Bone Age Determination by Radiology & Imaging in Bangladesh Perspective.

Determination of age is one of the most important and vital demand in legal affairs, court and young sports, especially from 7-21 years. There is no established age determination table in our county. So we are dependent upon Galstaun, Bashu & Bashu and other European tables, which sometimes provide misinterpretation and variation of opinion. We should have our own table suitable for our nation. So, this prospective study was carried out in the Department of Radiology and Imaging of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from July 2010 to June 2014 (five years) to assess the general skeletal maturity. Three hundred boys and girls of known date of birth were selected on random basis from Dhaka. Ages were limited within 7 to 21 year. Every 20 person for each age group, of them 10 were male and 10 were female. To observe the bony maturity, radiographs were taken at the end of their age belongs to. Thus a growth table is to be prepared for further evaluation.

Intradural intramedullary spinal cord meningioma in a seven years old female child.

Halima, a 7 years old female child was admitted initially in the Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Shahbagh, Dhaka, Bangladesh with the complaints of burning sensation in the neck for last four month. Initially pain was mild and gradually it became severe and agonizing at night which awakening her from sleep. Following fifteen days of admission, her left hand gradually became weak and numb. Subsequently, all four limbs became involved within one month. Magnetic resonance imaging (MRI) showed expansion of cervical cord with hypo-intense in T1 and inhomogeneous hyper-intense in T2 areas with widening of cervical canal. Post gadolinium diethylene triamine penta-acetic acid dimeglumine (Gd-DTPA) films showed mild heterogeneous contrast enhancement of the cord at the C2-C4 level. The cervical disc showed normal signal intensity on T2WI. During surgical procedure, laminectomy was done at C1-C5 level to release compression and dura matter was opened. Biopsy from involved tissue was taken and sent for histopathological examination and reported as embronal rhabdomyosarcoma. Immunohistochemistry (IHC) of tumor showed negative reaction for desmin, focal positivity for pancytokeratin and positivity for S-100 protein. The tumor was then diagnosed as atypical meningioma,intradural-intramedullary (WHO grade-II). Then, following transfer to the Department of Pediatric Hematology and Oncology, BSMMU, protocol based chemotherapy was started followed by subsequent radiotherapy. The child was gradually improving after decompression of dura matter, commencement of chemotherapy and following external beam radiotherapy. So, an awareness of varied clinical manifestation of atypical meningioma of intrdural-intramedullary spinal cord tumor should be suspected to establish a correct diagnosis when the presenting signs and symptoms are enigmatic, presenting with intractable burning sensation or pain in the neck and investigation should be done accordingly.

Ondansetron versus granisetron in the prevention of chemotherapy induced nausea and vomiting in children with acute lymphoblastic leukemia.

Effect of ondansetron and granisetron were evaluated in sixty (60) children (age 4-11 years) irrespective of sex, diagnosed case of acute lymphoblastic leukemia (ALL) who received high dose methotrexate and did not receive any antiemetic 24 hours prior to HDMTX. This was a prospective, randomized, double-blind, single center study. Of 60 children, 30 received oral ondansetron (4mg) and rest 30 granisetron (1mg) half an hour before therapy. Drugs were randomly allocated with appropriate code. The patients were followed up from day 1 to day 5 of therapy. Episodes of nausea and vomiting were recorded and scorings was done every 24 hours following chemotherapy. No significant difference was found between two groups according to acute emesis (Day-1) (p=0.053). In day two and day three it was significant (p<0.05). In day four it was significant (p=0.002). Early chemotherapy induced nausea and vomiting (CINV) were controlled 90% in children who received granisetron and 70% in children who received ondansetron. Delayed (Day 2-4) CINV were controlled in 80% of children who received granisetron and 43.4% who received ondansetron (p<0.05). Granisetron group required additional doses only 3.3% cases and ondanseton group 30% cases on the second day (p<0.05). Result was significant between two groups. About 36.7% patients had episodes of nausea on day four of chemotherapy in ondansetron group and it was only 3.3% in granisetron group due to adverse effects of antiemetic drug itself (p=0.001). Maximum episodes of vomiting were found on the second day in ondansetron group 33.3% and in granisetron group 3.3% (p=0.003). Though adverse effects like headache, constipation, abdominal pain and loose motion were common in both group of children but their number was much less in children who received granisetron. On second day of therapy score of nausea and vomiting was maximum in ondansetron and minimum in granisetron treated on day 4 and the result was significant. So, to prevent acute and delayed CINV in children with ALL, oral graniseteron can be considered as more effective and well tolerated with minimum adverse effects compared with ondansetrons.

Outcome of pregnancy in patients with congenital heart diseases.

This prospective study was conducted to evaluate the outcome of pregnancies in women with congenital heart diseases. In this study 50 pregnant women age between 20-45 years with congenital heart diseases were included. Twenty two (44%) were presented with atrial septal defect, 12(24%) with ventricular septal defect, 5(10%) were with patent ductus arteriosus, 6(12%) with Fallot's tetralogy, 2(4%) with pulmonary stenosis, 2(4%) with Eisenmenger syndrome, 1(2%) with dextrocardia. Shortness of breath (60%) was the main presenting complaint. Normal vaginal delivery (52%) was done in majority of cases. Spontaneous abortion occurred in 16% of pregnancies. Major complications were heart failure 16%, arrhythmias 21%, cardiovascular mortality 4%, preeclampsia 4%, and eclampsia 2%. Premature birth 16%, fetal demise 4%, neonatal death 2% and cardiac anomaly at birth 2% were also observed. The outcome of pregnancy in women with congenital heart diseases is favourable with considerable maternal and neonatal complications.

Back pain and vertebral compression: an unusual presentation of childhood acute lymphoblastic leukemia.

Junayet, a nine years and six months old boy was admitted to the hospital because of back pain and vertebral compression fractures. The boy had been well until two months earlier, when he began to have back pain after falling on his back along with occasional fever. The pain was intermittent initially but gradually it became constant. One month before admission, he fell again and the back pain became deteriorated. He was mildly pale, liver was palpable, skin survey revealed normal, BCG scar mark was present. He had bone pain, cervical lymphadenopathy and a tender swelling on the lumbusacral region. Two weeks before admission, the hematological findings were suggestive of leukemia of lymphoblastic type. Biochemical values were normal except high level of serum lactate dehydrogenase (LDH). Cerebrospinal fluid (CSF) examination was free of malignant cell. Skeletal survey showed diffuse osteopenia of the thoracic and lumber spine with multiple compression fracture of the vertebral bodies of D7, D8, D12 and L1, L3 and L5 with increased disc space. Radiograph of the chest also showed diffuse osteopenia of ribs. Magnetic resonance (MRI) showed uniform signal intensity in the marrow throughout the spine with compressed fracture of the same vertebrae. Bone marrow morphology study and the cytochemistry of the aspirated marrow were consistent with acute lymphoblastic leukemia (ALL-L2). Then, he was started protocol based chemotherapy for induction of remission, consolidation, high dose methotrexate and maintenance therapy. Now, he is on regular follow up with repeated hematological and radiological examinations. Following six month of chemotherapy the boy was found with significant improvement of his physical, hematological and radiological abnormalities.

Balloon mitral valvuloplasty: immediate and short term haemodynamic and clinical outcome.

This prospective study was carried out in the Department of Cardiology, University Cardiac Center, Banghabandhu Sheikh Mujib Medical University, Dhaka, to evaluate the short term clinical and haemodynamic outcome of Balloon mitral valvuloplasty in mitral stenosis. Total 100 patients underwent percutaneous mitral commissurotomy out of which 60 cases had pure mitral stenosis and 40 patients had concomitant other nonsignificant valvular disease. Mitral valve dilatation increases in mitral valve area from 0.5+/-0.22 to 1.80+/-0.41 cm2. Mitral valve mean pressure gradient decline from 24.0+/-6.48 mm of Hg to 6.1+/-3.0 mm of Hg: mean left arterial pressure decline from 21.40+/-4.80 mm of Hg to 6.50+/-2.82 mm of Hg (p<0.001). The pulmonary artery systolic pressure decreased from 78.7+/-20.34 mm of Hg to 30.18+/-10.8 mm of Hg (p<0.001). Procedural success, as defined final mitral valve area>1.5 cm2 or>50% increase in area, was achieved in 95% patients. Serious complications occurred in 2(2%) patients and no death occurred in the study. Minor complications such as vasovagal reaction (03%), balloon rupture without sequelae (1%), hypotension, Seizure etc. during the procedure were also noted. Although percutaneous transvenous mistral commissurotomy appears to be effective at relieving the hemodynamic effects of rheumatic mitral stenosis, it is not without risk. In properly selected patients, however, it appears to have low morbidity and mortality. The overall results of this study demonstrate that the short term clinical and haemodynamic outcome of the procedure were excellent and the incidence of related complications were reasonable.

Extensive skeletal lesions in childhood acute lymphoblastic leukemia.

A 2 years old male child was admitted in Dhaka Shishu Hospital with one month history of fever, swelling and pain in joints of right leg. Hematological and microbiological investigation revealed normal except radiological findings when there were destructive lesions of affected bones and thought to be Langerhan's cell histiocytosis but did not respond to treatment. Subsequently, he was transfer to Pediatric Hematology and Oncology, Bangabandhu Sheikh Mujib Medical University (BSMMU) for proper management. On examination, the boy was mildly pale, severe bone pain, no organomegaly but few occipital group of lymphnode were palpable. He had extensive red tender swelling over the hands and legs. Hematological values showed high WBC, low platelet count and lymphoblasts. Biochemical values were high serum LDH and serum uric acid. Skeletal survey showed diffuse osteolytic lesion and osteoporosis with evidence of transverse metaphyseal radiolucent bands (leukemic line), lamellar periosteal reactions and cortical erosions widespread throughout the skeleton with subperiosteal new bone formation. Radioisotop of skeleton showed increase uptake at the site of lesions. Bone marrow aspiration findings were suggestive of ALL-L1 and cytochemistry of aspirate showed PAS positive and Sudan black negative. Immunophenotype confirmed as pre-B ALL, Then, protocol based induction had given for 4 weeks. Thereafter, a short course of intensification followed by maintenance therapy had started with significant improvement of physical, hematological and radiological findings. So, an awareness of varied clinical and radiological manifestations of childhood ALL in bone marrow and skeletal system are needed in order to establish a correct diagnosis when the presenting signs and symptoms are enigmatic. It is also important to keep in mind the possibility of extensive skeletal involvement in ALL, especially when a child present with pain, swelling of limb with walking difficulties. The curability of ALL in contrast to metastatic malignancies makes accurate diagnosis of paramount importance.

Nutritional status at initial presentation in childhood acute lymphoblastic leukemia and its effect on induction of remission.

This prospective study was aimed to evaluate the nutritional status at initial presentation in childhood acute lymphoblastic leukemia (ALL) and to ascertain the effects of nutrition on induction of remission. The study was carried out in the Paediatric Haematology and Oncology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh during the period of one year starting from July 2006 to June 2007 on 66 diagnosed case of ALL, age ranged from 01 to 15 year irrespective of sex. The study subjects were stratified into undernourished (35) and well-nourished (31) based on weight for age. Then, protocol based induction of remission was started. Completion of induction was monitored through physical, haematological and morphological examination of bone marrow aspirate. Infection was ruled out clinically and culture sensitivity. Demographic, anthropometric, haematological, clinical and outcome variables were considered in both groups. At initial presentation, 53.03% were undernourished and 46.97% were well-nourished. Male preponderance was found in both groups. Under-nourished children of ALL had significantly decreased weight (p<0.03) and low haemoglobin concentration (p<0.04) at initial presentation. The undernourished children at initial presentation and during induction had about 2 to 3 times more common of culture and clinically proved infection. Undernourished children of ALL required significantly longer duration of induction (p<0.001) and prolonged period of hospital stay (p<0.001). So, it is concluded that under-nutrition is very usual at initial presentation in childhood ALL, are more prone to suffer from infection and thus prolong the duration of induction, hospital stay, even can lead to death. Optimum nutritional support can play a vital role in the outcome of induction of remission in childhood ALL.

Serum lactate dehydrogenase as a prognostic marker of childhood acute lymphoblastic leukemia.

The estimation of serum lactate dehydrogenase (LDH) is easy, readily available and economic. We can assume the prognosis of childhood acute lymphoblastic leukemia (ALL) through this measurement. This case control prospective study was aimed to evaluate that the level of serum LDH has the prognostic marker of childhood ALL. The study was carried out in the Paediatric Haematology and Oncology unit, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, during the period from January to December 2006 on 69 subjects with age ranging from birth to 15 years irrespective of sex. The study subjects were grouped into case (ALL-44) and control (healthy-25). Serum LDH level were performed in ALL patients on admission, day 14 and day 29 of induction and in healthy control when came for check up and found healthy. Haematological parameters were performed in ALL patients and in healthy control along with the measurement of serum LDH. On admission the level of serum LDH was significantly raised in ALL patients than healthy control (p<0.001). After induction, serum LDH level were significantly decreased at day 14 and day 29 of induction from admission (p<0.001). There was significant rise of platelet count were observed at day 29 of induction from admission (p<0.001). A significant decrease of peripheral and bone marrow blast cell percentages were observed at day 29 of induction from admission (p<0.001). The total WBC count was significantly decreased along with serum LDH at day 14 and day 29 of induction from admission (p<0.001). So, the measurement of serum LDH can be accepted as a good and reliable prognostic marker of childhood acute lymphoblastic leukemia.

Impact of Magnetic Resonance Imaging in the Diagnosis of Pituitary Adenoma.

Pituitary adenoma is the third most common primary intracranial neoplasm involving the adult population with clinical features due to excess or deficient hormone secretion or due to its mass effect. Debate about the diagnostic accuracy, sensitivity and specificity of MRI imaging in detecting pituitary adenoma has been continuing. The study was aimed to evaluate the accuracy, sensitivity and specificity of MR imaging in detecting pituitary adenoma. This cross sectional study was conducted in the Department of Radiology and imaging, Bangabandhu Sheikh Mujib medical University (BSMMU) from July 2013 to August 2015. It was carried out in 50 pituitary adenoma cases of which, 28 male and 22 female to see the impact of MRI in the diagnosis of pituitary of adenoma. Out of 50 cases 43 cases were diagnosed by MRI, 3 were normal and 2 were pituitary apoplexy, one was immature teratoma as confirmed through histopathology. So, MRI has got major impact in the diagnosis of pituitary adenoma.