First Monte Carlo beam model for ultra-high dose rate radiotherapy with a compact electron LINAC

BACKGROUND

FLASH radiotherapy based on ultra-high dose rate (UHDR) is actively being studied by the radiotherapy community. Dedicated UHDR electron devices are currently a mainstay for FLASH studies.

PURPOSE

To present the first Monte Carlo (MC) electron beam model for the UHDR capable Mobetron (FLASH-IQ) as a dose calculation and treatment planning platform for preclinical research and FLASH-radiotherapy (RT) clinical trials.

METHODS

The initial beamline geometry of the Mobetron was provided by the manufacturer, with the first-principal implementation realized in the Geant4-based GAMOS MC toolkit. The geometry and electron source characteristics, such as energy spectrum and beamline parameters, were tuned to match the central-axis percentage depth dose (PDD) and lateral profiles for the pristine beam measured during machine commissioning. The thickness of the small foil in secondary scatter affected the beam model dominantly and was fine tuned to achieve the best agreement with commissioning data. Validation of the MC beam modeling was performed by comparing the calculated PDDs and profiles with EBT-XD radiochromic film measurements for various combinations of applicators and inserts.

RESULTS

The nominal 9 MeV electron FLASH beams were best represented by a Gaussian energy spectrum with mean energy of 9.9 MeV and variance (σ) of 0.2 MeV. Good agreement between the MC beam model and commissioning data were demonstrated with maximal discrepancy < 3% for PDDs and profiles. Hundred percent gamma pass rate was achieved for all PDDs and profiles with the criteria of 2 mm/3%. With the criteria of 2 mm/2%, maximum, minimum and mean gamma pass rates were (100.0%, 93.8%, 98.7%) for PDDs and (100.0%, 96.7%, 99.4%) for profiles, respectively.

CONCLUSIONS

A validated MC beam model for the UHDR capable Mobetron is presented for the first time. The MC model can be utilized for direct dose calculation or to generate beam modeling input required for treatment planning systems for FLASH-RT planning. The beam model presented in this work should facilitate translational and clinical FLASH-RT for trials conducted on the Mobetron FLASH-IQ platform.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Menstrual Hygiene Practice among Rural Adolescent School Girls: An Intervention Study

Menstruation, an essential part of the reproductive cycle, is experienced by all adolescent girls. Poor menstrual hygiene is associated with serious ill-health and drop-out from school. An intervention study was carried out to evaluate the outcome of health education on menstrual hygiene practice among randomly selected 45 adolescent girls attending in a purposively selected Shomospur Girls' High School, Khoksha at Kushtia district in 2018. Data were collected before and after intervention by pre-tested, semi-structured interview schedule with a view to explore the practice during menstruation. Majority 23(51.11%) subjects were between 10 to 14 years of age with a mean of 14.42±1.03 years. Mean age at menarche was 12.38±1.15 years. During menstrual period, adolescent girls used to refrain from performing daily household chores (34), skip from attending school (26), stay alone (26) and avoid to mix with others (25). Over two-thirds 31(68.89%) girls forbade nutritious foods like fish, meat, egg and tamarinds. As many as 39(86.67%) girls used to clean their genitalia, and everybody used to have regular bath and washing hands after changing menstrual absorbent. Generally, most of the girls (39, 86.67%) accustomed to use the reusable absorbent. Nearly one third 15(33.33%) girls used to dry the reusable absorbent in room corner, while 5(11.11) in shaded area and 3(6.67%) in the toilet. A considerable number of girls (12) stored the reusable materials in room corner and under the bed. At least 27(60.00%) girls did not use to change menstrual absorbent at school. While after intervention, none of the girls hesitated to attend others and felt safe to perform daily household chores. Moreover, they were confident to attend school and need not to stay alone during menstruation. Cent percent girls practiced to have food containing iron, vitamin C, and drank plenty of water. Warm water with soap and/or detergent was used for cleaning sanitary cloths. An overwhelming number 42(93.33%) of girls used to dry reusable materials in sunlight with a statistically significant difference (p<0.05). Change of behaviour as to frequency of changing sanitary pad (p<0.05) and methods of disposal of sanitary materials was revealed. It can be concluded that imparting knowledge to adolescent girls is effective to keep away from harmful social behaviours, food intake practice and use of sanitary napkin, replace of menstrual absorbent at regular interval and cleaning and storage of reusable sanitary materials with their hygienic disposal.

Nitrous Oxide versus Medical Air Using in General Anaesthesia During Laparoscopic Cholecystectomy: A Comparative Study

This study was designed to observe the haemodynamic changes, recovery status and cost effectiveness during anaesthesia in laparoscopic cholecystectomy with medical air in comparison to anaesthesia with nitrous oxide associated with maintain of adequate analgesia and was conducted in the department of Analgesia and Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from January 2017 to June 2017. Nitrous oxide is popularly using as an analgesic in current balanced general anesthesia in addition carrier agent for anesthetic. Intraoperative pain intensity depends on many variables including, type of surgery, surgical stimulation and surgical incision. It is difficult to measure intraoperative pain properly under general anesthesia therefore anesthetist depends on the surrogate marker of inadequate analgesia like raised heart rate, blood pressure, sweating and lacrimation. However, unfortunately, these parameters may changes in same direction with light plane of anesthesia, hypercarbia and ongoing procedural status of the patient.

Huge Splenomegaly with Pancytopenia Due to Gaucher's Disease in a 22 Years Old Woman

Gaucher's disease is one of the important storage disorders. It belongs to the lysosomal storage disorders group. There is defective activity of an enzyme named β-glucosidase which ultimately renders the cell of macrophage lineage loaded with glucocerebrosides. There is multi-organ involvement that manifests as hepatosplenomegaly, variable cytopenias, skeletal disorders, neurological features etc. When serum β-glucosidase level is below 15% of mean normal activity Gaucher's disease is confirmed. Enzyme replacement is the definitive treatment. Here we report a case of type 1 or non-neuropathic form Gauchers disease presented with feeling of a lump in left upper abdomen and progressive generalized weakness and hepatosplenomegaly. Her complete blood count revealed pancytopenia and bone trephine biopsy showed Gaucher's cells. Diagnosis and management may be delayed as this disease is rare. Clinical and bone marrow examination is the mainstay of diagnosis. So emphasis should be given in this regard.

External Diameter of Vermiform Appendix in Bangladeshi People of Different Age & Sex

This cross sectional descriptive study was performed on 70 postmortem vermiform appendix (male 34 and female 36) to find out the external diameter of vermiform appendix of Bangladeshi people in different age and sex. The specimens were collected from autopsy laboratory of the Department of Forensic Medicine, Mymensingh Medical College, Mymensingh, Bangladesh from October 2016 to March 2017 by purposive sampling technique. The collected samples were divided into four age groups. They were Group A (upto 20 years), Group B (21 to 40 years), Group C (41 to 60 years) and Group D (above 60 years). Dissection was performed according to standard autopsy techniques. The vermiform appendix was collected and preserved in 10% formol-saline solution. The external diameter of vermiform appendix was measured with the help of digital slide calipers. Three measurements were taken at its base, middle and near the tip (1cm away from the tip) and expressed in mm. The data were analyzed by using student unpaired 't' test and compaired with the findings of other national and international studies and standard text books. It was observed that external diameter of vermiform appendix gradually decreased as age advanced. The mean±SD external diameter of vermiform appendix at base was 6.50±0.82 mm, 6.22±0.60 mm, 6.00±0.51 mm and 5.51±0.57 mm in Group A, B, C & D respectively. The mean±SD external diameter of vermiform appendix at middle was 6.09±0.89 mm, 5.67±0.65 mm, 5.38±0.59 mm and 4.95±0.76 mm in Group A, B, C and D respectively. The mean±SD external diameter of vermiform appendix near the tip (1 cm away from the tip) was 5.73±0.88 mm, 5.21±0.72 mm, 4.81±0.74 mm and 4.34±0.74 mm in Group A, B, C and D respectively. Statistical analysis shows that the mean differences of external diameter of vermiform appendix at its base between Group A&D, B&D were statistically moderately significant at p<0.01 level. Between Group C&D was statistically significant at p<0.05 level and between Group A&B, B&C, A&C were statistically non significant at p = or >0.05 level. Mean differences of external diameter of vermiform appendix at its middle between Group A&D, B&D were statistically moderately significant at p<0.01 level. Between Group A&C was statistically significant at p<0.05 level and between Group A&B, B&C, C&D were statistically non significant at p = or >0.05 level. Mean differences of external diameter of vermiform appendix near its tip (1 cm away from the tip) between Group A&D was statistically highly significant at p<0.001 and mean differences between Group B&D, A&C were statistically moderately significant at p<0.01 level. Between Group A&B was statistically significant at p<0.05 level and between Group B&C, C&D were statistically non significant at p = or >0.05 level. Mean external diameter of vermiform appendix in male was higher than that of female in all age group at its base, middle and near the tip (1cm away from the tip) but mean difference between sexes in the different study groups was statistically non significant at p = or >0.05 level. The present study will help to increase the information pool on the external diameter of vermiform appendix of Bangladeshi people.

Comparative Study between the Use of Multidose Standard Cardioplegia and Long Acting Del Nido Cardioplegia during Intracardiac Repair for Tetralogy of Fallot in Pediatric Patients

Pediatric myocardium is unique from mature myocardium; thus, the use of adult cardioplegia for pediatric cardiac operations may provide suboptimal myocardial protection. It is found that children undergoing heart surgery show evidence of less myocardial damage when del Nido cardioplegia is used instead of a standard cardioplegic solution. Del Nido cardioplegia solution provides a depolarized hyperkalaemic arrest lasting up to 60 minutes, reduces spontaneous and inducible activity during arrest, and prevents hyper contraction during early reperfusion. In this single blind randomized trial, a total of 60 patients underwent intra cardiac repair for TOF in National Institute of Cardiovascular Diseases, Dhaka, Bangladesh from July 2014 to January 2016 fulfilling inclusion and exclusion criteria. They were randomly assigned in two groups- 30 patients in Del Nido group (Group A) and 30 patients in standard group (Group B). Comparison between groups was done by Chi square test and Student's test. All data were analyzed by SPSS 20.0 for windows. P value less than 0.05 was considered as significant. There was statistically significant difference among the patients in terms of mean total initial cardioplegia volume, mean number of additional dose, mean additional dose amount, mean cross clamp time, mean CPB time (331.67±188.07 vs. 458.67±226.62, p=0.022; 0.13±0.35 vs. 1.27±0.89, p=0.000; 23.33±60.76 vs. 336.83±259.6, p=0.000; 45.10±10.35 vs. 59.23±23.21, p=0.003; 89.30±15.73 vs. 111.10±29.23, p=0.001 respectively). Mean post operative serum troponin I level at arrival in ICU and after 24 hours between two groups were statistically significantly different (55.60±32.91 vs. 83.5±58.99; p=0.024 and 13.01±5.84 vs. 18.16±9.51; p=0.014 respectively). The mean ventilation duration, mean ICU stay were also statistically significant. This study showed that cardiac arrest with Del Nido cardioplegia during intra cardiac repair for TOF was associated with improved myocardial protection over standard cardioplegia in terms of reduced CPB and cross clamp times, lower total volume of cardioplegia.

An epidemiological study of injury in a rural community in Bangladesh

Injuries are a focus of public health practice because they pose a serious health threat, occur frequently and are preventable. The evidence regarding injury, its contributing factor and its consequence in rural population of Bangladesh is scarce. Present study aimed to assess the epidemiology of injury in a rural area. The study was conducted in the 'Bairag' Union of Anwara upazilla in Chittagong district of Bangladesh. Data of 6256 individuals were collected from 1016 households. Three structured and standardized questionnaires were used for data collection. The questionnaires were pretested and validated prior to final survey. Severity of injury was assessed based on the number of days with restricted activity and consequences of injury were considered as a measure of severity of injury. A total of six people died due to injury in last one year in the survey, the death tolls to 0.096% (95% CI 0.037%-0.199%). A total of 392 experienced an injury that at least hampered one day's routine activity. Crude prevalence of injury over last one year is calculated to be 6.27% (95% CI 5.69%-6.89%). Of injured subject's majority (77.2%) were aged between 10 to 59 years, 73% were male, 55.6% were of lower class and among them 7.9 % suffered multiple injuries. More than 80% of the incident leading to injury happened during the day, (8 am to 6 pm). Daytime injury mostly occurs in afternoon. The mechanism of injury of 30% subjects were road accident, of 29.5% subjects was slip, trip or fall. In 17.9% victims' mechanism of injury was collision with a person or object. Around 10% had deep cut, 1.4% had superficial cut, and 3.3% patient had burn through contact with heat. Among the injured only 19.2% escaped any physical consequence, 27.2% suffered from decrease in work capacity, 48.1% developed temporary disability, 3.8% developed permanent disability, and 1.2% suffered disfiguration.

Correlation of the Serum Level of Carcinoembryonic Antigen and Prolactin with Different Stages of Colorectal Carcinoma According to Dukes' Staging

Carcinoembryonic antigen (CEA) is well established tumor marker for colorectal cancers worldwide. Recent studies show that serum prolactin level is also raised in colorectal cancers. The purpose of the study is to evaluate the correlation of serum CEA and Prolactin with Dukes' staging of colorectal carcinomas. Between January 2013 and June 2013, Serum CEA and Serum Prolactin were measured by radioimmunoassay from 103 patients who were histopathologically diagnosed as colorectal carcinomas. Evaluation of the stages of the colorectal cancers was done on the basis of preoperative investigations and postoperative histopathology and correlated with Preoperative Serum CEA and Serum Prolactin. Results were presented as median value, range and percentage. Male to female ratio was 1.4:1 with median age of 42.26 years (range 17-78 years). Most of the patients in this series presented with carcinoma rectum (42%). Most of the patients (52%) were found in Dukes' stage C and 27% and 15% cases were found as Dukes' stage B and Dukes' stage D respectively. Stage of the disease is directly proportionate to percentage of the patient with high serum prolactin except early stage (Dukes' A-50%, Dukes' B-28.6%, Dukes' C-33.3% & Dukes' D-46.7%). Similarly serum CEA level is directly proportionate to tumor stage (Dukes' A-0%, Dukes' B-32%, Dukes' C-40.7% & Dukes' D-74.7%). A preoperative high serum CEA value suggests advanced disease either locally or with distant metastasis. In contrast preoperative high serum prolactin (hyperprolactinaemia) did not suggest advanced disease as it can be elevated even in early stage of disease. Serum CEA and Serum Prolactin both are valuable tumor markers but serum CEA could not be replaced by serum Prolactin. Serum Prolactin may be a helpful marker in earlier stages of the colorectal cancer.

Non-Hodgkin's lymphoma by immunohistochemistry

Non Hodgkin's lymphomas (NHL) constitute a heterogeneous group of neoplasm of the lymphoid system. There are many histological subtype of NHL based on WHO classification of hematopoietic and lymphoid neoplasm. This cross-sectional study was carried out in the department of Pathology, Dhaka Medical College, Dhaka from January 2009 to December 2010 to observe the different subtypes of NHL using immunohistochemistry (IHC) with CD3. A total of 50 microscopically diagnosed case of NHL irrespective of age and sex were included in the study. The diagnostic morphologic criteria of each lymphoma subcategory were compiled and diagnosis was made. Mean age of the study subjects were 42.0±19.7 years with range 3-75 years and male female ratio was 1.8:1. Nodal NHL was 66% and extranodal cases were 34%. Maximum number of histolgic subtypes belonged to diffuse large B-cell lymphoma (DLBCL) and male was predominant in all histological subtypes, except peripheral T-cell lymphoma (PTCL). DLBCL was predominant in all B-cell NHL whereas PTCL was predominant in all T-cell NHL. The most childhood patients belonged to lymphoblastic lymphoma. Regarding cell lineage B-cell NHL was more common than T-cell NHL (88% vs. 12%), but high grade pattern was more predominant in T-cell type (83.3% vs. 65.9%). Among 50 study subjects histological (H & E) diagnosis reveals 46 cases as B-cell NHL and 4 as T-cell NHL but IHC confirms 6 cases as T-cell NHL.

An open randomized controlled trial to compare the efficacy of two fixed dose combinations of artemesinin based combinations for uncomplicated falciparum malaria in Bangladesh

National Malaria Control Program (NMCP) of Bangladesh has introduced Artemisinin Based Combination (ACT), Coartem(R) (Artemether-Lumefantrine (AL), fixed dose combination, in the confirmed cases of uncomplicated P. falciparum malaria since 2004. Despite the reduction of mortality due to malaria, the development and spread of anti-malarial drug resistance wordwide posing a threat to the health services and will make it difficult to control malaria in Bangladesh in future. We need to have an alternative to Coartem which could be Artesunate-amodiaquine (AA) in a fixed dose combination (FDC), a cheaper altenative not yet evidenced to be effective and safe to our population. In this study we compared the efficacy and safety of Artemether + Lumefantrene (FDC, Coartem®) with Artesunate +Amodiaquine tablets (100/270 mg FDC) for the treatment of uncomplicated P. falciparum malaria in three high risk multi-drug resistant malaria prevalent areas of Bangladesh. It was an open label randomized controlled trial conducted between December 2008 and November 2009 in 4 upazillas in patients over the age 12 to 60 years diagnosed as a case of uncomplicated P.falciparum malaria. The outcome of the cases were measured as clinical response, parasitological response, defervescence time and parasite clearance time. Drug safety was assessed by comparing the adverse events. A total of 252 cases were randomized to receive Artesunate + Amodiaquine (AA group, 147 cases) and Artemether + Lumefantrene (AL group, 106 cases), one lost to follow up at day 28 in AA group. The distribution of the cases was comparable by age, sex and study sites. Treatment success’ response was observed 100% in the AL group and AA group had 99%, two failures with AA were late treatment failures and the difference was not statistically significant (p>.1). The parasitological sensitive (S) response was observed in 97% of cases in AL group and 95% in the AA group, and was not a statistically significant difference. There was no significant difference in deffervescence time and parasite clearance time between two groups of cases. No serious adverse events were observed. The frequencies of minor adverse events were insignificantly different between the two treatment groups. The two ACT regimen, AA and AL had no significant difference in efficacy and safety for treatment of Uncomplicated Malaria in Bangladesh. However, there were few more failures with AA regimen compared to AL regimen, which was not statistically significant. Both these regimens can be used alternatively by the NMCP of Bangladesh as first-line treatment option. DOI: http://dx.doi.org/10.3329/bmrcb.v39i3.20310 Bangladesh Med Res Counc Bull 2013; 39: 109-115

Follicle Stimulating Hormone (FSH) Dosage Based on Body Weight Enhances Ovulatory Responses and Subsequent Embryo Production in Goats

An experiment was conducted to evaluate the efficacy of porcine follicle stimulating hormone (pFSH) dosage based on body weight (BW) on ovarian responses of crossbred does. Thirty donor does were divided into 3 groups getting pFSH dosages of 3, 5, and 8 mg pFSH per kg BW, respectively, and were named as pFSH-3, pFSH-5 and pFSH-8, respectively. Estrus was synchronized by inserting a controlled internal drug release (CIDR) device and a single injection of prostaglandin F2α (PGF2α). The pFSH treatments were administered twice a day through 6 decreasing dosages (25, 25, 15, 15, 10, and 10% of total pFSH amount; decreasing daily). Ovarian responses were evaluated on Day 7 after CIDR removal. After CIDR removal, estrus was observed 3 times in a day and pFSH treatments were initiated at 2 days before the CIDR removal. All does in pFSH-5 and pFSH-8 showed estrus signs while half of the does in pFSH-3 showed estrus signs. No differences (p>0.05) were observed on the corpus luteum and total ovarian stimulation among the treatment groups, while total and transferable embryos were higher (p<0.05) in pFSH-5 (7.00 and 6.71) than pFSH-3 (3.00 and 2.80) and pFSH-8 (2.00 and 1.50), respectively. In conclusion, 5 mg pFSH per kg BW dosage gave a higher number of embryos than 3 and 8 mg pFSH per kg BW dosages. The results indicated that the dosage of pFSH based on BW is an important consideration for superovulation in goats.

Diagnostic Efficacy of HbA1c in Diagnosis of Diabetes Mellitus in a Bangladesh Population

American Diabetic Association (ADA) affirms HbA1c with cut off value of 6.5% as a diagnostic criteria of diabetes mellitus. World Health Organization (WHO) also supports but recommended that a value <6.5% does not exclude diabetes which is diagnosed by glucose test. The aim of this study was to evaluate the diagnostic efficacy of HbA1c in terms of sensitivity, specificity, positive and negative predictive value and accuracy in a selected group of Bangladeshi subjects. This cross-sectional study included 761 adult Bangladeshi subjects of both sex attending the outdoor in a tertiary healthcare center during the period of September 2009 to September 2010. Fasting, postprandial (2 hours after glucose load) plasma glucose and HbA1c were measured. Diabetes is defined according to HbA1c and plasma glucose. Sensitivity, specificity, positive and negative predictive value of HbA1c were 90.00% (CI 86.48-92.86%), 76.21% (CI 71.68-80.35%), 78.17% (CI 73.94-82.00%) and 88.96% (CI 85.10-92.10%) respectively. Accuracy was 82.92% with odds ratio (OR) 28.84 (CI 19.10-43.54%); p < 0.001. Though HbA1c revealed remarkable diagnostic efficacy and ease of performance, still it can not over rule the role of plasma glucose in diagnosis of diabetes mellitus. DOI: http://dx.doi.org/10.3329/bmj.v41i1.18785 Bangladesh Medical Journal 2012 Vol. 41 No. 1; 53-54

Comparison of modified Friedewald's formula with direct measurement of low-density lipoprotein cholesterol in Bangladeshi population

A modification of Friedewald's formula to estimate serum low-density lipoprotein cholesterol (LDLC) up to serum triglyceride (TG) level of 11.3 mmol/L in Bangladeshi population has recently been published. The aim of this study was to compare the modified formula with direct measurement of LDLC in Bangladeshi population in a different setting. One thousand and fifty two specimens from adult subjects were analyzed. Serum total cholesterol (TC), high-density lipoprotein cholesterol (HDLC), LDLC and TG were measured by standard methods. The modified Friedewald's formula was applied to estimate LDL cholesterol concentration. Results were expressed as mean ± SD and calculated LDLC was compared with measured LDLC by two-tailed paired t test, Bland-Altman plot for absolute bias, Pearson's correlation coefficients of calculated LDLC with measured LDLC and Passing & Bablok regression equation of calculated LDLC against measured LDLC. The mean ± SD of measured LDLC was 2.98 ± 0.82 mmol/L. LDLC calculated by modified Friedewald's formula was 2.77 ± 0.86 mmol/L. The mean absolute bias was -0.20 ± 0.32 mmol/L, Pearson's correlation coefficient (r) was 0.9293 (P < 0.0001) and Passing & Bablok regression equation was y = - 0.3856+1.0597x for modified formula up to serum TG ≤ 11.3 mmol/L. Compared to original Friedewald's formula, performance of the modified Friedewald's formula was better up to serum TG ≤ 4.52 mmol/L. The study reveals that the modified Friedewald's formula may be used to calculate LDLC approximately in Bangladeshi population.

Histological scoring and associated risk factors of non-alcoholic fatty liver disease

Non alcoholic steatohepatitis is a hepatic disorder with histological features of alcohol induced liver disease that occurs in individual who do not consume significant alcohol. Liver biopsy is an important part of the evaluation in term of both grade & stage. A cross sectional study was carried out in the department of Pathology, Dhaka Medical College, Dhaka & department of Hepatology, Bangabandhu Sheikh Mujib Medical University (BSMMU) from July 2007 to June 2009. Total 55 adult subjects of both sex were included on the basis of predefined inclusion & exclusion criteria in this study to evaluate the histological pattern of non alcoholic fatty liver disease (NAFLD) and its correlation with risk factors. Liver biopsy was done and H & E and Masson's Trichrome stain slides were examined to evaluate the grade and stage of NAFLD. Scoring and semiquantitative assessment of steatosis and NAFLD severity was done according to Kleiner scale known as NAFLD activity score (NAS). The results of Pearson correlation showed only BMI and triglyceride level significantly correlated with NAS score. The results of Spearman's rank correlation showed that BMI, central obesity, triglyceridaemia and age significantly correlated with staging of fibrosis. The results of multiple regression analysis showed that variation of NAS depend on BMI and triglyceride level. The study also revealed that risk factors contributed about 29% risk for the occurrence of non alcoholic steatohepatitis.

Land Cover Change Analysis Around the Sundarbans Mangrove Forest of Bangladesh using Remote Sensing and GIS Application

Land cover change is a widespread and prominent feature in Bangladesh. It is more energetic in the South-west coastal region such as Khulna and Satkhira region. The research was completed by 30 years (1980 to 2009) by using four Landsat satellite images (1980, 1989, 2002 and 2009). During research it was originated that the main classes of changes were homestead, fallow land, water bodies and mangrove vegetation in the study area. The most imperative change was observed in fallow lands (the types of cultivable lands with or without any standing crops and also uncultivable lands). Fallow land was decreased, concerning 2,259 sq km in 2009 which land was 3,867 sq km during in 1980. It was dropped 49% to 29% of total study area between the years of 1980 to 2009. The water bodies were increased about 10% in those 30 years, regarding 14% to 24%. The total water bodies covered 1140 sq km at 1980 which was increased 1851 sq km during 2009 in the study area. The sea-level rise, increasing salinity and availability of less fresh water are responsible for inland intrusion of saline water and creating favorable environment for shrimp farming in the region. As a result farmers are converting fallow lands to shrimp farming which is economically very beneficial. Important agricultural and non-agricultural lands also converted by homestead intended for increasing population of Bangladesh. There was only 398 sq km (only 5%) area covered by homestead during 1980. But the homestead covered area was increased about 1490 sq km (19%) at 2009. So, compared to the last 30 years 14% homesteads land cover areas are increased. There was not any astonishing changed in mangrove vegetation. Some mangroves areas were shattered and some other mangroves were full-fledged again in delta areas. The harmful land cover changes are not expectable for the natural environment. But it transpires by many natural and anthropogenic tricks now a day. So, the authority should seize initiatives to protect this category of catastrophe. DOI: http://dx.doi.org/10.3329/jsf.v9i1-2.14652 J. Sci. Foundation, 9(1&2): 95-107, June-December 2011

Ecology of Sundarban, Bangladesh

Sundarban is the largest mangrove wetland in the world. It covers an area of about 1mha, of which 60% is located in Bangladesh and the remaining western portion, comprising 40%, lies in India. Mangrove ecosystems are of great ecological significance in the tropical and sub-tropical coast. They protect our coast from heavy wind, tidal waves, coastal erosion and sea water intrusion, generate substantial quantities of fishery resources and provide many useful forestry products. The Sundarban ecosystem supports rich fisheries diversity. This ecosystem support 27 families and 53 species of pelagic fish, 49 families 124 species of demersal fish, 5 families and 24 species of shrimps, 3 families and 7 species of crabs, 8 species of lobster. A total 334 plants, 165 algal, 13 special orchids, 17 fern, 87 monocotyledon and 230 dicotyledon belonging to 245 genera and 75 families from the sundarbans and adjacent area are found available. The principal tree species is Sundry (Heritiera fomes) which covers about 73% to total landmass and the second species is Gewa (Excoecaria agallocha) which covers about 16% of total forest area. The plant species include 35 legumes, 29 grasses, 19 sedges, and 18 euphorbias. Of the 50 true mangrove plant species recorded throughout the globe, the Sundarbans alone contain 35 species. The magnificent among the animals on land is Royal Bengal Tiger, Spotted deer, barking deer and wild boars are there in plenty. Besides those jungle cats, fishing cat, civet cat, monkey, bengal fox, jackle, water monitor, monitor lizard and snakes are important faunal spp. Moreover, abundant of the Sundarbans are purple heron, pond heron, cattle egret, little egret, open billed stork, smaller adjutant stork, brahmini kite, spotted dove, rose ringed parakeet, crow pheasant, wood pecker, bee eater, drongo, pide myna, jungle myna, bulbul, tailor bird, magpie robin, sparrow etc., Otherwise, recorded that wild Buffalo, 2 species of deer, javan rhinoceros extinct and presently 2 species of amphibians, 14 species of reptiles 25 species of birds and 5 species of mammals are considered as endangered species. This paper is to produce a new assessment of the mangroves ecology of Sundarbans. DOI: http://dx.doi.org/10.3329/jsf.v8i1-2.14618 J. Sci. Foundation, 8(1&2): 35-47, June-December 2010

Perceptions and treatment seeking behavior for dog bites in rural Bangladesh

We conducted a study of the knowledge, attitudes and practices regarding dog bites among residents of a rural community in Bangladesh from September 2006 to February 2007 using face to face interviews with 1,973 adults from five villages. The mean age of the respondents was 34+/-16 years. Sixty-eight percent of subjects were female, 7.3% of respondents reported a history of dog bite in a family member; 10% had been bitten twice. Sixty-five percent of subjects were aware of rabies and 99.1% knew a dog bite was the cause of rabies. Seventy-one percent of subjects were aware of a rabies vaccine, 77.5% of respondents stated rabies can cause death. Ninty percent of dog bite victims received treatment by traditional healers, 25% were treated with a rabies vaccine and 2.1% of victims died. Greater awareness is needed in rural Bangladesh regarding prevention of rabies.

Intradural intramedullary spinal cord meningioma in a seven years old female child

Halima, a 7 years old female child was admitted initially in the Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Shahbagh, Dhaka, Bangladesh with the complaints of burning sensation in the neck for last four month. Initially pain was mild and gradually it became severe and agonizing at night which awakening her from sleep. Following fifteen days of admission, her left hand gradually became weak and numb. Subsequently, all four limbs became involved within one month. Magnetic resonance imaging (MRI) showed expansion of cervical cord with hypo-intense in T1 and inhomogeneous hyper-intense in T2 areas with widening of cervical canal. Post gadolinium diethylene triamine penta-acetic acid dimeglumine (Gd-DTPA) films showed mild heterogeneous contrast enhancement of the cord at the C2-C4 level. The cervical disc showed normal signal intensity on T2WI. During surgical procedure, laminectomy was done at C1-C5 level to release compression and dura matter was opened. Biopsy from involved tissue was taken and sent for histopathological examination and reported as embronal rhabdomyosarcoma. Immunohistochemistry (IHC) of tumor showed negative reaction for desmin, focal positivity for pancytokeratin and positivity for S-100 protein. The tumor was then diagnosed as atypical meningioma,intradural-intramedullary (WHO grade-II). Then, following transfer to the Department of Pediatric Hematology and Oncology, BSMMU, protocol based chemotherapy was started followed by subsequent radiotherapy. The child was gradually improving after decompression of dura matter, commencement of chemotherapy and following external beam radiotherapy. So, an awareness of varied clinical manifestation of atypical meningioma of intrdural-intramedullary spinal cord tumor should be suspected to establish a correct diagnosis when the presenting signs and symptoms are enigmatic, presenting with intractable burning sensation or pain in the neck and investigation should be done accordingly.

Wandering spleen associated with β-Thalassemia: a case report

The clinical entity 'Wandering spleen' is an uncommon presentation and it is more often diagnosed in children than in adults, mostly women of reproductive age. Here is a case of a young woman who presented with generalized weakness and fever, and a painless mobile lump in her central abdomen. The laboratory evaluation revealed a haemolytic state and Haemoglobin electrophoresis showed β-Thalassemia trait (Hb A2 5.1%). Ultrasonography and Computerized Tomography (CT) scan confirmed that the mass is spleen and spleen is not present in its normal anatomical location. Abdominal CT described a well-defined, homogenous pediculated mass with echo texture comparable to spleen. Radioisotope scanning could be used as an alternative for confirmation of diagnosis of this rare condition, but was not done in our case. Colour Doppler sonography of the splenic circulation revealed no infarction and intact splenic vasculature. Wandering spleen should be considered in the differential diagnosis of idiopathic abdominal or pelvic lumps. The authoritative opinion for the treatment of such a case is splenectomy or splenopexy especially in children and here, in this case splenectomy was done.

Pre-referral rectal artesunate to prevent death and disability in severe malaria: a placebo-controlled trial

BACKGROUND

Most malaria deaths occur in rural areas. Rapid progression from illness to death can be interrupted by prompt, effective medication. Antimalarial treatment cannot rescue terminally ill patients but could be effective if given earlier. If patients who cannot be treated orally are several hours from facilities for injections, rectal artesunate can be given before referral and acts rapidly on parasites. We investigated whether this intervention reduced mortality and permanent disability.

METHODS

In Bangladesh, Ghana, and Tanzania, patients with suspected severe malaria who could not be treated orally were allocated randomly to a single artesunate (n=8954) or placebo (n=8872) suppository by taking the next numbered box, then referred to clinics at which injections could be given. Those with antimalarial injections or negative blood smears before randomisation were excluded, leaving 12 068 patients (6072 artesunate, 5996 placebo) for analysis. Primary endpoints were mortality, assessed 7-30 days later, and permanent disability, reassessed periodically. All investigators were masked to group assignment. Analysis was by intention to treat. This study is registered in all three countries, numbers ISRCTN83979018, 46343627, and 76987662.

RESULTS

Mortality was 154 of 6072 artesunate versus 177 of 5996 placebo (2.5%vs 3.0%, p=0.1). Two versus 13 (0.03%vs 0.22%, p=0.0020) were permanently disabled; total dead or disabled: 156 versus 190 (2.6%vs 3.2%, p=0.0484). There was no reduction in early mortality (56 vs 51 deaths within 6 h; median 2 h). In patients reaching clinic within 6 h (median 3 h), pre-referral artesunate had no significant effect on death after 6 h or permanent disability (71/4450 [1.6%] vs 82/4426 [1.9%], risk ratio 0.86 [95% CI 0.63-1.18], p=0.35). In patients still not in clinic after more than 6 h, however, half were still not there after more than 15 h, and pre-referral rectal artesunate significantly reduced death or permanent disability (29/1566 [1.9%] vs 57/1519 [3.8%], risk ratio 0.49 [95% CI 0.32-0.77], p=0.0013).

INTERPRETATION

If patients with severe malaria cannot be treated orally and access to injections will take several hours, a single inexpensive artesunate suppository at the time of referral substantially reduces the risk of death or permanent disability.

FUNDING

UNICEF/UNDP/World Bank Special Programme for Research and Training in Tropical Diseases (WHO/TDR); WHO Global Malaria Programme (WHO/GMP); Sall Family Foundation; the European Union (QLRT-2000-01430); the UK Medical Research Council; USAID; Irish Aid; the Karolinska Institute; and the University of Oxford Clinical Trial Service Unit (CTSU).

Evaluation of alternative diagnostic techniques for diagnosis of cerebral malaria in a tertiary referral hospital in Bangladesh

Five alternative techniques for diagnosis of malaria were evaluated in 124 clinically diagnosed cerebral malaria cases admitted in a tertiary hospital in Bangladesh. Clinical diagnosis of cerebral malaria was done by WHO criteria. The tests were conventional routine malaria microscopy; prolonged microscopy; dipstick antigen capture assay (Para Sight TM-F test); pigments in peripheral leucocytes and routine microscopy repeated at 12 hours interval. First four tests were done at 0 hours of hospital admission and repeat routine microscopy was added at 12 hours interval. Diagnostic capability of the test was 64%, 65%, 69%, 27% and 63% respectively. None of the tests except pigments in peripheral leucocytes was superior at initial evaluation. Only the dipstick test added 5% more diagnostic possibility compared with routine microscopy as standard. Stratification of diagnostic capability in different ways improved diagnosis 15% and 11% in smear negative cases by dipstick and prolonged microscopy respectively. It was increased by 50% (5/10 patients) with dipstick test in the smear negative patients with history of anti-malarials prior to hospital admission.

Role of homocysteine in cerebrovascular disease

Cerebrovascular disease (CVD) is one of the leading causes of morbidity and mortality worldwide and places a huge burden on the health care system. The most common forms of CVD are ischemic cerebrovascular disease (ICVD) and hemorrhagic cerebrovascular disease (HCVD). Since, the treatment, prognosis and rehabilitation of CVD is frustrating, prevention of CVD by properly addressing its modifiable risk factors might be the spearhead to combat the burden. There are several established risk factors associated with CVD, but a newer modifiable risk factor, hyperhomocysteinemia has created a new window for limiting the occurrence of CVD. Homocysteine is potentially vasculotoxic because of its association with endothelial dysfunction and impairment of fibrinolytic system. A total of 248 subjects were included in this case control study. Among them 104 were diagnosed CVD cases (ICVD-59, HCVD- 45) and 144 were age and sex matched healthy controls. Serum total homocysteine was measured in all the study subjects. Mean total homocysteine was found 12.95+/-6.20 micromol/L, 15.55+/-7.35 micromol/L in controls and cases respectively and 15.70+/-7.82 micromol/L, 15.34+/-6.78 micromol/L in ICVD and HCVD respectively. Homocysteine found to be significantly raised in CVD cases compared to controls but sub groups of CVD (ICVD & HCVD) did not differ between themselves with respect to serum homocysteine.

Direct in vivo assessment of microcirculatory dysfunction in severe falciparum malaria

BACKGROUND

This study sought to describe and quantify microcirculatory changes in the mucosal surfaces of patients with severe malaria, by direct in vivo observation using orthogonal polarization spectral (OPS) imaging.

METHODS

The microcirculation in the rectal mucosa of adult patients with severe malaria was assessed by use of OPS imaging, at admission and then daily. Comparison groups comprised patients with uncomplicated falciparum malaria, patients with bacterial sepsis, and healthy individuals.

RESULTS

Erythrocyte velocities were measured directly in 43 adult patients with severe falciparum malaria, of whom 20 died. Microcirculatory blood flow was markedly disturbed, with heterogeneous obstruction that was proportional to severity of disease. Blocked capillaries were found in 29 patients (67%) and were associated with concurrent hyperdynamic blood flow (erythrocyte velocity, >750 mm/s) in adjacent vessels in 27 patients (93%). The proportion of blocked capillaries correlated with the base deficit in plasma and with the concentration of lactate. Abnormalities disappeared when the patients recovered. In healthy individuals and in patients with uncomplicated malaria or sepsis, no stagnant erythrocytes were detected, and, in patients with sepsis, hyperdynamic blood flow was prominent.

CONCLUSION

Patients with severe falciparum malaria show extensive microvascular obstruction that is proportional to the severity of the disease. This finding underscores the prominent role that microvascular obstruction plays in the pathophysiology of severe malaria and illustrates the fundamental difference between the microvascular pathophysiology of malaria and that of bacterial sepsis.

Efficacy of chloroquine + sulfadoxine--pyrimethamine, mefloquine + artesunate and artemether + lumefantrine combination therapies to treat Plasmodium falciparum malaria in the Chittagong Hill Tracts, Bangladesh

Bangladesh faces growing levels of Plasmodium falciparum resistance to chloroquine (CQ) and sulfadoxine-pyrimethamine (SP). Alternative antimalarial therapies, particularly combination regimens, need to be considered. Therefore, the efficacy of three antimalarial combination therapies was assessed in Chittagong Hill Tracts. A total of 364 P. falciparum patients were recruited and randomly assigned to either CQ + SP, mefloquine + artesunate (MQ + AS) or lumefantrine + artemether (Coartem). Results showed that CQ + SP therapy was less effective than the two artemisinin-based combination therapies. The day 42 PCR-corrected efficacy rate was 62.4% for CQ + SP, 100% for MQ + AS and 97.1% for Coartem. Failures occurred at a shorter interval after CQ + SP treatment than after Coartem. The artemisinin-based therapies effectively prevented development of gametocytes, whereas CQ + SP did not. All three therapies were well tolerated, although reports of mild complaints during treatment appeared higher with MQ + AS. We conclude that CQ + SP is not a viable option for replacing CQ monotherapy as first-line P. falciparum treatment in this area of Bangladesh. A change to artemisinin-based combination therapy is recommended. Both Coartem and MQ + AS appear to be good options, effective in curing P. falciparum malaria and in preventing recrudescences following treatment.

Arthrographic distension of the shoulder joint in the management of frozen shoulder

The study was an open randomized controlled trial to compare the outcome at 8 weeks with two different modalities in the treatment of 'Frozen shoulder'. Clinical cases with painful limitation of movement of shoulder were randomized to receive physical therapies alone versus physical therapies and shoulder arthrography with intra-articular steroid in a sequential randomization process. Cases suspected of having a concomitant illness and has potential to cause secondary frozen shoulder were excluded, such as, history of trauma to shoulder over the last 6 months, symptomatic clinical cervical degenerative diseases, and causes in and around the shoulder (infective and non-infective). Physical Therapies provided to all patients were therapeutic exercises, transcutaneous electrical nerve stimulation (TENS) and infra-red radiation (IRR). Outcome measures were improvement of pain on a Visual Analogue Scale (VAS) score and range of motion measured by Goniometer at 8 weeks. Patients were followed weekly for 8 weeks and outcome parameters were recorded on every evaluation. The baseline range of motion in the two groups was comparable. At 8 weeks a statistically significant difference in outcome were observed in the two groups. The chi-square means difference of improvement in range of motion for abduction was p <0.00 and for external rotation was p <0. 00. The pain reduction on VAS score was not significant in the two groups (p <0. 40). In the present small series, the distension arthrography with intra-articular (IA) steroid plus physical therapy was superior over physical therapy alone in the functional improvement of the frozen shoulder. Further studies with larger sample size are required to confirm the observations.

Drug-resistant malaria in Bangladesh: an in vitro assessment

Forty-four Plasmodium falciparum isolates from Bangladesh and 22 from western Thailand were successfully tested for their drug susceptibility. High degrees of resistance were observed against chloroquine with geometric mean IC50s of 114.25 and 120.5 nM, respectively, for Bangladesh and western Thailand. Most isolates from both sites were sensitive to quinine, and all were sensitive to artesunate. Many isolates were considered in vitro resistant to mefloquine, but the geometric mean IC50 for the Thai isolates (98.79 nM) was 1.6 times (P = 0.002) higher than that of isolates from Bangladesh (60.3 nM). The high prevalence of in vitro mefloquine resistance in Bangladesh suggests that close surveillance is necessary to delay widespread multidrug resistant problems in the area.

A randomized controlled trial on the efficacy of alternative treatment regimens for uncomplicated falciparum malaria in a multidrug-resistant falciparum area of Bangladesh--narrowing the options for the National Malaria Control Programme?

We performed an open, randomized chemotherapy trial comparing the recommended first-, second- and third-line drug regimens, as well as mefloquine, for uncomplicated falciparum malaria in Bangladesh in 1996-97. The regimens were chloroquine for 3 days (CQ, Group I), quinine sulphate for 3 days followed by single-dose sulfadoxine-pyrimethamine (Q3 + SP, Group II), quinine for 7 days (Q7, Group III), and mefloquine 20 mg/kg single dose (MEF, Group IV). Subjects were symptomatic patients, aged > or = 12 years, with parasite density 500-250,000/mm3 and no history of taking antimalarials during the previous week. Drug administration was supervised and subjects were followed clinically and with blood slides in the hospital for 8 days, then as outpatients on days 14, 21 and 28. A total of 413 subjects (149, 145, 49 and 70 in Groups I-IV, respectively) completed the study. Early treatment failures (persistent or worsening clinical manifestations by day 3 confirmed with parasitological examinations) occurred only in the chloroquine group. RII and RIII parasitological failures occurred in 56%, 12%, 8% and 14% in Group I-IV, respectively. There were significantly more clinical and parasitological failures with chloroquine than with Q3 + SP, which we now recommend as a better (but far from ideal) choice for first-line therapy. The alternative compounds show parasitogical evidence of Plasmodium falciparum resistance. Further studies are needed to determine the optimum treatment for malaria in Bangladesh.

Prognostic factors relating to outcome of severe malaria among children in Bangladesh

This study was done in the Paediatric in-patient department of Chittagong Medical College Hospital (CMCH), Chittagong, Bangladesh to identify and quantify the prognostic factors associated with increased mortality in severe malaria (SM) cases. All the patients with parasitologically confirmed clinical syndromes of SM, admitted between June 1997 and May 1998, were included. A total of 53 consecutive cases were studied. Cerebral malaria (CM) was the commonest type of SM, observed in 36(68%) cases, second commonest type was severe anaemia 13(25%). More than one type of severe manifestations were present in 23(44%) cases. Overall case fatality rate (CFR) was 17% and it was 30% among those who had multi-organ manifestations. Important poor prognostic clinical variables were Blantrye coma score (BCS) score of 0 and 1 on day 1 (OR = 7.78) and day 2(OR = 40.0), multi-organ manifestations (OR = 6.8) and in-hospital complications (OR = 5.18). Important poor prognostic laboratory variables were day 2 parasite count > 50,000/cmm (OR = 5.5), blood glucose < 2.2 mmol/l (OR = 21.5) and raised CSF protein > 50 mg/dl (OR = 7.0). It can be concluded that certain clinical variables e.g. low BCS on day 1 & 2, multi-organ manifestations, in-hospital complications; and laboratory variables e.g. high parasite count, low blood glucose level, raised CSF protein levels are associated with increased mortality rate in SM cases.

A randomized controlled trial comparing artemether and quinine in the treatment of cerebral malaria in Bangladesh

A randomized controlled trial on 51 patients receiving artemether and 54 patients receiving quinine was undertaken to compare the effectiveness of intramuscular artemether and parenteral quinine in the treatment of cerebral malaria in adults in Bangladesh. Case fatality, fever and parasite clearance times were not significantly different in the two treatment groups. Coma resolution time was significantly delayed in artemether recipients. Results of the study suggest that treatment with artemether is as effective as parenteral quinine in the treatment of cerebral malaria in adults.

Monitoring efficacy of commonly used antimalarials by a 14-day in-vivo test in a new settler's camp in endemic zone at Cox's Bazar

The study was done in a new settler's camp "Barachara" under Sadar thana of Cox's Bazar district. It has a total population of 784 of all age groups, registered in the middle of the study period. A prospective evaluation of all cases of fever were done over 12 months, to see the pattern of febrile illness among the population and to compare the therapeutic efficacy of two alternative drug regimens for uncomplicated falciparum malaria (UM). Blood for malarial parasite (MP) was done in all cases of fever and was treated in line with the new clinical case definitions and treatment guidelines for malaria in Bangladesh. Slide positive UM cases were subjected to a "14-day in-vivo test" for therapeutic efficacy testing of antimalarial agents. The two drug regimens were randomised by lottery--a) 3 days oral chloroquine plus single dose sulphadoxin/pyrimethamine (CQ + SP) and, b) 3 days oral quinine plus single dose sulphadoxin/pyrimethamine (Q3 + SP). Drug administration was supervised by the field assistant and was followed up on days 3, 7 and 14 for blood slide examinations and clinical assessment. Sensitive response was observed in 79% of the cases in the CQ + SP group and 84% in the Q3 + SP group. Early treatment failure (persistently febrile and parasitaemic on days 3 or 7) was observed in 16% in the CQ + SP group and 9% in the Q3 + SP group. Both the evaluated drug regimens had less than 20% failures and can be used as alternative first line agents and Q3 + SP regimens can also be used as the second line agents for treatment failure (to chloroquine and/or SP) UM cases in the study area.

Cerebral malaria--a study of 104 cases

One hundred and four adult cases of cerebral malaria (73 male, 31 female) were studied between July 1995 to June 1996 in Chittagong Medical College Hospital. Diagnosis of cerebral malaria was based on unrousable coma or any neurological manifestation in a febrile patient with asexual Plasmodium falciparum in blood film. Intermittent fever (83%), vomiting (80%), headache (75%), convulsion (60%) and history of travel or residence in malaria endemic area were important features noted in patients with cerebral malaria. Most of the patients (69%) were admitted within 25 to 48 hours following unconsciousness. The factors are more common in cases with high mortality with diastolic blood pressure (DBP) below 60 mm of Hg, anaemia, persistence of Glasgow Coma Score below 5 on day 2, high parasite count at presentation, proteinuria and high level of serum urea. Out of 104 cases of cerebral malaria 66 patients (63.5%) recovered without sequelae, 34 patients (32.7%) died and 4 patients (3.8%) recovered with some residual sequelae. Establishment of intensive care unit in tertiary level hospitals is necessary to take appropriate measure for severe cerebral malaria cases for reduction of mortality.

Randomised trial of 0.2% chlorhexidine gluconate and 2.5% natamycin for fungal keratitis in Bangladesh

AIM

The management of suppurative keratitis due to filamentous fungi presents severe problems in tropical countries. The aim was to demonstrate the efficacy of chlorhexidine 0.2% drops as an inexpensive antimicrobial agent, which could be widely distributed for fungal keratitis.

METHODS

Successive patients presenting to the Chittagong Eye Institute and Training Complex with corneal ulcers were admitted to the trial when fungal hyphae had been seen on microscopy. They were randomised to drop treatment with chlorhexidine gluconate 0.2% or the standard local treatment natamycin 2.5%. The diameters, depths, and other features of the ulcers were measured and photographed at regular intervals. The outcome measures were healing at 21 days and presence or absence of toxicity. If there was not a favourable response at 5 days, "treatment failure" was recorded and the treatment was changed to one or more of three options, which included econazole 1% in the latter part of the trial.

RESULTS

71 patients were recruited to the trial, of which 35 were randomised to chlorhexidine and 36 to natamycin. One allocated to natamycin grew bacteria and therefore was excluded from the analysis. None of the severe ulcers was fully healed at 21 days of treatment, but three of those allocated to chlorhexidine eventually healed in times up to 60 days. Of the nonsevere ulcers, 66.7% were healed at 21 days with chlorhexidine and 36.0% with natamycin, a relative efficacy (RE) of 1.85 (CL 1.01-3.39, p = 0.04). If those ulcers were excluded where fungi were seen in the scraping but did not grow on culture, the estimated efficacy ratio does not change but becomes less precise because of smaller numbers. Equal numbers of Aspergillus (22) and Fusarium (22) were grown. The Aspergillus were the most resistant to either primary treatment.

CONCLUSIONS

Chlorhexidine may have potential as an inexpensive topical agent for fungal keratitis and warrants further assessment as a first line treatment in situations where microbiological facilities and a range of antifungal agents are not available.

Trial of chlorhexidine gluconate for fungal corneal ulcers

AIMS

Suppurative corneal ulcers due to filamentous fungi are a serious and intractable problem in many tropical developing countries. In vitro studies and a small pilot study have shown that chlorhexidine gluconate is effective. The aim was to establish the optimum concentration which would be appropriate to use in a larger randomized clinical trial.

METHODS

A masked randomized clinical trial of three concentrations of chlorhexidine compared with natamycin 5% was carried out in consecutive patients with established corneal ulcers shown by microscopy to contain fungal hyphae and later proven to be culture positive. Topical treatments were applied 1/2-hourly to 2-hourly for up to 5 days, with reduced frequency thereafter, and all patients were re-assessed at 21 days.

RESULTS

Of 60 patients entered in the trial, 2 were lost to follow-up, and 12 were classified as 'severe' with little prospect of recovery. At 5 days the response was related to the concentration of chlorhexidine, with 0.2% giving the best results. Compared with the response to natamycin as the referent, the relative efficacy was 1.17 with chlorhexidine 0.05%, 1.43 with 0.1%, and 2.00 with 0.2%. The superiority of 0.2% chlorhexidine over natamycin was statistically significant (relative efficacy 2.20, p = 0.043) in patients not having had prior antifungal treatment.

CONCLUSIONS

This preliminary study justifies further trials of chlorhexidine as a primary treatment for fungal corneal ulcers in circumstances where specific antifungal agents are not available.

Mycotic keratitis: susceptibility to antiseptic agents

Oculomycosis is a severe problem in most developing countries. Specific antifungal agents are often unavailable, and are expensive. The use of antiseptic agents was therefore explored. Fungal isolates from patients in India and Ghana were tested against chlorhexidine, povidone iodine, propamidine, and polyhexamethylenebiguanide, and compared with econazole by placing the drugs in wells made in Sabouraud's agar plates seeded with the test organism. Fungal sensitivity testing is a contentious area but this method is simple and cheap. Chlorhexidine showed a good dose related response, povidone iodine showed a good response at all concentrations and econazole was the most effective in vitro. A small pilot study was conducted in India to assess clinical efficacy for fungal corneal ulcers. Both chlorhexidine and econazole proved effective but povidone iodine was ineffective. We suggest that chlorhexidine may be a useful first line agent for fungal keratitis when other antifungals are not available.

A technique for quick fixation of whole Drosophila and other small insects for scanning electron microscopy

A procedure for fixing small insects in natural postures for scanning electron microscopy is reported. Anesthetized insects are partially restrained using a depression slide and a coverslip while preliminary fixation is carried out and wings and legs are positioned with a fine brush. Following this, fixation is completed and the insect is prepared for scanning electron microscopy by essentially standard procedures, which may include critical point drying. Figures illustrate, however, that critical point drying is not necessary for more rigid parts of the exoskeleton. Use of this procedure assures naturally disposed parts even when only a single specimen is available.

Reproductive Ecology of Mola (Amblypharyngodon mola)

Reproductive cycle of mola (Amblypharyngodon mola) in a pond and in a beel along with some aspects of their physico-chemical parameters, morphometry etc. were carried out at Rajshahi. The highest (81.08%) average monthly percentage of ovigenous female Mola in pond was in September and lowest (20%) in November, whereas the highest (87.30%) and the lowest (28.57%) values in beel were found in May and in November respectively. Both the Gonado Somatic Index (GSI) and Gonadal Langth Index (GLI) of Mola showed two distinct peaks, one in May and another in September where GSI values were 19.51% and 22.48% and GLI values were 36.31% and 36.19% respectively. Similar peaks were found in the beel where GSI values were 20.98% and 18.72% and GLI values were 41.77% and 40.58% respectively. The lowest mean fecundity of Mola in pond was 1023±625 and the highest was 6806±125 in size groups of 5.0-5.5cm and 8.1-8.5cm respectively. Ova diameter of Mola in pond showed two distinct peaks one in May and another in September where Ova diameter values were 30?m and 29?m respectively. Similar peaks were found in beel where OD values were 28?m and 27 ?m respectively. Above result shows that Mola (A. mola) breeds twice a year with one peak in May and another in September in both pond and beel. Some ecological parameters were also observed in the study areas. DOI: http://dx.doi.org/10.3329/jard.v6i1.1674 J Agric Rural Dev 6(1&2), 165-174, June 2008

Inequity of diagnosis of diabetes by plasma glucose and HbA1c

Objective: Both plasma glucose and glycosylated hemoglobin are the recommended tools to diagnose diabetes by the International Expert Committee and World Health Organization (WHO). The aim of this study was to compare these two parameters in the diagnosis of diabetes in a selected group of Bangladeshi subjects. Materials and Methods: This cross-sectional study included 800 subjects attending the outdoor in a tertiary healthcare center during the period of September 2009 to September 2010. Fasting, postprandial (2 hours after glucose load) plasma glucose and HbA1c were measured. Diabetes is defined according to HbA1c and plasma glucose. Subjects were classified into three groups according to HbA1c values (HbA1c: =6.5%, HbA1c: 6.0-6.4% and HbA1c: < 6.0%) and also in the diabetics, prediabetics (IGT+IFG) and nondiabetics by plasma glucose. Results of the HbA1c classified subjects were compared with the plasma glucose classified subjects to see the inequity of classification. Results: Inequity of classification occurred for 11.87% of the total subjects with HbA1c =6.5% but impaired (8.25%) and nondiabetic (3.62%) by plasma glucose; for 10.13% of the subjects with HbA1c: 6.0-6.4% but diabetic (3.25%) and nondiabetic (6.88%) by plasma glucose, and for 8.5% of the total subjects with HbA1c <6.0% but diabetic (1.88%) and impaired (6.62%) by plasma glucose. Concordant classification occurred for 69.5% and inequity of classification occurred for 30.5% of the total study subjects. Conclusion: Inequity of classification of diabetes by HbA1c and plasma glucose is remarkable in the study population. Key words: Plasma glucose; glycosylated hemoglobin; diagnostic criteria of diabetes DOI: http://dx.doi.org/10.3329/bjms.v10i4.9502 BJMS 2011; 10 (4): 284-286

Leptin Concentrations in Maternal and Umbilical Cord Blood in Relation to Maternal Weight, Birth Weight and Weight of the Placenta

Objective: Leptin is a hormone which regulates adipose tissue mass of the body. Substantial increase of leptin during pregnancy and detection of leptin and leptin receptor in placenta have led to the speculation that leptin is a gestational hormone with a possible role in regulation of fetal growth. The study was done to find out whether maternal and cord blood leptin correlate with birthweight and weight of the placenta. Materials and methods: A prospective cross sectional study was undertaken in the Department of Obsterics and Gynecology, Bangabandhu Sheikh Mujib Medical University from January 2005 to June 2005. The study was carried out on 39 pairs of mothers and newborns. Maternal venous blood was sampled just before delivery. Cord blood was obtained, birth weight and placental weight measurements were taken just after delivery of the baby. Serum leptin levels were measured by enzyme linked immunosorbent assay. Results: Maternal serum leptin was 24.50 ng/ml (range- 13.15-45.60 ng/ml) and cord serum leptin was 6.50 ng/ml (range- 2.02-12.30 ng/ml). There was no correlation between maternal leptin and birth weight or between maternal leptin and placental weight. Cord leptin was significantly correlated with birth weight but not with placental weight. There was no correlation between maternal and cord blood leptin. There was no significant gender differences in cord blood leptin concentrations. Conclusions: There may be an important role of leptin in regulation of fetal growth and development. Placenta may not be a major source of leptin in maternal and feto-placental circulation. Maternal leptin cannot be a reliable marker of fetal growth. Keywords: Serum leptin, birth weight, placental weight   doi: 10.3329/bjog.v23i1.3049 Bangladesh J Obstet Gynaecol, 2008; Vol. 23(1) : 3-7