Lessons learned from a delayed diagnosis of atrioesophageal fistula: A multidisciplinary approach.

Atrioesophageal fistulas are a rare complication of radiofrequency ablation (RFA) that requires rapid identification and emergent surgical repair to prevent morbidity and mortality. We report a case of a 32-year-old man with atrial fibrillation presenting with chest pain followed by rapidly progressive sepsis and embolic cerebrovascular accident 23 days after RFA. Subtle initially overlooked findings on multiple computed tomography caused a delay in diagnosis. Atrioesophageal fistulas remain diagnostically challenging. A high index of suspicion coupled with serial computed tomography of the chest with intravenous and oral contrast reviewed by a multimodal team is essential to make a timely diagnosis.

Advantages of Molecular Weight Identification during Native MS Screening.

Native mass spectrometry detection of ligand-protein complexes allowed rapid detection of natural product binders of apo and calcium-bound S100A4 (a member of the metal binding protein S100 family), T cell/transmembrane, immunoglobulin (Ig), and mucin protein 3, and T cell immunoreceptor with Ig and ITIM (immunoreceptor tyrosine-based inhibitory motif) domains precursor protein from extracts and fractions. Based on molecular weight common hits were detected binding to all four proteins. Seven common hits were identified as apigenin 6-C-ß-D-glucoside 8-C-α-L-arabinoside, sweroside, 4',5-dihydroxy-7-methoxyflavanone-6-C-rutinoside, loganin acid, 6-C-glucosylnaringenin, biochanin A 7-O-rutinoside and quercetin 3-O-rutinoside. Mass guided isolation and NMR identification of hits confirmed the mass accuracy of the ligand in the ligand-protein MS complexes. Thus, molecular weight ID from ligand-protein complexes by electrospray ionization Fourier transform mass spectrometry allowed rapid dereplication. Native mass spectrometry using electrospray ionization Fourier transform mass spectrometry is a tool for dereplication and metabolomics analysis.

The ability of non-physician health workers to identify chest indrawing to detect pneumonia in children below five years of age in low- and middle-income countries: A systematic review and meta-analysis.

Background: Non-physician health workers play a vital role in diagnosing and treating pneumonia in children in low- and middle-income countries (LMICs). Chest indrawing is a key indicator for pneumonia diagnosis, signifying the severity of the disease. We conducted this systematic review to summarize the evidence on non-physician health workers' ability to identify chest indrawing to detect pneumonia in children below five years of age in LMICs. Methods: We comprehensively searched four electronic databases, including MEDLINE, Embase, Web of Science, and Scopus, and reference lists from the identified studies, from January 1, 1990, to January 20, 2022, with no language restrictions. Studies evaluating the performance of non-physician health workers in identifying chest indrawing compared to a reference standard were included. We used the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool to assess the methodological quality of the selected studies and conducted a meta-analysis following a bivariate random effects model to estimate the pooled sensitivity and specificity. Results: We identified nine studies covering 4468 children that reported the accuracy of a non-physician health worker in identifying chest indrawing. Most studies were conducted in the 1990s, based at health facility settings, with children aged 2-59 months, and with pediatricians/physicians as the reference standard. Using the QUADAS-2, we evaluated most studies as having a low risk of bias and a low concern regarding applicability in all domains. The median sensitivity, specificity, positive predictive value, and negative predictive value were 44%, 97%, 55%, and 95%, respectively. We selected five studies for the meta-analysis. The pooled sensitivity was 46% (95% confidence interval (CI) = 37-56), and the pooled specificity was 95% (95% CI = 91-97). Conclusions: We found the ability of non-physician health workers in LMICs in identifying chest indrawing pneumonia is relatively poor. Appropriate measures, such as targeted identification and training, supportive supervision, regular performance assessment, and feedback for those who have a poor ability to recognize chest indrawing, should be taken to improve the diagnosis of pneumonia in children. New studies are needed to assess the new generation of health workers. Registration: PROSPERO (CRD42022306954).

Maternal mental health and child nutritional status in an urban slum in Bangladesh: A cross-sectional study.

Poor mental health may diminish a mother's capacity to adequately care for her child, resulting in a negative impact on the child's nutrition. This study aims to determine the association between maternal mental health and child nutritional status in a poor urban population in Bangladesh. We carried out a cross-sectional study among 264 mother-child pairs in an urban slum area of Bangladesh. The Self-Reporting Questionnaire-20 (SRQ-20) was used to assess maternal mental health. An SRQ-20 score ≥7 was considered a common mental disorder (CMD). Anthropometric measurements were performed to assess nutritional status of the children. The prevalence of maternal CMD was 46.2%. Maternal CMD was associated with poorer child feeding practice (p<0.001), poorer hygiene practice (p<0.001), poorer preventive care service use (p = 0.016), and suffering from diarrheal diseases (p = 0.049). The prevalence of stunting, wasting and underweight in children was 44.3%, 18.2% and 33.7%, respectively. A poorer child feeding practice was associated with wasting (p = 0.004) and underweight (p<0.001) but not with stunting. Poorer hygiene practices and suffering from diarrheal diseases were associated with stunting and underweight, but not with wasting. In multivariable analysis, maternal CMD was associated with child wasting (adjusted odds ratio, aOR = 2.25, 95% CI = 1.15-4.43). The association between maternal CMD and child underweight found in the bivariate analysis was attenuated and no longer statistically significant after multivariable analysis (aOR = 1.77, 95% CI = 0.94-3.33). No statistically significant association was observed between maternal CMD and stunting in this study (aOR = 1.46, 95% CI = 0.84-2.54). Maternal mental health affects nutritional status of the children where child feeding practice, hygiene practice and preventive care use might play a role. Interventions to address maternal mental health in child nutrition programs might improve child nutritional status.

Accuracy of Mid-Upper Arm Circumference for Detecting Acute Malnutrition in Children Aged 6-59 Months in an Urban Slum in Bangladesh: A Cross-Sectional Analysis.

Background The weight-for-height z-score (WHZ) is considered the gold standard for detecting acute malnutrition in children. However, an accurate assessment of WHZ can often be challenging, especially in community settings. Mid-upper arm circumference (MUAC) is a simple and easy-to-perform method to identify children with acute malnutrition. The objective of the study was to evaluate the accuracy of MUAC in detecting acute malnutrition compared to WHZ among children aged 6-59 months in Bangladesh. Methods We used anthropometric data for 239 children aged 6-59 months from a cross-sectional study conducted in 2013 in an urban slum in Dhaka, Bangladesh. The sensitivity and specificity of MUAC to detect acute malnutrition were calculated, considering WHZ as the gold standard. Results The mean age of the children was 29.4 ± 12.7 months, with a male-to-female ratio of 1:1.2. The prevalence of acute malnutrition was 17.1% and 22.5% based on WHZ and MUAC, respectively. The total area under the receiver operating characteristic curve was 0.816. For detecting acute malnutrition, the sensitivity of MUAC was 61.0% and the specificity was 85.4% for the World Health Organization (WHO) recommended cutoff of <125 mm. Using the Youden index, the best MUAC cutoff point to detect acute malnutrition was <128 mm with a sensitivity of 75.6% and a specificity of 74.7%. Conclusions Our study demonstrated a low sensitivity of MUAC to identify acute malnutrition at the WHO cutoff of <125 mm. The cutoff could be increased to <128 mm to capture more children with acute malnutrition.

A Case of Brain Tuberculosis With an Unusual Presentation Mimicking Viral Fever During a Dengue Outbreak in Bangladesh.

Both dengue and tuberculosis are endemic in South Asian countries, including Bangladesh. Here we report an interesting case presenting as suspected dengue fever and eventually diagnosed as a case of brain tuberculosis. A 27-year-old immunocompetent male presented to us with fever, headache, retro-orbital pain, and photophobia for five days. He had no other complaints, and clinical examination findings were normal. Full blood count revealed neutrophilic leukocytosis; dengue antigen test and anti-dengue antibody test were negative. Magnetic resonance imaging (MRI) of the brain showed both supra and infra-tentorial multiple small (2-4 mm) gadolinium-enhancing lesions suggestive of tuberculomas. A cerebrospinal fluid study revealed lymphocytic pleocytosis with raised protein, low sugar level, and positive Gene Xpert MTB/RIF (Cepheid, California, US) assay test. Investigations did not reveal the involvement of other organs except for the brain. We started standard anti-tuberculosis therapy (HRZE) along with steroids and pyridoxine, and the patient became symptom-free within one week. The patient was discharged with the advice of follow-up after one month. The clinical course and all investigation findings of this case are presented. Central nervous system tuberculosis may present with non-specific signs and symptoms and may be misdiagnosed as other infections, including dengue, particularly during an ongoing epidemic. It may cause significant morbidity and mortality when the diagnosis is delayed due to its vague clinical presentation.

Developing a video expert panel as a reference standard to evaluate respiratory rate counting in paediatric pneumonia diagnosis: protocol for a cross-sectional study.

INTRODUCTION: Manual counting of respiratory rate (RR) in children is challenging for health workers and can result in misdiagnosis of pneumonia. Some novel RR counting devices automate the counting of RR and classification of fast breathing. The absence of an appropriate reference standard to evaluate the performance of these devices is a challenge. If good quality videos could be captured, with RR interpretation from these videos systematically conducted by an expert panel, it could act as a reference standard. This study is designed to develop a video expert panel (VEP) as a reference standard to evaluate RR counting for identifying pneumonia in children. METHODS AND ANALYSIS: Using a cross-sectional design, we will enrol children aged 0-59 months presenting with suspected pneumonia at different levels of health facilities in Dhaka and Sylhet, Bangladesh. We will videorecord a physician/health worker counting RR manually and also using an automated RR counter (Children's Automated Respiration Monitor) from each child. We will establish a standard operating procedure for capturing quality videos, make a set of reference videos, and train and standardise the VEP members using the reference videos. After that, we will assess the performance of the VEP as a reference standard to evaluate RR counting. We will calculate the mean difference and proportions of agreement within±2 breaths per minute and create Bland-Altman plots with limits of agreement between VEP members. ETHICS AND DISSEMINATION: The study protocol was approved by the National Research Ethics Committee of Bangladesh Medical Research Council, Bangladesh (registration number: 39315022021) and Edinburgh Medical School Research Ethics Committee (EMREC), Edinburgh, UK (REC Reference: 21-EMREC-040). Dissemination of the study findings will be through conference presentations and publications in peer-reviewed scientific journals.

Digital auscultation as a diagnostic aid to detect childhood pneumonia: A systematic review.

Background: Frontline health care workers use World Health Organization Integrated Management of Childhood Illnesses (IMCI) guidelines for child pneumonia care in low-resource settings. IMCI guideline pneumonia diagnostic criterion performs with low specificity, resulting in antibiotic overtreatment. Digital auscultation with automated lung sound analysis may improve the diagnostic performance of IMCI pneumonia guidelines. This systematic review aims to summarize the evidence on detecting adventitious lung sounds by digital auscultation with automated analysis compared to reference physician acoustic analysis for child pneumonia diagnosis. Methods: In this review, articles were searched from MEDLINE, Embase, CINAHL Plus, Web of Science, Global Health, IEEExplore database, Scopus, and the ClinicalTrial.gov databases from the inception of each database to October 27, 2021, and reference lists of selected studies and relevant review articles were searched manually. Studies reporting diagnostic performance of digital auscultation and/or computerized lung sound analysis compared against physicians' acoustic analysis for pneumonia diagnosis in children under the age of 5 were eligible for this systematic review. Retrieved citations were screened and eligible studies were included for extraction. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. All these steps were independently performed by two authors and disagreements between the reviewers were resolved through discussion with an arbiter. Narrative data synthesis was performed. Results: A total of 3801 citations were screened and 46 full-text articles were assessed. 10 studies met the inclusion criteria. Half of the studies used a publicly available respiratory sound database to evaluate their proposed work. Reported methodologies/approaches and performance metrics for classifying adventitious lung sounds varied widely across the included studies. All included studies except one reported overall diagnostic performance of the digital auscultation/computerised sound analysis to distinguish adventitious lung sounds, irrespective of the disease condition or age of the participants. The reported accuracies for classifying adventitious lung sounds in the included studies varied from 66.3% to 100%. However, it remained unclear to what extent these results would be applicable for classifying adventitious lung sounds in children with pneumonia. Conclusions: This systematic review found very limited evidence on the diagnostic performance of digital auscultation to diagnose pneumonia in children. Well-designed studies and robust reporting are required to evaluate the accuracy of digital auscultation in the paediatric population.

Digital auscultation as a novel childhood pneumonia diagnostic tool for community clinics in Sylhet, Bangladesh: protocol for a cross-sectional study.

INTRODUCTION: The WHO's Integrated Management of Childhood Illnesses (IMCI) algorithm for diagnosis of child pneumonia relies on counting respiratory rate and observing respiratory distress to diagnose childhood pneumonia. IMCI case defination for pneumonia performs with high sensitivity but low specificity, leading to overdiagnosis of child pneumonia and unnecessary antibiotic use. Including lung auscultation in IMCI could improve specificity of pneumonia diagnosis. Our objectives are: (1) assess lung sound recording quality by primary healthcare workers (HCWs) from under-5 children with the Feelix Smart Stethoscope and (2) determine the reliability and performance of recorded lung sound interpretations by an automated algorithm compared with reference paediatrician interpretations. METHODS AND ANALYSIS: In a cross-sectional design, community HCWs will record lung sounds of ~1000 under-5-year-old children with suspected pneumonia at first-level facilities in Zakiganj subdistrict, Sylhet, Bangladesh. Enrolled children will be evaluated for pneumonia, including oxygen saturation, and have their lung sounds recorded by the Feelix Smart stethoscope at four sequential chest locations: two back and two front positions. A novel sound-filtering algorithm will be applied to recordings to address ambient noise and optimise recording quality. Recorded sounds will be assessed against a predefined quality threshold. A trained paediatric listening panel will classify recordings into one of the following categories: normal, crackles, wheeze, crackles and wheeze or uninterpretable. All sound files will be classified into the same categories by the automated algorithm and compared with panel classifications. Sensitivity, specificity and predictive values, of the automated algorithm will be assessed considering the panel's final interpretation as gold standard. ETHICS AND DISSEMINATION: The study protocol was approved by the National Research Ethics Committee of Bangladesh Medical Research Council, Bangladesh (registration number: 09630012018) and Academic and Clinical Central Office for Research and Development Medical Research Ethics Committee, Edinburgh, UK (REC Reference: 18-HV-051). Dissemination will be through conference presentations, peer-reviewed journals and stakeholder engagement meetings in Bangladesh. TRIAL REGISTRATION NUMBER: NCT03959956.

Safety of Single Stage Revision Laparoscopic Sleeve Gastrectomy Compared to Laparoscopic Roux-Y Gastric Bypass after Failed Gastric Banding.

BACKGROUND: Reoperation, after failed gastric banding, is a controversial topic. A common approach is band removal with conversion to laparoscopic Roux-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) in a single-step procedure. OBJECTIVE: This study aimed to assess the safety of revisional surgery to LSG compared to LRYGB after failed laparoscopic adjustable gastric banding (LAGB) based on MBSAQIP Participant User File from 2015 to 2018. METHODS: Patients who underwent a one-stage conversion of LAGB to LSG (Conv-LSG) or LRYGB (Conv-LRYGB) were identified in the MBSAQIP PUF from 2015 to 2017. Conv-LRYGB cases were matched (1:1) with Conv-LSG patients using propensity scoring to control for potential confounding. The primary outcome was all-cause mortality. RESULTS: A total of 9974 patients (4987 matched pairs) were included in the study. Conv-LRYGB, as compared with conv-SG, was associated with a similar risk of mortality (0.02% vs. 0.06%; relative risk [RR], 0.33; 95% confidence interval [CI], 0.03 to 3.20, p = 0.32). Conversion to LRYGB increased the risk for readmission (6.16% vs. 3.77%; RR, 1.63; 95%CI, 1.37 to 1.94, p < 0.01); reoperation (2.15% vs. 1.36%; RR, 1.57; 95%CI, 1.17 to 2.12, p = <0.01); leak (1.76% vs. 1.02%; RR, 1.57; 95%CI, 1.72 to 2.42, p < 0.01); and bleeding (1.66% vs. 1.00%; RR, 1.66; 95%CI, 1.7 to 2.34, p < 0.01). CONCLUSIONS: The study shows that single-stage LRYGB and LSG as revisional surgery after gastric banding, are safe in the 30-day observation with an acceptable complication rate and low mortality. However, conversion to LRYGB increased the risk of perioperative complications.

Proximal Myopathy With Hypercalcemic Crisis and Papillary Thyroid Carcinoma in a 38-Year-Old Female.

Although proximal myopathy is a well-known manifestation of primary hyperparathyroidism (PHP), it is usually not the first one. Here, we present the case of a 38-year-old female who presented to the neurology outpatient department with proximal myopathy as the presenting feature of PHP along with a hypercalcemic crisis. Her serum calcium and intact parathyroid hormone levels were very high. Her symptoms and calcium levels improved with adequate hydration and bisphosphonate therapy. Ultrasonography of the thyroid and parathyroid glands and Tc99m sestamibi single-photon emission computed tomography-computed tomography of the parathyroid glands suggested adenoma or carcinoma of the parathyroid gland on the right side with another irregular right-sided thyroid nodule. Electromyography showed low-amplitude polyphasic potentials suggestive of myopathy. Subsequently, the patient underwent surgical resection of both the right parathyroid glands and the thyroid nodule. Histopathology report was suggestive of parathyroid adenoma and papillary thyroid carcinoma. Hypercalcemic crisis is a rare clinical scenario, which needs prompt diagnosis and treatment. Otherwise, the condition may have a fatal outcome. Due to its diverse presentation, physicians should be aware of this condition. Moreover, we need to be cautious in treating a patient having hyperparathyroidism with thyroid nodule due to possible concomitant thyroid malignancy.

A Rare Case of Severe Neutropenia Due to Chikungunya Fever Which Improved With Filgrastim.

Chikungunya fever is a re-emerging viral illness affecting different parts of the world. Most patients recover without any serious complications. Here, we present a rare case of chikungunya fever with severe neutropenia and moderate thrombocytopenia. A 31-year-old male presented with a fever, body aches, and rash. Serial full blood counts revealed a very low neutrophil count (0.273 × 109/L) with a low platelet count (56 × 109/L). Dengue fever was excluded by doing both antigen and antibody tests. The IgM antibody against the chikungunya virus was positive. After giving one dose of granulocyte colony-stimulating factor (G-CSF) filgrastim, the neutropenia resolved. A few days later, the thrombocytopenia resolved as well. Other than episodic attacks of arthritis, he recovered completely. The absence of severe neutropenia and thrombocytopenia is considered a major demarcating feature between chikungunya fever and dengue fever. Cases like this one put physicians in a difficult position regarding accurate diagnosis and appropriate management plans. The use of filgrastim may be considered as rescue therapy in a situation like this.

Polyphenol-rich leaf of Aphanamixis polystachya averts liver inflammation, fibrogenesis and oxidative stress in ovariectomized Long-Evans rats.

Aphanamixis polystachya (Wall.) R.Parker, locally known as Pithraj, is a medicinal herb having enormous traditional applications. However, the scientific rationale underlying the ethnomedicinal claims was not well-founded. The current investigation aimed to explore the mechanistic insights of protective effects of ethanol extract of A. polystachya leaf (PT), given orally, on the chemical-intoxicated hepatic inflammation and fibrosis in Long-Evans female overiectomized rats. The GC-MS and HPLC-DAD analysis of PT revealed the presence of several bioactive metabolites, including polyphenolic compounds. Catechin hydrate, caffeic acid, syringic acid, epicatechin and p-coumaric acid have been identified and quantified in the ethanol extract of PT leaf. Intoxication with CCl4 developed the oxidative stress, fibrosis and inflammation in liver of rats. Moreover, thiobarbituric acid reactive substances (TBARS), nitric oxide (NO), advanced protein oxidation product (APOP) level were found increased; whereas superoxide dismutase (SOD) and catalase activities in the plasma and liver were decreased in CCl4 administered rats. Treatment with PT prominently mitigated the oxidative stress (TBARS, NO, APOP), and inflammatory (MPO) markers and improved the endogenous antioxidant enzymes (catalase and SOD) activities in CCl4-intoxicated rats. Additionally, histological assessment confirmed the clear manifestation of inflammation and fibrosis in the liver of CCl4-intoxicated rats, which was prevented by PT and silymarin treatment. In conclusion, PT treatment may protect the liver in CCl4-administered rats, probably by mitigating oxidative stress, inflammation and fibrosis, and also augmenting the function of the antioxidant enzymes.

Adverse Events Following COVISHIELD Vaccination Among Adult Population in Bangladesh.

The study aimed to determine how frequently the adverse events of the COVISHIELD vaccine occur among the Bangladeshi population. This cross-sectional study was conducted at Sheikh Russel Gastroliver Institute and Hospital, Mohakhali, Dhaka, Bangladesh, in May 2021. The inclusion criteria were the adult populations who received the 2nd dose of the COVISHELD vaccine and had passed 28 days following the completion of the 2nd dose. Three hundred and five persons fulfilling the inclusion criteria were asked over the telephone-based on a predesigned questionnaire. The rates of adverse events were 54.1% and 41.3% after the 1st and 2nd dose of vaccine, respectively, and the difference was statistically significant (p < 0.001). Pain at the injection site was the most common adverse event (32.5% following the 1st dose and 27.9% following the 2nd dose). All of the symptoms were mild and lasted for about 2 days. Age and comorbidities were significantly associated with the adverse events (p < 0.001). Neither doses had any vaccine-related life-threatening adverse event nor had any symptoms related to vaccine-related blood clotting. Nineteen persons (6.2%) had been diagnosed with COVID-19 after the 1st dose of vaccination, and three (1%) persons had been diagnosed with COVID-19 after the 2nd dose of vaccination. As no significant life-threatening adverse event was observed, this study might help reduce the hesitancy for vaccination among the population and thus help reduce transmission of this highly contagious virus.

Role of Personal Protective Measures in Prevention of COVID-19 Spread Among Physicians in Bangladesh: a Multicenter Cross-Sectional Comparative Study.

This study aims to determine the role of personal protective measures in the prevention of COVID-19 spread among the physicians working at different health facilities in Bangladesh. This hospital-based cross-sectional comparative study was conducted from May to June 2020. A total of 98 COVID-19 positive physicians and 92 COVID-19 negative physicians (physicians with no symptoms of COVID-19 or who tested negative) were enrolled. The questionnaire was adapted from a tool developed by the World Health Organization (WHO) for risk assessment and management of exposure of healthcare workers in the context of COVID-19. Data were collected from the respondents online using Google forms. There was no significant difference in baseline information between COVID-19 positive and COVID-19 negative physicians. The physicians, who were unaware of direct participation in COVID-19 patient care, had higher odds of being COVID-19 positive (OR = 4.018; CI: 1.532-10.535). Additionally, the physicians, who were unaware of the COVID-19 status while performing the aerosol-generated procedure (AGP), had a higher chance of being COVID-19 positive (OR = 2.522; CI: 1.020-6.233). Using face shields/goggles (OR = 0.437; CI:0.228-0.837) and regular decontamination of the patient's surroundings (OR = 0.392; CI:0.176-0.873) while usual take care of patients and use of N95 masks while performing AGP (OR = 0.372; CI:0.159-0.873) had protective roles against COVID-19 among the physicians. The physicians who had reused the medical gown had two times more chances of being tested positive for COVID-19 than those who had not reused it (OR = 2.3; CI:1.251-4.259). The use of face shields/goggles and N95 masks and decontamination of the patient's surroundings may give protection against COVID-19. Additionally, reusing medical gowns should be avoided as much as possible.

Effectiveness of the 10-valent pneumococcal conjugate vaccine against radiographic pneumonia among children in rural Bangladesh: A case-control study.

BACKGROUND: Pneumococcal conjugate vaccine (PCV) effectiveness against radiographic pneumonia in South Asia is unknown. Bangladesh introduced PCV10 in 2015 using a three dose primary series (3 + 0). We sought to measure PCV10 effectiveness for two or more vaccine doses on radiographic pneumonia among vaccine-eligible children in rural Bangladesh. METHODS: We conducted a matched case-control study over two years from 2015 to 2017 using clinic and community controls in three subdistricts of Sylhet, Bangladesh. Cases were vaccine eligible 3-35 month olds at Upazila Health Complex outpatient clinics with World Health Organization-defined radiographic primary endpoint pneumonia (radiographic pneumonia). Clinic controls were matched to cases within a one week time window by age, sex, and clinic and had an illness unlikely to be Streptococcus pneumoniae; community controls were healthy and similarly matched within a one week time window by age and sex, and distance from the clinic. We estimated adjusted vaccine effectiveness (aVE) using conditional logistic regression. RESULTS: We matched 1262 cases with 2707 clinic and 2461 community controls. Overall, aVE using clinic controls was 21.4% (95% confidence interval, -0.2%, 38.4%) for ≥2 PCV10 doses and among 3-11 month olds was 47.3% (10.5%, 69.0%) for three doses. aVE increased with higher numbers of doses in clinic control sets (p = 0.007). In contrast, aVE using community controls was 7.6% (95% confidence interval, -22.2%, 30.0%) for ≥2 doses. We found vaccine introduction in the study area faster and less variable than expected with 75% coverage on average, which reduced power. Information bias may also have affected community controls. CONCLUSIONS: Clinic control analyses show PCV10 prevented radiographic pneumonia in Bangladesh, especially among younger children receiving three doses. While both analyses were underpowered, community control enrollment - compared to clinic controls - was more difficult in a complex, pluralistic healthcare system. Future studies in comparable settings may consider alternative study designs.

Prevalence and factors associated with hypertension among adults in rural Sylhet district of Bangladesh: a cross-sectional study.

OBJECTIVES: Low-income and middle-income countries are undergoing epidemiological transition, however, progression is varied. Bangladesh is simultaneously experiencing continuing burden of communicable diseases and emerging burden of non-communicable diseases (NCDs). For effective use of limited resources, an increased understanding of the shifting burden and better characterisation of risk factors of NCDs, including hypertension is needed. This study provides data on prevalence and factors associated with hypertension among males and females 35 years and older in rural Bangladesh. METHODS: This is a population-based cross-sectional study conducted in Zakiganj and Kanaighat subdistricts of Sylhet district of Bangladesh. Blood pressure was measured and data on risk factors were collected using STEPS instrument from 864 males and 946 females aged 35 years and older between August 2017 and January 2018. Individuals with systolic blood pressure of ≥140 mm Hg or diastolic blood pressure of ≥90 mm Hg or taking antihypertensive drugs were considered hypertensive. Bivariate and multivariate analyses were performed to identify factors associated with hypertension. RESULTS: The prevalence of hypertension was 18.8% (95% CI 16.3 to 21.5) and 18.7% (95% CI 16.3 to 21.3) in adult males and females, respectively. Among those who were hypertensive, the prevalence of controlled, uncontrolled and unaware/newly identified hypertension was 23.5%, 25.9% and 50.6%, respectively among males and 38.4%, 22.6% and 39.0%, respectively among females. Another 22.7% males and 17.8% females had prehypertension. Increasing age and higher waist circumference (≥90 cm for males and ≥80 cm for females) were positively associated with hypertension both in males (OR 4.0, 95% CI 2.5 to 6.4) and females (OR 2.8, 95% CI 2.0 to 4.1). CONCLUSIONS: In view of the high burden of hypertension and prehypertension, a context-specific scalable public health programme including behaviour change communications, particularly to increase physical activity and consumption of healthy diet, as well as identification and management of hypertension needs to be developed and implemented.

Implementation research to support Bangladesh Ministry of Health and Family Welfare to implement its national guidelines for management of infections in young infants in two rural districts.

BACKGROUND: World Health Organization revised the global guidelines for management of possible serious bacterial infection (PSBI) in young infants to recommend the use of simplified antibiotic therapy in settings where access to hospital care is not possible. The Bangladesh Ministry of Health and Family Welfare (MoHFW), Government of Bangladesh (GOB) adopted these guidelines, allowing treatment at first-level facilities. During the first year of implementation, the Projahnmo Study Group and USAID/MaMoni Health Systems Strengthening (HSS) Project supported the MoHFW to operationalize the new guidelines and conducted an implementation research study in selected districts to assess challenges and identify solutions to facilitate scale-up across the country. IMPLEMENTATION SUPPORT: Projahnmo and MaMoni HSS teams supported implementation in three areas: building capacity, strengthening service delivery, and mobilizing communities. Capacity building focused on training paramedics to conduct outpatient management of PSBI cases and developing monitoring and supervision systems. The teams also filled gaps in government supply of essential drugs, equipment, and logistics. Community mobilization strategies to promote care-seeking and referrals to facilities varied across districts; in one district community, health workers made home visits while in another district, the promotion was carried out through community volunteers, village doctors, and through existing community structures. METHODS: We followed a plan-do-study-act (PDSA) cycle to identify and address implementation challenges. Three cycles-1 every 4 months-were conducted. We collected data utilizing quantitative and qualitative methods in both the community and facilities. The total sample size for this study was 13,590. DISCUSSION: This article provides implementation research design details for program managers intending to implement new guidelines on management of young infant infections. Results of this research will be reported in the forthcoming papers. Preliminary findings indicate that the management of PSBI cases at the UH&FWCs is feasible. However, MoHFW, GOB needs to address the implementation challenges before scale-up of this policy to the national level.

Chest radiograph reading panel performance in a Bangladesh pneumococcal vaccine effectiveness study.

Introduction: To evaluate WHO chest radiograph interpretation processes during a pneumococcal vaccine effectiveness study of children aged 3-35 months with suspected pneumonia in Sylhet, Bangladesh. Methods: Eight physicians masked to all data were standardised to WHO methodology and interpreted chest radiographs between 2015 and 2017. Each radiograph was randomly assigned to two primary readers. If the primary readers were discordant for image interpretability or the presence or absence of primary endpoint pneumonia (PEP), then another randomly selected, masked reader adjudicated the image (arbitrator). If the arbitrator disagreed with both primary readers, or concluded no PEP, then a masked expert reader finalised the interpretation. The expert reader also conducted blinded quality control (QC) for 20% of randomly selected images. We evaluated agreement between primary readers and between the expert QC reading and the final panel interpretation using per cent agreement, unadjusted Cohen's kappa, and a prevalence and bias-adjusted kappa. Results: Among 9723 images, the panel classified 21.3% as PEP, 77.6% no PEP and 1.1% uninterpretable. Two primary readers agreed on interpretability for 98% of images (kappa, 0.25; prevalence and bias-adjusted kappa, 0.97). Among interpretable radiographs, primary readers agreed on the presence or absence of PEP in 79% of images (kappa, 0.35; adjusted kappa, 0.57). Expert QC readings agreed with final panel conclusions on the presence or absence of PEP for 92.9% of 1652 interpretable images (kappa, 0.75; adjusted kappa, 0.85). Conclusion: Primary reader performance and QC results suggest the panel effectively applied the WHO chest radiograph criteria for pneumonia.

Adenomatoid odontogenic tumour: An enigma.

Adenomatoid odontogenic tumour (AOT) is an uncommon, hamartomatous, benign epitheial lesion of odontogenic origin. The current World Health Organisation (WHO) classification of odontogenic tumors defines AOT as being composed of the odontogenic epithelium in a variety of histoarchitectural patterns, embedded in mature connective tissue stroma, and characterized by slow, but progressive growth. The aim of this paper is to present three rare cases of intraosseous AOTs with varied clinical and radiographic features imposing the fact that AOT should be included in differential diagnosis of routine odontogenic cysts and tumours.