Awareness of Tetanus Toxoid Vaccination among Women of Reproductive Age Attending Outpatient Department in a Tertiary Level Hospital

Maternal and neonatal tetanus is still a major but preventable cause of mortality in many developing countries like Bangladesh. Women of reproductive age are very prone to tetanus infection. This descriptive cross-sectional study was carried out at outpatient department (OPD) of Sir Salimullah Medical College and Mitford Hospital, Bangladesh from October 2019 to April 2020 to determine the level of awareness about Tetanus Toxoid (TT) vaccination in women of reproductive age 15-49 years. Data were collected from 342 women by face to face interview with a semi-structured questionnaire. A large number of the respondents (43.27%) were belonged to 15-24 years age group, majority (92.98%) were Muslim and most of them (41.28%) were SSC passed. A very large number of them (78.36%) were married and (64.55%) had 1-2 children. More than three quarter (78.36%) of women heard about tetanus and 83.96% women thought that tetanus is preventable by TT vaccination. Among the respondents who had heard about tetanus, majority (68.67%) of them had taken TT vaccine, 92.58% of them had taken the first dose before 25 years of age and 71.05% had completed the full course. Regarding awareness of the respondents, 65.79% were aware of risk of neonatal tetanus of an unimmunized mother & 61.19% distinguished that agent of tetanus can be transmitted through wounds. It is considered that the findings of the study will provide a useful basis for further research and planning.

Effect of Slow Breathing Exercise on Glycaemic Status in Type 2 Diabetic Male Patients

Slow breathing exercise (SBE) improves the chronic disease conditions. This study aimed to observe the effects of slow breathing exercise on glycaemic status in male patients with type 2 diabetes mellitus (DM). This prospective interventional study recruited sixty (60) diagnosed male type 2 diabetes mellitus (T2DM) patients aged 45-55 years with disease history 5-10 years, from Out Patients Department (OPD) of Endocrinology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from January 2015 to December 2015. Thirty patients performed SBE for 30 minutes 2 times daily for 3 months (study group) and 30 patients did not perform any breathing exercise (Control) and were under follow up for similar duration. Fasting plasma Glucose (FPG), 2 hours Post prandial plasma glucose (PPPG) and glycosylated haemoglobin (HbA1c%) of all patients were assessed both at baseline and after3 months of study. Independent sample and paired sample t-test were used for statistical analysis. In this study the mean FPG, 2 hrs PPPG and HbA1c significantly (p<0.05) reduced in patients with SBE after 3 months whereas no significant changes in FPG, 2 hours PPPG were observed, moreover HbA1c significantly increased (p<0.01) after 3 months in patients who were not under SBE. This study reveals that slow breathing exercise significantly improves glycagemic status in type 2 diabetic patients.

Residue level and health risk assessment of organophosphorus pesticides in country bean and bitter gourd collected from Cumilla, Bangladesh

Organophosphorus pesticides are one of the most commonly used pesticide classes in agriculture in the management of insect pests due to their high efficacy. The extensive use of organophosphorus pesticides can contaminate both the atmosphere and food, which may lead to health problems. In this study, the residue level of organophosphorus pesticides, and their health risk assessment was evaluated on country bean and bitter gourd. Out of forty analysed samples of the country bean, two samples contained multiple residues, seven samples contained single residue. On the other hand, out of forty samples of bitter gourd, one sample contained multiple residues and three samples contained single residue. Among the organophosphorus pesticides, diazinon was the most frequently detected organophosphorus pesticide in country bean and bitter gourd. The highest short-term risks or acute risk (aHI) was below 1.83%, and the highest long-term risk or chronic risk (HQs) was below 10.46% for the country bean and bitter gourd, respectively. Short- and long-term risk assessment results showed that the intake risks of country bean and bitter gourd were acceptable. The health hazard results showed that country bean and bitter gourd consumption in Cumilla, Bangladesh does not pose an acute or chronic risk to human health. However, a routine monitoring system must be established to control the contamination of vegetables with pesticides.

The global incidence of bullous pemphigoid: a systematic review and meta-analysis

BACKGROUND

Bullous pemphigoid (BP) is an autoimmune blistering disorder that mainly affects older people. Although the disease is associated with considerable morbidity and mortality, the burden of disease worldwide is unclear.

OBJECTIVES

The study aim is to pool the global incidence of BP and determine whether this varies according to geographic area, age group, setting and study quality.

METHODS

Ovid MEDLINE, Ovid Embase and grey literature were systematically searched on 7 April 2020. Two reviewers independently screened, extracted data and appraised each study's quality using the Joanna Briggs Institute critical appraisal tool. Two domains, indicative of selection and survey bias, were used to identify high-quality studies. The cumulative incidence was standardized to 1 year and pooled in a random-effects meta-analysis. Subgroup and sensitivity analyses were conducted.

RESULTS

Twenty-seven studies were identified, of which 23 provided cumulative incidence and four provided incidence rates. The cumulative incidence of BP was 8·2 [95% confidence interval (CI) 4·8-13.7] per million people whereas the incidence rate was 34·2 (95% CI 19·2-60·7) per million person-years. Of the continents that contributed more than one study, the cumulative incidence was 10·3 (95% CI 5·8-18·2) and 5·6 (95% CI 3·5-9·0) per million people in Europe and Asia, respectively. The incidence was highest in studies including adults only (n = 2), in population-based studies (n = 9) and in more recent years. The cumulative incidence was higher (13·3 per million people, 95% CI 6·0-29·5) when restricting the analysis to higher-quality studies (n = 11). High heterogeneity (I² > 82%) was observed across all pooled estimates.

CONCLUSIONS

The incidence of BP varies globally, is generally low but appears to be increasing over time. The burden of disease is likely to be underestimated.

Characterization of a Coliphage AS1 isolated from sewage effluent in Pakistan

The emergence of multi-drug resistant (MDR) bacterial strains, which are posing a global health threat has developed the interest of scientists to use bacteriophages instead of conventional antibiotics therapy. In light of an increased interest in the use of phage as a bacterial control agent, the study aimed to isolate and characterize lytic phages from sewage effluent. During the current study, bacteriophage AS1 was isolated from sewage effluent against E.coli S2. The lytic activity of phageAS1 was limited to E.coli S2 strain showing monovalent behavior. The calculated phage titer was 3.5×109 pfu/ml. PhageAS1 was stable at a wide range of pH and temperature. The maximum stability was recorded at 37ºC and pH 7.0, while showing its normal lytic activity at temperature 60ºC and from pH 5.0 to11.0 respectively. At temperature 70ºC, phage activity was somewhat reduced whereas, further increase in temperature and decrease or increase in pH completely inactivated the phage. From the current study, it was concluded that waste water is a best source for finding bacteriophages against multi-drug resistant bacterial strains and can be used as bacterial control agent.

Residue level and health risk assessment of organophosphorus pesticides in eggplant and cauliflower collected from Dhaka city, Bangladesh

Residue levels of seven organophosphorus pesticides in two vegetables (eggplant and cauliflower) collected from major markets of Dhaka city, Bangladesh were analysed. The collected samples were analysed using a modified Quick, Easy, Cheap, Effective, Rugged, and Safe (QuEChERS) extraction technique by Gas Chromatography coupled with Flame Thermionic Detector (GC-FTD). Among the 50 analysed samples of the eggplant 12% samples contained residues of chlorpyrifos (0.384~0.980 mg/kg), 6% samples contained residue of dimethoate (0.052~0.132 mg/kg) and 2% samples contained residue of diazinon (0.01 mg/kg). Whereas, among the 50 samples of cauliflower, 12% samples contained residues of chlorpyrifos (0.056~0.540 mg/kg), 8% samples contained residues of diazinon (0.033~0.42 mg/kg) and 2% samples contained residues of quinalphos (0.06 mg/kg). The chlorpyrifos was found as the most frequently detected organophosphorus pesticide. Among the 21 contaminated samples, 20 were above EU-MRL. Short and long-term health risk assessment based on ARfD and ADI indicates that the intake risks of eggplant and cauliflower were in the acceptable range. Nevertheless, establishing strong monitoring and traceability system together with controlling pre-harvest interval needed to ensure food safety, consumer confidence and promote vegetable export from Bangladesh.

Suicide, self-harm and thoughts of suicide or self-harm in infectious disease epidemics: a systematic review and meta-analysis

AIMS

Suicide accounts for 2.2% of all years of life lost worldwide. We aimed to establish whether infectious epidemics are associated with any changes in the incidence of suicide or the period prevalence of self-harm, or thoughts of suicide or self-harm, with a secondary objective of establishing the frequency of these outcomes.

METHODS

In this systematic review and meta-analysis, MEDLINE, Embase, PsycINFO and AMED were searched from inception to 9 September 2020. Studies of infectious epidemics reporting outcomes of (a) death by suicide, (b) self-harm or (c) thoughts of suicide or self-harm were identified. A random-effects model meta-analysis for the period prevalence of thoughts of suicide or self-harm was conducted.

RESULTS

In total, 1354 studies were screened with 57 meeting eligibility criteria, of which 7 described death by suicide, 9 by self-harm, and 45 thoughts of suicide or self-harm. The observation period ranged from 1910 to 2020 and included epidemics of Spanish Flu, severe acute respiratory syndrome, human monkeypox, Ebola virus disease and coronavirus disease 2019 (COVID-19). Regarding death by suicide, data with a clear longitudinal comparison group were available for only two epidemics: SARS in Hong Kong, finding an increase in suicides among the elderly, and COVID-19 in Japan, finding no change in suicides among children and adolescents. In terms of self-harm, five studies examined emergency department attendances in epidemic and non-epidemic periods, of which four found no difference and one showed a reduction during the epidemic. In studies of thoughts of suicide or self-harm, one large survey showed a substantial increase in period prevalence compared to non-epidemic periods, but smaller studies showed no difference. As a secondary objective, a meta-analysis of thoughts of suicide and self-harm found that the pooled prevalence was 8.0% overall (95% confidence interval (CI) 5.2-12.0%; 14 820 of 99 238 cases in 24 studies) over a time period of between seven days and six months. The quality assessment found 42 studies were of high quality, nine of moderate quality and six of high quality.

CONCLUSIONS

There is little robust evidence on the association of infectious epidemics with suicide, self-harm and thoughts of suicide or self-harm. There was an increase in suicides among the elderly in Hong Kong during SARS and no change in suicides among young people in Japan during COVID-19, but it is unclear how far these findings may be generalised. The development of up-to-date self-harm and suicide statistics to monitor the effect of the current pandemic is an urgent priority.

The Additive Effects of Midazolam in Sub Arachnoid Block in Elective Caesarian Section: A Randomized Control Trial

The incidence of visceral pain among caesarean section can be as high as 50% in sub arachnoid block (SAB) in spite adequate sensory block, which requires conversion to general anesthesia. Different types of adjuvant have been used to augment the effect of local anesthetics but their use is limited due to adverse effects. The effect of intrathecal midazolam along with hyperbaric bupivacaine in sub arachnoid block is less known. So this randomized, double blind study was conducted to evaluate the additive effect of 0.4ml midazolam to 0.5% 3ml bupivacaine on sub arachnoid block in scheduled elective caesarean section. This study demonstrated that the addition of intrathecal 0.4ml midazolam to spinal 0.5% bupivacaine kept all the characteristics of block unaffected, furthermore pain score VAS 3.4±1.3 in Group A and 1.8±1.22 in Group B which is statistically significant, the requirement of intraoperative analgesia and also increased the duration of postoperative analgesia that is 130.3±5.4 minute in Group A, 265.1±3.6 minute in Group B and also statistically significant. Therefore addition of 2.0mg midazolam with 0.5% bupivacaine significantly reduces the VAS score, reduces the intraoperative visceral pain and need of analgesia.

Clinical Profile of Low Vision Patients Attending in Low Vision Clinic in a Tertiary Care Hospital

The purpose of the study was to determine the disease profile of patients attending the low vision clinic of a tertiary eye care hospital at National Institute of Ophthalmology & Hospital (NIO&H), Dhaka, Bangladesh July 2016 to June 2017. Low vision and blindness are major causes of morbidity and an economic burden on the individual, family and the country. Low vision service has emerged as a major challenge faced by the developing countries .so prompt diagnosis; early treatment and early use of low vision devices can improve the quality of life. It was a prospective observational study conducted in low vision clinic at a tertiary care hospital in Bangladesh for one year. A total 419 patient, aged 6-60 years among them 267(63.7%) were male and 152(36.3%) were female. The leading causes of low vision in patient attending the low vision clinic were Retinitis pigmentosa (31.3%) macular dystrophy/stargards diseases & maculopathy (20.3%) and myopia with macular degeneration (14.8%). The percentage of visual impaired (6/18-6/60) were 38.3%, severely visual impaired (<6/60-3/60) were 24.4% & (<3/60) 37.3%. Almost all the patient was prescribed spectacles and Telescope for distant vision, Hand held magnifier and video magnifier were prescribed for near vision. Vision improved with low vision devices (6/18 or better) in 49.5%, (6/18-6/60) in 47.3%, (<6/60-3/60) in 2.8%, (<3/60) in 0.3% patient. Vision with low vision devices were significantly changes (p=0.001). The present study shows that hereditary ocular anomalies (Retinitis pigmentosa, macular dystrophy, myopic degeneration) and amblyopia were more common causes of low vision in this part of world.

Modeling the economic outcomes of immuno-oncology drugs: alternative model frameworks to capture clinical outcomes

BACKGROUND

Economic models in oncology are commonly based on the three-state partitioned survival model (PSM) distinguishing between progression-free and progressive states. However, the heterogeneity of responses observed in immuno-oncology (I-O) suggests that new approaches may be appropriate to reflect disease dynamics meaningfully.

MATERIALS AND METHODS

This study explored the impact of incorporating immune-specific health states into economic models of I-O therapy. Two variants of the PSM and a Markov model were populated with data from one clinical trial in metastatic melanoma patients. Short-term modeled outcomes were benchmarked to the clinical trial data and a lifetime model horizon provided estimates of life years and quality adjusted life years (QALYs).

RESULTS

The PSM-based models produced short-term outcomes closely matching the trial outcomes. Adding health states generated increased QALYs while providing a more granular representation of outcomes for decision making. The Markov model gave the greatest level of detail on outcomes but gave short-term results which diverged from those of the trial (overstating year 1 progression-free survival by around 60%).

CONCLUSION

Increased sophistication in the representation of disease dynamics in economic models is desirable when attempting to model treatment response in I-O. However, the assumptions underlying different model structures and the availability of data for health state mapping may be important limiting factors.

Impact of terminal polar substitution on elastic, electro-optic and dielectric properties of four-ring bent-core nematic liquid crystals

Here we report the influence of terminal –F, –Cl and –NO₂ substitution on the elastic, dielectric and polar switching behavior of four-ring bent-core liquid crystals (LCs).

Detection of Plasmid Mediated AmpC-β lactamases Among Gram-Negative Uropathogens at a Tertiary Care Hospital, Dhaka City

Plasmid-mediated AmpC β-lactamase (PMABL) resistance among gram negative bacilli is an emerging problem worldwide. They likely originate from chromosomal AmpC of certain Gram-negative bacterial species and subsequently are mobilized to transmissible plasmids. There are reports of unfavorable clinical outcomes in patients infected with these organisms and treated with broad-spectrumcephalosporins. The present cross sectional study was designed to detect PMABL genes among gram negative uropathogens in a tertiary care hospital, Dhaka city, Bangladesh from January 2014 to December 2014. Total 138 gram negative uropathogens were identified by the conventional methods and were screened for AmpC production using cefoxitin discs. Confirmatory phenotypic identification was done by modified three dimensional test (MTDT). The common AmpC genotypes ACC, FOX, MOX, DHA, CIT and EBC types were determined by a multiplex PCR.PMABL genes were detected by PCR in 90% of cefoxitin resistant isolates and the molecular types of the genes detected predominantly were CIT, DHA followed by EBC and ACC types. Overall, PMABL genes were detected in 32.61% (45/138) of the studied gram negative uropathogens which is alarming. All (100%) the plasmid mediated AmpC β-lactamase producers showed resistance to amoxicillin-clavulanic acid, ceftazidime, ceftriaxone, cefotaxime and cefoxitin. These results emphasize that clinical laboratories should consider the tests for the detection of PMABL genes for infection control and formulation of effective antibiotic policy.

Correlation between Seropositivity of Chlamydia Trachomatis and Tubal and/or Pelvic Pathology Detected by Diagnostic Laparoscopy in Subfertile Women

This prospective observational study was carried out in the Infertility Unit, Department of Obstetrics and Gynaecology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, from February 2011 to December 2013. Sixty-nine (69) subfertile women who were seropositive for Chlamydia Trachomatis were included in this study. Inclusion criteria was patients with sub-fertility having age between 22 and 40 years, seeking infertility treatment, normal ovarian function, all normozoospermic male partner, duration of infertility ranged from 1.5 to 14 years. Exclusion criteria were patients having sub-fertility with extensive pelvic and/or ovarian surgery, endometriosis, ablation of endometriotic spots, pelvic tuberculosis and history of ectopic pregnancy. Before laparoscopic evaluation, all study women were screened for Chlamydia Trachomatis Specific IgG & IgM antibodies using ELISA in the Microbiology Department of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. All the study women had positive results for IgG antibodies. All study women underwent diagnostic laparoscopy. During laparoscopy, we observed the condition of pelvic cavity, uterus, fallopian tubes, ovaries, peritubal adhesions, tubo-ovarian relationship, status of Pouch of Douglas (POD), fimbriae etc. During dye test procedure, dilute methylene blue dye was injected through the cervical canal and the dye spill out was observed to confirm the tubal patency or blockage or pattern of flow of dye. The results of laparoscopic findings demonstrated that mobility of uterus was restricted in 20(29%) cases, adhesion of uterus with peritoneum was in 8(11.6%) cases, uterine fibroid was present in 11(15.9%) cases, hydrosalpinx in right fallopian tubes were in 27(39.1%) cases, in left fallopian tubes were in 32(46.4%) cases and in both fallopian tubes in 16(23.2%) cases, inflamed right fallopian tubes in 32(46.4%) cases, inflamed left fallopian tubes in 36(52.2%) cases and inflamed both fallopian tubes in 26(37.7%) cases, adhesions in pouch of Douglas was in 4(5.8%) cases, collections in pouch of Douglas was in 7(10.1%) cases and obliterations in pouch of Douglas was in 5(7.2%) cases. Results of Dye test during laparoscopy were that right fallopian tube was blocked in 32(46.4%) cases, left fallopian tube was blocked in 32(46.4%) cases and both fallopian tubes were blocked in 21(30.4%) cases. This study shows that by laparoscopy, significant number of cases of tubal and pelvic pathology was diagnosed in the chlamydia trachomatis seropositive subfertile female. This indicates strong correlation between seropositivity of chlamydia trachomatis and/or pelvic pathology detected by diagnostic laparoscopy.

Diagnosis of Dermatophytosis by Conventional Methods and Comparatative analysis of Sabouraud Dextrose Agar and Dermatophyte Test Medium for Isolation of Dermatophytes

Dermatophytosis is a fungal disease which ranked as one of the most common cutaneous condition in all over the world. The aim of this cross sectional observational study is to identify the etiological agent of dermatophytosis and comparison of Sabouraud dextrose agar (SDA) and Dermatophyte test medium (DTM) for the primary isolation of dermatophytes among the clinically suspected cases of dermatophytosis from the outpatient Department of Dermatology and Venereology, Mymensingh Medical College Hospital from July 2013 to December 2015. Two hundred thirty clinically suspected cases of dermatophytosis were subjected in this study. Sixty three cases (27.4%) were positive for fungus in direct microscopy while 53(23%) were culture positive. Trichophyton rubrum (83%) was found common etiological dermatophyte species followed by Trichophyton mentagrophytes 5(9.4%) and Epidermophyton floccosum 4(7.5%). There was no statistically significant difference between the SDA and DTM (p<0.01) in primary isolation of dermatophytes.

Emergence of CTX-M-15 producing E. coli O25b-ST131 clone in a tertiary care hospital of Bangladesh

BACKGROUND

Extended-spectrum β-lactamase (ESBL) producing uropathogens has become prevalent worldwide. E. coli O25b-ST131 clone, associated with blaCTX-M-15, has been reported from many parts of the world and is frequently associated with multidrug resistance. Thus far, there are no reports about this clone in Bangladesh. The objective of this study was to investigate ESBL producing uropathogens and to survey the prevalence of E. coli O25b-ST131 clone among ESBL positive E. coli isolates.

METHODS

From symptomatic urinary tract infection cases, a total of 800 urine samples were collected. Bacterial identification and antimicrobial susceptibility testing was performed using established methods. Screening of ESBL producers was done using the disk diffusion method. Screening positive isolates were phenotypically confirmed by double disk synergy (DDS) test. Genes encoding ESBLs (blaCTX-M-15, blaOXA-1) were identified both by PCR and DNA sequencing. Phenotypic positive ESBL producers were also studied by PCR for existence of class 1 integron. Subsequently, O25b-ST131 clone was identified by allele specific PCR.

RESULTS

Of 138 gram-negative uropathogens, 45 (32.6%) were positive for ESBLs. ESBL producers showed high frequency of antimicrobial resistance except imipenem. Among 45 ESBL producers, 36 (80%) produced blaCTX-M-15, 18 (40%) produced blaOXA-1. Fifteen (33.3%) strains simultaneously produced both blaOXA-1 and blaCTX-M-15. Class 1 integron was present in 30 (66.7%) isolates. Of the 31 blaCTX-M-15 positive E. coli, 22 (71%) were positive for E. coli O25b-ST131 clone and all (100%) belonged to B2 phylogenetic group.

CONCLUSION

Rising antimicrobial resistance among uropathogens, and especially the emergence of blaCTX-M-15 positive E. coli O25b-ST131 clone in Bangladesh has provided urgency to the development of novel preventive and therapeutic strategies.

Role of Serum Follicle Stimulating Hormone, Luteinizing Hormone, Testosterone and Prolactin Levels in Azoospermic Male Partner of Subfertile Couple

This cross sectional study was carried out in the Infertility Unit, Department of Obstetrics and Gynaecology, Bangabandhu Sheikh Mujib Medical University (BSMMU) from January 2011 and June 2013. Eighty one (81) consecutive azoospermic male partner of married couple, aged 20-50 years with at least two years of subfertility and no known endocrinopathy and ejaculatory dysfunction were included in this study to find out their abnormal hormonal pattern. None of them had received any form of treatment within the last 3 months prior to hormonal evaluation. Men with hypertension, recent fever, chemo or radiation exposure were excluded from the study. Eight weeks interval two semen analyses were done in the Andrology Laboratory of above department following standard WHO guideline, 2004. Using standard ELISA technique, serum levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), testosterone and prolactin were measured/assayed/estimated. The results of this study demonstrated that 40 (49.4%) men had normal endocrine pattern against 51 (50.6%) with endocrinopathy. The former may be related to obstructive azoospermia, which needs further analyses. Both the increased FSH (>11.1mIU/ml) and LH (>7.6mIU/ml) were observed in 25 (30.9%) men, only elevated FSH (>11.1mIU/ml) in 9(11.1%), and only elevated LH (>7.6mIU/ml) in 7(8.6%). Low testosterone level (<270ng/dl) was observed in 11(13.6%), low TSH (<0.4μIU/ml) in 1(1.2%) and low prolactin (<2.5ng/dl) in 5(6.2%).

Effect of community-based newborn care on cause-specific neonatal mortality in Sylhet district, Bangladesh: findings of a cluster-randomized controlled trial

OBJECTIVES

Community-based maternal and newborn intervention packages have been shown to reduce neonatal mortality in resource-constrained settings. This analysis uses data from a large community-based cluster-randomized trial to assess the impact of a community-based package on cause-specific neonatal mortality and draws programmatic and policy implications. In addition, the study shows that cause-specific mortality estimates vary substantially based on the hierarchy used in assigning cause of death, which also has important implications for program planning. Therefore, understanding the methods of assigning causes of deaths is important, as is the development of new methodologies that account for multiple causes of death. The objective of this study was to estimate the effect of two service delivery strategies (home care and community care) for a community-based package of maternal and neonatal health interventions on cause-specific neonatal mortality rates in a rural district of Bangladesh.

STUDY DESIGN

Within the general community of the Sylhet district in rural northeast Bangladesh. Pregnancy histories were collected from a sample of women in the study area during the year preceding the study (2002) and from all women who reported a pregnancy outcome during the intervention in years 2004 to 2005. All families that reported a neonatal death during these time periods were asked to complete a verbal autopsy interview. Expert algorithms with two different hierarchies were used to assign causes of neonatal death, varying in placement of the preterm/low birth weight category within the hierarchy (either third or last). The main outcome measure was cause-specific neonatal mortality.

RESULT

Deaths because of serious infections in the home-care arm declined from 13.6 deaths per 1000 live births during the baseline period to 7.2 during the intervention period according to the first hierarchy (preterm placed third) and from 23.6 to 10.6 according to the second hierarchy (preterm placed last).

CONCLUSION

This study confirms the high burden of neonatal deaths because of infection in low resource rural settings like Bangladesh, where most births occur at home in the absence of skilled birth attendance and care seeking for newborn illnesses is low. The study demonstrates that a package of community-based neonatal health interventions, focusing primarily on infection prevention and management, can substantially reduce infection-related neonatal mortality.

Preoperative neutrophil:lymphocyte and platelet:lymphocyte ratios predict endometrial cancer survival

BACKGROUND

Variations in systemic inflammatory response biomarker levels have been associated with adverse clinical outcome in various malignancies. This study determined the prognostic significance of preoperative neutrophil:lymphocyte (NLR), platelet:lymphocyte (PLR) and monocyte:lymphocyte (MLR) ratios in endometrial cancer.

METHODS

Clinicopathological and 5-year follow-up data were obtained for a retrospective series of surgically treated endometrial cancer patients (n=605). Prognostic significance was determined for overall (OS) and cancer-specific survival (CSS) using Cox proportional hazards models and Kaplan-Meier analysis. Receiver-operator characteristic and log-rank functions were used to optimise cut-offs. NLR, PLR and MLR associations with clinicopathological variables were determined using non-parametric tests.

RESULTS

Applying cut-offs of ⩾2.4 (NLR), ⩾240 (PLR) and ⩾0.19 (MLR), NLR and PLR (but not MLR) had independent prognostic significance. Combining NLR and PLR scores stratified patients into low (NLR-low and PLR-low), intermediate (NLR-high or PLR-high) and high risk (NLR-high and PLR-high) groups: multivariable hazard ratio (HR) 2.51; P<0.001 (OS); HR 2.26; P<0.01 (CSS) for high vs low risk patients. Increased NLR and PLR were most strongly associated with advanced stage (P<0.001), whereas increased MLR was strongly associated with older age (P<0.001).

CONCLUSION

Both NLR and PLR are independent prognostic indicators for endometrial cancer, which can be combined to provide additional patient stratification.

Household Animal and Human Medicine Use and Animal Husbandry Practices in Rural Bangladesh: Risk Factors for Emerging Zoonotic Disease and Antibiotic Resistance

Animal antimicrobial use and husbandry practices increase risk of emerging zoonotic disease and antibiotic resistance. We surveyed 700 households to elicit information on human and animal medicine use and husbandry practices. Households that owned livestock (n = 265/459, 57.7%) reported using animal treatments 630 times during the previous 6 months; 57.6% obtained medicines, including antibiotics, from drug sellers. Government animal healthcare providers were rarely visited (9.7%), and respondents more often sought animal health care from pharmacies and village doctors (70.6% and 11.9%, respectively), citing the latter two as less costly and more successful based on past performance. Animal husbandry practices that could promote the transmission of microbes from animals to humans included the following: the proximity of chickens to humans (50.1% of households reported that the chickens slept in the bedroom); the shared use of natural bodies of water for human and animal bathing (78.3%); the use of livestock waste as fertilizer (60.9%); and gender roles that dictate that females are the primary caretakers of poultry and children (62.8%). In the absence of an effective animal healthcare system, villagers must depend on informal healthcare providers for treatment of their animals. Suboptimal use of antimicrobials coupled with unhygienic animal husbandry practices is an important risk factor for emerging zoonotic disease and resistant pathogens.

Pregnancy outcome following myomectomy

In developing countries, abdominal myomectomy is still a modality of treatment for large and symptomatic uterine fibroid in women who wish to retain their fertility and preserve uterus. In order to assess the outcome of pregnancies after myomectomy, a prospective observational study was carried out in the Department of Obstetrics and Gynaecology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, from July 1999 and June 2011. Study included 40 married women of reproductive age, suffering either from primary or secondary subfertility, and who had uterine fibroid and strongly wished to conceive shortly after myomectomy using microsurgical procedure with no existence of other male and female subfertility factor. These women were followed up at 3, 6, 12 and 24 month intervals over telephone and outdoor visits. Data were recorded on preformed questionnaires. Post myomectomy hysterosalpingography was done at about 16 weeks after myomectomy. Patients were advised to try for pregnancy after 16 weeks of operation. Maximum number of women belonged to age group 31-35 years (n=14, 35%); primary subfertility was 67.5% and secondary 32.5%; in maximum number of cases duration of subfertility was 2-5 years (n=22, 55%); type of fibroid were solitary (52.5%) and multiple (47.5%); type of myoma were intramural (75%), submucous (2.5%) and combined (22.5%); location of myoma were fundal (5%), anterior wall (25%), posterior wall (20%) and combined (50%); diameter of removed myoma were <5cm (2.5%), 5-8cm (67.5%), >8-10(20%) and >10cm (10%); uterine size before myomectomy were (in weeks) <12(22.5%), 12-14 (27.5%), 15-20 (32.5%), 21-25 (15%) and >25 (2.5%). Hysterosalpingography was done in 16(40%) cases, and the findings were both tube patent (62.5%), unilateral tubal block (31.2%) and bilateral tubal block (6.2%). Menorrhagia after myomectomy was present only in 5% cases. After uterine myomectomy, 14(35%) women conceived, common time interval between myomectomy and conception was 1-2 years (42.9%), conception was spontaneous in 71.4%. Out of 14 who conceived after myomectomy 12(85.7%) delivered live babies by LUCS, and most of the babies weighed >3kg (58.3%).

Quality and quantity of infertility care in Bangladesh

Infertility is an important health issue which has been neglected in the developing countries. First test-tube babies (triplet) in Bangladesh were born on 30th May, 2001. Although there is no tertiary level infertility center in the public sector, several private centers have come up with the facilities. The objective of the study was to find i) the quality and quantity of infertility care in Bangladesh and ii) the cause of infertility in the attending patients iii) the treatment seeking behaviors iv) and the reasons for not taking treatment among the attending patients. There are now 10 tertiary level Infertility centers in Bangladesh. The information was collected in a preformed datasheet about the facilities and the profile of the patients and the treatment seeking behavior of the attending patients. Out of the ten centers two centers refused to respond and did not disclose their data. Around 16700 new patients are enrolled in a year in the responsive clinics. Five percent (5%) of the patients underwent ART, 7% of the patients gave only one visit, 84% of the patients completed their evaluation, 76% of the patients took treatment. Causes of infertility in the patients taking treatment were male factor in 36.4%, bilateral tubal block in 20.2%, PCOS and anovulation in 31.7%, endometriosis in 19.6%, unexplained in 10.95, combined in 3.5%, ovarian failure in 1.4%, testicular failure in 0.33%, congenital anomaly in 0.3%. The main reason for not taking treatment was financial constrainment. The quality and quantity of infertility care is dependent on the available resources and on the use of the resources by the patients. In developing countries the resources are merging and confined to specified areas which cannot meet the demand of their population. The study gives us the idea of the need and the demand of the services in the country.

Turner’s Syndrome in Adulthood and Cytogenetics

Aims: Turner’s syndrome is a chronic disease of chromosomal aberration. The purpose of the study was to find out the accurate identification of cell line, which is critical for cytogenetic studies, genetic counseling, phenotypic studies carried out with few reconstructive procedures to plan future sexual and reproductive life. Methods: This study design was a prospective hospital based clinical study. In this study, ninety six patients were studied with secondary sex characters with relevant ultrasonogram findings and hormonal assay who underwent karyotyping in Bangabandhu Sheikh Mujib Medical University, Dhaka for a study period of ten years from October 1997 to October 2007. Results: Among 96 patients, 62.5 % of the patients were from 15-18 years. Four girls who were less than 15 years came with Turner’s and testicular stigmata. Twenty women aged more than 26 years presented with coital problems.  Around 72.9% had no secondary sexual character, 20.83% had normal female type of secondary sex character, and 6.25% had virilizing type of secondary sexual character. Karyotyping of the cases revealed 72.9% (n = 70) had 45XO pattern, which belong to the Turner's stigmata and correlated well with the hormone profile. Whereas, 20.83% (n = 20) had 46XX pattern and 6.25% (n = 6) had 46XY pattern with testicular feminization syndrome with inguinal testis. Conclusions: About 60% of cases were in the 15-18 years age group. Most of the patients presented with no secondary sexual characteristics. 45XO chromosomal pattern was the most common presenting in 72.9% cases. DOI: http://dx.doi.org/10.3126/njog.v9i2.11744 

Evaluation of swabbing methods for estimating the prevalence of bacterial carriage in the upper respiratory tract: a cross sectional study

OBJECTIVES

Bacterial carriage in the upper respiratory tract is usually asymptomatic but can lead to respiratory tract infection (RTI), meningitis and septicaemia. We aimed to provide a baseline measure of Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa, Staphylococcus aureus, Haemophilus influenzae and Neisseria meningitidis carriage within the community. Self-swabbing and healthcare professional (HCP) swabbing were compared.

DESIGN

Cross-sectional study.

SETTING

Individuals registered at 20 general practitioner practices within the Wessex Primary Care Research Network South West, UK.

PARTICIPANTS

10,448 individuals were invited to participate; 5394 within a self-swabbing group and 5054 within a HCP swabbing group. Self-swabbing invitees included 2405 individuals aged 0-4 years and 3349 individuals aged ≥5 years. HCP swabbing invitees included 1908 individuals aged 0-4 years and 3146 individuals aged ≥5 years.

RESULTS

1574 (15.1%) individuals participated, 1260 (23.4%, 95% CI 22.3% to 24.5%) undertaking self-swabbing and 314 (6.2%, 95% CI 5.5% to 6.9%) undertaking HCP-led swabbing. Participation was lower in young children and more deprived practice locations. Swab positivity rates were 34.8% (95% CI 32.2% to 37.4%) for self-taken nose swabs (NS), 19% (95% CI 16.8% to 21.2%) for self-taken whole mouth swabs (WMS), 25.2% (95% CI 20.4% to 30%) for nasopharyngeal swabs (NPS) and 33.4% (95% CI 28.2% to 38.6%) for HCP-taken WMS. Carriage rates of S. aureus were highest in NS (21.3%). S. pneumoniae carriage was highest in NS (11%) and NPS (7.4%). M. catarrhalis carriage was highest in HCP-taken WMS (28.8%). H. influenzae and P. aeruginosa carriage were similar between swab types. N. meningitidis was not detected in any swab. Age and recent RTI affected carriage of S. pneumoniae and H. influenzae. Participant costs were lower for self-swabbing (£41.21) versus HCP swabbing (£69.66).

CONCLUSIONS

Higher participation and lower costs of self-swabbing as well as sensitivity of self-swabbing favour this method for use in large population-based respiratory carriage studies.

Evaluation of correlation between high serum-ascites albumin gradient and the upper gastrointestinal endoscopic parameters in children presenting with portal hypertension with ascites

Portal hypertension which usually leads to bleeding from oesophageal varices in children remain a difficult medical problem. The upper gastrointestinal endoscopy is currently considered as the best reliable method to diagnose oesophageal varices in portal hypertension. But endoscopic screening is an invasive procedure and is not easily available even in tertiary health care facilities of Bangladesh till now. Therefore an alternative noninvasive indicator is being looked for the diagnosis of portal hypertension. Patients with serum ascites albumin gradient (SAAG) values ≥1.1gm/dl have recently found to have presence of portal hypertension. The study was carried out to set up a diagnostic value of SAAG for the prediction of portal hypertensive changes (oesophageal and gastric varices, gastropathy) of upper gastrointestinal endoscopy in children. This cross sectional study was conducted at the Department of Paediatric Gastroenterology and Nutrition of Bangabandhu Sheikh Mujib Medical University. A total of 30 cases of portal hypertension were studied from November 2008 to February 2010. Oesophageal varices were found in 86.7% of cases. Significant association was found between high SAAG values and presence of oesophageal varices. Frequencies of oesophageal varices increased as the SAAG values increased. The cut off point of SAAG value was found to be 1.55gm/dl for the presence of oesophageal varices where sensitivity and specificity were found 84.6% and 100 % respectively. From this study, it can be concluded that SAAG value 1.6gm/dl is an indicator of portal hypertensive changes especially oesophageal varices in children.

Association of infertile patients having polycystic ovarian syndrome with recurrent miscarriage

Polycystic ovarian syndrome (PCOS) has a pivotal role in the development of various complications during pregnancy. Polycystic ovarian syndrome women having elevated LH and hyper insulineuia may be at increased risk of miscarriage. The study was done to find out the recurrent pregnancy loss among the PCOS patient. This was a cross sectional case control study in total 100 infertile patients between age 20-40 years attending BSMMU out patient Department from July 2011 to June 2012, among them 50 infertile patients with PCOS regarding as a case and 50 infertile patients without PCOS selected as a control. Regarding case (infertile patients with PCOS) shows 20(40%) recurrent miscarriage and among control (infertile patients without PCOS) shows recurrent miscarriage 6(12%). And also among case group shows insulin resistance 8(16%) and control group insulin resistance 1(2%). Six (75%) abortion occur among PCOS with insulin resistance and 5(62.5%) abortion occur among PCOS with raised testosterone level. It is observed that recurrent miscarriage is higher in PCOS group. And also concluded that insulin resistance and raised testosterone level is responsible for this condition. So, further large scale study would be needed to reduce the chance of recurrent pregnancy loss by treatment with insulin sensitizer in case of obese PCOS with insulin resistance patient.

A successful pregnancy outcome following abdominal metroplasty

A 35 years old lady presented to Out Patients Department of Bangabandhu Sheikh Mujib Medical University for secondary subfertility with history of recurrent abortion. She was diagnosed a case of bicornuate uterus following laparoscopy. After 3 months of her last abortion she was advised for metroplasty. Metroplasty was done, forming a single cavity. Dye test was positive on right side and negative on left side. After 3 months of metorplasty hysterosalphingography (HSG) was done and reports shows bilateral patent uterine tubes. One year after metroplasty. She was pregnant with letrozole and Gonadotrophin. Her pregnancy was diagnosed by ultrasonography and advised for admission. She was on regular antenatal follow up and all investigation was done. Anomaly scan was done at 20 weeks of pregnancy. She was properly immunized. Pregnancy period was uneventful until 37 weeks. At 37 weeks LUCS was done. A female healthy baby was born. APGAR score was 7/10 at 1, 10/10 at 5 minutes, baby weight 2.8kg postpartum period was uneventful. After abdominal metroplasty successful pregnancy outcome was occurred.

[Gastric and duodenal perforations: what is the role of laparoscopic surgery?]

INTRODUCTION

The gastric and duodenal perforations are a life-threatening complication of peptic ulcer disease with the indication for immediate surgical intervention. To which extent laparoscopy is a suitable method in an acute situation was examined in the present investigation.

MATERIALS AND METHODS

The data of all patients within a period of 15 years (01/1996-12/2010) who were operated laparoscopically because of a perforated gastric or duodenal ulcer, were collected prospectively in terms of age, gender, localisation of perforation, diagnostics, symptoms, surgical procedures, intraoperative and postoperative complications and postoperative course, and were analysed retrospectively.

RESULTS

During the observation period 45 patients were operated laparoscopically due to gastric or duodenal perforation. The median age at operation was 58 (18-91) years. An NSAID medication was present in 11 (24.4 %) patients. The perforation was juxtapyloric in 12 (26.7 %) patients, postpyloric in 10 (22.2 %) patients, one (2.2 %) patient in each small and greater curvature, in 18 (40.0 %) at the front and in three (6.7 %) patients on the rear wall. In two cases, previous surgical treatment in the upper abdomen was performed. After primary diagnostic laparoscopy, an indication for conversion was seen in 20 (44.4 %) patients. During laparoscopically completed operations simple suturing was done in 18/25 (72.0 %) patients and excision and suturing was performed in 7/25 (37.8 %) patients. After conversion simple suturing was observed in 7/20 (35.0 %) patients, whereas in 10/20 (50.0 %) patients excision and suturing was performed. 3/20 (15.0 %) patients underwent a resective operation. The median operative time was 105 (40-306) minutes and mean hospitalisation 11 (4-66) days. The ICU stay was in median 2 (0-37) days. Major complications were seen in 11 (24.4 %) patients, namely re-laparotomy (n = 7; 15.6 %) and haemorrhage (n = 4; 8.9 %). Minor complications were observed in 8 (17.8 %) of cases. The mortality rate was 11.1 % (n = 5).

CONCLUSION

The laparoscopic treatment of gastric and duodenal perforations is a minimally invasive therapeutic option for the definitive treatment of this life-threatening disease. The indication for a laparoscopic approach has to be considered individually and depends to a decisive extent on the experience of the laparoscopic surgeon.

[Diagnostics and therapy for neuroendocrine neoplasia of an unknown primary - a plea for open exploration]

BACKGROUND

Neuroendocrine neoplasia (NEN) are a rare and heterogenous tumour entity. The subgroup with unknown primary tumour (N-CUP) seems to have a worse prognosis as resection of the primary is necessary for cure. The diagnostics and therapeutic algorithms for N-CUP in a German single centre are presented.

PATIENTS/METHODS

Analysis of the surgical databank showed 35 cases of N-CUP in 261 cases with NEN from gastroenteropancreatic and lung origin over 2 decades (03/1990-03/2011). Three groups were built: K1 - primary detection after operative exploration (n = 10), K2 - unknown primary after operative exploration (n = 10) and K3 - no operative exploration for various reasons (n = 13).

RESULTS

Initially 13.4 % (35/261) of patients presented as N-CUP, after intensified diagnostics 12.7 % (33/261) and after operative exploration 8.8 % (23/261) remained with unknown primary tumour. The sex ratio was 1 : 1, the median age is significantly higher in N-CUP [63.8 years (y) vs. 55.9 y, p = 0.004), the 5-year-survival is lower (58 vs. 72 %, n. s.). compared to NEN with known primary. Operative exploration was performed in 60.6 % (20/33), 30 % (6/20) of them were found to have inoperable situations, in 20 % (4/20) single site metastases were removed completely and in 50 % (10/20) a primary tumour was detected (8 × midgut, 2 × pancreas) intraoperatively. In these cases 70 % (7/10) got complete tumour resection (R0) and in 30 % (3/10) primary tumour resection with debulking of liver metastasis was done. In K3 (39.4 %, 13/33) most patients [69.2 % (9/13)] were treated with chemotherapy. The median age in K1 was significantly lower than in K3 (54.9 y vs. 68.3 y, p = 0.028), male dominance was seen in K3 (3,3 : 1, n. s.). The average Ki-67 index was 4.3, 23.8 and 53 % in K1, K2 and K3 (p < 0.0001 for K1 and K3 and p = 0.035 for K2 and K3), respectively. The death rate was 20, 30 and 76.9 % in K1, K2 and K3, respectively.

CONCLUSION

Primary tumours of the midgut and pancreas are often found in the subset of well differentiated neuroendocrine CUP syndrome after open surgical exploration. A high rate of complete tumour resection and cure can be achieved in these cases. After common diagnostic tools (CT, MRI and somatostatin receptor scintigraphy), immunhistochemistry can give important hints (CDX-2 for midgut, TTF-1 for lung and thyroid) for a primary lesion. Also in single site metastasis without primary tumour detection a good clinical outcome is seen after complete resection.

[Neuroendocrine tumours of the GI tract--data from the German NET Registry]

BACKGROUND

Neuroendocrine tumours (NET) are rare and heterogeneous neoplasia. To obtain valid data on epidemiology, diagnostics, therapy, prognosis and risk factors is the aim of the German NET registry.

PATIENTS AND METHODS

Data from 2009 histologically proven NET were collected from 35 NET centres between 1999 and 2010. Data collection has been performed prospectively since 2004. Results: Median follow-up was 34.5 months and median age at diagnosis 56.4 years. Primary tumour localisations were pancreas (34.2%), midgut (5.8%), stomach (6.5%), bowel (6.9%), duodenum (4.8%) and neuroendocrine CUP (12.6%). Synchronous metastases were seen in 46% and second malignancies in 12%. From 860 patients, 402 (46.7%) had functional tumours with the following hormone excess syndromes: carcinoid syndrome (19.1%; n = 164), persistent hyperinsulinaemic hypoglycaemia (17.7%; n = 152), Zollinger- Ellison syndrome (7.1%; n = 61), glucagonoma (0.7%; n = 15), Verner-Morrison syndrome (0.4%; n = 8) and somatostatinoma syndrome(0.1%; n = 2). Surgical therapy was performed in 78%, therapy with somatostatin receptor analogues(SSA) in 28%, peptide radioreceptor therapy (PRRT) in 19%, chemotherapy in 18% and interferon therapy in 6.5%. Only surgery was done in 47%, whereas 53% received a second therapy. General mortality rate during follow-up was 14.9%. The tumour-specific survival rates for 2, 5 and 10 years were 94, 85 and 70%. The 5-year survival is dependent on the surgical or non-surgical therapy (82 versus 61%, p < 0.001) and also on the primary tumour site (90/30% for midgut, 85/65% for pancreas, p < 0.001). Grading (G1, G2, G3) based on proliferation index Ki-67 recommended by the ENETS guidelines and WHO classification is highly correlated to the 5-year survival rate (88, 82, 33%, p < 0.001).

CONCLUSION

The German NET registry provides valid multicentric data on NET in Germany. Surgical therapy is the most frequent and important therapy with good clinical outcome. In non-resectable, metastatic tumours, systemic therapies are common. Continuation and evaluation of the new WHO and TNM classifications for NET and their therapies will be a future focus of the registry.

Role of VIA in cervical cancer screening in low-resource countries

Cervical cancer is one of the few highly preventable cancers. The early detection and removal of precancerous cervical lesions effectively abolish the development of invasive cervical cancer. The Pap test has been the standard screening test in the Western world for the last five decades. Visual inspection of cervix with acetic acid (VIA) is currently more popular method of cervical cancer of screening test in low resource countries. Cervical cancer incidence and mortality have been reduced dramatically as a result of successful screening in many countries. Cancer cervix can be prevented through both primary prevention using human papilloma virus (HPV) vaccine and early detection using screening techniques. Several screening modalities are now available for early detection of cervical cancer and its precursor lesions. They all differ with regard to their test characteristics, feasibility and economic considerations. This review has different aspects of these screening modalities and provides different options considering mass application. In developed countries, Pap smear cytology is used for cervical cancer screening. But in low-resource country, like Bangladesh, it is too expensive and is not feasible. VIA, a non-cytological test is a simple and inexpensive test which can be provided by trained paramedical personnel with a short training. So VIA can be done in low-resource countries for screening of cervical cancer as an alternative to Pap smear cytology.

Valvular heart disease in pregnancy: maternal and fetal outcome

The aim of this study was to evaluate the maternal and fetal outcome of pregnancy in Valvular Heart Disease (VHD). A better understanding of the effects of valvular abnormalities on pregnancy outcome is of value for risk assessment and the design of a therapeutic plan from the available information of a series of patient. A multicenter prospective study was carried out over a period of 5 years (2005-2009) involving 60 pregnant patients with valvular heart disease. Thirty eight patients (64%) had single valve involvement and mitral stenosis was the most predominant lesion (50%). Ten patients (16.7%) had undergone interventional and surgical correction prior to the pregnancy. Fourteen (24%) patients were identified as a NYHA class III-IV. Women with VHD had 8.35% pulmonary edema, 15.03% developed different types arrhythmia. The incidence of preterm birth and small for gestational age newborn was 11.69% and 13.36% respectively. There was one (1.67%) maternal death. Pregnancy in women with valvular heart disease is associated with remarkable unfavourable effect on maternal and fetal outcome which are related to severity of disease.

Stress in mothers of preterm infants in Bangladesh: associations with family, child and maternal factors and children's neuro-development

BACKGROUND

The aim of this paper was to ascertain stress experienced by mothers of prospectively followed up preterm infants, and associations with family, child and maternal factors and children's neuro-development.

METHODS

Within a follow-up study of preterm infants<33 weeks gestational age at a Child Development Center in Dhaka Shishu Hospital, mothers were interviewed with the Self-Report Questionnaire (SRQ) at each visit. Association between SRQ scores and child, family and maternal variables at first and final visit and children's neuro-developmental outcomes was determined.

RESULTS

Low income mothers were more compliant (54%) compared with the defaulters (31%) (P=0.0001) among the 159 mothers enrolled. Of the 88 mothers who were followed up until a mean age of 22 months of their child, 29.3% were at high risk for psychiatric morbidity at first visit compared with 23.9% on their last visit. Use of abortifacients (P=0.026) and higher maternal age (P=0.040) were significantly associated with maternal stress at first visit; while at last follow-up, total number of visits had the most significant association (P=0.041). Twenty-five per cent and 19% of mothers were at risk for psychiatric morbidity in children developing normally and those with neuro-developmental impairments respectively.

CONCLUSIONS

Mothers at risk for psychiatric morbidity can be helped through follow-up support within public hospitals close to their homes, which is most availed by low income families. Neuro-developmental monitoring of high-risk infants closer to homes may be more feasible in resource poor countries than reliance on hospital visits, which increase stress. Biological markers of stress and coping strategies need further research.