Unveiling the effects of living standards on diabetes and hypertension with the mediating role of overweight and obesity: a cross-sectional study in Bangladesh

OBJECTIVE

The purpose of the study was to ascertain how the standard of living is associated with the likelihood of developing diabetes and hypertension directly as well as indirectly through overweight and obesity.

STUDY DESIGN

The study used 2017-2018 Bangladesh Demographic and Health Survey data. It examined the household living standard (LSD) as the main factor, and body mass index (BMI) as a mediator. Outcomes included diabetes status, hypertension status and their co-occurrence. Structural equation modelling with logistic regression and bootstrapping were used for mediation analysis and computing bias-corrected SEs.

SETTING

The research was carried out in Bangladesh and included both male and female adults.

PARTICIPANTS

The study encompassed a total of 11 961 adults (5124 males and 6837 females) aged 18 years or older.

RESULTS

Among the participants, 10.3% had diabetes, 28.6% had hypertension and 4.9% had both conditions. The prevalence of diabetes, hypertension or both conditions was 18.5%, 33.5% and 9.7%, respectively, among those with a high LSD. Regression analysis demonstrated that individuals with high LSD had significantly elevated risks of these conditions compared with those with low LSD: 133% higher odds for diabetes (OR 2.22; 95% CI 1.97 to 2.76), 25% higher odds for hypertension (OR 1.25; 95% CI 1.10 to 1.42) and 148% higher odds for both conditions (OR 2.48; 95% CI 1.96 to 3.14). Moreover, the indirect effects of high LSD through obesity surpassed its direct effects for developing diabetes, hypertension or both conditions.

CONCLUSION

This study emphasises that with the enhancement of LSD, individuals often experience weight gain, resulting in elevated BMI levels. This cascade effect significantly amplifies the risks of diabetes, hypertension or both conditions. To counteract this concerning trajectory, policy interventions and targeted awareness campaigns are imperative. These efforts must prioritise the promotion of heightened physical activity and the mitigation of the overweight/obesity surge associated with rising LSD.

Do education and living standard matter in breaking barriers to healthcare access among women in Bangladesh?

BACKGROUND

Barriers to healthcare access for women have a substantial influence on maternal and child health. By removing barriers to accessing healthcare, several sustainable development goals can be achieved. The goal of this study, based on the dominance analysis, was to examine how living standards and spousal education play role in removing barriers to healthcare access for women in Bangladesh.

METHODS

The study used the nationally representative Bangladesh Demographic and Health Survey (BDHS), 2017-18 data. A binary logistic regression model was applied for analyzing different types of health access barriers in the study. Additionally, a dominance analysis was conducted to identify the most responsible factors for removing barriers.

RESULTS

In Bangladesh, 66% of women faced at least one barrier in accessing healthcare. The results obtained from logistic regression and dominance analysis revealed that women's standard of living and spousal education explained the highest variation of having at least one barrier in accessing healthcare. Specifically, a high standard of living explained 24% of the total explained variation (OR 0.56, 95% CI 0.52-0.62), while both spousal education accounted for 27% (OR 0.49, 95% CI 0.45-0.54) of the total explained variation. The regression results also showed that women with higher standards of living as well as educated women having educated partners had lower odds of facing barriers in getting permission (OR 0.87, 95% CI 0.76-1.00 and OR 0.66, 95% CI 0.58-0.75) to go for advice/treatment, obtaining money (OR 0.43, 95% CI 0.39-0.47 and OR 0.37, 95% CI 0.34-0.40), distance to a health facility (OR 0.60, 95% CI 0.55-0.66 and OR 0.70, 95% CI 0.65-0.76), and not wanting to go alone (OR 0.72, 95% CI 0.66-0.89 and OR 0.75, 95% CI 0.69-0.81) for getting medical advice/treatment.

CONCLUSION

The findings of the study suggest paying extra attention to the spousal education and living standard of women to strengthen and reform the existing strategies and develop beneficial interventions to enhance unhindered accessibility to healthcare facilities for women.

Examining the influence of correlates on different quantile survival times: infant mortality in Bangladesh

BACKGROUND

Several studies have identified factors influencing infant mortality, but, to the best of knowledge, no studies assessed the factors considering unequal effects on different survival times of infant mortality in Bangladesh. In this study, it was examined how a set of covariates behaves on different quantile survival times related with the infant mortality.

METHODS

Data obtained from Bangladesh multiple indicator cluster survey (BMICS), 2019 have been used for purpose of the study. A total of 9,183 reproductive women were included in the study who gave their most recent live births within two years preceding the survey. Kaplan-Meier product limit approach has been applied to find the survival probabilities for the infant mortality, and the log-rank test has also been used to observe the unadjusted association between infant mortality and selected covariates. To examine the unequal effects of the covariates on different quantile survival time of infant mortality, the Laplace survival regression model has been fitted. The results obtained from this model have also been compared with the results obtained from the classical accelerated failure time (AFT) and Cox proportional hazard (Cox PH) models.

RESULTS

The infant mortality in Bangladesh is still high which is around 28 per 1000 live births. In all the selected survival regression models, the directions of regression coefficients were similar, but the heterogenous effects of covariates on survival time were observed in quantile survival model. Several correlates such as maternal age, education, gender of index child, previous birth interval, skilled antenatal care provider, immediate breastfeeding etc. were identified as potential factors having higher impact on initial survival times.

CONCLUSION

Infant mortality was significantly influenced by the factors more in the beginning of the infant's life period than at later stages, suggesting that receiving proper care at an early age will raise the likelihood of survival. Policy-making interventions are required to reduce the infant deaths, and the study findings may assist policy makers to revise the programs so that the sustainable development goal 3.2 can be achieved in Bangladesh.

Skilled maternal healthcare and good essential newborn care practice in rural Bangladesh: A cross-sectional study

Background and Aims

Essential newborn care (ENC) practices play an important role in reducing the risk of infant mortality and morbidity. Therefore, more studies are needed on ENC practices. Skilled maternal healthcare can be a good strategy to increase the practice. Learn about the independent and joint effects of skilled maternal healthcare during pregnancy and childbirth on newborn care practices.

Methods

The study used a cross-sectional data obtained from Bangladesh Multiple Indicator Cluster Survey, 2019. To investigate the association between maternal healthcare utilization and good ENC practice (cord care, delayed bathing, and immediate breast-feeding), χ 2 test and t-test in bivariate and binary logistic regression analysis, respectively have been performed after taking into account complex survey design.

Results

Only about 24% (95% confidence interval [CI]: 22.95%-25.89%) women given birth at home in rural Bangladesh followed good newborn care practice. The results obtained from adjusted regression analysis showed that a woman was 24%, 49%, and 75% more likely of having good ENC practice if she received four or more skilled checkups during antenatal period only (adjusted odds ratios [AOR]: 1.24, 95% CI: 0.97, 1.60), received assistance from SBA during delivery only (AOR: 1.49, 95% CI 1.12, 1.97) and received skilled healthcare in both pregnancy and delivery (AOR: 1.75, 95% CI 1.13, 2.71), respectively compared to a woman who did not get an opportunity to receive skilled healthcare during pregnancy and delivery. Among the selected confounders, maternal age at birth, birth order, education of household heads and religion showed a significant association with good ENC practice.

Conclusion

The study revealed that proper maternal healthcare during pregnancy and childbirth from skilled health personnel can improve the rate of ENC practices. For this, more training programs should be started, especially at the community level, and health promotion activities are needed to create awareness about efficient maternal healthcare practices.

How does mode of delivery associate with double burden of malnutrition among mother-child dyads?: a trend analysis using Bangladesh demographic health surveys

BACKGROUND

The simultaneity of undernourishment among child and overweight/obesity among mothers in lower-and-middle-income-countries (LMICs) introduces a new nutrition dilemma, known as double burden of malnutrition (DBM). Amidst of such paradox, the hike of caesarean section (CS) delivery is also triggering child undernutrition and maternal obesity. A gap of knowledge regarding the effect of mode of delivery on DBM still persists. The study aims to explore the association between DBM at household level and mode of delivery over time in LMICs.

METHOD

The study used data from recent four consecutive waves of Bangladesh Demographic and Health Survey (BDHS) ranging from BDHS 2007 to BDHS 2017. It considered the mother-child pairs from data where mothers were non-pregnant women aged 15-49 years having children born in last 3 years preceding the survey. Bivariate analysis and Logistic Regression were performed to explore the unadjusted and adjusted effect of covariates on DBM. An interaction term of mode of delivery and survey year was considered in regression model.

RESULTS

The study evinces a sharp increase of DBM rate in Bangladesh from 2007 to 2017 (2.4% vs. 6.4%). The prevalence of DBM in household level among the children delivered by CS is more than two times of those born by normal delivery (8.2% vs. 3.5%). The multivariate analysis also indicates that the children born by CS delivery are more likely to be affected by DBM at household level significantly than those born by normal delivery in each waves. Moreover, the odds ratio (OR) of DBM at household is increased by 43% for one unit change in time for normal delivery whereas CS delivery births have 12% higher odds of DBM at household level with one unit change in time.

CONCLUSION

The study discloses a drastic increase of rate of DBM among mother-child pairs over the time. It stipulates inflated risk of DBM at household with time for both mode of delivery but the children with CS delivery are at more risk to the vulnerability of DBM at household level. The study recommends a provision of special care to the mothers with CS delivery to reduce DBM at household.

On estimation for accelerated failure time models with small or rare event survival data

Background

Separation or monotone likelihood may exist in fitting process of the accelerated failure time (AFT) model using maximum likelihood approach when sample size is small and/or rate of censoring is high (rare event) or there is at least one strong covariate in the model, resulting in infinite estimates of at least one regression coefficient.

Methods

This paper investigated the properties of the maximum likelihood estimator (MLE) of the regression parameters of the AFT models for small sample and/or rare-event situation and addressed the problems by introducing a penalized likelihood approach. The penalized likelihood function and the corresponding score equation is derived by adding a penalty term to the existing likelihood function, which was originally proposed by Firth (Biometrika, 1993) for the exponential family models. Further, a post-hoc adjustment of intercept and scale parameters is discussed keeping them out of penalization to ensure accurate prediction of survival probability. The penalized method was illustrated for the widely used log-location-scale family models such as Weibull, Log-normal and Log-logistic distributions and compared the models and methods uisng an extensive simulation study.

Results

The simulation study, performed separately for each of the log-location-scale models, showed that Firth’s penalized likelihood succeeded to solve the problem of separation and achieve convergence, providing finite estimates of the regression coefficients, which are not often possible by the MLE. Furthermore, the proposed penalized method showed substantial improvement over MLE by providing smaller amount of bias, mean squared error (MSE), narrower confidence interval and reasonably accurate prediction of survival probabilities. The methods are illustrated using prostate cancer data with existence of separation, and results supported the simulation findings.

Conclusion

When sample size is small (≤ 50) or event is rare (i.e., censoring proportion is high) and/or there is any evidence of separation in the data, we recommend to use Firth’s penalized likelihood method for fitting AFT model.

Supplementary Information

The online version contains supplementary material available at (10.1186/s12874-022-01638-1).

Living standard and access to tetanus toxoid immunization among women in Bangladesh

BACKGROUND

Although Bangladesh has an impressive track record in the reduction of maternal and child mortality, tetanus, a dreadful disease, impedes the way to achieve Sustainable Development Goal (SDG) in this respect. Sufficient doses of tetanus toxoid containing vaccine during pregnancy ensure immunity against tetanus to mothers as well as newborns. Since inequalities persist across vaccination programs globally, in this paper, an attempt has been made to examine whether tetanus toxoid immunization (TTI) status among the women of reproductive age in Bangladesh for their most recent live birth born preceding 2 years of the survey changes with their living standard index (LSI).

METHODS

Five domains of deprivation such as energy use, improved sanitation, drinking water, housing and assets ownership were used to compute the LSI using a approach proposed by Alkire and Foster. The adjusted association between LSI and TTI was established by using logistic regression model. For the purpose of statistical analysis, a nationally representative cross-sectional data extracted from Bangladesh Multiple Indicator Cluster Survey (BMICS), 2019 have been used.

RESULT

The bivariate analysis revealed that 79.5% (95% CI 78.0-81.0) of women with low and 83.1% (95% CI 81.3-84.9) with moderate living standards had sufficient vaccination coverage for their most recent pregnancies while this percentage was higher for the women who belonged to high living standard (85.2, 95% CI = 84.2-86.2). A strong evidence for greater odds of sufficient immunization with TT among the women maintaining a high standard of living (AOR = 1.24, 95% CI = 1.08-1.42, p < 0.01) was found from regression analysis.

CONCLUSION

The results depict existing living standard disparity with respect to TT vaccination coverage among women in Bangladesh. Present research suggests that immunization campaigns need to be conducted especially for the disadvantaged people to improve their health care and immunization service utilization among women within the age bracket of 15 to 49. This study proposed a scientific way to enhance TT vaccination among Bangladeshi women, which could help Bangladesh attain a widespread tetanus protection and thus, meet the SDGs for maternal and child mortality reduction.

Link between unmet need and economic status in Bangladesh: gap in urban and rural areas

Background

Unmet need for family planning (FP) is a core concept in designing FP programmes and reduction of unmet need for FP can improve reproductive and maternal health services. Bangladesh is still away from achieving the target regarding unmet need for FP. This study aimed to explore the composite effect of economic status and place of residence on unmet need for FP among currently married women of reproductive age in Bangladesh after controlling the effect of other selected covariates.

Methods

The study used the data extracted from the Bangladesh Demographic and Health Survey (BDHS) 2017–2018, which is a nationally representative survey implemented using a stratified two-stage cluster sample design. A total of 13,031 currently married women of reproductive age were included in the final analysis. Binary logistic regression model has been employed to identify the factors influencing the unmet need for FP. Model-I investigated the effect of composite variable place-wealth on unmet need for FP and Model-II examined the effect of place-wealth on unmet need for FP after adjusting for the effect of other selected covariates. The Odds Ratios with p-values were reported to identify significant covariates.

Results

The rate of unmet need for FP was 15.48%. The composite factor of economic status and place of residence had significant influence on unmet need for FP in both models. Generally, rural women were significantly more likely to have unmet need for FP than their urban counterparts. In particular, women from rural areas and belong to rich families had the highest likelihoods of unmet need for FP. The other selected covariates also had significant influence on unmet need for FP.

Conclusion

This study shows that rural women had higher odds of unmet need for FP than urban women. The healthcare providers and stakeholders should take necessary actions to motivate women to use contraceptive specially the women who are residing in the rural areas.

Behavioural changes in air-conditioner use owing to the COVID-19 movement control order in Malaysia

Remote work (working from home) became a norm rather than an exception for the global workforce during the COVID-19 pandemic, influencing every facet of life in both positive and negative ways. The stringent action of the Malaysian government in enacting the Movement Control Order (MCO) motivated the investigation of its impact on the energy consumption behaviour of working people regarding air-conditioner (AC) use. To this end, this study conducted a cross-sectional survey through an online platform. An ordinal logistic regression model (ORL) was used to analyse the collected data of 1873 respondents to determine the factors influencing the ordinal variable of interest, AC-usage behaviour during remote work. Next, the variable with unordered categories, the MCO-induced change in AC-usage behaviour, was analysed using a multinomial regression model (MLT) to identify the potential determinants. Finally, a reason analysis unveiled aspects behind the transition in AC use during remote work. This study identified stopping AC use during remote work despite using it at the office before the MCO period as the most significant change in AC-usage behaviour due to MCO. This change was frequently adopted by people with medium-level incomes and high electricity bills. By contrast, participants unfamiliar with their electricity bill were most likely to start AC use during remote work, although they did not use it before the MCO. Participants working remotely in the communal spaces of their houses preferred to stop using ACs during MCO compared to private room users. Furthermore, age group and ethnicity significantly influenced AC-usage behaviour in remote work and changes in such demeanours. These findings recommend policy interventions to expedite limited AC use for a sustainable energy sector, even during future climatic emergencies .

Can women's 3E index impede short birth interval? evidence from Bangladesh Demographic and Health Survey, 2017-18

BACKGROUND

Women's empowerment, education, and economic status are jointly introduced as women's 3E. A number of studies found the significant association of these three variables with maternal health outcomes, but no studies, to the best of knowledge, have been found to justify the joint influence of women's 3E on the birth interval. As several studies have revealed that the short birth interval increases the risk of adverse maternal, perinatal, and infant outcomes and it is also responsible for increasing the country's population size, more research is needed on the birth interval. Therefore, the present study aimed to investigate the influence of women's 3E on the short birth interval after controlling the other selected covariates.

METHODS

Data from the Bangladesh Demographic and Health Survey (BDHS), 2017-18 have been used to serve the purpose of the study. To measure the birth interval, at least two live births for non-pregnant mothers and at least one live birth for currently pregnant mothers born in the 5 years before the survey were included in the study. The Chi-Square test was applied to know the unadjusted association of the selected covariates including women's 3E with the short birth interval. In order to find out the adjusted association of women's 3E with the short birth interval, sequential binary logistic regression models have been used.

RESULTS

The study found that about 23% of births in Bangladesh were born in a short birth interval. The likelihood of subsequent births of women decreases with an increase in the score of women's 3E before or after controlling the characteristics of women, child, and households. The results of the final model show that mothers with the coverage of 50% - 75%, 75% - 100%, and full coverage (100%) in 3E have a 23%, 41%, and 42% lower odds of having short birth interval compared to mothers with coverage of below 50% in 3E, respectively.

CONCLUSION AND RECOMMENDATION

Bangladesh still lags behind in meeting the minimum requirements for inter-birth intervals set by the World Health Organization. The study has shown that the 3E in women can contribute in prolonging the duration of subsequent births in Bangladesh. Policy-making interventions are needed to raise awareness among uneducated, under-empowered and economically poor reproductive women through family planning and fertility control programs so that the country can achieve the desired fertility rate.

Gender inequality in early initiation of breastfeeding in Bangladesh: a trend analysis

Background

Early initiation of breastfeeding within 1 hour after birth is essential for newborns, because it reduces risk of neonatal mortality and hypothermia to a great extent and also helps in preventing the long-term chronic diseases and in increasing energy and immunity to newborn. In order to reach the ‘very good state’ of timely or early initiation of breastfeeding recommended by WHO, Bangladesh needs to increase the current rate of 51.24 to 100%. An attempt has been made in this study to examine how the early breastfeeding practice changes among male and female children with time controlling the factors associated with this practice.

Methods

Data from last four consecutive Bangladesh Demographic and Health Surveys (BDHS) have been used in the study. The participants were included whose child born within the last 5 years preceding the surveys of 2004, 2007 and 2011, and within the last 3 years preceding the survey of 2014 in the study and the respective selected participants were 5145, 4765, 7099 and 4370. To conduct the trend analysis, the descriptive statistics of selected variables along with prevalence of early initiation of breastfeeding have been computed by different years and a multiple logistic regression model has been fitted to the pooled dataset of 2004–2014 considering survey years as time.

Results

Rate of early initiation of breastfeeding increased as time progressed and it was faster for female child compared to male child. For example, female children were significantly 10 and 6% less likely to be initiated early than their counterparts in 2004 and 2007, respectively; whereas after 2007 both male and female children were equally treated for breastfeeding practice. It was also found that rate of early initiation significantly increased for one unit increased in survey year and this increasing rate was higher for female child compared to male child. For example, for one unit of increased in survey year, the early initiation of breastfeeding increased by 60% for male child and by 67% for female child. Besides, survey time, gender, education of parents, wanted index child, mode of delivery, antenatal care visits, wealth index, exposure to media and division were found to have potential influence on early initiation of breastfeeding.

Conclusion

Demographic and health surveys conducted in Bangladesh since 2011 have shown no evidence of gender discrimination regarding timely initiation of breastfeeding. In order to achieve the target rate of early initiation of breastfeeding recommended by WHO, it requires to take effective intervention regarding maternal and child health education.

Association of biomass fuel smoke with respiratory symptoms among children under 5 years of age in urban areas: results from Bangladesh Urban Health Survey, 2013

BACKGROUND

Little is known regarding the effect of exposure to biomass fuel smoke inhalation on respiratory symptoms in the Bangladeshi population which is a major health hazard in most of the developing countries. This study aims to explore the association between respiratory symptoms and biomass fuel smoke exposure among children under 5 years of age.

METHODS

Data were extracted from the Bangladesh Urban Health Survey conducted in 2013. A total of 10,575 mothers with at least one surviving children were selected. Respiratory symptoms among children under 5 years of age were considered as the primary outcome. Sequential multiple logistic regression models were used to observe the association between respiratory symptoms and biomass fuel smoke exposure adjusting the effect of residential factors and mother and child characteristics.

RESULTS

Around 40% of the mothers exclusively used biomass fuel irrespective of the kitchen location and 54% of them were habituated in indoor cooking. The prevalence of respiratory symptoms of under-five children among in-house and outdoor biomass fuel users was 23.0% and 21.9%, respectively. Results of fitted multiple logistic regression models showed that the odds of having respiratory symptoms among children under 5 years of age were increased due to in-house biomass fuel use [OR = 1.18; 95% CI, 1.04-1.36] compared with the non-biomass user. An increased risk of respiratory symptoms was also significantly associated with mother's birth complication [OR = 1.51; 95% CI, 1.36-1.67], non-government organization (NGO) membership of mothers [OR = 1.32; 95% CI, 1.16-1.51], age of the child (6-23m) [OR = 1.29; 95% CI, 1.10-1.52], and nutritional status (stunting) [OR = 1.18; 95% CI, 1.06-1.31].

CONCLUSION

This study found the use of in-house biomass fuel as a significant risk factor associated with respiratory symptoms of children under 5 years of age. More longitudinal studies should be designed to establish a causal relationship between HAP (household air pollution) and respiratory symptoms among children with more direct measures of HAP and clinical procedure.

The Cytotoxic Necrotizing Factor of Yersinia pseudotuberculosis (CNFy) is Carried on Extracellular Membrane Vesicles to Host Cells

In this study we show Yersinia pseudotuberculosis secretes membrane vesicles (MVs) that contain different proteins and virulence factors depending on the strain. Although MVs from Y. pseudotuberculosis YPIII and ATCC 29833 had many proteins in common (68.8% of all the proteins identified), those located in the outer membrane fraction differed significantly. For instance, the MVs from Y. pseudotuberculosis YPIII harbored numerous Yersinia outer proteins (Yops) while they were absent in the ATCC 29833 MVs. Another virulence factor found solely in the YPIII MVs was the cytotoxic necrotizing factor (CNFy), a toxin that leads to multinucleation of host cells. The ability of YPIII MVs to transport this toxin and its activity to host cells was verified using HeLa cells, which responded in a dose-dependent manner; nearly 70% of the culture was multinucleated after addition of 5 µg/ml of the purified YPIII MVs. In contrast, less than 10% were multinucleated when the ATCC 29833 MVs were added. Semi-quantification of CNFy within the YPIII MVs found this toxin is present at concentrations of 5 ~ 10 ng per µg of total MV protein, a concentration that accounts for the cellular responses seen.

Fine and Gray competing risk regression model to study the cause-specific under-five child mortality in Bangladesh

Background

The cause-specific under-five mortality of Bangladesh has been studied by fitting cumulative incidence function (CIF) based Fine and Gray competing risk regression model (1999). For the purpose of analysis, Bangladesh Demographic and Health Survey (BDHS), 2011 data set was used.

Methods

Three types of mode of mortality for the under-five children are considered. These are disease, non-disease and other causes. Product-Limit survival probabilities for the under-five child mortality with log-rank test were used to select a set of covariates for the regression model. The covariates found to have significant association in bivariate analysis were only considered in the regression analysis.

Results

Potential determinants of under-five child mortality due to disease is size of child at birth, while gender of child, NGO (non-government organization) membership of mother, mother’s education level, and size of child at birth are due to non-disease and age of mother at birth, NGO membership of mother, and mother’s education level are for the mortality due to other causes.

Conclusion

Female participation in the education programs needs to be increased because of the improvement of child health and government should arrange family and social awareness programs as well as health related programs for women so that they are aware of their child health.

Cholera Toxin Production Induced upon Anaerobic Respiration is Suppressed by Glucose Fermentation in Vibrio cholerae

The causative agent of pandemic cholera, Vibrio cholerae, infects the anaerobic environment of the human intestine. Production of cholera toxin (CT), a major virulence factor of V. cholerae, is highly induced during anaerobic respiration with trimethylamine N-oxide (TMAO) as an alternative electron acceptor. However, the molecular mechanism of TMAO-stimulated CT production is not fully understood. Herein, we reveal that CT production during anaerobic TMAO respiration is affected by glucose fermentation. When the seventh pandemic V. cholerae O1 strain N16961 was grown with TMAO and additional glucose, CT production was markedly reduced. Furthermore, an N16961 Δcrp mutant, devoid of cyclic AMP receptor protein (CRP), was defective in CT production during growth by anaerobic TMAO respiration, further suggesting a role of glucose metabolism in regulating TMAO-mediated CT production. TMAO reductase activity was noticeably decreased when grown together with glucose or by mutation of the crp gene. A CRP binding region was identified in the promoter region of the torD gene, which encodes a structural subunit of the TMAO reductase. Gel shift assays further confirmed the binding of purified CRP to the torD promoter sequence. Together, our results suggest that the bacterial ability to respire using TMAO is controlled by CRP, whose activity is dependent on glucose availability. Our results reveal a novel mechanism for the regulation of major virulence factor production by V. cholerae under anaerobic growth conditions.

Log-Logistic Proportional Odds Model for Analyzing Infant Mortality in Bangladesh

Log-logistic parametric survival regression model has been used to find out the potential determinants of infant mortality in Bangladesh using the data extracted from Bangladesh Demographic and Health Survey, 2011. First, nonparametric product-limit approach has been used to examine the unadjusted association between infant mortality and covariate of interest. It is found that maternal education, membership of nongovernmental organizations, age of mother at birth, sex of child, size of child at birth, and place of delivery play an important role in reducing the infant mortality, adjusting relevant covariates.

Investigating the Responses of Human Epithelial Cells to Predatory Bacteria

One beguiling alternative to antibiotics for treating multi-drug resistant infections are Bdellovibrio-and-like-organisms (BALOs), predatory bacteria known to attack human pathogens. Consequently, in this study, the responses from four cell lines (three human and one mouse) were characterized during an exposure to different predatory bacteria, Bdellovibrio bacteriovorus HD100, Bacteriovorus BY1 and Bacteriovorax stolpii EB1. TNF-α levels were induced in Raw 264.7 mouse macrophage cultures with each predator, but paled in comparison to those obtained with E. coli. This was true even though the latter strain was added at an 11.1-fold lower concentration (p < 0.01). Likewise, E. coli led to a significant (54%) loss in the Raw 264.7 murine macrophage viability while the predatory strains had no impact. Tests with various epithelial cells, including NuLi-1 airway, Caco2, HT29 and T84 colorectal cells, gave similar results, with E. coli inducing IL-8 production. The viabilities of the NuLi-1 and Caco-2 cells were slightly reduced (8%) when exposed to the predators, while T84 viability remained steady. In no cases did the predatory bacteria induce actin rearrangement. These results clearly demonstrate the gentle natures of predatory bacteria and their impacts on human cells.

A determinant-based criterion for working correlation structure selection in generalized estimating equations

In generalized estimating equations (GEE), the correlation between the repeated observations on a subject is specified with a working correlation matrix. Correct specification of the working correlation structure ensures efficient estimators of the regression coefficients. Among the criteria used, in practice, for selecting working correlation structure, Rotnitzky-Jewell, Quasi Information Criterion (QIC) and Correlation Information Criterion (CIC) are based on the fact that if the assumed working correlation structure is correct then the model-based (naive) and the sandwich (robust) covariance estimators of the regression coefficient estimators should be close to each other. The sandwich covariance estimator, used in defining the Rotnitzky-Jewell, QIC and CIC criteria, is biased downward and has a larger variability than the corresponding model-based covariance estimator. Motivated by this fact, a new criterion is proposed in this paper based on the bias-corrected sandwich covariance estimator for selecting an appropriate working correlation structure in GEE. A comparison of the proposed and the competing criteria is shown using simulation studies with correlated binary responses. The results revealed that the proposed criterion generally performs better than the competing criteria. An example of selecting the appropriate working correlation structure has also been shown using the data from Madras Schizophrenia Study.

On Selecting Relevant Covariates and Correlation Structure in Longitudinal Binary Model: Analyzing Impact of Height on Type II Diabetes

To examine the impact of height on the occurrence of Type II diabetes, a longitudinal binary data set has been analyzed.  The relevant covariates were selected by using quasi-likelihood based information criteria (QIC) and correlation information criteria (CIC) was used to select the correlation structure appropriate for the repeated binary responses.  The consistent and efficient estimates of regression parameters were obtained from the generalized estimating equations (GEE).  With the selected covariates height, education level, gender and unstructured correlation structure, it is found that there exists a statistically significant inverse relationship between height of an individual and the development of Type II diabetes. Risk Ratios for different covariates along with standard errors and confidence intervals are also given.   

(p)ppGpp, a Small Nucleotide Regulator, Directs the Metabolic Fate of Glucose in Vibrio cholerae

When V. cholerae encounters nutritional stress, it activates (p)ppGpp-mediated stringent response. The genes relA and relV are involved in the production of (p)ppGpp, whereas the spoT gene encodes an enzyme that hydrolyzes it. Herein, we show that the bacterial capability to produce (p)ppGpp plays an essential role in glucose metabolism. The V. cholerae mutants defective in (p)ppGpp production (i.e. ΔrelAΔrelV and ΔrelAΔrelVΔspoT mutants) lost their viability because of uncontrolled production of organic acids, when grown with extra glucose. In contrast, the ΔrelAΔspoT mutant, a (p)ppGpp overproducer strain, exhibited better growth in the presence of the same glucose concentration. An RNA sequencing analysis demonstrated that transcriptions of genes consisting of an operon for acetoin biosynthesis were markedly elevated in N16961, a seventh pandemic O1 strain, but not in its (p)ppGpp(0) mutant during glucose-stimulated growth. Transposon insertion in acetoin biosynthesis gene cluster resulted in glucose-induced loss of viability of the ΔrelAΔspoT mutant, further suggesting the crucial role of acetoin production in balanced growth under glucose-rich environments. Additional deletion of the aphA gene, encoding a negative regulator for acetoin production, failed to rescue the (p)ppGpp(0) mutant from the defective glucose-mediated growth, suggesting that (p)ppGpp-mediated acetoin production occurs independent of the presence of AphA. Overall, our results reveal that (p)ppGpp, in addition to its well known role as a stringent response mediator, positively regulates acetoin production that contributes to the successful glucose metabolism and consequently the proliferation of V. cholerae cells under a glucose-rich environment, a condition that may mimic the human intestine.

"Impact of stature on non-communicable diseases: evidence based on Bangladesh Demographic and Health Survey, 2011 data"

BACKGROUND

In this paper, an attempt has been made to explore the relationship between height and occurrence of the non-communicable diseases such as diabetes and hypertension.

METHODS

For the purpose of analysis, Bangladesh Demographic and Health Survey (BDHS), 2011 data was used. Bivariate analysis along with a Chi-square test was performed to examine association between height and diseases. To measure the impact of stature on diabetes and hypertension, three different logistic regression models (Model I: considering only quartiles of height, Model II: covariates of model I along with demographic variables and Model III: covariates of model II along with clinical variable) were considered.

RESULTS

Occurrence of diabetes and hypertension was found to be inversely related with the height of participants. This inverse association was statistically significant for all three models. After controlling the demographic and clinical variables simultaneously, the odds ratio for highest quartile compared to the lowest quartile was 0.82 with 95% confidence interval (0.69, 0.98) for diabetes; whereas it was 0.72 with 95% confidence interval (0.55, 0.95) for hypertension.

CONCLUSIONS

Findings of this paper indicate that persons with shorter stature are substantially more likely to develop diabetes as well as hypertension. The occurrence of non-communicable diseases like diabetes and hypertension can be reduced by controlling genetic and non-genetic (early-life and childhood) factors that may influence the height.

Consequences of intimate partner violence against women on under-five child mortality in Bangladesh

It is well established that intimate partner violence (IPV) against women adversely affects maternal morbidity and mortality. But a limited number of studies were found in the literature regarding the association between IPV and under-five child mortality. In this article, using Bangladesh Demographic and Health Survey (BDHS) 2007 data, we examined the effect of IPV on under-five child mortality. A product-limit approach was used for bivariate survival analysis, and Cox proportional hazard multiple regression models were used to investigate the effect of IPV controlling potential confounders. In bivariate analysis, the variables exposure to IPV, mother's age at birth, mother's education, residence type, division, number of children, wealth index, occupation, access to media, and decision autonomy were found to be potential risk factors for child mortality. Results indicated that women exposed to IPV were more likely to experience under-five child mortality compared with women not exposed. The unadjusted hazard ratio for IPV was 1.21 (95% confidence interval [CI] = [1.09, 1.35]) with p value < .01, whereas it was 1.16 (95% CI = [1.04, 1.29]) with p value < .01 and 1.13 (95% CI = [1.01, 1.26]) with p value < .05 in two adjusted models. These results implied that IPV against women is a problem not only for women but also for their children's survival.

Cholera toxin production during anaerobic trimethylamine N-oxide respiration is mediated by stringent response in Vibrio cholerae

As a facultative anaerobe, Vibrio cholerae can grow by anaerobic respiration. Production of cholera toxin (CT), a major virulence factor of V. cholerae, is highly promoted during anaerobic growth using trimethylamine N-oxide (TMAO) as an alternative electron acceptor. Here, we investigated the molecular mechanisms of TMAO-stimulated CT production and uncovered the crucial involvement of stringent response in this process. V. cholerae 7th pandemic strain N16961 produced a significantly elevated level of ppGpp, the bacterial stringent response alarmone, during anaerobic TMAO respiration. Bacterial viability was impaired, and DNA replication was also affected under the same growth condition, further suggesting that stringent response is induced. A ΔrelA ΔspoT ppGpp overproducer strain produced an enhanced level of CT, whereas anaerobic growth via TMAO respiration was severely inhibited. In contrast, a ppGpp-null strain (ΔrelA ΔspoT ΔrelV) grew substantially better, but produced no CT, suggesting that CT production and bacterial growth are inversely regulated in response to ppGpp accumulation. Bacterial capability to produce CT was completely lost when the dksA gene, which encodes a protein that works cooperatively with ppGpp, was deleted. In the ΔdksA mutant, stringent response growth inhibition was alleviated, further supporting the inverse regulation of CT production and anaerobic growth. In vivo virulence of ΔrelA ΔspoT ΔrelV or ΔdksA mutants was significantly attenuated. The ΔrelA ΔspoT mutant maintained virulence when infected with exogenous TMAO despite its defective growth. Together, our results reveal that stringent response is activated under TMAO-stimulated anaerobic growth, and it regulates CT production in a growth-dependent manner in V. cholerae.

Activation of cholera toxin production by anaerobic respiration of trimethylamine N-oxide in Vibrio cholerae

Vibrio cholerae is a gram-negative bacterium that causes cholera. Although the pathogenesis caused by this deadly pathogen takes place in the intestine, commonly thought to be anaerobic, anaerobiosis-induced virulence regulations are not fully elucidated. Anerobic growth of the V. cholerae strain, N16961, was promoted when trimethylamine N-oxide (TMAO) was used as an alternative electron acceptor. Strikingly, cholera toxin (CT) production was markedly induced during anaerobic TMAO respiration. N16961 mutants unable to metabolize TMAO were incapable of producing CT, suggesting a mechanistic link between anaerobic TMAO respiration and CT production. TMAO reductase is transported to the periplasm via the twin arginine transport (TAT) system. A similar defect in both anaerobic TMAO respiration and CT production was also observed in a N16961 TAT mutant. In contrast, the abilities to grow on TMAO and to produce CT were not affected in a mutant of the general secretion pathway. This suggests that V. cholerae may utilize the TAT system to secrete CT during TMAO respiration. During anaerobic growth with TMAO, N16961 cells exhibit green fluorescence when stained with 2',7'-dichlorofluorescein diacetate, a specific dye for reactive oxygen species (ROS). Furthermore, CT production was decreased in the presence of an ROS scavenger suggesting a positive role of ROS in regulating CT production. When TMAO was co-administered to infant mice infected with N16961, the mice exhibited more severe pathogenic symptoms. Together, our results reveal a novel anaerobic growth condition that stimulates V. cholerae to produce its major virulence factor.

Comparative analysis of serum manganese, zinc, calcium, copper and magnesium level in panic disorder patients

The purpose of the study was to determine the serum concentration of trace elements of panic disorder patients and to find out the relationship between trace element levels and nutritional status or socio-economic factors. The study was conducted among 54 panic disorder patients and 52 healthy volunteers. Patients were recruited from Bangabandhu Sheikh Mujib Medical University by random sampling. Serum trace element concentrations were determined by flame atomic absorption spectroscopy (for Mg, Zn, Ca, and Cu) as well as graphite furnace (for Mn). Data were analyzed by independent t test, Pearson's correlation analysis, regression analysis, and ANOVA. The serum concentration of Mn, Zn, Ca, Cu, and Mg in panic disorder patients were 0.37 +/- 0.30, 0.67 +/- 0.20, 99.91 +/- 15.15, 0.83 +/- 0.23, and 21.14 +/- 3.72 mg/L, while those were 0.4163 +/- 0.2527, 0.86 +/- 0.3, 106.6073 +/- 18.6531, 0.8514 +/- 0.3646, and 21.37 +/- 2.03 mg/L in control subjects, respectively. The serum concentration of Zn decreased significantly (p = 0.001) in patient group. But the differences of the concentration of Mn, Ca, Cu, and Mg between patient and control group were not significant (p = 0.522, p = 0.065, p = 0.800, and p = 0.712, respectively). Socio-economic data reveal that most of the patients were very poor and middle aged. Mean BMIs of the control group (23.74 +/- 2.71 kg/m(2)) and the patient group (22.62 +/- 3.74 kg/m(2)) were within the normal range (18.5-25.0 kg/m(2)). There was no significant relationship between serum zinc level and BMI of patients (r = 0.038; p = 0.809). So the decreased level of serum zinc in panic disorder patients was not because of other reasons, but rather it may provide a prognostic tool for the diagnosis and treatment of this disease.

Immunoglobulin levels of vitiligo patients

In the present study, the serum immunoglobulin profiles of vitiligo patients were compared with that of cohort control and evaluated the correlation between immunoglobulin level with their socioeconomic factors and nutritional status. Thirty vitiligo patients were recruited randomly from the Department of Dermatology and Venereology, Bangabandhu Sheikh Mujib Medical University Hospital, Dhaka, Bangladesh for this study. Thirty healthy individuals as control group matched by age, sex, education and socioeconomic factors to the patient group were selected. Serum immunoglobulin concentrations were determined by turbidimetry method using immunoglobulin kit. The concentration of IgG and IgA decreased significantly (P<0.05), but the change of IgM was not significant. Socioeconomic data revealed that most of the patients were young and female. Moreover statistical analysis revealed that there was significant correlation between immunoglobulin (IgG and IgA only) concentrations and BMI and number of depigmented patches with IgG concentrations. Finally it can be concluded that the change of serum immunoglobulin concentration in vitiligo patients could be due to the disease condition as pathomechanism suggested the aberrations in cellular immunity. But study with larger number of population is required for further evaluation of the relationship between the immune response and disease state to confirm these findings.

Factors associated with delivery complications in rural Bangladesh

OBJECTIVES

There are only a few studies on maternal morbidity, delivery complications and maternal mortality in Bangladesh. This study analyzes data from a follow-up study conducted by the Bangladesh Institute of Research for Health and Technologies (BIRPERHT) on maternal morbidity in rural Bangladesh in 1993.

METHODS

A total of 1020 pregnant women were interviewed in the follow-up component of the study. The survey collected information on socioeconomic and demographic characteristics, pregnancy-related care and practice, morbidity during the period of follow-up as well as in the past, information concerning complications at the time of delivery and during the postpartum period. For the purpose of this study, we selected 993 pregnant women with at least one antenatal follow-up. Both bivariate and multivariate analyses were conducted to identify the potential risk factors for complication during delivery and duration of labor.

RESULTS AND CONCLUSIONS

It appears that complications during the antenatal period can result in various complications at the time of delivery. Some of the important findings are: hemorrhage during the antenatal period increases the risk of excessive hemorrhage during delivery, the risk of obstructed labor increases significantly if abdominal pain is observed during the antenatal period, prolonged labor appears to be significantly higher for the first pregnancy, and pregnancies suffering from abdominal pain during pregnancy tend to have a higher risk of prolonged labor during delivery. The duration of labor appears to be negatively associated with the number of previous pregnancies, being longest for the first pregnancies. The duration of labor pain is significantly higher for the respondents who reported the index pregnancy as undesired, and, similarly, the respondents who were reported to be involved with gainful employment would have a shorter duration of labor pain than those having no involvement with gainful employment.

Zinc, manganese, calcium, copper, and cadmium level in scalp hair samples of schizophrenic patients

The purpose of the study was to determine the concentration of trace elements present in scalp hair sample of schizophrenic patients and to find out the relationship between trace elements level and nutritional status or socioeconomic factors. The study was conducted among 30 schizophrenic male patients and 30 healthy male volunteers. Patients were recruited from Bangabandhu Sheikh Mujib Medical University by random sampling. Hair trace element concentrations were determined by flame atomic absorption spectroscopy and analyzed by independent t test, Pearson's correlation analysis, regression analysis, and analysis of variance (ANOVA). Mn, Zn, Ca, Cu, and Cd concentrations of schizophrenic patients were 3.8 +/- 2.31 microg/gm, 171.6 +/- 59.04 microg/gm, 396.23 +/- 157.83 microg/gm, 15.40 +/- 5.68 microg/gm, and 1.14 +/- 0.89 microg/gm of hair sample, while those of control subjects were 4.4 +/- 2.32 microg/gm, 199.16 +/- 27.85 microg/gm, 620.9 +/- 181.55 microg/gm, 12.23 +/- 4.56 microg/gm, and 0.47 +/- 0.32 microg/gm of hair sample, respectively. The hair concentration of Zn and Ca decreased significantly (p = 0.024; p = 0.000, respectively) and the concentration of Cu and Cd increased significantly (p = 0.021; p = 0.000, respectively) in schizophrenic patients while the concentration of Mn (p = 0.321) remain unchanged. Socioeconomic data reveals that most of the patients were poor, middle-aged and divorced. Mean body mass indices (BMIs) of the control group (22.26 +/- 1.91 kg/m(2)) and the patient group (20.42 +/- 3.16 kg/m(2)) were within the normal range (18.5-25.0 kg/m(2)). Pearson's correlation analysis suggested that only Ca concentration of patients had a significant positive correlation with the BMI (r = 0.597; p = 0.000) which was further justified from the regression analysis (R (2) = 44%; t = 3.59; p = 0.002) and one-way ANOVA test (F = 3.62; p = 0.015). A significant decrease in the hair concentration of Zn and Ca as well as a significant increase in the hair concentration of Cu and Cd in schizophrenic patients than that of its control group was observed which may provide prognostic tool for the diagnosis and treatment of this disease. However, further work with larger population is suggested to examine the exact correlation between trace element level and the degree of disorder.

Determinants of the use of maternal health services in rural Bangladesh

Utilization of health services is a complex behavioral phenomenon. Empirical studies of preventive and curative services have often found that use of health services is related to the availability, quality and cost of services, as well as to social structure, health beliefs and personal characteristics of the users. In this paper an attempt is made to examine the factors associated with the use of maternal health care services in Bangladesh on the basis of data from a survey of maternal morbidity in Bangladesh, conducted by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERHT). The results from both the bivariate and multivariate analyses confirmed the importance of mother's education in explaining the utilization of health care services. Female education retains a net effect on maternal health service use, independent of other women's background characteristics, household's socioeconomic status and access to healthcare services. The strong influence of mother's education on the utilization of health care services is consistent with findings from other studies. Women whose husbands are involved in business/services also positively influenced the utilization of modern health care services. However, the study results are inconclusive with respect to the influence of other predisposing and enabling factors, such as women's age, number of previous pregnancies and access to health facilities. Multivariate logistic regression estimates do not show any significant impact of these factors on the use of maternal health care. The influence of severity of disease condition in explaining the utilization of maternal health care appears to be significant. Multivariate analysis indicate that women having had a life-threatening condition are little over two times more likely to seek care from a doctor or nurse to treat their maternal morbidities.

A multistage model for maternal morbidity during antenatal, delivery and postpartum periods

There is acute dearth of information regarding factors affecting complications during different stages of childbearing in Bangladesh. This study employs a multistage model that involves transitions at different stages to complications. The proposed model appears to display more meaningful explanation concerning the impact of different factors on the incidence of complications taking into account types of transitions. Two alternative models are also presented in this paper in order to demonstrate possible simplifications of the proposed model. This study uses data from a prospective survey on Maternal Morbidity in Bangladesh. The survey was conducted during the period 11 1992-12 1993. A total of 1020 pregnant women were followed during pregnancy, delivery and 90 days after delivery. This study reveals some very important findings regarding the potential impact of antenatal visits, economic status, whether the index pregnancy was desired or not and number of pregnancies prior to the index pregnancy. It is observed that slightly more than 50 per cent of the women suffer from at least one of the major complications (haemorrhage, excessive vomiting, oedema and fits/convulsion) during pregnancy. It is noteworthy that if a woman suffers from one or more of the major complications during pregnancy, then it is more likely that she will suffer from complications during delivery. This study reveals that the women who suffer from one or more of the major complications during pregnancy are expected to have a substantially higher risk of suffering from complications during postpartum period, irrespective of no complications or complications during delivery. Generally speaking, higher economic status can reduce the complications at the postpartum stage, although women belonging to higher economic status may suffer from complications during pregnancy and delivery at a higher rate. It is surprising that antenatal visit is positively associated with incidence of complications during pregnancy and delivery, but antenatal visit reduces complications at the postpartum stage.

Analysis of ante-partum maternal morbidity in rural Bangladesh

This paper presents the results of a prospective study of maternal morbidity during the ante-partum period in rural areas of Bangladesh. The data came from a survey of Maternal Morbidity in Bangladesh, conducted by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERHT) during the period from November 1992 to December 1993. Since then no such national level survey has been conducted in Bangladesh. This paper employs multiple-decrement life table technique, a convenient way of analysing the risks of different types of disease conditions that women experience during the antenatal period for different age categories. The high-risk complications such as ante-partum haemorrhage, excessive vomiting, fits/convulsion and oedema were considered in this study. In this study a cause specific model was applied to explore the differences in the risks exerted at different ages of reproductive life attributable to some selected complications of pregnancy. The results of this study indicate that women of age 25-29 years are less susceptible to most of the selected life-threatening and high-risk complications during pregnancy such as haemorrhage, fits/convulsion and oedema. However, younger women (age < 25 years) are more likely to have excessive vomiting during pregnancy, and older women (age > or = 30 years) are at greater risk of haemorrhage, fits/convulsion and oedema.

The differentials and determinants of perinatal mortality in rural Bangladesh

OBJECTIVE

In Bangladesh, the perinatal mortality is very high. This study examined the differentials and determinants of perinatal mortality in rural Bangladesh.

METHODS

The study was based on the prospective data on maternal morbidity collected by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERHT). This prospective study was conducted during the period November 1992 to December 1993. In this study, the factors associated with perinatal deaths were examined, employing differential and multivariate analyses.

RESULTS

It was found that assisted delivery caused higher risks of stillbirth and death among live births during the first week of life. It was also observed that five or more pregnancies, prior to the index pregnancy, were positively associated with perinatal death.

CONCLUSION

If the delivery is assisted or there are complications in delivery, then it is likely that the incidence of perinatal mortality will increase sharply. If the newborn baby was given colostrum, then perinatal mortality decreased to a great extent.

Utilisation of postnatal care in Bangladesh: evidence from a longitudinal study

Utilisation of health services is a complex behavioural phenomenon. Empirical studies of preventive and curative services in Bangladesh have often showed that the use of health services is related to the availability, quality and cost of services, as well as to social structure, health beliefs and personal characteristics of the users. The present paper attempts to examine factors associated with the utilisation of healthcare services during the postnatal period in Bangladesh by using prospective data from a survey on maternal morbidity in Bangladesh, conducted by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERT). Both bivariate and multivariate analyses of the data confirmed that the mother's age at marriage had a significant and positive impact on the utilisation of quality healthcare services. The husband's occupation also showed a strong impact on healthcare utilisation, indicating higher use of quality care for postpartum morbidity by wives of business and service workers. The bivariate analysis showed that the number of pregnancies prior to the index pregnancy and desired pregnancies are significantly associated with the utilisation of postpartum healthcare. However, the results of this study were inconclusive on the influence of other predisposing and enabling factors, such as maternal education, the number of previous pregnancies, the occupation of the husband, antenatal care visits during pregnancy and access to health facilities. Multivariate logistic regression estimates did not show any significant impact of these factors on the use of maternal healthcare.

Acute myelomonocytic leukemia presenting as a primary cutaneous lymphoma of true histiocytes

Malignant histiocytic and monocytic infiltrates of the skin are seen in true histiocytic lymphomas, in malignant histiocytosis, and in monocytic leukemias. Occasionally such cutaneous lesions constitute the presenting manifestation of the underlying malignancy. We report here a patient whose first manifestation of acute myelomonocytic leukemia was a malignant histiocytic infiltrate in the skin. Cytochemical and electron microscopic data confirmed the histiocytic nature of the skin tumor, and cytochemical data documented the myelomonocytic nature of the subsequent leukemia. Purely histiocytic skin tumors do not often presage myelomonocytic leukemias, although they have developed into monocytic leukemias, and monocytic leukemias have been transformed into myelomonocytic leukemias.