Comparison of Recurrent Laryngeal Nerve Injury during Thyroidectomy with and Without Routine Identification of the Nerve Peroperatively.

Thyroidectomy is one of the commonest operative procedures performed in the neck and injury to recurrent laryngeal nerve (RLN) is not uncommon. It results in hoarseness to serious respiratory distress depending on the extent of the injury. The incidence of RLN injury varies widely and is multifactorial depending on the extent of surgical procedures, experience and expertise of the surgeons, nature of the thyroid diseases and a wide range of anatomical variations. Peroperative routine identification of the nerve during thyroidectomy can be a way to prevent injury. Despite recommendation for identification of the RLN peroperatively in thyroid surgery, a debate still exists whether the nerve to be identified peroperatively or not, to avoid its inadvertent injury. The aim of this study was to compare the incidence of RLN injury between two groups where RLN was identified peroperatively in one group and the nerve was not attempted for identification in the other group in thyroid surgery. A comparative cross-sectional study was carried out in the department of surgery and otolaryngology at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from June 2018 to November 2019, on patients who underwent elective thyroid surgery. Patients were included in RLN identified group and in RLN not identified group, by individual surgeons' preference to identify or not to identify the RLN peroperatively. Peroperative identification of the nerve was done by direct visualization. All cases were evaluated for vocal cord palsy preoperatively, during extubation and postoperatively. Patient's particulars, other parameters and perioperative data were recorded. A total of 80 cases were included in this study, 40 cases (50.0%) in the peroperative RLN identified group and 40 cases (50.0%) in the RLN not identified group. Unilateral RLN palsy was encountered in 2.5% (2 cases) in the RLN identified group and 6.3% (5 cases) in the nerve not identified group (p value 0.192). Transient unilateral RLN palsy was seen in 7.5% (6 cases) of patients; 2.5% (2 cases) in the RLN identified group and 5.0% (4 cases) in the RLN not identified group. And 1.3% (1 case) of permanent unilateral RLN palsy was encountered in this study, which was in the RLN not identified group; there was no permanent palsy in the RLN identified group. We did not encounter any bilateral RLN palsy. There was no statistically significant difference in the incidence of RLN injury between the peroperatively RLN identified group and no attempt to identify the nerve group despite recommendation for peroperative RLN identification in thyroid surgery to avoid its inadvertent injury. However, from this study, we recommend peroperative RLN identification in thyroid surgery to enhance surgical skill.

Outcome of Upper Gastrointestinal Surgery With or Without Nasogastric Intubation.

Nasogastric intubation is a common procedure with both merits and demerits. Controversies exist about the routine use of nasogastric intubation following upper gastrointestinal surgery. Good numbers of literatures were published in favour of selective nasogastric intubation pointing out some complications of routine use of nasogastric tube. In 1995, Cheatham et al. concluded in a meta-analysis that although patients may develop abdominal distension or vomiting without a nasogastric tube, this is not associated with an increase in complications or length of hospital stay. For every patient requiring insertion of a nasogastric tube in the postoperative period, at least 20 patients will not require nasogastric decompression. In July 2004, Cochrane database of systemic review published the result of their systemic review on the prophylactic decompression after abdominal surgery, that review was revised and updated in 2007. According to this database, routine nasogastric intubation should be abandoned in favour of selective use of nasogastric tube. In our country some surgeons are practicing it routinely and some are not. This observation prompted us to conduct this study in order to see and compare the outcome of upper gastrointestinal surgery with and without nasogastric intubation. This will help us to make decision whether nasogastric intubation will be done routinely or not following upper gastrointestinal surgery.

Comparative Efficacy of Local Steroid and Therapeutic Ultrasound for Quicker Functional Improvement in Tennis Elbow.

Lateral epicondylitis or Tennis elbow is very common repetitive stress injury or cumulative trauma disorder among active professionals and tennis players. Local steroid injection can provide quick functional improvement as sought by most of the patients. Therapeutic ultrasound and eccentric exercises can also improve the function. This study was carried out to see the comparative efficacy of these two modalities of treatments in terms of quicker functional improvement and this randomized interventional clinical trial was carried out in a private rehabilitation hospital in Dhaka. Patients attended the authors private chamber from January 2013 to December 2013 with clinical diagnosis of tennis elbow were included. Eighty adult patients diagnosed as lateral epicondylitis or tennis elbow were randomly divided into two groups. Group A received local steroid injection (triamcinolone acetate) and group B received therapeutic ultrasound for two weeks. Both the groups received eccentric exercises and advised to avoid provocative activities like twisting and lifting activities. Pain, tenderness and functional improvements were measured in traditional methods like visual analogue scale (VAS) and tenderness grade 0 to 4. Data were analyzed by SPSS. Most of the patients were female. None of them were tennis player. Younger housewives were common sufferer. Almost all patients in group A had very little or no pain or tenderness and no difficulty in lifting object at one week and two weeks. VAS was 13.62±6.503 and 4.15±5.517 respectively. Group B patients had mild improvement of pain and function at one week and moderate improvement at two weeks. VAS was 52.57±7.80 and 25.57±5.392 respectively. Similarly tenderness' were markedly improved in Group A at one and two weeks. They were 0.68±0.616 and 0.02±0.405 respectively for Group A and 1.60±0.553 and 1.14±0.335 respectively for Group B. Results were statistically significant in both groups at the end of two weeks. Local corticosteroid injections at extensor origin in tennis elbow patients are found to have better relief of pain and tenderness and quicker functional improvement than therapeutic ultrasound treatment. None of the patients were followed up for long term efficacy in either group.

Association of serum uric acid with ischemic stroke.

The present study has examined the association between ischemic stroke and hyperuricemia in Bangladeshi population. This age and sex matched case control study was carried out in the Department of Neurology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh during the period of January 2007 to December 2008. A total of 120 subjects were included in this study, among them 60 were cases and another 60 were controls. Data were collected purposively. Multiple logistic regressions were done to identify the risk factors for ischemic stroke. In this study 68.3% were male and 31.7% were female in both the groups. Male and female ratio of stroke patients was 2.16:1. Mean±SD of serum uric acid level of case and control group was 4.94±1.76 and 3.72±1.09 respectively. Among the case group 76.7% had normal and 23.3% had abnormal serum uric acid level. On the other hand, 93.3% respondents of control group had normal and 6.7% had abnormal serum uric acid (SUA) level. Significant differences was found between case and control group in term of SUA level (p<0.05). Since SUA level is a quantitative numerical variable, an increase in 1mg/dl has a 47.0% (95% CI 1.0% to 2.16%) increase in odds ratio (OR) of having ischemic stroke. This 47.0% is obtained by taking OR for uric acid-1. Elevated serum uric acid level is not significant for ischemic stroke among the Bangladeshi population.

Urinary microalbumin as a risk factor for ischaemic stroke.

Microalbuminuria (MA), a microvascular irregularity of the blood - urine interface within kidney glomeruli, may reflect the renal sign of global endothelial dysfunction, and has been associated with an elevated risk of serious cardiovascular events including stroke. This case-control study was carried out in the Department of Neurology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, from January 2008 to December 2009. This relationship appears graded with higher levels of microalbuminuria being independently associated with a greater magnitude of vascular risk over time. We studied 60 patients of ischemic stroke with in 4 weeks of onset of symptoms and performed a case control study for MA by spot urinalysis. The incidence of microalbuminuria was 31.7% of the patients compared with 8.3% of the controls. Of all the traditional risk factors for stroke - age, male gender, hypertension, diabetes, dyslipidemia, smoking showed a positive correlation with the presence of MA (p<0.05). The effect of microalbuminuria and subtypes of ischemic stroke was observed that small vessels stroke (lacunar infract) were more (70%) than large vessels stroke (30%) and effect of microalbuminuria 21.67% higher in small vessels stroke than large vessels stroke. The presence of microalbuminuria appears to independently predict proper clinical outcome following acute stroke.

Evaluation of transurethral ethanol ablation of prostate for symptomatic benign prostatic hyperplasia.

Evaluating short-term (03 months) efficacy and safety of transurethral intraprostatic injection of absolute ethanol to treat benign prostatic hyperplasia (BPH). This intervention study was conducted to evaluate 30 patients with benign prostatic hyperplasia treated by transurethral injection of dehydrated ethanol. Mean age was 69.96 years. Endoscopic injection of 6-13.5 ml ethanol was carried out at 4-8 sites in the prostate. International Prostate Symptom Score (IPSS), maximum flow rate, prostate volume, postvoid residual and side effects or complications were measured postoperatively. Mean IPSS (SD) improved significantly from 18.43 ± 2.38 preoperatively to 6.80 ± 1.34 at 03 months of follow-up, mean peak urinary flow rate increased from 7.33 ± 1.19 ml/s to 16.31 ± 1.69 ml/s after 3 months, mean residual urine volume had decreased from 54.16 ± 30.93 ml to 17.01 ± 9.59 ml after 3 months (p<0.05). The prostate volume decreased from 44.66 ± 9.52 gm preoperatively to 32.46 ± 7.78 gm after 3 months (statistically significant at 5% level). There were no intra-operative complications but post-operative haematuria occurred in two patients, urinary retention occurred in two patients after removal of the catheter. Urinary tract infection developed in one patient. Transurethral ethanol ablation of prostate appears to be safe and cost effective. No occurrence of retrograde ejaculation was detected. The short-term effects of ethanol injection at prostate were satisfactory and acceptable as a minimally invasive therapeutic modality in selected patients.

Effect of low dose levodopa on motor outcome of different types of stroke.

This case control study interventional study was carried out in Neurology out patient department of Bangabandhu Sheikh Mujib Medical University (BSMMU) from January 2004 to June 2005. The aim of the study was to investigate the effect of low dose levodopa on motor outcome of patients with stroke both ischaemic and haemorrhagic. A total of 97 patients of stroke confirmed by computerized tomography (CT) scan of brain were included in the study. Of them 51 were treated with levodopa 125mg (L group) and physiotherapy while 46 patients (NL group) were treated only with physiotherapy without levodopa. The patients were followed up every 2 weeks interval for 8 weeks. Motor outcome was measured in Rivermead Mobility Index (RMI). Comparison was made between L & NL group irrespective of stroke types at the end of 4th visit. Also the effect of levodopa was assessed separately in ischaemic & haemorrhaegic stroke. The results of the study showed that the age of stroke patients was 54.70±15.07 years in L group & 58.10±14.69 years in NL group. Ischaemic stroke patients were 72% and haemorrhagic stroke patients were 28%. The mean increase RMI score in L group irrespective of stroke subtypes was 6.9 while in NL group was 3.0. The increase in motor outcome was significantly higher in levodopa group than non-levodopa group (p<0.001). Similarly motor outcome measured in RMI score were significantly better individually in ischaemic & haemorrhagic stroke patients of L group than NL (p<0.001). So, the study result concludes that low dose levodopa improves motor outcome in patient with stroke both ischaemic and haemorrhagic.

Effect of dexamethasone on brain oedema following acute ischemic stroke.

A randomized clinical trial was conducted to asses the effects of dexamethasone on brain oedema following acute ischemic stroke in the departments of Medicine of different hospitals from July, 2003 to December, 2006. A total of 60 patients were included in the study. They were divided into two groups keeping the similarity regarding the age, sex and severity of the stroke between two groups. There were 30 patients in experimental group and 30 in control group. The level of consciousness was compared by Glasgow Coma Scale (GCS) on 3rd, 7th and 10th day of intervention and improvement was found in both the groups, but the improvement of level of consciousness was statistically significant in Dexamethasone treated group. The volume of hypodense area did not differ significantly in two groups in CT scans before and after treatment (p=0.74). The study results demonstrate that Dexamethasone improves the level of consciousness in acute ischemic stroke associated with brain oedema but did not reduce volume of hypodense area.

Informed consent: knowledge, attitude and practice of the researchers in a postgraduate institute of Bangladesh.

A prospective experimental study was conducted in a postgraduate institute in Dhaka, Bangladesh, from April '05 to September '05. A total of 214 doctors of a postgraduate medical institute were included in the study who was involved in research works. A written questionnaire was given to the respondents to assess their knowledge, attitude and practice about informed consent (IC). The data was analyzed statistically. Chi-Square test was done to see the level of significance. Regarding knowledge of IC, we found maximum participants were more or less knowledgeable about it. The attitude of the respondents was also in favour of taking IC. In practice, most of them had taken informed consent that was verbal (39.3%) and written (47.6%). But some of the researcher (13.1%) had not taken any informed consent. By the present study, it may be concluded that the researchers of the concerned institute were aware of IC.

Relative bioavailability and pharmacokinetic study of omeprazole 20 mg enteric-coated tablet in healthy Bangladeshi volunteers.

OBJECTIVE: Introduction of omeprazole constituted a break through in the management of acid-related gastric disorders. Omeprazole effectively suppresses the gastric acid secretion in the parietal cells of the stomach. It is a widely prescribed proton pump inhibitor in Bangladesh. The increasing number of omeprazole containing products available in the market raises questions of therapeutic equivalence and/or generic substitution which are yet to be conducted on the Bangladeshi population. The aim of the study is to assess the relative bioavailability and pharmacokinetic properties of two oral formulations of 20 mg omeprazole tablet, namely LOSEC(R) as reference product and Losectil DR as test product using serum data. MATERIALS AND METHODS: The randomized, two-way crossover study was conducted on 24 healthy male subjects in compliance with the Declaration of Helsinki and ICH Guidelines. Subjects were assigned to receive Losectil DR (Test) and LOSEC (Reference) as a single dose of 20 mg tablet under fasting conditions, following a washout period of 1 week. After oral administration, blood samples were collected at various time intervals and analyzed for omeprazole concentrations using a validated HPLC method. The pharmacokinetic parameters were determined by a non-compartmental method. RESULTS: From serum data, the obtained values for test and reference products were 593.05 +/- 84.85 and 607.92 +/- 67.07 ng/ ml for Cmax; 1756.71 +/- 287.29 and 1786.90 +/- 280.17 ng-h/ml for AUC0-24; 1889.26 +/- 286.46 and 1929.18 +/- 284.33 ng-h/ml for AUC0- yen, respectively. No statistically significant differences were observed between two formulations by analyzing different pharmacokinetic parameters in terms of period, sequence and formulation. From the paired t-test, no significant differences between two formulations were observed (p > 0.05). The 90% CIs of Cmax, AUC0-24 and AUC0- yen were found to be 91.59 - 122.60%, 101.86 - 116.78% and 102.77 - 116.68%, respectively, which are within the FDA accepted limits for bioequivalence (80 - 125%). CONCLUSION: Finally it can be concluded that both products are bioequivalent in terms of rate and extent of drug absorption and therefore interchangeable.

Reactions of pentachlorophenol with laccase from Coriolus versicolor.

Laccase, purified from Coriolus versicolor, removed pentachlorophenol (PCP) from solution at pH 5, depending on initial PCP concentration and amount of laccase. With 100 units of laccase, 100% of 25 microg ml(-1) PCP and 60% of 200 microg ml(-1) PCP were removed respectively over 72 h. No free chloride was released in the reaction. In reaction with 100 microg PCP, products were primarily polymers (about 80,000 MW) with only 2-3 pg of o- and p-chloranils formed. Polymers were stable to acid hydrolysis and no release of PCP, or other low-molecular-weight products, was detected over several weeks. Laccase has a potential use in the biotreatment of aqueous effluents containing PCP, with polymerised products being removed from solution due to their high molecular weight.

Evaluation of solid substrates for enzyme production by Coriolus versicolor, for use in bioremediation of chlorophenols in aqueous effluents.

In the development of a system for the removal of chlorophenols from aqueous effluents, a range of solid substrates for the growth of Coriolus versicolor were investigated. Substrates included wood chips, cereal grain, wheat husk and wheat bran. Suitability for transformation of chlorophenols depended on laccase production by the fungus. The greatest amount of laccase (<25 Units g(-1) substrate) was produced on wheat husk and wheat bran over 30 days colonisation. Aqueous extracts of laccase from wheat husk and wheat bran cultures removed 100% of 2,4-dichlorophenol (50 ppm) from solution within 5 h and 75-80% of pentachlorophenol (50 ppm) within 24 h. Wheat bran was formulated into pellets with biscuit flour to provide a compact substrate for fungal immobilisation. Addition of 8-12% yeast extract to the pellets increased laccase production five-fold. Colonised pellets were added to chlorophenol solutions in 200-4000-ml bioreactors, resulting in >90% removal of chlorophenols within 100 min.

Extent of utilization and factors influencing antenatal care in rural Rajshahi.

PIP: This cross-sectional study determined the extent of utilization of antenatal care (ANC) and identified factors influencing utilization. The study was conducted in 9 rural hospitals in Rajshahi district, Bangladesh, among 810 recently delivered women. Data were collected using a structured interview schedule and were analyzed using simple descriptive analysis, Chi-square test, and logistic regression. Of the 810 respondents, 30.05% had antenatal checkups and 81.3% received tetanus toxoid before delivery. 69.5% of the women did not have any antenatal check-ups for reasons such as absence of complications and the feeling that it was not mandatory to have such check-ups. Important factors influencing utilization of ANC were freedom of decision-making, perception about the need for ANC, and income. There is a need for improving utilization of ANC, especially through perception improvement about ANC and freedom of decision-making.^ieng

Plasmids in Vibrio parahemolyticus strains isolated in Japan and Bangladesh with special reference to different distributions.

We surveyed plasmids in naturally occurring Vibrio parahemolyticus strains isolated in Japan and Bangladesh. Among the strains isolated in Japan, about half of the strains isolated from stools of patients of domestic diarrhea outbreaks as well as of travelers returning from East Asia were found to have plasmids, but no strains from foods had plasmids. In contrast, among the strains isolated in Bangladesh, none of the four strains isolated from patients had plasmids, but two out of eight strains isolated from water had plasmids, suggesting that plasmids are common in strains from the water in Bangladesh. All plasmids so far reported in V. parahemolyticus were detected in strains isolated from stools of patients. Incidences of plasmids in this organism were not so high in either area. In Japan, all plasmids were detected in strains from human intestines at 37 C, but in Bangladesh, where the temperature is around 30-40 C, the plasmids were detected in strains from the natural environment. These results suggested the possibility that these plasmids can come from different bacteria under rather high temperatures and that incidences of plasmids are influenced by the incidences of plasmids in bacteria present in the vicinity of V. parahemolyticus strains. None of these plasmids were found to have any relation to the biological characters tested.