Comparative Study between Paracervical Block and Non-Steroidal Anti Inflammatory Drug for Relief of Pain during Manual Vacuum Aspiration Procedure

The incidence of first trimester pregnancy loss is around 10.0-20.0% of registered pregnancies. Manual vacuum aspiration is a safe, effective and acceptable option of treatment for patients diagnosed with first trimester pregnancy loss. Main disadvantage of MVA is the pain caused by manipulation of the cervix, the uterine suction and the cervical dilatation. This study showed the way how the pain and discomfort might be reduced. This was a cross-sectional comparative study was conducted at the obstetrics and Gynecological Department of Sadar hospital, Manikganj, Bangladesh from January 2017 to December 2017. All the consecutive women admitted and diagnosed as incomplete abortion, missed abortion and anembryonic pregnancy (blighted ovum) were included in this study. Sampling technique was purposive sampling. The objective of this study was to compare the effectiveness of paracervical block anesthesia with non-steroidal anti inflammatory drug (NSAID) for relief of pain during the manual vacuum aspiration procedure for the treatment of first trimester pregnancy loss. Total 120 cases were included in this study. Assigned study population were divided into two groups like Group A and Group B. 60 of the study population were included in Group A who were given paracervical block anesthesia 3 minutes before the procedure. Another 60 study population was included in Group B who was given diclofenac 75mg intramuscular injection, 30 minutes before the procedure. Both intraoperative and postoperative pain level was evaluated by using visual analog scale ranged from (0-10 points) 30 minutes after the procedure. At the same time the satisfaction level of the study population were measured by 5 points lickert scale. Regarding clinical profile of the study population it showed no significant difference in case of mean age, mean gestational age and mean duration of the procedure between two groups. The mean intraoperative pain score in Group A was 4.0±1.3, in Group B it was 5.4±1.5 (p=0.001) which was significant. So it showed that paracervical block anesthesia significantly reduced the pain in relation to diclofenac 75mg intramuscular injection. Mean postoperative pain level 30 minutes after procedure in Group A was 2.2±0.4 and in Group B was 2.4±0.4 (p=0.343), where post-operative pain is lower in Group A than Group B. Though this difference is not statistically significant (p=0.343). In Group A 73.0% (n=44) and in Group B 43.0% (n=26) study population were agreed that the procedure was easy. Most common adverse effect was epigastric pain which was 1.7% (n=1) in Group A and 10.0% (n=7) in Group B. Paracervical block significantly reduces intraoperative pain during Manual Vacuum Aspiration (MVA) procedure in the treatment of first trimester pregnancy loss in comparison to intramuscular injection of diclofenac. In conclusion it might be mentioned that regarding paracervical block anesthesia, efficacy is higher and side effects are less. Moreover paracervical block anesthesia is cost effective.

Effect of Meconium Staining Amniotic Fluid on Fetal Outcome

Meconium-stained amniotic fluid is the passage of meconium by a fetus in utero during the antenatal period or in labour. It has for long been considered to be a bad predictor of fetal distress and meconium aspiration syndrome (MAS). The objective of this study was to find out the fetal outcome of MSAF and clear amniotic fluid. This cross- sectional comparative study was carried out in Upazilla Health Complex, Palash, Narshingdi from July 2016 to June 2017. A total of 100 pregnant women among them 50 women with MSAF and 50 women with clear liquor were studied to see the record of ANC, mode of delivery and fetal outcome by APGAR score. Study showed that among MSAF group 76.0% (n=38) had irregular ANC and 24.0% (n=12) had regular ANC whereas in clear liquor 86.0% (n=43) had regular ANC 14.0% had irregular ANC. Among MSAF (50 cases) thick meconium was in 20 cases (40.0%) and thin meconium was in 30 cases (60.0%). Regarding mode of delivery 52.0% (n=26) MSAF cases had instrumental delivery and Caesarean section compared to 24.0% (n=12) in clear liquor group. Regarding thick MSAF among 40.0% (n=20), (n=14) had low APGAR score and (n=6) had normal score at one minute and (n=9) low APGAR score and (n=11) normal score at five minutes. In clear liquor, among 100.0% (n=50), 20.0% (n=10) had low APGAR score and 80.0% (n=40) had normal score at one-minute and at five minutes 8.0% (n=4) had low APGAR score and 92.0% (n=46) had normal score. Among MSAF 26.0% (n=13) were admitted to SCBU compare to 12.0% (n=6) in clear liquor group. The mean SCBU stay was 3.1 days in MSAF whereas 1.2 days in clear liquor. Among MSAF babies 4.0% (n=2) had MAS compared to no MAS in clear liquor group. Regarding Survivalist 92.0% (n=46) were alive in MSAF whereas 100.0% all (n=50) were alive in clear liquor group.

Impact of Levothyroxine on Lipid Profile in Patients with Hypothyroidism

Hypothyroidism is a common endocrine disorder and requires lifelong treatment. Hypothyroidism is often associated with dyslipidemia in some populations. The present study was designed to evaluate the impact of levothyroxine (LT₄) on lipid profile in hypothyroid patients. This cross-sectional analytical study was conducted in the Department of Pharmacology & Therapeutics, Rajshahi Medical College in collaboration with the Institute of Nuclear Medicine and Allied Sciences (INMAS), Rajshahi from July 2018 to June 2019 to compare serum total cholesterol (TC), serum triglyceride (TG), serum LDL-C and serum HDL-C levels among euthyroids, newly diagnosed hypothyroid patients and levothyroxine (LT₄) treated hypothyroid patients. A total of 30 patients with newly diagnosed hypothyroidism and an equal number of age-matched healthy controls (n=30, control group) of both sexes were recruited in the present study. Thirty (30) hypothyroid patients were reevaluated after 6 month of LT₄ therapy. The fasting blood samples were collected from the subjects for the estimation of lipid profile. Significantly higher values were observed in total cholesterol (TC) 198.5±19.2mg/dl, triglycerides (TG) 147.0±14.5mg/dl, low density lipoprotein cholesterol (LDL-C) 133.9±19.7mg/dl (p<0.001) and a significant decreased value was seen in high density lipoprotein-cholesterol (HDL-C) levels (35.1±3.67mg/dl) in newly diagnosed hypothyroid patients as compared to after LT₄ therapy and normal healthy individuals (p=0.009). These observations suggest that people with hypothyroidism have high risk of development of atherosclerosis which may lead to coronary heart diseases (CHD) due to persistent dyslipidemia. Hypothyroidism induces dyslipidemia or expedites the process of existing dyslipidemia, LT₄ therapy corrects it to a significant level thus reduce the risk for atherosclerosis.

Clinico-pathological Study of Malignant Ovarian Tumor in a Tertiary Care Hospital

Ovarian cancer is considered as one of the foremost gynecological malignancies due to its complex nature, unpredictable behavior and prognosis. Therefore, varying therapeutic strategies are necessitating an accurate diagnosis of this cancer. This study aimed to observe the frequency, age distribution, clinical presentation, gross features and histopathological pattern of the ovarian tumors among the Bangladeshi population. This cross-sectional observational study included 125 participants who were admitted in Bangabandhu Sheikh Mujib Medical University (BSMMU) with histologically proven ovarian cancer from January 2016 to December 2017. The epidemiological data and histopathological analysis of the ovarian cancer were performed. Among the 125 participants examined, the majority were in two age groups between 21-30 and 41-50 years. Histologically, serous adenocarcinoma (50.4%) was the commonest, least common being endometroid variety (0.8%). Furthermore, 40.1% of participants were presented with stage iii disease. Abdominal distention followed by abdominal pain was the main presenting complains. Adenocarcinoma is mostly serous in variety and higher in younger age group.

Relaparotomy Following Caesarean Section: A Cross Sectional Study

Delivery by caesarean section (CS) is the most common obstetric procedure in daily practice and rate is increasing worldwide. In spite of huge appeal for this operation, there is significant rate of short & long term complications. Relaparotomy after caesarean section in early post-operative period is one of the rarest short term complications but the fatality rate is very high. The objective of this study was to find out indications, managements, risk factors and outcomes of patients undergoing relaparotomy after CS. Finally to improve the quality of care for preventing this dreadful complication and to reduce the maternal mortality and morbidity. Purposive sampling was done, all consecutive patients who underwent relaparotomy within 6 weeks of CS in Rajshahi Medical College Hospital (RMCH) during study period from January 2015 to December 2015 has been included for this study. This was a cross-sectional and observational study in a tertiary referral and teaching hospital RMCH. During study period total admitted obstetric patients at RMCH were 12688. There were 9802 deliveries where 53.89% (n=5282) had vaginal delivery and 46.11% (n=4520) underwent caesarean sections. Among these 46.11% (n=4520) CS, relaparotomy was needed 0.18% (n=8) cases. Total relaparotomy was done in 0.39% (n=50) cases out of 12688 obstetric patients. Out of 50 cases 42 had caesarean delivery in other hospitals and clinics outside RMCH. The indications of relaparotomy were secondary post-partum hemorrhage (PPH) 28% (n=14), primary PPH 12% (n=6), haemoperitoneum 22% (n=11), pyoperitoneum 18% (n=9), subrectal hematoma 16% (n=8) and burst abdomen 4% (n=2). Main surgeries performed were subtotal hysterectomy in 44% (n=22) cases, total abdominal hysterectomy in 10% (n=5) cases, re-suturing of uterine incision 8% (n=4), drainage of pus & peritoneal toileting 8% (n=4), ligation of bleeding vessels 6% (n=3), drainage of subrectalhaematoma in 16% (n=8) cases, repair of intestinal injury 4% (n=2) and repair of anterior abdominal wall in 4% (n=2) cases. Case fatality of relaparotomy was high 18% (n=9), majority were preventable. Identification of risk factors, adequate attention, expert decision, prompt intervention & proper management will improve the outcome.

Induction by Misoprostol In Case of Intra Uterine Fetal Death: A Cross Sectional Study

The objective of this study was to find out the effectiveness and safety of vaginal misoprostol in delivering the dead fetus in cases of intrauterine fetal death (IUFD). This cross sectional study was undertaken among all consecutive patients admitted at the Department of Obstetrics and Gynecology, Dhaka Medical College Hospital, Dhaka, Bangladesh, from October 2012 to September 2013, were included for this study. Vaginal misoprostol was applied in 50 cases that were admitted and diagnosed as a case of IUFD. After taking informed written consent from patients 50μgm of tablet misoprostol was introduced per vaginally into the posterior fornix. Doses were repeated in every 4 hours up to effective contraction to a maximum 6 doses. Follow up was done in hourly interval. Those who did not respond, decision for other methods like oxytocin infusion or LUCS were done. Study showed 60% (n=30) patients belonged to age group of 18-24 years. Among study population 44% (n=22) of the patients belonged to 22-32 weeks of gestation, 30% (n=15) were 33-37 weeks and 26% (n=13) were 38-42 weeks. The causes of intrauterine death were unidentified among 60% (n=30) of cases. Regarding antenatal check up 54% (n=27) had no checkup, 26% (n=13) were irregular and 20% (n=10) were regular. 60% (n=30) of the patients had less Bishop Score <3. Ninety six percent (96%) (n=48) patients responded with vaginal misoprostol and only 4% (n=2) were non responder group. Most 84% (n=42) of the cases needed 2-3 doses, only 8% (n=4) cases needed single dose and 8% (n=4) cases needed 4 to 6 doses. The induction delivery interval varied from 6 to 23 hours and maximum 52% (n=26) of the patients delivered within 12 hours. Adverse effects such as uterine hyper stimulation, tachysystole were not detected. The major complications observed like postpartum hemorrhage 4% (n=2), reduced platelet count 2% (n=1), and chorioamnionitis 4% (n=2). However minor complications like nausea, shivering and mild fever also observed in few cases. Study showed successful induction of labor by misoprostol in a shorter time with significantly less side effects.

27 Re-Audit of Orthostatic Blood Pressure Measurement to Prevent Falls and Fall-Related Complications for Geriatrics Inpatients from A Secondary Care Hospital

Introduction

Orthostatic Hypotension is a common cause of falls leading to injury and morbidity in older adults. In the National Audit of Inpatient Falls 2015 audit, only 16% of 4846 patients had an orthostatic Blood Pressure (L/S BP) recorded by their third day in the hospital. There is also variation in the understanding of how doctors and nurses perform orthostatic BP. This could have adverse effects on detection rates and accuracy of the procedure resulting in misdiagnosis. As a result, the Royal College of Physicians (RCP) has released guidance on Orthostatic BP measurements to perform the standardising practice and improving accuracy. The purpose of this quality improvement project (QIP) is to work on the action plan from the orthostatic BP measurement QIP has done in 2017, by introducing laminated guidelines in patient’s notes and re-audited in 2018 to record any improvement. The re-audit of 2018 showed remarkable improvement but still not as equal as the gold standard as RCP. Therefore, the second loop of re-audit performed in 2019 in major Geriatrics wards and other wards while involved larger sample (patient) numbers. We used four questioners as the audit proforma.

Methods

Wards were audited to find out whether orthostatic BP is measured as per RCP guidelines. Afterward, a laminated copy of the RCP recommended method of measuring orthostatic BP was put into all Early Warning Score ‘Observation’ folders with a sheet designed specifically for recording Orthostatic (L/S BP). The procedure of L/S BP measurement was re-audited after the intervention to find out changes in performing orthostatic (L/S BP) (as per RCP guidelines).

Results

There is a remarkable improvement of outcome reveals in the second loop of re-audit. Regarding RCP guideline compliance, it is 93.33% which is closer to the gold standard. And in case of symptoms identification and documentation, it is 100%, which is equal to the RCP gold standard.

Conclusions

Inclusion of guidelines in notes improves investigation; inclusion of supplementary recording sheet improves documentation. Re-audit reflects the remarkable improvement to compliance with RCP guidelines in measuring Orthostatic BP measurement and patient’s symptoms documentation.

Genitourinary Fistula: A Curse to Neglected Pregnancy

Genitourinary fistula is a psychophysiosocial distress that results in prolonged labour. Gradually, it has become a public health issue globally with advancing of its incidence day by day. A handsome number of mothers are also suffering in Bangladesh from genitourinary fistula. This study was done to observe the patterns of presentations of genitourinary fistula and their fetal outcome. One hundred sixteen (116) consecutive patients were enrolled in the study by purposive sampling as a diagnosed case of genitourinary fistula presented in Department of Obstetrics & Gynecology of Dhaka Medical College Hospital, Dhaka, Bangladesh from January 2017 to September 2017. It was a prospective observational cross-sectional study. A pre-structured, interview and observation based, peer reviewed data collection sheet was prepared. Data regarding sociodemographic, clinical and Obstetrical profile were recorded. Statistical analysis was done with SPSS version 23. Data were presented as mean and standard deviation, frequency and percentage with range. The mean age of the respondents was 27.27±4.21 (age range: 20-35 years). The mean height of the respondents was 150.26±13.28cm (range: 133-172cm). Among 106 mothers 69(65.1%) and 25(23.6%) were primiparous and multiparous respectively. On the contrary, 5(4.7%) each were grand multiparous and experienced fistula due to non obstetrics complications like malignancy, hysterectomy and radiotherapy. Mothers had 1, 2 and 3 fistulas in 98(92.5%), 6(5.7%) and 2(1.9%) respectively. Among 106 mothers, 99(93.4%) experienced only urinary incontinence whereas 5(4.7%) experienced fecal incontinence. Only 2(1.9%) experienced both urinary and fecal incontinence. Maximum vesicovaginal fistula was due to obstructed labour (65.09%) which was subsequently followed by trauma (14.15%). Vesicovaginal fistula was the commonest type which was subsequently followed by vesicocervical fistula. Among 106 mothers, 73(68.9%) and 25(23.6%) gave birth, still birth and alive babies respectively. On the contrary, 4(3.7%) neonate experienced death in neonatal period whereas 1(0.9%) each twin deliveries resulted in 'one dead and one alive' and 'Twin alive' respectively. In case of only 3(2.8%) mothers 'no information' regarding fetal outcome could be recorded. Prolonged labour is the principal culprit to develop genitourinary fistulas among which VVF is the commonest variety. Still birth is the frequently evident fetal outcome in case of this clinical disaster of pregnancy.

Antibiotic Resistance: New Challenge in the Management of Bacterial Eye Infections

Ophthalmologists are still facing difficulties in managing bacterial eye infections. The study was designed for the isolation and identification of bacteria from infected eyes and observation of the sensitivity and resistant pattern. This cross sectional study was performed among 160 patients of suspected bacterial eye infection at Dr. K. Zaman BNSB Eye Hospital, Mymensingh and Department of Microbiology and Hygiene, Bangladesh Agricultural University, Mymensingh from March, 2010 to June, 2014. After collection of the samples from suspected infected eyes, it was nourished into nutrient broth in shaking incubator for three hours and then cultured into nutrient agar media followed by Mannitol salt agar, MacConkey's agar and blood agar. Bacteria were categorized by colony characteristics and Gram staining. Antibiogram was performed by disc diffusion method on Mueller Hinton agar media. McFarland Equivalence Turbidity Standard was maintained. The efficacy of the drug was evaluated by measuring the diameter of the zone of inhibition surrounding the disc. Ten percent Staphylococcus species isolates was resistant to Gatifloxacin, Gentamicin, Tobramycin and Cloxacillin, 26.0% to Ciprofloxacin, 40.0% to Azythromycin and Moxifloxacin, 58.0% to Cefixime and 64.0% to Cephalexin. Methicillin resistant Staphylococcus aureus was 62.8%. About 24.0% Streptococcus species isolates was resistant to Gatifloxacin, 33.3% to Azythromycin, Ciprofloxacin, Gentamycin, Moxifloxacin and Tobramycin, 52.4% to Cefixime and 71.4% to Cephalexin. About 9.0% of Pseudomonas species was resistant to Gatifloxacin and Tobramycin, 14.7% to Ciprofloxacin, 26.5% to Cefixime, 29.4% to Gentamicin and Moxifloxacin, 44.1% to Azythromycin and 82.3% to Cephalexin and Cloxacillin. Rational use of antibiotics and proper attentions of concerned authorities are necessary to overcome the emergent ocular situation leaded by antibiotic resistant.

Management of Infective Corneal Ulcer: Epidemiology Needs To Be Evaluated As Priority Basis

Because of known and unknown etiology, management of ocular devastating situation like corneal ulcer is still a challenge for the Ophthalmologists. The cross sectional study was designed for detection of predisposing factor and identification of causal agent. To serve the above purpose, a cross sectional study was performed among 140 patients of the corneal ulcer at Dr K Zaman BNSB Eye Hospital, Mymensingh and Department of Microbiology and Hygiene, Bangladesh Agricultural University, Mymensingh, Bangladesh. Detail history of patient was taken and recorded in a pretest questionnaire sheet. Two pieces of sample were collected from each corneal ulcer patient. One sample was examined in KOH wet mount for fungus. Other sample was nourished into nutrient broth and for further culture and identification. Bacterial corneal ulcer was higher among the patient of age group ≥46 years (61.9%) followed by 31-45 years (21.5%). P value is 0.261. Males were found predominant (58.5%). P value is 0.13. Agricultural related work was identified as most risky occupation in 83.1% of the total bacteria positive samples. P value is 0.01. Trauma was noted as most predominant influencing factor (56.9%). P value is <0.05. Bacteria were identified in 65(46.4%) and fungus in 40(28.6%) samples. Pseudomonas species were predominant (52.3%) followed by Staphylococcus species (26, 2%) and Streptococcus species (21.5%). No mixed infection was identified. For easier and earlier diagnosis of corneal ulcer, information about epidemiology is very essential. History should be taken meticulously followed by the laboratory procedures.

Dynamic modeling of α-synuclein aggregation in dopaminergic neuronal system indicates points of neuroprotective intervention: experimental validation with implications for Parkinson's therapy

Protein aggregation is the major pathological hallmark seen in neurodegenerative disorders such as Parkinson's disease (PD). Alpha-synuclein (αS) is the main component of protein aggregates that form Lewy bodies (LBs) in PD and dementia with LBs. There have been several attempts to intervene in the process of expression, modification, clearance, and aggregation of αS as a therapeutic strategy toward neuroprotection. In this study, we have employed a novel, predictive, system level approach in silico to study four different strategies of anti-aggregation therapies: (a) reduction in αS modifications such as phosphorylation, nitration, or truncation in an approach called "seed clearance;" (b) "anti-oligomerization" approach through blocking the early oligomers formation; (c) "oligomers clearance" process by increasing its lysosomal degradation; and (d) "anti-aggregation" that involves prevention of aggregate formation at a later stage. These strategies were tested in a virtual dopaminergic neuronal system triggered by overexpression (OE) of mutant αS-A53T with or without rotenone (Rot)-induced oxidative stress. The results were compared by analyzing markers related to various end points such as oxidative stress, dopamine (DA) metabolism, proteasome function, survival and apoptosis. The experimental system and anti-oligomerization strategies were recapitulated in vitro in M17 dopaminergic cells overexpressing mutant αS-A53T triggered with Cu(II)-mediated oxidative stress, and the experimental data prospectively corroborated with the predictive results. Through this analysis, we found that intervention in the early part of the aggregation pathway by prevention of oligomer formation and increased clearance is indeed a good neuroprotective strategy, whereas anti-aggregation efforts to break up the aggregate at later stages has negative effects on the system.

Observation of superior and inferior limit of lobes of the thyroid gland: a postmortem study

The size of thyroid gland varies considerably with age, sex, physiologic state, race and geographical location. Diseases of thyroid may need surgical intervention. This study is to carry out the macroscopic architecture of thyroid gland of different age and sex groups in Bangladeshi people to establish a normal standard. This is a descriptive cross-sectional study with an analytic component and was carried out on 54 autopsied human thyroid glands aged 5 to 65 years were collected from unclaimed dead bodies autopsied in morgue of Sylhet MAG Osmani Medical College, Sylhet. It was done in department of Anatomy, from 1st July 2006 to 30th June 2007. The collected specimens were divided into age Group A (10 years and below), Group B (11 to 20 years), Group C (21 to 30 years), Group D (31 to 40 years), Group E (41 to 50 years) and Group F (51 years and above). All specimens were examined morphologically by fine dissection method. It was observed that in most cases superior limit did not reach the midpoint of thyroid cartilage on either side. Inferior limit reached up to 6th tracheal ring on right side and 5th tracheal ring on left side in most cases.

Epidemiology and outcome of non viral keratitis

This cross sectional study was done to evaluate the epidemiological pattern of fungal keratitis. It was done among 120 patients, selected randomly, at the cornea clinic, BNSB Eye Hospital, Mymensingh during the period of April 2008 to July 2008. In this study Chi-square test was done and males were predominant. Rural patients were mostly affected (93%). Study showed bacterial infection (41.66%) and fungal infection (39.16%). Among the fungus infected patient, 49% had history of trauma and 51% had no history of trauma (p>0.05), about 30% had vegetative injury and 19% had injury other than vegetative. Fungus was identified under microscope, 95% of which was confirmed by culture. Fifty five percent (55%) patients of bacterial infection and 31% patients of fungal infection attended with hypopyon (p<0.05). For fungal keratitis, trauma considered as the important predisposing factor. Immuno-compromised condition, ocular surface disease and climatic effects should also be kept in consideration. Microscopic investigation at the beginning of the treatment might help to achieve better outcome.

Repeatability Estimates For Seminal Traits And Their Phenotypic Relationships With Testes Measurements And Performance Traits In Black Bengal Buck

Repeatability for seminal traits and their phenotypic relationships with testes measurements and performance traits in Black Bengal bucks were estimated from a total of 116 repeated observations on 15 young Black Bengal bucks. Performance traits included age, body condition and body weight of bucks. Testes measurements were testes length, breadth and volume, and scrotal circumference, while seminal traits were ejaculate volume, semen density, mass activity, sperm motility, sperm concentration, total sperm per ejaculation and percent of normal sperm. High positive correlations (ranging from 0.81 to 0.90) were found between body weight and testes measurements. Semen volume and percent of normal sperm were positively correlated with age, body condition and body weight of bucks (ranging from 0.24 to 0.60). The testes measurements were strongly and positively correlated with semen volume and total sperm per ejaculation (ranging from 0.53 to 0.61), while the correlations between testes measurement and percent of normal sperm were moderate (ranging from 0.34 to 0.44). Among seminal traits, strong correlations were found between semen volume and total sperm per ejaculation (0.81) and, between mass activity and sperm motility (0.82). Repeatability of ejaculate volume was higher (r = 0.78) which indicated that selection or culling for semen ejaculate volume could be practiced from single or few observations. It could be concluded that bucks’ age, body weight and body condition along with testes volume should be considered as selection criteria for improving semen quality and semen production of breeding bucks. DOI: http://dx.doi.org/10.3329/bjas.v37i2.9879 BJAS 2008; 37(2): 34-41