'We need to share our stories': the lives of Pakistanis with intellectual disability and their guardians.

INTRODUCTION: The experiences of Pakistanis with intellectual disabilities (IDs) and their family members have been underexplored empirically. METHOD: The present study sought to address this gap by understanding the lives of five Special Olympics Pakistan athletes and their guardians through PhotoVoice. FINDINGS: Through thematic analysis, we present the primary theme concerning Pakistan's cultural context that provides an empirical exploration of cultural beliefs about intellectual disability, cultural expectations and support received by people with intellectual disabilities and their guardians. DISCUSSION: We discuss implications for research and practice.

Digital workflow for virtually designing and milling ceramic lithium disilicate veneers: a clinical report.

Laminate veneers have been routinely used to restore and enhance the appearance of natural dentition. The traditional pathway for fabricating veneers consisted of making conventional polyvinyl siloxane impressions, producing stone casts, and fabricating final porcelain prostheses on stone dies. Pressed ceramics have successfully been used for laminate veneer fabrication for several years. Recently, digital computer-aided design/computer-aided manufacturing scanning has become commercially available to make a digital impression that is sent electronically to a dental laboratory or a chairside milling machine. However, technology has been developed to allow digital data acquisition in conjunction with electronically transmitted data that enables virtual design of restorations and milling at a remote production center. Following the aforementioned workflow will provide the opportunity to fabricate a physical cast-free restoration. This new technique has been reported recently for all-ceramic IPS e.max full-coverage pressed-ceramic restorations. However, laminate veneers are very delicate and technique-sensitive restorations when compared with all-ceramic full-coverage ones made from the same material. Complete digital design and fabrication of multiple consecutive laminate veneers seems to be very challenging. This clinical report presents the digital workflow for the virtual design and fabrication of multiple laminate veneers in a patient for enhancing the esthetics of his maxillary anterior teeth. A step-by-step process is presented with a discussion of the advantages and disadvantages of this novel technique. Additionally, the use of lithium disilicate ceramic as the material of choice and the rationale for such a decision is discussed.

Maxillary and Mandibular Rehabilitation in the Esthetic Zone Using a Digital Impression Technique and CAD/CAM-fabricated Prostheses: A Multidisciplinary Clinical Report.

Interdisciplinary treatment planning is necessary in certain clinical situations to optimize esthetic treatment outcomes. Patients presenting with severe wear of their anterior teeth from iatrogenic influences pose a particularly difficult problem in terms of esthetic treatment planning. Collaboration of practitioners from the disciplines of orthodontics, periodontics, and restorative dentistry is essential for the treatment of patients with complex esthetic dental needs. Careful assessment of clinical situations and corresponding specialty consultations are of utmost importance to achieve more predictable and esthetic treatment outcomes. The purpose of this clinical case is to report to the readership a novel digital fabrication of computer-aided design/computer-aided manufacturing milled acrylic provisional restorations and final lithium disilicate definitive restorations after orthodontic and periodontal therapy with virtual master impressions, casts, and articulation.

Dental student perception and assessment of their clinical knowledge in educating patients about preventive dentistry.

In today's dental school curricula, an increasing amount of time is dedicated to technological advances, and preventive dentistry topics may not be adequately addressed. Freshman (D1) students participated in a new Introduction to Preventive Dentistry course, which consisted of didactic lectures, active learning breakout sessions and case-based studies. The goal of this study was to determine if D1 dental students completing the course had a better knowledge and comfort level with basic preventive dentistry concepts and caries risk assessment than the upcoming graduating senior dental students. Following the completion of the course, D1 students were administered a survey that assessed their comfort level describing preventive dentistry topics to patients. This was immediately followed by an unannounced examination over the same topics. Senior (D4) students, who had not taken a formal course, reported statistically significant higher comfort levels than D1 students. However, the D4s scored significantly lower in all of the examination areas than the D1 students. Higher scores in D1s may have been due to recent exposure to the course material. However, the basic nature of the content-specific questions should be easily answered by novice practitioners educating their patients on oral disease prevention. As the current data shows lower content-specific scores of basic preventive dentistry knowledge amongst graduating D4 students, this may indicate a need for more guidance and education of students during the patient care. This study showed that implementation of a formalised course for D1 students can successfully ameliorate deficiencies in knowledge of preventive dentistry topics.

Identification and epidemiology of a rare HoBi-like pestivirus strain in Bangladesh.

The genus pestivirus of the family flaviviridae consists of four recognized species: bovine viral diarrhoea virus 1 (BVDV-1), bovine viral diarrhoea virus 2 (BVDV-2), classical swine fever virus and border disease virus. A new putative pestivirus species tentatively named as either 'HoBi-like pestivirus' or BVDV-3 has recently been identified in Brazil, Italy and Thailand. Despite reports of serological evidence of BVDV in Bangladesh, the types of the virus circulating in cattle have not been identified. We conducted surveillance in cattle from May 2009 to August 2010 in three government veterinary hospitals to characterize BVDV in cattle of Bangladesh. We tested serum for BVDV using an antigen-capture ELISA. Of 638 cattle samples, 3% (16/638) tested positive for BVDV antigen. The ELISA-positive samples were selected for further molecular detection and characterization of BVDV. Molecular analysis of the partial 5' untranslated region (UTR) nucleotide sequences of BVDV-positive samples identified the rare HoBi-like pestivirus or BVDV-3 virus circulating in cattle of Bangladesh. The identification of this rare HoBi-like pestivirus or BVDV-3 strain in Bangladesh warrants further surveillance to evaluate its impact on livestock production.

Molecular detection of noroviruses in hospitalized patients in Bangladesh.

From January 2004 to December 2005, a subset of stool specimens (n = 189) from patients who attended an urban hospital in Bangladesh, in which no pathogen was detected, was tested for the presence of noroviruses by conventional reverse transcription-polymerase chain reaction (RT-PCR). Norovirus RNA was detected in 37 samples (19.6%) in the no-pathogen-detected samples and the estimated overall norovirus detection rate was 8.5%. Diarrhea was generally moderate in the norovirus-infected patients and vomiting was the most common feature among them. Genetic analysis indicated that the GII genogroup was the most predominant norovirus strain (82.4%). The GI strain was found in 17.6% of samples and no cases of GIV were detected. This study indicates that a remarkable proportion of the diarrhea patients is hospitalized due to norovirus infection. Therefore, routine diagnosis of this virus in hospitalized patients is required. Since our study was based on hospitalized patients, community surveillance would be helpful to estimate the true burden of the virus in the country. The data regarding the genetic information of the circulating norovirus strains would be very useful for the norovirus vaccine development programs.

Successful co-administration of a human rotavirus and oral poliovirus vaccines in Bangladeshi infants in a 2-dose schedule at 12 and 16 weeks of age.

Co-administration of oral live-attenuated human rotavirus vaccine RIX4414 (Rotarix) and oral polio vaccine (OPV) was assessed. Healthy infants were randomised to receive 2-doses of either: RIX4414 or placebo co-administered with OPV (12 and 16 weeks of age); or RIX4414 or placebo given 15 days after OPV. After vaccination, 56.5-66.7% of RIX4414 and 18.6% of placebo recipients had seroconverted for rotavirus IgA. No significant differences between RIX4414 groups with or without OPV co-administration were observed. No statistically significant differences were observed between groups for polio seroprotection rates. RIX4414 vaccine was immunogenic when co-administered with OPV and did not interfere with OPV seroprotection rates.

Bangladesh moves from being a low-prevalence nation for HIV to one with a concentrated epidemic in injecting drug users.

Bangladesh has been conducting annual serological surveillance for HIV and syphilis since 1998 among most at-risk populations including sex workers, males having sex with males, injecting drug users (IDUs) and heroin smokers. During the seventh round conducted between January and June 2006, 10,368 people were sampled and the overall HIV prevalence was 0.9%. The highest HIV rate was recorded in male IDUs from the capital city Dhaka (7%), and the rates have risen significantly over the rounds (P < 0.001). In Dhaka, most of the HIV-positive IDUs (10.5%) were localized in one neighbourhood, while in the remaining neighbourhoods 1% were positive (P < 0.001). In all other groups, HIV prevalence was <1%. Active syphilis rates were highest in female IDUs (9.9%) followed by female street-based sex workers (8.6%). However, rates in female sex workers in Dhaka declined significantly over the years (P < 0.001). Bangladesh has to act urgently to prevent escalation of the epidemic.

Zinc supplementation in the management of shigellosis in malnourished children in Bangladesh.

OBJECTIVE: To assess the impact of zinc supplementation on clinical recovery, weight gain and subsequent growth and morbidity in moderately malnourished children with shigellosis. DESIGN: A randomized, double-blind, controlled trial. SETTING: Dhaka hospital of ICDDR,B: Centre for Health and Population Research, Dhaka, Bangladesh. SUBJECTS: Fifty-six moderately malnourished children, aged 12-59 months with culture-proven shigellosis. METHODS: Subjects were randomly allocated to receive zinc (20 mg/day elemental) in multivitamin syrup (intervention) or multivitamin syrup without zinc (control) in two equally divided doses daily for 2 weeks. All children received pivmecillinam in a dose of 15 mg/kg every 6 h for 5 days. After supplementation, children were followed in their respective homes every 2 weeks for 6 months. RESULTS: Children receiving zinc recovered from acute illness significantly faster than the control children (P<0.05). The medians time (days) to recovery and disappearances of blood and mucous were significantly 50% shorter in the zinc-supplemented group compared to the control group. The mean body weight of zinc supplemented children increased significantly from 8.8 kg on admission to 9.2 kg (P<0.01) at recovery, which was not observed in the control children (from 9.3 to 9.6 kg; P=0.12). During the 6-month follow-up period, zinc-supplemented children had significantly fewer mean episodes of diarrhoea compared to the control children (2.2 vs 3.3; P=0.03). CONCLUSION: Zinc supplementation significantly shortens the duration of acute shigellosis, promotes better weight gain during recovery and reduces diarrhoeal morbidity during the subsequent 6 months.

Safety and immunogenicity of tetravalent rhesus-based rotavirus vaccine in Bangladesh.

BACKGROUND: Rotavirus is the most common cause of severe gastroenteritis among children worldwide. OBJECTIVES: To compare the safety, immunogenicity and shedding patterns of rhesus rotavirus (RRV)-tetravalent vaccine vs. placebo among infants in rural Bangladesh. METHODS: A double blinded, placebo-controlled trial was conducted in which infants (n = 120) were randomly assigned to receive three doses of either vaccine or placebo administered at approximately 6, 10 and 14 weeks of age together with routine immunizations. Data on possible adverse effects of vaccinations were collected daily for 7 days after each dose. Stool samples were collected after each dose, and serum samples were obtained before the first and after the third vaccination. RESULTS: Fever (> or = 38 degrees C), as measured by study assistants, was noted more frequently among vaccinees (15%) than among placebo recipients (2%) during the 7 days after vaccination but was not reported more frequently by parents of vaccinees vs. placebo recipients. Overall 87% of vaccinees had an antibody response (measured by IgA or anti-RRV-neutralizing antibodies) after vaccination compared with 32% of placebo recipients. Rates of seroconversion were higher among subjects with lower levels of prevaccination antibodies and those who shed rotavirus after vaccination. Vaccine strain viruses were detected in stools from placebo vaccine recipients who had evidence of IgA seroconversion. CONCLUSIONS: In this population RRV-tetravalent vaccine was comparably immunogenic and safe as in trials conducted in developed countries, where this vaccine has been proved effective in preventing severe rotavirus diarrhea. These data support continued evaluation of rotavirus vaccines in developing countries.

Immune modulation after measles vaccination of 6-9 months old Bangladeshi infants.

Measles still causes high mortality in children younger than 1 year of age. Administration of high titre measles vaccines before 7 months of age led to increased overall mortality, raising questions as to the immunological effects of measles vaccine in young infants. We investigated the immune response to standard titre vaccines given to children in Bangladesh in a single dose at age 9 months, or two doses at 6 and 9 months. Of the children vaccinated at age 9 months, 95% serocoverted, compared with 70% at age 6 months. Delayed-type-hypersensitivity reactions to candida antigen were significantly reduced in both vaccine groups at 6 weeks post-vaccination, but responses to other recall antigens studied were not significantly different from controls. In both vaccine groups, peripheral blood lymphocytes isolated at 6 and 24 weeks after vaccination showed significantly higher expression of activation markers upon in vitro stimulation, and a sustained increase in IL-2 production. These findings suggest prolonged immune activation after measles vaccination at the same time as some reduction in delayed hypersensitivity responses. Further study of the clinical effects of these changes is warranted.

Immune response of Bangladeshi children with acute diarrhea who subsequently have persistent diarrhea.

BACKGROUND: Because altered immune responses may be a risk factor for persistent diarrhea, various aspects of the immune response were examined to elucidate the underlying immune mechanisms that may be involved in the development of persistent diarrhea. METHODS: Children (7-12 months of age) with watery diarrhea for 6 to 8 days from the Dhaka Hospital of the International Centre for Diarrheal Disease Research, Bangladesh (ICDDR,B), were enrolled. Children were classified as having acute diarrhea (AD) or persistent diarrhea (PD) if diarrhea resolved within 14 days or persisted for more than 14 days, respectively. Uninfected control children (n = 13), from the Nutrition Follow-Up Unit of ICDDR,B were also enrolled. Of the 123 children with diarrhea who were enrolled, 85 had AD and 38 had PD. Comparisons were performed for clinical features, nutritional status (weight for age, plasma transferrin, and serum albumin levels), and immune responses: neutrophil function; peripheral blood mononuclear cell function, delayed-type hypersensitivity (DTH) responses, plasma levels of immunoglobulins, tumor necrosis factor-alpha, and interferon-gamma. Univariate analyses were conducted to assess differences among the three groups of children and between children with AD and PD. Logistic regression was performed to determine risk factors for PD. RESULTS: There were no differences in clinical features and nutritional status among the groups of children studied. More children in whom PD developed had a negative DTH response to tuberculin than those with AD (P = 0.021). Also, a negative DTH response to tuberculin was a significant risk factor for PD (odds ratio [OR] = 3.8, 95% confidence interval [CI] = 1.5-9.9). CONCLUSIONS: Children with acute diarrhea with a negative DTH response to tuberculin are more likely to have development of persistent diarrhea.

Immune response of children who develop persistent diarrhea following rotavirus infection.

A prospective study was conducted with Bangladeshi children with rotavirus (RV) diarrhea to assess whether nutritional and clinical parameters, RV serotypes, levels of interleukin-10 (IL-10), tumor necrosis factor alpha (TNF-alpha), and gamma interferon (IFN-gamma), and RV-specific antibody titers in plasma and stool were associated with the development of persistent diarrhea. Children with watery diarrhea for 6 to 8 days, selected from the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), were enrolled in the study and monitored until diarrhea improved. Children were classified as having acute diarrhea (AD) if diarrhea resolved within 14 days of onset and as having persistent diarrhea (PD) if diarrhea persisted for more than 14 days after onset. Uninfected, control children (n = 13) from the Nutrition Follow-Up Unit of ICDDR,B were also enrolled. Of the 149 children with diarrhea enrolled, 29 had diarrhea with RV alone, of which 19 had AD and 10 developed PD. Samples of stool and blood were collected from all children on enrollment. Stool samples were collected again from children when they developed PD. Of the 10 children who had an initial RV infection and then developed PD, only one had persistent RV infection. Plasma levels of IL-10 and TNF-alpha were higher in children with diarrhea compared to uninfected controls but were similar in children with AD and PD. Plasma IFN-gamma levels were higher in children who developed PD than in those with AD (P = 0.008) or uninfected controls (P = 0.001). In stools, the levels of TNF-alpha, the only cytokine detected, were similar in the three groups of children. RV-specific immunoglobulin G (IgG) titers in plasma were higher in uninfected children than in those with AD (P < 0.001) or PD (P = 0.024) but titers were similar in children with AD and PD. RV-specific IgA titers in plasma and stool were similar in the three groups of children. From all observed parameters, only elevated plasma IFN-gamma levels were associated with subsequent development of PD. However, a larger sample size is necessary to substantiate this observation.

Antibodies to Shiga toxin in the serum of children with Shigella-associated haemolytic uraemic syndrome.

Antibodies to Shiga toxin (Stx) were measured in the sera of 49 children with Shigella dysenteriae serotype 1 infection, of whom 17 had haemolytic uraemic syndrome (HUS) and 32 had no complications (uncomplicated shigellosis, UCS). Children with HUS had lower levels of total IgG and IgM and lower IgM titres to Stx than those with UCS. The number of children with neutralising antibodies was similar in the two groups. Of the children with HUS, 11 had HUS on enrolment and six developed HUS subsequent to enrolment. Antibody titres in children who subsequently developed HUS were compared with those in children with UCS to assess whether differences in antibody titres occurred before the development of HUS. IgA titres to Stx were found to be higher in children who subsequently developed HUS than in those with UCS. However, logistic regression analysis revealed that titres of Stx antibodies in the serum were not significant risk factors for the development of HUS. Thus, although the levels of Stx antibodies were different in children with HUS, and higher IgA titres to Stx were identifiable in children who subsequently developed HUS compared with those with UCS, the relevance of these findings in the development of HUS remains to be elucidated.

Hepatitis B infection in Bangladeshi mothers and infants.

In order to estimate the relative importance of perinatal transmission of hepatitis B in rural Bangladesh a cross-sectional study was carried out. Paired-serum samples of infants aged 2-8 months old, a group of new born, and their mothers were tested for hepatitis B markers using a commercial ELISA test kit. In total, 107 (32.4%) positive for HBcAg, 18 (5.4%) for HBsAg, and 4 (1.2%) for HbeAg. Of the infants, 35 (10.5%) positive for HBcAg, 1 (0.3%) for HBsAg, and none for HBeAg. Of the 18 HBsAg positive mothers, 4 (22%) were HBeAg positive. All 14 children of mothers who were HBeAg negative were negative for HBsAg. Only one out of four (25%) of children of HBeAg positive mothers were HBsAg carriers (8 months old), and in three children transmission did not occur (two 8 months, one 6 months old). This survey indicates that hepatitis B is prevalent in rural Bangladesh and that the perinatal transmission mode may be relatively low.

Astrovirus infection in association with acute, persistent and nosocomial diarrhea in Bangladesh.

BACKGROUND: Diarrhea is an important public health concern in developing countries such as Bangladesh. Diarrhea in children that persists for 14 days or more occurs in 7% of patients in Bangladesh and frequently results in death. Astrovirus has been demonstrated as a cause of acute and nosocomial diarrhea and can be excreted for prolonged periods, yet its importance as a cause of diarrhea among children in a developing country like Bangladesh has not been investigated. METHODS: We tested 629 stool specimens from patients with acute diarrhea, 153 from patients with persistent diarrhea, 175 specimens from 76 patients hospitalized for diarrhea who were sampled repeatedly to detect nosocomial infection and 428 from nonhospitalized healthy children (controls). All children enrolled in the study were <5 years of age. Astrovirus was detected by enzyme immunoassay and other enteropathogens were detected by standard techniques. RESULTS: The detection of astrovirus increased significantly with the duration of diarrhea. Astrovirus was found in 23 (15%) specimens from patients with persistent diarrhea, 26 (4%) patients with acute diarrhea, but only 8 (2%) healthy controls. This trend remained when we limited our analysis to infants <12 months of age and to episodes in which astrovirus was the sole pathogen. Among patients with nosocomial diarrhea, 16% of postadmission specimens were positive for astrovirus when the admission specimen was negative. CONCLUSION: The observation that astrovirus is detected more frequently with diarrhea of increasing duration suggests the need for further studies to determine whether astrovirus plays a causative role in persistent diarrhea or is a secondary agent.

Lipopolysaccharide-specific antibodies in plasma and stools of children with Shigella-associated leukemoid reaction and hemolytic-uremic syndrome.

Antibody responses to the lipopolysaccharide (LPS) of shigellae were compared between children with uncomplicated and complicated Shigella dysenteriae 1 infection. One hundred fifteen children between 12 and 60 months of age with S. dysenteriae 1 infection were studied. Of these children, 42 had complications (leukemoid reaction and/or hemolytic-uremic syndrome [complicated shigellosis] and 73 had no complications (uncomplicated shigellosis). Antibodies to the LPS of S. dysenteriae 1 and Shigella flexneri Y were measured in plasma and stools, as were total immunoglobulin A (IgA) and IgG concentrations in plasma and the total IgA concentration in stool, on enrollment and 3 to 5 days later. In the plasma, the concentrations of homologous (IgG) and heterologous (IgA) LPS antibodies on enrollment were higher in children with complicated shigellosis than in those with uncomplicated shigellosis. In stool, the concentrations on enrollment were similar between the two groups of children. There was a rise in antibody concentrations in the plasma (homologous and heterologous) and stool (homologous) between the day of enrollment and 3 to 5 days later in children with uncomplicated shigellosis but not in those with complicated shigellosis. These findings suggest that systemic stimulation is more marked in children with complications, so that a subsequent rise in plasma antibody concentrations does not occur in these children. In contrast, the lack of a rise in stool antibody concentrations in children with complicated shigellosis is suggestive of a lower-level mucosal response. Because the duration of diarrhea before enrollment influenced the homologous antibody concentrations, children were further divided into three subgroups (short [3 to 5 days], medium [6 to 9 days], and long [> 9 days] diarrhea durations before enrollment). Comparisons of homologous antibody concentrations between the two groups of children following such subdivisions showed that in children with complicated shigellosis, antibody concentrations were higher in the plasma of children in the short diarrhea duration subgroup but lower in the stool children in the medium diarrhea duration subgroup. No differences in antibody concentrations were observed in children in the other diarrhea duration subgroups. Thus, complications in shigellosis are associated with an early and strong systemic stimulation without a concomitant stimulation of the mucosal antibody response.

Monoclonal antibodies to the enterotoxin of Bacteroides fragilis: production, characterization, and immunodiagnostic application.

A monoclonal antibody, ICT11, specific for the toxin of enterotoxigenic Bacteroides fragilis (ETBF) neutralized the cytotoxic effect of the toxin on human colonic cell line HT-29/C1. In an evaluation using 115 diarrheal stool specimens and culture as the "gold standard," the assay showed a sensitivity of 85% and a specificity of 100%. An ICT11-based sandwich enzyme-linked immunosorbent assay showed a sensitivity of 100% and a specificity of 98% for direct detection of toxin from stool samples compared with those of culture. Thus, ICT11-based assays will be useful for screening for ETBF.