Risk factors of multi-drug-resistant tuberculosis in Bangladeshi population: a case control study

Despite success in tuberculosis control, multi-drug resistant tuberculosis in Bangladesh is increasing and currently multi-drug-resistant tuberculosis rate is 3.6% in new cases and 19% in re-treatment cases. This study focused on determination of multi-drug-resistant tuberculosis which is warranted for effective prevention strategy. An unmatched case control study was conducted in 2010. Purposively recruited 136 culture-proved multi-drug-resistant- tuberculosis cases and 152 cured tuberculosis patients were interviewed. Associations between exposure and outcome variables were initially tested by chi2-test, t-test. A result was considered significant at p value < 0.05. Effects of exposure variables were also assessed after adjusting for other variables by binary logistic regression models. Crude and adjusted Odds Ratio with 95% Confidence Interval was computed. Younger age (p = 0.008) and, peri-urban locality (p = 0.002) were associated with multi-drug-resistant tuberculosis. History of contact (p < 0.001) and tuberculosis in the past (p < 0.001) were four and eight times, respectively, more likely to influence multi-drug-resistant tuberculosis. Regularity [Odds Ratio 0.05; 95% Confidence Interval (0.01 to 0.39)] and always observation of treatment [Odds Ratio 0.25; 95% Confidence Interval (0.10 to 0.61)], sputum conversion [Odds Ratio 0.02; 95% Confidence Interval (0.01 to 0.08)] negatively associated with multi-drug-resistant tuberculosis. Gender and socio-economic status did not show any influence. Treatment course and sputum conversion was the best predictors. Like other developing countries adequacy of treatment is the most important exposure variable. Strengthening of control activities might contribute in preventing development of resistance in tuberculosis patients.

Assessing glomerular filtration rate in healthy adult potential kidney donors in Bangladesh: a comparison of various prediction equations with measured glomerular filtration rate by diethylentriamine pentaacetic acid renogram

To ensure that potential kidney donors in Bangladesh have no renal impairment, it is extremely important to have accurate methods for evaluating the glomerular filtration rate (GFR). We evaluated the performance of serum creatinine based GFR in healthy adult potential kidney donors in Bangladesh to compare GFR determined by DTPA with that determined by various prediction equations. In this study GFR in 61 healthy adult potential kidney donors were measured with 99mTc-diethylenetriamine penta-acetic acid (DTPA) renogram. We also estimated GFR using a four variable equation modification of diet in renal disease (MDRD), Cockcroft-Gault creatinine clearance (CGCrCl), Cockcroft-Gault glomerular filtration rate (CG-GFR). The mean age of study population was 34.31 +/- 9.46 years and out of them 65.6% was male. In this study mean mGFR was 85.4 +/- 14.8. Correlation of estimated GFR calculated by CG-CrCl, CG-GFR and MDRD were done with measured GFR DTPA using quartile. Kappa values were also estimated which was found to be 0.104 for (p = 0.151), 0.336 for (p = 0.001) and 0.125 for (p = 0.091) respectively. This indicates there is no association between estimated GFR calculated by CG-CrCl, CG-GFR, MDRD with measured GFR DTPA. These results show poor performance of these equations in evaluation of renal function among healthy population and also raise question regarding validity of these equations for assessment of renal function in chronic kidney disease in our population.

Correlation between Intracerebral Hemorrhage Score and surgical outcome of spontaneous intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (ICH) comprises 10-15% of all strokes and has a higher risk of morbidity and mortality (40-45%). A simple and widely valid clinical grading scale, the Intracerebral Hemorrhage Score (ICH score) was developed to predict to outcome of spontaneous ICH. The aim of the present study was to assess the relation between the ICH score and the surgical outcome of ICH by Glasgow Outcome Scale (GOS) at the 30th post ictus day in our perspective. This prospective study was done during the period of April 2009 to October 2010 in Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka. Forty three cases were enrolled by set inclusion and exclusion criteria. Intracerebral Hemorrhage Score was calculated during admission and the surgical outcome of ICH was determined by GOS by face to face or telephone interview using structured questionnaire on their 30th post ictus day. Correlation between the ICH score and the surgical outcome of ICH was done by Pearson’s correlation coefficient test. Value of r was found to be -0.635 which was statistically highly significant (p=.001) and the relation was found to be negative. Higher ICH score had unfavorable outcome. As correlation between the ICH score and the surgical outcome of ICH was found statistically highly significant, it can be used widely as a grading scale in preoperative counseling. The use of ICH score could improve standardization of clinical treatment protocols and clinical research studies in ICH. Bangladesh Med Res Counc Bull 2013; 39: 1-5

Expression of microRNA and microRNA processing machinery genes during early quail (Coturnix japonica) embryo development

MicroRNA (miRNA) are small regulatory RNA molecules that are implicated in regulating and controlling a wide range of physiological processes including cell division, differentiation, migration, apoptosis, morphogenesis, and organogenesis. The aim of this study was to determine the expression pattern of 32 miRNA and 18 miRNA processing machinery genes during somite formation in quail embryos. The embryos were collected at stages HH (Hamburger and Hamilton) 4, 6, and 9 of embryo development (19, 24, and 30 h of incubation, respectively). Total RNA including miRNA was isolated from 4 groups of embryos (each group consisting of 6 to 8 embryos) were collected at each of the 3 stages (19, 24, and 30 h). The expression pattern of candidate miRNA and miRNA processing machinery genes was performed using quantitative real-time PCR. The results demonstrated that 7 miRNA (let-7a, mir-122, mir-125b, mir-10b, P < 0.01; let-7b, mir-26a, and mir-126, P < 0.05) were differentially expressed during early quail embryo development. In addition, the expression profile of 18 miRNA processing machinery genes was not significantly increased at 30 h of incubation compared with both 19 and 24 h. Our results suggest that machinery genes for miRNA biogenetic pathways are functional, and hence, miRNA may be involved in the regulation of early quail development. These 7 differentially expressed miRNA are suggested to play critical roles in quail embryo somite formation.

Surgery for primary intracerebral haemorrhage: is it safe and effective?

This prospective study was conducted to compare the outcome between medical and surgical treatment of primary intracerebral haemorrhage at the department of Neurosurgery, Dhaka Medical College Hospital from January 2006 to October 2007. All patients with primary intracerebral haematoma with Glasgow Coma Scale (GCS). 5-15 (on admission) and heamatoma volume 30 cc or above admitted at Neurosurgery department managed conservatively or surgically were included in this study. Total 60 patients were selected, of them 30 patients managed conservatively and 30 patients managed surgically. Conservatively managed patients regarded as control group (Group-A) and surgically managed patients regarded as experimental group (Group-B). Patients or attendants refused to operate were included in the conservative group. All the selected patients were evaluated on the basis of detailed history, clinical examination (general and neurological examination) and CT scan findings. Outcome was evaluated in term of Glasgow Outcome Scale (GOS). Best medical treatment was given for conservative group and operations were done for surgical group and followed up after surgery till discharge by observing GCS and GOS at discharge. Number of death were 15 (50%) patients in group-A and 13 (43%) patients in group-B. There was no significant difference in mortality rate between two groups but outcome was relatively better in group-B. According to Glasgow Outcome Scale, dependency in group-A and group-B was 26.6% and 23.4% respectively. So dependency were more in group-A. But there was no significant difference statistically. Seven (23.4%) patients were independent in group-A but 10(43.3%) patients were independent in group-B. However in relative terms of outcome of group-B was better than that of group-A. In our study we found no statistically significant difference in outcome between medical and surgical management of primary intracerebral haemorrhage.

Identification of potential targets in Staphylococcus aureus N315 using computer aided protein data analysis

Staphylococcus aureus is a gram positive bacterium, responsible for both community-acquired and hospital-acquired infection, resulting in a mortality rate of 39%. 43.2% resistance to methicilin and emerging resistance to Fluroquinolone and Oxazolidinone, have evoked the necessity of the establishment of alternative and effective therapeutic approach to treat this bacteria. In this computational study, various database and online software are used to determine some specific targets of Staphylococcus aureus N315 other than those used by Penicillin, Quinolone and Oxazolidinone. For this purpose, among 302 essential proteins, 101 nonhomologous proteins were accrued and 64 proteins which are unique in several metabolic pathways of S. aureus were isolated by using metabolic pathway analysis tools. Furthermore, 7 essentially unique enzymes involved in exclusive metabolic pathways were revealed by this research, which can be potential drug target. Along with these important enzymes, 15 non-homologous proteins located on membrane were identified, which can play a vital role as potential therapeutic targets for the future researchers.

Is there a difference in perioperative mortality between cemented and uncemented implants in hip fracture surgery?

INTRODUCTION

Although cemented implants have proven beneficial over uncemented implants for treatment of displaced sub-capital proximal femoral fractures, there are concerns regarding the haemodynamic consequence of using cemented implants in hip fracture patients. National Patient Safety Agency recently issued an alert regarding the use of cement in hip fracture surgery. We compared the incidence and pattern of 48 h perioperative mortality between patients receiving cemented and uncemented implants after hip fracture surgery.

METHODS

Using data prospectively recorded in hospital care records, we retrospectively reviewed the case records of all patients who died in hospital following hip fracture surgery between January 2005 and April 2010. We recorded demographic variables, type of fracture, implant used, medical co-morbidity, seniority of operating surgeon and anaesthetist, perioperative haemodynamic status, time and cause of death.

RESULTS

We identified 15 cases of perioperative death (PoD) over a 64-month period. PoD was 1% (15/1402). Eight of 15 deaths occurred following cemented hemiarthroplasty insertion. There were four cases of intra-operative death, two of them were following cemented hemiarthroplasty insertion. PoD following cemented hemiarthroplasty was 2.54% (8/314) and nil (0/168) following uncemented Austin-Moore hemiarthroplasty. Operations were performed by both trainees (six) and consultants (two). Both trainees (five) and consultants (three) anaesthetised the patients. None of the patients belonged to American Society of Anesthesiologists (ASA) I or II (ASA III 5 and IV 3). All patients had significant cardiovascular or pulmonary co-morbidity. Apart from the cases of immediate haemodynamic collapse and death, cemented implant insertion was followed by intra-operative haemodynamic instability in 2/15 and perioperative instability in 3/15 patients. Post-mortem was performed in 3/8 patients: 2/3 demonstrated pulmonary embolism (PE), 1/3 bronchopneumonia. Of the rest, 3/5 had suspected myocardial infarction (MI).

CONCLUSION

There was 1% risk of perioperative death after hip fracture surgery. Risk of perioperative death was significantly higher following cemented implant insertion. Mortality risk was exacerbated in patients with pre-existing cardiovascular morbidity and was independent of the seniority of the surgeon or the anaesthetist.

Immune functions of the garment workers

BACKGROUND

Occupational exposure to cotton dust, fibers, metal fumes and different chemicals used in the aparrel manufacturing industries cause a wide range of physical and psychological health problems in the garment workers that may also affect their immune function.

OBJECTIVE

To assess the immune system function in garment workers.

METHODS

A total of 45 workers of a garment factory, and 41 control subjects, not exposed to the garment working environment were enrolled in this study. In the study subjects, the complement system function was assessed as bactericidal activity on Escherichia coli DH5α cells using the standard plate count method. Serum complement components C3 and C4 were measured by immunoprecipitation, and IgG was measured by immunonephelometry.

RESULTS

The bactericidal activity of serum complement in the garment workers (range: 93.5%-99.9%) was significantly (p<0.01) lower than that in the controls (range: 98.6%-100%). The heat-inactivated serum of the workers showed a significantly enhanced bactericidal activity. In the garment workers, the mean levels of complement C3, and C4 were 1.75 and 0.26 g/L, respectively that were close to those of the controls. The mean IgG level in the garment workers was 13.5 g/L that was significantly (p<0.001) higher than that in the controls.

CONCLUSION

Working in a garment factory may affect the immune system.

Long-term survival in an un-operated single ventricle

Single ventricle is a rare and complex congenital heart disease. Neonates with single ventricle have a high mortality. Survival into adulthood is rare without surgical intervention. A case of single ventricle with double inlet and double outlet combined with severe valvular pulmonary stenosis and mitral regurgitation (Grade II) is being reported here. A 36 years old man was admitted for bluish discoloration of lips, tongue and fingers; shortness of breath and recurrent palpitation. His ECG showed atrial fibrillation with fast ventricular rate. Chest X-Ray depicted an enlarged cardiac shadow and right sided pleural effusion. Final diagnosis was made by echocardiogram which demonstrated single ventricle with double inlet and double outlet, severe valvular pulmonary stenosis and mitral regurgitation (Grade II) with good ventricular systolic function.

Anterior cervical discectomy and fusion without instrumentation for cervical spondylosis

This prospective study included 50 patients receiving anterior cervical discectomy and fusion (ACDF) was conducted at Mymensingh Medical College Hospital, Mymensingh, Bangladesh. The study period was 1st July 2006 to 30th June 2010. This study was done to see the functional outcome of surgery in relation to duration of symptoms and age of the patient. The clinical information and relevant imaging of 50 consecutive patients, 41 male and 9 female, was reviewed at 1 year after surgery. All surgery was performed at no more than 2 contiguous levels, by one surgeon. After anterior discectomy alone, or combined with posterior vertebral body margin osteophytectomy, anterior bone grafting was performed at each level using a tricortical autogenous iliac crest bone block inserted under compression. All surgery was completed without internal fixation. A postoperative semirigid cervical collar was prescribed for 2 months. In 50 patients, there were 4 pseudarthroses (8%). Only 4% of the 50 patients had pain related to the donor site. The functional outcome was excellent to good (87.5%) when duration of symptoms less than 1 year and outcome was excellent to good (85.29%) when the age less than 50 years. These results tend to confirm published reports of most expected outcome related to young age and short duration of symptoms. Patients with technically successful fusions were less likely to have postoperative neck pain. Donor site pain was not a significant postoperative complication. ACDF is a safe, cheap and effective procedure for cervical spondylosis. In this series no major operative complications have occurred. No extra expenditure for plate and screw in this procedure.

Large calcified subdural empyema

Subdural empyema is a known disease entity; however, calcified subdural empyema is uncommon. The authors present a case of an 11-year-old boy in whom there was diagnosed a chronic calcified subdural empyema 10 years after an attack of meningitis. The patient had suffered from generalized tonic clonic seizures occurring 2-6 times in a month. A large fronto-temporo-parietal craniotomy was carried out and the subdural empyema filled with numerous uncharacteristic tissue fragments with thick pus together with the partially calcified and ossified capsule was removed. The empyema mass was found to be sterile for bacteria. After the operation, no epileptic seizure occurred and the boy is on sodium valporate. We must emphasize the unusual occurrence of the chronic subdural empyema presenting with calcification-ossification and large size as observed in our case.

Postnatal development of renal function in preterm and term neonates

The study was done to determine the renal function in preterm and term newborn infants in the neonatology unit of the Department of Paediatrics and Labour Ward of the Department of Obstetrics and Gynaecology, Bangabandhu Sheikh Mujib Medical University (BSMMU) during the period of February 2002 to February 2003. Sixty physiologically stable newborn infants were enrolled in this study, 40 of those were preterm and 20 were term. The gestational ages of preterm and term babies were 35.6±4.7 and 39.10±1.41 weeks respectively. Mean weight of preterm babies was 1840±410 gm and term babies was 3150±340 gm respectively. Male to female ratio was1.6:1. The concentration of serum creatinine was high during the first week of life in both the term and preterm babies. The concentration decreased in both the groups during the subsequent 3 weeks. Although creatinine values were significantly high in preterm babies than the term babies at first week (p<0.001), the values reach to almost similar at 3rd week of life. A negative correlation was found between serum creatinine and gestational age (r=0.86, p<0.001). Creatinine clearance was found low at birth, the lowest values being observed in the most premature infants (p<0.0001) and was increased in the subsequent 3 weeks of the study period. Creatinine clearance showed a positive correlation to gestational age from the first week onwards (r=0.87, p<0.001). Fifteen percent preterm babies were hyponatraemic and in all term babies serum level of sodium was within normal limit. Fractional excretion of sodium was high in preterm neonate than the term neonate especially in early weeks of life (p<0.001). The value correlated negatively to gestational age (r=0.67, p<0.001). It was evident from the present study that the renal function is significantly lower in preterm neonates than term neonates. The study also indicates that the maturation of renal function occurs earlier in the term babies than the preterm babies.

Vecuronium and fentanyl requirement in abdominal surgery under combined epidural-general anaesthesia and general anaesthesia alone

Individual effect of epidural block and general anaesthesia is well established in the field of anaesthesiology. But adequate literature is yet not available to give decisive answer regarding the requirement of muscle relaxants and opioid analgesic when the two methods are combined together. In the present study, sixty patients, aged 18-50 years of both sexes with ASA (American Society of Anesthesiologists) grading I and II scheduled to undergo for major abdominal surgery were assigned randomly into two groups (30 in each group), where Group A received general anesthesia and Group B received combined epidural-general anesthesia. The patients with combined technique, epidural catheter tip were placed between T9-10. Ten ml of 0.125% bupivacaine was administered through the epidural catheter. Peripheral nerve stimulator was used to monitor neuromuscular transmission and subsequently to administer incremental dose of neuromuscular blocking drugs. All the patients were pre-medicated with fentanyl (2μg/kg) to reduce intubation reflex. Then the patients of both groups were pre-oxygenated for 3 minute and anaesthesia was induced with thiopental sodium 3-5 mg/kg body weight. Endotrachial intubation was facilitated by vecuronium 0.1mg/kg body weight. Anaesthesia was maintained with 60% N2O in O2 and halothane (0.4 to 0.8%). Fentanyl was given in incremental dose of 0.5 μg/kg to maintain an adequate analgesia. The vecuronium was given at the dose of 0.02 mg/kg, when TOF return to 25% of the base line. The mean±SD requirement of vecuronium in general anaesthesia group was 0.0016±0.00013 mg/kg/min and whereas in combined epidural-general anaesthesia, it was 0.0011±0.00014 mg/kg/min. The requirement of fentanyl was 0.71μg/kg/hr in general anaesthetic group whereas in combined group it was 0.31μg/kg/hr. These findings prompt us to place optimal dosing guidelines so as to avoid overdosing and thus delay recovery and help to get the excellent outcome of the surgery.

Hepatic hydatid cyst presenting as cutaneous abscess

Hydatidosis is a parasitic zoonotic echinococcal infection that affects both humans and other mammals. These diseases are common worldwide but particularly common in sheep and cattle farming regions. Anaphylaxis mediated by IgE is a serious complication of surgery or trauma which necessitates more aware of its clinical features, diagnosis and management. It is important to make a preoperative diagnosis based on the typical image findings, so that particular precaution can be taken not to rupture the lesion. A woman presented with a right upper quadrant cutaneous abscess. USG reveals multiple cystic lesions in the liver arranged in cartwheel appearance, CT disclosed a cystic lesions having daughter cysts, marginal calcifications, marginal enhancement and contiguous abdominal wall abscess, which led to a diagnosis of complicated hepatic hydatid cysts with abdominal wall abscess formation. FNAC showed scolices surrounded by chronic inflammatory cells. Abdominal wall abscess may be a presentation of hydatid liver disease.

The sentinel vein

Damage to the dorsomedial branch of the medial dorsal cutaneous nerve is not uncommon in surgery of the hallux. The resultant morbidity can be disabling. In the light of the senior author’s operative observation of a sentinel vein, we undertook a cadaver study to investigate the anatomical relationships of the dorsomedial branch of the medial dorsal cutaneous nerve. This established that in 14 of 16 cadaver great toes exposed via a modified medial incision, there is an easily identified vein which runs transversely superficial and proximal to the nerve. In a prospective clinical study of 171 operations on the great toe using this approach, we confirmed this anatomical relationship in 142 procedures (83%), with no complaint of numbness or pain in the scar at follow-up. We attribute this to careful identification of the ‘sentinel’ vein and the subjacent sensory nerve, which had been successfully protected from damage. We recommend this technique when operating on the great toe.

Pulmonary function status of Kolkata inhabitants of different economic class during rainy and winter seasons

The pulmonary function status of the Kolkata inhabitants was evaluated during rainy and winter seasons. The pulmonary function tests (PFT) of the 1st study was carried out in the months of July to August when the environment is pollution free and the 2nd study was carried out between November to January when the environment is polluted. In the 1st study a total of 162 (male-88, female-74) inhabitants were investigated and again they were repeated in same way in the 2nd study. To evaluate the respiratory function status, Slow Vital Capacity (SVC), Forced Vital Capacity (FVC) and Peak Expiratory Flow Rate (PEFR) were recorded. Forced expiratory volume in one second (FEV1), forced expiratory volume in 1 sec as the percentage of FVC (FEV1%), forced expiratory flow at 200mL-1200 mL, 25-75% and 75-85% were calculated from the same tracings. Males were having higher mean PFT values compared to females because of sex difference. In the 2nd study PFT values were significantly lower compared to 1st study. According to different durations of stay category the PFT values were significantly reduced in winter season. The regression lines showed decrement as the duration of stay on that area was increased and it was more in 2nd study compared to 1st study. In both studies the PFT values found higher in high economic class of people. Between the same economic class of people PFT values were significantly lower in winter season. Respiratory impairments were also found higher during winter and males were having more impairment compared to females. Respiratory impairments in both sexes were more in winter and low economic class of people had maximum respiratory impairments. In rainy season and winter season the respiratory impairments were less in non-smokers. Males had more respiratory function impairments compared to females.

Colles' fracture - is it a signal of osteoporosis?

Asymptomatic post-menopausal osteoporosis is common but some-times associated with pain and deformity. Symptomatic osteoporosis is usually associated with fracture. A 59 years old post-menopausal woman presented with a history of acute low-back-pain. She had menopause for 12 years. She gave history of colles' fracture at about two years back. Her mother died as consequences of femoral neck fracture. MRI of vertebral spine showed demineralization with partial collapse of D6,7,12 and L1 vertebra. Dual energy X-ray absorptiometry of vertebra showed BMD T-score of -4.5. Patient was managed with IV infusion of zoledronic acid, oral intake of vitamin D and calcium supplements and with regular non-weight-bearing exercises. Her condition improved gradually. During post-menopausal period, every women must be aware of osteoporosis and any fracture in that time must be evaluated to rule out osteoporosis.