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.

Groundwater Quality Evaluation for Irrigation and Drinking Utilities Collected from Sadar Upazila of Jamalpur District, Bangladesh

The study was undertaken to evaluate groundwater quality both for drinking and irrigation usage collected from the Sadar upazila of Jamalpur district, Bangladesh. Total 20 groundwater samples were collected from the whole area and analysed for various physicochemical parameters following standard protocols at the Department of Agricultural Chemistry, Bangladesh Agricultural University, Mymensingh during March to December 2017. Concentrations of different heavy metal (Fe, Mn, Cu, Pb, Cr, Cd and Zn) in groundwater samples were measured by an atomic absorption spectrophotometer (AAS). Major cation chemistry showed their dominance in order of Ca > Mg > Na > K. Among the anions, HCO3 was the most dominating ion, which makes all groundwater unsuitable for irrigation. But considering major cations and anions, all groundwater samples were rated as suitable for drinking. In context of heavy metals, the amounts of Mn, Cd and Pb in groundwater were comparatively higher than the standard limits, which makes 14, 8 and 19 samples problematic for irrigation, and 13, 18 and 1 samples unsuitable for drinking, respectively. Electrical conductivity (EC) and sodium adsorption ratio (SAR) reflected that all groundwater samples were low to medium salinity (C1-C2) and low alkalinity (S1) hazards classes. As regards to hardness, out of 20 groundwater samples, 9 samples were classified as moderately hard, 10 were hard and only 1 sample was very hard in quality. According to residual sodium carbonate (RSC), 18 groundwater samples were found in suitable class, 1 sample was rated as marginal and the rest 1 was categorised as unsuitable class. The study concluded that HCO3, Mn, Cd and Pb were the major contaminants in groundwater of Sadar upazila of Jamalpur district, Bangladesh. Finally, the study suggested that the groundwater in this area needs to treat to minimise the amount of contaminants before using both for irrigation and drinking.

Integrating Cervical Cancer Screening and Syndromic Management of Sexually Transmitted Infections in Resource-Limited Settings in India

Background: In India, annually, there are more than 120,000 women diagnosed with cervical cancer and more than half of them die of the disease. The link between cervical cancer and high-risk type of human papilloma virus (HPV) is well-established. In addition to this, low-risk type HPV can lead to sexually transmitted infections (STIs). It is believed that 6% of Indian adult population is affected by one or more STIs. However, due to geographical and socioeconomic barriers, rural and poor women do not always have access to updated sexual and reproductive health (SRH) information and relevant services, resulting in the delay of treatment. To address these challenges and to strengthen the existing health system, Family Planning Association of India (FPA India), a national level voluntary organization, integrated cervical cancer and STIs services into a 2-year project and delivered it in urban slums and rural areas. Aim: To evaluate the impact of integrated cervical cancer and STIs services in the resource-limited settings in India. Methods: FPA India implemented the integrated package through six branch health facilities to raise people's awareness and build institutional capacity for the screening of women. All detailed process is summarized in Fig 1. Data, such as the number of cervical cancer screening and syndromic treatment, was collected. Results: More than 14,000 people were reached and 14 service providers including midlevel providers were trained. The number of services significantly improved in the selected 6 branches and in all branches of FPA India. The numbers for syndromic treatment of STIs almost doubled in the selected 6 branches and showed a 50% rise in all the branches. The number of cervical cancer screenings was 2938 and 9862, before and after the project, respectively in the selected 6 branches. The progress nearly doubled at the whole association level. Additionally, in this project, the progress of visual inspection of the cervix with acetic acid (VIA) and Lugol´s iodine (VILI) was remarkable whether in 6 selected branches or in all branches. At the end of project implementation, VIA/VILI accounted for 90% of all cervical cancer screenings. Data are summarized in Table 1. Conclusion: This study presents FPA India's operational experience in carrying out integrated cervical cancer and STIs services, in urban slums and rural areas. This project reaffirms that raising people's awareness and building institutional capacity are core approaches to deliver certain SRH information and services as well as achieve better SRH outcomes. The shift from Papanicolaou test to VIA/VILI may be related to VIA/VILI's sensitivity, quick results and affordability. However, more studies are needed to explain this change.[Figure: see text][Table: see text]

Primary Non-Hodgkin Lymphoma of Sphenoid Sinus Involving Cavernus Sinus and Clivus with Isolated 3rd Nerve Palsy

Lymphomas are group of malignant neoplasm having origins from lymphoreticular cells. B cell Non Hodgkin Lymphoma (BNHL) of sphenoid sinus as primary site for lymphomas are very rare and whenever involves comes usually with ocular manifestations. The proximity of the lesion to optic nerve and cavernous sinus present a high risk of developing unilateral ophthalmoplegia or even blindness. The vast majority of cases of localized sphenoid sinus lymphomas are usually curable to surgery, chemotherapy alone or combination of both, sometimes radiotherapy. Here we report a case of 58 years old male attended at Bangabandhu Sheikh Mujib Medical University (BSMMU) on 9th February 2017 at 9:00 AM having headache and gradually developing ptosis in left eye over 15 days. MRI of brain revealed homogeneously enhancing lesion occupying sphenoid sinus, clivus extending towards left cavernous sinus. Gross total resection of tumor was achieved by endoscopic endonasal approach. Histopathology revealed non-Hodgkin lymphoma and immunohistochemically it was positive for CD 20, CD 45, CD 79 and BCL 2, strongly compatible with diffuse large B cell lymphoma. Treatment with R-CHOP regimen following surgery resulted in initiation of improvement of the condition of the patient. Primary B cell Non-Hodgkin Lymphoma (PBNHL) of the sphenoid sinus is a rare entity which can be perplexing and misleading for a surgeon until the histopathological proof is in hand. Early diagnosis with strong suspicion of sphenoid lymphoma in mind during workouts and timely management, close monitoring and follow ups have high potential for cure and longer disease-free survival of the BNHL patients.

Biogenic fabrication and characterization of silver nanoparticles using aqueous-ethanolic extract of lichen (Usnea longissima) and their antimicrobial activity

Background

Biogenic fabrication of silver nanoparticles from naturally occurring biomaterials provides an alternative, eco-friendly and cost-effective means of obtaining nanoparticles. It is a favourite pursuit of all scientists and has gained popularity because it prevents the environment from pollution. Our main objective to take up this project is to fabricate silver nanoparticles from lichen, Usnea longissima and explore their properties. In the present study, we report a benign method of biosynthesis of silver nanoparticles from aqueous-ethanolic extract of Usnea longissima and their characterization by ultraviolet–visible (UV-vis), Fourier transform infrared (FTIR) spectroscopy, transmission electron microscopy (TEM) and scanning electron microscopy (SEM) analyses. Silver nanoparticles thus obtained were tested for antimicrobial activity against gram positive bacteria and gram negative bacteria.

Results

Formation of silver nanoparticles was confirmed by the appearance of an absorption band at 400 nm in the UV-vis spectrum of the colloidal solution containing both the nanoparticles and U. longissima extract. Poly(ethylene glycol) coated silver nanoparticles showed additional absorption peaks at 424 and 450 nm. FTIR spectrum showed the involvement of amines, usnic acids, phenols, aldehydes and ketones in the reduction of silver ions to silver nanoparticles. Morphological studies showed three types of nanoparticles with an abundance of spherical shaped silver nanoparticles of 9.40–11.23 nm. Their average hydrodynamic diameter is 437.1 nm. Results of in vitro antibacterial activity of silver nanoparticles against Staphylococcus aureus, Streptococcus mutans, Streptococcus pyrogenes, Streptococcus viridans, Corynebacterium xerosis, Corynebacterium diphtheriae (gram positive bacteria) and Escherichia coli, Klebsiella pneuomoniae and Pseudomonas aeruginosa (gram negative bacteria) showed that it was effective against tested bacterial strains. However, S. mutans, C. diphtheriae and P. aeruginosa were resistant to silver nanoparticles.

Conclusion

Lichens are rarely exploited for the fabrication of silver nanoparticles. In the present work the lichen acts as reducing as well as capping agent. They can therefore, be used to synthesize metal nanoparticles and their size may be controlled by monitoring the concentration of extract and metal ions. Since they are antibacterial they may be used for the treatment of bacterial infections in man and animal. They can also be used in purification of water, in soaps and medicine. Their sustained release may be achieved by coating them with a suitable polymer. Silver nanoparticles fabricated from edible U. longissima are free from toxic chemicals and therefore they can be safely used in medicine and medical devices. These silver nanoparticles were stable for weeks therefore they can be stored for longer duration of time without decomposition.

The effect on clinical results of adding recombinant LH in late phase of ovarian stimulation of patients with repeated implantation failure: a pilot study

OBJECTIVE

To evaluate the efficacy of recombinant LH (r-LH) addition in the late phase of ovarian stimulation in patients with repeated implantation failure (RIF).

PATIENTS AND METHODS

66 infertile couples undergoing ICSI treatment due to male factor were allocated to group A (33) and to group B (33). Group A (29 subjects) received recombinant FSH (r-FSH) supplemented by r-LH in the late follicular phase starting the same day of GnRH-antagonist (GnRH-ant) administration, and group B (32 subjects) received r-FSH alone. All patients were stimulated with a GnRH-ant flexible protocol starting r-FSH on day 2 of a spontaneous or induced cycle. hCG (10000 IU) was administered by intramuscular route when at least 2 follicles reached 18 mm in diameter.

RESULTS

Metaphase II (MII) oocytes with cytoplasmic maturation showed a significant difference in the r-LH group (89.02%) compared to the one with FSH alone (81.15%) (p < 0.01). The number of positive pregnancy test, 14 (48.3%) and 8 (25%), was significantly greater in the r-LH group compared to the group treated with r-FSH alone (p < 0.03). The number of gestational sacs was 20 in the r-LH group vs. 9 in the r-FSH group (p < 0.001). The implantation rate was significantly higher in the r-LH group compared to the r-FSH only group (19% vs. 7% respectively; p < 0.01). Also, a lower abortion rate was found in the r-LH group (21% vs. 37.5% respectively - p < 0.01).

CONCLUSIONS

Ovarian stimulation should be personalized because it seems that some subgroups of patients, like those with RIF, reach a better clinical outcome with the addition of r-LH in the advanced follicular phase stimulation.

Human health risks and socio-economic perspectives of arsenic exposure in Bangladesh: A scoping review

Arsenic contamination of drinking water, which can occur naturally or because of human activities such as mining, is the single most important public health issue in Bangladesh. Fifty out of the 64 districts in the country have arsenic concentration of groundwater exceeding 50µgL^-1, the Bangladeshi threshold, affecting 35-77 million people or 21-48% of the total population. Chronic arsenic exposure through drinking water and other dietary sources is an important public health issue worldwide affecting hundreds of millions of people. Consequently, arsenic poisoning has attracted the attention of researchers and has been profiled extensively in the literature. Most of the literature has focused on characterising arsenic poisoning and factors associated with it. However, studies examining the socio-economic aspects of chronic exposure of arsenic through either drinking water or foods remain underexplored. The objectives of this paper are (i) to review arsenic exposure pathways to humans; (ii) to summarise public health impacts of chronic arsenic exposure; and (iii) to examine socio-economic implications and consequences of arsenicosis with a focus on Bangladesh. This scoping review evaluates the contributions of different exposure pathways by analysing arsenic concentrations in dietary and non-dietary sources. The socio-economic consequences of arsenicosis disease in Bangladesh are discussed in this review by considering food habits, nutritional status, socio-economic conditions, and socio-cultural behaviours of the people of the country. The pathways of arsenic exposure in Bangladesh include drinking water, various plant foods and non-dietary sources such as soil. Arsenic affected people are often abandoned by the society, lose their jobs and get divorced and are forced to live a sub-standard life. The fragile public health system in Bangladesh has been burdened by the management of thousands of arsenicosis victims in Bangladesh.

Length of Vermiform Appendix in Bangladeshi People of Different Age and Sex

A cross sectional descriptive study was performed on 70 postmortem vermiform appendix (male 34 and female 36) to find out the length of vermiform appendix of Bangladeshi people in different age and sex. The specimens were collected from autopsy laboratory of the Department of Forensic Medicine, Mymensingh Medical College, Mymensingh, Bangladesh from October 2016 to March 2017 by purposive sampling technique. The collected samples were divided into four age groups. They were Group A (upto 20 years), Group B (21 to 40 years), Group C (41 to 60 years) and Group D (above 60 years). Dissection was performed according to standard autopsy techniques. The vermiform appendix was collected and preserved in 10% formol-saline solution. The length of the vermiform appendix was determined by measuring the distance from its base to tip with the help of a flexible thread. Then the thread was placed on measuring scale graduated in centimeter which represents the length of vermiform appendix. The data were analyzed by using student unpaired 't' test and compared with the findings of other national and international studies and standard text books. It was observed that length of vermiform appendix gradually decreased as age advanced. The mean±SD length of vermiform appendix was 9.41±1.26cm, 8.63±1.32cm, 7.96±1.20cm and 6.81±0.75cm in Group A, B, C and D respectively. Mean length of vermiform appendix in male was 9.92±1.55cm in Group A, 9.09±1.19cm in Group B, 8.04±1.10cm in Group C, 6.88±0.86cm in Group D and in female mean length of vermiform appendix was 9.12±1.06cm in Group A, 8.31±1.34cm in Group B, 7.79±1.60cm in Group C, 6.69±0.63cm in Group D. Statistical analysis shows that the mean differences of the length of vermiform appendix between A & D, B & D were statistically highly significant. The mean difference between Group A & C was moderately significant. Between Group C & D the difference was statistically significant and between Group A & B, B & C were statistically non significant. No significance difference of length of vermiform appendix between male and female was observed. The present study will help to increase the information pool on the length of vermiform appendix of Bangladeshi people.

Female Sex and Alzheimer's Risk: The Menopause Connection

Along with advanced age and apolipoprotein E (APOE)-4 genotype, female sex is a major risk factor for developing late-onset Alzheimer's disease (AD). Considering that AD pathology begins decades prior to clinical symptoms, the higher risk in women cannot simply be accounted for by their greater longevity as compared to men. Recent investigation into sex-specific pathophysiological mechanisms behind AD risk has implicated the menopause transition (MT), a midlife neuroendocrine transition state unique to females. Commonly characterized as ending in reproductive senescence, many symptoms of MT are neurological, including disruption of estrogen-regulated systems such as thermoregulation, sleep, and circadian rhythms, as well as depression and impairment in multiple cognitive domains. Preclinical studies have shown that, during MT, the estrogen network uncouples from the brain bioenergetic system. The resulting hypometabolic state could serve as the substrate for neurological dysfunction. Indeed, translational brain imaging studies demonstrate that 40-60 year-old perimenopausal and postmenopausal women exhibit an AD-endophenotype characterized by decreased metabolic activity and increased brain amyloid-beta deposition as compared to premenopausal women and to age-matched men. This review discusses the MT as a window of opportunity for therapeutic interventions to compensate for brain bioenergetic crisis and combat the subsequent increased risk for AD in women.

Study of Flare Assessment in Systemic Lupus Erythematosus Based on Paper Patients

Objective

To determine the level of agreement of disease flare severity (distinguishing severe, moderate, and mild flare and persistent disease activity) in a large paper‐patient exercise involving 988 individual cases of systemic lupus erythematosus.

Methods

A total of 988 individual lupus case histories were assessed by 3 individual physicians. Complete agreement about the degree of flare (or persistent disease activity) was obtained in 451 cases (46%), and these provided the reference standard for the second part of the study. This component used 3 flare activity instruments (the British Isles Lupus Assessment Group [BILAG] 2004, Safety of Estrogens in Lupus Erythematosus National Assessment [SELENA] flare index [SFI] and the revised SELENA flare index [rSFI]). The 451 patient case histories were distributed to 18 pairs of physicians, carefully randomized in a manner designed to ensure a fair case mix and equal distribution of flare according to severity.

Results

The 3‐physician assessment of flare matched the level of flare using the 3 indices, with 67% for BILAG 2004, 72% for SFI, and 70% for rSFI. The corresponding weighted kappa coefficients for each instrument were 0.82, 0.59, and 0.74, respectively. We undertook a detailed analysis of the discrepant cases and several factors emerged, including a tendency to score moderate flares as severe and persistent activity as flare, especially when the SFI and rSFI instruments were used. Overscoring was also driven by scoring treatment change as flare, even if there were no new or worsening clinical features.

Conclusion

Given the complexity of assessing lupus flare, we were encouraged by the overall results reported. However, the problem of capturing lupus flare accurately is not completely solved.

A critical analysis of the tools to evaluate neuropsychiatric lupus

Neuropsychiatric symptoms occur commonly in patients with systemic lupus erythematosus, but they are not always due to active disease. It is crucial to identify cases that are due to active systemic lupus erythematosus so that appropriate treatment can be instituted. There is no single serological or imaging test that distinguishes active neuropsychiatric systemic lupus erythematosus from neuropsychiatric manifestations caused by other factors such as infection. Most patients with neuropsychiatric systemic lupus erythematosus have generalised features of disease activity. Raised anti-dsDNA and low C3 complement levels are often seen, but are not an invariable guide. The presence of antiphospholipid antibodies is more suggestive of thrombotic than inflammatory causation. A number of other autoantibody tests have been proposed as biomarkers for neuropsychiatric systemic lupus erythematosus, but results in clinical studies have been inconsistent and none has so far entered routine clinical practice. Cerebrospinal fluid features and magnetic resonance imaging appearances are non-specific in neuropsychiatric systemic lupus erythematosus, but are useful in excluding other causes of neuropsychiatric symptoms. Newer magnetic resonance imaging sequences show promise for distinguishing new neuropsychiatric systemic lupus erythematosus activity from previous damage and recent research suggests these may correlate with changes in cognitive function in patients with systemic lupus erythematosus. However, formal cognitive testing is seldom carried out in the acute setting.

Comparative Study of Outcome of Endoscopic Myringoplasty in Active and Inactive Mucosal Chronic Otitis Media Patients

The objective of this study was to compare graft uptake and hearing improvement in active and inactive mucosal chronic otitis media patients after endoscopic myringoplasty. This is prospective study conducted at a government medical college and hospital from February 2014 to August 2015. A total of 40 active (wet) ears with mucoid discharge and 40 inactive (dry) ears (at least 6 weeks dry before surgery) with mucosal chronic otitis media were operated on by endoscopic myringoplasty by transcanal approach. Graft uptake and hearing gain rates 3 months after surgery were compared for both groups. Endoscopic myringoplasty using temporal fascia graft via transcanal approach was used. The graft take rate was 77.5% for the active ear group and 85% for the inactive ear group. The hearing gain rate was 82.5% for the inactive ear group and 72.5% for the active ear group. Differences were found to be statistically insignificant for both graft uptake and hearing gain. The success of endoscopic myringoplasty is not adversely affected by the presence of mucoid ear discharge at the time of surgery, and outcomes are comparable to those of the operation done for inactive ear.

Association of time-varying clearance of nivolumab with disease dynamics and its implications on exposure response analysis

Nivolumab is a human monoclonal antibody that blocks the interaction between PD-1 programmed death-1 (PD-1) and its ligands, PD-L1 and PD-L2. Nivolumab demonstrated efficacy in clinical trials for various types of cancer. A time-varying clearance was identified for nivolumab. We show that the change of clearance over time is associated with the post-treatment effects: clearance decreases when disease status improves. This interaction between posttreatment effects and drug exposure may lead to a biased steep estimate of the exposure-response (E-R) relationship for efficacy. Under this scenario, simulations were performed to develop a proposed methodology to assess the causal effect of drug exposure upon clinical response. Data from nivolumab trials were subsequently used to verify the proposed methodology for E-R analysis. The results showed that E-R analysis results based on pharmacokinetic (PK) metrics derived from the first dose are more consistent with the true E-R or dose-response relationship than the steady-state PK metrics.

Radiographic diagnosis of proximal caries-influence of experience and gender of the dental staff

OBJECTIVES

The aim of this study was to examine the influence of experience and gender on the radiographic detection of proximal caries lesions and on therapeutic decisions.

MATERIALS AND METHODS

A survey of 220 examiners (students and employees at three universities and dentists in the field) was taken using a standardized written questionnaire concerning radiographic diagnosis and therapy planning. An expert opinion of four dentists was determined as radiographic reference. A mixed effect logistic regression model was used for statistical evaluation and the odds ratio and p values were calculated (α = 0.05).

RESULTS

Examiners with experience had an almost four times greater chance of a correct assessment, if proximal caries lesion was present or not, than examiners with low experience (OR 3.7 (95% CI 2.4-5.8)). No gender-specific differences were discovered (OR women vs. men 0.9 (95% CI 0.6-1.4)). There was a relationship between the severity of the burnout effect on the x-ray and false positive caries diagnosis. Overall, 43% of respondents would plan invasive treatment in the enamel on a patient at low risk of caries and 78% on a high-risk patient. The results showed that the more experienced practitioners would be more likely to postpone restorative therapy on proximal caries until the lesion reached a later stage.

CONCLUSIONS

The results of this study suggest that examiner's experience influences the radiographic diagnosis of proximal lesions. No gender-specific differences could be found.

CLINICAL RELEVANCE

Examiner's professional experience is an important factor when radiography is included for detection and treatment planning of proximal lesions.

Evaluation of prediagnosis emergency department presentations in patients with active tuberculosis: the role of chest radiography, risk factors and symptoms

INTRODUCTION

London has a high rate of tuberculosis (TB) with 2572 cases reported in 2014. Cases are more common in non-UK born, alcohol-dependent or homeless patients. The emergency department (ED) presents an opportunity for the diagnosis of TB in these patient groups. This is the first study describing the clinico-radiological characteristics of such attendances in two urban UK hospitals for pulmonary TB (PTB) and extrapulmonary TB (EPTB).

METHODS

We conducted a retrospective cohort study using the London TB Register (LTBR) and hospital records to identify patients who presented to two London ED's in the 6 months prior to their ultimate TB diagnosis 2011-2012.

RESULTS

397 TB cases were identified. 39% (154/397) had presented to the ED in the 6 months prior to diagnosis. In the study population, the presence of cough, weight loss, fever and night sweats only had prevalence rates of 40%, 34%, 34% and 21%, respectively. Chest radiography was performed in 76% (117/154) of patients. For cases where a new diagnosis of TB was suspected, 73% (41/56) had an abnormal radiograph, compared with 36% (35/98) of patients where it was not. There was an abnormality on a chest radiograph in 73% (55/75) of PTB cases and also in 40% (21/52) of EPTB cases where a film was requested.

CONCLUSIONS

A large proportion of patients with TB present to ED. A diagnosis was more likely in the presence of an abnormal radiograph, suggesting opportunities for earlier diagnosis if risk factors, symptoms and chest radiograph findings are combined.

Non-Hermitian engineering of synthetic saturable absorbers for applications in photonics

We introduce a new type of synthetic saturable absorber based on quantum-inspired Jx photonic arrays. We demonstrate that the interplay between optical Kerr nonlinearity, interference effects and non-Hermiticity through radiation loss leads to a nonlinear optical filtering response with two distinct regimes of small and large optical transmissions. More interestingly, we show that the boundary between these two regimes can be very sharp. The threshold optical intensity that marks this abrupt "phase transition" and its steepness can be engineered by varying the number of the guiding elements. The practical feasibility of these structures as well as their potential applications in laser systems and optical signal processing are also discussed.

Improvement of Liver Function, Quality of Life and Survival after Insertion of Endoprosthesis in Advance Malignant Biliary Obstruction

Obstructive jaundice due to advance malignancy is a fatal problem. It most commonly occurs at the distal common bile duct or at the hilum of liver. Magnetic Resonance Cholangio Pancreatography (MRCP) and Computed Tomography (CT) are most useful in identifying the underlying cause as well as localize the position of the stricture. For those patients with unresectable disease, progressive jaundice constitutes an immediate threat to their survival, in addition to significant loss to their quality of life secondary to pruritus, malaise and cholangitis. Effective and lasting decompression of the biliary tree is a priority and consists of positioning of a biliary endoprosthesis (stent). To observe the improvement of liver function, quality of life and survival after successful insertion of endoprosthesis (stenting) in malignant biliary obstruction, a study was performed in the department of surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from September 2013 to August 2014, in 50 patients with clinically visible jaundice and unresectable disease. There were significant (p<0.001) reductions in the levels of serum bilirubin, serum alkaline phosphatase, serum SGPT and Prothrombin time from the time of admission to 2 weeks and 3 weeks after stenting. Physical and functional quality of life was greatly improved 2-4 weeks after stenting, where emotional quality remained the same throughout the study period. Successful palliation by stenting of malignant biliary obstruction is a priority to achieve improvements in liver function, quality of life and prolong survival. Endoscopic stent placement appears to be safe, well tolerated and can be offered without delay as a primary treatment option for all patients with unresectable malignant biliary lesion.

Infant and mother related outcomes from exposure to metals with endocrine disrupting properties during pregnancy

BACKGROUND

Endocrine-related adverse health effects from exposure to heavy metals such as lead, arsenic, cadmium, and mercury are yet to be adequately described. The purpose of this review was to gain insight into maternal exposure to heavy metals, and to identify potential endocrine-related adverse health effects in the mother and the infant.

METHODS

Relevant databases were searched for original research reports and a total of 46 articles were retained for scrutiny. Required data was extracted from these studies and their methodology was assessed.

RESULTS

Impaired fetal growth was observed from exposure to all endocrine disrupting metals, while exposure to lead and arsenic were associated with spontaneous abortion, stillbirth and neonatal deaths. Maternal exposure to arsenic was associated with impaired glucose tolerance in these mothers.

CONCLUSION

Impaired fetal growth, fetal loss, and neonatal deaths were significantly associated with heavy metals exposure during pregnancy; however, hypertension and gestational diabetes require further investigation.

A feasibility study of educational tools for osteomalacia

Many people in the UK, particularly people of South Asian origin, are advised to supplement their vitamin D intake, yet most do not. This suggests an unmet educational need. The osteomalacia mind map was developed to meet this need. The mind map contains culturally sensitive images, translated into Urdu and made interactive on a DVD. This study explores the feasibility of a randomised controlled study to measure the effect of education on improving vitamin D knowledge and adherence. This was a pilot and feasibility study. Cluster randomisation was used to avoid inter person contamination. Two South Asian women's groups were recruited to receive information about osteomalacia either by interactive DVD or an Arthritis Research UK leaflet. Knowledge and compliance were tested before and after the educational interventions via a knowledge questionnaire and the measurement of vitamin D and parathormone levels. The groups were found to be mismatched for knowledge, educational attainment and language at baseline. There were also organisational difficulties and possible confounding due to different tutors and translators. The DVD group had high knowledge at baseline which did not improve. The leaflet group had low knowledge at baseline that did improve. The DVD group had lower parathormone which did not change. The leaflet group had an increase in vitamin D but parathormone remained high. Performing a randomised study with this population utilising an educational intervention was difficult to execute. If cluster randomisation is used, extreme care must be taken to match the groups at baseline.

Hepatoprotective potential of glyceryl trinitrate against chemically induced oxidative stress and hepatic injury in rats

Glyceryl trinitrate (GTN) has been used widely as a potent vasodilator to treat heart conditions, such as angina pectoris and chronic heart failure. This study aims to elucidate the effect of exogenous nitric oxide (NO) administration, using GTN, on carbon tetrachloride (CCl4)-induced oxidative stress and liver injury in rats. The results obtained demonstrated that NO generated by the administration of GTN affords protection against CCl4-induced oxidative stress and liver injury. Administration of CCl4 resulted in a significant ( p < 0.001) increase in lipid peroxidation and tissue damage markers (aspartate and alanine transaminase and lactate dehydrogenase) release in serum. Parallel to these changes, CCl4 also caused downregulation of antioxidant enzymes including glutathione peroxidase (GPx), glutathione reductase (GR), and glutathione-S-transferase (GST), and several fold induction in γ-glutamyl transpeptidase (GGT) activity. Subsequent administration of GTN resulted in significant ( p < 0.001) recovery of GSH-metabolizing enzymes in a dose-dependent manner. Further, administration of NO inhibitor, NG-nitro-l-arginine methyl ester (l-NAME), exacerbated CCl4-induced oxidative tissue injury. Overall, the study suggests that GTN might suppress oxidant-induced tissue injury and hepatotoxicity in rats.

Breast cancer in systemic lupus

Objective There is a decreased breast cancer risk in systemic lupus erythematosus (SLE) versus the general population. We assessed a large sample of SLE patients, evaluating demographic and clinical characteristics and breast cancer risk. Methods We performed case-cohort analyses within a multi-center international SLE sample. We calculated the breast cancer hazard ratio (HR) in female SLE patients, relative to demographics, reproductive history, family history of breast cancer, and time-dependent measures of anti-dsDNA positivity, cumulative disease activity, and drugs, adjusted for SLE duration. Results There were 86 SLE breast cancers and 4498 female SLE cancer-free controls. Patients were followed on average for 7.6 years. Versus controls, SLE breast cancer cases tended to be white and older. Breast cancer cases were similar to controls regarding anti-dsDNA positivity, disease activity, and most drug exposures over time. In univariate and multivariate models, the principal factor associated with breast cancers was older age at cohort entry. Conclusions There was little evidence that breast cancer risk in this SLE sample was strongly driven by any of the clinical factors that we studied. Further search for factors that determine the lower risk of breast cancer in SLE may be warranted.

Role of Clinical Pharmacology in the Development and Approval of Immunotherapies Targeting Immune Checkpoints

Immune surveillance plays a critical role in preventing the development and progression of cancer. Immune modulators, such as interferon-gamma or interleukin-2, have been a part of the cancer treatment armament over the past few decades. However, new understandings regarding the role of the costimulatory and coinhibitory molecules associated with T-cells and antigen-presenting cells as well as tumor necrosis factor receptors and ligands have ushered the new era of immunotherapy for cancer treatment. We now know that primary cancer cells evade screening by the innate immune system, proliferate, and form metastases by upregulating immune inhibitory pathways referred to as immune checkpoints. The recent development of therapies that target immune checkpoints, such as cytotoxic T lymphocyte antigen 4, programmed cell death 1, programmed cell death ligand 1, indoleamine 2,3-dioxygenase, T-cell immunoglobulin and mucin domain 3, and lymphocyte activation gene 3 precisely target the immune system and give new hope for treating various types of cancer. In select marker-enriched populations, immunotherapies provide high response rates as well as durable responses in terms of progression-free survival and overall survival. Numerous factors, such as patient's immune system, the expression of targets on both immune and cancer cells, maintenance of an effective drug exposure, and tolerability to these agents may play a role in this unique observation.

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

BACKGROUND

Although phenotypic drug susceptibility testing (DST) is endorsed as the standard for second-line drug testing of Mycobacterium tuberculosis, it is slow and laborious.

METHODS

We evaluated the accuracy of two faster, easier methodologies that provide results for multiple drugs: a genotypic TaqMan(®) Array Card (TAC) and the Sensititre(®) MYCOTB(TM) plate. Both methods were tested at three central laboratories in Bangladesh, Tanzania, and Thailand with 212 multidrug-resistant tuberculosis (MDR-TB) isolates and compared with the laboratories' phenotypic method in use.

RESULTS

The overall accuracy for ethambutol, streptomycin, amikacin, kanamycin, ofloxacin, and moxifloxacin vs. the phenotypic standard was 87% for TAC (range 70-99) and 88% for the MYCOTB plate (range 76-98). To adjudicate discordances, we re-defined the standard as the consensus of the three methods, against which the TAC and MYCOTB plate yielded 94-95% accuracy, while the phenotypic result yielded 93%. Some isolates with genotypic mutations and high minimum inhibitory concentration (MIC) were phenotypically susceptible, and some isolates without mutations and low MIC were phenotypically resistant, questioning the phenotypic standard.

CONCLUSIONS

In our view, the TAC, the MYCOTB plate, and the conventional phenotypic method have similar performance for second-line drugs; however, the former methods offer speed, throughput, and quantitative DST information.