Endovascular Aneurysm Repair for Infrarenal Abdominal Aortic Aneurysm: New Horizon in Endovascular Surgery in Bangladesh.

Abdominal aortic aneurysm remains mostly asymptomatic. It is usually detected incidentally with imaging studies. Here we present a 55 years old hypertensive, non smoker, non diabetic, male patient who was diagnosed as a case of infrarenal abdominal aortic aneurysm. He was treated by endovascular means using endograft without laparatomy. Endografts were deployed through bilateral femoral artery cut down technique under general anesthesia. Completion angiogram following this endovascular aneurysm repair (EVAR) technique revealed good technical success with no endoleak. This hybrid procedure was performed in a cathlab having surgical instruments in hand. Three years after the procedure, patient is doing well.

A Case Report of Porphyria Cutanea Tarda with Hepatitis-C Virus Co-infection.

Porphyria cutanea tarda is a rare disorder of heme metabolism due to deficiency of the enzyme uroporphyrinogen decarboxylase which is manifested as some typical dermatological features and hepatic dysfunction. The Hepatitis-C virus co-infection is common and it can be aggravated by other environmental factors. We report a case of porphyria cutanea tarda in a 37-year-old woman, who presented with recurrent skin blisters and has concomitant Hepatitis-C virus infection. She was taking oestrogen containing oral contraceptive pill for a long duration. The diagnosis of porphyria cutanea tarda was considered on the basis of clinical features and high level of urine porphyrin level. She was put on hydroxychloroquine and combination drugs for Hepatitis-C virus with significant improvement after 3 months of therapy.

Immunity after Primary Hepatitis B Vaccination in Children 7 Years or More Attending A Tertiary Care Hospital.

Hepatitis B virus is a serious public health problem. Effective hepatitis B vaccination gives protection in about 85-90% cases. Most follow-up studies in different countries showed a similar pattern of antibody decline with increasing age. Many authors observed a declined level of HBs-antibody over a period of 3-6 years. This study was aimed at to observe immune status in children 7 years or more after primary hepatitis B vaccination. This cross sectional descriptive study was conducted at the department of Pediatric Gastroenterology and Nutrition, BSMMU, Dhaka, Bangladesh from April 2015 to March 2016. For this study children of both sexes aged between 7 to 18 years, who had history of 2 or more doses of hepatitis B vaccine 7 or more years back were included in the study. All the serum samples were tested for anti HBs by chemiluminescence's technique. Total 120 children were studied among them male was 59.2% and male female ratio was 1.4:1 with a mean age of 8.6±1.7 years. Good immune response (66.7%) was observed against hepatitis B. Significantly higher geometric mean titer of anti HBs was found in the age group of 7-8 years (p=0.02). Waning of immunity including non seroprotectivity was significantly associated with increasing age (p=0.015). Majority (96.7%) of children received EPI vaccination than commercially available vaccine. Children with weight for age percentile (WAP), height for age percentile (HAP) and BMI for age lies below 5th percentile had comparatively lower non seroprotection rate than normal children, but this was not statistically significant. History of dental or surgical procedure, blood transfusion and family history of contact with known case of hepatitis B infection did not have any significant inference on anti- HBs response. The study detected a good immune response against hepatitis B. About 66.7% of children were seroprotective 7 years or more after primary hepatitis B vaccination. Waning of immunity including non seroprotectivity was significantly associated with increasing age. Further studies with larger sample size are needed about booster dose to come to a final conclusion.

Progressive Pseudo-rheumatoid Dysplasia: Two Cases in One Family.

Progressive pseudo-rheumatoid dysplasia is an autosomal recessive skeletal dysplasia. Spine radiographs show platyspondyly. The clinical presentations are similar to juvenile idiopathic arthritis, but not the laboratory findings. We report 2 cases of progressive pseudo-rheumatoid dysplasia in the same family. A 26 years old male was admitted in the department of Rheumatology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh with the complain of inflammatory joint pain, joint swelling, range-of-motion limitation, and joint deformities in the hands, wrists, ankles, knees and hips for 20 years. He was treated as juvenile idiopathic arthritis with different anti-inflammatory medications having progressing by flares and remissions. Erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, anti ccp antibody and HLAB27 levels were normal. Synovial fluid of the knees showed mechanical properties. Plain radiographs of the hands and knees showed evidence of joint destruction. Radiograph of the pelvis notes bilateral hip dysplasia. Platyspondyly was found in spinal radiograph. The diagnosis of juvenile idiopathic arthritis was reconsidered. His 22 years old younger brother had similar manifestations without laboratory evidence of inflammation; radiographs disclosed dysplasia of the hips and metacarpophalangeal epiphyses. Manifestation of spinal stiffness, thoracic kyphosis, and motion-range limitation at the hips; radiographs showed normal sacroiliac joints and bilateral hip dysplasia. So, a diagnosis of progressive pseudo-rheumatoid dysplasia with polyarticular involvement was done.

Analysis of Damage and Wound Healing in the Retinal Pigmented Epithelium.

Previous studies of retinal pigment epithelium (RPE) morphology found cell-level and spatial patterning differences in many quantitative metrics in comparing normal and disease conditions. However, most of these studies examined eyes from deceased animals. Here we sought to compare noninvasively imaged RPE cells from live mice to histopathology. We describe changes to improve noninvasive imaging of RPE in the live mouse. In retinal diseases, there can be invasion by Iba1-positive cells, which can be detected by noninvasive imaging techniques. Here we can detect potential Iba1-positive cells at the level of the RPE noninvasively.

Tuberculosis in Systemic Lupus Erythematosus Patients.

The tubercular infections (TB) are most important cause of morbidity and mortality in SLE patients worldwide and an ongoing alarming issue in developing countries. This observational study was carried out in SLE clinic of BSMMU, Bangladesh from April 2015 to March 2016 after taking ethical clearance from IRB to observe frequency and risk factors of tuberculosis in SLE patients. A total 230 consecutive SLE patients were enrolled. Patient's clinical characteristics, history of TB, SLEDAI score, cumulative doses of immunosuppressants were recorded. In clinically suspected cases tuberculin test, chest X-ray, spot and first morning sputum for AFB, Gene Xpert MTB/RIF, ADA, FNAC and tissue biopsy were requested along with routine tests. The multivariate logistic regressions were done for risk factors. Out of 230 patients TB was documented in 23 (10%) subjects. Among TB cases 16 women and 7 men. Mean age of patients was 27.56±9.3 years and mean duration of occurrence of tuberculosis after SLE diagnosis was 4.26±5.38 years. Present and past TB was observed in 10 and 13 cases respectively. Cough, night sweat, fever, anorexia were significant presenting features. Fifteen and 8 patients had pulmonary and extra pulmonary TB respectively. Organ involvement pattern was multi-lobed lungs, joint, meninges, lymph nodes, peritoneum and pleura. High disease activity disease (SLEDAI score >12), total intake of prednisolone >1000mg were risk factors of TB. Frequency of tuberculosis was high (10%) in SLE patients. Awareness including prevention of flares and judicious use of steroids might reduce the rate of TB.

Serum Homocysteine and its Association with Glycemic Control in Type 2 Diabetic Patients.

In developing countries like Bangladesh the prevalence of type 2 diabetes mellitus is increasing day by day. Among the long-term complications of diabetes mellitus, vascular complications represent a major cause of morbidity and mortality. Hyperglycemia is still considered the principal cause of diabetes complications. Total plasma homocysteine (tHcy) is an emerging cardiovascular risk factor. Hyperhomocysteinemia independently appears to be a stronger risk factor for mortality than other risk factors in type 2 diabetes than in non diabetes. It may partly explain the link between microalbuminurea and increased risk of cardiovascular disease. Objective of the study was to evaluate serum total homocysteine level and to correlate it with glycemic status in type 2 diabetic patients. This cross sectional study was conducted during the period of July 2011 to June 2013 on 95 patients of type 2 diabetes mellitus, attending the Endocrine OPD of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. The study was carried out in the Department of Biochemistry, Bangabandhu Sheikh Mujib Medical University, Shahbagh, Dhaka, Bangladesh. Study subjects were selected by purposive and convenient sampling technique. Study subjects were categorized according to the presence or absence of hyperhomocysteinemia. Among the total study population hyperhomocysteinemia was found in 21.05%. Among them number of male was greater. Overall glycemic control was poor in the patients. Mean HbA1c (%) was 8.31±2.04. Among those having hyperhomocysteinemia mean HbA1c (%) was significantly lower than those who had no hyperhomocysteinemia (7.2±1.5 vs. 8.6±2.06). Around one fifth of the type 2 diabetic patients had hyperhomocysteinemia. Those having hyperhomocysteinemia had significantly better glycemic control than those having no hyperhomocysteinemia.

Polyarthritis is a Rare Manifestation of Pachydermoperiostosis: A Case Report.

Pachydermoperiostosis or primary hypertrophic osteoarthropathy, also known as Touraine-Solente-Gole syndrome, is a rare process, frequently inherited. In its complete form it is characterized by pachydermia (thickening of the skin), skeletal changes (periostosis) and acropachia (digital clubbing). Diagnosis can be made considering the typical clinical features and the histological feature. We report a patient of 25-year old man presented with joint pain involving in multiple joints for last 7 years and progressive enlargement of his hands and feet with profuse sweating of palms and soles for last 4 years. Physical examination revealed thickened skin with excessive furrowing of his forehead, dropping of both eyelids, clubbing of all fingers, toes and enlargement of his hands and feet with pamoplantar hyperhidrosis. Laboratory investigation shows raised CRP, X-ray feet lateral view showed normal heel pad thickness, new bone formation and periosteal elevation in lower end of tibia and fibula and skin biopsy showed dense fibrocollagenous tissue in dermis and subcutis and mild acanthosis. With this scenario he was diagnosed as primary hypertrophic osteoarthropathy (Pachydermoperiostosis). After diagnosis he was treated with cholchicine (0.6mg) twice daily, naproxen (500mg) twice daily, and risedronate (150mg) monthly. After one year his skin texture became less thickened, joint pain improved, there was no further enlargement of acral part of fore arm. In this report we review the characteristic features of this syndrome. We highlight the importance of ruling out secondary forms of hypertrophic osteoarthropathy and of a close follow-up of these patients because of complications that might develop on long-term. Although no treatment was satisfactory, we wanted to emphasize that NSAIDs, Cholchicine and risedronate could be an effective treatment option.

Multidrug-resistant tuberculosis in Bangladesh: results from a sentinel surveillance system.

BACKGROUND: Multidrug-resistant tuberculosis (MDR-TB) is a serious obstacle to successful TB control. The 2010-2011 Bangladesh Drug Resistance Survey (DRS) showed MDR-TB prevalence to be 7% overall, 1.4% in new and 28.5% in previously treated patients. We aimed to determine the rate of MDR-TB in selected sentinel sites in Bangladesh. METHODS: Fourteen hospitals from the seven divisions in Bangladesh were selected as sentinel surveillance sites. Newly registered TB patients were systematically enrolled from August 2011 to December 2014. Sputum specimens were processed for culture and drug susceptibility testing by the proportion method using Löwenstein-Jensen medium. RESULTS: Specimens from 1906 (84%) of 2270 enrolled patients were analysed. Isolates from 61 (3.2%) were identified as having MDR-TB. The proportion of MDR-TB was 2.3% among new and 13.8% among previously treated TB patients (P < 0.001). The overall proportion of MDR-TB was 3.2%:3.5% in males and 2.3% in females; by age, the MDR-TB rate was highest (5.2%) in those aged 65 years. CONCLUSIONS: The high proportion of MDR-TB among new patients found in this sentinel surveillance significantly differs from that reported in the DRS. While the sentinel surveillance sites were not designed to be nationally representative, it is worrying to observe a higher number of MDR-TB cases among new patients.

Comparison of TaqMan(®) Array Card and MYCOTB(TM) with conventional phenotypic susceptibility testing in MDR-TB.

BACKGROUND: Although phenotypic drug susceptibility testing (DST) is endorsed as the standard for second-line drug testing of Mycobacterium tuberculosis, it is slow and laborious. METHODS: We evaluated the accuracy of two faster, easier methodologies that provide results for multiple drugs: a genotypic TaqMan(®) Array Card (TAC) and the Sensititre(®) MYCOTB(TM) plate. Both methods were tested at three central laboratories in Bangladesh, Tanzania, and Thailand with 212 multidrug-resistant tuberculosis (MDR-TB) isolates and compared with the laboratories' phenotypic method in use. RESULTS: The overall accuracy for ethambutol, streptomycin, amikacin, kanamycin, ofloxacin, and moxifloxacin vs. the phenotypic standard was 87% for TAC (range 70-99) and 88% for the MYCOTB plate (range 76-98). To adjudicate discordances, we re-defined the standard as the consensus of the three methods, against which the TAC and MYCOTB plate yielded 94-95% accuracy, while the phenotypic result yielded 93%. Some isolates with genotypic mutations and high minimum inhibitory concentration (MIC) were phenotypically susceptible, and some isolates without mutations and low MIC were phenotypically resistant, questioning the phenotypic standard. CONCLUSIONS: In our view, the TAC, the MYCOTB plate, and the conventional phenotypic method have similar performance for second-line drugs; however, the former methods offer speed, throughput, and quantitative DST information.

An Integer Programming Formulation of the Minimum Common String Partition Problem.

We consider the problem of finding a minimum common string partition (MCSP) of two strings, which is an NP-hard problem. The MCSP problem is closely related to genome comparison and rearrangement, an important field in Computational Biology. In this paper, we map the MCSP problem into a graph applying a prior technique and using this graph, we develop an Integer Linear Programming (ILP) formulation for the problem. We implement the ILP formulation and compare the results with the state-of-the-art algorithms from the literature. The experimental results are found to be promising.

Patient costs during tuberculosis treatment in Bangladesh and Tanzania: the potential of shorter regimens.

OBJECTIVE: To estimate the costs incurred by patients during the intensive and continuation phases of the current 6-month tuberculosis (TB) regimen in Bangladesh and Tanzania, and thus identify potential benefits to patients of a shorter, 4-month treatment regimen. DESIGN: The validated Stop TB patient cost questionnaire was adapted and used in interviews with 190 patients in the continuation phase of treatment with current regimens. RESULTS: In both countries, overall patient costs were lower during 2 months of the continuation phase (US$74 in Tanzania and US$56 in Bangladesh) than during the 2 months of the intensive phase of treatment (US$150 and US$111, respectively). However, continuation phase patient costs still represented 89% and 77% of the 2-month average national income in the respective countries. Direct travel costs in some settings were kept low by local delivery system features such as community treatment observation. Lost productivity and costs for supplementary foods remained significant. CONCLUSIONS: Although it is not a straightforward exercise to determine the exact magnitude of likely savings, a shorter regimen would reduce out-of-pocket expenses incurred by patients in the most recent 2 months of the continuation phase and allow an earlier return to productive activities.

Validation of a home-based neurodevelopmental screening tool for under 2-year-old children in Bangladesh.

BACKGROUND: Home-based screening to identify young children at risk for neurodevelopmental impairments (NDIs) is needed to guide the targeting of child neurodevelopmental intervention services in Bangladesh. This study aimed to validate such a tool for children under age 2 years. METHODS: A Developmental Screening Questionnaire was administered to mothers of children aged 0-<2 years in an urban community. Inter-rater reliability among the interviewers, who were high school graduates, was determined. All children who were screen positive and a proportion of screen negatives were subsequently assessed for NDIs by professionals. Sensitivity and specificity were calculated by comparing screening with assessment results. RESULTS: Mean kappa coefficient of agreement among interviewers was 0.95. A total of 197 children were screened, of whom 17% screened positive. Fifty-one children, including 24 screen negatives, were assessed for NDIs. Screen-positivity was significantly different between income groups (P = 0.019), and higher in stunted children (odds ratio = 5.76, 95% confidence interval = 1.72-19.28), indicating good discriminant validity Specificity was excellent (84-100%) for all developmental domains. Sensitivity was 100% for vision and hearing; 70% for speech; and 63%, 53%, 48%, and 45% for gross motor, behaviour, fine motor and cognitive impairments, respectively. CONCLUSION: A tool for screening <2-year-old children at risk for NDIs showed high specificity; and was able to identify all children at risk for vision and hearing impairments, nearly three-fourths with speech impairments, two-thirds with gross motor impairments, and about half with behavioural, cognitive and fine motor impairments. The Developmental Screening Questionnaire tool has potential for use by frontline workers to screen large populations and to link to definitive assessment as well as intervention services.

High quit rate among smokers with tuberculosis in a modified smoking cessation programme in Dhaka, Bangladesh.

SETTING: BRAC, a non-governmental organisation, implemented a modified smoking cessation programme for tuberculosis (TB) patients based on International Union Against Tuberculosis and Lung Disease (The Union) guidelines in 17 peri-urban centres of Dhaka, Bangladesh. OBJECTIVE: To determine whether a modified version of The Union's smoking cessation intervention was effective in promoting cessation among TB patients and determinants associated with quitting smoking. DESIGN: Cohort study of routinely collected data. RESULTS: A total of 3134 TB patients were registered from May 2011 to April 2012. Of these, 615 (20%) were current smokers, with a mean age of 38 years (±13.8). On treatment completion, 562 patients were analysed, with 53 (9%) lost to follow-up or dead, while 82% of smokers had quit. Patients with extra-pulmonary TB were less likely to quit than those with pulmonary TB. Patients with high-intensity dependence were less likely to quit than those with low-intensity dependence. CONCLUSION: This study suggests that a simplified smoking cessation intervention can be effective in promoting smoking cessation among TB patients in Bangladesh. This is encouraging for other low-resource settings; the Bangladesh National Tuberculosis Control Programme should consider nationwide scaling up and integration of this smoking cessation plan.

Factors associated with treatment delay among tuberculosis patients referred from a tertiary hospital in Dhaka City: a cross-sectional study.

SETTING: A tertiary medical college hospital in Dhaka City Corporation area, Dhaka, Bangladesh. OBJECTIVES: To identify factors associated with treatment delay among tuberculosis (TB) patients referred from a public diagnostic centre to various DOTS treatment centres in Dhaka City Corporation area, Bangladesh. METHODS: A cross-sectional study was conducted among 123 patients referred from the Dhaka Medical College Hospital to different DOTS treatment centres during July-October 2012. Factors associated with treatment delay (>1 day between referral and initiation of DOTS treatment) were identified. RESULTS: Among the 123 patients referred from the hospital, treatment delay was found to range between 2 and 17 days (median 2). In bivariate analysis, treatment delay was found to be significantly associated with the patient's diagnostic category. In multivariate analysis, World Health Organization (  WHO) Category II patients were found to be four times more likely to have treatment delay than WHO Category I patients, and married patients were much more likely to have treatment delays than unmarried patients. CONCLUSION: The study findings suggest that the main factors contributing to treatment delay among TB patients were history of previous anti-tuberculosis treatment, marital status and age. Patients should be given extensive information about the dangers of treatment delay before referring them to DOTS treatment centres.

Comparative study between clinical and sonographic estimation of fetal weight in third trimester of pregnancy and its relationship with actual birth weight.

This prospective study was undertaken to assess the accuracy of clinical and sonographic estimated fetal weight (EFW) in Bangladeshi population. The study protocol consisted of achieving clinical followed by sonographic estimated fetal weight (uEFW) using Shepard formula and then its correlation with actual birth weight (BW). A total of 140 pregnant women participated in this study. The study was conducted in the department of Radiology & Imaging and in the department of Gynae & Obs., Bangladesh Medical College Hospital (BMCH) from January 2005 to December 2005.Maximum number of patients belonged to 26-30 years age group and the mean +/-SD age of the study patients was 26.8+/-4.7 years. Maximum number of women (41.4%) was primigravida and 24.3% women were second gravida. The mean+/-SD gestational age of the patient was 35.9+/-2.8 weeks. We found, clinically EFW was 3432.1+/-410.1 gm (mean+/-SD) and uEFW was 2715.4+/-509.1gm (mean+/-SD) with difference 716.7+/-278.5 gm (mean+/-SD), (P<0.001), which is highly significant. Babies who were delivered within 1st week of clinical and sonographic EFW were selected and their weights were compared with actual BW. The Pearson correlation chi square test and student 't' test were the statistical analysis used. It was found that the P value of clinical versus actual BW was <0.05, this was significant. P value of sonographic versus actual BW was >0.05, this was not significant. Percent error (PE) was found 2+/-7.33% in calculating uEFW from actual BW with minimum error -23.9% and maximum error 11.81%. This study conducted on Bangladeshi fetus using the Shepard formula showed that the actual BW recorded after delivery of the fetus is more close to uEFW than clinically EFW.

Difficulties for mothers in using an early intervention service for children with cerebral palsy in Bangladesh.

Given the numbers of disabled children in Bangladesh and the lack of trained professionals, innovative forms of service delivery are required. The Bangladesh Protibondhi Foundation has developed an outreach parent training service based at two centres, one urban and one rural. Mothers are shown how to use pictorially based Distance Training Packages (DTP), which they take home. This paper presents findings concerning factors which seem to affect mothers' attendance with their children at DTP advisory sessions. The study followed 47 children with cerebral palsy, aged between 2 and 5.5 years, over a period of around 18 months. The main factors predicting higher attendance were the child's sex (i.e. boys were brought back more often), particularly in the rural area, and lower adaptation to the child reported by the mother. The problems described by mothers in using the DTP advisory service were economic (such as transport costs), cultural (such as mothers not being permitted out alone), and medical (such as the child having repeated fits). The implications for future service development are discussed.

A randomized controlled trial of alternative modes of service provision to young children with cerebral palsy in Bangladesh.

OBJECTIVE: To compare the efficacy of an outreach program for young children with cerebral palsy with center-based and "minimal intervention" control groups. DESIGN: Randomized controlled trial conducted in a group of 85 children between the ages of 1.5 and 5 years. Urban children were allocated to a daily center-based mother-child group or to monthly training of their parents along with a pictorial guidance manual. Rural children were allocated either to parent training or health advice. Outcome measures were changes in children's adaptive skills, maternal stress and adaptation to the child, satisfaction with social support, and knowledge of handling a physically disabled child. RESULTS: Fifty-eight children were successfully followed up. The pattern of change in children's adaptive skills was as predicted (ie, least progress in the health advice group). Positive effects of intervention also included increased maternal knowledge and perceived helpfulness of support from formal sources. However, maternal adaptation increased most in the health advice group with minimal intervention. When children had attended a program at least 4 times, their skills improved, and mothers' adaptation did increase. CONCLUSIONS: Outreach training for mothers in Bangladesh can help them to improve the skills of their young children with cerebral palsy and is perceived as helpful.

Mortality of urban and rural young children with cerebral palsy in Bangladesh.

Bangladesh has a high child mortality rate. However, little is known about the outcome for young children who have cerebral palsy (CP). Ninety-two children with CP with a mean age of 3 years 3 months at entry into the study were followed for up to 3 years as part of an intervention study. Eight children died: two of 49 (4%) from an urban area and six of 43 (14%) from a rural area. Extrinsic factors such as infections and drug reactions preceded all the deaths, but those who died were mostly severely malnourished and among the more severely disabled of the total group. Eighty-nine percent of rural children in the study were from low-income families. Intervention programmes for severely disabled children in developing countries must include primary health care and feeding programmes as well as rehabilitation services to address both the needs of the child and empowerment of the mother and the family.

PIP: Most children with disabilities live in developing countries. A large epidemiological study of children with disabilities aged 2-9 years in Bangladesh indicated a prevalence rate of 6.8% for all grades and types of disabilities, and of 1.5% for serious disabilities. This paper presents findings from the assessment of the death rate of 92 children with cerebral palsy (CP) aged 16-67 months, of mean age 39 months, at entry into the study who were followed for up to 3 years as part of an intervention study. 8 children died: 2 of 49 (4%) from an urban area and 6 of 43 (14%) from a rural area. Factors such as infections and drug reactions preceded all of the deaths, but the children who died were mostly severely malnourished and among the more severely disabled of the overall group. 89% of rural children in the study were from low-income families. Intervention programs for severely disabled children in developing countries must include primary health care and feeding programs as well as rehabilitation services.