Prenatal and postnatal risk factors for mental retardation among children in Bangladesh.

This study evaluated the contribution of prenatal, perinatal, neonatal, and postnatal factors to the prevalence of cognitive disabilities among children aged 2-9 years in Bangladesh. A two-phase survey was implemented in 1987-1988 in which 10,299 children were screened for disability. In multivariate analyses, significant independent predictors of serious mental retardation in rural and urban areas included maternal goiter (rural odds ratio (OR) = 5.14, 95% confidence interval (CI): 1.23, 21.57; urban OR = 4.82, 95% CI: 2.73, 8.50) and postnatal brain infections (rural OR = 29.24, 95% CI: 7.17, 119.18; urban OR = 13.65, 95% CI: 4.69, 39.76). In rural areas, consanguinity (OR = 15.13, 95% CI: 3.08, 74.30) and landless agriculture (OR = 6.02, 95% CI: 1.16, 31.19) were also independently associated with the prevalence of serious mental retardation. In both rural and urban areas, independent risk factors for mild cognitive disabilities included maternal illiteracy (OR = 2.48, 95% CI: 0.86, 7.12), landlessness (OR = 4.27, 95% CI: 1.77, 10.29), maternal history of pregnancy loss (OR = 2.61, 95% CI: 0.95, 7.12), and small for gestational age at birth (OR = 3.86, 95% CI: 1.56, 9.55). Interventions likely to have the greatest impact on preventing cognitive disabilities among children in Bangladesh include expansion of existing iodine supplementation, maternal literacy, and poverty alleviation programs as well as prevention of intracranial infections and their consequences. Further population-based studies are needed to confirm and understand the association between consanguinity and serious cognitive disability.

Predictors of stress in mothers of children with cerebral palsy in Bangladesh.

OBJECTIVE: To identify the stress experienced by mothers of young children with cerebral palsy in Bangladesh and to determine predictive factors. METHODS: We recruited 91 mothers of children with cerebral palsy ages 1.5 to 5 years as they sought services at an urban and a rural center for their children. Mothers were interviewed with the Self-Report Questionnaire and other family background and child behavior measures. The children were examined by a pediatrician and by a psychologist. RESULTS: Out of 91, 38 (41. 8%) mothers were at risk for psychiatric morbidity. Significantly associated factors included living in the rural area within a poor family, with a relatively older child. The strongest predictor of maternal stress in multivariate analysis was child behavior problems, especially those related to burden of caring. CONCLUSIONS: Ensuring practical help for mothers and advice on managing common behavior problems are important components of intervention, as they may directly help to relieve stress on mothers of young disabled children in developing countries.

Distinction between bronchioloalveolar carcinoma and hyperplastic pulmonary proliferations: a cytologic and morphometric analysis.

The objectives of this study were to identify key cytologic features for the morphologic differentiation of bronchioloalveolar carcinoma from reactive pulmonary proliferations, and to determine if morphometry of the cytologic specimens could provide additional data to distinguish the two processes. We analyzed 15 morphologic criteria in pulmonary cytologic specimens from 17 histologically proven cases of bronchioloalveolar carcinoma and 13 cases with reactive cellular changes and compared the findings using univariate analysis. This revealed four statistically significant features more commonly associated with bronchioloalveolar carcinoma: (i) predominance of two- and three-dimensional tissue fragments, (ii) tenacious intercytoplasmic connections between cells, (iii) intranuclear cytoplasmic inclusions, and (iv) paucity of multinucleated cellular forms. Morphometric measurement revealed significant differences between the mean of the nuclear area of benign reactive cells and that of the malignant cells. The utilization of these criteria is helpful to diagnose bronchioloalveolar carcinoma and to distinguish it from reactive pulmonary processes.

Cytopathology of retrograde renal pelvis brush specimens: an analysis of 40 cases with emphasis on collecting duct carcinoma and low-intermediate grade transitional cell carcinoma.

We report our experience with 40 retrograde renal brush samples of pelvic-calyceal lesions with confirmatory tissue studies. On-site cytopathologic evaluation was performed in 38 of these specimens. The final histologic diagnoses included 24 cases of transitional cell carcinoma (TCC), 17 of which were low-intermediate grade tumors. All 24 cases were diagnosed cytologically as TCC (22), or as suspicious for TCC (2). Three cases classified as collecting duct carcinomas were resected; the cytologic specimens in 2 of these cases were interpreted as TCC, and one as reactive change. There were three renal cell carcinomas (RCC); cytologically, one was considered a papillary neoplasm, one suspicious for malignancy, and one as reactive. Two cases of atypical renal cysts were reported as suspicious for malignancy in both cytologic and histologic material. There was one case of metastatic colon carcinoma identified in the brush specimen. Finally, tissue studies in the remaining 7 cases showed reactive/inflammatory changes; however, four of the corresponding pelvic brush specimens were considered abnormal. A review of the above cases is reported with the objective of presenting the cytologic features seen in collecting duct carcinoma, low-intermediate grade TCC, and diagnostically difficult cases with cyto/histomorphologic discrepancies. The contribution of on-site assessment to diagnostic accuracy is also discussed.

Efficacy of the Endo-pap sampler in detecting endometrial lesions.

OBJECTIVE: To determine the efficacy of the Endo-pap sampler, a device used to collect endometrial tissue fragments for cytologic examination, in detecting endometrial lesions. STUDY DESIGN: Reports from 1,983 Endo-pap smears collected from 1,248 outpatients over a 44-month period were retrospectively examined in conjunction with corresponding biopsy or hysterectomy reports. Endo-pap smears, histologic sections and clinical information were reviewed in cases originally reported as abnormal. RESULTS: Endometrial abnormalities were reported in 29 Endo-pap smears (1.5%). Among 21 reported as atypical, follow-up was normal in 19 but revealed hyperplasia in 1 and hyperplasia with a focus of carcinoma in 1 on histologic examination. Three were interpreted as malignant and one as suspicious; all had adenocarcinoma at endometrial biopsy. Endometrial abnormalities were reported in 19 of 220 patients who underwent endometrial biopsy following a previous Endo-pap smear reported as negative for malignancy. Their diagnoses included endometrial polyps (14), hyperplasia without atypia (3), atypical hyperplasia (1) and endometrial adenocarcinoma (1) three years after a negative Endo-pap smear. CONCLUSION: Although the sensitivity and specificity for malignancy were 100%, the overall sensitivity for any pathologic lesion was only 28%. We recommend proceeding directly to endometrial biopsy for a conclusive diagnosis in symptomatic patients.

Cytologic manifestations of respiratory syncytial virus pneumonia in bronchoalveolar lavage fluid: a case report.

BACKGROUND: Respiratory syncytial virus (RSV) pneumonia in immunocompromised patients, especially bone marrow transplant recipients, is associated with high mortality. Early diagnosis in these cases is important because antiviral therapy with ribavirin is effective in reducing mortality. CASE: A 45-year-old male with multiple myeloma who underwent autologous peripheral stem cell transplantation subsequently developed bilateral pulmonary infiltrates. A bronchoalveolar lavage specimen demonstrated the cytologic changes associated with RSV pneumonia. Infection with RSV was confirmed by indirect immunofluorescence, enzyme immunoassay and, later, on histology and electron microscopy at autopsy. CONCLUSION: Recognition of the cytologic changes associated with RSV pneumonia in immunodeficient patients can be life saving since this would initiate confirmatory immunologic studies and therapy.

Bronchoalveolar lavage cytology in pulmonary sarcoidosis.

OBJECTIVE: To study the cytomorphologic findings in bronchoalveolar lavage (BAL) fluid in pulmonary sarcoidosis, relationship of the cytologic findings to radiologic stage and cytohistomorphologic correlation. STUDY DESIGN: We retrospectively studied the cytologic findings in BAL specimens from 26 patients who had clinical features and histologic findings consistent with pulmonary sarcoidosis. RESULTS: Clean background; scattered, multinucleate giant cells; epithelioid cells; reactive alveolar macrophages; and a significant population of lymphocytes were observed in 88.5% (23/26) of cases of pulmonary sarcoidosis. A frequent finding was reactive nuclear changes in most multinucleate giant cells and epithelioid histiocytes, consisting of nuclear enlargement, open chromatin and one to two small, acidophilic nucleoli. CONCLUSION: The findings suggest that a BAL specimen in the majority of patients with pulmonary sarcoidosis yields this unique combination of cytologic features. The technique is accurate and economical and may be valuable in the management of such cases.

Ciliated hepatic foregut cyst. Report of a case with findings on fine needle aspiration.

Ciliated hepatic foregut cyst (CHFC) is an uncommon cystic lesion of the liver. It is analogous in nature and pathogenesis to the bronchial cysts that occur in the mediastinum. We report a case of CHFC diagnosed on fine needle aspiration (FNA) with a discussion of the cytologic findings and features and a review of the literature. Abdominal computed tomography (CT) detected the lesion during a workup for metastatic squamous cell carcinoma of the cervix in a patient with an intrauterine contraceptive device and uterine Actinomyces infection. Subsequent CT-guided FNA produced clear, viscid material that revealed numerous macrophages and scattered ciliated columnar cells within the mucinous background. The cytology and radiologic findings were essentially similar to those of a bronchial cyst and did not conform to any of the findings in generally known lesions of the liver. Awareness of this rare hepatic lesion will result in an accurate and definitive diagnosis by guided FNA biopsy and avoidance of surgical exploration and excision biopsy.

Evaluating a ten questions screen for childhood disability: reliability and internal structure in different cultures.

This paper uses five strategies to evaluate the reliability and other measurement qualities of the Ten Questions screen for childhood disability. The screen was administered for 22,125 children, aged 2-9 years, in Bangladesh, Jamaica and Pakistan. The test-retest approach involving small sub-samples was useful for assessing reliability of overall screening results, but not of individual items with low prevalence. Alternative strategies focus on the internal consistency and structure of the screen as well as item analyses. They provide evidence of similar and comparable qualities of measurement in the three culturally divergent populations, indicating that the screen is likely to produce comparable data across cultures. One of the questions, however, correlates with the other questions differently in Jamaica, where it appears to "over-identify" children as seriously disabled. The methods and findings reported here have general applications for the design and evaluation of questionnaires for epidemiologic research, particularly when the goal is to gather comparable data in geographically and culturally diverse settings.

Measures of socioeconomic status for child health research: comparative results from Bangladesh and Pakistan.

This paper examines the reliability and validity of several hypothesized indicators of socioeconomic status for use in epidemiologic research, particularly in studies of child health in the less developed world. Population-based surveys of child health and disability were completed in Bangladesh and Pakistan using standard questionnaires designed to measure four domains of household socioeconomic status: wealth, housing, parental education and occupation. Test-retest data indicate moderate to excellent reliability of most of the socioeconomic indicators in both countries. Loadings from factor analyses of the survey data provide further evidence of the reliability of the data, and confirm that the questionnaire measures housing and wealth as distinct domains in both countries. Parental education and occupation are correlated with housing and/or wealth in these data sets. Bivariate logistic regression analyses show that, although 11 of 12 dichotomous indicators of low socioeconomic status constructed from the data are predictive of child death in at least one of the four sub-populations studied (rural and urban Bangladesh, and rural and urban areas of Karachi, Pakistan), no single indicator is predictive of child death in all four sub-populations. These along with multivariate results demonstrate the importance of including multiple measures of distinct domains if the research aims include investigation and/or control of the effects of socioeconomic status on health in diverse populations.

Validity of the ten questions screened for childhood disability: results from population-based studies in Bangladesh, Jamaica, and Pakistan.

An international study to validate the Ten Questions screen for serious childhood disability was undertaken in communities in Bangladesh, Jamaica, and Pakistan, where community workers screened more than 22,000 children ages 2-9 years. All children who screened positive, as well as random samples of those who screened negative, were referred for clinical evaluations. Applying comparable diagnostic criteria, the sensitivity of the screen for serious cognitive, motor, and seizure disabilities is acceptable (80-100%) in all three populations, whereas the positive predictive values range from 3 to 15%. These results confirm the usefulness of the Ten Questions as a low-cost and rapid screen for these disabilities, although not for vision and hearing disabilities, in populations where few affected children have previously been identified and treated. They also show that the value of the Ten Questions for identifying disability in underserved populations is limited to that of a screen; more thorough evaluations of children screened positive are necessary to distinguish true- from false-positive results and to identify the nature of the disability if present.

Socioeconomic status and the prevalence of mental retardation in Bangladesh.

Results of a population-based study of the prevalence of mental retardation among 2- to 9-year-old children in Bangladesh were reported. More than 10,000 children were screened for mental retardation and other disabilities. All children with positive screening results plus a random sample with negative results were referred for clinical evaluations. The prevalence rates per 1,000 of severe and mild mental retardation in this population were 5.9 and 14.4, respectively. As found in studies in developed countries, the prevalence of mild mental retardation was strongly and significantly associated with low socioeconomic status, whereas the association for severe mental retardation was relatively weak and not significant.

The effects of a natural disaster on child behavior: evidence for posttraumatic stress.

OBJECTIVES: A prospective study of children examined both before and after a flood disaster in Bangladesh is used to test the hypothesis that stressful events play a causal role in the development of behavioral disorders in children. METHODS: Six months before the disaster, structured measures of selected behavioral problems were made during an epidemiological study of disability among 2- to 9-year-old children. Five months after the disaster, a representative sample of 162 surviving children was reevaluated. RESULTS: Between the pre- and postflood assessments, the prevalence of aggressive behavior increased from zero to nearly 10%, and 45 of the 134 children who had bladder control before the flood (34%) developed enuresis. CONCLUSIONS: These results help define what may be considered symptoms of posttraumatic distress in childhood; they also contribute to mounting evidence of the need to develop and evaluate interventions aimed at ameliorating the behavioral and psychological consequences of children's exposure to extreme and traumatic situations.

Endometrial papillary syncytial change. A nonspecific alteration associated with active breakdown.

Papillary syncytial change (PSC) of endometrial epithelium, often regarded as a metaplastic change, shows syncytial to papillary aggregates of eosinophilic cells along the surface epithelium. To determine the cause and significance of PSC, 250 consecutive endometrial biopsy and curettage specimens and curettings in patients with suspected endometrial abnormalities were reviewed. Papillary syncytial change was found in 43 (17%) of the cases. Often PSC was focal, but in 12 cases it was multifocal and in 7 cases it was extensive. Patients with PSC ranged from 22 to 86 years of age. The primary pathologic findings in endometria with PSC included a variety of benign organic lesions and hyperplasia, as well as proliferative and secretory changes that suggested dysfunctional bleeding. One consistent finding in all cases was associated active endometrial bleeding with glandular and stromal breakdown, cell necrosis, and neutrophils in close proximity to PSC. Immunohistochemical study of 6 cases with extensive PSC showed no difference in reactivity to high and low molecular weight keratin, vimentin, and carcinoembryonic antigen compared with surrounding unaffected epithelium. The association of PSC with endometrial breakdown in a variety of conditions suggests that PSC is a benign retrogressive alteration rather than a metaplastic transformation to another cell type. Papillary syncytial change appears to be a useful histologic marker of acute endometrial breakdown and bleeding, and recognition of this phenomenon will prevent misclassification of this relatively common finding.

Validity of the 'Ten Questions' for screening serious childhood disability: results from urban Bangladesh.

A survey of 2576 children aged two to nine years was carried out in Dhaka, Bangladesh, as part of a collaborative study to test the validity of a questionnaire (the Ten Questions) for screening severe childhood disabilities in community settings. Approximately 7% of the children were positive on the screen and this rate was slightly higher in boys than girls. The sensitivity, specificity and negative predictive value of the Ten Questions were perfect or nearly perfect for severe and moderate (serious) disabilities. The positive predictive value was only 22% for serious disabilities, but 70% of children classified as false positives were found to have mild disabilities or other conditions (such as ear infections) for which early detection and treatment could be beneficial. No major age or gender differences in the validity of the questionnaire were apparent, but this finding needs additional study and confirmation with studies based on larger samples. In general, the results indicate that the Ten Questions is a valid tool for screening serious disabilities in children and can potentially improve the efficiency of health services by reducing the number of children requiring attention from professionals. Future studies using the Ten Questions should foster greater attention to the dimensions of childhood disability as a public health problem in the less developed world.