Patterns of antibiotic use, pathogens, and prediction of mortality in hospitalized neonates and young infants with sepsis: A global neonatal sepsis observational cohort study (NeoOBS)

BACKGROUND

There is limited data on antibiotic treatment in hospitalized neonates in low- and middle-income countries (LMICs). We aimed to describe patterns of antibiotic use, pathogens, and clinical outcomes, and to develop a severity score predicting mortality in neonatal sepsis to inform future clinical trial design.

METHODS AND FINDINGS

Hospitalized infants <60 days with clinical sepsis were enrolled during 2018 to 2020 by 19 sites in 11 countries (mainly Asia and Africa). Prospective daily observational data was collected on clinical signs, supportive care, antibiotic treatment, microbiology, and 28-day mortality. Two prediction models were developed for (1) 28-day mortality from baseline variables (baseline NeoSep Severity Score); and (2) daily risk of death on IV antibiotics from daily updated assessments (NeoSep Recovery Score). Multivariable Cox regression models included a randomly selected 85% of infants, with 15% for validation. A total of 3,204 infants were enrolled, with median birth weight of 2,500 g (IQR 1,400 to 3,000) and postnatal age of 5 days (IQR 1 to 15). 206 different empiric antibiotic combinations were started in 3,141 infants, which were structured into 5 groups based on the World Health Organization (WHO) AWaRe classification. Approximately 25.9% (n = 814) of infants started WHO first line regimens (Group 1-Access) and 13.8% (n = 432) started WHO second-line cephalosporins (cefotaxime/ceftriaxone) (Group 2-"Low" Watch). The largest group (34.0%, n = 1,068) started a regimen providing partial extended-spectrum beta-lactamase (ESBL)/pseudomonal coverage (piperacillin-tazobactam, ceftazidime, or fluoroquinolone-based) (Group 3-"Medium" Watch), 18.0% (n = 566) started a carbapenem (Group 4-"High" Watch), and 1.8% (n = 57) a Reserve antibiotic (Group 5, largely colistin-based), and 728/2,880 (25.3%) of initial regimens in Groups 1 to 4 were escalated, mainly to carbapenems, usually for clinical deterioration (n = 480; 65.9%). A total of 564/3,195 infants (17.7%) were blood culture pathogen positive, of whom 62.9% (n = 355) had a gram-negative organism, predominantly Klebsiella pneumoniae (n = 132) or Acinetobacter spp. (n = 72). Both were commonly resistant to WHO-recommended regimens and to carbapenems in 43 (32.6%) and 50 (71.4%) of cases, respectively. MRSA accounted for 33 (61.1%) of 54 Staphylococcus aureus isolates. Overall, 350/3,204 infants died (11.3%; 95% CI 10.2% to 12.5%), 17.7% if blood cultures were positive for pathogens (95% CI 14.7% to 21.1%, n = 99/564). A baseline NeoSep Severity Score had a C-index of 0.76 (0.69 to 0.82) in the validation sample, with mortality of 1.6% (3/189; 95% CI: 0.5% to 4.6%), 11.0% (27/245; 7.7% to 15.6%), and 27.3% (12/44; 16.3% to 41.8%) in low (score 0 to 4), medium (5 to 8), and high (9 to 16) risk groups, respectively, with similar performance across subgroups. A related NeoSep Recovery Score had an area under the receiver operating curve for predicting death the next day between 0.8 and 0.9 over the first week. There was significant variation in outcomes between sites and external validation would strengthen score applicability.

CONCLUSION

Antibiotic regimens used in neonatal sepsis commonly diverge from WHO guidelines, and trials of novel empiric regimens are urgently needed in the context of increasing antimicrobial resistance (AMR). The baseline NeoSep Severity Score identifies high mortality risk criteria for trial entry, while the NeoSep Recovery Score can help guide decisions on regimen change. NeoOBS data informed the NeoSep1 antibiotic trial (ISRCTN48721236), which aims to identify novel first- and second-line empiric antibiotic regimens for neonatal sepsis.

TRIAL REGISTRATION

ClinicalTrials.gov, (NCT03721302).

Challenges in the Implementation of the NeoOBS Study, a Global Pragmatic Observational Cohort Study, to Investigate the Aetiology and Management of Neonatal Sepsis in the Hospital Setting

Neonatal sepsis is a significant cause of mortality and morbidity in low- and middle-income countries. To deliver high-quality data studies and inform future trials, it is crucial to understand the challenges encountered when managing global multi-centre research studies and to identify solutions that can feasibly be implemented in these settings. This paper provides an overview of the complexities faced by diverse research teams in different countries and regions, together with actions implemented to achieve pragmatic study management of a large multi-centre observational study of neonatal sepsis. We discuss specific considerations for enrolling sites with different approval processes and varied research experience, structures, and training. Implementing a flexible recruitment strategy and providing ongoing training were necessary to overcome these challenges. We emphasize the attention that must be given to designing the database and monitoring plans. Extensive data collection tools, complex databases, tight timelines, and stringent monitoring arrangements can be problematic and might put the study at risk. Finally, we discuss the complexities added when collecting and shipping isolates and the importance of having a robust central management team and interdisciplinary collaborators able to adapt easily and make swift decisions to deliver the study on time and to target. With pragmatic approaches, appropriate training, and good communication, these challenges can be overcome to deliver high-quality data from a complex study in challenging settings through a collaborative research network.

Low Cardiac Output Syndrome: Incidence after Mitral Valve Replacement with or without Preservation of Mitral Valve Apparatus

Standard mitral valve replacement in patients with chronic mitral valve regurgitation and mitral valve stenosis consistently results in a decrease in early postoperative left ventricular ejection performance. Some studies showed that preservation of mitral valve leaflet and subvalvular apparatus can reduce postoperative left ventricular dysfunction. On the basis of the concept, this randomized clinical trial comparing mitral valve replacement with preservation of mitral subvalvular apparatus and conventional mitral valve replacement performed in National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh, in the period of July 2010 to December 2011. We included 60 patients of mitral regurgitation and mitral stenosis, among them 30 patients underwent mitral valve replacement with preservation of mitral subvalvular apparatus (Group A) and 30 patients underwent conventional mitral valve replacement (Group B). There was no significant difference between two groups in terms of peri-operative variables. But there was significant higher incidence of Low cardiac output (LOS) syndrome [36.7% vs. 6.9% (p<0.05)] and congestive heart failure in Group B than Group A. The duration of ICU stay was also significantly higher in conventional mitral valve replacement group [113.23±11.30 hours vs. 96.23±20.02 (p=0.001)]. Additionally, there was significantly less fall of left ventricular ejection fraction in preservation of mitral subvalvular apparatus group [preop 65.27±5.45, at discharge 54.31±3.78, after 3 months 58.28±5.20 (p<0.0001)] than conventional group [preop 66.43±4.58, at discharge 46.43±3.87, after 3 months 46.55±3.63 (p<0.0001)]. In this study left ventricular ejection fraction was used as measure of left ventricular function. We postulate that, this relative preservation of left ventricular ejection fraction was likely the result of preservation of mitral subvalvular apparatus.

Home Based Pulmonary Rehabilitation on Oxygenation Status, Dyspnea and Fatigue in Stable Patients with COPD

Pulmonary rehabilitation (PR) program of a sufficient duration has impact on consequence of COPD. To evaluate the effects of combination of pursed lip breathing (PLB), diaphragmatic breathing (DB) and lower extremity endurance training (LEET) as part of PR program in stable patients with COPD on oxygenation status, dyspnea and fatigue. This prospective interventional study was performed in the Department of Physiology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from July 2010 to June 2011 and was performed on 116 male stable moderate COPD patients aged 50 to 65 years. Among them, 56 patients were without PR (control group) and 60 patients were intervened with PR (experimental group). The experimental patients were advised to perform the home based PR program (PLB, DB and LEET) for 30 minutes duration per session at home twice per day, along with standard drug treatment of COPD for uninterrupted 60 days. The control patients continued their treatment of COPD with standard drug for successive 60 days were advised. To evaluate the effects of PR, Peripheral capillary oxygen saturation (SpO₂, by pulse Oximeter), level of dyspnea and level of fatigue by Modified Borg Scale from baseline to end of six minute walk test (6MWT) of all subjects were recorded on day 0 and day 60 for both the groups. Independent sample 't' test and paired Student's 't' test were done with SPSS software. In the interpretation of results, p value of <0.05 was considered as statistically significant. In the present study, we found less decrement of SpO₂ and less increment of level of dyspnea as well as level of fatigue after 6MWT in the COPD patients with PR on 60th day of follow up. The study reveals that oxygenation status, dyspnea and fatigue improve after execution of regular home based PR program in patients with moderate stable COPD.

Pattern of Casualties Attending in the Casualty Department of Mymensingh Medical College Hospital, Mymensingh, Bangladesh

Casualty, in relation to personnel, any person who is lost to his organization; by reason of being declared dead, wounded, diseased, detained, captured or missing. Casualty service or department is not well organized in the hospitals of our country. We have recently started functioning casualty department to manage casualties properly in spite of the increasing workload and emerging needs of this department. This study was conducted in the Casualty department, Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh to analyze the number of patients and pattern of casualties. A total number of 17435 patients were enrolled in this retrospective observational study. Data was collected from hospital records of all patients attending in the Casualty Department, MMCH between November 19, 2017 and May 18, 2018 and patients were categorized on the basis of their mode of injury. The demographic characteristics of patients with mode of Casualty were analyzed. Male were 75% and female 25%. Avergae per day patient attended in the Casualty department was 96, maximum was 176 and minimum 33. According to age sub-division, 11-20 years age group attended maxiumum was 48. One day attended Road traffic accident (RTA) maximum was 65 and minimum was 3, Non-RTA maximum was 83 and minimum 25, physical assaults maximum was 48 and minimum 1. Injury due to fall and RTA were the common mode of casualty especially in the young population in the study area. Study showed that injury caused by fall was 44% among the all patients. Patients due to fall from tree was highest (35%) in April-May. Incidents of fall were followed by RTA which was 25%. Physical assaults (17%), machinery injury (9%) and others were 5%.

Assessment of the effects of teaching germ theory on changes in hygiene behaviors, cleanliness, and diarrheal incidence in rural bangladesh

Germ theory was taught as part of a hygiene intervention in five villages in Bangladesh in which 87 percent of mothers were illiterate. Volunteer mothers taught other community mothers interactively in small groups using demonstration and teaching aids developed by a community working group. At final measurement 91 percent of mothers could explain five simple messages defining germ theory. Using germ theory in groups they identified forty high risk day-to-day practices and modified them to reduce diarrheal transmission. They adopted these new hygiene practices at rates ranging from 65 percent to 100 percent. Regression analysis suggests that understanding of germ theory was an important determinant of hygiene practices, cleanliness, and reduction in diarrheal incidence. Understanding of germ theory appeared to reduce diarrheal incidence not only through the interventions designed by the project but also changing perceptions of risk in the environment which led to spontaneous improvement in hygiene behaviors. We believe that accurate understanding of causes, transmission, and prevention of disease can 1) empower community and individual actions; and 2) contribute significantly to the impact of hygiene interventions. Therefore, it may be imperative to integrate teaching germ theory into community health education.

Breastfeeding and cognitive development of children: assessment at one year of age

Breastfeeding is the fundamental component of child survival strategy. It significantly influences neurological development of children. The study was conducted to assess whether exclusive and prolonged breastfeeding improves children's cognitive development, including low birth weight (LBW) babies, in a developing country setting like Bangladesh. This observational study was done on a cohort of newborn infants who were discharged from the special care baby unit of Dhaka Shishu Hospital during January 2006 to December 2008 with proper counseling about exclusive and prolonged breastfeeding. Their neuro-developmental follow-up was started at 4 weeks postnatal age and continued at 3-monthly intervals up to 1 year of age. At each visit, cognitive development was assessed using the Bayley Scales of Infant Development (BSID II). Cognitive development was compared between the babies of exclusive vs. non exclusive breastfeeding, normal weight vs. low birth weight and male vs. female babies. A total of 105 cases were successfully followed-up during this period. Out of these 47(44.8%) babies were exclusively breastfed up to 6 month of age and 58(55.2%) were in nonexclusive group. Overall Psychomotor Development Index (PDI) was slightly more (108.40 ± 23.06 vs. 103.23 ± 19.87) in the exclusive breast fed babies in comparison to nonexclusive breast fed babies, but was significantly more in babies having birth weight >2.5 kg in comparison to those having birth weight of <2.5 kg. Other parameters of cognitive development were more or less same in both normal and LBW groups. Mental and motor development was same in both boys and girls. In behavior ratings, cooperation was significantly high (5.89 ± 2.54 vs. 4.71 ± 3.13, p=0.05) and vocalization (5.89 ± 1.07 vs. 4.58 ± 1.16) was also high, though not significant, in girls than boys.

Population-based incidence and etiology of community-acquired neonatal bacteremia in Mirzapur, Bangladesh: an observational study

BACKGROUND

To devise treatment strategies for neonatal infections, the population-level incidence and antibiotic susceptibility of pathogens must be defined.

METHODS

Surveillance for suspected neonatal sepsis was conducted in Mirzapur, Bangladesh, from February 2004 through November 2006. Community health workers assessed neonates on postnatal days 0, 2, 5, and 8 and referred sick neonates to a hospital, where blood was collected for culture from neonates with suspected sepsis. We estimated the incidence and pattern of community-acquired neonatal bacteremia and determined the antibiotic susceptibility profile of pathogens.

RESULTS

The incidence rate of community-acquired neonatal bacteremia was 3.0 per 1000 person-neonatal periods. Among the 30 pathogens identified, the most common was Staphylococcus aureus (n = 10); half of all isolates were gram positive. Nine were resistant to ampicillin and gentamicin or to ceftiaxone, and 13 were resistant to cotrimoxazole.

CONCLUSION

S. aureus was the most common pathogen to cause community-acquired neonatal bacteremia. Nearly 40% of infections were identified on days 0-3, emphasizing the need to address maternal and environmental sources of infection. The combination of parenteral procaine benzyl penicillin and an aminoglycoside is recommended for the first-line treatment of serious community-acquired neonatal infections in rural Bangladesh, which has a moderate level of neonatal mortality. Additional population-based data are needed to further guide national and global strategies.

Comparison of haematological values among different groups of low birth weight babies and normal birth weight babies

This prospective cross sectional study was carried out in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka. This study was undertaken to compare the haematological value (reference range) among Small for gestational age-low birth weight (SGA-LBW), Appropriate for gestational age-low birth weight (AGA-LBW) and Normal birth weight (NBW) babies. Total 90 (ninety) newborn babies were enrolled in this study. They were ultimately divided into three groups as a) Group I (SGA-LBW), b) Group II (AGA-LBW), c) Group III (NBW). Study period was one year (December 2003 to December 2004), Relevant informations were collected from the guardian of the babies before inclusion in the study. In group I, 19(63.3%) were preterm and 11(36.7%) were term. In group II, 30(100%) were preterm and in group III, 30(100%) were term. Mean Hb, and HCT levels were highest in group I (SGA-LBW) and the value was 17.14+/-1.41 gm/dl (Hb) and 0.51+/-0.04 (HCT) respectively. Mean Hb and HCT value were lowest in group II (AGA-LBW) and the value was 14.57+/-1.78 gm/dl (Hb) and 0.43+/-0.05 (HCT) respectively. In between value was found in group III (NBW) and the value was 16.14+/-1.09 gm/dl (Hb) and 0.48+/-0.04 (HCT) respectively. Differences were statistically significant. On the contrary, MCV Values were highest in group II (AGA-LBW) and the value was 103.23+/-4.99 (fl). Lowest MCV value was in group III (NBW) and the value was 98.13+/-3.93 (fl). In between result of MCV value was found in group I (SGA-LBW) and the value was 99.27+/-10.73 (fl). Differences were also statistically significant. MCH and MCHC level was also highest in group I (SGA-LBW). Difference was also statistically significant. No significant differences of TC of WBC and platelet counts were not found among different groups. Hb and HCT level had significant positive correlation with gestational age. Other parameters had no Positive correlation with gestational age.

How the health care system can improve mammography-screening rates for underserved women: a closer look at the health care delivery system

The way care is delivered has dramatic impact on the patient-provider interaction and the outcomes experienced by the patient. This article explores a deceptively simple but very powerful method for evaluating and improving care delivery. Mammography is a routine screening procedure. However, many factors can influence how frequently women seek and obtain mammograms. Twenty-five low-income women identified empowering factors and barriers they experienced when trying to obtain a mammogram.

Aberrant expression of MSG1 transcriptional activator in human malignant melanoma in vivo

MSG1 was originally isolated as a candidate pigmentation-related gene. MSG1 mRNA transcripts were expressed strongly in cultured human and mouse normal epidermal melanocytes, and in highly pigmented mouse melanoma cells, while its expression was very weak in cultured non-pigmented human melanoma cells. Thus, MSG1 was initially proposed to be a melanocyte-specific gene, and its possible role in pigmentation has been speculated. It was found recently that the MSG1 protein interacts functionally with Smad4, which plays a pivotal role in signal transduction of transforming growth factor-beta. In this study, we analyzed MSG1 protein expression by immunohistochemistry using human tumor samples from nevus and malignant melanoma to reveal its role in pigmentation and melanoma development in vivo. A relatively strong but heterogeneous expression of MSG1 protein was seen in melanomas compared with weak expression in nevi. In nevi, MSG1 expression was mostly confined to the pigmented region, while it was expressed in both pigmented and non-pigmented regions in melanoma. Intracellularly, MSG1 protein was localized in the cytoplasm of nevus cells, but was seen in both nuclei and cytoplasm of melanoma cells. These results support a hypothesis that MSG1 plays a role in pigmentation. It is also suggested that MSG1 may be involved in malignant transformation of pigment cells. Alternatively, the aberrant expression of MSG1 in melanoma cells might be due to the abnormal environment, including aberrant cytokine or growth factor expression, associated with melanoma formation.

Protective effect of topically applied olive oil against photocarcinogenesis following UVB exposure of mice

Reactive oxygen species have been shown to play a role in ultraviolet light (UV)-induced skin carcinogenesis. Vitamin E and green tea polyphenols reduce experimental skin cancers in mice mainly because of their antioxidant properties. Since olive oil has also been reported to be a potent antioxidant, we examined its effect on UVB-induced skin carcinogenesis in hairless mice. Extra-virgin olive oil was applied topically before or after repeated exposure of mice to UVB. The onset of UVB-induced skin tumors was delayed in mice painted with olive oil compared with UVB control mice. However, with increasing numbers of UVB exposures, differences in the mean number of tumors between UVB control mice and mice pretreated with olive oil before UVB exposure (pre-UVB group) were lost. In contrast, mice that received olive oil after UVB exposure (post-UVB group) showed significantly lower numbers of tumors per mouse than those in the UVB control group throughout the experimental period. The mean number of tumors per mouse in the UVB control, pre-UVB and post-UVB groups was 7.33, 6.69 and 2.64, respectively, in the first experiment, and 8.53, 9.53 and 3.36 in the second experiment. Camellia oil was also applied, using the same experimental protocol, but did not have a suppressive effect. Immunohistochemical analysis of DNA damage in the form of cyclobutane pyrimidine dimers (CPD), (6-4) photoproducts and 8-hydroxy-2'-deoxyguanosine (8-OHdG) in samples taken 30 min after a single exposure of UVB showed no significant difference between UVB-irradiated control mice and the pre-UVB group. In the post-UVB group, there were lower levels of 8-OHdG in epidermal nuclei, but the formation of CPD and (6-4) photoproducts did not differ. Exposure of olive oil to UVB before application abrogated the protective effect on 8-OHdG formation. These results indicate that olive oil topically applied after UVB exposure can effectively reduce UVB-induced murine skin tumors, possibly via its antioxidant effects in reducing DNA damage by reactive oxygen species, and that the effective component may be labile to UVB.

Preventive effect of antioxidant on ultraviolet-induced skin cancer in mice

Reactive oxygen species (ROS) have been shown to be responsible for inducing DNA damage after ultraviolet radiation (UV). Antioxidant, vitamin E and epigallocatechin gallate extracted from green tea, applied topically to the skin, delayed the onset of UV-induced skin cancer in mice. Since olive oil is reported to have a potent antioxidative effect in in vitro system, we asked whether, topical use of olive oil reduces the number and delays the onset of UV-induced skin cancer in mice. We found that super virgin olive oil painted immediately after UVB radiation significantly delayed the onset and reduced the number of skin cancer, but pretreatment of super virgin olive oil and pre- and/or post treatment by regular olive oil neither retarded nor reduced skin cancer formation in UV-irradiated mice. Further, 8-hydroxy-deoxyguanosine (8-OHdG) formation in mice epidermis was apparently reduced by super virgin olive oil painted immediately after UV radiation, although cyclobutane pyrimidine dimers and (6-4) photoproducts were not reduced by olive oil treatment. Our results suggest that daily topical use of super virgin olive oil after sun bathing may delay and reduce UV-induced skin cancer development in human skin, possibly by decreasing ROS-induced 8-OHdG which is responsible for gene mutation.

Difficulty in reaching low-income women for screening mammography

Low-income women have a high mortality from breast cancer. Yet, they participate in breast cancer early detection screening programs less than women in the general population. An intervention study to improve screening mammography rates of low-income women participating in Tennessee's TennCare program (state Medicaid and Medicare program) revealed significant barriers to reaching these women. Intervention methods included mail, telephone calls, and home visits. Results indicate that only 38 percent of the women could be contacted for a baseline survey. Reasons for noncontact included absence from home (39 percent), having moved (22 percent), refusal to participate (17 percent), having no physical domicile (15 percent), language barriers (4 percent), and miscellaneous other factors (4 percent). Women with telephones tended to have a relatively higher economic status and were more successfully reached than women without telephones. These findings provide useful insights for future program planning and research design.

The inhibitory effect of DL-alpha-tocopheryl ferulate in lecithin on melanogenesis

Oral vitamin E (alpha-tocopherol) supplementation has been reported to improve facial hyperpigmentation. The compound of alpha-tocopherol and ferulic acid, also an antioxidant connected with an ester bond, alpha-tocopheryl ferulate (alpha-TF) can absorb ultraviolet (UV) radiation and thus maintain tocopherol in a stable state. Our aim was to determine whether alpha-TF can be applied to improve and prevent facial hyperpigmentation induced by UV as a whitening agent as well as an antioxidant. In this study, the effects of alpha-TF on melanogenesis were examined using cultured human melanoma cells and normal human melanocytes in vitro. alpha-TF solubilized in 0.5% lecithin inhibited melanization significantly at the concentration of 30 micrograms/ml compared with arbutin (100 micrograms/ml), kojic acid (100 micrograms/ml), ascorbic acid (600 micrograms/ml), and tranexamic acid (600 micrograms/ml). alpha-TF had no effect on the protein amounts of tyrosinase, TRP (tyrosinase related protein)-1, and TRP-2 of human melanoma cells exposed to UV radiation, but inhibited tyrosine hydroxylase activity. alpha-TF neither directly inhibited tyrosinase activity of the large granule fraction extracted from melanoma cells, nor modulated glycosylation of tyrosinase. These results suggest that alpha-TF may be a candidate for whitening agent which suppresses melanogenesis, possibly by inhibiting tyrosine hydroxylase activity in an indirect manner. Further, alpha-TF decreased the amount of 8-hydroxydeoxyguanosine produced indirectly through active oxygen species (AOS) in guinea pig skin exposed to 2 times the minimal erythema dose of UVB radiation, but did not suppress the direct formation of cyclobutane pyrimidine dimers and (6-4) photoproducts. Thus alpha-TF may reduce AOS-induced DNA damage and thereby contribute at least in part to suppressing or retarding skin cancer development.

Induced expression of p16 and p21 proteins in UVB-irradiated human epidermis and cultured keratinocytes

It has been suggested that p16INK4a, the product of the cyclin-dependent kinase inhibitor 2 or multiple tumor suppressor 1 gene, prevents phosphorylation of the retinoblastoma gene product, and thus acts as a negative cell cycle regulator. To elucidate an effect of ultraviolet B (UVB) radiation on p16 expression and its relation to p21, and proliferating cell nuclear antigen (PCNA), immunohistochemical and western blot analyses were performed on UVB-irradiated normal human epidermis and cultured keratinocytes, respectively. Little p16 protein was seen in the control epidermis or keratinocytes. Increases in the levels of p16 protein in both UVB-irradiated epidermis and keratinocytes occurred in a similar manner, in which p16 was induced at 24-48 h and peaked at 72-120 h after irradiation. The induced expression of p21 was observed relatively earlier than that of p16, with peaked expression at 24-48 h and a return to control level by 168 h. PCNA expression was increased slightly until 48 h but significantly increased during 48-168 h of post-irradiation with peak expression at 72 h. These results indicate that together with p21, p16 protein may play an important role for protective or adaptive response to UVB exposure of human skin.

High levels of 8-hydroxy-2'-deoxyguanosine appear in normal human epidermis after a single dose of ultraviolet radiation

Major photoproducts induced by carcinogenic ultraviolet (UV) radiation are the cylobutane pyrimidine dimers (CPDs) and pyrimidine-pyrimidone (6-4) photoproducts (6-4 PPs). 8-Hydroxy-2 -deoxyguanosine (8-OHdG) is also a DNA base-modified product generated by reactive oxygen species in conditions of ultraviolet stress, Although UVB-induced CPDs and 6-4 PPs have been investigated in animal and human skin, little is known about the role of 8-OHdG in UVB-induced human skin damage or carcinogenesis. Normal human skin from three volunteers was exposed to UV radiation, and the time course of induction and removal of 8-OHdG was examined by immunohistochemical analysis with catalysed signal amplification on formalin-fixed paraffin sections. Formation of CPDs and 6-4 PPs was also examined by immunostaining on the same skin specimens. Control epidermis with no exposure to UV radiation showed little nuclear staining of 8-OHdG, but an increased level of 8-OHdG was clearly observed in epidermis biopsied after irradiation. Induced 8-OHdG can rapidly be removed from nucleus during the first 24-48 h, as the staining intensity diminished gradually, almost reaching the control level by 72-96 h after irradiation. Staining for CPDs or 6-4 PPs revealed induction of these photoproducts in human skin, although 6-4 PP-positive cells disappeared more rapidly than those that stained for CPDs or 8-OHdG. Together with protective effect of antioxidants, our results indicate that not only CPDs and 6-4 PPs but also 8-OHdG may play a significant part in UV carcinogenesis.

Regulation of expression of MSG1 melanocyte-specific nuclear protein in human melanocytes and melanoma cells

MSG1 is a nuclear protein and a possible transcriptional transactivator that is expressed strongly in melanocytes but very weakly, if at all, in most nonmelanocytic cells or adult mouse tissues. This strong expression of MSG1 in cultured normal human epidermal melanocytes was found to be dependent on both endothelin-1 and FGF-2. The phorbol ester TPA could be substituted for endothelin-1. The MSG1 mRNA transcripts were rapidly induced by either endothelin-1 or TPA. However, FGF-2 had no effects at the mRNA level, suggesting its contribution at the translational and/or posttranslational level(s). MSG1 (as well as its mRNA transcripts) was induced by TPA in human melanoma cells, which produce FGF-2 as an autocrine growth factor. Melanoma cells derived from primary tumors or tyrosinase-positive metastatic melanoma cells expressed MSG1 after TPA treatment, while tyrosinase-negative metastatic melanoma cells or nonmelanocytic cells did not. This TPA-induced MSG1 expression in melanoma cells correlated with the expression of the MSG1 mRNA transcripts and TPA-dependent transcriptional activation of the MSG1 promoter sequence, indicating its transcriptional regulation. In vivo, MSG1 protein was detected in human nevocytic nevus confined to the pigmented region, while MSG1 expression showed cell-level heterogeneity in pigmented melanoma tissues. These results demonstrate that MSG1 expression is regulated transcriptionally and posttranscriptionally by local growth factors as well as by the cellular status of differentiation.

Expression of fibroblast growth factor receptors in naevus-cell naevus and malignant melanoma

In a previous study, we showed by immunohistochemical analysis that basic fibroblast growth factor (bFGF) is expressed strongly and homogeneously in naevus-cell naevus (NCN), while that in malignant melanoma (MM) is heterogeneous and sometimes non-existent. In order to elucidate the role of bFGF in these pigmented tumours, the expression of its receptors must be determined. In this study, we performed an immunohistochemical analysis of FGF receptors 1, 2 and 3 (FGFR-1, FGFR-2 and FGFR-3, respectively) in NCN and MM and compared their expression and localization with those of bFGF. The expression of bFGF and its three receptors was also examined in melanoma cell lines. None of the 10 NCN that showed strong, homogeneous staining for bFGF expressed FGFR-1 or FGFR-3 proteins; six weakly expressed FGFR-2 protein. Ten primary and 10 metastatic MM showed heterogeneous expression for the three receptors, with larger populations of FGFR-3-negative cells in the primary than in the metastatic tumours. Western blot analysis showed homogeneous expression of bFGF protein in all four melanoma cell lines tested, while FGFR proteins had a heterogeneous distribution in the different cell lines. Cultured NCN and normal melanocytes showed no immunoreactive band for FGFR-1 protein, the only protein tested. Our results suggested that tumour-derived bFGF is involved in melanoma formation through an autocrine mechanism, but is involved mostly through a paracrine or other mechanisms in NCN.

Increased level of c-erbB-2/neu/HER-2 protein in cutaneous squamous cell carcinoma

Overexpression of c-erbB-2/neu/HER-2 oncoprotein, a receptor tyrosine kinase, has been demonstrated in a variety of human cancers. To elucidate the involvement of c-erbB-2 in human skin carcinogenesis, we examined expression of the protein in skin samples from five cases of keratoacanthoma (KA), 10 of actinic keratosis (AK), 24 of squamous cell carcinoma (SCC) and 10 of basal cell carcinoma (BCC) and five samples of normal epidermis, using an immunohistochemical method on formalin-fixed, paraffin-embedded sections. Expression of c-erbB-2 was also examined in cultured SCC cell lines, a premalignant cell line and in cultured normal keratinocytes. Normal epidermal cells showed no or very little c-erbB-2 protein, but the covering epidermal layer of some tumours showed a few strongly positive cells. Samples of KA and AK showed barely detectable c-erbB-2 protein in only a few cases. Twenty of the 24 cases of SCC had elevated expression of c-erbB-2 protein, with a tendency to more positive cells in metastatic lesions. Five of the 10 cases of BCC stained for c-erbB-2 but more weakly than those of SCC. Reaction products of the positive cells were seen in the cytoplasm. All three cultured SCC cell lines stained for c-erbB-2 protein more strongly than the premalignant HaCaT or normal keratinocytes. Our results indicate the possible involvement of c-erbB-2 overexpression in the malignant conversion of keratinocytes.

p21WAF1/CIP1 expression in non-melanoma skin tumors

Abnormal control of the cell cycle is closely linked to carcinogenesis. p21WAF1/CIP1 protein is a universal inhibitor of G1 cyclin-dependent kinase and is induced by p53-dependent and -independent pathways. In order to elucidate the role of p21WAF1/CIP1 in human skin carcinogenesis, protein expression in squamous cell carcinoma (SCC), basal cell carcinoma (BCC), Bowen's disease (BD), actinic keratosis (AK), keratoacanthoma (KA), seborrheic keratosis (SK), and normal skin was examined using an immunohistochemical method. In normal skin, a few positive cells were seen in some cases in the upper spinous layer of the epidermis; sebaceous glands also had positive cells. In cases of SK and KA, positive cells were found in the basal and suprabasal epidermal layers (proliferation pattern), and in cases of BD and AK, positive cells were seen mainly in the upper spinous layer (differentiation pattern). Cases of SCC had more positive cells and showed two staining patterns: proliferation, or mixed. Cases of BCC had no positive cells. p21WAF1/CIP1 has some unidentified role in keratinocyte tumorigenesis, which may not be related directly to carcinogenesis.

The expression of retinoblastoma protein in epidermis is induced by ultraviolet B exposure

DNA damage induced by ultraviolet light (UV) can be repaired while cells are arrested in the cell cycle. Tumour suppressor gene p53 has been implicated as being involved in the G1 arrest after UV irradiation. Normal human skin from three volunteers was exposed to UVB and the expression of p53, Ki-67 and retinoblastoma gene product (pRb) was examined immunohistochemically, in addition to observation for sunburn cells. p53 protein started to be expressed at 6 h after UVB irradiation. It peaked at 12-48 h. Ki-67 expression was induced after 48 or 72 h of irradiation. pRb begun to be expressed at 24 or 48 h and peaked at 48-96 h. p53-positive cells were distributed throughout the epidermis, while Ki-67 and pRb positive cells were seen mainly at the lower epidermis. Finally, sunburn cells, which are presumably apoptotic cells, appeared at 24 h and peaked at 24-48 h and were seen at upper epidermis. The different and co-ordinated expression, although variable between individuals, indicates important roles for p53 and pRb on the maintenance of the homeostasis of the epidermis after UV irradiation.

Cyclin D and retinoblastoma gene product expression in actinic keratosis and cutaneous squamous cell carcinoma in relation to p53 expression

Abnormality of the molecules regulating the cell cycle has been shown to lead cells to transformation. Recently, overexpression of cyclin D protein, one of the G1 cyclins, and the abnormality of the retinoblastoma gene have been found in various human cancers. We analyzed the expression of cyclin D, retinoblastoma gene product (pRB) and p53 in actinic keratoses (AKs) and cutaneous squamous cell carcinomas (SCCs) by immunohistochemistry to elucidate the role of these molecules in keratinocyte carcinogenesis. In the normal epidermis, a few cyclin D positive cells were seen mainly at the basal layer. In 11 seborrheic keratoses, no overexpression of cyclin D was observed. Twelve of 26 AKs (46%) and 27 of 45 SCCs (60%) showed cyclin D overexpression. A few pRB positive cells were seen in the basal layer and in the suprabasal spinous layer of the normal epidermis. An abnormality of pRB, loss of expression, was seen in 2 of 26 AKs (8%) and 7 of 45 SCCs (16%). p53 protein was positive in 12 of 26 AKs (46%) and 24 of 45 SCCs (53%). Forty-five SCCs examined were divided into 22 ultraviolet (UV)-related SCCs and 23 UV-unrelated SCCs. Though UV-related SCCs showed a significantly higher incidence of p53 positivity, as previously reported by us, no significant difference in cyclin D overexpression and loss of the pRB expression was observed between UV-related and UV-unrelated SCCs. These results suggest that cyclin D overexpression is frequently involved in keratinocyte carcinogenesis and that this is an early event, as well as p53 abnormality. In addition, abnormality of the retinoblastoma gene is also related to epidermal cell carcinogenesis, though the frequency is relatively low.

Developmental, behavioural, and environmental risk factors for diarrhoea among rural Bangladeshi children of less than two years

One hundred and eighty-five rural Bangladeshi children (80 boys and 105 girls) aged 4-27 months were observed to investigate developmental, behavioural, and environmental risk factors for diarrhoea during a 6-month period. Incidence of diarrhoea was found to be the highest among children aged 10-12 months. Children of this age group had the greatest exposure to environmental contaminants in the neighbourhood. Incidence of diarrhoea was the highest in hot, dry months. Risk factors for diarrhoea included: faecal contamination and garbage disposal in infant's outdoor play compound, crawling, contact of hand and mouth with contaminated materials, greater distance of household from water source, inadequate cleaning after defecation; dirt of child's face, presence of flies, feeding rotten food; insufficient washing of infant's and caretaker's hands before feeding rice meals or soft, wet foods; and lack of mothers' willingness to visit a modern (allopathic) health practitioner.

Nutritional correlates of frequency and length of breastfeeds in rural Bangladesh

In this rural Bangladeshi sample of 165 mothers and their breastfed infants aged 5-23 months, mean maternal body mass index (BMI) was 18, and 12-month infant height-for-age z-scores (HAZ), -2.35. Structured observations were conducted over 6 months on 1649 breastfeeds during 3324 weekly daytime observations. Infants' and mothers' 24-h dietary recalls, weights, lengths/heights and mothers' arm circumferences were taken monthly. When plotted with age, infants' anthropometric z-scores, food energy, and minutes observed breastfeeding revealed three patterns in age periods: 5-12, 13-18, and 19-23 months. In periods one (breastfeeding high) and three (breastfeeding low), food energy increased with age, linear growth paralleled the World Health Organization (WHO) reference standard, and the children grew thinner. In two, (breastfeeding declining), food energy did not increase and growth stasis occurred. Longer observed breastfeeding accompanied in period one, low maternal arm circumference, low infant energy intake from complementary foods and infant shortness and plumpness in period two, infant shortness, thinness, and underweight; and in period three, infants energy and thinness. In conclusion, the paper suggests that growth stasis occurs primarily during the second period, which should have highest priority for culturally sensitive interventions.

A longitudinal study of the impact of behavioural change intervention on cleanliness, diarrhoeal morbidity and growth of children in rural Bangladesh

A community-based intervention was developed through direct participation of the target population in assessment and iterative trials to improve hygiene practices and to reduce childhood diarrhoea in lowland rural Bangladesh. A total of 185 (98%) households with children ages 0-18 months in five contiguous villages were targeted for the interventions. A comparison site was selected for a detailed observational study and for use as a control for the intervention. About 97% of all households with children ages 0-18 months were enrolled for study at the control site. Children in this age group were targeted because at this developmental stage they were most vulnerable to diarrhoeal morbidity and malnutrition (related to unhygienic practices). The intervention was implemented with the assistance of village leaders through a "Clean Life" campaign by local project workers and volunteer mothers who were chosen from the target households. The intervention activities started in January 1986 and lasted for 7 months. Higher adoption rates of the intervention were associated with better cleanliness status, which was related to lower diarrhoea and malnutrition rates in the intervention site. The results of between-site longitudinal analyses showed that after the intervention, the intervention site had substantially higher cleanliness scores, lower diarrhoeal morbidity, and better growth status compared to those of the control site, with differences increasing over time. The findings suggest that this type of community-based intervention can be very beneficial in modifying hygiene behaviours and lowering childhood diarrhoea and malnutrition.

Analysis of Sociodemographic and Clinical Factors Associated with Hospitalized Stroke Patients of Bangladesh

A hospital based cross sectional study was carried out to analyze prevalence of risk factors for stroke in hospitalized patient in a medical college hospital. 100 patients were chosen using purposive sampling technique. Highest incidence of stroke was between the 6th and 7th decade. Patients came from both urban (54%) and rural (46%) areas and most of them belong to the low-income group (47%). In occupational category; service holder (28%) and retired person (21%) were the highest groups. Most of the study subjects were literate (63%). CT scan study revealed that the incidence of ischaemic stroke was 61% and haemorrhagic stroke 39%. Analysis indicated hypertension as major risk factor for stroke (63%) and major portion of the patients (42.85%) were on irregular or no treatment. Twenty four percent of the patients had heart diseases and out of 24 patients 45.83% were suffering from ischaemic heart disease. The present study detected diabetes in 21% patients. Fifty three percent of the study subjects were smoker, 39% patients had habit of betelnut chewing. Out of 26 female patients, only 23% had history of using oral contraceptives. Majority of the patients were sedentary workers (46%). Thirty seven percent of the stroke patients were obese. Among the stroke patients 9% had previous history of stroke and 3% had TIA respectively. Most of the patients (21%) were awake while they suffered from stroke and the time of occurrence was mostly in the afternoon (46%). This study found that hypertension, cigarette smoking, ischaemic heart disease and diabetes mellitus are the major risk factors prevalent in our community while other risk factors demand further study. Key words: stroke; risk factors; hospitalized patients; Bangladesh. DOI: 10.3329/fmcj.v6i1.7405 Faridpur Med. Coll. J. 2011;6(1): 19-23

Fast-track Cardiac Surgery in Children: Feasibility in Bangladeshi Setting

Background: Fast-track recovery protocols in cardiac surgery is gaining worldwide popularity and have contributed to significant reductions in the postoperative hospital stay and cost without any increase in postoperative mortality and morbidity. The aim of this study was to find out the feasibility of fast track paediatric cardiac surgery in Bangladeshi setting. Method: It was a prospective study conducted in National Institute of Cardio-vascular Diseases, Dhaka, from July 2009 to June 2010. All patients, between 3 to 18 years, underwent surgical closure of atrial or ventricular septal defect under cardio-pulmonary bypass. 20 patients from our unit served as fast track group and 30 patients from other units of the same hospital served as conventional group. Fast track patients were extubated in less than 6 hours after surgery, shifted from ICU in less than 24 hours and geared up to discharge home within 3 days of surgery. Result: 18 (90%) of the 20 patient of the fast track group were discharged within 3 days of surgery, 2 patients cannot be discharged within this time frame. Mean post operative hospital stay for study group was 3.1 days, whereas the mean hospital stay in the control group was 7.5 days. Follow-up was 100% complete at 30 days. There was no major in-hospital or out-of-hospital complications in either group. No patient was readmitted at our centre or elsewhere for any complication arising from this process. Conclusion: Fast tracking is feasible and safe in low-risk paediatric open-heart surgery in Bangladeshi scenario. A multidisciplinary approach with a set protocol is required to achieve this goal in a safe and reproducible manner. Keywords: Cardiac surgery; Congenital heart disease; Fast track; Hospital discharge. DOI: 10.3329/cardio.v3i1.6427Cardiovasc. j. 2010; 3(1): 50-54