Beyond the regulatory radar: knowledge and practices of rural medical practitioners in Bangladesh

BACKGROUND

Informal and unregulated rural medical practitioners (RMPs) provide healthcare services to about two-thirds of people in Bangladesh, although their service is assumed to be substandard by qualified providers. As the RMPs are embedded in the local community and provide low-cost services, their practice pattern demands investigation to identify the shortfalls and design effective strategies to ameliorate the service.

METHODS

We conducted a cross-sectional study in 2015-16 using a convenient sample from all 64 districts of Bangladesh. Personnel practising modern medicine, without any recognized training, or with recognized training but practising outside their defined roles, and without any regulatory oversight were invited to take part in the study. Appropriateness of the diagnosis and the rationality of antibiotic and other drug use were measured as per the Integrated Management of Childhood Illness guideline.

RESULTS

We invited 1004 RMPs, of whom 877 consented. Among them, 656 (74.8%) RMPs owned a drugstore, 706 (78.2%) had formal education below higher secondary level, and 844 (96.2%) had informal training outside regulatory oversight during or after induction into the profession. The most common diseases encountered by them were common cold, pneumonia, and diarrhoea. 583 (66.5%) RMPs did not dispense any antibiotic for common cold symptoms. 59 (6.7%) and 64 (7.3%) of them could identify all main symptoms of pneumonia and diarrhoea, respectively. In pneumonia, 28 (3.2%) RMPs dispensed amoxicillin as first-line treatment, 819 (93.4%) dispensed different antibiotics including ceftriaxone, 721 (82.2%) dispensed salbutamol, and 278 (31.7%) dispensed steroid. In diarrhoea, 824 (94.0%) RMPs dispensed antibiotic, 937 (95.4%) dispensed ORS, 709 (80.8%) dispensed antiprotozoal, and 15 (1.7%) refrained from dispensing antibiotic and antiprotozoal together.

CONCLUSIONS

Inappropriate diagnoses, irrational use of antibiotics and other drugs, and polypharmacy were observed in the practising pattern of RMPs. The government and other stakeholders should acknowledge them as crucial partners in the healthcare sector and consider ways to incorporate them into curative and preventive care.

Prevalence and Associated Risk Factors of Postpartum Anestrus in Dairy Cows of Sylhet District, Bangladesh

The objectives of current study were to assess the prevalence and risk factors associated with postpartum anestrus in lactating dairy cows in Sylhet region, Bangladesh. A total of 420 postpartum cows of different breed and age were selected randomly from different dairy farms in studied area. Structured questionnaire was used to collect data from farm owner on prevalence and risk factors for postpartum anestrus. Observed heat within 60 days after parturition was considered as normal cyclic cows and others were considered as postpartum anestrus. The prevalence of postpartum anestrus was 36.20%. The study shows that older cows take relatively more time for ovarian resumption. Cow’s having first parity shows cyclicity within 60 days of parturition, and postpartum anestrus increases significantly with the advancement of parity. Postpartum anestrus was significantly higher (P< 0.001) in cows with poor (≤1.0) and excessive (>3) body condition scores (BCS), respectively, compared to those with moderate/optimal BCS (2–3). The postpartum cyclicity in cows within 60 days with a history of normal placental expulsion was significantly higher than in the cows with RFM. Ovarian cyclicity was highest (75.92%) among the cows that were maintained in adequate hygienic conditions and lowest (43.51%) in a poor environment. The highest percentage (88.10%) of cows showed postpartum cyclicity with a history of short lactation length (0-150 days) and resumption of postpartum estrous cycle increases significantly with lactation length. Resumption of postpartum estrus cycles in cows takes more time with a history of minimal (<15 liters) daily milk production than the cow with medium (>15-25 liters) daily milk production. Cows get an adequate feed supply (both concentrate and green grass), which shows a positive effect on postpartum cyclicity. Pre and postpartum complications have a significant (p<0.001) effect on the postpartum cyclicity of cows. Endometritis (81.25%) followed by pyometra (75.76%) were recorded as major reproductive obstacles in ovarian resumption, whereas uterine prolapse (70.59%) followed by abortion (61.54%), milk fever (58.33%), stillbirth (58.33%) and dystocia (57.63%) were the major recorded complications in post-partum phase. The study also revealed that the non-restricted suckling period has a significant (p<0.001) negative effect on ovarian resumption. The risk factors including parity, BCS, placental expulsion, hygienic condition, lactation length, daily milk production and management system were significantly (P<0.01) influenced the postpartum cyclicity. Maintaining optimal BCS of cows, proper hygienic and good management practice, and farmer's training on management of cattle reproduction would improve the number of cows for breeding by 60 days postpartum.

778 Portfolio for Core Surgical Training: International Doctors’ Experience

Introduction

As the number of international medical graduates (IMG) applying for Core Surgical Training (CST) is growing, the understanding of the portfolio and application system is crucial to succeeding in this competitive application process. We conducted a webinar to grow the awareness of the system, especially amongst doctors still in the process of moving to the UK for surgical training.

Method

The webinar was part of an online teaching series for IMG doctors run by the SSID society. It was conducted in two separate two-hour sessions using a virtual conferencing tool in September and October 2021. Alongside, it was streamed on Facebook live to grow the reach. The advertising was done via flyers on social media and various WhatsApp groups. Each webinar was delivered by an IMG doctor in CST in the UK where they shared their personal experiences. Feedback was collected after each webinar using an online form generating tool and analysed on Excel. The certificate of attendance was distributed via E-mail.

Results

The webinar was viewed by 1200 on Facebook Live. Feedback was received from 66 attendees. 96.96% agreed that the webinar improved their understanding of the portfolio and 94.45% agreed they learned about ways to improve their portfolio. 89.39% agreed that they would change their practice after attending this webinar.

Conclusions

Simple online webinars can improve the understanding of the portfolio requirements for CST amongst IMG doctors. Subsequently, this could allow for early portfolio preparation opportunities, improve application self-assessment scores, and reduce the years needed to get a successful training number.

Characteristics of Rotavirus, ETEC, and Vibrio Cholerae Among Under 2-year Children Attending an Urban Diarrheal Disease Hospital in Bangladesh

Background

Information on comparative clinical and host characteristics of under-2 children with watery diarrhea caused by rotavirus, Enterotoxigenic Escherichia coli (ETEC), and Vibrio cholerae as single pathogens is lacking. We sought to investigate the sociodemographic, clinical, and host characteristics of under-2 children hospitalized due to these pathogens.

Methodology

We conducted a hospital-based case-control study using the icddr,b Diarrheal Diseases Surveillance System. Children of either sex, <2 years with diarrhea, who attended the hospital during 2014 to 2018, constituted the study population. Stool specimens having a single pathogen like rotavirus, ETEC, or Vibrio cholerae constituted the cases and stool specimens having no detectable common enteropathogens comprised the controls. Multinomial logistic regression analysis was done where control was the reference group.

Results

A total of 14 889 patients were enrolled, 6939 of whom were under-2 children, and 5245 (76%) constituted our study population. Among them 48% (n = 2532), 3% (n = 148) and 1% (n = 49) had rotavirus, ETEC, and Vibrio cholera, respectively. A control group (diarrhea without these 3 or Shigella, Salmonella, Aeromonas) accounted for 48% (n = 2516). In multinomial regression model, children with rotavirus (adjusted odds ratio [aOR], 1.36; 95% confidence interval [95% CI], 1.19-1.55) less often presented with dehydrating diarrhea compared to those with ETEC (aOR, 1.54; 95% CI, 1.05-2.26) and cholera (aOR, 2.25; 95% CI, 1.11-4.57). Rotavirus diarrhea was associated (aOR, 1.25; 95% CI, 1.07-1.46) with those who received antimicrobials prior to hospital admission and protectively associated with drinking tap water (aOR, 0.84; 95% CI, 0.73-0.95); however, ETEC diarrhea had protective association (aOR, 0.62; 95% CI, 0.43-0.92) with children who received antimicrobials prior to hospital admission and was associated with drinking tap water (aOR, 1.78; 95% CI, 1.19-2.66). Use of intravenous fluid was associated with cholera (aOR, 10.36; 95% CI, 4.85-22.16) and had protective association with rotavirus episodes (aOR, 0.64; 95% CI, 0.45-0.91).

Conclusions

Clinical presentations and host characteristics of rotavirus, ETEC, and Vibrio cholerae diarrhea differed from each other and the information may be helpful for clinicians for better understanding and proper management of these children.

Community-based screening to determine the prevalence, health and nutritional status of patients with CKD in rural and peri-urban Bangladesh

Background:

Studies have labelled chronic kidney disease (CKD) among the adult population in urban Bangladesh. To address knowledge gaps on CKD, we aimed to generate data on prevalence, health and nutrition of CKD individuals living in rural and peri-urban Bangladesh.

Methods:

Participants were recruited from the Mirzapur Demographic Surveillance System by age-stratified random sampling. We screened participants by measuring serum creatinine and urine albumin to creatinine ratio, and collected socio-demographic, lifestyles and health information (phase I). After 3 months (phase II), we repeated the urine and blood tests as per the Kidney Disease Outcomes Quality Initiative guidelines. The glomerular filtration rate was calculated using the CKD Epidemiology Collaboration equation.

Results:

Among 928 participants, 872 completed the study. In phase I, probable CKD cases were 281 (32.2%); in phase II, confirmed cases were 192 (22.0%) (stage 1, 4.0%; stage 2, 11.8%; stage 3, 5.5%; stage 4, 0.6%; stage 5, 0.1%). In multivariable analysis, associated factors for prevalent CKD included aged ⩾60 years [adjusted odds ratio (aOR) 5.02; 95% confidence interval (CI) 1.85–13.65], hypertension (aOR 3.08; 95% CI 2.07–4.59), diabetes (aOR 2.52; 95% CI 1.60–3.96), presence of red blood cell in urine (aOR 3.20; 95% CI 1.71–5.98) and anemia (aOR 2.50; 95% CI 1.63–3.84).

Conclusions:

This is the first ever research on CKD prevalence in rural and peri-urban Bangladesh and recorded about 22%, which is higher than urban settings. Monitoring systems are needed to evaluate the overall burden and to mitigate risk factors with an emphasis on the rural and peri-urban population.

Disproportionate COVID-19 vaccine acceptance rate among healthcare professionals on the eve of nationwide vaccine distribution in Bangladesh

BACKGROUND

: Acceptance of the COVID-19 vaccine by the target groups would play a crucial role in stemming the pandemic. Healthcare professionals (HCPs) are the priority group for vaccination due to them having the highest risk of exposure to infection. This survey aimed to assess their acceptance of COVID-19 vaccines in Bangladesh.

RESEARCH DESIGN AND METHODS

A cross-sectional survey using an online questionnaire was conducted between January 3 to 25, 2021, among HCPs (n=834) in Bangladesh. The main outcome measures were vaccine acceptance by HCPs if one was available.

RESULTS

Less than 50% of HCPs would receive the vaccine against COVID-19 if available and 54% were willing to take the vaccine at some stage in the future. Female participants (OR:1.64;95%CI:1.172-2.297), respondents between 18-34 years old (OR:2.42; 95% CI:1.314-4.463), HCPs in the public sector (OR:2.09; 95% CI:1.521-2.878), and those who did not receive a flu vaccine in the previous year (OR:3.1; 95% CI:1.552-6.001) were more likely to delay vaccination.

CONCLUSIONS

The study revealed that, if available, less than half of the HCPs would accept a COVID-19 vaccine in Bangladesh. To ensure the broader success of the vaccination drive, tailored strategies and vaccine promotion campaigns targeting HCPs and the general population are needed.

755 Elective Surgery in the COVID-19 Pandemic: Outcomes of 100 Consecutive Cases

Introduction

The COVID-19 pandemic halted elective surgical activity. Basildon University Hospital established an elective Green Zone for COVID-19 swab negative patients who isolated for 14 days. This study reviewed the outcomes of the first 100 patients.

Method

A single-centre study was performed. Demographic and perioperative electronic data were supplemented with telephone follow-up for the first 100 Green Zone patients and analysed in Microsoft Excel.

Results

One hundred Green Zone patients underwent surgery between 21/05/2020 and 16/06/2020. The median age was 55 (14-88) years. 52% were female. Their operations were performed by General Surgery (39%), Gynaecology (17%), Vascular Surgery (14%), Oral Surgery (12%), ENT (9%), Urology (8%), and Pain Management (1%).

Preoperatively, 100% had a negative SARS-CoV-2 swab and one had CT evidence of mild resolving COVID-19. Two patients had postoperative SARS-CoV-2 swabs, both negative. Median length of stay was 0 (0-7) days. 84% responded to telephone follow-up at a median 25 (13-54) postoperative days, 69% of whom were asymptomatic There were no 30-day major complications (>Clavien-Dindo IIIa) or 90-day mortality.

Conclusions

Elective surgery can be safe during the COVID-19 pandemic, with appropriate measures in place. This has significant implications in the context of an ever-expanding NHS waiting list during a pandemic of uncertain duration.

691 Audit of Drug Chart Completion in General Surgery

Introduction

The accuracy of drug charts is crucial for good clinical practice. The General Medical Council states, doctors must keep clear, accurate and legible records, also applying to prescriptions. This audit quantified the accuracy of drug chart completion in a General Surgery Department within a District General Hospital.

Method

Single-centre retrospective assessment of drug charts in November 2019, assigning binary outcomes to each domain: “100% complete” (all details such as drug name, dose, unit, route, frequency, indication, duration, signatures) vs. “incomplete”. After analysis (Microsoft Excel/IBM SPSS v.24), results were circulated locally, followed by re-audit during June-August 2020.

Results

Comparison of audit (n = 22) vs. re-audit (n = 25) drug charts across 17 domains demonstrated higher completion rates for 7 domains: Alerts/allergies (4/22:18% vs. 18/25:72%; p &lt; 0.001), signatures (2/22:9% vs. 17/25:68%; p &lt; 0.001), venous thromboembolism risk assessment (5/22:24% vs. 24/25:96%; p &lt; 0.001), antithrombotic (0/21 vs. 9/25:36%; p = 0.002), regular (1/22:5% vs. 10/25:40%; p = 0.04), as-required (0/21 vs. 5/22:23%; p = 0.020) medication and intravenous fluids (1/16:6% vs. 20/21:95%; p &lt; 0.001). Performance in 10 domains was not significantly different (p ≥ 0.05).

Conclusions

Standard documents like drug charts may appear accurate at first glance. However, when assessed with strict criteria, performance is suboptimal. Simple, cost-effective educational interventions can significantly improve accuracy, with positive implications for patient safety.

Laparoscopic vs open surgery during the COVID-19 pandemic: what are the risks?

INTRODUCTION

The initial intercollegiate surgical guidance from the UK during the COVID-19 pandemic resulted in significant changes to practice. Avoidance of laparoscopy was recommended, to reduce aerosol generation and risk of virus transmission. Evidence on the safety profile of laparoscopy during the pandemic is lacking. This study compares patient outcomes and risk to staff from laparoscopic and open gastrointestinal operations during the COVID-19 pandemic.

METHODS

Single-centre retrospective study of gastrointestinal operations performed during the peak of the COVID-19 pandemic. Demographic, comorbidity, perioperative and survival data were collected from electronic medical records and supplemented with patient symptoms reported at telephone follow up. Outcomes assessed were: patient mortality, illness among staff, patient COVID-19 rates, length of hospital stay and postdischarge symptomatology.

RESULTS

A total of 73 patients with median age of 56 years were included; 55 (75%) and 18 (25%) underwent laparoscopic and open surgery, respectively. All-cause mortality was 5% (4/73), was related to COVID-19 in all cases, with no mortality after laparoscopic surgery. A total of 14 staff members developed COVID-19 symptoms within 2 weeks, with no significant difference between laparoscopic and open surgery (10 vs 4; p=0.331). Median length of stay was shorter in the laparoscopic versus the open group (4.5 vs 9.9 days; p=0.011), and postdischarge symptomatology across 15 symptoms was similar between groups (p=0.135-0.814).

CONCLUSIONS

With appropriate protective measures, laparoscopic surgery is safe for patients and staff during the COVID-19 pandemic. The laparoscopic approach maintains an advantage of shorter length of hospital stay compared with open surgery.

Continuing professional education for general practitioners on chronic obstructive pulmonary disease: feasibility of a blended learning approach in Bangladesh

Background

Continuing medical education (CME) is essential to developing and maintaining high quality primary care. Traditionally, CME is delivered face-to-face, but due to geographical distances, and pressure of work in Bangladesh, general practitioners (GPs) are unable to relocate for several days to attend training. Using chronic obstructive pulmonary disease (COPD) as an exemplar, we aimed to assess the feasibility of blended learning (combination of face-to-face and online) for GPs, and explore trainees’ and trainers’ perspectives towards the blended learning approach.

Methods

We used a mixed-methods design. We trained 49 GPs in two groups via blended (n = 25) and traditional face-to-face approach (n = 24) and assessed their post-course knowledge and skills. The COPD Physician Practice Assessment Questionnaire (COPD-PPAQ) was administered before and one-month post-course. Verbatim transcriptions of focus group discussions with 18 course attendees and interviews with three course trainers were translated into English and analysed thematically.

Results

Forty GPs completed the course (Blended: 19; Traditional: 21). The knowledge and skills post course, and the improvement in self-reported adherence to COPD guidelines was similar in both groups. Most participants preferred blended learning as it was more convenient than taking time out of their busy work life, and for many the online learning optimised the benefits of the subsequent face-to-face sessions. Suggested improvements included online interactivity with tutors, improved user friendliness of the e-learning platform, and timing face-to-face classes over weekends to avoid time-out of practice.

Conclusions

Quality improvement requires a multifaceted approach, but adequate knowledge and skills are core components. Blended learning is feasible and, with a few caveats, is an acceptable option to GPs in Bangladesh. This is timely, given that online learning with limited face-to-face contact is likely to become the norm in the on-going COVID-19 pandemic.

Systematic review (protocol) of clinical effectiveness and models of care of low-resource pulmonary rehabilitation

More than half of the people with chronic respiratory diseases (CRDs) live in low- and middle-income countries (LMICs). The increasing disability, reduced productivity, associated anxiety and depression from CRDs result in social isolation and economic hardship for patients and their families. Pulmonary rehabilitation (PR) is a guideline-recommended multidisciplinary and multifaceted intervention that improves the physical and psychological condition of people with CRD. However, PR services are underprovided and uptake is poor in LMICs, especially in low-resourced setting. We aim to systematically assess the effectiveness, applicable components and mode of delivery of PR. We will search MEDLINE, EMBASE, CABI, AMED and CENTRAL from January 1990 using a PICOS search strategy (Population: adults with CRD (including chronic obstructive pulmonary disease, post-tuberculosis, remodelled asthma); Intervention: PR; Comparator: usual care; Outcomes: functional exercise capacity and Health-Related Quality-of-Life; Setting: low-resource settings). Two reviewers will independently screen titles/abstracts and full texts for eligibility and extract data from included papers. We will use the Cochrane Risk-of-Bias tool, rating the quality of evidence using GRADE. We will use narrative synthesis to answer our three objectives: What is the effectiveness of PR in low-resource settings? What components are used in effective studies? What models of service delivery are used? This systematic review will inform the potential impact and practical models of low-resource PR for the betterment of patients with CRDs to improve their substantial health-care burden and address poor quality of life.

Improving Physicians' Capacity for Chronic Obstructive Pulmonary Disease Care through Blended E-learning: A Pilot Study in Bangladesh

Patients with chronic obstructive pulmonary disease (COPD) are often under diagnosed and managed without evidence-based approach in primary care settings. This may be due to gaps in knowledge and practice of using updated COPD guidelines by the physicians in public and private sectors in Bangladesh. To our knowledge, this is the first study in Bangladesh which aims to evaluate a blended e-learning approach for building capacity of physicians working at low-resource environments on COPD patient care. In total, 32 practicing physicians were enrolled where 16 received training via blended approach and 16 received training via traditional classroom-based approach. Using a standard examination procedure and assessment approach both groups were assessed and results were documented. No statistically significant differences were found in the scores of theory (knowledge) and in the total scores (theory plus practicum) of both groups indicating that learning objectives were achieved in both the groups though the scores were significantly higher in practicum of the traditional learning group. Besides, Likert-scale-based self-reported pre-post changes indicate that both the groups were confident (statistically significant) in the management of COPD. Most importantly, the blended group had a minimal disruption of their services as they attended face-to-face only during the practicum sessions. Overall, the blended e-learning appears to be a feasible approach of training for physicians on standard management of COPD especially in health human resource-poor settings in Bangladesh.

Retaining Doctors in Rural Bangladesh: A Policy Analysis

Background: Retaining doctors in rural areas is a challenge in Bangladesh. In this study, we analyzed three rural retention policies: career development programs, compulsory services, and schools outside major cities – in terms of context, contents, actors, and processes.

Methods: Series of group discussions between policy-makers and researchers prompted the selection of policy areas, which were analyzed using the policy triangle framework. We conducted document and literature reviews (1971-2013), key informant interviews (KIIs) with relevant policy elites (n=11), and stakeholder analysis/position-mapping.

Results: In policy-1, we found, applicants with relevant expertise were not leveraged in recruitment, promotions were often late and contingent on post-graduation. Career tracks were porous and unplanned: people without necessary expertise or experience were deployed to high positions by lateral migration from unrelated career tracks or ministries, as opposed to vertical promotion. Promotions were often politically motivated. In policy-2, females were not ensured to stay with their spouse in rural areas, health bureaucrats working at district and sub-district levels relaxed their monitoring for personal gain or political pressure. Impractical rural posts were allegedly created to graft money from applicants in exchange for recruitment assurance. Compulsory service was often waived for political affiliates. In policy-3, we found an absence of clear policy documents obligating establishment of medical colleges in rural areas. These were established based on political consideration (public sector) or profit motives (private sector).

Conclusion: Four cross-cutting themes were identified: lack of proper systems or policies, vested interest or corruption, undue political influence, and imbalanced power and position of some stakeholders. Based on findings, we recommend, in policy-1, applicants with relevant expertise to be recruited; recruitment should be quick, customized, and transparent; career tracks (General Health Service, Medical Teaching, Health Administration) must be clearly defined, distinct, and respected. In policy-2, facilities must be ensured prior to postings, female doctors should be prioritized to stay with the spouse, field bureaucrats should receive non-practising allowance in exchange of strict monitoring, and no political interference in compulsory service is assured. In policy-3, specific policy guidelines should be developed to establish rural medical colleges. Political commitment is a key to rural retention of doctors.

Suicide and depression in the World Health Organization South-East Asia Region: A systematic review

Background Depression is the most common comorbid psychiatric disorder in people who die by suicide and 39% of global suicides occur in the World Health Organization (WHO) South-East Asia Region. The aim of this systematic review was to identify, for countries of this region, first the prevalence of depression among people who (i) die by, or (ii) attempt, suicide, and second, the proportion of people with depression who attempt or die by suicide. Methods PubMed, PsycINFO, EMBASE and Google Scholar were searched, together with five available national databases, for quantitative research papers published in English between 1956 and 4 September 2016 from the 11 countries of the WHO South-East Asia Region. Results The 19 articles that met the predefined eligibility criteria were from five countries: Bangladesh (1), India (12), Indonesia (1), Sri Lanka (3) and Thailand (2); no eligible papers from the remaining countries of the region were retrieved. Eight studies, from Bangladesh, India, Indonesia and Sri Lanka, reported the prevalence of depression among people who had died by suicide. The study settings varied, as did the proportion of depression recorded (6.9-51.7%), and the study sample sizes ranged from 27 to 372. Eight studies from India and one from Sri Lanka investigated depression among people who had attempted suicide. Using a range of screening and diagnostic tools, the reported prevalence of depression ranged between 22.0% and 59.7%. The study sample sizes ranged from 56 to 949. Only two articles were found, both from Thailand, that reported on suicide in people with depression. Conclusion Despite the high burden of mortality of suicide in the WHO South-East Asia Region, evidence on the relation between suicide and depression is scarce. There is a need to understand this phenomenon better, in order to inform suicide-prevention strategies in the region.

Nucleotide composition and codon usage bias of SRY gene

The SRY gene is present within the sex-determining region of the Y chromosome which is responsible for maleness in mammals. The nonuniform usage of synonymous codons in the mRNA transcript for encoding a particular amino acid is the codon usage bias (CUB). Analysis of codon usage pattern is important to understand the genetic and molecular organisation of a gene. It also helps in heterologous gene expression, design of primer and synthetic gene. However, the analysis of codon usage bias of SRY gene was not yet studied. We have used bioinformatic tools to analyse codon usage bias of SRY gene across mammals. Codon bias index (CBI) indicated that the overall extent of codon usage bias was weak. The relative synonymous codon usage (RSCU) analysis suggested that most frequently used codons had an A or C at the third codon position. Compositional constraint played an important role in codon usage pattern as evident from correspondence analysis (CA). Significant correlation among nucleotides constraints indicated that both mutation pressure and natural selection affect the codon usage pattern. Neutrality plot suggested that natural selection might play a major role, while mutation pressure might play a minor role in codon usage pattern in SRY gene in different species of mammals.

Developing effective policy strategies to retain health workers in rural Bangladesh: a policy analysis

INTRODUCTION

Retention of human resources for health (HRH), particularly physicians and nurses in rural and remote areas, is a major problem in Bangladesh. We reviewed relevant policies and provisions in relation to HRH aiming to develop appropriate rural retention strategies in Bangladesh.

METHODS

We conducted a document review, thorough search and review of relevant literature published from 1971 through May 2013, key informant interviews with policy elites (health policy makers, managers, researchers, etc.), and a roundtable discussion with key stakeholders and policy makers. We used the World Health Organization's (WHO's) guidelines as an analytical matrix to examine the rural retention policies under 4 domains, i) educational, ii) regulatory, iii) financial, and iv) professional and personal development, and 16 sub-domains.

RESULTS

Over the past four decades, Bangladesh has developed and implemented a number of health-related policies and provisions concerning retention of HRH. The district quota system in admissions is in practice to improve geographical representation of the students. Students of special background including children of freedom fighters and tribal population have allocated quotas. In private medical and nursing schools, at least 5% of seats are allocated for scholarships. Medical education has a provision for clinical rotation in rural health facilities. Further, in the public sector, every newly recruited medical doctor must serve at least 2 years at the upazila level. To encourage serving in hard-to-reach areas, particularly in three Hill Tract districts of Chittagong division, the government provides an additional 33% of the basic salary, but not exceeding US$ 38 per month. This amount is not attractive enough, and such provision is absent for those working in other rural areas. Although the government has career development and promotion plans for doctors and nurses, these plans are often not clearly specified and not implemented effectively.

CONCLUSION

The government is committed to address the rural retention problem as shown through the formulation and implementation of related policies and strategies. However, Bangladesh needs more effective policies and provisions designed specifically for attraction, deployment, and retention of HRH in rural areas, and the execution of these policies and provisions must be monitored and evaluated effectively.

Integration of solid-state nanopores in a 0.5 μm CMOS foundry process

High-bandwidth and low-noise nanopore sensor and detection electronics are crucial in achieving single-DNA-base resolution. A potential way to accomplish this goal is to integrate solid-state nanopores within a CMOS platform, in close proximity to the biasing electrodes and custom-designed amplifier electronics. Here we report the integration of solid-state nanopore devices in a commercial complementary metal-oxide-semiconductor (CMOS) potentiostat chip implemented in On-Semiconductor's 0.5 μm technology. Nanopore membranes incorporating electrodes are fabricated by post-CMOS micromachining utilizing the n+ polysilicon/SiO2/n+ polysilicon capacitor structure available in the aforementioned process. Nanopores are created in the CMOS process by drilling in a transmission electron microscope and shrinking by atomic layer deposition. We also describe a batch fabrication method to process a large of number of electrode-embedded nanopores with sub-10 nm diameter across CMOS-compatible wafers by electron beam lithography and atomic layer deposition. The CMOS-compatibility of our fabrication process is verified by testing the electrical functionality of on-chip circuitry. We observe high current leakage with the CMOS nanopore devices due to the ionic diffusion through the SiO2 membrane. To prevent this leakage, we coat the membrane with Al2O3, which acts as an efficient diffusion barrier against alkali ions. The resulting nanopore devices also exhibit higher robustness and lower 1/f noise as compared to SiO2 and SiNx. Furthermore, we propose a theoretical model for our low-capacitance CMOS nanopore devices, showing good agreement with the experimental value. In addition, experiments and theoretical models of translocation studies are presented using 48.5 kbp λ-DNA in order to prove the functionality of on-chip pores coated with Al2O3.

Rapidly swept, ultra-widely-tunable 1060 nm MEMS-VCSELs

Demonstrated are 1060 nm microelectromechanical-systems-based tunable vertical-cavity surface-emitting lasers (MEMS-VCSELs) with a 100 nm continuous tuning range under repetitively scanned operation at rates beyond 500 kHz and a 90 nm continuous tuning range under static operation. These devices employ a thin strained InGaAs multiple quantum well active region integrated with a fully oxidised GaAs/Al_xO_y bottom mirror and a suspended dielectric top mirror. The devices are optically pumped via 850 nm light. These ultra-widely tunable lasers represent the first MEMS-VCSELs reported in this wavelength range, and are ideally suited for application in ophthalmic swept-source optical coherence tomography.

CdSe/ZnS quantum dot size dependent carrier relaxation in hybrid organic/inorganic system

We have studied the CdSe/ZnS quantum dot (QD) size dependent carrier relaxation dynamics in hybrid organic/inorganic system for the first time. The QD size was from 5.0 to 2.0 nm. The optical narrow emission of quantum dots shift to higher energies as the size of dots gets smaller due to the 3-D confinement which splits the continuous band into a series of discrete quantum states and increases the band gap. The carrier relaxation time in QDs was found to increases as the pump power increased and reached saturation at approximately 326 microW excitation, probably due to the saturation of traps with the photoexcited charge carriers within individual nanoparticles. The relaxation rate was also increased with pump power, indicating that new relaxation processes e.g., Auger processes and faster carrier trapping were present. The slow decay component remained at the lowest power (51microW) excitation with no fast decay present. The decrease of CdSe/ZnS QD size increased the fast component relaxation rate probably due to a higher number of surface defects hence inducing faster trapping of carriers by shallow trap state.

Design of high efficiency organic solar cell with light trapping

We have designed a high efficiency organic solar cell with light trapping structure on transference cylindrical substrate. An electrical and optical simulation of the light trapping structure has been performed on the basis of finite element and transfer matrix formalism methods. Absorption spectrum, internal quantum efficiency, external quantum efficiency, maximum power output and efficiency of the organic solar cell are simulated and presented in terms of three variables: the height, diameter of the glass substrate and the thickness of the organic active layer. The efficiency of the proposed organic solar cell with light trapping structure is enhanced by a factor of 2 than the similar structure on the flat plain glass substrate. The optimum organic active layer thickness to achieve the highest efficiency is shifted from 65 to 20 nm. Finally, we have investigated the effect of light incident angle on the performance of the proposed cell structure.

High-sweep-rate 1310 nm MEMS-VCSEL with 150 nm continuous tuning range

Microelectromechanical-systems-based vertical-cavity surface-emitting lasers (MEMS-VCSELs) capable of a 150 nm continuous tuning range near 1310 nm are demonstrated. These devices employ a thin optically pumped active region structure with large free-spectral range, which promotes wide and continuous tuning. To achieve VCSEL emission at 1310 nm, a wide-gain-bandwidth indium phosphide-based multiple quantum well active region is combined with a wide-bandwidth fully oxidised GaAs-based mirror through wafer bonding, with tuning enabled by a suspended dielectric top mirror. These devices are capable of being scanned over the entire tuning range at frequencies up to 500 kHz, making them ideal for applications such as swept source optical coherence tomography and high-speed transient spectroscopy.

Effects of QD concentrations and thermal annealing on the performance of self-assembly QD-OLEDs

We have fabricated and investigated the effect of CdSe/ZnS quantum dot (QD) concentrations on the performance of self-assembly hybrid inorganic/organic light emitting diodes (QD-OLEDs). The uniform distribution of QDs with controllable density was achieved using the conventional spin-coating method. There was a QD threshold concentration for the emission of QDs in QD-OLED. Below that threshold concentration we did not observe the QD emission from the QD-OLED. The best performance of QD-OLED was found for the QD concentration of -9 x 10(11) cm(-2). The QD electroluminescence intensity was increased about three times after the annealing of QD-OLED at 80 degrees C for about 20 minutes in nitrogen atmosphere. The QD electroluminescence peak energy was remain same before and after the annealing of QD-OLED. The maximum external quantum efficiency was around 2.1%. The effect of process parameters and the QD emission mechanism are discussed.

Lumps, bumps and vasculitis

We report an unusual case of primary vasculitis presenting with unilateral submandibular gland enlargement and lymphadenopathy resulting in stridor.

Quaternary stratigraphy, sediment characteristics and geochemistry of arsenic-contaminated alluvial aquifers in the Ganges-Brahmaputra floodplain in central Bangladesh

This study focuses on the Quaternary stratigraphy, sediment composition, mineralogy, and geochemistry of arsenic (As)-contaminated alluvial aquifers in the Ganges-Brahmaputra floodplain in the central Bangladesh. Arsenic concentrations in 85 tubewells in Manikganj area, 70 km northwest of Dhaka City, range from 0.25 microg/L to 191 microg/L with a mean concentration of 33 microg/L. Groundwater is mainly Ca-HCO(3) type with high concentrations of dissolved As, Fe, and Mn, but low level of SO(4). The uppermost aquifer occurs between 10 m and 80 m below the surface that has a mean arsenic concentration of 35 microg/L. Deeper aquifer (>100 m depth) has a mean arsenic concentration of 18 microg/L. Sediments in the upper aquifer are mostly gray to dark-gray, whereas sediments in the deep aquifer are mostly yellowing-gray to brown. Quartz, feldspar, mica, hornblende, garnet, kyanite, tourmaline, magnetite, ilmenite are the major minerals in sediments from both aquifers. Biotite and potassium feldspar are dominant in shallow aquifer, although plagioclase feldspar and garnet are abundant in deep aquifer sediments. Sediment composition suggests a mixed provenance with sediment supplies from both orogenic belts and cratons. High arsenic concentrations in sediments are found within the upper 50 m in drilled core samples. Statistical analysis shows that As, Fe, Mn, Ca, and P are strongly correlated in sediments. Concentrations of Cd, Cu, Ni, Zn, and Bi also show strong correlations with arsenic in the Manikganj sediment cores. Authigenic goethite concretions, possibly formed by bacteria, are found in the shallow sediments, which contain arsenic of a concentration as high as 8.8 mg/kg. High arsenic concentrations in aquifers are associated with fine-grained sediments that were derived mostly from the recycled orogens and relatively rapidly deposited mainly by meandering channels during the Early to Middle Holocene rising sea-level conditions.

Herpes zoster ophthalmicus in an otherwise healthy 7 years child

A 07 years otherwise healthy child, non vaccinated for chickenpox and with a history of chickenpox infection at 02 years of age presented with red colored lesions in right upper lid, right side of forehead, vertex and right side of nose and defective vision in right eye in Mymensingh Medical College Hospital, 20 days after the appearance of blister in the same region. On examination granulation tissue was present on the same area. There was no hair and skin over that area. Lesion was strictly limited to right side of midline. Eyelashes of right upper lid were absent and there was defective closure of eyelids. Best corrected visual acuity of right eye was 3/60 and of left eye was 6/6. There was ciliary congestion of right eye with haziness of cornea at interpalpebral region of right eye. Corneal sensitivity was reduced and there was uniform fluorescein staining at central part of cornea. Mild flare and cells were present in anterior chamber. Fundus examination revealed no abnormality. He was treated with systemic acyclovir, antibiotics, topical acyclovir, antibiotic and atropine. Corneal ulcer and skin lesions were healed, but the patient developed cicatricial ectropion of right upper lid and best corrected visual acuity of right eye was reduced to 6/60 due to corneal opacity. So early diagnosis and treatment of herpes zoster ophthalmicus is mandatory to prevent sight threatening complications.

A giant vesical calculus

Massive or giant vesical calculus is a rare entity in the recent urological practice. Males are affected more than the females. Vesical calculi are usually secondary to bladder outlet obstruction. These patients present with recurrent urinary tract infection, haematuria or with retention of urine. We report a young male patient who presented with defaecatory problems along with other urinary symptoms. The patient having an average built, non diabetic but hypertensive. The stone could be palpated by physical examination. His urea levels were within normal limits but urine examination shows infection. USG reveals bilateral hydronephrosis with multiple stones in both kidneys along with a giant vesical calculus. After controlling urinary infection and hypertention he underwent an open cystolithotomy. During operation digital rectal help was needed to remove the stone as it was adherent with bladder mucosa. Post operative period was uneventful. His urinary output was quite normal and had no defaecatory problems. Patient left the hospital 10 days after operation.

The analysis of human cortical bone by terahertz time-domain spectroscopy

Samples of cortical bone, derived from human femur, have been studied using terahertz time-domain transmission spectroscopy. The relationship between the broadband THz parameters and the previously acquired values of Young's modulus and x-ray attenuation (CT number), and the density of each bone sample, is investigated. The only significant correlation is that between THz transmission and sample density, suggesting that the potential use of THz radiation as a non-invasive probe of bone quality is limited. The spectra of absorption coefficient and refractive index are plotted over the frequency range 0.1-1.25 THz. There is evidence that the sample hydration state is a factor in the resultant THz parameters.

PRINTS and its automatic supplement, prePRINTS

The PRINTS database houses a collection of protein fingerprints. These may be used to assign uncharacterised sequences to known families and hence to infer tentative functions. The September 2002 release (version 36.0) includes 1800 fingerprints, encoding approximately 11 000 motifs, covering a range of globular and membrane proteins, modular polypeptides and so on. In addition to its continued steady growth, we report here the development of an automatic supplement, prePRINTS, designed to increase the coverage of the resource and reduce some of the manual burdens inherent in its maintenance. The databases are accessible for interrogation and searching at http://www.bioinf.man.ac.uk/dbbrowser/PRINTS/.