and no major modification was required.   Treatment schedule: All enrolled patients were randomized into Control group (Group- A) and Experimental group (Group-B). Group-A participants were allowed to continue with once daily appropriate oral dose of L-T4 for 8 weeks. Group-B participants were treated with 2 gm oral solution of L-carnitine daily in two divided doses in addition to L-T4 therapy for 8 weeks. Patients were advised to take L-T4 in the morning before meal and L-carnitine in the morning and at night after meal. Compliance sheets were provided to each patient. Consumption of medicine was ensured by either telephone call, return of empty vials or from the patient’s compliance sheet. After 8 weeks, fatigue level was estimated again and blood was collected from both groups to measure the same parameters measured at baseline. Patients were asked to report adverse effects (if observed) of the medication given in the study. The procedure of the study is summarized in Figure-1. <![CDATA[Postnatal care services and factors affecting its utilization in slum areas of Dhaka city]]> Nilufar Yeasmin Nili https://imcjms.com/journal_full_text/330 2019-11-02 07:55:12 Original Article IMC J Med Sci 2019; 13(2): 009 Abstract Background and objectives: Maternal as well as infant mortality is high in Bangladesh. Utilization of post natal care (PNC) services is important to reduce maternal and infant mortality. Considering this matter, this study attempted to find out the level of PNC utilization by women living in slum areas of Dhaka city as well as to identify the factors associated with the utilization of PNC services. Methods: This study was conducted in Khilgaon and Rampura slums of Dhaka city. In each slum, women aged between 15-49 years who had given birth to at least one child were enrolled in the study by random sampling technique. Participants were interviewed with a semi-structured questionnaire which included information on socio-economic, demographic, cultural status as well as information on PNC service utilization. Results: Out of total 360 enrolled women in both slums, 58.6% utilized PNC services. The rate of utilization of PNC services was 55% and 62.2% in Khilgaon and Rampura slum respectively. Compared to 40-49 years age group, significantly (p<0.01) higher percentage of women aged <20, 20-29 and 30-39 years utilized PNC services (69.6%, 67.0% and 56.4% respectively). The significant associates of receiver of PNC were respondent’s education, number of antenatal care (ANC) received, level of tetanus vaccination, place of delivery, distance between home and clinic, mass media exposure, male participation and autonomy. Conclusion: Local socioeconomic and cultural aspects should be considered while planning intervention program to improve the utilization of PNC service. IMC J Med Sci 2019; 13(2): 009. EPub date: 18 January 2020. DOI: https://doi.org/10.3329/imcjms.v13i2.45287 Address for Correspondence: Dr. Nilufar Yeasmin Nili, Medical Officer, Department of General Surgery, Mugda Medical College & Hospital, Mugda, Dhaka, Bangladesh. Email: nilidr@gmail.com   Introduction Bangladesh is one of the developingcountries of the world, with a maternal mortality rate of 320/100,000 live births [1] while the estimated lifetime risk of dying from pregnancy and childbirth related causes is 1 in 21, compared to 1 in over 4,000 in 6 industrialized countries. Moreover, of the total maternal deaths, 69% are due to direct obstetric causes, 14% are due to injury and violence, leaving 17% due to indirect causes [2]. High rates of child mortality continue to be an important challenge for Bangladesh health systems as three million mothers become pregnant each year in Bangladesh where 600,000 are expected to develop complications. It has been also reported that about nine million women suffer from lasting complications such as fistulae, prolapsed uterus, urinary incontinence, or painful intercourse [3]. Postnatal checkups provide an opportunity to assess and treat delivery complications and to counsel mothers on how to care for themselves and their children. However, despite the necessity of post natal care (PNC) uptake in order to reduce the mortality and morbidity of both mother and children, the proportion of mothers seeking PNC from professionally trained personnel is very low, both in rural and urban areas of Bangladesh [4]. Most recent data has revealed that only 21.3% mothers receive PNC. More specifically, 19.5%, 0.6% and 1.2% of mothers receive PNC within 2 days, 3-6 days and 1-6 weeks after child birth respectively [5]. However, such utilization might be lower in areas with low socio-economic condition. Therefore, an attempt has been made in this study to find out the extent of PNC utilization and identify the factors associated with its utilization among the slum population of Dhaka city.   Materials and Methods Study place and population: This study was a primary data based cross sectional survey. Two slum areas of Dhaka city namely Khilgaon and Rampura were selected. The study participants were women of reproductive age (15-49 years) living in two slums, had given birth to at least one child before March, 2008 and either received or not received PNC checkup within the 42 days of the last delivery. Simple random sampling technique was employed to enroll the women in the study. Prior to enrollment, informed consent was obtained from all study participants after fully explaining the purpose and nature of the study. Interview: Eligible women were successfully interviewed with a semi-structured questionnaire which included socio-economic, demographic and cultural information as well as information on PNC service utilization and maternal health care services. Respondent’s knowledge on maternal health care services, male participation, women’s autonomy and attitude towards maternal health care services were measured respectively by asking yes/no type of questions. Mass media exposure was measured by frequency of listening to radio, watching television and reading newspaper per month. Some variables were measured as composite indices. All the score of the indicators of specific composite index was later converted into scale score by arithmetic transformation. Analysis: Chi-square test was applied in order to find the association between dependent and specific independent variable while cross tabulation was applied in order to provide the detail picture of association.   Results Total 180 eligible women from each slum were enrolled in the study. Therefore, out of total 360 enrolled women in both slums, 58.6% utilized PNC services. Age specific utilization of PNC services is shown in Table-1. The rate of utilization of PNC services among the women aged 15-49 years was 55% and 62.2% in Khilgaon and Rampura slum respectively (Table-1). Compared to 40-49 years age group, significantly (p<0.01) higher percentage of women aged<20 (69.6%), 20-29 (67.0%) and 30-39 (56.4%) yearsutilized PNC services.   Table-1: Age specific distribution of women who received PNC services in Khilgaon and Rampura slums     Table-2: Correlates of receiver of PNC in Khilgaon and Rampura slums Women who had higher number of antenatal care (ANC) visits, received tetanus vaccination during pregnancy and were delivered by health professional were significantly more likely to receive PNC in both areas except health professional assisted delivery in Rampura slum (Table-2). Among women who did not receive any ANC, only 7.2% of them reported to receive PNC service while it was more than 80% among women who received 1-2 and >3 ANC visits during their last pregnancy in Khilgaon slum (p<0.001). Almost similar result was observed in Rampura slum. Thus, it indicates that women receiving ANC services are more likely to receive PNC services. In both areas, women who did not receive tetanus vaccination during their last pregnancy received less PNC service (9.7% in Khilgaon and 26.2% in Rampura slum) compared to those who received vaccination (64.4% in Khilgaon and 73.2% in Rampura; p<0.001). Similarly in both slums, significantly higher number of women (p<0.001) utilized PNC services who delivered at institutions compared to those who had their delivery at home (94.1% vs 5.9% in Khilgaon, 90.3% vs 9.7% in Rampura). In both areas, significantly higher number of women utilized PNC service when theirdelivery was conducted by qualified health professionals than by traditional birth attendants (69.6% vs. 50% in Khilgoan; 70.4% vs. 56.9% in Rampura). The rate of utilization of PNC service was 59.8% and 26.7% in Khilgoan and 65% and 29% in Rampura when the distance of clinic from home was within 1 km and more than 2 Km respectively. The uptake of PNC was 100% in Rampura slum when knowledge regarding maternal health care services (MCHS) was high compared to 58.3% among women in Khilgaon slum. Among cultural characteristics, male participation, respondent’s autonomy and attitude towards maternal health care services were considered in this study. Women with no/low male participation received less PNC services compared to women with medium and high level male participation. Among women with high level of male participation, 62.6% and 80% women received PNC in Khilgaon and Rampura slum respectively while the rates were 12.5% and 43.2%when male participation was low. Almost similar observation was found with regard to woman’s autonomy. Among women with autonomy, 65.4% and 77.8% received PNC in Khilgaon and Rampura slum respectively while the rates were 46.5% and 46.7% among women with no autonomy. Among women with positive attitude towards MCHS, 64.7% and 68.1% reported to receive PNC in Khilgaon and Rampura slum respectively;   Discussion In this study, an attempt has been made to find out the rate as well as the associated factors regarding the use of PNC services among the women living in two slum areas of Dhaka city. In general, majority of women in study areas used PNC services. The proportion of women receiving of PNC in both study areas was higher compared to that of national statistics. In our study, more than 50%of women were found to receive PNC services in both slums. On the contrary, nationally, only 21% of women reported to uptake PNC service [5]. This may be due to availability and easy accessibility to service centers in urban areas and awareness among the women about the necessity of such services. We found that, greater number of younger women in both areas utilized PNC services. We found that women who had frequent ANC visits during their last pregnancy, received tetanus vaccination and delivered at institute were more likely to uptake PNC service compared to those who did not. It was assumed that women who received such care became aware of their rights and health need during and after the pregnancy. Exposure to mass media was also found to be associated with utilization of PNC in both the slum areas. This is because mass media are effective in information dissemination, which in turn increases awareness about social rights, knowledge about availability of health facilities and enhances behavioral changes for the adoption of new/different ideas [10]. Generally, women whose households are at more distance are less likely to receive health care services compared to women with household near to the clinic or hospitals. In consistent with this general argument, in both the slum areas we found lower rate of utilization of PNC services by women who lived at a greater distance from the clinic/hospital. The study revealed that further intervention program is necessary to improve the utilization of PNC services among the women living in poor and difficult socioeconomic conditions. Women’s social condition namely family environment, education, economic empowerment and accessibility to health care facilities should be considered during the planning of an intervention program to improve the utilization of PNC services in any area. <![CDATA[Radiographic evaluation of the quality of root canal treatment in a Bangladeshi population]]> Rafia Nazneen Rajesh Karmaker Gulnar Begum Nurul Amin https://imcjms.com/journal_full_text/333 2020-01-18 03:21:34 Original Article IMC J Med Sci 2019; 13(2): 009 Abstract Background and objective: Root canal treatment (RCT) has a high rate of success, when performed by properly trained dental surgeons. However, the failure rate is inappreciably high when the same procedure is done by less experienced dental graduates having no specialization on endodontics. This study was conducted to evaluate the technical quality of RCT performed by practicing dental graduates on Bangladeshi patient. Methods: This cross-sectional study was conducted in the Department of Dentistry of BIRDEM General Hospital Dhaka over a period of 6 months from January to June 2019. Radiographs of patients who had undergone RCT in last 6 months were included in the study. Parameters used to evaluate the obturation of the root canal were presence of root-filled, posts and voids. The RCT was assessed for filling at the end of the root with radiographic apex, the density of the filling material and taper from the orifice to apex. The quality of RCT was evaluated as totally unacceptable (score: 0-2), poorly acceptable (score: 3-4), acceptable (score: 5) and perfect (score: 6) based on the treatment score.Post-treatment complications were determined by furcation and cavity wall perforation, transportation, root perforation, instrument breakage, ledge formation, voids and missed canal. Result: A total of 180 postoperative readable radiographs with post root-canal treatment were evaluated. Evaluation of the technical quality of RCT revealed that 56% of the RCTs were of standard quality (41.7% were of perfect quality and 14.4% were of acceptable quality). The rest 23.3% were poorly acceptable and 20.6% were totally unacceptable. Majority (92.8%) of the obturation of the root canal revealed that roots were filled with sealing materials; however, 8.9% exhibited posts and 36.7% demonstrated voids. A sizable portion of the root canal obturation was unacceptable in terms of its length (12.2%), density (20%) and tapering (16.7%). Total 132 (73.3%) teeth developed at least one complication. Under filling and voids were predominant complications (42.8% and 41.1% respectively) followed by root perforation (12.2%), transportation (11.7%), ledge formation (5%), instrument breakage (2.8%) and missed canal (3.3%). Conclusion: The study concluded that over forty percent of the RCTs performed by dental graduates having no specialization on endodontics are of substandard quality and hence not acceptable. IMC J Med Sci 2019; 13(2): 010. EPub date: 18 January 2020. DOI: https://doi.org/10.3329/imcjms.v13i2.45288 Address for Correspondence: Dr. Rafia Nazneen, Assistant Professor, Department of Conservative Dentistry & Endodontics, Ibrahim Medical College and BIRDEM Genertal Hospital, 122 Kazi Nazrul Islam Avenue, Dhaka-1000, Bangladesh. Email: dr.rafianazneen@gmail.com   Introduction Retention of a high number of original teeth is becoming more popular in contemporary society [1]. Hence, endodontic therapy is becoming an increasingly routine part of general dental practice [2]. The primary goal of endodontic treatment is to eliminate or reduce the microbes from root canal space by chemo mechanical preparation in order to prevent re-infection and promote periapical healing by hermetically sealing the root canal space [3]. This treatment has a high rate of success (90 – 95%), when highest standards are followed during the procedure [4,5]. Root canal treatment involves the removal of the pulp (pulpectomy) and the preparation and obturation of the root canal system. Preparation of the canal involves the processes of cleaning and shaping; cleaning involves the removal of pulp tissue remnants and microorganisms, whilst shaping of the root canal involves its enlargement and the creation of a shape or form that will enhance irrigation and facilitate filling. According to European Association of Endodontists, a satisfactory root canal treatment shows a tapered canal from crown to apex and completely filled with sealing materials with no space between canal filling and canal wall. In addition, it should be 0–2 mm short of the radiographic apex to prevent post treatment failure [6]. However, there is substantial evidence that the technical quality of root canal treatment has a significant impact on the outcome of the procedure and the long-term retention of teeth. Chemo mechanical preparation and obturation confined to root canal space that is 0–2 mm from the radiographic apex is associated with less complication compared to obturation beyond the apex 7-11]. Also obturation is considered adequate when there are no voids within and between the root canal fillings and root canal walls. Post treatment disease is also caused by extrusion of necrotic debris into the periapex [12]. Research has confirmed that endodontic root canal fillings more than 2 mm from the radiographic apex, extruded beyond the apex and non-homogenous with voids between the fillings increase the risk of endodontic treatment failure [13]. Indeed, low quality root fillings assessed radiographically were found to be associated with post-treatment disease and reduced treatment outcomes [14,15]. Extensive investigations regarding the quality of root canal treatment performed by general dental practitioners in different populations demonstrated a high percentage of inadequate root canal treatment [16-18]. The reasons for this are complex and may be related to the endodontic teaching that was undertaken at the dental schools [19], which in turn, may be due to limitation of time allocated to endodontics, poor staff to student ratio and reluctance of the teachers to teach their students [20]. Technical difficulties in preparing the canal, quality of the sealing materials and poor coronal restoration may also be responsible. Data pertaining to radiographic problems and failures in endodontically treated teeth as well as frequency of procedural errors in cases treated by general dental practitioners are scarce in Bangladesh. In view of the above, the present study was conducted to evaluate the technical quality of root-canal treatment performed by practicing dental graduates on Bangladeshi patients by examining the radiographs of treated teeth. .   Methodology This cross-sectional study was conducted in the Department of Dentistry of BIRDEM General Hospital, Dhaka over a period 6 months from January 2019 to June 2019. Patients reporting to the Endodontic department who had RCT in the last 6 months were selected for the study. For evaluation, radiographs showing pre-operative condition, records of working length/master cone, diagnostic length, try-in point of affected teeth were collected. Information regarding affected tooth (incisor/canine/ premolar/ molar), total number of canals in the affected tooth, total number of affected teeth, type of canals (straight or curved), degree of curvature that have endodontic treatment failures were recorded. Two periapical radiographs were taken for each patient - one with straight angle and the other with mesial shift with long cone parallel technique. All the post root-canal treatment radiographs done in the last 6 months were provisionally included in the study. Radiographs in which root apex was not seen or too much elongated or shortened and of bad quality were excluded from the study. After screening, the eligible radiographs were kept for final analysis. The radiographs were independently evaluated by two endodontists. In case of disagreement a third, highly experienced endodontist was assigned to give final comment. All radiographs were viewed under even illumination using a magnifier (×2) with all extraneous light excluded. Issues considered while examining the radiographs were number of visible roots and canals, degree of curvature of the canal(s) which was categorized as 0–100 curvature, 110 or over, or not assessable. Parameters used to evaluate the obturation of the root canal were presence of root-filled, posts and voids. The RCT was assessed for filling up to the end of the root with radiographic apex, the density of the filling material, and taper from the orifice to apex. Detail of parameters used to evaluate the root canal obturation is shown in Table-1.   Table-1: Parameters used to evaluate the root canal obturation   The quality of RCT was categorized as totally unacceptable (score: 0-2), poorly acceptable (score: 3-4), acceptable (score: 5) and perfect (score: 6) based on the treatment score.Post-treatment complications were determined by furcation and cavity wall perforation, transportation, root perforation, instrument breakage, ledge formation, voids and missed canal. Data were processed and analyzed using SPSS (Statistical Package for Social Sciences), version 17.0.   Result A total of 180 postoperative readable radiographs with post RCT were evaluated. Distribution of the radiographic cases by tooth profile is shown in Table-2. Over half (52.2%) of the post root-canal treated radiographs were of male subjects and the rest (47.8%) were of female subjects. Nearly half (48.3%) of the radiographs showed maxillary tooth involvement and the rest half (51.7%) mandibular tooth involvement. Over two-thirds (68.9%) of the tooth were molar tooth, 17.8% were premolar and 13.9% were incisor. Approximately 44% of the canals were straight and 56.1% were curved. More than half (53.3%) of the curved canals had degree of curvature between 0 - 100, 33.9% had curvature of 110 or more and 12.8% of curved canals’ curvature were not assessable. The average number of roots visible was 2 and the average number of canals visible was also 2. History of similar previous treatment was found only in 12.8% cases (Table-2). Evaluation of the obturation of the root canal revealed that 92.8% of the roots were filled with sealing materials, 8.9% exhibited posts and 36.7% demonstrated voids (Table-3).   Table-2: Distribution of the radiographic cases by tooth profile (n = 180)     Table-3: Evaluation of the obturation of the root canal (n =180)     The length, density and taper of root canal obturation were found perfect in 59.4%, 58.9% and 57.8% of radiographs respectively (Table-4).  After summing up the root canal quality score, 41.7% was of perfect quality and 14.4% was of acceptable quality. The rest 23.3% was poorly acceptable and 20.6% totally unacceptable. Detail periapical status based on length, density and taper of the root canal obturation is given in Table-4.   Table-4: Periapical status based on length, density and taper of the root canal obturation (n=180)     Table-5: Complications seen radiographically during or after RCT     Analysis of complications resulting from root-canal treatment showed that a total of 132 (73.3%) teeth developed at least one complication (32.8% one complication, 32.2% two complications and 8.3% three complications). Under filling and voids were predominant complications (42.8% and 41.1% respectively). The less common complications were root perforation (12.2%) and transportation (11.7%). Ledge formation (5%), instrument breakage (2.8%), missed canal (3.3%), furcal perforation and cavity wall perforation seldom occurred (Table-5).   Discussion Evaluation of the success or failure of endodontic therapy is still problematic for the endodontists. Although root canal treatment is technically demanding, there is evidence that a substantial proportion of the root canal treatment performed by general dental practitioners all over the world including Bangladesh is of substandard quality which has a signiﬁcant impact on the outcome and the long-term retention of teeth. The present study revealed that about 55% of RCT performed by the dental graduates was of either perfect or of acceptable quality. Consistent with the findings of this study, Chowdhury et al [21] in a recent evaluation of the quality of root canal treatment by undergraduates of Bangladesh Dental College found 55% to be of acceptable quality. However, their perfect quality was very low (4%). Thus, the finding of the present study and that of Chowdhury et al suggest that Bangladeshi dental graduates are not skilled in performing RCT of teeth. Similar findings are reported from all over the world. Only 13% of root ﬁllings were categorized as satisfactory in terms of both radiographic quality of obturation and distance of the root ﬁlling from the radiographic apex [22]. Saunders et al. [10] found that 39% of root ﬁllings were greater than 2 mm from the radiographic apex and Dummer [23] found that only 10% of root ﬁllings placed by general dentists under the terms of the UK National Health Service fulﬁlled criteria for standards of care as deﬁned by the European Society of Endodontology [24]. A study from Switzerland noted that 64% of root ﬁllings were unsatisfactory because they contained voids or were greater than 2 mm from the apex [25].  About 43% of Norwegian root ﬁllings ended more than 2 mm from the apex [8]. A study from Sweden reported that only 38% of teeth were obturated completely and another study in USA found that only 42% of root ﬁllings were technically satisfactory [7,26]. Similarly, a study on French population also reported poor technical quality of RCT treatment [27]. Also, in our study we found that about 73% teeth developed at least one complication following RCT. The findings of the present study suggest that specific training during the undergraduate endodontic course might be useful to improve the skills of dental graduates and therefore, shall provide quality root canal treatment.   Acknowledgment I am thankful to Dr. Shiren Sultana and Dr. Suraiya Islam Dina of Dental unit of Ibrahim Medical College for their help in editing the manuscript.   References 1.     Daly RM, Elsner RJ, Allen PF, Burke FM. Associations between self-reported dental status and diet. J Oral Rehabil. 2003; 30: 964–970.  2.     Legan JJ, Brown CE Jr. Instrumentation enhances today's endodontic care. J Indiana Dent Assoc. 1998; 77: 30–34.  3.     Adebayo ET, Alhaji LE, Nnachetta RN, Nwankwo O, Akabogu-Okpeseyi N, Yaya MO, et al. Technical quality of root canal fillings done in a Nigerian dental clinic. BMC Oral Health. 2012; 12:42. 4.     Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long term results of endodontic treatment. J Endod. 1990; 16(10): 498–504. 5.     Kerekes K, Tronstad L. Long-term results of endodontic treatment performed with a standardized technique. J Endod. 1979; 5(3): 83–90. 6.     European Society of Endodontology. Quality guidelines for endodontic treatment consensus report of the European Society of Endodontology. Int Endod J. 2006; 39(12): 921–930. 7.     Petersson K, Petersson A, Olsson B, Hakinsson J, Wennberg A. Technical quality of root fillings in an adult Swedish population. Dent Traumatol. 1986; 2: 99–102. 8.     Eriksen HM, Bjertness E, Ørstavik D. Prevalence and quality of endodontic treatment in an urban adult population in Norway. Endod Dent Traumatol. 1988; 4: 22–26. 9.     Ray HA, Trope M. Periapical status of endodontically treated teeth in relation to the technical quality of the root filling and the coronal restoration. Int Endod J. 1995; 28: 625–627. 10.  Saunders WP, Saunders EM, Sadiq J, Cruickshank E. Technical standard of root canal treatment in an adult Scottish sub-population. Br Dent J. 1997; 182: 382–386. 11.  Segura-Egea JJ, Jimenez-Pinzon A, Poyato-Ferrera M, Velasco-Ortega E, Rio Santos JV. Periapical status and quality of root fillings and coronal restorations in an adult Spanish population. Int Endod J. 2004; 37(8): 525–30. 12.  Chugal NM, Clive JM, Spangberg LS. Endodontic infection: some biologic and treatment factors associated with outcome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003; 96(1): 81–90. 13.  Smith CS, Setchell DJ, Harty FJ. Factors influencing the success of conventional root canal therapy– a five-year retrospective study. Int Endod J. 1993; 26(6): 321–333. 14.  Ng YL, Mann V, Rahbaran S, Lewsey J, Gulabivala K. Outcome of primary root canal treatment: systematic review of the literature – part 2. Influence of clinical factors. Int Endod J. 2008; 41: 6–31. 15.  Ng YL, Mann V, Gulabivala K. A prospective study of the factors affecting outcomes of non-surgical root canal treatment: part 2: tooth survival. Int Endod J. 2011; 44: 610–25. 16.  Saunders WP, Saunders EM, Sadiq J, Cruickshank E. Technical standard of root canal treatment in an adult Scottish sub-population. Br Dent J. 1997; 182: 382–386. 17.  De Cleen MJ, Schuurs AH, Wesselink PR, Wu MK. Periapical status and prevalence of endodontic treatment in an adult Dutch population. Int Endod J. 1993; 26: 112–119. 18.  De Moor RJ, Hommez GM, De Boever JG, Delmé KI, Martens GE. Periapical health related to the quality of root canal treatment in a Belgian population. Int Endod J. 2000; 33: 113–120. 19.  Barrieshi-Nusair KM, Al-Omari MA, Al-Hiyasat AS. Radiographic technical quality of root canal treatment performed by dental students at the dental teaching center in Jordan. J Dent. 2004; 32: 301–307. 20.  Dummer PM. Comparison of undergraduate endodontic teaching programmes in the United Kingdom and in some dental schools in Europe and the United States. Int Endod J. 1991; 24: 169–177.  21.  Chowdhury F, Akter K, Shamsuzzaman M, Kobra K, Choudhury M, Alam MK. Quality of root canal treatment performed by undergraduate dental students of Bangladesh Dental College. Int J Human Health Sci. 2018; 2(3): 136-139. DOI: http://dx.doi.org/10.31344/ijhhs.v2i3.41 22.  Hayes SJ, Gibson M, Hammond M, Bryant ST, Dummer PHM. An audit of root canal treatment performed by undergraduate students. Int Endod J. 2001; 34: 501–505. 23.  Dummer PMH. The quality of root canal treatment provided by general dental practitioners working within the general dental services of England and Wales. Part 2. Dental Proﬁle. J Dent Pract Board of England and Wales. 1998; 19: 8–10. 24.  European Society of Endodontology. Consensus report of the European Society of Endodontology on quality guidelines for endodontic treatment. Int Endod J. 1994; 27: 115–124. 25.  Imfeld TN. Prevalence and quality of endodontic treatment in an elderly urban population of Switzerland. J Endod. 1991; 17: 604–607. 26.  Buckley M, Spångberg LSW. The prevalence and technical quality of endodontic treatment in an American subpopulation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995; 9: 92–100. 27.  Boucher Y, Matossian L, Rilliard F, Machtou P. Radiographic evaluation of the prevalence and technical quality of root canal treatment in a French subpopulation. Int Endod J. 2002; 35(3): 229-238. <![CDATA[Prevalence of helminthic infestations among Bangladeshi rural children and its trend since mid-seventies]]> Sadya Afroz Smita Debsarma Subarna Dutta Mir Masudur Rhaman Masuda Mohsena https://imcjms.com/journal_full_text/301 2018-10-03 13:08:23 Original Article IMC J Med Sci 2019; 13(1): 004 Abstract Background and objectives: Helminthic infestation is one of the commonest health problems in a developing country like Bangladesh. The objectives of the current study were to determine the prevalence of helminthic infestations, associated risk factors and its effects among the rural children in Bangladesh. The trend of helminthic infestation rate over time was also analyzed. Methodology: A cross-sectional study was conducted among the rural primary school children of Sreepur Upazilla of Gazipur District. The area is located about 40 km north-east of capital Dhaka. A total of 593 students aged 5-13 years were enrolled from 5 primary schools. Out of 593 children, 204 agreed to provide fecal samples. A semi-structured questionnaire was used to collect data by face to face interview method and several anthropometric measurements along with clinical examinations were also carried out. Helminth ova were detected by direct microscopy of fecal smear and floatation concentration methods. Data were analyzed using the software IBM SPSS (Version 20). Result: Out of 204, 80 (39.2%) children were infested with at least one species of helminth. Ascaris lumbricoides, Trichuris trichiura and mixed infection was 23%, 12.8% and 3.4% respectively. Overall prevalence of infection was higher among female students compared to male students (p<0.05). Living in mud-floor and thatch walled houses were significantly (p<0.05) associated with increased helminthic infestation. The risk behaviors commonly related to helminthic infestation revealed no difference between infected and non- infected groups of children. Height, weight, mid-upper arm circumference (MUAC), skin fold thickness, and waist and hip circumference of worm infested children were not significantly different from those without worm infestation. Conclusion: The results reflect that the deworming program of Sreepur Upazilla was not fully successful. Poor socio-economic condition and lack of awareness of personal hygiene played an important role in prevalence of parasite infestation. IMC J Med Sci 2019; 13(1): 004. EPub date: 20 February 2019. DOI: https://doi.org/10.3329/imcjms.v13i1.42038 Address for Correspondence: Dr. Sadya Afroz, Lecturer, Department of Community Medicine, Ibrahim Medical College, 122, Kazi Nazrul Islam Avenue, Shahbagh, Dhaka-1000, Bangladesh. E-mail: dr.sadya_afroz@yahoo.com   Introduction Helminthic infestation of children is a common public health challenge in developing and resource poor countries [1]. Transmission of intestinal nematodes involves contamination of the environment by helminth eggs due to lack of adequate sanitation, poor personal hygiene and low socio-economic conditions [2]. Occupation may also have an important influence on hookworm epidemiology as higher rates of hookworm infestation are observed among adults [3]. Engagement in agricultural pursuits remains a common denominator for human hookworm infection. Heavy infections in Sichuan Province, China and in Vietnam, for instance, are attributed to widespread use of faeces as night-soil fertilizer [4]. Globally more than two billion people are infected with soil-transmitted nematodes [5]. An estimated 874.5 million children require regular and periodic deworming in disease-endemic countries [6,7]. Geographically, the maximum numbers of children with intestinal worms live in India, followed by Nigeria, Indonesia and Bangladesh. Chronic morbidities resulting from high-intensity worm infection in children affects physical growth and cognitive development. Helminth-induced chronic malnutrition may result in growth stunting and decreased physical fitness that may resolve after deworming, although the deficits can be permanent in chronic cases [8,9]. Apart from physical growth and fitness, chronic parasitism can lead to decreased school attendance, decreased grade attainment, and reduced cognitive development [8,10,11]. In 2001, the World Health Assembly urged member states to control the morbidity of helminthic infestations through large-scale use of anti-helminthic drugs for school-aged children in developing countries [4]. However, improved sanitation and hygiene are essential for the long-term control of parasitic diseases. The preventive measures for the transmission of helminthic infestation include use of latrine, drinking safe water, not using human feces as fertilizer, improved hand hygiene, washing vegetables before cooking and appropriate covering of foods. Prior to the initiation of deworming program in Bangladesh in 2005, the prevalence of worm infestation was about 79.8% [12]. The government estimated that 20 million Bangladeshi children were at risk for soil transmitted helminthic infestations (STHI) [12]. At first, Ministry of Health began piloting deworming programs through STH Control Program in schools of three districts in 2005 and later achieved full national coverage by 2008. Deworming is now conducted for all school-age children aged five to twelve years old through all primary level institutions in the country biannually preferably in every May and November. A single dose of albendazole is administered. Out-of-school children are also covered under the deworming program. The intervention aims to achieve the global target of eliminating morbidity due to soil transmitted helminthiases in children by 2020 in Bangladesh [5]. Therefore, the objectives of the current study were to determine the prevalence of helminthic infestations, associated risk factors and effects of worm infestation among school going children in a rural area. The trend of worm infestation rate over time (from mid-70s to 2018) was also analyzed to understand the impact of mass deworming program.   Methodology The cross-sectional study was carried out in five primary schools from 15th February to 4th March 2018 in Sreepur Upazilla. The rural area is located about 40 km north-east of capital Dhaka. Children aged 5-13 years were enrolled purposively and conveniently from 5 primary schools. Written consent was taken from the Head of the schools and verbal consent was taken from each of the students. A total of 593 respondents were interviewed. A semi-structured questionnaire was used for data collection. Several anthropometric measurements namely height, weight, waist and hip circumference and mid-upper arm circumference (MUAC) were taken to assess the nutritional status with the aim to find the relationship between infestation rate and nutritional status of children. Each student was given a plastic pot for stool collection. Of the 593 children, 204 agreed to submit their stool for the diagnosis of helminth. Morning stool was collected in a previously labeled collection pot. The pot was tightly closed and sealed and put into a plastic bag. All sample pots were stored in a refrigerator at four degree temperature. It was transported to our microbiology laboratory in a cold box within 24 hours. Microscopic examination of stool was done by preparing slide using normal saline to observe ova of helminthes under 10X and 40X objectives. Stool samples were evaluated using the floatation concentration technique. BMI and waist-hip ratio were calculated from the collected data. The relationship between infection by intestinal parasites and the variables sex, age group, and neighborhood was assessed using the Chi-squared or the Fisher exact tests. Independent sample t- test was done to assess the difference in nutritional indicators between infected and non-infected groups. Statistical significance was assumed at a p-value <0.05. The statistical analyses were performed using IBM SPSS statistics 20 software. Participants infected with pathogenic intestinal parasites received appropriate treatment later. An attempt has been made in the current study to find out the trend of infestation of intestinal parasites over the years in Bangladesh and shown in Table 5 of the result chapter.   Result Out of 204 participants, 80 (39.2%) children were infected with at least one species of helminth (Table 1). Infections by A. lumbricoides predominated (23%) followed by T. trichiura(12.7%). Mixed infection was observed among 3.4% children. None of them were infected by hookworm.   Table-1: Rate of intestinal helminth infestation among study children     Table 2 shows that the overall prevalence of worm infestation was higher among female compared to male children (p<0.05). Living in mud-floor and thatch-walled house was significantly associated with being infected by helminthes. Other socio-demographic factors namely parent’s education, occupation, type of latrine did not vary among the infected and non-infected children. The students were asked about the behaviors commonly related to helminthic infestation (e.g. hand washing habits). The behaviors of children did not significantly affect the rate of worm infestation (Table-3).   Table-2: Rate of intestinal helminth infestation in relation to demographic characteristics of the study population (n=204)       Table-3: Rate of intestinal helminth infestation in relation to risk behaviors among the children (n=204)       Several anthropometric measurements were taken to see whether nutritional status varied among infected and non-infected children. No significant difference was observed in height, weight, BMI, MUAC, etc between the worm infested and non-infested groups (Table-4). Table 5 shows the data from several studies regarding the trend of helminthic infestations in rural and urban population of Bangladesh since mid-seventies. The overall rate of soil transmitted helminth infestation has declined overtime.   Table-4: Anthropometric parameters of children with and without worm infestation       Table-5: Trend of helminthic infestations in Bangladesh overtime among different population       Discussion Geographically the maximum number of infected individuals with overall helminthic infestation lives in South Asia (ie, Indian subcontinent), Southeast Asia, and East Asia, followed by sub-Saharan Africa and Latin America [2]. In terms of specific countries, the greatest numbers of children with intestinal worms lived in India, followed by Nigeria, Indonesia, and Bangladesh [7]. Bangladesh was seen to have all the requisite conditions for a high helminthic infestation. In this context, the current study was conducted to measure effects of various risk factors (like use of sanitary latrines, hand washing, walking barefoot, etc) on prevalence of helminthic diseases. The current study revealed that overall prevalence of helminthic infestation was 39.2%. Several international cross-sectional surveys reflected similar prevalence of overall helminthic infestation in comparison to the current study. For instance, in primary school children in a rural community in Imo State, Nigeria the overall prevalence of helminthic infestation was reported as 30.3% [1]. Similar rates of prevalence were reported in recent studies in different countries of Africa (Nigeria 28.9%), Middle East (Iran 25.1%), Asia (Tajikistan 32%, Nepal 23.7%) and Eurasia (Turkey 44.6%) [24-28]. Significantly lower (12.6%) prevalence rate was observed in Thailand, where as higher rates were reported in two different cities of India (63.9%) and Pakistan (66%) and also in Ethiopia (54.5%) [29-32]. Prevalence of A. lumbricoides (23.00%) and T. trichiura (12.8%) found in the present study was similar to the findings of various studies carried out in Bangladesh from 1976 till present [13-23]. In contrast, mixed infection (both A. lumbricoides and T. trichiura) was much lower (3.4%) in the present study compared to the rates reported in studies conducted previously in Bangladesh [13-23]. High rates of infestation of intestinal parasites have been observed throughout Bangladesh in several studies during the last five decades. Kuntz’s (1960) study showed a high infestation rate of intestinal parasites especially A. lumbricoides which was the first ever reported survey in Bangladesh [13]. Later in 1968, Muazzem & Ali found 25.6% of A. lumbricoides infestation in urban school children [14]. Muttalib reported prevalence rate of 92.9% and 52.46% of A. lumbricoides and T. trichiuria in 1976 in rural children and in 1979 Chowdhury reported the prevalence as 23.1% and 10.0% in urban children [15,16]. The overall prevalence as reported by Muttalib was as high as 99.03% among 1-15 years aged rural children in 1976 but on the other hand Huq & Sheikh reported 65.8% parasitic infestation in another study in the same year [15,17]. Khanum et al. did the prevalence study in 1997, 1999 and 2005, all of which showed significant improvement from 1976, but within the nine year period (1997-2005) there was no improvement, rather deterioration was observed in both A. lumbricoides and T. trichiura prevalence rates [18-20]. In 2005, Uddin et al also found surprisingly high infestation rate (71.01%) among rural adolescent girls and this trend continued till 2016 as shown in Table-5 [21-23]. However, the current study have found considerable decline in the prevalence of worm infestation among rural children. The high prevalence of worm infestation observed in the present study could be related to poor living standards and low socio-economic condition of the families of infected children in Sreepur Upazilla. The low socio-economic condition was reflected by their mud-floor and thatch-walled households. Surprisingly one-fifth of the participants reported not to use soap after defecation. The inadequacy in personal hygiene of the children was also found in this study; nearly half of the children had dirty finger nails. These issues need to be addressed in future programs. Moreover, this high prevalence could be an indicator of the failure of ongoing national deworming program. The nutritional status did not differ in two groups. This could be due to low infection loads of helminthes.   Conclusion The higher prevalence of helminthic infestation implies that further emphasis should be given on the deworming program as well as regular health education campaigns in schools of rural areas.   Acknowledgements We are also thankful to our students of IM-15 (C & D batch) for their active participation in the program. We are indebted to Ibrahim Medical College authority for their logistic support and especially to the Microbiology Department of BIRDEM for laboratory facilities.   Contribution of authors SA and SD1: involved in study design, data analysis and manuscript writing; SD2 did the microbiological work; MMR: supervised field work and data collection; MM: responsible for overall supervision.   SA and SD1 contributed equally to this study.   Conflict of interest: None   Fund: None   References 1.   Odinaka KK, Nwolisa EC, Mbanefo F, Iheakkaram AC, Okolo S. Prevalence and pattern of soil-transmitted helminthic infection among primary school children in a rural community in Imo State, Nigeria. J Trop Med. 2015; 2015: 1-4. doi: 10.1155/2015/349439. 2.   Olsen A, Samuelsen H, Onyango-Ouma W. A study of risk factors for intestinal helminth infections using epidemiological and anthropological approaches. J Biosoc Sci. 2001; 33(4): 569-84. 3.   Kightlinger LK, Seed JR, Kightlinger MB. Ascaris lumbricoides intensity in relation to environmental, socioeconomic, and behavioral determinants of exposure to infection in children from southeast Madagascar. J Parasitol. 1998; 84(3): 480-484. 4.   Brooker S, Bethony J, Hotez PJ. Human hookworm infection in the 21st century. Adv Parasitol. 2004; 58: 197–288. 5.   World Health Organization. Soil-transmitted helminthiases: eliminating soil-transmitted helminthiases as a public health problem in children: progress report 2001-2010 and strategic plan 2011-2020. Geneva, Switzerland: World Health Organization; 2012; 1-90. 6.   World Health Organization. Soil- transmitted helminthiases: number of children treated in 2011. Wkly Epidemiol Rec. 2013; 88(14): 145-151. 7.   Barry MA, Simon GG, Mistry N, Hotez PJ. Global trends in neglected tropical disease control and elimination; impact on child health. Arch Dis Child. 2013; 98(8): 635-641. 8.   King CH. Parasites and poverty: the case of schistosomiasis. Acta Trop. 2010; 113(2): 95-104. 9.   Bethony J, Brooker S, Albonico M, Geiger SM, Loukas A, Diemert D, et al. Soil-transmitted helminth infections: ascariasis, trichuriasis, and hookworm. Lancet. 2006; 367(9521): 1521–1532. 10.  Hotez PJ, Bundy DAP, Beegle K, Brooker S, Drake L, deSilva N, et al. Helminth infections: soil-transmitted helminth infections and schistosomiasis. In: Jamison DT, Breman JG, Measham AR, et al., editors. Disease Control Priorities in Developing Countries.2nd edition. Washington DC, New York: The international bank for reconstruction and development/ World Bank: Oxford University Press; 2006. 11.  Jukes MC, Nokes CA, Alcock KJ, Khamia C, Ngorosho N, Mbise A, et al. Heavy schistosomiasis associated with poor short-term memory and slower reaction times in Tanzanian schoolchildren. Trop Med Int Health. 2002; 7(2): 104–117. 12.  Technical brief: Assessing progress in fighting STHs in Bangladesh. End Neglected Tropical Diseases in Asia. FHI 360 Asia-Pacific Regional Office, Bangkok, Thailand. 2013. 13.  Kuntz R E. Intestinal protozoa and helminthes in school children in Dhaka, East Pakistan. Am J Trop Med Hyg. 1960; 19: 162-170. 14.  Muazzem MG, Ali AT. Incidence of intestinal parasites among the children of East Pakistan. Medicus. 1968; 25: 215-221. 15.  Muttalib MA, Islam N, Islam S. Prevalence of intestinal parasites in rural children of Bangladesh. Bang Med J. 1976; 5(1): 9-27. 16.  Chowdhury M, Brig MR. Intestinal parasitic infection in privileged class of Dhaka population. Bang Arm Med J. 1979; 4(1): 5-12. 17.  Huq N, Sheikh A. Incidence of intestinal parasite in children of different socio- economic population of Dhaka city. BMRC Bull. 1976; 11(1): 20-26. 18.  Khanum H, Islam NM, Dhar T. Prevalence of Ascarislumbricoides and Trichuristrichiuraamong the children of four slum areas of Dhaka city. Univ J Zool Raj Univ. 1997; 16: 89-94. 19.  Khanum H, Islam NM, Nahar NK. Intestinal nematode infestation among children of lower income group employees in Dhaka. Bang J Zool.1999; 27(2): 177-183. 20.  Alam SM, Khanum H. Infection of Ascaris lumbricoides and Trichuris trichiura among the children of two slum areas of Dhaka city. Bang J Zool. 2005; 33(1): 89-94. 21.  Uddin MH, Rahman MM, Khanum H. Haemoglobin level among adolescent girls and it’s relation to intestinal parasites. Bang J Zool. 2005; 33(2): 183-187. 22.  Uddin MH, Khanum H. Intestinal parasitic infestation and anaemic status among the adolescent boys in Bangladesh. Univ J Zool Rajshahi Univ. 2008; 27: 63-65. 23.  Khanum H, Nahar A, Karim MT, Banu H. Infection of protozoan and helminth parasites among the out-patients of Dhaka Medical College Hospital. Bang J Zool. 2016; 44(1): 89-97. 24.  Ekpenyong EA, Eyo, JE. Prevalence of intestinal helminths infections amongschooling children in tropical semi urban communities. Ani Res Int. 2008; 5(1): 804–810. 25.  Barazesh A, Fouladvand M, Tahmasebi R, Heydari A, Kooshesh F. Prevalence of Intestinal Parasitic Infections Among Primary School Children in Bushehr, Iran. Avicenna J Clin Microb Infect. 2017; 4(1): 1-6. doi: 10.17795/ ajcmi-34335. 26.  Matthys B, Bobieva M, Karimova G, Mengliboeva Z, Richard VJ, Hoimnazarova M, et al. Prevalence and risk factors of helminths and intestinal protozoa infections among children from primary schools in western Tajikistan. Parasites Vectors. 2011; 4: 1-13. doi:10.1186/1756-3305-4-195. 27.  Pradhan P, Bhandary S, Shakya PR, Acharya T, Shrestha A. Prevalence of intestinal parasitic infections among public school children in a rural village of Kathmandu Valley. Nepal Med Col J. 2014; 16(1): 50-53. 28.  Doni NY, Gürses G, Şimşek Z, Zeyrek FY. Prevalence and associated risk factors ofintestinal parasites among children of farmworkers in the southeastern Anatolian region of Turkey. Ann Agri Env Med. 2015; 22(3): 438–442. 29.  Ngrenngarmlert W, Lamom C, Pasuralertsakul S, Yaicharoen R, Wongjindanon N, Sripochang S, et al. Intestinal parasitic infections among school children in Thailand. Trop Biomed. 2007; 24(2): 83–88. 30.  Ashok R, Suguneswari G, Satish K, Kesavaram V. Prevalence of Intestinal Parasitic Infection in School Going Children in Amalapuram, Andhra Pradesh, India. Shiraz E-Med J. 2013; 14(4): 1-4. doi: 10.17795/semj16652. 31.  Ullah  I,  Sarwar  G,  Aziz  S,  MH.  Intestinal worm infestation in primary school children in rural Peshawar. Gom J Med Sci. 2009; 7(2): 132-136. 32.  Wale M, Wale M, Fekensa T. The prevalence of intestinal helminthic infections and associated risk factors among school children in Lumame town, Northwest, Ethiopia. J Parasitol Vector Biol. 2014; 6(10): 156-165. <![CDATA[Safety and feasibility of subarachnoid block in laparoscopic cholecystectomy]]> Mahmud Ekram Ullah Md. Mushfiqur Rahman Rajibul Haque Talukder Refat Uddin Tareq Md. Noor A Alam https://imcjms.com/journal_full_text/318 2019-05-05 10:19:23 Original Article IMC J Med Sci 2019; 13(1): 006 Abstract Background and objectives: Laparoscopic surgery is normally performed under general anesthesia (GA), but regional techniques like epidural or subarachnoid block (SAB) have been found beneficial in patients having associated major medical problems. In selected cases, it can be a safe alternative to GA. Hence, the present study was conducted to explore the safety and feasibility of SAB in otherwise healthy individuals undergoing laparoscopic cholecystectomy. Methods: Forty patients undergoing elective laparoscopic cholecystectomy and fulfilling specific inclusion criteria were included in the study. All patients received a segmental (L2-L3 injection) SAB with 3 ml (0.5%) of bupivacaine and 25 microgram of fentanyl. Laparoscopic cholecystectomy was done by standard 4 port technique. Intra-abdominal pressure was kept low at 9-10 mm Hg using CO2 pneumoperitoneum. Patients were followed up at 30 minutes, 4 hours, at the time of discharge and on day 7 after operation. Any unwanted voluntary or involuntary movement or exaggerated diaphragmatic excursion during the operation was monitored. Operation time, operating room (OR) occupancy time, hospital stay, post-operative pain, analgesic requirement, nausea, vomiting, headache, right shoulder pain, wound-related complications and patient satisfaction were recorded. Results: SAB was effective for surgery in all 40 patients. Two patients required conversion to general anesthesia for persisting low oxygen saturation. Hypotension was recorded in 23.7% patients while 10.5% experienced right shoulder pain. Average operating time was 37.3 minutes (21 - 77 minutes). Awkward movement and exaggerated respiratory excursion was noted in 23.7% and 18.4% cases respectively. Only two cases had to undergo (conversion to) GA. Mean period of hospital stay was 29.3 hours. No incidence of any major complication occurred. Conclusion: This study showed that SAB could be used successfully and effectively for laparoscopic cholecystectomy in healthy patients and may be a safe alternative to GA. IMC J Med Sci 2019; 13(1): 006. EPub date: 05 May 2019. DOI: https://doi.org/10.3329/imcjms.v13i1.42039 Address for Correspondence: Dr. Mahmud Ekram Ullah, Assistant Professor, Department of Surgery, BIRDEM General Hospital, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka 1000. E-mail: drmahmud50@gmail.com   Introduction Gall stone disease is prevalent worldwide and cholecystectomy is the treatment of choice for symptomatic cholelithiasis. For the last two decades, laparoscopic cholecystectomy has replaced more invasive open cholecystectomy because of advantages of less tissue trauma, short hospital stay and increased turnover of patients. It is also economical. Laparoscopic cholecystectomy is normally performed under GA, but regional techniques such as low thoracic epidural [1] and spinal block [2] have been usually used to manage patients with significantmedical problems. Until about a decade ago, the world literatures suggested general anesthesia as the only anesthetic option for abdominal laparoscopic surgery. But recently, laparoscopic cholecystectomy performed in selected patients under SAB or epidural anesthesia have been reported [2-5]. These studies have provided preliminary indication of the feasibility of segmental spinal anesthesia in patients undergoing routine laparoscopic cholecystectomy. Having the experience of performing upper abdominal surgery under SAB in good number of cases and high turnover of laparoscopic cholecystectomy cases in our center, we decided to explore the safety, outcome and feasibility of SAB in healthy patients undergoing laparoscopic cholecystectomy. Operations were performed using low pressure pneumoperitoneum (9-10 mm Hg) to avoid excess stretching of the diaphragm and to lower the complications rate of hypercarbia. Certain technical points were modified to avoid complications.   Materials and method Forty patients were selected prospectively from the patients with gallstone disease who opted for laparoscopic cholecystectomy. After obtaining written informed consent, patients were enrolled in the study. The study was conducted in BIRDEM general hospital and Islami Bank Hospital, Dhaka from May 2017 to October 2018. Patient aged 20-65 years, having BMI <25kg/m2, normal coagulation profile and fulfilled the American Society of Anesthesiologists (ASA) physical status classification I and II were included in the study. Patients with recent history of jaundice, previous history suggestive of cholangitis or bile duct stone, acute cholecystitis, history of previous upper abdominal operations, ultrasonography features of edematous/thick 3+mm gallbladder wall and suspected gallbladder malignancy were excluded from the study. Patients having contraindication for SAB were exempted as well. All patients were kept overnight fasting and preloaded with intravenous (IV) fluid. Under full aseptic precaution standard spinal puncture was donewith 25G spinal needle in L2-L3 intervertebral space in sitting position. Three milliliter of 0.5% bupivacaine + 25 microgram fentanyl was injected after confirming free flow of CSF. Head was tilted down to 10 degrees and was kept for 6 to 8 minutes to achieve desirable segmental block at   T4–T5 level. Anesthesia level was checked with pin prick sensation. After adequate block the patient was sedated with 25 mg pethidine and 0.5 mg/kg ketamine in IV route. Standard pulse-oximeter was used for monitoring pulse and oxygen saturation. CO2 pneumoperitoneum was done and intra-abdominal pressure was kept at 9-10 mm Hg. The patient was positioned to reverse Trendelenburg position with left lateral tilt. Blood pressure was monitored manually at five minutes interval. Any hypotension was managed with extra IV fluid infusion. Injection ephedrine (5 mg), single dose, per-operatively, was given intravenously in patients with systolic blood pressure falling more than 20 mm of Hg from baseline value even after adequate intravenous fluid infusion. The surgeons were prepared to ask for general anesthesia if they felt that the anesthetic technique was causing technical difficulty of the procedure. Laparoscopic cholecystectomy was done by standard four port technique. After pericholecystic adhesiolysis (if any) Callot’s triangle was dissected and cystic duct and artery were identified and skeletonized. Both the structures were clipped separately and then divided. Gall bladder was then dissected free off the under surface of liver. Hemostasis was ensured and gall bladder delivered through umbilical port which was then closed in layers. Local anesthetic xylocaine 2% was injected in all port sites. Any unwanted voluntary or involuntary  movement or exaggerated diaphragmatic excursion from too rapid/ heightened respiration that impeded surgeon’s work was monitored. Operation time, operating room (OR) occupancy time, hospital stay, post-operative pain and analgesic requirement, nausea and vomiting, headache, right shoulder pain, wound-related complications and patient satisfaction were noted. They were followed up at 30 minutes, 4 hours, at the time of discharge and on day 7 after operation. The patients were allowed to leave hospital once they passed urine, could comfortably move, had tolerated oral feeding and had been assessed by the surgeon as being free from any complications. Pain perception was assessed by verbal rating score (VRS). Patient satisfaction level was determined based upon parameters like management of pain and postoperative nausea vomiting (PONV), quality of life and fulfillment of their expectation on quality of care by the health service providers. Our endpoint outcome criteria were (1) cardiopulmonary stability in terms of blood pressure, respiration and O2 saturation during intraoperative and immediate post-operative period, (2) pain and PONV within first 4 hours after operation, (3) technical difficulties like space constraint and any unwanted movements of patient that impedes surgeon’s work and (4) operating time, operating room occupancy time and hospital stay.   Results A total of 40 patients were included in our study. The mean age of the study population was 37.2 years while the range was from 20 to 65 years. Fourteen (35.0%) patients were male and 26 (65.0%) were female. Mean body mass index was 22.9 kg/ m2 (range 19.3-24.7 kg/ m2). Out of 40 cases, 13 (32.5%) had diabetes mellitus. Detail characteristics are shown in Table-1.   Table-1: Baseline characteristics of the study population.     Two patients had to undergo general anesthesia later due to persistent low oxygen saturation possibly due to adverse effect of sedative drugs. So ultimately, laparoscopic cholecystectomy under spinal anesthesia was completed in 38 patients. Details of the spinal anesthesia and clinical conditions during the anesthesia of the cases are shown in Table-2. Blood pressure was maintained at normal range in 29 cases, but nine patients developed hypotensive episodes. Six patients were managed with additional IV fluid alone. Three patients needed injection ephedrine 5 mg, intravenously, single dose per-operatively along with IV fluid. Oxygen saturation was maintained in all cases around 98% with oxygen supplementation through nasal catheter if necessary. Operations were performed using low pressure pneumoperitoneum (9-10 mm Hg) to avoid excess stretching of the diaphragm and to lower the complications rate of hypercarbia. In spite of low pressure pneumoperitoneum, we did not have any space constraint or any gastric distension as well. However, two conditions namely - awkward movement in 9 patients and exaggerated respiratory motion in 7 cases were encountered that made the operative field unsteady for a brief period of time (Table-2).   Table-2: Details of SAB and clinical conditions of the cases during operation (n=38).     The duration of operations (skin incision to skin closure) was 21 to 77 minutes (mean 37.3 min). In three patients, wall of gallbladder was perforated during dissection. Saline irrigation and aspiration of the sub-hepatic space was done for bile spillage. In one case, stones were spilled out during dissection which was retrieved in an endobag. No other major complication was encountered (Table-3).   Table-3: Operation details of cases by laparoscopic cholecystectomy under SAB (n=38).     Conditions observed during follow up at different time intervals are shown in Table-4. All patients were followed up at 30 minutes, at 4 hours, at the time of discharge and on the 7th day after operation. Almost all patients were hemodynamically stable and maintained full O2 saturation (98.2, 97-99%) in the early post-operative period. Incidence of nausea, vomiting and headache was very low. Only two patients complained of post-spinal headache, especially where first spinal puncture was unsuccessful. Only one patient developed nausea and vomiting. No patient required injectable analgesic for surgical site pain within 4 hours. Four patients complained of right shoulder tip pain which was severe in one case. Those patients were managed by continuous finger massaging by a nurse over the right shoulder area of the patients. All patients tolerated oral feeding at 6 hours and most of them were discharged from the hospital within 24 hours of operation after assessing them to be free from complication. Mild purulent discharge from umbilical wound was noted in two cases on first follow-up. The wounds healed up spontaneously on dressing. All the patients were satisfied with results of operations. No patient complained against any step of anesthesia or the operation during follow up.   Table-4: Conditions of the patients observed during follow up at different time intervals (n=38).     Discussion Laparoscopic cholecystectomy is the gold standard for the treatment of uncomplicated symptomatic cholelithiasis. General anesthesia is regarded as safe and most widely practiced anesthesia for laparoscopic surgery in almost all of these cases. Regional anesthesia was seldom used in abdominal laparoscopic surgery except for diagnostic procedures [5]. The prime indication for using regional anesthesia in therapeutic laparoscopy is still limited. The preferred type of regional anesthesia is epidural anesthesia [1]. Thus, reports of laparoscopic cholecystectomy using subarachnoid block are limited [2-6]. Single puncture SAB is an easier and more cost effective technique than general anesthesia [7]. Complication of endotracheal intubations such as damage to oral cavity, teeth, sore throat, aspirations, failure of intubations, gastric distension are absent in spinal anesthesia. Therefore, monitoring of patients under SAB is relatively easy compared to general anesthesia. Nausea and vomiting are less with SAB [8]. Laparoscopic cholecystectomy with low-pressure pneumoperitoneum under SAB is effective in patients with COPD, who are unsuitable for GA [9,10]. Using low pressure (9-10 mm Hg) CO2 pneumoperitoneum during SAB for laparoscopic cholecystectomy have been reported to reduce the abdominal discomfort and chances of neck and right shoulder pain [11]. In our cases, operation was performed at an average pressure of 9-10 mm Hg using CO2 and no changes were necessary in port placement. Pursnani et al reported shoulder and neck pain in 2 out of 6 patients operated under SAB [10]. Surprisingly, right shoulder pain had never been a major problem in the present study. It occurred only in 10.5% patients and was managed by shoulder massage. In a study of 310 laparoscopic cholecystectomy cases performed under spinal anesthesia, only one patient needed conversion to GA because of intolerable shoulder pain [2]. Reason for conversion in both the cases of our study was persistence of low SPO2 (below 90%). Hypotension is a problem of SAB, which can be overcome by preloading with fluids [12]. In addition to spinal anesthesia related hypotension, the pneumoperitoneum induced rise in intra-abdominal pressure could be another cause for persistence of hypotension. In spinal anesthesia, hypotension was reported in 5.4% to 20.2% cases [13-15] compared to 23.7% cases in the present study. Lowering of head end of table after Callots’ triangle dissection, elevation of foot end of the table during repair of the ports and during postoperative period, as well as low pressure CO2 pneumoperitoneum prevent fall of blood pressure. An added advantage cited was the decrease in surgical bed oozing because of hypotension and bradycardia associated with spinal aesthesia [16]. On the contrary, laparoscopic surgery under general anesthesia is associated with hypertensive episodes which may augment bleeding during dissection causing operation difficult and lengthy; but under spinal anesthesia, there were no such episodes of hypertension in any patient. The status of respiratory parameters during laparoscopic cholecystectomy done under SAB should be taken into consideration. In this context it can be stated that spontaneous physiological respiration during SAB would always be better than artificial respiration as in general anesthesia. Intubation related morbidity and mortality can be avoided and is one of the most beneficial effects of SAB particularly in patients with poor respiratory reserve [5]. Pulmonary function takes 24 hours to return to normal after laparoscopic surgery performed under general anesthesia [11]. A specific advantage of SAB is less requirement of analgesic during early post-operative period. In a comparative study between SAB versus GA for laparoscopic cholecystectomy, MM Islam et al [5] reported only 10% patients in the SAB group required injectable analgesic against 90% in the GA group. This was consistent with the findings in our study as none of our patients needed injectable analgesic during first 4 post-operative hours. The problem of PONV was much less (3.3% in SAB group vs 20% in GA group) in the same study which was also supported by our study (only 2.6% patients). During the present study, two issues drew our attention from surgeon’s point of view that was linked to technical aspect of laparoscopic cholecystectomy under SAB. The surgeon may have to pause for a while during any awkward movement of the patient’s body involving upper extremity and/ or trunk that we came across in nine cases. Also, the surgeon may have to adjust for the heightened or faster diaphragmatic respiratory excursion that we encountered in seven patients. However, an experienced and competent surgeon can accommodate these events very well. Secure strapping of the patient and smooth, adequate sedation would help in this regard. Although          intra-abdominal space was relatively less (9-10 mm Hg compared to standard 12 mm Hg), it did not hamper any aspects of surgical maneuver. The time from application of anesthesia to wheeling the patient out of the operating room actually decreases when the patient is being operated under SAB as the time for intubation and extubation is saved [5]. SAB appears to be economical as it involves less medicine, decreased operation theater occupancy time, faster recovery and shorter hospital stay.   Conclusion This limited study involving 38 patients has provided preliminary evidence that in selected cases, SAB can be a safe and alternative technique to GA for routine laparoscopic cholecystectomy. However, further careful evaluation of the technique would be desirable and appropriate involving patients with varying types of co-morbidity.   Competing interest: None   References 1.   Gramatica L Jr, Brasesco OE, Luna AM. Laparoscopic cholecystectomy performed under regional anesthesia in patients with chronic obstructive pulmonary disease. Surg Endosc. 2002; 16: 472–5. 2.   Hamad MA, Ibrahim El-Khattary OA. Laparoscopic cholecystectomy under spinal anesthesia with nitrous oxide pneumoperitoneum: a feasibility study. Surg Endosc. 2003; 17: 1426–8. 3.   Sinha R, Gurwara AK, Gupta SC. Laparoscopic surgery using spinal anesthesia. J Soc Lap Surg. 2008; 12: 133 – 138. 4.   van Zundert AA, Stultiens G, Jakimowicz JJ, Peek D. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth. 2007; 98(5): 682–6. 5.   Islam MM, Hossain MI, Tarek MRU, Razon SMH, Ahmed I. Subarachnoid block versus general anesthesia for laparoscopic cholecystectomy – A comparative study. J Dhaka National Med Coll Hosp. 2015; 21(2): 38-41. 6.   Ciofolo MJ, Clergue F, Seebacher J. Ventilatory effects of laparoscopy under epidural anesthesia. Anesth Analg. 1990, 70(4): 357–361. 7.   Yuksek YN, Akat AZ, Gozalan U, Daglar G, Pala Y, Canturk M, et al. Laparoscopic cholecystectomy under spinal anesthesia. Am J Surg. 2008; 195: 533–6. 8.   Tzovaras G, Fafoulakis F, Pratsas K, Georgopoulou S, Stamatiou G, Hatizitheofilou C. Spinal vs. general anesthesia for laparoscopic cholecystectomy; interim analysis of a controlled randomized trial. Arch Surg. 2008; 143: 497–501. 9.   van Zundert AA, Stultiens G, Jakimowicz JJ, van den Borne BE, van der Ham WG, Wildsmith JA. Segmental spinal anesthesia for cholecystectomy in a patient with severe lungs disease. Br J Anaesth. 2006; 96: 464–6. 10.  Pursnani KG, Bazza Y, Calleja M, Mughal MM. Laparoscopic cholecystectomy under epidural anesthesia in patients with chronic respiratory disease. Surg Endosc. 1998; 12: 1082–4. 11.  Putensen-Himmer G, Putensen C, Lammer H, Linqnau W, Aigner F, Benzer H. Comparison of postoperative respiratory function after laparoscopy or open laparotomy for cholecystectomy. Anesthesiology. 1992; 77(4): 675-80. 12.  Hirvonen EA, Poikolainen EO, Paakkonen MF, Nuutinen LS. The adverse hemodynamic effects of anesthesia, head-up tilt, and carbon dioxide pneumoperitoneum during laparoscopic cholecystectomy. Surg Endosc. 2000; 14: 272–7. 13.  Hartman B, Junger A, Klasen J. Incidence and risk factors for hypotension after spinal anesthesia induction: an analysis with automated data collection. Anesth Analg. 2002; 94(6): 1521 – 1529. 14.  Palachewa K, Chau-In W, Naewthong P. Complications of spinal anesthesia at Stinagarind hospital. Thai J Anesth, 2001; 27(1): 7–12. 15.  Throngumachi R, Sanghirun D, Traluzxamee K,Chuntarakup P. Complications of spinal anesthesia at Lerdsin Hospital. Thai J Anesth. 1999; 25(1): 24 – 27. 16.  Casey WF, Spinal Anesthesia: A practical guideline. In update in anesthesia, 2000; 12(8): 1–7. <![CDATA[Respiratory and other illnesses among the jute-mill workers in an industrial unit of Bangladesh]]> Mir Masudur Rhaman M. Abu Hana Golam Morshed M. Abu Sayeed https://imcjms.com/journal_full_text/323 2019-06-01 14:14:43 Original Article IMC J Med Sci 2019; 13(1): 007 Abstract Background and aims: Bangladesh produces 33% of the world’s jute and about 40 million people in Bangladesh are directly or indirectly involved in the jute sector. The jute (organic) dust inhalation causes byssinosis and other respiratory illnesses. However, no study has yet addressed the health status of the jute handlers/workers in Bangladesh. This study aimed to determine the prevalence of respiratory illnesses among the Jute Mill Workers (JMWs). Additionally, this study tried to find out the overall health status of the JMWs which included presence of non-communicable diseases (NCD) and its related risk, which are usually ignored. Study design: A cross-sectional study conducted in a purposively selected jute mill - 40km off from Dhaka City. Of the 5500 workers, a list of 600 workers was provided by the mill authority for enrollment in the study. The investigations included – a) interviewing on socio-demography and clinical history; b) anthropometry (height, weight, waist- and hip-circumference); c) blood pressure measurement; d) estimation of fasting blood glucose and lipids; e) peak flow meter test; f) spirometry; g) high resolution computerized tomography (HRCT) and electrocardiography. Results:Of the enlisted 600 jute mill workers, 514 (men / women = 478 / 36) took part in the study. The response rate was 85%. For overall estimate of bio-physical characteristics (n = 514), the means (95% confidence interval) of age, body mass index (BMI), waist-hip ratio (WHR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 44.19 (43.34 – 45.04) years, 24.44 (24.16 – 24.73), 0.90 (0.90 – 0.91), 118.9 (117.4 – 120.4), 79.69 (78.81 – 8/0.54), respectively. Regarding social class and education, 84.4% were from non-affluent (poor) class and 50% were illiterate. About 88% of the JMWs had been working for ≥42 hours a week and 91.6% were exposed to moderate or heavy work (equivalent to ≥60 min walk). The prevalence of breathlessness, tightness of chest and chronic cough were 16.5%, 25.7% and 16.3%, respectively. The restrictive and obstructive pulmonary functions were detected in 7.0% and 0.8% of study population respectively. The prevalence of systolic hypertension was 16.5%, diastolic hypertension was 7.2% and diabetes (IFG+DM) was 13.3%. They had increased cardiovascular risks – hypertriglyceridemia (23.9%) and hypercholesterolemia (24.3%). Conclusions: JMWs have been suffering mostly from respiratory illnesses and a substantial number of them suffer from undiagnosed hypertension, diabetes and other non-communicable diseases. Dyslipidemia was also prevalent as a potential risk factor. The study could not assess ocular, auditory, musculoskeletal and mental health and it suggests that a well designed study should address these health related problems of JMWs. IMC J Med Sci 2019; 13(1): 007. EPub date: 01 June 2019. DOI: https://doi.org/10.3329/imcjms.v13i1.42040 Address for Correspondence: Prof. M. Abu Sayeed, Department of Community Medicine, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000. email: sayeed@imc.ac.bd   Introduction Byssinosis is a specific disease of respiratory organ caused mostly by an occupational exposure to organic dust from jute, cotton, hemp or flax [1]. These organic dusts are involved in pathogenesis of obstructing the small air tubes of the lungs. It may also cause permanent lung damage similar to chronic obstructive lung disease. It was reported that 22.8% workers in jute industry suffer from byssinosis-like illness [2]. In addition, the study showed acute and chronic changes of pulmonary function in 25.7% and 20.0% of workers respectively. Similar studies observed some acute and chronic changes of ventilatory function in 35.7% and 31.6% of workers, respectively [3, 4]. Thus, it appears that about one-fifth to one-fourth of the workers is at risk of byssinosis or similar pulmonary disorders. Bangladesh is one of the largest jute producing country. More than 1.5 million workers are employed in 11,983 presently functioning looms of jute industries in Bangladesh [5]. It is estimated that 307 jute mills (government /non-government = 26 /281) have been producing jute goods. The jute products are exported to India, Syria, Tunisia, Turkey, Iraq, Thailand and other countries. The daily average wage of jute-mill workers (JMW) has been reported as BDT ~308.00 (approximately USD 3.6) [5]. The health status of the low paid JMW remained unknown. In Bangladesh, no study has been so far conducted to assess their health problems. The common occupational health problems of the JMWs as mentioned earlier [2,3], are byssinosis like illness with symptoms of cough, chest tightness and breathlessness and other respiratory diseases due to organic dust inhalation. The other non-communicable diseases (NCD) like diabetes, hypertension, coronary heart diseases, though prevalent among them, are usually ignored. Therefore, this study has been designed to determine the prevalence of the above mentioned disorders, and to detect hitherto ignored diseases and the risk factors related to those diseases.   Study design This study protocol was approved by the Institutional Review Board of Ibrahim Medical College. Selection of Jute mill and participants: We purposively selected “Latif-Bawany Jute Mill”. This mill has been functioning with full capacity for decades. It is situated at Demra about 45 km off Dhaka City by the side of a river, Shitalaksma.  The jute mill authority was contacted from Ibrahim Medical College. The investigators from the Medical College discussed regarding the objectives and procedural steps of the study in detail with the mill authority. Workers working in the mill for at least 5 years were enrolled in the study. Six hundred participants were selected from a total of 5500 JMWs. The selection was randomized from every morning shift so that the looms remain functioning without interruption. Verbal consent was taken from each participant. A semi-structured questionnaire was used for data collection. Each participant was interviewed regarding - i) personal history (age, education, social class, family income, employment, type and duration of dust exposure, smoking) and ii) clinical history (past and present illness, medication, family history of obstructive lung disease, diabetes, stroke, hypertension and coronary artery disease). Anthropometry: Several anthropometric measurements namely height, weight, waist and hip circumference were taken to assess the general and central obesity status. Body mass index (BMI) was calculated using weight in kilogram divided by height in meter and expressed as kg/m2. Waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) were calculated as waist measurement divided by hip or height measurement respectively. BMI was used for determining the general obesity while the latter two (WHR, WHtR) indicated central obesity. Blood pressure of each participant was measured after ensuring at least ten minutes of rest in a complete relaxed environment. The means of two readings were accepted. are expressed in means with 95% confidence interval (Table-1). The means with 95% CI of age, BMI, WHR, SBP and DBP were 44.19 (43.34 – 45.04) years, 24.44 (24.16 – 24.73), 0.90 (0.90 – 0.91), 118.9 (117.4 – 120.4), 79.69 (78.81 – 8/0.54), respectively. The comparisons of bio-physical characteristics (mean with SDs) between men and women were also shown in the same Table. Some anthropometric measures differed significantly. The peak flow value was found significantly higher in men than women.     Table-2: Socio-demographic characteristics of participants (n = 514) The interviewing session (clinical history and medical records) revealed that 14.6%JMWs had diagnosed diseases and 85.4% were (apparently) healthy (Table-3). These findings indicate that some non-communicable diseases (NCDs) were prevalent at any given time. The most common ailment, as revealed from history and medical records, was hypertension (HTN, 5.2%) and other common illnesses were diabetes mellitus (DM, 4.5%)) and HTN plus DM (3.5%). For respiratory illness, only two (0.4%) had bronchial asthma.   Table-3: Prevalence of illnesses among the jute mill workers (n = 514) based on clinical history, medication and medical records.   Table-4: The prevalence of illnesses among the jute mill workers (n = 514; Male / Female = 478 / 36) identified following study investigations   The prevalence of systolic hypertension was 16.5% and diastolic hypertension was 7.2% and there was no significant difference between men and women. Known hypertension was 5.3% (Table-3), if compared with Table-4 then it would be clear that many of them had undetected hypertension. Likewise, diabetes also remained undetected (4.5% in Table-3, 11.9% in Table-4). As regards proteinuria the findings were similar ((0.2% vs. 3.1%). Only three participants (0.58%) had coronary heart disease. Interestingly, almost 1/4th of the study population had hypertriglyceridemia (23.9%) and hypercholesterolemia (24.3%). These findings indicate that these jute mill workers carry increased cardiovascular risks. Table-5 depicted how peak flow values correlated with the values of spirometry. Correlation coefficient ‘r’ assessed how much significant were the correlations of peak flow values (n=514) with that of spirometry values obtained from participants randomly selected (n=67) for spirometry test.   Table-5: Correlations between peak flow (liter/second) with values of spirometry   Most of the spirometry values correlated significantly with the values of peak flow indicating the importance of peak flow meter test. The spirometry values were used to detect restrictive and obstructive respiratory abnormalities. Table-6 compared the values between normal and restrictive lung function and Table-7 showed the comparisons between normal and obstructive ones. Both the tables showed significant differences of spirometry values between normal and restrictive; and between normal and obstructive lung functions.   Table-6: Comparison of spirometry findings between participants having normal and restrictive lung functions (normal and restriction: FEV1/FVC <85% and ≥85% of the predictive)   Table-7: Comparison of spirometry findings between participants having normal and obstructive respiratory abnormalities (normal and obstruction: FEV1/FVC ≥70% and <70% of the predictive)       High Resolution Computerized Tomography (HRCT) was done in participants with restrictive and obstructive disorders. The HRCT findings were mostly helpful in diagnosing the restrictive cases, where fibrosis was evident. Mild to moderate obstruction could not be detected by HRCT though very severe obstruction was detected as evidenced by hyperinflation.   Discussions This study is the first one that addressed the health of jute mill workers encompassing not only the respiratory illnesses but also other non-communicable diseases. The prevalence rates of byssinosis like syndrome, observed in this study, are consistent with other study [2,3]. But the complaints of chest tightness symptoms observed in this study was much higher (25.7%) than found by Saha et.al (5.1%) [9]. However, Mandal and Majumder reported even much higher rate (33.49%) of chest tightness among jute mill workers from West Bengal, India [10]. A study from Benin, Africa reported the prevalence of chronic cough, breathlessness (dyspnea), asthma and chronic bronchitis as 16.8%, 17.3%, 2.6%, and 5.9% respectively among textile workers exposed to cotton dust [11]. The findings are almost similar to our observations. The prevalence of obstructive lung disease was much less (0.8%) than that of other studies (17% - 28%) [12]. It may happen that the workers suffering from chronic obstructive pulmonary disease (COPD) are considered disable and removed from job. Thus, the prevalence of COPD among our study population was found low. The term byssinosis has been used for long time to denote an obstructiveairwaydisease due to inhalation of dust from cotton,flax,hemp, or jute, though it’s diagnostic criteria are ill defined. Garson Hollander reported first (1953) a case of byssinosis [13]. Its diagnosis was based on “careful history” (chest tightness, breathlessness, chronic cough) and the chest x-ray showing pulmonary tuberculosis like appearance. No matter how carefully the histories are taken from such suspected cases, these symptoms are likely to vary and the diagnostic validity may be challenged. It may be suggested that the term byssinosis or the criteria for its diagnosis needs evaluation and should be based on objective scientific evidence and methods. Most of the studies related to organic dust exposure, whether be it jute or cotton or silk, addressed only respiratory or ventilatory functional disorders. But, the illnesses of workers of these industries are not confined only to respiratory diseases. The other systemic illnesses need to be investigated. Our study not only addressed the respiratory diseases, but also focused into other systemic illnesses, which we considered important to assess the overall health of JMWs. The questions remained unanswered how healthy they are. It may be noteworthy to cite a report published online by Pyakurel et al from Nepal on “Catastrophic health expenditure among industrial workers” [14]. We emphasize that the industrial workers’ health need comprehensive care (promotive, preventive, curative and rehabilitative), keeping in mind that they are indeed low paid marginalized section of the society. It is not known however, how many of the workers lose their jobs due to illnesses and disabilities. This study had some important limitations. Many reports stressed that the exposure to both inhalable organic dust and airborne endotoxin are responsible for the pathogenesis of respiratory illnesses observed in cotton workers [15-17]. It may be mentioned that retting of jute is a special process where jute is soaked in a mixture of oil and water at 250C for 48 hours. The bacteria that grow during the process help in softening and easy separation of individual fiber from the jute sticks. However, these bacteria also produce endotoxin. The workers handling this process are therefore, likely to be exposed to the bacterial endotoxin. This endotoxin has been reported to cause lung tissue damage [15]. In the present study, we could not measure the endotoxin level in work place of the JMWs where they were likely to get exposed to it. As the jute mill workers are exposed to sound pollution, generated from looms, they are possibly at risk of developing hearing problem and mental irritability [18]. We could not assess these health problems. We also could not assess the ocular, auditory, dermal, musculoskeletal and mental illnesses. Had we performed the spirometry for all participants we could have more accurate rate of abnormal ventilatory functions of the JMWs. Physical activities were assessed using a crude estimation considering “x” min walking equivalent. It would have been better if we could assess their diet. Despite all those limitations this study explored some important information on health and diseases status of the JMWs.   Conclusions This study concludes that a sizeable proportion of industrial workers, exposed to organic dust, have been suffering from respiratory illnesses. In addition, the study has revealed that a substantial number of this population suffers from undiagnosed hypertension, diabetes and other non-communicable diseases. They also bear the brunt of undetected cardiovascular risk like dyslipidemia. It was not possible to determine the ocular, auditory, musculoskeletal and mental health problems. This study suggests that a well designed study should be undertaken addressing the limitations mentioned above.   Acknowledgement We are grateful to the authority of Latif-Bawany Jute mill for their assistance in arranging the site of investigation and giving the list of participants in such a way that the production in the mill remained uninterrupted. We are also very much grateful to the participants volunteering the study.   Contribution of Authors MMR: Project supervision, questionnaire designing data collection and entry; MAHGM: Performed biochemical tests; MAS: Study design, questionnaire preparation, data analysis and manuscript writing.   Conflict of Interest None.   Funding This study was financed by Ibrahim Medical College Research Fund.   Reference 1.   Annual Report. India: National Institute of Occupational Health; National Institute of Occupational Health. 1985-86, 1986-87,  1987-88. 2.   Chattopadhyay BP, Alam J, Bandyopadhyay B, Gangopadhyay PK. Study to evaluate the occurrence of byssinosis among jute mill workers by clinical history and acute and chronic changes of forced expiratory volume. Indian J Environ Prot. 1993; 13: 903–908. 3.   Chattopadhyay BP, Saiyed HN, Alam J, Roy SK, Thakur S, Dasgupta TK. Inquiry into occurrence of Byssinosis in jute mill workers. J Occup Health. 1999; 41: 225–31. 4.   Chatterjee BP, Alam J, Gangopadhyay PK. A study of dynamic lung function in jute mill workers. Indian J Indus Med. 1989; 35:   157–165. 5.   Bangladesh Bureau of Statistics (BBS) Statistics and Informatics Division (SID) Ministry of Planning. www.bbs.gov.bd. 6.   Quanjer PH, Stanojevic S, Cole TJ, Baur X, Hall GL, Culver BH, et al. Multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lung function 2012 equations. Eur Respir J. 2012; 40(6): 1324-1343. 7.   Niven R McL, Pickering CAC. Byssinosis: a review. Thorax. 1996; 51: 632-637. 8.   Pellegrino R, Viegi G, Brusasco V, Crapo RO, Burgos F, Casaburi R, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005; 26(5): 948-68. 9.   Saha A, Das A, Chattopadhyay BP, Alam J, Dasgupta TK. A Comparative study of byssinosis in jute industries. Indian J Occup Environ Med. 2018; 22(3): 170-176. 10.  Mandal (Majee) A, Majumder R. Pulmonary function of jute mill workers from West Bengal, India. Prog Health Sci. 2014; 4 (1): 7-17. 11.  Hinson AV, Lokossou VK, Schlünssen V, Agodokpessi G, Sigsgaard T and Fayomi B. Cotton dust exposure and respiratory disorders among textile workers at a textile company in the Southern Part of Benin. Int J Environ Res Public Health. 2016; 13(9): 895. 12.  Er M, Emri SA, Demir AU, Thorne PS, Karakoca Y, Bilir N, Baris IY. Byssinosis and COPD rates among factory workers manufacturing hemp and jute. Int J Occup Med Environ Health. 2016; 29(1): 55-68. 13.  Hollander G. Byssinosis. Chest J. 1953; 24(6): 674-678. 14.  Pyakurel P, Tripathy JP, Minn Oo M, Achrya B, Pyakurel U, et al. Catastrophic health expenditure among industrial workers in a large-scale industry in Nepal, 2017: a cross-sectional study. BMJ Open. 2018; 8(11): e022002. 15.  Christiani DC, Ye TT, Zhang S, Wegman DH, Eisen EA, Ryan LA, et al. Cotton dust and endotoxin exposure and long-term decline in lung function: Results of a longitudinal study. Am J Ind Med. 1999; 95: 321–331. 16.  Mayan O, Torres Da Costa J, Neves P et al. Respiratory effects among cotton workers in relation to dust and endotoxin exposure. Ann Occup Hyg. 2002; 46: 277–280. 17.  Smit LAM, Heederik DJJ, Doekes G, Lammers J-WL, Wouters I. Occupational endotoxin exposure reduces the risk of atopic sensitization but increases the risk of bronchial hyperresponsiveness. Int Arch Allergy Immunol. 2010; 152: 151–8. 18.        Roggia SM, de França AG, Morata TC, Krieg E, Earl BR. Auditory system dysfunction in Brazilian gasoline station workers. Int J Audiol. 2019; 24: 1-13. <![CDATA[Management of non-absorbable mesh infection after hernia repair by negative pressure wound therapy]]> Amreen Faruq HM Sabbir Raihan Muhtarima Haque https://imcjms.com/journal_full_text/324 2019-06-20 12:18:35 Original Article IMC J Med Sci 2019; 13(1): 008 Abstract Background and objectives: Mesh infection following hernia repair has previously often resulted in removal of mesh. The aim of this study was to evaluate if negative pressure wound therapy (NPWT) can be used to treat such complications and preserve the mesh. Materials and method: A prospective study was carried in the Department of Surgery, BIRDEM General Hospital from January 2017 to January 2019. Patients with deep wound infection and exposed infected mesh after hernioplasty were included in the study. Patients’ demographics, existing comorbidities and outcome were recorded. All patients were treated with NPWT till the wound was covered with healthy granulation tissue and closed. Results: NPWT was used to treat 7 patients with mesh infection following hernia repair. There was 2 male and 5 female cases and age ranged from 38-58 years. With NPWT the mesh in 6 patients (86%) out of 7 could be completely salvaged and wound closed with secondary suturing. However, in 1 patient although the mesh covered with granulation tissue by NPWT and wound was closed; but it had to be partly removed later on due to development of chronic discharging sinus 20 days after stitch removal. Conclusion: The study demonstrated that NPWT was a useful technique for the treatment and preservation of infected mesh after hernia repair. IMC J Med Sci 2019; 13(1): 008. EPub date: 20 June 2019. DOI: https://doi.org/10.3329/imcjms.v13i1.42041 Address for Correspondence: Dr. Amreen Faruq, Assistant Professor, Department of Surgery, BIRDEM General Hospital, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka 1000. E-mail: dramreen78@yahoo.com   Introduction The use of prosthetic mesh in the repair of abdominal wall hernias that occur either due to open or laparoscopic surgery is the gold standard treatment. Mesh repair significantly reduces hernia recurrence by 30 % [1-3]. However, as with any prosthetic implant the mesh is susceptible to infection. The reported incidence of mesh infection following hernia repair varies from 1% to as high as 7-8% [4-8]. The rate of mesh infection following hernia repair in our hospital is not available. The exact incidence may be difficult to find probably due to its variable presentation with symptoms starting in early postoperative period to several years after surgery. Mesh infection is a misery for the patient as it is associated with longer hospital stay, added expenditure and emotional trauma. The recommended treatment for mesh infection involving non absorbable mesh is early surgical removal of the mesh and wound care [4-10]. However, this may leave behind a more complex open wound with an abdominal wall weakness, resulting in a recurrent hernia. Negative pressure wound therapy (NPWT) is a newer technique used in the management of wound infection. This therapy enhances wound healing by (a) removing excess exudates, (b) providing a controlled moist environment, and (c) promoting neovascularization and granulation tissue formation. Moreover, it also stimulates shrinking of the wound size [11-13]. Taking into account of these properties, the present study was undertaken to evaluate the NPWT in the salvation/management of infected mesh of hernioplasty cases.   Materials and Methods This prospective study was carried out in the department of Surgery, BIRDEM General Hospital from January 2017 to January 2019. Patients included in the study were informed of the treatment options and informed written consent was obtained. Study population: All patients diagnosed with deep wound and mesh infection/exposure following hernia repair (incisional, inguinal, umbilical, paraumbilical) were included in the study. Minor superficial surgical site infection following mesh repair were excluded. Mesh infection was defined as presence of local signs of wound infection namely purulent discharge /pus or abscess formation at the level of mesh with positive microbiological culture results. Superficial surgical site infection was defined as infection that occurred within 30 days of surgery involving skin and subcutaneous tissue of incision while deep surgical site infection was defined as infection involving deep soft tissue (fascia, muscle) [14]. Information regarding age, body mass index (BMI)), presence of comorbidities , site of hernia wound and size, type of mesh used for the repair of hernia and number of days when infection occurred after hernioplasty operation were recorded in a pre-designed data sheet. Negative pressure wound therapy (NPWT): After obtaining consent, negative pressure wound therapy (NPWT) was employed for the management/ salvation of the infected mesh. NPWT procedure involved controlled application of sub-atmospheric pressure to a local environment using a sealed wound dressing connected to a vacuum pump [15]. Initially the wound size was measured and surgical debridement of the wound was done under general or spinal anesthesia. Then, wound size was again measured after debridement and NPWT applied. A sterile black sponge was cut into specific size according to shape, size and depth of the prepared wound. A tube with multiple perforations at one end was placed within the sponge ensuring that the end with perforations remained inside the sponge and the rest taken out through the sponge. The sponge was soaked in 10% povidone iodine solution and wrapped with Sofratulle (medicated Vaseline gauge) to prevent adherence of the sponge to the wound. The sponge was then placed on the wound just above the mesh; ensuring that the mesh was in firm contact with the underlying wound surface. A transparent occlusive and adhesive dressing was applied over the sponge and the tube brought out through it making sure that the dressing was airtight (Fig 1a, b, c, d). The drainage tube was connected to commercially available portable suction machine or wall mounted suction devices.   Fig-1a. Wound infection after hernioplasty (mesh repair) in an incisional hernia (arrow); 1b: Wound showing exposed mesh after debridement; 1c: NPWT dressing- Black sponge wrapped in Sofratulle being placed in wound; 1d: Airtight occlusive dressing on abdominal wound.   The negative pressure was set to-100 to- 120 mm Hg during the entire NPWT treatment. Suction was automated at 10 minutes interval. Initially the NPWT dressing was opened every third day and a new dressing given, this was done for first 2 sessions then dressing changed every 5th day or once a week depending on the wound condition. The dressing was continued till the wound and mesh was covered with healthy granulation tissue (Fig 2a and 2b). The wound was irrigated with normal saline mixed with 10% povidone iodine (3:1) once daily through the tube. Systemic antibiotics were used according to the results of culture and sensitivity.   Fig-2a. Granulation tissue formation after two sessions of NPWT; 2b: Wound and exposed mesh covered with granulation tissue.   The NPWT was continued till the mesh was covered with granulation tissue. Once the wound was covered with healthy granulation it was cleaned with normal saline and wound closure planned. The wounds were closed either by suture or skin graft depending on the size of the wounds. Healing by secondary intention was allowed in cases where suture or skin graft was not possible. After wound closure, the patients were carefully followed up till wound healed and stitches were removed. Duration of NPWT and length of total hospital stay were also recorded. Sample of wound swab was taken from each case for culture and sensitivity test. There was a follow up plan for 3 years for each patient from the time of wound closure to observe any delayed wound infection, fistula or hernia recurrence.   Results A total of 7 patients were included in this study. Out of 7 cases, 4 were patients primarily operated at BIRDEM General Hospital and 3 were referred from different hospitals after developing wound infection following hernioplasty operation. Among the study patients, 71% (5/7) were female and 29% (2/7) were male. The mean age and BMI of the study patient were 47.85±6.84 years and 30.02 ± 4.97 kg/m2 respectively. About 57% of study patients presented with incisional hernia. Incisional hernia was present mostly in older patients (>50 years) and paraumbilical hernia was present in relatively younger patients (<45 years). Polypropylene mesh was used in majority of the patients (5/7, 71%; Table-1). The mean postoperative day of diagnosis of wound infection was 7.71 ±2.56 days (range 4-11 days). Male patients developed infection earlier (< 6 post operative day) than female patients.   Table-1: Types of hernia and mesh used in study population   Table-2 describes the co-morbidities of the study patients. All the patients were diabetic. Hypertension, chronic kidney disease, bronchial asthma and hypothyroidism were present in 57.1%, 42.9%, 29% and 14% of the study patients respectively. Out 7 cases, 6 had multiple or more than one comorbidity.   Table-2: Details of co-morbidities present in all patients   Table-3 shows the pattern of bacteria isolated from the 7 cases prior to instituting NPWT. Pseudomonas sp was present in 42% patients either individually or in combination with other bacteria such as Esch. coli or Klebsiella sp. Out of 7 cases, 4 had wound infection with single bacteria while 3 had multiple organisms.   Table-3: Pattern of organisms isolated from wound samples of study cases (n=7)   Table-4 shows the size of the wound of the individual case before and after completion of NWPT. Wound size was measured after first debridement and after 3 sessions of NPWT in all patients and finally before closure. There was 22-24 % reduction in wound size after completion of NPWT in all 7 patients.   <![CDATA[A rare case of isolated tuberculous epididymitis in a young man]]> Majed Basit Momin Sandeep Satyanarayana Anamika Aluri https://imcjms.com/journal_full_text/314 2019-02-11 11:33:12 Clinical Case Report IMC J Med Sci 2019; 13(1): 003 Abstract Genitourinary tuberculosis is the second most common extrapulmonary tuberculosis (ETB), after lymph nodes. Isolated tuberculous epididymitis (ITE) is a rare entity among genitourinary tuberculosis and is defined as epididymitis without clinical evidence of either renal or prostate involvement. We present a case of epididymal tuberculosis in a 26 year old male which presented as a right scrotal mass. We discussed this case to emphasize that tuberculous etiology should also be considered in the differential diagnosis of scrotal mass besides malignancy, and an image guided fine needle aspiration cytology (FNAC) and stain for acid fast bacilli (AFB) play crucial role in diagnosis and treatment. IMC J Med Sci 2019; 13(1): 003. EPub date: 11 February 2019. DOI: https://doi.org/10.3329/imcjms.v13i1.42047 Address for Correspondence: Dr. Majed B Momin, Consultant Pathologist, Department of Laboratory Medicine, Yashoda hospital, Malakpet, Nalgonda x-roads, Hyderabad – 500036, India. Email: majedmomin9@gmail.com   Introduction Genitourinary tuberculosis (GUTB) contributes to 30% of extrapulmonary tuberculosis and is a major health problem in India. Epididymal involvement accounts for only about 20% of genitourinary TB. It has been postulated that TB epididymitis almost always results from a tuberculous lesion in the prostate, which is usually secondary to renal TB [1]. Isolated tuberculous epididymitis (ITE) without evidence of renal involvement is, therefore rare and difficult to diagnose. However, ITE may present with a clinical picture similar to that of a scrotal neoplasm [2]. Ultrasound guided FNAC has low risk of complications, performable in outpatient departments, repeatable and useful for multiple lesions [3]. Though ultrasound is able to differentiate neoplastic lesion from abscess but cannot differentiate tuberculous from non-tuberculous suppurative lesions. ITE, if diagnosed correctly, can potentially be cured by anti-TB medications, and surgical resection is usually reserved for those patients who do not respond to medical treatment [4]. Here,we present a case of isolated epididymal tuberculosis, which presented as a right scrotal mass in a 26 year old male. Cases Report A 26-year-young man presented to the outpatient Medicine department, Yashoda Hospital, Malakpet, Hyderabad (India), with a history of rapidly growing painful right sided scrotal mass over his right testicle for 6 weeks. The patient received treatment for non-specific epididymo-orchitis at another center, but regression was not observed and advised to do surgery. On physical examination, tender mass of the right epididymis; it is observed adhered to the testis with an irregular surface. The overlying skin was intact with no erythema. Examination revealed no signs of lymphadenopathy in the groin region. There were no signs of a direct or indirect hernia. The soft prostate was palpable by digital rectal examination, without any abnormal findings. The patient did not demonstrate any laboratory signs of inflammation. Laboratory tests namely complete blood and platelets counts, prothrombin time, partial and  thromboplastin levels were within normal limits. ESR was elevated (58 mm) at the end of one hour. Urinalysis was normal. Prostate specific antigen (PSA), alphafetoprotein, beta-human chorionic gonadotropin and lactic dehydrogenase (LDH) were within normal ranges.Mantoux test was also negative. Chest X-ray was clear. Scrotal ultrasonography (USG) showed enlarged epididymis with marked heterogenous ecotexture. Ultrasound guided FNAC was performed with needle no.23 (Figure 1a & 1b). Ultrasound guided fine needle aspiration of right epididymis was performed with needle number 23 and scanty yellowish pus like material was aspirated. Cytolological examination of aspirated material by hematoxylin and eosin (H&E) and Pap stains revealed caseous necrotic material, nuclear debris, histiocytes and few granulomas consisting of epithelioid cells (Fig-2A, B & C). Ziehl-Neelson (ZN) stain showed many acid fast bacilli (Fig-2D). Therefore, it was diagnosed as a case of tuberculous epididymitis. The patient was treated initially with isoniazid (INH) 300mg, Rifampin (RMP) 600mg, Pyrazinamide (PZA) 2000mg and Ethambutol (EMB) 1200mg daily for two months. Then, INH and RMP continued for further 6 months.   Fig-1a. Enlarged epididymis (blue arrow) with ultrasound guided needle within (red arrow); 1b. Enlarged epididymis (arrow) with hetergenous echotexture (*).   Fig-2. Photomicrograph of stained aspirated material obtained from right epididymal mass. A: H & E stain showing caseation necrosis, nuclear debris (10x); B: H&E stain showing epithelioid cells in loose clusters (red arrow) (10X); C: PAP stain showing granuloma (green arrow; 40x); D; ZN stain showing positive acid fast bacilli (green arrow).     Discussion Tuberculosis is a disease, which can involve any part of male reproductive system, including the epididymis, vas deference, seminal vesicle, prostate and least commonly the testis. ITE is more common in younger adults. Human immunodeficiency virus infection may increase the risk of genitourinary TB. Kidneys are often the primary organs infected by tubercule bacilli and then spread down the ureters into the bladder. The infecting organism, M. tuberculosis, reaches the epididymis by retrograde extension from the prostate and seminal vesicles, but lymphatic and hematogeneous spread are also possible [5]. The most common clinical presentation of ITE is painful scrotal swelling (40%), followed by scrotal sinus (20%), acute epididymo-orchitis (10%), infertility (10%), and hematospermia (5%) [6]. Interestingly, painless scrotal mass has been described as a common symptom in some case reports of tuberculous epididymitis (not ITE) Irritative voiding symptoms are not as commonly associated with ITE as they are with other genitourinary tuberculosis. ITE typically occurs unilaterally, but a rate of bilateral involvement of 12.5% has been reported. There is no specific laboratory investigation for genitourinary tuberculosis, especially for tuberculous epidydimitis, where urine cultures can be negative for bacilli in half of the specimens and there are no clinical symptoms from other organs or systems. Therefore, its diagnosis is difficult [7]. Imaging studies may show diffuse or focal heterogeneous lesions in the enlarged epididymis, with or without hydrocele, septation, extra-testicular calcification, scrotal abscess, or scrotal sinus tract, which are also common findings of other chronic inflammatory processes or testicular tumor. A definitive diagnosis of ITE is usually based on examination of material obtained by fine needle aspiration or surgical resection of the epididymis [8]. In our case, ultrasound guided FNAC with smear for AFB played a crucial role in diagnosis. It is an outpatient minimal invasive procedure and helps in diagnosing the pathology and nature of epididymal masses without the complication of implantation. Therefore, all patients, especially young men with a suspected epididymo-testicular lesion where differential diagnosis between a scrotal tumor and GUTB is particularly difficult should be further investigated with a fine-needle aspiration. ITE is potentially curable with anti-TB medications, consisting of RMP, INH, EMB, and PZA. The suggested duration of therapy varies from 2 months to 2 years, although a regimen of 9 to 12 months is generally accepted. Intratunical rifampin injection has been suggested as an effective alternative therapy that may enable the side effects of oral therapy to be avoided [9]. According to European Urology Guidelines, treatment of uncomplicated GUTB consists of the combination of either three anti-TB drugs (INH, RMP, EMB or streptomycin) given daily for a period of three months followed by two drugs (INH and RMP) for the next three months, or an initial four-drugs regimen (INH, RMP, EMB and PZA) for two months followed by INH and RMP for four more months [10]. However, some authors recommend surgical intervention if there is no sign of resolution within 2 months or if an intra-scrotal abscess is identified. Surgical resection is usually reserved for those patients who do not respond to medical therapy.   Conclusion Although the possibility of a scrotal neoplasm is high in young men presenting with swollen testicle, a careful diagnostic work-up like minimally invasive diagnostic approaches such as fine needle biopsy is important to avoid unnecessary and inadvertent epididymo-orchiectomy. Clinicians should also be aware of the case of ITE, an entity that can be cured by anti-tuberculous medications if diagnosed in an incipient phase.   Competing interest: Authors declare no conflict of interest   Funding: None   References 1.   Kapoor R, Ansari MS, Mandhani A, Gulia A. Clinical presentation and diagnostic approach in cases of genitourinary tuberculosis. Indian J Urol. 2008; 24: 401-405 2.   Lenk S, Schroeder J. Genitourinary tuberculosis. Curr Opin Urol. 2001; 11: 93-98. 3.   Koss LG, Zajicek J. Aspiration biopsy. In: Koss LG. Diagnostic cytology and histopathologic bases 4th ed. Philadelphia; Pennsylvania; 1992: 1234-1324. 4.   Cimen F, Saka D, Ünsal E, Önal M, Ceylan T, Atikcan  S,  Ogretensoy  M.  A  case  of  Isolated tuberculous epididymitis. Respir Dis J. 2013; 24: 79-81. 5.   Bhargava P Epididymal tuberculosis: Presentation and diagnosis. ANZ J Surg. 2007; 77: 495-496. 6.   Viswaroop BS, Kekre N, Gopalakrishnan G. Isolated tuberculous epididymitis: a review of forty cases. J Postgrad Med.  2005; 51: 109-11; discussion 111. 7.   Wolf JS Jr, McAninch JW. Tuberculous epididymo-orchitis: diagnosis by fine needle aspiration. J Urol. 1991; 145: 836–8. 8.   Muttarak M, Peh WC, Lojanapiwat B, Chaiwun B. Tuberculous epididymitis and epididymo-orchitis: sonographic appearances. AJR Am J Roentgenol. 2001; 176: 1459-66. 9.   Shafik A. Treatment of tuberculous epididymitis by intratunical rifampicin injection. Arch Androl. 1996; 36: 239-46. 10.  Mete C, Severin L, Kurt GN, Michael CB, Truls EBJ, Botto H, et al. EAU guide- lines for the management of genitourinary tuberculosis. Eur Urol. 2005; 48(3): 353–62. <![CDATA[Spontaneous hypoglycemia: a review]]> Sultana Marufa Shefin Nazmul Kabir Qureshi Ahmed Salam Mir Ahasnul Haq Amin Tareen Ahmed Faria Afsana Md. Shah Alam Farhana Akter Md. Shah Emran Tanjina Hossain Md. Shahjamal Khan Marufa Mustari Nusrat Sultana Mohammad Saifuddin Sadiqa Tuqan Shahjada Selim Samir Kumar Talukder Rafiq Uddin Md. Feroz Amin https://imcjms.com/journal_full_text/312 2019-01-24 12:09:35 Review IMC J Med Sci 2019; 13(1): 001 Abstract Spontaneous hypoglycemia is an important entity that may affect multiple organs. The differential diagnosis is broad in individuals with hypoglycemia in the absence of diabetes mellitus. Multiple etiologies may be present concurrently. Drugs, critical illnesses, hormone deficiencies, and non-islet cell tumors should be considered in those who are ill or taking medications. In apparently healthy individuals, endogenous hyperinsulinism due to insulinoma, functional β-cell disorders, or insulin autoimmune conditions are possible, as are accidental, surreptitious or factitious causes of hypoglycemia. Investigations should be guided by clinical scenario. Irrespective of the exact cause of the spontaneous hypoglycemia, treatment consists of correcting the glycemic state and preventing recurrence by alleviating underlying pathology. This review discusses the causes, diagnosis and management of spontaneous hypoglycemia. IMC J Med Sci 2019; 13(1): 001. EPub date: 24 January 2019. DOI: https://doi.org/10.3329/imcjms.v13i1.42048 Address for Correspondence: Dr. Sultana Marufa Shefin, Assistant Professor, Department of Endocrinology, BIRDEM General Hospital, 122 Kazi Nazrul Islam, Shahbag, Dhaka, Bangladesh. Email: shefin_neon@yahoo.com   Introduction In our day to day clinical practice, hypoglycemia is a common clinical problem in patients with diabetes mellitus (DM) using insulin or insulin secretagogues for maintaining the recommended glycemic status [1]. The diagnosis and treatment of a hypoglycemic event in a diabetic case, having medication to lower plasma glucose level are therefore simple. However, hypoglycemia occurring spontaneously in a person without diabetes, a condition referred to as a ‘spontaneous hypoglycemia’ is a puzzling clinical problem and needs its understanding both by the endocrinologist and physicians of all disciplines. Glucose homeostasis in the human body is under strict and continuous regulation of multiple hormones, the delicate balance of which maintains plasma glucose concentrations within the normal range to ensure sufficient nutritional support to organs. Spontaneous hypoglycemia is therefore, an important entity that may affect multiple organs in the body with a wide spectrum of clinical manifestations with significant morbidity in the affected individual [2]. In response to a falling blood glucose level, our body sets up an adaptive response that consists of rapid decline of endogenous insulin secretion, augmented glucagon secretion and sympathetic over-activity. This response is further enhanced with increased secretion of growth hormone and cortisol. When these adaptive physiological mechanisms fail, hypoglycemia becomes evident. Hence, spontaneous hypoglycemia merits a critical consideration in non-diabetic subjects [3,4,5]. The metabolic homeostasis of glucose in the body depends on several glucoregulatory organs such as pancreas, liver, adrenal glands, kidneys, pituitary gland, and the hypothalamus. It is also under the strict control of multiple hormones namely insulin, glucagon, catecholamines, cortisol, and growth hormone [6]. Hence, spontaneous hypoglycemia is unlikely without significant derangements of these systems [2]. Hypoglycemia may develops when the glucose utilization from blood by brain, red blood cells, renal medullae and insulin sensitive tissues, such as muscles exceeds glucose delivery into circulation from dietary carbohydrates and glucose produced from liver and kidneys [6,7]. Under physiological condition, glucose production is high when in need. Hypoglycemia may occur when this capacity falls absolutely or relatively below glucose utilization. In profound hypoglycemia, assays reveal derangement of plasma insulin, C-peptide and pro-insulin levels [6-8]. Therefore, recent progress in identifying etiology, diagnosis and management of spontaneous hypoglycemia is discussed in this review.   Evaluation, etiology and diagnosis of hypoglycemia The diagnostic process starts by the recognition of hypoglycemia as a cause of the presenting symptoms such as confusion, altered level of consciousness, seizure or any of the other autonomic and neuroglycopenic symptoms as mentioned in Table-1 [5, 9]. Diagnosis is difficult because the symptoms are not exclusive for hypoglycemia. Confirmation is done by documenting Whipple's triad [10,11]. The triad consists of (i) symptoms or signs consistent with hypoglycemia [Table 1], (ii) a plasma glucose level less than 55 mg/dl (3.1mmol/L) in venous blood sample and (ii) resolution of symptoms after raising plasma glucose level [11]. After documenting Whipple's triad, the two key elements in the management of non-diabetic subjects with hypoglycemia are: (a) identification of the hypoglycemic etiopathology, and (b) management of the low blood glucose level [8].   Table-1: Symptoms of hypoglycemia [9].     Symptoms that arise first are the autonomic symptoms, mediated by the adrenergic and cholinergic axes of the sympathetic nervous system. Adrenergic symptoms consist of palpitations, tremor, and anxiety and are mediated by an up-regulation of norepinephrine and epinephrine. Cholinergic symptoms include hunger, sweating, and paresthesia and are derived from the acetylcholine released by postganglionic sympathetic neurons. These responses are part of the physiological counter regulatory mechanism, directed against a decrease in plasma glucose level [3,11]. Although, the sympathetic response generates the first type of symptoms, it is not the first counter regulatory mechanism against hypoglycemia. The first physiological response to a decreasing plasma glucose level is a down-regulation of insulin secretion, followed by a second defense of heightened glucagon secretion when blood glucose level falls below 70 mg/dl (3.9 mmol/L). Only when these fail to halt the decreasing plasma glucose, a sympathetic response becomes apparent when blood glucose level falls below 60 mg/dl (3.3mmol/L) [4,12]. The second type of symptoms is the neuroglycopenic symptoms. These symptoms arise due to central nervous system glucose deprivation when blood glucose level falls below 50 mg/dl (2.8 mmol/L). Neuroglycopenic symptoms range from confusion to amnesia, blurred vision, diplopia, dysarthria, seizure and if sufficient, profound loss of consciousness [13]. Prolonged hypoglycemia can cause brain death and hypoglycemia has shown to increase all-cause mortality in cardiac patients [14,15]. Mortality is especially higher for the spontaneous hypoglycemia in non-diabetics [16]. The presence of neuroglycopenic symptoms in patients without diabetes is strongly suggestive of a hypoglycemic disorder [17]. Conversely, there is a low likelihood of a hypoglycemia disorder in those with the presence of neurogenic symptoms in the absence of a low plasma glucose concentration [18]. Capillary blood glucose measurements should not be used in the evaluation of hypoglycemia due to poor accuracy [17]. Symptoms of hypoglycemia may be absent in patients with hypoglycemia due to decreased sympathetic response to recurrent hypoglycemia, prior exercise or sleep [17,19-21]. Hypoglycemia disorders are traditionally classified as being post absorptive hypoglycemia (fasting hypoglycemia) and postprandial hypoglycemia (re-active hypoglycemia). Fasting hypoglycemia is caused by organic pathologies that presents mostly with neuroglycopenic symptoms and re-active hypoglycemia arises from functional disorder which presents often with autonomic features. An insulinoma can present with postprandial or a post-absorptive hypoglycemia [4,5,22]. This approach has limitation as it neither expedites diagnosis nor facilitates an understanding of the pathophysiology of the disorders. The differential diagnosis is broad when hypoglycemia occurs in individuals with hypoglycemia in the absence of diabetes mellitus (Table 2) [17]. Multiple etiologies may be present concurrently. Different causes of hypoglycemia should be considered in patients who are apparently healthy compared to those who are ill. Drugs, critical illnesses, hormone deficiencies, and non-islet cell tumors should be considered in those who are ill or taking medications. In apparently healthy individuals, endogenous hyperinsulinism due to insulinoma, functional β-cell disorders, or insulin autoimmune conditions are possible, as are accidental, surreptitious or factitious causes of hypoglycemia. Hypoglycemia in patients who have had bariatric surgery is increasingly recognized as the frequency of this surgery is in increase. Artifactual hypoglycemia can occur if blood samples are improperly handled (lack of antiglycolytic agent in the collection tube) and there is a delay in processing. Drugs are the most common cause of hypoglycemia (Table 3) [17]. Drug induced hypoglycemia is more common in older patients with underlying comorbidities and in those taking glucose lowering medications. Hypoglycemia in the setting of critical illness is not unusual. Sepsis, hepatic, renal or cardiac failure and hormone deficiencies (cortisol, glucagon and epinephrine) are other causes of hypoglycemia. Non-islet cell tumors and endogenous hyperinsulinism such as insulinoma, non insulinoma pancreatogenous hypoglycemia, and autoimmune hypoglycemia are rare causes of hypoglycemia [17]. Accidental, surreptitious or malicious hypoglycemia due to administration of insulin or insulin secretagogues need also to be considered.   Table-2: Causes of hypoglycemia in adults [17].     Insulinomas primarily cause hypoglycemia in the fasting state, but may cause symptoms in the postprandial period as well. The incidence is 1/250,000 patient/years. Less that 10% are malignant, or may be present in patients with multiple endocrine neoplasia type 1 (MEN1) syndrome [17]. Non-insulinoma pancreatogenous hypoglycemia( NIPHS) typically causes hypoglycemia in the postprandial state. These patients have diffuse islet involvement with nesidioblastosis (islet hypertrophy, hyperplasia and enlarged hyperchromatic β-cell nuclei) [23].   Table-3: Drugs associated with hypoglycemia [17].     Antibodies to insulin or the insulin receptor are rare causes of hypoglycemia [17,18]. Antibodies to native insulin occur primarily in patients of Japanese and Korean descent [24]. Patients with autoimmune hypoglycemia may have other autoimmune disease or exposure to sulfhydryl containing drugs [25]. Late postprandial hypoglycemia occurs as insulin secreted in response to the meal disassociates from antibodies. Diagnosis is made with documentation of elevated insulin antibody levels in the absence of exposure to exogenous insulin [26]. Spontaneous hypoglycemia can rarely be a result of paraneoplastic syndrome secondary to non-beta-cells tumors and is termed as non-islet cell tumor hypoglycemia (NICTH). A variety of malignant and non-malignant tumors such as solitary fibrous tumor and/or mesotheliomas, hemangiopericytoma, hepatocellular carcinoma, gastrointestinal stromal tumors, adenocarcinomas, sarcomas, and renal cell carcinomas may cause NICTH [27]. Unusual cases of NICTH have been reported with adrenocortical and thyroid cancers, Burkitt’s lymphoma, plasmacytoma, yolk cell tumor, Leydig cell tumor, and phyllodes tumor of the breast. These tumors secrete partially processed precursors of insulin-like growth factor-II (IGF-II), otherwise termed ‘big’-IGF-II or pro IGF-II that causes NICTH [27,28]. Big IGF-II interacts with IGF-I receptors and insulin receptors in the target tissues and results in hypoglycemia [2]. Consideration for hormone deficiencies and non-islet cell tumors should be given. When adrenal insufficiency is considered, an ACTH stimulation test should be performed. If the cause of hypoglycemia is not apparent then further laboratory testing is indicated. Capillary blood glucose measurements should not be used in the diagnosis of hypoglycemic disorders due to their poor accuracy in these situations. If possible, testing should be done during symptomatic hypoglycemia. Simultaneous measurements of plasma glucose, insulin, c-peptide, proinsulin, and beta-hydroxybutyrate and a screen for oral hypoglycemic agents (sulfonylureas and meglitinide) should be performed (Table 4).   <![CDATA[Brown Adipose Tissue - role in metabolic disorders]]> Tahniyah Haq Frank Joseph Ong Sarah Kanji https://imcjms.com/journal_full_text/307 2018-11-25 09:34:47 Review IMC J Med Sci 2019; 13(1): 002 Abstract Brown adipose tissue, a thermogenic organ, previously thought to be present in only small mammals and children has recently been identified in adult humans. Located primarily in the supraclavicular and cervical area, it produces heat by uncoupling oxidative phosphorylation due to the unique presence of uncoupling protein 1 by a process called nonshivering thermogenesis. BAT activity depends on many factors including age, sex, adiposity and outdoor temperature. Positron-emission tomography using 18F-fluorodeoxyglucose and computed tomography (18F-FDG PET–CT), magnetic resonance imaging (MRI) and thermal imaging (IRT) are among several methods used to detect BAT in humans. The importance of BAT is due to its role in whole body energy expenditure and fuel metabolism. Thus it is postulated that it may be useful in the treatment of metabolic diseases. However, there are still many unanswered questions to the clinical usefulness of this novel tissue. IMC J Med Sci 2019; 13(1): 002. EPub date: 03 February 2019. DOI: https://doi.org/10.3329/imcjms.v13i1.42049 Address for Correspondence: Dr. Tahniyah Haq, Assistant Professor, Department of Endocrinology, Room 1620, 15th Floor, Block D, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh. Tel phone: 01677791735, email tahniyah81@gmail.com   Introduction The rediscovery of functional brown adipose tissue (BAT) in adult humans has generated interest in its potential as a therapeutic target to improve metabolic health. BATis a thermogenic organ located primarily in the supraclavicular area in adult humans. Smaller deposits are also located in the paravertebral, perinephric and mediastinal areas [1-4]. They possess uncoupling protein 1 (UCP-1) which acts as an alternate proton channel through which hydrogen ions travel down the electrochemical gradient, bypassing adenosine triphosphate (ATP) synthase and dissipating energy as heat [5,6]. This process is called nonshivering thermogenesis and is activated by cold and regulated by the sympathetic nervous system [6,7]. Several studies have demonstrated that this thermometabolic organ contributes to whole body energy expenditure [8-11] and plays a role in glucose [11] as well as lipid metabolism [12]. There is ongoing research to explore the role of BAT in diseases such as type 2 diabetes mellitus, dyslipidaemia and nonalcoholic fatty liver disease. This review aims to highlight the morphology, location, mechanism of action, detection and clinical usefulness of BAT.   Morphology BAT is richly vascularized and densely innervated by terminal fibres of the sympathetic nervous system. It is characterized by polygonal cells with a central nucleus and multiple, small vacuoles that store triglycerides (i.e. multilocular lipid droplets). They are characteristically rich in large, spherical UCP-1 containing mitochondria. UCP-1 is uniquely expressed in the inner mitochondrial membrane and is essential in the uncoupling of mitochondrial oxidative phosphorylation [5].   Location and amount of BAT BAT is strategically located around major blood vessels to ensure adequate delivery of substrates and effective dissipation of heat throughout the body [13]. Infants and children have a considerable amount of active BAT which gradually regresses with age, especially after puberty [14]. In infants, BAT consists of around 1-5% of their body weight [15] and is predominantly found in the interscapular region. Retrospective studies under non-cold stimulated conditions have found that 18F-fluorodeoxyglucose (18F-FDG) uptake is present in 6.8-8.5% of adults [1,16,17]. Out of these adults with detectable BAT activity, 18F-FDG uptake is most commonly observed in the supraclavicular and cervical area (94.2%), paravertebral area (61.6%), mediastinal/para-aortic (28%) and perirenal areas (20.1%) [17]. Histological examination of tissue from the supraclavicular region has confirmed the presence of BAT [1-4,8,16,17]. The estimated amount of active BAT found in adult humans ranges from 4 to more than 1500 ml [18].   As noted earlier, BAT is characterized by an abundance of UCP-1 containing mitochondria. UCP-1, a six-domain transmembrane protein, is central to the production of heat by nonshivering thermogenesis. The expression of UCP-1 can be enhanced by adrenergic stimulation and peroxisome proliferator-activated receptor-γ (PPARγ) agonists [6]. Factors that can increase the metabolic activity of BAT include the use of sympathomimetics, β adrenergic agonists and cold exposure [6,7,19-21,25]. During BAT activation, there is upregulation of UCP-1, which allows protons to travel down the electrochemical gradient while bypassing the ATP synthase. As a result of this uncoupling of oxidative phosphorylation, ATP is not synthesized and energy is dissipated as heat. With less ATP production, there is no negative feedback inhibition of the respiratory chain, producing a futile cycle [6] (Figure 1).     In addition to the cooling protocol, the prevalence of BAT also depends on age, sex, adiposity and outdoor temperature [17]. Age is an independent negative predictor of BAT activity and mass, with BAT being more prevalent in younger individuals [2,10,16,17,22,23]. However, the cause of this age-dependent decline in BAT is currently unknown, but changes in sex and thyroid hormones as well as the activity of the sympathetic nervous system associated with increasing age have been speculated to be contributing factors [24]. Females have been observed to have more BAT activity and mass compared to males in some studies [16,17,22] but not all studies [23,25,26]. The difference in the prevalence of BAT between males and females may be due to the different effects of sex hormones on BAT activity [22] and the fact that females start to shiver at a higher temperature compared to males [27]. Body mass index (BMI), central obesity, body fat percentage and visceral fat are consistently lower in people with detectable BAT activity [2,10,16,23,28,29]. BMI is not only negatively correlated with BAT, but is also an independent predictor [1,2,16-17,28]. Whether increased BAT activity results in a lower BMI or vice versa is still not known. Nahon and colleagues reported that larger individuals with higher lean mass require exposure to lower temperatures to activate cold-induced thermogenesis due to higher basal heat generation in this population. As such, studies investigating the relationship between BAT and adiposity should consider body size, composition and energy expenditure when designing cold-induced thermogenesis studies [30]. BAT is more likely to be detected during the winter compared to summer [1,2,31]. In addition, BAT activity and mass is inversely related with outdoor temperature at the time [1] or day [17,32] of the scan.These studies show that lower outdoor temperature is associated with increased BAT prevalence, volume and activity. Multiple imaging modalities have been utilized to characterize and differentiate BAT from surrounding tissues based on its unique anatomical and functional properties. These techniques include 18F-FDG PET-CT, magnetic resonance imaging (MRI), infrared thermography (IRT) and autonomous temperature sensors (i.e. iButtons). A detailed review outlining recent advances in BAT detection has recently been published by our group and therefore will only be briefly discussed [33]. 18F-FDG PET-CT is the current reference standard in the detection of BAT. This modality measures the uptake of a glucose analogue (i.e. 18F-FDG) that is taken up by BAT but is not metabolized [34]. Moreover, PET-CT has been instrumental in advancing our knowledge in the identification, location and nature of BAT [1-3,8,16,17]. However, a major limitation of PET-CT is the significant and unnecessary exposure to ionizing radiation precluding its use in large cohorts and in children [35]. Thus, alternative modalities including MRI have been utilized in the detection of BAT. The use of this technique is dependent on the morphological differences between BAT and surrounding tissues resulting in unique MR signatures which can be measured using fat-fraction (FF) and T2* relaxation (T2*). Generally, BAT is characterized by smaller FF and T2* values due to its lower lipid content, greater vascularization and abundance of iron-rich mitochondria. In addition, both FF and T2* can also be used to measure BAT metabolic activity as reductions in these parameters have been associated with 18F-FDG uptake [36]. Imaging modalities that measure changes in skin temperature including IRT and autonomous temperature sensors have been used to detect BAT [13]. These techniques rely on the heat produced by BAT via non-shivering thermogenesis in the overlying skin when activated. However, the use of these modalities in measuring BAT activity is often confounded by skin thickness, increased blood flow and muscle activity upon cold exposure. As such, further investigation is warranted before these modalities can be widely adapted in the measurement of BAT. Other emerging modalities are currently being developed to measure BAT. However, these methods are of limited availability, expensive and still in their infancy. Examples include detection of BAT using hyperpolarized MRI [37,38], contrast ultrasound, near-infrared fluorescence imaging [39] and near-infrared time-resolved spectroscopy. 2.   Saito M, Okmatsu-Ogura Y, Matsushita M, Watanabe K, Yoneshiro T, Nio-Kobayashi J, et al. High incidence of metabolically active brown adipose tissue in healthy adult humans: effects of cold exposure and adiposity. Diabetes. 2009; 58: 1526–1531. 4.   Zingaretti MO, Crosta F, Vitali A, Guerrieri M, Frontini A, Cannon B, et al. The presence of UCP-1 demonstrates that metabolically active adipose tissue in the neck of adult humans truly represents brown adipose tissue. FASEB Journal. 2009; 23: 3113–3120. 6.   Richard D, Carpentier AC, Dore´ G, Ouellet V, Picard F. Determinants of brown adipocyte development and thermogenesis. Int J Obes. 2010; 34: S59–S66. 8.   Van Marken Lichtenbelt WD, Vanhommerig JW, Smulders NM, Drossaerts J M, Kemerink GJ, Bouvy ND, et al. Cold activated brownadipose tissue in healthy men. N Engl J Med. 2009; 360: 1500–1508. 10.  Yoneshiro T, Aita S, Matsushita M, Kameya T, Nakada K, Kawai Y, et al. Brown Adipose Tissue, Whole-Body Energy Expenditure, and Thermogenesis in Healthy Adult Men. Obesity. 2011; 19: 13–16. 14.  Virtanen KA, Nuutila P. Brown adipose tissue in humans. Nutr Metab. 2011; 22: 49–54. 16.  Lee P, Greenfield JR, Ho KKY, Fulham MJ. A critical appraisal of the prevalence and metabolic significance of brown adipose tissue in adult humans. Am J Physiol Endocrinol Metab. 2010; 299(4): E601–E606. 18.  Blondin DP, Labbé SM, Turcotte EE, Haman F, Richard D, Carpentier AC. A critical appraisal of brown adipose tissue metabolism in humans. Clin Lipidol. 2015; 10: 259–280. 22.  Pfannenberg C, Werner MK, Ripkens S, Stef I, Deckert A, Schmadl M, et al. Impact of age on the relationships of brown adipose tissue with sex and adiposity in humans. Diabetes. 2010; 59: 1789–1793. 24.  Lecoultre V, Ravussin E. Brown adipose tissue and aging. Cur Opin Clin Nutr Metab Care. 2011; 14: 1–6. 25.  Cypess AM, Chen YC, Sze C, Wang K, English J, Chan O, et al. Cold but not sympathomimeticsactivates human brown adipose tissue in vivo. Proc NatlAcad Sci USA. 2012; 109(25): 10001–10005. 27.  Van der Lans AAJJ, Wierts R, Vosselman MJ, Schrauwen P, Brans B, van Marken Lichtenbelt WD. Cold-activated brown adipose tissue in human adults: methodological issues. Am J Physiol Regul Integr Comp Physiol. 2014; 307: R103–R113. 29.  Green AL, Bagci U, Hussein S, Kelly PV, Muzaffar R, Neuschwander-Tetri BA, et al. Brown adipose tissue detected by PET/CT imaging is associated with less central obesity. Nucl Med Commun. 2017; 38(7): 629–635. 31.  Cohade C, Mourtzikos KA, Wahl RL. ''USA-Fat'': Prevalence Is Related to Ambient Outdoor Temperature--Evaluation with 18F-FDG PET/CT. The Journal of Nuclear Medicine. 2003; 44: 1267–1270. 35.  Cypess AM, Haft CR, Laughlin MR, Hu HH. Brown fat in humans: Consensus points and experimental guidelines. Cell Metab. 2014; 20: 408–415. 37.  Branca RT, White C, Zhang L. Detection of brown fat mass and activity by hyperpolarized xenon MR. Proceedings of the 21st Annual Meeting ISMRM, Salt Lake City, UT. 2013; 404. 39.  Azhdarinia A, Daquinag AC, Tseng C, Ghosh SC, Ghosh P, Amaya-Manzanares F, et al. A peptide probe for targeted brown adipose tissue imaging. Nat. Commu. 2013; 4: 2472. 41.  Iwen KA, Backhaus J, Cassens M, Walti M, Hedesan OC, Merkel M, et al. Cold-induced brown adipose tissue activity alters plasma fatty acids and improves glucose metabolism in men. J Clin Endocrinol Metab. 2017; 102(11): 4226-4234. 43.  Stefan N, Pfannenberg C, Häring HU. The Importance of Brown Adipose Tissue. N Engl J Med. 2009; 361(4): 416-417. 45.  Lee P, Smith S, Linderman J, et al. Temperature-acclimated brown adipose tissue modulates insulin sensitivity in humans. Diabetes. 2014; 63: 3686–369. 47.  Liu X, Wang S, You Y, Meng M, Zheng Z, Dong M, et al. Brown adipose tissue transplantation reverses obesity in ob/ob mice. Endocrinology. 2015; 156: 2461–2469. <![CDATA[A systematic review of implicit bias in health care: A call for intersectionality]]> Oluwabunmi Ogungbe Amal K. Mitra Joni K. Roberts https://imcjms.com/journal_full_text/315 2019-03-13 11:27:58 Review IMC J Med Sci 2019; 13(1): 005 Abstract Background and objectives: Health disparities are a growing concern in health care. Research provides ample evidence of bias in patient care and mistrust between patient and providers in ways that could perpetuate health care disparities. This study aimed to review existing literature on implicit bias (or unconscious bias) in healthcare settings and determine studies that have considered adverse effects of bias of more than one domain of social identity (e.g., race and gender bias) in health care. Methods: This is a systematic review of articles using databases such as EBSCO, Embase, CINAHL, COCHRANE, Google Scholar, PsychINFO, Pub Med, and Web of Science. Search terms included implicit bias, unconscious bias, healthcare, and public health. The inclusion criteria included studies that assessed implicit bias in a healthcare setting, written in English, and published from 1997-2018. Results: Thirty-five articles met the selection criteria – 15 of which examined race implicit bias, ten examined weight bias, four assessed race and social class, two examined sexual orientation, two focused on mental illness, one measured race and sexual orientation, and another investigated age bias. Conclusions: Studies that measured more than one domain of social identity of an individual did so separately without investigating how the domains overlapped. Implicit Association Test (IAT) is a widely used psychological test which is used to determine existence of an implicit bias in an individual. However, this study did not find any use of an instrument that could assess implicit bias toward multiple domains of social identities. Because of possible multiplicative effects of several biases affecting a single entity, this study suggests the importance of developing a tool in measuring intersectionality of biases. IMC J Med Sci 2019; 13(1): 005. EPub date: 13 March 2019. DOI: https://doi.org/10.3329/imcjms.v13i1.42050 Address for Correspondence: Amal K. Mitra, Professor of Epidemiology, School of Public Health, Jackson State University, 350 West Woodrow Wilson Drive, Room 216,Jackson, MS 39213; e-mail: amal.k.mitra@jsums.edu   Introduction Gender inequality is a major social issue which may adversely affect women’s health in developing countries. Similarly, race, gender, sexual orientation, body weight, social class, nationality, and religion are common social identities where discrimination or bias exists in many developing and developed societies. The combined adverse effects of implicit bias (or unconscious bias) towards persons with intersecting social identities are stronger than the separate effects of a single identity. An intersectionality framework is a useful approach to understanding the complexities of health disparities and inequalities. Intersectionality is a theoretical framework for understanding how several social identities such as race, gender, socioeconomic status, sexual orientation, disability etc., intersect on a micro level of individual experience to show interlocking systems of privilege and oppression (i.e., racism, sexism, heterosexism, classism, etc.) at the macro social-structural level [1,2]. The term ‘intersectionality’ was first coined by Kimberlé Crenshaw in 1989. Crenshaw in her 1989 essay “Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory, and Antiracist Politics,” described the understandings of race and sex/gender, by outlining marginalization of Black women from the discourse of White feminists and racism [3-5]. In the United States, the progress made in reducing implicit attitudes towards race and gender seem to have occurred at a surface level [9]. Such biases are well documented resulting in health disparities, inequities, and inequalities [6,10]–all focus areas of health care [7]. Intersectionality has been widely studied in law, psychology and gender studies, but is scarce in mainstream public health research [11,12]. Similar to intersectionality, the hypothesis of double jeopardy posits that when individuals, (especially women), belong to two or more subordinated groups, the disadvantage they face is added or multiplied. A common example is being a woman (gender bias) and being of color (racial bias). Chappell and Havens (2016) described this as the combined adverse effects of occupying two stigmatized statuses as being more significant than occupying each status separately [13]. Double jeopardy and intersectionality were confirmed in the empirical study by Williams (2014) [11]. The study also noted that biases experienced by women differed not only by race but within race, such that women of color have experiences of discrimination that are different from other women of the same race [11]. In contexts such as politics and employment, people’s behavior and decision making are greatly influenced by race and gender. The intersectionality of race and gender usually results in a multiplicative predictive value [14]. The presumption of intersectionality is not that all intersecting identities are equally disadvantageous. Instead, the theory considers how the low and high status of social identities multiplies to result in disparity. An intersectionality framework is useful for understanding the complexities of implicit biases and its result in health disparities and inequalities [12]. Therefore, the purpose of this study was to evaluate the literature on implicit bias in healthcare settings and determine whether the literature reflect studies that have considered the multiplicative effects of individuals when assessing implicit bias.   Methods Search Strategy Using recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [15], a comprehensive literature search was conducted from May 2017 to December 2018 of the databases such as EBSCO, Embase, CINAHL, COCHRANE, Google Scholar, PsychINFO, Pub Med, and Web of Science from the years 1997-2018 to capture studies investigating implicit bias. Studies were eligible for inclusion if they met the following criteria: 1) published in years 1997-2018; 2) assessed implicit bias in a healthcare setting; 3) the study population being patients or providers, and 4) the articles written in English. Dissertations were eligible, but editorials, responses, and commentaries were excluded. All experimental and quasi-experimental designs were included along with papers reporting any intervention used to reduce bias in a health setting.   Data Extraction Of the 2,267 research articles identified through database searching (Figure 1), 1,952 research articles were screened after removing duplicates. Next step of screening was to remove articles addressing implicit bias in non-health related fields and those which did not yield full articles (n = 1,868). The third step of screening was to exclude articles published before 1997 (n = 20), editorial or short commentary (n = 11), and those which did not meet other inclusion criteria (n = 18). This screening process yielded a total of 35 studies for final review.     Fig-1. PRISMA diagram   Measurement Tools of Intersectionality Quantitative methods A number of statistical methods have been proposed for testing intersectionality. These are: 1) The Hierarchical Classes Analysis (HICLAS) in which subgroup differences are examined [16]; 2) Cross-tabulation which was used in a study by Covarrubias (2011) [17]; and 3) Logistic Regression has also been used in a number of studies, especially with an addition of the multiplicative interaction term [18,19], as well as by creating pattern of association in multiple domains of implicit bias using Latent Class Analysis [20]. Some of these methods are based on the propositions of Hancock (2007) and McCall (2005) [21,22]. McCall (2005) described three possible methods to measure intersectionality quantitatively: Anti-categorical Complexity - this approach sees categories as divisions which were socially constructed by people but not based on reality; Intra-categorical complexity -here, categories are not rejected, they are not made the central point; and Inter-categorical complexity - this approach uses categories, but the focus is on the changing relationships between the different identities [22,23].   Qualitative methods Methods in qualitative research such as community participatory action research and ethnography (interviews and case studies) are well suited methods for conducting intersectionality research [24]. The intersectionality-informed qualitative research primer written by Hunting (2014) provides a comprehensive tool kit for qualitative research methods of intersectionality of social identities. Community participatory action research is useful in that the targeted population directly inform and dictate the direction of the research as well as appropriate interventions. Interviews and case studies are used to explore the intricacies of intersecting identities, and the effects on the lives of individuals [23,24].   Results In this review, more than half of the studies (19 of 35, 54%) focused on race/ethnicity implicit bias, followed by weight or fat-bias (10 of 35, 29%), and race and social class bias (4 of 35, 11%). Only 14% (5 of 35) of the studies measured more than one domain of implicit bias such as race and social class bias, and race and sexual orientation. Two studies reported bias related to mental illnesses, and two reported weight bias alone (Figure 2).     Fig-2. Categories (percent) of implicit bias identified in this study (n = 35)   Detailed information including the type of implicit bias, study population, aim of the study, and major findings of the 35 selected studies are presented in Table 1. Majority of the studies reported the presence of moderate to strong implicit bias among the participants. Twelve studies found strong evidence of implicit bias favoring White Americans [25-33], while two studies found weak to moderate evidence of race bias [34,35]. Green et al (2007) found implicit stereotypes of African Americans as less cooperative with medical procedures [10]. Some studies examined the relationship between clinician’s implicit bias and the quality of the provider-patient relationship [27,31,32,36,37]. Table-1: Type of implicit bias, study population, adverse effects of bias, and major findings of 35 studies   Type of implicit bias measured Aim of the study outcome Boysen & Vogel 2008 [2] 105 Counselor Trainees were assessed for implicit bias toward African Americans, lesbians and gay men and for self-reported multicultural competency. Implicit bias existed among Counselor Trainees despite high self-reported multicultural competency. Sabin et al. 2009 [16] To measure doctors’ (n = 2,535) implicit preference for patients by race. Strength of implicit bias exceeded self-report among all MDs except Black MDs. Women showed less implicit bias than men. Oliver et al. 2014 [27] 543 family and internal medicine physicians. To evaluate whether the magnitude of implicit racial bias predicts physician recommendation of total knee replacement for black and white patients with osteoarthritis. Participants had a strong implicit preference for Whites over Blacks, but this did not predict treatment recommendations. Hausmann et al. 2015 [29] 14 physicians and 162 patients with spinal cord injury (SCI). To examine implicit racial bias of physicians and its association with functioning and wellbeing for individuals with SCI. Physicians had a strong pro-white/anti-black bias. Greater physician bias was associated with disability among individuals with SCI. Haider et al. 2014 [31] To determine if unconscious race and class biases exist specifically among trauma/acute care surgeons and (n = 248); if so, whether those biases impact surgeons' clinical decision making. 74% of the participants had IAT scores demonstrating an unconscious preference toward White persons; 91% demonstrated an implicit preference toward upper social class persons. These biases were not statistically significantly associated with clinical decision making. Schaa et al. 2015 [33] 67 genetic counselors. To explore the relationship between genetic counselors’ implicit racial attitudes and their communication during simulated genetic counseling sessions. Genetic counselors showed a moderate to strong pro-White bias on the Race IAT. Counselors with stronger pro-White bias tended to use less emotionally responsive communication when counseling minority simulated clients. Sabin et al. 2012 [35] 86 academic pediatricians. To examine association between pediatricians’ attitudes about race and treatment recommendations by patients’ race. Pediatricians’ implicit attitudes about race affect pain management. Blair et al. 2013 [37] 210 physicians, 2,908 patients. To investigate whether clinicians’ explicit and implicit ethnic/racial bias is related to Black and Latino patients’ perceptions of their care. Clinicians’ implicit bias may jeopardize their clinical relationships with Black patients, which could have negative effects on other care processes. Haider et al. 2015 [39] 245 registered nurses. To find association between racial and social class bias with clinical decision making. Implicit association tests scores did not statistically correlate with vignette-based clinical decision making. Dabby et al. 2015 [41] 35 Psychiatry residents and 68 psychiatrists. Psychiatrists and residents did not harbor negative implicit bias towards mental illness. Schwart et al. 2003 [43] 389 clinicians and researchers. To determine the level of anti‐fat bias in health professionals specializing in obesity. Health professionals exhibited a significant pro‐thin, anti‐fat implicit bias on the IAT. In addition, the subjects significantly endorsed the implicit stereotypes of lazy, stupid, and worthless. Miller et al. 2013 [45] To determine the prevalence of weight-related biases among medical students (n = 310) and whether they were aware of their biases. 33% (101/310) self-reported a significant (“moderate” or “strong”) explicit anti-fat bias. No students self-reported a significant explicit anti-thin bias. According to the IAT scores, over half of students had a significant implicit weight bias: 39% (121/310) had an anti-fat bias and 17% (52/310) an anti-thin bias. Two-thirds of students (67%, 81/121) were unaware of their implicit anti-fat bias. Sabin et al. 2012 [47] 2,284 medical doctors. To examine implicit and explicit attitudes about weight among MDs and determine the pervasiveness of negative attitudes about weight among MDs. Strong implicit and explicit anti-fat bias is as pervasive among MDs as it is among the general public. Waller et al. 2012 [49] 45 nursing and 45 psychology students. A statistically significant implicit bias was found in both groups. Phelan et al. 2015 [51] 1,795 medical students surveyed at the beginning of their 1st year and end of their 4th year.To assess medical school factors that influence change in implicit and explicit bias against people with obesity. Increased implicit and explicit biases were associated with less positive contact with patients who have obesity and more exposure to faculty role-modeling of discriminatory behavior or negative comments about patients with obesity. Increased implicit bias was associated with training in how to deal with difficult patients. Sabin et al. 2015 [53] To examine attitudes toward heterosexual people versus lesbian and gay people in 2,338 medical doctors, 5,379 nurses, 8,531 mental health providers, 2,735 other treatment providers, and 214,110 non-providers in the United States. Generally, implicit preferences always favored heterosexual people over lesbian and gay people among heterosexual providers. Heterosexual nurses held the strongest implicit preference for heterosexual men over gay men (Cohen d = 1.30; 95% confidence interval = 1.28, 1.32 among female nurses; Cohen d = 1.38; 95% confidence interval = 1.32, 1.44 among male nurses). Penner et al. 2016 [55] 18 oncologists, 112 patients. To examine whether oncologists’ implicit bias negatively affect communication and patient reactions to recommended treatment. Oncologist implicit racial bias was associated with less patient centered and supportive communication, and less patient confidence in treatment. van Ryn et al. 2015 [57] 3,547 medical students. To examine the effect of medical education in changing students’ racial implicit bias. Medical school experience explored in the study was independently associated with a change in students’ implicit bias.   Mental Health Stull et al (2013) found that participants had implicit bias towards people with mental illness [40], while Dabby et al (2015) who measured implicit bias among psychiatrists and residents found no negative implicit bias towards patients with mental illness [41].   Weight Eight studies measured weight implicit bias and found moderate to strongimplicit bias among participants [42-49]. Of the two studies that employed an intervention, the intervention did not significantly improve implicit weight bias [48,50]. One study conducted by Phelan et al (2015) [51] found evidence that medical school factors may influence weight implicit bias. Such medical school factors include: 1) The type of interaction medical students has had with overweight or obese patients during training, whether positive or negative, interacted with their weight implicit bias; 2) Medical students in training perceived obese patients to be ‘difficult’ to manage, because more time is spent treating them, even though the circumstances are that obese patients are likely to have many co-morbidities, hence, requiring more treatments; 3) The medical school disparity curriculum is focused on racial implicit bias, and much less on other kinds of biases; and 4) Working with senior medical colleagues and treating them as role models during clinical rotations make negative comments or show negative attitudes towards patients based on their weight among medical students [51].   Sexual Orientation & Aging Boysen & Vogel (2008) measured race and sexual orientation bias and found implicit bias present towards African Americans, Lesbians and Gay men among the participants [2]. In both of the studies that examined implicit bias associated with sexual orientation, there were stronger implicit preferences for heterosexuals than Lesbians, and Gay, although the strength of association varied [52,53]. Ruiz et al (2015) showed that participants' implicit measure showed negativity towards the elderly, but there was no difference between the groups compared [54].    Bias in Healthcare In an attempt to predict physicians’ racial bias in the recommendation for thrombolysis in patients with acute coronary syndrome, three IATs were used: Race Preference IAT, Race Cooperativeness IAT, and Race Medical Cooperativeness IAT [10]. All three IATs showed significant racial bias. Physicians diagnosed more Blacks with coronary artery disease than White patients [10]. A similar study which measured implicit bias among physicians and people with terminal degrees found significant implicit bias especially among the female participants [25]. One study investigated the link between clinicians’ unconscious attitudes concerning race with the physician-patient communication during clinic visits and patient ratings of care. In particular, they examined two implicit attitudes about race: general racial bias and racial bias regarding stereotyping patient compliance. Studies found that physicians’ biases are associated with markers of poor visit communication and poor ratings of care, especially in Black patients [27]. Moskowitz et al (2012) observed that physicians stereotype certain diseases with Blacks. This suggests that diagnoses and treatment of Black patients may be biased [28]. The researchers focused on the following questions relating to the accessibility of healthcare professionals’ stereotypes: 1) Are stereotypes made accessible without awareness whenever one person categorizes another as a member of a stereotyped group? 2) Does this unconscious event result in both the factual information associated with a group and the incorrect, undesired elements of the stereotype (which are explicitly rejected) attaining accessibility and heightened potential influence? This study concluded that diagnoses and treatment of African American patients may be biased implicitly. The conclusions from this study are similar to results from Green et al (2007), Blair et al (2013), Cooper et al (2012), and Penner (2016) [10,36,55,56]. However, in studies conducted by Oliver et al (2014), Blair et al (2014), and Rojas et al (2017), there were insufficient evidence to conclude that racial implicit bias of healthcare providers influenced the quality of care or clinical judgment, although implicit bias was present among participants [27,32,34].   Types of Healthcare Personnel Measured About 64% of the studies measured implicit bias among medical doctors [10,26-32,34-37,41,42,44,46,55-57], the rest included registered nurses (11%), medical students (20%), genetic counselors (0.2%), research and health professionals (0.8%) [42,43], and pre-kinesiology students (0.2%). Forty-two percent of the studies included specific medical specialties: internal medicine, primary care physicians, and emergency residents [10,27,36,39,46]. Five studies showed evidence on both health care providers and patients. Types of patients were: patients with hypertension or spinal cord injury, and patients of different races [29,32,36,37,55]. More than a quarter (26%) of the study included participants who were students, the category of students being medical students, nursing students, psychology students, and masters level dietetic students [30,34,45,48,49,51,52,54].   Types of Measurement Tools Used Implicit Association Test Thirty-three of the 35 articles (94%) included in the review used IAT to measure implicit bias among the participants. Two of these was a pen-and-paper IAT [2], others were computer-based or online. The IATs varied by the type of implicit bias being measured. Two of the studies measured racial implicit bias using different methods such as Race preference IAT, Race Cooperativeness IAT, and Race Medical Cooperativeness IAT [10,27].   Case study Nine (26%) of the studies used case or clinical vignette [26,27,29,30,34,39,47]. One study used case vignette only, without the IAT, the rationale being that the latter is considered a non-blinded measure, and does not effectively measures behavior and clinical evaluation [34]. Another study used subliminal priming to measure implicit bias [28]. Another study had a pre-and post-test experimental design that used educational films as interventions and several measurements including IAT to compare the outcomes of the two groups [48]. Many of the studies in this review alsomeasured explicit biases that are at conscious level and made on purpose, but information about explicit bias was not included in the scope of this review.   Intersectionality Among the selected articles, 15 studies measured race/ethnicity implicit bias only; two studies focused on sexual orientation, two measured implicit bias of mental illness, ten examined weight (anti-fat) bias, while one article looked at anti-aging implicit bias only. Among the studies which measured more than one type of implicit bias, four assessed implicit bias on race and social class, one study measured race and sexual orientation. The studies that measured more than one domain (e.g., race and sexual orientation) did so separately without investigating how the domains overlapped or interacted with each other.   DiscussionThe studies included in this systematic review showed the outcome of six types of implicit bias such as race, weight or fat, social class, sexual orientation, mental illness, and aging. The outcome measurements were physician’s clinical decision making, physician’s preference for patients by race, doctor-patient communication, physician’s treatment recommendation, physician’s quality of care, and patient’s perception of their care. Of the 35 studies reviewed, the majority (n = 24, 68.6%) reported a positive adverse effect of bias on health outcome measurements. Two major biases identified in this study were race bias and weight or fat bias. These two biases, among others, could be considered major mediators of potential health disparities affecting the African American population in the United States. According to U.S. Census Bureau 2016 estimate [58], the African American population are mostly distributed in District of Columbia (49%), and in some southern states including Mississippi (38%), Louisiana (34%), Georgia (33%), South Carolina (29%), and Alabama (28%). Likewise, some of the southern states including Mississippi (37.3%), Oklahoma (36.5%), Alabama (36.3%), Louisiana (36.2%), and Arkansas (35.0%) are also ranked worst in terms of adult obesity rates in the country [59]. As a result of double whammy of having majority of Black population and the burden of obesity, these southern states are especially vulnerable to implicit bias in health care.In our analysis, only 14% (5 of 35) of the studies reported more than one domain of implicit bias affecting a single entity, whereas the studies did not examine the intersectionality of the domains investigated. Although intersectionality has been widely studied in law, psychology and other fields, this topic has received little attention in public health, especially in identifying the contributions of intersecting implicit biases to health disparities [12]. It is known that social identities intersect, and this has the potential to influence individuals’ life experiences, social interactions, and health status. Although some interlocking identities are favorable, the precept of intersectionality helps explain how neglect of overlapping social identities may translate into a health disparity. In a study, Bowleg (2012) identified intersectionality theory as an important theoretical framework for public health. The theory has the potential to enhance the precision of identifying marginalization, and developing intervention strategies with relevant outcomes [12,13].In developing countries, such as Bangladesh, India, Malaysia, Nepal, and Pakistan, the problem of biases in healthcare services is often overlooked. In these societies, preference for a male child is near universal and utilization of health care is preferred for boys over girls. In a cross-sectional study of 3,100 families in a rural community in western India, significantly more boys than girls (88.9% vs. 76.5%, respectively) were given treatment by a registered medical practitioner (odds ratio, 2.51) [60]. Referrals for further treatment were followed by parents significantly more often for their sons than daughters (69.2% vs. 25.0%; OR 6.75). Similar bias toward preferential healthcare for males was observed in a treatment center in Bangladesh [61]. In-depth surveys of intra-family food distribution showed that males consistently consumed more calories and proteins than females at all ages, even when nutrient requirements due to varying body weight, pregnancy, lactation, and activity levels were consideredmales consistently consumed more calories and proteins than females at all ages, even when nutrient requirements due to varying body weight, pregnancy, lactation, and activity levels were consideredmales were given In-depth dietary surveys showed that males consistently consumed more calories and proteins than females at all ages, even when nutrient requirements due to varying body weight, pregnancy, lactation, and activity levels were considered.more calorie- and protein-rich foods compared with females of all ages, even when nutrient requirements due to varying body weight, pregnancy, lactation, and activity levels were considered [61]. Due to scarce of data, there is an urgent need of future research on the issue of intersectionality of biases based on religion, cast, ethnic minority, and economically marginalized population (especially landless impoverished villagers, and ever-expanding urban slum dwellers) and their effects on the healthcare services in developing countries.To measure the intersectionality of implicit bias or evaluate multiple domains of social identities, an appropriate measurement tool is essential. IAT is the most widely used tool for assessing implicit bias, while this instrument measures a broad range of biases, each independently. The Hierarchical Classes Analysis (HICLAS) and statistical methods such as regression analyses, ANOVA, and qualitative methods have been identified as novel approaches to measuring interactions and the intersectionality of multiple identities [16]. However, the results of these analyses do not seem to describe the intersectionality theory. Issues such as differences in terminology, the amount of value ascribed to each identity in order to have a true mathematical meaning and incorporating intersectionality to population health models are described by Bauer (2014) [18]. Future studies are needed to measure the multiplicative effects of several biases identified in a single health care entity.The field of public health is inherently intersectional, which further emphasizes the need to employ multiple methods in the study of the intersectionality of implicit biases. The focus of implicit bias research has mostly been in a healthcare setting. Researches have also examined the effects of implicit bias on clinical judgment and its contribution to health disparities. It is high time that public health professionals focus on implicit bias within public health. Finally, intersectionality presents the field of public health with a framework for addressing health disparities, considering the dearth of public health research that addresses the multiplicity of social identities [1]. Nevertheless, the benefits of studies of intersectionality are not without their own challenges. The challenges of intersectionality research include: a lack of precise methodology to study intersectionality; the difficulty in determining weight of all intersectional identities; whether to focus on intersectional identities or processes [1, 12]; and lack of evidence of appropriate statistical methods in measuring the intersectionality of multiple identity. Public Health Implications1.The theory of intersectionality has not exhausted its movement. To further understand the relationships between implicit bias towards individuals based on their identities, and health disparity, the application of the intersectionality may provide new insight.2.The IAT has been well received in many fields of academia. It has been used by hundreds of studies and programs to measure implicit bias. However, the present IAT seem largely insufficient to measure the intersectionality of these biases. Hence, to fully explore these, a measurement tool that fulfills this need must be developed.3.Within the last decade, there has been an avalanche of studies programs and interventions aimed at mitigating health disparity. An interesting dimension would be studies that examine the intersectionality of these determinants of health, and how much the multiplicative effects contribute to health disparity and its effects on the health status of the population.4.The theory of intersectionality is similar to the theory behind the epidemiological and statistical procedure of effect modification using the multiplicative model. An exploration of the similarities between these should be explored, and the results would be instrumental in understanding and designing interventions directed at health disparity in public health. ConclusionsIntersectionality promises to be useful in understanding the interactions and complexities of social determinants of health, health disparities, and the effects of the multiplicities of various forms of implicit biases. This review shows a research gap of not measuring the multiplicative effects of implicit biases in public health. Intersectionality studies have several challenges, but it continues to evolve and should be explored by public health researchers and professionals. AcknowledgementsThe authors acknowledge the Jackson State University librarians who assisted with the identification of databases and the in-depth literature search. Authors’ contributionsOO collected data, wrote the initial draft, and revised the manuscript; AKM developed the concept, supervised the study, and edited the manuscript; and JKR developed the concept, collected data, and critically reviewed the manuscript. Conflict of Interest: The authors declare no conflict of interest. References1.Bowleg L. When black + lesbian + woman ≠ black lesbian woman: The methodological challenges of qualitative and quantitative intersectionality research. Sex Roles. 2008; 59(5-6): 312-325.2.Boysen GA, Vogel DL.The relationship between level of training, implicit bias, and multicultural competency among counselor trainees. Training Educ Professional Psychol. 2008; 2(2): 103-110.3.Carbado DW, Crenshaw KW, Mays VM, Tomlinson B. INTERSECTIONALITY: Mapping the movements of a theory. Du Bois Rev. 2013; 10(2): 303-312.4.Hull GT, Bell-Scott P, Smith B (eds). All the women are white, all the blacks are men: But some of us are brave. Black women’s studies. Second edition. The Femnist Press, 1991.5.Crenshaw K. Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. Univ Chicago Legal Forum. 1989.6.Blair IV, Banaji MR. Automatic and controlled processes in stereotype priming. J Personality Soc Psychol. 1996; 70(6): 1142-1163.7.Fazio RH, Jackson JR, Dunton BC, Williams CJ. Variability in automatic activation as an unobtrusive measure of racial attitudes: A bona fide pipeline? J Personality Soc Psychol. 1995; 69(6): 1013-1027.8.Devine PG. Stereotypes and prejudice: Their automatic and controlled components. J Personality Soc Psychol. 1989; 56(1): 5-18.9.Greenwald AG, Banaji MR. Implicit social cognition: Attitudes, self-esteem, and stereotypes. Psychol Rev. 1995; 102(1): 4-27.10.Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Int Med. 2007; 22(9): 1231-123811.Williams JC. Double jeopardy? An empirical study with implications for the debates over implicit bias and intersectionality. Harvard J Law Gender. 2014; 37(1): 185-242.12.Bowleg L. The problem with the phrase women and minorities: Intersectionality - an important theoretical framework for public health. Am J Public Health. 2012; 102(7): 1267-1273.13.Chappell NL, Havens B. Old and female: Testing the double jeopardy hypothesis. Sociological Quart. 2016; 21(2): 157-171.14.Parks GS, Rachlinski JJ. Unconscious bias and the 2008 presidential election. Cornell Law Faculty Publications. Paper 95, 2008.15.Moher D, Liberati A, Tetzlaff J, Altman DG. The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med. 2009; 6(7): e1000097.16.Stirratt MJ, Meyer IH, Ouellette SC, Gara MA. Measuring identity multiplicity and intersectionality: Hierarchical Classes Analysis (HICLAS) of sexual, racial, and gender identities. Self and Identity. 2008; 7(1): 89-111.17.Covarrubias A. Quantitative intersectionality: A critical race analysis of the Chicana/o educational pipeline. J Latinos Edu. 2011; 10(2): 86-105.18.Bauer GR. Incorporating intersectionality theory into population health research methodology: Challenges and the potential to advance health equity. Soc Sci Med. 2014; 110: 10-17.19.Dubrow J. Why should we account for intersectionality in quantitative analysis of survey data? In: Kallenberg V, Meyer J, Müller JM (Eds.). Intersectionality und Kritik. Springer Fachmedien Wiesbaden, 2013: 161-177.20.Garnett BR, Masyn KE, Austin SB, Miller M, Williams DR, Viswanath K. The intersectionality of discrimination attributes and bullying among youth: An applied latent class analysis, J Youth Adoles. 2014; 43(8): 1225-1239.21.Hancock AM. When multiplication doesn’t equal quick addition: Examining intersectionality as a research paradigm. Perspectives Politics. 2007; 5(1): 63-79.22.McCall L. The Complexity of Intersectionality. Signs. 2005; 30(3): 1771-1800.23.Witteloostuijn AO van. Applying intersectionality as a method. A critical analysis of how to apply feminist and intersectional methodologies in qualitative research.Utrecht University, 2018, Faculty of Humanities Thesis.24.Hunting G. Intersectionality-informed qualitative research: A primer. Institute for Intersectionality Research and Policy, Simon Fraser University, British Columbia, Canada. 2014.25.Sabin JA, Nosek BA, Greenwald AG, Rivara FP. Physicians’ implicit and explicit attitudes about race by MD race, ethnicity, and gender. J Health Care Poor Underserved. 2009; 20(3): 896-913.26.Puumala SE, Burgess KM, Kharbanda AB, et al. The role of bias by emergency department providers in care for American Indian children. Med Care. 2016; 54(6): 562-569.27.Oliver MN, Wells KM, Joy-Gaba JA, Hawkins CB, Nosek BA. Do physicians' implicit views of African Americans affect clinical decision making? J Am Board Fam Med. 2014; 27(2): 177-188.28.Moskowitz GB, Stone J, Childs A. Implicit stereotyping and medical decisions: Unconscious stereotype activation in practitioners' thoughts about African Americans. Am J Public Health. 2012; 102(5): 996-1001.29.Hausmann LRM, Myaskovsky L, Niyonkuru C, et al. Examining implicit bias of physicians who care for individuals with spinal cord injury: A pilot study and future directions. J Spinal Cord Med. 2015; 38(1): 102-110.30.Haider AH, Sexton J, Sriram N, et al. Association of unconscious race and social class bias with vignette-based clinical assessments by medical students. J Am Med Assoc. 2011; 306(9): 942-951.31.Haider AH, Schneider EB, Sriram N, et al. Unconscious race and class bias: Its association with decision making by trauma and acute care surgeons. J Trauma Acute Care Surg. 2014; 77(3): 409-416.32.Blair IV, Steiner JF, Hanratty R, et al. An investigation of associations between clinicians' ethnic or racial bias and hypertension treatment, medication adherence and blood pressure control. J Gen Int Med. 2014; 29(7): 987-995.33.Schaa KL, Roter DL, Biesecker BB, Cooper LA, Erby LH. Genetic counselors’ implicit racial attitudes and their relationship to communication. Health Psychology. 2015; 34(2): 111-119.34.Rojas M, Walker-Descartes I, Laraque-Arena D. An experimental study of implicit racial bias in recognition of child abuse. Am J Health Behav. 2017; 41(3): 358-367.35.Sabin JA, Greenwald AG. The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: Pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma. Am J Public Health. 2012; 102(5): 988-995.36.Cooper LA, Roter DL, Carson KA, et al. The Associations of clinicians’ implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. Am J Public Health. 2012; 102(5): 979-987.37.Blair IV, Steiner JF, Fairclough DL, et al. Clinicians' implicit ethnic/racial bias and perceptions of care among Black and Latino patients. Annals Fam Med. 2013; 11(1): 43-52.38.Haider AH, Schneider EB, Sriram N, et al. Unconscious race and social class bias among acute care surgical clinicians and clinical treatment decisions. JAMA Surgery. 2015; 150(5): 457-464.39.Haider AH, Schneider EB, Sriram N, et al. Unconscious race and class biases among registered nurses: Vignette-based study using implicit association testing. J Am College Surgeons. 2015; 220(6): 1077-1086.e1073.40.Stull LG, McGrew JH, Salyers MP, Ashburn-Nardo L. Implicit and explicit stigma of mental illness: Attitudes in an evidence-based practice. J Nervous Mental Dis. 2013; 201(12): 1072-1079.41.Dabby L, Tranulis C, Kirmayer LJ. Explicit and implicit attitudes of Canadian psychiatrists toward people with mental illness.Canadian J Psychiatry. 2015; 60(10): 451-459.42.Teachman BA, Brownell KD. Implicit anti-fat bias among health professionals: Is anyone immune? Int J Obes Related Metabolic Disorders. 2001; 25(10): 1525-1531.43.Schwartz MB, Chambliss HO, Brownell KD, Blair SN, Billington C. Weight bias among health professionals specializing in obesity. Obesity Res. 2003; 11(9): 1033-1039.44.Sabin JA, Moore K, Noonan C, Lallemand O, Buchwald D. Clinicians' implicit and explicit attitudes about weight and race and treatment approaches to overweight for American Indian children. Childhood Obesity. 2015; 11(4): 456-465.45.Miller Jr DP, Spangler JG, Vitolins MZ, et al. Are medical students aware of their anti-obesity bias? Acad Med. 2013; 88(7): 978-982.46.Phelan SM, Dovidio JF, Puhl RM, et al. Implicit and explicit weight bias in a national sample of 4,732 medical students: The medical student CHANGES study. Obesity (Silver Spring). 2014; 22(4): 1201-1208.47.Sabin JA, Marini M, Nosek BA. Implicit and explicit anti-fat bias among a large sample of medical doctors by BMI, race/ethnicity and gender. PLoS One. 2012; 7(11): e48448.48.Swift JA, Tischler V, Markham S, et al. Are anti-stigma films a useful strategy for reducing weight bias among trainee healthcare professionals? Results of a pilot randomized control trial. Obesity Facts. 2013; 6(1): 91-102.49.Waller T, Lampman C, Lupfer-Johnson G. Assessing bias against overweight individuals among nursing and psychology students: An implicit association test. J Clin Nurs. 2012; 21: 3504-3512.50.Rukavina PB, Li W, Shen B, Sun H. A service learning based project to change implicit and explicit bias toward obese individuals in kinesiology pre-professionals. Obesity Facts. 2010; 3(2): 117-126.51.Phelan SM, Puhl RM, Burke SE, et al. The mixed impact of medical school on medical students' implicit and explicit weight bias. Med Educ. 2015; 49(10): 983-992.52.Burke SE, Dovidio JF, Przedworski JM, et al. Do contact and empathy mitigate bias against gay and lesbian people among heterosexual first-year medical students? A report from the medical student CHANGE study. Acad Med. 2015; 90(5): 645-651.53.Sabin JA, Riskind RG, Nosek BA. Health care providers’ implicit and explicit attitudes toward lesbian women and gay men. Am J Public Health. 2015; 105(9): 1831-1841.54.Ruiz JG, Andrade AD, Anam R, et al. Group-based differences in anti-aging bias among medical students. Gerontol Geriatrics Educ. 2015; 36(1): 58-78.55.Penner LA, Dovidio JF, Gonzalez R, et al. The effects of oncologist implicit racial bias in racially discordant oncology interactions. J Clin Oncol. 2016; 34(24): 2874-2880.56.Blair IV, Havranek EP, Price DW, et al. An assessment of biases against Latinos and African Americans among primary care providers and community members. Am J Public Health. 2013; 103(1): 92-98.57.van Ryn M, Hardeman R, Phelan SM, et al. Medical school experiences associated with change in implicit racial bias among 3547 students: A medical student CHANGES study report. J Gen Int Med. 2015; 30(12): 1748-1756.58.U.S. Census Bureau 2016 Estimate. African American Population by State.59.Robert Wood Johnson Foundation. The state of obesity. Adult obesity rate by state, 2017.60.Ganatra B, Hirve S. Male bias in health care utilization for under-fives in a rural community of western India. Bull WHO. 1994; 72(1): 101-104.61.Chen LC, Huq E, D’Souza S. Sex bias in the family allocation of food and health care in rural Bangladesh. Pop Develop Rev. 1981; 7(1): 55-70. <![CDATA[Vitamin D and bone mineral density status among postmenopausal Bangladeshi women]]> A.K.M. Shaheen Ahmed Wasim Md. Mohosin Ul Haque Khwaja Nazim Uddin Fadlul Azim Abrar Farhana Afroz Hasna Fahmima Huque Samira Rahat Afroze Muhammad Abdur Rahim https://imcjms.com/journal_full_text/278 2018-03-05 15:41:21 Original Article IMC J Med Sci 2018; 12(2): 44-49 Abstract Background and objectives: Low vitamin D is a global problem in all age groups as is osteoporosis in postmenopausal women. The present study was carried out in an urban hospital to assess serum 25-hydroxyvitamin D [25(OH)D] level and bone mineral density (BMD) in postmenopausal women (PMW) and to evaluate correlation between serum 25(OH)D levels and BMD. Methods: A single center cross-sectional study was conducted among 133 apparently healthy PMW aged 45 years and above with the history of complete cessation of menstruation over a period of more than 1 year. Serum 25(OH)D, BMD and serum intact parathyroid hormone (iPTH) were determined. Patients having both vitamin D and BMD values were analyzed for correlations. Similarly, correlation of vitamin D, iPTH and BMD were determined. Results: Among the study population, 63 (47.4%) had deficient (<20 ng/ml), 46 (34.6%) had insufficient (20-30ng/ml) and 24(18%) had sufficient (30-100ng/ml) levels of serum 25(OH)D. Among the 121 patients whose BMD was done, 52 (43.0%) and 60 (49.6%) had osteoporosis and osteopenia respectively. Serum iPTH levels were normal in 34 (89.5%) patients. The proportion of osteopenia and osteoporosis in vitamin D deficient group were 44.1% and 50.8% and in insufficient group 47.5 and 45.0%, respectively. Age had significant negative correlation with BMD value (r=-0.246, p=.005) and significant positive correlation with serum iPTH (r=0.358, p=.024). There was no statistically significant influence of serum 25(OH)D or iPTH on occurrence of osteoporosis (P=0.322 and P=0.592 respectively). Conclusion: A large proportion of postmenopausal women had low vitamin D levels and as well as osteopenia and osteoporosis. Low vitamin D level coexisted with low BMD. However, there was no correlation between serum 25(OH)D levels and BMD status. IMC J Med Sci 2018; 12(2): 44-55. EPub date: 05 March 2018. DOI: https://doi.org/10.3329/imcjms.v12i2.39660 AKMSA & WMMH contributed equally to this study. Address for Correspondence: Dr. A.K.M. Shaheen Ahmed, Associate Professor,Department of Internal Medicine, BIRDEM General Hospital, 122 Kazi Nazrul Islam Avenue, Dhaka, Bangladesh;  Email: akm_shaheen@yahoo.com   Introduction It is well known that postmenopausal women (PMW) are prone to suffer from vitamin D deficiency and osteoporosis [1]. A study conducted among 18-33 years old Bangladeshi woman reported low vitamin D levels in 81% women despite being exposed to sun for more than 20 hours per week [2]. Low vitamin D status was observed among female Bangladeshi garment workers aged 20-40 years [3]. Few other studies also reported low vitamin D status in selected Bangladeshi women population [4,5]. Vitamin D deficiency is associated with low bone mineral density (BMD) leading to osteopenia or osteoporosis in adults. The deficiency is believed to cause secondary hyperparathyroidism, leading ultimately to bone loss by increased bone turnover [6,7]. There are reports of co-existence of vitamin D deficiency and low BMD among postmenopausal women of many countries of the world [8-10]. There is little information about vitamin D status and osteoporosis in Bangladeshi postmenopausal women. There is one study about the status of BMD in Bangladeshi women. The study showed, 43.6% and 5.5% of 16–45 years old women, and 40.7% and 41.8% of 46–65 years old women had osteopenia and osteoporosis respectively [11]. In view of the above, the present study was undertaken to determine the levels of serum 25-hydroxyvitamin D [25(OH)D], intact parathyroid hormone (iPTH) and BMD in postmenopausal women (PMW) and the correlation among them.   Materials and methods Study population: This cross-sectional observational study was conducted on 133 healthy postmenopausal women aged 45 years and above with the history of complete cessation of menstruation over a period of more than 1 year. Participants were enrolled as they presented for routine medical care to an urban hospital in Dhaka city from July 2016 to June 2017. Relevant data were obtained in a predesigned questionnaire. All women were from urban/semi-urban locality. They were included irrespective of any vitamin D or calcium intake and exposure to sunlight per day. A comprehensive physical examination was done. Women with a major medical illness such as hepatic dysfunction, significant thyroid dysfunction, renal disease, parathyroid or any other metabolic bone disorders and malignancies were excluded from the study. Women on steroid therapy or any anti-osteoporotic medications like hormone replacement therapy or bisphosphonates were also excluded from the study. All participants were enrolled in the study after obtaining informed consent.   Biochemical measurements: Serum 25(OH) D was measured by automated chemiluminescence immunoassy (Dimension EXL 200/Advia Centaur XP). Women were classified based on vitamin D levels as deficient (<20 ng/ml); insufficient (20–30 ng/ml); and sufficient (>30-100 ng/ml) [12]. Serum iPTH was measured by automated chemiluminescence immunoassay (Liaison Diasorin, Italy). Level <14.5 pg/ml was taken as low, 14.5  to 87.1pg/ml as normal and >87.1pg/ml as high.   Bone mineral density: BMD was assessed with dual-energy X-ray absorptiometry at lumbar spine and neck of femur (either left or right). Bone mineral density values were interpreted as T-score and lowest T-score at any of these sites was taken as the representative T-score. T-score was calculated as the difference between the measured BMD of the patient and the expected bone density value in a normal young person (YN) divided by the population SD. T-score= (BMD−YN)/SD. Normal T-score was defined as >−1, osteopenia −1 to −2.5 and osteoporosis as <−2.5 [13,14].   Statistical analysis: Analysis was performed with the use of IBM SPSS Statistics (version 20.0.0), USA. Results are presented as absolute values, percentage and mean ± standard deviation. Pearson's coefficient (r) was calculated for the correlation between continuous variables. Logistic regression was used to find out the influences of varies variables on occurrence of osteoporosis.   Results A total of 133 post-menopausal women were included in the study. The age ranged from 45-90 years, mean 63.9 ±9.1years. Out of 133 women, 77 (57.9%) and 56 (42.1%) belonged to 45-65 years and 66-90 years age group respectively. The overall results of serum vitamin D, iPTH and BMD T-score are shown in Table-1. Out of 133 women, only 24 (18%) had normal vitamin D level (30-100 ng/ml) while 47.4% and 34.6% were in deficient and insufficient categories respectively (Table-1). The mean vitamin D level of 133 cases was 22.1±11.3 ng/ml. Of the 133 cases, BMD was measured in 121 cases. According to the T-score of BMD measurement test, 42.5% and 49.6% of 121 cases had osteopenia and osteoporosis respectively. Of the 133 cases, serum iPTH was tested in 38 cases and majority (34/38, 89.5%) had normal levels of iPTH. Table-1: Vitamin D, BMD T-score and iPTH levels of the study population     Table-2 shows that 81.9% (deficient 48.1% and insufficient 33.8%) and 84.1% (deficient 46.4% and insufficient 37.7%) of study population belonging to 45-65 and 66-90 years age group respectively had low vitamin D levels. There was no significant (p>0.05) difference of any category of vitamin D levels between the two age groups.   Table-2: Serum vitamin D level in different age groups of study population (n=133)     Osteopenia and osteoporosis were present in 47.1% and 47.7% of study population aged between 45-65 years while only 7.1% had normal BMD T-score. The comparative rate of osteopenia and osteoporosis among 66-90 years age group was 37.3% and 54.9% respectively (Table-3). In Pearson’s correlation analysis, age had significant negative correlation with BMD values (r= -0.246, p=.005).   Table-3: Status of BMD in different age groups of study population (N=121)     The rate of osteopenia and osteoporosis was 44.1% and 50.8% in vitamin D deficient and 47.5% and 45% among insufficient groups. There were 31.8% and 54.5% osteopenia and osteoporosis respectively among women with sufficient level of vitamin D (Table-4). No significant correlations were found between vitamin D and BMD values (r= -0.056, p=.579). No significant difference regarding occurrences of osteopenia and osteoporosis were observed among women with normal vitamin D compared to that of women with deficient or insufficient levels.   Table-4: Distribution of BMD categories of study population according to vitamin D level (n=121)     Serum iPTH levels in women with normal and low vitamin D levels (deficient and insufficient) are shown in Table-5. About 84% to 94% of women with different grades of vitamin D level had normal serum iPTH. By Person’s analysis no significant correlation was found between vitamin D and serum iPTH levels (r=-0.302, p=.066). Also, in logistic regression model no statistically significant influence of vitamin D or serum iPTH were found on the occurrence of osteoporosis (p=0.322, p= 0.592) respectively.   Table-5: Serum iPTH levels in women with different grades of Vitamin D status (n=38)     Discussion The present study investigated the association of serum 25(OH) D levels and BMD in healthy PMW irrespective of dietary intake and sun exposer. Many studies have showed presence of hypovitaminosis D in people living in countries where sunlight is not a problem at all [2-5,15-17]. Vitamin D deficiency is thought to be an important risk factor for the development of osteoporosis. In our study we found high prevalence (82%) of hypovitaminosis D, which was consistent with other studies in Bangladesh and other Asian countries [2-5,16,18,8]. Prevalence of hypovitaminosis D in PMW was found to be 47% in Thailand, 49% in Malaysia, 90% in Japan and 92% in South Korea [19]. Around 40-50 % patients were either osteopenic or osteoporotic in low vitamin group in our study. Osteoporosis was more among relatively older patients. Interestingly, patients among the sufficient vitamin D group also suffered from significant osteopenia and osteoporosis. Begum et al [11] showed that even the younger Bangladeshi women had low BMD and 43.6% and 5.5 % of 16–45 year-old women had osteopenia and osteoporosis respectively. In our study, there was no correlation between serum 25(OH)D levels and BMD. Similar studies done in various part of the world demonstrated that BMD had no significant relation to serum 25(OH)D status [8,20-23]. However, a few studies have shown a positive correlation of serum 25(OH)D levels and BMD [24-26]. The high prevalence of vitamin D deficiency in Bangladesh may be due skin complexion, poor sun exposure (due to clothing), low milk intake, and lack of vitamin D fortification program despite availability of abundant sunlight. The association between 25(OH)D levels and BMD is still a debatable issue. These incongruous results regarding relationship of vitamin D and BMD status might be due to differences in population, age group and the vitamin D levels used to define deficiency and insufficiency in different studies. In this study, age had significant positive correlation with iPTH, chapuy et al found the same correlation in 124 normal subjects aged 20 to 90 years [27]. Probably with increasing age there is decreased calcium absorption resulting in secondary hyperparathyroidism When vitamin D falls below the lower physiological limit, iPTH level progressively rises, at the same time iPTH has a positive correlation with osteoporosis in postmenopausal woman [28]. However, we found no statistically significant association between vitamin D and iPTH or iPTH and osteoporosis. This can be explained by the smaller number of subjects tested for iPTH in current study; however other factors may also contribute. Sahota et al in a prospective study of 30 patients found a blunting response of iPTH to vitamin D deficiency in magnesium depleted patients [29]. The limitations of our study were the small sample, and exclusion of history of dietary habit. So multicentral, large scale study may provide more light into the occurrence of the low vitamin D level and low BMD status in our country. Vitamin D deficiency and osteoporosis are highly prevalent in post-menopausal Bangladeshi women. However, we found no correlation between vitamin D deficiency and osteoporosis in our study population as with many others. Although a direct relationship could not be established between 25(OH)D and BMD, vitamin D deficiency coexisted with low BMD in our study. We should emphasize on the role of adequate intake of calcium, hormone replacement and use of bisphosphonates for the management of osteoporosis in postmenopausal women along with adequate vitamin D intake.   Authors’ contribution AKMSA and WMMH designed the study, did data analysis, literature search and drafted the manuscript, KNU supervised the study, did data collection and revised the manuscript, FAA did data analysis and revised the manuscript, FA, HFH, SRA and MAR reviewed the manuscript, edited and had intellectual contribution to the manuscript   Funding Nil.   Conflicts of interest There are no conflicts of interest.   References 1.   Lips P, Hosking D, Lippuner K, Norquist JM, Wehren L, Maalouf G, et al. The prevalence of vitamin D inadequacy amongst women with osteoporosis: An international epidemiological investigation. J Intern Med. 2006; 260: 245–254. 2.   Micka A.Vitamin D status among Bangladeshi women of reproductive age. Masters Theses, Dhaka: 2009: 287. 3.   Islam MZ, Shamim AA, Kemi V, Nevanlinna A, Akhtaruzzaman M, Laaksonen M, et al. Vitamin D deficiency and low bone status in adult female garment factory workers in Bangladesh. Brit J Nutr. 2008; 99(6): 1322–1329. 4.   Islam MZ, Akhtaruzzaman M, Lamberg-Allardt C. Hypovitaminosis D is common in both veiled and non-veiled Bangladeshi women. Asia Pac J Clin Nutr.2006; 15(1):81–87. 5.   Islam MZ, Lamberg-Allardt C, Karkkainen M, Outila T, Salamatullah Q, Shamim AA. Vitamin D deficiency: a concern in premenopausal Bangladeshi women of two socio-economic groups in rural and urban region. Eur J Clin Nutr. 2002; 56(1): 51–56. 6.   Ooms ME, Lips P, Roos JC, van der Vijgh WJ, Popp-Snijders C, Bezemer PD, et al. Vitamin D status and sex hormone binding globulin: Determinants of bone turnover and bone mineral density in elderly women. J Bone Miner Res. 1995; 10(8):1177–1184.  7.   Dawson-Hughes B. Calcium, vitamin D and vitamin D metabolites. In: Papapolous SE, Lips P, Pols HA, Jhonston CC, Delmas PD, editors. Osteoporosis 1996: Proceedings of the 1996 World Congress on Osteoporosis. Excerpt Med Int Congr Ser 118. Amsterdam, The Netherlands: Elsevier; 1996. p. 299–303. 8.   Harinarayan CV, Sachan A, Reddy PA, Satish KM, Prasad UV, Srivani P. Vitamin D status and bone mineral density in women of reproductive and postmenopausal age groups: a cross-sectional study from south India. J Assoc Physicians India. 2011; 59: 698-704. 9.   Roy DK, Berry JL, Pye SR, Adams JE, Swarbrick CM, King Y, Silman AJ, et al. Vitamin D status and bone mass in UK South Asian women. Bone. 2007; 40(1): 200-204. 10.  Napoli N, Strollo R, Sprini D, Maddaloni E, Rini GB, Carmina E. Serum 25-OH Vitamin D in relation to Bone Mineral Density and Bone Turnover. Int J Endocrinol. 2014; 2014: 487463. 11.  Begum RA, Ali L, Akter J, Takahashi O, Fukui T, Rahman M. Osteopenia and osteoporosis among 16-65 year-old women attending outpatient clinics. J Community Health. 2014; 39(6): 1071-1076 12.  Holick MF. Vitamin D status: Measurement, interpretation, and clinical application. Ann Epidemiol. 2009; 19: 73–78. 13.  World Health Organization. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group. WHO Technical Report Series, No. 843, Geneva, Switzerland: WHO; 1994. 14.  World Health Organization. WHO Scientific Group on the Assessment of Osteoporosis at Primary Health Care Level. Summary Meeting Report. Brussels, Belgium: World Health Organization; 2004. 15.  Arya V, Bhambri R, Godbole MM, Mithal A. Vitamin D status and its relationship with bone mineral density in healthy Asian Indians. Osteoporos Int. 2004; 15: 56–61.  16.  Rahman SA, Chee WS, Yassin Z, Chan SP. Vitamin D status among postmenopausal Malaysian women. Asia Pac J Clin Nutr. 2004; 13:255–260.  17.  Fuleihan GE, Deeb M. Hypovitaminosis D in a sunny country. N Engl J Med. 1999; 340: 1840–1. 18.  Hwang JS, Tsai KS, Cheng YM, Chen WJ, Tu ST, Lu KH, et al. Vitamin D status in non-supplemented postmenopausal Taiwanese women with osteoporosis and fragility fracture. BMC Musculoskeletal Disorders. 2014; 15:257. 19.  Lim SK, Kung AW, Sompongse S, Soontrapa S, Tsai KS. Vitamin D inadequacy in postmenopausal women in Eastern Asia. Curr Med Res Opin. 2008; 24: 99–106. 20.  Kota S, Jammula S, Kota S, Meher L, Modi K. Correlation of Vitamin D, bone mineral density and parathyroid hormone levels in adults with low bone density. Indian J Orthop. 2013; 47: 402–7.  21.  Jolanta D, Alma C, Egidija R, Jolita B, Jelizaveta B, Ieva S, et al. Association between Vitamin D and bone mineral density in post-menopausal women with metabolic syndrome. Acta Med Lituanica. 2015; 22: 7–14. 22.  Kruavit A, Chailurkit LO, Thakkinstian A, Sriphrapradang C, Rajatanavin R. Prevalence of Vitamin D insufficiency and low bone mineral density in elderly Thai nursing home residents. BMC Geriatr. 2012; 12: 49. 23.  Beg M, Akhtar N, Alam MF, Rizvi I, Ahmad J, Gupta A. Vitamin D status and serum osteocalcin levels in postmenopausal osteoporosis: Effect of bisphosphonate therapy. J Indian Acad Clin Med. 2014; 15: 172–6. 24.  Bener A, Saleh NM. Low Vitamin D, and bone mineral density with depressive symptoms burden in menopausal and postmenopausal women. J Midlife Health. 2015; 6: 108–14.  25.  Li S, Ou Y, Zhang H, Zhang Z, Zhou H, Liu L, et al. Vitamin D status and its relationship with body composition, bone mineral density and fracture risk in urban central South Chinese postmenopausal women. Ann Nutr Metab. 2014; 64: 13–9.  26.  Singh A, Singh H, Patel S. Screening of bone mineral density by densitometer and correlation with serum calcium and Vitamin D levels to detect early osteoporotic changes in postmenopausal women in slum areas of Raipur and Kalupur of Ahmedabad. Int J Basic Clin Pharmacol. 2015; 4: 960–5. 27.  Chapuy MC, Durr F, Chapuy P. Age-related changes in parathyroid hormone and 25 hydroxycholecalciferol levels. J Gerontol, 1983;38(1): 19-22. 28.  Cerda D, Peris P, Monegal A, Albaladejo C, Martinez de Osaba MJ, Suris X, et al. Increase of PTH in post-menopausal osteoporosis. Rev Clin Esp. 2011; 211(7): 338-43. 29.  Sahota O, Mundey MK, San P, Godber IM, Hosking DJ. Vitamin D insufficiency and the blunted PTH response in established osteoporosis: the role of magnesium deficiency. Osteoporos Int, 2006; 17(7): 1013-21. <![CDATA[Morbidity and drug prescribing patterns at a rural primary health care center of Bangladesh]]> Hasina Momtaz Nehlin Tomalika Masuda Mohsena Mir Masudur Rhahman Niru Sultana M Abu Sayeed https://imcjms.com/journal_full_text/268 2017-09-17 12:40:25 Original Article IMC J Med Sci 2018; 12(2): 50-56 Abstract Background and objectives: World Health Organization (WHO) and the National Health Policy of Bangladesh have repeatedly been emphasizing on the use of essential drugs prescribed by generic names. The prescription monitoring studies provide a bridge between areas like rational use of drugs and evidence based medicine. Knowledge on distribution and burden of diseases in a community is essential for planning rational use of drugs in a community. The present study tried to determine the morbidity profile anddrug prescribing practices of healthcare providers in a rural primary health care. Methods: The study was conducted at a rural health center located 50 Km north of capital city Dhaka. A semi-structured questionnaire was used for collecting data on socio-demographic conditions, clinical complaints and types of drugs prescribed. WHO prescribing indicators was used to find out the drug prescribing pattern. Results: A total of 583 patients were enrolled. Problems related to respiratory system (21.1%), musculoskeletal system (17.3%) and skin diseases (11.1%) were common reasons for visiting health centre. Oral drugs were prescribed with highest proportion (96.1%). More than half (62.6%) of the drugs were prescribed from essential drug list. About half (49.1%) were antibiotics and 45.6% of the drugs were prescribed in their generic name. Anti-microbial (64.5%), anti-peptic ulcer (43.1%) and NSAIDs (42.5%) were most frequently prescribed. Out of five WHO core prescription indicators, four were below the acceptable values. Conclusion: The study demonstrated that there is an urgent need to promote rational use of drugs among the healthcare providers. IMC J Med Sci 2018; 12(2): 50-56. EPub date: 08 March 2018. DOI: https://doi.org/10.3329/imcjms.v12i2.39661 HM & NT contributed equally to this study. Address for Correspondence: Dr. Hasina Momtaz, Assistant Professor, Department of Community Medicine, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka. Email: dr.shapna@gmail.com   Introduction The assessment of drug utilization is important for medical, academic and commercial purposes [1,2]. Periodic evaluations of prescriptions are essential for monitoring therapeutic efficacy, adverse effects of drugs and also for providing feedback to the prescribers [3,4]. Moreover, high cost drugs can be identified by reviewing information on drug use [5]. Currently, irrational and improper uses of drugs are major concerns worldwide [6,7]. Adverse clinical consequences and burden on limited resources are the major impact of irrational use of medicines [8]. Information on morbidity or disease profiles of a health institution is important for planning, policy formulation and decision making for best utilization of resources of health sector. In Bangladesh, there are few studies on the morbidity and related drug prescription pattern in rural primary health care facilities. Most of the available studies were conducted in tertiary care hospitals [9,10]. In 2015, a study conducted in primary level rural hospital of Bangladesh reported high use of antibiotics [11]. Therefore, the objectives of this study were to determine the morbidity profiles of patients and to evaluate the drug prescribing practice of health care providers at a rural primary health care center near capital Dhaka using WHO recommended core prescribing indicators.   Materials and Methods This was an observational cross sectional study. The study was conducted at Sreepur upazilla (sub-district) health complex, a rural primary health center, located 50 Km north of capital city Dhaka, under Sreepur upazilla of Gazipur district, Bangladesh from 16 February to 4 March 2017. The health complex was a 50-bed primary care hospital that provide both out and inpatient services. The patients attending the outpatient department and those admitted in the health center during the study period were enrolled. Patients, who were advised investigations only, came for immunization, antenatal care, follow up or referral to a different health care centers, were excluded from this study. A total of 583 patients were enrolled. A semi-structured questionnaire was used for collecting data on socio-demographic conditions, clinical complaints, presentation and types of drugs prescribed. For socio-demographic conditions, data regarding age, sex, occupation, monthly expenditure and education were collected. Questions on signs, symptoms and system involved were raised for identifying morbidity profile. To assess drug prescribing pattern, enquires were made in accordance with WHO prescribing indicators (provided below). Prescriptions were checked to find out the treatment pattern and names and types of the drugs prescribed. In case of admitted patients their case files were checked to obtain detailed disease and treatment information. WHO recommended five core prescription indicators evaluated in this study were: (a) average number of drugs per encounter, (b) percentage of drugs prescribed by generic name, (c) percentage of encounters with an antibiotic prescribed, (d) percentage of encounters with an injection prescribed and (e) percentage of drugs prescribed from essential drugs list. Cut-off values of the indicators 2-5 were expressed as percentages [12]. Essential drugs list (EDL) of WHO was used as a framework for rational prescription of drugs [13]. The list contains drugs that are well established and already tested in practice; have established clinical use and lower cost than newer drugs. Drugs prescribed by generic name was defined when the drug(s) was mentioned in prescription by its chemical name. Verbal consents were obtained from all adult patients and from the guardians of the children patients. All the participants were assured of their anonymity and confidentiality. After collection, data were entered, cleaned, and analyzed using the software IBM SPSS version 20. Mean, standard deviation and frequency distribution of different variables were calculated and described here.   Results This study was conducted to assess morbidity profile and drug prescribing patterns among the patients attending a rural primary health care center in Sreepur upazilla. Analyses revealed that majority of the patients (58.5%) were female (Table-1). Among the patients higher proportion were found to be housewives (32.2%); whereas percentage of farmers was least (3.6%). About one third (36.0%) of the patients were illiterate. Table-2 shows that most of the patients visited the health centre for problems related to respiratory system (21.1%). Musculoskeletal system (17.3%), skin diseases (11.1%) and gastrointestinal involvement (10.5%) were also common reasons for visiting the health centre.   Table-1: Socio-demographic characteristics of the study population at health complex (n=583)     Table-2: Distribution of the study participants according to the system involved or diagnosis (n=583)     Prescriptions of patients were studied to assess the rates of WHO indicators. The distribution of routes of administration pattern indicated that oral drugs were prescribed with highest proportion (96.1%); next was topical (16.1%), and then injectable (13.6%). Majority (62.6%) of the prescribed drugs were from essential drug list. Among the prescribed drugs nearly half (49.1%) were antibiotics and 45.6% of all drugs were prescribed in their generic name (Table-3).   Table-3: Prescription patterns of the patients attending the health complex center (n=583)     Table-4 shows that most frequently prescribed drugs were antimicrobial (64.5%), followed by drugs for peptic ulcer (43.1%), NSAIDs (42.5%), antihistamine (40.7%), vitamins (39.5%) and minerals (27.6%). Least frequently used drugs were anxiolytic (1.9%) and antihypertensive (1.7%). The frequencies of commonly prescribed antimicrobials are presented in Table-5. More than one third of the prescription included azithromycin (28.7%). Amoxicillin (11.5%), metronidazole (9.1%), flucloxacillin (7.0%), ceftriaxone (6.6%) and cefuroxime (5.6%) were the other commonly prescribed antibiotics. The five core prescription indicators recommended by WHO were extracted from the collected data and presented in Table-6 along with WHO recommended values. None of the five indicators could meet the WHO guideline.   Table-4: Pattern of drugs prescribed by the physicians at health center (n=583)     Table-5: Commonly prescribed antibiotics by the physicians at health center (n=286)     Table-6: WHO core prescription indicators observed at health center       Discussion This study was an attempt to assess the morbidity profiles and the drug prescribing pattern at a primary rural health care center of Sreepur upazilla. The current study identified respiratory problems as the most prevalent health problem and it was followed by musculoskeletal problems, skin diseases and gastrointestinal disorders. The result is consistent with the findings of studies conducted at rural health center in Bangladesh and in South India [11,14]. Similar diseases are commonly encountered in outpatient department in Nepal and Nigeria [8,15]. Infectious diseases were the most frequently encountered diseases in this study indicating low socio-economic status of participants as infectious diseases are more prevalent among people living in poverty. Ongoing ill health is a major reason why the poor are not able to break out of the cycle of poverty and infectious diseases [16]. The results of the present study revealed that the average number of drugs prescribed per encounter was 3.3 which were not within the recommended range of WHO guideline. Similar prescribing trends were reported from earlier studies in Bangladesh and several other developing countries [9,10,17]. However, practice of prescribing drugs within the WHO recommended range (≤3) was observed in Zimbabwe, Jordan, Brazil, India and Nepal [18-22]. Practice of poly-pharmacy might be linked to financial incentives from the pharmaceuticals or local pharmacies or lack of therapeutic training of prescribers. It is well known that poly-pharmacy may lead to adverse drug reactions, increase risk of drug interactions, dispensing errors, decrease adherence to drug regimens and unnecessary expenses. This reflects the need to strengthen the habit of rational prescribing of drugs by medical practitioners. WHO strongly recommends prescribing medications by generic name as a safety precaution for patients because it identifies the drug clearly, enables better information exchange and allows better communication between health care providers [23]. About 45.6% of drugs in this study were prescribed by generic name which was far less than WHO recommended guideline of 100%. A previous study conducted at a tertiary care hospital of Bangladesh reported the rate of prescription of drugs by generic name around 50%, while another study at a Government referral hospital in northern Bangladesh found no prescription by generic name [9,10], The rate of prescribing drugs in generic name ranges from 27% to 61% in other developing countries of Asia and Africa [10,24-27]. High rate (39%-62%) of antibiotic prescription was reported from many developing countries of Asia, Africa and Middle East [18,28-30]. In the present study, about 50% of the prescription contained antibiotics; when according to WHO 15%-25% prescriptions with antibiotics are expected in developing countries where infectious diseases are prevalent [31]. High prevalence of infectious diseases in developing countries compared to developed countries might be a reason for frequent prescription of antibiotics. However, irrational prescribing of antibiotics was observed even in hospitals of developed countries [32]. Such practice may lead to increased risk of adverse reaction, hospital admission and emergence of antibiotic resistant bacteria [33,34]. In this study, the rate of prescribed parenterally administered drugs (13.6%) was found higher than the acceptable range of WHO guideline. Previous studies in tertiary care hospitals of Bangladesh reported this rate as 17.2% and 6.7% [9,10]. The rate was even higher in tertiary health care facilities in countries like Nigeria (26.9%-40.6%) and Ethiopia (38.1%) [35-37]. Use of injectable form of drugs was higher in tertiary health care facilities because in those hospitals patients with serious conditions were treated. Use of injections instead of oral formulations increases the costs of therapy and the risk of blood-borne diseases such as hepatitis and HIV. In this study, the percentage of drugs prescribed from the national EDL was found to be 62.6%, which was very low in comparison with the rates observed in different parts of the world. The study conducted in different countries revealed that drug prescribed from EDL were 99% in Ethiopia [38], 96.8% in Saudi Arabia [12] and 96.1% in Nigeria [15]. Generally, in other developing countries values higher than 80% had been observed [39]. One of the possible reasons for this lower rate could be the lack of prescribers understanding on the importance of essential drug concept. Other reason could be that most of the prescriptions included NSAIDs, anti-ulcerants, multivitamins and multi-minerals, which are not enlisted in EDL of Bangladesh. The current study had some limitations. The mean cost of drugs and mean consultation time were not calculated. The diagnoses of diseases were based upon clinical symptoms and the investigation reports were not available in most cases. The study had further limitation that it was not designed to reveal the reasons leading to irrational prescription of drugs. The current study recommends that clinicians should be made aware about the WHO guidelines for rational prescription of drugs.   Acknowledgments We acknowledge the active cooperation of 3rd year students (Batch IM-14) of IMC. We are thankful to the UHFPO of Sreepur upazilla health complex and his staff for their full support. We are also grateful to all participants who volunteered the study.   Contribution of authors HM and NT: Data analysis and manuscript writing; MM: Concept, data analysis and manuscript editing; NS: Preliminary concept; MMR: Supervision of field work and data collection; MAS: Overall supervision   Competing interest  None   Funding Ibrahim Medical College   References 1.   World Health Organization. Introduction to drug utilization research. Oslo: World Health Organization. 2003; 49 p. 2.   Uppal R, Nayak P, Sharma PL. Prescribing trends in internal medicine. Int J Clin Pharmcol Ther Toxicol. 1984; 22(7): 373-376. 3.   Krishnaswamy K, Kumar BD, Radhaiah G. A drug use survey- precepts and practice. Eur J Clin Pharmacol. 1985; 29(3): 363-370. 4.   Pradhan SC, Shewade DG, Shashindran CH, Bapna JS. Drug utilization studies. National Med J India. 1988; 1(4): 185-189. 5.   Marshner JP, Thürmann P, Harder S, Rietbrock N. Drug utilization review on a surgical intensive care unit. Int J Clin Pharmacol Ther. 1994; 32(9): 447-451. 6.   Hogerzeil HV. Promoting rational prescribing: an international perspective. Br J Clin Pharmacol. 1995; 39: 1-6. 7.   Yadav AK, Bhandari R, Rai B, Giri S, Baral DD, Mandal M. Presentation, prescription pattern and time taken to discharge from an emergency department of eastern Nepal. Health Renaissance. 2014; 12(3): 209-214. 8.   Lamichhane DC, Giri BR, Pathak OK, Panta OB, Shankar PR. Morbidity profile and prescribing patterns among outpatients in a teaching hospital in Western Nepal. Mcgill J Med. 2006; 9(2): 126-133. 9.   Afsan M, Alam MM, Noor N, Ahmed AHH. Prescribing practices in the outpatient department in a tertiary care teaching hospital in Bangladesh. Update Dent Coll J. 2012; 2(2): 13-17. 10.  Sultana F, Rahman A, Paul TR, Sarwar MS, Islam MAU, Rashid M. Prescribing pattern and prescription errors: A study at a tertiary care hospital of Bangladesh. Bangladesh Pharm J. 2015; 18(1): 20-24. 11.  Ahmed AA, Jilani MSA, Chowdhiry OA, Islam KMS, Hossain MA, Alam MJ, et al. Use of antibiotics in selected tertiary and primary level health care centers of Bangladesh. Ibrahim Med Coll J. 2015; 9(2): 42-44. 12.  World Health Organization. How to investigate drug use in health facility: selected drug use indicators. Geneva: World Health Organization; 1993. EDM research series no. 007. 13.  World Health Organization. The use of essential drugs. Seventh report of WHO expert committee (including the revised model list of essential drugs). Geneva: World Health Organization; 1997. 74 p Report No.:867. 14.  Gupta A, Chellaiyan V, Lohiya A, Suliankatchi RA, Upadhayay R, Palanivel C. Morbidity profile of out-patients attending a primary health centre in rural Puducherry, South India. Natl J Community Med. 2014; 5(4): 424-427. 15.  Jimoh AO, Omar I, Adebisi IM, Sani Z, Bello A, Abubakar SB, et al. Review of morbidity profiles and drug prescribing patterns of a university clinic in North-Western Nigeria. Int Inv J Med Med Sci. 2014; 1(8): 107-115. 16.  World Health Organization. Scaling up the response to infectious diseases - A way out of poverty. Geneva: World Health Organization. 2002; 101p Report No.: WHO/CDS/2002.7. 17.  Hogerzeil HV, Bimo, Ross-Degnan D, Lang RO, Ofori-Adjei D, Santoso B, et al. Field tests for rational drug use in twelve developing countries. Lancet. 1993; 342(8884): 1408-1410. 18.  Trap B, Chinyanganya FW, Hogerzeil HV, Nathoo KJ, Chidarikire A, Moore H. How to improve management of an essential drugs programme by regular surveys. Zimbabwe Essential Drugs Action Programme (ZEDAP), Ministry of Health and Child Welfare Directorate of Pharmacy. 1995; 113 p. 19.  Otoom S, Batieha A, Hadidi H, Hasan M, Al-Saudi K. Evaluation of drug use in Jordan using WHO prescribing indicators. East Mediterr Health J. 2002; 8(4-5): 537-543. 20.  Acurcio FA, Perini E, Magalhaes SM, Terceiro LG, Vieira Filho JM, Coutinho KE, et al. Analysis of medical prescriptions dispensed at health centers in Belo Horizonte, Minas Gerais, Brazil. Cad. Saúde Pública. 2004      2003; 20(1): 72-79. 21.  Mhetre NA, Bodhankar SL, Pandit VA, Zambare GN. Study of pattern of drug usage in an urban area. Indian J Pharmacol. 2003; 35: 316-317. 22.  Alam K, Mishra P, Prabhu M, Shankar PR, Palaian S, Bhandari RB, et al. A study on rational drug prescribing and dispensing in outpatients in a tertiary care teaching hospital of Western Nepal. Kathmandu Univ Med J. 2006; 4(4): 436-443. 23.  World Health Organization. Guidelines on the use of international nonproprietary names (INNs) for pharmaceutical substances. Geneva: World Health Organization. 1997; 41 p. 24.  Akande TM, Ologe MO. Prescription pattern at a secondary health care facility in llorin, Nigeria. Ann Afr Med. 2007; 6(4): 186-189. 25.  Enato EFO, Sounyo AA, Madadi P. Assessment of disease profiles and drug prescribing patterns of health care facilities in Edo state, Nigeria. J Public Health Afr. 2012; 3(25): 101-106. 26.  Shankar PR, Partha P, Nagesh S. Prescribing patterns in medical outpatients. Int J Clin Pract. 2002; 56(7): 549-551. 27.  Sarkar C, Das B. Prescribing trends in a teaching hospital in western Nepal. J Nepalgunj Med Coll. 2002; 2: 4-7. 28.  Karande S, Sankhe P, Kulkarni M. Patterns of prescription and drug dispensing. Indian J Pediatre. 2005; 72: 117-121. 29.  Sharif SI, Al-Shaqra M, Hajjar H, Shamout A, Wess L. Patterns of drug prescribing in a hospital in Dubai, United Arab Emirates. Libyan J Med. 2008; 3(1): 10-12. 30.  Moghadamnia AA, Mirbolooki MR, Aghili MB. General practitioner prescribing patterns in Babol city, Islamic Republic of Iran. East Mediterr Health J. 2002; 8(4/5): 550-555. 31.  International Network for Rational Use of drugs and World Health Organization. How to investigate drug use in health facilities: selected drug use indicators. Geneva: World Health Organization; 1993. Research Series No.7. 32.  Meesters K, Mauel R, Dhont E, Walle JV, De Bruyne P. Systemic fluoroquinolone prescriptions for hospitalized children in Belgium, results of a multicenter retrospective drug utilization study. BMC Infect Dis. 2018; 18: 89. doi.org/10.1186/s12879-018-2994-z. 33.  Wiffen P, Gill M, Edwards J, Moore A. Adverse drug reactions in hospital patients: a systematic review of the prospective and retrospective studies. Bandolier Extra. 2002; 1-14. 34.  World Health Organization. Containing antimicrobial resistance. Geneva: WHO Policy Perspectives on Medicines, 2005. 35.  Ibrahim MTO. Physicians prescribing behavior in two tertiary health care facilities in north western Nigeria, Analysis of 518 prescriptions. Sahel Med J. 2004; 7(4): 115-118. 36.  Aghaji MN. Injection practices in Enugu Nigeria. Jnl College of Medicine. 2002; 7(2): 118-120. 37.  Desalegn AA. Assessment of drug use pattern using WHO prescribing indicators at Hawassa University teaching and referral hospital, south Ethiopia: a cross-sectional study. BMC Health Serv Res. 2013; 13: 170. 38.  Ethiopia Ministry of Health, World Health Organization. Assessment of the pharmaceutical sector in Ethiopia. Addis Ababa, Ethiopia: World Health Organization; 2003. 40p. 39.  Hogerzeil HV, Walker GJ, Sallami AO, Fernando G. Impact of an essential drugs program on availability and rational use of drugs. Lancet. 1989; 1(8630): 141-142. <![CDATA[Factors influencing knowledge and practice of self-medication among college students of health and non-health professions]]> Amal K. Mitra Ayyub Imtiaz Yusuf A. Al-Ibrahim Mohammad B. Bulbanat Maha F. Al-Mutairi Sulaiman F. Al-Musaileem https://imcjms.com/journal_full_text/292 2018-06-19 13:45:44 Original Article IMC J Med Sci 2018; 12(2): 57-68 Abstract Background and objectives: Self-medication is commonly practiced throughout the world. The aim of this study was to ascertain the use prevalence and knowledge of harmful effects of self-medication among college students of health professions and non-health professions. Methods: A cross-sectional study was performed among 1,167 students from 12 faculties of a public university and two private universities in Kuwait. Data were collected using a self-administered pretested questionnaire containing 32 questions. Results: Among the participants, 70.4% (822/1,167) used self-medication. The prevalence of self-medication was significantly higher among students of non-health professions compared with those of health professions (35.9% vs. 25.9%, p = 0.004, 95% CI, 6.28% to 13.73%, respectively). Pain killer medicines (52.9%), vitamins/minerals (13.1%), and antihistamines (9.0%) were the most commonly used non-prescription medications. Antibiotics and sleeping pills were used without a prescription in 2.9% and 2.1%, respectively. Older age, non-Kuwaiti national, and students of 5th to 7th year of study were significant predictors of self-medication. Knowledge scores of harmful effects of self-medication were about two-fold higher among females than their male counterparts. Similarly, students of higher years of study (5th to 7th year) had higher knowledge score compared with others. Conclusions: The prevalence of self-medication was alarmingly high among young adults in Kuwait. People should be informed about adverse effects of self-medication through mass and social media campaign. IMC J Med Sci 2018; 12(2): 57-68. EPub date: 19 June 2018. DOI: https://doi.org/10.3329/imcjms.v12i2.39662 Address for Correspondence: Prof. Amal K. Mitra, Professor of Epidemiology, Department of Epidemiology and Biostatistics, Jackson State University, 350 W. Woodrow Wilson Dr., PO Box 17038, Jackson, MS 39213, E-mail: amal.k.mitra@jsums.edu   Introduction Self-medication is an increasing public health problem worldwide [1]. Self-medication is the selection and use of medicines by individuals to treat self-recognized illnesses or symptoms, as defined by the World Health Organization [2]. Self-medication is often due to the use of non-prescription medicines, commonly known as over-the-counter (OTC) medication. However, there are reports of indiscriminate use of prescription medications including antibiotics [3]. Unfortunately, a vast number of users of self-medication take medications without being fully informed about the associated risks, contraindications and adverse effects. Moreover, indiscriminate use of non-prescription medicines can interfere with desired treatment and result in harmful side effects [4]. Self-medication is common in low and middle-income countries. In the developing countries, inadequacies in the healthcare delivery systems including inadequate doctor-patient ratio, high cost of prescription medicines, lack of education, unregulated distribution of medicines, untrained medicine sellers in the pharmacy, and patient attitudes towards government health facilities and physicians are some of the key drivers of self-medication [5,6]. In a systematic review of 34 studies in 31,340 participants in developing countries, the overall prevalence of antimicrobial self-medication was 38.8%, which varied widely from as low as 4.0% in Yemen to as high as 91.4% in Nigeria [5]. It was also common in using antibiotics in viral infections, especially in the Middle East [7] and in Asia [8]. As a result, antimicrobial-resistance is becoming more prevalent in areas with frequent non-prescription use [9]. Prevalence of non-prescription medication varies according to geographic location and the demographics of the population. Among 183 undergraduate medical students in Nigeria, 38.8% used self-medication in the preceding two months of the study [10]. In a cross-sectional study of 1,200 students randomly selected from nine public and private universities in Bangladesh, 54.5% used analgesic/antipyretic medicines, and 49.8% took antibiotics as self-medication [11]. In New Delhi, India, the prevalence of self-medication was very high (85.4%) among college students despite majority being aware of the harmful effects of it [12]. Even among the undergraduate medical students the prevalence of self-medication was 75.3% among males and 81.2% among females in India [13]. A similarly high prevalence (84.0%) of self-medication was observed among undergraduate nursing students in India [14]. In another study of the medicines dispensed in pharmacies in Bangalore, India, 66.7% (174/261) pharmacies dispensed antimicrobials without a valid prescription [15]. The prevalence of self-medication was 69.2% (465/672) in a cross-sectional study in Italy [16]. In a rural population in Greece, 44.6% used antibiotics without medical prescription at least once in their life time [17]. The use of non-prescription medication is more common in females, younger individuals, or people who had a health problem in the past year [16]. However, younger aged users are more likely to abuse and develop dependence on non-prescription medication [20]. Many studies have revealed that lack of access to health care system, long delay of medical care, and the easy availability of OTC has contributed significantly to rising trends of self-medications [21]. It is also believed that self-medication trends are economically driven [22]. In Kuwait, government-run health clinics and hospitals provide healthcare services at no out-of-pocket cost for Kuwaitis and at a minimum fee for non-Kuwaiti nationals. It is important to explore reasons for a high prevalence of self-medication despite government-run low-cost health services in Kuwait. The previous studies were conducted among secondary school students [23] and among undergraduate medical students in Kuwait [1]. In this study, we aimed to: 1) determine the prevalence of self-medication use among college students, 2) compare the practice of self-medication between students from health faculties and those with non-health faculties, 3) identify the reasons for using non-prescription medication and 4) demonstrate the predictors of knowledge and practice of self-medication. Our hypothesis was that students of health-profession background would be better equipped with knowledge about problems of indiscriminate use of medicines without a prescription, and would practice self-medication less often compared to students with non-health background. <![CDATA[Status of implementation of short answer question in anatomy examination of MBBS course in Bangladesh]]> Jesmin Akhter Sharmina Sayeed https://imcjms.com/journal_full_text/297 2018-08-19 13:49:19 Original Article IMC J Med Sci 2018; 12(2): 69-72 Abstract Background and objective: Short answer question (SAQ) format has been introduced as a major component of summative professional examinations of MBBS (Bachelor of Medicine and Surgery) course in Bangladesh over a decade. No systematic evaluation has yet been conducted on implementation of SAQ as directed in curriculum to assess the medical students in the summative examination of MBBS course. The present study assessed the weightage given to the different components of cognitive domain in SAQs in anatomy in first Professional MBBS Examination under the University of Dhaka. Materials and method: This cross-sectional study was conducted in the Department of Anatomy, Ibrahim Medical College. Anatomy SAQ papers, Paper I and Paper II, from January 2009 to July 2014 of University of Dhaka were selected. A total of 24 SAQ papers containing 572 questions were included in this study. Every question in a paper was categorized as recall, understanding application types. Then the total number of marks allocated for each of the type of questions were calculated and compared with the total marks (98) allocated for the questions in a paper. Then the resultant weightage of marks were compared with the curricular directive weightage of marks allotted for SAQ. Result: On analysis it was found that during the period from 2009 to 2014 76.58% and 23.42% SAQ were recall and understanding types respectively. No question was found to assess the application component of the cognitive domain of the students. Conclusion: The study revealed that SAQ introduced as an assessment tool in undergraduate medical curriculum was not properly implemented and its desired objectives were not fully achieved. IMC J Med Sci 2018; 12(2): 69-72. EPub date: 19 August 2018. DOI: https://doi.org/10.3329/imcjms.v12i2.39663 Address for Correspondence: Dr. Jesmin Akhter, Associate Professor, Department of Anatomy, Ibrahim Medical College, 1/A, Ibrahim Sarani, Segunbagicha, Dhaka, Bangladesh. E mail: jesminakhterlina@gmail.com   Introduction Assessment is an educational tool to evaluate students and to understand how successfully the learning materials are delivered to the learners. It also serves to motivate and help students to structure their academic efforts [1]. Principle of assessment in medical education is to provide direction and motivation for future learning and protect the health of the public by upholding high professional standards [2]. Learning abilities must be assessed in multiple modes and contexts. In addition,goodassessmentcanhelpstudentsbecome more effective self-directed learners [3]. This cross-sectional study was conducted in the Department of Anatomy, Ibrahim Medical College. SAQ question papers on anatomy of first professional MBBS course (Paper I and Paper II), from January 2009 to July 2014 held under the University of Dhaka were selected. In first professional MBBS examination, the summative examinations on anatomy are held twice a year. A total of 24 SAQ papers were included in this study. In each paper there were Group A (35 marks) and Group B (35 marks). In each group there were seven (07) questions with or without multiple segments to assess different components of cognitive domain. Each question carried 07 marks. So, in each group 49 marks were allocated for 07 questions and in a paper with two groups, the total marks allocated for 14 questions were 98. Therefore, a total of 572 questions were included in the study, 281 questions from Paper I and 291 questions from Paper II. Every segment of the questions in a paper was categorized as recall, understanding or application types as described elsewhere [9]. Then the total number of marks allocated for each of the type of questions in a paper were calculated and compared with the total marks (98) allocated for the questions in a paper. Then the resultant weightage of marks were compared with the curricular directive weightage of marks allocated for respective component of cognitive domains. The curriculum recommended mark was 70% for recall, 20% for understanding and 10% for application types of questions [8].   Results   <![CDATA[Quality of life in patients with diabetes mellitus]]> Naima Ahmed Nehlin Tomalika Mir Masudur Rhaman Hasina Momtaz Md. Mahmudul Haque https://imcjms.com/journal_full_text/309 2018-12-31 15:34:51 Original Article IMC J Med Sci 2018; 12(2): 73-79 Abstract Background and objectives: Diabetes mellitus (DM) perpetually affects the quality of life. This non-communicable lifelong disease usually develops micro and macro-vascular complications affecting vital organs. Thus, it reduces the functional capability of health as assessed by the health-related quality of life (HRQOL) measuring tools. It is not known, how much HRQOL of the diabetic population in Bangladesh is affected. Therefore, the objective of the present study was to estimate the levels of HRQOL of cases with DM attending a tertiary care hospital in Dhaka city. The study considered socioeconomic condition, nutritional status, duration of diabetes and treatment modalities while analyzing the HRQOL. Methods: This study was conducted in a tertiary care hospital in Dhaka city from July 2016 to June 2017. Patients with DM were considered eligible and were recruited. Those who were found to have complications like retinopathy, nephropathy, neuropathy, hypertension and stroke were excluded based on previous investigations. Once selected, the study protocol was described to each of the diabetic patients. If agreed, the participant was interviewed. Short Form health survey questionnaire (SF-36) was used for assessment of HRQOL. The assessment of physical health components included physical function, role physical, body pain, and general health. Mental health components were emotion, vitality and social function. Results: A total of 150 diabetic patients (m/f: 80/70) were included in the study. Comparisons of demographic variables between male and female participants showed no significant difference. As regards HRQOL, physical function score was significantly reduced among those who had diabetes for more than 10 years (p=0.049). General health component was significantly impaired among those who had higher BMI (<30kg/m2; p= 0.016) and post-prandial hyperglycemia. Longer duration of DM (>10yrs) and higher BMI significantly reduced components of mental health quality. Conclusion: The study revealed that the overall physical and mental quality of life was significantly affected by longer duration of diabetes, obesity and glycemic status. IMC J Med Sci 2018; 12(2): 73-79. EPub date: 31 December 2018. DOI: https://doi.org/10.3329/imcjms.v12i2.39666 Address for Correspondence: Dr. Naima Ahmed, Lecturer, Department of Community Medicine, Ibrahim Medical College, 122, Kazi Nazrul Islam Avenue, Shahbagh, Dhaka-1000, Bangladesh, E-mail: drnaima1911@gmail.com   Introduction The worldwide estimated prevalence of diabetes has been reported to increase from 4.3% in 1980 to 9.0% in 2014 [1]. More than 2 million deaths every year is attributed to diabetes and its associated macro and microvascular complications and are the seventh leading cause of chronic morbidity worldwide [2,3]. Based on the number of people with diabetes in 2014, the direct cost of diabetes is around US$ 825 billion [4]. In Bangladesh, it is estimated that about 10% of population (8.4 million) above the age of 35 years have diabetes [5]. The annual per capita cost of diabetes care in Bangladesh has been reported to be US$ 314 to US$ 635 [6,7]. In addition to other complications of diabetes, it also affects quality of life in terms of physical and mental health [8]. It also affects psychological state, level of independence, social relationships, personal beliefs and their relationship with others [9]. Life-long medical treatment in diabetes may be taxing and reduce quality of life [10]. Physical activity and socio-economic factors largely influence the success of diabetes control. A meta-analysis which included 20 studies has confirmed that physically active individuals with diabetes maintains improved quality of life [11]. It was observed that education, self-management and psychological interventions helped to retard deterioration of quality of life in patients with diabetes [12]. The quality of life is based on an individual’s perception of life in the context of the culture and value systems in which one lives and in relation to goals, expectations, standards and concerns [13]. Therefore, evaluation of quality of life can help planning of educational programs and intervention strategies. In Bangladesh, no study has yet been carried out on the status of health related quality of life of patients with diabetes. Therefore, the present study was undertaken to determine the HRQOL in patients with DM.   Materials and Methods This cross-sectional study was carried out on diabetic patients attending a tertiary care hospital of Dhaka city from July 2016 to June 2017. Each patient was informed about the study for assessing health-related quality of life and was requested to participate. Anyone, who agreed to volunteer this study, was enlisted. Each enlisted participant was interviewed about his/her socio-demographic status and clinical history related to DM (time of diagnosis, duration and complications). Quantitative variables were expressed in mean with standard deviation (SD) and comparisons between men and women were done by student’s t test. Qualitative data were analyzed by Chi square or Z test. Different components of quality of life related to BMI, treatment modalities, duration of diabetes, etc were analyzed by ANOVA.   Results   Table-1: Socio-demographic and clinical status of study population   Detail scores of physical and mental dimensions of HRQOL are shown in Table-4 and 5. The overall scores of different physical dimensions were found reduced in patients with DM. Physical function score was significantly (p=0.04) reduced among those who had history of diabetes for more than 10 years compared to those with lesser durations. General health score was significantly impaired among those who had BMI of more than 30 kg/m2 (p=0.01) and post-prandial hyperglycemia of >13.1 mmol/l (p<0.01).For mental health component, patients with history of longer duration (>10 yrs) of DM had significantly reduced role emotion score (p<0.01) compared to other groups. None of the mental dimension components was affected by the treatment modalities. Vitality score was found significantly (p=0.02) reduced among those who had FBG level between 7.6-9.6 mmol/l compared to those with other glycemic levels. Significantly reduced mental health score was found among cases with 3-6 yrs of duration of diabetes (p=0.01). Higher obesity (>30 kg/m2) also revealed significantly reduced quality of mental health score (p<0.01). Cases with increased post-prandial hyperglycemia (≥13.1 mmol/l) also had significantly reduced quality of social function (p<0.01).   Table-2: Duration of diabetes mellitus and treatment category of study population     Table-3: Condition of Physical health components of HRQOL in relation to clinical and biochemical status of the study population   Table-4: Condition of mental health components of HRQOL in relation to clinical and biochemical status of study population     Discussion In the present study, we have observed the overall scores of different components of both physical   and mental dimensions of HRQOL were low in our study population. The mean scores of all components were around half of the highest scores of the scale. It was found that the longer duration of DM and higher BMI were the most important factors affecting negatively the quality of life. The quality of life in all areas was comparatively better when the duration of diabetes was less than 3 years. A study in Iran reported significant negative linear correlations between duration of disease and mean scores of all scales of HRQOL except physical functioning [15]. In the present study, there was no effect of use of insulin on any components of physical and mental health dimensions. However, Johnson et al [16] reported that insulin use in DM was related to worse HRQOL in terms of role-physical, general health, and social functioning. While Wexler et al [17] did not observe any relationship between treatment regimens in patients with DM and HRQOL. The study findings revealed that obese diabetic patients had a lower score of mental health compared to those having lower BMI. Similarly, general health scores were also lower in diabetic obese cases compared to other groups. Sepúlveda, et al, reported that obese patients had worse physical functioning than normal and overweight patients, and also worse vitality than their normal weight counterparts [18]. However, in the present study we observed lower body pain scores in normal weight than overweight patients. The current study showed a significantly better score in social function, general health and vitality components among the patients having better glycemic control. However, no significant positive or negative effect of glycemic status was observed on other physical and mental health components of HRQOL. The present study has demonstrated that DM adversely affects different aspects of the HRQOL. The overall scores of physical and mental health dimensions are reduced and the most important influencing factors are BMI and duration of diabetes.   Acknowledgements We are very grateful to the National Institute of Preventive & Social Medicine (NIPSOM), Bangabandhu Sheikh Mujib Medical University (BSMMU) and Ibrahim Medical College (IMC) for giving us active cooperation to complete the study. We are also grateful to Professor MA Sayeed, Professor J. Ashraful Haq, Dr. Masuda Mohsena and all colleagues of the Department of Community Medicine, Ibrahim Medical College for their valuable suggestions.   Author’s contributions NA was involved in project management & supervision and in maintenance of contact with BSMMU. NT was involved in data analysis and manuscript writing. MMR was involved in selection of participants, data analysis and manuscript writing. HM was involved in manuscript writing. MMH was involved in overall supervision of the study.   Competing interest: Authors declare no conflict of interest.   Ethics approval and consent to participate and publish This study was approved by the Ethical Committee of the National Institute of Preventive and Social Medicine. Written consent was collected from every participant for publication.   Funding: None   References 1.   Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4.4 million participants. The Lancet. 2016; 387(10027): 1513-1530. 3.   Global Burden of Disease Study Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet. 2015; 386: 743–800. <![CDATA[Correlation of serum intact parathyroid hormone and alkaline phosphatase in diabetic chronic kidney disease stage 3 to 5 patients with mineral bone disorders]]> Mehruba Alam Ananna Wasim Md. Mohosin Ul Haque Muhammad Abdur Rahim Tufayel Ahmed Chowdhury Tabassum Samad Md. Mostarshid Billah Sarwar Iqbal https://imcjms.com/journal_full_text/310 2019-01-02 17:50:34 Original Article IMC J Med Sci 2018; 12(2): 80-85 Abstract Introduction: Chronic kidney disease (CKD) amongst diabetic patients is a worldwide public health problem. It is associated with cardiovascular disease and CKD mineral bone disorder (CKD-MBD). Cardiovascular and MBD are important contributors of morbidity and mortality in CKD patients. Serum intact parathyroid hormone (iPTH) and alkaline phosphatase (ALP) are two important markers to identify and mange CKD-MBD. This study was designed to evaluate the relationship between serum iPTH and alkaline phosphatase in diabetic CKD stages 3-5 patients with MBD. Methods: This cross-sectional study was conducted in BIRDEM General Hospital, Dhaka, Bangladesh from January 2013 to December 2014. Diabetic patients suffering from stage 3-5 CKD with MBD and not on dialysis, were consecutively and purposively included in this study. Along with base-line characteristics, clinical and laboratory data including serum alkaline phosphatase and iPTH levels were recorded for all patients. Data were analyzed by using SPSS version 20.0 and Pearson’s correlation test was applied to evaluate the relationship between iPTH and serum ALP. Results: Total patients were 306, of which 166 (54.2%) were males and 140 females (45.8%). Mean age of the study population was 56.5±11.3 years. Mean duration of diabetes mellitus (DM) and CKD were 12.8±7.6 and 2.9±1.7 years respectively. Among the study population, 49 (16.0%) were in CKD stage 3, 90 (29.4%) in stage 4 and rest 167 (54.6%) in stage 5. The mean HbA1c level did not differ significantly (p>0.05 by ANOVA) amongst CKD-MBD stage 3, 4 and 5 cases. Mean±SE values of glycated haemoglobin (HbAlc %), serum creatinine (mg/dl), urea (mg/dl), calcium (mg/dl), phosphate (mg/dl), ALP (U/L) and iPTH (pg/ml) of total study population were 7.77±0.12, 6.8±0.17, 141.1±4.33, 8.1±0.07, 5.2±0.11, 164.1±7.74 and 229.7±8.64 respectively. Out of total cases, serum ALP was raised in only 53.9% CKD-MBD cases compared to 76.8% for iPTH. Serum iPTH level was found elevated in 79.6%, 83.3% and 72.5% CKD-MBD stage 3, 4 and 5 cases respectively while in comparison, serum ALP was found raised in 44.8%, 54.4% and 56.2% cases respectively. On correlation analysis between serum iPTH and ALP, the r values observed were 0.074, 0.231 and 0.046 for stage 3, 4 and 5 CKD-MBD cases respectively. Conclusion: The results of current study showed that most diabetic stage 3-5 pre-dialysis CKD-MBD patients had raised serum iPTH. In comparison, significantly low number of cases had raised serum ALP. IMC J Med Sci 2018; 12(2): 80-85. EPub date: 31 December 2018. DOI: https://doi.org/10.3329/imcjms.v12i2.39665 Address for Correspondence: Dr. Mehruba Alam Ananna, Assistant Professor, Department of Nephrology, Ibrahim Medical College and BIRDEM General Hospital, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka, Bangladesh. Email: ananna0701@gmail.com   Introduction Chronic kidney disease is a worldwide public health problem with increasing prevalence and potentially lethal adverse outcomes like progressive loss of renal function, cardiovascular disease and premature death. Ten percent of the population worldwide is affected with CKD and millions die each year because they do not have access to affordable treatment [1]. Among the different causes, diabetes mellitus (DM) is one of the leading causes of end-stage renal disease (ESRD) worldwide, though glomerulonephritis has been the more predominant cause in developing countries [2]. As a part of different metabolic disturbances, CKD causes alterations in mineral homeostasis affecting serum calcium, phosphate, serum ALP and iPTH. As a result of these changes in the mineral homeostasis there is increased risk of bone, vascular disease and disorder of mineral metabolism. Vascular calcification and bone disease labeled as CKD mineral bone disorder (CKD-MBD) are of particular concern. These abnormalities related to mineral metabolism and bone disorders have been implicated as novel risk factors and associated with increased morbidity and mortality in patients with CKD [3]. Greater risk of hip fractures and associated increased mortality in patients with CKD and ESRD has been reported [4-7]. Serum iPTH and ALP are two important markers to identify and mange CKD-MBD. These two markers are useful to guide the medical management of CKD-MBD. In human there are four isoenzyme forms of ALP, which are tissue non-specific, intestinal, placental and germ cell ALPs. Among these four types, tissue nonspecific isoenzyme is of particular interest in CKD, as tissue non-specific ALP exists in numerous isoforms and primarily differ in extent and type of glycosylation [8]. Bone ALP is an ectoenzyme anchored to the membrane of osteoblasts and thus reflects overall bone remodeling [9]. Few studies have suggested serum ALP as a potential biomarker of CKD-MBD and may be superior compared to iPTH as it shows less inter and within individual biological variation [10]. On the other hand, iPTH has a very short half-life of 2-4 minutes compared to 1.5 to 2.3 days of bone ALP. Also, iPTH has significant inter individual biological variation especially in patients undergoing hemodialysis. In addition, there is an analytical variation amongst clinical laboratories and lack of standardization of second and third generation commercially available iPTH assays [11]. Higher ALP levels in CKD patient correlate with increased mortality and progression to ESRD as well as progressive peripheral arterial calcification. There are similar association between higher total ALP levels and increased mortality in maintenance hemodialysis and peritoneal dialysis patients [12]. Several studies have reported total ALP appeared to be a more consistent and better predictor of adverse outcomes than iPTH. In a cohort of 74,000 patients there was U shaped correlation between mortality and iPTH level whereas ALP showed linear and incremental correlation [13]. Thus, ALP is a promising tool that has the potential to guide CKD-MBD management. But there are insufficient local data in this regard. So, the present study was undertaken to evaluate the serum ALP level in CKD stages 3-5 pre-dialysis patients with diabetes mellitus and to see its correlation with serum iPTH level in different stages of CKD patients.   Methods This cross-sectional study was conducted in BIRDEM General Hospital, Dhaka, Bangladesh from January 2013 to December 2014. All diabetic patients suffering from CKD stage 3-5 with MBD were purposively included in this study. CKD-MBD was defined as a systemic disorder of mineral and bone metabolism due to CKD manifested by either one or a combination of the (a) abnormalities of calcium, phosphorus, iPTH or vitamin D metabolism (b) abnormalities of bone turnover, mineralization, volume, linear growth or strength (c) vascular or other soft tissue calcification [13]. CKD was diagnosed and staging done as per Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guidelines 2012 [14]. eGFR was estimated by using chronic kidney disease-epidemiology (CKD-EPI) creatinine based formula. Patients who had history of parathyroid disorders/ surgery, primary or metastatic bone disease and diagnosed with any genetic or hereditary conditions were excluded from the study. Cases undergoing dialysis were also excluded. Base-line characteristics and laboratory data including serum ALP and iPTH levels of all enrolled patients were recorded. Serum iPTH was determined by Chemiluminescent Micropartical Immunometric Assay (CMIA). Data were analyzed by using SPSS version 20.0 and correlation test was applied to evaluate the relationship between ALP and iPTH. The normal range of serum ALP and iPTH were 45 to 115 U/L and 7-53 pg/ml respectively. Consent was obtained from enrolled participants.   Results In the present study, there were 306 participants who satisfied the selection criteria and out of them 166 (54%) were male. Mean age, duration of DM and duration of CKD of the study participants were 56.5 ± 11.3, 12.8 ± 7.6 and 2.9 ± 1.7 years respectively. Among the study population, 49 (16.0%) were in CKD stage 3, 90 (29.4%) in CKD stage 4 and rest 167 (54.6%) were in CKD stage 5. Two-thirds (202, 66%) of the study participants were receiving calcium and vitamin D, 52 (17%) were receiving only calcium and equal number (52, 17%) were not on any treatment regarding CKD-MBD. Base-line biochemical parameters of the total study participants are presented in Table 1. Selected biochemical parameters of CKD-MBD cases in different stages of CKD are presented in Table-2. Mean HbAlc (%) in CKD stages 3, 4 and 5 were 8.36±0.22, 7.99±0.20 and 7.77±0.17 respectively. The difference amongst the stage 3, 4 and 5 were not significant by ANOVA. Serum albumin was significantly (p<0.01 by ANOVA) reduced in stage 5 CKD-MBD cases compared to stage 3 and 4 cases.   Table-1: Base line biochemical characteristics of the study population (n=306)     Table-3 shows the rate of raised or elevated serum iPTH and ALP levels in stage 3, 4 and 5 CKD-MBD cases. The serum iPTH level was raised in 79.6%, 83.3% and 72.5% CKD-MBD stage 3, 4 and 5 cases respectively. But in comparison, the serum ALP was raised in significantly (p<0.01) low number of cases. It was 44.8%, 54.4% and 56.2% in CKD-MBD stage 3, 4 and 5 cases respectively. Overall the serum ALP was raised in only 53.9% CKD-MBD cases while iPTH was raised in 76.8% cases. There was no significant increase of rate of positivity of serum iPTH and ALP in any stage of CKD-MBD cases (p>0.05).   Table-2: Biochemical parameters of stage 3-5CKD-MBD cases (N=306)     Table-3: Comparative rate of raised serum iPTH and ALP levels in stage 3, 4 and 5 CKD-MBD cases     Fig.1: Correlation between serum iPTH and ALP in stage 3, 4 and 5 diabetic CKD-MBD patients   Figure-1 shows the correlation analysis between serum iPTH and ALP of CKD-MBD stage 3, 4 and 5 cases (r=0.073, r=0.231 and r=0.046 for stage 3, 4 and 5 respectively).   Discussion CKD-MBD is a recognized complication of advanced CKD patients but it is less addressed in our day to day practice. CKD-MBD has two distinct components; high iPTH related to high bone turn over and low iPTH resulting in adynamic bone disease [13]. Treatment of CKD-MBD is an integral component of CKD management. Serum iPTH is the key target for management of CKD-MBD [14,15]. Kidney disease wasting (KDW) also known as the malnutrition–inflammation complex, renal anemia and kidney bone disease (KBD) appear to be the 3 most important non-traditional risk factors associated with cardiovascular disease in CKD [11,17]. Kovesdy et al. described significant associations between higher total (nonspecific) ALP and increased all-cause mortality [18]. Unfortunately, there are very limited studies on this issue especially in this part of the world. In our study, we observed significantly low rate (44.8%-56.2%) of raised serum ALP in our CKD-MBD cases compared to 72.5%-83.2% rate of raised iPTH in those cases. Also, we did not observe the increase in the rate of raised serum iPTH and ALP with worsened CKD stages. In correlation analysis between iPTH and ALP, the r value was 0.046 to 0.231 for stage 3-5 cases indicating lack of useful association of the two markers. However, some studies have reported that elevated level of iPTH correlate well with elevated ALP level [19,20]. The study had few limitations. This study included a small sample size in a single centre and we could not prospectively follow the patients over time and assess the different subtypes of ALP. However, since there was raised serum ALP in about half of our study cases, serum ALP could be used as a surrogate marker for iPTH to detect CKD-MBD case in resource constraint settings. Test for serum ALP could be a much cheaper and easily available than that of iPTH test.   Authors’ contributions MAA and WMMH had equal contributions in this study. MAA and WMMH were involved in designing the study, collection and analysis of data, literature review and writing of the manuscript. MAR, TAC, TS, MMB and SI critically reviewed the manuscript and had significant intellectual contribution.   Competing interest Authors declare no conflict of interest.   Funding None   References 1.         Hill NR, Fatoba ST, Oke JL, Hirst JA, O’Callaghan CA, Lasserson DS, et al. Global Prevalence of Chronic Kidney Disease – A Systematic Review and Meta-Analysis. PLoS ONE. 2016; 11(7): e0158765. 2.         Barsoum RS. Chronic kidney disease in the developing world. N Engl J Med. 2006; 354: 997-9. 3.         Freethi R, Raj AV, Pooniraivan K, Khan MR, Sundhararajan A, Venkatesan. Study of serum levels of calcium, phosphorus and alkaline phosphatase in chronic kidney. Int J Med Res Health Sci. 2016; 5(3): 49-56. 4.         Nickolas TL, McMahon DJ, Shane E. Relationship between moderate to severe kidney disease and hip fracture in the United States. J Am Soc Nephrol. 2006; 17: 3223–32. 5.         Tentori F, McCullough K, Kilpatrick RD, Bradbury BD, Robinson BM, Kerr PG, et al. High rates of death and hospitalization follow bone fracture among hemodialysis patients. Kidney Int. 2014; 85: 166–73. 6.         Nitsch D, Mylne A, Roderick PJ, Smeeth L, Hubbard R, Fletcher A. Chronic kidney disease and hip fracture related mortality in older people in the UK. Nephrol Dial Transplant. 2009; 24: 1539–44. 7.         Mittalhenkle A, Gillen DL, Stehman-Breen CO. Increased risk of mortality associatedwith hip fracture in the dialysis population. Am J Kidney Dis. 2004; 44: 672–79. 8.         Nosjean O, Koyama I, Goseki M, Komoda T. Tissue nonspecific alkaline phosphatases: Sugar moiety induced enzymic and antigenic modulations and genetic aspects. Biochem J.1997; 321: 297-303. 9.         Sardiwa S, Magnusson P, Goldsmith DJ, Lamb EJ. Bone alkaline phosphatase in CKD-mineral bone disorder. Am J Kidney Dis. 2013; 62: 810–22. 10.        Gardham C, Stevens PE, Delaney MP, Le Roux M, Coleman A, Lamb EJ. Variability of parathyroid hormone and other markers of bone mineral metabolism in patients receiving hemodialysis. Clin J Am Soc Nephrol. 2010; 5: 1261-67. 11.        Souberbielle JC, Boutten A, Carlier MC, Chevenne G, CoumarosG, Law Son Body G. Inter method variability in PTH measurement: implication for the care of CKD patients. Kidney Int. 2006; 70: 345–50. 12.        Sigrist MK, Taal MW, Bungay P, Mcintyre CW. Progressive vascular calcification over 2 years is associated with arterial stiffening and increased mortality in patients with stages 4 and 5 chronic kidney disease. Clin J Am Soc Nephrol. 2007; 2: 1241–48. 13.        Coen G. Adynamic bone disease: an update and overview. J Nephrol. 2005; 18: 117-22. 14.        Moe S, Drüeke T, Cunningham J, Goodman W, Martin K, Olgaard K, et al. Definition, evaluation and classification of renal osteodystrophy: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2006; 69(11): 1945–53. 15.        Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2013; 3(Suppl): 1–150. 16.        Kalantar-Zadeh, Kuwae N, Regidor DL, Kovesdy CP, Kilpatrick RD, Shinaberger CS, et al. Survival predictability of time-varying indicators of bone disease in maintenance hemodialysis patients. Kidney Int. 2006; 70: 771–80. 17.        Lee GH, Benner D, Regidod DL, Kalantar- Zadeh K. Impact of kidney bone disease and its management on survival of patients on dialysis. J Ren Nutr. 2007; 17(1): 38–44 18.        Kovesdy CP, Ureche V, Lu JL, and Kamyar KJ. Outcome predibility of serum alakaline phosphatase in men with pre-dialysis CKD. Nephrol Dial Transplant. 2010; 25:3003-3011. 19.        Young EW, Albert JM, Satayathum S, Goodkin DA, Pisoni RL, Akiba T, et al. Predictors and consequences of altered mineral metabolism: The Dialysis outcomes and practice patterns study. Kidney Int. 2004; 67: 1179–87. 20.        Albalate M, de la Piedra C, Fernandez C, Lefort M, Santana H, Hernando P, et al. Association between phosphate removal and markers of bone turnover in haemodialysis patients. Nephrol Dial Transplant. 2006; 21: 1626–32. <![CDATA[Nephrotic-range proteinuria in a patient with dengue fever: a case report from Bangladesh]]> Shapur Ikhtaire https://imcjms.com/journal_full_text/298 2018-09-06 14:57:40 Clinical Case Report IMC J Med Sci 2018; 12(2): 86-89 Abstract We report a case of nephrotic range proteinuria with 24-hour urine protein level of 18.3 g/day, which developed following dengue fever (DF). The patient did not exhibit classical features of nephrotic syndrome (NS) and his renal function was not compromised during his illness. Proteinuria resolved without any specific treatment and precluded renal biopsy. Though the dengue fever and associated renal disorders are self-limiting, renal involvement in severe dengue infection is growingly seen in recent years and could cause increased mortality and long-term morbidity. IMC J Med Sci 2018; 12(2): 86-89. EPub date: 06 September 2018. DOI: https://doi.org/10.3329/imcjms.v12i2.39667 Address for Correspondence: Dr. Shapur Ikhtaire, Department of Internal Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU); Email: ikhtaireshapur@yahoo.com   Introduction Dengue fever is an acute febrile illness accompanyied by constitutional symptoms. Dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS) are the severe forms of dengue infection, which have become a major international public health issue [1]. Expanded dengue syndrome (EDS) is a relatively new entity which incorporates a wide spectrum of unusual manifestations of dengue virus infection involving kidney, liver, brain, heart and muscle [1]. The dengue virus is an RNA arbovirus from the genus Flavi virus (family Flaviviridae). It has four closely related serotypes: DEN-1, DEN-2, DEN-3 and DEN-4 based on antigenic characteristics of dengue virus. More recently, a new serotype DEN-5 was identified, which caused an epidemic of dengue in Malaysia in 2007 [2,3]. Over the past three decades, there has been a global increase in the frequency and epidemics of DF, DHF, DSS with a concurrent rise in disease incidence [1]. Though it is a self-limiting disease, in the recent years complications involving specific organ systems and dengue related mortality and morbidity have been observed at an increasing rate [4-6]. Here, we describe a case of dengue virus infection who exhibited massive nephrotic range proteinuria (18.3 g/day) following DF. Proteinuria improved without any specific treatments and precluded renal biopsy. To date, proteinuria of 18.3 g/day in DF has never been reported from Bangladesh and rarely from the other parts of the world.   Case report A 17-year-old boy without any past medical illness presented through emergency department of a hospital in Dhaka city with a 3-day history of high grade fever, chills, myalgia and headache. On admission, he was febrile (1020 F), with congested eyes without any systemic signs and bleeding manifestations. His pulse was 100 beats/min and blood pressure was 120/85 mm of Hg. Initial investigation on admission showed hemoglobin 116 gm/L, total white blood cell (WBC) 7.6x109/L, platelet count 155x109/L, which dropped to 110x109/L the next day. Packed cell volume (PCV) 35%, erythrocyte sedimentation rate (ESR) 05 mm in first hour and Dengue NS-1 Ag was positive (3rd day of his fever). His liver transaminase, renal function, blood urea and electrolytes were within normal limit. The case was diagnosed as DF and treated symptomatically with adequate fluid and anti-pyretic (paracetamol). By day 5 of fever, he noticed excessive frothiness of urine and he developed mild puffiness of face without any oedema, ascites, plural effusion and rise of blood pressure. Immediate urine examination revealed, presence of proteinuria (+++), RBC 2-3/HPF and pus cell 6-8/HPF. This proteinuria was quantified by 24 hours urinary total protein (UTP) test, which surprisingly exhibited as UTP 18.3 gm/24 hours (UTV 5000 ml). Accordingly, other relevant tests were done to exclude other potential systemic causes of nephrotic range proteinuria and pre-existing glomerulonephritis (GN). These included urine phase contrast microscopy to delineate glomerular pathology, which showed RBC 6-8/ HPF, dysmorphic RBC-15%, pus cell 8-10/HPF without the presence of any cast. Urine and blood culture revealed no growth. Anti-nuclear antibody (ANA), Anti ds-DNA, cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA),perinuclear antineutrophil cytoplasmic antibody (p-ANCA), C3, C4, immunochromatograpic test for malaria and hepatitis B surface antigen (HBsAg) were found negative. Serum creatinine and albumin were within normal reference limit. Surprisingly, regardless of massive nephrotic range proteinuria the patient did not have the essential criteria of classical nephrotic syndrome of hypoalbuminaemia, dyslipidaemia and oedema. By the 7th day of his illness, he noticed yellow coloration of eyes, severe myalgia and gum bleeding. At this stage his serum bilirubin was 37.62 µmol/L (normal 3-22 µmol/L) AST 246 U/L (normal-15-37 U/L), CPK 667 U/L (normal-24-190 U/L). Therefore, along with his initial presentation, additionally he developed hepatitis and myositis. Although, he had no bleeding manifestation, relevant tests were done which included bleeding and clotting time (BT, CT), reticulocyte count, activated partial thromboplastin time (APTT), INR, direct and indirect Coomb¢s tests. All of them were within normal limit. His platelet count was 125x109/L and peripheral blood film (PBF) showed normocytic normochromic anaemia without any features of haemolysis. Anti-dengue IgG was positive while IgM was negative. During his spectrum of illness, he did not exhibit any significant bleeding manifestation or any features of plasma leakage like ascites, plural effusion and rise of hematocrit value. His chest x-ray was normal and ultra sonogram of abdomen revealed mild splenomegaly. Based on clinical features and laboratory investigation he was diagnosed as a case of expanded dengue syndrome with unusual manifestation of nephrotic range proteinuria along with hepatitis and myositis. <![CDATA[Serum prolactin and gonadotropin levels in women with infertility in Bangladesh]]> Shamima Bari Rokeya Begum Qazi Shamima Akter https://imcjms.com/journal_full_text/246 2017-07-08 15:34:22 Original Article IMC J Med Sci 2018; 12(1): 01-05 Abstract Methods: The study involved a total of 100 women of which 50 had primary (Group A) and another 50 had secondary (Group B) infertility. Fifty fertile age-matched women were included as control (Group C). All the study participants were selected from women attending the infertility unit of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka. Serum prolactin, FSH and LH hormones were measured by radioimmunoassay with blood collected on the 2nd day of menstrual cycle. IMC J Med Sci 2018; 12(1): 01-05. DOI: https://doi.org/10.3329/imcjms.v12i1.35169 Address for Correspondence:Dr. Shamima Bari, Assistant Professor, Department of Physiology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka. E-mail: shamima.bari@yahoo.com Introduction Hormonal disorders of female reproductive system occur due to aberrant dysfunction of hypo-thalamic-pituitary-ovarian axis and are relatively common disorders leading to infertility. The increased or decreased levels of prolactin, FSH and LH hormones may cause infertility [8-10]. High level of prolactin may cause infertility affecting FSH and gonadrotropin releasing hormone (GnRH) [11]. High prolactin level inhibits GnRH and follicle stimulating hormone leading to infertility [12-16].   This cross sectional study was carried out in the department of Physiology, Dhaka Medical College, Dhaka from July 2010 to June 2011 and the protocol was approved by Ethical Review Committee of Dhaka Medical College.            Infertile women having husbands with normal semen analysis results and normal genitalia, uterus and adnexa were included. Women with tubal factor, congenital anomaly of urogenital tract and any obvious organic lesion or pelvic inflammatory diseases, and lactating women were excluded from this study. The purpose and benefits of the study were explained to each participant and informed written consent was taken from each of them. A detailed personal, medical, family, socio-economic and drug history were recorded in a predesigned questionnaire. Biochemical parameters and collection of blood: Aseptically 5 milliliter of blood was collected from medial cubital vein from each participant in the 2nd day of menstrual cycle. Blood was allowed to clot for 30-60 minutes at room temperature and then centrifuged at 3000 rpm for 5-10 minutes and serum was separated and preserved at -20°C for estimation of serum prolactin, FSH and LH. Prolactin, FSH and LH were measured by radioimmunoassay at the Centre for Nuclear Medicine and Ultrasound, Dhaka Medical College.The analysis was done within 2 weeks of blood collection. The normal range for prolactin, FSH and LH were 2 -25 ng/dl, 3.1-7.9 IU/L and 1.9 -12.5 IU/L respectively.     Out of 50 cases of primary infertility, 84% had normal and 16% had high prolactin level (>25 ng/dl). The rate was 86% and 14% respectively in secondary infertility cases. Only 2 cases (4%) with normal fertility had high prolactin level. In women with primary sterility, the serum FSH and LH levels were lower than the normal levels in 54% and 10% cases respectively while in secondary sterility the levels were low in 30% and 28% cases respectively. Compared to women with secondary sterility, significantly (p<0.05%) higher number of cases with primary sterility (30% vs. 54%) had FSH level below the normal range (Table-3). On the other hand, compared to primary sterility group significantly higher number of cases with secondary sterility (10% vs 28%) had LH level below the normal range.     Hormone levels in women with infertility have been evaluated by many researchers. High prolactin level has been reported as the cause of female infertility [12,13]. In the present study, the overall mean serum prolactin level was significantly higher in infertile women than that of control fertile women. However, only 14-16% women with primary and secondary infertility had prolactinemia above the recommended normal range. Similar observation was also reported by other investigators from different countries [16,19-24]. In the present study, the observation of high prolactinemia in 30% women with primary and secondary infertility in our study is in agreement with other studies elsewhere [15,25-29]. High prolactinemia is the commonest biochemical abnormality observed in infertility [28]. Furthermore, prolactin may affect the ovaries by altering ovarian progesterone secretion and estrogen synthesis leading to infertility [27,28]. Women with high level of prolactin may ovulate regularly but may not produce enough progesterone during luteal phase after ovulation. Deficiency of progesterone produced after ovulation, may hamper embryo implantation in a uterine lining [30,31]. Therefore, the present study has demonstrated that a significant number of women with primary and secondary infertility have altered prolactin, FSH and LH levels compared to fertile women.Acknowledgement   1.   Momtaz H, Flora MS, Shirin S. Factors associated with secondary infertility. Ibrahim Med Coll J. 2011; 5(1): 17-2. 3.   Safarinejad R. Infertility among couples in a population based study in Iran: prevalence and associated risk factors. Int J Andrology.2007; 31: 303-314. 5.   Farely TMM, Baisey EM. The prevalence of an etiology of infertility. Proceedings, The 1st African Population Conference. 1998; Senegal, Dakar, 1998. 7.   Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERHT), Briefing paper on Assessment of Reproductive Health Care needs and Review of Services provided at the level of Thana, Union and Village, Dhaka, Bangladesh, 1997; 5: 1-4. 9.   Roupa Z, Polikandrioti M, Sotiropoulou P, Faros E, Koulouri A, Wozniak G. Causes of infertility in women at reproductive age. Health Sci  J. 2009; 3: 80-7. 11.  Rajan R. Prolactin metabolism in infertility. J Obstet Gynecol India. 1990; 40: 243-7. 13.  Mishra R, Baveja R, Gupta V et al. Prolactin level in infertility with menstrual irregularities. J Obs Gyn India. 2002; 52:40-43. 15.  Akhter N, Hassan, MA. Subclinical hypothyroidism and hyperprolactinaemia in infertile women: Bangladesh perspective after universal salt iodinisation. The internet J Endocrinol. 2009; 5(1): 1-5. 18.  Peterson BD, Gold L, Feingold T. The experience and influence of infertility: considerations for couple counselors. Fam J. 2007; 15(3): 251-257. 20.  Del Pozo E, Wyss H, Tollis G, Alcaniz J, Campana A, Naftolin F. Prolactin and deficient luteal function. Obs Gyn.1979; 53(3): 282-286. 22.  Azima K, Samina J. Role of hyperprolactinemia in fertility. Pakistan J Med. 2002; 3: 41. 24.  Goswami B, Patel S, Chatterjee M, Koner BC, Saxena A. Correlation of prolactin and thyroid hormone concentration with menstrual patterns in infertile women. J Reprod Infertil. 2009; 10(3): 207-212. 26.  Kuku SF. African endocrine infertility: a review. Afr J Med sci. 1995; 24: 111-123. 28.  Audu I, Mohammed BK, Adebayo AE. Prolactin levels among infertile women in Maiduguri, Nigeria. Trop J Obstet Gynaecol. 2003; 20(2): 97-100. 30.  Akande AA Idowu AA, Jimoh AK. Biochemical infertility among females attending University of Ilorin teaching hospital, Nigeria. Niger J Clin Pract. 2009; 12(1):20-24. 32.  Moltz L, Leidenberger F, Weise C. Rational hormone diagnosis in normocyclic functional sterility. J Infertility. 1991; 51(9);756-68. <![CDATA[Clinical profile, degree of severity and underlying factors of acute pancreatitis among a group of Bangladeshi patients]]> Indrajit Kumar Datta Md Nazmul Haque Tareq M Bhuiyan https://imcjms.com/journal_full_text/266 2017-08-24 09:07:06 Original Article IMC J Med Sci 2018; 12(1): 06-10 Abstract Background and objectives: Acute pancreatitis is a common condition for hospital admission. In Bangladesh, no study has yet investigated the clinical profile, degree of severity and underlying factors of acute pancreatitis. The aim of the present study was to determine the clinical profile, degree of severity and underlying factors of acute pancreatitis in a cohort of Bangladeshi patients. Methods: This prospective study was conducted from April 2016 to March 2017 on patients admitted with acute pancreatitis at Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) General Hospital, Dhaka, Bangladesh. History and clinical features of each patient was systematically recorded. Diagnosis of acute pancreatitis was made by clinical findings, serum amylase and lipase levels (> 3 times the upper limit of normal values), evidences of acute pancreatitis by ultrasonography and computed tomography (CT). Severity of acute pancreatitis was classified according to the revised version of Atlanta classification. Results: A total of 40 patients with acute pancreatitis were enrolled in the study. Male and female were equally distributed. The mean age was 44.3±2.7 years. Among 40 cases, 26 (65.0%) and 14 (35%) had moderate and severe acute pancreatitis respectively. No specific clinical feature including ascites or pleural effusion was found significantly related to severity of the disease. Gall stone and metabolic (hypertriglyceridaemia/hypercalcemia) causes were present in 62.5% cases, but none had significant association with the severity of the disease. Conclusion: The present study has demonstrated that no specific observed clinical feature or underlying factor was related to the degree of severity of acute pancreatitis in a cohort of Bangladeshi patients. IMC J Med Sci 2018; 12(1): 06-10. DOI: https://doi.org/10.3329/imcjms.v12i1.35170   Introduction Acute pancreatitis is a medical emergency and is one of the most common gastrointestinal conditions for hospital admission. The reported annual incidence of acute pancreatitis is 13 to 45 per 100,000 populations in different countries of the world [1]. The risk, clinical features and severity of acute pancreatitis differ with age, sex, life style and presence of co-morbidities. Of the many complications, ascites and pleural effusion are important complications related to the severity of the disease [2,3,4]. So far, no systematic study has investigated the clinical profile, degree of severity and underlying factors of acute pancreatitis among Bangladeshi patients. Therefore, the present study has attempted to determine the rate of different grades of severity of acute pancreatitis and their associated clinical features in a group of Bangladeshi patients.   Materials and Methods The present prospective study was performed from April 2016 to March 2017 at the BIRDEM General Hospital, Dhaka, Bangladesh. All patients aged 18 years or more, diagnosed as a case of acute pancreatitis, were included in study. Informed consent was obtained from each participant. Diagnosis of acute pancreatitis was made by clinical findings, serum amylase and lipase levels more than 3 times the upper limit of normal value as well as by evidences of acute pancreatitis by ultrasonography and computed tomography (CT). Ultrasonography and CT scan were performed in all patients within 3 and 4 days of admission respectively. Abdominal ultrasonography was repeated when clinically indicated during hospitalization and 1 month after leaving the hospital. X-ray chest was done in all patients. Ascites and pleural effusion were diagnosed accordingly. Organ failure was diagnosed when shock, pulmonary insufficiency, renal failure and gastrointestinal bleeding were present. Presence of pancreatic necrosis, abscess and pseudocyst were recorded. Severity of acute pancreatitis was classified according to the revised version of Atlanta classification [5]. Moderately severe acute pancreatitis was diagnosed based on the presence of local complication and/or transient organ failure (<48 hours). Severe acute pancreatitis was defined as patients having persistent single or multiple organ failure for >48 hours – systolic blood pressure ≤ 90 mmHg or PaO2<60% or serum creatinine ≥2mg/dl [5]. Patients having ascites and pleural effusion due to cardiac, pulmonary and liver diseases and having other severe co-morbid condition were excluded from this study. Detailed history and biochemical parameters were recorded in a predesigned data sheet for determining possible etiological factors of acute pancreatitis. Gall stone pancreatitis was diagnosed if serum alanine aminotransferase level was more than 3 times the upper limit of normal value and/presence of gall stone in gallbladder or bile duct. Metabolic pancreatitis was diagnosed if serum triglyceride level was more than 1000 mg/dl or hypercalcemia was present [6]. The significance of association of clinical features with severity of pancreatitis was tested by chi-square and other appropriate statistical tests.   Results A total of 40 acute pancreatitis patients were enrolled in the study. Of the 40 cases, 19 (47.5%) and 21 (52.5%) were male and female respectively and the mean age was 44.25±2.7 years. Among them, 26 (65.0%) and 14 (35%) had moderate and severe acute pancreatitis respectively. The mean age of patients with severe acute pancreatitis (59.1±16.2 years) was significantly higher (p<0.01) than that of cases with moderately severe pancreatitis (36.2±11.5 years). Duration of hospital stay of patients with moderately severe acute pancreatitis cases (6.5±2.0 days; 95% CI: 5.6-7.3) was significantly (p<0.01) less compared to those with severe pancreatitis (9.4±5.1 days; 95% CI: 6.5 - 12.3).The overall mean hospital stay for all acute pancreatitis cases was 7.5±.6 days. Detail clinical profile of study population is shown in Table-1. The most common presentations of both moderate and severe acute pancreatitis were upper abdominal pain (100%) and vomiting (84.6% and 92.8%). Among the patients, ascites and pleural effusion were present in 30% (12/40) and 32.5% (13/40) respectively. Pleural effusions was bilateral in 7 (53.8%), left sided in 5 (38.46%) and right sided in 1 (7.69%). Bilateral pleural effusion was present in 21.4% and 15.4% cases with severe and moderately severe pancreatitis cases. No significant differences (p>0.05) were observed regarding occurrence of either ascites or pleural effusion in moderately severe and severe acute pancreatitis cases (ascites: 23% vs. 42.8%; pleural effusion: 23% vs. 50%). Both ascites and pleural effusion were together present in 11.5% and 35.5% patients with moderate and severe acute pancreatitis respectively (p=0.06). Ascites disappeared in all surviving patients before they were released from the hospital. Two patients were discharged from the hospital with pleural effusion but the effusion disappeared within one month. Leukocytosis was present in 19.2% and 57.1% cases with moderate and severe acute pancreatitis respectively. Only one patient died due to pancreatic necrosis and respiratory distress syndrome.   Table-1: Demographic and clinical profile of patients with moderate (n=26) and severe (n=14) acute pancreatitis     In this study, gallstones was associated with 15.3% and 42.8% patients with moderate and severe acute pancreatitis respectively; while metabolic syndrome was present in 46.1% and 21.4% cases respectively (Table-2). History of alcohol consumption was present in 15.3% patient with moderate acute pancreatitis and 7.1% in severe acute pancreatitis. No underlying cause was found (idiopathic) in 23% and 28.5% cases in both groups. None of the underlying factors were found significantly associated with the severity of acute pancreatitis.   Table-2: Etiology or underlying factor in cases with moderate and severe acute pancreatitis     Discussion The present study has attempted to determine the rate of different grades of severity of acute pancreatitis and their associated clinical features in a group of Bangladeshi patients. In this study, 65% of patients had a moderately severe and 35% had severe acute pancreatitis. Other studies reported the rate of severe acute pancreatitis as 21% to 25% [7,8]. The higher rate of severe pancreatitis in our patients could be due to delay in early intervention, food habits and underlying predisposing factors like diabetes mellitus. About 80% of our cases had diabetes mellitus of different duration. Out of our 40 cases, male and female were equally affected. Similar observation has also been reported by other investigators [9,10,11]. As reported by others [12], upper abdominal pain (100%) and vomiting (87.5%) were the most common clinical features. Ascites is a well known complication of acute pancreatitis. In our study, there was no significant difference of occurrence of ascites among moderate and severe acute pancreatitis cases though 42% severe cases had ascites compared to 23% in moderately severe cases. Studies elsewhere have reported the rate of ascites in severe pancreatitis cases from 18% to 60% [13,14]. Similarly, in the present study, we were unable to find any significant association of pleural effusion with the severity of acute pancreatitis though the rate of pleural effusion was much higher (23% and 50%) in our study than those (4% to 17%) reported by other studies [15,16]. In both moderate and severe disease, the majority of effusions were bilateral. Thus the site of pleural effusion offers no additional diagnostic information [17]. Perhaps studies large number of cases with stringent case selection criteria is needed to ascertain whether ascites and pleural effusion can be used as diagnostic criteria for severe acute pancreatitis. We tried to determine the underlying predisposing factors of acute pancreatitis in our cases. In the present study, metabolic cause was found to be the most common cause of acute pancreatitis (37.5%), followed by gallstone disease. Among the severe acute pancreatitis cases, we found gallstone disease as the most common cause (42.8%). One fourth of our cases were idiopathic. However, it is to be noted that over 80% of our cases had diabetes mellitus of different duration and, therefore, the presence of such co-morbid condition and use of certain anti-diabetic drugs might play a role in its pathogenesis [1]. However, we could not find any significant association of these factors with severity of the disease. The present study has demonstrated the frequency of severity and the clinical profiles of moderately severe and severe variety of acute pancreatitis among a cohort of Bangladeshi patients. Study with larger number of cases may be required to determine the specific underlying factor(s), predictive or prognostic criteria for different grades of acute pancreatitis in our population.   Author’s contributions IKD was involved in case enrollment, management and manuscript writing; MNH and TMB did overall supervision.   Competing interest Authors declare no conflict of interest.   Funding None   References 1.   Yadav D, Lowenfels AB. The epidemiology of pancreatitis and pancreatic cancer. Gastroenterology. 2013; 144(6): 1252-1261. 2.   Keith LM, Zollinger RM, McCleery RS. Peritoneal fluid amylase determination as an aid in diagnosis of acute pancreatitis. Arch Surg. 1950; 61: 930–936. 3.   Roseman DM, Kowlessar OD, Sleisenger MH. Pulmonary manifestations of pancreatitis. N Eng J Med.1960; 263: 294–296. 4.   Mitchell CE. Relapsing pancreatitis with recurrent pericardial and pleural effusion. Ann Intern Med. 1964; 60: 1047–1053. 5.   Banks PA, Bollen TL, Dervanis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis-2012: revision of Atlanta classification and definitions by international consensus. Gut. 2013; 62: 102-111. 6.   Tenner S and Steinberg WM. Acute pancreatitis. In: Feldman M ,Friedman LS, Brandt LJ, editors. Sleisenger and Fordtran’s Gastrointestinal and liver Disease. 10th edition. Philadelphia: Elsevier; 2010: p976-984. 7.   Buter A, Imrie CW, Carter CR, Evans S, McKay CJ. Dynamic nature of early organ dysfunction determines outcome in acute pancreatitis. Br J Surg. 2002; 89: 298-302. 8.   Rau BM. Outcome determinants in acute pancreatitis. Am J Surg. 2007; 194: S39-44. 9.   Imrie CW. Observations on acute pancreatitis. Br J Surg. 1974; 61: 539-44. 10.  Blamey SL, Imrie CW, O’Neil J, Gilmour WH, Carter DC. Prognostic factors in acute pancreatitis. Gut. 1984; 25: 1340-6. 11.  Corfield AP, Cooper MJ, Williamson RC, Mayer AD, McMahon MJ, Dickson AP, et al. Prediction of severity in acute pancreatitis: prospective comparison of three prognostic indices. Lancet. 1985; 2: 403-7. 12.  Jacobs ML, Daggett WM, Civette JM, Vasu MA, Lawson DW, Warshaw AL, et al. Acute pancreatitis: analysis of factors influencing survival. Ann Surg. 1977; 185: 43-51. 13.  Durenier T, Laterre PF, Reynaert MS. Ascites fluid in severe acute pancreatitis: from pathophysiology to therapy. Acta Gastroenterol Belg. 2000; 63: 264-8. 14.  Maringhini A, Ciambra M, Patti R, Randazzo MA, Dardononi G, Mancuso L, et al. Ascites, pleural and pericardial effusion in acute pancreatitis. A prospective study of incidence, natural history and prognostic role. Dig Dis Sci. 1996; 41: 848-52. 15.  Bradley EL III. Contemporary management of patients with acute pancreatitis. In: Bradley EL III, editors. Acute pancreatitis. Diagnosis and Therapy. New York, Raven Press; 1994. p.281-285. 16.  Gumaste V, Singh V, Dave P. Significance of pleural effusion in patients with acute pancreatitis. Am J Gastroenterol. 1992; 87: 871-874. 17.  Heller SJ, Noordhoek E, Tenner SM, Ramagopal V, Abramowitz M, Hudhes M and Banks PA. Pleural effusion as a predictor of severity in acute pancreatitis. Pancreas. 1997; 15(3): 222-225. <![CDATA[Prevention of peptic ulcer by aqueous extract of Aegle marmelos leaf in rats]]> Sharmin Rahman Mohammad Rezaul Quader Md. Ismail Khan https://imcjms.com/journal_full_text/267 2017-08-26 16:25:41 Original Article IMC J Med Sci 2018; 12(1): 11-14 AbstractBackground and objectives: Aegle marmelos (Bael), a medicinal plant, has been widely used indigenously to treat many diseases in Bangladesh and other countries. The present study was carried out to evaluate the efficacy of A. marmelos leaf to prevent ethanol induced gastric ulcer in a rat model. Methods: Thirty two Wister albino rats of either sex, weighing between 100-150g, were fed 200 mg/kg or 400 mg/kg aqueous extract of A. marmelos leaves one hour prior to oral administration of 90% ethanol (1 ml/200 gm body weight) to induce gastric ulcer. The animals were sacrificed after one hour and ulcer scores and index were determined. The protective efficacy of A. marmelos aqueous extract was expressed as percentage protection of ulcer. Results: Aqueous extract exhibited significant (p<0.05) dose dependent protection against gastric ulcer formation by ethanol in rat stomach. Percentage protection of ulcer with 200 mg/kg and 400 mg/kg of aqueous extract of A. marmelos leave were 19.3% and 37.2% respectively compared to standard anti-peptic ulcer drug omeprazole (50.4%). Conclusion: Thus, crude extracts of A. marmelos leave have been shown to have potential ability to prevent experimentally induced peptic ulcer formation in animal model. IMC J Med Sci 2018; 12(1): 11-14. DOI: https://doi.org/10.3329/imcjms.v12i1.35171 Address for Correspondence: Dr. Sharmin Rahman, Assistant Professor, Department of Pharmacology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbagh, Dhaka-1000, Bangladesh. Email: sharminrahman241980@gmail.com   Introduction Peptic ulcer refers to ulceration in the lower esophagus, stomach, duodenum, and jejunum, and rarely in the ileum adjacent to a diverticulam. Herbal medicine is fast emerging as an alternative treatment to available synthetic drugs for the treatment of peptic ulcer possibly due to lower costs, easy availability, fewer adverse effects and perceived effectiveness. A. marmelos, commonly known as ‘Bael’ in Bengali language, is one such plant that grows wildly all over Bangladesh and also in many countries of South East Asia including India, Sri Lanka, Myanmar, Thailand and Indochina [1]. Extensive chemical investigations on various parts of the tree have been carried out. Many active constituents has been isolated from A. marmelos and reported to have anti-ulcer, anti-inflammatory and antimicrobial properties [1]. The present study was designed to demonstrate the protective effect of aqueous extract of A. marmelos leaves on ethanol induced gastric ulcer in rat model.   Materials and Methods The study was conducted at the Department of Pharmacology, Dhaka Medical College, Bangladesh. Leaves of A. marmelos were collected from Botanical garden, Mirpur, Dhaka and authenticated by the Bangladesh National Herbarium.   Preparation of plant extract:Collected leaves (1kg) of A. marmelos were sun dried and the dried material was crushed to coarse powder with mechanical grinder. Aqueous extract was prepared at the Drug Research Laboratory, Center for Advanced Research of Science (CARS), Dhaka University. The dried powdered plant part was soaked in distilled water at room temperature for 72 hour and filtered. The filtrate was concentrated under vacuum rotator evaporator (40-500C) and semi-liquid extract of A. marmelos was obtained and preserved at 40C until used. The extract was diluted with measured amount of distilled water prior to use to get the required concentration.   Animals: Thirty two Wister albino rats of either sex, weighing between 100-150g were kept under standard condition of light and temperature, fed with standard rat pellet diet and allowed to drink water ad libitum.   Experiment Design:Preventive anti-peptic ulcer activity of aqueous extracts of A. marmelos leaves was assessed in ethanol induced gastric ulcer in rat model [2,3]. Experimental animals were randomly selected irrespective of sex and divided into 4 groups, each group comprising of 8 rats. Rats in group-I served as control and the other three comprised study groups. All the animals were kept fasting for 24 hours prior to administration of drugs. Rats in group-I received distilled water 5 ml/kg body weight and served as negative control. Rats in group-II and III received aqueous extract of A. marmelos leaves 200 mg/kg and 400 mg/kg body weight respectively in 1-2 ml distilled water by baby Ryle’s tube. Rats in group-IV received omeprazole 20 mg/kg body weight orally as standard reference drug. One hour after administration of A. marmelos leave extract and omeprazole, gastric ulcer was induced in rats by administering 90% ethanol (1 ml/200gm body weight) orally. One hour after ethanol administration rats were sacrificed. Their stomachs were isolated, washed gently under clean water and cut open along the greater curvature. The stomachs were then fixed in 10% formalin and the ulcers were scored as: no ulcer-0, red coloration of mucosa-0.5, spot hemorrhage-1, hemorrhagic streaks-1.5, ulcer-2 and perforation-3. Ulcer index (UI) was calculated using the following formula: UI =UN+US+UP ´ 10-1, where UN= average of number of ulcers/lesions per animal, US = average number of severity score of lesions and UP = percentage of animal with ulcers incidence. Percentage protection of ulcer was calculated by the following formula: Percentage protection = (mean ulcer index of control – mean ulcer index of test)x100 / mean ulcer index of control   Statistical Analysis All the results have been expressed as the mean ± standard error of mean (SEM). The significance of the differences between treatment and control group were calculated using student’s t-test.   Results The ulcer score, UI and protective effect of aqueous extract of A. marmelos leaves and omeprazole on ethanol induced gastric ulcer is shown in Table-1. The mean ulcer score and UI of rats fed with distilled water only (Group-I: control) were 2.83±0.21 and 18.16±0.21 respectively. Aqueous extract in doses of 200mg/kg body weight (Group-II) and 400 mg/kg body weight (Group-III) produced a significant dose dependent decrease in ulcer score to 1.58±0.15 and 0.83±0.25 while ulcer index to 14.66±0.15 and 11.40±0.25 respectively. The differences compared to control Group-I were statistically significant (p<0.05). Omeprazole (20 mg/kg body weight) also produced highly significant (p<0.001) decrease in ulcer score (0.67±0.17) and ulcer index (9.0±0.17) compared to control group (2.83±0.21 and 18.16±0.21) respectively (Table- 1). The percentage protection of ulcer was 19.27%, 37.22% and 50.4% with 200 mg/kg, 400 mg/kg dose of aqueous extracts of A. marmelos leaves and omeprazole respectively.   Table-1: Effects of aqueous extract of A. marmelos leaves on ethanol induced gastric ulcer in rats       Fig.1: Photograph showing effect of aqueous extract of A. marmelos leaves on ethanol induced ulcer in rat stomach. 1a: ethanol treated gastric mucosa of rat, 1b and 1c: effect of 200 mg/kg and 400 mg/kg body weight dose of aqueous extract of A. marmelos leaves and 1d: effect of omeprazole (20 mg/kg).   Discussion Many studies have demonstrated the importance of natural products in drug discovery. In this study, ability of aqueous extract of A. marmelos leaf to prevent ethanol induced gastric ulcer in rat model has been studied. The effect of aqueous extract of A. marmelos leaves was compared to standard anti- peptic ulcer drug, omeprazole. The ulcer index parameter was used for evaluation of ulcer protective activity. Earlier studies have shown that aqueous extract of A. marmelos leaves have variable ulcer protective effects in animal models with ethanol induced gastric ulcer [4,5]. Aqueous extracts of A. marmelos leaves, 200 mg/kg and 400 mg/kg body weight, produced significant (p<0.05) anti-ulcer effect, compared to control and omeprazole (20mg/kg body weight). Percentage protection against ulcer with 200 and 400mg/kg body weight of aqueous extract of A. marmelos leaves was 19.3% and 37.2% respectively.   Acknowledgment Authors acknowledge the valuable opinion and advice of Prof. Nazma Haque during the preparation of manuscript.     Author’s contribution SR was responsible for experiments, literature search and manuscript writing, MRQ helped in sample collection, laboratory work and manuscript writing and MIK designed the study and was overall supervisor.   Competing interest The authors declare that they have no competing interests.   Funding source None   References 1.   Sharma PC, Bhatiya V, Bansal N, Sharma A. A review on Bael tree. Nat Prod Rad. 2007; 6(2): 171-178. 2.   Gupta J, Kumar D, Gupta A. Evaluation of gastric anti-ulcer activity of methanolic extract of Cayratia trifolia in experimental animals. Asian Pac J Trop Dis. 2012; 99-102. 3.   Nwagba CA, Ezugwa CO, Eze CC, Anowi FC, Ezea SC, Nwakile CD. Anti ulcer activity of Bombax buonopozense p. beauv. aqueous leaf extract (Fam: Bombacaceae). J Appl Pharm Sci. 2013; 3(2): 139-142. 4.   Madhu C, Hindu K, Sudepthi CD, Maneela P, Reddy KV, Bhagya SB. Anti ulcer activity of aqueous extract of A. marmelos leaves on rats. Asian J pharm Res. 2012; 2(4): 132-135. 5.   Shenoy AM, Singh R, Samuel RM, Yedle R, Shabraya AR. Evaluation of anti ulcer activity of A. marmelos leaves extract. Int J Pharm Sci Res. 2012; 3(5): 1498-1501. <![CDATA[Factors associated with non-response to lactulose therapy in cirrhotic patients with minimal hepatic encephalopathy]]> Shireen Ahmed Md. Golam Azam Indrajit Kumar Datta Md. Nazmul Hoque Tareq M Bhuiyan https://imcjms.com/journal_full_text/231 2017-06-20 12:48:46 Original Article IMC J Med Sci 2018; 12(1): 15-21 Abstract Background and objectives: Minimal hepatic encephalopathy (MHE) impairs health related quality of life and predicts overt hepatic encephalopathy (HE) in cirrhotic patients. Lactulose is effective in the treatment of MHE. But the response to lactulose treatment depends on several factors. This study was aimed to find out the contributing factors to non-response to lactulose therapy. Materials and methods: The study was carried out at the BIRDEM general hospital from September, 2013 to March, 2015. Sixty patients were enrolled to assess the response of lactulose therapy in cirrhotic patients with MHE. MHE was diagnosed based on abnormal psychometric tests namely, number connection test (NCT), digit symbol test (DST) and high serum ammonia level. A daily dose of 30-60 ml of lactulose was given to all patients for one month. The response to treatment with regard to MHE was determined after one month using defined criteria. The response was graded as responder and non-responder. Results: The mean age of the study population was 57.0±10.3 years. Out of 60 cases, 46 (77%) were male and 39 (65%) had diabetes. Out of 60 enrolled MHE cases, 16 (27%) had Child-Turcotte-Pugh-A (CTP-A) score and 44 (73%) belonged to CTP-B & C category. Out of 60 MHE cases, 23 (38.3%) showed improvement in their MHE status based on normalization of psychometric tests and reduction of serum ammonia level to ≤32 µmol/L. Age, gender and diabetes were not associated with the response to lactulose therapy. Low baseline arterial pressure was significantly (p=0.003) associated with non-response to lactulose treatment. The mean baseline ammonia level was higher significantly among the non-responders compared to the responders (83.6±21.4 µmol/L vs 58.8±19.8 µmol/L, p<0.001). Compared to responders, low serum sodium and potassium and raised serum bilirubin levels of non-responders at baseline were found significantly (p<0.05) associated with non-response to one month of lactulose treatment. Initial hemoglobulin, peripheral leucocyte and platelet counts did not have any effect on the response to lactulose treatment in MHE cases. Conclusions:The status of MHE in patients with cirrhosis improved by one-month treatment with lactulose. Baseline low arterial pressure, hyperammonemia, hypokalemia and hyponatremia were major contributors to non-response to lactulose therapy. The findings of the study would be useful in treating patients of cirrhosis with MHE. IMC J Med Sci 2018; 12(1): 15-21. DOI: https://doi.org/10.3329/imcjms.v12i1.35172 Address for Correspondence: Dr. Shireen Ahmed, Registrar, Department of Gastroenterology Hepatobiliary and Pancreatic Disorders, BIRDEM General Hospital, 122 Kazi Nazrul Islam Avenue, Dhaka, Bangladesh. E-mail: a.alwasi15@gmail.com   Introduction Hepatic encephalopathy (HE) is defined as a spectrum of neuropsychiatric abnormalities in patients with liver dysfunction, after exclusion of other known brain disease. Hepatic encephalopathy is characterized by personality changes, intellectual impairment, and a depressed level of consciousness. An important prerequisite for the syndrome is diversion of portal blood into the systemic circulation through porto-systemic collateral vessels [1]. The development of hepatic encephalopathy negatively impacts patient survival. The survival probability of patients with HE requiring hospitalization has been reported to be 42% at 1 year of follow-up and 23% at 3 years. Approximately, 30% of patients dying of end-stage liver disease experience significant encephalopathy [2]. The economic burden of hepatic encephalopathy is substantial. After ascites, hepatic encephalopathy is the second most common reason for hospitalization of cirrhotic patients in the United States [3].   Apart from HE, a considerable number of patients with cirrhosis also develop minimum hepatic encephalopathy (MHE). MHEis a condition in patients with cirrhosis of the liver, who has  normal mental and neurological status on standard clinical examination while exhibit a number of neuropsychiatric and neurophysiological defects [4]. The prevalence of MHE varies from 30 to 70% in cirrhotic patients without overt hepatic encephalopathy [5,6,7]. MHE is associated with increased progression to HE and diminished quality of life [6,7]. Hence, psychometric tests are recommended to screen patients with cirrhosis for detecting MHE. The diagnostic criteria for MHE rest on careful patient history, physical examination, normal mental status examination, demonstration of abnormalities in cognition and/or neurophysiological function, and exclusion of concomitant neurological disorders [8]. MHE is considered clinically relevant for at least three reasons. It impairs patient’s daily functioning and health-related quality of life [9,10]. Second, it predicts the development of overt HE. Finally, it is associated with a poor prognosis [11]. In a variety of psychometric tests listed in the medical literature, DST and NCT part A were reported to have the advantages of simplicity and reliability [4]. Gut-derived nitrogenous substances are universally acknowledged to play a major role in the pathogenesis of hepatic encephalopathy. Pathogenesis of MHE is thought to be similar to that of overt HE. Specifically, ammonia is thought to be a critical factor in the pathogenesis [12]. Altered glio-neuronal communication as a result of low grade astrocyte swelling found in HE, have been noticed in patients with MHE and is the basis of new diagnostic tests for detecting MHE like critical flicker frequency and magnetic resonance spectroscopy [13]. Presently, lactulose is the mainstay of treatment for MHE [14,15]. Lactulose is metabolized into lactic and acetic acids, which results in acidification      of the gastrointestinal lumen. Gastrointestinal acidification ultimately inhibits the production of ammonia by coliform bacteria. Lactulose also acts as a cathartic. The typical dosage of lactulose is 30 ml 2–4 times per day, adjusted to achieve two to four soft stools/day [16]. Lactulose has been shown to improve cognitive function and health-related quality of life in patients with MHE [9]. A recent study has attributed lack of response to lactulose treatment in cirrhotic patients with MHE to low serum sodium levels and high serum ammonia levels [17]. However, not all patients with MHE respond to lactulose and the efficacy of lactulose varies from 40 to 70% in various studies [17]. In view of the above, the present study was aimed to evaluate the contributing factors of non-response to lactulose treatment in cirrhotic patients with MHE.   Methodology This prospective, longitudinal study was conducted to find the contributors to non-response to lactulose therapy in patients of MHE with cirrhosis of    liver at the Department of Gastroenterology Hepatobiliary and Pancreatic Disorders, BIRDEM General Hospital, Dhaka, Bangladesh from September, 2013 to March 2015. The study was approved by the Ethical Review Committee (ERC) of Diabetic Association of Bangladesh (BADAS). Cases were selected by purposive sampling technique and informed written consent was obtained. Patients of cirrhosis of liver, aged >18 years, having MHE with normal mental status with no history of taking lactulose and any antibiotics in the past 12 weeks were included in this study. Normal mental status was assessed by mini mental state examination (MMSE score ≥24) [18] and MHE was diagnosed by abnormal psychometric tests (NCT-B >30 second and DST >90 second including the error correction time) and raised serum ammonia (≥32 µmol/L) [4]. Cirrhosis was diagnosed based on clinical features, laboratory parameters, abdominal ultrasonography and endoscopic findings. The mini–mental state examination (MMSE) is a brief 30-point questionnaire test used to screen for cognitive impairment. It is also used to estimate the severity of cognitive impairment and to follow the course of cognitive changes in an individual over time, thus making it an effective way to document an individual's response to treatment. If the score is found ≥24 then it denotes that the person has normal mental status [18]. NCT-Bis a test of visuo-spatial orientation and psychomotor speed. The subject is shown a sheet of paper with 25 numbered circles which are randomly spread over the paper. The task is to connect the circles from 1-25 within 30 seconds. Test result is the time needed by the subject including error correction time [19]. In DST, the subject is given a series of double-boxes with a number given in the upper part. The task is to draw a symbol pertinent to this number into the lower part of the boxes. Nine fixed pairs of numbers and symbols are given at the top of the test sheet. Test result is the number of boxes correctly filled within 90 seconds. Pathological test results indicate a deficit in visuo-constructive abilities [20]. Cirrhotic patients who had HE or a history of HE within last three month, history of taking lactulose, any antibiotics, antidepressants, sedatives, prokinetic and antispasmodic drugs, alcohol intake, gastrointestinal hemorrhage or spontaneous bacterial peritonitis during the past 12 weeks, previous transjugular intrahepatic portosystemic shunt or shunt surgery, significant co-morbid illness such as heart, respiratory or renal failure, neurological diseases such as Alzheimer’s disease, Parkinson’s disease, non-hepatic metabolic encephalopathy, colour blindness, mature cataract, diabetic retinopathy, were excluded from the study. Lactulose was given to all patients with the dose of 30-60 ml daily for one month and ensured that stool passed 2-3 times per day. Patients on diuretics and beta blocker for ascites or edema and esophageal varix continued the maintenance dose. All patients receiving lactulose were followed up after one month and assessed for the response of lactulose. Response to lactulose on the status of MHE was determined after one month by NCT-B, DST and serum ammonia level. Response was graded as responders and non-responders to lactulose therapy. Responder was defined as cases with normalization of psychometric tests and reduction of serum ammonia level to≤32 µmol/L, while non-responder was cases with abnormal psychometric tests and no reduction or increased serum ammonia. Responder and non-responder groups were compared to find the contributing factors to non-response to lactulose treatment. Also, Child-Turcotte-Pugh (CTP) and Model for End Stage Liver Disease (MELD) scorings were used to compare the prognostic status of responder and non-responder to lactulose therapy [21]. CTP score was determined as described in Table-1 and MELD score was calculated by the formula: [3.8{in S. bilirubin (mg/dl)} +11.20 (in INR) +9.3 {in serum creatinine (mg/dl)} + 6.4]. Data was analyzed by chi-square and student’s t-tests, where applicable.   Results The study aimed to assess the response to lactulose therapy in patients of cirrhosis of liver with MHE. Total 60 patients were enrolled in the study. The mean age of participants was 57.0±10.3 years. Out of 60 cases, 46 (77%) were male and 39 (65%) had diabetes. Hepatitis B virus was positive in 13 (22%) cases while 9 (15%) had hepatitis C virus. Out of 60 enrolled cases, 16 (27%) had CTP-A score and 44 (73%) belonged to CTP-B & C category (Table-2). Of the 60 MHE cases, 37 (61.7%) were non-responders to one-month lactulose treatment while remaining 23 (38.3%) were responders based on normalization of psychometric tests and reduction of serum ammonia level to ≤32 µmol/L. Age, gender and diabetes were not associated with the response to lactulose therapy (Table-2). The mean baseline arterial pressure was significantly (p=0.003) low in non-responders (76.0±10.6 mmHg) than that of responders (84.5±9.9 mmHg). The mean baseline ammonia level was higher significantly among the non-responders compared to the responders (83.6±21.4 µmol/L vs 58.8±19.8 µmol/L, p<0.001). The mean serum ammonia level reduced significantly among the responders (21.2±5.5 µmol/L) after one month of lactulose therapy while it remained high in non-responders (88.8±17.7 µmol/L). The level remained about four times higher in non-responders on follow up after one month.   Table-1: Child-Turcotte-Pugh score     Table-2: Baseline demographic, clinical and biochemical parameters contributing response to lactulose treatment in MHE patients (n=60)     Compared to responders, low serum sodium and potassium and raised serum bilirubin levels of non-responders at baseline were found significantly (p<0.05) associated with non-response to one month of lactulose treatment (Table-2). Initial hemoglobulin, leucocyte and platelets as well as other biochemical parameters mentioned in Table-2 did not have any effect on the response to lactulose treatment in MHE cases.   Discussion MHE is a well-recognized cause of diminished quality of life and predisposes overt HE. Oral lactulose therapy is a treatment option for MHE. But some patients do not respond to lactulose. This prospective study was carried out to assess the response of lactulose therapy in patients with cirrhosis and MHE. In this study, sixty patients having cirrhosis of liver and MHE were included. This study showed more than half of the patients were non-responder to lactulose 37 (61.7%). It was assumed that non-responders could be less if patients could be followed up for longer duration with lactulose therapy. MHE reversed in 64.5% patients when treated with lactulose for three months [9]. In this study, it was found that the higher CTP score and low mean arterial pressure (MAP) as contributing factors to non-response to lactulose. As reported earlier, the present study showed that advance liver disease had less chance to response to lactulose therapy [22]. Splanchnic and systemic arterial vasodilatation is a hallmark of the progression of portal hypertension in patients with cirrhosis and leads to decreased effective circulating blood volume and ultimately to a decrease in blood pressure as well as MAP. This process is mediated by a number of endogenous substances, including nitric oxide (NO), carbon monoxide (CO), glucagon, prostacyclin, adrenomedullin, and endogenous opiates that are released or act locally in the vasculature in response to mechanical and inflammatory signals [23,24]. Hyperammonemia, hyponatremia, hypokalemia as well as increased bilirubin were found as predictors of non-response to lactulose treatment. Different studies also demonstrated that hyperammonemia, serum sodium concentration <135 mmol/L and serum potassium level of <4 mmol/L were associated with greater frequency of hepatic encephalopathy as well as minimal hepatic encephalopathy and reduced response to lactulose therapy [17,25,26]. Different factors are responsible for development of hepatic encephalopathy. These factors include the production of neurotoxins, altered permeability of the blood brain barrier, and abnormal neurotransmission. Ammonia is the best-described neurotoxin involved in HE. It is produced primarily in the colon, where bacteria metabolize proteins and other nitrogen-based products into ammonia. Enterocytes synthesize ammonia from glutamine [27,28,29]. Once produced, ammonia enters the portal circulation and, under normal conditions, is metabolized and cleared by hepatocytes. In cirrhosis and portal hypertension, reduced hepatocyte function and portosystemic shunting contribute to increased circulating ammonia levels. Acute hyperammonemia has direct effect on brain edema, astrocyte swelling, and the transport of neurally active compounds, thus contributing to HE [30,31,32]. Hyponatremia and hypokalemia are risk factor for hepatic encephalopathy as well as MHE, so if the levels are more reduced then the response to lactulose therapy is also decreased [25,26]. High baseline total leukocyte counts and creatinine level, and low platelet count have been reported to associated with nonresponse to lactulose [33]. However, this study failed to find any significant influence of these parameters with non-response to lactulose therapy (Table 2). This different outcome might be due to small sample size and different patient selection criteria. The present study evaluated the contributing factors to non-response to oral lactulose therapy in cirrhotic patients with MHE. On analysis, baseline low MAP, high CTP score, low serum sodium and potassium levels, increased serum bilirubin and hyperammonemia were found to be associated with non-response to lactulose therapy.   SA was involved in study design, data collection, literature review, data analysis and manuscript writing. MGA was involved in study design, statistical analysis and manuscript writing. IKD and MNH was involved in literature review and manuscript writing. TMB was involved in editing and final approval of the manuscript.   Authors declare no conflict of interest. Funding None   References 1.   Ferenci P, Lockwood A, Mullen K, Tarter R, Weissenborn K, Blei AT. Hepatic encephalopathy- definition, nomenclature and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 1998. Hepatology. 2002; 35(3): 716–721. 2.   Das A, Dhiman RK, Saraswat VA, Verma M, Naik SR. Prevalence and natural history of subclinical hepatic encephalopathy in cirrhosis. J Gastroenterol Hepatol. 2001; 16(5): 531–535. 3.   Groeneweg M, Moerland W, Quero JC, Hop WC, Krabbe PF, Schalm SW. Screening of subclinical hepatic encephalopathy. J Hepatol. 2000; 32(5): 748–753. 4.   Saxena N, Bhatia M, Joshi YK, Garg PK, Dwivedi SN, Tandon RK. Electrophysiological and neuropsychological tests for the diagnosis of subclinical hepatic encephalopathy and prediction of overt encephalopathy. Liver Int. 2002; 22(3): 190–197. 5.   Groeneweg M, Quero JC, De Bruijn I, Hartmann I, Essink-bot MI, Hop WCJ, et al. Subclinical hepatic encephalopathy impairs daily functioning. Hepatology. 1998; 28(1): 45–49. 6.   Marchesini G, Bianchi G, Amodio P, Salerno F, Merli M, Panella C, et al. Italian Study Group for Quality of Life in Cirrhosis. Factors associated with poor health-related quality of life of patients with cirrhosis. Gastroenterology. 2001; 120(1): 170–178. 7.   Schomerus H, Hamster W. Quality of life in cirrhotics with minimal hepatic encephalopathy. Metab Brain Dis. 2001; 16(1): 37–41. 9.   Prasad S, Dhiman RK, Duseja A, Chawla YK, Sharma A, Agarwal R. Lactulose improves cognitive function and health-related quality of life in cirrhotic patients with minimal hepatic encephalopathy. Hepatology. 2007; 45(3): 549–559. 11.  Cash WJ, Mc Conville P, McDermott E, McCormick PA, Callender ME, McDougall NI. Current concepts in the assessment and treatment of hepatic encephalopathy. Q J Med. 2010; 103(1): 9–16. 13.  Sharma P, Sharma BC, Puri V, Sarin SK. Critical flicker frequency: diagnostic tool for minimal hepatic encephalopathy. J Hepatol. 2007; 47(1): 67–73. 15.  Watanabe A, Sakai T, Sato S, Imai F, Ohto M, Arakawa Y, et al. Clinical efficacy of lactulose in cirrhotic patients with and without subclinical hepatic encephalopathy. Hepatology. 1997; 26(6): 1410–14. <![CDATA[Pattern of ear nose and throat diaseses in a tertiary hospital of Dhaka city]]> Badhan Kumar Dey Anamika Datta Mir Masudur Rhaman MA Sayeed https://imcjms.com/journal_full_text/269 2017-10-22 13:18:35 Original Article IMC J Med Sci 2018; 12(1): 22-26 Abstract Background and objectives:The magnitude of health problems related to ear, nose and throat (ENT) in Bangladesh has not been estimated in a larger scale and very little is known about the prevalence and types of ENT diseases. Some studies, however, addressed the prevalence of otitis among school children and very few of them reported hearing defect. This study aims to assess the overall types of ENT diseases encountered by the otolaryngologists at a referral or tertiary hospital. Methods: The cross sectional study was conducted in Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM). All patients registerd in the ENT-OPD from January to April in 2017 were included in the study for analysis. Diseases were diagnosed on the basis of clinical history, general and systemic examinations and relevant laboratory and imaging investigations. Results: A total of 435 (M:F=177:258) registered patients were analyzed. 44 0f them had no ENT diseases. Diseases of ear showed the highest prevalence (41.1%) followed by that of throat (31.7%) and nose (17.1%). There was no significant difference in ear and nose diseases between male and female groups. The throat diseases were significantly higher in female than the male group (37.2% vs.22.6%, p=0.018). Regarding infections of the specific organs: suppurative otitis media was the most common (acute and chronic suppurative otitis media 25.5%) followed by tonsillitis (7.1%), rhinitis (4.4%) and sinusitis (1.4%). These infections showed no significant difference between male and female patients; neither there was any significant difference between the diabetic and non-diabetic groups. Conclusion: Diseases of ear were most common followed by throat and nose. Both acute and chronic otitis media constituted one-fourth of all registered cases. The diabetic patients showed no increased risk for ENT diseases. IMC J Med Sci 2018; 12(1): 22-26. DOI: https://doi.org/10.3329/imcjms.v12i1.35173 Address for Correspondence: Dr. Badhan Kumar Dey, Registrar, Department of ENT & Head-Neck Surgery, BIRDEM General Hospital, 122 Kazi Nazrul Islam Avenue, Shahbagh, Dhaka. E-mail: badhan407@gmail.com   Introduction Several studies have reported the prevalence and types of ear, nose and throat (ENT) diseases among Bangladeshi population [1-6]. Some population based studies addressed chronic suppurative otitis media (CSOM) among children in Bangladesh. The comparison of CSOM in children showed higher prevalence in rural (6.02%) than urban (2.07%) area [1]. Other study among Bangladeshi rural children reported rate of CSOM as 5.2% [4]. In two slum populations of Dhaka City, the prevalence of CSOM among children was 7.4% [6]. The types of ENT diseases varied from country to country. For Nigeria, the prevalence of diseases of ear, nose and throat were 62.7%, 23.0% and 9.6%, respectively [7]. In Senegal, the rates were 22.8%, 54.6% and 22.4% [8] and in India, the rates were 36.6%, 23.5% and 16.58% respectively [9]. It is important to note that the disorders of ENT are not confined to these organs only but also affect quality of life rendering health care very expensive. For example, chronic sinusitis (CS) is a prevalent and disabling condition of the paranasal sinuses affecting approximately 31 million people in the United States with an estimated USD 8.6 billion health care expenditures [10]. CS is reported to affect quality of life more than other chronic conditions, such as congestive heart failure, chronic obstructive pulmonary disease (COPD), and chronic back pain [11-13]. Without objective evidence of inflammation, it is challenging to distinguish CS from conditions with overlapping symptoms, such as allergic rhinitis or migraine [14]. Furthermore, it is difficult to use symptoms alone to differentiate between CS subtypes, such as CS with nasal polyps and CS without nasal polyps [15]. Sometimes, ENT disorders are linked with other systemic illness like pemphigus vulgaris [16]. For Bangladesh, it may be important to consider ENT problems related to zoonotic diseases [17]. Because the Bangladeshi people are constantly exposed to zoonotic health hazards. Despite all these vulnerability of Bangladeshi people there is very little informationin this regard. On the other hand, diabetes is thought to increase the risk and severity of ENT disorders. Very insufficient data on the diseases of ENT are available even in a referral hospital. This study addressed the characteristics and types of ENT diseases in a tertiary hospital.   Methods This cross-sectional study was conducted in the department of ENT (otolaryngology) in BIRDEM general hospital (Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders). BIRDEM is a national referral center for diabetes and other metabolic diseases. The ENT department has almost all standard diagnostic facilities to deal with diseases of ear, nose and throat. The department has both out-patient (ENT-OPD) and in-patient (hospital) wings and delivers services to diabetic as well as non-diabetic patients. This center registers more than twenty thousand patients per year.   Overall, 435 (M:F=177:258) registered patients were analyzed for this study. Among them 44 patients have not been suffering from ENT diseases. The diseases of ear, nose and throat were 41.1% (M:F=45.2:38.4), 17.1% (20.3 : 14.7) and 31.7% (22.6:37.2) respectively [Table 1]. The distribution of diseases of ear, nose and throat according to age-quartile have been shown in  Table 1. There was no difference between male and female patients for diseases of ear and nose. Only significant difference was observed in case of the throat diseases. The female patients had significantly higher throat diseases than the males (p<0.05). This may be due to very high prevalence of throat diseases in the lowest age quartile (<40 years; M : F= 14.9 : 35.3; p = 0.018).   Table-1: Distribution of cases according to age and gender with overall ear, nose and throat diseases     Table-2: Distribution of tonsillitis, sinusitis, ASOM, CSOM, rhinitis and DNS according to gender and glycemic status (diabetes vs. non-diabetic groups)    Discussion This study attempted to determine the types and prevalence of specific types of ENT diseases encountered in a tertiary (national referral) hospital. In Bangladesh, most studies addressed ENT diseases among school children [1,3-6]. Tarafder et al addressed only hearing impairment [2]. Thus, this study possibly is the first to explore the types of ENT diseases commonly observed in a tertiary hospital. As there was no age limit it included both children and adult. The age below 20 years comprised 5% and below 40 years comprised 25%. It was apparent that the study population represented a wide age range. Moreover, the study enabled us to assess the types of ENT ailments commonly referred to a tertiary hospital. One-fourth of the participants had otitis, which was the highest ailments referred to ENT department of BIRDEM. This finding is consistent with the previous studies carried out in Bangladesh [1,3-5]. The prevalence of ENT diseases observed in this study are very much consistent with the findings of West Bengal [18]. Our findings showed that the diseases of ear, nose and throat were 41.1%, 17.1% and 31.7% respectively. In West Bengal, Barman D et al reported almost similar results: otological, nasal and throat cases were 42.41%, 28.98% and 28.60%, respectively [18]. Hearing impairment due to mechanical causes (foreign body, impacted ear wax) of this study also simulates the past findings [2]. The study had some major limitations. It did not include some important and relevant risk factors [18-20]. Occupation could have given valuable information as well as zoonotic link to ENT diseases [17]. Likewise, family income and poor living conditions could also be a risk for specific ENT illness [8,20]. This study revealed that otitis (ASOM and CSOM) was the most prevalent ailment registered in a tertiary health care center. Of the ENT diseases, highest number of patients presented with ear diseases followed by throat illnesses. The throat diseases were significantly higher in female than in the male participants. Hearing impairment was found mostly due to mechanical causes like foreign body and impacted wax. The diabetic patients showed no excess risk for ENT diseases. Further study may be undertaken considering these limitations. This study suggests that some important risk factors mentioned above (limitation) should be investigated and identified to improve ENT health care.   Acknowledgements We are very grateful to all the employees of the Department of ENT, BIRDEM. We are also indebted to the Departments of Radiology and Imaging, Pathology, Microbiology and Clinical Biochemistry for their active cooperation.   Author’s contributions BKD was involved in patient selection, reception, registration, diagnosis and confirmation of diagnosis. AD was involved in literature review. MMR was involved in data entry, data editing, analysis and interpretation. MAS was involved in manuscript writing and overall supervision.   Competing interest Authors declare no conflict of interest.   Funding None   References 1.   Shaheen MM, Nahar S. Comparison of chronic suppurative otitis media in rural and urban primary school children in Bangladesh. J Laryngol Otol. 2014; 128(6): 499-503. doi:10.1017/S0022215114001054. 2.   Tarafder KH, Akhtar N, Zaman MM, Rasel MA, Bhuiyan MR, Datta PG. Disabling hearing impairment in the Bangladeshi population. J Laryngol Otol. 2015; 129(2): 126-135. doi:10.1017/S002221511400348X. 3.   Alam MM, Ali MI, Habib MA, Siddique MA, Sanyal NP, Joarder AH. Otitis media with effusion in children admitted for adenoidectomy. Mymensingh Med J. 2015; 24(2): 284-289. 4.   Shaheen MM, Raquib A, Ahmad SM. Chronic suppurative otitis media and its association with socio-econonic factors among rural primary school children of Bangladesh. Indian J Otolaryngol Head Neck Surg. 2012; 64(1): 36-41. doi: 10.1007/s12070-011-0150-9. 5.   Roy E, Hasan KhZ, Haque F, Siddique AK, Sack RB. Acute otitis media during the first two years of life in a rural community in Bangladesh: a prospective cohort study. J Health Popul Nutr. 2007; 25(4): 414-421. 6.   Kamal N, Joarder AH, Chowdhury AA, Khan AW. Prevalence of chronic suppurative otitis media among the children living in two selected slums of Dhaka City. Bangladesh Med Res Counc Bull. 2004; 30(3): 95-104. 7.   Fasunla AJ, Samdi M, Nwaorgu OG.An audit of ear, nose and throat diseases in a tertiary health institution in South-western Nigeria. Pan Afr Med J. 2013; 14: 1. doi: 10.11604/ pamj.2013.14.1.1092. 8.   Tall H, Bah FY, Nasser T, Sambou A, Diallo BK. Ear, nose and thorat disorders in pediatric patients at a rural hospital in Senegal. Int J Pediatr Otorhinolaryngol. 2017; 96: 1-3. doi:10.1016/j.ijporl.2017.02.019. 9.   Singh A, Kumar S. A survey of ear, nose and throat disorders in rural India. Indian J Otolaryngol Head Neck Surg. 2010; 62(2): 121-124. doi: 10.1007/s12070-010-0027-3. 10.  Bhattacharyya N. Incremental health care utilization and expenditures for chronic rhinosinusitis in the United States. Ann OtolRhinolLaryngol. 2011; 120(7): 423–427. 11.  Gliklich RE, Metson R. The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryngology - Head and Neck Surgery. 1995; 113(1): 104–109. 12.  Macdonald KI, McNally JD, Massoud E. The health and resource utilization of Canadians with chronic rhinosinusitis. Laryngoscope. 2009; 119(1): 184–189. 13.  Soler ZM, Wittenberg E, Schlosser RJ, et al. Health state utility values in patients undergoing endoscopic sinus surgery. Laryngoscope. 2011; 121(12): 2672–2678. 14.  Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. The European position paper on rhinosinusitis and nasal polyps 2012. Rhinology. 2012 Suppl; 23: 1-299. 15.  Tan BK, Kern RC, Schleimer RP, Schwartz BS. Chronic rhinosinusitis: the unrecognized epidemic. Am J RespirCrit Care Med. 2013; 188(11): 1275–1277. 16.  Fawzy MM, Hegazy RA, Abdel Fattah AF. Ear, nose, and throat involvement in Egyptian pemphigus vulgaris patients: A step towards a better management. Int J Dermatol. 2013; 52(10): 1268-1273. doi: 10.1111/j.1365-4632.2012.05846.x 17.  Galletti B, Mannella VK, Santoro R, Rodriguez-Morales AJ, Freni F, Galletti C, et al. Ear, nose and throat (ENT) involvement in zoonotic diseases: a systematic review. J Infect Dev Ctries. 2014; 8(1): 17-23. doi: 10.3855/ jidc.4206. 18.  Barman D, Maridal S, Goswami S, Hembram R. Three years audit of the emergency patients in the department of ENT of a rural medical college. J Indian Med Assoc. 2012; 110(6): 370-4. 19.  Smith SS, Ference EH, Evans CT, Tan BK, Kern RC, Chandra RK. The prevalence of bacterial infection in acute rhinosinusitis: a Systematic review and meta-analysis. Laryngoscope. 2015; 125(1): 57-69. doi: 10.1002/lary.24709 20.  Sundaresan AS, Hirsch AG, Storm M, Tan BK, Kennedy TL, Greene JS, et al. Occupational and environmental risk factors for chronic rhinosinusitis: A systematic review. Int Forum Allergy Rhinol. 2015; 5(11): 996–1003. <![CDATA[Neovaginoplasty using sigmoid colon flap technique]]> Mohammed Rashedul Islam Anjan Kumar Deb Farzana Bilquis Ibrahim Raihan Anwar Md Anwarul Islam Morshed Uddin Akand https://imcjms.com/journal_full_text/237 2017-07-04 10:11:03 Original Article IMC J Med Sci 2018; 12(1): 27-31 Abstract Background and objectives: Vaginoplasty is a procedure for the reconstruction of vaginal canal. Various surgical techniques have been described for vaginal reconstruction with variable success. The aim of this study was to assess the use of sigmoid colon in vaginal reconstruction of patients with disorders of sex development. Methods: Eleven patients were included in this study from January 2009 to December 2016. All patients underwent karyotyping, pelvi-abdominal ultrasonography, endocrine and psychiatric assessment. Sigmoid neo-vaginoplasty was the procedure chosen for all the cases. Surgical and functional outcomes were assessed post-operatively over a period of 6 month to 6 years. Results: The preoperative diagnosis included 9 cases of aplasia of the Mullerian ducts or Mayer-Rokitansky-Küster-Hauser syndrome (MRKH), 1 androgen insensitivity syndrome (AIS) and 1 pseudohermaphrodite case. The mean age of the study population was 22.5 years (range 15-30 yrs). No intra-operative or early postoperative complications occurred. The mean vaginal length achieved was 13.0 cm (range 10.5 – 15 cm). Long term follow-up showed introital stenosis in 2 cases (17%) which resolved well to vaginal dilatation. One patient had pelvic abscess and treated by surgery. Sexual satisfaction was achieved in 10 cases, as 1 case was unmarried. Conclusion: For patients with disorders of sex development of various etiologies, sigmoid vaginoplasty is the preferred technique for vaginal reconstruction. It is a safe technique and provides the patient with a cosmetic neovagina of adequate caliber with satisfactory functional outcome. IMC J Med Sci 2018; 12(1): 27-31. DOI: https://doi.org/10.3329/imcjms.v12i1.35175 Address for Correspondence: Dr. Mohammed Rashedul Islam, Assistant Professor, Department of Plastic Surgery, BIRDEM General Hospital, Room No. 1119, 122 Kazi Nazrul Islam Avenue, Dhaka – 1000. Email: rashedplastic@gmail.com   Introduction Vaginoplasty is a procedure for the reconstruction of vaginal canal and the vulva that can be performed in various clinical situations. Though a rare procedure, the commonest indication is the congenital absence of the vagina, which occurs as a result of aplasia of the Mullerian ducts (46, XX) or Mayer-Rokitansky -Küster-Hauser syndrome (MRKH). Second indication is disorders of sex development (DSD). A large number of medical conditions involving the reproductive system fall under DSD, which is used as an umbrella term for these anomalies. The most common DSD is congenital adrenal hyperplasia (CAH) followed by androgen insensitivity syndrome (AIS, 46, XY) [1]. Genetic sexual ambiguity and vaginal loss resulting from gynecologic cancer or post traumatic injury are other two indications for neo-vaginoplasty [2]. The ovaries, given their separate embryologic source, are normal in structure and function. Reported incidences of congenital absence of the vagina vary from 1 in 4,000 to 5,000 female births [2,3]. The three basic tenets of vaginoplasty are: (a) creation of space between urethra and urinary bladder anteriorly anus and rectum posteriorly, (b) providing this space with a durable lining and (c) maintaining the dimensions and integrity of the newly created vagina. The advantages of using a bowel segment in contrast to other methods of vaginoplasty are: 1) no graft failure or secondary contracture/stenosis because a vascularized epithelial-lined tube is used, 2) patency and depth can be maintained without a mold and with minimal dilatation, 3) spontaneous mucus production matches that of the normal vagina and facilitates sexual intercourse, 4) dyspareunia, frequently seen with skin grafts, is avoided by the ability of the intestinal segment to withstand local trauma, 5) the use of an intestinal segment offers the option of performing a bowel interposition vaginoplasty during infancy at the time of surgical correction of more complex associated caudal anomalies and 6) avoids the disadvantage of sweating, maceration, hair growth and foul smell associated with skin flaps. The sigmoid colon is the best choice for interposition vaginoplasty because of size, location, and ease of preserving blood supply [8]. In this series, we evaluated the use of sigmoid colon for vaginal replacement among patients with MKRH and DSD.   Methods Study population and baseline investigations: The current study included 11 patients from January 2009 to December 2016. All were reared as females. Complete hormonal assessment was done. Sigmoid neo-vaginoplasty was the procedure chosen for all the cases. Surgical and functional outcomes were assessed postoperatively. All patients were subjected to history taking and physical examination. All patients underwent karyotyping, pelvi-abdominal ultrasonography, endocrine and psychiatric assessment. Informed written consent was obtained from all patients or their guardians. None of the patients underwent mechanical and/or antibiotic bowel preparation prior to surgery. <![CDATA[Detection of extended spectrum β-lactamase producing Gram-negative organisms: hospital prevalence and comparison of double disc synergy and E-test methods]]> Mili Rani Saha Sanya Tahmina Jhora https://imcjms.com/journal_full_text/270 2017-10-31 12:54:33 Original Article IMC J Med Sci 2018; 12(1): 32-36 Abstract Background and objectives: Emergence of extended spectrum beta-lactamase (ESBL) producing bacteria is a major public health concern. Detection of multi drug resistant (MDR) ESBL producing organisms is necessary to prevent its spread and effective treatment. The purpose of the present study was to determine the magnitude of ESBL producing organism in hospital setting and to compare the suitability of double disc synergy test (DDST) and cefepime-clavulanate E-test method for the detection of ESBL producing organisms in routine microbiology laboratory. Materials and methods: The study was carried out in the Department of Microbiology, Sir Salimullah Medical College, Dhaka from January 2011 to December 2011. Clinical samples included urine and pus from patients with suspected urinary tract and wound infections respectively. Standard microbiological methods were employed for isolation and identification of the organisms. DDST and E-test were used to detect ESBL producing Gram negative organisms. Results: A total of 186 Gram-negative organisms were isolated from various samples. Among the 186 Gram negative bacteria, 120 (64.5%) were Esch. coli while 33 (17.7%), 20 (10.8%) and 11 (5.9%) were Pseudomonas sp, Klebsiella sp and Proteus sp respectively. Out of total 186 isolates, 77 (41.4%) and 73 (39.2%) isolates were found ESBL producers by DDST and E-test method (p=0.674) respectively. Compared to Escherichia coli, Pseudomonas and Proteus, significantly high (p<0.01) proportion of Klebsiella were ESBL positive by both DDST and E-test methods. The detection rate of ESBL producing organisms was not significantly different by DDST and E-test (41.4% vs 39.2%). Non-determinable result was obtained for 4 (2.2%) isolates by E-test method. Conclusion: In our present study, a substantially large number of clinical isolates were found ESBL producers. Compared to E-test, DDST was found as a reliable, convenient and inexpensive method for detection of ESBL producing organism in routine microbiology laboratory practice. IMC J Med Sci 2018; 12(1): 32-36. DOI: https://doi.org/10.3329/imcjms.v12i1.35176 Address for Correspondence: Dr. Mili Rani Saha, Assistant Professor, Department of Microbiology, BIRDEM General Hospital, 122, Kazi Nazrul Islam Avenue, Dhaka 1000, Bangladesh, Email: milisaha77@yahoo.com   Introduction Extended spectrum beta-lactamases are enzymes that confer resistance to the penicillin, cephalosporins and aztreonam by hydrolysis of the antibiotics. ESBL enzymes are inactivated by beta-lactamase inhibitors such as clavulanic acid [1]. Treatment of ESBL producing organisms is now a therapeutic challenge in hospitalized patients worldwide. Indiscriminate administration of extended spectrum cephalosporins, prolonged hospital stay, mechanical ventilation and catheterization are the major risk factors for colonization of ESBL producing bacteria [2]. Detection of ESBL producing organisms is necessary to prevent its spread. Several ESBL detection tests have been proposed by NCCLS [3]. The degree of resistance against extended spectrum cephalosporins can also be highly variable for the different ESBL enzymes. Thus, ESBL producing bacteria need reliable detection method [4]. Therefore, the present study was undertaken to determine the magnitude of ESBL producing organisms in tertiary hospitals and to compare the DDST with that of commercially available E-test to detect ESBL producing Gram negative organisms isolated from clinical samples. Materials and Methods Isolation and identification of organisms: Samples were inoculated onto blood agar and MacConkey’s agar media for isolation and identification of the organisms. All plates were incubated at 370C aerobically for 24-48 hrs. Suspected organisms were identified by standard biochemical tests [10]. Tests for the detection of ESBL producing organisms: All isolated organisms were tested for ESBL production by DDS test and E-test methods. a.  Double Disc Synergy Test: All isolated Gram-negative bacteria were tested for ESBL production by DDST using aztreonam (30 µg), ceftazidime (30 µg), ceftriaxone (30 µg), cefotaxime (30 µg) and 20μg amoxicillin +10μg clavulanic acid discs. The four antibiotic discs were placed 20 mm apart from each other with amoxicillin /clavulanic acid disc at the center as shown in Fig-1a. ESBL production was considered positive when the zone of inhibition around any antibiotic disc was enhanced towards the amoxicillin/clavulanic acid disc [11].     Fig.1: Photograph showing DDST and E-test. 1a: DDST showing enhancement of zone of inhibition towards the aztreonam (30 µg), ceftazidime (30 µg), ceftriaxone (30 µg) and cefotaxime (30 µg) discs. Amoxicillin/clavulanic acid disc is at the center. 1b: E-test strip showing formation ellipse at the cefepime/clavulanic end compared to on cefepime end; 1c: E-test with non-determinable result.   Results A total of 354 samples were included in the study. Total 186 Gram-negative organisms were isolated from various samples. Among the 186 Gram negative bacteria, 120 (64.5%) were Escherichia coli while 33 (17.7%), 20 (10.8%) and 11 (5.9%) were Pseudomonas sp, Klebsiella sp and Proteus sp respectively. All the isolates were tested for production of ESBL by DDST and E-test methods. Out of total 186 isolates, 77 (41.4%) and 73 (39.2%) isolates were found ESBL producers by DDST and E-test method (p=0.674) respectively (Table-I). Compared to Escherichia coli, Pseudomonas and Proteus species, significantly high (p<0.01) proportion of Klebsiella sp (65-75%) were ESBL positive by both DDST and E-test methods (Table-1). The detection rate of ESBL was not significantly different by DDST and E-test for each type of organism.  Non-determinable result was obtained in 4 isolates by E-test method. These four isolates did not show any zone of inhibition either at cefepime (PM) or at cefepime-clavulanate (PML) end of the test strip (Fig 1c).   Table-1: Comparative detection rate of ESBL producing organisms by DDST and E-test   Discussion      The study has demonstrated that a good proportion of Gram-negative organisms isolated from clinical samples were ESBL producers. Compared to expensive E-test, DDST is a reliable, convenient, relatively inexpensive and easy to perform method for detection of ESBL producing organisms in routine clinical laboratories.   Author’s contributions MRS performed the experiments analyzed the results and wrote the manuscript.  STJ conceived, designed and supervised the study.                            Competing interest Authors declare no conflict of interest.   Funding None   References 2.   Chaudhary U, Aggarwal R. Extended spectrum β-lactamases (ESBL) – An emerging threat to clinical therapeutics. Indian J Med Microbiol.  2004; 22(2): 75-80. 3.   Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Disk Susceptibility Tests; Approved Standard. Clinical and Laboratory Standards Institute Document M100-S9. PA, USA, 1999. 4.   Sturenburg E, Mack D. Extended spectrum β-lactamases: implications for the clinical microbiology laboratory, therapy and infection control. J Infect. 2003; 47: 273-295. 6.   National Committee for Clinical Laboratory Standards. Performance standards for antimicrobial susceptibility testing. Twelfth informational supplement. M100 -S12 NCCL. PA, USA, 2002. 9.   Jain A, Mondal R. TEM & SHV genes in extended spectrum β-lactamase producing Klebsiella species & their antimicrobial resistance pattern. Indian J Med Res. 2008; 128: 759-764. 10.  Colle JG, Miles RS, Watt B. Tests for identificationof Bacteria. In: Collee JG, Fraser AG, Marmion BP & Simmons A. editors, Mackie & McCartney's Practical Medical Microbiology 1996; 14th ed and Edinburgh, Churchill Livingstone, New York 1996; 553 -559. 11.  Jarlier V, Nicolas MH, Fourier G, Phillippon A. Extended broad spectrum β -lactamases conferring transferable resistance to newer β-lactam agents in Enterobacteriaceae: hospital prevalence and susceptibility patterns. Rev Infect Dis. 1988; 10: 867-878. 13.  Livermore DM. β-lactamases-mediated resistance and opportunities for its control.  J Antimicrob Chemother. 1998; 41 suppl D: 25-41. 14.  Vercauteren E, Descheemaeker P, Ieven M, Sanders CC, Goossens H. Comparison of screening methods for detection of extended-spectrum β-lactamases and their prevalence among blood isolates of Escherichia coli and Klebsiella spp. in a Belgian teaching hospital. J Clin Microbiol. 1997; 35: 2191-2197. 15.  Wiegand I, Geiss HK, Mack D, Sturenburg E, Seifert H. Detection of extended-spectrum β-lactamases among Enterobacteriaceaeby use of semiautomated microbiology systems and manual detection procedures. J Clin Microbiol.2007;45: 1167-1174. <![CDATA[Distribution of New Delhi metallo-beta-lactamase producing Acinetobacter baumannii in patients with ventilator associated respiratory tract infection]]> Shahida Akter SM Shamsuzzaman https://imcjms.com/journal_full_text/258 2017-07-30 12:25:18 Original Article IMC J Med Sci 2018; 12(1): 37-41 Abstract Background and objectives: Ventilator-associated respiratory tract infection (VARTI) is a major cause of morbidity and mortality among the critically ill patients of intensive care units (ICU). Acinetobacter baumannii, an important offending pathogen in VARTI, has been found to be resistant to several antibiotics including carbapenems. The present study was conducted to determine the rate of New Delhi metallo-β-lactamase 1 (NDM-1) producing A. baumannii causing VARTI among the patients admitted in an ICU of a large tertiary care hospital. Methods: The study was conducted from July 2013 to June 2014. Endotracheal aspirates (ETA) were collected from patients with clinically suspected VARTI. Samples were collected from patients who were on mechanical ventilation for more than 48 hours. ETA samples were cultured aerobically and isolated A. baumannii were tested for susceptibility to carbapenem. Presence of NDM-1 encoded by the blaNDM-1 gene was detected by polymerase chain reaction (PCR). Results: A total of 138 VARTI cases were included in the study. Total 107 (77.5%) bacteria were isolated from 138 ETA samples of which 38 were A. baumannii. Out of 38 isolated A. baumannii, 35 (92.1%) were resistant to imipenem/meropenem and 33 (86.8%) were positive for blaNDM-1 gene by PCR. Conclusion: The present study demonstrated that high proportion of A. baumannii isolated from VARTI cases in ICU were carbapenem resistant and blaNDM-1 positive. Careful infection control program should be considered to contain the spread of this multi-resistant organism to other hospital and community. IMC J Med Sci 2018; 12(1): 37-41. DOI: https://doi.org/10.3329/imcjms.v12i1.35177 Address for Correspondence: Dr. Shahida Akhter, Assistant Professor, Department of Microbiology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Dhaka 1000, Bangladesh; Email: shahidamicro@gmail.com   Introduction Ventilator-associated respiratory tract infections (VARTI) in ICU patients include ventilator-associated pneumonia (VAP) and tracheobronchitis (VAT). The incidence of VAP and VAT in ICU patients ranges from 7% to 70% and 3% to 10% respectively [1-6]. Most cases of VAP are caused by bacterial pathogens that normally colonize upper respiratory tract and gastrointestinal tract of the patient. External sources like transmission from caregivers, environmental surfaces or other patients have been implicated. Detection of causative organisms and their antibiotic susceptibility is crucialfor diagnosis and effective treatment of VAP [7]. Several Gram positive and negative organisms namely methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, ESBL producing Enterobacteriaceae and multi-resistant A. baumannii have been isolated from cases of VARTI [8,9,4]. Besides in Klebsiella pneumoniae and Escherichia coli, metallo-b-lactamase (MBL) producing blaNDM-1 gene conferring resistance to carbapenem has recently been identified in A. baumannii in different countries of the world [10-14]. In view of the above, the present study was conducted to determine the presence of blaNDM-1 gene in A. baumannii isolated from ICU patients with VARTI of a tertiary care hospital in Dhaka city. The study was carried out at the ICU of Dhaka Medical College Hospital, Dhaka from July, 2013 to June 2014. All patients suspected to have either VAP or VAT were included in the study. The study was approved by the Institutional Review Board of Dhaka Medical College.   Endotracheal tube aspirates (ETA) were collected from clinically suspected VAP and VAT cases by gently introducing a 50cm/14Fr suction catheter through the endotracheal tube for a distance of approximately 25-26 cm. The ETA was obtained by suction, without instilling saline. Two milliliters of sterile phosphate buffered saline (PBS) was injected into the lumen of the catheter with a sterile syringe to flush the exudates. The exudates were collected into a sterile 50 ml Falcon tube and transported immediately to the laboratory for further processing. Only one ETA sample was collected from each patient [15,16].   Detection of blaNDM-1 gene by PCR: The isolates were screened for the presence of blaNDM-1 MBL gene by PCR with the primers reported previously [20]. The sequence of the primers is shown in Table-1. In brief, PCR was performed in a final reaction volume of 25μl in a PCR tube, containing 10μl of master mix (mixture of dNTP, taq polymerase, MgCl2 and PCR buffer), 4μl primers (Promega corporation, USA), 3 μl extracted DNA and 8μl of nuclease free water. PCR assay was performed in Eppendorf AG thermal cycler. After initial denaturation at 940C for 10 minutes, the reaction was subjected to 36 cycles. Each cycle consisted of denaturation at 940C for one minute, annealing at 600C for one minute and elongation at 720C for 90 seconds followed by final extension at 720C for 10 minutes. The product was analyzed by electrophoresis in 1.5% agarose gel containing ethidium bromide (0.5 μg/ml) in TBE buffer (0.04 M Tris acetate, 0.001 M EDTA; pH 8.6) and photographed under UV illumination. DNA of known imipenem sensitive K. pneumonia was used as negative control.   Table-1: The sequence of primers used for detection of blaNDM-1 gene in A. baumannii by PCR [20]     Result Total 138 VARTI cases were enrolled in the study of which 65 (47.1%) and 73 (52.9%) were VAP and VAT cases respectively. A total of 107 (77.5%) bacteria were isolated from ETA samples of which 38 were A. baumannii. Of the 38 isolates, 17 (26.2%) were isolated from VAP cases while 21(28.8%) were from VAT cases. Antimicrobial susceptibility of A. baumannii to different antibiotics is shown in Table-2. The resistance to imipenem/ meropenem, aminoglycosides, quinolones and third generation cephalosporins ranged from 92.1% to 100%. However, only 13.2% A. baumannii were resistant to colistin. PCR revealed presence of MBL blaNDM-1 gene in 33 (86.9%) out of 38 isolated A. baumannii (Table-3 and Fig-1). All of them were resistant to carbapenem.   Table-2: Resistance pattern of A. baumannii to different antibiotics (n=38).     Table-3: Distribution of blaNDM-1 gene in A. baumannii (n=38).         Fig.1: PCR analysis of  A. baumannii isolates from VARTI cases showing presence of 155 bp blaNDM-1 gene (Lane 2, 3, 5, 6, 7); Negative control (L1 and 8); L4: 100 bp DNA ladder.   Discussion Infection by MBL producing organism containing blaNDM-1 gene are increasing in the last few years in Bangladesh [12,21,22]. In 2011, about 3.5% blaNDM-1 positive Escherichia coli, K. pneumoniae, A. baumannii, Providencia rettgeri and Citrobacter freundii were reported from Bangladesh [21]. In 2013, another study from Bangladesh, reported the presence of blaNDM-1 gene in 22% of the imipenem resistant A. baumannii [22]. However, the present study has revealed that over 86% of A. baumannii isolated from high risk ICU patients were positive for blaNDM-1 gene and were resistant to several groups of antibiotics apart from carbapenem. MBL containing organisms are usually sensitive to polymyxins and tigecycline [23]. In the present study, though majority (>90%) of our blaNDM-1 positive A. baumannii were resistant to several classes of antibiotics, but 86.9% of them were sensitive to colistin. Therefore, the results of present study emphasize the necessity of strong infection control program and continuous monitoring of antibiotic susceptibility of offending organisms to contain the spread of multi-drug resistant blaNDM-1 positive A. baumannii in high risk areas of the hospitals. Also, strict and judicious use of effective antibiotic like colistin is necessary.   Author’s contributions SA designed the study, performed the experiments and wrote the manuscript. SMS conceived, designed and supervised the study.   Competing interest Authors declare no conflict of interest.   Funding None References 1.   Chastre J, Fagon JY. Ventilator - associated pneumonia.  Am J Respir Crit Care Med. 2002; 165(7): 867–903. 2.   Safdar N, Crnich CJ, Maki DG. The pathogenesis of ventilator-associated pneumonia: its relevance to developing effective strategies for prevention. Resp Care. 2005; 50: 725-739. 3.   Craven DE, Hjalmarson KI. Ventilator - associated tracheobronchitis and pneumonia: thinking outside the box. Clin Infect Dis. 2010; 51(1): 59-66. 4.   NseirS, Di Pompeo C, Pronnier P, Beaque S, Onimus T, Saulnier F, et al. Nosocomial tracheobronchitis in mechanically ventilated patients: incidence, aetiology and outcome. Eur Respir J. 2002; 20: 1483-1489. 5.   Koenig SM, Truwit JD. Ventilator - associated pneumonia: diagnosis, treatment and prevention. Clin Microbiol Rev. 2006; 19(4): 637-657. 6.   Alp E, Voss A. Ventilator associated pneumonia and infection control. Ann Clin Microbiol  Antimicrob. 2006; 5: 7. doi: 10.1186/1476-0711-5-7. 7.   Dey A, Bairy I. Incidence of multidrug resistant organisms causing ventilator - associated pneumonia in a tertiary care hospital: a nine-month prospective study. Ann Thorac Med. 2007; 2(2): 52-57. 8.   Trouillet JL, Chastre J, Vuagnat A, Joly-Guillou ML, Combaux D, Dombret MC, Gibert C. Ventilator associated pneumonia caused by potentially drug-resistant bacteria. Am J Respir Crit Care Med. 1998; 157(2): 531-539. 9.   Niderman MS, Craven DE. Guidelines for the management of adults with hospital acquired, ventilator associated pneumonia and health care associated pneumonia. Am J Respir Crit Care Med. 2005; 171: 388-416. 10.  Nordmann P, Nass T, Poirel L. Global spread of carbapenemase - producing Enterobacteriaceae. Emerg Infect Dis. 2011; 17: 1791-1798. 11.  Yong D, Toleman MA, Giske CG, Cho HS, Sundman K, Lee K, Walsh TR. Characterization of a new metallo-beta-lactamase gene, blaNDM-1, and a novel erythromycin esterase gene carried on a unique genetic structure in  Klebsiella pneumoniae sequence type 14 from India. Antimicrob Agents Chemother. 2009; 53(12): 5046-5054. 12.  Shamsuzzaman SM. NDM-1 producing new superbug bacteria: a threat to control infection. Bangladesh J Med Microbiol. 2011; 05(01): 1-2. 13.  Gottig S, Pfeifer Y, Wichelhaus TA, Zacharowski K, Bingold T, Averhoff  B, Brandt C, Kempf  VA. Global spread of New Delhi metallo-beta-lactamase-1. Lancet Infect Dis. 2010; 10(12): 828-829. 14.  Kaase M, Nordmann P, Wichelhaus TA, Gatermann SG, Bonnin RA, Poirel L. NDM-2 carbapenemase in Acinetobacter baumannii from Egypt. J Antimicrob Chemother. 2011; 66(6): 1260-1262. 15.  Park DR. Antimicrobial treatment of Ventilator - associated pneumonia. Resp Care. 2005 a; 50(7): 932-955. 16.  Goel V, Hogade SA, Karadesai SG. Ventilator associated pneumonia in a medical intensive care unit: microbial aetiology, susceptibility patterns of isolated organisms and outcome. Indian J Anaesth. 2012; 56(6): 558-562. 18.  Bauer AW, Kirby WMM, Sherris JC, Truck M. Antibiotic susceptibility testing by a standardized single disk method. Am J Clin Pathol. 1966; 36:493–6. 20.  Diene SM, Bruder N, Raoult D, Rolain Jean-Marc. Real-time PCR assay allows detection of the New Delhi metallo-β-lactamase (NDM-1) - encoding gene in France. Int J Animicrobial Agents. 2011; 37: 544-546. 22. Farzana R, Shamsuzzaman SM, Mamun KZ. Isolation and molecular characterization of  New Delhi metallo-beta-lactamase-1 producing superbug in Bangladesh. J infect Dev Ctries, 2013; 7(3): 161-168. <![CDATA[Chikungunya virus and dengue virus coinfection: a cases reports from Bangladesh]]> Muhammad Abdur Rahim Shahana Zaman Samira Rahat Afroze Hasna Fahmima Haque Farhana Afroz Tabassum Samad Khwaja Nazim Uddin https://imcjms.com/journal_full_text/272 2017-11-13 10:52:52 Clinical Case Report IMC J Med Sci 2018; 12(1): 42-43 Abstract A case of concurrent chikungunya virus and dengue virus infection is reported here. The patient presented with fever and generalized body ache. Diagnostic work-up revealed chikungunya-dengue co-infection. Dengue is endemic in Bangladesh while chikungunya is a recently emerging infection. As both the viruses are transmitted by a common vector, Aedes spp., such co-infections are likely to increase in coming years. IMC J Med Sci 2018; 12(1): 42-43. DOI: https://doi.org/10.3329/imcjms.v12i1.35178   Address for Correspondence: Dr. Muhammad Abdur Rahim, Assistant Professor, Department of Nephrology, BIRDEM General Hospital and IMC,  122 Kazi Nazrul Islam Avenue, Dhaka-1000, Bangladesh. Email: muradrahim23@yahoo.com   Introduction Chikungunya and dengue are two important and rapidly spreading mosquito-borne viral infections of global concern including Bangladesh. Dengue is endemic and chikungunya is an emerging infection in Bangladesh [1-3]. Since both the viruses are transmitted by Aedes mosquitoes, simultaneous or sequential infections by chikungunya and dengue viruses are not impossible. Here, we report a case of chikungunya-dengue co-infection occurring in a middle aged Bangladeshi patient.   Case 1 A 50-year-old lady presented with 3-day history of high grade continued fever and generalized body ache. She suffered a 5-day long febrile illness starting 15 days ago. Since the onset of fever for the first time, she had been experiencing pain in her hands and feet. She took paracetamol tablets during febrile periods and did not seek any medical advice before presenting to our center. On examination, patient was febrile (temperature 102°F) but hemodynamically stable [pulse 92/min, blood pressure 130/80 mm Hg]. There was no rash or lymphadenopathy. Other physical examination findings were unremarkable. Investigations revealed leucopenia [total white blood cell (WBC) count 2.5x109/L], lower normal platelet counts (150x109/L) and slightly raised erythrocyte sedimentation rate (25 mm in 1st hour). Both dengue nonstructural protein 1 (NS1) and immunoglobulin M (IgM) for chikungunya were positive by immuno-chromatographic test (Dengue NS1 by Humasis Co. Ltd., Republic of Korea; chikungunya IgM/IgG by SD BIOSENSOR, Republic of Korea). A diagnosis of chikungunya-dengue co-infection was made. She was treated with paracetamol and became afebrile after 5 days. Pain in feet continued even two weeks after she became afebrile and she was prescribed oral prednisolone 15 mg/day initially, with a plan to gradually tapper off over three weeks.   Discussion Chikungunya and dengue virus co-infections have been reported from India [4], Thailand [5], Yemen [6] and among returning travelers from Colombia [7] and Angola [8]. As both the viruses share common vector, chikungunya-dengue co-infection is likely to occur elsewhere. As chikungunya is a relatively new entity in Bangladesh [3], we did not find many cases of such co-infections, but we predict to deal increasing number of such co-infections in coming years. In our clinical practice, we dealt patients with chikungunya with evidences of past dengue infection (positive anti-dengue IgG antibody; unpublished observations). Chikungunya and dengue viruses share many similar epidemiological and clinical characteristics. Both can cause fever, rash, body aches and pains; though arthritis is more associated with chikungunya while retro-orbital pain is frequently present in dengue [2,3]. Reverse-transcriptase polymerase chain reaction (RT-PCR) technology is now-a-days available; which can efficiently detect ribonucleic acids (RNAs) of chikungunya and dengue sufficiently early in disease course. Leucopenia and thrombocytopenia are common in dengue whereas lymphocytopenia and raised erythrocyte sedimentation rate favor diagnosis of chikungunya infection [2,3]. Anti-chikungunya antibody (IgM) and anti-dengue antibody (IgM) may be detected in later part of first week or at the beginning of second week. Exclusion of dengue is more important than establishing chikungunya virus infection during febrile periods, as patients may require non-steroidal anti-inflammatory drugs (NSAIDs), which is not advocated during dengue infection [3]. Not only that, dengue has a higher mortality (0.5-3.5%) than chikungunya (<0.1%) and simultaneous infections by both viruses may result in serious disease though controversies exist [1]. Like any other vector borne disease, mosquito control is an important intervention to prevent dengue and chikungunya infections. Confining patients suffering from chikungunya and dengue under mosquito nets during viremic stage is an important intervention against disease transmission [3]. Creating and improving mass awareness, cleaning mosquito breeding sites as well as other public health measures are necessary to effectively reduce the burden of chikungunya and dengue infections in Bangladesh.   Author’s contributions MAR diagnosed and managed the cases, collected data, did literature search and drafted the manuscript, SH did literature search and helped in manuscript preparation, SRA, HFH, FH and TS followed up cases, collected data and edited the manuscript, KNU was the overall supervisor in diagnosing and managing cases and manuscript preparation.   Competing interest Authors declare no conflict of interest.   Funding None   References 1.   Furuya-Kanamori L, Liang S, Milinovich G, Magalhaes RJS, Clements ACA, Hu W, et al. Co-distribution and co-infection of chikungunya and dengue viruses. BMC Infect Dis. 2016; 16: 84. 2.   Ahmed JU, Rahim MA, Uddin KN. Emerging Viral Diseases. BIRDEM Med J. 2017; 7(3): 224-32. 3.   Rahim MA, Uddin KN. Chikungunya: an emerging viral infection with varied clinical presentations in Bangladesh. Reports of seven cases. BMC Res Notes. 2017; 10: 410. 4.   Saswat T, Kumar A, Kumar S, Mamidi P, Muduli S, Debata NK, et al. High rates of co-infection of Dengue and Chikungunya virus in Odisha and Maharashtra, India during 2013. Infect Genet Evol. 2015; 35: 134-41. 5.   Laoprasopwattana K, Suntharasaj T, Petmanee P, Suddeaugrai O, Geater A. Chikungunya and dengue virus infections during pregnancy: seroprevalence, seroincidence and maternal-fetal transmission, southern Thailand, 2009-2010. Epidemiol Infect. 2016; 144(2): 381-88. 6.   Rezza G, El-Sawaf G, Faggioni G, Vescio F, Al Ameri R, De Santis R, et al. Co-circulation of Dengue and Chikungunya Viruses, Al Hudaydah, Yemen, 2012. Emerg Infect Dis. 2014; 20(8): 1351-54. 7.   Rosso F, Pacheco R, Rodríguez S, Bautista D. Co-infection by Chikungunya virus (CHIK-V) and dengue virus (DEN-V) during a recent outbreak in Cali, Colombia: Report of a fatal case. Rev Chilena Infectol. 2016; 33(4): 464-67. 8.   Parreira R, Centeno-Lima S, Lopes A, Portugal-Calisto D, Constantino A, Nina J. Dengue virus serotype 4 and chikungunya virus coinfection in a traveller returning from Luanda, Angola, January 2014. Euro Surveill. 2014; 19(10).pii: 20730. <![CDATA[Factors determining conversion of laparoscopic to open cholecystectomy]]> Tapash Kumar Maitra Mahmud Ekramullah Faruquzzaman Samiran Kumar Mondol https://imcjms.com/journal_full_text/177 2017-03-22 13:14:35 Original Article IMC J Med Sci 2017; 11(2): 32-35 Abstract Background and objectives:Laparoscopic cholecystectomy (LC) has virtually replaced conventional open cholecystectomy (OC) as the standard procedure of treatment for cholelithiasis and cholecystitis. However, OC sometimes becomes a necessity considering the feasibility and safety of the surgical procedure. But the factors that demand conversion from LC to OC differ widely. The present study aimed to determine the prevalence of conversion from LC to OC and to assess the causes of conversion and risk factors related to conversion. Methods: The study was conducted in a referral hospital – ‘Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorder (BIRDEM)’ from September 2014 to September 2016. Cases of cholelithiasis with or without cholecystitis, and other gall bladder pathology were included in the study. A team of experienced surgeon performed LC of all selected cases. The causes of conversion to OC were systematically recorded by the surgical team and the risk factors (age, sex, obesity, history of previous abdominal surgery, gallbladder thickness) related to conversion from LC to OC was investigated. Results: A total of 261 (M / F = 87 /174) patients were considered eligible for the study. The mean age of all patients was 43 (±1.75) years. For the male and female groups the mean ages were 44±1.9 and 42±1.6 years respectively. Of the total 261 cases, 210 (80.5%) patients had cholelithiasis with chronic cholecystitis, 47 (18.0%) had gallbladder stone plus acute cholecystitis and 4 (1.5%) had gallbladder polyp. Open conversion was required in case of 19 patients. Thus, overall conversion rate was 7.3%. The common causes of conversion were a) difficulty in defining Calot’s triangle (42.1%), b) injury to cystic artery (21.1%) and c) injury to bile duct (15.8%). Both male and female had equal risk for conversion. The investigated risk factors like history of previous abdominal surgery, preoperative ERCP, acute cholecystitis, obesity, increased gallbladder-wall thickness and older age showed no significant association with conversion. Conclusion: The study revealed that a very few patents (7.5%) needed conversion from LC to OC. The commonest cause of conversion was difficulty in defining Calot’s triangle, injury to cystic artery and bile duct. The risk factors like previous abdominal surgery, preoperative ERCP, gallbladder wall thickness, obesity and old age were not found associated with conversion to OC. IMC J Med Sci 2017; 11(2): 32-35. DOI: https://doi.org/10.3329/imcjms.v11i2.33091 Address for Correspondence: Dr. Tapash Kumar Maitra, Associate Professor & Head, Department of Surgery, BIRDEM General Hospital, 122 Kazi Nazrul Islam Avenue,  Shahbagh   Dhaka, Bangladesh. Email: tapashkm1965@gmail.com   Introduction Laparoscopic cholecystectomy (LC) has been accepted as the most common surgical procedure for the treatment of cholelithiasis and associated surgical conditions [1]. However, there are factors that have increased the risk ofopenconversion [1-3]. LC also introduced a new spectrum of complications [1]. It has been reported that conversion from LC to OC is less common as consultant caseload increases [4]. This indicates that LC should be undertaken only by the experienced surgeons who perform operation on a substantial number of cholelithiasis and or cholecystitis cases [4]. Some authors suggest that a history of preoperative endoscopic sphincterotomy and a thickened gallbladder wall contribute to the likelihood of conversion [5]. This study was undertaken to determine the prevalence of conversion from LC to OC and the risk factors related to conversion.   Study population and Methods The study was conducted at BIRDEM hospital in Dhaka city for consecutive two years starting from 30 September 2014 to 30 September 2016. All cases of cholelithiasis with or without cholecystitis, and other gall bladder pathology admitted in the hospital during the above period were included in the study. Detail clinical history was recorded in a predesigned data sheet. Clinical history included gender, age, previous abdominal surgery, preoperative ERCP, jaundice, acute cholecystitis, obesity, gallbladder wall thickness. The relevant biochemical and imaging investigations were performed on each case for the diagnosis of cholelithiasis and associated pathology. An experienced team of surgeon of BIRDEM hospital performed LC of all selected cases. The data were presented as mean±SD and percentages. Chi-sq tests were used to determine the factors related to conversion.   Results The age and sex distribution of the study population is presented in Table-1 which suggest that majority of the patients were female (66.7%). The mean (±SD) age was 44±1.9 years and 42±1.6 years in case of male and female patients respectively. Majority of the patients (80.5%) selected for laparoscopic cholecystectomy had chronic cholecystitis and 18.0% had acute cholecystitis and 1.5% had other pathology like gall bladder polyp (Table-2).   Table-1: Age and sex distribution of study population     Table-2: Diagnosis following laparoscopic cholecystectomy     Of the total 261, the conversion from LC to OC was performed in 19 patients. Thus, the conversion rate reached 7.3%. The causes for conversion are shown in Table-3. The most common cause of conversion was a difficulty to define the anatomy of Calot’s triangle, which comprised 42.1%. The other major causes were injury to cystic artery (21.1%) and bile duct (15.8%). The risk factors for association with conversion of LC to OC were shown in Table-4. There was no significant association of gender, age, history of previous abdominal surgery, preoperative ERCP and jaundice with conversion. Likewise, acute cholecystitis, obesity, gallbladder wall thickness were also found not significant.   Table-3: The causes for conversion from LC to OC     Table-4: Factors associated with conversion to open cholecystectomy     Discussion For many years LC has been the standard treatment for symptomatic gallbladder disease [2,3,5]. The identification of factors that reliably predict the likely need to convert LC to an open procedure is important and beneficial in terms of patients’ education and postoperative expectations [3]. This study did not consider the risk score as suggested by CholeS study group [3]. However, the conversion rate of this study is consistent with the other studies [4,5,6]. A study in England reported the overall conversion rate as 5.2% [4]. Ishizaki et al observed the conversion rate from 5.3% to 10.6% [5]. It may be mentioned that Sippey M et al [7] found age, male gender, obesity, pre-operative alkaline phosphatase level, white blood cell count were independently associated with conversion to OC. In the present study age, gender and obesity were investigated but found not significant. Alkaline phosphatase and white blood cell count were not included in the study. Further study may be conducted to reveal the association of these factors to conversion. Patients with chronic cholecystitis were found as the most common candidates undergoing laparoscopic cholecystectomy. Very few patents required conversion from laparoscopic to open cholecystectomy. The most common cause of conversion was a difficulty in defining Calot’s triangle followed by injury to cystic artery and bile duct. The other reported risk factors like previous abdominal surgery, preoperative ERCP, gallbladder thickness, obesity and old age were found not associated with conversion to OC.   References <![CDATA[Clinical features and histological types of 35 cases of carcinoma esophagus: experience from two hospitals in Bangladesh]]> Md. Nazmul Hoque Md. Forhadul Islam Chowdhury Shireen Ahmed Md. Abdullah Al Mamoon https://imcjms.com/journal_full_text/173 2017-03-18 13:27:26 Original Article IMC J Med Sci 2017; 11(2): 36-39 Abstract Background and objectives:Esophageal malignancy is a fatal disease. Squamous cell cancer and adenocarcinoma are two most common types. The present study aimed to describe demographic characteristics, clinical features, histological types and associated among the selected Bangladeshi patients with esophageal cancers. Esophageal cancer usually presents at an advanced stage, and thus curative treatment is limited and the prognosis is poor [1].In spite of the recent development in cancer therapy, esophageal cancer remains one of the least treatment-responsive malignancies [2]. Even in developed countries, more than 85% of patients die within two years of diagnosis, making it the sixth most common cause of cancer-related deaths in the world [3]. The main histologic types of esophageal cancer are squamous cell carcinoma (SCC) and adenocarcinoma [4]. Esophageal cancer is generally more common in men than in women. The male-to-female ratio is 3 to 4:1. Esophageal cancer occurs most commonly during the sixth and seventh decades of life [5]. Approximately, 50% to 60% of squamous cell esophageal cancers occur in the middle third of the esophagus, 33% involve the distal esophagus, and 10% occur in the proximal esophagus [6]. In Western cultures, retrospective evidence has implicated cigarette smoking and chronic alcohol exposure as the most common etiologic factors for squamous cell carcinoma [7]. High body mass index, gastro esophageal reflux disease (GERD), and resultant Barrett esophagus are often the associated factors for esophageal adenocarcinoma [8, 9]. Caustic injuries, betel nut, certain fungus and smoking have been implicated to promote esophageal cancer in south Asia [10, 11].   This cross-sectional descriptive study was conducted from January to December 2016 at two hospitals of Bangladesh located in Feni district and Dhaka city. Feni district is located 128 km from Dhaka city in the south-eastern part of Bangladesh. Endoscopicaly diagnosed 35 adult consecutive cases of esophageal carcinoma were included. In this study either sex was consecutively and purposively included. Previously diagnosed case of carcinoma esophagus under treatment and patients with inconclusive histological findings were excluded from the study. Age, gender, history of chewing betel nut and smoking, clinical presentation and laboratory parameters were recorded systematically in a predesigned data sheet. Upper gastrointestinal (GI) endoscopy was done by Olympus CV 150 machine and 6 to 8 pieces of tissues were taken by Olympus biopsy forceps. Collected tissue was immersed in formalin container for histopathology examination. Histopathology was done by experienced pathologists. Patients were initially classified as esophageal cancer by gross endoscopic findings and later confirmed by histopathology examination. The data were presented as percentage and mean and relevant statistical tests were employed to determine significant association or differences among variables. A total of 35 consecutive cancer esophagus cases were enrolled. The mean age was 61.3 years and the range was 40 to 85 years while 80% were more than 50 years of age (Table-1). Of the 35 cases, 71.4% was male and 28.6% was female. Regarding the status of smoking it was found that 19 (54.3%) were either smoker or ex-smoker (Table I). Among the 35 cases, overall 62.9% cases had the history of betel nut chewing irrespective of the types of esophageal cancer. All the patients having esophageal cancer had dysphagia, of which 19 (54.3%) patients had relative dysphagia (dysphagia only for solid foods) and remainder 16 (45.7%) patients had absolute dysphagia (both solid and liquid; Table-2). The mean duration of the symptoms was 1.4 months. Out of 35 cases, 27 (77.1%) had SCC and 8 (22.9%) had adenocarcinoma by histological examination (Table-2). Endoscopic examination revealed that all adenocarcinoma were present in the lower part of the esophagus. Out of 27 SCC, 15 (55.6%) had lesion in mid-esophagus, 9 (33.3%) in lower and 3 (11.1%) in upper esophagus (Table-2). Table-3 shows that the habit of betel nut chewing was present in higher proportion of patients (70.4%; 19/27) with SCC compared to patients with adenocarcinoma (37.5%); 3/8). But the difference was not significant (p= 0.0907). On the other hand, history of smoking was present in 75% of cases with adenocarcinoma compared to 48.1% in cases with SCC. But the difference was not statistically significant (0.1782).   Table-1: Baseline characteristics of 35 esophageal cancer cases     Table-2: Major clinical features, endoscopic and histological findings of the study population     Table-3: Betel nut chewing and smoking habits of study population with SCC and adenocarcinoma     Discussion Worldwide esophageal cancer is the sixth leading cause of death due to cancer, accounting for about 5% (407,000 deaths) of all cancer deaths annually.It is the eighth most common cancer worldwide [12]. The treatment for esophageal cancer is protracted and is fatal in a significant number of cases. Therefore, in the current study we have tried to elucidate the socio-demographic characteristics, possible associated factors and histological types of esophageal cancer among Bangladeshi population. <![CDATA[Health related quality of life in children with autism spectrum disorder in Bangladesh]]> Farhana safa Md. Nazrul Islam https://imcjms.com/journal_full_text/166 2017-02-16 19:53:42 Original Article IMC J Med Sci 2017; 11(2): 40-44 Abstract Background and objective: Autism spectrum disorder (ASD) is considered as an emerging problem in our socioeconomic context. The objectives of this study were to compare the health related quality of life of children with autism spectrum disorder to that of typically developing peers. Methods: A cross sectional comparative study was conducted on autistic children and normal children in six centers of Dhaka city to see the health related quality of life from parent’s perspective by using the Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL scale). Total of 115 children within the age group of 8-12 years were selected, among them 57 were autistic and 58 were normal peers. Results: Children with autism spectrum disorder had poor physical (mean score 6.04), emotional (mean score 9.77) and social (mean score 14.51) functions as well as learning ability (mean score 8.12) whereas normal children’s functioning mean scores were 0.10, 1.79, 0.0 and 0.45 in respective domains and the differences were significant (p<.0001) in each aspect of quality of life. Conclusion: This study revealed that, children with autism spectrum disorder experienced poorer health-related quality of life than normal children and thus the findings would contribute in implementing different strategies for improving the health status of autistic children. IMC J Med Sci 2017; 11(2): 40-44. DOI: https://doi.org/10.3329/imcjms.v11i2.33093 Address for Correspondence: Dr. Farhana Safa, Lecturer, Department of Anatomy, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka, Bangladesh, Email:safa.somch@gmail.com   Introduction Autism spectrum disorder (ASD), sometimes referred to as “autism” is a chronic disorder whose symptoms include failure to develop normal social relations with other people, impaired development of communicative ability, lack of imaginative ability, and repetitive, stereotyped movements [1]. ASD affected individuals have markedly different social and emotional behaviors than non-autistic individuals. ASD also has an effect on intelligent quotient (IQ). About 30% of individuals with autism have an average or gifted IQ, while 70% are considered mentally retarded [2]. Health related quality of life in children with ASD is poor than the normally developing peers. In developing countries like Bangladesh, autism is considered as a curse. People of the society, sometimes parents are also ignorant about their children’s physical and mental condition. Moreover, institutions involved with the treatment and improvement of the health of the autistic children cannot properly deal with problems associated with autism. The last decade has witnessed a significant increase in the utilization of health related quality of life (HRQL) instruments in an effort to improve patient health outcomes and to determine the efficacy of healthcare services [3,4]. HRQL explores the well-being of individuals with various medical conditions and disabilities. Therefore, by using this scale we can estimate the actual health condition of the autistic children (8-12 years) and compare that with the normal developing child. The findings would be helpful for the effective management of autistic children. Therefore, the preset study was undertaken to find out the HRQL and socio-demographic characteristics of children with autism.   Materials and Methods Study population and place: This comparative cross sectional study was conducted in three centers which deal with autistic children and comparison was done with normal children from three other centers. Bangladesh Protibondhi Foundation (BPF), Kalyani, Institute of Neurodevelopment and Research Centre and Society for the Welfare of the Intellectually Disabled, Bangladesh (SWID Bangladesh) and its sister wing – Ramna Protibondhi Shongstha was chosen for data collection from parent of autistic children. Total 115 children were selected for the study. Among them 57 were autistic child and 58 were normally developing peers. The age range of both autistic and normal children was 8-12 years. In this study, children of this age group was selected because 8-12 years children are more appropriate for assessing the questions used in Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL). Children with ASD were eligible to participate in the study if (a) they have one of the three ASD diagnosis e.g. autism disorder, pervasive developmental disorders not otherwise specified or Asperger disorder, (b) they are not suffering from other complicated diseases and (c) the parents of autistic child willing to provide data. Research instrument: Data were collected from the parents (either mother or father) of the children because the autistic children could not provide the actual data that was needed and was collected by a semi-structured pre-tested interview questionnaire by considering all possible variables according to information, developed on the basis of relevant literature. The questionnaire contained socio-demographic characteristics of children and their parents along with the questions (modified) used in the PedsQL [5-8] to measure HRQL. The parents rated children’s HRQL over the past month on a 5-point scale (“never a problem” to “always a problem”) scored from 0 to 4 with lower scores indicating better HRQL. The PedsQL comprises a physical health summary (physical health subscale-8 items) and a psychosocial health summary (emotional-5 items; social-5 items; and school-5 items functioning subscales). During calculation for each child’s total health summery in 4 domains, 0-4 was considered as good and above 4 was considered as poor heath function. Procedure of data collection: Before getting started, permission for data collection was taken from every school. Data were collected from the parents at the school premises by face to face interview. The data collection for each participant required two or three visits within a 4-week period at a location of six study places. During the first visit, eligibility criteria were confirmed, and during the second visit, the PedsQL was administered. Parents or school authority were bound to provide a copy of the medical report documenting an ASD diagnosis. Healthy control children in the peer group met the same inclusion criteria except for a diagnosis of the autism spectrum. Ethical approval was obtained from institutional review board of American International University, Bangladesh (AIUB). Informed written consent was obtained from all participants and facilities involved in the study.   Result The study was carried out among 115 children, 57 of them were autistic (ASD) and rest were normal healthy children. The ASD group comprised of 44 boys and 13 girls, with a mean age of 9.67±1.42 years. The comparative healthy peer group comprised of 43 boys and 15 girls, with a mean age of 9.66±1.40 years. Participating families of both groups belonged to middle to higher socioeconomic status. In autistic group, 50.9% parents had graduate and postgraduate level of education and it was 75.9% in normal group. Educational status among the respondents of normal child was higher than the respondents of autistic child. Of the total 57 respondents of autistic child group, 61.4% were housewives, 28% service holder (both govt. and private) and rests were businessman (5.3%), unemployed, retired and agricultural worker (each 1.8%) whereas majority (51.8%) in control normal child group were service holder. Monthly family income of the all respondents ranged from Tk.10000 to Tk. 300,000 taka. Of the respondents of autism and normal healthy groups, 54.4% and 48.3% respectively had monthly family income of Tk. 25001 to Tk. 50000 taka. The socio-demographic characteristics of the parents of both groups were almost similar. Table-1 shows that the children with autism spectrum disorder had significantly higher mean scores for physical (mean 6.04), emotional (mean 9.77) and social functions (mean 14.51) as well as for learning ability (mean 8.12) compared to the normal children’s mean scores which were 0.10, 1.79, 0.0 and 0.45 in respective domains. Higher mean value of all these variables for autistic children than that of normal children indicated that autistic children had very lower quality of life.   Table-1: The mean PedsQL score of autistic and normal healthy children     Table-2 shows that, 54.4% autistic children had poor physical function while all the children in normal group had good physical function. It was found that 94.7% autistic children had poor emotional function whereas only 3.4% of the normal children were emotionally disturbed. Table 2 further shows that, no autistic children had good social function whereas only all the normal children were socially sound. Regarding learning abilities, 82.5% autistic children had impaired or poor abilities while all the normal children had good learning function according to the pedsQL scale. In all 4 domains of pedsQL scale there was significant association of autism with poor quality of life (p<0.0001).   Table-2: Status of physical, emotional and social functions as well as learning abilities of autistic and normal healthy children     Discussion The Center for Disease Control and Prevention states that the prevalence of autism is increasing at epidemic rates [9]. For decades since first described by Leo Kanner in 1943, autism was believed to occur at a rate of 4–5 per 10,000 children [10]. From surveys done between 1966 and 1998 in 12 countries (e.g., United States, United Kingdom, Denmark, Japan, Sweden, Ireland, Germany, Canada, France, Indonesia, Norway, and Iceland), the prevalence ranged from 0.7–21.1/10,000 population, with a median value of 5.2/10,000 (or 1/1923) [11]. The most recent results from the Centers for Disease Control and Prevention (CDC) suggest that, in the United States, the prevalence of ASD is 1/70 boys and 1/315 girls, yielding an overall rate of 1/110 [9]. This is nearly identical to the overall prevalence from a recent British study [12]. In our country it has been reported that out of every 94 boys, one is affected by autism. For girls, it is one in every 150. In Bangladesh, no systematic research has been carried regarding the magnitude or prevalence of autism but it is assumed that about 300,000 children are affected [13]. Previous studies related to HRQOL of autistic children tried to find out the agreement between children self and parent’s proxy report as well as children’s QOL and result revealed lower QOL of autistic group than normal peers. In this study, we have used the data from parent’s perspective. This study set out to increase our knowledge of children with ASD’s HRQL compared to typically developing peers from the parents’ perspective. The study revealed significantly poorer HRQL for children with ASD than their peers for the physical, emotional, social functions as well as learning ability at school. Children with ASD had consistently poor performance in those parameters. In relation to HRQL parameters it appeared that the children with ASD had lower well-being, which should be addressed by service providers. This confirms previous findings in children and adolescents with ASD and high functioning autism (HFA), but uses a control group of typically developing children instead of normative data [5,7,14-17]. ASD has been and continues to be a major health issue in our current society. Significant numbers of children are being diagnosed with ASD each year, and this includes young adults, indicating a need to increase the understanding and awareness of the general public. This study would help the policy makers and administrators to find out the actual condition of autistic children in comparison to normal one and thus would contribute in implementing different strategies for improving health status of autistic children.   References 2.   Sarason IG, editor. Abnormal psychology: the problem of maladaptive behavior. Upper Saddle Rivery, New Jersey; Pearson Education Inc.publisher; 2002. 4.   Varni JW, Burwinkle TM, and Lane MM. Health-related quality of life measurement in pediatric clinical practice: An appraisal and precept for future research and application. Health and Quality of Life Outcomes. 2005; 3: 34–43. 6.   Sheldrick RC, Neger EN, Shipman D. Quality of life of adolescents with autism spectrum disorders: concordance among adolescents’ self-reports, parents’ reports, and parents’ proxy reports. QualIty of Life. 2011; 21(1): 53–57. 8.   Limbers CA, Heffer RW, Varni JW. Health-Related Quality of Life and Cognitive Functioning from the Perspective of Parents of School-Aged Children with Asperger’s Syndrome Utilizing the PedsQL (TM). Journal of Autism and Developmental Disorders. 2009; 39(11): 1529–1541. 10.  Kanner L. Autistic disturbances of affective contact. Nerv. Child. 1943; 2: 217–250. 12.  Baird G, Simonoff E, Pickles A, Chandler S, Loucas T, Meldrum D. Prevalence of disorders of the autism spectrum in a population cohort of children in South Thames: the Special Needs and Autism Project (SNAP). Lancet. 2006; 368(9531): 210–215. 14.  Kamp-Becker I, Schröder J, Remschmidt H, Bachmann CJ, Schroder J. Health-related quality of life in adolescents and young adults with high functioning autism-spectrum disorder. German medical science: PsychoSocialMedicine. 2010; 7: 1–10. 16.  Kamp-Becker I, Schröder J, Muehlan H, Remschmidt H, Becker K, Bachmann CJ. Health-related quality of life in children and adolescents with Autism Spectrum Disorder. Zeitschrift für Kinder-und Jugendpsychiatrie und Psychotherapie. 2011; 39(2): 123–131. 17.  Lee LC, Harrington RA, Louie BB, Newschaffer CJ. Children with autism: Quality of life and parental concerns. Journal of Autism and Developmental Disorders. 2008; 38(6): 1147–1160. <![CDATA[Clinicopathologic features, management and outcome of ten cases of gastrointestinal stromal tumors]]> Md. Nazmul Hoque Samiron Kumar Mondal Md. Mohsin Kabir Indrejit Kumar Datta M Golam Azam Md. Abdullah Al Mamoon Shireen Ahmed https://imcjms.com/journal_full_text/201 2017-04-22 10:43:32 Original Article IMC J Med Sci 2017; 11(2): 45-49 Abstract Background and objectives:Gastrointestinal stromal tumor (GISTs) is an uncommon and rare disease in Bangladesh. Our aims were to describe socio-demographic characteristics, clinical presentations, anatomical location, morphological variation, treatment and outcome of GIST in ten cases. Methods:This study included consecutive ten cases of GISTs diagnosed and treated in two tertiary level hospitals in Dhaka, Bangladesh from 2013 to 2016. Patients’ socio-demographic characteristics, clinical presentations, anatomical location, histological types, presence of CD117 markers were determined. Outcome of the treatment by surgical intervention and imatinib mesylate (400mg/day) were evalauted. Results: Total 10 patients were included in the study. Among them 6 were male and 4 were female. The age range was 32-74 years. Abdominal pain, haematemesis, melaena, haematochezia and anaemia were the most common presentation. One patient had dysphagia and another had features of subacute intestinal obstruction. Five patients had GIST in the stomach (50%), two had in colon and one in esophagus, duodenum and ileum respectively. CD 117 was positive in 8 cases, majority had spindly type cell with low mitotic figure. Imatinib therapy was given in all the cases except two patients. Disease recurrence in the form liver metastasis was found in two cases and both died. Disease free survival for more than 2 years was observed in 4 cases. Conclusion: Haematemesis and melaena were common presentation of GISTs. Stomach was the most common site for GISTs and majority had spindle type of cells and positive CD117 marker. Surgical intervention and imatinib therapy was found effective. IMC J Med Sci 2017; 11(2): 45-49. DOI: https://doi.org/10.3329/imcjms.v11i2.33094 Address for Correspondence: Dr. Md. Nazmul Hoque, Consultant and Head, Department of GHPD, Ibrahim Medical College & BIRDEM General Hospital, 122 Kazi Nazrul Islam Avenue, Dhaka, Bangladesh. Email: alifbd@gmail.com   Introduction Gastrointestinal stromal tumors (GISTs) are the mesenchymal tumors of the gastrointestinal tract (GI) and account for less than 1% of GI tumors [1]. About 60%-70% GIST arises from the stomach and the rest are from small intestine (20% to 30%), colon and rectum (5%), and esophagus (<5%) [2]. A small number of stromal tumors may originate from outside the gastrointestinal tract. These are designated as extragastrointestinal stromal tumors (EGISTs) [3]. Historically, these lesions were classified as leiomyomas or leiomyosarcomas because they possessed smooth muscle features. With the advent of immunohistochemical staining techniques GISTs now are recognized as a distinct group of mesenchymal tumors. GISTs express c-kit protein also known as CD117, and is considered a specific marker that differentiates GIST from other mesenchymal tumors such as leiomyomas [4]. The most common clinical manifestation for symptomatic GIST is pain in abdomen and GI bleeding from mucosal ulceration [5]. Other presentations include mass in the abdomen or intestinal obstruction. Endoscopy and colonoscopy clearly delineate the site and macroscopic appearance. However, ultrasonography (USG) and computerized tomographic (CT) scan are useful to determine the location of tumor in the gastric or intestinal wall [6]. Tumors less than 2 cm in diameter with a mitotic rate of <5/50 HPF (high power field) have been shown to have lower risk of recurrence than larger tumors. All GIST tumors should be considered to have malignant potential [7]. At present, surgery remains the mainstay of treatment for GIST. Recently, imatinib mesylate has been introduced as an adjunct therapy for metastatic disease, for non resectable tumor and for prevention of recurrence [5]. In this report, we describe the socio-demographic characteristics, clinical presentations, anatomical location, investigations, morphological variation, treatment and outcome of GIST encountered over four years period at two tertiary care hospitals.   All the patients diagnosed with GISTs from 2013 to 2016 at two tertiary care of hospitals (BIRDEM General Hospital and Gastroliver Hospital) of Dhaka city were included in the study.GIST cases were analyzed for age, sex, clinical features, tumor location, size, histological characteristics and CD117 marker. Types of surgery, post operative event, outcome of imatinib therapy, disease recurrence, recurrence site and survival rate were also analyzed. Mitotic figure defined as number of mitosis per 50 HPF (high power field). Disease recurrence means local recurrence or distant metastasis. GIST cases with inconclusive histological findings during the study period were excluded. Long term follow up at intervals were done by clinical examination, routine blood test and abdominal USG. <![CDATA[Seroprevalence of Leptospira infection in selected rural and urban areas of Bangladesh by rLipL32 based ELISA]]> Shakila Tamanna Fahmida Rahman TH Tang Siti Aminah Ahmed KC Ang Kaniz-E-Zannat MSA Jilani M Mohiuddin J Ashraful Haq https://imcjms.com/journal_full_text/217 2017-05-16 09:02:18 Original Article IMC J Med Sci 2017; 11(2): 50-55 Abstract Background and objectives: Leptospirosis is a zoonotic infection with worldwide distribution caused by the Leptospira species and predominant in the tropical and subtropical regions. Information on leptospirosis in Bangladesh is limited. The present study was designed to detect anti-leptospiral antibodies in human serum samples in Bangladeshi population by developing an in-house ELISA using recombinant LipL32 (rLipL32) antigen. The study was conducted from April 2014 to December 2014. Method: Healthy individuals from two rural areas and fever cases from one urban healthcare center were enrolled in the study. Rural health centers were located at Sonargoan and Bajitpur sub-district (Upozilla) of Narayaganj and Kishorganj districts. Sonargoan health center is located 26 km south-east and Bajitpur is located 71 km north-east of Dhaka city. About 1-2 ml of blood was collected with aseptic measure and serum was separated and stored at -200C until used. Anti-leptospiral IgG antibody was determined by recombinant LipL32 (rLipL32) antigen based indirect enzyme linked immunosorbent assay (ELISA). Seropositive cases were further confirmed by commercial Leptospira IgG ELISA. Results: The study included 250 febrile cases and 376 healthy individuals from urban and rural areas, respectively. Out of total 626 study population, anti-LipL32 specific IgG antibody was detected in 70 individuals (11.2%). The rate of positivity of anti-LipL32 antibody among the healthy individuals from rural area was 10.6% while the rate was 12.0% in urban febrile population. The rate of positivity in rural and urban population was not significantly (p>0.05) different. Among the urban population, the rate of seropositivity was 9.1% and 16.4% in 21-40 yrs and above 40 years age group respectively while the rate was 7.2% and 14.0% in rural population respectively. Out of 70 seropositive cases detected by LipL32 ELISA, 65 (92.9%) were positive by commercial ELISA. Conclusion: The present study has revealed that leptospirosis is prevalent in Bangladesh and should be looked for in febrile and clinically suspected cases. The study has also demonstrated that rLipL32 protein may be used as a candidate antigen for the serodiagnosis of leptospirosis. IMC J Med Sci 2017; 11(2): 50-55. DOI: https://doi.org/10.3329/imcjms.v11i2.33095 Address for Correspondence:Prof. J Ashraful Haq, Professor of Microbiology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Dhaka, Bangladesh. Email: jahaq54@yahoo.com   Introduction Leptospirosis is a spirochetal zoonosis that infrequently causes a wide spectrum of clinical manifestations in humans. Currently leptospirosis is considered as an emerging global public health problem, particularly in resource-poor countries in tropics. The burden of leptospiral disease falls predominantly on people living in poverty and under inadequate sanitary conditions. Leptospira spp infect various animals including rat and other rodents. Animal excrete Leptospira through urine, which contaminate water and soil. People at risk for leptospirosis include farmers, abattoir workers, sewer workers and others who have contact with soil, water and animal [1-3]. The risk during the rainy season becomes higher after flooding when the human population may be exposed to water contaminated with urine from infected animals. The estimated annual leptospirosis morbidity in South and South-East Asia is 17.97 and 55.54 per 100,000 populations [2]. Although data on leptospirosis in Bangladesh is limited, a serological survey in a rural flood prone district of Bangladesh in 1994 showed 38% seropositivity in 89 samples of human sera tested, indicating that the rural population was at high risk of leptospiral infection [4]. In 2000, acute-phase serum specimens from 359 dengue-negative patients in Dhaka were assessed for leptospirosis. Leptospira spp was detected by polymerase chain reaction (PCR) in 63 (18%) of them [5]. Another study in 2000, screened people with fever in slum of Dhaka city and reported leptospirosis in 8.4% cases [6]. Presence of leptospirosis among the cattle in dairy farms in Chittagong division of Bangladesh had also been reported [7]. Several diagnostic tests are used to detect acute and past leptospiral infection. Microscopic agglutination test (MAT) is considered as gold standard test for the diagnosis of leptospirosis. But the test requires live organisms. Detection of leptospiral DNA in clinical samples by polymerase chain reaction (PCR) has been employed to diagnose leptospirosis [8,9]. Recently, rLipL32 antigen based serodiagnostic tests have been developed to conduct seroprevalence studies in human leptospirosis [8,10-12]. LipL32 is an outer membrane protein which is highly conserved among pathogenic Leptospira spp and prominent immunogen during leptospirosis. A study from Thailand has shown the diagnostic sensitivity and specificity of the LipL32 dipstick assay as 100% and 98.33%, respectively when compared to those of MAT. The results suggest that the recombinant LipL32 is a good diagnostic detection reagent for detection of antibodies against Leptospira. In view of the above, the present study was undertaken to determine the leptospiral infection among rural and urban people of Bangladesh using a rLipL32 based in-house ELISA.   Materials and Methods Study population and place: Healthy individuals from two rural areas and febrile cases from one urban healthcare center were enrolled in the study. Rural centers were located at Sonargoan and Bajitpur sub-district (Upozilla) under Narayaganj and Kishorganj districts respectively. Sonargoan is located 26 km south-east and Bajitpur is located 71 km north-east of Dhaka city. Individuals with no history of fever in last one month prior to enrollment were considered as healthy and enrolled in the study. Patients with fever for more than 5 days attending an urban healthcare center in Dhaka city were enrolled and were denoted as ‘febrile case’. In order to determine the cut-off optical density (OD) value of ELISA test, blood from 105 healthy newborn babies from a hospital of Dhaka city were included in the study. Samples from neonates were leftover blood collected for other routine investigations. The mothers of the neonates were from urban affluent class and had least chance of exposure to leptospiral infection. About 1-2 ml of blood was collected with aseptic measure and serum was separated and stored at -200C until used. Informed consent was obtained from the participants before collection of blood. The study was carried out from April to December 2014. Determination of anti-rLipL32 IgG antibody by ELISA: Recombinant outer membrane protein of 32 kDa, present in pathogenic Leptospira spp, was used for detecting Leptospira spp. specific IgG antibody by enzyme linked immunosorbent assay (ELISA) as described by Voller et al [13]. Recombinant LipL32 protein was over expressed from the recombinant plasmid pAELipL32 which we obtained from Prof. OA Dellagostin, Núcleo de Biotecnologia, Centro de Desenvolvimento Tecnológico, Universidade Federal de Pelotas, Brazil. The recombinant plasmid was transformed into BL21(DE3) plysS strain. For protein purification, positive clone was inoculated into 100 ml Luria Broth (LB) and allowed to grow at 370C until the OD reached to 0.5 to 0.6 at 600 nm, induced with 1.0 mM IPTG (isopropyl-b-D-thiogalactopyranoside) for about 4 hour. Cell pellet was resuspended in BugBuster Protein Extraction Reagent and purified using His•Bind Purification Kit (Novagen, USA). The purified antigen (Fig-1) was reconstituted with sterile distilled water to make a concentration of 1 µg/µl and aliquoted for further use. The expression and purification of protein was carried out at Advanced Medical & Dental Institute, Universiti Sains Malaysia, Malaysia. The 96 well EIA plate (Linbro, USA) was coated with rLipL32 antigen 5µg/ml in 0.5 M carbonate/bicarbonate buffer (pH 9.6). To each well 100 µl volume of coating buffer was added and incubated overnight at 40C. The plate was washed three times with PBS-0.05%Tween 20 (PBS-T, pH 7.4)) and blocked by incubating for 2 hrs with PBS-T containing 2% BSA at 370C. The plate was then washed three times with PBS-T. A volume of 100 µl serum (1:40 dilutions) sample was added into each well and incubated for 4 hours at 370C. After washing with PBS-T three times, 100 µl of horseradish peroxidase conjugated anti-human IgG antibodies (1:4000) was added and incubated at 370C for 2 hours. After washing three times with PBS-T, 50 µl of TMB substrate was added to each well and incubated at room temperature for 30 minutes in dark. Then 50 µl of 1M sulfuric acid was added in each well. The colour developed was measured by EIA plate reader (Human ELISA Reader) at 450 nm. Optimum concentration of the antigen (5µg/ml) and serum dilution (1:140) was predetermined by checkerboard titrations. A reagent blank and a positive and negative control wells were included in each plate along with the test samples. Determination of cut-off OD value: A cut off OD values for rLipL32 specific IgG antibody was determined to find out the exposure rate to Leptospira spp. in the study population. ELISA was performed with sera from 105 healthy newborn babies of Dhaka city who were presumed not to be exposed to Leptospira infection. The mean OD + 3xSD of these sera were taken as cut-off OD value to determine the exposure rate. The mean OD±SD of the 105 healthy newborn babies were 0.14±0.08. Therefore, the calculated cut-off OD value was 0.38 (0.14+3x0.08). Any sample showing OD above this cut-off value of 0.38 was considered as positive and referred to as exposed to Leptospira infection. Determination of Leptospira specific IgG antibody by commercial ELISA: Leptospira specific IgG antibody was also determined by commercial ELISA (DRG International Inc, USA) to compare the results obtained by in-house ELISA using rLipL32 antigen. The kit used purified Leptospira biflexa (serovar patoc 1) antigen for detection of antibody in serum. The assay was carried out as per instruction of the manufacturer.     Fig-1. SDS-PAGE showing rLipL32 protein expressed from the recombinant plasmid pAELipL32 and purified using His•Bind Purification Kit (Novagen, USA). Lane 1: Protein ladder, Lane 2: protein following viva spin, Lane 3: protein following acetone precipitation.   Result A total of 626 samples were included in the study. Out of which, 376 samples were healthy individuals from rural area and 250 were febrile cases from urban area. Out of total 626 study population, anti-rLipL32 specific IgG antibody higher than the cut-off OD value (>0.38) were detected in 70 individuals (11.2%). The rate of positivity of anti-rLipL32 antibody among the healthy individuals from rural area (Bajitpur and Sonargaon) was 10.6%, while the rate was 12.0% in urban population. The detail location wise (urban and rural) rate of seropositivity is shown in Table 1. The rate of positivity in rural and urban population was not significantly (p>0.05) different.   Table-1: Seroprevalence of anti-leptospiral IgG antibody among rural and urban study population by ELISA using rLipL32 antigen     Age specific seropositivity rate for anti-rLipL32 antibody is shown in Table-2. Among the urban population, the rate of seropositivity was 9.1% and 16.4% in 21-40 yrs and above 40 years age group respectively; while rate was 7.2% and 14.0% in rural population respectively. There was no positive case in age group 1-20 years in urban population while 5.4% was positive among rural population. There was an increased rate of seropositivity with the increase of age. The overall (rural and urban) rate of leptospira specific rLipL32 antibody was significantly (p<0.05) higher in people over 40 years of age compared to 21-40 years group (Table-2). Out of 70 seropositive cases by rLipL32 in-house ELISA, 65 (92.9%) were found positive by commercial ELISA.   Table-2: Age specific seropositivity rate of anti-leptospiral IgG antibody of study population by rLipL32 antigen based ELISA     Discussion Leptospirosis is an infectious disease with a worldwide distribution. Currently, prevention and control of leptospirosis have received much attention of public health authorities. Improved diagnostic test for leptospirosis is needed to aid clinical diagnosis of acute cases and assess the prevalence. Recently, recombinant antigen based serodiagnostic assays have been developed to diagnose human leptospirosis. Among the many candidate antigens, LipL32, an outer membrane protein, is highly conserved among pathogenic Leptospira spp [12]. In the present study, we have used rLipL32 antigen based ELISA to determine the seroprevalence of leptospiral infection in selected urban and rural population. We have used a cut-off OD of >0.38 for our in-house rLipL32 based ELISA to consider a sample positive for leptospiral infection. The results when compared with the commercial ELISA was found almost similar. Positive samples by rLipL32 ELISA was found positive in 92.9% cases by commercial ELISA. Therefore, rLip32 could be considered as a good candidate antigen for ELISA to detect Leptospira spp specific infection in our geographical locations. However, further study is necessary to optimize the test for detecting anti-leptosipral IgM antibody to detect acute infection. Leptospirosis has been reported to be prevalent in our neighbouring countries and other countries of South and South-East Asian regions [2]. In India, a 5 year consecutive sero-epidemiological study conducted in Kerala showed that 29.6% inhabitants possessed anti-leptospiral antibodies [14]. Previous studies from Bangladesh reported 8% to 38% leptospira infection among febrile cases from urban and rural areas of the country [4-6]. But there is no study regarding the sero-prevalence of leptospiral infection among healthy rural Bangladeshi population. In the present study, prevalence of leptospirosis was found 12% among the febrile urban population and 10.64% among the healthy individuals from rural areas. The rate of infection was not significantly different among urban febrile cases and healthy individuals of rural areas. However, the overall rate of infection increased significantly with the increase of age. Previous studies reported that older people (20 years and above) were at a greater risk for leptospirosis than children [2]. Presence of rLipL32 specific IgG among our study population has shown that leptospiral infection is prevalent both in rural and urban areas of Bangladesh. Anti-leptospiral IgG remains persistent for several years following acute infection [15-16]. Persistence of antibody may create problem in interpreting the serological tests detecting IgG antibodies in acute cases unless rising IgG antibody or Leptospira specific IgM is detected. The present study has demonstrated that a large proportion of people residing in both rural and urban areas of Bangladesh are exposed to leptospiral infection and rLipL32 antigen is a potential candidate for the serodiagnosis of leptospirosis.   References 1.   Jackson LA, Kaufmann AF, Adams WG, Phelps MB, Andreasen C, Langkop CW, et al. Outbreak of leptospirosis associated with swimming. Pediatr Infect Dis J. 1993; 12:  48-54. 2.   Costa F, Hagan JE, Calcagno J, Kane M, Torgerson P, Martinez-Silveira MS, et al. Global morbidity and mortality of leptospirosis: a systematic review. PLoS Negl Trop Dis. 2015; 9(9): e0003898. doi:10.1371/ journal. pntd.0003898. 3.   Whitney EAS, Ailes E, Myers LM, Saliki JT, Berkelman RL. Prevalence of and risk factors for serum antibodies against Leptospira serovars in US veterinarians. J Am Vet Med Assoc. 2009; 234: 938–944. 4.   Morshed MG, Konishi H, Terada Y, Arimitsu Y, Nakazawa T. Seroprevalence of leptospirosis in a rural flood prone district of Bangladesh. Epidemiol Infect. 1994; 112: 527–31. 5.   LaRocque RC, Breiman RF, Ari MD, Morey RE, Janan FA, Hayes JM, et al. Leptospirosis during dengue outbreak, Bangladesh. Emerg Infect Dis. 2005; 11(5): 766-769. 6.   Kendall EA, LaRocque RC, Brooks WA. Leptospirosis as a cause of fever in urban Bangladesh. Am J Trop Med Hyg. 2010; 82: 6 1127-1130. 7.   Parvez MA, Prodhan MAM, Rahman MA, Faruque MR.  Seroprevalence and associated risk factors of Leptospira interrogans serovar Hardjo in dairy cattle of Chittagong, Bangladesh. Pak Vet J. 2015;   35(3): 350-354. 8.   Musso D, Scola BL. Laboratory diagnosis of leptospirosis: A challenge. J Micro Immu Infec. 2013; 46: 245-252. 9.   Ahmed SA, Sandai DA, Musa S, Hoe CH, Riadzi M, Lau KL, Tang TH. Rapid diagnosis of leptospirosis by multiplex PCR. Malays J Med Sci. 2012; 19(3): 9-16. 10.  Boonyod D, Poovorowan Y, Bhattarakosol P, Chitrathaworn C. LipL32, an outer  membrane protein of Leptospira, as an antigen in a dipstick assay for diagnosis of leptospirosis. Asian Pac J Allergy Immunol. 2005; 23:     133-141. 11.  Flannery B, Costa D, Carvalho FP, Guerreiro H, Matsunaga J, da Silva ED, et al. Evaluation of recombinant leptospira antigen-based enzyme-linked immunosorbent assays for the serodiagnosis of leptospirosis. J Clin Microbiol. 2001; 39: 3303-10. 12.  Haake DA, Chao G, Zuerner RL, Barnett JK, Barnett D, Mazel M, et al. The leptospiral major outer membrane protein LipL32 is a lipoprotein expressed during mammalian infection. Infect Immun. 2000; 68: 2276- 2285. 13.  Voller A, Bartlett A, Bidwell DE. Enzyme immunoassays with special reference to ELISA techniques. J Clin Path. 1978; 31: 507-520. 14.  Kuriakose M, Paul R, Joseph MR, Sugathan S and Sudha TN. Leptospirosis in a midland rural area of Kerala State. Indian J Med Res. 2008; 128(3): 307-312. 15.  Cumberland P, Everard CO, Wheeler JG, Levett PN. Persistence of anti-leptospiral IgM, IgG and agglutinating antibodies in patients presenting with acute febrile illness in Barbados 1979-1989. Eur J Epidemiol. 2001; 17(7): 601-608. 16.  Finsterer J, Stöllberger C Sehnal E, Stanek G. Mild leptospirosis with three-year persistence of IgG- and IgM-antibodies, initially manifesting as carpal tunnel syndrome. J Infec. 2005; 51(2): E67-70. <![CDATA[Prevalence and pattern of gastrointestinal symptoms in patients with diabetes mellitus]]> Hafiza Lona Shahjada Selim https://imcjms.com/journal_full_text/234 2017-06-29 14:30:40 Original Article IMC J Med Sci 2017; 11(2): 56-60 Abstract Background and objectives: Gastrointestinal (GI) disorders are contributor of increased morbidity and poor quality of life in individuals with diabetes mellitus (DM). Racial, nutritional and life style may influence GI disorders to a large extent. Thus, the burden of GI disorders and its determinants warrant investigation in individual population. Therefore, the present study was undertaken to explore the types of GI symptoms in Bangladeshi population with DM for more than 10 years of duration. Methodology: This observational study was conducted on patients with DM for more than 10 years of duration at the outpatient department of BIRDEM general hospital from July 2009 to June 2010. A total of 301 DM patients responded to self-reporting questionnaire (Bengali adaptation of Rome III diagnostic questionnaire). Then 91 participants were further studied for glycemic status, liver function, kidney function and basic defects of diabetes through homeostasis model assessment. Results: The median age of 301 study population was 55 years (range 25 to 84 years) and the male female ratio was 1: 0.74. Out of 301 DM cases, 273 (90.7%) had GI symptoms. Significantly (p<0.05) higher number of males (93.6%) had GI symptoms compared to females (86.7%). Among the clinical conditions, unspecified functional bowel disorder (UFBD) was present in 88.3% cases, followed by cyclic vomiting syndrome (38.1%) and functional fecal incontinence (20.9%). Single GI symptom was present in 123 (45.1%) cases while 32.6%, 12.5% and 9.9% had two, three and more than three GI symptoms respectively. No significant difference was found in any biochemical parameter between cases with and without GI symptoms. Multiple logistic regression analysis revealed sex and residence as poor predictors of UFBD while other variables did not show any significant relation/risk to UFBD. Conclusion: A large proportion of patients with long duration of DM had GI symptoms. A comprehensive management of diabetes requires attention to GI disorders. IMC J Med Sci 2017; 11(2): 56-60.  DOI: https://doi.org/10.3329/imcjms.v11i2.33097   Address for Correspondence: Dr. Shahjada Selim, Assistant Professor, Department of Endocrinology & Metabolism, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka-1000, Bangladesh. Email:selimshahjada@gmail.com, selimshahjada@bsmmu.edu.bd   Introduction Gastrointestinal (GI) symptoms are more common in patients with diabetes compared to individuals without diabetes. The pathogenesis of symptoms remains poorly understood. It has been suggested that symptoms reflect abnormal GI motility as a manifestation of irreversible autonomic neuropathy. Evidence for this concept, however, is limited. Studies have implicated duration of diabetes, type of diabetes treatment, or an increased perception of abdominal distension the as risk factors for GI symptoms [1]. Many of the symptoms prominent in the functional gastrointestinal disorders (FGIDs) are consistent with dysfunction of the sensory and/or motor apparatus of the digestive tract [2]. Various combinations of such dysfunction occur in different regions of the digestive tract in the FGIDs. The understanding of the origins of this gut sensori-motor dysfunction is gradually increasing. Inﬂammatory, immunologic, and other processes, as well as psycho-social factors such as stress, can alter the normal patterns of sensitivity and motility through alterations in local reflex activity or via altered neural processing along the brain-gut axis. In this context, a potential role of genetic factors, early-life influences, enteric flora, dietary components and autonomic dysfunction have also been considered in the disease model [3]. Therefore, the present study was designed to explore the types of GI symptoms and the related factors in a group of Bangladeshi population with DM of more than 10 years of duration.   Materials and Methods The study was conducted at the outpatient department of BIRDEM general hospital from July 2009 to June 2010. It was designed in 2 steps. In step 1, 301 patients with DM of more than 10 years of duration were included, and in step 2 a subgroup of 91 cases were selected for biochemical analysis. Diabetes mellitus (DM) was defined as a condition of progressive pancreatic beta cell dysfunction having HbA1C level ≥6.5% or fasting plasma glucose (FPG) ≥7.0 mmol/l or two-hour plasma glucose ≥11.1 mmol/l during an OGTT or a random plasma glucose of ≥11.1 mmol/l in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis [4]. A Bengali version of Rome III diagnostic questionnaire for the adult functional gastrointestinal disorders (including alarm questions) and scoring was used after pretesting [5]. Enrolled participants were evaluated for their glycemic status, liver function, kidney function and basic defects of diabetes through homeostasis model assessment [6]. Statistical analysis was performed using SPSS (Statistical Package for Social Science) software for Windows version 20. The data were expressed as frequency, mean ± SD (standard deviation) or median (range) as appropriate. The statistical significance of differences between the values was assessed by student’s t test or Mann-Whitney U test as appropriate. Correlation was also analyzed among the parameters by using Pearson Correlation test. Regression analyses were done by taking appropriate dependent and independent variables. A p value of <0.05 was considered statistically significant.   Results The median age of 301 study population was 55 years and the age ranged from 25 to 84 years. Male female ratio was 1: 0.74. Out of 301 DM cases, 273 (90.7%) had GI symptoms. Significantly (p<0.05) higher number of males (93.6%) had GI symptoms compared to females (86.7%). The rate of GI symptoms among urban and rural dwellers was 91.3% and 89.8% respectively (Table-1). Distribution of clinical conditions among the 273 cases with GI symptoms is shown in Table-2. Among the clinical conditions, unspecified functional bowel disorder (UFBD) was the most frequent (88.3%), followed by cyclic vomiting syndrome (38.1%) and functional fecal incontinence (20.9%). Out of 273 DM cases with GI symptoms, 123 (45.1%) had single symptoms while 32.6%, 12.5% and 9.9% had two, three and more than three GI symptoms respectively.   Table-1:Characteristics of the study groups (n=301)     Table-3 compares the biochemical parameters of diabetic patient with and without GI symptoms. There were no significant differences in any biochemical parameters between cases with and without GI symptoms. Multiple logistic regression analysis of the association of unspecified functional bowel disorder (UFBD) present and absent with variables of interest is shown in Table-5. Sex and residence, though significant, were very poor predictors of UFBD. Other variable did not show any significant relation/risk to UFBD.   Table-2: Distribution of gastrointestinal symptoms among the study population (n=273)     Table-3: Comparison of biochemical parameters in patients with and without GI symptoms (n=91)     Table-4: Multiple logistic regression analysis of the association of unspecified functional bowel disorder (UFBD) present and absent with variables of interest (n=91).     Discussion In the present study, Rome III diagnostic criteria were used to determine the GI symptoms among the patients with diabetes mellitus of more than 10 years of duration. Rome III diagnostic criteria are considered to be one of the up to date instrument in this area for ascertaining the gastrointestinal symptoms. Over 90% of our study population had one or more GI symptoms. We found unspecified functional vowel disorder (UFBD) as the most frequent disorders among the study population (88.3%) which was followed by cyclic vomiting and fecal incontinence. Studies from USA, Europe and Australia have reported 40% to 55% GI disorders among patients with diabetes mellitus [7-12]. The effect was shown to be linked to poor glycemic control but not to duration of diabetes or type of treatment [11]. But in our study, in contrast to the prevalent concept of association between glycemic control and GI disorders, no significant relationship was found between the two variables. In addition to the glycemic status, no association of GI symptoms with lipidemic status and liver function was found. Data from other studies [5,12] support the present conclusion that blood glucose control may not affect GI symptoms in a straight forward way. Bangladeshi patients with type 2 DM have functional beta cell deficiency and secretory failure [13,14]. We have tried to find out whether these basic defects have any association with GI symptoms or not. No significant association was found between GI symptoms and insulin secretion and sensitivity from the absolute values of serum C peptide as well as from the derived values of HOMA% B (a measure of pancreatic β cell secretory function) and HOMA% S (a measure of insulin sensitivity) [15]. The present study, thus, revealed that a large proportion of Bangladeshi population with DM of long duration had one or more GI symptoms. Although, it may not be directly related to mortality in diabetes, it may have considerable impact on the quality of life of patients with DM. Therefore, attention to GI disorders should be given in planning comprehensive management of diabetes mellitus.   References <![CDATA[Coronary artery disease in a rural population of Bangladesh: is dyslipidemia or adiposity a significant risk?]]> Sajal Krishna Banerjee Chaudhury Meshkat Ahmed Mir Masudur Rhaman Mohammad Mainul Hasan Chowdhury M. Abu Sayeed https://imcjms.com/journal_full_text/235 2017-07-02 14:45:41 Original Article IMC J Med Sci 2017; 11(2): 61-69 Abstract Background and Aims: The prevalence of cardiovascular diseases (CVD) are on the increase worldwide and more in the developing countries. Coronary artery disease (CAD) constitutes the major brunt of CVD. Despite the increasing morbidity and mortality, Bangladesh has a few published data on CAD in rural population. This study addressed the prevalence of CAD and its risk factors in rural population of Bangladesh. Study methods: Sixteen villages were purposively selected in a rural area. A population census was conducted in the selected area. The census yielded eligible participants, who reached at least eighteen years of age. Those who willingly consented to participate were enlisted. Each participant was interviewed regarding CAD risk (age, sex, social class, occupation, illness, family history). Anthropometry (height, weight, waist- and hip-girth) was recorded. Resting blood pressure (BP) was measured. Blood sample was collected for fasting blood glucose (FBG), total cholesterol (Chol), triglycerides (Tg), low density lipoproteins (LDL), very low density lipoproteins (VLDL) and high density (HDL). All participants having FBG>5.5mmol/l or systolic (SBP) ³135 or diastolic BP (DBP) ³85mmHg underwent electrocardiography (ECG). A team of cardiologists selected and accomplished exercise tolerance test (ETT) and echocardiography (Echo). Results: The prevalence of CAD was 4.5% (95% CI: 3.85 – 5.15). Compared with the female (3.5%, CI, 2.76 – 4.24) the male participants had significantly higher prevalence of CAD (6.0%, CI, 4.83 – 7.13). Comparison of characteristics between participants with and without CAD showed that age, SBP, DBP and FBG were significantly higher in CAD group. Bivariate analysis showed that age, sex, social class, glycemic status, metabolic syndrome (MetS) and smoking were significantly related to CAD. Stepwise logistic regression proved only male sex, rich social class, hypertension and diabetes had independent risk of CAD; whereas, age, obesity and dyslipidemia were proved not significant. Conclusions: The study concludes that the prevalence of CAD in a Bangladeshi rural population is comparable to other developed countries. The male sex, rich social class, hypertension and diabetes were proved to have excess risk of CAD. Neither obesity nor dyslipidemia were found significant for CAD. The younger people had similar risk as the aged ones, which necessitate primordial and primary prevention of CAD. Further study may be undertaken, which should include and consider physical activity and diet; and if possible, C-reactive protein, Vitamin D and homocysteine level. IMC J Med Sci 2017; 11(2): 61-69. DOI: https://doi.org/10.3329/imcjms.v11i2.33098 Address for Correspondence: Prof. M. Abu Sayeed, Department of Community Medicine, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue Shahbag, Dhaka-1000. email: sayeed@imc.ac.bd   Introduction The burden of atherosclerotic diseases is progressively increasing [1]. The projected deaths from cardiovascular diseases (CVD) in 2030 is estimated to reach 23.6 million (34.8%) of the world population. Thus, it is clear that the clinical and socioeconomic impact of CVD is considerable. The World Health Organization (WHO) statistics of 2004 showed that CVD represents the number one cause of death worldwide, approximating 30% of total mortality [1]. Considering these facts, WHO and its partners launched a new initiative “Global Hearts” on 22 September, 2016 [2]. The initiative aimed to minimize the global threat of cardiovascular disease, the world’s leading cause of death. The questions remained still unanswered how to minimize the global threat and how to prevent morbidity and mortality of CVD. Though multiple risk factors like adiposity and metabolic disorders have been identified, these are found inconsistent in different studies. For example, some studies observed that obesity is a significant risk for coronary artery disease (CAD) [3,4]. In contrast, some studies reported that non-obese people also had risk for cardiovascular deaths [5] and different populations with an obesity paradox by BMI showed different risk [6]. As regards Bangladesh, there are few published data that estimated the magnitude of CVD and its related morbidity or mortality. Some investigators showed several known risks (obesity, smoking, lipids) prevalent amongst the south Asians (India, Pakistan, Bangladesh, Sri Lanka and Nepal) [8]. But these risk factors have not been studied in relation to CAD, and no study investigated which of the risks and how much of it significantly related to CAD. This study aimed to determine the prevalence of CAD in a rural community of Bangladesh. Additionally, the study attempted to investigate some known risk factors attributed to CAD.   Study design The study proposal was approved by the Ethical Review Committee of Bangladesh Diabetic Samity (BADAS). According to protocol, sixteen villages were purposively selected in a rural area - located north-east of Dhaka city and inhabited mostly by the population involved in agrarian occupation. The area is connected to Dhaka city by110 km of paved and 10 km of non-paved road. A census was conducted in these villages. The census included socio-demographic information (age, sex, education, occupation and family income). It also included family history of non-communicable diseases (NCD). Individual equal to or greater than 18 years of age was considered eligible. The eligible participants (≥18years) were randomized. The eligible participants were detailed (objectives, methods) about the study. Those who consented to volunteer the study were invited for stepwise investigations.   Step 1 Interviewing - In the morning, the participant was interviewed about occupation, education, income, illness (present or past) and medication. Interviewing on family-history included diabetes, hypertension (HTN), stroke, coronary heart diseases (CHD), peripheral vascular disease (PVD), foot-ulcer and leg amputation. The information was recorded based on medical reports (investigation, prescription) and verbal autopsy. Anthropometric and blood pressure (BP) measurements: Height, weight, waist- and hip-girth were measured. Body mass index (BMI = weight in kg / height in met sq.), waist-to-hip ratio (WHR = waist / hip) and waist-to-height ratio (WHtR =Waist / height) were calculated. Blood pressure was taken after 10 minutes of rest.   Step 2 Collection of blood sample: Five milliliter of fasting blood sample was collected aseptically for estimation of fasting blood glucose (FBG mmol/l) and lipids (total cholesterol, triglycerides, low-density lipoprotein, high-density and very high density lipoproteins). While collecting blood sample a drop of blood was taken on a finger strip for rapid assessment of FBG. The participants, who showed SBP / DBP ≥ 135 / 85 mmHg and/ or FBG ≥5.6 mmol/l were referred to electrocardiography (ECG) tracing. Step 3 A team of cardiologists examined all ECG tracings. According to the need of the cardiologists the ECG was repeated and for confirmation the participants were referred to the Department of Cardiology, Bangabandhu Sheikh Mujib Medical University (BSMMU) in Dhaka for ehocardiography (Echo) and exercise tolerance tests (ETT). Diagnosis of CAD was based on - a) history of angina plus ischemic change in ECG either at rest or on stress; b) post-myocardial infarction (MI) with Q-wave MI or non-QMI.     <![CDATA[A free vascularized fibular graft for reconstruction of mandibular bony defect following excision of odontogenic keratocyst]]> Farzana Bilquis Ibrahim Shamim Hassan Sajid Hasan Raihan Anwar Md. Rashedul Islam https://imcjms.com/journal_full_text/178 2017-03-31 21:07:15 Clinical Case Report IMC J Med Sci 2017; 11(2): 70-72 Abstract We present a case of reconstruction of a bony defect due to the excision of recurrent mandibular odontogenic keratocyst in a 45 years old diabetic male. Free vascularized fibular composite graft was taken from the contra lateral lower leg to reconstruct the defect. A two team approach consisting of plastic and maxillofacial (MF) surgeon was adopted. The functional and aesthetical outcome was satisfactory and bone healing occurred without any major complication. IMC J Med Sci 2017; 11(2): 70-72. DOI: https://doi.org/10.3329/imcjms.v11i2.33099 Address for Correspondence:Dr. Farzana B Ibrahim, Registrar, Department of Plastic Surgery, BIRDEM General Hospital, 122, Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000, Bangladesh. Email: ibrahimfarzana@hotmail.com   Introduction Cystic and cyst like lesions of the mandible are primarily ellipsoid, radiolucent, and clearly demarcated. It may be odontogenic or nonodontogenic. Odontogenic cysts and tumors develop during or after the formation of teeth [1]. Most odontogenic mandibular lesions are benign, but some particularly odontogenic keratocyst may be locally aggressive and destructive [2]. Odontogenic keratocysts are believed to arise from the dental lamina and other sources of odontogenic epithelium and is highly recurrent and locally aggressive. They represent 5%–15% of all jawcysts. Most odontogenic keratocysts are found during the 2nd to 4th decades of life, although they can occur at any age. The lumen of the cyst often contains “cheesy” material and has a parakeratinized lining epithelium [1]. Daughtercysts and nests of cystic epithelia are found outside the primary lesion; as a result, odontogenic keratocysts have the highest recurrence rate (50%) of any odontogenic cyst when treated conservatively with curettage [3]. Mandibulectomy has traditionally been the mainstay of surgical therapy for oral squamous cell carcinoma adjacent to or invading the mandible or for osteoradionecrosis. Combined bone grafts are used for large mandible defects [4,5,6]. Since microanastomosed bone grafts consist of living tissue, they are capable of independent survival within a compromised recipient site. Furthermore, vascularized grafts are able to improve the local wound regenerative situation. Most commonly used donor sites are iliac crest and fibula. Vascularized fibular grafts present numerous advantages for restoring mandible [3-6]. Their bony architecture is similar to that of the mandible, unlike iliac crest and they are capable of restoring defects up to a length of 25 cm. The grafts can be easily adjusted to the curvature of the mandible using the osteotomy technique. They are associated with very low postoperative donor site morbidity and facilitate the insertion of dental implants [7-9]. Since vascularized grafts behave like an edentulous mandible, osseointegration of dental implants can generally be achieved. We present a case of a 45 year old diabetic male in whom a free vascularized fibular composite graft from the left leg was used to reconstruct a 6 cm bony defect of the mandible following excision of odontogenic keratocysts. Informed consent was obtained from the patient to perform this procedure and to publish the case for academic purpose.   Case report A 45 year old, diabetic, male had cyst in the right side of the mandible with a history of repeated infection with pain and discharge for 2 years. Histopathologically the cyst was diagnosed as osteogenic keratocysts. He had history of extraction of lower right first premolar tooth and saucerization for several times but the cyst kept recurring. On examination, his gum was swollen, inflamed and there was absence of lower right 1st premolar tooth [Fig1a]. Radiology showed a large perforation of the cortical plates [Fig 1b, 1c]. Operation was performed under general anesthesia and two team approach was opted. Maxilllo facial surgeons performed the mandibular tumor resection while the plastic surgery team performed the flap and the receptor vessels dissection, and vascular anastomosis. Both teams participated at bone shaping and the final closure. Maxillofacial team excised about 6 cm of the mandible keeping the inner and lower cortex intact. The alveolar socket was also excised [Fig 1d]. The radical resection of the tumor was carried out. The plastic surgery team started with harvesting the free fibular composite graft from left leg. The course of the fibula was noted and marked [Fig 1e]. The majority of significant perforators emerge at 10 to 20 cm below the fibular head, thus it is preferable to locate the skin paddle within this location. As the anterior incision was made through the deep fascia, care was taken to avoid injury to the superficial branch of the peroneal nerve. The dissection continued posteriorly to the posterolateral intermuscular septum, exposing the peroneal muscles. The anterior surface of the septum was then followed down the fibula, and the peroneal muscles were elevated from the lateral and anterior surfaces of the bone. The posterior skin incision was then made through the deep muscle fascia, and the skin paddle was elevated to the edge of the soleus muscle. A 1-cm cuff of soleus muscle was taken from the lateral edge which was later excised. The fibular cuts were made with an oscillating saw. The proximal cut in the fibula was made first and positioned as superiorly as possible without endangering the peroneal nerve. To ensure stability of the knee the proximal 10 cm of fibula was preserved. Once both cuts were made, the fibula was retracted laterally. The peroneal vessels were located and followed distally where they were ligated and divided. The flap dissection continued in a medial to lateral direction to avoid injury to the perforating vessels of the skin. About 8 cm of fibula was harvested. Once the status of the neck vessels was assured and prepared, the peroneal vessels were divided, and the flap was transferred to the oral defect. A single closing wedge osteotomy was made to create a neoangle and the bone fragments were then stabilized with the rest of the mandible with nail plate and screw fixation. The graft was then revascularized using microvascular techniques [Fig 1f]. We performed peroneal vessel anastomosis to facial artery. Vein anastomosis was performed to the external jugular vein. End-to-end vascular anastomosis was used and microvascular anastomosis was performed as previously described under loupe magnification with 7.0 and 8.0 sutures. After checking for a watertight intraoral closure, the skin paddle was removed, the neck flaps were replaced, and the skin was closed over drains [Fig 1g]. The leg incision was closed primarily with suction drains in situ. The patient was hospitalized for two weeks. For the first week feeding was allowed with soft diet through naso-gastric tube. Lower limb was immobilized with a cast for the same period. His post operative period was uneventful. Drains and stitches were removed on 5th and 8th post operative day respectively. At three months follow up since the surgical reconstruction, the result was found satisfactory both from oncological and aesthetic point of view.     Fig-1: Photograph showing the mandibular bony defect and steps of reconstructive surgery. 1a: Absence of lower right 1st premolar tooth; 1b & 1c: Large perforation in the cortical plates as shown by CT scan and  X ray; 1d: Excised mandible; 1e: The marked course of the fibula for obtaining graft; 1f & 1g: Reconstrctuted graft. Arrow indicates the lesions     Discussion The free fibular osteofasciocutaneous flap can become the standard option for mandible reconstruction in our experience. The advantages were wide and safe resection and the better functional outcome. The associated morbidity at the donor site was minimal and the technique provided the opportunity of two-team approach thereby reducing the operating time. Immediately after integration dental implantation can be done.   References 1.   Goaz PW, White SC. Oral Radiology: principles and interpretation 3rd ed. St Lois, Mo: Mosby- Year Book, 1994; 398-676. 2.   Weber AL. Imaging of cysts and odontogenic tumors of jaw. Radiol Clin North Am. 1993; 31: 101-120. 3.   Oikarinen VJ. Keratocyst recurrences at intervals of more than 10 years: case reports. Br J Oral Maxillofac Surg. 1990; 28: 47-49. 4.   Hidalgo DA, Pusic AL. Free-flap mandibular reconstruction: a 10-year follow-up study. Plast Reconstr Surg. 2002; 110: 438-451. 5.   Hidalgo DA. Fibula free flap: A new method of mandible reconstruction. Plast Reconstr Surg. 1989; 84: 71-79. 6.   Sultan MR. Mandible reconstruction with the scapula osteocutaneous flap. Operative techniques in Plastic and Reconstructive Surgery. 1996; 3(4); 248-256. 7.   Kuprys R, Varinauskas V, Gervickas A, Stanaityte R. A review of mandibular reconstruction with free microvascularized fibular flap. Sveikatos mokslai/Health Sciences. 2012; 22 3(82): 170-174. 8.   Gbara A, Darwich K, Li L, Schmelzle R, Blake F. Long-term results of jaw reconstruction with microsurgical fibula grafts and dental implants. J Oral Maxillofac Surg. 2007; 65(5): 1005-1009. 9.   Ferrari S, Bianchi B, Savi A, Poli T, Multinu A, Balestreri A, Ferri A. Fibula free flap with endosseous implants for reconstructing a resected mandible in Bisphosphonate Osteonecrosis. J Oral Maxillofac Surg. 2008; 66(5): 999-1003. <![CDATA[Immunoglobulin G1 and G2 profile in children with Down syndrome]]> Supti Prava Saha Monsura Khan Ashesh Kumar Chowdhury https://imcjms.com/journal_full_text/157 2016-12-29 17:44:49 Original Article IMC J Med Sci 2017; 11(1): 1-4 Abstract Background and objectives: It is well known that children with Down syndrome (DS) suffer from frequent infections. There is an association of certain IgG subclass abnormalities with the predisposition to recurrent infection of the respiratory tract. Therefore, the study was conducted to determine the immunoglobulin G1 and G2 (IgG1, IgG2) profile in children with DS. Material and methods: Forty children between the ages of 6 months to 12 years with DS (47 XX/XY, +21) attending the Department of Immunology, BIRDEM were enrolled in the study. Age and sex matched 30 healthy normal children with 46 XX/XY were included as control. Enrolled DS and healthy children were divided into two age groups namely 6 months to 6 years and 7 years to 12 years. Serum IgG1 and IgG2 concentrations were determined by enzyme linked immunosorbent assay (ELISA) method. Results: The mean serum IgG1 concentrations of children with DS in both age groups did not differ significantly from that of normal healthy children. But the IgG2 level was significantly less (p<0.003 and p<0.004) in both age groups of children with DS compared to that of control healthy children. Conclusion: The study has demonstrated that the serum IgG2 level was significantly less in children with DS than that of matched normal healthy control children while there was no deficiency of IgG1. IMC J Med Sci 2017; 11(1): 1-4. DOI: https://doi.org/10.3329/imcjms.v11i1.31930 Address for Correspondence: Dr. Supti Prava Saha, Lecturer, Department of Pharmacology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka 1000, Bangladesh. Email: pipisu@yahoo.com   Introduction Down syndrome (DS) is one of the most common autosomal disorders. The prevalence of DS in Europe is reported to be 11.2 per 10,000 live births [1]. In USA the prevalence is 8.27 people per 10,000 population [2]. It is widely accepted that DS children suffer from frequent infections than normal children. Infections of the respiratory tract, particularly otitis media, have been identified as one of the most significant health problems in school age children with DS [3]. In previous study, it has been found that 54.9% children with DS suffer from ear infection and 11% suffer from upper respiratory tract infection [4]. The lower respiratory tract pathology is the most common cause for acute hospital admission among 1 to 5 years old children with DS [5]. The increased predisposition of infection in individuals with DS is attributed to underlying defects in the immune system which include abnormalities of cell mediated and humoral immune response [6]. In patients with DS, the serum concentration of total IgG may remain within normal range while the IgG2 and IgG4 concentrations are significantly reduced [7]. Also, people with recurrent sinopulmonary infections were found to have a normal serum immunoglobulin level, with selective IgG subclass deficiency [8]. Among the four subclasses of IgG, subclass IgG1 and IgG3 are more potent opsonizers than that of IgG2 and igG4 [9]. IgG1and IgG3 is generally produced in response to protein antigens of bacteria, viruses, vaccines and foods. IgG2 antibodies predominantly act against carbohydrate antigens and are important in protection against polysaccharide encapsulated organisms such as Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitides [10]. To date there is no study on immunoglobulin subclass pattern among Bangladeshi children with DS. Therefore, the present study was conducted to determine the IgG1 and IgG2 profile of Bangladeshi children with DS and whether they are different in comparison to normal children of the same age group.   Materials and methods The study protocol was approved by the Ethical Review Committee of the Diabetic Association of Bangladesh. Informed consent was obtained from parents of each participant prior to enrollment into the study.   Study population and collection of samples: Children between the ages of 6 months to 12 years having DS (47 XX/XY,+21) attending the Department of Immunology, BIRDEM were enrolled in the study. Age and sex matched healthy normal children with 46 XX/XY were included as control. The children were divided into two age groups namely, 6 months to 6 years and 7 years to 12 years. About 3 ml of blood was collected aseptically with venipuncture from all participants for estimation of IgG subclasses. Serum was immediately separated and stored in -800C until analyzed.   Estimation of IgG subclass: The concentration of IgG1 and IgG2 subclasses were determined by commercial sandwich enzyme linked immunosorbent assay (ELISA) kit. The kit was obtained from Elabscience Biotechnology Co, USA. The detection range of IgG1 and IgG2 was 1.56-100 µg/ml.   Result A total of 40 children with DS and 30 normal healthy children were included. There were 21 male and 19 female children with DS. There were 30 and 10 DS children in 6 months to 6 years and 7 years to 12 years age groups respectively. There were 15 normal healthy children in each age group. The mean concentration of IgG1 antibody of children with DS in 6 months to 6 years and 7 years to 12 years were 16.4 µg/ml and 9.9 µg/ml respectively compared to that of 11.5 µg/ml and 6.6 µg/ml. The concentration of IgG1 in DS and healthy children was not significantly different. The mean concentration of IgG2 in children with DS was significantly less (p<0.003 and p<0.004) than that of normal children in both age groups. Among 6 months to 6 years age group it was 7.4±5.6 µg/ml in DS versus 15±9.4 µg/ml in normal children. In 7 years to 12 years age group the mean IgG2 levels were 8.6±3.2 µg/ml and 14.9±8.2 µg/ml. The detail concentration of IgG1 and IgG2 are shown in Table-1.   Table-1: Serum IgG1 and IgG2 levels in children with DS and in normal children     1.   Loane M, Morris JK, Addor MC, Arriola L, Budd J, Doray B, et al. Twenty-year trends in the prevalence of Down syndrome and other trisomies in Europe: impact of maternal age and prenatal screening. Eur J Human Genet 2013; 21: 27–33. 2.   Presson AP, Partyka G, Jensen KM, Devine OJ, Rasmussen SA, McCabe LL, et al. Current estimate of Down syndrome population prevalence in the United States. J Pediatr 2013; 163(4): 1163–1168. 3.   Turner S, Sloper P, Cunningham C, Knussen C. Health problems in children with Down syndrome. Child Care Health Dev 1990; 16: 83–97. 4.   Selikowitz M. Health problems and health checks in school-aged children with Down syndrome. J Pediatr Child Health 1992; 28: 383–386. 5.   Hilton JM, Fitzgerald DA, Cooper DM. Respiratory morbidity of hospitalized children with trisomy 21. J Pediatr Child Health 1999; 35: 383–386. 6.   Ram G, Chinen J. Infections and immune-deficiency in Down syndrome. Clinical and Experimental Immunology 2011; 164: 9–16. doi:10.1111/j.1365-2249.2011.04335.x. 7.   Baptista CB, Charlton J, Mendoca P, Lopes AI, Palha M, Trindade JC. IgG subclasses serum concentrations in a population of children with Down syndrome: comparative study with siblings and general population. Allergologia et Immunopathologia 2002; 30(2): 57-60. 8.   Umetsu DT, Ambrosino DM, Quinti I, Siber GR, Geha RS. Recurrent sinopulmonary infection and impaired antibody response to bacterial capsular polysaccharide antigen in children with selective IgG-subclass deficiency. N Engl J Med 1985; 313:1247-1251. 9.   Levinson W. Review of medical microbiology and immunology. 13thed. The McGraw-Hill Companies, Inc. 2014; 510-511. 13.  Zaman K, Baqui AH, Yunus M, Sack RB, Bateman OM, Chowdhury HR, Black RE. Acute respiratory infections in children: a community-based longitudinal study in rural Bangladesh. J Trop Pediatr 1997; 43(3): 133-137. 14.  Anneren G, Magnusson CGM, Nordvall SL. Increase in serum concentrations of IgG2 and IgG4 by selenium supplementation in children with Down syndrome. Arch Dis Child 1990; 65: 1353-1355. 15.  Silk HJ, Ambrosino D, Geha RS. Effect of intravenous gammaglobulin therapy in IgG2 deficient and IgG2 sufficient children with recurrent infections and poor response to immunization with Hemophilus influenzae type b capsular polysaccharide antigen. Ann Allergy 1990; 64(1):21-25. <![CDATA[Tumors of the eyelid - a histopathological study at tertiary care hospitals in Dhaka, Bangladesh]]> Rita Paul Md. Nasimul Islam Enamul Kabir Harunur Rashid Khan Utpal Kumar Kundu https://imcjms.com/journal_full_text/161 2017-01-31 12:02:30 Original Article IMC J Med Sci 2017; 11(1): 5-10 Abstract Background and objective: Eyelid growth is a common clinical condition presented to ophthalmologists. Accurate diagnosis of eyelid tumors is necessary to guide ophthalmologists to design optimal management. We carried out the study to assess the histopathological types of different eyelid growth in tertiarycare hospitals of Dhaka city. Methods: This is a cross sectional study performed at the Department of Pathology of Sir Salimullah Medical College (SSMC), Dhaka, Bangladesh. Samples were collected from hospitals of SSMC and National Institute of Ophthalmology (NIO), Dhaka, Bangladesh. Study period was from January 2012 to December 2013. A total of 93 cases with eyelid growth of both sex were enrolled in the study. After obtaining informed written consent, tumors were excised by the ophthalmologist and the specimens were collected in 10% formalin for histopathological examination. Results: A total of 93 cases of eyelid lesions were examined. The most common age group affected was between 26-50yrs (50.54%). Mean age was 43.22±17.42 (range 19 – 90 years). Gender distribution of the patients was almost equal (male 51.6%, female 48.4%). Neoplastic lesions were found in 86 cases (92.47%) and non neoplastic growth was present in 7 (7.53%) cases. Benign, pre-malignant and malignant tumors were found in 52 (55.91%), 01(1.08%) and 33(35.48%) cases respectively. Among the malignant lesions, basal cell carcinoma was the most common malignant tumor (36.4%) followed by sebaceous gland and squamous cell carcinoma (27.3%). Nevus was the most common benign lesions (26.9%) followed by sudoriferous cyst (19.2%) and haemangioma (15.4%). Conclusions:All the eyelid lesions removed surgically should be examined histopathologically to establish the correct diagnosis. Accurate diagnosis of specific tumors is important for proper treatment and favorable prognosis. IMC J Med Sci 2017; 11(1): 5-10. DOI: https://doi.org/10.3329/imcjms.v11i1.31931   Address for Correspondence:Dr. Rita Paul, Assistant Professor, Department of Pathology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka, Bangladesh. E-mail: ritapaul16@gmail.com   Introduction Eyelid growth is a common clinical condition presented to ophthalmologists [1]. The eyelid is rich in glandular tissue which includes sweat glands of the eyelid skin, lacrimal gland of Krause and Wolfring, the apocrine gland of Moll, meibomian and the glands of Zeiss [2]. Pathologic conditions affecting the eyelid may be inflammatory or neoplastic. It has been reported that 90% of skin cancers occurs in head and neck region and 10% of them are located at eyelid level [2]. Benign epithelial lesions, cystic lesions, and benign melanocytic lesions of eyelid are very common [3].Among the benign lesions, squamous cell papilloma, seborrheic keratosis, melanocytic nevus are common. Most common malignant tumors of eyelid are basal cell carcinoma, squamous cell carcinoma and sebaceous carcinoma. Other less common malignant tumours include merkel cell carcinoma, lymphoma and secondary metastatic carcinoma [4]. Most of the eyelid tumors are of cutaneous origin, mostly epidermal, which can be divided into epithelial and melanocytic tumors. Basal cell carcinoma, benign epithelial lesions, cystic lesions, and melanocytic lesions represent about 85% of all eyelid tumors [5]. Inflammatory and infectious lesions simulating neoplasm are also common. Basal cell carcinoma is the most common malignancy of eyelid. It occurs most frequently in lower eye-lid, followed by medial canthus, upper eye-lid and lateral canthus [6]. Squamous cell carcinoma usually involves the lower lid margin in elderly fair-skinned persons. It most commonly arises from premalignant lesions like actinic keratosis, Bowen's disease, xeroderma pigmentosa and radiation dermatitis [7]. Eyelid malignancies are completely treatable if detected early. Early diagnosis of eyelid growth is thus of extreme importance to avoid high morbidity and mortality. Although, eyelid lesions are common in clinical practice, no systematic study has yet been performed in Bangladesh. Therefore, the present study was conducted to determine the histological types of eyelid lesions among the patients attending teaching hospitals of Dhaka city.   Materials and Methods This was a cross sectional study conducted at the Department of Pathology of Sir Salimullah Medical College, Dhaka, Bangladesh. Samples were collected form hospitals of SSMC and NIO. Study period was from January 2012 to December 2013. The study protocol was approved by the ethical committee of Sir Salimullah Medical College, Dhaka. Ref: Memo. No / SSMC /294. Date: 06/09/ 2012. Collection and processing of samples: A total of 93 patients with clinically diagnosed eyelid growth of both sex were enrolled in the study. All the patients presented with eyelid growth were examined by an ophthalmologist and complaints were recorded. After obtaining informed written consent, tumors were excised by the ophthalmologist and the specimens were collected by researcher for histopathology examination. The surgically excised specimens were preserved in 10% formalin solution. Size, shape and consistency of each specimen were recorded. Large specimens were cut sagitally into pieces and the very small ones were embedded as such and wrapped in wrapping paper and kept in cassettes and then placed in 10% formalin for overnight fixation. Following over night fixation in 10% formalin the tissue blocks were gradually dehydrated in ascending concentration of ethyl alcohol. The blocks were then cleared in xylene, impregnated in paraffin and then embedded in proper orientation in malted paraffin. Tissue sections of 5-7 um thick were prepared and stained with haematoxylin and eosin (H&E) stains as described elsewhere [8].   Results A total of 93 cases with eyelid growths attending the outpatient department of NIOH and SSMC hospital were included in the present study. Out of total 93 cases, males and females were almost equally distributed (51.6% vs. 48.4%). The mean age of the study population was 43.2±17.4 years (range 19 - 90 years). There was no significant difference (p>0.05) of mean age of male and female cases. Out of total 93 eyelid growth, 55.9% were benign lesions while 35.5% and 7.5% were malignant and non-neoplastic lesions respectively (Table-1). Benign lesions of the eyelid was significantly higher (p<0.05) than that of malignant lesions. There was only one case of premalignant lesion in a 65 years old male. The most common location of the eyelid lesions was upper eyelid (51.8%) while lower eyelids had 37.6% lesions. Of the malignant lesions, basal cell carcinoma was 12 (36.4%) followed by sebaceous gland carcinoma 9 (27.27%) and squamous cell carcinoma 9 (27.27%). Less common were non-Hodgkin’s lymphoma 2 (6.06%) and small cell carcinoma 1 (3.03%). Among 52 benign lesions, nevus was the most common (14/26.9%), followed by sudoriferous cyst (10/19.23%), haemangioma (8/15.38%), squamous papilloma (5/9.6%) and dermoid cyst (5/9.6%). Other less common lesions were epidermal inclusion cysts in 3 cases (5.77%), and sebaceous cysts in 2 cases (3.85%), fibroepithelial polyp 2 (3.85%). adenoma 1(1.92%), lipoma 1(1.92%), neurofibroma 1(1.92%). There were 2 cases of rhinosporodiosis among non-neoplastic lesions. Detail distribution of histopthologically diagnosed eyelid growths is shown in Table-2.   Discussion The present study was conducted with an aim to assess the histopathological types of eyelid growths. It was a hospital based cross sectional study which enrolled 93 clinically suspected eyelid growths. Out of them 86 were neoplastic and 7 were non- neoplastic growth. In our series we found 35.5% malignant and 55.9% benign growth. There was only one case of premalignant lesion. A study from Japan in 2012 has reported that out of 118 eyelid tumors that were removed and examined, 106 (89.8%) were benign and 12 (10.2%) were malignant [9]. Previous study in a tertiary care hospital in Thailand, has reported that out of 212 cases of eyelid tumor, 71.4% were benign and 10.8% were malignant [10]. We found a higher percentage of malignant growths. This might be due to the delay in seeking treatment because of lack of awareness, education and treatment facilities in rural areas, low socioeconomic status and less cosmetic concern. In the present study, the majority of the patients (47 out of 93) were in the 26 to 50 years age group. Mean age of the study population in the present study was 43.2 years. Most of the malignant eyelid lesions were in patients above 51 years of age and benign growths were within the age group 26-50 years. Mean age of the patients with malignant lesions was 56.3 years and those with benign was 35.9 years. Both benign and malignant lesions of the eyelid were most commonly seen in patients in their forties and fifties [11]. Studies from Thailand, Taiwan and Japan have reported the mean age of diagnosis of eyelid cancers was between 52.4 to 72 years [12,13,14]. However, malignant tumors like squamous and basal cell carcinoma of the eyelid have been reported in patients below 25 years of age [15]. In the present study, we found squamous and basal cell carcinoma of eyelid in 21 and 22 years old patients. Among the malignant tumors in the present study, most common was basal cell carcinoma (36.4%) followed by sebaceous gland (27.3%) and squamous cell carcinoma (27.3%). In western countries, basal cell carcinoma is the most common among malignant eyelid tumors, whereas in Japan and other parts of Asia, the frequency of sebaceous gland carcinoma and squamous cell carcinoma are relatively high [14]. Sebaceous gland carcinoma tumor is more common in Asian countries, reportedly comprising 33% of eyelid tumors and second behind basal cell carcinoma [16]. The upper eyelid is involved 2 to 3 times more commonly than the lower eyelid.Women are affected more than men. The etiology of sebaceous carcinoma is not entirely known. Human papilloma virus and increased expression of TP53 gene has been implicated as genetic factor in invasive sebaceous gland carcinoma [17,18]. In the present study, sebaceous gland carcinoma was found in 27.3% cases with malignant tumors. Females (6 out of 9) were affected more than male. In the present study, squamous cell carcinoma was found in 27.3% malignant cases. Eyelid squamous cell carcinoma is an invasive tumor arising from the squamous cell layer of the skin epithelium and affects mainly elderly fair-skinned individuals. The most common risk factor is exposure to ultraviolet light. Most commonly, it involves the lower lid margin and inner canthus. It may arise de novo but often it may arise from preexisting lesions such as actinic keratosis, xeroderma pigmentosum, carcinoma in situ (Bowen's disease), or following radiotherapy [19]. In the present study, other less common malignant tumors were non-Hodgkin’s lymphoma (2 cases) and small cell carcinoma (1 case). One case was histolologically diagnosed as actinic keratosis in the present study. Actinic keratosis (solar keratosis) is the most common precancerous cutaneous condition. It usually occurs in sun-exposed areas of the skin, including eyelids, and is a result of damage of the epidermal cells by near ultraviolet radiation. Actinic keratosis may transform to squamous cell carcinoma [20]. Among the benign lesions of eyelid, nevi were the most common in the present study. Out of 52 benign lesions, nevus was the most common (26.9%), followed by sudoriferous cyst (19.2%), haemangioma (15.4%), squamous papilloma (9.6%) and dermoid cyst (9.62%). Other less common lesions were epidermal inclusion cysts, sebaceous cysts, fibro epithelial polyp, adenoma, lipoma and neurofibroma. Similar pattern of benign growth of eyelids were reported by others [21,22]. Non-neoplastic lesions namely, molluscum contagiosum, rhinosporodiosis, chalazion/and lipogranuloma were found in the present study. Chalazion is a very common localized lipogranulomatous inflammatory lesion of the sebaceous gland of the eyelid, most often of the meibomian gland. It usually occurs spontaneously due to noninfectious obstruction of sebaceous gland ducts [19]. Molluscum contagiosum are common skin lesions, seen more in children, caused by the pox virus that often affects the eyelid and the periocular skin [23]. Rhinosporidiosis caused by Rhinosporodium seberii presents as a polypoidal and vascular mass. Conjunctiva, lacrimal sac, sclera and eyelids are the most common ocular sites [24]. Eyelid is composed of heterogeneous tissue. Hence, we tend to see a variety of tumor types and subtypes, both benign and malignant. The early diagnosis of these tumors is essential for proper treatment and favorable prognosis. The present study has showed the pattern of eyelid tumors in our population. The information is important to ophthalmologists for accurate diagnosis of eyelid growths and its proper management.   References 1.   Abdi U, Tyagi N, Maheshwari V, Gogi R, and Tyagi SP. Tumors of eyelid: a clinicopathologic study. J Indian Med Assoc. 1996; 94(11): 405-409. 2.   Myers M, Gurwood AS. Periocular malignancies and primary eye care. Optometry. 2001; 72(11): 705–712. 3. Pe’er J . Pathology of eyelid tumors. Indian J Ophthalmol. 2016; 64(3): 177–190. 4.   Klintworth GK, Cummings TJ. The eye and ocular adnexia. In: Mills SE, Carter D, Greenson JK, Reuter VE, Stoler MH, editors. Sternberg’s diagnostic surgical pathology, Vol. I. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2009, p965. 5.   Kersten RC, Ewing-Chow D, Kulwin DR, Gallon M. Accuracy of clinical diagnosis of cutaneous eyelid lesions. Ophthalmology. 1997; 104: 479–484. 6.   Baron K, Curling OM, Paridaens AD and Hungerford JL. The role of cytology in the diagnosis of peri-ocular basal cell carcinomas. Ophthal Plast Reconstr Surg. 1996; 12: 190-194. 7.   Vemuganti GK and Rai NN. Neoplastic lesions of eyelids, eyeball and orbit. J Cytol. 2007; 24: 30-36 8.   Gamble M, Wilson I. The hematoxylins and eosin. In: Bancroft JD, Gamble M, editors. Theory and practice of histological techniques. 5th ed. Edinburgh: Churchill Livingstone; 2002; p130.  10.Pornpanich K, Chindasub P. Eyelid tumors in Siriraj Hospital from 2000-2004. J Med Assoc Thai. 2005; 88 Suppl 9: S11-14. 11.  Mondal SK and Dutta TK. Cytohistological study of eyelid lesions and pitfalls in fine needle aspiration cytology. J Cytol. 2008; 25(4): 133-137. 12.  <![CDATA[A study on knowledge of patients with end stage renal disease towards dialysis in a tertiary care hospital in Dhaka city]]> Tufayel Ahmed Chowdhury Sarwar Iqbal Umme Salma Talukder Mehruba Alam Ananna A.S.M. Manzur Morshed Bhuiyan Mustarshid Billah Md. Abdur Rahim Tabassum Samad Rana Mokarrom Hossain https://imcjms.com/journal_full_text/164 2017-02-09 11:23:06 Original Article IMC J Med Sci 2017; 11(1): 11-14 Abstract Background and objective: There are approximately two million patients suffering from end stage renal disease (ESRD) worldwide requiring renal replacement therapy (RRT) in the form of dialysis. There are very few statistics regarding the knowledge and attitude towards dialysis among ESRD patients in Bangladesh. The present study was undertaken to understand the existing knowledge of the patients with ESRD regarding dialysis. Methods: This cross sectional descriptive study was done on 104 patients with ESRD requiring immediate dialysis. This study was conducted in the department of Nephrology, BIRDEM General Hospital, Dhaka, Bangladesh over a period of six months. After obtaining informed consent the participants were given a self-administered questionnaire that included questions on socio-demographic status, age, gender, different aspects of knowledge about dialysis and the reasons to accept and refuse dialysis for the treatment of ESRD. Results: A total of 104 patients with ESRD were enrolled in the study.  The mean age was 54.20(±11.82) years, 87.5% were more than 40 years of age, and 72.1% were male. Eighty two percent mentioned diabetes as the cause of kidney disease. About half of the respondents (52.88%) knew dialysis as an option for the treatment of ESRD followed by kidney transplant (11.54%). A few (7.3%) mentioned medicine and dietary modification as the treatment. There was no statistical association between prior knowledge and agreeing to do dialysis (χ2= 0.7814; p=0.376699). Most of the patients (78%) gathered knowledge about dialysis from doctors. Seventy two patients (69.2%) agreed to do dialysis. Among them 37 patients (51.4%) agreed as they considered it as a part of treatment and 32 patients (44.4%) agreed because they were advised by doctors. Reasons for refusal to do dialysis were - fear of death (59.37%), financial constraints (31.25%) and lack of availability of dialysis centre (9.37%) Among study populations, only 20 patients (19.2%) mentioned about peritoneal dialysis (PD) and all of them (100%) were informed by doctors. Conclusion: The present study has demonstrated that prior knowledge on dialysis has no influence on the decision to do dialysis for the treatment of ESRD. Availability and access to dialysis facility and counseling on beneficial aspects of dialysis is required to motivate the patients for dialysis with ESRD.  In addition to health care providers, social media may play an important role in promoting public awareness regarding dialysis as a treatment modality of ESRD. IMC J Med Sci 2017; 11(1): 11-14. DOI: https://doi.org/10.3329/imcjms.v11i1.31932   Address for Correspondence: Dr. Tufayel Ahmed Chowdhury, Registrar, Department of Nephrology, BIRDEM General Hospital, 122, Kazi Nazrul Islam Avenue, Shahbag, Dhaka. Email: dr_topu11@yahoo.com   Introduction There are approximately two million patients suffering from end stage renal disease (ESRD) worldwide.  The reported prevalence of ESRD is between 800 to 2000 per million population in countries of European Union, USA and Japan [1] while it is100 per million population in developing country like India. Reported low prevalence of ESRD in developing countries is probably due to lack of access of chronic kidney patients to healthcare facilities and under reporting. The estimated prevalence of chronic kidney disease in Bangladesh is about 16-18% and there would be about 30,000 new cases of ESRD per year [2]. Patients with ESRD require renal replacement therapy (RRT) either in the form of dialysis or kidney transplant. In Bangladesh, there are now approximately 84 dialysis centers in the whole country half of which are located in Dhaka city and remaining are in six large cities of the country [2]. Approximately, 800 patients are enrolled for hemodialysis in our BIRDEM hospital every year [3]. RRT in the form of dialysis improves the quality of life of patients with ESRD. But many with ESRD are not aware of the benefit of RRT or dialysis due to their lack of knowledge about it and suffer from debilitating morbidities. There are very few statistics regarding the knowledge about dialysis among ESRD patients. This study was therefore, undertaken to understand the existing knowledge of the ESRD patients regarding dialysis.   Methodology   Table 4 shows that out of 104 respondents, 72 (69.2%) agreed to do dialysis for the treatment and of which 55 (52.9%) had knowledge about dialysis and 49 (47.1%) had no prior knowledge regarding dialysis as a modality of treatment.  However, 73.5% of those who did not know dialysis as a mode of treatment of ESRD agreed to do dialysis compared to 65.5% of those who knew dialysis as a treatment. But, there was no statistical association between prior knowledge and agreeing to do dialysis (χ2= 0.7814; p=0.376699). Reasons for agreeing and refusing dialysis as a treatment modality of severe kidney disease by the study population are shown in Table-5. Out of 72 respondents who agreed to do dialysis for ESRD, 37 (51.4%) agreed because they considered dialysis as part of the treatment for kidney disease while 32 (44.4%) agreed because it was advised by the doctor. The reason for refusal to do dialysis was fear of death by 59.3% and financial constraint as 31.3% (Table-5).    Discussion The present study has demonstrated that majority of the respondents with ESRD were male and above 40 years of age. The male predisposition in our series could be due to importance of male population in the society and their access to health care services. Over 80% of the study population knew diabetes as a cause of ESRD while few mentioned hypertension and medicine as the possible causes. Most of the study partcipants were registered diabetic patients at BIRDEM hospital. BIRDEM hospital is a national referral center for diabetes and patients are regularly educated about the complications of diabetes namely kidney disease Therefore, this could be the reason for mentioning diabetes as a possible cause of kidney disease by the respondents and therefore might not reflect the knowledge of the general kidney patients in the country. Over half of the respondents (53.0%) stated dialysis as the treatment for ESRD and 11.54% thought of kidney transplant. More than 75% of the respondents obtained information about dialysis from the doctors.  It is important to note that only about 1.8% came to know about dialysis from media, Therefore, media and social networks need to provide more efforts in building awareness about such a life threatening disease.  It was interesting to note that prior knowledge about dialysis as a modality of treatment of ESRD did not have any significant influence on the decision to do dialysis or not (Table 4). Doctors’ advice was the main reason to decide in favor of doing dialysis. On the other hand, fear of death (59.3%) and financial constrains (31.3%) were the main reason to refuse dialysis. Therefore, proper counseling regarding its beneficial aspect like improved quality of life and availability of facility at low cost would help people to accept dialysis for the treatment of ESRD. It has been reported earlier that in 60% case, fear of death was the reason for non-compliance to do dialysis in ESRD [5]. Only about 19% of our respondents heard about PD. Patients with chronic kidney disease should be made aware and motivated for PD as it is less expensive and does not require costly machines and accessories [6-8]. Also, it is usually not associated with infection like hepatitis B and C as well as the quality of life of patients on PD is as good as that of HD [6-8]. The study findings indicate that there is a need for counseling of chronic kidney patients to create awareness about the role and values of dialysis as a treatment option of ESRD. Peritoneal dialysis should further be encouraged to make it familiar and popular amongst the kidney patients.   Author contributions The first two authors had equal contributions to this work. <![CDATA[Post-surgical outcomes of laparoscopic appendectomy observed at BIRDEM hospital]]> Tapash Kumar Maitra Mahmud Ekramullah Faruquzzaman Samiran Kumar Mondol https://imcjms.com/journal_full_text/165 2017-02-12 12:58:03 Original Article IMC J Med Sci 2017; 11(1): 15-18 Abstract Background and Objective: Currently, laparoscopic appendectomy (LA) is widely practiced for the management of acute appendicitis (AA). The application of laparoscopic technique for appendectomy is expanding very rapidly and now performed in almost all major cities and tertiary level hospitals. This study addressed to determine the outcomes of laparoscopic appendectomy in our surgical setup at Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorder (BIRDEM). Methodology: All admitted patients at BIRDEM hospital and clinically diagnosed as acute appendicitis considered eligible for the study. Based on clinical history relevant and routine biochemical investigations were done. A board of experienced surgeons selected the eligible cases for LA. The study continued from Sept 2014 to Sept 2016. Result: A total of 47 (M / F = 21 / 26) patients with acute appendicitis were admitted during this period. The mean (SD) age was 21 (±1.4) years in male and 19 (±1.7) years in female. The mean age of the total patients was 20 (±1.6) years. Eighty percent of the patients were of age 30 years or less. Per-operative laparoscopic findings revealed that five cases (10.6%) were misdiagnosed as appendicitis. Two (4.2%) cases were found to have other pathology and necessitated open appendectomy (OA). One was suspected for malignancy and other had appendicitis with adhesion. Overall, four important post-operative outcomes were observed: (a) post-operative pain was found reducing gradually and it fell below pain score 2 or even less after 30 hours; (b) port-site bleeding and infection were observed in 4.3% and 2.1%, respectively; (c) none had visceral bleeding or subcutaneous emphysema and (d) more than 80% were discharged within 72 hours. Conclusion: Most of the patients admitted with acute appendicitis were of younger age (<30 years). Though there was no comparative group undergoing open appendectomy (OA), it was apparent that laparoscopic approach was proved to have reduced pain, less complication and shorter hospital stay thus reducing the treatment cost. Thus, LA was found relatively safe and resilient procedure. An additional benefit of laparoscopy was that it revealed about 10% case were misdiagnosed as having appendicitis. Thus, this approach may be considered as a step forward in the treatment of appendicitis making easier to explore the abdominal cavity while keeping an option to perform an OA. IMC J Med Sci 2017; 11(1): 15-18. DOI: https://doi.org/10.3329/imcjms.v11i1.31933 Address for Correspondence: Dr. Tapash Kumar Maitra, Associate Professor & Head, Department of Surgery, BIRDEM General Hospital, 122 Kazi Nazrul Islam Avenue,  Shahbag, Dhaka, Bangladesh. Email: tapashkm1965@gmail.com   Introduction The laparoscopic surgery technique has rapidly spread because of its several advantages over conventional open surgery [1]. The diminishment of postoperative pain and the reduction of length of hospital stay as well as the earlier return to work generated a positive socioeconomic impact [2,3]. However, despite being minimal invasive this surgical method, postoperative complications and open conversion cannot be disregarded [4,5]. Open appendectomy (OA) has been the gold standard for the treatment of acute appendicitis since its introduction by Charles McBurney in 1894 [6]. Unfortunately, the diagnosis of acute appendicitis is often difficult, mainly clinical and always challenging. An accepted negative appendectomy rate for presumed appendicitis ranges from 15% to 20%, even higher in women of childbearing age (20% to 30%) [7,8]. Laparoscopic appendectomy (LA) has evolved since the first performed by a German Gynecologist Kurt Semm (1983) [9]. Laparoscopic appendectomy has gained acceptance as a diagnostic and treatment method for acute appendicitis with the technological advances of the past two to three decades. Since then, this procedure has been widely used. In spite of its wide acceptance, there remains a continuing controversy in the literature regarding the most appropriate way of removing the inflamed appendix because of a set of new operative complications relating to laparoscopic surgery [8,9]. Minimal access surgery has been proved to be a useful surgical technique. The application of the recent technology and skills can now provide a better and a cheaper choice of treatment. Despite a lot of randomized trials which have compared laparoscopic and open appendectomy, the indications for laparoscopy in patients with suspected appendicitis remains controversial and clinical trials comparing LA versus OA, a consensus concerning the relative advantages of each procedure has not yet been reached [10-11]. The present study was designed to assess the post-operative complications, pain, conversion rate and duration of hospital stay following LA in our surgical practice.   Materials and methods Study population and Methods: This study was carried out in Surgery Unit 1 of BIRDEM General Hospital, Dhaka, Bangladesh from 30.09.14 to 30.09.16. All patients admitted at BIRDEM hospital with the diagnosis of acute appendicitis (AA) were considered eligible and included in the study. But, those patients with congenital anomaly, morbid obesity and other systemic failure were excluded. The laparoscopic technique was performed after a Hasson trocar was placed through the umbilical scar with the open technique [3,5]. The camera was introduced into the abdomen through this trocar, two more trocars were positioned. The first one (5-mm) was placed in the midline just above the pubis and the second one (10 mm) in the left iliac fossa, in a point on the left-side perfectly symmetrical to the McBurney point. The appendicular artery was coagulated with a bipolar electrocautery. The procedure was completed by using two endoloops (ready-made or handmade) and the appendix extracted with an endobag. The patients were discharged after the passage of flatus. The socio-demographic data and the post-surgical information (duration of pain, hospital stay, per-operative findings) were noted and presented. The assessment of pain was done as suggested by Dansie EJ and Turk DC [13]. The qualitative data were presented in percentages and quantitative in mean with standard deviation (SD).   Results The age and sex distribution of the study population is presented in Table 1 which suggest that majority of the patients were female (55.3%). Mean age of male and female patients were 21±1.4 and 19±1.7 years respectively (Table 1). Of the total 47 clinically diagnosed cases of acute appendicitis, 5 (10.6%) were misdiagnosed as appendicitis and 2 (4.3%) patients underwent conversion to open surgery (OA), as required per-operatively, based on the laparoscopic findings. Those two were found to have other pathology that necessitated conversion to open appendectomy. One was suspected to be malignant though later proved otherwise and the other had extensive adhesion.   Table-1: Age and sex distribution of study population.     The result of postoperative assessment of pain is shown in Figure-1. It was found that the pain score of all cases was gradually reducing and fell below 2 or even less after 30 hours (pain scale: 0 to 10, where 0 reflects no pain and 10 indicate severe intractable pain) [13].     Fig.1: The assessment of post-laparoscopic pain with duration [13].     Fig.2: Average duration of hospital stay following laparoscopic appendectomy   Post-surgical complications were minimal. Port site bleeding was found only in 4.3% and port site infection was only 2.1%. There were no other complications like visceral bleeding, subcutaneous emphysema and injury. Post-surgical hospital stay was also very less. More than 80% patients were discharged from the hospital following laparoscopic appendectomy within 72 hours; whereas, only 4.3% patients required hospitalization after 72 hours for follow-up and management of bleeding (figure 2).   Discussion Recent studies compared clinical outcomes of laparoscopic appendectomy (LA) versus open appendectomy (OA) [3-5,7]. Most studies opined in favor of LA [1-3,4,5,7]. In this study, we found female preponderance and younger age. This finding is consistent with other studies [2,3,5]. As for other reported studies this study findings are consistent with the past experience in other population with regards to post-operative outcomes [8,10,11,13]. For example, the study patients had less duration of pain and hospital stay thus reducing treatment cost. Obviously, these are very much consistent with other studies as mentioned earlier. Again, the incidence of per- and post-operative bleeding were also negligible (<5%). The infection rate was also less (<3%). However, these findings could have been better judged or compared if we could have a comparative group undergoing open appendectomy. This was an important limitation of the study.   Conclusion Laparoscopic appendectomy (LA) was found relatively safe and resilient procedure. We had an additional benefit of LA. It revealed ten percent were misdiagnosed as having appendicitis. Though there was no comparative group, it was apparent that laparoscopic approach was proved to have reduced pain, less complication and shorter hospital stay thus reducing the treatment cost.   Acknowledgements We are very much grateful to the physicians working at outpatient department and Emergency department of BIRDEM for referring the patients to the department of Surgery. We are indebted to the nursing and other supporting staff for assisting in supervision and follow-up of the study patients.   References 1,   Costa-Navarro D, Jiménez-Fuertes M, Illàn-Riquelme A. Laparoscoic appendectomy: quality care and cost-effectiveness for today’s economy. World J Emerg Surg. 2013; 8(1): 1–5. 2.   Editorial. A sound approach to the diagnosis of acute appendicitis. Lancet. 1987; 1: 198-200. 3.   Horvath P, Lange J, Bachmann R, Struller F, Königsrainer A, Zdichavsky M. Comparison of clinical outcomes of laparoscopic versus open appendectomy for complicated appendicitis.Surg Endosc. 2016; doi: 10.1007/s00464-016-4957-z. 4.   Kehagias I, Karamanaks SN, Panagiotopoulos S, Panagopoulos K, Kalfarentzos F. Laparoscopic versus open appendectomy: which way to go? World J. Gastroenterol. 2008; 14: 4909–14. 5.   Wullstein C, Barkhausen S, Gross E. Results of laparoscopic versus conventional appendectomy in complicated appendicitis. Dis Colon Rectum.2001; 44:1700–5. 6.   McBurney C. The incision made in the abdominal wall in cases of appendicitis, with a description of a new method of operating. Ann Surg. 1894; 20: 38. 7.   Van LV, Jose MV. Laparoscopic Versus Conventional Appendectomy. Ann Surg. 1993; 218(5): 685-692. 8.   Nana AM, Ouandji CN, Simoens C, Smets D, Mendes da Costa P. Laparoscopic appendectomies: results of a monocentric prospective and non-randomized study. Hepatogastroenterology. 2007; 54(76): 1146-1152. 9.   Semm K. Endoscopic appendectomy. Endoscopy. 1983; 15:59-64. 10.  Long KH, Bannon MP, Zietlow SP, Helgeson ER, Harmsen WS, Smith CD, et al. A prospective randomized comparison of laparoscopic appendectomy with open appendectomy: clinical and economic analyses. Surgery. 2001; 129(4): 390-400. 11.  Martin LC, Puente I, Sosa JL, Bassin A, Breslaw R, McKenney MG, Ginzburg E, Sleeman D. Open versus laparoscopic appendectomy. A prospective randomized. Ann Surg. 1995; 222(3): 256-262. 12.  Guller LU, Hervey S, Purves H, Lawrence H. Laparoscopic versus open appendectomy: outcomes comparison based on a large administrative database. Ann Surg. 2004; 239(1): 43-52. 13.  Dansie EJ, Turk DC. Assessment of patients with chronic pain. Br J Anaesth. 2013; 111: 19–25. <![CDATA[Prevalence of chronic kidney disease stages 3-5 among patients with type 2 diabetes mellitus in Bangladesh]]> Muhammad Abdur Rahim Palash Mitra Hasna Fahmima Haque Tasrina Shamnaz Samdani Shahana Zaman Khwaja Nazim Uddin https://imcjms.com/journal_full_text/168 2017-02-26 13:33:09 Original Article IMC J Med Sci 2017; 11(1): 19-24 Abstract Background and objectives: Diabetes mellitus is one of the most common causes of chronic kidney disease (CKD). The prevalence of CKD in type 2 diabetes mellitus (T2DM) in Bangladesh is not well described. The present study aimed to find out the prevalence of CKD stages 3-5 and its risk factors among selected Bangladeshi T2DM patients. Methods: This cross-sectional study was conducted in BIRDEM (Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders) General Hospital, Dhaka, Bangladesh from July to December 2015. Diagnosed adult T2DM patients were consecutively and purposively included in this study. Pregnant women, patients with diagnosed kidney disease due to non-diabetic etiology, acute kidney injury (AKI), AKI on CKD and patients on renal replacement therapy were excluded. Age, gender, body mass index (BMI) and laboratory parameters were recorded systematically in a predesigned data sheet. Diagnosis of CKD and its stages were determined according to Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guidelines 2012 and estimated glomerular filtration rate (eGFR). Estimated GFR was calculated by using Modification of Diet in Renal Disease (MDRD), Cockcroft-Gault (CG) and Chronic Kidney Disease Epidemiology (CKD-EPI) creatinine based formula. Results: A total of 400 patients with T2DM of various durations were enrolled in the study. Out of 400 patients, 254 (63.5%), 259 (64.75%) and 218 (54.5%) cases had CKD stages 3-5 according to MDRD, C-G and CKD-EPI equations respectively. CKD was significantly more common in females (p<0.001) and in cases with long duration of diabetes (≥5 years; p=0.007). CKD stages 3-5 were significantly associated with hypertension (χ2=5.2125, p =0.02) and good control of diabetes (HbA1c <7%) as evidenced by higher proportion of CKD in them (73.3%) compared to those with poor glycemic control (52.1%). Conclusions: More than half of T2DM patients had CKD stages 3-5. Female gender, duration of diabetes and hypertension were significant risk factors and should be emphasized for the prevention of CKD in T2DM. Glycemic control may not reduce CKD in diabetes. IMC J Med Sci 2017; 11(1): 19-24. DOI: https://doi.org/10.3329/imcjms.v11i1.31934 Address for Correspondence: Dr. Muhammad Abdur Rahim, Assistant Professor, Department of Nephrology, Ibrahim Medical College & BIRDEM General Hospital. 122 Kazi Nazrul Islam Avenue, Dhaka, Bangladesh. Email: muradrahim23@yahoo.com   Introduction Diabetes mellitus (DM) is a global public health problem. The prevalence of DM, particularly type 2 DM (T2DM), is increasing more in low and middle-income countries [1]. DM is now one of the leading causes of chronic kidney disease (CKD) and end-stage renal disease (ESRD) both in developed and developing countries [2-7]. Approximately, 40% of all diabetic patients develop nephropathy and one-third to half of the patients requiring renal replacement therapy for their ESRD is primarily due to DM [8-11]. Increased longevity, long duration of DM, poor glycemic control, hypertension, dyslipidemia and other diabetic complications are established risk factors for nephropathy and CKD in diabetic patients [12]. The prevalence of nephropathy and CKD in patients with T2DM is 10.8% to 46% in different studies, largely depending on screening methods used. However, only limited information is available on prevalence of CKD among Bangladeshi population with T2DM [13]. Therefore, the present study was designed to evaluate the prevalence and potential risk factors of CKD stages 3-5 among Bangladeshi patients withT2DM.   Methods This cross-sectional study was conducted at the out-patient department (OPD) of Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) General Hospital, Dhaka, Bangladesh from July to December 2015. Diagnosed adult T2DM cases of either sex, irrespective of duration of diabetes were consecutively and purposively included in this study. Pregnant ladies with T2DM, patients with diagnosed kidney disease due to non-diabetic etiology, acute kidney injury (AKI), AKI on CKD and patients with a diagnosis of end stage renal disease (ESRD) on maintenance hemodialysis or continuous ambulatory peritoneal dialysis and renal transplant recipients were excluded from the study. Age, gender, BMI and laboratory parameters were recorded systematically in a predesigned data sheet. Enrolled patients were evaluated clinically for microvascular (retinopathy, nephropathy and neuropathy) and macrovascular (coronary artery disease, cerebrovascular disease including stroke and transient ischemic attack and peripheral vascular disease) complications. Diagnosis of CKD and its stages were determined according to the KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease [14] using estimated glomerular filtration rate (eGFR). Estimated GFR was calculated by    4-variable Modification of Diet in Renal Disease (MDRD), Cockcroft-Gault (C-G) and the Chronic Kidney Disease Epidemiology (CKD-EPI) creatinine based equations [14-17]. Stage 3 CKD was further sub typed as stage 3a (eGFR 45-59 ml/min/1.73m2) and 3b (eGFR 30-44 ml/min/1.73m2) based on eGFR values. Cases diagnosed as CKD stages 3-5 (eGFR 45 to < 15 ml/min/1.73m2) by CKD-EPI formula was only considered for determining the association between different variables. The qualitative data were presented in percentages and quantitative in mean with standard deviation (SD). χ2 -test was used to determine the association between variables.   Results A total of 400 T2DM patients were enrolled of which 169 and 231 were males and females respectively. The mean age of the study population was 54.9±10.5 years and the mean duration of diabetes from detection was 11.6±7.6 years. The mean HbA1c was 9.1±2.0% indicating poor glycemic control (Table-1). Diabetes related chronic complications of the study population are presented in Table-2.   Table-1: Baseline characteristics of the study population (n=400)     Table-2: Microvascular and macrovascular complications among the study population (n=400)     Out of 400 enrolled cases, 29.8%, 37.8% and 54.5% had neuropathy, retinopathy and CKD respectively. Macrovascular complications were present in 11.0% to 25.8% cases. Out of 400 cases, 254 (63.5%), 259 (64.75%) and 218 (54.5%) cases had CKD stages 3-5 according to MDRD, C-G and CKD-EPI methods respectively. Detail results of CKD stages 3-5 by MDRD, C-G and CKD-EPI methods are shown in Table-3.   Table-3: Frequency of different stages of CKD according to different equations among the study population (n=400)     Cases of CKD stages 3-5 diagnosed by CKD-EPI formula was considered to find out the association of CKD stages 3-5 with different variables namely gender, family history of diabetes, duration of diabetes, hypertension, BMI, dyslipidemia and HbA1c status. In our study, CKD stages 3-5 was associated in significantly (χ2=18.4, p≤0.001)higher proportion in females compared to males (63.6% vs. 42%) andin patients with diabetes of more than 5 years duration (59.6%) compared to those of less than 5 years (30.0%; χ2 =19.25, p≤.001). CKD stages 3-5 were present in 57.2% cases having pre-existing or concomitant hypertension while it was 42.7% among those who had no hypertension.  It was interesting to note that CKD stages 3-5 were present in higher number of cases (73.3%) having good glycemic control (HbA1c <7%) compared to those who had poor glycemic control (HbA1c ≥7%). On the other hand, there was no significant association of CKD with family history of diabetes,dyslipidemia and BMI (Table-4).   Table-4: Presence of CKD stages 3-5 in relation to different risk factors     Discussion DM is one of the most common causes of CKD. Most patients with CKD remain asymptomatic in early stages. Therefore, in the current study we have tried to evaluate clinically significant CKD stages 3-5 among T2DM patients. CKD implies considerable morbidity, mortality and health-care related costs [18]. Diagnosis of CKD in diabetic patients warrants significant changes in management of patients, both for DM and other cardiovascular risk factors. Many CKD patients die of cardiovascular events before reaching ESRD [19]. Worth mentioning that, early stages of diabetic nephropathy also increase cardiovascular risks by many folds [20]. The results of the present study showed that over half of the patients (54.5% to 64.8%) with T2DM had CKD stages 3-5 irrespective of methods/formulas used for estimation of eGFR. Depending on different equations used, the overall rates of CKD stages 3-5 were almost similar by three different methods. Studies from UK, USA, Spain and Australia have reported the prevalence of CKD in T2DM patients as 27.5% (stage 3-5), 43.5%, 27.9% and 47.1% respectively [21,2,22,23]. The rate is almost similar (23.8 to 46.0%) in developing countries [7,12,24,25]. The wide variation of prevalence of CKD among the T2DM cases in different studies may reflect quality of diabetes care, screening methods used and stages of CKD included in these studies. In the present study, we have used the number of patients diagnosed as having CKD stages 3-5 by CKD-EPI method for assessing its relation with different factors. We have found that CKD was significantly more common in females, inpatients with hypertension and in those with long duration of diabetes. These are well recognized risk factors for CKD in diabetes and have been reported in several studies done in developed as well as developing countries of the world [7,12,23,25]. It was interesting to note that CKD was present in significantly higher proportion in those who had adequate glycemic control (HbA1c <7%). But this finding is not unusual. Recent investigations contradict the previous thought that the strict glycemic control prevents microvascular diabetic complications [26]. Some observed that microvascular complications could not be altered by near-normalization of glucose [27]. Previous study in Bangladesh observed significantly higher microvascular complications in cases with strict glycemic control compared to those with inadequate glycemic control [28]. It may be possible that strict glycemic control may have injurious effects on kidney due to sustained low blood sugar level. Current study had some potential limitations. It was a single center study, done in a tertiary care hospital with relatively small number of patients with T2DM. It might not be generalized for Bangladeshi T2DM subjects. Moreover, we did not estimate urine for albumin to creatinine ratio (UACR) or 24-h urinary total protein, by which a good number of patients with early diabetic nephropathy/CKD could be identified. We only relied on eGFR. Further study including multiple centers, large number of study participants and evaluation of all stages of diabetic nephropathy/CKD would provide a more representative picture in this regard from Bangladesh. In conclusion, it can be said that, CKD stages 3-5 were present in more than 50% of patients with T2DM in this study and the prevalence was significantly higher in patients with hypertension and long duration of diabetes. Strict glycemic control may not prevent or reduce CKD in diabetes. Optimum control of hypertension may prevent the development of CKD and its progress in patients with T2DM. Physicians, especially those, who serve the diabetic patients at all levels starting from the primary care setting, should be aware of the possible risk factors of complications and should educate the patients about those potential factors.   Acknowledgement We express our acknowledgement to all our colleagues who helped us to collect data from the study participants. Conflict of interest: None declared.   References 1.   Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004; 27: 1047-53. 2.   Bailey RA, Wang Y, Zhu V, Rupnow MFT. Chronic kidney disease in US adults with type 2 diabetes: an updated national estimate of prevalence based on Kidney Disease: Improving Global Outcomes (KDIGO) staging. BMC Res Notes. 2014; 7: 415. 3.   The UK Renal Registry. The Sixth Annual Report 2003. 4.   ANZ Data Registry. The twenty-sixth report. Adelaide: Australia and New Zealand Dialysis and Transplant registry. 2003. 5.   Singh AK, Farag YMK, Mittal BV, Subramanian KK, Reddy SRK, Acharya VN et al. Epidemiology and risk factors of chronic kidney disease in India – results from the SEEK (Screening and Early Evaluation of Kidney Disease) study. BMC Nephrology. 2013; 14: 114. 6.   Ahmed ST, Rahim MA, Ali MZ, Iqbal MM. Prevalence of primary renal diseases among patients on maintenance haemodialysis: a hospital based study. KYAMC Journal. 2012; 2(2): 182-86. 7.   Fiseha T, Kassim M, Yemane T. Prevalence of chronic kidney disease and associated risk factors among diabetic patients in southern Ethiopia. Am J Health Res. 2014; 2(4): 216-21. 8.   Remuzzi G, Schieppati A, Ruggenenti P. Clinical practice. Nephropathy in patients with type 2 diabetes. N Engl J Med. 2002; 346: 1145-51. 9.   Ritz E, Rychlik I, Locatelli F, Halimi S. End-stage renal failure in type 2 diabetes: a medical catastrophe of worldwide dimensions. Am J Kidney Dis. 1999; 34: 795-808. 10.  USRDS: The United States Renal Data System. Experts from the USRDS 2009 annual data report: atlas of end-stage renal disease in the United States. Am J Kidney Dis. 2010; 55(suppl. 1): S1. 11.  Atkins RC. The epidemiology of chronic kidney disease. Kidney Int 2005; 67: 14-18. 12.  Al-Rubeaan K, Youssef AM, Subhani SN, Ahmad NA, Al-Sharqawi AH, Al-Mutlaq HM et al. Diabetic nephropathy and its risk factors in a society with a type 2 diabetes epidemic: a Saudi National Diabetes Registry-based study. PLoS ONE. 2014; 9(2): e88956. doi:10.1371/ journal. pone.0088956 13.  Latif ZA, Jain A, Rahman MM. Evaluation of management, control, complications and psycho-social aspects of diabetics in Bangladesh: DiabCare Bangladesh 2008. Bangladesh Med Res Counc Bull. 2011; 37(1): 11-16. 14.  Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. (Suppl.) 2013; 3: 1–150. 15.  Levey AS, Greene T, Kusek JW, Beck GL, MDRD Study Group. A simplified equation to predict glomerular filtration rate from serum creatinine (abstract). J Am Soc Nephrol. 2000; 11: 155A. 16.  Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron.1976; 16(1):31-41. 17.  Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro III AF, Feldman HI, et al. CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009; 150(9): 604-12. 18.  Afkarian M, Sachs MC, Kestenbaun B, Hirsch IB, Tuttle KR, Himmelfarb J et al. Kidney disease and increased mortality risk in type 2 diabetes. J Am Soc Nephrol. 2013; 24: 302-308. 19.  Collins AJ1, Li S, Gilbertson DT, Liu J, Chen SC, Herzog CA. Chronic kidney disease and cardiovascular disease in the Medicare population. Kidney Int Suppl. 2003; 87:S24-31. 20.  Daly C. Is early chronic kidney disease an important risk factor for cardiovascular disease? A background paper prepared for the UK Consensus Conference on early chronic kidney disease. Nephrol Dial Transplant. 2007; 22 (Suppl. 9): 19–25. 21.  Middelton RJ, Foley RN, Hegarty J, Cheung CM, McElduff P, Ginson JM et al. The unrecognized prevalence of chronic kidney disease in diabetes. Nephrol Dial Transplant. 2006; 21: 88-92. 22.  Prevalence of chronic kidney disease in patients with type 2 diabetes in Spain: PERCEDIME2 study. BMC Nephrology. 2013; 14: 46. 23.  Thomas MC, Weekes AJ, Broadley OJ, Cooper ME, Mathew TH. The burden of chronic kidney disease in Australian patients with type 2 diabetes (the NEPHRON study). Med J Aust. 2006; 185(3): 140-44. 24.  Prasannakumar M, Rajput R, Seshadri K, Talwalkar P, Agarwal P, Gokulnath G et al. An observational, cross-sectional study to assess the prevalence of chronic kidney disease in type 2 diabetes patients in India (START-India). Indian J Endocr Metab. 2015; 19:   520-23. 25.  Low SKM, Sum CF, Yeoh LY, Tavintharan S, Ng XW, Lee SBM et al. Prevalence of chronic kidney disease in adults with type 2 diabetes mellitus. Ann Acad Med Singapore. 2015; 44: 164-71. <![CDATA[Serum magnesium and copper levels in Bangladeshi women with gestational diabetes mellitus]]> Farzana Akonjee Mishu MA Muttalib https://imcjms.com/journal_full_text/169 2017-02-26 13:52:03 Original Article IMC J Med Sci 2017; 11(1): 25-28 Abstract Background and objectives: Alteration of magnesium (Mg) and copper (Cu) concentrations in blood has been observed in normal pregnancy as well as in gestational diabetes mellitus (GDM). The present study was aimed to evaluate the serum Mg and Cu levels in Bangladeshi women with GDM in their second and third trimester of pregnancy. Methods: The study was conducted at Mymensingh Medical College Hospital from July 2013 to June 2014. Pregnant women, in their second and third trimester, attending the outpatient department of Obstetrics and Gynecology and the Department of Endocrinology of Mymensingh Medical College Hospital were enrolled by purposive sampling technique. GDM was diagnosed on the basis of oral glucose tolerance test (OGTT) as defined in WHO criteria 2013. Blood glucose was estimated by enzymatic GOD-PAP colorimetric method. The cut off value for fasting plasma glucose level was ≥6.1 mmol/L or ≥7.8 mmol/L 2 hours after glucose load. Serum Cu was estimated by 3, 5-DiBr-PAESA method and Mg by Xylidyl Blue-I Method as per manufacturer’s instruction. Results: A total of 172 pregnant women in their second and third trimester were enrolled. Out of 172 participants, 86 had GDM and 86 were normoglycemic (control). The mean age of GDM and control groups was 28.6±3.2 years and 27.3±3.1 years respectively. The BMI was 26.4±1.5 m/kg2 and 26.3±1.3 m/kg2. Serum Mg level was significantly low (p< 0.001) in 2nd and 3rd trimesters in GDM cases (1.39±0.26 mg/dl and 0.93±0.15 mg/dl) compared to control group (1.67±0.3 mg/dl and 1.67±0.31mg/dl). On the contrary, serum Cu levels in GDM cases were significantly (p<0.002) higher in both trimesters (224±333.8 µg/dl and 243.91±6.89 µg/dl) compared to those without GDM (220.1±7.6 µg/dl and 234.9±4.6 µg/dl). There was significant (p<0.001) increase of serum Cu levels in 3rd trimester compared to 2nd trimester in both GDM and non GDM cases. Conclusion: There was distinct alteration of serum Mg and Cu levels in GDM compared to normal pregnancy. IMC J Med Sci 2017; 11(1): 25-28. DOI: https://doi.org/10.3329/imcjms.v11i1.31935 Address for Correspondence: Dr. Farzana Akonjee Mishu, Assistant Professor, Department of Physiology and Molecular Biology, BIRDEM General Hospital, 122 Kazi Nazrul Islam Avenue, Dhaka, Bangladesh.  Email: farzanamishu@yahoo.co.uk   Introduction Gestational diabetes mellitus is defined as carbohydrate intolerance resulting in hyperglycemia, with first onset or detection during pregnancy [1,2]. Usually initiation of GDM is in middle and late gestational period and continues to term [3]. Glucose intolerance usually returns to normal range within six weeks after delivery [4]. Approximately 1-14 % of all pregnancies are complicated by GDM [4]. The prevalence of GDM among Bangladeshi pregnant mothers has been reported as 9.7% [5]. Pregnancy is associated with physiological changes that result in increased plasma volume and decreased concentrations of plasma proteins and micronutrients [6]. It is a time of increased nutritional needs, both to support the rapidly growing fetus and the changes occurring in mother during pregnancy. Different researchers have demonstrated that macro and micro nutrients are essential for the optimum development of fetus. Among the micronutrients, Cu is important, especially early in the life for the development and maintenance of fetal organs and tissues. Deficiencies of Cu have been implicated in infertility, pregnancy wastage, congenital abnormalities, still birth and low birth weight [7,8]. Serum Cu values in healthy pregnant women increases with gestational period [9]. Serum Cu has been found to be significantly higher in GDM cases as compared to euglycemic healthy pregnant women [10]. Earlier studies reported higher level of serum Cu in full term healthy Bangladeshi pregnant women compared to non pregnant women [11,12]. Likewise, Mg has been found to be linked to fetal and maternal wellbeing. Mg deficiency during pregnancy is associated with intrauterine growth retardation and metabolic syndrome in later life of the offspring [13,14]. There is report of low and variable serum Mg level during second and third trimester of normal pregnancy [15]. It has been found that serum Mg is depleted at a greater extent in women with GDM [16]. However, there is no systematic study regarding the serum levels of Cu and Mg in Bangladeshi pregnant women with GDM. Therefore, the present study was undertaken to determine the serum Cu and Mg levels in second and third trimester of pregnancy in Bangladeshi women with GDM.   Materials and Methods The study was conducted at Mymensingh Medical College Hospital from July 2013 to June 2014 to evaluate the serum level of magnesium and copper in pregnant women with GDM. The study protocol was approved by the institutional review committee and written informed consent was obtained from all the participants prior to their enrolment into this study. Study population and collection of samples: Pregnant women, in their second and third trimester, attending the outpatient department of Obstetrics and Gynecology and the Department of Endocrinology of Mymensingh Medical College Hospital were enrolled by purposive sampling technique. Pregnant women with the previous history of diabetes, hypertension and other endocrine disorders were excluded from the study. Data were collected in a predesigned data collection sheet. The variables included were - age, height, weight, duration of gestation, family history of diabetes, previous history of pregnancy and gestational diabetes mellitus. About 5 ml of blood was collected aseptically with venipuncture from all participants for OGTT and estimation of serum Cu and Mg levels. Estimation serum glucose, Cu and Mg: Blood glucose was estimated by enzymatic GOD-PAP colorimetric method [17]. GDM was diagnosed on the basis of OGTT as defined in WHO criteria 2013 [1,18]. The cut off value for fasting plasma glucose level was ≥6.1 mmol/L or ≥7.8 mmol/L 2 hours after glucose load. Serum Cu and Mg were determined by commercial colorimetric assay kits obtained from Japan Institute for the Control of Aging (JaICA), Nikken Seal Co., Ltd, Japan. Serum Cu was estimated by 3, 5-DiBr-PAESA method and Mg by Xylidyl Blue-I Method as per manufacturer’s instruction. The results were analyzed and values were expressed as mean ±SD. The level of significance was determined by employing Student’s t test.   Result A total of 172 pregnant women in their second and third trimester were enrolled in the study of which 86 had GDM and 86 were normoglycemic by OGTT test. Pregnant women without GDM (normoglycemic) were considered as control group. The mean age of GDM and control groups were 28.6±3.2 years and 27.3±3.1 years while the mean BMI was 26.4±1.5 m/kg2 and 26.3±1.3 m/kg2 respectively (Table-1). Serum Mg level was significantly low (p<0.001) in 2nd and 3rd trimesters in GDM cases (1.4±0.3 mg/dl and 0.9±0.2 mg/dl) compared to control group (1.7±0.3 mg/dl and 1.7±0.3 mg/dl). The serum Mg level declined in 3rd trimester compared to 2nd trimester in GDM cases while there was no such change in cases without GDM. On the contrary, serum Cu levels in GDM cases were significantly (p<0.002) higher in both trimesters (224±3.8 µg/dl and 243.9±6.9 µg/dl) compared to those without GDM (220.1±7.6 µg/dl and 234.9±4.6 µg/dl). There was significant (p<0.01) rise of serum Cu levels in 3rd trimester compared to 2nd trimester in both GDM and non GDM cases (Table-2).   Table-1: Age and BMI of study population   Table-2: Serum concentration of Mg and Cu in GDM and euglycemic pregnant women     Discussion In this study, we have estimated serum Mg and Cu levels in pregnant women with GDM and in healthy pregnant women (euglycemic control). Serum Mg concentration in women with GDM was significantly low compared to that of control.The decrease in serum Mg might be caused by osmotic diuresis and by indirect hormonal effects. The low serum Mg levels seen in the diabetic population could be a consequence of insulin resistance and low dietary Mg intake and decreased intestinal absorption [16]. In the present study, the serum concentration of Cu in women with GDM were significantly higher (p<0.001) compared to the controls.The possible causes of high serum Cu concentration in GDM cases could be due to the hormonal, metabolic and enzymatic changes in pregnancy. Increased Cu level in GDM cases could be due to decreased insulin sensitivity in GDM [10]. Though studies have found increased level of copper in GDM, others have found no statistically significant difference of serum Cu concentrations between healthy pregnant women and women with GDM [19]. However, pregnant women with GDM should be carefully monitored for adverse effects of increased copper. The present study has revealed that there is pronounced alteration of serum Mg and Cu levels in GDM cases compared to normal pregnancy. Therefore, further study should be done to find out the underlying mechanism of alteration of serum Mg and Cu levels in DGM.   References 1.   Diagnostic criteria and classification of hyperglycaemia first detected in pregnancy: a World Health Organization Guideline. Diabetes Res Clin Pract. 2014; 103: 341–3632. 2.   Buckley BS, Harreiter J, Damm P, Corcoy R, Chico A, Simmons D, Vellinga A, et al. Gestational diabetes mellitus in Europe: prevalence, current screening practice and barriers to screening. A review. Diabet Med. 2012: 29(7): 844-54. doi: 10.1111/j.1464-5491. 2011.03541.x. 3.   Gokcel A, Bagis T, Killicadag EB, Tarim E, Guvener N. Comparison of the criteria for gestational diabetes mellitus by NDDG and Carpenter and Coustan, and the outcomes of pregnancy. J Endocrinol Invest. 2002; 25: 357-61. 4.   Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes. Diabetes Care. 2002; 25: 1862–8. 5.   Jesmin S, Akhter S, Akashi H, Al-Mamun A, Rahman MA, Islam MM, et al. Screening for gestational diabetes mellitus and its prevalence in Bangladesh. Diabetes Res Clin Pract. 2014; 103(1): 57-62. 6.   Ladipo OA. Nutrition in pregnancy: mineral and vitamin supplements. Am J clin Nutr. 2000; 72: 280-290. 7.   Ashworth CJ, Antipatis C. Micronutrient programming of development throughout gestation. Reproduction 2001; 122(4): 527-535. 8.   Keen CL, Uriu-Hare JY, Hawk SN, Jankowski MA, Daston GP, Kwik-Uribe CL. Effect of copper deficiency on prenatal development and pregnancy outcome. Am J Clin Nutr.1998; 67(suppl):1003S–1011S. 9.   Vukelić J, Kapamadžija A, Petrović D, Grujić Z, Novakov-Mikić A, Kopitović V, Bjelica A. Variations of Serum Copper Values in Pregnancy. Srp Arh Celok Lek. 2012; 140(1-2): 42-46. 10.  Asha D, Nanda N, Daniel M, Sen SK, Ranjan T.Association of serum copper level with fasting serum glucose in south Indian women with gestational diabetes mellitus. Int J Clin Exp Physiol. 2014; 1(4): 298-302. 11.  Sultana M, Jahan N, Sultana N, Ali ML, Sunyal DK, Al Masud MA. Serum Copper level in Term women. J Dhaka National Med Coll Hosp. 2011; 17(02): 18-20. 12.  Noor N, Jahan N, Sultana N. Serum Copper and Plasma Protein Status in Normal Pregnancy. J Bangladesh Soc Physiol. 2012; 7(2): 66-71. 13.  Goker TU, Tasdemir N, Kilic S, Abali R, Celik C, Gulerman HC. Alterations of Ionized and total Magnesium levels in Pregnant Women with Gestational Diabetes Mellitus. Gynecol Obstet Invest. 2015; 79: 19-24. 14.  Takaya J,Yamato F and Kaneko K. Possible relationship between low birth weight and magnesium status: from the standpoint of “foetal origin” hypothesis. Magnesium Res 2006; 19: 630-639. 15.  Baloch GH, Shaikh K, Jaffery MH, Abbas T, Das CM, Devrajan BR, et al. Serum magnesium level during pregnancy. World Appl Sci J. 2012; 17(8): 1005-1008. 16.  Bardicef M, Bardicef O, Sorokin Y, Altura BM, Altura BT, Cotton DB and Resnick LM. Extracellular and intracellular magnesium depletion in pregnancy and gestational diabetes. Am J Obstet and Gynecol. 1995; 172(3):1009-1013. 17.  Trinder P. Determination of glucose in blood using glucose oxidase with an alternative oxygen acceptor. Ann.Clin. Biochem 1969; 6: 24-7 18.  WHO Consultation: definition, diagnosis and classification of diabetes mellitus and its complications: report of a WHO Consultation. Part 1: diagnosis and classification of diabetes mellitus. Geneva, WHO/NCD/NCS/99. 2: World Health Organization; 1999. 19.  Loven A, Romem Y, Pelly IZ, Holeberg G, Agam G. Copper metabolism--a factor in gestational diabetes? Clin chim Acta. 1992; 213(1-3):51-59. <![CDATA[Facial nerve paralysis due to intra aural tick infestation: a case report]]> Nurul Atikah Binti Hamat Zulkiflee Salahuddin Rosdan Salim https://imcjms.com/journal_full_text/172 2017-03-16 12:14:37 Clinical Case Report IMC J Med Sci 2017; 11(1): 29-31 Abstract Tick infestation in the ear canal may have variable clinical presentations. We present here a case of facial nerve paralysis in a 73 years old lady due to intra aural tick infestation. The patient presented with left otalgia, vertigo and left sided facial asymmetry. The case could be confused with cerebrovascular accident or transient ischemic attack. IMC J Med Sci 2017; 11(1): 29-31. DOI: https://doi.org/10.3329/imcjms.v11i1.31936 Dr. Nurul Atikah Binti Hamat, Medical Officer, Department of Otorhinolaryngology-Head and Neck, Universiti Sains Malaysia, Health Campus, 16150 Kota Bharu, Kelantan, Malaysia. Email: asadun7@gmail.com   Introduction Foreign body, either animate or inanimate, in the ear is a common clinical condition encountered in otorhinolaryngology (ORL) practice. Among the live foreign bodies, ticks are easily transmitted from domestic animals to human mainly through direct contact [1]. Intra aural ticks can cause otitis externa, tympanic membrane perforation and otitis media. A neglected tick bites can cause complications such as allergic reactions, infections and rarely may lead to facial paralysis [2]. Most common presentations include otalgia which is followed by bleeding, vertigo and tinnitus. However, cases of isolated facial nerve paralysis due to tick infestation in auditory canal are rare and are less commonly reported in the literature [1-7]. We present here a case of left facial nerve paralysis following tick infestation in ear canal in a 73 years old lady.   Case report In July 2016, a 73 years old lady, with no known medical illness before, was admitted in medical ward with suspicion of transient ischemic attack (TIA). She experienced spinning sensation after waking up from sleep. The spinning sensation had a sudden onset that lasted for the whole day. It was aggravated by opening of the eyes. The symptoms were associated with nausea, vomiting and mild headache. On the same day, she developed left sided facial asymmetry and facial weakness (Figure 1). She was unable to close the left eye fully, with persistent drooling of saliva from the weakened left angle of the mouth. The hearing was reduced on left side. She gave history of left ear pain for one week prior to current presentation. However, there was no tinnitus, no ear bleeding or ear discharge. The speech was slurred but there was no blurring of vision. There was no weakness of the limbs. At emergency department, a computed tomography (CT) of brain suggested features that could represent foramen of Monroe haemorrhage, calcified lesion or vessel. Initially, she was managed by medical team. Subsequently, she was referred to otolaryngology (ORL) team as the case was not clinically suggestive of TIA. Upon examination, there was a left lower motor neuron facial nerve palsy grade IV House and Brackmann’s Classification [8]. Patient also had horizontal nystagmus to the right. Cerebellar signs were normal. Upon otoscopic examination, a tick was found over posterior ear canal. It was already disengaged from the wall of the ear canal and we could easily remove it with suction. However, the species of the tick could not be determined. There was healed tympanic membrane on left side and on right side a small central perforation of tympanic membrane was noticed. Rinne’s test on right side was negative and left side was positive while Weber test was lateralized to right. Otoacoustic emission test was performed and refer bilaterally. Pure tone audiometry results showed right mild to severe mixed hearing loss and left side moderate to profound sensorineural hearing loss, while the tympanometry results were type B on right side and type A on left side.   Fig.1: Left facial nerve paralysis grade IV House and Brackmann’s Classification [8].   She was prescribed betahistine 24mg, prednisolone 40mg, methylcobalamine 500mcg and intravenous augmentin. Levofloxacine eardrop and artificial eyedrop were also administered. Her symptoms improved and she was discharge with the above medications. Repeated pure tone audiometry one week later showed improvement of her hearing on left ear to moderate sensorineural hearing loss and also reversal of her symptoms. The facial nerve palsy resolved completely 2 weeks later on follow up. Based on the above, it was concluded that facial nerve palsy was due to the tick infestation. Informed consent was obtained from the patient for the publication of the case.   Discussion Tick infestations in the ear canal have been reported from all over the world particularly from tropical countries such as in India, Malaysia, Sri Lanka and Turkey [1-7]. It is a common occurrence seen in the east coast of Peninsular Malaysia and usually encountered in the dry months but also can occur anytime of the year [5]. There are two main families of ticks that are of medical importance to human, namely Ixodidae (hard tick) and Argasidae (soft tick) [9]. Both hard tick and soft tick secrete saliva together with enzymes and anticoagulants from their salivary gland into the skin. Otalgia is likely to be caused by these enzymes secreted during their attachment in the ear canal. These enzymes are capable of causing inflammation and pain. Ticks which belong to family Ixodidae have been widely implicated in causing nerve paralysis. These ticks are capable of producing neurotoxins from their salivary gland during the feeding cycle [9,10]. Neurotoxins have been shown to interfere the depolarization and acetylcholine release mechanism in presynaptic nerve terminal and cause blockade of transmission at neuromuscular junction with resultant nerve paralysis [10]. The passage of neurotoxins commences on third day of infestation and peak on fifth to sixth day. The onset of clinical signs usually occurs five to seven days after attachment of ticks to the ear canal [11]. In the present case, the patient had complaint of otalgia one week prior to vertigo, reduced hearing and facial paralysis. Peripheral facial nerve palsy was diagnosed based on the clinical presentation – weakness of all facial nerve branches, drooping of the brow, incomplete lid closure, drooping of the corner of mouth, impaired closure of the mouth and dry eye. The challenging part in intra-aural tick infestation was successful removal of the tick from ear canal. It is a very distressing experience to patients, especially children. Most of the times, the removal is made difficult by the swollen and narrowed canal from previous multiple attempts by inexperienced medical personnel with inadequate instruments [2,3]. It is always a wise decision to refer patients with insect or foreign body in the ear to the centre with the expertise and adequate instruments for ear examinations. Two approaches for removal of tick from ear canal have been described [4]. One is by application of a noxious stimulus to induce the tick to withdraw spontaneously and the second approached is by mechanical removal. Several reagents have been used intra aurally to remove tick from the ear canal with variable success. Spirit, olive oil, sodium bicarbonate, petroleum jelly and liquid paraffin are among various preparations used to facilitate tick removal with none of them proven to be superior to another. Cocaine (10%) has been used by Baharudin and group [4]. They found that removal of the tick became easier by doing ear suction or by using forceps under microscopy following administration of cocaine. Cocaine weakens the tick and as a result the tick gets dislodged from the tympanic membrane or wall of the ear canal. Cocaine also helps to reduce the pain and it decongests the swollen ear canal. However, in uncooperative children, removal under general anaesthesia is safer and less traumatic. Ticks are common living foreign body in the ears especially in tropical countries. One must consider intra aural ticks in patient presented with otalgia, vertigo and facial nerve palsy, and should look for hidden ticks within the ear canal. However, at the primary care level, the other prevalent causes of facial nerve palsy need to be considered such as systemic viral infections, trauma, surgery, diabetes, local infections, tumour, immunological disorders and drugs [11]. In case of suspected intra aural tick infestation, early referral to ORL clinic is required to remove the ticks and to avoid further complications.   Conflict of interest: None.   References 1.   Somayaji KSG, Rajeshwari A. Human otoacariasis. Indian J Otolaryngol Head Neck Surg. 2007; 59(3): 237-239. 2.   Indudharan R, Dharap AS, Ho TM. Intra-aural tick causing facial palsy. Lancet. 1996; 348: 613. 3.   Lazim NA, Mohammad I, Daud MK, Salim R. The many faces of intra-aural tick clinical presentation. J Pak Med Stud. 2012; 3(1): 34-37. 4.   Asha’ari ZA, Abdullah B, Hasan S, Sidek DS, Jusoh NM. Isolated facial palsy due to intra-aural tick (ixodoidea) infestation. Arch Orofacial Sciences. 2007; 2: 51-53. 5.   Shibghatullah AH, Abdullah MK, Pein CJ, Mohamad I. Acute labyrinthitis secondary to aural tick infestation. Southeast Asian J Trop Med Public Health. 2012; 43(4): 857-859. 6.   Edussuriya BD, Weilgama DJ. Case reports: intra-aural tick infestations in humans in Sri Lanka. Trans R Soc Trop Med Hyg. 2003; 97: 412-3. 7.   Gürbüz MK, ErdoğanM, Doğan N, Birdane L, Cingi C, Cingi E. Case report: isolated facial paralysis with a tick. Turkiye Parazitol Derg. 2010; 34(1): 61-64. 8.   House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg. 1985; 93: 146-147. 9.   Grattan-Smith PJ, Morris JG, Johnston HM, Yiannikas C, Malik R, Russel R, et al. Clinical and neurophysiological features of tick paralysis. Brain. 1997; 120: 1975-1987. 10.  Vedanarayanan V, Sorey WH, Subramony SH. Tick paralysis. Semin Neurol. 2004; 24(2): 181-184. 11.  Finsterer J. Management of peripheral facial nerve palsy. Eur Arch Otorhinolaryngol. 2008; 265: 743-752. <![CDATA[Sutureless and glue free conjunctival auto grafting after pterygium excision]]> MK Goswami Md Asaduzzaman https://imcjms.com/journal_full_text/142 2016-11-12 17:22:20 Original Article IMC J Med Sci 2016; 10(2): 36-38 Abstract Background and objectives: Suture or glue has been used to secure the conjunctival auto graft after excision of the pterygium. Recently, auto grafting using patient’s own blood as a bioadhesive to secure the graft in position has been described by several authors. Therefore, the present study was undertaken to determine the outcome of excision of pterygium and sutureless conjunctival auto graft using patients’ own blood as a bioadhesive. Methods: Patients with primary and recurrent pterygium attending the Department of Ophthalmology of Bangladesh Institute of Research, Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) hospital from March 2014 to July 2015 were included in the study. Pterygium was excised and conjunctival auto graft was applied. Grafts were secured to the pterygium excision area with auto blood fibrin clot. All patients were examined after 48 hr and followed for 1, 4 and 12 weeks for graft dislodgement, sub-conjunctival hemorrhage, graft recession, graft edema and recurrence of pterygium. Results: A total of 35 primary and 2 recurrent pterygium cases were included in the study. The mean operation time was 15±1 minutes. Out of 37 eyes 5 (13.5%) had subconjunctival hemorrhage and 2 (5.4%) had graft recession and edema after 48hrs of operation. At 3 months follow up, 2 cases (5.4%) of graft recession and no case of recurrence of pterygium was found. Conclusion: Pterygium excision and conjunctival auto graft without sutures appears to be an effective treatment modality for primary and recurrent pterygium with no additional cost. IMC J Med Sci 2016; 10(2): 36-38. DOI: https://doi.org/10.3329/imcjms.v10i2.31106 Address for Correspondence: Dr. Manash Kumar Goswami, Associate Professor, Department of Ophthalmology, BIRDEM General Hospital,  122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka. Email: manashkg@yahoo.com     Introduction A pterygium is a winged shaped growth of fibrovascular conjunctiva onto the cornea. Its incidence varies across geographical locations and several hypotheses have been ascribed to its etiology [1]. Currently, it is believed that the pterygium is a growth disorder characterized by corneal conjunctivalization due to exposure to ultraviolet light and microtrauma. Ultraviolet light induced localized stem cell dysfunction is possibly related to the formation of pterygium [2]. The indications for surgery include reduced vision due to encroachment of visual axis and irregular astigmatism, chronic irritation, recurrent inflammation and restriction of ocular motility and cosmetics. Numerous surgical techniques including bare sclera excision, with and without the use of adjuncts like beta irradiation, thiotepa eye drops, intra or postoperative mitomycin C or anti neoplastic agents, amniotic membrane transplantation, conjunctival auto graft with or without limbal stem cells have been described [3]. In conjunctival auto grafting after pterygium excision, the conjunctival graft is usually sutured or glued to the bed to secure its position. In sutureless glue free auto grafting technique, the conjunctival graft is placed on to the bed where the oozing blood clots and forms a bioadhesive, which secures the graft in its position [4]. Auto graft with suturing is more cumbersome to perform and causes postoperative irritation and discomfort to the patient. The procedure also takes longer time to perform. On the other hand, if glue is used instead of suture, there are chances of hypersensitivity reaction and it is expensive. The new technique of sutureless auto grafting where blood clot is used as a bioadhesive is free from the above disadvantages. To the best of our knowledge, this technique has not yet been applied in Bangladesh. Therefore, the present study was undertaken to evaluate the outcome of the technique of excision of pterygium and sutureless conjunctival auto graft using patients’ own blood as a bioadhesive.   Materials methods Selected patients with diagnosis of pterygium attending the Department of Ophthalmology of Bangladesh Institute of Research, Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) General hospital from March 2014 to July 2015 were included in the study. The study was approved by the Ethical Review Board of BADAS. Informed written consent was obtained from each participant.   Surgical technique All surgical procedures were done under peribulbar anesthesia. Pterygium was excised without application of cautery to the scleral bed. Blood was allowed to ooze and form a clot on the bed. A caliper was used to measure the size of the conjunctival auto graft. One millimeter over sized graft compared to the pterygium bed was created from upper temporal conjunctiva. Tenon’s capsule or limbal tissue was not included. The auto graft was then glided into place over the bare sclera in the correct anatomical orientation and conjunctival edges were apposed with non tooth forceps. Donor area was left as it is for re-epithelization. At the end of the surgery, eye speculum was carefully removed without distorting the graft. Eye was patched for 48 hours. All patients were given 1% prednisolone acetate eye drops 4-6 times daily and moxifloxacin eye drops for 15 days. Lubricating eye drops for 6-8 weeks were prescribed. Patients were followed up at48hrs,1,4and12weeksforgraftdislodgement, sub-conjunctival hemorrhage, graft recession, graft edema and recurrence of pterygium.   Results A total of 35 cases were included in the study. The mean age of the study population was 32±2 years. The male and female distribution was 30 and 05 respectively. The detail profile of the study population is shown in Table-1. All the patients were examined after 24-36 hrs following operation for graft dislodgement, recession, edema sub-conjunctival hemorrhage. Out of 37 eyes only 5 (13.5%) had subconjunctival hemorrhage and 2 (5.4%) had graft recession and edema after 48 hrs of operation. Two cases (5.4%) of graft recession were noted at 3 month follow up. There was no recurrence of pterygium (Table-2). The mean operation time was 15±1 minutes.   Table-1: Profile of the study population   Outcome Number (%) n=37 After 48 hrs Graft dislodgement Sub-conjunctival hemorrhage Graft recession Graft edema   After 12 weeks Graft dislodgement Sub-conjunctival hemorrhage Graft recession Graft edema Pterygium recurrence   0 (0) 5 (13.5) 2 (5.4) 2 (5.4)     0 0 2 0 0   Discussion Pterygium surgery should ideally have a low or no recurrence, minimal complications and be cosmeticallyacceptable.Severalsurgical techniques have evolved over the years with recurrence rates varying from 2 to 88% [4]. Surgical procedures like bare sclera technique introduced in 1960’s, though easy to do, has been abandoned due to very high recurrence rate in the range of 26.8 to 88% [4]. Application of intra operative mitomycin C has a recurrence of 0-43% with devastating ocular complications like sclera melt, ocular perforation, etc [5]. During 1980’s conjunctival auto graft has been introduced and currently is the standard procedure for pterygium surgery with low recurrence rates in the range of 0-9% [6]. Procedure involves thin conjunctival graft either with or without limbal tissue which is sutured to the graft area. It has good cosmetic result having no serious intraoperative complications. However, the procedure takes longer surgical time and there is suture related complications. During the present decade, fibrin glue application to fix the graft was developed with elimination of suture related complications and faster surgery [7]. But it has other drawback like increased cost, availability, anaphylactic reactions, bio degradability of glue within 3 hours of grafting and recurrence rate of 10-15% [8]. Recent introduction of auto graft technique using patient’s own blood as bioadhesive substance on the excised bed of the pterygium has gained popularity. The technique has eliminated several disadvantages encountered with earlier methods. It has minimized the surgical time, trauma to the conjunctiva and recurrence rate. In our series, the operation time was only 14 to 16 minutes and there was no single case of pterygium recurrence after 3 months of surgery though we had 2 cases of graft recession. There was no other complication observed in our cases. The result was comparable to other studies with similar techniques [9]. The technique is cost effective and easy to perform with less discomfort to patient. However, our series had short follow up period of 3 months and did not have different types of atypical pterygia. Sutureless and glue free conjunctival auto graft using blood clot as a bioadhesive is a useful alternative method for graft fixation in pterygium surgery. We found the new procedure of auto grafting free of any untoward complications.   Reference 1.   Hirst LW. Distribution, risk factors and epidemiology of pterygium. In Hugh R. Taylor (Ed.), Pterygium. The Netherlands: Kugler Publications; 2000. p. 15-27. 2.   Dushku N, Reid TW. Immunohistochemical evidence that human pterygia originates from an invasion of vimentin -expressing altered limbal epithelial basal cells- Curr Eye Res 1994; 13(7): 473-81. 3.   Hirst LW. The treatment of pterygium. Surv Ophthalmology 2003; 48(2): 145-180. 4.   Singh PK, Sing S, Vays C, Sing M. Conjunctival auto grafting without fibrin glue or sutures for pterygium surgery. Cornea 2013; 32(1): 104-107. 5.   Ang LP, Chua JL, Tan DT. Current concepts and techniques in pterygium treatment. Curr Opin Ophthalmol 2007; 18(4): 308-313. 7.   Marticorena J, Rodríguez-Ares MT, Touriño R, Mera P, Valladares MJ, Martinez-de-la-Casa JM, Benitez-del-Castillo JM. Pterygium surgery: conjunctival autograft using a fibrin adhesive. Cornea 2006; 25(1): 34-36. <![CDATA[Evaluation of Rapid stool antigen test for the diagnosis of Helicobacter pylori infection in patients with dyspepsia]]> Salma Khatun Fahmida Rahman Khandaker Shadia Indrajit Kumar Dutta Mohammad Nazmul Hoq Farjana Akter Jalaluddin Ashraful Haq https://imcjms.com/journal_full_text/150 2016-11-24 19:21:29 Original Article IMC J Med Sci 2016; 10(2): 39-44 Abstract Background and objectives:Several diagnostic assays are used for the detection of Helicobacter pylori infection in suspected peptic ulcer cases. H. pylori stool antigen test is a non-invasive method for the detection of active infection. The present study has evaluated the efficacy of rapid stool antigen test to diagnose H. pylori infection in patients with dyspepsia. Materials and methods: Adult patients with complains of dyspepsia attending the Department of Gastroenterology, Hepatobiliary and Pancreatic Diseases (GHPD) of BIRDEM hospital for endoscopy were included. Gastric biopsy, blood and stool samples were obtained from each participant after informed written consent. Rapid urease test (RUT), serum H. pylori immunoglobulin A (IgA) and IgG and rapid H. pylori stool antigen (HpSAg) tests were performed. Only stool samples were obtained from 31 neonates aged 1 to 30 days as negative control for HpSAg test. Results: A total of 91 adult patients with complain of dyspepsia were included in the study. Out of 91 cases, 17 (18.7%) and 74 (81.3%) had peptic ulcer and erosion respectively. HpSAg was positive in 63.7% cases compared to 42.9% and 62.6% respectively by RUT and IgA. The rate of HpSAg positivity was significantly higher (p<0.05) in ulcer compared to erosion cases. HpSAg test was positive in all (100%) RUT positive cases. Combination of HpSAg test and IgA yielded highest positive result in both ulcer (82.4%) and erosion (84%) cases. H. pylori IgG was positive in all cases. Conclusion: The study has demonstrated that HpSAg test is an effective and non-invasive diagnostic tool to detect active H. pylori infection in suspected dyspeptic patients. IMC J Med Sci 2016; 10(2): 39-44. DOI: https://doi.org/10.3329/imcjms.v10i2.31108 Address for Correspondence: Prof. Jalaluddin Ashraful Haq, Department of Microbiology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Dhaka 1000, Bangladesh. Email: jahaq54@yahoo.com   Introduction Helicobacter pylori is known to be associated with peptic ulcer diseases. More than half of the world's population is infected with Helicobacter pylori, which is acquired almost always within the first 5 years of life [1]. Like other developing countries, the prevalence of H. pylori is very high in Bangladesh. The reported prevalence of H. pylori infection in adults is about 90% and more than 80% children become infected with H. pylori by the age of 6-9 years [2, 3]. Both invasive and non-invasive tests are available for the diagnosis of H. pylori infection.Invasive tests namely culture, staining, histology or rapid urease test (RUT) require biopsy specimens during endoscopy while noninvasive tests include serology, urea breath test (UBT) and stool antigen test (HpSAg). Culture of the organism is the gold standard for diagnosis of H. pylori infection, but it is not available in most laboratories as it requires special growth condition and facilities [4]. Histology examination of biopsy material can provide important information about morphological features indicating severity of gastritis and evidence for dysplasia. However, the accuracy of histology may be variable due to density of H. pylori and sampling error and also subjective to experience of the pathologist [5]. Rapid urease test (RUT) is simple and provides quick results [6]. It is based on urease activity of H. pylori in biopsy sample taken during endoscopy. Sensitivity and specificity of RUT test depends on number of biopsies and bacterial load [7]. Any concomitant use of antibiotics reduces bacterial load, and may lead to false negative results in RUT, UBT and histology [8]. Furthermore, the presence of other microorganisms that produce urease can lead to false-positive results [9]. Serology is widely used for screening patients for H. pylori infection. It has a good sensitivity, is quick and relatively inexpensive, but has low specificity since antibody titers remain high for years after H. pylori eradication and have limited value to confirm H. pylori active infection [10]. The UBT provides a reliable noninvasive method for detection of H. pylori infection with sensitivity and specificity of 88-95% and 95%-100% respectively [7]. But UBT involves radio active materials and requires an expensive instrument, which is not always available in routine clinical laboratories. As a gastrointestinal pathogen, H. pylori also appear in the stool. Stool tests have the advantage of being noninvasive and the specimen is easily obtainable. H. pylori stool antigen (HpSAg) assay has been proven to be clinically useful with sensitivities and specificities of more than 90% and is advantageous to confirm eradication [8]. It can be used as a routine diagnostic tool for H. pylori infection because it seems to overcome the limitations of the conventional invasive techniques. HpSAg test is suitable to use particularly in developing countries. Detection of H. pylori antigens in fecal sample might be useful for noninvasive diagnosis of H. pylori infection in children. HpSAg may be useful particularly in selection of the cases requiring endoscopic examination, in monitoring the response to treatment and in epidemiological studies [11]. Therefore, the aim of the present study was to evaluate the efficacy of a rapid immuno-chromatographic stool antigen test to diagnose H. pylori infection in dyspeptic patients.   Materials and Methods Study population and sample collection: Ninety one adult patients with dyspeptic symptoms attending the Department of Gastrointestinal, Hepatobiliary and Pancreatic Diseases (GHPD) of BIRDEM General Hospital for diagnostic endoscopy were enrolled in the study. Patients treated with any antibiotics, colloidal bismuth compounds, proton pump inhibitors (PPI) or H2 blocker within the last four weeks were excluded from the study. Gastric biopsy specimen was obtained during endoscopy from every adult patient for detection of H. pylori infection by rapid urease test (RUT). In addition, stool (20-30 gm) and blood (2.5 ml) samples were collected from each patient. Stool samples were tested for H. pylori antigen within 6 hours of collection. Blood was collected for the detection of H. pylori IgG and IgA antibodies. Thirty one neonates aged 1 to 30 days who were admitted in Special Care Baby Unit (SCABU) of BIRDEM Hospital were included in the study as healthy control. Only stool samples were collected from the neonates for the detection of fecal H. pylori antigen. The study was approved by the Institutional Review Board and written informed consent was obtained from all cases. Consent was obtained from the guardians of the neonates for collection of fecal samples. All laboratory works were carried out in the Department of Microbiology, Ibrahim Medical College, Dhaka. The study period was from July 2012 to February 2014. Sample preparation: After collection, blood was kept at room temperature for at least half an hour followed by centrifugation at 1500 rpm for 10 minutes. Then the serum was separated and stored at –200C. Later on the serum was used for detection of anti H. pylori antibodies. For stool antigen assay, the cap of the specimen collection tube was unscrewed and then the specimen collection applicator was stabbed randomly into fecal specimen in at least 3 different sites to collect approximately 50 mg of feces. The applicator was inserted back into the tube and then the cap was tightened. Collection tube was shaken vigorously using vortex mixer and then centrifuged for 5 minutes at 4000 rpm. The supernatant was used for the assay. Rapid urease test (RUT):Immediately after collection, the biopsy specimen was suspended in the rapid urease test media. Then the medium was incubated at 370C and examined after 4 hours or after over-night incubation (24 hrs) to detect urease activity. The test was considered positive if the colour of the medium changed from yellow to pink [12, 13]. H. pylori stool antigen assay: Stool samples were analyzed for H. pylori antigen using ABON one step H. pylori antigen test device (Inverness Medical Innovation Hong Kong Limited). It is a lateral flow chromatographic immunoassay. The test was performed as per instruction of the manufacturer. Two drops of extracted stool sample was added to the sample well of the test kit. The result was read 10 minutes after dispensing the sample. A test was considered positive when a purple-pink line (test line) appeared in addition to the control line and was considered negative when only the control line appeared. Lack of control line indicated invalid result. H. pylori IgG and IgA detection by ELISA: Serum samples were tested for the presence of anti H. pylori IgG and IgA antibodies. Test was performed by DRG H. pylori IgG and IgA ELISA kit (DRG International Inc., USA) according to manufacturer’s instruction.   Results Present study was carried out on 91 adult dyspeptic patients and 31 neonates (aged 1– to 30 days). Of 91 patients, 17 (18.7%) were diagnosed as peptic ulcer and 74 (81.3%) as erosion by endoscopy. HpSAg showed higher positivity (76.5%) in ulcer cases. Overall positivity of HpSAg was higher (63.7%) in comparison to RUT (42.9%) and IgA (62.6%) except IgG (97.8%). Out of 91, cases, 83.5% was positive for either HpSAg or IgA (Table1). HpSAg test was compared with RUT and serology. Out of 58 HpSAg positive cases, 67.2% were positive by RUT (Table 2). None of the HpSAg negative case was positive by RUT. HpSAg positive cases show higher IgA and IgG positivity than stool Ag negative cases. IgG was positive in all HpSAg positive cases. RUT and serology were compared with HpSAg test alone and in combination (Table 3). All the 39 RUT positive cases were also positive by HpSAg test (100%). Out of 52 RUT negative cases, 19 (36.53%) were stool antigen positive. All the 26 RUT and IgA positive cases were also positive for HpSAg. We included fecal samples from 31 neonate aged 1 to 30 days as a negative control for stool antigen. It was considered that the neonates would not be exposed to H. pylori. Among them, 1 (3.23%) was positive for stool antigen. The HpSAg method had a sensitivity of 100% for detection of H. pylori infection.   Table-1: Results of RUT, serum H. pylori IgG, IgA and HpSAg tests for detection of H. pylori infection in study populationNumber (%) positive by RUT HpSAga IgA IgG HpSAg/ IgA HpSAg/RUT HpSAg/ IgG Ulcer 17 10 (58.8) 13  (76.5) 12 (70.5) 17 (100) 14 (82.4) 13 (76.5) 17 (100) Erosion 74 29 (39.1) 45  (60.8) 45 (60.8) 72 (97.2) 62 (84.0) 45 (61.0) 72 (97.2) Total 91 39 (42.9) 58 (63.7) 57 (62.6) 89 (97.8) 76 (83.5) 58 (63.7) 89 (97.8) Note: HpSAg/IgA indicate either HpSAg or IgA positive; HpSAg/RUT indicate either HpSAg or RUT positive; a= p<0.05), compared between ulcer and erosion cases for HpSAg test; p< 0.05, compared between HpSAg and RUT. For HpSAg 95% CI: 53.8%-73.6%. For HpSAg/IgA 95% CI: 75.8%-91.1%   Table-2: Relation of H. pylori stool antigen (HpSAg) detection with RUT and H. pylori antibodies in ulcer and erosion patients (n=91) Test No. of cases Number (%) positive by RUT IgA IgG 39 38 58 0 (57.5) (96.8) 17 (51.5) Table-3: Comparison of RUT, serum H. pylori IgG and IgA with HpSAg test <![CDATA[Detection of human papillomavirus by hybrid capture and real time PCR methods in patients with chronic cervicitis and cervical intraepithelial]]> Elisha Khandker https://imcjms.com/journal_full_text/151 2016-12-06 19:16:51 Original Article IMC J Med Sci 2016; 10(2): 45-48 Abstract Background and objectives:Cervical cancer due to Human papillomavirus (HPV) is one of the leading causes of morbidity and mortality in women. Testing of HPV can identify women who are at risk of cervical cancer. Nowadays, molecular methods like real time polymerase chain reaction (PCR) and hybrid capture technique are applied for detecting HPV in cervical specimens. The objective of the present study was to determine the rate of HPV infection in women with chronic cervicitis and cervical intraepithelial neoplasia (CIN) by a commercial real time polymerase chain reaction test kit and by a hybrid capture HPV DNA test. Methods:Women aged between 20 to 55 years with chronic cervicitis and CIN were enrolled in the study after obtaining informed consent. Cervical specimen was collected by using cervical brush and stored in transport medium until used. HPV was detected by High Risk Screen Real-TM Quant 2x (Sacace, Biotechnologies SrI, Italy) real time PCR kit (HR RT-PCR) and by Hybrid Capture-2 High-Risk HPV DNA (Hc-2; Digene Corporation, USA) test. Results: Total 72 women with chronic cervicitis and CIN of different grades were included in the study. Out of this, HPV infection detected by HR RT-PCR was 31 (43%) and by Hc-2 was 14 (19.4%). Both the tests were able to detect HPV infection in all the CIN 3 cases and in most of the CIN 2 cases. However, HR RT-PCR detected higher number of HPV in chronic cervicitis and CIN1 cases. Conclusion:The study has shown that HR RT-PCR and Hc-2 tests are equally effective in detecting HPV infection in patients with CIN 2 and CIN 3 lesions. However, HR RT-PCR is more sensitive test for detecting HPV in chronic cervicitis and early CIN lesions and, therefore can be used in epidemiological study to detect presence of HPV in general population. IMC J Med Sci 2016; 10(2): 45-48. DOI: https://doi.org/10.3329/imcjms.v10i2.31109 Address for Correspondence: Dr. Elisha Khandker, Lecturer, Department of Microbiology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka, Email: elishakhandk@ymail.com   Introduction Human papillomavirus (HPV) infection has a global distribution and has been identified as the leading cause for cervical cancer [1].  In Bangladesh, each year an estimated thirteen thousand women are diagnosed with cervical cancer and about six thousand die from the disease [2].   HPV are classified as high risk and low risk HPV. The high risk (HR) types include HPV-16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82. Among these, HPV-16 and 18 are responsible for approximately 70% of all cervical cancer cases [3, 4]. The diagnosis and accurate treatment of HPV infection depends on detection of HPV in the cervical smear and its genotyping. Several studies have shown that cervical cancer has decreased after the advent and implementation of Papanicolaou (PAP) test screening program [5, 6]. Recently, several molecular methods have been applied to identify HPV infection in patients with dysplastic changes. The first high risk HPV test approved by the USA Food and Drug Administration (FDA) was the Hybrid Capture-2 assay (Hc-2) manufactured by Qiagen, USA (Digene Corporation, USA). The Hc-2 detects HPV by hybridization of genotype-specific RNA probes to denatured viral DNA. The test has been optimized to detect 1.0 pg/ml of HPV target DNA or 5000 copies in the sample [7]. Another molecular test which is also frequently used to detect HPV infection in cervical cytology is real time PCR. PCR is a powerful method to detect cervical HPV infection and is used in epidemiological studies. It has a low detection limit of 10-200 copies [8]. The test depends on the amplification of the target DNA and quantification.  In view of the above, the present study was undertaken to determine the rate of HPV infection in patients with chronic cervicitis and different grades of cervical intraepithelial neoplasia(CIN)byHRRT-PCRandHc-2assays.   Materials and Methods This study was approved by the Ethical Review Committee of the Diabetic Association of Bangladesh. Informed written consent was obtained from each participant. Study population and place: This study was carried out at Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorder (BIRDEM) and at a private hospital of Dhaka city from July 2012 to June 2013. Seventy two women aged between 20 to 55 years, who were diagnosed as cases of chronic cervicitis, CIN or invasive cancer by Papanicolaou (Pap) smear and histopathology of colposcopy directed biopsy, were enrolled in the study. Collection of samples for detection of HPV for both molecular methods: The cervical specimen for detection of HPV was collected with the sampling cervical brush, provided with the HR RT-PCR kit (Sacace, Biotechnologies Srl, Italy). At first, excess mucus from the cervical os and surrounding ectocervix was removed with a cotton swab. The sampling brush was then inserted into the cervical os, until the largest bristle touched the ectocervix. The brush was rotated three full turns counterclockwise and removed and immediately placed in 0.3ml of transport medium provided with the PCR kit. The container was shaken vigorously for 15-20 seconds and then the sample was divided equally in two sterile tubes for Hc-2 and HR     RT-PCR assay. The samples were stored at -800 C until the tests were performed. Detection of HPV by real time PCR:HPV High Risk Real-TM Quant 2x commercial kit (Sacace, Biotechnologies SrI, Italy) was used for extraction and detection of DNA by real time PCR. Here DNA was extracted and the target region E2 and E1 was amplified according to the instruction of the manufacturer. By this method HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59 could be identified. A Ct value ≤ 33 or HPV DNA concentration of >log3 was considered as positive. The kit did not differentiate between the different genotypes. This kit allows detecting HPV DNA in 100% of the test with a sensitivity of not less than 100 copies/ml. Results Total 72 women with chronic cervicitis and different grades of CIN were included in the study. Out of 72 cases, 44 (61.1%) and 28 (38.9%) had chronic cervicitis and CIN, respectively (Table-1). The overall detection rate of high risk HPV among study population by HR RT-PCR and Hc-2 assays were 43.1% and 19.4%, respectively. Table-1 shows that, among the chronic cervicitis cases, HPV positive rate was 20.5% by HR RT-PCR compared to 2.3% by Hc-2 assay. Out of total 28 CIN cases, 78.6% and 46.4% were positive for high risk HPV by HR RT-PCR and Hc-2 tests respectively. The rate of detection of HPV was significantly higher by HR RT-PCR than that of Hc-2 test in both chronic cervicitis and CIN 1 cases.   Table-1: The distribution of chronic cervicitis and CIN cases and rate of detection of HPV by HR RT-PCR and Hc-2 methods   CIN grades No of cases HPV positive by HR RT-PCR n (%) Hc-2 n (%)    CIN 1 14 8 (57.1) 1 (7.1)    CIN 2 11 11 (100)   9 (81.8)    CIN 3   3   3 (100)   3 (100)   Table-2 compares HPV detection rate in different grades of CIN by both methods. The rate of detection of HPV by HR RT-PCR in CIN 2 and CIN 3 cases was 100% while by Hc-2 test it was 81.8% and 100% respectively. The detection rate of HPV in CIN 1 was significantly (p<0.05) lower by Hc-2 assay (7.1%) compared to HR RT-PCR (57.1%).   Discussion It is essential to understand the limitations and benefits of different types of molecular methods for proper detection of HPV infection [9-12]. This is necessary to implement the proper intervention for the management of CIN patients and undertaking decision regarding vaccination against HPV. In this study, we compared the Hc-2 with that of HR RT-PCR assays for the detection of HPV in cervical specimens collected from patients having chronic cervicitis and CIN. The present study has revealed that compared to Hc-2 test, HR RT-PCR is capable of detecting HPV infection in significantly higher number of cases with chronic cervicitis and CIN 1 lesions. In the present study, HPV was detected in 9 cases of cervicitis and in 8 CIN 1 cases by HR RT-PCR compared to only 1 in cervicitis and 1in CIN 1 cases by Hc-2 test. On the other hand, the rate of detection of HPV by both tests was almost similar (100% and 81 to 100%) in cases with CIN 2 and 3 lesions.  The low positivity rate by Hc-2 test could be due to presence of low viral load in chronic cervicitis and CIN 1 lesions. The HR    RT-PCR test used in the present study could able to detect HPV as low as 100 copies while the Hc-2 assay had been optimized to be positive at 5000 copies per assay [8]. Hc-2 assay had been optimized to this threshold level of viral DNA as lower threshold level may not to be associated with cervical diseases and is clinically irrelevant [13]. It seems that HR RT-PCR is an appropriate method to be used for epidemiological purpose and to determine the presence or absence of HPV in a given community. However, in chronic cervicitis and CIN 1 cases the detection of HPV by molecular test like HR RT-PCR should always be correlated with the clinical manifestations as most of these cases may not progress to advanced lesions or cervical cancer. The study has demonstrated that HR RT-PCR and Hc-2 tests are equally effective in detecting HPV infection in patients with CIN 2 and CIN 3 lesions and HR RT-PCR is a sensitive test for detecting HPV in chronic cervicitis and early CIN lesions.   Acknowledgement I am grateful to Mr. Ian T Martin, Vice President, Molecular Diagnostic (Asia Pacific, Qiagen Company) for providing the Kit.   References 1.   Clifford GM, Smith JS, Plummer M, Munoz N, Franceschi S. Human papillomavirus types in invasive cervical cancer worldwide: a meta-analysis. Br J Cancer 2003; 88(1): 63-73. 2.   Sankaranarayanan R, Bhatla N, Gravitt PE, Basu P, Esmy PO, Ashrafunnessa KS, Ariyaratne Y, Shah A, Nene BM. Human papillomavirus infection and cervical cancer prevention in India, Bangladesh, Sri Lanka, and Nepal. Vaccine 2008; 26: 1-16. 3.   Munoz N, Bosh FX, de Sanjose S, Herrero R, Shah KV, Snijders PJF, Meijer CJLM. Epidemioogical classification of Human papillomavirus types associated with cervical cancer. N Engl J Med 2003; 348: 518-527. 4.   Munoz N, Bosh FX, Castellsague X, de Sanjose S, Hammoudad D, Shah KV, Meijer CJLM . Against which human papillomavirus types shall we vaccinate and screen? The international perspective. Int J Cancer 2004; 111(2): 278-285. 5.   Franco EL, Duarte- Franco E, Ferenczy A. Cervical cancer: epidemiology, prevention and the role of human papillomavirus infection. Can Med Assoc J 2001; 164(7): 1017-1025. 7.   Lorincz A, Anthony J. Advances in HPV detection by hybrid capture®. Papillomavirus Rep 2001; 12(6): 145-154. 8.   Coutlee F, Rouleau D, Ferenczy A, Franco E. The laboratory diagnosis of genital human papillomavirus infections. Can J Infect Dis Med Microbiol 2005; 16(2): 83-91. 9.   Baleriola C, Millar D, Melki J, Coulston N, Altman P, Rismanto N, and Rawlinson W. Comparison of  a novel HPV test with the hybrid capture2 and a refernce PCR method shows high specificity and positive predictive value for 13 high risk-human papillomavirus infections. Clin Virol J 2008; 42(1): 22-26. 10.  Castle PE, Porras C, Quint WJ, Rodriguez AC, schiffman M, Gravitt PE, Gonzalez P, Katki HA, Silva S, Freer E, Van Doorn LJ, Jimenez S, Herrero R,and  Hildescheim A. Comparison of two PCR based human papillomavirus genotyping methods. J Clin Microbiol 2008; 46(10): 3437-3445. 11.  Iftner T, Germ L, Swoyer R, Kjaer SK, Breugelmans JG, Munk C, Stubenrauch F, Anonello J, Bryan JT, Taddeo FJ.  Study comparing human papillomavirus (HPV) real time multiplex PCR and hybrid Capture2 INNO-LiPA v2 HPV genotyping PCR assays. J Clin Microbiol 2009; 47(7): 2106-2113. 12.  Menzo S, Ciavattini A, Bagnarelli P, Marinelli K, Sisti S, Clementi M. Molecualr epidemiology and pathogenic potential of underdiagnosed huamn papillomavirus types. BMC Microbiol 2008; 8: 112. 13.  Snijders Peter JF, van den Brule Adrian JC, Meijer Chris LJM. The clinical relevance of human papillomavirus testing: relationship between analytical and clinical sensitivity. J Path 2003; 201: 1-6. <![CDATA[Outcome of intraoperative use of mitomycin C combined with conjunctival auto graft in recurrent pterygium]]> MK Goswami F Hossain AB Shamsudduha M Asaduzzaman https://imcjms.com/journal_full_text/152 2016-12-11 17:10:42 Original Article IMC J Med Sci 2016; 10(2): 49-52 Abstract Background and objectives: Recurrent pterygium is an important ocular problem in our country.  There are different modalities of treatment for recurrent pterygium. The present study was undertaken to determine the effect of intraoperative mitomycin C along with conjunctival auto graft to prevent recurrence of pterygium. Study population Group 1 Number (%) Group 2 Number (%) Total patients 27 27 Male 21 (77.8) 19 (70.4) Female   6 (22.2)   8 (29.6) Recurrence of pterygium after 1 year 21 (77.7)   0   Group 1= Conjunctival auto graft only; Group 2= Conjunctival auto graft plus intraoperative mitomycin C.   Discussion Pterygium surgery has changed over the past decade, and several techniques are now available. Our study presents the efficacy of   intraoperative use of mitomycin C along with conjunctival auto grafting to reduce the recurrence of pterygium with minimal postoperative complications. In pterygium surgery, daily administration or single intraoperative use of a variety of mitomycin C doses have been reported [5-8, 10-12, 22, 23]. However, the safest dosage of mitomycin C that can prevent the recurrence of pterygium without causing complications is still unknown. Postoperative use of topical mitomycin C is not recommended because of a possible drug misuse, which may cause severe ocular complications such as scleromalacia, corneal perforation, glaucoma, iritis, pain, and punctate keratopathy [6–9]. Single intraoperative use of mitomycin C has been found safer than postoperative topical daily application [10–12, 24]. The recurrence rate of primary and recurrent pterygia treated with mitomycin C was approximately 6.7-22.5% over different period of time, and only mild complications such as superficial punctate keratopathy and mild avascularity of the bare sclera area were observed [25, 26]. A study has recently demonstrated normal sclera thickness and conjunctival epithelial phenotype at the surgical site more than six years after pterygium surgery with mitomycin C [27]. When bare sclera technique is performed in a patient with normal ocular surface, the epithelialization of the wound area is usually completed within 7 to 14 days [10, 11]. Intact epithelium over the operated area is necessary to prevent scleral melting after pterygium surgery when mitomycin C is used. To prevent scleral melting, we kept the conjunctiva overlying the body of the pterygium and sutured it back to the sclera at the end of the procedure. To avoid severe ocular complications, patients with abnormal ocular surface who were at greater risk for a delay of epithelialization or excessive inflammation, such as patients with immune disorders, blepharitis or dry eyes, were excluded from our studies. Furthermore, postoperatively, we closely observed the patients until the epithelialization of the ocular surface was complete. In the present study, we found that conjunctival auto graft with single application of intraoperative mitomycin C had no post operative recurrence after 12 months of surgery while the  recurrence rate was 77.7% among the patients where only grafting was performed without mitomycin C. Therefore, conjunctival auto grafting combined with intraoperative application of 0.02% mitomycin C for one minute was more effective than conjunctival auto grafting alone. However, it is important to observe the recurrence rate in recurrent pterygium treated with single application of intraoperative mitomycin C over longer period of time.   Reference 1.   Chabner BA, Amrein PC, Druker BJ, Michaelson CS, Mitsiades CS, Goss PE, et al. Chemotherapy of neoplastic diseases. In:  Brunton LL, Lazo JS, Parker KL, editors. Goodman Gilman’s the pharmacological basis of therapeutics. New York: McGraw-Hill; 2006. p.1315-1404. 2.   Verweij J, Pinedo HM. Mitomycin C: mechanism of action, usefulness and limitations. Anticancer Drugs 1990; 1(1): 5–13. 3.   Chen CW, Huang HT, Bair JS, Lee CC. Trabeculectomy with simultaneous topical application of mitomycin C in refractory glaucoma. J Ocul Pharmacol 1990; 6(3): 175–182. 4.   Palmer SS. Mitomycin C as adjunct chemotherapy with trabeculectomy. Ophthalmology 1991; 98(3): 317–321. 5.   Singh G, Wilson MR, Foster CS. Long-term follow-up study of mitomycin eye drops as adjunctive treatment of pterygia and its comparison with conjunctival autograft transplantation. Cornea 1990; 9(4): 331–334. 6.   Hayasaka S, Noda S, Yamamoto Y, Setogawa T. Postoperative instillation of low-dose mitomycin C in the treatment of primary pterygium. Am J Ophthalmol 1988; 106(6): 715–718. 7.   Singh G, Wilson MR, Foster CS. Mitomycin eye drops as treatment for pterygium. Ophthalmology 1988; 95(6): 813–821. 8.   Hayasaka S, Noda S, Yamamoto Y, Setogawa T. Postoperative instillation of mitomycin C in the treatment of recurrent pterygium. Ophthalmic Surg 1989; 20(8): 580–583. 9.   Rubinfeld RS, Pﬁster RR, Stein RM, et al. Serious complications of topical mitomycin C after pterygium surgery. Ophthalmology 1992; 99(11): 1647–1654. 10. Frucht-Pery J, Ilsar M, Hemo I. Single dosage of mitomycin C for prevention of recurrent pterygium: preliminary report. Cornea 1994; 13(5): 411–413. 11.  Frucht-Pery J, Siganos CS, Ilsar M. Intraoperative application of topical mitomycin C for pterygium surgery. Ophthalmology 1996; 103(4): 674–677. 12.  Mastropasqua L, Carpineto P, Ciancaglini M, Lobefalo L, Gallenga PE. Effectiveness of intraoperative mitomycin C in the treatment of recurrent pterygium. Ophthalmologica 1994; 208(5): 247–249. 13.  Kenyon KR, Wagoner MD, Hettinger ME. Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology 1985; 92(11): 1461–1470. 14.  Lewallen S. A randomized trial of conjunctival autografting for pterygium in the tropics. Ophthalmology 1989; 96(11): 1612–1614. 15.  Chen PP, Ariyasu RG, Kaza V, LaBree LD, McDonnell PJ. A randomized trial comparing mitomycin C and conjunctival autograft after excision of primary pterygium. Am J Ophthalmol 1995; 120(2): 151–160. 16.  Riordan-Eva P, Kielhorn I, Ficker LA, Steele AD, Kirkness CM. Conjunctival autografting in the surgical management of pterygium. Eye 1993; 7(5): 634–638. 17.  Mutlu FM, Sobaci G, Tatar T, Yildirim E. A comparative study of recurrent pterygium surgery: limbal conjunctival autograft transplantation versus mitomycin C with conjunctival ﬂap. Ophthalmology 1999; 106: 817–821. 18.  Ti SE, Chee SP, Dear KB, Tan DT. Analysis of variation in success rates in conjunctival autografting for primary and recurrent pterygium. Br J Ophthalmol 2000; 84: 385– 389. 19.  Wong VA, Law FC. Use of mitomycin C with conjunctival autograft in pterygium surgery in Asian-Canadians. Ophthalmology 1999; 106(8): 1512–1515. 20.  Segev F, Jaeger-Roshu S, Gefen-Carmi N, Assia EI. Combined mitomycin C application and free ﬂap conjunctival autograft in pterygium surgery. Cornea 2003; 22: 598– 603. 21.  Joseph FP, Frederic R, Michael I, David L, Faik O, Abraham S. Conjunctival auto grafting combined with low-dose mitomycin C for prevention of primary pterigyum recurrence. Am J Ophthalmol 2006; 141(6): 1044-1050. 22.  Mahar PS, Nwokora GE. Role of mitomycin C in pterygium surgery. Br J Ophthalmol 1993; 77: 433–435. 23.  Frucht-Pery J, Ilsar M. The use of low-dose mitomycin C for prevention of recurrent pterygium. Ophthalmology 1994; 101: 759–762. 24.  Raiskup F, Solomon A, Landau D, et al. Mitomycin C for pterygium: long-term evaluation. Br J Ophthalmol 2004; 88:    1425–1428. <![CDATA[Humoral immune response to selective mycobacterial antigens and serodiagnosis of active tuberculosis in Bangladeshi patients]]> Md. Mohiuddin J. Ashraful Haq https://imcjms.com/journal_full_text/154 2016-12-15 17:01:15 Original Article IMC J Med Sci 2016; 10(2): 53-57 Background and objective: Serological test has become an important tool in the diagnosis of TB cases. This study focused on the analysis and comparison of antibody response to two Mycobacterium tuberculosis (MTB) antigens namely Ag85 complex and culture filtrate protein (CFP) in patients with tuberculosis. Antibody response to specific antigen was utilized as a diagnostic tool to detect active tuberculosis (TB) cases. Results: The mean OD values of serum IgM and IgG antibodies against Ag85 and CFP were significantly (p<0.0001) higher in patients than that of healthy control individuals. Among the 30 tuberculosis patients, anti-Ag85 complex IgM and IgG was positive in 66.7% and 70.0% patients respectively. The seropositive rate of anti-CFP IgM and IgG was 33.3% and 56.7% respectively. The sensitivity and specificity of anti Ag85 and anti-CFP IgM and IgG ranged from 60.0% to 96.7%. IMC J Med Sci 2016; 10(2): 53-57. DOI: https://doi.org/10.3329/imcjms.v10i2.31111   Tuberculosis (TB) caused by Mycobacterium tuberculosis(MTB) is one of the leading cause of morbidity and death in the world. In 2015, there were about 10.4 million new TB cases worldwide and 1.4 million deaths from TB [1]. The estimated annual incidence of TB in Bangladesh is 0.362 million cases [1]. Early diagnosis and treatment of TB patients is crucial for the control of TB [2]. In developing countries, current diagnosis of TB largely relies on clinical symptoms, radiographic evidence supported by presence of acid fast bacilli in smear and isolation of MTB by culture from the clinical specimen. Direct smear is fast and cheap method but it lacks sensitivity. Culture method is more sensitive but it is cumbersome and requires longer incubation period. In the recent years, the detection of MTB-specific antibodies has become important diagnostic aid in the diagnosis of TB especially in smear-negative sputum cases [3]. It is particularly important for pediatric and extra pulmonary tuberculosis and in those unable to produce sputum. Thus the antibody assay might be of great benefit for early diagnosis and control of TB. Serological methods have been regarded as attractive tools for rapid diagnosis of tuberculosis due to their simplicity, rapidity and low cost. Serodiagnosis also does not require safety measures associated with handling of live bacilli as in culture and offer the possibility of detecting cases often missed by routine sputum smear microscopy. It is estimated that a rapid and widely available diagnostic assay with 85% sensitivity and 95% specificity would result in 400,000 fewer deaths each year and would greatly reduce the global health cost of TB [7]. Materials and methods Study population: Study included thirty adult confirmed active pulmonary tuberculosis cases. Active TB cases were confirmed by clinical features, positive AFB sputum and culture. Age and sex matched thirty healthy individuals were enrolled in the study as healthy control. All the healthy individuals were BCG vaccinated and neither they nor any of their family members had history or any sign symptoms of tuberculosis. About 5 ml of blood was collected from each participant with aseptic precautions by venipuncture. The serum was immediately separated and stored at -200C until used. Interpretation of the result: The concentration of antibody was expressed in OD at a particular dilution of both patient and healthy control samples. In order to diagnose active tuberculosis cases by detecting IgM and IgG antibody response against specific antigens, a cut off OD value was determined by the following formula: Cut off OD value= Mean antibody (IgM/IgG) titer of healthy participants against specific antigen +2xSD. Any OD value above the cut off was considered as positive for respective antibodies. Significance of difference of mean OD value of IgM and IgG antibodies against respective antigens was calculated by independent student’s t test.   Results Antibody response to Ag85 complex and CFP was determined in sera of 30 confirmed cases of tuberculosis and 30 healthy individuals. IgM and IgG response against specific antigens were determined by ELISA method and concentration of antibodies was expressed in terms of OD value. Table-1 shows the antibody response to two mycobacterial antigens. It was observed that mean OD values of serum IgM and IgG antibodies against Ag85 complex and CFP were significantly higher in patients (p<0.0001) than that of healthy control subjects.   Table-1: Antibody response to different MTB antigens in tuberculosis and healthy participants   1.18±0.10 0.78±0.10 0.56±0.03 0.39±0.03 0.0001 0.0004 Antigen Mean serum OD±SD of healthy individuals for Cut off OD value (Mean OD +2xSD) IgM IgG IgM IgG Ag85 complex 0.56±0.16 0.87±0.39 0.88 1.66 CFP 0.57±0.39 1.36 Note: Cut off OD values were calculated from antibody response in healthy individuals.   Table-3 shows the seropositive cases of tuberculosis patients by detecting IgM and IgG antibodies against Ag85 complex and CFP antigens. It was observed that among the total number of 30 tuberculosis patients, anti-Ag85 complex IgM was positive in 66.7% patients and its sensitivity and specificity was 75.0% and 96.7% respectively. The anti-Ag85 complex IgG was positive in 70.0% of patients and its sensitivity and specificity was 76.9% and 93.75% respectively. The seropositive rate of anti-CFP IgM and IgG was 33.3% and 56.7% while the sensitivity and specificity was 60.0% and 96.7% respectively.   Table-3: Serodiagnosis of tuberculosis patients by detecting IgM and IgG antibodies against Ag 85 complex and CFP antigens   Sensitivity (%) 1.  World Health Organization. Global tuberculosis report 2016. Geneva: World health organization; 2016. 214 p. 3.  Wu X, Yang Y, Zhang J, Li B, Lian Y, Zhang C, Dong M. Comparison of antibody responses to seventeen antigens from Mycobacterium tuberculosis. Clin Chim Acta 2010; 411(19-20): 1520–1528. doi: 10.1016/j.cca.2010.06.014 5.  Demissie A, Leyten EM, Abebe M, Wassie L, Aseffa A, Abate G, et al. Recognition of stage specific mycobacterial antigens differentiates between acute and latent infections with Mycobacterium tuberculosis. Clin Vaccine Immunol 2006; 13(2):179–186. 10.  Xueqiong Wu, Yang Y, Zhang J, Li B, Liang Y, Zhang C, Dong M, Cheng H, He J. Humoral immune responses against the Mycobacterium tuberculosis 38-Kilodalton, MTB48 and CFP10/ESAT-6 antigens in tuberculosis. Clin Vaccine Immunol 2010; 17(3): 372-375. 11.  Prabha C, Jalapathy KV, Das SD. Humoral immune response in tuberculous pleuritis. Am J Immunol 2005; 1(2): 68-73. 13.  Voller A, Bartlett A, Bidwell DE. Enzyme immunoassays with special reference to ELISA techniques. J Clin Path 1978; 31: 507-520. 14.  Suraiya S, Musa M, Suppian R, Haq JA .Serological diagnosis for active tuberculosis in Malayasian population: comparison for four protein candidate. Asian Pac J Trop Dis 2012; 2: S312-S315. <![CDATA[Humoral immune response to Mycobactrium tuberculosis cell wall fraction and lipoarabinomannan antigens in Bangladeshi patients with active tuberculosis]]> Md. Mohiuddin J. Ashraful Haq https://imcjms.com/journal_full_text/155 2016-12-15 17:04:43 Original Article IMC J Med Sci 2016; 10(2): 58-60 Background and objective: This study focused on the analysis and comparison of humoral immune response to Mycobacterium tuberculosis (MTB) cell wall fraction (CWF) and lipoarabinomannan (LAM) antigens.   Tuberculosis (TB) caused by Mycobacterium tuberculosis(MTB) is one of the leading causes of death in the world. The estimated incidence of TB and its annual mortality in Bangladesh is 225 and 45 per 100,000 populations [1]. Early diagnosis and treatment of TB patients is crucial for the control of TB [2].In the recent years, understanding of humoral immune response to MTB and the detection of MTB antigen specific antibodies has been an important tool in the diagnosis of TB cases [3]. This is particularly important for pediatric and extra pulmonary tuberculosis and in those unable to produce sputum. Thus, exploring the antibody response to defined MTB antigens might be of great benefit for early diagnosis and control of TB as well as to understand the immunity to tuberculous infection.   The study was conducted in the Department of Microbiology, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka. Informed consent was obtained from each of the participant. Antigens: Purified CWF and LAM antigens of MTB were used. The antigens were obtained from the Department of Microbiology, Immunology and Pathology, Colorado State University, 1682 Campus Delivery, Fort Collins, CO 80523, USA. Detection of antibody by ELISA: IgM and IgG antibodies to CWF and LAM antigens were determined by enzyme linked immunosorbent assay (ELISA). ELISA was performed as described by Voller et al [8]. Briefly, the 96 well EIA plate was coated with respective antigen (CWF or LAM) at a concentration of 5µg/ml. The optimum working concentration of each antigen was predetermined by checkerboard method using antigen concentration of 2.5 µg/ml, 5 µg/ml and 10 µg/ml. Initially, checkerboard method was also used to optimize the working serum dilution (1:400 for IgM and 1:1600 for IgG). IgM or IgG anti-human-HRP conjugate was used at a dilution of 1:5000 (MP Biomedicals, USA). Absorbance optical density (OD) was read at 450nm in Human ELISA reader. 1.   World Health Organization. Global tuberculosis report 2016. Geneva: World health organization 2016; 214 p. 3.   Wu X, Yang Y, Zhang J, Li B, Lian Y, Zhang C, Dong M. Comparison of antibody responses to seventeen antigens from Mycobacterium tuberculosis. Clin Chim Acta 2010; 411(19-20): 1520–1528. doi: 10.1016/j.cca.2010.06. 014. <![CDATA[Predictors of Knowledge and Attitude Regarding Organ Donation in Kuwait]]> Batool Y. Bosakhar Zainab A. Al-Mesailekh Shareefah A. Al-Farhan Danah A. Arab Nour A. Al-Tawheid Nourah F. Al-Ali Amal K. Mitra https://imcjms.com/journal_full_text/89 2016-09-26 09:18:16 Original Article IMC J Med Sci 2016; 10(1): 01-09 Abstract Background and objectives: In Kuwait, information regarding public knowledge and attitudes towards organ donation are scanty. This study aimed to evaluate public knowledge and attitude regarding organ donation and determine factors which predict them. Methods: This cross-sectional study was conducted among 630 participants recruited from 27 randomly selected public cooperative societies and private supermarkets in Kuwait. A self-administered questionnaire was used to collect data. Results: The prevalence rate of knowledge about organ donation was 68%, with a significantly higher rate among females than males (73% vs. 63%, respectively, p = 0.01). A composite score of knowledge was also higher among females than males (8.4 ± 5.8 vs. 6.8 ± 5.8, respectively, p = 0.001). In multivariate analysis, female gender (OR = 1.7; 95% CI =1.2, 2.4) and an educational level of bachelor’s degree or higher (OR = 2.6, 95% CI = 1.7, 3.9) were significant predictors of the knowledge. Among the barriers, more females than males mentioned about the fear of the operative procedures (p<0.001) and complications after the surgery (p = 0.011). Overall, 73% accepted the idea of organ donation during life, and 67% actually opted for donating their organs during life. However, almost everybody wanted to donate organs to their relatives. Conclusion: The study identified factors predicting knowledge and attitude regarding organ donation. The results will help in planning how to improve the rate of donors in Kuwait. IMC J Med Sci 2016; 10(1): 01-09. DOI: https://doi.org/10.3329/imcjms.v10i1.31099 Address for Correspondence: Prof. Amal K. Mitra, Professor of Public Health, Department of Community Medicine and Behavioral Sciences, Faculty of Medicine, Kuwait University, Kuwait. E-mail: amalmitra16@yahoo.com   Introduction Many people around the world with end-stage organ failure are dying while on waiting lists for transplant surgery [1]. In 2012, 114,690 solid organs were reported to be transplanted globally, making a 1.8 % increase over the year 2011. Stillless than 10% of the global needs are met with the available donors. According to the Global Observatory on Donation and Transplantation (GODT), in 2012, the rate of organ donation in Spain was the highest worldwide, almost 35 deceased donors per one million, whereas, it was almost 26 deceased donors per one million persons in the United States, and 18 per one million in the United Kingdoms [2]. In Kuwait, the rate of organ donation is relatively low – only 6 deceased donors per one million persons, putting Kuwait well behind the US and Europe in this area. Between year 1996 and 2012 there were only 447 donations of kidneys, liver, pancreas, and heart [3]. A medical team in Al-Hamad Al-Essa Organ Transplant Center in Kuwait has performed 1,036 kidney transplant procedures from the period between November 1993 to December 2010, of which 278 were from brain death cases, 397 from relatives, and 361 from non-relative living donors. This makes the total number of kidney transplant procedures in Kuwait to be 1,596 procedures from the initiation of the program in Kuwait in February 1979 to January 2011 [3]. Still until October 2015, only 6,000 people in total in the country offering to donate their organs once they pass away through registration for organ donation card [4]. Several socio-cultural factors may influence attitudes of public towards organ donation. In a study conducted in late 2003 among Greater Detroit Arab Americans found Christian Arab Americans more likely than Muslim Arab Americans to believe organ donation after death being justifiable. Higher educational attainment and income, as well as greater acculturation into American society, were associated with greater odds of believing organ donation to be justified [5]. Regarding people’s awareness about organ donation, a national study was conducted in China which showed that nearly 94% of the people in China were aware of organ donation. However, only 19% of this sample population actually carried organ donation cards [6]. In Saudi Arabia, shortage of organ donation remains a major limiting factor for transplantation [7]. To evaluate factors affecting the knowledge and/or attitudes towards organ donation, a cross-sectional study conducted in Saudi Arabia showed that about 40% of respondents accepted the concept of organ donation after their death, hile 16% disagreed. When asked about possible reasons for organ donation refusal, 28% cited religious reasons and 23% did not want to have their bodies dissected after death [8]. Another study in Qatar revealed that about one-third of Qataris and more than onequarter of non-Qataris had no idea about the organ donation. The majority of the people in Qatar preferred donating organs to their close relatives and friends only [9]. Studies have suggested that knowledge and attitudes towards organ donation are influenced by factors such as gender, educational level, occupation, socio-demographic status, income level, culture, and religion [10]. Some of the barriers that may prevent people from donating organs include: fear of surgical and health risks, lack of knowledge, respect for cultural norms, financial loss, distrust in hospitals, and avoiding recipient indebtedness [11-12]. Studies have suggested that providing the general public by relevant information and correcting some of the misconceptions are likely to increase the number of individuals willing to donate organs [7]. In Kuwait, data regarding public knowledge and attitudes towards organ donation are scanty. Therefore, this study attempted to evaluate the knowledge and attitudes of people regarding organ donation.   Methods Study subjects The study was carried out among the general population in the city of Kuwait from December 2013 to January 2014. A list of 87 cooperative societies and private supermarkets were obtained from the Ministry of Commerce and Industry in Kuwait. Twenty-seven cooperative societies and private supermarkets were chosen by stratified random selection, using the administrative governorates as the strata. Cooperative Societies were chosen in the study for data collection since these are the main places where both expatriates and citizens from different socioeconomic backgrounds purchase their daily food supply and goods, making our sample most representative to the Kuwaiti population.   Ethical approval The study was approved by the Ethics Committees at the Health Sciences Center of Kuwait University. The approvals were then obtained from the head of all cooperative societies and the manager of each private supermarket. An informed consent was obtained from the participants before enrollment.   Data collection After reviewing published literature, a questionnaire was generated in both Arabic and English. The questionnaire consisting of 33 items was self-administered. Of them, 11 items assessed demographics, 12 items measured knowledge, and 10 items assessed attitude and willingness regarding organ donation. For each correct answer of the knowledge questions, a score of 1 was given. Regarding attitude, participants were asked if they are willing to donate, and if yes, which organs they are willing to donate and to whom (e.g. relative, friend, and/or anybody) during and/or after life. In addition, opinions about the barriers against organ donation and the best ways to promote organ donation were evaluated. The questionnaire was pre-tested among 20 persons recruited from the same population. Then modifications were made for clarity, simplicity and validity of the questionnaire. Two items were deleted for potential inconsistency in data. A convenience sample, on first-come, first-serve basis, was obtained in two shifts, morning from 9 am to 12 pm, and evening from 4 pm to 7 pm. The eligible participants were both females and males aged 18 years and above. People who could not read or write Arabic or English were excluded.   Sample size estimation Based on the published reports from Gulf region [9], the proportion of people with lack of knowledge regarding organ donation was 30%. In another study in China [6], 10% of the people had lack of knowledge about organ donation. In this study, the proportion of people with lack of knowledge about organ donation was considered to be not less than 10% (P1 = 0.10). To estimate the true proportion of the characteristics within 5% (P2= 0.15), and the power of the study being 95%, the required sample size was 562. Assuming a 10% dropout, the total sample size was 618. The sample size was estimated using the G-power program.   Statistical analysis Data analysis was done using SPSS for Windows software version 22 (SPSS Inc., Chicago, USA). Descriptive analysis was done to know the distribution of the data. For knowledge questions with known standard answers (e.g., organs to donate during life and after death) as obtained from the U.S Department of Health and Human Services (2013) [11], a scoring system was used by assigning one point for each correct answer. Mean values of knowledge scores were compared between people of either gender, nationality, marital status and education levels. Chi-square test was done for comparing categorical variables, and student t-test for continuous variables with normal distribution. Analysis of variance (ANOVA) was used to compare mean values of more than two groups. For data with non-normal distribution (e.g., knowledge scores), Mann Whitney U and Kruskal Wallis Test were used to compare mean values for two and more than two independent variables, respectively. A p-value of 0.05 was considered as statistically significant.   Results Demographics In total, 710 participants were handed out the questionnaire; 80 (11%) were dropped from this analysis due to missing data for major variables. However, those who dropped out did not differ from those who were remained in terms of demographic variables. Of the remaining 630 participants, 51.2% were females and 47.9% were males. Mean age (SD) of the participants was 33.4 (11.5) years, ranging from 18 to 76 years. Kuwaitis represented majority (66%) of the study population.   Knowledge about Organ Donation Table 1 shows that 68.3% (430/630) of the respondents knew about organ donation. Of those who knew about organ donation, 80.6% heard it from radio/television/internet as being their primary source of information, and 53.2% chose newspapers and magazines as their source of information. Only 27.7% of the respondents heard about organ donation card. A vast majority (71.1%) agreed that organ donation is possible in both during life and after death.   Table-1: Knowledge about organ donation and sources of information   Variable Male n = 302 Female n = 328 P-value All n = 630 Know about organ donation (%) 191 (63.2) 239 (72.9) 0.01a 430 (68.3) When can a person donate an organ     0.62a       During life 21/192 (10.9) 24/244 (9.8)   45/436 (10.3)     After death 39/192 (20.3) 42/244 (17.2)   81/436 (18.6)     Both 132/192 (68.8) 178/244 (73.0)   310/436 (71.1) Knowledge score             What organs a person can donate     during life (out of 8) 2.29 ± 2.08 2.79 ± 2.09 0.003b 2.55 ± 2.10     What organs a person can donate     after death (out of 8) 2.70 ± 2.84 3.40 ± 2.80 0.002b 3.07 ± 2.84     Who can donate an organ (out of 4) 1.84 ± 1.59 2.17 ± 1.56 0.007b 2.01 ± 1.58     Total score (out of 20) 6.83 ± 5.83 8.36 ± 5.82 0.001b 7.63 ± 5.87   aChi-Square Test; bMann-Whitney U Tes   Relation between Formal Education and Knowledge In terms of education, mean knowledge scores of organ donation increased linearly with higher levels of education (Figure 1). The people with a post-high school diploma showed a higher mean knowledgeable score about organ donation when compared with those with a high-school or less education, although data were not significant. Similarly, those who have had a bachelor degree or higher education showed a statistically significant higher knowledge score for organ donation compared to those who have had less than a bachelor degree education (p < 0.001). Fig.1:Knowledge scores for organ dontion by educational status of participants. Participants with bachelor’s degree or higher educational status had significantly more knowledge scores compared to the other levels of educationMultivariate Analysis to Predict Knowledge about   Organ Donation In logistic regression analysis (Table 3), female gender (OR = 1.7; 95% CI =1.2, 2.4), and an educational level of bachelor’s degree or higher (OR = 2.6, 95% CI = 1.7, 3.9) were significant predictors of those who had knowledge about organ donation. Those variables were selected based on significant associations observed in univariate analysis. The variables which were controlled for included location of residence (governorate), nationality, religion, family income, parents’ education, and occupation. Table-3:Logistic regression analysis to predict knowledge about organ donation   Variable Odds ratio 95% Confidence Intervals P value Age group       18-25 y Reference     26-45 y 1.03 0.62, 1.72 0.91 ≥ 46 y 1.98 0.97, 4.01 0.06 Gender       Male Reference       Female 1.68 1.16, 2.42 0.006 Nationality       Kuwaiti Reference     Non-Kuwaiti 1.38 0.94, 2.04 0.11 Marital status       Single Reference     Married 1.39 0.86, 2.24 0.18 Widowed or Divorced 3.58 1.09, 11.80 0.036 Education level       High school or less Reference     Post high school diploma 1.50 0.94, 2.40 0.09 Bachelor’s degree or higher 2.59 1.72, 3.89 <0.001  Attitudes about Organ Donation by Gender Table 4 shows that about 73% of the study participants opined favorably for organ donation during life. When asked if they are willing to donate his/her organs during life, 67% responded positively. A vast majority of them (98%) were willing to donate an organ for their family members, whereas 68% mentioned it for their friends, and only 37% mentioned that they would donate it for anybody. No differences were observed in the attitudes towards organ donation by gender.   Table-4:Comparison of attitudes about organ donation by gender   <![CDATA[Diabetic retinopathy and visual impairment in disaster prone coastal population of Bangladesh]]> M. Abu Sayeed AH Syedur Rahman Md. Hazrat Ali Mir Masudur Rhaman J Ashraful Haq Akhter Banu https://imcjms.com/journal_full_text/94 2016-10-01 01:16:34 Original Article IMC J Med Sci 2016; 10(1): 10-17 Abstract Methods: Thirty-two coastal communities in six coastal districts were purposively selected. All coastal people of age 18 years or more were considered eligible. Investigations included clinical history, anthropometry (height, weight, waist- and hip-girth), blood pressure and fasting blood glucose (FBG). The participants with hyperglycemia (FBG ≥5.6mmol/l) were undertaken for eye examination. Visual acuity was measured bilaterally using the Snellen chart. An Early treatment diabetic retinopathy study (ETDRS) cut out chart with E Optotypes was used. Conclusion: The study concludes that visual impairment and cataract of any type is almost comparable with other coastal populations. The coastal people had higher prevalence of DR compared to rural population from other areas of Bangladesh and it was also higher than global estimate. The persons with higher age from higher social class with higher central obesity had excess risk for DR. The risk of DR increased with increasing hyperglycemia. Further study may be undertaken to confirm these findings. IMC J Med Sci 2016; 10(1): 10-17. DOI: https://doi.org/10.3329/imcjms.v10i1.31100 Address for Correspondence: Of the alarming trend of non-communicable diseases (NCD), type 2 diabetes mellitus (T2DM) is common throughout the world and more alarming in the south-east Asian region [1]. A global estimate of diabetes in the year 2000 was 171 million. This figure is likely to be more than double (366 million) by 2030; and most significant increase will occur in the developing countries [1]. T2DM affects elderly people in the developed countries, whereas, in the developing and least developing countries, younger people are more affected [2]. We have the same experience in Bangladesh [3]. Additionally, the prevalence of micro-vascular complications is common in these populations [4-6]. Of the micro-vascular sequels, diabetic retinopathy (DR) was found to be the most disabling complications as it results into loss of vision. A community based study in Sri Lanka reported that more than one-fourth (27.4%) of the diabetic patients had DR [7]. This report indicates that the most diabetic people are prone to develop DR and eventually blindness. For Bangladesh, several population based studies reported the increasing trend of T2DM [8-10]; but there was no community based study on DR. This study addressed the prevalence and risk of DR at the community level in a disaster prone coastal population of Bangladesh.   Material and methods The study protocol was approved by the Ethical Review Committee of the Diabetic Association of Bangladesh (BADAS). Fig.1: Map of Bangladesh showing the location of six coastal districts included in the study [11] Fig.2: Map showing the study sites in each coastal district. Each Dot (n) indicates location of study site [11]   Collection of blood sample: Taking an aseptic measure five ml of fasting blood sample was collected for estimation of fasting blood glucose (FBG mmol/l) and lipids (total cholesterol [T-chol], triglycerides [TG], low-density lipoprotein [LDL] and high-density lipoproteins [HDL]). Finally, biochemical tests were carried out in BIRDEM laboratory. Plasma glucose was measured by glucose oxidase-peroxidase method using Technicon M-II auto-analyzer. To reduce the cost, a randomized sample was drawn (n=225) for the estimation of T-chol, TG and HDL by auto-analyzer (Hitachi-704) using enzymatic method. The coefficient of variation (CV) was allowed ≤5%. While collecting blood sample a drop of blood was taken on a hemo-glucotest strip (One Touch select sample, Lifescan) for rapid assessment of FBG [12]. We used ADA and WHO diagnostic criteria for hyperglycemia and predicting diabetes [13,14]. The participants, who showed FBG ≥5.6 mmol/l, were referred to ophthalmologist for eye examination (Fig 3). The participants presented with eye complaints, irrespective of glycemic status, were also referred.    Figure 3: Algorithm of the study Visual acuity was measured bilaterally using the Snellen chart. An early treatment diabetic retinopathy study (ETDRS) cut out chart with E Optotypes was used [15]. Torch light and pinhole were also used [16]. The cause of visual impairment (cataract, refractive error and retinopathy) was identified [16, 17]. Then the pupil was dilated by using 1% Tropicamide and the fundus was examined with direct ophthalmoscope [18]. Diabetic retinopathy (DR) was diagnosed and classified according to classification of DR and diabetic macular edema [19]. The study findings on DR have been modified for easy presentation: (a) Pre-proliferative – microaneurysms with or without intraretinal hemorrhages; (b) proliferative – neovascularization with or without Vitreous/preretinal hemorrhage; (c) Diabetic macular edema (maculopathy) – any thickening or lipid exudates in the macula [20].   Statistical analyses The prevalence rates of cataract, impaired visual acuity and diabetic retinopathy according to sex, family history and social class were given in percentages with 95% confidence interval (CI). The biophysical characteristics were shown in mean with standard deviation. We used unpaired t-test for comparison of characteristics between participants with and without retinopathy. For assessment of risk odds ratio (OR) with 95% CI were used. SPSS version 20 was used for all analyzing qualitative and quantitative data. Less than 0.05 was considered significant.   Results The prevalence of DR according to sex, social class and family history were shown in table 2. The prevalence of DR was significantly higher among those who had known diabetic member in their first degree relatives than those who had no known diabetic member in their families. Regarding social class, the affluent participants had significantly higher DR than their non-affluent counterparts. Compared with the women the men had higher frequency though not significant.   Table-2: Prevalence [% (95% CI*)] of retinopathy according to sex, family history (n=1412) and social class (n=1377)   Table 3 showed the comparisons of biophysical characteristics between participants with and without DR. The participants with DR had significantly higher age (p<0.001), higher central obesity (WHR p<0.001; and WHtR p=0.01), higher fasting FBG (p<0.001). Interestingly, there was no significant difference in general obesity (BMI p=0.917). Even more interesting is that the participants with DR had significantly lower total cholesterol (p=0.03) and lower low-density lipoprotein (LDL p=0.047).   Table-3: Comparison of characteristics between participants with and without retinopathy     No retinopathy n=617 Retinopathy n=145   Characteristics Mean SD† Mean SD p‡ Age (y) 47.7 13.4 52.4 12.8 0.001 BMI 23.6 3.9 23.6 3.5 .917 WHR 0.896 0.081 0.925 0.072 0.001 WHTR 0.507 0.072 0.523 0.061 .010 SBP (mmHg) 127.4 21.9 129.8 24.2 .238 DBP (mmHg) 81.8 12.6 81.9 11.1 .921 FBG (mmol/l) 6.8 3.1 8.9 4.5 0.001 Chol (mg/dl)* 221 69 189 48 .030 TG (mg/dl)* 176 122 150 82 .323  HDL (mg/dl)* 46.2 10.4 44.5 11.4 .468 LDL (mg/dl)* 139.9 59.6 114.6 41.5 .047 † SD – standard deviation; ‡ p after unpaired t-test; * - a randomized sample size (n = 225)   This is the first study, which addressed the prevalence of DR and visual impairment in a coastal population. Some socio-demographic and biophysical risk factors were also assessed. Two important aspects of the study are worth mentioning. Firstly, the study population has least access to health care services and diagnostic facilities. Secondly, the study areas are mostly inaccessible due to inconvenient communication and precarious weather condition. We had some advantages. We could refer the persons with cataract to nearby centers for surgery organized and maintained by Fred Hollow Foundation. The local people especially teachers and students were very much cordial. They actively and sincerely volunteered the study in every step (carrying message to the villagers from house to house and making list of the participants and taking them to the investigation site. So far available a population based study of Bangladesh showed that overall prevalence of DR was 5.4% among the rural people of age 30 years or older [22]. Our study demonstrated that compared with the rural people of other areas of Bangladesh, the coastal people had increased prevalence of DR. An estimated global prevalence of ‘any DR’ was found 6.96% (95CI, 6.87-7.04) [23]. Thus, the global estimate also indicates that the coastal people are more susceptible for developing DR. A ‘Singapore Eye Study’ among the migrant Indians (age >40y) reported that the prevalence of DR was 10.5% (95% CI, 9.3-11.8) [24]. This finding also showed that our study population bears greater risk for DR. An interesting finding was that the level of total cholesterol and LDL-cholesterol was found significantly lower in those who had no DR than those who had. The findings indicate that these lipid fractions appear to be protective against DR. The explanation is not known. We conclude that the prevalence of visual impairment and cataract is comparable with other studies; whereas, the prevalence of DR among the coastal people was higher than that of the rural Bangladeshis and also higher than global estimates and Indian migrants. The persons with higher age from higher social class with higher central obesity had excess risk for both diabetes and DR. Further study may be undertaken to confirm the study findings and if found consistent then the coastal people need an urgent Eye Care facilities for the prevention of visual impairment and blindness. Acknowledgements – We are grateful to Fred Hollow Foundation (FHF) for their financial support. We are indebted to Prof AH Syedur Rahman, Department of Ophthalmology, BIRDEM for his initiative to communicate to FHF. We deeply acknowledge him posthumously with all our deepest respect. We appreciate the cooperation extended by the Ibrahim Medical College and the Department of Ophthalmology, BSMMU, Dhaka. We are grateful and obliged to the teachers, students and all participants of coastal area for their cordial and pleasant hospitality.   References 2. World Health Organization: Guidelines for the prevention, management and care of diabetes mellitus. EMRO Technical publications series 32, Geneva 2006. 4. Sayeed MA, Khanam PA, Choudhury RI, Mahtab H, Azad Khan AK. Retinopathy and nephropathy are the most prevalent complications among diabetic subjects in Bangladesh. Diabetologia 2005; 48(Suppl 1): Abs-944 (P: A343). 6. Sayeed MA, Khanam PA, Mahtab H and Azad Khan AK. Microvascular complications among diabetic subjects predominate in the long-term follow up: 15-year retrospective study. Diab Res Clin Pract 2000; 50: S116. 7. Katulanda P, Priyanga Ranasinghe P and  Jayawardena R. Prevalence of retinopathy among adults with self-reported diabetes mellitus: the Sri Lanka diabetes and Cardiovascular Study. BMC Ophthalmol 2014; 14: 100. doi: 10.1186/1471-2415-14-100 8. Sayeed MA, Mahtab H, Khanam PA, Latif ZA, Banu A and Azad Khan AK. Prevalence of diabetes and impaired fasting glucose in urban population of Bangladesh. Bangladesh Med Res Counc Bull 2007; 33(1): 1-12. 10. Rahim MA, Hussain A, Azad Khan AK, Sayeed MA, Keramat Ali SM, Vaaler S. Rising prevalence of type 2 diabetes in rural Bangladesh: a population based study.Diabetes Res Clin Pract 2007; 77(2): 300-305. 12. Florkowski C, Budgen C, Kendall D, Lunt H and Moore MP. Comparison of blood glucose meters in a New Zealand diabetes centre. Ann Clin Biochem 2009; 46: 302–305. 14. American Diabetes Association. Standards of Medical Care in Diabetes—2011. Diabetes Care 2011; 34(Suppl 1): S11–S61. 16. Neena J, Rachel J, Praveen V, Murthy GV. Rapid assessment of avoidable blindness in India.PLOS One 2008; 3: e2867. 18. Klein R, Klein BEK, Moss SE, Davis MD, Demets DL. The Wisconsin epidemiologic study of diabetic retinopathy-X. Four year incidence and progression of diabetic retinopathy, when age at diagnosis is 30 years or more. Arch Ophthalmol 1989; 107: 244–49. <![CDATA[Clinical outcome of metformin treatment in patients of acanthosis nigricans with insulin resistance]]> Tahmina Akter Md. Reza Bin Zaid Zeenat Farzana Rahman M Abu Sayeed https://imcjms.com/journal_full_text/91 2016-09-26 09:36:36 Original Article IMC J Med Sci 2016; 10(1): 18-23 Abstract Methodology and Results: This prospective, controlled trial was conducted in Dermatology OPD of BIRDEM General Hospital, Dhaka from September 2012 to August 2013. All the participants of the study had clinical presentation of AN on different anatomic locations such as neck, axilla, elbow, knuckle and knee and biochemical evidence of IR. Participants were of either sex with age ranging from 18 to 80 years. Any case who had contraindications to metformin therapy were excluded. Severity of AN was examined and assessed by a quantitative scale for measuring acanthosis nigricans. After detecting IR by Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), cases and controls were selected by random sampling method. Randomization was done for metformin in ratio of 2:1. Every third patient was a control. Forty study participants were assigned to receive tablet metformin 500mg thrice daily after meal for three months and twenty control participants were continued on their existing therapy. To maintain a static metabolic status, patients were allowed to remain with their previous diet and lifestyle habit. After 3 months of metformin therapy, improvement was assessed and was compared with control group. Conclusion: Metformin therapy for AN with IR had a significant beneficial effect clinically and was safe and well-tolerated. The effect was more pronounced in neck and axilla.   IMC J Med Sci 2016; 10(1): 18-23. DOI: https://doi.org/10.3329/imcjms.v10i1.31101 Address for Correspondence: Dr. Tahmina Akter, Medical Officer, Department of Dermatology and Venereology, BIRDEM General Hospital, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka E-mail: rimjhimborsha@yahoo.com   Introduction Metformin is abundantly used in insulin resistant cases [13,14]. It may have some effects on AN by reducing IR and thus ultimately may reduce clinical manifestations of AN [15-17]. This randomized prospective controlled trial was conducted in the Department of Dermatology of Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Shahbag, Dhaka from September, 2012 to August, 2013. One hundred adult cases with clinical presentation of AN on neck and axilla with or without involvement of knuckles, elbows and knees and with the biochemical evidence of IR were primarily selected. Out of which, sixty patients consented to participate in the study. Patients with AN due to causes other than IR namely impaired renal or liver function and pregnant and nursing mothers were excluded. Interview was conducted at a suitable time and place that was convenient to the responder.   Scoring of AN and determination of IR The approximating equation for IR, in the early model, used a fasting plasma sample and was derived by use of the insulin-glucose product, divided by a constant:  HOMA-IR= Glucose x Insulin x 1/22.5(Glucose in mmol/L)  Our cut-off value of having IR in HOMA-IR was 1.82 [19].  Randomization of cases Data were expressed as mean and standard deviation. Paired Student’s t test was done for analysis of variables and Fisher’s Exact test was used to test for differences in proportions for categorical variables. A p value of <0.05 was considered as significant. The International Business Machines Corporation- Statistical Package for the Social Sciences (IBM-SPSS) version 20.0 software was used to analyze the data. Among the sixty participants, forty were in study group and twenty were in control group. Mean age of male: 19.75±2.36 and female: 26.58± 9.38, M:F= 1:14 (M 6.66%, F 93.33%), Body Mass Index (BMI) of male: 32.15 ± 4.15 and female:33.18 ± 8.05. History of gestational diabetes mellitus: 11.76%, family history of diabetes mellitus and/ or hypertension: 88.33%, hirsuitism: 46.55 % and menstrual irregularity: 46.55%. There was no significant difference between study and control groups in case of age, BMI and HOMA-IR levels. Baseline characteristics of the all participants are shown in Table-1.   Table-1: Baseline characteristics of the participants   Variables Mean score ± SD t-test Sig. Study group Control group Age 26.15±10.10 26.1±7.42 -0.02 0.98 BMI   34.45±8.55 30.43±5.41 -1.91 0.06 HOMA-IR*    9.41±8.63 6.34±2.38 -1.55 0.12 Sex (M/F)           3 / 37 1 / 19       *Cut-off value of having insulin-resistance in HOMA-IR was 1.82 [18].   After 3 months treatment with metformin, significant improvement (P< 0.005) of AN was observed clinically on neck and axilla compared to controls. Improvement rates with metformin in case of neck severity, neck texture and axilla were estimated as 67.5%, 62.2% and 70% consequently. However, regarding AN on knuckles, elbows and knees, the improvement rates with metformin were respectively 25%, 29.16% and 37.5% which were not significant. On the other hand, improvement rates of neck severity, neck texture and axilla among cases of control group was11.11%. Improvement rates in cases of control group of elbow, knee and knuckle were 14.28%, 16.66% and 0% respectively. No side-effect except nausea in four subjects was reported during study period.   Table-2: Improvement rates of AN on different anatomic locations   Severity / Presence of AN   Improved (%) Not Improved (%) P value Neck Severity (n= 60) Control (n=20) 11.11 88.89   Drug  (n=40 ) 67.5 32.5 <0.005 Neck Texture (n=60 ) Control (n=20) 11.11 88.89   Drug (n=40 ) 62.2 37.8 <0.005 Axilla (n=60 ) Control (n=20) 11.11 88.89   Drug (n= 40 ) 70.0 30.0 <0.005 Elbow (n=31 ) Control (n=7) 14.28 85.72   Drug (n=24) 29.16 70.84 >0.05 Knee (n=30 ) Control (n=6) 16.66 83.34   Drug (n=24 ) 37.50 62.50 >0.05 Knuckle (n=27 ) Control (n=7) 00.00 100.00   Drug (n=20 ) 25.00 75.00 >0.05     Table-3: Improvement of AN in different sites following metformin treatment as determined by quantitative scale of measuring AN   This study demonstrates that metformin therapy for AN with IR has a significant beneficial effect and is also safe and well tolerated. Improvement was assessed by reduction of score as measured by the quantitative scaling method scale [18] and vice versa. The study also reveals that metformin has different clinical effects on AN in different anatomic location. It seems that its effect is more pronounced in AN affecting axilla and neck. It could be due to the presence of more insulin-like growth factor 1 receptors in these specific sites. But further specific study is needed to elucidate its mechanism in these sites. Correcting hyperinsulinemia was presumably accomplished by metformin and led to improvement or resolution of AN. Oral metformin hydrochloride is a first choice drug in the treatment of AN associated to obesity and IR [1]. Metformin does not induce hypoglycemia but prevents hyperglycemia. In IR, hyperinsulinemia precedes type 2 diabetes mellitus sometimes by many years. AN develops during this non-diabetic hyperinsulinemic period. Thus, recognition of AN identifies those at increased risk of developing type 2 diabetes mellitus, dyslipidemia and hypertension. Therefore, recognition of AN offers an opportunity for both preventive measures and focused intervention. The present study had some limitations. The sample size was small and the long-term effects of metformin on the outcome of AN could not be assessed. The diagnostic and scoring criteria used in the study was based solely on direct visual examination. No histopathological scoring or grading technique of AN was available. Study was precisely directed to AN associated with biochemical evidence of IR and AN due to other causes was not included. This research was funded by Aristopharma Ltd. We express our acknowledgement to Dr. Shahidul Alam Khan, PhD, Chief Research Officer and Head, Dept. of Endocrinology and Immunology, BIRDEM, for overall guidance and support for performing laboratory works; Dr. Md. Zahid Hasan, Associate Prof. Dept of Physiology and Molecular Biology, BIRDEM, for his valuable opinion regarding the laboratory methods. We are also grateful to Dr. Anisur Rahman, Dr. Lipika and colleagues and staffs of Dermatology department of BIRDEM General Hospital for supporting and referring patients.   References 1.         Garofalo L, Biscozzi AM, Mastrandrea V, Bonifazi E. Acanthosis nigricans vulgaris. A marker of hyperinsulinemia. European Journal of Pediatric Dermatology 2003; 13: 85-88. 2.         Kong AS, Williams RL, Rhyne R, Sandoval VU, Cardinali G, Weller NF. Acanthosis nigricans: High prevalence and association with diabetes in a practice-based research network consortium- APRImary care Multi-Ethnic network (PRIME Net) study. J Am Board Fam Med 2010; 23(4): 476-85. 3.         Eberting CL, Javor E, Gorden P, Turner ML, Cowen EW. Insulin resistance, acanthosis nigricans, and hypertriglyceridemia. J An Acad dermatol 2005; 52(2): 341-44. 4.         Rigel DS, Jacobs MI. Malignant acanthosis nigricans: a review. J Dermatol Surg Oncol 1980; 6(11): 923-27. 5.         Maitra SK, Rowland Payne CM. The Obesity syndrome and acanthosis nigricans. J Cosmet Dermatol 2004; 3(4): 202-10. 6.         DeWitt CA, Buescher LS, Stone SP. Cutaneous manifestations of internal malignant disease: cutaneous paraneoplastic syndromes. In: Wolff K, Goldsmith LA, Katz GSI, Gilchrest BA, Paller AS, Leffell DJ, editors. Fitzpatrick’s Dermatology in General Medicine.7th eds. USA: McGraw-Hill 2008. 7.         Schwartz RA. Acanthosis nigricans. J An Acad dermatol 1994; 31(1):1–19.  8.        James WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin: Clinical Dermatology. 10th ed. USA: Elsevier 2006. 9.         Brown J, Winkelmann RK. Acanthosis nigricans: study of 90 cases. Medicine (Baltimore) 1968; 47(1): 33-51. 10.        Schnopp C, Baumstark J. Oral acanthosis nigricans. N Engl J Med 2007; 357(9): e10. 11.        Hasan I, Rashid T, Tasnim I, Rhaman MM. Hyperclycemia, Young Age, Altered Sleep Habits: The Three Shifting Paradigms of Coronary Artery Disease Risk Stratification. Ibrahim Medical College Journal. 2013; 6(2): 39-45. 12.        Omar HA, Logsdon S, Richards J. Clinical profiles, occurrence, and management of adolescent patients with HAIR-AN syndrome. The Scientific World Journal2004; 4: 507-11. 13.        Higgins SP, Freemark M, Prose NS. Acanthosis nigricans: a practical approach to evaluation and management. Dermatol Online J 2008; 14(9): 2. 14.        Romo A, Benavides S. Treatment options in insulin resistance obesity-related acanthosis nigricans. Ann Pharmacother 2008; 42(7): 1090-94. 15.        Tankova T, Koev D, Dakovska L, Kirilov G. Therapeutic approach in insulin resistance with acanthosis nigricans. Int J Clin Pract 2002; 56(8): 578-81. 16.        Hermanns-Lê T, Hermanns JF, Piérard GE. Juvenile acanthosis nigricans and insulin resistance. Pediatr Dermatol 2002; 19(1): 12-14. 17.        Rique S, Ibáñez L, Marcos MV, Carrascosa A, Potau N. Effects of metformin on androgens and insulin concentrations in type A insulin resistance syndrome. Diabetologia 2000; 43(3): 385-86. 18.        Burke JP, Hale DE, Hazuda HP, Stern MP. A quantitative scale of acanthosis nigricans. Diabetes Care 1999; 22(10): 1655-9. 19.        Hydrie MZ, Basit A, Fawwad A, Ahmedani MY, Shera AS, Hussain A. Detecting insulin resistance in pakistani subjects by fasting blood samples. The Open Diabetes Journal 2012; 5: 20-24. 20.        Bellot-Rojas P, Posadas-Sanchez R, Caracas-Portilla N, Zamora-Gonzalez J, Cardoso-Saldaña G, Jurado-Santacruz F et al. Comparison ofmetforminversus rosiglitazone in patients with acanthosis nigricans: a pilot study. J Drugs Dermatol 2006; 5(9): 884-89. 21.        Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner RC. Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia 1985; 28(7): 412–19. 22.        Levy JC, Matthews DR, Hermans MP. Correct homeostasis model assessment (HOMA) evaluation uses the computer program. Diabetes Care 1998; 21(12): 2191–92. 23.        Hermans MP, Levy JC, Morris RJ, Turner RC. Comparison of insulin sensitivity tests across a range of glucose tolerance from normal to diabetes. Diabetologia 1999; 42(6): 678–87. 24.        Rudenski AS, Matthews DR, Levy JC, Turner RC. Understanding insulin resistance: Both glucose resistance and insulin resistance are required to model human diabetes. Metabolism1991; 40(9): 908–17. 25.        Wallace TM, Levy JC, Matthews DR. Use and abuse of HOMA modeling. Diabetes Care 2004; 27(6): 1487–95. 26.        Turner et al. Measurement of insulin resistance and β-cell function: the HOMA and CIGMA approach. Current topics in diabetes research. In: Belfiore F, Bergman R, Molinatti G, editors. Front Diabetes. Basel, Karger 1993; 12: 66-75. 27.        Hermans MP, Levy JC, Morris RJ, Turner RC. Comparisons of tests of beta-cell function across a range of glucose tolerance from normal to diabetes. Diabetes 1999; 48(9): 1779–86. 28.        Acbay O, Gündoğdu S. Can metformin reduce insulin resistance in polycystic ovary syndrome? Fertil Steril 1996; 65: 946-49. 29.        Ehrmann DA, Cavaghan MK, Imperial J, Sturis J, Rosenfield RL, Polonsky KS. Effects of metformin on insulin secretion, insulin action and ovarian steroidogenesis in women with polycystic ovary syndrom. J Clin Endocrinol Metab 1997; 82: 524-30. <![CDATA[Prophylactic intracameral vancomycin: efficacy in preventing endophthalmitis after cataract surgery]]> Manash Kumar Goswami Md. Ferdous Hossain Md. Asaduzzaman https://imcjms.com/journal_full_text/92 2016-09-26 09:43:58 Original Article IMC J Med Sci 2016; 10(1): 24-28 Abstract Background and objective: Post Operative endophthalmitis is rare but devastating complication in ocular surgery. The present study determined the efficacy of intracameral vancomycin after phaco-emusification cataract surgery to prevent endophthalmitis. Method: A total of 768 cases who had undergone phaco-emusification cataract surgery were included in the study. Every alternate patient received 0.5 ml injection of vancomycin (1mg in 0.1 ml) in the anterior chamber after completion of phaco-emulcification and formation of anterior chamber. All the patients were examined for symptoms and signs of bacterial endophthalmitis at 24 hrs, 7 days, 15 days and subsequently at 1, 3 and 6 months following surgery. Results: No endophthalmitis case was recorded at any time period during 6 month follow up in either group. However, significantly higher number of cases in vancomycin group had cells in anterior chamber and disturbances in visual acuity at day 15 following surgery. Conclusion: Vancomycin did not have any prophylactic role in preventing endophthalmitis. Proper aseptic measures are important to prevent any infection in ocular surgery. IMC J Med Sci 2016; 10(1): 24-28. DOI: https://doi.org/10.3329/imcjms.v10i1.31102 Address for Correspondence: Dr. Manash Kumar Goswami, Associate Professor, Department of Ophthalmology, BIRDEM General Hospital,             122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka. Email: manashkg@yahoo.com   <![CDATA[Human papillomavirus infection among Bangladeshi women with cervical intraepithelial neoplasia and chronic cervicitis]]> Elisha Khandker Mansura Khan Ahesh Kumar Chowdhury https://imcjms.com/journal_full_text/104 2016-10-08 10:21:48 Original Article IMC J Med Sci 2016; 10(1): 29-32 Abstract Background and objectives: Cervical cancer is one of the leading causes of morbidity and mortality. Human papillomavirus (HPV) is known to be associated with cervical intraepithelial neoplasia (CIN) and cancer. The objective of the present study was to determine the rate of HPV infection among the Bangladeshi women with different grades of CIN and cancer. Methods: Women aged 20 to 55 years, diagnosed as a case of chronic cervicits, cervical intraepithelial neoplasia (CIN) or invasive cancer by Papanicolaou (Pap) smear and colposcopy directed biopsy were enrolled in the study. High and intermediate risk oncogenic HPV were detected in cervical samples by real time PCR (rt-PCR).  Results: Seventy two women with chronic cervicitis and different grades of CIN were included in the study. Out of 72 cases, 28 (38.9%) and 44 (61.1%) had chronic cervicitis and CIN respectively. Overall, the HPV infection  rate was 43.1% (95% CI= 32%-54%) among the study population. CIN cases had significantly high (p<0.01) HPV infection (78.6%; 95% CI=60%-89%) compared to cases with chronic cervicitis (18.2%; 95% CI=11.1%-34.5%). Women between the age of 20-30 years had the highest positive rate (50.0%) followed by 31-40 years age group (43.6%). All CIN grade 2 and 3 had HPV infection. Conclusion:  The study showed that HPV was strongly associated with different grades of CIN. Specific HPV types should be determined to find out  the most prevalent HPV types among the Bangladeshi women with CIN and cervical cancers.        A total of 72 women with chronic cervicitis and different grades of CIN were included in the study. Out of 72 cases, 28 (38.9%) and 44 (61.1%) had chronic cervicitis and CIN respectively. The distribution of HPV positive cases in different age groups is shown in Table-1. Overall, the HPV positive rate was 43.1% among the study population.  Women between the age of 20-30 years had the highest positive rate (50.0%) followed by 31-40 years age group (43.6%).  Age group 20-30 and 31-40 years had significantly higher (p<0.05) HPV positive rate compared to women above 40 years of age. Table 2 shows that cases with CIN had significantly high (p<0.01) HPV infection (78.6%) compared to those with chronic cervicitis (18.2%). All cases of CIN 2 and CIN 3 were positive for HPV compared to 57.1% cases of CIN 1.      Total Case Total positive N (%) 26 31 – 40 14 (43.6) 14 Total 31 (43.1)*              *95% CI for total HPV positivity rate= 32%-54%                           grade of CIN  and chronic cervicitis Category HPV positive case 1. Chronic cervicitis         CIN 1       CIN 3 28 11 9 (20.5) 09 (57.1)    3 (100.0)  Note: p < 0.01, compared between the CIN and chronic cervicitis group.             95% CI for CIN= 60%-89%; Chronic cervicitis= 11.1%-34.5%               Discussion The present study has demonstrated that high and intermediate risk oncogenic HPV types are prevalent in different grades of CIN and chronic cervicitis cases. All CIN grade 2 and 3 cases were positive for HPV while >50% was positive in CIN1. The rate of HPV infection was significantly low in chronic cervicitis (18.2%) but it was comparatively higher than in Bangladeshi women with normal cervical cytology [12]. Studies in different countries of Africa reported similar high rate of HPV infection in different grade of CIN [6]. But a previous study from Bangladesh in 2009 reported only 7-10% HPV positivity rate among CIN 2, CIN 3 and invasive carcinoma of the cervix [14]. In the present study, we could not determine the prevalence of particular HPV types as the commercial kit we used detected both high and intermediate risk HPV types as whole. A previous study in Bangladesh reported presence of high risk HPV type (16, 18, 31 and 45) in about 56% of women with high risk behavior [13]. Similarly, a population based study in Bangladesh also found the prevalence of high risk HPV types among women with normal cytology [12].   1. GLOBOCAN 2012: Population Fact Sheets World. GLOBOCAN 2012: Estimated Cancer Incidence, Mortality and Prevalence Worldwide in 2012. 3. Stanley M. Immune responses to human papillomavirus. Vaccine. 2006; 24:S16–S22 5. Bruni L, Diaz M, Castellsagué X, Ferrer E, Bosch FX, de Sanjosé S. Cervical human papillomavirus prevalence in 5 continents: Meta‑analysis of 1 million women with normal cytological findings. J Infect Dis 2010; 202:1789‑99. 7. Ebrahim S, Mndende XK, Kharsany ABM, Mbulawa ZZA, Naranbhai V, Frohlich J, et al. High burden of human papillomavirus (HPV) infection among young women in KwaZulu-Natal, South Africa. PLoS ONE  2016; 11(1): e0146603.doi:10.1371/journal.pone.0146603  papillomavirus infection in Beijing, People’s Republic of China: a population based study. British Journal of Cancer 2009; 101: 1635–1640. 10. Sukvirach S, Smith JS, Tunsakul S, Munoz N, Kesararat V, et al. Population-based human papillomavirus prevalence in Lampang and Songkla, Thailand. The Journal of Infectious Diseases 2003; 187: 1246–1256. 12. Nahar Q, Sultana F, Alam A, Islam JY, Rahman M, et al. Genital human papillomavirus infection among women in Bangladesh: findings from a population-based survey. PLoS ONE  2014; 9(10): e107675. doi:10.1371/journal.pone.0107675 14. Khatun S,  Hussain SMA, Hossain F, Chowdhry A. Human papillomavirus and other risk factors of carcinoma cervix. Bangladesh Medical Journal 2009; 38 (1): 22-27. <![CDATA[Autoimmune polyendocrine syndrome type 1 – a case report from Bangladesh]]> Tahniyah Haq Anisur Rahman Shapur Ikhtaire https://imcjms.com/journal_full_text/96 2016-10-01 09:45:42 Clinical Case Report IMC J Med Sci 2016; 10(1): 33-35 Abstract Autoimmune polyendocrine syndrome (APS) type 1 is a rare disorder characterized by multiple endocrine organ dysfunctions due to autoimmune activity [1]. This rare condition typically presents with mucocutaneous candidiasis followed or accompanied by endocrinopathies. We report a case of autoimmune polyendocrine syndrome type 1, which has rarely been reported in Bangladesh. However, our patient did not manifest candidiasis until several years after his initial presentation.    Case report On query, he mentioned that when he was 10 years old, he suffered from anorexia, weakness, weight loss and failure to gain height followed by an acute attack of vomiting and diarrhea with unconsciousness. He regained consciousness after being treated with intravenous fluids and hydrocortisone. At the age of ten, his height was 117 cm (below 3rd percentile), weight 21 kg (below 3rd percentile), BMI 15.3 kg/m2 (between 10 and 25th percentile), arm span 112 cm, upper segment 58 cm and lower segment 59 cm. Growth velocity was reduced (1cm/year). His blood pressure at the time was 110/90 mmHg lying and 100/75 mmHg standing. There was pigmentation over the lips, palate, buccal mucosa and widespread darkening of the skin. The thyroid gland was not palpable. Systemic examinations including the genitalia were unremarkable. At that time fasting blood glucose level was 5.1 mmol/L (3.5-5.5 mmol/L), serum sodium was 118 mmol/L (135-145 mmol/L), potassium was 5.2 mmol/L (3.6-5.5 mmol/L), and bicarbonate was 17 mmol/L (21-29 mmol/L). Bone age was not delayed. Primary adrenal insufficiency was suspected and confirmed by rapid adrenocorticotropic hormone (ACTH) stimulation test.  Morning cortisol level was 80 nmol/L (95-571 nmol/L). Serum cortisol at 30 min and 60 min was 143.26 nmol/L and 39.99 nmol/L respectively. He was prescribed lifelong replacement steroids (prednisolone 7.5 mg and fluodrocortisone 0.1 mg daily). Subsequently, he noticed dimness of vision and was diagnosed with bilateral cataract a year later. The cataract was surgically removed and intraocular lens implanted. At the age of 12 years, he noticed tingling, numbness and cramps in his hand and had signs of latent tetany i.e. trousseau’s sign. Calcium profile was done at that time and serum calcium was found to be 5.6 mg/dl (9-11 mg/dl), phosphate was 10.5 mg/dl (1.7-4.5) and serum alkaline phosphatase was 173 IU/L (<370). Despite a low serum calcium level, intact parathyroid hormone level was 3.5 pmol/L (1.6-7.5 pmol/L), i.e. not elevated. This confirmed a diagnosis of hypoparathyroidism. Accordingly, calcium 3 gm with vitamin D 800 IU were prescribed daily.   Autoimmune polyendocrine syndrome (APS) is a heterogenous group of rare diseases characterized by autoimmune activity against more than one endocrine organ. However, non-endocrine organs can also be affected [1]. The two major autoimmune polyendocrine syndromes are type 1 and 2, with type 2 being more common. APS 1 is inherited as an autosomal recessive manner and linked to mutation of the AIRE gene (autoimmune regulator gene) on chromosome 21 [2-4]. Strong genetic components have been reported in APS. Though the type 2 syndrome occurs in multiple generations, type 1 is most commonly reported among siblings [2]. Patients with APS type 1 express autoantibody which react with specific antigens. For example, the presence of anti-adrenal antibody (antibody against 21-hydroxylase) is linked to the development of Addison’s disease [5]. The clinical manifestation of type 1 APS is widely variable. Although the classic triad is composed of mucocutaneous candidiasis, hypoparathyroidism and primary adrenal insufficiency (Whitaker’s triad), many other components like autoimmune thyroid disease, diabetes mellitus type 1, hypergonadotropic hypogonadism, pernicious anemia, autoimmune hepatitis, tubulointerstitial nephritis, vitiligo and alopecia areata may also develop [6-8]. The disease presents with dental enamel dystrophy, nail dystrophy and ectodermal dysplasia. The onset of APS is usually in infancy and mucocutaneous candidiasis followed by primary adrenal insufficiency is typically the first manifestations to be observed. It is well recognized that several years may elapse between the onset of one endocrinopathy and the development of the next endocrine disorder. For example, 40 to 50% patients with Addison’s disease will subsequently develop other autoimmune diseases [9]. Therefore, continued monitoring for the development of other autoimmune diseases is mandatory. Diagnosis is made by the presence of two out of three components of the classic triad, or the presence of one criterion and a sibling previously diagnosed with ASP 1. Patients presenting without overt features of the syndrome can be diagnosed by molecular genetics. APS 1, though rare, is found in the community. It should be differentiated from other autoimmune polyendocrine syndromes such as APS 2. The patient with APS should be followed up and monitored for several years for the development of other endocrinopathies. Since the disorder runs in families, siblings should be screened for the disorder as well.   References 1.   Michels AW, Gottlieb PA. Autoimmune polyglandular syndromes. Nat Rev Endocrinol 2010; 6: 270–7. 2.   Barker JM. Clinical review: type 1 diabetes-associated autoimmunity: natural history, genetic associations, and screening. J Clin Endocrinol Metab 2006; 91: 1210–1217. 3.   Lindmark E, Chen Y, Georgoudaki AM, Dudziak D, Lindh E, Adams WC, et al. AIRE expressing marginal zone dendritic cells balances adaptive immunity and T-follicular helper cell recruitment. J Autoimmun 2013; 42: 62–70. 4.   Aaltonen J, Björses P, Sandkuijl L, Perheentupa J, Peltonen L. An autosomal locus causing autoimmune disease: autoimmune polyglandular disease type I assigned to chromosome 21. Nat Genet 1994; 8: 83–7. 5.   Perniola R, Falorni A, Clemente MG, Forini F, Accogli E, Lobreglio G. Organ-specific and non-organ-specific autoantibodies in children and young adults with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED). Eur J Endocrinol 2000; 143: 497–503. 6.   Bialkowska J, Zygmunt A, Lewinski A, Stankiewicz W, Knopik-Dabrowicz A, Szubert W, et al. Hepatitis and the polyglandular autoimmune syndrome, type 1. Arch Med Sci 2011; 7: 536–539. 7.   Oliva-Hemker M, Berkenblit GV, Anhalt GJ, Yardley JH. Pernicious anemia and widespread absence of gastrointestinal endocrine cells in a patient with autoimmune polyglandular syndrome type I and malabsorption. J Clin Endocrinol Metab 2006; 91: 2833–2838. 8.   Weiler FG, Magnus R, Dias-da-Silva, Lazaretti- Castro M. Autoimmune polyendocrine syndrome type 1: case report and review of literature. Arq Bras Endocrinol Metab 2012; 56(1): 54-66. 9.   Cutolo M. Autoimmune polyendocrine syndromes. Autoimmune Rev 2014: 13: 85–89. 10.  Ali MY, Rashiduzzaman HM, Masud M, Wadud MA, Quadir S, Fattah SKA, Karim ME. A Case report on autoimmune polyendocrine syndrome type 1. J Medicine 2014; 15: 98-101. <![CDATA[Non-fatal drowning in under-five rural children of Bangladesh]]> Syed Hassan Abdullah Meerjady Sabrina Flora https://imcjms.com/journal_full_text/75 2016-08-02 12:17:45 Original Article Ibrahim Med. Coll. J. 2015; 9(2): 37-41 Drowning has been identified as a major cause of death in children in both developed and developing countries. Non-fatal drowning is several times higher than the fatal drowning. To describe the socio-demographic and environmental attributes of non-fatal drowning in rural children this community based descriptive study was conducted on 122 children having non-fatal drowning events within one year of study period. This study was undertaken in Raigonj sub-district of Sirajgonj district in Bangladesh. Mothers of those children were interviewed using a structured questionnaire. Out of all participants 56.6% children were 2-4 years of age and male-female ratio was almost equal. Of the total respondent mothers 55% were illiterate and 41.8% were below the age of 25 years. Seasonal variation was observed in non-fatal drowning. Rainy season (50.8%) appeared as the most risky period followed by summer (29.5%). Higher incidence occurred (53.3%) between 10 am to 2 pm of the day. Although most of the drowning occurred outside the home, 9% drowning occurred in water container (like drum, tub) within the home. Pond (50.5%) was found as the most common place among open water source. During the occurrence, 23% child was not accompanied by parents or any caregivers. At the time of drowning, 47.5% mothers were engaged with usual household work and were not present at the place of occurrence whereas 13% mothers were present around the place of occurance. Before drowning, 45.1% victim was either playing, bathing or swimming in the water. Only 10.7% needed resuscitation, 25% were taken to health centre and reached the health centre within an hour, about a fifth (22.6%) of them were admitted. Restriction in dangerous water activities, strengthening supervision of children might decrease the incidence of drowning while quick and effective medical response might prevent its fatal consequences. Ibrahim Med. Coll. J. 2015; 9(2): 37-41     Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid. Its outcomes are death, morbidity, and no morbidity.1,2 Non-fatal drowning is the unintentional submersion in open water reservoir and household water containers with or without morbidity and no fatal consequence within 24 hours.3 Drowning has been identified as a major killer of children in both developed and developing countries. Children younger than 5 years old account for nearly 40% of all drowning fatalities.4-7 In 1–4 year old children, drowning is the second leading cause of injury death in the United States and Africa and the leading cause in Australia.8 There are an estimated 500,000 significant submersions in the United States each year; 50,000 of these require medical intervention. As many as 50% of all submersion victims are declared dead at the scene and never referred to medical facilities for care.8,9 For every death in child drowning, four cases are hospitalized and 16 receive emergency care for non-fatal drowning at the point of occurance.10 Although, in addition to mortality due to drowning, it is a major cause of morbidity for children while non-fatal drowning yet remains poorly understood. Most previous studies on drowning focused on description of drowning mortality and trends.11-13 There are few international studies done on non-fatal drowning in China14-16 USA17-19 and Australia.20-22 This exploratory study was an attempt to find out the issues and factors associated with non-fatal drowning cases in a rural area of Bangladesh. Methodology Mothers of index children were interviewed using a pretested semi-structured questionnaire in Bengali. The questionnaire was pretested and finalized after necessary modifications. A check list was prepared to observe certain environmental variables. Data were collected on variables related to socio-economic status and occurrence of non-fatal drowning. Statistical Package for Social Sciences (SPSS) version 17.0 was used to analyse the data. The study was approved by the Ethical Committee of National Institute of Preventive and Social Medicine (NIPSOM), Bangladesh. Informed consent was obtained from mothers after explaining the purposes of the research. Sex distribution of 122 non-fatal drowning cases was almost equal between boys (62) and girls (60). Mean age of the children was 43.8 months and 56.6%of children was between 2-4 years of age while 27% was more than 4 years of age.   Table 1 Parental Socio-demographic and economic characteristics of the parents of enrolled participants (n=122)                                                                                            Table 2 Distribution of non-fatal drowning events (n=122)         Table 3 Events while drowning took place         Table 4 Measures taken after non-fatal drowning event       Discussion In this study 91% non-fatal drowning incidents occured in natural bodies of water outside the home premises. The finding is similar with fatal drowning data in China.8 But it, is different from non-fatal drowning data of USA where 75% of non-fatal drowning occurred in swimming pools.18 This indicates that the locations of non-fatal drowning are likely to be different between and within countries due to geographical and economic differences. Seasonal variations in child drowning also observed in this study. About half of the drowining events occurred in rainy season. Bangladesh is a tropical country and during monsoon heavy rainfall floods and fills up the rivers, canals, ponds and ditches. For this, children have more chance to be exposed to wider area for risk of drowning. Hot summer season is also appeared as vulnerable (29%) as hot and humid temperature allure kids to more water fun which may end up in drowning in many cases. This trend has been observed in other studies in both developing and developed countries.8,16,18 Total 53.3% incidents occurred between 10 am to 2 pm followed by morning. During these time periods parents in rural area usually remain busy with livelihood or household works, elder siblings stay in school resulting in unattended kids. Early rescue and management, either on spot or in health centre, play vital role in preventing fatal outcome of drowning. In this study 10.7% cases received immediate resuscitation and 31 cases were taken to health centre and mostly reached the health facility within an hour. Minimum time loss before resuscitation is one of the key factors to save the life of drowning victim.18 These findings are supported by studies in China and Australia.8,21   1.    Krug E. Injury: A leading cause of the global burden of disease. Geneva: Department of Injuries and Violence Prevention, Non-communicable Diseases and Mental Health Cluster, World Health Organization 2002; 50. 3.    Wen JM, Shao PN et al. An analysis of risk factors of non-fatal drowning among children in rural areas of Guangdong Province, China: A case-control study. BMC Public Health 2010; 10: 156. 5.    Peden M, McGee K, Sharma G: The injury chart book: A graphical overview of the global burden of injuries. Geneva: World Health Organization 2002. 7.    Barss P. Drowning and other Water-related injuries in Canada. 1991-2000, Module 1: overview. The Canadian Red Cross Society 2006. 9.    Wintemute G, Kraus J, Teret S, Wright M. Drowning in childhood and adolescence: a population-based study. American Journal of Public Health 1987; 77: 830-832. 11.  Rahman A, Mashreky SR, Chowdhury SM, Giashuddin MS, Uhaa IJ, Shafinaz S et al. Analysis of the childhood fatal drowning situation in Bangladesh: exploring prevention measures for low income countries. Injury Prevention 2009; 15: 75-79. 13.  Rahman A, Rahman F, Shafinaz S, Linnan M. Bangladesh Health and Injury Survey: Report on children 2005; (5): 49–56. available at: http://www. unicef.org/bangladesh/Bangladesh_Health_and_Injury_ Survey-Report_on_Children.pdf 15.  Ma WJ, Xu YJ, Zhang YR. The study on death pattern and burden of disease in Guangdong province, China. Guangzhou: The economic press of Guangdong province 2008. 17.  Wintemute GJ. Childhood drowning and near-drowning in the United States. Am J Dis Child 1990; 144: 663–9. 19.  Calder RA, Clay CY. Drowning in Florida 1977–1986. J Flo Med Assoc 1990; 77: 679–82. 21.  Pitt WR, Balanda KP. Childhood drowning and near drowning in Brisbane: The contribution of domestic pools. Med J Aust 1991; 154: 661–5. 23.  Ahmed MK, Rahman M, Ginneken JV. Epidemiology of child death due to drowning in Matlab, Bangladesh. International Journal of Epidemiology 1999; 28: 306-311 <![CDATA[Use of antibiotics in selected tertiary and primary level health care centers of Bangladesh]]> Abdullah Akhtar Ahmed Md. Shariful Alam Jilani Osul Ahmed Chowdhury KM Shahidul Islam Md. Akram Hossain Md. Jahangir Alam Md. Abdullah Siddique Lovely Barai Fahmida Rahman J. Ashraful Haq https://imcjms.com/journal_full_text/76 2016-08-02 12:19:35 Original Article Ibrahim Med. Coll. J. 2015; 9(2): 42-44 A cross sectional study was conducted in inpatient department of seven primary level hospitals care centers (PLHCs) and six tertiary level hospitals (TLHs) of the country. Total 2058 hospitalized patients were interviewed over a six month period from October 2012. Most of the patients (85.9% in TLH and 100% in PLH) were prescribed with antibiotics at the time of admission. Only 6.4% patients of TLHs treated with antibiotic had culture proven infection and rest of the patient of TLH and all the patients of PLH were treated with antibiotic empirically. Top prescribed antibiotic was ceftriaxone (39.64% in TLH, 59.64% in PLH). Parenteral route of antibiotic administration was preferred for both at TLHs and PLHCs (63.3% and 76.9%). The results of the present study indicated that antibiotics were widely and inappropriately used without following standard guidelines or based on any rationality. This is an alarming situation, and needs to be addressed by the relevant authority to save the people from growing antibiotic resistance. Ibrahim Med. Coll. J. 2015; 9(2): 42-44     Medicines play an important role in health care delivery and disease prevention. The availability and affordability of good quality drugs along with their rational use is needed for effective health care. Antimicrobial agents are the most frequently prescribed drugs among hospitalized patients. However, irrational drug use is prevalent, especially in the developing countries due to irrational prescribing, dispensing, and administration of medications.1 Excessive and inappropriate antibiotic use can lead to the emergence of bacterial resistance. Resistance of common hospital-acquired bacteria to antibiotics is a worldwide problem. It can lead to increased morbidity, mortality, length of hospital stay and healthcare expenditures.2 Rational use of drugs is based on ‘Rule of Right’ - ‘The right drug given to the right patient at the right time with the right doses’. They should also fulfill safety, affordability, need and efficacy.3 Prevention of antibiotic misuse is the key for controlling the antibiotic resistance. Approximately, 80 % of antibiotic are used in primary care in India.4 Therefore, it is immensely important to review in and outpatient prescribing practice on regular intervals. We therefore, initiated this study to investigate the present status of inpatient prescription pattern of antibiotics in urban and rural healthcare facilities in Bangladesh. Materials and Methods Total 2058 admitted patient were included in this study. All relevant information were collected by trained data collectors from the patient’s treatment record file and documented in a pre-designed data sheet. These include the features of infection, culture and related investigations, diagnosis, antibiotics given with dose, route, and duration of therapy. Ethical approval was obtained from Institutional review committee of Ibrahim Medical College. Informed consent was obtained from all participants and facilities involved in the study. Result     Table-2: Indication and pattern on antibiotic prescription at TLHs & PLHCs   Discussion According to World Health Organization (WHO), 15% to 20% prescriptions are expected with antibiotics in most of the developing countries where infectious diseases are more prevalent.6 In the present study, we have found that more than 85% of admitted patients were treated with antibiotics in TLHs. The rate was high as 100% in PLHCs. Similar trend of frequent antibiotic use had been reported from Pakistan (78%), Nepal (79.9%) and India (80%).7-9 Most common suspected infection was respiratory tract infection followed by gastro-intestinal tract infection. In acute gastro-intestinal and respiratory tract infections antibiotic are often not needed as viruses are the most common cause. WHO guideline for the treatment of diarrhea, clearly mention that antibiotics should not be used routinely. It is not possible to distinguish clinically the episode of diarrhea caused by enterotoxigenic E. coli from those caused by rota viruses.10 This type of practice may be due to over estimation of severity of illness, demand of rapid symptomatic relief by patients and tendency towards empirical therapy rather than personalized therapy. It was also observed that ceftriaxone was the most frequently (39.64% in TLH, 59.64% in PLH) prescribed antibiotics in admission followed by ciprofloxacin (19.23% in TLH & 15.69% in PLH). The extensive use of third generation parentral cephalosporins has caused the emergence of extended spectrum beta-lactamases in Gram-negative bacteria worldwide.11,12 Third generation cephalosporins are being widely used in hospitals as empirical and prophylactic therapy. This would eventually limit their usefulness in life threatening conditions. Moreover, it appears that there was a tendency to use injectable antibiotics over oral forms. A large proportion of patients were given multiple antibiotics. Such irrational multidrug prescription would lead to increased cost of therapy, more adverse reaction and emergence of resistance.   1.    Ehijie FO Enato and Ifeanyi E Chima. Evaluation of drug utilization patterns and patient care practices. West African Journal of Pharmacy 2011; 22(1): 36–41. 3.    Islam MR, Misbahuddin M. General Principles of Pharmacology. 5th ed. Dhaka: Bengal Library2006; 170-73. 5.    Minyahil A, Woldu, Sultan Suleman, Netsanet Workneh and Hafty barhane. Retrospective study of the pattern of Antibiotic Use in hawassa University Referral Hospital Pediartric ward, Southern Ethiopia. Journal of Applied Pharmaceutical Science 2013; 3(02): 93-98. 7.    Das N, Khan AN, Badini ZA, Baloch H. Prescribing practices of consultants at Karachi, Pakistan. J Pak Med Assoc 2001; 51: 74-77. 9.    Kumari Indira KS, SJ Chandy, L Jeyaseelan, Rashmi Kumar, Saradha Suresh. Antimicrobial prescription patterns for common acute infections in some rural & urban health facilities of India. Indian J Med Resm 2008; 128: 165-171. 11.  Cosgrove SE, Kaye KS, Eliopoulous GM, Carmeli Y. Emergence of third-generation cephalosporin resistance in Enterobacter species. Arch Intern Med 2002; 162: 186-190. <![CDATA[Detection of OXA-181/OXA-48 carbapenemase producing Enterobacteriaceae in Bangladesh]]> Rehana Khatun S.M. Shamsuzzaman https://imcjms.com/journal_full_text/77 2016-08-02 12:20:57 Original Article Ibrahim Med. Coll. J. 2015; 9(2): 48-54   Carbapenem resistant Enterobacteriaceae (CRE) is becoming a major public health concern globally. Detection of carbapenem hydrolyzing enzyme carbapenemase in Enterobacteriaceae is important to institute appropriate therapy and to initiate preventive measures. This study was designed to determine the presence of carbapenemase producers among the CRE isolated from patients at Dhaka Medical College Hospital, Bangladesh. Twenty-nine CRE strains detected by disk diffusion technique were included in the study. Minimum inhibitory concentration of imipenem and tigecycline was determined by agar dilution method. Carbapenemase production was phenotypically detected by Modified Hodge test while MBL producers were detected by combined disk and double disk synergy tests. Genes encoding blaNDM-1, blaOXA-181, blaOXA-48, blaKPC, blaCTX-M-15, blaOXA-1-group were identified by polymerase chain reaction (PCR). The result of this study showed the presence of blaOXA-181/ blaOXA-48, blaNDM-1 positive strains in Bangladesh and colistin and tigecycline were the most effective drugs against carbapenemase producing Enterobacteriaceae (CPE). Epidemiological monitoring of carbapenemase producing organisms in Bangladesh is important to prevent their dissemination. Ibrahim Med. Coll. J. 2015; 9(2): 48-54     The emergence of carbapenem resistant Enterobacteriaceae (CRE) is a major concern worldwide. This is because of their importance as human pathogens especially within the hospital settings and its high transmissible nature and tendency for rapid spread.1 This resistance is mediated by the production of carbapenemases or hyper production of Amp C beta lactamase and up regulation of efflux pumps or by their combined mechanisms.2 Carbapenem hydrolyzing beta lactamases which belong to Ambler classes A, B and D have been reported worldwide in Enterobacteriaceae. The most clinically significant ones are class A enzymes such as KPC-types, class B enzymes such as IMP, VIM and NDM-1 types and class D enzymes such as OXA-48 and OXA-181 types. The genes encoding them are located on mobile genetic elements, which allow them to spread.2-4   The present cross-sectional study was conducted in the Department of Microbiology of Dhaka Medical College, Dhaka, Bangladesh, during July 2010 to June 2011. The research protocol was approved by the Research Review Committee (RRC) and Ethical Review Committee (ERC) of Dhaka Medical College. Written consent was obtained from each patient or their legal guardian before collection of samples. Bacterial isolates and identification: Twenty-nine Enterobacteriaceae isolates resistant to carbapenem by disk diffusion technique were included in the study. The organisms were isolated from various clinical specimens. The specimens included wound swab, endotracheal aspirate, blood and urine. All the organisms were identified by Gram stain, colony morphology, hemolytic criteria, pigment production and standard biochemical tests.9         Double-disk synergy test (DDST):Imipenem disc (10 µg) and a disk containing 20 µl of Tris-EDTA (1.0 M Tris-HCL, 0.1 M EDTA, pHapproximately 8.0) and 20 µl of 1:320 diluted 2-mercaptopropionic acid (MPA) were placed 10 mm apart in an inoculated Mueller-Hinton agar plate and incubated at 370 C for 24 hours. A clear extension of the edge of the inhibition zone of imipenem disk toward the Tris-EDTA-MPA disk was interpreted as MBLs production.15 Molecular characterization of carbapenemase producers:The presence of blaNDM-1, blaKPC, blaOXA-181, and blaOXA-48 among CRE were detected by polymerase chain reaction (PCR). In addition, ESBL encoding gene blaCTX-M-15 and blaOXA-1group were also identified among the CRE by PCR. The primers used are shown in Table 1.2,16-18 To prepare bacterial pellets, a loop full of bacterial colonies was inoculated into a Falcon tube containing trypticase soy broth. After incubation overnight at 370 C, the Falcon tubes were centrifuged at 4,000 g for 10 minutes, after which the supernatant was discarded. A small amount of sterile trypticase soy broth was added into the Falcon tubes with pellets and mixed evenly. Then an equal amount of bacterial suspension was placed into three 1.5 ml microcentrifuge tubes. The microcentrifuge tubes were then centrifuged at 4,000 g for 10 minutes and the supernatant was discarded. The microcentrifuge tubes containing bacterial pellets were kept at -200 C until DNA extraction. Bacterial DNA was extracted by boiling method.17Multiplex PCR was done for identification of blaNDM-1, blaOXA-48 and blaKPC. Multiplex PCR reaction cycle consisted of preheat at 940C for 10 minutes followed by denaturation at 940C for 30 seconds, annealing at 520C for 40 seconds, extension at 720C for 50 seconds with a final extension at 720C for 5 minutes. In case of OXA-181, CTX-M-15, OXA-1-group, PCR reaction consisted of initial denaturation at 950C for 10 minutes, then 35 cycles of denaturation at 950C for one minute, annealing at 550C for 45 seconds, extension at 720C for one minute and final extension at 720C for 10 minutes. The amplified DNA were loaded into a 1.5% agarose gel, electrophoresed at 100 volts for 35 minutes, stained with 1% ethidium bromide and visualized under UV light. Table-1: Primers used in this study.2,16-18   Result           The rate of resistance to different classes of antibiotics ranged from 63.2% to 100% except colistin and tigecycline (Table 4). All 19 isolates were sensitive to colistin. The rate of resistance to tigecycline and tetracycline was 5.3% and 63.2% respectively. Organism positive for OXA-181/OXA-48 had a low level of resistance to imipenem (MIC 1 - 4 μg/ml) while NDM-1 positive organisms had high level resistance to imipenem (MICs 16 - ³ 32 μg/ml (Table 2). MIC of tigecycline ranged from 2-0.5 μg/ml except one had MIC 8 μg/ml (Table 2). Out of 19 carbapenemase positive isolates, 12 (63.16%) were extensively drug-resistant (XDR) and were only sensitive to tigecycline and colistin. Discussion OXA-181 is a close relative of OXA-48 from which it differs by 4 amino acids.24 blaOXA-181 positive K. pneumonia infections were first described in India but imported cases have since been described in Oman, Netherlands and New Zealand.6,7,20 There are no reports of blaOXA-181 positive isolates in Bangladesh. However, this country borders India, which is a source of blaOXA-181 positive Enterobacteriaceae. These cases highlight potential problems that may arise from the rapidly increasing practice of traveling across international borders to obtain health care. The present study is the first report of the presence of blaOXA-181/blaOXA-48 genes in Enterobacteriaceae in Bangladesh. In this study, eleven OXA-181/OXA-48 producing organisms were isolated. Out of 11 OXA-181/OXA-48 producing organisms 6 were co-harbored with NDM-1 producing gene and showed high level of resistance to imipenem, 5 isolates which harbored only OXA-181/OXA-48 producing genes showed low level of resistance which correlates with one study where it was shown that co-producing NDM-1 and OXA-181 was fully resistant to carbapenem whereas all OXA-181 producing isolates showed an apparent susceptibility to carbapenem.5 This study evaluated the presence of ESBL encoding genes in CPE. All the CPE harbored ESBL producing gene blaCTX-M-15 except one C. freundii and nine isolates had blaOXA-1-group gene. In the present study, CDT was found to be the most sensitive test in detecting carbapenemase producing organisms compared to DDST and MHT. It was reported that, sensitivity of MHT was low for NDM-1 producers (50%) but was increased to 85.7% by adding ZnSO4 (100 µg/ml) in the culture medium.26 The effect of Zinc might be multiple such as, it acts by increasing stability of the enzyme or/and by modifying porin expression.27 But in the present study, MHT detected 81.82% OXA-181/OXA-48 producers. It appears that MHT is suitable for OXA-181/OXA-48 producers but not for NDM-1. No phenotypic method is adequate to detect carbapenemase producers. It may be concluded that multiple phenotypic methods and PCR could be the most reliable and acceptable approach for early and accurate identification of carbapenemase producers.   1.    Balm ND, Ngan G, Jureen R, Lin TP, Teo WP. OXA-181-producing Klebsiella pneumoniae establishing in Singapore. BMC Infect Dis 2013; 13: 58. 3.    Carrer A, Poirel L, Erakey H, Cagatay AA, Badur S, Nordmann P. Spread of OXA-48 positive carbapenem resistant Klebsiella pneumonia isolates in Istanbul, Turkey. Antimicrob Agents Chemother 2008; 52(8): 2950-54. 5.    Dortet L, Poirel L, Al Yaqoubi F, Nordmann P. NDM-1, OXA-48 and OXA-181 carbapenemase-producing Enterobacteriaceae in Sultanate of Oman. Clin Microbiol Infect 2012; 18: E144–E148. 7.    Koh TH, Cao DYH, Chan KS, Wijaya L, Low SBG, Lam MS, Ooi EE, Hsu LY. blaOXA-181-positive Klebsiella pneumoniae, Singapore. Emerg Infect Dis 2012; 18(9): 1524–1525. 9.    Cheesbrough M. Microscopical techniques used in Microbiology, culturing bacterial pathogens, biochemical tests to identify bacteria. District Laboratory Practice in Topical Countries, Part 2: Cambridge University Press: 35-70. 11.  Magiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, Harbarth S, Hindler JF, Kahlmeter G, Olsson-Liljequist B, Paterson DL, Rice LB, Stelling J, Struelens MJ, Vatopoulos A, Weber JT, Monnet DL. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect 2012; 18: 268-281. 13.  Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing. 19th Informational Supplement. CLSI document. Wayne, PA: Clinical and Laboratory Standards Institute 2009; M100-S19. 15.  Kim SY, Hong SG, Moland ES, Thomson KS. Convenient test using a combination of chelating agents for detection of metallo-beta-lactamases in the clinical laboratory. J Clin Microbiol 2007; 45: 2798-2801. 17.  Guerra B, Soto SM, Arguelles JM, Mendoza MC. Multidrug resistance is medicated by large plasmids carrying a class 1 integron in the emergent Salmonella enterica serotype. Antimicrob Agents Chemother 2001; 45: 1305-1308. http://dx.doi.org/10.1128/AAC.45.4. 1305-1308.2001 19.  Nordmann P, Naas T, Poirel L. Global spread of Carbapenemase producing Enterobacteriaceae. Emerg Infect Dis 2011; 17: 1791-1798. 21.  Kalpoe JS, Naiemi N, Poirel L, Nordmann P. Detection of an Ambler class D OXA-48-type b-lactamase in a Klebsiella pneumonia strain in the Netherlands. J Med Microbiol 2011; 60: 677–678. 23.  Paño-Pardo JR, Ruiz-Carrascoso G, Navarro-San Francisco C, Gómez-Gil R, Mora-Rillo M, Romero-Gómez MP. Infections caused by OXA-48 producing Klebsiella pneumoniae in a tertiary hospital in Spain in the setting of a prolonged hospital wide outbreak. J Antimicrob Chemother 2013; 68(1):     89-96. 25.  Kumar S, Bandyopadhyay M, Mondol S, Pal N, Ghosh T and Banerjee P. Tigecycline activity against metallo-β-lactamase-producing bacteria. Avicenna J Med 2013; 3(4): 92-96. <![CDATA[Effects of aqueous and ethanolic extracts of Aegle marmelos (BAEL) leaves on chronic inflammation in rats]]> Sharmin Rahman Eliza Omar Eva Rezaul Quader Muqbula Tasrin Md Ismail Khan https://imcjms.com/journal_full_text/257 2017-07-13 09:45:30 Original Article Ibrahim Med. Coll. J. 2015; 9(2): 52-54 Aegle Marmelos Linn (Rutaceae) is used as ethno medicine against various human ailments. Several curde extracts from various parts (Leaves, flower, stem, root etc) of the plant A. marmelos Linn have shown variable anti-inflammatory effects in acute and chronic inflammation in animal models. The anti-inflammatory effects of A marmelos linn may be of special advantage compared to conventional anti-inflammatory drugs. The present study has therefore been undertaken with the objective to evaluate the anti inflammatory effect of aqueous and ethanolic extracts of A. marmelos leaves, compared to a standard anti-inflammatory drug (indomethacin) in chronic inflammatory conditions. The anti-inflammatory effect was studied in rats using cotton pellet implantation, where granuloma formation was used as an index of chronic inflammation. Aqueous and ethanolic extracts of A. marmelos leaves were given orally for 7 days daily at doses of 100 mg/kg body weight. The percent inhibition of granuloma formation following treatment with aqueous and ethanolic extracts of A. marmelos leaves, and indomethacin compared to control were 16.5%, 25.72%, and 39.37% respectively. The differences were statistically significant (p<0.05 in case of aqueous and ethanolic extracts and p<0.001 in case of indomethacin). The results suggest that in case of chronic inflammation, both aqueous and ethanolic extracts of A. marmelos have significant anti- inflammatory effect. The ethanolic extracts compared to aqueous extract produced greater anti- inflammatory effects. Ibrahim Med. Coll. J. 2015; 9(2): 52-54   Inflammation is normally a primary physiologic defense mechanism that helps body to protect itself from tissue injury caused by physical trauma, noxious chemicals or microbiological agents. It is the body’s effort to inactivate or destroy the invading organisms, remove irritants and set the stage for tissue repair.1 Though it is a defense mechanism, the complex events and mediators involved in inflammatory reactions induce, maintain or aggravate many disease processes. An uncontrolled and persistent inflammation may act as etiologic factor for many chronic illness.2 The currently available antiinflammatory drugs are a heterogeneous group of compounds, often chemically unrelated, which nevertheless share certain unwanted effects. The most common adverse effect is a propensity to induce gastric irritation, hyperacidityand other symptoms. Therefore, the present trend is to find out more acceptable agents which would be devoid of the potential adverse effect. Use of herbal medicine throughout the world is increasing. Plants are the primary source of supply of many important drugs used in modern medicine also.   Plant material and preparation of extract   Thirty two (32) Wister Albino Rats of either sex, weighting between 100-150g were kept under standard condition of light and temperature, fed with standard rat pellet diet and allowed to drink water ad libitum. Experimental design Percent inhibition of granuloma formation was calculated in each case by using the formula: 100 x (1- Wt / Wc). Where, Wt =mean dry weight of granuloma in drug treated group;   All the results have been expressed as the mean ± standard error of mean. The significance of the differences between treatment and control group were calculated using student’s t-test. Results       Discussion The study showed that both aqueous and ethanolic extracts of Aegle marmelos leaves produced significant anti inflammatory effect. The results of the present study provide a rationale for use of A. marmelos leaves as a herbal medicine in chronic inflammatory conditions. However, further studies is needed to provide evidences for the safety of the long term administration of the extracts, before it can be recommended as potential anti-inflammatory drug in the management of chronic inflammatory conditions. Then further studies may be undertaken to isolate and identify the active antiiflammatory component from the studied crude extracts. References 2.    Kumar V, Abbas K, Fausto N, Jon C Aster. Robbin and Cortan, Acute and Chronic inflammation: pathologic Basis of disease, 8th edition. Philadelphia: Elsevier Saunders 2010; 45-75. 4.    Arul V, Miyazaki S, Dhananjayan R. Studies on the anti-inflammatory, anti pyretic and analgesic properties of leaves of Aegle marmelos corr. J of Ethnopharmacol 2005; 96: 159-63.  6.   Sharma GN, Dubey SK, Sati N,Sanadya J. Anti inflammatory activity and total flavonoid content of Aegle marmalos seeds. IJPSDR 2011; 3(3): 214-218. <![CDATA[Disseminated melioidosis involving skin and joint: a case report]]> Samira Rahat Afroze Muhammad Abdur Rahim Lovely Barai Khwaja Nazim Uddin https://imcjms.com/journal_full_text/78 2016-08-02 12:22:10 Clinical Case Report Ibrahim Med. Coll. J. 2015; 9(2): 55-57 Melioidosis is an infectious disease that can cause serious morbidity and may result in death if not treated early. Its causative organism, Burkholderia pseudomallei is present in soil and water. Here, we report a case of disseminated melioidosis involving skin and joint in a farmer residing in an area where the organism has been found in the soil. Ibrahim Med. Coll. J. 2015; 9(2): 55-57     Melioidosis, a potentially life threatening infectious disease, is caused by the Gram-negative bacillus, Burkholderia pseudomallei, a soil and fresh water saprophyte in tropical and subtropical regions. Although it is regarded as a public health problem in tropical Australia and in Southeast Asian countries, particularly Malaysia, Thailandand Singapore, the increasing number of reported cases in Bangladeshand India are alarming.1,2 In Bangladesh, this organism has already been isolated from the soil of Kapasia of Gazipur district in 2013 rendering this country as a definite country for melioidosis.3 Here, we report a case of disseminated melioidosis involving skin and joint from the same region. Case summery The patient was treated with intravenous imipenem (dose was adjusted according to renal function) and subcutaneous insulin. His general condition improved, joint swelling reduced and a repeat blood culture after 3 days showed no growth of the organism. The patient was discharged on request after two weeks with oral doxycycline (100mg bid) and amoxicillin-clavulanate (500/125mg bid) for 5 months. A follow up visit after 2 weeks showed disappearance of his neck swellings but his joint was mildly tender and swollen. However, no fluid could be aspirated. He was advised to continue his medications and start physiotherapy once his joint pain subsides. Unfortunately, the patient died of acute myocardial infarction 4 weeks after the follow-up visit.   Discussion On the other hand in Southeast Asia, primary skin melioidosis has been reported to be associated with necrotizing fasciitis, sepsis and internal organ abscesses.4,7,8 Blisters, superficial erythematous pustules, clusters of violaceous skin abscesses, cellulites and subcutaneous abscesses have commonly been reported.l,4 Treatment for melioidosis is effective and life saving provided the diagnosis is timely made and the   Melioidosis mimics tuberculosis in clinical, radiological and histo-pathological aspects. Considering the rising numbers of reported cases in our country and a high mortality rate in bacteraemic cases, it is important to suspect melioidosis in appropriate clinical settings where infection does not respond to conventional antibiotics or anti-tubercular medications. Awareness about the extent of this disease in our country needs to be developed among both clinicians and microbiologists. Acknowledgements References 2.    Barai L, Jilani SA, Haq JA. Melioidosis-Case reports and review of cases recorded among Bangladeshi population from 1988-2014. Ibrahim Med Coll J 2014; 8(1): 25-31. 4.    Chaowagul W, White N, Dance DAB, Wattanagoon Y, Naigowit P et al. Melioidosis: a major cause of community-acquired septicemia in Northeastern Thailand. Infect Dis 1989; 159: 890-9. 6.    Gibney KB, Cheng AC, Currie BJ. Cutaneous melioidosis in the tropical top end of Australia: a prospective study and review of the literature. Clinical Infectious Diseases 2008; 47: 603-9. 8.    Wang Y, Wong C, Kurup A. Cutaneous melioidosis and necrotizing fasciitis caused by Burkholderia pseudomallei. Emerg Infect Dis 2003; 9: 1484–5. 10.  Ezzedine K, Heenen M, Malvy D. Imported cutaneous melioidosis in traveler, Belgium. Emerg Infec Dis 2007; 13(6): 946-7. <![CDATA[Jejunal inflammatory fibroid polyp: a rare cause of intussusception]]> Md. Rajibul Haque Talukder Md. Noor A Alam Zahid Iqbal Jamal Uddin Nilufar Shabnam https://imcjms.com/journal_full_text/256 2017-07-12 08:58:56 Clinical Case Report Ibrahim Med. Coll. J. 2015; 9(2): 58-60 Inflammatory fibroid polyp is a benign and non-neoplastic condition of the gastro-intestinal tract, commonly affecting the gastric antrum, though it can affect any part of the gastro-intestinal tract. It is a submucosal, sessile, polypoid mass composed of myofbroblast like mesenchymal cells, numerous small blood vessels and marked inflammatory cell infiltrate mainly eosinophils. It commonly presents with intestinal obstruction or intussusception. We present here a case of recurrent episodes of small intestinal sub-acute obstruction due to intermittent intussusception associated with inflammatory ûbroid polyp of jejunum. Ibrahim Med. Coll. J. 2015; 9(2): 58-60     Inflammatory fibroid polyp (IFP) is a relatively rare disorder thought to be clinically and histologically benign and was first described as “polypoid fibroma” in 1920 by Konjetzny and as an eosinophilic granuloma by Vanek in 1949.1 It originates from sub mucosa and grows as a polypoid mass.2,3 It is an uncommon non-neoplastic proliferating lesion, most commonly occur in the gastric antrum, followed by the small bowel.4 However, it can develop in other parts of the gastro-intestinal tract. The term “inflammatory fibroid polyp” was first proposed by Ranier and Helwig5 in 1953 and is now a generally accepted term.   A 60-year-old woman, non-diabetic, normotensive, asthmatic, housewife was admitted to BIRDEM general hospital with the history of frequent colicky abdominal pain initially around the umbilical region and then spread to the whole abdomen for three months and was relieved by anti-spasmodic drugs. She also complained of abdominal distension and vomiting of partially digested food particles, the frequency of which increased up to 4 to 5 times a day. There was also history of occasional constipation for the same duration. On general examination, she was found to be anaemic and dehydrated. Her vital signs were within normal physiological limits. Her abdomen was found to be distended. A firm, mildly tender, elongated mass was palpable in the umbilical region and no other organomegaly was present. Percussion note was tympanic and bowel sound was present. There was no other physical finding. Ultra sonogram revealed an ovoid hypoechoic area in right paraumbilical region; suggested possibilities were gut originated mass or enlarged lymph node with thick walled distended bowel. Computed tomography (CT) scan revealed thick walled small bowel loops. Barium meal follow through X-ray showed segmental narrowing in the distal and lower part of jejunum in the left side of pelvic cavity (Fig. 1).   Laparotomy revealed that a 20 cm long portion of the jejunum was congested and particularly firm in consistency. The portion immediately distal to it was narrowed by a stricture. The bowel had undergone a jejuno-jejunal intussusceptions (Fig 2). Resection of the whole intussuscepted bowel was done and end to end anastomosis was performed. Post operatively the specimen was cut open which confirmed intussusception and a polypoid mass measuring about 4×3×3cm. The cut surface was white, firm with focal myxoid appearance (Fig 3). Microscopic examination showed sub mucosal tumor with overlying ulcerated jejunal mucosa. The background stroma was sclerotic and contained a fair number of plasma cells, lymphocytes, histiocytes and eosinophils. Based on the operative and histological findings, it was diagnosed as a case of jejunal intussusception due to inflammatory fibroid polyp.         Adult intussusception is caused by a well-definable pathological abnormality in 70–90% of cases.8 In general, benign lesions are the commonest causes of intussusception involving small bowel, accounting for 70% of cases.8 Examples of benign lesions include sub mucosal lipomas, Peutz Jeghers polyps, congenital band adhesions, intussuscepting Meckel diverticulum and inflammatory fibroid polyps. The most common site for inflammatory fibroid polyps is the gastric mucosa, accounting for 70% of cases.9 Of other gastrointestinal sites affected, the small bowel is the most common, accounting for 23%, with the ileum being predominating site.9  The colon (4%), gallbladder, esophagus, duodenum and appendix have also been described as rare sites.9 The fifth to seventh decade of life is the most common and both sexes are equally affected.9 The etiology of inflammatory fibroid polyps is unknown. Theories involving triggers such as foreign body, parasite and chronic H. pylori infection have been suggested but remain unsupported.9 A poorly controlled inflammatory response to a chemical, traumatic or metabolic mucosal injury has also been hypothesized.10 Given its marked eosinophilic infiltration in most cases, a localized variant of eosinophilic gastroenteritis is another proposed aetiology.11 We could not ascertain the factors associated with the development of this jejunal inflammatory fibroid polyp in our case. There was no previous report of jejunal intussusception due to inflammatory fibroid polyp from Bangladesh. Our case indicates that this condition should considered in elderly patients with features of chronic abdominal pain, vomiting and frequent distension of the abdomen. References 2.    Johnstone JM, Moroson BC. Inflammatory fibroid polyp of the gastrointestinal tract. Histopathology 1978; 2: 349-61. 4.    De la PR, Picardo AL, Cuberes R, Jara A, Martinez- Penalver I, Villanueva MC et al. Inflammatory fibroid polyps of the large intestine. Dig Dis Sci 1999; 44(9): 1810-6. 6.    Ali J, Qi W, Hanna SS, Huang S-N. Clinical presentations of gastrointestinal inflammatory fibroid polyps. CJS 1992; 35: 194-8. 8.    Yakan S, Caliskan C, Makay O, Denecli AG, Korkut MA. Intussusception in adults: clinical characteristics, diagnosis and operative strategies. Word J Gastroenterol 2009; 15: 1985–9. 10.  Rehman S, Gamie Z, Wilson TR, Coup A, Kaur G. Inflammatory fibroid polyp (Vanek’stumour), an unusual large polyp of the jejunum: a casereport. Cases J 2009; 2: 7152. <![CDATA[Evaluation of structured oral examination format used in the assessment of undergraduate medical course (MBBS) of the University of Dhaka]]> Md Shah Alam Tahmina Begum https://imcjms.com/journal_full_text/71 2016-08-02 12:10:29 Original Article Ibrahim Med. Coll. J. 2015; 9(1): 1-10 Objectives of this cross sectional descriptive study was to evaluate critically the current status of structured oral examination (SOE) format as practiced in the professional examination of undergraduate medical course (MBBS) and views of the faculties regarding the concept of SOE as an assessment tool. Analysis of the questions revealed majority (97%) were of recall type, only 3% were interpretation and problem solving types. The questions for 119 (97%) examinee did not address 10%-50% content area. About 38% examiners responded that they had no clear idea regarding learning objectives and none had idea regarding test blueprint.The examiners marked the domain of learning measured by SOE in favor of cognitive skill (61%), communication skill (38.5%), motor skill (11.5%), behavior and attitude (19%). No examiner prepared model answer of SOE questions by consensus with other examiner. Though more than 80% examiner agreed with the statement that pre-selection of accepted model answer is an important element for success of SOE. But no examiners of any SOE boards practiced it. Similarly, none of the examiners of SOE board kept records of individual question and the answer of the examinees. No boards maintained equal time for a candidate during SOE by using timer or stop watch. Examiners of 8 boards (44%) did not use recommended rating scale to score individual response of examinee rather scored in traditional consolidated way at the end of the candidate’s examination. Majority (94%) boards scored the prompted answer and allowed another questions when a candidate failed to answer. During SOE conduction, 22% examiner were absent from the board for a prolonged period and 3% was engaged in marking the written scripts. About 56% of the examiners arrived late than schedule time. Behaviors of 14% examiner showed abusing to the candidates. Introduction Goal of assessment is to provide direction and motivation for future learning and protect the public by upholding high professional standards and screening out trainees and physicians who are incompetent. Learning abilities must be assessed in multiple modes and contexts. Educational contents are the stimulus for learning and also provide a context to demonstrate one’s ability. Attributes of any instruments to assess different learning outcome should have four factors- validity, reliability, objectivity and practicality. The preferred learning style may be modified depending on the student’s perception of task and motivation towards it.2 Students’ learning is influenced greatly by the assessment method used3. The cognitive ability is assessed by the written examinations like essay question, modified essay question, short essay question (SAQ) and MCQ while skill by practical demonstration (OSPE/OSCE). The oral examination is still used in all subject centered medical curricula. Compared to essay questions, it is considered to probe deeply a student’s ability to think, to express more or less clearly his knowledge of isolated facts or group of facts that he ought to remember. For the measurement of these reasoning and deductive process, problem solving skill, capacity to defend decision, evaluation of competing choice and ability to prioritize, still make the oral examination a popular tool in summative assessment. Oral examination has its unique characteristics as face to face interaction, flexibility to concentrate on one area and exploration of the student view points. In view of those shortcomings, the oral examination should only be used to test the qualities that cannot be assessed by other method of evaluation. The qualities that are needed as medical professional include: Alertness, Confidence, Decisiveness and Ability to discuss logically. In the unstructured oral examination, the examinees are liable to be asked whatever the examiners chooses and there is a risk that the examiner may concentrate on his pet interests.17 Assessment of medical students using the traditional oral system has been marred by being highly subjective, non-structured and biased; and therefore suggestion was for the replacement the traditional oral examination by the ViPSCE for testing knowledge, problem solving and management abilities.18 In the undergraduate medical curriculum of 2002 of Bangladesh, extensive modification of the assessment system was done. In this new curriculum the written examination format modified to SAQ and MCQ along with 10% mark added by formative assessment. Traditional practical and oral assessment were modified to OSPE/OSCE and SOE. The curriculum recommends that while constructing the questions for SOE, the proportion of recall, interpretative and problem solving questions should be 50-60%, 20% and 10-20% respectively. Questions should be constructed by the examiner and typed on a card for the candidate to pick up the cards randomly from a box. Two boards consisting four examiners should conduct the examination. Each candidate is allotted fifteen minutes to answer.   This Cross sectional type of descriptive study was carried out over one year period from July 2007 to June 2008. The study was carried out in nine medical college centers under the University of Dhaka during the SOE of forensic medicine. The SOE in forensic medicine subject was chosen for evaluation as a reference and a representative discipline from other eleven subjects of MBBS course. Prior permission to observe was taken from appropriate authority. The conveners of examinations were informed about the intension for observing the session. The examiners were ensured that there would be no interference other than observation, documentation and collection of question asked to each candidate. Analysis was done using descriptive statistic. Results     Characteristics of a total of 2544 SOE questions that were asked to 123 examinees in relation to their learning hierarchy and content area in the forensic medicine showed majority (97%) of the questions were of recall type and very negligible numbers were interpretation (2%) and problem solving (1%) types (Table-2). Table-2:Distributions of the SOE questions by their content area in Forensic Medicine (n=2544)   Highest percentage of questions were from Forensic Pathology (24%), followed by 22.5% from Forensic Toxicology, from Forensic Gynecology (12%) and Forensic Thanatology (11%). About 7% of questions were from Introduction and Legal Procedure and 6% from Medical Ethics. The detail distribution is given in Table 2.         Fig-1. Distributions of the candidates by the SOE questions they were asked from the total content areas of Forensic Medicine (n=123) A significant number of examiners (10,38%) mentioned that they had no idea regarding learning objectives.     None of the examiners of 18 boards practice to prepare model answer nor even recorded the questions that were asked to the candidates and the answers of those questions. The examiners of 10 boards (56%) practiced scoring of every answer using rating scales but 8 (44%) of them scored in traditional consolidated way at the end when the candidates completed answering. Majority of examiner of the boards (94%) practiced scoring of prompted answer and equal number shifted to another question when candidates failed to answer. Equal time for a candidate was not maintained by stop watch in any of 18 boards (Table 4). Table-4: Distribution of SOE by their procedure of conduction by examiner   Other aspects of the behaviours of examiners during the SOE conduction revealed that 6-28% was involved in other activities during the examination procedure (Table 5). Only 28% of internals arrived one hour before schedule time. Both the internal and external talked over cell phone and eating food during the SOE (Table 5). Table-5: Distribution of(atmosphere of SOE) behavior of examiner(n=36)        The opinion of the examiners regarding the domain of learning outcome measured by the SOE, was a multiple response type question, hence 11 examiners marked more than one area. The opinions were 61% in favor of cognitive skill, 38.5% in favor of communication skill, 11.5% in favor of motor skill and 19% in favor of behavior and attitude. Only 11.5% teachers had no idea regarding measurement of learning domain (Table 7). Table 7: Teachers' opinion by the domain of learning outcome they want to measure by SOE   (n-26, multiple responses)   About 31% of examiners agreed that test blueprint provide a ground rule for construction of the question of learning hierarchy’ while 62% could not decide in selecting any one of the options (Table-8). Table 8: Distribution of teachers by their opinion about test blueprint and model answer for SOE (n=26)   Highest net priority score (149) was in favor of the advance construction of SOE questions followed by advance preparation of model answer (127). The next priority score was for non threatening environment (106), use of rating scale (95) and equal time for each candidate (93). Priority score for recording of question and answer was negative (-36) (Table 9). Table-9: Distribution of elements of SOE by their net priority   Table-10: Distribution of the respondent by their identified advantage of SOE             Discussion The low taxonomic level (recall of factual knowledge rather than problem solving) of this study indicates, the students were adopting surface approach in learning. The study of learning style of medical students had high scores on reproducing orientation were the evidence of surface approach in learning style.21 The preferred learning style may be modified depending on the students perception of task and motivation towards it. Student learning is influenced greatly by the assessment method used.3 Assessment strategies that focus predominantly on recall of knowledge will likely promote superficial learning but assessment strategies that demand critical thinking or creative problem solving will promote higher level of student performance or achievement. Higher education institution have been responding to a growing concern for the adequacy of professional and career preparation by specifying the outcome or abilities critical for future professional performance. Recent developments in assessment methodology have focused on performance assessment and good assessment can help students become more effective self-directed learners.4  Mainly internal examiners prepared the question for the current SOE session. This finding suggested reluctance of shouldering the responsibility by the examiner of SOE board. Wide variations in content and hierarchy discrimination could be avoided if the questions were constructed with the aid of prior prepared test specification (blueprint) and framing all 10 questions in a card distributing learning hierarchy and core content from all topics. Only 15% examiner responded that they used test blueprint in construction of question. Interestingly, even those examiners did not have proper knowledge about test blue print. All assessments should ensure that they are appropriate for the learning objective (Knowledge, skills and attitudes) being tested. The conceptual framework against which to plan assessment is essential and it is the test blueprint that provides a representative sample of instructionally relevant tasks. The test blueprint helps to achieve the validity of the content, response and consequence evidence. Scoring of students’ response demands marking of every answer in a rating scale. To score in a traditional way at the end causes the subjectivity and bias. Examiners of 44% SOE boards did not use rating scale to score individual response rather they scored in traditional consolidated way at the end. It is quite impossible for an examiner to remember all the responses after a prolong time, without subjective bias. Therefore, scoring of all the answer traditionally at the end definitely invite bias in scoring.22 The factors that influence rating, are the errors of leniency and central tendency and hallo effect which should be avoided in rating scale construction and use.23. But in this study no examiners prepared any rating scale and even significant portion of examiner scored traditionally at the end. The respondent prioritized the advance preparation of model answer in consultation with other examiner’s as 2nd highest essential element of SOE and majority examiner (80%) agreed that the pre-selection of model answer was important for success of SOE. The net priority score for preparation of accepted model answer was 127. But none of the examiner prepared any model answer of the questions. Specified answers and a specific marking scheme in an SOE for surgical resident in Canada produced an overall reliability of 0.75.25 Criteria for answer can provide clear guidelines on what is and is not an acceptable answer to the examiner’s question. The activities like talking over mobile, eating foods, prolonged outside staying and marking scripts during conduction of SOE, is unsuitable for establishment of cordial environment and unbiased scoring. Majority of external examiners were late than university schedule time. Examiners should arrived one hour before the university schedule time of starting SOE for selection of question, preparation of accepted answer on consensus and rating scale. However, it was interesting to note that all the examiners prioritized the establishment of a non-threatening environment as an essential element of SOE. Education is a process the chief goal of which is to bring change in human behavior. This behavior explicitly defined in the form of educational objectives, which are the guiding principles to plan educational activities and assessment. A significant percentage of examiners (38%) had no clear idea regarding learning objectives. The lack of knowledge regarding learning objectives indicate basic defect to overcome all the barriers of effective medical education system. Definition of educational objectives is an essential step before choosing teaching method and a system of evaluation. In the present study, about 12% respondent could not decide learning domain measured by SOE, 12% marked in favor of motor skill, 19% responded in favor of attitude and 10% for behavioral domain of learning. The findings were suggesting that significant number of examiners did not perceived the elements measured by SOE. The findings indicate that there is an urgent need of training for faculty development.   The elements of SOE were not properly followed during assessment of students’ in forensic medicine. Without using test blue print in construction and framing of questions it is quite impossible to assess the candidate’s learning hierarchy and coverage of essential content. Advance preparation of accepted model answer though essential in scoring without bias was not practiced by the examiners of any board. The medical colleges were selected purposively and therefore, all medical colleges could not be included. The examiners of different subject could not be interviewed and all SOE boards could not be observed However, the reasons for not implementing vis a vis following the attributes of SOE were not explored. The study was done only in Forensic medicine but similar situations may exist in other subjects also. The study revealed that SOE introduced as assessment tool in undergraduate medical curriculum was not properly implemented and its desired objectives not fully achieved. Recommendation     1.    Joughin G. Dimensions of oral assessment and student approaches to learning. In: Brown S,  Glasner A eds. Assessment matters. Buckingham: The Society for Research into Higher Education & Open University Press 1999; 146-156. 3.    Wood DF. ABC of learning & teaching in med problem based learning. British Med J.2003; 326: 328-330 5.    Bull GM. Examinations. J Medical Education. 1959; 34: 1154-1158. 7.    Swanson DB. A measurement framework for performance based test. In: Hart IR, Harden RM eds. Further developments in assessing clinical competence. Montreal, CanHeal 1987. 9.    Colton T & Paterson OL. An assay of medical student’s ability by oral examination. J of Medical Education 1967; 42: 1005-1014. 11.  Newble DI, Hoare J & Efmsli RG. The validity & reliability of a new exam of the clinical competency of medical students. Medical Education 1981; 15: 46-52. 13.  Ferdousi S, Latif SA, Ahmed MM, Nessa A. Summative assessment of undergraduate medical students’ performance in physiology by Structured Oral examination. Mymensingh Med J 2007; 16(1): 64-69. 15.  Kearny RA, Puchalski SA, Yang HYH and Skakun EN. The inter-rater and intra-rater of reliability of a new Canadian oral examination format in Anaesthesia is fair to good, Canadian. J Anaesthesia 2002; 49: 232-236. 17.  Oyebode F,George F, Math V & Haque S. Inter examiner reliability of the clinical parts of MRCPPsyc Part-II exam. Psychiatry Bulletin 2007; 31: 342-344. 19.  van der Vleuten CPM, Scherpbier AJJA, Dolmans DHJ, Schuwirth LWT, Verwijnen GM, Wolfhagen HAP. Clerkship assessment assessed. Medical Teacher 2000; 22(6): 592-600. 21.  Newble DI, Gordon MI. The learning style of medical students. Medical Education1985; 19: 3-8. 23.  Guilbert JJ. Comparison of advantage and disadvantage of different types of test, Educational handbook for health personnel, Geneva, WHO 1977; 416. <![CDATA[Pvevalence of hypertension in people living in coastal areas of Bangladesh]]> M. Abu Sayeed AH Syedur Rahman Md. Hazrat Ali Subrina Afrin Mir Masudur Rhaman Mohammad Mainul Hasan Chowdhury Akhter Banu https://imcjms.com/journal_full_text/72 2016-08-02 12:12:09 Original Article Ibrahim Med. Coll. J. 2015; 9(1): 11-17 The prevalence of hypertension was reported higher in the coastal areas in different populations of the world. There was no study on the prevalence of hypertension among the coastal people in Bangladesh. This study addressed the prevalence and risk of hypertension among people living in the coastal areas of Bangladesh. Overall, 7058 (m / f = 2631 / 4427) people volunteered to participate in the study. The crude prevalence of sHTN was 17.8% [95% CI, 17.39 – 18.21] and dHTN was 19.0% [95% CI 18.08 – 19.92]. Compared to female, the male participants had higher prevalence of both sHTN (16.4 v. 20.2 %, p<0.001) and dHTN (17.4 v. 21.5%, p<0.001). The prevalence rates of sHTN were 14.6, 18.5 and 24.6% in the poor, the middle and in the rich class, respectively (p<0.001). Similar trend was observed with dHTN. Both types of HTN increased with increasing age (p<0.001), BMI (p<0.001), WHR (p<0.001) and WHtR (p<0.001). Logistic regression analyses proved that the participants of higher social class, of advancing age and with higher obesity had excess risk of hypertension. Positive family history of HTN, DM and stroke had also increased risk for HTN. Introduction   The study protocol was approved by the Ethical Review Committee of the Bangladesh Diabetes Association (BADAS).     Fig.1: Map of Bangladesh showing the location of six coastal districts included in the study.         Blood pressure was taken after 10 min rest with standard cuff, fitted with mercury sphygmomanometer while the participant sitting face to face and talking comfortably with relax mood. A mean of the two measures was accepted. The cut-off values for systolic and diastolic hypertension (sHTN, dHTN) were >135 and >85mmHg, respectively.   The biophysical characteristics (mean with standard deviation) were compared between participants with and without hypertension (both sHTN, dHTN). The Chi-sq test estimated the association of hypertension with age-groups, sex, social class and obesity. Logistic regression estimated the effect of risk factors (sex, age, income, BMI, WHR and WHtR) in different models with different combinations taking sHTN and dHTN as dependent variables. Family history of HTN was also included in the models. The quantitative variables (age, BMI, WHR, WHtR) were transformed into quartiles (Q1, Q2, Q3, Q4) and entered in the regression analyses where the Q1 was taken as a reference category. All statistical tests were considered significant at a level of £5%. SPSS version 20.0 was used. Results Biophysical characteristics were compared between subjects with and without hypertension. Compared with the non-sHTN (SBP: <135 vs. ³135 mmHg) the participants with sHTN had significantly higher age (p<0.001), higher obesity (BMI, WHR, WHtR for all p<0.001) and higher FBG (p<0.001). There was no significant difference for T-chol, TG, HDL and LDL [table 1]. Likewise, compared with the non-dHTN (DBP: <85 vs. ³85 mmHg) the participants with dHTN had significantly higher age and higher obesity though no difference was observed in lipids (table not shown). Table-1: Prevalence (%) of systolic and diastolic hypertension (sHTN, dHTN) of the study population according to sex and social class                  Binary logistic regression analysis quantified the effect of individual risk factor (sex, social class, family-history, age, BMI, WHR, WHtR) on hypertension. The analyses included sHTN and dHTN as dependent variables separately. The risk factors were entered into the equation as the independent variables in different combination of different models (model 1-4). Model 1 included sex, family history of hypertension and social class; Age quartiles were added to model 2; BMI and WHtR quartiles were added to model 3 and 4, respectively. Considering all the models, family history of hypertension, higher social class, advancing age and increasing obesity were found to have excess risk for systolic hypertension. The increasing WHtR was proved to be an important obesity indicator, which profoundly reduced the effect of higher age (model 3 vs. 4); whereas, the increasing BMI, an indicator for general obesity had no such effect on age for developing sHTN. The findings of logistic regression taking sHTN as a dependent variable were found almost similar to dHTN (Table not shown). Discussion The response rate was satisfactory (80.2%). The prevalence of hypertension in the coastal population is higher (19%) than that of rural (16.8%) and urban (11.3%) native Bangladeshis.4,5 It is lower than the Chinese study,2,3 which reported an increasing trend over time. In China, the observed prevalence of hypertension was 9.8% in the 1980s, 18.5% in the 1990s and 30.0% in the 2000s. We have no previous report. Hence, it is not possible to assess the trend in the study population. Yadav et.al observed a higher prevalence of hypertension (32.2%) in India,12 but the study participants were affluent people and older (age ³30y). Another Indian study by Anchala et.al13 that included population from different areas reported prevalence of hypertension similar to this study. The study had some limitations. The determination of accurate age was difficult. Most of the participants did not know their date of birth. The age of the participant was approximated based on some national political and / or historical events like liberation war of Bangladesh and worst disasters faced by the coastal people. We could not also assess the grading of physical activities due to different types of lifestyle and occupational heterogeneity. Furthermore, we had to abandon the history taking on dietary habit – firstly, because of diversity in different communities and secondly, it was a time consuming exercise. Again, it would have been better if we could have estimated the salt content of the local drinking water and the locally produced food products. Conclusions   We are indebted to The Fred Hollows Foundation (FHF) for the financial support. We are grateful to the Principal of Barisal Medical College for making arrangements of temporary laboratory room in his college premises. We acknowledge the help extended by the leaders, the teachers, students and the participants of coastal communities. We appreciate the cooperation and support given by the authority of the Ibrahim Medical College and the Department of Community Medicine, Ibrahim Medical College. 1.    Khan AE, Ireson A, Kovats S, Mojumder SK, Khusru A, Rahman A, Vineis P. Drinking Water Salinity and Maternal Health in Coastal Bangladesh: Implications of Climate Change. Environ Health Perspect 2011; 119(9): 1328–1332 3.    Huang F, Zhu PL, Xiao HZ, Lin F, Yuan Y, Gao ZH, Li JW, Chen FL. Cardiovascular disease risk and vascular damage status in pre- and hypertension population in coastal areas of Fujian province. Zhonghua Xin Xue Guan Bing Za Zhi 2013; 41(10): 876-81. 5.    Sayeed MA, Banu A, Khanam PA, Mahtab H and Azad Khan AK. Prevalence of Hypertension in Bangladesh: effect of socioeconomic risk on difference between rural and urban community. Bang Med Res Coun Bull 2002; 28(1): 7-18. 7.    Tsai PS, Ke TL, Huang CJ, Tsai JC, Chen PL, Wang SY, et al. Prevalence and determinants of prehypertension status in the Taiwanese general population. J Hypertens 2005; 23(7): 1355–60. 9.    Danaei G, Finucane MM, Lin JK, Singh GM, Paciorek CJ, Cowan MJ, Farzadfar F, Stevens GA, Lim SS, Riley LM, Ezzati M. Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group (Blood Pressure). National, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5·4 million participants. Lancet 2011; 377(9765): 568-77. 11.  Czernichow S, Zanchetti A, Turnbull F, Barzi F, Ninomiya T, Kengne AP, et al. The effects of blood pressure reduction and of different blood pressure-lowering regimens on major cardiovascular events according to baseline blood pressure: meta-analysis of randomized trials. J Hypertens 2011; 29(1): 4–16. 13.  Anchala R, Kannuri NK, Pant H, Khan H, Franco OH, Di Angelantonio E, Prabhakaran D. Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and control of hypertension. J Hypertens 2014; 32(6): 1170-7. 15.  Sampson UK, Edwards TL, Jahangir E, Munro H, Wariboko M, Wassef MG, Fazio S, Mensah GA, Kabagambe EK, Blot WJ, Lipworth L. Factors associated with the prevalence of hypertension in the southeastern United States: insights from 69,211 blacks and whites in the Southern Community Cohort Study. Circ Cardiovasc Qual Outcomes 2014; 7(1): 33-54. 16.          Sayeed MA, Mahtab H, Latif ZA, Khanam PA, Ahsan KA, Banu A, and Azad Khan AK. Waist-to-height ratio is a better obesity index than body mass index and waist-to-hip ratio for predicting diabetes, hypertension and lipidemia. Bang Med Res Coun Bull 2003; 29(1): 1-10. <![CDATA[Child abuse in Bangladesh]]> Farzana Islam Gulshan Ara Akhter https://imcjms.com/journal_full_text/73 2016-08-02 12:13:13 Original Article Ibrahim Med. Coll. J. 2015; 9(1): 18-21 In Bangladesh, a large number of children are deprived of their basic human rights due to unacceptable health, nutrition, education as well as social conditions. In addition, children are exposed to severe forms of sexual, physical and mental abuses at home, in the work place, in institutions and other public places. The nature and extent of violence against children irrespective of age, sex and class has been increasing day by day. These include physical torture, rape, homicide and sometimes heinous attacks with acid. Children are also victims of child labor and trafficking, both of which are treated as the most severe form of child exploitation and child abuse in the world today. This review article is aimed to focus on the present situation of various forms of child abuses in our country. Data collection is based on secondary sources of information from Dhaka Medical College Hospital, One Stop Crisis Center (OCC),UNICEF, Ministry of Home Affairs, Ministry of Women and Children Affairs, several Dhaka based organizations and news paper clipping. Ibrahim Med. Coll. J. 2015; 9(1): 18-21     Across the globe, children are exposed to different forms of violence that impedes their mental, physical, psychological and moral growth.1 Child abuse or maltreatment as defined by World Health Organization (1999) constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power.2 The definition could range wider to include societal forms of violence- the effects of poverty, exploitative child labor, lack of adequate health care and education and non deliberate neglect by the state, parents and others. However, the focus here is on interpersonal violence to children. Article 1 of the Convention of the Rights of the Child defines a child as “Every human being below the age of 18yrs unless, under the law applicable, majority is attained earlier”.3 No group of child is immune from being a victim of child abuse, although girls are more often vulnerable of sexual abuse than boys. For all other types of abuse and neglect, statistics are about equal for both boys and girls.   Violence against children is causing increasing concern in Bangladesh as it is not confined to any specific zone. Home, workplace, street, and prisons- everywhere children become easy prey of violence.4 A study was conducted in 2005 about crime statistics by the Ministry of Home Affairs, Government of Bangladesh. The study revealed that there were 555 cases of child abuse reported to the police on that particular year. By 2010, this number increased to 1,542 (Table 1). Table 2 shows the scenario of homicide committed on young children over the years till March 2016. These cases are only the reported cases and may not reflect the real situation of child abuse and violence in the country. Table-1: Year wise reported cases of child abuse from 2001 to 2010     The epidemiology of child abuse can be classified into three sub headings- host of abuse, agent of abuse and environment. These are discussed below: Host of abuse   Child abuse can take several forms. The four main types are physical abuse, psychological abuse, neglect and sexual abuse. a.Physical abuse: Excessive intentional physical injury to a child as a result of punching, shaking, beating, biting, kicking, burning or otherwise physically harming the child. These include- battered baby syndrome, corporal punishment. When an infant or child suffers repetitive physical injuries inflicted by a parent or guardian in circumstances where accident can be excluded, it is most likely to be regarded as physical abuse. The common physical lesions are in the skin in the form of skin bruising.6 Bruising occurs around the limbs and in infants around the ankles. The older child may be gripped by the upper arms in order to be shaken known as Shaken Baby Syndrome that often results in permanent neurological damage in 80% of cases or death in 30% of cases. This sort of abuse in young children of 1-2 yrs may cause important regions of the brain to fail to form or grow properly resulting in impaired development.These alterations in brain maturation have long-term consequences for cognitive, language & academic abilities.7       c. Child neglect: Child neglect includes failure to provide basic physical, emotional, medical and educational need a child.1   a. Child labor: Child labor is considered as one of the worst forms of child exploitation around the world.13 Children are forcefully engaged in risky work including pushing rickshaws, as helpers at railway stations, launch ghat & bus terminals, breaking bricks at construction sites, carrying groceries for consumers in shops, peeling and packing in industries and large scale factories. The minimum age for employment according to Child Labor Code is 14yrs depending on the nature of the work, but this is not implemented in Bangladesh. Violence in the work place includes using abusive languages, low payment, long working hours, no leisure time or holidays and beatings. These children become mentally unhealthy and suffer from emotional stress and developmental problems. c. Violence on the streets: Children living on the streets are mostly vulnerable to abuse and exploitation according to report prepared by UNICEF in 2009.These children grow up without suitable accommodation, protection, education, health care, food, safe drinking water, security, supervision, recreation and guidance. Criminal networks engage these children in commercial sex work, smuggling, stealing and distribution of drugs and weapons.16 The early experience of child abuse can trigger changes in child’s behavior including discipline problems, insomnia, nightmares, anxiety, depression etc. This also causes problem with mental development of a child which interrupt his feelings, empathy, sympathy, reasoning, rational thinking and benevolence. Children who have been abused or neglected are more likely to be arrested as juvenile offenders & are more likely to be a sadist and involve in criminal activities as an adult.1 Measures to be taken to reduce child abuse   Child abuse is a silent epidemic. It is a social crime and is therefore a threat to our civilization. The intense media spotlight, often on particularly horrifying individual cases of violence against children suggests-greater prevalence. Children are probably the most neglected members of our society. As a result they are consistently becoming easy victims of all sorts of abuses. Violence against children must be stopped and the judiciary, law enforcing agents, parents and guardians of the children themselves must be sensitized to the provisions of the convention on the Rights of the child and the laws protecting children in Bangladesh. It is important for everyone to know the signs of child abuse and how to report it. We all share a responsibility to help keep our children safe. Children have the right to be children, to be loved, cherished, educated, nourished, clothed, pampered as children when they are children. Our vision should be to establish a healthy, child-rights enriched society, free of abuse, exploitation and discrimination for the disadvantaged children of Bangladesh. References 2.    Report of the consultation on child abuse prevention.  Geneva: World Health Organization; 1999. 4.    Amnesty International. Children in South Asia-securing their rights. London: Amnesty International; 1998. 6.    Shepherd R. Child abuse in Simpson’s Forensic Medicine.12th ed. London: Arnold; 2003. 8.    Mohiuddin H, Khatun A, Kamal MA. Corporal punishment in Bangladesh school system: an analytic appraisal of elimination strategy directions. ASA University Review 2012; 6(2). 10.  UNICEF. Ending child marriage: progress and prospects. UNICEF; 2014.  12.Breaking the Silence. Non-commercial sexual abuse of children in Bangladesh. Dhaka:Breaking the Silence; 1997. 14.  UNICEF. Daily lives of working children. Dhaka: UNICEF;1997. 16.  Aktar J. Health and living conditions of street children in Dhaka City. Dhaka, Bangladesh: ICDDRB; 2004. <![CDATA[Molecular detection of atypical microorganisms in patients with ventilator associated pneumonia]]> Shahida Akter Rehana Khatun S.M Shamsuzzaman https://imcjms.com/journal_full_text/252 2017-07-12 08:36:18 Original Article Ibrahim Med. Coll. J. 2015; 9(1): 22-25 Ventilator-associated pneumonia (VAP) is one of the major causes of morbidity and mortality among the critically ill patients of intensive care units (ICU). The present cross sectional study was conducted to isolate and identify bacterial causes of VAP among the patients admitted in intensive care unit (ICU) of Dhaka Medical College Hospital. The study was conducted between July, 2013 to June 2014. A total of 65 endotracheal aspirate (ETA) and blood samples were collected from patients with clinically suspected ventilator associated peumonia(VAP). Samples were collected from patients on mechanical ventilation for more than 48 hours. ETA and blood samples were cultured aerobically. Multiplex PCR was performed with ETA to detect Mycoplasma pneumoniae, Legionella pneumophila and Chlamydia pneumoniae. Among the atypical bacteria, M. pneumoniae were detected in 5 (7.69%), L. pneumophila in 4 (6.15%) cases by multiplex PCR in ETA from VAP cases. No C. pneumoniae was detected. The study revealed that in VAP cases atypical bacteria should be considered as a possible bacterial agents. Ibrahim Med. Coll. J. 2015; 9(1): 22-25     Patients in intensive care unit are at risk of dying not only from their critical illness but also from secondary processes such as nosocomial infection. Pneumonia is the second most common nosocomial infection in critically ill patients, affecting 27% of all critically ill patients and 86% of nosocomial pneumonias are associated with mechanical ventilation.1,2 The risk for pneumonia increases 3 to 10 fold in patients receiving mechanical ventilation.3 Ventilator-associated pneumonia (VAP) is a major cause of morbidity and mortality among the patients of intensive care units (ICU).4 Most cases of VAP are caused by bacterial pathogens that normally colonize upper respiratory tract and gastrointestinal tract of the patient. External sources like transmission from caregivers, environmental surfaces or other patients have been implicated. Common pathogens include Enterobacteriaceae, Pseudomonas species, Gram-positive bacteria and Haemophilus species.5 In addition, atypical bacteria like M. pneumoniae, L. pneumophila, C. pneumoniae, viruses and fungi have also been implicated as causes of VAP.5,6 However, these atypical bacteria cannot be cultured easily and needs special techniques and facilities. Recently, molecular methods like polymerase chain reaction (PCR) has been used to detect these fastidious organisms in clinical samples.   Study population and sample collection: Patients in ICU having mechanical ventilation for more than 48 hours with suspected VAP were enrolled in the study. Criteria for suspected VAP include a new and persistent (>48-h) or progressive radiographic infiltrate plus two of the following: temperature of >38°C or <36°C, blood leukocyte count of >10,000 cells/ml or <5,000 cells/ml, purulent tracheal secretions, and gas exchange degradation.2 Endotracheal tube aspirates (ETA) and blood samples were collected from clinically suspected VAP cases.  ETAwas collected using a 50 cm and 14Fr suction catheter, which was gently introduced through the endotracheal tube for a distance of approximately 25-26 cm. The ETA was obtained by suction, without instilling saline and the catheter was withdrawn from the endotracheal tube. Two milliliter of phosphate buffered saline (PBS) was injected into the lumen of the catheter with a sterile syringe to flush the exudates.The exudates were collected into a sterile 50 ml Falcon tube and transported immediately to the laboratory for further processing.7 Only one ETA sample was collected from each patient.8 Sample processing for culture and PCR: ETA was mechanically liquefied and homogenized by vortexing for one minute with glass bead (1-2 glass bead). After vortexing sample was centrifuged at 2000 rpm for 10 minutes. Supernatant was discarded using a sterile pipette and the deposit was further mixed by vortexing. The processed specimen was used for culture in recommended media, Gram staining and PCR. Extraction of DNA: One hundred µl lytic buffer (composition-tris–HCL, proteinase-K and Tween 20 solution) was added to the pellet and vortexed thoroughly. The mixture was incubated at 60°C for 2 hours. After incubation the tube was placed in a block heater (DAIHA Scientific, Seoul, Korea) at 100°C for 10 minutes. Then it was-immediately transferred to the ice and kept for 5 minutes. The solution was then centrifuged at 13000 rpm at 4°C for 10 minutes. The supernatant was used as template DNA.      PCR was performed in a final reaction volume of 25µl in a PCR tube, containing 10 µl of master mix (mixture of dNTP, taq polymerase, MgCl2 and PCR buffer), 2 µl forward primer and 2 µl reverse primer (Promega corporation, USA) 3 µl extracted DNA and 8 µl of nuclease free water. After a brief vortex, the PCR tubes were centrifuged in a micro centrifuge for few seconds.   A total of 65 suspected VAP cases were enrolled. Out of 65 VAP cases, M. pneumoniae and L. pneumophila were detected in 5 (7.69%) and 4 (6.15%) cases respectively by multiplex PCR (Table -2 and Fig -1). No C. pneumoniae was detected. Out of 9 positve cases which showed presence of M. pneumoniae and L. pneumophila, only 2 cases did not have any other pathogen by culture. Seven cases had mixed infection (Table-3) along with the presence of atypical bacteria. Table-2: Distribution of atypical bacteria identified by PCR from ETA of VAP patients (n=65) Table-3: Distribution of other organisms isolated from VAP cases positive for atypical bacteria   Fig-1: Multiplex PCR showing amplified DNA of L. pneumophila and M. pneumonia. Lane 1: negative control (DNA of Ps. Aerufinosa). Lane-2: positive control of Legionella pneumophila. Lane 3: ETA test sample. Lane 4: 100bp DNA ladder. Lane 5: ETA test sample. Lane 6: Positive control of M. pneumonia Lane 7: Negative control (DNA of K. pneumonia) The present study has revealed that atypical bacteria are important causes of VAP, besides typical bacteria which are routinely detected by culture of ETA or bronchoalveolar lavage. In the present study, 13.84% VAP cases had infection with atypical bacteria like M. pneumoniae and L. pneumophila. But it is to be noted that except 2 cases, majority of the cases had mixed infection with other bacteria. Studies in other countries also reported the presence of such atypical bacteria in VAP cases. The reported rate of infection ranged from 6.6% to 15%.12,13   1.    Richards MJ, Edwards JR, Culver DH, Gaynes RP, et al. Nosocomial infections in Medical intensive care units in the United States. Crit Care Med 1999; 27: 887-892. 3.    Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med 2002; 165(7): 867–903. 5.    Park DR. The Microbiology of Ventilator-Associated Pneumonia. Respiratory Care 2005; 50(6): 742-765. 7.    Park DR. Antimicrobial treatment ofVentilator-associated pneumonia. Respiratory Care 2005; 50(7): 932-955. 9.    Verkooyen R, P, Willemse D, Casteren S.C.A.M, Joulandan S.A.M, et al. Evaluation of PCR, Culture and Serology for Diagnosis of Chlamydia Pneumoniae Respiratory infections. J Clin Microbiol 1998; 2301-2307. 11.  Afrin S. Bacterial causes of ventilator associated respiratory tract infection. (M.Phil Thesis) Dhaka, Bangladesh: Department of Microbiology, DMC 2013. <![CDATA[Prevalence of CTX-M β lactamases among Gram negative bacteria in a tertiary care hospital in Bangladesh]]> Taslima Yasmin Md. Akram Hossain Shyamal Kumar Paul Golam Mowla Safia Sultana https://imcjms.com/journal_full_text/253 2017-07-12 08:42:13 Original Article Ibrahim Med. Coll. J. 2015; 9(1): 26-30 Extended spectrum beta lactamases (ESBLs) produced by Gram negative bacteria are mainly mediated by three important genes, namely TEM, SHV and CTX-M. In this study, we used a multiplex PCR to determine the prevalence of CTX-M and its subgroups CTX-M-3, CTX-M-14, among the members of Enterobacteriaceae family and in Pseudomonas spp that were isolated from different clinical samples in a tertiary care hospital in Bangladesh. Out of 300 isolates tested, 71.3% were positive for ESBL production by DDDT. The rate of positivity for TEM, SHV and CTX-M genes in 107 randomely selected isolates was 83.2%. Among these, 56.2% (50/89) was positive for CTX-M. Among the CTX-M positive isolates, CTX-M-3 and CTX-M-14 were 78.0% (39/50) and 80.0% (40/50) respectively. Our study demonstrated that CTX-M variants were common in Enterobacteriaceae and Pseudomonas spp prevalent in the hospital of Bangladesh. Ibrahim Med. Coll. J. 2015; 9(1): 26-30     Extended spectrum beta-lactamases (ESBLs) are enzymes that mediate resistance to third generation cephalosporins as well as monobactams and are inhibited in vitro by b-lactamase inhibitors such as clavulanic acid and tazobactam.1 Most ESBLs are mutants of TEM and SHV enzymes, but CTX-M enzymes are also increasingly becoming important. These CTX-M enzymes predominantly hydrolyze cefotaxime.2 In clinical strains, CTX-M encoding genes have commonly been located on plasmids that vary in size from 7 to 160 kb.3 ESBLs have been reported worldwide in many different genera of Enterobactericeae and Pseudomonas spp.4 ESBL producing organisms have been reported from different parts of the world and ESBLs production rates are now very high in Asia compared to Europe.5 Epidemiological reports demonstrate that some enzymes are more frequently reported than others. Predominant enzyme type varies with country and that diverse CTX-M types often exist within a single country.6 CTX-M-3, a variant of CTX-M-5 has also been reported from India.3 There was no systematic study about ESBL in Bangladesh until 2004. In 2004, it was first reported that 43.2% and 39.5% Esch. coli and K. pneumoniae isolated from clinical samples were positive for ESBL respectively7 and in 2010 it increased to 57.89%.8   Total 300 clinical isolates were collected from both the outpatients and inpatients departments of Mymensingh Medical College Hospital (MMCH) over a period of 6 months from January 2011 to June 2011. Urine and pus from skin wound were used as specimen. Specimens were collected aseptically. All samples were routinely cultured on MacConkey and blood agar plates at 370C aerobically for 18 hours. Gram negative isolates were identified by standard biochemical tests.10 The susceptibility to antibiotics was determined by Kirby Bauer method on Muller Hinton agar according to CLSI 2010 protocols for Gram negative panels.11 ESBL production was determined by double disc diffusion test (DDDT).12     Electrophoresis of the amplified product was done in 1.0% agarose gel and visualized by staining with ethidium bromide (0.5 mg/ml). A 100 bp molecular weight ladder (Roche, USA) was used to measure the molecular weights of the amplified products. The images of ethidium bromide stained DNA bands were digitized using a gel documentation system (AlphaimagerTM 3400, USA). All th laboratory works were carried out in the department of Microbiology at Mymensingh Medical College. Results     Table-3: Distribution of CTX-M gene among 89 genotypic positive ESBL organisms   Table-4: Pattern of CTX-M-3, CTX-M-14 distribution in CTX-M positive isolates  Discussion In Europe, CTX-M is also predominant and among them CTX-M-3 and CTX-M-14 are most frequently detected.21 In 2002, CTX-M-1, CTX-M-3 and CTX-M 14 were isolated from Enterobacteriaceae in France and China.20,22 Similar predominance of CTX-M-3 and CTX-M-14 has been reported from other countries of Asia and America.15,23-26 In our isolates the CTX-M-3 and CTX-M-14 were found to co-exist in both Esch. coli, Klebsiella and other Enterobacteriaceae. The co-existence of two or more kinds of ESBLs in a single isolates also common in study done by Lin et al.27 Other variants of CTX-M genes may exist elsewhere in Bangladesh. Regular screening and national surveillance characterizing the CTX-M genes needs to be instituted at different geographical locations and healthcare settings to monitor the transmission and spread of ESBL mediated resistance. References 2.    Woodford N, Ward ME, Kaufmann ME, Turton J, Fagan EJ, James D, et al. Community and hospital spread of Escherichia coli producing CTX-M extended-spectrum beta-lactamases in the UK. J Antimicrob Chemother 2004; 54: 735-43. 4.    Pitout JDD, Laupland KB. Extended Spectrum b Lactamase producing Enterobacteriaceae: an emerging public health concern. Lancet Infectious Disease 2008; 8: 159-66. 6.    Livermore DM, Woodford N. The b-lactamase threat in Enterobacteriaceae, Pseudomonas and Acinetobacter. Trends Microbiol 2006; 14: 413–20. 8.    Haque R, Salam MA. Detection of ESBL producing nosocomial gram negative bacteria from a tertiary care hospital in Bangladesh. Pakistan J Med Sci 2010; 26(4): 887-891. 10.  Cheesbrough M. District laboratory practice in tropical countries. Vol 2,  Cambridge University Press, UK 2006. 12.  Clinical Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing. 16th Informational supplement 2006; M100-S15. 14.  Pagani L, Amico ED, Migliavacca R, D’Andrea MM, Giacobone E, Amicosante G, Romero E, and Rossolini GM. Multiple CTX-M-Type Extended-Spectrum b-Lactamases in Nosocomial Isolates of Enterobacteriaceae from a Hospital in Northern Italy. Journal of Clinical Microbiology 2003; 41(9): 4264-4269. 16.  Lal P, Kapil A, Das BK and Sood S. Occurence of TEM and SHV gene in extended spectrum beta lactamases (ESBLs) producing Klebsiella spp.isolated from a tertiary care hospital. Indian Journal Medcal Research 2007; 125: 173-178. 18.  Livermore DM, Woodford N. The beta-lactamase threat in Enterobacteriaceae, Pseudomonas and Acinetobacter. Trends Microbial 2006; 14(9): 413-420. 20.  Chanawong A, Lulitanond A, Kaewkes W, Lulitanond V, Srigulbutr S, Homchampa P. CTX-M Extended spectrum b lactamases among clinical isolates of Enterobacteriaceae in a thai university hospital. Southeast Asian J Trop Med Public Health 2007; 38(3): 493-500. 22.  Dutour C, Bonnet R, Marchandin H, Boyer M, Chanal C, Sirot D and Sirot J. CTX-M-1, CTX-M-3, and CTX-M-14 b-Lactamases from Enterobacteriaceae Isolated in France. Antimicrobial Agents and Chemotherapy 2002; 46(2): 534-537. 24.  Jabeen K, Zafar A, Hasan R, et al. Frequency and sensitivity pattern of Extended spectrum beta lactamase producing isolates in a tertiary care hospital laboratory of Pakistan. Journal Pakistan Medical Association 2005; 55(10): 436-9. 26.  Pitout JDD, Gregson DB, Church DL, Elsayed S, and Laupland KB. Community wide outbreaks of Clonally Related CTX-M-14 b-lactamase-producing Escherichia coli Strains in the Calgery health region. Journal Clinical Microbiology 2005; 43(6): 2844-2849. <![CDATA[Apolipoprotein A-I and B levels in Bangladeshi patients with coronary artery disease]]> Ashesh K. Chowdhury Abu Mohammed Shafique Zeenat F. Rahman https://imcjms.com/journal_full_text/254 2017-07-12 08:47:53 Original Article Ibrahim Med. Coll. J. 2015; 9(1): 31-33 Coronary arteay disease (CAD) is an important cause of morbidity and mortality in developed as well as developing countries like Bangladesh. In this study, the status of serum apolipoprotein A-I (Apo A-1) and apolipoprotein B (Apo B) levels were assessed in Bangladeshi patients with coronary artery diseases. The mean age of total study population was 51.4 ± 10.8 years while the mean age of the patients and control was 51.3 ± 10.9 and 51.4 ± 10.9 years respectively. The study revealed significant alteration of serum Apo A-I level and Apo B/Apo A-I ratio in patients with CAD compared to those without CAD. Further large-scale study is needed to evaluate the exact influence of apolipoproteins on coronary artery disease in Bengali ethnic population. Ibrahim Med. Coll. J. 2015; 9(1): 31-33     Cardiovascular disease is an important health problem in Bangladesh. Studies in Bangladesh reported the prevalence of hypertension as 11, rheumatic fever and heart disease as 7.5 and ischemic heart disease as 3.3 per thousand Bangladeshi populations.1,2 Another study conducted among five hundred rural people of Bangladesh reported the prevalence of cardiovascular diseases as 4.6%.3 Acute myocardial infarction (AMI) has been reported as the leading cause of death in Bangladesh in the 4th decade of life.4 The prevalence of ischemic heart diseases (IHD) in Bangladesh and other developing countries are gradually increasing due to rapid urbanization, migration of people from village to the cities, change in life style and food habits. Hypertension, diabetes mellitus, dyslipidaemia, smoking and family history of ischemic heart disease are some established risk factors for coronary artery disease. Now a days, altered triglycerides, low and high density lipoproteins (LDL, HDL), total cholesterol-HDL cholesterol ratio, apolipoprotein A-I and apolipoprotein B are considered as risk factors for coronary artery disease. In light of the above, the present study was undertaken to determine the blood levels of apolipoproteins in Bangladeshi patients with coronary artery disease. Methodology The study population was recruited from University Cardiac Centre, Bangabandhu Seikh Mujib Medical University (BSMMU), Dhaka from April, 2005 to June, 2005. Fifty consecutive patients with coronary artery disease, documented by coronary angiogram (CAG), were included in the study. Patients with valvular and congenital heart disease and hypertrophic cardiomyopathy were excluded. Fifty individuals of similar age and sex having no electrocardiographic or CAG evidence of coronary artery disease were included as control. Collection of blood samples and estimation of apolipoproteins   The research protocol was approved by the Thesis committee. The aims and objectives of the study along with its diagnostic procedures were explained to the patients/attendants of the patients in easy understandable language and then informed written consent was obtained from each participant. The collected data were computed and analyzed by SPSS 12.0 program. The difference between groups was evaluated by student’s t test. Total 100 participants were enrolled in the study. Among them, 50 were cases admitted in CCU of BSMMU had demonstrable coronary artery disease on coronary angiogram and 50 were controls with ETT negative and/or normal CAG. The mean age of the total studied population was 51.4 ± 10.8 years. The mean age of control group was 51.3 ±10.9 years and that of case was 51.40 ±10.9 years. There was no statistically significant mean age difference between the two groups (p=0.987). Highest number of participants was within 45 - 54 years age range (40%) in both groups. The male female distribution was equal in both groups (40 vs 10). Table-1: The levels of apolipoproteins  AL and B study population. Apolipoproteins     The objective of the present study was to find out the status of serum apolipoprotein B and A1 levels in Bangladeshi ethnic patients with coronary artery disease. These markers are considered as potential risk factors associated with CAD. Determination and monitoring of these markers would therefore help in better management of CAD. We have found significantly raised mean Apo B level in patients with CAD compared to our control group. The ratio of Apo B to Apo AI is also found to be significantly raised from control group ( 1.25 vs 0.95). It has been reported over the last several years that assessment of serum Apo B, Apo AI and their ratio are better markers of CAD than LDL cholesterol. In 2004, the global INTERHEART study of risk factors for acute myocardial infarction in 52 countries demonstrated that raised Apo B/A-I ratio was the most important risk factor in all geographic regions.9 Similar observation was also reported by CARDS study involving type 2 diabetes patients.10,11 The mean level of Apo A-I in CAD patients was significantly lower than that of control group. Similar observation was also reported by other.12 It is to be noted that the levels of serum apolipoproteins seem to be lower in Indian population as compared to those reported from the West.8   1.    Malik A. Congenital and acquired heart disease. A survey of 7062 persons. Bangladesh Med Res Coun Bull 1976; 2: 116. 3.    Ullah A and Barman A. Coronary Heart disease and food. Bangladesh Heart Journal 1991; 6: 12-14. 5.    Cerne D, Ledinski G, Kager G and Greilberger J. Comparison of laboratory parameters as risk factors for the presence and the extent of coronary or carotid atherosclerosis: the significance of apolipoprotein B to apolipoprotein all ratio. Clin Chem Lab Med 2003; 38(6): 529-38. 7.    Reinhart RA, Gani K, Arndt MR, Broste SK. Apolipoproteins A-I and B as predictors of angiographically defined coronary artery disease. Arch Intern Med 1990; 150(8):1629-33. 9.    Yusuf S, Hawken S, Ounpuu S, et al; INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004; 364: 937-952. 11.  Colhoun HM, Betteridge DJ, Durrington PN, et al; CARDS investigators. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomized placebo-controlled trial. Lancet 2004; 364: 685-696. <![CDATA[Atypical central serous chorioretinopathy treated with intravitreal injection of bivacizumab – a case report]]> Manash Kumar Goswami https://imcjms.com/journal_full_text/74 2016-08-02 12:14:18 Clinical Case Report Ibrahim Med. Coll. J. 2015; 9(1): 34-36 Central serous chorioretinopathy (CSCR) is common in adult male having sudden dimness of vision in one eye and typical pattern of leakage in fundus fluorescein angiography. Treatment of typical central serous chorioretinopathy is conservative and / or focal laser photocoagulation. But atypical central serous chorioretinopathy is uncommon having different patterns of clinical presentation and features in fundous fluorescein angiography. Treatment option of atypical central serous chorioretinopathy is not yet established. Here, we present a case of atypical central serous chorioretinopathy successfully treated with intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF, Bivacizumab). Ibrahim Med. Coll. J. 2015; 9(1): 34-36     Central serous chorioretinopathy is a common vision lowering disease after age related macular degeneration, diabetic retinopathy and vascular occlusive disease.1 First described by Vongraefe in 18662 and later OLMSTED study in Minnesota, USA reported that 9.9 per 10000 men and 1.7 per 10000 women were affected by this disease.3 Mean age of onset is 41-45 years in case of acute CSCR and for chronic CSCR it is 51yrs.In older population (age>51 years), CSCR is more likely to have bilateral involvement.4 Risk factors are type A personality,5 Cushing syndrome,6 pregnancy,7 systemic steroid use8 and collagen vascular diseases.9 Psychosomatic factor is also related with CSCR. In stress, the increased levels of stress hormones and glaucocorticoids have direct relationship with macular thickness.10 Here, we present a case of atypical central serous chorioretinopathy in a 41 years old male. Case presentation Patient underwent fundus fluorescent angiography which showed multifocal hyper fluorescence diffusely present in the macula and perimacular region extending to the temporal retina in both eyes. The hyper fluorescent increased with time (Fig-1). Optical Coherent Tomography (OCT) of both maculae showed huge sensory retinal detachment with accumulation of fluid involving the entire macular region (Fig-2). Blood biochemistry showed no abnormalities. Based on the multiple leakage in macula and perimacular region, elevation of entire macular region with entire sensory detachment and simultaneous bilateral involvement of both eye, the patient was diagnosed as a case of acute bilateral atypical CSCR and advised intraviteral injection of 1.25 mg anti-vascular endothelial growth factor (Bivacizumab). A total of three doses of Bivacizumab were given over three months period with non-steroidal anti-inflammatory (NSAID) eye drops twice daily in both eyes. One injection was given each month in each eye. Vision improved gradually after each injection of Bivacizumab. One month after the 3rd injection the vision improved to 6/12 in right eye and 6/9 in left eye. OCT after the third injection showed normal macular contour (Fig-3). The patient had 6/6 vision in both eye and normal retinal integrity both clinically and by OCT one year after the last injection.   Fig.2: Optical Cohherent Tomography (OCT) of Maculae shows areas of sensory retinal at maculae of both eyes.   Fig.3: OCT of both eyes after treatment with injection of bivaczumab show normal macular contour Discussion In our case, the clinical presentation was sudden, bilateral with profuse deterioration of vision within a very short period of time. This is unusual because the usual presentation of typical CSCR is unilateral with moderate deterioration of vision with a central scotoma.1 In our case, diminution of vision was profound, which was reduced to counting finger close to the eyes. The findings of multifocal leakage and diffuse appearance in FFA were also contrary to single smoke steak appearance seen in typical CSCR. In this aspect the presentation of our case was atypical. Several treatment options have been described for acute CSCR with variable success. The treatment of CSCR includes focal argon laser,13 photodynamic therapy with verteporfin,14 micropulse diod laser15 and Anti-VEGF injection in the intravitreal space.16 In our case the leakages in the FFA are multifocal and did not have typical smoke stack appearance. Focal laser photocoagulation could not be done. So intravitreal Bivacizumab was administered. The visual improvement after multiple intravitreal injection of Bivacizumab supported the earlier reports of its success in the treatment of acute CSCR. Acute atypical CSCR with multifocal leakage in the FFA and huge sensory retinal detachment, involving the whole macula responds well with intravitreal injection of Bivacizubab in repeated doses. Acute bilateral extensive CSCR with multifocal leakage and grossly reduced vision can be treated successfully with intravitreal injection of anti-VEGF instead of laser. References 2.    Yannuzzi LA. Type A behavior and central serous chorioretinopathy. Retina 1987; 7: 111-31. 4.    Spaide RF, Campeas L, Haas A et al. Central serous chorioretinopathy in younger and older adults. Ophthalmology 1996; 103: 2070-9. 6.    Bauzas EA, Scott MH, Mastorako SG, Chrousos GP, Kaiser Kupfer MI. Central serous corioretinopathy in endogenous hypercortisolism. Arch Opthalmol 1993; 111: 1229-33. 8.    Haimovici R, Koh S, Gagnon DR, Lehrfeld T, Wellik S. Risk factor for central serous Chorioretinopathy: a case control study. Opthalmology 2004; 111: 244-9. 10.  Garg SP, Dada T, Talwar D, Biswas NR. Endogenous cortisol profile in patients with central serous chorioretinopathy. Br J Ophthalmol 1997; 81: 962-4. 12.  Yannuzzi LA, Shakin JL, Fisher YL, Altomonte MA. Peripheral retinal detachment and retinal pigment epithelium atrophic tracts secondary to central serous pigment epitheliopathy. Ophthalmology 1984; 91: 1554-72. 14.  Taban M, Boyer SD, Thomas EL, Taban M, Chronic central serous chorioretinopalty: Photodynamic therapy. Am J Ophthalmol 2004; 137: 1073-80. 16.  Lim JW, Ryu SJ, Shin MC. The effect of intravitreal bivacizumab in patients with acute central serous chorioretinopathy. Korean J Ophthalmol 2010; 24: 155-8. 18.  Aydin E. The efficacy of intravitreal bivacizumab for acute central serous Chorioretinopathy. Journal of Ocular Pharmacology and Therapeutites 2013; 29(01): 10-13. <![CDATA[Determinants of Contraceptive Use in Bangladesh]]> Masuda Mohsena Nashid Kamal https://imcjms.com/journal_full_text/68 2016-08-02 12:05:20 Original Article Ibrahim Med. Coll. J. 2014; 8(2): 34-40 Background: Bangladesh is experiencing a plateau phase in fertility decline after its dramatic reduction in early nineties. Aspects of contraceptive use dynamics have important influences on fertility. Results: The results showed that individual level characteristics had strong influence on contraceptive use. These variables included educational level of the couples, autonomy of woman, male child preference, woman’s membership with an NGO, visit by family planning worker, region and type of residence. Ibrahim Med. Coll. J. 2014; 8(2): 34-40 Address for Corresponded: Dr. Masuda Mohsena, Associate Professor, Department of Community Medicine, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000. email: masuda669@gmail.com   Bangladesh, having a population of 140 million and a corresponding population density of more than 900 per square km happened to be one of the most densely populated countries in the world1. The policy to reduce fertility rate was repeatedly emphasized by the Government of Bangladesh since its liberation in 1971. In 1976, the Government declared the rapid growth of the population as the country’s top-most problem and adopted a broad-based, multi-sectoral family planning program along with an official population policy. Population planning was seen as an integral part of the total development process of the country and was incorporated into successive five-year plans2. There are programmatic and policy importance of understanding the choice of contraceptive method use and factors affecting contraceptive choice in order to reduce the total fertility rate (TFR) of a country5. As any future reduction in fertility in Bangladesh may be largely dependent on the increased use of effective birth control measures, identification of specific determinants of each method is needed. To facilitate that effort, by using a single model and controlling for the various factors, this study aims to 1) Analyze socio-economic and demographic determinants of different contraceptive methods choice in Bangladesh; and 2) Discuss the policy implication of the findings. Methods and Models The dependent variable in this study was “current method of contraception adopted by the woman”. BDHS 2004 collected information on pill, intrauterine device (IUD), injection, condom, female and male sterilization, periodic abstinence, withdrawal, norplant and other methods. Here four groups were considered: Non-user, folk and traditional method users were considered as one group and coded as 0. Pill users, having highest frequency were coded as 1. Permanent method acceptors (tubectomy and vasectomy) were coded as 2. Long term temporary method users (injection, norplant and IUD) were coded as 3. Condom users, as the use additionally gives protection against Sexually Transmitted diseases (STDs) and AIDS were coded as 4. The frequencies of use of these four methods were presented in Figure 1. Fig.1: Contraceptive method preferences among married couples, BDHS 2004  In the BDHS, there were many variables available related to mobility of the women. Principal Component Analysis (PCA) technique was employed to create the variables into a mobility score for each woman6. On the basis of prior knowledge of determinants of contraceptive use educational level of the women, her religion, number of living son, her membership with an NGO, husband’s education level, wealth index, age of women, her type of residence (urban/ rural), division to which she belonged were entered as independent ones in the model. These independent variables were tested for statistical significance using bivariate techniques such as chi square tests (Table 1). Finally, Multinomial Logistic Regression (MLR) model was employed to estimate the relationship between contraceptive use and socio-economic and demographic factors using SPSS software.   Among the 10,554 currently married women surveyed in BDHS 2004, 53.14% either did not practice any method or relied on folk or traditional methods. Oral contraceptive method seemed to be the most popular one having 25.4% use rate. Long term methods (norplant, IUD and injections) came out as the second most popular method (11.0%), 5.6% couples accepted either male or female sterilization method. Condom had the lowest frequency (4.8%) of use. Results of the MLR analysis are presented in Table 2. From the model ‘education level of the women’ came out as a strong predictor of contraceptive use. The probability of being a pill user was 1.24 times higher if the woman had secondary education compared to woman having no education. The probability of using condom for husbands of highly educated women (with post-secondary education) was 4 times higher compared to the husbands of non-educated women, whereas the values were almost 2.5 and 1.5 times higher for husbands of secondary educated women and those of primary educated women, respectively. Women who were illiterate were more likely to be users of long term temporary methods compared to primary (17% less) and secondary educated women (28% less). Uneducated women were more likely to be users of permanent method of contraception, as-well, compared to primary and secondary educated women. Table-2: Multinomial logistic regression of modern contraceptive methods used by females on selected variables, Bangladesh DHS 2004   Odds of taking pill was found to be almost two and a half times higher in women having one living son compared to those having no living son. Couples with one or two sons preferred condom twice (1.8 and 2.02) more than those having no son. Having at least one son increased the odds of using long term and permanent methods by more than 2.5 and 3.5 times, respectively compared to women having no living son. From the table it was observed that Muslim women were significantly lower users of pill and had less chance of being a permanent method acceptor compared to non-Muslim women. Religion turned out to be an insignificant predictor for condom use. Contrary to expectation, the study finding showed that Muslim women had 1.56 times more probability of being acceptors of long term temporary methods than non-Muslim women. The model showed that women living in urban areas had higher odds of being users of modern contraceptive methods than women living in rural areas. Division also mattered in the pattern of contraceptive use. Using Sylhet as the reference category, it was found that the women, who were from Rajshahi division, showed highest odds of using all types of modern contraceptive methods; use of pill was 5 times higher in women from Rajshahi compared to women from Sylhet. Compared to women who lived in Dhaka division, condom use were significantly less among women of Barisal and Sylhet divisions. Data of Rajshahi, Khulna and Barisal division showed higher use of long term methods of contraception by the women in these divisions compared to those in Dhaka, whereas women in Sylhet again showed poorer performance. Husbands who had higher education showed 2.4 times more likelihood of being a condom user compared to those who were uneducated. Husband’s level of education was an insignificant predictor of pill use by their wives. Husband with secondary or higher education showed 0.19 and 0.46 times lower odds of their wives using long term temporary methods compared to non-educated husbands, uneducated husbands preferred the permanent method, whereas, probability of using this method decreased by 25% if educational status increased to secondary education. Discussion Among the other factors, the status of women also depend on whether she can move outside of the homestead alone, thus enabling a woman to cross several socio-cultural barriers7. This ‘mobility’ also has influences over her contraceptive behavior. Higher odds in use of all types of modern methods were observed in women having higher mobility score. To achieve higher rates of contraceptive prevalence, there is a need for widespread measures that will enhance the mobility of the women. Kamal and Mohsena(2011) made recommendations for extending projects like Grameen Bank and Bangladesh Rural Advancement Committee (BRAC) for achieving further autonomy of women6. Interestingly, finding of this study suggests that woman’s membership with an NGO increased her probability of using the pill, sterilization and long-term methods, but condom use was almost the same between women involved or not involved with NGOs. This may be due to the reason that NGOs are now providing family planning services along with their credit programs10; but their service effort probably is targeted to overall contraceptive prevalence rate (CPR). In these days of impending epidemic of AIDS and higher prevalence of sexually transmitted diseases (STDs) use of condom can serve as double protection, both against unwanted fertility and STDs/ HIV. During group-participation of women in NGOs promotion of condom use could be successful. One advantage to be noted here is that influence of religious beliefs in this regard is negligible. Gender discrimination and preferences for sons are key demographic features in South Asia12; Bangladesh being no exception. After the birth of oneson, the odds of using all types of contraceptives increase, ranging from 1.8 to 3.7. This existence of son preference in a region, where the official target is to decline fertility, has implications for future population policy. This sex preference is likely to correlate with women’s autonomy. Girls are not encouraged to engage in any economic activities outside their homes and an associated custom is the practice of dowry payments. These norms always impoverish the parents of girls and enrich the parents of boys. The improvement of women’s status, their education levels, their employment and the value of girls in the society should therefore be future policy measures. The study findings of this study have a number of policy implications for Bangladesh. The measures that are expected to be useful in devising ways to increase the Contraceptive Prevalence Rate and thus bring about a further reduction in fertility in Bangladesh are multidimensional. Provision of education and employment to women, as well as their male counterpart proved to be the key policy. Policy should be targeted to prevent high dropout rates from secondary schools, which in turn will enable them to get greater degree of autonomy. Kamal and Haider (2006)15 also recommended that providing free female education alone cannot let the chair stand, it comprises of only one leg, the other legs need to be in place as well. Campaigns should be done to raise the value of girl child in the society and reduce son preference. Demographers have associated ‘Dowry’ as a major cause of son preference. Motivational campaigns and application of legislation strictly may turn out to be the solution. Besides, improving the employment situation of women will also enable them in obtaining some family power to make family planning decision. Improving the home visit of the family planning workers should be highlighted in policy, as this visit still comes out as a strong predictor of contraceptive use.Various researches showed that role of NGOs in women empowerment are encouraging; where women empowerment is defined as a function of her relative physical mobility and economic security. Contraceptive awareness may be targeted to the credit-receiving clients; involvement of the NGOs in advocating contraceptive use, especially in promoting condom may give better result. Reference 2.    Menken J and Rahman MO. Reproductive Health. In: H MM, E BR, J MA, editors. International Public Health Diseases, Programs, Systems and Policies Gaythersburg, Maryland: Aspen Publishers 2001. 4.    Islam MM, Islam MA and Chakroborty N. Fertility Transition in Bangladesh: Understanding the Role of the Proximate Determinants. Journal of Biosocial Science 2004; 36(3): 351-69. 6.    Kamal N and Mohsena M. Twenty Years of Field Visits by Family Planning Workers in Bangladesh: Are They Still Needed? The Indian Journal of Family Welfare 2011; 57(1): 10-21. 9.    Amin S, Selim N and Kamal N. Causes and Consequences of Early Marriage in Bangladesh. Background Report for Workshop on Programs and Policies to Prevent Early Marriage. Dhaka, Bangladesh: Population Council 2006. 11.  Kamal N. Role of Government Family Planning Workers and Health Centres as Determinants of Contraceptive Use in Bangladesh. Asia-Pacific population Journal/United Nations 1994; 9(3): 59-65. 13.  Ullah MS and Chakraborty N. The Use of Modern and Traditional Methods of Fertility Control in Bangladesh: A Multivariate Analysis. Contraception 1994; 50(4): 363-72. 15.Kamal N and Haider S. Role of Education in Enabling Empowerment of Women in Bangladesh.CHPD Seminar Series; 15 March; IUB, Bangladesh 2006. <![CDATA[First Line Anti-Tubercular Drug Resistance Pattern of Mycobacterium Tuberculosis Isolated From Specialized Hospitals of Dhaka City]]> Md. Mohiuddin J. Ashraful Haq https://imcjms.com/journal_full_text/69 2016-08-02 12:06:05 Original Article Ibrahim Med. Coll. J. 2014; 8(2): 41-46 The present study was undertaken to determine the drug resistance pattern of M. tuberculosis isolated from 225 pulmonary and 45 extrapulmonary tuberculosis cases. The samples were cultured on Lowenstein Jensen (L-J) media for isolation of M. tuberculosis. Drug resistance to first line anti tubercular drugs- namely isoniazid (INH), rifampicin (RIF), Ethambutol (ETH) and streptomycin (SM) were determined by indirect proportion method. The overall drug resistance of M. tuberculosis was 53.6% to any of the first line anti tubercular drugs. Rate of multi drug resistant tuberculosis (MDR-TB) among the untreated cases was 4.2%, while it was 36.0% in previously treated cases. It was found that 83.3% rifampicin resistant M. tuberculosis was cross resistant to one or more of other first line anti-tubercular drugs, while cross resistance of INH, ETH and SM resistant isolates was much low. The present study revealed that high level of drug resistance exists to individual anti tubercular drugs and MDR-TB is an emerging problem, particularly in treated cases. Rifampicin resistance could be used as a surrogate marker for drug resistance to other first line anti tubercular drugs. Address for Correspondence:Prof. J. Ashraful Haq, Professor, Department of Microbiology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000. e-mail: jahaq54@yahoo.com Introduction In Bangladesh, TB remains a major public health problem. Over 300,000 new cases of TB and 70,000 deaths are estimated to occur per year in Bangladesh and the country ranks 6th out of the 22 highest TB burden countries of the world.2 The estimated incidence and prevalence rate of all forms of TB were 223 and 387 per 100,000 population respectively. The estimated death rate was 45 per 100,000 population. Globally the median prevalence of drug resistance to any drug in untreated cases was the highest (19.8%) in South East Asia (SEA) followed by Western Pacific (11.4%) and Europe (8.4%). The median prevalence of drug resistance to any drug in treated cases was the highest (63.3%) in the Eastern Mediterranean followed by SEA (39.9%) and (in Europe (15.9%). The rate of MDR- TB ranged from 4.7%-48.3% in above regions.5 The present study was undertaken to determine the rate of drug resistance of MTB to first line anti-tubercular agents in patients attending tertiary care hospitals of Dhaka city. The study also investigated the concomitant resistance of MTB among rifampicin resistant MTB. Materials and Methods   The early morning sputum samples were collected in clean, sterile wide mouthed container closed with lid. The quantity of sputum collected from each patient was 2 – 5 ml. The LN aspirates were collected aseptically in 50 ml of sterile Falcon tubes containing 3 ml sterile distilled water in each container. The containers were labeled with patient’s name, identification number and date. The samples were brought to the department of Microbiology, BIRDEM, Dhaka as soon as possible, where necessary laboratory tests were done after processing the samples in Class 2 bio-safety cabinet. The processed products of the samples were kept in 3 different eppendorf tubes for: a) Ziehl-Neelsen (ZN) stain, b) culture of mycobacteria on Lowenstein Jensen (L-J) media and c) rapid detection of mycobacteria by PCR method. Smear was stained by ZN method for the detection of acid fast bacilli (AFB). Culture was done by inoculating it on L-J media and incubating it at 370C for isolation of mycobacterium. The culture bottles were examined weekly for 8 weeks for the evidence of growth. On appearance of visible colonies, the colony morphology, rate of growth and pigment production were noted. The growth of M. tuberculosis was identified by staining of colonies with ZN stain and confirmed by necessary biochemical tests.6 Drug susceptibility test   The number of colonies on control and drug containing media were counted and the percentage of the resistant organisms was calculated as follows: If the percentage of resistant organism was 1% or more, then the isolate was considered resistant to the specific drug. A set of tubes with and without drugs were incubated with reference strain M. tuberculosis H37Rv as a quality control. Results Table-1 shows the results of culture of the study samples. Out of the total 300 samples, sputum sample was 255 of which 180 (70.59%) were culture positive, 40 (15.69%) were culture negative and 35 (13.72%) became contaminated. Among the 45 lymph node aspirates 20 (44.45%) were culture positive, 15 (33.33%) were culture negative and 10 (22.22%) became contaminated. Table-2 shows the species distribution of culture positive mycobacteria in sputum and LN aspirates. Out of 180 culture positive isolates from sputum 176 (97.8%) were M. tuberculosis and 4 (2.2%) were mycobacterium other than tuberculosis (MOTT). Out of 20 isolates from lymph node aspirates 16 (80.0%) were M. tuberculosis and 4 (20.0%) were MOTT. Table-1: Results of culture of study samples   Table-2: Species distribution of culture positive Mycobacteria in sputum and LN aspirates  Overall susceptibility pattern of M. tuberculosis and MOTT to first line anti-TB drugs are depicted in Table-3. Out of 192 M. tuberculosis isolates 89 (46.35%) were sensitive to all of the four first line anti-TB drugs and 103 (53.65%) were resistant to any of the four first line anti-TB drugs. In case of the MOTT, all 8 (100%) were resistant to any of the first line anti-TB drugs. Table-3: Overall susceptibility pattern of M. tuberculosis and MOTT to first line anti-TB drugs       Table-5 shows resistance pattern of 167 M. tuberculosis isolates to 4 first line anti-TB drugs in untreated cases. Out of the total 167 isolates, 53 (31.74%) were resistant to one drug, 19 (11.38%) were resistant to two drugs, 3 (1.80%) were resistant to three drugs and 3 (1.80%) were resistant to four drugs. Table-6 shows resistance pattern of M. tuberculosis to four first line anti-TB drugs in previously treated cases. Out of the total 25 isolates, 4 (16.0%) were resistant to one drug, 13 (52.0%) were resistant to two drugs, 1 (4.0%) was resistant to three drugs and 7 (28.0%) were resistant to four drugs. Table-5: Resistant pattern of M. tuberculosis to 4 first line anti-tubercular drugs isolated from untreated tuberculosis cases (n=167)     Table 7 shows the rate of MDR-TB in untreated and treated pulmonary TB cases. Among the untreated cases, MDR-TB was 4.2% while it was 36.0% among the treated cases. The rate was significantly higher in previously treated group. The rate of concomitant resistance pattern of RIF resistant M. tuberculosis to INH, ETH and SM are described in Table-8. It was observed that 83.3% RIF resistant M. tuberculosis isolates were resistant to other three drugs. The association of RIF resistance with resistance to other three drugs were significantly associated (p<.05). The concomitant resistance of INH, ETH and SM resistant M. tuberculosis to any other three drugs were 55.5-74.3% and the co-resistance was not significantly associated (P>0.05). Table-7: Rate of isolation of MDR-TB from untreated and treated pulmonary tuberculosis cases      Table-9: Rate of concomitant resistance of RIF / INH / ETH /SM sensitive M. tuberculosis to corresponding drugs Table-9 shows the concomitant resistance rate of M. tuberculosis to any three first line anti-TB drugs which were sensitive to RIF, INH, ETH or SM. Rate of resistance to three other drugs ranged from 34.78% to 43.21% among RIF, INH, ETH or SM sensitive isolates. Discussion Monitoring of drug resistance pattern, early diagnosis and initiating prompt treatment has been the mainstay to interrupt the transmission of tuberculosis. In this context, the present study was designed to determine the drug resistance pattern of mycobacterium. In the present study, about 70.0% sputum samples yielded positive culture results on L-J media. Various authors have reported similar culture positivity rate in L-J media which ranged from 59.72 to 87.2%.8-11 However, the culture positivity rate was only 44.0% in lymph node aspirate samples. The failure to isolate mycobacteria in about 30-56% sputum and lymph node aspirates was due to contamination of media or damage to organisms during decontamination process. Previous studies reported the contamination rate from 1.2% to 27.2%.9-13 Therefore, the isolation rate of mycobacteria can be increased if contamination is prevented and sample processing procedure is further improved. Out of the 200 isolates of mycobacteria, 96.0% were M. tuberculosis and 4.0% were MOTT. Earlier, a study in Dhaka by Miah et al. reported 95.3% isolates as M. tuberculosis and 4.7% as MOTT.3 The resistance pattern of first line anti-tubercular drugs observed in the present study among untreated cases was almost similar to the resistance pattern reported previously in 2000 and 2007.3,4 Almost similar rate of resistance was observed in other neighboring countries.14,15 In the present study, out of 30 RIF resistant M. tuberculosis, 83.3% were also concomitantly or cross resistant to other three first line anti-tubercular drugs (p<0.05; Table-8). On the other hand, of the 50 INH resistant M. tuberculosis, 64.0% were concomitantly or cross resistant to other three first line anti tubercular drugs (p>0.05) while for ETH and SM the rate was 74.3% and 55.5% respectively. Resistance to RIF in M. tuberculosis occurs in a high frequency and mono resistance to RIF is rare, whereas mono resistance to INH is common.17 It has been proposed that resistance to RIF can be used as a surrogate marker for MDR-TB as nearly 90% of the RIF resistant strains are also INH resistant.17,18 It is to be noted that only 43.21% M. tuberculosis isolates which were sensitive to RIF, was concomitantly resistant to other 3 drugs (Table-9). This indicates that a sensitive M. tuberculosis isolates (sensitive to RIF, INH, ETH and SM) could be resistant to any of the three other first line anti-TB drugs and it could not therefore, predict that if an isolate sensitive to any single first line drug would simultaneously be sensitive to other three drugs.   1.    World Health Organization Report 2010: Global tuberculosis control. World Health Organization, 1211 Geneva 27, Switzerland. 2010; 5-7. 3.    Miah MR, Ali MS, Saleh AA, Sattar H. Primary drug resistance pattern of mycobacterium tuberculosis in Dhaka, Bangladesh. Bangladesh Med Res Council Bull 2000; 26: 33-40. 5.    World Health Organization: Global tuberculosis control: surveillance, planning and financing. World Health Organization, 1211 Geneva 27, Switzerland 2006a; 362. 7.    Velayati AA, Masjedi MR, Farnia P, Tabarsi P, Ghanavi J, Ziazarifi AH, et al. Emergence of new forms extensively drug-resistant tuberculosis bacilli: super resistant strains in Iran. Chest 2009; 136: 420-25. 9.    Hanna BA, Ebrahimzadeh A, Elliot LB, Morgan MA, Novak SM, Rusch-Gerdes S, et al. Multicentre evaluation of BACTEC MGIT 960 system for recovery of mycobacteria. J Clin Microbiol 1999; 37: 748-52. 11.  Uddin MN, UddinMJ, Mondol MEA, Islam SMJ, Wadud ABM. Comparison of conventional and automated culture system for isolation of Mycobacterium tuberculosis. JAFMC Bangladesh 2009; 5: 14-17. 13.  Chien HP, Yu MC, WU MH, Lin TP, Luh KT. Comparison of the BACTEC MGIT 960 with Lowenstein Jensen media for recovery of mycobacteria from clinical specimens. Int J Tuberc Lung DIS 2000; 4: 866-70. 15.  Iqbal R, Shabbir I, Khan SU, Saleem S, Munir K. Multidrug resistance tuberculosis in Lahore. Pak J Med Res 2008: 47: 22-25. 17.  Somoskovi A, Parsons LM and Salfinger M. The molecular basis of resistance to isoniazid, rifampicin and pyrazinanide in Mycobacterium tuberculosis. Respir Res 2001; 2: 164-68. <![CDATA[Lipid Profile of Women with Polycystic Ovary Syndrome Attending a Tertiary Care Hospital of Dhaka City]]> Rona Laila Nusrat Mahmud Monnujan Nargis TA Chowdhury https://imcjms.com/journal_full_text/70 2016-08-02 12:07:35 Original Article Ibrahim Med. Coll. J. 2014; 8(2): 47-49 Polycystic ovary syndrome (PCOS) is one of the common disorders in women at child bearing age. The purpose of the present study was to investigate the lipid profile in patients with polycystic ovary syndrome. Ibrahim Med. Coll. J. 2014; 8(2): 47-49 Address for Correspondence: Dr. Rona Laila, Assistant Professor, BIRDEM General Hospital. 1/1 Ibrahim Sarani, Segunbagicha, Dhaka-1000, Bangladesh. Mobile: +8801711985438, Email: ronalaila7776@gmail.com   One of the most common disorders in women at child bearing age is polycystic ovary syndrome (PCOS), which is a complex disorder affecting not only the normal development of eggs in the ovaries but also other metabolic pathways.1-3 PCOS is a common endocrine disorder affecting 5-10% women of reproductive age.4,5 It is associated with diabetes and cardiovascular disease. In view of the above, the present study was undertaken to evaluate the lipid parameters in women with PCOS.        Study population Anthropometry and laboratory methods Oral glucose tolerance test (OGTT) was performed in all subjects following the WHO criteria (1999). The selected subjects were requested to fast overnight (8-12 hours). In the following morning, fasting blood samples (10 cc) was collected in an EDTA containing tube. After two hrs of glucose load (75 gm) another 5 ml blood was drawn in another tube. Serum lipids were determined from fasting sample.   The detail anthropometric characteristics of the study population are shown in Table 1. The mean BMI±SD of the 103 participants was 25.84±5.54 kg/m2. Out of 103 study women 50 (48.5%) had family history of diabetes. Among 103 women with PCOS, 30 (29.1%) showed impaired glucose tolerance (OGTT value: 7.8-11.0 mmol/L), 5 (4.9%) were T2DM (fasting blood sugar >7.0, OGTT value >11.1mmol/L) and 68 (66%) showed normal glucose tolerance (OGTT value <7.8 mmol/L). Table-1: Anthropometric and other characteristics of the study population (n=103)  Detailed anthropometry, laboratory and other clinical characteristics of women with PCOS having NGT, IGT and T2DM are recorded in Table 2. Mean age of NGT, IGT, and T2DM was 23.68±4.57, 25.03±6.09 and 30.48±2.88 years respectively. The BMI of women having NGT, IGT and T2DM ranged from 24.86 kg/m2 to 32.7 kg/m2.In NGT group 16.2% had BMI>30 kg/m2 where as 23.3% of IGT and 40% of T2DM had BMI>30 kg/m2. The mean cholesterol levels in NGT, IGT and T2DM groups ranged from 182 mg/dl to 236 mg/dl. Details of other lipid parameters are shown in the Table 2. Table-2: Anthropometric, laboratory and other characteristics of women with PCOS having NGT, IGT and T2DM  Discussion Dyslipidemia is common in PCOS compared to weight matched controls with higher triglyceride and lower high-density lipoprotein cholesterol.9,11 The dyslipidaemia occurs independent of BMI.14 The causes of dyslipidaemia in PCOS are again multi-factorial. Insulin resistance appears to have an important role mediated by simulation of lipolysis and altered expression of lipoprotein lipase and hepatic lipase.15 It is thought that approximately 70% of the patients with PCOS have disturbances in serum lipid levels.16 A study on Bangladeshi women with PCOS reported increased levels of triglyceride, LDL and total cholesterol.17 In our study, the lipid profiles of women with PCOS was generally higher than normal healthy women.   1.    Azziz R, Woods KS, Reyna R, Key TJ, Knochenhauer ES and Yildiz BO. The prevalence and features of the polycystic ovary syndrome in an unselected population. J Clin Endocrinol Metab 2004; 89: 2745-49. 3.    Taylor, A.E. Understanding the underlying metabolic abnormalities of polycystic ovary syndrome. Am J Obstet Gynecol 1998; 179: S94-S100. 5.    Diamanti-Kandarakis E, Kouli CR, Bergiele AT, et al. 6.    Wild RA, Alaupovic P, Parker IJ. Lipid and  apolipoprotein abnormalities in hirsute women. Am J Obstet Gynecol 1992; 166: 1191-97. 8.    DeFronzo RA, Hendler R, Simonson. Insulin resistance; a multifaceted syndrome responsible for NIDDM, obesity, hypertension, dyslipidemia and atherosclerosis. Neth J Med 1997; 50: 191-97. 10.  Christian RC, Dumesic DA, Behrenbeck T, Oberg AL, Sheedy PF et al. Prevalence and predictors of coronary artery calcification in women with polycystic ovary syndrome. J Clin Endocrinol Metab 2003; 88(6): 2562-68. 12.  Moran LJ, Misso M, Wild RA, Norman R. Impaired glucose tolerance, type 2 diabetes and metabolic syndrome in polycystic ovary syndrome: A systematic review and  meta-analysis. Human Reproduction Update 2010; 16: 347-63. 14.  Wild RA, Bartholomew MJ. The influence of body weight on lipoprotein lipids in patients with polycystic ovary syndrome. Am J Obstet Gynecol 1988; 159: 423-27. 16.  Gateva A, Kamenov Z. Cardiovascular risk factors in Bulgarian patients with polycystic  ovary syndrome and/or obesity. Obstet Gynecol Int 2012; doi: 10.1155/2012/306347. <![CDATA[Is Estimated Glomerular Filtration Rate (eGFR) a Better Predictor than Creatinine Cutoff to Detect Chronic Kidney Disease (CKD)?]]> Parvin Akter Khanam Tanjima Begum Md. Morshed Alam Khan Sarwar Iqbal Akhter Banu Mir Masudur Rhaman M Abu Sayeed https://imcjms.com/journal_full_text/249 2017-07-10 11:07:54 Original Article Ibrahim Med. Coll. J. 2014; 8(2): 50-55 Chronic kidney disease (CKD) with diabetes mellitus is one of the most common and major public health problems globally. In Bangladesh, several studies indicate an increasing prevalence of diabetes though very few studies are available on CKD. For CKD, diagnostic method, criteria or cutoffs still remained undecided. This study aimed to determine the prevalence of CKD among the hospitalized patients and to compare the diagnostic approach practiced in the hospital. Results: A total of 4172 patients got admitted in the study period of 90 days; and 442 patients (m / f = 256 / 186) were investigated. Of the total (n=4172), 241 (5.8%) had CKDcreat and 272 (6.5%) had CKDgfr. Of the investigated 442 patients, 241 (54.5%) had CKDcreat and 272 (61.5%) had CKDgfr. The differences of characteristics between CKDcreat and non-CKDcreat groups were almost similar to the differences between CKDgfr and non-CKDgfr groups. Higher age, higher social class and higher blood pressure showed significant (p<0.001) and similar associations with both CKDcreat and CKDgfr. Interestingly, if the cut-off of eGFR is taken at <90 ml/min/1.732, as suggested by K/DOQI, the prevalence of CKDgfr increases to 86.7%. This indicates a wide variation (32.2%) between the two criteria (CKDcreat: creat >1.2 mg/dl and CKDgfr: <90 ml/min/1.732). Thus, a large proportion remained either under- or over-diagnosed depending on the criterion used. Ibrahim Med. Coll. J. 2014; 8(2): 50-55   Chronic kidney disease (CKD) is a growing public health problem both in the developing and developed world.1 Prevalence is estimated to be 8-16% worldwide. The complications of CKD related to and resulted in increased all-cause and cardiovascular mortality.2 More striking is the fact that diabetes mellitus is the most common cause of chronic kidney disease, but in some regions other causes, such as herbal and environmental toxins, are more common.2 About 5% of the adult populations have some form of kidney damage and every year millions of people die prematurely of cardiovascular diseases linked to CKD. The recent literatures indicate that diabetes and hypertension are becoming the most common causes of CKD, especially in older people both in developed and developing nations,3,4 CKD is estimated to effect 19 million people of US population and greater than 50 million people worldwide.5,6 In Bangladesh, a survey among the disadvantaged community in Dhaka City revealed that 13.1% had CKD.7 This indicates that the prevalence of CKD is not negligible. Early diagnosis of CKD and intervention are the imperative measures to prevent or retard life-threatening complications. The intervention measures initiating low-protein dietary changes, close monitoring of blood pressure, control of blood glucose levels, health related education, exercise, and so on.9 The aim of this study was to estimate the burden of CKD in hospitalized patients and to compare the two diagnostic criteria practiced in the hospital setting with a view to accept a cheaper and simpler diagnostic method. Subjects and Methods Statistical analyses: Socio-demographic characteristics were given in percentages for qualitative and mean (SD) for quantitative variables. Independent t-tests were applied for comparisons of characteristics between CKDcreat and NCKDcreat group and between CKDgfr and NCKDgfr groups to see any difference observed between these two comparisons. The prevalence rates for CKDcreat and CKDgfr were givenin percentages. We also used c2-test to assess risk factors like sex, age, residence, social class, hypertension status, occupation and smoking for both types of CKD. The values for eGFR based on K/DOQI and the corresponding values for creatinine were shown in means with 95% confidence interval. A p< 0.05 was considered statistically significant. All statistical analyses were performed using SPSS 20.0. Results Of the study population (n = 442) the males were 256 and females were 186. Based on the two criteria (creat >1.2mg/dl) and eGFR (<60 ml/min/ 1.73m2), the prevalence of CKDcreat and CKDgfr was 5.8% and 6.5%, respectively, among the admitted (n=4172) patients. In other words, at any given period in a hospital, the prevalence of CKD ranges from 5 – 7%. In contrast, when only the investigated (n = 442) patients were considered the prevalence of CKDcreat was 54.5% and CKDgfr, was 61.5%. (table 1). If the cut-off of eGFR is taken at <90 ml/min/1.73m2, as suggested by K/DOQI, the prevalence of CKDgfr increased further to 86.7%. Thus, there was a wide variation (32.2%) between the two criteria (CKDcreat: creat >1.2 mg/dl and CKDgfr: <90 ml/min/1.732).   The socio-demographic characteristics are shown in Table 2. The mean (SD) age was 56.1 (13.9) and BMI was 23.3 (4.3). Forty years and above comprised   almost 90%. Table-2: Demographic characteristics of the study population (N=442).   Table-3: Comparison of characteristics between non-CKD (NCKD) and CKD based on serum creatinine and eGFR (cut-off: creat 1.2mg/dl and eGFR 60 ml/min/1.73m2).3       Table-4: Comparison of Prevalence of CKD (based on both criteria) according to sex, age, residence, social class, hypertension, occupation and smoking habit.     Discussion Then which criteria should we follow? The prevalence of CKDgfr (eGFR <90 ml/min/1.73 m2) was found 86.7%, based on K/DOQI (table 3). In contrast, the prevalence of CKDcreat was found 54.5%. based on creatinine level (>1.2mg/dl). This means that about 38.5% remained undiagnosed by CKDcreat or over-diagnosed by CKDgfr criteria. The controversy remained still unsettled as reported from Pakistan.12 Had we included other variables like micro-albuminuria, gross proteinuria, albumin-creatinine ratio or evidence of other micro-angiopathic (retinopathy or neuropathy) and macro-angiopathic lesions like coronary artery disease or cardiovascular morbidity then we could have better assessment of diagnosis or grading of CKD. The recent suggestion is that serum cystatin C alone or creatinine plus cystatin C may predict better CKD.13 But, this recommendation was challenged by others.14 Considering the above mentioned studies it remained unsettled issue to recommend an accurate diagnostic tool for CKD. This study concludes that the prevalence of CKD among the hospitalized patients is almost comparable to other studies and the prevalence was found much higher if K/DOQI is used. Older age, hypertension, rich class and urbanization were found significantly associated CKD. The study suggests that inclusion of serum creatinine with eGFR, micro-albuminuria, gross proteinuria, albumin-creatinine ratio and cystatin C in a prospective cohort may determine more reliable and acceptable method for the staging of CKD, which in turn may help screening of CKD. We also propose that any population, free from diseases, should have the reference values (mean, median, deviation percentile) of creatinine and body surface area (for eGFR), any value exceeding 95th percentile may be considered abnormal for staging of CKD. Acknowledgements   1.    The World Health Report 2003. Shaping the future. World Health Organization; 2003. 3.    Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Inter Med 2003; 139: 137-47. 5.    Coresh J, byrd-Holt D, Astor BC, Briggs JP, Eggers PW, Lacher DA, Hostetter TH: Chronic kidney disease awareness, prevalence, and trends among U.S adults, 1999 to 2000.  J Am Soc Nephrol 2005; 16: 180-88. 7.    Huda MN, Alam KS, Rashid HU, Alam MR, Rahman MH and Selim SI. Prevalence of Chronic Kidney Disease in adult Disadvantageous Population. Journal of Chittagong Medical College Teachers’ Association 2010; 21(2): 25-29. 9.    McClellan WM: Epidemiology and risk factors for chronic kidney disease. The Medical clinics of North America 2005; 89(3): 419-45. 11.  Valmadrid CT, Klein R, Moss SE, Klein BE: The risk of cardiovascular disease mortality associated with microalbuminuria and gross proteinuria in persons with older-onset diabetes mellitus. Arch Intern Med 2000; 160: 1093–1100. 13.  Shlipak MG, Matsushita K, Ärnlöv J, Inker LA, Katz R, Polkinghorne KR, Rothenbacher D, Sarnak MJ, Astor BC, Coresh J, Levey AS, Gansevoort RT; CKD Prognosis Consortium. Cystatin C versus creatinine in determining risk based on kidney function. N Engl J Med. 2013; 369(10): 932-43. 15.  Mulder WJ, Hillen HFP. Renal function and renal disease in the elderly. Eur J Int Med 2001; 12: 86-97. <![CDATA[Activity of Mecillinam and Clavulanic Acid on ESBL Producing and Non- ESBL Producing Escherichia Coli Isolated From UTI Cases]]> Khandaker Shadia Abdullah Akhtar Ahmed Lovely Barai Fahmida Rahman Nusrat Tahmina J. Ashraful Haq https://imcjms.com/journal_full_text/250 2017-07-10 11:15:31 Original Article Ibrahim Med. Coll. J. 2014; 8(2): 56-60 Mecillinam is one of the very few oral antibacterial agents used against extended spectrum b-lactamase (ESBL) producing Escherichia coli (E. coli) causing urinary tract infection (UTI)). It is reported that, resistance to mecillinam can be reversed to some extent by adding beta lactamase inhibitor like clavulanic acid. The present study was aimed to determine in-vitro activity of mecillinam and mecillinam-clavulanic acid combination on the susceptibility of ESBL producing and non-ESBL producing E. coli. Total 124 E. coli (78 ESBL positive and 46 ESBL negative) isolates from urine samples of patients with UTI were included in the study. Organisms were isolated from patients attending BIRDEM General Hospital from July 2012 to December 2012. ESBL production was tested by double disc synergy test. Minimum inhibitory concentration (MIC) of mecillinam and clavulanic acid against E. coli was determined by agar dilution method. Of the total E. coli isolates, 62.9% was ESBL positive and 37.1% was negative for ESBL. Out of ESBL positive isolates, 75.6% was sensitive to mecillinam while ESBL negative isolates showed the sensitivity as 67.4%. The sensitivity to mecillinam of ESBL positive and negative isolates increased to 85.9% and 86.9% respectively by addition of clavulanic acid with mecillinam. The MIC values of intermediate and resistant isolates converted to sensitive MIC range after addition of clavulanic acid with mecillinam. Conversion of resistance of ESBL producing isolates by adding clavulanic acid was also evident by the reduction of MIC50 and MIC90 from 4µg/ml to £1 µg/ml and from 128 µg/ml to 64 µg/ml respectively. Similar trend of reduction of MICs was also observed in non-ESBLs. Ibrahim Med. Coll. J. 2014; 8(2): 56-60 Address for Correspondence:Dr. Khandaker Shadia, Assistant Professor, Department of Microbiology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000.   Escherichia coli (E. coli) remains an important cause of urinary tract infections (UTIs). UTI by extended-spectrum β-lactamase (ESBL) producing strains of E. coli is difficult to treat. Concomitant resistance to other non β-lactam antibiotics like aminoglycosides and fluoroquinolones has further complicated the situation and left very limited treatment options, especially per oral regimes.1 Mecillinam is an oral amidinopenicillin which acts by binding with penicillin binding protein-2 (PBP-2). It is relatively stable to β-lactamase enzymes and reaches very high concentration in urine.2 Thus mecillinam is proven to be a suitable antimicrobial agent against ESBL producing uropathogens like E. coli and Klebsiella spp. But, chromosomal mutation and few beta-lactamase induced mechanism results in mecillinam resistance in clinical isolates.3-5 Though mecillinam resistance has been reported from various part of the world it is less pronounced than other beta-lactams.6,7 In vitro studies have shown that mecillinam resistance conferred by higher inoculum can be reversed by addition of beta-lactamase inhibitors like clavulanic acid.8 Clavulanic acid is a beta lactam compound that has weak intrinsic antibacterial activity. When used in combination with other β-lactam drugs it exerts synergistic effect by inhibiting beta lactamase enzymes.9,10   Bacterial strains   Double disc synergy test was employed to detect ESBL production.12 Bacterial suspension of 0.5 McFarland standard was plated in Muller-Hinton agar with Amoxycillin-clavulanic acid (30 µg) disc in between and 20 mm apart from Ceftazidime (30 µg) and Ceftriaxone (30 µg) discs. Expansion of the zone of inhibition around Ceftriaxone and/or ceftazidime disc towards the amoxycillin-clavulanic acid disc was considered ESBL production. Determination of MIC   Table-1 shows the susceptibility pattern of ESBL positive and negative E. coli isolates to mecillinam and mecillinam+clavulanic acid according to MIC values. Mecillinam sensitivity was demonstrated in 75.6% ESBL positive and 67.4% ESBL negative isolates which was augmented to 85.9% and 86.9% respectively after addition of clavulanic acid. In ESBL positive and negative strains 5.2% and 8.7% isolates were intermediately sensitive to mecillinam, whereas none of the isolates were intermediate sensitive to mecillinam+ clavulanic acid combination. Resistance to mecillinam was found in 19.2% and 23.9% ESBL positive and negative isolates that were reduced to 14.1% and 13.1% after adding clavulanic acid with mecillinam respectively. Table-1: Susceptibility pattern of ESBL positive and ESBL negative E. coli to mecillinam and mecillinam+ clavulanic acid according to MIC values (N=124)  All the isolates having 16 µg/ml and 32 µg/ml MIC of mecillinam converted to sensitive after addition of clavulanic acid. Out of 5 isolates having MIC of 64µg/ml, 2 (40%) were converted to sensitive. But the isolates having MIC of ³ 128 demonstrated no change in susceptibility. Total 55.9% intermediately sensitive and resistant E. coli became sensitive to mecillinam by adding clavulanic acid (Table-2). Table-2: Change of susceptibility in relation to MIC values of intermediate sensitive and resistant isolates after adding clavulanic acid  The MIC of mecillinam against ESBL producing E. coli ranged from £1-³1024 µg/ml. MIC50 and MIC90 were 4 and 128 µg/ml respectively. After adding clavulanic acid with mecillinam MIC50 and MIC90 reduced to £1 µg and 64 µg/ml respectively. In non-ESBL producing E. coli isolates MIC50 and MIC90 were 4 and 64 µg/ml respectively with mecillinam and £1and 32 with mecillinam+clavulanic acid (Table-3). Table-3: Change of MIC50 and MIC90 values of ESBL producing and non-ESBL producing E. coli isolates by addition of clavulinic acid with mecillinam     ESBL producing E. coli is isolated in very high frequency in nosocomial as well as community acquired urinary tract infections.8,13-15 In the present study, about 69% inpatient and 57% outpatient E. coli isolates were found ESBL producer. This proportion of ESBL isolation is similar to those described in several studies in home and abroad.8,13,14 A considerable numbers of isolates irrespective of ESBL production showed sensitivity to mecillinam. The high susceptibility rate of ESBL producing E. coli to mecillinam as determined by MIC method in this study is comparable to the findings of others who found 94% and 85% sensitivity respectively.13,14 But in the context of Bangladesh, mecillinam sensitivity of E. coli was reported as 43-67% in 2009.14,15 This divergence may be due to the fact that, in those studies uropathogenic E. coli irrespective of ESBL production was considered and disc diffusion method was used to determine the sensitivity instead of MIC method. Mecillinam is one of the very few oral drug used in treating community acquired urinary tract infection. According to in-vitro findings, it is stable against beta lactamase enzymes produced by gram negative as well as gram positive bacteria. Extensive use of mecillinam because of its effectiveness in UTI has exerted selective pressure resulting in chromosomal mutation of the drug target and emergence of resistance. Further, few beta lactamases like type IIIa and IVc have activity against mecillinam causing hydrolysis of the agent.10 These factors together results in mecillinam resistance in clinical practice. Addition of any compound that has inhibitory effect on these enzymes may improve the antibacterial activity of mecillinam. In this ground, activity of mecillinam in combination with a beta lactamase inhibitor, clavulanic acid, was also evaluated in the study. Using the agar dilution method with standard inoculum of 1x104 cfu/spot, there was a marked decrease in the MIC of mecillinam when combined with clavulanate. As a result, sensitivity of ESBLs producing E. coli improved from 75.6% to 85.9% and for non-ESBLs producers from 67.4% to 86.9%. The MICs of individual isolates markedly reduced after adding clavulonic acid, but overall range of MICs was not changed (ranging from £1 - ³1024). Because MICs of some isolates were out of the test range it was not possible to determine whether there was a significant (³8 fold) decrease in MIC or not. The lowest value of MIC in our assay was 1 µg/ml; so in those isolates where MIC reduced beyond the concentration of 1 µg/ml could not be determined. Similar things happened in some highly resistant isolates having the MIC of >1024 µg/ml which was the highest MIC value tested. But the additional inhibitory effect of clavulanic acid could be predicted from the reduction of MIC50 and MIC90 of mecillinam after adding clavulonic acid (Table-3). Using the standard inoculum 1x104 cfu/spot, MIC50 of mecillinam was reduced from 4 µg/ml to £1 µg/ml and MIC90 from 128 µg/ml to 64 µg/ml. These findings were in accordance with previous studies.8,17 In the present study similar trend of reduction of MICs was also observed among ESBL negative E. coli. The observed synergistic effect of mecillinam-clavulanic acid combination on ESBL negative isolates could be due to the presence of other broad spectrum β-lactamases which were inhibitable by clavulanic acid or due to the primary affinity of clavulanic acid for PBP-2 of E. coli like mecillinam.18,9 Altogether, by adding clavulonic acid with mecillinam about 56% of resistant isolates became sensitive which were resistant or intermediately sensitive with mecillinam alone (Table-2). In the present study, we have further observed that all intermediate and resistant isolates having MIC of 16 µg/ml and 32 µg/ml became sensitive (MIC £1-8) when clavulanic acid was added with mecillinam. But, only 40% isolates having MIC of 64 µg/ml reverted to sensitive range and none of the isolates having MIC ³128 µg/ml became sensitive by adding clavulanic acid. It suggests that there is chance of treatment response with mecillinam-clavulanic acid combination in infection with resistant E. coli having such range of MICs. However, this combination may not be useful in severe infection by ESBL producers due to the inoculum effect of the offending organism on the drugs.7,8,19    This study was funded by the Research Grant of Ibrahim Medical College. We thank General Pharmaceutical Ltd, Bangladesh and Incepta Pharmaceutical Ltd, Bangladesh for kindly providing the pivmecillinam and potassium clavulanate. References 2.    Sougakoff W and Jarlier V. Comparative potency of mecillinam and other beta-lactam antibiotics against Escherichia coli strains producing different beta-lactamases. J Antimicrob Chemother 2000; 46(Suppl 1): 9–14. 4.  Abhilash KP, Veeraraghavan B and Abraham OC. Epidemiology and outcome of bacteremia caused by extended spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella spp. in a tertiary care teaching hospital in south India. J Assoc Physicians India 2010; 58: 13-7. 6.    Kahlmeter G, Poulsen HO. Antimicrobial susceptibility of Escherichia coli from community-acquired urinary tract infections in Europe: the ECO.SENS study revisited. Int J Antimicrob Agents 2012; 39: 45–51. 8.    Lampri N, Galani I, Poulakou G et al. Mecillinam/clavulanate combination: a possible option for the treatment of community-acquired uncomplicated urinary tract infections caused by extended spectrum β-lactamase producing Escherichia coli. J Antimicrob Chemother 2012; 1-5. 10.  Bongaerts GPA and Bruggeman-ogle KM. Effect of Beta-Lactamase and salt on mecillinam Susceptibility of Enterobacterial strains. Antimicrob agents and chemotherapy 1980; 18(5): 680-86. 12.  Jarlier V, Nicolas MH, Fournier G and Philippon A. Extended spectrum beta lactamases conferring transferable resistance to newer beta lactam agents in Enterobacteriaceae- Hospital prevalence and susceptibility patterns. Rev Infect Dis 1988; 10: 867-78. 14.  Saleh AA, Ahmed SS, Ahmed M et al. Changing trends in Uropathogens and their Antimicrobial sensitivity pattern. Bangladesh J Med Microbiol 2009; 3(1): 9-12. 16.  Auer S, Wojna A and Hell M. ESBL producing Escherichia coli in uncomplicated urinary tract infections – oral treatment options? 49th ICCAC, San Fransisco CA. 2009 18.  Goldstein EJ, Citron DM and Cherubin CE. Comparison of the inoculum effects of members of the family Enterobacteriaceae on cefoxitin and other cephalosporins, β-lactamase inhibitor combinations, and the penicillin-derived component of these combinations. Antimicrob Agents Chemother 1991; 35: 560-66. <![CDATA[Primary Squamous Cell Carcinoma of Gall Bladder: A Case Report]]> Shamima Ferdousi Sadia Armin Khan https://imcjms.com/journal_full_text/251 2017-07-10 11:20:37 Clinical Case Report Ibrahim Med. Coll. J. 2014; 8(2): 61-63 Squamous cell carcinoma of the gall bladder is rare.  It accounts for less than 12.7 % of all cases of gall bladder cancer. Pure squamous cell carcinoma is even less common with a reported incidence of 3.3%. We present a case of 70 years-old man with decreased appetite, vomiting and fever associated with right upper quadrant pain for two months. Ultrasonography of the abdomen revealed a distended gallbladder with multiple calculi along with large hyperechoic area of sludge. Provisional diagnosis was cholelithiasis with empyema of gall bladder. Cholecystectomy was done. Histopathological examination  revealed well to moderately differentiated squamous cell carcinoma of the gall bladder without evidence of metastasis.   Squamous cell carcinoma (SCC) of the gall bladder is rare and accounts for about 12.7% of all cases of gall bladder cancer.1-4  Pure squamous cell carcinoma is even less common with a reported incidence of 3.3%.1-4 SCC of the gall bladder usually runs an ill defined clinical course and is frequently detected at an advanced stage because of its tendency to infiltrate the adjacent organs and silent rapid growth pattern.1,2 Survival of the patients with squamous cell carcinomas/adenosquamous carcinomas has been reported to be significantly worse than that of adenocarcinomas of the gallbladder.3 We report a single case of squamous cell carcinoma of the gallbladder that was clinically diagnosed as calculus cholecystitis with sludge empyema of gallbladder. Case report Ultrasonography (USG) of abdomen revealed a distended gallbladder with the wall thickness of 6 mm and of a large hyperechoic mass measuring 4.5x3 cm within the gallbladder sludge. On this basis, a clinical diagnosis of calculus cholecystitis with sludge empyema of gallbladder was considered and the patient was admitted for surgery. Cholecystectomy was performed which revealed cholelithiasis of gall bladder with a friable mass, possibly carcinoma. No obvious involvement of hepatic flexure, common bile duct and extrahepatic biliary tree was observed. The gall bladder measured 7x5 cm with wall thickness of 8 mm. Lumen showed friable mass measuring 4x2 cm with multiple yellow colored cholesterol stones. Multiple tissue samples from representative areas were processed by hematoxylin and eosin stain (H&E). Microscopic examination demonstrated well to moderately differentiated large flat squamous cells with keratinized foci and tumor cells exhibiting intercellular bridges [Fig.1, 2, & 3]. Few mitotic cells and angiolymphatic invasion was present [Fig. 4]. The carcinoma perforated the gallbladder wall and extended up to the serosa. Surrounding gall bladder mucosa showed features of chronic cholecystitis. Histopathologic examination revealed a well to moderately differentiated squamous cell carcinoma of gall bladder confined to the serosa. Discussion Gallbladder cancers are asymptomatic at early stages. When symptomatic, the presentation is similar to biliary colic or chronic cholecystitis. If signs of biliary colic or chronic cholecystitis are present in an elderly patient in combination with decreased appetite and weight loss, carcinoma of the gall bladder should be considered as a differential diagnosis.5 Squamous cell cancer is characterized by rapid growth, early metastatic dissemination and diffuse local and regional infiltration. Despite local and regional infiltration, peritoneal seeding is rare. Hepatic metastases are more frequent in squamous cell carcinoma than adenocarcinoma of the gall bladder.4  Gallbladder stones appear to be a major risk factor in the carcinogenesis of carcinoma of any type but more so for squamous cell carcinoma. Approximately 90% of squamous cell carcinoma cases invariably have cholelithiasis.7 A previous study of seven patients with squamous cell carcinoma of gall bladder reported cholesterol stones in all the seven cases.8 Our case also revealed cholesterol stones. Other pathologies that have been associated with increased risk of gall bladder carcinomas include polypoidal lesions, adenomas, calcified porcelain gall bladder, cholecysto-enterior enteric fistulae, ulcerative colitis, adenomyosis, polyposis coli and anomalous connection between CBD and pancreatic duct. Mutations affecting decreased expression of c-erbb2 gene product have also been identified as a contributing factor.9 Radical resection is the mainstay of treatment for locally invasive squamous cell carcinoma and offers a chance for cure. References 2.    Soyama A, Tajmia Y, Kuroki T,  Tsneoka N,  Ohno S,  Adachi T, Eguchi S and  Kanematsu T. Radical surgery for Advanced Pure Squamous cell Carcinoma of the Gallbladder: Report of a case. Hepatogastroenterology 2011; 58(122): 2118-2120. 4.    Waisberg J, Bromberg SH, Franco MIF et al. Squamous Cell Carcinoma of the Gallbladder.  Sao Paulo Medical Journal 2001; 119(1): 43. 6.    Rai A, Ramakant, Kumar S, Pahwa SH, Kumar S. Squamous Cell Carcinoma of the Gallbladder: an unusual presentation. The Internet Journal of Surgery 2010;  22: 5. 8.    Cariati A, Francesco C. Squamous Cell Carcinoma and Non-squamous Cell Carcinoma: A case study.  J Diagn Med Sonography 2004; 20: 347-350. <![CDATA[Plasma B-Type Natriuretic Peptide (BNP) As a Marker of Left Ventricular Diastolic Dysfunction in Diabetic Patients]]> MM Zahurul Alam Khan AKM Mohibullah Md. Zahid Alam AMB Safdar Shabnam Jahan Hoque Ashish Kumar Chowdhury https://imcjms.com/journal_full_text/64 2016-08-02 11:53:53 Original Article Ibrahim Med. Coll. J. 2014; 8(1): 1-5 The first stage of diabetic cardiomyopathy is represented by left ventricular diastolic dysfunction (LVDD) with preserved systolic function, in an asymptomatic patient. B-type Natriuretic Peptide (BNP) is a cardiac neurohormone predominantly released from the cardiac ventricles in response to left ventricular volume expansion and pressure overload. The diagnostic role of BNP for detecting LVDD in asymptomatic diabetic patients is still debated and this study was undertaken to find out this relationship of plasma BNP level with LVDD in asymptomatic diabetic patients. First 100 patients who had type 2 diabetes for more than 5 years and had no known cardiac disease other than LVDD (grade-1 & 2), admitted in BIRDEM Hospital were recruited. Plasma BNP was measured by fluorescence polarization immunoassay (FPIA) method using AXSYM auto analyzer. Two-dimensional, M-mode, spectral, and color flow Doppler echocardiograms was repeated on the same day of blood collection for plasma BNP measurement. After processing of all available data, statistical analysis of their significance was done with the help of computer based SPSS (Statistical Program for Social Science) program. Male female distribution of the study participants was 46% and 54% respectively. Mean plasma BNP level in all participants was 150 pg/ml. In male and female participants the values were 168 and 135 pg/ml respectively. The distribution did not show any significant association (p=0.491).  Of the 100 study participants 89% had E/A ratio <1. Distribution of participants with abnormal E/A and E/e did not show any significant association (p=0.955 and 0.844 respectively). Study participants with varying level of plasma BNP level were analyzed in terms of E/A and E/e ratio. Distribution of participants between BNP Groups and E/A and E/e groups did not show statistically significant association (p=0.529). We concluded that plasma BNP has no relation with LVDD (grade-1 and 2) in patients with type 2 diabetes mellitus (T2DM) who had no known cardiac disease. Introduction Great majority of the diabetic patients (80%) die of macrovascular complications, including coronary artery disease (CAD), stroke, and peripheral vascular disease (PVD).4  Cardiac involvement in diabetes covers a wide spectrum, ranging from asymptomatic silent ischemia to clinically evident heart failure.5  The first stage of diabetic cardiomyopathy is represented by left ventricular diastolic dysfunction (LVDD) with preserved systolic function, in an asymptomatic pattern.5-8 The global prevalence of diastolic dysfunction largely ranges from 30% to 75%, depending on the defined echocardiographic parameters.6,9-12 No data is available in Bangladesh. In India, the overall prevalence of LVDD in asymptomatic type 2 DM subjects is 54%.10 The diagnostic role of natriuretic peptides for detecting LVDD in asymptomatic diabetic patients is still debated.26,30-33  However, a single study in Bangladesh showed that raised plasma BNP level may indicate LVDD.34 Probably the reason of this association is the presence of high risk group of ischemic heart diseases (IHD) in their study population. Hence, this study was undertaken to find out the relationship of plasma BNP level with LVDD in patients with type 2 DM without any known cardiac disease. Subjects and Methods A total 100 adult patients with type 2 diabetes mellitus (T2DM) with duration of diabetes more than five years and diagnosed case of diastolic dysfunction without coronary artery disease (CAD) and congestive heart failure (CHF) were recruited. As the patients with diastolic dysfunction of grade-3 & 4 are symptomatic, they were excluded from our study. CAD and CHF were excluded according to history, physical findings, ECG and chest radiography (CXR). Any patients with ambiguous clinical features or borderline abnormal ECG & CXR for CAD and CHF were excluded.   After processing of all available data, statistical analysis of their significance was done. Obtained data were expressed in frequency, percentage, mean and standard deviation as applicable. Continuous variables were expressed as mean ± SD. Comparison between groups was done by the Student’s t-test where appropriate for continuous variables. Categorical data were analyzed by Chi-square test. The whole analyses was done with the help of computer based SPSS (Statistical Program for Social Science) program. P-value of <0.05 was considered as significant. Results Mean plasma BNP in all subjects was 150pg/ml. In male and female subjects the value was 168 and 135 pg/ml respectively.  Considering the nature of distribution of the variables median value for all subjects in either gender was calculated which were 93.6 pg/ml, 108 pg/ml and 89.8 pg/ml respectively. In subjects with Grade 1 LVDD (E/A ratio <1) plasma BNP was 137 (pg/ml) [SD-127; range-10-593]. In those with Grade 2 LVDD (E/e ratio ³10) plasma BNP level was   117 (pg/ml) [SD-91; range-31-384]. Mean plasma BNP level between the LVDD groups did not show significant statistical difference (p=0.448; Table 1). Table-1: Plasma BNP level in subjects with different grade of LVDD        Correlation analysis was performed between plasma BNP levels and variables of interest. Statistical significant association was lacking for any one of the target variables. Discussion An important limitation of this study was the lack of coronary angiographic (CAG) evaluation of coronary arteries and therefore, the inability to correlate the echocardiographic findings with underlying coronary artery disease. Because diabetes is notoriously associated with silent myocardial ischemia in up to 10-20% cases,39-41 asymptomatic patient with normal ECG would not exclude true cardiac ischemia. However, CAG is an expensive and time-consuming investigation to rule out CAD and is not always used to detect ischemic heart disease. Another important limitation was relative small size of the study population which was mainly due to lack of sufficient fund and time. In conclusion, the study  revealed that the plasma BNP level had no relation with LVDD (grade 1 and 2) in patients with T2DM without any known cardiac disease. Acknowledgement   1.    Wild S, Roglik G, Green A, Sicree R, King H. Global Prevalence of Diabetes. Diabetes Care 2004; 27:     1047-53. 3.    Rahim MA, Hussain A, Khan AKA, Sayeed MA, Ali SMK, Vaaler S. Rising prevalence of type 2 diabetes in rural Bangladesh: A population based study. Diabetes Research and Clinical Practice 2007; 77(2): 300-5. 5.    Galderisi M, Anderson KM, Wilson PW, Levy D. Echocardiographic evidence for the existence of a distinct diabetic cardiomyopathy (the Framingham Heart Study). Am J Cardiology 1991; 68: 85–9. 7.    Dinh W, Lankisch M, Nickl W, Scheyer D, Scheffold T, Kramer F, et al. Insulin resistance and glycemic abnormalities are associated with deterioration of left ventricular diastolic function: a cross-sectional study. Cardiovasc Diabetol 2010; 9: 63-75. 9.    Nicolino A, Longobardi G, Furgi G, Rossi M, Zoccolillo N, Ferrara N, et al. Left ventricular diastolic filling in diabetes mellitus with and without hypertension. Am J Hypertens 1995; 8: 382-9. 11.  Boyer JK, Thanigaraj S, Schechtman KB, Pérez JE. Prevalence of ventricular diastolic dysfunction in asymptomatic, normotensive patients with diabetes mellitus. Am J Cardiol 2004; 93: 870-5. 13.  Maeda K, Tsutamoto T, Wada A, Hisanaga T, Kinoshita M. Plasma brain natriuretic peptide as a biochemical marker of high left ventricular end-diastolic pressure in patients with symptomatic left ventricular dysfunction. Am Heart J 1998; 135: 825–32. 15.  Maisel AS, Koon J, Krishnaswamy P, Kazenegra R, Clopton P, Gardetto N, et al. Utility of B-natriuretic peptide (BNP) as a rapid, point-of-care test for screening patients undergoing echocardiography for left ventricular dysfunction. Am Heart J 2001; 141: 367–74. 17.  Lubien E, DeMaria A, Krishnaswamy P, Clopton P, Koon J, Kazanegra R, et al. Utility of B-natriuretic peptide in detecting diastolic dysfunction: comparison with Doppler velocity recordings. Circulation 2002; 105: 595–601. 19.  Lubien E, DeMaria A, Krishnaswamy P, McCord J, Hollander JE, Duc P, et al. Utility of B-natriuretic peptide in detecting diastolic dysfunction: comparison with Doppler velocity recordings. Circulation 2002; 105(5): 595-601. 21.  Maisel AS, McCord J, Nowak RM, Hollander JE, Wu AH, Duc P, et al. Bedside B-Type natriuretic peptide in the emergency diagnosis of heart failure with reduced or preserved ejection fraction. Results from the Breathing Not Properly Multinational Study. J Am Coll Cardiol 2003; 41(11): 2010-7. 23.  Senni M, Rodeheffer RJ, Tribouilloy CM, Evans JM, Jacobsen SJ, Baily KR, et al. Use of echocardiography in the management of congestive heart failure in the community. J Am Coll Cardiol 1999; 33: 124–70. 25.  Albertini JP, Cohen R, Valensi P, Sachs RN, Charniot JC. B-type natriuretic peptide, a marker of asymptomatic left ventricular dysfunction in type 2 diabetic patients. Diabetes Metab 2008; 34: 355-62. 27.  Beer S, Golay S, Bardy D, Feihl F, Gaillard RC, Bachmann C, et al. Increased plasma levels of N-terminal brain natriuretic peptide (NTproBNP) in type 2 diabetic patients with vascular complications. Diabetes Metab 2005; 31: 567-73. 29.  Maisel A, Mueller C, Adams K Jr, Anker SD, Aspromonte N, Cleland JG, et al. State of the art: using natriuretic peptide levels in clinical practice. Eur J Heart Fail 2008; 10(9): 824-39. 31.  Valle R, Bagolin E, Canali C, Giovinazzo P, Barro S, Aspromonte N, et al. The BNP assay does not identify mild left ventricular diastolic dysfunction in asymptomatic diabetic patients. Eur J Echocardiogr 2006; 7: 40-4. 33.  Kiencke S, Handschin R, von Dahlen R, Muser J, Brunner-Larocca HP, Schumann J, et al. Pre-clinical diabetic cardiomyopathy: prevalence, screening, and outcome. Eur J Heart Fail 2010; 12: 951-7. 35.  Redfield MM, Jacobsen SJ, Burnett JC Jr. Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. JAMA 2003; 289: 194. 37.  Cohen GI, Pietrolungo JF, Thomas JD, Klein AL. A practical guide to assessment of ventricular diastolic function using Doppler echocardiography. J Am Coll Cardiol 1996; 27: 1753. 39.  Boras J, Brkljacic N, Ljubicic A, Ljubic S. Silent ischemia and diabetes mellitus. Diabetologia Croatica 2010; 1: 39-2. 41.  Janand-Delenne B, Savin B, Habib G, Bory M, Vague P, Lassmann-Vague V. Silent myocardial ischemia in patients with diabetes. Diabetes Care 1999; 22: 1396–1400. <![CDATA[Effect of Edible Mushroom (Pleurotus ostreatus) on Type-2 Diabetics]]> M. Abu Sayeed Akhter Banu Khaleda Khatun Parvin Akter Khanam Tanjima Begum Hajera Mahtab J Ashraful Haq https://imcjms.com/journal_full_text/65 2016-08-02 11:56:07 Original Article Ibrahim Med. Coll. J. 2014; 8(1): 6-11 The prevalence of non-communicable diseases (NCD) like diabetes, hypertension, dyslipidemia and atherosclerotic cardiovascular diseases (CVD) are on the increase globally and predominantly in the South East Asian Region (SEAR). The increasing NCD and its complications burdened the health cost of Bangladesh. The available literatures suggest that edible mushrooms are effective in controlling metabolic risks like hyperglycemia and hypercholesterolemia. A total of 5000 newly registered diabetic women were screened for eligible participants (urban housewives, age 30 – 50y, BMI 22 – 27, FBG 8 – 12 mmol/l; free from complications or systemic illnesses and agreed to adhere to the study for 360 days). The investigations included weight and height for BMI, waist- and hip-girth for WHR, BP, FBG, 2ABF, T-chol, TG, HDL, LDL, ALT and Creatinine starting from the day 0 (baseline) and each subsequent follow-up days: 60, 120, 180, 240, 300 and 360 for comparison between placebo and mushroom groups and also within group (baseline vs. follow up days), individually for placebo and mushroom. The daily intake of mushroom was 200g for the mushroom group and an equivalent calorie of vegetables for the placebo group. Mushroom was found to have significant effect in reducing blood glucose, T-chol, TG and LDL. No impaired function was observed for liver, kidney and hemopoeitic tissue in taking mushroom for 360 days of the study period.   Introduction Bangladesh is one of the least developing countries with the highest population density of the world. And the brunt of NCD is overwhelming considering its poor economy, which is already overburdened with population explosion and communicable diseases. Very few of the NCD population can afford the cost of lifelong treatment. Only 1.4% of GDP is allocated to health and 43.3% of its population are below international poverty line (£US$1.25 per day).7 The NCD patients need lifelong follow up treatment. A diabetic patient needs medication either oral hypoglycemic agent (OHA) or insulin for life. Likewise, lifelong antihypertensive medications are essential for a hypertensive subject. The dyslipidemic patients need lipid lowering agent(s) to prevent atherosclerosis. For lifelong maintenance of these medication is expensive and hardly feasible or affordable for most of the NCD patients. Considering the increasing NCD population at the face of poor affordability of treatment one has to explore alternative approach. And we have edible mushroom, popularly known and consumed as “Beneficial for Health” though exactly not known what the true benefit is. There are cumulative evidences that some edible mushroom, particularly, oyster mushroom (OM) rich in digestible proteins and bioactive compounds like vitamins, minerals, β-glucans (or immuno-modulants) that have effects in combating NCDs.8 The metabolic effects have been reported by many investigators, but these were observed in animal models.9-11 Very few studies have been carried out in human subjects.12,13 Based on some important considerations this study was undertaken: a) an increasing trend of NCDs in Bangladesh; b) the suffering individuals can not afford lifelong treatment and frequently develop disabling complications; c) the oyster mushroom is popularly accepted and taken as beneficial vegetables for health; d) if this proved to be effective in reducing hypertension, hyperglycemia and hyperlipidemia without adverse outcomes then it would create immense economic possibilities – reducing import of medicine that required for millions of NCD patients in the country and saving hard earn foreign currency, increasing mushroom production by generating employment to such an extent that result in cultivating and exporting it to the increasing global need of rising NCD population. Thus, the aims of this study were to determine the metabolic effects of edible (Pleurotus ostreatus) mushroom in diabetic subjects and to assess any undesirable effect among subjects who were familiar with mushroom. Study Population and Methods From the BIRDEM Registry, a total of 5000 newly registered female diabetic subjects were screened for the selection of eligible participants. Of them, 300 women satisfied the eligible criteria as mentioned above. They were enrolled for the study. The protocol was discussed and they were informed about the procedural details. Of the 300 eligible participants, 173 agreed to volunteer the study. These subjects were reinvestigated for baseline data and to assess whether there was any complication. Microproteinuria was found in 15, background retinopathy in 19, proliferative retinopathy 2 and maculopathy in 1. Neurological assessment revealed peripheral neuropathy in 17, and autonomic neuropathy in 21. Oral hypoglycemic agent failed to control in 25, who were prescribed insulin and were excluded from the study. So, the remaining 73 were finally selected as eligible participants. Of these 73, 43 women were familiar with the mushroom as they used to take the mushroom occasionally, and 30 women never tasted the mushroom. So, the former group was assigned to mushroom (n=43) and the later assigned to placebo group (n=30). The stepwise selection of the study participants based on eligibility criteria is depicted in Figure-1. The daily mushroom intake was prescribed 200g and the placebo group was prescribed equivalent calorie of locally available vegetables exchange. The mushroom packets, each containing 200g, were supplied twice a week from the “Govt. Mushroom Farm” at Savar near Dhaka city. The field workers maintained home-visit twice a week, distributing mushroom and checking whether the participants were consuming it daily, and reporting to the physician if there was any irregularities in continuing mushroom intake. Home visit was also maintained to the placebo participants twice weekly. The follow up was strictly maintained for each participant as long as she was residing in the Dhaka City Corporation (DCC) area and was lost to follow up only if she left DCC area or withdrew from the study. The mushroom and the placebo groups were followed up from the day 0 (baseline) through the day 360 (Figure 2). The investigations in each visit on day 0, 60, 120, 180, 240, 300 and 360 included BMI, SBP, DBP, FBG, 2ABF, T-chol, HDL, TG, Hb, creatinine and ALT for both mushroom and placebo group. The study protocol was duly approved by the Ethical Review Committee of Diabetes Association of Bangladesh (DAB). Results i.    Comparison between mushroom and placebo group: The mean (with SEM) values of BMI, SBP, DBP, FBG, 2ABF, T-chol, HDL, TG, Hb, creatinine and ALT of the placebo group were compared with that of the mushroom group on day 0 (baseline) and then on each subsequent follow-up visits. Compared to the placebo, the mushroom group showed significantly lower values for FBG (p<0.001), 2ABF (p<0.001) [Fig (2a), (2b)], T-chol (p<0.001), TG (p=0.03) and LDL (p<0.001) [Fig-(3a), (3b), (3c)]; whereas, the differences were not significant for BMI, SBP, DBP, HDL, Hb, creatinine and ALT (data not shown).               Figure-2: Comparison of mushroom and placebo groups for fasting blood glucose (2a) and glucose 2ABF  (2b) at   day 0, 60, 120, 180, 240, 300 and 360. Compared to placebo the mushroom group showed significant reduction (p<00.1) in FBG levels at day 120 to 360 and for 2ABF level from day 60 to 360 except at day 300. FBG: Fasting blood glucose, 2ABF: 2hrs after breakfast     Figure-3:  Comparison of serum total cholesterol (3a), triglycerides (3b) and, LDL (3c) levels of mushroom and placebo groups at day 0, 60, 120, 180, 240, 300 and 360. For total cholesterol p< 0.01 at day 120, 300 and 360; For  triglyceride p< 0.03 at day 120, 240, 300 and 360; For LDL p< 0.001 at day 360.     iv.  The mushroom showed no significant effect on hemoglobin, creatinine and alanine amino transferase (ALT). Discussion This study clearly demonstrated that Oyster mushroom (OM) had anti-hyperglycemic and anti-lipids effects which are consistent with other studies.8-10 In India, Bajaj et al made similar conclusions that mushroom had hypocholesterolemic effect.13 These evidences are consistent with other studies.14,15 Though some other studies claimed that mushroom had anti-obesity effect16 this study showed no such effect. Again this study found that edible mushroom did not reduce blood pressure significantly as claimed by other though in rat model.17 Conclusions   We are very much grateful to the authorities of “Strengthening Mushroom Development Project, Department of Agricultural Extension under M/O Agriculture” for funding the project. We are indebted to BIRDEM Authority and Ibrahim Medical College for providing space, access to the patients and facilities for laboratory investigations. References 2.    McKeigue PM, Marmot MG, Syndercombe Court YD, Cottier DE, Rahman S, Riemersma RA. Diabetes hyperinsulinemia and coronary risk factors in Bangladeshis in East London. Br Heart J 1988; 60: 390-396. 4.    Sayeed MA, Mahtab H, Sayeed S. Begum T, Khanam PA and Banu A. Prevalence and risk factors of coronary heart disease in a rural population of Bangladesh. Ibrahim Med Coll J 2010; 4(2): 37-43. 6.    Rahim MA, Hussain A, Azad Khan AK, Sayeed MA, Keramat Ali SM, Vaaler S. Rising prevalence of type 2 diabetes in rural Bangladesh: a population based study. Diabetes Res Clin Pract 2007; 77(2): 300-5. 8.    Lo HC, Wasser SP. Medicinal mushrooms for glycemic control in diabetes mellitus: history, current status, future perspectives, and unsolved problems (review). Int J Med Mushrooms 2011; 13(5): 401-26. 10.  Kanagasabapathy G, Kuppusamy UR,  Malek SNA,Abdulla MA, Chua KH and Sabaratnam V. Glucan-rich polysaccharides from Pleurotus sajor-caju (Fr.) Singer prevents glucose intolerance, insulin resistance and inflammation in C57BL/6J mice fed a high-fat diet. BMC Complement: Altern Med 2012; 12: 261. 12.  Khatun K, Mahtab H, Khanam PA, Sayeed MA and Azad Khan AK. Oyster Mushroom reduced blood glucose and cholesterol in diabetic subjects. Mymensingh Med J 2007; 16(1): 94-99. 13.  Hossain S, Hashimoto M, Choudhury EK, Alam N, Hussain S, Hasan M, Choudhury SK,Mahmud I. Dietary mushroom (Pleurotus ostreatus) ameliorates atherogenic lipid in hypercholesterolaemic rats. Clin Exp Pharmacol Physiol 2003; 30(7): 470-5. 16.  Jeon BS, Park JW, Kim BK, Kim HK, Jung TS, Hahm JR, Kim DR, Cho YS, Cha JY.Fermented mushroom milk-supplemented dietary fibre prevents the onset of obesity and hypertriglyceridaemia in Otsuka Long-Evans Tokushima fatty rats. Diabetes Obes Metab 2005; 7(6): 709-15. <![CDATA[Antimicrobial Sysceptibility Pattern of Enteropathogenic Escherichia coli (EPEC) in Paediatric Diarrhoeal Patients]]> Shimu Saha Sanya Tahmina Jhora Tanjila Rahman https://imcjms.com/journal_full_text/66 2016-08-02 11:57:46 Original Article Ibrahim Med. Coll. J. 2014; 8(1): 12-16 Enteropathogenic Escherichia coli (EPEC) mediated infantile diarrhoea among children is an important cause of morbidity and mortality in developing countries. The antimicrobial susceptibility pattern of EPEC strains isolated from children under 5 years of age was studied. Stool samples from 272 patients with diarrhoea were collected from two tertiary care hospitals. Out of 272 stool samples, 20 (7.35%) isolates were identified as EPEC on the basis of presence of bfpA gene detected by polymerase chain reaction and antibiotic susceptibility testing was performed on these EPEC strains by Kirby-Bauer disc diffusion method. The antimicrobial susceptibility test revealed that the EPEC isolates were highly resistant to ampicillin (100%), nalidixic acid (95%) and tetracycline (95%) and were sensitive to ceftazidime (95%), cefotaxime (90%), ceftriaxone (95%), imipenem (100%) and levofloxacin (85%). Isolation of EPEC is of great importance since they are responsible for acute diarrhoeal diseases in large number of children under the age of five years. The high antimicrobial resistance observed in our study indicates indiscriminate or improper use of antimicrobials, besides the risks of self-medication. Introduction   Stool or rectal swab (R/S) samples were collected from Sir Salimullah Medical college and Mitford Hospital (SSMC & MH) and Dhaka Shishu Hospital (DSH) from 272 patients under 5 years of age, presenting with acute diarrhoea and who did not take any antibiotic during the last 30 days.6 All the samples were collected within the period from January to December 2011. Standard microbiological techniques were followed for culture and isolation of Escherichia coli (Esch. coli). Detection of bfpA genes of EPEC by PCR assay   Susceptibility of isolated EPEC strains to different antibiotics was determined by Kirby-Bauer disc-diffusion techniqueas specified by the National Committee for Clinical Laboratory Standards (NCCLS).8 The antibiotic discs used in this study were Ampicillin (10 µg), ceftazidime (30 µg), cefoxitin (30 µg), cefotaxime (30 µg), ceftriaxone (30 µg), ciprofloxacin (5 µg), chloramphenicol (30 µg), gentamycin (10 µg), imipenem (10 µg), levofloxacin (5 µg), nalidixic acid (30 µg), piperacillin tazobactum (110 µg), tetracycline (30 µg ), cotrimoxazole (trimethoprim sulphamethoxazole) (25 µg).5 All the antibiotic discs used for the study were obtained from Oxoid Ltd. Bashingstore Hampaire, UK. Inoculum standardization   Within 15 minutes after standardization of inoculums, a sterile cotton swab was immersed into bacterial suspension. The swab was then streaked evenly on the surface of the plate in three different planes by rotating the plate to get a uniform distribution of inoculum. The inoculum was allowed to dry for 15 minutes at room temperature with lid closed. The antimicrobial discs were then placed on the inoculum surface by a sterile fine pointed forceps 10-15 mm away from the edge of the Petri dishes and 24 mm gap between the discs. The plates were incubated at 37º C for 24 hours. Measurement of inhibition zone   The zone of inhibition in growth produced by each antimicrobial agent on the test organisms were categorized into sensitive (S) and resistant (R) according to NCCLS.8 Results           Discussion A total of 272 samples either stool or rectal swab collected from the patients with diarrhoea were investigated. The EPEC strains identified on the basis of presence of bfpA gene detection by PCR. In this study Esch. coli were isolated from all specimens. All Esch. coli isolates were investigated by PCR to detect the presence of bfpA gene. The bfpA genes were identified in 20 (7.35%) Esch. coli isolates. Similar result was reported by Iman et al., (2011).11 Around 3.2% EPEC diarrhoea was reported from Thailand in 2004,12 6.6% from Vietnam in 2005,13 15.8% from India in 2008.14 Lower isolation rate of EPEC in our study could be due the fact that only bfp A gene was detected by PCR and other genes like eaeA gene was not considered. Also, lower isolation rates might be due to inclusion of breast fed children. Breast milk (colostrum) from mothers living in endemic areas have been reported to contain high levels of immunoglobulin A (IgA) antibodies against the EPEC virulence factors. Other reasons could be increased awareness about food and hand hygiene, resulting from intensive education programs carried out by the media after H5N1 (Avian flu) and H1N1 (Swine flu) outbreaks in 2006 and 2008 respectively.11 Another cause of lower isolation rate of EPEC in the present study was probablly for not detecting EPEC by serotyping as polyvalent and specific monovalent antisera for EPEC sero-groups were not available. The susceptibility test results showed that, most of the EPEC strains were multidrug resistance. EPEC strains were highly susceptible to ceftazidime (95%), cefotaxime (90%), ceftriaxone (95%), imipenem (100%), levofloxacin (85%). The most effective beta-lactam antibiotics were ceftazidime, ceftriaxone, imipenem and piperacillin-tazobactam. Such results may indicate that the isolated strains of EPEC were not extended-spectrum beta-lactamase producers, since resistance to third generation cephalosporin was not observed.17 The results imply that the strains were likely to have originated from the community, which supports the observation of low levels of resistance to such drugs.18,19 Sensitivity was moderately high for gentamicin (80%) and piperacillin tazobactum (60%). Moreover, such antimicrobials are generally used in hospitals, and bacteria resistant to theses agents originating from the community are not expected.20 Several studies in different parts of the world showed similar sensitivity pattern of EPEC.5,21 Low levels of resistance against levofloxacin were observed in this study. The literature has reported varying rates of resistance against both levofloxacin and ciprofloxacin, which can be explained by the use of these drugs in some countries as a treatment for enteric infections.22,23 However, studies to assess the role of these antimicrobial agents in the treatment of EPEC infections in children are needed. It has been shown that the treatment of diarrhoea caused by EPEC with antibiotics, specifically co-trimoxazole, decreases the duration and intensity of the diarrhoea.24   1.    Nataro J, and. Kaper J. Diarrheagenic Escherichia coli. Clin. Microbiol. Rev. 1998; 11: 142–201. 3.    Jordi V, Martha V, Climent C, Honorato U, Mshinda H, David S, Joaquim G. Antimicrobial Resistance of diarrheagenic Escherichia coli Isolated from Children under the Age of 5 Years from Ifakara, Tanzania. American Society for Microbiology 1999; 43(12):  3022–3024. 5.    Khairun N, Dilruba A, Johirul I, Lutful F, Anowar M. Usefulness of a Multiplex PCR for Detection of Diarrheagenic Escherichia coli in a Diagnostic Microbiology Laboratory Setting. Bang J Med Microbiol 2007; 01(02): 38-42. 7.    Svenungsson B, Lagergren A, Erik E, Birgitta E, Hedlund K, Karnell A, Lofdahl S. Enteropathogens in adult patients with diarrhoea and healthy control subjects: A 1-Year prospective study in a Swidish Clinic for infectous disease. Clin Inf Dis 2000; 30: 770-78. 9.    Voetsch A, Angulo F, Rabatsky T. Laboratory practices for stool-specimen culture for bacterial pathogens, including Escherichia coli 0157:H7, in the Food Net sites. Clin infect Dis 2004; 38(3): 190-197. 11.  Iman K, Emad A, Entsar A and Rania S. Enteropathogenic Escherichia coli Associated with Diarrhoea in Children in Cairo. Egypt The Scientific World J 2011; 11: 2613–2619. 13.  Nguyen R, Taylor L, Tauschek M. Atypical enteropathogenic Escherichia coli infection and prolonged diarrhoea in children. Emerge infect Dis 2006; 12(4): 597-603. 15.  Murray C and A. Lo´pez D. Mortality by cause for eight regions of the world: global burden of disease study. Lancet 1997; 349: 1269–1276. 17. Goyal, A, Prasad K, Prasad A, Gupta S, Ghoshal U, and Ayyagari A. Extended spectrum β-lactamase in Escherichia coli, Klebsiella pneumonia and associated risk factors. Indian MedJ 2009; 129: 695-700. 19.  Erb A, Stürmer T, Marre R and Brenner H. Prevalence of antibiotic resistance in Escherichia coli: overview of geographical, temporal and methodological variations. Eur. J. Clin. Microbiol.Infect. Dis. 2007; 26: 83-90. 21. Patrícia G, Vânia L, and Cláudio G. Occurrence and Antimicrobial Drug Susceptibility Patterns of Commensal and Diarrheagenic Escherichia coli in Fecal Microbiota from Children With and Without Acute Diarrhoea. The J of Microbiol. 2011; 10: 2102-3213. 23. Yang, C, Lin M, Lin C, Huang Y, Hsu C and Liou L. Characterization of antimicrobial resistance patterns and integrons in human fecal Escherichia coli in Taiwan. J. Infect.Dis. 2009; 62: 177-181. <![CDATA[Melioidosis – Case Reports and Review of Cases Recorded Among Bangladeshi Population from 1988-2014]]> Lovely Barai Md. Shariful Alam Jilani J Ashraful Haq https://imcjms.com/journal_full_text/247 2017-07-10 09:06:34 Clinical Case Report Ibrahim Med. Coll. J. 2014; 8(1): 25-31 Melioidosis, caused by Burkholderia pseudomallei, is a potentially fatal infectious disease. Early and correct diagnosis is important, as mortality in untreated melioidosis is high. The first case of melioidosis from Bangladesh was reported in 1988. Since then a few cases have been reported from Bangladesh. We report here four culture confirmed cases of melioidosis diagnosed in BIRDEM Genaral Hospital during May 2009 to April 2010.The detail demographic data, clinical features and outcome are discussed. We have also reviewed all the melioidosis cases among Bangladeshi population recorded from 1988 to 2014. Ibrahim Med. Coll. J. 2014; 8(1): 25-31 Address for Correspondence: Prof. Jalaluddin Ashraful Haq, Professor, Department of Microbiology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka, Bangladesh. e-mail: jahaq54@yahoo.com     Melioidosis is an emerging infection in Bangladesh. It is a disease caused by Burkholderia pseudomallei, a Gram-negative bacterium, found in wet soil, mud and pooled surface water in the tropics and subtropics. It is endemic in many countries of the world.1 Documented reports of melioidosis from Bangladesh have been few and sporadic. The first culture proven case was reported from Bangladesh in 1988.2 Later on, in 2001 another case of melioidosis in an adult with diabetes mellitus was reported from BIRDEM hospital.3 Mortality associated with this infection is high and early diagnosis and specific antimicrobial therapy can minimize the fatal outcome.4-6 Therefore, awareness regarding the disease and correct identification of the offending organism is important.   A 60-year-old diabetic (Type 2) male from Tangail district presented with persistent high-grade fever and burning sensation during micturation for two months. He was initially treated for these complains in the local district hospital with intravenous ceftriaxone for 12 days, but fever did not subside. So, he was admitted in BIRDEM Genaral Hospital on 3rd November 2009 for better management. He had a history of successfully treated pulmonary tuberculosis ten years ago. Physical examination revealed low-grade fever. Spleen, liver and lymph nodes were not palpable. There was no documentation of per rectal examination of prostate of this patient. His total leucocyte count was 10x109/L with a shift to left, ESR 150 mm in 1st hour, HbA1c 10.0%, fasting blood glucose 15.3 mmol/L. Other biochemical parameters were within normal limits. Ultrasound showed enlarged prostate with prostatic abscess involving left seminal vesicle and cystitis (Figure-1). Routine urine investigations revealed pyuria. Culture of the midstream urine grew oxidase positive, lactose fermenting gram-negative bacilli, which were identified as Burkholderia pseudomallei by standard biochemical test. The strain was resistant to gentamicin, netilmicin, aztreonam, cefotaxime, colistin and sensitive to ceftazidime, ceftriaxone, ciprofloxacine, cotrimoxazole, piperacillin and imipenem. Subsequently, transurethral resection of prostate (TURP) with endoscopic drainage of prostatic abscess was done. Pus and tissue were sent for further evaluation. Histopathology report revealed acute and chronic prostatitis with abscess. Pus from abscess yielded growth of B. pseudomallei. The antibiotic sensitivity pattern was same as the strain isolated previously from urine. He was treated with intravenous ceftazidime 1gm 8 hourly for four weeks and oral co-trimoxazole (800/160mg) twice daily. He was discharged after remission of fever and improvement of overall condition with advice to continue cotrimoxazole twice daily for a period of six months. On follow up after one month and six months after  discharge, he was asymptomatic and his urine culture showed no growth.            Figure-1: Ultrasonography of prostate showing enlarged prostate with multiple hypoechoic areas suggestive of abscess.  Left seminal vesicle was enlarged and loculated (Case -1) Case 2 (2009)   On 16th January 2010, a 41 years old diabetic man from Gazipur district presented to BIRDEM General Hospital with painful right ankle joint, three months history of low grade fever, weight loss and burning micturation for 4 days. He had been admitted in our hospital one month ago for similar pain in right ankle joint and was then diagnosed as a case of reactive arthritis with hyponatraemia and treated accordingly. At that time culture of urine was yielded no growth though pyuria was noted in routine microscopy of urine. Physical examination revealed low grade fever with tender and swollen right ankle joint. Liver and spleen was normal. There was no documentation of per rectal examination of prostate. Investigation revealed total leucocyte count 7.5x109/L with a shift to left, ESR 130 mm in 1st hour, HbA1c 7.1%, fasting blood glucose 14.1 mmol/L and serum uric acid 2.9 mg/dl. The plain x-rays of right ankle joint were normal but USG of whole abdomen showed prostatic abscess (11x23mm;  Figure-3)) and cholelithiasis. Urine microscopy showed pyuria and on culture B. pseudomallei grew, which was sensitive to ceftazidime, augmentin, cotrimoxazole, imipenem and resistant to amikacin, netilmicin, gentamicin, ciprofloxacin, polymixin B. He was treated for  45 days with intravenous ceftazidime 2 gm 8 hourly, followed by oral cotrimoxazole (800/160mg) twice daily for 20 weeks. The prostate abscess was not drained. He made a good recovery, remained well six months after discharge.     Figure-3: Ultrasonography of prostate showing multiple hypoechoic areas suggestive of abscess (Case 3)   In 23rd January 2010, a 41 years old diabetic female from Savar, (about 27 km north of Dhaka city) presented with 20 days history of fever, cough, and breathlessness. Prior to admission in BIRDEM hospital on 23rd January’15, she was diagnosed as a case of diabetes mellitus with ketoacidosis and lung abscess in another hospital and was treated with intravenous ceftriaxone and levofloxacine. After recieving antibiotics for twelve days she continued to remain febrile, hence she was referred to our hospital. Physical examination was unremarkable. X-ray chest (P/A view) revealed a large lung abscess in right upper lobe (Figure-4). Sputum examination was negative for AFB. Blood analysis yielded haemoglobin 8.9 g/dl, total leucocyte count 8.23x109/L with neutrophil 77%, ESR-120 mm in 1st hour, HbA1c 15%, blood glucose  2 hours after breakfast 9.2 mmol/L, serum cholesterol 202 mg/dl, triglyceride 144 mg/dl. Blood and urine culture were negative, but sputum culture yielded growth of B. pseudomallei which was sensitive to ceftazidime, tetracycline, augmentin, cefotaxime, imipenem but resistant to ciprofloxacin, cotrimoxazole, aminoglycosides and polymyxin B. She was treated with intravenous ceftazidime (120 mg/kg/day) and oral doxycycline 200 mg twice daily for initial one month. The patient showed marked clinical, microbiological and radiological improvement in one month. She was discharged with oral doxycycline 200 mg twice daily for six months.     Fig-4: X-ray chest (P/A view) showing large lung abscess in right upper lobe (Case 4) All four cases were culture confirmed (Figure-5) chronic suppurative form of melioidosis involving different organs of the body. The demographic data, clinical feature and outcome of the four cases described above are summarized in Table-1.     Figure-5:  Culture shows the growth of B. pseudomallei in Blood (left) and MacConkey (Right) agar plates. Note the shiny metallic texture of the colonies. Fig.6: Map showing geographical distribution of all recorded melioidosis cases in Bangladesh from 1988 to 2014. Table-1: Summary of four cases of melioidosis described above   Melioidosis, caused by B. pseudomallei, was first reported from our neighboring Rangoon in 1912. Since then, many cases of melioidosis have been reported in India, Srilanka, Thailand, Malaysia and many other countries of the world. Though Bangladesh has similar environmental and climatic conditions, only two cases of culture confirmed melioidosis have so far been reported during the period from 1988 to 2009.2-3  Other six  cases of melioidosis were reported among immigrant Bangladeshi population in UK between 1991 to 1999 (Table-2).7-9 In 2007, a 90 years old Belgium traveler developed melioidosis after visiting Rangpur district of Bangladesh several times particularly in rainy months of the year.10  Table-2: Cases of melioidosis recorded among local and immigrant Bangladeshi population from 1988 to 2014 (Total cases - 15)   The presentation of melioidosis ranges from localized to systemic infection. Infection by the causative agent B. pseudomallei causes abscess formation in different organs of the body, which includes lung, liver prostate and soft tissues.11-13 It presents as a febrile illness, ranging from acute fulminent septicemia to a chronic, debilitating localized infection. About 18% of adult males with melioidosis in North Australia had prostate abscess compared with fewer than 2% in Thailand.14 The lung is another most commonly affected organ in melioidosis, which can present as acute or chronic pneumonia to abscess formation.15 In our fourth case, cavitary lesion with large lung abscess in right upper lobe was seen in chest X-ray. Cavitary lesions may sometimes mimic the lesion seen in pulmonary tuberculosis, but diagnosis of melioidosis was demonstrated by isolation of B. pseudomallei from the sputum culture. Melioidosis is most commonly associated with underlying diseases like diabetes mellitus, renal disease and immunodeficiency disorders.4-6 Of these, diabetes is the most common risk factor,7,8 as was seen in our all four patients (Table-1). The estimated relative risk of melioidosis for diabetic patients was 13.1% in Australia.4 Table-1 summarizes the presentation and organ involvement in four cases of melioidosis. We have reviewed all known or reported cases of melioidosis detected in Bangladesh from 1988 to 2014. Altogether nineteen melioidosis cases (4 in Table 1 and 15 in Table 2) have so far been recorded either amongst the local or migrated Bangladeshi population. Out of nineteen cases, five cases of melioidosis were detected and reported from UK among Bangladeshi immigrant as ‘imported cases’7-9 while one was a 90 years-old Belgium traveler who stayed in northern district of Bangladesh (Rangpur) for sometime on several occasions.10 Table-2 summarizes the clinical features and other epidemiological data of all those cases. Apart from the four cases described above, we have detected six more cases in BIRDEM General Hospital within the period from 2010 to 2014 (Table-2). Out of nineteen cases, majority had abscess in different parts or organs of the body while some developed septicemia. Even though the presentation of those cases varied but majority had diabetes mellitus as an underlying disease and risk factor. Out of nineteen recorded cases, few died which indicate that the outcome is favourable with correct and timely diagnosis of the condition. The cases described and reviewed above indicate that melioidosis is endemic in Bangladesh particularly in north and northeastern districts of the country. Physicians and medical microbiologists should investigate for this important infection when diabetic patients, especially from endemic zone, present with characteristics clinical features. The prevalence of melioidosis is probably underestimated due to the lack of awareness among the microbiologists and doctors of the country about the disease. The true incidence of the disease in Bangladesh may actually be much higher than is currently believed. Therefore, systematic study is needed to determine the actual extent of the disease. Rererences 2.    Struelens MJ, Mondol G, Bennish M, Dance DAB. Melioidosis in Bangladesh: a case report. Trans R Soc Trop Med Hyg 1988; 82: 777-778. 4.    Cheng AC, Currie BJ. Melioidosis: epidemiology, pathophysiology and management. Clin Microbiol Rev 2005; 18(2): 383-416. 6.    Jilani MSA, Haq JA. Melioidosis in Bangladesh- a disease yet to be explored. Ibrahim Med Coll J 2010; 4(1): i-ii. 8.    Hoque SN, Minassin M, Clipstone S, Lloyd-Owen SJ, Sheridan E, Lessing MPA. Melioidosis presenting as septic arthritis in Bengali men in East London. Rheumatology 1999; 38(10): 1029-1031. 10.  Ezzedine K, Malvy D, Steels E, De Dobbeeler G, Struelens M, Jacobs F, Heenen M. Imported melioidosis with an isolated cutaneous presentation in a 90-year-old traveler from Bangladesh. Bull Soc Pathol Exot 2007; 100(1): 22-25. 12.  Vidyalakshmi K, Shrikala B, Bharathi B, Suchitra U. Melioidosis: an under diagnosed entity in western costal India: a clinico-microbiological analysis. Indian J Med Microbiol 2007; 25(3): 245-8. 14.  Ng TH, How SH, Amran AR, Razali MR, Kuan YC. Melioidotic prostatic abscess in Pahang. Singapore Med J 2009; 50(4): 385-389. 16.  Raja NS, Ahmed MZ, Singh NN. Melioidosis: An emerging infectious disease. J Postgrad Med 2005; 51(2): 140-144. 18.  Majumder MI, Haque MM, Ahmed MW, Alam MN, Rahman MW, Akter F, Basher A, Maude RJ, Faiz MA. Melioidosis in an adult male. Mymensingh Medical Journal 2013; 22(2 ): 413-416. <![CDATA[Thyroid Stimulating Hormone Resistance Syndrome – A Case Report]]> SM Ashrafuzzaman Zafar A Latif https://imcjms.com/journal_full_text/248 2017-07-10 09:11:05 Clinical Case Report Ibrahim Med. Coll. J. 2014; 8(1): 32-33 Resistance to thyrotropin or thyroid stimulating hormone (RTSH) can be defined as decreased responsiveness to thyroid stimulating hormone (TSH) characterized by high TSH with normal but occasionally low T4 and T3 usually in absence of goiter or ectopic thyroid. It can be diagnosed when TSH is >30 mIU/L but free T4 (FT4) is within normal limit. Patient usually presents in euthyroid state with abnormally high TSH but may also present with mild to overt hypothyroidism. The precise prevalence is not known, but 20-30% infants may show transient mild RTSH. In adults it is rare. Ibrahim Med. Coll. J. 2014; 8(1): 32-33 Keyword:  Resistance syndrome, TSH, FT4 Address for Correspondence: Dr. S.M. Ashrafuzzaman, Associate Proessor, Department of Endocrinology, BIRDEM, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka, Bangladesh. E-mail: ashraf_zaman1961@yahoo.com     Resistance to thyroid stimulating hormone (TSH) is a syndrome characterized by a high serum TSH level due to decreased sensitivity of thyroid cells to TSH. It can be diagnosed when TSH level is >30 mIU/L. However thyroid hormone concentration may vary, normal to high depending upon the resistance.1,2 Patients may present in euthyroid state with or without goiter. Some may present with mild to severe hypothyroidism. Affected individuals usually have normal or hypoplastic thyroid glands, high serum TSH concentrations, and normal or low serum T4 and T3 concentrations. In case of hypothyroidism of RTSH, even after treatment with thyroxin, FT4 remains within normal range but TSH remains very high.   A 19 years old girl came to the deparment of Endocrinology of BIRDEM General Hospital with the complains of swelling in front of the neck (Thyroid) for last 6 months. She was born by normal vaginal delivery and her parents were unrelated. There was no history of developmental delay or growth retardation. She had no signs or symptoms of thyroid dysfunction (hypo or hyper) except thyroid enlargement (WHO Grade 2a). She had menarche at 11 years of age and her menstrual cycle was regular. She was the youngest among 3 children of her parents. There was  no history of thyroid disease or any autoimmune disease in her family. She was from a low income family and her intelligence quotient (IQ) was normal. Investigations showed Free T4 (FT4) 14.6 pmol/L (Normal RR 9.14-23.81) and TSH >100 mIU/ml (Normal RR 0.47-5.01). Anti-thyroid antibody was negative. Ultrasonogram of thyroid gland revealed mild enlargement of both lobes (right Lobe 3.5 cm and left lobe 3.2 cm at its long axis). Thyroid scan (99Tc) showed diffuse mild enlargement of both lobes. As patient was completely euthyroid with only mild diffuse goiter and normal FT4 but had very high TSH level, the diagnosis was thyroid stimulating hormone resistance syndrome (RTSH). No thyroxin was given and the patient was kept in follow up.   TSH resistance syndromes (RTSH) can be broadly defined as reduced or absent end-organ responsiveness to thyrotropin or TSH. The other forms of disorders of thyroid may be reduced sensitivity to thyroid hormone which is a process that impairs the effectiveness of thyroid hormone and ersistent elevation of serum levels of T4 and T3 with “inappropriately” nonsuppressed TSH.1 Affected individual with RTSH has high serum TSH concentrations, and normal or low serum T4 and T3 concentrations. They are often identified at birth through neonatal screening for congenital hypothyroidism. When FT4 is within normal limit but TSH is >30 mIU/L, it indicates TSH resistance. The most important differential diagnosis is TSH secreting tumor of the pituitary, which presents with thyrotoxicosis, high TSH with high T4 and T3. Though the precise prevalence is not known, but 20-30% infants may show mild RTSH which is transient. In adults it is rare. RTSH is inherited in either autosomal recessive or dominant manner.1,3 Three genetic causes of RTSH have been so far identified. They involve two distinct genes and linkage to a gene locus. The hormone resistance may be due to the following mechanisms: Impaired biologic activity of the hormone, impaired function of hormone receptor, quantitative reduction in receptor without receptor gene defect and post receptor abnormalities.3-5 In our case, the patient had fully compensated RTSH and  need no thyroxin. Such cases should be monitored every 6-12 months for thyroid functions. In our knowledge, previously no RTSH case was reported from Bangladesh. Reference 2.    Refetoff S. Resistance to thyrotropin. J Endocrinol Invest 2003; 26: 770-9. 4.    Ahlbom BD, Yaqoob M, Larsson A, et al. Genetic and linkage analysis of familial congenital hypothyroidism: exclusion of linkage to the TSH receptor gene. Hum Genet 1997; 99: 186. <![CDATA[Subclinical Hypothyroidism & Infertility: A Review]]> HS Ferdous Faria Afsana Nazmul Kabir Qureshi Rushda SB Rouf Irfan N Noor AA Parvez AS Mir https://imcjms.com/journal_full_text/67 2016-08-02 11:59:22 Review Ibrahim Med. Coll. J. 2014; 8(1): 17-24 Subclinical hypothyroidism (SCH) may be of greater clinical importance in women with “unexplained” infertility, especially when the luteal phase is inadequate, and such patients should be investigated for thyroid dysfunction in detail. To date, studies investigating the association between SCH and infertility are still based on the high serum thyroid stimulating hormone (TSH) levels while some older studies are based on the presence of an abnormal serum TSH after a thyrotropin releasing hormone (TRH) stimulation test. The recommendation in the current guidelines to treat subclinical hypothyroidism is based on minimal evidence and it is thought that with treatment the potential benefits outweigh the potential risks. Thyroxine-replacement therapy should be started in patients with SCH caused by conditions which are at high risk of progression to overt hypothyroidism. Introduction   Infertility is defined as inability to conceive after one year of regular normal sexual activity without any contraceptive measures.8 This definition was based on a study conducted on 5574 women during the period between 1946 and 1956 who had unprotected intercourse and  ultimately conceived. Among these women 85% conceived within 12 months, 72% within first 6 months, and 50% within first 3 months. Two more recent prospective population-based studies showed that 50% of healthy women having unprotected intercourse become clinically pregnant during the first two cycles, and 80–90% during the first 6 months.9,10 Though these studies may not represent the general population globally, but these indicate that under appropriate circumstances, most females are likely to conceive  early.11 The prevalence of infertility has been found stable over the recent decades.12 Causes of female infertility comprise endometriosis, tubal damage and ovulatory dysfunctions. Excepting tubal disorders which is more prevalent in Africa due to infections, all other causes of infertility have similar worldwide prevalence.15 Endometriosis is only considered as a cause of infertility when the disease exceeds stage I (as defined by the American Society for Reproductive Medicine).16 The cause of ovulatory dysfunction is further divided according to criteria established by  World Health Organization (WHO) into: hypogonadotrophic - with low level of endogenous gonadotophins (Group -I), normogonadotrophic - with lnormal endogenous gonadotophins (Group -II) and hypergonadotrophic defective ovulation (Group -III).17 Age and smoking habit of woman also constitute important prognostic factors.18-21   In a Consensus Development Conference held in September, 2002 the American Association of Clinical Endocrinologists(AACE), American Thyroid Association (ATA) and The Endocrine Society (TES) have defined SCH as a disorder with high serum thyroid-stimulating hormone (TSH) level above upper limit of the reference range with normal serum free thyroxine (FT4) level.25 The third National Health and Nutrition Examination Survey (NHANES III)26 screened 13,344 disease-free, euthyroid participants who were thyroid antibody negative. In this population, the median TSH concentration was1.39 mIU/L [95% CI: 0.45-4.12 mIU/L]. This was accepted as normal by the above mentioned consensus conference on sub clinical thyroid diseases25 and Surks et al.27  agreed with this reference range. In contrast, the National Academy of Clinical Biochemistry28 suggested 0.4–2.5 mIU/L as the normal range, while Wartofsky and Dickey29 and the AACE suggested  0.3–3.0 mIU/L  as normal.30 According to United States Preventive Services Task Force (USPSTF) Guidelines defined SCH to have high serum TSH  2.5-10 mIU/L with a normal FT4 concentration.   Evidence based literatures strongly suggest that reference range for TSH is lower throughout pregnancy,  both the lower and upper normal limit of serum TSH are decreased by about 0.1-0.2 mIU/L and 1 mIU/L respectively, compared with the customary TSH reference interval of 0.4–4.0 mIU/L in non-pregnant women. The largest decrease in serum TSH is observed during the first trimester which is transient, apparently related to hCG levels. (Table 1) Table-1: Trimester-Specific Serum TSH Reference Intervals   Sub clinical hypothyroidism (SCH) has recently been challenged. Variations of FT4 within the reference range in individual is less than that observed  in a population. These data might reflect an abnormally low FT4 value for patients who present with a mildly increased serum TSH.40,41 Many authors have proposed serum TSH 2·5 mIU/L as upper normal limit. However, there is no general agreement among the endocrinologists about the most appropriate normal (i.e. physiologically relevant) upper limit serum TSH.42 Sub clinical hypothyroidism (SCH) and infertility     Recently, Raber et al. Investigated prospectively a group of 283 women with infertility.49 All patients underwent a TRH stimulation test (SCH was defined as a serum TSH >15 mU/L). Women with a diagnosis of SCH were treated with thyroxine and followed prospectively over a 5-year period. Among these women 34% had SCH, an unusually high prevalence reflecting the specific referral pattern. Among the women who became pregnant during the follow-up period, over 25% still had SCH. Furthermore, the women who never achieved a basal serum TSH<2·5 mU/L or a TRH-stimulated TSH<20 mU/L became pregnant less frequently than those who could achieve. More frequent abortions were also observed in the women with a higher basal serum TSH (independent of the presence of autoimmunity). Arojoki et al found elevated serum TSH levels (>5·5 mU/L) in 4% women presenting with infertility for the first time.50 The prevalence of having an increased serum TSH was highest in the group with ovulatory dysfunction (6·3%). Prior to infertility examinations, 10 of 299 women were already receiving L-thyroxine for primary hypothyroidism. The incidental finding of an elevated serum TSH value in patients with infertility was therefore reduced to four among 299 women (1·3%), and this was in the range of the prevalence of SCH in the general population in Finland (2–3%). The prevalence of SCH was considerably higher in the studies based on a TRH stimulation test to detect SCH compared with the studies that were based only on the upper limit of basal serum TSH. This difference might indicate that in older studies, using less sensitive measurements of serum TSH, the actual TSH reference levels are perhaps slightly  higher in the setting of infertility. In a study, basal and TRH-stimulated TSH concentrations were measured in 834 infertile women, and 20% had abnormal results.51 Postcoital tests and spontaneous conceptions were significantly poorer in women with SCH than in controls. Staub et al.52 suggested that secondary hyperprolactinemia could be a cause of infertility in SCH women. In contrast, menstrual function in SCH patients and controls was similar, such as luteinizing hormone pulse patterns, 24-h mean serum luteinizing hormone, TSH, and prolactin concentrations.53 Lincoln et al. reported a 2.3% prevalence of elevated serum TSH concentrations in 704 women with infertility for at least 1 year. Eleven out of sixteen hypothyroid patients’ had ovulatory dysfunction. TSH values were not determined in the control group.54 Treatment interventions and guideline for subclinical/clinical hypothyroidism Two cohort studies reported on pregnancy complications for women with clinical or sub clinical hypothyroidism who were adequately, and who were not adequately treated.56,57 Not adequately treated hypothyroid women had higher TSH and a lower than normal thyroxine level, despite treatment. In the case of subclinical hypothyroidism, a TSH higher than the reference interval despite treatment was defined as not adequately treated. The first study showed no significant difference in the prevalence of gestational hypertension in 68 women not adequately treated for subclinical or clinical hypothyroidism compared with 38 women who remain still hypothyroid despite treatment (RR: 0.14, CI: 0.01–2.20: P ¼ 0.16) for clinical hypothyroidism, (RR: 0.41, CI:0.11–1.62:P¼0.21) for subclinical hypothyroidism.56 The second study reported no significant difference in Neonatal Intensive Care Unit (NICU) admissions             (RR:0.31, CI:0.08–1.2: P¼0.09). A significant difference was found in low birth weight (RR:0.31, CI: 0.11–0.92: P¼ 0.04) for 127 women with subclinical hypothyroidism with normal TSH level with levothyroxine treatment compared with 40 women with abnormal TSH levels in the first trimester despite levothyroxine treatment, while Caesarean section rates were almost similar in the two groups, respectively 27.5% and 29.1%.57 One case control study on 38 women with hypothyroidism treated with levothyroxine during pregnancy reported no significant difference in the IQ level, verbal performance or cognitive performance between the 19 children of subclinically hypothyroid mothers despite treatment and 19 children of mothers who were euthyroid with treatment.58   Severe hypothyroidism is commonly associated with failure of ovulation. Ovulation followed by pregnancy can occur in case of mild hypothyroidism. However, these pregnancies are often associated with abortions, stillbirths, or pre-maturity. Subclinical hypothyroidism may be of greater clinical importance in women with “unexplained” infertility, especially when the luteal phase is inadequate, and such patients should be investigated in depth for thyroid dysfunction. Treatment with levothyroxineis is recommended for women with clinical hypothyroidism because it lowers the risk for miscarriage and preterm delivery. Our review shows that for subclinical hypothyroidism there is insufficient evidence to recommend for or against the universal treatment with levothyroxine. But in case of infertility it is always a preferable option to start levothyroxine as it not only enhance the fertility but also ensures euthyroid state which is very important to continue the pregnancy till delivery. References 2.    Healy DL, Trounson AO, Andersen AN, et al. Female infertility: causes and treatment. Lancet 1994; 343: 1539–1544. 4.    Hoxsey R, Rinehart JS. Infertility and subsequent pregnancy. Clinics in Perinatology 1997; 4: 321–342. 6.    Mosher WD, Pratt WF. Fecundity and infertility in the United States: incidence and trends. Fertility &Sterility 1991; 52: 192–193. 8.    Evers JL. Female subfertility. Lancet 2002; 360: 151–159. 10.  Gnoth C, Godehardt D, Godehardt E, Frank-Herrmann P, Freundl G. Time to pregnancy: results of the German prospective study and impact on the management of infertility. Human Reproduction 2003;18:1959–1966. 12.  Mosher WD, Pratt WF. Fecundity and infertility in the United States: incidence and trends. Fertility and Sterility 1991; 56: 192–193. 14.  Healy DL, Trounson AO, Andersen AN. Female infertility: causes and treatment. Lancet 1994; 343: 1539–1544. 16.  Schenken RS, Guzick DS. Revised endometriosis classification: 1996. Fertility and Sterility 1997; 67: 815–816. 18.  Augood C, Duckitt K, Templeton AA. Smoking and female infertility: a systematic review and meta-analysis. Human Reproduction 1998; 13: 1532–1539. 20.  Delhanty JD. Pre-implantation genetics: an explanation for poor human fertility? Annals of Human Genetics 2001; 65: 331–338. 22.  ESHRE Capri Workshop Group. Diagnosis and management of the infertile couple: missing information. Human Reproduction 2004; 10: 295–307. 24.  Rosene-Montella K, Keely E, Laifer SA, Lee RV. Evaluation and management of infertility in women: the internists’ role. Annals of Internal Medicine 2000; 132: 973–981. 26.  Hollowell JG, Staehling NW, Flanders WD, et al. Serum TSH, T(4), and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrinol Metab 2002; 87: 489–499. 28.  Baloch Z, Carayon P, Conte-Delvox B, et al. Guidelines Committee, National Academy of Clinical Biochemistry. Laboratory medicine practice guidelines. Laboratory support for the diagnosis and monitoring of thyroid disease. Thyroid 2003; 13: 3–126. 30.  American Association of Clinical Endocrinologists. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism and hypothyroidism. Endocr Pract 2002; 8: 457–469. 32.  Maes M, Mommen K, Hendrickx D, et al. Components of biological variation, including seasonality in blood concentrations of TSH, TT4, FT4, PRL, cortisol and testosterone in healthy volunteers. Clin Endocrinol (Oxf) 1997; 46: 587–598. 34.  Haddow JE, Knight GJ, Palomaki GE, McClain MR, Pulkkinen AJ. The reference range and within-person variability of thyroid stimulating hormone during the first and second trimesters of pregnancy. J Med Screen 2004; 11: 170–174. 36.  Panesar NS, Li CY, Rogers MS. Reference intervals for thyroid hormones in pregnant Chinese women. Ann Clin Biochem 2001; 38: 329–332. 38.  Bocos-Terraz JP, Izquierdo-Alvarez S, Bancalero-Flores JL, Alvarez-Lahuerta R, Aznar-Sauca A, Real-Lopez E, Ibanez-Marco R, Bocanegra-Garcia V, Rivera-Sanchez G. Thyroid hormones according to gestational age in pregnant Spanish women. BMC Res Notes 2009; 2: 237. 40.  Andersen S, Pedersen KM, Bruun NH, Laurberg P. Narrow individual variations in serum T(4) and T(3) in normal subjects: a clue to the understanding of subclinical thyroid disease. Journal of Clinical Endocrinology and Metabolism 2002; 87: 1068–1072. 42.  Brabant G, Beck-Peccoz P, Jarzab B, Laurberg P, OrgiazziJ,Szabolcs I, Weetman AP, Wiersinga WM. Is there a need to re-define the upper normal limit of TSH? European Journal of Endocrinology 2006; 154: 633–637. 44.  Bals-Pratsch M, De Geyter C, Muller T, Frieling U, Lerchl A, Pirke KM, et al. Episodic variations of prolactin, thyroid-stimulating hormone, luteinizing hormone, melatonin and cortisol in infertile women with subclinical hypothyroidism. Human Reproduction 1997; 12: 896–904. 46.  Shalev, E., Eliyahu, S., Ziv, M. & Ben-Ami, M. Routine thyroid function tests in infertile women: are they necessary? American Journal of Obstetrics and Gynecology 1994; 171: 1191–1192. 48.  Poppe K, Glinoer D, Van Steirteghem A, Tournaye H, Devroey P, Schiettecatte J, Velkeniers B. Thyroid dysfunction and autoimmunity in infertile women. Thyroid 2002; 12: 997–1001. 50.  Arojoki M, Jokimaa V, Juuti A, Koskinen P, Irjala K, Anttila L. Hypothyroidism among infertile women in Finland. Gynecological Endocrinology 2000; 14:     127–131. 52.  Staub JJ, Althaus BU, Engler H, et al. Spectrum of subclinical and overt hypothyroidism: effect on thyrotropin, prolactin, and thyroid reserve and metabolic impact on peripheral target tissues. Am J Med 1992; 92: 631–642. 54.  Lincoln SR, Ke RW, Kutteh WH. Screening for hypothyroidism in infertile women. J Reprod Med 1999; 44: 455–457. 56.  Leung AS, Millar LK, Koonings PP, Montoro M, Mestman JH. Perinatal outcome in hypothyroid pregnancies. ObstetGynecol 1993; 81: 349–353. 58.  Behrooz HG, Tohidi M, Mehrabi Y, Behrooz EG, Tehranidoost M, Azizi F. Subclinical hypothyroidism in pregnancy: intellectual development of offspring. Thyroid 2011; 21: 1143–1147. 60.  Krassas GE, Thyroid disease and female reproduction. Fertility and Sterility 2000; 74: 1063-1070. <![CDATA[Prevalence and perinatal outcomes in GDM and non-GDM in a rural pregnancy cohort of Bangladesh]]> M. Abu Sayeed Samsad Jahan Mir Masudur Rhaman M Mainul Hasan Chowdhury Parvin Akter Khanam Tanjima Begum Umme Ruman Akhter Banu Hajera Mahtab https://imcjms.com/journal_full_text/60 2016-08-02 11:41:03 Original Article Ibrahim Med. Coll. J. 2013; 7(2): 21-27 Ibrahim Med. Coll. J. 2013; 7(2): 21-27 Background For Bangladesh, it seems important to determine the prevalence of GDM for several reasons. Firstly, Bangladeshi women showed higher prevalence of IGT than their male counterpart.7 Secondly, compared with the other Southeast Asian Region (SEAR), Bangladesh is known to have higher birth rate and higher prevalence of multiparous women.8 It is also reported that multiparity contributes to the development of glucose intolerance.9 Thirdly, the prevalence of infant mortality is also high in Bangladesh.8 Fourthly, high prevalence of cardiovascular morbidity and mortality in the SEAR may be due to higher risk among the offspring of mother with gestational diabetes.10 Finally, though not documented, frequency of congenital malformations and low birth weight and fetal loss appears to be higher in Bangladesh. Considering the above-mentioned factors one can postulate the importance of assessing the prevalence of GDM in the population. A single study was carried out, which reported a high prevalence of GDM (6.8%).14 However, there has been no follow-up report and outcome of these GDM subjects. This study addressed to determine the prevalence of GDM and determine the outcomes of these pregnancies like fetal loss, congenital anomalies, perinatal morbidity and mortality. Research design and methodology This population-based prospective cohort of pregnant women was selected from the rural communities of ten villages having most typical rural characteristics. The rural people of the study area maintain traditional lifestyle. The characteristics of rural life defined for this study are the livelihood primarily related to agrarian activities (ploughing, plantation, irrigation, harvesting, fisheries, poultry etc.). The rural women are actively involved in these agricultural physical works. Sample size determination The study was conducted in purposively selected ten villages with a total population of 22000 in Nandail under the district of Mymensingh. According to Bangladesh Bureau of Statistics there were 150 eligible couple (married women of age 15-45y) per 1000 population in Bangladesh [BBS].15 Thus, 3300 eligible participants were expected in a population of 22000. This estimation was based on the prevalence rate of pregnancy (5 per thousand women) through personal communication from an ongoing “JivitA project” in Rangpur, where 65000 married women of reproductive age have been followed up since 2001. Additionally, we considered the prevalence of diabetes (T2DM), impaired fasting glucose (IFG) and gestational diabetes (GDM) were 4.0%, 13.0% and 6.8% in the rural population.14,16 Considering all these data we estimated at least 125 subjects could have been detected as diabetes with pregnancy and GDM. The stepwise selections of the pregnant women are depicted in Figure 1. Data collection     The diagnosis of pregnancy was made on the basis of clinical findings: (i) a history of amenorrhoea, (ii) an enlarging uterus, (iii) nausea or vomiting, (iv) breast tenderness, (v) Montgomery’s tubercles, (vi) quickening, and (vii) other signs, e.g. fundal height, chloasma, linea nigra, striae, fetal heart sound, palpation of fetus.17 All these above mentioned variables (biophysical characteristics) were compared between pregnant and non-pregnant women. For the pregnant group, the comparisons were made between GDM and non-GDM.   We used diagnostic criteria of gestational diabetes mellitus (GDM) revised by American Diabetes Association Diabetes (ADA, 2013).18,19 According to ADA criteria OGTT is recommended noting Data analysis – The prevalence rates of GDM are shown in simple percentages and presented with 95% confidence interval (CI). The biophysical characteristics are given in mean with standard deviation SD). The Chi-sq tests were used to determine the association between hyperglycemia and pregnancy and outcomes. Results The prevalence of pregnancy was found 9.3, 76.1 and 14.7% in the age groups <19, 20-34 and >35y, respectively. The comparisons of anthropometric and biochemical characteristics between pregnant and non-pregnant women were shown in table 2. As expected, anthropometric variables (BMI, WHR) were significantly higher in the pregnant women than their non-pregnant counterparts (p<0.001). In contrast, both systolic and diastolic blood pressure was found significantly lower in the pregnant women (p<0.001). Interestingly, there was no significant difference of fasting plasma glucose between them though the prevalence (95% CI) of hyperglycemia (FPG >5.1mmol/l) was found significantly higher in the non-pregnant than the pregnant women [19.8% (18.9 – 20.8) vs. 8.9% (7.0 – 10.8)].   Table-1: Distribution of census population by age, sex and marital status     Table-3: Comparison of characteristics between pregnant women with and without GDM (FPG >5.1 vs. FPG <=5.1 mmol/l).     Undoubtedly, this pregnancy cohort in a rural setting is a unique study. It has been a common impression that prevalence of hyperglycemia was more in the gestational women. There are reports that hyperglycemia in pregnancy are detrimental to pregnancy outcomes.4-6 This pregnancy cohort showed that the pregnant women had lower FPG and significantly lower prevalence of hyperglycemia. In addition, contrary to the other findings suggesting unfavorable outcomes in GDM, this study observed no significant adverse outcome among the GDM subjects compared with the non-GDM subjects. It is not clear why there was no excess morbidity or mortality in the GDM women. This may due to inadequate number in the GDM group for comparison as against a larger number of the non-GDM women (20 vs. 204). May be there are some other factors that remain to be identified. The study experienced some limitations. We could investigate only once for history, anthropometry and collection of blood sample for screening of fasting plasma glucose and lipids. The interim pregnancy period could not be monitored for glycemic fluctuations if any. A single screening test for GDM may not reflect the entire period of metabolic status in pregnancy. Thus, there might be some errors in assessing the metabolic status related to pregnancy outcomes. Further study may be undertaken considering such weakness that we experienced in this study. Had we got the facility for assessing HbA1c or monitoring plasma glucose in subsequent months we could have better conclusions. Conclusions   1.   American Diabetes Association: Gestational diabetes mellitus (Position Statement). Diabetes Care 2000; 23:(Suppl.1): S77-S79. 3.   T Wagaarachchi L, Fernando P, Premachadra DJS, Fernando P. Screening based on risk factors for gestational diabetes in an Asian population. J Obstet Gynaecol 2001; 21: 32-34. 5.   Farrell T, Neale L, Cundy T. Congenital anomalies in the offspring of women with type 1, type 2 and gestational diabetes. Diabet Med 2002; 19: 322-6. 7.   Sayeed MA, Hussain MZ, Banu A, Ali L, Rumi MAK, Azad Khan AK. Effect of socioeconomic risk factor on difference between rural and urban in the prevalence of diabetes in Bangladesh. Diabetes Care 1997; 20: 551-555. 9.   Juntunen K, Kirkinen P, Kauppila A. The clinical outcome in pregnancies of grand multiparous women. Acta Obstet Gynecol Scand 1997; 76(8): 755-9. 11.Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS. Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial Group. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005; 352: 2477-86. 13.Most OL, Kim JH, Arslan AA, Klauser C. Maternal and neonatal outcomes in early glucose tolerance testing in an obstetric population in New York city. J Perinat Med 2009; 37(2): 114-7. 15.Bangladesh Bureau of Statistics. Statistical Pocket Book of Bangladesh 2005. Ed: Chowdhury JA, Dey AK, Sikder AR, Statistical Division, Ministry of Planning, Government of The People’s Republic of Bangladesh. 17.Bovonne S, Pernoll ML. Normal pregnancy and prenatal care. In: Decherney AH and Nathan L, eds. Current Obstetric and Gynecologic Diagnosis and Treatment, 9th edn. XXX: McGraw-Hill 2003: 193-198. 19.Carpenter MW, Coustan DR. Criteria for screening test for gestational diabetes. Am J Obstet Gynecol 1982; 144: 768-773. 21.Currie LM, Woolcott CG, Fell DB, Armson BA, Dodds L. The Association Between Physical Activity and Maternal and Neonatal Outcomes: A Prospective Cohort. Matern Child Health J 2013. 23.Yang YD, Zhai GR, Yang HX. Factors relevant to newborn birth weight in pregnancy complicated with abnormal glucose metabolism. Zhonghua Fu Chan Ke Za Zhi 2010; 45(9): 646-51 (chinese). 25.Sugiyama T, Metoki H, Hamada H, Nishigori H, Saito M, Yaegashi N, Kusaka H, Kawano R, Ichihara K, Yasuhi I, Hiramatsu Y, Sagawa N. The Japan Gestational Diabetes Study Group. A retrospective multi-institutional study of treatment for mild gestational diabetes in Japan. Diabetes Res Clin Pract 2014; pii: S0168-8227(13) 00450-6. 26.  Freathy RM, Hayes MG, Urbanek M, Lowe LP, Lee H, Ackerman C, Frayling TM, Cox NJ, Dunger DB, Dyer AR, Hattersley AT, Metzger BE, Lowe WL, Jr. HAPO Study Cooperative Research Group. Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study: common genetic variants in GCK and TCF7L2 are associated with fasting and post-challenge glucose levels in pregnancy and with the new consensus definition of gestational diabetes mellitus from the International Association of Diabetes and Pregnancy Study Groups. Diabetes 2010; 59: 2682–89. [PubMed] <![CDATA[High level gentamicine resistance and susceptibility to vancomycine in enterococci in a tertiary care hospital of Dhaka city]]> Shakila Tamanna Lovely Barai AA Ahmed J Ashraf Haq https://imcjms.com/journal_full_text/61 2016-08-02 11:44:47 Original Article Ibrahim Med. Coll. J. 2013; 7(2): 28-31 Vancomycin and high level gentamicin resistant enterococci detection is important for effective treatment and control of nosocomial infection. The present study was undertaken to determine the species distribution of Enterococcus and the rate of vancomycin and high level gentamicin resistant enterococci (HLGRE) in clinical samples in a tertiary care hospital of Dhaka city. Enterococci were identified to species level by standard biochemical and serological methods. Their susceptibilities to antibiotics were determined by disc diffusion method according to CLSI guideline. Minimum inhibitory concentration (MIC) of vancomycin and gentamicin were determined by agar dilution method. The study was conducted from July 2009 to February 2010. The study indicated high prevalence of HLGRE in our hospital population. MIC method was more accurate in detecting high level gentamycin resistant enterococci compared to disc diffusion method with 120 µg gentamicin disc. However, none of the enterococcal strains showed resistance to vancomycin. HLGRE should be monitored regularly in clinical samples as it is difficult to treat. Key word: Enterococcus, HLGRE, VRE Address for Correspondence:Prof. J. Ashraful Haq, Professor of Microbiology & Principal, Ibrahim Medical College 122 Kazi Nazrul Islam Avenue, Shahbagh, Dhaka-1000. E-mail: jhaq54@yahoo.com   Enterococcus is a leading cause of nosocomial infections and important for its ability to acquire antibiotic resistance determinant from other organisms. Enterococcus includes more than 17 species. Enterococcus faecalis (90-95%) and Enterococcus faecium (5-10%) are the two species commonly present in human intestine as commensal. Other species account for less than 5% of clinical isolates. Enterococci are estimated to cause 5-15% of all cases of bacterial endocarditis.1 Recently, the treatment of enterococcal infections is increasingly become difficult due to emegernce of antibiotic resistant strains. E. faecium represents most vancomycin resistant enterococci, but vancomycin resistant strains of E. faecalis also occur. Vancomycin resistant enterococci (VRE) are now a common cause of hospital-acquired infection and are difficult to treat pathogen with currently available antibiotics.2,3 Combination of a cell wall active antibiotic such as penicillin and an aminoglycoside such as gentamicin is essential for severe enterococcal infection. Although enterococci have intrinsic low-level resistance to aminoglycoside, they have synergistic susceptibility when treated with a cell wall acting antibiotic and an aminoglycoside. However, some aminoglycosides are not susceptible to synergism.4,5 Emergence of high level resistance to gentamicin (MIC of >500 µg/ml) by some enterococci has caused the failure of synergistic effects of combination therapy.6   Study place, samples and organisms   All samples collected during the above period were routinely cultured on blood agar media. All suspected colonies of enterococci were identified by Gram staining, cultural characteristics, motility, growth in bile esculin media and in media containing 6.5% NaCl, catalase, litmus milk reduction and L-arabinose hydrolysis tests using the standard microbiological techniques.7 Specific antiser (Streptex, Ramel Europe Ltd. UK) was used to determine the serogroups. Antibiotic susceptibility testing   A total of eighty enterococci were isolated during the study period. Of the 80 Enterococcus isolates, 71 were from urine, 8 from wounds/pus and 1 from tracheal aspirate. Among 80 isolates, 76 (95%) were Enterococcus faecalis and 4 (5%) were E. faecium. The detail antimicrobial susceptibility pattern of the 80 isolates to different antibiotics is shown in Table-1. Most of the isolates were sensitive to the tested antibiotics except ciprofloxacin and cotrimoxazole. About 82-95% enterococci was sensitive to penicillin and ampicillin. Out of 80 isolates, 72 (90%) were sensitive while 8 (10%) were intermediate resistant to vancomycin (30 µg) by disc diffusion method. But all the intermediate resistant isolates were found susceptible by agar dilution method. The MIC range of those 8 intermediate resistant enterococci was 2-4 µg/ml. Of the 80 isolates, 49 (61.25%) were sensitive while 31 (38.75%) were resistant to gentamicin by disc diffusion method. All 31 gentamicin resistant enterococci by disc diffusion method showed high level resistance (MIC > 500 µg/ml) by agar dilution method (Table-2). But, out of 49 gentamicin sensitive isolates by disc diffusion method, six isolates showed high level resistance to gentamicin. Both MIC50 and MIC90 of vancomycin were 2 µg/ml while for gentamicin it was 64 µg/ml and 4096 µg/ml respectively (Table 2). Table-1: Antimicrobial susceptibility patterns of Enterococcus by disk diffusion method (n=80)    Table 2: Comparative susceptibility pattern of isolated enterococci to vancomycin and gentamicin by disc diffusion and agar dilution MIC method   Discussion The results of the study indicated the absence of VRE and high prevalence of HLGRE in tertiary care hospital of Dhaka city. Enterococci have both an intrinsic and acquired resistance to antibiotics, making them important nosocomial pathogens. As VRE and HLGRE are difficult to treat, resistance should be monitored regularly in a wide range of clinical samples. References 2.    Leclercq R, Derlot E, Duval J, Courvalin P. Plasmid-mediated resistance to vancomycin and teicoplanin in E. faecium. N. Engl. J. Med. 1988; 319: 157-161. 4.    Swenson JM, Ferraro MJ, Sahm DF, et al. Multi laboratory evaluation of screening methods for detection of high-level aminoglycoside resistance in enterococci. Journal of Clinical Microbiology 1995; 33: 3008-18. 6.    Levine DP. Vancomycin: a history. Clinical Infectious Diseases 2006; 42: S5–12. 8.    Bauer AW, Kirby WMM, Sherris JC, and Turek M. Antibiotic sensitivity testing by a standardized single disk method. American Journal of Clinical Pathology 1966; 45: 493-496. 10.  Washington JA, II: Suscptibility tests: agar dilution. In EH Lennette, A. Balows,W.J. Hausler and HJ Shadomy (eds), Manual of Clinical Microbiology. 4th ed. American Society for Microbiology, Washington DC 1985; 967-971. 12.  Love R M. Enterococcus faecalis – a mechanism for its role in endodontic failure. Int Endod J 2001; 34: 399–40. 14.  Adhikari L. High-level aminoglycoside resistance and reduced susceptibility to vancomycin in nosocomial enterococci. J Glob Infect Dis 2010; 2: 231–235. 15.   Chenoweth CE, Bradley SF, Terpenning MS, Zarins LT, Ramsey MA, Schaberg DR, Kauffman CA. Colonization and transmission of high level gentamicin-resistant enterococci in a long-term care facility.  Infection Control and Hospital Epidemiology 1994; 15: 703-709. <![CDATA[Association of elevated serum cardiac troponin-I level and complications in acute heart failurecases]]> Farjana Akhter Selina Ahmed https://imcjms.com/journal_full_text/62 2016-08-02 11:45:56 Original Article Ibrahim Med. Coll. J. 2013; 7(2): 32-34 Ibrahim Med. Coll. J. 2013; 7(2): 32-34   Introduction The predictors of adverse outcomes in acute heart failure are - older age, male gender, increased serum cardiac troponin-I (cTn-I), lower systolic blood pressure, increased serum cystatin - C, renal failure.3 Recently cTn-I has also been proposed as a diagnostic and prognostic marker of acute heart failure. Increased cTn-I appears to be a sensitive and specific risk factor of complications in acute heart failure.6 Patients with an elevated cTn-I (³ 1.0 ng/ml) had lower systolic blood pressure and a lower ejection fraction than those who had normal cTn-I.7 Researchers also suggested that early risk stratification of positive cTn-I patients could result in better management in terms of treatment and follow-up monitoring.   A total of 100 acute heart failures cases were selected purposively from the patients admitted in Cardiac Coronary Care Unit of Dhaka Medical College Hospital and National Institute of Cardiovascular Diseases (NICVD), Dhaka, from January 2010 to December 2010. The acute heart failure was diagnosed by physical examination, ECG and echocardiography. Detail clinical history and all information were recorded in a pre-designed data collection sheet. Serum cTn-I level was estimated in all study population. Based on the serum CTn-I level, the study population was divided into two groups. Group A consisted of patients having serum cTn-I level of ³ 1.0 ng/ml while group B had cTn-I level < 1.0 ng/ml. Both the study groups were followed during the hospital stay to observe the outcomes. Values of different parameters were compared to see the difference between two groups by using student’s t test, chi-square test & Fisher exact test. Written informed consents were obtained from all patients. Results Table-1 shows that significantly high (P<0.05) number of group A (28%) patients in comparison to group B (10%) suffered from left ventricular systolic dysfunction (lower ejection fraction) as diagnosed by echocardiography during their hospital stay time. Renal failure was observed in 10 (20%) group A and 2 (4%) group B study subjects (P<0.05). Similarly, impaired liver function was higher in group A (22%) compared to group B (8%) patients but was not statistically significant (P > 0.05). During the hospital stay, electrolyte imbalance was observed in 26.0% of group A compared to 4% of group B cases (P<0.004). Table-1: The rate of complications in acute heart failure cases having elevated and normal serum cTn-I level (n=50)     There are different predictors of adverse outcomes in acute heart failure cases. Cardiac troponin-I has been found to be a better marker of adverse outcomes by many workers.8,9 Recently, cardiac troponin- I was also proposed as a diagnostic and prognostic marker in acute heart failure.6 So, the present study was aimed to evaluate cTn-I as a predictor of outcomes of acute heart failure. Acute heart failure is a clinical emergency that might be fatal in some instances. Prognosis depends on many associated clinical conditions and institution of prompt treatment. A single specific easily measurable biochemical marker like serum cTn-I could a play role in the better management of the patients. Therefore, estimation of serum cTn-I in acute heart failure cases may be recommended to categorize patients for their proper management.   1.    Newby DE, Grubb NR and Bradbury A. Cardiovascular disease, in Nicki R. Colledge, Brian R. Walker, Stuart H. Ralston (eds), Davidson’s principles & practice of Medicine 2010; 21th edn, Churchill livingstone Elseveir, Philadelphia, USA,   543-550. 3.    Ilva T, Lassus J, Waris KS, Melin J, Peuhkurinen K, Pulkki K et al. Clinical significance of cardiac troponins I and T in acute heart failure. European journal of heart failure, 2008; 10: 772-779. 5.    Grewal J and Gin K. Troponin, Marks the spot. Perspectives in cardiology, 2004; 35-40. 7.    Peacock WF, Marco TD, Fonarow GC, Diercks D, Wynne J, Apple FS and Wu AHB. Cardiac Troponin and Outcome in acute heart failure. N ENGL J MED, 2008; 358(20): 2117-26. 9.    Sukova J, Ostadal P, Diercks D and Widimsky P. Profile of the patients with acute heart failure and  elevated troponin I levels. Exp Clin Cardiol, 2007; 12(3): 153-156. <![CDATA[Effect of aegle Marmelos fruit pulp powder on glycemic status of type 2 diabetic patients]]> Murshida Aziz Liaquat Ali Masfida Akhter https://imcjms.com/journal_full_text/241 2017-07-05 15:36:19 Original Article Ibrahim Med. Coll. J. 2013; 7(2): 35-37 Plant materials are considered to be attractive potential sources of alternate agents in the prevention and management of type 2 diabetes mellitus (T2DM). Different parts of Aegle marmelos have been claimed to possess anti-glycemic property. The present study was conducted at Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka, Bangladesh from July 2010 to June 2011 to determine the anti-glycemic effect of A. marmelos unripe fruit pulp in T2DM patients. The experiment was conducted under a crossover design and the effects were analyzed during the 0-21 as well as 28-49 days with 7 days wash out period. The data were then pooled and the baseline versus endpoint values was also compared. The mean fasting blood glucose (FBG) values did not significantly differ between the two groups at any time points. No significant difference between the baseline and end point values regarding FBG. The effect on blood glucose was not significant in any of the analysis. This study did not reveal any anti-glycemic effect of A. marmelos fruit pulp in T2DM patients. Introduction Conventionally, Type 1 Diabetes Mellitus (T1DM) is treated with exogenous insulin and T2DM with synthetic oral hypoglycemic agents like sulphonylureas and biguanides.4 A substantial proportion of T2DM also requires insulin. However, the existing therapeutic agents have considerable limitations in the management of this complex disorder and search for alternate agents are continuing all over the world. Many plant materials had since been described for the treatment of diabetes, but scientific studies with these materials are limited. Among traditional medicinal plants, Aegle marmelos (Bael in Bengali) has enormous traditional uses against various diseases. Traditionally, various parts of the plant, Aegle marmelos, are used for the treatment of a variety of disorders. Aegle marmelos originated in India and is presently growing in most of the countries of Southeast Asia.5 Extensive chemical investigation on various parts of the tree have been carried out and more than 100 compounds have been isolated. The bioactive compounds isolated from these fruits were marmelosin, luvangetin, aurapten, psoralen, marmelide and tannin. In the above context, the present study was undertaken to explore the anti-glycemic effects of A. marmelos unripe fruit pulp powder in patients with T2DM. Materials and Methods Preparation of A. marmelos fruit pulp powder: Unripe fruits of Aegle marmelos were collected from specific area of Chapainawabgonj. Fruit pulps of A. marmelos (FPAM) were dried in sunlight for 5 to 6 days, coarsely powdered by grinder machine and stored in a dry cool place. Statistical analysis was performed using SPSS (Statistical Package for Social Science) software for Windows version-16 (SPSS Inc., Chicago, Illinois, USA). The data were expressed as proportion and mean±SD (standard deviation) as appropriate. The statistical significance of differences between the values was assessed by paired or unpaired student’s t test as appropriate. Correlation analysis between the parameters was done by using Pearson’s Correlation test. Results   Table-1: Socio-demographic characteristics of the study subjects (n=30)     Table 2: Glycemic status of T2DM cases following A. marmelos fruit pulp drink daily for 21 days among control and intervention groups       Table 3: Glycemic status of T2DM cases following 21 days of A. marmelos fruit pulp drink daily among control and intervention groups after cross over and 7 days wash out period     A number of parts of A. marmelos have been studied for the anti-diabetic properties in diabetic rat models. The present one was probably the first study in which a part of the plant was tested on human for anti-diabetic properties. The part chosen was the unripe fruit pulp of A. marmelos as this was the commonest part consumed by people as drink and prescribed by the traditional healers in Bangladesh. In fact, a few commercial preparations of the pulp are now available in Bangladesh market with wide spectrum of therapeutic claims including for diabetes. Testing the efficacy and safety of the fruit pulp has thus public health importance.   1.    Zimmet P. Diabetes epidemiology as a tool to trigger diabetes research and care. Diabetologia 1999; 42: 499-518. 3.    Wild S, Roglic G, Green A, Sicree R, King H. Global Prevalence of Diabetes. Estimates for the year 2000 and projections for 2030. Diabetes Car 2004; 27:           1047-1053. 5.    Parmar C, Kaushal MK. In: Wild Fruits. Kalyani Publishers, New Delhi, India, Aegle marmelos 1982; 1-5. 7.    Kamalakkanan N, Prince PSM. Hypoglycemic effect of water extract of Aegle marmelos fruits in streptozotocin induced diabetes rats. J Ethnopharmacol 2003; 87: 207-210. 8.     Kamalakkanan N. and Prince PS.. The effect of Aegle marmelos fruit extract in streptozotocin diabetes: a histopathological study. J. Herb Pharmacother 2005; 5: 87-96. <![CDATA[Laparoscopic evaluation of tubal pathology in cases of infertility]]> Maherunnessa T.A. Chowdhury https://imcjms.com/journal_full_text/244 2017-07-08 12:49:58 Original Article Ibrahim Med. Coll. J. 2013; 7(2): 38-40 Laparoscopy examination is an important tool for evaluation of tubal pathology contributing to infertility and might play a major role in infertility management. Introduction With this background the present study was undertaken to assess different anatomical and pathological conditions of fallopian tubes by laparoscopy in infertile female patients. Materials and Methods Before admission, detailed history was taken and clinical examination was done. A set of basic investigations were carried out for fitness of anesthesia before laparoscopy. In suspected cases of thyroid disease serum thyroid stimulating hormone level was performed. To evaluate any follicular phase defect serum follicular stimulating hormone, luteinizing hormone and serum prolactin level were done. Finally, patients selected for laparoscopy were admitted on 18-21 days of their menstrual cycle. The study protocol was approved by the Ethical Committee of Bangladesh College of Surgeons and Physicians. Informed consent was taken from the participants before enrollment. Results             Introduction of laparoscopy has tremendously improved the ability to investigate long standing infertility. Uterus, tubes and ovaries can be visualized by laparoscopy directly and full information about concurrent pelvic pathologies can be obtained. In addition to the above, abnormalities of the uterus may cause infertility. In this study, fibroid uterus was found in 9% cases and bicornuate uterus was found in 2% cases which could be the contributing factors for infertility. References 2.   Chang YS. Lee JY, Moon SY, Kim J. G Diagnostic Laparoscopy in Gynaecological disorder. Asia Ocenia J. Obs and Gynae Col 1982; 13(5): 29-34. 4.   Otolorin EO, Ojengbede O and Falase AO. Laparoscopic evaluation of the tubo-peritoneal factor in infertile Nigerian women. Int J Gynecol Obstet 1987; 25(1): 47-52. 6.   Musich JR and Behrman SJ. Infertility laparoscopy in perspective: review of five hundred cases. Am J Obstet Gynecol 1982; 143(3): 293–03. 8.   Mol BW, Dijkman B, Wertheim P, Lijmer J, van der Veen F and Bossuyt PM. The accuracy of serum chlamydial antibodies in the diagnosis of tubal pathology: a meta-analysis. Fertil Steril 1997; 67(6): 1031–37. 10.Lavy Y, Lev-Sagie A, Holtzer H, Ravel A, Hurwitz A. Should laparoscopy be a mandatory component of the infertility evaluation in infertile women with normal hysterosalpingogram or suspected unilateral distal tubal pathology? Eur J Obstetrics and Gynaecology Reproductive Biology 2004; 114(1): 64-68. 12.Sinawat S, Pattamadilok J, Seejorn K. Tubal abnormalities in Thai infertile females. J Med Assoc Thailand 2005; 88(6): 723-727. <![CDATA[A case of acute liver failure in dengue hemorrhagic fever]]> Rama Biswas Kazi Ali Hasan https://imcjms.com/journal_full_text/63 2016-08-02 11:48:11 Clinical Case Report Ibrahim Med. Coll. J. 2013; 7(2): 41-42 Dengue is an arboviral disease endemic in many parts of the world. The clinical presentation of dengue viral infection ranges from asymptomatic illness to fatal dengue shock syndrome. Although, it is known to cause hepatic involvement, it occasionally results in acute hepatic failure. We report a case of dengue hemorrhagic fever presenting with acute liver failure. The case recovered completely after treatment. Introduction   A 35-year-old housewife came to the emergency with the complaints of high grade fever with chills, myalgia for 4days and severe abdominal pain with non-bilious vomiting for 2 days. There was no history of bleeding from any site and she was not exposed to any hepatotoxic drugs. There was no significant past medical or surgical history. On examination, she was febrile, dehydrated and normotensive. Abdomen was diffusely tender and chest examination revealed reduced air entry in right infrascapular and infra-axillary area. On the following day, platelet count dropped to 8. 0x109/L and haematocrit level rose to 53%. There were petechial hemorrhages and mild gum bleeding. By the next day, she became dyspnoic and her level of consciousness deteriorated. Her pulse rate was 140/min, blood pressure was 100/60 mm of Hg, respiratory rate was 44/min and Glasgow coma scale was 10/15. She became icteric and developed tender hepatomegaly and moderate ascites. The platelet count rose to 38.0x109/L and haematocrit became 42% after one unit of apheretic platelet was transfused. The liver function tests further deteriorated: serum bilirubin 3.2 mg/dL, ALT -2150 IU/L, AST – 3050 IU/L. Prothrombin time (PT) was 32 seconds against control of 13 seconds and activated partial thromboplastin time (APTT) was 43.8 second (normal 13-25 seconds). Serum ammonia was 70 mmol/L and serum lactate was 108 mg/dl. She was shifted to intensive care unit and intubated due to severe metabolic acidosis with increased oxygen requirement. Antibodies to hepatitis A, C, and E as well as hepatitis B surface antigen were negative. Peripheral smear for malarial parasites were negative. Dengue NS1 antigen and dengue IgM antibody against dengue virus were positive. Computed tomography of brain showed diffuse cerebral edema. Based on the above findings, she was diagnosed as a case of dengue hemorrhagic fever with hepatic encephalopathy.   Dengue infections are caused by a flavivirus which has four serotypes (DEN1-4). It is the commonest arbovirus and a common cause of hemorrhagic fever in the world. The virus is transmitted by mosquitoes of Aedes genus, mainly Aedes aegypti. Dengue virus can infect many cell types in the body to cause diverse clinical effects. Liver involvement appears to occur more commonly with serotypes DEN3 and DEN4.5 Although liver is not the main target organ, direct infection of hepatocytes and Kupffers cells by dengue virus can be observed.6 An increase in liver transaminases is observed in the first week of dengue infection mainly in dengue hemorrhagic fever rather than in dengue fever. This can vary from 2-3folds to more than 10 fold rise from normal level. AST raises more than ALT which is different from other types of hepatitis.6 Similar pattern was observed in our patient as well. The management in such cases includes supportive therapy in the form of adequate and cautious fluid replacement, timely ventilator support, prophylactic antibiotic coverage, anticerebral edema measures and continuous monitoring of neurological status.     1.    World Health Organization: Dengue haemmorhagic fever: diagnosis, treatment, prevention and control. 2nd edn. World Health Organization, Geneva 1997; 12-23. 3.    George R, Lum LCS. Clinical spectrum of dengue infection. In: Gubler DJ, Kuno G (eds). Dengue and dengue hemorrhagic fever. Washington: Cab International; 1997. 5.  Gasperino J, et al. Fulminant hepatic failures secondary to hemorrhagic fever in an international traveler. Liver Int. 2007; 27: 1148-51. 7.  Sirivichayakul C, Sabcharoen A, Chanthavanich P, Pengsaa K, Chokejindachai W, Prarinyanupharb V: Dengue infection with unusual manifestations: a case report. J Med Assoc Thai 2000; 83: 325-329. 9.   Malavige GN, Ranatunga PK, Velathanthiri VGNS, Fernando S,  Karunatilaka DH,  Aaskov J,  Seneviratne SL. Patterns of disease in Sri Lankan dengue patients. Arch Dis Child 2006; 91: 396-400. 10.   de Souza LJ, Alves JG, Nogueira RMR, Neto CG, Bastos DA, et al. Aminotransferase changes and acute hepatitis in patients with dengue fever: analysis of 1,585 cases, Braz J Infect Dis 2004; 8: 156-63. <![CDATA[Peripheral soft tissue ewing’s sarcoma: a rare case report]]> Farzana Shegufta Mahfuz Ara Ferdousi Md Abu Taher https://imcjms.com/journal_full_text/245 2017-07-08 13:47:49 Clinical Case Report Ibrahim Med. Coll. J. 2013; 7(2): 43-46 A 22 years male patient presented with gradual left forearm swelling for 6 months. X ray forearm revealed large soft tissue swelling with tiny calcification and mild scalloping at inner aspect of ulna and ultrasonogram (USG) revealed soft tissue mass having calcification and necrotic areas within and spectral Doppler showed arterial type of blood flow with no augmentation. Later computerized tomography (CT) scan showed soft tissue mass with necrotic area and calcification with no bony involvement. Magnetic resonance imaging (MRI) with contrast revealed a large heterogeneously enhancing lobulated mixed intensity lesion in antero-medial compartment of the left forearm involving flexor group of muscles causing displacement of fat plane. MRI and subsequent histopathology of the lesion revealed it as a rare soft tissue Ewing’s sarcoma / primitive neuroectodermal tumor (PNET) in extremity. 1.   Smoll, N.R. Relative survival of childhood and adult medulloblastomas and primitive neuroectodermal tumours (PNETs). Cancer 2012; 118(5): 1313-1322. 3.   Schajowicz F. Ewings sarcoma and reticulumn cell sarcoma of bone with special reference to the histochemical demonstration of glycogen as an aid to differential diagnosis. J Bone Joint Surg Am 1959; 41(2): 349-362. 5.   Siebenrock KA, Nascimento AG and Rock MG. Comparison of soft tissue Ewing’s Sarcoma and peripheral neuroectodermal tumour.Clinical Orthopaedics and Related Research 1996; 329:       288-299. 7.   Stout AP. A tumor of the ulnar nerve. Proc NY Pathol Soc 1918; 18: 2-11. 9.   Toro JR, Travis LB, Wu hj, Zhu K, Fletcher CDM and Devesa SS. Incid-ence patterns of soft tissue sarcomas, regardless of primary site, in the surveillance, Epidemiology and End Results Program.1978-2001: an analysis of 26,758 cases. International Journal of Cancer 2006; 119(12):      2922-2930. 11.Rud NP, Reiman HM, Pritchard DJ, Frassica FJ and Smithson WA. Ext-raosseous Ewing’s Sarcoma: A study of 42 cases. Cancer 1989; 64(7): 1548-1553. 12  Cotterill SJ, Ahrens S, Paulussen M, Jurgens HF, Voute PA, Gadner H and Craft AW. Prognostic factors in Ewing’s tumour of bone: Analysis of 975 patients from the European Intergroup Cooperative Ewing’s Sarcoma Study Group. Journal of clinical oncology 2000; 18(17): 3108-3114. <![CDATA[Maternal and childhood undernutrition in Bangladesh: Keeping the issue on the agenda]]> Masuda Mohsena https://imcjms.com/journal_full_text/243 2017-07-06 09:36:25 Editorial Ibrahim Med. Coll. J. 2013; 7(1): i-ii Recent analysis of a total of 8,858 under-two children of the data of National Nutrition Programme baseline survey revealed that 40.5% of the children were stunted (15.6% severely stunted), 35.4% were underweight (11.5% severely underweight) and 17.8% were wasted (3% severely wasted).5 Analysis of the Bangladesh Demographic Health Survey (BDHS) data showed that there has been some improvement in child nutritional status over the past years. The level of stunting has declined from 51% in 2004 and 43% in 2007 to 41% of children under five in 2011. The pattern and change in wasting has been small and inconsistent. It increased from 15% in 2004 to 17% in 2007, and declined to 16% by 2011. The level of underweight has been declining from 43% in 2004, to 41% in 2007, and to 36% in 2011.6 Although there were modest improvements in past decades, the nutritional status of women in Bangladesh is still alarming. The FSNSP data reported that around 28% of Bangladeshi women, having under five children in their families, suffered from chronic energy deficiency (CED).7 Ahmed et al.5 reported that the nutritional status of women in Bangladesh is showing an improving trend. In 1997, 52% of women had CED; since then, a sustained reduction has been observed in the prevalence of CED; the prevalence being 30% in 2007. BDHS data analysis likewise showed that 39.2% of the mothers of under five children were suffering from CED, while 5.6% of them had a BMI less than 16 kg/m2.6 The multifaceted nature of undernutrition means that it may be effectively addressed only when several sectors and strategic efforts are combined together. Ahmed et al.5 recommended that the interventions targeting undernutrition should be scaled up to cover at least 70% of the total population to show tangible outcomes. Community level integrated packages to address hunger and undernutrition in women and children are being implemented across many countries, this consisted mainly of developing cross-sectoral interventions addressing malnutrition and implementing them in targeted areas/vulnerable communities. The main activities included: (1) Growth Monitoring and Promotion (GMP); (2) Intense nutrition, health, and hygiene advocacy; (3) Behaviour Change Communication (BCC) to promote Infant and Young Child Feeding (IYCF); (4) Improving health and immunization services for women and children; (5) Micronutrient and food supplementation; and (6) Expanding treatment and rehabilitation of severely malnourished children both at community and facility levels. The integrated packages gave equal emphasis to preventive (nutrition and health education), and curative (nutrition rehabilitation centers) strategies and implemented a mix of direct and indirect interventions.     Dr Masuda Mohsena Department of Community Medicine References 2.    Stevens GA, Finucane MM, Paciorek CJ et al. Trends in mild, moderate, and severe stunting and underweight, and progress towards MDG 1 in 141 developing countries: a systematic analysis of population representative data. The Lancet 2012; 380: 824-34. 4.    World Bank. To the MDGs and Beyond: Accountability And Institutional Innovation In Bangladesh. Dhaka: The World Bank 2007. 6.    BDHS. Bangladesh Demographic and Health Survey 2011. Dhaka, Bangladesh and Calverton, Maryland, USA: National Institute of Population Research and Training, Mitra and Associates, and Macro International 2011. 8.    ICDDR B. An overview of under-nutrition in Bangladesh. Health and Science Bulletin 2011; 9: 9-16. <![CDATA[Evaluation of MRSA chrome agar for the detection of methicillin resistant staphylococcus aureus]]> Durdana Chowdhury Sanya Tahmina Jhora Tarek Mahbub Khan Sadia Afroz https://imcjms.com/journal_full_text/56 2016-08-02 11:29:24 Original Article Ibrahim Med. Coll. J. 2013; 7(1): 1-4 The aim of this study was to evaluate the efficacy of MRSA Chrome agar to detect methicillin resistant Staphylococcus aureus (MRSA) and compare it with 1µg oxacillin disc diffusion tests and detection of mecA gene by PCR. A total 116 Staphylococcus aureus (S. aureus), isolated from various clinical samples, were obtained from three tertiary care hospitals of Dhaka city. S. aureus was identified by colony characters, Gram stain and standard biochemical procedures. MRSA was detected by susceptibility to 1µg oxacillin disc, growth of denim blue color colonies of S. aureus on the Brilliance MRSA Chrome agar at 24 and 48 hours of incubation. PCR was performed for amplification of mecA gene as a gold standard method. Out of 116 isolated S. aureus, 33 (28.44%) were MRSA by oxacillin disc diffusion test where mecA gene was detected in 28 strains. On MRSA Chrome agar, 29 (25.0%) S. aureus produced denim blue colonies at 24 hours, of which 28 isolates possessed mecA gene. At 48 hours incubation, an additional 4 isolates yielded denim blue colonies from which mecA gene could not be identified. All the strains of S. aureus that produced denim blue colonies at 24 and 48 hours were resistant to oxacillin. The sensitivity, specificity and accuracy of oxacillin disc diffusion test were 100%, 94.31% and 95.68% and Chrome agar at 24 hours were 100%, 98.86% and 99.13% respectively. Thus MRSA Chrome agar could be good choice in clinical microbiology laboratory for rapid and accurate identification of MRSA. Introduction The methods currently used for screening of MRSA include standard culture and susceptibility to oxacillin, chromogenic media and molecular based testing. FDA approved PCR assays have been proven to be an excellent method for a rapid detection of MRSA. But the cost is very high as it requires expensive equipments and highly trained personnel. In recent years, the chromogenic media have been introduced for the rapid detection of S. aureus in clinical samples.4 This media detects key enzyme as diagnostic marker for MRSA by the use of “chromogenic” substrates incorporated into a solid agar based matrix and antibiotics for selective growth of MRSA.4 In contrast to conventional culture media, chromogenic media allow direct colony color-based identification of the MRSA from the primary culture. Therefore, the total turnaround time for the detection of MRSA is reduced to 1.4-1.7 days by eliminating the need for further biochemical testing.   Samples   A 0.5 McFarland standard suspension of the isolated S. aureus was prepared. Mueller Hinton agar (supplemented with 4%NaCl) was inoculated with 0.5 McFarland suspension of the isolate which was spread evenly by rotating the plate approximately 600 for three times to get a uniform distribution of inoculums. Oxacillin (1µg) disc was placed and incubated at 350C for 24 hours. The diameter of the inhibition zones was measured as per recommendations of the National Committee for Clinical Laboratory Standards (NCCLS).5 An inhibition zone diameter of £13 mm was considered as resistant. Brilliance MRSA Chrome agar (Oxoid, UK) was inoculated with 0.5 McFarland suspension of the isolate and incubated at 35°C. The plates were read after 24 and 48 h of incubation. The growth of denim blue colored colonies indicates presence of MRSA. Polymerase Chain Reaction (PCR) for identification of mecA gene Mec-Al (+) 5´AAAATCGATGGTAAAGGTTGGC-3´ and PCR were performed in a thermal cycler (Eppendorf) by using supermix (Promega, USA) following the manufacturer’s recommendations. 12.5 ml super mix and 2ml template DNA were taken to each PCR reaction tube. 8.5 ml PCR water and 1.0 ml mecA1, 1.0 ml mecA2 primer was added to each tube. So the final volume in each tube was 25 ml. The following amplification protocol was used: initial denaturation for 3 minutes at 94°C, then final denaturation continued for 40 cycles of 30s at 94°C, 45s at 60°C, annealing at 60°C for 1.5 minutes. Extension of primer was done at 72°C for 3.5 minutes with a total of 40 cycles.   The sensitivity and specificity of Chrom Agar and Oxacillin disc diffusion test were determined by the standard formula as described elsewhere.7 Results     Table-2: Sensitivity and specificity of MRSA Chrome Agar and oxacillin disc diffusion test for the detection of MRSA   Methicillin resistant S. aureus was first identified in 1961, since then MRSA has been increasingly reported in both hospital and community settings.8 Rapid and accurate identification of MRSA is important for effective patient care and prevention of its further spread. The present study evaluated the MRSA Chrome agar for rapid detection of MRSA. In this study, detection of MRSA was done by oxacillin disc diffusion test, culture on MRSA Chrome agar (Brilliance MRSA agar, Oxoid, UK) and detection of mecA gene by PCR. Detection of mecA gene by PCR was considered as a gold standard method for MRSA confirmation.9 MRSA Chrome agar is a selective chromogenic medium, which is more reliable and faster for screening of MRSA than oxacillin disc diffusion method and also less costly compared to the PCR.10 Different studies have reported the sensitivity and specificity of MRSA Chrome agar as 90% to 100%.4 It is easy to perform and the interpretation of results does not need any expertise. On MRSA Chrome agar, 29 (25.00%) strains of S. aureus produced denim blue colonies at 24 hours indicating MRSA. Additional four strains produced denim blue colonies at 48 hours. So at 48 hours, a total of 33 (28.34%) isolates were MRSA Chrome agar positive. All of these strains were resistant to oxacillin. Out of 29 positive strains at 24 hour, mecA genes were detected in 28 (96.56%) strains. No mecA gene was found in the additional 4 isolates that produced denim blue colonies at 48 hours. The sensitivity, specificity and accuracy of MRSA Chrome agar at 24 hours were 100%, 98.86% and 99.13% respectively, which was better than the sensitivity (100%) and specificity (94.31%) at 48 hours (Table-2). This finding was similar to the results of Peterson et al. (2010) who reported the sensitivity and specificity at 24 hours 96% and 99.6% and at 48 hours 96% and 95.2% respectively.13 Almost similar result was reported by Kristien et al. (2010), in which the sensitivity and specificity were 95% and 97.4% at 24 hours and 98.9% and 89.4% at 48 hours respectively.14 The remaining false positive results could be due to an inherent limitation of any subjective test. The result of MRSA Chrome agar permitted sensitive and specific detection of MRSA at 24 hours which was more specific than that achieved at 48 hours and of oxacillin disc diffusion test. Methicillin sensitive S. aureus was not grown on the chromogenic media as it contained combination of antibacterial compounds.14 MRSA can be detected within 24 hour when specimens are inoculated directly on to it, which is a one day improvement in turnaround time compared to oxacillin disc diffusion tests which usually needs 2 to 3 days to detect MRSA and the specificity is also less. Gene detection by conventional PCR requires labor, time, costs and special set up.   1.    Song MD, Wachi M, Doi M, Ishino F, and Matsuhashi M. Evolution of an inducible penicillin- target protein in methicillin resistant Staphylococcus aureus by gene fusion. FEBS Lett 1987; 221: 167-171. 3.    Jonas D, Speck M, Daschner V, and Grundmaun H. Rapid PCR-based identification of methicillin-resistant Staphylococcus aureusfrom screening swabs. J Clin Microbial 2002; 40: 1821-1823. 5.    Villanova PA. Performance standards for antimicrobial disc susceptibility tests. In: National Committee for Clinical Laboratory Standards. Approved standard.7thedn. National Committee for Clinical Laboratory Standards: 2000. P. M2-A7. 7.    Akobeng AK. Understanding diagnostic tests 1: sensitivity, specificity and predictive values. Acta Pædiatrica 2006; 96: 338–341. 9.    Skov R, Smyth R, Larsen AR, Bolmstrom A, Karlssen A et al. Phenotypic detection of methicillin resistance in Staphylococcus aureusby disc diffusion testing and e-test on Mueller-Hinton agar. J Clin Microbial 2006; 44: 4395-9. 11.  Nicole MB, Tam TV, Timothy AM, Steven AM and David MW. Comparison of cefoxitin and oxacillin disc diffusion methods for detection of mecA- mediated resistance in Staphylococcus aureus in a large - scale study. J Clin Microbial 2009; 47: 217-219. 13.  Peterson JF, Alexander A D, Katherine M. R, Gerri S H et al. Alternative Use for Spectra MRSA Chromogenic Agar in Detection of Methicillin-Resistant Staphylococcus aureus from Positive Blood Cultures. J Clin Microbiol 2010; 48: 2265-67. 14.  Kristien VV, Reinoud C, Guy C, Johan F, Anne- Marie V den A, Hans de B. Performance of new chromogenic medium, BBL CHROM agar MRSA II (BD) for detection of methicillin resistant Staphylococcus aureus in screening samples. J Clin Microbiol 2010; 48: 1450-1451. <![CDATA[Conjunctival bacterial flora in diabetic patients]]> Najmun Nahar Shaheda Anwar Md. Ruhul Amin Miah https://imcjms.com/journal_full_text/57 2016-08-02 11:30:40 Original Article Ibrahim Med. Coll. J. 2013; 7(1): 5-8 Conjunctival flora refers to population of microorganisms that dwell within the eyes of healthy individuals and is important in maintaining a healthy ocular surface and normal conjunctival function. Conjunctival flora may be altered by a variety of factors that include age, immunosuppression and geography. Immune function is compromised in diabetes mellitus. The aim of the present study was to see the pattern of conjunctival bacterial flora in diabetic and non-diabetic patients. This cross sectional study was carried out in BSMMU during the period of January 2011 to December 2011. Total 500 conjunctival swabs were collected from both eyes of 50 diabetic patients attending OPD of Endocrinology Department of BSMMU and 200 non-diabetic individuals. Significant number of culture was positive in diabetic patients (64.0%) compared to that of non-diabetic individuals (38.0%). Staphylococcus epidermidis was predominant  in both study groups (diabetic vs non-diabetic: 41.3% vs 65.26%). Staphylococcus aureus (15.22%), Escherichia coli (6.52%) and Enterobacter (8.33%) were isolated in diabetic patients. Rate of positive culture in both and single eyes were higher in diabetic (28%, 36.0%) than that of non-diabetic individuals (9.5%, 28.5%). Introduction In a healthy person, surface tissues such as skin and mucous membranes are constantly in contact with environmental organisms and becomes colonized by various micro-organisms which are referred to as normal flora.3 Bacteria and fungi are considered as normal flora of conjunctiva whereas viruses and parasites are not considered as the members of the normal flora.4 Normal conjunctival flora remains relatively consistent among human populations. However, it may be altered by a variety of factors including age, immunosuppression, ocular inflammation, dry eye, use of contact lens use, antimicrobials, surgery, external exposure, climate and geography. Some members of the conjunctival flora play a pathogenic role in diabetes mellitus when immune function is compromised, which may lead to serious infection.6 As such, the present study was designed to see the pattern of conjunctival bacterial flora in healthy individuals and diabetic patients. Materials and Methods   Total 250 patients attending Eye OPD of BSMMU with complaints other than eye infections, mostly refractive error, were enrolled in the study. On the basis of history and glycemic status 50 patients were included in the diabetic group and another 200 were non-diabetics. Slit lamp examination was performed on each patient to find out any evidence of infection or inflammation. Sample collection   Smear was prepared with one swab from each sample and Gram staining was performed to demonstrate pus cells to exclude infection. Second swab was inoculated onto blood agar, chocolate agar, MacConkey agar, blood tellurite agar and Haemophilus selective agar media and were incubated at 37ºC aerobically for 48 hours. Chocolate agar and Haemophilus selective agar plates were incubated in candle extinction jar. After 48 hours, all the organisms were identified by standard microbiological procedures namely colony morphology, Gram staining, pigment production and relevant biochemical tests (catalase, coagulase, novobiosin sensitivity, oxidase, MIU, mannitol fermentation, bile solubility, bile esculin test, rapid carbohydrate utilization test, growth factor requirement test, Haemophilus satellitism and butyrate esterase test).9,10 All data were collected in a predesigned data sheet and checked, edited and analyzed using SPSS (Statistical Package of Social Science) software. The data obtained from healthy individuals and diabetic patients were compared by Chi-square (χ2) test. Results     Among the culture positive samples, different bacterial species were isolated from conjunctival swabs of diabetic and non-diabetic patients. S. epidermidis was the most commonly isolated bacteria in both the study population but it washigher in non-diabetics (65.26%). Other isolated bacteria were S. aureus, S. saprophyticus, viridans streptococci, Moraxella sp, H. influenzae and Pseudomonas sp in different percentages among the both groups (Table-2). S. saprophyticus (4.21%) and Diphtheroids (2.11%) were isolated only in non-diabetic patients while S. pneumoniae (2.17%), Esch. coli (6.52%) and Enterobacter sp (8.3%) were isolated in diabetic patients only (Table-2). Table 2: Pattern of bacteria isolated from conjunctival swabs   The conjunctival sac is parasitized with microflora that changes dynamically throughout the life time because of its long-term exposure to the environment and these flora are part of the defense mechanism of the eye in preventing colonization by more pathogenic microorganisms.11 In the present study, conjunctival bacterial flora was isolated more frequently in diabetic patients (64%) than the non-diabetics (38%). Martin et al. (2004) also observed higher frequency of conjunctival culture positivity in diabetic group than those of nondiabetic group (94.18% vs. 73.33%).13 In their study, they have correlated the frequency of culture positivity with diabetic retinopathy and the frequent bacterial isolation in those patients indicated that retinopathy might be a factor for altered conjunctival flora.   1.    Snell RS and Lemn MA. Conjunctiva. In: Clinical anatomy of eye. 2nd edition. Blackwell Science, USA. 1998; 108-112. 3.    Todar K. The normal bacterial flora of humans, Online Text Book of Bacteriology. 2009; Available at kentodar@textbookofbacteriology.net. Accessed on 2/01/2012. 5.    Therese KL & Madhavan HN. Microbiological procedures for diagnosis of ocular infections, L & T Microbiology Research Centre, Vision Research Foundation l8, College Road, Chennai 600 006. 2004. 7.    Skarbez K, Priestley Y, Hoepf M and Koevary SB. Comprehensive review of the effects of diabetes on ocular health. Expert Rev Ophthalmology 2010; 5:   557–577. 9.    Cheesbrough M. Microbiological tests. In: District Laboratory Practice in Tropical Countries. Cambridge University Press 2000; 64-404. 11.  Liu J, Li J, Hu J and Xie H. Identification and quantitation of conjunctival aerobic bacterial flora from healthy residents at different ages in Southwest China. African J Microbiol Res 2011; 5: 192-197.       Impaired leucocyte functions in diabetic patients. Diabet Med 1997; 14: 29-34. <![CDATA[Drug resistance pattern of M. tuberculosis in category II treatment failure pulmonary tuberculosis patients]]> Fahmida Rahman Sadia Sharmin Md. Mustafa Kamal Md. Ruhul Amin Miah https://imcjms.com/journal_full_text/58 2016-08-02 11:32:04 Original Article Ibrahim Med. Coll. J. 2013; 7(1): 9-11 This study was designed to determine the extent of drug resistance of M. tuberculosis (MTB) isolated from category II treatment failure pulmonary tuberculosis (PTB) patients. A total of 100 Ziehl-Neelsen (Z-N) smear positive category II failure PTB patients were included in this study. Sputum culture was done in Lowenstein-Jensen (L-J) media. Conventional proportion method on Lowenstein-Jensen (L-J) media was used to determine the drug susceptibility of M. tuberculosis to isoniazid (INH), rifampicin (RMP), ofloxacin (OFX) and kanamycin (KA). Out of 100 sputum samples, a total of 87 samples were positive by culture. Drug susceptibility test (DST) revealed that 82 (94.25%) isolates were resistant to one or more anti -TB drugs. Resistance to isoniazide (INH), rifampicin (RMP), ofloxacin (OFX) and kanamycin (KA) was 94.25%, 82.75%, 29.90% and 3.45% respectively. Among these isolates, 79.31% and 3.45% isolates were multi-drug resistant (MDR) and extended drug resistant (XDR) M. tuberculosis respectively.  High rate of anti-tubercular drug resistance was observed among the category II treatment failure TB patients. Introduction Both MDR-TB and XDR-TB are the emerging threats to the success of tuberculosis control programs. Although treatable, MDR-TB cases are difficult and costly. On the other hand, XDR-TB cases are virtually untreatable since none of the standard or reserve drugs is effective. To prevent the transmission of these strains, early identification of this type of resistant strain is important. Such early detection could optimize treatment, improve the outcome and prevent the transmission of MDR-TB.   A total of 100 Z-N smear positive category II treatment failure pulmonary tuberculosis patients of different age and sex were enrolled in this study. Sample collection and laboratory works were done in the National Tuberculosis Referral Laboratory (NTRL) and National Institute of Disease of Chest and Hospital (NIDCH), during the period of January to December 2010. Drug susceptibility was done only on culture positive isolates.   During the study period a total of 100 smear positive category II treatment failure pulmonary tuberculosis patients were enrolled. Out of the 100 patients, sputum samples from 87 (87%) were positive by culture. All were identified as M. tuberculosis complex. Out of 87 isolates, 82 (94.25%) were resistant to one or more drugs. Highest resistant was found against isoniazid (94.25%) followed by rifampicin (82.75%), ofloxacin (29.90%) and Kanamycin (3.45%) either alone or in combination with other drugs (Table-1). Sixty nine (79.31%) isolates were detected as MDR while three (3.45%) were XDR (Table-2). Ten (11.49%) isolates were detected as resistant to only INH while no RMP mono resistant isolate was detected in the present study. Out of 87 isolates, five were sensitive to all four drugs tested. Table 1: Resistance pattern of M. tuberculosis isolated from category II treatment failure cases     Discussion Among these culture positive isolates, 79.31% were diagnosed as MDR-TB. Previously in 2009, similar high rate of multi drug resistant M. tuberculosis (83% and 87%) was also reported in two different studies among category II failure Bangladeshi patients.9,10 No national study has been conducted in Bangladesh to evaluate the current status of MDR/XDR-TB among the category II treatment failure cases. Recent national Drug Resistance Surveillance (DRS) data recorded the rate of MDR-TB as 1.4% among new cases and 29% among previously treated TB cases.5 Therefore, routine bacteriological monitoring of category II failure cases is needed to detect and isolate MDR-TB cases to prevent transmission and mortality. Out of total 87 isolates, about 10% isolates showed resistance to ofloxacin. Fluroqunolone is frequently used in respiratory tract as well as other types of community acquired infections. So, irrational and frequent short course use of fluoroquinolones for various other type infections may be restricted to prevent the development of fluoroquinolones resistance among M. tuberculosis.  Three isolates (3.45%) were diagnosed as XDR-TB. This high rate of XDR M. tuberculosis could be due to the fact that our enrolled patients were category II treatment failure cases from a tertiary care centre where difficult cases were referred from all over the country. However, the overall prevalence of XDR-TB among all MDR-B isolates was 6.6% worldwide, 6.5% in industrialized countries, 13.6% in Russia, 1.5% in Asia and 0.6% in Africa.7   1.    Gursimrat KS. Tuberculosis current situation, challenges and overview of its control program in India. J Glob Infect Dis 2011; 3: 143-150. 3.    Global tuberculosis control: surveillance, planning, financing; WHO report, WHO/HTM/TB/2009.411 5.    World Health Organization. Tuberculosis profile 2011. Available at : http//: www.who.int/countries/bgd/en/ 7.    Amita J and Pratima D. Multidrug resistance to extensively drug resistance tuberculosis: What is next? J Biosci 2008; 33: 605-16. 9.    Kamal SM, Shamim MD, Van Deun et al. An Anti-Tuberculosis Drug resistance Patterns among Category 2 failure patients in Bangladesh. Chest & Heart Journal 2009; 33: 118-21. 11.  Vernon A, Burman W, Benator D, et al. Acquired rifamycin monoresistance in patients with HIV-related tuberculosis treated with once-weekly rifapentine and isoniazid. Tuberculosis Trials Consortium. Lancet; 353: 1843–47. <![CDATA[A rare case of sarcomatoid carcinoma of the pancreas associated with pancreatolithiasis]]> Rashid MM Rabbi H Islam MA Husain MM Minu AR Ali M https://imcjms.com/journal_full_text/59 2016-08-02 11:33:56 Clinical Case Report Ibrahim Med. Coll. J. 2013; 7(1): 12-15 Pancreatolithiasis is a risk factor for developing pancreatic cancer. We report here a rare case of sarcomatoid carcinoma of the pancreas in a 55-year old diabetic male associated with pancreatolithiasis. CT scan of abdomen revealed a large operable mass occupying the distal body and tail of the pancreas. Per-operative survey revealed a small metastatic nodule in the surface of hepatic segment IVa. Histopathology of the distal pancreatic lesion revealed sarcomatoid carcinoma. Hepatic nodule was a metastatic adenocarcinoma. Distal pancreatectomy and splenectomy was done en-mass, along with non-anatomical resection of the hepatic metastatic nodule. Combined with six cycles of chemotherapy, the patient survived a total of another fourteen months. Introduction   A 55 year male college teacher, known diabetic for 25 years and on insulin for 6 years, was diagnosed as a case of pancreatolithiasis for last two years. Pancreatolithiasis was diagnosed by plain X-ray of the abdomen which showed multiple large stones in the pancreas (Fig:1a). He presented to Hepato-Biliary out-patient department with occasional colicky pain in the left hypochondrium, anorexia and weight loss for last one year. His built and nutrition was average, but he was anxious for pain because it was hampering his regular activities. He was not anemic or icteric, and vital signs and symptoms were stable. Abdominal examination revealed mild tenderness at left hypochondrium with no organomegally or ascites. Haematological and biochemical parameters including liver function tests and pancreatic enzymes were within normal limits. Ultrasonography of the abdomen revealed pancreatolithiasis, dilated major pancreatic duct (main pancreatic duct diameter 17mm) and a mass lesion occupying the distal body and tail of the pancreas. Computerized tomography (CT) scan of abdomen showed a fairly large mass (6.5 X 5.0 X 5.0 cm) occupying the distal pancreas (Fig1b). CA 19-9 level was 183 u/L (n= <37 u/L). CT guided fine needle aspiration cytology (FNAC) was done and it was positive for malignant cells.   Fig. 1 a) Plain X-ray of abdomen showing pancreatolithiasis;  1 b) CT scan of abdomen showing distal pancreatic mass Our impression waspancreatolithiasis with a malignant lesion in the distal pancreas. Plan of management was to perform distal pancreatectomy and splenectomy en-mass along withpancreatolithotomy and Roux-en-Y pancreatojejunostomy. Patient was prepared accordingly and was vaccinated against Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitides as per schedule.         First follow up was after one month and subsequently the patient was followed up for next one year. During this period he received six cycles of chemotherapy and was under the care of an oncologist. After one year, there was recurrence of the tumor in the operative bed. With consultation of the oncologist, chemotherapy was restarted, but the patient died of disseminated disease after two months. Discussion The overall survival for ACP is poor when compared with pancreatic duct adenocarcinomas (PDA) but several studies suggest that operative resection provide little benefit.11,12 A Mayo Clinic Institutional Review Board approved cohort study using the Surveillance, Epidemiology and End Results (SEER)cancer registry databasehas shown that males are more affected by ACP than females, the size of ACP is larger at presentation than other PDA (median tumor size 6.0 cm vs. 3.5 cm) and PDA are located more in the head region of the pancreas whereas ACP are located more distally in the body and tail region.13 However, local recurrence of the disease is very high in ACP and Strobel and colleagues (2011)5 has shown in a study that after curative resection of ACP, median survival is only 7.1 months. Yamaguchi et al. (1998) has shown a zero one-year survival for patients with ACP.12 Therefore, it is suggested that pre-diagnosed case of ACP should not undergo surgery. In our case, the decision of operation was influenced by FNAC report, but subtype categorization of pancreatic carcinoma was difficult with FNAC because of the small sample examined microscopically.14 Recently, Clark et al. (2012)11 has mentioned in his study that patients of ACP who underwent pancreatic resection had an overall survival comparable to patients with PDA. Therefore, they recommended that patients with ACP should be offered pancreatic resection when technically feasible. So the operation was justified in our case even with the hepatic metastasis and the patient got a total of fourteen months survival benefit.   1.    Rashid M, Ahmed T, Alam H et al. Evaluation, surgical approaches & results of treatment of pancreatolithiasis in 120 patients. J Surgical Scien 2006; 10: 21–26. 3.    Barretoa SG, Shuklab PJ and Shrikhandeb SV. Tumors of the Pancreatic Body and Tail. Cancer Facts & Figures. Atlanta, GA: American Cancer Society, 2004. 5.    Strobel O, HartwigW, Bergmann F et al. Anaplastic pancreatic cancer: presentation, surgical management, and outcome. Surgery 2011; 149: 200–208. 7.    Lewandrowski KB, Weston L, Dickersin GR et al. Giant cell tumor of the pancreas of mixed osteoclastic and pleomorphic cell type: evidence for a histogenetic relationship and mesenchymal differentiation. Hum Pathol 1990; 21: 1184–1187. 9.    Manduch M, Dexter DF, Jalink DW et al. Undifferentiated pancreatic carcinoma with osteoclast-like giant cells: report of a case with osteochondroid differentiation. Pathol Res Pract 2009; 205: 353–359. 11.  Clark CJ, Graham RP, Arun JS, Harmsen WS and Reid-Lombardo KM. Clinical Outcomes for Anaplastic Pancreatic Cancer: A Population-Based Study. J American Coll Surgeons 2012; 215: 627-634. 13.  Surveillance, Epidemiology and End Results (SEER). National Cancer Institute. Bethesda, MD. Available at: http://seer. cancer.gov. Accessed on February 16, 2012. <![CDATA[Breast abscess due to salmonella enterica serovar typhi in ayoung diabetic female]]> Lovely Barai SA Jilani J. Ashraful Haq https://imcjms.com/journal_full_text/239 2017-07-05 15:20:49 Clinical Case Report Ibrahim Med. Coll. J. 2013; 7(1): 16-17 Abstract Ibrahim Med. Coll. J. 2013; 7(1): 16-17 Key words: Salmonella Typhi, breast abscess, asymptomatic typhoid fever.   Address for Correspondence:Prof. J. Ashraful Haq, Department of Microbiology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Dhaka-1000. E-mail: jahaq54@yahoo.com     Typhoid fever is a common febrile illness in many developing countries of the world including Bangladesh. It is caused by Salmonella enteric serovar Typhi (S. Typhi) and Paratyphi A, B and rarely C. Extra-intestinal manifestations of typhoid fever such as abscess due to Salmonella Typhi are not common. Infection due to S. Typhi is occasionally associated with abscess formation in various organs namely pancreas, brain, liver, spleen, muscle and breast.1-6 The abscess due to S. Typhi during typhoid is always associated with specific clinical features of enteric fever. But the presence of abscess without the general and specific symptoms of typhoid fever is unusual. We describe here a rare case of breast abscess without the presence of general and specific symptoms of typhoid fever in a young diabetic female. Case Report She gave a history of high grade fever and malaise one month prior to the appearance of the swelling in the breast and treated irregularly with various antibiotics by local doctors. There was no past history of any breast disease. She had no loose motions, constipation or urinary abnormality nor had she taken any vaccination against S. Typhi. She was diabetic (type-2) for last two years and on oral anti-diabetic agents with irregular follow up for blood glucose control.   S. Typhi causes typhoid which is a multisystem disease with generalized manifestations. Among the known extra intestinal manifestations, breast abscess due to S. Typhi is rare. In a large study conducted in India on 6250 cases of salmonellosis, 0.016% cases had focal pyogenic infection with only one case of breast abscess.8 Literature review revealed few published cases of breast abscess due to S.Typhi.9-14 Unlike our case, all the reported breast abscess cases due to S. Typhi had general and specific features of enteric fever. But our patient presented with a swelling in her left breast without fever or any other features of enteric fever. But, after the isolation of S. Typhi from the pus, on further enquiry, the patient revealed that she had an acute episode of fever one month prior to the development of breast swelling. Therefore, it appears that she might have had an attack of typhoid fever and the organism got seeded in breast tissue during the bacterimic phase of the diseases. It became reactivated because of her uncontrolled glycemic status (blood sugar level 27mmol/l) and diabetes. There were two other case reports which described abscess in testis and psoas muscle due to S. Paratyphi and S. Typhi respectively without fever or any other specific features of typhoid fever.15,16 References 2.    Hanel RA, Araújo JC, Antoniuk A et al. Multiple brain abscesses caused by Salmonella typhi: case report. Surg Neurol 2000; 53: 86-90. 4.    Naranje KM, Devidayal, Sodhi KS and Singh M. Multiple splenic abscesses caused by Salmonella typhi in a child: case report and brief literature review. J Ped Scien 2011; 3: e113. 6.    Singh S, Pandya Y, Rathod J and Trivedi S. Bilateral breast abscess: A rare complication of enteric fever. Indian J Med Microbiol 2009; 27: 69-70. 8.    Lalitha MK and John R. Unusual manifestations of salmonellosis: A surgical problem. Quarter J Med 1994; 87: 301-309. 10.  Viswanathan R, Shah AH, Nagori LF and Gupta MK. Salmonella typhi in breast abscess. Bombay Hospit J 2003; 45: 452. 12.  Mahajan RK, Duggal S, Chande DS et al. Salmonella enterica serotype Typhi from a case of breast abscess. J Commun Dis 2007; 39: 201-4. 14.  Salahuddin U, Tambawala A and Salahuddin N. Breast abscess and acute cholangitis:Two rare manifestations of Salmonella typhi in the same patient. Infect Dis J Pakistan 2008; 17: 27-29. 16.  Shakespeare WA, Davie D, Tonnerre C et al.. Nalidixic acid resistant Salmonella enterica Serotype Typhi presenting as a primary psoas abscess: Case report and review of the literature. J Clin Microbiol 2005; 43: 996-998. <![CDATA[AcidViolence: A burning issue in Bangladesh]]> Gulshan Ara Akhter Farzana Islam https://imcjms.com/journal_full_text/240 2017-07-05 15:26:26 Review Ibrahim Med. Coll. J. 2013; 7(1): 18-20 Acid violence is a barbaric form of violence in Bangladesh. Acid violence also called acid throwing or vitriolage, is defined as the act of throwing of strong corrosives on face and body of a person with the intention of causing permanent disfiguration, intense pain, scarring and sometimes blindness. All of these injuries are considered as ‘grievous hurt’ under section 320 of B.P.C (Bangladesh Penal Code). For the last few years it is on the rise in both urban and rural areas of Bangladesh. The perpetrators are mostly men and adolescent boys. The overwhelming majority of the victims are women and many of them are girls and young females. Recently, however, there have been acid attacks on children, older women and also men. These attacks are often the result of family and land dispute, dowry demands or a desire for revenge due to failure in love affairs or marriage proposals. It is considered as one of the extreme forms of repression and violation of women’s right. This review article is aimed to focus on the present situation of this barbaric act of vengeance against women and young adolescent girls with regard to frequency, causes, long term consequences and creating public awareness on the issue by tightly regulating the sale and transport of acid as well as enacting harsher penalties for perpetrators. Ibrahim Med. Coll. J. 2013; 7(1): 18-20 Key words: Acid violence, Grievous hurt, Women rights violation.   Address for Correspondence:Dr. Gulshan Ara Akhter, Associate Professor, Department of Forensic Medicine, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Dhaka 1000     Introduction Acid violence is one of the worst manifestation of violence against women. Acid attacks occur throughout South East Asia, especially in Pakistan, India, Cambodia and Bangladesh. Globally at least 1500 persons in 20 countries were attacked last year in this way, 80% of whom being females and somewhere between 40% and 70% under 18yrs of age. In Bangladesh, acid throwing are mostly a form of domestic violence primarily targeted at women. It is a relatively recent form of violence. The first documented case of acid attack occurred in 1983 in Sylhet.1 In Bangladesh, there have been many incidence of acid attacks due to dowry disputes leading often to blindness, disfigurement and death. In 2002, 315 women and girls in Bangladesh were victims of vitriolage. The chemical agents most commonly used to commit these attacks are sulphuric acid, hydrochloric acid and nitric acid. These acids have a catastrophic effect on human flesh, causing the skin tissue to melt, often exposing the bones below the flesh, sometimes even dissolving the bones. Acid is cheap and easily available and is the quickest way to destroy a woman’s life.2   Incidences of Acid Violence The number of acid attacks have been rising in Bangladesh. Documentation from ASF reveals that young women are commonly the targets of acid attacks. Out of total 252 women assaulted with acid, from 1995 to 1998, 134(53%) were below 20 years of age, 8(3%) were minor girls below 10 years of age. During January-March 1993, 33 persons were victims of acid attacks of which 23 were female and 10 were male. Tables 1 and 2 show the scenario of Acid attacks on women over the years. These cases are only the reported cases and may not reflect the real situation of the violence against women.   Table 1: Frequency of Acid attacks from 1990-2001   Table 2: Cases of reported acid throwing against women by years   Table 3: Incidence of Acid assaults followed up with the police     Table 4: Age category of victims of acid attack: VAW, 2008     Table 5: Causes of Acid Attack (1995-98)     Causes and Consequences of Acid Violence 1. Lack of self-defence: Women are not socialized to protect themselves and despite an active feminist movement in the country, they are not physically trained to protect themselves. 2. Male ego and problems in dealing with rejection is another important cause of acid throwing. Refusal of love, marriage proposals and family disputes are three major causes of this type of violence. After marriage when dowry demands are not met, brides may become victims of acid throwing. Other causes of acid throwing include family dispute, protest of husband’s second marriage, failure to misappropriate wife’s wealth, sterility and getting divorce from wife, refusal of sexual relationship, failure to kidnap, the woman not being agreeable to prostitution and the woman’s refusal to agree with husband’s second marriage.3 The illegal sale of acids, cheap and easy availability in any roadside shop is considered an important factor contributing to the practice of acid violence. Impunity, protection of criminals by the politically powerful, and the information about the possibility of assaulting others with acid are probably the main reasons behind the increase in incidences of acid assaults.4 Lack of proper infrastructure and transport facilities is a factor that makes acid violence all the more harmful.   Place of acid violence Many cases of acid violence occur within the woman’s own home and at night. In rural areas or even in urban slums, houses are mainly made of bamboo and thus they can easily be broken into. Such insecurity in the place of residence makes women more vulnerable to attacks by men in their area.5 In many cases the acid is aimed at women’s genitalia. This is achieved because shared toilets are located at a distance from their houses. Either they are attacked in toilets or acid is placed in the water they use to clean themselves with.   Legislation The “Nari O Shishu Domon Act 2000” is intended to address the need for more effective prosecution of perpetrators. In 2002, Bangladesh introduced the death penalty for throwing acid and laws strictly controlling the sale, use, storage and international trade of acids. The two major laws relating to acid violence are The Acid Crime Prevention act 2002 and The Acid Control Act 2002.6   Rehabilitation of the acid victims A survivor of acid violence often requires medical attention during the crisis period. In addition, she also often needs protection, safe accommodation, support, counseling and legal assistance. Victims with acid burn demonstrate a wide range of emotional responses including anger, frustration, irritability and psychological states such as delirium, anxiety, depression and grief. Post traumatic stress disorder (PTSD) may occur after an acid burn.7 These patients need help from primary or specialized care providers like “Acid Survivors Foundation” to recover psychologically. Consequently the victim is faced with physical challenges which requires long term surgical treatment as well as psychological challenges, which require in-depth intervention from psychologists and counselors at each stage of their physical recovery. Family members should be encouraged to sit with the patient and communicate with them providing a sense of purpose which will help to alleviate feelings of helplessness.   Prevention of Acid violence Acid violence can be prevented by passing of strict laws by the parliament, rapid verdict and implementation or punishment by special tribunals, implementation of the dowry prohibition act, regulating the sale of acid, raising awareness in the community, encouraging participation of men against acid violence to women and children, sensitive media reporting, counseling the perpetrator with special focus on adolescent boys. More importantly advocacy, campaign and dialogue with communities particularly with men are essential for bringing forth positive changes.   Conclusion The consequence of acid attacks on survivors brings dramatic change in their life style. Most of them have to give up their education or work. Social isolation, fear of further attacks and insecurity damage their self-esteem and confidence. Illiteracy, poverty, threats to further retribution and ignorance about legal support increase their miseries. Gradual increase of acid attacks suggests that legal provisions and its enforcement is not adequate and effective. Data on acid violence must be gathered to monitor changes in this respect. The goals to be achieved by the government is to increase social awareness, psychological support and rehabilitation of the victims and strict enforcement of laws.   References 2.    Kunkel DB. Burning issues: acids and alkalis,11. Skin and eye exposures: Emerg Med 1984; 16:        165-71. 4.    GR Nagesh.Corrosive poisons in Text book of Forensic Medicine & Toxicology. 2nd edition 2010; 450-452. 6.    Acid survivors Foundation Bulletin of Bangladesh 2000. 7.    Saukko P, Knight B. Corrosive acids, alkalis and phenols in Knight’s Forensic Pathology. 3rd edition 2004; 610-619. <![CDATA[Control of hospital acquired infection in Bangladesh – an endeavor to be strengthened]]> J. Ashraful Haq https://imcjms.com/journal_full_text/229 2017-06-05 09:30:00 Editorial Ibrahim Med. Coll. J. 2012; 6(2): i-ii   Today in USA, over 2 million people acquire nosocomial infection each year causing about 90, 000 deaths and costing US$ 4 to 11 billion.4 Today surveillance programs estimate the rate of this infection as 5-10% of hospital admissions all over the world.4 Bangladesh is no exception. Systematic studies on the magnitude and extent of the problem are lacking, but a study conducted in 2004 in BIRDEM hospital, excluding burn, neonatal and adult intensive care units, has documented the rate of hospital acquired infection as 2.4%.5 Hospital acquired infection is not only responsible for increased morbidity or mortality but it exerts significant economic pressure on the national healthcare sector of all countries of the world and more so where the resources are meager. Nosocomial infection increases the cost of treatment due to prolongation of hospital stay, use of expensive antibiotics for emerging multiple antibiotic resistant bacteria like methicillin resistant Staphylococcus aureus (MRSA), extended spectrum beta lactamase (ESBLs) and metalo-beta lactamse (MBLs) producing  organisms. In Bangladesh, a limited single study has recorded the mean duration of hospital stay is significantly long (20 to 26 days) for cases who acquired hospital infection compared to non-infected cases (9.5 days).6  In a multi-center study involving four geographic divisions of Bangladesh, the rate of isolation of MRSA from hospital patients ranged between 32-63%.7 Another study conducted in a referral hospital of Dhaka city reported 43.2% and 39.5% of E. coli and K.pneumoniae as ESBL phenotypes respectively.8 The situation is even dismal in high risk areas of the hospital like intensive care units (ICU). All the isolates from an ICU of BIRDEM hospital were highly resistant (>80%) to cephalosporins and fluoroquinolones.9 This entire scenario invites the urgent need for initiation of a systematic infection control program in all hospitals of the country.   Professor Ibrahim Medical College References 2.   Jessney B. Joseph Lister (1827-1912): a pioneer of antiseptic surgery remembered a century after his death. J Med Biography 2012; 20(3): 107-10. 4.   Samuel SO, Kayode OO, Musa OI, Nwigwe GC, Aboderin AO, Salami TAT, Taiwo SS. Nosocomial infections and the challenges of control in developing countries. African Journal of Clinical And Experimental Microbiology 2010; 11(2): 102-110. 6.   Mohiuddin M, Haq JA, Hoq MM, Huq F. Microbiology of nosocomial infection in  tertiary hospitals of Dhaka city and its impact. Bangladesh J Medical Microbiology 2010; 4: 32-38. 8.   Rahman MM, Haq JA, Hossain MA, Sultana R, Islam F, Islam AHMS. Prevalence of extended-spectrum- b lactamase-producing Escherichia coli and Klebsiella pneumoniae in an urban hospital in Dhaka, Bangladesh, International Journal of Antimicrobial Agents 2004; 24: 508-510. <![CDATA[Hyperglycemia, Young Age, Altered Sleep Habits: The Three Shifting Paradigms of Coronary Artery Disease Risk Stratification]]> Irtiza Hasan Tasnuva Rashid Iffat Tasnim Mir Masudur Rhaman https://imcjms.com/journal_full_text/52 2016-08-02 11:07:45 Original Article Ibrahim Med. Coll. J. 2012; 6(2): 39-45 The study was undertaken to estimate the risk factors age, gender, race, obesity (BMI), glycemic status (prediabetes, diabetes), exercise and psychosocial factors (sleep, sadness) related to coronary artery disease (CAD). The data set for this study is the National Health Interview Survey (NHIS), which is a large scale, cross sectional, voluntary, household interview survey maintaining data on health status, health care access and progress towards achieving the national health objectives in the USA. A total of 26,965 (male/female =55.8/ 44.2%) subjects were included in the study. Of them, 79.9% were less than 65 years of age. Regarding obesity, overweight, obese and morbid obese were 34.8, 17.3 and 11.0%, respectively. Sadness of any degree was reported in 28%. Sleep duration was found <5h/d in 8.7% and > 9h/d in 9.7%. Heart disease was reported in 4.9%. About 10% were reported to have diabetes and 4.1% prediabetes. 40% of the respondents’ maintained exercise once per week and only 12.8% maintained 10 or more times per week. Logistic regression estimated that compared with the non-diabetics, the subjects with prediabetes (OR 3.27, 95% CI, 2.32-4.59) and diabetes (OR 6.44 95% CI, 5.21-7.96) had excess risk of CAD, more significant in the younger subjects (<65y) than in the older (>65y). The risk of CAD was found significant in both prediabetes (OR 2.47, 95% CI, 1.44-4.23) and diabetes (OR 3.03, 95% CI, 2.16-4.24) as compared with non-diabetic group who slept >9h a day. The subjects with prediabetes or diabetes had excess risk for CAD compared with the non-diabetic subjects, which was more marked in the younger people. Again, compared with the non-diabetic people, the subjects with prediabetes or diabetes, having less sleep or excess sleep, had excess risk for CAD. Further study may confirm our findings. Introduction An increase in blood glucose may result in prediabetes and diabetes. According to the American Diabetic Association, prediabetes is a stage where the blood glucose level is higher than normal but not high enough to be diagnosed as diabetes and include impaired fasting glucose (IFG) and impaired glucose tolerance (IGT).6 It has been estimated that the global diabetes prevalence among adults over 19 years would be 6.4%, affecting 285 million adults in 2010, and might increase to 7.7% and 439 million adults by 2030. Between 2010 and 2030, there will be a 69% increase in numbers of adults with diabetes in developing countries and a 20% increase in developed countries.7 The increase in the incidence of prediabetes, diabetes and heart disease is increasing in the same fashion and same distribution.8 There are many known modifiable (eg. smoking, obesity, physical inactivity, hypertension, hyperglycemia, dyslipidemia) and non-modifiable (e.g. ageing, heredity / ethnicity) risk factors for developing atherosclerotic heart disease.8,9 Younger aged people with diabetes were found to have enhanced atherogenesis than their non-diabetic younger counterparts.10 Psychosocial stress, sleep disorders, mood disorders have also been found to have detrimental effect on coronary artery disease (CAD).11-14 This study aimed to measure the risk factors for CAD like age, gender, race, obesity (BMI), glycemic status (prediabetes, diabetes), exercise and psychosocial factors (sleep, sadness). Additionally, habit of smoking and excess sugar intake was also investigated as risk factor. Materials and Methods The NHIS data set of 2010 was used in our study.1 The inclusion criteria included all the adults of age 18 or more who were in any of the four racial groups as Hispanics, non-Hispanic White, non-Hispanic Blacks and non-Hispanic Asians. The exclusion criteria included those who could not be classified in either of the four race groups and who were less than 18 years of age. We initially merged the dataset for adult person and family questions from core questionnaire. The merged data set had 27,157 observations from which the non-Hispanic and all other racial groups were excluded (n=192) resulting 26,965 observations. Taking CAD as an outcome variable we included age, race, gender, race, obesity (BMI), exercise, and habit of smoking and added sugar consumption as the other risk variables (covariates). For a crude assessment of psychosocial risks sadness and sleep status were included as other covariates. Education was included as a surrogate social class.   A description of the baseline characteristic of the study population is provided in Table 1. The total sample size for the study was 26,965, of which 79.9% were less than 65 years of age with an average age of 47.8 years, with a slight female predominance (55.8% vs. 44.2% male) and 57.3% were non-Hispanic White. Regarding obesity, overweight, obese and morbid obese were 34.8%, 17.3% and 11.0%, respectively. Sadness of any degree was reported in 28%. Sleep duration was found lower than 5h/d in 8.7% and higher than 9h/d in 9.7%. Heart disease was reported in 4.9%. About 10% were reported to have diabetes and 4.1% prediabetes. 40% of the respondents used to maintain exercise for less than 1 time per week and only 12.8% maintained 10 or more times per week.Table-1. Study characteristics, National Health Interview Survey, 2010(1) (n=26,965) The measurement of association of risk variables with CAD are shown in Table 2. Compared with the younger subjects the elderly people had more risk (OR, 6.4; 95% CI, 5.7-7.2). Compared with the women the men had higher risk (OR, 1.7; 95% CI, 1.5-1.9). For other categorical variables, the risks of CAD were found significantly increasing with increasing obesity (BMI), hyperglycemia and sadness, and with decreasing exercise (Table 2). As regards race, compared with other groups, non-Hispanic whites had excess risk. Taking sleep duration of 6–8 h/d as normal and reference category, both lower (<5h/d) and higher (>9h/d) duration of sleep had more risk. An association was also found with smoking. Education level, marital status and added sugar intake were found to have no significant effect on CAD. Table-2. Study characteristics by Coronary Artery Disease (CAD), National Health Interview Survey, 2010(1) The unadjusted logistic regression model for unweighted data (Table 3) showed a significant positive association of CAD with prediabetes (OR 2.97, 95% CI, 2.39- 3.69) and with diabetes (OR 5.81, 95% CI, 5.13- 6.57). When adjusted for the possible confounders, those with prediabetes were 2 times more likely and those with diabetes were 3.2 times more likely to have coronary artery disease compared to non diabetics. When weighted data was used, although the adjusted association remained significant but there was a slight increase in odds ratio and narrowing of the confidence interval possibly because the data was weighted to a larger population. We need to use special statistical techniques to correct the confidence interval and standard error which is beyond the scope of this study. As the association more or less remained similar, so we would be using unweighted data for further analysis. Table-3. Crude and adjusted Odds Ratios for the Association between Diabetes and Prediabetes with Coronary Artery Disease(1) The risk of CAD related to prediabetes and diabetes according to age-groups and sleep duration was shown in Table 4. The analyses included “no diabetes” as a reference category, and adjusted for gender, race, sadness status, BMI, smoking status, education level, exercise status, added sugar consumption and marital status. Compared with the subjects having no diabetes, the subjects with prediabetes (OR 3.27, 95% CI, 2.32-4.59) and diabetes (OR 6.44, 95% CI, 5.21-7.96) were proved to have excess risk of CAD, which were strongly significant in the relatively younger subjects (<65y); whereas, for the elderly subjects (>65y), the prediabetes group showed no significant risk though it was somehow significant for the diabetes group. The subjects having diabetes and used to sleep <5h a day had significant risk for CAD as compared with the non-diabetic subjects having same duration of sleep. The risk of CAD was found significant in both prediabetes (OR 2.47, 95% CI, 1.44-4.23) and diabetes (OR 3.03, 95% CI, 2.16-4.24) as compared with non-diabetic group having sleep >9h a day.Table-4. Effect of Prediabetes and Diabetes on CAD by Age group and sleep abnormalities(1)   The study investigated some known risk factors (age, sex, race, obesity, diabetes, exercise and smoking) related to coronary artery disease (CAD). Other possible risk factors like mood disorders (sadness), altered sleep habits (lack or excess) and social status (education) were also estimated to relate CAD. As Stern pointed out that diabetes and cardiovascular diseases are very much interrelated,3 it is important to determine the quantity of association between diabetes and CAD. Thus, this study addressed important issues in quantifying some risk factors related to CAD. Altered sleep habits, either less (<5h/d) or excess (>9h/d), were found to have significant risk for developing CAD. This finding is important because either extreme of sleep abnormalities predict CAD. Other investigators also observed similar association of sleep abnormalities with hypertension, diabetes and CAD.12-14 So, our findings also indicate the importance of early detection and intervention of sleep habit changes. Further studies may be undertaken to relate sleep with CAD. The cross sectional nature of the dataset limits the study to measure association only and not temporality and causality. The self reporting of diabetes status and heart disease might provide erroneous information and result in misclassification and recall bias. The sensitivity and specificity of the data could have been increased if we had medical and laboratory report which is one of the many drawbacks of the data set. We could not take into consideration income, occupational status, stress factor, use of diabetic medications, and duration of diabetes either due to unavailability of variable or large number of missing data.   Hyperglycemia of any grade – mild, moderate or severe whether prediabetes or diabetes was proved to have significant risk for CAD. The diabetic subjects aged less than 65 years were more prone to develop CAD than their non-diabetic counterparts. Again, compared with the non-diabetic people, the subjects with prediabetes or diabetes, having less sleep or excess sleep, had excess risk for CAD. Further study may confirm our findings. Acknowledgment    1.   Schiller JS, Lucas JW, Ward BW, Peregoy JA. Summary health statistics for U.S. adults: National Health Interview Survey, 2010. National Center for Health Statistics. Vital Health Stat 2012; 10(252): 1-207. 3.   Stern M. Diabetes and cardiovascular disease. The “common soil” hypothesis. Diabetes1995; 44: 369-74. 5.   CDC. Heart Disease Facts, 2012; Available from: http://www.cdc.gov/heartdisease/facts.htm. 7.   Shaw J, Sicree R, Zimmet P. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes research and clinical practice 2010; 87: 4-14. 9.   Haffner SM. Pre-diabetes, insulin resistance, inflammation and CVD risk. Diabetes research and clinical practice 2003; 61: S9-S18. 11.Hancox RJ, Landhuis CE. Association between sleep duration and haemoglobin A1C in young adults.  J Epidemiol Community Health 2011. 13.Chao CY, Wu JS, Yang YC, Shih CC, Wang RH, Lu FH, et al. Sleep duration is a potential risk factor for newly diagnosed type 2 diabetes mellitus. Metabolism; 60: 799-804. 15.Grundy SM, Benjamin IJ, Burke GL, Chait A, Eckel RH, Howard BV, et al. Diabetes and cardiovascular disease: a statement for healthcare professionals from the American Heart Association. Circulation 1999; 100: 1134-46. 17.Deedwania PC, Fonseca VA. Diabetes, prediabetes, and cardiovascular risk: shifting the paradigm. The American journal of medicine 2005; 118: 939-47. 18.  Centers for Disease Control and Prevention. Racial/Ethnic and Socioeconomic Disparities in Multiple Risk Factors for Heart Disease and Stroke—United States, 2003. Morb Mortal Wkly Rep 2005; 54(5): 113–117. <![CDATA[Diagnosis of Tubercular Lymphadenitis by PCR of Fine Needle Aspirates]]> Masud Parvez Md. Mohiuddin Md. Zahid Hassan Farooque Ahmad J. Ashraful Haq https://imcjms.com/journal_full_text/53 2016-08-02 11:09:29 Original Article Ibrahim Med. Coll. J. 2012; 6(2): 46-49 A definitive and accurate diagnosis of tubercular lymphadenitis is important for its proper management. Fine needle aspiration cytology (FNAC) is an easy procedure for collection of material for cytopathological and bacteriological examination. But the detection rate of M. tuberculosis from the aspirated material is low with Ziehl-Neelson (Z-N) stain and even with culture. Polymerase chain reaction (PCR) is a rapid method for diagnosis of tuberculosis from various clinical samples. In the present study, PCR was employed for the detection of mycobacterial DNA sequences in fine needle aspirates of twenty cases of suspected tubercular lymphadenitis and compared with cytomorphological characteristics, Z-N stain and culture. Thermo stable multiplex PCR was used to detect Mycobacterium specific DNA. The rate of PCR positivity for mycobacterial DNA was 70% as compared to 50% and 60% by Z-N stain and culture respectively. Papanicolaou as well as Hematoxylin and Eosin (H&E) stains of fine needle aspirated (FNA) materials detected granulomatous lesions suggestive of tubercular infection in only 50% cases. FNAC with Type 3 cytomorphological pattern without presence of granuloma yielded highest positivity rate by PCR. PCR was found more sensitive technique to detect Mycobacterium in patient with tubercular lymphadenitis. Introduction Recently, the amplification of specific DNA sequences by polymerase chain reaction (PCR) is a novel tool for the detection of mycobacterial DNA sequences in several clinical sample materials.9,10 However, there have been few reports which have described the detection of mycobacterial DNA by PCR in FNAC materials. The present study investigated FNA samples from suspected tubercular lymphadenitis for the presence of mycobacterial DNA in aspirated materials having different cytological pattern and compared with Z-N stain and culture of M. tuberculosis. Materials and Methods This study was carried out in the Department of Pathology, Dhaka Medical College and Microbiology Department, BIRDEM Hospital over a period of six months (February to July 2007). Patients attending outpatient department of Dhaka Medical College Hospital with cervical and axillarylymphadenopathy suspected of tubercular lymphadenitis were included in the study. Sample collection and processing   The smears were grouped into three categories cytomorphologically as described earlier.12 The cytomorphological categories of lymph node aspirates were as follows: Type 2: Epithelioid granuloma with caseous necrosis. In addition to epithelioid cells, the smear contained clumps of amorphous debris or caseous necrotic material. Lymphocytes, Langhans giant cells and neutrophils may be found.   Extractions of DNA from lymph node aspirates: Lymph node aspirates were digested and decontaminated by NALC-sodium hydroxide method and pellets are used for DNA extraction. 100 micro liter of DNA extraction buffer (supplied with kits) was added to the pellet and it was vortexed briefly to mix. Then it was heated at 1000C for 10 minutes and vortexed briefly to mix. Then it was centrifuged at 12000g for 15 minutes. Fifty micro liter of supernatant was collected into a sterile micro centrifuge tube. Only five micro liters was used for PCR reaction. Procedure for PCR A commercial thermo stable multiplex PCR kit (EZTB PCR kit) designed to detect both the M. tuberculosis specific and mycobacterium genus specific DNA was used. The kit was obtained from MBDr, Biodiagnostic research Sdn Bhd, Malaysia. The kit contained thermo stable PCR reagents and primers specific for M. tuberculosis and Mycobacterium genus. Five pairs of primers were used. Two pairs of primer were for M. tuberculosis and two pairs for genus specific. One pair of primer was used for internal control. The targets for the primers and the corresponding size of the amplified products were as follows: IS6110 - 541bp, HSP65 -127bp, ISB9 - 383bp, DNAJ - 211bp. Fifteen micro liter of water (supplied) was added to each thermo stabilized PCR mix tube, left for ten minutes at room temperature and then vortexed briefly to ensure that the thermo stabilized PCR mix was well dissolved. Five micro liter of extracted DNA sample was added to the thermo stable PCR mix. Positive control was prepared by adding forty micro liter of water (supplied) and then it was left for 2 minutes at room temperature. The tube was vortexed to reconstitute. Then 5 µl was added to the thermo stable PCR mix. For negative control, 5 micro liter of water (supplied) was added to the thermo stable PCR mix. The tubes were placed in thermal cycler and PCR reaction was started by using PCR cycling condition for 32 cycles as per instruction by the manufactures. The amplified PCR product was detected by agarose gel electrophoresis. Results Based on the nature of the material aspirated and/ or cytomorphologic findings, the cases were categorized into three types (Table 1 and Fig 1). Out of 20 cases, 10 (50%) were Type III which showed suppurative features not consistent with typical granulomatous lesion of mycobacterial infection. The results of bacteriological examination of these cases are shown in Table 1. Direct smears for AFB and culture was positive in 10 (50%) and 12 (60%) cases respectively while the positivity rate was 70% by PCR. Culture positivity was found in a higher percentage of cases with type 1 and 2 smears as compared to Type 3. But AFB positivity in smears was lower in Type 1 and 2 compared to Type 3. PCR methods for mycobacterial DNA was highest in Type 3 which did not show typical granulomatous lesions.   Fig.1: H&E stain of FNA aspirated material showing different smear types: (a) Epithelioid granuloma without caseous necrosis pattern. FNA smear showing a granuloma consisting of epithelioid cells intermixed with lymphocyteswithout caseous necrosis (Type 1). (b) Caseous necrotic pattern - only fragmented amorphous eosinophilic tissue debris is present (Type 2). (c) Necrotic pattern - note the numerous polymorphs and the absence of epithelioid granuloma (Type 3) All of the AFB and culture positive cases were also positive by PCR (Table-2). But it is important to note that out of 10 AFB negative cases 4 became positive by PCR. Similarly, out of 8 culture negative cases 2 were positive by PCR. Out of 14 positive cases, 3 were Mycobacterium other than tuberculosis (MOTT) as detected by culture and PCR.Table-1: Results of cytomorphological types, Z-N stain, L-J culture and PCR of twenty FNA aspirated material from suspected lymphadenitis cases  Table-2: Correlation of PCR results with Z-N and culture methods for the detection of Mycobacterium   In this study, H&N stain of the FNA aspirated materials from lymphadenitis cases showed typical granuloma with caseation necrosis or necrotic materials in 50% cases (Type 1 and 2) indicative of tubercular infections. The remaining 50% cases revealed no granuloma but only necrosis (smear type 3) suggestive of pyogenic suppurative infections which were cytologically not considered of mycobacterial infections. But Prasad et al (1996) reported the sensitivity and specificity of cytological examination of FNA materials as 83.3% and 94.3%, respectively for tubercular infection.13 Epithelioid granulomas with or without necrosis are usually considered as the hallmark of tubercular infection and presence of polymorphs are uncommon findings as seen in Type 3 lesions. But the ZN stain, culture and PCR proved that the lesions without typical granulomatous features might be due to mycobacterial infection. Therefore, the absences of granulomas in FNA material do not exclude tuberculosis. Similarly, FNA materials yielding pus do not indicate mere pyogenic infections. Of the three methods used for detection of mycobacterial infection, PCR was found as the most sensitive technique; however it did not differentiate between live or dead tubercular bacilli. Compared to PCR, the rate of detection of bacilli by Z-N stain is between 25-45%.7 It is because of the fact that at least 1x104 organisms/ml had to be present in the sample for the Z-N smear to be positive.14 If the number is less than this, the bacilli may not be detected in the smears. On the other hand, only two organisms are enough to detect successfully with PCR amplification.9,15 It may also be mentioned that PCR method is able to detect Mycobacterium other than tuberculosis (MOTT) rapidly in clinical samples.   1.   World Health Organization. Global Tuberculosis Control: Surveillance, Planning, Financing. WHO Report 2002. Geneva: World Health Organization. 3.   Appling D & Miller RH. Mycobacterium cervical lymphadenopathy: 1981 update. Laryngoscope, 1991; 1259–1266. 5.   Karim MM, Chowdhury SA, Hussain MM, Faiz AM. A clinical study on extrapulmonary tuberculosis. Journal of Bangladesh College of Physicians And Surgeons 2006; 24(1): 19-28. 7.   Gupta SK, Chugh TD, Sheikh ZA, al-Rubah NA. Cytodiagnosis of tuberculous lymphadenitis. A correlative study with microbiologic examination. Acta Cytol 1993; 37(3): 329-32. 9.   Plikaytis BB, Eisenach KD, Crawford JT, Shinnick TM. Differentiation of Mycobacterium tuberculosis and Mycobacterium bovis BCG by a polymerase chain reaction assay. Mol Cell Probes1991; 5: 215-9. 11.Kubica GP. Clinical Microbiology 1984. New York and Basel: Marcell Dekker Inc. 13.Prasad RR, Narasimhan R, Sankaran V, Veliath AJ. Fine needle aspiration cytology in the diagnosis of superficial lymphadenopathy, an analysis of 2418 cases. Diagnostic Cytopathology 1996; 15(5): 382-6. <![CDATA[Relationship Between Substance Abuse and Multidrug-Resistant Tuberculosis]]> Sadya Afroz Meerjady Sabrina Flora https://imcjms.com/journal_full_text/54 2016-08-02 11:11:46 Original Article Ibrahim Med. Coll. J. 2012; 6(2): 50-54 This case control study was conducted between January to June 2010 to determine the relationship between substance abuse and multidrug- resistant tuberculosis. A total of 73 cases were selected purposively, from culture- positive multidrug- resistant tuberculosis patients admitted in the National Institute of Diseases of the Chest and Hospital, Dhaka and compared with 81 un-matched controls, recruited from the cured patients of pulmonary tuberculosis who attended several DOTS centers of ‘Nagar Shastho Kendra’ under Urban Primary Health Care Project in Dhaka city. Data were collected by face to face interview and documents’ review, using a pre- tested structured questionnaire and a checklist. Multidrug- resistance was found to be associated with smoking status (χ2 = 11.76; p = 0.01) and panmasala use (χ2 = 8.28; p = 0.004). The study also revealed that alcohol consumption and other substance abuse such as jarda, sadapata, gul, snuff, heroine, cannabis, injectable drugs was not associated with the development of multidrug- resistant tuberculosis. Relationship between substance abuse and multidrug- resistant tuberculosis are more or less similar in the developing countries. Bangladesh is not out of this trend. The present study revealed the same fact, which warrants actions targeting specific factors. Further study is recommended to assess the magnitude and these factors related to the development of multidrug- resistant tuberculosis in different settings in our country. Introduction Estimates suggest that daily about 880 new TB cases and 176 TB deaths occur in the country.4 In Bangladesh the number of MDR-TB cases is increasing gradually despite the government’s success in TB treatment by 92% and the detection rate of 72% in 2007. From July 2007 to Feb 2008, 165 cases of MDR-TB were detected in the National Institute of Diseases of Chest and Hospital (NIDCH).5 According to the WHO report 2008, the MDR-TB rate in Bangladesh is estimated at 3.6% and 19% among new and previously treated TB cases, respectively.4 In such a situation, the emerging drug resistance in Bangladesh needs further exploration.6 Those factors are required to be assessed, evaluated and weighted in terms of their role in increasing the risk of MDR-TB in our perspective. In order to adopt and implement the strategies and changes that may be necessary at present or in future, to combat this deadly form of TB, accurate and comprehensive information regarding its development, is a prime requirement.   Material and Methods   Results The respondents were asked about their habits of smoking and other smokeless tobacco. Among the cases 24.7% were past smokers which was higher than the controls (19.8%; p = 0.01). Cases and controls were further stratified by their gender to find the smoking data precisely. Among the male cases 54.8% were past smokers whereas it was 39% among the controls (p = 0.02). There was no difference in number of cigarettes smoked per day or proportion of heavy/moderate smokers, even when it stratified by gender. Odds ratio showed that the past smokers were 1.02 times more likely to develop MDR- TB in reference to those who never smoked. Table-1: Smoking status of the cases and controls   The respondents were asked about their history of other smokeless tobacco use. Some of them answered ‘no’ and some of them answered either regular or occasional history of tobacco use. The regular/ occasional users were recorded as ‘yes’. Other substance abuse     Discussion Statistically smoking status was found to be significant for the development of MDR- TB (p = 0.02). A study in Russia reveals that for isoniazid and rifampicin resistance male sex, smoking is the significant risk factor.15 In a Pakistani study smoking shows an association with MDR- TB.9 Among the smokeless tobaccos only panmasala found to be statistically significant (p =0.004) in this study. Alcohol consumption was not associated with the development of MDR-TB although a number of studies showed association.9,17,18 This study did not found any association of MDR- TB with drug abuse as heroine, cannabis. Overall substance abuse was less common in this study sample. A similar study in Iran showed no significant difference incase of MDR-TB groups in terms of drug abuse (p = 0.63).11   The study revealed that, smoking status and panmasala use of the TB patients were significantly associated with the development of multidrug- resistance. Alcoholism and other drug abuse had no association to develop MDR- TB. Relationship between substance abuse and multidrug- resistant tuberculosis are more or less similar in the developing countries. Bangladesh is not out of this trend. The present study supports the same fact, which warrants actions targeting specific factors.   This study was supported by a grant from National Tuberculosis Control Programme (NTP).   1.   Lee SW, Jeon K, Min KH. Multidrug-resistant Pulmonary Tuberculosis Among Young Korean Soldiers in a Communal Setting. Journal of Korean Medical Science 2009; 24; 592-5. 3.   Zager EM, McNerney R. Multidrug-resistant tuberculosis. BMC Infectious Diseases 2008; doi: 10.1186/1471-2334/8/10. 5.   Amin MN, Rahman MA, Flora MS, Azad MAK. Factors associated with multidrug-resistant tuberculosis. Ibrahim Medical College Journal 2009; 3(1): 29-33. 7.   Parvaneh Baghaei, Payam Tabarsi, Ehsan Chitsaz et al. Risk Factors Associated with Multidrug- Resistant Tuberculosis. National Research Institute of Tuberculosis and Lung Disease, Iran. Tanaffos (2009); 8(3): 17- 21. 9.   Franke MF, Appleton SC, Bayona J, Arteaga F, Palacios E, Liaro K. et al. Risk Factors and Mortality Associated with Default from Multidrug- Resistant Tuberculosis Treatment. Clinical Infectious Diseases 2008; 15: 1844-1851. 11.Suarez GI, Rosriquez BA, Vidal- Perez JL Garcia-Viejo MA, Jaras- Hernandez MJ, Lopez O et al. Risk factors for multidrug – resistant tuberculosis in a tuberculosis unit in Madrid, Spain. European Journal of Clinical Microbial Infectious Diseases 2009; 28(4): 325-30. 13.Piryani Rano Mal, Rizvi Nadeem. Presentation of Pulmonary Tuberculosis in Cannabis or/ and Opiates Drugs Abusers. SAARC Journal of Tuberculosis, Lung Diseases and HIV/ AIDS 2006; 3(1): 26-55. 15.Ruddy M, Balabanova Y, Graham C, Fedorin I, Malomanova N, Elisarova E. et al. Rates of drug resistance and risk factor analysis in civilian and prison patients with tuberculosis in Samara Region, Russia.; 60: 130- 135. doi: 10.1136/ thx. 2004. 026922. 17.Espinal MA, Laserson K, Camacho M, Fusheng Z, Kim SJ, Tlali E. et al. determinants of drug- resistant tuberculosis: analysis of 11 countries. International Journal of Tuberculosis and Lung Diseases 2001; 5(10): 887-893. 18.  Anunnatsir S, Chetchotisakd P, Wanke C. Factors Associated with Treatment outcomes in Pulmonary Tuberculosis in Northeastern Thailand. South East Asian Journal of Tropical Medicine and Public Health 2005; 36(2): 324-330. <![CDATA[Anti-hyperlipidemic action of Zingiber officinale (Ginger) juice in alloxan induced diabetic rats]]> Selima Sultana Shakil Akter Md. Ismail Khan https://imcjms.com/journal_full_text/224 2017-06-04 12:47:33 Original Article Ibrahim Med. Coll. J. 2012; 6(2): 55-58 Hyperlipidemia is an important modifiable risk factor contributing to atterosclerosis in diabetes mellitus. Zingiber officinale (ginger) widely consumed as spice is known for its hypoglycemic and hypochlosteremic actions. The present study was undertaken to investigate anti-hyperlipidemic action of ginger juice in alloxan-induced diabetic rats. Male Wister rats, 130-150 g wt, fed on standard diet and water ad libitum were divided into 4 groups (n=6 in each group): group I non-diabetic control, group II non-diabetic treated; group III diabetic control and group IV diabetic treated. Diabetes was induced by Inj. alloxan 150 mg Kg–1 b.w., i.p. (group III & IV) on Day 2. Rats having blood glucose level of >7 mmol/l on day 5 (72 hrs after alloxan Inj.) were considered diabetic and selected for experimentation. Both non-diabetic and diabetic treated groups (Gr II & IV) received Zingiber officinale (ginger) juice (4 ml Kg–1 b.w., p.o.) for 10 days (day 2-day 11) through Ryles tube. On Day 12, animals were sacrificed under light ether anaesthesia, blood was collected by cardiac puncture and serum separated for estimation of lipids. The results suggest a significant anti-hyperlipidemic action of Zingiber officinale (ginger) juice in alloxan induced diabetic rats. The findings may be clinically significant and exploited. Address for Correspondence: Dr. Selima Sultana, Assistant Professor, Department of Pharmacology & Therapeutics, Ad-din Women’s Medical College, 2 Bara Magbazar, Dhaka-1217, e-mail: ark_udd@yahoo.com   Cardiovascular diseases (coronary artery diseases, strokes and peripheral vascular diseases) constitute the major causes of morbidity and mortality in diabetes mellitus. Diabetic individuals have 2-4 times increased risk of clinical atherosclerotic diseases.1 Hyperlipidemia is one of the most important modifiable risk factors contributing to atherosclerosis in diabetes and may be the result of unbalanced metabolic status of diabetes namely hyperlipidemia and insulin resistance.2 The present study was undertaken to investigate the effect of fresh ginger juice on lipid profile (hyperlipidemia) in alloxan induced diabetic rats compared to non-diabetic controls. Materials and Methods   The fresh rhizome of Z. officinale (ginger) was obtained from local market. 1 Kg of fresh rhizome were crushed, then squeezed in muslin cloth to obtain the juice using the method of Akhain et al.4 Sodium benzoate (0.5%) was added as preservative. The juice was stored in the refrigerator at 2-80C in a well-closed glass container. Animals   After 24 hrs fasting, rats (group III & IV) were injected alloxan 150 mg Kg–1 b.w.ip on Day 2 of the study. Fasting blood glucose levels were estimated on Day 1 (before Inj. alloxan), on Day 5 (72 hrs after Inj. alloxan) and on Day 12 of the experimental study. Blood glucose was estimated by placing a test strip in the glucometer (ACCU-CHEK, Roche diagnostic GmbH). A drop of blood was collected by asceptically cutting the tail at the tip (0.1 cm) with shrap sterile blade and then applying the drop of blood to the test area of the strip. Rats with blood glucose of >7 mmol/l on Day 5 (i.e 72 hrs after Inj. alloxan) were considered diabetic and selected for experimentation. Experimental design   The results are presented as mean±SD. Unpaired ‘t’ test was performed and p value <0.05 was considered as statistically significant. Results i.   The mean±SD of blood glucose (mmol/l), in normal (non-diabetic) rats (group I) on day 2 and day 12 of the study were 5.40±0.76 and 5.45±0.76 respectively, while in normal (non-diabetic) treated (ginger juice 4 ml Kg–1 b.w. for 10 days) rats (group II) were 5.45±0.76 and 5.47±0.59 respectively. The differences between two group (I vs II) were not statistically significant (p <0.05) suggesting that ginger juice did not lower blood glucose level in normal (non-diabetic) rats. iii.The mean±SD of blood glucose (mmol/l), of diabetic control rats (group III) and of diabetic treated (ginger juice 4 ml Kg–1 b.w. for 10 days) rats (group IV) on day 12 of the study were 8.52±0.68 and 7.52±0.42 respectively. The differences between two groups (III vs IV) were statistically significant (p <0.01) suggesting that treatment of diabetic rats with ginger juice produced significant decrease in blood glucose level. Table-1: Effects of Zingiber officinale (ginger) juice on lipid profile in normal (non-diabetic) rats   i.   Effect of Zingiber officinale (ginger) juice on lipid profile in normal (non-diabetic) rats ii.  Effect of Zingiber officinale (ginger) juice on lipid profile in diabetic rats      The results are shown in Table-2. Table-2: Effect of Zingiber officinale (ginger) juice on lipid profile in diabetic rats   The present study was undertaken to investigate the effects of Zingiber officinale (ginger) juice on lipid profile in alloxan induced diabetic rats compared to normal non-diabetic controls. Injection of alloxan   (150 mg Kg–1 b.w,i.p) produced marked hyperglycemia and hyperlipidemia (increased Tol. chol, LDL-chol & TG and decreased HDL-chol). Treatment with Zingiber officinale (ginger) juice (4 ml Kg–1 b.w, p.o) for 10 days to alloxan induced diabetic rats produced significant blood glucose and lipid lowering (decreased Tol. chol, LDL-chol & TG and increased HDL-chol) effects. However treatment of ginger juice for 10 days to normal non-diabetic rats did not produce significant lipid lowering effects; thus suggesting a significant anti-hyperlipidemic action for Zingiber officinale (ginger) juice in alloxan induced diabetic rats. The results are in agreement with those of previous studies2,5,6,8 who showed similar lipid lowering effects of Z. officinale in different experimental animal models.   1.   Nathan DM, Meigs J, Singer DE. The epidemiology of cardiovascular disease in type 2 diabetes mellitus. Lancet 1997; 350(1): SI4-9. 3.   Bhandari U, Grover JK. Effect of ethanolic extract of ginger on hyperglycemic rats. Int. J. Diabetes 1998; 6: 95-96. 5.   Fuhrman B, Rosenblat M, Hayek T, Coleman R, Aviram M. Z. officinale extract consumption reduces plasma cholesterol, inhibits LDL oxidation and attenutes development of atherosclesosis in atheroscherotic, apolipoprotein E-deficient mice. J. Nutr 2000; 130: 1124-1131. 7.   Park KK, Chun KS, Lee JM, Lee SS, Surh YJ. Inhibitory effects of 6-gngerol, a major pungent principle of ginger on phorhol ester-induced inflammation, epidermal ornithine decarboxylase activity and skin tumor promotion in ICR mice. Cancer Letters 1998; 129: 139-144. 9.   Katiyar SK, Agarwal R, Mukhtae H. Inhibition of tumor promotion in SENCAR mouse skin by ethanol extract of Zingiber officinale rhizome. Cancer Research 1996; 56: 1023-1030. <![CDATA[Cirrhosis of liver and diabetes mellitus]]> Smita Debsarma Md. Ziaul Islam https://imcjms.com/journal_full_text/225 2017-06-04 13:14:26 Original Article Ibrahim Med. Coll. J. 2012; 6(2): 59-63 Diabetes mellitus is being recognized as a serious global health problem and frequently associated with cirrhosis of liver. The cross-sectional comparative study was conducted among 83 diabetic cirrhotic patients admitted in Gastrointestinal Hepatobilliary and Pancreatic Disorders Department of Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic disorders and 83 non-diabetic cirrhotic patients admitted in Gastroenterology and Hepatology Department of Bangabandhu Sheikh Mujibar Medical University, Dhaka to assess the relationship between cirrhosis of liver and diabetes mellitus. The study was carried out during the period of January to June, 2010 and data were collected through face to face interview and reviewing medical documents by using a semi-structured questionnaire and checklist. Male, Muslims and illiterate were predominant in both diabetic and non-diabetic cirrhotic patients. It was found that non-viral cirrhosis was much higher in older age group (51-60years) than in younger age group (41-50years) in comparison to viral cirrhosis and this difference was found statistically significant [χ2(3)=20.97, p<0.001]. Association of non-viral cirrhosis was found with hyperglycemia [χ2(1)=15.65, p<0.001], poor glycaemic control [χ2(1)= 9.86, p<0.01] and longer duration of diabetes [χ2(2) =9.51, p<0.01]. Non-viral cirrhosis was significantly higher (28.3%) among the diabetic patients than the non-diabetic patients who suffered more (28.3%) from viral [χ2(1)=41.36, p<.001]. The study recommends for glycemic control by leading disciplined life and taking apposite therapy for prevention of non-viral cirrhosis among diabetic patients. Address for Correspondence:Dr. Smita Debsarma, Lecturer, Department of Community Medicine, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbagh, Dhaka 1000   The increasing prevalence of non-communicable diseases is a serious challenge, where the success in extending life expectancy is translated into a real threat to global health.1 Non-communicable diseases are responsible for 60% of all deaths, 80% of these deaths are in low- and middle-income countries.2 In 2000, Bangladesh had 3.2 million people with diabetes and was listed at 10, which will occupy the 7th position with 11.1 million in 2030.3 The prevalence of type 2 diabetes observed in Bangladesh was 5.2 (rural 4.3%, urban 6.9%) at 1994-5 and 11.2% (urban) and 6.8% (rural) at 2003-4.4 Prevalence of diabetes is just double in urban areas due to unplanned urbanization and change in lifestyle.5 Nonalcoholic steatohepatitis (NASH) is an under-recognized cause of cryptogenic cirrhosis (CC) on the basis of higher prevalence of obesity and type II diabetes.10 NAFLD is observed principally in developed countries where sedentary lifestyle and high calorie, sugar, and fat diets lead to DM2 and obesity. Individuals with type-2 diabetes have a high (70.0%) prevalence of NAFLD, and seem to have an increased severity of disease. Prevalence of NAFLD is higher (20.0%) than that of NASH (3.0%) in developed countries and prevalence of each is presumably much higher among obese and diabetic persons because 55.0% of patients with NASH have DM2 and 95.0% are obese.11   The cross-sectional comparative study was conducted among 83 diabetic cirrhotic patients and 83 non-diabetic cirrhotic patients who were admitted in Bangladesh Institute of Research and Rehabilitation in Diabetes and Hepatology Department of Bangabandhu Sheikh Mujibar Medical University, Dhaka respectively. The study was carried out over the period of 6 months from January to June 2010. Both diabetic and non-diabetic cirrhotic patients were included conveniently irrespective of age and sex and obtaining informed written consent. Viral and non-viral cirrhotic patients were diagnosed by viral markers and USG of whole abdomen. HbA1C, fasting blood glucose and 2 hrs after breakfast were done to see glycemic control and blood glucose level of the diabetes patients.   Mean age for diabetic patients was 56.93 (±11.68) years while mean age for the non-diabetic patients was 46.19 (±13.85) years. Among diabetic patients, majority were in the older age group (51-60 years) while majority of the non-diabetic patients were in the productive age group (<40years). Male, Muslim and married were predominant in both the groups. [Table-1] Table-1: Socio-demographic variables between diabetic and non-diabetic patients     Mean age for developing viral cirrhosis was lower (48.75 ±13.01 years) than the mean age for developing non-viral cirrhosis (57.24±13.89 years). Majority (32.4%) of the cirrhotic patients of viral origin were in the age group of 41-50 years while majority (41.8%) of the cirrhotic patients of non-viral origin were in the age group of 51-60 years and this difference was found statistically significant [χ2(3)=20.97, p<.001]. Both viral and non-viral cirrhosis were significantly higher among married patients [χ2 (1) =7.133, p<.05]. Though both viral (66.7%) and non-viral (61.8%)cirrhosis were predominant among the males than their counterpart females but this sex differential was not statistically significant [χ2(1)=0.38, p=0.54]. Non-viral cirrhosis was significantly higher among the patients with hyperglycemia (76.6%) [χ2(1)=15.65, p<.001], poor glycaemic control (59.6%) [χ2(1)= 9.86, p<.01] and longer duration of diabetes (83.0%) [χ2(2)=9.51, p<.01]. [Table-4] Among the diabetics, majority (28.3%) patients had non-viral cirrhosis while 21.7% had viral cirrhosis while majority (45.2%) of the non-diabetes patients had viral cirrhosis and only 4.8% had non-viral cirrhosis and this difference was statistically significant [χ2(1)=41.36, p< .001]. Table-3: Distribution of socio-demographic variables by cirrhosis of liver   Table-5: Relationship between diabetes mellitus and cirrhosis of liver   The cross sectional comparative study was aimed to assess the relationship between cirrhosis of liver and diabetes mellitus and to find out the underlying causes of cirrhosis of liver among 83 diabetes and 83 non-diabetes patients. The current study estimated 51.2% HBV and 15.7% HCV infections among diabetes patients. Previously reported by Pazhanivel M and Jayanthi V diverse findings where HBV infection was18.38% and HCV infection was 6.01% among DM patients.15 This variation may be due to unawareness and transfusion of unscreened blood and blood products in our country. It was also found that majority (28.3%) diabetes patients had non-viral cirrhosis while majority (45.2%) of the non-diabetes patients had viral cirrhosis and this difference was found statistically significant [χ2(1)=41.36, p<.001]. But the study conducted by Amarapurkar D found majority of both diabetic (34.9%) and non-diabetic (28.2%) had non-viral cirrhosis.16 Conclusion   References 2.   Preventing chronic diseases; A vital Investment. WHO 2010. Available from: http://www.who.int/chp/chronic_disease_report/overview. 4.   Mahtab H, Latif ZA, Pathan F. Diabetes Mellitus- a handbook for professionals. Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) 2007; 4: 24-29. 6.   Cirrhosis of Liver, 2010. Available from: http://www.digestive.niddk.nih.gov/ddiseases/pubs/cirrhosis. 8.   Ingrid J. Hickman, Graeme A. Macdonald. Impact of Diabetes on the Severity of Liver Disease. The American Journal of Medicine 2007; 120: 829-834. 10.Poonawala A, Nair SP, Thuluvath PJ. Prevalence of obesity and diabetes in patients with cryptogenic cirrhosis: A case control study. Hepatology 2000; 32(4): 689-692. 12.World Health Organization. Issues and challenges in the prevention and control of Non-communicable diseases in South East Asia Region. WHO regional office South East Asia, Delhi, India, 2009. 14.Bangladesh Bureau of Statistics. Statistical Pocket book of Bangladesh 2008. Dhaka: Planning Division, Ministry of Planning, Government of the People’s Republic of Bangladesh 2009; 2, 6,10, 38. 16.Amarapurkar D, Das HS. Chronic liver disease in diabetes mellitus. Trop Gastroenterol 2002; 23(1): 3-5. <![CDATA[Virilization in a Girl with Adrenocortical Adenoma: A Case Report]]> Tahniyah Haq S M Ashrafuzzaman Zafar A Latif https://imcjms.com/journal_full_text/55 2016-08-02 11:14:14 Clinical Case Report Ibrahim Med. Coll. J. 2012; 6(2): 70-72 We present a case of Cushing’s syndrome and virilization in a 15 year old girl which was suspected to be due to an adrenal carcinoma. She presented with features of virilization in addition to those of hypercortisilism. Her high androgen levels especially dehydroepiandrosterone sulfate (DHEAS) were also in favor of an adrenal carcinoma. An unenhanced computerized tomography (CT) scan showed a mass (size: 5.3 cm) in the right adrenal gland with a soft tissue intensity of more than 10 HU which was suggestive of adrenal carcinoma. But, histopathology of the resected mass revealed a benign adrenocortical adenoma. Address for Correspondence: Dr. Tahniyah Haq, Department of Endocrinology, BIRDEM, 122 Kazi Nazrul Islam Avenue, Dhaka 1000, Bangladesh, E mail: tahniyahhaq@yahoo.com   A few cases of adrenal adenoma have been reported with features of virilization.1,2 As far as we know, previously no cases of virilizing adrenal adenoma have been reported in Bangladesh. We describe here a case of adrenal adenoma in a young Bangladeshi girl with features of virilization and a high androgen level. Case presentation On physical examination, she was noticed to have a round plethoric face with moderate acne and hirsutism. The Ferriman-Gallway score for hirsutism was 1 for upper lip, 4 for chin, 4 for trunk and limbs. There were purple striae over her axillae, abdomen and thigh (Figure 1a). Acanthosis nigricans was present over the axillae. Tanner stage was V for breast and IV for pubic hair. She had clitoromegaly (Figure 1b). No lump was palpable on abdominal examination, but there was tenderness over the right lumbar area. Her blood sugar fasting and after 75g of glucose meal was 5.7mmole/L and 10.5mmole/L respectively. Serum sodium level was 146mmole/L and S. potassium was 3.6mmole/L. All other biochemical and haematological parameters were unremarkable. Chest X-ray and ECG were normal. On March, 2011 endocrine evaluation showed a luteinizing hormone level of 0.64 mIU/ml (normal: 1.1-11.6 mIU/ml), FSH was 0.36mIU/L (2.8-11.3 mIU/ml). Her androgen levels were extremely elevated. Testosterone was 17.05nmol/L (0.89-4.22), dehydroepiandrosterone sulfate (DHEAS) was 458 µgm/dL (35-430). ). After 4 months, testosterone level rose even higher to 43.90nmol/L. 17-OH progesterone level was normal (3.92ng/ml). Serum cortisol at 9am was 1303.80nmole/L (116-1065) and at 5pm 1656nmole/L. Twenty four hour urinary cortisol was high (1937.52 nmole/L). Overnight dexamethasone suppression test was done. Next morning cortisol was 1139.84nmole/L. ACTH level was 33.8pg/ml (8.3-57.8). Patient was euthyroid as the FT4 and TSH levels were 10.94pmole/L and 0.91IU/ml respectively. An ultra sonogram (USG) of the whole abdomen did not reveal any abnormality. A repeat USG of abdomen 6 months later detected a hypoechoic mass measuring 5cm × 3.9cm in the right adrenal gland. Left adrenal gland and ovary were normal in appearance. The mass was evaluated further with a computerized tomography (CT) imaging. CT findings showed an oval shaped well circumscribed soft tissue density (HU 46) mass lesion measuring about 5.3cm × 4.7cm in the right suprarenal area (Figure 1c). After intravenous contrast there was minimum enhancement (HU 51). Flat plane around mass was well preserved. No perilesional structural involvement was seen. Left adrenal gland was normal.   Fig.1a: Wide, purple striae over lower abdomen, 1b: Clitoromegaly, 1c: Contrast CT showing an oval shaped well circumscribed soft tissue density (HU 51) mass measuring about 5.3cm × 4.7cm in the right suprarenal area with minimum contrast enhancement. 1d: H&E staining of resected tumor showing polygonal cells having round to oval nuclei and abundant eosinophilic cytoplasm. The case was diagnosed as adrenal carcinoma based on high androgen levels especially DHEAS and the presence of a mass (5.3 × 4.7cm) in the right adrenal gland having a soft tissue density of 46HU. Following surgery, menstruation started on the first postoperative day. Blood pressure came down to normal and anti-hypertensives drugs were stopped from the first postoperative day. The cushingoid features and hirtutism resolved over 6 months following surgery. The patient was maintained on steroids which was planned to be gradually withdrawn over months. Discussion Our patient presented with features of virilization such as hirsutism and clitoromegaly. She had markedly increased levels of DHEAS and unenhanced CT scan showed a 5.3 cm mass with an intensity of 46 HU (i.e. more than 10 HU). All these features suggested an adrenal carcinoma. However, histopathology later proved the tumor to be of benign nature. Therefore, the final diagnosis was adrenocortical adenoma.   1.   Dahms T W, Gray G, Vrana M, New M I.  A case presenting as Cushing syndrome with virilization. Am J Dis Child 1973; 125: 608-611. <![CDATA[A rare case of intra-osseous meningioma of the sphenoid bone – a case report]]> Mahfuz Ara Ferdousi Md. Mofazzal Sharif Hijbul Bahar A.S. Mohiuddin ATM Mosharef Hossain Sultana Gulshana Banu https://imcjms.com/journal_full_text/227 2017-06-05 09:14:05 Clinical Case Report Ibrahim Med. Coll. J. 2012; 6(2): 73-75 A 42-year-old female patient presented with loss of vision and proptosis of her right eye. Computerized tomography (CT) scan revealed hyperostotic lesion involving the right sphenoid ridge, anterior clinoid process and roof and lateral wall of orbit with mass effect on the intraorbital contents. CT findings were suggestive of intra-osseous meningioma arising from right sphenoid bone. Later, MRI of the brain and orbit and histopathology of the lesion confirmed the case as an intra-osseous meningioma of the sphenoid bone. Though meningioma of tuberculum sella and primary calvarial meningioma were reported earlier, intraosseous meningioma of the sphenoid bone is rare. Address for Correspondence:Dr. Mahfuz Ara Ferdousi, Associate Professor, Radiology and Imaging, BSMMU, and Department of Radiology and Imaging, BIRDEM   Meningioma of tuberculum sella and primary calvarial meningioma were reported in Bangladesh. But, no case of intra-osseus meningioma of sphenoid bone was reported earlier in our country. Here, a rare case of intra-osseus meningioma of sphenoid wing in a female is described which was initially suspected by CT scan of the brain and orbit. Case Report The patient underwent resection of the mass, optic nerve decompression and tumor debulking with subsequent orbital reconstruction. Histopathological examination of the resected grayish white mass showed the presence of plump oval to elongated cells arranged in whorls and syncytial pattern. Some of these cells had intranuclear inclusions. The cells were infiltrating in between the bony trabeculae. Not much atypia or mitoses were seen. Histopathological diagnosis was an intraosseus meningioma (WHO grade1).     Fig-2. MR image in T1 (contrast) weighted sequence showing irregular frank expansion and deformity of right sphenoidal wing suggesting possibilities of intraosseus meningioma, bony neoplasm or polyosteotic fibrous dysplasia. Discussion Frontoparietal and orbital regions are the most common locations of intra-osseous meningiomas.7 All reported intraosseous meningiomas have been in the cranial bones.8 Extraneuraxial meningiomas can involve orbit, paranasal sinuses and nasopharynx. The symptoms of intra-osseous meningioma are mostly due to the compression of the surrounding structures as seen in our case. Dural involvement may cause pain.   1.   Buetow MP, Buetow PC, Smirniotopoulos JG. Typical, atypical, and misleading features in meningioma. Radiographics, 1997; 11(6): 1087-106. 3.   Longstreth WT, Jr., Dennis LK, McGuire VM, Drangsholt MT, Koepsell TD. Epidemiology of intracranial meningioma. Cancer 1993; 72: 639-648. 5.   Tokgoz N, Oner YA, Kaymaz M, Ucar M, Yilmaz G, Tali TE. Primary intraosseous meningioma: CT and MRI appearance. Am J. Neuroradiology 2005; 26: 2053-2056. 7.   Agrawal V, Ludwig N, Agrawal A, Bulsara KR. Intraosseous intracranial meningioma. Am J. Neuroradiology 2007; 28: 314-315. 9.   Harris WH, Dudley HR, Barry RJ. The natural history of fibrous dysplasia. An orthopaedic, pathological, and roentgenographic study. J Bone Joint Surg Am 1962; 44: 207-233. 11.Rahman L, Karmakar P. Giant meningioma of parieto-occipital lobe of brain–A case report. The Journal of Teachers Association 2003; 16(1): 30-31. 12.  Talha KA, Khan SH, Islam MT et al. A case of primary calvarial meningioma- A relative rare histologic subtype, Nepal J of Neuroscience 2009; 6: 68-71. <![CDATA[Post vaccination myelitis in a young woman following administration of rabies chick embryo cell vaccine – a case report]]> Shapur Ikhtaire M A Faiz https://imcjms.com/journal_full_text/228 2017-06-05 09:20:32 Clinical Case Report Ibrahim Med. Coll. J. 2012; 6(2): 76-77 A case of post-vaccination myelitis following administration of chick embryo cell rabies vaccine in a 20 year-old young lady is described. The case presented with paraplegia five days after receiving the third dose (on 12th day) of the vaccine for rabies. Myelitis was confirmed by signal changes on magnetic resonance imaging (MRI). She improved considerably on steroids treatment. This is the first case of myelitis following rabies chick embryo cell vaccination in Bangladesh. Address for Correspondence: Dr. Shapur Ikhtaire, Medical Officer, Department of Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU). Email: ikhtaireshapur@yahoo.com   There have been reports of neuroparalytic complications following nerve tissue anti-rabies vaccination.1,2 Also, a case of myelitis occurring after administration of rabies duck embryo vaccine has been reported.3 Here, a case of myelitis in a young Bangladeshi woman following rabies chick embryo cell vaccination is described. Case presentation Treatment was started with high dose intravenous steroids consisting of 1gm methyl prednisolone daily for 3 days. This was followed by oral prednisolone at a dose of 40mg daily for 1 month with gradual tapering. Retention was initially relieved by urinary catheterization. Urinary catheter was removed on the second day of therapy. Patient was able to pass stool after another two days. Although weakness of the lower limbs improved after a week, jerks still remained brisk and the planter reflexes remained extensor. The remaining doses of rabies vaccine were stopped and vaccination was discontinued. The patient was discharged with oral prednisolone. A diagnosis of post-rabies vaccine myelitis was made based on the history of recent vaccination, upper motor neuron signs and high signal intensity on MRI. Discussion There have been reports of myelitis occuring after rabies duck embryo vaccine. In one report, a 41-year-old farmer developed myelitis 14 days after the first inoculation of rabies duck embryo vaccine.3 Four cases of transverse myelitis were reported among 424,000 people who received duck embryo rabies vaccine between 1958 and 1971.4     There are many cases of myelitis in our country. A precipitating factor is not always sought. Rabies vaccination may be an important cause and should be searched for in the history of patients with myelitis. People who are vaccinated with purified chick embryo rabies vaccine should be followed to see if they develop signs of spinal pathology. A thorough search of the literature indicates that our case is the first case of myelitis following rabies chick embryo cell vaccination in Bangladesh. References 2.   Ahasan HA, Chowdhury MA, Azhar MA, Rafiqueuddin AK. Neuroparalytic complications after anti-rabies vaccine (inactivated nerve tissue vaccine). Tropical  Doctor 1995; 25: 94. 4.   Rubin RH, Hattwick MAW, Jones S, Gregg MB, Schwartz V D. Adverse reactions to duck embryo rabies vaccine. Journal of the American Medical Association 1973; 78: 643-649. 5.    Bir LS, Eþmeli FO, Cenikli U, Erdoðan C, Deðirmenci E. Acute transverse myelitis at the conus medullaris level after rabies vaccination in a patient with Behçet’s disease. Journal of Spinal Cord Medicine 2007; 30(3): 294–296. <![CDATA[Maternal mortality – a public health problem]]> Sonia Shirin Shamsun Nahar https://imcjms.com/journal_full_text/226 2017-06-04 13:56:36 Review Ibrahim Med. Coll. J. 2012; 6(2): 64-69 Maternal mortality is an important indicator which reflects the health status of a community. It can be calculated by maternal mortality ratio (MMR), maternal mortality rate (MMRate), and adult life time risk of maternal death. MMR estimates are based on varieties of methods that include household surveys, sisterhood methods, reproductive-age mortality studies (RAMOS), verbal autopsies and censuses. Main causes of maternal mortality are hemorrhage, infection, unsafe abortion, hypertensive disorder of pregnancy and obstructed labour. Factors of maternal mortality have been conceptualized by three delays model. Estimates of maternal mortality ratio (MMR) trend between 1990 and 2010 (over 20 years period) suggest a global reduction (47%), with a greater reduction in developing countries (47%) including Bangladesh than in developed countries (39%). However, to meet the challenge of Fifth Millennium Development Goal (MDG5 i.e. to ensure 75% reduction of MMR by the year 2015), the annual rate of MMR decline and increase of skilled attendant at birth need to be still faster. Address for Correspondence:Dr. Sonia Shirin, Assistant Professor, Department of Community Medicine, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbagh, Dhaka 1000   Mothers are important constitute of a population and maternal mortality is the culmination of a series of detrimental events in a woman’s life.1 Maternal mortality ratio (MMR) represents the status of health care services and social wellbeing of a country.2 Since the launching of the Safe Motherhood Initiative in 1987, there has been a worldwide effort to reduce maternal mortality and to identify its determinants. These efforts have been directed by the outputs of a number of international conferences over the past decade such as the International Conference on Population and Development in 1994, and the Fourth World Conference on Women in 1995. The declaration of the Fifth Millennium Development Goals (MDG-5) aiming at reducing by three-quarters the MMR by 2015 has also increased the demand for measuring maternal mortality at national and subnational levels.3 There is a greater disparity in levels of maternal mortality than in any other public health indicator between developed and developing countries. While in the developing countries including Bangladesh significant progress has been made in reducing infant mortality, the same is not true for maternal mortality. Although the actions needed to reduce maternal mortality have been in place in most developing countries, 1 woman in 50 is still dying as a result of pregnancy-related complications and the figure rises to 1 in 10 in many parts of Africa. By contrast, the figure for developed countries may be as low as 1 in 8,000.5 The main causes of maternal mortality are severe bleeding, infection, unsafe abortion, eclampsia, hypertensive disorders of pregnancy and obstructed labor.8 Very little scientifically based information is available on cause-specific mortality rates for many developing countries.9 Most of the information comes from the verbal autopsy (VA), used to obtain causes of death by interviewing lay respondents on the signs and symptoms experienced by the deceased before death.10-14 In the present article, the global and regional estimates and trends of maternal mortality has been reviewed to understand the causes and factors related to maternal mortality and the challenge facing the developing world in particular in achieving MDG 5 by 2015. Maternal Mortality and its estimation: methods used The tragedy is that these women die during normal life enhancing process of procreation and not from disease.21-23 Although widely-used standardized definitions of maternal mortality exist, it is difficult to measure accurately the levels of maternal mortality in a population – for several reasons. First, it is challenging to identify maternal deaths precisely – particularly in settings where routine recording of deaths is not complete within civil registration systems. Second, even if such a death were recorded, the woman’s pregnancy status may not have been known and the death would, therefore, not have been reported as a maternal death. Third, in most developing-country settings where medical certification of cause of death does not exist, accurate attribution of female deaths as maternal death is difficult. In the absence of complete and accurate civil registration systems, MMR estimates are based upon a variety of methods namely household surveys, sisterhood methods, reproductive-age mortality studies (RAMOS), verbal autopsies, and censuses.26-28 MMR trends between 1990-2010   Fig-1. Global Reduction of MMR in Developed and Developing Countries based on WHO estimates 4 Eastern Asia ranked highest (69%) in reducing MMR between 1990 and 2010 followed by Northern Africa (66%), Southern Asia (64%), Sub-Saharan Africa (41%), Latin America and the Caribbean (41%), Oceania (38%) and finally Caucasus and Central Asia (35%) (Fig 2).       Fig-3.Region experiencing 75% reduction in MMR by 2010 The Government of Bangladesh is also committed to achieving its targets for MDG 5; reducing the maternal mortality ratio (MMR) and increasing skilled attendance at birth to improve maternal health.32 According to a WHO estimate,4 trend in decline in MMR between 1990 and 2010, in Bangladesh was highly satisfactorily (70%) with expectation to reach the target (75% reduction) by 2015 (Fig 4). Unfortunately however, the rate of skilled birth attendants of delivery remained as low as 27% against a targeted goal of 50% during the period.19 In Bangladesh, 85% of births still takes place at home. Only one in five mothers and neonates receive postnatal care from a medically trained provider within 42 days after birth.33     Evidence suggests that the direct consequences of pregnancy and childbirth continue to account for most maternal deaths in developing countries. To obtain reliable information on the individual medical causes of maternal mortality is however extremely difficult, especially for deaths that occur at home. In a systematic review of the causes of maternal mortality WHO showed severe bleeding, hypertensive diseases and infections as the dominant causes.5 There is hardly any systematic review or study about the causes of maternal deaths in Bangladesh. A study conducted by ICDDR’B at Matlab seems to be reflective of general scenario in Bangladesh. This study reviewed the major causes of maternal death, using a combination of record review and field interviews. The major causes of maternal mortality were haemorrhage (20%), complications of abortion (18%), eclampsia (12%), violence and injuries (9%), concomitant medical causes (9%), postpartum sepsis (7%), and obstructed labour (6.5%). Deaths caused by postpartum haemorrhage were positively associated with both maternal age and parity, whereas those caused by eclampsia and injuries were more common among young and low-parity women.35   Factors that contribute to a higher risk of maternal mortality include such factors as biomedical, reproductive, health service, socioeconomic and cultural factors and have been conceptualized in the ‘Three Delays Model’.This ‘Three Delays Model’ identified individual decision making, access to affordable services, and the provision of skilled personnel as the main factors which can delay access to effective interventions to prevent maternal mortality.36,37 The first delay is on the part of the mother, family, or community not recognizing a life-threatening condition. Because most deaths occur during labor or in the first 24 hours postpartum, recognizing an emergency is not easy. Most births occur at home with unskilled attendants, and it takes skill to predict or prevent bad outcomes and medical knowledge to diagnose and immediately act on complications. By the time the lay midwife or family realizes that there is a problem, it is too late. The second delay is in reaching a health-care facility, and may be due to road conditions, lack of transportation, or location. Many villages do not have access to paved roads and many families do not have access to vehicles. Public transportation may be the main transportation method. This means it may take hours or days to reach a health-care facility. Women with life-threatening conditions often do not make it to the facility in time. The third delay occurs at the healthcare facility. Upon arrival, women receive inadequate care or inefficient treatment. Resource-poor nations with fragile health-care facilities may not have the technology or services necessary to provide critical care to hemorrhaging, infected or convulsive patients. Omissions in treatment, incorrect treatment, and a lack of supplies contribute to maternal mortality.38 Cham et al utilized ‘The Three Delay’ framework in a study to identify contribution of three delays in Gambia which was mentioned as for i) seeking medical care (22%), ii) reaching an appropriate medical facility (84%) and iii) receiving required care at health facility (97%). Furthermore, 22% had all three phases of delay, 66% were subjected to two phases of delay and 9% had only one phase of delay.39 Timing of maternal mortality In Bangladesh, mortality was also highest on the first day after pregnancy. Pregnancies ending in abortions and stillbirths accounted for 50% of deaths in women within 6 weeks of the end of pregnancy, and mortality after these outcomes was between two and four times as high as mortality after a livebirth.41 In Matlab, Bangladesh, data shown that 20% of all maternal deaths occurred during pregnancy, 44% during labour and the two days following delivery, and 6% during the remaining postpartum period.35 Factors related to maternal mortality   Maternal mortality is still a major challenge to the health system worldwide. Systematic review of the ratio and trends in maternal mortality is essential for planning, resource mobilization and assessment of progress towards MDG-5, the target for 75% reduction in MMR by 2015. Estimates of ratio and trend of MMR over a 20 years’ period (1990 - 2010) suggest a global reduction with a greater reduction in developing countries including Bangladesh, than in developed countries. There has been considerable progress with regard to MMR, but still much to do to increase skilled attendant at birth. Awareness campaign aiming at lowering fertility and increasing skilled attendant at birth may help to reach the target of MDG-5 in time. Acknowledgements   1.   Stokoe U. Determinants of maternal mortality in developing world. Australia NZ Journal of Obstetrics and Gynaecology 1991; 31(1): 8-16. 3.   Betran AP, Wojdyla D, Posner S, Gulmezoglu AM. National estimates for maternal mortality: an analysis based on WHO systematic review of maternal mortality and morbidity. BMC Public Health 2005; 5: 131. doi:10.1186/1471-2458-5-131. 5.   AbouZahr C, Wardlaw T, Stanton C, Hill K. Maternal mortality. World Health Stat Q 1996; 49(2): 77-87. 7.   Atrash HK, Alexander S, Berg CJ. Maternal mortality in developed countries: not just a concern of the past. Obstet Gynecol 1995; 86(4): 700-5. 9.   Anker M, Black RE, Coldham C, Kalter HD, Quigley MA, Ross D, et al. A standard verbal autopsy method for investigating causes of death in infants and children. Geneva, World Health Organization, 1999. 11.Byass P, Huong DL, Minh HV.  A probabilistic approach to interpreting verbal autopsies: Methodology and preliminary validation in Vietnam. Scandinavian Journal of Public Health 2003; 31(suppl.62): 32-7. 13.Fantahun M, Fottrell E, Berhane Y, Wall S, Hogberg U, Byass P. Assessing a new approach to verbal autopsies interpretation in a rural Ethiopian community: the interVA model. Bulletin of the World Health Organization 2006; 84(3): 204-10. 15.Reducing maternal deaths: Evidence and action, A strategy for DFID. Department for International Development 2004. 17.Ronsmans C, Graham WJ. Maternal mortality: who, when, where, and why. Lancet 2006; 368: 1189-200. 19.Khan R., Bilkis S., Blum LS., Nahar Q, Streatfield PK. IFGH 2012: Barriers Faced by Community Skilled Birth Attendants to Conduct Deliveries At Home. Irish Forum for Global Health 29 Jan 2012. 21.Harrison KA. Maternal mortality developing countries. British Journal of Obstetrics and Gynaecology1989; 96(1): 1-3. 23.Hill K, AbouZahr C, Wardlaw T. Estimates of maternal mortality for 1995. Bulletin World Health Organization 2001; 79(3): 182-93. 25.Wilmoth J.  The lifetime risk of maternal mortality: concept and measurement. Bulletin of the World Health Organization 2009; 87(4): 256-62. 27.Horon IL. Underreporting of maternal deaths on death certificates and the magnitude of the problem of maternal mortality. American Journal of Public Health 2005; 95(3): 478-82. 29.Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM et al. Maternal mortality for 181 countries, 1980 – 2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010; 375(9726): 1609–23. 31.WHO, UNICEF and UNAIDS. Global HIV/AIDS response: epidemic update and health sector progress towards universal access: progress report 2011. Geneva, World Health Organization 2011. 33.UNICEF. State of the World’s Children 2009: Extreme Risks for Pregnant Women and Newborn Babies in Developing Countries, Dhaka, 2009. 35.Fauveau V, Koenig MA, Chakraborty J, Chowdhury AI. Causes of maternal mortality in rural Bangaldesh, 1976–85. Bulletin World Health Organization 1988; 66(55): 643–51. 37.Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Social Science and Medicine 1994; 38(8):1091-1110. 39.Cham M, Sundby J, Vangen S. Maternal mortality in the rural Gambia, a qualitative study on access to emergency obstetric care. Reproductive Health 2005, 2: 3. 41.Hurt LS, Alam N, Dieltiens G, Aktar N and  Ronsmans C. Duration and magnitude of mortality after pregnancy in rural Bangladesh. International Journal of epidemiology 2008; 37(2): 397- 404. <![CDATA[Organ transplantation in Bangladesh – challenges and opportunities]]> Professor Mohammad Ali https://imcjms.com/journal_full_text/218 2017-05-16 14:01:59 Editorial Ibrahim Med. Coll. J. 2012; 6(1): i-ii Organs that can be transplanted are the heart, kidneys, eyes, liver, lungs, pancreas, intestine and thymus. Transplantable tissues and cells include bones, tendons, cornea, bone marrow, skin, heart valves, veins and islet cells of pancreas. Worldwide, the kidneys are the most commonly transplanted organs followed by liver and the heart. Organ transplantation in Bangladesh is emerging steadily, but still in its budding stage of development. Cornea transplantation began as early as 1974. Despite massive public awareness campaign extending over 3 decades about cornea donation countering the false perceptions in the society, to-date only about 150-175 cornea transplants are done every year in four centres at Dhaka. The first successful kidney transplantation was done at the then Institute of Postgraduate Medicine & Research (now Bangladesh Sheikh Mujib Medical University) in October 1982 and thereafter regular kidney transplantation from ‘living donor’ donations of close relatives only has been continuing since 1988. Only around 1000 patients had kidney transplantation within the country since then. However, demand for kidney transplants far outstrips the number of available organ donors. It is estimated that only 130 patients (of end stage renal failure requiring kidney transplant) on average can manage donors to undergo kidney transplant against the annual demand of estimated 5000. More recently, the first successful liver transplantation of the country was done in June 2010 at BIRDEM Hospital, followed by yet another successful transplant in August 2011 in the same Institute. Presently, organ transplantation (kiney & liver) are done from ‘living donor’ donation of close relatives only. The law does not permit selling organs or taking organs from living strangers. However, recent media reports suggest that many of the organ transplants are happening through commercial dealings, raising debate on ethical issues. Unfortunately the debate produced negative impact on public awareness about organ donation and virtually put the organ transplantation in the country on hold. Patients desperately in need of life saving transplants are either dying or suffering excruciating pain and hoping perhaps against hope that someone in the family will make enormous personal sacrifice to donate organ; or are leaving the country if they can afford in search for a commercial donor and a transplant abroad. Transplant facilities must also be started in the Government Hospitals so that common people get its benefit.  More transplant centers should be started in the private hospitals so that all types of transplants will be easily available with affordable cost within the country. Infact, development of ‘multi-organs transplant centres’ will be our ultimate goal.     Honorary Professor <![CDATA[Underutrition and Adiposity in Children and Adolescents: A Nutrition Paradox in Bangladesh]]> M. Abu Sayeed Mir Masudur Rhaman Akhter Banu Hajera Mahtab https://imcjms.com/journal_full_text/48 2016-08-02 10:49:51 Original Article Ibrahim Med. Coll. J. 2012; 6(1): 1-8 Many studies reported a high prevalence of undernutrition in the under-5 children in Bangladesh. But very few information are available about undernutrition and adiposity among school children and adolescents in Bangladesh. This study addressed the prevalence of undernutrition and obesity among school going children and adolescents. A total of 15 secondary schools were purposively selected from rural, suburban and urban areas. The teachers were detailed about the study protocol. Then the teachers volunteered to register the eligible (age 10 – 18y) students for the study. Each student’s parent was interviewed for family income. Height (ht), weight (wt), mid-upper arm circumference (MUAC) and blood pressure were taken. Fasting blood samples were collected for fasting plasma glucose, total cholesterol (Chol), triglycerides (TG), high-density lipoproteins (HDL). Body mass index (BMI) was calculated (ht/wt in met. sq) for diagnosis of undernutrition (BMI <18.5), normal weight (BMI 18.5 – 22.9) overweight (BMI 23.0 – 25.0) and obesity (BMI >25.0). A total of 2151 (m-1063, f-1088) students volunteered the study. Of them, the poor, middle and rich social classes were 25.4, 53.1 and 21.5%, respectively. Overall, the prevalence of underweight, normal, overweight and obesity were 57.4%, 35.0%, 4.9% and 2.7%, respectively. For gender comparison, there has been no significant difference of BMI between boys and girls. By social class, the prevalence of underweight was significantly higher in the poor than in the rich (62.2% v. 43.6%) and obesity was higher in the rich than in the poor (6.1% v. 1.2%) [for both, p<0.001]. Logistic regression showed that the participants from urban (OR 1.51, 95% CI 1.03 – 2.22) and the rich (OR 2.03, 95% CI 1.24 – 3.33) social class had excess risk for obesity. The risk for undernutrition was found just reverse. Undernutrition was found most prevalent among the rural students and among the poor social class; whereas, prevalence of overweight and obesity appears to be increasing with urbanization and increasing family income. Thus, the study showed a nutrition paradox – adiposity in the midst of many undernourished children and adolescents in Bangladesh. Further study may be undertaken in a large scale to establish diagnostic criteria for age specific nutrition assessment in Bangladesh. A prospective children cohort may help assessing the cut-offs for unhealthy sequels of undernutrition and adiposity. Address for Correspondence:Dr MA Sayeed, Professor & Head, Department of Community Medicine, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Dhaka 1000. Email: sayeed1950@gmail.com   Bangladesh is a least developing country and more than one-third of its children are exposed to undernutrition. Undernutrition is also common among the pregnant mothers. Low birth weight was reported to be 36%.1 Thus, these Bangladeshi children experience nutritional deficiency from birth. The prevalence of moderate to severe malnutrition in children (Gomez Classification) was reported to be the same (~36%). The prevalence rates of underweight (weight for age, <2SD), stunting (height for age, <2SD) and wasting (weight for height, <2SD) in children of age 6-71 months were 51.1, 48.8 and 11.7%, respectively.1 These figures indicate that majority of the children are exposed to undernutrition. Such undernutrition at early life leads to some metabolic disorders in adulthood.2,3 This has also been reported in other developing communities.4-6 Interestingly, some observed that the combination of underweight and overweight in children coexist in the same community or even in the same family.7 This is dubbed as the “dual burden household”. It is postulated that a relatively new phenomenon is emerging in the developing countries. It leads to the nutrition transition along with socioeconomic and demographic transition resulting changes in diet, food availability and lifestyle. In Bangladesh too, possibly due to such socio-economic transition and changes in lifestyle, undernutrition and adiposity coexist. This appears to be a nutrition paradox. An awesome undernutrition is now added with obesity– an emerging health problem in children. So far, most of the studies conducted in Bangladesh addressed ‘undernutrition in children of age below 71 months’. There has been very few information about childhood nutrition beyond this age group. This study addresses the overall nutritional status among children and adolescents in Bangladesh. Additionally, the study attempts to assess the socio-demographic and socio-economic risks related to both undernutrition and obesity. Subjects and Methods Purposively, we selected secondary schools. The schools from rural, suburban and urban were 8, 2 and 5, respectively. All students of age group 10 to 18 years were considered eligible and enlisted in each school. An attempt was made to maintain population proportion of geographical sites (rural, urban and suburban)1 with an equal ratio of male and female participants. We discussed the objectives and investigation procedures with the teachers. We sought help from the teaching staff and the students to prepare the list of participants. They gave their assent and prepared the list of eligible participants. At registration, each student was advised to attend the school at 8AM with an overnight fast accompanied by a parent. The parents were interviewed about annual family income in order to classify social class according to income tertile (poor, middle and rich). As regards nutritional status, we estimated underweight, normal weight, overweight and obesity with corresponding BMI <18.5, 18.5 – 22.9, 23 – 25 and >25.0 kg/m2, respectively.8,9 We used the term adiposity (overweight and obesity) when BMI was found greater than 22.9. Data analysis   A total of 2151 (m-1063, f-1088) students volunteered the study (table-1). The participants from rural, suburban and urban were 800, 402 and 949, respectively. Of them, (53%) were from social middle and 25.5% from social poor class (table-1). For age tertile in table-2, mostly, the mean (SD) values for ht, wt, BMI, MUAC, SBP, DBP and TG were found significantly higher in female than male students in the age group 10 – 12y (tertile1); but, with the advancing age these were reversed and found significantly higher in males (15 – 18y, tertile3). FPG, Chol and HDL showed some differences but were inconsistent. Comparison between rural and urban showed that BMI (18.7 v. 18.2, p<0.01) and MUAC (22.1 v. 20.0, p<0.001) of both sexes (m + F) were significantly higher in the rural than urban [data not shown]. On the contrary, DBP (61 v.58 mmHg, p<0.001), FPG (4.9 v. 4.4 mmol/l, p<0.001), T-cholesterol (157 v. 148 mg/dl, p<0.001) and HDL-cholesterol (52.3 v. 39.1 mg/dl, p<0.001) of both sexes were found significantly higher in urban than the rural participants [not shown in table]. It may be noted that height, weight, SBP and TG of both sexes did not differ between rural and urban. The prevalence of underweight and adiposity (overweight and obesity) by social class were presented in table 5. Overall, the prevalence of underweight (BMI=<18.5) was 57.4% and adiposity (overweight + obesity) was 7.6%. The prevalence of adiposity was found mostly in the middle and rich class, and underweight was most prevalent in the middle and the poor class. Thus, middle class was found to have undernutrition (32.2%) and adiposity (3.7%). Obviously, nutrition status was found related to the gradient across social class – undernutrition among the poor and overweight or obesity among the rich (Chi sq 6.8, p<0.001). If we accept 15th, 85th and 95th percentile of BMI as underweight, overweight and obesity then BMI cut-offs of these participants would be 15.6, 21.4 and 24.0, respectively. Logistic regression was also used to quantify the predictors of undernutrition taking BMI <18.5 as a dependent variable (data not shown). The poor social class and the rural area were found to be the independent risks for underweight. Table-1: Distribution of student participants according to sex, area and social class.     Table 3: Comparison of biophysical characteristics between male and female participants according to geographical sites.     Table 5: Distribution of underweight and adiposity according to social class     Discussion The study has several limitations. Firstly, central obesity (waist/hip) and skin-fold thickness were not taken. So, fat patterning of this age group could not be assessed. Secondly, assessment of dietary intake and physical activity were not included in the study. These information could have improved the study. Very similar study was reported from south Korea that the percentiles for underweight, overweight, and obesity corresponding to BMI of 18.5, 23.0, and 25.0 kg/m2 at age 18 were the 13.0th percentile, the 77.8th percentile, and the 91.2nd percentile, respectively.10 The corresponding prevalence of underweight, overweight, and obesity were 12.1, 12.5, and 9.8%, respectively. So, large proportions (57.5%) of our children were underweight as compared with the Sri Lankan and Korean children.9,10   We conclude that the prevalence of underweight among children and adolescent still remains high and related mainly to poor and partly to middle socio-economic class irrespective of geographical sites. The prevalence of adiposity (overweight and obesity) appears to be high among the rich, moderate among the middle and very low among the poor social class. The urban students of both sexes have excess risk for overweight and obesity. Thus, the children and adolescent of Bangladesh showed a nutrition paradox – adiposity coexists with prevalent undernutrition. Further study may be undertaken to determine nutritional status in relation with dietary intake, physical activity and fat distribution. Finally and importantly, we need to define underweight, overweight and obesity for Bangladeshi population for specific age groups. Acknowledgements   1.   Bangladesh Bureau of Statistics. Statistical Pocket Book of Bangladesh. Ed: Mollah MSA, Statistical Division, Ministry of Planning, Government of The People’s Republic of Bangladesh 2009. 3.   G.E. Miller, E. Chen, A.K. Fok, H. Walker, A. Lim, E.F. Nicholls, S. Cole, M.S. Kobor. Low early-life social class leaves a biological residue manifested by decreased glucocorticoid and increased proinflammatory signaling. Proceedings of the National Academy of Sciences 2009; 106(34): 14716-14721. 5.   Popkin BM, Richards MK, Monteiro CA. Stunting is associated with overweight in children of four nations that are undergoing the nutrition transition. J Nutr 1996; 126: 3009–16. 7.   Benjamin Caballero. A Nutrition Paradox — Underweight and Obesity in Developing Countries. N Engl J Med 2005; 352: 1514-1516. 9.   Wickramasinghe VP, Lamabadusuriya SP, Atapattu N, Sathyadas G, Kuruparanantha S, Karunarathne P. Nutritional status of schoolchildren in an urban area of Sri Lanka. Ceylon Med J 2004; 49(4): 114-8. 11.Thorpe LE, List DG, Marx T, May L, Helgerson SD, Frieden TR. Childhood obesity in New York City elementary school students. Am J Public Heath 2004; 94(9): 1496-500. <![CDATA[Comparison of three mycobacterial DNA extraction methods from extrapulmonary samples for PCR assay]]> Khandaker Shadia Shaheda Anwar Sayera Banu Ahmed Abu Saleh Md. Ruhul Amin Miah https://imcjms.com/journal_full_text/49 2016-08-02 10:51:32 Original Article Ibrahim Med. Coll. J. 2012; 6(1): 9-11 Sensitivity of the molecular diagnostic tests of extrapulmonary tuberculosis largely depends upon the efficiency of DNA extraction methods. The objective of our study was to compare three methods of extracting DNA of Mycobacterium tuberculosis for testing by polymerase chain reaction. All three methods; heating, heating with sonication and addition of lysis buffer with heating and sonication were implicated on 20 extrapulmonary samples. PCR positivity was 2 (10%), 4 (20%) and 7 (35%) in the samples extracted by heating, heat+sonication and heat+sonication+lysis buffer method respectively. Of the extraction methods evaluated, maximum PCR positive results were achieved by combined heat, sonication and lysis buffer method which can be applied in routine clinical practice. Address for Correspondence:Dr. Khandaker Shadia, Assistant Professor, Department of Microbiology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Dhaka 1000, Bangladesh, e-mail: drsadialima@ymail.com   Isolation of nucleic acid (DNA) from mycobacteria is difficult due to its complex cell wall structure.1 Therefore, most of the simple and commonly used DNA extraction methods result in poor quality and low yield of DNA, which is also affected by type of sample used.2 However, the sensitivity of molecular diagnosis is largely dependent on the efficiency of cell lysis and extraction of DNA.3 Several methods for mycobacterial cell wall lysis and DNA extraction have been used like simple boiling in distilled water, disruption by glass bead or sonication, enzymatic lysis, chemical lysis or combination of these techniques.4 The objective of this study was to compare three methods of extracting M. tuberculosis DNA from various types of extrapulmonary specimens. Materials and Methods During DNA extraction in heat method aliquots of the sediments were washed with distilled water and boiled at 95°C for 30 minutes in a water bath. After centrifugation at 10,000 rpm for 5 minutes supernatant was collected in a 1.5 ml tube.7,8 In combined heat and sonication method, after removal from water bath lysate was sonicated in an ultrasonication bath (Branson 1200 E4, Branson Co, Danbury, CT) for 15 min at    30 W.9,10 Then supernatant was recovered in the same way. In the third method, at first deposit was suspended in 135 ml of lysis buffer [Prepared by mixing 20 mM Tris/HCl (pH 8.3), 1mg proteinase K/ml, 0.5% Tween 20 and 10ml sterile distilled water] instead of distilled water and incubated at 56°C for 3 hours. Then the lysate cooled to room temperature and centrifuged at 12000 rpm for 15 min. Resultant pellet was resuspended with 100 ml distilled water and rest of the method repeated as method-2. Briefly, heating, sonication, centrifugation and finally collection of the supernatant in 1.5 ml tube.11,12 Amplification and detection procedures   Three DNA extraction methods were applied in 8 AFB smear and/or culture positive and 12 negative samples. Maximum positivity was seen in the method using heat, sonication and lysis buffer in combination. Among 8 AFB smear and/or culture positive cases 6 (75%) were positive by this method whereas 4 (50%) were positive by heat-sonication and 2 (25%) by only heating method. Among 12 AFB smear and/or culture negative samples one (8.3%) sample was PCR positive by heat+ sonication+lysis buffer method. None of the AFB negative sample was positive by only heating or heat + sonication method. Table 1: Comparison of PCR results with the DNA extracted by three different methods (n=20).   Several DNA extraction methods can be employed for the isolation of mycobacterial nucleic acid from clinical samples. But in case of samples of extrapulmonary TB more precise method is required due to the paucibacillary nature of these samples. Moreover in highly TB prevalent country like Bangladesh the method should be simpler and reasonably cost effective. In this context, kit based extraction offers quality-controlled reagents with optimized compositions for all steps, but they are relatively costly and have variable sensitivity.14 Heating is simplest and widely used method but its sensitivity in smear negative pulmonary as well as extrapulmonary samples is not satisfactory.7,8,15 In fact, association of physical disintegration by bead beating or sonication in a specific enzyme and detergent containing buffer is appropriate for mycobacterial cell wall lysis.14  Though the main disadvantage of the sonication method was the need of a sonicator for cell lysis and the third method needs extra 3 hours incubation but in consideration of proper diagnosis it can be acceptable. This incubation time can be lowered by further experiment as different authors mentioned different ranges of incubation times.8,11,12 Lastly, from our experiment it is apparent that combination of lysis buffer and sonication with heating is considerably bring better DNA yield in detecting M. tuberculosis by PCR, especially in samples with extrapulmonary samples that have low number of mycobacteria. Obviously the limitation of our study is small sample size and lack of observation of quality and quantity of recovered DNA. Further study with large number of pulmonary and extrapulmonary samples following necessary modification may strengthen our findings. 1.   Barry MC, Mdluli K. Drug sensitivity and environmental adaptation of Mycobacterial cell wall components. Trends Microbiol 1996; 4: 275-8. 3.   Honore’-Bouakline S, Vincensini JP, Giacuzzo V et al. Rapid Diagnosis of Extrapulmonary Tuberculosis by PCR: Impact of Sample Preparation and DNA Extraction. J Clin Microbiol 2003; 2323-2329. 5.   Khaled NA and Enarson DA. Tuberculosis. A Manual for medical Students. Geneva, World Health Organization. (WHO/CDS/ TB/99.272) 1999; 14-21. 7.   Aldous WK, Pounder JI, Cloud JL and Woods GL. Comparison of Six Methods of Extracting Mycobacterium tuberculosis DNA from Processed Sputum for Testing by Quantitative. J Clin Microbiol 2005; 43(5): 2471–73. 9.   Buck GE, O’Hara LC & Summersgill JT. Rapid simple method for treating clinical specimens containing Mycobacterium tuberculosis to remove DNA for polymerase chain reaction. J Clin Microbiol 1992; 30: 1331–1334. 11.Orallo RLC, Mendoza MT, Ann MD et al. Evaluation of the Usefulness of PCR in the diagnosis of Mycobacterium tuberculosis in tissues and body fluids in UP-Philippine General Hospital. Philippine J Microbiol Infect Dis 2008; 37(1): 20-32. 13.Haldar S, Sharma N, Gupta VK and Tyagi JS. Efficient diagnosis of tuberculous meningitis by detection of Mycobacterium tuberculosis DNA in cerebrospinal fluid filtrates using PCR. J Med Microbiol 2009; 58: 616–624. 15.Padilla E., Gonza´lez V, Manterola JM et al. Evaluation of two different cell lysis methods for releasing mycobacterial nucleic acids in the INNO-LiPA mycobacteria test. Diag Microbiol Infect Dis 2003; 46: 19–23. <![CDATA[Pattern of lipid profile among type 2 diabetic patients]]> Nazia Elham Meerjady Sabrina Flora https://imcjms.com/journal_full_text/50 2016-08-02 10:53:07 Original Article Ibrahim Med. Coll. J. 2012; 6(1): 12-17 Diabetes mellitus is recognized as a serious global health problem and frequently associated with disabling and lifethreatening complications related to some modifiable risk factors. One of the modifiable factors is dyslipidemia. This study addressed the dyslipidemic status of 124 subjects with type 2 diabetes mellitus (T2DM) attending the outpatient department, Ibrahim General Hospital and Diabetic Care and Education Center Dhanmondi, Dhaka during the period from January to June 2010. The diagnosed diabetic subjects were interviewed and the biochemical investigation data were collected from record review. Three fourth of the respondents were female and majority (24.2%) of them were 46 to 50 years of age. Most of the respondents were graduates having neuclear families. The mean total cholesterol and triglyceride were found 181.7±43.0 mg/dl and 161.0±112.5 mg/dl respectively. According to NCEP ATP III (2001), 59.7% of the participants had high level of low density lipoproteins (LDL) and only 18% had desired level of high density lipoproteins (HDL). The mean (±SD) of LDL and HDL were 109.8±37.0 mg/dl and 41.0±7.9 mg/dl respectively. Men had elevated level of mean TG with wide variation (185.98±179.56 mg/dl) than women (151.63±72.16 mg/dl). The mean (±SD) of HDL was found lower in men than women (35.8 ± 6.3 vs. 42.9 ± 7.5 mg/dl, p< 0.05) though not significant. The study revealed that dyslipidemia (high TC, TG, LDL and low HDL) was prevalent among the T2DM subjects, which needs attention of equal importance to maintain within normal limit as with the control of hyperglycemia and hypertension. Address for Correspondence:Dr. Nazia Elham, Lecturer, Department of Community Medicine, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbagh, Dhaka, E-mail: naziaelham@yahoo.com   Diabetes mellitus (DM) is considered as a compound of complex metabolic syndrome and can lead to both micro and macrovascular complications.1 The long–term effects of diabetes mellitus include progressive development of the specific complications of retinopathy, nephropathy, and or neuropathy with risk of foot ulcers, amputation, and features of autonomic dysfunction. People with diabetes are also at increased risk of cardiovascular, peripheral vascular and cerebrovascular disease.4 Diabetic subjects have significantly higher cholesterol, triglycerides, LDL and significantly lower HDL cholesterol as compared to non diabetic subjects.8 The plasma triglyceride levels are the metabolic markers most closely related to poor glycemic control and high levels of VLDL and LDL and with a low level of HDL are associated with poor glycemic control also.2 High proportion of upper-body fat or abdominal fat, independent of overall obesity, is recognized as an important component in the insulin resistance linked to obesity and type 2 diabetes mellitus. 9   This cross sectional study was carried out on 124 already diagnosed adult type 2 diabetic patients attending the outpatient department of Ibrahim General Hospital and Diabetic care and education Center, Dhanmondi, Dhaka during the period from January to June 2010. Patients of both sexes aged 20-60 years and having lipid profile done within 3 months of the interview were purposively selected in the study. Desired and abnormal category of lipid profiles of the respondents was done by following cut off values according to the National Cholesterol Education Program guideline. The study was approved by the Ethical Committee of the National Institute of Preventive and Social Medicine.   Socio-demographic characteristics of the respondents   Lipid profile data included total cholesterol (TC), triglyceride, LDL and HDL. About one-third of the diabetics were with high TG and less than one-third (27%) and more than half (59.7%) were with high total cholesterol (TC) and high LDL respectively. HDL was abnormal in more than 80% patients. ANOVA was done to see the difference in lipid profile between different age groups but found insignificant. The Pearson’s correlation coefficient between age and lipid profile also didn’t show any significant relation. ANOVA was done to see the difference of lipid profile in different occupation. Mean TC and TG was highest among the businessmen. Housewives had highest mean HDL (42.82±7.59 mg/dl). The differences in TC, TG and LDL was not statistically significant but the difference in HDL was statistically significant between housewives and respondents of other occupation (F=5.87, p < 0.05). According to standard cut-off value the lipid profile data were categorized into normal and abnormal and the influence of socio-demographic status was tested. Respondents in the middle age group had more commonly high TC, TG and LDL level than other groups. Aged persons (>55 years) had lowest percentage of high cholesterol (13.6%) and high TG (22.7%). LDL were high in 41.7% of the youngest age group of <36 years and 45.5% of the oldest age group. Desired HDL level was observed in 33.3% of respondents of <36 years age. Other age groups included a few with desired HDL level. Chi-square test did not show any influence of age on lipid profile. Businessmen had highest percentage of high cholesterol (40%) and TG (45%) than the other groups. Service holders had highest percentage (57%) and housewives had lowest percentage (5%) of high LDL. Desired HDL level was observed highest in housewives (30.0%). Occupation had no significant influence on lipid profile. [Table 2]     Table 2: Sociodemographic characteristics and percentage of dyslipidemia   This was a cross sectional study carried out among 124 diagnosed adult type 2 diabetic patients. Patients having diabetic complications were excluded from the study. Patients having severe physical and mental illness were also excluded from the study. Most of the respondents resided in the urban area (95.2%). This was due to purposive selection of study place, which was a diabetic hospital located in the center of the capital city Dhaka. So urban people naturally had more chance for being included in the study. Majority of the respondents were housewives (58.1%) as female subjects constituted three-fourth of the samples. Among the males the second highest group was service holders (25.8%) and 16.1% were business men. In this study TC, TG, LDL and HDL data were collected from record and reviewed. A study done by Arora et al. shows that abnormal lipid profile is common in diabetic patients and is an important predictor for metabolic disturbence.13 Therefore one of the important target for diabetes management is to keep lipid profile within normal limit. This study revealed that most of the respondents had total cholesterol and triglyceride within normal limit but majority had abnormal LDL (about 60%) and HDL (82%) level. Businessmen had highest mean cholesterol (40%) and TG (45%) among all occupation groups. Housewives had highest mean HDL (42.94±7.59mg/dl). T. cholesterol, TG and LDL was not statistically significant but the difference of HDL was statistically significant between housewives and respondents of other occupation (F= 5.87, p < 0.05). This cannot be explained why the housewives had significantly higher level of HDL than other occupational groups. It may be due to less psychosocial stress or dietary habit or household physical activities or may have combined influence. The study had several limitations. Had this study included anthropometry and dietary intake it could have some chances to explain further. Probably due to small sample size associations of lipid fractions with age, sex, education, occupation and family-income could not be estimated. The study did not include the duration of diabetes which could also have influence on the interaction of the said socio-demographic characteristics. The other important limitation is that there were no reference values of lipid fractions for Bangladeshi population for valid comparison. Conclusion   1.   World Health Organization. Definition, Diagnosis and Classification of Diabetes Mellitus and its complications: Report of a WHO Consultation. Part 1: Diagnosis and Classification of Diabetes Mellitus. Geneva: World Health Organization; 1999. 3.   Rahim MA, HussainA, Khan AK et al. Rising prevalence of type 2 diabatas in rural Bangladesh: a population based study. Diabetes research and clinical practice 2007; 77: 300-5. 5.   Shammari F, Al-Meraghi O, Nasif A,Al- Otaibi S. The Prevalence of Diabetic Retinopathy and associated Risk Factors in Type 2 Diabetes Mellitus in Al-Naeem area (Kuwait). Middle East Journal of Medicine 2005; 3(2): 7.   Ravid M, Brosh D, Safran D, Levy Z et al. Main Risk Factors for Nephropathy in Type 2 Diabetes Mellitus Are Plasma Cholesterol Levels, Mean Blood Pressure, and Hyperglycemia. Archives of Internal Med 1998; 158: 998-1004. 9.   Fox C, Coady S, Sorlie P et al. Increasing Cardiovascular Disease Burden Due to Diabetes Mellitus. Circulation 2007; 115: 1544-1550. 11.Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and treatment of High Blood Cholesterol in Adults. final report. National Institute of Health 2002. NIH Publication No. 02-5215. 13  Arora M, Koley S, Gupta S et al. A Study on Lipid Profile and Body Fat in Patients with Diabetes Mellitus. Journal of Anthropologist 2007; 9(4): 295-298. 15.France M, Kwok  S, McElduff  P. Seneviratne C. Ethnic trends in lipid tests in general practice. Oxford Journals 2003; 96(12): 919-923. <![CDATA[Thickening of gallbladder wall in chronic liver disease – a marker for esophageal varices]]> Shamsi Ara Begum Arif Akbar Saibal Kanta Das Sharmistha Dey Akhtar Uddin Ahmed A S Mohiuddin Mohsin Kabir https://imcjms.com/journal_full_text/219 2017-05-16 14:10:37 Original Article Ibrahim Med. Coll. J. 2012; 6(1): 18-20 This study was done to find out the relationship between gallbladder wall thickening and esophageal varices in chronic liver disease (CLD) patients. A total of 61 CLD patients were included and divided into two groups. Group A included 13 CLD patients with no oesophageal varices and Group B composed of 48 CLD patients with esophageal varices. Mean gallbladder wall thickness (GBWT) of Group B was 5.6±0.2mm compared to 2.7±0.1mm of Group A. The mean differences of GBWT were statistically significant between group A and group B (P<0.05). The mean GBWT was significantly (p<0.05) higher in CLD patients with grade III and IV varices (6.1±.8 mm) compared to grade I and II (3.9±0.7 mm). The result suggests that GBWT may be considered as an important marker for the presence of esophageal varices in CLD patients. Address for Correspondence: Dr.Shamsi Ara Begum, Registrar, Department of Radiology and Imaging, Ibrahim Medical College& BIRDEM, 122 Kazi Nazrul Islam Avenue, Shahbagh, Dhaka-1000   Chronic liver disease (CLD) is an emerging health problem in our country. Chronic liver disease results in liver damage and development of portal hypertension. One of the main feature of portal hypertension is the development of gastro-esophageal varices. As bleeding from esophageal varices is a life threatening condition, an early prediction and detection of esophageal varices is important. Endoscopic examination is an invasive as well as expensive procedure for detection of esophageal varices. Therefore, alternative non-invasive procedure is sought for the detection of esophageal varices. Portal hypertension leads to edema and congestion in gallbladder wall and causes ‘congestive cholecystopahty’ resulting into its wall thickening.1 Colour and power doppler study can identify these dilated venous channels.2,3 So, gallbladder wall thickening (GBWT) observed at ultrasonography in chronic liver disease patients may be used as a marker for the presence of esophageal varices.4   The study was conducted on 61 diagnosed patients of CLD at the Radiology & Imaging Department of BIRDEM during June 2006 to May 2007. The patients were divided into two groups: Group A consisted of 13 patients with no esophageal varices while Group B consisted of 48 patients with esophageal varices. Patients with hepatic failure or coma, bleeding episode, intrinsic diseases of gallbladder were excluded from the study. After ultrasonographic examination of abdomen, every patient underwent endoscopic examination of upper GIT by gastroenterologist. Grading of oesophageal varices was done according to the defined standard.5 All the relevant collected data were analyzed. Result     Discussion The present work has revealed that GBWT measured at abdominal sonogram can play a significant role in detecting the presence of esophageal varices in patients with portal hypertension due to CLD. GBWT measured by ultra sonogram is an important marker for the diagnosis of esophageal varices compared to the invasive and expensive upper gastrointestinal endoscopic procedure. However, further studies can be carried out by larger number of study subjects with inclusion of other conditions causing portal hypertension. References 2.  Helbich T, Breitenseher M, Heinz-Peer G, Vergesslich, K, Granditsch G, Kainberger F. Color Doppler ultrasound of gallbladder varicose veins in children. A rare sign of portal hypertension. Ultraschall Med 1994; 15(3): 126-30. 4.  Galip E, Omer O, Salih AU, Mustafe Y, Zeki K., Yucel B. Gallbladder wall thickening as a sign of esophageal varices in chronic liver disease, The Turkish Journal of Gastroenterology 1999; 10(1): 23-29. 6.  Saverymuttu SH, Corbishley CM, Maxwell JD, Joseph AE. Thickened stomach- an ultrasound sign of portal hypertension. Clin Radiol 1990; 41(1): 17-8. <![CDATA[Antidiabetic and analgesic effects of Glycosmis pentaphylla (Retz.) in Swiss albino mice]]> Most. Chand Sultana Khatun M. Ripon Mia M. Ashraf Ali M. Moshiur Rahman Khadiza Begum Kohinur Begum https://imcjms.com/journal_full_text/220 2017-05-16 14:40:35 Original Article Ibrahim Med. Coll. J. 2012; 6(1): 21-26 Background and purposes: Glycosmis pentaphylla (Retz.) Correa, a medicinal plant is popularly used as herbal remedy for various ailments in Bangladesh. It was also reported that GP has both anti-hyperglycemic and analgesic effects and being widely used to reduce blood glucose and to alleviate pain for many years in this region though published literatures are scarce. The present study was designed to evaluate whether ethanolic extract of Glycosmis pentaphylla (GP) have anti-hyperglycemic and analgesic effects. A total of 60 Swiss Albino male mice of nine weeks (weight, 20-25g) were used for investigation. Of them, 40 were made diabetic by alloxan. They were investigated in two groups – a) 20 mice by oral glucose tolerance test (4 samples OGTT) – at 0, 30, 90 and 120 min; and b) 20 mice for a week-long antihyperglycemic activity on day 0, 1, 3 & 7. Both the groups were subdivided into four, each having 5 mice – i) the ‘control’ received only 0.5% methyl cellulose as vehicle; ii) ‘Standard’ received vehicle plus metformin; iii & iv) test ‘DGP250’ & ‘DGP500’ received vehicle plus GP extract with 250 & 500 mg /kg, respectively. For the analgesic activity, 20 mice were investigated in four subgroups, each having 5 mice and similar steps were adopted. Here, vehicle was used 1% Tween 80 and intra-peritoneal injection of Acetic acid for eliciting pain in all four subgroups. The ‘standard’ group got diclofenac sodium for comparison with the test groups ‘GP250’ and ‘GP500’. In OGTT, Ethanolic extract of GP250 and GP500 reduced blood glucose at 90 min. But the levels of reduction were more significant at 120 min, 50.7% by GP250 and 66% by GP500 (p<0.001). The reduction is almost comparable with that induced by metformin. Likewise, for a weeklong anti-hyperglycemic activity, the GP extracts were found as equally effective as metfomin, which was also dose dependent. In addition to antihyperglycemic effect, the ethanolic extract of GP showed significant analgesic effect that was also dose dependent. Our results indicate that GP extract has antihyperglycemic effect in both short and in weeklong duration, which is almost comparable to Metformin HCL, a known and widely used antihyperglycemic agent. The GP extract was also found to have an analgesic effect almost comparable to diclofenac sodium, a known analgesic drug. Further study is needed to confirm the anti-hyperglycemic and analgesic effect of GP including its side effects in long term use. Address for Correspondence: Dr. Kohinur Begum, Department of Pharmacy, Bangladesh University, 15/1 Iqbal Road, Mohammadpur, Dhaka-1207. E-mail: kohinur025@yahoo.com   Diabetes is a global disease with a huge adverse impact on health and mortality particularly of cardiovascular disorders. Diabetes mellitus (DM) is major clinical disorder affecting nearly 10% of the populations all over the world.1 In Bangladesh, the situation is most vulnerable; the number of people with diabetes will rise from 3.2 million in 2000 to 11.7 million by 2030.2 Patient with diabetes have an increased risk of coronary heart disease, peripheral vascular disease, strokes and may account for more than 65% death among people with diabetes mellitus.3,4 Multiple pathophysiologic mechanisms play a role in the risk of cardiovascular events in the metabolic syndrome including glucose intolerance, hyperglycemia, hypertension, dyslipidemia, atherosclerosis that are caused primarily by insulin resistance.5,6 Traditional medicines are used to reduce blood glucose level as well as have beneficial effects on complication of diabetes.7 Glycosmis pentaphylla is a small trees or shrubs belonging to family of Rutaceae, which grows to a height 5 m. It is widely distributed in tropical forest at low altitudes like India, South China, Thailand, Malaysia, Indonesia and Philippines Islands.11 Arborine [2-benzyl-1-methyl-4-quinazolone] was isolated as the major compound from ethyl acetate soluble fraction of leaf extract of Glycosmis pentaphylla.12 The root bark contains alkaloid skimmianine, g-fagarine, dictamine, arbone, 3-methoxycarbazone, glycone, glycozoline and glycozolicine and beta-sitosterol.13 A paste prepared from leaves of GP and ginger can be used for treatment of eczema and other skin infection.11 Extract of leaves of GP is used in fever, liver complains, cough and jaundice.14 But still no scientific and methodical investigation has so far been reported in literature regarding its anti-diabetic and analgesic activity. Therefore as a part of our ongoing phytochemical and pharmacological investigations on local medicinal plants of Bangladesh, the present study has been designed to examine anti-diabetic and analgesic activity of ethanolic extracts of leaf of Glycosmis pentaphylla. Methods and Materials Fresh leafs of Glycosmis pentaphylla. (Vernicular name- tooth brush plant) was collected from Savar, Dhaka in September 2009 and plant authenticity was confirmed from the Bangladesh National Herbarium, Dhaka. Preparation of ethanol extract   The active drug, Metformin hydrochloride and Diclofenac-Na were collected from Square Pharmaceuticals Ltd; Pabna Bangladesh. Alloxan was purchased from Sisco Research Laboratories Pvt. Ltd. Mumbai, India. These sixty mice were divided into three experimental groups, each group with 20 mice. Two groups (20 + 20 = 40) were studied for antihyperglycemic activity – one for short term and the other for a weeklong duration. Both of the two groups were made diabetic by alloxan (alloxan is selectively toxic to insulin-producing pancreatic beta cells because it preferentially accumulates in beta cells through uptake via the GLUT2 glucose transporter). These alloxan induced two diabetic groups were investigated for a short term – a) by oral glucose tolerance test (n=20, 4 samples OGTT) – at 0, 30, 90 and 120 min; and b) for a week-long antihyperglycemic activity (n=20) on day 0, 1, 3 & 7. Both the groups were subdivided into four, each having 5 mice – i) the ‘control’ received only 0.5% methyl cellulose as vehicle; ii) ‘Standard’ received vehicle plus metformin; iii & iv) test ‘DGP250’ & ‘DGP500’ received vehicle plus GP extract with 250 & 500 mg /kg, respectively. All blood samples were taken from tail-vein for estimation of blood glucose by Glucometer, a reflectance photometer. For the analgesic activity, 20 mice were investigated in four subgroups, each having 5 mice and similar steps were adopted as for the antihyperglycemic effect. Here, vehicle was used 1% Tween 80 and intra-peritoneal injection of Acetic acid for eliciting pain in all four subgroups. The ‘standard’ group got diclofenac sodium for comparison with the test groups ‘GP250’ and ‘GP500’. Oral glucose tolerance test (OGTT)   Short term test: One ml (50mg/ml) of glucose solution in a dose of 2 gm/kg body weight was administered to all groups by gastric tube. Simultaneously, one ml of 0.5% methyl cellulose for the control (DC) and 1 ml (2.5mg/ml of 0.5% methyl cellulose) of standard drug metformin and one ml of ethanolic extract for group 250 (6.25mg/ml) and for group 500 (12.5mg/ml) were administered orally to respective groups. The blood glucose content was measured after 30 mins, 90 mins and 120 mins.   Analgesic activity of ethanolic extract was studied by acetic acid-induced writhing test in mice. Mice were divided into four groups (each group comprises five mice). Control group mice received vehicles (1% Tween 80 in water), Standard Group received Diclofenac-Na 10 mg/kg body weight , Test Group I and Test Group II were received 250 and 500 mg/kg b. wt. of ethanolic extract of GP. Test samples and vehicle were administered orally 30 mins before intra-peritoneal administration of 0.7% acetic acid and Diclofenac-Na (0.25mg/ml ) was administered intra-peritoneally 15 mins before injection of acetic acid. After 5 mins interval, mice were observed for specific contraction of body referred to as “writhing” for next 10 mins.15 Phytochemical screening   The results were expressed as mean ± Standard Error of Mean (SEM). Statistical analysis was performed by using ANOVA followed by Tukey’s test using Graph pad Prism Software version 5.03 (Graph Pad Software, San Diego, CA, USA, www.graphpad.com). P values < 0.05 were considered as statistically significant. Results After oral administration of glucose, blood glucose levels were significantly higher in mice and results shown in Figure 2. In diabetic control peak blood glucose concentration was observed after 30 mins and remained high after next hour. Mice treated with extract in Group DGP-250 and Group DGP-500 showed a significant decrease in blood glucose concentration 50.7% and 66% respectively, at 120 mins compared with diabetic control mice. Anti hyperglycemic effect of ethanolic extract in diabetic mice hypoglycemic test was performed and compared with diabetic control (DC group). After 7 days of treatment with extract glucose level were significantly lowered 48.1% and 63.10% in Group DGP-250 and DGP-500, respectively (figure 3). Hypoglycemic effect was found dose dependent. Analgesic activity of ethanolic extract   Chemical constituents were identified by characteristic color changes. The screening results were as follows: Alkaloids + ve; Carbohydrates - ve; Proteins and amino acids + ve; Phenols + ve; Flavonoids + ve; Saponin + ve and Tannins + ve. Where + ve and – ve indicates presence and absence of compounds.   Fig 2. Glucose tolarence effect of Glycosmis pentaphylla extract in diabetic mice. Values were expressed in Mean ±SEM. Each group comprises 5 mice. Control group received 0.5% Methyl cellulose and standard group received Metformin 100 mg/kg. *p<0.05, **p<0.01, and ***p<0.001 indicate compared with diabetic control.     Fig 4. Analgesic effect of ethanolic extract of Glycosmis pentaphylla. Values were expressed in Mean ± SEM.  Control group mice received vehicles (1% Tween 80 in water), Standard Group received Diclofenac-Na 10 mg/kg body weight, Test Group I and Test Group II were received 250 and 500 mg/kg b. wt. of ethanolic extract of GP, respectively. Discussion Glycosmis pentaphylla has not been subjected to pharmacological investigations so far analgesic screening to provide scientific justification to its traditional claim in various pains. Therefore, present study has shown to establish remarkable analgesic potential of GP (figure 4). Acetic acid-induced writhing model represent pain sensation by triggering localized inflammatory response. The Prostaglandins mainly prostacyclin and prostaglandin-E have been reported to be responsible for pain sensation by exciting A-fibres. Activities in A-fibres cause a sensation of sharp well localized pain. Any agent that lowers the number of writhing will demonstrate analgesia preferably by inhibition of prostaglandin synthesis, a peripheral mechanism of pain inhibition.19 The response is thought to be mediated by peritoneal mast cells, acid sensing ion channels and prostaglandin pathway.20 Flavonoids being powerful antioxidants are reported to play a role in analgesic activity by targeting prostaglandins.21 Overall analgesic action of GP is assumed to be due to inhibition of prostaglandin synthesis. Conclusions   1.   Burke JP, Williams K, Narayan KMV. A population perspective on diabetes prevention; whom- weight gain. Diabetes Care 2003; 26: 1999-2004. 3.   Brown WV. Lipoprotein disorders in diabetes mellitus. The medicinal clinics of North America 1994; 87: 143-161. 5.   Reaven GM. Role of insulin resistance in human disease. Diabetes 1988; 37: 1595-1607. 7.   Dixit PP, Londhe JS, Ghashadi SS and Devasagayam TPA. Antidiabetic and Related beneficial properties of Indian medicinal plants in Herbal Drug Research. In Sharma, R.K. and Arora R eds. A twenty first century perspective. Jaypee brothers medical publisher Limited 2006; 377-386. 9.   Raquibul Hassan, et al. Analgesic and Antioxidant Activity of the Hydromethnolic Extract of Mikania scandens (L.) Wild. Leaves. American Journal of Pharmacology and toxicology 2009, 4(1): 1-7. 11.Samy J, Sugumaran M. and Lee KLW. Herbs of Malaysia. Federal Publications Sdn. Berhod 2005, 114-115. 13.Daniels M. Medicinal plants, Chemestry and Properties. Science Publishers Enfield, USA 2005; 43. 15.Ahmed F, Selim MST, Das AK. and Choudhuri MSK. Anti-inflammatory and antinociceptive activities of Lippa nodiflora Linn. Pharmazie 2004; 59: 329-333. 17.Gold AH. The effect of diabetes and insulin on liver glycogen synthetase activation. J Biol Chem.1970; 245: 903–5. 19.Brown JE and Evans CAR. Luteolin rich artichoke extract protects low density lipoprotein from oxidation in vitro. Free Radic. Res. 1998; 29: 24255. 21.Rajanarayana KMS, Reddy MR. Chaluvadi and Krishna DR. Biflavonoids classification, pharmacological, biochemical effects and therapeutic potential. Ind. J. Pharmacol 2001; 33: 2-16. <![CDATA[Virulence factors and antibiotic susceptibility pattern of Acinetobacter species in a tertiary care hospital in Bangladesh]]> Azizun Nahar Shaheda Anwar Ahmed Abu Saleh Md. Ruhul Amin Miah https://imcjms.com/journal_full_text/221 2017-05-18 09:55:59 Original Article Ibrahim Med. Coll. J. 2012; 6(1): 27-30 Acinetobacter species are aerobic Gram variable coccobacilli that are now emerging as an  important nosocomial pathogen. Infections caused by them are difficult to control due to multidrug resistance. The purpose of this study was to detect virulence factors namely gelatinase production, biofilm formation and antibiotic susceptibility of Acinetobacter species. Two hundred fifty six clinical samples collected from Bangabandhu Sheikh Mujib medical University (BSMMU) and from burn unit of Dhaka Medical College Hospital were included in the study. Gelatinase production was seen on Luria Bertani agar media containing gelatin (30 gm/l) and biofilm formation was detected in microtiter plate assay. Out of 256 clinical samples, 52 (20.3%) were Acinetobacter species. Out of 52 Acinetobacter isolates, none were gelatinase producer but 39 (75%) were found biofilm producers. Acinetobacter isolates were 100% resistant to ceftazidime, cefotaxime cefuroxime and ceftriaxone. High level of resistance was also recorded for amoxicillin (98.1%), aztreonam (98.1%), gentamicin (90.4%), ciprofloxacin (73.1%), amikacin (57.6%), netilmicin (53.8%) and imipenem (44.2%). Susceptibility to colistin was maximum (96.2%). The present study demonstrated a high propensity of biofilm formation by the clinical isolates of Acinetobacter species and most of the Acinetobacter  were multidrug resistant. Address for Correspondence:Dr. Azizun Nahar, Senior lecturer, Department of Microbiology, Bangladesh Medical College, Dhaka, Bangladesh.  E mail: drnahar.a_26@yahoo.com   Acinetobacter species are Gram negative, strongly aerobic, catalase positive, oxidase negative, non motile encapsulated coccobacilli. Acinetobacter are widely distributed in nature and are commonly found as a part of normal flora of human skin and occasionally in the respiratory tract, genitourinary tract, gastrointestinal tract and conjunctiva.1,2 Although Acinetobacter species are considered to be relatively of low virulence pathogens, certain characteristics of these organisms may enhance the virulence of the strains involved in infections. These characteristics include (i) the property of adhesion to human epithelial cells in the presence of fimbriae and / or capsular polysaccharide, (ii)  lipopolysaccharide component of the cell wall and the presence of lipid A, (iii) biofilm formation and (iv) gelatinase production. Gelatinase is a protease that is capable of hydrolyzing gelatin, collagen, casein, haemoglobin, and other bioactive peptides.5 The potential ability of Acinetobacter baumannii to form biofilms might also explain its outstanding antibiotic resistance, survival properties and increased virulence and further dissemination in the hospital setting.6,7 The presence of indwelling medical devices increases the risk for biofilm formation and subsequent infection especially in the ICU. Therefore, the aim of the present study was to detect gelatinase production, biofilm formation and antimicrobial susceptibility of Acinetobacter species isolated from various clinical specimens. Material and Methods Microbiological methods b. Gelatinase activity: Gelatinase production was detected by inoculating Acinetobacter isolates on the Luria Bertani agar media containing gelatin (30 g/l). After inoculation the plates were incubated overnight at 370C and then cooled for 5 hours at 40C. The appearance of a turbid halo around the colonies was considered positive for gelatinase production.5 Serratia spp. was used as positive control and E. coli was used as negative control in this test. d. Antimicrobial susceptibility tests: All the isolated Acinetobacter species were tested for antimicrobial susceptibility testing by disc diffusion method using the Kirby-Bauer technique11 and as per recommendations of the National Committee for Clinical laboratory Standards (NCCLS).12 Amoxicillin (10µg), ciprofloxacin (5 µg), gentamicin (10µg), ceftriaxone (30µg), ceftazidime (30µg), cefuroxime (30µg), cefotaxime (30µg), amikacin (30µg), aztreonam (30µg), imipenem (10µg), netilmicin (30µg) and colistin (10µg) discs were used. Results     Discussion In this current study, out of 52 Acinetobacter isolates, none produced gelatinase while 75% was positive for biofilm production. Sechi et al found no gelatinase activity and biofilm formation by 80% Acinetobacter isolates.13 Cevahir et al detected gelatinase activity in 14.0% and biofilm formation in 74.4% Acinetobacter isolates.14 Acinetobacter isolated from CVC blood, peripheral blood and tracheal aspirates showed higher biofilm production (84-100%). The presence of indwelling medical devices increases the risk for biofilm formation and subsequent infection especially in the ICU.7 Biofilm production in Acinetobacter species might promote increased colonization and persistence leading to higher rate of device related infections. A greater understanding of the nature of biofilm production by Acineotbacter spp, their role in pathogenicity and in serious infections will help in development of more effective treatment for Acinetobacter infections. References 2    Patil JR, Jog NR, Chopade B AIsolation and Characterization of Acinetobacter Spp From Upper Respirator Tract of Healthy Humans and Demonstration of Lectin Activity. Indian J of Medical Microbiology 2001; 19(1): 30-35. 4. Tomaras AP, Dorsey CW, Edelmann RE, Actis LA. Attachment to and biofilm. formation on abiotic surfaces by Acinetobacter baumannii: involvement of a novel chaperone- usher pili assembly system. Microbiology 2003; 149(Pt 12): 3473-84. 6.   Bergogne Berezin E, Towner KJ. Acinetobacter spp. as Nosocomial Pathogens: Microbiological, Clinical and Epidemiological Features. Clinical Microbiology Reviews 1996; 9(2): 148-165. 8.   Forbes BA, Sham DF, Weissfeld AS. Bailey and Scott’s diagnostic Microbiology, 10th Edition. Mosby, New York, 1998; 167-87. 10.Stepanovic S, Vukovic D, Hola V, Bonaventura G D, Djukic S, Cirkovic I, Ruzicka F. Quantification of Biofilm in microtitre plates: overview for assessment of biofilm production by staphylococci. APMIS 2007; 115: 891-9. 12.National Committee for Clinical Laboratory Standards. (2001) Performance standards for Antimicrobial Susceptibility Tests. Eleventh informational supplement. NCCLS document M100-S11 NCCLS. Wayne, Pennsylvania, USA. 14.Cevahir N, Demir M, Kaleli I, Gurbuz M, Tikvesli S. Evaluation of Biofilm production, gelatinase activity and mannose- resistant hemagglutination in Acinetobacter baumannii strains. J of Microbiology, Immunology and Infection 2008; 41: 513-518. <![CDATA[A Complex Case of Haemoglobin E Disease with Immune Thrombocytopenia and Combined Iron, Folate and Vit B12 Deficiency]]> Md. Sirazul Islam Tashmim Farhana Dipta Gazi Sharmin Sultana https://imcjms.com/journal_full_text/51 2016-08-02 10:54:45 Clinical Case Report Ibrahim Med. Coll. J. 2012; 6(1): 31-33 This is a case report of a 13 years old indigenous ‘Garo’ girl who presented with purpuric spots and ecchymotic patches all over the body with menorrhagia, mild jaundice, severe anaemia, marked thrombocytopenia, moderate neutrophil leucocytosis and reticulocytosis. Investigations revealed this as a complex case of Haemoglobin E disease with immune thrombocytopenia (ITP) and combined iron, folate and vitamin B12 deficiency. The case is discussed thoroughly. Address for Correspondence: Professor Md Sirazul Islam, Department of Clinical Pathology, Clinical Biochemistry & Haematology, 122 Kazi Nazrul Islam Avenue, BIRDEM Dhaka- 1000, Email: drmsiraz@gmail.com Cases report On examination the girl was severely anaemic and mildly icteric with normal vital signs. Multiple petechiae, purpura and bruise were found. There was no lymphadenopathy, organomegally, bony tenderness or signs of meningeal irritation. All other systemic examinations revealed no abnormality. Initial blood count reports showed hemoglobin 5.7 g/dl, MCV: 66.5 fl, RDW (CV): 27.3%, total leukocyte count (WBC): 11,900/ cmm & differential count: N-76%, L-19%, M-04%, E-01%, B-00% and platelet count: 5000/cmm. Reticulocyte count was 10%. Blood film showed dimorphic picture with anisochromia and anisopoikilocytosis, some hypochromic microcytes and normochromic normocytes, a few macrocytes including macro-ovalocytes, target cells, elliptocytes, irregularly contracted cells and few fragmented cells including schistocytes and helmet cells, a few polychromatic cells and occasional nucleated red cells. WBCs were mature with mildly increased Neutrophils. Platelets were markedly decreased in number with normal morphology (Figure-1). The features were nonspecific with neutrophil leucocytosis and thrombocytopenia but possibilities to be ruled out were- Evans’s syndrome i.e., autoimmune haemolytic anemia with immune thrombocytopenia, haemoglobinopathy, microangiopathic haemolytic anaemia with disseminated intravascular coagulation and combined iron and folate / vit B12 deficiency. Bone marrow examination revealed a moderately hypercellular particulate marrow with decreased M/E ratio (about 1:2). Erythropoiesis was markedly hyperactive and mainly normoblastic with some megaloblastic features. Granulopoiesis appeared normal with maturing to segmented forms. Giant metamyelocytes were not seen. Blasts were not increased. Megakaryocytes appeared normal in number and morphology with occasional hyperpolyploid forms (Figure-2). Perls’ staining for iron revealed no stainable marrow iron. In conclusion, bone marrow revealed marked erythroid hyperplasia with some megaloblastic changes and absent stainable marrow iron, suggestive of combined iron and folate/ Vit B12 deficiency. The features were also compatible with ITP as well due to the presence of adequate number of megakaryocytes.         Hb-electrophoresis showed HbA: 28.4%, Hb E: 71.6% on 1% agarose gel at alkaline pH (8.6) suggesting a diagnosis of homozygous HbE (EE) disease. Parent’s haemoglobin electrophoresis revealed both parents as haemoglobin E traits. Serum bilirubin (total) -3.2 mg/dl, mostly indirect (3.0 mg/dl), direct and indirect coomb’s tests were negative, antinuclear antibody (ANA) screening was negative, serum calcium was normal. Our final diagnosis was haemoglobin E disease with ITP and combined iron, folate and vitamin B12 deficiency.   The case aroused lot of suspicions like haemoglobinopathy, microangiopathic haemolytic anaemia with disseminated intravascular coagulation and combined iron and folate/vit B12 deficiency due to complex peripheral blood findings. Appropriate investigations finally revealed that it was a complex case of haemoglobin E disease with ITP and co-existent combined iron, folate and vitamin B12 deficiency. ITP is a relatively common disorder and highest incidence has been considered to be in the women aged 15 -50 years. It may be acute (childhood ITP) and chronic (adult ITP). The clinical features of ITP include abrupt or gradual onset of symptoms, purpura, menorrhagia, epistaxis, gingival bleeding. ITP is the most common cause of acute onset of thrombocytopenia in otherwise healthy child. In ITP, only platelet count is decreased but haemoglobin and leukocyte counts remain almost normal unless profuse bleeding occurs. Bone marrow usually reveals increased or normal number of megakaryocytes with some young forms. In our case instead of increase in young forms occasional hyperpolyploid megakaryocytes were present. This is probably due to co-existent folate and vitamin B12 deficiency. Granulopoiesis may be normal with some degree of marrow eosinophilia. This type of co-existent entities of multiple pathologies was not reported before in Bangladesh. It may be noted that presence of multiple pathologies, sometimes opposing in nature, may co-exist in a patient. Careful blood film examination by an experienced morphologist can guide investigations to the appropriate direction thus saving much time and money. References 2.   Shashik ant C.U. Patne, Jyoti Shukla. Hb-E disorders in Eastern Uttar Pradesh. Indian Journal of Pathology and Microbiology 2009; 52(1): 110-2. 4.   Gordon-Smith EC and Marsh JCW: Acquired haemolytic anaemias. In: Hoffbrand AV, Catovsky D, Tuddenham EGD, editors. Postgraduate Haematology 5th ed. 2005, Blackwell Publishing Ltd, Oxford, UK, 151-68. <![CDATA[Gitelman’s syndrome presented with tetany: a case report]]> Md. Zahid Alam AMB Safdar Shabnam Jahan Hoque Rownak Jahan Tamanna Rowsan Ara MM Zahurul Alam Khan https://imcjms.com/journal_full_text/222 2017-05-18 10:04:33 Clinical Case Report Ibrahim Med. Coll. J. 2012; 6(1): 34-36 Gitelman’s syndrome is an autosomal recessive disorder caused by a defect of the thiazide-sensitive sodium chloride co-transporter at the distal tubule, characterized by hypomagnesemia, hypokalemic alkalosis and hypocalciuria. We report a case of Gitlman’s syndrome in a 44 years old female patient who presented with generalized muscle weakness and carpal spasm and characteristic electrolyte abnormalities. This condition is sometimes confused with Bartter’s syndrome. Address for Correspondence:Dr. Md. Zahid Alam, Junior consultant, Department of Cardiology (Room: 813), BIRDEM Hospital, 122 Kazi Nazrul Islam Avenue, Shahbagh, Dhaka-1000, email: ilazybear@yahoo.com   Gitelman’s syndrome is an autosomal recessive disorders with characteristic metabolic abnormalities which are hypokalemia, metabolic alkalosis, hyperreninemia, hyperplasia of the juxtaglomerular apparatus, hyperaldosteronism and in some patients, hypomagnesemia.1-3 It is usually confused with Bartter’s syndrome and primary hyperaldosteronism. However, Gitelman’s syndrome is usually not present until adulthood and has hypocalciuria which are opposite features of Bartter’s syndrome. Gitelman’s syndrome also differs from primary hyperaldosteronism in two ways – the patients are not hypertensive and the plasma renin activity is increased which is not suppressed by aldosterone induced volume expansion.4,5 The estimated prevalence is approximately 1 per 40,000.6 It is often not diagnosed until late childhood or even adulthood.2 The dominant features are fatigue, weakness, muscle cramp, polyuria and nocturia.4,7,8 Here we report a case of Gitelman’s syndrome presented with tetany. Case report On examination, she was clinically euvolemic with normal skin turgor and no peripheral edema. Carpal spasm was present with positive Chvostek’s sign. The blood pressure was 110/70 mmHg and pulse rate was 84/ minute. Apart from mildly reduced ankle jerks there was no other neurological deficit or proximal muscle weakness. ECG showed prolong QT interval with hypokalemic changes. Laboratory investigations showed low serum potassium (2.4 meq/L), sodium (119 meq), chloride (75 meq/L), magnesium (0.4 mmol/L) and calcium (6.8 mg/dl). Serum bicarbonate was 28 meq/L while serum urea and creatinine were 12 mg/dl and 0.8 mg/ dl respectively. Blood pH was 7.50. The urinary calcium was subnormal at 18 mg/24 hour while on intravenous calcium supplementation (normal range 250 - 300 mg/24 hour in a high Ca2+ supplement). Urine sodium was 117 mmol/24 hour (40-220 mmol), potassium 22 mmol/24 hour (25-150 mmol) and chloride 115 mmol/24 hour (110-250 mmol). Urine specific gravity and urine osmolality were normal. Thyroid function tests (FT3, FT4, TSH), serum parathyroid and cortisol levels were normal. Ultrasound of the abdomen did not reveal any abnormality. Patient was treated with electrolyte supplement. But she did not recover from hypokalemia until spironolactone (100mg twice daily) was started. Based on the above features, the case was diagnosed as Gitleman’s syndrome. Discussion The tubular defect in sodium chloride transport is thought to initiate initial salt loss leading to mild volume depletion and activation of the renin-angiotensin-aldosterone system. The combination of hyperaldosteronism and increased distal flow, due to the reabsorptive defect, enhance potassium and hydrogen secretion at the secretory sites in the collecting tubules leading to hypokalemia and metabolic alkalosis. Because of the tendency to renal salt wasting, patients with Gitelman’s syndrome have a lower blood pressure than that seen in the general population.14,15 The hypocalciuria of Gitelman’s syndrome suggests the involvement of the distal convoluted tubule, where reduced chloride absorption is associated with augmented calcium absorption.16   1.   Stein JH. The pathogenetic spectrum of Bartter’s syndrome. Kidney Int 1985; 28: 85. 3.   Kurtz I. Molecular pathogenesis of Bartter’s and Gitelman’s syndromes. Kidney Int 1998; 54: 1396. 5.   Umami V, Oktavia D, Kunmartini S, Wibisana D, Siregar P. Diagnosis and Clinical Approach in Gitelman’s Syndrome. Acta Med Indones 2011; 43(1): 53-8. 7.   Monnens L, Bindels R, Grunfeld JP. Gitelman syndrome comes of age (editorial). Nephrol Dial Transplant 1998; 13: 1617. 9.   Barakat AJ, Rennert OM. Gitelman’s syndrome (familial hypokalemia- hypomagnesemia). J Nephrol 2001; 14: 43-7. 11.Nakamura A, Shimizu C, Nagai S. A rare case of Gitelman’s syndrome presenting with hypocalcemia and osteopenia. J Endocrinol Invest 2005; 28: 464-8. 13.Al-Ali N, Al-Sayed A, Ramadan A. A Case of Gitelman’s Syndrome Presenting with Hypocalcemia. Kuwait Medical Journal 2008; 40(1): 67-9. 15.Fujita T, Ando K, Sato Y. Independent roles of prostaglandins and the renin-angiotensin system in abnormal vascular reactivity in Bartter’s syndrome. Am J Med 1982; 73: 71. 17.Robson WL, Arbus GS, Balfe JW. Bartter’s syndrome. Am J Dis Child 1979; 133: 636-8. <![CDATA[Recurrent mediastinal lipoma: a case report]]> Jafreen Sultana Zinat Nasrin Md. Mahfuzar Rahman Nayeema Rahman Abul Khair Ahmedullah https://imcjms.com/journal_full_text/223 2017-05-18 10:11:44 Clinical Case Report Ibrahim Med. Coll. J. 2012; 6(1): 37-38 Mediastinal lipoma (ML) is a rare entity. Though the mediastinum is the most common site of intrathoracic lipoma, ML constitutes less than 1% of all mediastinal tumours. ML frequently presents on incidental radiographic finding, CT scan is considered the investigation of choice. CT features of lipoma are quite characteristic. They are clinically significant because: (1) Despite their benign nature, these tumours tend to reach an enormous size and can cause compression of lungs and mediastinal structures; (2) It may not always be possible to differentiate a ML from a liposarcoma by CT or MRI alone. Address for Correspondence:Dr. Jafreen Sultana Assistant Professor, Department of Radiology & Imaging, Ibrahim Medical College & BIRDEM Hospital, 122 Kazi Nazrul Islam Avenue, Shahbagh, Dhaka, Bangladesh   Most mediastinal lipoma are discovered incidentally. Although lipoma are the most common benign neoplasm, its occurrence within the thoracic cage is uncommon. In contrast to the frequently multiple subcutaneous lipoma, intrathoracic lipoma is usually a single lesion. Multiple intrathoracic lipomas have been reported rarely.1 Case Report On admission chest radiograph and CT scan were done. Chest X-ray P/A view showed a lobulated opacity in the left mid and lower zones near paracardiac location obscuring the left cardiac border and left hemidiaphragm. Ill-defined opacity was also seen in the right lower zone (Fig. 1a).       Fig 1b. Contrast enhanced CT scan of chest shows the non-enhancing fat density lesion in the anterior mediastinum. Her past history revealed that in the year 2002, the patient had a thoracotomy for anterior mediastinal mass. The patient was admitted with the same complain and a chest X-ray (Fig. 2a) and subsequent CT scan (Fig. 2b) revealed a large lesion mostly in right hemithorax and partly on the left side with evidence of compression on superior vana cava and pulmonary arteries with their posterior displacement. Significant lung compression was also present at that time. The patient underwent right sided thoracotomy on February 2002. The encapsulated mass was completely excised including the capsule. Histopathology revealed lipoma and no evidence of malignancy. Post operative recovery was uneventful with satisfactory lung expansion. The patient was alright for the last few years but again developed the same complaints of dyspnoea (2009) and was admitted in the hospital once again. As mentioned ealier, X-ray and CT scan revealed a lipomatous lesion which was subsequently cinfirmed by CT guided FNAC. The final radiological diagnosis was recurrence of mediastinal lipoma.     Fig 2b. CT scan of chest shows a large, non-enhancing hypodense mass in the anterior mediastinum.   Lipomas are well circumscribed mesenchymal tumors that originate from adipose tissue.2 They occur predominantly in the anterior mediastinum and are reported to represent 1.6-2.3% of all primary mediastinal tumours.3,4 Because of the slow growth of the lesions, the presenting symptoms are often due to mass effect (i.e., compression of primary bronchi, esophagus, phrenic nerve, or vagus nerve). Symptoms can include dysphagia, dyspnea, dry cough, jugular distension, and cardiac arrhythmias.2 Simple excision of this well-demarcated tumor can be performed if it is symptomatic. In its undifferentiated form, a liposarcoma may be identifiable from a lipoma due to the higher density and better enhancement. But this differentiation is lost in a well-differentiated and encapsulated liposarcoma.5 For this reason a complete excision is the diagnostic and therapeutic modality of choice. Where surgery is not contemplated as in small and asymptomatic lesion, a needle biopsy or a thoracoscopic incisional biopsy is necessary. When the report is a liposarcoma, an excision is essential. A biopsy picture of a lipoma in such a patient may be managed by clinical and chest CT follow up. When attempted, surgical removal of lipoma must be completed due to a tendency of recurrence. Conclusion   1.   Johansson L, Soderlund S. Intrathoracic lipoma. Acta chir Scand 1963; 126: 558-565. 3.   Baris YI, Kalyoncu AF, Aydiner A, Gulekon N, Eryilmaz M, Selcuk ZT, Sahin AA. Intrathoracic lipomas demonstrated by Computed Tomography. Respiration 1990; 57: 77-80. 5.   Tanaka F, Kitano M, Tatsumi A, Huang CL, Nagasawa M. A case of mediastinal liposarcoma. Nippon Kyobu Geka Gakkai Zasshi. J Jpn Thoracic Surg Soc 1992; 40: 1125-1130. <![CDATA[Critical care medicine in Bangladesh: a national health care challenge]]> Mohammad Omar Faruq https://imcjms.com/journal_full_text/212 2017-05-07 12:35:21 Editorial Ibrahim Med. Coll. J. 2011; 5(2): i-ii In general it is the most expensive, technologically advanced and resource intensive area of medical care. In the year 2000 in USA, the estimated expenditure for critical care medicine was arround $ 55 billion accounting for 0.5% of GDP and 13% of national health care expenditure.2 For Bangladesh we have no statistics to assess the share of critical care services in the overall health care cost of our country. The first ICU in Bangladesh was established in 1980 at National Institute of Cardiovascular Disease (NICVD). A study4 conducted in 2007 by the Department of CCM, BIRDEM General Hospital found total number of ICU beds to be 424 in 40 ICUs of Bangladesh, of which 80% were located in the city of Dhaka. 68% of ICUs were run by anesthesiologists who lacked proper training & qualifications in CCM. Only 15% ICUs were run by primary care Intensivists in the set up of closed ICUs as opposed to open ICUs which were more common. Several earlier studies5-6 showed that care provided by Intensivists in the set up of closed ICUs provided better outcomes and were more cost effective. In North America, CCM and in Europe, Intensive Care Medicine have been recognized as independent speciality over last 3-4 decades. In Bangladesh although relatively new, CCM is now being increasingly recognised as an important medical speciality. The first postgraduate MD course in CCM was introduced in 2007 by the University of Dhaka. Departments of CCM, BIRDEM General Hospital and Dhaka Medical College Hospital offer the same course and both the institutions together admit only 14 postgraduate students per year. But Bangladesh should by now have at least 600 postgraduate qualified Intensivists or critical care medicine specialists and atleast 5000 allocated ICU beds,7 for a total of 75000 general hospital beds.8 The other issue is the rapidly growing but poorly managed private ICUs rendering unethical standards of care. This has resulted in inappropriately high cost, increased mortality and poor outcomes of critically ill patients. Bangladesh Medical & Dental Council (BM&DC) in spite of its limitation of manpower should play a major role in enforcing operational registration for all these ICUs.   Mohammad Omar Faruq Ibrahim Medical College & BIRDEM General Hospital   1.   Ewart GW, Marcus L, Gaba MM et al. The critical 2.   Halpern NA, Pastores SM, Guerenstein RJ. Critical Care Medicine in USA 1985-2000, an analysis of bed numbers, use and costs. Critical Care Medicine 2004; 32(6): 1254-1259. 4.   Faruq MO, Ahsan ASMA, Fatema K, Ahmed F et al. An audit of Intensive Care Services in Bangladesh. Ibrahim Medical College Journal 2010; 4(1): 13-16. 6.   Hanson CW 3rd, Deutschman CS, Anderson Hl 3rd et al. Effects of an organized critical care service on outcomes and resource utilization: a cohort study. Critical Care Medicine 1999; 27(2): 270-4. 8.   Bangladesh Bureau of Statistics. Statistical pocket book of Bangladesh 2009; 2010: p 375. <![CDATA[Knowledge, Attitude and Practice of Hypercholesterolemic Type 2 Diabetic Subjects on Dyslipidemia]]> Farzana Saleh Shirin Jahan Mumu Fadia Afnan Liaquat Ali Habib Sadat Chaudhury Afroza Akhter Kazi Rumana Ahmed Sanzida Akter https://imcjms.com/journal_full_text/44 2016-08-02 10:23:57 Original Article Ibrahim Med. Coll. J. 2011; 5(2): 37-41 This study was undertaken to assess the knowledge, attitude and practice (KAP) of hypercholesterolemic type 2 diabetic subjects on dyslipidemia and to analyze the influence of some demographic and socioeconomic factors on the level of KAP.It was a descriptive cross-sectional survey. One hundred eleven newly diagnosed type 2 diabetic subjects (male 61%, female 39%, age 45±9 years, BMI 24±4.8 Kg/m2) with hypercholesterolemia (fasting plasma total cholesterol >200 mg/dl) were selected from the out patient department of BIRDEM by purposive sampling method. Data were collected by a pre-designed, pretested, interviewer-administered questionnaire. Three categories were defined on the basis of the score obtained by each subject namely low, medium and high as follows: knowledge-score <50%, 50-60% and >60%; attitude-score <60%, 60-80% and >80%; and practice-score <50%, 50-70% and >70% respectively. The levels of knowledge were low in 42%, medium in 35% and high in 23% of the study subjects. The corresponding attitude levels were low in 1%, medium in 31% and high in 68%, and the levels of practice were low in 80%, medium in 14% and high in 6% of the subjects. The knowledge score was higher in secondary and graduate (53.4±8.9%, and 54.9±10.1%) groups compared to illiterate-primary group (48.9±9.9%). Practice score of illiterate-primary group (34.5±16.8%) was lower than secondary and graduate (43.1±13.9% and 46.7±18.1%) groups, but they did not differ on attitude. The various income groups did not differ on knowledge. Attitude score of high-income group (78.7±8.4%) was better than low-income group (70.9±11.8%). Practice score in high-income group (44.7±16.0%) was better than medium income and low-income groups (31.3±14.5% and 28.6±15.0%). Knowledge and practice score in Bangladeshi hypercholesterolemic type 2 diabetic subjects are not satisfactory although they have fairly good attitude levels. Education and income status are the major determinants of knowledge, attitude and practice regarding dyslipidemia in diabetes. A coordinated  policy is required to promote knowledge and attitude on healthy lifestyle and to translate those into practice. Address for Correspondence:Farzana Saleh, Assistant Professor, Department of Community Nutrition, Bangladesh Institute of Health Sciences, 125/1 Darussalam Mirpur Dhaka-1216, Bangladesh. e-mail: farzanasaleh_sumona@yahoo.com   Diabetic dyslipidemia appears to be a very important component of the accelerated atherogenesis and cardiovascular disease that occurs in patients with diabetes. Dyslipidemia is observed practically in all patients with type 2 diabetes. It is possible to reduce mortality and cardiac events among patients with type 2 diabetes by lowering their LDL-C levels. Pharmacological and non-pharmacological therapy may be effective in the management of dyslipidemia with type 2 diabetic subjects. Non-pharmacological therapy includes dietary control and exercise. Changes in lifestyle and diet has increased the life expectancy as well as profoundly influenced the burden of  cardiovascular (CVD) and other chronic diseases.1-3 Determining the knowledge, attitudes and related practice of the population towards dyslipidemia is necessary before effective prevention strategies can be introduced. Dyslipidemia is a major problem in Bangladesh. A pilot study conducted on newly diagnosed type 2 diabetic patients in a tertiary hospital of Diabetic Association of Bangladesh showed that the prevalence of dyslipidemia with type 2 diabetic subjects were as follows-hypercholesterolemia 51%, hypertryglycerimia 47%, high LDL-C 10%, and low HDL-C 51%.4 To best of our knowledge KAP (knowlwdge, attitude and practice) of the diabetic patients regarding dyslipidemia has not never been studied before in Bangladesh although these are important for appropriate use of limited resources in health care in countries like Bangladesh. The aim of the study is to assess the KAP of hypercholesterolemic type 2 diabetic subjects on dyslipidemia and to analyze the influence of some of the demographic and socioeconomic factors on the level of KAP in a hospital situation. The results of this study may help to develop a hospital protocol for the management of patients with dyslipidemia. Material and Methods One hundred and eleven type 2 diabetic subjects with hypercholesterolemia (fasting serum total cholesterol >200 mg/dl5) were recruited from the Out-Patient Departments of BIRDEM which is a tertiary care hospital of Diabetic Association of Bangladesh. Study design   Methodologies adapted in different countries for KAP studies6-8 were modified in the context of Bangladeshi population. The KAP of the subjects was assessed by an interviewer-administered questionnaire. Likert scales9, 10 were used to assess attitude on various items. Detailed socioeconomic and anthropometry data of the study subjects were recorded. A biochemical report of the patients was collected from the patients’ guidebook. Knowledge was assessed by questionnaires based on definition, causes of hypercholesterolemia, control levels, recognition of complications, diet modification, importance and duration of exercise. The attitude was assessed by questionnaires about control of hypercholesterolemia through diet and exercise and finally practices were assessed by scrutinizing patients’ record books for clinical, biochemical and treatment parameters and by questionnaires on diet and exercise. Income was categorized into three groups: low income group (<30,000 BDT), medium income group (30,000- 50,000 BDT) and high income group (>50,000 BDT). Moderate worker was defined as shop assistants, drivers etc, heavy workers were farmers, fisherman, forestry workers and sedentary workers were office workers, students, unemployed etc. KAP Score   Data editing was carried out by checking and verifying the completed questionnaire at the end of interview and also at the end of the whole survey and before analysis. The data analysis was done by using Statistical Package for Social Science (SPSS,Windows version 10.0). P value less than or equal to 0.05 was considered significant. Unpaired student’s t test was performed to compare any two means. One-way ANOVA (with Post Hoc-Bonferroni) test was done to compare means between more than two groups. Results Among the study subjects, the levels of knowledge were low in 42%, medium in 35% and high in 23%. (Fig.1). The levels of attitude were also described accordingly as low 1%, medium 31% and high 68%. (Fig.1). The levels of practice of study subjects were found to be low in 80%, medium in 14% and high in 6% (Fig.1).   Fig-1. Levels of knowledge, attitude and practice of the study subjects The KAP scores of moderate, heavy and sedentary workers (52.7±10.6 vs 50.3±3.1 vs 50.6±9.6; 77.7±9.1 vs 76.6±11.8 vs 77.1±9.3; 39.7±15.5 vs 41.4±17.3 vs 42.6±18.3) did not differ significantly. The KAP scores of urban, semi-urban and rural residents did not significantly differ (52.1±10.2 vs 54.8±5.2 vs 51.5±10.4, 78.1±9.4 vs 83.5±5.1 vs 75.9±9.3, 43.1±17.5 vs 39.1±12.9 vs 33.5±15.1; P=ns). Compared with illiterate-primary group (48.9±9.9%) knowledge score was significantly high in secondary and graduate (53.4±8.9% and 54.9±10.1%, P=0.022) groups. Practice score of illiterate-primary group (34.5±16.8%) was significantly lower than secondary and graduate (43.1±13.9% and 46.7±18.1%, P=0.005) groups but they did not differ on attitude. Income group did not differ on knowledge. Attitude score of high-income group (78.7±8.4%) was better than low-income group (70.9±11.8%, P=0.02). Compared with high-income group (44.7±16.0%), practice score was better than medium income group and low-income group (31.3±14.5% and 28.6±15.0%, P=0.0001) (Table 3). Better knowledge was associated with better attitude (r= 0.275, p=0.004) and also better attitude was associated with better practice (r= 0.187, p=0.05). Table-1: Characteristics of the study subjects     Table-3: KAP score of the study subjects according to the different variables   Diabetic dyslipidemia is an important cause of accelerated atherogenesis and cardiovascular diseases in patients with diabetes. A person’s knowledge and attitude regarding the disease play an important role in the overall success of the treatment. To best of our knowledge, KAP of the diabetic patients regarding dyslipidemia have never  been studied in Bangladesh.   Diabetic Association of Bangladesh References 2.   Popkin BM, Horton S, Kim s. Trends in diet, nutritional status, and diet-related noncommunicable diseases in China and India: the economic costs of the nutrition transition. Nutr Rev 2001; 59:379-390. 4.   S Nahar, K Akter, T Ferdoushy, S Akhter, S Ahmed, F Akter, K Fatema, HS Chaudhuryand L Ali. Dietary fiber intake and prevalence of dyslipidemia in Type-2 diabetic subjects. IX Asian Congress of Nutrition. New Delhi 2003 February 23-27; India. 6.   Mehrotra R, Bajaj S, Kumar D, Singh K J. Influence of education and occupation on knowledge about diabetes controls. Natl Med J India 2000; 13: 293-296. 8.   Nicolucci A, Ciccarone E, Consoli A, Martino GD, Penna GL, Latorre A et al. Relationship between patient practice-oriented knowledge and metabolic control in intensively treated type 1 diabetic patients: results of the validation of the Knowledge and Practices Diabetes Questionnaire. Diab. Nutr. Metab. 2000; 13: 276-283. 10.Gardner PL. The Dimensionality of Attitude Scales: A Widely Misunderstood Idea. Int J of Sci Edu 1996; 18(8): 913-919. <![CDATA[Trends of antibiotic susceptibility of Salmonella Enterica serovar typhi and paratyphi in an urban hospital of Dhaka city over 6 years period]]> Khandaker Shadia Shajeda Binte Borhan Humaira Hasin Sharmin Rahman Shahin Sultana Lovely Barai MS Alam Jilani J. Ashraful Haq https://imcjms.com/journal_full_text/45 2016-08-02 10:25:55 Original Article Ibrahim Med. Coll. J. 2011; 5(2): 42-45 The antibiotic resistance pattern of salmonella is ever changing over time. The present study is a retrospective analysis of rate of isolation of Salmonella Typhi and Paratyphi and their antibiotic resistance pattern over 6 years period in an urban hospital of Dhaka city.  Blood culture submitted in BIRDEM hospital from 2004-2009 were analyzed. Isolated Salmonella sp were identified and antimicrobial susceptibility testing was carried out by a standard disc diffusion method. Ibrahim Med. Coll. J. 2011; 5(2): 42-45 Key words: Salmonella, antibiotic Introduction The present study investigated the trend of isolation of Salmonella species responsible for typhoid fever and their antibiotic resistance pattern over the last six years (2004-2009) in urban area of Dhaka city. Materials and Methods   A total of 385 Salmonella were isolated from blood cultures over the period of 6 years. S. Typhi was the predominant serotype followed by Salmonella Paratyphi A (Table-1). The isolation rate of S. Typhi has gradually decreased where as that of S. Paratyphi A has increased over last six years. Table-1: Species distribution of Salmonella sp. isolated between 2004- 2009     Fig-1: Single and multi drug resistance rate to 3 first line antibiotics namely ampicillin (AMP), chloramphenicol (CHLO) and cotrimoxazole (SXT) of isolated S. Typhi during 2004-2009. Note: 3 drugs indicate concurrent resistance to AMP, CHLO and SXT   Fig-2: The resistance pattern of isolated S. Paratyphi A to three first line anti- antibiotics during 2007-2009. Table-2 shows that 80-100% of the isolated S. Typhi and 75-94% of S. Paratyphi A were nalidixic acid resistant. There were no remarkable changes in the resistance pattern of S. Typhi and S. Paratyphi A to nalidixic acid in last 6 years. Only few isolates of S. Typhi were found fully resistant to ciprofloxacin during the period.   Table-2: Rate of isolation of nalidixic acid resistant S. Typhi and S. Paratyphi A from 2004-2009.   Discussion The number of S. Typhi simultaneously resistant to all three first line drugs namely ampicillin, chloramphenicol and cotrimoxazole declined towards 2007 and continued through 2009. It might be due to the loss of unstable resistant gene resulting from removal of selection pressure of these antibiotics.15 Re-emergence of the sensitivity to these drugs were also reflected from the individual upward trend of sensitivity pattern through recent years. S. paratyphi A showed moderate to high sensitivity to those drugs through out the last six years and there was only one multi drug resistant isolate out of total 81 isolates. Ciprofloxacin is being used as the first choice of empiric treatment of typhoid in Bangladesh for last several years. But the current study revealed that about 80-100% of S. typhi and S. Paratyphi A were resistant to nalidixic acid. The treatment of typhoid due to nalidixic acid resistant Salmonella sp with ciprofloxacin is less effective as there were reports of treatment failures from Bangladesh and other countries.7-10 It was due to higher minimum inhibitory concentration of ciprofloxacin of these isolates. Nalidixic acid resistant S. Typhi had been reported to have higher minimum inhibitory concentration of ciprofloxacin compared to susceptible strains.10 So, it has been recommended that quinolones should not be used as the first-line therapy in populations like Bangladesh where nalidixic acid resistance is common among isolates of salmonella. However, gatifloxacin may be used as alternative as because it has different mechanism to develop resistance than that of ciprofloxacin.17   1.   Rowe B, Ward LR, Threlfall EJ. Multidrug-resistant Salmonella typhi: a worldwide epidemic. Clin Infect Dis 1997; 24(Suppl 1): S106-9. 3.   Islam A, Buttler T, Kabir I, Alam NH. Treatment of typhoid fever with ceftriaxone for 5 days or chloramphenicol for 14 days: a randomized clinical trial. Antimicrob Agents Chemother 1993; 37: 1572-5. 5.   Asna SM, Haq JA, Rahman MM. Nalidixic acid resistant Salmonella enterica serovar Typhi with decreased susceptibility to ciprofloxacin caused treatment failure: a report from Bangladesh. Japanese J Infect Dis 2003; 56: 32-3. 7.   Slinger R, Desjardins M, McCarthy AE, Ramotar K, Jessamine P, Guibord C and Toy B. Suboptimal clinical response to ciprofloxacin in patients with enteric fever due to Salmonella spp. with reduced fluoroquinolone susceptibility: a case series. BMC Infectious Diseases 2004; 4: 36. 9.   Threlfall EJ,Ward LR. Decreased susceptibility to ciprofloxacin in Salmonella enterica serotype Typhi, United Kingdom. Emerg Infect Dis 2001; 7: 448-50. 11.Padmapriya V, Kenneth J, Amarnath SK. Re-emergence of Salmonella Paratyphi A: a shift in immunity? National Medical Journal of India 2003; 16: 47-48. 13.Baron EJ, Peterson LR, Finegold SM, editors. Enterobacteriaceae. Bailey and Scott’s diagnostic microbiology. 9th ed. St. Louis, MO: Mosby; 1994; 362–85. 15.Towner KJ.Bacterial genetics. In: Greenwood D. Slack RCB. Peutherer JF. Medical Microbiology.14th ed. New York: Churchill Livingstone. 1992; 85-94. 17.Pandit A, Arjya A, Day JN, Paudyal B, Dangol S, Zimmerman MD, Yadav B, Stepniewska K et al. An open randomized comparison of gatifloxacin versus cefixime for the treatment of uncomplicated enteric fever. Plos One 2007; 6: e542: 1-9. <![CDATA[Liver enzymes in diabetic and non diabetic subjects with clinically diagnosed hepatitis]]> Bidhan Chandra Sarkar Hasi Rani Saha Palash Kumar Sarker Niranjan Kumar Sana M Abu Sayeed Subhagata Choudhury https://imcjms.com/journal_full_text/46 2016-08-02 10:27:27 Original Article Ibrahim Med. Coll. J. 2011; 5(2): 46-50 The occurrence of liver disease and raised liver enzymes is common in diabetic patients and the increasing level of enzymes indicates the severity of hepatic injury. Very few studies have addressed this issue in Bangladesh though Bangladeshi population is very much susceptible to diabetes. The biochemical markers (ALT, AST, ALP, bilirubin) did not differ significantly between non-diabetic male and female subjects. Neither the differences were significant between diabetic males and females though the diabetic patients had higher level of markers. In contrast, when compared between diabetic and non-diabetic subjects there were striking differences in either sex. Compared with the non-diabetic the diabetic subjects had significantly higher level of ALT (48.3 vs. 277.0), AST (42.0 vs. 213.0) and ALP (148 vs. 302) in males (p<0.005 for all). Similarly, these values were found significantly higher in diabetic females than their non-diabetic counterparts (p<0.01). For bilirubin, it was also found significant in males (p<0.001). Ibrahim Med. Coll. J. 2011; 5(2): 46-50 Key words: Liver function tests (LFTs), bilirubin, ALT, AST, ALP, hepatitis. Table-1: Proportion of Diabetic and non-diabetic subjects referred to BIRDEM with the clinical diagnosis of chronic hepatitis     These biochemical markers when tested only for the abnormally elevated groups with the exclusion of normal values, as shown in table 2, the mean (±se) values were found markedly elevated in diabetic than their non diabetic counterparts in either sex. For example, male and female of non-diabetic groups showed mean (U/L) of ALT (48.3 vs. 51.9), AST (42.0 vs. 41.7) and ALP (148 vs. 154) almost within similar range. Similar range, though at much higher level, were also observed between male and female in diabetic groups. In contrast, when compared between diabetic and non-diabetic referred subjects there were striking differences. The mean values showed markedly elevated in diabetic than non-diabetic groups. Thus, these observations were for ALT (48.3 vs. 277.0), AST (42.0 vs. 213.0) and ALP (148 vs. 302) in males. Likewise, in females these were ALT (51.9 vs. 228.0), AST (41.7 vs. 205.0) and ALP (154 vs. 238). In either sex, the differences of ALT, AST and ALP between diabetic and non-diabetic subjects were found significant (p<0.005).  For bilirubin, it was also found significant in male (p<0.001); whereas, in females, comparison could not be made due to lack of non-diabetic patients (table 2).   Table-3: Pearson’s correlations ( r ) between biochemical markers for hepatitis in non-diabetic (n=100) and diabetic (802) subjects.     Discussion This study compared the biochemical markers, commonly used for liver function tests (LFT), between diabetic and non-diabetic subjects. The study is unique in the sense that there has been no such comparative study conducted on Bangladeshi population. But, the study has some limitations. Socio-demographic and clinical variables have not been taken properly and could not be analyzed. The study could have taken the final or confirmed diagnosis of the patients. Age, nutritional status, fasting blood glucose and lipids could have been the important biophysical variables for determination of association between liver enzymes. The study findings are consistent with other studies. Elevated activities of serum aminotransferases are a common sign of liver disease and are observed more frequently among diabetics than in the general population.12 In a previous study by Erbey et al, type-2 diabetes has been reported to be associated with mild (asymptomatic) elevations in the serum levels of certain enzymes including serum ALT.13 Elevated ALT levels have been reported as more frequently observed for diabetics than for the general population studies by Everhart JE.14  We found that the prevalence of elevated ALT and AST was higher in diabetic patients (1400 patients, male 808, female 592) than in non diabetic patients. The prevalence of elevated ALT and AST in type 2 diabetic patients was higher than general population,15 but lower than studies done in diabetic patients.16  M. A. Meybodi et al, of 348 patients that entered the study, mean age was 58.8±11.5. Elevated ALT and AST were found in 10.4 and 3.3% of type 2 diabetic patients, respectively. The prevalence of elevated ALT increased with increasing age. Overall, the prevalence of elevated alanine transaminase (ALT) was 10.4% (n=105) with the gender-wise prevalence of 12.8% (n=71) in men, and 7.4% (n=34) in women. The prevalence of elevated AST was 5.4% (n=56) with the gender-wise prevalence of 5.6 %( n=31) in men and 5.4 % (n=25) in women. Only 4.5% (n=44) showed elevated levels of both ALT and AST. Of patients with high ALT levels, 88 patients (83.8%) had mild, 13 (12.4%) had moderate, and only four patients (3.8%) had marked elevation of the enzyme activity. Male gender and high waist circumference were associated with an increased risk of elevated ALT levels. Younger patients had a higher tendency to have elevated ALT compared to those over 65 years. As age and nutritional variables were not included in the study these could not be compared.   Conclusion It may be concluded that the liver enzymes were found elevated in both diabetic and non-diabetic subjects who were referred with a clinical diagnosis of hepatitis. Very markedly elevated enzymes were found among the diabetic than non diabetic patients indicating hepatic injury was more likely among the diabetic patients. Further study may confirm these findings. It is suggested that other socio-demographic and biophysical risk factors are important to be investigated in order to prevent hepatic damage among the diabetic subjects.   References 1.   Bradley RF, Sagild V. and Schertenleib FE. Diabetes mellitus and liver function. New England Journal of Medicine1955; 253: 454-458. 2.   Guyton C. Text Book of Medical Physiology. 8th ed. W.B. Saunders Company, Harcourt brace Jovanovich Inc, Philadelphia, PA. 1991; 772-800. 3.   Consoli A, Nurjhan N, Capani F and Gerich J. Predominant role of gluconeogenesis in increased hepatic glucose production in NIDDM. Diabetes 1989; 38(5): 550-557. 4.   Chatila R and West AB. Hepatomegaly and abnormal liver tests due to glycogenesis in adults with diabetes. Med Balt 1996; 75: 327-333. 6.   Bowers GN Jr, and McComb RB. A continuous spectrophotometric method for measuring the activity of serum alkaline phosphatase. Clin. Chem 1966; 12(2): 70-89. 8.   Bessay OA, Lowry OH and Brock M. The determination of alkaline phosphatase activity from blood serum. J. Biol.chem 1964; 164: 321-329. 10.Bergmeyer HU, Herder M and Rej R. Approved recommendation 1985 on IFCC methods for the measurement of catalytic concentration of enzymes Part 3. (IFCC Method for Alanine aminotransferase. J Clin Chem Clin Biochem 1998; 24(15): 481-489. 12.Fagiuoli SR and Van Thiel DH. The liver in endocrine disorders. In: Rustgi VK, Van Thiel DH, editors. The liver in systemic disease. New York: Raven Press 1993; 285-301. 14.Everhart JE. Digestive diseases and diabetes. In: Diabetes in America. 2nd ed. National Institute of Health. National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: GPO: 1995; 457-483. 16.West J, Brousil J, Gazis A, Jackson L, Mansell P, Bennett A and Aithal GP. Elevated serum alanine transaminase in patients with type 1 or type 2 diabetes mellitus. Q. J. Med 2006; 99: 871-876. <![CDATA[Sonographic measurement of inferior vena cava diameter – a noninvasive tool to detect acute blood loss]]> Kanta Das Shamsi Ara Begum Sharmistha Dey MA. Quddus AS Mohiuddin https://imcjms.com/journal_full_text/47 2016-08-02 10:29:14 Original Article Ibrahim Med. Coll. J. 2011; 5(2): 51-53 Detection and monitoring of blood loss in trauma patients can often be challenging. Change in the inferior vena cava diameter (IVCd) occurs due to alteration in circulating blood volume (CBV) and blood loss. Ultrasonographic measurement of IVCd provides a noninvasive real-time information of the CBV. The present study was designed to determine whether acute blood loss could be detected by sonographic measurement of the IVCd. A total of 50 volunteer blood donors aged 18 to 57 years were studied in the Department of Radiology and Imaging of Dhaka Medical College Hospital (DMCH) from July 2004 to June 2005. The inferior vena cava diameters, both during inspiration and expiration were measured by ultrasound examination immediately before and after donation of a single unit (450ml) of blood. During examination, the transducer was applied to the epigastrium parallel to the median line about 2 cm to the right of it for sagittal sections, and at a right angle to the median line about 3 cm below the xiphoid process for transverse sections. In sagittal sections, the inferior vena cava behind the liver were imaged during inspiration and expiration. The mean diameter of IVC during expiration before and after the blood donation was 17.5mm (±1.56mm) and 11.93mm (±1.48mm) respectively. Likewise, the mean diameter of IVC during inspiration before and after the blood donation was 12.96mm (±1.61mm) and 7.58mm (±1.29mm) respectively. The decrease in INV diameter following blood loss was significant (p< 0.01). Thus, the acute depletion of CBV could be detected by measuring the change of IVCd by sonography. Further study may be undertaken to determine the relationship of unit change of IVCd due to acute blood loss in case of trauma or other conditions. Address for Correspondence:Dr. Kanta Das, Junior consultant, Department of Radiology and Imaging, BIRDEM, 122 Kazi Nazrul Islam Avenue, Shahbagh, Dhaka 1000, Bangladesh   Acute loss of blood or hemorrhage frequently occurs in accidents, trauma and other clinical conditions. Physicians lack accurate tools to quantify the amount of blood lost by examining the patient. Physical examination, vital signs, and laboratory evaluation of patients often are unreliable to determine the blood loss because of multiple factors.1-3 Traditionally, diagnostic peritoneal lavage has been the primary tool for assessing intraabdominal blood loss but it is invasive and somewhat non-specific. Increasingly, ultrasonography, a noninvasive bedside tool, is used to detect the subcapsular, intraparenchymal and intramesenterial hematomas.4 Sonographic measurement of the inferior vena cava (IVC) has been shown to correlate with the circulating blood volume (CBV). Using the correlation between IVC diameter (IVCd) and CBV, unique information regarding acute and ongoing blood loss and response to resuscitation of the trauma patient can be gained. This is an attractive tool for several reasons. First, it is a noninvasive bedside procedure and can be performed serially or when there is a change in the condition of the patient. The measurement of the IVCd is easily performed, and more importantly, this measurement is well suited to the trauma patient because it is performed in the supine position, requires no patient cooperation and less time consuming. The present study was designed to determine whether acute blood loss in a potential trauma patient could be detected by sonographic measurement of the IVCd and if repeated measurements of the IVCd could monitor ongoing blood loss. Materials and Methods   Fifty healthy blood donors (m/ f= 27/23) were studied. The mean diameter of IVC during expiration before blood donation was 17.50 ±1.55mm and after blood donation was 11.93±1.48mm. The difference of IVCd during expiration before and after blood donation was 5.58±0.71mm. The mean diameter of IVC in inspiration before and after blood donation was 12.96 ±1.61mm and 7.58±1.29mm respectively. The decrease of IVCd in inspiration after blood donation was 5.38 ± 0.77mm. The decrease of IVCd in both inspiration and expiration phase after blood donation was significant (p<0.1). Table: The sonographic measurement of the inferior vena cava diameter during inspiration and expiration   The objective of the study was to measure the change in the inferior vena cava diameter in relationship to blood loss. Voluntary blood donor was used as a model for trauma patients because a known amount of blood was removed from the circulating blood volume in a controlled fashion. In addition, the blood removed occurred over a brief period of time simulating acute blood loss condition in trauma. Normal diameter of IVC is 25mm.5 Lyon et al. (2004) with 31 volunteer blood donors demonstrated a significant (p<0.05) correlation between blood loss and change in IVCd in both expiratory and inspiratory phase.6 The change was approximately 5 mm decrease in diameter of IVC both during inspiration and expiration and was consistent regardless of the initial diameter. Our study also revealed that on an average, there was a 5 mm drop in diameter of IVC after 450 ml blood loss in both phase of respiration. Our data indicate that the measurement of the IVC diameter is a reliable indicator of blood loss, even in small amounts. The measurement of the IVCd is a powerful technique to evaluate hypovolemia due to internal and external hemorrhage as well as a guide in resuscitation in trauma patients. Areas of future study include the determination of minimum decrease in IVCd at which an individual would be expected to become hypotensive due to blood loss. Further studies may be undertaken to determine the unit change of IVCd predicting the change in CBV due to sudden blood loss in case of trauma or other clinical conditions.   1.   Wo C, Shoemaker W, Appel P, Bishop M, Kram H, Hardin E. Unreliability of blood pressure and heart rate to evaluate cardiac output in emergency resuscitation and critical illness. Crit Care Med 1993; 21(2): 218-223. 3.   Porter J, Ivatury R. In search of the optimal end points of resuscitation in trauma patients: a review. J Trauma 1998; 44(5): 908-914. 5.   Datta AK, Essential of human Anatomy, Part 1, 4th edition, Current book of international, Calcutta. 1999; 153-154. <![CDATA[Growth of very low birth weight infants and its association with feeding regimens]]> Mohammad Faizul Haque Khan MAK Azad Chowdhury Md. Mahbubul Hoque Mohammed Maruf-ul-Quader Mahfuza Shirin M Monir Hossain Rumana Aziz https://imcjms.com/journal_full_text/213 2017-05-07 12:49:38 Original Article Ibrahim Med. Coll. J. 2011; 5(2): 54-58 Clinical care of infants with very low birth weight (weighing<1500 gm at birth) in developing countries can be labour intensive and is often associated with a prolonged stay in hospital. Although several studies have shown the benefits of early discharge from the hospital for premature infants, it is still a common practice to delay discharge of these infants until they reach a weight of 2000 gm or more. The present study was undertaken to test the assumption that very low birth weight (VLBW) infants can attain optimum growth at home and to find its association with feeding regimens. This prospective observational study was conducted at Neonatal Out-patient Department, Dhaka Shishu  Hospital over a period of 1 year from January 2010 to December 2010. A total of 92 very low birth weight neonates were enrolled during discahrge in the Neonatal Unit of Dhaka Shisu Hospital. Out of these 92 neonates 16 neonates expired while 7, 4 and 1 neonates dropped out in the first, second and third follow up respectively. The neonates after discharge were fed on three types of feeding regimens at home. The feeding regimens were expressed breast milk (EBM), EBM+ infant formula (mixed feeding) and infant formula only).The outcome variable was growth in terms of increase in weight, length and occiputo-frontal circumference (OFC). The other outcome measures were respiratory tract infection (RTI), diarrhoea and anaemia, visit to physician and readmission to hospital for the morbidities they encountered. The neonates were observed up to three consecutive follow-ups from their date of discharge. The median gestational age at birth was 31 weeks. Approximately 57% of the neonates were admitted within 72 hours of birth with median age at admission being 24 hours. Females were slightly higher (54.3%) than the males (45.7%). The mean weight, length and OFC at admission were 1208 gm 39.8 cm and 28.3 cm respectively. The study demonstrated a steady increase of weight, length and OFC of the infants up to a median age of 6 months with mixed  and EBM feeding compared to infant formula group. Regarding RTI, diarhoea and anaemia  the breast fed group suffered less frequently than the groups fed with infant formula and EBM+infant formula groups. The frequency of visits to physician and hospital admission were significantly lower in the EBM group than the other two groups. Higher frequency of breast feeding reduced the chance of infection and its severity. Infants discharged below1500 gm grew well with exclusive breast milk. Address for Correspondence:Dr. Mohammad Faizul Haque Khan, Medical Officer, Department of Neonatology, Dhaka Shishu Hospital, Dhaka, Bangladesh E-mail: khan.faizul@gmail.com   Management of very low birth weight (weighing < 1500 gm) infants has always been a problem for both clinician as well as parents. In the developed world survival and outcome of these infants have improved tremendously in recent years accounting for 80 – 90% survival rates for infants weighing 750 – 1500 gm [1,2]. Early neonatal intensive care unit (NICU) discharge has been advocated for selected preterm infants to reduce both the adverse environment of prolonged hospital stay and to encourage earlier parental involvement by empowering parents to contribute to the ongoing care of their infants and thereby reducing costs of care. Although several studies have shown the benefits of early discharge from the hospital for premature infants, it is still a common practice to delay discharge of these infants until they reach a weight of 2000 gm or more [3,4]. The consequences of prolonged hospitalization are well-established. They are maternal deprivation affecting the growth and development of the infants [5], skilled nursing time that should be devoted to sick infants are spent in the routine care of healthy infants, chances of increased nosocomial infection and considerable drain of scarce health resources [3,6]. In this context, several studies concurrently reported some criteria needed to be achieved before hospital discharge of the premature infants. The creteria were temperature stability out of an incubator, ability to suck and gain weight on oral intake and no symptoms [3,4,7]. All these studies suggest that achieving these criteria, instead of attaining a targeted weight, are sufficient to augment normal growth, reduce the incidence of RTI, diarhoea and recurrent hospitalization provided the feeding  regimen is nutritionally sound. The World Health Organization (WHO) is in favour of mothers’ milk alone during the first six months of life [9], though research data from industrialized countries suggest that VLBW infants require additional nutrients which is unavailable in unmodified mothers’ milk [10]. Another study reported that infants fed on Preterm Formula (PTF) grew significantly better than those fed on breast milk alone or in combination with PTF. These trails demonstrate that WHO feeding strategy is not enough for VLBW infants during the first month of life [11]. Faced with this background, the present study was undertaken to determine whether preterm neonates discharged at or below 1500 gm can attain optimum growth  at  home care with appropiate feeding regimens. The effetcs of different feeding regimens on subsequent morbidity was also assessed. Material and Methods At discharge mothers were instructed as to how to take care of their neonates and to bring them regularly at follow up clinic specially designed to provide care for the VLBW babies. The neonates were observed up to three consecutive follow-ups from their date of discharge. In the follow up sessions information was collected on weight, length, OFC and other pertinent variables. Data were analyzed using SPSS (Statistical Package for Social Sciences) version 11.5. The statistics used  were Chi-square (c2) or Fisher’s Exact Probability Test and ANOVA . Results Baseline characteristics show that median gestational age at birth was 31 weeks. Approximately 57% of the neonates were admitted within 72 hours of birth with median age at admission being 24 hours. Females were slightly higher (54.3%) than the males (45.7%) (Table-1). Table-1: Baseline characteristics of neonates(n = 92)     At 1st follow up     At 2nd follow up   Anthropometric measurements at 3rd follow up (median follow up time 6 months) demonstrated that infants of mixed feeding and EBM groups  had the almost similar gain in  weight (6683±395, 6565±503).  Infants fed   with infant  formula alone had  much lower wieght gain then the above two groups (6235±351, p=0.001). Increase in OFC was also observed  significantly faster in EBM and mixed feeding groups than that in infant formula group (p=0.003), although increase in length was almost identical in all the three groups (p = 0.293). Feeding pattern and comorbidity     Visit to physician and hospital admission Causes of hospital admission   Conventionally preterm infants are discharged from the hospital when they reach a prefixed weight, although no published studies support the benefit of attaining a specific weight before discharge. Several published studies dating from as early as 1971 have presented data supporting earlier nursery discharge [1-4,6,7,12,13]. These studies have put emphasis on infant’s capabilities related to maturity rather than weight as discharge criteria. All have selected infants on the basis of their ability to feed and maintain body temperature. In the present study as well the infants were selected at discharge on the basis of their ability to maintain body temperature outside incubator, able to suck and gain weight on oral intake with no symptoms of systemic illness. No clear-cut feeding policy was suggested, though breast milk was encouraged. The neonates after discharge fed on three types of feeding regimens at home. The study demonstrated a steady growth of the infants up to a median age of 6 months with EBM and mixed feeding compared to infants fed on formula only. However, all the three groups of neonates experienced RTI, diarhoea and anaemia to some extent with breast feeding group suffering less frequently than the infant formula and mixed formula groups. The frequency of visits to physician and hospital admission were significantly lower in the EBM group than the other two groups. Frequency of health service utilization was less in EBM group indicating less severity of infections in this group than their two other counterparts. The present study showed that breast milk alone was adequate to achieve a targeted growth for VLBW infants. Higher frequency of breast feeding lowered the chance of infection and its severity. The study, therefore, concludes that VLBW infants, discharged on the basis of their behavioral criteria, grow well provided their feeding regimen is nutritionally sound. References 2.  Fanaroff AA, Hack M, Walsh MC. The NICHD neonatal research network: changes in practice and outcomes during the first 15 years. Semin Perinatol 2003; 27: 281-7. 4.  Schmidt RE, Levine DH. Early discharge of low birth weight infants as a hospital policy. J Perinatol 1990; 10: 396-8. 6.  Casiro OG, McKenzie ME, McFadyen L et al. Earlier discharge with community-based intervention for low birthweight infants: a randomized trial. Pediatrics 1993; 92: 128-34. 8.  Were FN, Bwibo NO. Neonatal nutrition and later outcomes of very low birthweight infants at Kenyatta National Hospital. African Health Services; 7(2):       108-14. 10.Brooke OG, Wood Cand Barley J. Energy balance, nitrogen balance, and growth in preterm infants fed on expressed milk, a preterm infant formula, and two low-solute adapted formulae. Arch Dis Child 1982; 57: 898-904. 12.Lucas A. Early nutrition and later outcome. Nutrition of the very low birth weight infant. Nestle Nutrition Workshop Series, Lippincott Williums & Wilkins, Philadelphia, 1999; 43: 2-18. 14.Lucas A, Morley R, Cole TJ, Gore SM. Early diet in in preterm babies and developmental status at 18 months. The Lancet 1990; 335: 1477-81. <![CDATA[Distribution of phenotypic and genotypic ABO and rhesus blood groups among Bangladeshi population]]> Tashmim Farhana Dipta Md. Roushan Iqbal Ahmed Zahid Hossain Md. Tahminur Rahman Subhagata Chowdhury https://imcjms.com/journal_full_text/214 2017-05-07 12:57:48 Original Article Ibrahim Med. Coll. J. 2011; 5(2): 59-62 The present study is a retrospective analysis of allelic frequency of ABO and Rhesus (D) blood groups of donors attending the Deaprtment of Transfusion Medicine of Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka. BIRDEM IS a 625 bed hospital, where patients and blood donors come from all parts of Bangladesh. A total of 1, 28,506 blood donors of both genders were included in the study over fourteen years from June 1995 to June 2009 for analysis. Blood group was determined by performing the both tube and slide method blood grouping method. The distribution of blood groups in our population was B>O>A>AB in Rh positive groups donors and O>B>A>AB among Rh negative donors. Blood group B was more common among the males (37.42%) while O was predominant among female donors (33.83 %). On the other hand, blood group O negative was predominant in both genders (36.88%). In this study, Hardy- Weinberg equilibrium law was used to calculate the allelic frequency for ABO/ Rh system. Homozygous allelic frequency for Rh negative population was only 0.0007. Although phenotypically B group was dominant and AB was rare in our population, but according to Hardy- Weinberg equilibrium law the estimatedallelic frequency of A (0.3694) and O (0.3040) showed higher frequency than B type (0.2300) in Bangladeshi population in both homozygous and heterozygous state. So, with increasing population of Bangladesh, this changing trend in estimated blood group in ABO system may play an important role in our genetic pattern. Address for Correspondence:Dr. Tashmim Farhana Dipta, Associate Professor, Department of Transfusion Medicine, BIRDEM Hospital and Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbagh, Dhaka-1000, Bangladesh; email: tashmim@yahoo.com   The ABO and Rhesus (RhD) blood groups and the allelic frequencyvary amongst the different population of the world. It varies from race to race, one country to another and even in different regions of a country [1-15]. This spectrum of difference may be attributed to genetic factors and natural selection which is affected mainly by traditions and habits namely exogamy and endogamy. Global frequency pattern of the type B blood allele is highest in central Asia and in few pockets of Africa but lowest in the America and Australia [2,15]. On the other hand, equal dominance of group B and O is seen among the population of Indo-Pak subcontinent including Bangladesh and India [9,15-17). Previous studies among Bangladeshi population reported that blood group B as the most common type followed by O and A type while group AB type as the least [16]. Limited studies among Bangladeshi population of Rajshahi, Jessor, Faridpur, Khulna and Nilphamari districts reported the frequency of blood group B from 32.58%to 35.20% [11,16].   This study was carried out in the Department of Transfusion Medicine of Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka. Blood groups of 1,28,506 donors attending BIRDEM from June 1995 to June 2009 of both genders were analyzed. Forward grouping or cell typing was done on red blood cells after adding anti-A, anti-B and anti-AB antiserum (Biotec Laboratories, UK) and reverse grouping or serum typing was done on serum with known A, B and O cell (pool, freshly prepared). Presence of RhD antigen was determined by anti-D (Biotech Laboratories LTD, UK and Serological Lab, UK). Coomb’s reagent (Serological Lab, UK) was used for the detection of Rhesus (Rh) weak D (Du). The data were analyzed for the  frequency of ABO and Rhesus blood groups. The Hardy-Weinberg equilibrium was used to calculate the estimated allelic or genotypic frequency of ABO/Rh blood group system in our studied population [17]. Results     Table-2: Distribution of Rhesus blood groups among different ABO blood groups of study population     Table-4: Expected phenotypic and genotypic frequencies of the ABO and Rhesus blood group system according to Hardy –Weinberg equation.   In our study population, blood group B was the predominant phenotype (34.56%) among ABO blood group system with dominant Rhesus D positivity (97.41%). Blood group AB was rare in both genders. Our study correlates with the studies done in India and Pakistan [9,2]. The studies reported the frequency of blood group B in India and Pakistan as 32.50% and 34.00% respectively. Our study also correlates with the previous study done among Bangladeshi population, where B group was reported as 35.20% to 32.58% [11.16]. But a study conducted on haemato-onchology patients showed O as the predominant blood group [14] . Our study also differs with an Indian study, where distribution of ABO and RhD blood group among 150,536 blood donors in Christian Medical Collage Hospital, Vellore showed O blood group as the predominant (38.75%) type [9].  The prevalence of RhD positive rate correlates well with other reported studies from Bangladesh, India and Pakistan.   1.   Boskabody MH, Shademan A. Ghamami G, Mazloom R. Distribution of blood groups among population in the city of Mashhad (North East of Iran). Pak J Med Sci.2005; 21(2): 194-8. 3.   Shtayeh MSA, Hamlin AH, Fendy YR. Distribution of ABO  blood group and Rh factor in Palestinian living in the Northern part of the west Bank. Najah Res J 1988; 2(1): 35-41. 5.   Awny AY, Kamel K, Hoerman KC. ABO blood groups and hemoglobin variants among Nubian Egypt. UAR Amer J Phys Anthro 1965; 23: 81-2. 7.   Al-Khafaji SD, Al-Rubeaj MA. The Frequency of ABO and Rh(D) blood groups in Kurdish population of Iraq. Ann Hum Biol 1976; 3(2): 189-91. 9.   Das PK, Nair SC, Harris VK, et al. Distribution of ABO and RhD blood groups among blood donors in a tertiary care centre in South India. Trop Doct. 2001; 31(1): 47-8. 11.Hossain MM, Khyirul Ataturk SFM, Saifuddin Ekram ARM, Azad MAK. Study on ABO and Rhesus Blood Groups in Rajshahi Medical College Hospital. Journal of Teachers Association RMC, Rajshahi 2004; 17(1): 38-40. 13.Ahamad MSU, Mirjada MR, Pahan D. Pattern of ABO and Rh (D) blood group among leprosy patients. Journal of Chittagong Medical College Teachers’ Association 2008; 19(2): 51-3. 15.Anees M, Mirza MS. Distribution of ABO and Rh blood group alleles in Gujrat region of Punjab, Pakistan. Proc. Pakistan Acad Sci 2005; 42(4): 233-8. 17.Merten, TR. Introducing students to population genetics and the Hardy-Weinberg Principle. The American Biology Teacher 1992; 54(2): 103-107. <![CDATA[Diseases of social and mental health: are we concerned?]]> M Abu Sayeed https://imcjms.com/journal_full_text/202 2017-04-30 14:51:02 Editorial British Crime Survey (2009/10) reported that violence against girls and women are becoming a common hidden crime in UK.1 At least 1 in 4 women in the UK experienced domestic abuse in their lifetime; almost 1 in 5 women are likely to experience sexual assault in their lifetime. It is estimated that about 66,000 women in England and Wales have had female genitals mutilated (FGM) and 100-140 million women have undergone FGM worldwide. The Bureau of US Statistics (1998) reported – “just over 1,800 murders were attributable to intimates in 1996; nearly 3 out of 4 of these had a female victim; in 1976 there were nearly 3,000 victims of intimate murder”.2 Overall, 65 percent of all intimate murders were committed with a firearm. In 1996, women in the USA experienced an estimated 840,000 rapes, sexual assault, robbery and aggravated assault.2 The declining trend of SC in the USA over the last four decades resulted in a fundamental shift in: a) Political and civic engagement: Voting, political knowledge, political trust, and grassroots political activism are all down.3,4 Americans sign 30 per cent fewer petitions and are 40 per cent less likely to join a procession of protest, as compared to just 3 to 4 decades ago. The declines are in community life: membership and activity in all sorts of local clubs, civic and voluntary organizations have been falling at an accelerating pace. In the mid-1970s the average American attended some club meeting every month, by 1998 that rate of attendance had been cut by nearly 60 per cent. b) Informal social ties: In 1975 the average American entertained friends at home 15 times per year; the equivalent figure (1998) is barely half that. Virtually all leisure activities that involve doing something with someone else, from playing volleyball to playing chamber music, are declining. c) Tolerance and trust: Americans trust one another less now than in the past. Survey data provide, for example, employment opportunities for police, lawyers, and security personnel were stagnant in the past - had fewer lawyers per capita in 1970 than in 1900. But in the last quarter century with the erosion of SC and trust these occupations have boomed, as people have increasingly turned to the courts and the police.4,5 The elements of SC are bonding, bridging, and linking characterized by strong ties within a network that strengthen common identities and functions as a source of help and support among members, ties that link people from different networks together and become important sources of information and ties between people in different hierarchies. Studies have found that walking, cycling, public transport sharing, friendly neighborhoods can help create more SC through enhanced levels of community and social engagement and social relationships. Improved social life would provide more local schools, parks, play ground or other places where people interact and provide gathering spots for teens and the elderly. The poor quality of relationships between teens and elderly predict poor future health, both physical and mental. Lack of care, support and warmth, and conflict, over-control and inappropriate discipline appear to be detrimental to health. The impact of poor social relationships could be demonstrated on health, symptoms of common health problems, mental health and specific diseases such as cardiovascular disease, cancer, musculoskeletal problems, depression and attempted suicide. Child development is powerfully shaped by rich SC. Trust, networks, and norms of reciprocity within a child’s family, school, peer group, and larger community have far reaching effects on their opportunities and choices, educational achievement, and hence on their behavior and development. People are friendlier, and the streets are safer. Places have higher crime rates in large part because people don’t participate in community organizations, don’t supervise younger people, and are not linked through networks of friends. Regular club attendance, volunteering, entertaining, or attending cultural or traditional or national festivals is the happiness equivalent of getting a college degree or more than doubling one’s income. The SC becomes mentors helping our children to become compassionate, courageous, respectful, confident and purposeful. The greatest gift SC can give our children is the authentic self-esteem that comes from developing their virtues — becoming contributors rather than consumers. To reduce the prevalence of DSMH and crimes the world needs people willing to volunteer community responsibility with the maxim – “think together and work together, share miseries and happiness together”.   Professor, Department of Community Medicine   Source information 2.   U.S. Department of Justice, Prevalence, Incidence, and Consequences of Violence against Women: Findings from the National Violence against Women Survey, November 1998. 4.   Putnam RD. Bowling Alone: The collapse and revival of American community, New York: Simon and Schuster 2000; 288-290. <![CDATA[Diagnostic significance of pleural fluid adenosine deaminase activity in tuberculous pleurisy]]> Sharmeen Ahmed Reaz Fatema Ahmed Abu Saleh Humayun Sattar Md. Ruhul Amin Miah https://imcjms.com/journal_full_text/40 2016-08-02 10:08:02 Original Article Ibrahim Med. Coll. J. 2011; 5(1): 1-5 Diagnosis of tuberculous pleural effusion (TPE) is difficult because of its non-specific clinical presentation and insufficient efficiency of conventional diagnostic methods. The study was carried out to evaluate the utility of adenosine deaminase (ADA) activity in pleural fluid for the diagnosis of TPE. ADA activity was measured in pleural fluid of 103 pleural effusion patients by colorimetric method using a commercial ADA assay kit. The diagnosis of TPE was made from pleural fluid examinations (including cytology, biochemistry, and bacteriology) and pleural biopsy. Patient with negative result of this methods were diagnosed by response of empirical treatment. Out of 130 cases, 62 (61.1%) had TPE and the remaining 41 (39.8%) had pleural effusion due to non tuberculous diseases. There was statistically significant difference (p < 0.001) between the mean of pleural fluid ADA levels (70.82±22.54 U/L) in TPE group and (30.07±22.93 U/L) in non-TPE group. Of 62 TPE cases, microscopy for AFB and culture for M.tuberculosis in pleural fluid revealed positivity in 9.6% and 22.5% cases respectively, and biopsy of pleura showed typical epithelioid granuloma in only 43.5% cases. The cut-off value of ADA for diagnosing TPE was 40 U/L using a ROC curve, with a sensitivity of 94% and specificity of 88%. Positive and negative predictive value of ADA assay were 92% and 90% respectively. The overall test accuracy was 90%. Pleural fluid ADA assay is therefore a simple, rapid, highly sensitive and specific adjunct test for diagnosis of TPE. Address for Correspondence:Dr. Sharmeen Ahmed, Associate Professor, Department of Microbiology and Immunology, Bangabandhu Sheikh Mujib Medical University(BSMMU), Shahbagh, Dhaka-1000   Bangladesh ranks sixth in the world of tuberculosis (TB) disease burden with estimated 300,000 new cases and 70,000 death per year.1 Pleural tuberculosis is a common manifestation of extrapulmonary TB and with or without pulmonary TB, is present in around 4% of all TB cases.2 If undetected, it may resolve spontaneously, but untreated pleural TB is a progressive disease with high recurrence rate. Diagnosis of pleural TB is difficult because of non-specific clinical presentation and insufficient efficiency of traditional diagnostic methods due to paucity of bacteria in pleural cavity.3,4 Pleural biopsy has been the gold standard in diagnosis but is invasive and often requires several attempts to locate the infectious loci.4 Present study tried to find out the significance of Adenosine deaminase activity in pleural fluid for the diagnosis of tuberculous pleural effusion. Materials and Methods This cross sectional type of comparative study conducted in 103 pleural effusion patients admitted to in-patient departments of Bangabandhu Shiekh Mujib Medical University (BSMMU) and National Institute of Disease of Chest and Hospital (NIDCH) during the period of January 2008 to December 2008. All patients underwent thoracentesis and parietal pleural biopsy with Abram’s needle by trained physicians. Patients with empyema thoracis, haemothorax and patients on anti-tuberculous treatment were excluded from the study. Laboratory methods Effusions were classified as transudates or exudates using Light’s criteria9 and this required a blood sample to be collected on the day of thoracentesis in order to measure total protein and LDH. Three pieces of pleural tissue were taken for histology. Diagnostic criteria Malignant pleural effusion was diagnosed when malignant tissue was shown by pleural tissue or cytopathology. Some of the malignant cases were diagnosed by fiber optic bronchoscopy. Effusion was considered parapneumonic when there was an acute febrile illness associated with pneumonia and complete response to antibiotic treatment. Rest of the non-tuberculosis patients (nephrotic syndrome, congestive cardiac failure and rheumatoid arthritis) were diagnosed by standard clinical procedure. Statistical analysis   Out of 103 pleural effusion cases, 62 (60.1%) were diagnosed as tuberculous pleural effusion (TPE) and 41 (39.1%) were non-TPE cases. The non-TPE cases group included 30 (29.1%) cases with malignant pleural effusion, 8(7.7%) patients with parapneumonic effusion and 3 cases of effusion due to nephrotic syndrome, cardiac failure and rheumatioid arthritis each. Among the 62 of TPE, 49 (79%) were male and 13 (21%) were female with a male female ratio 3.8:1. The mean age of all tuberculous cases was 35.85±14.59 years.   Fig-1. ROC plot of pleural fluid ADA activity. Dotted diagonal line indicates the line of no discrimination         Discussion TPE represent an immunological reaction to relatively few AFB in pleural space. Hence direct examination of pleural fluid by Ziehl-Neelsen (Z-N) staining has low sensitivity (0-10%).14,18,19 In the present study, Z-N staining of pleural fluid revealed positivity in 9.6% cases and pleural fluid culture yielded M.tuberculosis in 22.5% cases. Culture requires a minimum of 10-100 viable bacilli and, therefore, is more sensitive than Z-N staining.20 Majority of series showed diagnostic yields of <30%.18,21,22 Presence of granulomatous inflammation is frequently used as a diagnostic criteria for TPE,23,18 and biopsy of parietal pleura showed typical epithelioid granuloma in 50% to 84% of TPE cases.23,24,25 In this study, pleural biopsy showed diagnostic granuloma in only 43.5% of TPE cases. The low positivity might be due to non repetition of pleural biopsy in this series. Moreover, biopsy requires greater expertise and subject to sampling error to locate the infection foci.4     1.   WHO report 2008. Global tuberculosis control, country profile, Bangladesh. Geneva WHO 2008. 3.   Laniado-Laborin R. Adenosine deaminase in the diagnosis of tuberculous pleural effusion: Is it really an ideal test? A word of caution. Chest 2005; 127: 417-8. 5.   Barnes PF, Mistry SD, Cooper CL, Pirmex C, Tea TH, Modlin. Compartmentalization of CD4+ T lymphocyte subpopulation in tuberculous pleuritis. J Immunol 1989; 142: 1114-9. 7.   Perez-Rodriguez E, Walton IJP, Hernandez. JJS, Pallaris E, Rubi J, Castro DJ, Diaz Nuevo G. ADA1/ADAp ratio in pleural tuberculosis: an exellent diagnostic parameter in pleural fluid. Respir Med 1999; 93(11): 816-21. 9.   Light RW. Diagnoistic principles in pleural disease. Eur Respir J 1997; 10: 476-81. 11.Riantawan P, Chaowalit P, Wongsangiem M and Rojanaraweewong P. Diagnostic value of pleural fluid adenosine deaminase in tuberculous pleuritis with reference to HIV coinfection and a Bayesian analysis. Chest 1999; 116: 97-103. 13.Banales JL, Pineda PR, Fitzgerald JM, Rubio H, Selman M, and Salazar-Lezama M. Adenosine deaminase in the diagnosis of tuberculous pleural effusions, a report of 218 patients and review of the literature. Chest 1991; 99: 355-7. 15.Valdes L, Jose ES, Alvarez D, Valle JM. Adenosine deaminase (ADA) isoenzyme analysis in pleural effusions: diagnositc role and relevance to the origin of increased ADA in tuberculous pleurisy. Eur Respir J 1996; 9: 747-51. 17.Haque ME, Ahmad MM, Hiron MM. Aetiological diagnosis of pleural effusion. Chest & Heart Journal 2000; 24(1): 1-4. 19.Escudero-Bueno C, Garain-Clemente M, Cuesta-Castro B, et al. Cytologic and bacteriologic analysis of fluid and pleural biopsy with cop’s needle. Arch Intern Med 1990; 150: 1190-4. 21.Liam CK, Lim KH, Wong CMM. Tuberculous pleurisy as a manifestation of primary and reactivation disease in a region with a high prevalence of tuberculosis. Int J Tuberc Lung Dis 1999; 3(9): 816-22. 23.Seibert AF, Haynes J, Middleton R, Bass JB. Tuberculous pleural effusion. Twenty year experience. Chest 1991; 99: 883-6. 25.Relkin F, Aranda CP, Garay SM, et al. Pleural tuberculosis and HIV infection. Chest 1994; 105: 1338-41. 27.Chen ML, Yu WC, Lam CW, Au KM, Kong FY, Chan AY, Diagnostic value of pleural fluid adenosine daminase activity in tuberculous pleuritis. Clin Chim Acta 2004; 341(1-2): 101-7. <![CDATA[Inducible clindamycin resistance among staphylococci isolated from clinical samples in an urban hospital of Dhaka city]]> Shameem Akhter S M Zahurul Haque Asna M Mushfequr Rahman https://imcjms.com/journal_full_text/41 2016-08-02 10:09:44 Original Article Ibrahim Med. Coll. J. 2011; 5(1): 6-8 Inducible clindamycin resistance was deremined in 200 clinical isolates of staphylococci from pus (53.5%) and wound  swab (46.5%). The study was done from July 2009 to June 2010, in the Department of Microbiology, BIHS Hospital Dhaka. Inducible clindamycin resistance was demonstrated by placing an erythromycin disc (15 mg) 15 mm apart from the edge of a clindamycin (2 mg) disc in Mueller Hinton agar. When the clindamycin inhibited zone becomes D- shaped the organism was regarded as postive for inducible resistance (D- test positive). Out of 200 staphylococci, 20% had inducible clindamycin resistance, 5% had constitutive clindamycin resistance and remaining 75% was clindamycin sensitive. In case of methicillin resistant Staphylococcus aureus (MRSA), 48% had inducible clindamycin resistance while 11.5% was constitutively resistant to clindamycin and remainder were clindamycin sensitive. All clindamycin resistant strains were 100% sensitive to vancomycin and linezolid followed by gentamycin (42%) and tetracycline (42.3%). The findings demonstrated that a substantial proportion of staphylococci in our tertiary care hospital had inducible   resistance to clindamycin. Address for Correspondence:Dr. S M Zahurul Haque Asna, Professor, Department of Microbiology, Bangladesh Institute of Health Sciences(BIHS), 125/1 Darussalam, Mirpur, Dhaka-1216, Bangladesh. e-mail: asnabd04@yahoo.com   Multidrug resistance is an ever increasing problem in staphylococci which is responsible for nosocomial as well as community acquired infections.1 Methicillin resistant Staphylococcus aureus (MRSA) poses special threat to treatment because these are resistant to most common drugs.2,3 So, newer drugs are needed to treat infections with MRSA. The prevalence of positive D–test has been reported as 21.9% in all staphylococcal strains, 24.4% in MRSA and 14.8% in MSSA (methicillin sensitive Staphylococcus aureus) in India.5 The rate in methicillin sensitive and resistant coagulase negative Staphylococus (CoNS) are 25.7% and 19.9%  respectively.5   The study was conducted over a period of one year from July 2009 to June 2010 at the Department of Microbiology, BIHS hospital, Mirpur, Dhaka. Clinical specimens such as pus and wound swab were cultured and Staphylococcus was identified following standard procedure.7,8 The erythromycin-clindamycin double disc susceptibility test (D-test) was performed as per CLSI guideline 2004.6 An erythromycin disc (15 mg) was placed 15mm apart from the edge of a clindamycin (2 μg) disc in Mueller Hinton agar media. When the clindamycin zone became D- shaped, the organism was regarded as positive for inducible resistance to clindamycin (D- test positive, Fig-1).6,7 Fig-1. D-test positive isolate showing flattening of zone of inhibition of clindamycin towards to erythromycin disc Results     Table-2: Antibiotic susceptibility profile of Clindamycin resistant MRSA (n=52)   Clindamycin, though not a new drug and is used for other purposes, can be used for the treatment of MRSA and multiple resistant staphylococci. It is a lincosamide drug having good tissue penetration and is well tolerated even in kidney diseases.4 This study has been conducted to see the prevalence of inducible clindamycin resistance among clinical isolates of staphylococci and to study the antibiogram of clindamycin resistant strains.In this study, 22% (44 out of 200) staphylococci had inducible clindamycin resistance, 5% had constitutive clindamycin resistance The incidence of constitutive clindamycin resistance is variable in different studies. Angel et al. and Gadepalli et al. did not find any constitutive resistant strains in their studies.10,11 Others found constitutive clindamycin resistance in 3.8%- 44.2% of their MRSA isolates.9,12,5 However, incidence of constitutive clindamycin resistance in our study was 5% in MRSA strains which is much nearer to that of Mallick et al.9 In our study, inducible clindamycin resistance was found in 4.8% of coagulase negative staphylococci (CoNS). However, no constitutive clindamycin resistance was found in these strains.  Yilmaz et al. reported both inducible (24.3%) and constitutive (31.5%) clindamycin resistance in CoNS.5   1.   Hiramastsu K, Hankaki H, Ino T, Yabuta K, Oguri T. Tenover F.C. Methicillin-resistant Staphylococcus aureus Clinical Strain with reduced vancomycin susceptibility. J. Antimicrob Chemother 1997; 40: 135-6. 3.   Levinson W. Gram positive cocci. Medical microbiology and immunology. 9th edition. Lange Medical Books/McGrawHill Newyork 2007; 110. 5.   Yilmaz G, Aydin K, Iskender S, Caylan R and Koksal I. Detection and prevalence of inducible clindamycin resistance in staphylococci. Journal of Medical Microbiology 2007; 56: 342-345. 7.   Weisblum B and Demohn V. Erythromycin inducible resistance in Staphylococcus aureus; survey of antibiotic classes involved. J. Bacteriol 1969; 98: 447-452. 9.   Mallick SK, Basak S, Boses S. Inducible clindamycin resistance in Staphylococcus aureus – Therapeutic challenge. Journal of Clinical and Diagnostic Research 2009; 3: 1513-1518. 11.Gadepalli R, Dhawn B, Mohanti S, Kapil A, Das BK and Chaudhary R. Inducible clindamycin resistance in clinical isolates of Staphylococcus aureus. Indian J Med Res 2006; 123: 571-3. <![CDATA[Body mass abdominal index: A new index for adiposity among pre-school children]]> Subal Das Kaushik Bose https://imcjms.com/journal_full_text/42 2016-08-02 10:11:17 Original Article Ibrahim Med. Coll. J. 2011; 5(1): 9-12 The new index Body Mass Abdominal Index (BMAI) has been derived by combining two separate indices – weight for height and waist for height ratios. Our study investigated the relationship of common indicators of abdominal adiposity – waist circumference (WC), waist-hip ratio (WHR), waist-height ratio (WHTR), conicity index (CI) and newly proposed body mass abdominal index (BMAI) with body mass index (BMI) among 347 pre-school children of Purulia District, India. Results showed that significant correlations were observed for all adiposity measures except WHR. A noteworthy point was that the correlations were strongest (p < 0.01) with BMAI (boys: r = 0.863, girls: r = 0.863). The correlations of BMAI with BMI were similar in both sexes. In conclusion, our results indicate that the new index BMAI has a distinct advantage as it relates much strongly with overall adiposity (BMI) than the other commonly used indicators of adiposity. Address for Correspondence:Dr. Kaushik Bose, Reader in Biological Anthropology, Department of Anthropology, Vidyasagar University, Midnapore–721 102, West Bengal, India, E-mail: banda@vsnl.net and kaushikbose@cantab.net   Childhood obesity is one of the most serious public health challenges of the 21st century. Overweight and obesity are defined as “abnormal or excessive fat accumulation that presents a risk to health”. The problem is global and is steadily affecting many low- and middle-income countries, particularly in urban settings. The prevalence has increased at an alarming rate. Globally, in 2010 the number of overweight children under the age of five is estimated to be over 42 million. Close to 35 million of these are living in developing countries. It is difficult to develop one simple index for the measurement of overweight and obesity in children and adolescents because their bodies undergo a number of physiological changes as they grow.1 Furthermore, obesity in children is a cause for concern because it may predict adult obesity and increased risk of coronary heart disease in adult life.6 The adiposity in preschool children is measured by using weight for length, waist-to-height index and body mass index.2 Currently increase in weight gain and obesity in preschool children are measured independently either by weight for length index,7 waist – to - hip ratio,8 or BMI for age.7 There is another index, Conicity index, which is a function of weight, height and waist circumference, but it has been shown in one of the studies that BMI is better than conicity index in predicting coronary artery disease.9 Therefore, all these ratios have mathematical complexity. Recent evidence indicates a disturbing trend of increasing adiposity in developed and developing countries including India.10-12 It would be of interest to determine if a similar trend is observable at an earlier age and that too from a developing country like India, which is currently undergoing a nutritional transition.13 Materials and Methods BMAI= Weight / Height X Waist Circumference          = Weight / (Height)2 X Waist Circumference Where Weight is in kg and Waist Circumference and Height are in meters. The objective of our paper is to study the relationship of four common indicators of abdominal adiposity, namely waist circumference (WC), waist-hip ratio (WHR), waist-height ratio (WHTR), conicity index (CI) and BMAI with overall adiposity as measured by BMI. Results       The correlation coefficients (r) of the adiposity measures with BMI are shown in Figure 1. Ideally, any acceptable and good adiposity measure must have a strong positive relationship with BMI which is an indicator of overall adiposity. This should be equally true for both sexes. On the other hand, an adiposity measure at any particular site which does not have a strong relationship with BMI may accurately reflect regional adiposity, but it fails to relate adequately with overall adiposity (BMI). Hence, it may be of limited use in epidemiological studies, particularly those dealing with the anthropometric evaluation of nutritional status. Fig-1. Correlation of BMI with WC, WHR, WHTR, CI and BMAI Conclusion   The co-operation of all participating subjects, villagers and block authorities are gratefully acknowledged. Subal Das received financial assistance in the form of Junior Research Fellowship from University Grants Commission, Government of India (UGC- ref. no. 223/NET- Dec. 2008). References 2.   Kumar PA. Hypothetical Index for Adiposity “Body Mass Abdominal Index”- That will predict Cardiovascular disease risk factors in Children. Internet J Ped Neonat 2009; 11: 1. 4.   Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. “Long-term morbidity and mortality of overweight adolescents. A follow-up of the Harvard Growth Study of 1922 to 1935”. N Engl J Med 1992; 327(19): 1350–1355. 6.   Must A, Strauss RS. Risks and consequences of childhood and adolescent obesity. Int J Obes Relat Metab Disord 1999; 23: S 2-11. 8.   Li C, Ford ES, Mokdad AH, Cook S. Recent studies in waist circumference and waist – height ratio among US children and adolescents. Pediatr 2006; 118: e1390-e1398. 10.Nunez-Rivers HP, Monge-Rojas R, Leon H, Rosello M. Prevalence of overweight and obesity among Costa Rican elementary school children. Rev Panam Salud Publica 2003; 13: 24-32. 12.Kapil U, Sing P, Dwivedi SN, Bhasin S. Prevalence of obesity amongst affluent adolescent school children in Delhi. Indian Pediatr 2002; 39: 449-452. <![CDATA[Knowledge, attitude and practice of maternal health care amongst the married women in a rural area of Bangladesh]]> Sonia Shirin https://imcjms.com/journal_full_text/203 2017-04-30 14:55:18 Original Article Ibrahim Med. Coll. J. 2011; 5(1): 13-16 Bangladesh is facing a big challenge in reducing maternal and neonatal mortality. Addressing maternal health issues is now on the global social agenda in the new millennium. This cross sectional descriptive study was conducted in the unions of Sreepur Upazilla in March 2010 among 300 rural married women having at least one living child. Data were collected by face to face interviews using a semi-structured questionnaire to asses the knowledge, attitude and practice on maternal health care of married women in Sreepur Upazilla. The mean ± SD age of women was 33.5 ± 10.4 years and monthly income was Tk. 6,518.3 ± 5,142.4. Reproductive history of the women reveals that mean ± SD age at marriage, age at first child, and parity were 15.3 ± 2.9, 18.2 ± 3, 3 ± 2 years respectively. Only 42.3% of the respondents knew about swelling of the foot, 36.3% were aware of fits, 25.7% knew about severe headache and 24.7% knew about unusual bleeding as warning signs of pregnancy. About 84.3% respondents knew that the first meal of the baby should be colostrum. Among the participants 57%, 70.7% and 62.3% had average knowledge on ANC, INC and PNC respectively. Rural married women having a positive attitude towards maternal health care was 96.3% in ANC, 80% in home delivery, 61.3% in hospital delivery and 95.3% in PNC. Itwasfoundthat35.6%and27.1%respondentsweretakingANC3 and4timesrespectively.Among the respondents 66.7% had done their laboratory examination and 84.7% took vitamins adequately. About 67.2% respondents performed normal physical work as before during pregnancy and 30.5% took more food than before. Home delivery was practiced by 88.3% respondents and 10.3% women delivered their baby at the hospital. Among the respondents who delivered their baby at home, 64.9% of them practiced few of the features of safe home delivery. Practice was good on ANC among 55.3% respondents where poor practice was found 69.3% on INC and 72.3% on PNC. Age and monthly income were related to knowledge on ANC (P<.001, P<.05) and PNC (P<.01, P<.05) respectively. Practice on maternal health care also related to socio-economic condition of the rural women. Women in rural settings are vulnerable due to poor maternal health care and exposed to risk of pregnancy and child birth. Appropriate health education activities, encouraging institutional delivery and development of socio-economic status are key factors to improve our maternal health. Address for Correspondence: Dr. Sonia Shirin, Assistant Professor, Department of Community Medicine, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbagh, Dhaka-1000, Bangladesh   Maternal and child health are important indicators for describing mortality conditions, health progress and the overall social and economic wellbeing of a country. Maternal health refers to the health of women during pregnancy, childbirth and the postpartum period. Pregnancy is a natural process and every woman have the right of access to appropriate health care services that will enable her to plan and go safely through pregnancy and child birth.1 Pregnancy and child birth related complications are among the leading causes of maternal mortality in Bangladesh.2 Bangladesh records a high maternal mortality ratio, with 320 deaths per 100,000 births.3 This means that about 12,000 women die from pregnancy or childbirth related complications every year – more than 30 every day.3 Bangladesh is facing a big challenge in reducing maternal and neonatal mortality.4 The aim of this study was to find out the level of knowledge, attitude and practice (KAP) on maternal health care of rural married women of Sreepur Upazilla. KAP study tells us what people know about certain things, how they feel and also how they behave.   This cross sectional study was conducted in the month of March 2010 in 8 villages of 2 unions of Sreepur upazilla which was purposively selected as a part of our residential field site training (RFST) program. Rural married women having at least one live child living in different unions of Sreepur upazilla were taken as a sample. A total of 300 respondents were selected on the basis of their availability for interview. After taking a verbal consent, a face to face interview was conducted using a pre-tested questionnaire having both structured and open ended questions. All collected data were corrected and entered into the computer based SPSS program for analysis. To estimate the level of knowledge, attitude and practice of respondents, questions were asked on maternal health care and for each appropriate answer a score of 1 was given while score 0 was given to each inappropriate answer. Results The respondents’ knowledge about the warning signs during pregnancy were poor. Only 42.3%  knew about swelling of the foot, 36.3% were aware of fits, 25.7% knew about severe headache and 24.7% knew about unusual bleeding. While inquiring about breastfeeding, 84.3% respondents mentioned colostrum as the baby’s first meal. Among the participants 57%, 70.7% and 62.3% had average knowledge on ANC, INC and PNC respectively. Rural married women had positive attitude towards maternal health care i.e. 96.3% in ANC, 80% in home delivery, 61.3% in hospital delivery and 95.3% in PNC. Three and four times ANC were taken by 35.6% and 27.1% respondents respectively. Among the respondents 66.7% had done their laboratory examination and 84.7% took vitamins adequately. About 67.2% respondents continued normal physical work  and 30.5% took more food than before. Home delivery was practiced by 88.3% respondents and 10.3% women delivered their baby in a hospital. Among the respondents who delivered their baby at home, 64.9% of them practiced few of the features of safe home delivery. Practice on ANC was good among 55.3% respondents while 69.3% on INC and 72.3% on PNC had poor practice (Fig1).   There was a significant relationship between age and monthly income of the respondent to knowledge on ANC (p <.001, p <.05) and PNC (p <.01, p<.05) respectively (Tables 1 & 2). Table-1: Knowledge of ANC in relation to socio-demographic variables     Socio-economic condition of rural women was related to practice on ante natal care (Table 3). Practice on intra natal care and post natal care was also significantly related to monthly income (p<.05) and age (p<.01) respectively. Table-3: Practice of ANC in relation to socio-demographic variables   To assess the knowledge, attitude and practice on maternal health care among rural married women, we carried out a cross sectional descriptive study in Sreepur Upazilla by interviewing 300 mothers. The respondents’ knowledge about the warning signs during pregnancy was poor. Only 42.3% of the respondent’s knew about swelling of the foot, 36.3% were aware of fits, 25.7% knew about severe headache whereas 24.7% knew about unusual bleeding. However in Rahman M et al. report, 54.6% respondents knew about severe headache, 36.4% were aware of convulsions and 19% were aware about vaginal bleeding.10 Of the respondents 57% had an average knowledge on ANC. Regarding attitude, 96.3% respondents showed a  positive attitude towards ANC, 80% showed a positive attitude towards home delivery and 95.3% showed positive attitude towards PNC. About 61.3% showed positive attitude towards hospital delivery, which is higher than the data of another report by Yasmin N et al., which showed 49.3% respondents gave their opinion on hospital delivery as safe.2 In this study, 88.3% respondents had home delivery and a huge difference is seen when this result is compared with a rural community of China, where only 3% respondents had their delivery at home.14   Rural married women are still victims of early marriage and early child birth. Hence these women are more prone to complications before, during and after delivery. Knowledge on ANC was better than  INC and PNC. Practice on ANC was good where as in INC and PNC it was poor. There is still a preponderance of home delivery over institutional  delivery amongst the rural women. A significant relationship exists between maternal health care and socio-economic status of women. Focusing health education activities in all settings providing maternity services that ensures clients’ participation in the learning process and encourage institutional delivery are essential to bring about changes in the maternal health status.  Lastly, improvement in the overall  socio-economic status is crucial in improving our maternal health. References 2.   Yasmin N, Alam K, Lahiry S, Faruquee MH, Ahmed T. Knowledge, attitude and practice regarding hospital delivery among rural married women in northern Bangladesh. Ibrahim Med. Coll. J. 2009; 3(1): 17-20. 4.   Begum HA, Khan MFH. Knowledge and practice on neonatal care among selected mothers attending Dhaka shishu hospital. Ibrahim Med. Coll. J. 2009; 3(2): 59-62. 6.   UNICEF. The State of World’s Children 2004. 8.   Safdar S, Inam SN, Omair A, Ahmed ST. Maternal health care in a rural area of Pakistan. The Journal of Pakistan Medical Association 2002; 52(7): 308-11. 10.Rahman M, Abedin S, Kamruzzaman, Islam N. Women’s Empowerment and Reproductive Health: Experience from Chapai Nawabganj District in Bangladesh. Pakistan Journal of Social Sciences 2008; 5(9): 883-88. 12.Sherbini AF, Torky MA, Ashmawy AA, Abdel-Hamid HS. Assessment of knowledge, attitude and practices of expectant mothers in relation to antenatal care in Assiut governorate. The Journal of Egypt Public Health Association 1993; 68 (5-6): 539-65. 14.Wu Z, Viisainen K, Li X, Hemminki E. Maternal care in rural China: a case study from Anhui province. BMC Health Services Research 2008; 8: 55. <![CDATA[Factors associated with secondary infertility]]> Hasina Momtaz Meerjady Sabrina Flora Sonia Shirin https://imcjms.com/journal_full_text/204 2017-04-30 15:00:18 Original Article Ibrahim Med. Coll. J. 2011; 5(1): 17-21 Infertility is an experience that strikes at the very core of a woman’s life and as a whole her family and society. Studies in Bangladesh to evaluate the factors are difficult to come by. This case control study was carried out from Jan 2010 to June 2010 to find out the factors associated with secondary infertility. A total of 70 cases were selected from the infertility unit of Bangabandhu Sheikh Mujib Medical University and 70 unmatched controls from the same hospital attending the pediatrics unit with their children were also recruited. Data were collected by interview and review of documents. No age difference was noticed between the cases (29.26 ± 4.13) and controls (29.21 ± 3.95). Association of secondary infertility was found with body mass index (p=0.036), previous bad obstetric history (p = 0.011) and previous caesarian delivery (p=0.044). Women with secondary infertility were more than four times more likely to have gynecological problem(s) than their fertile counterparts [OR 4.76 with 95% CI (2.018-11.270)]. The factors identified in this study might help the policy makers in designing prevention and health care programmes and thus reducing the hidden burden of secondary infertility. Address for Correspondence:Dr. Hasina Momtaz, Lecturer, Department of Community Medicine, Ibrahim Medical College, 122 Kazi Nazrul Islam, Avenue, Shahbagh, Dhaka-1000, Bangladesh   Secondary infertility refers to couples who are unable to conceive after one year of unprotected intercourse after a previous pregnancy in the reproductive age group. Globally, approximately, 10-15% of couples are infertile, affecting more than 80 million people worldwide. Secondary infertility outnumbers primary infertility.1 Either the male or female partners can be responsible for infertility in around 30% cases or both are involved in another 25 to 30% cases. In the remaining 10 to 15% case no cause could be found, which is known as unexplained infertility.4 Many factors including infectious, environmental, genetic, and even dietary in origin can contribute to infertility. Because of the under reporting of secondary infertility in institution based studies, information on the causes of infertility is likely to consistently underestimate the role of infection, which is the most frequent cause of secondary infertility.5 In western countries, obesity affects approximately half of the general population and is thus a common problem among the infertile population. Obese women have a higher prevalence of infertility compared with their lean counterparts. The majority of women with an ovulatory disorder contributing to their infertility have polycystic ovary syndrome (PCOS) and a significant proportion of women with PCOS are obese. Ovulation disorders and obesity-associated infertility represent a group of infertile couples that are relatively simple to treat.7 In Bangladesh very little is known about the status of infertility. However, the problem is considered quite prevalent. According to a WHO survey report, infertility rate was found to be 6.9 percent and from BIRPERHT’s Reproductive Health Care Need Study (RHCNS), 1996 primary infertility rate was estimated at 3.2 percent and secondary infertility rate was found to be 2.9 percent.9 Infertility has been relatively neglected as both a health problem and a subject for social science research in South Asia, as well as the developing world. The general thrust of both programmers and research has been on the correlates of high fertility and its relation rather than on understanding the context of infertility, its cause and consequences. Moreover, in pronatalist cultures such as those of India, and South Asia more generally, the consequences of infertility for women can be devastating.10   This case control study was conducted on 70 cases and 70 unmatched controls for a period of 6 months commencing from January 2010. Women who failed to conceive after 1 year of unprotected intercourse with a history of one previous conception, and coming to the infertility unit of Bangabandhu Sheikh Mujib Medical University (BSMMU) during data collection period, were taken as cases. Women having a second child and attending the pediatric unit of BSMMU for treatment or vaccination of their baby were taken as controls. The cases were selected by purposive sampling. Data were cleaned, edited, coded and computed with the help of soft-ware SPSS version 11.5. Quantitative data were analyzed to find out the mean and standard deviation and mean differences were tested by Student’s t-test. Qualitative data were analyzed to estimate the proportion and were tested by c2 test. Odds Ratio with 95% confidence interval was estimated. Results     Cases, on average, got married at a later age (20.80 ± 4.70) than the controls (19.89 ± 3.20). Use of hormonal contraception was more common in cases (54.3%) than in controls (48.6%). There was no difference in menstrual hygiene. More than half of the infertile women (55.7%) had poor delivery outcome in their first pregnancy whereas only one third of controls had similar findings (34.3%). Secondary infertile couples were 2.4 times more likely to have a bad obstetric outcome in their previous pregnancy than fertile couples [OR 2.68 with 95% CI (1.01 to 7.12)]. The chance of developing secondary infertility is 2.68 times more with previous caesarian delivery than normal vaginal delivery (Table-2). Table-2: Distribution of reproductive characteristics between cases and controls       Although the distribution was not significantly different, it showed a higher proportion of class II obese in cases (14.3%) than in controls (2.99%). Association was found between body mass index (BMI) and secondary infertility. Cases were, on average, with 1.5 higher BMI than in controls (p=0.036, Table- 4). Table-4: Distribution of body mass index between cases and controls   The study was undertaken to gain insight into the problem of infertility. The relationship between secondary infertility and its associated factors is difficult to study. Prospective studies need large cohorts, which are difficult and expensive to follow and have the additional drawback of losing the subjects in the control group. This case control study was carried out in 70 cases and 70 unmatched controls to find out the factors associated with secondary infertility. Although it was not planned, controls matched with cases in relation to age and other socio-demographic variables as no difference was noticed between the two groups. But a previous study found that prevalence of secondary infertility increased with age from 4% in women aged 15-24 years to 17% in those >39 years.2 Pelvic surgery shows, proportion of caesarian section was more in controls (63.6%) than cases (48.1%). But the number of pelvic surgery was more in cases than controls. There was no significant difference in pelvic surgery between cases and controls. But in other studies, pelvic surgery was found to be a contributing factor for development of secondary infertility.13 This difference probably was attributed to differences in sample characteristics. Detection of any gynecological factors that may be associated with secondary infertility was explored by checking the ultasonography report. Association was found between abnormal ultrasonogram findings with secondary infertility. Risk of developing secondary infertility was 4.76 times more with abnormal findings in ultra sonogram report than with normal findings. The abnormal finding includes PCOS,fibroid uterus and others. And the distribution shows higher proportion of abnormal findings contributing to PCOS. Association of secondary infertility with PCOS was also found in other studies.15 Conclusion   1.   Ali T, Sami N, Khuwaja A. Are unhygienic practices during the menstrual, partum and postpartum periods risk factors for secondary infertility? J Health Popul. Nutr 2007; 25(2): 189-194. 3.   Papreen N, Sharma A, Sabin K, Begum L, Ahsan SK, Baqui AH. Living with infertility: experiences among Urban slum populations in Bangladesh. Bangladesh Health Matters 2000; 8(15): 33-44. 5.   Barbara T. The epidemiology of infertility in Aberdeen Medical Sociology Unit. Aberdeen Br Med J 1990; 301: 148-152. 7.   Wilkes S, Murdoch E, Alison D. Obesity and female fertility: primary care perspective. Journal of Family Planning and Reproductive Health Care 2009; 35: 181-185. 9.   Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERHT), Briefing paper on Assessment of Reproductive Health Care needs and Review of Services provided at the level of Thana, Union and Village, Dhaka, Bangladesh, 1997; 5: 1-4. 11.Tzonou A, Hsieh C, Trichopoulos D, Aravandinos D, Kalandidi A, Margaris D et al. Induced abortions, miscarriages, and tobacco smoking as risk factors for secondary infertility. J Epidemiol Community Health 1993; 47(1): 36-39. 13.Homan M, Davies R, Norman: The impact of lifestyle factors on reproductive performance in the general population and those undergoing infertility treatments. Human Reproduction and Embryology oxfordjournals.org 2007. 15.Dewailly S, Hieronimus P, Mirakian N. Polycystic ovary syndrome (PCOS). D’Endocrinologe 2010; 71(1): 8-13. <![CDATA[Effect of Nigella Sativa Linn (Ranunculaceae) ground seed extract on Carrageenan induced inflammation in rats]]> Saima Parveen Sitesh Chandra Bachar Zinnat Ara Begum https://imcjms.com/journal_full_text/205 2017-04-30 15:10:58 Original Article Ibrahim Med. Coll. J. 2011; 5(1): 22-24 Nigella sativa Linn (Family: Ranunculaceae) Bengali name “kalo jera” is used as spice in Bengali foods. Native to Western Asia, Turkey, Iraq and Egypt, the black seed oil has been valued for its health benefits for centuries. This plant has been used in traditional medicine for the treatment of stomach aches, asthma, bronchitis, coughs, fevers, tumour and as a tonic. The dried and grounded seed was extracted with ethanol and the extract was evaluated for anti-inflammatory activity in carrageenan induced rat paw edema model. The extracts were administered orally at the doses of 250 and 500 mg/kg body weight, and statistically significant (p<0.05) anti-inflammatory effects were observed in a dose dependant manner. The extract showed 28.75% and 43.79% inhibition of inflammation at the doses of 250 and 500 mg/kg body weight after first hour of the carrageenan administration which was comparable to that of standard drugs aspirin 40.52% and hydrocortisone 47.71% respectively. The result of this study supported the traditional medicinal uses of this seed. Address for Correspondence:Dr. Saima Parveen, Lecturer, Department of Pharmacology and Therapeutics, Holy Family Red Crescent Medical College, Moghbazar, Dhaka, Bangladesh   Inflammation is a protective response intended to eliminate the initial cause of cell injury as well as the necrotic cells and tissues resulting from the original insult.1 The anti-inflammatory drugs which are currently available are a heterogeneous group of compounds, often chemically unrelated, which nevertheless share certain unwanted effects. The most common is a propensity to induce ulceration. Therefore, the present trend is to find out more acceptable agents which will be devoid of the potential adverse effect. Use of herbal medicine throughout the world is increasing. Plants are the primary source of supply of many important drugs used in modern medicine. Our chosen herb Nigella sativa Linn (Family: Ranuculaceae) is a common spice of south east Asia. N. sativa (locally called Kalajira) has been in use in Bangladesh, India & many Middle Eastern communities as natural remedy of many acute conditions for two thousand years. Various research works proved previously that thymoquinone- an active component of N. sativa is a potent inhibitor of prostaglandins (PGs), histamine, 5HT, leucotrienes polymorphonuclear leucocytes.2   Plant Material Extraction   Long Evans Norwegian rats of either sex (weighing 200-250gm) were collected from BSMMU research division. The animals were kept in polyvinyl cages under controlled room temperature (25±2 ºC) in the laboratory environment. The rats were kept 12 h in dark and 12 h light cycle for seven days. The ICDDR, B formulated food pellets were supplied to the animals along with water ad libitum. Animals were fasted overnight and weighed before the experiment. The study involving rats was approved by the Bangladesh Medical Research Council, and the experiments were carried out strictly in accordance with the guidelines provided by the World Health Organization. Preparation of the samples   The anti-inflammatory activity of the extracts of N. sativa was measured by the carrageenan-induced rat paw oedema model.3 Experimental animals were randomly selected, irrespective of sexes, and divided into five groups consisting of 6 rats in each group. Group I: Received 0.6ml normal saline administered orally and served as control. Group-II: received ethanol extract of N. sativa 250mg/kg (0.6ml) body weight administered orally. Group-III: received ethanol extract of Nigella sativa 500mg/kg (0.6ml) body weight administered orally. Group-IV: received aspirin 100mg/kg body weight administered orally. Group-V: received hydrocortisone 2mg/kg body weight administered subcutaneously. After 1 h of treatment, acute inflammation was produced by sub-planter injection of 0.1 ml of 1% suspension of carrageenan in sterile water in the right hind paw of the rats. The paw volume was measured plethysmometrically (Ugo Basile, Italy) after one hour of carrageenan injection. Results were expressed as percentage of inhibition of oedema calculated by the formula- (1 - Vt/Vc) × 100, where Vt and Vc are the mean paw volume in the treated and controlled groups, respectively. Statistical Analysis   The mean initial (0 hr.) paw volume of group-I, II, III, IV and V were 117.25±1.28, 121.05±3.32, 133.69±2.48, 128.63±5.16, 131.59±4.63 respectively. Simultaneously the mean paw volume after 1 hour of Carrageenan injection pretreated with test drugs were 193.75±2.14, 175.55±2.10, 176.69±1.17, 174.13±1.68, 171.59±1.23 respectively (Table- 1). All units were expressed in mm3. The percentage inhibition of oedema formation in group - II, III, IV and V were 28.75%, 43.79%, 40.52%, 47.71% at a dose of N. sativa 250mg/kg, N. sativa 500mg/kg, aspirin 100mg/kg and hydrocortisone 2mg/kg body weight respectively in comparison to control (Table-1). From the result it was found that a significant anti-inflammatory effect was exhibited by the ethanolic extract of N. sativa at 500mg/kg body weight with 43.79% inhibition. Table-1: Effects of administration of ethanol extract of N. sativa, aspirin and hydrocortisone on carrageenan-induced paw oedema after 1 hour of carrageenan injection.   The frequency of intake of NSAIDs and their reported common side effects is increasing day by day, there is need to focus on the scientific exploration of herbal drugs having fewer side effects. So, there is a continuous search for indigenous drugs, which can provide relief to inflammation. To give a scientific validation to the plant N. sativa, an attempt was made to study the anti-inflammatory activity4 of the ethanolic extract of its seeds. Administration of ethanol extract of ground seed of N. sativa at a dose of 250 mg/kg and 500mg/kg body weight orally exerted anti-inflammatory effect, where the percentage of inhibition of oedema formation was 28.75% and 43.79% respectively. And the effect was dose dependent. Following the administration of aspirin and hydrocortisone the percentage of inhibition of oedema were 40.52% in aspirin and 47.71% in hydrocortisone. The effect of N. sativa extract at a dose of 500mg/kg body weight was better than that of non-steroidal reference standard aspirin, and was little bit less than that of steroidal  hydrocortisone. Thus it can be concluded that ground seed of the plant N. sativa possess significant anti-inflammatory activity in rats. Further studies involving the purification of the chemical constituents of the plant and the investigations to elucidate mechanism of action and safety profile may result in the development of a potent anti-inflammatory agent with a low toxicity and better therapeutic index. Acknowledgement   1.   Robbins and Cotran, Acute and Chronic inflammation: Pathologic basis of discase. Published by Elsevier, a division of Reed Elsevier India Private Limited 2007; 31-58. 3.   Winter CA, Risley EA, Nuss GW. Carrageenan induced oedema in hind paw of the rat as an assay for anti-inflammatory drugs. P Soc Exp Biol Med 1962; 111: 544-547. 5.   Tekeoglu I, Dogan A, Demiralp L, Effects of thymoquinone (volatile oil of black cumin) on rheumatoid arthritis in rat models, Yuzuncu Yil University, Medical School, Department of Rehabilitation and Rheumatology, Maras cad. 65100, Van, Turkey. Phytother res 2006; 20(10): 869-71. <![CDATA[Awareness of HIV / AIDS among the grass-widows]]> Tazreen Mona https://imcjms.com/journal_full_text/206 2017-04-30 15:14:43 Original Article Ibrahim Med. Coll. J. 2011; 5(1): 25-28 The migrant workers in Bangladesh are at high risk of getting HIV infection due to factors like staying away from family for long periods which leave them vulnerable towards sexual relationship with commercial sex workers (CSW) and having sexual relationship with other men (MSM). This paper aimed to explore the level of awareness on HIV/AIDs among the women whose husbands stay apart from them for over a period of 6 months. For this cross sectional study, women attending public and private hospitals in Dhaka city were selected purposively. The participants were interviewed using a partially open-structured questionnaire. A total of 404 subjects were interviewed. Most of the respondents were housewives (85.7%). The higher education group had a high prevalence of awareness (>=HSC vs. SSC: 45.0% vs. 8.5%; p<0.001).  The prevalence of awareness was significantly higher among the employed than the housewives (50% vs. 12.4%, p<0.001). Although the wives of the unskilled labor and the skilled employee were equal (25% vs. 25%), the wives of skilled employee had significantly higher awareness than the wives of the unskilled laborer (30.7 vs. 10.9%, p = 0.001). The study concludes that higher awareness level was significantly associated with higher education of the participants and higher education of the husband. Occupationally, housewives were found to have very low level of awareness compared with the employed group of participants. Again the wives of skilled employees had a significantly higher prevalence of awareness compared with the wives of unskilled laborer. Introduction One of the ways HIV can be introduced into a low prevalence country is through people returning from high prevalence countries where they have engaged in risky behaviors. Data from three Voluntary Counseling and Testing Units of ICDDR,B indicate that 47 (18.1%) of the 259 people tested between 2002 and 2004 were HIV positive. Of these, 29 were adult males who had returned from abroad, seven were wives of migrant workers, and four were children of HIV positive migrant workers.1 In the last decade, around 200,000 Bangladeshi men were officially recorded as migrating out for work each year, mostly to the Middle East, and many more are known to leave informally.2 According to several studies, extra-marital sex by men are quite common; it was much more prevalent among migrant men who had lived apart from their wives, in Bangladesh or abroad. Women were also more likely to report extra-marital sex if their husbands were living away from home. The likelihood of extra-marital sex increased with length of separation.   The target population of this  study was women whose husbands are migrant workers and have been living abroad for more than six months. For this study only external migrations were selected as cases, as in most of the cases of internal migration the duration of staying apart is likely to be shorter than six months. The analytical plan of the study included description of the study population by their socio-demographic characteristics. For this, some descriptive statistics were used like mean, median, mode and percentages. In order to find out association between the dependent and independent variables, Chi-Square tests were performed to find out the bi-variate relationships and their levels of significance. Results Regarding education of husbands, 44.2% attained a  level higher than HSC and by occupation, 30.9% were semi-skilled. Compared with the lower education group, higher education group had high prevalence of awareness (>=HSC vs. SSC: 45.0% vs. 8.5%; p<0.001) [Table-1]. Likewise, the group with higher education of husbands showed higher levels of awareness than the group of lower educated husbands (25.3% vs. 10.0%; p<0.005) [Table-2]. Table-1: Relation between respondents’ education and their awareness level on HIV/AIDs     Occupationally, 85.6% were housewives and only 11.8% were employed. The prevalence of awareness was significantly higher among the employed than the housewives (50% vs. 12.4%, p<0.001) [Table-3]. Although the wives of the unskilled labor and the skilled employee were equal (25% vs. 25%), the wives of skilled employee had significantly higher awareness than the wives of the unskilled labor (30.7 vs. 10.9%, p = 0.001) [Table 4]. Table-3: Relation between respondents’ occupation and awareness on HIV/AIDs     Discussion It was assumed that based on education, economic status, occupation, access to media and cultural traits of a community, the awareness on HIV/AIDs would vary. The findings of the study do reveal that all these factors have an effect on the awareness level of the target population. Based on the ranking generated by the variables of the questionnaire, 82.5% of the respondents had a low awareness on HIV/AIDs; this being an alarming situation demanding immediate and appropriate intervention for prevention of HIV/AIDs in the country. Behind the low awareness, the factors that worked were lack of knowledge, lack of recollection or adaptation of the preventive measures, and lack of understanding the risk of having an HIV positive partner.   The study revealed that the awareness level of HIV and AIDs among the grass-widows, a high risk group for contacting the disease was dangerously low. Higher awareness level was significantly associated with higher education of the participants and higher education of the husband. By occupation, the housewives were found to have very low level of awareness compared with the employed group of participants. Again the wives of skilled employee had significantly higher prevalence of awareness compared with the wives of unskilled labor. Overall, higher education and higher quality of employment in either spouse were positively related to the awareness of HIV/AIDs. Acknowledgement   1.  Zaidi A. Zahiruddind M, Parvez M et al. Profile of HIV positive clients attending a VCT unit in Bangladesh. In: Abstract for the 15th International AIDs Conference, Bangkok, July 2004. Bangkok. Accessed on 16 September 2004; http://www.iasociety.org/ejias/show.asp?abstract_id=2173468. <![CDATA[Compound odontome with unerupted permanent incisor]]> Mahfujul Haq Khan Md. Manjurul Karim Sejuty Haque Saeed Hossein Khan Mohammad Towfiq Alam https://imcjms.com/journal_full_text/43 2016-08-02 10:13:06 Clinical Case Report Ibrahim Med. Coll. J. 2011; 5(1): 29-31 Odontomas are mixed odontogenic tumors composed of both epithelial and mesenchymal dental hard tissues. They are usually asymptomatic and are often discovered during routine radiography. A case of odontoma in a 21 year old man is described who presented with delayed eruption of upper central and lateral incisor teeth. The odontome was surgically removed followed by re-implantation of preserved extracted lateral incisor and a porcelain crown. Address for Correspondence:Dr. Mahfujul Haq Khan, Associate Professor, Department of Dentistry, Bangladesh Institute of Research & Rehabilitation in Diabetes, Endocrine & Metabolic Disorder (BIRDEM) and Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Dhaka-1000, Bangladesh, email: mahtink@yahoo.com   A 21-year-old- man reported to the Department of Dentistry, BIRDEM Hospital, Bangladesh, with the complaint of missing upper right central and lateral incisors and hard swelling on apical region of that missing alveolus. He had normal shedding of upper deciduos central and lateral incisors teeth at the age of 6-8 years and since then no permanent dentition of upper right central and lateral incisors occured. The patient was healthy and well developed with an unremarkable medical history. He had no history of trauma to oro-facial region or dental extraction. There was no family history of unerupted teeth or hypodontia. Extra oral examination revealed no abnormality in the upper lips as well as in the right side of the maxilla. Intra oral examination revealed a well defined gingival hard swelling which was palpated in the apical area of unerupted incisors (Figure -1a). No inflammatory change was noticed on the overlying and marginal gingiva and interdental papilla. The space for the eruption of the maxillary right central incisors was naturally maintained in the dental arch but the space for lateral incisor was reduced due to medial drifting of maxillary right canine. No midline deviation was diagnosed in comparison to the dental arch and the facial midline. There was no regional lymphadenopathy. An intra oral periapical and panoromic radiograph revealed impacted lateral incisor with multiple radio-opaque structures around the crown of the unerupted incisors region obstructing the eruption of the tooth (Figure -1b). The mass was surrounded by a narrow radiolucent zone. On the basis of clinical examination and radiological evaluation, the case was diagnosed as a compound odontome with impacted lateral incisor. Surgical removal of the odontome, extraction of impacted lateral incisor and its re-implantation was planned.   Fig 1: (a): Missing upper right central and lateral incisors and a hard swelling on upper right anterior part of alveolus. (b): X-ray OPG shows  a calcified mass with multiple teeth like structures with impacted right lateral incisor, arrow indicates central incisor. (c): 15 pieces of tiny tooth like structure. (d): Final esthetic appearence   after surgical removal of odontome and re-implantation. After 3 months, the re-implanted lateral incisor was assessed clinically and radiologically. There was no significant mobility. Periapical radiograph showed new bone formation around the root of the re-implanted tooth. For esthetic purpose, a porcelain crown having a shape of central incisor was made on the lateral incisor (Figure-1d). A Maryland bridge was selected to distribute the occlusal load applied on the lateral incisor. Discussion The frequency of occurrence of odontomas varies greatly in different population groups. Odontomas are most common in Caucasian population where it accounts for over 65% of all odontogenic tumours.6 In contrast, odontomas are rare in Chinese populations with an occurrence of only 6% to 6.7%.7,8 It remains to be proved whether geographical variation is racially based.8 In general, odontomas mostly occur in the permanent dentition and are very rarely associated with the primary teeth.6 An odontome can occur at any age but most commonly occurs at 2nd decade of life and there is no gender predilection. Of all odontomas combined, 67% occured  in the maxilla and 33% in the mandible. The compound odontoma has predilection towards the anterior maxilla (61%) compared to only 34% of complex odontomas. In general, complex odontoma had a predilection for the posterior jaws (59%). Interestingly, both type of odontomas occur more frequently on the right side of the jaw then on the left (compound 62%, complex 68%).9,10,11   We are thankful to Dr. Alif, Dr. Hossein, Dr. Persa, Dr. Sakina and Dr. Fatema for technical support to complete a case report. Special thanks to Dr. Towfik Alam to complete the referrences. References 2.   Phillipsen H, Reichardt P, Praetorious F. Mixed odontogenic tumours and odontomas. Considerations on interrelationship. Review of literature and presentation of 134 new cases of odontomas. Oral Oncol 1977; 33: 86–99.  4.   Ida-Yanemochi H, Noda T, H S, T S. Disturbed tooth eruption in osteopetrotic (op/op) mice: histopathogenesis of tooth malformation and odontomas. J Oral Med Oral Pathol 2002; 31: 361–373.  6.   Regezi JA, Kerr DA, Courtney RM. Odontogenic tumors: Analysis of 706 cases. Journal of Oral Surgery 1978; 36: 771-778. 8.   Lu Y, Xuan M, Takata T, Wang C, He Z, Zhou Z, Mock D, Nikai H. A demographic study of 759 cases in a Chinese population. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, Endodontics 1998; 86(6): 707-714. 10.Cawson and Odell. Odontogenic tumors and tumors like lesions of the jaws. In essentials of Oral Pathology and Oral Medicine. 6th Ed, Churchill Livingstone 1998; 117-131. <![CDATA[An 8-year-old boy with renal artery stenosis and cerebral infarct]]> Syed Dawood Md.Taimur Tamzeed Ahmed Md. Golam Muinuddin Salma Jahan Farzana Islam https://imcjms.com/journal_full_text/209 2017-05-04 13:21:09 Clinical Case Report Ibrahim Med. Coll. J. 2011; 5(1): 32-33 Secondary hypertension is more common in children compared to that in adults, leading to organ damage and increased mortality. Renal artery stenosis could be a sequel to secondary hypertension in children and give rise to serious outcomes. A case of renal artery stenosis in an eight year old boy is presented in this study in whom PTA was performed with successful results. Blood pressure was controlled and all antihypertensive drugs could be withdrawn in a short period of time. Address for Correspondence:Dr. Syed Dawood Md. Taimur, Department of Cardiology, Ibrahim Cardiac Hospital & Research Institute, 122 Kazi Nazrul Islam Avenue, Shahbagh, Dhaka-1000. Email: dr.sdmtaimur@yahoo.com   An 8-year-old boy presented with history of headache and blurring of vision, weakness in left side of the body for one month. Physical examination revealed a conscious (Glasgow coma scale – 9 to 10), oriented, mildly edematous boy with puffy face. His pulse rate was 120 per minute which was regular in rhythm, and normal in volume. There was no radio-radial and radio-femoral delay. Blood pressure was 190/100 mm Hg in both upper limbs and 180/100 mm Hg in both lower limbs. Common carotid pulsations were equal on both sides. Carotid bruit was absent on both sides though audible only over right renal angle. Examination of cardiovascular system revealed that jugular venous pulsation was not raised. There was no visible cardiac impulse present. Apex beat was placed normally in the left fifth inter-costal space just lateral to mid clavicular line. First and second heart sounds were normally audible and there was absence of murmur. Hematological examination showed that hemoglobin level was 11.9gm / dl, erythrocyte sedimentation rate (ESR) was 30 mm in first hour, total count of red blood cell was 4.44 m/µl and total leukocyte count was 13,900/cumm (Neutrophil-82%, Lymphocyte-13%). Peripheral blood film showed that red blood cells were normocytic and normochromic. There was neutrophillia with cytoplasmic vaculation in some neutrophils, platelets were normal. Liver function tests, serum electrolytes, lipid profile and renal function tests were found normal. HBsAg, Anti-HCV, Anti-HIV and TPHA were negative. Cardiovascular system examination was found normal. Electrocardiographic (ECG) tracing was normal. Radiological examination of chest and echocardiography were found normal. Coronary angiogram showed that epicardial coronary arteries were normal and flash aortogram ruled out coarctation of aorta.   Fig-1a. Right renal artery stenosis     Fig-1b. After PTA of right renal artery For neurological deficiency, computed tomography scan of brain was done. A massive right cerebral infarct with focal hemorrhagic transformation in right temporal region was detected together with one small infarct in left parietal region (Figure 2).   As soon as the diagnosis of stenosed right renal artery was confirmed, a percutaneous transluminal angioplasty (PTA) was done with bare metal stent (3.0X13 mm) in the same setting. The patient was discharged with antihypertensive and anti-platelet drugs. He was advised to continue physiotherapy of affected limbs and to maintain weekly follow-up for a month and fortnightly thereafter. During follow-up, his clinical condition improved significantly. Hematological values, serum creatinine, urine analysis were becoming normal, and more importantly, blood pressure was found controlled with gradual reduction of antihypertensive drugs. However, antihypertensive and anti-platelet medication continued as monitored by follow up. Discussion Aims of the treatment modalities like medical treatment, PTA and surgery are done usually to control blood pressure and preservation of renal function. In our case, we performed PTA, which resulted in controlling blood pressure and finally normotensive with gradual withdrawal of number and doses of several antihypertensive drugs.   1.   National High Blood Pressure Education Program. Working Group on Hypertension in Children and Adolescents. Update on the 1987 Task Force Report on High Blood Pressure in Children and Adolescents. A working group report from the National High Blood Pressure Education Program. Pediatric 1996; 98: 649-658. 3.   Dillon MJ. The diagnosis of renovascular hypertension. Pediatric Nefrol 1997; 11: 366-372. 5.   Estepa R, Gallego N, Orte L, Puras E, Aracil E, Ortuño J. Renovascular hypertension in children. Scand J. Urol Nephrol 2001; 35: 388-392. 7.   McTaggart SJ, Gulati S, Walker RG, Powell HR, Jones CL. Evaluation and long-term outcome of pediatric renovascular hypertension. Pediatr Nephol 2000; 14: 1022-1029. <![CDATA[Bee envenomation induced acute renal failure in an 8 year old child]]> Farzana Islam Syed Dawood Md. Taimur C M Shaheen Kabir https://imcjms.com/journal_full_text/208 2017-04-30 15:27:23 Clinical Case Report Ibrahim Med. Coll. J. 2011; 5(1): 34-36 Massive envenomations by bees are capable of causing multiorgandysfunction as a result of direct toxic effects of the largevenom load received. Although all varieties of honey bee havethe potential for these attacks, the Africanized honey bee (Apismellifera scutellata) is the most commonly implicated subspecies.In the United States, the Africanized strain is found primarilyin the southwestern states and is known for its highly defensivebehavior if disturbed. Mechanisms behind the multiorgan dysfunctionproduced by these mass envenomations are not clearly understood.We present a case of an 8-year-old boy who was stung by multiple bees and developed progressive upper-body swelling andsystemic manifestations of mass envenomation including rhabdomyolysis,renal insufficiency, and a transient transaminase elevation. Address for Correspondence:Dr. Farzana Islam, Department of Paediatric Nephrology, Block: D, 3rd Floor, Bangabandhu Sheikh Mujib Medical University. Shahbagh, Dhaka-1000, Bangladesh, Mobile: +8801718011237, Email: dr.farzanaislamsilvi@yahoo.com   Stinging events involving honeybees and wasps are rare; most deaths or clinically important incidents involve very few stings (<10) and anaphylactic shock. However mass stinging events can prove life threatening via toxic action of the venom when injected in large amounts.1 Several types of uncommon reactions have been described including serum sickness, renal diseases, respiratory and neurological manifestations, hepatic dysfunction and delayed hypersensitivity phenomena.2  Case Report Arterial blood gas (ABG) revealed pH 7.35, paO2 80 mmHg, paCO2 34, HCO3 18 meq/L. Urine examination: color was reddish, appearance was initially clear then hazy, albumin ++, pus cells 2-6 /hpf, RBCs 35-45/hpf, urine hemoglobin +, urine culture - sterile.Laboratory findings were consistent with intravascular hemolysis, rhabdomyolysis, acute renal failure and hepatic dysfunction. Patient was treated with fluid restriction, diuretics, antibiotics, steroids, antihistamins and sodium bicarbonate. Ultimately he needed four sessions of hemodialysis after which he gradually improved and renal function returned to near normal by day fifteen.   This case demonstrates that multiple bee stings may cause rhabdomyolysis and hemolysis with consequent ATN. Components of venom include toxic surface-active polypeptides (mellitin and apamin), enzymes (phospholipase A2 and hyaluronidase) and low molecular weight agents (histamine and aminoacids). Mellitin and phospholipase are important components causing rhabdomyolysis following a toxic action on striated muscles which also acts on the red cell membrane and provokes hemolysis.3 The elevated levels of enzymes CPK and aspartate-aminotransferase suggest the existence of rhabdomyolysis and hemolysis is suggested by anemia, unconjugated hyperbilirubinemia, reticulocytosis, increased serum LDH and hemoglobinuria.3  The mortality associated with Africanized honeybee attacks is primarily the result only of the number of the number of stings.5 A number of about 500 stings have been considered necessary to cause death by direct toxicity, but as few as 30-50 stings have proved fatal in children.3 Our patient had about 200 stings and survived with complete renal recovery. The primary therapeutic goal is to prevent the factors that cause ARF, i.e. volume depletion, tubular obstruction, aciduria and free radical release. Patients are administered saline for intravascular volume expansion and sodium bicarbonate for urine alkalization (to urine pH level above 7). The ideal fluid regimen for patients with rhabdomyolysis consists of half isotonic saline (0.45%, or 77 mmol/L sodium), to which 75 mmol/L of sodium bicarbonate is added. Once overt renal failure has developed, the only reliable therapeutic modality is extracorporeal blood purification.4 Exchange transfusion or plasmaphresis has been found useful because it acts through a direct effect of reduction of the massive circulating venom or removal of the circulating mediators of inflammation caused by the venom itself.3,6 1.   Vetter RS, Visscher PK, Camazine S. Mass envenomations by honey bees and wasps. West J Med 1999; 170: 223-227. 3.   Bresolin NL, Carvalho LC, Goes EC, Fernandes R, Barotto AM. Acute renal failure following massive attack by Africanized bee stings. Pediatr Nephrol 2002; 17: 625-627. 5.   Schumacher MJ, Schmidt JO, Egen NB. Lethality of “killer” bee stings. Nature 1989; 337: 413. <![CDATA[Medical education in Bangladesh – past, present and future]]> M Abu Sayeed https://imcjms.com/journal_full_text/188 2017-04-19 14:56:25 Editorial Ibrahim Med. Coll. J. 2010; 4(2): i-ii Throughout the colonial rule of two hundred years, we had no choice other than to accept the westernized medicinal practice. In fact, during this period, Europe and America experienced a revolutionized stage of development in culture, science and industry. And so is the medical science and medical education. The medical schools opted primarily on an apprenticeship model of education.1 The medical education curricula started with the basic medical sciences during the first two preclinical years. The preclinical subjects were anatomy (including histology and embryology), physiology (including biochemistry), pharmacology, pathology, and bacteriology. With the advancement of research and discoveries in the twentieth century, new areas of knowledge were added. Immunology, virology, and genetics were increasingly loaded with enormous input though stayed within the discipline-oriented structure.2 Thus, the old model of ‘basic science education’ faced challenges increasingly with the rapidly generated new information and that necessitated a change in medical education. Many more changes and variations were undertaken to deal with the newly emerged situation for medical education. Finally, the Medical Curriculum Committee at Brown Medical School approved a vision for curriculum transformation that would build upon the competency-based curriculum. The curriculum was found effective and was implemented in 1996, incorporating five essential elements – 1. integrated coursework; 2. patient-centered focus; 3. small group active learning methods, 4. an educational environment that is both humane and conducive to learning, and 5. fuller and more robust integration of new technology. The old model of preclinical basic science (anatomy, physiology, biochemistry) has no chance of developing PBL and no practice of exercising previous knowledge. As a result the students can not decide what more they have to learn. Conversely, in the integrated model, courses supposed to be taught as disciplines like histology, anatomy and physiology are taught as part of the integrated teaching in each block. For example, understanding ischemic heart disease and heart failure, during the circulation and respiratory block, students will learn the anatomy, histology and physiology of the heart and blood vessels including lungs that they would have previously learned in separate courses. Additionally, they will also be introduced to information from other disciplines as appropriate. Another example, learning about staphylococcus as a prototypical Gram-positive bacterium during the infectious disease block cellulitis is described. They learn about the general principles of the inflammatory response at the same time, thus incorporating material that is currently taught in the general pathology course. Principles of pharmacology may also be introduced early as with specific pharmacological agents, with the level of understanding increasing over the two years with repeated exposures. Undoubtedly, our medical education in Bangladesh has failed to produce efficient professionals considering the need of the people and time. The proofs are plenty. Many a people opt to get medical treatment abroad if their financial ability permits to. There are substantial reports that have criticized medical education for emphasizing scientific knowledge over biologic understanding, clinical reasoning, practical skill, and the development of character, compassion, and integrity. More and more frustrations have been expressed in the Dailies almost frequently and regularly. How did this situation arise, and what can be done about it? Obviously, one of the important causes of this adverse outcome is the education model that we are running. We must feel the need to change the hundred years’ old model to IMC. Successful implementation of an integrated curriculum may face serious obstacles. Sufficient time and determination for faculty to meet together to plan the curriculum is the most critical ingredient for success. The departments and faculties are likely to feel pressure to spend time on obtaining research grants and clinical activities. If these constraints on faculty time and allocation can be mitigated, then the likelihood for success is high. Thirdly, assessment of competence and performance of a medical student is another flaw. Competence is not an achievement but rather a habit of lifelong learning.6 Assessment plays an integral role in helping physicians to identify and respond to their own learning needs. Ideally, the assessment of competence (what the student or physician is able to do) should provide insight into actual performance (what he or she does habitually when not observed), as well as the capacity to adapt to change, find and generate new knowledge, and improve overall performance. We have no mechanism to assess competence and performance of medical professionals. To conclude let us review our glorious history of medicine and the apprenticeship and the philanthropic behavior of the physicians of the past. Let us accommodate the new knowledge in medical education curriculum on a scientific basis. Let our medical students be exposed to primary health care in the community and to be actively involved in research on our own health issues. Let us develop mechanism for the assessment of competence and performance. Let ourselves (the teachers) exercise our honesty and integrity in academic performance, research activities and assessment skill so that our medical students develop attributes of medical professionalism – capable of transmitting knowledge, to impart skills and to inculcate the values of the profession.   Professor, Department of Community Medicine   1.   Bonner TN. Becoming a Physician: Medical Education in Britain, France, Germany, and the United States, 1750-1945. Oxford, Oxford University Press, 1995. 3.   McGaghie WC, Miller GE et al. Competency-based curriculum development in medical education: an introduction. Geneva, World Health Organization, 1978. 5.   Fragstein MV, Silverman J, Cushing A, Quilligan S, Salisbury H, Wiskin C.UK consensus statement on the content of communication curricula in undergraduate medical education. Medical Education 2008; 42: 1100-1107. <![CDATA[Prevalence and risk factors of coronary heart disease in a rural population of Bangladesh]]> M Abu Sayeed Hajera Mahtab Shurovi Sayeed Tanjima Begum Parvin Akter Khanam Akhter Banu https://imcjms.com/journal_full_text/189 2017-04-19 15:04:58 Original Article Ibrahim Med. Coll. J. 2010; 4(2): 37-43 Coronary heart disease (CHD) is a major global health problem with the majority of burden observed increasingly in the developing countries. There has been no estimate of CHD in Bangladesh. This study addresses the prevalence of CHD in a Bangladeshi rural population which also aimed to determine the risk factors related to CHD. Ten villages of Nandail sub-district under Mymensingh were selected purposively. All subjects of age ³20y were considered eligible and were interviewed about family income, family history of T2DM, CHD and HTN. The investigations included height, weight, waist-girth, hip-girth, systolic and diastolic blood pressure (SBP & DBP), fasting blood glucose (FBG), triglycerides (TG), cholesterol (Chol) and high density lipoprotein (HDL). Hemoglobin A1c (HbA1c) and albumin-creatinine ratio (ACR) were also estimated. Finally, electrocardiography (ECG) was undertaken in all participants who had family history of diabetes or hypertension or CHD. Diagnosis of CHD was based on history of angina or changes in ECG or diagnosed by a cardiologist. A total of 6235 subjects were enlisted as eligible (age ³20y) participants. Of them, 4141 (m / f: 1749 / 2392) subjects volunteered for the study. The age-adjusted (20-69y) prevalence of CHD was 1.85 with 95% CI, 1.42 – 2.28. There was no significant difference between men and women. The mean (SD) values of age (p<0.001), SBP (p<0.01), DBP (p<0.05), HbA1c (p<0.05) and ACR (p<0.01) were significantly higher among subjects with CHD than those without; whereas, there were no significant differences in BMI and WHR, TG, Chol and HDL. Logistic regression analysis showed that adjusted for age, sex, social class and obesity, the subjects with higher age (³45y), higher 2hBG (³7.0mmol/l), higher ACR (³17.2) and family history of CHD had significant risk for CHD. The prevalence of CHD is comparable with other Asian population. Family history of CHD and age over 45 years, and who had hyperglycemia and higher ACR were proved to be the independent predictors of CHD. CHD was found to affect participants irrespective of sex, social class, obesity and lipid status. Though the IFG and diabetes groups appeared to have similar biophysical characteristics, only the diabetes group had significant risk for CHD. Further study in a larger sample may be undertaken to confirm the study findings and to explore some unidentified risk factors of CHD. Address for Correspondence: Prof. M Abu Sayeed, Department of Community Medicine, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000, e-mail: sayeedma@dab-bd.org   Morbidity and mortality from coronary heart disease (CHD) have increased to an epidemic form in the past several decades. A substantial number of reports indicatethattheprevalenceofCHDhasincreasedboth in the developed and in the developing countries.1-4 Recently published reports suggests that CHD is related to social deprivation and low socio-occupational classes.5,6 It is well known that Bangladesh is one of the least developing countries and its per capita GNP is one of the lowest (USD 370) in the world.7 Another important and relevant consideration is that CHD is the leading cause of death among individuals with diabetes.8 The information on CHD and its association with known risk factors in populations with high rates of diabetes is limited and the influence of known duration of diabetes was not observed to be a significant contributor to the cardiovascular risk factors.9 The risk factors were found to be significant in the sub-sample of patients with duration of diabetes even less than 15 years. As regards diabetes, Bangladeshis were found to have a high prevalence of impaired fasting glucose (IFG: 4 – 12%) and type-2 diabetes (T2DM: 4-11%) in the age group equal to or greater than 20 years.10-13 Thus, it appears that the people of Bangladesh are likely to develop CHD for the two obvious reasons – first, due to the exposure of social deprivation; and second, there being a high prevalence of diabetes. However, there has been no known study so far conducted to address this issue. This study was undertaken to determine the prevalence of CHD in a sub-sample of the vast majority of rural Bangladesh and to investigate the risk factors acting upon them. Subjects and Methods The objectives and procedural steps were informed to every individual participant for taking consent. Having consent each individual was requested to attend a nearby investigation spot with at least 12h fast. Each participant was interviewed for clinical history, medication and physical activities, and for women, menstrual history to exclude pregnancy [Figure-1]. Measurements of height, weight, and girth of waist and hip were taken with light clothes and barefooted. Blood pressure was measured after 10min rest. Hemocue Cuvettes were used for measuring capillary fasting blood glucose (FBG). The participants were classified into hyperglycemic and normoglycemic groups based on FBG cut-off at 5.6 mmol/l. All the subjects with hyperglycemia (³5.6mmol/l) were considered eligible for further investigations like oral glucose tolerance test (OGTT), total cholesterol (t-chol), triglycerides (TG), high-density-lipoprotein chol (HDL-Chol), hemoglobin A1c (HbA1c), electrocardiogram (ECG) and urinary albumin-creatinine ratio [Figure-1]. Additionally, the normoglycemic (FBG <5.6mmol/l) subjects also had all these investigations but only in randomly selected 20%.       A total of 6235 subjects of 10 villages were found eligible for the study. Of them, 4141 (m / f = 1749 / 2392) volunteered for the study. The mean (SD) age of the participants was 37.6 (15.2) years and the values for BMI, WHR, SBP, DBP and FBG were 19.4 (2.9), 0.84 (0.07), 120 (18) mmHg, 77 (12) mmHg and 4.7 (0.89) mmol/l, respectively (Table-1a). The participants, as mentioned, were categorized into hyperglycemic (FBG ³5.6) and normoglycemic (FBG<5.6) groups [figure 1]. Further biochemical investigations are also shown in the same table. Hyperglycemia was found in 7.2% (n=300) and normoglycemia in 92.8% (n=3841) subjects. All of the hyperglycemic and 20% of the randomly selected normoglycemic subjects (n=768) were undertaken for further investigations like cholesterol, TG, HDL, HbA1c, ACR shown in Table-1b. The characteristics of the hyperglycemic and normoglycemic subjects were compared (Table 2). Compared with the normoglycemic, the hyperglycemic subjects had significantly higher age, WHR, WHtR, SBP, DBP and FBG; whereas, they did not differ with respect to sex, social class, family history of HTN and CHD. In contrast, the family history of diabetes was significantly higher among the hyperglycemic group (p<0.01). Fig.1: Algorithm for investigation:     Table 1b: Investigations undertaken for the hyperglycemic and randomly selected groups (n = 976)     Table-3 shows the comparison of characteristics between subjects with and without CHD. The subjects with CHD had a significantly higher age (p<0.001), WHtR (p<0.03), SBP (p<0.01), DBP (p<0.05), FBG (p<0.001) and ACR (p<0.01) than their non-CHD counterpart; whereas, other characteristics like BMI, WHR, Chol, TG, HDL, LDL, VLDL and lipoprotein (a) did not differ. Table 3: Comparison of characteristics between subjects with and without coronary heart disease (CHD)       We also estimated the association of CHD with family income, education, occupation and smoking habits. None of these variables showed any significant association with CHD. In contrast, family history of hypertension and family history of CHD proved to have a significant risk for CHD.     Discussion     Additional merit of the study is that more than 90% of the selected participants volunteered for ECG, OGTT, t-cholesterol, TG, HDL, LDL and ACR in a rural setting. As regards risk factors for CHD, advancing age, diabetes, hypertension, family history of CHD and high ACR are very consistent with other studies.14-16,18-20 Interestingly, smoking habit, general obesity (high BMI), central obesity (high WHR), dyslipidemia (high chol, TG, low HDL) and extremes of social class (affluent or socially deprived) were found not significantly related to CHD. Why these known risk factors are not related to CHD in the study population is not clear. Possibly, the study population was neither obese (mean BMI±SD: 19.4±2.9; WHR: 0.84±0.07) nor dyslipidemic (95% CI: cholesterol, 121 -129, TG, 105 – 117) and not exceeding the thresholds of obesity or dyslipidemia for developing CHD. Consequently, these risk factors were found not contributing to atherosclerosis.   The study concludes that the prevalence of CHD is almost comparable with the Indians and even higher than Japanese and Chinese. Family history of CHD and age over 45 years, and who had hyperglycemia and higher ACR were observed to be the independent predictors of CHD. CHD was found to affect participants irrespective of sex, social class, obesity and lipid status. Although the IFG and diabetes groups appeared to have similar biophysical characteristics, only the diabetes group had a significant risk for CHD. Further studies on a larger sample may be undertaken to confirm the study findings and to explore some unidentified risk factors of CHD. Acknowledgements   1.   Azambuja MI, Levins R. Coronary heart disease (CHD)—one or several diseases? Changes in the prevalence and features of CHD. Perspect Biol Med 2007; 50: 228-42. 3.   Jabara R, Namouz S, Kark JD, Lotan C. Risk characteristics of Arab and Jewish women with coronary heart disease in Jerusalem. Isr Med Assoc J. 2007; 9: 316-20. 5.   Strong M, Maheswaran R, Radford J. Socioeconomic deprivation, coronary heart disease prevalence and quality of care: a practice-level analysis in Rotherham using data from the new UK general practitioner quality and outcomes framework. J Public Health (Oxf) 2006; 28: 39-42. 7.   Musa AKM, Khan AH. Statistical pocket book of Bangladesh 2004: Bangladesh bureau of statistics, planning division, ministry of planning, Government of the Peoples’ Republic of Bangladesh 2006; 437-8. 9.   John L, Nayyar V, Shyla PM, Kanagasabapathy AS. Comparison of cardiovascular risk factors in type II (non-insulin dependent) diabetics with and without coronary heart disease. J Assoc Physicians India. 1993; 4: 84-7. 11.Sayeed MA, Banu A, Khanam PA, Mahtab H and Azad Khan AK. Prevalence of Hypertension in Bangladesh: effect of socioeconomic risk on difference between rural and urban community. Bang Med Res Coun Bull 2002; 28: 7-18. 13.Sayeed MA, Mahtab H, Khanam PA, Ali SMK, Chowdhury RI, Vaalar S, Hussain A and Azad Khan AK. Fasting cut-offs in determining the prevalence of diabetes and intermediate glucose abnormality in a non-obese population. Bang Med Res Counc Bull 2004; 30: 105–114. 15.Silbiger JJ, Ashtiani R, Mehran Attari, Tanya M. Spruill, Mazullah Kamran, Deborah Reynolds, Russell Stein and David Rubinstein. Aheroscerlotic heart disease in Bangladeshi immigrants: risk factors and angiographic findings. Int J Cardiology 2008; 12: 175 [letter]. 17.Rahman MA, Zaman MM. Smoking and smokeless tobacco consumption: Possible risk factors for coronary heart disease among young patients attending a tertiary care cardiac hospital in Bangladesh. Public health J 2008; 122: 1331-1338. 19.Joshi R, Chow CK, Raju PK, Raju R, Reddy KS, MacMahon S, Lopez D, Neal B. Fatal and nonfatal cardiovascular disease and the use of therapies for secondary prevention in a rural region of India. Circulation. 2009; 119: 1950-1955. 21.Nazarethhttp://heartasia.bmj.com/content/2/1/28. abstract - aff-1 I, D’Costa G, Kalaitzaki E, Vaidya R, King M. Angina in primary care in Goa, India: sex differences and associated risk factors. Heart Asia 2010; 2: 28-35. 23.Yusuf S, Reddy S, Ounpuu S and Anand S. Global burden of cardiovascular diseases: Part II: Variations in cardiovascular disease by ethnic groups and geographic regions and prevention strategies. Circulation 2001; 104: 2855-2864. <![CDATA[Utilization of maternal health care services in slum areas of Dhaka city, Bangladesh]]> Housne Ara Begum Nilufar Yeasmin Nili Amir Mohammad Sayem https://imcjms.com/journal_full_text/190 2017-04-20 09:46:28 Original Article Ibrahim Med. Coll. J. 2010; 4(2): 44-48 Bangladesh has one of the highest maternal mortality rates (MMR) in the world. The estimated lifetime risk of dying from pregnancy and childbirth related causes in Bangladesh is about 100 times higher compare to developed countries. However, utilization of maternal health care services (MHCS) is notably low. This study examines the socio-economic determinants of utilization of MHCS in some slum areas of Dhaka city. The overall utilization was 86.3% of women; however, utilization of different sorts of MHCS was very low, i.e., the mean utilization was found to be 2.25 out of 5 MHCS. Indicator wise, ANC, TT, institutional delivery, delivery assistance by health professional and PNC were received by 61.3%, 80.4%, 12.6%, 33.2% and 55.4% of women respectively. Variation was observed with different socio-economic variables. Multiple regression model could explain 38% of variance (P<0.001). Among the significant determinants, order of last birth negatively explained the most variance (15.2%). Similarly, distance between home and clinic was found to affect the utilization negatively. Besides, some respondents’ socio economic variables had a significant positive effect on MHCS utilization. To reduce maternal mortality in disadvantaged women in slum areas, this study might suggest a few pointers while considering formulation of policies and planning. Introduction Despite the presence of strategic and programmatic initiatives in order to reduce maternal and child health, maternal mortality and child mortality and morbidity continue to be high. Bangladesh has one of the highest maternal mortality rates (MMR) in the world, i.e. 3/1000 live births.5 The tragic consequence of these deaths is that about 75% of the babies born to these women also die within the first week of their lives. On the other hand, infant and child mortality are respectively 52 per 1000 live birth and 14 per 1000 children.6   The data used in this study were collected from three randomly selected slum dwelling women of reproductive age through a semi structured survey questionnaire which included the socioeconomic, demographic and cultural characteristics of respondents as well as the family, and utilization of maternal health care services in their last pregnancy. The slums were identified applying the cluster sampling technique. From the three slums, 540 women were successfully interviewed. Simple linear regression analysis was considered at multivariate level in order to identify the factors affecting the utilization of maternal health services. In this regard, the following equation was used to estimate the regression coefficients: Where, Y= dependent variable, a = constant, b = the regression coefficient, X = independent variables of the model, K= end number of the series, e = error term. Results Utilization of the number of services by the women in general was lower than expected. On average, women utilized 2.25 MHCS with standard deviation 1.46. Among 86.3% women who utilized MHCS, 21.1%, 17.8% and 29.4% of them utilized respectively 1, 2 and 3 MHCS while only 9.8% and 8.1% women respectively utilized 4 and 5 MCHS.         Correlates of Utilization of Maternal Health Care Services     Besides, the order of last birth had a significant negative association with utilization of MHCS. On average, women who had given only one birth utilized 2.92 MHCS which almost gradually decreased to around 1.72 among women who had given birth to more than 6 children. Almost similarly, distance form home to clinic and respondent’s age at last birth had significant association with utilization of MHCS suggesting that women whose households were far away from clinic and who were older were more likely to utilize MHCS less than those women whose household was nearer to the clinics and were at a younger age. Determinants of Utilization of MHCS The overall regression model explained 38.0% (Adjusted R Square) of variance with P<0.001 in utilization of MHCS (Table 3). The most explanatory variable was order of the last birth which alone explained 15.2% variance (P<0.001) indicating that women’s higher birth order of the last child were less likely to utilize MHCS in slum areas. With similar direction to order of last birth, distance between home and clinic and age at last birth respectively explained 3.0% and 0.6% of variance.   Over all, the level of the utilization of maternal health care services was no satisfactory in the slum areas. On average, women received 2.25 MHCS. Due to the greater confidence and experience of the older and higher parity women together with greater responsibilities within the household and for child care, these women were more likely to utilize maternal health care services.7 However, in this study, the findings were opposite. Similar findings were also found in other studies.8, 9,10 Women having a longer distance from home to clinic utilized less MHCS than women with shorter distance. This is similar to many other studies.19-26 This may be because poor road conditions and congested houses can make it extremely difficult for women to reach even relatively nearby facilities. In a study conducted in Tanzania, it was found that women who gave birth at home actually intended to deliver at a health facility but could not do so due to distance and lack of transportation.27 Mass media increases awareness about innovations, and fosters inter-personnel communication, which could facilitate behavioural changes allowing for the adoption of new/different behaviours.28-29 Consistently, mass media exposure had significant positive impact on maternal health care services utilization. Women with higher positive attitude towards maternal health care services were found to utilize MHCS more than that of women with negative attitude. This may be because positive attitude diverts them from traditional way of care seeking such as from traditional birth attendant and/or relatives. Women who gave birth at higher ages were found to utilize MHCS more compared to women with lower age at last birth. Most probably this was because the former group were more experienced on complications due to pregnancy and were more inclined to seek service from health professional. Conclusion   We acknowledge the financial support provided by United Nations Population Fund (UNFPA) for conducting this research. References 2.   The state of world population: United Nations Population Fund, New York, 1995. 4.   The Progress of Nations, UNICEF: New York, 1996. 6.   Bangladesh Demographic and Health Survey 2007. 8.   Elo TI. Utilization of maternal health-care services in Peru: the role of women’s education, Heal Trans Rev 1992; 2: 49–69. 10.Wong EL, Popkin BM, Gullkey DK, Akin JS. Accessibility, quality of care and prenatal care use in the Philippines, Soc Sci Med 1987; 24: 927-944. 12.Addai I. Demographic and socio-cultural factors influencing use of maternal health services in Ghana, African J Repro Heal 1998; 2: 73-80. 14.Fosu GB. Childhood morbidity and health services utilization: cross-national comparisons of user-related factors from DHS data, Soc Sci Med 1994; 38: 1209-1220. 16.Navaneetham K., Dharmalingam A. Utilization of maternal health care services in Southern India, Soc Sci Med 2002; 55: 1849-1869. 18.Rani M, Bonu S. Rural Indian women’s care seeking behavior and choice of provider for gynecological symptoms, Stud Fam Plann 2003; 34: 173-185. 20.Alix-Dancer P. Access to health care in developing countries. In: Developing countries, society and technology. Stockholm: Royal Institute of Technology (KTH), 2003. 22.Rahaman MM, Aziz KM, Munshi MH, Patwari Y, Rahman M.A diarrhoea clinic in rural Bangladesh: influence of distance, age and sex on attendance and diarrheal mortality, Am J Pub Heal 1982; 72: 1124-1128. 24.Abbas AA, Walkern GJA. Determinants of the utilization of maternal and child health services in Jordan, Int J Epidem 1986; 15: 404-407. 26.Paul BK. Health service resources as determinants of infant death in rural Bangladesh: an empirical study, Soc Sci Med 1991; 32: 43-49. 28.Ahmed SM, Adams AM, Chowdhury M, Bhuiya A. Gender, socioeconomic development and health seeking behavior in Bangladesh, Soc Sci Med 2000; 51: 361-371. <![CDATA[Waist-to-height ratio and socio-demographic characteristics of Bangladeshi adults]]> Meerjady Sabrina Flora CGN Mascie-Taylor Mahmudur Rahman https://imcjms.com/journal_full_text/191 2017-04-20 09:51:10 Original Article Ibrahim Med. Coll. J. 2010; 4(2): 49-58 Anthropometric indicators of abdominal obesity are associated with cardiovascular risk factors, such as type 2 diabetes, hypertension, and dyslipidemia. Controversy remains regarding the best anthropometric indices for cardiovascular risk. Waist-to-height ratio has been reported to be an effective predictor of metabolic risks and it may be a better measure of relative fat distribution amongst subjects of different age and statures. Bangladeshi data lack in this perspective. To determine waist-to-height ratio of Bangladeshi adults along with its variation with socio-economic status, cross-sectional studies were conducted in 2002 and 2003. Data were collected through interviewing and measuring height and waist circumference of 22,995 adult males and females of an urban (Mirpur, Dhaka City) and rural area (Kaliganj sub-district). The mean waist-to-height ratio of 0.48 significantly varied with socio-demographic variables and it was markedly higher in females, older age groups, urban residents and the better educated. Urban residents, females, older people, better educational status, the non-paid and married individuals were more likely to have high waist-to-height ratio (³0.5). High waist-to-height ratio levels using sex-specific cut-offs were more common in females, urban residents, Christians, older individuals, married, the better educated and the non-paid. Age and locality were identified as best predictors in males and females, respectively. Address for Correspondence:Dr. Meerjady Sabrina Flora, Associate Professor of Epidemiology, National Institute of Preventive and Social Medicine, Mohakhali, Dhaka, Bangladesh. e-mail: meerflora@yahoo.com   Bangladesh is having a double burden of health problems; the occurrence of non-communicable diseases is also increasing in addition to existence and emergence of infectious diseases. Moreover, it faces nutrition transition with over-nutrition and under-nutrition occurring simultaneously. While about a quarter of rural, and lower class urban people have chronic energy deficiency; the prevalence of obesity in the upper and middle class urban people is between 9-11%.1 It is being increasingly recognised that central, rather than general obesity, is likely to coexist with type 2 diabetes and lead to complications including cardiovascular diseases. Although its importance is acknowledged, no unified definition exists for central obesity; several anthropometric indexes such as waist circumference (WC), waist-hip ratio (WHR), waist-to-height ratio (WHtR), conicity index (Cindex) etc, are being used.2 These anthropometric indices are associated with cardiovascular risk factors, such as type 2 diabetes, hypertension, and dyslipidemia. However, controversy remains regarding the best anthropometric indices for cardiovascular disease (CVD) risk.3 WC was the main variable used as a measure of central obesity as it is much simpler and more practical to use and because it associates more strongly with cardio-vascular diseases and is a better predictor of future risk of metabolic diseases.4 However, WC measurement has been criticized for not taking into account differences in body height, and the WHtR value is a better predictor of cardiovascular risk factors.3 The ratio of waist circumference to height may be a superior measure for women as well as men5 and a simple index for measuring coronary risk. Waist circumference reflects abdominal obesity, and height is relatively constant in adults and can be used to compensate for variations in frame size.6 WHtR has been reported to be an effective predictor of metabolic risks and it may be a better measure of relative fat distribution amongst subjects of different age and statures.7 The index, especially for women, is a better indicator for predicting obesity-related CVD risk factors than other indices.8 Collection of good quality national data on different indicators of central obesity is needed. So far data available in this regard, are mostly on WC and WHR. In an earlier publication of this study the Cindex of Bangladeshi population is described.9 The current attempt is to explore WHtR. A small scale study, which was done on rural adults only, provide mean WHtR data of adult male (0.43 ± 0.04) and female (0.44 ± 0.05) Bangladeshi.10 Therefore, the current study attempted to find out the WHtR of rural as well as urban adults from a large sample. Materials and methods Subjects were measured wearing minimal attire. All the equipment was checked regularly to minimise random errors. Height was measured to the nearest 0.1 cm with a specially constructed wooden height stand to which a plastic measuring tape was attached. The subject stood without shoes or head gear (cap, ribbon etc) in an upright posture with their head in the Frankfurt plane. Subjects were asked to keep their heels close together with their hands hanging freely by their side, palms facing inwards. The horizontal blade of the stadiometer was gently placed on the crown of the head to take the measurement. A flexible plastic tape was used to measure waist circumference, accurate up to the nearest 0.1cm. Waist circumference was measured at the level mid way between the lowest rib margin and the superior iliac crest on the mid-axillary line in a horizontal plane. The subjects stood erect with abdomen relaxed, the arms at the side and feet together and breathing normally.   The mean (SD) waist-to-height ratio was 0.48 (0.07), but there was considerable variation in relation to socio-demographic status (Table 1). Age showed a curvilinear association (3rd order polynomial) with WHtR; WHtR gradually increased with age, ending in a plateau in the 40-69 age group and falling slightly in the 70+ group; after correcting for sex the trend was more pronounced with greater increments between each age group. Females had higher WHtR than males, before and after, controlling for age effects. Urban residents had, on average, a higher WHtR while Hindus, unmarried individuals and manual labourers had, on average, a lower WHtR. There was a general upward trend in mean WHtR with improvement in educational status. Table 1: Waist-to-Height Ratio in Relation to the Socio-demographic Variables   Waist-to-height ratio was categorised as normal and high based on a cut-off of 0.5 for both sexes. Overall 32% of the sample were found in the high category although the percentages varied widely by socio-demographic variable (Table 2). Females and urban residents were almost twice more likely to have high WHtR. The proportion of high WHtR increased with age up to 40-49 years, then gradually decreased with advancing age. The proportion also increased with educational attainment. Manual labourers, unmarried individuals and Hindus were less likely to have a high WHtR. Table 2: Wais- to-Height Ratio Categories Using a Common Cut-off (both sex) in Relation to the Socio-demographic Variables       WHtR was also categorised using sex-specific cut-offs (male 0.48 and female 0.45) and half of the sample were found to have high WHtR. Considerable heterogeneity was observed in the WHtR categories in relation to the socio-demographic variables (Table 4). Females, urban residents, the better educated, older individuals, widows/divorcees, the non-paid and Christians were more likely to have a high WHtR. Table 4: Waist-to-Height Ratio Categories Using Sex-specific Cut-offs in Relation to the Socio-demographic Variables     Table 6: Comparison of Mean BMI, WC, WHtR and Cindex between the Current and Other Asian Studies   Vague was the first to observe that women with android obesity had a high prevalence of diabetes and atherosclerosis.12 Subsequent studies have shown that abdominal obesity, as measured by the waist circumference or related indexes, is associated with the subsequent development of type 2 diabetes13-16 and ischemic heart disease17-19 as well as with risk factors for CVD.20 The advantages of WHtR were listed by Hsieh et al. (2003): “(1) closer agreement of values between men and women at all ages; (2) more accurate tracking of fat distribution and accumulation by age; (3) closer correlation with morbidity index for coronary risk factors; (4) more comprehensive identification of overweight individuals and those of normal weight facing higher risks (5) greater simplicity, in that a single rule (keep your waist circumference below half your height) may be applied both for men and women, enabling busy physicians and other professionals to screen and counsel examinees who face higher metabolic risks during physical examinations”. In this way, the index can serve as a ‘second stethoscope’.25 Adult anthropometric data in Bangladesh cover weight and BMI and most nutrition research has focused on under-nutrition, particularly among women and children. BMI does not give any indication of the distribution of weight in the body. Anthropometric indicators of abdominal obesity estimate the amount of visceral fat tissue which, in turn, is associated with a higher risk of development of cardiovascular diseases. So, waist circumference, waist–to-height ratio as well as conicity index were also used in order to provide some notion of central obesity. However, WC, a much studied indicator and Cindex did not show high predictive accuracy. The current study focused on this important but relatively less used indicator. The overall mean WHtR in the current study was 0.48 mean which is comparable with other Asian studies as shown in Table 6 with mean values in the current study within the Asian range. The average WHtR was higher in females suggesting consistency with the findings of Sayeed et al.10 The overall WHtR seems higher than the previous Bangladeshi data because that study was done in rural samples which were lower than urban residents. The current study supports this idea showing higher WHtR in urban residents. Overall 19% of the variation in WHtR were explained by socio-demographic variables, and the main predictors were locality, age, and education. The current study used both Japanese7 and Taiwanese8 cut-offs to detect high WHtR. About 32% and half of the samples respectively were identified as high WHtR using cut-off of 0.5 for both sex and sex-specific cut-off. Urban residents, females, older people, better educational status, the non-paid were more likely to have a high WHtR. Occupation followed by locality (for WHtR ³0.5) and sex followed by age (for WHtR ³0.48 for men and ³0.45 for women) were the best predictors. Age and locality were identified as best predictors in males and females, respectively. No such data were available to compare with.   The authors are grateful to the Department for International Development (DFID), United Kingdom, Board of Graduate Studies, the University of Cambridge, The British Federation of Women Graduates Charitable Foundation, The Charles Wallace Bangladesh Trust, and Churchill College, the University of Cambridge for their support. References 2.   Mamtani MR & Kulkarni HR. Predictive performance of anthropometric indexes of central obesity for the risk of type 2 Diabetes. Arch Med Res 2005; 36: 581-589. 4.   Ford ES, Mokdad AH & Giles WH. Trends in waist circumference among US adults. Obes Res 2003; 11: 1223-1231. 6.   Hsieh SD & Yoshinaga H. Waist/Height ratio as a simple and useful predictor of coronary heart disease risk factors in women. Int Med 1995; 34: 1147-1152. 8.   Lin WY, Lee LT, Chen CY, Lo H, Hsia HH, Liu IL et al. Optimal cut-off values for obesity: using simple anthropometric indices to predict cardiovascular risk in taiwan. Int J Obes 2002; 26: 1232-1238. 10.Sayeed MA, Mahtab H, Latif ZA, Khanam PA, Ahsan KA, Banu A et al. Waist-to-height ratio is a better obesity index than body mass index and waist-to-hip ratio for predicting diabetes, hypertension and lipidemia. Bangladesh Med Res Counc Bull 2003; 29: 1-10. 12.Vague J. The degree of masculine differentiation of obesities:afactordeterminingpredispositiontodiabetes, atherosclerosis, gout, and uric calculous disease. Am J Clin Nutr 1956; 4: 20–34. 14.Tulloch-Reid MK, Williams DE, Looker HC, Hanson RL & Knowler WC. Do measures of body fat distribution provide information on the risk of type 2 diabetes in addition to measures of general obesity? Comparison of anthropometric predictors of type 2 diabetes in Pima Indians. Diabetes Care 2003; 26: 2556–2561. 16.Schulze MB, Heidemann C, Schienkiewitz A, Bergmann MM, Hoffmann K & Boeing H. Comparison of anthropometric characteristics in predicting the incidence of type 2 diabetes in the EPIC-potsdam study. Diabetes Care 2006; 29: 1921–1923. 18.Yarnell JW, Patterson CC, Thomas HF & Sweetnam PM. Central obesity: predictive value of skinfold measurements for subsequent ischaemic heart disease at 14 years follow-up in the Caerphilly Study. Int J Obes Relat Metab Disord 2001; 25: 1546–1549. 20.Despres JP. Is visceral obesity the cause of the metabolic syndrome? Ann Med 2006; 38: 52–63. 22.Bosy-Westphal A, Geisler C, Onur S, Korth O, Selberg O, Schrezenmeir J et al. Value of body fat mass vs anthropometric obesity indices in the assessment of metabolic risk factors. Int J Obes 2006; 30: 475– 483. 24.McCarthy HD & Ashwell M. A study of central fatness using waist-to-height ratios in UK children and adolescents over two decades supports the simple message—keep your waist circumference to less than half your height. Int J Obes (Lond) 2006; 30: 988 –992. 26.Yasmin & Mascie-Taylor CGN. Adiposity indices and their relationship with some risk factors of coronary heart disease in middle-aged Cambridge men and women. Ann Hum Biol 2000; 27: 239-248. 28.Pitanga FJG & Lessa I. Sensitivity and specificity of the conicity index as a coronary risk predictor among adults in salvador, Brazil. Rev Bras Epidemiol 2004; 7: 259-269. 30.Ko GTC, Chan JCN, Cockram CS & Woo J. Prediction of hypertension, diabetes, dyslipidaemia or albuminuria using simple anthropometric indexes in Hong Kong Chinese. Int J Obes 1999; 23: 1136-1142. <![CDATA[Anthropometric profile of the urban senior citizens]]> Md. Anisur Rahman Monira Akhter Moni Kamal Ahmed Md. Shafiqul Islam Md. Abidul Haque https://imcjms.com/journal_full_text/192 2017-04-20 09:58:33 Original Article Ibrahim Med. Coll. J. 2010; 4(2): 59-62 This cross-sectional study was carried out from January to June 2006 to find out the anthropometric profile of the urban seniors living in three selected areas (Nakhal Para, Badda and Mirpur) of Dhaka city. A total of 317 individuals of both sexes aged 60 years and above were recruited by convenient sampling. Data were collected by a pre-tested questionnaire and a check list. Mean body mass index, waist circumference and waist to hip ratio were 17.8 ± 4.0, 75.5 ± 12.5 cm and 0.87 ± 0.12, respectively. Although only 3% elderly were obese, substantial proportion of the sample were overweight. Females were more prone to health risks than male. Measures should be taken to create awareness amongst these populations for controlling their health risk. Key words: Anthropometry, elderly, Body Mass Index (BMI), Waist Circumference (WC), Waist to Hip Ratio (WHR).   Introduction In the developing countries aging issues have only recently begun to emerge as a cause of concern. Bangladesh is one of the twenty developing countries with the largest number of senior citizens. About 7.2 million (around 6%) of the total population of Bangladesh constitutes the elderly population. This figure was 1.37, 1.86, 4.90 and 6.05 millions in the year 1911, 1951, 1981 and 1991, respectively.3 By 2025 along with other Asian countries, Bangladesh will account for almost half of the world’s total senior citizens. This change is predicted to have seriousconsequences.4 Most of the elderly in Bangladesh suffer from some basic human problems like such as poor financial support, exclusion, negligence, deprivation, insecurity, senile diseases and absence of proper health and medical care. They become frustrated and suffer from illness without care and company.3 This study aimed to assess the anthropometric profile of the senior citizens of an urban community with a view to help in formulating appropriate intervention measures to address the health need of the aged.Materials and Methods BMI was calculated with formula weight in Kg / height in meter square. The following cut-off points were used in this study:             Under nutrition                          < 18.5                          Overweight                                25.00 – 29.99               Normal range                             Male <94, Female <80             Substantial Health Risk               Male >102, Female >88             Health Risk                                WHR             Health Risk                                Male ³ 1.01, Female ³ 0.86 Results     On average, females were having significantly lower height, weight, WC whereas no significant difference was noticed in hip circumference and body mass index between the sexes. Anthropometric values by gender are shown in Table 2 and Table 3. Only about 3% of the elderly samples were obese. One-fifth of the males and one-fourth of the females were underweight whereas overweight and obese were about 14% and 17%, respectively. But the observed differences were not statistically significant. Higher proportion of females (10.6% and 35.6%, respectively) were with health risk WC (p<0.01) and WHR (<0.001) compared to males (0.8% and 7.0%, respectively). Table 2: Anthropometric indicators of the senior citizens by sex (n = 317)     Discussion In most studies, mentioned below, BMI was found higher in females than males. Other indices found having different findings in different studies. In a study on Filipino adults including approximately 8,500 subjects (20-65 years old), BMI, WC and WHR were found higher for the males than females.10 In population-based, cross-sectional studies in Chile and Cuba on the elderly, BMI values were significantly higher in women than in men.11,12 In another study in Brazil among the elderly, a total of 1,894 older adults (men and women > 60 years) were examined from January to March 2001. Body mass index (BMI), waist (WC) and hip (HC) circumferences were measured. BMI was significantly higher (p < 0.01) in women than men (all age groups).13 In a cross sectional study on 60-year-old-and older Mexican men and women in Mexico City, the values in the male group were higher than in the female group for WC; women showed higher values in BMI, and hip circumference (p < 0.01).14 In a Mexican national survey, BMI values indicated that 62.3% of the population and 73.6% of the women were overweight.15 In a cross-sectional study on randomly selected 3,356 elderly Italian population, BMI was significantly higher in women than in men (27.6 ± 5.7 v. 26.4 ± 3.7; P<0.001). Prevalence of malnutrition was lower than 5% in both genders, whereas obesity was shown to have a higher prevalence in women than in men (28% v. 16%; P<0.001).16 In another cross-sectional study of 874 free-living, apparently healthy Irish-born elderly individuals aged over 65 years, one-third had a BMI between 20-25 kg/m2, approximately two-thirds (68.5% of males and 61% of females) were classified as overweight or obese, almost one-fifth having a BMI over 30 kg/m2 (17% of men and 20% of women). Very few were underweight, only 3% having a BMI below 20 kg/m2.17 An institution based study on 305 elderly people, of both sexes, living in six geriatric institutions were assessed. Mean values of the weight, height, body mass index in men were higher than those in women. Of the mean difference of the variables, body mass index was not statistically significant (p>0.05).18 In this study, majority of elderly were found well nourished and had no health risk by anthropometric measurements. Females were at a higher health risk compared to males. As the study was conducted only in some selected areas of Dhaka city with a small sample size, the study findings may not represent the actual national situation. Further large scale in-depth studies with appropriate design are recommended to get a detailed national picture. Acknowledgements   1.   Living Arrangements of Older Persons: Critical Issues and Policy Responses. United Nations, New York; 2001. 3.   Mc Williams LA, Cox BJ, Enns MW. Mood and anxiety disorder associated with chronic pain: an examination in nationally representative sample. Pain 2003; 42: 462-464. 5.   Ming-J et al. Relation between weight and body fats distribution and ambulatory blood pressure in Chinese elderly. Clin Exp Hypertension 1994; 16: 545-63. 7.   Flavio DF, Miguel G, Leila BM et al. Anthropometric indices and the incidence of hypertension: A comparative analysis. Obesity Research 2005; 13: 1515-1517. 9.   Haque MA, Moni MA, Rahman MA, Ahmed K, Islam MS, Billah SMB. Hypertension among the senior citizens of selected areas in Dhaka city. JOPSOM 2006; 25: 44-52. 11.Santos JL, Albala C, Lera L, García C, Arroyo P, Pérez-Bravo F et el. Anthropometric measurements in the elderly population of Santiago, Chile. Nutrition 2004; 20: 452-7. 13.Barbosa AR, Souza JM, Lebrão ML, Laurenti R, Marucci Mde F. Anthropometry of elderly residents in the city of São Paulo, Brazil. : Cad Saude Publica 2005; 21: 1929-38. 15.Sánchez-García S, García-Peña C, Duque-López MX, Juárez-Cedillo T, Cortés-Núñez AR, Reyes-Beaman S. Anthropometric measures and nutritional status in a healthy elderly population. BMC Public Health 2007; 7: 2. 17.Corish CA, Kennedy NP. Anthropometric measurements from a cross-sectional survey of Irish free-living elderly subjects with smoothed centile curves. Br J Nutr 2003; 89: 137-45. <![CDATA[Phenotypic detection of metallo-β-lactamase among the clinical isolates of imipenem resistant Pseudomonas and Acinetobacter in tertiary care hospitals of Dhaka city]]> Shaheda Anwar Md. Ruhul Amin Miah Ahmed Abu Saleh Humayun Sattar Sharmeen Ahmed https://imcjms.com/journal_full_text/193 2017-04-20 10:22:20 Original Article Ibrahim Med. Coll. J. 2010; 4(2): 63-65 The rapid spread of Metallo-b-lactamase (MBL) producing Gram negative bacilli represents a matter of great concern worldwide. The study analyzed the occurrence of MBL production in carbapenem resistant Pseudomonas and Acinetobacter isolates over one year period. A total of 132 Pseudomonas and 76 Acinetobacter isolates were obtained from two tertiary care hospitals of Dhaka city. A total of 53 Pseudomonas and 29 Acinetobacter isolates were selected because of their resistance to carbapenem specially imipenem (IPM). Screening for MBL production was performed in these isolates by IPM-EDTA microdilution MIC method. 44 (83%) IPM resistant Pseudomonas and 19 (65.5%) Acinetobacter isolates were MBL producer by IPM-EDTA microdilution MIC method. These results suggest that MBL producing Pseudomonas and Acinetobacter isolates are emerging in our country and it is essential to screen  carbapenem resistant isolates for MBL production. Ibrahim Med. Coll. J. 2010; 4(2): 63-65 Introduction There are several mechanisms of resistance for carbapenem such as lack of drug penetration due to mutation in the porin channel, loss of outer membrane proteins, efflux mechanisms and Ambler class B carbapenemase or Metallo-b-lactamases (MBL). MBL require divalent cations of zinc as cofactor for their enzymatic activity and they are susceptible to inhibition by metal chelators such as EDTA and thiol based compounds like 10-phenanthroline, 2-mercaptopropionic acid (2-MPA), etc. MBLs are most important because they confer high resistance to all b lactams except aztreonam. They are not inhibited by beta-lactamase inhibitors like clavulunate, salbactam, tazobactam. MBL production is typically associated with resistance to aminoglycoside and quinolones further compromising the therapeutic options. They are often expressed in combinations with other b lactamases like AmpC b lactamase and extended spectrum b lactamases (ESBL). The genes for MBL are inserted in integron structures that reside on mobile genetic elements like plasmid, transposons having the potential for rapid and generalized dissemination.2 In view of the above, the present study was undertaken to determine the prevalence of MBL producing Pseudomonas and Acinetobacter isolates in two tertiary care hospitals of Dhaka city by IPM-EDTA MIC method. Materials and Methods All the 208 isolates (132 Pseudomonas and 76 Acinetobacter) from sputum, urine, tracheal aspirate, blood, wound swab were obtained from the patient admitted in ICU, ward and outpatient department of Bangabandhu Sheikh Mujib Medical university (BSMMU) and Bangladesh Institute of Research and Rehabilitation for Diabetes, Endocrine and Metabolic Disorders (BIRDEM). Samples were collected from January 2009 to December 2009. Isolation, identification and antimicrobial susceptibility testing of organisms All the isolates were tested for susceptibility to IPM by disk diffusion method of Kirby-Bauer4 and as per the recommendations of the NCCLS.5 The antibiotic testing disks were obtained from Oxoid Ltd (Basingstoke, Hampshire, UK). Antibiotic potency of the disks were standardized against the reference Pseudomonas ATCC 25853 strain. Tests for MBL-production by EDTA-IPM microdilution MIC test   A total of 132 Pseudomonas and 76 Acinetobacter were studied of which 90 Pseudomonas were isolated from BSMMU (53 non ICU and 37 ICU) and 42 were from BIRDEM (13 non ICU and 29 ICU). Out of 76 Acineobacter 62 (36 non ICU and 26 ICU) from BSMMU and 14 were from BIRDEM (6 non ICU and 8 ICU). Amongst them, 53 (40.1%) Pseudomonas and 29 (38.1%) Acinetobacter isolates were resistant to IPM. These IPM resistant isolates were tested for MBL production by IPM-EDTA microdilution MIC method. Table 1: Rate of IPM resistance among Pseudomonas and Acinetobacter collected from different hospitals and detection of their MBL production by EDTA-IPM microdilution MIC test     In this study 53 (40.1%) Pseudomonas and 29 (38.1%) Acinetobacter were found to be IPM resistant. This finding was consistent with other studies. Noyal et al showed high prevalence of imipenem resistant Pseudomonas spp (31.1%) and Acinetobacter spp (59%) in India in 2008.7 Indiscriminate use of carbapenems could have resulted in the increase in carbapenem resistant Pseudomonas and Acinetobacter spp.7 The IPM resistant MBL negative isolates also showed high MIC, the reason for their resistance may be due to mechanism other than MBL production, like hyper production of serine beta lactamases and /or a change in the membrane permeability in the bacteria, efflux pump or mutation in the porin.9 In this study, one Pseudomonas and one Acinetobacter isolate having MIC of 4mg/ml and 8mg/ml respectively were MBL positive though both were within sensitive range for IPM. But both were considered as IPM resistant by disk diffusion method. It has been reported that over 30% MBL carrying isolates, particularly Enterobacteriaceae, were found to be IPM sensitive by MIC method though they were IPM resistant in disk diffusion method.2 These carbapenem sensitive MBL producer may carry “hidden” MBL gene or they may be low level MBL producer. As a result of difficulties in their detection, these organisms may pose a significant risk due to their unnoticed spread within the hospital and their ability to transfer resistant gene to other organisms.2   1.   Gupta V, Datta P and Chander J. Prevalence of metallo-b-lactamase (MBL) producing Pseudomonas spp and Acinetobacter spp. in a tertiary care hospital in India. J Inf 2006; 52: 311-314. 3.   Forbes BA, Sham DF, Weissfeld AS. Laboratory methods and strategies for antimicrobial susceptibility testing. In Forbes BA et al -eds Bailey and Scott’s diagnostic Microbiology, 12th ed. Mosby, New York 2007; 187-213. 5.   National Committee for Clinical Laboratory Standards. Performance standards for Antimicrobial Susceptibility Testing: Eleventh informational supplement. NCCLS document M100-S11 NCCLS. Wayne, Pennsylvania, USA 2001. 7.   Noyal M, Menezes G, Harish B, Sujatha S, & Parija S. Simple screening tests for detection of carbapenemases in clinical isolates of nonfermentative Gram-negative bacteria. Indian J Med Res 2009; 129: 707-712. 9.   Livermore DM and Woodford N. Carbapenemases: a problem in waiting? Current opinion in Microbiology 2000; 3: 489-495. <![CDATA[Bacterial profile and their antimicrobial resistance pattern in an intensive care unit of a tertiary care hospital in Dhaka]]> Lovely Barai Kaniz Fatema J Ashraful Haq Mohammad Omar Faruq ASM Areef Ahsan Md. Abu Hana Golam Morshed Md. Belayet Hossain https://imcjms.com/journal_full_text/194 2017-04-20 10:41:39 Original Article Ibrahim Med. Coll. J. 2010; 4(2): 66-69 Critically ill patients admitted in intensive care units (ICU) are always at a higher risk of developing infections with various antibiotic resistant organisms. The objective of this study was to know the antibiotic resistance pattern of the common isolates from blood, urine, respiratory secretions and pus/wound swab of patients admitted in ICU at BIRDEM (Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorder) hospital, during a one year period from March 2006 to February 2007. A total of 1660 samples were analyzed. Growth was obtained in 34% of the samples yielding 632 organisms. The major organism isolated were Pseudomonas sp. (29.1%), Acinetobacter sp. (27.5%), Candida sp. (12.8%), Escherichia coli (10.3%) and Klebsiella sp. (9.7%). Staphylococcus aureus, Enterobacter sp, Citrobacter sp, Enterococcus sp, Providencia sp and Serratia sp accounted for 10.6% of the isolates. All the isolates were highly resistant (>80%) to cephalosporins and fluoroquinolones. The frequency of third generation cephalosporin resistant E. coli, Klebsiella and imipenem resistant Pseudomonas and Acinetobacter were >50%. Acinetobacter was remarkably resistant to most antibiotics including imipenem (>70% resistant), but most of the members of the Enterobacteriacae group showed maximum sensitivity to imipenem (50%-94%). The findings of this study might help clinicians to formulate their first line empirical antibiotic treatment regimens for the patients admitted in ICUs. Address for Correspondence:Dr. Lovely Barai, Assistant Professor, Department of Microbiology, BIRDEM, 122 Kazi Nazrul Islam Avenue, Dhaka 1000. e-mail: barai_lovely@yahoo.com   Critically ill patients admitted in intensive care units (ICU) are always at a higher risk of developing nosocomial infections with resistant strains.1 Patients admitted in ICUs have an increased susceptibility to infection because of decreased mobility and increased use of invasive devices.2 A knowledge of the antibiotic susceptibility of the organisms isolated in the ICU helps to formulate an antibiotic policy for the ICU. This also avoids unnecessary use of broad spectrum antibiotics and prevents emergence of drug resistant bacterial strains.7 The data on the changing antibiotic susceptibility trends is important for infection control activities in ICU settings. Presently, data on pattern of organisms and their antibiotic susceptibility in ICUs of large hospitals of our country are lacking. Therefore, the present study was undertaken to determine the pattern of organisms causing infection in ICU with their antibiotic sensitivity patterns over a one year period in a 600 bed tertiary care hospital of Dhaka city. This data may be useful to plan antibiotic guidelines as well as antibiotic cycling in ICU settings. Material and Methods   A total of 1660 samples were analyzed which included blood (811), urine (372), respiratory secretions (448) and pus or wound swab (29). Out of 1660 samples, organisms were isolated from 564 samples (Table 1). Table 1: Sample profile and rate of positive culture from different samples       Major organisms isolated from blood were Pseudomonas sp. (51.7%) and Acinetobacter sp. (18.4%) while from urine it was Candida sp (43.3%) and E. coli (19.3%). The most frequently isolated organisms from both respiratory secretions and pus were Acinetobacter sp. (40.9% and 27% respectively) and Pseudomonas sp. (32.9% and 27% respectively).     About 77 % of isolated S. aureus were methicillin resistant (MRSA). Discussion In this study, about 55.7% of the organisms were isolated from respiratory secretions (sputum and tracheal aspirate) which probably were due to the fact that most patients either had prior respiratory problems or were in ventilators. Reduction in antimicrobial resistance in the ICUs has been a goal for all intensive care units as it improves the outcome and reduces total expenses as well as duration of ICU stay. The extreme antibiotic use results in the emergence of multi-resistant microorganisms in the ICU environment. The present study revealed high prevalence of antibiotic resistant organisms in our ICU. More than 75% Pseudomonas sp. showed resistance to third generation cephalosporins and fluoroquinolons. In 2005, a study conducted in the same ICU reported 82% of Pseudomonas as resistant to third generation cephalosporins.11 But it has been observed that the frequency of fluoroquinolon and imipenem resistant Pseudomonas (79.1% and 58.9%) has increased in the present study compared to that of 2005 (48% and 36% respectively). Candida species was the third frequently isolated organism in our ICU. Both C. albican and non- albican Candida species were found. Most were isolated from urine. High number isolation of Candida might be due to the presence of underlying conditions like poor nutritional status, diabetes mellitus and the use of steroids and broad spectrum antibiotics.   1.   Singh AK, Sen MR, Anupurba S, Bhattacharya P. Antibiotic sensitivity pattern of the bacteria isolated from nosocomial infections in ICU. Journal of Communicable Diseases 2002; 34: 257-263. 3.   Kaul S, Bahmadathan KN, Jagannati M, Sudarsanam TD, Pitchamuthe K, Abraham OC et al. One year trends in the gram negative bacterial antibiotic susceptibility patterns in a medical intensive care unit in South India. Indian J Med Microbiology 2007; 25: 230-5. 5.   Patwardhan RB, Dhakephalkar PK, Niphadkar KB, Chopade BA. A study on nosocomial pathogens in ICU with special reference to multiresistant Acinetobacter baumannii harbouring multiple plasmids. Indian J Med Res 2008; 128: 178-187. 7.   Tullu MS, Deshmukh CT, Baveja SM. Bacterial profile and antimicrobial susceptibility pattern in catheter related nosocomial infections. J Postgraduate Med 1998; 44: 7-13. 9.   Bauer AW, Kirby WMM, Sherris JC, Tierch M. Antibiotic susceptibility testing by a standardized sigle disc method. Am J Clin Pathol 1966; 45: 493-9. 11.Basunia MRA, Rahman MR, Faruq MO, Huq F, Ahsan A, Hasan R, Ahmed B. Microbial pathogens and antibiotic sensitivity at intensive care unit of BIRDEM: A retrospective study. Bangladesh J Medicine 2005; 16: 14-20. <![CDATA[Risk factors and outcome of neonatal jaundice in a tertiary hospital]]> Bedowra Zabeen Jebun Nahar N Nabi A Baki S Tayyeb Kishwar Azad Nazmun Nahar https://imcjms.com/journal_full_text/195 2017-04-20 10:53:43 Original Article Ibrahim Med. Coll. J. 2010; 4(2): 70-73 Abstract Neonatal jaundice is a common cause of newborn hospital admission. The risk factors, the characteristics and outcomes related to neonatal jaundice in Bangladesh has not been studied so far. This study addressed the outcomes, characteristics and risks of the jaundiced newborn admitted into hospital. The babies who had significant jaundice and required phototherapy and /or exchange transfusion were investigated. A detailed history of delivery with gestational age was noted and clinical examination of the admitted newborn was done. Birth weight was recorded. The investigations included complete blood count, ABO and Rh compatibility, serum bilirubin, glucose 6 phosphate dehydrogenase (G6PD), thyroid stimulating hormone (TSH) and ultrasonography (USG) of brain. The newborns were closely monitored for the prognosis. The requirement of individualized phototherapy and exchange transfusion were also noted. Finally, the outcomes were recorded. Overall, 60 (m v. f = 58.3 v. 41.7%) newborns were found who developed significant jaundice and were investigated. Of them, 35% had gestational age less than 32wks and only 32% had equal to or greater than 35wks. Regarding delivery, 83.3 % had the history of caesarean section. ABO- and Rh– incompatibilities were found in 13.3% and 3.3%, respectively. Septicemia was diagnosed among 26.7% though blood culture yielded growth only in 20%. Compared with the higher gestational age-group ( 35 wks) the lower group (<32 wks) showed significantly higher rate of septicemia (12.5 v. 68.8%, p<0.005). G6PD deficiency was found in only one (1.7%) case. Birth asphyxia was found as a concomitant factor in three patients. Exchange transfusion was done only in 2 (3.3%) babies. Among them one was preterm IDM with septicemia and other had G6PD deficiency. None of these babies developed kernicterus. Five (8.3%) babies died, all of them had septicemia and one baby also had intraventricular hemorrhage (IVH) with PDA. The study revealed that a substantial number of neonatal jaundice had the history of lower gestational age in Bangladeshi newborns; and the lower gestational age is significantly associated with septicemia and possibly with hyperbilirubinemia. More study is needed to establish the study findings. Ibrahim Med. Coll. J. 2010; 4(2): 70-73 Address for Correspondence:Dr. Bedowra Zabeen, Registrar, Dept. of Paediatrics, BIRDEM, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka, Bangladesh   Introduction Neonatal jaundice is estimated to occur in 60% of term newbornsin the first week of life,1 and < 2% reach total serum bilirubin(TSB) levels of 20 mg/dL.2 In rare instances, the TSB reaches levels thatcan cause kernicterus, a condition characterized by bilirubinstaining of neurons and neuronal necrosis involving primarilythe basal ganglia of the brain and manifested in athetoid cerebralpalsy, hearing loss, dental dysplasia, and paralysis of upwardgaze.3 Risk factors recognized to be associated with severe hyperbilirubinemiain newborns have jaundice in the first24hoursof life.Glucose-6-phosphatedehydrogenase (G6PD) deficiency, ABO incompatibility, low birth weight and sepsis are the common causes of neonatal jaundice in Asian and South-east Asian regions, but there is a group of babies whose cause of neonatal jaundice has yet to be found. Genetic factors and unidentified environmental factors may also play a role in the prevalence of neonatal jaundice.4 Glucose 6-phosphate dehydrogenase (G6PD) deficiency is the mostimportant disease of hexose monophosphate pathway. G6PD is anx-linked recessive disease, where the deficiency of the enzymecauses a spectrum of clinical manifestations ranging from neonataljaundice to chronic nonspherocytic anemia, anddrug-induced hemolysis.5 Neonatal jaundice is a fairly common cause of morbidity in Bangladesh. However; little information is available on patterns of neonatal jaundice. Special Care Baby Unit (SCABU) in BIRDEM is a neonatal intensive care unit (ICU), which has been running for last 13 years where seriously ill babies are referred to. In one study in SCABU it was observed that incidence of neonatal jaundice was 23.5%; and among them about 17% required exchange transfusion.6 Identifying infants at risk of developing severe hyperbilirubinemia and early intervention have reduced levels of morbidity and mortality associated with bilirubin encephalopathy. This study was designed mainly to find out the characteristics of the jaundiced newborns and their outcomes; and to detect the risk factors related to the newborn hyperbilirubinemia, which is prevalent in Bangladesh.   Materials and Methods This study investigated the jaundiced newborns admitted in SCABU, BIRDEM from November 2007 to May 2008. All newborns who developed hyperbilirubinemia and required phototherapy and/or exchange transfusion within the first seven days of life were included in this study. Physiological jaundice and jaundice not requiring phototherapy were excluded from this analysis. All babies were managed according to a standardized management protocol. Complete blood count, serum bilirubin, blood group and TSH were done in all babies. Serum bilirubin was done by Jendraffik method. Blood Culture was done in those newborns who were having clinically suspected septicemia. Coombs test and reticulocyte count were done in babies of O+ve or Rh-ve blood group mothers. USG of brain was done in babies who were preterm LBW having suspected IVH. TORCH screening was done who were having clinically suspected congenital infection. G6PD deficiency was screened in red cells by a quantitative method (by Autoanalyzer Hitachi 912, Pentra-400 & NOVAemiaCRas septicTld ly suspecte4) in those babies who had rapid rise of serum bilirubin. Case records of all newborn infants were evaluated for details of the maternal antenatal history, labor, and mode of delivery. Septicemia was defined clinical suspicion with positive blood cultures and/or features (reluctance on feeding or poor feeding, abdominal distension, less activity, respiratory distress, apnea, hypo or hyperthermia etc.) of infection necessitating antibiotics for  7 days, in the absence of other attributable causes. Newborn infants < 37 wks gestational age with significant hyperbilirubinemia who could not be categorized into any other major etiological category were considered to have ‘prematurity’ associated jaundice. Jaundiced newborns who could not be categorized into any of the aforementioned criteria were placed in an “Unknown” category. Data was analyzed using SPSS (Statistical Package for Social Sciences) version 12. Appropriate statistical test of significance like t-test or chi-sq test were used as necessary. P value <0.05 was taken as level of significance.   Results A total of 60 newborn infants (m / f = 35 / 25) were investigated. The characteristics of the infants are shown in (table -1). The mean gestational age and birth weight were 33.8 ± 2.8 wks and 1.94 ± 0.68 kg, respectively.   Table 1: Characteristics of the investigated newborns (n=60)     The mean Hb (SD) level was 16.3 (2.3) gm/dl, total serum bilirubin was 15.4 (2.3) gm/dl, G6PD level was 224 (83) U/dl, WBC count was 13550 (99636) / cmm and TSH level was 3.6 (2.5) µIU/L. No hypothyroidism was found.  The peak TSB level varied from 8.6 to 26.5 mg/dl with maximum TSB> 20 mg/dl in 7 (11.6%) cases. Premturity, IDM, septicemia and ABO incompatibility were observed in 44 (73.3%), 21 (35%), 16 (26.6%) and 8 (13.3%) cases respectively. G6PD deficiency was found in only one (1.7%) case. Two babies had intraventricular hemorrhage. Birth asphyxia was found as a concomitant factor in three patients. Regarding risk assessment ABO incompatibility was significantly higher in the term (p<0.02) and IDM was significantly higher in preterm (p<0.05) group compared with their counterparts (table 2). More significant differences of risk factors were observed when comparison was made between the first and third tertile of gestational age (<32 v.  35wks) (table 2).   Table 2: Comparison of risk factors of the newborn babies between Term v. Preterm (<35 v. ³35wks) and also between first tertile (<32wks) and third tertile (³35wks) of gestational age     Exchange transfusion was done only in 2 (3.3%) babies. Among them one was preterm IDM with Septicemia and other had G6PD deficiency. None of these babies developed kernicterus. Five babies died who developed septicemia and one of them also had IVH with PDA.   Discussion In our study population male (58.3%) were predominant with ratio of male to female 1.4:1. This result coincided with that of 64.2 percent from a study conducted in India.7 Total serum bilirubin (TSB)  20 mg/dl occurred in 7 (11.6%) cases. This high level of TSB level was reported only in 1.5% and 1.3% of live births by other studies.7,8 This difference of prevalence might be due either to difference in procedure or to severity of the cases recruited in this study who required intervention. Prematurity (73.3%) was the most common cause of neonatal hyperbilirubinemia whereas ABO incompatibility and prematurity were reported as commonest causes of hyperbilirubinemia by Dawodu et al. from United Arab Emirates (UAE) and by Guaran et al. from Australia.9,10 Sepsis was incriminated in 26.6% cases whereas one of the similar study reported sepsis in 36.4% case of neonatal hyperbilirubinaemia.11 ABO incompatibility and Rh incompatibility were found in 13.3% and 3.3% respectively. A similar type was found in a study where 12% had ABO incompatibility and 5.3% had Rh incompatibility.12 Thirty five percent neonates were IDM in this study which is quite different than other studies where only 3.3% were IDMs.13 this might be that we have a good number of diabetic mothers who deliver their babies at BIRDEM. G6PD level was estimated in 30 newborns whose bilirubin was rapidly rising and we found G6PD deficiency only in 1 case. Actual incidence of G6PD deficiency in Bangladesh is very few. Akhter N, et.al. found that 7.7% had G6PD deficiency among infants with neonatal jaundice.14 In contrast, the prevalence was as high as 62 % in Kurdish Jews15 and 31% in northern Vietnam.16 In this study baby who was detected G6PD deficiency had rapidly rising bilirubin level and required exchange transfusion. In this study, 1.7 percent had no obvious cause and may be considered as idiopathic. Various reports from India revealed that Idiopathic Neonatal jaundice ranged between 8.8 to 57.6 percent.17,18,19 Our findings is inconsistent to the Indian reports – may be due to different genetic and / or environmental factors. Birth Asphyxia was found to be concomitant factor in 5% babies which was very close to that of 7% mentioned in one study.20 In our series none of the babies had any abnormal neurological symptoms or signs. Though one study in Canada 19.8% infants had abnormal neurological symptoms.21 This may be the reason that we could not follow up the babies for prolonged time. Only two (3.3%) patients required exchange transfusion which is comparable with a study in Pakistan (3%).13   Conclusion In our study prematurity, IDM and septicemia were found to be most frequent causes of neonatal jaundice. Hemolytic causes like rhesus, ABO incompatibility and glucose-6-phosphate dehydrogenase (G6PD) deficiency were found insignificant. The babies who died developed septicemia. This was a hospital based study conducted on small sample size. A well designed population based study is needed to confirm the risk factors related to newborn jaundice, which in turn help prevention of neonatal mortality and morbidity in Bangladesh.   Acknowledgement This work is supported by BCPS Research grant.   References 1.    American academy of pediatrics, provisional committee for quality improvement. Practice parameter: management of hyperbilirubinemia in the healthy term newborn. Pediatrics 1994; 94: 558–565. 2.    Newman TB, Escobar GJ, Gonzalez VM, et al. Frequency of neonatal bilirubin testing and hyperbilirubinemia in a large health maintenance organization. Pediatrics 1999; 104: 1198–1203. 3.    Maisels MJ. Jaundice. In: Avery GB, Fletcher MA, MacDonald MG, eds. Neonatology: Pathophysiology and Management of the Newborn. 6th edition, Philadelphia, PA. JB Lippincott Co 2005, 768-846. 4.    Ho NK. Neonatal jaundice in Asia. Baillieres Clin haematol1992; 5: 131-42. 5.    Srivatsa A, Bharti B, Shighi SC. Does nimesulide induce hemolysis in glucose-6-phosphate dehydrogenase deficiency? Acta Paediatr 2003; 92: 637–38. 6.    Hasan HSM, Fateha US, Abdullah AHM, Azad K. Neonatal jaundice. Experience at BIRDEM proceedings of the 4th national conference and scientific seminar of Bangladesh neonatal forum 2004; Dhaka. 7.    Narang A, Gathwala G and Kumar P. Neonatal Jaundice-An analysis of 551 cases, Ind J Ped 1997; 34: 429-32. 8.    Hardy JB, Drage JS and Jackon EC. The first year of life. The collaborative perinatal project of national institute of neurological and communicative disorders and stroke. Baltimore, John Hopkins University presses 1970; 104. 9.    Dawodu A, Qureshi MM, Moustfa IA, Bayoumi RA, Guaran RL, DrewJH, Watkins AM. Epidemiology of clinical hyperbilirubinaemia in Al Ain, United Arab Emirates. Ann Trop Paediatr 1998; 18: 93-9. 10.  Guaran RL, Drew JH, Watmins AM. Jaundice: clinical practice in 88,000 liveborn infants Aust NZ J Obstet Gynaecol 1992; 32: 186-92. 11.  Joshi BD, Singh R, Mahato D, Prasad R. A clinico-Laboratory profile of Neonatal hyper-bilirubinemia in term babies at B.P. Koirala institute of health sciences (BPKIHS), Dharan, Nepal. Journal of Nepal Health Research Council 2004; 2: 28-30. 12.  Arora S, Sharma S and Chhetri. 200. A “Clinical profile of neonatal hyperbilirubinaemia” Pedicon 2000; 4: 161-2. 13.  Arrif K, Bhutta AZ. Risk factors and sectrum of neonatal jaundice in a birth cohort in Karachi. Indian Pediatrics 1999; 36: 487-493. 14.  Akhter N, Begum N, Ferdousi S, Khan WA. Glucose-6-Phosphate Dehydrogenase (G6PD) status in neonatal jaundice and its relationship with severity of hyperbilirubinemia. J Bangladesh Soc Physiol 2009; 4: 71-76. 15.  Ilkw O, Ipek and Bozaykut A. Clinically significant neonatal hperbilirubinaemia: An analy1sis of 646 cases in istambul research letters 2008; 211-12. 16.  Verle P, Nhan DH, Tinh TT, Uyen TT, Thuong ND, Kongs A, Stuyft P, Coosemans M. Glucose-6- phosphate dehydrogenase deficiency in northern vietnam. Tropical Medicine & International Health 2000; 5: 203-6. 17.  Bajpai PC, Mishra PK, Agarwal M and Engineer AD. An etiological study of neonatal hyperbilirubinaemia. Ind J Ped 1971; 38: 424-29. 18.  Merchant RH, Merchant SM and Babar ST. A study of 75 cases of neonatal jaundice. Ind. J. Ped. 1975; 12: 889-94. 19.  Singhal Pk, Singh M, Paul VK, Deorari AK and Ghorpade MG. Spectrum of neonatal hyperbilirubinaemia: an analysis of 454 cases. Ind J Ped 1992; 319-25. 20.  Joshi BD, Singh R, Mahato D, Prasad R. A clinico-laboratory profile of neonatal hyper-bilirubinemia in term babies at B.P. Koirala institute of health sciences (BPKIHS), Dharan, Nepal. Journal of Nepal Health Research Council 2004; 2: 28-30. 21.  Sgro M, Campbell D, Shah V. Incidence and causes of severe neonatal hyperbilirubinaemia in Canada. CMAJ 2006; 6: 587-90. <![CDATA[Age related volume of cadaver-prostates in Bangladesh]]> Rukshana Ahmed Shamim Ara https://imcjms.com/journal_full_text/196 2017-04-20 11:02:08 Original Article Ibrahim Med. Coll. J. 2010; 4(2): 74-77 Pathological changes in the prostate gland occur commonly with advancing age including inflammation, atrophy, hyperplasia and carcinoma and a change in volume is also evident. Estimation of volume of prostate may be useful in a variety of clinical settings. A cross-sectional descriptive study was designed to see the changes in volume of the prostate with advancing age and done in the Department of Anatomy, Dhaka Medical College, Dhaka from August 2006 to June 2007. The study was performed on 70 post-mortem human prostates collected from the unclaimed dead bodies that were under examination in the Department of Forensic Medicine, Dhaka Medical College, Dhaka. The samples were divided into three age groups; group A (10-20 years), group B (21-40 years) and group C (41-70 years). Volume of the sample was measured by using the ellipsoid formula. The mean ± SD volume of prostate was 7.68 ± 3.64 cm3 in group A, 10.61 ± 3.99 cm3 in group B and 15.40 ± 6.31 cm3 in group C. Mean difference in volume between group A and group C, group B and group C were statistically significant (p<0.001). Statistically significant positive correlation was found between age and volume of prostate (r = + 0.579, p < 0.001). Address for Correspondence:Dr. Rukshana Ahmed, Lecturer, Department of Anatomy, Dhaka Medical College, Dhaka-1000, Bangladesh. E-mail: rukshanakahmed@yahoo.com   The prostate is partly glandular; partly fibro muscular organ.1 It is the largest accessory sex gland in the male reproductive system.2 It produces a thin milky fluid containing citric acid and acid phosphatase that is added to the seminal fluid at the time of ejaculation.3 Pathological process in prostate gland occurs commonly in association with aging and includes inflammation, atrophy, hyperplasia and carcinoma.4 Estimation of volume of prostate may be useful in a variety of clinical settings. For example, a precise estimate of the amount of BPH would help to determine the appropriate therapy as well as assist in the interpretation of serum prostate specific antigen (PSA) levels for the presence of cancer. Also the decrease in prostate mass after hormonal manipulation or radiation therapy can be used as an indicator of therapeutic efficacy.5 Also for PSA density determination accurate volume measurement is necessary.6 The effect of prostate volume on biopsy outcome was assessed and noted that there was an inverse relationship between the size of the gland and prostate cancer. When the gland size was less than 40 ml, 17 had prostate cancer and when more than 40 ml, only 7 were found to have prostate cancer. 7 The changes in prostate size i.e. volume are highly variable among aging men. Although benign prostatic hyperplasia with an increase in volume is very common, a considerable portion of aging men have a stable or decreasing prostate size.8 With the above perspectives, the volume of the prostate was thought to be of great value for diagnosis and treatment of various diseases of the prostate. As data on the volume of the prostrate in Bangladeshi males are scarce, this study was conducted, albeit on cadavers, to achieve the same. Materials & Methods   Volume of the prostate was measured by applying ellipsoid formula which requires measurement of three prostatic dimensions. Dimensions were first determined in the axial plane by measuring the transverse and antero-posterior dimensions at the estimated point of widest transverse dimension. The longitudinal dimension was measured in the sagittal plane. The ellipsoid volume formula10 was then applied as follows: The volumes were expressed in mean with standard deviation (SD) and comparison among the different age groups was made using ANOVA. The correlation coefficient was used to determine the association between age and volume of prostate. The SPSS version 11.0 was used. Results     Discussion   The present study showed the volume of the prostate according to the age group. It revealed – more is the age larger is the volume. The age group only over 40 years had a significantly larger prostate, indicating a significant increase in prostate size only in the aging male Bangladeshi population. Further studies may be undertaken in living humans with a view – a) to determine the prostate volume of different age group; b) to delineate the age when the prostate starts increasing in size and c) to identify the risk factors related to enlarged prostate both benign and malignant. Acknowledgement   1.   Sinnatamby CS. Last’s Anatomy: regional and applied. 11th ed. London: Elsevier Churchill Livingstone; 2006; 309-10. 3.   Snell RS. Clinical anatomy by regions. 8th ed. Baltimore: Lippincott Williams & Wilkins; 2008; 353-7. 5.   Terris MK, Stamey TA. Determination of prostate volume by transrectal ultrasound. J Urol 1991; 145: 984-7. 7.   Iqbal SA, Kumar RR, Beck R, Iacovou J. Prostate specific antigen (PSA) – to test or not to test. Bangladesh J Urology 2005; 8: 9-11. 9.   Begum S. An anatomical study of age changes of prostate in Bangladeshi people. (M.Sc. Thesis). Dhaka: IPGMR, University of Dhaka 1991; 37. 11.Moore RA. The evolution and involution of the prostate gland. Am J Path 1936; 12: 599-624. 13.Gearhart JP, Yang A, Leonard MP, Jeffs RD, Zerhouni EA. Prostate size and configuration in adults with bladder exstrophy. J Urol 1993; 149: 308-10. 15.Chicharro-Molero JA. Burgos-Rodriguez R. Sanchez-Cruz JJ, del Rosal-Samaniego JM, Rodero-Carcia P, Rodriguez-Vallejo JM. Prevalence of benign prostatic hyperplasia in spanish men 40 years old or older. J Urol 1998; 159: 878-82. 17.Overland GB, Vatten L, Rhodes T, DeMuro C, Jacobsen G, Vada K et al. Lower urinary tract symptoms, prostate volume and uroflow in Norwegian community men. Eur Urol 2001; 39: 36-41. <![CDATA[Dietary intake, physical activities and nutritional status of adolescent girls in an urban population of Bangladesh]]> Ali Abbas Mohammad Kurshed Md. Masud Rana Sabina Khan T.M. Alamgir Azad Jamila Begum Md. Aminul Haque Bhuyan https://imcjms.com/journal_full_text/197 2017-04-20 11:10:50 Original Article Ibrahim Med. Coll. J. 2010; 4(2): 78-82 In Bangladesh, under-nutrition is a common health problem, but for socio-cultural background, it is most predominant among the female population starting from their early life to motherhood. For the adolescent girls, there has been no such study though they will be the future mothers. Therefore, this study is designed to address the lifestyle and nutrition of the Bangladeshi female adolescents. The study was conducted purposively in Dhaka selecting randomly 15 of 95 City corporation wards of Dhaka City. All adolescent girls aged 10–18 years were considered eligible participants of an urban population of Bangladesh. The study included socio-demographic information, clinical examination, dietary intake, physical activities and body mass index (BMI = weight in kg / height in m. sq.). Overall, 352 adolescent girls volunteered. Socio-economically, 51% of them had monthly family income ³ 20,000 BDT and 11.4% had <10,000 BDT. Of the participants, 14.8% had BMI <18.5, 80.7% had 18.5 – 24.9, and 4.6% had ³ 25. BMI was found not to have significant association with physical activities. No clinical signs of vitamin A deficiency were observed. On clinical examination 75% of the participants were found healthy, 15.9% had anemia and 5.7% had diarrhea. Compared with the national dietary intake, the cereal intake was lower but protein containing foods like pulse and nuts, meat, egg, fish, milk and milk products were found very much close to the national intake. On the average, 95 % of calorie, 93.5 % of protein and 96.5 % of fat requirement were met. For micronutrient requirement, very low intake was observed with calcium (62 %) and iron (63 %). In conclusion, the participants consumed rice daily with frequent consumption of vegetables. Although the study subjects were mostly from higher class of urban dwellers their dietary intake was found not healthy as evidenced by daily rice intake and very low intake of fruits, calcium and iron indicating lack of awareness regarding food habit. Further study is needed to confirm the study findings and to initiate health education on diet among the Bangladeshi adolescent girls. Ibrahim Med. Coll. J. 2010; 4(2): 78-82 Introduction   Study design A questionnaire was developed to obtain relevant information on socioeconomic status, dietary intake, history of illness and physical activity. All questions were designed and checked by field trial. The interviewer were trained for definition of data included in the questionnaire. Anthropometric assessment   A clinical examination was conducted to detect the clinical signs of vitamin A deficiency and nutritional anemia as well as to detect other health problems. Dietary assessment   The data was first checked, cleaned, and entered into the computer (using SPSS for Windows version 12.0) from the numerical codes on the form. The data was edited if there were any discrepancy found. The frequency distribution of the entire variables was checked by using SPSS for Windows version 12.0 program. After summarizing the collected data for each of the suggested indicators to answer the questions based on the objective of the study, analysis was preceded according to the plan. Results The results revealed that, 9.1% respondents had a monthly family income <10,000 BDT; 11.4% had income 10,000-15,000; 25.0% had income 15,001-20,000 and 51% had income >20,000.     The Body mass index was calculated as weight in kg / and height in meter square. The BMI revealed that 14.8% of the girls were underweight (BMI <18.5), 80.7% were within normal limits (BMI 18.5 – 24.99) and 4.6 were either overweight or obese (BMI ³ 25). The WHO classification was used for interpretation of the results (Fig. 1).   Physical activities in the form of exercise/ walking/ playing were found to have no significant association with BMI.   Fig. 2: Percent distribution of diseases of adolescent girls within last two months Table 2: Percent distribution of the respondents on the BMI and exercise time       Percentages of calorie and nutrient requirement fulfilled by the population are depicted in Table 4. The intakes of all macronutrients were less than the average requirement of Bangladeshi adolescent except carbohydrate. On the average the studied population fulfilled 95% of calorie, 93.5% of protein and 96.5% of their fat requirement. They also fulfilled almost 62%, 63%, 120%, 93%, 77%, 104%, 112.5% of their Ca, Fe, Vit A, Thiamin, Riboflavin, Niacin and Vit C requirement respectively. Table 4: Mean calorie and nutrient intake (per capita per day) and percentage of the requirement by different socio-economic groups         The present study revealed that more than 70% girls were from a family from 4-5 members and more than 50% respondents had a total monthly family income of above 20,000 taka. This level of income is higher than any normal Bangladeshi family, which means these girls have better access to nutrients compared to any girl from low income family may be from a village. Three meals per day were taken by 90-95% of the girls i.e. of Breakfast, Lunch and Dinner. Girls were consuming rice as well as chapatti (wheat) but the frequency and quantity was low, so the overall consumption of cereals was 341 gm/per person/ day which is lower than the national consumption of cereals which was 452 gm/person/day. Protein intake was 43.0 gm/day/person, which was also less than the requirement of protein which was 46 gm/day/ person. Average pulses and nuts consumption was 11 gm/day/person which was higher than the national consumption of 10 gm/day/person. Average consumption of vegetables 87.9 gm/day, 5.2 gm/day of edible oil, and these figures are not better than the national consumption figures, which are 113 gm/day and 6.0gm/day respectively. No clinical signs of vitamin A deficiency were seen in the study population. Although this study shows a low prevalence rate of anemia but in reality anemia was recognized as the greatest nutritional problem among women as 52% of non-pregnant women suffer from Anemia (WHO, 1992). The present study reveals that the prevalence of anemia was 15.9%. The cause of anemia in the selected girls was low intake of iron foods as meat / meat products and green leafy vegetables. Meat intake was poor and only contributes to 10% of the total protein intake. Intake of protein in the girls was sufficient, but the major portion of the proteins was having low biological value. The main source of iron for the girls was from cereals (wheat & rice), but the iron in the cereal food groups is less bio-available to the body because of the high contents of inhibitors i.e. phytate and tannins. Conclusion   1.   World Health Organization. Young People’s Health-A Challenge for Society. Report of a WHO Study Group on Young People and Health for All by the Year 2000. Technical Report Series No. 731. Geneva: WHO, 1986. 3.   Mahan LK & Escott-Stump S. Krause’s Food, Nutrition, and Diet Therapy, 9th edn. Philadelphia: WB Saunders; 1996. 5.   Nutrition of Adolescent Girls Research Program. Research Report Series No.1-11. International Center for Research on Women 1994; Washington, DC. 7.   Bull NL. Studies of the dietary habits, food consumption and nutrient intakes of adolescents and young adults. World Rev. Nutr. Diet. 1988; 57: 24-74. 9.   Ali SMK, Pramanik MMA. Conversion factors and dietary calculations. Institute of Nutrition and Food Science, Dhaka, Bangladesh: University of Dhaka, 1991. 11.Gopalan C. Ramasastri BV, Balasubramanian SC. Nutritive Value of Indian Foods. National Institute of Nutrition, Hydrabad, India. Indian Council of Medical Research, 1993. 13.Physical Status: The Use and Interpretation of Anthropometry; WHO Technical Report Series (854), 1995; Geneva. <![CDATA[Consequences of misdiagnosis of diabetic Charcot arthropathy of the ankle]]> Chowdhury Iqbal Mahmud https://imcjms.com/journal_full_text/198 2017-04-20 11:16:23 Clinical Case Report Ibrahim Med. Coll. J. 2010; 4(2): 83-86 Permanent deformity and disability can occur in diabetic Charcot arthropathy (neuropathic arthropathy) if not diagnosed and treated promptly. We report two patients with uncontrolled diabetes mellitus in whom the diagnosis of ankle neuro-arthropathy was delayed by up to six months, with misdiagnoses including ankle arthritis, osteomyelitis and cellulitis. The clinical scenario and appearances of the ankle and foot were typical of Charcot arthropathy. Unfortunately, both of them sustained ankle fracture-dislocation without a history of significant trauma. Both the patients were treated by ankle arthrodesis (fusion of joint). Prevention and early diagnosis of diabetic foot is the key to avoid the development of complications. In diabetic patients, a higher index of suspicion for the possibility of Charcot’s disease is needed. Address for Correspondence: Dr. Chowdhury Iqbal Mahmud, Registrar (Orthopaedics), Room No.1110, BIRDEM Hospital, Ibrahim Memorial Diabetic Centre, 122, Kazi Nazrul Islam Avenue, Dhaka-1000, E-mail: cimahmud@yahoo.co.uk   Diabetic Charcot arthropathy, also known as neuropathic arthropathy, is a part of diabetic foot disease. Diabetic foot is usually associated with neuropathy which may lead to ulceration and neuroarthropathy. Diabetic neuropathic arthropathy is a destructive process of the bony components of a denervated joint. Diabetes mellitus is now the most common cause of neuro-arthropathy, which often manifests itself as a ‘Charcot foot’. Patients usually have established diabetes with a sensory neuropathy, and present with painless or painful swelling and warmth in the region of the ankle and/or mid foot.1,2   A 80-year-old man with type 2 diabetes of 15 years duration was reffered to BIRDEM hospital OPD with a 7 days history of dull pain and swelling in his right ankle and foot following a minor trauma. He was unable to walk and his ankle was grossly deformed and unstable. There were no signs of inflammation, and sensation in the foot including pain and touch was reduced. He was known to have neuropathy and peripheral vascular disease with poor control of blood sugar. Intermittent pain and swelling in the foot had started six months previously. He was treated by doctors with diagnosis of ankle arthritis and osteomyelitis on different ocassions. Several courses of antibiotics and analgesics were prescribed. Two separate ankle and foot X-rays were done in BIRDEM, which revealed gross osteopenia, soft tissue swelling and fracture-dislocation of the right ankle with bony fragmentation of the mid foot (Fig.1). His inflammatory markers of the blood were unremarkable. Fig. 1. Pre-operative X-ray:Fracture and dislocation in a right ankle Charcot joint     A 65-year-old man with type 2 diabetes of eight years duration was referred to BIRDEM hospital OPD with unexplained pain and swelling in his left foot and ankle. He was known to have retinopathy, neuropathy and peripheral vascular disease. His glycaemic control was poor. Pain and swelling in the ankle and foot had started six months previously. He could walk with the help of a crutch. His ankle was deformed and unstable, and sensation in the foot including pain and touch was reduced. He had been investigated by his general practitioner. As there was no history of trauma, his physician did not get a x-rays done. Alkaline phosphatase, C-reactive protein, urate level were slightly elevated and rheumatoid factor was normal. Possible diagnosis was considered as gout and cellulitis and several courses of antibiotics were prescribed.       Neuroarthropathy, or “Charcot arthropathy”, is a diagnosis that predates the modern era of long-term survival with diabetes, having been first described in patients with tertiary syphilis.5 Charcot arthropathy is a severe destructive arthropathy which can occur in any patient with a sensory deficit. It was originally described in tertiary syphilis. Nowadays most cases occur in diabetics, but about 10% of Charcot patients have other causes, such as spina bifida, hereditary motor/sensory neuroapthy, post-traumatic sensory deficits, alcoholic peripheral neuropathy and sensory neuropathy of unknown origin.6,7 The progression of Charcot neuroarthropathy most often follows a predictable clinical and radiographic pattern, and is classified by the widely recognized Eichenholtz classification, which consist of 3 stages of fragmentation, coalescence and reconstruction.11 Charcot arthropathy can be sudden and dramatic. It is one of the most difficult and intractable sources of excess mechanical pressure in the diabetic foot and can create large osseous prominences in various locations. Ulceration and rapid progression to osteomyelitis can follow. A large prospective study of risk factors for ulcerations in a population of male diabetic patients showed that the presence of Charcot arthropathy carried the highest relative risk of all of the factors examined, eclipsing even the absence of protective sensation.12 Management is based on a variety of factors, including location, phase of the disease process, presence of infection, deformity, and comorbidities. Treatment should be guided by specific and realistic goals, depending on the severity of the disease and the patient’s functional capacity. This can vary from basic shoe modifications to major limb amputations. It is important to prevent the development of Charcot arthropathy by controlling blood sugar and early diagnosis of diabetic foot. Marked osteopenia has been noted in patients with Charcot neuroarthropathy and Bisphosphonates have shown promising short-term results in preventing bone resorption.14 Arthrodesis (fusion of joint) may be the only option in severly unstable and deformed joint. Effective internal fixation techniques in arthrodesis include screws, pin, and plate fixation. Simon et al. showed promising results with fusion during the fragmentation stage, with no major complications, and a return to regular shoe wear in a mean of 27 weeks.17 Correction of deformity may be a good option by midfoot osteotomy-fusion, triple fusion or tibio-talo-calcaneal fusion, depending on the level of deformity.6,18   There is clearly a worrying lack of awareness of the possibility of Charcot arthropathy in diabetic patients presenting with acute foot and ankle swelling. A high index of diagnostic suspicion is required. Diabetic Charcot feet are often thought to be relatively rare, but this is not the impression received by our department. Indeed, more patients with the condition appear to be presenting. Strict metabolic control, prevention or minimisation of deformity by total contact casting or use of a diabetic walker boot and avoidance of weight bearing may prevent or delay the development of complication of diabetic arthropathy. A safe clinical policy would be to assume that diabetic patients with recent onset of foot or ankle swelling have neuroarthropathy until proved otherwise. References 2.   Jeffcoate W, Lima J, and Nobrega L. The Charcot foot. Diabetic Med 2000; 17: 253–258. 4.   Jude EB, Selby POL, Burgess J et al. Biphosphonates in the treatment of Charcot neuro arthropathy: a double blind randomised controlled trial. Diabetologia 2001; 44: 2032–2037. 6.   Schon LC, Easley ME and Weinfeld SB. Charcot neuroarthropathy of the foot and ankle.Clin Orthop Relat Res 1998; 349: 116-131. 8.   Gough A, Abraha H, Li F et al. Measurement markers of osteoclast and osteoblast activity in patients with acute and chronic diabetic Charcot neuroarthropathy. Diabet Med 1997; 14: 527-531. 10.Brodsky JW. The diabetic foot, in Coughlin MJ, Mann RA, Saltzman CL, eds: Surgery of the foot and ankle, ed 8. St. Louis, MO, Mosby, 2006; 1281-1368. 12.Boyko EJ, Ahroni JH, Stensel V, Forsberg RC, Davignon DR, Smith DG. A prospective study of risk factors for diabetic foot ulcer. The seattle diabetic foot study. Diabetes Care 1999; 22: 1036-42. 14.Rogers MJ. New insights into the molecular mechanisms of action of bisphosphonates. Curr Pharm Des 2003; 9: 2643-2658. 16.Shaw JE, Hsi WL, Ulbrecht JS, Norkitis A, Becker MB, Cavanagh PR. The mechanism of plantar unloading in total contact casts: Implications for design and clinical use. Foot Ankle Int 1997; 18: 809-817. 18.GJ Sammarco and SF Conti. Surgical treatment of neuroparthropathic foot deformity. Foot and Ankle Int 1998; 19: 102–109. <![CDATA[A prophylactic amputation]]> Faria Afsana Tofail Ahmed Hajera Mahtab https://imcjms.com/journal_full_text/199 2017-04-20 11:20:55 Clinical Case Report Ibrahim Med. Coll. J. 2010; 4(2): 87-89 A case of amputation of the fourth toe is described in a diabetic patient. The patient had overlapping of third and fourth toes since her childhood and later she developed soft lipomas over the fourth toe and lateral aspect of the dorsum of the foot. The lipomas were excised without relief of pain. Subsequently, the fourth toe was disarticulated with relief of pain and healing of ulcers. The role of prophylactic amputations in such cases is described. Address for Correspondence:Dr Faria Afsana, Preventive Foot Care Unit, BIRDEM, 122 Kazi Nazrul Islam Avenue, Dhaka, Bangladesh. e-mail: fariaafsana@yahoo.com       Radiological examination revealed that there were expansion and deformity of right 3rd and 4th toe with osteophytosis. Fig-2. X-Ray of the Foot After all these clinical examination and radiological findings she was advised to maintain a posture with mechanical devices so that the 2nd, 3rd, 4th toes were kept separated. On trying to keep the toes apart they become very much painful. She consulted a surgeon. The surgeon identified several subcutaneous lipomas in the flexor tendon of 4th toe and these were excised and removed to relieve overlapping 4th on the 3rd. Fig-3. After tendon excision   Gradually the friction site of the 3rd toe totally healed. The size of callus reduced and eventually it was no more detectable. Her gait started normalizing with the decreasing intensity of pain to a stage of completely pain free. Now, she is in regular follow up in foot care unit, BIRDEM wearing shoes of same size in both feet. Fig-5. Two weeks following Surgery Discussion   Bony deformities increase the risk of foot ulceration. Deformities lead to bony prominences, areas of high-localized pressure and total weight bearing area of foot is reduced. The overlying skin is subjected to high mechanical pressure. Deformities should be recognized and treated early to avoid callus and foot ulcer.5 Foot care education is an integral component of diabetes management. Proper education about foot care and warning signs of foot can save a foot from serious complications. Acknowledgement   1.   Gibbons G, Eliopoulos GM. Infection of the diabetic foot. In: Kozak GP et al., eds. Management of diabetic foot problems. Philadelphia: Saunders, 1984; 97-102. 3.   American Diabetes Association. Preventive foot care in people with diabetes. Diabetes Care 2000;      23(Suppl 1): S55–6. 5.   Pendscy S. Deformities. In: Diabetic foot: A Clinical Atlas, 1st ed, New Delhi, Jaypee Brothers Medical Publishers (P) Ltd 2003; 53-57. <![CDATA[Vaginal Schwannoma]]> Shamsun Nahar Md. Tahminur Rahman Shamima Ferdousi Tashmim Farhana Dipta Rahima Begum Habiba Khatoon Shamsad Jahan https://imcjms.com/journal_full_text/200 2017-04-20 11:26:31 Clinical Case Report Ibrahim Med. Coll. J. 2010; 4(2): 90-91 Vaginal Schwannoma is very rare and till now few cases have been reported in the literature. A case of vaginal Schwannoma is reported here. The patient was a 59 years old woman with the complaints of per vaginal bleeding with an attempt of D&C failure. Ultimately hysterectomy was done and the diagnosis of Vaginal Schwannoma was made on histopathological examination of the excised tumor. Clinicians should be aware and bear in mind about the differential diagnosis of vaginal Schwannoma in case of any per vaginal bleeding. Address for Correspondence:Dr. Shamsun Nahar, Consultant, Department of Gynae & Obstertrics, BIRDEM Hospital, 122 Kazi Nazrul Islam Avenue, Shahbagh, Dhaka 1000 Bangladesh   Schwannomas are usually benign tumors that arise from the neural crest derived Schwann cells. They can arise as isolated tumors or as part of a neurofibromatosis type 2. Symptoms are referred to local compression of involved nerve or adjacent structures. Sporadic Schwannomas are due to mutation of NF2 gene located in chromosome number 22. It occurs commonly within cranial vault common site root of cerebellopontine angle attached to the vestibular branch of 8th nerve. The patient presents with tinnitus and hearing loss. Other common sites are within dura. Sensory nerves are preferentially affected like branches of trigeminal nerve and dorsal roots. In extramural locations, Schwannomas are associated with large nerve trunks where motor and sensory modalities are intermixed. Rarely Schwannomas can occur in the retroperitoneum, orbit, vagina and cervix. Grossly Schwannomas are well circumscribed, encapsulated mass attached to nerve root and can be separated from it. They are firm, gray masses but may have retrograde changes. Microscopically there are more cellular areas (AntoniA) and less cellular areas (AntoniB). The cells are elongated, have cytoplasmic process and arranged in fascicles. Nuclear pallisading in cellular areas are called Verocay bodies. A variety of degenerative changes may be found in Schwannomas like nuclear pleomorphism, xanthmatous change, vascular hyalinization. Malignant changes can occur but are extremely rare. Local recurrence can occur after incomplete resection. Schwan cells show positive reactivity for S100.1 Case Report The patient was obese (72 kg), height 160 cm, BMI 35.5. Hematological tests revealed mild anaemia, raised ESR, but other hematological and biochemical tests for liver function, renal function, lipids were normal. Her glycaemic tests revealed IGT. USG showed a bulky mass arising from the vaginal wall and extending around the cervix. Abdominal hysterectomy was done and the growth was removed piece by piece which was grossly ulcerated and bled on touch. The vault and vaginal wall became free of the tumor. The tumor was sent for histopathological examination and the diagnosis of Schwannoma made. Fig.1: Photomicrograph of the tumor: Schwannoma, showing cellular (thick arrow) and hypocellular areas (thin arrow) The post operative period was uneventful and the patient recovered well during 2 weeks and later discharged with proper medication. Follow up was done after 3 months/6 months. On follow up patient was alright. Her vault cytology was negative after 6 months. She was advised for glycaemic control by diet, OHG agent and later physical exercise. After one year the patient could not be traced as she didn’t come up for further follow up. Discussion   From the present case report, it may be concluded that any tumor/polyp in vagina in any age group should bear a differential diagnosis of Schwannoma, neurofibroma, lipoma, desimoid tumors and require histopathological and immunohistochemistry for exact diagnosis. PV examination, USG, biopsy or resection and IHC are essential for confirmation of diagnosis of Schwannoma. This will lead to define a better treatment plan and reduce the clinical complains like irregular PV bleeding, and tumors difficult to approach by PV route. References 2.   Obeidat BR, Amarin ZO, Jallad MF. Vaginal Schwannoma: a case report. Reprod Med 2007; 52: 341-2. 4.   Kell SB, Clement PB, Prat J, Young RH. Malignant Schwannoma of the uterine cervix: a study of three cases. Int J Gynecol Pathol 1998; 17: 223-30. 6.   Gonzalvo PV, Polo PA, Gomes CA, Presencia RG, Gaso MM, Botella AR. Retrovessical Schwannosarcoma. Actas Urol Esp 1997; 21: 4169. 8.   Ueda M, Okamoto Y, Ueki M. A pelvic retroperitoneal Schwannomaarising in the right paracolpium. Gynecol Oncol 1996; 60: 1480-83. <![CDATA[Melioidosis in Bangladesh – a disease yet to be explored !]]> Md. Shariful Alam Jilani J Ashraful Haq https://imcjms.com/journal_full_text/181 2017-04-11 16:11:09 Editorial Ibrahim Med. Coll. J. 2010; 4(1): i-ii Melioidosis is a disease of public health importance in Thailand, Vietnam, Malaysia, Laos, Myanmar and northern Australia where it is associated with high case-fatality rates. In endemic areas, sero-epidemiological surveys have showed that the infection is fairly common in childhood as 80% of children had antibodies by the age of four years.2 In infected individuals the organism may remain dormant inside the phagocytic cells for months, years or decades.3 The factors that provoke reactivation of this latent, dormant “time bomb” are stress and alteration of immune status. Diabetes mellitus, chronic renal failure, cirrhosis of liver, AIDS, hematological malignancies seem to predispose the activation of the disease in an otherwise dormant latent infection. The manifestations are highly diverse ranging from acute pulmonary infection, septicemia, acute or chronic suppurative infections involving almost all organ systems to meningitis.4 Fulminant sepsis is much more common and is associated with high mortality. B.pseudomallei is inherently resistant to a number of antibiotics and even with aggressive antibiotic therapy, the mortality rate remains high and the incidence of relapse is common. Mortality in disseminated septicemic melioidosis is 82-87%. However, with ceftazidime therapy, the mortality rate was cut by half to 35-40%. Fatalities are related to the speed of diagnosis and initiation of treatment. With prolonged maintenance treatment with cotrimoxazole relapse occurs in 4-23%.4 Melioidosis is rarely diagnosed in Bangladesh. In Bangladesh, the first case of melioidosis was reported in 1988 by ICDDR, B.6 Subsequently, between 1988 to 1999 five more cases were detected in United Kingdom among Bangladeshi immigrants from Sylhet region.7 Later on, in 2001 and in 2009 we have detected and reported 3 more cases of melioidosis among diabetic patients. All the three cases were from greater Mymensingh area.8-11   Md. Shariful Alam Jilani Ibrahim Medical College J Ashraful Haq Ibrahim Medical College Reference 2.   Kanaphun P, Thirawattanasuk N, Suputtamongkol Y, et al. Serology and carriage of Pseudomonas pseudomallei: a prospective study in 1000 hospitalized children in noreast Thailand. J Infect Dis; 167: 230-3. 4.   Leelarasamee A. Burkholderia pseudomallei: the unbeatable foe? Southeast Asian J Trop Med Public Health 1998; 29(2): 410-5. 6.   Streulenes MJ, Mondol G, et al. Melioidosis in Bangladesh – a case report. Trans R S Trop Med Hyg 1988; 82: 778-79. 8.    Halder D, Nik Zainal and Haq J Ashraful. Neonatal meningitis and septicaemia caused by Pseudomonas pseudomallei. Annals of Tropical Pediatrics 1998; 18: 161-164. 10.Haq JA. Melioidosis in Bangladesh. Presented in Scientific Seminar, Mymensingh Medical College 2009; 10. <![CDATA[Breast Cancer among Pakistani women in referral hospital: an overview of risk factors]]> Maria Shabbir Saria Masoom Raza Mirza Lubna Habib Muhammad Zubair https://imcjms.com/journal_full_text/32 2016-08-02 09:08:32 Original Article Ibrahim Med. Coll. J. 2010; 4(1): 1-3 The aim of this study was to determine the significance of various reproductive risk factors amongst Pakistani women suffering from breast carcinoma. This observational study was carried out from March 2007 to February 2009 at three hospitals. The women who presented with breast swelling withorwithoutdischargefromnipplewereincludedinthestudy.Thediagnosisofbreastcancerwas confirmed by histopathological examination. A questionnaire included history and various reproductive risk factors. The study patients were divided into two groups by their menopausal history – pre-menopausal and post-menopausal as ‘group A’ and ‘group B’, respectively. A total of 70 patients had the diagnosis of breast cancer. Of them, 32 were in group A and 38 in group B. Regarding age distribution, 49% were found in ³51 years of age and 29% in the age group 30 – 40 years. The mean age at menarche was 13.3 years in group A and 12.4 years in group B. Nulliparity was seen in 12.5% cases in group A and 5.26% in group B. History of first full term pregnancy (FFTP) below the age of 20 was present in majority of cases in both groups though higher in group B. Breast cancer in post-menopausal women was exclusively found among those who had early menarche (<=11 years) and was more frequent among those who had FFTP below 20 years of age compared with the pre-menopausal group (88% vs. 66%). The study showed higher frequency of breast cancer in post-menopausal women having early menarche and also more frequent among those with early FFTP. Parity, breast feeding, oral contraceptive pill use were not related to breast cancer. Address for Correspondence: Dr. Masoom Raza Mirza, Associate Professor, Department of Surgery, Hamdard University Hospital (Taj Medical Complex), M. A. Jinnah Road, Karachi -74400, Pakistan. Tel: +9221327788161-2, Cell:+923218713256. E.mail:doctormasoom@yahoo.com   Breast carcinoma is also one of the commonest cancers among Pakistani women. The aim of this study was to investigate the significance of various reproductive factors amongst Pakistani women suffering from breast carcinoma. Subjects and Methods   Overall, 70 patients presented with swelling in their breast with or without discharge from nipple. Cancer was diagnosed after cytology. Of these 70 patients, 32 were in group A and 38 in group B. The mean age at menarche in group A was 13.28 years and in group B 12.42 years. The post-menopausal breast cancer was exclusively found among those who had early menarche (<=11 years). The breast cancer in postmenopausal was more frequent among those who had full term pregnancy below 20 years of age compared with the pre-menopausal group (88% vs. 66%). Family history of endometrial carcinoma was present in 2 patients from group A and 4 from group B. History of exogenous hormone intake was present in two patients in each groups. Discussion Early menarche was found significant in this study and is consistent with other findings.6 Various studies in the west have shown that nulliparity and late age at first birth increases the life time incidence of breast cancer.6,7 In contrast, this study showed no such association with parity which remains to be explained. However, FFTP below 20 years of age in relation to breast cancer of the study is found to be consistent to other studies.6,8 According to our observation early marriage and subsequent FFTP occur at an early age as compared to the western society. Other risk factors like genetic predisposition and mutant gene (BRCAI and BRCA2) could have played a role in developing breast cancer but these factors have not been addressed.6,10 Conclusion   1.   Mc Pherson K, CM Steel, JM Dixon. Breast Cancer-Epidimiology, risk factors and genetics. ABC of Breast Diseases. Clinical Review, BMJ 2000; 321(a): 624-628. 3.   Anderson WF, Matsuno RK, Shermon ME, et al. Estimating age specific breast cancer risks:a descriptive tool to identify age interactions. Cancer Causes Control 2007; 18(4): 439-47. 5.   Gangat SA, Rehman A, Ahmed MF. et al. Patterns of Aetiological and Predisposing Factors regarding carcinoma Breast. Pak Journal of Sutgery 2007; 23(1): 7-9. 7.   Jatoi I, Anderson WF, Rosenberg PS. Qualitative age interactions in breast cancer: a tale of two diseases? Am J Clin Oncol 2008; 31(5): 504-6. 9.   Pervez T, Anwar MS, Sheikh AM. Study of risk factors of carcinoma Breast in Adult female general population in Lahore. J Coll Pysicians Surg Pak 2001; 11(5): 291-3. <![CDATA[Religious and spiritual beliefs and practices in medicine: an evaluation in a tertiary care hospital in Malaysia]]> RM Yousuf ARM Fauzi S F U Akter S M S Azarisman O A Marzuki https://imcjms.com/journal_full_text/33 2016-08-02 09:11:38 Original Article Ibrahim Med. Coll. J. 2010; 4(1): 4-8 In recent years there has been growing awareness regarding the role of religion and spirituality   (R/S) in the practice of clinical medicine. Despite hundreds of articles in professional journals on the subject, little is known about physician beliefs regarding the influence of religion on health. We aim to assess the beliefs and observations of physicians regarding the role of R/S and patient’s health and whether they address such issues in their clinical practice. Concomitantly, we aim to assess the beliefs of our patients and whether they like to address such issues. Questionnaire was based on a cross sectional survey among hospitalized patients and their treating physicians. Nearly all patients and physicians reported a high prevalence of religiosity. Patients also acknowledged that their R/S was respected by the staff, and that physicians inquired R/S about half of the time. R/S was described as beneficial as it enabled patients to cope better with their illness and gave them a positive state of mind. Religion is important to many patients and physicians, but half of the physicians ignore it in their clinical practice. Physicians need to be attentive to patients R/S issues and address them in specific clinical situations. Introduction   This was a questionnaire based cross sectional study among 280 hospitalized patients from Hospital Tengku Ampuan Afzan (HTAA) and their treating doctors (92) to inquire about their religious affiliation, beliefs and experiences regarding the role of R/S in specific clinical situations. Malaysia is a multi-racial, multi-religious, fast developing country where a western oriented information delivery policy is adopted in the medical curriculum. HTAA is an 800-bed, tertiary level state hospital in Pahang- the biggest state in Peninsular Malaysia with a population of about 1.6 million people. It is also the main teaching hospital for the medical faculty of the International Islamic University Malaysia (IIUM). A similar self-reported questionnaire based study of physicians from the same hospital was conducted and questions were framed on similar issues. They were approached individually, provided with a brief description and aim of the study and requested to fill up the questionnaire form at their leisure. The forms were collected again after contacting the respondents. Ninety two physicians responded by filling the questionnaire out of 110 approached.   Of the 92 participant physicians (men 61, women 31), the majority were Muslim (53), followed by Hindu (17) and Buddhist (12). Table 1 summarises the beliefs of the physicians towards R/S. Table 2 depicts the physicians clinical practices/observations. Most physicians reported a high prevalence of religiosity and were inquisitive but respectful of patients’ R/S issues. About two thirds (65%) did encourage R/S practices and 54% would do so irrespective of R/S beliefs of their patients. Of the 280 participating patients (men 176, women 104), 75% were Muslims and 11% were Buddhists, and the rest were from Christian and Hindu religion. Regarding education, 80% were from primary and secondary and 5.7% were from tertiary level and 13.3% were illiterate. Patients reported high religiosity, acknowledged that their R/S was respected by the staff, and that physicians inquired about half of the time about R/S (Table 3). About half of the patients could not recall any inquiry by physicians about religious issues. About 79% patients noticed increase in faith due to illness and wanted religious counselor to help them rather than a psychiatrist. Table 4 compares the religiosity of HIV/AIDS patients relative to rest of the patients. It was found that patients in HIV/AIDS category, 22.1% had never performed meditation or Salat as against 24.7% who had daily performance of meditation or Salat. Table-1: Belief of physicians     Table-3: Belief of patients       In general, research has shown R/S positively affects physical and mental health and the findings apply across boundaries and religions.1,4,16-18 Physicians in our sample were in agreement that religion has a positive impact on health. 85% of our patients who used prayer for their health concerns reported high levels of perceived helpfulness as has been reported by earlier studies.19 R/S beliefs and practices are associated with not only lower anxiety, lesser degree and frequency of depression, lower suicide rates, less substance abuse, but also help patients to cope better with greater wellbeing, hope and optimism, more purpose and meaning in life, greater marital satisfaction and higher social support.1,20 R/S practices are also statistically significant in coping with a terminal illness.21 Many prospective studies have also shown that R/S involvement lead to reduced death rates from cancer, lower rates of heart disease, emphysema and cirrhosis; lower blood pressure and lower levels of cholesterol, reduced rates of myocardial infarction and increased longevity.11,22-24 Religion serves an important preventive role, as most religions discourage or as in the case of Islam altogether ban alcohol and drug abuse. Many studies have found inverse relationship between religiosity and substance abuse.21,25,26 According to a report by the Center for Harm Reduction in Australia’s Burnet Institute based on illicit drug and injection safety study of 20 Asian countries, drug use has become one of the major causes of the HIV epidemic in Asia. Most (81.5%) of the HIV infected persons were young males (age 20-40 years) - people in their prime of life.27 Among our patients 27.5 % had HIV/AIDS, 88.3% of whom were young IVDUs with mean age of 34 ±7 years. They were least religious as depicted by their religious activities (p<0 .001). When asked whether they were told their diagnosis and how they felt about it, many of them responded by saying “Don’t bother.” Drug abuse renders a person a diseased member of society and may result in the destruction of the family, and commit various types of crime, homicide and suicide.   Physician is not just a dispenser of medicine but a value maker, having ethicist, social force and political influence in the life of his patients. Religion and spirituality deserve attention in professional practice, as it appears to have a positive influence on patients’ health. It may also go a long way in making the practice of medicine more holistic, ethical and compassionate. It will also strengthen medical students in their commitment as caring doctors. Acknowledgment   1.   Curlin FA, Sellergren SA, Lantos JD, Chin MH. Physicians’ Observations and Interpretations of the Influence of Religion and Spirituality on Health. Arch Intern Med. 2007; 167(7):649-54. 3.   Chatters LM. Religion and health: Public health research and practice. Annu Rev Public Health 2000; 21: 335-67. 5.   Hill PC, Pargament KI. Advances in the conceptualization and measurement of religion and spirituality. Implications for physical and mental health research. American Psychologist 2003; 58(1), 64–74. 7.   Cohen Z, Headley J, Sherwood GW. Spirituality and bone marrow transplantation: When faith is stronger than fear. Int J Human Caring Summer 2000; 40-6. 9.   Harold G. Koenig Religion, Spirituality, and Medicine: Application to Clinical Practice. JAMA 2000; 284(13):1708 (doi:10.1001/jama.284.13.1708) http://jama.ama-assn.org/ cgi/ content/ full/ 284/ 13/ 1708. 11.Sloan RP, Bagiella E, VandeCreek L, et al. Should physicians prescribe religious activities? N Engl J Med 2000; 342:1913-1916. 13.Sulmasy DP. Spiritual issues in the care of dying parents: “…It’s okay between me and God”. JAMA 2006; 296: 1385-92. 15.  Koenig HG, Idler E, Kasl S, et al. Religion, spirituality and medicine: a rebuttal to skeptics. Int J Psychiatry Med 1999; 29: 123-31. 17.  Baetz M, Bowen R, Jones G, et al. How spiritual values and worship attendance relate to psychiatric disorders in the Canadian population. Can J Psychiatry 2006; 51: 654–661. 19.  McCaffrey AM, Eisenberg DM, Legedza ATR, Davis RB, Phillips RS. Prayer for health concerns: results of a national survey on prevalence and patterns of use. Arch Intern Med 2004; 164: 858–62. 21.  McClain CS, Rosenfeld B, Breitbart W. Effect of spiritual well-being on end-of-life despair in terminally-ill cancer patients. Lancet 2003; 361: 1603-7. 23.  Matthews DA, McCullough ME, Larson DB, Koenig HG, Swyers JP, Lilano MG. Religious commitment and health status: A review of the research and implications for family medicine. Arch Fam Med 1998; 7: 118-24. 25.  Shields J. J, Broome K. M, Delany P. J, et al.Religion and Substance Abuse Treatment: Individual and Program Effects. JSSR 2007; 46(3): 355-71. 27.  Cassel CK, Foley KM. Principles for Care of Patients at the End of Life: An Emerging Consensus among the Specialties of Medicine. 1999; NY: Milbank Memorial Fund. 29.  Puchalski CM, Larson DB. Developing curricula in spirituality and medicine. Acad Med 1998; 73: 970-4. 31.  Brunt PW, Short DS. Body, mind and spirit. What doctors need to know about the Scottish health department’s spirituality initiative? Scott Med J 2005; 50: 3–4. <![CDATA[Blood pressure levels among the studentsof a selected school]]> Abdullah Al-Shafi Mazumder Meerjady Sabrina Flora Md. Shahidullah Rokeya Khanam Md. Abdur Rashid Md. Hasan Iqbal https://imcjms.com/journal_full_text/34 2016-08-02 09:14:06 Original Article Ibrahim Med. Coll. J. 2010; 4(1): 9-12 In Bangladesh, limited data are available on paediatric hypertension as well as their normal values. This study was done to assess the level of blood pressure in this population group. A total of 1118 students from class I to X of a selected school were measured twice for systolic and diastolic BP within five minutes interval following a standard protocol. The phase V diastolic blood pressure was recorded. The average of two readings was taken. Age was obtained from the school records. The mean age was 10.53 (± 0.09) years and 46.9% of the recruited students were females. The mean (±SE) and median of systolic and diastolic blood pressure were 97.89 (±0.39) and 97.50 mm Hg and 57.58 (±0.39) and 60.00 mm Hg, respectively. Boys had a significantly higher systolic (99.34 ± 0.56 mm Hg) and diastolic (62.59 ± 0.41 mm Hg) blood pressure than the girls (96.78 ± 0.50 mm Hg systolic BP and 51.54 ± 0.55 mm Hg diastolic BP; P<0.001). Systolic blood pressure was found to be positively correlated with age, height and weight and diastolic blood pressure was correlated with height and weight. Although this study gave us an insight into the paediatric BP situation in a particular school, a community based study with representative sample is recommended to develop a reference data on paediatric blood pressure for our country. Ibrahim Med. Coll. J. 2010; 4(1): 9-12 Introduction The long-term natural history of blood pressure is not well understood. The level is considerably lower in children than the adults and increases steadily throughout the first two decades of life. A direct relation between weight and blood pressure has been documented as early as five years of age and is more prominent in the second decade. Height is independently related to blood pressure at all ages. Sex does not have the same impact on blood pressure in children as in adults.1 Systolic (1-17 years): 100 ± (Age in years x 2) Diastolic (11-17 years): 70 ± (Age in years)   This cross-sectional study to measure the blood pressure levels of the school students of Dhaka city was conducted in Government Gono-Bhaban High School, Dhaka. One thousand one hundred and eighteen healthy students from Class I-X who were available and willing to participate were included in the study. To rule out known disease conditions, students were asked a few screening questions before recruitment. Data were analyzed using the software SPSS PC. Body Mass Index (BMI) and height for age percentile was calculated using the software Epi Info. Results     Both systolic and diastolic blood pressure was seen to have a cubic association with height (the correlation coefficient were 0.454 and 0.178, respectively). Systolic blood pressure had a linear (r = .551) and diastolic blood pressure had a cubic relation (r = .204) with weight. The 50th and 90th percentile of blood pressure by age, sex and 50th percentile of height-for-age are shown in Tables 2 and 3. Due to low number of samples, data has not been shown in some age and sex categories. Table-2: Systolic Blood Pressure of School Children by Age and Sex     Discussion South Asian children have a higher body-mass-adjusted blood pressure level than white children in the United States. The mean BMI-adjusted systolic blood pressure levels (±SD) were 100 (11) versus 99 (11) mm Hg (P<0.001), and diastolic blood pressure levels (±SD) were 63 (10) versus 52 (12) mm Hg (P<0.001) in South Asian versus US children, respectively. The current study findings do not match with these data, probably because it included school children from low socio-economic background. Conclusion   1.   Sinaiko AR. Hypertension in children. NEJM 1996; 335(26): 1968-73. 3.   Bianchetti MG, Ardissino G, Fossali E, Ramelli GP, Salice P. Tips for the use of antihypertensive drugs: DELTAREPROSI [editorials] J. Pediatr 2004; 145: 288-90. 5.   Thakor HG, Kumar P, Desai VK. Effect of physical and mental activity on blood pressure. Indian J Pediatr 2004; 71(4): 307-12. 7.   Munter P, He J, Cutler JA, Whelton PK. Trends in blood pressure among children and adolescents. JAMA 2004; 291(17): 2107-13. <![CDATA[An audit of intensive care services in Bangladesh]]> Mohammad Omar Faruq ASM Areef Ahsan Kaniz Fatema Fatema Ahmed Afreen Sultana Rashed Hossain Chowdhury https://imcjms.com/journal_full_text/182 2017-04-11 16:21:02 Original Article Ibrahim Med. Coll. J. 2010; 4(1): 13-16 This study was conducted to survey the facilities, bed strength, functional characteristics, manpower, operational practices and distribution of intensive care units in Bangladesh. Direct interview of consultants in charge of different Intensive Care Units (ICUs) in the city of Dhaka was conducted by a structured questionnaire. All Adult Intensive Care Units (ICUs) and Coronary Care Units (CCUs) with ventilator support in the city of Dhaka belonging to government and private sectors were included. Our survey showed that 90% of all Intensive Care Units in Bangladesh were located in the city of Dhaka. There were 40 Intensive Care Units in the city of Dhaka, of which 33 were ICUs and 7 CCUs with ventilator support (also considered as ICU). Only 4 (10%) ICUs were located in government hospitals. Rest of the ICUs was in private hospitals / clinics. Total number of ICU beds was 424 and total numbers of beds in these hospitals were 8824. So 4.8% of total hospital beds were provisioned for critical care. Among these only 240 beds (60%) had ventilator support. 27(68%) of the 40 ICUs were multidisciplinary, 7(18%) CCUs, 5(12%) cardiac surgery and 1(2%) neurology. 64% ICUs were run by anesthesiologists. 85% facilities were open units as opposed to 15% closed units. Nurse: bed ratio of 1:1 was seen in 15(42%) facilities. On duty doctor: patient ratio was variable and highest was 1:4 in 9 ICUs (27 %). ICUs in Bangladesh are mainly situated in the city of Dhaka and mostly in the private sector. The standards and management strategies vary greatly. Address for Correspondence: Mohammad Omar Faruq, Professor & Head of the Dept. of Critical Care Medicine, Room # 452(ICU), BIRDEM Hospital, Shahbagh, Dhaka,, Phone: 880-2-9661551-60/Ext 2399(Office), 01674999897(Cell), Fax: 880-2-9667812, E-mail: faruqmo@yahoo.com   Critical care medicine is the direct delivery of medical care by a physician to a critically ill or critically injured patient. Critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition. Care of these patients can take place anywhere in the inpatient hospital setting, although it typically occurs in the ICU. Critical care involves highly complex decision making to assess, manipulate, and support vital system functions, to treat single or multiple vital organ system failure, and/or to prevent further life-threatening deterioration of the patient’s condition.1 Intensive care is a known but neglected concept in Bangladesh. The first ICU in Bangladesh was established in the National Institute of Cardiovascular Diseases (NICVD) in 1980. Since then many ICUs have emerged. In Bangladesh there is no governing body like Bangladesh Medical and Dental Council (BMDC) that can scrutinize standards of such units. And there are no statistics regarding the number, bed strength, facilities, strength of medical and nursing staffs, and cost benefits of these ICUs, so that relevant recommendation regarding quality of management can be made. The objective of our study was to have an overall idea of intensive care facilities in Bangladesh. Methodology We prepared a structured questionnaire and visited the units. Then consultants in-charge of each ICU were interviewed except for 2 ICUs where we obtained information from the senior medical officers.   The first ICU in Bangladesh was established in 1980 at the National Institute of Cardiovascular Diseases (NICVD). Since then the number of ICUs have grown steadily but mostly in the city of Dhaka which is the capital (Fig 1). A total of 44 ICUs were identified in the country. Among them, 40 ICUs were situated in Dhaka city, remaining 4 ICUs were located in other districts of Bangladesh. Of the 40 ICUs of Dhaka, 7 were CCUs with ventilator support, 36 ICUs (90%) were in private hospitals, rest in government hospitals. Total beds in these study hospitals were 8828 and total number of ICU beds was 424 (4.8%). In 1980, there were only 28 ICU beds in Dhaka city. Since then the number of ICU beds have gradually increased (Fig 2).     Fig-2: Trend of number ICU beds in city of Dhaka Of all the hospitals studied, 25% hospitals had ³10% beds, and 27.5% hospitals had 5-9% beds dedicated to ICU. Total number of ventilators were 240 in 40 ICUs (i.e. 56.6% ICU beds had accompanying ventilators). 25% ICUs had a ventilator: bed ratio of 1:1. 6 (15%) ICUs were closed ICUs and 34 (85%) were open units. 9 facilities (27%) had on duty doctor: patient ratio of 1: 4. In 8 ICUs (24%), on duty doctor: patient ratio was 1:5. Only 4 ICU (12%) had ratio of 1:3. A nurse: bed ratio of 1:1 was seen in 15 (42%) units. 51% ICU doctors at 27 ICUs and 36% ICU nurses at 32 ICUs were cardio pulmonary resuscitation (CPR) trained. The remaining ICUs failed to furnish the information regarding CPR training of their duty doctors and nurses. Among supporting facilities, 19 hospitals had high dependency unit (HDU) support, 10 hospitals had dialysis units and 3 hospitals had CRRT (continuous renal replacement therapy) facilities and only one hospital had bed side routine hemodialysis facility. Population of Dhaka City Corporation is 5333571.4 So there was one ICU bed for aprox. 12579 residents of city of Dhaka. Discussion No ICU existed in Bangladesh before its independence in 1971 and in 1980 the first ICU was established. Since then the number of ICUs has been increasing steadily but almost all are concentrated in Dhaka city. Among all the ICUs, 90 % are in private sector. This is a major drawback in providing critical care facilities to the mass population as majority of them cannot afford the cost of private hospitals. As most of the ICUs are located in the city of Dhaka, this causes great difficulties in transporting patients from the peripheries of the country to the capital. 68% ICUs in Bangladesh provide mixed services, managing medical, surgical. gynecological and obstetrics patients. It is recommended that 25% of senior nursing staff should hold a formal qualification related to intensive care,7 and mandatory training of basic life support (BLS) is an important requirements for all critical care nurses.8 In our country there is no formal training in critical care nursing and according to our study only 36% nurses had BLS or CPR training.   Through this survey an attempt was made to assess the facilities, bed strength, spectrum of management, clinical skills available in the field of Intensive care in Bangladesh and areas where improvements need to be stressed. Acknowledgement   1.   Ewart GW, Marcus L, Gaba MM, Bradner RH, Medina JL, Chandler EB.The critical care medicine crisis-a call for federal action. Chest 2004; 125: 1518-21. 3.   Bennett D, Bion J. ABC of intensive care. British Medical Journal 1999; 318: 1468-70. 5.   Kennedy P, Pronovost P. Shepherding change: how the market, healthcare providers and public policy can deliver quality care for the 21st century. Crit Care Med 2006; 34: S1-6. 7.   Standards for intensive care units. Intensive care society [serial online] 1997 [cited 2009March19]; 1(1): [72screens]. Available from:URL: http:/www.library.nhs.uk 9.   Manthous CA, Amoateng-Adjepong Y, Al-Kharrat T, Jacob B, Alnuaimat HM, Chatila W et al. Effects of a medical intensivist on patient care in a community teaching hospital. Mayo Clin Proceedings 1997; 72(5): 391-9. 11.Safar P, Grenvik A. Organization and physician staffing in a community hospital intensive care unit. Anesthesiology 1977; 47: 82-95. 13.Reynolds HN, Haupt MT, Thill-Baharozian MC, and Carlspon RW. Impact of critical care physician staffing on patients with septic shock in a university hospital medical intensive care unit. JAMA 1988; 260: 3446-50. <![CDATA[Socio-economic factors and knowledge influencing newborn care practices: experience at Dhaka Shishu hospital]]> Housne Ara Begum Mohammad Faizul Haque Khan https://imcjms.com/journal_full_text/183 2017-04-11 16:29:17 Original Article Ibrahim Med. Coll. J. 2010; 4(1): 17-20 Reducing maternal and neonatal mortality remains a big challenge for a developing country like Bangladesh. Mothers’ knowledge in neonatal care plays an important role in bringing down the mortality as well as morbidity. This study was conducted in Dhaka Shishu Hospital during the period of December 2007 to February 2008 and was based on primary data collected on socioeconomic status, knowledge and practice of mothers of neonates attending the hospital. A total of 400 mothers were interviewed. More than fifty percent mothers had an appropriate knowledge on feeding neonates, hand washing before handling neonates, care of eye, care of umbilicus and they were practicing as well. Where as less than fifty percent mothers had appropriate knowledge on keeping neonates warm, cutting hair, bathing, vaccination, oil massage and their practice rate also commensurate well with their knowledge level. Majority of the mothers were in the age group of 21-25 years, having completed primary education or passed SSC exam. They were house wives living in an urban area, with a monthly family income of 3000-7000 taka. Statistically significant association was found between socio demographic variables and knowledge and practices on neonatal care of the mothers. Address for Correspondence: Housne Ara Begum, Assistant Professor, Institute of Health Economics, University of Dhaka, Dhaka-1000, Bangladesh, Phone: 088 02 9661920-50 Ex-8649 (Off), email:drhousne@gmail.com   Neonatal mortality contributes to almost two thirds of infant deaths in Bangladesh. Infection, prenatal asphyxia, premature birth and low-birth are identified as major causes of neonatal mortality. These deaths can only be seriously addressed if there is informed demand for and provision of quality promotive, preventive and curative neonatal care services.1 Skilled professional care during pregnancy, at birth and during the postnatal period is as critical for the newborn baby as it is for its mother. The challenge is to find a better way of establishing continuity between care during pregnancy, at birth, and when the mother is at home with her baby. While the weakest link in the care chain is skilled attendance at birth, care during the early weeks of life is also problematic because professional and programmatic responsibilities are often not clearly delineated.2   This was a cross-sectional study among the mothers of the neonates attending Dhaka Shishu Hospital during the period of December 2007 to February 2008. Sampling was purposive and only willing mothers were interviewed. The sample size was determined by using the following formula for cross sectional study: n = Z2 (p x q) / d2 where n= required sample size, Z = the standard normal deviate/ distribution 1.96 at 95% confidence level /interval. p=0.5; q= (1-p) = (1- .5) = 0.5; d = (error), degree of accepted allowable sampling error was 0.05 (5%) in this study. Based on this calculation the estimated sample size was 384. Data collection tool was a combination of structured type of questionnaire which was tested in the OPD and IPD of Dhaka Shishu Hospital. To find out the level of knowledge and practice appropriate answer was given score 1 and inappropriate answer was given score 0. Then they were computed and recoded and grouped in three categories; excellent (7-9), optimum (5-6), poor (0-4). Results     Table 2 shows that only 5.8% mothers had excellent knowledge on neonatal care, 55.3% mothers had optimum knowledge, and 39% mothers had poor knowledge.The level of practice of the respondent mothers on neonatal care observed that only 5.5% mothers performed excellently where as 71.8% mother performed poorly, only 22.8% mother performed optimally. 10.5% of the respondent mothers started breast feeding within 6hrs, 10.5% of the respondent mothers gave colostrum, 95.5% of the respondent’s mothers exclusively breast fed for 6 months where as 4.3% of the respondent mothers did not feed colostrum. Table-2: Level of knowledge of respondent mothers on neonatal care (n=400)   There was significant association between knowledge and practice on care of the umbilicus, cutting hair, hand washing, massage oil, feeding (Tables not shown). The nature of association between knowledge and practice among the above mentioned variables need further study. But there were no significant associations between vaccinations of neonates, bathing the neonates, and care of the eyes of neonates. Discussion Although 90.8% of the respondents replied that hand washing was essential before handling a neonate, 51.8% of them admitted doing so. A 1 year prospective study on routine gowning before entering a neonatal unit was conducted in a maternity hospital in Singapore. The investigators recommend that routine gowning before entering a neonatal unit is not essential and cost effective for the purpose of reducing infection. Rather the focus should be on adequate hand washing by all hospital personnel and visitors before handling neonates.6 During a study of pregnancy in a poor rural tropical area, a high prevalence of neonatal fever and umbilical cord infection was detected. Interim analysis showed that this was associated with subsequent development of neonatal sepsis The study demonstrates the importance of umbilical cord care in the etiology of life threatening neonatal morbidity in village births in a developing country and the effect of a simple intervention in reducing morbid episodes in the neonate.7 As unhygienic newborn-care practices lead to continued high risk for omphalitis, in addition to topical antiseptics, simple, low-cost interventions such as hand washing, skin-to-skin contact, and avoiding unclean cord applications should be promoted by community-based health workers.8 Present study found a statistically significant association between education of mother and shaving hair, hand washing, umbilical care, bathing, massage oil, vaccination, and proper eye care. Mothers had a fair knowledge regarding need for immunization but a poor knowledge regarding the diseases prevented and doses of the vaccines. Health workers were the major source of information and 76% knew the use and maintenance of immunization cards.9 About 88% of the respondent agreed to consult a doctor for any kind of eye problem. But 11.8% applied kajol, 5.8% used homeopaths drugs, 2.5% applied oil, 13.5 applied breast milk. Mothers got information on neonatal care mainly from relatives/ guardians, books/TV, posters, which played a very insignificant role. There was significant association between occupation of mother and umbilical care, bathing and eye care. Residenceof parentsandbathingandeyecarealsohad a statistically significant association. Income of parents and shaving hair and bathing had also been associated. Conclusion   1.   Save the Children, USA. Newborn Care Practices in Rural Bangladesh. Save the Children Federation, 2003; VII. 3.   Essential newborn care 1996 WHO/FRH/MSM/96.13. 5.   Christensson K, Ransjö-Arvidson AB, Kakoma C, Lungu F, Darkwah G, Chikamata D and Sterky G. Midwifery Care Routines and Prevention of Heat Loss in the Newborn. A Study in Zambia. Journal of Tropical Pediatrics 1988; 34(5): 208-212. 7.   Paul G, Lai D, Manasseh B, Edwards K and Heywood P. Avoiding Neonatal Death: An Intervention Study of Umbilical Cord Care. Journal of Tropical Pediatrics 1994; 40(1): 24-28. 9.   Singh MC, Badole CM, Singh MP. Immunization coverage and the knowledge and practice of mothers regarding immunization in rural area. Indian J Public Health 1994; 38(3): 103-7. 11.LC Mullany, G L Darmstadt, SK Khatry and JM Tielsch. Traditional Massage of Newborns in Nepal: Implications for Trials of Improved Practice. Journal of Tropical Pediatrics 2005; 51(2): 82-86. <![CDATA[Relationship of microalbuminuria with different clinical and biochemical parameters in newly detected diabetes mellitus cases]]> Indrajit Prasad Zafar Ahmed Latif Tofail Ahmed Faruque Pathan S.M. Ashrafuzzaman Firoz Amin https://imcjms.com/journal_full_text/184 2017-04-11 16:34:21 Original Article Ibrahim Med. Coll. J. 2010; 4(1): 21-25 This study was conducted to assess the presence of microalbuminuria in newly detected diabetes mellitus (DM) cases in a small group of Bangladeshi population attending BIRDEM out patient department and to find out the relationship (if any) of microalbuminuria with different clinical and biochemical parameters. Out of 110 DM cases, 10 (9.1%) were found to have microalbuminuria. Blood pressure, both systolic (r=0.190) and diastolic (r = 0.30) had significant positive correlation with urinary albumin. There was no association of microalbuminuria with waist circumference, waist to hip ratio, serum triglycerides, HDL cholesterol, fasting blood glucose, age, sex, weight, height or BMI. This suggests that all newly detected diabetes mellitus should be screened for raised blood pressure and if found positive be given the same importance as blood glucose. They should be treated meticulously to revert or prevent microalbuminuria and thus prevent complications. Ibrahim Med. Coll. J. 2010; 4(1): 21-25 Introduction   This cross sectional study was conducted between January 2006 to May 2007 in the Department of Endocrinology, Bangladesh Institute of Research and Rehabilitation for Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka, Bangladesh. The subjects were selected purposively. The calculated sample size was 162. A total of 185 newly detected diabetic cases were selected which was 15% more than the calculated sample size. 75 cases could not be included in the final analysis, as 73 cases had UTI or gross proteinuria and in 2 cases ACR was more than 300 mg/g. As such, 110 cases were valid for analysis.   One hundred ten newly detected diabetes mellitus cases were studied.   Table-1: Clinical and biochemical characteristics of total study subjects (n=110)     Only diastolic blood pressure was significantly higher in the microalbuminuric patients (p< 0.005).       In this study efforts were made to detect risk factors in the development of microalbuminuria in newly detected diabetes mellitus cases. A cross sectional study conducted in USA also found strong association of microalbuminuria with high blood pressure.20 Other studies conducted in different countries have also found an association of microalbuminuria with hypertension.16,17-19 Increases in intraglomerular capillary pressure are thought to cause leakage of albumin.21 Clinically microalbuminuria may be an indicator of early vascular complication of hypertension.20 Signs of early endothelial dysfunction as manifested by microalbuminuria may herald impending renal impairment and may offer another focus for treatment.20 Waist circumference was not associated with microalbuminuria (p=0.16). In a study conducted in USA, large waist was not associated with microalbuminuria20 but other studies conducted in Europe23 and other places11,12 showed a significant association. The small sample size genetic factors and different cut-off points for abnormal value of waist circumference in this study may be the cause of the different findings and further studies with larger sample size is necessary to substantiate the findings. No relationship was found between serum triglyceride or serum HDL with microalbuminuria. Other studies also showed similar results.20,22 No association was found between the hip-circumference and microalbuminuria or waist hip ratio with microalbuminuria. One study in the Korean population22 found association of microalbuminuria with waist hip ratio. Ethnic differences may be an explanatory factor for these differences. In this study no association was seen between microalbuminuria and BMI. BMI was associated with microalbuminuria in previous studies25,26  but not in recent ones.27  No significant association was found in respect to age, sex, weight, height with microalbuminuria. Use of antihypertensive drugs did not show any type of correlation with microalbuminuria. This finding may be due to inadequate treatment of hypertension. Conclusion   1.   Vijay V, Seena R, Lalithas et al. Significance of microalbuminuria at diagnosis of type 2 diabetes. Int J Diab Dev Countries 1998; 18: 5-6. 3.   Dinneen SF, Gerstein HS. The association of microalbuminuria and mortality in non-insulin-dependent diabetes mellitus. A systematic overview of the literature. Arch Intern Med 1997; 157: 1413-1418. 5.   Pedrinelli R, Dell’Omo G, Giampietro O, Giorgi D, Di Bello V, Bandinelli S et al. Dissociation between albuminuria and insulinaemia in hypertensive and atherosclelotic men. J Hum Hypertens 1999; 13:    129-134. 7.   Knight EL, Kramer HM, Curhan GC. High-normal blood pressure and microalbuminuria. Am J Kidney Dis 2003; 41: 588-595. 9.   Basdevant A, Cassuto D, Gibaut T, Raison J, Guy-Gand B. Microalbuminuria and body fat distribution in obese subject. Int J Obese Relat Metab Disord 1994; 18: 806-811. 11.Hoffmann IS, Jimenez E, Cubeddu LX. Urinary albumin excretion in lean, overweight and obese glucose tolerant individuals: its relationship with dyslipidaemia, hyperinsulinaemia and blood pressure. J Hum Hyperts 2001; 15: 407-412. 13.Chen J, Muntner P, Humm LL, Jones DW, Batuman V, Fonseca V et al. The metabolic syndrome and chronic kidney disease in US adults. Ann Intern Med 2004; 140: 167-174. 15.Chan J, Muntner P, Hamm L, Jones D, Batuman V, Fonseca V et al. The metabolic syndrome and chronic kidney disease in US adults. Ann Intern Med 2004; 140: 167-174. 17.Liese AD, Hense HN, Doring A, Stieber J, Keil U. Microalbuminuria, central adiposity and hypertension in the non-diabetic urban population of MONICA Augsburg Survey 1994/95. J Hum Hypertensions 2001; 15: 799-804. 19.Jiang X, Srinivasan SR, Radhakrishnamurthy B, Dalferes ER Jr, Bao N, Berenson GS. Microalbuminuria in young adults related to blood pressure in a biracial (black-white) population. The Bogalusa Heart Study. Am J Hypertension 1994; 7: 794-800. 21.Brenner BM. Hemodynamically mediated glomarular injury and the progressive nature of kidney disease. Kidney Int 1983; 23: 647-655. 23.Bonnet F, Marre M, Halimi J et al. Waist circumference and the metabolic syndrome predict the development of elevated albuminuria in non diabetic subjects: the DESIR study. Journal of Hypertension 2006; 24: 1157-1163. 25.Valensi P, Assayag M, Busby M et al. Microalbuminuria in obese patients with or without hypertension. Int J Obesity Relat Metab Disorders 1996; 20: 574-579. 27.Pascual JM, Rodi Ua E, Gonzalez C, Perez-Hoyoss et al. Long-term impact of systolic blood pressure and glycemia on the development of microalbuminuria in essential hypertension. Hypertension 2005; 45: 1125-1130. <![CDATA[Simple screening tests for the detection of metallo-β-lactamase (MBL) production in clinical isolates of Pseudomonas and Acinetobacter]]> Shaheda Anwar Md. Ruhul Amin Miah Ahmed Abu Saleh Humayun Sattar Sharmeen Ahmed https://imcjms.com/journal_full_text/185 2017-04-11 16:40:40 Original Article Ibrahim Med. Coll. J. 2010; 4(1): 26-30 There are no standard methods for the detection of metallo-b-lactamase (MBL) production in gram negative organism in routine microbiology practice. The present study was undertaken to evaluate the screening tests like double disk synergy test (DDST) and disk potentiation test (DPT) using ceftazidime (CAZ) and imipenem (IPM) disks with chelating agents like EDTA, 2-mercaptopropionic acid (2-MPA). A total of 132 Pseudomonas and 76 Acinetobacter isolates were obtained from Bangabandhu Sheikh Mujib Medical University (BSMMU) and Bangladesh Institute of Research and Rehabilitation for Diabetes, Endocrine and Metabolic Disorders (BIRDEM) hospitals of Dhaka city. A total of 53 and 29 IPM resistant Pseudomonas and Acinetobacter isolates were selected. EDTA-IPM microdilution minimum inhibitory concentration (EDTA-IPM MIC) method detected MBL in 44 (83%) IPM resistant Pseudomonas and 19 (65.5%) Acinetobacter isolates. DDST with CAZ-0.1M EDTA and CAZ-2-MPA detected MBL in 73.6% and 67.9% of IPM resistant Pseudomonas and 55.2% and 48.3% of Acinetobacter isolates respectively. The detection rate was 67.9% and 66.1% in Pseudomonas and 51.7% and 44.8% in Acinetobacter isolates by EDTA-IPM and IPM-2-MPA methods respectively. In comparison to DDST, DPT with CAZ-0.1M EDTA showed higher sensitivity (89.7% ) and specificity (100%) for detection of MBL in Pseudomonas and Acinetobacter. The results showed that simple screening tests like DPT with 0.1M EDTA was able to detect MBL producing Pseudomonas and Acinetobacter from clinical samples with high sensitivity and specificity. Ibrahim Med. Coll. J. 2010; 4(1): 26-30 Address for Correspondence: Dr. Shaheda Anwar, Department of Microbiology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka   Carbepenem, namely imipenem is the drug of choice for the treatment of infections caused by multidrug resistant gram-negative bacilli specially Pseudomonas and Acinetobacter. Recently, metallo-b-lactamase (MBL), a carbepenemase, has been reported to be involved in mediating resistance against imipenem.1 It is a class B beta-lactamase enzyme capable of hydrolyzing all b-lactams except monobactam and their catalytic activities are generally not inhibited by inhibitors like clavulanic acid, salbactam and tazobactam. MBLs are sensitive to metal chelators like EDTA and thiol based compounds and these inhibitors are exploited to detect MBL activities of the organisms.2 Currently, there is no recommended method for the detection of MBL in routine laboratory practice. Therefore, the aim of this study is to evaluate screening tests like DDST and DPT for the detection of MBL producing Pseudomonas and Acinetobacter isolated from clinical samples. Materials and Methods All the 208 isolates (132 Pseudomonas and 76 Acinetobacter) from sputum, urine, tracheal aspirate, blood, wound swab were obtained from the patient admitted in ICU, ward and outpatient department of BSMMU and BIRDEM hospitals. Samples were collected from January 2009 to December 2009. Identification and antimicrobial susceptibility testing All the isolates were tested for imipenem susceptibility by disk diffusion method using the Kirby-Bauer technique8 and as per the recommendations of the NCCLS.9 Imipenem (10µg) and ceftazidime (30µg) disks were obtained from Oxoid Ltd (Basingstoke, Hampshire, UK). Antibiotic potency of the disks were standardized against the reference Pseudomonas ATCC 25853 strain. Detection of MBL-production The EDTA-IPM microdilution MIC test was a modification of EPI microdilution MIC test as described by Migliavacca et al.10 MIC of IPM were determined with a standard microdilution assay in 96 well microtiter plates using Mueller Hinton broth (MHB) and a bacterial inoculum of 5x 104 CFU per well, in a final volume of 100µl. IPM concentrations in the range of 512 to 0.5 µg/ml were tested in the study. The MICs of IPM were determined with IPM alone and IPM plus 0.4mM EDTA. The best results of MIC of IPM were observed with a concentration of EDTA of 0.4mM. One well containing the bacterial suspension alone and another well containing 0.4mM EDTA alone were used as control. Results were recorded by visual inspection of microtiter plates after 18 hour of incubation at 37°C. A minimum fourfold reduction in the MIC of IPM in presence of EDTA in comparison to IPM alone was designated as the cutoff value for detection of MBL producers.10 The test has been used as gold standard for detection of MBLs production in this study. 2. Double disk synergy test (DDST)   DPT was performed according to the method described by Galani et al.12 Three CAZ (30µg) disks and three 10µg IPM disks were placed on the plates. The distance between every CAZ/IPM disk was about 3-4cm from center to center. 10µl of 0.1M EDTA was added to one CAZ/IPM disk and 10µl of 1:12 2-MPA was added to another CAZ/IPM disk. The plate was incubated at 37°C overnight. Enlargement of the diameter of growth inhibitory zone around CAZ/IPM+EDTA/2-MPA disk by ³7mm compared to CAZ/IPM alone was considered as positive for MBL. Result The details of the results of DDST and DPT are given in Table 1 and 2. In DDST, higher doubtful results were obtained by EDTA-IPM (5.6%) or IPM-2-MPA (7.5%) compared to CAZ plus EDTA/2MPA disks. Similarly, higher doubtful results were also obtained with EDTA-IPM (10.3%) or IPM-2-MPA (13.8%) for Acinetobacter compared to CAZ-EDTA and CAZ-2-MPA by DDST. But no doubtful results have been observed for either Pseudomonas or Acinetobacter in detecting MBL by DPT. Table-1: Comparison of detection of MBL positive Pseudomonas with DDST and DPT using CAZ/IPM with EDTA and 2-MPA     Discussion In this study, initially different concentrations of EDTA (0.1M and 0.5M) and 2-MPA (1:8,1:12) were used in DDST and DPT. The purpose of using different concentrations was to identify the most optimum concentration of these agents to detect MBL producing organism. For detection of MBL, 25 Pseudomonas and 19 Acinetobacter were tested with 0.1M and 0.5M EDTA by DDST. All gave positive results with 0.1M EDTA without any equivocal results but with 0.5M EDTA only 76% Pseudomonas and 73.7% Acinetobacter isolates were positive for MBL while 24% and 26.3% showed equivocal results respectively. Distances of 1, 1.5, 2, 2.5,3,4 cm (from center to center) between EDTA/2-MPA and CAZ/IPM were tested for DDST for detection of MBL production. It was found that 1-1.5 cm distance between EDTA/2-MPA and CAZ/IPM disks showed a clear and distinct synergistic zone towards EDTA/2-MPA in DDST. By comparing the sensitivity and specificity of DDST and DPT to detect MBL producing Pseudomonas and Acinetobacter isolates, DPT with 0.1M EDTA provided higher sensitivity and specificity results. DDST with 2-MPA showed the lowest specificity for detection of MBL. Franklin et al showed that DPT had 100% sensitivity and 98% specificity whereas DDST had a sensitivity of 79% and specificity of 98%.13 DPT is preferred because of its objective interpretation compared to DDST. Interpretation of DDST depends on the technician’s expertise in discriminating true synergism from intersection of the inhibitory zones.14 Also, it may be noted that the synergistic zone of inhibition sometimes may be masked if the resistance to CAZ is conferred by AmpC b-lactamase or ESBL.   1.   Nordmann P, and Poirel L. Emerging carbapenemases in Gram negative aerobs. Clin Microbiol Infect 2002; 8: 321-331. 3.   Walsh TR, Bolmstorm A, Gales A. Evaluation of a new E-test for detecting Metallo-b-lactamases in routine clinical testing. J Clin Microbiol 2002; 40: 2755-9. 5.   Walsh, T.R., Neville WA, Haran MH, Tolson D, Payne J, & Bateson JH. Nucleotide and amino acid sequences of the metallo-b-lactamases, ImiS, from Aeromonas veronii bv sorbia. Antimicrob Agents Chemother 1998; 42: 436-439 . 7.   Forbes BA, Sham DF, Weissfeld AS. Bailey and Scott’s diagnostic Microbiology, 10th Edition. Mosby, New York 1998; 167-87. 9.   National Committee for Clinical Laboratory Standards. Performance standards for Antimicrobial Susceptibility Testing: Eleventh informational supplement. NCCLS document M100-S11 NCCLS. Wayne, Pennsylvania 2001; USA. 11.Kim SY, Hong SG, Moland ES, & Thomson SK. Convenient Test Using a Combination of Chelating Agents for Detection of Metallo-b-lactamases in Clinical Laboratory. Journal of Clinical Microbiology 2007; 45(9): 2798-2801. 13.Franklin C, Liolios L, & Peleg A Phenotypic Detection of Carbapenem- Susceptible Metallo-b-lactamase Producing Gram-Negative Bacilli in the Clinical Laboratory. Journal of Clinical Microbiology 2006; 44(9): 3139-3144. <![CDATA[Cutaneous metastatic adenocarcinoma]]> Mazharul Huque Khan Nurul Islam Noor-A-Alam Tapash Kumar Maitra SM Zaved Hossain Tamanna Narmeen https://imcjms.com/journal_full_text/35 2016-08-02 09:15:52 Clinical Case Report Ibrahim Med. Coll. J. 2010; 4(1): 31-33 A 51 year old man presented with multiple painless skin nodules throughout his body for 3 weeks. He complained of cramping pain in his calf muscles and thighs for 3 months, occasional fever with chills for 2 months and lost about 10kgs in these 3 months. Initially he was diagnosed as a case of viral myositis. His CPK and LDH were raised, febrile antigens and widal test were negative, CA 19-9 was very high (5018 u/ml). Biopsy of skin nodules showed features of metastatic adenocarcinoma. Address for Correspondence: Mazharul Huque Khan, Professor, Department of Surgery, Bangladesh Institute of Research and Rehabilitation for Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka, Bangladesh, E-mail: mazhar.huque@gmail.com   Cutaneous metastasis from underlying carcinoma is relatively uncommon in clinical practice, but is very important to be recognized. Skin involvement has been reported as the first sign in approximately 1% of patients suffering from internal malignancy. Involvement of skin can occur as a result of direct extension of tumor, local or distant metastasis. Early recognition helps in accurate and prompt diagnosis and timely treatment. A high index of suspicion is required because the clinical findings may be subtle. The recognition of cutaneous metastasis often dramatically alters therapeutic plans as it signals to widespread dissemination and poor prognosis. Case report   The excised nodule was about 2cmx3cm in size, oval in shape, firm to hard in consistency, with irregular surface. Cut surface was fleshy at look.     Fig-2. Cutaneous nodule on the anterior aspect of right MICROSCOPIC appearance of excised nodule:   Fig-3. Biopsy taken from one of the multiple nodules Diagnosis: The case was diagnosed as one of adenocarcinoma, metastatic in nature.                         Histo-pathological slides of cutaneous nodule:   Discussion Cutaneous metastases are commonly early indicators of metastatic disease.5 Diagnosis may be delayed for several months unless the skin lesion grows rapidly or other sites such as the lung or liver are affected by tumour spread.6 In general, skin metastasis is a poor prognostic sign. If the primary tumour is the lung, cervix or the oesophagus most patients die within three months. In the case of colorectal cancer however skin involvement is not a preterminal event.7 Treatment involves radiotherapy or excision and patients may survive up to a year.7,8   1.  Spencer PS, Helm TN. Skin metastases in cancer patients. Cutis 1987; 39:119-121. 3.  Johnson WC. Metastatic carcinoma of the skin: incidence and dissemination. In Lever’s Histopathology of the Skin, 8th edn, Edited by Elder D, Elenitsas R, Jaworsky C, Johnson Jr. B, Lippincott-Raven, Philadelphia, 1997; 1011-1018. 5.  Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with metastatic carcinoma: A retrospective study of 4020 patients. J Am Acad Dermatol 1993; 29: 228–236. 7.  Brady LW, O’Neill EA, Farber SH. Unusual sites of metastases. Semin Oncol 1977; 4: 59–64. <![CDATA[An anomalous left anterior descending artery]]> M Maksumul Haq Mahboob Mansur M Syed Dawood Md. Taimur https://imcjms.com/journal_full_text/186 2017-04-11 16:46:09 Clinical Case Report Ibrahim Med. Coll. J. 2010; 4(1): 34-36 Coronary artery fistulas can go undetected as they tend to remain clinically silent. Larger fistulas can end up with sudden death, ischemia, endocarditis or CCF. However, these are detected incidentally during non-invasive or invasive diagnostic testing for unrelated symptoms. This report describes such a case in a 56 year old male while undergoing a coronary angiogram following an anteroseptal infarction three weeks prior to the procedure. The fistula arose from the proximal left LAD and was seen in all views. It is important for cardiologists to remember about the possibility of such uncommon possibilities. Address for Correspondence:Dr. Syed Dawood Md. Taimur, Registrar, Department of Clinical & Interventional Cardiology, Ibrahim Cardiac Hospital & Research Institute (ICHRI), 122, Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000, Bangladesh, Mob: +88 01712801515, Email: sdmtaimur@yahoo.com   A 56 years old male patient underwent elective coronary arteriography at Ibrahim Cardiac Hospital & Research Institute, Dhaka. He had the history of anteroseptal infarction 3 weeks prior to the procedure. He was a smoker, diabetic for 8 years (treated with insulin) and hypertensive for 20 years. He did not have any dyslipidaemia or any family history of premature coronary artery disease. On examination, his pulse rate was 74 / min, normal in volume and regular in character. His systolic / diastolic blood pressures were recorded at 120 / 80 mm of Hg, respectively. Heart sounds were normal with no added sound. On auscultation, both lungs were clear. All routine pre-cath investigations were within normal limits. Resting ECG showed sinus rhythm with Q in V1 to V4 and T-wave inversion in I, avL, V5 and in V6. Echocardiography showed moderately hypokinetic anteroseptal wall with left ventricular ejection fraction (LVEF) of 45%.     This case was diagnosed as a case of single vessel disease (SVD). He had the fistula repaired by ligation along with a percutaneous transluminal angioplasty (PTA) to left circumflex artery (LCx). Antibiotic prophylaxis for endocarditis is recommended for coronary artery fistula. Coronay artery fistulas may also be treated with percutaneous transcathetar occlusion using a detachable balloon, detachable coils, double umbrella devices and microparticles of polyvinyl alcohol foam or they can be treated surgically with a simple ligation. Ligation is performed preferably at the point of entry of the coronary artery to the cardiac chambers. When this is not possible ligation is performed internally. Most coronary artery anomalies are clinically silent and do not affect the quality of life or life span of the affected individuals. These are usually discovered incidentally during non invasive or invasive diagnostic testing for unrelated symptoms. Large coronary artery fistulas may be associated with sudden death, myocardial ischemia, bacterial endocarditis or congestive heart failure. The exact incidence of these clinical events is not known. In large fistulas, sudden death has been attributed due to impairment of diastolic coronary artery flow. Large fistulas may reduce myocardial perfusion and thus cause ischemia. Large coronary artery fistulas may result in right or left sided cardiac volume overload with or without symptoms of congestive heart failure. The haemodynamic effects of coronary artery fistulas depend on their site of drainage, diameter and length. Drainage into the right heart produces right to left shunt with dilation of the right heart chambers and increase in pulmonary resistance. Drainage into the left heart produces left ventricular volume overload that may clinically mimic insufficiency. Coronary artery fistulas may result in an increased risk of infective endocarditis or endarteritis depending on the location of the fistula. The exact pathogenic mechanisms for development of coronary fistulas are not well understood. According to extensive embryologic studies, formation of a normal coronary arterial system depends on multiple morphologic features, including formation of cardiac sinusoids, development of coronary buds on embryologic aorto-pulmonary trunk, and selective connection between the two systems. Any malformation within these systems may lead to development of coronary artery anomalies i.e. coronary fistulas. Some congenital heart diseases are found in association with coronary artery fistulas. Pulmonary valve atresia with intact ventricular septum may be associated with solitary coronary artery or coronary artery fistula draining into the right ventricle. Tetralogy of Fallot (TOF) may be associated with ectopic coronary artery origin or coronary artery fistula draining into the pulmonary trunk. Coronary artery fistulas can cause sudden cardiac death, myocardial ischemia, congestive heart failure and bacterial endocarditis. Hence it is clinically important to know about this abnormality and cardiologists should remember its possibility however uncommon it might be. References 2.   Donaldson RM, Raphel M, Radley-Smith R, et al. Angiographic identification of primary coronary anomalies causing impaired myocardial perfusion. Cathet Cardiovasc Diagn 1983; 9: 237-49. 4.   Click RL, Holmes DR Jr, Vlietstra RE, et al. Anomalous coronary arteries: Location, degree of atherosclerosis and effect on survival – A report from the Coronary Artery Surgery Study. J Am Coll Cardiol 1989; 13: 531-37. 6.   Topaz O, De Marchena EJ, Perin E, et al. Anomalous coronary arteries: Angiographic findings in 80 patients. Int J Cardiol 1992; 34: 129-38. 8.   Kardos A, Babai L, Rudas L, et al. Epidemiology of congenital coronary artery anomalies: A coronary arteriography study on a central European population. Cathet Cardiovasc Diagn 1997; 42: 270-75. 10.Angelini P, Velasco JA, Flamm S, Coronary anomalies: Incidence, pathophysiology, and clinical relevance. Circulation 2002; 105: 2449-54. 12.Libby P, Bonow RO, Mann DL, Zipes DP, editors Braunwalds Heart disease. 8th ed, Philadelphia: Saunders, 2007; P 487. 16.Valji K, editor Vascular and Interventional Radiology 2nd ed, Philadelphia: Saunders, 2006; P67-68. 18.Kouchoukos NT, Blackstone EH, Doty DB, Hanley FL, Karp RB, editors Kirklin/Barratt-Boyes Cardiac Surgery.3rd ed, Philadelphia: Churchill Living stone, 2003; P1241-43. <![CDATA[Road traffic accidents in Bangladesh]]> Prof. Mamunar Rashid https://imcjms.com/journal_full_text/138 2016-11-09 13:38:17 Editorial Ibrahim Med. Coll. J. 2009; 3(2): i-ii Road traffic injuries remain a major cause of death, injury and disability all over the world. The Global Status Report on Road Safety states that over 1.2 million people die each year on the world’s roads. A much larger number (between 20 and 50 million) suffer non-fatal injuries. Few countries have reliable data on road traffic injuries out of which Bangladesh is one. Reliable data on deaths and non-fatal injuries are needed by countries to assess the scope of their road traffic injury problem, to target responses to it, and to monitor and evaluate the effectiveness of intervention measures. Underreporting of road traffic deaths remain a big problem in many countries, and the situation is even worse with regard to non-fatal injuries. Road safety action requires the involvement of many different disciplines and the cooperation of a wide range of government, private and civil sectors with a firm governmental/organizational commitment. Recognition of the seriousness of the road accident problem by the Government of Bangladesh is reflected in the various measures taken to combat the alarming situation. The National Road Safety Council (NRSC) was established in 1995, which drew up the National Road Safety “Strategic Action Plan” covering the period from July 1997 to June 1999. Subsequently, a revised three-year action plan (2002-2004) was prepared in November 2001. Currently there are two core organizations responsible for preparing the national policy on road safety and ensuring its implementation. These are the National Road Safety Council (NRSC) and the Road Safety Cell (RSC). The NRSC acts as the apex body for approving and driving forward the national policy and plans, whereas the RSC established at the Bangladesh Road Transport Authority (BRTA) carries out preparation of plans, coordination, and monitoring and evaluation of planned activities assigned to different agencies and implementation of some programmes assigned to it. Besides NRSC, The Road Safety Action Plan identified nine priority sector activities for improvement. These are: Planning, management and coordination; Accident data system; Road engineering; Traffic legislation; Traffic enforcement; Driver training and testing; Vehicle safety; Education and publicity; and Medical services. Indeed, the focus activities of the strategic action plan are similar to those covered by the ADB/ESCAP road safety guidelines (ADB, 1997). For the purpose of implementation of the road safety action plan, the following leading agents have been nominated. These are: Roads and Highways Department (RHD); Dhaka City Corporation (DCC); Bangladesh Police; Bangladesh Road Transport Authority (BRTA); Ministry of Education and the Ministry of Health. But till date, very little has been done or achieved in relation to road safety. According to the official statistics, in 2000 there were about 4000 fatalities from Road Traffic Accident alone. In an estimate made by the Police HQ in 2000, there were 3970 no. of accidents causing 4046 no. of fatalities estimating 2270 no. of injuries and 163 deaths per 10000 vehicles. Between 70 - 80 % of RTAs occur on highways and rural roads. Up to 70% of road accidents are pedestrians alone. Trucks and buses are major contributors to road traffic accident fatalities. From a hospital based study, it has been found that injury patients comprised more than one fifth of all admissions and about half (49.8%) of all surgical beds of a district hospital. At the first referral level, graduate physicians are providing trauma care. In every teaching hospital, there is a full fledged department of Orthopaedic surgery, where trauma patients are managed by trained physicians. At national level, there is a National Institute for Traumatology and Rehabilitation providing specialized services to trauma victims. Besides government health facilities a number of NGO and private clinics are also providing trauma care services to injury victims. Besides all these facilities, five trauma centers have been established by the side of some high risk national highways to provide emergency services to trauma victims. Too many accidents are still occurring needlessly and taking the lives of innocent people, mainly through the reckless behaviour of the drivers of buses and trucks. Vehicles pass fitness tests without proper verification. Obtaining driving licenses are either too easy or too difficult and motor driving schools remain unsupervised and have not been given any scope to get involved in the development of the traffic safety programme. We strongly urge government and private agencies involved in roads and traffic as well as the road using public to do everything possible to address this problem which has become a public health issue of gigantic proportions in our country.   Prof. Mamunar Rashid Professor & Head Department of Community Medicine Ibrahim Medical College <![CDATA[Ultrasound differentiation of benign and malignant cervical lymph nodes]]> Md. Mizanur Rahman ASQM Sadeque Eliza Omar Sonjoy Kumar Bhakta https://imcjms.com/journal_full_text/139 2016-11-09 15:19:37 Original Article Ibrahim Med. Coll. J. 2009; 3(2): 40-44 Abstract Address for Correspondence: Dr. Md. Mizanur Rahman, Assistant Professor, Department of Radiology and Imaging, Dhaka Medical College, Dhaka   Introduction FNAC (Fine needle aspiration cytology) has an important role in the diagnosis of diseases of enlarged cervical lymph nodes with good diagnostic yield. Procedure is easy, safe, simple, quick, inexpensive and reliable,8 but biopsy of the cervical lymph node is most important so far as diagnosis is concerned. However, both the procedures are invasive. Bruneton et al., Hajek et al. and Sakai et al.13-15 suggested nodal size to be a reliable indicator for differentiating benign from malignant nodes. Another group of authors suggested that L/S ratio is a reliable indicator of a metastatic node.9-11,15 Toriyabe et al.16 described different types of echopattern in lymph nodes. They concluded that homogeneous hypoechoic pattern was seen more in benign enlarged nodes whereas heterogeneous patterns of echo were more common in metastatic nodes. Sanders17 claimed that echogenic hilum in a large node is a good indicator that it is benign and is due to fat deposition. Rubaltelli et al.18 also concluded that echogenic hilum is a valid criterion for benignity. Some authors differed and opined that echogenic hilum is not specific for benignity or malignancy.10,19 The study was carried out in the Department of Radiology and Imaging, Bangabandhu Sheikh Mujib Medical University (BSMMU) and Dhaka Medical College Hospital (DMCH) from January 1998 to December 1998. Patients having enlarged cervical lymph nodes were scanned by high frequency (5.0 MHz) curvilinear probe. Lymph node size (measured by maximal short axis diameter), lymph node shape (expressed by dividing the long axis diameter by the short axis diameter or L/S Ratio), marginal clarity, internal echopattern and hilar echogenicity were the criteria that were individually brought into consideration for differentiating benign from malignant nodes (Table 1).   Table-1: Ultrasound criterion used in this study to differentiate benign from malignant.   After ultrasound evaluation, specimens were collected by excision biopsy. Gross and histopathological examinations were then done. Data collected from each individual was then analyzed using computer based statistical software. Chi-square test was used and a   p value of <0.05 was taken as significant.   Results Fig-1. Shows a maximal short axis diameter of  21.7 mm and a L/S Ratio of 1.46. The node was a metastatic carcinoma. Smooth margin is missing at places. Echo pattern is heterogeneous with no hilar echogenic line.   Among the 65 enlarged nodes, 39 had a maximal axial diameter <1 cm, of which 31 (79.5%) were histo-pathologically benign and the rest 8 (20.5%) were malignant. 26 (100%) nodes with maximal axial diameter of >1 cm were all histo-pathologically malignant and none were benign (2=39.5; df=1.0; p<0.001). Fig-2. Shows a maximal short axis diameter of 15 mm, a L/S ratio of 1.28 and was proved to be a metastatic enlarged cervical node. Margin in this node was regular with hypoechoic homogeneous echo pattern with absence of hilar echogenicity.   Sonographic Parameters used Number Benign Malignant Total 65 No % no % Maximal short axis diameter           <1 cm n=39 31 79.49 08 20.51 >1 cm n=26 0 0 26 100 L/S Ratio            2 n=31 27 87.10 04 12.90 < 2 n=34 04 11.76 30 88.24 Margin           Regular n=39 28 71.79 11 28.21 Irregular n=26 03 11.54 23 88.46 Echopattern           Homogeneous hypoechoic n=32 28 87.50 04 12.50 Heterogeneous n=33 03 9.09 30 90.91 Hilar Echogenicity           Echogenic n=43 31 72.10 12 27.90 No echogenicity n=22 0 0 22 100   All the individual parameters showed high statistical significance (p < 0.001).   Of the 32 enlarged nodes with homogeneous hypoechoic echo-pattern, 28 (87.5%) were benign and 4 (12.5%) were malignant. 33 nodes showed heterogeneous echopattern of which 30 (90.9%) were malignant and 03 (9.1%) were benign. (2=42.17; df=1.0; p<0.001). There are approximately 800 lymph nodes in the body of which 300 lie in the neck.1 In this prospective study, nodal size, shape, marginal clarity, internal echo-pattern and hilar echo-genicity were the criteria selected to differentiate benign from malignant group of enlarged cervical lymph nodes. As far as the L/S ratio was considered, among the nodes with L/S ratio <2, 30 (88.2%) were malignant and 4 (11.8%) were benign. Among the nodes with    L/S ratio  2, 27 (87.10%) were benign and 04 (12.90%) malignant. Steinkemp et al.20 found 90% of the enlarged nodes to be metastatic with L/S ratio <2. Vassallo et al.10 showed that 86% of primary nodal malignancies and 85% of nodal metastasis had L/S ratio <2. So, malignant nodes have larger axial diameter thus reducing the L/S ratio and the malignant nodes becoming more roundish. This was also found true in this series. In this study, 28 (87.5%) nodes were benign among 31 enlarged nodes with homogeneous hypoechoic internal echopattern. In contrast 30, (90.9%) were malignant among 34 enlarged nodes with heterogeneous echopattern. Toriyabe et al.16 showed 90.9% nodes with homogeneous hypoechoic pattern to be benign and 86.7% with heterogeneous echopattern to be malignant. These findings are also consistent with the findings of the present study. This study was performed using a 5.0 MHz high frequency probe. Probe with a larger frequency like 7.5 MHz might have shown the above signs more clearly, particularly the marginal clarity, internal echopattern and presence or absence of echogenic hilum. But this much can be concluded that when all the parameters are evaluated simultaneously, a better interpretation or differentiation between benign and malignant cervical nodes is possible with real time high resolution ultrasound.   References 1.   Mann CV, Russell RCG, Williams NS. Editors, Lymphatics and Lymph nodes and The Neck. In Bailey and Love’s short practice of surgery, 22nd edition ELBS with Chapman and Hall, London. 1995; 187-94 and 497-505. 2.   Baatenburg de Jong RJ, Rongen RJ, Lameris JS. Metastatic node disease, palpation VS ultrasound examination. Arch Otolaryngol Head Neck Surg 1989; 115: 689-90. 3.   Van den Brekel MWM, Stel HV, Castaijns JA. Lymph node staging in patients with clinically negative neck examination by ultrasound and ultrasound guided aspiration cytology. Am J Surg 1991; 162: 362-6. 4.   John DG, Williams SR, Anaes FC. Palpation compared with ultrasound in the assessment of malignant cervical lymph nodes. J Laryngol Otolaryngol 1993; 107: 821-23. 5.   Marchal G, Oyen R, Verschakelen J, Gelin J, Baert L, Steessens RS. Sonographic appearance of normal lymph nodes. J of Ultrasound Med 1991; 4: 417-19. 6.   Ishii J, Amagasa T, Tachibana T. US and CT evaluation of cervical lymph node metastasis from oral cancer. J Cranio-Max-Facial Surg 1991; 19: 123-7. 7.   Cole I, Chu J, Kos S. Metastatic carcinoma in the neck: A clinical, computerized tomography scan and ultrasound study. Aust NZ J Surg 1993; 63: 468-74. 8.   Gupta AK, Nayar M. Critical appraisal of fine needle aspiration cytology in tuberculous lymphadenitis. Acta Cytol 1992; 36: 391-4. 9.   Ishii J, Amagasa T, Tachibana T. Ultrasonic evaluation of cervical lymph node metastasis of squamous cell carcinoma in oral cavity. Bull Tokyo Med Dent Univ 1989; 36: 63-7. 10.  Vassallo P. Wernecke K, Ross N, Peter PE. Differentiation of benign from malignant superficial lymphadenopathy: The role of high resolution US. Radiology 1992; 188: 215-20. 11.  Vassallo P. Edel G, Ross N. In vitro high resolution ultrasonography of benign and malignant lymph nodes: A sonographic-pathologic correlation. Invest Radio 1993; 28: 698-705. 12.  Eichorn T, Schroeder HG. Ultrasound in metastatic neck diseases. J Oto Rhino Laryngol related special 1993; 55: 256-62. 13.  Bruneton JN, Roux P, Caramella E. Ear, nose and throat cancer: Ultrasound diagnosis of metastasis to cervical lymph nodes. Radiology 1984; 12: 771-3. 14.  Hajek PC, Salomonowitz E. Lymph nodes of the neck: Evaluation with US. Radiology 1986; 158: 739-42. 15.  Sakai F, Kiyono K, Sone S. Ultrasonic evaluation of cervical metastatic lymphadenopathy. J Ultrasound Med 1988; 7: 305-10. 16.  Toriyabe Y, Nishimuro T, Kita S, Saito Y, Miyokawa N.       Differentiation between benign and metastatic cervical lymph nodes with ultrasound. Clin Radiol 1997; 52: 927-32. 17.  Sanders RC. Neck Mass in clinical sonography, 2nd edition 1984; 369-76. 18.  Rubaltelli L,Proto E,Salmaso R,Bortoletto P,Candiani F, Cagol P. Sonography of abnormal lymph nodes in vitro: correlation of sonographic and histologic findings. Am J Roentgenol 1990; 155: 1241-4. 19.  Evans RM, Ahuza A, Metreweli C. The linear echogenic hilus in cervical lympadenopathy: a sign of benignity or Malignancy? Clin Radiol 1993; 47: 262-4. 20.  Steinkemp HJ, Cornehl M, Hosten N, Pegios N, Vogl T, Felix R. Cervical lymphadenopathy, ratio of long to short axis diameter as a predictor of malignancy. Br J Radiol 1995; 68: 266-70. <![CDATA[Influence of diabetes on physical function among the elderly persons]]> Farzana Tabassum Meerjady Sabrina Flora https://imcjms.com/journal_full_text/140 2016-11-09 15:24:17 Original Article Ibrahim Med. Coll. J. 2009; 3(2): 45-49 Abstract There is growing recognition that the complications associated with type-2 diabetes may translate into functional impairments in older people.This cross sectional study was conducted between January and June 2008 to determine the influence of diabetes on physical functions in an elderly (³55 years) population. Fifty-five elderly diabetics attending the out-patient department of a diabetic centre were selected by convenient sampling and compared with fifty-five non-diabetic elderly persons of the near-by community. Their physical functions were assessed by Barthel Index, SF-36 Health Survey and Modified Physical Performance test. Diabetic elderly persons, on average, obtained lower scores in all these three tests. After removing the effect of socio-demographic variables, influence of diabetes on level of independence measured by Barthel Index did not persist. However, the difference in SF-36 health survey and Modified Physical Performance test scores between diabetics and non-diabetics remained significant after controlling for socio-demographic variables. The current study showed influence of diabetes on physical functions in the elderly. People should be motivated and guided properly to practice a healthy lifestyle in order to prevent and control diabetes and thus avoid complications of diabetes mellitus and disabilities in later life. Ibrahim Med. Coll. J. 2009; 3(2): 45-49 Keywords: Diabetes mellitus, Physical function, Barthel Index, Short Form-36 Health Survey, Modified Physical Performance Test. Address for Correspondence:Dr. Meerjady Sabrina Flora, Associate Professor of Epidemiology, National Institute of Preventive and Social Medicine, Mohakhali, Dhaka. e-mail: flora@citechco.net   Introduction The aged population in Bangladesh is growing both in absolute numbers and as a percentage of the total population. Although the steady increase in proportion doesn’t seem to be remarkable, yet the increase in absolute numbers is quite significant.1 According to 2001 census, 6.2% of the total population of Bangladesh is 60 or higher years of age.2 Those over 60 or 65 years of age are prone to develop certain diseases and ailments which are uncommon in younger years. The problems are mainly due to the aging process such as, senile cataract, glaucoma, osteoporosis; some diseases are associated with long term illnesses, like degenerative diseases of the heart and blood vessels, cancer, accidents, diabetes, diseases of the locomotor system, respiratory illness, hearing impairments, genito-urinary problems and psychological problems such as, mental changes and emotional disorders, which affect their quality of life.3 Physical functioning is a core element of health related quality of life and predicts further functional decline, morbidity, health service use and death.4 Although diabetes is often accompanied by vascular and neuropathic co-morbidities,5 the threats of physical disability, loss of independence, and diminished quality of life may ultimately be the greatest concern for many with the disease.6-8 The prevalence and projection of diabetes for all age groups worldwide were estimated to be 2.8% in 2000 and 4.4% in 2030. Diabetes mellitus of all ages is reaching epidemic proportions in Bangladesh. In some sectors of the society, more than 10% of the people have diabetes.9 Estimated total cases of diabetes in Bangladesh was 3.2 million in the year 2000 (Ranking 10 in the world) and projected at 11.1 million in 2030 (Ranking 7 in the world).10 Although there are many reasons to suspect that diabetes could lead to increased physical disability, the magnitude or key factors explaining such a relationship have rarely been examined.5 The primary prevention of diabetes and the prevention of complications and co-morbid conditions among people with diabetes will be necessary to help reduce the burden of physical limitations and disability. Further studies are needed to identify factors and interventions that will help to delay or prevent the progression from diabetes to disability.11 Although many studies have described the high prevalence of complications and morbidity in type 2 diabetes mellitus patients, very few data concerning the impact of type 2 diabetes mellitus on the functional health status of elderly patients are available,13 particularly in our setting. This study compares the functional impairment between elderly diabetic and non-diabetic persons.   Materials and Methods To compare the physical functions, this cross-sectional study was conducted on two samples of elderly persons of 55 years and above, one sample of 55 diabetic and another 55 non-diabetics, were selected by purposive sampling technique. The diabetics were recruited from a diabetic centre and the non-diabetics from a nearby community so that respondents of both the groups possessed similar socioeconomic status. The diabetic status of the non-diabetics was excluded by using glucometers. The total study period lasted six months commencing from January 2008. Physical functions of the respondents were tested by Barthel Index, SF-36 Health Survey and Modified Physical Performance test. The Barthel Index is an ordinal scale used for measuring functional independence in the domains of personal care and mobility. The main aim is to ascertain the degree of independence from any help, physical or verbal, however minor and/or whatever reason. Individuals are scored on ten activities which are summed to give a score of 0 (totally dependent) to 20 (fully independent).14 The SF-36 Health Survey is a generic measure of health related quality of life, with scores ranging from 0 to 100, higher scores indicating greater satisfaction. Aggregate scores of 8 categories are compiled as a percentage of the total points possible; using the Research and Development (RAND) scoring table.15 The Modified Physical Performance test is a 9 item test which measures the physical function by testing usual daily basic activities of daily living. Each of 9 items has levels of performance scored from 0 to 4 based on completion of the task. The individual item scores are added for a total score (range= 0-36).16 Scores obtained by three different scales were compared between the diabetics and non-diabetics by uni-variate analysis first and then after removing the effect of socio-demographic variables by multiple regression model.   Results Both the samples were similar in all socio-demographic characteristics except for occupation (p<0.05) where housewives were seen in a higher proportion (56.4%) in the diabetic group while working persons (34.5%) and retired (32.7%) were more common in the non-diabetic group (Table 1).   Table-1: Socio demographic characteristics of the respondents     Level of independence was measured using Barthel Index. Table 2 shows overall average Barthel score of the diabetic and non-diabetic elderly. Although diabetics scored, on average, significantly lower points (18.27) than the non-diabetic respondents (19.56, p = 0.011), after removing the effect of socio-demographic variables this difference did not persist.   Table-2: Barthel Index mean score in diabetic and non-diabetic respondents     There were 8 categories of questions in the SF-36 health survey. The categories included general health, physical functioning, role of physical health, role of emotional health, social functioning, bodily pain, vitality and mental health. The mean (±SD) general health score was lower in the diabetic (25.55 ± 22.21) than the non-diabetic respondents (55.82 ± 16.91) and this difference was statistically significant before and after removing the effect of socio-demographic variables (p<0.001). The multiple regression model could explain 66% of the variation in the general health score. The diabetic elderly persons obtained significantly, on average, lower score in physical function (25.91 vs. 63.75, p<0.001), physical health (16.82 vs. 63.64), emotional health (39.39 vs. 94.53), social functioning (41.36 vs. 80.91), bodily pain (63.09 vs. 87.36), vitality (37.82 vs. 58.55) and mental health (47.09 vs. 69.82) than their non-diabetic counterparts (Table 3). After adjusting for the socio-demographic variables by multiple regression analyses, these differences remained significant.   Table-3: Score of different categories of SF-36 Health Survey in diabetic and non-diabetic respondents     Table 4: shows the comparison in the mean score of modified physical performance test between diabetic (21.52) and non-diabetic (28.89) persons. The difference in the mean score between diabetic and non-diabetic respondents was statistically significant before and after adjusting for the socio-demographic variables.   Table-4: Score of Modified Physical Performance test in diabetic and non-diabetic respondents     Discussion This study was done to compare the functional impairments of the elderly diabetic and non-diabetic persons. Various parameters like degree of independence, health related quality of life, physical functions were taken into account to assess the functional capability in this study. This was the first attempt to explore this influence of diabetes on functional capability which might be utilized as baseline data for further research work. Considering the Bangladeshi population structure and life expectancy at birth, the current study defined those, who were ³55 years, as elderly whereas most international studies on this issue consider ³60 years as the cut-off point. However, ³60 years old elderly constitute three fourths of this study sample. The mean (±SD) age was 64.95 ± 5.03) years in non-diabetics and 65.93 ± 5.85 years in the diabetic subjects. Sinclaire et al.17 included samples with mean (±SD) age of 75 ± 7.1 years (diabetic) and 75 ± 6.9 years (non-diabetic). Although two groups were not matched initially but the data showed that both the groups were similar in socio-demographic characteristics except for their occupational status. Housewives were in higher proportion (56.4%) in diabetic group and other occupations i.e., working persons (34.5%) and retired (32.7%) were more in the non-diabetics. The level of functional independence was measured by using Barthel Index (BI), a scale which measures the basic activities of daily living with higher scores indicating greater independence. This is an internationally accepted ordinal scale that measures the degree of independence from any help, physical or verbal for minor or major reasons. Diabetics scored, on average, lower Barthel points (18.27) than the non-diabetic respondents (19.56, p<0.05). It also showed similarity with the result of the study done by Sinclaire et al. (p<.0001).17 However, the difference did not remain significant in the current study after removing the effect of socio-demographic variables. In all the 8 areas in SF-36 health survey diabetics obtained, on average, significantly lower score than the non-diabetics. The score obtained in physical function domain corresponds with the studies conducted by Caruso et al.18 and Sinclair et al.17 The scores obtained in others categories could not be compared with other study findings as no such data could be found by the researcher. Physical function was measured by using the 9-item Modified Physical Performance Test. It was a test of usual daily activities. The diabetic respondents scored lower than the non-diabetics. None of the study findings could be compared with Bangladeshi data as no such study could be retrieved in extensive literature searches. Diabetic elderly persons scored lower than the non-diabetic persons in all the three tests. This might be probably due to the accompanied co-morbidities of the diabetic persons. Data showed that diabetic respondents were more commonly with different types of co-morbidities and on average, had a higher number of morbidities (2.64 vs. 1.25, p<.05). Although this study found some association between the functional and diabetic status, the association doesn’t mean any causal inference as the study was cross sectional in design. Therefore, the study findings need to be interpreted carefully. However, as diabetes undoubtedly causes functional impairment, individuals should be encouraged to practice healthier lifestyles in order to prevent diabetes as well as to avoid complications and disabilities in their later life.   References 1.   Rashid K M, Rahman M, Hayder S. Textbook of community medicine and public health. Health of the aged. 4th ed. R K H Publishers; 2007: 518-525 2.   Bangladesh Bureau of Statistics, Statistical Pocket Book of Bangladesh 2005, 25th edition 3.   Park K. Park’s Textbook of preventive and social medicine. Preventive medicine and geriatrics. 19th ed. M S Banarsidas Bhanot Publishers; 2007: 475-477 4.   Lloyd-Sherlock P. Population aging in developed and developing region: implications for health policy. Soc Sci Med 2000; 51: 887-895 5.   Gregg EW, Beckles GL, Williamson DF, Leveille SG, Langlois JA, Engelgau MM, Narayan KM. Diabetes and physical disability among older U.S. adults. Diabetes Care 2000; 23: 1272-1277. 6.   Maddigan SL, Feeny DH, Majumdar SR, Farris KB, Johnson JA. Understanding the determinants of health for people with type 2 diabetes. Am J Public Health 2006; 96:1649-1655. 7.   Songer T: Disability in diabetes in America. 2nd ed. Harris MI, Cowie CC, Stern MP, Boyko EJ, Riber GE, Bennett PH, Eds. Washington, DC, U.S. Govt. Printing office, 1995: 429-448 (NIH publ. no.95-1468). 8.   Centre for Disease Control and Prevention: Diabetes Surveillance, 1997. Atlanta, GA, U.S. Department of Health and Human Services, 1997. 9.   Emneus M, Bjork S, Christiansen T, Green A. The societal impact of diabetes mellitus and diabetes care: A case study from Bangladesh year 2001. Global Forum 9; 2005 Sep 11-16; Mumbai, India. 10.  Wild S, Sicree R, Roglic G, King H, Green A. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 2004; 27(5): 1047–1053. 11.  Ryerson B, Wang J, Tierney E, Thompson T, Engelgau M, Gregg EW: Excess physical limitations among adults with diabetes in the U.S. population 1997-1999. Diabetes Care 2003; 26: 206-210. 12. Songer T: Disability in diabetes in America. 2nd ed. Harris MI, Cowie CC, Stern MP, Boyko EJ, Riber GE, Bennett PH, Eds. Washington, DC, U.S. Govt. Printing office, 1995: 429-448 (NIH publ. no.95-1468). 13.  Grauw W JC, Lisdonk E H, Behr R RA, Weel C V: The impact of type 2 diabetes mellitus on daily functioning. Family Practice –An International Journal 1999; 16: 133-139 14.  Wilkinson A. Functional status [cited 2008 March 23] Available from: URL: http://www.gwu.edu/-cicd/toolkit/function.htm. 15.  RAND Health [cited 2008 July 7] Available from: URL: http://www.rand.org/health/about.html 16.  Brown M, Sinacore, DR. physical and performance measures for the identification of mild to moderate frailty. J Gerontol A Biol Sci Med Sci 2005; 55: M 350-5. 17.  Sinclaire AJ, Conroy SP, Bayer AJ. Impact of diabetes on physical function in older people. Diabetes Care 2008; 31: 233-235. 18.  Caruso LB, Silliman RA, Demissie S, Greenfield S, Wagner EH. What can we do to improve physical function on older person with type 2 diabetes. The Journal of Gerontology 2000; Series A: Biological Science and medical science 55: M372-377. <![CDATA[A bacteriological study of diabetic foot infection in an urban tertiary care hospital of Dhaka city]]> Samir Paul Lovely Barai Ashraf Jahan J. Ashraful Haq https://imcjms.com/journal_full_text/141 2016-11-09 15:33:36 Original Article Ibrahim Med. Coll. J. 2009; 3(2): 45-49 Identification of organisms and effective antibiotic therapy is an important component of treatment of diabetic foot infections. This study was undertaken to determine the organisms associated with diabetic foot infection (DFI) and their antibiotic sensitivity pattern. A total of 75 patients having type 2 diabetes mellitus with Wagner’s grade 1-5 foot ulcers attending BIRDEM hospital were included in the study. Specimens were processed for aerobic culture. The bacteriological isolation and antimicrobial sensitivity tests of the isolates were done by standard microbiological methods. Gram negative bacilli were tested for extended spectrum b lactamase (ESBL) production by double disc diffusion method. Culture was positive in 92% of the cases which yielded 135 pathogens. Of the positive culture, 75.3% had multiple organisms. Polymicrobial infection was more in higher grade of foot ulcers. Gram negative organisms were most frequently isolated (80%) bacteria. Pseudomonas (48%) and Proteus sp.(33%) was the most common Gram negative organisms isolated. Staphylococcus aureus was the most commonly isolated gram positive organism (21.3%). ESBL production was noted in 31.5% Gram negative bacilli and methicillin resistance was noted in 43.8% of Staphylococcus aureus. Most of the Gram negative bacilli were resistant to various classes of antibiotics. Imepenem was the most effective agent against Gram negative organisms, while vancomycin was for staphylococcus. The present study has shown that infection with multidrug resistant Gram negative bacilli is the most common cause of DFI in BIRDEM hospital. Ibrahim Med. Coll. J. 2009; 3(2): 50-54 Introduction A good outcome of DFI depends upon being familiar with the microbiological profile of the infection that can help in selecting the most appropriate antimicrobial therapy.13 This study was conducted with an aim to attempt determining the microbiological and microbial susceptibility profile of organisms isolated from diabetic foot ulcers of patients attending BIRDEM hospital. Methods Seventy five diabetic patients with clinically infected foot ulcers attending both Surgery and Orthopedics outpatient and inpatient departments at BIRDEM hospital during the period of June 2008 to October 2008 were studied.   Fig-1: Different grades of diabetic foot ulcers: A- Grade 0, B- Grade 1, C- Grade 2, D- Grade 3, E- Grade 4, F- Grade-5. Grade 0- Preulcer. No open lesions, skin intact; may have deformities, erythemetous areas of pressure or hyperkeratosis. Grade 2- Full thickness ulcer. Penetrates through fat to tendon, or joint capsule without deep abscess or osteomyelitis. Grade 4- Denotes gangrene of a geographical portion of the foot such as toes, forefoot or heel. The remainder of the foot is salvageable though it may be infected.   Culture specimens were obtained after the surface of the wound had been washed vigorously by saline and followed by debridement of superficial exudates. The materials used were curettage of the base of the ulcer, needle aspiration of the abscess material and deep wound swab. Microbiological methods   The clinical characteristics of 75 study population are shown in Table 1. Males were predominant (69.3%) and the mean age of the patients was 52.8 ± 11.7 years. All of them were suffering from type 2 diabetes mellitus (T2DM) and the duration of diabetes ranged between 3-20 years. Among them, 25 (33.3%) had neuropathy and 18 (24%) had peripheral vascular disease. The majority (53.3%) had infected foot ulcer for >1 month and 50 (66.7%) of them had prior antibiotic intake while more than two thirds (70.7%) received surgical treatment prior to admission into BIRDEM hospital. The foot ulcers fell into all the grades (1-5), the most common being grade 3 ulcers (36%). Table-1: Clinical features of 75 diabetic patients with infected foot ulcer       Table 3 shows the frequency of isolation of different organisms from diabetic foot ulcers. Gram negative organisms were most frequently isolated (80%) followed by Gram positive (19.3%) and fungus (0.7%). Pseudomonas species (36 isolates) was isolated from 48% cases and accounted for one third of all isolates. Other organisms were Proteus sp (33.3%), Klebsiella sp (28%), Esch. coli ((14.7%), Acinetobacter sp (6.6%), Citrobacter sp (5.3%), Serratia sp (1.3%) and Providencia sp (1.3%). S. aureus was the most common Gram positive organism and accounted for 21.3% of the infections. Table-3: Rate of isolation of organism from foot ulcers       Table-5: Rate of isolation of ESBL producing Gram negative bacilli and ulcer infection rate with ESBL and MRSA   Our study was designed to detect the bacteria responsible for diabetic foot infections among patients attending the out and in-patient departments of BIRDEM hospital. Most of our patients had grade 3 ulcers. Our study shows that in chronic, complex and previously treated wounds, infections are generally polymicrobial with mixed Gram positive and Gram negative organisms. We found Gram negative aerobic bacteria as the most frequently isolated organism though previous studies had shown Gram positive aerobes as the predominant organisms in DFI.9,14,18,19 Thus the major infective organisms in diabetic foot ulcer in our patients appear to be different. The ratio of Gram positive to Gram negative was 1:4. The differences in the age-sex composition and ulcer grades between our study population and those of earlier studies might be the reason for these differences. However, our results are in tune with other studies done in India which also showed that Gram negative bacteria were the most predominant organisms in DFI.10,11 The role of anaerobic organisms in DFI could not be determined as no attempt was made in this study to isolate the anaerobes.   We thank the staff of Department of Surgery and Orthopedics, BIRDEM hospital for their contribution in sample collection. References 2.   Khan MH. Pathogenesis of diabetic foot ulcer. Diab Endocr J 2006; 34(suppl 1): 11. 4.   Saleh F, Ahmed KR, Rashid IB, Akter F, Hannan JMA, Ali L, Rahman M, Mannan S, Thilsted S. Evaluation of the levels of knowledge, attitude and practices of Bangladeshi Type 2 Diabetic subjects. Diab Endocr J 2005; 33(1): 24-27. 6.   Dang CN, Prasad YD, Boulton A.J., Jude EB. Methicillin resistant Staphylococcus aureus in the diabetic foot clinic: a worsening problem. Diabet Med 2003; 20: 159-161. 8.   Lipsky BA, Pecoraro SA, Larson M, Hanley E, Ahroni JH. Outpatient management of uncomplicated lower extremity infections in diabetic patients, Arch Intern Med 1990; 150: 790-797. 10.Gadepalli R, Dhawan B, Sreenivas V, Kapil A, Ammini AC, Chaudhry R. A Clinico-microbiological study of diabetic foot ulcers in an Indian tertiary care hospital. Diabetes Care 2006; 29(8): 1727-1732. 12.Lipsky BA, Pecoraro RE, Wheat JL. The diabetic foot: soft tissue and bone infection. Infect Dis Clin North Am 1990; 4(3): 409-432. 14.Sharma VK, Khadka PB, Joshi A, Sharma R. Common pathogens isolated in diabetic foot infection in Bir Hospital. Katmandu University Medical Journal 2006; 4(3): 295-301. 16.Emery CL, Weymouth LA. Detection and clinical significance of extended spectrum b-lactamases in a tertiary-care medical center. J Clin Microbiol 1997: 2061-67. 18.Yoga R, Khairul A, Sunita K, Suresh C. Bacteriology of diabetic foot lesions. Med J Malaysia 2006; 61(suppl A); 14-6. <![CDATA[Awareness on organ transplantation among health care professionals and medical students]]> Zahedul Karim Ahmad Md. Humayun Kabir Abdul Mazid Gulshan Ara Akther Md. Nur Hossain Farzana Islam Parvin Dilara Zaman https://imcjms.com/journal_full_text/143 2016-11-13 08:48:17 Original Article Ibrahim Med. Coll. J. 2009; 3(2): 55-58 Ibrahim Med. Coll. J. 2009; 3(2): 55-58 Keywords: Organ transplantation, awareness, healthcare professionals, religious sanctions. Introduction An organ transplant is a surgical operation where a failing or damaged organ in the human body is removed and replaced by a new one. The organs and tissues to be transplanted may come from three sources: a) homologous transplantation- here tissue is moved between sites on the same body b) live donation- in this process tissue is taken from a living donor whose tissues have been matched to or are compatible with those of the recipient and the largest source c) cadaver or deceased donation- when the organs are taken from a recently deceased person.1 The results are the best if the organs are obtained while circulation is still present or immediately after cessation of the circulation giving rise to the importance of the concept of brain death. If an individual can be certified to be brain dead, his or her organs may be removed for transplantation purposes provided there are legal sanctions to the process of organ transplantation in the country in question. Most developed countries have sophisticated laws to regulate organ donation and transplantation. The world has come a long way since the times of third century saints Damian and Cosmos trying to replace the gangrenous leg of the Roman deacon Justinian with the leg of a recently deceased Ethiopian.2 An Organ Transplantation Law also exists in Bangladesh. The law is embodied in an act known as the “Human Organ Transplantation Act 1999”. This act defines ‘Organ’ as kidney, heart, liver, pancreas, bone, bone marrow, eyes, skin or any other human organ or tissue. The act also defines the legal heirs or successors of the body of a deceased person and is according to priority as follows: husband, wife, adult son and daughter, adult brother or sister, or any other adult blood related persons. Section 5 of the act defines the meaning of brain death and is in conformity with the clinical criteria of diagnosing brain death. The act also specifies the composition of the brain death declaration team.3  However, in spite of this law, organ transplantation is yet to gain grounds in Bangladesh. Though there are many reasons behind such a situation it is felt that lack of awareness and religious misconceptions are primary. This study attempts to find out the awareness level and attitude regarding organ transplantation among health care professionals and medical students in large teaching hospitals in the capital of the country who can play a pioneering role in popularizing the procedure. Materials and Methods This descriptive cross-section designed study was conducted at Ibrahim Medical College and BIRDEM Hospital, Holy Family Red Crescent Medical College and Hospital and Holy Family Red Crescent Nursing Institute in Dhaka city during the month of Jan, 2009 to March 2009. In total 462 respondents were selected purposively, of them 71 were graduate doctors, 32 post-graduate doctors, 41 diploma nurses, 50 BSC nursing students and 268 medical students. They were interviewed by a pre-tested structured questionnaire. Data were analyzed with the help of a computer. Results Of the respondents, 137 (29.6%) were males and 325 (70.4%) were females. The mean age of the doctors was 34.2 years, while for the nurses, it was 31.5 years and 20.5 for the medical students. Three fourths (76.4%) were Muslims, followed by Hindus (16.9%), Christians (5.4%) and Buddhists (1.3%). More than half (53.2%) of the post graduate doctors, 35.1% of the MBBS doctors, 26.8% of the diploma nurses, 28% of the BSC nursing students and 29.1% of the medical students and on average 31.4% of the total respondents knew that there was an organ transplantation law in Bangladesh while 16.5% said that there was no such law, whereas 52.2% have no idea about organ transplantation law (Table 1). Table-1: Distribution of respondents according to their awareness about organ transplantation law in Bangladesh. Yes Not Known MBBS Doctor 12 (16.9) 71 (100) 17 (53.1) 7 (21.9) Diploma Nurse 7 (17.1) 41 (100) 14 (28) 23 (46) Medical students 36 (13.4) 264 (100) 145 (31.4) 241 (52.2)   Although 70.8% of the respondents were in favour of the need of an organ transplantation law in our country, 7.4% were not in favour of such a law. A fifth (21.9%) had no idea about such a law to enable them to comment (Table 2). Table-2: Distribution of the respondents on need of organ transplantation law in Bangladesh Yes Not sure 54 (76.1) 12 (16.9) 28 (87.5) 3 (9.4) 24 (58.5) 10 (24.4) 31 (62) 7 (14) 190 (70.9) 69 (25.8) 327 (70.8) 101 (21.9)     Respondents No (%) MBBS Doctors (n = 71) 19 (26.8) Post graduate doctors (n = 32) 12 (37.5) Diploma Nurses (n = 41) 27 (65.9) BSC nursing students (n = 50) 27 (54.0) Medical students (n = 268) 109 (40.7) Total (n = 462) 194 (42.0)   Opinion was sought from the respondents on which organ or organs they were willing to donate after their death. The most common organ cited was the eye. 140 (30.3%) were willing to donate their eyes, 42 (9.1%) their kidneys and 23 (4.9%) their heart (Table 4). Table-4: Distribution of organs likely to be donated by the respondents Frequency 140 (30.3) 42 (9.1) 23 (4.9) 1 (0.2) 6 (1.3) 57 (12.3)     Respondents No (%) Total (%) 15 (21.1) 38 (53.5) Post graduate doctors 5 (15.6) 32 (100) 15 (36.6) 6 (14.6) BSC nursing students 29 (58.0) 50 (100) 71 (26.5) 97 (36.2) Total 172 (37.2) 462 (100)       1.   Shepherd R. The Medical Aspects of Death in Simpson’s ForensicMedicine.12th Edition. 2003.Arnold,London. 3.   The Human Organ Transplantation Act of 1999 of Bangladesh. 5.   Background document of Regional Meeting on WHO guiding principles on Organ, Tissue and Cells Transplantation, Jaipur, India, 2-5 February 2009. 7.   J Godard, AN Turner, AD Cumming, LS Stewart. Kidney and Urinary Tract Disease in Davidson’s Principles and Practice of Medicine Edited by Boon NA, Colledge N R, Walker BR. 20th Edition. 1st India Reprint; 2006 Elsevier, India: 494. <![CDATA[Knowledge and practices on neonatal care among selected mothers attending Dhaka Shishu Hospital]]> Housne Ara Begum Mohammad Faizul Haque Khan https://imcjms.com/journal_full_text/144 2016-11-13 09:14:27 Original Article Ibrahim Med. Coll. J. 2009; 3(2): 59-62 Address for Correspondence: Dr Housne Ara Begum, Institute of Health Economics, University of Dhaka, Dhaka-1000, Bangladesh, email:drhousne@gmail.com           Characteristics Mother’s age (yrs) <20 21-25 26-30 31-35 >35 Mean (SD) Education of Mothers Illiterate Primary SSC HSC Graduation Residence of Parents Urban Rural Family income (Taka) > 3000 3000-7000 7001-15000 < 15000   To estimate the level of knowledge, mothers were asked questions on breast feeding, maintenance of body temperature, skin care, care of umbilical stump, eye care, immunization, early detection of serious diseases, social beliefs and source of information. Scores were given as 1 (for appropriate answer) or 0 (for inappropriate answer). Then they were computed and recoded and grouped in three categories as excellent, optimum, and poor. Only 5.8% mothers had excellent knowledge on neonatal care, 55.3% mothers had optimum knowledge, and 39% mothers had a poor knowledge. Level of practice of the respondent mothers on neonatal care was also calculated by following the same method. Only 5.5% of the mothers had an excellent performance whereas 71.8% mothers performed poorly. Regarding breast feeding, 10.5% of the respondent mothers told breast feeding should be initiated within 6 hrs, 10.5% of the respondent mothers told about feeding colostrum, 95.5% of the mothers told exclusive breasting should be up to 6 months where as 4.3% answered none. As regards ritual or traditional practices kajol, homeopathic drugs, breast milk, oil and similar items were used for treating various eye problems. Match box, iron sticks, brooms, shoes, scissors were mentioned by 46.5% of the respondents as materials to ward off evil spirit. For source of information for neonatal care, 96.8% of the mothers got suggestion and information from relatives and guardians. Only around 5% mothers got information from books, radio, TV and posters. Discussion This study revealed that less than half (42%) of the respondents knew how to care for the neonates. Many newborn deaths can be avoided by interventions that have important preventive effects like thermal protection. Simple measures such as a warm room for delivery, immediate drying of the baby and skin-to-skin contact with the mother can prevent loss of body warmth.4 In a study on the care of 62 normal newborns at four levels of institutions, the majority being at the University Teaching Hospital in Lusaka, it was seen at discharge after an average of 14 hours, half the babies had a body temperature below 36°C, i.e. mildly hypothermic. In another study, a significant decrease in body temperature was observed between 30 and 120 minutes post-partum.5 In this study, only 23.5% of the respondents kept neonates attached to mother with head covering. Neonates can easily loose body temperature. About one fifth of the temperature is lost through head. Although most neonates are adequately covered, their heads remain uncovered. Often they become hypothermic which goes unnoticed, resulting in mortality. Interestingly 22.5% respondents knew that shaving off hair is harmful but around 65% respondents told that they shave off their neonate’s hair. These practices make neonates more vulnerable to hypothermia. Those in favor of cutting hair of neonates argue that it is impure. Offering neonates anything other than breast milk makes them more prone to infection. In this study most of the mothers (91%) were in favor of breast feeding after birth. Some of them offered honey, sugar, misri (locally produced crystallized sugar), cow’s/goat’s milk as first feed. It indicates very few mothers were practicing early feeding of breast milk. When questioned about hypoglycemia, only 19 (29.2%) stated that the mother should increase the feeding frequency. Thirty subjects (46.2%) recounted the belief about “weak milk”. On the topic of contraception, 27 (41.5%) had proper knowledge on how to avoid a new pregnancy during lactation. Hugo et al.6 found that very few mothers had the knowledge of formulas for artificial milk. Same findings were shown in this study. Regarding the human milk substitutes, only 7 subjects (10.8%) knew that artificial formulas were made from cow or soybean milk. And 37 (56.9%) acknowledged the impact of the cost of the artificial formulas on the household income. Data on potential risk factors for omphalitis were collected during a community-based, umbilical cord care trial in Nepal during 2002–2005. Handwashing was associatedwith fewer infections and needs to be promoted by community-based healthworkers.7 More than half (54%) of the respondents thought that the umbilicus of the new born should be kept dry and nothing applied to it. Interventions introduced in both developed and developing countries to reduce exposure of the cord to infectious pathogens include clean cord cutting, hand-washing before and after handling the baby.8 During a study on pregnancy in a poor rural tropical area, a high prevalence of neonatal fever and umbilical cord infection was detected.9 It was found that 94% mothers thought oil massage was good for neonates and 87% of the respondents practiced so. Most of them used mustard oil. They did not know that it could be harmful for the tender skin of the infants. Twice-daily application of mustard oil for 7 days resulted in sustained delay of barrier recovery. Mustardoilisusedroutinelyinnewborncare throughout South Asia, having toxic effects on the epidermal barrier that warrant further investigation.10,11 Conclusion The study revealed that almost half of the respondent mothers were unaware of proper neonatal care. Many of them had not only inadequate knowledge but also maintained some rituals or traditional attitudes that proved to be unhealthy and even injurious to neonates. The mothers had a fair knowledge regarding need for immunization but a poor knowledge regarding the prevention of diseases. The health planners and policy makers should look into this important issue. Only educational interventions may significantly reduce neonatal morbidity and mortality and improve the overall health situation of infants. References 2.   AlecMercer, Hossain M, Fariha K, Nafisa H, Huq L, Nowsheruddin, Larson C. Level and determinants of neonatal mortality in rural areas of Bangladesh served by large NGO programme; ICDDR,B Neonatal Report 2005. 4.   WHO 1996. Essential newborn care. WHO/FRH/MSM/96.13. 6.   Hugo I, Borges M, Rodrigues S, Maria S. Knowledge of newborn healthcare among pregnant women: basis for promotional and educational programs on breastfeeding. Sao Paulo Med Journ 2001; 119(1): 35-39. 8.   Mullany, Luke C. Armstadt G, Tielsch J. Role of antimicrobial applications to the umbilical cord in neonates to prevent bacterial colonization and infection: a review of the evidence. Pediatric Infectious Disease Journ 2003; 22(11): 996-1002. 10.Darmstadt G.L, Mao-Qiang M, Chi E, Saha SK, Ziboh VA, Black RE, Santosham M, Elias PM. Impact of topical oils on the skin barrier: possible implications for neonatal health in developing countries. Acta Paediatri 2002; 91(5): 546. <![CDATA[Awareness on HIV/AIDS among the blood donors of a city hospital]]> Niru Sultana https://imcjms.com/journal_full_text/145 2016-11-13 09:17:40 Original Article Ibrahim Med. Coll. J. 2009; 3(2): 63-66 Although 93.6% of the respondents heard about AIDS (TV being the most common source), none had a good or excellent level of awareness about the disease. About mode of transmission, 20.9% had average and very few had a good level of knowledge regarding its prevention. When asked for an opinion about the country’s risk for HIV/AIDS, more than half (54.2%) had the view that the country was at a risk from the disease and nearly three quarters (72.5%) were of the opinion that mass awareness campaigns on HIV/AIDS could improve the situation. Address for Correspondence: Dr. Niru Sultana, Lecturer, Department of Community Medicine, Ibrahim Medical College, 122 Kazi Nazrul Islam, Avenue, Shahbagh, Dhaka, Bangladesh           Occupation Group# Chi-square value Average Grossly dissatisfactory 16 (84.2)* 4 (19.0) 0.001 3 (15.8) 17 (81.0)   19 21   *Percentages in parentheses. – Group I comprised of Service-holders, housewives and students, while Group II consisted of businessmen, drivers, unemployed and others.     Income (Tk) Chi-square value Average Grossly dissatisfactory 2 (10.5)* 14 (66.7) 0.004 17 (89.5) 7 (33.3)   19 21   * Percentages in parentheses.   Two-thirds (65.5%) of the respondents donated blood once in their lifetime, while 23.6% donated twice. The rest 10.9% did the same >2 times in their lifetime. Nearly two-thirds (65.7%) of the respondents got information on AIDS from television followed by newspapers, friends, and posters. Books, AIDS patients and Health workers were not found to play any significant role in enriching the respondents’ knowledge about the disease. Knowledge was associated directly with their level of education (Table 3). Table-3: Association between education and level of knowledge about HIV/AIDS Level of knowledge p-value Poor Primary-secondary 35 (64.8) 13.935 Above secondary 19 (35.2)   Total 54     ** Chi-square (c2) statistics was used to analyse the data and the level of significance was 0.05, with df 3 The respondents were asked about the mode of spread of HIV/AIDS. Of those who knew the answer, almost all of them said that one gets the infection by having sex with an infected HIV person (Table 4). Table-4: Respondents’ knowledge about mode of transmission of the disease. no How does the disease occur:   63 Through breast feeding 82.3 12 By needles/syringes 43.1 14 Transfused with HIV infected blood 1.5 – Total will not correspond to 100% because of multiple responses.       1.   Epidemiology and Basic Facts about RTI/STI and HIV/AIDS. Curriculum on RTI/STI, Urban Family Health Partnership, March 2002; p 5. 3.   UNAIDS. Report on the Global AIDS Epidemic – Executive summary. 2004; Geneva. 5.   Health and Science Bulletin: Centre for Health and Population Research, ICDDR, B, March 2005; 3(1). 7.   Bhuiya I. Hossain SMI. Streatfield K. The Population Council, South & East Asia. 1996; no. 6. 9.   Bhattacharya G, Cleland C, Holland S. Knowledge about HIV/AIDS, the perceived risk of infection and sources of information of Asian – Indian  adolescents born in USA. AIDS Care 2000; 12(2): 203–209. <![CDATA[High prevalence of HCV and diabetes mellitus in multi-transfused subjects]]> Tashmim Farhana Dipta Ahmed Zahid Hossain Khadija Nazneen https://imcjms.com/journal_full_text/146 2016-11-13 09:33:34 Original Article Ibrahim Med. Coll. J. 2009; 3(2): 67-70 Ibrahim Med. Coll. J. 2009; 3(2): 67-70 Key words: Multitransfused, HCV, Diabetes mellitus Introduction Blood and blood products are necessary supportive options for thalassaemia, cancer, hemodialysis, blood loss and in various medical, gynecological and surgical emergencies.1 Diabetes is common among multitransfused patients having various blood diseases and bleeding disorders.1 An increased prevalence of hepatitis C virus (HCV) infection in patients with diabetesand a higher prevalence of diabetes in HCV-infected patients have been reported.2,3,4 Impaired glucose tolerance and diabetes are common in beta thalassaemic multitransfused patients.2,4 Iron overload, chronic liver disease, viral infection and genetic factors may play an important role in diabetes mellitus.4 Existing hemosiderosis may mark the effect of HCV infection on glucose metabolism.2,4 There is high frequency of diabetes in thalassaemic patients with HCV. Chronic hepatitis is usually evident in patients over twenty five years.2,3 Multitransfused adult beta thalassaemic patients also show higher prevalence of HCV infection due to transmission of HCV infected blood.1,2,4,5 Diabetes mellitus is one of the common cause of end stage renal disease who need haemodialysis which itself is a risk factor for transmission of hepatitis C virus.6,7 Prevalence of HCV in haemodialysis patients with diabetes mellitus is two times higher.6 Thus diabetes acts as an important factor for the increase in ferritin level in patients with HCV and worsen the situation futher.2-4 The seroprevalence of HCV infection in our country has been reported at 4.6% in apparently healthy individuals and 4.8% in professional blood donors.8 In transfused recipients, the HCV incubation period is 40 to 60 days which is considerably shorter than the 90 to 180 days with HBV.9 The residual risk of HCV transmission due to donations in the anti-HCV window period at present is about 1 in 100000 transfusions of cellular products.9 The aim of the study was to assess the prevalence of HCV and Type 2 Diabetes mellitus (T2DM) among multitransfused patients attending the Department of Transfusion Medicine. Materials and Method The study was conducted in two tertiary care centers in Dhaka City from July 2006 to July 2007. These centers (Department of Transfusion Medicine of BIRDEM, Department of Transfusion medicine and Haematology Department, BSMMU and Bangladesh Thalassaemia Society) have the experience of blood transfusion with well equipped standard facilities. Hundreds of patients get transfusion every year. We selected those subjects who come to the transfusion center and got transfused with at least five units of blood. Three ml. of venous blood was drawn from the ante-cubital vein aseptically by using disposable syringes. Blood was collected in plain, dry and sterile test tubes. Serum was separated and stored at –200 C until testing. All samples were tested for Anti-HCV by ELISA using kits from Detect-HCV (V.3) as per guideline of manufacturer of kits. Device sensitivity was 98.2%. In brief, in plate dilution method (IPD) 20 micro litre sample added to wells with 200 micro liter sample diluent and incubated for 60 minutes at 370 C. Aspiration was done and washed 5 times with wash solution. Then addition of 100 micro liter peroxidase conjugate solution reincubated for 30 minutes at room temperature and reaspirated and rewashed 5 more times with wash solution. Reading of absorbance was taken at 450 nm. After a second wash during incubation, a blue color developed in proportion to the amount of anti-HCV antibody bound to the well. Wells containing samples negative for anti-HCV antibody remained colorless. Positive sera were re-tested using the same method. Positive results were interpreted according to the manufacturer’s recommendations. For diagnosis of T2DM and IGT, oral glucose tolerance test (OGTT) was done using the WHO criteria of 1997. Additionally, T2DM was presumed if the patient had any history of diabetes or reported use of insulin or an oral hypoglycemic agent at the time of the study. Results A total of 125 multitransfused patients who received more than 5 units of blood were included in this study. Of them, 95 (76%) were males and 30 (24%) were females. The disease prevalence according to T2DM and IGT are shown in Table 1. The crude prevalence of HCV was 15%, T2DM was 28% and IGT was 13%. Of the diabetic subjects, 31.4% were found positive for HCV and among the IGT subjects 12.5% were HCV positive. In contrast, of the total 74 non-DM and non-IGT subjects, only 8.1% were found positive for HCV. Of the total HCV positive subjects, 48% attended for hemodialysis and 37% with thalassaemia (Table 2). Among the non-DM subjects, 42% were anti-HCV positive in the age group of 51 - 60 years of age; whereas, in T2DM subjects, 94% were anti-HCV positive in the age group ³40 years, indicating an earlier onset of HCV in the hyperglycemic subjects. Table-1: Diseases found in multitransfused patients with type 2 diabetes mellitus (T2DM) and impaired glucose tolerance (IGT) (n = 51) Diabetic (n=35) Thalassaemia 5 (31) 5 (14) Gynecological 1 (6) 2 (6) Surgical cause 2 (13) 12 (33) Cardiac surgery 1 (6) (Percentages in parenthesis) Table-2: Categories of diseases in the HCV positive multi-transfused patients HCV positive ( n=19) 7 (37) 1 (5) 1 (5) 1 (5) 9 (48) (Percentages in parenthesis) Discussion Higher prevalence of HCV in T2DM and IGT subjects observed in this study is consistent with other studies.1-4,10 When glycaemic status and age of onset of HCV was considered, 42% had T2DM in age group 51 to 60 years, whereas, 94% of anti-HCV positive in T2DM were of age forty years or older. This observation is similar to other studies.2-4,11,12 In USA, HCV infection was three times more common in T2DM than those without.11 Highest percentage of positive HCV were among the patients having hemodialysis (48 %), next to those in the thalassaemic group (37%) which were consistent with other studies.6,7 In this study, highest number of diabetic patients was in the haemodialysis group followed by the thalassaemic group. So the haemodialysis and thalassaemic patients were suffering from both diabetes and positive HCV viral marker, the same being reported in other studies.2-4,6,7,13,14 In USA, the prevalence of HCV infection is higher in patients with maintenance haemodialysis ranging from 5 to 25%,15 very similar to this study. Various studies show T2DM was present with a higher HCV infection such as 15.2% in Iran,4 20.8% in Turkey16 and 21.2% in Saudi Arabia;12 which has similarity with this study (31.43%). Impaired glucose tolerance is more among thalassaemic (31%) also supports different studies.2-4,14,15,17,18 In USA, 25% patients were diabetic with iron overload, 19.5% of patients were diabetic among multitransfused beta-thalassaemic and 8.5% had impaired glucose tolerance.14 Among the total 125 patients 19 (15%) had positive hepatitis C viral marker which is consistent with other studies.2-4,6,7,10,11,13,16,19 Conclusion A higher prevalence of type 2 diabetes and hepatitis C was observed in the multitransfused subjects. The HCV prevalence was found most common in the diabetics and more common in IGT and least common in the non-hyperglycemic multitransfused subjects. The study also revealed an younger aged onset of HCV infection in the hyperglycemic subjects. Additionally, it showed the distribution of types of diseases in multitransfused subjects encountered in the blood transfusion centers in Dhaka City. As this sample was small, further elaborative studies are needed among thalassaemic and dialysis patients where the parameters of HCV and diabetes were found to be more common. References 2.   Labropoulou-karatza C, Gontsas C, Fragopanagou H etal. High prevalence of diabetes mellitus among adult beta-thalassaemic patients with chronic hepatitis C. Eur J Gastroenterol Hepatol 1999; 11(90): 1033-6. 4.   Mowla A; Karimi M, Afrasiabi A, de Sanctis V. Prevalence of diabetes mellitus and impaired glucose tolerance in beta-thalassaemia patients with and without hepatitis c virus infection. Paediatr Endocrinol Rev 2004; 2 Suppl 2: 282-4. 6.   Ocak S, Duran N, Kaya H, Emir. Seroprevalence of hepatitius C in patients with type 2 diabetes mellitus and non-diabetic on haemodialysis. Int J Clin Pract 2006; 60(6): 670-4. 8.   Institute of Epidemiology Disease control and Research (IEDCR). AIDS/HIV Surveillance Activities., Strategic plan of the National AIDS program of Bangladesh, 1997-2002, drafted in 1997 in collaboration with national AIDS / STD program in May 2000; Pp: 1-8. 10.Piquer S, Hernandez C, Enriquez J et al. Islet cell and thyroid antibody prevalence in patients with hepatitis C virus infection : effect of treatment with interferon. J Lab Clin Med 2001; 137(1): 38-42. 12.Akbar DH, Siddique AM, Ahmed MM. Prevalence of type-2 diabetes in patients with hepatits C and B virus infection in Jeddah, Saudi Arabia. Med Princ Pract 2002; 11(2): 82-5. 14.Sundararaman Swaminathan, Vivian A. Fonseca, Muhammad G. Alam, sudhir V. Shaha. The role of iron in Diabetes and its complications. Diabetes Care 2007; 30: 1926-1933. 16.Ozyurek E etal. Transfusion-transmitted virus prevalence in Turkish patients with thalassaemia. Pediatr Hematol Oncol 2006; 23(4): 347-53. 18.Ashkan Mowla, Mehran Karimi, Abdolreza Afrasibi, Vincenzo De sanctis. Prevalence of diabetes mellitus and impaired glucose tolerance in beta-thalassaemia patients with and without hepatitis C virus infection. Paediatric Endocrinology Reviews 2004; 2(2): 282-284. <![CDATA[Gingivitis in primary school children of Bangladesh]]> Masuma Pervin Mishu Richard Marshall Hubbard Sejuty Haque M Abu Sayeed Syed Touseef Imam Parvin Akhter Khanam Tanjima Begum Mahfujul Haq Khan https://imcjms.com/journal_full_text/147 2016-11-13 09:48:46 Original Article Ibrahim Med. Coll. J. 2009; 3(2): 71-74 Though early diagnosis and intervention of gingivitis in school children can eliminate progression to frank periodontal diseases, no such measures in Bangladesh are in place to detect gingivitis at an early stage in school children. This survey was conducted in 2007 in the primary schools of rural, suburban and urban areas of Bangladesh to evaluate oral hygiene with special emphasis on gingivitis prevalent among 6-13 years school children. The clinical examination of the gingiva was carried out using a mouth mirror and a periodontal probe. A total of 1,820 primary school students (m/f = 946/873) took part in the investigation. The crude prevalence of gingivitis, AS* and plaque were 17.5%, 9.2% and 56.0% respectively. The prevalence of gingivitis was significantly higher in males than females (20.3 vs. 14.3%, p<0.001), lower than upper social class (21.1 vs. 12.6%, p<0.001) and in rural than urban plus suburban children (22.5 vs. 15.1%, p<0.001). Likewise, the prevalence of AS was higher in females, lower social class and rural children. Significantly lower prevalence of gingivitis, AS and plaque was found among those who used tooth brush and tooth paste than those who did not (15.4% vs 22.4%, p<0.001). The study concludes that the prevalence of oro-dental diseases is high in Bangladeshi children. The male children of low social class of rural communities are the most vulnerable group. Address for Correspondence: Dr. Mahfujul Haq Khan, Assoc. Prof., Dept of Dentistry, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) & Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbagh, Dhaka-1000, Bangladesh. e-mail: mahtink@yahoo.com   In many developing countries, the prevalence of dental caries and periodontal diseases are increasing, thereby constituting a public health problem.1 To control such diseases, good oral and dental health should be achieved at both public and personal levels. People in developing countries are burdened excessively by oral disease, particularly periodontal disease. This is aggravated by poverty, poor living conditions, ignorance concerning health education, lack of government funded policies to provide sufficient oral health workers.2 Few published studies have described the trends in the prevalence of dental caries and periodontal disease in children.3,4    The survey was conducted among primary school children of Bangladesh from 20 June to 31 July in 2007. The survey was constructed in a simple block design, each group of children being divided according to their residence in urban, suburban, or rural area. Seven locations were purposively selected within 3 hours drive of Dhaka city and 3 were selected in areas outside of Chittagong. Overall, 3 urban, 3 suburban and 4 rural schools were included.   A total of 1,820 primary school students (m/f = 946/873) of age 6 to 13 years took part in the investigation. The characteristics of the participants were shown in Table 1. Their mean (SD) age was 8.83 (2.0) years. The mean (SD) values for ht, wt, HC, MUAC were 125.6 (11.9) cm, 23.5 (6.7) kg, 50.0 (1.8) cm and 17.4 (1.9) cm, respectively. The mean BMI was 14.6 (2.1). These anthropometric measures did not differ between male and female students. Adjusted for age and sex, the BMI significantly correlated with HC and MUAC and also with height and weight (Table 2). Table-1: Characteristics of the Children (n=1803) Range Age (y) 8.83 (2.0) 87.5 – 168.0 Weight (kg) 23.5 (6.7) 40.0 – 57.5 Mid-upper arm circumference (cm) 17.42 (1.9) 8.76 – 29.8       Variables MUAC Height HC 0.34 0.33   Ns p<0.001 MUAC - 0.38     p<0.001 BMI - –0.35     p<0.001       * Chi-square and p values are shown for the association with risk variables. For the social class comparison, the prevalence of gingivitis (21.1 vs. 12.6%), AS (12.4 vs. 4.8%) and plaque (61.6 vs. 48.1%) were significantly higher in the students from lower social class than students from upper social class (for all, p<0.001). Compared with other devices of cleaning teeth, tooth brush was found to have reduced chances of gingivitis (p<0.001), AS (p<0.001), and plaque (p=0.02). Likewise, using tooth paste as a teeth-cleaning substance, compared with other substances like charcoal, salt, ash was found to have beneficial effect against gingivitis, AS and plaque (Table 3). Discussion  The prevalence rates of gingivitis, AS and plaque were significantly higher in the poor social class than their rich and middle-class counterparts. These findings are inconsistent with Marisa et al. who reported no correlation between gingivitis and the studied socioeconomic variables.9 On the other hand the findings are very much consistent with the Adenubi’s observation among Nigerian children, who found that calculus and gingivitis in the private school children of higher social class had significantly lower prevalence than that found in the government school children.7 They suggested that better oral hygiene practices in the higher socioeconomic group of private school children might have reduced the incidence of oro-dental disorders. Similar findings were also reported by Ta’ani in her study in Jordanian school children.5 She found that bleeding and calculus score were prevalent in pupils of both types of schools though slightly higher in pupils of public schools than that of private schools. This is also consistent with other reports.10,11   There is scarcity of population based study on oral heath of primary school children in Bangladesh. This study explored the higher prevalence of gingivitis, angular stomatitis and dental plaque among primary school children. It also determined the significant associations of these oro-dental diseases with sex, social class, geographical sites and the use of tooth cleaning devices and tooth cleaning substances. These findings may be of importance for oral health education at primary school level in our country. Acknowledgment   1.    Sheiham A. Changing trends in dental caries. Int J Epidemol 1984; 13: 142-147. 3.    Cahen P M, Obry Musset A M et al. Caries prevalence in 6-15 year old French children based on the 1987 and 1991 national surveys. J Dent Res 1993; 72: 1581-1587. 5.    Quteish Ta’ani D. Caries prevalence and periodontal treatment needs in public and private school pupils in Jordan. Int Dental J 1997; 47: 100-104. 7.    Adenubi J O. The Gingival health of eight year old Nigerian children. J of Public Health Dentistry 1984; 44(2): 61-72. 9.    Marisa M, Berenice B, Silva. Relationship between caries, gingivitis and flurosis and the socioeconomic status among school children. Rev Saude Publica 2001; 35(2): 170-176. 11.  Athanassouli I, Mamai-Homata E, Panagopoulos H et al. Dental caries changes between 1982 and 1991 in children aged 6-12 in Athens, Greece. Caries Res 1994; 28: 378-382. 12.           Loe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 1963; 21: 533-551. <![CDATA[Effect of nonpharmacological interventions on dietary practices, energy expenditure and biochemical parameters of hypercholesterolemic type 2 diabetic subjects]]> Fadia Afnan Farzana Saleh Shirin Jahan Mumu Afroza Akhter Kazi Rumana Ahmed Sanzida Akter Tanjuma Pervin https://imcjms.com/journal_full_text/148 2016-11-13 11:12:34 Original Article Ibrahim Med. Coll. J. 2009; 3(2): 75-77 Address for Correspondence: Farzana Saleh, Assistant Professor, Department of Community Nutrition, Bangladesh Institute of Health Sciences, Dhaka 1207, Bangladesh, e-mail: farzanasaleh_sumona@yahoo.com         Table-1: Characteristics of the study subjects (n=80)   Results are expressed as Number(%), mean±SD. SBP= Systolic blood pressure, DBP=Diastolic blood pressure   Table-2: Dietary intake of the study subjects after receiving intervention (n=80)                                     Results are expressed as mean ± SD and median (Range).   Table-3: Energy intake and energy expenditure of the study subjects after receiving intervention (n=80)   Variables Before After t/p FSG (mmol/ dl) 9±3.89 7±1.43 4.2/0.001* SGABF (mmol/ dl) 16±6.46 11±4.08 6.4/0.001* Total Cholesterol (mg/dl) 231±31.89 217±35.10 7.5/0.001*       The study was supported by ENRECA under DANIDA, Denmark; International Program in the Chemical Sciences (IPICS), Uppasala University, Sweden; Bangladesh Diabetic Somity. References 2.   American diabetes Association: Standards of medical care in diabetes-2007. Diabetes Care 2007; 30(Suppl 1): S16. 4.   Tuomilehto J, LindstrÖm J, Eriksson GJ, Valle TT, Hämäläine H, Parikka I P, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001; 344(18): 1343-1349. 6.   Pan XR, Li GW, Hu YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: the Da Qing IGT and Diabetes Study. Diabetes Care 1997; 20: 537-44. <![CDATA[Torsion of the gravid uterus]]> Samsad Jahan Masuma Jalil Masuda Islam Khan Suha Jesmin Umme Rumman https://imcjms.com/journal_full_text/149 2016-11-13 11:18:17 Clinical Case Report Ibrahim Med. Coll. J. 2009; 3(2): 78-79 MRS. X was a 28 years old second gravida hailing from Dhaka. Her first child was delivered about 3.5 years back by lower uterine caesarian section (LUCS) at 40 weeks due to non-progress of labour. In her second pregnancy, she was under routine antenatal check up and pregnancy proceeded normally. At about 37 wks of gestation she developed pain in abdomen and back, which was very severe and intermittent in nature. There was scar tenderness and a history of previous LUCS which went for a decision to perform LUCS. It was performed by opening the abdomen with Pfannenstiel incision excising the previous scar. On entering the abdominal cavity, omental adhesion with the anterior abdominal wall was seen. The uterus was found totally levo-rotated to about 1800. Uterovesical fold of peritoneum could not be identified and previous uterine scar was also not visible. It was impossible to untwist the uterus due to its enlargement with pregnancy. A transverse incision was given in the lower part and a healthy male baby weighing 3.4 kg was delivered by vertex presentation. Placenta was removed after spontaneous separation. It was possible to untwist the uterus after delivery of the baby and placenta. It was found that the uterine incision was on the posterior surface of the uterus and the utero-vesical fold was in the normal position. As uterus was scarred on both surfaces, the patient was counseled and bilateral tubectomy was performed. Postoperatively, the patient remained well and was discharged on the 4th post operative day. Discussion Uterine torsion is an infrequently reported and potentially dangerous complication of pregnancy that occurs mainly in the third trimester with adverse maternal and neonatal consequences.1 Uterine torsion is more frequently dextrorotatory.2 The diagnosis is difficult and generally done during Cesarean section because it is frequently non-symptomatic. Uterine torsion signs, when present, are not specific. Pain, nausea and vomiting may present without any sign of shock, as in this patient.2 Sometimes ultrasonography can lead to a correct diagnosis, showing a modification of the placenta site during pregnancy, or an abnormal positioning of the ovarian vessels which pass in front of the lower uterine segment. Some authors report cardiotocographic abnormalities probably due to a reduction in the blood flow caused by the torsion. A quick surgical intervention is fundamental for the reduction of fetal mortality which is very frequent in a large number of cases, while maternal mortality is not so frequent but possible.2 A diligent amniocentesis and ultrasonographic examination are often useful to single out the rare cases of uterine torsion in pregnancy. Deliberate posterior Cesarean hysterotomy is an option for fetal delivery with irreducible torsion, and round ligament plication may prevent recurrent torsion in the immediate puerperium.3 Regarding historical background, torsion of the gravid uterus is rare.4-8 The earliest report of this condition was made by an Italian veterinarian by the name of Columbia in 1662.9 Almost 200 years later, in 1863, Virchow reported the first case in a human observed at post-mortem examination. In 1876 this abnormality was described in a living woman for the first time by Labbe. Nesbitt and Corner5 reviewed this subject in 1956 and found only 107 cases in the world’s literature. Another instance was reported by Piot, Gluck and Oxorn in 1973.10 In almost a third of the cases, the condition is usually associated with tumor and presents as an acute abdomen. Complication includes uterine rupture and pulmonary embolism. Treatment is by laparotomy and detorsion with Caesarian section if at or near term. The over all maternal mortality rates associated with torsion of the gravid uterus is about 13% and is directly related to the duration of the gestation. Under 5 months it is 0% where as at term it reaches 18.5%. It is also directly related to the degree of twisting. It is about 7.4% in torsion of 900-1800 which increases to 50% when rotation is 1800-3600. Perinatal mortality is about 30% and it increases with the degrees of rotation. It is as high as 75% in rotation exceeding 1800. The only hope for a successful maternal and fetal outcome is laparotomy and correction of the torsion. At or near term Cesarean section is the procedure of choice. At an earlier stage, the causative factor should be corrected if possible and the pregnancy be allowed to continue to term. References 2.   Guié P, Adjobi R, N’guessan E, Anongba S, Kouakou F, Boua N, Dia J, Kouyaté S, Tegnan JA, Djanhan L, Bohoussou E, Yao I. Uterine torsion with maternal death: our experience and literature review. Clin Exp Obstet Gynecol 2005; 32(4): 245-6. 4.   Adam GS. Axial rotation of pregnancy. Br Med J I 1940; 808. 6.   Day H: Torsion of the pregnant uterus. N Engl J Med 1985; 213: 605. 8.   Nessitt RE, Coner GW. Torsion of the human pregnant uterus. Obstet Gynaecol Survey 1956; 11: 311. 10.Barozzi J: Manuel de. Gynecologic Pratique, Paris 1907. <![CDATA[Emerging bacterial resistance to antibiotics – fighting a losing battle !]]> J. Ashraful Haq https://imcjms.com/journal_full_text/128 2016-11-06 10:15:20 Editorial Ibrahim Med. Coll. J. 2009; 3(1): i-ii As we approach the end of first decade of 21st century, it is now time to seriously reconsider the hopes and zeal that transpired in the thirties and forties of the last century with the discovery of antimicrobials like sulfa and penicillin. These magic bullets saved millions of lives from deadly infectious agents. However, by the beginning of 1960s, the enthusiasm soon faded away as many of the organisms like Staphylococcus aureus, a gram positive bacterium, became resistant to penicillin due to its capability to produce penicillin destroying enzymes called penicillinase or beta-lactamase. The discovery of penicllinase or beta-lactamse resistant penicillins like methicillin soon outwitted the smart bacteria. But this also did not last long. Staphylococcus aureus started to become resistant to methicillin. The resistance was due to a subtle change in its penicillin binding protein called PBP2a. Today, methicillin resistant S. aureus (MRSA) is a leading cause of hospital acquired infection in all countries of the world including Bangladesh. In a multi-center study involving four divisions of Bangladesh, the rate of isolation of MRSA from hospital patients ranged between 32-63%.1 The trend is alarming. There are not many affordable drugs to treat simple infections with MRSA. The emergence of antibiotic resistance is now widespread and involves both gram positive and a wide range of gram negative organisms. One example is the spread of antibiotic resistance in Salmonella typhi, a gram negative bacterium, responsible for typhoid fever in Bangladesh and in many countries of the world. Typhoid fever was treated by simple antibiotics like ampicillin, cotrimoxazole or chloramphenicol till the mid 1980s. Since then, ciprofloxacin or third generation cephalosporins have been increasingly used in the treatment of typhoid fever in Bangladesh due to development of resistance to earlier drugs.2 Since 1997, treatment failures with ciprofloxacin have slowly started to emerge in Bangladesh and other countries due to infection with nalidixic acid resistant Salmonella typhi or NARST.3-6 NARST has decreased susceptibility to ciprofloxacin. A study conducted in an urban hospital of Bangladesh noted 75% of S. typhi resistant to nalidixic acid vis-a-vis ciprofloxacin.7 Wonder drugs for treating typhoid have now become archaic and the list becomes ever growing. Today, many of the bacteria which were sensitive to and treatable with cephalosporins have become resistant due to production of extended spectrum beta-lactamases (ESBL). The enzyme effectively inactivates all generation of cephalosporins leaving the medical doctors with only few choices of more expensive antibiotics. A study conducted in a referral hospital of Dhaka city has noted 43.2% and 39.5% of E. coli and K. pneumoniae were of ESBL phenotypes respectively.8 The picture is similar in many other countries. Scientists are striving to develop newer drugs to combat the emerging bacterial resistance. Exploitation of quorum sensing phenomena, use of bacteriophage and antimicrobial peptides are few examples. Many strategies have been taken to control the never ending challenges of resistant bacteria. Effective infection control and antibiotic policy are few of them. We must now cautiously prescribe antibiotics particularly, those which are considered as reserve antibiotics for multi-resistant organisms. But the most important of all is not the discovery of new wonder drugs but the prudent and restrained use of antibiotics by the medical community and raising the public awareness regarding the dangers of prolific use of new and costly antibiotics. If we wish to live in a world where bacteria live subjugated to human beings, then we must realize a simple fact – the war against bacteria is far from over. References 2.  Haque Asna SMZ and Haq JA. Decrease of antibiotic resistance in Salmonella typhi isolated from patients attending hospitals of Dhaka City over a 3-year period. International Journal of Antimicrobial Agents 2000; 16: 249-251. 4.  Threlfall EJ, Ward LR, Skinner JA, et al. Ciprofloxacin-resistant Salmonella typhi and treatment failure. Lancet 1999; 353: 1590–1. 6.  Wain J, Hoa NT, Chinh NT, et al. Quinolone-resistant Salmonella typhi in Vietnam: molecular basis of resistance and clinical response to treatment. Clin Infect Dis 1997; 25: 1404–10. 8.  Rahman MM, Haq JA, Hossain MA, Sultana R, Islam F, Islam AHMS. Prevalence of extended-spectrum- b lactamase-producing Escherichia coli and Klebsiella pneumoniae in an urban hospital in Dhaka, Bangladesh, International Journal of Antimicrobial Agents 2004; 24:508-510. <![CDATA[Conicity index of adult Bangladeshi population and their socio-demographic characteristics]]> Meerjady Sabrina Flora CGN Mascie-Taylor Mahmudur Rahman https://imcjms.com/journal_full_text/129 2016-11-06 10:31:15 Original Article Ibrahim Med. Coll. J. 2009; 3(1): 1-8 In spite of acknowledged importance, no unified definition exists for central obesity. Several anthropometric indexes such as waist circumference, waist-hip ratio, waist-to-height ratio, conicity index etc, are being used. Cindex has been shown to correlate well with various cardiovascular risk factors associated with visceral fat accumulation in some population. Data were collected through interviewing and measuring 22,995 adult males and females of an urban (Mirpur, Dhaka City) and rural area (Kaliganj sub-district) in 2002 and 2003. Overall the mean (SD) conicity index was 1.20 (0.10) and 40.8% of this sample had a high Cindex. Females, increasing age, urban residents, Christians, the better educated, married and farmers were more likely to have higher Cindex than their counterparts. There is a scarcity of data about the conicity index of Bangladeshis and this cross-sectional study is the first large-scale attempt. So it can be used as a baseline data for further research in this field. Address for Correspondence: Dr. Meerjady Sabrina Flora, Associate Professor, Department of Epidemiology, National Institute of Preventive and Social Medicine (NIPSOM), Mohakhali, Dhaka. e-mail: flora@citechco.net   Anthropometry is the single most universally applicable, inexpensive, and non-invasive method available to assess the size, proportion, and composition of the human body.1 It is being increasingly recognised that central obesity, rather than general, is likely to coexist with type 2 diabetes and lead to complications including cardiovascular diseases. If abdominal obesity is more predictive of multiple risk factors, it is necessary to determine a suitable and widely accepted parameter for this kind of obesity as Body Mass Index is for general obesity. But in spite of its acknowledged importance, no unified definition exists for central obesity; several anthropometric indexes such as waist circumference (WC), waist-hip ratio (WHR), waist-to-height ratio (WHtR), conicity index (Cindex) etc, are being used.2 There is no universally agreed way of measuring adiposity, nor is it known which measure is the best predictor of cardiovascular disease. BMI, WC, WHR, WHtR, Cindex all are found to associate with cardiovascular risk factors.3 Valdez et al. (1993) proposed that ‘the conicity index (Cindex) seems to be a viable approach to assess abdominal adiposity and its concomitant health risks in large-scale studies.4 Cindex has been shown to correlate well with various cardiovascular risk factors associated with visceral fat accumulation in some population.4,5 Cindex showed the highest correlation with total cholesterol, and low density lipoproteins (LDL) in a study by Yasmin & Mascie-Taylor (2003).3 There was evidence that the central obesity indices, especially Cindex and WHR, are better at discriminating High Coronary Risk (HCR) than of general obesity (BMI). The largest area under the Receiver Operating Characteristics (ROC) curve was found between Cindex and HCR, in males, which was significantly different from other obesity indices. In women, the largest area found under the ROC curve was equally between Cindex, WHR and HCR indices.6 No study, so far, has been conducted to assess the centralobesityofBangladeshipopulationusingconicity index. This study is the first attempt to do so. Materials and Methods Subjects were measured wearing minimal attire. All the equipments were checked regularly to minimise random errors. Height was measured to the nearest 0.1 cm with a specially constructed wooden height stand to which a plastic measuring tape was attached. The subject stood without shoes or head gear (cap, ribbon etc) in an upright posture with their head in the Frankfurt plane. Subjects were asked to keep their heels close together with their hands hanging freely by their side, palms facing inwards. The horizontal blade of the stadiometer was gently placed on the crown of the head to take the measurement. Weight was measured using a bathroom scale accurate to 0.5 kg with the subject wearing minimal attire. The scale was placed on a hard flat surface and the subject was requested to step onto it in bare feet without holding onto anything. The weighing scale was set to zero before every measurement. A flexible plastic tape was used to measure waist circumference, accurate up to the nearest 0.1cm. Waist circumference was measured at the level mid way between the lowest rib margin and the superior iliac crest on the mid-axillary line in a horizontal plane. The subjects stood erect with abdomen relaxed, the arms at the side and feet together and breathing normally. Cindex = Waist Circumference (m)/ [0.109 XÖ {Body weight (kg)/ Height (m)}] The analyses were carried out primarily using the Statistical Package for Social Sciences (SPSS) version 14.0. Statistical tests used to determine the association between exposure and outcome variables included c2 test and Student t-test. A result was considered significant at a p value level <0.05 but given the large sample sizes a more stringent cut-off of p<0.01, or less, was usually used. In addition because a number of statistical tests were conducted, the Bonferroni correction (a/K, where a is the p value & K is the number of tests used) was used. Effects of exposure variables were also assessed after adjusting for other variables by multivariate analyses. Result     Sequential multiple regression analyses were also undertaken to determine the effect of each socio-demographic variable after correcting for all the other socio-demographic variables. The full model was significant (F = 133.3; p<0.001) but only explained 10.8% of the variance in Cindex. After adjustment for the other socio-demographic variables it was found that females, increasing age, urban residents, Christians, the better educated, married and farmers were more likely to have a higher Cindex than their counterparts. Sequential binary logistic regression models were used to test the effect of individual socio-demographic variables, after adjusting for the other variables. Table-3 shows that the likelihood of high Cindex increased with age and better education. Gender was strongly associated with Cindex; females were 7.5 times more likely to have high Cindex than males. High Cindex was more often found in urban residents, married, farmers and business persons. When all the socio-demographic variables were entered into the model they significantly predicted Cindex (c2=4974.2; p<0.001; Nagelkerke R2 = .264) and overall 69.9% and 76.5% of normal Cindex, and 60.4% of high Cindex, were correctly predicted. The forward binary logistic regression revealed sex and age group as the best predictors of Cindex categories. When the analyses were repeated for each sex separately, age was the best predictor of Cindex categories in both sexes, followed by occupation in males and locality in females. Discussion There is a dearth of adult anthropometric data in Bangladesh other than weight and BMI and most nutrition research has focused on under-nutrition, particularly among women and children. To meet the scarcity of data in regard to Cindex of Bangladeshi population, this study was an attempt to measure the level of Cindex and magnitude of central obesity as classified by the Cindex. The study also observed the variation in Cindex statistically with differences in the socio-demographic status of the Bangladeshi population. This could work as a baseline data for further studies. Given the large sample size of this study, particular care was taken when interpreting ‘significant’ results and a more stringent cut-off of p<0.01, or less, was usually used. In addition because a number of statistical tests were conducted, the Bonferroni correction (a/K, where K is the number of tests used) was used to reduce Type I errors. The combination of more stringent p value and correction for the number of test undertaken, lowered the cut-off p value for significance to <0.0014 and most of the p-values were <0.001. The magnitude of the difference for statistically significant results was also considered. For example, with a quantitative (continuous) variable a small difference in means might be significant because the standard errors will be small given these sample sizes. However, for a qualitative variable, much larger differences would be required in a chi-square test because the denominator is the expected value, which would be large. Even so, the primary aim of inferential statistics is to generalize from a sample to a population and so the large sample size used here will more closely approximate to the adult Bangladesh population and the 95% confidence intervals will be small. However, this was a cross-sectional study and is the simplest form of epidemiological study and so the associations discussed later do not indicate causality.14 A survey on medical students of United Kingdom showed that females of South Asian descent had a significantly higher conicity index than females of European descent irrespective of how the groups were compared. This difference in conicity was not significant in the male group as a whole, or when ethnic pairs were matched for body weight or body mass index. Male students of South Asian origin in the top tertile for body weight or body mass index had a significantly greater conicity index than European males in these top tertiles. However, the trend towards higher conicity (i.e. abdominal obesity) in young Asians may help explain the higher incidence of diabetes and cardiovascular disease seen in elderly Asians living in the United Kingdom.7   The authors are indebted to the Department for International Development (DfID), United Kingdom, Board of Graduate Studies, the University of Cambridge, The British Federation of Women Graduates Charitable Foundation, The Charles Wallace Bangladesh Trust, and Churchill College, the University of Cambridge for their support. References 2.   Mamtani MR & Kulkarni HR. Predictive Performance of Anthropometric Indexes of Central Obesity for the Risk of Type 2 Diabetes. Arch Med Res 2005; 36: 581-589. 4.   Valdez R, Seidell JC, Ahn YI & Weiss KM. A New Index of Abdominal Adiposity as an Indicator of Risk for Cardiovascular Disease. A Cross-population Study. Int J Obes 1993; 17: 77-82. 6.   Pitanga FJG & Lessa I. Sensitivity and Specificity of the Conicity Index as a Coronary Risk Predictor among Adults in Salvador, Brazil. Rev Bras Epidemiol 2004; 7: 259-269. 8.   Lohman TG, Roche AF & Martorell R, eds Anthropometric Standardization Reference Manual. Champaign, Illinois: Human Kinetic Books: 1988. 10.World Health Organization. Obesity: Preventing and Managing the Global Epidemic: Report of WHO Consultation. WHO Technical Report Series No. 894. Geneva: WHO 2000. 12.Stevens J & Plankey MW. The Conicity Index (letter). Int J Obes 1993; 17: 727. 14.Cole TJ. Sampling, Study Size, and Power. In: Margetts BM & Nelson M eds. Design Concepts in Nutritional Epidemiology. 2nd ed. UK: Oxford University Press 2004. p.64-86. <![CDATA[Vitamin A concentration in cord and maternal serum and its relation to birth weight]]> Dipi Barua T.A. Chowdhury Ashim Ranjan Barua https://imcjms.com/journal_full_text/130 2016-11-06 10:44:06 Original Article Ibrahim Med. Coll. J. 2009; 3(1): 9-12 Ibrahim Med. Coll. J. 2009; 3(1): 9-12 Key words: LBW, Vitamin A, cord blood, neonates Address for Correspondence: Dr. Dipi Barua, Asstt. Prof. of Gynae & Obstetrics, Holy Family Red Cresent Medical College, Moghbazar, Dhaka   Materials and Methods This prospective randomized study was carried out in Maternity and Child Health Training Institute (MCHTI), Azimpur, Dhaka. The period of study was from January 2000 - July 2002. The study was conducted on 100 pregnant women (gestational age 38 – 40 wks) who visited the hospital for the purpose of delivery. The study included all 100 newborns of those mothers. Only those with single term pregnancy and having a normal delivery and with known gestational age were included in the study. Not included were those with medical diseases, obstetrical complications, and congenital malformations of infants. Mixed venous-arterial cord blood (about 3 ml) from the clamped umbilical cord (placental line), just after delivery (prior to expulsion of placenta) was collected directly into a glass tube. Serum was separated and immediately stored at –200C until Vitamin A level estimation was done. Maternal venous blood was drawn just before delivery and was processed similar to the cord serum. Estimation of Vitamin A was measured by using high performance liquid chromatography (HPLC). Neonate’s weight was taken within 20-30 minutes of delivery. Results It was found that 18% of the neonates had birth weights below 2500 gm and 82% were either 2500 gm or above. Thus majority of the neonates were within the normal range. Table 1 shows the mean (±SE) concentration of Vit A in cord and maternal serum. Cord serum Vit A level was found to be 58.27 ± 1.7µg/dl with a range of 4.93 - 102.04µg/dl, while maternal serum Vit A level was found to be (53.51 ± 1.48) µg/dl with a range of 17.19 – 89.17µg/dl. Table-1: Mean cord and maternal serum Vit A level of study population (n=100). Mean ± SE Cord serum Vit A (µg/dl) 4.93 – 102.04 53.5167 ± 1.4899   Table 2 shows the mean (±SE) concentration of serum Vitamin A level in cord serum by sex. Level of cord serum Vit A was found to be 59.05 ± 2.46µg/dl and 57.54 ± 2.43µg/dl for male and female neonates respectively. No significant sex difference was found in the concentration of cord serum A level. Table 3 shows that neonates having birth weight 2500 gm and above had cord Vitamin A level 57.84 ± 2.06 µg/dl and those with low birth weight i.e. below 2500 gm had 60.18 ± 2.03 µg/dl. No difference in relationship was found between birth weight and the level of Vit A in cord serum. Table 3 also shows that maternal serum Vit A level is 49.40 ± 3.04µg/dl in neonates weighing <2500gm and 54.49 ± 1.6µg/dl in case of neonates weighing 2500 gm or above having no significant difference. Table-2: Cord serum Vit A level of newborn neonates by sex (n=100) Sex Cord serum Vit A level Mean±SE Cord serum 48 4.09–64.02 Cord serum 52 52.64–62.43     Measures Level of Significance ³2500(Normal) 49.40±3.04 NS 60.18±2.03 NS     References 2.   WHO. Commentry on current world health organization used in perinatal statistics. Arch. Dis Child 1986; 61: 711-15. 4.   Khatoon SA. Low birth weight neonates: problem, how to solve it. Bangladesh J Child Health 1991; 15: 92-95. 6.   Shenai JP, Cytil F, Jhaveri A. and Stahlman MT. Plasma Vitamin A and retinol binding protein in premature and term neonates. J. Padiatr 1981;  99: 302-305. 8.   Shah R, Rajalakhsmi R, Bhatt RV, Hazra MN, Patel BC and Swmy NB. Liver store of Vitamin A in human fetuses in relation to gesttional age, fetal size and maternal nutritional status. Br. J. Nutr 1987; 58:       181-189. 10.Howells DV, Hastle F, Rosenberg D, Brown IRF and Brood OG. Investigation of Vitamin A nutrition in pregnant British Asians and their infants. Human nutrition: Clinical Nutrition 1986; 40: 794-800. 12.Bloem MW, Huq N and Matzger H (1994). Vitamin A deficiency among women in the reproductive years; an ignored problem. In: Report of the XVI IVACG meeting, Chiang Rai, Thailand, IVACG Secretariat: Washigton DC, USA, 16. 14.INFS (1983). Nutritional survey of rural Bangladesh. Institute of Nutrition and Food Science. University of Dhaka, Bangladesh. 16.Sikorski R, Paszkowaski T, Milart P, Radomaski T and Szkoda J. Intrapartum levels of trace metals in maternal blood in relation to umbilical cord blood values: lead, iron, copper, zinc. Int. J Gynecol. Obstet 1981; 26: 213-221. 18.Bhatia, BD and Taygi, NK. Birth weight with other fetal anthropometric parameters. Ind. Ped 1984; 21: 833-838. 20.Chowdhury KMM, Sukanta SNI, Rahaman S and Suman NCM. Anthropometry and mode of delivery of newborn neonates in different economic groups and its impact on newborns. Bang. J. Nutr 1991-1992; 5: 43-48. 22.Barua S and Begum R. Birth weight in relationship with the level of Vitamin A and alpha-tocopherol in cord and maternal serum. Growth hormone gene expression. Nature,1989; 339: 231-4. Bangl.J.Nutr 1996; 9(1-2): 41-49. 24.Bedo D, Santisteban P, Aranda A. Retinoic acid regulates growth hormone gene expression. Nature 1989; 339: 231-4. <![CDATA[Effect of gestational homocysteine on fetal growth in Bangladeshi women]]> Farzana Shirin Tahrim Mehdi Md. Mahbubul Alam Ronjon Kumer Nath Md. Mozammel Hoque https://imcjms.com/journal_full_text/131 2016-11-06 13:42:58 Original Article Ibrahim Med. Coll. J. 2009; 3(1): 13-16 Ibrahim Med. Coll. J. 2009; 3(1): 13-16 Keywords: Homocysteine, intrauterine growth restriction, low birth weight, pregnancy. Address for Correspondence: Dr. Farzana Shirin, Assistant Professor, Department of Biochemistry, Khwaja Yunus Ali Medical College, Sirajganj   Although hyperhomocysteinemia may be a sequel to B-vitamin deficiency, it could be due to other causes as well. Unilateral hyperhomocysteinemia with normal vitamin B12 and folic acid status tends to cause IUGR by placental insufficiency whereas hyperhomocysteinemia following B12 and folic acid deficiency appears to be associated with IUGR like a bi-directional saw. Irrespective of B-vitamin status, it is claimed that hyperhomocysteinemia can be treated successfully by B12 and folate supplementation during pregnancy, thereby preventing many cases of IUGR. With this end in view, the present study was designed to evaluate the maternal homocysteine status with respect to neonatal size in Bangladeshi pregnant women. Materials and Methods The present study was conducted in the Dept. of Biochemistry, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh during the period from July 2006 to June 2007. A total of 80 pregnant women in the 3rd trimester were included in the study as subjects. Using ultrasonogram, 50 were included as controls having an appropriate for gestational age (AGA) while 30 were cases of IUGR. The pregnant women suffering from diabetes, malnutrition, eclampsia and preclampsia, hepatic disorder, chronic renal disease, hypothyroidism, chronic illness and the patients taking folic acid and vitamin B12 supplementation were excluded from the study. At 3rd trimester, maternal serum Hcy was estimated by fluorescence polarization immunoassay (FPIA) method by Abott Ax SYM system analyzer.5 At delivery anthropometric measurements such as weight, height and occipital frontal circumference (OFC) were taken from all newborns. Age, body weight and height of the mothers were also recorded. Statistical analyses – The data were analyzed by using SPSS. Unpaired ‘t’ test was done to see the significance between the groups (cases vs. control). Pearson correlation coefficient test was done to see the correlation of serum Hcy concentration with the anthropometric measurements (weight, length and OFC) of newborns at birth. OR (95% CI) was calculated to see the association of maternal serum Hcy concentration with birth weight, birth length and birth OFC of newborn. Results The comparison of characteristics of cases and control groups are shown in Table 1. Both the groups were matched for age, weight and height though they differed in Hcy level. Hcy level was significantly higher in the cases. Table-1: Comparison between case (pregnant with IUGR: n=30) and control (n=50). Case mean ± SD Age (y) 24.88 ± 4.18 56.67 ± 3.11 Height (cm) 150.04 ± 3.74 19.36 ± 7.32         Variables Babies born to controls (n=50) p mean ± SD 2.02 ± 0.22 - 5.75 Height (cm) 48.05 ± 1.44 .000 32.98 ± 1.06 - 9.23 Weight (kg) 3.25 ± 0.42 .000 student’s t-test Table-3: a) Correlations of maternal Hcy with weight, length and OFC of newborn; b) Odds ratio (OR) of Hcy for the same anthropometric variables (n=80). a b Weight 5.23 (1.92-14.23) -.563, <0.01 OFC 3.04 (1.15-8.04) r – correlation coefficient, CI – confidence interval       1.   Blanc A and Wardlaw T. Monitoring low birth weight; an evaluation of international estimates and updated estimation procedure. WHO Bulletin 2005; 83: 178-185. 3.   Sharma VK. Blood lipids in preeclamsia and intrauterine growth restriction. Mphil (Biochemistry) thesis 2006, BSMMU. 5.   Abott laboratories 2004, “3rd generation TSH”, Abott Park, USA. 7.   Yajnik, CS, Deshpands, SS, Panchanadikar, A, Naik, SS, Deshpande, JA, Coyaji, KJ, Caroline, F, and Refsum, H. Meternal total homocysteine concentration and neonatal size in India. Asia pac, J. Clin Nutr 2005; 14: 179-181. 9.   Lindblad B, Zama S, Malik A, Martin H, lkstrom A, Amu S, Holmgren A, and Norman M. Folate, Vitamin B12 and Homocysteine levels in South Asian women with growth retarded fetuses, Acta Obstet. Gynecol. Scand 2005; 84: 1055-1061. 11.Revard CI, Rivard GE, Gauthier R, and Theoret Y. Unexpected relationship between plasma homocystine and intrauterine growth restriction. Clin. Chem 2003; 49(9): 1476-1482. 13.Ronnenberg A, Goldman M, Chen D, Aitken I, and Willett WJ. Preconception homocysteine and B vitamin status and birth outcomes in Chinese women. Am. J. Clin. Nutr, 2002; 76: 1385-1391. 15.Deveris JI, Dekker JA, Hujigens PC, Blomberg BM and Van HP. Hyperhomocysteinemia and protine S deficiency in complicated pregnancies. Br J Obstet Gynaecol 1997;104: 124-154. 17.Leeda M, Riyazi N, Veries J, Jakob C, Gelj H and Dekker G. Effects of folic acid and vitamin B6 supplementation on women with hyperhomocysteinemia and a history of preeclamsia on fetal growth restriction. Am J Obstet and Gynaecol 2005; 179: 135-139. 19.Ureland PM, and Vollset SE. Homocysteine and Folate in pregnancy. Clin. Chem 2004; 50(8): 1293-1295. <![CDATA[Knowledge, attitude and practice regarding hospital delivery among rural married women in northern Bangladesh]]> Nawzia Yasmin Khairul Alam Suman Lahiry Mahmud Hossain Faruquee Tamjida Ahmad https://imcjms.com/journal_full_text/132 2016-11-06 13:47:27 Original Article Ibrahim Med. Coll. J. 2009; 3(1): 17-20 Ibrahim Med. Coll. J. 2009; 3(1): 17-20 Key Words: Knowledge, attitude and practice (KAP), hospital delivery, married women Address for Correspondence: Nawzia Yasmin, Head and Academic Program Director, Department of Public Health, State University of Bangladesh           Variables % 211 Attitude for hospital delivery 100.0 210 Attitude towards vaccination during pregnancy 99.1 208 Married women having knowledge on danger signs 98.1 84 Autonomy in treatment seeking 5.7 11 Hospital delivery considered as sin 0.9 1   Based on principal component analysis (PCS) among the interviewed respondents, 85% had a positive attitude towards hospital delivery and the rest showed a negative attitude towards hospital delivery. Regarding the level of attitude on safe motherhood on different aspects, it was found that, all the respondents had a positive attitude towards importance of ANC and hospital delivery, seeking care after notification of danger sign and vaccination. However, 40% of the respondents did not agree to the presence of male attendants during labor. Most striking finding was that, only 6% had autonomy in health care seeking behavior. Very few opined that hospital delivery is a sin or shameful practice. Table-2. Distribution of the respondents by level of practice on safe motherhood Frequency(n) Registered for health problem   203    No 3.8      Yes 5.2 200 Faced complications at home during delivery   30    No 77.7 17 Trained Birth Attendant at delivery   11    No 8.5 182 Ever practiced ANC   152    No 20.4 16 Vaccination during last pregnancy   150    No 21.3 16 Index birth at hospital   53    No 66.4 18 History of hospital delivery   52    No 66.8 18 Any family member had practice of hospital delivery   113    No 46.4       1.   Bangladesh Demographic and Health Survey Report 2004. 3.   Barbhuiya MA, Hossain S, Hakim MM, Rahman SM. Prevalence of home deliveries and antenatal care coverage in some selected villages. Bangladesh Med Res Counc Bull 2001; 27(1): 19-22. 5.   Khan AK. Obstetric complications: the health care seeking behavior & cost pressure generated from it in rural Bangladesh. Mymensingh Med J 2002; 11(2): 110-2. 7.   Kaartinen L, Diwan V.  Mother and child health care 8.   Brieger WR, Luchok KJ, Eng E, Earp JA. Use of maternity services by pregnant women in a small Nigerian community. Health Care Women Int 1994; 15(2): 101-10. <![CDATA[High prevalence of caesarian sections at a referral hospital in Bangladesh]]> Abdul Latif Bhuiya https://imcjms.com/journal_full_text/133 2016-11-06 13:50:52 Original Article Ibrahim Med. Coll. J. 2009; 3(1): 21-23 Ibrahim Med. Coll. J. 2009; 3(1): 21-23 Keywords: Pregnancy, normal delivery, Caesarean delivery, delivery practices, tertiary hospital. Introduction Of 146 million people living in Bangladesh, 20 per cent are women of reproductive age and maternal mortality is a serious problem in this country. Recognizing the comprehensive nature of package services required for maternal and child care for the development of the reproductive health and safe motherhood, Government is committed to the reduction of maternal mortality in Bangladesh. Efforts are being directed to antenatal care, TT vaccination, identification of high risk pregnancies, TBA training, promotion of safe birth practices and family planning which influences maternal and neonatal mortality. There were several studies that address obstetric problems in Bangladesh, particularly those related to abortions, septic or habitual, and toxemia of pregnancy.1-8 Some reported on forceps delivery. 9,10 Although there are a number of studies on Caesarian deliveries done elsewhere,11-16 there is a dearth of data regarding Caesarian deliveries in Bangladesh. This study looks into the prevalence and practices of deliveries with a focus on Caesarian sections, in a large referral hospital in the capital of the country. Methods and Materials This observational study interviewed and investigated the records of 2714 subjects attending the Postnatal Ward of a referral hospital of Dhaka from August 1994 to March 1995. Data were collected from their registries and clinical history sheets. These history sheets usually maintained detailed clinical information starting from her admission till she got discharged.  Hospital records were utilized for collection of data using a checklist. Patients delivered normally or by Caesarian section were interviewed to gather in-depth data on key variables using a pre-tested semi-structured interview schedule. SPSS/PC+ was used to prepare frequencies and cross-tabulations. Results Table 1 shows the different types of deliveries conducted in different sites with different outcomes of deliveries. Of these participants (n = 2714), 1509 (55.6%) had a history of normal delivery and 1150 (42.4%) underwent Caesarean sections. Very few (1.7%) had other means of delivery and only 0.7% reported to have forceps delivery. The Caesarian delivery for the first baby was 14.1%, which gradually decreased in subsequent deliveries. Table-1: Obstetric histories regarding types, sites and outcomes of deliveries (n=2714)                                     Delivery order Sites of delivery Normal Home Alive First 27 (14.1) 69 (35.9) 14 (7.3) 100 (86.2) 88 (75.9) 103 (88.8) Third 5 (8.6) 11 (19.0) 3 (5.2) 28 (90.3) 22 (71.0) 26 (83.9)     Most of the deliveries, whether normal or Caesarean, were conducted by the trainee doctors (43.6%) and Medical Officers (25.7%) (table 2). Professors and Assistant Professors performed less than 1%. The normal or Caesarean deliveries were assisted mostly by trainee doctors (54.4%), interns (19.0%) and nurses (15.8%); and very few by Medical Officers (8.3%) and Assistant Registrars (2.1%). The neonatal death was very high ranging from 7.3% at first delivery to 16.1% at the fourth one (table not shown). Table-2: Normal or Caesarean deliveries performed by different categories of doctors or nurses n Deliveries assisted by % 1 Registrar 0.4 3 Assistant Registrar 2.1 14 Medical Officer 8.3 93 Trainee doctor (PG) 54.4 129 Intern doctor 19.0 219 Nurse 15.8 41     2     502 Total 100.0       This study was conducted through a research grant from the World Bank through the Bangladesh Medical Research Council (BMRC). References 2.   Begum SF. Surgical treatment of recurrent second trimester abortion: report on 32 cases. Dhaka Med Coll J 1974; 87-90. 4.   Burhanuddin AFM. Interruption of pregnancy by indigenious method. Bang Med J 1973; 2(2): 53-6. 6.   Azim AKMA. Septic abortion in relation to maternal mortality. Bang J Obstet Gynecol 1989; 4(1): 19-25. 8.   Ali SE and Zakaria GM. Management of a case of severe toxaemia of pregnancy. Syl Med Coll J 1979; 19-22. 10.Begum A and Tahera D. Forceps delivery – a critical analysis of indications and complications. Bang J Obstet Gynecol 1990; 5(1): 1-7. 12.Guillemette J and Fraser MD. Differences between obstetricians in caesarian section rates and the management of labour. Br J Obstet Gynecol 1992; 99(2): 105-8. 14.Pridjian G et al. Caesarian: changing the trend. Obstet Gynecol 1991; 77(2): 195-200. 16.Muyder XD and Thiery M. The caesarian delivery rate can be safely reduced in a developing country. Obstet Gynecol 1990 Mar; 75(3) Pt 1: 360-4. 18.Safe Motherhood. Millions of women lack maternity care. Safe Motherhood Newsletter 1994; 14: 1. <![CDATA[Unmet need of contraceptives among eligible couples of urban slum dwellers in Dhaka]]> Shamsun Nahar Farhana Amin https://imcjms.com/journal_full_text/134 2016-11-06 13:56:35 Original Article Ibrahim Med. Coll. J. 2009; 3(1): 24-28 Ibrahim Med. Coll. J. 2009; 3(1): 24-28 Key words: Unmet need, contraceptive, reasons of unmet need Introduction The term unmet contraceptive need is defined as the percentage of currently married women in their reproductive ages who do not want additional children or wanting to postpone child bearing by at least two years and yet are not practicing any contraceptive method.1 This gap between some women’s reproductive intention and their contraceptive behaviour clearly poses a challenge to the ongoing family planning program.Unmet need has generated much interest, both among academics and policy makers over the years. At the international level, the policy makers are unanimous about the usefulness of this concept which has been amply reflected in the following statement of the International Conference on Population and Development “governmental goals for family planning should be defined in terms of unmet needs for information and services.”2, 3 Over the past three decades, Bangladesh has made impressive gains in indicators related to population and family planning.Ever use of any contraceptive method increased five-fold during the past two decades, from 13.6% in 1975 to 69.2% in 1997. The contraceptive prevalence rate (CPR) has increased six-fold, from 8% in the mid-1970s to 58% in 2004.4 Total fertility rate (TFR) dropped by half, from about 6 children per women to about 3 children per woman. However, there is a discrepancy between rural and urban areas, as well as between rich and poor population.5 Around 148 million people live in Bangladesh with majority below the level of poverty.6 Increasing landlessness, underemployment in the rural areas are the main factors to cause constant migration of the rural poor to the urban sector and the percentage of urban population has increased from 8.8 percent in 1974 to 18 percent in 1991.7, 8 With the expansion of the urban centers and increase in the urban population, the number of slums and slum dwellers are rapidly increasing. The slum dwellers are largely the distressed migrants from the rural areas and, more importantly, most of them live below the poverty line. The slum dwellers do not have sufficient access to education, employment and health facilities of the formal sector: The health and nutritional status and contraceptive use of the urban poor are even worse than that of the rural poor. In recent years much attention has been devoted to the replacement of demographic targets by a focus upon unmet needs to raise the contraceptive prevalence above the level inherent in the demographic target.9 Thus, this group of deprived urban slum dwellers become an area of research to find out the unmet contraceptive needs among the eligible couples. Materials and Methods This cross-sectional study was conducted on married women residing in urban slums of Kamrangirchar in Dhaka. Kamrangirchar is adjacent to Dhaka city and has 42 areas (paras/mohollas). Of those four paras: Matborbazar, Munshihati, Parshim Rasulpur, Nobinogor, were purposively selected for the study. Sample size was calculated by using formula n = Z2pq/d2,taking the prevalence rate of unmet need (p=11%),4 the calculated sample size coming to 150. Cluster sampling technique was used to select the sample. Data were collected by face-to-face interview with a pre-tested structured questionnaire, visiting every house in the selected slum areas. As per inclusion criteria a total of 265 eligible couples were found in the cluster. As all were included in the study, the number of sample was more than the calculated sample size. Results     Characteristics %   15 – 19 14.3 74 25 – 29 20.8 98 Respondents age at marriage (yrs)   99 15 – 19 55.8 18 Respondents’ education   84 Sign only 30.6 63 Secondary 11.3 07 Husbands’ education   84 Sign only 31.7 48 Secondary 12.5 16 Respondent’s occupation   197 Labour & garments’ workers 14.4 30 Husbands’ occupation   108 Business 27.5 79 Unemployed 1.9   < 5000 30.9 180 > 10000 1.1   Never pregnant 8.3 61 Twice 18.1 134 Outcome of last pregnancy   223 Still-birth 1.1 10 MR/Abortion 2.6 22   Fig-1. Subgroups of Married Women Reproductive Age (MWRA) Constituting Unmet Need Reasons of unmet need for contraceptiveAbout 35% of the respondents with unmet contraceptive need mentioned not menstruating after last child birth as reason of non-use of any method though they are all beyond the post partum period, about 24% did not specify any reason of unmet need, side effect of past use were 19%, discouraged by husband or other family members were 11%, did not know about any method or did not know where to get contraceptives from were also 11% (Figure 2).       1.   Adam Sonfield. Working to eliminate the world’s unmet need for contraception. Guttmacher Policy Recview 2006; 9: Number-1. 3.   De Graff, D.S. and V. De Silva (1991). Unmet need for contraception in Sri Lanka. International Family Planning Perspectives 17(4): 123-130. 5.   Islam, M.N. and M.M. Islam. Biological and behavioural determinants of fertility in Bangladesh: 1975-1989. Asia-Pacific Pnpulation Journal 1993; 8(1): 318. 7.   Stalker P. A Fork in the Path: Human Development choice for Bangladesh, FAO, ILO, UNDP, UNFPA, WHO, The World Bank Dhaka, 1995. 9.   Mahmud M. Adolescent reproductive behaviour in Bangladesh M.Sc. thesis (unpublished), Department of Statistics, Dhaka University, 1994. 11.Bangladesh Demographic and Health Survey. NIPORT, Mitra and Associates, 1996-1997. 13.Chaudhury, R.H. The influence of female education, labor force participation, and age at marriage on fertility behavior in Bangladesh. Social Biology 1984; 31(1-2): 57-9. <![CDATA[Factors associated with multidrug-resistant tuberculosis]]> Md Nurul Amin Md Anisur Rahman Meerjady Sabrina Flora Md Abul Kalam Azad https://imcjms.com/journal_full_text/135 2016-11-06 14:08:56 Original Article Ibrahim Med. Coll. J. 2009; 3(1): 29-33 This case control study was conducted in selected centers of Dhaka City from March to July 2008 to determine the association of multidrug-resistant tuberculosis with the attributes related to treatment and socio-economic condition of tuberculosis patients. Sixty seven culture-proven multidrug-resistant tuberculosis cases and similar number of age and sex matched controls were selected purposively. Data were collected by face to face interview and documents’ review, using a pre tested structured questionnaire and a checklist. Multidrug-resistance was found to be associated with occupation (p=0.001) and residential status (p=0.001) of the tuberculosis patients. Tuberculosis patients who did not remain under directly observed treatment were 3 times more likely to develop multidrug-resistant tuberculosis (OR 3.21, 95%CI=1.59-6.52). Multidrug-resistance was associated with inadequacy of treatment (OR 2.56, 95%CI=2.03-3.23). Failure of sputum conversion at the end of 2 months of treatment was detected to be the best predictor of multidrug-resistant tuberculosis (OR 11.82, 95% CI=4.61-30.33), followed by treatment with non Directly Observed Treatment Short course regimen and high labor intensive occupations like agriculture, production and transport. The risk factors of multidrug-resistant tuberculosis warrant much improvement in the effective implementation of control programs. Introduction In Bangladesh the number of MDR-TB cases is increasing gradually despite the government’s success in TB treatment by 92% and the detection rate of 72% in 2007. From July 2007 to Feb 2008, 165 cases of MDR TB were detected in the National Institute of Diseases of Chest and Hospital (NIDCH).6 WHO estimated 14% MDR-TB rate among previously treated cases and 1.8% among new cases.7   Sixty seven cases were selected, as defined by WHO5 ‘resistant to the two main first line drugs, Isoniazid andRifampicin’,fromculture-provedMDR-TBpatients admitted in National Institute of Disease of Chest and Hospital (NIDCH). Equal number of age and sex matched controls, the cured patients of TB, as defined by NTP,9 who had been smear-positive initially but became smear negative in the last month of treatment and on at least one previous occasion, were selected from NIDCH and other DOTS centers in Mohakhali, North Badda, Adorsha Nagar and Rampura in Dhaka City. The sample size of 134 was estimated following WHO guideline.10 Data were collected by face to face interview and documents’ review, using a pre tested structured questionnaire and a checklist on background characteristics of the samples, socio-economic data and data related to anti tuberculosis treatment. Ethical clearance was obtained from the Ethical Committee of NIPSOM before data collection. Data were processed and analyzed by SPSS version 12.0. Results Cases and controls were matched for age and sex. No significant difference was observed in marital status, religion, house-type and income level between cases and controls (Table–1). Although initially showed, after Bonferroni correction no significant difference was observed in educational status between cases and controls. Cases and controls significantly differed by their places of residence (p=0.001) and occupational categories (p=0.001). TB patients with high labor intensive occupations like agriculture, production and transport were five times more likely and those who lived in rural areas were fourteen times more likely to develop MDR TB than their counterparts. Table-1: Distribution of the respondents by socio-demographic characteristics       Entering all independent variables together, a logistic regression model was constructed with overall 84% correct prediction. Failure of sputum conversion at the end of 2 months of treatment was detected as the best predictor of MDR TB, followed by treatment with non-DOTS regimen, high labor intensive occupations and lastly non-observation of treatment (Table-3). Table-3: Factors of MDR TB after adjusting for other variables   This study was designed to determine the association of multidrug- resistant tuberculosis with the socio-economic and treatment related factors of TB-patients. In the present study, highest proportion of the MDR TB cases (61.2%) were found to be involved in occupations like agriculture, production and transport. Occupation might have an association with MDR TB (p<0.01). This might be because, these are the occupations where maintenance of a strict, meticulous and long course like TB-treatment seems to be difficult without special motivation.  The study revealed that, failure of sputum conversion at the end of 2 months of treatment was the best predictor of MDR TB. In a study in India in 2000, researchers found that more than half of the patients receiving category II treatment who remained sputum positive after 3 or 4 months of treatment, had MDR TB.17   This study was supported by a grant from Bangladesh Medical Research Council (BMRC). References 2.   Onorato IM, Kent JH and Gastro KG. Epidemiology of tuberculosis. In Tuberculosis. Lutwic kLI (ed). Chapman and Hall Medical. 1st(edin)1995; 3: 20-53. 4.   Biswas MS. Acknowledgement. In: NTP, DGHS. Tuberculosis Control in Bangladesh, TB Annual Report 2007. Dhaka 6.   Arju A.Number of MDR-TB patients on the rise.The Daily New Age 2008; VI(5):19s (col.2-4). 8.   Khalequzzaman M, Younus M, Rahim J, Arifeen SE, Baqui AH, Hossain S, et al. Epidemiology and surveillance of multidrug- resistant tuberculosis in urban and rural areas of Bangladesh.[cited 2008 Mar24]. Http://www.icddrb.org/pub 10.        Lwanga Sk,Lemeshow S. Sample size determination in health studies, A practical Manual. WHO, Geneva 1991; p 9 and 45. 12.Yang BF, Xu B, Jiang WL, Jhou PY, Jiang QW. Study on the epidemiology and determinants of drug resistant tuberculosis in northern rural area of Jiangsu province. Zhonghua Liu Xing Bing Xue Za Zhi 2004; 25(7): 582-5.      Pandey RM, Jain NK, et al. Clinical and genetic risk factors for the development of multidrug-resistant tuberculosis in non-HIV infected patients at a tertiary care center in India: a case control study. Infect Genet Evol 2003; 3(3):183-8. 15.Wells CD, Cegielsky JP, Nelson LJ, Laserson KF, Holtz TH, Finlay A, et al. HIV infection and multidrug-resistant tuberculosis: the perfect storm. J Infect Dis 2007; 196 Suppl 1: S86-107. 17.Santha T, Garg R, Freiden TR, Chandrasekaran V, Subramani R, Gopi PG, et al. Risk factors associated with default, failure and death among tuberculosis patients treated in a DOTS programme in Tiruvallur District, South India, 2000. Int J Tubercle Lung Dis 2003; 7(2): 200-1. <![CDATA[Protein C deficiency in a patient of acute myocardial infarction]]> Tamzeed Ahmed Mahbub Mansur https://imcjms.com/journal_full_text/136 2016-11-06 14:14:53 Clinical Case Report Ibrahim Med. Coll. J. 2009; 3(1): 34-35 Ibrahim Med. Coll. J. 2009; 3(1): 34-35 Key words: myocardial infarction, risk factors, protein C deficiency, anticoagulation. Introduction A small group of patients with myocardial infarction have none of the usual and well defined risk factors. We report a 42-year male patient with acute inferior myocardial infarction who as a risk factor only had a very well controlled blood pressure and in whom recognition of a coagulation defect led to specific preventive measures. Case report In July 2007, a 42-year old male (165 cm, 76 kg) was admitted with an inferior wall myocardial infarction. The patient had never smoked and he did not have diabetes. His blood pressure was well controlled with amlodipine. He did not have any contributory family history, his total cholesterol was in the upper limit of normal range and all other lipids were normal. He was previously diagnosed with hyperuricaemia and was on regular Xanthine Oxidaze inhibitors (i.e. Allupurinol). He did not have any history of renal disease. The patient presented with severe central chest pain with radiation to left forearm for five hours associated with diaphoresis and palpitation. An ECG showed ST segment elevation in leads II, III and aVF with a rise of CK-MB to 534 and Troponin I to 22.74 units. Transthoracic echocardiography showed mild hypokinesis of basal and mid segments of inferior wall with ejection fraction ~ 50%. Accordingly, the patient was thrombolyzed with Streptokinase uneventfully. Coronary angiogram via femoral arterial route showed ectatic epicardial coronary arteries without any flow-limiting stenosis. No femoral venous puncture was done during the angiographic procedure, the patient was kept under observation with LMWH (Enoxaparin), ASA, clopidogrel, statins and Beta Blockers and Ramipril. Three days after the procedure the patient developed stiffness, swelling and tenderness of right leg and thigh with good ADP, PTA and poplitial pulses. Duplex study of both arterial and venous system of right lower limb revealed deep vein thrombosis of right ileofemoral segment without any echo evidence of puncture site bleeding. The patient was given bolus heparin followed by a maintenance dose of 1200 ml/hour, APTT~42 sec, INR~2. A full coagulability testing showed decreased protein C activity of 57% (normal value >70%). FDP and d-dimer was normal. The patient was anticoagulated with wafarin; the symptoms subsided gradually and the patient was discharged with advice for lifelong warfarin therapy (INR~2-3). At follow up, the patient was feeling well, physically active and resumed his duties. Discussion Protein C deficiency is present in approximately 0.2% of the general population. Protein C, a serine protease activated by the thrombin thrombomodulin complex, is part of the infiltrator system of plasma coagulation. Activated protein C exerts a feedback on the intrinsic and extrinsic pathways for inactivation of factors VI and VIIIa in the presence of proteins and phospholipids. It increases fibrinolytic activity, possibly by neutralization of the plasminogen activator inhibitor 1; therefore, deficiency of protein C induces hypercoagulability. The genetic defect is a single point imitation in exon 7 of the protein C gene located on chromosome 2z13-q14.1 There are two classifications of protein C deficiency; type I, resulting from inadequate amount of protein C present (the protein C functions normally but the amount is insufficient to control coagulation cascade) and type II, characterized by defective protein C, where amount is normal, but is unable to interact normally with other factors implied in coagulation to perform its function. Protein C deficiency usually manifests as thrombosis of the venous system. The prevalence of arterial thrombosis in 337 heterozygote was 7.1%. It has been suggested that additional vascular risk factors are required for the involvement of the arterial system. A MEDLINE search revealed three detailed publications on patients with myocardial infarction associated with protein C deficiency2-4 and all these patients had one or more of the other risk factors (smoking, diabetes mellitus, abnormal concentrations of HDL, LDL, fibrinogen, Lp(a) Lipoprotein, as homocysteine). Our patient also had hypertension as a risk factor for coronary artery disease. It may be worthwhile to mention that if the patient did not develop deep vein thrombosis within a few days of the myocardial infarction, the concomitant presence of protein C deficiency might not have been associated with acute myocardial infarction. Our case supports the idea that there is a useful role for measurement of endogenous anticoagulant pathways in assessing patients at risk for arterial thrombosis.5 A detailed medical history is crucial for an accurate diagnosis and effective prevention of further thrombotic events. In contrast to other congenital risk factors, there is an effective treatment for protein C deficiency. Whereas platelet aggregation inhibitors such as aspirin and clopidogrel are ineffective, anticoagulation with warfarin (coumadine) or similar drugs prevents further thrombotic events. References 2.   De Stefano V, Leone G, Micalizzi P, et al. Arterial thrombosis as clinical manifestation of congenital protein C deficiency. Ann Haernatol 1991; 62: 180-183. 4.   Kwio K, Matsuo T, Tai S, et al. Congenital protein C deficiency and myocardial infarction; concomitant factor VII hyperactivity may play a role in the onset of arterial thrombosis. Thrombin Res 1992; 67: 95-103. <![CDATA[Large Cell Neuroendocrine Cancer (LCNEC) of uterine cervix]]> Gehanath Baral Reetu Sharma https://imcjms.com/journal_full_text/137 2016-11-06 14:27:37 Clinical Case Report Ibrahim Med. Coll. J. 2009; 3(1): 36-38 Ibrahim Med. Coll. J. 2009; 3(1): 36-38 Key words: Uterine cervix, neuroendocrine cancer (NEC), human papilloma virus (HPV) Introduction Large cell neuroendocrine carcinoma (LCNEC) of the uterine cervix is a very rare malignancy (less than 5% of all cervical malignancies) that is highly aggressive with unfavorable outcomes.1,2 These tumors have been classified into four categories: small cell, large cell, classic carcinoid, and atypical carcinoid. Most patients with early stage disease develop metastasis. Frequent metastatic sites include the central nervous system, lung, and bone.3 Despite aggressive surgical therapy, even in early-stage patients, mortality is high. This propensity for rapid, local and distant spread in early-stage disease emphasizes the need for systemic treatment.2 In some cases, the initial diagnosis maybe confused with either poorly differentiated squamous- or adeno-carcinomas.3 Case history A 45 year old, grandmultipara, whose last childbirth was 5 years ago, came to ObGyn OPD, for the first time, from a remote area of Nepal, in September 2005. She had a history of irregular bleeding and whitish discharge per vagina since last 6-7 months. She had no other complain. On pelvic examination, there was a growth of 4x4 cm, arising from the posterior lip of the cervix. The growth was soft and bled on touch. Uterine size was normal, no parametrial thickening and no palpable adnexal masses could be palpated. She was advised to have diagnostic biopsy which she declined. She however came back after five months and was advised to undergo biopsy which she denied but opted for a total abdominal hysterectomy with bilateral salpingo-oophorectomy. Part of the parametrium was also excised along with the uterus which looked grossly normal. There was no ascites, no abnormality in abdominal visceras and no palpable lymph nodes. Uterine body, tubes and ovaries looked normal. Post operative period was uneventful. Results Grossly, on cut section, the tumor showed a yellowish white mass located in the posterior lip of cervix, measuring approximately 4 cm in diameter with gray white areas (Figure 1). Tissues were sectioned, stained with hematoxyllin and eosin and evaluated under light microscopy. Sections showed tissue lined by stratified squamous epithelium (Figure 2). Underlying stroma showed a tumor composed of malignant cells arranged in clusters, trabeculae, insular pattern, and solid sheets. The cells showed pallisading at the periphery of the clusters (Figure 3). Clear cleft like retraction spaces were seen around the cell clusters. At some areas the cells were arranged around blood vessels. At several foci the cells formed numerous rosettes and pseudo rosettes (Figure 4). The cells showed moderate cytoplasm with oval to round nuclei with mild pleomorphism and fine to coarse chromatin. Atypical mitotic figures were observed. The criterion used to diagnose the disease entity was, a tumor of the uterine cervix composed of relatively uniform medium to large cells exhibiting neuroendocrine differentiation apparent by light microscopy, as evidenced by trabecular or insular arrangements of the cells, eosinophilic cytoplasmic granules of the type seen in neuroendocrine cells, or both of these features.4 Thus the histopathological diagnosis was “large cell type of neuroendocrine cancer of uterine cervix and surgical margins free of tumor.”   Fig-2. Adjacent stratified squamous epithelium of the ectocervix (10X, hematoxyllin and eosin stain)   Perivascular pseudo rosettes    Discussion Large cell neuroendocrine carcinoma (LCNEC) of the uterine cervix is a rare malignancy that is highly aggressive and usually results in unfavorable outcomes. They are rarely discovered on routine Pap smear due to the submucosal location of the tumor with intact overlying mucosa in its earlier stages. The 5-year survival rate is similar to that of small cell type i.e. 14-39%.5 Early cases are asymptomatic. Usual presentation will be irregular vaginal bleeding,2 postcoital vaginal spotting and sanguineous vaginal discharge. Pelvic examination may reveal either cervical erosion or a cervical growth. It is quite possible that LCNECsare frequently misdiagnosed as poorly differentiated squamouscell carcinomas or poorly differentiated adenocarcinomas, basedupon the identification of focal areas of squamous or glandulardifferentiation, respectively.3,6,7 In such cases, the subtleneuroendocrine features of the large cell neoplasm are easilyoverlooked. In such cases neuroendocrine markers will be of help. Early-stage large cell neuroendocrine tumors of the cervixareag gressiveun likes quamouscell carcinomas. Multimodal therapy should be considered at the time of initial diagnosis. Based on the rarity of cervical neuroendocrine tumors it is difficult to perform large-scale randomized control trials to delineate optimal therapy. Therefore, the basis for treatment of large cell neuroendocrine tumors is derived from therapy for small cell cervical carcinoma and small cell lung carcinoma.2,3 Due to the rarity of this tumor even in pulmonary LCNEC, the incidence, prognosis and optimal treatment remain undetermined.8-10 Large cell neuroendocrine tumors of the cervix are uncommon, and typically the patients have a poor prognosis. Disease recurrences are frequent and distant metastasis is common.2,9 Frequent metastatic sites include the central nervous system, lung and bone. Conclusion Our case study reports that LCNEC may present as a bleeding cervical polyp. It should be interpreted carefully on histopathology so that it is not misdiagnosed as poorly differentiated carcinoma of cervix. Since LCNEC is an aggressive tumor, multimodality treatment is advised for the benefit of the patient to reduce mortality. Acknowledgement   1.   Tsou MH, Tan TD, Cheng SH, Chiou YK. Small cell carcinoma of the uterine cervix with large cell neuroendocrine carcinoma component. Gynecol Oncol 1998; 68(1): 69-72. 3.   Krivak TC, McBroom JW, Sundborg MJ, Crothers B, Parker MF. Large cell neuroendocrine cervical carcinoma: a report of two cases and review of the literature. Gynecol Oncol 2001; 82(1): 187-91. 5.   WHO classification of tumors. Tumors of the Breast and Female Genital Organs. 2003. 7.   Sato Y, Shimamoto T, Amada S, Asada Y, Hayashi T. Large cell neuroendocrine carcinoma of the uterine cervix: a clinicopathological study of six cases. Int J Gynecol Pathol 2003; 22(3): 226-30. 9.   Tangjitgamol S, Manusirivithaya S, Choomchuay N, Leelahakorn S, Thawaramara T, Pataradool K, et al. Paclitaxel and carboplatin for large cell neuroendocrine carcinoma of the uterine cervix. J Obstet Gynaecol Res 2007; 33(2): 218-24. 11.Albores-Saavedra J, Gersell D, Gilks CB, Henson DE, Lindberg G, Santiago H, et al. Terminology of endocrine tumors of the uterine cervix: results of a workshop sponsored by the College of American Pathologists and the National Cancer Institute. Arch Pathol Lab Med 1997; 121(1): 34-9. <![CDATA[Corrigendum]]> https://imcjms.com/journal_full_text/276 2018-01-30 09:41:30 Others In the article “Pattern of musculoskeletal disorders among diabetic patients attending a tertiary care hospital in Dhaka” by Md. Shah Zaman Khan, MA Shakoor, Md. Moyeenuzzaman and Md. Quamrul Islam, published in Ibrahim Med. Coll. J. 2008; 2(2): 65-66, Table-1 contained some mistakes. The printers devil got the upper hand and now stands corrected. The Editor regrets this inadvertent mishap. The text should read — Rheumatoid arthritis was the commonest (2.6%) inflammatory arthropathy while lumber and cervical spondylosis constituted about 37% of all disorders. <![CDATA[AVIAN INFLUENZA A (H5N1) IN BANGLADESH]]> Mamunar Rashid https://imcjms.com/journal_full_text/119 2016-10-31 10:27:52 Editorial Ibrahim Med. Coll. J. 2008; 2(2): i-ii Over the past one year, people of Bangladesh became familiar with the term “bird flu” if not avian influenza. The latter terminology became a buzz word in the literate circle and H5N1 virus was a much talked about topic amongst the medical scientists and public health specialists. The reasons were obvious. News papers reported authoritative sources saying that 152 poultry farms in 47 districts (out of 64) detected presence of bird flu. Hundreds of thousands of chickens were culled by February 2008. People were reluctant to consume chicken as well as eggs and consumption dropped more than 50%. Losses of Taka 5000 crore or more were estimated. With the advent of summer, the threat of the flu petered out but the farm owners were reluctant to invest in a fresh start fearing a return of the virus. This was particularly so for the ‘layers’ which take a longer time to raise. As a consequence, the price of eggs continued to be higher than usual. The overall effect of this was a compromise in the diet, particularly for the children. Their diet remained protein void resulting in a further lowering of their already compromised nutritional status. Avian influenza, or “bird flu”, also called “H5N1 virus” – is an influenza A virus subtype that occurs mainly in birds, being highly contagious (among birds), and deadly to them. H5N1 virus does not usually infect people, but infections with these viruses have occurred in humans. Most of these cases have resulted from people having direct or close contact with H5N1-infected poultry. Influenza viruses are grouped into three types, designated A, B, and C. Only influenza A viruses can cause pandemics. Influenza A viruses have 16 H subtypes and 9 N subtypes. Only some of the viruses of the H5 and H7 subtypes are known to cause the highly pathogenic form of the disease. The current outbreaks of highly pathogenic avian influenza, which began in South-East Asia in mid-2003, are the largest and most severe on record. Never before in the history of this disease have so many countries been simultaneously affected, resulting in the loss of so many birds. The causative agent, the H5N1 virus, has proved to be especially tenacious. Despite the death or destruction of an estimated 150 million birds, the virus is now considered endemic in many parts of Indonesia and Viet Nam and in some parts of Cambodia, China, Thailand, and possibly Laos. Control of the disease in poultry is expected to take several years. The widespread persistence of H5N1 in poultry populations poses two main risks for human health. The first is the risk of direct infection when the virus passes from poultry to humans, resulting in very severe disease. Of the few avian influenza viruses that have crossed the species barrier to infect humans, H5N1 has caused the largest number of cases of severe disease and death in humans. A second risk, of even greater concern, is that the virus – if given enough opportunities – will change into a form that is highly infectious for humans and spreads easily from person to person. Such a change could mark the start of a global outbreak (a pandemic). Direct contact with infected poultry, or surfaces and objects contaminated by their faeces, is presently considered the main route of human infection. To date, most human cases have occurred in rural or periurban areas where many households keep small poultry flocks, which often roam freely, sometimes entering homes or sharing outdoor areas where children play. As many households in Asia depend on poultry for income and food, many families sell or slaughter and consume birds when signs of illness appear in a flock, and this practice has proved difficult to change. Exposure is considered most likely during slaughter, defeathering, butchering, and preparation of poultry for cooking. An important public health issue has been, whether we should advice people to continue consuming chicken. The Government of Bangladesh is rightly promoting the safety in consumption of poultry and eggs. However, certain precautions should be followed. In areas free of the disease, poultry and poultry products can be prepared and consumed as usual with no fear of acquiring infection with the H5N1 virus. In areas experiencing outbreaks, poultry and poultry products can also be safely consumed provided these items are properly cooked and properly handled during food preparation. The H5N1 virus is sensitive to heat. Normal temperatures used for cooking (70oC in all parts of the food) will kill the virus. Consumers need to be sure that all parts of the poultry are fully cooked (no “pink” parts) and that eggs, too, are properly cooked (no “runny” yolks). Avian influenza is not transmitted through cooked food. To date, no evidence indicates that anyone has become infected following the consumption of properly cooked poultry or poultry products, even when these foods were contaminated with the H5N1 virus. The first and only human case in Bangladesh was reported in a 16 month old child. The onset was estimated to be on the 22nd of January, 2008. A chicken was bought from a nearby retail poultry shop who in turn imported it from a HPAI H5N1 endemic area despite a ban on inter district movement of poultry. The child reportedly played with the live chicken before being slaughtered by the child’s mother. The child was detected with the virus as a part of the population based surveillance on H5N1 in urban Dhaka (Kamlapur) and later confirmed from CDC, Atlanta. Luckily the child survived. The H5N1 virus that has caused human illness and death in Asia is resistant to amantadine and rimantadine, two antiviral medications commonly used for influenza. Two other antiviral medications, oseltamivir (commercially known as Tamiflu) and zanamivir (commercially known as Relenza) would probably work to treat influenza caused by H5N1 virus, but additional studies still need to be done to demonstrate their effectiveness. Preventive measures, including modernization of poultry farms with support from Government, and creating awareness amongst the masses should go a long way in tackling this grave situation. <![CDATA[Effects of methanol extract of Piper chaba stem bark on chronic inflammation in rats]]> Fouzia Begum Kamal Uddin Syeeda Sultana Abul Hasnat Ferdous Zinnat Ara Begum https://imcjms.com/journal_full_text/19 2016-08-02 08:20:31 Original Article Ibrahim Med. Coll. J. 2008; 2(2): 37-39 Piper chaba Hunter (Piperaceae), a climbing glabrous shrub grows in plenty in southern Bangladesh. Popularly known as ‘Choi’ it is used as spices and believed to have medicinal value in a wide variety of disease conditions including arthritis, asthma, bronchitis and piles. Earlier studies on methanol extract of Piper chaba stem bark have reported anti-inflammatory activities against acute inflammation. In the present study, effect of methanol extract of Piper chaba stem bark on chronic inflammation has been reported. The anti-inflammatory effect was studied in rats using cotton pellet implantation method, where granuloma formation was used as an index of chronic inflammation. Ibrahim Med. Coll. J. 2008; 2(2): 37-39 Address for Correspondence: Dr. Fouzia Begum, Lecturer, Department of Pharmacology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbagh, Dhaka-1000 Introduction Considering its reported anti-inflammatory properties and availability in our country, the present study was undertaken to evaluate the anti-inflammatory effect of methanol extract of Piper chaba stem bark, compared to steroidal and non-steroidal anti-inflammatory agents in case of chronic inflammation in rats. Materials and Methods 30 Long Evan Norwegian rats of either sex, weighing between 150-200g were kept under standard conditions of light and temperature, fed with animal pellets and allowed to drink water ad libitum.   The dry weight of the granuloma as measured by the formula CPW2 – CPW1 was 24.2 mg ± 0.08 mg for the control group, while those of methanol extract of Piper chaba (125 mg/kg b.w.), methanol extract of Piper chaba (250 mg/kg b.w.), aspirin (100 mg/kg b.w.) and hydrocortisone (2 mg/kg b.w.) treated groups were 18.3 ± 0.20, 17.5 ± 0.28, 14.3 ± 0.18, 10.49 ± 0.17 mg respectively. The differences compared to the control group in the dry weight of granuloma were statistically significant (Table 1). Compared to control group, the percent inhibition of granuloma formation with methanol extracts of Piper chaba (125 mg and 250 mg/kg b.w.), aspirin and hydrocortisone treated groups were 25, 28, 41 and 58 respectively. The percent inhibition with methanol extracts of Piper chaba (25% and 28%) was comparatively less than that of aspirin (41%) and hydrocortisone (58%) (Table 1). Table-1: Anti-inflammatory effects of Piper chaba extracts, aspirin and hydrocortisone on cotton pellet induced granuloma in rat. weight of cotton pellet (CPW1 in mg) mean±s.e.m. Increment of cotton pellet (CPW2-CPW1 in mg) mean ± s.e.m. Group-I (Control) 46.22 ± 0.18   20.00 ± 0.018 18.3 ± 0.20* Group-III (Piper chaba extract 250 mg/kg b.w.) 37.53 ± 0.20 28 20.00 ± 0.018 14.3 ± 0.18*** Group- V (hydrocortisone 2 mg/kg b.w.) 30.37 ± 0.18 58 * P< 0.05 in a test of significance difference from control. *** P < 0.001 in a test of significance difference from control. Discussion Earlier studies showed a significant anti-inflammatory effect of methanol extract of Piper chaba stem bark in case of acute inflammation.6 However, no report is available in case of chronic inflammation. The results suggest that Piper chaba stem bark possess mild to moderate anti-inflammatory effect compared to aspirin and hydrocortisone in case of chronic inflammation. However, further studies should be carried out to isolate the active principle and to evaluate further its dynamics, kinetics and safety profile before it can be recommended for clinical use.   1.  Kirtikar KR, Basu BD. Indian Medicinal Plants,        Piper chaba. International Book Distributors 1987; 3: 2130-2131. 3.  Yusuf M, Chowdhury JU, Begum DJ, Medicinal Plants of Bangladesh, Bangladesh Council of Scientific and Industrial Research, Dhaka, Bangladesh, 1994;192. 5.  Morikawa T, Matsuda H, Yamaguchi I, Pongpiriyadacha Y, Yoshikawa M. New amides and gastroprotective constituents from the fruit of Piper chaba. Planta Medica 2004; 70: 152-159. 7.  Gupta KC, Rupawalla EN and Sheth UK. Anti-inflammatory and other pharmacological studies of N-b (3, 4-dimethoxyphenylethyl) anthramilic acid (RH-15): a non-steroidal anti-inflammatory agent. Indian J Med Res 1970; 58: 110-118. 9.  Robbins SL and Cotran RS –Ed. Acute and chronic inflammation: Pathologic basis of disease. 7th Ed. Reed Elsevier India Private Limited. 2004; 48-86. <![CDATA[Detection of Enteropathogenic Escherichia Coli (EPEC) by serotyping and cell adhesion assay among children in north-eastern peninsular Malaysia–a hospital based study]]> J Ashraful Haq Hin Choon Li Rosliza Abdur Rahman https://imcjms.com/journal_full_text/120 2016-10-31 10:37:33 Original Article Ibrahim Med. Coll. J. 2008; 2(2): 40-43 Ibrahim Med. Coll. J. 2008; 2(2): 40-43 Key Words: EPEC, diarrhea, serotyping, Malaysia Introduction Enteropathogenic Escherichia coli (EPEC) is a leading cause of acute diarrhea among children in developing countries. It accounts for about 7-23% of all diarrhea pathogens.1-4 EPEC attaches to the brush border of the mucous membrane of the small intestine in a characteristic manner, producing ultra structural changes known as attachment effacement (AE) lesions.5 The AE lesion is mediated by intimate attachment of bacteria to the apical enterocyte causing localized destruction of brush border microvilli and perhaps thereby mediating increased secretion.3 The laboratory counterpart of muscosal colonization is adherence of EPEC to cells such as HEp-2 and HeLa cells. E. coli exhibiting localized adherence (LA), diffuse adherence (DA), aggregative adherence (AA) and localized adherence-like (LAL) patterns with HEp-2 or HeLa cells has been implicated as diarrhreal pathogens.6,7 Among the three phenotypes, LA is highly correlated with classic EPEC serotypes. However, studies have demonstrated that E. coli exhibiting DA pattern should be considered enteropathogenic as 38.2% of isolated E. coli from diarrhea cases exhibited DA in HEp-2 cell compared to 8-9% of controls.2 Fluorescence actin staining (FAS) test was reported for the identification of E. coli causing the AE lesion.8 Recently, it has been shown that cortactin isnecessary for organizing actin pedestals in responseto EPEC in HeLa cells.9   Study population Stools or rectal swabs were obtained from children below 5 years of age attending HUSM with acute diarrhea. HUSM is located in Kota Bharu, Kelantan, the northeastern state of Malaysia. Acute diarrhea was defined as four or more loose stools a day, with or without abdominal pain and fever for at least one day. The duration of the episode should be less than ten days.10 Age matched healthy children without history of diarrhea one month prior to the date of enrollment in the study was included as control. Microbiological methods   In this study, 60 stool samples or rectal swabs were collected from children with acute diarrhea while 16 samples were taken from age matched healthy children without diarrhea as control. Out of 60 diarrhea cases, 36 (60%) were below 2 years of age. EPEC serotype was isolated from 14 (23.3%) diarrhea cases by serotyping (Table 1). Nine different serotypes of EPEC were isolated and the most prevalent strain was 0125:K70 by serotyping (28.57%). Only one EPEC (6.25%) was isolated from healthy control children. Table-1:  Rate of isolation of EPEC from diarrhea cases (n=60) by serotyping Total  No. positive (%) No. positive 5 (8.3) 0111:K58(B5) O126:K71(B16) 1 2 6 (10.0) O125:K70(B15) 1 1 3 (5.0) O124:K72(B17) 2 14 (23.3)   Note:  Only one EPEC was detected out of 16 control subjects (6.25%) by EPEC antisera (Polyvalent 4)   Table 2 shows the results of HeLa and HEp-2 cell adhesion assay of E. coli isolated from diarrhea and control cases. Out of 60 diarrhea cases, 30.0% and 26.6% showed one or other adherence pattern with HeLa and HEp-2 cells assay respectively. The comparative figures for the control were only 12.5% and 6.25% respectively. Diffuse adherence (DA) pattern was predominant in both HeLa and HEp-2 cell assay systems. Out of total strains positive by cell adherence assay, 81.25% and 88.88% exhibited DA pattern by HEp-2 and HeLa cell respectively. Table-2: Results of HeLa and HEp-2 cell adhesion assay of E. coli isolated from diarrheal and control cases Diarrhea cases(n=60) No.positive in HEp-2 cells (%) No.positive in HEp-2 cells (%) Diffuse adherence 16 (26.66) 2 1 (1.66) 0 Aggregative adherence 1 (1.66) 0 16 (26.66) 1 (6.25)   Table 3 shows that about 44.0% of E. coli that was positive in cell adherence assay was negative by EPEC antisera. The single EPEC isolated from control case did not show any adherence pattern with HeLa or HEp-2 cells assay. Table-3: Relationship of cell adherence assay and serotyping by EPEC antisera Total Positive No. Positive by EPEC antisera (%) HEp-2 Cells 9 (56.3) HeLa Cells 10 (55.6)              were negative by HEp-2 and HeLa cell assays respectively.     1.    Levine MM. Escherichia coli that cause diarrhea: enterotoxigenic, enteroinvasive, enterohaemorrhagic, and enteroadherent. J Infect Dis 1987; 155: 377-389. 3.    NM Thielman: Enteric Escherichia coli infections. Current Opinion in Infectious Disease 1994; 7:        582-591. 5.    Echeverria PK, Serichantalerg O, Changchawalit S, Baudy B, Levine MM, Orskov F, Orskov I. Tissue culture adherent Escherichia coli in infantile diarrhea. J Infect Dis 1992; 165: 141-143. 7.    Nataro JP, Kaper JB. Diarrheogenic Escherichia coli. Clinical Microbiology Review 1998; 11: 142-201. 9.    Vlademir V, Cantarelli A, Takahashi I, Yanagihara Y, Akeda K, Imura T, Kodama G, Kono Y, et al. Cortactin is necessary for f-actin accumulation in pedestal structures induced by enteropathogenic Escherichia coli infection. Infection and Immunity 2002; 70: 2206-2209. 11.  Edward PR, Ewings WH. Identification of enterobacteriacae, 3rd edition. Minneapolis, Burgess Publishing Co. 1972. 13.  Kaper JB. Defining EPEC. Review of Microbiology 1996; 27:130-133. 15.  Gomes TAT, Blake PA, Trabulsi LR. Prevalence of Eschericia coli strains with localized, diffuse and aggregative adherence to HeLa cells in infants with diarrhea and matched controls. J Clin Microbiology 1989; 27: 266-269. <![CDATA[Prevalence of metabolic syndrome in three urban communities of Dhaka city]]> Shurovi Sayeed Akhter Banu Parvin Akter Khanam Sharmina Alauddin Sabrina Makbul Tanjima Begum H Maahtab M Abu Sayeed https://imcjms.com/journal_full_text/21 2016-08-02 08:24:56 Original Article Ibrahim Med. Coll. J. 2008; 2(2): 44-48 Bangladeshis are prone to develop type 2 diabetes mellitus (T2DM), hypertension (sHTN and dHTN) and atherosclerotic heart diseases, observed more predominantly in the urban population. Though metabolic syndrome (MetS) is a related disorder, there are few studies in this regard. The prevalence of obesity, T2DM and MetS in three urban communities of Bangladesh were addressed in this study. Nine hundred non-slum urban households in three Dhaka City Wards were randomly selected. One member (age ³ 25y) from each household was invited for investigation with an overnight fast. Socio-demographic information as well as height, weight, waist-girth, hip-girth and blood pressure were measured. Fasting plasma glucose (FPG), total cholesterol (chol), triglycerides (TG) and high-density lipoproteins-c (HDL) were estimated. A total of 705 (m / f = 239 / 466) subjects volunteered for the study. The mean value with 95% confidence interval (CI) of age was 42.4 (40.9 – 43.1) years for men and 37.8 (36.8 – 38.7) for women. The mean (CI) body mass index (BMI) was 21.0 (20.6 – 21.5) and 22.6 (22.2 – 22.9) and waist hip ratio (WHR) was 0.84 (0.83 – 0.84) and 0.82 (0.81 – 0.83), respectively for men and women. The mean (CI) FPG (fasting plasma glucose) was 5.5 (5.2 – 5.7) for men and 5.2 (5.0 – 5.4) for women. The prevalence of obesity (BMI ³ 25.0) was 21%, T2DM (FPG ³ 6.1 mmol/l) was 22.2%, triglyceridemia (TG ³ 150mg/dl) was 45.1% and low HDL-c (HDL<40mg/dl) was 43.8%. The crude prevalence of MetS varied based on different cluster combinations, being the lowest (0.3%) recommended by WHO cluster (FPG + BMI + SBP/DBP) and the highest (8.7%) by International Diabetes Federation (IDF) cluster (waist + FPG + HDL). The MetS was found higher in male than female by NCEP criteria and higher in female than male by IDF criteria. The study revealed an increased prevalence of obesity, T2DM and MetS in the urban communities. It also revealed that T2DM and MetS are moderately common and of growing healthcare burden in the rapidly growing urban population. Additionally, the study observed the wide ranging prevalence rates of MetS in the same study population indicating the need to establish a consistent and useful MetS-cluster depending on population characteristics. Introduction   The study was conducted from October 2004 to February 2005. Three City Corporation Wards (CCW) of Dhaka City were purposively selected. Each CCW has its own household (HH) number. Three hundred HHs were randomly selected from each CCW. Thus, in 3 CCWs 900 HHs were selected for this study. One member who attained the age of 25 years was enlisted from each HH as an eligible participant. The enlisted member was then informed about the objectives and procedural details of the study. Informed consent was taken and invited to volunteer for the study. The willing participant was advised to attend a nearby site in the next morning with an overnight (~12h) fast for investigation. The investigation included interviewing (education, occupation, income and clinical history), anthropometry (height, weight, waist- and hip-circumference), systolic and diastolic blood pressure (SBP & DBP) and biochemical tests like fasting plasma glucose (FPG), total cholesterol (Chol), triglycerides (TG) and high-density lipoprotein-cholesterol       (HDL-c).   The prevalence rates of diabetes, hypertension, obesity and metabolic syndrome were given in percentages. The characteristics were shown in mean with 95% confidence interval (CI) separately for men and women. Simultaneously, unpaired t-test was used to show comparison of characteristics between male and female subjects. The associations between MetS and risk variables like social class, sex, physical activities were determined by Chi-sq test. SPSS 11.5 was used for all statistical analysis. The level of significance was accepted at 0.05 level. Results The characteristics of both male and female participants are shown in table 1. The mean value of each characteristic with 95% confidence interval (CI) is given separately for either sex. The comparisons between sexes are also shown. The mean values (95% CI) for age, height, weight, WHR and TG were significantly higher in male than female; whereas BMI, HDL-c and LDL-c were significantly higher in female than male subjects. Fasting plasma glucose and blood pressure did not differ. Table-1: Comparison of characteristics between male and female participants       Diabetes – The prevalence of IFG was 9.1% and T2DM was 21.1%. Compared with the female, the male subjects had significantly higher prevalence of T2DM (p=0.02) and triglyceridemia (p=0.01).     The prevalence of MetS (WHO criteria) was significantly higher among the higher social class than among the lower and middle social class (8.0 v. 1.8%, p<0.001). It was also higher among those with sedentary habits than among those with regular physical activity (4.3 v. 1.1%, p<0.02). There was no significant difference of prevalence between male and female participants. As regards physical activity there was no difference between those with and without brisk walking of less than 15 min; and also between those with and without leisurely walking of less than 30 min. Discussion The study revealed that the prevalence of obesity (BMI>25) almost equals the prevalence of thinness (20.9 v. 17.7%). This indicates that both extremes of nutritional problems coexist in the heterogeneous urban dwellers. Interestingly, obesity was more prevalent among women and thinness among men. It is not clear why the females are more obese than males. This may be due to an occupational hazard as more than 80% of the female participants were housewives. Culturally and traditionally housewives are confined to the house and have less opportunity for outdoor walking or exercise. Their lifestyle may contribute to obesity. On the other hand, the thinness (BMI<18.5) was more prevalent among the male participants of the low and middle social class. Obviously, this may be attributed to their nutritional deficiency with respect to their energy requirement. As already mentioned, the prevalence of MetS varied (0.3 to 8.7%) depending on the different diagnostic criteria. The variation of prevalence rates were also reported by several studies.10-12 Considering the prevalence of MetS found in Greece13 and in African Americans14 Bangladeshis had a lower prevalence. Hoang et al.12 rightly pointed out that the East Asians have a lower prevalence than that of Caucasians. Though general obesity and central obesity was not very marked (table-1), the level of TG was very high and HDL-c was very low in the study population. This was also observed by Zaman et al.9 This indicates that dyslipidemia is one of the important components that should be addressed while measuring the risk factors. Conclusions   We are grateful to BIRDEM authority for providing the logistics and the laboratory facilities. We are thankful to the social leaders of Azimpur, New Market and Mughda for their active cooperation. We are indebted to the local volunteers and participants who helped us in every step of the investigation. References 2.  James WP. The epidemiology of obesity: the size of the problem. J Intern Med 2008; 263(4): 336-52. 4.  Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006; 3(11): e 442. 6.  Amuna P, Zotor FB. Epidemiological and nutrition transition in developing countries: impact on human health and development. Proc Nutr Soc 2008; 67(1): 82-90. 8.  Erem C, Hacýhasanoglu A, Deger O, Topbaº M, Hosver I, Ersoz HO, Can G. Prevalence of metabolic syndrome and associated risk factors among Turkish adults: Trabzon MetS study. Endocrine 2008 Mar 13 [Epub ahead of print]. 10.Bhopal R, Fischbacher C, Vartiainen E, Unwin N, White M, Alberti G. Predicted and observed cardiovascular disease in South Asians: application of FINRISK, Framingham and SCORE models to Newcastle Heart Project data. J Public Health (Oxf). 2005; 27(1): 93-100 12.Hoang KC, Le TV, Wong ND. The metabolic syndrome in East Asians. J Cardiometab Syndr. 2007; 2(4): 276-82. 14.Taylor H, Liu J, Wilson G, Golden SH, Crook E, Brunson CD, Steffes M, Johnson WD, Sung JH. Distinct Component Profiles and High Risk among African Americans with the Metabolic Syndrome: The Jackson Heart Study. Diabetes Care 2008; Mar 10. <![CDATA[Socio-cultural determinants of contraceptive use among rural women aged 15-29 years from marriage to first live birth]]> Amir Mohammad Sayem Housne Ara Begum https://imcjms.com/journal_full_text/121 2016-10-31 11:28:26 Original Article Ibrahim Med. Coll. J. 2008; 2(2): 49-54 Contraceptive prevalence rate (CPR) is lower while the fertility is higher among rural married women aged 15-29 in Bangladesh. Thus, this comparative study attempted to identify the socio-economic and cultural determinants of contraceptive use in different rural settings. In this primary data based cross sectional study, a  semi-structured questionnaire was applied to women aged 15-29 years in two rural areas who had at least one live birth on/before 20 December, 2006. The study areas were identified by multi-stage random sampling technique. Results showed that CPR was slightly higher in Dariadaulat (43.4%) than that of Chardigoldi union (41.6%) while the mean duration of use was slightly higher in Chardigoldi compared to Dariadaulat (5.04 v. 4.59 mo). Regression model for Dariadaulat (38.7% with P<0.001) better explained the use of contraception than that of Chardigoldi (30.0% with P<0.001). Among the determinants in Dariadaulat the most explanatory variable was mass media exposure (15.8%) while it was desired number of children in Chardigoldi (12.6%). Among others, joint decision of using contraception, familiarity with contraceptives before marriage, desired number of children, electricity, family interference and family size were found to have significant impact in Dariadaulat. On the other hand, the other explanatory variables in Chardigoldi were joint decision of using contraception, family interference and familiarity with contraceptives before marriage and age at present. It may be concluded that the CPR is markedly low in rural communities. The lack of accessibility to mass media, lack of joint decision with husband, premarital unawareness regarding contraceptive use, lack of post-marital planning and family interference are major contributory factors for the low CPR in the study population. Address for Correspondence: Dr. Housne Ara Begum, Assistant Professor, Institute of Health Economics, University of Dhaka, Dhaka 1000, Bangladesh, e-mail: drhousne@gmail.com   In spite of various socio-economic challenges, Bangladesh National Family Planning Programme has made remarkable strides toward a higher quality of life for its people. One substantial improvement is the increased contraceptive prevalence rate (CPR) from 7.7 percent in 1975 to 55.8 percent in 2007.1 During the same period, the total fertility rate (TFR) has declined from 6.3 to 2.7 births per woman. Different studies have shown that higher contraceptive use is associated with decreasing fertility.2-5   The primary data for this study was collected from women in two rural areas of Bangladesh. Study areas were identified through multi-stage random sampling technique. Two districts such as Brammanbaria and Narshingdi were selected from respectively Chittagong and Dhaka division and then two thanas namely Bancharampur and Narshingdi were chosen. At the final stage, one union from each thana was selected as study area (Dariadaulat from Bancharampur and Chordigoldi from Narshingdi). The subjects of this cross sectional survey were women within 15-29 years of age who had at least one live birth before December 20, 2006. From each union 250 eligible women were successfully interviewed with a structured questionnaire. Y= a + b1*X1…………………+ bk* Xk + e Y    =   dependent variable b    =   the regression coefficient K    =   end number of the series   Use of Contraceptives     Table 1 presents the results of bi-variate analysis of months of contraceptive use among women in two areas by different socio-economic, demographic and cultural factors. Duration of schooling was found to be positively associated with longer duration of use. The women aged 19 years or greater were found to use contraceptives for a longer period in both areas. The women with the facility of electricity, mass media exposure and smaller family size used contraceptives for a longer period in Dariadaulat than that observed in Chardigoldi (P<.01). Table-1: Mean comparison of contraceptive use in months among rural women aged 15-29 in Dariadaulat and Chardigoldi union     In order to identify the socio-economic, demographic and cultural determinants of months of contraceptive use, simple linear regression technique was used. Two separate models were analyzed for two regions. Variables significant at bi-variate analysis were included into the regression model. Between the models, model for Dariadaulat (38.7%) explained higher variation than that of Chardigoldi (30.0%).     Women with familiarity with contraception before marriage, electricity and larger family size were found to use contraceptive for longer time and respectively explained 6.1%, 2.2% and 1.6% variation. As expected, women’s desired number of children and family interference were found to have negative impact. Women with family interference and larger number of desiredchildrenwerelesslikely tousecontraceptive.     Women with familiarity with contraception before marriage and age at present were, similar to the model for Dariadaulat, found to have positively significant impact on months of contraceptive use. Family interference explained 5.1% of variation in month of contraceptive use. Similar to Dariadaulat, family interference in this model also indicates that women with such pressure were less likely to use contraceptive. Discussion It was found that promotion of family planning through radio or television can be an important means of raising awareness, improving knowledge and stimulating the use of modern contraceptive methods.6-8 However, mass media exposure had no universal impact on use of contraception in this study. But in Dariadaulat union, the impact of mass media showed significant explanatory power in determining the use of contraception since marriage to first live birth. Electricity provides the ground to utilize the mass media which is the access of rural people to the outer world. The electricity in this study was found to have significant positive impact on months of use of contraception only in Dariadaulat. This may be due to that in Dariadaulat union the household electricity was more prevalent than that of Chardigoldi union. Bangladesh is a traditional patriarchal society where women are expected to be guided by their husband’s decision in every sphere of life. Therefore, it is expected that husband’s approval or disapproval determines the use of contraception by women in Bangladesh. However, in this study joint decision by husband and wife for using contraception was found to have significant positive impact on use of contraception in both areas which is similar to a study in Nepal.10 It is evident from the study that women aged 15-29 yrs were less likely to use contraceptives since marriage to first live birth in the study population. Moreover, mean months of use was also very low. However, an increase of CPR may be possible to a significant level if different socio-economic and cultural determinants are considered within the planned program.   1.  National Institute of Population Research and Training (NIPORT), Mitra Associates Measures DHS, 2007. Ministry of Health and Family Welfare, Macro International, Calverton, Maryland, USA (2007). Bangladesh Demographic and Health Survey, Preliminary Report 2007. 3.  Mauldin W Segal. Prevalence of contraceptive use in developing countries: A Chart Book. Rockefeller Foundation: New York, United Nations, 1986. 5.  Frank O, Bongaarts J. Behavioural and biological determinants of fertility transition in Sub-Saharan Africa. Stat Med 1991; 10(2): 161-75. 7.  Olaleye DO, Bankole A. The Impact of mass media family planning promotion on contraceptive behaviour of women in Ghana. Pop Res Pol Rev 1994; 13:         161-177. 9.  Islam M, Kane TT, Khuda B, Reza MM, Hossain MB. Determinants of contraceptive use among married teenage women and newlywed couples. ICDDR,B, 1998 (Work. Pap. no. 117). <![CDATA[Patients’ satisfaction of health care services provided at out patient department of Dhaka medical college hospital]]> Md. Ziaul Islam Md. Abdul Jabbar https://imcjms.com/journal_full_text/122 2016-10-31 11:33:24 Original Article Ibrahim Med. Coll. J. 2008; 2(2): 55-57 Ibrahim Med. Coll. J. 2008; 2(2): 55-57 Key Words: Patients’ satisfaction, OPD services, socio-economic variables, DMCH Introduction Studies on patients’ satisfaction have been recognized as ways to identify priorities and problems of health care services. Patients’ satisfaction increases accessibility to health care, which enhance its efficient utilization.1 Attitude and behavior of providers, adequate drug supply, diagnostic and waiting room facilities influence patients’ satisfaction.2,3 Patient’s satisfaction of public health care services continues to remain low despite tangible progress made in the development of health services of Bangladesh.2 Survey on Health and Population Sector Program (1998-2003) showed that the rate of satisfied service users of public health facilities decreased from 66% in 2000 to 56% in 2003.4 Studies on patients’ satisfaction help policy makers to find out the pitfalls of health care delivery system and formulate strategies accordingly.6 Dhaka Medical College Hospital (DMCH) is a tertiary level public health care facility of the country and around 900 patients visit its OPD everyday.5 This study was designed to assess patients’ satisfaction regarding OPD services of DMCH. Materials and Methods This descriptive cross sectional study was conducted for a period of 6 months from November 2005 to April 2006 at three (Medicine, Surgery and Gynae & Obstetrics) outpatients Departments of Dhaka Medical College Hospital. 299 patients were selected by systematic random sample technique. The patients were interviewed face to face at the exit point after taking informed consent using a semi structured questionnaire. The level of patients’ satisfaction was graded on a four-point scale – excellent, good, fair and poor. Data was analysed with the help of SPSS software (version 13.0). Results Majority of the patients was male (54.85%) with mean age of 35.79±11.29 years, married (75.92%) with a family size of 5-7; (5.66 ±SD 1.98), of education level from illiterate to below SSC (71.91%) and from lower (46.44%, monthly income range: Tk 2000-5000) and lower middle (38.20%, monthly income range: Tk 5001-1000) income group. Majority of the patients visited OPD with medical (53.18%), followed by surgical (26.76%) and gynaecological (20.06%) problems. The main reasons for choosing DMCH were effective (32.78%), free (24.41) and/or low cost (18.73%) treatment. There was long waiting time (31.74 ±SD 3.74). However, majority (81.14%) of the patients expressed satisfaction (ranging from fair to good) with respect to adequacy of space, sitting arrangement and cleanliness of the waiting rooms, but were dissatisfied (75.31%) with respect to toilet facilities and supply of drinking water (Table-1). Majority (74.90%) of patients were satisfied (ranging from fair to good) with OPD staffs with respect to their availability and readiness to register and make appointment with doctors, but most (41.06%) were dissatisfied with respect to their willingness to listen with compassion and reassure the patients with their problems (Table-1). Table-1: Patients’ satisfaction regarding different aspects of waiting room and helpfulness of OPD staff Level of patients’ satisfaction Good % Poor % 3.01 40.46 Cleanliness 50.17 10.70 3.68 38.46 Adjacent toilet facilities 8.92 71.00 1.33 11.00 Different aspects of helpfulness of OPD staff     2.69 35.91 Readiness to register and make appointment with doctors 37.46 27.56 1.38 29.66 Willingness to help and reassure patients about their problem 24.21 43.86     1.  Rudzick AEF. Examining health equity through satisfaction and confidence of patients in primary health care in the Republic of Trinidad and Tobago. J Health Popul Nutr 2003; 21(3): 243 - 250. 3.  Rashid KM, Raman M, Haider S. Text Book of Community Medicine and Public Health. 4th Edition. RHM Publishers, Dhaka, 2004; 13. 5.  Statistical Record Book of Dhaka Medical College Hospital. Dhaka, 2005; 12-15. 7.  Hannan MA, Chowdhury MZ, Azad AK, Haque MM, Karim MR, Ahmed BN et al. Quality of services provided to the tuberculosis patient in a selected TB treatment center. JOPSOM 2000; 19(1): 18-20. 9.  Das AM, Shahidullah M et al. Patients’ perception of medical care at Dhaka Medical College Hospital. National Institute of Preventive and Social Medicine, Mohakhali, Dhaka, 1988; 46-67. <![CDATA[Prevalence of tobacco consumption in a rural community of Bangladesh]]> Shaila Ahmed Masuma Akter Rishad Mahzabeen Samia Sayeed Hasina Momtaz MA Sayeed https://imcjms.com/journal_full_text/123 2016-10-31 11:41:18 Original Article Ibrahim Med. Coll. J. 2008; 2(2): 58-60 Ibrahim Med. Coll. J. 2008; 2(2): 58-60 Key Words: Tobacco consumption, smoking, rural community. Address for Correspondence: Dr. Shaila Ahmed, Associate Professor, Department of Community Medicine, Ibrahim Medical College           Variables %        15-30 yrs 41.1 275      > 60 yrs 8.9        Male 68.4 174 Education   191      Can Read & Write 13.3 123      Secondary 22.5 39 Occupation   81      Service 10.4 151      Day labourer 9.3 210 Housing   339      Kacha 28.5 54      Sanitary Latrines   478      Absent 13.1        Tk 0-3,000 34.0 241      Tk 6,001-10,000 22.2     About 42% of the smokers puffed 6-20 sticks daily while the frequency of chewing was 1-5 times a day in 59% of them as shown in Table 2. A large percentage of the respondents (94%) knew about the adverse health effects of tobacco consumption while the rest 6% had no idea about the ill effects. Table-2: Frequency of tobacco consumption (n=426) n Smoking (sticks per day)   80       6-20 41.8 69 Chewing (times per day)   173       6-10 22.4 56   Discussion This cross sectional study was done in a rural community of Sreepur thana with an attempt to determine the prevalence and pattern of tobacco consumption, and to know whether the respondents had any knowledge regarding the bad health effects of this habit. A total of 550 respondents were interviewed, out of whom 426 were found to be consumers of tobacco. Most of the people residing in the study areas were found to be illiterate (35%) with only 22% having primary or secondary level education. Forty four percent of the households had a monthly expenditure of Tk.3001-6000. Majority of the houses were tin roofed (61.6%) and sanitary latrine was present in 87% of them. Prevalence of tobacco consumption found among the 15 years and above age group was 77.5%. Smokers constituted 59.1% and chewers 41%. The Bangladesh Demographic and Health Survey (BDHS) 2004 found the overall prevalence of tobacco consumption to be 59%.6 In another study conducted in 1995 to estimate the global prevalence, it was seen that smoking habit was highest in persons aged 30 to 49 years. Low- and middle-income countries accounted for 82% of the world’s smokers. In East Asia and the Pacific, 32% of the population aged 15 years and older were tobacco consumers.1 This study found that 69.1% of the smokers preferred cigarettes and the rest bidi. Jarda was the most popular form of chewing found among the chewers (94.6%). BDHS 2004 concluded bidi smoking to be 29.6%, cigarette smoking 27.8% and chewing betel quid with tobacco/jarda 17.5% respectively. A study conducted in India found 50 to 80% of the smokers smoke bidis, and the remainder smoke cigarettes.7 Forty two percent smokers consumed 6-20 sticks daily as estimated in this study while frequency of chewing was 1-5 times a day in about 59% of chewers. Surprisingly it was seen that majority of the respondents (94%) knew about the adverse health effects of tobacco consumption although they made no efforts to quit the habit. This figure was found to be 80% in another study conducted among the population of some developing counties.8 Conclusion and Recommendation This cross sectional study was a limited attempt in a rural community of Bangladesh to estimate the prevalence of tobacco consumption and some other associated variables. The calculated prevalence was 77.5% which is quite alarming compared to some previous data. It indicates that both communicable and non communicable disease burden will rise in the future. Although majority of the consumers knew about the adverse health effects of smoking and chewing tobacco, they were reluctant to give up the habit. This study suggests that planning anti-smoking campaigns and health education programs for the general mass needs to be geared up. Further in-depth studies to find out the factors related to tobacco consumption and inability to quit, along with the health hazards present among the consumers will be of great value. References 2.   Peto R, Lopez AD. The Future Worldwide Health Effects of Current Smoking Patterns.  Global Health in the 21st Century. New York, NY: Jossey-Bass 2000; 154–161. 4.   Ahmed S, Rahman A, Hull S. Use of Betel Quid and Cigarettes Among Bangladeshi patients in an Inner-City Practice: Prevalence and Knowledge of Health Effects. Br J Gen  Pract 1997; 47(420): 431–434.  6.  Bangladesh Demographic and Health Survey 2004. (Dhaka, National Institute of Population and Training, Mitra and Associates, ORC Macro). 9.   Peto R, Lopez AD, Boreham J, Thun M, Heath C. Mortality from Smoking in Developing Countries, 1950-2000. Oxford: Oxford University Press, 1994. The following students of IM-4B were involved in this study: Ishita Mou, Shanjida Hoque, Nurun Nahar, Maftahul Jannaty, Tamanna Hossain Editor’s Note: In continuation of our interest in publishing articles resulting from our Residential Field Site Training (RFST) Programme for the 4th year MBBS students, we are publishing this article. Articles resulting from  RFST Programme  were published in our previous issues. <![CDATA[Cost differentials between private and public hospitals for antimicrobial treatment of admitted patients suffering from pneumonia and diarrhoea]]> Seikh Farid Uddin Akter MA Jabbar Saroj Kumar Mazumder Abdul Mazid Mia Afia Fazlul https://imcjms.com/journal_full_text/124 2016-10-31 11:56:29 Original Article Ibrahim Med. Coll. J. 2008; 2(2): 61-64 Ibrahim Med. Coll. J. 2008; 2(2): 61-64 Key Words: Antimicrobial therapy, cost differentials, pneumonia, diarrhoea. Pneumonia and diarrhoea are two major paediatric health problems in developing countries including Bangladesh.1-3 It has been calculated that the average individual ingests about 8 microorganisms per minute or 10,000 per day.4 The respiratory and gastro intestinal tracts are the most common sites for infection by pathogens, often requiring antimicrobial therapy. The World Health Organization estimates that up to 40% of the total health care cost in developing countries may be for drugs.5  Several studies in developing countries such as India, Thailand and Tanzania estimate that from 24 to 50% of the total pharmaceutical budget are spent on antimicrobial agents in these countries.6-8 This study was conducted in the paediatric wards of two randomly selected medical college hospitals in Bangladesh - one public and another private. The data collection procedure was prospective in nature. The treatment charts of 107 admitted paediatric patients who received antimicrobial agent(s) for the treatment of pneumonia (88) or diarrhoea (19) were reviewed daily from the day of admission of the patients till their discharge. There were 18 pneumonia patients in the public and 70 in the private hospital. These figure were 7 and 12 respectively for the diarrahoea cases. The total cost of antimicrobial agents per patient was based on the current market price of these agents. Estimation of the cost per patient: CTiAM = å (Unit price of each antimicrobial agent ´ ‘quantity used per day’ ´ duration of hospital treatment). The calculated total cost was determined by summing up costs of all antimicrobial agents given to individual patients.   Results Table-1: Distribution of antimicrobial agents used for the treatment of pneumonia (*n = 127) Medical College Hospitals Private No.(%) Amoxicillin 40 (38.46) Gentamicin 40 (38.46) Ceftriaxone 8  (7.69) Cephradine 10  (9.62) Ceftazidime 6  (5.77) Total 104 (100)   *n=number of courses of commonest five antimicrobial agents.   Table-2: Distribution of antimicrobial agents used for the treatment of diarrhoea (*n = 14) Medical College Hospitals Private No.(%) Ceftriaxone 2 (22.22) Cephradine 2 (22.22) Amoxicillin 2 (22.22) Metronidazole 1 (11.12) Ampicillin 2 (22.22) Total 9   (100)   Pneumonia:Diarrhoea: The average cost of antimicrobial agents per patient suffering from diarrhoea was Taka 221.45 across the hospitals while it was Taka 199.31 and Taka 279.00 in private and public hospital respectively (Table-3).   Table-3: Average costs of antimicrobials used for the treatment of admitted paediatiric patients     Table 3 shows that the average costs of antimicrobial agents used for both pneumonia and diarrhoea varied among hospitals. The average costs for antimicrobial treatment of pneumonia were far greater in the private hospital. The average cost of antimicrobial treatment of diarrhoea was surprisingly higher in the public hospital.   Discussion In both conditions, there was a great potential for saving hospitals’ and patients’ treatment cost if appropriate intervention(s) are made and/or strategies improved for antimicrobial prescribing practices in hospitals of Bangladesh. 1.     Liss RH, Batchelor RF. Economic evaluations of antibiotic use and resistance—a perspective: report of Task Force 6. Reviews of Infectious Diseases 1987; 9 (supplement 3): S297–S312. 3.     Kunin CM, Lipton HL, Tupasi T, Sacks T, Scheckler WE, Jivani A, et al. Social, behavioural, and practical factors affecting antibiotic use worldwide: report of Task Force 4. Reviews of Infectious Diseases 1987; 9 (supplement 3): S270–S285. 5.     Kunin CM. In comment. Journal of the American Medical Association 1974; 227: 1030–1032. 7.     Anonymous. Drug use in the Third World [letter]. Lancet 1980; 1: 1231–1232. 9.     Kabir AL, Kawser CG, Shohidullah M, Hassan MQ, Talukder MQK. Situation analysis of child health in Bangladesh. Bangladesh Journal of Child Health 1994; 19(2): 63–68. 11.  Ali L, Choudhury SAR. Study of drug utilization pattern at a teaching hospital. Bangladesh Journal of Physiology and Pharmacology 1993; 9: 27–28. 13.   Choudhury AKA, Hossain MH, Bhuiya MDH, Islam MA. A study report on prescribing pattern in diarrhoeal disease in three districts of Bangladesh. Unpublished, 1991; 7. 15.   Sultan-Ul-Alam M, Barua PC, Rashid DMH, Islam AFMS. A survey of the pattern of drug utilization for watery diarrhoea at Primary Health Care level of Chittagong division. Hygeia 1993; 7(1): 15–18. 17.   Choudhury AKA, Khan OF, Matin A, Haque Z, Bhuiya AL. Impact of standard treatment guidelines and small group training on prescribing for diarrhoea in under five children in Thana Health Complexes in Bangladesh. International Conference on Improving Use of Medicines, April 1-4, 1997; Chiang Mai, Thailand. <![CDATA[Pattern of musculoskeletal disorders among diabetic patients attending a tertiary care hospital in Dhaka]]> Md. Shah Zaman Khan MA Shakoor Md. Moyeenuzzaman Md. Quamrul Islam https://imcjms.com/journal_full_text/125 2016-10-31 12:02:50 Original Article Ibrahim Med. Coll. J. 2008; 2(2): 65-66 Ibrahim Med. Coll. J. 2008; 2(2): 65-66 Key Words: Musculoskeletal (MSK) disorders, diabetic patients, BIRDEM Introduction Diabetes is a multi-system disorder affecting 3 -7% of the adult population in different geographical areas.1,2 Diabetic patients may present with various MSK disorders. Adhesive capsulitis of shoulder joint is well established as a complication of diabetes.3,4 Trigger finger, catching and snapping of the fingers and complications involving joints e.g. Charcot’s arthropathy are frequent in diabetic patients.5,6 The aim of this study was to find out the pattern of MSK disorders among the Bangladeshi diabetic patients attending the Department of Physical Medicine and Rehabilitation of a tertiary care hospital in Dhaka. Materials and Methods Diabetic patients with complains of MSK disorders attending the Department of Physical Medicine and Rehabilitation of  Bangladesh Institute of Research and Rehabilitation for Diabetes, Endocrine and Metabolic Disorders (BIRDEM) between January – December 2005 were included  in the study.  Patients were categorized according to the criteria of American Rheumatology Association based on history, clinical examination and relevant investigations. Results A total of 2062 patients with MSK disorders were studied. Out of them 927 (44.9%) were males and 1135 (55.1%) were females. Out of 2062 patients, 31.9% were between the age group of 41-50 years and 29.8% was between 51 - 60 years.  Majority were house wives (56.5%) followed by retired servicemen (16.3%), service holders (13.8%), businessmen (7.4%) and teachers (2.3%). Rheumatoid arthritis was the commonest (20.1%) inflammatory arthropathy while lumber and cervical spondylosis constituted about 37% of all disorders. Details of the common MSK disorders are presented in Table-1. Table-1: Common MSK disorders among diabetic patients (n=2062) Number Rheumatoid arthritis 20.1 394 Cervical spondylosis 18.3 341 Osteoarthritis of knee joint 8.1 102 Trigger fingers 3.9 65 Planter fosciitis 3.1 54     1.  Report of a WHO consultation. Definition, diagnosis and classification of diabetes mellitus and its complications 1999; 2. 3.  Arkkila PE, Kantolac M, Vikari JS et al. Shoulder copsulitis in type I and type II diabetic patients associated with diabetic complications and related diseases. Ann Rheum Dis 1996; 55: 907. 5.  Benedetti A, Noacco C, Simonutti M, Taboga C Diabetic trigger finger. N Engl J Med 1982; 306: 1552. 7.  Alam MN, Haq SA, Moyeenuzzaman M et al. Rheumatological disorders in IPGMR. Bangladesh J Medicine 1996; 7: 1-7. 9.  Sucur A. Evaluating the magnitude of socio-medical problem of rheumatic diseases in adult urban population. Acta Med Lugosl 1990; 44: 407-4. <![CDATA[Does ‘Honeymoon period’ exist in type 2 diabetes mellitus]]> SM Ashrafuzzaman Zafar A Latif https://imcjms.com/journal_full_text/22 2016-08-02 08:26:51 Clinical Case Report Ibrahim Med. Coll. J. 2008; 2(2): 67-69 Introduction In type 1 diabetes mellitus (T1DM), a period of temporary remission often occurs following initiation of insulin therapy. The period of remission is variable and it usually does not continue more than 6 months. Such temporary remission does not indicate cure. The residual beta cell mass is enough to maintain normoglycemia during this period.1 This period of temporary remission is called ‘honey moon period’ in T1DM. Though, no such period of temporary remission is usually seen in type 2 diabetes mellitus (T2DM), we describe here such temporary period of remission in two cases which fulfill all the clinical criteria of T2DM. Case I: A 30 year old Bangladeshi got admitted in BIRDEM hospital in February 2007 with a history of diabetes and frequent hypoglycemic attacks. He was a Bangladeshi immigrant to USA. In USA, he was well till August 2006, when he noticed polyuria, polydypsia and general weakness, though not severe enough to hamper daily activities. He had no other systemic illness and occasionally used to take anxiolytic or sleeping pills. His body mass index (BMI) was 28.8 kg/m2 and was normotensive. In USA, he was diagnosed as diabetic as his blood glucose level was 26.2mmol/l after 2 hours of glucose drink. Along with diet and exercise he was prescribed gliburide 5 mg in the morning and combination of metformin 500 mg + rosiglitazone 2 mg twice daily. He was reasonably well till January 2007. Random blood glucose level was monitored occasionally during this period which remained within 4~6 mmol/l. However, he had complains of occasional weakness, lethargy, tiredness, but no other symptoms of hypoglycemia. He was asked to continue his medications. At the end of January 2007 in USA, while at home, he suddenly developed diarrhoea followed by sweating, palpitation, restlessness, tremulousness and feeling of impending doom. He had no chest pain or heaviness. He was admitted in hospital and treated for hypoglycemia. He was discharged from the hospital after a few days with counseling about hypoglycemia. Shortly after that he stopped taking oral anti-diabetic (OAD) drugs as he was planning to visit Dhaka. While in Dhaka he frequently felt symptoms mimicking hypoglycemia even though he was not taking any OAD. His symptoms abated with sweet/glucose drinks. But blood glucose level was never less than 5mmol/l by self monitoring with glucometer. At the time of admission at BIRDEM, his BMI was 27.2 kg/m2, blood pressure 120/80 mm of Hg, pulse 88/min. Oral glucose tolerance test (OGTT) was done with 70 gm glucose drink. His fasting and 2 hours post glucose blood sugar levels were 4.3 mmol/l and 6.9 mmol/l respectively. Corresponding insulin and C-peptide level were also within normal reference range which excluded type 1 diabetes. Thyroid function and adrenal functions were normal. He was advised not to take any refined sugar on his own if he would experience hypoglycemia like symptoms because he was not taking any OAD drugs since January 2008. He had few episodes of hypoglycemia like attacks during his hospital stay. But his blood glucose level was always within 5-7 mmol/l without any sugar supplement during such symptomatic attacks. He was counseled for this panic attack and advised frequent small complex carbohydrate diet with high fiber. Psychotherapy and an anxiolytic (Clonazepam) was prescribed. He was discharged after 4 days with advice for regular follow up. Three months after discharge from the hospital he had normal blood glucose level and normal physical and mental health with no such attacks of hypoglycemia. The case was diagnosed as a T2DM having the so-called temporary remission. Case II: A 24 year old male student of Dhaka University, who came from a lower middle class farmer family, having no family history of diabetes mellitus, was admitted to a local district hospital in an unconscious state. After admission, he was diagnosed as a case of diabetic ketoacidosis (DKA) with 38.0 mmol/l blood glucose. After initial treatment he was referred to BIRDEM hospital, Dhaka where he was admitted under Endocrinology unit. He had a history of viral hepatitis one year back. For this latter conditions he was treated with traditional medicines and took plenty of glucose drinks and sugarcane juice. Jaundice gradually improved but there was weight loss and general weakness. He also noticed polyurea and polydypsia. At BIRDEM hospital, he was found to have very high blood glucose and DKA. He was treated for DKA accordingly. There was mild renal impairment (serum creatinine 1.9 mg/dl), due to transient acute renal failure which subsequently became normal. On the second day he became conscious, oriented. Acidosis was corrected. Blood glucose was 6-10 mmol/l throughout the day. Insulin infusion was stopped and switched over to subcutaneous insulin as oral feeding was started. He was on Actrapid HM 10 IU pre-brakefast, and 8 IU pre-dinner and Insulin retard HM 14 IU pre-breakfast and 10 IU pre-dinner times. His blood glucose profile remained within normal limits. He was investigated to classify his diabetes. He was labeled as a case of type 2 diabetes based on clinical features, plain x-ray abdomen and normal c-peptide level. Education for diabetes was given to the patient as well as his family members. During regular follow up, his insulin requirements were gradually lowered and ultimately stopped with advise for strict follow up. After few months of stopping insulin his blood glucose level remained within normal limit. At this time he was prescribed gliclazide 40 mg once daily. After another couple of months, oral OAD drug was stopped due to occasional hypoglycemic symptoms and low blood glucose level (3.5-5 mmol/l). In subsequent follow up, his blood glucose was found within normal physiological limits without any OAD drug. OGTT was done which showed fasting plasma glucose at 5.2 mmol/l, and 2 hours post glucose at 6.7mmol/l. His HbA1C was 5.2% and BMI was 23 kg/m.2 He was diagnosed as a case of type 2 diabetes mellitus having the period of temporary remission. Discussion The ‘honeymoon period’ (temporary remission) is characterized by reduced or no insulin requirement in T1DM when good glycemic control is maintained.2 The clinical significance is the potential possibility for pharmacological intervention during this period to either slow down or arrest the ongoing destruction of the remaining beta-cells. Less severe disease has more chance of temporary remission. Hypoglycemia and low blood glucose are also commonly seen in the course of treatment in this period. Beta cell function, c-peptide level and also the insulin level varies in theses patients with or without temporary remission. The incidence and duration of honeymoon phase varies depending on residual beta-cell function and insulin resistance at the onset of type 1 diabetes. The duration usually varies from 6 months to 2 years.1 It is never considered as a ‘permanent cure’. The two cases described above show that temporary remission of the disease might also occur in T2DM. This temporary remission in T2DM was observed after the initiation of anti-diabetic treatment for glycemic control. The remission was similar to the honey moon phase of T1DM. The patients did not require any anti-diabetic agents and maintained a normal glycemic status. However, the duration of such remission in T2DM needs to be determined. There are few reported cases of temporary remission in type 2 diabetes.3 At this period, residual beta-cell mass might be enough to maintain normoglycemia. It is better to closely monitor these cases regarding their progression to T1DM or T2DM. Our second case presented with DKA. Recently, in an editorial of Diabetes Care journal, there is a discussion on “Ketosis prone type 2 diabetes”.4 These patients were without autoimmunity but preserved β-cell function (A-β+). Despite their presentation with DKA or severe metabolic decompensation, most patients showed clinical and biochemical characteristics of type 2 diabetes. Most A-β+ subjects have new onset diabetes and are usually obese, middle aged males with a strong family history of type 2 diabetes. Evidences showed that they do not require any insulin or ODA therapy after sometime. Our second case probably falls under this category of patients. Therefore, temporary remission or honey moon phase may also be encountered in T2DM.   1.  Lombardo F, Valnzise M, Wasniewska M, Mssina MF, Ruggeri C, Arrigo T, et al. Two year prospective evaluation of the factors affecting honeymoon frequency and duration in children with insulin dependent diabetes mellitus; the key role of age at the diagnosis. Diabetes Nutr Metab 2002; 15: 246-51. 3.  John C Pickup. Text book of diabetes. 3rd edition. 2003; 43, 14. <![CDATA[Urinary bladder Leiomyoma – a rare case report]]> H U Bhuiyan https://imcjms.com/journal_full_text/126 2016-10-31 12:07:55 Clinical Case Report Ibrahim Med. Coll. J. 2008; 2(2): 70-71 Ibrahim Med. Coll. J. 2008; 2(2): 70-71 Key Words: Urinary bladder leiomyoma, laparotomy, excision biopsy Address for Correspondence: Dr. HU Bhuiyan, Consultant Radiologist, Hospital Duchess of Kent (HDOK), Sandakan, Sabah, Malaysia, helaldin@yahoo.com       1.  Campbell EW and Gislason GJ: Benign mesothelial tumors of the urinary bladder: review of the literature and a report of a case of leiomyoma. J Urol 1953; 70: 733-742. 3.  Silva-Ramos M, Masso P, Soares J, Pimenta A.: Leiomiomas de vejiga. Analisis de agregación de 90 casos. Act Urol Esp; in press. 5.  Kabalin JN, Freiha FS, Niebel JD: Leiomyoma of the bladder. Report of 2 cases and demonstration of ultrasonic appearance. Urology 1990; 35: 210-212. 7.  Kroll LD, Segura JW, Scheithauer BW. Leiomyoma of the bladder. J Urol 1986; 136: 906-908. <![CDATA[Obesity, diabetes and leptin: lessons learned from obese hyperglycemic mice]]> Meftun Ahmed https://imcjms.com/journal_full_text/127 2016-10-31 12:14:36 Review Ibrahim Med. Coll. J. 2008; 2(2): 72-84 The recent epidemic nature of obesity and association of obesity with the development of type 2 diabetes demands dissection of the pathophysiology of this morbid disorder which is essential for better understanding of the process of evolution of insulin resistance. Different animal models have been used to explore the mechanism linking obesity to insulin resistance and type 2 diabetes. The discovery of ob gene and its product, leptin, has revealed the signaling system regulating energy balance in rodents. The mice lacking this ob gene, ob/ob mice, display obesity, hyperglycemia and hyperinsulinemia and has been extensively used for the study of type 2 diabetes and for potential drug development. In this review,  the features and development of obese hyperglycemic syndrome, the role of leptin in the pathogenesis of the syndrome and finally the applicability of the findings in rodents to body weight regulation and pathogenesis of insulin resistance in humans have been summarized. Ibrahim Med. Coll. J. 2008; 2(2): 72-84 Introduction   Marked obesity, hypoactivity, hyperphagia, transient hyperglycemia (subsiding around 14-16 weeks), severe hyperinsulinemia and insulin resistance are the cardinal features of obese hyperglycemic syndrome when ob gene is expressed in the C57BL/6J strain background.5,12-14 In contrast to the C57BL/6J strain, BL/Ks ob/ob mice are characterized by obesity, severe hyperglycemia and glucose intolerance, transient hyperinsulinemia, islet atrophy and early death.14,15 Early signs of the obese hyperglycemic syndrome are loweroxygen consumption,16 decreasedthermogenesis17 and increased weight gain.12 Metabolism The obese mice are hypercholesterolemic.12,22 However, the increase is primarily in high-density lipoprotein cholesterol, so that atherosclerotic lesions are unusual in this mouse model.23 Plasma triglyceride levels are also elevated in the ob/ob mice. Rate of lipogenesis in the liver and adipose tissue is more than doubled and both intraperitoneal and subcutaneous deposit of fat is increased.4,18 The increased amount of lipids stored by ob/ob mice is accommodated through both hyperplasia and hypertophy of adipocytes; whereas in other genetic obesities in mice, increase in fat depots is entirely due to cell hypertrophy.24 Body weight   Fig-1. Lean C57BL/6J (top) and an obese mice (B6.V-Lepob, bottom). Life span     Islet morphology and biochemistry Immunocytochemical studies demonstrate that glucagon, gastric inhibitory polypeptide and somatostatin containing cells were intermingled with the b-cells in obese mouse islets in addition to their peripheral localization.32,36 In contrast, its lean littermates show only a peripheral localization of these cell types. There are signs of b-cell degranulations in islets from obese mice with increased nuclear and nucleolar size.1,37-39 The islets of the obese mice are remarkably hyperemic;30,39,40 pseudocysts, dilated ducts and dilated capillaries are also common findings in ob-mouse islets.32   The ob/ob mice exhibit an increased sensitivity to low levels of glucose and a left shift in the glucose-response curve.35 The threshold for glucose-induced insulin secretion from perifused islets in fed ob/ob mice is about 2 mmol/L and in 24 hrs fasted obese mice is about 3 mmol/L.47 In contrast, islets from lean mice exhibit considerably higher thresholds - about 5 and 7 mmol/L glucose in fed and 24 hrs starved lean mice, respectively. When insulin secretion was measured from equally-sized islets in ob/ob (Uppsala colony) and lean mice, no significant differences were noted between them both in basal and higher glucose level.48 However, in a similar experimental protocol, islets of ob/ob mice from Michigan colony hypersecreted insulin in response to high concentrations of glucose than that of lean mice.47  Neurotransmitters and hormones that normally potentiate insulin secretion only above 6 mM glucose in lean mice are found to stimulate insulin secretion in ob/ob mice at basal glucose levels.35,47 The ob/ob islets of Norwich colony are permanently more depolarized even in the absence of a primary stimulus to secretion than the lean ones.52 While b-cells of lean mice show continuous spike activity above 16 mM glucose, ob/ob b-cells often exhibit a burst pattern of electrical activity at glucose concentrations as high as 33 mM.52,53 They also exhibit an increased responsiveness to quinine (a KATP channel blocker) and apamin (a Ca2+-dependent K+ channel blocker) suggesting an altered sensitivity of KATP and Ca2+-activated K+ channels.54 Electrophysiological studies and 86Rb+ efflux data also suggest a modified K+ permeability in pancreatic b-cells from Norwich ob/ob mice.52,53 However, with patch-clamp measurements, KATP channels in ob/ob mice islets display a normal behavior in respect of conductance, ionic selectivity, kinetic behavior, voltage dependency, and sensitivity to glucose and ATP/ADP.55 Monoamines (dopamine and 5HT) are stored in the insulin secretory granules of b-cells and may affect the granule maturation and (or) exocytotic procedure.67 Glucose itself induces a significant suppression of islet monoamine oxidase (MAO) activity within 2 min after an intravenous injection.68 Generally, MAO levels rise as glucose levels fall, but this correlation is not observed in islets of ob/ob mice.69 Adrenals   Diffuse nodular lipohyaline deposits are present in the kidney in aging obese mice and they are primarily localized to the mesangial cells.71,72 Obese mice are sterile.2 Infertility is an absolute characteristic of the ob/ob females; however about 20% of the ob/ob male can reproduce.73 The level of LH, FSH and testosterone in serum is lower in obese mice compared to their lean littermates.18 In female obese mice the ovaries and uterus remain atrophic;74 whereas the male counterpart is characterized by smaller testes, hypoplastic seminal vesicles, atrophic interstitial Leydig cells and a slight decrease in the number of spermatozoa.73 Thus, it has been suggested that there is a persistent immaturity of the hypothalamic-pituitary axis in obese mice.75 Endocrine abnormalities Many symptoms in adult ob/ob mice, eg, their low metabolic rate, hypercholesterolemia, decreased body temperature, susceptibility to cold and hypoactivity suggest functional hypothyroidism.18,84 But conflicting results in serum concentrations of thyroid hormones (serum TSH, T3 and T4 and also hypothalamic content of TRH) in ob/ob mice have been reported – either lower,85 higher86,87 or the same88-90 as in lean mice. However, van der Kroon et al84 have tried to explain the discrepancy in results about thyroid activity in ob/ob mice and provided support for the hypothesis that the obese hyperglycemic syndrome in mice is characterized by congenital hypothyroidism. Mobley and Dubuc91 found that obese mice have significantly reduced hormone concentrations between 10 and 21 days of age. Thereafter, the values remained equal to, or above those of their lean littermates. This result is consistent with human data provided by Ozata et al.92 They have demonstrated that thyroid function is abnormal only in the obese child of the leptin gene mutant family but is normal in the adult patients. Thus, it is most likely that in adult ob/ob mice pituitary-thyroid hormone levels remain normal and their apparent hypothyroidism is largely independent of hormone availability to target tissues rather depends on defective target tissue responses.86,93 This interpretation is supported by a number of observations, including decreased 5´-deiodinase activity in brown adipose tissue,94 liver90 and kidney;89 and decreased transport of T3 across the hepatic plasma membrane and a reduced nuclear T3 receptor occupancy.95,96 These findings suggest that T3 availability to target tissues may be impaired in obese mice, which may contribute to diminished thyroid hormone expression and heat production in these animals.89 Furthermore, the thyroid-stimulated component of Na+-K+-ATPase is deficient in ob/ob mice.18 The activity of Na+-K+-ATPase is low in liver, kidney and skeletal muscle of ob/ob mice.97 And a defective regulation of this enzyme may lead to decreased thyroid action.18 Others   Time course of the developing obese hyperglycemic syndrome indicates that the obesity, hyperinsulinemia, and skeletal growth deficits that characterize mature ob/ob mice develop before weaning and are clearly defined as early as 17 days of age.13 Other studies regarding developmental sequence of the abnormalities demonstrate that obesity precedes hyperinsulinemia, which precedes the onset of insulin resistance and hyperglycemia.13,104,105 When lean and obese mice are compared as groups there is a significant difference in weight at day 6 in Jackson colony16 or at day 12 in Swedish colony.106 And at day 18, clinical diagnosis of the ob/ob syndrome could be made with 100% certainty. Already at day 17, Dubuc13 and Garthwaite et al26 found higher insulin levels in obese mice, others reported about day 20.12,106 However, there is no significant rise in blood sugar until day 22, but afterward, obese animals have higher blood glucose values than their lean littermates.106 These results suggest, since obesity and hyperinsulinemia are manifested well before the presence of hyperglycemia, neither hyperglycemia nor insulin resistance seems to be responsible for the development of the obesity nor of the hyperinsulinemia that occurs in mature ob/ob mice.13 However, based on the manifestation of features, the development of obese hyperglycemic syndrome in ob/ob mice can be differentiated into three distinct phases. The first phase is the dynamic phase. After an initial asymptomatic period the dynamic phase is characterized by rapid weight gain, increasing insulin secretion and decreasing glucose tolerance with fasting hyperglycemia.12,25,107 The next phase is the transitional phase, which is characterized by shifting of glucose pattern, ie, extremely poor glucose tolerance and extremely high serum insulin level is followed by improving glucose tolerance and decreasing insulin levels. Body weight gradually reaches to its maximum value. In the final static phase, blood glucose and serum insulin levels return to near normal values and body weight slowly decreases. Ingalls et al2 first described the obese hyperglycemic syndrome in 1950 as a single gene mutation in the C57BL/6J mouse strain. Previous studies with ob/ob mice have demonstrated that several experimental techniques reduce the severity of the behavioral and metabolic abnormalities displayed by these mice. For example, treatment with b-cytotoxic agents, or the implantation of pancreatic islets from lean littermates reduces hyperinsulinemia, hyperglycemia and increased body weight.108-110 Adrenalectomies, hypophysectomy, alterations of diet and food restriction are also effective in normalizing some aspects of the obese-hyperglycemic syndrome.111-114 However, they are not enough to conclude which metabolic disturbance is directly related to the genetic lesion. In an elegant experiment, Coleman5 showed that parabiosis of obese mouse (ob/ob) with a normal one suppressed weight gain in the obese mouse, whereas parabiosis to diabetes mouse (db/db) caused profound weight lost and death of the obese one. Taken together, these results suggest that the ob gene was necessary for the production of a humoral satiety factor that regulates energy balance and due to the mutation, obese mouse does not produce sufficient satiety factor to turn off its eating drive.5,115 This long search for the precise nature of the defect come to an end in 1994, when Zhang et al,10 cloned the ob gene and confirmed Coleman’s hypothesis.   Fig-2. Physiological role of leptin in glucose homesotasis. Leptin stimulates the rate of hepatic glucose output (HGO), inhibits insulin secretion, increases glucose uptake and glycogenesis in muscle. It stimulates lipolysis and decreases lipogenesis in adipoytes.   Fig-3. Development of the features in obese hyperglycemic syndrome due to lack of circulating leptin. NPY, AGRP, POMC and CART neurons are directly responsive to leptin. NPY and AGRP stimulate feeding (orexigenic), whereas α-melanocyte stimulating hormone and CART inhibit feeding (anorexigenic). These neurons also project to the lateral hypothalamus and regulate the expression of melanin-concentrating hormone (MCH) and possibly orexins (hypocretin). Leptin inhibits the expression and secretion of NPY via Y1 receptor. NPY = Neuropeptide Y; AGRP = agouti-related peptide; MCH = melanin-concentrating hormone; POMC = proopio-melanocortin; αMSH = α-melanocyte stimulating hormone (a product of POMC); CART = cocaine- and amphetamine-regulated transcript; CRH = corticotropin-releasing hormone; TRH = thyrotropin-releasing hormone; SS = somatostatin; GHRH = growth hormone-releasing hormone; GnRH = gonadotropin-releasing hormone; ACTH = Adrenocorticotrpin hormone; TSH = Thyroid-stimulating hormone; GH = Growth hormone; LH = Luteinizing hormone; FSH = Follicle-stimulating hormone; T3 = Tri iodothyronine; T4 = Thyroxine; TH = Helper T cells. Sequences in development of ob/ob syndrome   Fig-4. Sequences in the development of ob/ob syndrome due to lack of leptin. Use of ob/ob mice   In humans, circulating leptin concentrations have been reported to correlate closely with the body mass index (BMI),124,125 total amount of body fat126 as well as the size of adipose tissue mass.127 The normal range for plasma leptin in healthy humans is 3-5 ng/ml and in obese subjects are in the range of 8-90 ng/ml.126 The increase in serum leptin concentration in obesity involves both the increase in number of adipocytes and induction of ob mRNA. The large adipocytes, which are commonly present in obese subjects due to hypertrophy and hyperplasia of adipose tissue, express more ob mRNA than small adipocytes.128 The ob mRNA expression is also upregulated by glucocorticoids.129,130 By contrast, stimulation of the sympathetic nervous system or the increase in circulating epinephrine results in inhibition of ob mRNA expression.130 In human beings, there is a highly organized pattern of leptin secretion over a 24-h period. The circadian pattern is characterized by basal levels between 08:00 and 12:00 hours, rising progressively to peak between 24:00 and 04:00 hours and receding steadily to nadir by 12:00 hours.133 However, these changes in leptin plasma concentrations are not acutely altered by food intake or changes in insulin and glucose concentrations in humans. The underlying mechanism is not fully understood, but leptin rhythm seems to be more associated with meal timing than to the circadian clock.134,135 It has been speculated that the nocturnal rise in leptin could have an effect in suppressing appetite during the night while sleeping136 and since leptin and cortisol show an inverse circadian rhythm,137 it has been suggested that a regulatory feedback is present. Glucocorticoids act directly on the adipose tissue and increase leptin synthesis and secretion in humans.138 Leptin levels are markedly increased in Cushing’s syndrome patients and in other pseudo-Cushing’s syndrome states.138 However glucocorticoids appears to play a modulatory, but not essential roles in generating leptin diurnal rhythm. Increased leptin secretion glucocorticoids in turn augments coordinated activation of anorexigenic pathways and inhibition of orexigenic pathways mediated by leptin-responsive neurons in the hypothalamus.138,139 Furthermore the modulatory role of glucocorticoids could be altered in obesity, but the precise mode of action is still unknown. Human obesity is often associated with severe insulin resistance with high circulating levels of both insulin and leptin.142 In this regard, the failure of the elevated leptin levels to restore normal energy and metabolic homeostasis is commonly viewed as evidence for leptin resistance. Resistance is likely caused by a combination of resistance at the receptor and post-receptor levels (level of signaling) as well as a decreased ability of the blood-brain barrier (BBB) to transport circulating leptin into the brain.126 Several studies have documented various types of evidence for impaired transport of leptin across the BBB. For example, obese humans have a decreased CSF-to-serum ratio for leptin despite high circulating levels of leptin, and some obese rats that no longer respond to peripherally administered leptin can still respond to leptin given directly into the CNS.126 Rising leptin levels associated with progressing obesity are generally regarded as simply a consequence rather than a causative factor in the leptin resistance and obesity. Though serum leptin levels are high in obesity, obese as well as lean subjects with type 2 diabetes display reduced leptin levels.143 This lower leptin levels in diabetics have been speculated to contribute in accumulation of cellular lipids that is associated with diabetes.143,144 The absolute requirement for leptin in controlling body fat mass and regulating reproduction is firmly shared between mouse and man.154,155 Similar to ob/ob mice, leptin helps in regulation of ovarian development and steroidogenesis and serves as either a primary signal initiating puberty or a permissive regulator of sexual maturation.156,157 Leptin regulates the growth and development of conceptus, fetal/placental angiogenesis, embryonic hemopoiesis and hormonal biosynthesis within the maternal–fetoplacental unit and could be taken as a marker of fetal mass in humans.157 Elevated leptin concentrations in cord blood are associated with macrosomia158 and recently, it has been found that leptin levels of amniotic fluid and maternal serum were higher in pregnant women who had fetuses with neural tube defect than in women with healthy fetuses.159 Human leptin has been purified and identified in milk and colostrum from nursing mothers and it has been suggested that in the neonatal period it may play a role in the regulation of neonatal food intake and in the intestinal maturation.160,161 Clinical implications The marked insulin resistance and hyperlipidemia in leptin-deficientrodent models of lipoatrophy is largely reversed by leptin administration.167-169 Low-dose leptin treatment has dramatic effects to ameliorateinsulin resistance and hyperlipidemia in patients with low leptinlevels resulting from congenital or acquired lipodystrophy.170 The beneficial metabolic effects were associated with reducedtriglyceride deposition in liver and intramyocellular lipidcontent in skeletal muscle.171,172 Leptin also improved pituitary,reproductive, and thyroid axis function in lipoatrophic patients.173 Plasma leptin concentrations are also decreased in some patients with lipodystrophy associatedwith human immunodeficiency virus infection and antiretroviraltreatment.174,175 It is possible that leptin replacement therapywould be beneficial in managing some of the metabolic abnormalities(hepatic steatosis, hyperlipidemia, and insulin resistance)in the patients with low leptin levels. Conclusion   I gratefully acknowledge Dr MO Faruque, Department of Biochemistry & Cell Biology, BIRDEM, Dhaka, Bangladesh for kindly reviewing the manuscript. I acknowledge the staff of the Department of Medical Cell Biology and BMC Library, Uppsala University, for their support. References 2.    Ingalls AM, Dickie MM, Snell GD. J Hered 1950; 41: 317-8. 4.    Herberg L, Coleman DL. Metabolism 1977; 26(1): 59-99. 6.    Hansen AK, Dagnaes-Hansen F. An introduction to the use of rodent models in diabetes research: Mollegaard Ltd and Bomholtgaard Ltd. Denmark 1990. 8.    Hahn HJ, Hellman B, Lernmark Å, Sehlin J, Täljedal IB. J Biol Chem 1974; 249(16): 5275-84. 10.  Zhang Y, Proenca R, Maffei M, Barone M, Leopold L, Friedman JM. Nature 1994; 372(6505): 425-32. 12.  Westman S. Diabetologia 1968; 4(3): 141-9. 14.  Coleman DL. Diabetes 1982; 31(Suppl 1 Pt 2):1-6. 16.  Boissonneault GA, Hornshuh MJ, Simons JW, Romsos DR, Leveille GA. Proc Soc Exp Biol Med 1978; 157(3): 402-6. 18.  Bray GA, York DA. Physiol Rev 1979; 59(3): 719-809. 20.  Seidman I, Horland AA, Teebor GW. Diabetologia 1970; 6(3): 313-6. 22.  Uysal KT, Scheja L, Wiesbrock SM, Bonner-Weir S, Hotamisligil GS. Endocrinology 2000; 141(9): 3388-96. 24.  Johnson PR, Hirsch J. J Lipid Res 1972; 13(1): 2-11. 26.  Garthwaite TL, Martinson DR, Tseng LF, Hagen TC, Menahan LA. Endocrinology 1980; 107(3):         671-6. 28.  Lane PW, Dickie MM. J Nutr 1958; 64: 549-54. 30.  Gepts W, Christophe J, Mayer J. Diabetes 1960; 9(1): 63-9. 32.  Starich GH, Zafirova M, Jablenska R, Petkov P, Lardinois CK. Acta Histochem 1991; 90(1): 93-101. 34.  Petersson B, Hellman B. Metabolism 1962; March; 11(3): 342-8. 36.  Makino H, Matsushima Y, Kanatsuka A, Yamamoto M, Kumagai A, Nishimura M. Endocrinology 1979; 104(1): 243-7. 38.  Hellman B, Petersson B. Acta Path Microbiol Scand 1960; 50(3): 291-6. 40.  Rooth P, Grankvist K, Taljedal IB. Microvasc Res 1985; 30(2): 176-84. 42.  Gingerich RL, Gersell DJ, Greider MH, Finke EH, Lacy PE. Metabolism 1978; 27(10): 1526-32. 44.  Tomita T, Doull V, Kimmel JR, Pollock HG. Diabetologia 1984; 27(4): 454-9. 46.  Petersson B, Lundqvist G, Andersson A. Experientia 1979; 35(1): 127-8. 48.  Lernmark Å, Hellman B. Life Sci 1969; 8(2): 53-9. 50.  Khan A, Chandramouli V, Ostenson CG, Berggren PO, Low H, Landau BR, et al. Endocrinology 1990; 126(5): 2413-6. 52.  Rosario LM, Atwater I, Rojas E. Q J Exp Physiol 1985; 70(1): 137-50. 54.  Fournier LA, Heick HM, Begin-Heick N. Biochem Cell Biol 1990; 68(1): 243-8. 56.  Black MA, Fournier LA, Heick HM, Begin-Heick N. Biochem J 1988; 249(2): 401-7. 58.  Black M, Heick HM, Begin-Heick N. Biochem J 1986; 238(3): 863-9. 60.  Ahmed M, Grapengiesser E. Endocrine 2001; 15(1): 73-8. 62.  Black MA, Heick HM, Begin-Heick N. Am J Physiol 1988; 255(6 Pt 1):E833-E8. 64.  Chen NG, Romsos DR. Endocrinology 1995; 136(2): 505-11. <![CDATA[IS BANGLADESH READY TO COPE WITH HER FUTURE DISEASE BURDEN?]]> Md. Abu Sayeed https://imcjms.com/journal_full_text/115 2016-10-10 14:05:34 Editorial Ibrahim Med. Coll. J. 2008; 2(1): i-ii Bangladesh is the most densely populated (913 per sq. km) country in the world. She is exposed to natural calamities  like flood, cyclone and tidal bore almost every year. Her population suffers from poverty, illiteracy and malnutrition. These three major factors produce a vicious cycle. High prevalence of low birth weight and protein energy malnutrition and parasitosis among infants and children leads to impaired immunity and susceptibility to infections; consequently, there is slower recovery, higher morbidity, higher disability and a higher mortality. Malnutrition and frequent infections in early life affects both growth (increase in physical size of the body) and development (increase in skills and functions). Thus, Bangladesh is being populated with an increasing proportion of inefficient and disabled man power. This results in severe limitations in national growth and development caught in this vicious cycle spanning from one generation to the next. According to mortality estimates of eight regions of the world in 1990, 98% of all deaths in children younger than 15 years are in the developing world1. The communicable diseases (CDs), maternal, perinatal, and nutritional disorders accounted for 17.2 million deaths, non-communicable diseases for 28.1 million deaths and injuries for 5.1 million deaths. Overall, five of the ten leading killers are CDs, perinatal, and nutritional disorders largely affecting children of the developing or disadvantaged communities. The non-communicable diseases (NCDs) were also found to be major public health challenges in the developing counties. Injuries, which account for 10% of global mortality, are often ignored as a major cause of death. It is likely that as a least developing country, Bangladesh has the same disease burden of both CDs and NCDs. For Bangladesh, we have very little information in this regard. There are some recent reports on the prevalence of diabetes2, hypertension3 and metabolic syndrome4 indicating that the prevalence of NCDs is on the increase5. Additionally, there are other population based studies that addressed nutritional status among the rural women and children. Some of these studies were recently conducted by the Department of Community Medicine, utilizing the students of Ibrahim Medical College in the community surveys as part of their academic exercise6. Three more studies are published elsewhere in this issue7–9. Although the sample sizes were small, these studies explored some important health problems, which are consistent with the above mentioned report1. So we have to consider the present disease load of malnutrition and CDs in the vast majority who are chronically exposed to extreme poverty and unhygienic environment creating a ‘susceptible population’ to be invaded by more and more diseases. Added to this, there has been an alarming increase of NCDs leading to chronic disabilities like stroke, nephropathy, retinopathy (even blindness), leg amputation etc. In short, we are finding the entire population on the verge of a disease disaster. What do we have to cope with this future disease burden? As we plan for future needs, we must also look for reasons for failures to contain the disease burden. The most common reasons are failure of compliance of Primary Health Care (PHC) like – a) a poor budgetary allocation for the health care b) equitable (not equal) distribution of health care is yet to be implemented and c) unavailability of and inaccessibility to health care. Even more important, as we see, is the lack of appropriate training and development of health personnel. A physician is a leader of a health team. The physician must be capable of guiding the health team. Therefore we must now look for quality in medical education and revival of moral and ethical values in professional conduct. It is imperative to address these issues with priority. We recommend that the possible implications of these needs and changing trends for human and economic development in a poorly-resourced healthcare setting in Bangladesh be addressed immediately to cope with the future disease burden.   Md. Abu Sayeed Professor Department of Community Medicine Ibrahim Medical College   1. Murray CJ, Lopez AD. Mortality by cause for eight regions of the world: Global Burden of Disease Study. Lancet 1997; 349(9061): 1269-76. 3. Sayeed MA, Mahtab H, Khanam PA, Latif ZA, Keramat Ali SM, Banu A, Ahren Bo and Azad Khan AK. Diabetes and Impaired Fasting Glycemia in a Rural Population of Bangladesh. Diabetes Care 2003; 26: 1034-1039. 5. Hussain A, Vaaler S, Sayeed MA, Mahtab H, Ali SMK and Azad Khan AK. Type 2 diabetes and impaired fasting blood glucose in rural Bangladesh: a population-based study. Eur J Public Health 2007; 17(3): 291-296. 7. Ahmed S, Mohsena M, Shirin S et al. Nutritional status, hypertension, proteinuria and glycosuria amongst the women of rural Bangladesh. Ibrahim Med Coll J 2008; 2(1): 21-24. 9. Rasul FB et al. Nutritional status, proteinuria and glycosuria among primary school children in a rural community of Bangladesh. Ibrahim Med Coll J 2008; 2(1): 36-37 [Letter]. <![CDATA[IN BANGLADESH DIABETES STARTS EARLIER NOW THAN 10 YEARS BACK: A BIRDEM STUDY]]> Parvin Akter Khanam Hajera Mahtab Ashraf Uddin Ahmed M. Abu Sayeed A K Azad Khan https://imcjms.com/journal_full_text/16 2016-08-02 08:09:45 Original Article Ibrahim Med. Coll. J. 2008; 2(1): 1-3 BIRDEM is the largest referral center of diabetes in the world. It registered more than 300,000 diabetic patients from 1956 to 2005. This retrospective study compared the biophysical characteristics of diabetic patients registered in 1995 to those registered in 2005. Information on social (income, education), clinical (height, weight, blood pressure) and oral glucose tolerance (OGTT) of patients registered in 1995 and 2005 were retrieved from the BIRDEM registry. The age group ³ 20y was considered eligible. Overall, there were 11489 patients for 1995 and 19580 for 2005. Compared with the registry of 1995, a significant increase of registry for female patients were observed (39.5 vs. 46.7%, p<0.001) and also the rural population (31.9 vs. 47.4%, p<0.001). Likewise, the number of poor social class was also found higher in 2005 (5.2 vs. 25.5%, p<0.001). Young aged (<40y) registry was also significantly higher in 2005 (34.4 vs. 37.1%, p<0.001). Compared with the registered patients of 1995, adjusted for sex and area, those of 2005 had a significantly higher BMI, higher FPG and higher 2hPG (for all, p<0.001). In contrast, a significantly lower age, lower height and lower blood pressure were observed in those of 2005. We conclude that the age at registration for diabetes has decreased significantly in 2005 compared to that in 1995 indicating an earlier onset of diabetes. Significantly higher obesity in the year 2005 than 1995 indicates that there has been an increase in obesity that might be an important contributing factor for earlier onset of diabetes. Introduction   When a patient is suspected of having diabetes, s(he) is usually referred to BIRDEM. The referral system is maintained not only for Dhaka but for almost all of Bangladesh. During registration each patient is interviewed with regard to social and demographic information. The variables are age, sex, family income, education, occupation and area of residence, height and weight and calculated body mass index (BMI). Systolic and diastolic blood pressure is also taken. Two-sample oral glucose tolerance (OGTT, WHO criteria) of each patient is undertaken for confirmation of diabetes. All information of the registered patients is preserved in computer using the SPSS package. These records of the diabetic patients registered in 1995 and 2005 were retrieved for analytical purposes.   A total of 30,588 diabetic subjects were investigated. 56% were males and 44% were females. Of them, 11671 (M= 7062, F= 4609) diabetic subjects were taken from 1995 and 18914 (M= 10077, F= 8837) were taken from 2005. Biophysical characteristics between 1995 and 2005: Table 1 shows the comparison of rural men and women of 1995 with their counterparts of 2005. Similar comparisons were made for urban and women of 1995 with those of 2005 (Table 2). Thus, adjusted for sex and area, compared with the registered patients of 1995, those of 2005 had a significantly higher BMI, higher FPG and higher 2hPG (for all, p<0.001). In contrast, significantly lower age, lower height and lower blood pressure were observed in those of 2005. Table-1: Comparison of characteristics between 1995 and 2005 for rural men (n: 1995/2005= 2093/4344) and women (n: 1995/2005=1232/3590) Table-2: Comparison of characteristics between 1995 and 2005 for urban men (n: 1995/2005= 4320/4730) and women (n: 1995/2005= 2895/4236) Table-3: Comparison of variables between subjects registered in 1995 and 2005. The registration of women increased from 39.5% in 1995 to 46.7% in 2005 (p<0.001) (Table 3). Likewise, the registration from rural diabetics had also increased (31.9 vs. 47.4%, p<0.001). Again, compared with 1995, the registration from poor class increased manifolds in 2005 (5.2 vs. 25.5%, p< 0.001). More interesting finding was that the diabetes registration from lower age (<40y) group had increased in 2005 than in 1995 (37.1 vs. 34.4 %, p<0.001). The prevalence of obesity (BMI>22.0) and insulin treatment at the time of registration was found significantly higher in 2005 than that of 1995. Discussion The registration from rural areas has also increased in 2005. It was reported that severe glycemia and proteinuria were registered from the rural population6. As already discussed, very few diabetic patients were registered at BIRDEM from rural community although 70% of Bangladeshis live in the rural area7. However, the policy makers should keep in mind that there is a possibility of undetected diabetes cases in the rural community and their number is not negligible. Conclusions   1.  Sayeed MA, Banu A, Khanam PA, Mahtab H, Azad Khan AK. Prevalence of hypertension in Bangladesh: Effect of socioeconomic risk factors on difference between rural and urban community. Bang Med Res Counc Bull 2002; 28(1): 7-18. 3.  Sayeed MA, Mahtab H, Khanam PA, Ahsan KA, Banu A, Bazlur Rashid ANM and Azad Khan AK. Diabetes and impaired fasting glycemia in the tribes of the Khagrachari Hill Tracts of Bangladesh. Diabetes Care 2004; 27(5): 1054-1059. 5.  Sayeed M A, Hussain M Z, Islam M A, Azad Khan A K. Characteristics of the diabetic subjects: BIRDEM diabetes registry, 1984. J Diab Assoc Bang 1994; 22(1): 8-20. 7.  Yusuf F H (Ed.). Statistical pocket book of Bangladesh 2004. Dhaka, Bureau of Statistics, Statistical Division, Ministry of Planning, Government of the People’s Republic of Bangladesh, 1984-5. 9.  Harris KM, Gordon-Larsen P, Chantala K, Udry JR. Longitudinal trends in race/ethnic disparities in leading health indicators from adolescence to young adulthood. Arch Pediatr Adolesc Med 2006; 160(1): 74-81. <![CDATA[SUPPLY-SIDE EFFECT OF HEALTH CARE FACILITIES ON PRODUCTIVITY AMONG THE FEMALE WORKER IN THE READYMADE GERMENT SECTOR]]> Md Aminul Haque Housne Ara Begum Homayra Fahmida https://imcjms.com/journal_full_text/17 2016-08-02 08:11:43 Original Article Ibrahim Med. Coll. J. 2008; 2(1): 4-8 Ibrahim Med. Coll. J. 2008; 2(1): 4-8 Key words: health care, supply-side effect, access, productivity. Address for Correspondence: Md Aminul Haque, Assistant Professor, Department of Population Sciences, University of Dhaka     The growth of export in the Ready Made Garment (RMG) sector from 1993 to 2004 showed that in 1993 it amounted to 61.4 percent of the country’s total export income, and by 2004 it was 78.05 percent. This indicates how rapidly the export of the RMG has grown4,5. In between this period, the level of employment has increased from some 10,000 to approximately 1.5 million today with a simultaneous increase in the manufacturing industry. As such, it was felt relevant to evaluate the overall health conditions of the female garments workers in Bangladesh as well as the health-care access to find out the relationship between the health care facilities of the female workers and its effects on overall productivity. Materials and Methods A semi-structured questionnaire was used for collecting information on the garment workers. It consisted of different sections, namely, socio-demographic, economic, health care facilities and access, unit production of garment pieces. Questions with predictable possible answers were pre-coded while some questions were kept open to get in-depth views of the respondents on several issues. The female workers working in different types of garment factories in Dhaka, Chittagong, Narayanganj and other districts of Bangladesh were selected. The working pattern and environment were similar in the garment factories of all districts. The types of the Garment Factories (GF) were knitting, dyeing, finishing etc. There are 3000 listed (approximate) GF in Dhaka city. The GF were selected randomly. The required numbers of female workers were selected by using the lottery method. A total of 300 female workers were randomly selected, which was taken from 1300 female workers out of four GFs.  Data cleaning, validation and analysis were performed using the SPSS software. Results In Dhaka, respondents came from all over the country, highest (16.3%) being from Barisal, age ranged from 15 to 19 years (56.0%) and 59.3% were in the unmarried adolescent group, mostly (58.4%) with primary education perhaps as a consequence to the Bangladesh Government’s free female education policy. About half (53.7%) of the respondents had to take care of their parents and brother/sister (49.0%). They also were taking care of the husband, father and mother  in-law, mother, children, husband and father (14.3%). The average income of the respondent was Taka 1791 ranging from Taka 900 to 3800 (Table-1). Table-1: Distribution of the respondents by monthly income No. of respondents £ 1000 13.7 49 1501-2000 51.7 55   Half of the respondents had 1501 to 2000 taka monthly income followed by 1 of 5 with more than Tk 2001. Almost one third respondents’ income was within 1001 to 1500 taka or less. The lowest income of the respondent was Tk 900 and the highest income of one respondent was Tk 3800 per month. Most respondents (62.3%) lived with their relatives and majority of the respondents (76.4%) (> 5 persons in a room) lived in polluted housing conditions, which are harmful for women, particularly those in their adolescence. It was observed that the respondents woke up very early in the morning (5:00 to 6:00 AM) and were busy until 12:00 midnight. It implies that the respondent’s life style was always under pressure and strenuous for their health. A total of three categories of garment jobs were included and among them 64.7% were found in the sewing section which was hard work and prone to sickness. Other sections were the finishing section (21.3%) and working as helpers (14.0%). Table 2 showed that the average number of products produced per day by the garment respondents were 1016 pieces ranging from 600 to 1600 pieces. Almost two-thirds (63.6%) of the garments worker produced 1000-1200 pieces per day. The average duration of over time work of the garment respondents was 3.83 hours with a range from 3 to 5 hours and almost all of them (92.6%) had to do over time work up to 4 hours. Table 2: Distribution of the respondents by per day product Frequency <1000 31.1 191 >1200 5.3 300   In this study, 1 of 4 (36.7%) respondents were not sick during the past one month whereas almost 1 of 2 (45.3%) were sick at least one time. Most of the women became sick (one time) in a month and suffered from physical weakness (81.0%), followed by vertigo & headache (49.1%), gastric pain (33.0%), pain in body (27.0%), common cough cold (22.3%), back pain (22.0%) and other diseases (such as  palpitation, frustration, dysentery, asthma, weight loss, holitosis, night sweating, painful eyes and itching). Most of the female workers suffered from physical weakness probably due to poor nutrition. It was observed that 64% of the workers faced abrasion, pricking, hand cutting, and fracture while working in the factories. It is seen in Table 3 that 43.7% respondents receive treatment from pharmacies followed by government hospitals (31.0%), non government hospitals (9.7%), kabiraj (9.3%) and homeopathy (6.0%).  Only savlon and paracetamol (98.0%) were supplied from the factory. There was no provision of doctors and also no provision of health care services to meet any emergency. Only three categories of persons were given some health care facilities at the factory- floor in charge (36.0%), store keeper (34.7%) and supervisor (28.7%). In this study it was found that majority of the respondents mentioned (86.7%) that they had provision of leave during family member’s sickness. The respondent could avail this leave without pay. They did not get any support or allowance during treatment of complicated diseases and emergency treatment of other family members. The respondents had no health education in the GF, no maternity leave, and no provision for breast feeding was available in the working place. Table-3: Distribution of the respondents by healthcare facilities Frequency Pharmacy 43.7 93 Non Govt. Hospital 9.7 28 Homeopathy 6.0 1 Total 100     Figure 2 shows per day hour loss mentioned by the 300 respondents expressed in hours and production loss for illness expressed in pieces. A significant positive correlation was found between hour loss and production loss for illness. The value of Pearson’s correlation coefficient was 0.9283 and it was significant (p<0.001). Therefore, there was a linear association between hour loss and production loss for illness in the study population. Fig-2: Correlation between hour and production loss for illness by the respondents         1.  Health Service Report of Bangladesh Garments Manufacturers and Exporters Association (BGMES). Dhaka, 2005. 3.  Majumder PP and Begum S. Upward Occupational Mobility Among Female Workers in the Garment Industry of Bangladesh. Research Report No. 153, Bangladesh Institute of Development Studies (BIDS). Dhaka, Bangladesh, 1997. 5.  Survey on Health Status of the Workers Employed in the Garment Sector of Bangladesh. Bangladesh Institute of Development Studies (BIDS). Dhaka. April-August, 1998. <![CDATA[REPRODUCTIVE HEALTH AND NUTRITIONAL STATUS OF GIRL STUDENTS IN AN URBAN AREA OF BANGLADESH]]> Tahera Parvin Seikh Farid Uddin Akter Sharmin Akhtar MA Jabbar AM Miah https://imcjms.com/journal_full_text/20 2016-08-02 08:22:06 Original Article Ibrahim Med. Coll. J. 2008; 2(1): 9-11 Abstract Methods: This cross sectional descriptive study was conducted in four selected girl’s high schools. A structured pre-tested questionnaire and a checklist were used to collect data through face-to-face interview and anthropometry. Conclusion: More than half of the adolescents were malnourished, practiced unhygienic protective measures during menstruation and disclosed different types of reproductive health complaints. Findings of the study strongly recommend that adolescent girls of urban Bangladesh need proper and appropriate management of their reproductive health problems. Introduction Adolescents are an important resource for their families, communities and nation. With proper attention, support, guidance and nurturing, their contribution and participation can be greatly enhanced. To improve the health status of this group there is an urgent need to identify and address the reproductive health needs and address the nutritional status of the adolescent girls. Materials and Methods   Among the selected 360 adolescent girls, less than half (45.8%) were found to have a BMI within the normal range (18.5-24.99). About half of the respondents (49.3%) had their BMI less than 18.5. Among the undernourished population, 15% of the total respondents had a BMI less than 16 with grade-3 under-nutrition. About 11.8% of the total had a BMI within the range of 16-16.99 with grade-2 under nutrition and 22.5% of the total were found to have BMI within the range of 17-18.49 with grade-1 under-nutrition. Only 4.6% had BMI ³ 25 representing the overweight portion of the respondents. The mean BMI was 18.9 ± 3.1 (Table1). Table-1: Nutrition status of the adolescent girls using BMI Interpretation (Kg/sq.m.) (%) <16 (grade-3 under nutrition) 15.0 16-16.99 (grade-2 under nutrition) 11.8 17-18.49 (grade-1 under nutrition) 22.5 18.5-24.99 45.8 25-29.99 (grade-1 overweight) 4.3 30-39.99 (grade-2 overweight) 0.6 40 (grade-3 overweight) 0 Total 100.0       Number Pain in lower abdomen during menstruation 60.0 92 Excessive bleeding 24.5 141 Desquamation/soreness of vulva/thigh 24.5 29 Hygienic practices during menstruation:*   300 Sanitary/cotton pads 31.8 294 Wear under garments 52.9 70     This cross sectional study may not necessarily reflect the actual picture of the adolescent’s nutritional and reproductive health status of the country, but it reflects a picture of the less privileged group. In this study the mean age of the 360 respondents was 14.5 years, which also support the study done by Haseen F9 where the mean age at menarchae was 12.4 years. Lowest and highest age of the respondents was 9 and 15 years respectively that is consistent with other studies10,11. This similarity of the findings may be due to the respondents belonging to very similar socio-economic groups, living standards and nutritional status between the studies on the adolescent girls. Regarding reproductive health status, majority (83%) reported having some sort of complaints during or after menstruation, which is also reflected in the findings of BIRPERHT study10 where about 65% adolescents have had some menstrual problems. Considering menstrual problems, more than half (60%) experienced dysmenorrhoea, which is consistent with other study findings10,11. About one-fourth (25%) had complaints of per vaginal whitish discharge and the other one-fourth (25%) had desquamation or soreness in inner part of thigh or vulva. These findings may be due to improper drying of menstrual rags, use of rough cloths that become a vector for fungal infection and soreness, which ultimately leads to vaginal discharge. These results were also found in other studies11,13. Most of the respondents (84%) used old cloths during menstruation, which is an unhygienic practice and only 30% used sanitary or cotton pads that is considered hygienic. They practice unhygienic measures mostly due to monetary constrains and or ignorance. These findings correlate with other studies too9,14. Conclusion   1.   Anonymous. Young peoples health- A challenge for society. WHO Technical Report Series 731, Geneva 86: 11-23, 69. 3.   Hossain SMI, Bhuiya I, Rob AKU, Anam R. Directory of Organizations Working with adolescents/youth in Bangladesh. First Edition. Dhaka: Population Council 1998; 2-16. 5.   Anonymous. Adolescent health and development: Issues andStrategies. Empowering adolescent girls for sustainable human development: Bangladesh Country Report, South Asia Conference on Adolescents; 1998 July; New Delhi, India. Dhaka, Bangladesh 1998; 5: 9-12. 7.   Bangladesh Population Census 1991 Final Report. Dhaka: Bangladesh Bureau of Statistics 1994 Sept. Analytic Report Vol (1): 296. 9.   Vaidya RA, Shringi MS, Bhatt MA, Gajjar M, Joshi JV, Galvankar P et al. Menstrual pattern and growth of school girls in Mumbai. The Journal of Family Welfare 1998; 44(1): 66-71. 11.Begum R. Role of occupation and household access to food in nutritional assessment of slum people in Dhaka city (in Beaton G et al. Apprppriate use of anthropometric indices in children,1990 Dec. ACC/SCN State of the art series on nutrition policy discussion paper no.7. United Nations. Administrative committee on coordination/ sub committee on nutrition: 1-51 and Gibson RS. Anthropometric assessment, ed. In: Principles of nutritional assessment. Oxford University Press 1990: 155-160.) Dhaka: Bangladesh 1999; 13-17. 13.Haider SJ, Saleh SN, Kamal N, Gray A. Study of Adolescents: Dynamics of perception, Attitude, Knowledge and use of Reproductive health care. Population Council, Dhaka, Bangladesh 1997; 17-21. <![CDATA[EFFECTS OF PARBOILING AND PHYSICO-CHEMICAL CHARACTERISTICS OF RICE ON THE GLYCEMIC AND INSULINEMIC INDICES IN TYPE 2 DIABETIC SUBJECT]]> Shahana Parvin Qamrul Hasan Knud Erik Bach Knudsen Liaquat Ali https://imcjms.com/journal_full_text/109 2016-10-08 14:37:18 Original Article Ibrahim Med. Coll. J. 2008; 2(1): 12-16 Abstract Methods: Seventeen type 2 diabetic subjects ingested five test meals of 50g available carbohydrate as white bread, cooked rice with high (29%) and low amylose content (13%), undergoing different processing and gelatinization temperatures. The diets were taken in a random order after a 10h overnight fast with approximately 7 days interval as wash out period. Conclusions: In type 2 diabetic subjects the investigated rices were all low glycemic as compared to white bread, independent of parboiling and physico-chemical characteristics. The study showed that the amylose content, but not the gelatinization temperature, may be an useful criteria in selection of low GI rices irrespective of parboiling status. Address for Correspondence: Dr. Shahana Parvin, Associate Professor, Department of Biochemistry; Northern International Medical College; Plot #8A, Road # 7, Dhanmondi; Dhaka – 1205, Bangladesh, Phone: 880-2-9668018, 8621479 - 83; Ext – 228   Rice, the staple food, constituting up to 80% of the daily energy intake, is the main carbohydrate source of Bangladeshi population and is predominant in the daily diet for these people1. Diabetic subjects are especially prescribed starchy foods with low glycemic responses2. Wide variations have been observed in the glycemic responses to rice. Some studies have found a low glycemic response for rice compared to white bread3. In contrast, Miller found higher glycemic responses to rice than to white bread4. The aim of the study was to examine the relationship between parboiling and physico-chemical characteristics of different rice varieties and the impact on blood glucose and insulin responses in type 2 diabetic subjects. Materials and Methods Seventeen type 2 diabetic subjects (8 male, 9 female) were included in this study. The subjects were selected from the out-patients department of BIRDEM. Diabetes was diagnosed and classified by the WHO criteria5. Patients with acute or chronic complications of diabetes mellitus and those using insulin, oral contraceptives or steroids were excluded from the study. Pregnancy was also an exclusion criterion. All participants gave their written consent after being fully informed about the nature of the study. Methods Four varieties of rice and white bread as reference food, having 50g available carbohydrate were given to the subjects. The rice varieties (BR16, BR25 and BR32) were obtained from Bangladesh Rice Research Institute (BRRI), Gazipur, where they were grown, harvested, parboiled, husked and milled. White bread was baked in one batch, sliced and portioned. Each bread portion was kept frozen and removed from the freeze 45 mins before serving. The rice was boiled in excess water and cooked to its minimum cooking time to ensure the same degree of gelatinization of the starch. Physico-chemical characteristics of test food   All chemical analysis was determined in duplicates at the National Institute of Animal Science, Foulum, Denmark. Dry matter (DM) was determined by oven drying at 105ºC for 20h. Available carbohydrate was determined as total starch by an enzymatic colorimetric method8. Protein (N*6.25) was analyzed using a Kjell-Foss 16200 Autoanalyser and fat was determined after hydrolysis and diethyl ether extraction according to Stoldt9. Biochemical analysis   The incremental plasma glucose and insulin response areas were calculated geometrically according to Wolever and Jenkins10. Results were expressed as means ± SD. Data were analyzed by a two way analysis of variance (ANOVA) followed by paired t-tests of means if the ANOVA indicated significance. The limit of significance was set at p<0.05. Results     Variables Age (years, M±SD) BMI (M±SD) Waist-hip ratio (M±SD) Female : Male Rural : Urban Duration of diabetes (months- M±SD) Fasting plasma glucose (mmol/L, M±SD) Annual income (median-range) in US Dollars HbA1C (%, M±SD)       Non-parboiled and parboiled rice of the same variety did not show statistical difference in incremental glucose and insulin response areas (Table 3). This was also reflected in their GI values (50±7 for BR16pb and 52±7 for BR16np) (Table 3). Amylose content     Rice variety BR16pb BR32pb GT / Alkali spreading value 4 4 3 7 Equilibrium water content (%)* 11 26 28 28   Gel consistency: hard (<40 mm), medium (41-60 mm), soft (>61 mm); Length/breath ratio: long grain (³3.1), medium grain (2.1-3.0), short grain (£2.0) Table-3: Metabolic responses to test meals (n = 17 type 2 diabetic patients) WB BR16pb BR32pb 756±65a 391±69b 361±48b 100a 50 ± 7b 47 ± 4b 20184±1643 12811±1505 13011±1949 Results are expressed as mean ± SD. P<0.05 was taken as the level of significance. iAUC: Incremental area under cure; GI: glycemic index; WB: white bread. Means in the same row followed by different superscript letters are significantly different. Gelatinization Temperature (GT)   Rice is suitable for use as low glycemic diets in the dietary management of type 2 diabetic subjects. Interestingly it is widely believed particularly in Asia like Bangladesh that diabetic subjects should limit their rice intake due to a positive association between a high intake of rice and the risk of developing diabetes. As starch is the principal component of rice, the physicians and dieticians advise diabetics as well as cardiovascular patients with substantial restriction of this major carbohydrate source. To rationalize the advice, it is important to know their physicochemical properties and their biological responses. The substitution of calories and other nutrients may then be done on the basis of patient’s choice, socioeconomic capability and availability in the market. The low GI of rice may be due to a delayed enzymatic hydrolysis of the whole grains, a process that can be accelerated by grinding11. In contrast Miller et al. found high GI to a number of Australian rice varieties4. These discrepancies may be due to differences in the physico-chemical characteristics, processing and/or cooking time of the rice varieties. Differences in the cooking time may influence the degree of gelatinization of the rice starch and the glycemic responses12. In the present study, the minimum cooking time for the rice was estimated and applied, ensuring that ³90% of the rice kernels have full cooked centers. Thus, the low GI of rice in type 2 diabetic subjects found in the present study cannot be explained by the cooking time. The study found no effect of parboiling on plasma glucose and insulin responses as well as in the GI values. This is in accordance with the results of Miller, but in contrast to Casiragi4, 14. One explanation for the varying effects may be ascribed to the parboiling process used. In our study, a traditional parboiling process, adapted from BRRI, was applied. This method may be regarded as a relatively mild procedure compared to the parboiling process used in the industrial trade, e.g. pressure parboiling. The severity of parboiling has been shown to affect some of the physico-chemical properties of rice starch15. Panlasigui et al. suggested that GT might be a useful parameter to predict the variation in the metabolic responses observed for rices with similar amylose content12. From the study we found no differences in the plasma glucose and insulin responses in the study subjects after ingestion of parboiled rice with low and high GT. A number of reasons may explain this result. We cooked the rice samples to the estimated minimum cooking time. It is also possible that the parboiling process reduced a possible effect of GT on the glycemic and insulinemic responses. Finally, the two rice varieties varied in gel consistency, which may have acted as a confounding factor. Conclusions   1.  Choudhury OH. A review of literature on nutrition studies in Bangladesh. Dhaka: Bangladesh Institute of Development Studies, 1992. 3.  Jenkins DJA, Wolever TMS, Tailor RH, Barker H, Fielden H, Baldwin JM et al: Glycemic Index of foods: a physiological basis for carbohydrate exchange. Am J Clin Nutri 1981; 34: 362-366. 5.  WHO Study Group. Prevention of diabetes mellitus. WHO Technical Report Series no 844. World Health Organization, Geneva, 1994. 7.  Little RR, Hilder GB and Dawson EH. Differential effect of dilute alkali on 25 varieties of milled white rice. Cereal Chemists 1985;  35: 111-126. 9.  Stoldt W. Suggestions to standardize the determination of fat in foodstuffs. Fette, seifen, anstrichtsmitted 1952; 54: 206–207. 11.O’Dea K, Nestal PJ and Antonoff L. Physical factors influencing postprandial glucose and insulin responses to starch. Am J Clin Nutr 1980; 33: 760-765. 13.Kaplan NM. Hypertension and diabetes. In: Porte D Jr, Sherwin RS, editors. Ellenberg and Rifkin’s Diabetes Mellitus. 5th ed. Stamford Connecticut: Appleton and Lange 1996; 1097–1104. 15.Biswas SK and Juliano BO. Laboratory parboiling procedures and properties of parboiled rice from varieties differing in starch properties. Cereal Chemists 1988; 65: 417-423. 17.Sowbhagya CV, Ramesh BS and Ali SZ. Hydration, Swelling and solubility behavior of rice in relation to other physico-chemical properties. J Sci Food Agric 1994; 64: 1-7. <![CDATA[DIABETIC KETOACIDOSIS IN CHILDREN – AN EXPERIENCE IN A TERTIARY HOSPITAL]]> Bedowra Zabeen Jebun Nahar Fauzia Mohsin Kishwar Azad Nazmun Nahar https://imcjms.com/journal_full_text/110 2016-10-09 11:37:58 Original Article Ibrahim Med. Coll. J. 2008; 2(1): 17-20 Abstract Ibrahim Med. Coll. J. 2008; 2(1): 17-20 Key words: Ketosis, children, diabetes, BIRDEM Introduction BIRDEM is a tertiary level referral hospital. It is expected that childhood diabetics who visit this hospital represent the population (childhood diabetics) of Bangladesh as patients come to this hospital from almost all parts of the country.In this study we have reviewed the experience of a major paediatric diabetes care service over the last five years in respect of admissions for DKA, its etiology and outcome. Methods Results have been reported as mean ± SD. The detailed case records of the children were analyzed by SPSS programme. A p value of less than .05 was considered to be significant. Results         The median duration of polyuria and/or polydipsia varied between newly diagnosed and known diabetics (3.2 - 25d) (p<.001). Among other symptoms, 57.8 % had vomiting and 35.7% had abdominal pain. All patients presented with altered levels of consciousness and 35 (67.3%) were unconscious of different grades. Table-1: Glycaemic status in two groups Group I RBS 24 ± 8.4 13.8 ± 2.9   Blood urea was higher in the newly diagnosed patients but was not significant between the two groups (p<.738). Serum creatinine was higher in group I than group II (p<.031). Cholesterol level was also higher in group I than group II (p<.034). Mean pH was 7.18 ± 0.14 and HCO3 was 8.94 ± 6.6. There was no statistical difference between two groups. Complications noted were acute renal failure and cerebral edema. Three patients developed acute renal failure which improved after peritoneal dialysis. There were four episodes of cerebral oedema with two associated deaths. Table-2: Cause of deaths in children with DKA Group I Septicaemia 2 1 Cerebral oedema 1 2     This study provides a different picture regarding types of diabetes presenting with DKA. One FCPD and three secondary types presented with DKA which is different compared to the western world where mostly type 1 diabetic children present with DKA9. The frequency of DKA at onset of diabetes varies considerably from country to country. In our study, half of the patients presented with ketoacidosis which is similar to different studies where 25% to 40% of children are newly diagnosed10,11. Amongst the precipitating causes, infection was the commonest (50%) which is similar to a study in Sudan where acute infections accounted for 38% of the episodes12. In our study those in the age range 10-14 years suffered from DKA which was significant between the two groups and the mean age was 11.2 ± 4.4 years. The percentage of DKA cases in boys and girls is usually considered to be the same11,13. In our study, girls faced an increased risk of developing DKA at onset of diabetes mellitus. A study from Australia was analogous in many ways: Bui et al.14 found a ratio of 1.3:1.0 in newly diagnosed patients with DKA. Whilst newly diagnosed patients appeared to have a very short duration (3.2 days) of polyuria and polydispia, the known diabetics had a longer duration (25 days) in our study. Approximately 50% of the newly diagnosed patients had experienced polyuria and/or polydipsia for more than 2 wks14. The outcome of treatment in the whole group was good in 46 (86.7%) patients who recovered without complications. Five patients died, the causes of death being septicaemia (n= 2), cerebral oedema (n-2) and pneumonia (n=1). There was no significant difference in between the two groups regarding outcome (p< .707). Sepsis and cerebral oedema have been reported as cause of death in DKA patients in India22. Conclusion   1.   Scibilia J, Finegold D, Dorman J, Becker D, Drash A. Why do children with diabetes die? Acta Endocrinol 1986; Suppl 279: 326-333. 3.   James R. Gavin III, K.G.M.M Alberti et al. Report of the expert committee on the diagnosis and classification of Diabetes mellitus. Diabetes Care 1999; 22(Sup1): 5-17. 5.   Wolfsdorf J, Glaser N, Sperling M.A. Diabetic ketoacidosis in infants, children and adolescents. Diabetes Care 2006; 29(5): 1150-1159. 7.   ISPAD Guidelines 2000, Ed, PGF Swift, Publ, Med forum, Zeist, Netherlands. 9.   Glaser, Nicole, Kuppermann, Nathan. The evaluation and management of children with diabetic ketoacidosis in the emergency department. Paediatr Emerg Care 2004; 20(7): 477-481. 11.Pinkney J, Bingley P, Sawtell P. Presentation and progress of childhood diabetes mellitus: a prospective population-based study. Diabetoogia 1994; 37: 70-74. 13.Sebastiani L, Guglielmi A. The Eurodiab experience in Lazio. Ann Ig 1992; 4: 173-178. 15.Rosilio M, Cottton JB, Wieliczko MC et al. Factors associated with glycaemic control. A cross-sectional nationwide study in 2,579 French children with type 1 diabetes. Diabetes Care 1998; 21: 1146-1153. 17.Mortensen HB, Robertson KJ, Aanstoot HJ et al. Insulin management and metabolic control of type 1 diabetes mellitus in childhood and adolescence in 18 countries. Hvidore Study Group on Childhood Diabetes. Diabet Med 1998: 15: 752-759. 19.Glaser N, Barnett P, McCaslin I, et al.  Risk factors for cerebral edema in children with diabetic ketoacidosis: the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Eng J Med 2001; 344: 264 –269. 21.Edge JA, Hawkins MM, Winter DL, Dunger DB. The risk and outcome of cerebral oedema developing during diabetic ketoacidosis. Arch Dis Child 2001; 85: 16–22. <![CDATA[NUTRITIONAL STATUS, HYPERTENTION, PROTEINURIA AND GLYCOSURIA AMONGST THE WOMEN OF RURAL BANGLADESH]]> Shaila Ahmed Masuda Mohsena Sonia Shirin Nargis Parvin Niru Sultana Rishad Mahzabeen Masuma Akter Samia Sayeed MA Sayeed https://imcjms.com/journal_full_text/111 2016-10-09 12:43:11 Original Article Ibrahim Med. Coll. J. 2008; 2(1): 21-24 Methods and materials – A rural community was purposively selected in Sreepur thana of which four villages were selected randomly. The total population of all age groups was 14,165 and the eligible reproductive aged females were 3,820 based on age between 15 and 45 years. Sample size was estimated at 573 (15%) of the eligible participants depending on the availability of time and logistic support. The study design was to use a questionnaire related to age, education, family income, housing and sanitation. Height (ht), weight (wt) and blood pressure (BP) were measured. Urine protein was estimated. Clinical examinations noted the presence of anemia, jaundice, edema, ring-worm, scabies, goiter, xerophthalmia and gum bleeding. Body mass index (BMI) was calculated to determine their obesity or wasting. Conclusions – Despite time and logistic constraint, the study revealed that most of the rural women had a poor nutritional status (80% had BMI<23.0). The prevalence of hypertension and glycosuria were also not negligible. Vitamin deficiency disorders (xerophthalmia), gum-bleeding, angular stomatitis were also very high among them. The study also revealed that the poor social class had a significantly lower BMI, higher proteinuria and higher skin problems than their rich counterparts.    Introduction There are several published reports on the prevalence of hypertension and diabetes mellitus in the adult (³20y) population of India and Bangladesh1-3. It was also reported that there has been an increasing trend of these non-communicable diseases in the developing countries4. Additionally, some investigators opined that the more disadvantaged section of the population were more prone to develop hypertension and diabetes. It is also known that the rural women of Bangladesh are the disadvantaged class with regard to their social position, employment, wage, nutrition and health care5. Usually the rural women are not aware about hypertension, diabetes and kidney diseases. In this study a few specific health problems were selected like hypertension, proteinuria, glycosuria and nutritional status that may affect not only women as mothers but also their fetuses and lactating infants. Thus, the study was undertaken to assess the nutritional status and to determine the prevalence of hypertension, proteinuria and glycosuria among the women of reproductive age in the rural community. Materials and Methods     From a total of 3,820 eligible participants 501 took part in the investigation in four randomly selected villages [table 1]. The response rate was 87.4%. Table-1: Total population and the participants in the randomly selected 4 villages (n = 501)        Table-4: Prevalence of diseases/disorders due to deficiency Regarding nutritional deficiency, about half of the rural women (52%) had some form of signs related to Vit-A deficiency and 65% had signs of Vit-B complex deficiency either in the form of glossitis or of angular stomatitis or both. Of those with Vit-A deficiency, 52% complained of night blindness, 37% had Bitot’s spot plus night blindness, 3% had toad skin, 2% had Bitot’s spot and corneal / conjunctival xerosis. Of the vitamin B deficiency disorders, 65% presented with glossitis, 19% with angular stomatitis and 16% with both angular stomatitis and glossitis. Discussion This study attempted to explore the general health status of rural women who are almost always neglected from their early childhood. This is possibly the first study in a RFST programme that addressed the nutritional status of rural women of reproductive age and an attempt was made to determine the prevalence of hypertension, proteinuria and glycosuria among them. About one-third of these women were found to be illiterate, which is consistent to the national report5. Regarding nutritional status the BMI observed in this study does not differ from the previous reports1,6. Similarly, the prevalence of hypertension is almost comparable to other reported studies1,3,6. The prevalence of proteinuria could not be compared because of non-availability of data in this regard. It is also true, as mentioned that the cause(s) of proteinuria could not be detected. Same is the case with glycosuria prevalence – the cause and type of glycosuria remained undetected.   The study revealed that most of the rural women had a poor nutritional status (80% had BMI<23.0). Hypertension and glycosuria were frequently found but it goes undetected. Vitamin deficiency disorders (xerophthalmia, gum-bleeding, angular stomatitis) were also very high among them. It was also observed that the poor social class had a significantly lower BMI, higher proteinuria and higher skin lesions than their richer counterparts. Further study with a larger sample using adequate diagnostic tools may be undertaken to confirm these exploratory findings. Acknowledgement   1.Sayeed MA, Hussain MZ, Banu A, Ali L, Rumi MAK, Azad Khan AK. Effect of socioeconomic risk factor on difference between rural and urban in the prevalence of diabetes in Bangladesh. Diabetes Care 1997; 20: 551-555. 3.Gupta A, Gupta R, Sarna M, Rastogi S, Gupta VP, Kothari K. Prevalence of diabetes, impaired fasting glucose and insulin resistance syndrome in an urban Indian population. Diabetes Res Clin Pract 2003; 61: 69-76. 5.Hussain ST, Sikder AR. Population Census 2001, Preliminary Report. Bangladesh Bureau of Statistics, Statistics Division, Ministry of Planning, Government of the People’s Republic of Bangladesh. Parishankhan Bhaban, Agargaon, Sher-e-Banglanagar, Dhaka 2001.         Editor’s Note: Residential Field Site Training (RFST) is an academic and university requirement for the 4th year MBBS students. Students’ exposure to the rural community under this programme can be utilized in an effective and proper teaching environment. This paper shows that proper utilization of the allotted time can yield the desired goals. It is a culmination of the integration of teaching and practical application of research methods, community health problems, report writings, presentations, and group efforts. One such report was published in the last issue and we will publish further articles on RFST programs. <![CDATA[A FOLLOW UP ON BIOCHEMICAL PARAMETERS IN DENGUE PATIENTS ATTENDING BIRDEM HOSPITAL]]> Khwaja Nazim Uddin AKM Musa Wasim Md. Mohosinul Haque Rene Suzan Claude Sarker AKM Shaheen Ahmed https://imcjms.com/journal_full_text/18 2016-08-02 08:13:29 Clinical Case Report Ibrahim Med. Coll. J. 2008; 2(1): 25-27 During a one-year period between January to December 2002, a total of 84 cases were clinically diagnosed as dengue in the medical unit I of BIRDEM. They were classified into 4 groups: dengue fever (28), DHF-I (31), DHF-II (17), and DHF-III (8). Amongst the patients, 52 (61.9%) were males and 32 (38.1%) were females. SGPT and SGOT were above normal cutoff (40 IU) points in 64 (76.2%) and 73(86.9%) cases respectively. SGOT was higher than SGPT in most cases. S. Bilirubin was almost normal in all cases. S. Calcium level was low in a significant number of cases. Mean S. Ca was 8.69 ± 0.68 in case of DF and lower, i.e. 7.83 ± 0.66 in DHF-III. Mean Hb% also correlated with severity, i.e. 13.3 (SD ± 1.6) in DF and 14.8 ± 1.3 in DHF-III. ESR was lowest in DHF-III. Anti dengue IgM and IgG were done on 58 cases; 41 (70.7%) were IgM positive while 37 were positive for IgG. Address for Correspondence: Prof. Khwaja Nazim Uddin, Department of Internal Medicine, Ibrahim Medical College & BIRDEM, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000   Dengue virus infection is a serious cause of morbidity and mortality in most countries in the tropical and subtropical areas of the world and is considered to be one of the most important infectious diseases in these regions1. In most of the cases the disease can be managed well according to the guidelines provided by WHO2. In this study the biochemical parameters of 84 dengue patients admitted in medical unit I of BIRDEM were prospectively followed for 1 year between January to December 2002, with the view to relate important biochemical parameters (changes) to the severity of the disease. Methods   A total of 84 clinically diagnosed dengue infection were recruited. They were classified into 4 groups: 28 cases of dengue fever, 31 cases of DHF-I, 17 of DHF-II and 8 in DHF-III category. There were no patients in DHF-IV category (Table 1 and 2). The study population were all adults, age ranging between 26 to 63 years, 52 (61.9%) were males and 32 (38.1%) were females. The study showed that levels of SGOT and SGPT were significantly higher. SGPT and SGOT were above normal cutoff value (40IU) in 64 (76.2%) cases and in 73 (86.9%) cases respectively. SGOT was higher than SGPT in most cases. Highest value of SGOT and SGPT were 3320 IU/L and 2645 IU/L. S. bilirubin was normal in most cases. S. bilirubin above 2 mg/dl was found in 3 cases only. S. Calcium level was low in a significant number of patients. Mean S. Ca was 8.7 ± 0.7 mg/dl in case of DF and lower, i.e. 7.8 ± 0.7 mg/dl in DHF-III. The lowest value was 6.8 mg/dl. LDH, CPK and CKMB were found invariably raised, highest value of LDH, CPK and CKMB were 2500 (DHF I), 402 (DHF II) and 48 (DHF I). Mean Hb% also correlated with severity, i.e. 13.3 ± 1.6 in DF and 14.8 ± 1.3 in DHF-III. Overall TC was low. The lowest value of WBC count was 1200/cmm while the highest was 12800 with an average of 5000/cmm. The lowest ESR was 2 mm in 1st hr (DHF-III); highest was105 (DHF-II with secondary bacterial infection). Average was 22.7 mm in first hour. PCV and platelet count showed typical association – highest PCV and lowest platelet count were 53% (DHF III) and 7000/cmm (DHF II). Anti dengue IgM and IgG were done on 58 cases. 41 (70.7%) were IgM positive and 37 (63.7) were positive for IgG. Both IgM and IgG were positive in 22 (38%) cases. Table-1: Sex distribution of study population                         Sex Total DHF-I DHF=III 16 12 53 12 5 31 28 (33.3%) 17 (20.2%) 84 (100%) Table-2: Hematological and biochemical parameter of study population DF DHF II Total count (cmm) 5013 6316   25868 ESR (mm) 24 11 13 14 PCV 42.3 44.4 204 385 SGPT(IU/L) 110 582 0.6 0.9 Serum Ca (mg/dl) 8.3 7.8 8.15 8.08 Post prandial blood glucose (mmol/l) 9.2 14.2 19.7 27.7 Serum creatinine 1.0 1.4 572 856 CPK 113 154 21 23.7 Anti dengue IgM (%) 62 83 33 85   In this study we primarily focused on the biochemical indices of severity. Alhough WHO severity parameter does not include biochemical changes, several studies3,4 suggest that only WHO criteria of severity may not be sufficient to categorize and treat the patients of dengue, particularly those receiving tertiary level care, where mostly the complicated cases are dealt with. Within the several biochemical derangements found in this study, the detection of hypocalcemia demands special consideration. There is a scarcity of literature reporting hypocalcemia as a complicating factor of dengue. Only one case report5 is available describing severe hypocalcemia in a complicated dengue patient. Interestingly a significant number of patients in this series had hypocalcemia, and some of them were symptomatic. Hypocalcemia was correlated with conventional severity parameter; i.e. mean calcium level was lowest in DHF III patients. Another important biochemical parameter was amino-transferase: SGOT and SGPT were found to be isolated severity index; although they were not always correlated with grading of dengue but higher values were found to be associated with a higher morbidity. It was seen in another study that a higher transaminase level was associated with greater morbidity and mortality irrespective of grade of dengue6. Bilirubin was usually not raised significantly whatever the transferase levels were, which is very peculiar in dengue. Alkaline phosphatase was also not elevated significantly. Another interesting finding in this study was the invariable elevation of muscle enzymes, concentrations were higher in higher grade of dengue. This is may be due to subclinical myositis7. There are some reported cases of ARF in dengue following severe rhabdomyolysis with very high CPK values. In our cases serum creatinine and blood urea were not significantly raised, though there are reports of ARF following dengue infections8,9 which may be due to immune-complex deposition or severe rhabdomyolysis. In this study blood glucose was found higher in more severe cases. Control of blood sugar in diabetic dengue patients need special attention, as diabetes had shown to be a complicating factor of dengue10,11 There were some cases in which glucose intolerance developed with dengue, but more study is needed to establish an association between dengue and glucose intolerance. Hemoglobin, PCV and ESR maintained the usual correlations. ESR is not raised in uncomplicated cases12. In early stages raised ESR or high TC indicates secondary bacterial infection. Conclusion   1.  Parry J. Experts predict big rise in dengue fever in South East Asia. BMJ 2003; 327(7428): 1368. 3.  Balmaseda A, Hammond SN, Perez MA, et al. Assessment of the World Health Organization Scheme for Classification of Dengue Severity in Nicaragua. Am J Trop Med Hyg 2005; 73(6): 1059-62. 5.  Jirapinyo P, Treetrakarn A, Vajaradul C, Suvatte V. Dengue hemorrhagic fever: a case report with acute hepatic failure, protracted hypocalcemia, hyperamylasemia and an enlargement of pancreas. J Med Assoc Thai 1988; 71(9): 528-32. 7.  Kalita J, Misra UK, Mahadevan A, Shankar SK. Acute pure motor quadriplegia: is it dengue myositis? Electromyogr Clin Neurophysiol 2005; 45(6): 357-61. 9.  Wiwanitkit V. Acute renal failure in the fatal cases of dengue hemorrhagic fever: a summary in Thai death cases. Ren Fail 2005; 27(5): 647. 11.Cunha RV, Schatzmayr HG, Miagostovich MP, et al. Dengue epidemic in the State of Rio Grande do Norte, Brazil, in 1997. Trans R Soc Trop Med Hyg 1999; 93(3): 247-9. 13.Teruel-Lopez E. [Dengue. A review]. Invest Clin 1991; 32(4): 201-17. <![CDATA[UNRELATED DONOR MARROW TRANSPLANTATION FOR A CASE OF CHIÉDIAK-HIGASHI SYNDROME WITH HEREDITARY ELLIPTOCYTOSIS]]> Abu Sharif Moh’d Akramul Islam Md. Sirazul Islam Zakaria Muhammad Hawsawi https://imcjms.com/journal_full_text/112 2016-10-10 11:22:17 Clinical Case Report Ibrahim Med. Coll. J. 2008; 2(1): 28-31 Chédial-Higashi syndrome (CHS) in an autosomal recessive disease with delayed microbial killing caused by mutation of the lysosomal trafficking gene termed CHS1 (LYST) gene which is located in the long arm of human chromosome number one (1q)1,2. CHS was described first by Begnez Cesar in 1943 and later by Steinbrick in 1948, Chédial: in 1952 and Higashi in 19543. Chédial: described the full clinical and haematological features including large inclusion like peroxidase positive granules in the blood and bone marrow granulocytes4. About 50-80% of patients enter into an “accelerated phase” which is characterized by generalized lymphohistiocytic infiltrates, fever. jaundice, hepatosplenomegaly, lymphadenopathy, pancytopenia and bleeding5,6. The disease is often fatal in childhood as a result of infections, bleeding and development of accelerated lymphoma-like phase. Survival into the second and third decades has been reported but invariably leads to premature death7. After the first description of CHS to date, around 170 human cases are mentioned in the literature worldwide.   A seven year old partially albino Saudi boy, product of normal pregnancy and delivery was first admitted to Madinah Maternity and Children Hospital at the age of two years with the complaints of fever, diarrhoea and vomiting. Clinical examination and investigations revealed anaemia, neutropenia and thrombocytopenia (Pancytopenia), mild hepatosplenomegaly with mild unconjugated hyperbilirubinaemia. Since the age of one year he had been admitted to several hospitals for recurrent infections with similar presentations. Based on clinical findings and peripheral blood and bone marrow morphology i.e. giant abnormal granules in leucocytes and their precursors (Figures 1a and 1b), the child was diagnosed as a case of Chédial Higashi syndrome (CHS) with hereditary elliptocytosis (HE). Dominant elliptocytosis was confirmed by blood film morphological findings of both parents, one being normal and another having elliptocytosis. One of the paternal uncles (younger brother of father) of the patient had suffered from acute lymphoblastic leukemia at the age of eight years who died of his disease at the age of 11 years in spite of conventional chemotherapy. Fig-1a: Blood film showing elliptocytosis and giant inclusions in a polymorph (Wright’s stain). The parents are second-degree cousins and the boy is their first child. By this time, they have two other daughters and one more son all of whom are physically well. Fig-1b: Bone marrow smear showing giant inclusions in precursors and elliptocytosis of red cells (Wright’s stain). After initial diagnosis and counseling, the patient’s parents decided to go abroad (Germany) for further evaluation and management of the patient. The diagnosis was confirmed and a BMT was performed from an HLA-matched unrelated donor. BMT was successful and the patient is disease free after five years of follow up. He is cured of both CHS and HE as evidenced by clinical and morphological evaluation. He is now all right save for partial albinism. No more symptoms or signs of the disease are present. Haematological and biochemical parameters reveal normal findings including normal granularity of peripheral blood and bone marrow leucocytes and their precursors (Figure 2). Fig-2: Photomicrograph of bone marrow smear after successful ailogenic bone marrow transplantation. There is no evidence of’ elliptocytosis in red blood cells and no giant granules in mycloid precursors or polymorphs. (Wright-Giemsa stain) Discussion A significant number of CHS cases have been reported to off springs of consanguineous parents10,11 like our case. Other reports have mentioned children of unrelated parents12. CHS is a disease of infancy and early childhood and only few patients survive into their teenage. The homozygous children usually manifest by partial occulocutaneous albinism, pale retina, transient iriditides and photosensitive dermatitis, and later with recurrent pyogenic infections of respiratory tract, mouth, and skin with increased bleeding tendency5,6. The disease remains mostly quiescent in early childhood with minor infections in over 85% cases until changes to the lymphoma like “accelerated phase” which is characterized by refractory fever, jaundice, hepatosplenomegaly, lymphadenopathy, pancytopenia, coagulopathy, peripheral neuropathy and lymphohistiocytic organ infiltrates, leading to infections and death6,12,13 Approximately half of the patients develop neurological manifestations like peripheral neuropathy, long tract signs, seizures and mental impairment9,12. This child was healthy until 12 months of age when first presented with recurrent fever, hepatosplenomegaly, occasional diarrhoea and vomiting but no neurological manifestations probably due to early detection. Some patients present only with manifestations probably due to early detection. Some patients present only with albinism without any other clinical stigmata, even infections are absent11. Our patient was born with ashen-grey hair and light complexion (partial albinism) with normal eyes. Fukai et al. reported a case of a Japanese female child of consanguineous parents presenting with hyper-pigmented skin of sun-exposed areas. She was healthy until 12 years of age when she developed pneumonia with hepatosplenomegaly14. Thrombocytopenia and leucopenia present was probably due to storage pool defects and intra-medullary granulocyte destruction respectively. Most of the reported cases demonstrate thrombocytopenia, coagulopathy and leucopoenia3,8. In our case the clinical picture and laboratory data without biopsy indicates that the disease was in an “accelerated phase”. The importance of careful examination of blood film by an experienced morphologist (haemato-pathologist) cannot be overemphasized. The diagnosis becomes easier when the crucial leucocyte finding of abnormal giant granulation is detected. Since the disease is usually lethal in the first decade, BMT is the only curative approach. BMT from an unrelated donor may be an effective treatment option when sibling donors are not available.   1.  Ramsay M. Protein trafficking violations. Nat Genet 1996; 14: 242-5. 3.  Sato A. Chédiak and Higashi’s disease. Probable identity of “new leukocyte anomaly” (Chédiak) and “congenital gigantism of peroxidase granules” (Higashi) Tohoku J Exp Med 1955; 61: 201. 5.  Bejaoui M, Verber F, Girault D, Gaud C, Blanche S, Griscelli C et al. The accelerated phase of Chédial-Higashi syndrome. Arch Fr Pediatr 1989; 46: 733-6. 7.  Miale TB. The Chédiak-Higashi syndrome. Textbook of Laboratory Medicine: Hematology. 6th edition. St Louis: CV Mosby Co; 1982. 9.  Williams WJ, Beutler E, Erslev AJ, Lichtman MA. Chédiak-Higashi syndrome. In: Hematology. 4th edition. New york: McGraw-Hill Publishing Company, 1991; 821-4. 11.Katzot D, Richter K, Gierth-Fiebig K. Oculocutaneous albinism, imrnunodeticiency. Hematological diagnosis of minor abnormalities: a new autosomal recessive syndrome? Am J Med Genet 1994; 50: 224-7. 13.Harfi HA, Malik SA. Chédialc-Higashi syndrome: clinical, hematological and immunological improvement after splenectomy. Ann Allergy 1992; 69: 147-50. 15.Ayuro C, Defain TMV, Tissera G, Osta V, Bedroznik L. Chédiak-Higashi syndrome: a laboratory finding. Sangre (Barc) 1998; 43: 426-9. <![CDATA[GUILLAIN-BARRÉ SYNDROME ASSOCIATED WITH ACUTE HEV HEPATITIS]]> Rawshan Ara Khanam Mohammad Omar Faruq Rawshan Ali Basunia ASM Areef Ahsan https://imcjms.com/journal_full_text/113 2016-10-10 12:08:20 Clinical Case Report Ibrahim Med. Coll. J. 2008; 2(1): 32-34 Guillain-Barré Syndrome (GBS) otherwise known as Acute Inflammatory Polyneuritis, characterized by acute progressive limb weakness and aretlexia, is the prototype of a post infectious autoimmune disease. Two-thirds of the cases of GBS emerge from viral or bacterial infection. In August 2006, a 20 year old man presented at ICU, BIRDEM Hospital with a history of brief icteric illness followed by progressive bilateral symmetrical hypotonic aretlexic muscular weakness, bilateral infra-nuclear facial palsy and bulbar weakness. Later on, he was diagnosed as a case of GBS and acute hepatitis E. Up till now, only three cases of GBS associated with hepatitis E have been reported in the medical literature world wide. This is probably the 4th case to be reported. Address for Correspondence: Prof. Rawshan Ara Khanam, Department of Internal Medicine, Ibrahim Medical College & BIRDEM, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000   The incidence of the typical GBS has been reported to be relatively uniform between 0.6 and 4 cases per 100 000 per year thought-out the world1. In two thirds of cases there are occurrences of gastroenteritis or flu like illness within six weeks of onset of GBS2-3. Campylobacter jejuni is reported to be the most frequent antecedent pathogen followed by cytomegalovirus4. Association of GBS with viral hepatitis is well documented. Most of the reported associations are with acute hepatitis B5-6 and hepatitis A7. Few cases also have been reported with Hepatitis C8. Association of GBS with HEV hepatitis is rare. Only three such cases have been published so far9-11. Case Report On admission, he was conscious and mildly icteric. Respiratory rate was 24/min, pulse 100/min, blood pressure 150/80 mm of Hg and temperature 99° F. Systemic examination revealed mild tenderness in right hypochondrium and soft enlarged tender liver about 2 cm from the right costal margin. Neurological examination showed bilateral lower motor neuron (LMN) type facial palsy with evidence of dysphagia. Muscle power was 2/5 in all four limbs with diminished muscle tone. All the deep tendon and superficial reflexes were absent. Planter responses were equivocal. All sensory functions including touch, temperature and vibration were intact and there was no sign of meningeal irritation. Ultrasonography revealed hepatomegaly suggestive of acute hepatitis. Nerve conduction studies revealed both demyelinating and axonopathic sensory motor polyneuropathy. CSF study showed albumin 190 mg/dl with “0” cell count – suggestive of albuminocytologic dissociation.   GBS is a disease of peripheral nervous system, which is caused by aberrant immune response, directed against some components of peripheral nerves12. The targeted antigens may be gangliosides present on plasma membrane of cell (e.g. GM-1, GD-1a), Swchawnn cell neurons (nerve growth cone region). There are four common sub types based on clinical and neuro-physiological studies e.g. 1. Acute Inflammatory Demyelinating Polyneuropathy (AIDP), 2. Acute Motor Axonal Neuropathy (AMAN), 3. Acute Motor Sensory Axonal Neuropathy (AMSAN), 4. Millar Fisher’s Syndrome13. In rare cases, where nerve conduction studies cannot be done because of lack of recordable action potential, nerve biopsy can differentiate the subtypes. However this is done only for research purposes16-17. CSF studies shows raised protein and paucity of cell in 80% cases (albuminocytologic dissociation), in 20% cases CSF study is usually normal in first few days of illness18-19. In this case, albuminocytologic dissociation was present when the CSF was studied four days after admission.   1.  Hubhcs RAC, Rees JH. Clinical and epidemiological features of Guillain-Barré Syndrome. J Infect Dis 1997; 176(suppl): S92-98. 3.  Guillain- Barré Syndrome study group. Guillain-Barré Syndrome: an Italian multicentre case control study. Neurol Sci 2000; 21: 229-34. 5.  Berger JR, Ayyar R, Sharemata WA. Guillain-Barré Syndrome complicating acute hepatitis B. A case with detailed electrophysiological and immunological studies. Arch Neurol 1981; 38: 366-8. 7.  Chitamber SD. Fadnis RS, Joshi MS, Habbu A, Bhatia SG. J Med Virol 2006; 78(8): 1011-4. 9.  Sood A, Midha V, Sood N, Guillain-Barré Syndrome with Acute Hepatitis E. AM J Gastroenterol 2000; 95(12): 3667-8. 11.Kamani P, Baijal R, Amarapurkar D, Gupte P, Patel N, Kumar PH, Agal S. Guillain-Barré Syndrome associated with Acute Hepatitis E. Indian J Gastroenterol 2005; 24: 216. 13.Rchard AC Hughes, David R Cornblath, Lancet 2005; 336: 1653-66. 15.Ho TW, Mishu B Li CY, et al. Guillain-Barré Syndrome in northern China. Relationship to campylobacter jejuni infection and anti glycolipid antibodies. Brain 1995; 118: 597-605. 17.Barciano J, Figols J, Garcia A, et al. Fulminant Guillain-Barré Syndrome with universal excitability of peripheral nerves. A clinicopathological study. Muscle Nerve 1997; 20: 846-57. 19.Hughcs RAC. Guillain-Barré Syndrome. Heidelberg: springerverlag; 1990. 21.Van der Mechc FGA, Schmitz PIM, Dutch. Guillain-Barre Study group. A randomized trial comparing intravenous immunoglobulin and plasma exchange in Guillain-Barre Syndrome, N Engl J Med 1992; 326: 1123-29. <![CDATA[KNOWLEDGE, ATTITUDE AND FEEDING PRACTICES AMONG THE MOTHERS HAVING UNDER-5 CHILDREN IN A RURAL COMMUNITY OF BANGLADESH]]> Mustafizur Rashid Khan Iftekhar Mahmud Sayeeda Samiha Md. Najibul Islam AFM Mahabubur Rahman Silvia Sohelin Ismat Jahan Tasira Sarram Rubayet Zereen KM Majidul Islam Md. Delowar Hossain Md. Abdur Rouf https://imcjms.com/journal_full_text/114 2016-10-10 14:01:12 Others Ibrahim Med. Coll. J. 2008; 2(1): 35   Maternal education is significantly related to early childhood morbidity and mortality. In Bangladesh, most mothers do not have a correct knowledge on exclusive breastfeeding and the appropriate time for introduction of weaning foods; and only 3% of them know how to prepare proper weaning foods1. Another study conducted in the rural population reported that according to Gomez classification, 96% of children had varying degrees of protein energy malnutrition (PEM) (28.4% mild, 58.2% moderate and 9.2% severe)2. Timely weaning, education and promotion of essential vaccination may reduce childhood malnutrition, especially severe PEM. It has also been reported that the prevalence of breastfeeding in Bangladesh is one of the highest in the world where diarrheal diseases are hyper-endemic and issues of breastfeeding in several diarrheal diseases have been well documented3. We undertook this study to determine knowledge, attitude and feeding behavior of the mothers in a rural community. A total of 500 families were visited in four villages. Of these families, 409 (81.1%) women were selected. Of the 91 non-participants, 85 women had no children below 5 years and only 6 women refused to participate. The mean age of the participants was 25 years (16-45y). The average family size was 4 (4-11) and the average monthly expenditure was 3751 (500- 15000) taka. About 25% were illiterate and 95% were housewives. Most of the families had access to tube well water for drinking and domestic purposes. Of them, 94% had living rooms with corrugated tin sheet. It may be concluded that about one-fourth of the rural mothers were illiterate though the feeding practices for their children during fever and diarrhea were satisfactory (70 – 88%). As regards weaning practices, about 38% were found not giving their babies supplementary food and almost one-third did not know the beneficial effects of fruits and vegetables for their babies. The low income and high illiteracy among rural mothers were found to affect the rearing practices and also nutrition during pregnancy and lactation. More studies are needed to confirm our findings and it is important to initiate programs for educating mothers with special emphasis on energy dense food during pregnancy and lactation and to emphasize the requirements of fruits and vegetables.   1.Das DK, Ahmed S. Knowledge and attitude of the Bangladeshi rural mothers regarding breastfeeding and weaning. Indian J Pediatr 1995; 62(2): 213-7. 3.Mitra AK, Rabbani F. The importance of breastfeeding in minimizing mortality and morbidity from diarrhoeal diseases: the Bangladesh perspective. J Diarrhoeal Dis Res 1995; 13(1): 1-2. <![CDATA[NUTRITIONAL STATUS, PROTEINURIA AND GLYCOSURIA AMONG PRIMARY SCHOOL CHILDREN IN A RURAL COMMUNITY OF BANGLADESH]]> Fatema Binte Rasul Nandini Datta Md. Juber Alam Malabika Bardhan Afrina Shams Chowdhury Chowdhury Dilabiz Mahmood Md. Saif Bin Mizan Rajib Bhadra Roni Jhumur Ghosh Rifat Imam Majumder Saad Ahmed Ferdous Roksana Sherin Mahadi Hassan Md. Mamunur Rashid https://imcjms.com/journal_full_text/275 2018-01-20 15:37:35 Others Ibrahim Med. Coll. J. 2008; 2(1): 35-36 [Ibrahim Med. Coll. J. 2008; 2(1): 35-36] To the Editor This cross sectional study was conducted in the purposively selected four primary schools situated in 4 villages of Sreepur Thana. The villages were Satkhamair, Mulaid, Ansar Tapirbari and Tangra situated about 80 km off Dhaka City. All students of the primary schools were considered eligible for the investigation. The school teachers were contacted and the purpose of the study and procedural details were explained to them. We started interviewing the students one by one in a room provided by the school authority. The interviewing sessions included information on their socio-demographic characters like name, age, sex, housing, and the use of latrine and drinking water. The teachers helped us in assessing family income either by checking information from admission registry or personal impression. Then each student was examined for height, weight and mid-upper arm circumference (MAC) including signs of vit-A, vit-B, vit-C deficiency. The presence or absence of anemia and goiter as a sign of iron and iodine deficiency respectively were noted. Each student was provided with a test tube and instructions on how to collect his / her urine. Urine samples were examined for the presence of glucose with an enzyme (glucose oxidase) impregnated test-strip. Following the glucose-oxidase test, the urine was tested for the presence of protein in urine using salicylic sulfonic acid. The mean ± (SD) age was 8.5 (1.7) years. Their mean (SD) height, weight and MAC were 124.3 (10.2) cm, 21.0 (4.8) kg and 16.9 (1.7) cm, respectively. The estimated body mass index (BMI) was 13.5 (1.6) and body surface area (BSA) was 0.86 (0.13). The comparisons of age, height, weight, MUAC, BMI and BSA between male and female participants did not differ (data not shown). According to Gomez’ classification of nutritional status – only 13.8% was graded as “normal” and 7% as “3rd degree or severe malnutrition” [table 1].  The partial correlation as expected, the age was significantly (p<0.001 for all) correlated with height (r=0.79), weight (r=0.73) and MUAC (r=0.55). Similar correlations were also found with BMI and BSA (table not shown). Table 1. Nutritional status of the school children of age 6-12 years (n=456): Gomez’ classification N  (%) 63 (13.8) 222 (48.7) 139 (30.5) 32 (7.0) The prevalence of anemia was found among 18.7% of the children. Regarding oral hygiene, 55% of them had dental caries and 23.7% reported gum-bleeding during brushing of teeth. Skin examination revealed that 2.8% had scabies and 2.4% had fungal infection. Although proteinuria was detected among 2.2% of the participants there was no case of glycosuria. As regards nutritional deficiency, sign(s) of Vitamin A deficiency was found in 11.7% and Vitamin B deficiency in 29.3%. Visible goiter was detected in 1.3% of the participants [table-2]. Table 2. General clinical features and diseases and signs of micronutrient deficiency. N  (%)   1 (0.2) 86 (18.7) 6 (1.3)   109 (23.7) 253 (55.0)   13 (2.8) 11 (2.4) 10 (2.2) 0 (0)   54 (11.7) 135 (29.3) 6 (1.3) Although the investigation was conducted on a small sample (n = 460) from four purposively selected village-schools, very few reports are seen for this group in Bangladesh. There are several reports on nutrition in Bangladesh and other countries but those are mostly in the under-fives1, 2. Very few studies address the nutritional status of children and adolescents in the rural community. As there was no other anthropometric study of this age group it was not possible to compare our anthropometric findings to that of the others. According to Gomez’ classification, not even one-fifth of the study subjects had a “normal” nutritional status. This finding indicates that more than 80% of the children of age 6 – 12 years suffer from mild to severe malnutrition and about 40% suffer from moderate to severe malnutrition. Fatema Binte Rasul, Nandini Datta, Md. Juber Alam, Chowdhury Dilabiz Mahmood, Md. Saif Bin Mizan, Saad Ahmed Ferdous, Roksana Sherin, Mahadi Hassan,   1.  Faruque AS, Khan AI, Malek MA, Huq S, Wahed MA, Salam MA, Fuchs GJ, Khaled MA. ICDDR,B: Center for Health and Population Research, Dhaka, Bangladesh. gfaruque@icddrb.org <![CDATA[Past, Present and Future of Laparoscopic Surgery]]> Prof. H. Kabir Chowdhury https://imcjms.com/journal_full_text/118 2016-10-22 09:32:13 Editorial Ibrahim Med. Coll. J. 2007; 1(2): i-ii Laparoscopic Surgery has revolutionized the surgical arena and brought the greatest changes in the technical practice of surgery. It has evolved as a part of general surgery with the introduction of laparoscopic cholecystectomy and very soon found its place in the surgical practice, mostly due to its great patient demand, which the surgeons could not deny. The benefits conferred to patients by less invasive procedures, minimum scar, decreased pain, shorter hospital stay and shorter recovery all took this technology to a new height. Loss of work became less and most of all fear of surgery diminished substantially. Such a revolution was not without a history. Dr. Carl Johan August Langenbuch, a German surgeon performed the first Cholecystectomy on 15th June 1882 on a 42-year-old man and almost one hundred years later in 1987 a French gynecologist Dr. Philip Mouret performed the first laparoscopic Cholecystectomy. An Arab physician Abul Kasi (936-1013 A.D.) first used a reflected light to examine the cervix, which was the first attempt to examine an internal organ1. Bozzani of Frankfurt in 1805 reported an attempt to visualize the urethra and bladder with a crude instrument called ‘Licht Leiter’ using a candle as a light source. Segal in 1826 developed a urethroscope. In 1867, Andrews introduced the idea of a burning Magnesium wire in a kerosene flame to provide better light and after Edison invented electric light in 1880, it was used as a light source. In 1901, Ott, a famous Petrograd gynaecologist introduced the idea of examining the abdomen through a small incision, which he called ventroscopy2. Kelling, a surgeon from Dresdon examined a living dog’s abdomen with cystoscope and called it clioscopy3. In 1910 Jacobaeus of Stockholm first used the word Laparoscopy where pneumoperitonium was done with air and in 1942 he reported 115 laparoscopic examinations used primarily to diagnose cirrhosis, metastatic cancer or tuberculosis4. Zolli Kofer from Switzerland in 1924 introduced the use of CO2 for insuflation5. Kalk developed a new system of lens in 1929 and Professor Horold H.Hopkins of University of Reading in 1976 developed the rod lens system6. In 1950 Geotze and Veress developed insuflation needle, which is popularly known as Veress needle. The most important technological improvement necessary was the camera, and in 1980 a small colour, high-resolution camera became available to adapt a laparoscope. Since Dr. Philip Mouret of Lyon France did the first Laparoscopic Cholecystectomy, this new technology has advanced very rapidly. Both the surgeons and the patients took serious interest in this new kind of surgical approach. Industry started presenting new equipments almost every day. Soon appendicectomy, inguinal hernia repair, fundoplication for reflux oesophagitis, and splenectomy became routine procedure in the developed world. Now resection of colon surgery, rectopaxy for rectal prolapse, partial and total gastrectomy, pancreatic tumor surgery, pseudopancreatic cyst operation and even a Whippple’s procedure can be done using this new technology. Adrenalectomy both by trans abdominal and retroperitoneal approach is done routinely in many centers. In the acute abdominal conditions laparoscopic surgery has proved to be very useful. Perforation of the duodenal ulcer, acute appendicitis, acute cholecystitis, intestinal obstruction, gynecological emergencies like twisted ovarian cyst, ruptured ectopic pregnancy etc, has seen the successful use of Laparoscopic technique. Orthopaedic surgeons have used this to do spinal surgery. In many centres urologists are routinely using this to remove stones from the kidney pelvis. Even in kidney transplant, the donor kidney is being removed laparoscopically. Developments in creating artificial space around the target organ have helped surgeons to approach the thyroid, parathyriod, and the breast. Retroperitoneal adrenalectomy, and extraperitoneal hernia repair have found place in routine operating lists in many centers. Cardiac surgeons are doing bypass procedures and also using robotic arms to achieve perfection in the procedure. Development of new equipments have helped the surgeons to achieve this in such a short time. Among the new equipments, one of the most useful and popular one is the Harmonic scalpel, which helps to coagulate tissue and divide it without producing lateral heat and as a result does not damage the surrounding tissue. For most of the advanced laparoscopic procedures it is a very useful tool. There are newer diathermy equipments, robotic arms to minimize number of assistants, newer camera systems with 3D vision, head hold LCD screen and voice operated computers to adjust different settings during surgery. Natural orifice transluminal endoscopic surgery (NOTES), is the most recent adventure of surgery, which is still in its infancy. There are reports of some experimental transgastric and transvaginal cholecystectomy and appendicectomy done in few centers. Bangladesh did not stay back to accept and start this new technology. In 1991 for the first time in Bangladesh a Japanese Surgeon, Prof Hashimoto demonstrated this technique at BIRDEM hospital and then since early 1993 we started laparoscopic surgery on a regular basis in the country. Very rapidly a good number of surgeons got trained and the procedure spread throughout the country both in government and private sectors. At BIRDEM apart from cholecystectomy we have performed laparoscopic procedures in appendicectomy, vagotomy, gastrojejunostomy, hemicolectomy fundoplication, choledocholithotomy, splenectomy, abdomino-perineal resection of rectum, hernioplasty for both inguinal and incisional hernia, repair of chronic duodenal ulcer perforation, drainage of liver abscess, thoracic sympathectomy, adrenalectomy, thyroidectomy etc. Most of the advanced procedures that are now done laparoscopically around the world are being conducted at BIRDEM hospital. Other surgeons interested in laparoscopic surgery in the country are also doing lots of advanced procedures. With a new approach to a standard operation, many of the principles of surgery need to be reemphasized and new areas of technology need to be learnt. Training of the young doctors and trained general surgeons need attention of the surgical societies.  Credentialing of the surgeons demands serious thoughts for near future; basic principles in selecting the criteria may include trained general surgeons capable of managing complications of open surgery, attending hands on workshops and experience in supervised and proctored performance of laparoscopic surgery. Surgery of the future will be increasingly fast, increasingly safe and increasingly cheap. Voice controlled robots now can perform many procedures. These are improvements on natural human precision, stamina, speed and calmness. Intercontinental telesurgery has passed the test of science in 1998. Laparoscopic cholecystectomy was done on a patient in USA by a surgeon from Singapore by using satellite communication and robot. Next generation robots will communicate tactile information to the surgeons. In a number of centers robots are being used to do laparoscopic surgery routinely. The application of laparoscopy in current surgical practice is undergoing constant changes and rapid developments. These developments have to be weighed against over-enthusiasm and the problems created by a lack of familiarity with new techniques and instruments. Proper training and exposure to this technology is must to avoid complications. Active interest and innovation could make this patient friendly surgical technique revolutionize the whole surgical arena of the present world, both for the poor and the rich. The growth of science and technology suggests that the techniques our future surgeons will use to perform surgical procedures is now beyond our imagination. So we have no time left to catch-up with the present and prepare for the future.   1.  Filipi CJ, Fitzgibbons RJ, Salerno GM. Historical review: diagnostic Laparoscopy to laparoscopic cholecystectomy and beyond. In: Zucher KA, ed. Surgical laparoscopy, St. Louis: Quality Medical Publishing, 1991. 3.  Killing G. Uber Oesophagoscopie, Gastroscopie, and colioskpie. Munch med Wochenschr 1902; 49: 21. 5.  Wittman I. Peritoneoscopy. Budapest: Akademiai kiado 1966. <![CDATA[NEONATAL MORBIDITY AND MORTALITY PATTERN IN THE SPECIAL CARE BABY UNIT OF BIRDEM]]> Jabun Nahar Bedowara Zabeen Shahida Akhter Kishwar Azad Nazmun Nahar https://imcjms.com/journal_full_text/12 2016-08-02 07:53:00 Original Article Ibrahim Med. Coll. J. 2007; 1(2): 1-4 Ibrahim Med. Coll. J. 2007; 1(2): 1-4 Key Words: Neonates, morbidity, mortality, baby care. Address for Correspondence: Dr. Jebun Nahar, Department of Paediatrics, Ibrahim Medical College & BIRDEM, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000   Introduction The Millennium Development Goal for child survival cannot be met without substantial reduction in neonatal mortality. Very few studies have reported information on the neonatal situation in our country. This retrospective study was done at BIRDEM hospital to identify the main causes of neonatal morbidity and mortality.   Methods A total of 361 neonates were included in this cohort. The ratio of male (55.4%) and female (44.6%) neonates was 1:0.7. Most of the babies were born in this hospital (83%). About four-fifths of neonates were born by lower uterine caeserian section (81.4%) and two-thirds were admitted within first 24 hours of delivery. There were 219 (60.7%) premture deliveries with a mean gestational age of 35.6 ± 3.4 weeks and 174 LBW neonates with mean birth weight of 2420 ± 808 gm. According to their weight for gestational age, 78.4%, 13.9% and 7.8% were age appropriate for gestational age (AGA), small for gestational age (SGA) and large for gestational age (LGA) respectively. Major causes of morbidity were prematurity (60.7%), LBW (48.2%), jaundice (23.3%), SPA (10.8%), TTN (10.8%), RDS (6.4%) and sepsis (6.4%) (Table-1). Infants of diabetic mothers (63%) were also one of the major causes of morbidity.   Table-1: Neonatal morbidities at admission   Morbidity Sick neonates n (%) Deaths      n (%) Relative Risk of death (95% CI) Proportion of total (%)* Prematurity 210 (60.5) 27 (12.9) 0.55 (0.3-1.1) 71.1 LBW 167 (48.1) 25 (15.0) 3.9 (1.8-8.3) 65.8 IUGR 50 (14.4) 09 (18.0) 0.6 (0.3-1.1) 23.7 RDS 23 (6.6) 14 (60.9) 8.2 (5-13.6) 36.8 SPA 36 (10.4) 7 (19.4) 2 (0.9-4.1) 18.4 Sepsis/Pneumonia 26 (7.5) 6 (23.1) 2.3 (1.9-5) 15.9 MAS 06 (1.7) 1 (16.7) 1.3 (0.2-8.5) 2.6 *Congenital anomalies 03 (0.9) 3 (100.0)   7.9   *A neonate having more than one morbidity is counted in each category. Hence, the sum may be more than the total neonates or deaths in the study population.   Mortality rates in neonates were analysed. Half of all neonatal deaths occurred in the babies weighing less than 1500g of birth weight and in premature babies having gestational age less than 34 weeks (Table-3). Table-3: Neonatal mortality by birth weight and gestation period Birthweight/gestation Total No of deaths(%) <1500g 56 (16.1) 21 (55.3) 1500-2499g 111 (32) 08 (21.1) 2500g-3999g 167 (48.1) 08 (21.1) >/4000g 13 (3.7) 01 (02.6) <34weeks 71 (20.5) 19 (50.0) 34-37weeks 140 (40.3) 09 (23.7) >37weeks 136 (39.2) 10 (26.3) Outcome of babies born in this hospital (inborn) and of babies referred from other hospitals (outborn) was analyzed. Among inborn babies 23 (8%) expired, while 15 (25.4%) expired among outborn. The difference was significant (p <0.05). Primary causes of neonatal deaths for inborn and outborn are shown in Table-4. Prematurity with LBW and prematurity with or without respiratory distress syndrome were the dominant causes of death among inborn babies, while prematurity with RDS and SPA were the most important causes of mortality among the outborn neonates.   Table-4: Primary Causes of Neonatal Mortality Inborn & Outborn Compared   In our study about two-thirds of neonates were premature. High proportion of high-risk pregnancies may be responsible for this high incidence of prematurity. Respiratory distress (10.4%), jaundice (13.7%) and infection (10%) were the main presenting features among the admitted premature babies in our study. In a hospital based study6, the incidence of premature delivaries were 16.3%. Premature babies suffered adverse effects like respiratory distress, apnoea, infection and jaundice. According to one UNICEF report3, one third of neonates are born with LBW in Bangladesh. The high proportion of LBW (48.2%) in this study was similar to those reported from other tertiary level care centers in the country7,8.  Perinatal asphyxia is an important cause of neonatal morbidity and mortality. Several grades of perinatal asphyxia was observed in 103 (28.5%) newborns in the present study. Among them 38 (36.9%) had severe perinatal asphyxia. The incidence of perinatal asphyxia in our finding was similar to Chandra et al.’s finding from India11. In developing countries, neonatal sepsis is a great problem and dominates as the major cause of death16. It accounted for 16% of neonatal deaths in our study. 1.   Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: When? Where? Why? Lancet 2005; 9-18. 3.   UNICEF. The State of the World’s Children 2005. New York: UNICEF 2005. 5.   Chowdhury EM, Akter HH, Chongsuvivatwong V and Geater FA. Neonatal mortality in rural Bangladesh: An exploratory study. J. Health Population 2005; 23(1): 16-24. 7.   Rashid A, Ferdous S, Chowdhury T and Rahman F. Morbidity pattern and hospital outcome of neonates admitted in a tertiary level hospital in Bangladesh. Bangladesh J Child Health 2003; 27(1): 10-3. 9.   Hasan HSM, Fateha US, Abdullah AHM and Azad K. Neonatal jaundice: Experience at BIRDEM. Proceedings of the 4th National Conference and Scientific Seminar of Bangladesh Neonatal Forum 2004; Dhaka. 11.  Chandra S, Ramji S and Thirpuram S. Perinatal asphyxia: Multivariate analysis of risk factors in hospital births. Indian J. Paediatrics 1997; 34:      206-12. 13.  Manji KP, Massawe AW and Mgone JM. Birth weight and neonatal outcome at the Muhimbili Medical Centre, Dares-Salaam, Tanzania. East African Medical J 1998; 75(7): 382-7. 15.  Pankaj G, Rajeev K and DK Shukla. NICU in a community level hospital. Indian J. Paediatrics 2005; 72(1): 27-30. 17.  Ahmed FU, Alam MB, Bhuiyan SN. Birth weight specific neonatal mortality and morbidity in a birth cohort. Bangladesh J. Child Health 1999; 23(1/2): 1-5. <![CDATA[KNOWLEDGE ON AIDS AMONG THE ADOLECENT STUDIES OF TWO SELECTED COLLEGE OF DHAKA CITY]]> Sonia Shirin Shaila Ahmed https://imcjms.com/journal_full_text/13 2016-08-02 07:54:51 Original Article Ibrahim Med. Coll. J. 2007; 1(2): 5-8 Ibrahim Med. Coll. J. 2007; 1(2): 5-8 Key Words: HIV/AIDS, adolescents, awareness, Bangladesh Introduction AIDS has become a major public health concern throughout the world and is taking a major toll of human lives and spreading relentlessly1. By the mid 1980’s it was evident that the virus had spread largely unnoticed with a global effect2.WHO/UNAIDS estimates that world wide about 63 million men, women and children have been infected with HIV since the beginning of the epidemic3. In Bangladesh, the number of adolescents is around 31 million, or close to 26% of the total population4. Available statistics on AIDS patients since 1984 revealed quite a large number from this group of population5. It is estimated that about four million people have acquired HIV/AIDS in the South East Asia region; the majority of new infection occurring during adolescence6. Although Bangladesh has not reported any major figures of HIV/AIDS sufferers, little is known about its awareness amongst the adolescents. Various government and non-government agencies have conducted limited studies focusing primarily on adult population7. Adolescents, though vulnerable, have little or no knowledge on AIDS. This study was conducted on a number (139) of college going boys and girls to have some information about their awareness on this emerging problem in Bangladesh.Materials and Methods This descriptive type of study was conducted between April and June 2003. A total of 139 respondents were selected from two colleges, namely Notre Dame College (Boy’s) and Siddeshwari College (Girl’s) within Dhaka City. A face to face interview on the basis of their availability were conducted using a semi-structured questionnaire. The students’ knowledge on AIDS was calculated by constructing a score sheet. A total of 31 correct options were present against various questions on knowledge of AIDS. The following method was adopted for scoring: Each correct answer = 1mark. A score of 3 was assigned to those who could answer ³ 3 correct options against one question. A score of 2 was assigned when one answered at least 2 correct options against a question. A score of 1 was given for at least 1 correct option. Thus the total score for 31 correct answers was calculated, 31 being the highest achievable total mark. Based on this total score the following categories were made:    Good knowledge:    20 - 31     Average knowledge:   10 - 19    Poor knowledge:     <10   Respondents were asked about the consequence of AIDS. Their responses are shown in Table-1. Table-1: Distribution of the respondents by their knowledge on consequences of AIDS No of Respondents Premature death 81.9 7 Easy entrance of other diseases 3.6 26 Others (burden of society, social boycott etc.) 5.0 Prostitutes, blood receiver, sharing needle among drug addicts were high risk groups for contracting AIDS as stated by 133 (95.7%), 129 (92.8%) and 126 (90.6%) respondents respectively. Foetus of AIDS infected pregnant mothers, babies of nursing mothers and health personnel were also mentioned by some to be in the high risk group. The respondents’ knowledge on AIDS was calculated as per the score described in the methods section. This is shown in Table-2.   aspects of AIDS Score 1 Score 3 4 (2.9%) 132 (94.9%) 15 (10.8%) 10 (7.2%) 26 (18.7%) 41 (29.5%)                                                                             Poor Knowledge Average Knowledge Good Knowledge Total 14 (23.0) 9 (14.8) Arts 12 (50.0) 24 (100) 25 (46.3) 1 (1.9) Total 78 139             c = 10.750, df = 4, p = 0.030 Discussion This study attempts to determine the level of knowledge on AIDS amongst adolescent students. One male and a female college were selected for this purpose where the students were in their adolescence (16.8 ± 0.56 years). Similar age groups have been studied in China, Thailand, Zimbabweand USA8-12. Almost all the respondents heard the name of AIDS which was also true in other studies conducted within the country13,14. Similar to studies by Jingqi C et al.15 and Bari MA et al.13, more than 90% respondents did mention sexual relation, blood transfusion and sharing of needles as a major route of transmission of AIDS. Although trans-placental transmission was mentioned by 94.3% respondents in a study conducted by Peking University, China15, this was relatively unknown in our respondents. The major consequence of AIDS that is decreased immunity and vulnerability to various diseases was not known to many. While tabulating the score sheet, for disease transmission, 95% respondents received a score of 3. Study conducted in similar groups of respondents showed almost same level of knowledge (90%)13. Regarding high risk groups and prevention, majority of the respondents got a score of 2. The level of knowledge on HIV/AIDS focused that average knowledge was found among most of the respondents (56.1%). A similar study on Thai youths8 revealed same findings. But the level was much lower in other studies(1,16) while in the University of Central Florida, the young college students were much more knowledgeable on HIV/AIDS10. The students belonging to the Science group were perceptibly more knowledgeable than the other groups. The reasons could be two. One, better students opt for the science group, and two, biology as a subject is covered in this group. Almost all respondents (91.4%) mentioned the television as a source of information on AIDS. Several studies mentioned this as a powerful medium for gathering knowledge on recent topics including AIDS(7,12-14,16,17). Conclusion Respondents had very little knowledge on the consequences of HIV. Less than half had any knowledge about the role of condoms in preventing AIDS. Most of the respondents got information from the TV regarding AIDS. Mass media like TV should be more frequently utilized to disseminate information on HIV/AIDS, by focusing in-depth discussion on the consequences and role of condoms in preventing AIDS. The focus group should primarily be the adolescents who seem to be the most vulnerable and least targeted. References 2.    Mannan S, Alamgir ASM, Begum K. HIV/ AIDS and STD situation in Bangladesh. In: Hossain AMZ, editor. Yearly health situation report 2000. Institute of epidemiology disease control and research 2001: 122-24. 4.    UNESCO: Booklet 1 on Demographic profile for communication and advocacy strategies adolescent reproductive and sexual health. UNESCO PROAP Regional Clearing House on Population Education and Communication; Bangkok, Thailand, 1999. 6.    WHO: Strategies for adolescent health and development, South-East Asia Region: Report of an inter-country consultation. New Delhi, 26-29 May, 1998. 8.    Khan MI. Study on the relationship between premarital sexual experience and knowledge about HIV/ AIDS among Thai youth. Asia Pacific conference on reproductive health 2001, Feb 15-19; Philippine Trade Training Centre, Manila, Philippines. 10.  Brown EJ. AIDS related risk behavior of young college students. ABNF-J 2000 Mar-Apr; 11(2): 37-43. 12.  Campbell B, Mbizvo MT. Sexual behavior and HIV knowledge among adolescent boys in Zimbabwe. Cent Afr J Med 1994; 40(9): 245-50. 14.  Shahidullah MD, Bangali MA. Assessing awareness and perception of AIDS. JOPSOM 1990; 4(2): 47-52. 16.  Zamora RM, O’Brien EM, Mahinay MA. A study on the knowledge, attitude and practices of the general population in Davao city in terms of HIV/AIDS/STD issues. Asia Pacific conference on reproductive health 2001, Feb 15-19; Philippine Trade Training Centre, Manila, Philippines. <![CDATA[AGE AT MARRIAGE AND FERTILITY PATTERN OF ADOLESCENT MARRIED WOMEN IN RURAL BANGLADESH]]> Shaila Ahmed Shamsun Nahar Md. Nurul Amin Sonia Shirin https://imcjms.com/journal_full_text/14 2016-08-02 07:56:30 Original Article Ibrahim Med. Coll. J. 2007; 1(2): 9-12 This cross sectional descriptive study was conducted in two purposively selected rural areas of Faridpur district - Alfadanga and Boalmari. The objectives were to find out the age at marriage and fertility pattern amongst the adolescent married women residing in the study areas. A total of 426 women were selected purposively and interviewed using a pre-tested structured questionnaire. Most (97.2%) were in the age group of 15-19 years, being married by 15.5 ± 1.5 years. Although 57.5% had a secondary level education, almost all (97%) were found to be housewives. Monthly income was between Taka 2001-4000 in 41.3% of the households. Regarding fertility pattern, 19% of the adolescent women were found to be pregnant at the time of survey. The total fertility rate (TFR) among this age group was estimated to be 2.6 per woman. To help improve the situation, awareness on the negative consequences of early marriage and consequent childbearing needs to be created not only among the young adolescent girls but should be targeted towards their parents too. Introduction Early marriage is considered as a prime determinant of fertility in developing countries, given their relatively low contraceptive use. It leads to larger family sizes and rapid national population growth6. Because the adolescent population constitute the fertility potential cohort, their age at marriage and fertility behaviour has to be controlled effectively if national demographic goals are to be achieved on time. In view of the negative health, social and economic consequences of early marriage and early childbearing, it is also important to have a clear understanding of the marriage and fertility patterns of adolescents in order to design interventions to improve the situation. This study was designed to look into these patterns amongst the adolescent girls living in a rural setting. Methods and Materials Data were collected on socio-demographic variables including age at marriage, fertility pattern of the adolescent girls (current status of pregnancy, number of living children). Age specific fertility rate (ASFR) and total fertility rate (TFR) were estimated using standard calculations. Results More than half of the respondents (57.5%) had secondary level education whereas this percentage was only 27.2% among the husbands. Almost all (97.7%) were found to be housewives. Fifty eight percent of their husbands were working as day laborers and 41% of the households had a monthly income of Taka 2001-4000 (Table 1). Fig-1: Age specific fertility per 100 women Table-1: Socio-demographic characteristics of the respondents (n=426)   Among the selected socio-demographic characteristics, husband’s education was found to be significantly associated with respondent’s age at marriage while respondent’s education and her occupation had significant association with the number of living children (Tables 2 and 3). The TFR of the study population was calculated to be 2.6 per woman. Table-2: Respondents’ age at marriage and demographic characteristics (n=426)       Figures in the parentheses denote corresponding %; Data were analysed using Chi-squared (c2) Test. Discussion Education up to secondary level was seen to be higher in the women (57.5% vs 27.2%) than their husbands. Bangladesh Fertility Survey (BFS) conducted in 1989, found 70% of the married adolescents to be illiterate and only 13% had seven or more years of schooling7. Higher education level may have a significant effect in reducing the incidence of teenage marriage. Regarding husband’s occupation, it was seen that 58.0% of them were working as day laborers whereas the percentage found in BFS 1989 was 70%. Monthly income was between Taka 2001- 4000 in 41% of the households. It was found that 19% adolescents were pregnant during the time of survey. Thirty five percent of the women had one living child while 3.5% had two living children. Bangladesh Demographic and Health Survey (BDHS) 1996/97, found the percentage of females who were mothers by age 15, 16, 17, 18 and 19 to be 8.5%, 23.5%, 32.6%, 43.2% and 54.6% respectively. In that survey, the age specific fertility rate (ASFR) among the 15-19 year age group was found to be 147 per 1000 women8. The corresponding data found in BDHS 2004 was 142 per 1000 women9. These data differ from the one found in this study which was 410 per 1000 women. This may be due to the fact that the denominators used in those surveys were quite different from the one used in this study. The ASFR in the 15-19 year age group found in Philipines, Indonesia, Pakistan and India was 50, 61, 84 and 121 respectively1. BDHS 2004 also estimated TFR to be 3 per woman which is a little higher than the TFR of 2.6 per woman found in this study.   In this study, an attempt has been made to find out the age at marriage and the fertility pattern of adolescent married girls residing in rural areas of Bangladesh. The mean age at marriage was observed to be 15.5 ± 1.5 years which was below the minimum legal age for marriage of females. Although a trend towards increasing age at marriage is observed in this study, the rise is very slow and too little. The total fertility rate among this group was estimated to be 2.6 per woman. In order to reduce the rate of early marriage and childbearing, adolescents, their parents and communities should be made more aware of the negative health, social and economic consequences of these events. Such awareness could be created through social mobilization and information, education and communication campaigns. Opportunities for education, empowerment in decision making and employment outside the home for young women are likely to result in delayed marriage. Another important measure could be an extension of the interval between marriage and first birth through effective use of family planning methods. References 2.  Islam MM, Mahmud M. Marriage Patterns and Some Issues Related to Adolescent Marriage in Bangladesh. Asia-Pacific population Journal 1999; 11(3): 27-42. 4.  Singh S. Adolescent Childbearing in Developing Countries: A Global Review. Studies in Family Planning 1998; 29(2): 117-136. 6.  Islam MM. Adolescent Childbearing in Bangladesh. Asia-Pacific Population Journal 1999; 14(3): 73-87. 8.  Mitra SN, Al-Sabir A, Cross AR, Jamil K. Bangladesh Demographic and Health Survey 1996-97 (Dhaka, Mitra and Associates). <![CDATA[REPRODUCTIVE TRACT INFECTION AND TREATMENT SEEKING BEHAVIOUR OF THE MARRIED WOMEN OF REPRODUCTIVE AGE IN A SLUM OF DHAKA CITY]]> Mekhala Sarkar Seikh Farid Uddin Akter Md Zillur Rahman https://imcjms.com/journal_full_text/88 2016-09-21 09:54:12 Original Article Ibrahim Med. Coll. J. 2007; 1(2): 13-16 Objectives:To determine the proportion of reproductive tract infection (RTI) among the married women of reproductive age in a slum of Dhaka and to ascertain their treatment seeking behaviour. Place and period of the study:The study was undertaken from March to June in the year 2003 in the Naderkhan slum of Rayer Bazar area in Dhaka City. Conclusion:Although a considerable number of the married women of reproductive age living in the slum suffered from various types of RTIs, only one fourth of them received any sort of treatment, and that also mainly from the traditional healers. Bangladesh being a signatory to the MDG, maternal health is a priority area. Urban slums cannot be overlooked. Introduction RTIs are being increasingly recognized as a serious global health problem with impact on individual women and men, their families and communities. They can have severe consequences, including infertility, ectopic pregnancy, chronic pelvic pain, miscarriage, and increased risk of HIV transmission. The World Health Organization (WHO) estimates that each year, over 333 million new cases of curable sexually transmitted infections (STI) occur and most of them take place   in developing countries. RTIs that are not sexually transmitted are considered even more common2. In this study an attempt was made to determine the proportion of RTIs among the married women of reproductive age in a slum of Dhaka as well as to assess their treatment seeking behavior. As women of reproductive age are the most vulnerable to RTIs, the study was designed to confine it to this group2. Methods and Materials A total of 207 married women of reproductive age (15-49 years) who were not menstruating, not pregnant or not in immediate postnatal period (6 weeks after delivery) during the time of interview were identified as the study subjects. Data were collected through a face-to-face interview. The interview was conducted anonymously and privately. Results In these 207 married women, RTI was found in 94 (45.4%) women. These were categorised as: abnormal vaginal discharge (73.4%), lower abdominal pain (44.9%), painful coitus (41.5%), burning sensation during urination (28.7%), itching in genital area (20.2%) and pain during urination (8.5%). The mean duration of abnormal vaginal discharge was 39.87 ± 35.15 months.     Characteristics  Yes(%)                    No(%) Test statistic Illiterate 83 (60.1)   10 (55.6) 18 (8.7) Class 1-5 16 (45.7) p = 0.141 10 (62.5) 16 (7.7) Main occupation of the respondents 67 (52.8) 127 (61.4) Maid servant 29 (70.7) c2(3)=8.607 12 (42.9) 28 (13.5) Others 8 (72.7)   Nuclear 83 (53.2) c2(1)=0. 486 21 (41.2) 51 (24.6) Family size     20 (32.3) 62 (30) ³4 71 (49.0) p = 0.013     Yes 3744.6 t (205)=-.959 113 ±1119.5       Treatment providers Abnormal Vaginal discharge (n=28) Vaginal itching (n=6) Painful coitus (n=8) 17.9 33.3 12.5 25.0 - - 17.9 66.7 - 0.5 -   35.7 - 87.5 Discussion In this study only the married women of reproductive age, majority being in the age group of 15 to 19 years were selected. The mean age of the respondents (26.09 ± 8.06 years) made no statistically significant difference between the RTI positive and negative cases. This is similar to a study conducted by Hussain et al. in 1996 among the rural women, where also, age didn’t show any significant influence4. The above two findings in the context of educational status and monthly family income, runs contrary to our assumption that RTI will be more common among the poor socio- economic groups and in those with a lower level of education. No plausible explanation can be put forward but suggest to policy makers that due attention be given to all groups and not remain confined to the lower SES groups as far as mitigation of RTI is concerned. Larger families (³4) also contributed to higher RTI thus suggesting that the prevention program of RTI would be more effective if family planning services were incorporated at this point. Looking at the utilization pattern of different sources of treatment, except for dysuria and vaginal itching, most of the respondents sought treatment from traditional healers for rest of the symptoms of RTI. Several studies also reveal that acceptance of traditional medicine for reproductive health is due to a blind reliance on this6-10. This we need to take into consideration because such behaviour leads to patients receiving either inappropriate or insufficient medication. Conclusion   <![CDATA[GERIATRIC HEALTH PROBLEMS IN A RURAL COMMUNITY OF BANGLADESH]]> Shaila Ahmed Sonia Shirin Masuda Mohsena Nargis Parvin Niru Sultana Samia Sayed Rishad Mahzabeen Masuma Akter Md. Abu Sayeed https://imcjms.com/journal_full_text/98 2016-10-04 11:31:00 Original Article Ibrahim Med. Coll. J. 2007; 1(2): 17-20 This cross sectional descriptive study was conducted in some rural communities of Sreepur Thana during the month of April 2007. The study population included those aged 50 years or more and residing in the study areas. A total of 226 respondents were selected purposively and were interviewed using a pre-tested questionnaire. The objective of this study was to assess their socio economic condition and identify their health problems. Ibrahim Med. Coll. J. 2007; 1(2): 17-20 Indexing Words: Geriatric problems, old age, community health, RFST. Introduction Bangladesh, with one of the highest population densities (985/km sq) in the world, is projected to experience a dramatic growth in the absolute number of its population aged 60 years or older from the current level of approximately 7 million to 14 million by 20204. Very little is known about the health of the aged and its problems in Bangladesh. This study was undertaken to explore the health problems present among the elderly people residing in some rural areas of Bangladesh. Materials and Methods Systolic and diastolic blood pressure (SBP, DBP) were measured using a mercury sphygmomanometer after 10 minutes of complete physical relaxation. Fasting blood glucose (FBG) was estimated after about 12 hour fast using spectrophotometer [‘One Touch’ of LifeScan]. The subjects who had experience of chest pain with sweating were considered eligible for ECG. Geriatric population- The population which consisted of people aged 50 years and above was termed as geriatric population. Primary education- Education up to class five (5 academic years); Secondary education- Education up to class ten (10 academic years); Normal eyesight- Can perform daily activities without difficulty; Impaired eyesight- Has difficulty in performing daily activities; Hypertension (sHTN, dHTN) - systolic and diastolic pressure more than 135 and 85 mmHg, respectively. Impaired fasting glucose (IFG)- FBG 5.6-6.9 mmol/l; Type2 Diabetes mellitus (T2DM)- FBG e” 7.0 mmol/. Overall, 226 (121men and 105 women) senior subjects from four villages volunteered in the study. The mean ± SD values of the participants for age, SBP and DBP were 62 ± 11.4 y, 123 ± 18.8 and 74 ± 12.5 mmHg respectively. Among the participants, 64% were illiterate, 67% were somehow dependant on other earning member(s) of the families and 58% were unemployed (Table 1). Table-1: Socio-demographic characteristics of the respondents (n= 226) n Sex   121 / 105 Education   145      Primary 23.9 27 Employment status   95      Unemployed 58        Dependent 67.3 74 Sanitary latrine   193      Absent 14.6        Tube well 97.3 6   Impaired vision was found among 21.6% of elderly men and women. A large number of the participants (65.5%) had complaints of pain in their joints which could be attributed to arthralgia or arthritis, common in the elderly [Table 2]. The women were more affected than the men (52 v.48%, p <0.02). Lesser number of participants had complaints of chest pain associated with sweating (14.2%). Again, the women had a higher frequency of this symptom (65.6 v. 34.4%). Likewise, history of fall was also significantly higher in the elderly female than their male counterparts (p<0.05). Table-2: The prevalence of old-aged diseases or symptoms or events (n=226) Total n (%) Women (%)      Systolic hypertension 19 (47.5) 0.008          Visual impairment 29 (60.4) ns 40 (17.7) 24 (60.0)      Joint pain (Arthralgia/arthritis) 71 (48.0) 0.015 94 (41.6) 52 (55.3)      Cough (not categorized) 36 (69.2) 0.007 42 (18.6) 20 (38.9)      Chest pain (non-specific) 20 (40.0) 0.022 32 (14.2) 21 (65.6)   Regarding fasting blood sugar level, only 3 (9.7%) respondents had FBS level more than 6.9 mmol/l and were diagnosed as diabetic.   This cross-sectional study conducted in a rural community of Bangladesh is an exploratory attempt to detect the prevailing ailments in the elderly people. A total of 226 respondents were interviewed. The study had some limitations. It did not allow in depth exploration of the health problems and confirmation of diagnosis was not possible. ECG could be done on only 22 subjects where the only complaint used as a selection criterion was chest pain accompanied by sweating. In this group, the prevalence of LVH was 22.7% and IHD was 27.3%, which if extrapolated for the entire study population, would be 2.7 and 2.2%, respectively. Thus, the findings are consistent with a published report for both the sexes (2.6%) 6. The study revealed that the prevalence of hypertension, diabetes and ischemic heart disease among the elderly people in the rural community are not negligible. The complaints related to joints are more common than all the other symptoms or diseases of elderly people of rural Bangladesh. Compared with elderly men, the elderly women were found to have higher risks (higher SBP, chest pain with sweating, palpitation) related to atherosclerotic heart diseases. Conclusion and Recommendations   We are grateful to the Principal of IMC and his associates for the grant and logistic support to conduct this study. We are also thankful to the staff of Gono Shasthya Kendra (GSK), Sreepur Unit for their sincere cooperation throughout the study. We also acknowledge the sincerity of the IM-3 students whose relentless effort in collecting the data and involvement in the analysis made this study possible. References 2.  Gorman M. Global Ageing- the non governmental organization role in the developing world. Int J Epidemiol 2002; 31: 782-785. 4.  Solomons NW. Health and Ageing. In R. Flores. & S. Gillepsie,(eds.), Health and Nutrition: Emerging and Reemerging Issues in Developing Countries. Washington D.C.: International Food Policy Research Institute 2001. 6.  Musa AKM, Khan AH. Statistical Pocket Book of Bangladesh 2004: Bangladesh Bureau of Statistics, Planning Division, Ministry of Planning, Government of the Peoples’ Republic of Bangladesh. January 2006; 437-8. <![CDATA[OCCULT FOLLICULAR THYROID CARCINOMA - AN UNUSUALPRESENTATION OF MULTIPLE LYTIC BONY METASTASIS IN THE SKULL OF A 66-YEAR MALAY MAN]]> Md. Tahminur Rahman Venkatesh R. Naik Prokash Rao https://imcjms.com/journal_full_text/99 2016-10-04 11:48:46 Clinical Case Report Ibrahim Med. Coll. J. 2007; 1(2): 25-27 Abstract Ibrahim Med. Coll. J. 2007; 1(2): 25-27 Address for correspondence: Prof. Md. Tahminur Rahman, Department of Pathology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000 Introduction   A 66 year old Malay man presented with an occipito-parietal swelling for 2 years with a sudden rapid enlargement in the last one year. He had no constitutional symptoms before but for last 2 months he complained of dizziness, tinnitus, loss of weight and loss of appetite. On examination, the swelling measured 15x15 cm in size. There was no thyroid enlargement. Ultrasonogram (USG) of the thyroid and biochemical thyroid profile (T3, T4 & TSH) were normal. X-ray skull showed the mass was eroding the occipital bone. Fine needle aspiration cytology (FNAC) performed prior to resection was reported as suggestive of a metastatic lesion from thyroid (fig:1). Fig-1: showing the FNAC of the lesion. Clusters of follicular cells (black arrow head) and colloid (white arrow head) are easily recognizable in a bloody background (papanicolaou stain X 40 ) The magnetic imaging resonance (MRI) of brain done with contrast showed a large well defined lesion noted at the vertex measuring 12x10x1 l.6cin. There was destruction of part of the occipital bone and both parietal bones (Fig 2). Fig-2: MRI of brain with contrast showing destruction of occipital  & parietal bone & well defined lesion at vertex.     Follicular thyroid carcinoma usually presents as a thyroid nodule, with rare cases showing metastatic disease at diagnosis. The initial presentation of distant metastases in patients with thyroid carcinoma is an uncommon eventl. In  two large series distant metastases were present at the initial time  of diagnosis in about 4%of cases, 5-11% in follicular carcinoma  thyroid and 2% in papillary carcinoma thyroid. Metastatic tumors to the skull, though relatively rare most often come from the 1ung, breast, prostate and kidney. Metastasis to these unusual sites has often been associated with widespread internal metastatic disease having a poor prognosis. Atypical presentation in the form of a follicular carcinoma associated with hyperthyroidism from a hot nodule in the same lobe and occurrence of both anaplastic and follicular carcinomas are also reported. But occult follicular thyroid carcinoma presenting as multiple skull metastasis in an elderly without any thyroid abnormalities (no thyroid enlargement, biochemical and other thyroid function tests remaining within normal limits) are rare.   We report here this case to caution the clinicians to bear in mind about occult follicular carcinoma of thyroid as a differential diagnosis when they come across any lytic lesion of the skuIl. Also if there is no thyroid enlargement and biochemical thyroid profile is normal in such cases, they should advise computerized tomography (CT), magnetic resonance imaging (MRI) and FNAC, histopathology of the lesion for early, correct diagnosis to exclude metastatic thyroid malignancies for better treatment of the patient. References 2.  Wong GK, Boet R, Poon WS. Ng HK. Lytic skull metastasis secondary to thyroid carcinoma in an adolescent. Hong Kong Med J 2002; 8(2): 149-5 I. 4.  Moudouni SM, En-Nia I, Rioux-Leclerq N, Manunta A, Guille F, L obel B. Follicular carcinoma of the thyroid metastasis to the kidney nine years after resection of the primary tumor. Ann Urol (Paris) 2002; 36(1): 36-7. 6.  Agarwal A, Mishra SK, Jain M. Follicular thyroid carcinoma with metastasis to the mandible. J Indian Med Assoc. 1998; 96(11): 354-5. <![CDATA[HEPATOBLASTOMA AS A RARE CAUSE OF PRECOCIOUS PUBERTY]]> Md. Abu Taher AHM Abdul Fattah Dilruba Khandker Abu Saleh Mohiuddin Md. Mahfuzar Rahman AKSM Shahidul Islam Akhtar Uddin Ahmed https://imcjms.com/journal_full_text/103 2016-10-06 14:16:39 Clinical Case Report Ibrahim Med. Coll. J. 2007; 1(2): 28-32 A 15-month old boy presented with an abdominal swelling and early development of secondary sexual characteristics for the last 5 months. The mass was initially suspected to be of adrenal origin. Radiological and biochemical (hormonal) findings diagnosed the case to be a hepatoblastoma later confirmed by histopathological examination. Hepatoblastoma, an aggressive primary liver tumor, is a rare form of childhood malignancy and a rare cause of precocious puberty compared to the more common adrenal causes including congenital adrenal hyperplasia, adrenal tumors and the testicular tumors. Thus, when virilization occurs postnatally in boys, or girls presenting with ambiguous genitalia at birth, a virilizing adrenocortical tumor is usually given the first consideration (according to its frequency of incidence), followed by CNS causes. Rarely does one think of the other possibilities. This report describes the typical presentations and clinical features of hepatoblastoma highlighting its usual radiological features. Key Words: Hepatoblastoma, precocious puberty, imaging features.   Precocious puberty is said to occur when secondary sexual characteristics develop in girls less than 8 years of age and boys before 9 years of age. In boys, 25-75% are found to have an underlying organic cause advocating the need for further investigations including CT & MRI of the abdomen and brain. Precocious puberty in them may be of a) true / central type which is gonadotropin dependent, due to the premature activation of the hypothalamic-pituitary axis (ie. CNS cause). These causes include hamartoma of the tuber cinereum (most common), midline mass lesions in and around the hypothalamus (including the pituitary), and the various causes of raised intracranial pressure. On the other hand, b) incomplete / pseudo-precocious puberty is due to the autonomous secretion of sex steroids (i.e. androgens) or hCG. Its causes include congenital adrenal hyperplasia (CAH, due to deficiency of 21- & 11-b hydroxylase in 95% and 5% cases respectively), adrenal tumors (adenoma-30%, carcinoma-60%), and testicular tumors. The rarer causes of precocious puberty in boys are the hCG-secreting tumors (eg. hepatoblastoma, teratoma, germinoma of the pineal gland) and the McCune-Albright Syndrome. The present case Fig-1: A 15 months old boy with precocious puberty showing in (a) a mature looking face with fine moustache, in (b) distended abdomen and (c) a mass producing a visible bulge in the right hypochondrium. Hormonal assay revealed raised S.testosterone level- 3.15 ng/ml (normal post pubertal level is 3.4–14.0 ng/ml, pre pubertal level being barely recordable), S. Cortisol & DHEAS were within normal limits. The patient also had very high S. AFP (alpha-feto protein)- 27900ng/dl (normal level is 0.6-6.0ng/dl) and high b-hCG level-123.94mU/ml (normal is<7mU/ml). Radiological findings included           d)  CT-Abdomen and Lower Chest- A huge heterogeneous mass with scattered flecks of calcifications was found occupying almost the whole of the right lobe of the liver. On post contrast CT it showed heterogeneous enhancement with intervening lakes of hypodense areas possibly due to necrosis. The interface between the mass and skin and the diaphragm could not be well delineated and a spicule could be traced direct up through the diaphragm into the right lung field in the sagittal reconstructed view. Chest cuts also revealed numerous metastatic nodules in both lung fields. (Fig-4). Fig-4: CT abdomen and lower chest: (a) CE-CT shows a heterogeneous mass occupying almost the whole of the right lobe of the liver with flecks of calcifications. (b) CE-CT shows heterogeneous enhancement of the lesion with intervening hypodensities denoting lakes of necrosis. (c) CE-CT- Involvement of anterior abdominal wall by the lesion and right kidney is separate. (d) and (e) CT lower chest shows distinct nodules indicative of pulmonary metastasis in both lungs. (f) Sagittal reconstruction of CE-CT delineates the vertical extension of the mass lesion with upward protrusion through the diaphragm. In conformity with these typical imaging features, the impression was that it was a hepatoblastoma with probable extension into the anterolateral abdominal wall and lung metastasis.   In children, most hepatic neoplasms are malignant1. The hepatoblastoma (HB) is an extremely rare, highly aggressive primary liver tumor of childhood. Among the childhood hepatic neoplasms it is the most common one -54%, followed by HCC –35% and others –11%2. It is a tumor of embryonal hepatocytes or mesenchymal cells, histologically classified into a) epithelial and b) mixed varieties- which is useful for prognosis3,4. It forms 0.2-5.8% of all primary pediatric malignancies5. The majority appear within the first 3 years of life (rarely thereafter)1. They are more frequent in boys and occur most often in the right lobe of the liver (60%)6. Regarding the pathophysiology of the precocious pseudo-puberty in hepatoblastoma - the primitive hepatoblastoma cells secrete hCG which acts on LH-receptor of the testes, inducing them to release increased amounts of testosterone which results in sexual precocity in these patients 7-11 (Fig-5).   Common sites of metastasis include the lungs (most common, and often present- in 10-20% at presentation), brain, bone, bone marrow, ovary, orbit6.   Typically, ultrasonography (USG) is the initial imaging evaluation in these children. The usual sonographic and CT findings are those that were found in our patient. Because these lesions can invade vascular structures such as the portal and hepatic veins, careful assessment of these structures by color flow Doppler is essential. One literature describes the prenatal diagnosis of a case at 37 weeks gestational age by USG13. However, it is not an adequate method of image staging of the neoplasm. CT is done for staging to assess the feasibility of surgery both before and after chemotherapy. One group1 states that to assess the liver, CT is to be done by using biphasic (hepatic arterial and portal venous) dynamic contrast-enhanced spiral CT, followed by standard axial CT imaging of the remainder of the abdomen and chest. As in USG, thrombus may be found in the hepatic vein, portal vein and IVC. Metastases to bone and brain are rare, and therefore imaging is advised only if clinical signs and symptoms warrant doing so1.   Precocious pseudo puberty due to hepatoblastoma is extremely rare. A high index of suspicion is necessary on the part of the radiologists and endocrinologists by excluding usual causes like diseases of the adrenocortico-hypothalamo-pituitary axis. When a boy of 1-3 years presents with a mass in the right upper abdomen with typical physical and radiological features and hormonal assay findings, the possibility of this rare tumor should be kept in mind. Early diagnosis of hepatoblastoma is indispensible due to its highly aggressive nature. Appropriate and timely surgical and oncological interventions are worthwhile only in the early stages of the disease, which could lead to substantial reduction in the mortality and morbidity of the patient. Radiology and imaging plays a key role in the diagnosis adjuvant to biochemical parameters. Acknowledgement   1.  Pollock AN, Towbin RB, Charron M, and Meza MP. Imaging in Pediatric Endocrine Disorders. Sperling MA ed. In Pediatric Endocrinology, 2nd edn. Saunders: Philadelphia 2002: 567-569, 747-749. 3. McTavish JD, Ros PR. Hepatic Mass Lesions. Haaga JR, Lanzieri CF, and Gilkeson RC eds. In Computed Tomography and Magnetic Resonance Imaging of the Whole Body, 4th edn. Mosby: St. Louis, Missouri 2003: 1293 – 1294. 5. Thomas KE and Owens CM. The Paediatric Abdomen. Sutton D ed. In Textbook of Radiology and Imaging, 7th edn. Churchill Livingstone: Edinburgh 2003: 878 – 879. 7. Navarro C, Corretger JM, Sancho A, Rovira J, Morales L. Paraneoplastic precocious puberty: Report of a new case with hepatoblastoma and review of the literature. Cancer 1985; 56: 1725-1729. 9. Nakagawara A, Ikeda K, Tsuneyoshi M, Daimaru Y, Enjoji M, Watanabe I et al. Hepatoblastoma producing both alpha-fetoprotein and human chorionic gonadotropin: Clinicopathologic analysis of four cases and a review of the literature. Cancer 1985; 56: 1636-1642. 11. Murthy AS, Vawter GF, Lee AB, Jockin H, Filler RM. Hormonal bioassay of gonadotropin-producing hepatoblastoma. Arch Pathol Lab Med 1980; 104: 513-517. 13. Aviram R, Cohen IJ, Kornreich L, Braslavski D, Meizner I. Prenatal imaging of fetal hepatoblastoma. J Matern Fetal Neonatal Med 2005; 17: 157-159. 15. Czauderna P, Otte JB, Aronson DC, Gauthier F, Mackinlay G, Roebuck D et al. Childhood Liver Tumor Strategy Group of the International Society of Paediatric Oncology (SIOPEL): Guidelines for surgical treatment of hepatoblastoma in the modern era- recommendations from the SIOPEL. Eur J Cancer 2005; 41: 1031-1036. 17. Abbasoglu L, Gun F, Tansu Salman F, Relik A, Saraq F, Unuvar A et al. Hepatoblastoma in children. Acta Chir Belg 2004; 104: 318-321. <![CDATA[HEALTH ATTAINMENT IN BANGLADESH AS REFLECTED BY SELECTED PERFORMANCE INDICATORS: A REVIEW OF EVIDENCE]]> Azaher Ali Molla https://imcjms.com/journal_full_text/15 2016-08-02 07:57:45 Review Ibrahim Med. Coll. J. 2007; 1(2): 21-24 Ibrahim Med. Coll. J. 2007; 1(2): 21-24 Key Words: Performance indicators, health attainment. Address for Correspondence: Azaher Ali Molla, Institute of Health Economics, University of Dhaka   A substantial number of countries have indicated their interest in collaborating with the World Health Organization (WHO) in reviewing their own health system, and relate this to policy, thus contributing to future development of the assessment of methods and tools.   To provide the health improvement in the past and the present status of some selected indicators, the author has gone through different reports and publications. The Directorate of Health Services published the first organized report in 1985 followed by the 2nd in 1989, third in 1996, fourth in 1998-99 and the fifth in 1999-20001-5. These reports are reviewed here to see the trends of performance indicators in respect of good health. Data from UNICEF’s State of the Worlds’ Children, 1996, 1999 and 2003 are also included6-8. Low Birth Weight Data are obtained from National Low Birth Wight Survey 2003-049. Infant Mortality Rates for the year 1989 to 2003 period are provided from BDHS 200410 . Two other goals of the health sector performance i.e. fair financial contribution and responsiveness were not reviewed here due to lack / shortage of data. Health Attainments Crude Birth and Death Rate (CBR and CDR): The crude birth rate per 1,000 population was 33.6 in 1985. This rate remained unchanged in 1989, followed by a trend of decline up to 2001, where it stood at 19.9 per 1,000 (figure 2). The crude death rate per 1,000 population also showed a decreasing pattern, from 11.6 in 1985 to 4.6 per 1,000 in 2001 (figure 3). Maternal Mortality Ratio (MMR): The data showed a remarkable decline from 7 in 1985 to 3/1000 live births in 2001 (figure 6). There remains a possibility that some of the reported ‘accidental’ deaths might have been included in the MMR.   These days, the long-term measure of good health is life expectancy. For the nation as a whole, life expectancy has increased from just over 53 years at birth to 61 years between 1985 and 2001. Women in developed countries almost always have higher life expectancies than men11.Currently, the worldwide life expectancy for all people is 64.3 years but for males it is 62.7 years while for females, it is 66 years, a difference of more than three years. The sex difference ranges from four to six years in North America and Europe to more than 13 years between men and women in Russia, whereas in Bangladesh females had a lower life expectancy than males till 200111. This reverse statistics indicates a disadvantageous position of women in this society. At the same time, narrowing the gap between life expectancies of male and female over this period indicates that ‘inequality’ and ‘gender discrimination’ issues are being rightly addressed in different health, education and awareness programs. WHO credits this increase in life expectancy to the decline in infant and child mortality due to the successful implementation of certain health programs like immunization as well as disease control programs such as those for ARI and diarrhoeal diseases11. The infant mortality rate (IMR) has been criticizedas a measure of population health because it is narrowly basedand likely to focus the attention of health policy on a smallpart of the population to the exclusion of the rest. More comprehensivemeasures such as disability-adjusted life expectancy (DALE)have come into favor as alternatives. But IMR and DALE data for 1997 obtained from the WorldBank and the World Health Organization for 180countries found a strong (generally) linear association betweenDALE and IMR (r=0.91). Countries with high DALE tend to havea high IMR and so for countrieswith limited resources that require an easily calculatedmeasure of population health, IMR may remain a suitable choice12. The reduction in maternal mortality in the past 15 years is 22%, right on target towards Millennium Development Goal (MDG) of a 75% reduction between 1990 and 201513. However, the Maternal Mortality Ratio (MMR) still remains unacceptably high (320 per 100,000) in Bangladesh, which is one of the highest, even by the standards of other developing countries14. The National Strategy for Maternal Health will be successful only when families are motivated to make use of the medically trained providers for dealing pregnancy related complications15.   The results suggest that Bangladesh has gone far to achieve the targets of MDG, but still there are a lot of formidable challenges to be met. The author admits the limitation of this review. Here only a few indicators were analyzed to show trends in different health status achievements, most of whom were mortality indicators. Different countries are now using composite indicators to evaluate their morbidity and disability status; unavailability of such data did not permit to do such analysis in this review for Bangladesh. References 2.   MOHFW, Directorate General of Health Services, Bangladesh Health Service Report, 1989. 4.   MOHFW, Directorate General of Health Services, Bangladesh Health Bulletin, 1998-99. 6.   UNICEF: The State of the Worlds’ Children, 1993. 8.   UNICEF: The State of the Worlds’ Children, 2003. 10.  NIPORT, Mitra and Associates, ORC Macro, Bangladesh Demographic and Health Survey (BDHS) 2004, Dhaka Bangladesh, and Calverton, Maryland USA: NIPORT, Mitra and Associates and ORC Macro, 2005. 12. Reidpath D D and Allotey P, Infant mortality rate as an indicator of population health, Journal of Epidemiology and Community Health 2003; 57: 344-346. 14. NIPORT, ORC Macro, JHU and ICDDR,B: Bangladesh Maternal Health Services and Maternal Mortality Survey, 2001. <![CDATA[Innovation and Re-Orientation in Medical Education and Research: Challenges for Ibrahim Medical College]]> Prof. A.K.M. Nurul Anwar Prof. K.M. Fariduddin https://imcjms.com/journal_full_text/117 2016-10-22 09:27:31 Editorial Ibrahim Med. Coll. J. 2007; 1(1): i-ii Medical Education in Bangladesh is still predominantly in the public sector, controlled by the Ministry of Health & Family Welfare; regional public Universities conduct examinations and confer degrees; while Bangladesh Medical & Dental Council (BM&DC) oversee the standard and equivalence. Medical education under the rule of the triumvirate – the Ministry, the University and the BM&DC has developed without a progressive plan to keep pace with exponential growth of medical knowledge and technology on one hand and ever growing health needs of the people on the other. The ‘Undergraduate Medical Curriculum’ first made available in the written form in 19821 and updated in 20022 still remained largely disease and treatment oriented rather than emphasizing prevention of the diseases and promotion of health. It is still a blend of traditional with sporadic inclusion of modern advances. The new additions without concomitant removal of the old and outdated have made the curriculum lengthy and at places boring. Priorities in selecting topics reflected more of faculties’ choice of academic interest and of recent advances rather than national perspectives that emphasizes diseases with greater potential for harm to public health, diseases that are preventable and focus for national disease control programmes. The teaching strategies largely remained didactic, teacher centered, lecture dominated and examination oriented and is devoid of motivation for self and continuous learning. The teaching-learning activities in basic science departments have been criticized for their lack of clinical relevance, while those in clinical departments for their undue stress on diseases and their treatment at the tertiary level rather than symptoms oriented approach for early diagnosis; dependence on laboratory investigation rather than development of clinical acumen through elicitation of history and thorough clinical examination; and use of hospital inpatients rather than outpatients and community settings3. Private initiatives in the establishment of medical colleges started with the promise of a competition for better future. However rapid establishment of quite a number of private medical colleges over a short period has generated considerable concern, for acute dearth of qualified teachers particularly in basic science departments and non-availability of adequate hospital beds for teaching may have adverse effects on the quality of education and training provided. It is in this background, the Diabetic Association of Bangladesh established Ibrahim Medical College after the name of its founder National Prof. Md. Ibrahim with a vision to develop it as a trend-setting Institute, so as to demonstrate a high standard of undergraduate medical education, so badly needed in the country. The college is committed to provide an environment conducive to innovation and re-orientation in medical education and research appropriate to the need of the country while at the same-time remaining at par with world standard. The goal of the college is to create future leaders of the profession who will be competent, caring and willing to serve the community. The college is to provide a broad based education through a well designed curriculum that stresses the national perspective; utilizing effective educational strategies to encourage self learning; and continuously monitoring and rigorously evaluating all activities and systems. Medicine is a science with a human understanding and warmth; and embraces man, his environment and society. Medical Colleges have an obligation to the society to direct its education, services and research towards addressing the priority health concerns of the community they have a mandate to serve4. The focus therefore is on professional development for the students to equip them with knowledge, skill and attitude necessary not only to address the priority health problems of the community; but also to acquire a firm basis for future training and studies; to develop a capacity for self-education so that he may continue to extend his knowledge and skill throughout his professional life; and to recognize his obligation to contribute if he can, to the progress of medicine and to new knowledge. Following the recommendations of the World Congress of Medical Education5, the college is committed to enlarge the range of settings in which educational programmes are conducted to include all health resources of the community and not hospitals alone. It is implementing a comprehensive approach to conduct community related educational programmes and services throughout undergraduate education and during internship and to conduct operational research on community health problems. The College provides the right academic environment for faculty development. Fellowship, travel grants and exchange programmes for teachers have been planned to give teachers access to outside academic world. There are opportunities for young doctors in teaching for career development with provisions for scholarships and study leave. The college attaches highest priority and encourages ways and means to promote research activities in the college. Research is considered as yardstick for measuring excellence of an academic institution. Education confined to text books and repetition of the same dull chores round the year do not stimulate true learning. Through research, teacherscancommunicatewithrestofthescientific world,removeacademicisolation,bringinnovative changes in teaching strategies and add to the prestige of the Institution and of the country. The publication of “Ibrahim Medical College Journal” is a step in that direction and a great leap forward towards a highly productive academic pursuit. We wish the publication a continued success.   1.  Centre for Medical Education, DGHS: Curriculum for Undergraduate Medical Education in Bangladesh, 1988. 3.  Anwar, AKMN. Editorial: Medical Education for Bangladesh in the New Millennium. Bangladesh J. Physiol & Pharmacol 2002; 16(2): 47-49. 5.  Proceedings of the World Congress of Medical Education, Edinburgh 1990. <![CDATA[RISK OF OBESITY FOR HYPERTENSION DIFFERS BETWEEN DIABETIC AND NON-DIABETIC SUBJECTS]]> MA Sayeed Akhtar Banu Parvin Akhter Khanam Hajera Mahtab AK Azad Khan https://imcjms.com/journal_full_text/1 2016-07-23 08:05:50 Original Article Ibrahim Med. Coll. J. 2007; 1(1): 1-6 Abstract In recent years, non-communicable diseases (NCD) like obesity, hypertension (HTN) and Type2 diabetes (T2DM) are on the increase, specially in the developing nations. Body mass index (BMI), waist-to-hip ratio (WHR) and Waist-to-height ratio (WHtR) are used as indices of obesity to relate T2DM, HTN and coronary artery disease (CAD). This study addresses whether the risk of obesity for HTN differs between T2DM and non-DM subjects. We investigated 693 diabetic patients from BIRDEM and 2384 from communities. We measured height, weight, waist-girth, hip-girth and blood pressure. All subjects underwent oral glucose tolerance test (OGTT). BMI, WHR and WHtR were calculated. Systolic and diastolic hypertension (sHTN and dHTN)) were defined as SBP >=140 and DBP >= 90 mmHg, respectively. The prevalence of both sHTN and dHTN in T2DM was higher than the non-DM subjects (sHTN: 49.1 vs 14.3%, dHTN 19.6 vs. 9.5%). The comparison of characteristics between subjects with and without hypertension showed that the differences were significant for age, weight, waist-girth, BMI, WHR and WHtR for both T2DM and non-DM subjects (for all p<0.001). The increasing trend of hypertension with increasing obesity was observed more in the non-DM than in the T2DM subjects. The risk (OR) of obesity for hypertension increased with increasing WHR and WHtR in the non-DM than the T2DM subjects. Compared with the non-DM the T2DM participants had two to three folds higher prevalence of HTN. In either group, BMI, WHR and WHtR were significantly higher in the hypertensive than the non-hypertensive subjects. The prevalence of hypertension increased with the increasing BMI, WHR and WHtR but significant only in the non-DM. Further studies may confirm these findings and determine whether there was any altered association between blood pressure and obesity in diabetes possibily, with or without autonomic neuropathy. Ibrahim Med. Coll. J. 2007; 1(1): 1-6 Keywords: obesity, hypertension, diabetes, odds ratio Abbreviation: BMI, body mass index (weight in kg / height in m.sq.); CAD, coronary artery disease; NCD, non-communicable disease; SBP, DBP, systolic & diastolic blood pressure; sHTN, dHTN, systolic and diastolic hypertension; OR, odds ratio; CI, confidence interval; SD, standard deviation; T2DM, Type 2 diabetes mellitus; WHR,  waist-to-hip ratio; WHtR, waist-to-height ratio. Address for Correspondence: Prof. MA Sayeed, Department of Community Medicine, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000   Introduction Recently, the developing communities are burdened increasingly with the metabolic and other non-communicable diseases1. It was reported that Bangladeshis are more susceptible to develop obesity, diabetes, hypertension, and coronary artery diseases compared with other South Asian migrants (Indian, Pakistani) settled in United Kingdom2. The risk factors related to these disorders were more prevalent in Bangladeshis than the native population3,4. Bangladeshis among the entire South Asian immigrants had highest risk of morbidity and mortality from HTN, T2DM and CAD5,6 and these are emerging as major health problems in Bangladesh. Now, these diseases are given research priorities by the government7. It may be noted that small community surveys conducted at different time-points revealed an increasing trend of hypertension and diabetes in Bangladesh8. These studies showed that increasing central obesity (high WHR and WHtR) has been found significantly related to insulin resistance, which in turn may be related to hypertension and diabetes. This study addresses the association of obesity with hypertension and determines whether there was any difference of risk for developing hypertension in diabetic and non-diabetic subjects.   Subjects and Methods This study was conducted on – a) diabetic patients registered in a referral center, BIRDEM in Dhaka City; b) a mixed community of rural and urban participants. All subjects of age 20 years or more were considered eligible for the study. Eight hundred diabetic patients were selected randomly from BIRDEM registry starting from January to April 1996, based on patients’ reference number. For community participants, we selected five villages from rural and two city corporation wards from urban (Dhaka City), purposively. We estimated sample size taking formula, n = z2 pq / e2; where, z = standard variate at a confidence level of 1.96, (approx, 2), p = prevalence of hypertension 11%9,10, q = 100 – prevalence (11%) = 89, e = acceptable error (precision, 10% of the prevalence). According to the formula, sample size was estimated at 3236. The investigations included age, sex, height, weight, blood pressure and blood glucose – both fasting and post-challenge. We informed each participant about the objectives and investigation procedures. Only after verbal consent, we enlisted them for investigation. Measurements of height, weight, and waist- and hip-girth were taken with subjects wearing light clothes and no shoes. The weighing scales were calibrated daily by known standard weight. For recording the height, the subject stood in erect posture with his / her occiput, back, hip and heels touching the wall while gazing horizontally in front, keeping the tragus and lateral orbital margin in the same horizontal plane. The waist girth was measured by placing a plastic tape horizontally mid-way between the lower border of the12th rib and iliac crest along the mid-axillary line. Similarly, the hip was measured by taking a point at the extreme end on the buttock in stooping posture and the other point on the symphysis pubis. BMI, WHR and WHtR were calculated taking the anthropomtric measures. Blood pressure was taken after 10 min rest with standard cuffs for adult fitted with mercury sphygmomanometer. All measurements were taken in sitting position placing the wrapped cuff at the heart level. Systolic and diastolic hypertension (sHTN and dHTN)) were defined as systolic and diastolic BP (SBP and DBP) =>140 and => 90 mmHg, respectively. For comparison, the diabetic subjects were excluded from the community participants. Fasting and 2h post-load plasma glucose was estimated by the glucose oxidase (enzymatic oxidation) method (GOD/PAP Kit; Randox, Antrim, U.K.) using the auto-analyzer Screen Master-3000 (B.S. Biochemical Analyzer, Arezzo, Italy).   Statistical Analyses The prevalence of hypertension was given in simple percentages. For comparison of continuous variables between groups (hypertensive vs non-hypertensive), we used Student’s t-test. We divided all obesity variables (BMI, WHR, WHtR) into quartiles for estimation of odds ratio (OR) to assess risk of obesity for developing systolic and diastolic hypertension, separately in diabetic and non-diabetic individuals. We used SPSS version 12.0. We accepted 0.05 as level of significance.   Results Of the selected 800 diabetic subjects, 693 (men 295, women 398) took part in the investigation from BIRDEM. The response rate was 86.6%. For the community participants, 2384 (men 1491, women 893) participated. Overall, the response rate was 70%. The rural participants were 1332 (m / f = 808 / 524) and the urban participants were 1052 (m / f = 683 / 369). Thus, the response rates from the rural and urban communities were 74.8 and 59.1%, respectively. The prevalence of both systolic and diastolic hypertension (sHTN, dHTN) in diabetic subjects was higher than the non-diabetic subjects (sHTN: 49.1 vs 14.3%, dHTN 19.6 vs. 9.5%). The prevalence of sHTN among the male and female diabetic subjects were 45.0 and 52.6% and dHTN were 26.0 and 14.2%, respectively (table not shown). Much lower prevalence was observed in the non-diabetic subjects (sHTN: m / f =13.3 / 14.9%; dHTN: m / f = 10.1 / 9.2%).      The characteristics of the community participants were given in table-1 and that of diabetic participants in table-2. The comparison of characteristics between subjects with and without systolic hypertension were given in table-3. The differences were significant for age, weight, waist-girth, BMI, WHR and WHtR (for all p<0.001). Only height did not differ.   Table 1. Characteristics of non-diabetic participants (n = 2384).    Characteristics Range Mean SD Age (y) 20 – 99 40.3 13.7 Height (cm) 107 – 183 157.6 8.9 Weight 25 – 89 50.2 10.5 BMI 11.9 – 45.3 20.5 3.6 Waist (cm) 30 – 99 71.4 9.9 Hip (cm) 32 – 115 81.8 8.0 Waist-to-hip ratio 0.52 – 1.38 0.87 .08 Waist-to-height ratio 0.21 – 0.78 0.45 0.06 Systolic blood pressure (mmHg) 70 – 230 116.4 20.5 Diastolic blood pressure (mmHg) 40 – 130 72.7 11.3 Blood glucose 2h post-load (mmol/L) 2.0 – 27.7 6.7 2.9   Table 2. Characteristics of diabetic patients (n = 693).   Characteristics Range Mean SD Age (y) 30 – 60 47.1 8.6 Height (cm) 135 – 186 157.8 8.8 Weight (kg) 35 – 97 61.3 10.2 BMI 13.9 – 39.3 24.6 3.57 Waist (cm) 67 – 120 88 7.9 Hip (cm) 63 – 116 89.8 7.0 Waist-to-hip ratio 0.81 – 1.52 0.98 .05 Waist-to-height ratio  0.43 – 0.79 0.56 .06 Systolic blood pressure (mmHg) 90 – 230 136.2 19.2 Diastolic blood pressure (mmHg) 55 – 120 83.4 8.8 Blood glucose 2h post-load (mmol / L) 7.0 – 40.0 18.4 6.2    Table 3. Comparison of characteristics between subjects with and without systolic hypertension among non-diabetic participants (n = 2381).                                            Characteristics SBP<140mmHg n = 2043 SBP =>140mmHg n = 341 t-test p Mean SD Mean SD Age (y) 38.5 12. 9 51.3 13.5 <0.001 Height (cm) 157.7 8.8 156.9 9.9 ns Weight (kg) 49.9 10.3 52.1 11.7 <0.001 Body mass index 20.0 3.5 21.1 4.0 <0.001 Waist (cm) 70.8 9.7 74.8 10.4 <0.001 Hip (cm) 81.6 7.9 83.1 8.4 <0.01 Waist-to-hip ratio 0.87 0.08 0.90 0.08 <0.001 Waist-to-height ratio 0.45 0.06 0.48 0.07 <0.001 Systolic BP (mmHg) 110 13.1 154 17.4 <0.001 Diastolic BP (mmHg) 71 10 86 10.7 <0.001 Blood glucose (2h post-load, mmol/l) 6.5 2.6 7. 9 4.3 <0.001 SBP – systolic blood pressure   Table 4. Comparison of characteristics between subjects with and without systolic hypertension among diabetic participants (n = 693).                                     Characteristics SBP<140mmHg N = 331 SBP => 140mmHg N=362 t-test p Mean SD Mean SD Age (y) 45.7 8.6 48.4 8.4 <0.001 Height (cm) 158.7 8.6 156.9 8.9 <0.01 Weight (kg) 60.7 9.9 61.8 10.4 ns Body mass index 24.0 3.1 25.1 3.7 <0.001 Waist (cm) 86.9 7.6 88.9 8.1 = 0.001 Hip (cm) 88.7 6.7 90.8 7.2 <0.001 Waist-to-hip ratio 0.98 .06 0.98 0.05 ns Waist-to-height ratio 0.55 0.05 0.57 0.06 <0.001 Systolic BP (mmHg) 121 9 150 15 <0.001 Diastolic BP (mmHg) 79 5 87 9.5 <0.001 Blood glucose (2hh post-load, mmol/l) 18.7 6.6 18.2 5.9 ns SBP – systolic blood pressure   For the diabetic participants, the differences were similar to that of non-diabetics with the exception that weight, WHR and 2h post-load glucose did not differ (table 4). It should be noted that the hypertensive diabetics were significantly shorter than their non-hypertensive counterparts (p<0.01). To determine the risk of obesity for developing hypertension, we estimated odds ratio for lower to higher quartiles in diabetic and non-diabetic population for a comparison. The comparisons were shown in figure 1 and 2. The increasing trend of developing systolic hypertension with increasing obesity quartile was profound in the non-diabetic than the diabetic subjects (figure 1: left vs. right). Figure 1. Odds ratio (OR) of systolic hypertension by quintiles of obesity indices of non-diabetic (left) and diabetic (right) subjects   Figure 2. Odds ratio (OR) of diastolic hypertension by quintiles of obesity indices of non-diabetic (left) and diabetic (right) subjects   Figure 3. Odds ratio (OR) for developing sHTN (left) and dHTN (right) by BMI quintile: non-DM vs. DM   Figure  4. Odds ratio (OR) for developing sHTN (left) and dHTN (right) by WHR quintile: non-DM vs. DM   Figure 5. Odds ratio (OR) for developing sHTN (left) and dHTN (right) by WHtR quintile: non-DM vs. DM   The differences of the increasing trend  was more obvious for diastolic hypertension (figure 2: left vs. right). To make the comparison more sharp we compared the trend for each obesity index (figure 3 for BMI, figure 4 for WHR and figure 5 for WHtR). Marked differences were observed for quartiles of WHR and WHtR (Fig 4,5). Both the measures-WHR, WHtR indicate central obesity. The risk (OR) for hypertension increased with increasing quintiles of WHR and WHtR in the non-DM but not in the T2DM, and marked difference was observed for diastolic hypertension.   Discussion As regards the community participation the response rate, 59.1% from urban and 74.8% from rural limits the strength of the study results. It would have been more acceptable if we could ensure partipation over 80%. It may be noted that it was not a bias selection neither from the urban nor from the rural community. The response rate could not be increased due to time taken for OGTT. About 15% refused to wait for two hours after glucose drink in urban and 10% in rural area. This refusal reduced the response rate. However, the response rate for estimated diabetic participants was satisfactory (86.6%). This study reasonably compared the prevalence of hypertension in diabetic and non-diabetic subjects keeping an approximate representation from rural and urban community. Possibly, this is the first study that corpared the differential effect of increasing obesity on hypertension between diabetic and non-diabetic subjects. The comparison of characteristics showed that age, and all obesity variables ((BMI, WHR, WHtR) were significantly higher in the subjects with hypertension than without, irrespective of their glycemic status (T2DM and non-DM). This finding is not inconsistent to other studies10-12. The novel findings are that the trend of increasing prevalence of hypertension with the increasing general obesity (BMI) and central obesity (WHR and WHtR) differed between (T2DM) and non-diabetic (non-DM) subjects. The non-DM subjects showed higher prevalence of HTN with higher obesity, whereas, the T2DM showed very litte or no increase. A substantial if number studies reported that obesity is significantly related to hypertension2,5, 10-12. But it is not clear why there was no increase of hypertension with increasing obesity in the diabetic subjects. Possibly, autonomic neuropathy among T2DM changes the physiologic relationship between obesity and blood pressure. Jarmuzvwskaet al.13 found that the presence of sympathetic neuropathy and higher blood pressure remained independent predictors of SBP fall not only during the acute transition from supine to standing position but also during sustained orthostasis in type 2 diabetes. They concluded that lower baseline plasma adrenaline concentrations and plasma renin activity might be involved in the genesis of this hemodynamic response. In Bangladesh, the diagnosis of diabetes appears to be late or mostly diagnosed in the advanced stage of the disease. Very few people diagnosed had early diagnosis before developing typical symptom like excessive thirst, excessive urination and weight loss. It is common for the developing communities that the diabetic patients present with these typical features in advanced stages of the metabolic disease when some form of complication like neuropathy has already developed. Ravisankar et al.14 also observed that there were differences between BMI and BP indices, which might be due to differences in autonomic function and or energy metabolism. The diabetic participants might have developed some form of diastolic dysfunction, which is not infrequent as observed by some other studies15,16.   Conclusion The prevalence of hypertension among the diabetic subjects were 2 to 3 times higher than the non-diabetic population. Both general and central obesity were found to be significantly higher in the hypertensive than the non-hypertensive participants irrespective of their glycemic status. The increasing trend of hypertension with increasing obesity was significant only in the non-diabetic but not in the diabetic subjects, possibly, due to sympathetic neuropathy developed in the latter. Further study may be designed to confirm these findings and to determine whether there was any altered association between blood pressure and obesity in diabetes with or without autonomic neuropathy and / or ventricular dysfunction.   Acknowledgement We are very much grateful to the participants of rural and urban communities who volunteered this study. BIRDEM authority kindly provided us with 75g glucose  packets and laboratory facilities for blood glucose estimation.   References 1.         King, H. and Rewers, M. Global estimates for prevalence of diabetes mellitus and impaired glucose tolerance in adults. Diabetes Care 1993; 16: 157-177. 2.         McKeigue PM, Miller GJ, Marmot MG. Coronary heart disease in South Asians overseas - a review. J Clin Epidemiol 1989; 42: 597-609. 3.         McKeigue PM, Bela Shah, Marmot MG. Relation of central obesity and insulin resistance with high diabetes prevalence and cardiovascular risk in South Asians. Lancet 1991; 337: 382-386. 4.         McKeigue PM, Pierpoint T, Ferrie JE, Marmot MG. Relationship of glucose intolerance and hyperinsulinemia to body fat pattern in South Asians and Europeans. Diabetologia 1992; 35:785-791. 5.         McKeigue PM, Marmot MG, Syndercombe Court YD, Cottier DE, Rahman S, Riemersma RA. Diabetes hyperinsulinemia and coronary risk factors in Bangladeshis in East London. Br Heart J 1988; 60: 390-396. 6.         Wild S, Roglic G, Green A, Sicree R, King H, Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 2004; 27 (5): 1047-53. 7.         The current status of Health Research in Bangladesh (1991): submitted by The Essential Health Research Working Group in Bangladesh. 8.         West KM, Kalbfleisch JM, Glucose tolerance, nutrition and diabetes in Uruguay, Venezuela, Malaya and East Pakistan. Diabetes 1966; 15: 9-18. 9.         Mahtab H, Ibrahim M, Banik NG, Gulshan-E-Jahan and Ali SMK. Diabetes detection survey in a rural and semiurban community in Bangladesh. Tohoku J Exp Med 1983;141: 211-217. 10.        Sayeed MA, Khan AR, Banu A, Hussain MZ. Prevalence of diabetes and hypertension in a rural population of Bangladesh. Diabetes Care 1995; 18 (4): 555-558. 11.        Sayeed MA, Hussain MZ, Banu A, Rumi MAK, Azad Khan AK. Prevalence of diabetes in a suburban population of Bangladesh. Diab Res Clin Pract 1997; 34: 149-155. 12.        Sayeed MA, Hussain MZ, Banu A, Ali L, Rumi MAK, Azad Khan AK. Effect of socioeconomic risk factor on difference between rural and urban in the prevalence of diabetes in Bangladesh. Diabetes Care 1997; 20: 551-555. 13.        Jarmuzewska EA, Rocchi R, Mangoni AA. Predictors of impaired blood pressure homeostasis during acute and sustained orthostasis in patients with type 2 diabetes. Panminerva Med 2006; 48: 67-72. 14.        Ravisankar P, Madanmohan, Udupa K, Prakash ES. Correlation between body mass index and blood pressure indices, handgrip strength and handgrip endurance in underweight, normal weight and overweight adolescents. Indian J Physiol Pharmacol. 2005; 49 (4): 455-61 15.        Wong CY, O’Moore-Sullivan T, Leano R, Hukins C, Jenkins C, Marwick TH. Association of subclinical right ventricular dysfunction with obesity. J Am Coll Cardiol 2006; 47: 611-6. 16.        Abhayaratna WP, Marwick TH, Smith WT, Becker NG. Characteristics of left ventricular diastolic dysfunction in the community: an echocardiographic survey. Heart. 2006 Mar 17; [Epub ahead of print] <![CDATA[FINE NEEDLE ASPIRATION CYTOLOGY OF PROSTATIC LESSIONS WITH HISTOLOGIC CORRELATION]]> Tariqul Islam Tamanna Chowdhury KH Khan AR Barua Mohammed Kamal AJE Nahar Rahman https://imcjms.com/journal_full_text/2 2016-07-23 08:17:36 Original Article Ibrahim Med. Coll. J. 2007; 1(1): 7-10 Abstract Ibrahim Med. Coll. J. 2007; 1(1): 7-10 Key words :  FNAC, Franzen, Papaniculaou Address for Correspondence: Dr. Tariqul Islam, Registrar-Pathology, Department of Pathology & Laboratory Medicine Square Hospital Limited, 18/F West Panthopath, Dhaka-1205 Introduction Fine needle aspiration biopsy of prostate is exclusively used in Scandinavian countries and in recent years it is also widely practiced in United Kingdom and United States of America. This study was undertaken with the aim to evaluate the effectiveness of transrectal fine needle aspiration cytology in the diagnosis of prostatic lesions and to determine the cytomorphological features of prostatic lesions. Materials and Methods         A total of 62 selected patients underwent fine needle aspiration of the enlarged prostate. FNAC was carried out with the help of 10 ml disposable plastic syringe with attached 23-25 gauge spinal needle under guidance of finger cot in all cases. Smears were stained with Papanicolaou’s stain. In only two cases, the smears were inadequate. Biopsy for histopathological examination was available in 58 cases. Table 1: Cytopathological diagnosis of 62 cases of prostatic lesions. Number of patients Benign lesions ( n=36) 58.06 32 Atypical hyperplasia 4.84 1 Malignant tumours (n=21) 33.9 19 Adenosquamous 1.61 1 Suspicious cells 4.84 2 Total 100.00         Histopathological Diagnosis FNA cytological Diagnosis   Nodular Hyperplasia Nodular hyperplasia Atypical Hyperplasia   Carcinoma Atypical hyperplasia Atypical Hyperplasia Carcinoma Carcinoma   Nodular Hyperplasia Total     Fig.4: Photomicrograph shows smear preparation of atypical hyperplasisa Biopsy specimen were available in 58 cases. Of them, 38caseswerediagnosedasnodularhyperplasia,2cases as atypical hyperplasia and 18 cases as carcinoma. Among the 38 benign cases, 34 cases were correctly diagnosed cytologically as nodular hyperplasia but in the remaining 4 cases, 3 cases were diagnosed as carcinoma and one case as atypical hyperplasia. Both cases of atypical hyperplasia were correctly diagnosed by cytology with 100% correlation. The sensitivity of this study is 94% and specificity is 92%. Discussion Prostatic cancer is often localized to the peripheral part of the gland, especially the posterior lobe but also the lateral lobes. It is therefore accessible to transrectal puncture biopsy. The instrument is directed towards the suspected part of the prostate. With experience it is seldom difficult to reach a suspicious area in the posterior part of the prostate by fine needle. On the other hand, if the lesion is central or situated near the floor of the bladder, it may be more readily accessible with a fine needle. In this study of 62 cases, satisfactory smears were obtained in 60 cases (96.77%) and in two cases (3.22%) smears were inadequate. A review of literature revealed that inadequate smears were obtained in many of the studies. In this study, 21 (33.87%) cases were diagnosed cytologically as carcinoma of prostate. Out of these 21 cases, one case as metastatic transitional cell carcinoma, one case as adenosquamous carcinoma and 19 cases were diagnosed as adenocarcinoma. Biopsy was available in 18 cases. Out of these 18 cases, 17 cases were diagnosed as carcinoma histologically and 1 case was diagnosed as nodular hyperplasia. The concordance rate in the present study and the other studies are similar in case of carcinoma of prostate. Cytologic features in this study also agreed with Lin et al.4.   In our country the incidence of prostatic diseases, both carcinoma and nodular hyperplasia, is increasing with the demographic shift to longevity. With increased awareness of the clinical significance of prostate cancer and the advances made in surgical treatment, there is renewed clinical interest in attempting to identify patients with surgically curable disease. FNAC of prostate is of great importance as it helps the urologist to take proper decision about surgery. It is useful in distinguishing between benign and malignant lesions of prostate. No appreciable complications have occurred with this technique except mild discomfort and pain in some cases.   1.  Bruins JL, Lycklama A, Nijeholt AAB, Beekhuis- Brussee JAM. The value of fine needle aspiration biopsy in comparison with core biopsy histology. World J Urol 1989; 7: 2-26. 3. Koss LG. Diagnostic cytology and its Histopathologic bases. 4th ed. Philadelphia 1992. J.B. Lipinncott company; 1001-1002. 5.  Esposti PL. Cytological diagnosis of prostatic tumours with the aid of transrectal aspiration biopsy. A critical review of 11110 cases and a report of morphologic and cytochemical studies. Acta Cytol 1996; 10: 182. <![CDATA[CLINICAL PROFILE OF DIABETES MELLITUS IN CHILDREN AND ADOLESCENTS UNDER EIGHTEEN YEARS OF AGE]]> Fauzia Mohsin Bedowra Zabeen Rahelee Zinnat Kishwar Azad Nazmun Nahar https://imcjms.com/journal_full_text/3 2016-07-23 08:26:58 Original Article Ibrahim Med. Coll. J. 2007; 1(1): 11-15 A total number of 125 patients with diabetes mellitus (DM) under eighteen years of age were admitted in the Paediartic department of BIRDEM hospital between January 2001 to October 2002. Eighty-eight patients (71%) were newly detected. Female to male ratio was 3:1. Out of the total admission 38 (30.4%) patients had type 1 DM (group 1), 37 (29.6%) patients had fibrocalculous pancreatic FCPD diabetes (group II), 48 (38.4%) patient had malnutrition modulated diabetes mellitus MMDM (group III) and 2 (1.6%) patients had type 2. Mean age of onset was 9±3.9 yrs in group I and 13±2.3 yrs in group II and group III. All groups had very high glucose and HbA1c value at presentation. The mean fasting glucose (mmol/l) was 19±7.14, 22.39±9 and 19.54±7.9 in group I, group II and group III respectively. The Mean HbA1c (%) value in the three groups was 14.4±2.7, 16.72±2.26 and 15.27±3.05 respectively. FCPD patients had poorest glycaemic status. Acute complications were more common in type 1 patients. Twelve (31.5%) patients had diabetic ketoatin DKA and two (5%) patients had hypoglycaemia in group I. Chronic complications were present in all three groups.  MMDM patients had highest rate of complications. which was present in 2.6%, 21.6% and 33.3% patients in group I, group II and group III respectively. The rate of microalbuminuria was 5.3%. 10.8% and 18.8% in the three groups respectively. The rate of neuropathy was 2.6%, 16.2% and 20.8% in the three groups respectively. Among the associated problems skin infection, pulmonary tuberculosis and bilateral parotid swelling were common. Malnutrition was present in 66%, 86% and 100% in group I, group II and group III respectively. Majority (50% in group I, 91.6% in group II and 100% in group III) of our patients came from poor socio-economic background. Ibrahim Med. Coll. J. 2007; 1(1): 11-15 Introduction Bangladesh Institute of Research and Rehabilitation on Diabetes, Endocrine and Metabolic disorders (BIRDEM) is an internationally reputed tertiary level hospital for care of diabetic patients. By the end of 2003, the number of registered diabetic patients in BIRDEM was 320,000. The proportion of diabetics under eighteen years of age was found to be 1.58% among the registered cases of BIRDEM. It is expected that the under eighteen registered diabetic patients in BIRDEM represent the population of childhood and adolescent diabetics of Bangladesh. The present study was undertaken to examine the clinical profile of DM in children and adolescents in the Department of Paediatrics, BIRDEM. Patients and Methods 1.   Type 1 DM (group I): Patients with early onset and/or with typical sign/symptoms of diabetes for a short duration were classified as type 1 diabetics. Patients presenting with diabetic ketoacidosis (DKA) were also included in this group. 3.   MMDM (group III): Patients with lean body mass (BMI less than 5th centile for age), other evidence of malnutrition and no pancreatic calcification. They had signs/symptoms of diabetes for prolonged period but absence of ketosis. Microalbuminuria was defined as albumin/creatinine ratio (ACR): 30-300mg/gm in spot urine. All the data were expressed as mean±standard deviation, median (range) and/or number (%) as appropriate. Statistical analysis was done by using SPSS for windows package. Appropriate statistical test of significance like unpaired t test was used as necessary. P<0.05 was taken as minimal level of significance. Correlation study was done by Pearson correlation. Results All patients in group II and group III had typical symptoms of diabetes at diagnosis. In addition, 32% of FCPD patients had history of recurrent abdominal pain. One patient in group I had nocturnal enuresis as the only presenting symptom. Seven (24%) of type 1 diabetic patients developed DKA at first presentation, six of them had typical symptoms of DM for a short period (few days to few weeks) before developing DKA, but one patient presented with DKA only without preceding symptoms of diabetes. A substantial number of patients presented themselves with chronic complications such as cataract, microalbuminuria and neuropathy at diagnosis. Out of 25 cases of cataract, 16 (64%) cases were newly detected. Ten (66%) out of fifteen patients with microalbuminuria and 12 (70%) out of seventeen patients with neuropathy were newly detected. Among the newly detected patients mean(±SD) duration (months) of  typical symptoms of DM prior to diagnosis was 2.0 ±2.9, 6.3 ± 9.6 and 13 ±12  in group I, group II and group III respectively. There was significant difference in duration of symptoms among the three groups (p=0.02 in group I vs. group II; p<0.0001in group I vs. group III; p=0.03 in group II vs. group III). MMDM group had longest duration of typical symptoms of diabetes.     Glyacemic control Group II Fasting blood glucose (mmol/l) 22.39±9 Blood glucose 2 hour after breakfast ( mmol/l) 31.07±7.1 HbA1c (%) 16.72±2.26   Acute complications were more common in type 1 patients. In group I, twelve (31.5%) patients had DKA and 2 (5%) patients had hypoglycaemia. The first presentation was with DKA in seven (24%) type 1 diabetic patients. Only one (2.7%) FCPD patient had DKA along with septicaemia.   No significant correlation was found between any of the complication and duration of diabetes, duration of symptom, glycaemic status, age of onset or age on admission. There were some associated problems as shown in table 2. Table 2. Distribution of associated problems as among the three groups Group Group III 1 (2.6%) 7 (14.6) 19(2.6%) 5 (10.4%) 0 12 (25%) Family history of diabetes was present in eight (22.2%) type 1, one (2.6%) FCPD and three (8.1%) MMDM patients. Majority (50% in group I, 91.6% in group II and 100% in group III) of our patients came from poor socio-economic background. During the study period 2 patients died. One patient with type 1 DM died of DKA. One patient with FCPD died of septicaemia and pneumonia. She developed DKA before death. Discussion There was a female preponderance, consistent with our previous studies in BIRDEM8. Patients in FCPD and MMDM groups were mostly adolescents (mean age 13±2.3 years). In the majority of FCPD patients diagnosis is made between the ages of 20 and 40 years of age but onset in childhood, in infancy and at older age groups are not uncommon9-11. Onset of MMDM is commonly between 10 to 30 years but onset at preschool age and over the age of 30 years can also occur7. There is said to be a bimodal distribution for type 1 diabetics, with a minor peak at 4 to 6 years and a major peak at 10 to 14 years. In our study population, the mean age onset of type 1 diabetics was 9±3.9 years. The very high blood glucose and HbA1c in the three groups is not unexpected, as most of these are values at first presentation of diabetes. Glycaemic control was worst in FCPD patients. A striking feature of our study population was the presence of microvascular complications (microalbuminuria and neuropathy) even at presentation and a very high rate of complication in the MMDM group. Possible explanation is that they may have very slow onset diabetes or have remained undiagnosed for a long time. This is possible because despite having severe hyperglycaemia they are ketosis resistant19. Positive family history was present in 22.2%, 2.7% and 8.1% Type 1, FCPD and MMDM patients respectively. Although genetic factor is important for the development of type 1 diabetes, positive family history is uncommon (<10%) in MMDM suggesting that the disease is more likely environmental than genetic 7. Familial aggregation of FCPD patients have been reported from India and Bangladesh suggesting genetic susceptibility21,22.   The overall clinical presentation of our diabetic population is somewhat different from that of developed and western world. Acute complications such as DKA and hypoglycaemia are more common in Type 1 patients as found worldwide but the high rate of complication even at presentation among FCPD and MMDM patients and their poor nutritional status are of concern.   1.    Ruwaard D, Hirasing RA, Reeser HM et al. Increasing incidence of type 1 diabetes in the Netherlands. The second nationwide study among children under 20 years of age. Diabetes care 1994; 17: 599-601. 3.    WHO technical report series 727. Diabetes Mellitus. World Health Organization, Geneva, 1985. 5.    Tripathy BB, Samal KC. Overview consensus statement on Diabetes in Tropical areas. Diabetes /Metab Rev 1997; 13: 63-7. 7.    Samal KC, Kanungo A, Sanjeevi CB. Clinicoepidemiological and Biochemichal profile of Malnutrition-Modulated Diabetes Mellitus. Ann. N.Y. SCI. 2002; 958: 131-137. 9.    Mohan V, Ramachandran A,Viswanathan N. Childhood onset fibrocalculous pancreatic diabetes. Int J Diabetes  Dev Countries 1990; 10: 24-26. 11.  Mohan V, Suresh S, Indrani S et al. Fibrocalculous Pancreatic Diabetes in the elderly. J Assoc Phys Ind 1989; 37: 342-344. 13. Mohan V, SnehalataC, Ramachandran A et al. Plasma glucagons response in tropical fibrocalculous pancreatic diabetes. Diabetes res Clin Pract 1990; 9: 97-101. 15. Donaghue KC, Fairchild JM, Chan A et al. Diabetes complication screening in 937 children and adolescents. JPEM 1999; 12: 185-92. 17.  Ludvigsson J, Johanesson G, Heding L et al. Sensory nerve conduction velocity and vibratory sensibility in juvenile diabetics. Relationship to endogenous insulin. Acta Paediatr Scand 1979; 68: 739-48. 19.  Hugh-Jones P. Diabetes in Jamaica. Lancet 1955; 2: 891. 21. Chowdhury ZMd, McDermott MF, Davey S et al. Genetic susceptibility to fibrocalculous pancreatic diabetes in  Bangladeshi subjects: a family study. Genes and Immunity 2002; 3: 5-8. <![CDATA[THE EFFECT OF GARLIC ON CHOLESTEROL INDUCED HYPERLIPIDAEMIA IN RABITS]]> Aftab Uddin Ahmed Syeda Farida Begum Humaira Naushaba Md. Noor Islam Begum Samsun Nahar https://imcjms.com/journal_full_text/4 2016-07-23 08:36:43 Original Article Ibrahim Med. Coll. J. 2007; 1(1): 16-20 An experimental biochemical study was made on rabbits to demonstrate the possible role of aqueous extract of garlic as an antilipidaemic agent in the prevention of hyperlipidaemia. Untreated rabbits on atherogenic diet showed worse lipidaemic status than the normal control ones, as evident in higher serum cholesterol, triglycerides (TG), low-density lipoprotein (LDL) and lower high-density lipoprotein (HDL) level. On the otherhand the rabbits on atherogenic diet treated with aqueous extract of garlic showed significantly better lipidaemic status. It is suggested that aqueous extract of garlic is an important determinant of serum lipid level, which is an antilipidaemic agent against the pathogenesis of atherosclerosis. Address for Correspondence: Prof. Aftab Uddin Ahmed, Department of Anatomy, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000   1.  Normal Control (6):  On basal laboratory diet containing wheat and wheat brans (30% each), maize, Jill cake, kheshari (10% each), soybean oil 4%, molasses 1% with skimmed milk powder, vitamin mixtures and minerals in appropriate proportions. The diet was prepared according to the formula followed by the International center for Diarrhoeal Disease Research, Bangladesh (ICDDRB). 3.  Garlic treated (6):  On atherogenic diet +10ml/kg freshly prepared aqueous extract of   garlic daily. The bulbs of Garlic were sliced into pieces and homogenized with cold distilled water at a proportion of 1:3 by weight. The filtered mixture was centrifuged at 3000rpm for 15 minutes. The supernatant fluid was used for treating the rabbits. The procedure of preparation and the doses of aqueous extract of garlic were chosen from Augusti and Methew9. To see the antilipidaemic effects of garlic, biochemical parameters were used. Serum cholesterol, triglycerides, low-density lipoprotein and high-density lipoprotein were estimated at the beginning and on the day of sacrifice for each animal of each batch. Comparative studies were made between the results among different batches of rabbits.   Results After 8 weeks of atherogenic diet feeding, the rabbits developed small nodular skin lesions mostly in both ears. The initial lipid levels in different batches of rabbits were close to each other. At the end of the experiment, the serum lipid level of the cholesterol fed animals increased many folds to that of the initial levels except in the normal control batch (Table 1). Serum cholesterol level increased maximally to about 14 times the initial level and showed markedly higher level of cholesterol. The increase of serum triglycerides was relatively lower as compared to serum cholesterol and LDL level. The mean final serum HDL levels were less than the mean initial ones in all batches of rabbits.   Table – I: Serum lipid levels in different batches of rabbits at the beginning and end of the experiment   In the present study, the mean final serum HDL level in the garlic treated rabbits was increased by about 25% than that in the atherosclerotic control ones. Similar results were also reported by Bordia et al.6 and Sainani et al.10. Both observed quite higher levels of serum HDL in the cholesterol fed rabbits treated with garlic. Huq13 found serum HDL level increased by 30% in the garlic treated rats in comparison to rats fed on cholesterol diet only. References 2.  Assmann G. Lipid metabolism and atherosclerosis. Central Laboratory of the Medical Faculty, University of Munster and Institute for Arteriosclerosis Research at the University of Munster, Stutgart, New York: Schattauer, 1982. 4.  Bordia A, Bansal HC, Arora SK, Rathore AS, Ranawat RVS, Singh SV. Effect of the essential oil (active principal) of garlic on serum cholesterol, plasma fibrinogen, whole blood coagulation time and fibrinolytic activity in alimentary lipaemia. J Assoc Phys Ind 1974;  22: 267-70. 6.  Bordia A, Verma SK, Khabia BL, Vyas A, Rathore AS, Bhu N, Bedi HR. The effective of active principle of garlic and onion on blood lipids and experimental atherosclerosis in rabbits and their comparison with clofibrate. J Assoc Phys Ind 1977b; 25: 509-12. 8.  Arora RC, Arora S, Gupta RK. The long-term use of garlic in ischaemic heart disease: an appraisal. Atherosclerosis 1981; 40: 175-79. 10.  Sainani GS, Desai DB, Natu MN, Katrodia KM, Valame VP, Sainani PG. Onion, Garlic and experimental atherosclerosis. Jap Heart J 1979; 20(3): 351-57. 12.  Jain RC. Onion and Garlic in experimental cholesterol induced atherosclerosis. Ind J Med Res 1976; 74: 1504-14. 14.  Zacharias NT, Sebastian KL, Philip B, Augusti KT. Hypoglycaemic and hypolipidaemic effects of garlic in sucrose fed rabbits. Ind J Physio Pharmac 1980; 24(2): 151-53. <![CDATA[CORONARY ARTERY FISTULA: A CASE REPORT]]> MZ Chowdhury MA Bari AR Khan AK Miah https://imcjms.com/journal_full_text/6 2016-07-23 09:05:08 Clinical Case Report Ibrahim Med. Coll. J. 2007; 1(1): 32-33 Abstract Dr. MZ Chowdhury, Department of Cardiology, Ibrahim Medical College & BIRDEM, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000   A congenital coronary arteriovenous fistula is an anomaly that consists of a communication between a coronary artery and either atrium or ventricle (coronary cameral fistula) or coronary sinus, superior venaecava or pulmonary artery (coronary arteriovenous fistula). Sometimes both of these groups are included under one or the other name¹. It is observed in 0.1% to 0.2% of coronary angiography studies². Case report     Congenital abnormalities of coronary artery occur in 1 - 2% of general population. These abnormalities may be of origin, distribution and termination. Coronary artery fistulae (CAF) are considered to be termination abnormalities3. CAF accounts for 0.2- 0.4% of congenital cardiac anomalies. Approximately 5% of coronary anomalies are CAF4. Common sites of fistulae are right coronary artery or its branches (55%), left coronary artery or its branches (35%) or both (5%)5. Embryologicaly, persistence of some of the inter-trabecular spaces in the primitive myocardium lead to coronary cameral fistula. On the other hand communication between the primitive coronary artery and mediastinal plexus of vessels gives rise to fistulae from coronary artery or pulmonary artery or bronchial artery or mediastinal artery. The fistulous coronary artery may be small or large and tortuous, and it enters the effected chamber by one or several openings. Small fistula does not cause any haemodynamic effect but large fistula causes left to right shunt large enough to cause volume overload though significant pulmonary hypertension is rare. Significant run off through the fistula may decrease flow through more distal coronary artery and cause a coronary steal1. Male and female is equally effected. Small fistula is asymptomatic. In large fistulae, symptoms are rare before 20 years of age. Symptoms include fatigue, exertional dyspnoea and chest pain. The latter is usually seen in 80% of the patients over 50 years. On examination there is thrill and continuous murmur on the mid left or right sternal border louder in mid diastole. It may be absent if LCx is involved. There may be features of complications like congestive cardiac failure, pulmonary hypertension, myocardial ischemia, bacterial endocarditis and saccular aneurysmal dilation rarely leading to spontaneous rupture. For diagnosis electrocardiography, chest radiography, transthoracic echocardiography (2-D & Doppler colour flow), transoesophageal echocardiography, coronary angiogram or laid back aortogram or CT scan can be done5. Except for the very small, most coronary arteriovenous fistulae should be closed by ligation, microparticle embolization or wire coils6. Prognosis is excellent if closure is done early before development of any complication.   1.  Hoffman JIE. Congenital Anomalies of the Coronary vessels and the aortic root. In: Moss and Adam. Eds. Heart Disease in Infants, Children and Adolescents. 4th edition. Williams and Wilkins, Baltimore, 1989: 769-790. 3.  Darwazah AZ, Hussein IH, Hawari MH. Congenital Circumflex Coronary arteriovenous Fistula. Texas Heart Institute Journal 2005; 32: 56-59. 5.  Friedman WF, Silverman N. Congenital Heart Disease in infancy and childhood. In: Braundwald E, Zipes DP, Libby P. Eds. Heart disease 6th edition WB Saunders, Philadelphia, 2001: 1505-1582. <![CDATA[ENTERIC MYOCARDITIS: A CASE REPORT]]> Kawkab Mahmud AKM Musa AKM Shaheen Ahmed Khwaja Nazimuddin RSC Sarker https://imcjms.com/journal_full_text/87 2016-09-19 15:09:54 Clinical Case Report Ibrahim Med. Coll. J. 2007; 1(1): 34-37 Abstract Introduction Based on DNA studies, all salmonellae are now considered a single species (S choleraesuis), separated into 7 distinct subgroups. Multiple serotypes of Salmonella cause the syndrome of enteric fever, of which typhoid fever is the best studied and described4,5.  Caused by Salmonella typhi and occurring only in humans, typhoid fever is a severe multisystem illness and potentially fatal if untreated. Death may occur from overwhelming toxemia, myocarditis, intestinal hemorrhage, or perforation.   In September 2005, a 22 year old febrile man was admitted in the department of internal medicine, BIRDEM with the complaints of productive cough and exertional dyspnoea. He was febrile for last 10 days; fever was high grade intermittent in nature, associated with mild headache and myalgia. Highest temperature recorded was 105°F. For the last 5 days he developed cough, first mucoid then becoming productive along with progressive dyspnoea later on orthopnoea. He gave history of loose motions 2-3 times a day for the last 3 days but there was no vomiting. He was non-smoker, non asthmatic. He refused any recent travel abroad, or to the hill-tracts. He took a course of oral ciprofloxacin 500mg bid for 5 days. Systemic examination revealed fine crepitations in mid and lower zone of both lung fields with vesicular breath sound. Right hypochondrium was mildly tender. Liver, spleen and lymph nodes were not palpable. On routine investigations, complete blood count showed total count of WBC was at lower normal range with normal distribution and thrombocytopenia. (TC-4100, P/C-33000, DC-N=79%, L=15%, M=6%, E=1%). Liver enzymes were slightly raised. SGPT-68 U/L, SGOT-72 U/L and serum bilirubin 3.2 mg/dl. Blood urea and s. creatinine were normal. On the 10th day blood, urine and sputum samples were sent for culture along with blood for triple antigen and viral markers. Bedside urine examination was normal. ECG showed nonspecific ST change. There was bilateral patchy opacities on CxR in mid and lower zone. But on the 3rd day of admission, i.e. 13th day of the onset of fever, patient was still febrile, respiratory distress worsened. He also complained of palpitation. On examination there was undue tachycardia (142 b/min) and tachypnoea (34 breath/min). On auscultation fine basal crepitations were found on both lungs. Urgent chest X-ray showed cardiomegaly with evidence of pulmonary edema along with the previous radiological findings. Arterial blood gas analysis revealed Type I respiratory failure. (PO2=55 mm of Hg, PCO2=23 mm of Hg, SaO2=76%, pH=7.45, HCO3=20 mmol/L). Viral markers for hepatitis were negative. Then investigations supported the clinical suspicion. Echocardiography revealed global hypokinesia with ejection fraction only 37%. CPK- 583u/l, CK-MB 70u/l, S. LDH-1510 u/l. Troponin-I was found normal. Diuretic was continued. On the 4th day patient was not dyspnoeic any more but fever still persisting with cough. So we reached our final diagnosis-Enteric fever with myocarditis with  acute left ventricular failure.   Myocarditis is used to describe simply as an inflammatory process with necrosis involving myocardium. According to Dallas criteria, the diagnosis of active myocarditis is defined as an inflammatory infiltrate of the myocardium with injury to the adjacent myocyte not typical for ischaemic damage associated with coronary artery disease. It usually forms part of a generalized  infection, so far most commonly initiated by viral infection but can also be due to  drugs, toxin, hypersensitivity reaction, collagen vascular disease and autoimmune reaction and less commonly with other infections like bacteria, rickettsia, spirochete, fungi, protozoa. ECG changes of myocarditis are often nonspecific usually appearing only in the first two weeks of illness. Commonest ECG abnormality was Q-Tc prolongation (29%) followed by ST-T changes (20%), bundle branch block (7%), first degree A-V Block and arrhythmia (2%)6. Other evidence for myocarditis include myocardial imaging, cardiac catheterization. Endomyocardial biopsy is considered the gold standard. But according to the ‘Myocarditis Treatment Trial’ it is no longer mandatory in the evaluation of unexplained heart failure. This was a case of myocarditis due to enteric fever which was confirmed by blood culture sensitivity report. Usually diagnosis of enteric fever is suggested by assays that identify Salmonella antibodies, antigens, or DNA and is then confirmed by isolation of the organism. The most sensitive method of isolating S typhi is obtaining a bone marrow aspirate (BMA) culture, positive in 90% cases7. Blood, urine, and stool cultures are still frequently used but the yield is only about 70%8. Rectal swab and bile from duodenal string test can also be used8,9. The Widal reaction is indicative in only 40-60% of patients during  admission10. Although not commercially available, DNA probes have been developed for identifying S typhi from bacterial culture isolates and directly from blood11. Our patient improved with ceftriaxone, diuretics and bed rest. He did not respond to oral ciprofloxacin though this drug combines a lower documented resistance rate with excellent penetration into macrophages and the biliary system12. Since 1989, S typhi strains with simultaneous plasmid-mediated resistance to chloramphenicol, ampicillin, and co-trimoxazole have emerged and spread rapidly in the Indian subcontinent and parts of Southeast Asia13,19. Between 10% and 20% of patients treated with antibiotics have a relapse after initial recovery. Thus now the fluoroquinolones and the third-generation cephalosporins are the antibiotics of choice to treat these multidrug-resistant (MDR) strains, both in children and adults14-16. Furazolidone and Azithromycin are also used to treat typhoid in children in some parts of the developing world17,18. Case fatality rates of 10-50% have been reported from endemic countries when diagnosis is delayed or in cases of severe typhoid fever not treated with high-dose corticosteroid therapy and antibiotics20.. The two most common complications of enteric fever are intestinal hemorrhage and perforation 21. Among other complications, pancreatitis and simultaneous acute renal failure and hepatitis, cholangitis, meningism, encephalomyelitis, subclinical disseminated intravascular coagulation, osteomyelitis, arthritis have been reported22-26. Early antibiotic therapy has reduced the rate of these systemic complications transforming a previously life threatening illness into a short time febrile illness with negligible fatality.  Parenteral corticosteroid is recommended in severe typhoid fever with shock or depressed level of consciousness. As far our case is concerned, supportive treatment for myocarditis included absolute bed rest and diuretics. Judicious use of corticosteroids is indicated in selected cases of severe myocarditis. In conclusion, our case again emphasizes the utmost importance of early and proper use of antibiotic therapy in determining the prognosis of disease. 1. World Health Organization: Background document: the diagnosis, treatment, and  prevention of typhoid fever. Geneva, Switzerland: 2003. 3. Ryan CA, Hargrett-Bean NT, Blake PA: Salmonella typhi infections in the States, 1975-1984: increasing role of foreign travel. Rev Infect Dis 1989: 11(1): 1-8. 5. Farmer JJ: Enterobacteriaceae: introduction and identification. In: Murray PR, Baron EF, Pfaller MA, eds. Manual of Clinical Microbiology. 6th ed. Washington, DC: American Society for Microbiology; 1995: 438-49. 7. Hoffman SL, Edman DC, Punjabi NH, et al: Bone marrow aspirate culture superior to streptokinase clot culture and 8ml 1:10 blood-to-broth ratio blood culture for diagnosis of typhoid fever. Am J Trop Med Hyg 1986 Jul; 35(4): 836-9. 9. Duodenal string-capsule culture compared with bone-marrow, blood, and rectal- swab cultures for diagnosing typhoid and paratyphoid a fever. J Infect Dis 1984 Feb; 149(2): 157-61. 11. Rubin FA, McWhirter PD, Punjabi NH, et al: Use of a DNA probe to detect Salmonella typhi in the blood of patients with typhoid fever. J Clin Microbiol 1989 May; 27(5): 1112-4. 13. Butler T, Rumans L, Arnold K: Response of typhoid fever caused by Chloramphenicol-susceptible and chloramphenicol-resistant strains of Salmonella typhi to treatment with trimethoprim-sulfamethoxazole. Rev Infect Dis 1982 Mar-Apr; 4(2): 551-61. 15. Tran TH, Bethell DB, Nguyen TT, et al: Short course of ofloxacin for treatment of multidrug-resistant typhoid. Clin Infect Dis 1995 Apr; 20(4): 917-23. 17. Carcelen A, Chirinos J, Yi A: Furazolidone and chloramphenicol for treatment of typhoid fever. Scand J Gastroenterol Suppl 1989; 169: 19-23. 19. Fever in Anand AC, Kataria VK, Singh W, Chatterjee SK: Epidemic  multiresistant enteric eastern India. Lancet 1990 Feb 10; 335 (8685): 352. 21. Rowland HA: The complications of typhoid fever. J Trop Med Hyg 1961; 64: 143-8. 23. Khan M, Coovadia Y, Sturm AW: Typhoid fever complicated by acute renal    failure and hepatitis: case reports and review. Am J Gastroenterol 1998 Jun; 93(6): 1001-3 25. Baker NM, Mills AE, Rachman I, Thomas JE: Haemolytic-uraemic syndrome in Typhoid fever. Br Med J 1974 Apr 13; 2(910): 84-7. 27. Hanel RA, Aravjo JC, Antoriuk A, et al: Multiple brain abscesses caused by solmonella typhi: Case report. Surg Nevrol 2003; 53(i): 86-90. 28. Julia J, Canet JJ, Lacasa XM, et al: Spantoneous spleen rupture during typhoid fever. Int J Intect Dis 2000; 4(2): 108-9. <![CDATA[CALCIUM OSCILLATIONS AND IT'S FUNCTIONAL SIGNIFICANCE IN CHRONOBIOLOGY OF PANCREATIC B-CELLS: THE ART OF DISCOVERING SCIENCE]]> Meftun Ahmed KM Fariduddin Fatima Khanam Jesmin Ara Begum Zinat Ara Samarjit Deb https://imcjms.com/journal_full_text/5 2016-07-23 08:59:19 Review Ibrahim Med. Coll. J. 2007; 1(1): 21-31 Address for Correspondence: Prof. KM Fariduddin, Department of Physiology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000 Historical Perspectives “They’ll find I’ th’ physiognomiesO’ th’ planets, all men’s destinies They’ll feel the pulses of the stars To find out agues, cough, catarrhs; And tell what crisis does divine”.                                     Butler, Hudibra, I. Throughout the annals of time, men even the prehistoric ones have been fascinated by the ever-existing rhythmic processes in living systems. However, this idea wasn’t completely in the open till 1797 when Hufeland proposed rhythmic events of life in relation to 24 hours or solar day as a prime unit of functional chronology1. In Florida, nose and throat surgeons found that hemorrhages in throat operation were 82% higher during the second quarter of the cycle of the moon than at other times2. Similarly, insulin sensitivity index was found to be lower during winter than summer in Swedish population3. Seasonal variations of HbA1C in diabetic subjects and glycemic variations in healthy subjects have also been   reported4-6.Thus, it seems that periodic biological events are intimately related to the non-biological cycles, whether terrestrial, astronomical, physical, electrical or others. But certainly it has been realized by the early scientists that the universe is rhythmic and displays incessant movement in the form of periodicity. The capacity to follow them, to oscillate, would enhance the survival potential of a species, including we, the human beings. In 1843, nearly half a century after Hufeland’s Publication, Chossat presented his report of 20 years of study on the changes in cloacal temperature of pigeons under various experimental conditions as to environmental temperature and nutrition1. Further analyses on biological rhythms revealed that ‘a close study of these rhythms should yield vital information concerning the construction of various biochemical reactions in the body, especially if cybernetic and thermodynamic principles are applied’. Many enthusiastic scientists and clinicians then devoted themselves for basic understanding of the fundamentals of biological rhythms. In the 30’s of the twentieth century, the periodic behavior of the normal blood glucose was characterized. In this case small meals were given regularly throughout the day and generally each meal produced a variable, transient increase. However, it was found that the glucose concentration often tended to drop somewhat at about 2 to 3 p.m. even if food was given7. The essential feature of this periodic behavior is that the blood glucose level is relatively stable, varying between 4.4 and 6.6 mM/L. It was discovered later, that under physiological conditions the blood glucose level is kept at around 5 mM/L in fasting mammals, including humans due to the pulsatile release of the glucostatic hormone insulin.  Pancreatic β-Cells and Calcium Insulin is secreted from the pancreatic β-cells in a highly regulated fashion. Among the factors affecting insulin release, glucose is the most important physiological stimulant and is considered as the primary regulatory signal. The exact sequence of biochemical events involved in glucose stimulated insulin secretion (GSIS) has not yet been identified. Nevertheless, it is well documented that GSIS is manifested due to a rise of cytosolic Ca2+ ([Ca2+]i), which acts as the primary intracellular messenger that couples physiological or pharmacological insulin secretegogues to insulin release from stored granules8. A characteristic feature of the [Ca2+]i response to glucose is its oscillatory nature observed both in individual pancreatic β-cells and in intact pancreatic islets9-12. Recent experiments have shown that the [Ca2+]i oscillations correspond to pulsatile insulin secretion and electrical activity of β-cells and thus it has been suggested that the [Ca2+]i oscillations may have important role in maintaining pulsatile release of insulin13-18. Pancreatic β-cell’s response to glucose is oscillatory. When glucose enters the b-cells through high capacity glucose transporters, its metabolism through glycolysis and Kreb’s cycle causes changes in the ATP/ADP ratio in the cytoplasm resulting in closure of the ATP-sensitive K+ channels and thereby trigger membrane depolarization19,20. This leads to the opening of voltage dependent calcium channels (VDCCs), Ca2+ influx and to subsequent rise in [Ca2+]i that promotes insulin secretion (Fig 1). Apart from the voltage-sensitive  Ca2+ influx from extracellular space, another major source of [Ca2+]i rise is mobilization of Ca2+ from intracellular stores21-23. Recent studies also suggest the existence of store operated Ca2+ entry in pancreatic b-cells24-26. However, once the [Ca2+]i is elevated, to restore it to its basal level, the b-cells drive Ca2+ actively either out of the cell across the plasma membrane through calcium pump and Na/Ca exchanger or to various intracellular stores27-29. We can simply postulate that the upstroke of the oscillation is due to Ca2+ influx and/or the release and the descending phase involves stimulation of outward Ca2+ transport and/or intracellular sequestration. And oscillations are generated and maintained via dynamic interplay of discrete signaling cascades which provides complex feedback, as well enhances co-ordination that critically maintains the fine tuning of [Ca2+]i fluctuations during different phases of the oscillation.   Figure 1. Schematic representation of ionic events in ‘glucose stimulated insulin secretion’ from pancreatic B-cells. IC = intracellular compartments.   Properties of [Ca2+]i Oscillations Oscillations in [Ca2+]i are of different fundamental types, involving different mechanisms. However, in secretory cells two major kinds of [Ca2+]i oscillations are seen – baseline transients or spikes and sinusoidal oscillations30,31. Spikes are characterized by transient increase in [Ca2+]i that rise rapidly from a baseline of [Ca2+]i. The shape of transients may vary depending on agonist-type: they may be symmetrical or may have a relatively rapid rising phase with a slower falling phase (Fig 2). Sinusoidal oscillations generally appear as symmetrical oscillations superimposed on a sustained level of [Ca2+]i usually above the pre-stimulus baseline level. They resemble more closely to true sine waves. These oscillations are generally considered insensitive to variations in agonist concentrations and may simply reflect how certain cells respond to a maintained elevation of calcium30. A less common [Ca2+]i oscillatory pattern that seems to be distinct from the spiking and sinusoidal patterns has been described by Rooney and Thomas32. The oscillations are highly asymmetric, consisting of a rapid increase in [Ca2+]i followed by a slow decline during which the next asymmetric oscillation is initiated. Such a pattern is extremely prominent in adrenal glomerulosa cells, in neutrophils and in mucosal mast cells33.   Figure 2. Different patterns of calcium oscillations. (A) Transient oscillations or spikes. Symmetrical transients (left) and transients  with slower recovery phase (right). (B) Sinusoidal oscillations. (C) Asymmetric oscillations.   In pancreatic islets, stimulatory glucose concentrations (>7mM) induce two types of [Ca2+]i oscillations – fast and slow. Fast oscillations are transient spikes in which the [Ca2+]i level rises sharply and then subsequently decreases along an exponential-like time course10. They oscillate at a frequency ranging from 2 to 5/min with duration of 3-11s (Fig 3). They are the direct consequence of β-cell bursting electrical activity, their duration depends on glucose concentration, and they are synchronous throughout the islet34. In contrast, slow oscillations are characterized by smooth rising and falling phase with duration of 1-3 min and frequency of 0.2-1/min. A mixed pattern of fast oscillations superimposed on the slow pattern is also a common observation. Both the slow and fast oscillations of [Ca2+]i in pancreatic islets depend on periodic entry of Ca2+.However, the fast ones somehow depend also on mobilization of Ca2+ from intracellular stores35.   Figure 3. Traces showing different oscillatory patterns of (Ca2+), in pancreatic islets. Stimulation of pancreatic islets with 11 mM glucose can produce fast (upper trace), slow (middle trace) or mixed (lower trace) patterns of (Ca2), oscillations.   Individual pancreatic b-cells exhibit different types of [Ca2+]i oscillations36. Type a or slow [Ca2+]i oscillations are sinusoidal which usually appear at glucose concentration of 7-20 mM with different thresholds for the individual cells (Fig 4). These oscillations have typical frequencies of 0.05-0.5/min, starting from the basal level with amplitudes of 300-500 nM37,38. The initial response of individual β-cells to glucose is characterized by a transient initial lowering of [Ca2+]i,due to sequestration of Ca2+ into intracellular compartments39-41, followed by a sharp rise of Ca2+ (Fig 5). The slow [Ca2+]i oscillations are strictly dependent on extracellular Ca2+ and disappear in the presence of the voltage-dependent Ca2+ channels (VDCC) blockers42. The slow [Ca2+]i oscillatory response is elicited not only by glucose as well leucine43, isoleucine44, ±-ketoisocaproate45 and tolbutamide46. Various mechanisms have been proposed to explain the generation of this [Ca2+]i fluctuations at single cell level including oscillations in glucose metabolism47-51, fluctuations of inositol 1,4,5 trisphosphate production52, oscillations of Ca2+ in the endoplasmic reticulum53, periodic Ca2+ influx during bursting electrical activity42,54 and cyclical periods of Ca2+ induced Ca2+ release55. But still it is an ongoing problem and no definitive conclusion has been reached so far.   Figure 4. (Ca2+)1 oscillations in individual pancreatic β -cell. Differentt types have been reffered to as a-d. (Reproduced with permission from Elsevier Science Publishers. Hellman B. Gylfe E, Grapengiesser E, Lund PE, Berts A. Cytoplasmic Ca2+ oscillations in pancreatic B-cells. Biochem Biophys Acta 1992, 1113:295-305).   Type b or fast [Ca2+]i oscillations usually appear as superimposed on the slow oscillations or on a sustained level of elevated [Ca2+]i. They occur at a frequency of 2-8/min with a duration of approximately 10s and amplitudes of 70-250 nM (Fig 4). The proportion of b-cells responding to glucose with the type b oscillations is higher in cells analyzed shortly after isolation than in those kept in culture for 1-2 days36. A critical cAMP concentration may be required for the appearance of these type b oscillations38,56.   Figure 5. Effect of raising glucose concentration from 3 to 11 mM on (Ca2+), of a single pancreatic β-cell. The horizontal bar indicates the period with the higher glucose concentration.   Type c oscillations are irregular [Ca2+]i transients with a duration of <10s and sometimes observed during glucose stimulation alone but becomes more frequent when cells are exposed to high concentrations of glucagon or when the adenylate cyclase activity has been stimulated with forskolin. The [Ca2+]i transients are independent of voltage dependent Ca2+ influx and disappear after addition of sarco-endoplasmic reticulum Ca2+-ATPase (SERCA) blocker, thapsigargin, indicating that the mobilization of Ca2+ from intracellular stores is responsible for their generation57. Type d oscillations are seen when b-cells, stimulated with glucose, are exposed to extracellular ATP or charbachol, which results in a series of [Ca2+]i transients of decreasing amplitude and increasing duration (Fig 4). It reflects mobilization of Ca2+ from intracellular stores mediated by activation of inositol 1,4,5-trisphosphate receptors and/or ryanodine receptors. These transients exhibit characteristic patterns, making it possible to identify individual b-cells by their [Ca2+]i ‘fingerprints’58. Significance of oscillatory [Ca2+]i signals In pancreatic b-cells, Ca2+ is the ‘naturally selected’ second messenger59,60 that decodes signals from different stimuli and relays messages to the biochemical machinery within the cell. But why does [Ca2+]i oscillate? Does it really need to oscillate for proper signal transduction in pancreatic β-cells? Although results of some experiments intriguingly suggest that [Ca2+]i oscillations are no more effective in insulin release than a sustained signal in pancreatic β-cell61-63, certainly [Ca2+]i oscillations confer positive functional advantages. In the following sections we will focus on the functional significance of oscillatory [Ca2+]I signals in the pancreatic β-cells. Regulation of insulin secretion. Oscillations in [Ca2+]i permit a finer control of secretion than a sustained elevation of [Ca2+]i as prolonged stimulation of cellular processes can cause desensitization64,65. It is anticipated that the various steps involved in exocytosis are also sensitive to distinct aspects of [Ca2+]i signals, eg, kinetics, multiple spikes, amplitude, and localization66. In pancreatic β-cells, KCl alone induces a sustained [Ca2+]i increase but causes transient insulin secretion67. In contrast, when glucose concentration is raised from basal to stimulatory, it induces [Ca2+]i oscillations and a continuous oscillatory insulin release from intact islets and individual β-cells16,17,68. Regulation of gene expression. Kinetics of oscillatory [Ca2+]i signaling exhibit significant variation in patterns and mechanisms of recognition69,70. It has been suggested that calcium spiking behavior permits information to be encoded and detected over a much broader range of signaling levels than with sustained [Ca2+]i increases31. Thus, oscillations of [Ca2+]i might regulate cellular processes other than insulin secretion, eg, gene expression. Glucose increases insulin gene expression both at transcriptional and translational levels71. The glucose induction of insulin transcription was inhibited by VDCC blocker suggesting that the stimulatory effect observed is mediated by Ca2+. Thus, glucose-induced oscillatory [Ca2+]i signal acts as a common pathway for effectively stimulating both the synthesis and release of insulin. Experimental results have clearly shown that [Ca2+]i oscillations and their frequencies are specific for gene activation, both in terms of efficiency and selectivity72. Li et a1.73 and Dolmetsch et a1.74 provided ample evidence for oscillatory [Ca2+]i signals to be more effective to activate Ca2+-dependent transcription factors than a single, prolonged increase. Regulation of metabolism. Oscillations in [Ca2+]i are also integrated at the level of the metabolic response. In hepatocytes, vasopressin-induced [Ca2+]i oscillation with the frequency of 0.5/min induces mitochondrial redox responses that were effectively maintained close to the peak response75. By contrast, sustained [Ca2+]i increases induced by maximal vasopressin doses were associated with only a single transient increase of NADH. Thus, a Ca2+ response system, in this case mitochondrial energy metabolism, can be tuned to the oscillatory change of [Ca2+]i signaling and actually tuned out by sustained [Ca2+]i signal31. In pancreatic b-cells, KCl induced a sustained [Ca2+]i increase and transient [Ca2+]m increase, while glucose induced [Ca2+]i oscillations and an oscillatory [Ca2+]m increase, suggesting that repetitive transients of [Ca2+]m associated with [Ca2+]i oscillations are necessary for continuous stimulation of mitochondrial metabolism and thereby continuous secretion of insulin76,77. It is also possible that oscillations prevent mitochondrial calcium overload and damage in chronically stimulated cells60,78. The Na+-dependent carriers, which discharge Ca2+ from mitochondrial matrix, are inhibited by increasing the extra-mitochondrial Ca2+ concentration within the physiological range79. Thus, the sustained increase in [Ca2+]i induced by KCl may attenuate the movement of Ca2+ from the mitochondrial matrix and consequently prolong the time course of the [Ca2+]m decline77. Regulation of apoptosis. Long-lasting sustained elevations of [Ca2+]i activates Ca2+-dependent degradative enzymes, e.g., protein kinases, endonucleases, proteases, and phospholipases,80,81 whose prolonged activation can result in extensive catabolism of cellular constituents and lethal injury. Oscillatory [Ca2+]i signals prevent these potentially damaging effects of Ca2+-dependent enzymes. McCormack et a1.82 have shown that induction of thymocytes apoptosis by glucocorticoid hormones are dependent on an early, receptor-mediated, sustained increase in [Ca2+]i concentrations. In hepatoma 1c1c7 cells low ATP concentrations (1-10 µM) stimulate a transient, receptor mediated Ca2+ response whereas high concentrations of ATP (mM) can also cause a sustained increase in the [Ca2+]i80,83. It appeared that treatment of the hepatoma cells with high levels of ATP could activate Ca2+-dependent, enzymatic DNA cleavage and contribute to cell killing80, Uncontrolled steady-state rise of [Ca2+]i can also induce Ca2+-dependent activation of several genes that characterize many types of acute lethal injury. These genes can be induced within 15 min or less, as in the case of c-fos66 and c-jun, to trigger additional events, such as the ced 3/ICE protease family members, which appear to be close to the final phase of cell death81. In pancreatic β-cells, increased cell death has been reported at elevated glucose concentrations when intracellular Ca2+ is not oscillating84.Recently, Iwakura et al.85 have shown that sustained enhancement of Ca2+ influx induced by continuous exposure to glibenclamide caused apoptotic cell death in rat insulinoma cell line (RINm5F cells). These results are consistent with the concept that oscillatory [Ca2+]i signals in pancreatic β-cells prevent cellular damage. In pancreatic β-cells, increased cell death has been observed at elevated glucose concentrations when [Ca2+]i is not exhibiting oscillations84.Recently, it has been shown that sustained enhancement of Ca2+ influx induced by continuous exposure to glibenclamide caused apoptotic cell death in rat insulinoma cell line, RINm5F cells85.These results are consistent with the idea that oscillatory Ca2+ signals in pancreatic β-cells prevent cellular damage. Role in energy homeostasis. Oscillations are less costly for maintenance of cell homeostasis65 considering that elevation of [Ca2+]i activates energy-consuming processes for extrusion of the ion33,60,while shortening of the time with a raised [Ca2+]i will conserve energy64.As an example of the efficiency of oscillatory system in conserving energy, the calculated results suggest that the dissipation of free energy is reduced by 5-10% in oscillatory glycolysis86. Synchronization of cellular processes. Oscillations can be integrated in single cell or tissue level. [Ca2+]i oscillations that result in asynchronous pulsatile responses in individual cells or groups of cells will be integrated into a smooth and continuous response in the total output of the tissue31. For example, response of single β-cell to glucose is heterogeneous – some cells display [Ca2+]i oscillations, others show a sustained rise, whereas a small proportion appear unresponsive87-89. However, a consistent oscillatory [Ca2+]i response is observed in clusters of 5-8 mouse pancreatic b-cells stimulated with 15 mM Glucose37,65. The heterogeneous response of isolated cells to glucose is masked when they are organized in the whole islets as a result of a very efficient coupling mechanism, which leads to synchronous glucose-induced oscillations of [Ca2+]i34,35. Analysis of [Ca2+]i oscillations in different regions of a single glucose-stimulated islet also showed that they may be of variable amplitude but are always synchronous. Simultaneous measurements of [Ca2+]i and insulin secretion in single mouse islets show that each [Ca2+]i oscillation is accompanied by an oscillation of secretion90. This synchrony persists when the frequency of [Ca2+]i oscillations is modified by a change in glucose concentration9l. Thus, pulsatile insulin secretion, triggered by highly integrated [Ca2+]i oscillations, from each islet is ultimately responsible for integrated pulsatile secretion by the whole pancreas and the generation of plasma insulin oscillations which are important for optimal action of the hormone65. Temporal control of cellular activity. In the biological targets the [Ca2+]i signal responds to the frequency of [Ca2+]i spikes rather than to the amplitude of [Ca2+]i change. This has given rise to the concept of frequency-modulated [Ca2+]i signaling78,86. However, it has also been reported that Ca2+ oscillations can be modulated both in frequency and amplitude92-94. Frequency encoding results in enhanced precision of control; it is particularly resistant to distortion by background noise86. Frequency dependent control systems also succeed in environments where amplitude dependent controls fail. If the [Ca2+]i is to be used as an amplitude-dependent signal, in which case its level would have to be maintained at a higher concentration for prolonged periods, it would cause calcium toxicity95. In pancreatic β-cell the frequencies of the [Ca2+]i oscillations vary as a function of agonist concentration58. For example, 25 µM carbamylcholine produced transients approximately every 15s, while at 200 µM transients occurred at ~10s intervals. Furthermore, Gilon et a1.91 explicitly demonstrated that when the concentration of glucose is raised, the peak of [Ca2+]i oscillations did not change significantly, but the frequency of [Ca2+]i oscillations clearly increased. This may result from glucose capacity to increase the efficacy with which frequency-encoded Ca2+ signals activates the exocytotic process and increases insulin release. Spatial control of cellular activity. Oscillations of [Ca2+]i show spatial order, which has indeed functional advantage for periodicity in biological control86. A distinctive attribute of biological system is to do the right thing at the right time in the right place. In heart, the temporal entrainment sequence (SA-node to Purkinje fibers to the ventricles) ensures the correct spatial sequence. Failures in this entrainment process can result in some of the clinically observed cardiac arrhythmias. Thus, Durham96 has speculated, “it is more plausible that every region (of the organism) can potentially oscillate at some frequency. Those parts with the highest inherent frequency will establish a phase lead and drive other regions. Waves will, therefore, move along membranes down gradients of inherent frequency”. Another crucial biological process in which precise spatial control is of central importance is the development of multicellular organisms from a single fertilized egg cell97. The events are particularly ordered in time and in space. However, the spatial organization of Ca2+ oscillations in pancreatic β-cell is not yet convincing. With digital imaging of the Ca2+-dependent fluorescence signal it has been demonstrated that [Ca2+]i varies substantially within the cell98a. [Ca2+]i first increases in a rim close to the plasma membrane. As the duration of the depolarization is increased, the [Ca2+]i-transient extends progressively deeper into the cell. However, at least during the first 350ms, [Ca2+]i remains highest in the vicinity of the plasma membrane. It is of interest, that the increase in [Ca2+]i is particularly rapid and pronounced in the upper right part of the cell whereas other parts of the cell remain relatively unaffected98a. The observation, that the [Ca2+]i-increase is more pronounced in certain parts of the cell may indicate an uneven distribution of Ca2+-channels in the β-cell membrane. It is tempting to speculate that regions of the plasma membrane with a high Ca2+-channel density correspond to ‘hot spots’ of exocytosis. Thus the spatial organization of oscillatory Ca2+ signal could lead to a provision of high Ca2+ concentration needed at the exocytotic sites while lower [Ca2+]i may be sufficient to activate other essential processes, such as the movement of insulin granules from storage to release sites98b. Discrimination between signal and noise. Calcium signal is digitized in the form of oscillations95,99 and a digitally encoded signal with the all or none property has favorable ‘signal-to-noise’ ratios70,100. By relying on large, discrete digital events, e.g. calcium oscillations, cells can readily distinguish an “intentional” calcium signal from potentially spurious wanderings of the steady-state, cytoplasmic calcium concentration. Indeed, in the brain, bursts of electrical activity are more readily perceived as signals than are action potentials that arrive singly.   Conclusion The periodic changes of [Ca2+]i is of great physiological and pathological importance since [Ca2+]i oscillates in synchrony with electrical activity and oscillations in [Ca2+]i correspond to pulsatile insulin release13-17. It has also been proposed that oscillatory insulin secretion is important in terms of insulin action on target organs, perhaps because of reducing down-regulation of receptors and thereby enhancing hormone action101. Several studies have demonstrated a greater hypoglycemic effect of insulin infused in a pulsatile manner and an enhancement of glucose disposal102-104. The greater potency of pulsatile insulin administration has also been demonstrated in perifused liver and in humans with IDDM105,106. Whether the loss of oscillations during the development of type 2 diabetes contributes to insulin resistance has not yet been established. But it is a widely acknowledged fact that the regular pattern of oscillatory insulin release is altered or lost in both developing type 1 and type 2 diabetes and disappearance of [Ca2+]i oscillations is a sensitive indicator of β-cell damage107-112. Thus, a detailed study of the mechanisms which underlay the presence of regular [Ca2+]i oscillations may help to find out the molecular and physiological defects involved in the pathogenesis of diabetes.   References 1.    Visscher MB. Summary of conference on rhythmic functions in the living system. Ann N Y Acad Sci 1962; 98: 1316-1321. 2.    Wolf W. Introductory remarks. Ann N Y Acad Sci 1962; 98: 755-756. 3.    Zethelius B, Berglund L, Lithell H, Berne C. Seasonal variations of insulin sensitivity, plasma glucose and insulin secretion. Ups J Med Sci 2001; 106 Supp12: 87. 4.    Carney TA, Guy SP, Helliwell CD. Seasonal variation in HbA1C in patients with Type 2 diabetes mellitus. Diabet Med 2000; 17: 554-555. 5.    Ishii H, Suzuki H, Baba T, Nakamura K, Watanabe T. Seasonal variation of glycemic control in type 2 diabetic patients. Diabetes Care 2001; 24: 1503. 6.    Maguire GA, Edwards OM. Seasonal variation in glycated haemoglobin in diabetics. Ann Clin Biochem 2001; 38: 59-60. 7.    Mollerstrom J, Sollberger A. Fundamental concepts underlying the metabolic periodicity in diabetes. Ann N Y Acad Sci 1962; 98: 984-994. 8.    Hellman B, Gylfe E, Bergsten P, Grapengiesser E, Lund PE, Berts A, Tengholm A, Pipeleers DG, Ling Z. Glucose induces oscillatory Ca2+ signalling and insulin release in human pancreatic beta cells. Diabetologia 1994; 37 Supp12: S11S20. 9.    Grapengiesser E, Gylfe E, Hellman B. Glucose-induced oscillations of cytoplasmic Ca2+ in the pancreatic b-cell. Biochem Biophys Res Commun 1988; 151: 1299-1304. 10.   Valdeolmillos M, Santos RM, Contreras D, Soria B, Rosario LM. Glucoseinduced oscillations of intracellular Ca2+ concentration resembling bursting electrical activity in single mouse islets of Langerhans. FEBS Lett 1989; 259: 19-23. 11.   Ahmed M, Grapengiesser E, Hellman B. Amino acid transformation of oscillatory Ca2+ signals in mouse pancreatic b-cells. J Endocrinol 1999; 160: 191-195. 12.   Fernandez J, Valdeolmillos M. Synchronous glucose-dependent [Ca2+]i oscillations in mouse pancreatic islets of Langerhans recorded in vivo. FEBS Lett 2000; 477: 33-36. 13.   Rosario LM, Atwater I, Scott AM. Pulsatile insulin release and electrical activity from single ob/ob mouse islets of Langerhans. Adv Exp Med Biol 1986; 211: 413-425. 14.   Santos RM, Rosario LM, Nadal A, Garcia-Sancho J, Soria B, Valdeolmillos M. Widespread synchronous [Ca2+]i oscillations due to bursting electrical activity in single pancreatic islets. Pflugers Arch 1991; 418: 417-422. 15.   Gilon P, Henquin JC. Influence of membrane potential changes on cytoplasmic Ca++ concentration in an electrically excitable cell, the insulin-secreting pancreatic B cell. J Biol Chem 1992; 267: 20713-20720. 16.   Gilon P, Shepherd RM, Henquin JC. Oscillations of secretion driven by oscillations of cytoplasmic Ca2+ as evidences in single pancreatic islets. J Biol Chem 1993; 268:22265-22268. 17.   Bergsten P, Grapengiesser E, Gylfe E, Tengholm A, Hellman B. Synchronous oscillations of cytoplasmic Ca2+ and insulin release in glucose-stimulated pancreatic islets. J Biol Chem 1994; 269: 8749-8753. 18.   Gylfe E, Ahmed M, Bergsten P, Dansk H, Dyachok O, Eberhardson M, Grapengiesser E, Hellman B, Lin JM, Sundsten T, Tengholm A, Vieira E, Westerlund J. Signaling underlying pulsatile insulin secretion. Ups J Med Sci 2000; 105: 35-51. 19.   Ashcroft FM, Rorsman P. Electrophysiology of the pancreatic b-cell. Prog Biophys Mol Biol 1989; 54: 87-143. 20.   Misler S, Barnett DW, Gillis KD, Pressel DM. Electrophysiology of stimulus secretion coupling in human b-cells. Diabetes 1992; 41: 1221-1228. 21.   Rana RS, Sekar MC, Mertz RJ, Hokins LE, MacDonald MJ. Potentiation by glucose metabolites of inositol trisphosphate-induced calcium mobilization in permeabilized rat pancreatic islets. J Biol Chem 1987; 262: 13567-13570. 22.   Roe MW, Lancaster ME, Mertz RJ, Worley JF, III, Dukes ID. Voltage dependent intracellular calcium release from mouse islets stimulated by glucose. J Biol Chem 1993; 268: 9953-9956. 23.   Liu YJ, Grapengiesser E, Gylfe E, Hellman B. Crosstalk between the cAMP and inositol trisphosphate-signalling pathways in pancreatic b-cells. Arch Biochem Biophys 1996; 334: 295-302. 24.   Worley JF, III, McIntyre MS, Spencer B, Dukes ID. Depletion of intracellular Ca2+ stores activates a maitotoxin-sensitive nonselective cationic current in b-cells. J Biol Chem 1994; 269: 32055-32058. 25.   Miura Y, Henquin JC, Gilon P. Emptying of intracellular Ca2+ stores stimulates Ca2+ entry in mouse pancreatic b-cells by both direct and indirect mechanisms. J Physiol 1997; 503 (Pt 2): 387-398. 26.   Liu YJ, Gylfe E. Store-operated Ca2+ entry in insulin-releasing pancreatic b-cells. Cell Calcium 1997; 22:277-286. 27.   Gagliardino JJ, Rossi JP. Ca2+-ATPase in pancreatic islets: its possible role in the regulation of insulin secretion. Diabetes Metab Rev 1994; 10: 1-17. 28.   Varadi A, Molnar E, Ashcroft SJ. A unique combination of plasma membrane Ca2+-ATPase isoforms is expressed in islets of Langerhans and pancreatic b-cell lines. Biochem J 1996; 314 (Pt 2): 663-669. 29.   Van Eylen F, Svoboda M, Herchuelz A. Identification, expression pattern and potential activity of Na/Ca exchanger isoforms in rat pancreatic B-cells. Cell Calcium 1997; 21: 185-193. 30.   Berridge MJ. Cytoplasmic calcium oscillations: a two pool model. Cell Calcium 1991; 12: 63-72. 31.   Thomas AP, Bird GS, Hajnoczky G, Robb-Gaspers LD, Putney JW, Jr. Spatial and temporal aspects of cellular calcium signaling. FASEB J 1996; 10: 15051517. 32.   Rooney TA, Thomas AP. Organization of intracellular calcium signals generated by inositol  lipid-dependent hormones. Pharmacol Ther 1991; 49: 223-237. 33.   Fewtrell C. Ca2+ oscillations in non-excitable cells. Annu Rev Physiol 1993; 55: 427-454. 34.   Valdeolmillos M, Nadal A, Soria B, Garcia-Sancho J. Fluorescence digital image analysis of glucose-induced [Ca 2+];oscillations in mouse pancreatic islets of Langerhans. Diabetes 1993; 42: 1210-1214. 35.   Liu YJ, Tengholm A, Grapengiesser E, Hellman B, Gylfe E. Origin of slow and fast oscillations of Ca2+ in mouse pancreatic islets. J Physiol 1998; 508 (Pt 2): 471-481. 36.   Hellman B, Gylfe E, Grapengiesser E, Lund PE, Berts A. Cytoplasmic Ca2+ oscillations ,in pancreatic b-cells. Biochim Biophys Acta 1992; 1113: 295-305. 37.   Gylfe E, Grapengiesser E, Hellman B. Propagation of cytoplasmic Ca2+ oscillations in clusters of pancreatic b-cells exposed to glucose. Cell Calcium 1991; 12: 229-240. 38.   Grapengiesser E, Gylfe E, Hellman B. Cyclic AMP as a determinant for glucose induction of fast Ca2+ oscillations in isolated pancreatic b-cells. J Biol Chem 1991; 266: 12207-12210. 39.   Rorsman P, Abrahamsson H, Gylfe E, Hellman B. Dual effects of glucose on the cytosolic Ca 2+ activity of mouse pancreatic b-cells. FEBS Lett 1984; 170: 196200. 40.   Gylfe E. Glucose-induced early changes in cytoplasmic calcium of pancreatic bcells studied with time-sharing dual-wavelength fluorometry. J Biol Chem 1988; 263: 5044-5048. 41.   Roe MW, Mertz RJ, Lancaster ME, Worley JF, III, Dukes ID. Thapsigargin inhibits the glucose-induced decrease of intracellular Ca2+ in mouse islets of Langerhans. Am J Physiol 1994; 266: E852-E862. 42.   Grapengiesser E, Gylfe E, Hellman B. Three types of cytoplasmic Ca2+ oscillations in stimulated pancreatic b-cells. Arch Biochem Biophys 1989; 268: 404-407. 43.   Grapengiesser E, Gylfe E, Hellman B. Ca2+ oscillations in pancreatic b-cells exposed to leucine and arginine. Acta Physiol Scand 1989; 136: 113-119. 44.   Martin F, Soria B. Amino acid-induced [Ca2+]i oscillations in single mouse pancreatic islets of Langerhans. J Physiol 1995; 486 (Pt 2): 361-371. 45.   Martin F, Sanchez-Andres JV, Soria B. Slow [Ca2+]i oscillations induced by ketoisocaproate in single mouse pancreatic islets. Diabetes 1995; 44: 300-305. 46.   Grapengiesser E, Gylfe E, Hellman B. Sulfonylurea mimics the effect of glucose in inducing large amplitude oscillations of cytoplasmic Ca2+ in pancreatic b-cells. Mol Pharmacol 1990; 37: 461-467. 47.   Corkey BE, Tornheim K, Deeney JT, Glennon MC, Parker JC, Matschinsky FM, Ruderman NB, Prentki M. Linked oscillations of free Ca2+ and the ATP/ADP ratio in permeabilized RINm5F insulinoma cells supplemented with a glycolyzing cell-free muscle extract. J Biol Chem 1988; 263: 4254-4258. 48.   Corkey BE, Deeney JT, Glennon MC, Matschinsky FM, Prentki M. Regulation of steady-state free Ca2+ levels by the ATP/ADP ratio and orthophosphate in permeabilized RINm5F insulinoma cells. J Biol Chem 1988; 263: 4247-4253. 49.   Longo EA, Tornheim K, Deeney JT, Varnum BA, Tillotson D, Prentki M, Corkey BE. Oscillations in cytosolic free Ca2+, oxygen consumption, and insulin secretion in glucose-stimulated rat pancreatic islets. J Biol Chem 1991; 266: 9314-9319. 50.   Dryselius S, Lund PE, Gylfe E, Hellman B. Variations in ATP-sensitive K+ channel activity provide evidence for inherent metabolic oscillations in pancreatic b-cells. Biochem Biophys Res Commun 1994; 205: 880-885. 51.   Larsson O, Kindmark H, Brandstrom R, Fredholm B, Berggren PO. Oscillations in KATP channel activity promote oscillations in cytoplasmic free Ca2+ concentration in the pancreatic b-cell. Proc Natl Acad Sci USA 1996; 93: 5161-5165. 52.   Ämmälä C, Larsson O, Berggren PO, Bokvist K, Juntti-Berggren L, Kindmark H, Rorsman P. Inositol trisphosphate-dependent periodic activation of a Ca2+-activated K+ conductance in glucose-stimulated pancreatic b-cells. Nature 1991; 353: 849-852. 53.   Gilon P, Arredouani A, Gailly P, Gromada J, Henquin JC. Uptake and release of Ca2+ by the endoplasmic reticulum contribute to the oscillations of the cytosolic Ca2+ concentration triggered by Ca2+ influx in the electrically excitable pancreatic B-cell. J Biol Chem 1999; 274: 20197-20205. 54.   Dryselius S, Grapengiesser E, Hellman B, Gylfe E. Voltage-dependent entry and generation of slow Ca2+ oscillations in glucose-stimulated pancreatic b-cells. Am J Physiol 1999; 276: E512-E518. 55.   Leech CA, Holz GG, Habener JF. Voltage-independent calcium channels mediate slow oscillations of cytosolic calcium that are glucose dependent in pancreatic b-cells. Endocrinology 1994; 135: 365-372. 56.   Ahmed M, Grapengiesser E. Pancreatic b-cells from obese-hyperglycemic mice are characterized by excessive firing of cytoplasmic Ca2+ transients. Endocrine 2001; 15: 73-78. 57.   Ahmed M, Grapengiesser E. Ca2+ handling of rat pancreatic beta-cells exposed to ryanodine, caffeine, and glucagon. Endocrine 2002; 17: 103-108. 58.   Prentki M, Glennon MC, Thomas AP, Morris RL, Matschinsky FM, Corkey BE. Cell-specific patterns of oscillating free Ca2+ in carbamylcholine-stimulated insulinoma cells. J Biol Chem 1988; 263: 11044-11047. 59.   Whitaker M. Ways of looking at calcium. Microsc Res Tech 1999; 46: 342347. 60.   Carafoli E, Penniston JT. The calcium signal. Sci Am 1985; 253: 50-58. 61.   Gilon P, Jonas JC, Henquin JC. Culture duration and conditions affect the oscillations of cytoplasmic calcium concentration induced by glucose in mouse pancreatic islets. Diabetologia 1994; 37: 1007-1014. 62.   Bergsten P. Glucose-induced pulsatile insulin release from single islets at stable and oscillatory cytoplasmic Ca2+. Am J Physiol 1998; 274: E796-E800. 63.   Jonas JC, Gilon P, Henquin JC. Temporal and quantitative correlations between insulin secretion and stably elevated or oscillatory cytoplasmic Ca2 in mouse pancreatic b-cells. Diabetes 1998; 47: 1266-1273. 64.   Jacob R. Calcium oscillations in electrically non-excitable cells. Biochim Biophys Acta 1990; 1052: 427-438. 65.   Henquin JC, Jonas JC, Gilon P. Functional significance of Ca2+ oscillations in pancreatic b-cells. Diabetes Metab 1998; 24: 30-36. 66.   Schlegel W, Mollard P: Electrical activity and stimulus-secretion coupling in neuroendocrine cells, in Scherubl H, Hescheler J (eds): The electrophysiology of neuroendocrine cells, CRC Press, 1995; pp 23-38. 67.   Sato Y, Aizawa T, Komatsu M, Okada N, Yamada T. Dual functional role of membrane depolarization/Ca2+ influx in rat pancreatic B-cell. Diabetes 1992; 41: 438-443. 68.   Cunningham BA, Deeney JT, Bliss CR, Corkey BE, Tornheim K. Glucoseinduced oscillatory insulin secretion in perifused rat pancreatic islets and clonal b-cells (HIT). Am J Physiol 1996; 271: E702-E710. 69.   Brabant G, Prank K, Schöfl C. Pulsatile patterns in hormone secretion. TEM 1992; 3: 183-190. 70.   Putney JW, Jr. Calcium signaling: up, down, up, down ...what’s the point? Science 1998; 279: 191-192. 71.   Melloul D, Cerasi E: Transcriptional regulation of proinsulin synthesis by glucose, in Flatt PR, Lenzen S (eds): Insulin secretion and pancreatic B-cell research, Smith Gordon: London, 1994; pp 7-13 72.   Meldolesi J. Calcium signalling. Oscillation, activation, expression. Nature 1998; 392: 863, 865-863, 866. 73.   Li W, Llopis J, Whitney M, Zlokarnik G, Tsien RY. Cell-permeant caged InsP3 ester shows that Ca2+ spike frequency can optimize gene expression. Nature 1998; 392: 936-941. 74.   Dolmetsch RE, Xu K, Lewis RS. Calcium oscillations increase the efficiency and specificity of gene expression. Nature 1998; 392: 933-936. 75.   Hajnoczky G, Robb-Gaspers LD, Seitz MB, Thomas AP. Decoding of cytosolic calcium oscillations in the mitochondria. Cell 1995; 82: 415-424. 76.   Pralong WF, Spät A, Wollheim CB. Dynamic pacing of cell metabolism by intracellular Ca2+ transients. J Biol Chem 1994; 269: 27310-27314. 77.   Nakazaki M, Ishihara H, Kakei M, Inukai K, Asano T, Miyazaki JI, Tanaka H, Kikuchi M, Yada T, Oka Y. Repetitive mitochondrial Ca2+ signals synchronize with cytosolic Ca2+ oscillations in the pancreatic beta-cell line, MIN6. Diabetologia 1998; 41: 279-286. 78.   Woods NM, Cuthbertson KS, Cobbold PH. Repetitive transient rises in cytoplasmic free calcium in hormone-stimulated hepatocytes. Nature 1986; 319: 600-602. 79.   McCormack JG, Browne HM, Dawes NJ. Studies on mitochondrial Ca2+-transport and matrix Ca2+ using fura-2-loaded rat heart mitochondria. Biochim Biophys Acta 1989; 973: 420-427. 80.   Nicotera P, McConkey DJ, Dypbukt JM, Jones DP, Orrenius S. Ca2+-activated mechanisms in cell killing. Drug Metab Rev 1989; 20: 193-201. 81.   Trump BF, Berezesky IK. The role of altered [Ca2+]i regulation in apoptosis, oncosis, and necrosis. Biochim Biophys Acta 1996; 1313: 173-178. 82.   McConkey DJ, Nicotera P, Hartzell P, Bellomo G, Wyllie AH, Orrenius S. Glucocorticoids activate a suicide process in thymocytes through an elevation of cytosolic Ca2+ concentration. Arch Biochem Biophys 1989; 269: 365-370. 83.   Mirabelli F, Bellomo G, Nicotera P, Moore M, Orrenius S. Ca2+ homeostasis and cytotoxicity in isolated hepatocytes: studies with extracellular adenosine 5’-triphosphate. J Biochem Toxicol 1986; 1: 29-39. 84.   Efanova IB, Zaitsev SV, Zhivotovsky B, Kohler M, Efendic S, Orrenius S, Berggren PO. Glucose and tolbutamide induce apoptosis in pancreatic b-cells. A process dependent on intracellular Ca2+ concentration. J Biol Chem 1998; 273: 33501-33507. 85.    Iwakura T, Fujimoto S, Kagimoto S, Inada A, Kubota A, Someya Y, Ihara Y, Yamada Y, Seino Y. Sustained enhancement of Ca 2+ influx by glibenclamide induces apoptosis in RINm5F cells. Biochem Biophys Res Commun 2000; 271: 422-428. 86.   Rapp PE. Why are so many biological systems periodic? Prog Neurobiol 1987; 29: 261-273. 87.   Herchuelz A, Pochet R, Pastiels C, Van Praet A. Heterogeneous changes in [Ca2+], induced by glucose, tolbutamide and K+ in single rat pancreatic B cells. Cell Calcium 1991; 12: 577-586. 88.   Grapengiesser E, Gylfe E, Hellman B. Glucose sensing of individual pancreatic b-cells involves transitions between steady-state and oscillatory cytoplasmic Ca2+. Cell Calcium 1992; 13: 219-226. 89.   Jonkers FC, Jonas JC, Gilon P, Henquin JC. Influence of cell number on the characteristics and synchrony of Ca2+ oscillations in clusters of mouse pancreatic islet cells. J Physiol 1999; 520 (Pt 3): 839-849. 90.   Bergsten P. Slow and fast oscillations of cytoplasmic Ca2+ in pancreatic islets correspond to pulsatile insulin release. Am J Physiol 1995; 268: E282-E287. 91.   Gilon P, Henquin JC. Distinct effects of glucose on the synchronous oscillations of insulin release and cytoplasmic Ca2+ concentration measured simultaneously in single mouse islets. Endocrinology 1995; 136: 5725-5730. 92.   D’Andrea P, Codazzi F, Zacchetti D, Meldolesi J, Grohovaz F. Oscillations of cytosolic calcium in rat chromaffm cells: dual modulation in frequency and amplitude. Biochem Biophys Res Commun 1994; 205: 1264-1269. 93.   Eberhardson M, Tengholm A, Grapengiesser E. The role of plasma membrane K+ and Ca2+ permeabilities for glucose induction of slow Ca2+ oscillations in pancreatic b-cells. Biochim Biophys Acta 1996; 1283: 67-72. 94.   Pabelick CM, Prakash YS, Kannan MS, Jones KA, Warner DO, Sieck GC. Effect of halothane on intracellular calcium oscillations in porcine tracheal smooth muscle cells. Am J Physiol 1999; 276: L81-L89. 95.   Berridge MJ, Galione A. Cytosolic calcium oscillators. FASEB J 1988; 2: 3074-3082. 96.   Durham AC. A unified theory of the control of actin and myosin in nonmuscle movements. Cell 1974; 2: 123-135. 97.   Miyazaki S. Repetitive calcium transients in hamster oocytes. Cell Calcium 1991; 12: 205-216. 98a.  Rorsman P, Bokvist K, Ammala C, Eliasson L: Ca2+-channels, cytoplasmic Ca2+-concentration and exocytosis in pancreatic B-cell, in Flatt PR, Lenzen S (eds): Insulin secretion and pancreatic B-cell research, Smith Gordon: London, 1994; pp 187-194. 98b.   Barg S, Ma X, Eliasson L, Galvanovskis J, Gopel SO, Obermuller S, P <![CDATA[In Memoriam: National Prof. Mohammad Ibrahim (1911 - 1989)]]> Prof. A.K.M. Nurul Anwar https://imcjms.com/journal_full_text/512 2024-01-31 12:47:16 Others Another field of social welfare in which Prof. Ibrahim left indelible mark was family planning. He was a founder member of Bangladesh Family Planning Association which started family planning program first in this country in mid fifties. As an Adviser (Minister) of the Ministry of Health and Population Control, Govt. of Bangladesh in mid seventies, he introduced multisectoral approach – involving various ministries, agencies of the Govt., NGOs, social leaders and the people with the family planning awareness program, which subsequently proved crucial for the success of the program. As a teacher, he always laid emphasis on punctuality, discipline, devotion to duty and practice rather than precept. Prof. Ibrahim instilled confidence and trust in his students and helped them to inculcate the habit of deducting reasoning, enquiry and adherence to clinical methods. Prof. Ibrahim always believed that an institution achieves its goal and excellence not by bricks and mortars, nor by machines or metals but by their human resources and he spent all his life in developing these human resources. Ibrahim Medical College is yet another Institute of Diabetic Association of Bangladesh dedicated to his memory and committed to develop the human resources for health of highest order, true to the ideals of Prof. Ibrahim. <![CDATA[Efficacy and safety of lentivirus gene therapy in the correction of sickle cell disease]]> https://imcjms.com/journal_full_text/574 2025-09-07 12:13:20 Original Article July 2025; Vol. 19(2):007 Background and objective: Lentivirus gene therapy (LGT) is an emerging therapy for sickle cell disease (SCD), although its efficacy and safety are under evaluation in clinical trials. This review assessed the efficacy and safety of LGT in relation to hydroxyurea (HU). Results: There was a significant increase (p-value<0.00001) in haemoglobin (Hb) level after LGT and production of HbAT87Q and foetal haemoglobin (HbF). Clinical outcome decreased significantly, and no hospitalization was required following LGT. A significant age-related difference in the LGT outcome was observed. Mode 1 treatment had significantly higher (p=0.004) outcome compared to mode 2 treatment. There was a significant increase (p<0.00001) in treatment outcome in SCD patients treated with LGT compared to those treated with HU. Gastroenteritis and leucopenia were the most reported adverse effects. July 2025; Vol. 19(2):007.  DOI: https://doi.org/10.55010/imcjms.19.018 *Correspondence: Chikadibia Fyneface Amadi, Department of Medical Laboratory Science, PAMO University of Medical Sciences, Rivers State, Nigeria. Email: worldwaiting@yahoo.com. © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License(CC BY 4.0). Introduction The pathophysiology of SCD is intricate, involving several factors, such as hemolysis, vaso-occlusion, inflammation, oxidative stress, endothelial dysfunction, and hypercoagulability [6-8]. Treatment of SCD aims to prevent or mitigate the frequency and severity of complications, enhance quality of life, and extend lifespan of the patient. Existing therapeutic approaches encompass supportive care, pharmacological agents, and hematopoietic stem cell transplantation (HSCT) [9,10]. Various supportive care approaches include hydration, analgesics and antibiotics administration, blood transfusions, and immunization modalities [11,12]. Among pharmacological agents, hydroxyurea stands out—an agent boosting fetal hemoglobin production, thereby reducing the polymerization of hemoglobin S and the sickling of RBCs [12]. Demonstrating efficacy, hydroxyurea has been linked to a decrease in pain crises, incidents of acute chest syndrome, hospitalizations, and increased mortality rate in SCD patients [13]. Nevertheless, challenges such as variable response, adverse effects, and compliance issues temper its utility [14]. At present, a cutting-edge alternative in SCD intervention is gene therapy, aiming to rectify the underlying genetic anomaly at its source. This innovative approach involves the introduction of a functional gene into specific target cells, notably hematopoietic stem cells (HSCs), to bring about modifications in their gene expression and phenotype character [16]. Gene therapies broadly fall into two categories: gene addition and gene editing. Gene addition involves incorporating a therapeutic gene into the genome of the target cells without altering existing genes [16]. On the other hand, gene editing entails the precise modification or correction of the target gene, employing advanced tools such as zinc finger nucleases, transcription activator-like effector nucleases, or the CRISPR-Cas9 system [17,18]. One of the most exciting advances in sickle cell disease (SCD) treatment is the use of CRISPR/Cas9 gene editing, a technology that allows scientists to make precise changes to DNA. Generally, CRISPR is palindromic sequence in bacterial genome which can be excised by the cas9 enzyme, allowing scientists to modify, edit, insert or delete genes according to convenience. This breakthrough has led to CASGEVY™ (exagamglo gene autotemcel, or exa-cel), the first FDA-approved CRISPR-based therapy for SCD, developed by Vertex Pharmaceuticals and CRISPR Therapeutics. CASGEVY works by editing a patient’s own stem cells to boost the production of fetal hemoglobin (HbF), which helps counteract the harmful effects of sickle hemoglobin [19,20]. The FDA approval of CASGEVY in late 2023 was a landmark moment not just for SCD patients, but for the entire field of gene therapy. For decades, researchers have been working toward a true cure for SCD, and this therapy represents a major step forward. Clinical trials have shown that CASGEVY can dramatically reduce or even eliminate pain crises in many patients, offering hope for a life free from the most debilitating symptoms of SCD [21]. Beyond its clinical success, CASGEVY’s approval also sets a precedent for future gene-editing treatments, proving that CRISPR technology can be both safe and effective in treating genetic disorders. While challenges like cost and accessibility remain, this therapy opens a new era of personalized medicine for SCD patients [22,23].   (B) In Vivo Gene Therapy: Systemic delivery of a gene-modifying agent with affinity for HSCs directly targets cells within the patient's body, providing a streamlined and less invasive gene therapy approach. The efficacy of LGT hinges on the type of therapeutic gene delivered by the lentiviral vector [29]. In the context of sickle cell disease (SCD), there are two primary strategies for LGT: anti-sickling gene therapy and globin gene therapy [16,25-34]. Anti-sickling gene therapy entails the delivery of a gene encoding a modified hemoglobin variant capable of preventing or reducing the polymerization and sickling of hemoglobin S [32-34]. Examples of anti-sickling genes include hemoglobin F (HbF), the fetal form of hemoglobin typically silenced after birth, and hemoglobin A (HbA), the normal adult form of hemoglobin mutated in SCD [32-34]. Other examples involve hemoglobin A2 (HbA2), a minor adult hemoglobin form, and hemoglobin mutants like hemoglobin E (HbE) and hemoglobin G (HbG), both possessing reduced affinity for hemoglobin S [32-35].     To gauge the effectiveness of this therapeutic approach, a range of assessment methods is employed. In vitro analyses are conducted to scrutinize alterations in vector titers and transduction efficacy [42]. In vivo studies entail the transplantation of vector- or mock-transduced cells into animal models to evaluate therapeutic effectiveness [42]. Rigorous clinical trials are undertaken to assess the safety and efficacy of the lentiviral vector, the in vivo gene transfer clinical protocol, and the sustained correction of associated pathological symptoms [43]. The evaluation of vector integration sites is crucial to ensure the safety of the gene therapy [43]. Additionally, measuring degradative metabolite levels in patients during treatment aids in evaluating therapeutic efficacy [43]. The monitoring of clinical endpoints involves observing changes in disease symptoms, the frequency of disease-related complications, and the overall health and quality of life of patients [44]. These outcomes aim to improve oxygen-carrying capacity, minimize painful episodes, prevent life-threatening complications, and enhance the overall well-being of individuals with SCD. While LGT has shown promising outcomes, it is essential to acknowledge certain limitations that warrant attention. These limitations are limited patient numbers, short follow-up periods, and a deficiency in long-term data [47]. To strengthen the robustness of LGT's safety and efficacy profile, further studies are imperative. These studies should delve into critical parameters such as lentiviral vector design, conditioning regimens, transduction protocols, and comparative analyses with alternative gene therapy strategies [47]. Additionally, the optimization of clinical endpoints and the resolution of practical challenges, including cost, accessibility, ethics, and regulation, are pivotal for propelling LGT toward becoming a viable treatment for Sickle Cell Disease [47].   The Preferred Reporting Items for Systematic Review and Meta-analysis (PRIMSA) protocol of 2015 [49] was followed in the step-by-step development of the review to ensure reproducibility and transparency in the review process. The summary of the PRISMA protocol was reported using a PRISMA flowchart. Exclusion criteria: Studies not relevant to LGT in SCD such as other haemoglobinopathies like thalassemia were excluded. Animal studies, editorials and review articles, original studies using other forms of gene therapy were also excluded. Search strategy: A comprehensive search strategy was developed using a combination of Boolean function [50] and filters to narrow the study to original articles and clinical trials (randomized and non-randomized clinical trials) with advanced search including specific keywords like “lentivirus sickle cell disease” particularly for ScienceDirect. It is important to mention that the search strategy was adjusted to the specific provisions of each database.   Data management: All search results from the listed databases were first imported and managed by EndNote software, after which they were exported as XML files to Covidence for screening, selection, extraction and quality assessment of the included studies. Leveraging on the features of the software (EndNote), streamlining the process of reference formatting of included studies to the desired citation style was possible [51]. Covidence is a web-based tool for systematic review management [52,53] following PRISMA guideline, including title and abstract screening, full text screening, quality assessment. The Covidence tool was also used for data extraction and PRISMA flowchart generation [52,53]. Quality assessment: Virtually all the studies included were in the 1/2 phase of clinical trial. Since these phases of studies are typical of pilot studies, the checklist tool used was put into consideration to capture the peculiarity of such studies because studies in early phase clinical trials may require modifications in their quality assessment due to their uniqueness. In this case the studies were neither a full-scale clinical nor randomized clinical trial. To fulfill this purpose, the University of Chicago checklist for pilot studies was used to judge the quality of each study. It reflected at parameters such as the study’s goal, the reason for doing it, whether the way data was collected matched the goal, the number of participants (though not in a strict statistical way), if the data collection method would work in a larger study, and whether there was a good reason to move forward with a full-scale study.[54]. Ethical consideration: Following the fact that the review depended on already published data (secondary data) available in the public domain for public use, ethical clearance was not required for the commencement of the study. However, all used data from the secondary sources were duly cited. Results   Figure-3: PRISMA Flowchart Figure-3 above shows the PRISMA flowchart illustrating the review process. Out of449 studies, 10 were considered eligible for quality assessment and onward data extraction. Study Design Treatment Summary of the findings Studies on Hydroxyurea therapy Lad et al., 2022 [65] Clinical trial SCD patients Sample size: 138 Mean age: ≤14 yrs Hydoxyurea; Dose(CD34+) (cells/Kg):18.7 24 months The study showed that post-treatment hemoglobin levels averaged 9.2 g/dL with 25.6% HbF production. Clinical outcomes showed minimal vaso-occlusive pain (3.6%) and no chest pain, though non-cardiac pain remained prevalent at 54.3%. Hospitalization data was not reported Hoppe et al., 1999 [66] Clinical trial Severe SCD patients Sample size: 8 Mean age: 3.7 yrs Hydroxyurea; Dose(CD34+) (cells/Kg): 27 137 weeks The study demonstrated the highest hemoglobin improvement among hydroxyurea studies (10.7 g/dL) with 19% HbF. Notably eliminated all vaso-occlusive and non-cardiac pain, but reported a 20% hospitalization rate post-treatment Ofakunrin et al., 2018 [67] Quasi-experimental study SCA patients Sample size: 54 Mean age: 8.4 yrs Hydroxyurea; Dose(CD34+) (cells/Kg): n/m     12 months The study achieved hemoglobin levels of 9.3 g/dL, though HbF percentages were not documented. The study reported complete resolution of both vaso-occlusive and non-cardiac pain (0% for both), with no reported hospitalizations. PTA interval: Post-treatment assessment interval; SCD: Sickle cell disease; SCA: Sickle cell anaemia; n/m: Not mentioned   Meta-analysis of the efficacy of a treatment (Lentivirus gene therapy) in managing sickle cell disease based on Haemoglobin     Figure-4 shows that among the seven studies, there was statistical difference among the groups of the studies (Z=2.20, P<0.03). This implies significant reduction in Hemoglobin before gene therapy (MD= -3.50, 95% C.I [-6.63, -0.38]). Also, significant heterogeneity was seen across the studies (I2= 99%; P<0.00001). Table-3: Summary of the efficacy of a treatment (lentivirus gene therapy) in managing sickle cell disease     Table-4: Proportion of HBAT87Q and HbF among the studies       Age dependent variation in treatment outcome     Table-6 provides a summary of descriptive statistics related to age-dependent variation in treatment outcomes for sickle cell disease across different studies. The table includes data on the ages of individuals who participated in the studies. The average age of the participants across all studies is approximately 22 years, with an age interval spanning from 14 to 32 years. The table presents various treatment outcomes, including the percentage of HbAT87Q treatment, the percentage of HbF treatment, absolute reticulocyte count (ARC) after treatment, and lactate dehydrogenase (LD) levels after treatment. Table-6: Summary of descriptive statistics on age dependent variation in treatment outcome   Mode 2: represents treatment targeted at improving HbF level. Figure-6 below shows the meta-analysis of treatment outcome based on mode of action of lentiviral gene therapy across the studies. It was seen that there was a significant mean difference between the mode 1 and mode 2 groups and Lentiviral gene therapy favoured mode 1 action (IV=-14.69, 95% CI [-24.61, -4.77], Z=2.90, p=0.004). Significant heterogeneity existed among the groups (I2= 100%, P<0.00001). Treatment outcome based on disease severity Figure-7: Forest Plot showing treatment outcome based on disease severity (SSCD versus SCD)       Based on Figure-8 as illustrated, the meta-analysis of treatment outcome based on duration of treatment assessment revealed no effect for duration of treatment assessment at 1 year duration term and <1 year duration term (OR, 0.78, 95% [0.34, 1.79), Z=0.59, p=0.55). Meta-analysis of treatment outcome between lentivirus gene therapy and hydroxyurea for SCD     Table-7 presents a summary of descriptive statistics comparing treatment outcome (HbF) between two different approaches for managing sickle cell disease (SCD): lentivirus gene therapy and hydroxyurea treatment.     Comparison clinical outcome between lentivirus gene therapy and Hydroxyurea for SCD Figure-10: Forest plot showing the comparison of clinical outcomes between lentivirus gene therapy and Hydroxyurea for SCD The meta-analysis of the comparison of clinical outcomes between lentivirus gene therapy and hydroxyurea for SCD (Figure-10) showed that there was no significant difference between lentivirus gene therapy and hydroxyurea for SCD (IV=1.88, 95%, [-10.50, 14.26], Z=0.30, P=0.77). There wassignificant heterogeneity among the studies (I2=100%, P<0.00001). Discussion The substantial increase in Hb levels indicated a positive response to the therapy, as higher Hb levels are generally desirable in managing sickle cell disease. A reduction in absolute reticulocyte count (ARC) is typically seen as a positive response to treatment in sickle cell disease as well as a decrease in lactate dehydrogenase (LD) levels. All these changes in the parameters are often indicative of improved red blood cell health. These findings are in consonance with the study conducted by Abraham in 2021 who reported that increase in Hb level is an indication of improvement of red blood cell health and treatment success [25,68]. This is to say that the decrease in ARC and LD levels reported in this review were suggestive of therapeutic success of LGT in SCD patients whose red blood cells were often destroyed or lysed due to their sickle shape. In general, the increase in Hb, and decrease in ARC and LD levels suggested that the therapy was effective in improving the health of individuals with SCD [69]. Clinical outcomes such as vaso-occlusive pain, chest pain syndrome, hospitalization and non-cardiac pain were assessed among the studies. The findings revealed that there were no reported cases of hospitalization after treatment although there were few reported cases of vaso-occlusive pain [58,60,63], chest pain syndrome [60,64], and non-cardiac pain [58,60,63]. These findings support the fact that LGT improves the quality of life as reported by other studies [58,72-74]. It is noteworthy that LGT provides therapeutic intervention via any of the two mechanisms: gene addition [16] and promoting HbF production [25-33]. In comparing between modes of treatment, since the results showed that there was significant improvement in the treatment outcome in mode 1 compared to mode 1I, it implies that the LGT was more effective when the treatment was targeted towards correcting the mutant gene than when treatment was targeted towards improving HbF level. This means that whether the LGT was made to fix the faulty gene or to increase fetal hemoglobin levels, both approaches showed better treatment result, although correcting the mutant gene provided better therapeutic achievement than improving foetal haemoglobin level.Till now, no study has compared the treatment outcomes between these two modes. The study conducted by Demirci and Germino-Watnick who reported improvements in total Hb levels in lentiGlobin gene and BCL11A shmiR gene infusion [33,76] supports the fact that both modes of treatments achieved therapeutic success. The result presented in Figure-6 highlighted the diversity in the duration of treatment assessment across the studies, however, the duration of the treatment (whether long term or short term) did not make any difference in the success achieved. This may be due to the sustained presence of the corrected gene in the haematopoietic stem cell infused in the treatment process, resulting in continuous production of healthy red blood cells and improved treatment outcome. This is supported by the works conducted by Kanter and Drakopoulou in 2021 and 2022 respectively who reported long term effectiveness of LGT [16,78]. When it comes to the percentage of HbF, it appears that lentivirus gene therapy, as seen in Esrick et al. [59], and Malik et al. [62] resulted in slightly higher percentages compared to HU treatment. However, it is important to note that these changes may be due to chance, or on various factors, including individual patient characteristics, the specific protocol used in each study, mechanism of drug action and the duration of treatment. Some safety concerns were identified in course of this review. One study identified some safety concerns such as occurrence of Type 1 diabetes and respiratory infection, but he reported those adverse effects were not necessarily related to the effect of the administered treatment (LGT) [59]. Hydroxyurea treatment was reported to have a few safety concerns also such as leucopenia, myelosuppression, brain infarction. However, although there was no leading or most frequent safety issue identified, leucopenia was consistent in both HU treatment and LGT. This may be due to the impact the treatments have on haematopoietic system and bone marrow. Studies have established a dose-dependent relationship of leucopenia occurrence in HU [80]. Based on previous reports by Kanter and Ofakunrin, the leucopenia may be due to neutropenia which gave rise to the condition febrile neutropenia reported by them [16,61]. Contrarily, Lad and his colleagues did not identify any adverse effect after the administration of HU [67].   This study comprehensively examined the efficacy, clinical outcomes, and safety of LGT for sickle cell disease (SCD) in comparison with HU. This review has revealed that although both treatment interventions provided improvement in the laboratory data like haemoglobin level, LGT had better treatment achievement compared to HU. While both treatments had improvements in the clinical outcomes, there was no significant difference in the improvement levels between both treatments. This suggests that both treatment approaches have comparable outcomes in terms of managing these clinical manifestations of SCD.   To gain better comprehensive understanding of the comparative effectiveness of these treatments and their long-term impact on the quality of life for individuals with SCD, further research, including large-scale clinical trials and extended follow-up studies is imperative. Since LGT has better efficacy and comparable safety concerns with HU, LGT may be considered a better treatment option for SCD patients. Owing to the fact there were limited studies in LGT, most studies on LGT were currently non-randomized clinical trials, and therefore, it is recommended that future studies should be designed as randomized controlled clinical trials. Further research should build upon the lessons learned from early clinical trials and preclinical models to refine treatment protocols and enhance the safety profile of LGT. Limitation   We extend our acknowledgments to family members, friends and academic colleagues who provided various kinds of support on this research journey. Very importantly, we extend our appreciation to Department of Biomedical Science, College of Medicine, University of Chester for providing the platform and approval for this research. Author’s contributions Conflict of interest Funding   <![CDATA[Histomorphological patterns and diagnostic utility of crush and imprint smear cytology in mucormycosis: a prospective study]]> Ruquiya Afrose Zikki Hasan Fatima Mohd. Yasir Zubair* Mahboob Hasan Sayeedul Hasan Arif Mohammad Aftab Mehtab Ahmad https://imcjms.com/journal_full_text/589 2025-12-23 09:36:18 Original Article

Introduction: Mucormycosis is a rare but deadly fungal infection that often affects those with weakened immune systems. With the rise in predisposing factors such as diabetes, use of steroids, rise in cases of cancer, among others, cases of mucormycosis are increasingly being observed. A surge of cases was noted due to the situation arising out of the COVID-19 pandemic.

Materials and methods: This study analyzed various histo-morphological tissue reaction patterns associated with mucormycosis and explored the utility of crush smear and imprint smear cytology in confirming the presence of fungi. A total of 63 samples were taken. Meticulous history and clinical examination were done. History of COVID-19 infection, diabetes mellitus, hospitalization, intensive care stay, and steroid therapy was taken into account. Biopsy specimens (rhino-orbital, sino-nasal, rhino-cerebral and bone) received in normal saline were first subjected to cytopathological examination using both crush smears and imprint smears and further processed for histopathological examination.

Results: The mean age of the patients was 48.76 ± 13.24 years. Male preponderance was seen with male to female ratio of 1.65:1. An overwhelming majority (92.6%) of patients had a history of COVID-19 infection. Pre-existing diabetes mellitus was found in 83.3% of patients, steroid intake in 72% of patients, and medical oxygen administration in 46.3% of patients. Out of 63 clinically suspected patients, 54 (85.7%) cases were diagnosed with mucormycosis on histopathology. The most common site involved was rhino-orbital (62.9%), followed by sino-nasal (25.9%) and rhino-cerebral (7.4%). Five histo-morphological patterns were identified namely infarct-like necrosis with or without angio-invasion (50%), exudative pattern (24%), mixed pattern (11%), granulomatous (9%) and predominantly histiocytic pattern (6%). With histopathology as gold standard, crush smear cytology yielded a sensitivity of 72.2% (95% confidence interval/CI: 58.4-83.5%), specificity of 77.8% (95% CI: 40.0-97.2%), positive predictive value (PPV) of 95.1% (95% CI: 83.5-99.4%) and negative predictive value (NPV) of 31.8% (95% CI: 13.9-54.9%), with overall diagnostic accuracy of 73.0%. Imprint smear cytology showed marginally better performance with sensitivity of 75.9% (95% CI: 62.4-86.5%), specificity of 77.8% (95% CI: 40.0-97.2%), PPV of 95.3% (95% CI: 84.2-99.4%) and NPV of 31.8% (95% CI: 13.9-54.9%), with overall diagnostic accuracy of 76.2%.

Conclusion: Various histo-morphological patterns encountered on histopathological examination help us keep the suspicion index high and warrant extensive examination for fungi. Histopathology remains the gold standard, providing prompt and definitive diagnosis, essential for establishing surgical and antifungal therapy, prognostication and evaluation of treatment response. Both crush smear and imprint cytology demonstrate high sensitivities (72-76%) and excellent PPVs (>95%), making them valuable rapid diagnostic tools for confirming mucormycosis when positive results are obtained. However, their low NPVs (31.8%) indicate that negative cytology results cannot reliably exclude mucormycosis, and histopathological examination remains mandatory in clinically suspected cases with negative cytological findings.

January 2026; Vol. 20(1):001, DOI: https://doi.org/10.55010/imcjms.20.001

*Correspondence: Mohd. Yasir Zubair, Department of Community Medicine, VALASMC, Etah, UP, India. Email: yasmuhsin@gmail.com.

]]> <![CDATA[Comparison of four different multi-detector computed tomography based split renal function (SRF) evaluation methods and their correlation with nuclear scintigraphy derived SRF for functional assessment of potential living renal donors]]> Sarfraz Ahmad Raghunandan Prasad Hira Lal Sukanta Barai Aneesh Srivastava S Danish Iqbaal* https://imcjms.com/journal_full_text/595 2026-01-25 12:37:04 Original Article January 2026; Vol. 20(1):002 Background and Objectives: Preoperative anatomical and functional evaluation of donor kidneys is crucial for successful renal transplantation. While multi-detector computed tomography (MDCT) angiography is the standard imaging modality for anatomical assessment, nuclear scintigraphy using Technetium-99m Diethylenetriamine Pentaacetate (Tc-99m DTPA) remains the gold standard for evaluating split renal function (SRF). However, MDCT-based SRF estimation has recently emerged as a viable alternative.

The aim of this study is to compare four different MDCT-based SRF measurement techniques and assess their correlation with SRF obtained from nuclear scintigraphy.

Materials and Methods: This prospective study included 111 living kidney donors from 2019 to 2021 who underwent MDCT angiography. SRF was estimated using four CT-based methods: total renal volume, cortical renal volume, ellipsoid method (all using semi-automated ROI-Region of Interest), and differential attenuation of contrast. All measurements were performed using an Advantage Workstation (GE). The calculated SRFs were compared with Tc-99m DTPA-based SRF using the Pearson correlation coefficient.

Results: The mean age of donors was 44.32±10.25 years (range: 22–69). All four MDCT-based methods showed statistically significant correlation with nuclear scintigraphy SRF. For the right kidney, correlation coefficients (r) were 0.574 (total renal volume), 0.509 (cortical volume), 0.288 (ellipsoid method), and 0.323 (contrast attenuation); for the left kidney, r-values were 0.513, 0.473, 0.262, and 0.251, respectively (all p<0.001).

Conclusion: MDCT-based SRF measurements demonstrate a significant correlation with nuclear scintigraphy. Given that MDCT angiography is routinely performed for anatomical evaluation, it can serve as a comprehensive, single-modality approach for both anatomical and functional assessment in living kidney donors.

January 2026; Vol. 20(1):002. DOI: https://doi.org/10.55010/imcjms.20.002

*Correspondence: S Danish Iqbaal, Department of Community Medicine, Indira Gandhi Institute of Medical Sciences, Patna-800014, Bihar, India. Email: iqbalsdalig@gmail.com

]]> <![CDATA[Changes in corneal endothelial cell density and central corneal thickness in patients with type 2 diabetes mellitus]]> Umama Islam* Ferdous Akhter Jolly Md. Ferdous Hossain Md. Faizul Ahasan https://imcjms.com/journal_full_text/597 2026-02-24 11:44:00 Original Article January 2026; Vol. 20(1):004 Background and objectives: The corneal endothelium is essential for maintaining corneal transparency and visual function. Chronic hyperglycaemia in type 2 diabetes mellitus (T2DM) can impair endothelial pump activity, resulting in reduced endothelial cell density (ECD) and increased central corneal thickness (CCT). Because endothelial cells do not regenerate, progressive cell loss may lead to irreversible endothelial decompensation. This study evaluates the association of T2DM with ECD and CCT and examines how these parameters relate to diabetes duration, glycaemic control (HbA1c) and diabetic retinopathy (DR).

Materials and methods: This cross-sectional study, conducted at BIRDEM General Hospital, included 86 patients with T2DM and 86 individuals in the non-diabetic group. The T2DM group was subdivided by DR status (no DR, non-proliferative DR and proliferative DR). Following standard ophthalmic examinations, specular microscopy was performed to measure ECD and CCT in the right eye. Data were analyzed using t-test, ANOVA, correlation analysis and multivariate regression (SPSS version 26).

Results: Individuals with T2DM demonstrated a significant loss of endothelial cells, with mean ECD 275 cells/mm² lower than the non-diabetic group (2585·18 ± 263·12 vs 2860·06 ± 244·45 cells/mm²; p<0·001). CCT did not differ significantly between groups (527·60 ± 32·93 vs 524·37 ± 40·81 µm; p=0·568). In multivariate regression, age contributed to a loss of 21·25 cells/mm² per year (p<0·001), while T2DM independently accounted for an additional loss of 191·12 cells/mm² (p<0·001). Increasing intraocular pressure (IOP) had no significant effect on ECD (loss of 15·17 cells/mm² per mmHg; p=0·277).

Conclusion: T2DM is associated with substantial endothelial cell loss, which is accentuated by longer disease duration, poor glycaemic control and the presence of DR, whereas CCT remains unaffected.

January 2026; Vol. 20(1):004. DOI: https://doi.org/10.55010/imcjms.20.004

*Correspondence: Umama Islam, Cornea, LASIK & Refractive Surgery, Vision Eye Hospital, 229, Green Road, Dhanmondi, Dhaka-1205.Email: dr.umamaislam@gmail.com.

]]> <![CDATA[Sodium intake and blood pressure regulation in CKD: a systematic review and meta-analysis]]> Williams Tarimobowei Tabowei Chikadibia Fyneface Amadi https://imcjms.com/journal_full_text/596 2026-02-05 12:20:31 Review January 2026; Vol. 20(1):003 Background and objective: Salt intake is an important factor in blood pressure regulation in chronic kidney disease (CKD). This review assessed the impact of salt intake on blood pressure (BP) among CKD patients taking age and duration of intake into consideration.

Materials and methods: Using PRISMA guidelines, a systematic literature search was carried out on Semantic Scholar, ScienceDirect, and PubMed databases. The inclusion criteria were guided by the PICO framework. A total of 337 studies were gathered, after screening 8 studies met the criteria for quality assessment and data extraction (primary outcomes: systolic and diastolic BP). A random-effects model determined the overall effect sizes and heterogeneity across the studies.

Results: Low sodium intake significantly (p=0.02) reduced systolic blood pressure (SBP) but did not affect the diastolic blood pressure (DBP). High sodium intake had no significant effect on either systolic or diastolic BP. CKD patients aged≤50 years had lower systolic and diastolic blood pressure compared to patients >50 years. Additionally, long-term low salt intake had lower systolic and diastolic BP compared to short-term intake in patients with CKD.

Conclusion: Low dietary sodium intake improves only systolic BP in CKD patients, especially in younger individuals. CKD patients may benefit more from long-term salt reduction than short-term intake.

January 2026; Vol. 20(1):003. DOI: https://doi.org/10.55010/imcjms.20.003

*Correspondence: Chikadibia Fyneface Amadi, Department of Medical Laboratory Science, PAMO University of Medical Sciences, Rivers State, Nigeria. Email: worldwaiting@yahoo.com.