Violations of International Code of Breast-milk Substitutes (BMS) in commercial settings and media in Bangladesh

The International Code of Marketing of Breast‐milk Substitutes (BMS) instituted to protect breastfeeding against unethical marketing, has been adopted by many countries, including Bangladesh. Despite national adoption, evidence suggests violations occur and inadequate BMS Code implementation is an issue. The study aimed to assess violations of the International BMS Code and the national ‘Breast‐milk Substitutes, Infant Foods, Commercially Manufactured Complementary Foods and the Accessories Thereof (Regulation of Marketing) Act, 2013’ of Bangladesh in commercial settings (retail outlets and media) in Bangladesh, for different types of milk, bottles, and teats using a standardized Network for Global Monitoring and Support for Implementation of the Code and Subsequent relevant World Health Assembly Resolutions (NetCode) protocol. This cross‐sectional quantitative study was conducted in Bangladesh from January to September 2018 in Dhaka, Chattogram, and Sylhet cities. Descriptive statistics were reported and χ² tests were conducted to assess differences between categorical variables of interest. Data were analysed using SPSS version 20. In retail outlets, there were higher proportion of violations observed in Dhaka than in Sylhet and Chattogram (p < 0.001). Significantly greater proportion of violations in product labels occurred among products sold without local distributors compared to others (p < 0.05); violations were higher among “other milk” for children aged 0 to <36 months compared to formulas and growing‐up milk (p < 0.05). Among media channels, internet clips had significantly higher proportions of violations compared to television, radio and newspaper (p < 0.001). BMS Code violations were prevalent in product labels and promotion of products through retail outlets. The study findings highlight the need for specific multisectoral strategies for better enforcement of BMS Code and points to the need for periodic assessment of Code violations.

This is the first known study documenting violations in retail outlets, online stores, and media using the standard NetCode protocol in Bangladesh.

BMS Code violations were high in retail stores and were more prevalent in the capital city compared to others.

Violations were significantly higher in the internet compared to radio, television, and newspapers, highlighting the need for strengthening the monitoring of internet‐based promotions.

It is essential to allocate resources to sensitize retail stores to the BMS Code to enhance the implementation of the law.

Mitral regurgitation protects from left atrial thrombogenesis in patients with mitral valve disease and atrial fibrillation

The aim of this study was to test the hypothesis that mitral regurgitation (MR) has a protective effect on the development of left atrial thrombus (LAT) in patients with rheumatic heart disease and atrial fibrillation (AF). The study population consisted of 48 anticoagulated patients (mean age = 57.1 +/- 10 years). Predominant mitral stenosis (MS) was present in 14 patients, predominant MR in 14, and a mechanical valve in 20. All patients underwent detailed transesophageal echocardiography. Severity of MR was based on measurements of the MR jet by color flow mapping. Patients were divided into two groups: (a) those with MR > or = 3+ (n = 12, 25%), and (b) those without significant MR (n = 36, 75%). A LAT was found in six patients (12.5%), who also had spontaneous echo contrast (SEC), while another group of 30 patients (62.5%) had SEC only. LAT and/or SEC were present in 2/12 patients (16.6%) with significant MR versus 34/36 patients (94.4%) without significant MR (P < 0.001). In addition to the absence of significant MR, left atrial diameter (LAD) > 60 mm, and severity of MS were also related to the presence of thrombus and/or SEC. Significant MR had a protective effect against thromboembolism, although this effect was abolished if LAD > 60 mm was present. In conclusion, in patients with mitral valve disease and AF, significant MR protects against LAT formation and systemic embolization. This protective effect was lost when LAD was > 60 mm.

Non-invasive evaluation of coronary reserve. Assessment of coronary reserve in patients with coronary artery disease by transesophageal-Doppler echocardiography

We assessed coronary flow reserve using transesophageal Doppler echocardiography in patients with coronary artery disease. The study included 33 coronary artery disease patients who were undergoing coronary arteriography. The blood flow velocities of the left anterior descending artery before and after intravenous infusion (0.56 mg/min for 4 min) of dipyridamole were recorded using transesophageal Doppler echocardiography. Fourteen normal healthy individuals, matched for age, served as a control group. The index of coronary flow reserve, i.e. the ratio of dipyridamole to baseline maximum diastolic velocity, was calculated. Maximal coronary flow reserve in coronary artery disease patients was significantly lower than in the control group (1.4+/-0.2 vs. 2.8+/-0.3, P<0.001). The coronary artery disease patients were classified into three groups: Group A included 10 patients with <50% left anterior descending artery stenosis; Group B included seven patients with 50-69% left anterior descending artery stenosis; 16 patients with >70% left anterior descending artery stenosis constituted Group C. The maximum coronary flow reserve was significantly different for A vs. B and A vs. C. (A, 1.77+/-0.18; B, 1.51+/-0.1; C, 1.28+/-0.24). A strong and significant correlation was found between the maximum coronary flow reserve and the degree of proximal left anterior descending artery stenosis (r=0.78, P<0.001). Coronary artery disease patients without left anterior descending artery stenosis on the arteriogram exhibited lower maximum coronary flow reserve compared to the control subjects (1.78+/-0.19 vs. 2.8+/-0.3, P=0.000).

Stress echocardiography using adenosine combined with nitroglycerin-dobutamine in the detection of viable myocardium in patients with previous myocardial infarction

The aim of this study was to assess the value of adenosine (A) and the combination of nitroglycerin (N) with dobutamine (D) stress echocardiography (SE) in the identification of viable myocardium. The clinical and electrocardiographic (ECG) effects of both tests were also evaluated. Fifty-two coronary artery disease patients, aged 56.4 +/- 8 years, with left ventricular dysfunction due to a previous myocardial infarction (mean ejection fraction: 49 +/- 8%) were included in the study. Cardiac catheterization was performed in all patients before A (140 micrograms/kg/minute for five minutes) and the combination of N with D (5-10 micrograms/kg/minute) stress echocardiography. On the echocardiogram, the left ventricle was divided into 16 segments and wall motion was graded semiquantitatively from 1 (normal) to 4 (dyskinesia). The echocardiographic index was also estimated. A segment was considered viable during A infusion when resting asynergy showed deterioration of one grade or more. In contrast, segmental viability was considered to be present during the combination of N with D infusion when resting asynergy showed improvement of one grade or more. A thallium 201 single photon emission computed tomography (SPECT) with reinjection was performed as reference standard for the identification of viable myocardium. Stress echocardiography during infusion of A was associated with short-duration angina attacks in 3 (5.8%) patients and transient complete atrioventricular (AV) block in 1 (1.9%), whereas during the combination of N with D infusion, 6 (11.5%) patients experienced ventricular bigeminy lasting for a short period. ST segment elevation greater than 1 mm was recorded in those leads having a Q wave, in 19 (36.5%) patients. In 10 of these 19 (52.6%), viable myocardium was present in SPECT, as it was in 33 patients (63.5%) having no ST segment elevation (P = NS). Of a total of 832 segments that were graded during A-SE, 276 exhibited resting asynergy and the remaining 556 had normal motion and thickening at rest. The echocardiographic index during A infusion increased from 1.52 +/- 0.22 to 1.71 +/- 0.24 (P < 0.001), whereas during D and N infusion it decreased from 1.53 +/- 0.31 to 1.30 +/- 0.42 (P < 0.001). With SPECT considered as the gold standard for the identification of viable myocardium, sensitivity, specificity, and positive and negative predictive values of A-SE in detecting viable myocardium were 54%, 86%, 65% and 80%, respectively. The respective values for the combination of nitroglycerin with D-SE were 91%, 89%, 78%, and 96%, respectively. Stress echocardiography during A, and the combination of N with D, constitute safe methods in the identification of viable myocardium. The detection of ST segment elevation in the ECG leads with a Q wave during the combined infusion of nitroglycerin and dobutamine is not related to the presence of viable myocardial tissue. The A-SE provide moderate diagnostic accuracy, while the combination of N with D during SE is much superior in detecting viable myocardium.

Effects of magnesium and potassium on Wolff-Parkinson-White syndrome

To investigate the effects of electrolytes on anterograde conduction via accessory pathways, 12 patients with Wolff-Parkinson-White syndrome received, while in sinus rhythm, intravenous KCl (7 mEq in 200 mL of 0.9% NaCl), MgSO4 (10 mL 20% in 200 mL of 0.9% NaCl), NaCl (0.9%, 200 mL), and procainamide (maximal dose, 10 mg/kg of body weight over a 5-minute period) in a randomized fashion. NaCl had no effect on preexcitation. Procainamide abolished preexcitation in seven patients, of whom five had a similar response with MgSO4 and four with KCl. The finding that potassium and magnesium transiently abolish preexcitation in some Wolff-Parkinson-White patients deserves further study, especially during tachyarrhythmias in patients with accessory pathways.

Significance of echocardiographic atrioventricular plane displacement for the evaluation of left ventricular filling and end-diastolic pressure in patients with coronary artery disease

The aim of this study is to assess the left ventricular filling and estimate the end-diastolic pressure of the left ventricle in patients with coronary artery disease (CAD) by echocardiographic measurement of the atrioventricular plane displacement (AVPD). In 101 patients (mean age 59 +/- 12 years) with CAD, a complete transthoracic echocardiographic study was performed, just prior to cardiac catheterization. The AVPD was recorded by M-mode echocardiography, from apical four and two chamber views. The recordings were obtained at four sites, corresponding to the septal, lateral, anterior and inferior walls of the left ventricle. The mean AVPD resulting from atrial systole (At), the mean total (T) diastolic AVPD, the ratio At/T(%) and the ratio of mitral annulus excursion during early and late diastole [(T-At)/At] were calculated. Firty-two age-matched healthy subjects served as control group. Both At and At/T were significantly greater in patients with CAD than in the controls (6.06 +/- 0.94 vs 5.53 +/- 0.55 mm, p < 0.01 and 43.4 +/- 5.9% vs 33.49 +/- 4.45%, p < 0.001 respectively). The ratio [(T-At)/At] correlated with the E/A ratio of transmitral flow, both in healthy subjects (r = 0.850, p < 0.001) and in patients with CAD (r = 0.722, p < 0.001). Correlation also existed both in patients with segmental wall motion abnormality (SWMA) (r = 0.691, p < 0.001) and in patients with SWMA (r = 0.818, p < 0.001). In patients with CAD, At/T further correlated with the left ventricular end-diastolic pressure (r = 0.517, p < 0.001). In patients with SWMA and in patients without, a correlation was also found (r = 0.516, p < 0.001 and r = 0.566, p < 0.001 respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of left atrioventricular plane movement during diastole in ischemic heart disease

The aim of the present study was to investigate the properties of diastolic left atrioventricular plane displacement (AVPD) in coronary artery disease (CAD) patients. In 125 patients (mean age 58.7 +/- 13.7) with CAD and in 51 age-matched healthy subjects, a complete transthoracic echocardiographic study was performed. The AVPD was recorded by M-mode echocardiography, from apical four and two chamber views at four sites corresponding to the septal, lateral, anterior and inferior walls of the left ventricle. Mean AVPD in early diastole (E-AVPD), mean AVPD from atrial systole (A-AVPD) and the ratio A-AVPD/E-AVPD were determined. In normal subjects, such as in 35 patients without left ventricular segmental wall motion abnormalities (SWMA), stepwise multiple regression analysis showed none of these factors to be significantly related to E-AVPD or A-AVPD. Aging was correlated negatively to the E-AVPD/A-AVPD ratio (p < 0.05). In 90 patients with left ventricular SWMA, stepwise multiple regression analysis showed that indices of left ventricular systolic function correlated positively to E-AVPD (p < 0.001) and A-AVPD (p < 0.001). The E-AVPD/A-AVPD ratio was correlated to left ventricular ejection fraction and heart rate (p < 0.005). Mean E-AVPD was significantly lower in CAD patients than in normal subjects (p 0.001), while A-AVPD was higher in patients without left ventricular SWMA in comparison to normal subjects (p = 0.02). Also, mean A-AVPD/E-AVPD was higher in CAD patients than in the control group (p < 0.001). Mean E-AVPD/A-AVPD was correlated to the E/A ratio of transmitral flow in CAD patients with (r = 0.669) and without (r = 0.771) SWMA. The E-AVPD and A-AVPD in CAD patients with SWMA is reduced according to the deterioration of left ventricular systolic function. The atrial contribution to the longitudinal distension of the left ventricle is increased in CAD patients. In CAD patients, especially those without left ventricular SWMA, the E-AVPD/A-AVPD ratio has a good correlation to left ventricular filling behavior.

Apical hypertrophic cardiomyopathy with unusual features in a Greek woman

We present a Mediterranean female patient with abnormal electrocardiographic findings and a history of shortness of breath during excessive effort (NYHA I) in whom apical hypertrophic cardiomyopathy with unusual features was detected by echocardiography and magnetic resonance imaging. There was a single fused apical hypertrophic papillary muscle and akinesia of the left ventricular apical segment. Abnormal left ventricular filling was also detected by Doppler echocardiography.