Diagnostic efficacy of Aldehyde test in late cases of Kala-azar.

This case control study was carried out in the Paediatric wards of Mymensingh Medical College Hospital for a period of one year from April 2002 to March 2003 to determine the sensitivity, specificity and predictive values of Aldehyde test in the diagnosis of Kala-azar. A total of seventy five febrile cases of Kala-azar from Paediatric wards were enrolled in the study and Seventy five controls having splenomegaly with or without fever were also included from the same source. Aldehyde test was done in both cases and controls. Diagnosis of Kala-azar was confirmed by demonstration of Leish-man-Don-o-van body (LD) in bone marrow or splenic aspirates. Out of 75 parasitologically proven cases of Kala-azar, AT was positive in 56 cases. The sensitivity irrespective of duration of illness was 74.6%. We found sensitivity of AT increases with the duration of illness where AT was sensitive in 34.7% cases having fever for less than 3 months, 90.90% with fever for 3 months to less than 6 months and 100% with fever for 6 months or more in duration. Specificity of AT was calculated as 96% with positive and negative predictive values of 94.9% and 79.1% respectively. So AT is a very sensitive and specific test with high positive and negative predictive values. Considering the cost, availability, simplicity, sensitivity, and specificity we would recommend the Aldehyde test as an important diagnostic tool for field diagnosis of Kala-azar especially after three months of febrile illness.

Efficacy of azithromycin in the treatment of childhood typhoid Fever.

An intervention study was carried out in Paediatric wards for a period of one year from January 2003 to December 2003 to determine the efficacy and safety of azithromycin in the treatment of uncomplicated childhood typhoid fever. A total of 50 cases were enrolled in the study. The inclusion criteria of the cases were: documented fever for more than 7 days plus two or more of the following clinical features: toxic appearance, abdominal tenderness, hepatomegaly, splenomegaly, diarrhoea, constipation and coated tongue plus positive Widal test and/or blood culture positivity. Patients who had complication like gastrointestinal tract (GIT) haemorrhage; intestinal perforation and/or shock were excluded from the study. Data were collected in a structured questionnaire. Azithromycin was given at a dose of 10mg/kg /day for a period of 07 days. The time to defervescence was 3.82+/-1.49 days. The minimum defervescence time was 02 days and maximum was 07 days. Clinical cure rate was 94%. No serious adverse effect was noted related to azithromycin therapy except nausea, vomiting, and jaundice. Prior treatment with antibiotics did not affect defervescence time (P>0.05). Pre-treatment febrile period has got positive and linear correlation with clinical response (r = +0.593). It was found that once daily administration of oral azithromycin for seven days in the treatment of uncomplicated typhoid fever was effective and reasonably safe.

Knowledge and attitude of clinical students on problem based learning.

An intervention study was carried out in Mymensingh Medical College between December 2002 to November 2003 to determine knowledge and attitude of clinical students on problem based learning (PBL) before and after exposure to a PBL course. This is an intervention study. A total of 17 health problems were discussed in the integrated small group tutorials in the departments of Pediatrics and Medicine. Two problems were discussed in a week & each PBL class was lasted for 2 hours. Pretest was done before exposure of the students to the PBL course using self-administered questionnaire and posttest was done immediately after finishing the PBL course. Significance of proportions was calculated by Chi-square (X2) test. PBL course increased knowledge of clinical students on PBL significantly (P < 0.001). Increased number of clinical students also stated that PBL is effective in problem solving (70% before and 97% after the PBL course), and the difference is highly significant (P < 0.001). Increased number of students (about 72% before & 83% after the PBL course) stated that PBL is better than traditional ward teaching (P < 0.01). Majority of our students (about 61% before & 88 % after the PBL course) stated that PBL enhances self-directed learning (P < 0.005). A good number of students (about 63% before & 81% after PBL course) recommended PBL to be included in Undergraduate Medical Curriculum (P < 0.05). It can be concluded that exposure of students to PBL course can improve knowledge, attitude & practice of clinical students significantly. Regular exposure (at least twice a year) of clinical students to symposium centered on PBL is recommended

Knowledge and attitude of faculty members on problem based learning.

An intervention study was carried out in Mymensingh Medical College during the second week of January, 2003 to compare knowledge and attitude of the faculty members of Mymensingh Medical College on PBL before and after exposure to a symposium. Pretest was done among 48 faculty members before and 45 faculty members after exposure to the symposium using a self-administered questionnaire. Before the symposium about 17% of faculty members had a sound knowledge on PBL, the figure rose significantly to about 61% after exposure to the symposium (P < 0.001). About 73 % of faculty members felt that PBL is effective in problem solving after exposure to the symposium, as compared to about 60% who felt that PBL is effective in problem solving before the symposium (P < 0.01). About 69% of faculty members stated that PBL is better than traditional ward teaching after exposure to the symposium, as compared to 51.1% who stated that PBL is better than traditional ward teaching before the symposium (P < 0.001). About 69% of faculty members stated that PBL enhances self-directed learning after exposure to the symposium, as compared to about 52% who stated PBL enhances self-directed learning before the symposium(P <0.005). About 64% of faculty members affirmed that they will welcome PBL in clinical teaching after exposure to the symposium, as compared to 62.5% of faculty members who would welcome PBL in clinical teaching before the symposium (P < 0.01). A total of 59% of faculty members asserted that they will recommend PBL to be included in Undergraduate Medical Curriculum after exposure to the symposium, as compared to 60.3% who would recommend PBL in Undergraduate Medical Curriculum before the symposium. About 51 % of faculty members agreed that practicing PBL will help students after graduation to continue independent learning before the symposium, as compared to 60% who agreed that practicing PBL will help students after graduation after exposure to the symposium (P < 0.05). It can be concluded that exposure to a symposium centered on PBL can improve knowledge and attitude of faculty members on PBL positively & significantly.

Problem based learning.

PBL, an educational format, stimulates active and life long learning. PBL improves the motivation of students, stimulates integration of disciplines, small group learning; improves clinical reasoning, problem-solving and decision making. It has been introduced increasingly in the curricula of a number of countries in South-East Asia, viz. Thailand, India, Myanmar and Nepal. We feel that the seed of PBL should be sown in the soil of the Undergraduate Medical Curriculum in Bangladesh urgently.

Updating of hereditary haemoglobin disorders.

Hereditary haemoglobin disorders (E-beta Thalassaemia & Thalassaemia) are inherited as recessive disorders so that the heterozygote subjects are generally healthy. They commonly present with progressive pallor, thalassaemic facies, splenohepatomegaly & growth retardation. Diagnosis of carriers & patients are usually confirmed by haemoglobin electrophoresis. Transfusion-chelation therapy is usually employed for their treatment. Allogenic bone marrow transplantation is the only definite cure. Gene therapy remains to be the major challenging goal of future curative therapy. During the last 10 years wit medical advances, the number of pregnancies in thalassaemia is increasing. Normal pregnancy can be maintained with regular packed blood cells transfusion given carefully. In Bangladesh, HHD can be prevented by I. carrier identification and marriage counseling, II. passing and enforcing laws against marriage between two carriers, III. introducing thalassaemia in school curriculum and IV. creating public awareness.

Prognostic factors relating to outcome of severe malaria among children in Bangladesh.

This study was done in the Paediatric in-patient department of Chittagong Medical College Hospital (CMCH), Chittagong, Bangladesh to identify and quantify the prognostic factors associated with increased mortality in severe malaria (SM) cases. All the patients with parasitologically confirmed clinical syndromes of SM, admitted between June 1997 and May 1998, were included. A total of 53 consecutive cases were studied. Cerebral malaria (CM) was the commonest type of SM, observed in 36(68%) cases, second commonest type was severe anaemia 13(25%). More than one type of severe manifestations were present in 23(44%) cases. Overall case fatality rate (CFR) was 17% and it was 30% among those who had multi-organ manifestations. Important poor prognostic clinical variables were Blantrye coma score (BCS) score of 0 and 1 on day 1 (OR = 7.78) and day 2(OR = 40.0), multi-organ manifestations (OR = 6.8) and in-hospital complications (OR = 5.18). Important poor prognostic laboratory variables were day 2 parasite count > 50,000/cmm (OR = 5.5), blood glucose < 2.2 mmol/l (OR = 21.5) and raised CSF protein > 50 mg/dl (OR = 7.0). It can be concluded that certain clinical variables e.g. low BCS on day 1 & 2, multi-organ manifestations, in-hospital complications; and laboratory variables e.g. high parasite count, low blood glucose level, raised CSF protein levels are associated with increased mortality rate in SM cases.

Vitamin A deficiency in children with acute diarrhoea: a community-based study in Bangladesh.

The prevalences of nightblindness and xerophthalmia were assessed in 400 children, aged 6-59 months, with acute diarrhoea in a rural community in Bangladesh. The prevalences of nightblindness, conjunctival xerosis, and Bitot's spot were 7.8%, 9.5%, and 2.7% respectively. Fifty-two percent of the children who complained of nightblindness had ocular signs of vitamin A deficiency compared to 9% of those without nightblindness (p < 0.000). The nightblindness was significantly higher among the male children, aged 24-59 months, who were dysenteric and undernourished, did not consume vitamin A-containing foods daily, and were not breastfed. The coverage of periodic administration of vitamin A capsule was inversely related to the prevalence of nightblindness. This finding was determined by logistic regression analysis of data indicating that a combination of male sex, history of dysentery, absence of periodic administration of vitamin A treatment, and daily intake of vitamin A-containing foods gave the best-fitted model with an overall prediction of 92.5% of being nightblind. The findings of the study suggest that mothers should be educated to observe their diarrhoeal children about development of nightblindness and to seek treatment for it. The locally-relevant nutrition education should also be offered to them.

Mothers' skills in preparing oral rehydration salt solution.

This was a community based thirty cluster survey, carried out in rural Chittagong district, Bangladesh during 1996 with the objective to assess the skill of mothers in preparing packet ORS solution. A total of 420 mothers whose children had been suffering from acute diarrhoea were investigated. There were 377 (89.8%) mothers who demonstrated the preparation of ORS and 43 (10.2%) mothers never ever prepared the solution and were unable to demonstrate the preparation. One hundred and forty (33.3%) mothers were able to demonstrate the preparation correctly and the rest 237 (56.4%) demonstrated the preparation incorrectly. The incorrect preparation was found to be associated significantly with the refusal of ORS solution by the children (p < 0.01). None of the maternal factors were found to be associated with the correctness of preparation of ORS solution except previous exposure of the mother to the demonstration of ORS solution preparation (p < 0.000). Therefore, demonstration of preparation of ORS solution to the mothers should be in built in the health education package of oral rehydration therapy for diarrhoeal diseases.

Limiting factors of ORS intake.

This was a thirty cluster survey; carried out to identify the factors which limit ORS intake during a diarrhoeal episode in rural Bangladesh. 420 mother-child pairs were investigated. In addition to the verbal interview, the index child was examined physically and mother's skill of preparing ORS was assessed. The ORS was known to more than 95% mothers but used by only 33.3%. The average intake of ORS was 320 ml per diarrhoea day. The correct amount of oral rehydration fluid was received by 145(34.5%) cases. Twenty eight socio-demographic-maternal-host(child)-environmental factors were studied for their probable influence on intake of correct amount of oral rehydration fluid. In bivariate analysis, fourteen factors were found to be associated significantly with oral rehydration fluid intake (P < 0.05-< 0.0001). These fourteen factors were treated with stepwise logistic regression analysis. Sensitivity and specificity were the key measures for decision of best fitted model. A combination of child age, mother's education, socio-economic condition and method of feeding ORS provide the maximum sensitivity (90.20%) and specificity (74.19%) for predicting oral rehydration fluid intake. The study emphasized the need for further strengthening of health education incorporating the findings of the research to ensure required amount of oral rehydration fluid intake during diarrhoeal episode.

Effect of health warning on the use of breast milk substitutes by lactating mothers.

This cross-sectional study was carried out with the objectives to determine the awareness, readability and understandability of health warning and its effect on the use of breast milk substitutes(BMS) by lactating mothers. A total of 400 mothers who had infant of less than 5 months of age & able to read the bangla newspaper were interviewed at urban EPI centres. The mothers were requested to locate and read the health warning on BMS container. The BMS were used by 189(47.25%) mothers but only 137(34.3%) mothers knew the health warning. The mean time taken by mothers to locate the health warning in the BMS container was 40.4 +/- 40.9 seconds(95% CI 35-45). The health warning in the container could not be located by 97(24.2%) mothers and another 51(12.2%) located it with difficulty. There were 263(65.8%) mothers who were able to read the health warning easily and the rest either read with difficulty (10.0%) or unable to read(24.24%). More than one third of the mothers did not understand the meaning of health warning. Even after the education on health warning during the course of interview, 170(42.5%) mothers responded in favour of using BMS. The low level of awareness and poor understanding of the meaning of health warning by the lactating mothers might be the cause of a high rate of BMS use which calls for strengthening of information, education and communication (IEC) activities.

Misuse of drugs in acute diarrhoea in under-five children.

This was a community based, thirty cluster survey, carried out in Chittagong metropolitan area of Bangladesh, aimed to determine the extent of misuse of drugs in acute diarrhoea among under-five children. Data were collected from 360 mothers whose under-five children had suffered from acute diarrhoea during the preceding two weeks of interview. Data were pertained to type and duration of diarrhoea and treatment received. There were 339(94.2%) cases of acute watery diarrhoea and 21 (5.8%) cases of dysentery i.e. blood in stool. The mean duration of the diarrhoeal episode was 3.17 +/- 1.69 days (95% CI, 2.99-3.34). Three hundred twenty eight (91.1%) cases received treatment. There was a total of 401 consultations, out of which 328(81.8%) had first, 69(17.2%) had second and 4(1.0%) had third consultations. The first and second treatment were provided predominantly by care-providers (43.3%) and physicians (5.5%) respectively. Only 82(26.7%) cases of acute watery diarrhoea received WHO recommended treatment and only 5(23.8%) cases of dysentery received appropriate antibiotics. The rest 241(73.5%) cases received inappropriate treatment either antibiotic or drugs other than WHO recommendation. The average number of drugs prescribed per patient was 1.5 during the episode. The commonly prescribed drugs were metronidazole (38.6%) and antibiotics (17.3%). Those who consulted health professionals were at 5.7 times higher risk of receiving drugs. The mean duration of the episode of acute watery diarrhoea was increased significantly when drug is used in the treatment. It is concluded that there was high prevalence of misuse of drugs in the treatment of acute diarrhoea among under-five children which calls for intervention to improve the prescribing pattern as per WHO recommendation.

Prelacteal feeding: influencing factors and relation to establishment of lactation.

This study was carried out with a view to finding out factors influencing prelacteal feeding and its relation to establishment of lactation in rural Bangladesh. 420 mothers in early post-partum period were interviewed at home. Prelacteal feeding was given to 77% of the babies, and honey was given to 72% of them. The common methods of prelacteal feeding were by finger (41%) and spoon (40%). Twelve socio-demographic and health care variables were studied for their probable influence on prelacteal feeding. Nine of them accounted for 22% of the variability in giving prelacteal feeding. Reasons of giving prelacteal feeding and the time of first breast feeding influenced the practice significantly (P < 0.05). Type and duration of prelacteal feeding had significant negative influence on "coming in" of milk (P < 0.05). Prelacteal feeding accounted for 44% of variations in coming in of milk. Prelacteal feeding and coming in of milk formed a vicious cycle: the former delayed initiation of lactation and on the other hand delay in coming in of milk encouraged prelacteal feeding. These observation emphasized the need for coordinated efforts for promotion of proper infant feeding practices in our rural community.