Idiopathic Normal Pressure Hydrocephalus: Surgical Outcome of Endoscopic Third Ventriculostomy Comparing VP Shunt

Background:Normal-pressure hydrocephalus (NPH) affects the older people and the presentations aregait disturbance, incontinenceand dementia. The reason is still unknown and there is increased CSF volume causing pressure to the periventricular brain causing the symptoms where there is no evidence of absorption failure or obstruction of the CSF pathway. Aims: The main objective of this study is to compare the surgical outcome of endoscopic third ventriculostomy (ETV) and VP shunt (VPS) in NPH.Methodology: Atotal of 24 patients were included in the study where 12 patients underwent ETV and 12 patients VPS. Patients having a definite cause of hydrocephalus and multipleco-morbid diseases were excluded from the study. Various Scoring systems were studied to see the efficiency of ETV. Results:About 60% of patients were successfully recovered. 40% needed to revision surgery either VP shunt or LP shunt. Some scales showed higher effieciency of ETV.Conclusion: ETV in NPH is a safe and effective procedure. Whether the CSF absorption is hampered at arachnoid granulation is doubtful for failure cases. ETV is a short procedure with a good success rate in selected patients

Off Pump CABG along with Resection of Giant Thymoma : A Case Report.

Coronary artery disease is the most common form of heart disease and the single most important cause of premature death world-wide. Thymomas are anterior mediastinal neoplasms, characterized by epithelial cells and lymphocytes. Although they are often encapsulated and well differentiated tumors, they can show local invasion, pleural invasion or extrathoracic metastasis. In this article, we report the case of a rare patient who underwent thymectomy along with off-pump coronary artery bypass graft surgery.

Clinico-pathological study in large posterior fossa midline tumors.

This cross sectional analytic study was carried out among the admitted patients of the department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Dhaka during the period of 1st July 2002 to 31st December 2004. The age ranged from 2.5 years to 70 years. The size of all posterior fossa tumors at presentation were more than 3 cm and the mean size of posterior fossa tumor was 4.38 cm. 62% of posterior fossa mid-line tumors were mixed density in NECT (non-contrast CT).Regarding enhancement characteristics, mild-moderate enhancement and marked heterogeneous enhancement was equally distributed 46% followed by marked homogeneous enhancement only 08%.. The calcification was present only in 07 (14%) patients and most of them were ependymoma. Histopathologically, medulloblastoma was the common variety (32%). The CT scan diagnostic modality sensitivity, accuracy and positive predictive value were 100%, 84.78% and 84.78% respectively but in MRI diagnostic modality 100%, 91.30% and 91.30% respectively.

Mitral stenosis in a girl of five years.

Mitral stenosis(MS) detected below the age of 20 years is called juvenile mitral stenosis (JMS). JMS constitute 25-40 % of all cases of isolated mitral stenosis, though overall incidence of rheumatic fever and rheumatic heart disease (RHD) within mixed population is 7.5- 7.8 per thousand. The patient was 5 years old girl hailing from Modhupur, Tangail got herself admitted into CCU Mymensingh Medical College Hospital with the complaints of low grade fever, shortness of breath and also associated with failure to thrive. She was ill looking, mildly anaemic. Precordial examination revealed apex beat was in the left 5th intercostals space, tapping in nature, palpable P(2). There was left parasternal heave. 1st heart sound loud, pulmonary component of the 2nd heart sound was accentuated, opening snap with mid diastolic murmur with pre systolic accentuation. Routine blood examination reveals leucocytosis with raised ESR. C-reactive protein (CRP) and ASO titre were significantly raised. X-ray chest P/A view showing the features of mitral stenosis. Echocardiography showing MS (moderate) with pulmonary hypertension. She was treated with antibiotics and other relevant drugs and discharge with an advice for follow up and take preparation for cardiac intervention.

Neurophysiology in clinical practice.

Clinical neurophysiology is concerned with the recording of generation and propagation of electrical potentials of nerve and muscle cells. It can provide important information about brain and neuromuscular disorders. Electro encephalogram (EEG), Evoked potentials (EP), Nerve conduction study (NCS) and electromyogram (EMG) are the four main techniques used in clinical neurophysiology. EEG reflects the electrical activity arising from the cerebral cortex. Evoked Potentials are measurements of classic stimulus response. VEP, SSEP and BSAEP are most useful in diagnosing Multiple Sclerosis, Plexus lesions and 8(th) cranial nerve tumor, CP angle tumor respectively. Nerve conduction studies are the measurement of velocity of nerve impulse. It gives information about the lesion of a myelinated nerve. Electromyogram gives information about the integrity of innervations, condition of neuromuscular junctions and also condition of the muscle fiber itself.

Studies on clinical pattern of glomerulonephritis.

A prospective study of primary glomerulonephritis covering two and half years period was done at Dhaka Medical College Hospital & IPGMR, Dhaka from June 90 to July 92. A total of 100 cases were included in this study. All of the patients were of 13 years and above, clinically diagnosed, and by laboratory investigations, the diagnoses were established. In this study, we have tried to find out age incidence, sex ratio, possible aetiological factors, common clinical presentation, biochemical parameters and histological typing of primary glomerulonephritis.

Hairy cell leukaemia with advanced treatment - a case report.

A case of hairy cell leukaemia (HCL), a rare leukaemia, is reported here. The patient was presented with high grade continuous fever with left upper abdominal discomfort for 6 days. He was moderately anaemic, had no peripheral lymphadenopathy with mild hepatosplenomegaly. He was anaemic (Hb-7.8 gm/dl), total leukocyte count was 20 x 109/L. Peripheral blood film showed lymphocytosis (92%) with neutropenia (8%) and absolute neutophil count (ANC) was 1 x 109/L. On review, 88% of the peripheral cells had peripheral hairy projections resembling hairy cell (HC). Bone marrow examination was consistent with HCL (morrow hairy cell = 52%) including marker studies. Tartrate resistant acid phosphatase test (TRAP) was also positive. He had opportunistic mycobecterial infection giving a positive bronchial lavage for acid fast bacilli. After controlling the infection he was advised a single dose chemotherapy of 2-chlorodeoxyadenosine (2-CDA). After that he was in partial remission and after 25 months clinical and pathological relapses occurred and a second dose of 2-CDA was given and the patient went into complete remission.

A case report on Wilson's disease.

A case of Wilson's disease, a rare autosomal recessive disorder of copper metabolism is reported here. The patient was presented with the difficulty in speech and writing for 4 years and also on walking for 1 year. He also noticed difficulty to perform any work by hands for 6 months. He had splenomegaly and bilateral gynaecomastia. His speech was low volume slurred and monotonous, muscle tone was mildly increased, and gait was limping. Slit lamp examination of eye revealed bilateral Kayser-Fleischer ring with normal visual acuity. Investigations revealed low serum albumin(26 gram/L), increased alanine trans-aminase ( A.L.T=57 U/L). Ultrasonogram of hepatobiliary system revealed coarse hepatic tissue echotexture with splenomegaly. Liver scan showed slightly nonuniform radiotracer distribution in the liver, there was slight increased bony uptake. Serum caeruloplasmin level was 11.51 mg/dl. 24 hours urinary copper excretion was 150 microgram per day. Liver biopsy revealed cirrhotic change. Now he was advised for taking copper chelating agent (penicillamine) in a dose of 1 gram/day.

A case of acromegaly.

A fifty years old woman hailing from Purbadhala of Netrokona district complaining of gradual enlargement of hands, feet, nose and other acral parts of the body for about last eight years. She noticed coarsening of the skin and gradual protrusion of her lower jaw. She complained of headache, vertigo, frequent passage of urine, increased thirst, weight loss and fatiguability. She was found hypertensive having blood pressure 200/110 mm of Hg. Her appearance was coarse with rough skin. There were enlargement of hands, feet, nose, lower jaw with prognathism and enlargement of other acral parts. Investigations revealed high plasma glucose level, both fasting and 2 hrs. after glucose, high level of growth hormone, failure of suppression of growth hormone during OGTT. Thyroid function tests of the patient were found normal with increased heel pad size and enlarged sella turcica in all diameters. She was diagnosed as a case of acromegaly due to growth hormone hypersecretion.

Risk factors & clinical presentations--a study of eighty-five hospital admitted stroke cases.

Stroke is the commonest neurological cause of morbidity and mortality. Changes in risk factors may influence stroke incidence. Definitive diagnosis of the type of stroke is necessary for management and it has a strong impact on stroke outcome. A total of eighty-five consecutive stroke patients irrespective of age and sex admitted during the period of August 2000 to June 2001 were studied. They were asked about occupation, area of habitat, smoking habit, family history of ischaemic heart disease and/or stroke, any febrile illness, recent history of productive cough, dysuria and diarrhoea. They were searched for hypertension, diabetes mellitus, ischaemic heart disease, valvular heart disease and dislipidaemia. In every patient complete blood count, urine examination, fasting blood glucose and serum lipids, ECG, x-ray chest were performed. CT scan of brain was performed in 68 cases. Male was found 81.18% of cases with age 62.54 +/- 13.08 (m +/- SD) years. Female were 18.82% of cases with age 58.81 +/- 12.77 (m +/- SD). 75.29% of patients were belongs to middle class family. 51.76% of patients came from rural area and 48.24% of patients came from urban area. 78.82% of patients were hypertensive. Infection was associated with 37.65% of cases. Hemiplegia was commonest presentation (88.24%). Though altered consciousness was found more in haemorrhagic stroke (54.84%) but it was not significantly. High from ischaemic cases (p > 0.10) Male suffer more from stroke. Hypertension is the commonest risk factor. Infection is a common association of stroke. Altered consciousness is not a reliable guide to differentiate between ischaemic and haemorrhagic stroke is hospitalized cases.

Immunofluorescent microscopic findings in glomerulonephritis.

Histopathology and direct immunofluorescence (DIF) microscopy were performed on renal biopsy specimens of 60 clinically suspected cases of glomerulonephritis (GN). Histopathological diagnosis was obtained in 44 (73.3%) cases and immune complex deposition were detected by DIF in 28 (46.7%) cases. Immune complex deposition were observed in all cases of membranous GN, systemic lupus erythematosus (SLE), and rapidly progressive GN (RPGN), most of the cases of diffuse proliferative GN (2 out of 3) mesangioproliferative GN (12 out of 15) and focal glomeruloscleros is (3 out of 5 cases). No immune deposits were observed in minimal change GN, chronic GN, and diabetic nephropathy. Histopathological diagnosis was not obtained in 16 (26.7%) cases, 3 (5%) of which showed immune complex deposition by DIF. Anti-GBM nephritis was demonstrated in one (3.6%) case, the rest were immune complex nephritis.

Comparative studies on IFAT, ELISA & DAT for serodiagnosis of visceral leishmaniasis in Bangladesh.

The purpose of the study was to estimate the specificity and sensitivity of different serological methods for the diagnosis of visceral leishmaniasis in Bangladesh. Blood samples from 155 suspected kala-azar patients together with 80 sick subjects and 50 healthy subjects from the endemic areas were collected. Out of the 155 suspected kala-azar patients, bone marrow were collected from 126 patients. All bone marrow samples were examined by direct microscopy. 92 bone marrow samples were also examined by culture method. Blood samples were examined by various serological tests. Out of 126 marrow samples, LD bodies were present by microscopy in 77 (61.1%) cases and out of 92 marrow samples, cultures for LD bodies were positive in 33 (35.9%) cases. All the three serological tests (IFAT, ELISA & DAT) were positive in all parasitologically positive kala-azar patients. They were also positive in seven (15.5%) out of 45 parasitologically negative cases and 10 (34.4%) out of remaining 29 cases in whom bone marrow samples were not available. Thus the serological tests proved to be simple, non-invasive, highly sensitive and specific methods for the diagnosis of visceral leishmaniasis. DAT is the simplest of these serological tests, although these tests did not differ in sensitivity and specificity.

Role of a large plasmid in mediation of multiple drug resistance in Salmonella typhi and paratyphi A in Bangladesh.

From 405 patients of suspected typhoid fever, 94 Salmonella typhi and 17 Salmonella paratyphi A, were isolated from blood and/or stool at the Institute of Postgraduate Medicine and Research, Dhaka during March 1992 to February 1993. Forty seven percent of the isolates were resistant to multiple drugs which included amoxicillin, ampicillin, chloramphenicol and co-trimoxazole. A large plasmid of 140 MDa was isolated from 73% of multidrug resistant (MDR) strains. However, no plasmid was isolated from any of the strains sensitive to above mentioned antibiotics. Majority of MDR Salmonella transferred resistance to E. coli K-12 (Lac+, F-, NxR.) by conjugation method. The transconjugants were similarly resistant to multiple drugs. All Salmonella were sensitive to ciprofloxacin and ceftriaxone.

Study on Mycobacterium tuberculosis: the primary drug resistance pattern.

The study was carried out to investigate the primary drug resistance pattern of tubercle bacilli isolated from the pulmonary tuberculosis patient attended in Shyamoli TB clinic, Dhaka. Sputum from 961 suspected tuberculous patients were randomly collected and stained by Ziehl-Neelsen (Z.N) stain. 135 were microscopically positive for Acid Fast Bacilli (AFB). Among them 30 patients were excluded from the study as they received antitubercular treatment before. So only 105 microscopically positive cases were cultured on Lowenstein-Jensen (L-J) media and 100 showed pure growth and rest 5 were contaminated with fungus. These 100 cases were studied on 4 antitubercular drugs. Out of these 100 isolates, 91 were M. tuberculosis and rest 9 in the nonchromogen group of mycobacteria other than tuberculosis (MOTT) species. Among 91 M. tuberculosis species, 89 (97.80%) to Isoniazid (INH), 73 (80.21%) to Rifampicin (RMP) and 91 (100%) to Streptomycin (SM) and Ethambutol (ETHM) were sensitive. Of the 9 MOTT species, 4 (44.44%) to SM, 7 (77.78%) to ETHM were sensitive and all (100%) were resistant to INH and RMP. Among the 100 isolates, 27 (18 M. tuberculosis and 9 MOTT) were resistant to 4 drugs either single or in combination. Of the 18 (66.67%) M. tuberculosis species, 16 (59.26%) to RMP, and 2 (7.41%) to RMP and INH were resistant. Of the 9 (33.33%) MOTT species, 4 (14.81%) to RMP and INH, 3 (11.11%) to RMP, INH and SM and 2 (7.41%) to RMP, INH, SM and ETHM were resistant.

Studies on the bacterial flora of fish which are potential pathogens for human. Virulence factors of potential human pathogen isolated.

Tests for various virulence factors, such as production of haemolysin on sheep blood agar plate, cytotoxin on HeLa cell line and enterotoxin in GM-1 ELISA and suckling mouse assay model, were done among the various strains of Aeromonas spp., Vibrio spp., Plesiomonas shigelloides and Esch. coli isolated from fresh water fish samples. Invasive properties of the isolates were also seen by using Sereny test. Haemolysin production was observed in 85.7% of Aeromonas, all (100%) of Vibrios, 13.3% of Esch. coli and none (0%) of P. shigelloides strains. Cytotoxin production was demonstrated in 60.8% of Aeromonas, 38.4% of Vibrios and none (0%) of P. shigelloides and Esch. coli strains. About 8% of Vibrio spp., were found positive for LT in GM-1 ELISA method whereas, none of the Aeromonas spp., Plesiomonas and Esch. coli. strains were found positive for LT and ST in GM-1 ELISA. By suckling mouse assay model 43.4% strains of Aeromonas were found positive for enterotoxin production whereas, strains of Vibrio spp., Plesiomonas and Esch. coli yielded negative results. Sereny test for invasive property was found negative in all the strains tested. The isolates from fish possess various virulence factors which contributes for pathogenicity in order to cause various diseases to susceptible individual.

Serum immunoglobulin profiles of septicemic versus healthy neonates.

We studied 125 clinically suspected septicemic neonates (Patient) aged from 1 to 28 days and 25 healthy neonates (control) of comparable age and sexes. Cultures of blood were done and serum immunoglobulins (IgG, IgA) were estimated in all the subjects. Blood cultures were found positive in 45 (36%) patients. Preterm patients showed significantly higher number of positive blood cultures as compared to term patients. The mean serum IgG level in patients was found significantly lower than that of the controls. The serum IgG levels were also found significantly lower in 75 preterm as compared to 50 term, and in 45 blood culture positive patients as compared to 80 blood culture negative patients. On the other hand, the mean serum IgM level in patients was found significantly higher as compared to controls. Similarly, serum IgM levels were found higher in preterm patients as compared to term patients and in blood culture positive patients as compared to blood culture negative patients. No significant difference of mean serum IgA level was found among the subjects. It is evident from our study, that blood culture positive patients were mostly preterm, in whom transplacental passage of IgG is insufficient and due to low IgG level, preterm baby cannot counteract bacterial invasion and as such, suffer from septicemia more frequently. Septicemic neonates as a rule showed higher level of serum IgM due to synthesis by themselves in primary response to infection.

Studies on the anaerobic (bacterial) vaginosis among the Bangladeshi women of reproductive age group.

Vaginal swab from 190 patients aged between 15 to 45 years with the complaint of excessive and foul smelling vaginal discharge and 50 healthy controls of comparable age were studied. Different diagnostic techniques used for the detection of G.vaginalis were compared. Antibiogram of isolated G.vaginalis was also performed to determine the drug sensitivity pattern. G. vaginalis were isolated from 74 patients (38.9%) and from 6 controls (12%). The rate of isolation of G. vaginalis in the vaginal swabs of patients is significantly higher (p < 0.001) as compared to controls. Vaginal flora in 91% of G. vaginalis positive patients were Gardnerella morphotype and clue cells were found in vaginal discharge in 85% of these cases. In contrast, vaginal flora of 92% control group were Lactobacilli morphotype N and no clue cell was detected. No pus cell was observed in the vaginal discharge of 66 (89.2%) of 74 patients infected with G. vaginalis. Amine test was positive in 81% G. vaginalis positive patients. The test was negative in all the control cases. Significance of these findings were discussed in detail.

Studies on the bacterial flora of fish which are potential pathogens for human. Isolation of various potential human pathogenic organisms from different parts of fish and their significance in initiating human diseases.

Freshwater fish of different categories, collected from market of Dhaka City of Bangladesh, were studied for the bacterial flora. Potential human pathogens were isolated from about eighty-five percent of the fish studied. Organisms isolated were Aeromonas spp., (69.2%), Vibrio spp., (42.3%), Plesiomonas shigelloides (35.9%) and Escherichia coli (16.7%). The high association of potential human pathogens among the freshwater fish suggest that if fish are handled improperly or if consumed undercooked or uncooked may cause various diseases to susceptible individual.

Antigen profile of Helicobacter pylori strains isolated from peptic ulcer patients in Dhaka, Bangladesh.

The whole-cell-extract and the acid-extract preparations of Helicobacter pylori strains isolated from peptic ulcer patients and the NCTC 11638 control strain were studied to compare their antigen profiles. Besides, the anti-H. pylori-antibody profile in serum from H. pylori-infected peptic ulcer patients were also studied to define the antigen stimulating specific anti-H. pylori-antibody response in the infected patients. The whole-cell extract (WCE) and the acid-extract (AE) preparations showed a general antigenic homogeneity among the H. pylori strains isolated from the patients and the NCTC 11638 control strain. A humoral immune response against the infecting organism was observed and three antigenic bands of approximate molecular masses of 61 kDa, 58 kDa and 24 kDa were recognized by all the tested sera. Those bands were found to be unique for H. pylori and did not show any cross reaction with the Campylobacter jejuni antigenic bands. This makes them a candidate for the specific antigens required to develop a specific serological diagnostic test. Further purification and characterization of the protein bands may be carried out to define their probable diagnostic or immuno-pathogenic role.

The transformation in vitro of peripheral lymphocytes of malnourished children.

Children with protein energy malnutrition showed high deranged cellular immunity as evidenced by impairment of lymphocyte transformation after stimulation by phytohaemagglutination (PHA). The proliferative response (PR) to PHA measured by estimating incorporation of tritiated thymidine into newly synthesized DNA. In-vitro proliferative response to PHA was used as a marker for studying the functional characteristics of T lymphocytes of children with different categories of malnutrition. PHA response of peripheral blood lymphocytes obtained from different categories of severely malnourished children were significantly low compared to healthy control children (P < 0.01). The results indicate that cell mediated immunity was grossly depressed in severe malnutrition.