Status of Serum Magnesium, Serum Zinc and C-reactive Protein in Hospitalized Patients with Chronic Kidney Disease in Mymensingh Locality

Chronic Kidney Disease (CKD) is an important public health issue, with a leading cause of death and disability around the world. This cross-sectional study was conducted from January 2021 to December 2021 in the department of Biochemistry in Mymensingh Medical College in cooperation with the Department of Nephrology, Mymensingh Medical College Hospital, Mymensingh, Bangladesh. The study was carried out to evaluate the status of serum magnesium, zinc and CRP in patients with CKD not on dialysis for monitoring the disease progression. For this purpose, 110 subjects were included, where 55 Hospitalized CKD patients were considered as Group I and 55 normal healthy individuals as Group II. Study subjects were selected on the basis of inclusion and exclusion criteria by purposive and convenient sampling method. Serum magnesium and zinc were determined by colorimetric method while CRP was measured by CRP-Latex Test (Slide Agglutination Test) from each sample. SPSS windows package, version 21.0 was used to perform the statistical analysis. Statistical significance of difference between Group I and Group II were evaluated by using student's unpaired 't'-test and the significance was defined as p<0.05. Correlation was done by using Pearson's correlation coefficient test. Mean age of Group I was 52.65±4.93 and Group II was 51.15±6.32 years. P-value was 0.165 which is statistically insignificant. The mean ±SD of BMI was 24.46±1.84 Kg/m² for Group I and 24.50±1.05 Kg/m² for Group II. P-value was 0.886 which is statistically insignificant. Among the study groups the mean serum magnesium were 2.25±0.17 and 1.95±0.05mg/dl, zinc were 88.64±9.21 and 102.11±12.93μg/dl, CRP were 24.00±16.73 and <6.0±0.00mg/L in Group I and Group II respectively. Analysis showed that, the mean serum magnesium and CRP were significantly increased while serum zinc was significantly decreased in CKD patients in comparison to that of healthy individual. There was negative correlation between serum zinc and CRP. This study was done within the context of the facilities available to us.

Association of Serum Vitamin D level with Asthenozoospermic Male

Although vitamin D deficiency is one of the most common health problems throughout the world, conflicting information exists on the potential association between serum vitamin D levels and semen quality. Currently available data identifies that vitamin D has a vital role in reproductive process as it affects sperm motility. This study was done with the rationality to evaluate the association between serum vitamin D levels with asthenozoospermic males. This cross-sectional analytic study was conducted on 314 men who attended the Department of Reproductive Endocrinology and Infertility, Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh July 2018 to June 2019. Considering the inclusion and exclusion criteria all participants were categorized into two groups; Group I included 157 asthenozoospermic male and Group II included 157 normozoospermic male according to World Health Organization 'strict' criteria 2010. Participants completed the questionnaires after they had agreed on a informed consent. Blood and semen samples were obtained for assessment and all data were adjusted for age, body mass index (BMI), total motility and progressive motility. Vitamin D levels were classified according to the Endocrine Society guideline. Statistical analyses were carried out by using the Statistical Package for Social Sciences version 22.0 for Windows (SPSS Inc., Chicago, Illinois, USA). The results showed that the mean vitamin D level was 16.63±5.54ng/ml in asthenozoospermic group and 19.83±5.33ng/ml in normozoospermic group. The mean vitamin D level was significantly (p<0.05) lower in asthenozoospermic group. It was noticed that 86.6% patients had vitamin D deficiency (≤20ng/ml) in asthenozoospermic group compared to 56.7% in the normozoospermic group. The study found that low vitamin D was associated with a fivefold increased risk of developing asthenozoospermia at 95% CI (2.74-8.99). Moreover, there was a positive significant correlation (r=0.285; p<0.001) between serum vitamin D level with total motility and progressive motility (r=0.232; p<0.001). Hence, the study suggests a significant association between asthenozoospermia and low vitamin D levels. However, clinical trials are warranted to further reinforce the findings.

A Morphometric Study of Glenoid Cavity of Scapula in Bangladeshi Population

This cross-sectional descriptive purposive study was conducted among 150 (70 right and 80 left) fully ossified dry human scapulae of Bangladeshi people from January 2019 to December 2019 in the Department of Anatomy, Mymensingh Medical College, Mymensingh. Shape of the glenoid cavity was observed as pear, oval or inverted comma shape. Morphometric parameters such as length and breadth of glenoid cavity were measured by digital Vernier slide calipers. In this study, 19.13% cases were found inverted comma shaped, 35.65% cases were oval and 45.22% cases were pear shaped. The mean±SD length of glenoid cavity was 37.5±3.61 mm and 36.19±3.68 mm on right and left sided scapulae respectively and mean±SD breadth was 23.6±2.73 mm on right and 23.42±2.75 mm on left side respectively. Mean±SD glenoid cavity index was 62.89±4.39 on right and 64.61±4.74 on left sided scapulae. Morphometric analysis of glenoid fossa of scapula might help clinicians in shoulder and its associated diseases.

Variation of Acromiocoracoid and Acromioglenoid Distance in Bangladeshi People

This cross-sectional descriptive purposive study was done on 150 (70 right and 80 left) fully ossified dry human scapulae of Bangladeshi people to find out the variation in length of acromiocoracoid and acromioglenoid distance. Sample collection was carried out in the Department of Anatomy, Mymensingh Medical College, Bangladesh from January to December 2019. Any kind of damaged or broken scapulae were excluded to maintain standard measurement. Length of these distances was measured with the help of digital Vernier slide calipers. The mean±SD acromiocoracoid distance were 35.8±4.64 mm and 36.32±5.55 mm on right and left sided scapulae respectively and the mean±SD acromioglenoid distance were 27.69±3.43 mm on right sided scapulae and 28.18±3.26 mm on left sided scapulae. These data are important to compare Bangladeshi scapulae to those from various other races that could contribute to demographic studies of shoulder disease probability and management in Bangladeshi population.

Study of Nutrient Foramina of Dry Adult Human Clavicle

As a modified long bone, the clavicle is most important bone for transmission of body weight from upper limb to the axial skeleton, for attachment of muscles and is a significant source of bone grafting. This descriptive cross-sectional study was conducted among 150 (65 right and 85 left) fully ossified dry human clavicle in Mymensingh Medical College, Mymensingh, Bangladesh from January 2020 to December 2020. Sample was collected by the help of nonrandom purposive sampling technique from Anatomy department of Mymensingh Medical College and Community Based Medical College, Bangladesh, Mymensingh. In this study, nutrient foramen was present in 86.67% (130) cases. On the right side, 87.69% (57) cases and on the left side, 85.88% (73) cases were found present. Out of 130 clavicles where nutrient foramen were present, 52.31% (68) nutrient foramina were on inferior surface, 46.92% (61) on posterior surface and 0.77% (1) on superior surface. On the right side, 49.12% (28) cases were found on inferior surface and 49.12% (28) were on posterior surface and remaining 1.75% (1) was on superior surface. On the left side, 54.79% (40) cases were found on inferior surface and 45.21% were on posterior surface whereas none was found on superior surface. Among the present 130 cases, 1 nutrient foramen was found in total 80% (104) cases and 2 in 20% (26) cases. In right side, the numbers of cases were 75.44% (43) for 1 and 24.56% (14) for 2 nutrient foramina. In left side, the number of cases of 1 was 83.56% (61) and 16.44% (12) for 2 foramina. The nutrient foraminal direction was 98.46% (128) towards acromial end and 1.54% (2) to sternal end. In the right side, the direction was 100% (57) towards acromial end. In the left side, the direction was 97.26% (71) towards acromial end and 2.74% (2) to sternal end. In the current study, the mean ±SD nutrient foramina of 65 clavicles of right side were 71.04±13.91 and 67.13±16.30 in 85 left sided clavicles. The purpose for undertaking this study was to obtain baseline data on nutrient foramen to help to predict the success rate and different surgical interventions regarding fractures and grafting.

Health System Strengthening Through Professional Midwives in Bangladesh: Best Practices, Challenges, and Successes

In 2008, a cadre of professional midwives was introduced in Bangladesh. Since then, 120 midwifery educational programs have been established. There are 2,556 midwives serving at 667 government health facilities, and there are more midwives working in nongovernmental organizations and the private sector. This case study documents the process of establishing a midwifery profession with distinct midwifery expertise in Bangladesh and aims to guide other low- and middle-income countries in best practices and challenges. We describe the national administrative groundwork for the profession's launch, roll-out of an education program aligned with the International Confederation of Midwives, national deployment, enabling environments in deployment, and the professional association. Bangladesh's professional midwives' roles in humanitarian response and the COVID-19 pandemic are also discussed. The first and final authors were closely involved in supporting the government's establishment of the profession, and their direct experience is drawn upon to contextualize the topics. In addition, the authors conducted a desk review of documents that supported the profession's integration into the health system and documented its results. Both routine program data and existing research studies were reviewed. Outcomes show that midwives are deployed to 95% of government subdistrict hospitals. About 50% of these hospitals are fully staffed with 4 midwives, and within the hospitals, midwives are in charge of 90% of the maternity wards and attend 75%-85% of the births. Since the midwives' deployment, significant quality improvement for most World Health Organization indicators has been found, along with increases in service utilization. The experience of establishing a new midwifery profession in Bangladesh shows that it is possible for a lower middle-income country to introduce a globally standard midwifery profession, distinct from nursing, to improve quality sexual, reproductive, maternal, newborn, and adolescent health services in both humanitarian and development settings.

Midwife-led pandemic telemedicine services for maternal health and gender-based violence screening in Bangladesh: an implementation research case study

BACKGROUND

The COVID-19 pandemic disrupted maternal and newborn health services in Bangladesh, exacerbating the large gaps in service utilization that existed prior to the pandemic. As part of its response, Bangladesh initiated remote antenatal and postnatal care telemedicine services led by midwives in 36 sub-district hospitals across five of Bangladesh's 64 districts. Gender-based violence screening and referral were integrated into the service to address a reported rise in violence following the country's pandemic lockdown.

METHODS

Mixed-methods implementation research was used to develop an intrinsic case study describing the design and implementation of the telemedicine program. Qualitative analysis comprised document review, key informant interviews, and focus group discussions. Quantitative analysis employed an interrupted time series analysis with segmented multi-variate regression to compare maternity care service use trends before and after implementation. Poisson regression analysis was used to examine the trend in number of gender-based violence remote screenings, sessions held, and cases identified.

RESULTS

A statistically significant change in trend for onsite antenatal and postpartum care as well as women seeking care at the hospital as a result of postpartum hemorrhage arising in the community was observed following the introduction of telemedicine. Facility births and cases of eclampsia appropriately identified and managed also had significant increases. In addition, over 6917 women were screened for GBV, 223 received counseling and 34 referrals were made, showing a statistically significant increase in frequency over time following the implementation of the telemedicine program. Challenges included that not all midwives adopted GBV screening, some women were reluctant to discuss GBV, there was an unanticipated need to introduce a patient visit scheduling system in all intervention hospitals, and many women were not reachable by phone due to lack of access or network coverage.

CONCLUSIONS

Maternal health and gender-based violence telemedicine led by midwives was an effective, low-cost intervention in Bangladesh for addressing pandemic and pre-pandemic gaps in service use. Other low and middle-income countries planning to implement remote maternal health interventions via midwives should consider whether a patient visit scheduling system needs to be introduced, as well as limitations around mobile phone access and connectivity. Future research should include care quality oversight and improvement, and a more well-informed strategy for facilitating effective GBV screening.

Correlation between Depth of Medial and Lateral Curvatures of Clavicle

Having the first bone to ossify clavicle is a bone of pectoral girdle. It is the only bony attachment between the trunk and upper limb. To obtain the precise data that is required to investigate the range in size and morphological features of the human clavicle, a study was undertaken on dry human clavicles which had been sourced from the Department of Anatomy. The purpose for undertaking this study was to obtain baseline data on the clavicular bow in the transverse plane. This cross-sectional descriptive study having some analytical components was done among 150 (65 right and 85 left) fully ossified dry clavicles in Mymensingh Medical College, Bangladesh from January 2020 to December 2020. Sample which met the inclusion criteria was collected through non random sampling technique, from Anatomy department of Mymensingh Medical College and Community Based Medical College Bangladesh. The parameters (the depth of medial and lateral curvatures) were measured with the help of rigid osteometry board and were expressed in millimeter. In the current study, the mean±SD depth of medial curvature of 65 clavicles of right side was 15.54±3.54mm and 15.45±3.24mm of 85 left clavicles. The mean±SD depth of lateral curvature of right side was 11.71±2.54mm and of left side was 9.21±2.31mm. Correlation was done in between depth of medial and lateral curvatures on both sides and the regression line showed positive correlation but these differences were statistically non-significant on both sides.

Status of Serum Calcium and Magnesium in Hospital Admitted Chronic Kidney Disease Patients in Mymensingh Locality of Bangladesh

The study was designed to evaluate the serum calcium and magnesium levels in hospitalized patients with Chronic Kidney Disease (CKD). This cross-sectional study was carried out in the Department of Biochemistry, Mymensingh Medical College (MMC), Bangladesh with the help of the Department of Nephrology, Mymensingh Medical College Hospital, Bangladesh from the period of January 2021 to December 2021. The subjects were selected on the basis of inclusion and exclusion criteria by purposive and convenient sampling method. A total of 110 subjects were included in this study. Among them, 55 were diagnosed CKD patients denoted as Group I and 55 were normal healthy individuals denoted as Group II. The subjects were briefed and written consents were taken. Under aseptic precaution 5.0ml of venous blood was collected from median cubital vein. Analyses were carried out in the Department of Biochemistry, Mymensingh Medical College and serum calcium and magnesium levels were measured. All values were expressed as Mean±SD. All statistical analysis was done by using SPSS (statistical package for social science) windows package version 21.0. Statistical significance of difference between Group I and Group II were evaluated by using Student's unpaired 't' test and the significance was defined as p<0.05. Correlation was done by using Pearson's correlation coefficient test. The mean±SD values of serum calcium were 8.15±0.54mg/dl and 9.80±0.50mg/dl and serum magnesium were 2.25±0.17mg/dl and 1.95±0.50mg/dl in Group I and Group II respectively. We found mean serum calcium was highly significantly (<0.001) decreased and serum magnesium was highly significantly increased (<0.001) in CKD patients in comparison to that of healthy individual.

Serum Albumin and C-reactive protein in Hospital Admitted Patients with Chronic Kidney Disease

Adequate knowledge about the causes of chronic kidney disease and their potential prevention can improve poor clinical outcome in chronic kidney disease (CKD) patients. The study was designed to evaluate the serum albumin and C-reactive protein (CRP) levels in hospitalized patients with Chronic Kidney Disease. This cross-sectional study was carried out in the Department of Biochemistry, Mymensingh Medical College, Mymensingh, Bangladesh with the collaboration of the Department of Nephrology, Mymensingh Medical College Hospital, Mymensingh, from January 2021 to December 2021. The subjects were selected on the basis of inclusion and exclusion criteria by purposive and convenient sampling method. A total of 110 subjects were included in this study. Among them, 55 were diagnosed CKD patients denoted as Group I and 55 were normal healthy individuals denoted as Group II. In this study, serum albumin and CRP levels were measured. All values were expressed as Mean±SD. All statistical analysis was done by using SPSS (statistical package for social science) windows package version 21.0. Statistical significance of difference between Group I and Group II were evaluated by using student's unpaired 't'-test and the significance was defined as p<0.05. Correlation was done by using Pearson's correlation coefficient test. Mean age of Group I was 52.65±4.93 and Group II was 51.15±6.32 (p=0.165). The mean±SD of BMI was 24.46±1.84 for Group I and 24.50±1.05 for Group II (p=0.886). The mean±SD values of serum albumin were 3.62±0.26g/dl and 4.16±0.69g/dl in Group I and Group II respectively. We found highly significant (p<0.001) decrease in serum albumin. The mean±SD values of CRP were 24.00±16.73mg/L and <6.0±0.00mg/L in Group I and Group II respectively. So, we found significant (p<0.05) increase in CRP levels. There was negative correlation between serum albumin and CRP. Analyzing the findings of this study, significant decrease in serum albumin and significant increase in CRP levels were observed in CKD patients.

Rare Presentation of Giant Cell Tumors of the Tendon Sheath: Bilateral Involvement of Tendoachilles

Giant cell tumor of tendon sheath arises from the synovium of tendon sheaths, joints, or bursa, mostly affects adults between 30 and 50 years of age, and is slightly more common in females. It corresponds to a localized form of pigmented villonodular synovitis (PVNS). Typically occur in the hand where they represent the second most common type of soft tissue tumors after synovial ganglions. Bilateral giant cell tumor of tendon sheath of tendoachilles is a rare presentation. We report the case of a 22-years-old female presenting with pain in both ankles without any history of trauma. On clinical examination, tenderness on both tendoachilles and local indurations were observed. Ultrasonography showed focal thickening of Achilles tendon bilaterally, and Doppler demonstrated increased flow in peritendinous area. MRI findings showed that most of the tumor had intermediate signal intensity and portions of the tumor had low signal intensity. Fine needle aspiration cytology confirmed the diagnosis of giant cell tumor of tendon sheath. Excision biopsy was done with no recurrence on subsequent follow-up.

Association between Serum Vitamin D and Metabolic Syndrome in Women with Polycystic Ovary Syndrome

Vitamin D deficiency (VDD) is common in women with and without polycystic ovary syndrome (PCOS) and may be associated with metabolic and endocrine disorders in PCOS. Aim of the study was to evaluate the association between serum vitamin D level and metabolic syndrome (MS) in PCOS. This cross-sectional study was conducted in PCOS clinic of infertility outpatient department of the department of Reproductive Endocrinology and Infertility at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from July 2018 to June 2019. A total of 170 diagnosed patients with PCOS of aging 20 to 40 years were included in this study. Out of which 85 patients with PCOS MS and rest 85 patients without PCOS MS were considered as Group I and Group II respectively. Serum vitamin D was measured using a chemiluminescent microparticle immunoassay (CMIA). Almost two third (72.9%) populations had vitamin D moderate deficiency (10-20ng/ml) in Group I and 46(54.1%) in Group II. The mean vitamin D was 13.97±4.53ng/ml in Group I 16.02±6.62ng/ml in Group II. There were significant negative correlation found between vitamin D level with weight (r = -0.169; p=0.028), waist circumference (r = -0.208; p=0.007), Waist/Hip ratio (r = -0.205; p=0.007) and diastolic blood pressure (r = -0.187; p=0.014). In binary logistic regression analysis diastolic blood pressure (OR=1.04, 95% CI 0.89-1.29), fasting Glucose (OR=1.09, 95% CI 0.89 - 1.42), HDL (OR=1.11, 95% CI 1.05 - 1.17) and Vitamin D (OR=1.37, 95% CI 1.01 - 1.82) were significant risk factors of metabolic syndrome of the study patients. Vitamin D level was lower in PCOS subjects having MS and higher frequency of body weight, vitamin D deficiency was observed in them compared to the non-MS group. Waist: hip ratio, waist circumference and diastolic blood pressure were the negatively correlated with of vitamin D in the study subjects.

Correlation between Antero-posterior Diameter and Vertical Diameter of Both Ends of Fully Ossified Dry Human Clavicle

Clavicle is an upper limb locomotory bone which helps in formation of pectoral girdle and connected the upper limb with axial skeleton. There is no baseline data of clavicle in contrast to demographic variation in our country, so the study was designed to obtain baseline data on clavicle for anthropological, forensic and clinical use. This descriptive cross-sectional study was done among 150 (65 right and 85 left) fully ossified dry human clavicle in Mymensingh Medical College, Mymensingh, Bangladesh from January 2020 to December 2020. Sample was collected by the help of nonrandom purposive sampling technique from Department of Anatomy of Mymensingh Medical College and Community Based Medical College, Bangladesh, Mymensingh. The parameters were the antero-posterior diameter and vertical diameter of sternal and acromial ends of clavicle, measured with the help of digital vernier slide caliper and expressed in millimeter. In the current study the mean±SD antero-posterior diameter of sternal end of 65 clavicles of right side was 21.97±2.889mm and 85 clavicles of left side were 20.30±3.459mm. The mean±SD antero-posterior diameter of acromial end of 65 right sided clavicles was 21.96±5.161mm and 85 clavicles of left side were 21.00±4.002mm. Correlation was done in between antero-posterior diameter and vertical diameter of sternal end of clavicle and the differences were highly significant on both sides. Similarly, when correlation was done for the acromial end of clavicle the difference was found non-significant on right side and highly significant on left side.

Clinical and Demographic Predictor of the Advanced Stage of Carcinoma Cervix in a Tertiary Level Hospital of Bangladesh

Though cervical cancer is a preventable disease it is the most progressive and devastating diseases posing a threat of mortality for women of developing countries. Majority of the cases present to hospital at advanced stage when treatment is less feasible. Objective is to determine the factors associated with the advanced stage presentation to the hospital, socio-demographic factor, patterns of complications and histological types among patients with carcinoma cervix. This was an observational descriptive type of cross-sectional study carried out in the department of Obstetrics and Gynecology, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from 15 January to 27 September 2017. Women who were newly confirmed to have cervical cancer by histology were enrolled. Stages IIB and above was considered as advanced disease. The patients were interviewed face to face by the researcher for the purpose of collection of data. Then the patients were examined by the researcher for certain sings and those would be recorded in the check-list. Histopathological report was noted in data collection sheet. In this study data analysis was done by SPSS version 22.0. Total 66 clinically and histologically confirmed advanced ca-cervixes were taken up during this study. Most common stage was stage III, 49(74.2%) out of 66 population. Majority of female were found 34(51.5%) in age group 51-60. More than half of population 54(81.8%) were living with their husband and 12(18.1%) were widow at the time of study. High level of illiteracy among women and their problematic health seeking behavior for gynecological symptoms are responsible for advanced diagnosis of cervical cancer.

Comparison of the Levels of Blood Homocysteine between Women with Unexplained Infertility and Normal Fertility

Infertility is a common gynaecological problem which remains unexplained in 10-30% cases. This study explores the difference of blood levels of homocysteine between women with unexplained infertility and normal fertility. This was a cross-sectional study conducted from January 2015 to December 2015 in the Department of Gynaecology and Obstetrics of a tertiary care hospital of Bangladesh drawing 30 women with normal fertility as controls and 30 with unexplained infertility as cases. The subjects in both groups were well matched in terms of age (p value 0.875) as well as height, weight and BMI (p value 0.418). There was no statistically significant difference between the two groups in socio-economic status and educational levels. The two groups had similar duration of marriage (7.88±3.5 years in controls vs. 8.15±3.88 years in cases) and coital frequency (3.63±0.76 week in controls vs. 3.33±0.55 week in cases). Based on the institutional cut-off value for normal serum fasting homocysteine level of 15 micromoles/L, the frequency of hyper-homocysteinemia was significantly higher (40%) in unexplained infertility group compared to control group (16.7%, p value 0.044). Fasting serum homocysteine levels were significantly higher in the unexplained infertility group compared to the normal fertility group (13.46±5.05 vs. 9.87±4.84 micromoles/L, p value 0.007). Serum fasting homocysteine levels and frequency of hyper-homocysteinemia were increased in women with unexplained infertility compared to age and BMI matched women with normal fertility.

Using Virtual Learning to Develop Palliative Care Skills Among Humanitarian Health Workers in the Rohingya Refugee Response in Bangladesh

BACKGROUND

Palliative care is an essential component of health responses in humanitarian settings, yet it remains largely unavailable in these settings, due to limited availability of palliative care training for healthcare professionals. Online training programs which connect experts to clinicians in the field have been proposed as an innovative strategy to build palliative care capacity humanitarian settings.

OBJECTIVE

To describe the implementation and evaluate the impact of delivering palliative care education using an established virtual learning model (Project ECHO) for healthcare clinicians working in the Rohingya refugee response in Bangladesh. Program acceptability and the impacts on learners' self-reported knowledge, comfort, and practice changes were evaluated.

METHODS

Using the Project ECHO model, an education program consisting of 7 core sessions and monthly mentoring sessions was developed. Each session included a didactic lecture, case presentation and interactive discussion. Surveys of participants were conducted before and after the program to assess knowledge, confidence, and attitudes about palliative care as well as learning experiences from the program.

RESULTS

This virtual palliative care training program engaged 250 clinicians, including nurses (35%), medical assistants (28%) and physicians (20%). Most participants rated the program as a valuable learning experience (96%) that they would recommend to their colleagues (98%). Participants reported improvements in their knowledge and comfort related to palliative care after participation in the program, and had improved attitudes towards palliative care with demonstrated statistical significance (p < 0.05).

CONCLUSIONS

Virtual training is a feasible model to support healthcare providers in a humanitarian health response. Project ECHO can help to address the urgent need for palliative care in humanitarian responses by supporting healthcare workers to provide essential palliative care to the growing number of individuals with serious health-related suffering in humanitarian settings.

Effect of pretreatments and temperature on rehydration kinetics of naga chili (Capsicum chinense)

Naga chili (Capsicum chinense) is rich in capsaicin content that provides a distinctive aroma and strong pungency. Drying with pretreatment is regarded as a cost-effective approach to retain better nutrient quality, whereas rehydration properties consider a quality index to optimize the drying conditions. This study aimed to determine rehydration kinetics and rehydration characteristics of pretreated hot-air dried Naga chili. The pretreatment was consisting of water blanching (90°C for 5 mins), steam blanching (100° C for 1 min), microwave treatment (650 W for 100 s), and dipping into sugar 70°Bx, 0.5% citric acid, 2% ethyl oleate + 3% potassium carbonate, and 2% potassium meta bi-sulfite solution. After drying at 60°C, the rehydration was done at 25°C, 50°C, and 75°C, respectively. The rehydration kinetics were evaluated by fitting the experimental data into empirical kinetic models: Peleg's model, 2nd order, 1st order, and Zero-order kinetics. Among these models, the rehydration behavior was best described by Peleg's model, where the highest R2 (0.9964), lowest χ 2 (0.0001) and RMSE (0.0064) values were obtained. Different rehydration characteristics such as moisture content, equilibrium moisture content, rehydration ratios were also determined. The highest moisture content (8.10 g moisture/g dry sample) was found at higher rehydration temperature (75°C), whereas the lowest moisture content ranges were recorded at 25°C. After moisture contents got equilibrium, the rehydrated samples gain weight to 100.15% at 75°C in comparison to the untreated samples. The rehydration ratios were also getting higher with increasing rehydration temperatures.

A Rare Case of Polyorchidism: Sonographic and MR Evaluation of Four Testes

Polyorchidism is a rare congenital anomaly reported about 200 cases in the world text. A number of theories have been planned concerning the making of polyorchidism, but the real explanation is still not acknowledged. Here we are going to present a case study of polyorchidism. A 70 years old gentleman complained with left supernumerary testes in the left hemiscrotum. His left hemiscrotum was painless with mass. Polyorchidism without malignancy or any other concomitant features were revealed by both ultrasound and MRI examinations. In most cases the ultrasonograph alone is diagnostic. In complicated cases of polyorchidism MRI may provide additional information.

Outcome of Operative Management of Lumbar Spinal Canal Stenosis at Mymensingh Medical College & Hospital

Variety of conditions may be responsible for low back pain but lumber spinal canal stenosis is an important cause of low back pain. Lumber spinal canal stenosis usually presents with low backache with neurogenic claudication and shortness of walking distance in adult patient. Surgical management of lumbar spinal canal stenosis by decompression surgery is effective method. This prospective interventional study was performed in patient with clinical features like low back pain with radicular pain, neurogenic claudication, signs of root compression, positive MRI findings attending in department of Orthopaedic Surgery Mymensingh Medical College Hospital and Private Hospital from July 2016 to June 2019. Thirty patients were evaluated among those 20(66.6%) were 50 years and above. The mean age was 47.5±1.6 years. Male to female ratio was roughly 8:1. Almost all of the patients had low backache with radiation to the back of the thigh and leg with motor weakness (60%). About 66.6% of the patients had sensory deficit and 83.3% had neurogenic claudication. Majority (80.0%) of the patients at presentation had a suffering of 12 or >12 months. The mean duration of suffering was 14.7±5.1 months. About 55% of the patients were able to perform heel-walking and 36.0% tip-toe walking. Nearly 57% of the patients had sensory deficit along the distribution of 1st sacral nerve and 53.3% along the distribution of lumber 5 nerves. Diagnosis shows that 16.6% of patients had L4 lesion, 50% L5, 10.0% patients had L4 & L5 and 46.6% S1. Laminectomy was done in 26.6% of patients, laminectomy and disectomy in 33.3% and laminectomy, discectomy & foraminal decompression in 40.0% of patients. Twenty five (83.5%) of patients was free from symptoms. Eighty percent (80.0%) of patients shows minimal disability and 20.0% moderate disability on the basis of Oswestry Disability Index, while by MacNab criteria, most (80%) of patients was excellent, 10% good and another 10% fair. Repeated measure ANOVA statistics showed that mean Oswestry score decreased significantly from 54.5% at baseline to 22% at the end of 1 year (p<0.001).

A Comparative Study of Craniosonogram and CT scan of Brain in CNS Complication of Perinatal Asphyxia

Pereinatal asphyxia is one of the most important complications related with the process of birth and this complications affect not only the brain but also many other organs. The purpose of this cross sectional study is to compare the role of craniosonogram and CT scan of the brain to delineate the cerebral pathology in respondent of preterm and term infant and to assess the Kappa test for agreement. This study was carried out in the department of Radiology & Imaging of Mymensingh Medical College Hospital, during the period of July 2015 to June 2017. A total number of 40 neonates clinically diagnosed as perinatal asphyxia referred for Craniosonogram and Computed tomography (CT) were included in this study. The test of agreement of USG in detection of neonatal cerebral pathology was calculated. Male to female ratio was 1:1.4. More than half (55.0%) patients were preterm age. The mean birth weight was found 2.3±0.6 kg and mean age was 22.7±12.7 days. Fifty five percent respondent mothers had antenatal check up and 27% had anemia, 11% had premature rupture of membrane, 9% had multiple pregnancy and 7% patient had hypertension. Cerebral pathology was found 28 and 31 cases by Craniosonogram and CT scan respectively. Germinal matrix hemorrhage/IVH (Intra ventricular hemorrhage) found 7(17.5%) in USG and 4(10.0%) in CT scan. Hypoxic ischaemic changes with mild ventriculomegaly observed 5(12.5%) in USG and 7(17.5%) in CT scan. Hypoxic ischaemic change found 4(10.0%) in USG and 5(12.5%) in CT scan. In USG evaluation of 28 patients having cerebral pathology & 16(72.7%) had in preterm group and 12(66.7%) in term group. In CT scan of brain 31 patients with cerebral pathology & 15(37.5%) in preterm group and 16(40.0%) in term group. CT scan found cerebral pathology 77.5% (31/40) cases and USG found 70.0% (28/40), with Kappa value was 0.551, which indicates that fair agreement between USG and CT scan for detection of cerebral pathology in respondent. Craniosonogram is a useful method in all neonates specially preterm to see the CNS complication of perinatal asphyxia.

Outcome of Bone Marrow Injection in Patient with Delayed Union and Non-Uninon of Long Bone Fracture

Bone marrow is a source of osteoprogenitor cells which are the most important factor of bone formation and healing of fracture. The aim of the study is to evaluate the outcome of bone marrow injection in the management of delayed union and non-union. This prospective study was performed in the department of Orthopaedics, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from January 2017 to June 2019. In this study 21 patients with delayed union and non-union were treated by bone marrow injection. Bone marrow were aspirated from the anterior or posterior iliac crests then injected percutaneously into the fracture site. Full union was achieved in 15 cases, while failed in the others. No major complications were seen during or after the procedure. It is a safe, easy and a minimally invasive procedure compared to usual open bone graft especially for cases with high risk of anesthesia or risk of infection.

Brachial Plexus Schwannoma: A Case Report with Emphasis on Imaging

Brachial plexus tumors are rare. Schwannomas are benign nerve sheath tumors and only about 5% arise from brachial plexus. Diagnosis of these tumors are challenging for radiologists as well as clinicians as they are rare and the anatomy of the neck is complex. We report a case of a middle aged woman who was admitted in Mymensingh Medical College in Neurosurgery Department on 15th December 2017 with right supraclavicular swelling; based on the clinical findings was provisionally diagnosed as supraclavicular lymphadenopathy; Ultrasonography and Magnetic Resonance Imaging suggested schwannoma. Complete excision of the mass through supraclavicular approach showed the origin of it from the brachial plexus, which subsequently was confirmed to be a schwannoma with histopathology.

Giant Cell Tumour of the Talus: A Rare Case Report

Giant-cell tumor constitutes 4-20% of all primary bone tumors in south East Asian population. They are benign locally aggressive bone tumour first described by cooper in 1818. These tumors occur predominantly in meta-epiphyseal region. Most often they are located around the knee joint. Although most of the tumors are diagnosed on plain radiograph alone, varying CT and MRI presentations of these tumors are essential to narrow down the differentials has an extended pre operative assessment.

Prevalence of Generalized Anxiety Disorder and its effect on Daily Living in the Rural Community of Rajshahi

This cross-sectional type of descriptive study was conducted in three villages of Puthia Upazila under Rajshahi district to find out the prevalence of Generalized Anxiety Disorder (GAD) and its effect on their daily living. A total of 876 adult people of aged 18 years and above, were selected purposively. Data were collected by face to face interview with the help of a semi-structured questionnaire which contained Hamilton’s 7-point anxiety scale. Out of 876 respondents, 80% had GAD, where mild, moderate and severe GAD being 42.5%, 31.8% and 5.7% respectively. GAD was found to be more frequently associated in the 3rd and 5th decades of life, which constituted 27% and 12.9% respectively (p < 0.001). Having GAD, females have more ability to cope with daily living than males, though GAD was not found to be associated with sex (p >0.05). Illiterate and primary level educated respondents were more often associated with GAD (40.4 and 25% respectively) than the SSC and higher level educated people (p < 0.001). Businessmen were found to be significantly associated with GAD (29.7%) than the other occupations (p < 0.001). Poor people tend to be associated with GAD significantly more than the middle class and the rich (p < 0.01). Widow(er) and married and living together were likely to have GAD than the single or divorced or separated (p < 0.001). Activities of daily living gradually becoming more difficult when intensity of anxiety status increased which is statistically significant (p<0.001).The association between sex and problem facing in everyday life shows that over 40% of the females did not have any difficulty in dealing with problem situation as compared to only 25.8% of the males, while nearly half (48.6%) of males had quite difficulty in dealing with a problem as compared to 37.3% in females (p < 0.001). The present study concluded that majority rural adult people (4 in every five) suffer from generalized anxiety disorder (GAD). The ability of coping with a problem is higher in females than the males. This study might be the basis for further in depth study in this regard.TAJ 2014; 27(1): 14-23

Hepatic Hydatid Cyst: A Case Report

Hepatic hydatid disease is a goonotic disease caused by Echinococcus granulosus and it is endemic in different parts of the world. This infection is an important public health problem. Although it is distributed throughout the world but common in the livestock grazing regions of the world such as in Central Europe, Africa, South America, Central Asia and China. Here we present the case "30 years old female" with the complaints of right upper abdominal pain for 3 months, nausea & occasional vomiting for 1 month and was admitted under general surgery ward at Mymensingh Medical College Hospital, Mymensingh, Bangladesh on 12th March 2018. Considering history, physical examination, serological investigations, imaging studies and exploratory laparotomy the diagnosis is hepatic hydatid cyst. Echinococcus granulosus produces cysts in almost every organs of the body most commonly in the liver. Man is the incidental intermediate host where definitive host is carnivores such as dogs. Hydatid cyst always starts as a fluid filled, cyst like structure (stage I), which may proceed to a stage II lesion if daughter cysts and/or matrix develop. In some instances, the stage II lesion becomes hypermature and due to starvation, dies to become a mummified, inert, calcified, stage III lesion. Ultrsound is the preferred firstline imaging but CECT give more precise information regarding the morphology of the cyst. Magnetic Resonance Imaging is particularly useful because of its multiplaner capabilities and more detail anatomical resolution.

Magnetic Resonance Imaging of Cerebral Palsy in the Assessment of Time of Brain Insult

The aim of this cross-sectional study was to find out the role of Magnetic resonance imaging (MRI) in the assessment of time of brain insult in cerebral palsy (CP). The study was conducted in the Department of Radiology & Imaging, Mymensingh Medical College Hospital, Mymensingh and a total number of 35 patients with were enrolled from January 2015 to December 2016. Maximum patients (57.2%) were under five years followed by 34.3% were of 5 to <8 years and 8.7% were of 8 to <12 years of age and mean age was 4.7 years. Majority of the patients were male 28(80%) and female were 7(20%). Among the patients 23(65.7%) came from poor, whereas 11(31.4%) came from middle class and only one (2.9%) from rich socioeconomic group. According to gestational age of the patients, 26(74.3%) were term (≥37weeks) at delivery and rest (25.7%) were preterm (<37 weeks). Delayed cry after birth were present in 32 (80%) patients. Regarding types of cerebral palsy spastic diplegia, spastic quadriplegia, hemiplegia and extrapyramidal were found 3(8.6%), 25(71.4%), 4(11.4%) and 3(8.6%) respectively. Abnormal MRI was reported in 94.2% patients and gave clues to time of insult in 79.9% (excluding the 14.3% miscellaneous findings). The findings were mal-developments (5.7%), periventricular white matter lesions (25.7%), cortical or deep grey matter lesions (48.6%), miscellaneous (14.3%) and normal (5.7%). Brain mal-developments were more seen in term than in preterm born children (5% vs. 0%). Periventricular white matter lesions were seen significantly more in preterm than in term born children (77.8% vs. 3.9%). Cortical or deep grey matter lesions occurred significantly more in term than in preterm born children (60% vs. 20%). Based on the study it can be concluded that Magnetic Resonance Imaging (MRI) can help in the assessment of time of insult to the developing brain in cerebral palsy (CP).

Association between Serum Apolipoprotein-B and Acute Ischaemic Stroke

Stroke is one of the leading causes of death and disability in developed as well as developing countries like Bangladesh. There is a crucial need to identify additional risk factors that are easily measurable and treatable in general population. Role of serum lipids, lipoproteins and lipoprotein related variables in the prediction of stroke is less clear. Abnormalities in plasma lipoproteins are the most firmly established and best understood risk factors for atherosclerosis and they are probable risk factors for ischaemic stroke, largely by their link to atherosclerosis. High serum apolipoprotein-B (Apo-B) levels may predict an increased risk for ischaemic stroke. Aim of the study was to evaluate the association between serum Apo-B level and acute ischaemic stroke and to measure and compare serum Apo-B level in ischaemic stroke and normal subjects. A cross-sectional comparative study was carried out in the department of Neurology, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from July 2013 to June 2015. A total number of 100 subjects within 18-70 years were considered for the study. Fifty (50) subjects with stroke (both clinically as well as CT scan of head or MRI of brain proven) were taken as the cases and 50 age and sex matched nearly healthy individuals without stroke were taken as the controls by using non-probability sampling procedure. Total cholesterol, HDL cholesterol and triglycerides were estimated by enzymatic method using Semiautoanalyser. LDL cholesterol was estimated by Friedewald formula. Apo-B was estimated by immunoturbidimetric method using Semiautoanalyser. Finally collected data were analyzed by using SPSS software Version 20. Student 't' test was used to compare the data between cases and controls. P value was set <0.05. Diagnostic validity tests were conducted to assess the diagnostic efficiency of Apo-B. Total cholesterol, LDL cholesterol and triglycerides are significantly increased in cases compared to controls. HDL-cholesterol was significantly decreased in cases compared to controls. Apo-B was significantly increased in cases compared to controls. The result was statistically significant. Apo-B may be used as predictors of ischaemic stroke components.

Ultrasonographic Evaluation of Malignant Pediatric Abdominal Tumour with Histopathological Correlation

Ultrasonography is a very useful diagnostic tool to evaluate pediatric abdominal mass. This cross sectional study was conducted among clinically suspected patients having malignant abdominal mass attending in the department of Radiology & Imaging, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from January 2008 to December 2009. Total 56 patients were included in this study. Patients were scanned by high resolution gray scale ultrasonography of the abdominal masses. After surgical procedure, biopsy specimen were collected in a container containing 10% formalin and sent for histopathological examination. Mean age of the patients group was 5.91 years with a standard deviation of ±3.21 years. All patients were within 2 to 13 years age. Out of all patients, male were 33(58.9%) and 23(41.1%) were female. Male and female ratio was 1.4:1. Ultrasonographic diagnosis as Wilm's tumour were 27(48.2%), hepatoblastoma 8(14.3%), lymphoma 7(12.5%), neuroblastoma 6(10.7%), suspected malignancy 6(10.7%) and lastly teratoma were 2(3.6%). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of ultrasonography in the evaluation of Wilm's tumour were 100.0%, 90.6%, 88.9%, 100.0% and 94.6% for neuroblastoma 83.3%, 98.0%, 83.3%, 98.0% and 96.4% for lymphoma 83.3%, 96.0%, 71.4%, 98.0% and 94.6% and for hepatoblastoma 100.0%, 100.0%, 100.0%, 100.0% and 100.0% respectively. It is a noninvasive and cost effective modality. Carefully performed ultrasonographic study would give reliable and accurate information needed in the diagnosis of abdominal malignancy in children.

An Evaluation of the Result of Fenestration and Discectomy for the Treatment of Prolapsed Lumber Intervertrebal Disc (PLID)

The aim of this study is to asses the result of fenestration and discectomy for the treatment of PLID. This Prospective quasi experimental study was conducted on 29 Patient of PLID with different ages at Dhaka Medical College Hospital (DMCH), Dhaka, Bangladesh from July 2014 to June 2016. Post Operative outcome was assessed through Modified Macnab Criteria & Visual Analogue Score (VAS). The mean age of patient were 38.14±9.20 years and ranging from 24 to 55 years. The mean age of male was 37.21±9.72 years and female patient was 39.90±8.32 years. Overall subjective assessment of this study revealed that 79.2% patients had excellent functional outcome, 13.8% good and 6.9% fair and there was no poor functional outcome a according to modified Macnab criteria.

Growth and survival of the tropical sea urchin, Salmacis sphaeroides fed with different macroalgae in captive rearing condition

An experiment was undertaken to develop appropriate culture techniques for high-valued tropical sea urchin, Salmacis sphaeroides under captive aqua-rearing conditions. Three-month-old juveniles produced through induced breeding, larval rearing and metamorphic induction were stocked with 20 juveniles in each of nine well-aerated glass aquaria (46 x 30 x 30 cm).? Juveniles fed with red alga (Amphiroa fragilissima) were designated as Treatment-1 (T1), brown alga (Sargassum polysystum) as Treatment-2 (T(2)) and sea grass (Enhalus acoroides) as Treatment-3 (T(3)). At the time of stocking, juveniles were under the same age group and batch-reared with a mean length and weight of 9.98 ? 0.56 mm and 0.49 ? 0.11 g, respectively. The juveniles were fed ad libitum, and the seawater in each rearing aquarium was changed at bi-monthly intervals. The culture was carried out for one year during which time the juveniles attained sexual maturity. Growth performances (viz., final weight, weight gain, final length, length gain, specific growth rate and daily growth rate) and survival of adults were significantly higher (P < 0.05) in T(1) than those in T(2) and T(3), respectively. Gonad production, in terms of wet gonad weight and gonad index, also followed the same trend as that for growth. Hence, of the three algal feed evaluated, red alga appeared to be the most suitable food for rearing of S. sphaeroides under captive conditions. The present study is the first demonstration of successful culturing of S. sphaeroides in a static aquarium system, the findings of which could be helpful towards the commercial sea urchin aquaculture. ?

Study on Neurological Consequence of Eclampsia

The present study was carried out in the Department of Obstetrics and Gynecology at Mymensingh Medical College Hospital, Mymensingh, Bangladesh for a period of one year from 1st June 2009 to 30th June 2010 to see the Neurological Consequence of Eclampsia. A total number of 37 patients were enrolled in this study. Among 37 patients majority are in the age group of 21-30 years which is 19(51.4%) cases followed by less than or equal to 20 years and more than 30 years which are 13(35.1%) cases and 5(13.5%) cases respectively. Knee jerk is present in 28(75.7%) cases and absent in 8(21.6%) cases. The exaggerated knee jerk is present in only in 1(2.7%) case. The rate of Glasgow coma scale is less than 5 in 21(56.8%) cases, 14(37.8%) cases in 5-10 and 2(5.4%) cases is in more than 10. Focal sign is absent in 22(59.5%) cases and present in 15(40.5%) cases. Majority of the patients is presented with absence of neck stiffness which is 35(94.6%) cases and the rest 2(5.4%) cases are presented with neck stiffness. Flexor planter response is found in 20(54.1%) cases which is the highest in number followed by extensor which is 15(40.5%) cases. In only 2(5.4%) cases the planter reflex is not elicitable. Presence of infarct is found in 15(40.5%) cases which is the highest number. Cerebral edema and Presence of haemorrhage is found in 3(8.1%) cases in each. Leuko-encephalopathy is found in 2(5.4%) cases. Encephalopathy and Both infarct & haemorrhage is found in 1(2.7%) case of each. Normal CT scan findings of brain are found in 12(32.4%) cases.

Targeting Bone Marrow to Potentiate the Anti-Tumor Effect of Tyrosine Kinase Inhibitor in Preclinical Rat Model of Human Glioblastoma

Antiangiogenic agents caused paradoxical increase in pro-growth and pro-angiogenic factors and caused tumor growth in glioblastoma (GBM). It is hypothesized that paradoxical increase in pro-angiogenic factors would mobilize Bone Marrow Derived Cells (BMDCs) to the treated tumor and cause refractory tumor growth. The purposes of the studies were to determine whether whole body irradiation (WBIR) or a CXCR4 antagonist (AMD3100) will potentiate the effect of vatalanib (a VEGFR2 tyrosine kinase inhibitor) and prevent the refractory growth of GBM. Human GBM were grown orthotopically in three groups of rats (control, pretreated with WBIR and AMD3100) and randomly selected for vehicle or vatalanib treatments for 2 weeks. Then all animals underwent Magnetic Resonance Imaging (MRI) followed by euthanasia and histochemical analysis. Tumor volume and different vascular parameters (plasma volume (v_p), forward transfer constant (K^trans), back flow constant (k_ep), extravascular extracellular space volume (v_e) were determined from MRI. In control group, vatalanib treatment increased the tumor growth significantly compared to that of vehicle treatment but by preventing the mobilization of BMDCs and interaction of CXCR4-SDF-1 using WBIR and ADM3100, respectively, paradoxical growth of tumor was controlled. Pretreatment with WBIR or AMD3100 also decreased tumor cell migration, despite the fact that ADM3100 increased the accumulation of M1 and M2 macrophages in the tumors. Vatalanib also increased K^trans and v_e in control animals but both of the vascular parameters were decreased when the animals were pretreated with WBIR and AMD3100. In conclusion, depleting bone marrow cells or CXCR4 interaction can potentiate the effect of vatalanib.

A Comparative Study of Abdominal Hysterectomy versus Vaginal Hysterectomy in Non Descent Cases

Abdominal and vaginal hysterectomies are the two main operative modalities for various uterine conditions; however the indications for selecting a particular procedure in any setting may not be optimally defined. The present study was done with the objective to study the comparative risks of complications of abdominal and vaginal hysterectomies during intra-operative and post-operative period thereby improve the proportion of hysterectomies done vaginally. This randomized comparative study was carried out in the Department of Gynaecology and Obstetrics, Bangabandhu Sheikh Mujib Medical University, during the period from January 2012 to December 2012. Sixty subjects were equally divided into vaginal hysterectomy (Group A) and abdominal hysterectomy (Group B), thirty in each group for non-prolapsed cases with good uterine mobility and uterine size less than 12 weeks. Intra-operative blood loss, mean operating time was more in Group A than in Group B (250 ml, 72.97 ± 9.27 min) and (200 ml, 55.27 ± 1.80 min) respectively. Postoperative fever (17% & 7%), bleeding requiring transfusion (72% & 28%) and abdominal wound infection (13%, 0%) was more common in Group A as compared to Group B. From the study results it can be concluded that patients requiring hysterectomy for benign non prolapsed cases be offered the option of vaginal route which is less invasive, minimal or no complications, more economical and effective. In our centre, it is likely to replace abdominal hysterectomy as the operation of choice.

Maternal mortality in obstetrics and gynaecology in a tertiary care hospital

Maternal mortality is the leading causes of death and disability of reproductive age in the developing countries. Bangladesh is one of the developing countries where maternal mortality is very high. The purpose of the present study was to see the causes of maternal deaths at Obstetrics and Gynaecology ward. This retrospective study was carried out in the Department of Obstetrics and Gynaecology at Dhaka Medical College Hospital (DMCH). All maternal deaths were included in this study from July 2003 to June 2004 for a period of one year. The incidence of maternal death was 18.5/1000 live birth. Hypertensive disorder of pregnancy (41.84%) was the most common cause of maternal death followed by unsafe abortions (21.4%), PPH (10.2%), obstructed labour (8.2%). Among 98 patients 36(36.7%) cases are died due to eclampsia. Death due to pre-eclampsia (5.1%), unsafe Abortion (21.4%), Obstetric haemorrhage (18.4%) and obstructed labour (8.3%) were commonly found in this study. The study permits to conclude that Hypertensive disorder of pregnancy is the leading cause of pregnancy related deaths followed by unsafe abortions and obstetric haemorrhage. Other causes include obstructed labour, anaesthetic complications and others.

Uterus didelphys with unilateral obstructed hemivagina and haematocolpos with ipsilateral renal agenesis - a case report

Mullerian anomalies are a relatively uncommon occurrence with implication for adolescents and adults as they may result in specific gynaecologic, fertility and obstetrical issues. Uterus didelphys with blind hemivagina and ipsilateral renal agenesis is a rare congenital anomaly. Patient may be asymptomatic and unaware of having double uterus or may present with severe dysmenorrhoea or dyspareunia or a palpable mass due to unilateral haematocolpos. We report a case of 12 year old girl with this condition who was diagnosed as uterus didelphys with unilateral haematocolpos with ipsilateral renal agenesis on the basis of clinical association, physical examination and sonography and intravenous urogram.

Conjoined twins with single heart and liver - a case report

Twin pregnancy is common but conjoined twins are an extremely rare congenital malformation without any known genetic predisposition. The incidence of conjoined twins is estimated to be around 1 in 250,000 live births with a female predilection. We presented an extremely rare case of abdomino-thoracopagus with single heart and liver. In this paper, the imaging of conjoined twins both antenatally and postnatally is reviewed, in particular taking into consideration recent advances with gray scale and color Doppler ultrasound. This case is of particular interest because of the rarity of abdomino-thoracopagus twins with single heart and liver, in literature.

What is the quality of economic evaluations of non-drug therapies? A systematic review and critical appraisal of economic evaluations of radiotherapy for cancer

BACKGROUND

Breast, cervical and colorectal cancers are the three most frequent cancers in women, while lung, prostate and colorectal cancers are the most frequent in men. Much attention has been given to the economic evaluation of pharmaceuticals for treatment of cancer by the National Institute for Health and Care Excellence (NICE) in the UK and similar authorities internationally, while economic analysis developed for other types of anti-cancer interventions, including radiotherapy and surgery, are less common.

OBJECTIVES

Our objective was to review methods used in published cost-effectiveness studies evaluating radiotherapy for breast, cervical, colorectal, head and neck and prostate cancer, and to compare the economic evaluation methods applied with those defined in the guidelines used by the NICE technology appraisal programme.

METHODS

A systematic search of seven databases (MEDLINE, EMBASE, CDSR, NHSEED, HTA, DARE, EconLit) as well as research registers, the NICE website and conference proceedings was conducted in July 2012. Only economic evaluations of radiotherapy interventions in individuals diagnosed with cancer that included quality-adjusted life-years (QALYs) or life-years (LYs) were included. Included studies were appraised on the basis of satisfying essential, preferred and UK-specific methods requirements, building on the NICE Reference Case for economic evaluations and on other methods guidelines.

RESULTS

A total of 29 studies satisfied the inclusion criteria (breast 14, colorectal 2, prostate 10, cervical 0, head and neck 3). Only two studies were conducted in the UK (13 in the USA). Among essential methods criteria, the main issue was that only three (10%) of the studies used clinical-effectiveness estimates identified through systematic review of the literature. Similarly, only eight (28%) studies sourced health-related quality-of-life data directly from patients with the condition of interest. Other essential criteria (e.g. clear description of comparators, patient group indication and appropriate time horizon) were generally fulfilled, while most of the UK-specific requirements were not met.

CONCLUSION

Based on this review there is a dearth of up-to-date, robust evidence on the cost effectiveness of radiotherapy in cancer suitable to support decision making in the UK. Studies selected did not fully satisfy essential method standards currently recommended by NICE.

Color Doppler sonography and resistivity index in the differential diagnosis of hepatic neoplasm

The purpose of this study was to determine the usefulness of color doppler sonography and resistivity index (RI) in differentiating liver tumors. The study was carried out in the Department of Radiology and Imaging, Mymensingh Medical College Hospital, and Institute of Nuclear Medicine and Allied Sciences (INMAS), Mymensingh, Bangladesh, during the period of July 2009 to June 2011. Total 50 consecutive cases were studied. Among them 27 were hepatocellular carcinomas, 19 were metastatic tumors, 03 were hemangiomas and 01 was hepatic adenoma. Doppler sonographic findings were then correlated, case by case, with final diagnosis- either pathologically by USG guided Fine-needle aspiration or by other imaging modalities (e.g., CT scan and RBC liver scan for hepatic hemangioma). The RI value of hepatocellular carcinoma was 0.69±0.096 and in metastatic tumors 0.73±0.079. The results showed no significant difference between the RI of hepatocellular carcinomas and metastatic liver tumors but it was significantly higher than benign lesions (p<0.05). RI of hemangiomas was 0.49±0.64 and in one hepatic adenoma was 0.65. When RI was <0.6 for benign liver tumors and ≥0.6 for malignant tumors we calculated a sensitivity of 89.14%, specificity of 66.7%, accuracy of 85.71% positive predictive value of 97.62% and negative predictive value of 28.57% in differentiating benign and malignant tumors. Thirty four of 46(73.9%) malignant lesions had intratumoral flow and 25% of benign lesions also showed intratumoral flow. The difference of intratumoral flow between malignant and benign lesions was significant (p<0.01). Two of 4 benign lesions (50%) had peritumoral vascularity where 6% of the malignant tumors showed peritumoral vascularity. In conclusion, combined studies of the type of intra-and peri-tumoral flow signals in CDFI and the parameter of RI would be more helpful in the differential diagnosis of benign and malignant liver tumors.

Evaluation of the results of operative management of lumbar spinal canal stenosis

Lumber spinal canal stenosis is an important cause of low back pain and it frequently presents with low backache with neurogenic claudication. Operative management of lumbar spinal canal stenosis by decompression surgery is an effective method. This prospective interventional (quasi experimental) study was performed in patient having history of characteristic clinical features like low backache with radicular pain, neurogenic claudication, signs of root compression, positive MRI findings attending in the department of Orthopaedic Surgery and Neurosurgery, Dhaka Medical College Hospital and NITOR. Dhaka, from July 2008 to June 2010. Thirty patients were evaluated among those 18(60%) were 50 years and above. Male to female ratio was roughly 9:1. About 87% of the patients had sensory deficit and 50% had neurogenic claudication. Majority (83.3%) of the patients at presentation had a suffering of 12 or >12 months. Diagnosis shows that 3.5% of patients had L4 lesion, 60% L5, 6.5% patients had L4 & L5 and 30% S1. Laminectomy was done in 43.3% of patients, laminectomy and disectomy in 30% and laminectomy, discectomy & foraminal decompression in 26.7% of patients. Relief of symptoms occurred in 25(83.5%) of patients. Over three-quarter (76.7%) of patients exhibited minimal disability and 23.3% moderate disability based on Oswestry Disability Index, while by MacNab criteria, most (80%) of patients was excellent, 10% good and another 10% fair. Repeated measure ANOVA statistics showed that mean Oswestry score decreased significantly from 54.5% at baseline to 22% at the end of 1 year (p<0.001).

Echocardiographic assessment of cardiac involvement in systemic lupus erythematosus patients

This study was designed to assess cardiac abnormalities in patients with systemic lupus erythematosus (SLE) by echocardiography. It was an analytic type of cross sectional study, conducted in lupus clinic, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from July 2008 to June 2009. Fifty lupus patients, diagnosed on the basis of ACR criteria, without cardiovascular symptoms, were enrolled in the study and were evaluated by standard echocardiography with color Doppler. SLEDAI was applied for assessment of disease activity. Out of 50 patients 80% had abnormal echocardiographic findings. Pericardial thickening was found in 38% patients, pericardial effusion 20%, diastolic dysfunction 72%, hypokinesia of ventricular wall 8%, overall valvular abnormalities 20%, commonest being aortic regurgitation (12%), followed by mitral regurgitation (8%), and 6% had pulmonary hypertension. Males (100%) were more vulnerable to cardiac involvement than females (68.2%) and later age of disease onset (31-40 years) was associated with higher (87.5%) chance of echo abnormalities. The differences, however, were not statistically significant (p>0.05). There was significant relationship between disease duration and cardiac abnormalities (p<0.01). Active disease (80.08%) was associated with higher frequency of cardiac involvement than disease in remission (62.50%) but the result was not statistically significant (p=0.151). Cardiac abnormalities are very common in lupus patients even when clinically asymptomatic from cardiac aspect. Echocardiography is an excellent non-invasive tool for cardiac evaluation. These observations emphasize a need for further assessment of early intervention to reduce subsequent cardiac morbidity and mortality among the lupus patients.

Ultrasound evaluation of traumatic patient in a tertiary level hospital

This study was designed to assess the use of ultrasonography in evaluation of trauma patients to see any intraperitoneal collection, collection in pleural cavity, any vital organ injury or any localized collection in blunt trauma to abdomen. This cross sectional study was performed in patient having history of trauma who attended the Centre for Nuclear Medicine & Ultrasound (CNM&U), Mymensingh for ultrasonic evaluation. Ultrasonography scanning was done to see any intraperitoneal collection, pleural collection or vital organ injury. Vulnerable age, causes of trauma, types of organ injury and relation between ages & types of organ involved were also evaluated. Fifty patients were evaluated among those 44(88%) were male & 6(12%) were female. Ultrasonographic examination detected 26(52%) patients with intraperitoneal collection, 13(26%) patients with intraabdominal organ injury, 5(10%) patients with pleural collection. Liver (30%) is the mostly affected organ. It was also found that the most vulnerable age having trauma to abdomen was 11 to 30 (54%) years. The most common cause of trauma was road traffic accident (46%). Younger people were more vulnerable to liver and pancreatic injury, older people to splenic injury and middle aged to renal injury. Ultrasonography is a useful primary tool for evaluating traumatic patient specially to detect intraperitoneal collection and organ injury in country like Bangladesh where accidental injury is very common.

Present status and approaches for the sustainable development of community based fish culture in seasonal floodplains of Bangladesh

Coordination among the different stakeholders at policy planning, implementation and target beneficiary level, particularly among the agencies responsible for development and management of water resources, agriculture and fisheries, is essential for overall sustainable development. Stocking of larger fingerlings at suitable stocking densities of endemic (rohu, catla, mrigal) and exotic (silver carp, bighead carp, common carp/mirror carp) species should be stocked at varying proportion. Floodplain fish production depends only on the natural fertility of the water bodies. Technological interventions should include the installation of low cost bamboo fencing at water inlet and outlet points and setting of ring culverts for maintaining suitable levels of water for fish culture without hampering the production of rice and other crops in the intervention areas, selective stocking with native and exotic carps, restricted fishing for certain period of time and guarding. It is expected to exert positive influences in enhancing the standing crop and biodiversity of non-stocked species of fishes in the intervention seasonal floodplain. Entry of fish larvae, hatchlings and young fry of wild non-stocked fishes into the seasonal floodplains because of large fence spacing (approximately 1.0 cm), could restrict fishing for certain period, undisturbed habitat and guarding could contribute to higher productivity and enhancement of fish biodiversity in the seasonal floodplains. Proper motivation and effective cooperation of the beneficiaries are extremely important to culture fish in the seasonal floodplains under community based management system. Institutional support and constant vigilance from the Department of Fisheries (DoF) and local administrations are indispensable to ensure the sustainability of fish culture initiatives in the seasonal floodplains. Active participation and involvement of the local community people in all stages of fish culture operation beginning from selection of floodplains, formation of floodplain management committee, planning of fish culture activities, exercise of technical intervention, selective stocking with large fingerlings, guarding, monitoring and supervision, adopting harvesting strategies, marketing and distribution of benefits are extremely essential to ensure sustainability of the program. Mutual trust, sense of respect and good working relationship among the committee members are the basic social elements required for the success of community based fish culture initiatives.

Diversity and distribution of fishes in tropical estuary Kuantan, Pahang, Malaysia

A study on diversity and distribution of fish communities and water qualities were carried out from January 2009 to December 2010 to cover monsoon and non-monsoon at Kuantan estuary, Pahang, Malaysia. A total of 19 species of primary marine fish belong to 12 families were recorded. Out of 311 individuals the fish fauna was dominated by Ariidae followed by Lutjanidae and Lactaridae. As such Ariidae contributes 50% of the fish caught in the study area and its diversity index (H') was 0.97. A The Ariidae family consist of four (4) species; Arius maculatus, Arius sumatranus, Arius tenuispinis and Arius thalassinus. The Ariidae family can be found in all stations as they are euryhaline (highly tolerant to salinity) and this fish family are known to be a hardy estuarine catfish. Among all species in family Ariidae, Arius thalassinus was the most dominant (23%) among all species. As such collected species showed highest species diversity (0.34) followed by Arius tenuispinis (0.25) compared to other species. Arius tenuispinis alone contributed 11.90% among the samples caught from all stations. The fishes were caught and recorded highest in September-December. Pseudorhombus quinque ocellatus, Nibea soldado, Sardinella fimbriata, Toxotes jaculatrix, Dasyatis ushiei, Setipinna taty were the least dominant in the Kuantan estuary with 9.33% of total abundance. Physico-temperatures, such as temperature (22.03-30 degrees C), Conductivity (10.342.43 mS cm(-1)), TDS (0.06-26.34 mg L(-1)), salinity (0.05-29.09 ppt), DO (6.37-8.38 mg L(-1)), pH (4.97-8.03), Chl a (0.01-1.33 microg L(-1)), nitrite (0.01-0.08 mg L(-1)), nitrate (0.60-0.88 mg L(-1)), phosphate (0.24-0.40 mg L(-1)). Nevertheless, the study envisages that the water quality and fish diversity are still conducive in the Kuantan estuary. The fish diversity of Pahang estuary was high monsoon compared to non-monsoons. The station 4 (LKIM fishing boat jetty and adjacent Hospital Kuantan) is the most polluted area due to the presence of several outskirts could be alarming for the sustainable development of fish and other aquatic organisms in Kuantan estuary in the long run.

What is the clinical effectiveness and cost-effectiveness of using drugs in treating obese patients in primary care? A systematic review

BACKGROUND

Obesity [defined as a body mass index (BMI) ≥ 30 kg/m(2)] represents a considerable public health problem and is associated with a significant range of comorbidities and an increased mortality risk. The primary aim of the management of obesity is to achieve weight reduction in the interests of health. For obese patients who cannot achieve or maintain a healthy weight by non-pharmacological means, drug therapy is recommended in combination with non-pharmacological interventions such as dietary modifications and exercise.

OBJECTIVE

To evaluate the clinical effectiveness and cost-effectiveness of three pharmacological interventions in obese patients.

DATA SOURCES

Clinical effectiveness data used in the meta-analysis were sourced from articles identified in a systematic review of the literature. Data used to inform transitions to obesity-related comorbidities were derived from the General Practice Research Database (GPRD). The results of the meta-analysis and GPRD analyses informed the economic model supplemented by data from the Health Survey for England and other UK-specific data sourced from the literature.

REVIEW METHODS

A systematic literature review was conducted of the clinical effectiveness and cost-effectiveness of orlistat, sibutramine and rimonabant within their licensed indications for the treatment of obese patients. Electronic bibliographic databases including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, The Cochrane Library databases and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched in January 2009, and the reference lists of relevant articles were checked. Studies were included if they compared orlistat, sibutramine or rimonabant with lifestyle and/or exercise advice (standard care), placebo or metformin.

RESULTS

Overall, 94 studies involving 24,808 individuals were included in the clinical meta-analysis. Eighty-three trials included data on weight change, 41 included data on BMI change and 45 and 36 studies reported on 5% and 10% body weight loss, respectively. Overall, the results show that the active drug interventions are all effective at reducing weight and BMI compared with placebo. In the case of sibutramine, the higher dose (15 mg) resulted in a greater reduction than the lower dose (10 mg). Generally, the data quality of the trials included was low with poor reporting of standard errors and standard deviations. Results from the BMI risk models derived from the GPRD showed consistent increases in risk with increasing BMI. Adjustments for key confounders, such as age, sex and smoking status, were found to be statistically significant at the 5% level, in all risk models. Applying linear models to estimate BMI trajectories, for the diabetic cohort, an average increase in BMI of 0.040 per year for both men and women was observed. The non-diabetic cohort model showed an increase in BMI of 0.175 per year for women and 0.145 per year for men. The results of the cost-effectiveness analyses suggest that sibutramine 15 mg dominates the other three active interventions and the net benefit analyses show that sibutramine 15 mg is the most cost-effective alternative for thresholds > £2000 per quality-adjusted life-year (QALY). However, both sibutramine and rimonabant have been withdrawn because of safety concerns relating to potential treatment-induced fatal adverse events. If the proportion of patients who experienced a fatal adverse event was > 1.8% (1.5%, 1.0%) for sibutramine 15 mg (sibutramine 10 mg, rimonabant) the treatment would not be considered cost-effective when using a threshold of £20,000 per QALY.

LIMITATIONS

The clinical review did not include all possible lifestyle comparators, with the inclusion limited to only those trials included one of the active drug interventions. We also excluded all studies not reported in English. Although the clinical review included data from 94 studies, the quality of data was generally low, particularly in terms of the reporting of standard deviation. There was also inconsistency between the results of the mixed-treatment comparison (MTC) and the pair-wise analyses.

CONCLUSION

The MTC of anti-obesity treatments shows that all the active treatments are effective at reducing weight and BMI. The economic results show that, compared with placebo, the treatments are all cost-effective when using a threshold of £20,000 per QALY, and, within the limitations of the data available, sibutramine 15 mg dominates the other three interventions. This work has highlighted many areas of methodological research that could be explored, including assessing inconsistencies within a network to determine differences between the results of pair-wise and MTC analyses; the use of meta-regression methods to look for effect modifiers; exploring the effect of local publication bias; and the use of joint models to analyse the repeated measures of BMI and the time-to-event processes simultaneously.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

A systematic review and mixed treatment comparison of pharmacological interventions for the treatment of obesity

The study aims to compare anti-obesity interventions in a single evidence synthesis framework. Electronic databases were searched for randomized controlled trials of orlistat, rimonabant or sibutramine reporting weight or body mass index (BMI) change from baseline at 3, 6 or 12 months. A mixed treatment comparison was used to combine direct and indirect trial evidence. Ninety-four studies involving 24,808 individuals were included; 83 trials included data on weight change and 41 on BMI change. All results are in comparison with placebo. The active drugs were all effective at reducing weight and BMI. At 3 months, orlistat reduced weight by -2.65 kg (95% credibility interval -4.00 kg, -1.31 kg). For sibutramine, 15 mg gave a greater reduction than 10 mg at 12 months, -6.35 kg versus -5.42 kg, respectively. Rimonabant reduced weight by -11.23 kg at 3 months and -4.55 kg at 12 months. Lifestyle advice alone also reduced weight at 6 and 12 months, but was less effective than the pharmacological interventions. In conclusion, modest weight reductions were seen for all pharmacological interventions. Those interventions which have now been withdrawn from use (sibutramine and rimonabant) seem to be the most effective, implying that there may be a place in clinical practice for similar drugs if side effects could be avoided.

Pharmacotherapy for Osteoarthritis: A Review

Osteoarthritis (OA) is a leading cause of disability in the elderly. The goal of OA treatment is to control symptoms, prevent disease progression, minimize disability, and improve quality of life. The management can be divided into non pharmacologic interventions, pharmacologic interventions, and surgical options. Pharmacologic interventions can be further subdivided into symptomatic therapy and potential structureor disease-modifying therapy. There are, at present, no specific pharmacologic therapies that can prevent the progression of joint damage due to OA. Acetaminophen is the first line of therapy, although most of the patient requires NSAIDs. Risk of gastrointestinal (GI) bleeding and cardiovascular risk need to be considered, especially for elderly. With inflammatory components, intra-articular glucocorticoid injection gives short term benefit. Compared with corticosteroid injections, hyaluronan injections have similar clinical effects. But it is more costly. So far research with potential structure- and disease-modifying drugs in osteoarthritis includes tetracyclines, glycosaminoglycan polysulfuric acid, pentosan polysulfate, diacerein, glucosamine and others. Scientists are looking for new therapeutic targets like IL-1 receptor antagonist (IL-1Ra), mitogen-activated protein (MAP) kinases inhibitors, NF-kappaB inhibitors. Gene therapy, Chondrocyte and stem cell transplants showed some promise in animal models. Keyword: Osteoarthritis, pharmacologic therapy, disease modifying therapy DOI: http://dx.doi.org/10.3329/jom.v12i2.7690 JOM 2011; 12(2): 142-148 

Prescribing high-dose lipid-lowering therapy early to avoid subsequent cardiovascular events: is this a cost-effective strategy?

BACKGROUND

While evidence shows high-dose statins reduce cardiovascular events compared with moderate doses in individuals with acute coronary syndrome (ACS), many primary care trusts (PCT) advocate the use of generic simvastatin 40 mg/day for these patients.

METHODS AND RESULTS

Data from 28 RCTs were synthesized using a mixed treatment comparison model. A Markov model was used to evaluate the cost-effectiveness of treatments taking into account adherence and the likely reduction in cost for atorvastatin when the patent expires. There is a clear dose-response: rosuvastatin 40 mg/day produces the greatest reduction in low-density lipoprotein cholesterol (56%) followed by atorvastatin 80 mg/day (52%), and simvastatin 40 mg/day (37%). Using a threshold of £20,000 per QALY, if adherence levels in general practice are similar to those observed in RCTs, all three higher dose statins would be considered cost-effective compared to simvastatin 40 mg/day. Using the net benefits of the treatments, rosuvastatin 40 mg/day is estimated to be the most cost-effective alternative. If the cost of atorvastatin reduces in line with that observed for simvastatin, atorvastatin 80 mg/day is estimated to be the most cost-effective alternative.

CONCLUSION

Our analyses show that current PCT policies intended to minimize primary care drug acquisition costs result in suboptimal care.