Simcrafting: A comprehensive framework for scenario development for simulation

Simulation can be an excellent teaching and learning method if the scenarios are created appropriately. It starts with assessing the learner's needs and is followed by laying down objectives embracing the SMART principles. While creating a scenario, it is essential to consider the different aspects of realism, such as physical, contextual and psychological aspects. Using moulages and props helps in creating physical realism. The simulation expert should also be aware of the learner's experience and decide the SimZones for their learners based on their level of clinical expertise. The scenario progression needs to be laid down in stages. The role of the embedded participant needs to be decided a priori, and the embedded participant should be well-versed in their role. Pilot testing is a crucial step in simulation development as it keeps the simulation expert aware of the loopholes in the simulation scenario before running.

Simulation in airway management teaching and training

There is a gradual shift in training and teaching methods in the medical field. We are slowly moving from the traditional model and adopting active learning methods like simulation-based training. Airway management is an essential clinical skill for any anaesthesiologist, and a trained anaesthesiologist must perform quick and definitive airway management using various techniques. Airway simulations have been used for the past few decades. It ensures active involvement, upgrading the trainees' airway management knowledge and skills, including basic airway skills, invasive procedures, and difficult clinical scenarios. Trainees also learn non-technical skills such as communication, teamwork, and coordination. A wide range of airway simulators are available. However, texture surface characteristics vary from one type to another. The simulation-based airway management training requires availability, understanding, faculty development, and a structured curriculum for effective delivery. This article explored the available evidence on simulation-based airway management teaching and training.

Dynamic Contrast Enhanced MRI as a Biomarker of Tumor Response and Oncologic Outcomes in Head and Neck Cancer: Results of a Single Institution Prospective Imaging Study

PURPOSE/OBJECTIVE(S)

We aim to determine the correlation between vascular parameters of Dynamic contrast enhanced (DCE) MRIs and tumor response and outcomes in head and neck (HNC) patients treated with definitive radiation therapy (RT).

MATERIALS/METHODS

Eighty-two HNC patients are included in this prospective study in one institute. All patients had malignant head and neck neoplasm indicative of curative- intent treatment. Patients were imaged using MRIs pre-, mid-, and post-RT completion at 8-12 weeks. T2-weighted sequences were used for tumor contouring then it was co-registered to respective DCE images. The response to treatment was checked at mid-radiotherapy (mid-RT) and at the end of RT. Mid-RT MRI was co-registered to baseline images and the manually segmented baseline primary tumor regions of interest were propagated to mid-RT images. Quantitative maps (Ktrans, Kep, Ve and Vp) were generated with the extended Tofts pharmacokinetic models and were used for analysis. These vascular parameters were presented as a mean value and percentile using histogram analysis and the following parameters were extracted using an in-house programming environment script: mean, 5th, 10th, 20th, 30th, 40th, 50th (i.e., median), 60th, 70th, 80th, 90th, 95th percentile. The non-parametric Wilcoxon signed-rank test was used to assess the changes of mid-RT DCE parameters compared to baseline. Recursive partitioning analysis (RPA) was used to identify the delta DCE threshold associated with relapse. We assessed the identified thresholds' correlation with oncological and survival endpoints using Cox regression with and without standard clinical variables.

RESULTS

The median age for patients is 61 years old (33-78 range). Never smokers are 39 (47%), 35 (43%) are former smoker and 8 (10%) are current smoker with a mean value of 14 pack per year and 26 standard deviations. Using AJCC 8th edition, 39 (47%) are stage I and 19 (23%) are stage II and stage III and IV are 15 (18%) and 9 (10%) respectively. HPV positive are 72 (88%). For patients with GTV-P at baseline (n = 60), 11 (18%) had mid-RT CR at the primary site which increased to 50 (83%) post-RT. The LC and RFS for the entire cohort were 91.4%, and 79.2% respectively. In GTV-P, none of the pre-radiotherapy DCE parameters were correlated with LC or RFS. Wilcoxon signed rank test was statistically significant in 80, 90 and 95 percentiles with (p<0.05). RPA analysis identified different thresholds for each DCE parameter, and its inclusions to the multivariate model improved its performance. In GTV-P, RPA analysis identified ΔKtrans 40 percentiles >15.6% at mid-RT as the most significant point. When this value of ΔKtrans added to the multivariate analysis it was associated with a significantly better model performance in RFS (p = 0.00001).

CONCLUSION

DCE parameters are a very promising tool to correlate with response and outcomes in H&N cancer patients. Future work is warranted for external validation of our findings.

Assessment of Dynamic Contrast Enhanced (DCE) MRI for Detection of Radiotherapy Induced Alteration in Mandibular Vasculature

PURPOSE/OBJECTIVE(S)

We aim to determine the kinetics of DCE-MRI changes in various mandibular risk volumes based on radiation (RT) dose received.

MATERIALS/METHODS

Eighty-eight head and neck cancer (HNC) patients (Pts) who underwent definitive RT were enrolled in this prospective study after IRB approval and informed consent. Images were acquired at pre-RT (Baseline), 3 weeks after RT start date (Mid-RT), 3 mos post-RT (PostRT1), and 6 mos post-RT (PostRT2). Manually segmented mandibular volumes on T2-weighted images were propagated to co-registered DCE-MRIs. Planning CTs and dose grids were also co-registered to corresponding baseline T2 images to create 3-D dose subvolumes. These were used to create 3 risk subvolumes; <30 Gy, 30-50 Gy, and >50 Gy ROIs. DCE images of different timepoints (TPs) were deformably co-registered and the dose subvolumes were propagated to each TP. We used the extended-Tofts model to generate the vascular quantitative maps (Ktrans and Ve). Each subvolume histogram parameters were extracted at each TP. Wilcoxon Signed Rank test was used to compare the changes at different TPs compared to baseline. We classified Pts' delta parameters at different TPs -based on our prior extensive QA assessment- into Pts with stable vascular profile (±25% change), Pts with significant increase (>25% change) and Pts with significant decrease (<-25%). Chi-square test was used to assess the change at different TPs.

RESULTS

For <30 Gy subvolumes, there were no significant changes (p > 0.05) in the studied DCE parameters at all TPs except a significant decrease (p < 0.001) in median Ktrans at PostRT2. For 30-50 Gy subvolumes, there was a significant increase in median Ktrans that started at MidRT (p = 0.006) and continued at PostRT1 (p = 0.04) but recovered to baseline values at PostRT2. Median Ve on the other hand only showed significant increase at PostRT1 (p = 0.001), but other TPs were not significantly different compared to baseline. Similarly, subvolumes >50 Gy showed same kinetics as in 30-50 Gy with significant increase of Ktrans at MidRT and PostRT1 and significant increase in Ve in only PostRT1 (P <0.05). For <30 Gy, there was significant increase in the number of Pts with stable or decrease in Ktrans at PostRT2 compared to earlier TPs (70% vs. 60% at PostRT1 and 54% at MidRT p = 0.003). 30-50 Gy subvolumes showed similar profile like <30 Gy with significant increase in the percentage of Pts with recovery at PostRT2. However, for >50 Gy, there was no significant increase in the number of Pts who recovered at PostRT2 (p = 0.3). Ve showed no significant increase in the percentage of Pts with recovery at different TPs (p > 0.05).

CONCLUSION

Results showed that for all dose mandibular subvolumes, there is an acute vascular insult that tends to recover at +6 months post-RT except for a selective group of patients who continue to have persistence of the vascular insult at high dose subvolumes. These findings are of importance for future selection of high risk population for prophylactic intervention against osteoradionecrosis.

Severe Anaplasmosis With Multiorgan Involvement in a Rheumatoid Arthritis Patient

Anaplasmosis, caused by the tick-borne bacterium Anaplasma phagocytophilum, is an emerging infectious disease with a broad spectrum of clinical manifestations. Here, we present a case report of a 66-year-old Caucasian woman residing in Connecticut who exhibited severe anaplasmosis with multi-organ involvement. The patient, with a medical history of rheumatoid arthritis and hypothyroidism, presented with confusion, lethargy, fever, myalgia, generalized weakness, and poor appetite in May 2023. Laboratory investigations revealed pancytopenia, hyponatremia, elevated liver enzymes with mild hyperbilirubinemia, and lactic acidosis. A buffy coat smear analysis demonstrated basophilic intracytoplasmic inclusion bodies in the neutrophils, supporting the diagnosis of severe anaplasmosis. Prompt administration of doxycycline, the recommended treatment for anaplasmosis, was initiated. However, the patient subsequently developed acute respiratory distress syndrome (ARDS) necessitating heated humidified high-flow nasal cannula (HFNC) therapy. Anaplasma polymerase chain reaction (PCR) confirmed the presence of the bacterium in the patient's blood. Following doxycycline treatment, the patient demonstrated improvement in peripheral blood findings, resolution of ARDS, and complete neurologic recovery. This case underscores the potential severity and diverse clinical manifestations of anaplasmosis, highlighting the importance of early recognition, prompt diagnosis, and timely initiation of appropriate treatment to prevent severe complications and improve patient outcomes.

Study of the gut microbiome in Egyptian patients with active ulcerative colitis

INTRODUCTION AND AIM

Ulcerative colitis (UC) is characterized by chronic, uncontrolled inflammation of the intestinal mucosa. Gut microbiota dysbiosis was reported to be a factor in intestinal inflammation. The aim of the present study was to study changes in the gut microbiome in Egyptian patients with active UC.

MATERIALS AND METHODS

In this cross-sectional study, the gut bacterial microbiome of 21 UC patients and 20 control subjects was analyzed using the quantitative SYBR Green real-time PCR technique, targeting the 16S rRNA gene of selected bacterial phyla/genera and/or species.

RESULTS

UC patients showed marked dysbiosis evidenced by a significant decrease in the Firmicutes and F. prausnitzii anti-inflammatory bacteria. The Firmicutes/Bacteroidetes ratio was also lower in the UC cases (1.65), compared with the healthy controls (2.93). In addition, the UC cases showed a statistically significant decrease in Ruminococcus, compared with the control group. However, there were no statistically significant differences between UC patients and the controls, regarding A. muciniphila, Bifidobacterium, Lactobacillus, Bacteroides, and Prevotella. One UC case was positive for the pathogenic bacterium, Clostridioides difficile, with low relative abundance.

CONCLUSION

The current study showed differences in the gut microbiome of UC patients, compared with healthy controls. This may help in identifying the gut microbiome and specific bacterial changes that can be targeted for treatment of UC.

Diagnostic Dilemma of Frozen Shoulder in Post CABG Patient: A Case Report

Frozen shoulder, also known as adhesive capsulitis, is a condition featured by stiffness and pain in shoulder joint. In this report, we present a case of 58 years old diabetic male patient with the history of coronary artery bypass grafting (CABG) 06 months back. He presented with persistent right shoulder pain for 05 months. Clinical examinations reveal restriction of the right shoulder joint movement in all directions and wasting of the right supraspinatus, infraspinatus and trapezius muscles. Both active and passive range of motions was restricted with painful right shoulder joint. Pain free abduction range was about 40 degrees in right shoulder. Plain X-ray of right shoulder joint and other relevant investigations show normal findings. Considering the clinical and laboratory findings decision was taken to treat the patient with exercise, pain killer and ultrasound therapy which were found to be optimistic.

Antibacterial Effect of Moringa (Moringa oleifera) Leaf Ethanolic Extract Against Staphylococcus aureus and Escherichia coli

Increasing resistance of pathogenic microorganisms to synthetic antibiotics has lead to the search for alternative drug sources. In this regard, one of the reputed Medicinal plant, Moringa (Moringa oleifera) was investigated for potential antimicrobial effect against some commonly encountered bacteria such as Staphylococcus aureus, Escherichia coli. This experimental study was conducted from July 2019 to June 2020 in the Department of Pharmacology and Therapeutics in collaboration with the Department of Microbiology, Mymensingh Medical College, Bangladesh to determine the antibacterial effect of Ethanolic extract of Moringa oleifera leaf (EMLE) against aforementioned bacteria. The antibacterial activity was tested at different concentrations (100, 200, 400, 600, 800 and 1000μg/ml) of Ethanolic extract by using disc diffusion and broth dilution method. Dose dependent inhibitory effect was seen against the test organisms using disc diffusion method. The maximum zone of inhibition was 19 mm against S. aureus and 20mm against E. coli at 100.0% (1000μg/ml) concentration. The minimum inhibitory concentrations (MICs) of EMLE were 400μg/ml and 500μg/ml against Staphylococcus aureus and Escherichia coli respectively. The present study showed that Ethanolic extract of Moringa leaf demonstrated antibacterial effects against food borne pathogens. Further studies are required to detect and isolate the active ingredients present in the Moringa leaves extract responsible for its antibacterial effect.

Effects of Amlaki (Emblica officinalis) on Serum Lipid Profile in Rats

The effect of Amlaki (Emblica officinalis) on lipid profile (Serum cholesterol, triglyceride, HDL-cholesterol & LDL-cholesterol) in normal and fat fed rats were studied. The experimental study was carried out in the department of Pharmacology, Sir Salimullah Medical College (SSMC), Mitford, Dhaka and in the animal house of Institute of Science & Technology (IFST) of Bangladesh Council of Scientific & Industrial Research (BCSIR) Laboratory, Dhaka, Bangladesh from January 2005 to December 2005. Twenty four adult rats of both sexes weighing between 200-300gms were used. The experiment was divided into two parts: Part-1 and Part-II. In Part-I: to demonstrate the effect of Amlaki on serum lipid profile in normal rats, a total number of twelve rats were taken and divided into two groups. Group A₁: Consisted of 6 rats, received normal laboratory diet and water to 1.5-2.0ml daily for 21 days and served as normolipidemic control group. Group A₂: Consisted of 6 rats which received normal laboratory diet and Amlaki in a dose of 1.5gm/kg body wt. daily orally for 21 days and served as normolipidemic experimental group. On 22nd day, rats of both groups were sacrificed and estimation of serum lipid profile was done. In the first part of this study, administration of Amlaki for 21 days to normal rats, significantly reduced the serum cholesterol level (p<0.01), triglycerides (p<0.01) and LDL-cholesterol level (p<0.01). But there was no significant change in serum HDL-cholesterol level (p>0.1). In Part-II: to demonstrate the effect of Amlaki on lipid profile in fat fed rats, a total number of twelve rats were taken and divided into two groups. Group B₁: Consisted of 6 rats, received normal lab. diet and fat (1% cholesterol plus 0.25% cholic acid dissolved in 100ml vegetable oil) in a dose of 1.5ml daily orally for 28 days serve as a hyper-lipidemic control group (fat fed). Group B₂: Consisted of 6 rats and received normal lab. diet and cholesterol rich diet and Amlaki in a dose of 1.5gm/kg body wt. daily orally for 28 days and served as a hyper-lipidemic experimental group. On 29th day, rats of both groups were sacrificed and estimation of serum lipid profile was done. In the second part of this study, fat feeding produced a significant increase in serum cholesterol (p<0.001), triglyceride (p<0.001) and LDL-cholesterol level (p<0.001) and a significant reduction of serum HDL-cholesterol level (p<0.001) i.e. a state of hyper-lipidemia was produced. In the 2nd part of this study, concomitant administration of Amlaki and fat rich diet daily orally in rats for 28 days, produced a significant reduction in serum total cholesterol (p<0.001), triglyceride (p<0.001) and LDL-cholesterol level (p<0.001). The serum HDL cholesterol level was increased but not significantly (p>0.1). In the light of these results, it may be concluded that Emblica officinalis (Amlaki) has significant hypo-lipidemic effect in both normal and fat fed rats.

Association of Body Mass Index with Angiographic Severity of Coronary Artery disease in patients with Acute Coronary Syndrome

Coronary artery disease (CAD) is the leading cause of death in developed and developing countries. Associated co-morbidities like diabetes, hypertension and obesity are making the situation worse. WHO enlisted obesity as an epidemic which also affects a great number of young population. Some recent studies showed the presence of an apparent paradoxical relationship between obesity and cardiovascular prognosis in certain subsets of patents. As BMI is an established marker of obesity; an attempt has been made to assess relationship between BMI and angiographic severity of coronary artery disease in Acute Coronary Syndrome (ACS) patients of Bangladeshi origin. To assess the association between body mass index and angiographic severity of coronary artery disease in patients with acute coronary syndrome; this cross sectional analytical study was conducted in the Department of Cardiology, Mymensingh Medical College Hospital (MMCH) and Bangabandhu Sheikh Mujib Medical University (BSMMU) from December 2016 to February 2018 among purposively selected 65 patients. Relevant ethical issues were taken into consideration. Coronary angiogram was done in the same index hospitalization period. After coronary angiogram performed patients were grouped into two groups according to their BMI. Patients with BMI <25kg/m² as Group I and those ≥25kg/m² as Group II. Angiographic severity of coronary artery disease was assessed by vessel score and Syntax score. Mean age of Group I was 54.45±10.42 years, while in Group II it was 50.76±8.89 years reflecting the early presentation of higher BMI patients. Male to female ratio was 12:1. Mean BMI of Group I and Group II was 22.56±1.59 and 28.67±2.64 respectively. In Group I, 10(25.0%) had single vessel lesion, 15(37.5%) had double vessel lesion and 14(35.0%) had triple vessel lesion, while in Group II, 6(24.0%) had single vessel lesion, 12(48.0%) had double vessel lesion and 5(20.0%) had triple vessel lesion. Mean Syntax score of Group I and Group II was 13.18±8.45 and 10.42±7.14 respectively. Patients in the increasing BMI class had a higher prevalence of diabetes, hypertension and dyslipidaemia. A negative correlation was observed between BMI and angiographic severity (Vessel score, Syntax score and HRCA e.g. LM disease) of CAD indicating that patients with higher BMI had a lower coronary artery disease (CAD) severity than their normal BMI counterparts. Patients with high BMI have a lower CAD severity than usually expected. After adjustment for co-morbidities, BMI was not found as an independent predictor of severity of coronary artery disease.

A comparative evaluation of Airtraq and Hansraj Video laryngoscopes in patients undergoing tracheal intubation with cervical spine immobilization - A randomized prospective study

Background and Aims:

Airway management is a key concern in trauma patients with cervical spine fracture. Application of manual inline axial stabilization (MIAS) has become the standard of care in these patients. Indirect laryngoscopy only requires alignment of the pharyngeal and laryngeal axis. Hence the primary objective of the study was to compare two indirect laryngoscopes, Airtraq (with adaptor) and Hansraj Video laryngoscopes based on its Intubation Difficulty Score.

Material and Methods:

Sixty anesthetized patients were divided into two groups using computer-based randomization, and tracheal intubation was performed using either Airtraq or Hansraj Videolaryngoscope with cervical spine immobilization.

Results:

Both Airtraq and Hansraj groups were comparable in terms of percentage of glottic opening (POGO) scoring (92 ± 9.88% vs. 89.3 ± 10.4%.) and duration of intubation attempt (14.9 ± 4.36 sec vs. 16.97 ± 3.64 sec). Intubation difficulty scale (IDS) score was significantly shorter with Airtraq (1 ± 0.58 vs. 1.8 ± 0.805; P < 0.0001). The mean duration of time taken for laryngoscopy in Airtraq (12.9 ± 2.07 s vs. 19.06 ± 3.83 s; P < 0.0001)) was significantly shorter and also the duration of time taken to secure airway in Airtraq VL was significantly shorter (29.47 ± 4.75 s vs. 36.03 ± 5.80 sec; P < 0.0001). The heart rate and MABP changes were modest in both groups, but was significantly more in Hansraj VL as compared to Airtraq VL, post-intubation.

Conclusion:

Both Airtraq and Hansraj videolaryngoscope can be used as first-hand device in the scenario of cervical spine stabilization. Airtraq videolaryngoscope is better than Hansraj videolaryngoscope due to shorter IDS and lessor hemodynamic changes.

Role of High Neutrophil Lymphocyte Ratio as an Independent Predictor of Adverse In-Hospital Outcomes in Patients with First Attack of ST-Elevation Myocardial Infarction Thrombolysed with Streptokinase

Atherosclerosis is the pathognomic sign of ischaemic heart disease. Inflammation of the coronary artery contributes to the development of atherosclerosis. Neutrophil-to-lymphocyte ratio (NLR) has been reported to predict the risk of CAD and associated events in patients with ST-Segment elevation myocardial infarction (STEMI). This study was done to investigate the role of neutrophil-to-lymphocyte ratio (NLR) in predicting in-hospital adverse cardiac events in patients with STEMI thrombolysed with streptokinase (STK). This cross sectional descriptive type of study was conducted in the Department of Cardiology, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from August, 2017 to October, 2018. The STEMI patients, thrombolysed with STK had blood samples at admission, analyzed for complete blood counts and NLR calculated. They were grouped into two, low and high NLR, taking 4.50 as cut-off value. Chi square test was used to compare rate of adverse events and death in hospital stay. Logistic regression analysis was used to estimate predictive ability of NLR for in-hospital cardiac events. A total of 87 (39.90%) patients had complications. Patients in high NLR group had higher rate of complications (48.3% vs. 22.5%, p<0.001) in hospital than those in low NLR group. Arrhythmias (21.1% vs. 9.9%, p<0.041), heart failure (27.9% vs. 14.1%, p=0.024), cardiogenic shock (16.3% vs. 4.2%, p<0.011), death (6.8% vs. 2.8%, p=0.227), re-infarction /post MI angina (4.1% vs. 0.0% p=0.084) occurred more in high NLR group. Mean NLR was significantly different between Group I and Group II (3.11±0.84 vs. 10.20±6.08, p<0.0001). Multivariate regression analysis showed NLR an independent predictor of in-hospital adverse cardiac events (p<0.0001). High on admission NLR is an independent predictor for in-hospital adverse cardiac events in patients with STEMI thrombolysed with streptokinase.

Open Label Randomized Controlled Comparison of Three Alternative Regimes of Ciprofloxacin, Azithromycin and Cefixime for Treatment of Uncomplicated Typhoid Fever in Bangladesh

Multi-drug resistant Typhoid fever (resistant to previously used chloramphenicol, ampicillin, amoxicillin, and trimethoprim-sulfamethoxazole) has been commonly described in the South East Asia region and a recent report suggests that the salmonella typhi have reduced response to fluoroquinolones (nalidixic acid-resistant). The optimum treatment protocol for this type of serovar has not been established. This study compared different antimicrobial regimens for the treatment of uncomplicated typhoid fever which was conducted in the medicine ward of Dhaka Medical College Hospital (DMCH) and outdoor setting in private practice in Dhaka metropolitan city, Mymensingh and Sylhet town from January 2017 to December 2017. Bangladeshi adults with uncomplicated typhoid fever were included in this an open-label randomized controlled trial. Ciprofloxacin (20mg/kg of body weight/day for 14 days), azithromycin (20mg/kg/day for 14 days), and Cefixime (16mg/kg/day for 14 days) were compared. Of the 81 enrolled patients, 62 were eligible for analysis (61 S. enterica serovar Typhi, 1 Salmonella enterica serovar paratyphi A). Of the S enterica serovar Typhi isolates, 88.7% (55/62) were MDR and 93.5% (58/62) were nalidixic acid resistant (NAR). The clinical cure rate was 62% (13/21) with ciprofloxacin, 71% (15/21) with Cefixime, and 85% (17/20) with azithromycin (p=0.053). The mean (95% confidence interval [CI]) fever clearance time for patients treated with azithromycin (5.8 days [5.1 to 6.5 days]) was shorter than that for patients treated with cefixime (7.1 days [6.2 to 8.1 days]) and ciprofloxacin (8.2 days [7.2 to 9.2 days]) (p<0.001). All three antibiotics were well tolerated. A 7-day course of azithromycin can be successfully used in uncomplicated typhoid fever due to isolates of MDR S enterica serovar Typhi.

Post-traumatic brain injury antithrombin III recovers Morris water maze cognitive performance, improving cued and spatial learning

BACKGROUND

Neuroinflammation and cerebral edema development following severe traumatic brain injury (TBI) affect subsequent cognitive recovery. Independent of its anticoagulant effects, antithrombin III (AT-III) has been shown to block neurovascular inflammation after severe TBI, reduce cerebral endothelial-leukocyte interactions, and decrease blood-brain barrier permeability. We hypothesized that AT-III administration after TBI would improve post-TBI cognitive recovery, specifically enhancing learning, and memory.

METHODS

Fifteen CD1 male mice were randomized to undergo severe TBI (controlled cortical impact [CCI]: velocity, 6 m/s; depth, 1 mm; diameter, 3 mm) or sham craniotomy and received either intravenous AT-III (250 IU/kg) or vehicle (VEH/saline) 15 minutes and 24 hours post-TBI. Animals underwent Morris water maze testing from 6 to 14 days postinjury consisting of cued learning trials (platform visible), spatial learning trials (platform invisible, spatial cues present), and probe (memory) trials (platform removed, spatial cues present). Intergroup differences were assessed by the Kruskal-Wallis test (p < 0.05).

RESULTS

Morris water maze testing demonstrated that cumulative cued learning (overall mean time in seconds to reach the platform on days 6-8) was worst in CCI-VEH animals (26.1 ± 2.4 seconds) compared with CCI-AT-III counterparts (20.3 ± 2.1 seconds, p < 0.01). Cumulative noncued spatial learning was also worst in the CCI-VEH group (23.4 ± 1.8 seconds) but improved with AT-III (17.6 ± 1.5 seconds, p < 0.01). In probe trials, AT-III failed to significantly improve memory ability. Animals that underwent sham craniotomy demonstrated preserved learning and memory compared with all CCI counterparts (p < 0.05).

CONCLUSION

Antithrombin III improves neurocognitive recovery weeks after TBI. This improvement is particularly related to improvement in learning but not memory function. Pharmacologic support of enhanced learning may support new skill acquisition or relearning to improve outcomes after TBI.

LEVEL OF EVIDENCE

Therapeutic/care management, level II.

Antithrombin III ameliorates post-traumatic brain injury cerebral leukocyte mobilization enhancing recovery of blood brain barrier integrity

BACKGROUND

Acute traumatic coagulopathy often accompanies traumatic brain injury (TBI) and may impair cognitive recovery. Antithrombin III (AT-III) reduces the hypercoagulability of TBI. Antithrombin III and heparinoids such as enoxaparin (ENX) demonstrate potent anti-inflammatory activity, reducing organ injury and modulating leukocyte (LEU) activation, independent of their anticoagulant effect. It is unknown what impact AT-III exerts on cerebral LEU activation and blood-brain barrier (BBB) permeability after TBI. We hypothesized that AT-III reduces live microcirculatory LEU-endothelial cell (EC) interactions and leakage at the BBB following TBI.

METHODS

CD1 mice (n = 71) underwent either severe TBI (controlled cortical impact (CCI), 6-m/s velocity, 1-mm depth, and 4-mm diameter) or sham craniotomy and then received either AT-III (250 IU/kg), ENX (1.5 mg/kg), or vehicle (saline) every 24 hours. Forty-eight hours post-TBI, cerebral intravital microscopy visualized in vivo penumbral microvascular LEU-EC interactions and microvascular leakage to assess BBB inflammation/permeability. Body weight loss and the Garcia neurological test (motor, sensory, reflex, balance) served as surrogates of clinical recovery.

RESULTS

Both AT-III and ENX similarly reduced in vivo penumbral LEU rolling and adhesion (p < 0.05). Antithrombin III also reduced live BBB leakage (p < 0.05). Antithrombin III animals demonstrated the least 48-hour body weight loss (8.4 ± 1%) versus controlled cortical impact and vehicle (11.4 ± 0.5%, p < 0.01). Garcia neurological test scores were similar among groups.

CONCLUSION

Antithrombin III reduces post-TBI penumbral LEU-EC interactions in the BBB leading to reduced neuromicrovascular permeability. Antithrombin III further reduced body weight loss compared with no therapy. Further study is needed to determine if these AT-III effects on neuroinflammation affect longer-term neurocognitive recovery after TBI.

Rehabilitation Approach of a Patient with Myositis Ossificans: Non-surgical Management, Hazard of being Unguided Over Exercised

Myositis ossificans (MO) is a condition where calcification occurs in the soft tissue as well as around the bone following fracture, vigorous exercise or trauma. Although it is a radiological diagnosis, it often leads physician to an incorrect or missed diagnosis as recurrent fracture. Frequently, it follows haemorrhage into the muscle in the tissue space. We report a 45 years old house-wife presented with the complaints of weakness of right side of body and pain with restricted range of motion (ROM) in right lower limb. She was a diagnosed case of recurrent stroke with rheumatic valvular heart disease. After discharge, vigorous physical exercise was done at home by local physiotherapist without appropriate guidance from physiatrist. Gradually pain was so severe that she didn't allow moving her right lower limb. Over the course of time, she became incapacite and bed bound. She denied any positive family history. With the hip and lower limb problems she consulted with orthopedic surgeon and was referred to Physical Medicine and Rehabilitation department of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh for further management & rehabilitation. This case is presented to focus on hazard of being unguided, over-exercised and non-surgical management approach of this rare condition.

Predictive Value of Waist Height Ratio, Waist Hip Ratio and Body Mass Index in Assessing Angiographic Severity of Coronary Artery Disease in Myocardial Infarction Patients

Coronary artery disease (CAD) is the leading cause of mortality and morbidity both in developed and developing countries. The body mass index (BMI), waist hip ratio (WHR) and waist height ratio (WHtR) are some of the clinical tools enabling clinicians to assess obesity. Although for decades there have been controversy regarding the relationship between obesity and CAD; it has been assumed that high BMI is a risk factor for CAD. However, the findings of some recent studies were paradoxical. The aim of this study was to identify the best tool among BMI, WHtR and WHR to evaluate angiographically severe CAD in myocardial infarction patients. This was a cross-sectional analytical study carried out in the Department of Cardiology, Chattogram Medical College and Hospital (CMCH), Chattogram, Bangladesh from January 2017 to December 2017. Three hundred and thirty two consecutive MI patients undergoing CAG during the study period were included in the study as per inclusion and exclusion criteria. Severity of CAD was calculated by using Gensini score. Patients were categorized and compared according to anthropometric indices and CAD severity. The mean±SD of the age of study population was 53.62±10.36 years (range 25-92) and 276(83.1%) were male. Regarding cardiovascular risk factors, 113(34%) patients had diabetes mellitus, 108(32.5%) had dyslipidaemia, 137(41.3%) had hypertension, 205(61.7%) were current or ex-smokers and 59(17.8%) had a family history of CAD. The mean±SD of the patients' BMI was 24.05±3.24kg/m² (range 16.14-32.72), mean±SD of their WHR was 0.964±0.052 (range 0.823-1.125) and mean±SD of their WHtR was 0.546±0.059 (range 0.389-0.748). The mean±SD of the severity of CAD according to the Gensini score was 41.11±28.66 (ranged from 2 to 244). Study findings showed a positive correlation between the severity of CAD with WHtR and WHR but not with BMI, according to Gensini scores (p=0.004, p=0.023 and p=0.43 respectively). Receiver Operating Characteristics (ROC) curve analysis revealed that waist height ratio had the highest area under the curve (AUC) among the three anthropometric parameters for predicting presence of severe CAD. Study showed the superiority of WHtR over WHR and BMI for predicting angiographic severity of CAD in patients with MI. WHtR should therefore be considered as a screening tool.

Design and formulation of polymeric nanosponge tablets with enhanced solubility for combination therapy

Three drugs namely caffeine, paracetamol, and aceclofenac are commonly used for treating various acute and chronic pain related ailments. These 3 drugs have varied solubility profiles, and formulating them into a single tablet did not have the desired dissolution profile for drug absorption. The objective of the present research was to tailor the drug release profile by altering drug solubility. This was achieved by loading the drug into nanosponges. Here, three-dimensional colloidal nanosponges were prepared using β-cyclodextrin with dimethyl carbonate as a cross-linker using the hot-melt compression method. The prepared nanosponges were characterized by FTIR, ¹H NMR spectroscopy, DSC, XRPD studies and SEM. The FTIR and DSC results obtained indicated polymer-drug compatibility. The ¹H NMR spectroscopy results obtained indicated the drug entrapment within nanosponges with the formation of the inclusion complex. XRPD studies showed that the loaded drug had changed crystalline properties altering drug solubility. SEM photographs revealed the porous and spongy texture on the surface of the nanosponge. Box–Behnken experimental design was adopted for the optimization of nanosponge synthesis. Among the synthesized nanosponges containing paracetamol, aceclofenac and caffeine, batch F3–P31, F3–A31 and F3–C31 were considered optimized. Their particle size was 185, 181 and 199 nm with an entrapment efficiency of 81.53, 84.96, and 89.28% respectively. These optimized nanosponges were directly compressed into tablets and were studied for both pre and post-compression properties including in vitro drug release. The prepared tablet showed desired drug dissolution properties compared to the pure drug. The above outcomes indicated the applicability of nanosponges in modulating the drug release with varied solubility for combination therapy.

Polymeric nanosponges as potential carriers for successful combination therapy of poorly soluble drugs (paracetamol, aceclofenac, caffeine).

Correlation of Mean Platelet Volume with ST Segment Resolution after Thrombolytic Therapy in Patients with ST Elevation Myocardial Infarction

Acute occlusive thrombosis of the coronary artery is the principal cause of myocardial infarction where platelets play an important role. Large size platelets, easily measured by mean platelets volume (MPV) are thrombogenic and commonly seen after ST-segment elevation myocardial infarction (STEMI). ST segment resolution has been shown as a simple non-invasive marker that reflects both epicardial and myocardial reperfusion following thrombolysis. The present study intended to investigate whether MPV on admission correlated with ST segment resolution following thrombolysis in STEMI patient. This cross-sectional analytical study was conducted in the department of cardiology, Mymensingh Medical College and Hospital (MMCH), Mymensingh, Bangladesh from December, 2016 to June, 2018. Total 284 patients with first attack of STEMI were included after considering inclusion and exclusion criteria. Sample population was divided into two groups, Group I - Patients with successful ST segment resolution (≥50%). Group II - Patients with impaired ST segment resolution (<50%). MPV on admission was estimated during estimation of Complete Blood Count (CBC) by Automated Haematology Analyzer & compared between two groups. Successful ST segment resolution (≥50%) was seen in 67% of patients after thrombolysis. Admission MPV was higher in patients with impaired ST segment resolution (<50%) group than patients with ≥50% ST-segment resolution group (12.42±0.89fl vs.10.35±0.77fl respectively, p=0.001). Statistically significant strong negative correlation between MPV and ST segment resolution percentage (r = -0.742, p=0.001) suggesting that the higher the level of MPV, the lower the ST segment resolution percentage in first attack of STEMI patients. Multivariate regression analysis found MPV level on admission as an independent predictor of ST segment resolution. The study concluded that high MPV on admission correlate with impaired ST segment resolution following thrombolysis in STEMI patients.

Relation of Obesity with Breast Cancer among the Patients Attending at National Institute of Cancer Research & Hospital

Breast cancer among women is gradually increasing in Bangladesh day by day. A number of breast cancer related etiological factors identified as age, reproductive factors, menarche, menopausal status, life style, hormone replacement therapy, genetics and alcohol intake. Obesity is an important factor for developing breast cancer in different countries. Obesity is one of the modifiable factors. The aim of the study was to find out the factors which might be associated with obesity among female breast cancer patients in Bangladesh. It was a case-control study conducted at the Department of Medical Oncology, National Institute of Cancer Research & Hospital (NICRH), Dhaka, Bangladesh from August 2014 to July 2015. Ninety one case and equal numbers of age matched controls were included in the study. The mean age of the case was 42.99 (±9.24) years and that of the control was 44.11±8.97 years. Majority of patients i.e. 59.3% (n=54) in case group was in pre-menopausal state where as 52.7% (n=48) of respondents in control group were in menopausal state. Increased waist to hip ratio (>0.85) was associated with increased risk of breast cancer (OR: 8.1). This was also true for increased BMI of ≥25kg/m² (OR: 4.57), increased waist circumference (OR: 3.52) and ever OCP use (OR: 2.11). However, para >3, education and moderate to heavy work were found to be protective against breast cancer (OR: <1). In clinical setting waist-to-hip ratio, body mass index (BMI) and waist circumference (WC) can be used effectively to identify women with an increased risk of breast cancer.

Indian Resuscitation Council (IRC) suggested guidelines for Comprehensive Cardiopulmonary Life Support (CCLS) for suspected or confirmed coronavirus disease (COVID-19) patient

Management of the recent outbreak of the novel coronavirus disease (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) remains challenging. The challenges are not only limited to its preventive strategies, but also extend to curative treatment, and are amplified during the management of critically ill patients with COVID-19. Older persons with comorbidities like diabetes mellitus, cardiac diseases, hepatic impairment, renal disorders and respiratory pathologies or immune impairing conditions are more vulnerable and have a higher mortality from COVID-19. Earlier, the Indian Resuscitation Council (IRC) had proposed the Comprehensive Cardiopulmonary Life Support (CCLS) for management of cardiac arrest victims in the hospital setting. However, in patients with COVID-19, the guidelines need to be modified,due to various concerns like differing etiology of cardiac arrest, virulence of the virus, risk of its transmission to rescuers, and the need to avoid or minimize aerosolization from the patient due to various interventions. There is limited evidence in these patients, as the SARS-CoV-2 is a novel infection and not much literature is available with high-level evidence related to CPR in patients of COVID-19. These suggested guidelines are a continuum of CCLS guidelines by IRC with an emphasis on the various challenges and concerns being faced during the resuscitative management of COVID-19 patients with cardiopulmonary arrest.

In Vitro Antibacterial Activity of Ethanol Extracts of Cinnamomum zeylanicum against Pseudomonas aeruginosa

Cinnamomum zeylanicum as medicinal plants are measured as new resources for preparing elements in the treatment of antibiotic-resistant microbes as alternatives to antibiotics. This study was aimed to evaluate the antibacterial activity of ethanol extracts of Cinnamomum zeylanicum against a Gram-negative bacteria Pseudomonas aeruginosa. This experimental study was carried out in the department of Pharmacology & Therapeutics and department of Microbiology, Mymensingh Medical College, Mymensingh, Bangladesh from July 2017 to July 2018. Evaluation of the in vitro antibacterial activity of ethanol extracts of Cinnamomum zeylanicum against Pseudomonas aeruginosa was performed by disc diffusion method. And also in this study we used broth dilution method to determine the minimum inhibitory concentration (MIC). Ethanol cinnamon extract (ECE) was found active against P. aeruginosa. Zone of inhibition (ZOI) ranged between 6-25mm at different concentration of extracts. The MIC was 0.3g/ml. Cinnamomum zeylanicum showed strong antibacterial activity against a Gram-negative bacteria Pseudomonas aeruginosa. The results may contribute to the development of potential antimicrobial agents for inclusion in antipseudomonal regimens.

Effect of Educational Intervention on Perception of Adverse Drug Reaction Reporting Among Medical Practitioners

Spontaneous reporting of suspected adverse drug reaction by healthcare professionals is the cornerstone of pharmacovigilance. National pharmacovigilance program of Bangladesh was started to promote the pharmacovigilance activity in this country. But in Bangladesh the pharmacovigilance program is still in its infancy due to lack of reporting culture amongst healthcare professionals of this country. This cross sectional, questionnaire based study was conducted to assess the knowledge, attitudes and practices regarding adverse drug reaction reporting as well as to evaluate the effectiveness of educational intervention to improve the pharmacovigilance status of this country in the Department of Pharmacology & Therapeutics, Sylhet MAG Osmani Medical College (SOMC) in collaboration with the Internal Medicine, Dermatology & Venerology and Cardiology departments of SOMC and Jalalabad Rageeb Rabeya Medical College (JRRMC), Selhet, Bangladesh. A seminar (educational intervention) was conducted for the doctors of Internal Medicine, Dermatology & Venerology and Cardiology departments of SOMCH. The survey questionnaire was administered to 51 doctors who had attended the seminar in SOMCH (interventional group) and 33 doctors who had not attended the seminar in JRRMCH (non-interventional group). The study found that there is significant improvement in intervention group in comparison to non-intervention group in terms of knowledge and attitude about ADR reporting (in all cases those were statistically significant). Inadequate perception about ADR reporting among medical practitioners is the main factor for underreporting, which can be overcome by educational intervention. So, different types of educational intervention should be implemented among medical practitioner in different healthcare facilities for the improvement of the pharmacovigilance status of this country.

The Antibacterial Activity of Ethanolic Extract of Cinnamon (Cinnamomum zeylanicum) against two Food Borne Pathogens: Staphylococcus aureus And Escherichia coli

Evaluation of the in vitro antibacterial activity of the ethanolic extract isolated from Cinnamomum zeylanicum bark against two food borne pathogens, Gram-positive Staphylococcus aureus and Gram-negative Escherichia coli. This experimental study was carried out in the department of Pharmacology & Therapeutics in collaboration with the department of Microbiology, Mymensingh Medical College, Mymensingh, Bangladesh from July 2017 to July 2018. The antibacterial activity was tested at different concentrations of extracts of spice by using disc diffusion method. The extracts were prepared by using a solvent ethanol. The test microorganisms were also tested for their activity against a standard antibiotic Amikacin (500mg) by disc diffusion method and the result was compared with that of ethanolic extracts. Cinnamon had inhibitory activity against both Staphylococcus aureus and Escherichia coli. The ethanolic extracts were more effective against Staphylococcus aureus than E. coli. Staphylococcus aureus showed activity from 60% conc. (zone of inhibition 17mm) where E. coli from 80% conc. (ZOI 18mm). Maximum zone of inhibition was 26mm for both the test organisms. This result was also compared to those obtained against a standard antibiotic Amikacin where extract produced wider zone of inhibition of 26mm as compared to Amikacin for both test organisms. The present study showed that ethanolic extract of cinnamon demonstrated stronger antimicrobial effect against food borne pathogens.

Hypertension in School Children of Dhaka City and Associated Risk Factors

Hypertension has its origin in childhood but goes undetected unless specially looked for detection of hypertension in children will increase the awareness and lead to preventive strategies. The objective of the study was to determine the prevalence of hypertension in school children. This cross sectional study was conducted among children aged 10 to 17 years in three secondary level schools of Dhaka city, Bangladesh. This study included 1146 participants (both boys and girls) by systematic random sampling. Blood pressure was measured and plotted in Blood pressure (BP) chart to define hypertension and structured questionnaire were used to collect socio demographic information. The prevalence of hypertension in school children was 1.8% (male was 1.68% and female was 1.99%). It was noted that there was a strong correlation between body weight and BMI of the children with hypertension. A significant portion of the respondents had family history of hypertension, diabetes and obesity. There was also a positive relation between hypertension and food habit that include low vegetables and more fast food. It was concluded that hypertension exists among secondary level school children in Dhaka, Bangladesh and it is related with obesity, increased BMI, family history and dietary habit.

A new scope for orlistat: Effect of approved anti-obesity drug against experimental microsporidiosis

As the current therapies for intestinal microsporidiosis are either inconsistent in their efficacies or hampered by several adverse effects, alternative antimicrosporidial agents are being sought. The present study is the first that was designed to evaluate the potency of orlistat, an approved anti-obesity drug, against intestinal microsporidiosis caused by both Enterocytozoon bieneusi and Encephalitozoon intestinalis. Results were assessed through studying fecal and intestinal spore load, intestinal histopathological changes, viability, and infectivity of spores from treated animals. Results showed that orlistat has promising antimicrosporidia potential, with better results in E. intestinalis than E. bieneusi. The animals that received orlistat showed statistically significant decrease in the fecal and intestinal spore load, when compared to the corresponding control infected nontreated mice. The results were insignificant compared to fumagillin and albendazole. Light microscopic examination of stained intestinal sections revealed amelioration of the pathological changes and decreased inflammatory cells detected in the control infected nontreated mice. Spores encountered from stool of orlistat-treated E. bieneusi and E. intestinalis mice showed low viability and significant reduction of infectivity versus their control. Thus, considering the results of the present work, orlistat proved its effectiveness against the intestinal microsporidial infection.

Isolated Nonspecific Colonic Ulcer: A Case Report From a Tertiary Care Hospital in Pakistan

Simple, isolated nonspecific colonic ulcer (NSCU) is a rare pathological entity which has not been adequately explored in the past literature. It is predominant between the ages of 40 and 60 years, and the most common complication is perforation which can be life threatening. Here we present a case of a young female who presented with a perforated NSCU and was successfully managed surgically.

Correlation Between Body Mass Index and Fibroadenoma

Introduction Among all benign conditions, the fibroadenoma is the most common lesion worldwide as well as in Pakistan. Clinicians often face the dilemma of whether to remove the mass or to monitor it by means of periodic follow-up examinations. Although the removal of these lesions is a definitive solution, surgery may involve unnecessary excision of benign lesions and unbecoming cosmesis. Body mass index (BMI) is a known risk factor for the development of breast cancer.However, the relationship between BMI and benign breast diseases is still unclear. Some studies showed that increased BMI is a risk factor for benign breast diseases; however, a large number of studies showed that a decrease in BMI is the risk factor for benign breast diseases. Material and methods This was a descriptive cross-sectional study conducted at the Department of General Surgery, Pakistan Institute of Medical Sciences (PIMS), Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad, Pakistan. All patients fulfilling inclusion criteria were assessed in the breast clinic of PIMS. A final diagnosis of fibroadenoma was made after a triple assessment. Weight in kilograms and height in meters were measured. All the information was recorded in a specifically designed proforma accordingly by the postgraduate trainee. BMI was calculated by the formula: BMI=Weight in kgs/height in meters. Other variables that were noted include patients' age, gender, contact number, and hospital visit. The data were analyzed using SPSS version 21 (IBM Corp., Armonk, NY, US). Results The BMI of study patients was 21.8 ± 1.3, ranging from 19 to 24.9. Out of 300 patients presenting with benign breast disease, 60 (20%) had a fibroadenoma while 240 (80%) had other benign breast diseases. Out of 136 patients with high BMI, 42 (30.8%) had a fibroadenoma while out of 74 patients with low BMI, eight (10.8%) had a fibroadenoma; however, out of 90 patients with normal BMI, 10 (11.1%) had a fibroadenoma. Our study population showed an increased risk of fibroadenoma formation in the adolescent age group with an OR value of 8.54 (CI 4.38-16.63, P<0.001). There were also additional statistical correlations between higher BMI and the site of the lesion being the upper outer quadrant of the breast (t= 4.326 P<0.01). There was no significant correlation of BMI with size and increased number of lesions (P=0.280 and P=0.175). Conclusion High BMI seems to be a substantial risk factor for the development of a fibroadenoma, particularly in young adolescent females.

Dengue Myocarditis: An Important Clinical Entity to Consider in Dengue Patient

We are going to report a case study of dengue fever (DF) affecting myocardium and explore the literature. A gentleman of 28 years old experienced DF which was complicated by acute myocarditis, acute kidney injury and hepatitis in the Emergency Department of Apollo Hospitals, Dhaka, Bangladesh on 5th August 2017. Clinically it was considered as an acute coronary syndrome due to depressed ST segment in chest leads ECG, extreme bradycardia but normal serum troponin-I level. He had to undergo temporary pacemaker insertion for symptomatic bradycardia and later on, he was monitored closely. Fortunately, he recovered; pacemaker was removed on day 8 of his admission without any further complication. After 3 days, patient recovered with symptomatic treatment. In different publications, various manifestations of cardiac complications occurred, from self-limiting tachy-brady arrhythmia to severe damage of the myocardium, causing reduced blood pressure and pulmonary edema. To reduce morbidity and mortality, physicians should suspect for cardiac complications in patients with dengue fever and should manage these complications.

Study on Endoscopic Retrograde Cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is a modern & universally established modality in the evaluation and treatment of suspected biliary and pancreatic disease. In Bangladesh, ERCP services are limited to few tertiary care centers mostly in the capital & large city. ERCP was 1st introduced in Mymensingh on 3rd April 2016 in a private hospital. Since then, Mymensingh Medical College Hospital (MMCH) provides ERCP services to a large volume of patients in collaboration with private center for diagnostic accuracy & therapeutic purpose. The aim of this study was to evaluate our experience in ERCP, to characterize & evaluate the aetiology, findings of ERCP & frequency of complications. This prospective type of study was carried out by the department of hepatology, MMCH from 3rd April 2016 to 10th July 2018 in collaboration with that private center where ERCP has been established. All patients undergoing ERCP during this period were included. Aetiology & findings were assessed at the time of ERCP & complications were assessed during procedure, index hospitalization & within 30 days after the procedure by telephone contact. A total of 301 consecutive ERCP were performed during the study period. Among them, 182(60.5%) were male & 119(39.5%) were female with an age range of 18-78 years. The most common indications for ERCP were: cholangiocarcinoma in 98(32.56%) & choledocholithiasis in 95(31.56%) followed by periampullary growth in 93(30.89%), suspected CBD stricture in 12(4%) & chronic pancreatitis in 2(0.66%). The most common findings were choledocholithiasis (32.56%), cholangiocarcinoma (32.56%), biliary obstruction due to periampullary growth (30.56%). Biliary fistula with distal bile duct stricture was found in (1.66%), bile duct stricture in (1.33%), chronic pancreatitis in (0.66%), and organic papillary stenosis with deformed bulb were discovered in (0.34%) case. All ERCPs were done for therapeutic purpose. Endoscopic sphincterotomy was the most common therapeutic procedure (87.04%) of which biliary stenting was done in (67.44%) & stone extraction in (33.71%). Stone extraction from biliary tree was successfully done in 94 cases (98.67%) but it was unsuccessful from biliary tree in 4 cases (1.33%) & also from pancreatic duct in a separate case. The most frequent complication was Post-ERCP pancreatitis in 9 patients (2.99%) followed by acute confusional state (1.33%). Post-ERCP cholangitis occurred in (0.99%) & death was reported in 2 cases (0.66%) due to anaesthetic hazard.

Measuring institutional community engagement: Adding value to academic health systems

Beyond medical schools' historical focus on pillar missions including clinical care, education, and research, several medical schools now include community engagement (CE) as a mission. However, most academic health systems (AHSs) lack the tools to provide metrics, evaluation, and standardization for quantifying progress and contributions of the CE mission. Several nationwide initiatives, such as that driven by the Institute of Medicine recommending advances in CE metrics at institutions receiving Clinical and Translational Science Awards, have encouraged the research and development of systematic metrics for CE, but more progress is needed. The CE components practical model provides a foundation for analyzing and evaluating different types of CE activities at AHSs through five components: research, education, community outreach and community service, policy and advocacy, and clinical care. At the Medical College of Wisconsin (MCW), an annual survey administered to faculty and staff assessed the types and number of CE activities from the prior year. Survey results were combined to create a CE report for departments across the institution and inform MCW leadership. Insights gathered from the survey have contributed to next steps in CE tracking and evaluation, including the development of a CE dashboard to track CE activities in real time. The dashboard provides resources for how individuals can advance the CE mission through their work and guide CE at the institutional level.

Cerebral Edema and Neurological Recovery after Traumatic Brain Injury Are Worsened if Accompanied by a Concomitant Long Bone Fracture

Progression of severe traumatic brain injury (TBI) is associated with worsening cerebral inflammation, but it is unknown how a concomitant bone fracture (FX) affects this progression. Enoxaparin (ENX), a low molecular weight heparin often used for venous thromboembolic prophylaxis, decreases penumbral leukocyte (LEU) mobilization in isolated TBI and improves neurological recovery. We investigated if TBI accompanied by an FX worsens LEU-mediated cerebral inflammation and if ENX alters this process. CD1 male mice underwent controlled cortical impact (CCI) or sham craniotomy with or without an open tibial FX, and received either ENX (1 mg/kg, three times/day) or saline for 2 days following injury. Randomization defined four groups (Sham, CCI, CCI+FX, CCI+FX+ENX, n = 10/group). Two days after CCI, neurological recovery was assessed with the Garcia Neurological Test (GNT); intravital microscopy (LEU rolling and adhesion, microvascular leakage) and blood hemoglobin levels were also evaluated. Penumbral cerebral neutrophil sequestration (Ly-6G immunohistochemistry [IHC]) were evaluated post-mortem. In vivo LEU rolling was greater in CCI+FX (45.2 ± 4.8 LEUs/100 μm/min) than in CCI alone (26.5 ± 3.1, p = 0.007), and was suppressed by ENX (23.2 ± 5.5, p = 0.003 vs. CCI + FX). Neurovascular permeability was higher in CCI+FX (71.1 ± 2.9%) than CCI alone (42.5 ± 2.3, p < 0.001). GNT scores were lower in CCI+FX (15.2 ± 0.2) than in CCI alone (16.3 ± 0.3, p < 0.001). Hemoglobin was lowest in the CCI+FX+ENX group, lower than in Sham or CCI. IHC demonstrated greatest polymorphonuclear neutrophil (PMN) invasion in CCI+FX in uninjured cerebral territories. A concomitant long bone FX worsens TBI-induced cerebral LEU mobilization, microvascular leakage, and cerebral edema, and impairs neurological recovery at 48 h. ENX suppresses this progression but may increase bleeding.

Comparison among Different Culture Media for the Detection of Dermatophytes

Dermatophytes are a group of closely related fungi that have the capacity of invading the keratinized tissue of human to produce infections known as dermatophytosis which is commonly referred to as ringworm. Other than routine microscopy, different culture media are available for the detection of dermatophytes from patient's specimen. This cross sectional study was designed to evaluate the outcome of three different culture media and microscopy for the detection of dermatophytes from clinical samples. Skin, hair and nail samples from 84 clinically suspected cases of dermatophytosis who attended at OPD of Dermatology Department, Sylhet MAG Osmani Medical College Hospital, Sylhet, Bangladesh from July 2014 to June 2015 were screened by direct microscopic examination using potassium hydroxide (KOH) mount. All the samples were inoculated for culture in Sabouraud's Dextrose Agar (SDA), Dermatophytes Test medium (DTM) and Sabouraud's Cycloheximide Chloramphenicol Agar (SCCA). The percentage of samples positive by microscopy was 37.5%, whereas the rate of positivity by culture was 47.6% which showed that culture was more sensitive than microscopy for the diagnosis of dermatophytosis. The efficiency of SDA and SCCA was found to be almost equal. There was no statistically significant difference between SDA and DTM in primary isolation of dermatophytes, though isolation rate was slightly higher in DTM. Though direct examination by microscopy is an efficient screening technique, culture should be done for accurate diagnosis. As DTM is easy to evaluate even without handling the growth of culture in the laboratory, it is recommended to use as screening medium for the detection of dermatophytes.

Ebstein's Anomaly Associated with Atrial Septal Defect and Wolff-Parkinson-White (WPW) Syndrome

Ebstein's anomaly is a rare congenital heart disorder, accounting for <1% of all cases of congenital heart disease. It is a congenital malformation of the heart that is characterized by apical displacement of the septal and posterior tricuspid valve leaflets, leading to atrialization of the right ventricle with a variable degree of malformation and displacement of the anterior leaflet. We report the case of a 25 years old female with Ebstein's anomaly which was associated with Ostium Secundum type of atrial septal defect and WPW syndrome, who presented with dyspnea, palpitations, cyanosis, clubbing and cardiomegaly.

Sonographic Evaluation of Colonic Carcinoma in Comparison to Colonoscopy

Colon cancer is one of the main causes of cancer death. Diagnosis requires the examination of the entire large bowel by means of radiological or endoscopic techniques. Though there is not a remarkable advancement in gastrointestinal (GI) tract evaluations, the modern radiological imaging methods emphasize the importance of ultrasonography (US) evaluations and stand US out as the scanning method in malignancies of the GI tract. The objective of this study is to investigate the role of ultrasonography in the diagnosis of cancers of the colon & it's accuracy in comparison to colonoscopy. This cross sectional analytical study included a total of 62 patients, including 38(61.29%) male and 24(38.71%) female patients who came at Mymensingh Medical College Hospital & Popular Diagnostic Center, Mymensingh from January 2013 to November 2015 & whose ultrasonography and endoscopic examinations were planned with suspicion of colon cancer. Considering the colonoscopic biopsy as a gold standard, the sensibility, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the ultrasonography were evaluated manually. All patients underwent ultrasonography and colonoscopy and results were compared with histopathologic diagnosis. Malignancy was histopathologically identified in 37(59.68%) patients. The sensitivity of ultrasound to identify colon cancer was 86.48%, its specificity was 84%, positive predictive value and negative predictive value was 88.89% & 80.77% respectively. The sensitivity of endoscopic intervention was 100%, its specificity was 96% and positive predictive value was 93.7%. Likewise, a series of analytical and clinical parameters were evaluated, in an attempt to establish associated factors of a colon cancer by means of the statistical package SPSS 13.0 for Windows. Therefore, we believe that abdominal ultrasonography which is non-invasive, easily accessible, cost-efficient method may detect a colonic mass or wall thickening consistent with a colonic carcinoma with a high degree of accuracy.

A prospective randomized control study comparing classic laryngeal mask airway with Guedel's airway for tracheal tube exchange and smooth extubation

INTRODUCTION

Extubation in deep plane of anesthesia followed by Guedel's oropharyngeal airway (OPA™) insertion is a routine method to avoid hemodynamic changes associated with tracheal extubation. Exchange of endotracheal tube (ETT) with Classic laryngeal mask airway (LMA™) prior to emergence from anesthesia also serves similar purpose. We had compared the hemodynamic changes involved during this ETT/LMA™ and ETT/OPA™ exchange technique.

MATERIAL AND METHODS

This was a randomized prospective study on ASA I and 2 patients undergoing elective surgery under general anesthesia. These patients were randomly divided into two groups i.e. OPA group and LMA group of 50 patients each. Hemodynamic parameters i.e. systolic blood pressure (SBP) and heart rate (HR) were recorded during exchange of ETT with OPA™ or LMA™. Coughing / bucking during removal of OPA™ and LMA™, and presence of post operative sore throat for both the groups were also graded and recorded. Data within the groups have been analyzed using paired "t" test while those between the groups were analyzed using unpaired "t" test. Chi square test was used to analyze grades of coughing and post operative sore throat.

RESULTS

In both groups, hemodynamic parameters rose significantly as OPA™/LMA™ was placed (P < 0.05) and then started declining. Hemodynamic parameters continued to fall in LMA group after extubation. However in OPA group, hemodynamic parameters continued to rise even after extubation and declined only when OPA™ was removed. There was no statistical significant difference between the LMA and OPA group in respect to coughing and post operative sore throat.

CONCLUSION

LMA™ is superior to OPA™ for exchange of ETT as it provides greater hemodynamic stability.

An Unusual Case of Suicide Attempt Using Intravenous Injection of Kerosene

Kerosene belongs to the hydrocarbon group of compounds, used as a fuel for lamps, as well as heating and cooking in developing countries. Accidental kerosene poisoning and intoxication usually occur by inhalation or by occupational percutaneous absorption. Adults usually ingest kerosene for the purpose of self-harm, and children may ingest accidentally. Suicidal attempt using intravenous kerosene is an extra ordinary and very rare occurrence. A very few data are available regarding effects of intravenous administration of kerosene and its management.

A case of severe perioperative hypoxia in uncorrected tetralogy of fallot: Anesthetic management

Tetralogy of fallot (TOF) is one of the most common congenital heart disease (CHD) in children. With the development of pediatric surgery and intensive care units, increasing number of grown-up CHD patients are presenting for non-cardiac surgeries. Non-operated TOF patients suffer from chronic hypoxia and decreased pulmonary blood flow resulting in considerable alteration in the physiology. The optimal management of these patients, therefore, require a thorough understanding of the pathophysiology of the uncorrected TOF. We hereby report a case of successful management of a 10-year-old child with an uncorrected TOF posted for tibial external fixation device.

Opening the Black Box: Conceptualizing Community Engagement From 109 Community-Academic Partnership Programs

BACKGROUND

This research effort includes a large scale study of 109 community-academic partnership projects funded by the Healthier Wisconsin Partnership Program (HWPP), a component of the Advancing a Healthier Wisconsin endowment at the Medical College of Wisconsin (MCW) in Milwaukee, Wisconsin. The study provides an analysis unlike other studies, which have been smaller, and/or more narrowly focused in the type of community-academic partnership projects analyzed.

OBJECTIVES

To extract themes and insights for the benefit of future community-academic partnerships and the field of community-engaged research (CEnR).

METHODS

Content analysis of the final reports submitted by 109 community-academic partnership projects awards within the time frame of March 2005 to August 2011.

RESULTS

Thirteen themes emerged from the report analysis: community involvement, health accomplishments, capacity building, sustainability, collaboration, communication, best practices, administration, relationship building, clarity, adjustment of plan, strategic planning, and time. Data supported previous studies in the importance of some themes, and provided insights regarding how these themes are impactful.

CONCLUSION

The case analysis revealed new insights into the characteristics of these themes, which the authors then grouped into three categories: foundational attributes of successful community-academic partnership, potential challenges of community-academic partnerships, and outcomes of community-academic partnerships. The insights gained from these reports further supports previous research extolling the benefits of community-academic partnerships and provides valuable direction for future partners, funders and evaluators in how to deal with challenges and what they can anticipate and plan for in developing and managing community-academic partnership projects.

Importance of Amino Acids, Gln-119 and Tyr-376, in the S1 Pocket of Escherichia coli Peptidase N in Determining Substrate Specificity

Peptidase N (PepN) is a broad specific metallo-peptidase and the sole member of the M1 class encoded by Escherichia coli. Comparative analysis of residues present in the S1 subsite of E. coli PepN with other family members revealed that Tyr-381 is conserved whereas Glu-121, Gln-119 and Tyr-376 are partially conserved. The functional importance of these amino acids was investigated by protein engineering studies. The change in Glu-121 to Gln and Tyr-381 to Phe led to catalytically inactive PepN. At the same time, the change in Gln-119 to His (Q119H) and Tyr-376 to Phe (Y376F) led to alterations in substrate specificity. Kinetic studies revealed that purified PepN variants, Q119H and Y376F, cleaved some substrates (e.g. Arg) similar to wild type PepN. However, these variants displayed lower efficacy with other substrates (e.g. Tyr, AAF and Suc-AAF). Q119H or Y376F, cleave a natural peptide (insulin B chain) and a loosely folded protein (casein) with greatly reduced efficacy. The double mutant, i.e. harboring both Q119H and Y376F, displays greatly reduced catalytic activity with respect to all substrates studied. The in vivo significance was addressed by expressing these variants in ΔpepN during nutritional downshift and high temperature (NDHT) stress. Compared to wild type PepN, the Y376F and Q119H variants display lower intracellular amounts of free N-terminal amino acids and reduction in growth during NDHT stress. Finally, structural modeling, using the crystal structure of E. coli PepN bound to substrates, Arg or Tyr, shed insights into the roles of Q119H and Y376F in determining substrate preferences.

The Advancing a Healthier Wisconsin Endowment: How a Health Care Conversion Foundation Is Transforming a Medical School

Health care conversion foundations, such as the Advancing a Healthier Wisconsin Endowment (the endowment) at the Medical College of Wisconsin (MCW), result from the conversion of nonprofit health organizations to for-profit corporations. Over the past several decades, nearly 200 of these foundations have been created, and they have had a substantial impact on the field of health philanthropy. The MCW was a recipient of funds resulting from Blue Cross & Blue Shield United of Wisconsin's conversion from a nonprofit to a for-profit status in 1999. Established in 2004, the endowment has invested approximately $185 million in 337 research, education, and public and community health initiatives that benefit Wisconsin residents. However, the transformative potential of the health care conversion foundation has extended well beyond the opportunities provided through the endowment's financial resources. As the endowment celebrates its 10th anniversary, the authors describe the transformative nature of the endowment, as well as significant accomplishments and lessons learned, in the following areas: shared power, community partnerships, translational research, and integration of medicine and public health. It is the authors' hope that these lessons will be valuable to other medical schools and the communities they serve, as they invest in improving the health of their communities, irrespective of the funding source.

Multiple Foreign Bodies in GIT in a Child Managed by Conservative Approach

A seven years old child presented with multiple pebble stones in the gastro intestinal tract. Clinical examination did not reveal any abnormality except mild dehydration. Serial clinical examination for period of three days and regular radiographic follow up was done. Spontaneous expulsion of all the pebbles per rectum without any complication occurred in three days. In the absence of emergency surgical situation observation and watchful follow up of the patients will suffice the management.J Nepal Paediatr Soc 2015;35(1):67-69