Evaluating the Respiratory Support Pattern and Relationship with Initial Oxygen Saturation of the COVID Isolation Unit Patients in Sylhet

COVID-19 is the devastating pandemic of the century predominantly fatal due to its respiratory failure nature. Severe and critical patients need oxygen supplementation in different forms. This cross-sectional study was conducted in four tertiary hospitals of Sylhet, Bangladesh from November 2020 to March 2021. All the patients admitted in the COVID-19 isolation units and fulfill the selection criterion were enrolled in this study. The primary objective of this study was to evaluate different types of respiratory supports and its relationship with initial oxygen saturation (SpO₂). Total 481 patients were enrolled. There was a male predominance (65.00%) in the participants. Highest number of participants was from 61-70 years age group. Number of ventilated patients were significantly high (p<0.001) in the COVID-19 patient group. The initial SpO₂ and hospital staying period of COVID-19 positive and negative group did not show any significant difference but these two parameters showed significant difference among died and survived group (p<0.001). Nearly one fourth patients (24.94%) of total patients were treated in ICU with high flow nasal cannula (HFNC), non-invasive ventilation (NIV) and mechanical ventilation. Among the ICU admitted patients nearly one-fourth (24.16%) patients were treated with mechanical ventilation. Mortality rate was 62.00% for ventilated patients, 70.60% for NIV patients and 15.80% for the HFNC patients.

Double-blind cluster randomised controlled trial of wheat flour chapatti fortified with micronutrients on the status of vitamin A and iron in school-aged children in rural Bangladesh

Food fortification is a cost-effective and sustainable strategy to prevent or correct micronutrient deficiencies. A double-blind cluster (bari) randomised controlled trial was conducted in a rural community in Bangladesh to evaluate the impact of consumption of chapatti made of micronutrient-fortified wheat flour for 6 months by school-aged children on their vitamin A, haemoglobin and iron status. A total of 43 baris (group of households) were randomly selected. The baris were randomly assigned to either intervention or control group. The intervention group received wheat flour fortified with added micronutrients (including 66 mg hydrogen-reduced elemental iron and 3030 μg retinol equivalent as retinyl palmitate per kilogram of flour), while the control group received wheat flour without added micronutrients. A total of 352 children were enrolled in the trial, 203 in the intervention group and 149 in the control group. Analyses were carried out on children who completed the study (191 in the intervention group and 143 in the control group). Micronutrient-fortified wheat flour chapatti significantly increased serum retinol concentration at 6 months by 0.12 μmol L(-1) [95% confidence interval (CI): 0.06, 0.19; P < 0.01]. The odds of vitamin A deficiency was significantly lower for children in the intervention group at 3 months [odds ratio (OR) = 0.26; 95% confidence interval (CI): 0.07, 0.89; P < 0.05] and 6 months (OR = 0.21; 95% CI: 0.06, 0.68; P < 0.01). No demonstrable effect of fortified chapatti consumption on iron status, haemoglobin levels or anaemia was observed. Consumption of fortified chapattis demonstrated a significant improvement in the vitamin A status, but not in iron, haemoglobin or anaemia status.

Impact of NGO training and support intervention on diarrhoea management practices in a rural community of Bangladesh: an uncontrolled, single-arm trial

PURPOSE/OBJECTIVE

The evolving Non-Governmental Organization (NGO) sector in Bangladesh provides health services directly, however some NGOs indirectly provide services by working with unlicensed providers. The primary objective of this study was to examine the impact of NGO training of unlicensed providers on diarrhoea management and the scale up of zinc treatment in rural populations.

METHODS

An uncontrolled, single-arm trial for a training and support intervention on diarrhoea outcomes was employed in a rural sub-district of Bangladesh during 2008. Two local NGOs and their catchment populations were chosen for the study. The intervention included training of unlicensed health care providers in the management of acute childhood diarrhoea, particularly emphasizing zinc treatment. In addition, community-based promotion of zinc treatment was carried out. Baseline and endline ecologic surveys were carried out in intervention and control villages to document changes in treatments received for diarrhoea in under-five children.

RESULTS

Among surveyed household with an active or recent acute childhood diarrhoea episode, 69% sought help from a health provider. Among these, 62.8% visited an unlicensed private provider. At baseline, 23.9% vs. 22% of control and intervention group children with diarrhoea had received zinc of any type. At endline (6 months later) this had changed to 15.3% vs. 30.2%, respectively. The change in zinc coverage was significantly higher in the intervention villages (p<0.01). Adherence with giving zinc for 10 days or more was significantly higher in the intervention households (9.2% vs. 2.5%; p<0.01). Child's age, duration of diarrhoea, type of diarrhoea, parental year of schooling as well as oral rehydration solution (ORS) and antibiotic usage were significant predictors of zinc usage.

CONCLUSION

Training of unlicensed healthcare providers through NGOs increased zinc coverage in the diarrhoea management of under-five children in rural Bangladesh households.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02143921.

Abstract 372: Electronic Medical Records Can Identify Patients With Persistently Elevated Blood Pressure Without A Prior Diagnosis Of Hypertension

Background: The diagnosis of hypertension requires systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg on at least 2 different occasions. Therefore, there is the possibility of patients with elevated BP remaining undiagnosed if not seen by the same provider.

Purpose: To utilize electronic medical records (EMR) to identify patients not previously diagnosed with hypertension that have elevated blood pressure meeting criteria for a diagnosis of hypertension using a threshold of SBP ≥ 140mmHg or DBP ≥ 90 mmHg (high BP) on 2 or more occasions.

Methods: This was a cross sectional design utilizing retrospective multi-year billing and clinical data from a large multi-specialty center in the Midwest. Using electronic records of all outpatient visits in each year from 2009 - 2011, patients with at least 2 visits with SBP ≥ 140mmHg or DBP ≥ 90 mmHg (2HBP) in the measurement year were identified. These patients were compared with previously identified cohorts of known hypertension patients (Known HTN) compiled using the EMR problem list. A sensitivity analysis was done using patients with high BP at 2 consecutive visits (2CHBP) and also those with high BP at 3 consecutive visits (3CHBP). We compared proportions of patients with high BP without a prior diagnosis of hypertension (UDHTN).

Results: The proportion of patients with SBP ≥ 140mmHg or DBP ≥ 90 mmHg without a prior diagnosis of hypertension (UDHTN) when compared to the cohort of known patients with a diagnosis of hypertension (Known HTN) was 25% in 2009, 26% in 2010, and 28% in 2011 in the 2CHBP cohort compared to 27% in 2009, 28% in 2010, and 30% in 2011 in the 2HBP cohort and 18% in 2009, 19% in 2010 and 23% in 2011 in the 3CHBP cohort.

Conclusion: About a quarter of patients meeting current thresholds on multiple and consecutive visits did not have a known diagnosis of hypertension. The use of EMR can identify these patients for commencement of appropriate management.

Table 1

Disparities in preventive health services among Somali immigrants and refugees

African immigrants and refugees-almost half of them from Somalia-account for one of the fastest-growing groups in the United States. There is reason to suspect that Somali-Americans may be at risk for low completion of recommended preventive health services. This study's aim was to quantify disparities in preventive health services among Somali patients compared with non-Somali patients in an academic primary care practice in Rochester, Minn. It also examined the effect of medical interpreters, emergency department visits, and primary care visits on the completion of preventive services. Rates of pap smears, vaccinations (influenza, pneumococcus, and tetanus), lipid screening, colorectal cancer screening, and mammography were assessed in Somali and non-Somali patients during the second quarter of 2008. Data were collected regarding the utilization of medical interpreters, emergency services, and primary care services among Somali patients. Results were reported using standard descriptive statistics. Of the 91,557 patients identified in the database, 810 were Somali. Somali patients had significantly lower completion rates of colorectal cancer screening, mammography, pap smears, and influenza vaccination than non-Somali patients. Use of medical interpreters and primary care services were generally associated with higher completion rates of preventive services. There are significant discrepancies in the provision of preventive health services to Somali patients compared with that of non-Somali patients. These findings suggest the need to identify the root causes of these discrepancies so that interventions may be crafted to close the gap.

Abstract 309: Prioritizing Blood Pressure Measurements Results In Improved Hypertension Control

Background: Blood pressure (BP) measurement is a national core quality measure for hypertension care and hypertension control rates remain a major performance measure. It remains unclear whether improving measurement directly results in better control rates in hypertension management.

Purpose: To utilize electronic medical records to explore the relationship between measurement of blood pressure and hypertension control rates among 4 eligible primary care providers groups - Primary Care Internal Medicine (PCIM), Family medicine (FM), General Internal Medicine (GIM), Preventive Medicine (PREV) - and 2 eligible specialist groups - Cardiology (CARD), Nephrology (NEPH) at an academic group medical practice.

Methods: A two year cross sectional study involving adults seen by eligible primary or specialist providers at 2 or more office visits with a hypertension ICD-9 code in two years with at least one office visit in the measurement year. We measured the proportion of patients who had their BP measured at their last hypertension visit (LHV) in 2009 and 2010. We compared measurement rates with control rates as defined by the proportion of hypertension patients with BP < 140/90 mmHg at their LHV.

Results: In 2009, 84.2% of 17989 patients (95% CI 83.6 - 84.7%) had their BP measured at their LHV compared to 85.3% (95% CI 84.8 - 85.8%) of 17992 patients in 2010, an increase of 1.2% (p=0.0026).

Measurement rates varied widely across the different provider groups. PCIM, a high performing group, had significant improvement in measurement rates from 2009 to 2010 and demonstrated improvement in control rates. Lower performing groups, Nephrology and GIM, had significant improvement in measurement but did not see a direct translation to improved control rates. There was an associated worsening of the control rates for Preventive medicine along with a decrease in the measurement rates from 2009 to 2010.

Conclusion: High BP measurement rates are associated with high hypertension control rates. Prioritizing BP measurement may result in improved intermediate outcomes in hypertension management.

A qualitative analysis of EHR clinical document synthesis by clinicians

Clinicians utilize electronic health record (EHR) systems during time-constrained patient encounters where large amounts of clinical text must be synthesized at the point of care. Qualitative methods may be an effective approach for uncovering cognitive processes associated with the synthesis of clinical documents within EHR systems. We utilized a think-aloud protocol and content analysis with the goal of understanding cognitive processes and barriers involved as medical interns synthesized patient clinical documents in an EHR system to accomplish routine clinical tasks. Overall, interns established correlations of significance and meaning between problem, symptom and treatment concepts to inform hypotheses generation and clinical decision-making. Barriers identified with synthesizing EHR documents include difficulty searching for patient data, poor readability, redundancy, and unfamiliar specialized terms. Our study can inform recommendations for future designs of EHR clinical document user interfaces to aid clinicians in providing improved patient care.

Abstract 76: Meaningful Use Of Electronic Medical Records Provides A More In-depth Assessment Of Quality Of Hypertension Care

Background: Hypertension (HTN) control rate is a core clinical quality measure. It is presently assessed by manual review of a random sample of patients with HTN billing claims. There is an increasing push by regulators towards the use of electronic medical records (EMR) to assess quality of care.

Purpose: To use EMR to obtain a more in-depth assessment of quality of hypertension care.

Methods: Cross sectional study involving adults with HTN seen at 2 or more office visits in 2009 by eligible primary or specialist providers at a large medical group practice. We measured the proportion of HTN patients with blood pressure (BP) at goal (BP < 140/90 mm Hg) at their last hypertension visit (LHV).

Results: Of a total of 10,401 patients, 5970 (57%) were controlled and 1959 (19%) were uncontrolled at their LHV. Control could not be assessed in 2472 (24%) as BP values were unavailable from the vital signs section of the visit notes in the EMR. Of a random sample of 250 patients with unavailable BP, only 94 (37.6%) had BP values documented in other parts of the visit note. In 29 patients (11.6%) billing for HTN was done without adequate evidence that it was addressed at that visit. Control rates were highest for primary care providers where measurement and documentation of BP was a focus - Family Medicine 77% controlled, 1% unavailable; Primary Care Internal Medicine 71% controlled, 4% unavailable. A considerable proportion of patients in the other four provider groups did not have BP available from their last hypertension visit - Cardiology 59% controlled, 22% unavailable; Nephrology 38% controlled, 47% unavailable; Preventive Medicine 48% controlled, 39% unavailable; General Internal Medicine 41% controlled, 45% unavailable. Control rates were similar across provider groups when patients with unavailable BP were excluded: Family Medicine 78%, Primary Care 74%, Cardiology 75%, Nephrology 73%, Preventive Medicine 79%, and General Medicine 75%.

Conclusions: Up to a quarter of HTN patients did not have properly documented BP in the EMR at their LHV. For those with measurements recorded, control rates were similar across primary care and specialty clinics, but measurement rates were higher for primary care practices. Use of the EMR facilitates efficient and granular assessment of the measurement process and control rates for HTN among various provider groups.

Use of a clinical decision support system to increase osteoporosis screening

BACKGROUND

In 2002, the US Preventive Services Task Force recommended routine osteoporosis screening for women aged 65 years or older. However, studies have indicated that osteoporosis remains underdiagnosed, and various methods such as the use of health information technology have been tried to increase screening rates. We investigated whether we could boost the low rates of bone mineral density testing with implementation of a point-of-care clinical decision support system in our primary care practice.

METHODS

We retrospectively reviewed the medical records of female patients eligible for osteoporosis screening who had no prior bone mineral density test who were seen at our primary care practice sites in 2007 or 2008 (before and after implementation of a point-of-care clinical decision support system).

RESULTS

Overall, screening rates were 80.1% in 2007 and 84.1% in 2008 (P < 0.001). Of patients who did not have osteoporosis screening before the visit, 5.87% completed the screening after the visit in 2007, compared with 9.79% in 2008 (when the clinical support system was implemented), a 66.7% improvement (P = 0.025).

CONCLUSION

Clinical decision support for primary care doctors significantly improved osteoporosis screening rates among eligible women. Carefully designed clinical decision support systems can optimize care delivery, ensuring that important preventive services such as osteoporosis screening for patients at risk for fracture are performed while unnecessary testing is avoided.

Population informatics-based system to improve osteoporosis screening in women in a primary care practice

OBJECTIVE

To study the effects of using a population-based informatics system for osteoporosis screening and treatment in women aged 65 years or older.

DESIGN

A population-based informatics system (PRECARES: PREventive CAre REminder System) was implemented to meet the needs of the workflow of a primary care practice. Patients treated in either of two sections of a primary care internal medicine department were selected for the intervention, and patients of a comparable third section served as the control group. PRECARES identified women in the intervention group who were due for osteoporosis screening on the basis of age and who had no record of previous screening in our clinical system. If these eligible patients did not have an upcoming outpatient appointment, appointment secretaries sent a letter requesting that they call to make an appointment for a dual-energy x-ray absorptiometry scan.

MEASUREMENTS

At baseline and 3 months after the letters were sent, a database was used to determine the rate of osteoporosis screening in the intervention and control groups.

RESULTS

A total of 689 patients in the intervention group were sent the letter. Three months after the letters were sent, the rate of osteoporosis screening was 76.4% (2409/3152) in the intervention group vs 69% (928/1344) in the control group (p<0.001). In the intervention group, 25% of the 689 patients responded to the letter and completed osteoporosis screening. Patients who had osteoporosis screening received appropriate treatment.

CONCLUSION

A population-based informatics system for primary care practice significantly improved the rate of osteoporosis screening.

Clinical informatics to improve quality of care: a population-based system for patients with diabetes mellitus

BACKGROUND

The prevalence of diabetes mellitus is increasing in the USA. However, control of intermediate outcome measures remains substandard. Recently, significant emphasis has been placed on the value of electronic medical records and informatics systems to improve the delivery of health care.

OBJECTIVE

To determine whether a clinical informatics system improves care of patients with diabetes mellitus.

METHODS

In this quality improvement pilot initiative, we identified 48 patients with diabetes mellitus who were due for their annual haemoglobin A1c (HbA1c), low-density lipoprotein (LDL) and microalbumin tests. Through our newly developed clinical informatics initiative, patients were reminded to schedule tests and a physician appointment. Seventy-five patients without reminders served as controls.

RESULTS

A significant improvement in LDL control was achieved in the intervention group (35.4% vs 13.3%; P=0.004). The intervention group had a greater percentage of patients who underwent the three tests, and members of this group also showed greater control of haemoglobin A1c, but these differences were not statistically significant.

CONCLUSIONS

A clinical informatics system, used to deliver proactive, co-ordinated care to a population of patients with diabetes mellitus, can improve process and also quality outcome measures. Larger studies are needed to confirm these early findings.

Web-based proactive system to improve breast cancer screening: a randomized controlled trial

BACKGROUND

Screening mammography is recommended for early detection of breast cancer but screening rates remain suboptimal.

METHODS

A primary care portal for a large academic primary practice was developed for all preventive services. Another Web-based system (PRECARES [PREventive CAre REminder System]) was developed for appointment secretaries to manage proactive breast cancer screening. Female patients aged 40 to 75 years were randomly assigned to a control group (usual care) and an intervention group. For the intervention group, 2 monthly letters inviting patients to undergo mammography were sent starting 3 months before they were due for annual screening, followed by a telephone call to nonresponding patients. A subgroup of women employees was further randomized to receive a reminder by either US mail or e-mail.

RESULTS

Of the total eligible population of 6665 women identified as having consented to participate in research, 3339 were randomly assigned to the control group and 3326 to the intervention group. The screening rate for annual mammography was 64.3% for the intervention group and 55.3% for the control group (P <.001). There were no significant differences between the 2 groups for any of the other adult preventive services. For the employee subgroup, the screening rate was 57.5% for the control group, 68.1% for the US mail group, and 72.2% for the e-mail group (intervention vs control, P <.001; e-mail vs US mail; P = .24).

CONCLUSION

The breast cancer screening rate improved significantly with the practice redesign of having appointment secretaries proactively manage breast cancer screening needs.

Comparison of chronic illness among children receiving mechanical ventilation in a cohort of children's hospitals in 1991 and 2001

OBJECTIVE

To compare the prevalence of chronic illness and characteristics of children who underwent mechanical ventilation in a cohort of patients at large children's hospitals between 1991 and 2001.

STUDY DESIGN

This was a retrospective, cross-sectional study using the National Association of Children's Hospitals and Related Institutions (NACHRI) case mix database to identify children who underwent mechanical ventilation and compare the prevalence of chronic illness and incidence of mechanical ventilation.

RESULTS

The proportion of children who underwent mechanical ventilation who had at least 1 chronic condition increased from 72% in 1991 to 75% in 2001. The incidence of mechanical ventilation in hospitalized children almost doubled during this decade, from 77 per 1000 hospitalizations in 1991 to 124 per 1000 in 2001. The rate of mechanical ventilation increased with increasing numbers of chronic conditions. The mortality of children who underwent mechanical ventilation decreased from 14% in 1991 to 11% in 2001.

CONCLUSIONS

The increase in mechanical ventilation in hospitalized children is due to both an increased incidence of chronic illness and higher use within diagnostic categories. Unlike utilization of some services, the use of mechanical ventilation in hospitalized children may be a marker of increased severity of illness and need, because it is plausible that mechanical ventilation use is not primarily supply-sensitive.

Testicular atrophy, zinc concentration, and angiotensin-converting enzyme activity in the testes of vitamin A-deficient rats

Angiotensin-converting enzyme (ACE) as a part of the renin angiotensin system (RES) regulates blood pressure and fluid and electrolyte homeostasis, and the enzyme is considered to have a function in reproduction. Reduced enzyme activities have been observed in atrophied testes as a results of zinc and pituitary deficiencies. Vitamin A deficiency causes atrophy of testes. The present study was conducted on three groups of male, 3-wk-old, Wistar rats. After 54 d of the experimental period, testicular weights of the vitamin A-deficient rats (A- group, allowed free access to vitamin A- deficient diet) was significantly lower than its pair-fed, PF (given restricted amount control diet) and A+ (allowed free access to control diet) groups. Zinc concentrations and both soluble and particulate ACE activities in the testes of vitamin A- deficient rats (A- group) were significantly lower than the other two groups. No significant differences were observed regarding zinc concentration, particulate ACE, and total ACE activities in the testes of PF and A+ groups. Vitamin A deficiency did not significantly affect the enzyme activity in the lung. From the observations of the present study, we speculate that testicular atrophy in vitamin A deficiency may have resulted from lower zinc concentration and decreased ACE activity in that organ.

Glutamine is superior to glucose in stimulating water and electrolyte absorption across rabbit ileum

L-Glutamine is the primary metabolic fuel of the intestinal mucosa. This in vivo study compares the effect of L-glutamine 50 mM with that of D-glucose 50 mM on water and electrolyte absorption in jejunal and ileal loops of healthy rabbits. Using polyethylene glycol (PEG) as a nonabsorbable marker and an incubation at 37 degrees C, we found that absorption of water (P = 0.000), sodium (P = 0.002), potassium (P = 0.001), and chloride (P = 0.003) from the glutamine electrolyte solution was greater than from the glucose electrolyte solution in the ileum. A similar trend was shown in the jejunum. We conclude that L-glutamine may be a useful component to be tested in oral rehydration solutions for treating diarrheal dehydration.

Intestinal transport of water, sodium & glucose from an electrolyte solution with & without bicarbonate

In this study we have evaluated the role of bicarbonate on water and sodium transport in normal and secreting ilea of rabbits as controversy exists regarding the inclusion of bicarbonate in oral rehydration solution (ORS). In anaesthetized rabbits 10 cm closed ileal loops were constructed and filled with 5 ml of an electrolyte solution with and without bicarbonate, which contained polyethylene glycol (PEG; mol wt 4,000) as a non-absorbable marker. The fluid was withdrawn after an hour and analyzed for PEG, sodium and glucose. Similar studies were carried out in loops one hour after exposure to 1 microgram/ml of purified cholera toxin. Body temperature was maintained at 37 degrees C during the experiment by using a lamp. The mean +/- SE of water and sodium absorption, with bicarbonate versus without bicarbonate, was -1.4 +/- 0.1 vs -1.1 +/- 0.3 ml/h/10 cm, and -340.8 +/- 23.0 vs -308.4 +/- 35.6 mM/h/10 cm, respectively from secreting rabbit ilea. A similar effect was observed in normal ilea. It is concluded that bicarbonate containing electrolyte solution has no additional promoting effect on water and sodium absorption in normal or secreting ilea of rabbits.

Neurological disorder and excessive accumulation of calcium in brain of clinically vitamin A-deficient rats

Three groups of rats were fed two types of synthetic diets for 52 d. The -A group was allowed free access to a vitamin A-deficient diet and showed classical signs of vitamin A deficiency. The brain was the only organ in our experiment where no significant weight difference was present among the three groups. In the brain, calcium concentration was significantly higher in the -A group when compared with the PF (Pair-fed; allowed restricted amount of control diet) and +A groups (allowed free access to control diet). In the tibia, calcium and magnesium concentrations were significantly lower in the -A group when compared with other two groups. Excessive accumulation of calcium in brain and apparently similar unbalance in bone mineral concentration were observed in central nervous system (CNS) degenerative diseases. Our results suggest that abnormal metabolism of calcium and magnesium in some tissues and excessive accumulation of calcium in brain may be responsible for the development of neurological disorders in vitamin A-deficient rats.

Iron, zinc, and copper levels in different tissues of clinically vitamin A-deficient rats

To clarify the effect of vitamin A deficiency on iron, zinc, and copper status in different tissues, three groups of rats were fed two types of synthetic diets for 52 d. Group one, which was fed a vitamin A-deficient diet, showed severe signs of vitamin A deficiency. Groups two (fed restricted amount, pair-fed with group one), and three (fed diet ad libitum) were fed a control diet. After said period of feeding, iron, zinc, and copper were measured in different tissues. Significant changes observed when the groups were compared are summarized below: 1. Iron and copper in testes were increased significantly, whereas zinc was strikingly decreased in group one when compared with the other groups; 2. Copper (in lung and kidney) and iron (in the spleen) were increased significantly in group one compared with the other groups; 3. In the liver, iron, zinc, and copper were significantly different between group one and group two; 4. In muscle, iron was significantly higher in group one than group two; 5. In tibia and blood, iron levels (but not zinc and copper) in groups one and two were significantly higher than group three. These results suggest that vitamin A deficiency affects iron, zinc, and copper status in rats.

Thermal stability of an oral killed-cholera-whole-cell vaccine containing recombinant B-subunit of cholera toxin

An oral killed cholera vaccine containing 1 x 10(11) cells of Vibrio cholerae O1 (heat- or formalin-killed) representing the Ogawa and Inaba biotypes and containing 1 mg of B-subunit of cholera toxin (CTB) produced by recombinant DNA technology (the WC/rCTB vaccine) was subjected to temperatures of 4 C, 30 C or 42 C for up to 6 months time. Lipopolysaccharide antigen (LPS) and CTB content of the vaccine samples determined at various times remained unchanged during the study except for the CTB component which decreased by about 50% after 6 months of storage at 42 C. Immunogenicity determined by immunization of rabbits with the vaccine in Freund's complete adjuvant and measuring anti-LPS and anti-CTB antibody titers in the serum by an ELISA was also found to be unaltered. Lyophilization of the vaccine and storage at room temperature for 7 days also did not have any adverse effect on antigen content or immunogenicity as tested above. There was up to one log reduction in serum antibody titers after immunization without using any adjuvant or using Freund's incomplete adjuvant, and up to two logs following oral immunization. Immunization by oral feeding of the vaccine followed by RITARD challenge with a virulent V. cholerae O1 strain showed evidence of protection against severe or lethal diarrhea. The results suggest that the vaccine retains its antigen content and ability to induce antibodies unchanged when maintained at elevated temperatures for relatively long periods of time.

Octreotide (SMS 201-995) as an antisecretory agent in cholera toxin & bile acid induced intestinal secretion in an in vivo animal study

The effect of Octreotide (SMS 201-995), synthetic somatostatin analogue on small intestinal and colonic fluid secretion induced respectively by cholera toxin (CT) and deoxycholic acid (DCA) was investigated in rabbits using in vivo isolated loops. After exposure to CT and DCA, marked fluid accumulation was observed in the small intestinal and colonic loops, along with elevation of jejunal and colonic mucosal cyclic AMP concentrations. Octreotide inhibited CT and DCA induced small intestinal and colonic secretion, dose-dependently. This anti-secretory effect was observed after both intramuscular and oral administration of octreotide. In contrast, octreotide did not affect the elevated mucosal cyclic AMP concentrations. These results suggest that octreotide inhibits CT and DCA induced intestinal secretion, and this anti-secretory effect is produced by affecting processes beyond cyclic AMP formation.

Effects of tropisetron, a 5-hydroxytryptamine type 3 receptor blocker, on intestinal secretion induced by cholera toxin or deoxycholic acid in rabbits in vivo

It has been suggested that 5-hydroxytryptamine is involved in the pathogenesis of various intestinal hypersecretory states including cholera. In this study, the effect of tropisetron (ICS 205-930), a specific 5-hydroxytryptamine type-3 receptor blocker, on jejunal and colonic fluid secretion induced respectively by cholera toxin and deoxycholic acid was investigated in rabbits using isolated loops of intestine in vivo. Marked fluid accumulation in both the jejunal and colonic loops was observed after exposure to cholera toxin and deoxycholic acid respectively. Elevation of jejunal and colonic mucosal cyclic adenosine monophosphate concentrations was also noted. Intraperitoneal administration of tropisetron dose-dependent inhibited jejunal secretion induced by cholera toxin. In contrast, no significant anti-secretory effect of tropisetron was observed against colonic secretion induced by deoxycholic acid. Tropisetron did not affect elevated mucosal cyclic adenosine monophosphate concentrations. The inhibitory effect of tropisetron on intestinal secretion induced by cholera toxin, which was independent of cyclic adenosine monophosphate formation, suggests that 5-hydroxytryptamine plays an important role in this type of secretion.

Pathogenesis of Providencia alcalifaciens-induced diarrhea

Providencia alcalifaciens is a member of the family Enterobacteriaceae. There are reports that P. alcalifaciens can cause diarrhea, but the mechanism(s) by which it causes diarrhea is known. We studied P. alcalifaciens isolated from a child and two adults with diarrhea for enteropathogenicity. The three isolates did not exhibit any characteristic adherence to cultured HEp-2 cell monolayers, and they did not produce enterotoxins, cytotoxins, or keratoconjunctivitis in the Sereny test. Two isolates invaded cultured HEp-2 cell monolayers, producing localized bacterial clusters and actin condensation. The pattern of actin condensation was different from that produced by enteropathogenic Escherichia coli but similar to that produced by Shigella flexneri. Invasion and actin condensation were poor for the third isolate. Histology of adult rabbit small intestinal loops inoculated with all three isolates revealed bacterial attachment to, penetration of, and microulcer formation on the surface epithelium and hyperemia, edema, and polymorphonuclear cell infiltration of lamina propria. All the isolates produced diarrhea in rabbits with removable intestinal ties, and some of these rabbits developed hindlimb paralysis. Intestinal histology of the rabbits with removable intestinal ties which developed diarrhea showed changes similar to that in adult rabbits on which ileal loop assays had been performed. Transmission electron microscopy of intestinal tissues also confirmed tissue penetration by the isolates. Nerve tissue histology of two rabbits that developed hindlimb paralysis showed focal mononuclear cell infiltration around peripheral nerve sheaths. It is concluded that some strains of P. alcalifaciens are enteropathogenic and that they cause diarrhea by invading the intestinal mucosal epithelium. However, the relevance to human disease of the hindlimb paralysis observed in this animal model is not clear.

Population explosion and population control programmes in Bangladesh: an overview

"The authors discuss in detail efforts made by [the] Bangladesh Government to control its population through planned efforts since 1953. Covering persistent setbacks and reasons thereof in governmental efforts, the authors highlight shifts in policies and strategy.... The [government family planning] programme provides a wide range of contraceptive choice to eligible couples in a manner as acceptable and convenient as possible to the client. The programme is totally voluntary and the government is firmly opposed to coercion or pressure on couples to accept contraception. As a strategy, the programme has integrated health and [family planning] while various ministries have attempted to encourage the acceptance of low-fertility behaviour through socio-economic incentives and educational motivation programmes."

Rice-ORS shortens the duration of watery diarrhoeas. Observation from rural Bangladesh

In rural Bangladesh, standard glucose based oral rehydration salt (glucose-ORS) and rice based oral rehydration salt (rice-ORS) were compared as domiciliary treatment for watery diarrhoea. Using identical supply systems, packaged glucose-ORS was provided in one area and packets of rice-ORS in another. Mothers of under-five children in each area were trained in the preparation and use of the respective ORS. A third area, where no ORS was provided from the study source, served as comparison. In two years of surveillance and follow-up about 10,000 diarrhoeal episodes were detected in each area, approximately one-third of which were watery diarrhoea. Rice-ORS alone was used to treat 74% of these episodes and glucose-ORS alone for 65% of the episodes in the respective areas. Drugs were the main treatment regimen used in the comparison area. Results of the study showed that rice-ORS treated episodes of watery diarrhoea ended with shorter duration (median duration 2 days vs. 4 days) and fewer hospitalisation (0.1% vs. 0.5%) compared to those treated with glucose-ORS. These differences were statistically significant. But, diarrhoeal mortality was unaffected by the use of either ORS under the study situation.

Enhanced sodium absorption by citrate: an in vivo perfusion study of rat small intestine

The effect of citrate on sodium, potassium chloride, and water absorption in the presence of glucose from the whole rat small intestine was studied by an in vivo marker perfusion technique. The perfusion solutions contained glucose and were similar in their electrolyte composition to the currently recommended oral rehydration solution for the treatment and prevention of diarrheal dehydration. Significantly more sodium and water absorption occurred from the citrate-containing solution than from the one without citrate. It is concluded that citrate enhances net sodium absorption from a glucose electrolyte solution in the rat small intestine independent of glucose-stimulated absorption.

Rotavirus as an important cause of diarrhoea in a hospital for children in Dammam, Saudi Arabia

A major cause of morbidity and mortality among children in developing countries is acute diarrhoea and rotavirus, a reovirus-like agent, is found to be a leading causative agent. We report here the incidence of rotavirus infection among infants and young children with gastro-enteritis treated at the Children's Hospital in Dammam, Kingdom of Saudi Arabia. One hundred and fifty children, aged between 1 and 60 months, suffering from diarrhoeal illness, were selected as the study cohort; another 150 hospitalized children of the same age group, but not suffering from diarrhoea, served as controls. Sixty-two per cent of the study children complained of watery diarrhoea and 39% of vomiting; all had mild to moderate dehydration. Seventy-two per cent had fever and 30% associated respiratory illness. Worst affected were those 7-12 months old, among whom rotavirus was detected by ELISA techniques in 39.6%, compared with 7.5% of the control children of comparable age group. We could not detect any rotavirus from control children aged over 36 months, whereas approximately 15% of the study children in this age group yielded rotavirus from the stool. The second most common pathogen isolated was Shigella ssp. It was isolated from 18.7% of children under study as against 3% of the controls.

Cryptosporidium as a pathogen for diarrhoea in Bangladesh

Cryptosporidiosis, a zoonosis caused by Cryptosporidium species is a newly recognized coccidial protozoan infection causing diarrhoea in humans. Using a modified acid fast technique, the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) has been screening a 4% sample of diarrhoea patients attending the ICDDR,B diarrhoea treatment center for Cryptosporidium in their stools as a part of an ongoing surveillance program. Positive specimens were confirmed by the standard Giemsa method. Cryptosporidia were identified predominantly in young children and were associated with watery diarrhoea, vomiting, cough and mild to moderate dehydration. The protozoan had a seasonal pattern with an increase in the hot, humid weather. We conclude that Cryptosporidium infection is relatively common in children in Bangladesh and may be responsible for a significant proportion of diarrhoea in this area.

An outbreak of nosocomial cholera in a rural Bangladesh hospital

At a time of year when Vibrio cholerae infection accounted for over 50% of admissions to a rural Bangladeshi diarrhoea treatment centre, 29% of 48 patients hospitalized with non-cholera diarrhoea developed nosocomial V. cholerae infection. During an investigation of the 8-week outbreak, only the severity of the non-cholera diarrhoea which prompted hospital admission emerged as an important risk factor for nosocomial infection; food, intravenous solutions, oral rehydration fluid, patient attendants and hospital personnel could not be implicated as transmission sources. Patients receiving antibiotics while hospitalized did not develop nosocomial infection. Antecedent non-cholera diarrhoea may represent an important risk factor in some cases of V. cholerae infection occurring in persons who reside in cholera-endemic areas where rates of non-cholera diarrhoea are also high.

Mothers can prepare and use rice-salt oral rehydration solution in rural Bangladesh

A feasibility study of rice-salt solution for oral rehydration (OR) was conducted in a village in the Chandpur area of rural Bangladesh in 1983. 305 mothers of children aged 0-4 years were interviewed with a pretraining questionnaire to find out about the availability of rice. The mothers were then trained and encouraged to use rice-salt OR solution to treat patients with diarrhoea. Evaluation of training was assessed by means of field diarrhoea surveillance, case follow-up, rice-salt OR solution sample analysis, and a post-training survey. The study showed that mothers in rural areas could prepare rice-salt OR solution quite easily and use it to treat diarrhoea patients. Mothers considered that this method would increase the utilisation of OR treatment in rural homes. After training rice-salt OR solution was the most common method of treatment for diarrhoea.

Cryptosporidiosis in Bangladesh

Images

Study of makeshift hospital during cholera outbreak

This is a report on the study of utilization pattern of a makeshift hospital during a major cholera outbreak, by analyzing data on dehydration status, distance covered, number of deaths averted, and operation-wise comparison with other permanent facilities. To avoid unnecessary deaths due to dehydration and to ensure prompt and adequate care to suddenly accumulated debilitated patients, the makeshift hospital intervened. Subsequent to the intervention, a gradual reduction in patient admissions and cholera case accumulations was noted. Nearly half the cholera cases attending the makeshift hospital came from relatively far (13 + miles). The reporting of the majority (72%) of cholera patients with none-to-mild dehydration indicates an increased awareness of the need for early treatment during a cholera outbreak. Early attendance of diarrhoeal patients probably saved more patients by preventing shock and complications. Para-professionals given a short training accomplished similar efficacy as in a permanent facility. Nearer the affected areas, a simple but effective temporary facility is more effective than a sophisticated facility which is further away and takes several hours to reach, with risk to patients.

Beliefs and treatment related to diarrhoeal episodes reported in association with measles

Eighty mothers whose children had measles in the past month were interviewed for beliefs and practices related to the management of measles and measles associated diarrhoea. Beliefs and practices about diarrhoea, associated with measles are described. Diarrhoea during and after measles was considered beneficial by mothers, who believed it helped to flush out impurities from the body. Paradoxically ORS was not used because of an erroneous idea that ORS would stop diarrhoea. Informing mothers that ORS will not stop diarrhoea, but will help in flushing out the impurities, could enhance ORS use, reducing morbidity and mortality. The prevalent belief, that measles patients must be kept in a clean environment is useful and should be encouraged. Other beliefs and practices to hasten the eruption are neutral, but since they encourage cleanliness and isolation, need not be discouraged.

Classical Vibrio cholerae biotype displaces EL tor in Bangladesh

The EL Tor biotype of Vibrio cholerae caused all endemic and epidemic cholera in Bangladesh from 1973 until Sept. 3, 1982, when the first classical strain was isolated from a patient in Matlab. Since then the number of isolations of the classical biotype has increased very rapidly and spread to other districts, replacing the EL Tor biotype as the main epidemic strain. The classical strains isolated in the 1982 outbreak were indistinguishable by the standard tests from those isolated a decade ago and the very few isolates in 1979, 1980, and 1981. This suggests that beyond the taxonomic traits used to identify the classical and EL Tor strains, there may be other more crucial biological characteristics that have given this new strain an advantage over the existing strains. The mechanism by which a new biotype of V. cholerae 01 achieves such a crucial biological advantage to displace the existing strains may be a key point in control of the global spread of cholera.

Diarrhoeal disease in Bangladesh: epidemiology, mortality averted and costs at a rural treatment centre

The basic epidemiology of acute diarrhoeal disease seen at a rural Bangladesh hospital in 1975 is reviewed. V. cholerae 01 was isolated from 28% of 1 964 patients. Significant differences in hospitalisation rates were observed between males and females in several age groups. Overall hospital case fatality was 9/1000 cases. We estimate that approximately a quarter to half of the hospitalised patients would have died had no rehydration therapy been available. The region's total mortality was reduced by approximately 7%-15%, at a cost of United States $0.14 per capita. Mortality from acute diarrhoeal diseases was greatly reduced for all age groups, and total mortality and mortality from all diarrhoeal diseases were particularly reduced for young children and young adults. Rehydration therapy used in a field hospital was apparently highly effective in reducing general mortality and mortality from acute diarrhoeal diseases.

A two-year study of bacterial, viral, and parasitic agents associated with diarrhea in rural Bangladesh

Enteric pathogens associated with diarrhea were studied for two years at a diarrhea treatment center in rural Bangladesh. Enterotoxigenic Escherichia coli (ETEC) was the most frequently identified pathogen for patients of all ages. Rotavirus and ETEC were isolated from approximately 50% and approximately 25%, respectively, of patients less than two years of age. A bacterial or viral pathogen was identified for 70% of these young children and for 56% of all patients with diarrhea. Most ETEC isolates were obtained in the hot dry months of March and April and the hot wet months of August and September. Rotavirus identification peaked in the cool dry months of December and January, but infected patients were found year-round. The low case-fatality rates for patients with watery diarrhea and substantial dehydration further document the usefulness of treating patients with diarrhea with either a glucose- or sucrose-base electrolyte solution such as those used in this treatment center.

Vibrio parahaemolyticus enterocolitis in Bangladesh: report of an outbreak

In March 1974 eight men in Chandpur, Bangladesh, experienced an illness characterized by severe abdominal cramps, nausea, vomiting and bloody diarrhea with onset 20 min to 9 h (median 2.5 h) after eating one of two fish dishes at a restaurant. Rectal cultures from all eight grew Kanagawa-positive strains of Vibrio parahaemolyticus (serotype O3K5) that were negative in the Sereny test for invasiveness and the Y-1 adrenal cell and infant mouse assays for enterotoxin production. The short incubation, severity of abdominal cramps and grossly bloody stools distinguish this illness from that usually associated with V. parahaemolyticus infection in the United States.

Field trials of monovalent Ogawa and Inaba cholera vaccines in rural Bangladesh--three years of observation

A controlled cholera vaccine field trial was carried out to test the efficacy of monovalent whole-cell Inaba and Ogawa cholera vaccines and a purified Inaba antigen. This study was designed particularly to study the level of protection produced by these vaccines against homologous and heterologous serotypes and to correlate the results with mouse protection tests and human serological response to the vaccines. A cohort of 45 000 children, aged 0-14 years, was divided into a control group and three vaccine groups. Inoculations were given annually for 2 years just before the start of the cholera season, and follow-up was continued for one additional year. Essentially, all cholera cases were due to the Inaba serotype, so that protection could be studied only against that serotype. Two annual injections of the whole-cell Inaba vaccine gave the highest level of protection, averaging 84% over the 3 years of follow-up; a single injection of the purified Inaba vaccine gave less protection (51%). Two annual injections of the whole-cell Ogawa vaccine failed to protect children under the age of 5 but did produce 48% protection for children aged 5-14 against Inaba cholera. Serological surveys correlated poorly with protection; specifically, the Ogawa vaccine produced high anti-Inaba titres in young children but no protection. The cross-protection against Inaba cholera produced by Ogawa vaccine in the older children is assumed to be due to boosting of naturally acquired immunity in this population. Monovalent vaccine cannot be recommended for general public health use because of the serotype specificity of protection that this study has demonstrated.