Barriers and facilitators to social prescribing in child and youth mental health: perspectives from the frontline

There is growing interest in the role of Social Prescribing (SP) to help promote mental well-being and support individuals with mental health difficulties. Yet, implementation of SP to children and young people (CYP) has proved slow and underdeveloped compared with adult populations. Understanding the barriers and facilitators will help key stakeholders to better embed SP for CYP into practice. Using the Theoretical Domains Framework (TDF), a comprehensive, theoretical-led framework, underpinned by 33 behaviour change theories and 128 constructs, perceived barriers and facilitators to SP were investigated. The sample comprised of 11 Link Workers and 9 individuals involved in facilitating SP with CYP, who took part in semi-structured interviews. Transcripts were analysed using a deductive thematic analysis, and themes were coded under each theoretical domain. Overall, 33 barriers and facilitators for SP were identified across 12 domains of the TDF. Under capability, barriers and facilitators were found for knowledge, skills, memory/attention/decision making processes, and behavioural regulation. For opportunity, barriers and facilitators were found for social/professional influences, as well as environmental context and resources. Finally, for motivation, domains covered included: beliefs about consequences, beliefs about capabilities, optimism, motivations/goals, reinforcement, and emotions. Findings suggest that a wide range of barriers and facilitators affect the implementation of CYP SP to improve mental health and well-being. Interventions which target different domains related to capability, opportunity and motivation should be developed to better facilitate CYP SP.

High-resolution melt curve analysis: An approach for variant detection in the TPO gene of congenital hypothyroid patients in Bangladesh

TPO (Thyroid Peroxidase) is known to be one of the major genes involved in congenital hypothyroid patients with thyroid dyshormonogenesis. The present study aims to validate high-resolution melting (HRM) curve analysis as a substitute method for Sanger sequencing, focusing on the frequently observed non-synonymous mutations c.1117G>T, c.1193G>C, and c.2173A>C in the TPO gene in patients from Bangladesh. We enrolled 36 confirmed cases of congenital hypothyroid patients with dyshormonogenesis to establish the HRM method. Blood specimens were collected, and DNA was extracted followed by PCR and Sanger sequencing. Among the 36 specimens, 20 were pre-sequenced, and variants were characterized through Sanger sequencing. Following pre-sequencing, the 20 pre-sequenced specimens underwent real-time PCR-HRM curve analysis to determine the proper HRM condition for separating the three variations from the wild-type state into heterozygous and homozygous states. Furthermore, 16 unknown specimens were subjected to HRM analysis to validate the method. This method demonstrated a sensitivity and specificity of 100 percent in accurately discerning wild-type alleles from both homozygous and heterozygous states of c.1117G>T (23/36; 63.8%), c.1193G>C (30/36; 83.3%), and c.2173A>C (23/36; 63.8%) variants frequently encountered among 36 Bangladeshi patients. The HRM data was found to be similar to the sequencing result, thus confirming the validity of the HRM approach for TPO gene variant detection. In conclusion, HRM-based molecular technique targeting variants c.1117G>T, c.1193G>C, and c.2173A>C could be used as a high throughput, rapid, reliable, and cost-effective screening approach for the detection of all common mutations in TPO gene in Bangladeshi patients with dyshormonogenesis.

Study of Serum Zinc Level in Patients with Type 2 Diabetes Mellitus

A major global public health concern is the prevalence of diabetes mellitus, especially in developing countries like Bangladesh. While still battling communicable diseases, Bangladesh is already inundated with non-communicable diseases. Type 2 diabetes has been found in almost 90.0% of all instances of diabetes. The main risk factors for type 2 diabetes are an excessively caloric diet, advanced age, sedentary behavior and obesity. Along with preexisting risk factors, many micro-nutrients have been related to a rise in the incidence of diabetes. The study's objective was to measure and contrast the zinc levels in serum between individuals with type 2 diabetes mellitus and healthy controls. This cross-sectional study was conducted from July 2018 to June 2019 at the Mymensingh Medical College, Mymensingh, Bangladesh. Based on inclusion and exclusion criteria, the subjects were chosen using a purposeful (non-random) sample method. In total, 100 people participated in this study. They were divided into two groups: 50 individuals who had been diagnosed with type 2 diabetes mellitus were chosen as cases and 50 individuals who appeared to be in generally excellent health were chosen as controls. For the analytical aims of this investigation, serum zinc levels were examined. All values were expressed as the mean SD. The statistical analyses were carried out using the Windows program statistics package for social science (SPSS). The statistical significance of the difference between the case and control groups was evaluated using the Student's unpaired 't' test. A thorough research revealed that type 2 diabetes mellitus patients had significantly lower mean serum zinc levels than healthy controls (case group was 110.96±13.60 and control group 130.18±9.95μg/dl). Cross-sectional research was used in this study. The current study's findings showed that type 2 diabetes mellitus patients had dramatically changed serum zinc levels. The study's hypothesis was verified as a result.

Comparison of Serum Zinc in Children of Wilson Disease and Non-Wilsonian Volunteers in Bangladesh

Wilson disease (WD) is an autosomal recessive disorder of copper metabolism with diverse clinical manifestations. Zinc (Zn) has been used for treatment of WD. Recent studies showed low serum zinc level in patients suffering from WD than the normal. This cross-sectional analytical study has been designed to compare the serum zinc level between paediatric patients suffering from WD but yet not started treatment and children who have normal ALT level. This study was carried out at the Department of Pediatric Gastroenterology and Nutrition, BSMMU, Dhaka, Bangladesh from July 2018 to June 2019. Total 51 children were included in this study. Among them 27 were diagnosed case of WD aged between three to eighteen years and 24 children of same ages who were suffering from other than liver disease having normal ALT were included as volunteers. The patients of WD were divided into four groups according to their presentation as acute hepatitis, chronic liver disease (CLD), acute liver failure & neuropsychiatric manifestation. Informed written consent was obtained from all patients and volunteers for participation in this study. Along with other physical findings and laboratory investigations 3 ml of venous blood were collected for estimation of serum zinc level. After estimation of serum zinc level results were analyzed statistically. The difference in serum zinc levels were compared between the groups. Serum zinc level was significantly lower in Wilson disease patients (43.8±19.7μg/dl; range: 13-83) compared to volunteers group (67.8±11.8μg/dl; range: 47-97) p<0.001. Among the diseased group, serum zinc level were significantly lower in 18 CLD (38.4±17.4μg/dl) and in 4 acute liver failure (33.1±3.7μg/dl) compared to 4 acute hepatitis (71.8±4.3μg/dl) (p=0.001) and (p<0.001) respectively. Mean serum zinc level was low in 4 Wilsonian acute liver failure (33.1±3.7μg/dl), which was significant compared to those (23) who presented as Wilson disease non acute liver failure (45.7±20.8μg/dl) (p=0.013). Serum zinc level was significantly lower in Wilson disease children compared to the volunteers. Zinc level was also found significantly low in Wilson disease presented as CLD and acute liver failure in comparison to Wilson disease presented as acute hepatitis.

Antibacterial and antibiotic potentiating capabilities of extracts isolated from Burkillanthus malaccensis, Diospyros hasseltii and Cleisthanthus bracteosus against human pathogenic bacteria

Antibiotics which once a boon in medicine and saved millions of lives are now facing an ever-growing menace of antibacterial resistance, which desperately needs new antibacterial drugs which are innovative in chemistry and mode of action. For many years, the world has turned to natural plants with antibacterial properties to combat antibiotic resistance. On that basis, we aimed to identify plants with antibacterial and antibiotic potentiating properties. Seventeen different extracts of 3 plants namely Burkillanthus malaccensis, Diospyros hasseltii and Cleisthanthus bracteosus were tested against multi-drug resistant Acinetobacter baumannii, Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Methicillinresistant Staphylococcus aureus (MRSA) and methicillin-susceptible Staphylococcus aureus (MSSA). Antibacterial activity of hexane, methanol and chloroform extracts of bark, seed, fruit, flesh and leaves from these plants were tested using, disk diffusion assay, minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) assays. Antibiotic potentiating capabilities were tested using time-kill assay. B. malaccensis fruit chloroform extract showed the biggest zone of inhibition against MRSA (13.00±0.0 mm) but C. bracteosus bark methanol extract showed the biggest inhibition zone against MSSA (15.33±0.6 mm). Interestingly, bark methanol extract of C. bracteosus was active against MRSA (8.7±0.6 mm), MSSA (7.7±0.6 mm) (Gram-positive) and A. baumannii (7.7±0.6 mm) (Gram-negative). Overall, the leaf methanol and bark methanol extract of C. bracteosus warrants further investigation such as compound isolation and mechanism of action for validating its therapeutic use as antibiotic potentiator importantly against MRSA and A. baumannii.

Relationship of Serum Creatinine Level in Heart Failure Patients in Bangladesh

Heart failure means that the heart is unable to pump blood around the body properly. It usually happens because the heart has become too weak or stuff. In collaboration with department of Cardiology, Mymensingh Medical College Hospital, Mymensingh, Bangladesh this cross-sectional study from January to December 2018 was performed in the department of Biochemistry in Mymensingh Medical College, Mymensingh, Bangladesh. The aim of this study was to explore the relationship of serum creatinine in patients with heart failure (HF) for management purpose. In this study 120 subjects were included, where 60 patients of diagnosed HF acts as case group and 60 individuals were normal healthy acts as control group. Serum creatinine was determined by colorimetric method from each sample. Statistical analysis was performed by SPSS windows package, version 21. Among the study groups the mean serum creatinine levels were 2.20±0.87mg/dl and 0.92±0.26mg/dl in case and control group respectively. Analysis showed that the mean serum creatinine level was highly significantly (p<0.001) increased in HF patients in comparison to that of control group.

Study of Serum Calcium and Magnesium Levels in Type 2 Diabetes Mellitus Patients

The prevalence of diabetes mellitus is a significant global public health concern, particularly in emerging nations like Bangladesh. Bangladesh is already overrun with non-communicable diseases while still battling communicable diseases. About 90.0% of all cases of diabetes that have been diagnosed are type 2 diabetes. High calorie diet, age, sedentary lifestyle and obesity are the main risk factors for type 2 diabetes. Different micronutrients have been linked to an increased incidence of diabetes in addition to existing risk factors. The goal of the study was to assess the serum levels of calcium and magnesium in people with type 2 diabetes mellitus and compare them to those in healthy controls. This cross-sectional study was conducted from July 2018 to June 2019 at the Mymensingh Medical College, Mymensingh, Department of Biochemistry in cooperation with the Department of Endocrinology, Mymensingh Medical College Hospital, Mymensingh, Bangladesh. Purposive (non-random) sampling was used to pick the subjects based on inclusion and exclusion criteria. This study had 100 individuals in total. Out of them, 50 people with type 2 diabetes mellitus who had been diagnosed were chosen as cases, and another 50 people who appeared to be in generally good health were chosen as controls. Serum calcium and magnesium levels were measured for this study's analytical purposes. The mean±SD was used to express all values. The statistical package for social science (SPSS), a Windows application, was used to conduct the statistical analyses. Using the Student's unpaired 't' test, the statistical significance of the difference between the case and control groups was assessed. Following comprehensive analysis, it was discovered that type 2 diabetes mellitus patients had considerably lower mean serum calcium (in case group was 8.46±0.63 and control group 8.86±0.64mg/dl) and magnesium levels (in case group was 2.09±0.42 and control group 2.24±0.16mg/dl) than healthy controls. According to the results of the current investigation, patients with type 2 diabetes mellitus had significantly altered serum calcium and magnesium levels. As a result, the study's hypothesis was accepted.

Assessing the Effectiveness of Clinical Skills Laboratory and Traditional Lecture in Teaching Basic Life Support and Performance Evaluation According to Different Domains of Revised Bloom's Taxonomy

Sudden cardiac arrest out-side hospital is serious global concern. If non-medical people are taught to initiate the basic life support (BLS) training with cardiopulmonary resuscitation (CPR) then the mortality could be reduced significantly. This was a non-randomized controlled study to evaluate clinical skills laboratory (CSL) as teaching tool for basic life support (BLS) training in comparison to traditional lecture. Sample size was 68 and performed in Sylhet Women's Medical College from July 2022 to September 2022. All the participants were third year nursing students. They were enrolled in to two groups. Group-A were taught BLS by clinical skills laboratory (CSL) and Group-B were taught by traditional lecture (TL). At the end of the teaching all of them were tested by a vetted multiple choice question (MCQ) set. The questions were set according the 5 levels of revised Blood's taxonomy. Mean score of Group-A (CSL) were higher the TL group (p=0.0003). Among the revised Bloom's taxonomy understand, apply and evaluate domains were significantly better taught (p<0.05) by CSL. The sensitivity of CSL was 0.559 in comparison to TL for BLS training. In the modern medical education teaching and assessment should be focused on the higher levels of learning taxonomy. Introducing CSL in medical education could boost up the psychomotor and cognition both in the medical education.

HbA1c and Troponin-I Levels and Their Relationship in Patients with Acute Coronary Syndrome

Acute coronary syndrome is a growing public health concern. Diabetic patients are more vulnerable to develop acute coronary syndrome due to accelerated atherosclerosis. Acute coronary syndrome is common in diabetes mellitus and is a major cause of mortality and morbidity in these patients. Troponin-I is a biochemical marker for cardiac muscle injury. Elevated glycated hemoglobin (HbA1c) is also regarded as an independent risk factor for acute coronary syndrome in patients with diabetes mellitus.The aim of this study was to assess the relationship of HbA1c and Troponin-I level in patients with acute coronary syndrome. This cross-sectional study was conducted in the Department of Biochemistry, Dhaka Medical College, Dhaka, Bangladesh from July 2018 to June 2019. Total study subjects were ninety five of both gender selected from the admitted patients of the cardiology department of the National Institute of Cardiovascular Diseases (NICVD), Dhaka. Diagnosis of acute coronary syndrome was confirmed by cardiologist. Diagnosis of diabetes mellitus was confirmed by Random Blood Glucose (RBG) level. Study subjects were grouped, acute coronary syndrome with diabetes mellitus as Group A and acute coronary syndrome without diabetes mellitus as Group B. Baseline parameters was recorded in data collection sheet. HbA1c, Troponin-I level of all study subjects were analyzed and recorded. Mean age of the study subjects in Group A and Group B were 51.06 years and 51.66 years respectively. Male gender was predominant in both groups. Mean SBP and DBP were significantly higher in Group A than Group B. Mean HbA1c level of the study subjects in Group A was significantly higher than Group B (p=0.001). Mean Troponin-I level in Group A was also significantly higher than Group B (p=0.023). HbA1c and Troponin-I levels were positively correlated in Group A (r=0.471, p=0.001). The present study demonstrated significant positive correlation of HbA1c and Troponin-I level in diabetic patients with acute coronary syndrome.

Study of Changes in Serum Copper Level in Patients with Acute Myocardial Infarction

Acute myocardial infarction (AMI) commonly known as heart attack is defined pathologically as the irreversible death of myocardial cells caused by ischemia. Risk factors include high blood pressure, smoking, diabetes, lack of exercise, obesity, high blood cholesterol and excessive alcohol intake. The major cause of acute MI is coronary atherosclerosis with superimposed luminal thrombus, which accounts for more than 80% of all infarcts. Micronutrients and trace elements are very essential for normal functioning of the body. Even though they are required in very small amount, an alteration in the level of this element may lead to serious diseases like CAD and its consequences. The injury induced by reperfusion of the ischemic myocardium could result partially from the cytotoxic effects of oxygen free radicals. Copper is involved in several of the reactions in the protection from free radical damage. So, this study was designed to evaluate serum cupper level in AMI patients. This case-control study was conducted in the Department of Biochemistry, Mymensingh Medical College, Mymensingh, Bangladesh from July 2016 to June 2017. Total number of subjects was 120 in number. Among them 60 were diagnosed case of acute myocardial infarction and 60 were apparently healthy volunteers. Data were collected using pre-designed data collection sheets. After proper counseling informed written consent was taken from the study population. The study revealed that mean serum copper level was higher in case group as compared to control group. The mean±SD values of copper were 105.44±24.15μg/dl and 146.49±23.52μg/dl in control and case group respectively. The level of significance was 0.001 (p<0.05). After analyzing the results of the study it is concluded that serum copper level was significantly higher in Acute Myocardial Infarction patients than normal individuals. Therefore, estimation of serum copper level in AMI patients might be useful to take appropriate measure to prevent free radical induced reperfusion injury.

Evaluation of Liver Function Tests in β-Thalassemia Major Children

Thalassemia is the most prevalent single gene defect in human beings worldwide. Repeated blood transfusions along with chelation therapy are mainstay of treatment in thalassemia patients. However these recurrent blood transfusions result in iron overload which along with chelation therapy causes deterioration of liver function. Aim of the study was to evaluate the liver function tests in β-thalassemia major patients. This cross sectional study was conducted in the Department of Biochemistry, Dhaka Medical College, Dhaka, Bangladesh from January 2017 to December 2017. In this study, 50 diagnosed patients of β Thalassemia major (Group A) and 50 apparently healthy children (Group B) of both sexes were selected from the department of Paediatrics, Dhaka medical college. The study parameters were serum ferritin, bilirubin, AST, ALT, ALP. The results were compared statistically between groups. Serum ferritin level (mean±SD) in thalassemic major patients in Group A (890±446.38 microgram/L) which is significantly higher above normal level. Serum bilirubin in Group A (3.27±2.62 mg/dl) and in Group B (0.48±0.24 mg/dl), Serum ALT in Group A (53.06±34.0 U/L) and in Group B (16.70±4.81 U/L), AST in Group A (84.56±33.54 U/L) and in Group B (11.60±2.72 U/L) and ALP levels in Group A (422.42±226.99 IU/L) and in Group B (221.86±80.54 IU/L). All the values were significantly higher (p<0.001) in β-thalassemia patient than that of normal children. This study concludes that liver function parameters are significantly higher in β thalassemia major patients. So routine evaluation of liver function tests may be advocated for thalassemic patients to predict early onset of hepatic dysfunction.

Ocular Manifestation and Correlation with CD4+ T Cell Count among Adult HIV/AIDS Patients in Bangladesh

Patients with HIV or AIDS suffer from wide varieties of complications that are related to infection. The eye as an organ is not spared from HIV-related manifestations. The ocular manifestations can be the presenting sign of a systemic infection in an otherwise asymptomatic HIV-positive person. The disease can have adnexal, anterior segment, posterior segment, orbital and neuro-ophthalmic manifestations. The objective of the study was to evaluate the ophthalmological manifestations among adult HIV infected patients of Bangladesh and co-relate the findings with CD-4+ T cell count. This cross sectional study was conducted in the department of Community Ophthalmology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from January 2013 to September 2015. Purposive sampling technique was applied to enroll the patients. Total 110 patients were enrolled regardless of their immunological status by inclusion and exclusion criteria. Relevant clinical evaluation including history & physical examinations, laboratory investigations and some ocular examinations like- visual acuity, slit lamp biomicroscopy, IOP, indirect ophthalmoscopy with +90D (diopter) and +20D were done. The age of the study population ranged from 20-58 years with mean±SD 37.63±8.16 years. Among the study population 67(60.9%) were male and 43(39.1%) were female. According to ART status, 58(52.7%) were on ART and 52(47.3%) were ART naive. The mean CD4+ T- cells count was 410±281.65 with minimum to maximum was 6-1266 cells/μl. Among them 53(48.2%) had HIV related ocular findings and 57(51.8%) had no HIV related ocular manifestation. In relation with CD+ T- cells count, highly significant relation was found with lower CD4+ T- cells count and ocular manifestation (p=0.001).

POS1547-HPR CREATION OF A MULTI-DISCIPLINARY TEAM (MDT) RHEUMATOLOGY CLINIC AT UNIVERSITY COLLEGE LONDON HOSPITAL (UCLH) TO TACKLE THE BACKLOG OF PATIENTS WAITING FOR TREATMENT AS A RESULT OF THE COVID-19 PANDEMIC

Background

Covid-19 has consumed hospital resources since January 2020. In the UK, routine care has been disrupted with an estimated 30 million fewer outpatient attendances (2020/21) and over 6 million patients waiting for consultant led care (1). The British Society for Rheumatology ‘Rheumatology Workforce: a crisis in numbers (2021)’ highlights the challenges facing National Health Service rheumatology departments in managing rising caseloads (2). In 2021, UCLH wait time for follow up rheumatology appointments was 9 months. We were inundated with patients requiring urgent treatment. Innovative ways of running outpatients were required which led to the formation of an MDT clinic.

Objectives

Create a Rheumatology MDT clinic to:

Reduce follow up time

Increase clinic capacity

Reduce number of hospital attendances

Add value to each clinic encounter

Methods

The consultant lead identified an existing clinical nurse specialist (CNS) interested in supporting the MDT. With a UCLH Outpatient Transformation grant of £15,000 we recruited an advanced physiotherapy practitioner (APP) and administrator for a 6 month trial period. Managerial support was provided by the board. We met weekly to agree aims and allocate responsibilities. We did the following:

•Reviewed clinic lists for 6 months to identify duplicate appointments.

•Identified patients with CNS and consultant follow up scheduled in a short time frame and cancelled unnecessary appointments.

•Reviewed the clinic list weekly to identify patients suitable for APP management. This allowed overbooking of urgent cases.

•Embedded hand ultrasound appointments in the clinic template.

•Created CNS ‘Zoom’ virtual drop-ins for routine enquiries to reduce the administrative burden of patient emails/phone calls occurring outside the clinic.

•Organised patient participation sessions to help shape the service and collected patient feedback questionnaires.

Results

We reduced our waiting time for follow up appointments from 9 months to 2 months. Pre-MDT the average wait from consultant referral to physiotherapist appointment was 55 days. The MDT allows for same day assessment (reducing 2-3 patient journeys a clinic) and where suitable, facilitates discharge or onwards referral to the appropriate service i.e. pain management, hand therapy, APP-led hypermobility programme. A dedicated MDT CNS has shortened treatment times, reduced email traffic between CNS and consultant and allows for same day, joint decision making resulting in fewer appointments. Patients welcomed the Zoom sessions as an efficient, reliable method of raising concerns/queries. Our administrator helps to facilitate communication between patients and clinicians and streamline MDT processes. Embedding point of care ultrasound reduces hospital visits and enhances treatment decision making thereby reducing follow up attendances.

Conclusion

Our MDT model has reduced waiting lists, decreased treatment delays and cut the number of hospital visits. Performing ultrasound in clinic helped prevent patients being sent for scans at private providers. This cost saving likely covers the APP, ensuring the project is close to cost neutral. Shared decision making added value to outpatient attendances, reflected in patients positive feedback. The MDT enhances the role of APP and CNS, utilising their unique skill set. Administrative support is crucial, enhances team working and places added value on this often underappreciated role. We encourage other Rheumatology departments to adopt an MDT approach to tackle the backlog of patients awaiting treatment, add value to clinic encounters and maximise the skill set of clinicians involved in patient care.

References

[1]NHS backlog data analysis. British Medical Association. Online; NHS backlog data analysis (bma.org.uk)

[2]Rheumatology workforce: a crisis in numbers. British Society for Rheumatology. Workforce Policy Report 2021. BSR-workforce-report-crisis-numbers.pdf (rheumatology.org.uk)

Acknowledgements

I would like to thank the UCLH Outpatient Transformation Team for their support and funding to carry out this pilot project.

Disclosure of Interests

None declared

Comparative Effect of Losartan and Atenolol on Heart Rate Variability in Untreated Essential Hypertensive Patients by Power Spectral Analysis

Autonomic balance in untreated essential hypertension is altered and antihypertensive drugs may improve autonomic balance. Losartan and atenolol is drug of choice to treat essential hypertension. Power spectral analysis of Heart Rate Variability (HRV) is a tool for detecting autonomic balance. This study aimed to compare the effect of losartan and atenolol on autonomic balance in essential hypertensive patients. This longitudinal study was conducted in the Department of Physiology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from July 2012 to June 2013. For this study, 120 diagnosed male hypertensive patients without any treatment (age 30-55 years) were selected from the Out Patients Department of Cardiology, BSMMU, Dhaka on their first day of visit. Sixty apparently healthy normotensive male subjects with similar age were also studied as control. Patients were divided into two equal groups. Sixty (60) patients received 50 mg losartan (oral) and 60 patients received 50 mg atenolol (oral) daily. Autonomic balance was assessed by power spectral analysis of HRV and HRV data were recorded by a polyrite D. HRV data of the patients were measured at baseline, after 3 months and 6 months of medication and data of control were recorded at baseline. For statistical analysis ANOVA, independent sample 't' test and paired sample 't' were performed. High frequency normalized units (HF n.u), total power (TP) were significantly lower (p<0.001) and low frequency normalized unit (LF n.u), LF/HF ratio were significantly higher (p<0.001) in all patients before treatment compared to control. In both drug groups HF n.u and total power were found significantly higher (p<0.001) whereas LF n.u and LF/HF ratio were found significantly lower (p<0.001) after 3 months of treatment compared to their baseline values. After 6 months of treatment, data demonstrated significant further increase (p<0.001) in HF n.u and total power compared to their values after 3 months of treatment. Again these values were found significantly higher in atenolol treated patients compared to losartan group at the end of 6 months of treatment. These result concluded that cardiac autonomic nerve functions may be impaired in essential hypertensive patients before treatment which may improve by treatment with both drugs but the effect is more pronounced in atenolol treatment after longer duration.

A Young Girl with a Complex Female Genital Tract Malformation

Complex malformations of the female genital tract are not as uncommon as they are thought to be. But because of their heterogeneous presentation they often pose a diagnostic dilemma and thus their management plan is crucial. Here we express a case report of a 12 year old girl with a rare and complex female genital tract malformation of uterine didelphys with obstructed hemi uterus due to unilateral cervical agenesis with ipsilateral renal agenesis and contralateral cervical dysgenesis. The girl presented to us with severe lower abdominal pain and progressive pelvic lump. In order to preserve menstrual function and fertility, a cervical fistula was made and the patient has been kept under follow up since then.

An Overview of Unsafe Abortion: Patterns and Outcomes in a Tertiary Level Hospital

Unsafe abortion is one of the most critical global public health concerns and human rights challenges of the current time. The complications arising from unsafe abortion account for the death of almost 192 women each day; that is one woman every eight minutes and nearly all of them in developing countries. It is a descriptive type of observational study where all abortion related admissions from July 2017 to June 2018 in Obstetrics & Gynaecology department of Mymensingh Medical College Hospital were analyzed. Cases of unsafe abortion were identified as missed abortion, incomplete abortion and septic abortion. Total 2396 abortion related cases were admitted in one year. Among them 2173 cases were unsafe abortion (90.69%). The commonest mode of unsafe abortion was by taking improper regimen of different types of oral abortifacients either by self-administration or by improper prescriptions of local medical dispensers in 90% women. The commonest clinical presentation was per vaginal moderate to heavy bleeding in 88.5% women. After evaluation, the commonest diagnosis made was incomplete abortion in 92.87% women. The first line of intervention taken was recommended dose of medications like Misoprostol alone or Misoprostol followed by Mifepristone in 96.3% women to avoid unnecessary endometrial injury by surgical procedure. Further 44.2% women underwent Manual Vacuum Aspiration and thus reducing hospital stay to around 3.0±0.25 days. Almost all the patients (94%) were given post abortion contraceptives along with long acting family planning services to 20% patients. The miserable complication was septic abortion in 1.29% women and they were mainly done by insertion of foreign bodies which contribute to total 4.4% of maternal death. The impact of unsafe abortion on the woman and her family is intimidating. Timely and proper management of unsafe abortions and their complications with adequate provision for post abortion care may reduce the morbidity and mortality related to it. Moreover, use of long acting contraceptives to prevent unintended pregnancy and access to safe abortion may reduce the burden of unsafe abortions on public health system.

Association of Hyperbilirubinemia Requiring Phototherapy or Exchange Transfusion with Hearing Impairment among Admitted Term and Late Preterm Newborn in a NICU

Hearing impairment is one of the deleterious ramifications of neonatal hyperbilirubinemia, but its impact during the newborn period has not been well studied in Bangladesh. This prospective observational study was conducted during January 2016 to December 2017 in the Department of Neonatology and Otolaryngology-Head and Neck Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh to identify the relationship between hyperbilirubinemia requiring phototherapy or exchange transfusion with hearing impairment in term and late preterm neonates. Admitted term and late preterm neonates with hyperbilirubinemia requiring either phototherapy or exchange transfusion were taken as hyperbilirubinemia group. Neonates without hyperbilirubinemia from postnatal ward were taken as control. All newborn were screened with Distortion Product Otoacoustic Emissions (DPOAE) prior to discharge from hospital. A second screen was done in referred newborn after one month of first screen. A diagnostic Auditory Brainstem Response (ABR) was performed in both the ears prior to 3 months of postnatal age if referred in both 1st and 2nd screen. Total 264 neonates included in this study; 132 in the hyperbilirubinemia and 132 in the control group. In the hyperbilirubinemia group 74(56.06%) were male and 58(43.94) were female. Mean gestational ages in the hyperbilirubinemia group and control group were 36.95±1.60 weeks and 37.01±1.67 weeks respectively. Newborn in the hyperbilirubinemia group, 4(3.03%) had hearing impairment and none had hearing impairment in the control group. Peak Total Serum Bilirubin (TSB) 23mg/dl was found as best cut off value with a sensitivity of 100% and specificity of 93% for the development hearing impairment. Hearing impairment was significantly more frequent among newborn with TSB level >23mg/dl when compared to those having TSB level ≤23mg/dl (20% vs. 0.9%, p=0.009; OR=29, 95% CI 2.79, 301). Hearing impairment was associated with newborns with hyperbilirubinemia requiring phototherapy or exchange transfusion. Peak TSB level >23mg/dl can be predictive for the development of hearing impairment.

Home Based Pulmonary Rehabilitation on Oxygenation Status, Dyspnea and Fatigue in Stable Patients with COPD

Pulmonary rehabilitation (PR) program of a sufficient duration has impact on consequence of COPD. To evaluate the effects of combination of pursed lip breathing (PLB), diaphragmatic breathing (DB) and lower extremity endurance training (LEET) as part of PR program in stable patients with COPD on oxygenation status, dyspnea and fatigue. This prospective interventional study was performed in the Department of Physiology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from July 2010 to June 2011 and was performed on 116 male stable moderate COPD patients aged 50 to 65 years. Among them, 56 patients were without PR (control group) and 60 patients were intervened with PR (experimental group). The experimental patients were advised to perform the home based PR program (PLB, DB and LEET) for 30 minutes duration per session at home twice per day, along with standard drug treatment of COPD for uninterrupted 60 days. The control patients continued their treatment of COPD with standard drug for successive 60 days were advised. To evaluate the effects of PR, Peripheral capillary oxygen saturation (SpO₂, by pulse Oximeter), level of dyspnea and level of fatigue by Modified Borg Scale from baseline to end of six minute walk test (6MWT) of all subjects were recorded on day 0 and day 60 for both the groups. Independent sample 't' test and paired Student's 't' test were done with SPSS software. In the interpretation of results, p value of <0.05 was considered as statistically significant. In the present study, we found less decrement of SpO₂ and less increment of level of dyspnea as well as level of fatigue after 6MWT in the COPD patients with PR on 60th day of follow up. The study reveals that oxygenation status, dyspnea and fatigue improve after execution of regular home based PR program in patients with moderate stable COPD.

Clinicoradiologic Profile and Outcome of Children With Tubercular Meningitis in a Tertiary Care Hospital in Bangladesh

BACKGROUND

Children are most vulnerable to tubercular meningitis. Neuroimaging is an important initial investigation in tubercular meningitis.

OBJECTIVE

This study was done to describe the clinical profile, neuroimaging changes, and clinical outcome in children with tubercular meningitis.

METHODOLOGY

This was an observational cohort study on children with tubercular meningitis, between January 2012 and June 2018. Tubercular meningitis was diagnosed on the basis of clinical criteria, cerebrospinal fluid analysis, neuroimaging, and response to antitubercular drug treatment. Preferably magnetic resonance imaging (MRI) with contrast was done.

RESULT

Out of 79 pediatric patients, 17 patients were lost during follow-up; thus, a total of 62 patients were studied. Mean age at presentation was 7.040 (±3.99 SD) year, 51.6% children were male. Rural children were more affected. Twenty eight (45.2 patients had contact with a person with tuberculosis. Only 3 (4.8%) patients presented within 10 days of duration of illness. Most of the cases (67.7%) were in stage 2 at the time of diagnosis. The most common clinical feature was fever, seizure, and signs of meningeal irritation (all present in 12.9%). In neuroimaging most common findings were tuberculoma (50%), hydrocephalus (54.8%), and basal meningeal enhancement (33.8%). Regarding outcome, 6 (9.67%) patients expired and 47 (75%) patients had sequelae. The most common complications were hydrocephalus (30.64%) and intellectual disability (12.9 ). Hydrocephalus was the most common neuroimaging finding among the patients who expired (33%).

CONCLUSION

Hydrocephalus is the most common neuroimaging finding. Normal neuroimaging is associated with good outcome whereas all the patients who died had abnormal neuroimaging.

Sliding Luttinger liquid with alternating interwire couplings

We study a phase diagram for the sliding Luttinger liquid (SLL) of coupled one-dimensional quantum wires packed in a two-dimensional array in the absence of a magnetic field. We analyse whether the nearest-neighbour inter-wire interactions, stabilise the SLL phase. We construct an analogue of a Su-Schriefer-Heeger (SSH) model (allowing alternating couplings between wires). Calculating the scaling dimensions of the two most relevant perturbations, charge-density wave, and superconducting inter-wire couplings, but excluding the inter-wire single-particle hybridisation, we find a finite stability region for the SLL. It emerges due to the inter-wire forward scattering interaction, and remains stable up to a significant asymmetry between alternating couplings.

Fasting Serum Glucose Level in Male Cigarette Smoker

Cigarette smoking is a practice in which tobacco (leaf of Nicotina Tabacum) is burned and the smoke (heterogeneous aerosol) is tasted or inhaled. Smoking may be linked to insulin resistance that leads to impaired glucose and lipid metabolism. Aim of the study was to assess the levels of fasting serum glucose level in healthy male cigarette smokers in order to compare this parameter with healthy non smokers. This comparative study was carried out in the Department of Physiology, Mymensingh Medical College, Mymensingh, Bangladesh from July 2013 to June 2014. One hundred healthy male subjects (75 male were cigarette smokers as study group and 25 male were non smokers as control group) aged between 16 to 40 years were enrolled in this study. Fasting serum glucose was estimated by GOD-PAP Method. Data were expressed as mean±SD and statistical significance of difference among the group was calculated by unpaired students''t' test. The mean±SD fasting serum glucose (FSG) levels were higher in smoker group in comparison to the non smoker group. There were gradual increases in FSG levels in the smokers as the duration of smoking was increased and these were 4.75±0.88, 5.12±0.67, 5.29±0.47 and 5.58±2.05mmol/L in group I, IIA, IIB and IIC respectively. This study concludes cigarette smoking impair the carbohydrate metabolism and increase fasting serum glucose level in accordance with the duration of smoking.

Enzymatic quantification of total serum bile acids as a monitoring strategy for women with intrahepatic cholestasis of pregnancy receiving ursodeoxycholic acid treatment: a cohort study

OBJECTIVE

To evaluate enzymatic total serum bile acid quantification as a monitoring strategy for women with intrahepatic cholestasis of pregnancy (ICP) treated with ursodeoxycholic acid (UDCA).

DESIGN

Cohort.

SETTING

One UK university hospital.

POPULATION

29 ICP cases treated with UDCA.

METHODS

Serial samples were collected prospectively throughout gestation. Total serum bile acids were measured enzymatically and individual bile acids by high-performance liquid chromatography-tandem mass spectrometry. Data were log-transformed and analysed with random effects generalised least square regression.

MAIN OUTCOME MEASURES

The relationship between enzymatic total bile acid measurements and individual bile acid concentrations after UDCA treatment.

RESULTS

In untreated women, cholic acid was the principal bile acid (51%) and UDCA concentrations were <0.5%, whereas UDCA constituted 60% (IQR 43-69) of serum bile acids following treatment and cholic acid fell to <20%. Changes in the total bile acid measurement reflected similar alterations in the concentrations of the pathologically elevated bile acids, e.g. a two-fold increase in enzymatic total bile acids is accompanied by approximately a two-fold increase in cholic acid and chenodeoxycholic acid at most UDCA doses (P < 0.001). Most of the effects of UDCA on cholic acid occur in the first week of treatment (60% relative reduction, P = 0.025, 95% CI 0.2-0.9, from 10 micromol/l (4.7-17.6) to 3.5 micromol/l (1.4-7.5).

CONCLUSION

Ursodeoxycholic acid becomes the main component of the bile acid measurement after treatment. Enzymatic total bile acid assays are good predictors of both cholic acid and chenodeoxycholic acid, the primary bile acids that are raised prior to treatment.

TWEETABLE ABSTRACT

Ursodeoxycholic acid constitutes approximately 60% of the bile acid measurement and reduces pathological cholic acid in treated women.

Serum Calcium Level in Preeclamptic Patients of Bangladesh

Preeclampsia is one of the most frequent complication of pregnancy which manifested by hypertension during pregnancy for the first time after 20th weeks of gestation with proteinuria. The aim of the study was to estimate the changes in serum calcium level in preeclamptic patients when compared with normal pregnant women. The case control study was carried out in the Department of Biochemistry, Mymensingh Medical College, Mymensingh, Bangladesh in collaboration with the Department of Obstetrics and Gynecology, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from July 2016 to June 2017. A total of 100 subjects were included. Among them 50 were subjects of preeclamptic patients as case and another 50 were apparently healthy normal pregnant women as control. The study revealed that serum calcium level was lower in preeclamptic women (case) as compared to healthy control subjects. The mean values of serum calcium levels were 7.63±0.42 and 8.12±0.94mg/dl in case and control group respectively. The difference in mean serum calcium were highly significant (p<0.001) when compared between case and control.

Transmigrated and Impacted Upper 2nd Premolar Associated with Dentigerous Cyst

A male patient about 45 years old came to my private clinic "The Dental Aid", Dhanmondi, Dhaka, Bangladesh last year (February 2016) with the complaint of pain at right palatal premolar region. On clinical examination we found the absence of upper left 2nd premolar from the series of dentition but on the right side premolars are present. The oral mucosa was intact and normal in color. There was no caries, dental pocket or any other pathology in the teeth of both jaws. On palpation we found soft area on the right palatal side at the premolar area. We took intraoral peri-apical radiograph and found impacted left 2nd premolar whose crown was encircled by radiolucent area at the palatal side. Here, we present a rare case of transmigrated and impacted left 2nd maxillary premolar associated with dentigerous cyst. The cyst was successfully treated under general anaesthesia by enucleation along with extraction of the involved maxillary transposed and impacted left second premolar.

Comparison between Carbetocin and Oxytocin in Active Management of 3rd Stage of Labour in Preventing Post Partum Hemorrhage

The third stage of labour is considered to be the most critical part of child birth due to the risk of post partum haemorrhage (PPH). To compare the effectiveness of carbetocin and oxytocin in the management of 3rd stage of labour in preventing post partum hemorrhage, this experimental clinical trial was conducted in the Department of Obstetrics and Gynecology, Sir Salimulla Medical College Hospital, Dhaka, Bangladesh from January 2015 to June 2016. Three hundred women undergoing normal vaginal delivery were consecutively enrolled. They were divided into two groups, one group was treated with carbetocin 100μg IV and another group was treated with oxytocin 10 unit IV. Post partum haemorrhage was developed in 23(15.3%) and 31(20.7%) patients in carbetocin and oxytocin groups respectively. Among these PPH patients, 17(73.9%) patients received oxytocin, 21(91.3%) patients received Ergometrin and 14(60.9%) patients received misoprostol in carbetocin group as additional drug. In oxytocin group 30(96.8) patients received ergometrin and 26(83.9) patients received misoprostol. Significantly higher number of patients was treated with balloon catheter in oxytocin group (77.4%) than carbetocin group (39.1%). Thirteen (41.9%) patients in oxytocin group and 4(17.4%) patients in carbetocin group needed to treat in ICU. In carbetocin Group I patient (4.3%) and in oxytocin Group II patients (6.5%) died. carbetocin is better than oxytocin in the management of 3rd stage of labour to prevent post partum haemorrhage (PPH).

Neonatal Glycemic Status of Infants of Diabetic Mothers in a Tertiary Care Hospital

BACKGROUND

Diabetes is a common medical complication during pregnancy that results in significant neonatal morbidities. In infants of diabetic mothers (IDMs), hypoglycemia is a common complication.

OBJECTIVE

To study the neonatal hypoglycemia in IDMs in a tertiary care hospital.

SETTINGS AND DESIGN

A cross-sectional study was done in postnatal ward in Bangladesh Institute of Research and Rehabilitation in Diabetic, Endocrine and Metabolic Disorders from January to December 2009.

SUBJECTS AND METHODS

The data of IDMs were collected from postnatal ward. All IDMs delivered during this period staying in postnatal ward were included in this study. The outcomes were compared between the hypoglycemic and normoglycemic IDMs and between gestational diabetes mellitus (GDM) and pre-GDM in hypoglycemic group using Chi-square test and Fisher's exact test. The data analysis was performed with Epi-enfo7 software. Statistical significance was set at P < 0.05.

RESULTS

A total of 363 IDMs were included in this study. Hypoglycemia developed in 38.3% IDMs and 43.2% mothers of hypoglycemic IDMs had GDM and 56.8% had pre-GDM. Duration of maternal diabetes (P = 0.04) and large for gestational age (P = 0.0001) were associated with hypoglycemia. Multigravidae (82.2% vs 68.3%, P = 0.03), prolonged duration of maternal diabetes (45.46 weeks vs 3.23 weeks, P = 0.00001), preterm babies (48.1% vs 28.3% P = 0.009), and control of diabetes by insulin (81% vs 46.7%, P = 0.001) were more in pre-GDM, and statistically significant. About 85% IDMs developed hypoglycemia within 6 h of birth (P-value 0.00001) and majority (68%) were at 2 h of age. Forty percent of hypoglycemic IDMs from postnatal ward were admitted in special care baby unit.

CONCLUSION

Hypoglycemia observed in 38.3% IDMs and developed within 6 h of age and maximum were at 2 h. Early recognition and appropriate intervention are needed in IDMs.

Alternating Hemiplegia of Childhood: Report of Two Cases

Alternating hemiplegia of childhood (AHC) is a rare disorder which presents before 18 months of age characterized by repeated attacks of hemiplegia involving either side of the body, paroxysmal disturbances,developmental delay and learning disability. The cause of AHC remains largely unknown and treatment evidence is less available. AHC is unreported in Bangladeshi literature. We report two cases of AHC. Our first case is a 16-month-old girl who presented with hemiplegia in alternate side for four episodes. She also had abnormal body movement and irritability during awakening. Every episode subsided spontaneously after 2 to 5 days. All investigations were normal except iron deficiency anemia. She was treated with flunarizine. Our second case, a 7 year and 10 month-old boy presented with recurrent alternate hemiplegia since 3½ years of age with epilepsy. His attacks were precipitated in high temperature. His EEG was abnormal. He was treated with multiple antiepileptic drugs and flunarizine. These are first two cases reported from Bangladesh. AHC remains undiagnosed in many cases. So a detailed history and diagnostic evaluation is very important for early counseling and treatment.J Enam Med Col 2018; 8(1): 46-49

Non-convulsive Status Epilepticus in Children: Clinical Profile, EEG Characteristics and Treatment

Non-convulsive status epilepticus (NCSE) is a term used to denote a range of conditions in which electrographic seizure activity is prolonged and results in non-convulsive clinical symptoms. This study was done to describe the clinical spectrum, EEG findings and to evaluate the efficacy of different therapeutic agents in children with NCSE in 33 patients from January 2011 to December 2015 period. All patients had EEG before and after treatment. Age range was 6 months to 14 year, 25 were male. Regarding development status, 48% had developmental delay, 21% had normal development, 9% had regression and 21% had both developmental delay and regression. Twenty nine cases were previously diagnosed as epilepsy. EEG diagnosis was as follows: Generalized NCSE 23(69%), focal 9(27%), unknown 1(3%). Eighteen patients were treated with Midazolam drip out of which 1 patient had complete remission in EEG, 6 had >80% remission, 5 had >50% remission and 5 patients had minimal or no response. Thirteen patients were treated with methyl prednisolone bolus out of which 2 patients had complete remission, 4 patients had >80% remission while 4 patients had >50% remission and 3 patients showed no response. NCSE may present with various clinical feature without any convulsion. Midazolam, methyl prednisolone and oral drugs are equally effective for treatment of NCSE. However, further randomized controlled study is needed to chalk out management of NCSE.

Clinical profile and pattern of congenital heart disease in infants of diabetic mother and infants of non-diabetic mother at a tertiary care hospital

OBJECTIVES

To assess the clinical manifestations and pattern of congenital heart diseases (CHD) in infants of diabetic mothers (IDMs) and infants of non-diabetic mothers.

METHODS

A prospective cross sectional study was carried out at tertiary care center over a period of thirty months. All neonates were included in this study if CHD were identified by echocardiography within this study period. Chi-square test and Fisher's exact test were used to compare between groups.

RESULT

Out of 62 neonates, IDMs and non-IDMs were equal in number, male and female ratio was 3 : 2, and majority were delivered by cesarean section (85.5%). Mean gestational age was 35 weeks, 62.3% were preterm, and 37.7% were term. Common clinical presentations were cardiac murmur (61%), and respiratory distress (43.5%). Less common presentations were low SaO2 (27.4%), tachycardia (24.2%), and cyanosis (24.2%). Common combination of presentations were murmur and tachypnea (38.7%); cyanosis and low SaO2 (24.19%); and low SaO2 and tachypnea 15(24.19). The common echocardiographic findings were atrial septal defect (ASD; 72.6%), patent ductus arteriosus (PDA; 45.2%), and ventricular septal defect (VSD; 25.8%). ASD (77.4% vs 67.7%) and VSD (35.5% vs 16.1%) were more in IDMs, and PDA (48.4% vs 41.9%) was more in non-IDMs. These differences were not significant between groups.

CONCLUSION

Clinical presentation and echocardiographic findings of CHD were similar in IDMs and non-IDMs.

Death audit in the neonatal ICU of a tertiary care hospital in Bangladesh: a retrospective chart review

BACKGROUND

Expectant reduction of neonatal mortality and formulation of preventive strategies can only be achieved by analysis of risk factors in a particular setting. This study aimed to document incidence of neonatal death and to analyze the risk factors associated with neonatal death.

METHODS

This retrospective study was carried out in department of Neonatology, Bangabandhu Sheikh Mujib Medical University (BSMMU) over a 12-month period from January to December 2015. The newborns that died within 28 d of life were defined as "Cases" and "Control" were the surviving newborn discharged to home as healthy. Two birth weight and gestational age matched controls were taken for each case. Maternal, obstetric, and newborn characteristics were analyzed between both the groups. Data analysis was performed using SPSS version 20.0 (SPSS Inc., Chicago, IL). A probability of < .05 was considered statistically significant. The strength of association was determined by calculating odds ratio and their 95% confidence intervals (CIs).

RESULTS

During the study period, the proportion of death was 9.6% (64/612). Both in Chi-square analysis and in logistic regression analysis, less than four antenatal visits (odds ratio (OR) 2.78; 95% CI: 1.23-6.28, p = .014) and sepsis (OR 2.37; 95% CI: 1.07-5.26, p = .034) were found to be independent risk factors for deaths, whereas LUCS found to be protective for deaths (OR 0.40; 95% CI: 0.19-0.83, p = .015).

CONCLUSION

In conclusion, less than four antenatal visits and presence of sepsis were found to be independent risk factors whereas LUCS protective of newborn death.

Barriers to and enablers of insulin self-titration in adults with Type 2 diabetes: a qualitative study

AIMS

To identify the barriers to and enablers of effective insulin self-titration in people with Type 2 diabetes.

METHODS

A qualitative semi-structured interview approach was used. Questions were structured according to the Theoretical Domains Framework, which outlines 14 domains that can act as barriers to and enablers of changing behaviour. Interviews were audio-recorded and transcribed verbatim. The data were coded according to the 14 domains, belief statements were created within each domain, and a frequency count of the most reported barriers and enablers was then carried out. Analyses were conducted by two researchers, and discrepancies agreed with a third researcher.

RESULTS

A total of 18 adults with Type 2 diabetes took part in an interview. The majority were of South-Asian ethnicity (n = 8) and were men (n = 12). Their mean age was 61 years old. The mean duration of diabetes was 16 years and time on insulin 9 years. Inter-rater reliability for each of the domains varied (29-100%). The most frequently reported domains were Social Influence and Beliefs about Consequences; the least frequently reported were Optimism and Reinforcement. Interviewees reported receiving support to self-titrate from a range of sources. Self-titrating was perceived to have a range of both positive and negative consequences, as was not titrating.

CONCLUSIONS

The findings highlight that those interviewed experienced a range of barriers and enablers when attempting to self-titrate. Improved education and training when initiating insulin treatment among adults with Type 2 diabetes, and throughout their journey on insulin therapy could help identify and address these barriers in order to optimize self-titration.

Bardet-Biedl syndrome

<p>The Bardet-Biedl syndrome is a rare genetically heterogeneous, autosomal recessive inherited disorder with wide variability in expression. It presents with varied clinical manifestations like retinitis pigmentosa, polydactyly, central obesity, mental retardation and renal dysfunction. Other rare manifestations include diabetes mellitus, heart disease, hepatic fibrosis and neurological manifestations. Mutations in 16 genes have been identified as causative factors. We, here, have presented a 12 year old male patient exhibiting characteristic features of Bardet Biedl syndrome.</p><p> </p>

Pediatric gastrointestinal tuberculosis with hematochezia and polyarthritis: An unusual presentation

Tuberculosis may present with variable symptoms and signs, sometimes presentations are unusual. An eight year old boy was admitted with the complaints of low grade fever, weight loss, abdominal pain, hematochezia and polyarthritis. Colonic biopsy was suggestive of tuberculosis and Gene-Xpart of sputum showed of multidrug resistant tuberculosis. We are reporting a case presented with hematochezia and poloyarthritis, an unusual presentation who was subsequently diagnosed as a case of multi drug resistant intestinal tuberculosis.

Towards predicting the solubility of CO2 and N2 in different polymers using a quasi-SMILES based QSPR approach

The solubility of gases in various polymers plays an important role for the design of new polymeric materials. Quantitative structure-property relationship (QSPR) models were designed to predict the solubility of gases such as CO2 and N2 in polyethylene (PE), polypropylene (PP), polystyrene (PS), polyvinyl acetate (PVA) and poly (butylene succinate) (PBS) at different temperatures and pressures by using quasi-SMILES codes. The dataset of 315 systems was split randomly into training, calibration and validation sets; random split 1 led to 214 training (r(2) = 0.870 and RMSE = 0.019), 51 calibration (r(2) = 0.858 and RMSE = 0.020) and 50 validation (r(2) = 0.869 and RMSE = 0.017) sets. The suggested approach based on the quasi-SMILES, which are analogues of the traditional SMILES gives reasonable good predictions for solubility of CO2 and N2 in different polymers. The described methodology is universal for situations where the aim is to predict the response of an eclectic system upon a variety of physicochemical and/or biochemical conditions.