Frequency and Risk Factors Association with Metabolic Syndrome among the Hypertensive Patients in Jashore, Bangladesh.

Metabolic Syndrome (METS) plays a pivotal role in the development of diabetes mellitus, coronary artery diseases and stroke. Due to the scarcity of data in this issue, this study aims to assess the frequency and risk factors association of METS among the hypertensive patients. This cross-sectional study recruited 667 eligible hypertensive patients aged between 20 and 70 years using non-probability purposive sampling method conducted from 1st January 2019 to 30th June 2019. Hypertensive patients with the known history of diabetes, thyroid, renal, cardiac, or hepatic disease, Cushing syndrome or malignancy and secondary causes of obesity, confirmed pregnancy, bed ridden, taking lipid lowering drugs or drugs that affect lipid and glucose metabolism were excluded from the study. METS among the hypertensive patients (DE novo or established hypertensive patients) of this study was demonstrated by NCEP-ATPIII (National Cholesterol Education Program-Adult Treatment Panel III) criteria having two or more of the following points [a) increased waist circumference ≥102cm in men and ≥88cm in women, b) hypertriglyceridemia: ≥150mg/dl, c) reduced High density lipoprotein cholesterol (HDL-C) <40mg/dL (1.04mmol/L) in men and <50mg/dL (1.29mmol/L) in women, d) high fasting blood glucose: 110mg/dl]. Significantly high frequency (69.9%, p<0.001) of METS was found with a significant female preponderance (52.5%, p<0.001) where the mean age of the study population was 48±11 years. Sex (p<0.001), education (p=0.041), occupation (p<0.001), Body mass index (BMI) (p<0.001) and hypertensive status (p=0.002) showed a highly significant role in the development of METS. Following binary logistic regression analysis after adjusting for confounders, the female sex was 17 times higher than the male [Adjusted odd ratio (AOR) =16.96, 95% CI=4.91-58.66, p<0.001)], obesity 4 times higher than non-obese [BMI (obese AOR=4.24, 95% CI=2.55-7.98, p<0.001)], hypertensive status [established hypertension two times higher than de novo (de-novo AOR=0.60, 95% CI=0.037-0.97, p=0.037)] were significant and independent predictors of METS. Significantly high BMI (27.7±4.2 and p<0.001), high waist circumference (60.4%, p<0.001) and hyper tri-glyceridaemia and reduced HDL (46.0%, p<0.001 and 51.3%, p<0.001) were found in the subjects with METS. In conclusion, high frequency of METS among the hypertensive patients was found in Jashore, Bangladesh with significant risk factors related to female sex, education, occupation, BMI and hypertensive status. So, a holistic evaluation of metabolic components among the hypertensive patients may reduce premature cardiovascular morbidity and mortality.

Study of Operative Events and Time Requirement of Hepaticoduodenostomy for the Treatment of Type I Choledochal Cyst- the Experience at BSMMU Hospital.

Of all varieties, Type I Choledochal cyst causing saccular or fusiform dilatation of the extra-hepatic biliary ductal system is the commonest (90.0 - 95.0%). Its presentations vary. To restore the continuity of the extra-hepatic biliary tract after excision of type I Choledochal cyst, surgeons have few alternatives to use, with their advantages and disadvantages. Roux en-Y Hepatico-jejunostomy (RYHJ) has been very popular and long studied standard surgical treatment for type I Choledochal cyst. But now Hepatico-duodenostomy (HD) is also being practiced and studied in different centers all over the world for the treatment of the same disease. For the last five years, we, at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, have been using Hepatico-duodenostomy as preferred anastomotic option in treating type I Choledochal cyst. Here, we are presenting our experience at BSMMU Hospital, regarding operative events and time requirement of Hepaticoduodenostomy for the treatment of type I Choledochal cyst and, to show whether this procedure can be safely practiced, producing acceptable results. It is a retrospective document study, from January 2013 to December 2017, at BSMMU Hospital, on forty two, MRCP confirmed type I Choledochal cyst patients of pediatric age. Patients' particulars, history, physical examination, investigations (including MRCP confirmation), assessment, surgical plan were collected from relevant medical records and documented in duly coded individual data collection sheet maintaining standard privacy protocol. Information regarding presentations, operative findings and procedural events including per-operative mortality, injury to the vital structures during operation, conversion to RYHJ, operative time (minutes), blood loss and transfusion requirements (ml) of Heaticoduodenostomy for type I Choledochal cyst, were specially searched for. There was no operative mortality. None of these patients required per-operative blood transfusion. Nor there was any inadvertent injury to the adjacent structures. The mean operative time required for Hepaticoduodenostomy was 88 minutes with a range of 75 to 125 minutes. Through this study, at BSMMU Hospital, operative events and time requirement of Hepatico-duodenostomy for treating type I Choledochal cyst, was found to be yielding acceptable results, for safe practice.

Study of Immediate Postoperative Outcome of Hepaticoduodenostomy for the Treatment of Type I Choledochal Cyst: The Experience at BSMMU Hospital.

Excision of type I choledochal cyst mandates restoration of continuity of extrahepatic biliary drainage system through anastomotic options having their advantages and disadvantages. Roux en-Y Hepaticojejunostomy (RYHJ) has been very popular and long studied standard surgical treatment for type I choledochal cyst. But now Hepaticoduodenostomy (HD) is also being practiced and studied in different centers all over the world for the treatment of the same disease. We have been practicing Hepaticoduodenostomy for treating type I choledochal cyst, at Bangabandhu Sheik Mujib Medical University (BSMMU), for last five years. Here, we are presenting our experience at BSMMU Hospital, regarding immediate post-operative outcome of Hepaticoduodenostomy for the treatment of type I Choledochal cyst, to show whether this procedure can be safely practiced, producing acceptable results. It is a retrospective document review of forty two MRCP confirmed type I Choledochal cyst children, admitted and operated at BSMMU Hospital, from January 2013 to December 2017. Patient's particulars, history, physical examination, investigations (including MRCP confirmation), assessment, surgical plan were collected from relevant medical records under standard privacy protocol. Information regarding early post-operative outcome of Hepaticoduodenostomy in treating uncomplicated type I choledochal cyst were searched for review and evaluation, specifically with respect to- a) mortality (if any); b) morbidities like- i) prolonged post-operative abdominal pain, ii) anastomotic bile leak, iii) features of early Cholangitis, iv) wound dehiscence and c) prolonged Hospital stay. There was no immediate post-operative mortality. But 9(21.42%) patients had prolonged post-operative pain requiring parenteral Pethidine 'on demand' beyond second post-operative day, 2(4.76%) had anastomotic bile leak, 7(16.67%) had early cholangitis and 1(2.38%) had abdominal wound dehiscence; they (21.42%) also stayed in hospital for more than fourteen days. The outcome was acceptably safe when compared with other studies abroad. Through this study, at BSMMU Hospital, immediate post-operative outcome of Hepaticoduodenostomy for treating type I choledochal cyst- in terms of morbidity, mortality and hospital stay- was found to be yielding acceptable results, for safe practice.

Management of a Subgingivally Fractured Maxillary Central Incisor by Reattachment Technique.

Reattachment of a fractured fragment to the remaining tooth is challenging but one of the best treatment protocols in regards to aesthetics, function as well as patients acceptance. If the original tooth fragment is retained following fracture, the natural tooth structures can be reattached using adhesive protocols to ensure reliable strength, durability and aesthetics. This case report will discuss a 13 years old boy with a complicated crown-root fracture of maxillary right central incisor tooth. The procedure used to repair the fracture regarding this case including flap surgery with endodontic treatment. The root canal was filled with a root canal sealer and gutta-percha. After root canal obturation, fragment was reattached with an adhesive tooth reattachment technique. After 6 months evaluation, clinical and radiographic examinations showed a stable re-attachment, good aesthetic and healthy periodontium.

Evaluation of Corrosion and Tarnishing of Intra-oral Nickel Chromium and Gold-alloy Cast Crown.

Although esthetic factors might limit by the presentation of materials used, all-metal complete cast crown should always be offered to patients requiring restoration of endodontically treated posterior tooth. The complete cast crown has the highest longevity of all fixed restorations. It could be used to rebuild a single tooth or a retainer for a fixed prosthesis. It involves all the axial walls as well as the occlusal surface of the tooth to be restored. All restorations are placed in the oral environment in contact with the gingival tissue. Thus clinicians must choose nontoxic or least toxic metal alloys, since any release of elements that might cause reactions. This study was designed to observe clinical responses of nickel chromium alloy and gold alloy cast crown and provide guidance to ascertain the best alloy for cast metal crown, which serves better functional restoration.

Study on Endoscopic Retrograde Cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography (ERCP) is a modern & universally established modality in the evaluation and treatment of suspected biliary and pancreatic disease. In Bangladesh, ERCP services are limited to few tertiary care centers mostly in the capital & large city. ERCP was 1st introduced in Mymensingh on 3rd April 2016 in a private hospital. Since then, Mymensingh Medical College Hospital (MMCH) provides ERCP services to a large volume of patients in collaboration with private center for diagnostic accuracy & therapeutic purpose. The aim of this study was to evaluate our experience in ERCP, to characterize & evaluate the aetiology, findings of ERCP & frequency of complications. This prospective type of study was carried out by the department of hepatology, MMCH from 3rd April 2016 to 10th July 2018 in collaboration with that private center where ERCP has been established. All patients undergoing ERCP during this period were included. Aetiology & findings were assessed at the time of ERCP & complications were assessed during procedure, index hospitalization & within 30 days after the procedure by telephone contact. A total of 301 consecutive ERCP were performed during the study period. Among them, 182(60.5%) were male & 119(39.5%) were female with an age range of 18-78 years. The most common indications for ERCP were: cholangiocarcinoma in 98(32.56%) & choledocholithiasis in 95(31.56%) followed by periampullary growth in 93(30.89%), suspected CBD stricture in 12(4%) & chronic pancreatitis in 2(0.66%). The most common findings were choledocholithiasis (32.56%), cholangiocarcinoma (32.56%), biliary obstruction due to periampullary growth (30.56%). Biliary fistula with distal bile duct stricture was found in (1.66%), bile duct stricture in (1.33%), chronic pancreatitis in (0.66%), and organic papillary stenosis with deformed bulb were discovered in (0.34%) case. All ERCPs were done for therapeutic purpose. Endoscopic sphincterotomy was the most common therapeutic procedure (87.04%) of which biliary stenting was done in (67.44%) & stone extraction in (33.71%). Stone extraction from biliary tree was successfully done in 94 cases (98.67%) but it was unsuccessful from biliary tree in 4 cases (1.33%) & also from pancreatic duct in a separate case. The most frequent complication was Post-ERCP pancreatitis in 9 patients (2.99%) followed by acute confusional state (1.33%). Post-ERCP cholangitis occurred in (0.99%) & death was reported in 2 cases (0.66%) due to anaesthetic hazard.

Transcatheter Closure of Post Infarction Subacute Ventricular Septal Defect: A Case Report.

Ventricular septal rupture (VSR) is an uncommon but lethal complication of acute myocardial infarction (MI). Although early surgical closure is the treatment of choice, hospital mortality after emergency surgery remains high. Transcatheter closure of post myocardial infarction ventricular septal defect (PIVSD) has emerged as a potential treatment option in selected cases. Herein, we report a case present in AFC Health FORTIS Heart Institute, Khulna, Bangladesh on 10 February 2017 of sub acute post-MI VSR that was successfully closed using an Amplatzerseptal occlude (ASD) device. The patient had undergone primary percutaneous coronary intervention (PCI) 15 days earlier in the setting of acute MI.

Pulmonary alveolar microlithiasis (PAM) in a child.

A 4 year 7 month-old girl of consanguineous parents presented with only fever for 25 days but no cough or respiratory distress. Ches x-ray showed bilateral diffuse nodulo-striate opacities in both lungs. Investigations for any infection were negative including tuberculosis. Thoracoscopic biopsy showed alveolar microliths on histopathology suggesting the diagnosis of pulmonary alveolar microlithiasis (PAM).

Antibiotic prophylaxis is unnecessary in clean surgery.

A significant number of paediatric surgical patients undergone clean surgical procedures. Most of the paediatric surgeon use perioperative prophylactic antibiotic in this clean procedure because of undue fear of infection in their mind. The objective of this study is to evaluate whether the use of perioperative prophylactic antibiotics have an effect to prevent post operative wound infection in clean operation in paediatric surgical patients. This study was conducted in the paediatric surgery department of Bangabandhu Sheikh Mujib Medical University and some private clinics of Dhaka city from January 2009 to December 2009. Two hundred patients who were undergone clean elective surgical procedure on day case basis were included in this study. They were divided into two equal groups (Group A and Group B). The patients of Group A were given intransverse Cephradine 30 minutes before incision and then oral Cephradine was advised postoperatively for 7 days. The patients of Group B were not given any perioperative antibiotic. All the patients of both groups were advised to come on 3rd, 6th and 10th postoperative day for examination of wound. In Group A (With chemo prophylaxis), five patients (5%) developed postoperative wound infection and in Group B (without chemo prophylaxis), three patients (3%) developed postoperative wound infection. Thus the rate of postoperative wound infection is slightly more in patients with chemo prophylaxis but it was not statistically significant by chi-square test. Based on the result of this study, it may be concluded that the antibiotic prophylaxis is not necessary in clean surgery in paediatric age group.

Melanotic neuroectodermal tumour of infancy.

Melanotic neuroectodermal tumour in infancy is rare, mainly benign with little tendency to recur after excision or effective curettage. This pigmented neoplasm of neural crest origin occurring in infants before 1 year of age. The most common site of occurrence is the anterior maxillary alveolar ridge (70%), following by the skull, brain and mandible. The genital organ is the most frequent extra cranial site. We report a 6 months old male baby with a similar tumour arising from right half of cheek involving the maxilla. We diagnosed the case after histological report. We remove the tumour through a sub-labial incision. The mass was blackish in colour, and was mobilized from all side including from the maxillary sinuses. The author thought that this should be reported for improving the clinical awareness and treatment of pigmented soft tissue mass in children. Almost one year follow up of the patients showed no recurrence.

Consecutive bites on two persons by the same cobra: a case report

In tropical countries like Bangladesh, persons are bitten by snakes every day and a considerable number of patients die en route to the hospital. An event of consecutive neurotoxic bites on two men by a single snake was observed in the Snake Bite Study Clinic (SBSC) of the Chittagong Medical College Hospital (CMCH). Two brothers, working in their semi-pucca restaurant, were successively bitten by the same cobra on their lower limbs. Within an hour, they were taken to the CMCH. Few minutes after admission, both developed symptoms of neurotoxicity: ptosis, nasal voice, dysphagia, broken neck sign, etc. They received polyvalent antivenom (Haffkine Bio-Pharmaceuticals Company, India) and other auxiliary treatment immediately. Within few hours, neurotoxic features were completely absent. Later, the snake was captured in the restaurant kitchen and identified as monocellate cobra (Naja kauthia) by the SBSC. The elder brother developed significant antivenom reactions and both presented necrosis and ulceration at the bite sites. In these cases, immediate arrival to the hospital and early administration of antivenom resulted in successful recoveries.(AU)

Anti-snake venom: use and adverse reaction in a snake bite study clinic in Bangladesh

Snakebites can present local or systemic envenomation, while neurotoxicity and respiratory paralysis are the main cause of death. The mainstay of management is anti-snake venom (ASV), which is highly effective, but liable to cause severe adverse reactions including anaphylaxis. The types of adverse reaction to polyvalent anti-snake venom have not been previously studied in Bangladesh. In this prospective observational study carried out between 1999 and 2001, in the Snake Bite Study Clinic of Chittagong Medical College Hospital, 35 neurotoxic-snake-bite patients who had received polyvalent anti-snake venom were included while the ones sensitized to different antitoxins and suffering from atopy were excluded. The common neurotoxic features were ptosis (100%), external ophthalmoplegia (94.2%), dysphagia (77.1%), dysphonia (68.5%) and broken neck sign (80%). The percentage of anti-snake venom reaction cases was 88.57%; pyrogenic reaction was 80.64%; and anaphylaxis was 64.51%. The common features of anaphylaxis were urticaria (80%); vomiting and wheezing (40%); and angioedema (10%). The anti-snake venom reaction was treated mainly with adrenaline for anaphylaxis and paracetamol suppository in pyrogenic reactions. The average recovery time was 4.5 hours. Due to the danger of reactions the anti-snake venom should not be withheld from a snakebite victim when indicated and appropriate guidelines should be followed for its administration.(AU)

Thyrohyoid approach to cidofovir injection: a case study.

Various techniques for injection into the larynx have been well described, including transoral injection with indirect laryngoscopy or direct laryngoscopy and transcutaneous injection through the thyroid cartilage or cricothyroid membrane. We describe a case not amenable to these techniques, in which entry through the thyrohyoid membrane for injection of cidofovir was successfully performed with a thyrohyoid approach. This technique is described, and comparisons are made with currently available techniques.

A retrospective study on genito urinary Rhabdomyosarcoma.

A retrospective study was carried out on Genitourinary Rhabdomyosarcoma in the Department of Paediatric Surgery of Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh during the period January 1990 to December 1999. Total thirteen patients were treated during this period, age ranging from 1 month to 12 years. Eight patients were male and five were female (M: F = 1.6: 1). Diagnosis was made by history, thorough physical examination, digital rectal examination, ultrasonography, intravenous urography, CT scan and biopsy. All the patients were treated with chemoradiation theraphy as a first line of management and surgical excision was done for local residual tumours. Eight children (61.5%) were asymptomatic after completion of chemo-radiation therapy. Three (23.07%) patients discontinued the chemo-radiation schedule. Residual mass was present in one (7.7%) case for which partial cystectomy was done and the patient died in the 5th post operative day. Another patient (7.7%) who had pulmonary metastasis at the time of diagnosis, died during chemo-radiation therapy.

Proton pump inhibitor resistance in the treatment of laryngopharyngeal reflux.

OBJECTIVE: To describe the occurrence of relative proton pump inhibitor (PPI) drug resistance in the treatment of laryngopharyngeal reflux (LPR). STUDY DESIGN AND SETTING: A retrospective review was performed for 1053 consecutive adults undergoing double-probe (simultaneous esophageal and pharyngeal) pH testing in our laboratory. Two hundred five patients who had pH studies performed while taking at least a daily dose of PPI therapy were identified; 167 qualified for further analysis. The pH data was reviewed for the presence of abnormalities in either esophageal or pharyngeal acid exposure to evaluate drug efficacy. RESULTS: Forty-four percent (74/167) of the study patients demonstrated abnormal levels of acid exposure. Results were further analyzed to compare failure rates based on different dosage regimens. Patients on once daily doses of PPI failed at a rate of 56%, with lower failure rates for higher-dose regimens. CONCLUSIONS: A significant number of LPR patients on PPI therapy demonstrate relative drug resistance.

Cryopreservation of epididymal spermatozoa collected by needle biopsy from cynomolgus monkeys (Macaca fascicularis).

We have examined the motility, morphology, and cryopreservation of epididymal spermatozoa collected by needle biopsy from cynomolgus monkeys (Macaca fascicularis). At collection, epididymal sperm (23 x 10(6) +/- 4 x 10(6) sperm/sample; 611 x 10(6) +/- 116 x 10(6) sperm/ ml; n = 18) were alive (79 +/- 2%), motile (67 +/- 2%), and exhibited intact membranes (65 +/- 2%). Sperm maintained at room temperature in handling medium exhibited decreased motility over time, but head-to-head agglutination was limited. Tris egg-yolk extender containing 6% glycerol and dimethylsulfoxide (DMSO) did not significantly affect functional morphology, whereas extender containing propanediol significantly reduced motility, survival, and membrane integrity. Cryostorage reduced all measures of functional morphology independent of cryoprotectant. Post-thaw motility was superior for glycerol and DMSO compared to propanediol. Variation in glycerol concentration (4, 6, and 8%) produced equivocal effects on sperm functional morphology post-thaw. Needle biopsy may be a useful technique for laboratory and field-based collection of spermatozoa from nonhuman primates.

Diagnostic laryngeal electromyography: The Wake Forest experience 1995-1999.

BACKGROUND: Laryngeal electromyography (LEMG) is a valuable diagnostic/prognostic test for patients with suspected laryngeal neuromuscular disorders. OBJECTIVE: To report our experience with diagnostic LEMG at the Center for Voice Disorders of Wake Forest University and to evaluate the impact of LEMG on clinical management. METHODS: Retrospective chart review of 415 patients who underwent diagnostic LEMG over a 5-year period (1995-1999). RESULTS: Of 415 studies, 83% (346 of 415) were abnormal, indicating a neuropathic process. LEMG results altered the diagnostic evaluation (eg, the type of radiographic imaging) in 11% (46 of 415) of the patients. Unexpected LEMG findings (eg, contralateral neuropathy) were found in 26% (107 of 415) of the patients, and LEMG results differentiated vocal fold paralysis from fixation in 12% (49 of 415). Finally, LEMG results altered the clinical management (eg, changed the timing and/or type of surgical procedure) in 40% (166 of 415) of the patients. CONCLUSIONS: LEMG is a valuable diagnostic test that aids the clinician in the diagnosis and management of laryngeal neuromuscular disorders.

Hemicricoidectomy for voice rehabilitation following hemilaryngectomy with ipsilateral arytenoid removal.

The purpose of this article is to describe an approach to reconstruction of the larynx after vertical partial laryngectomy with removal of the ipsilateral arytenoid cartilage. This method addresses the problem of postoperative posterior glottal incompetence (aphonia with or without aspiration). The technique involves resection of the ipsilateral half of the cricoid cartilage, use of an inferiorly based strap muscle flap for vocal fold reconstruction, and placement of a customized stent. This technique may be used at the time of the primary cancer extirpation or as a secondary rehabilitative procedure. Generally, patients who have undergone this procedure have had minimal postoperative breathiness with good phonatory and airway function. We recommend this reconstructive technique for patients with large posterior defects following hemilaryngectomy.

Predicting outcome in pediatric coin ingestion.

OBJECTIVE: To determine the relationship between coin size, coin location, patient age, and patient weight and likelihood of coin passage through the esophagus following pediatric coin ingestion. A secondary objective is to test the hypothesis that coin denomination can be determined based on radiographic appearance. METHODS: A retrospective review was performed of all children seen and evaluated for coin ingestion at a single institution over a 25-month period. Outcome measures included the number of coins that were retained in the esophagus, and the number that passed. Various factors were assessed for their predictive value in judging outcome in coin ingestion cases. RESULTS: Nineteen percent of patients (15/79) in the study passed their ingested coins. Coin denomination could be accurately determined on every patient that had a standard AP or lateral X-ray film. These findings were marked when compared with the lack of reliability of history in determining coin denomination. Patients who passed coins were as a group older (4.6 vs. 3.2 year, P=0.04), but did not differ significantly by weight (19.5 vs. 15.4 kg, P=0.07) from those that retained the coins. Coins located at the gastroesophageal junction had a significantly higher passage rate than coins located elsewhere in the esophagus (89 vs. 8.2%, P<0.01). Coin size was not predictive of coin passage (P=0.7 by chi(2)). CONCLUSIONS: Radiographic assessment of coin denomination is reliable, but in this study could not be used to predict coin passage. Patient age and coin location at the gastroesophageal junction, however, do correlate with this event.

Suppression of tumourigenicity, and induction of differentiation of the canine mammary tumour cell line MCM-B2 by sodium phenylacetate.

The authors evaluated the cell growth inhibition, reduction of tumourigenicity, and differentiation-inducing effects of sodium phenylacetate (NaPA) on a canine mammary tumour cell line. Treatment of the canine mammary tumour cell line (MCM-B2) with NaPA lead to the arrest of cell growth. Sodium phenylacetate induced changes in the cells to non-malignant characteristics, as indicated by a reduction of colony formation in semi-solid agar and a decrease in tumour formation in athymic mice. Moreover, NaPA induced morphological changes from a spindle-shaped to an epithelial-like appearance, and significant accumulation of lipid droplets in the cytoplasm. Immunohistochemically, these treated cells reacted clearly with the antibody for keratin/cytokeratin. Sodium phenylacetate treatment increased the expression of the milk-specific genes alpha-lactalbumin and beta-casein. The results of this study warrant an evaluation of NaPA in a clinical trial to establish its possible value as adjunctive treatment of malignant canine mammary tumours.