Screening for antimicrobial residues in poultry eggs in Bangladesh using Charm II radio-receptor assay technique following validation

The aim of the study was to screen for the presence of antimicrobial residues in poultry eggs from Bangladesh using the Charm II radio-receptor assay in the absence of expensive confirmatory instrumentation. This was based on cut-off values as set in the validation guidelines according to Commission Decision 2002/657/EC and Commission Implementing Regulation (EU) 2021/808. Fortified eggs spiked with fixed concentrations of doxycycline, erythromycin A, sulphamethazine, and benzylpenicillin were used to determine the cut-off values and detection capabilities (CCβ). Other validation parameters included were applicability, ruggedness, and robustness. A total of 201 egg mix samples from native organic chicken, duck, and commercial farm-raised laying hens (both brown and white eggs) were tested and after analysis 13%, 10%, and 4.5% of the egg mix samples showed positive signals for sulphonamides, macrolides/lincosamides, and tetracyclines, respectively. Presence of multiple drug residues were also suspected in 11 out of 201 egg mix samples.

Frequency and outcome of thrombocytopenia in neonates who are at risk of developing thrombocytopenia - a prospective observational study

Thrombocytopenia is the commonest hematological abnormality encountered in the neonatal intensive care unit (NICU). This prospective, observational study was conducted among 78 consecutive at-risk neonates admitted in NICU, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka from September 2016 to August 2017. Platelet count was measured in all at risk neonates at enrollment and less than 1,50,000/cmm was consiered as the cut off point for determining thrombocytopenia. Platelet count was measured every alternate day till discharge or normalisation of platelet count if the initial platelet count was low. If initial platelet count revealed normal, then the babies were followed up clinically if they develop any further risk condition for developing thrombocytopenia. During the period from enrollment to discharge, if any baby develops thrombocytopenia at any time then baby was defined as thrombocytopenic. Overall 39.7%patients found to be thrombocytopenic among 78 at-risk neonates. Pregnancy induced hypertension (PIH), neonatal sepsis and small for gestational age (SGA), intra uterine growth restriction(IUGR), prematurity, necrotizing enterocolitis (NEC) were significantly associated with thrombocytopenia. Sepsis and NEC were found to be independent risk factor for thrombocytopenia. Regarding outcome, length of hospital stay was significantly more in thrombocytopenic patients than non-thrombocytopenic patients. Death rate was also higher in thrombocytopenic patients in comparison to non-thrombocytopenic patients. BSMMU J 2022; 15(2): 115-120

Clinical Risk Index for Babies II Score as a Predictor of Neonatal Death among Preterm Low Birth Weight Babies

Clinical risk index for babies II (CRIB II) score is simple, validated and widely used risk-adjustment instrument for predicting mortality among preterm low birth weight babies. To assess the efficacy of CRIB II score as a tool to predict the risk for neonatal death among the preterm and LBW babies admitted in NICU of BSMMU, a tertiary care hospital in Bangladesh. This prospective observational study was conducted in Department of Neonatology in BSMMU from September 2016 to August 2017. Inborn preterm neonates with gestational age ≤34 weeks admitted were enrolled in the study. CRIB-II score was calculated for each infant within 1 hour of birth from birth weight, gestational age, sex, admission temperature and base excess. The primary outcome measured in the study was neonatal death or survival up to 28 days. Total 112 patients were finally analyzed in this study. Mean CRIB II score was significantly higher in the non-survivor group compared to the survivor group (p-value <0.0001). Receiver operating characteristic (ROC) curve analysis for mortality prediction by CRIB II score, gestational age and birth weight showed AUC 0.87 (95% CI 0.76-0.97), 0.76 (95% CI 0.63-0.88) and 0.79 (95% CI 0.66-0.92) respectively. ROC curve analysis also revealed that the most suitable cut-off points for predicting mortality were 5 for CRIB II score, 32 weeks for gestational age and 1250 gram for birth weight. Using these most suitable cut-off points, CRIB II score had the highest sensitivity and specificity followed by birth weight and gestational age. In this study, CRIB II score was found to be an effective tool for predicting neonatal death among preterm LBW babies. It predicted outcome more accurately than birth weight or gestational age alone.

Early Versus Delayed Enteral Feeding for Achieving Full Feeding in Preterm Growth-Restricted Infants: A Randomized Clinical Trial

Optimal enteral nutrition is essential for growth restricted preterm infants because if nutrition remains suboptimal during early days of life, physical and neuro-developmental outcome might be in danger. However, chronic hypoxia during antenatal period makes them susceptible for feeding intolerance and necrotising enterocolitis during post natal period. So this randomized clinical trial was conducted in the department of Neonatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from January 2018 to June 2019; to evaluate the effect of early versus delayed enteral feeding on preterm growth-restricted infants. During the study period, out of 127 infants with small for gestational age, 50 babies were enrolled and randomly assigned to either early feeding group (n=25) or late feeding group (n=25). Clinical characteristics at trial entry were well balanced between groups. Newborn enrolled in early feeding group reached full feed significantly faster than late feeding group (p=0.001; Hazard ratio 1.24). Early feeding group regained birth weight faster; experienced lesser incidence of neonatal sepsis, experienced less number of feed intolerance, had shorter mean duration of hospital stay and achieved higher weight on post natal age 16th days. All values were statistically significant. Early enteral feeding found to be safe and beneficial in reducing the time to reach full enteral feeding and better weight gain in growth restricted preterm infants.

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.

Antenatal Bartter Syndrome: A Case Report

Bartter syndrome is an autosomal recessive disorder manifested by a defect in sodium-potassium-chloride transport in the thick ascending limb of Henle with different genetic origins and molecular pathophysiology. Bartter syndrome usually a common disease in children and in early infancy presented with persistent polyuria and associated with dehydration, electrolyte imbalance, and failure to thrive. Though prompt diagnosis and proper treatment of Bartter syndrome may improve the outcome, some children will progress to renal failure. We report a case of a 6 days-old male infant who was admitted in Neonatal Intensive Care Unit, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh on 26 April 2018 for prematurity and low birth weight. On subsequent follow up he developed electrolyte imbalance and failure to thrive. Laboratory studies revealed hyponatremia, hypochloremic metabolic alkalosis with severe hypokalemia. When excessive chloride losses appear to be renal in origin and the patient has normal blood pressure and high levels of serum renin and aldosterone were considered as Bartter syndrome. Molecular genetic studies are indicated to identify the primary genetic defect.

Risk Factors and Complications of Newborns with Birth Defect: A Hospital based Case-Control Study

Background: Birth defect is one of the most important causes of neonatal mortality worldwide. In a developing country like Bangladesh many possible factors for birth defects are present which should be identified. This study was performed to determine those risk factors of birth defect and complications associated with it. Materials and Methods: A hospital based matched case-control study was conducted from August 2015 to July 2016 in department of Neonatology along with Obstetrics and Gynecology at BSMMU. A total of 98 mother-infant pair (49 babies with birth defect as cases and 49 healthy babies without any birth defects as controls) was included in the study. For each case, a gestational age, sex and post-natal age matched control was taken. Data was collected by face to face interview. Univariate and multivariate conditional logistic regression models were computed to examine the effect of independent variables on outcome variable using SPSS 23.0. Variables with p-value <0.05 were considered statistically significant. Results: The mean (± SD) birth weight for cases and controls were 2718.37 (±756.9) grams, and 2617.14 (±978.8) grams respectively. Cardiovascular system was the predominant system (21%) involved in birth defects. Maternal age between 20-29 years (AOR: 4.69; 95% CI 1.078, 20.448), less than four antenatal care visits (AOR: 10.07; 95% CI 2.816, 36.0), no multivitamin intake (AOR: 7.38; 95% CI 1.791, 30.365) and presence of maternal diabetes (AOR: 0.194; 95% CI 0.047, 0.799) were significantly associated with birth defects among newborns. Sepsis, asphyxia, hypoglycemia and dyselectrolytemia were the most prevalent problems among these babies. The need of intravenous fluid, thermal care, antibiotics and mechanical ventilation was also high among the cases. Conclusion: Birth defect is an upcoming issue in current newborn health situation which need to be prioritized. Significant risk factors should be addressed timely for early diagnosis and proper management of these babies can help in reduction of mortality. Bangladesh Journal of Medical Science Vol.19(1) 2020 p.133-140

Off-Label Medication in Children: Responsibilities of Pediatrician and Neonatologist

Use of drug in pediatrics and neonatology should be rational. There are clinical situations when the use of unlicensed medicines or use of medicines outside the terms of license (i.e., 'off-label') may be judged by prescriber in the best interest of the patient. Off-label prescribing is clinically appropriate when the benefits outweigh the potential risks. Such practice is particularly common in pediatrics and neonatology where development of age-appropriate formulations is difficult. Before going to prescribe a drug on off-label basis, the clinician should be satisfied that an alternative medicine would not meet the patient's needs. The clinician should be satisfied that there is sufficient evidence base safety and efficacy on off-label drug use. Communication with legal guardian with sufficient information about proposed treatment is needed. The clinician has a responsibility to monitor the off-label use of drug. He should submit a report on suspected adverse drug reactions if he observes to the authorized body.

Randomized Controlled Trial between Levetiracetam and Phenobarbital in the Treatment of Neonatal Seizure due to Perinatal Asphyxia

Background: Seizure occurs more frequently in neonatal period and incidence of seizure is 50%-68% in perinatal asphyxia. At present phenobarbital is the drug of choice for treating neonatal seizure, which has some adverse effects on neurodevelopment status. Levetiracetam is a novel antiepileptic agent well-tolerated and effective in focal, generalized and neonatal seizure as well and lacks the adverse effects like phenobarbital. The present study was undertaken to compare the safety and efficacy of levetiracetam to phenobarbital in the treatment of neonatal seizure due to perinatal asphyxia.Methodology: This interventional study (Randomized Controlled Trial) was conducted in Department of Neonatology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka and Dhaka Medical College Hospital, Dhaka, Bangladesh from 1st January’ 2014 to 30th June’ 2015. Intravenous levetiracetam injection, 50 mg/kg loading followed by 10 mg/kg 8 hourly maintenance was used and phenobarbital intravenous 20-40 mg/kg loading and 2.5 mg/kg/dose 12 hourly maintenance was given as per institutional protocol.Results: Sixty-nine term asphyxiated neonates (intention to treat population) provided analyzable data. Seizure control was found significantly higher (p = 0.011) higher in levetiracetam group in comparison to phenobarbital group (71% vs 40%). Need for more than one drug was significantly lower in levetiracetan group (p=0.011). Adverse effects were found significantly (p=0.001) lower in levetiracetam group (9% vs 43%). No serious adverse effect was observed in any group and most common adverse effect was somnolence in both group followed by irritability. Restlessness, sedation and shallow breathing were found only in phenobarbital group.Conclusion: Levetiracetam is more effective and safe in comparison to phenobarbital in the treatment of neonatal seizure due to perinatal asphyxia.Bangladesh J Child Health 2018; VOL 42 (2) :67-72

Pyrolysis and co-composting of municipal organic waste in Bangladesh: A quantitative estimate of recyclable nutrients, greenhouse gas emissions, and economic benefits

Waste causes environmental pollution and greenhouse gas (GHG) emissions when it is not managed sustainably. In Bangladesh, municipal organic waste (MOW) is partially collected and landfilled. Thus, it causes deterioration of the environment urging a recycle-oriented waste management system. In this study, we propose a waste management system through pyrolysis of selective MOW for biochar production and composting of the remainder with biochar as an additive. We estimated the carbon (C), nitrogen (N), phosphorus (P) and potassium (K) recycling potentials in the new techniques of waste management. Waste generation of a city was calculated using population density and per capita waste generation rate (PWGR). Two indicators of economic development, i.e., gross domestic product (GDP) and per capita gross national income (GNI) were used to adopt PWGR with a projected contribution of 5-20% to waste generation. The projected PWGR was then validated with a survey. The waste generation from urban areas of Bangladesh in 2016 was estimated between 15,507 and 15,888 t day^-1 with a large share (∼75%) of organic waste. Adoption of the proposed system could produce 3936 t day^-1 biochar blended compost with an annual return of US $210 million in 2016 while it could reduce GHG emission substantially (-503 CO₂ e t^-1 municipal waste). Moreover, the proposed system would able to recover ∼46%, 54%, 54% and 61% of total C, N, P and K content in the initial waste, respectively. We also provide a projection of waste generation and nutrient recycling potentials for the year 2035. The proposed method could be a self-sustaining policy option for waste management as it would generate ∼US$51 from each tonne of waste. Moreover, a significant amount of nutrients can be recycled to agriculture while contributing to the reduction in environmental pollution and GHG emission.

An icteric newborn with bad obstetric history

No abstract

Immediate Outcome of Preterm Neonates with Respiratory Distress Syndrome Required Mechanical Ventilation

Since its inception, the neonatal mechanical ventilator has been considered an essential tool for managing preterm neonates with Respiratory Distress Syndrome (RDS) and is still regarded as an integral component in the neonatal respiratory care continuum. Mechanical ventilation of newborn has been practiced for several years with several advances made in the way. This clinical intervention study was done to analyze immediate outcome of preterm neonates with RDS required mechanical ventilation and conducted on preterm neonates with RDS required mechanical ventilation from July 2014 to June 2015. Total of 31 preterm neonates with RDS were mechanically ventilated during the study period, of which 77.42% (N=24) survived. The survival rate was highest among 30- <34 weeks (100%) gestational age (GA) group and lowest in 27- <30 weeks (56%) GA, (p=0.0036). The neonates with Birth Weight (BW) 1500gm -1800gm were higher rate of recovery which was 100% and gradually declined in 1000-1499gm (93.75%) and 800-999gm (33.33%) BW groups (p=0.00083). In this study most of the neonates were male (61.29%) but recovery rate was relatively better among baby girls (83.33%) than baby boys (73.68%) (p=0.53). RDS with surfactant therapy was better outcome than non surfactant group & survival of neonates who got surfactant were 93.33% & non surfactant neonates were 62.50%, (p=0.040). Majority (71.43%) of RDS with surfactant therapy recovered earlier <7 days than non surfactant therapy neonates (30.00%) and most of non surfactant neonates (70.00%) required prolonged ventilator support >7days (p=0.045). During the period of ventilation a total 17(54.84%) neonates developed different complications, of which ventilator associated pneumonia was (16.13%), sepsis (16.13%), pneumothorax (9.68%), pulmonary hemorrhage (6.45%) and intraventricular hemorrhage (6.45%) and among them 10 neonates recovered. No complications encountered in 14(45.16%) neonates, all of them survived, (p=0.0064). All (N=31) preterm neonates were candidate for surfactant therapy but only 15 neonates got surfactant therapy, remaining (N=16) did not get for their financial issue. As mechanical ventilation with surfactant therapy reduces the neonatal mortality; hence, facilities for neonatal ventilation and cost effective surfactant therapy should be included in the regional and central hospitals providing intensive care for neonates.

Predicting Neonatal Hyperbilirubinemia Using First Day Serum Bilirubin Level in Late Preterm and Term Healthy Newborn

Hyperbilirubinemia is a common problem during the neonatal period and is the most common reason for readmission after early hospital discharge of the healthy near term and term infants. This early discharge policy along with limited follow-up facilities in developing countries and inadequate communication between physicians and parents necessitates a prognostic test to predict hyperbilirubinemia in these newborns; for early and effective management and prevention of potential complication before it occurred. This observational analytical study was done to determine the predictability of day1 total serum bilirubin (TSB) level as a screening test and identify the best cutoff value which would predict neonates likely to develop significant hyperbilirubinemia. The study was carried out in the Department of Neonatology and Department of Gynecology and Obstetrics, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from 1st April 2013 to 31st March 2014. A TSB level of ≥17mg/dl after 72 hours was defined as significant hyperbilirubinemia. By purposive sampling method, 100 healthy late preterm and term neonates fulfilling the inclusion criteria were enrolled and 89 were finally analyzed. Among 89 neonates 14(15.74%) developed significant hyperbilirubinemia (Group II) and 75(84.26%) did not develop hyperbilirubinemia (Group I). Mean time of sample collection was similar in both groups. Mean TSB level on day1 was significantly higher in Group II (5.97±1.74mg/dl) than Group I (3.19±1.4mg/dl). By using ROC (Receiver Operating Characteristic) analysis, TSB level of 5.65mg/dl on day 1 has the best combination of sensitivity (86%) and specificity (91%) to predict neonates at risk of significant hyperbilirubinemia (AUC-0.880, p=0.001). At this cut-off PPV was 63% and NPV 97%. Total serum bilirubin level on first day of life predicts neonates at risk of subsequent significant hyperbilirubinemia and late preterm and term babies with TSB level of ≥5.65mg/dl on day 1 of life should be followed up strictly either in the hospital or in the outpatient department on day 5.

Neonatal Hyperbilirubinemia associated with Minor Blood Group Incompatibility: Two Case Reports

Abstract not availableBangladesh J Child Health 2017; VOL 41 (1) :64-66

Comparison of Serum Bilirubin with Transcutaneous Bilirubinometry in Late Preterm and Term Newborn

Neonatal jaundice or hyperbilirubinemia is a common occurrence in newborns. It can progress to develop kernicterus unless intervention is initiated. Severity and decision for management are usually based on serum bilirubin which needs blood sampling. Transcutaneous bilirubin measurement is a noninvasive technique and correlates closely with serum bilirubin. This Cross sectional study was done in the Department of Neonatology, Bangabandhu Sheikh Mujib Medical University from March 2013 to August 2014 to evaluate the transcutaneous bilirubin in comparison to serum bilirubin. Total 160 infants with ≥35 weeks were purposively included over a period of 16 months. Neonates with less than 35 weeks, previously exposed to phototherapy, serious illness which leads to impaired circulation, who have had exchange transfusion, having major congenital malformation were excluded. Transcutaneous bilirubin measurement was performed within 30 minutes of obtaining sample for total serum bilirubin measurements. Of the enrolled infants, mean birth weight was 2631±520 grams, postnatal age was 4.99±3.02 days ranging from 2 to 25 days and mean transcutaneous bilirubin and serum bilirubin value was 14.59±2.55 and 13.62±2.86mg/dl respectively. Mean difference of transcutaneous bilirubin and serum bilirubin was 0.97±1.01mg/dl. In the total enrolled infant, transcutaneous bilirubin and serum bilirubin values showed significant correlation (r = 0.93, r2 = 0.876, p<0.001) and this was not affected by sex, gestational age, postnatal age, and birth weight. The area under ROC curve for transcutaneous bilirubin was 87% (p value <0.001). If the cut off value of transcutaneous bilirubin was set at 15 mg/dl, then a sensitivity of 77%, specificity of 88% and accuracy of 82% were obtained. Use of transcutaneous bilirubin can reduce need for serum bilirubin in assaying neonatal jaundice; as it showed significantly high correlation with serum bilirubin. Predictive accuracy of transcutaneous bilirubin was found to be statistically significant in comparison to serum bilirubin.

Randomized Controlled Trial of Slow Versus Rapid Enteral Feeding Advancements on the Clinical Outcomes in Very Low Birth Weight Neonates

Starting and advancement of feeding in very low birth weight (VLBW) infants are big challenges for the neonatal practitioners. Wide variations in volume of feed advancement have observed in earlier trials both in slow and rapid advancement groups. Volume advancement in slow advancement groups have ranged from 10ml/kg/day to 23ml/kg/day and in rapid advancement groups have ranged from 15ml/kg/day to 45ml/kg/day in earlier different studies. This randomized controlled trial was conducted in neonatal intensive care unit (NICU) of Bangabandhu Sheikh Mujib Medical University (BSMMU) from April 2013 to July 2014 to evaluate the effects of slow versus rapid rates of feeding advancements on the clinical outcomes in very low birth weight infants. A total 95 infants were enrolled into two strata according to their birth weight. Infants of each stratum were randomly allocated to either slow or rapid advancement group during initiation of feeding. After gut priming over five days, feeding was advanced daily 10ml/kg in slow and 15ml/kg in rapid advancement group for 1000 - <1250gm weighing infants. For 1250 - <1500gm weighing infants, feeding was advanced daily 15ml/kg in slow and 20ml/kg in rapid advancement group. The primary outcome variable was time taken to achieve full enteral feed. Total 82 infants completed the trial. Demographically both groups were same. Infants in the rapid feeding advancement group achieved full enteral feedings before the slow advancement group, had significantly fewer days of parenteral nutrition and regained birth weight earlier. There were no statistical differences in episodes of feed interruption, number of infants with apnea, feed intolerance or diagnosis of sepsis. Rapid enteral feeding advancements were well tolerated by very low birth weight infants.

Retinopathy of prematurity and its association with neonatal factors

<p>Retinopathy of prematurity is considered as an important cause of blindness. This prospective study was undertaken to document the frequency and the associated factors of retinopathy of prematurity among 97 preterm newborn weighing &lt;2000 g and/or with a gestation of &lt;35 weeks. The first eye examination was performed by an ophthalmologist at 4 weeks of postnatal age for the infants born at ≥30 weeks of gestation or birth weight ≥1200 g and at 3 weeks of postnatal age for the infants &lt;30 weeks of gestation or birth weight &lt;1200 g. The overall incidence of retinopathy of prematurity was 23.7%. Premature newborn with retinopathy was having significant low mean birth weight (p=0.001) and the mean gestational age (p=&lt;0.001) when compared with newborns without retinopathy of prematurity. Newborns with retinopathy of prematurity were requiring a longer duration of oxygen (p=0.005) than that of non-retinopathy of prematurity newborns. Logistic regression shows the duration of oxygen in the hospital and lower gestational age were independent risk factors of retinopathy of prematurity. Prematurity and longer duration of oxygen administration were the risk factors for the development of retinopathy of prematurity.</p>

Granulomatosis with Polyangiitis (Wegener Granulomatosis) with Unusual Presentation

We came across a 32 years old male admitted in our hospital with prolonged low-grade fever, haemoptysis, leg swelling, weight loss, purpuric rashes and malaena. He received anti-TB treatment at another hospital without any improvement. He was pale with bullous and purpuric lesions over legs and feet. He also had features of consolidation over both lung fields. His CRP was 312mg/L, Urine R/M/E showed 40-50 RBC/HPF, Chest X-ray showed features of bilateral consolidation, c-ANCA-10U/L (positive); Tracheal aspirate for AFB was found to be negative. We diagnosed the case as Granulomatosis with Polyangitis (WG) and started treatment with steroid and cyclophosphamide. But the patient could not be saved probably due to delay in starting management.

Neonatal Transport - Experience of a Tertiary Care Hospital of Bangladesh

Safe transportation is mostly an unnoticed neonatal health issue in Bangladesh and no documentation is available regarding the existing practices. So this study was intended to document transport status of the referred newborn to a tertiary care hospital. This observational study included 150 out born neonates over 12 months period transported from various places to NICU, Bangabandhu Sheikh Mujib Medical University (BSMMU) from May 2015 to April 2016. A structured data collection form was used to record information categorized into pre-transport, during transport and at admission. At admission detailed clinical assessment of the baby was done and recorded. Outcome was determined as discharge or death. Of 150 transported neonates, two-third were preterm 115(77%) & LBW 113(75%). Common indications for referral were prematurity and sepsis. Most of the patients were referred from private hospital 107(71%). Majority of newborns (86%) were referred from hospitals of Dhaka city while only 14% were referred from outside Dhaka. Referral notes were supplied in most of the cases 134(89%) but comprehensive information was obtainable only in 3 cases. Although main transport vehicle was ambulance 130(87%), medical personnel accompanied the sick baby only in 6(4%) of cases. The distance traveled was less than 10 kilometers (kms) in 95(63%) and more than 100 km in 10(7%) of enrolled neonates. Transport time was less than 1 hour in 72(48%), 1-6 hours in 66(44%) and more than 6 hours in 12(8%) of cases. Nearly two third of newborn were transported after office period, 107(72%). At admission 21(14%) babies had hypothermia, 8(7.62%) hypoglycemia, 16(11%), poor perfusion 28(19%), low saturation 27(18%). Hyperthermia & hyperglycemia were observed in 8(5%) & 7(5%) cases respectively. Of the total 150 babies referred, 17(11%) died. While comparing with discharged newborn, died newborn were more frequent sufferer of hypothermia (p value 0.007) and low saturation (p value 0.049) at admission. Premature, low birth weight and sick newborns are being transported despite lack of safe transport system.

Local flap for reconstruction of nasal defect following excision of basal cell carcinoma of nose

<p class="Abstract">Reconstruction of soft tissue at the nose following excision of basal cell carcinoma is always challenging, because of both functional and aesthetic importance of nose. The local flap is always preferable to skin graft as this produces “like with like” replacement, pliable cover and vascularized tissue over the skeletal framework. In this paper, we discussed six cases of nasal reconstruction with bilobed flap, forehead flap, and nasolabial flap. All flaps survived and the patients had satisfactory outcome.</p>

Efficacy of prophylactic phototherapy for prevention of hyperbilirubinemia in very low birth weight newborns

<p><strong>Background:</strong> Jaundice is a common clinical condition in newborn occurring in approximately 60% of term and 80% of preterm infants. Unconjugated hyperbilirubinemia is universally common in all preterm infants especially in newborns with very low biLth weight. Low birth weight and premature infants are at major risk for exaggerated hyperbilirubinemia that can lead to bilirubin encephalopathy. Significant heterogeneity in the approach to the treatment of jaundiced neonates exists throughout the world. Phototherapy is the most common treatment for neonatal hyperbilirubinemia and could be most effective in preventing the sequelae of hyperbilirubinemia if initiated prophylactically. This randomized clinical trial has been proposed with the objective of assessing the efficacy of prophylactic photo therapy in preventing significant rise of unconjugated hyperbilirubinemia in premature neonates weighing less than 1500 gram and therefore to decrease the need for exchange transfusion and finally to reduce hospital stay due to hyperbilirubinemia. <strong></strong></p><p><strong>Methods:</strong> This randomized controlled clinical trial enrolled sixty newborns with birth weight less than 1500 gram. They were divided into two groups: 1) Prophylactic group, in whom phototherapy was started within 24 hours of birth and continued for 7 days and 2) Control group in whom therapeutic phototherapy was started considering serum bilirubin level and other clinical condi­tions as per institutional guidelines. Mean value of total serum bilirubin (TSB), duration of phototherapy, the need for exchange transfusion and duration of hospital stay in both groups were analyzed.</p><p><strong>Results:</strong> The maximum mean TSB level in prophylactic group was observed on 7th day and in control group it was observed on 3rd day of life. The total serum bilirubin levels were significantly lower in the 3rd and 5th days of life in the prophylactic group in comparison to control group (P value 0.001). Total serum bilirubin level exceeded therapeutic range in 6 (21 %) and 14 (50 %) newborns of the prophylactic group and control groups respectively (P value 0.026). No documented side effects of prophylactic photo­therapy was observed.<strong> </strong></p><p><strong>Conclusion:</strong> The use of prophylactic photo therapy for infants weighing less than 1500 grn is effec­tive and sate when compared to the control group, considering satisfactory maintenance of low total serum bilimbin levels during first 7 days of life.</p>

A Survey on Current Practice of Management of Early Onset Neonatal Sepsis

It was a survey type of cross sectional study where the participants were from different teaching/referral hospital across the country and was done to gather information regarding current practice of management of neonatal sepsis among paediatricians and neonatologists and was conducted on the spot during a national conference of Bangladesh Perinatal Society in December 2013. Specialists in neonatology, paediatrics, and some other disciplines working in different institutes across the country were requested to respond. Out of 150 physicians, 92 (61.33%) were neonatologists. Physicians suspected early onset neonatal sepsis (EONS) when there is history suggestive of prolonged rupture of membrane (74.77%), prolonged labour (9.33%), chorioamnionitis (7.33%) and maternal fever (2%). Clinical sepsis is found commonly (53.33%) which is later proved by laboratory evidences such as Hb%, TC, DC PBF (peripheral blood film), C-reactive protein, chest X-ray etc. Injection Ampicillin and Gentamycin are still the first choice of antibiotics (61.3%). Preferred route was intravenous (95.3%). Antibiotics were given for 7-10 days by most of the physicians (48.77%). However there is lack of uniformity among the participants in regard to taking decision about antibiotics, the choice of first line and the subsequent options of antibiotics. So, neonatal sepsis is the most important cause of neonatal mortality in the community. Therefore a standard protocolized approach for diagnosis and management of Early Onset Neonatal Sepsis may prove critical which is currently not in practice uniformly.

Neonatal Conjunctivitis Leading to Neonatal Sepsis--A Case Report

Neonatal conjunctivitis is the most common occular disease in neonates. Most infections are acquired during vaginal delivery. In spite most of these cases are benign; some of them may progress to systemic complications like loss of vision if left untreated. The authors present a case of a newborn who developed late onset neonatal sepsis from E. coli positive conjunctivitis. The baby was treated with Injection Meropenem and Injection Amikacin for 10 days. The course was uneventful, after that baby responded well and discharged home on 24th day.

Salt Losing Variety of Congenital Adrenal Hyperplasia--A Case Report

Congenital adrenal hyperplasia is a genetic endocrinologic disorder. The severe classic form occurs in one in 15,000 births worldwide. Twenty-one-hydroxylase deficiency (21-OHD) is the most common cause in this autosomal recessive disease. It can cause virilization, ambiguous genitalia at birth and severe life threatening condition due to salt wasting. In this report we describe the clinical course of a male neonate presenting with lethargy, failure to thrive (FTT), genital pigmentation, electrolytes imbalance and high serum 17-hydroxy-progesterone (17-OHP) level and subsequently diagnosed as Congenital Adrenal Hyperplasia. After the initial crises management, the child was continued on replacement therapy. During the follow up, he was found to grow appropriately and achieving normal milestones for age.

Brinjal shoot and fruit borer infestation in relation to plant age and season

Brinjal shoot and fruit borer infestation varied significantly in relation to plant age and season. The peak shoot infestation was 8.56% in the 10th week of transplanting. No infestation of BSFB was found up to 5 weeks of transplanting. The shoot infestation was initiated in the 6th week of transplanting which increased to a little higher level in the next week. Then it showed an exponential increase of shoot infestation up to 10th week after which it declined steadily. Flowering and fruit setting started in the 9th week of transplanting. Infestation of brinjal shoot and fruit borer (BSFB) shifted to fruits from shoots causing a steady declined in the trend of shoot infestation. Plant age had significant effect (r2=0.87) on fruit infestation. The fruit infestation reached the highest level (38.56%) in 14th week of transplanting. However, the level of infestation at different ages of the plant may vary depending on the location, temperature, variety etc. The shoots and fruits of brinjal plant were found to be infested by BSFB throughout the year, although the level of infestation varied. Maximum shoot and fruit infestation was found in the month of September.Bangladesh J. Agril. Res. 40(3): 399-407, September 2015

Osteopenia of Prematurity: Are We at Risk?

The continuous advances in intensive care have led to increased survival of premature infants. As a consequence, the problem of less imminent, slowly progressing disorders such as osteopenia of prematurity has been emerging. Osteopenia of prematurity (OOP) also called metabolic bone disease of prematurity (MBD) or rickets of prematurity is characterized by a reduction in bone mineral content usually manifest between 6th to 12th weeks of corrected gestational age. It occurs in up to 55% of infants born with weight <1000gm and 23% of infants weighing <1500gm. Clinical features of osteopenia of prematurity are mostly non-specific often appears as a late symptoms. Several biochemical markers have frequently been used as screening tools and diagnostic markers, but timing of measurements and the levels at which treatment should be initiated vary widely. Dual energy X-ray absorptiometry (DEXA) and Quantitative ultrasnogram are important diagnostic tool. Standard X-ray, a widely accepted but cannot detect osteopenia unless 20% loss of bone mineralization. The treatment of osteopenia includes provision of adequate mineral supplementation. Monitoring of serum and urinary markers are mandatory. The focus on prevention has largely centered on providing adequate intake of phosphorus and calcium but more research is needed. Till date there are neither enough data regarding clinical risk factors, valid biochemical markers which can detect premature babies at risk of osteopenia nor supplementation as well as appropriate timely management protocol is practicing in Bangladesh.

Identification of bacterial isolates in neonatal sepsis and their antimicrobial susceptibility

A cross-sectional descriptive study was conducted in the Neonatal Intensive Care Unit (NICU) of Ad-din Medical College Hospital during the period of January to December 2011 to determine the pattern of bacterial agents causing neonatal sepsis and their susceptibility pattern to various antimicrobial agents. Blood cultures were performed on admitted newborn babies (0-28 days) to rule out sepsis. Antimicrobial susceptibility testing was done for all blood culture isolates according to the criteria of the National Committee for Clinical Laboratory Standards by disk diffusion method. Out of 1000 screened blood cultures, 87(8.7%) reported as positive and the gram positive and gram negative bacteria accounted for 21(24.1%) and 66(75.9%) respectively. The most common gram positive organisms were Coagulase Negative Staphylococcus Aureus (CONS) (18.4%) and Staphylococcus Aureus (4.6%) and gram negative organisms were Acinetobacter (34.4%), Pseudomonas (21.8%) and Klebsiella spp. (6.9%). The susceptibilities were remarkably low to Ampicillin (20%) and Cefotaxim (29.6%) for both gram positive & gram negative isolates. Gram positive group had susceptibilities of 71.1% to Gentamicin, 85.7% to Imipenem & 100% to Amikacin & Vancomycin. Gram negative isolates showed higher sensitivities to Colistin (96.9%), Piperacillin-Tazobactum (78.7%), Imipenem (74.2%), Levofloxacillin (71.2%), respectively. Gram-negative bacteria showed high level of resistance to commonly used antibiotics (Ampicillin, Ceftazidim and Cefotaxim). Gentamicin, Amikacin, Imipenem and Levofloxacin were the most effective drugs compared to others. Routine bacterial surveillance and their sensitivity patterns must be an essential component of neonatal care.

Augmented post-induction therapy for children with high-risk acute lymphoblastic leukemia and a slow response to initial therapy

BACKGROUND

Children with high-risk acute lymphoblastic leukemia (ALL) who have a slow response to initial chemotherapy (more than 25 percent blasts in the bone marrow on day 7) have a poor outcome despite intensive therapy. We conducted a randomized trial in which such patients were treated with either an augmented intensive regimen of post-induction chemotherapy or a standard regimen of intensive post-induction chemotherapy.

OBJECTIVE

To compare the effect of augmented therapy with standard intensive post induction therapy in children with high-risk ALL who entered remission after a slow response to initial therapy.

METHODS

Between January 2005 and December 2011, 311 children with newly diagnosed ALL who were either 1 to 9 years of age with white cell counts of at least 50,000 per cubic millimeter or 10 years of age or older, had a slow response to initial therapy, and entered remission at the end of induction chemotherapy were randomly assigned to receive standard therapy (156 children) or augmented therapy (155). Those with lymphomatous features were excluded. Event-free survival and overall survival were assessed from the end of induction treatment.

RESULTS

The outcome at five years was significantly better in the augmented-therapy group than in the standard-therapy group. The difference between treatments was most pronounced among patients one to nine years of age, all of whom had white-cell counts of at least 50,000 per cubic millimeter (P<0.001). Risk factors for an adverse event in the entire cohort included a white-cell count of 200,000 per cubic millimeter or higher (P=0.004). The toxic effects of augmented therapy were considerable but manageable.

CONCLUSION

Augmented post-induction chemotherapy results in an excellent outcome for most patients with high-risk ALL and a slow response to initial therapy.

Newborn hearing screening: what are we missing?

The objectives of the study were to demonstrate hearing status in newborns at first screening by Transient Evoked Otoacoustic Emissions and to find out the relationship between abnormal hearing screening and known risk factors. This study was conducted in the department of neonatology of Bangabandhu Sheikh Mujib Medical University in collaboration with department of otolaryngology and department of obstetrics and gynaecology. This prospective observational study included a cohort of 168 neonates from Neonatal Intensive Care Unit and neonatal Nursery (Minimal care unit). All were screened for hearing impairment using Transient Evoked Otoacoustic Emissions in out-patient department of otolaryngology by a trained audiologist before discharge from hospital. Risk factors analysed were according to the criteria of American Academy of Pediatrics. Of the total neonates screened, Refer rate was 32.7% irrespective of presence or absence of risk factors. Small for gestational age, in-utero infections, ototoxic medications, birth weight < 1500, sepsis/meningitis, hyperbilirubinemia were found to be significant risk factors (p < 0.0001). It can be recommended that hearing screening should be universally done for all newborns.

Clinical experience with BIAsp 30: Results from the Bangladesh cohort of the global A1chieve study

The aim of A1chieve was to remedy the deficit of data on the efficacy and safety of insulin analogues in routine clinical care in less well-resourced developed countries. To present results from the Bangladesh cohort of the A1chieve study receiving BIAsp 30 ± oral anti diabetic drugs. A1chieve was a 6-month, observational study of 66,726 people with type 2 diabetes, started on insulin detemir, insulin aspart or biphasic insulin aspart (BIAsp 30) in 28 countries across four continents. A total of 1,093 subjects were recruited from 49 sites in Bangladesh and 580 subjects initiated on BIAsp 30 were studied. In the entire cohort, treatment with BIAsp 30 for 24 weeks significantly reduced mean HbA(1c) (2.8%, p < 0.001), fasting plasma glucose (4.0 mmol/L, p < 0.001) and post prandial plasma glucose (6.6 mmol/L, p < 0.001) levels from baseline. The rate of overall hypoglycaemic events in the entire cohort also reduced significantly at 24 weeks (1.86 to 0.02 events/person year, p < 0.0001). BIAsp 30 can be considered as a safe and effective option for initiating as well as intensifying insulin therapy for type 2 diabetes.

Short-term outcome of magnesium sulfate infusion in perinatal asphyxia

This randomized, single blind, controlled, clinical trial was done to see the effect of magnesium sulfate infusion in perinatal asphyxia. This study was conducted in the Department of Neonatology, Bangabandhu Sheikh Mujib Medical University and Dhaka Medical College Hospital from January, 2010 to October, 2010. Total 50 term neonates having postnatal age less than 12 hours with history of perinatal asphyxia and had history of hypoxic ischemic encephalopathy (moderate or severe) were included in this study. Patients were assigned randomly to receive either 3 doses of magnesium sulfate infusion at 250mg/kg per dose (0.5ml/kg per dose) 24 hours apart (experimental group) or 3 doses of normal saline infusion 24 hours apart (placebo-controlled group). Both groups also received supportive care according to the unit protocol for perinatal asphyxia. Baseline characteristics of 50 neonates had no differences in gestational age, birth weight, gender, mode and place of delivery, parity, ANC, liquor colour and hypoxic-ischemic encephalopathy (HIE) staging and mean age of intervention between the experimental and controlled groups. The mean serum magnesium at admission was 1.6±0.3mg/dl and 1.8±0.4mg/dl and after 48 hours was 3.9±0.6mg/dl and 1.9±0.2mg/dl in experimental group and in controlled group respectively. There was no significant difference or alteration in colour, heart rate, respiration, capillary filling time/blood pressure and oxygen saturation between the experimental and control groups. At discharge, 26% (5 of 19) of infants in the experimental group had neurological abnormalities, compared with 61% (11 of 18) of infants in the control group. At discharge experimental group were received more (78% vs. 44%) oral feedings by sucking compared with the controlled group. There is no significant difference in Electroencephalographic (EEG) abnormalities between groups. Good short-term outcomes at discharge were seen more (60% vs. 32%) in the experimental group, compared with the placebo-controlled group. The overall mortality rate in our study was 26%. Postnatal magnesium sulfate infusion is effective in improving short-term outcomes in neonate with perinatal asphyxia.

Neonatal Sepsis – A Review

DOI: http://dx.doi.org/10.3329/bjch.v36i2.13084 Bangladesh J Child Health 2012; Vol 36 (2): 82-89

Prevalence and Pregnancy Outcome of Gestational Diabetes Mellitus Among Bangladeshi Urban Pregnant Women

Objective: To assess the prevalence of gestational diabetes mellitus (GDM) among the pregnant women of Dhaka city and to find out the consequences or effects of GDM on pregnancy outcome. Materials and methods: This was a descriptive type of cross sectional study followed by cohort type of study, conducted in different hospitals in Dhaka city. Initially 960 pregnant women of 24th to 28th weeks were selected purposively; plasma glucose was measured at fasting and two hours after taking 75g oral glucose load. Modified method of Carpenter and Coustan criteria was followed to diagnose GDM. For each GDM case diagnosed, one non-GDM pregnant women was taken as control after matching age and parity. Both groups were followed up to 4 wks after delivery to find out maternal and neonatal mortality and morbidities. Results: Out of 960 pregnant women 72 were GDM positive (7.5%).There was no maternal mortality but morbidities like hydramnions (p<0.001)), pre-eclampsia (p<0.001)), urinary tract infection (p<0.05), puerperial sepsis (p<0.05)) and surgical interventions (p<0.001) were more prevalent in GDM compared to non-GDM groups. The prevalence of antipartum haemorrhage, post partum haemorrhage, and eclampsia did not vary between the groups. There was one still birth, one perinatal mortality (due to respiratory distress syndrome) and one congenital anomaly observed in neonates of GDM mothers. More pre-term (p<0.01), post-term (p<0.01), low birth weight (p<0.001) and macrosomic (p<0.001) babies were found among the babies of GDM mothers than non-GDM mothers. More babies also suffered from neonatal jaundice (p<0.05) and respiratory distress syndrome (p<0.05) in GDM groups than non GDM groups. Conclusion: The prevalence of GDM in urban Bangladeshi population is about 7.5%. Maternal morbidities like hydramnios, pre-eclampsia, infections and operative interventions were observed more in GDM mothers. Pre-term, post-term and LBW babies alone with perinatal morbidities like respiratory distress syndrome, macrosomia and neonatal jaundice were more common in babies of GDM mothers. DOI: http://dx.doi.org/10.3329/jom.v13i2.12749 J Medicine 2012; 13 : 147-151

Maternal and foetal risk factor and complication with immediate outcome during hospital stay of very low birth weight babies

This prospective study was done to find out the maternal and foetal risk factors and complications during hospital stay. It was conducted in Special Care Neonatal Unit (SCANU), Department of Child Health, Bangabandhu Memorial Hospital (BBMH), University of Science and Technology Chittagong (USTC) from1st October 2001 to 30th March 2002 and cases were 35 very low birth weight (VLBW) newborns. Common complications of VLBW babies of this series were frequent apnea (40%), Septicemia (25.71%), Hypothermia (17.14%), NEC (14.28%), Convulsion (11.43%), Hyper-bilirubinaemia (8.57%), Anemia (5.71%), IVH (5.71%), RDS (2.86%), HDN (2.86%), CCF (2.86%), ARF (2.86%), either alone or in combination with other clinical conditions. Newborns 62.86% male, 37.14% female & their mortality rate were 40.91% & 38.46% respectively; Preterm 88.57% & their mortality (41.93%) were higher than term babies (25.00%); AGA 62.86%, SGA 37.14% & mortality rate of AGA babies (45.46%) were higher than of SGA (30.77%) babies. The mortality rate of VLBW infants of teen age (≤ 18 years) mothers (57.14%) & high (≥ 30 years) aged mothers (50.00%) were higher than average (19-26 yrs) maternal age mothers (33.33%). Mortality rate was higher among the babies of primi (41.67%) than multiparous (36.36%), poor socioeconomic group (53.33%) than middle class (30.00%) & mothers on irregular ANC (47.83%) than regular ANC (25.00%). It has been also noted the mortality rate of home delivered babies (50.00%) higher than institutional delivered (34.78%) babies; higher in LUCS babies (46.15%) than normal vaginal delivered babies (31.58%); higher in the babies who had antenatal maternal problem (48.15%) than no maternal problems babies (12.50%); higher in the babies who had fetal distress (50.00%) and twin (46.67%) than no foetal risk factors (28.57%) during intrauterine life; higher in the babies who had problems at admission (46.67%) than no problems (35.00%); and mortality higher in twin (46.67%) than singleton babies (35.00%). Maximum VLBW babies who died during hospital stay had multiple problems and mortality was varied from ?60-100%. The babies who had frequent apnea have been carried relative better outcome (mortality rate 35.72%). In this study out of total 35 studied baby 21(60.00%) survived and 14(40.00%) died. Frequent apnea, sepsis, hypothermia, NEC, convulsion, jaundice, anemia, IVH, and RDS are common complications in VLBW babies. Male sex, prematurity, primiparity, average (middle) socio-economic status, irregular ANC, preterm labor, toxemia of pregnancy, prolonged rupture of membrane, malnutrition, multiple gestations and foetal distress are risk factor for VLBW delivery. Clinical outcome depends on maturity, birth weight, centile for weight, maternal age, parity, maternal nutrition & socio-economic status, ANC, place & mode of delivery, maternal problems during antenatal & perinatal period, number of gestation, fetal condition, presentation at admission, postnatal problems, time of start of management & referral and level of care.

Out come of induction of remission in undernourished children with acute lymphoblastic leukaemia

Acute lymphoblastic leukaemia (ALL) is the most common childhood leukaemia. On the other hand under-nutrition is a common problem in our country. This prospective study was conducted to see the outcome of induction of remission in undernourished children with acute lymphoblastic leukaemia. This study was carried out in the department of Paediatric hematology and oncology of Bangabandhu Sheikh Mujib Medical University (BSMMU) during the period from November 2002 to October 2004. A total of sixty (60) children who were diagnosed as acute lymphoblastic leukaemia in 1 to 15 years of age were included in this study. But the children with previous history of congenital disease and that of chemotherapy or steroid were excluded from this study. Patients were divided into two groups on the basis of Z score of weight for age. Thirty (30) children those with Z score- 2 or less were classified as undernourished and was labeled as Group A and another thirty (30) patient those Z score above-2 were classified as well nourished and was placed in Group B, After inclusion into the study, completion of induction of remission was monitored by physical examination and laboratory investigations. The result showed that mean age in Group A was 77.16 ± 7.07 months and that in Group B was 74.13 ± 5.09 months with male preponderance in both the groups. Mean body weight in Group A was 14.55 ± 0.76 Kg and that in Group B was 21.40 ± 1.05 kg (p<0.001). Children in Group A required 39.06 ± 0.72 days to complete induction but in Group B it required 31.63 ± 0.17 days (p<0.04). Hospital stay in Group A children was 52.10 ± 1.08 days and in Group B 42.37 ± 0.50 (p<0.002). The result suggested that under nutrition has an influence on the out come of induction of remission in undernourished children with acute lymphoblastic leukaemia. So appropriate measures are essential to improve nutritional status of children for successful management of ALL in children.

Nutritional parameters in children with cancer

The study was conducted in the Departments of Pediatric Haemato-Oncology, Bangabandhu Sheikh Mujib Medical University, Shahbagh, Dhaka, Bangladesh from January 2007 to May 2009. Total 44 children (34 males and 10 females) aged between 10 months and 12 years with newly diagnosed malignancy. Nutritional status of 44 children with newly diagnosed malignancy was evaluated by anthropometric, hematological results and biochemical parameters before initiating therapy and response to therapy was assessed during follow up. Malnutrition was seen in 56.8% children by weight for age criteria (WFA <-2z). Low hemoglobin was found in 82% children, 25% had low total proteins (<5.7g/dL), 20.5% low serum albumin (<3.2g/dL), 27.3% low serum transferrin (<210mg/dL) and 16.3% low serum iron (<60μg/dL). Mean anthropometric and biochemical parameters were higher among the survivors compared to non-survivors. Significant difference between the well nourished and the malnourished group was detected in the achievement of remission/response (69.5% vs. 38.1%), delays in therapy (8.7% vs. 38.1%) and mortality (30.5% vs. 61.9%). Complications like febrile neutropenia and bleeding were more in the malnourished group. A statistically significant higher incidence of infection was seen in children with serum iron <60μg/dL than those with higher values of serum iron (42.8% vs. 8%).

Effect of recombinant human granulocyte colony stimulating factor (rhG-CSF) for the treatment of neonates in presumed sepsis with neutropenia

Bacterial sepsis continues to be an important cause of morbidity and mortality in neonates. In newborn with presumed sepsis, short-term treatment with rhG-CSF increased the neutrophil count and more importantly improved survival. The objective of the study was to evaluate the effect of rhG-CSF for the treatment of neonates in presumed sepsis with neutropenia. This interventional study was conducted in the Department of Neonatology, BSMMU, Dhaka during July 2009 to May 2010. Total 30 neonates of presumed sepsis with absolute neutrophil count ≤5000/cumm, age<28 days and birth weight 1000-2000g were included in the study. A subcutaneous injection of rhG-CSF (10μgm/kg/day) was administered to 15 neonates for 5 consecutive days (study group) and 15 neonates did not receive it (control group) in addition to standard antibiotic protocol for neonatal sepsis. Baseline characteristics of 30 neonates shows male/female ratio, weight on admission, gestational age were similar in both groups. Among 30 neonates of clinically presumed sepsis 7(23%) were culture proven. E. coli was the most common organism. After 24 hours of treatment mean ANC was increased more in study group (p<0.05) compared to control group. Mean ANC after 72 hours of treatment was increased significantly in study group than control group: 5940.00 versus 5706.00 (p=0.01). At the end of treatment, the mean ANC was higher than that of control (p=0.001). Twelve neonates in study group and ten neonates in control group survived to hospital discharge. The mortality rate in the study group 3/15(20%) and in control group 5/15(33%) were not significant. Duration of hospital stay was less in study group but not significant. The study concluded that before routine use of rhG-CSF in neonatal sepsis with neutropenia further large scale, multi-centre, randomized, placebo controlled trial are needed to validate the beneficial effect.

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.

17β-hydroxysteroid dehydrogenase-3 deficiency in disorder of sex development

A 29 years old patient, claimed to be a male, presented to us with pubertal gender swing from female to male. Since birth he was reared as a female child. His breasts, axillary hairs and pubic hairs developed at about 11-12 years of age. At that time he also observed the mental and physical changes towards a male. He began to feel sexual attraction towards females due to enlargement of his phallus and he preferred to behave as a male. The patient further noticed deepening of voice as well as appearance of facial hairs at about 15 years of age. He never experienced menstruation. His parents are first degree cousins. On examination, there was facial hairs in upper lip and chin (G3), breasts were in mature stage (B5), pubic hairs were darker, coarser and curlier and spreading sparsely (P3), and stretched dorsal phallic length was 6cm. In perineoscrotal area, there was hypospadias with blind vaginal pouch, partially fused, pigmented & ruggated bilateral labio-scrotal folds and soft palpable ellipsoid gonads measuring about 8 ml (each) in volume within labio-scrotal folds. Ultrasound examination revealed no uterus and karyotyping test found 46XY. Provisionally, he was diagnosed as a case of 46,XY Disorders of Sex Development (DSD). On further investigations, serum testosterone was low, serum LH and DHEA were raised and serum electrolytes were normal. From history, physical examination and investigations we diagnosed the case as 46,XY DSD due to 17β-hydroxysteroid dehydrogenase-3 deficiency.

Role of serum procalcitonin and C-reactive protein in the diagnosis of neonatal sepsis

This cross sectional observational study was done in the division of neonatology, department of pediatrics, Bangabandhu Sheikh Mujib Medical University (BSMMU) in the year 2007. The study population was 50 newborns in total who needed evaluation of sepsis on clinical suspicion. The main objective of this study was to assess serum procalcitonin (PCT) as a better diagnostic marker than C-Reactive Protein (CRP) in neonatal sepsis. The total study populations were classified into 4 groups like highly probable, probable, and possible and no sepsis group according to the clinical and blood parameters. PCT and CRP were assessed and compared by statistical analysis. For the estimation of PCT and CRP, venous blood was drawn and centrifuged and stored at - 20 degrees C in the refrigerator. Later on PCT was measured by rapid semi quantitative immunochromatographic test. Level of CRP was determined by semi quantitative method (latex). All data were analyzed by SPSS version 10 windows. For statistical analysis appropriate tests were done. In all observations sepsis was found to be more common in male newborns and in those who were delivered by caesarean section. In low birth weight and preterm newborns sepsis was more prevalent. Premature rupture of membrane (PROM) was found to be the commonest maternal clinical condition as a risk factor of sepsis. There was positive correlation between serum PCT and CRP and values of serum PCT as well as CRP differed significantly in the different categories of sepsis indicating relation to the severity of sepsis. PCT is a useful, sensitive and independent biomarker of neonatal sepsis. CRP measurement along with PCT measurement may increase the specificity. Though PCT measurement is comparatively expensive but an easy bed side promt convenient procedure for sick neonates in addition to CRP for rapid evaluation of neonatal sepsis rather than waiting for the report of blood culture.

Human rabies among the paediatric population in Bangladesh

This cross sectional study in the Infectious Disease Hospital (IDH), Mohakhali, Dhaka on rabies affected paediatric population was carried out to see the patterns of presentation, age group at risk, state of vaccination following animal exposure and the interval between animal exposure and the development of the disease. This one year study included the patients aged less than 15 years with clinically diagnosed rabies referred to the IDH between July 2008 and June 2009. Data was collected from the case sheets of rabies patients given by the relatives and attendants of the victims. A total of 70 cases were included in the study. In the present study most common age group were 5 to 10 years of age with 31(44.3%) patients followed by less than 5 years 23(32.9%) and the rest 16(22.9%) were more than 10 years of age. The male female ratio was 3:1. Among the 70 patients 59(84.3%) were from rural areas and only 11(15.7%) were from urban areas. Sixty six (94.3%) patients presented with bleeding from the site of injury and 4(5.7%) were without bleeding. Among the patients 53(75.7%) presented with bite on the limbs followed by bite on the face 8(11.4%), body 5(7.1%) and head 4(5.7%) cases. Thirty nine of the cases (55.7%) presented with multiple bites and 31(44.3%) had single bite. More than half that is 37(52.9%) patients presented with severe bite, 31(44.3%) had moderate bite and only 2(2.9 %) patients presented with mild bite. Fifty nine (84.3%) patients were unvaccinated whereas 11(15.7%) had history of vaccination after bite. Fifty two (74.3%) gave the history of bite by stray animal, 10(14.3%) by known rabid animal whereas 8(11.4%) had the history of bite by pet animal. Sixty eight patients (97.1%) had the history of bite by dog whereas 2(2.9%) reported cat bite. The mean±SD incubation period 45.38±26.91 days and range was 11-150 days. In the present study it is concluded that the 5-10 years group children were affected most, bites were mostly by stray animal, most of the children did not get post exposure prophylaxis and incubation period was between 11 to 150 days.

Mineral homeostasis in children with acute lymphoblastic leukemia before and after chemotherapy

A prospective study was carried out in the Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh to evaluate the pattern of mineral changes in children treated for acute lymphoblastic leukemia (ALL) before and after induction chemotherapy. A total number of 32 children aged 1-14 years of both sexes were evaluated. Serum calcium, phosphate, alkaline phosphatase, albumin and creatinine and urinary creatinine and calcium were estimated in cases and control. The mean calcium level at presentation and post induction was 9.50±1.48 mg/dl and 9.08±1.30 mg/dl. Serum phosphate was higher in preinduction mean of 4.83±2.71 mg/dl than post induction value of 4.75±1.38 mg/dl and it was statistically significant. Serum alkaline phosphatase was higher in the post induction period. It was 324.8±128.17 U/L in pre induction and 331.59±93.97 u/l in post induction period. It was not statistically significant. No statistically significant difference was found in pre and post induction urinary calcium and creatinine.

Effect of parenteral amino acid supplementation in preterm low birth weight newborn

This interventional study was done to determine the effect of parenteral amino acid supplementation on weight change, biochemical effect and incidence of sepsis in preterm low birth weight newborns during their hospital stay. It was carried out during the period of June 2006-May 2007 in the Newborn unit of a tertiary care hospital of Bangladesh. Sixty preterm (28-34weeks), low birth weight (1000-1800g) AGA (appropriate for gestational age) newborns were enrolled within 24 hours of birth. Intervention and control newborns were matched in terms of birth weight and gestational age. Samples were volunteers. Parenteral amino acid (5%) supplementation in addition to usual nutritional management until enteral feeding reached three fourth of total calorie intake. Usual nutritional management was 10% intravenous dextrose and subsequent enteral feeding. Main outcome measured with weight change, biochemical effect and incidence of sepsis. Weight change was observed by two parameters such as mean percentage of maximum postnatal weight loss and mean days to reach birth weight, both were significantly lower in intervention than control group (p<0.05). Biochemical effect of parenteral amino acid supplementation investigated in this study has been shown to have no effect. There was no difference in incidence of sepsis between intervention and control group (p>0.05). Improved nutritional supplementation with parenteral amino acids resulted in better growth as evident by lesser degree of weight loss and earlier regaining of birth weight in the early neonatal period. Biochemical parameters are not affected by parenteral amino acid supplementation.

Escalated regimen of hepatitis B vaccine in childhood hematological malignancies while on chemotherapy

This prospective study was conducted to find the effective vaccination schedule against hepatitis B virus (HBV) infection for children with hematological malignancies. Sixty patients ages 2-15 years old with hematological malignancies on chemotherapy, negative for hepatitis B surface antigen (HBsAg) and never vaccinated for HBV before, were vaccinated with 40 microg of vaccine at 0, 1 and 2 months. Antibody titers were measured 6 weeks after administration of last dose. Out of the 60 children enrolled, 5 died during the course of treatment and 4 dropped out before completion, leaving 51 for final analysis. More than 70% exhibited protective levels of antibodies (> 10 mIU/ml) against hepatitis B virus. There were no significant effects of age or sex on the antibody response, although antibodies were higher among girls (90.9%) than boys (65%). Patients with non-Hodgkin's lymphoma were found to exhibit a better antibody response than leukemic children (p = 0.024). Children with hematological cancers should be vaccinated with an escalated regimen of the vaccine.

Utility of C-reactive protein and hematological parameters in the detection of neonatal sepsis

The present study was undertaken to find out and compare the usefulness of C-reactive protein (CRP) and hematological value with the blood culture in the diagnosis of neonatal sepsis. This prospective and cross sectional study was carried out in the Department of Neonatology, Bangabandhu Sheikh Mujib Medical University (BSMMU) during the period of July 2003 to January 2005. One hundred cases of suspected septicemia and fifty of controls were enrolled in this study. Blood was collected for the estimation of CRP, hematological parameters (total leukocyte count, differential count, platelet count) and blood culture from the newborns having suspected sepsis and CRP and hematological parameters from the control. CRP was raised in 72% of cases and 4% of control. Total leukocyte count (TLC) was elevated in a total of 10% cases and only in 4% controls. Leucopenia occurred in 6% cases. In 50% cases of culture proven sepsis there was thrombocytopenia. Sensitivity and specificity of CRP were 78.6%and 62.5% respectively in suspected neonatal sepsis & 92.86% and 36.11% respectively in culture proven sepsis. This study concluded that CRP is most sensitive method (93%) in culture proven sepsis and (79%) in suspected sepsis and its positive predictive value in suspected sepsis amounts to 88%. In this study among the suspected sepsis TLC and its differential count didn't show any positive results significantly but thrombocytopenia was present in 50% cases of culture positive sepsis. Therefore, CRP can be taken as alternate method for the diagnosis of neonatal sepsis specially in developing countries like Bangladesh.

Ethical issues in surgical intervention in medical college hospitals

The aim of this study was to investigate the ethical issues of the patients selected for surgical interventions. A total of 105 patients were selected consecutively on the basis of defined criteria at the Department of Surgery and the Department of Gynecology & Obstetrics of Sir Salimullah Medical College Mitford Hospital, Dhaka from March 2007 to November 2007. Results showed that 76.19% of the patients were found to be literate and 23.81% were illiterate. In profession, 53.34% of the patients were found to be involved in household works, 16.19% were service holders, 12.38% were businessmen, 9.52% were cultivators, 5.71% were students and the rest were day laborers. Nearly 60.0% of the patients had no monthly income. Most of the patients were adults of age ranges from 16-70 years. Results about ethical issues showed that 52.38% of the patients had no knowledge about surgical treatment of their diseases prior to operation, 26.67% had poor knowledge and 20.95% had sufficient knowledge. Adequate counseling earlier to surgical intervention were ensured for 11.43% (n=12) patients only. Rest of the patients (88.57%) was not experienced counseling before operation. Nearly 81.0% of the patients did not understand about their treatment by surgical intervention. About 94.0% of the patients and their close relatives had no knowledge about informed consent and its importance as well as procedure of obtains but they sign it just before operation. Around 91.0% of the informed consents were not taken in presence of any witness. In postoperative counseling, 88.57% of the patients had not counseled. Nearly 66.0% of the patients did not satisfy about their treatment. In conclusion, truth-telling through counseling and informed consent were not found to be exercised properly in most of the patients undergoing surgical interventions in medical college hospitals.

Acute and long-term neurological complications in children with acute lymphoblastic leukemia

The pattern of acute and long-term neurological complications in 133 children with acute lymphoblastic leukemia (ALL) treated with two treatment protocol was reviewed. Twenty patients developed neurological complications. Nine out of 20 patients received MRC UK ALL X and the remaining 11 received MRC UK ALL XI protocol. There was no difference of neurological complications between MRC UKALL X and UK ALL XI protocol groups. The numbers of patients who developed neurological complications during induction of remission period were 11 of 133 patients (8.2%). 122 patients were observed during the maintenance period of treatment (from 6 months to 36 months). Six out of 122 patients developed neurological complications during this period. 88 patients were followed for a period of up to 6 months after the cessation of chemotherapy, i.e., in the late period. Neurological complications were found in 3 during this period. Neurological complications rate was 4 times higher in the relapsed group than in the no relapsed group (p < 0.05). Systemic chemotherapy (including vincristine, high-dose methotrexate) and intrathecal chemotherapy seem to be the most common predisposing factors.