Systemic Therapy of Dermtophytosis with Voriconaole: A Clinical Observational Study of 250 Bangladeshi Patients

Superficial fungal infection or dermatophytosis is one of the most common dermatological problems in a tropical country like Bangladesh. For last 4-5 years this skin problem is on rise with increase in cases of recalcitrant, recurrent and chronic dermatophytosis. In place of an easy task to treat dermatophytosis recently it has evolved into difficult to treat by traditional antifungal agents. Meanwhile, voriconazole, primarily appeared as an agent for deep fungal infections, has come out as a new promising systemic antifungal drug for dermatophytosis also. In Bangladesh recently an endeavor has been made to treat superficial fungal infection with voriconazole. Two hundred and ninety four patients suffering from recalcitrant, recurrent, resistant and chronic dermatophytosis between 12 and 70 years of age and both sexes were selected for the study between August 2018 and November 2018 from different parts of the country. Two categories of therapy were designed: Group A - 200mg 12 hourly for 14 days and Group B - 200mg 12 hourly for 28 days. Patients showing full response in 2 weeks were declared apparently cured and were kept under follow up. Those who did not show significant response (less than 50% improvement) in 2 weeks were considered failed. Unresponsive cases after 28 days were considered failed. Both groups were followed up for 4 weeks. Cases not showing any activity of the disease and negative microscopy on two occasions at 2 weeks interval were considered cured. Two hundred and fifty patients completed the study. Incidence of cure rate was more in Group B (93.04%) which is statistically significant (p<0.005). Relapse rate was observed more in Group A (22.83%). Visual side effects were 4.4% while vertigo and headache were observed in 12.0% and 10.8% respectably. Voriconazole is a promising treatment option for recurrent, recalcitrant and chronic dermatophytosis in dosage of 200mg twice daily for at least 4 weeks with negligible side effects. More diversified studies with longer follow up period is required for further opinion to establish an authenticated dosage schedule for treatment of superficial fungal infection.

MO111PATTERN OF CARDIAC AND RENAL RISK FACTORS PREVAILING IN HYPERTENSIVE SUBJECTS OF RURAL COMMUNITY: PRIMARY RESULTS FROM AN ONGOING SYSTEMATIC SURVEY IN BANGLADESH

Background and Aims

Hypertension is the leading entity of non communicable diseases (NCD). Some 15-30% adult population is identified suffering from hypertension at any given time worldwide. Complications of hypertension cause severe functional deficit and a major decline in quality of life for the patient and family.

This study was carried out to identify the presence and pattern of cardiac and renal risk factors influencing major morbidity and mortality in hypertensive subject by performing relevant clinical and laboratory evaluations.

Method

In this survey adult subjects were selected randomly from a defined rural area. Their demographic, anthropometric and clinical information was recorded by WHO STEP wise approach surveillance-Instrument v.3.1. Information on prevailing NCDs and related risk factor were collected on a short questionnaire by face-to-face interview. Blood Pressure (BP) was measured by digital blood pressure monitor (Omron) with standard sized cuff after 10-15 minutes of rest in sitting posture by taking mean of two readings. Systolic BP ≥140 and/or diastolic BP ≥90mmHg or subjects taking antihypertensive medications were considered for hypertension. Early morning urine and fasting blood sample was collected for glycemic profile, lipid profile, serum creatinine, eGFR (MDRD equation) and urine ACR estimations for identifying diabetes, dyslipidemia and nephropathy. Results from an early group are presented here.

Results

From surveyed population consequative 300 hypertensive subjects with 100 normotensive subjects were analyzed. Male/female distribution was 66% and 34%. Age in 75% was between 25-55 years and BMI overweight to obese in 45%. Etiology wise in 81% it was essential hypertension followed by diabetes 18% and nephropathies in rest. Mean systolic BP was 147±16 and diastolic BP 71±9 mmHg. Comparison of hypertensive vs. normotensives showed FBS 6.7±3 vs. 5.8±1.0 mmol/l, (p&lt;0.001). Lipids as cardiac markers were TG 170±107 vs. 130±76 g/dl, (p&lt;0.001); Cholesterol 195±50 vs. 180±49 g/dl, (p&lt;0.001); LDL 170±107 vs. 130±76 g/dl, (p&lt;0.04); and HDL 42±7 vs. 46±8 g/dl, (p&lt;0.001). Renal parameters like eGFR was 88±22 vs. 98±26 ml/min, (p&lt;0.001); and ACR 99±556 vs. 30±87 mg/g, (p&lt;0.04). These comparisons showed fasting hyperglycemia with most of the lipids higher and HDL lower in hypertensives. Renal parameters like eGFR was lower and albuminuria was significantly higher with similar urinary Na and K excretion in hypertensives. Other cardio renal markers like Uric Acid and hCRP was similar in both groups. Pearson’s correlations showed a positive correlation of systolic and diastolic BP with major components of cardiac, renal and metabolic risk factors.

Conclusion

It is found that hypertension is essential in nature among 81% of rural subjects. Nearly half of the study subjects are overweight. Dyslipidemia, albuminuria and low GFR is more pronounced in hypertensives in comparison to the normotensive counterparts. So, hypertension is mostly associated with adverse cardio-renal risk markers.

Circulating tumor cells demonstrate a positive biomarker in head and neck squamous cell carcinoma (HNSCC) in tobacco consuming population of Bangladesh

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Background: Tobacco consumption accounts for 1.6 million deaths annually in the South East Asia Region (SEAR). Notably, amongst 10-20% of the global population consuming the betel quid and tobacco, about 81% concentration is in SEAR regions, including India and Bangladesh. The prevalence of HNSCC in these regions is rising alarmingly. For example, HNCs account for 23% of total 156775 cancer incidences in Bangladesh. Liquid biopsy tools are unavailable and expensive for most patients in this region. However, early cancer detection using tumor biomarkers, for example, Circulating Tumor Cells (CTCs) is highly implicated. Furthermore, such biomarkers are being validated and have potential for screening of high-risk patients, such as genetic predisposition, tobacco consumption, etc. We report the first observational study in HNSCC patients in Bangladesh correlating the presence of CTCs to chronic tobacco consumption. Methods: The study involved 70 cancer patients and 10 healthy volunteers (no prior cancer history). 87% of the patients had a specified history of chronic tobacco consumption. CTCs were isolated in 1.5 ml of blood using OncoDiscover Liquid Biopsy Test, which is clinically approved by the Drug Controller General of India, that contains an enriching anti-EPCAM antibody immunomagnetic kit. CTCs are qualified as CK18+, DAPI+and CD45-. Subsequently, CTCs were imaged using Zeiss Axio Observer 7 and quantified for Mean Fluorescence Intensity (MFI) for clinicopathological parameters; age/gender, HNSCC sub-population, and CTC distribution. Results: This is the 1st study on Bangladesh phenotype accounting for the presence of CTCs in HNSCC patients. In this population, 34 males (66%) and 10 females (52%) accounted for 91 CTCs. CTC distribution was 0 to 6 with mean and median ̃ 2.02 and 2, respectively. 25 patients (17 males, 8 females) were negative for any CTCs. Interestingly, 02 patients exhibited CTC clusters indicative of aggressive metastasis in which 01 patient had no prior tobacco usage or family cancer history. There was no correlation between CTC presence in males (66 %) and females (52 %). Healthy volunteer samples exhibited no false positives. The MFI values ranged between 23 and 766, with mean and median MFI values were 157 and 96, respectively, indicative of CK overexpression on CTCs of HNSCC patients. Conclusions: HNSCC patients with a history of chronic tobacco consumption in Bangladesh correlated the presence of CTCs in 64 % of the cases. Prospectively, CTCs may be validated as a biomarker for screening chronic tobacco users in Bangladesh to detect early cancers and HNSCC. Clinical trial information: BMRC/Grants/2018/99 (1-100).

170 Primary Breast Lymphoma-Mimicking Inflammatory Breast Disease: A Case Report

Primary breast lymphoma (PBL) is an unusual clinical entity accounting for 0.4–0.5% of all breast neoplasms. The usual presentation includes a painless palpable mass similar to that of breast carcinoma. Diffuse large B-cell lymphoma (DLBCL) is the most common identifiable type of PBL based on the histopathological examination.

We report an unusual case of 22 years old Bangladeshi woman presented with a 6-month history of a lump on left breast. Although the lump was initially small, it began a rapid growth after 4 months. The swelling was localized and did not show any skin involvement or discharge and as she didn’t have any positive familial history of breast carcinoma her primary attending physician diagnosed it as a case of breast abscess. When local incision and drainage proved ineffective, she was referred to us. After doing an immunohistochemistry from incisional biopsy the diagnosis was confirmed as Diffuse Large B-cell Lymphoma. The patient was treated initially by chemotherapy with CHOP therapy followed by wide local excision.

Early and accurate diagnosis of PBL is crucial for selecting the appropriate MDT treatment strategies to avert potentially harmful surgical interventions.

P134 Under the weather: The Meteorological correlation in Orthopaedic Trauma and within Hertfordshire

Background

The paper aims to understand the effect of meteorological factors on the number of referrals and volume of trauma operating cases within our local area.

Method

Trauma data was analysed in our database: (eTrauma), a digital clinical platform that co-ordinates all admissions and: trauma theatre activity. Data consisted of number of referrals per day, patient: age, mechanism of injury and type of orthopaedic injury. Weather data was: gathered from a local weather station which: records daily weather observations.

Results

1160 consultations wereanalysed, 779 required an operative intervention. Neck of femur fractures: and ankle trauma were the two most common cause of trauma, accounting for 27% and 15% respectively. Neck of femur fracture pathology were not significantly correlated with any meteorological factor studied. On the contrary, ankle trauma were the only injuries significantly correlating with temperature (p < 0.03) and due point (p < 0.04).

Conclusion

Weather has no effect on neck of femur fractures, the most common trauma pathology treated in our department. In all seasons allocated specific trauma lists for the latter should be arranged irrelevant of the weather conditions. We identified the days receiving highest referral rate, using this data to shape the future on call trauma service.

Diagnostic Accuracy of Detecting Diabetic Retinopathy by Using Digital Fundus Photographs in the Peripheral Health Facilities of Bangladesh: Validation Study

BACKGROUND

Diabetic retinopathy can cause blindness even in the absence of symptoms. Although routine eye screening remains the mainstay of diabetic retinopathy treatment and it can prevent 95% of blindness, this screening is not available in many low- and middle-income countries even though these countries contribute to 75% of the global diabetic retinopathy burden.

OBJECTIVE

The aim of this study was to assess the diagnostic accuracy of diabetic retinopathy screening done by non-ophthalmologists using 2 different digital fundus cameras and to assess the risk factors for the occurrence of diabetic retinopathy.

METHODS

This validation study was conducted in 6 peripheral health facilities in Bangladesh from July 2017 to June 2018. A double-blinded diagnostic approach was used to test the accuracy of the diabetic retinopathy screening done by non-ophthalmologists against the gold standard diagnosis by ophthalmology-trained eye consultants. Retinal images were taken by using either a desk-based camera or a hand-held camera following pupil dilatation. Test accuracy was assessed using measures of sensitivity, specificity, and positive and negative predictive values. Overall agreement with the gold standard test was reported using the Cohen kappa statistic (κ) and area under the receiver operating curve (AUROC). Risk factors for diabetic retinopathy occurrence were assessed using binary logistic regression.

RESULTS

In 1455 patients with diabetes, the overall sensitivity to detect any form of diabetic retinopathy by non-ophthalmologists was 86.6% (483/558, 95% CI 83.5%-89.3%) and the specificity was 78.6% (705/897, 95% CI 75.8%-81.2%). The accuracy of the correct classification was excellent with a desk-based camera (AUROC 0.901, 95% CI 0.88-0.92) and fair with a hand-held camera (AUROC 0.710, 95% CI 0.67-0.74). Out of the 3 non-ophthalmologist categories, registered nurses and paramedics had strong agreement with kappa values of 0.70 and 0.85 in the diabetic retinopathy assessment, respectively, whereas the nonclinical trained staff had weak agreement (κ=0.35). The odds of having retinopathy increased with the duration of diabetes measured in 5-year intervals (P<.001); the odds of having retinopathy in patients with diabetes for 5-10 years (odds ratio [OR] 1.81, 95% CI 1.37-2.41) and more than 10 years (OR 3.88, 95% CI 2.91-5.15) were greater than that in patients with diabetes for less than 5 years. Obesity was found to have a negative association (P=.04) with diabetic retinopathy.

CONCLUSIONS

Digital fundus photography is an effective screening tool with acceptable diagnostic accuracy. Our findings suggest that diabetic retinopathy screening can be accurately performed by health care personnel other than eye consultants. People with more than 5 years of diabetes should receive priority in any community-level retinopathy screening program. In a country like Bangladesh where no diabetic retinopathy screening services exist, the use of hand-held cameras can be considered as a cost-effective option for potential system-wide implementation.

Early Induction of Cross-Reactive CD8+ T-Cell Responses in Tonsils After Live-Attenuated Influenza Vaccination in Children

BACKGROUND

Live-attenuated influenza vaccine (LAIV) was licensed for prophylaxis of children 2-17 years old in Europe in 2012 and is administered as a nasal spray. Live-attenuated influenza vaccine induces both mucosal and systemic antibodies and systemic T-cell responses. Tonsils are the lymph nodes serving the upper respiratory tract, acting as both induction and effector site for mucosal immunity.

METHODS

Here, we have studied the early tonsillar T-cell responses induced in children after LAIV. Thirty-nine children were immunized with trivalent LAIV (containing A/H1N1, A/H3N2, and B viruses) at days 3, 7, and 14 before tonsillectomy. Nonvaccinated controls were included for comparison. Tonsils and peripheral blood (pre- and postvaccination) were collected to study T-cell responses.

RESULTS

Tonsillar and systemic T-cell responses differed between influenza strains, and both were found against H3N2 and B viruses, whereas only systemic responses were observed against A/H1N1. A significant increase in cross-reactive tonsillar CD8+ T cells recognizing conserved epitopes from a broad range of seasonal and pandemic viruses occurred at day 14. Tonsillar T cells showed significant cytokine responses (Th1, Th2, and granulocyte-macrophage colony-stimulating factor).

CONCLUSIONS

Our findings support the use of LAIV in children to elicit broadly cross-reactive T cells, which are not induced by traditional inactivated influenza vaccines and may provide protection to novel virus strains.

Anorectal Malformations and Associated Anomalies in Children

Anorectal malformations (ARM) incorporate a broad spectrum of diseases, can affect both sexes, and involve the distal anus and rectum as well as the uro-genital tracts. Defects range from the minor which can be treated easily with an excellent outcome, to those are complex and often associated with other anomalies are difficult to manage with poor functional prognosis. This study was done to observe the hospital incidence of Anorectal malformations, frequency of types, sex distribution and spectrum of associations with ARM. The effects of presence of associated anomalies on morbidity and mortality also observed. Detailed history, clinical examinations and relevant investigations were performed for the primary and as well as the associated anomalies. A total of 80 patients were admitted in the department of pediatric surgery in Mymensingh Medical College Hospital during the period of June 2016 to May 2017. Age of the patients was ranging from 1-180 days with the mean age of 0.49±1.002 months. Male: Female ratio was 1.6: 1. Among them 48(60%) were high and 32(40%) were low variety of ARM. In male 37(46.2%) had high and 13(13.7%) were low variety whereas in female 11(13.7%) were high and 19(23.7%) had low ARM. Associated anomalies were seen in 25(31.2%) patient -18 in males and 7 in females; 20 in high and 5 in low ARM. Associated anomalies were uro-genital 11(13.8%), cardiovascular 10(12.5%), vertebral 4(5%), limb defects 3(3.5%) and others 2(2.5%). Four patients have more than one anomaly. Anorectal malformations occur more in boys than girls. Males were more likely to have high lesions and without fistula was the common defect. Low variety ARM were found more in females with Anovestibular fistula is the commonest defect. The most common associated anomalies were recto urinary fistula (13.8%). Associations were more in high than low ARM but not significant (p>0.05). Post operative complications were more in high ARM in both sexes with associated anomalies. The effects of types and associations on morbidity and mortality were significantly different (p<0.05).

Hemoprotozoa and Anaplasma spp. in rodents and shrews of Bangladesh

Hemoprotozoans are important pathogens of animals and humans, among which some species have zoonotic significance. The prevalence of different hemoprotozoa and Anaplasma spp. in larger mammals have been reported from different regions of the world. But, very few studies have been conducted to estimate the prevalence of hemoprotozoa in rodents and shrews of South-East Asia. The study assessed the prevalence of hemoprotozoa and Anaplasma spp. in rodents and shrews of Bangladesh. Blood samples (n=451) were collected from rodents and shrews between June 2011 and June 2013 and July-December 2015 from 4 land gradients of Bangladesh. Giemsa-stained blood smears revealed that 13% of animals were harboring hemoprotozoa (4.7% Babesia spp., 0.67% Plasmodium spp.), and Anaplasma spp. (7.5%). The study may serve as a guide for future hemoparasitic research of rodents and shrews.

The correlation between bowel complications and cardiac surgery

Although advances in knowledge and technology have improved outcomes in surgical cardiac patients over the last decade, complications following cardiac operations still remain to be potentially fatal. Gastrointestinal complications, in particular, tend to have high rates of reintervention and mortality following cardiac surgery, with ischemia and hemorrhage being two of the commonest underlying causes. The intention of this review is to identify which risk factors play important roles in predisposing patients to such complications and to gain better insight into the pathogenesis of the sequelae. Furthermore, strategies for prevention have been discussed to educate and increase awareness of how adverse cardiac surgical outcomes can be minimized.

Setting up pharmacovigilance based on available endTB Project data for bedaquiline

SETTING: Active pharmacovigilance (PV) is recommended for TB programmes, notably for multidrug-resistant TB (MDR-TB) patients treated with new drugs. Launched with the support of UNITAID in April 2015, endTB (Expand New Drug markets for TB) facilitated treatment with bedaquiline (BDQ) and/or delamanid of >2600 patients in 17 countries, and contributed to the creation of a central PV unit (PVU).OBJECTIVE: To explain the endTB PVU process by describing the serious adverse events (SAEs) experienced by patients who received BDQ-containing regimens.DESIGN: The overall PV strategy was in line with the ‘advanced´ WHO active TB drug safety monitoring and management (aDSM) system. All adverse events (AEs) of clinical significance were followed up; the PVU focused on signal detection from SAEs.RESULTS and CONCLUSION: Between 1 April 2015 and 31 March 2019, the PVU received and assessed 626 SAEs experienced by 417 BDQ patients. A board of MDR-TB/PV experts reviewed unexpected and possibly drug-related SAEs to detect safety signals. The experts communicated on clusters of risks factors, notably polypharmacy and off-label drug use, encouraging a patient-centred approach of care. Organising advanced PV in routine care is possible but demanding. It is reasonable to expect local/national programmes to focus on clinical management, and to limit reporting to aDSM systems to key data, such as the SAEs.

Introducing new and repurposed TB drugs: the endTB experience

In 2015, the initiative Expand New Drug Markets for TB (endTB) began, with the objective of reducing barriers to access to the new and repurposed TB drugs. Here we describe the major implementation challenges encountered in 17 endTB countries. We provide insights on how national TB programmes and other stakeholders can scale-up the programmatic use of new and repurposed TB drugs, while building scientific evidence about their safety and efficacy. For any new drug or diagnostic, multiple market barriers can slow the pace of scale-up. During 2015-2019, endTB was successful in increasing the number of patients receiving new and repurposed TB drugs in 17 countries. The endTB experience has many lessons, which are relevant to country level introduction of new TB drugs, as well as non-TB drugs and diagnostics. For example: the importation of TB drugs is possible even in the absence of registration; emphasis on good clinical monitoring is more important than pharmacovigilance reporting; national guidelines and expert committees can both facilitate and hinder innovative practice; clinicians use new and repurposed TB drugs when they are available; data collection to generate scientific evidence requires financial and human resources; pilot projects can drive national scale-up.

Complaints of neuropathic pain, noxious cervical plexus neuropathy and neck tightness are reported by patients who undergo neck dissection: an institutional study and narrative review

There exists a subgroup of patients who undergo neck dissection (ND) who postoperatively complain of either neuropathic pain, dysaesthesia and/or discomfort that is located within the dermatomal distribution of the cervical plexus. The purpose of our study was to determine the prevalence, characteristic, and demographics of these symptoms in our patient cohort. We undertook a retrospective randomised observational cohort study of 105 patients who had undergone ND. The primary predictor variable was the undertaking of a ND. The secondary outcome variable was the complaint of either neuropathic pain or a noxious neuropathy, at a minimum of twelve months after surgery. A recognised symptom questionnaire and a visual analogue score was employed for the purpose of the study. A descriptive and statistical analysis was applied to the assembled data. Twenty patients (19%) complained of either spontaneous (n=9) or evoked (n=11) neuropathic pain that occurred within the surgical site. In addition, 71 patients (68%) described an altered sensation in the dermatomal distribution of the great auricular or tranverse cervical nerves while 70 patients (67%) described the feeling of 'neck tightness'. There were no characteristics of the study cohort that underpinned these results. Neuropathic pain can occur following ND. This can cause distress to a small but defined group of patients. Despite its importance, we found a paucity of studies in the literature that have investigated neuropathic pain following ND. We believe this condition requires more research attention and clinical awareness.

Chemotherapeutic resistance of head and neck squamous cell carcinoma is mediated by EpCAM induction driven by IL-6/p62 associated Nrf2-antioxidant pathway activation

Overexpression of epithelial cell adhesion molecule (EpCAM) has been associated with chemotherapeutic resistance, leads to aggressive tumor behavior, and results in an adverse clinical outcome. The molecular mechanism by which EpCAM enrichment is linked to therapeutic resistance via Nrf2, a key regulator of antioxidant genes is unknown. We have investigated the link between EpCAM and the Nrf2 pathway in light of therapeutic resistance using head and neck squamous cell carcinoma (HNSCC) patient tumor samples and cell lines. We report that EpCAM was highly expressed in Nrf2-positive and HPV-negative HNSCC cells. In addition, cisplatin-resistant tumor cells consisted of a higher proportion of EpCAM^high cells compared to the cisplatin sensitive counterpart. EpCAM^high populations exhibited resistance to cisplatin, a higher efficiency in colony formation, sphere growth and invasion capacity, and demonstrated reduced reactive oxygen species (ROS) activity. Furthermore, Nrf2 expression was significantly higher in EpCAM^high populations. Mechanistically, expression of Nrf2 and its target genes were most prominently observed in EpCAM^high populations. Silencing of EpCAM expression resulted in the attenuation of expressions of Nrf2 and SOD1 concomitant with a reduction of Sox2 expression. On the other hand, silencing of Nrf2 expression rendered EpCAM^high populations sensitive to cisplatin treatment accompanied by the inhibition of colony formation, sphere formation, and invasion efficiency and increased ROS activity. The molecular mechanistic link between EpCAM expression and activation of Nrf2 was found to be a concerted interaction of interleukin-6 (IL-6) and p62. Silencing of p62 expression in EpCAM^high populations resulted in the attenuation of Nrf2 pathway activation suggesting that Nrf2 pathway activation promoted resistance to cisplatin in EpCAM^high populations. We propose that therapeutic targeting the Nrf2-EpCAM axis might be an excellent approach to modulate stress resistance and thereby survival of HNSCC patients enriched in EpCAM^high populations.

P0835IDENTIFYING THE FREQUENCY OF CHRONIC KIDNEY DISEASE OF UNKNOWN ETIOLOGY (CKDU) IN A RURAL POPULATION OF BANGLADESH

Background and Aims

The common etiologies of CKD are diabetes, hypertension and glomerulonephritis. Prevalence of CKD of unknown (CKDu) etiology is being increasingly considered as an emerging etiology, especially in the developing countries, with environmental predisposition to hot humid climate, dehydration and toxic metal contaminations. The aim was to identify the frequency of CKDu as an etiology in a rural population with environmental exposure.

Method

In this observational study subjects were selected from a geographically defined rural population in Bangladesh. Baseline information was recorded by the translated WHO STEP wise approach surveillance- Instrument v.3.1 (Core and Expanded). Blood Pressure was measured by digital blood pressure monitor. Serum creatinine was measured by enzymatic method using assays traceable to isotope dilution mass spectrometry (IDMS). A fasting blood sample and spot urine was collected. BP ≥140/90mmHg; FBS &gt; 5.6 mmol/l and HbA1c ≥6.5%; and eGFR&lt; 60ml/min (CKD-EPI equation) or urine ACR &gt; 30mg/g was taken as diagnostic cut-offs for hypertension, diabetes and nephropathy respectively. From diagnosed CKD patients CKDu group was further identified by stepwise approach of WHO criteria as suspected and probable stages.

Results

The mean age was 41.3 ± 12.7 years with male/female ratio 37/63 in preliminary 303 study subjects. They were 12.5% diabetic, 21% hypertensive and 75% had some form of dyslipidemia. Among all 51 subjects (16.8%) were diagnosed as CKD based on single measurement of eGFR and ACR. Of these 30 study subjects (58%) met the criteria of suspected CKDu. After repeat measures of eGFR and ACR at 3 months, prevalence of CKD came down to 10.2% persisting in 31 subjects (G1:5.3%, G2:2.3% and G3: 2.6%). Of these 7 study subjects (23%) met the criteria of probable CKDu. The main etiologies of CKD among these subjects were diabetic nephropathy (48%) followed by CKDu. The frequency of CKDu in total study population as a whole was 2.3%.The pattern of environmental exposures like types of farming, use of pesticide-fertilizer, NSAIDs intakes, water sources, amount of drinking water per day, duration of work under direct sun, pattern of fish-meat intakes, etc. were not different between subjects with CKDu versus the others.

Conclusion

The prevalence of chronic kidney disease in a rural area of Bangladesh is one in ten (10.2%). Among these nearly one-fourth (23%) of the subjects belonged to probable CKDu category. This alarmingly high frequency of CKDu needs further extensive evaluation to identify the predisposing factors responsible.

Effect of vitamin D on bone strength in older African Americans: a randomized controlled trial

There is controversy over whether African Americans have higher vitamin D requirements than recommended by the Institute of Medicine. We previously reported that maintaining serum 25(OH)D above 30 ng/mL does not prevent age-related bone loss. Herein, we report that bone strength is also unaffected by maintaining this level in this population.

INTRODUCTION

The role of vitamin D in bone strength has not been investigated in the African American (AA) population.

METHODS

A 3-year randomized controlled trial was designed to examine the effect of vitamin D supplementation on physical performance, bone loss, and bone strength in healthy older AA women. A total of 260 postmenopausal AA women, ages ≥ 60 years were randomized to a vitamin D₃ or placebo arm. Vitamin D₃ dose was adjusted to maintain serum 25OHD > 30 ng/mL. Bone mineral density, femoral axis length, and femoral neck (FN) width were measured by dual-energy X-ray absorptiometry. Composite indices of FN strength [compression strength index (CSI), bending strength index (BSI), and impact strength index (ISI)] were computed.

RESULTS

The mean age of participants was 68.2 ± 4.9 years. Baseline characteristics between groups were similar. The average dose of vitamin D₃ was 3490 ± 1465 IU/day in the active group. The mean serum 25OHD was 46.8 ± 1.2 ng/mL versus 20.7 ± 1.1 ng/mL in the active versus placebo group. Serum 25OHD did not correlate with any composite indices. The longitudinal differences observed in FN width, CSI, BSI, and ISI in both groups were not statistically significant (all p values > 0.05). Further, there was no group × time interaction effect for any of the composite indices (all p values > 0.05).

CONCLUSION

Maintaining serum 25OHD > 30 ng/mL (75 nmol/L) does not affect bone strength in older AA women. There is no evidence to support vitamin D intake greater than the recommended RDA by the Institute of Medicine in this population for bone strength.

A Machine Learning Enabled Wireless Intracranial Brain Deformation Sensing System

A leading cause of traumatic brain injury (TBI) is intracranial brain deformation due to mechanical impact. This deformation is viscoelastic and differs from a traditional rigid transformation. In this paper, we describe a machine learning enabled wireless sensing system that predicts the trajectory of intracranial brain deformation. The sensing system consists of an implantable soft magnet and an external magnetic sensor array with a sensing volume of 12 × 12 × 4 mm³. Machine learning algorithm predicts the brain deformation by interpreting the magnetic sensor outputs created by the change in position of the implanted soft magnet. Three different machine learning models were trained on calibration data: (1) random forests, (2) k-nearest neighbors, and (3) a multi-layer perceptron-based neural network. These models were validated using both in vitro (a needle inserted into PVC gel) and in vivo (blast exposure to live and dead rat brains) experiments. The in vitro gel deformation predicted by these machine learning models showed excellent agreement with the camera measurements and had absolute error = 138 μm, Fréchet distance = 372 μm with normalized Procrustes disparity = 0.034. The in vivo brain deformation predicted by these models had absolute error = 50 μm, Fréchet distance = 95 μm with normalized Procrustes disparity = 0.055 for dead animal and absolute error = 125 μm, Fréchet distance = 289 μm with normalized Procrustes disparity = 0.2 for live animal respectively. These results suggest that the proposed machine learning enabled sensor system can be an effective tool for measuring in situ brain deformation.

Association of Hyperbilirubinemia Requiring Phototherapy or Exchange Transfusion with Hearing Impairment among Admitted Term and Late Preterm Newborn in a NICU

Hearing impairment is one of the deleterious ramifications of neonatal hyperbilirubinemia, but its impact during the newborn period has not been well studied in Bangladesh. This prospective observational study was conducted during January 2016 to December 2017 in the Department of Neonatology and Otolaryngology-Head and Neck Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh to identify the relationship between hyperbilirubinemia requiring phototherapy or exchange transfusion with hearing impairment in term and late preterm neonates. Admitted term and late preterm neonates with hyperbilirubinemia requiring either phototherapy or exchange transfusion were taken as hyperbilirubinemia group. Neonates without hyperbilirubinemia from postnatal ward were taken as control. All newborn were screened with Distortion Product Otoacoustic Emissions (DPOAE) prior to discharge from hospital. A second screen was done in referred newborn after one month of first screen. A diagnostic Auditory Brainstem Response (ABR) was performed in both the ears prior to 3 months of postnatal age if referred in both 1st and 2nd screen. Total 264 neonates included in this study; 132 in the hyperbilirubinemia and 132 in the control group. In the hyperbilirubinemia group 74(56.06%) were male and 58(43.94) were female. Mean gestational ages in the hyperbilirubinemia group and control group were 36.95±1.60 weeks and 37.01±1.67 weeks respectively. Newborn in the hyperbilirubinemia group, 4(3.03%) had hearing impairment and none had hearing impairment in the control group. Peak Total Serum Bilirubin (TSB) 23mg/dl was found as best cut off value with a sensitivity of 100% and specificity of 93% for the development hearing impairment. Hearing impairment was significantly more frequent among newborn with TSB level >23mg/dl when compared to those having TSB level ≤23mg/dl (20% vs. 0.9%, p=0.009; OR=29, 95% CI 2.79, 301). Hearing impairment was associated with newborns with hyperbilirubinemia requiring phototherapy or exchange transfusion. Peak TSB level >23mg/dl can be predictive for the development of hearing impairment.

Proton pump inhibitors and histamine-2 receptor antagonists on the risk of pancreatic cancer: a systematic review and meta-analysis

BACKGROUND

Proton pump inhibitors (PPI) and histamine-2 receptor antagonists (H2RA) have been widely used for multiple purposes. Recent studies have suggested an association between these medications and the risk of pancreatic cancer. However, the results have been inconclusive.

AIM

We, therefore, conducted a study to assess the risk of developing pancreatic cancer in patients who used PPI and H2RA.

DESIGN

A systematic review and meta-analysis.

METHODS

A literature search was performed using MEDLINE and EMBASE databases from inception through February 2019. Studies that reported risk ratio comparing the risk of pancreatic cancer in patients who received PPI or H2RA versus those who did not receive treatments were included. Pooled risk ratios (RR) and 95% confidence intervals (CI) were calculated using a random-effect generic inverse variance method. Sensitivity analysis, excluding one study at a time, was performed.

RESULTS

After screening abstracts from the searching methods, seven studies (six case-control studies and one cohort study) were included in the analysis with total 546 199 participants. Compared to patients who did not take medications, the pooled RR of developing pancreatic cancer in patients receiving PPI and H2RA were 1.73 (95% CI: 1.16-2.57) and 1.26 (95% CI: 1.02-1.57), respectively. However, the sensitivity analysis of PPI changed the pooled RR to 1.87 (95% CI: 1.00-3.51) after a study was dropped out. Likewise, H2RA sensitivity analysis also resulted in non-significant pooled RR.

CONCLUSIONS

This meta-analysis did not find the strong evidence for the associations between the use of PPI and H2RA and pancreatic cancer.

Financial support to the poor for the detection of smear-negative pulmonary and extra-pulmonary TB in Bangladesh

BACKGROUND: The study was conducted in BRAC-administered areas of the Bangladesh National Tuberculosis (TB) Programme (42 of 64 districts). According to the 2013-2017 financial support scheme, direct costs due to TB diagnosis were reimbursed among economically disadvantaged people with presumptive smear-negative pulmonary (PTB) and extrapulmonary TB (EPTB).OBJECTIVE: To describe the implementation of the scheme and associated changes in case notification.DESIGN: This was a descriptive study involving programme data.RESULTS: Between 2013 and 2017, persons reimbursed reduced from 125 680 to 88 763, and the case detection ratio increased from 18% to 24%. The number of patients with presumptive EPTB who were reimbursed decreased from 5024 to 3484. More than 95% were reimbursed for chest radiograph, fine-needle aspiration cytology and biopsy. However, large numbers of ancillary investigations were also reimbursed. During 2013-2017, the observed national quarterly new smear-negative PTB case notification rates (CNRs) were significantly higher than the forecasted CNRs (based on CNR trends during 2008-2012). New EPTB and all form TB CNRs increased but not significantly.CONCLUSION: Implementation of the financial support scheme was accompanied by a significant improvement in new, smear-negative PTB notification. The absence of a comparison arm was a key limitation, but comparison was not possible as the scheme was implemented in all districts.

An Ultrasonically Powered Implantable Microprobe for Electrolytic Ablation

Electrolytic ablation (EA) is a promising nonthermal tumor ablation technique that destroys malignant cells through induction of a locoregional pH change. EA is typically performed by inserting needle electrodes inside the tumor followed by application of direct current (DC), thus inducing electrolysis and creating localized pH changes around the electrodes. In this paper, we report an ultrasonically powered implantable EA microprobe that may increase the clinical relevance of EA by allowing wireless control over device operation (capability to remotely turn the device on and off) and providing flexibility in treatment options (easier to administer fractionated doses over a longer period). The wireless EA microprobe consists of a millimeter-sized piezoelectric ultrasonic receiver, a rectifier circuit, and a pair of platinum electrodes (overall size is 9 × 3 × 2 mm³). Once implanted through a minimally invasive procedure, the microprobe can stay within a solid tumor and be repeatedly used as needed. Ultrasonic power allows for efficient power delivery to mm-scale devices implanted deep within soft tissues of the body. The microprobe is capable of producing a direct current of 90 µA at a voltage of 5 V across the electrodes under low-intensity ultrasound (~200 mW/cm²). The DC power creates acidic (pH < 2) and alkaline (pH > 12.9) regions around the anode and the cathode, respectively. The pH change, measured using tissue-mimicking agarose gel, extends to 0.8 cm³ in volume within an hour at an expansion rate of 0.5 mm³/min. The microprobe-mediated EA ablative capability is demonstrated in vitro in cancer cells and ex vivo in mouse liver.

Neuro-Imaging Changes in Cerebral Palsy: A Cross Sectional Study

Cerebral palsy (CP) is a non- progressive disorder of movement and posture due to a lesion of the developing brain. It is the commonest physical disability in childhood that affects function and development. Neuro imaging is currently recommended as a standard evaluation in children with cerebral palsy. This hospital based cross-sectional study was conducted in Paediatric Neurology out-patient department of Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from July 2015 to December 2015 to see the frequency and pattern of neuro-imaging findings in children with cerebral palsy. A total of 130 cases those who were attended and diagnosed as cerebral palsy based on history, clinical examination and neuro developmental assessment included in this study. All patients were sent to radiology & imaging department of same hospital for CT scan of brain. Among total 130 cerebral palsy patients male were more affected than female (88 boys and 42 girls) with male to female ratio 2.09: 1. Their ages ranged between 6-72 months with a mean age 25.6 months. The commonest age group was 6-24 months (46.9%). Common mode of delivery was normal vaginal delivery (62.3%) & Perinatal asphyxia (PNA) occurred in 66.9% cases. The commonest type of cerebral palsy was spastic form. Among them most cases were quadriplegic type, 64 cases (53.3%). Other cases were hemiplegic 27(20.7%) diplegic 13(10.0%). Total 84.7% had documented cerebral neuroimaging abnormalities; among them, diffuse cortical atrophy (46.9%), encephalomalacic change (19.9%), malformation (6.1%), and calcification (5.3%). CT scan was normal in 15.3% cases of cerebral palsy. The commonest co morbidity was speech delay (50%). Most of the patient with CP had abnormal CT scan finding though some patient had normal CT scan. Diffuse cerebral atrophy and encephalomalacic changes constitute frequent CT neuroimaging findings and commonly found in quadriplegic type of cerebral pulsy patients. Though diagnosis of cerebral palsy is essentially clinical, neuro imaging improves the understanding of the neuro-anatomical basis for function in CP. Etiology, type of CP and extent of motor impairments can easily be identified by the neuro imaging.

Association of Estimated GFR (By MDRD) with the Carotid Intima Media Thickness (CIMT) in Different Stages of CKD among Patients with Type 2 Diabetes Mellitus

Most of the mortalities among Diabetic Nephropathy patients are cardiovascular, if we identify the risk factor, measures can be taken to prevent it. Hence an objective was set to evaluate the association between carotid artery intima media thickness (CIMT) with eGFR in patients of CKD stage III, IV and V among patients with type 2 diabetes mellitus; also, correlation with age, BMI, lipid profile. This cross-sectional, observational study was performed in 70 patients in different stages of CKD in Diabetic Patients selected by Inclusion Criteria (Diabetic nephropathy patients with stages III, IV, V and exclusion Criteria (Acute kidney injury, History of carotid surgery, Patients of MI and stroke). This study was performed in Department of Nephrology, Dhaka Medical College in collaboration with the Department of Radiology and Imaging, laboratory of Department of Biochemistry and Department of Microbiology at Dhaka Medical College Hospital (By standard method in laboratory) from 1st January 2016 to 31st December 2016. eGFR was measured by MDRD formula and the CIMT was measured using an ultrasonographic examination. The mean CIMT was 0.9±0.21mm, and 62.9% of the subjects showed IMT thickening (≥1mm). The carotid IMT elevated significantly with the stage progression of CKD (Overall eGFR mean 28.8±14.5mL/min/1.73m² in CIMT<1mm with range from 6 to 54 and 9.1±9.0mL/min/1.73m² in CIMT ≥1mm with range from 3 to 32 (p=0.001). The eGFR was significantly lower in the patients with CIMT thickening than those without CIMT thickening. eGFR was also significantly associated with CKD stages (p=0.001), serum creatinine (p=0.001), BMI (r = -0.330, p=0.005), and negatively associated with age group, duration of hypertension, smoking. However, the CIMT was not significantly different among the patients at different stages of diabetic nephropathy (r = -0.172, p=156) and age group. It has been concluded that the mean CIMT was markedly high in patients with CKD compared to normal expected value. This study showed a relationship between the CIMT and the renal parameters as eGFR and the stages of diabetic nephropathy with a confirm association between the CIMT and diabetic macroangiopathy.

Environmentally-friendly thermal and acoustic insulation materials from recycled textiles

Continuing increase in energy consumption and environmental pollution are some of the main challenges of the 21st century. One of the approaches to overcome these challenges is to increase the use of recycled materials and environmentally-friendly approaches to manufacturing. Thermal and acoustic insulation in buildings and transport vehicles from recycled textiles can play an important role in energy savings and reduction of environmental pollution. Textiles contribute a significant amount to the waste stream since most of these valuable fiber products are discarded after use. These discarded but valuable textiles can be recycled to produce several products including thermal and acoustic insulation materials. In this paper, a comprehensive review of the current state of textile waste generation and its environmental effects, and present progress of using industrial and post-consumer recycled textiles in insulation materials is provided. Mechanism of acoustic and thermal insulation materials of textile fibers are also reviewed. Existing research of some textile waste used as building insulation materials, method of conversion of textile waste into building insulation materials, comparative analysis of different insulation materials and life cycle assessment of textile fibers are assessed.

P4755Sex differences in admission rates, use of anticoagulation, and outcomes for emergency department presentations of atrial fibrillation

Background

Studies in non-Emergency Department (ED) settings have shown women with non-valvular atrial fibrillation (NVAF) differ in presentation, treatment, and outcomes compared to men. Despite AF being a common reason for ED visit, little is known regarding sex differences in patients presenting to ED.

Purpose

We sought to determine whether sex differences exist in rates of admission among NVAF patients presenting to the ED and if oral anticoagulant (OAC) use and outcomes differ by ED discharge status.

Methods

Patients≥18 years old, presenting to the ED with incident NVAF in two western Canadian provinces (Alberta and British Columbia) from April 2012 to March 2015 were included. ED records were linked to hospital records to identify patients admitted to hospital versus discharged from the ED. Outcomes of interest were 30-day mortality and 1-year stroke, heart failure (HF) and mortality. Pharmaceutical claims were queried for OAC use within 90 days following NVAF ED event.

Results

Of 16,991 ED NVAF patients, 7,770 (46%) were women and 9,221 (54%) were men (p<0.001). Compared to men, women were older (73.9 vs 65.6 years, p<0.001) and presented with higher CHA2DS2-VASc scores (4.0 vs 2.0, p<0.001). Overall, 41% of women and 37% of men were admitted to hospital (p<0.001). OAC rate was 50% among admitted and 37% among discharged (p<0.001). OAC rates were 53% in women and 48% in men among admitted (p<0.001), and 39% in women and 35% in men among discharged (p<0.001). OAC rates were higher in patients with CHA2DS2-VASc ≥1 who were admitted (53% in women (n=2,781) and 52% in men (n=2,683), p=0.63) than in those who were discharged (39% in women (n=4,435) and 45% in men (n=3,866), p<0.01). Women had higher rates of mortality at 30-days and 1-year, and stroke at 1-year compared to men, irrespective of ED discharge status (all p<0.02). Women admitted had higher HF rates at 1-year compared to men (p=0.002). (Table)

Outcomes by Sex and ED Discharge Status Outcome Discharged Admitted Women (N=4,560) Men (N=5,780) p-value Women (N=3,210) Men (N=3,441) p-value 30 Day Mortality, n (%) 63 (1.4) 50 (0.9) 0.01 261 (8.1) 228 (6.6) 0.019 1 Year Mortality, n (%) 270 (5.9) 248 (4.7) <0.001 717 (22.3) 604 (17.6) <0.001 Stroke*, rate (SE) 1.7 (0.19) 0.9 (0.13) <0.001 4.0 (0.37) 2.6 (0.28) 0.001 Heart Failure*, rate (SE) 3.6 (0.28) 3.1 (0.23) 0.16 12.9 (0.62) 10.4 (0.54) 0.002 *Censored on death.

Conclusions

In this population-based study of patients presenting to ED with NVAF, we found women were more likely to be admitted to hospital than men. Women had a worse prognosis than men, irrespective of ED discharge status. Use of OAC was suboptimal, regardless of patient sex.

Acknowledgement/Funding

Heart and Stroke Foundation of Canada, UBC Cardiology, Servier Alberta Innovation Health Fund

Implementation of screening and management of household contacts of tuberculosis cases in Daru, Papua New Guinea

SETTING

Daru Island, Western Province, Papua New Guinea (PNG).

OBJECTIVE

To describe the implementation of a screening programme for household contacts of tuberculosis (TB) cases residing on Daru Island.

DESIGN

This was a retrospective descriptive study evaluating two periods of implementation: introduction and expansion of a screening programme for household contacts of drug-resistant TB (DR-TB) cases (March 2016 to September 2017), and inclusion of drug-susceptible TB (DS-TB) cases with provision of preventive therapy for eligible contacts between October 2017 and March 2018.

RESULTS

In the first period, the contact screening programme was established and strengthened by increasing coverage over time. There was a large number of contacts (median 8) in each household, and a high uptake of screening. In the second period of evaluation, respectively 412 and 223 contacts of 42 DS-TB and 25 DR-TB index cases were screened. Overall, 156 (24.6%) contacts reported TB-related symptoms and 9 (1.4%) were diagnosed with active TB. All 9 commenced TB treatment: 5 had DS-TB and 4 had DR-TB. Of 82 child contacts of DS-TB cases eligible for preventive therapy, 57 (69.5%) commenced treatment and 45 completed treatment.

CONCLUSION

Community-based household contact screening and management was successfully implemented under programme conditions in this high burden TB and DR-TB setting in PNG.

A pilot model of patient education and counselling for drug-resistant tuberculosis in Daru, Papua New Guinea

Education and counselling for people with drug-resistant tuberculosis (DR-TB) is recommended by the World Health Organization, given the arduous treatment journey. A model of education and counselling involving counsellors and peer counsellors, standard sessions and novel education tools was piloted in the high DR-TB burden context of Daru, Papua New Guinea. The pilot contributed to high retention in care, highlighting the need for investment in scalable models. Future models will need to be adapted as better tolerated regimens are introduced. A focus on patient-centred care requires prioritisation in order to meet the End TB Strategy targets.

Does Time Since Injury and Time Spent in Physical Therapy Treatment Affect Outcomes for Concussion Patients?

Purpose

To evaluate the effects of: 1) time between injury and physical therapy treatment and 2) time spent in physical therapy, on concussion symptom resolution.

Methods

Retrospective data was obtained for 202 patients who sustained a concussion and were referred for physical therapy. Subjects were assigned to groups based on type of injury (sport-related or not), time elapsed between concussion and therapy (0-14 days, 15–30, 31–60, 61–120, 121–365), and months spent in treatment (1 thru 4). Pre- and post- treatment scores were compared for the following measures: Sport Concussion Assessment Tool (SCAT), Convergence Insufficiency Symptom Survey (CISS), Dizziness Handicap Inventory (DHI), and Modified Clinical Test of Sensory Interaction on Balance (mCTSIB) using ANOVAs, with a Bonferroni-corrected p-value of p<.005.

Results

There was no significant difference in outcomes for athletes vs. non-athletes on SCAT Symptom (p=.74) or Severity Score (p=.18), CISS (p=.52), DHI (p=.05), or mCTSIB (p=.10); in outcomes for time elapsed since injury on SCAT Symptom Score (p=.80), SCAT Symptom Severity Score (p=.97), CISS (p=.61), DHI (p=.65), mCTSIB (p=.13); or in outcomes for months in treatment on SCAT Symptom Score (p=.23), SCAT Symptom Severity Score (p=.04), CISS (p=.41), DHI (p=.37), mCTSIB (p=.50).

Conclusion

Post-therapeutic improvements were noted for athletes receiving post-concussive physical therapy. Type of injury, time between injury and treatment, and time spent in treatment did not differentiate treatment outcomes for those receiving physical therapy post-concussion.

Association of Serum Vitamin D (25OHD) Level with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Acute exacerbations of COPD is characterized by a change in the patients baseline dyspnoea, cough and/or sputum that is beyond normal day to day differences and guides to a change in standard medications in a patient with COPD. Vitamin D influences the innate & adaptive immune system, and exerts pleiotropic antimicrobial and anti-inflammatory responses. Vitamin D deficiency is frequent among COPD patients but its contributory role in disease exacerbations is widely debated. This study was aimed to assess relationship between reduced serum vitamin D (25-OHD) level with COPD severity and acute exacerbation. This observational cross-sectional study was carried out in the department of Respiratory Medicine, NIDCH, Mohakhali, Dhaka, Bangladesh from October 2016 to September 2017. Consecutive 80 hospital admitted patients with acute exacerbation of chronic obstructive pulmonary disease diagnosed on the basis of clinical history & pulmonary function tests and 78 age & sex matched controls were investigated for serum vitamin D (25-OHD) level. Among the COPD patients, 37% had Vitamin D deficiency (<20ng/ml) and 28.75% had Vitamin D insufficiency (20-29ng/ml). Mean vitamin D (25-OHD) level of COPD patients (25.82±10.62ngm/ml) was found to be significantly lower than healthy controls (32.57±11.32ngm/ml). Vitamin D deficiency was found, by Pearson correlation test, to be significantly associated with severity of COPD. Multivariate analysis showed that age (in years), FEV1 (percent predicted), frequent exacerbators (≥2 in the last year), and smoking (>40 pack year) were significantly associated with Vitamin D deficiency. Acute exacerbation of chronic obstructive pulmonary disease patients was found to have vitamin D deficiency and vitamin D deficiency was significantly associated with severity of COPD. Vitamin D deficiency was also associated with frequent disease exacerbation.

Comparative metabolomic profiling in the roots and leaves in contrasting genotypes reveals complex mechanisms involved in post-anthesis drought tolerance in wheat

Understanding the contrasting biochemical changes in different plant parts in response to drought can help to formulate smart strategies to develop drought tolerant genotypes. The current study used metabolomics and physiological approaches to understand the differential biochemical changes coupled with physiological adjustments in leaves and roots to cope with drought stress in two wheat genotypes, LA754 (drought tolerant) and AGS2038 (drought sensitive). The gas chromatography-mass spectrometry (GC-MS) analysis and physiological trait estimation were performed in the roots and leaves after drought imposition. Drought induced reduction was observed in all physiological and yield related traits. In LA754, higher numbers of metabolites were altered in leaves (45) compared to roots (20) which indicates that plants allocated more resources to leaves in tolerant genotype. In addition, the metabolic components of the root were less affected by the stress which supports the idea that the roots are more drought tolerant than the leaf or shoot. In AGS2038, thirty and twenty eight metabolites were altered in the leaves and roots, respectively. This indicates that the sensitive genotype compromised resource allocation to leaves, rather allocated more towards roots. Tryptophan, valine, citric acid, fumaric acid, and malic acid showed higher accumulation in leaf in LA754, but decreased in the root, while glyceric acid was highly accumulated in the root, but not in the leaf. The results demonstrated that the roots and shoots have a different metabolic composition, and shoot metabolome is more variable than the root metabolome. Though the present study demonstrated that the metabolic response of shoots to drought contrasts with that of roots, some growth metabolites (protein, sugar, etc) showed a mirror increase in both parts. Protein synthesis and energy cycle was active in both organs, and the organs were metabolically activated to enhance water uptake and maintain growth to mitigate the effect of drought.

Outcome of Single Stage Correction of High Variety of Anorectal Malformation

The standard treatment of high variety anorectal malformation (ARM) is the staged approach. A growing interest in one stage correction of high variety ARM was noted recently. The aim of this study was to examine the feasibility, safety and outcome of single stage correction of High variety ARM. This prospective study was carried out in the Department of Paediatric Surgery, Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh from July 2012 to September 2013. It was conducted among 30 patients, all having high ARM. The type of ARM was diagnosed by clinical examinations and imaging studies like Invertogram and Transperineal USG. Other associated congenital anomalies were excluded. Out of 30 patients 11(36.67%) were male and 19(63.33%) were female. The age incidence ranges from 2 days to 5 months with the mean±SD age 1.70±1.63 months. The type of fistula present along with ARM in male varies from rectobulber urethral fistula, recto prostatic urethral fistula, recto vesical fistula and in one case without any fistula. Type of fistula was rectovestibular, rectovaginal and one cloacal malformation among the female patients. The treatment modalities in male patients vary in transabdominal pull through anorectoplasty and PSARP, in which the former was done more (72.73%). In case of female patients, treatment modalities vary in transabdominal pull through and anorectoplasty and transfistulous anorectoplasty, with the later done more (52.63%). Regarding post operative complications, there was 1(14.29%) wound infection in male and 1(33.33%) in female, partial wound disruption in 1(14.29%) male patient, mucosal prolapse 2(28.57%) in male and 1(33.33%) in female, anal stenosis 1(14.29%) in male and 1(33.33%) in female, perianal soiling in 1(14.29%) male patient. All the complications were treated by adopting various measures. One stage correction of High variety ARM in both male and female patients is technically feasible. The safeties of this approach depend on the adherence to strict inclusion criteria. The early post operative complications are acceptable and can be managed successfully.

Extranodal lymphoma of the tongue, a very rare entity-report of two cases with literature review

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The extranodal lymphoma of the base of the tongue is extremely rare.

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Among the lymphoma of the tongue; B cell lymphoma is more common than T cell lymphoma.

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It should be included in the differentials in patients with tumors arising from this site.

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Early detection and treatment can often result in a complete cure and a better long-term survival.

Background

Lymphomas are malignant neoplasms of the lymphocyte cell lines affecting the lymph nodes, spleen and other nonhemopoietic tissues. Of the extranodal lymphomas found in the head and neck region, 3–5% of malignant lymphomas arise in the oral and paraoral region, mainly from Waldeyer's ring. The involvement of the base of the tongue is extremely rare.

Summarised Case

Case 1: 64 year old female who presented initially with an enlarged occipital lymph node which gradually became generalized cervical lymphadenopathy with initial histology confirmed reactive lymphoid hyperplasia. Biopsy of left postero-lateral tongue lesion eventually showed high grade T cell lymphoma.

Case 2: 85 year old male presented with history of dysphagia for one year who was found to have a lesion extending from his base of tongue into the nasopharynx. Histology showed a diffuse B cell lymphoma.

Discussion

Both patients were noted to have lesion of the tongue, but tongue lesions are noted in the literature to be extremely rare. When tongue lymphomas do occur, most are of B-cell origin; the diffuse large-cell variety is the most common. Extranodal lymphomas of the T cell phenotype tend more to be sinonasal in origin than of the tongue, with T cell lymphomas of the tongue being even rarer than B cell lymphomas.

Conclusion

With regards to tumours arising in the tongue, squamous cell carcinomas are still classified as the most common. Lymphomas however, should still be kept in consideration as a differential diagnosis with regards to lesions arising from this site.