SIR SALIMULLAH MEDICAL COLLEGE JOURNAL

SIR SALIMULLAH MEDICAL COLLEGE JOURNAL

VOL. 27, NO. 2, JULY 2019

An Official Journal

of

Sir Salimullah Medical College Teachers’ Association

EDITORIAL BOARD

Address of Correspondence:

Dr. Sudip Das Gupta, Editor-in-Chief, Sir Salimullah Medical College Journal

Department of Medicine, Sir Salimullah Medical College & Mitford Hospital, Dhaka-1100.

Mobile: 880-1912085952, email: [email protected]

Date of Publication: June 2020

Chairman

Prof. Dr. Uttam Kumar Paul

Editor-in-Chief

Dr. Sudip Das Gupta

Joint Editors

Prof. Dr. Zahed Ali

Prof. Dr. Ahmed Hossain Ali

Dr. Sunirmal Roy

Prof. Dr. Gobinda Chadra Saha

Dr. Muna Shalima Jahan

Assistant Editors

Dr. Afshan Zareen

Dr. Roma Chowdhury

Dr. Md. Moshiur Rahman Khokon

Dr. Amiruzzaman

Prof. Dr. Farhat Hossain

Prof. Dr. Shanjoy Kumar Paul

Prof. Dr. Chandra Shekhar Majumder

Prof. Dr. Mahmuda Begum

Prof. Dr. Abu Jafar

Prof. Dr. Dewan Golam Akaiduzzaman

Prof.Dr. Sika Paul

Dr. Ranajit Sen Chowdhury

Dr. Irin Parveen Alam

Dr. Nasrin Rosy

Dr. Pallab Kanti Saha

The Sir Salimullah Medical College Journal a biannual (January &

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Salimullah Medical College Teachers’ Association. Each issue

includes editorial, original articles, review articles and case reports

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1. Articles in Journal

a. List all six authors when six or less;

Vega KJ, Pina I, Krevsky B. Heart transplantation

is associated with an increased risk for

pancreatobiliary disease. Ann Intern Med 1996;

124 : 980-3.

b. When seven or more, list the first three and

then add et al; Parkin DM, Clayton D, Black

RJ et al. Childhood leukemia in Europe after

Chernobyl 5-year follow-up. BR J Cancer 1996;73 : 1006-12.

c. No author given

Cancer in South Africa (editorial). S Afr Med J

1994; 84 : 15.

d. Organization as author

The Cardiac Society of Australia and New

Zealand. Clinical exercise stress training. Safety

and performance guideline. Med J Aust 1996;

164 : 282-4.

2. Books and Others Manuscripts

a. Personal author

Laurence DR, Bennett PN, Brown MJ. Clinical

Pharmacology Eighth ed. New York : Churchill

Livingstone; 1997.

b. Editor(s), (s) as author

Katzung BG, editor,. Basic & Clinical

Pharmacology. 6th ed. Connecticut : Appleton

& Lange; 1995.

c. Organization as author and publisher

World Health Organization, Ethical criteria for

Medical Drug Promotion: World Health

Organization; 1988.

d. Chapter in a book

Philips SJ, Whisnant JP. Hypertension and

stroke. In : Laragh JH, Brenner BM, editors.

Hypertension: pathophysiology, diagnosis, and

management. 2nd ed. New York : Raven Press;

1995; p. 465-78.

e. Dissertation

Kaplan SJ. Post-hospital home health care :

the elderly's access and utilization

(dissertation). St. Louis (MO) : Washington

Univ; 1995.

3. Other published material

a. Newspaper article

Lee G. Hospitalizations tied to ozone pollution

: study estimates 50,000 admissions annually.

The Washington Post 1996; June 21; Sect. A : 3

(col. 5).

b. Dictionary and similar references

Student's medical dictionary. 26th ed.

Baltimore : Williams & Wilkins; 1995.

Apraxia; p. 119-20.

4. Unpublished material

a. In press

Leshner Al. Molecular mechanisms of cocaine

addition. N Engl J med In Press 1997.

5. Electronic Material

a. Journal articles in electronic format

Morse SS. Factors in the emergence of

infectious diseases. Emerg Infect Dis I Serial

online I 1995 Jan-Mar I cited 1996 June 5 I;

1(1) : 24 screens I.

Available from : URL : http: //www.cdc.gog/

ncidod/ EID/eid.htm

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Editorial

Stroke is one of the most common causes ofmortality and morbidity worldwide. Traditionallywe used to encounter stroke patient by interveningthe modifiable risk factors, treating the cause,complications and maintaining a preventivetherapy. But there are limitations in our countryin managing the stroke patient, specially theischemic stroke patient.

Principle of Acute stroke management

The central purpose is to preserve the ischemicpneumbra from being infracted by restoring theblood flow to the compromised area. Recanalizationis the main strategy for restoring the blood flowand preserving the pneumbra.

Recanalization procedurei. Thrombolysis therapy

a. Intravenous approachb. Intra arterial approach

ii. Mechanical thrombectomy

Thrombolysis is done by alteplase, a recombinanttissue plasminogen activator (rtPA)

Time schedule for thrombolysis therapyThrombolysis establishes revascularization torescue the pneumbra from the irreversible celldeath from infarction. So there is a definite timelimit for the thrombolysis therapy.

Intravenous rt.PA should be administrated toeligible acute stroke patient within certain timeof last known normal. The certain time is• 3 hrs (according to American stroke association)• 4.5 hrs ( according to European Co-operative

Acute Stroke Study III)

Support for recanalization processi. CT scan of Headii. MRI of brain including

DWI (for acute ischemic stroke)GRE (for Hemorrhage)

iii. CT perfusion map- To find out the pneumbra extentiv. Cath-Lab for the endovascular approacha. Intra arterial thrombolysisb. Mechanical thrombectomy

Low equipped hospital just having CT scan machinecan start intravenous thrombolysis for acute strokepatient coming within the recommended time afterexcluding hemorrhage by doing CT scan. Probablefinding in CT imaging of head in acute ischemic

Acute Stroke Management

stroke patient within recommended time for thethrombolysis therapy are

i. Normal CT Scan

ii. Effacement of cortical sulcus as well as loss ofinsuler ribbon sign due to parenchymal cytotoxicoedema resulting from ischemic stroke.

iii. Loss of gray and white matter differentiation

iv. Hyperdense MCA sign

Role of MRI

• The specificity and sensitivity is higher in theDWI sequence of MRI then that of CT scan indiagnosing acute ischemic stroke.

• DWI diagnosed infarcts which are not seen inT2 and FLAIR sequences are hyper acuteischemic stroke seems to have enoughpneumbra to be beneficial in doing thrombolysis.

Outcome of I/V thrombolysis

Maintaining the proper guideline and appropriaterecommended time I/V thrombolysis can establishrevascularization for the 30% of patient, 60% mayremain unchanged and the rest 6% may withintracerebral hemorrhage.

In Bangladesh the I/V thrombolysis for the acuteischemic stroke patient has been initiated limitedlyin some corporate hospital. There is scope toinitiate it in the government hospital to providethe service extensively.

Challenges

i. Scarcity of neurologist for 180 million people.

ii. Lack of patient’s awareness in recognizing thestroke symptom and coming to the hospitalwith in the 4.5 hrs.

iii. Traffic system may hamper the time limit

iv. Poor infrastructure of the neurology wardwithout having supporting equipment andseparate ICU

v. For mechanical thrombectomy well equippedCath-Lab is needed.

Combating the challenges hopefullyrecanalization procedure can be started in ourgovernment hospital in the near future.

Zahed Ali

Professor and Head, Department of Neurology,Sir Salimullah Medical College, Dhaka

65 Sir Salimullah Med Coll J Vol. 27, No. 2, July 2019

Original Articles

Effect of deep relaxation technique and supine rest on

Heart Rate Variability in Type 2 Diabetes MellitusFarhana Rahman1, Mohammed Masudur Rahman2, Ismoth Ara Jerin3, Sultana Ferdousi4

Abstract

Background: Cardiac autonomic nerve dysfunction has been associated with type 2 diabetes

mellitus (T2DM) with reduced heart rate variability (HRV). Regular practice of deep relaxation

technique (DRT) and supine rest (SR) may cause improvement of this impaired autonomic

nerve function.

Objective: To assess the comparative effect of DRT and SR on cardiac autonomic nerve function

by analysis of HRV in patients with T2DM.

Methods: This prospective interventional study was carried out on 60 female T2DM patients

aged 50-55 years with duration of diabetes of 5-10 years enrolled from the Out Patient Department

of Endocrinology, Bangabandhu Sheikh Mujib medical University, Dhaka. Thirty(30) patients

performed DRT (20 minutes twice daily) for 3 months and another group of thirty (30) patients

performed SR for same duration. To assess the cardiac autonomic nerve function, frequency

domain measures of HRV of all subjects were recorded by a data acquisition device Power Lab

8/35 (Australia). HRV data of all subjects were collected at baseline (Pre) and also after 3

months (Post). For statistical analysis, paired and independent sample t-test were used. Results:

Incase of DRT, the post-intervention values of LF normalized unit (LF nu), LF/HF ratio and

urinary VMA were significantly (p<0.001) lower and HF normalized unit (HF nu) significantly

(p<0.001) higher compared to pre-intervention values. Again, in the group of SR, the post-

intervention values of LF nu, LF/HF ratio were reduced and HF nu was increased but these

changes were not statistically significant (p>0.05) in diabetic patients. In addition, baseline

values of LF nu, LF/HF ratio, HF nu and urinary VMA of DRT group were similar to baseline

values of SR group but after 3 month of intervention, LF nu, LF/HF ratio and urinary VMA

were significantly decreased (p<0.05) and HF nu significantly increased (p<0.05) after performing

DRT compared to SR group.

Conclusion: Cardiac autonomic nerve dysfunction may occur in T2DM and 3 months regular

practice of DRT may significantly improve cardiac autonomic nerve function with

parasympathetic dominance and it was more effective than SR.

Key words: Deep relaxation technique, Supine rest, Autonomic nerve function, Heart rate

variability, type 2 Diabetes Mellitus.

(Sir Salimullah Med Coll J 2019; 27: 66-72)

1. Assistant Professor, Department of Physiology, Sir Salimullah Medical College and Mitford Hospital, Dhaka.2. Assistant Professor, Department of Surgery, Sir Salimullah Medical College and Mitford Hospital, Dhaka.3. Assistant Professor, Department of Physiology, Jalalabad Ragib Rabeya Medical College, Sylhet.4. Professor and Chairman, Department of Physiology, Bangabandhu Sheikh Mujib Medical University (BSMMU),

Bangladesh.Corresponding author: Farhana Rahman, Assistant Professor, Department of Physiology, SSMC and Mitford Hospital,Dhaka, Telephone: 01833339999, E-mail: [email protected]

Introduction

Type 2 diabetes mellitus (T2DM) is the most widelyrecognized type of diabetes.1 Cardiac autonomicneuropathy (CAN) is the most prominent focus ofdiabetes because of the life-threateningconsequences of this complication.2 CAN may beclinically apparent or in apparent.3 SubclinicalCAN does not manifest any symptoms of CAN andclinical CAN may be manifested by resting

tachycardia, orthostatic hypotension, exerciseintolerance and silent mayocardial ischemia.4 Oncethe feature of CAN is clinically evident, it cannotbe reversed effectively by any treatment.5

Therefore, it is conscious to intervene at itssubclinical stage in diabetic patients.

In recent days, various relaxation techniquesdemonstrated promise to help to cope with variousstress related health problems to such as-cancer

and pain.6 Significant improvement in angina,diabetes, cardiac arrhythmias, hypertension,bronchial asthma, insomnia, rheumatoid arthritishas been reported with trial of these yoga basedrelaxation therapy.7 Among relaxation techniques,deep relaxation technique (DRT), Shavasan orsupine rest (SR), cyclic meditation (CM) anddifferent form of meditation have been studied byseveral investigators in both health and diseasedcondition.8-12 DRT has been ascribed as a procedureof meditation in which the subject adopts a posturecomfortable for him/her usually in supine posturewith eyes closed. Then he/she focuses mind onbreathing which leads to the state of relaxation ofbody and mind.7,9 In addition, SR has beendescribed as relaxation and awareness on theborder between sleep and wakefulness, allowingcontact with the sub conscious and unconsciousmind.8 Among these two techniques SR is easierto perform and involves no instruction, nomaneuver compared to DRT.

Various investigators investigated the effect ofrelaxation response on cardiac autonomic nervefunction by assessment of heart rate variability(HRV) which is more sensitive, non invasiveprocedure to quantify cardiac parasympathetic andsympathetic activity.11-15

Among the different HRV outcome measuresfrequency domain measures of HRV include highfrequency (HF) norm which determines vagalmodulation and low frequency (LF) norm representssympathetic modulation on heart and also LF/HFreflects sympathovagal balance of cardiacautonomic control.15,16 Reduced HRV was reportedin T2DM by several studies.17-20

Several studies observed the relation of HRVmeasure to catecholamines in plasma and inurine.21-23 Furthermore, urinary excretion ofvanillyl mandelic acid (VMA) which is a metabolicend product of released catecholamines incirculation has been measures as a marker forsympathetic activity.24-26

In healthy subjects irrespective of sex, significanthigher values of HF norm and lower values of LFnorm and LF/HF has been reported after practicingDRT but they failed to show any significant changeof these parameters after practicing SR.27-30

Though, the benefit of relaxation technique onautonomic function has been tested in healthysubjects,27-33 the information about the effect ofrelaxation technique in diabetic patients for itautonomic benefit is lacking and the effect of DRTand SR on HRV in sedentary female wasinvestigated32 but the data on effect of DRT andSR on HRV in T2DM has not been published yet.Therefore, this study has been designed to evaluatethe impact of deep relaxation technique and supinerest and their comparative effect on autonomic tonein patients with T2DM so that the outcome can beused to suggest it as an adjunct to typical treatmentstrategy for T2DM to improve the cardioautonomicdysfunction and also to reduce cardiovascular andcardiac autonomic neuropathy, morbidities, longterm complications and ensure healthy life indiabetic patients.

Methods

This prospective interventional study wasconducted during 2016 in the Department ofPhysiology, Bangabandhu Sheikh Mujib MedicalUniversity, Dhaka. The protocol of this study wasapproved by the institutional review board ofBSMMU. This study enrolled to 60 diagnosedfemale patients of T2DM following criteria ofWHO34 (age: 50 to 55 years; HbA1C: 5-10%; 5 to10 years duration of DM) as study group bypurposive sampling from the Endocrinology OutPatient Department, BSMMU, after taking writteninformed consent. Among 60 patients, 30 patientsperformed DRT and another 30 patients performedSR for 3 months. HRV data of all patients werestudied at baseline before beginning DRT and SRand same patients were reassessed afterperforming relaxation technique for 3 months.History of DAN, T1DM, diabetic retinopathy,nephropathy, hypertension, coronary arterydiseases, epilepsy, migraine, psychiatric disorders,respiratory disorders, hypo & hyperthyroidism,consuming drugs with effect on autonomic nervoussystem function, yoga practitioners and athleteswere excluded. The aim and objectives of the studywere explained and they were encouraged forvoluntary participation. Subsequently, a thoroughclinical examination was done and a detail familyand medical histories and also physical activitystatus were recorded in a prefixed data schedule.


For HRV recording, the finally selected subjectswere prepared from one day prior to the test. Theywere advised to take their meal by 9.00 p.m. andhave sound sleep and avoid any physical or mentalstress and also sedative medications. In addition,they were advised to take light breakfast in themorning without tea and coffee and to attend atthe Autonomic Nerve Function Test Laboratoryin the Department of Physiology of BSMMUbetween 9.00 a.m. to 11.00 a.m. on the day ofexamination. For HRV measurement, the roomtemperature of the Autonomic Lab was maintainedaround 25ºc-28ºc and the subject was allowed to sitfor 15 minutes to adjust with the lab conditions.Then, ECG was recorded on Lead II for 5 minutes,by Power Lab 8/35 (ADInstrument, Australia) fromwhich measures of HRV was analysed by Lab chartsoftware.

24 hour urine of all patients were collectedrandomly for determination of VMA usingautoanalyzer in the immunological lab ofdepartment of Endocrinology of BIRDEM.

The patients were asked to perform DRT and SRtwice daily for 3 months. For this purpose, patientswere trained by demonstrating DRT and SR fortwenty minutes by the researcher. During thissession, incase of DRT group, instruction to thesubjects were given by an audiotape. Throughoutthe practice of DRT, the participants laid in supineposition with eyes closed, then each specific partof the body were relaxed sequentially from tip ofthe toes to the neck with chanting “A-U-M”.10,27

And incase of SR group, the participants laid insupine in the corpse posture (shavasan) with eyesclosed, legs apart and arms away from thebody.10,27 They were requested to practice thesteps twice daily in peaceful, lighted and wellventilated room at home.

Data were expressed as mean and SE. SPSS forwindows, version 22.0 was used for statisticalanalysis. Independent sample t-test was done tocompare the mean values between DRT group andSR group of patients at their baseline and after 3months and also paired sample t-test was done tocompare mean values of data between before andafter intervention with DRT and SR. p value of <0.05 was taken as statistically significant.

Results

Incase of DRT, the post-intervention values of LFnormalized unit (LF nu), LF/HF ratio and urinaryVMA were significantly (p<0.001) lower and HFnormalized unit (HF nu) significantly (p<0.001)higher compared to pre-intervention values (TableI). Again, in the group of SR, the post-interventionvalues of LF nu, LF/HF ratio were reduced andHF nu was increased but these changes were notstatistically significant (p>0.05) in diabetic patients(Table II). In addition, baseline values of LF nu,LF/HF ratio, HF nu and urinary VMA of DRTgroup were similar to baseline values of SR group(Table III) but after 3 month of intervention, LFnu, LF/HF ratio and urinary VMA weresignificantly decreased (p<0.05) and HF nusignificantly increased (p<0.05) after performingDRT compared to SR group (Table IV).

Table I

Frequency domain measures of HRV in DRT group (n=30)

Parameters T2DM (n=30) T2DM(n=30)baseline/pre-exercise value after 3 months/post-exercise value

LF (n.u.) 70.34±2.03 56.25±0.75**

HF(n.u.) 27.14±1.85 41.24±0.97**

LF/HF 3.19±0.3 1.43±0.06**

VMA(mg/day) 13.5±0.64 09.11±0.40**

Data were expressed as mean ± SE. Statistical analysis was done by independent sample t-test andpaired sample t-test. T2DM= Type 2 diabetes mellitus; LF= Low frequency; HF= High frequency; VMA=Vanillyl mandelic acid; n=number of subjects; DRT= Deep relaxation technique. (*= baseline vs after 3months; **=p<0.001)

Effect of deep relaxation technique and supine rest on Heart Rate Variability Farhana Rahman et al 68

Table II

Frequency domain measures of HRV in SR group (n=30)

Parameters T2DM (n=30) T2DM(n=30)

baseline/pre-exercise value after 3 months/post-exercise value

LF (n.u.) 65.05±2.92 62.12±1.52##

HF (n.u.) 30.50±2.47 32.61±1.33##

LF/HF 2.74±0.47 1.94±0.13##

VMA(mg/day) 12.20±0.50 11.00±0.58##

Data were expressed as mean ± SE. Statistical analysis was done by independent sample t-test andpaired sample t-test. T2DM= Type 2 diabetes mellitus; LF= Low frequency; HF= High frequency; VMA=Vanillyl mandelic acid; n=number of subjects; SR= Supine rest (# = baseline vs after 3 months; ## =p>0.05)

Table III

Baseline frequency domain measures of HRV and VMA in different groups (n=60)

Parameters SR group T2DM (n=30) DRT group T2DM(n=30)

baseline/pre-exercise value baseline/pre-exercise value

LF (n.u.) 65.05±2.92 70.34±2.03##

HF(n.u.) 30.50±2.47 27.14±1.85##

LF/HF 2.74±0.47 3.19±0.3##

VMA(mg/day) 12.20±0.50 13.5±0.64##

Data were expressed as mean ± SE. Statistical analysis was done by independent sample t-test andpaired sample t-test. T2DM= Type 2 diabetes mellitus; LF= Low frequency; HF= High frequency; VMA=Vanillyl mandelic acid; n=number of subjects; DRT= Deep relaxation technique; SR=Supine rest (#=baseline SR group vs baseline DRT group; ##=p>0.05)

Table IV

Post-intervention values of frequency domain measures of HRV and VMA in different groups (n=60)

Parameters SR group T2DM (n=30) DRT group T2DM(n=30)

after 3 months/post-exercise value after 3 months/post-exercise value

LF (n.u.) 62.12±1.52 56.25±0.75*

HF(n.u.) 32.61±1.33 41.24±0.97*

LF/HF 1.94±0.13 01.43±0.06**

VMA(mg/day) 11.00±0.58 09.11±0.40**

Data were expressed as mean ± SE. Statistical analysis was done by independent sample t-test andpaired sample t-test. T2DM= Type 2 diabetes mellitus; LF= Low frequency; HF= High frequency; VMA=Vanillyl mandelic acid; n=number of subjects; DRT= Deep relaxation technique; SR=Supine rest (*=post-exercise SR group vs post-exercise DRT group; *=p<0.05; **= p<0.01)


Discussion

In the present study significantly higher values ofLF norm, LF/HF and lower value of HF normsuggest higher sympathetic tonic discharge andlower cardiac vagal tone in all diabetic patientsbefore intervention were almost similar to theresults of other investigators.16-20,35

It is interesting to note that after 3 months ofregular practice of DRT, the diabetic patientsshowed significant improvement of autonomicnerve function supported by significant decreasein LF norm, LF/HF and significant increase in HFnorm but these changes were failed to achievestatistical significance after practicing SR. Theseresults were consistent with other studiesconducted to observe the effect of DRT and SR oncardiac autonomic nerve function but theyobserved in healthy subjects.14,29,30,36,37

In addition, the mean values of all HRV parametersand urinary VMA were similar in both groups beforeintervention but These all values were significantlyimproved after performing DRT compared that ofSR group.

Literature review showed that urinary VMA is oneof the end product of metabolic degradation ofcatecholamines in circulation.38 Its urinaryexcretion is a measure of sympathetic activitywhich cause release of catecholamines incirculation.26,38 In this study urinary level of VMAdid not reflect any significant variation than theircorresponding pre-exercise value after practicingSR for 3 months. This VMA result in diabeticpatients of SR group provided further evidence forincreased sympathetic activity in diabetics.

The exact mechanism involved in the autonomicresponse to this kind of yogic relaxation responsehas not been clearly delinated. But the body ofliterature review proposed, the highly focusedattention and willful muscle relaxation which is apart of the procedure of DRT probably created anintegrated hypothalamic response by neural signalfrom increase activation of pre frontal cortex (PFC),anterior cingulated cortex and other part of limbicsystem with a consequence of parasympatheticpredominance in the diabetic patients.7,9,39-43 Inaddition, DRT have been found to exert profoundeffect on restoration of autonomic balance incomparison to SR though both are regarded asrelaxation method because it is apparent that the

procedure of DRT is a combination of supinerest(SR), muscle relaxation and cognitivecomponent. Hence, the relaxation effect of DRT ismore powerful than SR alone because relaxationis augmentd by focus attention and guidinginstruction.

Conclusion

From this study, it can be concluded that therewas autonomic nerve dysfunction with sympatheticpredominance occurred in T2DM which wascounterbalance by exercising DRT for 3 months.Therefore, it is evident that regular performanceof deep relaxation technique is an effectivemeasure to improve autonomic nerve dysfunctionin its subclinical stage and can delay and preventclinical autonomic neuropathy in Type 2 diabetesmellitus and it is more effective than SR.

Acknowledgment

Authors of this study are thankful to the authorityof the Department of Endocrinology, BSMMU fortheir cooperation during this study.

Conflict of interest None

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Bacteriological analysis of gall bladder bile in

uncomplicated symptomatic cholilithiasisMohammed Masudur Rahman1, Sadia Afroz2, Md Tasnimul Khair Shovon3, Farhana Rahman4,

A.B.M Bayezid Hossain5

Abstract

Background and aim: Laparoscopic cholecystectomy is currently a commonly performed

operation in surgical unit. Gall stone with in gall bladder or biliary tree is associated with the

bacterial colonization of the bile. Acute cholangitis spans a continuous clinical spectrum and

can progress from a local biliary infection to advanced disease with sepsis and multiple organ

dysfunction syndrome. So it is important to know the microbiological flora of the gall bladder

before prophylactic antibiotics are given. Aim and objective of this study was to evaluate

microbiological profile of bile from gall bladder and choose the appropriate antibiotic as per

culture sensitivity report.

Methods: This was a prospective analytic study carried out in Sir Salimullah Medical College

and Mitford Hospital, Dhaka form September, 2016 to November, 2018. A total 72 patients

under gone laparoscopic cholecystectomy who fulfill the inclusion criteria were included in

this study. 3-5 cc bile was aspirated from all patients, this collected bile from gallbladder before

surgical dissection was transported to the laboratory in sterile test tube. This specimen was

evaluated to find out any presence of bacteria, if present then its culture for sensitivity test was

done against antibiotic.

Results: 19 patients showed positive bile culture in which Escherichia coli was the most

common isolated bacteria (17 cases). 89.47% among positive bile culture in which 52.94% male

and 47.05% female. No growth of bacteria found in 53 cases in which male 12 (32.05%) and

female 41 (67.95%). Staphylococcus aureus found in one patients’s bile (5.20% for positive bile

culture) and 1.38% among all patients. Acinetobacter isolated in another patient’s bile (5.20%

for positive bile culture)and 1.38% among allpatients. Among the positive culture results 47.36%

were male and 52.63% were female. Post operative wound infection was found in two patients

with positive culture report of total 17 patients.

Conclusions: It was found that sensitivity to 3rd and 4th generation cephalosporin was higher

than 1st and 2nd generation cephalosporin and aminoglycoside. In this study levofloxacin and

chloramphenicol showed good sensitivity against isolated organism from bile. Resistance to 1st

and 2ndgeneration cephalosporin and combined amoxicillin plus clavulanic acid were increased.

For pre-operative prophylaxis 3rd and 4th generation cephalosporin and levofloxacin showed

better promise and may be used as first line antibiotic in routine laparoscopic cholecystectomy.

Key words: Laparoscopic cholecystectomy, bacteriology, cephalosporin, gall stone.


1. Assistant Professor, Department of Surgery, SSMC and Mitford Hospital, Dhaka.2. Associate professor, Department of Microbiology, Sathkhira Medical College, Sathkhira, Khulna3. Indoor Medical Officer, Department of Surgery, SSMC and Mitford Hospital, Dhaka.4. Assistant Professor, Department of Physiology, SSMC and Mitford Hospital, Dhaka.5. Professor and Head of Department of Surgery, SSMC & Mitford Hospital, Dhaka.Address for Correspondence: Dr. Mohammed Masudur Rahman, Assistant Professor, Department of Surgery, SirSalimullah Medical College, Dhaka. Mobile no-01711960474. Email: [email protected]

Introduction

Laparoscopic cholecystectomy is the commonestsurgical procedure in general surgery unit. Themost common reason forcholecystectomy issymptomatic cholilithiasis. Gall stone diseaseindicate presence of bacteria in 20-46% of the

patient.1,2,3,4 In case of healthy individual, nobacteria usually found in bile.1,3,4,5 In patientwithout gall stone disease, previous biliaryinstrumentation associated with high rates ofbactibilia. Incase of normal bile flow, bacteria inbiliary system are of no clinical significance. When

bile flow obstructed, bacteria proliferate instagnant bile while biliary pressure increases.Eventually, bacteria translocate into thecirculation causing a systemic infection. Acutecholangitis spans a continuous clinical spectrumand can progress from a local biliary infection toadvanced disease with sepsis and multi organdysfunction syndrome. Since biliary bacteria havea strong association with pigment stone,microorganisms are also isolated from bile withcholesterol stones.6-9Post operative infection andits prevention is of concern to most surgeons. Rateof wound infection after elective in uncomplicatedsymptomatic cholilithiasis ranges from 7% to20%.1,10-13

Therefore, it is important to know the micro-organism of bile of the gall bladder beforeprophylactic antibiotics are given. Culture of bilefrom the gall bladder for patient withuncomplicated cholilithiasis has shown principallyE.coli.9,10,12,14 Others include pseudomonas spp.,Enterococcus faecalis, streptococcus spp andklebsiella spp.10,12,14 Prophylactic antibioticsprevent infections even though they do notsterilize the bile.15 Yet decreased rate of postoperative infection are invariably reported inpatient who have received prophylaxis, even whenrates of bactibilia are similar in treated patientsand untreated controls. Prophylaxis would beappropriate according to bacteria isolated fromthe bile and could prevent post operative infection.To justify antibiotic prophylaxis against biliaryorganisms, it requires to be shown that bile iscolonized with bacteria.

Aim of the study

To choose proper antibiotic for pre-operativeprophylaxis in cholecystectomy patients based onbacteriological profile of bile.

To evaluate the bacteriological profile of bile fromgall bladder in patient’s undergoing laparoscopiccholecystectomy for uncomplicated symptomaticcholilithiasis.

Methods

This is a prospective observational study carriedout at Surgery unit I, Sir Salimullah MedicalCollege and Mitford Hospital, Dhaka from

October,2016 to November 2018. The study wasundertaken after clearance from the ethicalCommittee of SSMC and Mitford Hospital, Dhaka.

Inclusion criteria:Patients undergoinglaparoscopic cholecystectomy and giving informedconsent for this study were included.

Exclusion criteria:Patient’s age less than18years,immunocompromised patients, anyknown source of sepsis in patients, pre-operativediagnosis of empyema gall bladder, history ofascending cholangitis, obstructive jaundice, pre-operative temperature higher than 37.3p c, WBCcount more than 14×109/L, diagnosed case ofcarcinoma gall bladder, CRP higher than 6 mg/Land ESR >20 mm/h in first hour.

Patient who had undergone endoscopic retrogradecholangio-pancreaticography(ERCP) andendoscopic sphincterotomy with in one weekexcluded from the study. All demographic datalike name, age and sex noted. Detailed historywas taken with physical examination andinvestigations were done. Ultrasonography weredone for all patients if needed, computedtomography and MRCP also done to confirm gallbladder pathology before surgery. All surgerydone under general anaesthesia and prophylacticantibiotics given at the time of induction. Operationfindings, complications and dates all are notedproperly.

Ultrasonography image shows echogenic calculiin the gall bladder with dense after shadow.

Bacteriological analysis of gall bladder bile in uncomplicated symptomatic Mohammed Masudur Rahman et al 74

Collection of bile:

3-5 cc bile aspirated with the use of sterile 20 No.spinal needle with 10 cc sterile syringe inlaparoscopic cholecystectomy after inserting fourports and before starting dissection. This collectedbile was transported to the laboratory in sterile testtube at room temperature within an hour forculture.

Method of culture

Bile samples were cultured aerobically in bloodagar, McConkey agar and chocolate agar and itwas performed in Microbiology department inSSMC. Direct inoculates of culture media andplates were incubated at 37p c under aerobicconditions. Direct gram staining was done to testfor the presence of organisms and pus cells. Theculture plates were examined at 24 and 48 hoursfor bacterial growth. An aliquot of bile wasinoculated into brain heart infusion (BHI) as anenrichment procedure. The broths were sub-cultured onto solid media following 24 hours ofincubation at 37p c. The plates were examined forbacterial growth at 24 and 48 hours. Then isolatedorganism identified by microbiological tests.Antibiotic sensitivity testing was performed for thesame.

Results

A total 72 patients admitted to Surgery Unit IDepartment of Sir Salimullah Medical College andMitford Hospital and undergone laparoscopiccholecystectomy were included in the study. Anevaluation was undertaken to study Bacteriologicalanalysis of bile and sensitivity of isolated organismto antibiotics was determined. Out of these 19patients whose bile cultures were positive and 59patients whose bile cultures were negative.

Maximum number of patients belonged to 41-50years. Organism isolation from bile foundmaximum in 19-30 years age group. Females werepredominated. Organism was isolated in total 19patients from which 5 patients with acutecholecystitis and 14 patients with chroniccholecystitis. In 53 patients no organism wasisolated, from which 5 with acute cholecystitis and48 with chronic cholecystitis. In most of thepatients duration of surgery was 55 to 90 mins.In13.95% (i.e.17 cases) E.coli, 5.20% (i.e. 1 case)Staphylococcus aureus, 5.20% (i.e.1 case)Acinetobacter was isolated in bacterial culture. In75.64% (i.e. 53 cases) no organism isolated.Bacterial sensitivity to the antibiotic result was asmentioned in Table I. Most of the organism showedsensitivity against levofloxacin, chloramphenicol,cefuroxime ,ceftazidime, cefixime, cefipime andimipenem. Post operative wound infection wasmore common (08.01%) in group of patients withisolated organism from bile. 2 patients wasdeveloped post-operative wound infection of 17patients.

Axial CT image in the portal venous phase showsmultiple hyper dense gall bladder calculi.

Aspiration of bile in laparoscopic cholecystectomywith 10cc sterile syringe and 20 No. spinal needle.

Sterile test tube.


Table-I

Number of sensitive bacteria

Name of antibiotic Escherichia coli Staphylococcus aureus Acinetobacter

(17, M-09, F-08) (1, M-0, F-1) (1, M-0, F-1)

Amoxycillin R-1Amoxyclav S-3, I-1, R-11 R-1Amikacin S-6, I-2, R-3 I-1 S-1Azithromycin R-6 S-1Aztreonam S-2, I-2, R-4 R-1Ceftriaxone S-4, R-7 S-1Cefixime S-3, R-7 S-1Ceftazidime S-5, R-9 R-1 S-1Cefuroxime S-5, R-7 S-1 S-1Cefutaxime S-3, R-5 S-1Cephradine S-1, R-3Cefipime S-10, I-2, R-3 S-1 S-1Ciprofloxacin S-5, I-1, R-5 S-1Chloramphenicol S-5, I-2, R-2 S-1 S-1Cloxacilin I-1, R-1 S-1Co-trimoxazol S-4, R-5 S-1Doxycycline S-2, R-1Gentamicin S-3, I-2, R-3Imipenem S-10, I-2, R-2 S-1 S-1Levofloxacin S-5, R-2Meropenem S-2NeomycinNalidixic acid S-2, R-9Nitrofurantion S-3,R-7Tetracycline S-1, R-3Colistin S-3, R-3 S-1

S= Sensitive, I=Intermediate, R= Resistant

Discussion

Aerobic bacteria, facultative aerobes andanaerobes may invade the biliary tract byascending from the duodenum and by thehematogenous route from the hepatic portal vein.Usually 85% of patients with gallstones remainasymptomatic for over 10 years.16,17 About 15% ofpatients with gallstones are subjected to surgeryfor uncomplicated symptomatic gallstones.9,17

There is a higher incidence of postoperativemorbidity and infectious complications in patientswith pathogenic bacteria in gallbladder bile thanin patients with no bacterial growth oropportunistic bacteria.9,16,17

Positive bile cultures are significantly morecommon in elderly (>60 years) patients with

symptomatic gallstones than in younger patients(45% versus 16%).18,19 Gram- negative aerobes arethe organisms most frequently isolated from bilein patients with symptomatic gallstones, acutecholecystitis or cholangitis. These studiesdocument a strong association between thepresence of bacteria in bile cultures taken atsurgery and the occurrence of subsequentinfection.14,20,21

Prophylactic antibiotics prevent infections eventhough they do not sterilize bile.22,23 Rates ofbactibilia are not reduced by prophylacticantibiotics that achieve bile levels that exceed theminimum inhibitory concentrations of recoveredbacteria.24 Yet, decreased rates of postoperativeinfection are invariably reported in patients who


have received prophylaxis even when rates ofbactibilia are similar in treated patients anduntreated controls.24 In most studies, infectionsdevelop in only 5-15% of patients with positive bilecultures who received prophylaxis.25,26

In this study the age pattern for patientspresenting for cholecystectomy showed that mostof the patients were belonging to the 3rd and 4th

decades of life. In AlaattinOzturk et al. study,27

ages ranged from 17 to 86 years with a mean ageof 48.6±16.8. Majority of patients were female(Female:male=2.5:1).In this study majority ofpatients found in age group between 41-50 years.Organism found maximum in 19-30 years agegroup. Majority of the patients in both groups werefemale (51 females and 21 males).

In AcharyaSuri et al. study,15 the highestincidence of positive cultures was noted in patientswith acute cholecystitis (40%). Although thisdifference was statistically not significant. InAlaattinOzturk et al. study,27 the highest incidenceof positive cultures was noted in patients withchronic cholecystitis (66.7%). In acute cholecystitisincidence of positive cultures was (20%) and thirdgroup acute cholecystitis with choledocholithiasisincidence were 3 patients out of 15 (13.3%). Amongthis group difference was statistically significant(p value=.003). In this study positive bile culturewas a more common finding (50% of patients werebile culture positive) in patients with acutecholecystitis. In the vast majority of patients withchronic cholecystitis, the bile was sterile (only20.59% of patients were bile culture positive).Although this difference was statistically notsignificant (pvalue=0.10)

In AcharyaSuri et al.,27 on gram staining, noorganism was found microscopically in the bile of24 (82.6%) patients. Later on, it was confirmed thatsuch bile was sterile because no growth appearedon culture plates, both aerobic and anaerobic. Inthe present study only aerobes were cultivated.Escherichia coli (13.95%) was one of the mostcommon isolated bacteria followed byStaphylococcus aureus (5.20%) and Acinetobacter(5.20%). In none of the cultures Streptococcus,Clostridium orKlebsiella was present. Thesefindings are similar to as observed in other studies.

In AcharyaSuri et al.,27 the sensitivity of theorganisms grown in our analysis of 26 out of 150

patients was tested againstcefuroxime,cefoperazone and cefepime and it was found thatsensitivity to third and fourth generationcephalosporins was higher as compared to secondgeneration cephalosporins in acute as well aschronic cholecystitis. The resistance to secondgeneration cephalosporins has increased whilethird and fourth generation cephalosporins showbetter promise and may be used as the first line ofpreoperative prophylaxis in operations forcholecystectomy.18 In our study, sensitivity of theorganisms grown in our analysis of 19 out of 72patients were tested against amoxyclav.amikacin,azithromycin, ceftriaxone, cefixime, ceftazidime,cephradine, chloramphenicol, gentamicine,imipenem , levofloxacin, tetracycline and it wasfound that sensitivity to third and fourthgeneration cephalosporins (ceftazidime,cefouroxime, cefepime etc.) was higher ascompared to aminoglycoside, 1st and 2nd

generations cephalosporins in acute as well aschronic cholecystitis. Levofloxacin also showedgood sensitivity against isolated organism frombile. Majority of the organisms were sensitive tothird generation cephalosporins and one patienthad multi resistant organisms. The resistance tofirst and second generation cephalosporins andaminoglycoside has increased while thirdgeneration, fourth generation cephalosporins andlevofloxacin ,imipenem show better promise andmay be used as the first line of preoperativeprophylaxis in operations of cholecystectomy.

Valazquez-Mendoza JD et al.28 study, total 80patients, 40 patients with bile culture positive and40 patients with wound culture positive. There wasno statistically significant difference whencomparing surgical site infection in both groups.In our study, 2 patients showed wound infection(3.1%) with positive culture reports which wassimilar with micro-organism isolated in bileculture of same patients. Clinically there wasstrong correlation between bile culture and woundculture.Statistically on application of rankcorrelation p value 0.01. This showed there was astatistically significant correlation between bileculture and same wound culture.

Conclusion

In majority of patients the bile was sterile. Only19 patients had positive bile culture. The third and


fourth generation cephalosporins and levofloxacinshow better promise and may be used as the firstline of preoperative prophylaxis in operations foruncomplicated symptomatic cholilithiasisundergoing cholecystectomy.

Conflict of interest None

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16. Csendes A, Mitru N, Maluenda F, Diaz JC, Burdiles P,Csendes P, et al. Counts of bacteiliria and pyocites ofcholedochal bile in controls and in patients withgallstones or common bile duct stones with or withoutacute cholangitis. Hepatogastroenterology.1996;43:800-806.

17. Samy AK, Macbain G. Associations of positive bilecultures with the magnitude of surgery and the patientsage. J R CollSurgEdinb. 1995;40: 188-191.

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Correlation between Helicobacter pylori infection

and perforated duodenal ulcer diseaseIshrat Jahan1, Sadia Imdad2

Abstract

Background: Though the role of H. pylori in the pathogenesis of chronic duodenal ulcer is

well established its role in perforated duodenal ulcer needs to be worked out in more detail. For

treatment of perforated duodenal ulcer to be rational, not arbitrary, clinicians definitely need

a lot more basic information like whether perforation is just a complication of duodenal ulcer

or sufficiently different to be recognized as a distinct entity with separate etiology and

pathogenesis.

Methods: In this prospective study 35 patients with perforated duodenal ulcer disease were

purposively selected from January 2011, to June 2012 at the Department of Surgery, Sir

Salimullah Medical College Mitford Hospital, Dhaka. To detect whether patients has or had H.

pylori infection circulating IgG to H.pylori was detected by ELISA from patient’s blood sample

using Helicop-G Kit. The patients were given eradication therapy during discharge and were

asked to visit after 6 months for follow up during which an upper gastrointestinal endoscopy

was done to evaluate the status of the duodenal ulcer disease.

Results: The mean age of the patient was 33.23(±9.55; SD) years and no absolute majority seen

in any age group. Most of the patients were male (94.3%) being day laborer (28.6%) and

businessman (25.7%).68.6% patients had a previous history of peptic ulcer disease. 49.1% patients

gave history of taking NSAIDs. 82.9% was found to have Anti H.pylori IgG in their blood. No

significant relationship was found between presence of Anti- H.pylori IgG and age, sex, religion,

occupations, smoking habits, previous history of peptic ulcer diseases and history of taking

NSAIDs. (p>.05)

Conclusion: This study indicates that majority of the patients had antibody to H. pylori in

their blood sample mostly due to area specific patients’ characteristics rather than as an etiological

factor. A single course of conventional eradication therapy following proper counseling to

ensure compliance was 100% successful. So there is definite need to pay attention for eradication

of H.pylori in every patient being presented with perforated duodenal ulcer disease to prevent

future complications.

Keywords Helicobacter pylori, peptic ulcer disease, perforation.


1. Associate Professor, Department of Surgery, SSMCMH, Dhaka2. Junior Consultant, Department of Surgery, ShSMCH, Dhaka.Correspondence: Dr. Ishrat Jahan, Associate Professor, Department of Surgery, Sir Salimullah Medical College MitfordHospital Tel: +8801711150220; [email protected]

Introduction

Though for many years, excess acid was believedto be the major cause of peptic ulcer disease andemphasis was given on neutralizing and inhibitingsecretion of gastric acid and many factors likechronic use of NSAIDs, steroids, smoking havebeen reported contributing to ulcer pathogenesis,currently the leading cause is thought to beinfection of the stomach and duodenum byHelicobacter pylori.1

At least half of the world’s population is infectedby this Gram-negative microaerophilic bacterium

whereas only < 30% are symptomatic.2Prevalenceof infection is higher in developing countries likeours due to poor socio-economic conditions andovercrowding.2 In Bangladesh such prevalence is40% in infant and 74% in 2-5 years age grouprespectively.3 Though prevalence is very high inour country only <15% of infected populationdevelop peptic ulcer diseases.4

Among peptic ulcer patients, duodenal ulcer wasfound to be commoner than gastric ulcer orcoexistent duodenal and gastric ulcer.5 Helicobacter

pylori infection causes predominant antral gastritisleading to disturbance in gastrin secretion and

henceforth acid hypersecretion.6 In response tothis, areas of gastric metaplasia may develop inthe duodenum which are subsequently colonizedby Helicobacter pylori that ultimately become thesites for ulcer formation in the duodenal. 7 Withthe advent of excellent anti-ulcer pharmacotherapycomplications of duodenal ulcer disease in generalhas been reduced tremendously.1 But the incidenceof the most notorious acute complication that isperforation has not decreased at the same rate.1

Traditionally simple closure with or withoutGraham patch is the accepted practice duringlaparotomy as the procedure is a short low riskedone and could be carried out completely even byjunior surgeons.6

But whether colonization by Helicobacter pylori

plays any role in the pathogenesis of thisperforated duodenal ulcer disease is yet unknown.Various international and a few national studieswere done with a view to answer this intriguingquestion. Our study similarly aimed to investigatethe correlation between Helicobacter pylori

infection and perforated duodenal ulcer disease.

Methods

From January 2011 to June 2012 thirty fivepatients presenting with perforated duodenal ulcerdisease were studied in the surgical units of SirSalimullah Medical College Mitford Hospital.Patients with features of perforation due toperforated gastric ulcer, jejunal perforation,perforated ileum, burst appendix, traumaticperforation and death during resuscitation wereexcluded. Patients taking steroids were also excluded.A comprehensive details like age, sex, past medicalhistory, past history of peptic ulcer disease, historyof dyspepsia, drug history, smoking and drinkinghabits, family history etc. were recorded.

A patient was considered to have a past history ofpeptic ulcer disease when an active ulcer ordeformed duodenum was found in previous filmsof barium meal or from endoscopic views or bylaparotomy findings or when he had experiencedepisodic upper abdominal pain with nocturnal painthat have some relation to food and was relievedby taking any sort of anti-ulcer therapy.

All patients were treated by urgent laparotomyfollowing resuscitation as and when required.Simple closure of the perforation site in theduodenum was done using 2/0 atraumatic vicrylalong with over sewing omental patch. Thorough

peritoneal toileting was done in all the cases.Mortality was nil and morbidity as superficialsurgical site infection in few cases was noted andtreated on its own merit.

There are six different types of antigens found inHelicobacter pylori which are isolated by theirmolecular weight (KDa).Namely 116 KDa, 89 KDa,37 KDa, 35 KDa, 30 KDa, and 19.8 KDa.; amongthem 116 KDa is known as Cytotoxin AssociatedGene (Cag A+) and 89 KDa is known asVascuolating Cytotoxin Gene (Vac A S1) and theyare more specific. Thus Helicobacter pylori elicitboth a local mucosal and a systemic antibodyresponse. To detect whether patients has or hadHelicobacter pylori infection, circulating IgG toH.pylori was detected by ELISA from patient’sblood sample using Helicop-G Kit.

All patients were given eradication therapy afterproper counseling to ensure compliance duringdischarge and were asked to visit after 6 monthsfor follow up during which an upper gastrointestinalendoscopy was done to evaluate the status of theduodenal ulcer disease.

After compilation of data, obtained data werechecked, verified, edited and coded and appropriatestatistical tests were done depending on thedistribution of the data.

Results

The mean age of the patient was 33.23(±9.55; SD)years. The range was 19-60 years and no absolutemajority seen in any age group. It was found thatpatients’ belonging to 30-34 years age group wasslightly higher (25.7%) than the other groups.

0 5 10 15 20 25 30

Below 25

25-29

30-34

35-39

40 & >40

Distribution of Patients by Age Groups (n=35)

Frequency (%)

Fig-1: Distribution of patients by age (n=35)

Correlation between Helicobacter pylori infection and perforated duodenal Ishrat Jahan & Sadia Imdad 80

94.3% of the patients were male .The patients wereengaged in different types of occupation with themajority being day laborer.

Non smoker patients were predominant in thisstudy (60%) and 68.6% patients stated that theyhad peptic ulcer disease anytime in the past forwhich 45.7% was taking ranitidine and 22.9% wastaking omeprazole but neither any of themcompleted their treatment schedule nor have evertaken any sort of eradication therapy forHelicobacter pylori. 49.1% patients gave history oftaking NSAIDs within last 24 hour.

Out of 35 patients 29 (82.9%) was found to haveAnti-H.pylori antibody in their blood. There wasno significant relationship (p>.05) between the ageof the patients and the presence of Anti-H.pylori

antibody in their blood samples.Fig.-2 Distribution of patients by occupation (n=35)

Business (25.7%)

Day Labor (28.6 %)

Garment Worker(8.6%)

Driver[Taxi,Rickshaw](19%)

Farmer(5.7%)

Others(8.7%)

Table I

Relationship between ages with presence Helicobacter pylori infection (n=35)

Name ofCharacteristics Presence of Anti H.pylori antibody N Mean SD P

Age of the Patient Yes 29 33.66 9.51 .569

No 6 31.16 10.36

Relationship between presence of Helicobacter pylori infection and other variables was sought and nostatistically significant (p>.05) relationship was found as shown in table II.

Table II Relationship between other variables with Helicobacter pylori infection. (n=35)

Name of Variables Helicobacter pylori infection P

Positive Negative

Sex Male 28(84.8%) 05(1.2%) >.05

Female 01(50%) 01(50%)Total 29(82.9%) 06(17.1%)

Occupation Day Labor 08(80%) 02(20%) >.05

Business 07(77.8%) 02(22.2%)Driver 06(85.7%) 01(14.3%)Others 08(88.9%) 01(11.1%)Total 29(89.2%) 06(17.1%)

Smoking Yes 11(78.6%) 03(21.6%) >.05

No 18(85.7) 03(14.3%)Total 29(89.2%) 06(17.1%)

Previous history of PUD Yes 09 (81.8%) 02(18.2%) >.05

No 20(83.3%) 04(16.7%)Total 29(89.2%) 06(17.1%)

History of taking NSAIDs Yes 10(58.82%) 7(41.18%) >.05

No 9(50%) 9(50%)Total 19(54.28%) 16(45.72%)

22 cases attended follow up with upper GI endoscopy that revealed healed ulcer in 100% cases; no reperforation was noted.


Discussion

This prospective study definitely reveals highprevalence of Helicobacter pylori infection inperforated duodenal ulcer disease in our context.82.9% patients had circulating antibodies toHelicobacter pylori in their blood. Similar highprevalence was also noted by other authors likeKumar et al8, Metzger et al9, Chu et al10 andMihmani et al11. The question remains whetherthis is just an association or the microbe plays anyrole in the pathogenesis of the complication ofduodenal ulcer disease like perforation.

No single age group had absolute majority.Percentage of infected perforated patients was notincreasing with age. There is controversy aboutthis phenomena; some author like Pounder RE2

found that percentage was increasing with age like50% infected over the age of 60 compared to 10%between 18 and 30 years and some like Ng EK etal12 found it to be decreasing with age. But thefindings of Lee et al13 and Reinbach DH et al14

have similarity with our study. This variation ismostly due to difference in sociodemographicvariables of different study population.

The reason for male predominance and day laborerto be the occupation of most cases in our seriesmay be due to that they lead a comparatively morestressful life, have more chance of taking NSAIDsand are more habituated to smoking in our socialcontext. Life style of day laborer (overcrowdingand poor hygiene) also favors contamination withHelicobacter pylori henceforth they have highpercentage of positive Anti-H.pylori antibody intheir blood sample. Pounder RE2, Ng EK et al.12

found similar male predominance but Reinbach DHet al.14 and Mihmani et al11 found no genderpredominance. Other investigators found differentoccupations relating to this disease. This resultsmight be area specific hence the disparity.

A majority of patients (68.6%) gave history ofprevious symptoms of PUD but none completedtheir treatment and none had eradication therapyfor Helicobacter pylori. This is a commonphenomena in our population cause they are usedto treat themselves with known over the counteranti-ulcer therapy irrationally when facing withthe complain of pain or dyspepsia. Furthermorethe need for eradication of Helicobacter pylori isnot well understood among the physicians yet as

there is no definite national guideline. Chu et al.10

found 41.1% patients giving history of recurrentepigastric pain , 9.5% of whom also had a historyof bleeding ulcer . In our country Sultana et al.3

found 73% of their study population having chronicPUD. The chronicity was attributed mainly to non-compliance, irrational use of NSAID’s, and havingirregular food habit. But Kumar et al.8 found only8.14% cases with history of previous symptoms ofPUD. The lower rate of chronic PUD in the westis thought to be due to higher hygienic standardsand widespread practice of eradication along withappropriate health care delivery system.

Relationship between Helicobacter pylori infectionand other variables like sex, occupation, smokinghabit, previous history of peptic ulcer disease andtaking NSAIDs was sought and no statisticallysignificant (p>.05) relationship was found. Thoughfindings of Lee et al.13 correlates well with us butPillay et al.15 showed significant associationbetween Helicobacter pylori infection and age,ethnicity, smoking status and NSAIDs usage.Hamajima et al.16 and Lin et al.17 both in theirstudies found significant association betweenpresence of Anti-H.pylori IgG and current femalesmokers (OR=2.8 & 1.9 respectively) but notcurrent male smokers; the reason of which theycould not describe. Our lack of any substantialfindings may be due to our small sample size.

Sebastian et al.18 and Chu et al.10 commented thatHelicobacter pylori infection is related to high rateof duodenal ulcer persistence and recurrent ulcerdisease in patients with a history of perforatedduodenal ulcer. Rodriguez-Sanjuan et al.19 founderadication therapy to be associated with low rateof recurrence and no re perforations in case ofperforated duodenal ulcer disease. Our patientswere all given eradication therapy and 62.8% casesattended follow up with upper GI endoscopy thatrevealed healed ulcer in all cases.

Matsukura et al.20 found presence of Anti-H.pylori

IgG in 95% of perforated versus 93% of nonsurgicalduodenal ulcer disease and assumed thatHelicobacter pylori is not etiologically related toperforated duodenal ulcer disease. Reinbach DHet al.14 also due to lack of association betweenperforated duodenal ulcer and Helicobacter pylori

infection suggested that perforated duodenal ulcerhas a different pathogenesis from chronic duodenal

Correlation between Helicobacter pylori infection and perforated duodenal Ishrat Jahan & Sadia Imdad 82

ulcer. In our series we also failed to establish anyetiological relationship between the two entities.

Undoubtedly perforated duodenal ulcer disease isan extreme phase of duodenal ulcer disease whereatrocity of the causative factors is suspected to beat maximum. To prevent disease persistence andto reduce recurrent perforation rate plausible allkinds of prudent precautions need to be taken.Eradication therapy is an easy but easily ignoredstep among these precautions.

Our current findings are area specific. The patientscoming to SSMCMH mostly hail from old Dhaka,belong to low socio-economic community, live inovercrowded spaces and lacks standard hygiene whichmakes them prone to contamination by the microbeas well as chronicity of the duodenal ulcer diseaseand that is our assumption for the high prevalence ofHelicobacter pylori infection in this particularperforated duodenal ulcer disease patient group.

Conclusion

Duodenal ulcer perforation is a multi-factorialdisease and in addition to the microbial gastro-duodenitis there are many other disease modifierssuch as acid-pepsin secretory potential, smoking andother genetic and environmental factors. Theinterplay of these various variables might explainwhy some of the patients with duodenal ulcer diseaseare developing complications like perforation andothers do not. Yet it is an established cause of diseasepersistence and recurrence. A simple conventionaleradication therapy to date is sufficient enough toensure healing. So attention needs to be paid foreradication of Helicobacter pylori in every patientbeing presented with perforated duodenal ulcerdisease to reduce recurrence rate and futurecomplications.

Reference1. Christensen A. Bousfield R. Christiansen J. Incidence

of perforated and bleeding peptic ulcer before and afterthe introduction of H2 receptor antagonist. Ann Surg1988; 207: 4-6.

2. Pounder RE, Ng D (1995). The prevalence ofHelicobacter pylori infection in different countries.Aliment. Pharmacol Tacr. 9 suppl 2: 33-9.

3. Sultana S, Sarker SA, Satter S, Ahmed T, Suchs GJ,Davidsson L et al. Serum ferritin, haemoglobin, solubletransferring receptor and Helicobacter pylori infectionin peri-urban community children in Bangladesh.Abstract of the 8th Commonwealth Congress inDiarrhoea and Malnutrition of CAPGAN onHelicobacter pylori infection in children, ICDDR,B,Dhaka. February 6-8, 2006;33.

4. Poddar U, Thapa BR. Helicobacter pylori infection inchildren. Indian Pediatr , 2000; 37:275-283.

5. Kuster JG, Van Vliet AH, Kuiper EJ (July 2006).Pathogenesis of Helicobacter pylori infection. ClinMicrobiol Rev 19th (3): 449-90.

6. Graham GV, Gom F. Helicobacter pylori: Current status.Gastroenterology 1993;105:279-282.

7. Rauws EJA, Tytgat DNJ. Cure of duodenal ulcerassociated with eradication of Helicobacter pylori. Lancet2000; 55: 1233-35

8. Kumar S, Mittal GS, Gupta S, Kaur I, Aggarwal S.Prevalence of Helicobacter pylori in patients withperforated duodenal ulcer. Trop Gastroenterol. 2004Jul-Sep; 25(3):121-4.

9. Metzger J, Styger S, Sieber C, von Flue M, VogelbachP, Harder F. Prevalence of Helicobacter pylori infectionin peptic ulcer perforations. Swiss Med Wkly. 2001 Feb24; 131 (7-8):99-103.

10. Chu Km, Kwok KF, Law SY, Tuen HH, Tung PH,Branki FJ , Wong J. Helicobacter pylori status andendoscopy follow up of patients having a history ofperforated duodenal ulcer. Gastrintest Endosc. 1999Jul; 50(1): 58-62.

11. Mihmanli M, Isgor A, Kabukchouglu F, Turkay B, CiklaB, Baykan A. The effect of H. pylori in perforation ofduodenal ulcer. Hepatogastroenterology. 1998, Sep-Oct;45(23):1610-2.

12. Ng EK, Chung SC, Sung JJ, Lam YH, Lee DW, Lau JY,Ling TK, Lau WY, Li Ak. High prevalence ofHelicobacter pylori infection in duodenal ulcerperforations not caused by non-steroidal anti-inflammatory drugs. Br J Surg. 1996 Dec; 83(12):1779-81.

13. Lee WJ, Wu MS, Chen CN, Yaun RH, Lin JT, ChangKJ. Seroprevalence of Helicobacter pylori in patientswith surgical peptic ulcer. Arch Surg. 1997; 132 (4):430-433.

14. Reinbach DH, Cruickshank G, McColl KE, Acuteperforated duodenal ulcer is not associated withHelicobacter pylori infection. Gut 1993;34:1344-1347.

15. Pillay KV, Htun M, Naing NN, Norsaadah B.Helicobacter pylori infection in peptic ulcer disease: theimportance of smoking and ethnicity. Southeast AsianJ Trop Med Public Health. 2007 Nov; 38(6): 1102-10.

16. Hamajima N, Inoue M, Tajima K. Lifestyle and anti-Helicobacter pylori immunoglobin G antibody amongoutpatients. Jpn J Cancer Res 1997; 88:1038-43.

17. Lin SK, Lambert JR, Nicholson L. Prevalence ofHelicobacter pylori in a representative Anglo-Celticpopulation of urban Melbourne. J GastroenterolHepatol 1998; 13:505-10.

18. Sebastian M, Cruickshank G, McColl KE. Acuteperforated duodenal ulcer is not associated withHelicobacter pylori infection. Gut 1993; 34:1344-47.

19. Rodriguez-Sanjuan JC, Fernandez-Santiago R, GarciaRA, Trugedo S, Seco I, La de Torre F, Naranjo A,Perforated peptic ulcer treated by simple closure andHelicobacter pylori eradication. World J Surg. 2005. July;29(7): 849-52.

20. Matsukura M, Onda M, Tokunaga A, Kato S, YoshiyukiT, Hasegawa H, Yamashita K, Tomtichong P, HayashiA. Role of Helicobacter pylori infection in perforation ofpeptic ulcer: an age and gender matched case-controlstudy. J Clin Gastroenterol. 1997; 25 Suppl 1:S235-9.


Spinal Cord Compression Secondary to Extra

Medullary Hematopoiesis in a 26-Year-Old Man

with Hb E-Beta Thalassemia: A Case ReportRanajit Sen Chowdhury1, Sarder Md Giasuddin2, Md. Moshiur Rahman3

Abstract:

Extra medullary Hematopoiesis(EMH) refers to hematopoiesis occurring in organs outside of

the bone marrow and it is found in a variety of hematologic illnesses including thalassemia

and myeloproliferative disorders. Although extra medullary hematopoiesisusually occurs in

the liver, spleen, and lymph nodes, rarely it may also occur within the spinal canal and in those

cases,hematopoietic cell colonies may disrupt the cortex of the bones involved and even form

para spinal masses of extra medullary hematopoietic material which may produce spinal cord

compression.We present a very rare case in which a 26-year-old man with HbE-Beta thalassemia

presented with bilateral lower limb paresis.His MRI of Dorso-Lumber Spine show lobulated

paravertebral soft tissue swelling from D2-D12 vertebra.The diagnosis of extra medullary

hematopoiesis was confirmed with CT guided FNAC from paravertebral mass.This report

illustrates that,although Paravertebral extra medullary hematopoiesis is rare, should always

be considered in the differential diagnosis of any spinal cord compression (SCC) in patient

with thalassemia.

Keywords: Extra medullary Hematopoiesis; Spinal Cord Compression;Hb E-Beta Thalassemia


1. Associate Professor (Medicine), Sir Salimullah Medical College &Mitford Hospital, Dhaka, Bangladesh2. Indoor Medical Officer (Medicine), Sir Salimullah Medical College& Mitford Hospital, Dhaka, Bangladesh3. Assistant Professor, Department of Nephrology, Sir Salimullah Medical College& Mitford Hospital, Dhaka, BangladeshAddress of Correspondence: Dr. Ranajit Sen Chowdhury, Associate Professor(Medicine), Sir Salimullah Medical College& Mitford Hospital, Dhaka, Bangladesh, Email: [email protected]

Introduction

Extra medullary hematopoiesis is a compensatoryphenomenon which occurs when there is notenough functional red blood cells to fulfil the body’soxygen demands, usually seen in hematologicconditions that can reduce the amount of functionalred blood cells like thalassemia1,2, sickle cellanemia, hereditary spherocytosis, myelofibrosis3

and polycythemia Vera etc. EMH is mainly seenin liver, spleen and lymph nodes4, less commonsites include the retroperitoneal tissue, kidneys,adrenal glands, paravertebral area, thymus,breasts,lung, sweat glands, pleura, gastrointestinaltract, prostate,skin, brain and broad ligaments.2,5.

Very rarely extra medullary hematopoiesisoccursin the spinal canal.6 The 1st case of spinal cordcompression (SCC) due to extra medullaryhematopoiesis in a patient with Thalassemia wasreported by Gatto in 19547, while the 1st Indiancase was reported by Prabhakar et al in1980.Among the documented episodes ofthalassemia-associated extra medullaryhematopoiesis, intraspinally located growths occur

in 11–15% of cases.8,9 The presence of extramedullary hematopoiesis is particularly worrisomein the spinal region as it acts as a space occupyinglesion (SOL) in a region that is alreadycompromised for space, thus producing morbidconsequences.Within the spine, the most commonsite is the thoracic region, followed by the lumbarregion5, moreover, the thoracic spine can beproblematic for extra medullary hematopoiesisbecause the spinal canal is especially narrow inthis region.5,10,11 As the condition is rare, there isno definite consensus regarding the treatment forthis condition which includes several options likesurgical resection, Radiotherapy(RT), Hypertransfusion (HT), Hydroxyurea (HU)administration or a combination of the above04

We present a case of a 26-year-old male whopresented with bilateral lower limb weakness,sensory deficits, bowel and bladder dysfunctionalong with anaemia and jaundice.

Case Report

Md Sumon Mia, 26 years of old, normotensive, non-diabetic and smoker gentleman, hailing from

sherpur got admitted into MU -6, SSMC & MitfordHospital on 11.11.18 with the complaints of pallor,gradual weakness & Yellowish discoloration ofskin, sclera and urine for 1 year and GradualWeakness of both lower limbs for same duration.According to the patient’s statement, he has beensuffering from generalized weakness and lethargysince childhood. At his 13 years of age, he gotadmitted into a local hospital with fever &transfused with1 unit of whole human blood tocorrect anaemia which was not associated withepistaxis, gum bleeding, hematemesis, maleanaor any other sorts of blood loss & was not evaluatedfurther at that time. For last 1 year, his weaknessand pallor have become more marked along withdevelopment of yellowish discoloration of sclera,skin and urine.Patient also complaints of weaknessof both lower limbs for last 1 year, which isgradually increasing and now he is completelyunable to move his lower limbs and becomes bedbound. He also complaints of numbness of lowerpart of his body. Patient gave no history of lowback pain, trauma or fall from height.Patient alsocomplaints of development of incontinence of bowel& became unaware of his micturition reflex.Patientgave history of recurrent bouts of low grade feverwhich has no diurnal variation, not associated withchills & rigor or sweating and gave history of weightloss but his fever and weight loss are notdocumented.

With these complaints, he admitted into a privatehospital 6 months back and diagnosed as a case ofHbE B Thalassemia with presenile cataract of botheye and got 6 units of fresh whole human bloodtransfusion in 3 occasions.Patient gave no historyof cough, chest pain, back pain, vertigo, diplopia,facial weakness, dysphagia or contact with TBpatient.

On general examination, patient is anxious, illlooking, moderately anaemic and mildly icteric.his pulse is 96 bpm, BP is 110/60 mmHg,temperature normal, RR is 16 bpm. There is nolymphadenopathy, bony tenderness. There is abony prominence at the level of T 10.Abdominalexamination revealed spleen is enlarged by 16 cmalong it’s long axis, firm, non-tender, splenic notchis palpable. Liver is not palpable. Para aortic lymphnodes are not palpable. No Ascites is present.

Nervous system examination revealed there ismuscle wasting along with reduced bulk of musclein both lower limb, muscle tone is increased,muscle power is (0/5), knee and ankle jerks areexaggerated, planter reflex is extensor, ankleclonus present in both lower limbs.

Abdominal reflex and cremasteric reflex are lost.Inboth upper limbsfindings are normal. There is lossof all modalities of sensation up to T6 level.Cranialnerves are intact; cerebellar signs are intact. Thereis no sign of meningeal irritation. Gait couldn’t beevaluated due to weaknessof both lower limbs.Onfundoscopy, left eye is normal, right eye could notbe examined due to presence of cataract.

Investigations revealed following findings: Hb%:4.8 gm/dl, ESR: 25 mm in 1st hour, MCV:59.5 fL,MCH: 16.9 pg, MCHC: 28.4 gm/dl, PBF showsmicrocytic hypochromic anaemia stronglysuggestive of hereditary hemolytic anaemia andeosinophilia, Urine R/E:Protein: Nil,Sugar: Nil,Pus Cells: 0-2/ HPF,S. Creatinine:0.8 mg/dl,RBS:5.4 mg/dl, ECG:Within Normal Limit, CXRP/A view:Cardiomegaly, Echocardiography:normal.EF (61%),SerumIron:50 mg/dl, S.Ferritin :1396.33ng/ml, T.I.B.C: 220 mg/dl,S. Bilirubin:3.8 mg/dl,USG of W/Abdomen: shows Spleen is enlarged insize (16 cm) & uniform in echotexture.X-Ray Dorso–Lumbar Spine:Osteoporotic change in D/L Spine.

Fig.-1: Wasting of both lower limb.Fig.-2: X-ray D/L Spine: Osteoporotic change in

D/L spine


Hb Electrophoresis showsHb E Beta Thalassemia,Serum Ig Electrophoresis: no band is seen on serumcapillary IFE, suggestive of no abnormal (increased)accumulation of Ig molecule or free chain in theserum. MRI of Dorso-Lumber Spine showsLobulated paravertebral soft tissue swelling isnoted from D2-D12 vertebra showingheterogeneously hyper signal intensity on bothT1W and T2W images. Extension of soft tissueswelling is also noted in the spinal canal whichcompressing the adjacent spinal cord.

CT guided FNAC from paravertebral mass showsfeatures are consistent with extra medullaryhaematopoiesis.

So, finally the patient was diagnosed as Hb E BetaThalassemia with Spastic Paraplegia due to extramedullary haematopoiesis and was treated byHydroxyurea 500 mg twice daily along with four-unit blood transfusion and give advice to takeradiotherapy. After getting radiotherapy, he feltsymptomatically better.

Discussion:

Extra medullary haematopoiesis is defined ashematopoiesis that occurs outside bone marrow.It is a compensatory phenomenon that occurs inconditions whenerythrocyte productionisdiminished ordestruction is accelerated likeThalassemia [1,2], Sickle cell anemia, Hereditaryspherocytosis, Myelofibrosis.3 Acquired hemolyticanemias, Vitamin B12 and folic acid deficiency,Bone marrow

irradiation, Lymphomas as well as in condition ofclonal disorder of hematopoiesis likePolycythemiaVera, Chronic Myeloid Leukemia and MyeloidMetaplasia. Among these thalassemia-associatedextra medullaryhaematopoiesis that results inspinal cord compression(SCC) is far from common.Thalassemia Intermediawas reported to have anincidence of 15-20%, while it is less than 1% incases of Thalassemia Major [12,13]. Despiteextensive literature search, there are only twocases reported in literature of spinal cordcompression(SCC) due to extra medullaryhematopoiesis in patients with Thalassemia Minor.Extra medullary hematopoiesis commonly involvesthe liver, spleen and lymph nodes. Less commonlyit can involve pleura, adrenals, breast, thymus,kidneys, gastrointestinal tract, intracranialstructures, retroperitonealtissue, sweat glands,prostate, broad ligaments, peripheralnerves, heart,retroperitoneal fat, Para spinal regions.2,5 Paraspinal location of extra medullary hematopoiesishas been noted in 11-15% cases. However, Kochet al reported para spinal locationin only 0.6%cases of extra medullary hematopoiesis[12-15].Paraspinal extra medullary hematopoiesis is importantas it tends to form pseudo tumors which behavinglike a SOL and causing spinal cord compression(SCC) that has considerable morbidity [12-14].Thoracic and lumbar regions are most frequently

Fig.-3: MRI of D/L Spine. Lobulated paravertebral

soft tissue swelling is noted from D2-D12 vertebra.

Medullary expansion with cortical breech is notedin the posterior end of rib and posterior arch ofvertebra from D2-D12.This features are consistentwith extra medullary haematopoiesis.

Fig.4 MRI of D/L Spine. Extension of soft tissue

swelling in the spinal canal compressing the

adjacent spinal cord.

Spinal Cord Compression Secondary to Extra Medullary Hematopoiesis Ranajit Sen Chowdhury et al 86

affected4,12,13 The exact cause for this is notknown, however it adds to the morbidity as thespinal canal is quite narrow here and has limitedmobility. Patients with SCC secondary to EMHpresent mainly in the third to fourth decades oflife4,12 However similar cases have been reportedin the 1st decade suggesting that it might beaffected by the severity and chronicity of theunderlying disorder. Males have a higherpreponderance with sex ratios ranging from 5:1 to2.5 :112,13 Most cases present with para paresis,sensory impairmentand occasionally sphincterdisturbances. Complete paraplegia has beenreported very rarely in thalassemia and occursmore frequently in polycythemia rubravera andsickle cell anemia. MRI is now considered to bethe diagnostic modality of choice [16] which showsan isointense mass with a high signal intensityrimon T1_weighted images and ahyper intensemass on T2-weighted images and consideredsuperior to computed tomography (CT). MRI ishighly sensitive in detecting the exact site andextent of the lesion, in demonstrating SCC andalso results in lesser exposure to radiation. CTimaging of active lesionswill demonstrate softtissue density on CT. Inactive lesions composed ofiron deposits will demonstrate high density on CT,whereas fatty deposits will show low density.12,17

Biopsy is not always required for diagnosis5, but ifneeded, it can be obtained via CT-guided needlebiopsy.18 However, in some studies noninvasiveprocedures such as 18F-FLT PET/CT and 99M TC-SC SPECT/CT scintigraphy is recommended toestablish the definite diagnosis. Differentialdiagnosis includes Metastatic malignantneoplasms, Lymphomas, Multiple myeloma,Vascular anomalies and Epidural abscess.Histopathological examination reveals maturetriliniage proliferation of erythroid, myeloid andmegakaryocyte proliferation along with adiposetissue. The differential diagnosis to this conditionis neoplastic proliferation of myeloid lineage inwhich there is monomorphous population ofimmature myeloid cells.12

Multiple treatment options have been describedin literature with variable results for EMH-inducedspinal cord compression including surgicaldecompression, radiotherapy (RT), hypertransfusion (HT) of red blood cells. Often, morethan one type of therapy will be utilized for each

patient.1,5 As an adjuvant, hydroxyurea issometimes used for its myelosuppressiveproperties.5

When extra medullary hematopoiesis is associatedwith neurological deficits, surgical intervention isnecessary to decompress the neural elements andobtain a tissue for histopathological diagnosis.

However, gross total resection of an extramedullary hematopoiesis mass is not alwayspossible due to the borderless nature of thehematopoietic process.2 Surgery also has theassociated risks of general anesthesia, which isgenerally required for spinal operations and suddenclinical deterioration as these tissues areresponsible in maintaining the necessaryhemoglobin levels. Although opinions vary, it isgenerally agreed that surgical management ofextra medullary hematopoiesis should be reservedfor acute, severe, or recurrent cases1,5 For manypatients, radiotherapy is emerging as thetreatment of choice for extra medullaryhematopoiesis induced spinal cord compressionbecause Hematopoietic tissue is highly sensitiveto ionizing radiation.2 is of low risk and welltolerated. One group indicated that the extramedullary hematopoiesis volume decreases by16.4% immediately after radiotherapy.20 However,one problem with radiotherapy is that it canexacerbate anemia by decreasing hematopoiesisin the surrounding tissue5, and therapy cannot beinitiated without establishing a diagnosis first.19

Hyper transfusion of red bloods cells is anotherrising therapy that is considered to be the leastinvasive option for the management of EMH-induced spinal cord compression.10 In addition toits therapeutic benefits, hyper transfusion can alsobe diagnostic, since a response to this treatmentindicates an anemic etiology.5 One problem withthis type of treatment is that symptoms can recurshortly afterwards. Hyper transfusion appears tobe the best option for mild cases or for diagnosticpurposes.17 and in conditions where both surgicalmanagement and radiotherapy is not possible likein pregnancy. A few authors have reported goodresults with the use of hydroxyurea along withhyper transfusion. The drug, in addition to itscytostatic effects, has a favorable effect on fetalhemoglobin production. Gamberiniet al, treated a24-year patient with thalassemia intermedia withparaplegia due to EMH, with hydroxyurea 1000mg/


day for 5 months followed by 500 mg/day for 25months.However, Response to Hydroxyurea (HU)is variable as there is associated variability ingenetic mutation.

Conclusion:

This case report showed that although rare, aparavertebral extra medullary hemato-poiesisshould always be considered in thedifferential diagnosis of any upper motor neurondisease due to para spinal lesion in patients withhematological disorder specially with thalassemia,so that appropriate studies can be performed toinvestigate the cause of the lesion and suitabletreatment can be undertaken.

References:

1. Martínez-Rodrigo MA, Sanjuanbenito L, Rodríguez delBarrio E, et al: Spinal cord compression secondary toepidural extra medullary hematopoiesis in thalassemia:a clinical case and review of literature (in Spanish). RevNeurol 1998;27:998–1004.

2. Singhal S, Sharma S, Dixit S, et al: The role of radiationtherapy in the management of spinal cord compressiondue to extra medullaryhematopoiesis in thalassemia. JNeurolNeurosurg Psychiatry 1992;55:310–312

3. Orphanidou-Vlachou E, Tziakouri-Shiakalli C,Georgiades CS: Extra medullary-hemopoiesis. SeminUltrasound CT MR 2014;35:255–262.)

4. Wang A, Carberry N, Solli E, Gillick J, Islam H, HillardV. Spinal Cord Compression Secondary to ExtraMedullary Hematopoiesis: Case Report and Review ofthe Literature. Case Rep Oncol. 2016 May31;9(2):290-7.

5. Chehal A, Aoun E, Koussa S, et al: Hyper transfusion:a successful method of treatment in thalassemiaintermedia patients with spinal cord compressionsecondary to extra medullary hematopoiesis. Spine(Phila Pa 1976) 2003;28:E245–E249.

6. Monti L, Romano D, Gozzetti A, et al: Myelodysplasiapresenting as a thoracic spinal epidural extra medullaryhematopoiesis: a rare treatable cause of spinal cordmyelopathy. Skeletal Radiol 2012;41:611–614

7. Gatto I, Terrana V, Biondi L: Compression of the spinalcord due to proliferation of bone marrow in epiduralspace in a splenectomized person with Cooley’s disease.Haematologica 1954;38:61–76.

8. Amirjamshidi A, Abbassioun K, Ketabchi SE, et al:Spinal extra medullary hematopoiesis in adolescents

with thalassemia: report of two cases and a review ofthe literature. Childs NervSyst 1991;7:223–225.

9. Dore F, Cianciulli R, Rovasio S, et al: Incidence andclinical study of ectopic erythropoiesis in adult patientswith thalassemia intermedia. Ann Ital MedInt1992;7:137–140.

10. Evrard C, Pichereau D, Alsweis S, et al: Extra medullaryhematopoiesis of thoracic and vertebral intraductallocalization. A propos of a case. Review of the literature(in French). Ann Chir 1994;48:284–293

11. Luitjes WF, Braakman R, Abels J: Spinal cordcompression in a new homozygous variant ofbetathalassemia. Case report. J Neurosurg 1982;57:846–848

12. Haidar R, Mhaidli H, Taher AT. Para spinalextramedullary hematopoiesis in patients with thalassemiaintermedia. Eur Spine J. 2010 Jun 5;19(6):871-8.(5)

13. Zhang H-Z, Li Y, Liu X, Chen B-R, Yao G-H, Peng Y-N.Extra medullary hematopoiesis: A report of two cases.ExpTher Med. 2016 Dec 2;12(6):3859-62.(6)

14. Ito S, Fujita N, Hosogane N, Nagoshi N, Yagi M,Iwanami A, et al. Myelopathy due to Spinal ExtraMedullary Hematopoiesis in a Patient withPolycythemia Vera. Case Rep Orthop. 2017;2017:2416365.(8)

15. Musallam KM, Taher AT, Rachmilewitz EA. ß-thalassemia intermedia: a clinical perspective. ColdSpring HarbPerspect Med. 2012 Jul 18;2(7):a013482.(9)

16. Soman S, Rosenfeld DL, Roychowdhury S, DrachtmanRA, Cohler A. Cord Compression due to Extra MedullaryHematopoiesis in an Adolescent with Known BetaThalassemia Major. J Radiol Case Rep. 2009 Jan4;3(1):17-22.(4)

17. Tsitouridis J, Stamos S, Hassapopoulou E, et al: ExtramedullaryPara spinal hematopoiesis in thalassemia: CTand MRI evaluation. Eur J Radiol 1999;30:33–38.

18. Sproat IA, Dobranowski, Chen V, et al: Presacralextramedullary hematopoiesis in thalassemia intermedia.Can AssocRadiol J 1991;42:278–282.

19. Coskun E, Keskin A, Süzer T, et al: Spinal cordcompression secondary to extra medullary hemato-poiesis in thalassemia intermedia. Eur Spine J1998;7:501–504.

20. Cianciulli P, Sorrentino F, Morino L, et al: Radiotherapycombined with erythropoietin for the treatment of extramedullary hematopoiesis in an all immunized patientwith thalassemia intermedia. Ann Hematol 1996;72:379–381.

Spinal Cord Compression Secondary to Extra Medullary Hematopoiesis Ranajit Sen Chowdhury et al 88

Evaluation of Preventable Risk factors of Febrile

Neutropenia of Acute Lymphoblastic Leukemia in

a Tertiary Care CentreMed. Lutfor Rahman Molla1, AKM Amirul Morshed2, Olia Sharmin3, Zannat Ara4, Md. Bani

Yeasmin5, SM Rezanur Rahman6, Muhammad Tanvir Ahmad7, Ibrahim Khalil8,

Mostafijur Rahman9, Sunirmal Roy10

Summary:

Introduction: Fever in severe chemotherapy induced neutropenic patients is the most frequent

manifestation of a potentially lethal complication of current intensive chemotherapy regime.

This study aimed at establishing a model for predicting the preventable risk of febrile neutropenia

in patient of acute lymphoblastic leukemia.

Method: This descriptive observational study was carried in the department of pediatric

hematology and oncology department of Bangabandhu Seikh Mujib Medical University during

the period of 1st February 2013 to 31st January 2014. Through purposive sampling 40 neutropenic

patients were selected. Their total history and behavioral pattern regarding the supportive

management (neutropenic diet, use of aciflavine solution, nystatin oral solution, mouth wash

with povidone iodine),Total duration of hospital stay, duration of neutropenia, no of attendant

during hospital stay were recorded.

Result: Most of the studied children were in induction phase of therapy. The mean hospital

stay was 8.56±6.75 days and mean no of attendant with each patient was 2.02±0.65. Majority of

the patient were on neutropenic diet and freshly cooked food (87.5%). This study shows a large

portion (52.5%) of the studied population did not use acriflavine as per advice. It also revealed

majority of the child did not use povidone iodine mouth wash (52.5%) and nystatin (47.5%) as

per advice.

Conclusion: This study showed that majority of the patient did not properly follow the advice

regarding behavioral and supportive management. Duration of hospital stay and no of attendant

were also high. So a large scale multicentre cohort study should be done to validate these

finding before establishing as risks.

Key words: Febrile neutropenia, myelosuppresion, neutropenic diet.


1. Assistant Professor, Department of Pediatric Hematology and Oncology, SSMC2. Professor, Department of Pediatric Hematology and Oncology, DMC3. Associate Professor Department of Pediatric Hematology and Oncology, SSMC4. Assistant Professor, Department of Pediatric Hematology and Oncology, SSMC5. Assistant Professor, Department of Pediatric Hematology and Oncology, CMC6. Assistant Professor, Department of Pediatric Hematology and Oncology, DMC7. Assistant Professor, Department of Pediatric Hematology and Oncology, DMC8. Assistant Professor, Department of Pediatrics, SSMC9. Assistant Professor, Department of Pediatrics, SSMC10. Associate Professor, Department of Neonatology, SSMC, Dhaka*Address of correspondence: Dr. Lutfor Rahman Molla, Asstt Prof, Department of pediatric hematology and oncology,SSMC, Dhaka. Mob:01817524734, E mail: [email protected].

Introduction:

Acute lymphoblastic leukemia (ALL) is the mostcommon malignancy in children. It accounts for¼ th of all childhood cancer and 75% of all cases ofchildhood leukemia. Approximately 4900 childrenare diagnosed with ALL in each year in the UnitedStates with an incidence of 3.4 cases per 100000white children. The peak incidence occur between

2-5 yrs of age1. Advances in the study andtreatment of pediatric acute lymphoblasticleukemia are often cited as the paradigm of successin modern clinical trial. Overall cure rate of ALLhave improved from virtually zero in the 1950s tothe current event free survival rate of 75%-85%.The advances are due to development of activechemotherapeutic agents, improvement of

knowledge regarding dose and combination of theseagents more effectively and significant advancesin the supportive care. Although the improvementin the cure rates have been gratifying to thepatients, physicians and researchers, this progresshas sometimes come at a significant price in termof both short and long term complication1.

Febrile neutropenia is a common and seriouscomplication of cancer chemotherapy.Traditionally, the empiric therapy for all febrileneutropenic patients is broad spectrumintravenous antibiotics2 .However more recentlyit has become clear that patients with febrileneutropenia are not all the same risk for significantcomplication or death from infection. Identificationof low risk factors may allow these patients toreceive simplified anti infective therapy relatedtoxicity, an improved quality of life and decreasescost3.

As strategies for managing the febrile neutropeniccancer patients have evolved during the last fourdecades and risk for infections have beendelineated, the spectrum of infecting agents hasbroadened and routine empirical antimicrobialtherapy has been adapted. The degree and durationof neutropenia continues to be the most importantfactor predictive of infection, although the statusand type of underlying malignancy, degree ofdisruption of host defenses and the presence ofcentral venous catheters influence the risks andtype of infections encountered4.

A few centers have begun selecting patients at lowrisk for bacteremia for initial outpatientmanagement, using criteria derived from acombination of personal experience and previouslypublished research. Investigators at the Universityof Texas South Western Medical Center in Dallashave used clinical appearance, negative bloodcultures, control of local infection if present,absence of fever and evidence of marrow recoveryto identify a low risk set of patients. Patientsclassified as low risk by these criteria generallyhave done well even empiric therapy has beendiscontinued5.

Children with cancer differ from their adultcounterparts in multiple ways. These differenceinclude the spectrum of oncologic diagnosis, theintensity of chemotherapeutic regimens, the

overall incidence of therapy related neutropeniaand relative immunosuppression and the incidenceand severity of relative co morbid medicalcondition preceding the diagnosis in cancer. inaddition the rate of serious medical complicationand death during febrile neutropenia have beenshown to be significantly lower in children than inadult6.So, it would be a great benefit for theseunlucky child of ALL as well as their family if thecommon preventable risk factors for febrileneutropenia that can be easily managed, are earlyidentified and treated properly.

Method:

This prospective observational study was done from1st Februay2013-31st January 2014 in theDepartment of Pediatric Hematology andOncology,BSMMU. Sahbagh , Dhaka. FortyChildren of ALL attended in the hospital with alow ANC were studied thoroughly. Patients wereselected by purposive sampling. A typedquestionnaire was supplied to all patients and thosewho gave the written consent were selected ascases.

Their full initial presentations, initial total count,previous neutropenia, H/O recent chemotherapywith their intensity, central venous access, bonemarrow involvement after initial recovery, H/Oany associated comorbidity like Diarrhea, shock,DIC, Severe bleeding manifestation, behavioralhistory regarding bathroom and feeding practice,number of attendants of specific patients duringtheir hospital admission , food habit during hospitaladmission and at home & full physical examinationwere recorded. Patients with septicemia wereundergone a thorough septic workup includingCBC, Blood C/S, Urine R/E & C/S, X ray chest,Stool R/E &C/S ,Throat swab, Swab from theinvolved site(in specific cases),metabolic work upincluding the SGPT, S.Creatinine, LDH, Selectrolytes were done. Blood was taken from theperipheral vein .CBC was analyzed through thesysmax auto analyzer in the department. Blood,urine and stool culture were done in themicrobiology department of BSMMU. X-ray chestwas done in the radiology department and onemergency cases bed side x-ray was done.Antibiotic therapy was started in all patients aftersending the blood, stool, urine samples for cultureand sensitivity. Antibiotic was changed on the basis

Evaluation of Preventable Risk factors of Febrile Neutropenia Med. Lutfor Rahman Molla et al 90

of the sensitivity pattern. If there was noimprovement after 5 days of antibiotic therapy andthe patient remain neutropenic then antifungal(amphotericin-B) therapy was started afterevaluating serum electrolytes and renal function.Both the tests were done daily to monitor thetoxicity of the antifungal agent. In case of extrememucositis and with the evidence of viral infectionantiviral (acyclovir ) was given .

Result:

During a 12 month period from February 2013-January 2014, a total of 40 febrile neutropenicpatients were analyzed in this study.Theirbehavioral pattern regarding feeding, use ofacriflavine solution, povidone iodine mouth washand use of nystatin drop were recorded andanalyzed. Total duration of hospital stay, no ofattendant of each patient and time period todevelop fever after neutropenia was also recorded.

Table I

Age distribution of the patients.

Age Frequency Percentage

<5 18 45.0

5 - 10 18 45.0>10 4 10.0

Total 40 100.0

Table II

Patients distribution by chemotherapy status

during enrollment

Chemotherapy status Frequency Percentageduring enrollment

Induction 31 77.5

Consolidation 2 5.0Interim maintenance 2 5.0Delayed intensification 5 12.5

Total 40 100.0

Table III

Distribution of patients by intensity of

myelosuppression

Intensity of Frequency PercentagemyelosuppressionGrade II 17 42.5

Grade III 23 57.5

Total 40 100.0

Myelosuppressive intensity were calculated on theexpected duration of neutropenia ( in days)-GradeI. None expected, Grade II d”10 days Grade III >10days. None patients were in grade I.42.5% pt werein grade II and 57.5% were in grade III.

Table IV

Frequency of feeding practice at home

Feeding practice at Frequency Percentagehome

Neutropenic/ freshly 35 87.5cooked food

Traditional food 5 12.5

Total 40 100.0

Table V

Frequency of use of acriflavin solution hip bath

Acriflavin solution Frequency Percentage

hip bath

Done as per advice 19 47.5

Not done as per advice 21 52.5

Total 40 100.0

Table VI

Frequency of use of Povidone iodine mouth wash

Povidone iodine Frequency Percentage

mouth wash



Not done at all 1 2.5

Total 40 100.0

Table VII

Frequency of use of Nystatin drop

Use of Nystatin drop Frequency Percentage



Not done at all 1 2.5

Total 40 100.0


Table VIII

Distribution of patients by duration of hospital

stay and no. of attendant.

Mean ± SD Min - Max

Duration of hospital 8.56 ± 6.75 0.00 - 26.00

stay(days)

No. of attendant during 2.02 ± 0.65 1-3

hospital admission

Discussion

Children with acute lymphoblastic leukemia (ALL)are usually treated according to risk groups definedby both clinical and laboratory features7.Theintensity of treatment required for favorableoutcome varies substantially among subsets ofchildren with ALL8 . Risk-based treatmentassignment is utilized in children with ALL so thatpatients with favorable clinical and biologicalfeatures who are likely to have a very good outcomewith modest therapy can be spared more intensiveand toxic treatment, while a more aggressive, andpotentially more toxic, therapeutic approach canbe provided for patients who have a lowerprobability of long-term survival9.

Certain ALL study groups, such as the Children’sOncology Group (COG), use a more or lessintensive induction regimen based on a subset ofpretreatment factors, while other groups give asimilar induction regimen to all patients. Factorsused by the COG to determine the intensity ofinduction include immunophenotype and theNational Cancer Institute (NCI) risk groupclassification. The NCI risk group classificationstratifies risk according to age and white blood cell(WBC) count6. All study groups modify the intensityof post induction therapy based on a variety ofprognostic factors, including NCI risk group,immunophenotype, early response determinationsand cytogenetics9.Risk-based treatmentassignment requires the availability of prognosticfactors that reliably predict outcome. For childrenwith ALL, a number of factors have demonstratedprognostic value10.

In this study a total number of 40 acutelymphoblastic leukaemic patients were recruited.The distribution of gender among the studypopulation was recorded. It is interesting that male(70.0%) were predominant over female (30.0%).

The male and female ratio was 1:0.43. This findingindicates that ALL occurs more commonly amongthe male. A similar result has been reported byPui et al (1999) and has mentioned that male ispredominant than female10.

Regarding age maximum patients were in agegroup 5-10 years (45%) and <5 years (45%) and theremaining10% patientse were > 10 yrs. It is veryclear that the ALL patients are most commonlydetected at the age of less than 10 years. Similarto the present study result Vonder-Weid et al(2003) have reported that majority of the ALLpatients are below the age of 10 years11.Association of feeding practice of the studypopulation was recorded in this study. Regardingfeeding practice most of the patients tookneutorpenic or freshly cooked food 87.5%.Thefeeding practice is an important factor during ALLtreatment. Similar result was reported by Bhatiaand has mentioned that feeding practice is directlyrelated with the intensity of myelosuppression12.

Frequency of use of acriflavine solution of thestudied patients was recorded. In connection withacriflavine solution maximum (52.5%) patients didnot use acriflavine solution as per advice, only47.5% patients used it as per advice. This resultindicates that the acriflavine solution is usefulamong ALL patients during treatment. Regardingthe use of povidone iodine mouth wash only 18(45%) patients used povidone iodine mouth washas per advice and maximum 21 (52.5%) patientsdid not use it as per advice and 1 (2.5%) patientsnever used it. Use of nystatin drop was recorded.only 50% patients used nystatin drop as per adviceand 47.5% patients did not use it as per adviceand 2.5% patients never used it. Similar result hasbeen reported by Levy-Polack et al (1998) and hasmentioned that the effectiveness of a preventiveoral protocol in children receiving antineoplastictreatment for acute lymphoblastic leukemia (ALL)is better and significantly reduces the incidence oforal complications13. Costa et al (2003) havementioned that use of oral medication has a greatrole in the causation of many complications amongthe ALL patients14.

Conclusion:

This study found that majority of the patients didnot follow the advice properly regarding the use ofnystatin drop, acriflavine solution and povidone

Evaluation of Preventable Risk factors of Febrile Neutropenia Med. Lutfor Rahman Molla et al 92

iodine mouth wash but feeding practice at homewas satisfactory. The mean duration of hospitalstay was 8.56±6.75 days. The mean no attendantduring hospital admission was 2.02±0.65.

References:

1. Margolin JF, Steuber CP & Poplack DG. AcuteLymphoblastic Leukaemia. In: Pizzo PA & Poplack DG.eds 2005. Principle and Practice of Pediatric oncology.Philadelphia:Lippincott-Williams &Wilkins.

2. Pizzo, PA () “Management of fever in patients withcancer and treatment-induced neutropenia”, N Engl J

Med 1993;5:1323-32.

3. Alexander SW, Wade KC, Hibberd PL, Parson SK. ()“Evaluation of riskprediction criteria for episode offebrile neutropenia in children with cancer”. J Pediatr

Hematol Onco 2002;24:38-42.

4. Jakson MA, Swanson DS. () “Infectious complication inthe neutropenic patients,” Seminars Ped Infect Dis J,2000; 11: 90-96

5. Talcott JA, Finberg R, Mayer RJ, Goldman. () “Themedical course of cacer patients with fever andneutropenia. Clinical identification of a low subgroupat presentation,” Arch intern Med, 1998;148:2561-2568.

6. Smith M, Arthur D, Camitta B. () “Uniform approach torisk classification and treatment assignment for childrenwith acute lymphoblastic leukemia.” J Clin Oncol.1996;14 (1) :18-24

7. Carroll WL, Bhojwani D, Min DJ, () “Pediatric acutelymphoblastic prognostic markers from the Pediatric

Oncology Group (POG) and Children’s Cancerleukemia”. Hematology, 2003;1:102-31

8. Schultz KR, Pullen DJ, Sather HN. () “Risk- andresponse-based classification of childhood B-precursoracute lymphoblastic leukemia: a combined analysis ofGroup (CCG).” Blood. 2007;109 (3): 926-35

9. Vrooman LM, Silverman LB () “Childhood acutelymphoblastic leukemia: update on prognostic factors.”Curr Opin Pediatr2009; 21(1):1-8

10. Pui CH, Boyett JM, Relling MV, Harrison PL, RiveraGK, Behm FG, et al. () “Sex Differences in Prognosisfor Children With Acute Lymphoblastic Leukemia.”Journal of Clinical Oncology, 1999; 17:818

11. Vonder-Weid N, Mosimann I, Hirt A, Wacker P,Nenadov Beck M, et al. () “Intellectual outcome inchildren and adolescents with acute lymphoblasticleukaemia treated with chemotherapy alone: age-andsex- related differences.” European Journal of Cancer.200339:359-365

12. Bhatia S. () “Influence of race and socioeconomic statuson outcome of children treated for childhood acutelymphoblastic leukemia”. Curr Opin Pediatr. 6(1) 2004:9-14

13. Levy-Polack MP, Sebelli P, Polack NL. () “Incidence oforal complications and application of a preventiveprotocol in children with acute leukemia.” Spec Care

Dentist. 1998;18(5):189-93.

14. Costa EM, Fernandes MZ, Quinder LB, de Souza LB,Pinto LP. () “Evaluation of an oral preventive protocolin children with acute lymphoblastic leukemia.” Pesqui

Odontol Bras. 2003; 17(2):147-50.


Hepatitis B Awareness among the Health Care

Workers and Medical students in Sir Salimullah

Medical College Mitford Hospital, an

Observational StudyMd. Fazal Karim, Shawkat Hossain, Mohammad Nasirul Islam, Provat Kumar Podder

Abstract

Introduction: Hepatitis B is one of the most important causes of acute and chronic hepatitis in

Bangladesh. It can progress to cirrhosis of liver or hepatocellular carcinoma. Bangladesh is in

intermediate prevalence range of chronic HBV infection (2-7%). Health care workers are

particularly at high risk of hepatitis B virus infection which is about 10 times higher than that

of general population. As hepatitis B virus infection is a potential risk of health hazard, all the

health care workers must be aware of route of transmission of HBV infection. The objective of

the study was to assess the awareness regarding hepatitis B virus infection among the health

care workers in Mitford Hospital.

Materials & Methods: The study was done at the department of Hepatology, Sir Salimullah

Medical College Mitford Hospital, Dhaka on 28th July 2018 on the occasion of ‘World Hepatitis

Day’2018 vaccination program for Anti-HBc(Total) negative doctors, nurses, medical students

and medical staffs at Mitford hospital. It was a cross-sectional observational study conducted

by 10 questions to assess the awareness among the health care workers and medical students

regarding the hepatitis B related health hazards.

Result: A total of 134 health care workers and medical students were participated in the study.

Majorities (75.7 %) were in the age group of 20-25, mean age was found 24.14 ± 5.84 (age range

18-57). About half of the participants 83 (67.5 %) were medical students. The medical students

were found more conscious and aware of HBV infection rather than the working doctors of this

hospital. 42 (31.3 %) had previous history of blood transfusion. Around one third (31.3%)

participants had previous history of blood transfusion which is one of the potential roots of

entry of HBV infection. Out of 134, 12 (9.0%) had history of needle stick injury but they did not

take any definite measure after injury despite being a health care worker. 13 (9.7%) and 8 (6%)

had history of minor and major surgery respectively. 35 (26.1 %) under went for dental procedure

previously. It was also observed that, despite being a health care worker among the participants

who underwent major surgery or underwent dental procedure were not immunized against

HBV infection at the time of operation.

Conclusion: Awareness, precaution, and protection should be advocated in order to prevent the

transmission of hepatitis B virus infection among the health care workers in Sir Salimullah

Medical College Mitford Hospital.

Key words: HBV (Hepatitis B virus) infection, Health care workers, Awareness.


Department of Hepatology, Sir Salimullah Medical College Mitford Hospital, Dhaka

Address of Correspondence: Md. Fazal Karim, Sir Salimullah Medical College Mitford Hospital, Dhaka, Tel: + 8801715004634; Fax: 880-02-57314786; E-mail address: [email protected]

Introduction

Hepatitis B virus infection is highly infectiousand causes serious health hazards. Worldwidearound 240 million people are infected byhepatitis B virus and annually about 1 million

people die due to the consequences of thisinfection1. It is one of the most important causesof acute and chronic hepatitis in Bangladeshwhich can progress to cirrhosis of liver orhepatocellular carcinoma. According to

epidemiology the prevalence of chronic hepatitisB infection in different geographical areas areclassified into three categories; High (>8%),intermediate (2-7%) and low (<2%)2. Bangladeshis in intermediate prevalence range of chronicHBV infection (2-7%)3. Commonly hepatitis Bvirus is transmitted by percutaneous or mucosalcontact of blood or blood products and also bodyfluids including saliva, menstrual, vaginal andseminal fluid4. It can also be transmitted byaccidental inoculation of minute amount ofinfected blood or fluid during medical, surgicalor dental procedure5. Health care workers suchas, doctors, nurses, medical students and othermedical staffs are particularly at high risk ofhepatitis B virus infection which is about 10times higher than that of general population6,7.According to the report of WHO, each year about6% of health care providers are exposed to blood-borne hepatitis B infection8. The infectivity ofhepatitis B virus is 10 times higher than hepatitisC infection and 100 times higher than HIVinfection9. The risk increases up to 62% if thesource patient is HBeAg positive10. As hepatitisB virus infection is a potential risk of healthhazard, all the health care workers must beimmunized against hepatitis B virus infection aswell as post exposure prophylaxis in case ofaccidental exposure to infected blood, body fluidand needle stick injury.

Materials and Methods

The study was done at the department ofHepatology, Sir Salimullah Medical College andMitford Hospital, Dhaka on 28th July 2018 on theoccasion of ‘World Hepatitis Day’2018 vaccinationprogram for HBsAg negative doctors, nurses,medical students and medical staffs in Mitfordhospital. It was a cross- sectional observationalstudy which was conducted to assess theawareness among the health care workers(Doctors, nurses and medical staffs) and medicalstudents in this medical college hospital regardinghepatitis B virus related health hazards. 134paticipants including doctors, nurses, medicalstudents and medical staffs participated in thestudy. A structured questionnaire was supplied

to each participant containing 10 questionsprepared in English language regarding causes,risk and mode of transmission of hepatitis B virusinfection. Data sheets were supplied to theparticipants by 2 senior staff nurses of thedepartment of Hepatology, Mitford Hospital. Aftercompletion they again collected the data sheetsfrom the participants. The principal investigatorcheeked the completeness, consistency andaccuracy of the collected data. Data entry anddescriptive data analysis was done by SPSSversion 23. Data were presented in frequenciesand percentages (%). Ethical clearance wasobtained from departmental ethical committee ofSir Salimullah Medical College and MitfordHospital. Informed consent was taken from allwho participated in the study. Confidentiality ofthe information was strictly maintained; thus thename and address of the participants were notrecorded in the data collection sheet. All the datawere protected in a lock-up safe which was onlyaccessible to the researcher.

Results

As shown in Table-I, out of 134 participantsincluded in the study, 83 (61.9%) were males.Majority (75.7 %) was in the age group of 20-25years, mean age of the HCW found 24.14 ± 5.84(age range 14-57). About half of the participants83 (61.94 %) were medical students, 12 (9.0 %)were intern doctors, only 7 (5.2%) were nurses,29 (21.64%) were mid-level and senior doctorsincluding medical officer, resident doctor,Assistant registrar, Registrar, AssistantProfessor, Associate Professor and Professor. 3(2.2%) were medical staffs. 42 (31.3%) hadprevious history of blood transfusion. 5 (3.7 %)had previous history of viral hepatitis among them2 were infected with hepatitis A virus and 1 withhepatitis E. 2 others could not tell about definiteviral infection. Out of 134, 12 (9.0%) had historyof needle stick injury. 13 (9.7%) and 8 (6%) hadhistory of minor and major surgery respectively.35 (26.1 %) under went for dental procedurepreviously. Injectable drug abuse were found in 4(3%) among the participants.


Table-I

Distribution of the participants according to the

base line characteristics

Variable Frequency Percentage(n=134) (%)

Age in years14-19 6 4.4%20-24 90 67.1%25-29 18 13.5%30-34 12 9.0%35-39 2 1.40%40-44 1 0.7%45-49 1 0.7%50-54 1 0.7%55-59 1 0.7%SexMale 83 61.9%Female 51 38.1%DesignationStudent 83 61.94 %Nurses 7 5.2 %Medical staff 3 2.2 %Intern doctor 12 9.0 %Resident 1 0.7 %Medical officer 22 16.42 %Assistant registrar 2 1.5 %Registrar 1 0.7 %Assistant professor 1 0.7 %Associate professor 1 0.7 %Professor 1 0.7 %H/O Previous Blood TransfusionYes 42 31.3 %No 92 68.66 %H/O previous viral hepatitisYes 5 3.7 %No 129 96.27 %H/O needle stick injuryYes 12 9.0 %No 122 91.04 %H/O minor surgeryYes 13 9.7 %No 121 90.30 %H/O major surgeryYes 8 6.0 %No 126 94.03 %H/O dental procedureYes 35 26.1 %No 99 73.89 %H/O injectable drug abuseYes 4 3.0 %No 130 97.01 %

Discussions

Health care workers are always at risk oftransmission of HBV infection because of theirprofession. So, we sought to determine the levelof knowledge, attitude, and behavior of the doctors,nurses, medical students and medical staffs abouthepatitis B infection. Also, we wanted to encouragethe health care workers to increase the level ofknowledge and to follow the infection controlmeasures.

In this study out of 134 participants, majority(61.9%) were male, most of them were from agegroup of 20-25 years. Around half (61.94%) weremedical students. Only 9.0% were intern doctors,21.64% were mid-level and senior doctors, 5.2%were nurses and 2.2% were medical staffs. Thisindicates that, the medical students are moreconscious and aware of HBV infection rather thanthe working doctors of this hospital. A consciousattitude was seen regarding HBV infection andprevention among the medical students which wasvery much encouraging. Choudhury et al.11, intheir study showed that, 83% of medical studentswere found to show positive attitude regarding theHBV infection. Debes. D et al.12 showed low self-awareness of HBV infection and vaccination withrelatively high level of knowledge about HBVinfection which is similar to our study. Anotherobservation could be, as it was a vaccinationprogram on the occasion of ‘World Hepatitis day’2018, most of the working doctors in this hospitalmay be previously immunized against HBVinfection. That’s why the number of theirparticipation in this study was small. Around onethird (31.3%) participants had previous history ofblood transfusion which is one of the potentialroute of entry of HBV infection. Though in thisstudy we assessed the Ant-HBc (Total)seropositivity of the health care workers beforevaccination who had history of blood transfusion,but Amiwero CE et al.13 showed 11.7% health careworkers with history of blood transfusion, 10.3%and 65.5% were HBsAg and Anti-HBc positiverespectively. 5 (3.7%) had previous history of viralhepatitis out of which 2 with hepatitis A and 1 withhepatitis E infection. But 2 others could not tellabout definite viral etiology despite being a healthcare worker. In our study out of 134, 12 (9%) hadprevious needle stick injury. Mihir G. et al.14

showed 2.17 % needle stick injury among health

Hepatitis B Awareness among the Health Care Workers and Medical students Md. Fazal Karim et al 96

care workers which is lower than our study result.This indicated that, our health care workers shouldbe more cautious during the working hours at thehospital and also safety measures should be undertaken in the working environment as well asworking instruments should be properly sterilized,wearing glove, sheets and proper disposal ofsyringe, sharp instruments, blood and bloodproducts. Regarding the measures after needlestick injury, 3 could not recall about any measuresand 9 including one associate professor andassistant professor of Gynae and obs departmentdid not take any active measures other than handwashing with disinfectants. Warner BG15 foundthat, the risk of transmission of HBV infection isbetween 30 and 62% depending on presence orabsence of e antigen. So, according to our studyout of 12, at least 4 had chance of having HBVinfection and maximum could be 8 by needle stickinjury. Among the participants 8(6%) had historyof major surgery including Cesarean section,Appendisectomy, Tonsilectomy and Septoplasty.These surgeries have potential risk of transmissionof HBV infection if the surgical instruments arenot properly sterilized. CDC has included majorabdominal, cardiothoracic, orthopedic, repair ofmajor traumatic injuries, hysterectomy, cesareansection, oral and maxillofacial surgeries asexposure prone procedures which increase the riskof transmission of HBV infection16. It was alsoobserved that, despite being a health care workeramong the participants, who underwent majorsurgery were not immunized against HBV infectionat the time of operation. Among the totalparticipants 35 (26.1%) underwent dentalprocedures previously which is a potential modeof transmission of HBV infection. Though they arehealth care workers, they were not in immunizedstate against HBV infection at the time ofprocedure. Cleveland et al.17 reported that, thereis increasing HBV infections with dental proceduresdue to contamination of instruments with HBVviruses. Another observation was found in thisstudy that, 4 (3%) participants were found to haveinjectable drug abuse.

Limitation of the study

Though the study was conducted to assessawareness regarding hepatitis B virus infection,

among the health care workers and medicalstudents, but most of the participants were medicalstudents who are not directly involved in patientand hospital management rather than doctors,nurses and medical staffs.

In this study, no HBsAg positive group was takenso that, the study result could not be compared toassess the risk factors of transmission of HBVinfection.

Conclusions

Awareness, precaution, and protection should beadvocated in order to prevent the transmission ofhepatitis B virus infection among the health careworkers and medical students in Sir SalimullahMedical College and Mitford Hospital. Therefore,there is a need for well-planned and clear policiesfor HBV screening, vaccination, and serologicalresponse checkups for all health care workersworking in this hospital.

Recommendations

Safety for the health care workers is a challengethat must be met with a comprehensive effort. So,our recommendation is to put more emphasis onthe followings:

a. Hospital waste management including bloodand blood products, proper disposal of HBVcontaminated body fluids is a very importantaspect in preventing the HBV infection whichshould not be overlooked. All the health careworkers should be trained and periodicallymonitored for effective hospital waste disposal.This waste should be disposed in yellow bin.

b. Proper sterilization of surgical and laboratoryinstruments must be ensured to prevent riskof transmission of HBV infection.

c. Early detection and surveillance of HBVinfection should be done periodically by doingscreening program.

d. Implementation of hepatitis B vaccine toprevent HBV transmission among the healthcare workers in this hospital.

e. Health education campaigns, training andawareness programs should be regularlyorganized for health care workers to preventHBV infection.


References

1. Ott, J. J, Stevens G.A, Groeger J, Wiersma S. T. Globalepidemiology of hepatitis B virus infection: newestimates of age-specific HBsAg seroprevalence andendemicity. Vaccine 2012; 30: 2212–2219.

2. Previsani N, Lavanchy D. Hepatitis B. Department ofCommunicable Diseases Surveillance and Response,World Health Organisation, Geneva 2002.

3. Rahman R, Mahtab M, Karim F. Guideline for TreatingHepatitis B Virus Infection in Bangladesh. BangladeshLiver Journal. 2009; 1: 6-12.

4. Mast E. E, Alter M. J, Margolis H. S. Strategies to preventand control hepatitis B and C virus infections: A globalperspective. Vaccine 1999; 17:1730–1733.

5. WHO. Guidelines for The Prevention, Care AndTreatment of Persons with Chronic Hepatitis BInfection. Geneva, 2015.

6. Vishal B, Amitava G, Sunil D, Dinesh K, Narendra B.Hepatitis B immunization in healthcare workers. Annalsof Gastroenterology 2015; 1: 1–5.

7. Centers for Disease Control and Prevention. CDCguidance for evaluating health-care personnel forhepatitis B virus protection and for administering postexposure management. Morbidity and Mortality WeeklyReport (MMWR) 2013; 62.

8. Ustun P, Rapiti E, Hutin Y. Estimation of the globalburden of disease attributable to contaminated sharpsinjuries among health-care workers. The AmericanJournal of Industrial Medicine 2005; 48: 482–490.

9. Kent AS, Eisenberg L. Occupational Deaths amongstHealthcare Workers. Emerging Infectious Diseases2005; 11(7): 1003-1008.

10. Villiers D, Nel M, Prinsloo E. Occupational exposure toblood borne viruses amongst medical practitioners inBloemfontein, South Africa. SA Fam Prac 2007;49(3):14.

11. Choudhury P, Mishra S, Kandula S, ChinnannavarSN, Rout P, Panigrahi R. Awareness of hepatitis Binfection among healthcare students in a privatemedical college in Odisha. Journal of InternationalSociety of Preventive and Community Dentistry 2015;5: 63-67.

12. Debes JD, Kayandabila J, Pogemiller H. Knowledge ofHepatitis B Transmission Risks among Health Workersin Tanzania. American Journal of Tropical Medicineand Hygine 2016; 94(5): 1100-1102.

13. Amiwero CE, Nelson EA, Yusuf M et al. 13. Knowledge,Awareness and Prevalence of Viral hepatitis AmongHealth Care workers (HCWs) of the Federal MedicalCentre Bida, Nigeria. The Journal of Medical Research2017; 3(3): 114-120.

14. Mihir G, Parul P, Sunil N et al. Needle Stick and SharpInstruments Injuries Among Health Care Providers atCardiology Institute, Ahmedabad. National Journal ofCommunity Medicine 2010; 1(2): 114-117.

15. Werner BG, Grady GF. Accidental hepatitis-B-surfaceantigen-positive inoculations: use of e antigen toestimate infectivity. Ann Intern Med 1982; 97:367-9.

16. Center for Disease Control and Prevention. UpdatedCDC Recommendation for the Management of HepatitisB Virus-Infected Health-Care Providers and Students.2012; 61(3): 1-12.

17. Cleveland JL, Siew C, Lockwood SA, Gruninger SE,Gooch BF, Shapiro CN. Hepatitis B vaccination andinfection among U.S. dentists, 1983-1992. J Am DentAssoc 1996; 127(9):1385-90.

Hepatitis B Awareness among the Health Care Workers and Medical students Md. Fazal Karim et al 98

Association of maternal education with infantile

diarrheaRahat Bin Habib1, A.R.M. Luthful Kabir2, Md Abdur Rouf3, Sunirmal Roy4,

Md. Kamrul Ahsan Khan5, Muzibur Rahman6, Md. Nazmul Hossain7, Md. Anisur Rahman8,

Mohammad Rezaul Haque9, Md. Abdul Mannan10

Abstract

Introduction: Diarrhoea is a leading cause of under-five morbidity and mortality in Bangladesh.

Maternal education is an important determinant of health status of children. Very few studies

have investigated the relationship between maternal education and infantile diarrhea in

Bangladesh. Therefore, this study was implemented to fill the gap.

Methodology: The study design was descriptive type of cross-sectional done in Institute of

Child and Mother Health (ICMH). Total 212 children, aged 0-12 months were investigated and

the dependent variable was diarrhea status of infants in the last two weeks prior the study. The

main independent variable was maternal education. Data were analyzed using Chi-square

(±=0.05).

Results: Diarrhea prevalence was 60% and higher (43.5%) among infants of mother who have

less education. In this study we found that 21% infants had history of less diarrhoea whose

mothers were more then 10 years educated and 45.5% infants AWD more whose mothers were

less educated (X² 7.984 df 1 P value <0.001).

Conclusion: This study indicate mother’s education is a protective factor for infantile diarrhoea.

Maternal education also an important predictor of diarrhea among children aged 0-12 months

in Bangladesh. Policies to reduce diarrhea among children in Bangladesh should target infants

of the illiterate, less educated mothers.

Key words: Infants, Diarrhoea, Maternal education.


1. Junior consultant (Pediatrics), Director General Health Service (DGHS), Dhaka, Bangladesh. Email- [email protected]

2. Professor of Pediatrics, Department of Pediatrics, Ad Din Medical Collage & Hospital, Dhaka.

3. Professor & Head, Department of Pediatrics, Sir Salimullah Medical College and Mitford Hospital, Dhaka.

4. Associate Professor, Department of Neonatology, Sir Salimullah Medical College and Mitford Hospital, Dhaka.

5. Assistant Professor (Neonatology), Sheikh Sayera Khatun Medical Collage, Gopalganj.

6. Associate Professor and In charge of Neonatology, Institute of Child and Mother Health (ICMH), Dhaka.

7. Associate Professor, Department of Pediatrics, Institute of Child and Mother Helath (ICMH), Dhaka

8. Assistant Professor, Department of Pediatrics, SSMC and Mitford Hospital, Dhaka.

9. Associate Professor, Department of Paediatrics, Institute of Child and Mother Health (ICMH), Dhaka.

10. Associate Professor, Deartment of Pediatrics, Royal College of Medicine Perak University Kuala Lumpur, Malaysia.Correspondence to: Dr. Rahat Bin Habib, Junior consultant (Pediatrics), Director General Health Service (DGHS), Dhaka,Bangladesh. Email- [email protected]

Introduction

Diarrhoeal disorders in childhood account for 18%of childhood deaths, with an estimated 1.5 milliondeaths per year globally, making it the second mostcommon cause of child deaths worldwide1. InBangladesh, diarrhea accounts for 11% of under-ûve mortality2. Each episode deprives the child ofnutrients necessary for growth, thus diarrhoea isa major cause of malnutrion and malnourishedchildren are more likely to die from this problem4.

Maternal education is recognized as one of thestrongest determinants of infant survival in

developing countries19. In Bangladesh, most of thestudies linking maternal education and childnutrition have focused on detecting different waysthrough which the education of a mother affectsthe health of her children7,20. Raji and Ibrahim(2011) argued further that the education of themother plays an important role in determiningchild survival. The pathways highlighted by hispaper include improved mother’s healthknowledge and greater control over the healthchoices for her children, among others. Alsostudies from Caldwell’s paper have shown mixed

results about the effect of maternal education onchild health status21. Gwatkin et al.12 found thatprevalence of child health especially diarrhea islower among children of educated mothers. It istherefore not unlikely that low level of mother’sknowledge may militate against the effectiveperformance of diarrhea prevention practices.However, it is expected that maternal educationshould improve child health because education hasbeen linked to family socioeconomic situation,which in itself is a determinant of child health3.Above and beyond this, maternal education ishypothesized to bring about certain changes inindividual behavior that result in better childhealth23. Caldwell and Caldwell21 suggests twopotential paths: education improves child healthsolely by enhancing the use of modern healthservices; and education results in a wide range offavorable behaviors-mostly connected with childcare-that play a role in improving child health.Years of formal education are a well recognizedindicator of social position and have been frequentlyused in international surveys to explore socialinequalities24,25,26. These studies show that peoplewith progressively more advanced levels ofeducation have better health and longer lives thanthose without. However, going by the benefits ofeducation in the management of disease conditions,one may ponder that maternal education is likelyto be linked to diarrhea, since women are primarycaregivers of under-five children. Therefore, thisstudy investigated the relationship betweenmaternal education and childhood diarrhea amongchildren aged 0-12 months which in agreement withother studies is a less researched area in Bangladesh.The study also seeks to understand the mechanismby which education affects child health as animperative for policy making.

Aim of this study was to identify any relation ofmaternal education with infantile diarrhoea.

Methods

Study area

The study was conducted in ICMH, Dhaka,Bangladesh. Here children come to the hospitalwhose live surrounding areas of the hospital.

Data collection and sample selection

The study was cross-sectional in design andpurposive sampling approach was used to select

the respondents based on allocation of specificnumbers of children. Semi structuredquestionnaire were designed to obtain informationrelated to children, mother and their education.However, the current study used infant’s data andanalysis was based on information of child by theirmother.

Variable description

In the original questionnaire used for the study, aquestion was asked from parents of the child aboutdiarrhea in the last 2 weeks prior the study andthe response was either yes or no. This variablewas used as the dependent variable anddemographic variables such as; age, sex of the childand education level of mother were used asindependent variables.

Data analysis

Purposive sampling approach was used for datacollection. Data were analyzed using descriptivestatistics, Chisquare. Frequency distribution wasused to present the data and Chisquare test wasconducted to determine factors that aresignificantly associated with diarrhea status of thechildren. At multivariate level of analysis, was useddue to dichotomous nature of the dependentvariable to identify the predictors of diarrheaamong the children. At this stage of analysis, threemodels were generated. Three models were usedto describe the relationship between maternaleducation and diarrhea among 0-12 months oldchildren. In the first model, only maternaleducation, which was the main independentvariable, was introduced into the model while thedisposal of youngest baby’s stool in the householdand education were jointly used in the secondmodel, the third model is the full model where allvariables that were found to be statisticallysignificant at bivariate level of analysis were used.The last model was used to identify the predictorsof diarrhea among children aged 0-12 months. Italso reveals the influence of other variables onthe relationship between education and diarrheaamong the children. All statistical tests wereperformed at 5.0% level of significance.

Ethical consideration

The three models were defined by themathematical equations as follow Ethicalconsideration. Ethical approval was obtained from

Association of maternal education with infantile diarrhea Rahat Bin Habib et al 100

the Ethical Board of ICMH before conducting thisstudy. Informed consent was obtained from thestudy participants at the point of data collectionand all the consented participants were assured ofconfidentiality and anonymity of the informationthey supplied.

Limitations of the Study

The data used for this study was cross-sectionalsurvey based on information on diarrhea statusby the mother or caregiver of the index child intwo weeks preceding the survey. As such, theirresponses could be subjected to recall bias andmisreporting of other diseases for diarrhea.Although, the data originator ensured that sucherrors were minimized at the time of the study.Also, diarrhea reported for the children was notbased on their clinical examination especially sincereporting of illnesses differs among differentparents, this could be a source of variability andthus generalization should be done with caution.

Result

The study was conducted in a tertiary care hospital(ICMH), Dhaka, Bangladesh. Data were collectedabout 12 months for 212 infants from their parentsabout the nature and frequency of defecation withsociodemographic characters.

Table-I

Gender Variation

Sex of infants Frequency Percent

1. Male 121 57%

2. Female 91 43%

Total 212 100%

More then half were male (57%) infants andremaining (43%) were female infants.

Table-II

Mother’s Education Frequency Percent

Upto 5 years 32 15

Upto 10 years 95 45

Upto 15 years 61 29

More then 15 years 19 09

No education 05 02

Total 212 100

Upto 10 years educated mothers were 62% andremaining 38% were more then 10 years education.Most mothers (45%) were upto 10 years educatedand higher level education get 09%. Some mothers(n=05) were never schooling.

Table-III

Non parametric test on Mother’s education and

loose motion

Diarrhoea Not Total

diarrhoea

Mother’s educa- 92 (43.5%) 40 (19%) 132 (62%)tionupto 10 years

Mother’s educa- 35 (16.5%) 45 (21%) 80 (38%)tionmore then10 years

Total 127 (60%) 85 (40%)212 (100%)

X² 7.984 df 1 P value <0.001

In this non parametric study we found that 21%infants had history of less diarrhoea whosemothers were more then 10 years educated and45.5% infants AWD more whose mothers were lesseducated. This indicate mother’s education is aprotective factor for infantile diarrhoea.

Discussion

This was a descriptive type of cross sectional studyin a tertiary care hospital (ICMH), Dhaka,Bangladesh, on 212 infants for 12 months. Amongthem more then half were male (57%) infants andremaining (43%) were female infants. Studies indeveloped and developing countries haveinvestigated factors contributing to the prevalenceof diarrhea among infants in diverse settings27,28.A number of studies conducted in Bangladeshfocused on diarrhea morbidity, risk factors, careand management7,20,28. There are however fewdocumented national studies that used maternaleducation as a major factor for diarrheaoccurrence. This study has therefore revealed howmaternal educational attainment influenceschildhood diarrhea in Bangladesh. In this study,the factors found to be associated with diarrheaamong children aged 0-12 months were; maternaleducation and diarrhoea. Substantial considerationhas been given to the relationship betweenmaternal education, and child health in theliterature. Among all the social determinants of


health that explain health inequalities in anypopulation, education has been consistentlyidentified as a main factor and this has beenextensively established in wider literature29.Education is critical to population health and itshealth benefits accrue at the individual,community and socio-cultural context30. Moreeducated women may have tendency to navigatethe health care system, have better personal healthbehaviors, and better able to possess acomprehension of the basic consequences ofunhealthy living than the less educated. World-wide, previous studies have identified maternaleducation as a major predictor of child healthoutcomes31. In this study, maternal education hasbeen identified as an important predictor ofchildhood diarrhea. This finding is an indicationthat children of mothers with lower educationalattainment have a higher risk of experiencingchildhood diarrhea than those whose mothers arebetter educated. This is in line with community-based studies conducted in South East Asia andsub-Saharan Africa25,26,32,33. The possible reasonsfor this finding in Bangladesh, is that bettereducated mothers are involved in practices thatare of benefit to the health of their children.Chronic diarrhea can affect children of any agebut its occurrence varies across childhood period.In this study, children aged between 7 and 18months were found to experience higheroccurrence of diarrhea than those below 7 monthsand those above 18 months. This pattern could beexplained that this age range is the period in whichmost children are exposed to contaminants throughtheir surroundings by crawling. This period is alsoassociated with the weaning period of the childrenand its associated challenges. A study by Sinmegnet al34, corroborates this assertion. Wealth indexwas found to be related to the occurrence ofdiarrhea and more prevalent among children ofwomen from poorer homes. This finding iscorroborated by the study of Boardi andKeutunen35. However, according to Siziya, et al36,no relationship was established between wealthindex and childhood diarrhea. In Bangladesh,potable water as one of the key socialresponsibilities of the Government is either notavailable or not within the reach of the generalityof the population. While the rich circumvent thissituation by sinking boreholes in their houses, the

poor still get their domestic water sources fromunprotected wells, brooks and streams. Ability tomake provisions for some factors that could limitdiarrhea disease transmission by wealthierfamilies can be explained from these findings.Bangladesh is a large country in terms ofpopulation and geographical distribution. Theaccess to good health varies widely across theregions in Bangladesh. The literacy level variesconsiderably across the regions in Bangladesh. Aresearch report by Raji et al37, has also confirmedinstances of disease outbreak in this region ofBangladesh due primarily to water contamination.The same study showed that drinking watersampled from Sokoto, a major town in this regionwas found to contain a very high load of microbeswhich were far beyond the allowable limits byWHO6. A study carried out in Sudan by Siziya etal36, also supports variation in diarrhea prevalenceby geographic distribution. The often consistentoutcome in Bangladesh could be due to theintensity of grazing which exposes most of thefarmlands to contamination by cow dung and someof these animals drink from the same watersources as humans.

Conclusion

Maternal education is an important predictor ofdiarrhea among children aged 0-12 months inBangladesh. While care should be provided for allchildren, strategies to reduce diarrhoeal diseaseamong children in Bangladesh should focus moreon the children of the uneducated, less educatedmothers. This study has provided a baseline forfuture intervention studies which could informpolicy formulation and review in Bangladeshtowards diarrhea prevention and its control.

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differentials in risk factors for childhood malnutritionin Bangladesh. BMC pediatric, 2014; 14(1), 1.

2. Behrman RE. Nelson Textbook of Pediatrics, 19thed:Philadelphia: Saunders Elsevier; 20:13.

3. Mathers C. et al Global, regional, and na onal causes ofchild mortality in 2008: a systema c analysis. Lancet2010;375:1969-987.

4. Parsons MB, et al. Risk Factors for Death amongChildren Less than 5 Years Old Hospitalized withDiarrhea in Rural Western Kenya; 2005-2007.

5. Teferra AS. et al Determinants of childhood diarrheaamong underfive children in Benishangul Gumuz

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Regional State, North West Ethiopia. BMC pediatric,2014; 14(1)

6. World Health Organisation (WHO). Reducing mortalityfrom major childhood killer diseases.Mortality CountryFact Sheet. 2006.

7. Ayede AI. et al Hygiene and sanitation risk factors ofdiarrheal disease among under-five children in Ibadan,Nigeria. African Health Sciences, 2014; 14(4).

8. Tumwine JK. et al Prevalence and factors associatedwith rotavirus infection among children admitted withacute diarrhea in Uganda. BMC pediatrics, 2010; 10(1),69.

9. Monitoring the situation of children and women. NigeriaMultiple Indicator Cluster Survey 2011SummaryReport. National Bureau of Statistics, Abuja Nigeria.2011.

10. World Bank. World Development Indicators: Mortality.World Bank Group. 2013

11. Amoo EO. A Statistical Analysis of Child Mortality:Evidence from Nigeria Journal of Demography andSocial Statistics, 2014; 1, 11-10.

12. Population Reference Bureau. World Population Datasheet with a special focus on human needs andsustainable resources. 2016

13. Adepoju AO. Differential Pattern in Child Mortality Ratein Rural Nigeria. Annual Research & Review in Biology,2015; 7(5): 39-37.

14. Okolo S. Prevalence of diarrhea disease and risk factorsin Jos University Teaching Hospital, Nigeria. Annals ofAfrican medicine, 2012; 11(4), 27

15. Kok FJ. et al. Association of food-hygiene practices anddiarrhea prevalence among Indonesian young childrenfrom low socioeconomic urban areas. BMC public health,2013; 13(1), 1.

16. Banda, JM. et al Incidence of rotavirus infection inchildren with gastroenteritis attending Jos universityteaching hospital, Nigeria. Virology journal, 2011; 8(1),1.

17. Black RE. et al Diarrhea incidence in low-andmiddleincome countries in 1990 and 2010: a systematicreview. BMC public health, 2012; 12(1), 1.

18. National Population Commission (NPC) and ICFInternational. 2014. Demographic and Health Survey2013. Abuja, and Rockville, Maryland, USA: NPC andICF International.

19. Louckx F. et al The impact of parental education oninfant in Gaza strip, Palestine. Journal of Public Healthand Epidemiology 2011; 3(1), 28-33.

20. Raji MIO and Ibrahim YKE. Prevalence of waterborneinfections in Northwest Nigeria: A retrospective study.Journal of Public Health and Epidemiology 2011; 3(8),3-5.

21. Caldwell JC. Education as a factor in mortality declinean examination of Nigerian data. Population studies,1979; 5-13.

22. A. Wagstaff. et al. Socioeconomic Differences in Health,Nutrition and Population in Cameroon. Washington2005; (15) 13-26.

23. Van Ginneken JK. et al Maternal education and childsurvival in developing countries: the search for pathwaysof influence. Social science & medicine, 1988; 27(12),17-18.

24. Raine R. et al The relationship between maternaleducation and mortality among women giving birth inhealth care institutions: analysis of the cross sectionalWHO Global Survey on Maternal and Perinatal Health.BMC public health, 2011; 11(1), 1.

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Clinicopathological Study of Pelvic Inflammatory

Disease Among Reproductive Women in BSMMUSakila Sharmin1, Md. Mostafizur Rahman2, Bilkis Ferdous3, Shelina Pervin4, Sunirmal Roy5,

Md. Saiful Islam6

Abstract

Background & Objectives: Pelvic inflammatory disease (PID) presents as a spectrum of

infections of the upper genital tract that includes endometritis, salpingitis, pelvic peritonitis,

and tubo-ovarian abscess. Chlamydia trachomatis and Neisseria gonorrhoeae account for

approximately one-third to half of cause of the pelvic inflammatory disease (PID). Thus in up

to 50-70% causes of PID is unknown. To identify the causes, clinical presentation & causative

agent of pelvic inflammatory disease among women of reproductive age group. Methods; This

was a prospective cross sectional study. It was done in the department of Obstetrics and

Gynaecology Bangabandhu Sheikh Mujib Medical University (BSMMU) Dhaka during the

period of September 2011 to February 2012.Fifty patients were enrolled, those having pelvic

inflammatory disease, with tubo-ovarian mass size <8 cm and absence of overwhelming sepsis.

A detail history including Age, Presenting complaints, Menstrual problem, Past obstetric history,

Pregnancy termination, Contraceptive history, Morbidity Pattern, were taken properly Per

abdominal examination, USG of the lower abdomen and culture & sensitivity (c/s) of vaginal

swab were done.

Results: The mean age was 27.16±4.19 years. Eighty eight percent were married. Almost three

fourth (72.0%) of the patients were house wives. Presenting complaints were lower abdominal

pain (78.0%), dyspareunia (66.0%), vaginal discharge (56.0%),backache (36.0%),congestive

dysmenorrhoea (76.0%), infertility (14.0%) and menorrhagia (52.0%). Sixty-eight percent patients

were multipara. About the pregnancy termination menstrual regulation (MR) was found in

48.0%, induced abortion 20.0% and spontaneous abortion was found in 6.0% of the patients.

Endocervical swab for c/s showed, that no growth in 22%, N gonococcus 20%, Chlamydia

trachomatis 16% streptococcus pyogenes, 12% enterococcus, 12% E. coli 10% and 8% was in

proteus.

Conclusion: In pelvic inflammatory disease, lower +abdomen pain, dispareunia, vaginal

discharge and backache are common presenting feature. Most of the patient were younger age,

married, low-socioeconomic status, multipara and H/O termination of pregnency Gonococcus,Chlamydia trachomatis streptococcus pyogenes, enterococcus, E. coli and proteus.are the

common organisom.


1. Department of Obst & Gynae 100 Bedded DistrictHospital Norshindi

2. Department of Paediatrics, Siralimullah Medical College& Mitford Hospital, Dhaka.

3. Department of Obst & Gynae BSMMU, Dhaka.

4. Department of Obst & Gynae, 500 bedded Generalhospital, Mugda Dhaka

5. Department of Paediatric, Siralimullah Medical college& Mitford Hospital, Dhaka.

6. Department of Cardiology, Narsingdi Sadar Hospital,Narsingdi

Address for Correspondence : Dr. Sakila Sharmin,Department of Obst & gynae 100 bedded district hospitalNorshindi, Mobile: 02552202055, E-mail: [email protected]

Introduction

Pelvic inflammatory disease (PID) presents as aspectrum of infections of the upper genital tractthat includes endometritis, salpingitis, pelvicperitonitis, and tubo-ovarian abscess.1 In general,acute pelvic inflammatory disease is caused byascending spread of microorganisms such asChlamydia or gonorrhea from the vagina and/orendocervix to the endometrium and fallopiantubes.2 Pelvic inflammatory disease is a commondisease that affects nearly one million women eachyear. It appears most frequently in women whoare younger than 20 years old. About one in everyeight women in this age range develops pelvic


inflammatory disease.3 About 10% of women withpelvic inflammatory disease are infertile and 30%develop chronic abdominal pain. Up to 5% ofwomen who subsequently conceive have an ectopicpregnancy.4 The common symptoms of pelvicinflammatory disease include abdominal pain,vaginal discharge, fever, painful sexual intercourse,painful urination, fatigue, nausea and vomiting.Antibiotic therapy is the treatment for PID andcan prevent serious complications.5 Pelvicinflammatory disease can lead to potentially life-threatening complications if left untreated. Severeinfection may lead to shock,coma, and even death6

Women who acquire acute PID are at risk for long-term sequelae, including infertility, ectopicpregnancy, chronic pelvic pain, and recurrentPID.6-9 Pelvic inflammatory disease (PID) isassociated with major medical and economicconsequences for women of reproductive age.Identification of the risk factors associated with PID is crucial for prevention of these consequences. Prevalence of pelvicinflammatory disease (PID) is affected by variouscommunity and individual risk factors. Sexuallytransmitted infections (STIs) such as Chlamydiatrachomatis and Neisseria gonorrhoeae have beenidentified as main causative agents, additional STIsincluding Mycoplasma genitalium, anaerobes andother organisms may also be implicated7. In thepast, PID was believed to be a monoetiologicinfection, primarily caused by N. gonorrhoeae.Today the polymicrobic etiology of PID is wellestablished and has resulted in utilization of broad-spectrum antimicrobial regimens for treatment ofacute pelvic inflammatory disease (PID) .8 Manyof the nongonococcal, nonchlamydialmicroorganisms recovered from the upper genitaltract in acute PID are associated with bacterialvaginosis (BV). Multiple investigations have beendemonstrated an association between bacterialvaginosis and acute PID.9

There is no recent statistical report in our countryto see the presentation & cause of pelvicinflammatory disease. So, this study has beendesigned to observe the presentation & cause ofpelvic inflammatory disease.

Objectives of the study to evaluate the clinicalpresentation, etiological factors and causativeorganism of pelvic inflammatory disease amongreproductive age group women.

Methodology:

It is a prospective cross sectional study .The studywas carried out in the Department of Obstetrics &Gynecology, Bangabandhu Sheikh Mujib MedicalUniversity, Dhaka, from September 2011 toFebruary 2012. Permission was taken from theresearch review committee (RRC) and the ethicalreview committee (ERC) Bangabandhu SheikhMujib Medical University, Dhaka. Informedwritten consent was taken from all the patient /guardian of study subjects after explaining thenature and purpose of the study in good details.

Sample size was 50. For this purpose 50 patientswere selected from the department of Gynecologyand Obstetrics BSMMU with pelvic inflammatorydisease. Inclusion criteria were lower abdominalpain, adnexal tenderness, cervical motiontenderness, vaginal discharge & size of tubo-ovarian mass <8 cm. Immunocompromised &overwhelming sepsis patient were excluded fromthe study

Data collection procedure:

A detail history including age, educational status,occupation, marital status, economic status, parity,menstrual history, H/O Lower abdominal pain, MR,abortion and vaginal discharge was taken properly.USG of the lower abdomen were done in thedepartment of radiology & imaging. Vaginal swabwere collected and culture & sensitivity (C/S) weredone in the microbiology department.

Procedure of Data analysis:

Data were collected in a pre-designed form. Alldata were analyzed by using computer based SPSS(version 16.0) programmed. Statistical analysis wasperformed, categorical variables was presented inthe form of frequency and percentage. Quantitativedata were presented in the form of mean andstandard deviation.

Results:

The mean age of the study group was 27.6 yearswith range from 20 to 36 years. Educational levelof 32.0% of the patients had primary class, 16.0%secondary, 16.0% higher secondary, 8% weregraduate & 28.0% Illiterate. Seventy two percentwere house wives and 28.0% were service holder.Monthly income of the study group were <5000taka 20%, 5000-10,000 taka 28%, 11,000-15,000taka 28% & >15,000 taka 24%.Eighty-eight percent

Clinicopathological Study of Pelvic Inflammatory Disease Among Reproductive Women Sakila Sharmin et al 106

was married, 8.0% were widow and 4.0% weredivorced. Sixty-eight percent patients weremultipara, 6.0% were grand multipara and 26%primipara.

Presenting complaints were lower abdominal pain78.0%, dyspareunia 66.0%, vaginal discharge56.0%,backache 36.0%, and infertility 14.0%.About the pregnancy termination, MR was found48.0%, induced abortion 20.0%, spontaneousabortion was found in 6.0% and 26% had no historyof pregnancy termination. Endocervical swab forc/s showed, gonococcus 20%, Chlamydiatrachomatis 16% streptococcus pyogenes, 12%enterococcus, 12% E. coli 10%, proteus 8% andno growth 22%.

Table I

Age distribution of the study patients (n=50).

Age (in years) Number of patients Percentage

d”25 18 36.0

26-30 22 44.0

>30 10 20.0

Mean ± SD 27.6

Range (min-max) (20 -36)

\

Table II

Educational status distribution of the study

patients (n=50).

Education Number of patients Percentage

Primary 16 32.0

Illiterate 14 28.0

Secondary 8 16.0

Higher secondary 8 16.0

Graduate 4 8.0

Table III

Distribution of the study patients according to

patients occupation (n=50).

Patients occupation No. of patients Percentage

House wife 36 72%

Service holder 14 28%

20.0

28.0 28.0

24.0

0

5

10

15

20

25

30

<5000 6000-10000 11000-15000 >15000

Pe

rec

nta

ge

Monthly Income

Fig 1: Bar diagram shows distribution of the study

patients according to Monthly income (n=50).

2 (4.0%)4 (8.0%)

44 (88.0%)

0

5

10

15

20

25

30

35

40

45

50

Married Widow Separated

Marital status

Pe

rce

nta

ge

Fig. 2: Bar diagram shows distribution of the study

patients according to marital status (n=50).

Fig.-3: Bar diagram shows the study patients

according to presenting complaints (n=50).

39(78.0%)

33(66.0%)

28(56.0%)

18(36.0%)

7(14.0%)

0 20 40 60 80 100

Pain in the lower abdomen

Dyspareunia

Vaginal discharge

Backache

Infertility

Percentage

Pre

sen

tin

g c

om

pla

ints

Table IV


past obstetric history (n=50).

Past obstetric Number of Percentagehistory patients

Parity 0 7 14.0

Parity 1 6 12.0Parity 2 – 5 34 68.0Parity > 5 3 6.0


Table V


pregnancy termination (n=50).

Pregnancy termination Number of Percentage

patients

MR 24 48.0

Induced abortion 10 20.0

Spontaneous abortion 3 6.0

No history of pregnancy 13 26.0

termination

Table VI


endocervical swab for c/s (n=50).

Endocervical swab s Number of Percentagefor c/s patients

No growth 11 22

Gonococcus 10 20

Chlamydia trachomatis 86 1612

Streptococcus pyogenes

Enterococcus 6 12

E.coli 5 10

Proteus 4 8

Discussion:

This prospective cross sectional study was carriedout with an aim to evaluate the clinicalpresentation, etiological factors and causativeorganism of pelvic inflammatory disease amongreproductive age group women.In this currentstudy it was observed that the mean age was 27.6years, Pavonen et al.found mean age was 26 years,Ness11 et al.showed mean age 26 year’s.Haggerty10and Schulz12 found mean age 26 years,which are consistent with the current study. Inthis study it was observed that educational levelof 32.0% of the patients had primary, 16.0%secondary, 16.0% higher secondary, 8% weregraduate & 28.0% Illiterate.Haggerty10, Ness11

and Schulz12 showed 41% patient hadprimary,34%,secondary,and 25% were abovesecondary. .In this current series it was observedthat more two third (72.0%) of the patients werehouse wife and 28.0% was service holder which

are consistent with Haggerty10 but not consistentwith Ness11 et al study.

Monthly income of the study group were <5000taka 20%, 5000-10,000 taka 28%, 11,000-15,000 taka28% & >15,000 taka 24%. not consistent Ness11 etal study. In this present study it was observed thatmost (88.0%) patients were currently married,8.0% was widow and 4.0% was separated.Haggerty10, Schulz12 and Ness11 showed 11.0%married, 13.6% separated/ divorced/ widowed and75.4% were never married which are not consistentwith the current study Most of the patients (80.0%)were multipara and 6.0% were grand multipara.14%primipara it is consistent with Weston13.The mostcommon presenting symptoms of the patientspelvic inflammatory disease in the present studywere lower abdomen pain (78.0%), dyspareunia(66.0%), vaginal discharge (56.0%), backache(36.0%) and infertility 14.0%. Similar finds alsoobtained by Westrom14 Mardh15, and Haggerty10

et al. In this present series it was observed thatMR were done in 48.0%, induced abortion 20.0%,spontaneous abortion 6.0% and 26.0% patients hadno previous history of pregnancy terminationwhich is consistent with Westrom14 and .Adler 16.According to endocervical swab for c/s in this seriesit was observed that no growth was found 22%,gonococcus 20%, Chlamydia trachomatis 16%streptococcus pyogenes, 12% enterococcus, 12% E.

coli and 10% and 8% was in proteus. Ness11 et al,reported in their study that pelvic inflammatorydisease caused by Enterococcus species,Escherichia coli and Streptococcus speciesincluding S. pneumonia, which support the presentstudy. Mardh15 and Westrom13 mentioned thatPID may follow infection with Neisseriagonorrhoeae, Chlamydia trachomatis, or genitalmycoplasmas.

Conclusion:

In pelvic inflammatory disease, lower abdomenpain, dispareunia, vaginal discharge and backacheare common presenting feature. Most of thepatient were younger age, married, low-socioeconomic status, multipara and H/Otermination of pregnency .Gonococcus,

streptococcus pyogenes, enterococcus, E. coli andproteus.are the common organisom.

Clinicopathological Study of Pelvic Inflammatory Disease Among Reproductive Women Sakila Sharmin et al 108

Limitations of The Study

Small sample sizes, short duration of study period,single center study, which may not represent thewhole scenario of pelvic inflammatory disease inour country.

References

1. Sam JW, Jacobs JE, Birnbaum BA. Spectrum of CTFindings in Acute Pyogenic Pelvic InflammatoryDisease. Am. J. Obs. & Gyn 2010; 195: 1327-34.

2. Centers for disease control and prevention. Sexuallytransmitted diseases treatment guidelines 2006;55(11):56-61.

3. Sweet, R L. Treatment strategies for pelvicinflammatory disease. Pharmacother 2009, 10(5), 823-37.

4. Haggerty, C L Ness, R B. Diagnosis and treatment ofpelvic inflammatory disease. Womens Health 2008; 4(4):383-97.

5. Hillier S L, Kiviat NB, Hawes SE, Hasselqulst M B,Hanssen PW, Eschenbach D A, “et al”. Role of bacterialvaginosis-associated microorganisms in endometritis.Am J Obstet Gynecol 2004;175: 435-41.

6. Duthie S J, Hobson, A L Pratt, B C Lowe, N Sequeira, JL Hargreaves. Morbidity after termination of pregnancyin first Trimester.Genitourin Med 1987; 63:182-187.

7. Hebb, J K Cohen, C R Astete, S G Bukusi, E A Totten,P A Rosa, et al. Detection of Novel OrganismsAssociated with Salpingitis, by Use of 16S rDNAPolymerase Chain Reaction. The Journal of InfectiousDiseases.2004;190: 2109-20.

8 Soper, D E Brockwell, N J Dalton, H P Johnson.X.Observations concerning the microbial etiology of acutesalpingitis. Am J Obstet Gynecol, 1987; 186(4), pp. 1008-1415.

9. Botte J, Peipert JF, Sweet RL, Wiesenfeld HC, editors,pelvic inflammatory disease, Taylor & Francis, London,2006:1-18.

10. Haggerty, C L Hillier, S.L Bass, D.C., and Ness, R.B.Bacterial Vaginosis and Anaerobic Bacteria AreAssociated with Endometritis. Clinical InfectiousDiseases,2004; 39:990-95.

11. Ness, R.B. Newest Approaches to Treatment of PelvicInflammatory Disease: A Review of Recent RandomizedClinical Trials. Clinical Infectious Diseases 2007; 44:953-60. .

12. Schulz, K.F. Cates W. Prophylactic antibiotics forcurettage abortion. Am J Obstet Gynecol. 2001;170:689-94.

13. Birch J, Mare WS, Forster GE, Munday PE, HelsinkiJP, Paton J, Preston JT, Yarmouth G. Management ofacute pelvic inflammatory disease. Royal College ofObstetrician and Gynaecologist, 2008 Green – top guideline No. 32.

14. Westrom L etal. Effect of acute pelvic inflammatorydisease on fertility. Am J Obstet Gynecol, 1975.121(5),707-13. .

15. Mardh PA, Westrom L. Tubal and cervical cultures inacute salpingitis with special reference to Mycoplasmahominis and T-strain mycoplasmas.British Journal ofVenereal Diseases.2009;41:179-86.

16. Adler, M.W., Belsey, E.H and O’Connor B.H. Morbidityassociated with pelvic inflammatory disease Br J VenerDis, 2005; 58: pp.151-7.

Comparison of Clinical Profiles of

Hyperbilirubinaemia in Term and Preterm

Neonates Aged 3-7daysBithi Rani Shaha1, AFM Salim2, Khondker Qamruzzman3, Tasnuva Khan4, Naima Sultana5,

Md. Abdul Mannan6

Abstract

Background: Physiological jaundice is common both in term and preterm neonates. In addition,

jaundice due to septicemia, umbilical sepsis, chest infection, meningitis, skin sepsis or other

infections are also seen quite frequently. Blood group incompatibilities, such as ABO or Rh

incompatibilities are also found. In some cases, neonates admitted with birth asphyxia,

hypoglycemia, neonatal convulsion may also develop jaundice. Clinical presentation of these

neonates, both term and preterm, is therefore very important for proper treatment. The present

study was undertaken with the aim of comparing the clinical profiles of hyperbilirubinaemia

in both term and preterm neonates aged 3-7 days.

Objectives: To compare the clinical profiles of hyperbilirubinaemia in both term and preterm

neonates aged 3-7 days.

Methods: The study was carried out in the Special Care Baby Unit of Institute of Child Health

& Shishu Shasthya Foundation Hospital (ICH & SSFH), Dhaka, Bangladesh from January,

2014 to June 2014. All the babies developing jaundice and meeting the clinical criteria were

included in the study. Detailed information was obtained in each cases according to protocol.

Complete history was taken from accompanying attendants. Thorough clinical examinations

and laboratory investigations (complete blood count, s. bilirubin, CXR, urine R/M/E, S. Ca2+,

blood grouping & Rh typing, serum electrolyte, CSF study) were done. Relevant investigations

reports were collected. All the information was recorded in the fixed protocol. Collected data

was classified, edited, coded and entered into the computer for statistical analysis.

Results: There were 80 patients, out of whom 40 were preterm and the rest term babies. The

mean age in the preterm group was 5.45 (±1.19) days (range 3-7 days) and 5.05 ((±1.56) days

(range 4-7 days) in term group. In the preterm group, 29 (72.5%) were male and 11 (27.5%)

female babies while in term group, 21 (52.5%) were male and 19 (47.5%) female babies. Among

preterm babies with jaundice, 18 (45%) had perinatal asphyxia, 14 (35%) had septicaemia, 14

(35%) had IDM, 11 (27.5%) had premature rupture of membrane, eight (20%) had ABO

incompatibilities, five (12.5%) had Rh incompatibilities, one (2.5%) had intracranial hemorrhage,

and 10 (25%) had physiological jaundice. In one (2.5%) baby, no definite cause of jaundice could

be identified. Among term babies with jaundice, 17 (42.5%) had ABO incompatibilities, 14

(35%) had premature rupture of membrane, nine (22.5%) had birth asphyxia, six (15%) had

IDM, two (5%) had septicaemia, one (2.5%) had Rh incompatibilities, one (2.5%) had intracranial

hemorrhage, and seven (17.5%) had physiological jaundice. In three (7.5%) babies, no definite

cause of jaundice could be identified.

Conclusion: Study revealed jaundice occurs in preterm babies of 3-7 days old mainly due to

perinatal asphyxia, septicaemia, IDM, premature rupture of membrane, ABO incompatibilities,

Rh incompatibilities and physiological reasons. On the other hand, main causes of jaundice in

term babies of the same age group are ABO incompatibilities, premature rupture of membrane,

birth asphyxia, IDM, septicaemia, idiopathic and physiological reasons.

Keywords: Hyperbilirubinaemia, term, pre-term, neonates


1. Medical Officer, Child OPD, Sir Salimullah Medical College Mitford Hospital, Dhaka2. Professor of Paediatrics, Central Hospital, Dhaka3. Assistant Professor, Department of Paediatrics, Sir Salimullah Medical College Mitford Hospital, Dhaka4. Assistant Registrar, Department of Paediatrics, Dhaka Medical College Hospital5. Indoor Medical Officer, Department of Paediatrics, Sir Salimullah Medical College Mitford Hospital, Dhaka6. Associate Professor, Deartment of Pediatrics, Royal College of Medicine Perak University Kuala Lumpur, Malaysia.Correspondence: Dr. Bithi Rani Shaha, Medical Officer, Child OPD, Sir Salimullah Medical College Mitford Hospital,Dhaka, Mobile: +8801717333665, Email: [email protected]

Introduction

Neonatal hyperbilirubinaemia/jaundice is definedas a total serum bilirubin more than 5 mg/dl(86micromol/l).1 During the 1st week of life,approximately 60% of term and 80% of pretermneonates may develop jaundice.2

Bilirubin is a breakdown product of RBC andneonates are incapable of removing bilirubinefficiently due to immaturity of hepatic enzymeresulting in jaundice in term and pretermneonates. There are two major types ofhyperbilirubinaemia:

a) unconjugated/indirect hyperbilirubinaemia(can be physiological or pathological) and

b) conjugated/direct hyperbilirubinaemia (alwayspathological).

According to a study at the Special Care Baby Unit(SCABU) of BIRDEM, the incidence of jaundice inneonates was 23.5%.3

A retrospective study was carried out in all termbabies with neonatal jaundice in B.P. KairalaInstitute of Health Sciences (BPKIHS) over theperiod of two years between May, 2000, and April,2002. Out of 636 admissions in nursery and NICU,22 had significant jaundice. There was malepreponderance. Septicaemia and ABOincompatibility were common causes of jaundiceseen in 36.36% (8/22) and 31.8% (7/22) of babiesrespectively. Birth asphyxia, as concomitantaggravating factor, was seen in two patients.4 Interm babies, physiological jaundice appearsbetween 30-72hrs of age, maximum intensity ofjaundice is seen on the fourth day, and jaundicedisappears by 10-14th day of life. Among pretermbabies, the maximum intensity of jaundice isreached on the 4th-7th day and it may persist upto 14 days. Serum bilirubin may go up to 15mg%.5

Physiological jaundice is more common in termbabies. On the other hand, birth asphyxiahypoglycemia, chest infection, sepsis, skin infection,convulsion etc could cause jaundice in pre-termneonates. Other common causes ofhyperbilirubinaemia include blood groupincompatibility, sepsis, G6PD deficiency, andmajority being idiopathic. Other less commoncauses include polycythemia, cephalhematoma.6,

7 Approximately 5-10% of them have clinicallysignificant hyperbilirubinaemia mandating the use

of phototherapy. Lower gestation babies are athigher risk of developing hyperbilirubinaemia andrequire closer surveillance and monitoring.8

Singhal et al. showed prematurity as the secondmost common cause of Hyperbilirubinaemia intheir studies. Out of a total 7680 live births, 454(59%) developed hyperbilirubinaemia (serumbilirubin >12 mg/dl).(56.8%)neonates were male.76neonates (16.7%)were premature,(29.1%) were lowbirth weight,(34.6%)due to idiopathic,birth asphyxia(12.1%), infants of diabetic mothers (9.5%),hypoglycemia (9.3%), respiratory distresssyndrome 6.4%) and polycythemia (5.7%).9 A study,conducted on 120 neonates at an Indian hospital,found 49 neonates were less than 37 weeksgestation and 71 neonates were having gestationalage more than 37 weeks, and 56.67% were maleand 43.33% female. The etiology was idiopathichyperbilirubinaemia in 42(35%),physiologicalhyperbilirubinaemia in 36 (30%),ABO incompa-tibility in 17(14.16%),septicaemia in 10(8.33%),Rh-incompatibility in 8 (6.66%), cephalhematoma in 3(2.5%),G-6-PD deficiency in 1 (0.83%) neonate, andmiscellaneous in 1 (0.83%) neonate, one neonatehad both ABO incompatibility and septicaemia, oneneonate had both cephalhematoma as well assepticaemia.10 A study at BIRDEM in Bangladeshshowed that overall 60 (male: female = 58.3: 41.7%)newborns were found who developed significantjaundice and were investigated. The peak totalserum bilirubin (TSB) level varied from 8.6 to26.5mg/dl with maximum TSB> 20 mg/dl in 7(11.6%) cases. Of them, 35% had gestational ageless than 32wks and only 32% had equal to orgreater than 35wks. Prematurity was in 44 (73.3%) cases, IDM in 21 (35%), septicaemia in 16(26.6%), ABO incompatibilities in 8 (13.3%), and-Rh incompatibilities in 2 (3.3%) cases. G6PDdeficiency was found in only one (1.7%) case. Twobabies had intra-ventricular hemorrhage. Birthasphyxia was in three patients. Regarding riskassessment, ABO incompatibility was significantlyhigher in the term (p<0.02) and IDM wassignificantly higher in preterm (p<0.05) groupscompared with their counterparts. Compared withthe higher gestational age-group (e” 35 wks), thelower group (<32 wks) showed significantly higherrate of septicaemia (12.5 v. 68.8%, p<0.005).11

In view of the above studies, the present studywas undertaken to analyse clinical profiles related

Comparison of Clinical Profiles of Hyperbilirubinaemia in Term and Preterm Neonates Bithi Rani Shaha et al 110

to neonatal hyperbilirubinaemia in term andpreterm neonates. Identifying infants at risk ofdeveloping severe hyperbilirubinaemia and earlyintervention will reduce the levels of morbidityand mortality associated with encephalopathy.

Aim and Objectives

General objective:

To compare the clinical profile ofhyperbilirubinaemia in both term and pretermneonates aged 3-7days.

Specific objectives:

1. To identify the causes of jaundice in both term& preterm neonates

2. To evaluate the clinical profiles

3. To assess the severity of jaundice between thistwo groups

4. To find out the characteristics of jaundicednewborns

Methods:

This study was a prospective comparative studythat was carried out at the Department ofPaediatric Medicine, ICH & SSFH, Dhaka.Newborns of 3 to 7 days suffering from jaundiceadmitted to the above mentioned hospital was thestudy population. Sample size is 76.66 accordingto formula; therefore 80 neonates withhyperbilirubinaemia were enrolled in this study.Sampling method was purposive sampling.

Data were collected using a structuredquestionnaire containing all the variables ofinterest keeping compliance with HelsinkiDeclaration for Medical Research involving Humansubjects 1964.Both term and preterm neonates,aging 3 to 7 days admitted to SCANU of ICH &SSFH with hyperbilirubinaemia and/orhyperbilirubinaemia with perinatal asphyxia,convulsion, meningitis, skin infection, umbilicalsepsis, birth trauma, blood group incompatibilityand other clinical features, fulfilling the inclusioncriteria were interviewed after taking informedconsent from the parents about the purpose of thestudy. Detailed history was taken meticulouslyusing clinical variables. CBC, blood grouping & Rhtyping of baby and mother, CRP, S bilirubin (total,direct, indirect), blood C/S, CXR, and other relevantinvestigations were done. Then, after enrollment,clinical profiles of hyperbilirubinaemia in term and

preterm neonates were compared. Data wereprocessed and analysed using computer softwareSPSS (Statistical Package for Social Sciences),version 17.0. The test statistics to be used aredescriptive statistics and Chi-square or Student’st-Test as and where applicable. Level of significancewas set at 5% and p-value < 0.05 was consideredsignificant.

Inclusion criteria:

• Neonates with jaundice delivered outside theinstitute, admitted in SCANU.

• Age group 3-7days.

• Neonates with serum bilirubin more than10mg/dL

• Those who gave consent to participate in thestudy

Exclusion criteria:

• Babies who severely sick and referred to otherhospitals

• Babies with congenital anomaly

Results

Table-I

Age group distribution of the study group

Age group Preterm Term Total

3-5 days 23(57.5) 25(62.5) 48

6-7 days 17(42.5) 15(37.5) 32

Total 40(100) 40(100) 80

Mean ±SD 5.45(±1.19) 5.05(±1.56) 3-7 days

Table shows age between 3-5 days 23(57.5%) werepreterm baby and 25(62.5%) were term babies. Agebetween 6-7 days 17(42.5%) were preterm babiesand 15(37.5%) were term babies.

Table-II

Sex distribution of the study population

Sex Preterm Term Total

Male 29(72.5) 21(52.5) 50

Female 11(27.5) 19(47.5) 30

Total 40(100) 40(100) 80

Table shows sex distribution of the patients. Therewere 29(72.5%) preterm and 21 (52.5%) term malebabies whereas there were 11 (27.5%) preterm


female babies and 19 (47.5%) term female babies.In preterm neonates, the male and female ratiowas 2.6:1

In term neonates, the male and female ratio was1.1:1.

Table-V

Distribution of physiological reason in term and

preterm babies

Physiological Preterm Term Total P

value

Yes 10(25%) 07(17.5%) 17 0.41 ns

No 30(75) 33(82.5) 63

Total 40(100) 40(100) 80

Table shows physiological reason in preterm andterm babies was found in 10(25%) and 07(17.5%)babies respectively. The p value (0.41) was notstatistically significant.

Table-VI

Distribution of ABO incompatibility in term and

preterm babies

ABO Preterm Term Total P

incompatibility value

Yes 08(20) 17(42.5) 25 0.02

No 32(80) 23(57.5) 55

Total 40(100) 40(100) 80

Table shows ABO incompatibility was found in 8(20%) preterm and 17 (42.5%) term babies. The pvalue (<0.001) was statistically significant in theircases.

Table-VII

Distribution of septicaemia in term and preterm

babies

Septicaemia Preterm Term Total P

value

Yes 14(35) 02(5) 16 <0.001

No 26(65) 38(95) 64

Total 40(100) 40(100) 80

According to the statistics of this table, septicaemiawas found in 14 (35%) preterm and 2 (5%) termbabies. The p value (<0.001) was found statisticallysignificant.

37

3

31

9

0

5

10

15

20

25

30

35

40

Preterm Term

Doctor Dai

Fig.-1: Deliveries conducted by doctors and ‘dai’

Figure shows deliveries conducted by doctors inpreterm were 37 (92.5%) and 31 (77.5%) in term,3 (7.5%) deliveries were conducted by ‘Dai’ inpreterm and 9 (22.5%) in term group. P value (0.11)was not statistically significant.

Table-III

History of cry after birth of the study population

History of cry Preterm Term Total Pafter birth value

Yes 22(55%) 31(77.5%) 53 0.03

No 18(45) 09(22.5) 27

Total 40(100) 40(100) 80

This table shows 22 (55%) preterm and 31 (77.5%)term babies cried after birth. The p value (0.03)was statistically significant.

Table-IV

History of premature rupture of membrane of

term and preterm babies

History of pre- Preterm Term Total Pmature rupture valueof membrane

Yes 11(27.5) 14(35) 25 0.46

No 29(72.5) 26(65) 55

Total 40(100) 40(100) 80

Table shows history of premature rupture ofmembrane was found in 11 (27.5%) preterm and14 (35%) term babies. The p value (0.46) was notstatistically significant.


Table-VIII

Distribution of Rh incompatibility in term and

preterm babies

Rh incompa- Preterm Term Total P

tibility value

Yes 05(12.5) 01(2.5) 06 0.02

No 35(87.5) 39(97.5) 74

Total 40(100) 40(100) 80

Table shows Rh incompatibility was found in 5(12.5%) preterm babies and 1 (2.5%) term baby andthe p value (0.02) was statistically significant.

Table-IX

Idiopathic causes of hyperbilirubinaemia in term

and preterm babies

Idiopathic Preterm Term Total P

value

Yes 01(2.5) 03(7.5) 04 0.61

No 39(97.5) 37(92.5) 76

Total 40(100) 40(100) 80

According to this table, 1 preterm baby wasidiopathic while the number of idiopathic babieswas 3 in term group.The p value (0.61) was notstatistically significant.

Table-X

Distribution of intracranial hemorrhage in term

and preterm babies

Intracranial Preterm Term Total P

hemorrhage value

Yes 01(2.5) 01(2.5) 02 1.0

No 39(97.5) 39(97.5) 78

Total 40(100) 40(100) 80

As per this table, intracranial hemorrhage wasfound in 1 (2.5%) baby both in preterm and termgroups. The p value (1.0) was not statisticallysignificant.

Table-XI

Distribution of IDM in preterm and term babies

IDM Preterm Term Total P

value

Yes 14(35) 06(15) 20 0.03

No 26(65) 34(85) 78

Total 40(100) 40(100) 80

Table shows significantly higher rate of IDMpresence in preterm and term babies.

14 (35%) babies in preterm and 06 (15%) in termgroup had IDM and that the p value (0.03) wasstatistically significant.

Table-XII

Etiology of jaundice of term and preterm babies

Etiology of Preterm Term Total Pjaundice n(%) n(%) value

Physiological 10(25) 07(17.5) 17 0.41

ABO incompatibility 08(20) 17(42.5) 25 0.02*

Septicaemia 14(35) 02(5) 16 <0.001*

Rh incompatibility 05(12.5) 01(2.5) 06 0.2

Idiopathic 01(2.5) 03(7.5) 04 0.61

Intracranial 01(2.5) 01(2.5) 02 1.0

hemorrhage

IDM 14(35) 06(15) 20 0.03*

History of premature 11(27.5) 14(35) 25 0.46

rupture of membrane

History of cry 22(55) 31(77.5) 53 0.03*

after birth

*= significant

Table shows among preterm babies with jaundice,18 (45%) had perinatal asphyxia, 14 (35%) hadsepticaemia, 14 (35%) had IDM, 11 (27.5%) hadpremature rupture of membrane, eight (20%) hadABO incompatibilities, five (12.5%) had Rhincompatibilities, one (2.5%) had intracranialhemorrhage, and 10 (25%) had physiologicaljaundice. In one (2.5%) baby, no definite cause ofjaundice could be identified.

Among term babies with jaundice, 17 (42.5%) hadABO incompatibilities, 14 (35%) had prematurerupture of membrane, nine (22.5%) had birth


asphyxia, six (15%) had IDM, two (5%) hadsepticaemia, one (2.5%) had Rh incompatibilities,one (2.5%) had intracranial hemorrhage, and seven(17.5%) had physiological jaundice. In three (7.5%)babies, no definite cause of jaundice could beidentified.

Discussion

Hyperbilirubinaemia is quite common in neonates.Physiological jaundice is common both in term andpreterm neonates. Nevertheless, jaundice due tosepticaemia, umbilical sepsis, chest infection,meningitis, septic spots or other infections are alsoseen quite frequently.

Blood group incompatibilities, such as ABO or Rhincompatibilities, are also found. In some cases,neonates admitted with birth asphyxia,hypoglycemia, neonatal convulsion may alsodevelop jaundice. It was a hospital-basedprospective comparative study conducted at theICH & SSFH. The study population werecomprised of 80 jaundiced term and pretermneonates aged between 3 to 7 days delivered outsideof the hospital. Of them, 40 were preterm and therest were term babies.

In the preterm group, the mean age was 5.45(±1.19) days whereas in term group, the mean agewas 5.05 (±1.56) days.

There were 29(72.5%) preterm and 21 (52.5%) termmale babies whereas there were 11 (27.5%) pretermand 19 (47.5%) term female babies. Overall, bothsexes are equally affected, but the males showedhigher rates of preponderance.

This result coincided with that of a study (Naranget al) conducted in India that found 64.2% of thosewho developed pathological hyperbilirubinaemiawere males.

According to Joshi BD et al, out of 636 nurseryand NICU admissions, 22 (3.46%) had significantjaundice with male predominance (15 were maleand 7 female where male and female ratio is 2.1:1).

Maisal et al12 1998, showed in a study consistingof 29,934 infants, factors associated withreadmission for jaundice. Male sex in the studygroup was 74.8% compared to control with 49.6%,with p value 0.007, showing that male sex hasmore risk of readmission for neonatalhyperbilirubinaemia.

Amar Taksande et al13 2005, in a study on 200neonates with 82 males and 118 females, showed8 males and 11 females had serum bilirubin levelof (e”17mg/dl) with p value of 0.323. So, they foundno correlation between the sex of the newborn andthe neonatal hyperbilirubinaemia (³17mg/dl).

Rudy Satrya et al14 2009, showed significantcorrelation between the sex of the newborn andneonatal hyperbilirubinaemia with p value <0.05.Of 88 newborns, 21 developed hyperbilirubinaemiawhere 16 were male and 5 female.

Trivedi et al15 in 2013 showed, gender wise malebabies have shown higher incidence of developinghyperbilirubinaemia than female babies. Studygroup consisted of 605 newborns, 305 males and300 females. Neonatal hyperbilirubinaemiadeveloped in 115 males and 90 females.

This study shows delivery conducted by doctors inpreterm and term babies was 37(92.5%) and31(77.5%). In case of deliveries conducted by Dai,the number was 3 (7.5%) in preterm and 9 (22.5%)in term babes. The p value was (0.11) that was notstatistically significant.

This study shows common etiology of jaundice inpreterm babies were no cry after birth (45%),septicaemia (35%), IDM (35%), premature ruptureof membrane (27.5%), physiological (25%), ABOincompatibilities (20%), Rh incompatibilities(12.5%), idiopathic (2.5%), intracranial hmg (2.5%).

On the other hand, main causes of jaundice in termbabies were ABO incompatibility (42.5%), PROM(35%), asphyxia (22.5%), physiological (17.5%), IDM(15%), idiopathic (7.5%), septicaemia (5%), Rhincompatibility (2.5%), intracranial hmg (2.5%).

Merchant et al16 (1975) found idiopathichyperbilirubinaemia is 66% cases. Verma et al17

(1988) found idiopathic hyperbilirubinaemia in 35%cases.

Singhal et al10 (1992) found idiopathichyperbilirubinaemia in 34.4% vases while Naranget al7 (2001) found it in 57.8% cases. This studyshows idiopathic hyperbilirubinaemia in pretermbabies is 2.5% and in term is 7.5%.

Septicaemia as a cause of hyperbilirubinaemia wasfound in 8% neonates by Merchant et al16 (1975),in 11.6% neonates by Verma et al17 (1988), in 5.7%neonates by Singhal et al10 (1992), and in 9.6%


neonates by Narang et al7 (2001). In our study,jaundice due to septicaemia is 35% in preterm andis 5% in term group.

Rh incompatibility was found in 18.6% neonatesby Merchant et al (1975), in 8.1% neonates bySinghal et al (1992), in 2.9% neonates by Narangrt al (2001), in 6.67% by Kulkarni et al10 (2013).

A study by Verma et al (1988) showed 9.6%neonates had Rh incompatibility. In our study, Rhincompatibility was the reason of jaundice in 12.5%neonates of in preterm group and in 2.5% neonatesof term group.

ABO incompatibility was found in 22.6% neonatesby Merchant et al (1975), in 22.6% neonates byVerma et al (1988), in 14.3% neonates by Singhalet al (1992), in 15% by Kulkarni et al (2013). Ourstudy found ABO incompatibility in 20% pretermand 42.5% term neonates.

A study by Merchant et al (1975) foundphysiological jaundice in 25.3% cases, and Kulkarniet al (2013) in 30% cases.

This study reveals physiological jaundice inpreterm group in 25% cases while the percentageis 17.5 in term group.

Cephalhaematoma as a cause of jaundice was foundin 2.6% neonates by Merchant et al (1975), in 2.9%neonates by Singhal et al (1992), in 6.3% neonatesby Narang et al (2000), in 3.33% by Kulkarni et al(2013).

Our study found cephalhaematoma as a cause ofjaundice in 2.5% both in term and preterm groups.

Rasul CH study reported ABO incompatibility(11.3%) was more than twice as common as Rhincompatibility (5.4%).18 The incidence of Rhisoimmunization has decreased as a result of theintroduction of Rh (D) immunoglobulin to Rh-negative mothers. However, Hoque studiedhaemolytic disease in newborns and found that 39%of cases were the result of ABO incompatibilityand 34% cases were the result of Rhincompatibility.19

Limitation

Sample size is small, duration of the study is notsufficient, the study was carried out in a selectedpopulation belonging to a similar demographiccharacter

Conclusion

Study revealed jaundice occurs in preterm babiesof 3-7 days old mainly due to perinatal asphyxia,septicaemia, IDM, premature rupture ofmembrane, ABO incompatibilities, Rhincompatibilities and physiological reasons. On theother hand, main causes of jaundice in term babiesof the same age group are ABO incompatibilities,premature rupture of membrane, birth asphyxia,IDM, septicaemia, idiopathic and physiologicalreasons.

References

1. Meredith LP, Beth LD. 2002. Hyperbilirubinemia in theTerm Newborn, Am Fam Physician, 65(4), 599-607.

2. Behrman RE, Kliegman RM, Stanton BF Geme St,Schor. 2011. Jaundice and hyperbilirubinemia in thenewborn. 1. 19th ed. Philadelphia: W.B. Saunders, 603-611.

3. Hasan HSM, Fateha US, Abdullah AHM, Azad K. 2004.Neonatal Jaundice. Experience at BIRDEM proceedings

of the 4th national conference and scientific seminar of

Bangladesh neonatal forum, Dhaka.

4. Joshi BD Singh R, Mahato D, Prasad R. 2004. A cliniclaboratory profile of neonatal hyperbilirubinemia in termbabies at BPKIHS, Dharan, Nepal. Journal of Nepal

HRC, 2, 28-30.

5. Singh M. Care of the Newborn, 2004. ed 6, SagarPublications, 239-259.

6. Narang A, Gathwala G and Kumar P. 2001. NeonatalJaundice-An analysis of 551 cases, Indian Journal of

pediatrics, 68, 977-980.

7. Lochmann KK, Sodhi M and Singh G. 2004. Incidenceof neonatal jaundice. Pedicon Abstracts, 158-159.

8. Mishra S, Agarwal R, Deorari AK, Paul VK. 2008.Jaundice in the Newborns, Indian Journal of Pediatrics,

75(2), 157-163.

9. Singhal PK, Singh M, Paul VK, Deorari AK andGhorpade MG. 1992. Spectrum of neonatalhyperbilirubinemia: an analysis of 454 cases. Indian

Journal of Pediatrics, 58, 319-325.

10. Kulkarni SK, Dolas AL, Doibale MK. 2013. Profile &causes of neonates with indirect hyperbilirubinemia ina tertiary care centre. International Journal of Basic

and Applied Medical Sciences, 3 (2), 110-115.

11. Zabeen B, Nahar J, Nabi N, Baki A, Tayyeb S, Azad K,Nahar N. 2010. Risk factors and outcome of neonataljaundice in a tertiary hospital. Ibrahim Medical College

Journal, 4(2), 70-73.

12. Maisels MJ, Kring E. 1998. Length of stay, jaundiceand hospital readmission. Pediatrics, The official

journal of the American Academy of Pediatrics, 101,995-998.


13. Amar Taksande, Krishna Vilhekar, Manish Jain, PreetiZade, Suchita Atkari,Sherin Verkey. 2005. Predictionof the development of neonatal hyperbilirubinemia byincreased umbilical cord blood bilirubin. Ind Medica,9(1), 5-9.

14. Rudy Satrya, Sjarif Hidayat Effendi, Dida AkhmadGurnida. 2009. Correlation between cord blood bilirubinlevel and incidence of hyperbilirubinemia in termnewborns. Paediatrica Indonesiana, 49(6), 349-354.

15. Trivedi JD. 2013. Cord serum bilirubin and albumin inneonatal hyperbilirubinaemia. International Journal

of Intregative Sciences, Innovation and Technology, 2(2), 39-42.

16. Merchant RH, Merchant SM and Babar ST. 1975. Astudy of 75 cases of neonatal jaundice, Ind. J. Ped. 12,889-894.

17. Verma Manorama, Jugesh Chatwal and Daljit Singh(1988). Neonatal hyperbilirubinemia, Indian Journal

of Paediatrics, 55, 899-904.

18. Rasul CH, Hasan A, Yasmin Farhana. 2010. Malaysian

Medical Science

19. Hoque MM, Hossain MM, Hassan MQ, Uddin ASMN,Begum JA, Chowdhury MAK. 2004. Neonatalhyperbilirubinemia requiring exchange transfusion–management and outcome. Bangladesh Journal of

Child Health. 28, 55–59.


Communication Impairment among Post Stroke

Patient With Right Cerebral Hemisphere Disorder:

Observation Through Neurolinguistic ApproachFahmida Ferdous1, Jinat Imtiaz Ali2, Syed Shahrier Rahman3, Md. Faruq Alam 4, Dionéia Motta

Monte-Serrat5, Hariprakash Chakravarty6, Nayan Ranjan Sarker7, Mohammad Abu Sayed Miah8,

Shishir Ranjan Das9

Abstract

Background: Communication impairment after stroke are not only associated with left

hemisphere damage also with right hemisphere damage.

Objective:To find out communication impairment among the stroke patients with right

hemisphere disorder

Methods:This cross-sectional study was conducted in the Department of Neuroscience of Z.H

Sikder Women’s Medical College and Hospital from January 2018 to December 2018 over a

period of one year. Thirty six stroke patients with right cerebral hemisphere disorder were

selected for this study from 110 stroke patients.

Results:Maximum patients were more than 50 years old. Males (69.4%) were predominant than

females (30.6%). Hypertension was found in 36.1% cases, diabetes mellitus in 33.3% cases

anddislipidemia in 16.7% cases. Smoker was 8.3%. Most of the study patients were unable to

understands any speech well (80.6%); 69.4% were unable to accurately produce the correct

words or sentences during speaking, Phonetics and Phonological Disorder due to paralysis;

44.4% cannotfind out the correct words for the things during speaking due to impairment of the

cognitive linguistic ability; 47.2% also unable to read adequately due to Cognitive linguistic

Disorder and Phonetics and Phonological Disorder. Behavior towards family members were

destructive 80.6% cases due to Sociolinguistic disorder. Articulation deficiency was observed

in 69.4% patients, pragmatic ability in 44.4% cases, A-grammatism in 47.2% cases, conversation

disorder in 72.2% cases, auditory sentences comprehension & cognitive linguistic disorder in

75.0% cases, vocabulary and visual perception disorder in 50.0% cases and auditory speech

perception disorder in 80.6% cases.

Conclusion: According to this study finding, it can be concluded that right hemisphere dominant

disorder among post stroke patients in Bangladesh have communication impairment. This

may go unnoticed, if not actively screened by clinicians and clinical linguist could impact

negatively on management outcomes if not attended appropriately.

Keywords: Stroke, Communication impairment, right cerebral hemisphere.


1. Department of Psychiatry, Z H Sikder Women’s Medical College & Hospital, Dhaka, Bangladesh.

2. Department of Linguistics, University of Dhaka. Dhaka, Bangladesh.

3. Department of Linguistics, University of Dhaka, Dhaka, Bangladesh.

4. Adolescent & Family Psychiatrist, National Institute of Mental Health (NIMH), Sher-E-Bangla Nagar Dhaka, Dhaka,Bangladesh.

5. Faculty Member of Law, Department of University of Ribeirao Preto, UNAERP, Brazil

6. Department of Neurosurgery, Z H Sikder Women’s Medical College & Hospital, Dhaka, Bangladesh.

7. Assistant professor, Department of Nephrology, Sir Sallimullah Medical College and Mitford Hospital.

8. Senior Clinical pathologist, Sir Sallimullah Medical College and Mitford Hospital.

9. Professor and Head, Department of Neonatology, Colonel Malek Medical College, Manikganj

Address of Correspondence : Dr. Fahmida Ferdous, Department of Psychiatry, Z H Sikder Women’s Medical College &Hospital, Dhaka, Bangladesh. [email protected]

Introduction

Stroke is one of the neurologic deficits, which hasa strong co-relation with significant communicationimpairment.1Communication impairments arefrequent in post stroke patient.Human beingacquires the capacity to perceive and acquirelanguage as well as to produce and use languagefor communication. Language disorder areany kindof manifest as impairment of almost all verbalexpression, difficulties in understanding spokenlanguage, reading and writing also. Whenlanguagedisorders develop than impaircommunication and start emotional maladjustmentalthough auditory ability is maintained.2-4Howevergrammatical structures is usually impaired due tophonemic distortion and phonemic paraphasia,omitting some phonemes and words, long sentencesare regularly shaped.But paraphasia or neologism,occurs as a consequences of brain dysfunctions byaffecting either right dominant hemisphere or leftdominant hemisphere.5Disruption to languageprocessing following a right dominant hemispherestroke must have atypical languagelateralization.6Right dominant hemisphere hasessential roles in the processing of languageunderstanding metaphor, humor, inference as wellas recognizing and expressing affective oremotional prosody changes in rate, rhythm,in pitchand emotions. Right dominant hemisphere damagecan impair attention, perception, learning memory,recognition and expression of emotion. This canalso damage working memory which is essentialfor language processing in the sentencecomprehension.7 Because of semantic and lexicalprocessing, patients face significant challenges insocial aspects of communication. By hearingauditory sentences turn to perception andcomprehension8 due to the affect of the syntacticprocessing or the integration of syntactic words,prosody, which includes attention, memory, andexecuting functioning of spoken and writtenlanguage at the cognitive linguistic and pragmaticlevels.9 The patient faces difficulties in speechperception, comprehension, more complexsemantically reversible sentences in subject, verb,object relationship .Communication impairmentsare important in practical localization of brainlesions and these impairments affect patient’sability to interact in society. The most importantaspect of communication impairment is the

necessity to detect, where are the deficits, to startearly intervention by speech language therapy foreveryday communication also for overallrehabilitation of patients.7 The goal of this paperis to discuss the communication deficit foundamong Right Dominant Hemisphere post strokepatient for fruitful intervention.

Method:

This cross-sectional study was conducted in theDepartment of Neuroscience of Z.H SikderWomen’s Medical College and Hospital fromJanuary 2018 to December 2018 over a period ofone year. Thirty six stroke patients with rightcerebral hemisphere disorder were selected for thisstudy. After taking written consent they wereenrolled in this study. They were interviewedindividually and a predesigned questionnaire wasfilled up with collected information. Data werepresented as table.

Table-I

Demographic profile of the study subjects (n=36)

Frequency (n) Percentage (%)

Age (years)35-40 01 2.841-50 09 25.051-60 12 33.361-70 06 16.7>70 08 22.2Mean ±SD 58.33 ± 12.30 (35 - 85)GenderMale 25 69.4Female 11 30.6Education levelFormal 6 16.7Primary 14 38.9SSC 6 16.7HSC 5 13.9Graduate and above 5 13.9

Maximum patients were in age group 51-60 yearsfollowed by 41-50 years (25.0%),>70 years (22.2%),61 – 70 years (16.7%) and 35 – 40 years (7.5%).Males (69.4%) were predominant than females(30.6%). Maximum patients had primary education(38.9%) followed by 16.7% had formal and SSC,13.9% HSC and graduate & above.

Communication Impairment among Post Stroke Patient with Right cerebral Fahmida Ferdous et al 118

Table-II

Risk factors of the study subjects (n=36)


Diabetes mellitus 12 33.3 Hypertension 13 36.1Dislipidemia 06 16.7 Smoking 03 8.3Betel nut chewing 01 2.8Alcoholism 01 2.8

Maximum patients had hypertension (36.1%)followed by diabetes mellitus (33.3%) anddislipidemia (16.7%). 8.3% patients had smokinghabit, 2.8% had betel nut chewing habit and 2.8%were alcoholic.

Most of the study patients were unable to wellunderstand any speech(Receptive/ConceptualDisorder) (80.6%); 69.4% were unable to accuratelyproduce the correct words or sentences duringspeaking, Phonetics and Phonological Disorder dueto paralysis; 44.4% cannot find out the correctwords for the things (such as objects, people, placesor events) during speech due to impairment of thecognitive linguistic ability; 47.2% also unable toread adequately due to Cognitive linguisticDisorder and Phonetics and Phonological Disorder.Behavior towards family members were destructive80.6% cases due to Sociolinguistic disorder.

Table-III

Stroke related information of the study subjects (n=36)


Unable to accurately produce the correct words or sentences during 25 69.4speaking Phonetics and Phonological Disorder due to paralysis.Unable to find out the correct words for the things. Such as 16 44.4(objects, people, places or events) during speaking due toimpairment of the cognitive linguistic ability.Usually unable to understands any speech well(Receptive/ 29 80.6Conceptual Disorder)Usually unable to read adequately due to Cognitive linguistic 17 47.2Disorder and Phonetics, Phonological Disorder.Behavior towards family persons(Sociolinguistic Disorder)Constructive 06 16.7Destructive 29 80.6

Table-IV

Stroke related information of the study subjects (n=36)


Articulation deficiency 25 69.4Pragmatic disorder (Unable to use of language in a specific context) 16 44.4A-grammatism (grammatical part of sentences and formation 17 47.2of sentences disorder)Conversation Disorder 26 72.2Receiving proverbial (Auditory sentences Comprehension & Cognitive 27 75.0linguistic Disorder)Spoken Picture description task (Vocabulary and Visual 18 50.0perception Disorder)Embedded meaning, word length, anomalous sentences (Disorder in 29 80.6auditory speech perception that means phonological and integrationof syntactic and semantic information in a sentence disorder)

Articulation deficiency was observed in 69.4% patients, pragmatic ability in 44.4% cases,

A-grammatismin 47.2% cases, conversation disorder in 72.2% cases, auditory sentences comprehension& cognitive linguistic disorder in 75.0% cases, vocabulary and visual perception disorder in 50.0% casesand auditory speech perception disorder in 80.6% cases.


Discussion:

In our study, male predominance is obvious (69.4%)which is consistent with other studies.10-12 In thisstudy, maximum patients have hypertension(36.1%) followed by diabetes mellitus was 33.3%and dislipidemia was 16.7%. Smoking habit waspresent in 8.3% cases. In a study in China, Yao etal.10 found 38.0%, 66.2% and 22.2% of the strokepatients had hypertension, diabetes mellitus andsmoking habit respectively.

In our study, 69.4% patients were unable toaccurately produce the correct words or sentencesduring speaking; 44.4% patients were unable tofind out the correct words for the things (such as-objects, people, places for events); 80.6% patientswere unable to understand any speech and 47.2%were unable to read. In the study of Sinanoviæetal.1, the frequencies of different type ofcommunication disorders after stroke: 12.0% studysubjects were unable to accurately produce correctwords or sentences during speaking (Brocas), 16.0%patients were unable to receptions of speech(Wernicke’s), absence of social values and norms(anomic) 25%. In our study, behavior toward familypersons was destructive in 80.6% cases, pragmaticdisorder in 44.4% cases, a-grammatism in 47.2%cases and conversation disorder in 72.2% cases,receiving proverbial (Auditory sentencescomprehension & Cognitive linguistic Disorder) in(75.0%) cases, Spoken Picture description task(Vocabulary and Visual perception Disorder) in50.0% cases and embedded meaning, word length,anomalous sentences (Disorder in auditory speechperception that means phonological and integrationof syntactic and semantic information in asentence disorder) in (80.0%) cases. The study ofSheppard and Hillis7 found 12/93 with righthemisphere stroke patients were impairedauditory sentences to picture matching and 9/12patients had auditory speech perception andcomprehension difficulties.

Some studies prove that brain plasticity surpassessome language impairments. 13-15 It is noteworthythat studies on language deficits must beaccompanied by practices developed with a focuson these language problems that have the purposeof organizing linguistic functioning adequately todelimit the probable subtypes and profiles of thesyndrome. There are successful results, forexample, in a subject with a corpus callosumproblem in which logical reasoning techniqueswere developed to organize the formation ofmeaning in the discursive chain. 15

Conclusion:

It has been traditionally assumed that lefthemisphere dominant for language disorderproduces the communication impairment butmany patients with right hemisphere dominantdisorder among post stroke have communicationimpairment but they remain unrecognized anduntreated. If these patients were screenedroutinely for communication disorders along withneurological disorder and were provided withspeech language therapy for developing theircommunication can go a long way in improvingthe quality of life.

References:1. Sinanoviæ O, Mrkonjiæ Z, Zukiæ S, Vidoviæ M,

Imamoviæ K. Post-strokelanguagedisorders. ActaClinica Croatica. 2011 Mar 31;50(1):79-93.

2. Sinanoviæ O, Smajloviæ D. Osnoveneuropsihologije ineurologijeponašanja. Univerzitet; 2005. Ociæ G.Klinièkaneuropsihologija. Zavodzaud•benike inastavnasredstva; 1998.

3. Ociæ G. Klinièkaneuropsihologija. Zavodzaud•benike inastavnasredstva; 1998.

4. LaPointe LL, editor. Aphasia and related neurogeniclanguage disorders. Thieme Medical Pub; 2005.

5. Mariën P, Paghera B, De Deyn PP, Vignolo LA. Adultcrossed aphasia in dextrals revisited. Cortex. 2004 Jan1;40(1):41-74.

6. Ross ED, Monnot M. Neurology of affective prosody andits functional–anatomic organization in right hemisphere.Brain and language. 2008 Jan 1;104(1):51-74.

7. Sheppard SM, Hillis AE. That’s right! Languagecomprehension beyond the left hemisphere. Brain. 2018Nov 29;141(12):3280-9.

8. Searleman A. A review of right hemisphere linguisticcapabilities. Psychological Bulletin. 1977 May;84(3):503.

9. Seikel JA. An Attentional View of Right HemisphereDysfunction. Clinical Archives of CommunicationDisorders. 2018 Apr 30;3(1):76-88.

10. Yao XY, Lin Y, Geng JL, Sun YM, Chen Y, Shi GW, XuQ, Li YS. Age-and gender-specific prevalence of riskfactors in patients with first-ever ischemic stroke inChina.Stroke research and treatment;2012.

11. Hayashi H, Okada E, Shibata Y, Nakamura M, OjimaT. The Influence of Speech-Language-Hearing TherapyDuration on the Degree of Improvement in PoststrokeLanguage Impairment.Rehabilitation research andpractic;2017.

12. Stein LA, Goldmann E, Zamzam A, Luciano JM, MesséSR, Cucchiara B, Kasner SE, Mullen MT. Associationbetween anxiety, depression, and post-traumatic stressdisorder and outcomes after ischemic stroke. Frontiersin neurology. 2018;9:890.

13. Carter R, Aldridge S, Page M, Parker S. O livro docérebro. Rio de Janeiro: Agir. 2012:125.

14. Dehaene S. LesNeurones de lalecture. Paris: OdileJacob, 2007.

15. Monte-Serrat D. Inclusion in Linguistic Education:Neurolinguistics, Language, and Subject. InPsycholinguistics and Cognition in Language Processing2018 (pp. 169-187). IGI Global.

Communication Impairment among Post Stroke Patient with Right cerebral Fahmida Ferdous et al 120

Review Article

Paediatric Intravenous Cannulation for

ChemotherapyAshis Kumar Ghosh1, Saha SK2, Al-Amin ANM3, Saha J4, Das Gupta SP5,

Sunirmal Roy6, Shishir Ranjan Das7

Abstract

Intravenous (IV) cannulation is an integral part of modern cancer treatment and is practiced in

virtually every health care setting. Intravenous cannulation is more important in case of

paediatric cancer treatment as cannulation is a bit difficult in small children. Venous access

allows the sampling of blood, as well as administration of fluids, medications, parenteral

nutrition, chemotherapy, and blood products. Whilst the insertion of a cannula is a routine

event for health care professionals, many children and families associate it with dramatic

events and serious illness. Cannulation can be both traumatic and painful for the child and

stressful for the family. They will require support and encouragement to deal with the procedure.

More over our doctors and nurses are not properly trained to do the procedure. This article seeks

to review all this area and to outline good medical practice.


1. Assistant Professor. Department of Paediatric Haematology and Oncology, National Institute of Cancer Research and Hospital2. Assistant Professor. Department of Neurosurgery, Sir Salimullah Medical College3. Senior Consultant, Medicine.Shaeed Tajuddin Ahmad Medical College Hospital4. Consultant. Department of Paediatric Haematology and Oncology, National Institute of Cancer Research and Hospital5. Assistant Professor. Sapporo Dental College and Hospital6. Associate Professor, Department of Neonatology, Sir Salimullah Medical College, Dhaka7. Professor and Head, Department of Neonatology, Colonel Malek Medical College, ManikganjCorrespondence to: Dr. Ashis Kumar Ghosh. Assistant Professor, Department of Paediatric Haematology and Oncology,National Institute of Cancer Research and Hospital, Email. [email protected]

Introduction

Intravenous chemotherapy means havingchemotherapeutic drugs treatment into a vein.One may have an injection or a drip through eithera small tube in patient’s arm or a line in chest. Indeveloped countries chemotherapy is giventhrough a pump. The pump slowly pushes thechemotherapeutic drugs into the vein at a carefullycontrolled rate but in Bangladesh paediatricchemotherapy is given in IV drip. In developedcountries trained oncology nurses are responsiblefor the safe and timely administration of IVtreatments to the patients through peripheral andcentral venous catheter (CVC) and managementof any possible complication. But in Bangladeshpaediatric oncology nurses are not so available andmore over not properly distributed in appropriatecentres. So paediatric IV cannulation become aproblem in sometimes.

In modern medical practice, up to 80% ofhospitalised patients receive intravenous therapyat some point during their admission.1,2

Medication, fluids, nutrition, chemotherapy drugs

and blood products can all be given via theintravenous route, which can be either peripheralor central. Although common, these practices arenot devoid of complications, which may lead tomortality and morbidity, increased duration ofhospital stay, and significant costs. So doctor andregistered nurses must ensure their knowledgeand skills related to the management of peripheralvenous catheter (PVCs) are up to date and evidencebased in order to reduce the complicationsassociated with these devices. As in Bangladeshwe use mainly peripheral venous route toadministrate fluid, drugs and nutrition for cancerchild, our discussion will remain mainly aboutperipheral venous cannulation.

Peripheral Venous Cannulation (PVC)

Peripheral venous cannulation is the commonestmethod used in Bangladesh for paediatricintravenous chemotherapy.The commonrecognised indications are- iv fluid administration,drug administration, chemotherapy,bloodsampling,nutritional support, blood or bloodproducts administration,IV administration of

radiologic contrast agents.3 And contraindicationsof PVC are inflammation or infection of theinsertion site, small veins with low flow rates ofleg and foot veins in case of irritant drugs, burnedextremity and Irritant solutions (pH < 5, pH >9,or osmolarity >600 mOsm/L, including sclerosingsolutions, some chemotherapeutic agents, andvasopressors) also are more safely infused into acentral vein.4

Sites of IV cannulation for Paediatric

chemotherapy5,6

There are several sides for cannulation to infusedrugs into blood stream. We can have themthrough.

• A small tube put into a vein in hand, arm ,leg,scalp or in jugular vein

• A central line put into a vein in chest throughyour neck or chest

• A PICC line (Peripherally Inserted CentralCatheter. ) put into a vein in chest throughyour arm

• A portacath, which is also called a port or atotally implantable venous access device(TIVAD)

Choice of sites and nature of veins is very importantfor peripheral cannulation in children. Thecommonly used sites are hands, wrists, feet,antecubital fossae, and the scalp in babies, althoughthe latter can present problems with stabilizationof cannulae and increased risk of extravasation.The long saphenous vein is usually palpable as itcourses anterior to the medial malleolus. Lessusual sites of peripheral cannulation include theexternal jugular, abdominal, and axillary veins.

For cannulation in children some veins should beavoid those are thrombosed, sclerosed or fibrosedveins. Inflamed/bruised veins, Thin / fragile veinsand veins near the infection, oedema or phlebitisshould be avoid.7

Peri-procedural Care

Before cannulation it is important to obtaininformed verbal consent from the patient (wherepossible) and to explain both the procedure andthe need for cannulation.8

Choice of Catheter

IV catheter available in various gauges(Table-1)lengths (19 mm - 45 mm), compositions anddesigns.

In general, the smallest gauge of catheter shouldbe selected for the prescribed therapy, with theaims of preventing damage to the vessel intimaand ensuring adequate blood flow around thecatheter so as to reduce the risk of phlebitis.9 24Gcatheter is suitable for children.

Table-I

Various specification of IV cannula.

SpecificationsGauge Colour Ext. Dia. Length Flow rate

code mm mm ml/min14G Orange 2.1 45 24016G Grey 1.8 45 18018G Green 1.3 32/45 9020G Pink 1.1 32 6022G Blue 0.9 25 3624G Yellow 0.7 19 2026G Violet 0.6 19 13

Patient preparation

Doctor should prepare the patient and family forthe procedure. Aseptic technique should be usewhen preparing and administering fluids andmedications. Children should involve play anddistraction techniques, relaxation and other copingskills appropriate to the age may be helpful.

Positioning

Adequate light and warm room temperature toencourage vasodilatation is important foruneventful catheterization. Adjust the height orposition of the bed or chair to make sure that thedoctor is comfortable and to prevent unnecessarybending. Make sure that the patient is in acomfortable position, and place a pillow or a rolledtowel under the patient’s extended arm.

Anaesthesia

Both intradermal injection of a topical anestheticagent just prior to IV insertion and topicalapplication of a local anesthetic cream about 30minutes prior to IV insertion have been shown tosignificantly reduce the pain associated with IVcatheterization. One or the other should be usedunless the situation is an emergency.10.11.12

Vapo-coolant sprays (e.g. ethyl chloride,ûuorohydrocarbons, and alkane mixtures) act byrapidly cooling the skin, resulting in an immediate,temporary interruption of pain sensation. They are

Paediatric Intravenous Cannulation for Chemotherapy Ashis Kumar Ghosh et al 122

applied for 3–10 seconds and provide analgesia for<60 seconds.13

Procedure

Use properly fitted no sterile gloves and eyeprotection device to prevent exposure viaaccidental blood splashes. Place a venoustourniquet over the patient’s non-dominant armand select a site for IV catheter insertion.

For prolonged courses of therapy, it isrecommended, though not always practical, to startdistally and move proximally as distal cathetersare replaced. In infants, the dorsal hand and dorsalfoot veins are usually easier to access than theantecubital vein.

If difficulty is encountered in finding an appropriatevein, one of the following techniques may be used:

• Inspection of the opposite extremity

• Opening and closing the fist

• Using gravity (holding the arm down)

• Gentle tapping or stroking of the site

• Applying heat (warm towel/pack) or a nitro-glycerine ointment

Ultrasound guidance has been shown to facilitateperipheral venous placement in emergencydepartment patients with difficult IV access andshould be used when appropriate veins are notreadily visualized or palpable. 14,15,16

Apply an antiseptic solution ( 2% chlorhexidinesolution or 70% alcohol) with friction for 30-60seconds. Though concerns have been raised overthe use of alcoholic chlorhexidine for skinpreparation in small infants as a result of multiplecase reports highlighting skin damage andconcerns over systemic absorption ofchlorhexidine.17 Allow to air-dry for up to 1 minuteto ensure disinfection of the site and to preventstinging as the needle pierces the skin. Once theskin is cleaned, does not touch or repalpate it.

Stabilize the vein using nondominant hand (thumb)to apply traction to the skin distal to the chosensite of insertion. This will prevent superficial veinsfrom rolling away from the needle. Stabilizationshould be maintained throughout the procedure.

Holding the venous access device in dominant handwith the bevel facing upward; this will ensure

smoother catheterization because the sharpest partof the needle will penetrate the skin first. Releasethe needle from the catheter and replace it,confirming that the catheter was not damaged orfragmented. This will ensure smooth advancementonce the venous access device is inside the vein.

The angle of the needle entry into the skin willvary according to the device used and the depth ofthe vein. Small superficial veins are best accessedby using a small catheter (22-24 gauge) placed at a10-25º angle. Deeper veins should be accessed witha larger catheter at a 30-45º angle. Upon entryinto the vein, the practitioner might feel a “givingway” sensation. Blood should appear in thechamber of the venous access device (i.e.,flashback). The angle of the venous access deviceshould be reduced to prevent puncturing theposterior wall of the vein. It should be advancedgently and smoothly an additional 2-3 mm into thevein.

If no blood is observed in the flashback chamber,the device should be withdrawn to just beneaththe skin level, and another attempt to recatheterizethe vein should take place. Flashback may stop ifthe device has punctured the posterior wall of thevein or if the patient is extremely hypotensive. Ifswelling develops, withdraw the device, release thetourniquet, and apply direct pressure for 5 minutesfor a hematoma.

If venous catheterization is unsuccessful, theneedle should never be reintroduced into thecatheter. This could result in catheterfragmentation and embolism.

After the venous access device’s hub is dropped tothe skin, maintain skin traction with practitioner’snondominant hand. Hold the needle grip of thevenous access device in place betweenpractitioner’s dominant thumb and middle finger,while using dominant index finger to slide the hubof the catheter over the needle and into the vein.

Use practitioner’s nondominant middle finger toapply pressure over the catheter to prevent bloodspill, and hold the hub in place using nondominantindex and thumb fingers. Then practitioner’sdominant hand to withdraw the needle. Secure theneedle in its safety cover, a dedicated biohazardsharps container, or both.


Then release the tourniquet. While applyingpressure to the catheter to prevent blood spillageand while continuously stabilizing the hub andwings to the skin as previously described,disconnect the blood sampling adapter or syringe,and securely attach the pre-flushed saline orheparin lock to the hub of the venous access device.Secure the venous access device to the skin usingthe transparent dressing and tape

Using the saline or heparin flush syringe, withdrawa small amount of blood to verify that the catheteris still inside the vein. Immediately flush the tubingwith the remainder of the solution. Slide the plastictubing lock, and continue to lock the tubing.

Finish securing the tubing to the skin using tape.Place a label indicating the date, the time, andother facility-specific required information over thetransparent dressing. (Fig-1)

assist nurses in assessing and managing PVC sites.Clinical requirement should be considered at leastdaily and the PVC should be removed as soon as itis deemed unnecessary. It has been suggested thatclinical indication alone should drive the removalof PVCs.21,22 However, most of the guidelines statethat removal should be considered if the PVC hasbeen in situ for longer than 72 hours or 72-96 hoursas the risk of complications increases with time.

Removal of intravenous catheter:

Stop the infusion solution and disconnect thetubing, leaving just the saline/heparin lock tubingconnected to the venous access device. Release theadhesive tape and transparent dressing from theskin. Withdraw the catheter outside of the vein,and apply direct pressure with gauze for at least 5minutes.

Inspect the catheter for fragmentation, anddocument in the patient’s chart the date, time,and reason for catheter removal and the integrityof the catheter as inspected.Place a 2 × 2 gauzepad or a cotton ball with a paper tape over the IVinsertion site and instruct the patient to continuemanual pressure for 10 more minutes in order tominimize hematoma formation.

Complications

Periprocedural and post procedural complicationsmay include the following:

• Pain

• Failure to access the vein

• Blood stops flowing into the flashback chamber

• Difficulty advancing the catheter over theneedle and into the vein

• Difficulty flushing after the catheter was placedin a vein

• Arterial puncture

• Thrombophlebitis

• Peripheral nerve palsy-Median nerve

• Compartment syndrome

• Skin and soft tissue necrosis

Conclusions

Peripheral and central venous cannulation iscommonplace in the hospital environment but canlead to complications that cause patient morbidity

Fig-1. Securing paediatric venous access device

In emergency situations, particularly inhypotensive victims, peripheral venous cut downis a viable option. A skin incision can be madedirectly over either the long saphenous vein inthe ankle or the median basilic vein in the elbow.The vein is exposed by blunt dissection andcannulated under direct vision after making a smallincision in the wall and ligating the distalend.18,19,20

Care of Catheter

Observation and monitoring of the PVC site andlocalised tissue are essential for getting optimumservice from IV cannulation. Phlebitis scales, suchas the Visual Infusion Phlebitis Scale of Jacksoncan

Paediatric Intravenous Cannulation for Chemotherapy Ashis Kumar Ghosh et al 124

and in rare circumstances, mortality. It is thereforeimportant to consider the genuine indications andto follow some of the simple measures outlined inthis article to avoid complications. For centralcannulae in particular, it is essential to ensurethat insertion is performed using an aseptictechnique. Once a cannula has been inserted, it isimportant not to forget about it, to take regularcare of it , review the need for it on a daily basis,and to remove it as soon as clinically indicated.Finally doctor and nurses can signiûcantlyinûuence the quality of care provided by adoptingthe principles associated with the safe managementand care of patients who have these devices in situ.

Video can be available in the address-

http://emedicine.medscape.com/article/2008690-overview#a3

References:

1. Tjon JA, Ansani NT. Transdermal nitroglycerin for theprevention of intravenous infusion failure due tophlebitis and extravasation. Ann Pharmacother2000;34:1189–92.

2. Tager IB, Ginsberg MB, Ellis SE, et al. An epidemiologicstudy of the risks associated with peripheral intravenouscatheters. Am J Epidemiol 1983;118:839–51.

3. Datta S. How to insert a peripheral venous cannula.Br J Hosp Med 1990;43:67–9.

4. Shlamovitz,GZ. Pediatric IntravenousCannulation Periprocedural Care. [Internet]. Sep 18,2017. Available from: https://emedicine. medscape.com/article/2008690-periprocedure

5. Intravenous (IV) chemotherapy | Cancer Research UK. 2016 December. Available:http://www.cancerresearchuk.org/ aboutcancer/cancers ing e n e r a l / t r e a t m e n t / c h e m o t h e r a p y / h a v i n g /ivchemotherapy?view=PrinterFriendly

6. Feldman R. Venipuncture and peripheral intravenousaccess. Reichman EF, Simon RR, eds. Emergency

Medicine Procedures. New York: McGraw-Hill; 2004.297-313.

7. Roseman JM. Deep percutaneous antecubitalvenipuncture: an alternative to surgical cutdown. Am

J Surg 1983 Aug; 146(2):285.

8. Tully JL, Friedland GH, Baldini LM, et al. Complicationsof intravenous therapy with steel needles and Tefloncatheters. A comparative study. Am J Med 1981;70:702–6

9. Dougherty L. Peripheral cannulation. Nurs Stand 2008.3-9; 22(52):49-56.

10. Burke SD, Vercler SJ, Bye RO, Desmond PC, ReesYW. Local anesthesia before IV catheterization. Am J

Nurs 2011; 111(2):40-5.

11. Valdovinos NC, Reddin C, Bernard C, Shafer B, TanabeP. The use of topical anesthesia during intravenouscatheter insertion in adults: a comparison of pain scoresusing LMX-4 versus placebo. J Emerg Nurs 2009;35(4):299-304.

12. McNaughton C, Zhou C, Robert L, Storrow A, KennedyR. A randomized, crossover comparison of injectedbuffered lidocaine, lidocaine cream, and no analgesiafor peripheral intravenous cannula insertion. Ann

Emerg Med 2009; 54(2):214-20.

13. Zempsky WT. Pharmacologic approaches for reducingvenous access pain in children. Pediatrics 2008; 122.

14. Khedir Al-tiae T, Sattarian M, Ding R, Shokoohi H,Boniface K, McCarthy M , et al. Ultrasound-guidedperipheral intravenous access program is associatedwith a marked reduction in central venous catheteruse in noncritically ill emergency departmentpatients. Ann Emerg Med 2013; 61(2):198-203.

15. Heinrichs, J., Fritze, Z., Vandermeer, B., Klassen, T.,Curtis S. Ultrasonographically guided peripheralintravenous cannulation of children and adults: asystematic review and meta-analysis. Ann Emerg Med2013; 61(4):444-54.

16. Schreiber S, Zanchi C, Ronfani L, Delise A, Corbelli A,Bortoluzzi R, et al. Normal saline flushes performedonce daily maintain peripheral intravenous catheterpatency: a randomised controlled trial. Arch Dis Child

2015; 100 (7):700-3.

17. Ponnusamy V, Venkatesh V, Clarke P. Skin antisepsisin the neonate: what should we use? Curr Opin InfectDis 2014; 27: 244–50

18. Rhee KJ, Derlet RW, Beal SL. Rapid venous accessusing saphenous vein cutdown at the ankle. Am JEmerg Med 1989;7:263–6.

19. National Institute for Clinical Excellence. Guidance onthe use of ultrasound locating devices for placing centralvenous catheters. Technology appraisal guidance No49. London: NICE, 2002

20. C Waitt, P Waitt, M Pirmohamed. Intravenous therapy.Postgrad Med J 2004;80:1–6.

21. MC Louise. Care of peripheral venous cannula sites.Nursing Times 2012;108:34-35

22. Webster J et al (2010) Clinically indicated replacementversus routine replacement of peripheral venouscatheters. Cochrane Database Systematic Review. 3:CD007798.


Case Report

Triorchidism: A rare Case Report of Male

Reproductive SystemJamiul Hossain1, Ranajit Sen Chowdhury2, Abu Bakar Siddique3,Tanima Roy4

Abstract

Polyorchidism is an extremely rare congenital anomaly which refers to the presence of more

than two testicles.There are very few reports of triorchdism in Bangladesh as wellas

worldwide.Polyorchidism usually discovered incidentally. The most common anomalies

associated with polyorchidism are inguinal hernia(30%), Maldescended testis(15 to

30%),testicular torsion (13%)and hydrocele(9%)1. A 25 years old male was presented to the

Institute of Nuclear Medicine and Allied Science(INMAS)at Mitford Hospital with palpable

mass on left testis since childhood, that was evaluated and diagnosed by ultrasonography and

MRI. Triorchdism get a higher chance of testicular malignancy.So, periodic self –examination

is necessary as well as patient awareness for any testicular swelling even if painless is an

important issue.

Keywords: Triorchidism, Polyorchidism, Supernumerary testicle, A congenital testicular

anomaly


1. Associate Professor and PMO, INMAS, Mitford Hospital;

2. Associate Professor of Medicine, Sir Salimullah Medical College and Mitford Hospital, Dhaka;

3. Associate Professor and PMO National Institute of Nuclear Medicine and Allied Sciences (NINMAS), Shahbag ,Dhaka;

4. Consultant Ultrasonologist, Medinova Medical Services, Dhaka

Address of Correspondence: Dr. Jamiul Hossain, Associate Professor, PMO INMAS, Mitford Hospital, [email protected]

Introduction

Polyorchidism is an uncommon pathology involvingthe genitourinary tract in which additional testicleis present. Less than 200 cases in the literaturehave been reported. The majority of the cases areclinically silent and detected incidentally witheither scrotal or inguinal mass. The median ageof presentation in 50% of the cases between 15 to25 years of age1.

Case report

A 25-year-old unmarried male patient presentedto the institute of nuclear medicine and alliedsciences ( INMAS), Mitford Hospital campus , witha palpable mass in the left hemiscrotum since childhood . Physical examination revealed normal righttestis and left non-tender rounded mass smallerthan the normal appearing adjacent testicle, butit has a similar consistency. The mass has notchanged in position with cough. There is nosignificant prior medical illness or history of

trauma was given. Sonographic evaluationrevealed two testicles on the left hemiscrotum withechotexure and vascularity similar to that of theright testicle, consistent with triorchidism (MRIwas performed to confirm the diagnosis oftriorchidism and for better anatomical delineation.The superior left testicle measures 2.6 × 2.8 cmand demonstrates ectasia of the rete testis. Theinferior left testicle measures 2.5 × 1.6 cm. Thetesticles showed homogenous intermediate signalon T1-weighted images and high signal intensityon T2-weighted images . There was no masssuspicious for malignancy. There is one apparentleft vas deferens which bifurcate in the left scrotumto supply each testicle. It was difficult to confirm if1 or 2 left epidydymii is present. The right testicleis normal in size and morphology, measures 3.6 ×2.3 cm. Conservative management wasdetermined. Plan is to continue physicalexamination and imaging surveillance.

Discussion

Polyorchidism is rare congenital anomaly definedas the presence of more than two testicles. Mostcommonly present in the scrotum (66%), inguinalcanal (23%) or retropretoinum (9%)3.The etiologyis still uncertain, but may be related to peritonealfolding, segmentation of the primitive gonadslongitudinal or transverse division of the genitalridge4. Functional classification system has beenpublished by Leung based on embryologicdevelopment: type 1 supernumerary testis withoutepididymis and vas deference; type 2supernumerary testis shared common epididymisand vas deference with ipsilateral testicle; type 3supernumerary testis has its own epididymis butshares a common vas deferens with the ipsilateraltesticle; type 4 there is complete duplication oftestis, epididymis and vas5. Associated anomalieswith polyorchidism are testicular maldescent (40%),inguinal hernia (30%), testicular torsion (13%),hydrocele (9%), and hypospadias (1%)6. Mostpatients are asymptomatic or present with painlessscrotal mass. Testicular cancer is the mostconcerning cause of a painless scrotal mass.Although it is rare compared with other causes ofextra testicular scrotal masses such as hydrocele,spermatocele, varicocele and less commonlypolyorchidism. Therefore, further evaluation withimaging work-up is warranted to excludeunderlying malignancy. The estimated increasedrisk of malignancy in supernumerary is about 6%,and the commonly encountered histological typeinclude included seminoma, choriocarcinoma, andteratoma7. Only non-scrotal location ofsupernumerary testis has shown an increased riskof malignancy. The management ofsupernumerary is varied between expectantobservation and surgical removal depending on thefertility status and the location of thesupernumerary testis. The benefits of preservingfunctioning supernumerary testis must be weighedagainst the increased risk of malignancy. Ourpatient is planning to have children in the futureand the treatment plan was to continue onconservative management based on the patient’sfertility purpose, presence of reproductive abilityand the absence of malignancy. Functionalclassification has been suggested by Singer et aland have recommended excision of all non-functioning or ectopically located supernumerary

Fig.-1: USG of scrotum : Sonogram of the scrotum

demonstrate double testicles in the left hemi

scrotum and tubular ectasia of the rete testis in

superior testicle.

Fig.-2: Sagittal MRI T2 FRFSE with fat saturation

showing supernumerary testicle in the left side

inferiorly, having the same MR imaging

characteristics as the normal testes.

Fig.-3: Axial MRI T2 FRFSE with fat saturation

demonstrate three homogenous moderately high

T2 signal intensity testicles inside the scrotal sac

and confirm the diagnosis of triorchidism.


testes. However, functioning intra-scrotalsupernumerary tests is indicated for resection inthe presence suspected malignancy on biopsy orimaging. Absent reproductive potential or patientsdesire to have a single testis and if regular follow-up is impossible.

Patient with triorchidism harbor a higher chanceof testicular cancer. Periodic self–examination isrecommended, and the presence of newapplications of technology in ultrasound and theaddition of MRI for accurate diagnosis andclassification. These strategies would appear to besafe to preserve a viable intra scrotalsupernumerary testis found incidentally.

Conclusion

Triorchidism is a rare anomaly and should beincluded in differential diagnosis of solid extratesticular mass. Ultrasound is accurate andsufficient tool for diagnosis, however; MRI issuperior for anatomical and functionalclassification. Polyorchidism is associated withundescended testes, inguinal hernia, infertility; andmalignancy. Conservative management and

imaging follow up versus surgical resection is madeaccording to the type.

References

1. Trupti T,Sing G.,Koushik P.,Tumepalli T.,Triorchidism:A rare genitourinary abnormality. JSTCR,Jul-Dec 2012; 4(2) :126-128

2. Kharrazi S.M., Rahmani M.R., Sakipour M., Khoob S.Polyorchidism: Acase report and review ofliterature. Urol J. 2006;3(3):180–183. [2. KheirandishP., Chinegwundoh F. An unusual case oftriorchidism. JRSM Short Rep. 2010;1(6):55.

3. P.Kheirandish, F.Chinegwundoh. An Usual case oftriorchidiem. JRSM ShortRep, 1 (6) (2010), p 55

4. Yalcinkaya S., Sahin C., Sahin A.F. Polyorchidism:sonographic and magnetic resonance imagingfindings. Can Urol Assoc J. 2011;5(5):E84–E86.

5. Arlen A.M., Holzman S.A., Weiss A.D. Functionalsupernumerary testis in a child with testicular torsionand review of polyorchidism. Pediatr SurgInt. 2014;30(5):565–568.

6. Nane I., Ozkan L., Ander H. Inguinal orchiectomy forthe extra testis with suspected tumor in a polyorchidicpatient: a case report. Int Urol Nephrol. 2007;39(2):557–559.

7. Singer B.R., Donaldson J.G., Jackson D.S.Polyorchidism: Functional classification andmanagement strategy. Urology. 1992;39(4):384–388.

Triorchidism: A rare Case Report of Male Reproductive System Jamiul Hossain etal 128


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