Cervical tuberculous lymphadenitis: clinico-demographic profilesof patients in a secondary level hospital of Bangladesh

Objective: Tuberculosis [TB] is a major public health problem in Bangladesh since long. The present incidence and prevalence rates of all forms of TB are 227 and 404/100,000 population respectively. The aim of this study was to find out the clinical characteristics of involved cervical lymph nodes, demographic characteristics of the patients and response to treatment of Cervical Tuberculous Lymphadenitis [CTL] cases

Methods: A prospective study was performed in Shaheed Shamsuddin Ahmed Hospital, Sylhet, Bangladesh from June 2012 to June 2014. Total 65 patients having CTL attending outpatient department of the hospital were enrolled

Results: Age of the patients ranged from 5 to 60 years with a mean of 25.6 years. Two third [67.7%] of the patients were female. Male: Female ratio was 1:2.1. More than half of the patients came from rural areas [53.8%] and from low socio-economic conditions [58.5%]. Most of the patients presented with unilateral [87.7%], multiple [82.3%], matted [68.6%] lymph nodes, <3cm diameter [54%], commonly in right side [57.9%]. Abscess was found in 21.5% cases. Discharging sinus was found in 9.2% cases. Most commonly involved lymph node group was level V [59.4%] followed by level II [42.2%]. Systemic features were found in 63.07% patients. Associated lung lesion was found in 3.1% cases. FNAC was found positive for tuberculosis in 83.9% cases. Most of the patients [78.46%] were cured with six months anti-tubercular chemotherapy

Conclusions: Early diagnosis and treatment is critical in reducing the overall prevalence. It is essential to have awareness regarding common presentations of cervical tuberculous lymphadenitis among the general population as well as healthcare professionals working in the resource poor primary and secondary level hospitals

Efficacy of probiotics versus placebo in the prevention of necrotizing enterocolitis in preterm very low birth weight infants: a double-blind randomized controlled trial

Objective: To evaluate the efficacy of orally administered probiotics in preventing necrotizing enterocolitis [NEC] in preterm very low birth weight [VLBW] infants

Study Design: A randomized double blind controlled trial

Place and Duration of Study: The Paediatrics Department of Sylhet M.A.G. Osmani Medical College Hospital, Sylhet Bangladesh, from July 2012 to June 2015

Methodology: Preterm [28 - 33 weeks gestation] VLBW [birth weight 1000 - 1499 g] neonates were enrolled. The study group was fed with probiotics once daily with breast milk from first feeding, and the control group with only breast milk without the addition of probiotics. Both the groups received other standard care. The primary outcome was the development of NEC [stage II and III], categorized by modified Bell's classification

Results: In 108 neonates, development of NEC was significantly lower in the study group than that of control group [1 [1.9%] vs. 6 [11.5%]; p=0.044]. Age of achievement of full oral feeding was significantly earlier in the study group than that in the control group [14.88 +/-3.15 and 18.80 +/-4.32 days; p < 0.001]. Duration of hospital stay was significantly short in the study group compared to the control group [15.82 +/-2.94 days vs. 19.57 +/-4.26 days; p < 0.001]

Conclusion: Probiotic supplementation reduces the frequency of necrotising enterocolitis in preterm neonates with very low birth weight. It is also associated with faster achievement of full oral feeding and short duration of hospital stay

Pattern of Anti-Microbial Sensitivity and Resistance against Salmonella Species in a Tertiary Hospital in Dhaka.

Background: Drug resistant Salmonella spp. continues to remain a health problem as last two decades have witnessed the emergence and spread of multidrug resistance against conventional anti-typhoid drugs. Multidrug resistant (MDR) typhoid is now a serious problem in many developing countries including Bangladesh. Objectives: To find out antimicrobial sensitivity and resistance patterns of different types of Salmonella spp. in patients with enteric fever and to find out the epidemiological strains (e.g. resistant strain, epidemic strain, MDR strain) in patients with enteric fever. Materials and Methods: This cross-sectional study was done during October 2009–November 2010 and January–December 2012 at United Hospital Limited, Dhaka. Laboratory reports of blood culture were collected from those patients who were investigated as suspected cases of enteric fever. Both the indoor and outdoor patients were enrolled in the study. Salmonella species resistant to one or more of the first line drugs were divided into resistant strain, epidemic strain and multi-drug resistant strain. Results: During the period October 2009–November 2010, total 210 subjects were enrolled. Among the participants, 122 were male and 88 were female. S. typhi were found in 133 samples whereas 76 were S. paratyphi A and only 1 S. paratyphi B. Sensitivity was found 77% for ampicillin, 91.4% for cotrimoxazole, 78.6% for chloramphenicol, 87.6% for ciprofloxacin, 96.6% for cefixime, 98% for ceftriaxone and only 22.1% for azithromycin (77.9% resistant). Total 91 (43.3%) cases were found having resistant strain, 6 (2.8%) epidemic strain and 8 (3.8%) MDR strain Salmonella spp. The sensitivity of azithromycin was analyzed among different categories of strains and revealed that 52.7% showed resistance in resistant strain, 100% in epidemic strain and 87.5% in MDR strain. During the period between January–December 2012, total 139 subjects were enrolled. Among the participants 68 were male and 71 were female with a ratio of 1:1.04. S. typhi were found in 84 cases whereas 55 were S. paratyphi A and no S. paratyphi B. Sensitivity was found 62.7% for ampicillin, 82% for cotrimoxazole, 83% for chloramphenicol, 45.2% for azithromycin, 95% for ciprofloxacin, 99.3% for cefixime and 100% for ceftriaxone. Total 55 (39.6%) cases were found having resistant strain, 3 (2.1%) epidemic strain and 17 (12.2%) MDR strain Salmonella spp. Against azithromycin 67.3% showed resistance in resistant strain, 33.3% in epidemic strain and 29.4% in MDR strain. Conclusion: The policy of empirical treatment of enteric fever needs to be rationalized and newer generation antibiotics should be restricted only for multi-resistant cases of enteric fever.

Severe haemolytic anaemia due to ingestion of naphthalene [mothball] containing coconut oil

Naphthalene, a widely used industrial and household chemical, has rarely been an agent of poisoning worldwide. Severe haemolysis from naphthalene poisoning is rare and can be a challenge to clinicians. We report a 22-year-old female, who accidentally ingested naphthalene mixed coconut oil and got admitted with recurrent vomiting, headache and passage of dark urine. Severe intravascular haemolysis with hypotension and neutrophilic leukocytosis was detected. She was treated with red blood cell transfusions, intravenous saline infusion and ascorbic acid

Health seeking behavior of stroke patients: experience from a tertiary care centre of Bangladesh

This prospective cross-sectional study was conducted to find out the health seeking behavior of stroke patients and their associates as well as to identify the barriers of service intervention. The study was done at Occupational Therapy Department of Centre for the Rehabilitation of the Paralyzed [CRP], Dhaka, Bangladesh. A purposive sampling technique and pre-tested structured questionnaire were used for data collection. Face-to-face interviews were taken from 133 respondents obtaining informed consent. Majority [74.4%] of the patients took treatment from medical graduates and rest from village doctors [10.5%] and traditional healers [15.0%]. 51.1% patients knew about stroke from hospital whereas 14.3% from Kobiraj/Homeopath and 14.3% from their own experiences. Majority [85.7%] patients knew about the importance of initial treatment and 50.4% respondents had knowledge of better treatment facilities whereas 49.6% didn't. Participants view to seek treatment after stroke was significantly high [p < 0.001] despite barriers. The barriers were lack of money [52.6%], difficulties in transportation [31.6%] and lack of interest and family support [15.8%]. The result might be useful for policy makers to take further initiatives for better management of stroke patients and to improve the quality of their life

Lab diagnosis and evaluation of fungal keratitis

This study is aimed to evaluate the usefulness of Sabouraud dextrose agar in the confirmatory diagnosis of suspected cases of fungal keratitis. Pre-designed prospective study of corneal scraping obtained after detailed slit-lamp examination and documentation from all patients seen for non-viral microbial infective keratitis. This study was conducted in the Department of Ophthalmology, JPMC, Karachi from July 2008 to June 2011. 128 cases of non-viral microbial infective keratitis. Corneal scraping of 128 patients with microbial keratitis Smears of corneal scraping were stained with Gram's Method and inoculated specimens on Sabouraud dextrose agar [SDA] and incubated for 3-4 days. In a series of suspected cases of fungal keratitis, 119/128 [75% patients] had positive results for fungus in corneal scrapings by direct microscopy using Grams staining method and culture on Sabouraud dextrose agar [SDA]. 43% males and 32% females had Candidial keratitis and 11% males and 7% females had Fusarium infection. Other samples showed presence of Gram positive cocci on smears and were negative for SDA. Fungal keratitis continue to be an important cause of ocular morbidity, since it becomes difficult to clinically diagnose and differentiate between bacterial and mycotic keratitis in complicated cases. It is better to use a standard culture medium like Sabouraud agar [SDA] when confirming ocular mycosis

Hereditary multiple exostoses causing cord compression

Hereditary multiple exostoses [HME] is an autosomal dominant skeletal disorder characterized by the presence of multiple osseous prominences. It can occur sporadically or within families [22 - 56%]. Two genes, EXT1 and EXT2 located respectively at 8q24 and 11p11-p12, have been isolated to cause HME. It can cause gross deformity of limbs and growth disturbance which is quite a common complication. Malignant transformation to chondrosarcoma can also occur. Neurological presentations are rare and usually happened due to direct compression of a peripheral nerve or nerve root or less often the spinal cord. This case is possibly the first case of HME described from Bangladesh, presented with dorsal cord compression. Decompression was done and the complaints of myelopathy were improved

Effects of mitral valve replacement with and without chordal preservation on cardiac function: early and mid-term results

Convention mitral valve [MV] replacement is known to cause deterioration in the left ventricle function, the major mechanism responsible being disruption of the annulo-papillary continuity, thus favoring preservation of the mitral subvalvular apparatus. The aim of this study was to compare the early and midterm results, in terms of cardiac mechanics and clinical outcomes, of preserving the subvalvular apparatus [partial/complete] verses resection during mitral valve replacement. This was a prospective non randomised trial. One hundred and twenty-two patients [mean age 40.36 +/- 14.27 years] admitted for MV replacement from January 2009 to September 2009 were included in the study. They were divided into 3 groups: complete excision of the subvalvular apparatus [group 1=32]; preservation of the posterior leaflet [group 2=54] and total chordal preservation [group 3=36]. Echocardiography was done preoperatively, at discharge, and at 6 months follow-up. The preservation groups 2, 3 revealed marked improvements with respect to the End-diestolic Volume [EDV] and End-Systolic Volume [ESV] as compared to the non-preservation group 1 at discharge from hospital. At follow-up, the preservation groups showed improved EDV and ESV in contrast to the non-preservation group, where the ventricular volumes had a declining pattern. Ejection fraction remained below the baseline preoperative level in all three groups at discharge from hospital. In the follow-up, chordal preservation groups showed significant improvements in the ejection fraction as compared to the resection group. An interesting finding was that of PA pressures and LA size between the groups. It was significantly improved in the preservation groups as compared to the resection group. At follow-up, 43.5% of patients in group 1 were in AF compared with 27.5% in group 2 and 21.4% in group 3. More patients in group 1 were in NYHA functional class III or IV at follow-up: 30.4% versus 7.5% and 7.1% respectively. Preservation of the mitral subvalvular apparatus resulted in a greater decrease of ventricular dimensions at discharge which was maintained at follow-up; complete resection resulted in ventricular dilatation at follow-up. Furthermore, the ejection fraction improved in the preservation groups compared to the complete resection group which showed a decline at follow-up

Takayasu's arteritis in association with tuberculosis in a young woman

A possible relationship between Takayasu's arteritis [TA] and Tuberculosis [TB] has been proposed. Both diseases present similar chronic inflammatory lesions and occasionally granulomas on the arterial walls. We report a case of simultaneous presence of Takayasu's arteritis and tuberculosis in a 20 year old lady. She presented with fever, pain and intermittent claudication of all four limbs and easy fatigability for two months. We found an enlarged lymph node in left axillary region. All the peripheral pulses were absent and measurement of blood pressure was not possible. Her ESR was 62 mm in 1[st] hour and C reactive protein was 12mg/L. Duplex vascular USG revealed significant narrowing of both subclavian arteries and descending abdominal aorta. Histopathology of left axillary lymph node showed caseating tubercles suggestive of granulamatous tuberculous lymphadenitis

Pathophysiology and appropriate management of acute asthma

To study pathophysiology and guidelines for the diagnosis and management of acute asthma. Prospective study of management of known cases of acute asthma for a period of 3 months. Department of Chest Medicine, Jinnah Post Graduate Medical Centre, Karachi. 300 cases of known acute asthma were included. Management was initiated with saturated oxygen and Salbutamol nebulizer. Subsequent treatment was added if sign and symptom did not regress. Hydrocortisone [after 15 minutes], Ipratropium [after 30 minutes] and Aminophylline [after 1 hour]. 190/250 [76%] males and 40/50 [80%] females, total 210/300 [70%] patients became stable after initial treatment. 3 0/60 [50%] males and 10/10 [100%] female, total 40/70 [57%] were stable after Hydrocortisone was added. 20/30 [66%] male patient became asymptomatic after treatment with Ipratropium. 10 patients became asymptomatic after 1 hour of treatment with Arninophylline. No adverse effects were observed. Acute asthma is highly variable clinical condition therefore the level of control must be monitored on a periodic basis to determine whether therapy should be maintained or adjusted. It includes symptomatic relief as well as arrest of pathophysiolgical mechanism of asthma

Comparison of Losartan and Amlodipine in hypertensive type-II diabetic patients

The present study assesses whether Losartan and Amlodipine, alone or in combination, prevent microalbuminuria in hypertensive type II diabetic patients. Department of pharmacology, Basic Medical Sciences Institute [BMSI], Jinnah Post Graduate Medical Centre, Karachi from June 2006 to January 2007. In this study 60 hypertensive diabetic patients were divided into 3 groups having 20 each. Group 'N' patients were kept as control, group 'A' patients were treated with Losartan, 50 mg once daily, group 'B' with Amlodipine 10 mg once daily and Group 'C' patients were given a combination of both the drugs i.e. tab losartan and tab amlodipine. Tablet Glibenclamide 5 mg was given according to the glicemic control. Although all the three groups showed a comparable effect in lowering both the systolic and diastolic blood pressure but the effect on proteinuria was variable. Losartan treated patients in Group 'A' shows marked reduction of proteinuria but non-significant change in creatinine clearance. In Group 'B' the patients who were treated with Amlodipine showed significant reduction in creatinine clearance, but non-significant change in proteinuria and Group 'C' patients showed countable reduction in proteinuria but a non-significant increase was observed in creatinine clearance. The results suggest that in hypertensive type II diabetic patients Losartan is worthwhile reducing both systolic and diastolic blood pressure and proteinuria significantly

Proteinuria a target for reno-protection in hypertensive patients with type 2 diabetic nephropathy

To study the response of angiotensin II [ATI] receptor antagonist ARE [Losartan] as monotherapy in diagnosed hypertensive, non-insulin dependent diabetes mellitus [NIDDM] patients with nephropathy [albuminuria]. Department of pharmacology, Basic Medical Sciences Institute [BMSI], Jinnah Post Graduate Medical Centre [JPMC], Karachi. This study is a randomized trial used to examine the effects of ARB [Losartan] on the renal outcome of 20 diagnosed cases of hypertensive noninsulin dependent diabetes [NIDDM] with base line proteinuria. 20 normal subjects were also selected as control group. Baseline albuminuria is almost linearly related to renal outcome, and is the strongest predictor among all measured well-known baseline risk parameters. The changes in albuminuria in the first 3 months of therapy are roughly linearly related to the degree of long-term renal protection. ARB [Losartan] showed 58% [P<0.001] reduction in proteinuria, 4.7% reduction in serum urea, 7.06% [P<0.01] reduction in serum creatinine, creatinine clearance by 4.72%, serum potassium increases by 5.07% [P<0.01] and FBS reduced by 33.29% I [P<0.001]. Baseline to final change for SBP as well as for, DBP was significantly reduced i.e.19.20% [P<0.001] and 16.16%[p<0.001] respectively. In conclusion, albuminuria should be considered a risk marker for progressive loss of renal function in hypertensive type 2 diabetic patients with nephropathy, as well as a target for therapy. Reduction of residual albuminuria to the lowest achievable level should be viewed as a goal for future renoprotective treatments

Fatal outcome of Stevens Johnson syndrome [SJS] associated with azithromycin

Most of the medical practitioner's are under the impression that Stevens Johnson Syndrome [SJS] is art uncommon life threatening drug reaction. In fact it is not as rare a disorder as we are led to believe. Stevens Johnson Foundation claims that they come to know of 15 new cases a week and that is only people with internet access. In Bangladesh the real burden is never estimated as information on monitoring and reporting of adverse drug reactions are not available. Stevens Johnson Syndrome is an immune complex mediated idiosyncratic systemic hypersensitivity reaction that may be triggered by medications, viral, bacterial, fungal infection and malignancies. Recent reports link SJS to the use of drugs rather then other etiologies. Here we report a case of SJS with fatal outcome which is probably the first case encountered in Bangladesh induced by Azithromycin

Early effects of coronary artery bypass grafting on left ventricular regional wall motion abnormalities

To determine the early effects of Coronary Artery Bypass Grafting [CABG] on regional left ventricular wall motion abnormality in patients undergoing surgery for proven Coronary Artery Disease [CAD]. Quasi-experimental study. Department of Cardiac Surgery, National Institute of Cardiovascular Diseases, Karachi. from October 2005 to April 2006. Patients and Methods: A total of a 100 adult patients who underwent elective CABG were selected. Pre-operative echocardiography was done to note if segmental left ventricular wall motion at basal, mid and apical levels were normal, hypokinetic, akinetic, dyskinetic, or aneurysmal. Postoperative echocardiography was done between 4th and 6th day and change in left ventricular segmental wall motion was noted. Seventy-five patients [n=75] were included in the analysis. These results showed that effect of CABG on anterior segmental wall motion abnormalities was insignificant [p=.609], the effect on the anterior IVS showed deterioration of segmental wall motion and this effect was significant [p=.001], effect is insignificant on anteriolateral segmental wall motion abnormalities [p=.078], normal pre-operative segments in posterior wall showed stability [p=.664] while disappearance of dyskinetic, reduction in akinetic segments postoperatively and inferior wall motion have same effects as of posterior wall. Comparison of pre-operative and postoperative echocardiographic data revealed early improvement in segmental wall motion of posterior and inferior wall, while alterations in segmental wall motion of anterior, anterior-lateral and septal wall. Myocardial revascularization by CABG improves early left ventricular regional wall motion abnormalities where SVG is used as conduit for revascularization whereas no significant improvement occurs in early segmental wall motion in areas revascularized by LIMA