Enzymatic quantification of total serum bile acids as a monitoring strategy for women with intrahepatic cholestasis of pregnancy receiving ursodeoxycholic acid treatment: a cohort study

OBJECTIVE

To evaluate enzymatic total serum bile acid quantification as a monitoring strategy for women with intrahepatic cholestasis of pregnancy (ICP) treated with ursodeoxycholic acid (UDCA).

DESIGN

Cohort.

SETTING

One UK university hospital.

POPULATION

29 ICP cases treated with UDCA.

METHODS

Serial samples were collected prospectively throughout gestation. Total serum bile acids were measured enzymatically and individual bile acids by high-performance liquid chromatography-tandem mass spectrometry. Data were log-transformed and analysed with random effects generalised least square regression.

MAIN OUTCOME MEASURES

The relationship between enzymatic total bile acid measurements and individual bile acid concentrations after UDCA treatment.

RESULTS

In untreated women, cholic acid was the principal bile acid (51%) and UDCA concentrations were <0.5%, whereas UDCA constituted 60% (IQR 43-69) of serum bile acids following treatment and cholic acid fell to <20%. Changes in the total bile acid measurement reflected similar alterations in the concentrations of the pathologically elevated bile acids, e.g. a two-fold increase in enzymatic total bile acids is accompanied by approximately a two-fold increase in cholic acid and chenodeoxycholic acid at most UDCA doses (P < 0.001). Most of the effects of UDCA on cholic acid occur in the first week of treatment (60% relative reduction, P = 0.025, 95% CI 0.2-0.9, from 10 micromol/l (4.7-17.6) to 3.5 micromol/l (1.4-7.5).

CONCLUSION

Ursodeoxycholic acid becomes the main component of the bile acid measurement after treatment. Enzymatic total bile acid assays are good predictors of both cholic acid and chenodeoxycholic acid, the primary bile acids that are raised prior to treatment.

TWEETABLE ABSTRACT

Ursodeoxycholic acid constitutes approximately 60% of the bile acid measurement and reduces pathological cholic acid in treated women.

Serum Calcium Level in Preeclamptic Patients of Bangladesh

Preeclampsia is one of the most frequent complication of pregnancy which manifested by hypertension during pregnancy for the first time after 20th weeks of gestation with proteinuria. The aim of the study was to estimate the changes in serum calcium level in preeclamptic patients when compared with normal pregnant women. The case control study was carried out in the Department of Biochemistry, Mymensingh Medical College, Mymensingh, Bangladesh in collaboration with the Department of Obstetrics and Gynecology, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from July 2016 to June 2017. A total of 100 subjects were included. Among them 50 were subjects of preeclamptic patients as case and another 50 were apparently healthy normal pregnant women as control. The study revealed that serum calcium level was lower in preeclamptic women (case) as compared to healthy control subjects. The mean values of serum calcium levels were 7.63±0.42 and 8.12±0.94mg/dl in case and control group respectively. The difference in mean serum calcium were highly significant (p<0.001) when compared between case and control.

Transmigrated and Impacted Upper 2nd Premolar Associated with Dentigerous Cyst

A male patient about 45 years old came to my private clinic "The Dental Aid", Dhanmondi, Dhaka, Bangladesh last year (February 2016) with the complaint of pain at right palatal premolar region. On clinical examination we found the absence of upper left 2nd premolar from the series of dentition but on the right side premolars are present. The oral mucosa was intact and normal in color. There was no caries, dental pocket or any other pathology in the teeth of both jaws. On palpation we found soft area on the right palatal side at the premolar area. We took intraoral peri-apical radiograph and found impacted left 2nd premolar whose crown was encircled by radiolucent area at the palatal side. Here, we present a rare case of transmigrated and impacted left 2nd maxillary premolar associated with dentigerous cyst. The cyst was successfully treated under general anaesthesia by enucleation along with extraction of the involved maxillary transposed and impacted left second premolar.

Comparison between Carbetocin and Oxytocin in Active Management of 3rd Stage of Labour in Preventing Post Partum Hemorrhage

The third stage of labour is considered to be the most critical part of child birth due to the risk of post partum haemorrhage (PPH). To compare the effectiveness of carbetocin and oxytocin in the management of 3rd stage of labour in preventing post partum hemorrhage, this experimental clinical trial was conducted in the Department of Obstetrics and Gynecology, Sir Salimulla Medical College Hospital, Dhaka, Bangladesh from January 2015 to June 2016. Three hundred women undergoing normal vaginal delivery were consecutively enrolled. They were divided into two groups, one group was treated with carbetocin 100μg IV and another group was treated with oxytocin 10 unit IV. Post partum haemorrhage was developed in 23(15.3%) and 31(20.7%) patients in carbetocin and oxytocin groups respectively. Among these PPH patients, 17(73.9%) patients received oxytocin, 21(91.3%) patients received Ergometrin and 14(60.9%) patients received misoprostol in carbetocin group as additional drug. In oxytocin group 30(96.8) patients received ergometrin and 26(83.9) patients received misoprostol. Significantly higher number of patients was treated with balloon catheter in oxytocin group (77.4%) than carbetocin group (39.1%). Thirteen (41.9%) patients in oxytocin group and 4(17.4%) patients in carbetocin group needed to treat in ICU. In carbetocin Group I patient (4.3%) and in oxytocin Group II patients (6.5%) died. carbetocin is better than oxytocin in the management of 3rd stage of labour to prevent post partum haemorrhage (PPH).

Neonatal Glycemic Status of Infants of Diabetic Mothers in a Tertiary Care Hospital

BACKGROUND

Diabetes is a common medical complication during pregnancy that results in significant neonatal morbidities. In infants of diabetic mothers (IDMs), hypoglycemia is a common complication.

OBJECTIVE

To study the neonatal hypoglycemia in IDMs in a tertiary care hospital.

SETTINGS AND DESIGN

A cross-sectional study was done in postnatal ward in Bangladesh Institute of Research and Rehabilitation in Diabetic, Endocrine and Metabolic Disorders from January to December 2009.

SUBJECTS AND METHODS

The data of IDMs were collected from postnatal ward. All IDMs delivered during this period staying in postnatal ward were included in this study. The outcomes were compared between the hypoglycemic and normoglycemic IDMs and between gestational diabetes mellitus (GDM) and pre-GDM in hypoglycemic group using Chi-square test and Fisher's exact test. The data analysis was performed with Epi-enfo7 software. Statistical significance was set at P < 0.05.

RESULTS

A total of 363 IDMs were included in this study. Hypoglycemia developed in 38.3% IDMs and 43.2% mothers of hypoglycemic IDMs had GDM and 56.8% had pre-GDM. Duration of maternal diabetes (P = 0.04) and large for gestational age (P = 0.0001) were associated with hypoglycemia. Multigravidae (82.2% vs 68.3%, P = 0.03), prolonged duration of maternal diabetes (45.46 weeks vs 3.23 weeks, P = 0.00001), preterm babies (48.1% vs 28.3% P = 0.009), and control of diabetes by insulin (81% vs 46.7%, P = 0.001) were more in pre-GDM, and statistically significant. About 85% IDMs developed hypoglycemia within 6 h of birth (P-value 0.00001) and majority (68%) were at 2 h of age. Forty percent of hypoglycemic IDMs from postnatal ward were admitted in special care baby unit.

CONCLUSION

Hypoglycemia observed in 38.3% IDMs and developed within 6 h of age and maximum were at 2 h. Early recognition and appropriate intervention are needed in IDMs.

Alternating Hemiplegia of Childhood: Report of Two Cases

Alternating hemiplegia of childhood (AHC) is a rare disorder which presents before 18 months of age characterized by repeated attacks of hemiplegia involving either side of the body, paroxysmal disturbances,developmental delay and learning disability. The cause of AHC remains largely unknown and treatment evidence is less available. AHC is unreported in Bangladeshi literature. We report two cases of AHC. Our first case is a 16-month-old girl who presented with hemiplegia in alternate side for four episodes. She also had abnormal body movement and irritability during awakening. Every episode subsided spontaneously after 2 to 5 days. All investigations were normal except iron deficiency anemia. She was treated with flunarizine. Our second case, a 7 year and 10 month-old boy presented with recurrent alternate hemiplegia since 3½ years of age with epilepsy. His attacks were precipitated in high temperature. His EEG was abnormal. He was treated with multiple antiepileptic drugs and flunarizine. These are first two cases reported from Bangladesh. AHC remains undiagnosed in many cases. So a detailed history and diagnostic evaluation is very important for early counseling and treatment.J Enam Med Col 2018; 8(1): 46-49

Non-convulsive Status Epilepticus in Children: Clinical Profile, EEG Characteristics and Treatment

Non-convulsive status epilepticus (NCSE) is a term used to denote a range of conditions in which electrographic seizure activity is prolonged and results in non-convulsive clinical symptoms. This study was done to describe the clinical spectrum, EEG findings and to evaluate the efficacy of different therapeutic agents in children with NCSE in 33 patients from January 2011 to December 2015 period. All patients had EEG before and after treatment. Age range was 6 months to 14 year, 25 were male. Regarding development status, 48% had developmental delay, 21% had normal development, 9% had regression and 21% had both developmental delay and regression. Twenty nine cases were previously diagnosed as epilepsy. EEG diagnosis was as follows: Generalized NCSE 23(69%), focal 9(27%), unknown 1(3%). Eighteen patients were treated with Midazolam drip out of which 1 patient had complete remission in EEG, 6 had >80% remission, 5 had >50% remission and 5 patients had minimal or no response. Thirteen patients were treated with methyl prednisolone bolus out of which 2 patients had complete remission, 4 patients had >80% remission while 4 patients had >50% remission and 3 patients showed no response. NCSE may present with various clinical feature without any convulsion. Midazolam, methyl prednisolone and oral drugs are equally effective for treatment of NCSE. However, further randomized controlled study is needed to chalk out management of NCSE.

Clinical profile and pattern of congenital heart disease in infants of diabetic mother and infants of non-diabetic mother at a tertiary care hospital

OBJECTIVES

To assess the clinical manifestations and pattern of congenital heart diseases (CHD) in infants of diabetic mothers (IDMs) and infants of non-diabetic mothers.

METHODS

A prospective cross sectional study was carried out at tertiary care center over a period of thirty months. All neonates were included in this study if CHD were identified by echocardiography within this study period. Chi-square test and Fisher's exact test were used to compare between groups.

RESULT

Out of 62 neonates, IDMs and non-IDMs were equal in number, male and female ratio was 3 : 2, and majority were delivered by cesarean section (85.5%). Mean gestational age was 35 weeks, 62.3% were preterm, and 37.7% were term. Common clinical presentations were cardiac murmur (61%), and respiratory distress (43.5%). Less common presentations were low SaO2 (27.4%), tachycardia (24.2%), and cyanosis (24.2%). Common combination of presentations were murmur and tachypnea (38.7%); cyanosis and low SaO2 (24.19%); and low SaO2 and tachypnea 15(24.19). The common echocardiographic findings were atrial septal defect (ASD; 72.6%), patent ductus arteriosus (PDA; 45.2%), and ventricular septal defect (VSD; 25.8%). ASD (77.4% vs 67.7%) and VSD (35.5% vs 16.1%) were more in IDMs, and PDA (48.4% vs 41.9%) was more in non-IDMs. These differences were not significant between groups.

CONCLUSION

Clinical presentation and echocardiographic findings of CHD were similar in IDMs and non-IDMs.

Death audit in the neonatal ICU of a tertiary care hospital in Bangladesh: a retrospective chart review

BACKGROUND

Expectant reduction of neonatal mortality and formulation of preventive strategies can only be achieved by analysis of risk factors in a particular setting. This study aimed to document incidence of neonatal death and to analyze the risk factors associated with neonatal death.

METHODS

This retrospective study was carried out in department of Neonatology, Bangabandhu Sheikh Mujib Medical University (BSMMU) over a 12-month period from January to December 2015. The newborns that died within 28 d of life were defined as "Cases" and "Control" were the surviving newborn discharged to home as healthy. Two birth weight and gestational age matched controls were taken for each case. Maternal, obstetric, and newborn characteristics were analyzed between both the groups. Data analysis was performed using SPSS version 20.0 (SPSS Inc., Chicago, IL). A probability of < .05 was considered statistically significant. The strength of association was determined by calculating odds ratio and their 95% confidence intervals (CIs).

RESULTS

During the study period, the proportion of death was 9.6% (64/612). Both in Chi-square analysis and in logistic regression analysis, less than four antenatal visits (odds ratio (OR) 2.78; 95% CI: 1.23-6.28, p = .014) and sepsis (OR 2.37; 95% CI: 1.07-5.26, p = .034) were found to be independent risk factors for deaths, whereas LUCS found to be protective for deaths (OR 0.40; 95% CI: 0.19-0.83, p = .015).

CONCLUSION

In conclusion, less than four antenatal visits and presence of sepsis were found to be independent risk factors whereas LUCS protective of newborn death.

Barriers to and enablers of insulin self-titration in adults with Type 2 diabetes: a qualitative study

AIMS

To identify the barriers to and enablers of effective insulin self-titration in people with Type 2 diabetes.

METHODS

A qualitative semi-structured interview approach was used. Questions were structured according to the Theoretical Domains Framework, which outlines 14 domains that can act as barriers to and enablers of changing behaviour. Interviews were audio-recorded and transcribed verbatim. The data were coded according to the 14 domains, belief statements were created within each domain, and a frequency count of the most reported barriers and enablers was then carried out. Analyses were conducted by two researchers, and discrepancies agreed with a third researcher.

RESULTS

A total of 18 adults with Type 2 diabetes took part in an interview. The majority were of South-Asian ethnicity (n = 8) and were men (n = 12). Their mean age was 61 years old. The mean duration of diabetes was 16 years and time on insulin 9 years. Inter-rater reliability for each of the domains varied (29-100%). The most frequently reported domains were Social Influence and Beliefs about Consequences; the least frequently reported were Optimism and Reinforcement. Interviewees reported receiving support to self-titrate from a range of sources. Self-titrating was perceived to have a range of both positive and negative consequences, as was not titrating.

CONCLUSIONS

The findings highlight that those interviewed experienced a range of barriers and enablers when attempting to self-titrate. Improved education and training when initiating insulin treatment among adults with Type 2 diabetes, and throughout their journey on insulin therapy could help identify and address these barriers in order to optimize self-titration.

Bardet-Biedl syndrome

<p>The Bardet-Biedl syndrome is a rare genetically heterogeneous, autosomal recessive inherited disorder with wide variability in expression. It presents with varied clinical manifestations like retinitis pigmentosa, polydactyly, central obesity, mental retardation and renal dysfunction. Other rare manifestations include diabetes mellitus, heart disease, hepatic fibrosis and neurological manifestations. Mutations in 16 genes have been identified as causative factors. We, here, have presented a 12 year old male patient exhibiting characteristic features of Bardet Biedl syndrome.</p><p> </p>

Pediatric gastrointestinal tuberculosis with hematochezia and polyarthritis: An unusual presentation

Tuberculosis may present with variable symptoms and signs, sometimes presentations are unusual. An eight year old boy was admitted with the complaints of low grade fever, weight loss, abdominal pain, hematochezia and polyarthritis. Colonic biopsy was suggestive of tuberculosis and Gene-Xpart of sputum showed of multidrug resistant tuberculosis. We are reporting a case presented with hematochezia and poloyarthritis, an unusual presentation who was subsequently diagnosed as a case of multi drug resistant intestinal tuberculosis.

Towards predicting the solubility of CO2 and N2 in different polymers using a quasi-SMILES based QSPR approach

The solubility of gases in various polymers plays an important role for the design of new polymeric materials. Quantitative structure-property relationship (QSPR) models were designed to predict the solubility of gases such as CO2 and N2 in polyethylene (PE), polypropylene (PP), polystyrene (PS), polyvinyl acetate (PVA) and poly (butylene succinate) (PBS) at different temperatures and pressures by using quasi-SMILES codes. The dataset of 315 systems was split randomly into training, calibration and validation sets; random split 1 led to 214 training (r(2) = 0.870 and RMSE = 0.019), 51 calibration (r(2) = 0.858 and RMSE = 0.020) and 50 validation (r(2) = 0.869 and RMSE = 0.017) sets. The suggested approach based on the quasi-SMILES, which are analogues of the traditional SMILES gives reasonable good predictions for solubility of CO2 and N2 in different polymers. The described methodology is universal for situations where the aim is to predict the response of an eclectic system upon a variety of physicochemical and/or biochemical conditions.