Estimation of 10-Year Fracture Risk with and without Bone Mineral Density in Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is the most common inflammatory arthritis affecting 0.5-1.0% of the general population worldwide and although RA is properly considered a disease of the joints, it can cause a variety of extra-articular manifestations. This study was performed to find out any discrepancy in fracture risk estimates with and without bone mineral density (BMD) in rheumatoid arthritis (RA) patients. This observational cross-sectional study was carried out in the Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh from July 2013 to July 2015. Total 65 consecutive patients with RA fulfilling ACR/EULAR criteria aged 40-90 year were recruited. Ten year fracture risk of these patients was evaluated by the FRAX score with and without BMD and differences were observed. FRAX score without BMD revealed that major fracture risk was low in 58(89.2%) patients, moderate in 7(10.8%) patients but re-estimation with BMD revealed that 55(84.6%) patients remained in low risk group, 8(12.3%) patients in moderate risk group and 2(3.1%) patients went to the high risk group. In case of hip fracture risk without BMD, risk was low in 58(89.2%) patients, high in 7(10.8%) patients; but with BMD, 50(76.9%) patients remained in low risk group but risk of 15(23.1%) patients became high. Almost all the high risk patients (93.3%) were ≥55 years of age. Increasing age, female sex, disease duration and use of steroid were positively correlated with increased FRAX score where as high BMI and high BMD were associated with low FRAX score. But in multivariate analysis it was found that only relation with age was at statistically significant level. Significant numbers of patients with rheumatoid arthritis have high risk of fracture especially hip fracture. The mean of FRAX score increased in both major & hip osteoporotic fracture risk after adding BMD. More than half of the patients above fifty five years or more had high risk of fracture. So, BMD should be done in patients aged more than fifty five.

Modification of Cellulose Acetate Microfiltration Membranes Using Graphene Oxide-Polyethyleneimine for Enhanced Dye Rejection

Pressure-based membrane processes represent excellent water resource recovery prospects from industrial waste streams. In contrast with conventional pretreatment technologies, studies have shown that membrane pretreatment applications, such as microfiltration (MF), are more cost-effective and improve the results of the overall treatment processes. Hence, enhancing rejection efficiency of MF will enhance the performance of any downstream treatment processes. In this study, 0.45 µm cellulose acetate (CA) microfiltration membranes were modified by vacuum filtration-assisted layer-by-layer deposition of bilayers composed of negatively charged graphene oxide (GO) and positively charged polyethyleneimine (PEI). The performance of 1-, 2-, and 4-bilayer GO-PEI-modified membranes were investigated for their dye-rejection of anionic eriochrome black T (EBT) dye and cationic methylene blue (MB) dye in a cross-flow membrane module. As the number of bilayers on the membrane increased, the membrane thicknesses increased, and the deionized (DI) water flux through the membranes decreased from 4877 LMH/bar for the control (no bilayer) membrane to 2890 LMH/bar for the 4-bilayer membrane. Conversely, the dye-rejection performance of the modified membranes increased as increasing bilayers of GO-PEI deposited on the membranes. The anionic EBT dye saw superior rejection (~90% rejection) compared to the cationic MB dye (~80% rejection), which can be attributable to the electrostatic repulsion between the negatively charged GO surface and anionic EBT dye. After 50% recovery of the saline and dye-laden feed water, there was an observed drop in DI water fluxes of ~40-41% and 36%, respectively. There was also a slight increase in EBT dye-rejection during the composite feed-water experiments, attributed to the precipitation of salts on the membrane feed side or pore spaces, which subsequently reduce the membrane pore sizes.

Nitrogen and organic load removal from anaerobically digested leachate using a hybrid electro-oxidation and electro-coagulation process

This study evaluated the performance of an integrated electrochemical process, which simultaneously utilizes electro-oxidation (EO) and electro-coagulation (EC) methods while removing organic and nitrogen loads from high-strength leachate obtained from anaerobic digesters. A bipolar arrangement of the aluminum electrode, sandwiched between a monopolar boron-doped diamond anode and stainless-steel cathode, integrates EC and EO into a single reactor. This arrangement demonstrated an enhancement of 33%, 27%, and 24% in removal capacity for ammonia nitrogen (AN), total Kjeldahl nitrogen (TKN), and total nitrogen, respectively, when compared to just EO at 0.8 A current intensity after 24 h. Increasing the current intensity from 0.4 A to 1.0 A enhanced the organic nitrogen and AN removal. Chemical oxygen demand (COD) exhibited initial faster removal kinetics with higher current intensities and eventually reached 95%-98% removal for intensities of 0.6 A or higher. Additional removal for AN, TKN were also observed with increasing current intensity. Lowering the pH further expedited the COD removal kinetics. Reducing and maintaining the pH at 4, 6, and 8 by dosing of hydrochloric acid (HCl) resulted in the 100% removal of AN and TKN from the integrated system in 6, 8, and 20 h, respectively. Accelerated removal of COD and the enhanced removal of AN and TKN through pH control could be linked to the formation of active chlorine species in bulk solution. The integrated system offered lower energy consumption than EO due to oxidation on the additional anodic surface of the bipolar electrode, as well as the adsorption-precipitation of contaminants in aluminum flocs.

Energy recovery and carbon/nitrogen removal from sewage and contaminated groundwater in a coupled hydrolytic-acidogenic sequencing batch reactor and denitrifying biocathode microbial fuel cell

Developing cost-effective technology for treatment of sewage and nitrogen-containing groundwater is one of the crucial challenges of global water industries. Microbial fuel cells (MFCs) oxidize organics from sewage by exoelectrogens on anode to produce electricity while denitrifiers on cathode utilize the generated electricity to reduce nitrogen from contaminated groundwater. As the exoelectrogens are incapable of oxidizing insoluble, polymeric, and complex organics, a novel integration of an anaerobic sequencing batch reactor (ASBR) prior to the MFC simultaneously achieve hydrolytic-acidogenic conversion of complex organics, boost power recovery, and remove Carbon/Nitrogen (C/N) from the sewage and groundwater. The results obtained revealed increases in the fractions of soluble organics and volatile fatty acids in pretreated sewage by 52 ± 19% and 120 ± 40%, respectively. The optimum power and current generation with the pretreated sewage were 7.1 W m^-3 and 45.88 A m^-3, respectively, corresponding to 8% and 10% improvements compared to untreated sewage. Moreover, the integration of the ASBR with the biocathode MFC led to 217% higher carbon and 136% higher nitrogen removal efficiencies compared to the similar system without ASBR. The outcomes of the present study represent the promising prospects of using ASBR pretreatment and successive utilization of solubilized organics in denitrifying biocathode MFCs for simultaneous energy recovery and C/N removal from both sewage and nitrate nitrogen-contaminated groundwater.

Fouling and wetting in the membrane distillation driven wastewater reclamation process - A review

Fouling and wetting of membranes are significant concerns that can impede the widespread application of the membrane distillation (MD) process during high-salinity wastewater reclamation. Fouling, caused by the accumulation of undesirable materials on the membrane surface and pores, causes a decrease in permeate flux. Membrane wetting, the direct permeation of the feed solution through the membrane pores, results in reduced contaminant rejection and overall process failure. Lately, the application of MD for water recovery from various types of wastewaters has gained increased attention among researchers. In this review, we discuss fouling and wetting phenomena observed during the MD process, along with the effects of various mitigation strategies. In addition, we examine the interactions between contaminants and different types of MD membranes and the influence of different operating conditions on the occurrence of fouling and wetting. We also report on previously investigated feed pre-treatment options before MD, application of integrated MD processes, the performance of fabricated/modified MD membranes, and strategies for MD membrane maintenance during water reclamation. Energy consumption and economic aspects of MD for wastewater recovery is also discussed. Throughout the review, we engage in dialogues highlighting research needs for furthering the development of MD: the incorporation of MD in the overall wastewater treatment and recovery scheme (including selection of appropriate membrane material, suitable pre-treatment or integrated processes, and membrane maintenance strategies) and the application of MD in long-term pilot-scale studies using real wastewater.

Efficacy of Vitamin C in Lowering Serum Uric Acid

The objective of the study was to determine the efficacy of vitamin C in reducing serum uric acid (UA). This study was a double-blind placebo-controlled randomized trial conducted in the Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University (BSMMU) Dhaka, Bangladesh from July 2007 and August 2008. Study participants were included from out patient department (OPD) of Rheumatology of BSMMU suffering from various Rheumatological problems other than gouty arthritis. All of the participants were non-smokers, non-alcoholics, and randomized to take either placebo or vitamin C (500 mg/day) for 12 weeks. A total of 98 subjects were enrolled in the study; 71 completed the trial, with 34 in the placebo group and 37 receiving vitamin C. Serum uric acid levels were not significantly reduced in the experimental group and they increased in the placebo group. In the vitamin C group, the mean change was -0.32mg/dl [95% confidence interval -0.73, 0.77], whereas in the placebo group, the mean change was +0.12mg/dl [95% confidence interval was -0.22, 0.47]. Subgroups were defined by sex, body mass index, and quartiles of baseline serum uric acid levels. In a subgroup analysis, vitamin C lowered serum uric acid significantly in those who had comparatively higher baseline uric acid levels. Although vitamin C did not lower serum uric acid significantly, participants with higher baseline serum uric acid levels experienced a significant uric acid lowering effect, but as the sample size was very small, it is difficult to draw any definitive conclusion.

Tuberculosis is a Mimicker of JIA: A Rare Case Report

Cystic tuberculosis of the bone is a rare form of tuberculosis (TB). The condition presents like Juvenile idiopathic arthritis (JIA) of children. In children, the lesions symmetrically involve the peripheral skeleton, which are less sclerotic than adults. A case report is presented here where the patient presented with i) the extensive involvement of bones with cystic lesion, ii) Hand & feet involvement with multiple bony exostosis iii) Synovial swelling of multiple joints and 4) fever for 6 months. Swelling of the joints was disproportionately greater than pain. For the last 6 month patient developed low grade fever with evening rise of temperature & dry cough. There was associated anorexia & significant weight loss. Patient was moderately anaemic & there was cervical lymphadenopathy on both sides. The chest examination revealed features suggestive of consolidation in the right lung. Regarding MSK findings there was swelling of both knee & right wrist with G-II tenderness, sublaxation of both anterior and posterior cruciate ligament with mild effusion. Bony exostosis at the base of left index finger & at the base of right middle finger was found. Investigation shows low Hb, very high ESR, positive tuberculin test. X-ray Chest suggestive of consolidation, FNA of right cervical lymph node consistent with tuberculosis. X-ray Pelvis has shown expansile mixed sclerotic radiolucent areas with interval septation involving upper part of both femoral shafts. MRI findings of right knee joint were suggestive of tuberculous osteomyelitis. At this stage the patient was put on Anti-TB chemotherapy. After 2 month and 4 month of follow up with Anti-TB drug both MSK & lung condition was improved significantly. Ultimately the patient was diagnosed as cystic tuberculosis of bone & continued Anti-TB drugs.

Association of Immunofluorescence pattern of Antinuclear Antibody with Specific Autoantibodies in the Bangladeshi Population

Antinuclear antibody (ANA) is useful in the diagnosis of connective tissue disorder (CTD). Association of specific autoantibodies with the immunofluorescence pattern of ANA in CTD, noted in western literature has been considered as reference in all over the world. However, in Bangladesh no such research work or data correlating the autoantibodies and their ANA patterns is found. Objective of the study was to identify an association between immunofluorescence patterns of antinuclear antibody on HEp-2 cell and more specific antinuclear reactivities (e.g. anti-dsDNA and anti-extractable nuclear antigen) in the serum samples of CTD patients. Serum samples of 152 CTD patients (Systemic lupus erythematosus, Rhumatoid arthritis, Sjogren's syndrome, Systemic sclerosis, Polymyositis, Mixed connective tissue disease) were diagnosed clinically, attending at Bangabandhu Sheikh Mujib Medical University (BSMMU) during the study period of January, 2010 to December, 2010. Samples were subjected for ANA testing by Indirect Immunofluorescence (IIF) on HEp-2 cell (ALPHADIA) in dilution of 1:40, anti-dsDNA by ELISA and anti- extractable nuclear antigen (anti-ENA) by Dot Immunoblot. Dot blot strips were tested for anti-Sm, anti-RNP, anti-SSA/Ro, anti-SSB/La, anti-Scl-70 and anti-Jo-1. Out of 152 patients 110 (72.3%) cases were ANA positive by IIF on HEp-2 cell. ANA positive sera exhibited four fluorescence patterns such as speckled (50.8%), peripheral (21.6%) , homogenous (18.1%) and nucleolar pattern (9%). Peripheral pattern and homogenous pattern was predominantly associated with anti-dsDNA (p < 0.05). Speckled pattern was significantly associated with anti-ENA (p < 0.05).The most commonly identified antinuclear autoreactivity was directed towards anti-RNP (25.7%) then anti-Scl-70 (20%), anti-SSA (14.2%) and anti-SSB (5.7%). Multiple anti-ENA reactivities were identified in 34.28% cases. Peripheral and homogenous pattern is strongly associated with anti-dsDNA and speckled pattern may predict anti-ENA (specially ribonucleoprotiens). As a definite correlation between the ANA patterns and the group of antibodies was detected by dot immunoblot, one could predict presence of certain specific auto antibodies for a particular ANA pattern identified. This may restrict on the cost of laboratory investigations in a developing country like Bangladesh. Thus, ANA-IIF method may reduce the expense of detailed immunological work-up with minimal loss in diagnostic accuracy.

Haemodynamic and end tidal CO₂ changes during laparoscopic cholecystectomy under general anaesthesia

A prospective observational study was done on 50 patients to investigate the haemodynamic and end tidal CO₂ (EtCO₂) changes in healthy patients without cardiopulmonary pathology during elective laparoscopic cholecystectomy in head up position under standard protocol of general anaesthesia. During surgery, intra abdominal pressure was maintained at 15 mmHg by a CO₂ insufflator and minute ventilation was controlled with a constant tidal volume and fixed respiratory rate. Haemodynamic parameters, EtCO₂, SpO₂ and ECG were recorded before and after induction and positioning of the patients and at 5 minutes interval for the first 30 minutes, then 10 minutes interval for the rest of the period. Highly significant increase (p<0.001) in pulse rate, systolic, diastolic and mean arterial pressure occurred at 30 minutes after insufflations and positioning of the patient. A very highly significant (p<0.001) increase in EtCO₂ from the base line was at 40 minutes after insufflations and positioning of the patients. There was no change in SpO₂ and ECG. This study supports the significant physiological changes in terms of haemodynamic and EtCO₂ during laparoscopic cholecystectomy and recommends the meticulous monitoring of these parameters during the surgery and balance the benefit of laparoscopy against the intra operative risk.

Haemodynamic and end tidal CO2 changes state after inflation and deflation of pneumatic tourniquet on extremities

The use of a tourniquet for obtaining a bloodless field is an essential and accepted tool for extremity surgery. A prospective study was done on 30 adult patients undergoing elective limb surgery requiring tourniquet application for haemodynamic and End tidal CO2 (EtCO2) changes. After the induction of general anaesthesia a tourniquet was applied on the limb. There was gradual increase in heart rate & EtCO2 through out the whole period of tourniquet inflation. There was also significant increase of mean arterial pressure during the inflation period. At the end of surgery tourniquet was deflated. Tourniquet time was 76.83+/-16.94 minutes. After deflation of the tourniquet, heart rate & EtCO2 value increased & the values were maximum at 5 minutes. These values came down to the base line at 15 minutes. There was significant decrease of mean arterial pressure (MAP) at 5 minute; it also came to the base at 15 minute. These changes are usually benign but can be significant in patients with co-existing cardiovascular & intracranial diseases. In conclusion, we recommend the haemodynamic and End tidal CO2 monitoring as well as rapid fluid infusion along with hyperventilation for 15-30 minutes after deflation of tourniquet.

Prevalence of genital mycoplasma & ureaplasma infections in pregnancy & their effect on pregnancy outcome

A cohort of 200 women with singleton pregnancies attending the antenatal clinic, were studied to determine the prevalence of genital mycoplasma and ureaplasma infections in pregnant women and the effect of infection on pregnancy outcome. Vaginal and endocervical swabs were taken at 26-30 wk and again at 36-38 wk of pregnancy and cultured for mycoplasma and ureaplasma. Forty (20%, 95% CI 14.5-25.6%) women were found to be infected with arginine metabolising mycoplasmas and 79 (39.5%, 95% CI 32.7-46.3%) with ureaplasma at either site or either time. The mean +/- SD birth weight of infants born to women infected with mycoplasma alone was 2879 +/- 471 g while that of infants born to women infected with ureaplasma alone was 2964 +/- 412 g. Mean +/- SD birthweight of infants born to women infected with both organisms was 2969 +/- 389 g while that of infants born to uninfected women was 2919 +/- 432 g. These differences were not statistically significant. The median gestation at delivery was 39 wk in the cohort; the differences among the groups were minor and statistically not significant. Thus, although genital mycoplasma/ureaplasma infections were frequent, no association was observed between infection and pregnancy outcome.

Conformational structure variations in DNA: a PCILO study

Perturbative configuration interaction using localized orbital (PCILO) computations have been carried out on conformational preference of d(GpC) and d(CpG) units of Z-II DNA. By keeping the sugar pucker fixed in the crystallographic conformation, PCILO energies have been calculated as a function of torsion angles alpha and zeta around two P-O ester bonds with preselected values of beta, gamma and epsilon. The results indicate that the d(GpC) unit is energetically more stable than the d(CpG) unit and prefers a g+ t conformation in (alpha-zeta) hyper-space observed in the crystal structure. The d(CpG) unit, on the other hand, shows intrinsic preference for g-g- conformation with other torsion angles close to DNA-B structure. The possibility of d(GpC) unit responsible for the stability of Z-helix has been discussed.