Effect of Supplementation of Oral Zinc on Serum Lipid Profile Status in Patients with Type 2 Diabetes Mellitus: A Prospective Study.

Diabetes mellitus is one of the most widespread endocrine disorders that have effects on lipid metabolism. Supplementation of oral zinc may improve the abnormalities of lipid metabolism in patients with type 2 diabetes mellitus. To evaluate the effects of oral supplementation of zinc on serum lipid profile levels in patients with type 2 diabetes mellitus. This prospective interventional study was conducted in the Department of Physiology, Dhaka Medical College (DMC), Bangladesh from January 2016 to December 2016. After fulfilling the ethical aspect, during the study a total number of 51 diagnosed type 2 diabetic patients of both sexes were selected with age ranging from 40 to 55 years. Among them, 26 type 2 diabetic patients with supplementation of oral zinc (40mg/day) for 12 weeks were considered as study group (Group B). Another 25 age matched type 2 diabetic patients without supplementation of oral zinc were considered as control group (Group A) for comparison. The subjects were selected from Outpatient Department of Endocrinology, Dhaka Medical College Hospital, Dhaka and personal contacts from Dhaka city on the basis of inclusion and exclusion criteria. Serum lipid profile levels were estimated by enzymatic endpoint method in auto-analyzer. The study parameters were measured 2 times in all subjects of control and study groups i.e. at the beginning of study (base line) and after 12 weeks of study period. For statistical analysis, paired Student's 't' test and unpaired Student's 't' test were performed as applicable using SPSS for windows version 22.0 In this study, serum TC, TG and LDL levels were significantly decreased (p<0.001) and serum HDL level was significantly increased (p<0.001) in diabetic patients after supplementation with oral zinc in comparison to that of their baseline value. Again, after 12 weeks, serum TC, TG, LDL levels were significantly lower (p<0.05) and HDL (p<0.05) level was significantly higher in diabetic patients supplemented with oral zinc in comparison to that of diabetic control group. In control group, there was no significant change in serum TC, TG, HDL and LDL levels between baseline and after 12 weeks of follow-up. From the results of the study, it can be concluded that oral zinc may improve serum TG and TC levels in patients with type 2 diabetes mellitus and may be helpful to minimize the complications in type 2 diabetes mellitus.

Pattern of Prescribing Drugs in Chronic Obstructive Pulmonary Disease in a Tertiary Care Hospital of Bangladesh.

Chronic obstructive pulmonary disease (COPD) is a chronic obstructive disease of the airways. It is one of the most common and important chronic respiratory conditions in terms of years lived with disability. Incidence is increasing in Bangladesh like other developing countries. To evaluate drug prescription pattern for COPD, this cross-sectional, observational study was conducted from January to December in 2020 at the Department of Pharmacology in collaboration with the Department of Medicine in Mymensingh Medical College, Bangladesh. A total of 168 patients were selected for the study by non-random purposive sampling technique. Age distribution indicates that 31.5% of patients were in the 50-59 years age group and males were 93.5%. The majority (82.1%) of the participants were smokers. In this study, majority (34.12%) of the drugs were used as oral form and second most common dosage form was nebulization (26.75%). Bronchodilators were mostly prescribed 652(57.19%), followed by corticosteroids 222(19.47%) and antibiotics 165(14.47%) among drugs used for COPD. Beta sympathomimetics 322(45.49%) were mostly prescribed, followed by anticholinergics 186(28.52%) and methylxanthines 144(22.08%) as bronchodilators. Out of 1140 drugs for COPD, 53.06% and 34.12% were delivered as inhalation and oral forms, respectively. Inhalation route was the most (60.37%) preferred one over oral route (37.63%) for steroid use. The most of the patients [152 (90.48%)] were treated with combination therapy. Mostly (39.6%) used Fixed Dose Combination (FDC) therapy was salbutamol and ipratropium bromide followed by salmeteroal and Fluticasone (30.83%). Both FDC were prescribed in 57.7% of study population. Considering nomenclature, trade name was used in 24.4% of prescription.

Comparison of Risk Factors between Younger and Older Patients of Myocardial Infarction among Bangladeshi Rural People: A Hospital Based Study.

Myocardial infarction among patients is a concern as young patients live longer in the aftermath of this critical illness. Still, there is a wide knowledge gap about modifiable risk factors that may help to alter the course of this extreme end of coronary artery disease spectrum among young patients. The trend of socioeconomic changes in developing countries like Bangladesh has resulted in increasing non-communicable diseases like coronary artery disease. Prevalence and risk factors of myocardial infarction among people living in a rural community are largely unknown, particularly in the younger age group. We tried to find out the risk factors differences between young and old MI groups as well as proportion of myocardial infarction among patients out of total hospitalized MI patients. This cross-sectional analytical study was done among the patients admitted to a rural cardiac center. For risk factor analysis, patients with new MI, including both non-ST-elevation and ST-elevation myocardial infarction were included according to preset inclusion and exclusion criteria. Patients were grouped as young (age ≤45 years) MI and old (age >45 years) MI. Data was collected using a questionnaire after informed consent was taken. American Heart Association's continuous dietary scoring system and Holmes Rahe Stress Scale were used to identify dietary patterns and mental stress levels, respectively, among the sample. Logistic regression analysis was performed to explore the risk factors of premature MI. On the other hand, to identify the proportion of young MI patients among the hospitalized MI patient's hospital registry was used to count the cases over almost one year. For risk factor analysis between young and old MI groups, 137 MI patients were selected according for inclusion and exclusion criteria. Out of them 62 and 75 patients were in the young and old age groups, respectively. The mean ages of younger and older groups were 39.0±5.9 years and 58.8±8.2 years, respectively. In both groups, 112(81.8%) patients were male. Only 42(30.7%) patients had BMI ≥25kg/m². In the unadjusted analysis, hypertension, family history of hypertension, consumption of fatty food, dairy products, and free-range chicken were found to be associated with premature MI. No significant difference in triglyceride, cholesterol or LDL level was found between the groups. But in the multivariate analysis, only the male gender was a significantly higher risk of premature MI (aOR 7.00; 95% CI: 1.51-42.42). Interestingly, HTN (aOR 0.46; 95% CI: 0.19-1.14) and smoking (aOR 0.26; 95% CI: 0.05-0.98) tend towards increased the risk of MI among the older age group compared to the younger group. According to hospital registry analysis, 22.9% of total MI patients admitted in the cardiac center were younger than 45 years. The incidence of myocardial infarction among young patients in rural areas in Bangladesh is probably more than what is known. Other than the male gender, which is a significant un-modifiable risk factor for young myocardial infarction patients; dietary factors, diabetes, and increased body mass index may play a vital role. On the contrary, hypertension and family history of hypertension are significantly higher among the older age group.

Normocephalic sagittal craniosynostosis in young children is common and unrecognized.

OBJECTIVE: Sagittal craniosynostosis (SC) is usually diagnosed during early childhood by the presence of scaphocephaly. Recently, our group found 3.3% of children under 5 years of age with normocephalic sagittal craniosynostosis (NSC) using computed tomography (CT) scans. This paper aims to validate our preliminary findings using a larger cohort of patients, and analyze factors associated with incidental NSC. METHODS: A retrospective review of head CT scans in patients aged 0 to 71 months who presented to the emergency department of our tertiary care institution between 2008 and 2020 was completed. Patients with syndromes associated with craniosynostosis (CS), history of hydrocephalus, or other brain/cranial abnormalities were excluded. Two craniofacial surgeons reviewed the CT scans to evaluate the presence and extent of CS. Demographic information, gestational age, past medical and family history, medications, and chief complaint were recorded as covariates, and differences between patients with and without CS were analyzed. Furthermore, comparison of the prevalence of CS across age groups was studied. Additional analysis exploring association between independent covariates and the presence of CS was performed in two sub-cohorts: patients ≤ 24 months of age and patients > 24 months of age. RESULTS: A total of 870 scans were reviewed. SC was observed in 41 patients (4.71% - 25 complete, 16 incomplete), all with a normal cranial index (width/length > 0.7). The prevalence of SC increased up to 36 months of age, then plateaued through 72 months of age. Patients under 2 years of age with family history of neurodevelopmental disease had 49.32 (95% CI [4.28, 567.2]) times higher odds of developing CS. Sub-cohort of patients above 24 months of age showed no variable independently predicted developing CS. CONCLUSION: NSC in young children is common. While the impact of this condition is unknown, the correlation with family history of neurodevelopmental disease is concerning.

A Study on Outcome of Surgical Treatment of Chronic Retrocalcaneal Bursitis.

Retrocalcaneal bursitis is one of the important causes of posterior heel pain which is due to repetitive friction of the retrocalcaneal bursa between the postero-superior calcaneal tuberosity (haglund deformity) and Achilles tendon. Most of the patients are treated by conservative methods. But when the condition becomes chronic and not responding to the conservative treatment, surgical treatment is an option of these cases. This prospective interventional study was conducted in the Department of Orthopaedic Surgery, BSMMU (Bangabandhu Sheikh Mujib Medical University), Dhaka, Bangladesh from September 2017 to August 2019. Within this period, total 40 cases of chronic retrocalcaneal bursitis were operated at BSMMU. The clinical and functional outcome was evaluated according to AOFAS (American Orthopedic Foot Ankle Society) scale. The results of this study showed significantly improvement of pain, functional status and deformity at the time of final follow-up period of 1 year, total mean score improved from 46/100 to 89/100. The outcome of the subjects was satisfactory 90% and unsatisfactory 10%. Surgical intervention is an effective option of treatment with satisfactory outcome, in the treatment of chronic retrocalcaneal bursitis.

Pattern of Casualties Attending in the Casualty Department of a Tertiary Level Hospital of Bangladesh.

A casualty is a loss resulting from an accident or someone who is hurt, wounded, diseased, detained or dead in an accident. The term casualty means a seriously injured patient. It is predominantly a military word, generally used for service for accidents. After a battle or accident the dead, the wounded, the sick are called together as "casualties". Casualty, in respect to personnel, any individual who is lost to his organization by reason of being declared dead, wounded, diseased, detained, captured, or missing. Hospital casualty service is not fully organized all over the Bangladesh. In view of the increasing workload and emerging need, functional casualty services have recently been introduced in our hospital to manage properly the accident patients. This retrospective observational study was carried out in the Casualty department of Mymensingh Medical College Hospital, Mymensingh, Bangladesh. Patients were enrolled total number of 69740 to investigate the quantity of patients and pattern of casualties. Patients were categorized according to their mode of injury. Total data was collected from hospital records of all patients attended in the Casualty Department of the hospital from November 19, 2017 to November 18, 2019. The modes of Casualties with demographic characteristics of patients were analyzed. Male and female ratio was 3:1. Patient attended in the Casualty department was average 96 per day, maximum was 176 and minimum was 33. According to age sub-division, 11-20 years age group attended in casualty was maximum and it was 48 in number. One day attended Road traffic accident (RTA) maximum was 65 and minimum was 3, maximum Non-RTA was 83 and minimum was 25, maximum physical assaults was 48 and minimum was 1. RTA and Injury due to fall were the common mode of casualty especially in the young population within the study area. We have seen that injury caused by fall from height was 43% among the all patients. Patients due to fall from tree was highest (35%) yearly in between April to June. Second to incidents of all fall was RTA which was 25%. Physical assaults (18%), machinery injury (9%) and others were 5%.

Frequency and Risk Factors of Erectile Dysfunction among Bangladeshi Adult Men with Type 2 Diabetes Mellitus.

Various forms of sexual dysfunction occur in men with diabetes mellitus (DM) including disorders of libido, ejaculatory problems, and erectile dysfunction (ED). This cross sectional study was conducted in a tertiary hospital of Bangladesh from December 2017 to May 2018 to find out the frequency and risk factors of ED in subjects with type 2 DM (T2DM). One hundred fifty (150) consecutive male patients with T2DM attending the Endocrinology outpatient department (OPD) of the hospital during the study period were evaluated for the presence of ED by using the International Index of Erectile Function-5 (IIEF-5) questionnaire; their socio-demographic, anthropometric, and clinical data were also recorded. Glycemic status was assessed by measurement of fasting plasma glucose (FPG) and HbA1c. Morning serum testosterone was measured in all. Among 150 subjects 68(45.3%) had ED; ED was mild in 14.7%, mild to moderate in 18.0%, moderate in 6.0% whereas severe ED was present in 6.7% of the subjects. The subjects with ED had higher mean age, longer duration of DM, higher body mass index (BMI), higher HbA1c, higher FPG, higher serum creatinine, and lower serum testosterone level than those without ED. Study subjects in the higher age group and higher duration of DM had higher frequencies of ED. IIEF-5 score showed significant negative correlation with age, duration of DM, HbA1c, fasting plasma glucose, serum creatinine and significant positive correlation with serum testosterone. In logistic regression analysis, duration of DM and serum testosterone were found be independent predictors of ED. Frequency of ED among Bangladeshi type 2 diabetic males is high; duration of DM and serum testosterone are independent predictors of ED in them.

Correlation of Foot Height with Stature in 5-10 Years Aged Bangladeshi Children.

This cross sectional, descriptive and analytic type study was conducted among 5-10 years aged Bangladeshi children at different areas of Mymensingh district (Fulpur, Muktagacha, Fulbaria, Trisal and Haluaghat) on 109 Bangladeshi children (70 male and 39 female) from January 2016 to December 2016. Sample collection was done by nonrandom purposive sampling technique. Any kind of foot deformity resulting either from congenital or physical injury were excluded to construct standard measurement. The present anthropometric study was designed to construct data of 5 to 10 years aged Bangladeshi children regarding foot height, to measure correlation of stature with foot height and an attempt has been made out to grow interest among the researchers for future study and also to compare the data with the data of the people of other races. Stature of the subject was measured with the stadiometer and foot height was measured using flexible measuring tape. The children were asked to stand with weight distributed equally on both feet. The legs were perpendicular to the feet. The mean foot height of both sides of 5, 6, 7, 8, 9 and 10 years aged male were 5.90±0.76cm, 5.76±0.64cm, 6.80±0.35cm, 6.86±0.35cm, 7.24±0.46cm and 7.28±0.66cm respectively and those of female were 5.48±0.67cm, 6.25±0.28cm, 6.19±0.58cm, 6.42±0.34cm, 6.30±0.49cm and 6.30±0.39cm respectively. Correlation between stature and foot height was made. Foot height showed non-significant positive correlation with stature in 5 years old male, 6 years old male, 7 years old male and female, 8 years old male, 9 years old male and female and 10 years old male and female. In case of 5 years old female, it showed significant positive correlation with stature.

Primary extramedullary esophageal plasmacytoma - a case report.

Extramedullary plasmacytomas are very uncommon tumors, may occur commonly in the upper respiratory passages. These are rarely seen in the middle and lower gastrointestinal system and exceptional to originate in the esophagus. We present a novel case of a 65-year old man who presented with dysphagia and weight loss. After taking detailed clinical history and physical examination endoscopy was performed that showed an ulcero-proliferative lesion involving the lower third of esophagus. Histopathological examination revealed sheets of malignant plasma cells, some with prominent nucleoli. Immuno-histochemistry could not be done due to unavailability. A bone marrow biopsy was performed which was negative for involvement. This is a rare case of esophageal plasmacytoma diagnosed on endoscopy in a patient presenting with dysphagia.

Parotid gland metastasis - an unusual presentation of adenocarcinoma of lung.

Lung cancer is the most frequent malignant disease and the most common cause of cancer death in the world. Primary carcinoma of the lung was an uncommon cancer until the 1930s. Common cell types in bronchial carcinoma are squamous 35%, Adenocarcinoma 30%, Small-cell 20%, Large-cell 15%. We present a case of a bronchial neoplasm metastasis to the parotid gland. A 50 years old male patient presented with a 7×5cm painless parotid mass that was metastatic adenocarcinoma on histopathology. Then we thoroughly examined the patient and he was investigated accordingly. There was an abnormal shadow in the lung on chest x-ray, CT revealed a lung tumour on left side. Metastasis to the parotid gland from any distant primary site is quite unusual. We are going to present this case in the journal because of its rarity. Parotid gland metastasis from the lung is rare & if a careful examination is not performed primary focus may be overlooked, negatively affecting the lifetime survival rate & the prognosis of the patient.

Case report on carotid body tumor.

A 40 years old lady presented to us with the complaints of repeated attack of syncope with left sided neck swelling. Ultrasonography, Color Doppler study and arteriography were done which revealed a solid vascular mass in the carotid bifurcation. Mass was resected and histopathology was done. Histopathologic findings were typical of a carotid body tumour. As carotid body tumour is a rare disease. So, we are going to present this in this article.

Cirrhosis of liver and portal vein thrombosis - a review article.

Cirrhosis is characterized by diffuse hepatic fibrosis and nodule formation which can occur at any age with significant morbidity and is an important cause of premature death. Occlusive portal vein thrombosis (PVT) is common complication of chronic liver disease with prevalence ranging from 1% to 16% of population. The occurrence of portal vein thrombosis is influenced by local factors (cirrhosis with associated liver architectural changes and increased resistance effects), systemic factors (inherited and acquired abnormalities leading to hyper coagulability) and development of hepatocellular carcinoma. The majority of patients with cirrhosis PVT are diagnosed on radiographic studies although in some patients PVT may present with decompensated chronic liver disease but the natural history of PVT in patients with cirrhosis is largely unknown. However patients with cirrhosis and PVT have been shown to have inferior survival in comparison with patients without PVT.

Amiloride as an Alternate Adjuvant Antiproteinuric Agent in Fabry Disease: The Potential Roles of Plasmin and uPAR.

Patients with Fabry disease present a higher risk of cardiovascular and kidney morbidity. We present a patient with a past history of biopsy-proven Fabry disease and stage 3 chronic kidney disease. Proteinuria partially dropped from 6.8 g/day to 2.1 g/day despite an aggressive regime which consisted of low-salt diet, agalsidase beta infusions, dual blockade of the renin-angiotensin system, and low-dose maintenance of steroids. As proteinuria is considered a risk marker of cardiovascular disease and of progression of kidney disease, we added amiloride 5 mg/day, a drug with proven effects in podocyte stabilization and proteinuria actions at the distal convoluted tubule. Proteinuria finally decreased to 0.8 g/day. This report highlights the relevance of intervening on proteinuria in a multitarget approach in order to reduce it as much as possible. Due to this pharmacological response, we suggest that although agalsidase beta specific treatment protects the endothelium, the podocyte, and the tubule in Fabry disease and secondary haemodynamic and immunologic pathways are treated with inhibition of the renin-angiotensin system and steroids, amiloride may act as a complementary tool in podocyte stabilization and in proteinuria effects at the distal tubule.

Initially Nondiagnosed Fabry's Disease when Electron Microscopy Is Lacking: The Continuing Story of Focal and Segmental Glomerulosclerosis.

Focal and segmental glomerulosclerosis is classified as either primary or secondary. We present a patient with a past history of biopsy-proven focal and segmental glomerulosclerosis. Despite initial response to dual blockade and steroids, proteinuria raised when steroids were decreased. After the patient was restarted on steroids, proteinuria did not improve. Another biopsy confirmed the previous diagnosis but suggested Fabry's disease, later confirmed by electron microscopy, α-galactosidase A serum and leukocyte deficiency as well as genetic studies. Proteinuria decreased when agalsidase ß was prescribed in parallel with steroid tapering, increased with steroid discontinuation and improved with meprednisone administration. This report highlights the relevance of electron microscopy in kidney biopsy. In glomerulosclerosis, despite specific treatment, secondary hemodynamic and immunologic pathways may contribute to the development of proteinuria and accelerate the renal disease progression due to the primary disease. We discuss possible pathophysiologic pathways involved in proteinuria in Fabry's disease according to the biopsy and the therapeutic response.

A molecular and genetic outline of cardiac morphogenesis.

Perturbations in cardiac development result in congenital heart disease, the leading cause of birth defect-related infant morbidity and mortality. Advances in cardiac developmental biology have significantly augmented our understanding of signalling pathways and transcriptional networks underlying heart formation. Cardiogenesis is initiated with the formation of mesodermal multipotent cardiac progenitor cells and is governed by cross-talk between developmental cues emanating from endodermal, mesodermal and ectodermal cells. The molecular and transcriptional machineries that direct the specification and differentiation of these cardiac precursors are part of an evolutionarily conserved programme that includes the Nkx-, Gata-, Hand-, T-box- and Mef2 family of transcription factors. Unravelling the hierarchical networks governing the fate and differentiation of cardiac precursors is crucial for our understanding of congenital heart disease and future stem cell-based and gene therapies. Recent molecular and genetic lineage analyses have revealed that subpopulations of cardiac progenitor cells follow distinctive specification and differentiation paths, which determine their final contribution to the heart. In the last decade, progenitor cells that contribute to the arterial pole and right ventricle have received much attention, as abnormal development of these cells frequently results in congenital defects of the aortic and pulmonary outlets, representing the most commonly occurring congenital cardiac defects. In this review, we provide an overview of the building plan of the vertebrate four-chambered heart, with a special focus on cardiac progenitor cell specification, differentiation and deployment during arterial pole development.

Tobacco Chewing and Associated Factors Among Youth of Western Nepal: A Cross-sectional Study.

BACKGROUND: Smokeless tobacco is found to be as addictive and harmful as smoking but have not been explored into, especially among youth. OBJECTIVES: This study was conducted to find the prevalence of tobacco chewing among college students in Nepal and the factors that have influence over their use. STUDY DESIGN: A cross-sectional study with a self-administered questionnaire. MATERIALS AND METHODS: Five colleges of different streams in Pokhara city were selected for the study. A total of 816 students participated. The study was conducted during the period of May 2006-February 2007, using a semi-structured, self-administered questionnaire. RESULTS: Overall prevalence of ever tobacco chewing was 21.3% (males 30.2% and females 10.9%) among the youth with average age of initiation 15.7 years. Pan masala and gutka were used by 63.6% and frequency of use varied widely and only 5.7% said they were daily users. Reasons cited for chewing were most commonly 'just like it' or 'friends chew'. Multiple logistic regression analysis showed age, ever smoking status, being ever alcoholic, and having friends or family members who chewed were significantly associated with students' tobacco chewing. Almost one-tenth of the students believed they were addicted to chewing tobacco and 42.5% of them had tried to quit the habit. CONCLUSION: The study shows a high prevalence of tobacco chewing by Nepali youth. Important factors that influenced the habit were having chewer friends, their own smoking and alcohol status and having family members who chewed. It is pertinent to consider these when formulating cessation and prevention programs.

Smoking among Nepali youth--prevalence and predictors.

Tobacco is the single largest risk factor for various diseases and its presence in the young heralds more serious problems as they may be exposed for longer periods. Prevalence and predictors of smoking among youth will aid in formulating effective preventive and control measures. A cross-sectional study was therefore conducted among 816 students selected from five colleges of Western Nepal using a self-administered questionnaire. Prevalence of ever smoking was 34.2% (males 47.6% and females 18.4%) and for current smoking was 17%. It was higher among youth belonging to 21 years or older as compared to younger age groups. Mean age of initiation was 16.8 years (standard deviation 2.8 years) and the most common reasons cited for smoking were; like it, to feel more relaxed, out of boredom and to look more mature. Proportion of youth who said they felt they were addicted was 43.1% and 64.7% said that they had tried to quit the habit. Most important predictors having independent effects on youth being ever smokers were having three or more smoker friends (OR=18), their own chewing (OR=4.8) or alcohol use (OR=4.2), male gender (OR=3.7) and the type of course they were pursuing, with professional course students having higher risk. With almost one fifth of college-going youth smoking and a higher prevalence in older age groups within them, smoking is a serious concern for young people in Western Nepal.

Physical assault related injuries in Western Nepal--a hospital based retrospective study.

OBJECTIVE: The study was carried out to study the pattern of injuries and epidemiological factors in Nepal where there is no systematic surveillance system for injuries. DESIGN: A hospital based, retrospective study conducted by extracting data from the medico-legal register of the Emergency Department of a Regional Hospital for 3 years. SETTING: Regional Hospital in Pokhara, Western Nepal. RESULTS: A total of 1100 cases of physical assault had been reported. Male to female ratio was 3.6:1 and most commonly involved age group in males was 16-25 and in females was 26-35 years. Contusion (28.7%) was the commonest type of injury followed by incised wounds (25.7%). Most commonly used weapon was wooden stick and clubs (21.5%) followed by kicks and punches (20.6%). The most frequently affected anatomical site involved was the head and neck (57.06%), followed by the upper limbs (17.74%) and the lower limbs (10.5%). Assailants for females were most commonly spouse (40%) and in-laws (14%) and for males it was unspecified known individuals (18%) followed by neighbours (11%). Maximum number of physical assault injuries occurred between evening and midnight (59.59%). CONCLUSION: Injuries from physical assault occurred in all age groups but most commonly affecting the young males and majority of them were in the productive age group. Commonest type of injury was contusion and weapon used wooden sticks and clubs. Assailants were spouses in females and known but unspecified individuals in men.