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ascl.phdes. h€ used to .npld page mackup-final.qxd editorial research for god’s sake! z.a.m.h1. zabidi-hussin2 this is a familiar battle cry in academia. it’s a worldwide phenomena and some says a mad crave. it comes, usually as a top down decree from university vice chancellors and seeps through to faculty deans and eventually ends on the cluttered table of professors and academics on the ground. it’s an academic battle cry spurred by intense desire to participate in international pursuit for research glory, nobel prize and improved university rankings. ‘instigated’ by reputable names in public media such as the times higher education supplemenst and several other agencies, such pursuits have pushed some governments of the day to stare at their institutes of higher education and began flicking their powerful fingers. “common guys, we publicly fund you. get on with your researchfor god’s sake!!” slowly and surely the results are delivered, much like the pangs of hard labour. it becomes a proud show case for governments when universities under their respective commands gain international recognition as the ‘top 100 or 2 “in the chart of the ivy league. world rankings bring other exploits. it attracts more and in most cases, better international students thus contributing to the ‘hub chase’, enhancing the country’s standing as a hub for education. high rankings also bring in good money, investment on a variety of academic ventures such as research and product development, yet again spinning the country’s economic pursuit into a possible state of heightened dizziness. hence the ‘battle cry’. it is similar to the battle cry in history’s great wars, neatly packaged as battles for academic strengths, principles, glory and honour. competing with the world best in research “olympics” require more than a battle cry and powerful fingers. the united states of america, china, europe and korea and several of the more advanced countries in this league spend substantial sums of money, time and resources to be in the circle of the best. backed by years of nurturing human talents (imported, if necessary) these countries developed the right fundamentals for strong research culture. with research spending exceeding usd 100 billion annually, the us , as an example, managed to ensure dominance in research world rankings comfortably. countries in asia, burdened by the need to address health access and inequalities, malnutrition and snailpace advances to improve the milleaneum development goals in maternal and child parameters naturally struggles to even smell the heaven of research feat even with the availability of the most talented brains. the gross expenditure on r&d tp gdp ratio of most asian countries is usually below1. a except of cthat fundamentals also involved major shift in attitude, some, predates an entry of a student in university. fundamentals of love of science and knowledge enquiry have been developed even during primary school days when attitude formation starts. rote learning in early education will not help nurture those budding talents into highly inquisitive individuals with strong sense of research enquiry. period. refrrence pressure on universities to achieve international ranking bangladesh journal of medical science vol. 12 no. 03 july’13 243 corresponds to: prof. zamh zabidi-hussin, dept. of paediatrics, school of medical sciences, universiti sains malaysia, 16150 kubang kerian, kotabharu, kelantan, malaysia. email: zabidi@kb.usm.my page mackup july-14.qxd editorial untreated pain a ‘scandal of global proportions’ doherty m when a child is diagnosed with cancer in bangladesh, it is likely that he or she will not receive any pain medications stronger than paracetamol. globally more than 5 billion people live in countries where access to opioids is extremely limited or not available at all. in many cases, drug regulations intended to prevent misuse leave many patients without access to essential opioid analgesia. currently low and middle-income countries account for only 7% of global opioid consumption despite having 80% of the world’s population. the recent results of the global opioid policy initiative (gopi) survey by the european society for medical oncology (esmo) found that in the most countries, multiple barriers prevent the routine use of inexpensive and effective opioid pain medications, such as morphine. pain relief is widely accepted as a patient right and a human right. the global action plan for the prevention and control of non-communicable diseases (ncd) published by the world health organization (who) in 2013 calls for the integration of palliative care and pain relief into the care of all patients with ncd and strongly urges all developing country governments to improve access to these medications. although it is important to prevent misuse of opioids, many developing countries, including bangladesh, have extremely strict opioid control policies that significantly limit the supply, distribution, and consumption of opioids, and prevent most patients with severe pain from accessing these essential medications. the international association for hospice and palliative care (iahpc), recommends 7 essential opioids be available in all countries. these include codeine, oral oxycodone, transdermal fentanyl, immediate and slow release oral morphine, injectable morphine, and oral methadone. in bangladesh only 3 of these medications are on the national formulary and none are actually available more than half of the time according to the gopi survey published in annals of oncology1. many physicians in bangladesh are hesitant to prescribe opioids due to widespread fears and misconceptions about the risk of addiction and respiratory depression. many clinicians incorrectly believe that opioids should only be used in patients who are dying. all physicians will encounter patients who need palliative care and pain management in the course of their career. thus, training and education in these areas should be included in standard medical curriculum at the undergraduate and postgraduate levels. unnecessarily stringent opioid control policies continue to significantly impede clinicians’ ability to prescribe opioids in this country. these regulations must change, empowering properly trained clinicians to prescribe opioids based on individual patients’ needs. patient and public misconceptions about the safety of opioids compound the issues facing physicians when prescribing opioids. patients are often unaware that opioids are a safe and effective option to treat their pain and fear addiction. complicated registration procedures for patients and difficulty obtaining medications discourage many from accessing appropriate opioid analgesia. what are the next steps as moving forward? the solutions must be adapted to the local context. lessons can be learned from developing countries who have improved opioid access dramatically, including: uganda, vietnam, nepal, and ukraine. in each of these corresponds to: megan doherty, practicing in pediatric palliative care, children's hospital of eastern ontario/roger's house, canada, email: mdoherty@cheo.on.ca bangladesh journal of medical science vol. 13 no. 03 july’14 249 doi: http://dx.doi.org/10.3329/bjms.v13i3.17694 bangladesh journal of medical science vol. 13 no. 03 july '14. page: 249-250 countries, an essential early step was reform of national drug control and public health policies, which were preventing medical access to opioids. ensuring that pain relief policies are developed as part of the national cancer control plan is also an important step. lastly, physicians must engage with their paitents, civil society, and health advocates to create a movement for change. untreated pain a ‘scandal of global proportions’ 250 references: 1. cleary j, radbruch l, torode j, cherny ni. formulary availability and regulatory barriers to accessibility of opioids for cancer pain in asia: a report from the global opioid policy initiative (gopi). ann oncol 2013;24(11):1124–1132.[cited 2014 jan 17 ] page mackup-final.qxd case report isolated nerve sheath tumor of jejunum presenting as acute abdomen mohanty j1, prasad s2 abstract nerve sheath tumors of gastrointestinal tract are rare and occurs more frequently as systemic manifestations of generalized neurofibromatosis type-1(nf-1).in neurofibromatosis-1 lesions may be scattered or solitary tumor. occasionally ,such tumors may be the initial presenting feature of nf-1.rarely ,cases of isolated nerve sheath tumor of small intestine presenting with bleeding and obstruction have been documented. we report a 19years male presenting with nerve sheath tumor of jejunum in acute abdomen. his investigations show no features of nf-1. keywords: nerve sheath tumor, neurofibromatosis, isolated, intestinal. introduction nerve sheath tumors of small intestine may manifest in various forms and accordingly given different descriptive terms including intestinal neurofibromatosis, ganglioneuromatosis, neuronal intestinal dysplasia and diffuse plexiform neurofibromatosis. these lesions may be seen in 25% cases of neurofibromatosis-1 and multiple endocrine neoplasia type 2b.there occurrence without nf-1 and men-2b are very rare1. no consensus has been made yet whether these isolated lesions represent different phenotypic manifestations of the neurocutaneous or multiple endocrine neoplasia syndromes or whether they represent separate and distinct entities. case report a 19 years old male presented to us with acute abdomen of 1 day history with symptoms of pain around umbilicus and 2 episodes of vomiting. on examination he had tachycardia and tenderness over umbilical and hypogastrium regions with bp-90/60mm of hg. he had rigidity and rebound tenderness more marked in lower abdomen. usg shows a oval well defined hypo echoic solid lesion seen in lower abdomen infraumblical region to the left of midline. cect shows a isodense inhomogeneously enhancing soft tissue exophytic tumor of size 5.8*4.2*4.3 arising from small bowel likely to represent gastrointestinal stromal tumor. there is no lymphadenopathy with moderate amount of free fluid in the pelvis. initially we proceed with laparoscopic exploration .but due to dense adhesions we converted it into formal laparotomy with lower midline incisions. after entering into abdominal cavity a tumor arising from jejunum approximately 7 feet distal to d-j junction with dense adhesions with surrounding bowels was seen .[figure-1] after clearing all adhesions carefully segmental resection of bowel having tumor carried out with 1. dr. jignyasu mohanty, associate professor, room no307, mgm medical staff quarters, mgm medical college, sector 18 kamothe, navi mumbai, raigad district, maharashtra, india, e-mail: drjignyasu@rediffmail.com 2. dr. sujit prasad, consultant general surgeon, mgm hospital, sector 7, vashi, navi mumbai, maharashtra, india, e-mail:prasadsujitin@yahoo.com corressponds to: dr. jignyasu mohanty, associate professor, room no307, mgm medical staff quarters, mgm medical college, sector 18 kamothe, navi mumbai, raigad district, maharashtra, india, e-mail: drjignyasu@rediffmail.com bangladesh journal of medical science vol. 12 no. 01 january’13 91 figure i intra operative photograph showing tumor arising from jejunum end to end anastomosis. [figure-ii] the postoperative orally allowded on 4th postoperative day and recovery was uneventful .biopsy sent to 3 different labs. histopathology from all the 3 labs reported uniform epithelioid morphology with spindle component . these cells are very strongly positive for s100[figure-3] and negative for c-kit, cd34, sma, calponin, hmb45, melan a. there is no mitoses or necrosis. the patient is followed for 8months without any complication. discussion isolated nerve sheath tumors are benign neural lesions of intestinal tract which may be initial presenting feature of nf-1 and men tepe2b. affected patient may present with altered bowel habit2, abdominal pain3, intestinal obstruction4 or with palpable abdominal mass. in setting of nf-1 associated clinical findings including dermal neurofibromas, café-au-lait spots and lisch nodules may be seen. in men type 2b thickened lips, marfanoid habitus and medullary carcinoma of thyroid may be seen. isolated nerve sheath tumors commonly involve colon , terminal ileum , and appendix5. surgical excision is the treatment of choice for these lesions these cases need to be followed up closely to exclude nf-1 and men type2b in future. references 1. hochberg fh, dasilva ab, galdabini j, richardson ep jr. gastrointestinal involvement in von recklinghausen's neurofibromatosis. neurology. 1974;24:1144-1151 http://dx.doi. org/10.1212/wnl.24.12.1144 pmid:4374669 2. kim hr, kim yj. neurofibromatosis of the colon and rectum combined with other manifestations of von recklinghausen's disease: report of a case. dis colon rectum. 3. bononi m, de cesare a, stella mc, fiori e, galati g, atella f, angelini m, cimitan a, lemos a, cangemi v. isolated intestinal neurofibromatosis of colon. single case report and review of the literature. dig liver dis. 2000;32:737-742. http://dx. doi.org/10.1016/s1590-8658(00)80340-0 4. urschel jd, berendt rc, anselmo je. surgical treatment of colonic ganglioneuromatosis in neurofibromatosis. can j surg. 1991;34:271276 pmid:1905194 5. shekitka km, sobin lh. ganglioneuromas of the gastrointestinal tract. relation to von recklinghausen disease and other multiple tumor syndromes. am j surg pathol.1994;18:250-257 http://dx.doi. org/10.1097/00000478-199403000-00004 pmid:7906923 isolated nerve sheath tumor of jejunum presenting as acute abdomen 92 figure ii immunohistochemistry showing strong s100 reaction page mackup january-14.qxd 99 bangladesh journal of medical science vol. 13 no. 01 january’14 introduction among other tropical diseases, filariasis is a major public health problem in the african and asian subcontinent. it is transmitted by the culex mosquito and is caused by two closely related nematodes: wuchereria bancrofti and brugia malayi. filariasis affects the lymphatic system with a predilection for lower limbs, retroperitoneal tissues, spermatic cord, and epididymis1. filaria can affect other sites rarely. though single or small number of cases on microfilaremia at various sites as lymphnode, breast lump, bone marrow,bronchial aspirates, nipple secretion, pleural and pericardial fluid, ovarian cyst fluid and cervico vaginal smear have been reported, thyroid is another site from which microfilaria has been isolated. so far only nine case reports are available. it is estimated that approximately 600 million people are living in areas endemic for lymphatic filariasis southeast asia region. there are approximately 60 million people infected in the region and approximately 31 million people have the clinical manifestation of this disease2. here we present a patient with filariasis of the thyroid detected by fine needle aspiration cytology (fnac) of thyroid gland. case presentation a 36-year-old female presented with a slowly enlarging painless swelling of thyroid gland over a period of two years. clinically patient had no other complain. thyroid function was normal. on examination a 3×3 cm, firm, non-tender thyroid nodule was palpable over left lobe. no cervical lymph node was palpable. fine-needle aspiration of the thyroid nodule revealed blood mixed colloid. slides were stained with leishman-giemsa stain. microscopic examination of the smear showed the presence of microfilarial larvae with few mono-layered clusters of benign follicular cells in the background of blood mixed colloid. the microfilariae had blunt head and pointed tail with a sheath projected slightly beyond the extremities of the embryo (fig.1). somatic cells or nuclei appeared as granule in the central axis of the body and were absent at the tip of the tail. all the features distinguish m. bancrofti from the other sheathed larvae. discussion filariasis is a global problem. it is also a major health problem in india3 .this patient also presented as euthyroid state similar to the findings of kundu case report: a rare case of microfilaria in thyroid aspirate mondal rk1, ray r2, kawsar h3, ali ms4. abstract filariasis is a major health problem in the indian subcontinent. due to its nocturnal periodicity it may be difficult even to demonstrate in the blood. in heavy parasitic load they may appear in the blood, urine with chyle and at times in scrotal aspirates. it is very rare and unusual to find microfilaria in thyroid aspirate. this case report of presence of microfilaria in thyroid aspirate suggest that careful screening is important for thyroid lesions as patients may present with thyroid enlargement other than usual thyroid lesions. key words: microfilaria, thyroid, fnac corresponds to: dr.rajib kumar mondal, assistant professor, dept. of pathology, vill-barjora, schooldanga, po+ps-barjora, dist-bankura, westbengal, pin-722202, india, email: rajibkmondal@yahoo.co.in 1. mondal rajib kumar, assistant prof,bsmch 2. ray rudranarayan, assistant prof,bsmch 3. kawsar hena, pgt, bsmch 4.ali md. sadakkas, resident surgeon, nrs medical college, kolkata doi: http://dx.doi.org/10.3329/bjms.v13i1.14217 bangladesh journal of medical science vol. 13 no. 01 january '14 page 99-100 et al, kar d.k. et al and mohanti et al4,5,6. in no case reported previously suspect of microfilaria was made. all the cases were sent for fnac for diagnosis of other primary lesions similar to our case2. the clinical manifestations of lymphatic filariasis may range from asymptomatic microfilariasis to hydrocele, lymphangitis, lymphadenitis with highgrade fever (filarial fever), and lymphatic obstruction7. in our case it presented with asymptomatic thyroid swelling, similar findings have been noted by study of mohanti et al and vargese et al6,8. microfilaria of thyroid has never been suspected in any case reports including those cases where high eosinophilia has been reported2. there are eight identified species of filarial parasite among them only three (i.e., w. bancrofti, b. malayi, and brugia timori) are known to cause lymphatic filariasis . these are sheathed species. in india microfilariae bancrofti and microfilariae malayi are the commonly prevalent species. species diagnosis is made on the basis of morphology of the microfilaria. microfilariae of b. malayi are smaller than those of w. bancrofti, possess secondary kinks instead of a smooth curve, and unlike the latter, the tip is not free of the nuclei9. conclusions in conclusion, filariasis of the thyroid is an uncommon condition and need a high index of suspicion and careful screen of fna smears especially in asymptomatic patients belonging to endemic zones, so as not to miss this incidental finding especially in patients from endemic areas . references 1. faust ec, russell pf, jung rc. craig and faust's clinical parasitology, 8th ed. philadelphia: lea & febiger; 1970. 2. chowdhary m, langer s, aggarwal m, agarwal c. microfilaria in thyroid gland nodule. indian j pathol microbiol. 2008 ; 51(1):94-6 pmid:18417874 http://dx.doi.org/10.4103/0377-4929.40415 3. park k.textbook of preventive and social medicine. 21st ed. jabalpur: banarsidas bhanotn; 2011. 4. kundu ak, giri a, ghosh g, saha sr. microfilaria in a thyroid nodule which resolved on treatment.trop doct. 2002 ;32(4):248 pmid:12405321 5. kar dk, agarwal g, krishnani n, mishra sk. microfilaria in thyroid: a histopathological encounter. thyroid 2001 ;11(4):401 http://dx.doi.org/10.1089/10507250152039172 pmid:11349842 6. mohanty sk, patnaik s, dey p. microfilaria in thyroid aspirate. diagn cytopathol 2002;26(3):197-8 h t t p : / / d x . d o i . o r g / 1 0 . 1 0 0 2 / d c . 1 0 0 5 2 pmid:11892028 7. maheshwari v, khan l, mehdi g, zafar u, alam k. microfilariae in thyroid aspiration smear—an unexpected finding. diagn cytopathol. 2008 ; 36(1):40-1. h t t p : / / d x . d o i . o r g / 1 0 . 1 0 0 2 / d c . 2 0 5 4 9 pmid:18064692 8. varghese r, raghuveer cv, pai mr, bansal r. microfilariae in cytologic smears: a report of six cases. acta cytol 1996;40 (2):299-301 h t t p : / / d x . d o i . o r g / 1 0 . 1 1 5 9 / 0 0 0 3 3 3 7 5 5 pmid:8629415 9. chatterjee kd. parasitology. 13th ed. new delhi: cbs publishers; 2009. 100 microfilaria in thyroid aspirate page mackup-final.qxd casereport: a rare fracture of the mandible sulabha an1, sameer ac2,warad nm3 abstract maxillofacial traumas are common and mandible is most frequently fractured bone in the lower third of face. here we report a rare horizontal fracture of mandible from right molar to left molar. fracture was adequately reduced and fixed with two holed miniplates. the possible mechanism of such an unusual fracture is discussed. key words: horizontal fracture, mandible, reduction introduction maxillofacial injuries are common. they occur in a variety of situations: road traffic accidents, interpersonal violence, as a result of criminal activity, fall or during the contact sports 1 . mandible fractures occur more frequently than any other fractures of the facial skeleton. in urban areas in more recent years particularly, interpersonal violence has accounted for an increasing proportion of the mandible fracture along with zygomatic fractures 2. the mandible constitutes the bony structure of the lower third of the face .mandible is the strongest and most rigid component of the facial skeleton. it is more commonly fractured than any other bone of face, a fact directly related to its prominent and exposed situations 2 . the most common sites of fracture in mandible are angle, subcondylar area, body, symphsis, ramus, coronoid process. 3 here we report an isolated case of horizontal fracture of mandible below the mental foramen resembling the osteotomy for genioplasty. extensive research revealed only two cases of horizontal fracture of symphysis. case report a 35 year old female reported to department of oral medicine with a complaint of swelling in the lower mandibular region since 8-10 days. history revealed that she was hit by a stone in the interpersonal violence 8-10 days before. she developed pain and swelling for which she consulted local dentist and his prescription revealed her of pain and swelling but not completely. extra oral examination revealed mild swelling along entire lower mandibular region extending from angle to angle. on palpation it was tender and soft. intraoral examination revealed no soft tissue abnormality. occlusion was normal. panoramic view showed isolated horizontal undisplaced fracture from right molar to left below the mental foramen on both sides (fig-1). 1. dr. sulabha .a.n. professor, department of oral medicine and radiology, al-ameen dental college and hospital, bijapur-586108, karnataka 2. dr. sameer. a.c. reader, department of oral and maxillofacial surgery, al-ameen dental college and hospital, bijapur-586108, karnataka 3. dr. warad. n.m. professor, department of oral and maxillofacial surgery, al-ameen dental college and hospital, bijapur-586108, karnataka corresponds to: dr. sulabha. a. n. professor, department of oral medicine and radiology, al-ameen dental college and hospital, bijapur-586108, karnataka, india, e-mail: sulabha595@rediffmail.com bangladesh journal of medical science vol. 11 no. 04 oct’12 353 fig-i panoramic view of horizontal fracture of mandible risdon’s degloving incision was taken from angle to angle, blunt dissection was done to expose the fracture site, and exposed fracture resembled horizontal osteotomy (fig-ii). fracture site was reduced and two holed two miniplates were fixed on right and left side of mandible at canine region. incision closure was done in layers (fig-iii). postoperative healing was uneventful (fig-iv). discussion: despite the many variables associated with the etiology of mandibular fractures, vehicular accidents and assaults are undoubtedly the primary cause of the mandibular fracture throughout the world. mandibular fracture are more prevalent in the interpersonal violence when compared to accidents which involves majority involves midfacial fractures 4 . the mandible has few mechanically weak portions including angle, condylar precess and both sides of mentum. the location and direction of mandibular fracture are nearly constant, although the impacts and direction of external force are variable 5 . mandible having long canines, unerupted third molars, unerupted or absent premolars are significantly weaker and represents the lines of weakness along with the condylar process and both sides of mentum, making these areas more prone for fractures 2,6 . isolated horizontal fracture of mandible are rare 5 .only two cases have been reported in the literature.ladeinde et al reported horizontal fracture of mandibular symphsis, more involving the left body of mandible caused by matchet cut 5 . mitsukawa reported a horizontal fracture of mandibular symphysis resembling horizontal osteotomy for genioplasty 7 . in contrast to only reported two cases, the present case involved horizontal fracture from molar to molar. lesser violence from interpersonal assaults tends to cause fracture at the usual point of impact on one side 2 . the object that caused the fracture can also influence the type and number of fracture. a blow from smaller well defined object may cause single commutated fracture since the impact of force is concentrated in smaller area 3 . horizontal fractures occur only when local stresses exceed the ultimate strength of the bone in that region. only an object approaching at high speed could produce enough of impact force to fracture the bone in non biomechanical pattern. the object would have to have a horizontal orientation with a sharp edge when striking the mandible and such an acute loading would act like an osteotome to produce the fracture. in the present case high speed a rare fracture of the mandible 354 fig-iv postoperative radiograph fig-iii immediate postoperative photograph fig-ii intraoperative photograph showing the horizontal fracture stone with enough of impact force, having sharp edge might have acted as osteotome to cause such an unusual fracture of mandible 5 . to conclude such horizontal fractures very rare and occurs when the local stresses exceed the ultimate strength of bone and these fractures need to be classified in classification of mandibular fractures. references 1. booth pw, schendel sa, hausamen je. maxillofacial surgery. vol 1. churchill livingstone, london; 1999: pg 3-11 2. banks p. killey’s fractures of the mandible. 4th ed. varghese publishing house. bombay.1993: pg 1-19 3. fonseca rj, walker rv, betts nj, barber hd. oral and maxillofacial trauma. vol 1. 2nd ed.w bsaunders.phildelphia.1997: pg 473-522 4. lee kh, snape l, steenberg lj, worthington j. comparison between interpersonal violence and motor accidents in the aetiology of maxillomandibular fractures. anz j surg 2007; 77(8):695-98http://dx.doi.org/10.1111/j.14452197.2007.04189.xpmid:17635287 5. ladeinde al, adeyemo wl, ogunlewe mo, gbotolorun om. an unusual fracture of mandible. ghana medical journal 2009; 4 3 ( 4 ) : 1 7 9 8 0 p m i d : 2 1 3 2 6 9 9 9 pmcid:2956366 6. reizik m, lownie jf, cleaton jones p, and austin j. experimental fractures of monkey mandibles. int j oral surg 1978; 7:100-103 http://dx.doi.org/10.1016/s03009785(78)80054-4 7. mitsukawa n, satoh k, umeura t, hosaka y. an unusual traumatic fracture of mandibular symphysis resembling horizontal osteotomy for genioplasty. j craniofac surg 2004; 15:229-31 h t t p : / / d x . d o i . o r g / 1 0 . 1 0 9 7 / 0 0 0 0 1 6 6 5 200403000-00011pmid:15167236 sulabha an, sameer ac,warad nm 355 page mackup-final.qxd case report a forensic case of sacralization of the sixth lumbar vertebra in skeletal remains. tanaka n1, kinoshita h2, jamal m3, tsutsui k4, motomura h5, ameno k6 abstract lumbosacral transitional vertebrae (lstvs) are a common congenital anomaly of the spine. in the present case, we observed lstvs in the excessive (sixth lumbar) vertebra. in forensic practice, this anomaly may be useful for personal identification of skeletal remains. key words: lumbosacral transitional vertebrae (lstvs), skeletal remains, personal identification introduction personal identification is an essential subject in forensic medicine [1,2]. morphological characteristics such as healed fractures, bone disease, congenital defects and prosthesis provide useful information for personal identification in case of skeletal remains1-6. here we describe lumbosacral transitional vertebrae (lstvs), a congenital anomaly in the part of spine7, in relation to forensic skeletal remains. case history: almost completely skeletonized human remains were found in a house, where an aged person had lived alone. anthropological findings led us to determine that the deceased was a male between 60 to 80 years of age. the stature of the victim, calculated from the length of the femoral bones, was approximately 160-165cm, and the postmortem interval was estimated at approximately 2-4 years. no dental work, healed fractures, surgical intervention or recent injuries were recognized. the skeleton had extra lumbar vertebrae and sacralization of a sixth lumbar vertebra (type iib) was observed in the spine as a characteristic finding (figure 1). figure 1. anterior (a) and posterior (b) views of the sacralization of the sixth lumbar vertebra in the present case. subsequent dna examination using ampflstr® identifiler® pcr amplification kit (applied biosystems, usa) identified the remains as the resident of this house. his age was within the esti1. naoko tanaka, department of forensic medicine, faculty of medicine, kagawa university, 17501, miki, kita, kagawa, 761-0793, japan. 2. hiroshi kinoshita, department of forensic medicine, faculty of medicine, kagawa university, 1750-1, miki, kita, kagawa, 761-0793, japan. 3. mostofa jamal, department of forensic medicine, faculty of medicine, kagawa university, 17501, miki, kita, kagawa, 761-0793, japan. 4. kunihiko tsutsui, health sciences, school of nursing, faculty of medicine, kagawa university, 1750-1, miki, kita, kagawa, 761-0793, japan. 5. hiroyuki motomura, forensic science laboratory, hyogo prefectural police headquarters, 4-1, shimoyamate-dori 5-chome, chuo-ku, kobe, 650-8510, japan. 6. kiyoshi ameno, department of forensic medicine, faculty of medicine, kagawa university, 17501, miki, kita, kagawa, 761-0793, japan. corresponds to: dr. h. kinoshita, department of forensic medicine, faculty of medicine, kagawa university, 1750-1, miki, kita, kagawa, 761-0793, japan. e-mail: kinochin@med.kagawa-u.ac.jp bangladesh journal of medical science vol. 12 no. 02 april’13 224 mated range. discussion personal identification was performed by dna typing in the present case. lstvs are common congenital anomalies, and are defined as either sacralization of the lowest lumbar segment or lumbarization of most superior sacral segment of the spine 7 . four types of lstvs have been classified on the basis of morphological characteristics 8 . the frequency of occurrence of lstvs varies in different human population groups, and it observed in 424% of the general population 9 and in 15-18.1% of the japanese population 10,11 . however, as the frequency of conversion of lstvs into an excessive vertebra is 1.6% 12 , its characteristic findings may be useful for personal identification. it has been previously reported that low back pain associated with lstvs is called bertolotti’s syndrome 13 . although the relationship between lstvs and low back pain remains controversial 14 , it has been reported that the incident of lstvs in patient with low back pain is higher than that of the general population 9 . the person who has low back pain seems to seek medical examination, and they may have a higher opportunity to take x-ray films of the spinal region 15 . comparisons of radiological morphological features between antemortem and postmortem x-ray films have been performed for personal identification in case of skeletal remains 16-20 . the morphological characteristic findings of spinal region may also provide useful information, if antemortem lumbosacral x-ray films was available in the present case. references 1. knight b. forensic pathology. 2nd edition. london: arnold, 1996; 95-132. pmid:9414393 2. jackson arw, jackson jm. forensic science. essex: pearson education limited 2004; 339349. 3. ohshima t, maeda h, takayasu t, zhu b, lin z, nishigami j, nagano t. three cases of personal identification on cadavers with advanced postmortem changes. res pract forens med 1991; 34: 299-305. 4. aoki y, nata m, hashiyada m, saigusa k, nakayama y. five cases of positive identification by means of implanted medical equipment. res pract forens med 1998; 41: 193-198. 5. kinoshita h, motomura h, kasuda s, nishiguchi m, matsui k, takahashi m, ouchi h, minami t, yamamura t, otsu n, yoshida s, adachi n, ohta t, hishida s. positive identification facilitated by implanted metallic plate and screws. soud lek 2009; 54: 16. pmid:19534396 6. kinoshita h, tanaka n, ohi t, jamal m, ohkubo e, ameno k. prior surgical intervention of the bone; useful finding for the examination of the skeletal remains. bangladesh j med sci 2010; 9: 93-94. 7. konin gp, walz dm. lumbosacral transitional vertebrae: classification, imaging findings, and clinical relevance. ajnr am j neuroradiol 2010; 10: 1778-1786.http://dx.doi.org/ 10.3174/ajnr.a2036pmid:20203111 8. castellvi ae, goldstein la, chan dpk. lumbosacral transitional vertebrae and their relationship with lumbar extradural defects. spine 1984; 9: 493-495.http://dx.doi. o r g / 1 0 . 1 0 9 7 / 0 0 0 0 7 6 3 2 1 9 8 4 0 7 0 0 0 00014pmid:6495013 9. delport eg, cucuzzella tr, kim n, marley j, pruitt c, delport ag. lumbosacral transitional vertebrae: incidence in a consecutive patient series. pain physician 2006; 9: 53-56. pmid:16700281 10. sato t, akita k. (ed) anatomic variations in japanese. tokyo: university of tokyo press 2000; 8. 11. amako t. (ed) jinnaka's textbook of orthopedic surgery (20th eds). tokyo: nanzando 1978; 603-605. bangladesh journal of medical science vol. 12 no. 02 april’13 225 12. takeuchi s. a study on the number of the japanese vertebrae. tokyo jikeikai medical journal 1980; 95: 584-597. 13. quinlan jf, duke d, eustace s. bertolotti's syndrome. a cause of back pain in young people. j bone joint surg br 2006; 88: 1183-1186. h t t p : / / d x . d o i . o r g / 1 0 . 1 3 0 2 / 0 3 0 1 620x.88b9.17211pmid:16943469 14. apazidis a, ricart pa, diefenbach cm, spivak jm. the prevalence of transitional vertebrae in the lumbar spine. spine j 2011; 11: 858-862.http://dx.doi.org/10.1016/j.spinee.2011.08.005pmid:21951610 15. kanchan t, shetty m, nagesh kr, menezes rg. lumbosacral transitional vertebra: clinical and forensic implications. singapore med j 2009; 50: e85-e87.pmid:19296021 16. ikeda n, umetsu k, harada a, suzuki t. radiologic identification of human skeletal remains: a acse report. nihon hoigaku zasshi 1987; 41: 270-273.pmid:3682300 17. owsley dw, mann rw. positive personal identity of human skeletonized remains using abdominal and pelvic radiographs. j forensic sci 1992; 37: 332-336.pmid:1545209 18. gunji h, hiraiwa k. radiographic identification of unknown human remains with a bone island in the sacrum. res pract forens med 1992; 35: 297-300. 19. sakaihara m, terazawa k. a case of positive personal identity of skeletonized remains using lumbar radiograph. hokkaido igaku zasshi 2002; 77: 157-160. pmid:11968851 20. kahana t, goldin l, hiss j. personal identification based on radiographic vertebral features. am j forensic med pathol 2002; 23: 36-41. h t t p : / / d x . d o i . o r g / 1 0 . 1 0 9 7 / 0 0 0 0 0 4 3 3 200203000-00007 pmid:11953491 n tanaka, h kinoshita, m jamal, k tsutsui, h motomura, k ameno 226 page mackup april-14.qxd bangladesh journal of medical science vol. 13 no. 02 april’14 228 case report a rare case of subcutaneous mycosis due to rhizoctonia solani sahu. s1, padhy .s2, dash.m3, mohanty.i4, pattnaik.s5 introduction: rhizoctonia solani (r.solani) is the most commonly identified species of rhizoctonia. it is a soil borne pathogen with a great diversity of host plants. it was described by julius kuhn on potato in 1858.it is a basidiomycete fungus that does not produce any asexual spores. in nature, it reproduces asexually and exists primarily as vegetative mycelium and/or sclerotia1.the vegetative mycelium of rhizoctonia solani are colorless when young but become brown colored as they grow and mature.the key to identify r.solani are characteristics of its septate hyphae branching at 90? angles ,constrictions at the base of the hyphal branching sometimes with anastomosis and clear white , darkbrown to black colored colonies on sda. it can be able to survive for extended periods of time in the absence of living host plants by feeding on decaying organic matter2.to the best of our knowledge this is the first ever case of human subcutaneous mycosis due to rhizoctonia solani reported from south odisha. case report: a 52 year old female agricultural worker by profession came with a complaint of progressive swelling over the upper part of left leg for the past 3 months .it is a single circular swelling of size 6x5 cm present on the anterior part of the left leg extends up to lower border of patella . it extended medial and lateral compartments slightly.skin over the swelling was normal without any inflammatory signs.no visible veins,pulsations ,sinus or any discharge from the swelling were seen .on palpation there was no local rise of temperature ,no tenderness and skin over the swelling was pinchable. all the borders were well defined and it was soft in consistency. there was no restricted joint mobility. there was a history of trauma while working in the paddy field.on general examination all the vitals were normal. she had mild pallor.the patient was diabetic but not hypertensive. pus was aspitated under aseptic conditions and sent to the department correspond to: dr.susmita sahu, department of microbiology m.k.c.g medical college, berhampur odisha pin760001 e-mail: susmitakumarisahu@gmail.com abstract: rhizoctonia solani is a very common soil borne pathogen with a great diversity of host plants. a 52 year old lady presented with sole manifestation of subcutaneous swelling over the left leg for 3 months pus was collected by aspiration revealed septatate fungal hyphae. after culture on sda at 25 c showed white cottony growth initially, progressed to buff colored to black colonies on further incubation. on lpcb mount we found septate hyphae with acute and right angled branching with out any conidia and hyphal anastomosis which resembled features of rhizoctonia solani. patient was put on fluconazole and responded well to the treatment. 1. sahu. s, senior resident, m.k.c.g medical college 2. padhy .s, assistant professor, m.k.c.g medical college 3. dash.m , assistant professor, m.k.c.g medical college 4. mohanty.i , senior resident, m.k.c.g medical college 5. pattnaik.s, junior resident, m.k.c.g medical college department of microbiology; m.k.c.g medical college berhampur, odisha, india. doi: http://dx.doi.org/10.3329/bjms.v13i2.15060 bangladesh journal of medical science vol.13(2) 2014 p.228-230 of microbiology for examination. it was thick and brown in colour without any odour on gross examination .gram stain of the pus revealed few number of pus cells with septate hyphae. basing on the preliminary staining report pus sample was inoculated into sda (sabourauds dextrose agar) slants incubated at 25?c and 37?c . after 5 days of incubation at 25?c cottony white growth was appeared which later turned tan to black colored starting from the periphery of the media. on further incubation.the whole colony turned dark black coloured .the reverse side showed white to grey colour lpcb mount of the colony showed septate hyphae without conidia.the hyphae showed right angled branching hyphae at some places fused together to form anastomosis .this was identified as rhizoctonia solani basing on above features.patient was put on oral fluconazole and the whole pus was drained. the patient was discharged with advice for follow up in out patient department. discussion: rhizoctonia solani belongs to the phylum basidiomycota,class agaricomycetes, order cantharellales,family ceratobasidiaceae and genus rhizoctonia2 .it usually exists in nature as vegetative mycelium and does not produce any asexual spores. it consists of hyphae partitioned into individual cells by septum containing small pore through which movement of cytoplasm, mitochondria and nuclei from cell to cell occurs.the hyphae branch often branch at a 900 angles and usually possess more than three nuclei per hyphal cells. the branched hyphae is sometimes slightly constricted at the origin.they produce sclerotia which are resistant to variation in environmental conditions. these above features differentiate r.solani from other rhizoctonia fungi. r.solani grows on potato dextrose agar and forms grey to black colored colonies at the temperature range of 18-280 .sclerotia are produced on the surface of cultures after 4 to 6 six weeks of incubation2. in 1969, j.r parmeter and his colleagues reintroduced the concept of ‘hyphal anastomosis’ to characterize and identify rhizoctonia.this includes that the isolates of rhizoctonia which have the ability to recognize and fuse with each other are genetically related,where as isolates that do not have this ability are genetically unrelated3,4.this hyphal anastomosis criteria have been extensively used to place isolates of rhizoctonia into taxonomically distinct groups .it is grouped into 13 anastomosis groups (ag) that vary in pathogenecity,physical characsteristics and sequence variations5. it is the method of genetic recombination in rhizoctonia. it causes wide range of commercially significant plant diseases ,but reports of human diseases caused by it are very rare6. till now two cases of human mycosis due rhizoctonium solani causing keratitis7 and extensive mycosis2 were reported. in this case the patient was a agricultural field worker and gave the history of trauma while working in the field.this might be the cause of infection by penetration of soil pathogen through the injury.also the patient is a known diabetic which helped the pathogen to grow at the site of injury. to conclude ,r.solani is a well known plant pathogen and very rarely causes human infection.this case was reported because of its rarity. figure-1: subcutaneous swelling on left leg. figure-2: gram staining of pus sample showed septate branched hyphae subcutaneous mycosis due to rhizoctonia solani 229 reference: 1. paulo ceresini pathogen profile created by course pp728 soil borne plant pathogens,offered on spring1999 2. kaore nm,atul ar,khan mz,ramnani vk. a rare case of human mycosis by rhizoctonia solani.indian j med microbiol 2012; 30:361-3. http://dx.doi.org/10.4103/0255-0857.99508 3. anderson na.the genetics and pathology of rhizoctonia solani. annu rev phytopathol 1982; 20:329-47. http://dx.doi.org/10.1146/annurev.py.20.090182.001553 4. gracia vg,onco map,susan vr.review,biology and systematics of the form genus rhizoctonia.span j agric res 2006;4:55-79. 5. foley rc,gleason ca,anderson jp,hamann t,singh kb(2013). genetic and genomic analysis of rhizoctonia solani interactions with arabidopsis;evidence of resistance mediated through nadph oxidases.plosone 8(2):e56814 doi :10.137/journal.pone.0056814. 6. manisha k,panwar n.morphological effects of isolated fungal specis on human p o p u l a t i o n . 1 : 5 2 1 . d o i : 1 0 . 4 1 7 2 / s c i e n t i f i c reports.521.2012;1:1-6. 7. srivastava op,lal b,agarwal pk,agarwal sc,chandra b,mathur is.myotic keratitis due to rhizoctonia sp.sabouraudia 1977;15:125-31. http://dx.doi.org/10.1080/00362177785190201 sahu. s, padhy .s, dash.m, mohanty.i, pattnaik.s 230 figure-3: growth of rhizoctonia after 12 days on sda agar. figure-3: fig 4 lpcb mount from slide culture showing right anglebranching and anastomosis page mackup january-14.qxd bangladesh journal of medical science vol. 13 no. 01 january’14 background acute promyelocytic leukaemia (apml) is a condition classically characterised by t(15,17) (q22,q21), with disseminated intravascular coagulopathy (dic) being a major cause of death. central nervous system involvement with apml commonly occurs in relapse; however, it is rarely seen at presentation, with only six reported cases in the literature1. approximately 20 to 30% of patients died of hemorrhage, most often intracerebral in location, either at presentation or after the initiation of chemotherapy2,6. the bleeding diathesis became a major focus of research because the outcome of patients with apl appeared to be more favourable compared with that of patients with other subtypes of aml. case report a 17year male without a significant medical history was referred to our hospital in january 2013 complaining of repeated seizures for last 2 weeks. later on he developed vomiting and photophobia. the haematological finding obtained was leukocyte count (3,28,000/mm3), hemoglobin (5.6 g/dl), platelet count(34,000/mm3), and differential white cell count was lymphocyte 11%, myelocyte 08%,promyelocyte 41%, myeloblast 40%. bone marrow examination revealed more than 70% hypergranular promyelocytes with atypical features. laboratory tests showed a prolonged prothrombin time (27 seconds) and activated partial thromboplastin time( 41 seconds), the presence of d-dimer, a fibrinogen concentration of 84 mg/dl all of which were compatible with dic. the ct scan of brain revealed two frontal areas of hyperattenuation, which was suggestive of hemorrhage. the patient was diagnosed as acute promyelocytic leukemia with intracerebral haemorrhage. he was transfused with fresh frozen plasma. the patient died on the same day. acute promyelocytic leukaemia is frequently associcase report: acute promyelocytic leukemia in a 17yr male presenting as intracerebral haemorrhage rauta s1, sahoo a k2 abstract acute promyelocytic leukemia (apml), once highly fatal, has emerged as the most curable subtype of acute myeloid leukemia in adults. early mortality most often is due to a severe catastrophic bleeding, often intracerebral in location. here we report a 17year male patient presented with status epilepticus having high leukocyte count (3,28,000/mm3) and low platelet count(34,000/mm3).peripheral blood & bone marrow was showing good no. of atypical promyelocytes. ct scan of brain revealed an intracerebral haemorrhage with laboratory profile of prolonged prothrombin time and activated partial thromboplastin time, the presence of ddimer and decreased fibrinogen concentration. the patient was diagnosed as acute promyelocytic leukemia with intracerebral haemorrhage. the patient died on the same day. apml is the notorious subtype of acute myeloid leukemia which causes fatal intracranial haemorrhage which has high mortality and morbidity. clinically significant coagulopathy is present in 70%– 80% of apml patients at the time of diagnosis. early detection and aggressive correction of coagulopathy may prevent the catastrophic event. prompt image study for locations and types of ich can predict outcomes. key words : acute promyelocytic leukemia, dic, intracerebral haemorrhage 1. rauta s ,asst. professor, dept. of pathology. 2. sahoo a k, asst. professor dept. of general medicine. maharajah’s institute of medical sciences vizianagaram, andhra pradesh 535217 india corresponds to: rauta s, asst. professor, dept. of pathology. maharajah’s institute of medical sciences vizianagaram, andhra pradesh 535217, india doi: http://dx.doi.org/10.3329/bjms.v13i1.14482 bangladesh journal of medical science vol. 12 no. 05 january '14 page 88-90 88 ated with clotting abnormalities and carries a high risk of intracranial haemorrhage7. cns involvement in apml is extremely rare at presentation but not infrequent at relapse, and associated factors include raised white cell count (>10 x 109/l), prior cns haemorrhage, microgranular variant and bcr3 pml/rar type8,9. past studies have revealed that fatal intracranial hemorrhage (40%) is the leading cause of death from cytotoxic chemotherapy10 , although current treatment that combines all-transretinoic acid (atra) and conventional chemotherapy has much improved the prognosis. routine coagulation tests reveal prolongation in the pt and aptt, low fibrinogen levels, and elevation in the d-dimer and fibrin degradation products (fdps) in most but not all patients with apl11. these observations suggests that the bleeding diathesis is due to disseminated intravascular coagulation.the pathogenesis includes consumptive coagulopathy and procoagulant activity, fibrinolysis, proteolysis & increased angiogenesis. the use of atra to treat apl, especially in combination with chemotherapy, in patients with coagulopathy has improved the survival rate12-15. few case supports that high-risk patients, in particular those who have intracranial haemorrhage and high white cell count at presentation, should have diagnostic lumbar puncture performed earlier once the coagulopathy has resolved. this approach may allow earlier detection and treatment of occult cns disease and consequently reduce the risk of future relapse. conclusion: acute promyelocytic leukemia (apl), once highly fatal, has emerged as the most curable subtype of acute myeloid leukemia in adults. cure is now expected in 70 to 90% of patients when treatment includes atra combined with anthracycline based chemotherapy. early mortality most often is due to a severe and often catastrophic bleeding, often intracerebral in location, and remains a major cause of treatment failure. the most important therapeutic strategy is early institution of atra at the first suspicion of the diagnosis (without waiting for genetic confirmation) and aggressive blood product. 89 acute promyelocytic leukemia presenting as intracerebral haemorrhage. ct scan of brain showing intracerebral haemorrhage bone marrow showing good no. of hypergranular promyelocytes with prominent nucleoli(leishman stain) bone marrow showing good no. of hypergranular promyelocytes with prominent nucleoli(leishman stain) references: 1. bhuller k, m kwan acute promyelocytic leukaemia presenting with subarachnoid haemorrhage and complicated by central nervous system involvement blood cancer journal (2011) 1, e25; doi:10.1038/bcj.2011.21 http://dx.doi.org/10.1038/bcj.2011.21 2. kantarjian hm, keating mj, walters rs, et al. acute promyelocytic leukemia: md anderson hospital experience. am j med 1986;80:789–797. http://dx.doi.org/10.1016/0002-9343(86)90617-0 3. cordonnier c, vernant jp, brun b, et al. acute promyelocytic leukemia in 57 previously untreated patients. cancer 1985;55:18–25. http://dx.doi.org/10.1002 / 1 0 9 7 0 1 4 2 ( 1 9 8 5 0 1 0 1 ) 5 5 : 1 < 1 8 : : a i d cncr2820550104>3.0.co;2-b 4. petti mc, avvisati g, amadori s, et al. acute promyelocytic leukemia: clinical aspects and results of treatment in 62 patients. haematologica 1987;72:151–155. pmid:3114070 5. stone rm, maguire m, goldberg ma, et al. complete remission in acute promyelocytic leukemia despite persistence of abnormal bone marrow promyelocytes during induction therapy: experience in 34 patients. blood 1988;71:690–696. pmid:3422828 6. avvisati g, petti mc, lo coco f, et al. induction therapy with idarubicin alone significantly influences event-free survival duration in patients with newly diagnosed hypergranular acute promyelocytic leukemia; final results of the gimema randomized study lap 0389 with 7 years of minimal follow-up. blood 2002;100:3141–3146. h t t p : / / d x . d o i . o rg / 1 0 . 11 8 2 / b l o o d 2 0 0 2 0 2 0 3 5 2 pmid:12384411 7. chen cy, tai ch, tsay w, chen py, tien hf. prediction of fatal intracranial haemorrhage in patients with acute myeloid leukaemia. ann oncol 2009; 20: 1100–1104. http://dx.doi.org/10.1093/annonc/mdn755 pmid:19270342 8. montesinos p, diaz-mediavilla j, deben g, prates v, tormo m, rubio v et al. central nervous system involvement at first relapse in patients with acute promyelocytic leukaemia treated with all-trans retinoic acid and anthracycline monotherapy without intrathecal prophylaxis. haematologica 2009; 94: 1242–1249. http://dx.doi.org/10.3324/haematol.2009.007872 pmid:19608685 pmcid:pmc2738716 9. breccia m, carmosino i, diverio d, de santis s, de propris ms, romano a et al. early detection of meningeal localisation in acute promyelocytic leukaemia patients with high presenting leucocyte count. br j haematol 2003; 120: 266–270. http://dx.doi.org/10.1046/j.1365-2141.2003.04056.x pmid:12542484 10. humphries je, hess ce, stewart fm. acute promyelocytic leukemia: impact of hemorrhagic complications on response to induction chemotherapy and survival. south med j 1990;83:1157–61. http://dx.doi.org/10.1097/00007611-19901000000010 pmid:2218655 11. daly pa, schiffer ca, wiernik ph. acute promyelocytic leukemia—clinical management in 15 patients. am j hematol 1980;8:347–359. h t t p : / / d x . d o i . o r g / 1 0 . 1 0 0 2 / a j h . 2 8 3 0 0 8 0 4 0 3 pmid:6932177 12. barbui t, finazzi g. the impact of all-trans-retinoic acid on the coagulopathy of acute promyelocytic leukemia. blood 1998; 91:3093–102. pmid:9558362 13. tallman ms, andersen jw, schiffer ca, appelbaum fr,feusner jh, woods wg, ogden a, et al. all-transretinoic acid in acute promyelocytic leukemia: longterm outcome and prognostic factor analysis from the north american intergroup protocol. blood 2002;100:4298–302. http://dx.doi.org/10.1182/blood2002-02-0632 pmid:12393590 14. n çelik, s kara, hb toksoy, d içagasioglu, d büyükkayhan, o bulut. encephalomyelopathy in a child with acute lymphoblastic leukemia who had received radiotherapy and intrathecal chemotherapy. bangladesh journal of medical science 2010; 09 (3): 174-176. doi: 10.3329/bjms.v9i3.6481 http://dx.doi.org/10.3329/bjms.v9i3.6481 15. advani sh, nair r, bapna a, gladstone b, kadam p, saikia tk, parekh pm, et al. acute promyelocytic leukemia: all-transretinoic acid (atra) along with chemotherapy is superior to atra alone. am j hematol 1999;60:87–93. h t t p : / / d x . d o i . o r g / 1 0 . 1 0 0 2 / ( s i c i ) 1 0 9 6 8652(199902)60:2<87::aid-ajh1>3.0.co;2-5 90 rauta s, sahoo a k page mackup-final.qxd case report a case of battered wife ahmed ks1, begum a2, alamgir m3, masud maa4 abstract the use of corrective force against the wife is still rife in all cultures and even socially acceptable in some culture. domestic violence is still common in our society. we report a case of 20 years old woman who admitted into occ of dmch through emergency department owing to be assaulted by her husband. this case is exceptional one because the injuries inflicted upon her were over the middle of the forehead and clean cut in nature, though non fatal. awareness and education is needed to stop this social stigma. key wards battered wife, assault, injury. introduction: under section 17, the penal code of bangladesh an injury is defined as any harm caused illegally to a person in his body, mind, reputation or property. whereas wound is defined as breach or break of continuity of skin and mucous membrane following trauma or injury. assault is defined as any attempt or offer of threat to the body of a person with an evil motive which may cause physical injury or not and the actual application of assault is known as battery1,2. battered wife simply means physical assault to a wife by her husband. but busutill defines a battered wife as a woman who has suffered demonstrable and repeated physical injuries at the hands of the man with whom she lives or from the father of one of her children3. the injuries are commonly multiple bruises on exposed parts of the body specially face and arms. a study where 100 battered wives were interviewed all had bruising, often together with other injuries such as lacerations and fractures4. case report: a 20 year old married woman brought to emergency department of dmch with the history of assault by her husband and sent to occ of the same hospital (ref: dmch reg. no.12803/32, dated 18.05.2008 & occ reg. no. 223/08 dated 18.05.2008) for taking appropriate measures. on local examination, two parallel incised wounds were found over the middle of the forehead measuring 11/2× ¼ inch and 1×¼ inch scalp depth respectively. the wounds were stitched later on. in studying this case the following points were considered determination of the nature of the weapon, age of the injury, manner of the injury, fate of the injury and legal aspects of the injury. the nature of the injury inflicting weapon is determined by characteristics of the wound. in this particular case the injuries were sharp and clean cut, hence the causative weapon seemed to be sharp cutting. it is important to note that an injury over the forehead or scalp is usually split type lacerate. in these area bones are just below the skin and subcutaneous tissue without any intervening muscle layer. hence impact of two hard objects defines the lacerated type of injury. the split laceration is more or less similar to incised wound when examined with naked eyes, hence it is also called incised like wound or incised looking wound. but on using magnifying glass the margins and edges of split laceration are found ragged and irregular. whereas the margins of incised wound are smooth, well defined, clean cut and regular5. so, this case is exceptional as the wounds were corresponds to: dr. khan shakil ahmed, assistant professor, department of forensic medicine, enam medical college, savar, dhaka. 1. dr. khan shakil ahmed, assistant professor, department of forensic medicine, enam medical college, savar, dhaka. 2. dr. asma begum, assistant professor, department of forensic medicine, ibn sina medical college, kallyanpur, dhaka. 3. dr. mithun alamgir, assistant professor, department of community medicine, enam medical college, savar, dhaka. 4. dr. mohammad abdullah al masud, assistant professor, department of pharmacology, enam medical college, savar, dhaka. bangladesh journal of medical science vol. 11 no. 03 july’12 231 caused by sharp cutting weapon, which found in a very rare occasion. to determine the duration of any injury the gross appearance of the injury is carefully looked at, observe histochemical and histopathological changes and enquiring the victim about the time of the incidence. the age of the abrasion and bruise can be calculated by observing the color changes of the injury. histochemical changes involve the study of enzymes, atpase amino peptidase and acid phosphatase etc in the wound region. the activity of atpase increases by one hour and amino peptidase two hours respectively after injury. histopathological examinations look for cellular infiltrations and collagen formation. polymorph leykocytes migration in the small blood vessels occur from 30 minutes to 4 hours, leukocyte infiltration and appearance of mononuclear cells occur 4 to 12 hours, collagens begin to form in the capillaries and giant cells may be visible from 3 to 6 days after injury6. scar formation is completed usually within 6 to 15 days after injury if not accompanied by infection. the age of the injury in this case was about two and half days. the manner of an injury often depicts whether it is suicidal, homicidal or accidental. it is usually seen that accused denies the charge of inflicting injuries upon their wives and also tries narrate it as self inflicted. there are number points to differentiate self-inflected wounds from others. fatality and complications of any injury are also of considerations. in our opinion the present case was not self-inflicted, which, however, was non fatal and uncomplicated at the end. in legal procedure the site of injury inflicted is considered seriously. although the injury was nonfatal and uncomplicated but left permanent disfiguration of head and face which fulfill the no 6 criteria of grievous hurts. our opinion regarding this case was that 'the injuries were caused by sharp cutting weapon, the age of the injury was about two and half days and the injuries were grievous in nature'. discussion: women have accepted ill treatment at the hands of men they live with since time immemorial in this region. they are reluctant to bring to light their personal problems for fear of shame, disgrace and threat. a study on the silence of the victims of battered wife indicated that unawareness of actual victims stems from an incomplete understanding of the reality of the "battered wife syndrome," lack of knowledge about the various forms of abuse and the silence of the victims themselves7. so, some prefer just to leave home whilst others indulge in self inflicting injury or attempt suicide by poisoning, self immolation, hanging and using overdoses of sleeping pills. the offence comes to light when the victim requires hospital treatment or dies under suspicious circumstances. wife battering is common in all socioeconomic groups, however, mainly seen among the low income group in this part of the world. the chief offender is the man and mainly attributed to dowry. among other causes which results in thinning of man involved are personality disorder, emotional stress, indulgent into drinking and gambling and instigation by family members. it was observed that violent episodes in which the husband was drinking included more frequent and severe act of household violence8. temporary lapse of sanity resulting in homicide is an important factor when the man suspects the fidelity of his wife and often results is killing. . a visit to a doctor or hospital emergency department for a trivial unexplained injury should arouse examiner's suspicion of wife battering. when a woman complains of unendurable behavior at the hands of her husband and seeks help from a medical practitioner he has an important role to play not only in hospitals but also his private chamber and he must include an assessment of injury to her health by physical or other means in his/her report3. it has been shown that effective management of domestic violence involves raising the victim's self-esteem so that she is able to alter her situation herself9. conclusion: wife battering is not uncommon in our country. in this case the victim is lucky that she escape from any type of serious injury like intracranial hemorrhage which may be fatal. so the assailant must be punished by the law in any circumstances, as it will be an example and may prevent many of wife battering incidences due to fear of punishment by the court of law. acknowledgement: the authors gratefully acknowledge the institutional ethical committee of dmch to kindly provide the ethical approval for the publication of the case. a case of battered wife 232 references: 1. mechanical injuries. in: the essentials of forensic medicine and toxicology. reddy nks. ed. 28th ed. hyderabad: india. 2009; p157. 2. medicolegal aspects of wounds. in: the essentials of forensic medicine and toxicology. reddy nks. ed. 28th ed. hyderabad: india. 2009; p254-256 3. parikh ck. violence in the home. in: parikh's text book of medical jurisprudence, forensic medicine and toxicology for classrooms & courtrooms. parikh ck. ed. 6th ed. new delhi: india 2007; p4.191 4. gayford jj, wife battering: a preliminary survey of 100 cases, bmj 1975;1 ; 194197.http://dx.doi.org/10.1136/bmj.1.5951.194 pmid:1111742 pmcid:1672091 5. apurba n, mechanical injuries. in principles of forensic medicine. nandy a, sen m. eds. 3rd ed. kolkata: india 2009; pp339-365. 6. saukko p and knight b. the pathology of wounds. in knight's forensic pathology. saukko p and knight b. eds. 3rd ed. london: england 2004; p167-168 7. blair ka. the battered woman: is she a silent victim?, nurse pract 1986; 11: 38, 40-44and47. 8. testa m, quigley bm, leonard ke. j interpers violence. 2003; 18: 735-743. http://dx.doi.org/ 10.1177/0886260503253232pmid:14675506 9. knowlden sm, frith jf. domestic violence and the general practitioner. med j 1993; 158:402406. pmid:8479354 ahmed ks, begum a, alamgir m, masud maa 233 117 bangladesh journal of medical science vol. 14 no. 02 april’15 editorial in memory of prof. ghulam muazzam: legendary medical scholar of bangladesh muazzam n1, al-mahmood ak2 corresponds to: prof naima muazzam, member, editorial board, bangladesh journal of medical science, ibn sina trust, ibn sina medical college bhaban 1/1-b, kallyanpur, dhaka-1216. doi: http://dx.doi.org/10.3329/bjms.v14i2.18261 bangladesh journal of medical science vol.14(2) 2015 p.117-118 on behalf of ‘bangladesh journal of medical science’ and its publisher ‘ibn sina trust’ we deeply express condolence on the death of its founder editor-in-chief and the senior most pathologist of the country prof. muhammad ghulam muazzam. prof. muazzam was one of the greatest medical scholars and scientist born in this subcontinent. he was born in birgaon under brahmanbaria district in 1927 and passed away on 22nd january 2015 in dhaka. prof. dr. muhammad ghulam muazzam was a brilliant and extremely meritorious student. he received merit scholarships throughout his educational careerfrom upper primary examination (1936) up to post graduate studies. he passed his matriculation examination in 1943 in the 1st division with distinctions in two subjects under calcutta university. the jurisdiction of calcutta university was entire bengal (present bangladesh, west-bengal and assam). he passed his i.sc in 1st division with distinction from calcutta islamia college under calcutta university and was placed 4th among muslim students according to merit. following i.sc, he went to study medicine at calcutta medical college. he completed his m.b.s.s at the esteemed calcutta medical college where he entered on the basis of general merit category amongst all the students (1st ten students used to get admission on merit basis). during his days in calcutta medical college he showed his brilliance. he stood first in the university in medical jurisprudence and received university gold medal (roy debendranth raibahadur) in medical jurisprudence. he was awarded a gold medal for his outstanding result in the 4th year of mbbs exam. he stood first in the test examination of the final mbbs part 1b. he completed mbbs in 1950 with distinction. career: he started his career as a demonstrator (lecture) of pathology in dhaka medical college in the year 1951. later he was awarded central govt. scholarship for higher studies in the uk, there he obtained highest degree (mrcpath) in pathology. on his return from uk in 1959 he joined in the department of pathology in dhaka medical college. he worked as professor of pathology in rajshahi medical college. after his nuffield fllowship he joined as founder professor of microbiology in ipgmr in 1968. later on he served as principal of sylhet and rangpur medical college. he also worked as director of bmdc in 1974-75. for sometime worked as professor of pathology in al-fateh university of libya. he was a selected expert in the field of pathology & microbiology by commonwealth in the panel of experts of commonwealth fund for technical co-operation (cftc) and in that capacity worked in bahamas for the period of 1977-79 and ghana university for the period of 1988-91. from the early days of his career he showed his commitment in medical research and innovation. he published numerous articles in internationally reputed journals between 1959 and 60’s1-5. prof. muazzam wrote many books on scientific aspects of islam and holy quran.. he prof. dr. muhammad ghulam muazzam mb (cal), frcpath (eng) ist july 192722nd january 2015 1. prof naima muazzam, member, editorial board, bangladesh journal of medical science. 2. prof. abu kholdun al-mahmood, executive editor, bangladesh journal of medical science. 118 in memory of prof. ghulam muazzam: legendary medical scholar of bangladesh was possibly the first scientist to carry on research on the effects of ramadan fasting on health. he hypothesized that ramadan fasting has beneficial effect on health. he published his observation on ramadan fasting on health in international and regional journals1,3,6-8, which ultimately promote much research on this field. many scientists took this fasting habit of muslim community in their holy month to study different metabolic events in feed-fast states. he was one of the founder faculty members of the then ipgmr and pioneered many medical research there2,4-5, 9-13. professor muazzam was instrumental in the establishment of the microbiology department in ipgmr. he retired from the government service in 1982 and engaged himself to establish laboratory services of the ibn sina trust which has become a pioneer private medical diagnostic lab in bangladesh. through his relentless efforts he raised the lab to an international standard laboratory. in the year 1994 ‘ibn sina trust’ started publication of ‘bangladesh journal of medical science’, prof. muazzam acted as founder editor-in-chief of this journal. during it’s early years of publication the journal received many contributions from him14-21. he led from the fore front until the last day of his life for the journal to maintain quality and achieve international affiliation. it is worth mentioning that prof muazzam was editor of east pakistan medical journal and first editor of medical bulletin of ipgmr. professor muazzam was also involved with many social and philanthropic activities. he was life member of natab bangladesh, society of pathologists, bangladesh. he was past treasurer of pak medical association (east zone). he was past president of society of pathologists, bangladesh. he was the past general secretary of calcutta medical college ex-student association, bangladesh. he was honored with ‘ibn sina gold medal’ by the the ibn sina trust in 2002 for his contribution in medical science in the country. he was an ever smiling, guiding and patronizing person to all level of his colleagues. with his priceless contributions he will remain as everlasting icon of medical science in bangladesh. references: 1.muazzam mg, khaleque ka. effects of fasting in ramadhan. j trop med hyg. 1959;dec;62:292-94. pmid:14424866 2.khaleque ka, muazzam mg, chowdhury ri.examination of sputum for eosinophils. j trop med hyg. 1960 dec;63:291-2. pmid:13755590 3.khaleque ka, muazzam mg, ispahani p. further observations on the effects of fasting in ramadhan. j trop med hyg. 1960 oct;63:241-3.pmid:13755591 4.islam n, muazzam mg, khaleque ka. idiopathic tropical eosinophilia. j lancet. 1960 aug;80:389-96. pmid:14405939 5.muazzam mg, khaleque ka, ibrahim m.hepatic ascariasis. j trop med hyg. 1960 apr;63:95-7. pmid:14424865 6. khaleque ka, muazzam mg, chowdhury ri. stress in ramadhan fasting. j trop med hyg. 1961 nov;64:277-9. pmid:14455514 7. mg muazzam. ramadan fasting and medical science. bangladesh journal of medical science vol.1(1) 1994 pp.38. doi: http://dx.doi.org/10.3329/bjms.v1i1.7851 8. mg muazzam. effects of ramadan fasting on health. bangladesh journal of medical science . 1997; 4(3): 12-25. doi:http://dx.doi.org/10.3329/bjms.v4i3.8231 9. khaleque ka, muazam mg, chowdhury ri. anthrax in east pakistan. j trop med hyg. 1961 jan;64:18-9. pmid:13755589 10. islam n, asiruddin m, muazzam mg.aneurysm of the splenic artery (with a case report). br j clin pract. 1961 jun;15:527-31. pmid:13718040 11. khaleque ka, muazzam mg, ispahani p. a simple method for the use of water melon seed preparation in the estimation of blood urea. j clin pathol. 1964 jan;17:97-8.pmid:14100015 http://dx.doi.org/10.1136/jcp.17.1.97 12. muazzam mg, sneddon m. sensitivity of baby hamster kidney (bhk 21-c 13) cells to enteric viruses. brief report. arch gesamte virusforsch. 1970;30(4):405-7. pmid:4318626 13. alam sa, muazzam mg. dermatophytes in bangladesh. j trop med hyg. 1974 nov;77(11):267-9. pmid: 4463252 14. microscopic findings of stool analysis of 4000 adults in bangladesh. mg muazzam.bangladesh journal of medical science. 1(4) 1994 pp.15-19 15.an unusual case: intestinal polyposis coli. mg muazzam. bangladesh journal of medical science. 1(4) 1994 pp.37-39. 16.autopsy findings of 15,823 natural deaths in accra, ghana. mg muazzam, y tette, r gyasi. bangladesh journal of medical science. 1(1) 1994 pp.12-21. doi: http://dx.doi.org/10.3329/bjms.v1i1.7847 17.congenital anomaly: closed prepuce. mg muazzam. bangladesh journal of medical science vol.1(1) 1994 pp.39. doi: http://dx.doi.org/10.3329/bjms.v1i1.7852 18.stool analysis of 3000 children in bangladesh. n muazzam, mg muazzam. bangladesh journal of medical science vol.1(1) 1994 pp.28-34. doi: http://dx.doi.org/10.3329/bjms. v1i1.7849 19.history of medicine – 1.the editor. bangladesh journal of medical science vol.1(1) 1994 pp.35-37. doi: http://dx.doi. org/10.3329/bjms.v1i1.7850 20.male infertility in libyan arab jamahiriya. mg muazzam. bangladesh journal of medical science. 1994; 1 (3) (doi: http://dx.doi.org/10.3329.bjms.v1i3.17910 21. investigation of infertility semen analysis. mg muazzam. bangladesh journal of medical science . 1996; 3(1): 32-35. doi:http://dx.doi.org/10.3329/bjms.v3i1.8225 page mackup-final.qxd original article longterm effects of compression method in the surgical treatment of bleeding haemorrhoids alfazzaman m 1 , goldin va 2 , anwary sa 3 , rahman mm 4 , islam mr 5 abstract objective: present study was undertaken to find out the long term effect of application of compression probe after haemorrhoidectomy in the treatment of bleeding haemorrhoids. materials and methods: they study was carried out in the department of clinical surgery, russian people's friendship university, moscow, russia, from january 1992 to december 2001, on 80 patients, equally divided into two groups, case (haemorrhoidectomy plus application of compression probe) and control (haemorrhoidectomy only). results: long term follow up showed higher good outcome in case group (82.1%) compared to control (53.8%) (p<0.05), satisfactory and unsatisfactory outcome was higher in control group (17.9% and 28.2%) compared to case group (12.8% and 5.1%). conclusion: application of compression problem after haemorrhoidectomy in patients with bleeding haemorrhoids gives better long term results. key words: bleeding haemorrhoids, compression probe introduction the surgical illnesses of anorectum are frequently observed disease among the persons of working age. haemorrhoids is one of the most common disease of anorectum. the frequency of it among the adult population varies within the limits of 60 to 70 percent1. according to data, absolute increase of this pathology only in russia annually 600,000 patients are admitted to hospitals. a large number of patients receiving outpatient treatment engaged a self treatment plan is not included in the statistics2. majority of the patients are from the working age group 30 65 years. among these patients, 29 90% encounter from 2 6 episodes per year, and for each episode loss of working days range from 6 to 35 days. therefore, haemorrhoids represent an important social problem3. patients with bleeding haemorrhoids have the agonizing problems due to passage of blood per rectum after defaecation which are worrisome and may result in fatal outcome due to loss of excessive blood. various methods of surgical treatment of bleeding haemorrhoids have been described in the literature but none of these are considered to be radical because of their side effects, complication and even fatal outcome4 6. compressive probe was used effectively in bleeding haemorrhoids as part of conservative treatment in patients in whom general or spinal anaesthesia was contraindicated7. surgical treatment of haemorrhoids, especially, the bleeding haemorrhoids is a concern of colorectal surgeons, and this article shows the effectiveness of compressive probe with the combined surgical treatment of bleeding haemorrhoids. materials and methods subjects this study was carried out in the department of clinical surgery, russian peoples' friendship university, moscow, russia (hospital no. 17), during january 1992 and december 2001, and included 80 patients with bleeding haemorrhoids. the corresponds to: dr. victor alexieavich goldin, professor, department of clinical surgery, russian peoples' friendship university, moscow, russia 1. dr. md. alfazzaman, assistant professor, department of surgery, z.h. sikder women's medical college and hospital, dhaka 2. dr. victor alexieavich goldin, professor, department of clinical surgery, russian peoples' friendship university, moscow, russia 3. dr. shaheen ara anwary, assistant professor, department of obstetrics and gynaecology, bsmmu, dhaka 4. dr. md. mujibur rahman, associate professor and head, department of urology, z.h. sikder women's medical college and hospital, dhaka 5. prof. md. rezaul islam, professor and head, department of anaesthesiology, z.h. sikder women's medical college and hospital, dhaka bangladesh journal of medical science vol. 12 no. 02 april’13 129 patients were subdivided into case (n=40) and control (n=40). patients with bleeding haemorrhoids concomitant with rectal polyp, chronic anal fissure, partial prolapsed rectal mucosa and patients with condyloma of anus were included in the case group. histologically confirmed cases with rectal carcinoma were excluded from the study. informed consents were obtained from study patients and hospital authorities. ethical approval was taken from the hospital authorities before study. methods all 80 patients underwent milligan morgan haemorrhoidectomy. after operation, in 40 case group patients, after operation, compressive probe was applied at the internal and external haemorrhoidal sites of the anorectum with inflated balloon (50 mmhg in each balloon) for 24 hours (fig. 1). in control group, after operation proper haemostasis was ensured and antibacterial ointment soaked tampon was introduced into the anorectum. the patients were discharge from hospital only after full recovery. all 80 patients were followed up on outdoor basis for a period ranging from 6 months to 9 years. long term follow up results could be obtained from 78 patients, as one patient from each group died due to other disease not related to haemorrhoidectomy. out of 78 patients, 21 patients were followed up at the outpatient department, and data from the rest 57 patients were obtained with the help of data collection form provided to them as they were unable to ethical approval: this protocol was approved by institutional ethics committee. long term assessment long term follow up results were evaluated as (1) good: when a patient has no complaint related to the operation on anorectum, as there are no exacerbation or relapse of haemorrhoids, i.e. there is no nodulation, bleeding or prolapse of haemorrhoids; (2) satisfactory: when there is no nodulation or prolapse of haemorrhoids, but only periodic bleeding or difficulties at defaecation (with or without pain) or disturbance in micturition; (3) unsatisfactory: when there are relapse of haemorrhoids which demanded repeated operative measure. statistical methods data were expressed a number (percentage) and mean (±sd). statistical analyses were done by unpaired student's 't' test and chi square test. results table i shows patient data. mean (±sd) are showed no significant difference between case (42.70±7.88 years) and control (43.55±6.72 years) groups. sex also showed to significant variation between groups. in case and control groups, respectively, there were 28 (70%) and 26 (65%) males, and 12 (30%) and 14 (35%) female. associated diseases in case and control group, respectively, were polyp of anal canal (10% and 20%), anal fissure (2.5% each), anal stenosis (7.5% and 2.5%), condyloma of anus (2.5% each), prolapse of anal mucosa (10% and 0%), and none (67.5% and 72.5%). distribution of associated diseases between groups showed statistically no significant variation. none of the case group of patients required blood transfusion, however, 9 (22.5%) control group of patients required blood transfusion (p<0.01). mean (±sd) hospital stay was significantly high (p<0.001) for control group of patients compared to case (12.3±1.54 vs 6.83±0.98 days). preoperative and postoperative mean (±sd) haemoglobin level in case and control groups showed significant difference between groups. preoperative haemoglobin level was 13.04±0.56 and 12.57±0.89 g/dl (p<0.01), and postoperative was 12.84±0.56 and 11.23±1.00 g/l (p<0.001). mean change in haemoglobin level at postoperative period from preoperative level was 0.20 ( 1.54%) in case and 1.34 ( 10.73%) in control group. table ii shows long term follow up results. in case group, out of 39 patients, 32 (82.1%) were evaluated as good. in these patients, there was no complaint related to the performed operation. satisfactory results was obtained in case of 5 (12.8%) patients though they did not show any sign of relapse. two patients (5.1%) of case group showed unsatisfactory results. in one case, there was only internal nodulation, but there was no bleeding per rectum or haemorrhoidal relapse, in second case, periodic bleeding per rectum was present without any sign of haemorrhoids. out of 39 control patients, outcome results in 21 (53.8%) were evaluated as good based on their health and absence of any complaints connected to anorectum operation. in case of 7 (17.9%) patients follow up outcome was satisfactory, as they developed constipation and period bleeding but had no signs of haemorrhoidal nodules. four patients longterm effects of compression method in the surgical treatment of bleeding haemorrhoids 130 developed increased frequency of micturition and two patients lost their capacity to work. in control group, 11 (28.2%) patients follow up results were unsatisfactory as they showed signs of relapse of haemorrhoids requiring repeated operative treatment. comparing the long term outcome of treatment of haemorrhoids and benign tumours of anorectum, it was noted that good outcome was higher in case group (82.1%) in comparison to control group (53.8%), satisfactory outcome was higher in control group (17.9%) in comparison on case group (12.8%), and also unsatisfactory outcome was higher in control group (28.2%) in comparison to case group (5.1%). higher satisfactory and unsatisfactory result obtained in control group may be attributed to non application of compressive probe after haemorrhoidectomy. statistically, good result was significantly high (p<0.05) in case group in comparison to control. discussion haemorrhoidctomy is the method of choice in the m alfazzaman, va goldin, sa anwary, mm rahman, mr islam 131 table i: patient data variables case control p value (n=40) (n=40) age (years) mean±sd 42.70±7.88 43.55±6.71 0.605ns no. (%) no. (%) p value sex 0.633ns male 28 (70.0) 26 (65.0) female 12 (30.0) 14 (35.0) associate diseases 0.269ns polyp of anal canal 4 (10.0) 8 (20.0) anal fissure 1 (2.5) 1 (2.5) anal stenosis 3 (7.5) 1 (2.5) condyloma of anus 1 (2.5) 1 (2.5) prolapse of anal 4 (10.0) 0 mucosa none 27 (67.5) 29 (72.5) blood transfusion 0.001** required 0 9 (22.5) not required 40 (100.0) 31 (77.5) hospital stay (days) mean±sd 6.83±0.98 12.30±1.54 0.0001*** variables case control p value (n=40) (n=40) haemoglobin (g/dl) preoperative mean±sd 13.04±0.56 12.57±0.80 0.003** postoperative mean±sd 12.84±0.56 11.23±1.00 0.0001*** mean change -0.20 -1.34 percent change -1.54 -10.73 unpaired student's 't' test/chi-square test ns = not significant, ** = significant (p<0.01), *** = significant (p<0.001) table ii: outcome of treatment outcome case control p value (n=39) (n=39) no. (%) no. (%) good 32 (82.1) 21 (53.8) satisfactory 5 (12.8) 7 (17.9) 0.012* unsatisfactory 2 (5.1) 11 (28.2) chi-square test * = significant (p<0.05) treatment of bleeding haemorrhoids. the compressive probe applied after haemorrhoidectomy revealed better results in comparison to haemorrhoidectomy alone. long term compression in haemorrhoidal zones of anorectum results in the reduction of influx of blood on arteriolovenular anastomoses of cavernous bodies and simultaneous elimination of stagnation of blood in the haemorrhoids. therefore, the pressure in the lumen of cavernous bodies is reduced; they are drained and the lumens of the cavernous bodies collapse. in addition to this, at pressure on haemorrhoids, the nerve receptors are irritated, simulates the contraction of muscles of anal sphincters, which even more signifies compression on haemorrhoids and accelerates the process of collapse of walls of ecstatic vessels. there is an oxygen deficiency in tissues of haemorrhoids, the physicochemical properties of walls of pathologically changed vessels and their surrounding tissues are changed; stimulation of development of young connective tissues and the process of cicatrization is magnified7. the walls of pathologically changed vessels of haemorrhoids in connection with a long time compression and local hypoxia are squeezed, gradually scleroses, emptying of haemorrhoids and bleeding ceases8. from our data, we found that the application of compressive probe in the conservative method of treatment of bleeding haemorrhoids intended for stoppage of haemorrhoidal bleeding, lowering of activity of arteriolovenular anastomoses, normalization of microcirculation in cavernous bodies, and thus it was effective as conservative treatment of bleeding haemorrhoids. the duration was for 4 hours per day, and the process was repeated for 4 5 times at an interval of 1 4 days7. the application of compressive probe after surgical treatment of bleeding haemorrhoids was directed to stop the residual bleeding, restoration of bloodflow and normalization remaining cavernous bodies, adaptation of edges of sutures mucosa and to reduce perianal oedema. the time of application of compressive probe was for 24 hours after operation. conclusion the application of compressive probe at the end stage of haemorrhoidectomy in patients of bleeding haemorrhoids provided the elimination of stagnation of blood in the cavernous derivations, resulting in all and aseptic pasting together of their walls, sclerosis and shrinkage of haemorrhoidal clusters. thus, it prevented relapse of haemorrhoids in the long term. references 1. dultsev yu v, titov a yu, coauth. haemorrhoidectomy with suturing apparatus. j surg 1989; 2:115 118. 2. vorobeov gi, glagodorni la. choice of methods of treatment of haemorrhoids. j surg 1999; 8:50 55. 3. rivkin vl, kapuller ll. haemorrhoids, constipation. m medpractice 2000; 158. 4. akopian ea b, nazarov l yu, et al. surgical treatment of haemorrhoids. bull surg 1989; 142:113 116. 5. stelzner f. haemorrhoidectomy a simple operation? incontinence, stenosis, fistula, infection and fatalities. chirurg 1992; 63:316 326. pmid:1597095 6. standards task force american society of colon and rectal surgeons. practical parameters for the treatment of haemorrhoids. dis col rect 1993; 36:1118-1120. http://dx.doi.org/10. 1007/bf02052259 pmid:8253007 7. digeshwar t. compression method in the treatment of haemorrhoids [phd dissertation in medical science]. moscow 1993. 8. goldin va and degeshwar t. modern method of treatment of bleeding haemorrhoids. in: actual problems in clinical surgery (collection of works of moscow medical and dental institute after name of na semashka). moscow 1993l 94 7. longterm effects of compression method in the surgical treatment of bleeding haemorrhoids 132 compressive probe for the treatment of haemorrhoids. 336 bangladesh journal of medical science vol. 14 no. 04 october’15 original article usefulness of modified alvarado score in diagnosis of acute appendicitis in adults mondal hp1, hadiuzzaman m2, mukhopadhyay c3, chattopadhyay s4, biswas sk5, bhoj ss6 abstract: background: definitive diagnosis of acute appendicitis preoperatively is sometimes difficult. failure to make a diagnosis is the main reason for persistent rate of morbidity and mortality. various scoring systems are devised to aid diagnosis of acute appendicitis. in some studies the modified alvarado score was helpful, reliable and practical in minimizing unnecessary appendectomy. objective: the purpose of this study was to evaluate the usefulness of modified alvarado score for the diagnosis of acute appendicitis. materials and method: a prospective study of 89 adult patients, admitted with abdominal pain suggestive of acute appendicitis, from july 2011 to june 2012, was conducted. data including clinical signs and symptoms and laboratory findings were recorded in modified alvarado score record form. all 89 patients underwent appendectomy. final diagnosis was confirmed by histopathological examination. reliability of scoring system was assessed by negative appendectomy rate and positive predictive value. results: out of 89 patients who underwent appendectomy, 85 had acute appendicitis on histopathology. positive predictive value was 95.5% and negative appendectomy rate was 4.5%. 52.8% had score 7 or above and 47.2% had score less than 7. from score it is difficult to predict which patient warranted appendectomy and who may be safely observed or discharged. conclusions: diagnosis of acute appendicitis remains mainly clinical evaluation and it is more helpful than modified alvarado scoring system in adults. keywords: modified alvarado score; acute appendicitis; adults corresponds to: corresponds to: dr.hari pada mondal. associate professor, dept. of surgery, north bengal medical college, sushrutanagar, darjeeling. 3/1,rajanikantasarani, hakimpara, siliguri. dist. darjeeling. pin-734001. email: drhpmondal@gmail.com 1. hari pada mondal, associate professor, 2. md. hadiuzzaman, pgt, 3. chandranath mukhopadhyay, rmo-cum-clinical tutor, dept. of surgery, north bengal medical college, sushrutanagar, darjeeling. 4. shibram chattopadhyay, assistant professor, dept. of g&o, burdwan medical college, burdwan. 5. sajal kumar biswas, assistant profesor, 6. sudhansu sekhar bhoj, professor, dept. of surgery, north bengal medical college, sushrutanagar, darjeeling. introduction: acute appendicitis is a common cause of acute abdominal pain in emergency. failure to make an early diagnosis is a main reason for the persistent rate of morbidity and mortality. prompt diagnosis and surgical intervention reduce the risk of perforation and infectious complications. emergency physicians may find it difficult to diagnose acute appendicitis based on clinical grounds alone. various scoring system have been devised to aid diagnosis and to determine earlier and more convincingly the group of patients who will require further investigation, observation or urgent surgery1-7.alvarodo score was devised in 19867.good diagnostic validity of alvarado score has been reported in diagnosing acute appendicitis(chan2001)8. although some reports have found that the alvarado score alone is inadequate as a single diagnostic test(ohman1995)9.classic alvarado score included shift to left of neutrophil maturation (score 1) yielding a total score of 102,7 . kalan et al, omitted this parameter and produced a modified score6 .the purpose of this study is to evaluate the usefulness of modified alvarado score in predicting acute appendicitis in adults in our set up. materials and methods: this is a prospective study conducted on 89 patients bangladesh journal of medical science vol. 14 no. 04 october’15. page: 336-338 doi: http://dx.doi.org/10.3329/bjms.v14i4.16257 http://dx.doi.org/10.3329/bjms.v14i4.16257 337 usefulness of modified alvarado score of acute appendicitis above 12 yrs. admitted through emergency surgical dept. of north bengal medical college, darjeeling with clinical diagnosis of acute appendicitis during the period from july, 2011 to june, 2012. data including age, sex, symptoms, physical signs and laboratory findings such as white blood counts were recorded in modified alvarado score form (table 1). all the patients underwent emergency appendectomy. definite diagnosis of acute appendicitis was based on post-operative pathologic study. parameters score symptoms migratory of pain 1 anorexia 1 nausea/vomiting 1 signs rlq pain 2 rebound tenderness 1 elevation temp 1 investigation leucocytosis 2 total score 9 table 1: modi�ed alvarado score forms results: we conducted our study on 89 adult patients with clinical features suggestive of acute appendicitis. among this 30 were female (33.7%) and 59 were male (66.3%). incidence of acute appendicitis was most frequent in 21-29 yrs. age group (39.3%) and least in age group 48-55 yrs.(1.1%). frequency of symptoms, signs and investigation findings in accordance with modified alvarado score are shown in table 2 and table 5. it showed most of the parameters are less commonly found in acute appendicitis patients. table 2: frequency distribution of patients according to symptoms/signs/investigation parameters frequency percentage migration of pain 67 75.3 anorexia 55 61.8 nausea/ vomiting 56 62.9 rlq pain 86 96.6 rebound tenderness 65 73 elevation temperature 52 58.4 leucocytosis 49 55.1 modified alvarado score of 89 patients who had acute abdominal pain suggestive of acute appendicitis are recorded in table3. 47 patients had score 7 and above, 42 patient had score less than 7. pathological stages in 89 patients who underwent appendectomy with confirmed appendicitis by histopathology are summarized in table 4. 95.5% of appendectomy patient had appendicitis, only 4.5% had negative appendectomy rate. table 3: frequency distribution of patients according to modified alvarado score score frequency percentage 1 0 0 2 1 1.1 3 6 6.7 4 13 14.6 5 11 12.4 6 11 12.4 7 19 21.3 8 13 14.6 9 15 16.9 total 89 100 table 4: pathological stage of acute appendicitis stage frequency percentage acute appendicitis 45 50.6 gangrenous appendiciti 9 10.1 recurrent appendicitis 31 34.8 normal 4 4.5 total 89 100 table 5: age incidence of acute appendicitis age frequency % 12-20 13 14.7 21-29 35 39.3 30-38 22 24.7 39-47 13 14.6 48-55 1 1.1 55-64 2 2.2 >65 3 3.4 total 89 100 discussion: accurate diagnosis is the key to decrease morbidity and mortality in any disease condition. various scoring system are developed to aid preoperative diagnosis of acute appendicitis. among these most famous ones are alvarado score and its modified form6,7 . modified alvarado score is based on patient history, physical examination and blood leucocyte counts (table1). previous studies showed 80percent of acute appendicitis cases may present with migratory pain. it may range from 61-92% for nausea/vomiting and 74-78% to loss of appetite. pyrexia found in 96% case10 . in our study these were 75.3%, 62.9%, 61.8% and 58.4% respectively. negative appendectomy ranges from 8-33percent in different studies 11-13. in our study 95.5% of patient had acute appendicitis 338 mondal hp, hadiuzzaman m, mukhopadhyay c, chattopadhyay s, biswas sk, bhoj ss according to histopathology reports. in our study 21.3% of patient have score 7 and 16.9% have score 9 only. 52.8% had score 7or above and 47.2% had score less than 7. modified alvarado score was neither sensitive nor specific in our study. there are studies who agree or disagree with modified alvarado score as its usefulness as a reliable prediction system for preoperative diagnosis of acute appendicitis14,6,11 . in our study many of the parameters are not commonly found, thereby lower scoring of modified alvarado score .lower scoring may be the result of inability of the patient to define the symptoms well for low socioeconomic status. traditional system of clinical diagnosis of acute appendicitis was highly sensitive (95.5%) in our study which was in concordance with previous studies where accuracy is between 76 and 92%15-17. conclusion: diagnosis of acute appendicitis depends on experience and clinical judgement. modified alvarado scoring system does not predict clearly which patient warrants surgical intervention and who may be safely observed or discharged. thus less helpful than clinic based surgeons’ decision to improve diagnostic accuracy and consequently reduce complication rate. references: 1.tzanakis ne, efstathiou sp, danulidis k, rallis ge, tsioulos di, chatzivasiliou a, peros g, nikiteas ni. a new approach to accurate diagnosis of acute appendicitis. world j surg. 2005 sep;29 (9):1151-1156. http://dx.doi.org/10.1007/s00268-005-7853-6 2. sitter h, hoffmann s, hassan i, zielke a. diagnostic score in appendicitis. validation of a diagnostic score(eskelinen score) in patients in whom acute appendicitis is suspected. langenbecks arch surg. 2004 jun;389 (3)213-218. 3. van den broek wt, bijnen bb, rijbroek b, gouma dj. scoring and diagnostic laparoscopy for suspected appendicitis. eur j surg. 2002;168 (6):349-354. http://dx.doi.org/10.1080/11024150260284860 4. nozoe t, matsumata t, sugimachi k. significance of sirs score in therapeutic strategy for acute appendicitis. hepatogastroenterology. 2002 mar-apr;49 (44):444-446. 5. zielke a, sitter h, rampp ta, schafer e, hasse c, lorenze w, rothmund m. [validation of a diagnostic scoring system(ohman score) in acute appendicitis]. chirurg. 1999 july;70 (7): 777-783. german. http://dx.doi.org/10.1007/s001040050721 6. kalan m, talbot d, cunliffe wj, rich aj, evaluation of the modified alvarado score in the diagnosis of acute appendicitis: a prospective study. ann r coll surg engl. 1994 nov;76 (6): 418-419. 7. alvarado a. a practical score for the early diagnosis of acute appendicitis. ann emerg med 1985;15:557-564. http://dx.doi.org/10.1016/s0196-0644(86)80993-3 8. chan my, teo bs, ng bl. the alvarado score and acute appendicitis. annals of the academy of medicine singapore 2001;30(5): 510-512. 9. ohman c, yang q, franke c. diagnostic scores for acute appendicitis. abdominal pain study group. the european journal of surgery 1995;161(4): 273-281. 10. craig s. appendicitis, acute. in:www.emedicine.com/ emerg2005 may 26: topic 41.htm. 11. al-hashemy am< seleem mi. appraisal of the modified alvarado score for acute appendicitis in adults. saudi med j. 2004 sep;25(9): 1229-1231. 12. denizbasi a, unluer ee, the role of the emergency medicine resident using the alvarado score in the diagnosis of acute appendicitis compared with the general surgery resident. eur j emerg med 2003 dec;10(4): 296-301. http://dx.doi.org/10.1097/00063110-200312000-00011 13. flum dr, koepsell t. the clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis. arch surg 2002 jul;137(7): 799-804. http://dx.doi.org/10.1001/archsurg.137.7.799 14. malik aa, wani n a. continuing diagnostic challenge of acute appendicitis: evaluation through modified alvarado score. aust n j g surg 1988 jul;68(7): 504-505. http://dx.doi.org/10.1111/j.1445-2197.1998.tb04811.x 15. anderson re, hugander a, ravn h,offenbartl k, ghazi sh, nystrom po, olaison g. repeated clinical and laboratory examinations in patients with an equivocal diagnosis of appecdicitis. world j surg. 2000 apr;24(4):479-485. http://dx.doi.org/10.1007/s002689910076 16. graffeo cs, countselman fl. appendicitis.emerg med clin north am. 1996 nov;14(4):653-671. http://dx.doi.org/10.1016/s0733-8627(05)70273-x 17. guss da, richards c. comparison of men and women presenting to an ed with acute appendicitis. am j emerg. 2000 july;18(4):372-375. http://dx.doi.org/10.1053/ajem.2000.7323 page mackup july-14.qxd bangladesh journal of medical science vol. 13 no. 04 october’14 401 original article untoward obstetric outcome among smokeless tobacco (st – mishri) users in western maharashtra pratinidhi a1, ganganahalli p2, kakade sv3 introduction: tobacco use is widely recognized as one of the leading threats to global health. historically, the prevalence of smoking among women in the developing world has been very low, in part because of strong cultural constraints against women's smoking1. the use of new tobacco products is increasing not only among men but also among children, teenagers,and women of reproductive age group, mishri is one among them2. mishri is prepared by roasting tobacco leaves, principal constituent alkaloid nicotine being 1 to 7%. various studies have estimated the prevalence of the use of mishri from 17% 45%3,4. smoking is an established cause of adverse pregnancy outcome. it is associated with higher rates of abortion, ectopic pregnancy, still birth, placenta previa, abruptio placentae, premature rupture of membranes, preterm birth, intrauterine growth retardation and sudden infant death syndrome3,5. low birth weight and preterm birth are powerful determinants of morbidity and mortality in newborn babies and infants. it has been known for last few decades that babies born to mothers who smoke weigh less than babies whose mothers don’t. there are indications that using smokeless tobacco could be as detrimental to fetal health as cigarette smoking6. objective to compare outcome of pregnancy among women using mishri and not using mishri during pregnancy at krishna hospital, karad material and methods: the study was conducted in krishna hospital for the period of six months (from 01st january to 30th june 2011). all pregnant women admitted to krishna hoscorresponds to: dr. praveen ganganahalli, assistant professor, dept. of community medicine, krishna institute of medical sciences, karad (satara) 415110, maharashtra, email: dr.pravin2000@gmail.com abstract: background: use of tobacco and new products is increasing not only among men but also among children, teenagers, women of reproductive age group. mishri (st) is one among them. smoking is an established cause of adverse pregnancy outcome. there are indications that using smokeless tobacco could be as detrimental to fetal health as cigarette smoking. objective: to compare the outcome of pregnancy among women who were using mishri during pregnancy and those not using it at krishna hospital, karad. materials and methods: pregnant women using mishri during pregnancy were selected for study from krishna hospital, karad and equal numbers of pregnant women not using tobacco were selected as comparison group after matching for age and parity. observations: the proportion of pregnant women using mishri during pregnancy was 12%. a significant number of users was found to be anemic (69.8%). significantly higher number of mishri users experienced complications like oligohydramnios, fetal distress, delivery before edd (91.9%) and birth of low birth weight babies (81.7%) with short stature and increased ponderal index. conclusion: special attention should be given to avoid or at least reduce the use of mishri during pregnancy as a part of routine antenatal care to reduce the adverse perinatal outcome. keywords: smokeless tobacco (st); mishri; pregnant women; anaemia; low birth weight; length at birth; ponderal index 1. dr. asha pratinidhi, director of research, krishna institute of medical sciences university, karad 2. dr. praveen ganganahalli, assistant professor, dept. of community medicine, krishna institute of medical sciences, karad. 3. dr. satish.v kakade , statistician/associate professor, dept. of community medicine, krishna institute of medical sciences, karad. doi: http://dx.doi.org/10.3329/bjms.v13i4.15215 bangladesh journal of medical science vol. 13 no. 04 october '14. page: 401-405 pital for delivery and using mishri (st) during pregnancy were enrolled as study subjects and those pregnant women who were not using any form tobacco as control subjects after matching for age and parity. data collection was done by using a structured and pretested proforma on the day of delivery, which included personal profile, sociodemographic profile, obstetrics profile, details of delivery and its outcome and anthropometry of newborn babies. statistical analysis was done for significance and association. informed verbal consent from the pregnant women and clearance from institutional ethical committee and hospital administration was obtained prior to the study. results: a total of 12% (258) of hospital deliveries were found using mishri (st) during pregnancy in six months of study period. equal numbers of control subjects were selected after matching for age and parity. among all the users 29% were teenagers, 68% were primis, 78% were housewives, and 77% belonged to class iii according to modified b.g prasad classification. there was no significant difference between users and nonusers of mishri (st) regarding these variables. significant numbers of mishri (st) users were found anemic at the time of delivery compared to nonusers of mishri (st). mean hemoglobin (g%) was found significantly less (t=-15.24, p=0.000) among users (10.4±0.90) compared to nonusers of mishri (st) (11.6±1.05). the complications like oligohydramnios and fetal distress was found to be significantly more among users of msihri although pregnancy induced hypertension (pih), past history of spontaneous abortion was found more among users as compared to nonusers did not reach the level of statistical significance (table i). s i g n i f i c a n t number of users of mishri (91.9%) delivered before the expected date of delivery compared to nonusers of m i s h r i (74.4%). mean number of days before edd among users was found to be 5 which was s i g n i f i c a n t l y less compared to nonusers ( 2 . 2 d a y s ) ( t = 8 . 6 4 , p=0.000). there was no significant difference in relation to type of delivery, outcome of pregnancy and gender of the baby. the apparently higher rate of still births untoward obstetric outcome among smokeless tobacco users 402 variables mishri (st) users (n=258 ) non mishri (st) users (n=258) total (n=516) χ 2 value p value number (%) number (%) number (%) anaemia present absent 180(69.8) 78 (30.2) 42(16.3) 216 (83.7) 219 (42.4) 297 (57.6) 144.58 0.000 oligohydramnios present absent 17(6.6) 241 (93.4) 07(2.7) 251 (97.3) 24 (4.6) 492 (95.4) 4.37 0.037 fetal distress present absent 29(11.2) 229(88.8) 14(5.4) 244(94.6) 43 (8.4) 473 (91.6) 5.70 0.017 pregnancy induced hypertension present absent 22(8.5) 236 (91.5) 15(5.8) 243 (94.2) 37 (7) 479 (93) 1.42 0.232 past history of spontaneous abortion present absent 11 (4.3) 247 (95.7) 07 (2.7) 251 (96.5) 18 (3.5) 498 (96.5) 0.92 0.337 table i: comparison of complications associated with pregnancy. among users as compared to nonusers of mishri was not found statistically significant (table ii). significant number of mishri users (81.7%) delivered babies with birth weight less then 2.5kg compared to nonusers ( 6 . 2 % ) ( ? 2 = 2 9 9 . 7 , p<0.000). mean birth weight (kg) of babies born to mishri users was about 600gm lesser than babies born to nonusers of mishri. a significant number of babies born to mishri users (82.9%) were found to shorter than babies born to nonusers of mishri (1.9%) ( ? 2 = 3 4 6 . 5 , p < 0 . 0 0 0 ) . t h e ponderal index of newborn babies was calculated by the formula pi=birth weight (gm) x 100 / (length at birth in cm)3 & found that ponderal index of babies born to the mothers using mishri was significantly higher than the babies born to the nonusers.(x2=12.03,p<0.000). discussion: the study revealed that 12% of pregnant women have been using mishri during pregnancy among all hospital deliveries, which is lower as compared to that observed by gupta p.c6 (17%) and pardeshi et al7 (51%), however, global adult tobacco survey report india 2009-108 has shown the prevalence of mishri use among women in maharashtra to be 8%. pardeshi et al7 have also found that 27.3% teenage pregnant women, pratinidhi a, ganganahalli p, kakade sv 403 variables mishri (st) users (n=258) non mishri (st) users (n=258) total (n=516) χ 2 value p value number (%) number (%) number (%) delivery before due date on due date (edd) after due date 237 (91.9) 15 (5.8) 06 (2.3) 192 (74.4) 50 (19.4) 16 (6.2) 429 (83.1) 65 (12.5) 22 (4.4) 7.674 0.006 type of delivery vaginal operative 209(81) 49 (19) 204(79.1) 54 (20.9) 413 (80) 103 (20) .303 0.582 outcome live birth stillbirth 253(98.1) 05 (1.9) 256(99.2) 02(0.8) 509 (98.6) 07 (1.4) .579 0.447 gender of baby male female 112(43.4) 146 (56.6) 134(51.9) 124 (48.1) 246 (47.6) 270 (52.4) 3.76 0.052 table ii: comparison of obstetric outcome among users & nonusers of mishri (st) variables mishri (st) users (n=258) non mishri (st) users (n=258) t value p value mean ± s.d mean ± s.d birth weight (kg) 2.2 ± 0.24 2.8 ± 0.27 -25.33 0.001 length of baby (cm) 43 ± 5.4 52 ± 1.8 -24.14 0.001 ponderal index 2.857 ± 1.207 1.948 ± 0.216 12.03 0.0001 table iii: anthropometric profile of babies born to subjects. 48% illiterate, 90.9% housewives, 35% pregnant women from lower class have been using mishri during pregnancy, which is similar to our observations. gupta p.c6 have found anaemia among 68.6% of pregnant women using smokeless tobacco compared to nonusers (16.3%) & pardeshi et al7 have found it to be 44.2% vs. 37%, which is comparable to our finding. mean hemoglobin (g%) was found to be 10 by subramanhya s9 among smokeless tobacco users which is almost similar to that of present study10.4 (g%). this is substantiated by the findings of subramanhya s10 who have reported that anaemia was significantly associated with smokeless tobacco (or=1.7; 95% ci=1.2-2.5). pratinidhi et al3 in their previous study have demonstrated that fetal distress and pregnancy induced hypertension is significantly associated with mishri use. the present study revealed similar trend. gupta p.c6 have previously observed that delivery took place 6.2 (days, mean) before the edd among the st users which was reported to be 5.6 (days) by pardeshi et al7 and in the present study it is 5 (days). this suggests st use might be linked to relatively early delivery by nearly one week than the edd. pratinidhi et al3 also have found the relative risk of preterm delivery among smokeless tobacco users to be 2.8 times higher than nonusers which has been 1.4 in the study by gupta et al6. pratinidhi et al3 have demonstrated 19.3% lbw babies among mishri (st) users compared to 9% among nonusers where as proportion has beeen found to be 28.6% and 19.9% respectively by gupta p.c6. however in the present study proportion of lbw babies has been found to be exceptionally high i.e.,81.7% among the babies of st users as compared to 6.2% among nonusers. babies born to st users has been found to be 400 (g) lighter by pratinidhi et al3 and pardeshi et al7 and 189 (g) by gupta p.c6. in the present study st user mother has delivered babies 600 (g) lighter that the babies of nonuser mothers. no studies have so far found to compare the length of babies at birth among mishri (st) users compared to nonusers of mishri (st). there have been studies11-14 stating higher and lower ponderal index among newborns of smokers as compared to newborns of nonsmokers respectively. this is due to differential reduction in weight and length of the foetuses due to nicotine effect of the smoking by the mothers. in the present study the ponderal index is significantly higher among the newborns of mothers using mishri (st) as compared to the newborns of the non users of mishri (st) indicating more nicotine effect on length as compared to the weight of the baby. hoque et al5 in their study, conducted in bangladesh, have found the rate of still birth of about two times higher among smokeless tobacco users as compared to nonusers (p<0.001). they have also found that frequency of preterm deliveries, lbw, spontaneous abortions are significantly more among smokeless tobacco users as compared to non users. in the present study we have found a significantly high proportion of preterm and lbw babies born to st users as compared to the non st users. conclusion: use of mishri is increasing among women who are pregnant and is not only known to affect general health but also pregnancy and its outcome. so special attention need be given to avoid or at least reduce the use of mishri during pregnancy as a part of routine antenatal care. untoward obstetric outcome among smokeless tobacco users 404 references: 1. michele blocg et al. tobacco use & secondhand smoke exposure during pregnancy: an investigative survey of women in 9 developing nations. am j pub health 2 0 0 8 ; 9 8 : 1 8 3 3 1 8 3 8 . http://dx.doi.org/10.2105/ajph.2007.117887 2. gupta p.c, ray c.s. smokeless tobacco in india and southeast asia. respirology 2003;8: 419-31. http://dx.doi.org/10.1046/j.1440-1843.2003.00507.x 3. pratinidhi a, gandham s, shrotri a, patil a, pardeshi s. use of 'mishri (st)' a smokeless form of tobacco during pregnancy and its perinatal outcome. indian j com med 2010;35:14-18. http://dx.doi.org/10.4103/0970-0218.62547 4. gupta p.c, subramoney s. smokeless tobacco use and risk of still birth: a cohort study in mumbai, india. epidemiology 2006;17:47-51. http://dx.doi.org/10.1097/01.ede.0000190545.19168.c 4 5. hoque m, rahaman e, dey p.r. pregnancy outcome of mothers who used smokeless tobacco for five years or more. bang j child health 2011;35:6-10. 6. gupta p.c, sreevidya s. smokeless tobacco use, birth weight and gestational age: population based prospective study of 1217 women in mumbai, india. bmj 2 0 0 4 ; 3 2 8 : 1 5 3 8 . http://dx.doi.org/10.1136/bmj.38113.687882.eb 7. pardeshi s, pratinidhi a.k, gupte a. use of 'mishri (st)' – a smokeless form of tobacco during pregnancy and its effect on the outcome of pregnancy. res j krishna institute, karad 2008;1:8-14. 8. global adult tobacco survey india report 2009-2010. ministry of health and family welfare, government of india, new delhi. 9. subramoney s, gupta p.c. anaemia in pregnant women who use smokeless tobacco. nicotine and tobacco research 2008;10(5):917-920. http://dx.doi.org/10.1080/14622200802027206 10. subramoney s, gupta p.c. correspondence: anaemia in pregnancy. india j med res 2008;128:780-781. 11. marzenna króll, ewa florek, wojciech piekoszewski, renata bokiniec and maria k. kornacka the influence of prenatal exposure to tobacco smoke on neonatal body proportions j women's health care 2012;1:4 http://dx.doi.org/10.4172/2167-0420.1000117 12. lindley aa, becker s, gray rh, herman aa .effect of continuing or stopping smoking during pregnancy on infant birth weight, crown-heel length, head circumference, ponderal index, and brain:body weight ratio. am j epidemiol 2000;152:219 225. http://dx.doi.org/10.1093/aje/152.3.219 13. samper mp, jiménez-muro a, nerín i, marqueta a, ventura p, et al. maternal active smoking and newborn body composition. early hum dev2012;88:141-145. http://dx.doi.org/10.1016/j.earlhumdev.2011.07.015 14. pichini s, garcia-algar o, mu-oz l, vall o, pacifici r, et al. assessment of chronic exposure to cigarette smoke and its change during pregnancy by segmental analysis of maternal hair nicotine. j expo anal environ epidemiol 2003;13:144-151. http://dx.doi.org/10.1038/sj.jea.7500264 pratinidhi a, ganganahalli p, kakade sv 405 l climcal patiern of ne1onatal m'rectio]iss .julv t99l"june 19931 m, n, istamr , abdul hm2, s. zemd ho$dns. md. habibu ranl'h4, s, a. n€onatal i.fecdon is d t4ortdt cause ol mo.btdtty and monality mone hlaits. clhical pattm of n€mtal infection ln the neonarar rnit of institute of post craduate merlcine & res€rch upgm&r). dhal<a n6 been .eport€d: out or tot l 2160 nconatal admrsston from july 1991 to june 1993. 320 (1a€%l ca$s of nonatal inf*uons wre tound. sepscamta wa9 lh€ connon€st tyre fou'rd h rra (5.5%) cases. other rnfecuons hcluded unb:lrcal s.ps,s 14.7%) skb rnfecdons u.6%), mdrneujs (1.2%1, t€tanus neomtrun ftre not includ€d, out of 32o .ases, 20 pati€nt dtcd (6.2%). preletu, b{ bln]: {eieht dd birth aspbt da sg€ the connm nsk factof. iatndrcilod i.jecdons ae a nequmt dd lnportant gue of monitdlty dd no.tallb, ln the nmnabl p€nod. ,c. m y as 2% of betu*s ae tfected tn utei! dd upto l0% rrfmb m bf{red dutne delvery or th. fi$i bonth of mel. inlection €n b€ of s! e?es. eary on6et jnlecdon *lrh pdlet€r paihogen€sb ,hose usual on$t is v,ltlrh 72 hour, wher6 late neonatal hfeddon is applred to rrf€cuons thosc occu aite. one sek. neomtal rnl€ctlons vary ftoh the tnrral (minor) whi.h does not 6dan8€r lrf€ to pnfoudry damagr8 (majorl2,3. they -"y b. s'b.tnical br may k l the n bom. among lhe najor tnf€cuons, sep0.aenta, pneufonia, dtanhoea, !tuary b?ct hf.ctton luflj, n€.t€tils *e connon. wh@s oinor hfecdons, cg omphalrtrs. conjdctmt s are comoon prcblems. nemtal septicaenla ls a clftar *ndrome chdacterlz.d by sigc of bfectton md deloelt€d by a pgttiv€ blood cultur€ ]n the ltrst four veeks of lif€. the if'dm,e oi neotubl .epd.c.da lu" bftn "stimried b ange lrom i ro lo pfr iooo lve births.4 5 e ly onset sepsf rs mdrc indindt, combonly dragnged dtl n the ngt 4a hous dd almost always drine th€ lirst week oi nfe. late onet spsrs rs mo.e hsidio6. d€spite the drelopm€nt of broad spectnm and mlcrcblal agents and lmproved obstetic ud paedjatic ce. s€pflcaeota sdrl @ntlbulcs geuy to neomtzl norbiditr md nortaliv paiticlndy lrl dsetoprng !ourde<.6 lr bancladesh. rh.'5 -o dennre s'udy on re u udence, euotos,,risk rddob and pmgnoes or neo!"rct seprcreaa bur .r js lrety to b" tueh-jn banstad€sh xke oth d€v€toptng comtries.t rjsk raciors lor a*bpn;! of nconar6r sepsts e lov btrlh werghi, apg score tcss tno 7 at sq. cohpxcauon of labour e.e. p.otoneed labour. .arly ruptu.e of mdb.alq nalp'*entcrlon !ompkarod or deljvfr rkc scpn. deln-ry rnshmenfl d.llwru end pnmsry @e.mr sruon dd poor sorto-fonon ctuup b slr€pto4oc@s & escneichia con ae rh. tcadbe €u*s of $p6ts. oth6 pathog€ns like siaphylococcus aureus, kjebsielta, ente.obacrd. croud d s(cproi o.fl and prcuoomonas df'oenocc nerl4,lde ard ha.mopbius mnuel%ar rrety .n.ounte dso common.rr mcuulbs f one or dr rpol@tbmr or url..uons. i bdy be $nl dd b3ct hr. tr f on6 6a$dared q4'h.eps,s rd ts d cau{ ors€ dmr morbdr.y 4 d don-iry l6.r/. 3 u'rl f nrybom 5 drm.,nt ro 4bbt,b beca6e, as mny as 40% of the hfections € asyrptobauc.rg dimhoa t, one of rhe inpondl componenr of nalo. hr€ctjons dd js a leadinf cause of mness dd death aaong chjrdr€n of the ds€rophg countnes.2o anone thc nntr. ht€cuob n.2r.22 h€ pfstr, judy ms he dr-l.l pa,rer, e,.otosrrt sg.-f. mat.dars ud m.tto& nr.s drrdv bci don" unr o lhe depsnden, oi paedfhc.. ceduar" v.dl.lne d re*arh rrpcv&r'. dhsr.a ovc' a pertod of 2 y€ars fton july t99r ro june lss3, l.hfte hurdrcd t{eb? n€onares ulth dlre.€nr glp* of infedon were duded. torch injecuo b ud nrcnatal ret"nu. wec ex, tuded rom fijs s,ld) br.au* tbese m*: ".fa&nrtted r4 a sep ate hrecrous disease hosptrat. a detdled pftmbr, naral md post natar hrsbry frtn spe.ral emphasis o. any pr€disposhg faclors fo. inf€ction ms ralen bd tnorough cthrcal eajfuaum rrc done h si $e cses and w€re 'flord-d. panen' 3 prlrutrs uke, 'fdnpss 6rund rhe unb.l,,us, unb.lical drschdge, fev€r, hy?oih€da, drarhoea, esplatory dlsrres dd feedt g brstorv ve.e noted, ha€noelobh. iotal hd diffcrenual count of wb vtre done in ai padents. smbs nm dre umbilcus & *pdc spors @re sent for grm stardng 3id c/s. cdrlres of urhe. sr.ot & btood wrc crded out ,n all c6es, radiogephs of rh€ chest and csf *mimtion m.€ canted out vh€lffi of th€ total 2160 neonatal adnrsstons, 320 o4.a) had diflerenr tytes of i.f€cuons, there were 2i2 (66.2%l male and roa (33.a%) femat€ babies. ase drstrlbuuon is snom in tabk r. mem age @s 9.5 days. tabl€ll shows tne of rnf€crtons. septtcaemra r13 (36.37%), pn€umonis 70 (21.37%) dd mtfuetds 20 (6.25%) wre rh€ major inl€cuons whle omphaxds ror (3r-56%) md penpr gus 2a 1a.75%) '€re the mtnor tntec$otu in the i sludied populatron. table-in shns ihe age ol onset of hfecrjons. most pauerrs frth major or ninor tnfecrons presented after 4a hi, table-iv shovs tlc risk lacrors ol rnrcctto!. pretem low bftn weght 223 (7t%) prolonged rupture of ncnbde roa (33.7%l blrl! asphyda !t6 (r4.3%) nom€ delivft by unb,rned p4ons 52 (16.2%) dd u6e ol undte.n€ blade ro cut rhe cod 36 (a%) cses rerc the rrsk facrois in tre 51udy eroxp. fev€r 160 (5o%), rr5 t35.92%t, reluciant ro feeds r12 (35%). atldomrnat distensron 1o2 {31.a%). vom'thg 9a {30.6%1. apno,c spens 23 (3,796). jaundte 36 01.2%1, ror sn lxrg umbrlrcal drschalge 30 {25%), hypothemia rr €.4%), penphigus 2a {4.7%) dd convulslons were the cltntcal presentation. of course rhey had ovedaptng or clhlcal presentatlons oable \4 tabl€-\4 shms the orgdisms tsolat€d lron sanples ofblood, urtn€, siool and +nbili.ar swab. blood cullure done inla4 pa!€nb shomd po @ses of vhtch 35 shomd e. coli and 6 pad€nts showed staph aureus, urrne cuhure done i. 1a4 cas€s felded rhe gmv,rh of e. col, tn r5 patlelts. st ot ses. umbmcar sub clltle showed rhe browtn ol sbph au. s rn 75 c6es rd e. @li in a gses. unt rron 20,ooo,30.ooo/cn3 h r20 (37.5%l dd f.om ro,ooo ro 2o.ooo/.n3 h l4o (43.7%) cases. padents had hazy csf drh plenry of n€urophils. cram statnhg shned the presenc€ ol 6 ad a cases ol cram posttiv€ dd c.ad neeative backna especuvely. h@de. cultm dld.oi show eros-ft of my bactdia, med €rue of proid & sug{ h csf w€re 15? & 22ngldl gspectivety. table-da sbows the x-ey lindirgs of the studterl populatton. 30 142.a%j cases ih€ lung fi.lds. out of 32o c6es of n€onstal infe.rion 20 (6.2%) parients died in hfectom of the neonates d special care baby urits. tlns study shmd ihe !}atr€m ad prcdspodng fftbrs of rdnatal jnfectjoe h a tediary cmft frtn onc or the brg bdgladesh. out of 32o 'eonates. r34 had major hrectrons and the renahtne had mhor hfecrioe. nosdy onphalrds. s.pflcacmla alonc or ln assrarion mth pneunonre, men,ngds dranhca and nrl wre tnc major lnfc sepd.aemta vere pncumonra rn (21.3?%1, nenrngu's rr {6.25%1, drarhoea h l2.rs%l w\ 11.27%\ cases (tabb d malodry or these padots wee .erered rmm ditr€renr chtcs, home and oth.r hosptl:rs. vdous rnappropdat. or !o teatnent eic. .ould be the contdbltory factoe for the hlahd lfttdence of lnfccdon. the.€ @s a prepdderenc of hoys over efls tn an ttes of lrtfecuon. the male to renale raiio ms 2:t. the prepondcrence or n3le s* is posturabd to be rink€d to tte x'lrnked factor23. it nuht be d!€ to g.eaie. cd€ gva to the nbre chrd h our seler set ud4. h thts strdy. msi padenb were low btrth vetght (43.75%). nunerous studres havc found lbw io be predspodiig factor for neomtar infecdon. rd btrth rcigtt qd pretem babr€s ha\e ld i3.c as mrl .s rmpafed leuu5r lmdututo nrr "k tor noe.omra.rtuedon ls &edgr rn holprtat. t ,s e\rabltsb.d rlet rmbrlldl b.unp,s eoodmedra fd_llrnnant gro*rh or det' or orsernsns2s. bur rn tbrs $;y ft vs ob$rcd that most of ihe patienb nad rhetr unb1ncal cord cur 6epucany. rr"uscledon w needrd m l4.j?l6 caces lr rhe mslor crup ot.d{uons most otthe ndndres prsen'ed u,trh pvr{a ol\e, fertue. btrc r.spraery. sr>s, r.luctant to f€ed, abdontnat dist€nslon. mnr!.g, apnoic spens, radndi.e etc. pytua b on€ o, r,\r npolbr gs rur.s of s"pui d.nla26. pneumoda un2? rd menrnsrrs.6 ffvs ltempe'arure 5bo!e 3a.ct hcd b"en re, orded h 50% o deonates dih tnfectron h tlds se.res. resplrarory distress was pr€sent rn 35,32% ca*s vbich ts sitund b the nndjngs of ofte. abdonhal dlstmsron ftr neonat€s !n 11$ srudy qs 3r,a7% vhlch b hrghd tltu among ti€ bino. rnfe.flons. omphatitis vas the,cobdon€sr. mosi of thed {e-4%r had fo'i selllnc purulent dlschfse md penudo cdl rednes dlgiosb or neonatal .nleilon ts one or lhe mod di,{dent authoe hav€ sugg*red swerat tabo.atory d€rmiquts33. p.e*nce of neutrophrl precursors rs bore sugg€s|ve of rrrecuon th t}le totar drfierenrbl .ount, other aurhors demonstrated ihar a. low (<rsooo/cn3) or htarr (>20,000/chs) wbc count '€re assodated dth neomiar inr*don3a. h.u;s serrs lmst wbc cou es aooo/chs. hom a cdut over 2o,ooo/.ns ms lound .n 37.5q !a"cs thus n this qed hqh wbc was . i qehjt ,ndt.a,o, of mreton. c'itur€ o, r ebjrcal seb3 k'c done rn alt !6e or study predotuar orgdism wrc gla poiuv€ cd sraphyt rouno i ss l5dn.*fs ard e {h d 5.s3\ fte ttndfes conrasl! @ rhf fdf, ondhc" wherc e.,ot wde fornd m 5560n dd ,lph aur.ub.n 20% on lh. orbc-hand htu rd ste, h lhe ffndneor anm.o haqu. d atrd. tr u-ts en6 no group b str.ptocdci w tsolat€d. the edorosr of n€onatrl *d.a€da en€s troh dunl-y to cmrr sd fon o'e hosplbr to the;th€r, th€ djtfe.snce ls du€ to preerlhg obstetnc sd nleery fac[rues and paneh of usag€ ot dur crcb'al agmrs. blood.dru.€ done in rs4 es6 sealed posur.t€ curiu; h 4r {22.24%) €s€s. srrha er ar reporred tu isoladon nt€ of 2a.oa%, khatua €t sr found a much hlghd rare of tsolation {60%). trls hteh rate ot tuoladon could probably be due to the usc ot more senstdve m€dla. ches! xray shomng unilateral and bllateer patchy opacides tn vdous zones of lungs vere rh; radrologtcal cllddce of pr€senc€ 9t pneumonta. mo6t paucdts had rmerved ttbrouc pdor to adnlsston. more of o.ganisms coutd be erp€.ted rf prior ddbtoflcs were not eiven. 20 {6.25%) parients sfth neonatal errght dd mre hosp[abed h a ddcat sta!. of lnes6. stlll rcmahs a pmlona€d ruptur€ of n€hbrane, dr€aded dt*ase;.pr€tem low ttrth welght, bith asphyia. hon€ deuvcry erc. were the rmpoltarr rhk faciors lor inf€.tion. sepuca.mia, pneumonia, merl]ngltl3, db.rho€a, ut! vere the najor infccirons prcscnlcd clth.r 3hgly or nt combhaen. omphalids tu the comon€sr mhor mdit€sta{d. alrhough 1b13 !s a hosptar based dudy h a rcferel hospttal, rt has neen anb b lndout tlc cnnhal patbm ol neombl bfection. mo.e q1ensrre studres lnelvlng la8er smpl. ol n6mtb dih good tulftbrological support ls d4'lable to study the c[nrcal patt€m ol n@nalar bfetbc t! rh€ cdnr4. ase dd sd distnbudds (n = 320.1 r4 1\,25 slectrum of inf€ctlon (n=320) !&l!il!&c!!e: th.rc wer€ dslapb€ of mlor bfes@s h sod€ larl€ntg age at oet of bfecu@s 55 rrsk factos for infe.tions r. prctem low ltrth wt. 2. proloneed ruptue otm€nbtue 4. hom€ dellvsy untrah.d pemn 5, use ofueie.dc blad. for dttxrt cdd. th€rc we morc thd tu dsk fa.for tn nmy subjdts. foul strelxng ffiblllcal rl&harge 11 ?5major in=1a4) \rnor n=r361 136 i5 h&matolobcal data h lnfeuon ha@tolodicar data i@e csf study h medngrs tn=2o) wbc (ndfophlrs) nmv qeq\nil![q (6rm st in) culture gogeeu!@ fadtlodcal findliss ln pn{bar a ln-7o) btlatefar pabhy opacrty,n lung n€lds opactry rn th€ rr uooer md ddzonb opactty h the f{i uppcmn€ of the lunas r. bch re, vaughd vc, $ptrd.fb'.jpedbbl97o:?6|142.4s. 4 s.gd ,jd. mc cral<e gh. *p3ie n omtmm, n eng j md re -,i5€hcnr or s*r. nemdral s.pl.mf qtn s,irra. enencyqbaurtsplbj'ty hrebor. ^ erc. j;.d rs'6i2e4. 7s3 75b $fd erd hr. chaiees h lne da,* "i "*j *pu...* *ar4b4rc. h. j. d* ch d 1966r 12: 33-3s. ..pdctu b d:e nmar an. j, d 13. bha!6 on, aemar kc, nad]{ ^, bba&chdq ha,6b dd @bst or nmabl seplcedaadd!@ rrrb im j d.b ch d edrbe. hre.lotu rt .,* ol r.63 & nsbon 2nd ed. pbrladelphb w.b. $nnd$s 17. behmm s. vauehm vc. m@hsrft. rn ndts3 aq$ook o $. wtnb.rg !t. eprd.doro6/ oi idue scod r9?4: '5' tsuppl). dn oflig a'h dg tsston of rolaitus 2, ctsbhe a, h. frphaltb a 23, scbr.ed l belr&de ra rncesd su*adbtlity ol narc to i dry nosdrrdl o,is*lod dhjb..die. or 4jttutued sugfom_reerl 25. tubnd jp, ceu cd. vogc cltuburg cds. m.rar, unn ry tact ht*hdn b y@ng hrdb 2j' b.hlru re. vaulhs vc r4h.dph'hd.rphh'v9'sau&e sh ts.p'tc ll6rt sbtron of congdbl pdoad b,bly'.qddtb'ccdosin-d rnr;r mdby cd'pmy le33: 650'6$. 32. bar.i'l tutdw ct l cndcal tutthdt or rcb k n pd dangladdb cdn.s. olphry€l.g3isu4mu' blrdtn.hamtologi.alva]ue; 34. nrrb ags. h.dt jr. edy dhencrs of ndmtal asis fh.d i rmabr s.pt6hb {dreton) nbm'hld rdpsrdal .u'nh. oi rcds b n pfrhd.s, rsr, b.f, lb ebdsh coll.8. dav{dm page mackup-final.qxd original article prevalence of ciprofloxacin resistance among gram-negative bacilli at a specialist hospital in saudi arabia ahmad s abstract: background: resistance to antimicrobials of different structural classes including fluoroquinolones has arisen in a multitude of bacterial species both in the community and the hospitals. this may complicate the therapeutic management of infections. decreased susceptibility to fluoroquinolones arises mainly by singlestep mutations in the gyra and parc genes, which encode the fluoroquinolones targets, the topoisomerase enzymes, conferring cross resistance to all fluoroquinolones. accumulation of multiple mutations in several genes confers increasing level of resistance associated with clinical failure. however, even low level resistance can generate therapeutic failure. in 1998, some mobile elements with a potential for the horizontal transfer of the quinolone resistance genes were described. the loci which are responsible for this plasmid-mediated quinolone resistance, which have been designated as qnra, qnrb and qnrs, have been identified in the enterobacteriaceae species. aim: to evaluate the susceptibility pattern of the isolates to various antibiotics and to know the prevalence rate of ciprofloxacin resistance in our hospital. materials & methods: a total of 916 gram-negative bacilli (gnb) were isolated from different clinical specimens over a period of nine months, were subjected to antibiotic susceptibility testing. isolates with resistance or with a decreased susceptibility to ciprofloxacin (£20 mm) were then screened for their minimum inhibitory concentration (mic) by using the e-test. results: out of 916 gnb, 321 (35%) isolates were resistant to ciprofloxacin. the mic of these isolates ranged from 4 to >32?g/ml. conclusion: the resistance rate to ciprofloxacin was 35% in our study. most of the ciprofloxacin resistant isolates were from urinary tract infections (uti). the ciprofloxacin resistance was also closely associated with multi-drug resistance, thus limiting the treatment options. ciprofloxacin resistance can be used as a general surrogate marker of multidrug resistance, thus limiting the already restricted treatment options. the considerably high mic values for ciprofloxacin in this study reflected the extent of the treatment problems for these resistant isolates and a need for the continuous evaluation of the commonly used antibiotics. key words: gram-negative bacilli, fluoroquinolones, ciprofloxacin, mic introduction: fluoroquinolone antimicrobial drugs were a major therapeutic advance of the 1980s because they have 100-fold greater activity than their parent compound, nalidixic acid 1. unlike nalidixic acid, which is used only for urinary infections and occasionally shigellosis, the fluoroquinolones have a broad range of therapeutic indications and are given as prophylaxis, e.g., for in veterinary medicine fluoroquinolones are used as treatment and metaphylaxis but not as growth promoters. early researchers thought that fluoroquinolone resistance was unlikely to evolve, largely because resistant escherichia coli mutants are exceptionally difficult to select in vitro 2 and because plasmid-mediated quinolone resistance remained unknown even after 30 years of nalidixic acid usage. nevertheless, mutational fluoroquinolone resistance emerged readily in staphylococci and pseudomonads, which are inherently less susceptible than e. coli. more recently, fluoroquinolone resistance has emerged in e. coli and other enterobacteriaceae, contingent on multiple mutations that diminish the affinity of its topoisomerase ii and iv targets in varying ways reduce permeability, and up regulate efflux 3 . plasmid-mediated quinolone resistance has been reported, but it is exceptional 4 . ciprofloxacin is a broad-spectrum antibiotic which is active against both gram-positive and gram-negative bacteria, which belongs to the fluoroquinolone class 5. bacterial resistance is a growing therapeutic problem, both in the community and the hospitals, involving all the antibiotics, which include fluoroquinolones. a decreased susceptibility to fluorocorresponds to: dr.shamweel ahmad, associate professor of medical microbiology and consultant microbiologist, department of medical laboratory sciences, college of medical sciences, salman bin abdul aziz university, kingdom of saudi arabia. e-mail: dshamweel@ksu.edu.sa bangladesh journal of medical science vol. 11 no. 04 oct’12 317 quinolones arises mainly due to single-step mutations in the gyra and the parc genes, which encode the fluoroquinolones targets, the topoisomerase enzymes 6 . in 1998, some mobile elements which were responsible for the horizontal transfer of the quinolone resistance genes were described 7,8 . this study was undertaken to evaluate the susceptibility of gnb to various antibiotics and to know the prevalence rate of ciprofloxacin resistance in our hospital. materials and methods: a total of 916 gram-negative bacilli were isolated from different clinical specimens i.e., urine, pus, sputum, blood etc, received in the microbiology laboratory over a period of nine months were subjected to the study. specimens were processed using different media like macconkey’s agar, cystein lactose electrolyte deficient (cled) agar, sheep blood agar and chocolate agar. all isolates were identified using standard biochemical tests 9 . in addition commercially available biochemical kits, api 20e (analytic profile index system, la balme les grottes, france) were also used for the identification of enteric pathogens. antibiotic sensitivity testing was performed using the disc diffusion method on 85 mm mueller-hinton agar (oxoid) plates with agar depth of 4 mm. the bacterial suspension that was prepared for antibiotic sensitivity testing on mueller-hinton agar was adjusted to the recommended turbidities for all species 10 . the antibiotics tested on each disc were ampicillin 25 µg, amoxicillin-clavulanic acid (20/10 µg), trimethoprim-sulphamethoxazole (1.25/23.75 µg), cephalothin 30 µg, cefuroxime 30 µg, cefotaxime 30 µg, ciprofloxacin 5 ?g, norfloxacin 30 µg (for urinary isolates), nalidixic acid 30 µg (for urinary isolates), nitrofurantoin 300 µg (for urinary isolates), gentamicin 10 µg, amikacin 30 µg and imipenem 30 µg. the clinical laboratory standards institute (clsi) break points were used for interpretation of susceptibility patterns as sensitive or resistant 11 . isolates with resistance or with decreased susceptibility to ciprofloxacin (?20mm) were subjected to further study. this study design and protocol was approved by ‘research and ethics committee’ of the institute. e-test the resistance to ciprofloxacin was confirmed by breakpoint minimum inhibitory concentration (mic in ?g/ml) by using e-test strips. the isolates with mic value ?4 ?g/ml were defined as resistant isolates, as outlined by clsi guidelines 11 . results:escherichia coli (29.4%) was the most predominant isolate which was found among the gnb, followed by klebsiella pneumoniae (26.2%) pseudomonas aeruginosa (25.0%) and proteus species (12.9%) as shown in table i. table i: total number of gram-negative bacilli isolated from different clinical specimens (n=916) out of 916 gram-negative bacilli, 321 (35%) isolates were resistant to ciprofloxacin. high rates of resistance were observed for ampicillin and amoxicillinclavulanic acid, followed by cephalothin, trimethoprim-sulphamethoxazole, and cefotaxime, while low levels of resistance were observed for nitrofurantoin, nalidixic acid, amikacin and norfloxacin, as shown in table ii. table ii: antibiotic susceptibility pattern of the isolates to various antibiotics (n=916) prevalence of ciprofloxacin resistance among gram-negative bacilli 318 percentage (%) total number isolated organism s. no. 29.4% 269 escherichia coli 1. 26.2% 240 klebsiella pneumoniae 2. 25.0 229 pseudomonas aeruginosa 3. 12.9% 118 proteus species 4. 5.3% 49 acinetobacter species 5. 1.2% 11 citrobacter species 6. 100.0% total total no of resistant isolates (%) total no of sensitive isolates (%) antibiotics s. no. 724 (79%) 192 (21%) ampicillin 1. 687 (75%) 229 (25%) amoxicillinclavulanic acid 2. 549 (60%) 367 (40%) trimethoprimsulphamethoxazole 3. 559 (61%) 357 (39%) cephalothin 4. 237 (26%) 679 (74%) cefuroxime 5. 541 (59%) 375 (41%) cefotaxime 6. the lowest level of resistance was observed for imipenem (4%). the resistance rate for ciprofloxacin was 35%. the mic of ciprofloxacin for these isolates ranged from 4 to >32 ?g/ml (table iii). table iii: mic values of the resistant gram negative bacilli to ciprofloxacin (n=321) the isolated bacteria showed wide differences in their susceptibility to ciprofloxacin. a high rate of resistance to ciprofloxacin was observed among pseudomonas aeruginosa, klebsiella pneumoniae, acinetobacter sps., and proteus sps. followed by e. coli. discussion: evolution of reduced susceptibility to the quinolones is causing concern following rapidly rising rates of fluoroquinoloneresistant e. coli in many parts of the world 12 . the surveillance network database (http://www.mrlworld.com) shows resistance trends (with intermediate counted as resistant) in bloodstream isolates from 250 u.s. hospitals as follows: e. coli, 1.8% in 1996 and 4.3% in 1999; klebsiella spp., 7.1% in 1996 and 6.7% in 1999; enterobacter spp., 6.6% in 1996 and 6.5% in 1999; and p. mirabilis, 5.7% in 1996 and 12.7% in 1999. much higher rates are reported from barcelona, spain, where 17% of e. coli isolates from community infections were ciprofloxacin resistant 13 , and india, where up to 50% of hospital e. coli are reported resistant 14 . high rates in e. coli may reflect contamination via the food chain: the spanish study found quinolone-resistant e. coli in 90% of chicken feces and noted similar fecal carriage rates of resistant e. coli in children and adults. there is a small set of drugs commonly used to treat p. aeruginosa infection, including ciprofloxacin, tobramycin, gentamicin, ceftazidime, and imipenem. while p. aeruginosa has developed various levels of resistance to each of these, its response to ciprofloxacin is of particular interest because the drug is initially very effective, but p. aeruginosa rapidly acquires highlevel resistance, rendering the drug impotent. in clinical isolates, approximately 30% of strains now present high-level ciprofloxacin resistance 15 . the resistance rate for ciprofloxacin was 35% in our study. most of the ciprofloxacin resistant isolates were obtained from uti samples. this may be because fluoroquinolones are preferred as the initial agents for empiric therapy in uti, because of their excellent activity against the pathogens which are commonly encountered in uti 16 . this emphasises the importance of the re-assessment of the antibiotics which are used in the empiric treatment of utis. most of the isolates from utis were susceptible to nitrofurantoin, nalidixic acid, amikacin and imipenem. this was in agreement with the finding of a study reported by astal ze, 2005 17 . these data suggest that nitrofurantoin can still be successfully used in the treatment of uti. the ciprofloxacin resistance was also closely associated with multi-drug resistance, thus making the treatment options limited 18 . ciprofloxacin resistance can be used as a general surrogate marker of multi-drug resistance. hence, it severely limits the already restricted treatment options. this finding was in accordance with the finding of a study which was conducted by paterson et al 19 . the high resistance pattern which was seen in our study was probably due to the inappropriate prescribing of antibiotics, lack of antibiotic policy and the poor infection control strategies. but the antibiotic history could not be properly elicited from the patients in this study. ciprofloxacin remains a potent antibiotic; but the slow accumulation of resistant enterobacteriaceae is disturbing, not least because resistance is a class effect, affecting all fluoroquinolones. ultimately, this resistance may be partly overcome by inhibiting the efflux pumps that contribute to the resistance 20 , ahmad s 319 ( )( ) 321 (35%) 595 (65%) ciprofloxacin 7. (23%) 247 (77%) norfloxacin(for urinary isolates=321 gnb) 8. 67 (21%) 254 (79%) nalidixic acid(for urinary isolates=321 gnb) 9. 64 (20%) 257 (80%) nitrofurantoin (for urinary isolates=321 gnb) 10. 284 (31%) 632 (69%) gentamicin 11. 174 (19%) 742 (81%) amikacin 12. 37 (4%) 879 (96%) imipenem 13. >32μg/ ml 32μg/ ml 16μg/ ml 8μg/ ml 4μg/ ml ciprofloxacin mic values 112 (35%) 51 (16%) 39 (12%) 42 (13%) 77 (24%) total no. of isolates but this strategy is still several years from fruition. in the interim, the best approach lies in the prudent use of fluoroquinolones in humans and animals, coupled with an emphasis on preventing patient-to-patient spread of resistant strains. the antibiotic which showed maximum activity against most of the isolates was imipenem. though carbapenems remain the final options for treating these infections, there is a possibility that the increasing use of carbapenems may lead to a rapid emergence of carbapenem resistance. conclusion: the considerably high mic values for ciprofloxacin in this study reflect the limited treatment options which are available for these resistant isolates and a need for the continuous evaluation of the commonly used antibiotics. repeated surveillance, the formulation of an antibiotic policy, the prudent prescription of antibiotics and the recycling of antibiotics are the possible routes which can be used to curb the rapid emergence and the spread of these resistant isolates. references: 1. bauernfeind a, petermuller c. in vitro activity of ciprofloxacin, norfloxacin and nalidixic acid. eur j clin microbiol 1983; 2:111–5. h t t p : / / d x . d o i . o r g / 1 0 . 1 0 0 7 / b f 0 2 0 0 1 5 7 5 pmid:6222896 2. smith jt. the mode of action of 4-quinolones and possible mechanisms of resistance. j antimicrob chemother 1986; 18:21-9. pmid:3542946 3. everett mj, jin yf, ricci v, piddock lj. contributions of individual mechanisms to fluoroquinolone resistance in 36 escherichia coli strains isolated from humans and animals. antimicrob agents chemother 1996; 40:2380–6. pmid:8891148 pmcid:163538 4. martinez-martinez l, pascual a, jacoby ga. quinolone resistance from a transferable plasmid. lancet 1998; 351:797–9. http://dx. doi.org/10.1016/s0140 6736(97)07322-4 5. drlica k, zhao xk. dna gyrase, topoisomerase iv and 4-quinolone. microbiol mol biol rev 1997; 61(3): 377-92. pmid:9293187 pmcid:232616 6. hooper dc. the emerging mechanisms of fluorquinolone resistance. emerg infect dis 2001; 7:337-41. http://dx.doi.org/10. 3201/eid0702. 010239pmid:11294736 pmcid:2631735 7. martinez-martinez l, pascual a, jacoby ga. quinolone resistance from a transferable plasmid. lancet 1998; 351:797-9.http://dx.doi.org/ 10.1016/s0140 6736(97)07322-4 8. nordmann p, poirel l. the emergence of plasmidmediated resistance to quinolones in enterobacteriaceae. j anti-microb chemother 2005; 56:463-9. http://dx.doi.org/10. 1093/jac/dki245pmid:16020539 9. mackie and mccartney. textbook of practical medical microbiology. 14th edition; 153, 416. 10. ericsson hm, sherris js. antibiotic sensitivity testing. report of an international collaborative study. acta pathologica scandinavica 1971; section b suppl: 1-89. 11. clsi. performance standards for antimicrobial susceptibility testing. 2009; m100-s19 clsi, wayne, pa. 12. livermore dm: has the era of untreatable infections arrived? j antimicrob chemother 2009; 64 (1):29-36.http://dx.doi.org/10.1093/jac/dkp255 pmid:19675016 13. zinner sh. changing epidemiology of infections in patients with neutropenia and cancer: emphasis on gram-positive and resistant bacteria. clin infect dis 1999; 29:490–4. http://dx.doi. org/10.1086/598620pmid:10530434 14. garau j, xercavins m, rodriguez-carballeira m, gomez-vera jr, coll i, vidal d, emergence and dissemination of quinolone-resistant prevalence of ciprofloxacin resistance among gram-negative bacilli 320 escherichia coli in the community. antimicrob agents chemother 1999; 43:2736–41. pmid:10543756 pmcid:89552 15. manno, g., m. cruciani, l. romano, s. scapolan, m. mentasti, r. lorini, and l. minicucci. antimicrobial use and pseudomonas aeruginosa susceptibility profile in a cystic fibrosis centre. int. j. antimicrob. agents 2005; 25:193–197.http://dx.doi.org/10.1016/j.ijantimicag.2004.11.009pmid:15737511 16. schaeffer aj. the expanding role of fluoroquinolones. am j med 2002; 113(suppl 1a):45s–54s.http://dx.doi.org/10.1016/s0002 9343(02)01059-8 17. astal ze. the increasing ciprofloxacin resistance among prevalent urinary tract bacterial isolates in gaza strip. singapore med j 2005; 46(9):45760.pmid:16123829 18. kang ci, kim sh, kim dm, et al. the risk factors for ciprofloxacin resistance in bloodstream infections which were caused due to extendedspectrum ?-lactamase producing escherichia coli and klebsiella pneumoniae. microb drug resist 2004; 10: 71-76. http://dx.doi.org/10. 1089/107662904323047835 pmid:15140397 19. paterson dl, mulazimoglu l, casellas jm, ko wc, goossens h, von gottberg a, mohapatra s, trenholme gm, klugman kp, mccormack jg, yu vl. epidemiology of ciprofloxacin resistance and its relationship to extended spectrum ?lactamase production in klebsiella pneumoniae isolates, which caused bacteremia. clin infect dis 2000; 30(3): 473-78. http://dx.doi.org/10. 1086/313719pmid:10722430 20. nema s, premchandani p, asolkar mv, chitnis ds. emerging bacterial drug resistance in hospital practice. indian j med sci 1997; 51:275–80. pmid:9491681 21. mm rahman. molecular methods in medical microbiology: current and future trends. bangladesh journal of medical science 2011; 10(3): 141-147. doi: http://dx.doi.org/ 10.3329/bjms.v10i3.8355 ahmad s 321 page mackup january-15.qxd bangladesh journal of medical science vol. 14 no. 01 january’15 65 original article hepatitis a virus vaccination strategy and pre-immunization screening of bangladeshi children mahmud s1, karim asmb2, alam j3, islam mmz1, sarker nk1, munshi as1, sarker s1 introduction hepatitis a virus (hav) infection occurs throughout the world but most common in developing countries.1 in these countries with high endemicity, 90% of the population is infected by 10 years of age.2 here children are continuously exposed to the virus, which confers lifelong immunity.3 in many developing countries like india, pakistan, nepal several sero-prevalence studies have shown high rates of sero-positivity among child by sub-clinical infection4-9. therefore, mass vaccination against hav has not been recommended in endemic countries.10 furthermore, hepatitis-a vaccine is expensive. in bangladeshi children, limited data are available regarding the sero-prevalence of hav antibody.11 in this context, the present study was designed to see the prevalence of hav antibody (igg & igm) among children of different age group and to perform a cost benefit analysis study before formulating a vaccination strategy for the children of bangladesh. materials & methods a cross sectional observational study was conducted from july 2008 to june 2009. blood was collected at blood collection centers of bangabandhu sheikh mujib medical university (bsmmu) hospital & dhaka shishu (children) hospital (dsh). a total of corresponds to: dr. salahuddin mahmud, assistant professor, dhaka shishu (children) hospital, dhaka, e-mail: drsmbablu@gmail.com abstract: background: hav infection is endemic in many developing countries like india, pakistan, nepal etc. several seroprevalence studies show high rates of sero-positivity among children by sub-clinical infection. therefore mass vaccination against hav has not been recommended in endemic countries. objective: to determine whether routine hepatitis a vaccination is indicated for all bangladeshi children & also to know whether pre-vaccination screening is necessary. materials & methods: serum samples from 254 children aged between 1-15 years were tested for antibody (igm & igg) against hepatitis a virus (hav) to determine the seroprevalence of hav antibody and do a cost-benefit analysis for decision making about vaccination against hav among the children of bangladesh. results: hepatitis a virus antibody was positive in 141 (55.5%) of 254 children. age-specific sero-prevalence was 13 (23.2%) of 56 in 1-3 year,64 (55.2%) of 116 in 3-5 year, 39 (70.9%) of 55 in 5-10 year & 25 (92.6%) of 27 in 10-15 year age group. cost benefit analysis showed that the total cost of screening followed by vaccination was almost 1.8 times less than the total cost of vaccination of all children without screening. conclusions: majority of the children were found sero-positive against hav around 15 year of age. therefore mass vaccination against hav may not be required for bangladeshi children. key words: hepatitis a virus (hav); hav seroprevalence; hav vaccine 1. salahuddin mahmud, assistant professor, bangladesh institute of child health, dhaka shishu hospital 2. a.s.m. bazlul karim, professor, paediatric gastroenterology & nutrition, bsmmu 3. jahangir alam, professor, bangladesh institute of child health, dhaka shishu hospital 4. m.m. ziaul islam, assistant professor, bangladesh institute of child health, dhaka shishu hospital. 5. n.k. sarker, assistant professor, bangladesh institute of child health, dhaka shishu hospital. 6. a.s. munshi, assistant professor, bangladesh institute of child health, dhaka shishu hospital. 7. shaoli sarker, assistant professor, bangladesh institute of child health, dhaka shishu hospital. doi: http://dx.doi.org/10.3329/bjms.v14i1.21561 bangladesh journal of medical science vol. 14 no. 01 january'15. page: 65-69 254 children aged 1-15 years (boys=139 & girls=115), who had no previous history of jaundice or hepatitis or hepatitis a vaccination but attended opd of these two hospitals for other illnesses were included in this study. the sample size was determined by the prevalence rates of neighburing countries with a similar socioeconomic condition (e.g., india & pakistan) as there are no previous data on hav prevalence particularly in the children of bangladesh. with prior written consent, clinical history and relevant data were recorded and 2 ml of blood was collected from each of the study cases. serum was separated, stored at -20°c and were tested for hav antibody (igg & igm) by elisa using the elisa kit (diasorin italy, eti-ab-havk plus, no136, 01/2009) at the department of virology laboratory of bsmmu, dhaka. the cut-off value was determined by the mean absorbance of the calibrator values. the presence or absence of antihav was determined by comparing the absorbance values of unknown samples with the absorbance values below/above the cut-off values of the controls. for cost benefit analysis, pre-vaccination screening price was 2$ for each child & vaccine price along with vaccination charge was 15$ (per dose). a preformed semi structured data collecting form was used as a data collection instrument. data were collected by researcher and analyzed by statistical package for social science (spss) version 11.5 program. p value of <0.05 was considered as statistically significant. results hepatitis a virus antibody (total) was found positive in 141 (55.5%) of 254 children (fig:i) fig: i anti-hav positivity among all children total 172 children from 1-5 year age group, 55 children from 5-10 year age group and 27 children from 10-15 year age group were taken. boys were 139 & girls 115 so male:female ratio was 1.2: 1. age distribution of the children positive for hav antibody shows that with the advancement of age, anti-hav positivity increases. anti-hav of 1-5 year age group was found to be 44.7%, it gradually increased to 70.9% in 5-10 year age group and finally to 92.6% in 10-15 year age group. anti-hav positivity of 510 year age group was significantly higher than that of 1-5 year age group (p=0.001) and antibody positivity of 10-15 year age group was significantly higher than that of 5-10 year age group (p=0.026). (table 1.1). table 1.2 shows anti-hav positivity in children aged 1-5 year. anti-hav was found 18.9% in 1-2 year age group, 31.6% in 2-3 year age group, 53.1% in 3-4 year age group & 56.7% in 4-5 year age group. pre-immunization screening of bangladeshi children 66 hav antibody age (yrs) n positive negative χ2 p-value 1 – 5 172 77 (44.7) 95 (55.3) 5 – 10 55 39 (70.9) 16 (29.1) 11.397 4.970 0.001 0.026 10 – 15 27 25 (92.6) 2 (7.4) table 1.1 anti-hav positivity with age #data were analysed using chi-square (x2) test figures in the parentheses denote corresponding percentage table 1.2 seroprevalence of antibodies in children aged 1-5 year # data were analysed using chi-square (x2) test; figures in the parentheses denote corresponding percentage hav antibody age (yrs) n positive negative χχ2 p-value 1 – 2 37 7 (18.9) 30 (81.1) 2 – 3 19 6 (31.6) 13 (68.4) 1.129 0.467 3 – 4 49 26 (53.1) 23 (46.9) 2.536 0.111 4 – 5 67 38 (56.7) 29 (43.3) 0.153 0.696 table 1.3 shows, total number of subjects were 254. current cost of 2 doses of vaccine is 15$×2=30$. anti-hav assay by elisa costs 2$ per test. total cost of vaccination of all the 254 children without screening is (30$×254) 7620$. on the other hand total cost of screening all the children is (2$×254) 508$. after screening of all the 254 children, 113 were found anti-hav negative, who needed vaccination. cost of vaccination of these 113 children is (30$×113) 3390$. thus, total cost of vaccination after prior screening is (508$+3390$) 3898$. therefore the cost of vaccination without screening is almost 2 (1.95) times more than the cost of vaccination after screening (table 1.3). therefore, it is worthwhile to screen the individuals before recommending hepatitis a vaccine. discussion acute viral hepatitis caused by hav is an acute, self-limiting infection.12 hepatitis a virus infection is very common in early childhood and most of the infections are asymptomatic or mildly symptomatic.13 immunity that develops following natural infection is stronger and persists longer than that develops following vaccination.14 three epidemiological patterns of endemicity (low, intermediate and high) are observed worldwide. each pattern has a different rate of infection, prevailing age of infection, and transmission model. hav epidemiological pattern are highly dependent on age and level of hygiene. the distribution of hav seroprevalence by age group may reflect current hepatitis a endemicity in countries and regions. the countries with low endemicity include japan, singapore, hongkong and taiwan whereas those with moderate endemicity include thailand, malaysia and sri lanka. countries with high endemicity for hav infections include india, china, nepal, bangladesh, pakistan, myanmar and philippines.15 in many developing countries of africa, asia and latin america, most infections occur by 5 years of age where seroprevalence approach 90-100% by 10-15 years of age.1 in africa, hendricks et al.16 showed anti-hav positivity of >90% among the 5-10 year age group among lower class black children. india, china, nepal, pakistan and bangladesh are included in high endemic zone15 and a large number of populations acquire immunity through subclinical infections in early life.17 during the last 5 years several reports from countries in southern asia, latin america and europe showed a decreasing seroprevalence of protective antibody against hepatitis a virus.18 in the present study the average prevalence of antihav was 55.5%. only 44.7% individuals were positive at the age range of 1-5 years. anti-hav seroprevalence increased with age from 44.7% in 1-5 year age group to 92.6% in the 10-15 year age group. it was also observed that in 1-5 year age group (younger children), about one third of children were anti-hav positive by 2-3 year of age and more than half by 3 years of age. similar results were also observed in other studies in bangladesh. ahmed et al.19 found a high prevalence (74.8%) of anti-hav among bangladeshi children and adult. he also reported anti-hav positivity of 38% in 1-5 year age group, 75.2% in 5-10 year age group, 80.4% in 1115 year age group and 98.5% in 15-20 year age group. saha et al.11 also reported anti-hav positivity of 40.4% in 1-5 year age group which gradually increased to 98.4% in >30 year age group. another study by sheikh et al.20 reported anti-hav positivity of 100% in 15-20 year age group. these findings are similar to the findings of our neighbouring counmahmud s, karim asmb, alam j, islam mmz, sarker nk, munshi as, sarker s 67 vaccine strategy total 254 children number of elisa tests cost of elisa 2$ per test number of vaccinees cost of vaccine 15$ per dose × 2 total cost without screening 254 0 0 254 7620$ 7620$ with screening 254 254 508$ *113 3390$ 3898$ table 1.3: the cost benefit analysis of hepatitis a virus vaccination strategies *113 were found negative for anti-hav pre-immunization screening of bangladeshi children 68 tries. mall et al.2 from india (calcutta) reported 40% anti-hav positivity in 1-5 year age group and through gradual increase in age the prevalence reached to 97% in the >16 year age group. a recent study by kamath et al.5 reported anti-hav positivity of 61.6% in 5-10 year age group and 97% in 11-15 year age group in chennai, india. agboatwalla et al.8 & sawayama et al.21 also reported similar results from pakistan (94.1% seropositive by the age of 5 years) and nepal (91.1% seropositive) respectively. anti-hav positivity was found 94.1% in 1-5 year age group at rawalpindi and 99% in two rural villages in nepal. in africa, raharimanga et al.14 reported that the overall seroprevalence of anti-hav was 92.2%. in 8-10 year age group it was 83.7% and in 10-24 year age group it was 95.5%. in the present study, it was evident that the cost of vaccination with screening is more than 2 times cheaper (3898$) than the cost of vaccination without screening (7620$). as such, these findings suggest to screen the individuals before recommending hepatitis a vaccination. ahmed et al. 19 also observed that the cost of vaccination with screening was almost three times cheaper (us$3418) than the cost of vaccination without screening (us$8928). it is to be economically worthwhile, the cost of vaccinating a group of people must be equal to or less than the cost of testing the entire group plus the cost of vaccinating the non-immune group22. in india also reported that, if anti-hav positivity is >50% in a particular age group, then it is advisable to screen the individual before hav vaccination. on the other hand, when the chance of positivity is <50% in a particular age group, then vaccination can be offered without screening for antibodies. 13 it is evaluated that in india, selective vaccination of high risk populations, based on their serological evidence of hav antibody, could be a rational and cost effective approach. 23 in a developed country like argentina reported that universal vaccination against hav was cost effective. 24 conclusions in the studied children anti-hav positivity was more than 50% after 3 years of age and finally increased to more than 90% after 10 years of age. so, high proportion of children in the present study acquired hav antibody since early childhood and anti hav positivity increased with increase in age. on cost benefit analysis, the cost of vaccination with screening was almost 2 times cheaper than the cost of vaccination without screening. therefore mass vaccination or vaccination without prior knowledge regarding the serostatus could be an unnecessary immunological assult & may not be a suitable strategy for bangladesh in lieu of the present socioeconomic condition. assult recommendations based on the present study, it may be recommended that in children less than 3 years of age vaccination without prior screening can be done. however in children of ?3 years of age, pre-vaccination screening should be done prior to vaccination as this is cost effective, safe and more rational. further community based studies with larger sample size are required before giving a final recommendation for routine hav vaccine to children of bangladesh. limitations of study small sample size, selection biasness and absence of socio-economic status are the three limitations of this study. acknowledgement prof. c. a. kawser, phd, chairman of pediatrics, bsmmu. prof. samir k. saha, phd, head, dept. of microbiology, bich, dsh. mahmud s, karim asmb, alam j, islam mmz, sarker nk, munshi as, sarker s 69 reference: 1. pickering lk, snyder jd. viral hepatitis. in: kliegman rm, behrman re, jenson hb, stanton bf, editors. nelson textbook of pediatrics. 17th ed. saunders elsevier, new delhi; 2004. p 1324-32. 2. mall ml, rai rr, philip m, naik g, parekh p, bhawnani sc et al. ‘seroepidemiology of hepatitis a infection in india: changing pattern’. indian journal of gastroenterology 2001; 20: 132-35. 3. kaw hw, aschcavai m, redekar ag. ‘the persistence of igm antibody after acute clinical hepatitis a’. hepatology 1984; 4: 933-6. http://dx.doi.org/10.1002/hep.1840040525 4. chadha ms, lole ks, bora mh & arankalle, va. ‘outbreaks of hepatitis a among children in western india’. transactions of the royal society of tropical medicine and hygiene 2009; 1088: 1-6. 5. kamath sr, sathiyasekaran m, raja te & sudha. ‘profile of viral hepatitis a in chennai’. indian pediatrics 2009; 46: 642-3. 6. joshi n, rao s, kumar a, patil s & rani s. ‘hepatitis a vaccination in chronic liver disease: is it really required in a tropical country like india?’ indian journal of microbiology 2007; 25(2); 137-39. http://dx.doi.org/10.4103/0255-0857.32720 7. hussain z, das bc, hussain s, murthy ns & kar p. ‘increasing trend of acute hepatitis a in north india: need for vaccination of high-risk population for vaccination’. journal of gastroenterology and hepatology 2006; 21: 8 9 9 3 . http://dx.doi.org/10.1111/j.1440-1746.2006.04232.x 8 . agboatwalla m, isomura s, miyake k, yamashita t, morishita t & akram ds. ‘hepatitis a, b and c seroprevalence in pakistan’. the indian journal of pediatrics 1994; 61: 545-9. http://dx.doi.org/10.1007/bf02751716 9. anish k & xavier s. ‘is hepatitis a vaccination necessary in indian patients with cirrhosis of liver?’ indian journal of gastroenterology 2003; 22(2): 54-58. 10. who. ‘department of communicable disease surveiliance and response’, hepatitis a 2000; 1-39. 11. saha sk, setarunnahar s, shakur s, hanif m, habib ma, dutta sk et al. ‘seroprevalence of hepatitis a infection by age group and socioeconomic status of bangladesh’. 13th international congress on infectious diseases abstracts, poster presentations 2008; 16(43): 101-02. 12. feinstone sm, gust id. hepatitis a virus. in: richman dd, whitley rj, hayden fg, editors. clinical virology. 2nd ed. asm press, washington d.c; 2002. p 1019-32. 13. arora nk & mathur p. ‘epidemiological transition of hepatitis a in india: issues for vaccination in developing countries’. indian journal of medical research 2008; 128: 699-704 14. raharimanga v, carod jf, ramarokoto ce, chertien jb, rakotomanana f, talarmin a et al. ‘age specific seroprevalence of hepatitis a in antananarivo (madagascar)’. bmc infectious diseases 2008; 8(78): 1-6. 15. kar p. ‘is there a change in seroepidemiology of hepatitis a infection in india?’ indian journal of medical research 2006; 123: 727-29. 16. hendrickx g, herck kv, vorsters a, wiersma s, shapiro c, andrus jk et al. ‘has the time come to control hepatitis a globally? matching prevention to the changing epidemiology’. journal of viral hepatitis 2008; 15: 1-15. http://dx.doi.org/10.1111/j.1365-2893.2008.01022.x 17. arankalle va, devi kls, leo ks, shenoy kt, verma v & haneephabi m. ‘molecular characterization of hepatitis a virus from a large outbreak from kerala, india’. indian journal of medical research 2006; 123: 760-69. 18. batra y, bhatkal b, ojha b, kaur k, saraya a, panda sk & acharya sk. ‘vaccination against hepatitis a virus may not be required for school children in northern india: results of a seroepidemiological survey’. bulletin of the world health organization 2002; 80(9): 728-31. 19. ahmed m, munshi su, nessa a, ullah ms, tabassum s & islam mn. ‘high prevalence of hepatitis a virus antibody among bangladeshi children and young adults warrants pre-immunization screening of antibody in hav vaccination strategy’. indian journal of medical microbiology 2009; 27(1): 48-50. 20. sheikh a, sugitani m, kinukawa n, moriyama m, arakawa y, komiyama k et al. ‘hepatitis e virus infection in fulmimant hepatitis pattern and an apparently healthy population in bangladesh’. american journal of tropical medicine and hygiene 2002; 66(6): 721-24. 21. sawayama y, hayashi j, ariyama i, furusyo n, kawasaki t, kawasaki m et al. ‘a ten year serological survey of hepatitis a, b and c viruses infections in nepal’. journal of epidemiology 1999; 9(5): 350-54. http://dx.doi.org/10.2188/jea.9.350 22. mathur, p & arora, nk. ‘considerations for hav vaccine in india’, indian journal of pediatrics 1999; 66: 1112 0 . http://dx.doi.org/10.1007/bf02752368 23. gupta, a & chawla, y. ‘changing epidemiology of hepatitis a infection’, indian journal of medical research 2008; 128: 7-9. 24. gentile, a. ‘the need for an evidence based decision making process with regard to control of hepatitis a’, journal of viral hepatitis 2008; 15: 16-21. http://dx.doi.org/10.1111/j.1365-2893.2008.01023.x page mackup january-14.qxd 58 bangladesh journal of medical science vol. 13 no. 01 january’14 original article: evaluation of attributes to hyperbilirubinaemia in neonates in a tertiary care hospital in the dhaka city choudhury s1, h shaila2, islam mz3, akhter s4, arifa s5, hayat sms6 abstract objective: the study was aimed to evaluate the attributes related to hyperbilirubinaemia among neonates. materials and methods: a total number of 120 neonates with hyperbilirubinemia included in the study. data were collected using hospital records and by face-to-face interview of mother of those neonates using a predesigned questionnaire. data were expressed as mean±sd and number (percent) as appropriate. both descriptive and inferential statistics were considered in data analysis. statistical analyses were performed using spss software. result: of the total neonates, 57% were baby boys. in age group of 2nd to 7th days were 59.2% of neonates. according to the birth weight, neonates distribution was 38.3% in very low (<2000g), 42.5% low (2001-2500g) and 19.2% normal (>2500g) birth weight group. abo incompatibility was found in 14.2% and rh 8.3% cases of hyperbilirubinaemia. birth trauma was found in 7.5% and congenital anomalies 3.3% neonates. pre-maturity (gestational age <37 wks) was found in 73.3% cases. normal vaginal delivery was performed in 59.2% of cases. exclusive breast feeding was given by 43.33% mothers. of the mothers 93.4% were housewives. thirty percent (30%) of mothers were adolescents (<20 years) and 27.5% young adults (20 to 25 years). of the 120 mothers 56.7% had primary level education. low birth weight (<2000g to 2500g) neonates had significantly higher (p<0.005) serum bilirubin than the normal birth weight counterpart. among the neonates of the mothers with gdm, 9.2% had serum bilirubin level above 20mg/dl and the distribution showed significant association (p<0.005). conclusions: it is concluded that low birth weight and prematurity remained to the major causes of neonatal hyperbilirubinemia in neonates. other common causes, particularly abo and rh incompatibility, are also present which could be avoided by meticulous clinical practice and burden of neonatal morbidity and mortality related to hyperbilirubinemia can be reduced. keywords: neonates, hyperbilirubinaemia, prematurity, low birth weight. 1. dr. shamima choudhury, lecturer, department of community medicine, ibn sina medical college, kallyanpur, dhaka. 2. prof. dr. shaila hossain, head, department of community medicine, national institute of preventive and social medicine (nipsom), mohakhali, dhaka. 3. dr. md. ziaul islam, associate professor, department of community medicine, nipsom, mohakhali, dhaka. 4. dr. shaheen akhter, consultant, sonologist, cmud, 20 green road, dhaka. 5. dr. sonia arifa, lecturer, department of community medicine, ibn sina medical college, kallyanpur, dhaka. 6. dr. syed muhammad shahin-ur hayat, medical officer, icu, ibn sina hospital, dhanmondi, dhaka. corresponds to: dr. shamima choudhury, lecturer, department of community medicine, ibn sina medical college, 1/1-b, kallyanpur, dhaka, 1216, bangladesh introduction neonatal hyperbilirubinaemia resulting in clinical jaundice is a common problem among neonates, particularly during the first weeks of life1. cephalo-caudal progression of staining correlates with increasing level of serum bilirubin1. at birth and early days of life, serum bilirubin more that 7mg/dl becomes visible as jaundice; rise in bilirubin in newborn remains undetectable for some time until bilirubin rises2. effect of hyperbilirubinaemia depends on its cause and the degree of elevation3. the situation of neonatal jaundice in developing countries is relatively same to that of developed countries4. in bangladesh 60% neonates found to be admitted in hospitals due to neonatal jaundice5. major factors related to neonatal jaundice found to be male gender, low birth weight, prematurity, abo incompatibility, mode of delivery, birth trauma, neonatal infection, doi: http://dx.doi.org/10.3329/bjms.v13i1.17430 bangladesh journal of medical science vol. 13 no. 01 january '14 page 58-62 gestational dm and breast feeding6. the mortality and morbidity picture of neonatal jaundice is markedly different in the developed and developing countries. neonatal jaundice is a fairly common cause of morbidity in bangladesh but little information is available on patterns of neonatal jaundice. attitude and health care pattern of people and early detection of high risk groups are of paramount importance in preventing complications of neonatal jaundice4. considering the realities of multiple risk factors of neonatal hyperbilirubinaemia, the study tried to determine the independent contribution of each risk factor. as a global problem, preventive and control strategies of hyperbilirubinaemia should be based on adequate knowledge and information regarding the incidence and risk factors, which are not available in the developing countries where the vast majority of births occur at home. identifying infants at risk of severe hyperbilirubinaemia and early intervention may reduce the levels of morbidity and mortality associated with bilirubin encephalopathy7. this study was designed to access neonatal and maternal risk factors related to the hyperbilirubinaemia among the neonates. the study findings may contribute to formulation of guidelines and strategies for better management and prevention of hyperbilirubinaemia among the vulnerable neonates. materials and methods this descriptive cross-sectional study was conducted to evaluate the attributes of hyperbilirubinaemia among the neonates admitted in the department of neonatology, dhaka medical college and hospital. a total number of 120 neonates with jaundice were purposively recruited. data were collected by faceto-face interview and reviewing medical documents. neonatal factors considered for study were prematurity, birth weight, abo and rh incompatibility, birth trauma, gender, congenital anomalies and septicaemia and, maternal factors gestational age, mode of delivery and breast-feeding. maternal co-morbidities were gestational diabetes, hypothyroidism and hepatitis b considered. data regarding socio-demographic profile of mothers were age, religion, educational status and occupation. statistical analysis data were expressed as mean±sd and number (percent) as appropriate. proportion and chi-squared (fisher’s exact) tests were performed as applicable. data were analyzed using statistical package for social science (spss) version 18. a two tailed p value less than 0.05 was considered statistical significant. ethical issue the study was approved by the ethical committee of nipsom and all ethical considerations thoroughly followed. result of the total 120 neonates, 57% were baby boys. age range of the 120 neonates was 1-21 days. mean±sd age of the neonates was 5.36±4.43 days. distribution of the neonates was 15.0%, 59.2% and 25.8% in 1, 2-7 and more than 7 days group respectively (figure 1). total serum bilirubin level varied from 12 – 23.8 mg/dl and 63.3% (76 out of 120) had the level between 17 to 20 mg/dl. figure 1: distribution of subjects on the basis of duration of age (days). mean (±sd) birth weight (g) of the neonates was 2291± 461. of the neonates 38.3% had very low (<2000g), 42.5% low (2001g to 2500g), and 19.2% normal birth weight (figure 2). among them, 17 (14.2%) had abo incompatible, 10 (8.3%) rh incompatible and 29 (24%) had septicemia as major causes of hyperbilirubinaemia. birth trauma was found in 9 (7.5%) neonates while congenital anomalies were found only in 4 (3.3%) cases (table 1). figure 2: distribution of neonates on the basis of birth weight. 59 hyperbilirubinaemia in neonates in a tertiary care hospital 15% 59.20% 25.80% 1 day 2-7 days > 7 days 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% < 2000 2001-2500 >2500 birth weight (g) table 1: neonatal factors related to hyperbilirubinaemia maternal related risk factors of 73.3% of neonates with jaundice had gestational age was less than 37 weeks. of the neonates under study mother of 59.2% cases had normal vaginal delivery. exclusive breastfeeding was given to 43.3%, formula feeding 20.8% and mixed feeding 35.9% neonates (figure 3). figure 3: distribution mothers provided their neonates exclusive breastfeeding. maternal co-morbidity gdm was found in 19 (15.8%), hypothyroidism 8 (6.7%) and hepatitis b positive 11 (9.2%) cases (table 2). table-2: maternal related factors in cases of neonatal jaundice nvd, normal vaginal delivery; cs, caesarian section; gdm, gestational diabetes mellitus mean (±sd) age (yrs) of the mothers was 23.73±5.44 (table 3). frequency distribution regarding maternal age was shown in figure 4. of the 120 mothers 30% were adolescents (<20 yrs) and 27.5% young adult (20 to 25 years). of the total mothers 93.4% were housewives. mother’s formal education status was as follows: 20.8% illiterate, 56.7% primary level and 22.5% secondary level (table 3). figure 4: distribution of mother with neonatal jaundice on the basis of their age. table 3: socio-demographic profile of mothers of neonates different level of bilirubin in neonates was explored with their birth weight. distribution of number of neonates in three levels of total bilirubin showed significant association (p<0.005) (table 4). table 4: distribution of neonates with different level of total bilirubin on the basis of birth weight birth weight group total bilirubin level (mg/dl) of the 120 neonates 9.2% had bilirubin level more than 20 mg/dl and 5% between 17-20 mg/dl. none of the neonate was in group of bilirubin level 12-16.9 mg/dl. of the 103 neonates of abo compatible had bilirubin 60 choudhury s, h shaila, islam mz, akhter s, arifa s, hayat sms 30.0% 27.5% 17.5% 35.0% < 20 yrs >20-25 yrs >25-30 yrs > 30 yrs attributes findings gestational age (mean ±sd, wks) 35.4±2.3 mode of delivery [nvd (cs)] (%) 59.2 (40.8) feeding pattern (%) exclusive breast feeding 52 (43.33) formula feeding 25 (20.84) mixed feeding 43 (35.83) history of jaundice of previous baby 33 (27.5%) gdm 19 (15.8%) hypothyroidism 8 (6.7%) hepatitis b 11 (9.2%) total bilirubin level (mg/dl) 12-16.9 17-20 >20 birth weight group n (%) n (%) n (%) <2000 (g) 0 (0) 35 (29.1) 11 (9.2) 2000-2500 (g) 10 (8.3) 41 (34.2) 0 (0) >2500(g) 23 (19.2) 0 (0) 0 (0) attributes findings age of mother (mean±sd, yrs) 23.73±5.44 religion [islam (hinduism)] (%) 90 (10) education [n (%)] illiterate 25 (20.8) primary 68 (56.7) secondary 27 (22.5) occupation of mother job (%) 8 (6.6) housewife (%) 112 (93.4) attributes findings gender [male (female)] (%) 57 (51) age [mean ±sd, days] 5.36±4.43 birth weight [mean ±sd, g] 2291±461 abo incompatibility [n (%)] 17 (14.2%) rh incompatibility [n (%)] 10 (8.3%) septicaemia [n (%)] 29 (24%) birth trauma [n (%)] 9 (7.5%) congenital anomalies [n (%)] 4 (3.3%) level up to 16.9 mg/dl. the distribution showed statistical significant associated (p<0.001) (table 5). table-5: distribution of neonates with abo incompatibility in relation to total bilirubin level gestational diabetes mellitus was present in 19 mothers. baby of the 19 mother 11 (9.2% of total) had bilirubin more than 20 mg/dl and none of those with normal glucose. in 56.5% of neonates bilirubin levels was between 17-20 mg/dl. at same bilirubin level 6.7% cases of neonate mothers had gdm. this distribution showed statistical significant association (p<0.005) (table 6). table 6: distribution of neonates with their mother’s diabetes status in relation to total bilirubin level discussion: proportion of male neonates with hyperbilirubinemia in the present study was 57.0% which found to be almost similar to that of earlier reported by zabeen et al7. they have demonstrated that 11.6% of their neonates had serum total bilirubin ³20 mg/dl where as in the present study the proportion was 9.2%. in the present study 17 (14.2%) neonates had abo and 10 (8.3%) rh incompatibility. proportion of neonates with abo incompatibility in these study subjects found to be consistent with the other studies. the study carried out on iranian population showed the abo incompatibility to be 12%8 and earlier study in bangladesh 11.3%5. abo incompatibility was reported to be the commonest cause of neonatal hyperbilirubinemia according to the study conducted in uae7. however, rh incompatibility relatively higher the present study than the previous study (5.4%)5. this feature may be attributed to the relatively small number of samples. prematurity is one of the major causes of neonatal jaundice. in this study 77.3% (88 out of 120) neonates were premature which is almost similar to the findings of dawodu and his group7. the study reconfirmed the prematurity as prominent cause of hyperbilirubinemia in neonates. it is usually seen that in most of the cases hyperbilirubinemia present within the first week of life. the present study the scenario was also similar where in 74.2% of the neonates had 7 days or less. birth weight is regarded as the indicator of fetal well being and used to assess risk of neonatal morbidity and mortality. low birth weight babies are found to be susceptible to develop hyperbilirubinemia. in the present study 38.3% of the neonates were of low birth weight (<2500g) which is consistent with other studies5,7. these low birth weight babies had significantly higher level of bilirubin compared to the other groups (table 4). this finding highlighted fact of low birth increase the risk of development of hyperbilirubinemia and its level. in the present study 15.8% of mothers of hyperbilirubinemic neonates had gdm which is lower than the earlier report that showed very high proportion (35%) of mothers with gdm, this variation, however, might be explained by the fact of recruiting the cases from birdem hospital5 for the later study. on the other hand 15.8% of gdm mothers in the present study appeared to be markedly high to that of 3.3% in another study9 where, however, number of study samples was much higher. study involving large number of subjects and adaptation of more stringent inclusion criteria may explain the issue clearly. it is important to note that significantly more neonates of gdm (9.2%) than non-gdm mothers had higher bilirubin level (p<0.005) which strengthened the notion that neonates of gdm mothers are more likely to suffer from neonatal hyperbilirubinemia. the present study demonstrated that normal vaginal delivery was done in 59.2% cases and rest had caesarian section which is almost similar (63.6% vs 36.4% respectively) to other report8. relatively high proportion of delivery done caesarian section might have been compounded by the fact that in case of normal vaginal delivery mother and the newborn left the hospital much earlier than their counterpart and in case need sought clinical advice elsewhere but those with caesarian section stayed in the hospital till 6th or 7th postoperative day and the neonates represented relatively higher number. 61 hyperbilirubinaemia in neonates in a tertiary care hospital total bilirubin level (mg/dl) 1216.9 17-20 > 20 abo incompatibility n (%) n (%) n (%) abo incompatible 0 (0) 6 (5) 11 (9.2) abo compatible 33 (27.5) 70 (58.3) 0 (0) total bilirubin level (mg/dl) 1216.9 17-20 > 20 gdm n (%) n (%) n (%) yes 0 (0) 8 (6.7) 11 (9.2) no 33 (27.5) 68 (56.6) 0 (0) fisher’s exact test = 47.833, p value <0.005, ci = 95%) exclusive breast feeding argued to be beneficial to neonates in many ways. however, breast fed babies often shows early onset of jaundice may be due to ineffective lactation in first few days after birth resulting in dehydration or in some instances use of water or glucose in water finally cause aggravation of jaundice. the condition is also seen in successful feeding as well. it is suggested that glucuronidase containing breast milk may have a role in this respect. in neonates intestinal absorption of bilirubin appears to be enhanced by breast-feeding and by decrease or delay in the passage of muconium. in the present study 43.33% of the respondents had history of exclusive breast feeding. higher proportion of neonates with hyperbilirubinemia was also shown by in another study8. neonatal sepsis was found to be present in 24% of hyperbilirubinemic cases which was consistent with other study where it was demonstrated 26.6%7. this finding excluded sepsis as a major cause of jaundice in the neonates. it is concluded that low birth weight and prematurity remained to the major causes of neonatal hyperbilirubinemia in neonates. other common causes, particularly abo and rh incompatibility, are also present which could be avoided by meticulous clinical practice and burden of neonatal morbidity and mortality related to hyperbilirubinemia can be reduced. references 1. tikmani ss, warraich hj, abbasi f, et al. incidence of neonatal hyperbilirubinaemia: a population-based prospective study in pakistan. tropical medicine and international health 2010;15:502-507. http://dx.doi.org/10.1111/j.1365-3156.2010.02496.x pmid:20412075 2. agarwal kn, pediatrics and neonatology, 2nd edition, new delhi, cbs publishers & distributors 2008;200-204. 3. chapman rw, collier jd, hayes pc. liver and biliary tract disease in boon na, colledge nr, walker br, et al. davidson's principles & practice of medicine, 20th edition, edinburgh, elsevier limited, 2006; 944-945. 4. huang ms, lin mc, chen hh, et al. risk factor analysis for late-onset neonatal hyperbilirubinaemia in taiwanese infants. pediatr neonatol 2009;50:261-265. http://dx.doi.org/10.1016/s1875-9572(09)60074-7 5. rasul ch, hasan ma, yasmin f. outcome of neonatal hyperbilirubinaemia in a tertiary care hospital in bangladesh. malaysian j med sci 2010;17(2):40-44. 6. linn s, schoenbaum sc, monson rr, et al. epidemiology of neonatal hyperbilirubinaemia. pediatrics 1985;75:770-774. pmid:3982909 7. zabeen b, nahar j, nabi n, et al. risk factors and outcome of neonatal jaundice in a tertiary hospital. ibrahim med. coll. j 2010;4:70-73. http://dx.doi.org/10.3329/imcj.v4i2.6500 8. heydarian f, majdi m. severe neonatal hyperbilirubinaemia; causes and contributing factors leading to exchange transfusion at ghaem hosopital in mashhad. acta medica iranica 2010;48:399-402. pmid:21287481 9. maisels mj, kring e. the contribution of hemolysis to early jaundice in normal newborns. pediatrics 2006;118:276-279. http://dx.doi.org/10.1542/ peds.2005-3042 pmid:16818575 10. manning d, todd p, maxwell m, et al. prospective surveillance study of severe hyperbilirubinaemia in the newborn in the uk and ireland. arch dis child fetal neonatal 2007;92:342-346. http://dx.doi.org/10.1136/ adc.2006.105361 pmid:17074786 pmcid:pmc2675352 11. onyearugha cn, onyire bn, ugboma haa. neonatal jaundice: prevalence and associated factors as seen in federal medical centre abakaliki, southeast nigeria. journal of clinical medicine and research 2011;3:40-45. 12. khan mr, rahman me, essence of pediatrics, 3rd edition, dhaka, 2008;60-69. pmcid:pmc3074334 13. watchko jf, lin z, clark rh, et al. complex multifactorial nature of significant hyperbilirubinaemia in neonates. pediatrics 2009;124:e868-e877. h t t p : / / d x . d o i . o r g / 1 0 . 1 5 4 2 / p e d s . 2 0 0 9 0 4 6 0 pmid:19858149 14. maisels mj, gifford k. normal serum bilirubin levels in the newborn and the effect of breast-feeding. pediatrics 1986;78:837-843. pmid:3763296 15. wood b, culley p, roginski c, et al. factors affecting neonatal jaundice. archives of disease in childhood (bmj) 1979;54:111-115. http://dx.doi.org/10.1136/adc.54.2.111 16. dawodu a, qureshi mm, moustfa ia, et al. epidemiology of clinical hyperbilirubinaemia in al ain, united arab emirates. ann trop paediatr 1998;18:93-9. pmid:9924569 62 choudhury s, h shaila, islam mz, akhter s, arifa s, hayat sms page mackup-final.qxd review article pregnancy and nutrition asma rs1, asma-uh2, ashraful a3 abstract pregnancy is a specially important time in women’s life to focus on proper health care and nutrition. nutrition during childhood and adolescence influence a women’s preconceptional nutritional status which subsequently influence the outcome of pregnancy and health of the baby. good nutrition is the key to a successful pregnancy for both mother and child. the mother’s nutrition from the moment of conception is an important factor in the development of the infant’s metabolic pathway and future wellbeing. the diet during pregnancy should be adequate to provide maintenance of maternal health, the need of growing fetus, the strength and vitality required during labour and successful lactation. all women need to gain weight during pregnancy. weight gain during pregnancy depends on pre-pregnancy weight. a healthy weight gain for most of the women is between 25-35lb. during pregnancy a women has different nutritional need for different trimester to meet extra food needs and extra caloric requirement. normal weight women need an extra 300 kcal /day during the 2nd and 3rd trimester of pregnancy. the total amount of needed calorie 2000-2500 kcal/day for a normal weight women. needs for almost all nutrients are greater during pregnancy for own bodies growth, for baby and successful lactation. the dietetic advice given to the mother should be reasonable and realistic to the individual women. key words: pregnancy, nutrition, weight gain. introduction good nutrition is the key to a successful pregnancy for both mother and child. it is especially important during child bearing years. the types and amount of food taken during pregnancy can affect the growth and development of the baby. what pregnant women eat will have a great impact on her unborn child during development and in the future. eating well can help her have a healthy pregnancy and a healthy newborn. it can also contribute to the development of wholesome eating habits for the growing child. during pregnancy, there is increased calorie requirement due to increased growth of maternal tissue, fetus, placenta and increased bmr. the increased calorie requirement is to extent of 300 kal over nonregnant state during 2nd half of pregnancy 1 . the diet during pregnancy should be adequate to provide –maintenance of maternal health, the need of growing fetus, the strength and vitality require during labour, successful lactation 2 . the mother’s nutrition from the moment of conception is an important factor in the development of the infants’ metabolic pathways and future well being. the pregnant women should be encouraged to eat a balanced diet and should be made aware of special needs for iron, folic acid, calcium and zinc 3,4 . weight gain during pregnancy all women need to gain weight during their pregnancy. adequate weight gain during pregnancy is needed to provide the mother and child with good nutrition. weight gain during pregnancy depends on pre-pregnancy weight gain. a healthy weight gain for most of the women is between 25 to 35lb. a gradual weight gain is important during the first 3 month, a weight gain of only 2lb to 4lb is adequate since the fetus is very small at this time. starting with the 4 th month of pregnancy, most women need an extra 300 calorie per day. after that a weight gain of ½ to 1 lb/week or 3 to 4lb/month is suggested. too much or too little weight gain may cause health problem for both mother and fetus. fetus is only part of weight gain. if weight gain is less, the chances of fetus for good health go down at birth and on later 1. asma rumanaz shahid, lecturer, department of anatomy, dhaka medical college, dhaka. email: rumanaz@gmail.com 2. asma-ul-hosna, assistant professor, department of obstetrics & gynaecology, bsmmu, dhaka. 3. ashraful alam, medical officer, department of obstetrics & gynaecology, bsmmu, dhaka. corresponds to: dr. asma rumanaz shahid, lecturer, department of anatomy, dhaka medical college, dhaka. email: rumanaz@gmail.com bangladesh journal of medical science vol. 11 no. 04 oct’12 267 life. under weight women may need to gain more, whereas obese women should gain only 7-11.5 kg (15-25lb). heavier women and those with excessive weight gain during pregnancy are likely to have macroscopic infants. inadequate weight gain is associated with small for gestational age (sga) infant. a weight gain of 11.5-16 kg (25-35lb) during singleton pregnancy is recommended. for a twin pregnancy, 35-45 lb, for a triplet 50lb weight gain is recommended.6,8 most healthy baby, weight gain between 7-8lb, some baby little less and some more. the fetus gain most of the weight and has rapid brain growth in last weeks of pregnancy 5,6,7. a women should not try to loose weight during pregnancy, because it she do not eat required calories or variety of foods, the baby will not get the nutrients, she or he needs to grow1,8,9. table-i: recommended weight gain during pregnancy as follows: 6,7,8. table-ii: based on a “normal” pre-pregnancy weight, this chart shows how the weight gained during pregnancy is distributed: 6,7,8. daily food guide and calorie requirement the pregnancy diet ideally should be light, nutritious, easily digestible and rich in protein minerals and vitamins. dietetic advice should be given with due consideration to the socioeconomic condition, food habit and the test of the individual. during pregnancy a women has different nutritional needs for different trimester. to meet extra food needs, a women need to add an average 300 kcal extra calories per day to her diet after first trimester. at this extra calories, with extra servings of milk, low fat cheese, lean meats, poultry, fish, leafy and dark green vegetables, dried beans and pear, fruits, whole grain and enriched breads and cereals 3,4 . women with normal bmi should eat as to maintain the schedule weight gain during pregnancy. diet2000-2500kcal/day for normal weight women and restriction to 1200-1800 kcal/day for over weight women is recommended. a healthy eating plan for pregnancy includes a variety of nutrient rich food. eating a variety of foods that provide enough calories help the mother and the body gain the proper amount of weight. during the first three month of pregnancy the pregnant women do not need to change the number of calories, she get from her food she eat. normal weight women need an extra 300 cal/day, during the last 6 month of pregnancy. this total amount 2000-2500 cal/day. if any one is under weight or over weight or obese before become pregnant or it is a twin pregnancy need of calories may be different 10,11,12 . table-iii: recommended daily dietary allowances for non pregnant and pregnant women are given below 3 pregnancy and nutrition 268 pre-pregnancy weight recommended weight average adult weight for height 25-35 lb under weight 28-40 lb over weight 15-25 lb obese 15 lb affected anatomy additional weight fetus 7.0lb placenta (after birth) 1.5lb amniotic fluid 2.0lb uterus 2.0 lb breasts 1.0 lb blood 3.0 lb fluid 3.0 lb fat 9.0lb total 28.5lb non pregnant women (age in years) pregnant women 15-18 19-24 25-50 50+ energy (kcal) 2100 2100 -2100 -2000 +300 protein (g) 48 46 46 46 +30 fatsoluble vit. vit. a (iu) 800 800 800 800 800 vit. d (iu) 400 400 200 200 400 vit. e (iu) 8 8 8 8 10 water soluble vit. vit. c (mg) 60 60 60 60 70 folate (ng) 180 180 180 180 400 niacin (mg) 15 15 15 13 17 riboflavin (mg) 1.3 1.3 1.3 1.2 1.6 thiamine (mg) 1.1 1.1 1.1 1.0 1.5 vit. b6 (mg) 1.5 1.6 1.6 1.6 2.2 vit. b12 (mg) 2 2 2 2 2.2 minerals calcium (mg) 1300 1000 1000 1200 1000 iodine (mg) 150 150 150 150 150 iron (mg) 15 15 15 15 30 magnesium (mg) 300 280 280 280 300 phosphorus 1200 800 800 800 1200 zinc (mg) 12 12 12 12 15 food groups needs for almost all nutrients (vitamin and minerals) are greater during pregnancy. nutrients are important for own body’s growth for baby and later for breast feeding 11 . healthy protein: at least half of the total protein should be first class containing all essential amino acid. good source of protein are chicken, fish, lean meat, low fat dairy products, eggs, bean and nut. fish is the source of dha. if any one is not able to eat fish, she should try other source of dha like, walnuts, wheat germ, omega 3 enriched eggs or consider taking a supplement with dha. healthy fat: majority of the fat should be animal type contain vit. a and d. pregnant and breast feeding women needs healthy fat for baby’s development. one should avoid transfat as food with hydrogenated or partially hydrogenated fat like many packaged and processed foods, friend foods and fast food. limits saturated fat like butter, whole milk dairy products, high fat meat. healthy fat, are found in olive oil, fatty fish, canola oil, peanut butter, nuts, seeds etc. healthy carbohydrates: fruits and vegetables are healthy source of carbohydrates. dark and bright colour fruits and vegetables are richer source of vitamins and minerals. whole fruit rather than juice is acceptable. eat whole grain products like brown rice, whole wheat bread etc. limit instant grains and refined carbohydrate like cookies, soda etc. fluid: one should drink enough water to never feel thirsty. so urine is light in colour. choose pasteurize low fat milk, limit juice and beverage which are high in calories. vitamins and minerals: if any one is planning for pregnancy, she should take vitamins and minerals supplement that includes 400mg of folic acid to prevent birth defect and 200-400 i.u of vit. d. in some cases a women’s diet may not include enough of a certain nutrient such as iron, or calcium and additional supplement may be necessary. women, who follow vegetarian diet, usually require vit. b12, d and zinc. during pregnancy she should take prenatal vitamin and mineral supplement that includes 220 µg of iodine and does not contain more than 30 mg of iron. to get calcium, drink 2-3 cup of low fat milk. if any body cannot to get needed calcium through food to take calcium supplement. the pregnant women may need vit. b12 supplement, if she is complete vegetarian, calcium supplement under age 25 years specially if she does not drink enough milk 10,11,12 . iron and folate: the amount of iron and folate in diet is very important. so one should eat food containing these nutrients often. iron; more iron is needed during pregnancy for the baby. but it is hard to get enough iron from food alone. there is a negative iron balance during pregnancy and the dietetic iron is not enough to meet the daily requirement specially in the 2nd half of pregnancy. thus the supplement iron therapy is needed for all pregnant mothers from 16 weeks onwards. iron should be taken in between meals or at bed time on an empty stomach for its better absorption 1,2 . the iron in meat, fish and poultry is more readily absorbed by the body than the iron in plant foods. to increase iron absorption, eat plant foods with meat or with foods that contain vit. c 10,11,12 . folate : folate is a ‘b’ vitamin that helps body to make rbc and genes. during pregnancy, double amount of folate is needed. pregnant women should eat various food containing folate, to get its required amount 1,2,10 . table-iv: food sources of iron and folate 3,4 : iron rich food folate rich food lean meat, poultry, fish, organ meat such an liver. dried beans and peas dark green vegetables whole grain and enriched breads and cereals. liver dried beans and peas dark green leafy vegetables whole grain breads and cereals, cereals fortified with folic acid. fruits (such as oranges and orange juice, grape fruit, bananas, tomatoes). sodium: salt does not need to be restricted in pregnancy for most of the women to avoid excessive salt, limit intake of highly process food such as canned soup, salted snacks etc. 13,14,15,16 . food safety and preparation during pregnancy women are at increased risk of food born illness because of hormonal changes during pregnancy weakens the immune systems. so, one should wash hands before and after food preparation. wash fruits and vegetable well. food should be cook well. meat, fish, eggs and poultry should asma rs, asma-uh, ashraful a 269 properly handled. egg should be cooked until firm. avoid half done food, raw meat, unpasturized milk17. avoidance of food there are certain foods and beverage that are harmful for the fetus, if they are taken during pregnancy. fish with high level of methyl mercury soft cheese – goat cheese, ready to eat meatcontain bacteria (listeria) which are harmful for unborn baby. raw or undercooked fish, meat or poultry. drinking alcohol can be dangerous to unborn child. more than 50% of the child born alcoholic mother syndrome, miscarriage, low birth weight. so both the rda and the us surgeon general have recommended that pregnant women should avoid drinking any alcohol during pregnancy18. large amount of caffeine containing beverage. caffeine is stimulant found in coffee, tea, coca-cola and some drugs. pregnant women should take controlled food containing tea/coffee. women who smoke, put their babies at much higher risk of premature birth, low birth weight and still birth compared to non smoker, so pregnant women should avoid smoking5,19. some drugs are appropriate for use during pregnancy. but there are some drugs, those are contraindicated during pregnancy. women should avoid taking drugs in the first trimester unless it is indicated for any medical indication8. anything that are not food. some pregnant women may have crave for something that are not food such as laundry starch, clay etc20. women during her pregnancy period should avoid taking lots of cookies, candies, cakes, chips, soft drinks and fats such as butter, margarine, gravy, fried foods, salad dressings and mayonnaise. these high calorie foods provide very little nourishment for the mother and the baby21,22. conclusion pregnancy is a specially important time in women’s life to focus on proper health care and nutrition. it is important to take a life cycle approach to the issue improving nutrition among child bearing women and their children rather than focusing solely on nutrition during pregnancy and postpartum period. nutrition during childhood and adolescence influence a women’s pre-conceptional nutritional status which subsequently influence the outcome of pregnancy and health of the baby. malnutrition is perpetuated across generation via this cycle. for this reasons, programme to improve the nutrition of women and children must be comprehensive targeting all stages of life cycle23, 2527. policy makers and service provider’s can take action by making maternal and child nutrition and integral part of the comprehensive programme that serve women and children. references 1. american red cross. better eating for better health: participant's guide. i'm pregnant: what should i eat? washington, d.c.: american red cross, 1984. pmid:12650145 2. iom. (institute of medicine). food and nutrition board. nutrition during pregnancy, executive summary. report of the subcommittee on nutritional status and weight gain during pregnancy and the subcommittee on dietary intake and nutrient supplements during pregnancy. washington, d.c.: national academy press, 1990. 3. nrc. (national research council). food and nutrition board. recommended dietary allowances. 10th rev. ed. washington, d.c.: national academy press, 1989. pmid:12444835 4. united states department of agriculture/united states department of health and human services. home and garden bulletin no. 232. nutrition and your health: dietary guidelines for americans. fifth edition, 2000. 5. american college of obstetricians and gynecologists: smoking cessation during pregpregnancy and nutrition 270 nancy. acog educational bulletin no. 260, september 2000. 6. abraham b, altman sl, picker ke; pregnancy weight gain; still controversial. am j clin nutr 2000; 71 (suppl); 12335. pmid:19788746 pmcid:2762469 7. the millennium development goals report 2007, new york: united nation; 2007. pmid:15072759 8. institute of medicine. subcommittee on nutritional status and weight gain during pregnancy. nutrition during pregnancy: part i, weight gain : part ii, nutrient supplements / subcommittee on nutritional status and weight gain during pregnancy, subcommittee on dietary intake and nutrient supplements during pregnancy, committee on nutritional status during pregnancy and lactation, food and nutrition board, institute of medicine, national academy of sciences. washington, dc: national academy press; 1990. pmid:11023760 9. suitor cw. 1997. maternal weight gain: a report of an expert work group. arlington, va: national center for education in maternal and childhealth.pmid:19193292 pmcid:2657644 10. children’s hospital medical center of akron. 1997. what you should know about folic acid: for parents who have lost a pregnancy or had a child with spina bifida, anencephaly, or encephalocele. akron, oh: children’s hospital medical center of akron. pmid:18455958 11. institute of medicine. food and nutrition board. 1998. dietary reference intakes for thiamin riboflavin, niacin, vitamin b6, vitamin b12, panthothenic acid, biotin, and choline. washington, dc. national academy press. 12. institute of medicine. subcommittee on nutrition during lactation. nutrition during lactation / subcommittee on nutrition during lactation, committee on nutritional status during pregnancy and lactation, food and nutrition board, institute of medicine, national academy of sciences. washington, dc: national academy press; 1991. pmid:19235872 13. cousinss l. pregnancy compilations among diabetic women: review 1965-1985. obstet gynecol surv 1987; 42: 140-48. 14. national academy of sciences, institute of medicine, food and nutrition board, committee on nutritional status during pregnancy and lactation. 1992. nutrition during pregnancy and lactation: and implementation guide, washington, dc: national academy press. 15. adams kl, hongshe l, nelson rl, et al. sequelae of uncrecognized gestational diabetes. am j obstet gynecol 1998; 178: 1321-32. pmid:18536887 16. march of dimes. nutrition today matters tomorrow: a report from the march of dimes task force on nutrition and optimal human development. wilkes-barre, pa: march of dimes; 2002. pmid:9466772 pmcid:104573 17. c caballero b, popkin bm, eds. the nutrition transition: diet and disease in the developing world. new york, ny: academic press; 2002. 18. centers for disease control and prevention: update: trends in total alcohol syndrome – united states, 1979-1993. mmwr morb mortal wkly rep 1995; 44: 13. 19. american college of obstetrician and gynecologists: smoking cessation during pregnancy. acog educational bulletin no. 260, september 2000. 20. national academy of sciences, institute of medicine, food and nutrition board, committee on nutritional status during pregnancy and lactation. 1992. nutrition services in perinatal care (2nd ed.). washington, dc: national academy press. 21. institute of medicine. subcommittee on nutritional status and weight gain during pregnancy. nutrition during pregnancy: part i, weight gain : part ii, nutrient supplements / subcommittee on nutritional status and weight gain during pregnancy, subcommittee on dietary intake and nutrient supplements during pregnancy, committee on nutritional status asma rs, asma-uh, ashraful a 271 during pregnancy and lactation, food and nutrition board, institute of medicine, national academy of sciences. washington, dc: national academy press; 1990. pmid:14730271 22. united states department of agriculture/united states department of health and human services. home and garden bulletin no. 232. nutrition and your health: dietary guidelines for americans. fifth edition, 2000. 23. iom. (institute of medicine). food and nutrition board. nutrition during pregnancy, executive summary. report of the subcommittee on nutritional status and weight gain during pregnancy and the subcommittee on dietary intake and nutrient supplements during pregnancy. washington, d.c.: national academy press, 1990. pmid:20404458 24. joseph ks. validating the fetal origins hypothesis: an epidemiologic challenge. in: black re, michaelsen kf, eds. public health issues in infant and child nutrition. philadelphia, pa: lippincott, williams & wilkins; 2002:295-316. nestle nutrition workshop series; vol. 48. 25. ogden cl, flegal km, carroll md, johnson cl. prevalence and trends in overweight among us children and adolescents, 1999-2000. jama journal of the american medical association 2002; 288(14):1728-1732. pmid:19287833 26. islam mz, h shaila, z farzana. reproductive health profile of married women: experience from a rural community of bangladesh. bangladesh journal of medical science 2011; 10(04): 252-256.pmid:1950639. doi: http://dx.doi.org/10.3329/bjms.v10i4.9496 27. s jahan, t gosh, m begum, bk saha. nutritional profile of some tropical fruits in bangladesh: specially anti-oxidant vitamins and minerals. bangladesh journal of medical science 2011; 10(02): 95-103. doi: http://dx.doi.org/10.3329/bjms.v10i2.7804 pregnancy and nutrition 272 page mackup july-14.qxd bangladesh journal of medical science vol. 13 no. 04 october’14 454 original article visual inspection with acetic acid (via) in cervical cancer screening in low resource settings shaheen1, sharma r2, rashi3 introduction: cervical cancer is the second most common cancer in women, and 80% of these cases occur in underdeveloped countries1. it comprises 15% of the cancers diagnosed in women in underdeveloped countries. it kills approximately 270,000 women worldwide each year, with nearly 85% of those deaths occurring in resource-poor settings2. while the incidence and mortality rates of cervical cancer have declined in developed countries since the advent of successful screening programs3-5, there has been no such trend in developing countries. screening programs were implemented in developing countries since the early 1980’s, yet have failed to reduce the mortality rates. the who in 2002 estimated that only 5% of women in developing countries are screened appropriately. likely reasons for failure in screening programs include lack of funding, insufficient access in rural areas where most of the population in developing countries reside, lack of awareness/education as to need for screening, and poor follow-up. about 50% of all cancers occur in developing countries, yet only 5% of resources are spent on the fight against cancer worldwide. india accounts for one-fifth of the world burden of cervical cancer and continues to be the most common genital cancer1. in india approximately, 90,000 new cases of cancer cervix occur every year. the incidence in india is 45 per one lakh women6. in developing countries as in india, alternative, lowcost and effective early diagnosis methods are needed. visual inspection with acetic acid(via) is a simple and easy-to-learn method and does not require laboratory equipment. test results are immediate after administration. via is an attractive method for these reasons in underdeveloped countries7-9. with suspicious lesions detected, corresponds to: prof. r sharma, 2/65,vishnupuri, aligarh, up (india) email: rajyashri.sharma@gmail.com abstract: objective: to evaluate the feasibility and validity of visual inspection of the cervix with acetic acid (via) for screening cervical intraepithelial neoplasia. materials and methods: in this study, 942 women recruited from gynecology outpatient clinic, were screened using the papanicolaou (pap) smear, and via. the sensitivity and specificity of both the screening methods were analyzed. results: via was positive in 29.3%. the sensitivity of via (74.16%) was much higher than that of the pap smear (47.83%). the specificity of via (50.00%) was lower than that of the pap smear (74.16%), resulting in high false-positive rates for via. conclusion: visual inspection of the cervix with acetic acid is sensitive for ectocervical lesions. the advantage of the via method lies in its easy technique, low cost and high sensitivity which are important factors for determining the efficacy of any screening program in developing countries. keywords: cervical cancer screening; papanicolaou (pap) smear; visual inspection of the cervix with acetic acid (via) 1. dr. shaheen, associate professor, department of obstetrics & gynecology, jn medical collage, amu, aligarh 2. dr. rajyashri sharma, professor, department of obstetrics & gynecology, jn medical collage, amu, aligarh 3. dr. rashi, postgraduate, department of obstetrics & gynecology, jn medical collage, amu, aligarh doi: http://dx.doi.org/10.3329/bjms.v13i4.15019 bangladesh journal of medical science vol. 13 no. 04 october '14. page: 454-459 women are directed to further treatment8,10,11. visual inspection-based approaches to cervical cancer screening have been extensively investigated in india. the performance characteristics of unaided visual inspection (without acetic acid), also known as ‘‘downstaging’’, has been addressed in several studies12. the purpose of this study was to test the validity of via in cervical cancer screening (sensitivity, specificity, and positive and negative predictive values) and compare it with findings from the papanicolaou test. material and methods: this hospital based prospective cohort study was carried out in j n medical college hospital at aligarh in the out patient department of obstetrics and gynecology between june 2008 and september 2010. nine hundred forty two women with inclusion and exclusion criteria were screened for cin and early cervical cancer. the study protocol was reviewed and approved by institutional ethical committee and informed consent was obtained from each woman. relevant obstetric and gynecological history was obtained and recorded. inclusion criteria: all women exposed to early sexual life, with multiple sexual partners, low socioeconomic status, having history of std’s, with foul smelling discharge and with post coital bleeding were included in the study. exclusion criteria unmarried women, women with frank invasive cancer cervix, women with bleeding per vaginum, and pregnancy were excluded. all women were subjected for per speculum examination to observe the size and shape of the cervix, the external os identified with pinkish squamous epithelium and reddish columnar epithelium and transformation zone. the pap smear was taken and two samples were taken one from ectocervix and other from endocervix. the pap smear slide was immediately fixed with 90% ethyl alcohol. later, the slide was sent for cytology in the department of pathology, j n, medical college hospital, aligarh. pap smear reporting was done according to the bethesda classification . after taking pap smear, the same women were subjected to visual inspection of the cervix after application of 5% acetic acid. using a cotton swab soaked in acetic acid was applied on cervix for one minute and then the cervix was carefully inspected for any aceto-white lesions, particularly in the transformation zone. reporting of test outcome in the study, test was reported as positive, negative and inconclusive via test. positive test: visualization of the dense acetowhite lesion with sharp margins located in the transformation zone, close to squamo-coloumner junction (scj). negative test: if no acetowhite lesions were observed on the cervix polyps protruding from cervix, bluish white in color, nabothian cysts which appear as button like areas as whitish area or pimples, dot like areas present in the endocervix which were due columnar epithelium staining with acetic acid; if there were shiny pinkish white, cloudy white or bluish white, faint patchy or doubtful lesions with ill defined, indefinite margins or irregular, acetowhite lesions resembling geographical lesions away from the scj. if via turns out to be positive the patient was subjected to further investigations such as colposcopy and guided biopsy. statistical analysis the results of visual inspection of cervix with acetic acid (via) were correlated with that of pap smear on the basis of sensitivity, specificity and positive and negative predictive value. results: of the 942 women who participated, 45.5% were 31 to 40 years of age and 38.9% were 20 -30 years; the mean (sd) age was 34.52±2 years. all (100%) were married, 53.33% were married when they were 15 years or younger, and 39.61% married between the ages of 18 and 20 years. in the observations made after the application of the acetic acid, via was negative in 79.7% of the women and positive in 29.3% of the women (table 1). similarly, 80.10% of the women had negative smear test results and 18.89% had positive smear test results. when the papanicolaou test results were classified according to the bethesda system, 42.89% of the women had normal smear test results, 38.22% of them had an inflammatory smear, 2.12% had atypical squamous cells of undetermined significance (ascus), 0.42% had atypical glandular cell of undetermind significance (agus), 9.13% had low grade squamous intraepithelial lesion (lsil), and 7.22% had high grade squamous intraepithelial lesion (hsil) (table 1). using the papanicolaou test, the sensitivivisual inspection with acetic acid (via) in cervical cancer screening 455 ty of via was 74.16% and specificity was 50.00%. the positive predictive value (ppv) of via was 47.83%, and its negative predictive value (npv) was 75.78% (table 2). discussion: in our study via was positive in 29.30%, which is almost comparable to studies by tayyeb et al, 28.9%9,belinson et al13 , 27.3%, and doh et al14, 21.7% (table 3). in our study with via, results for sensitivity and specificity were 74.16%, and specificity of 50.0% which is almost comparable to studies shown in londhe et al15 as sensitivity 72%, and specificity 54% (table 4). other studies were showing the sensitivity of 71% and specificity of 74% in belinson et al13, and sensitivity of 67% and specificity of 83.0% in denny et al16, in the johns hopkins' program for international education in reproductive health (jhpiego)11, sensitivity was 77% and specificity was 64%. additional results from other studies are listed in more detail in table 4. when the studies made by using acetic acid in the recent years are examined, it is seen that the sensitivity of via is between 60% and 95.7% and its specificity is between 30.4% and 98%9,17-19. decreasing via specificity means a risk of increased false-positive patient ratio. for this reason, treatment may be recommended for some women who have no neoplasm or have a low-stage disease. despite such risks, via is still the most cost-efficient prognostic method for the underdeveloped countries. in our study, similar to the findings of some other studies (table 4) made in other countries, via sensitivity was high, as noted in the outcomes of the comparisons of via and papanicolaou test results. this finding highlights the importance of training and experience for the clinicians who are completing the visual evaluations. in our study, via specificity was low, as noted in the outcomes of comparing via with papanicolaou test results, perhaps in part because inflammatory lesions become aceto-white. also, several other variables affect the performance of via as the light source, which should be white and condensed and the training and experience of the observer. the reasons behind the via specificity being high or low in different researches could be the personnel completing the via assessment, clinical criteria not properly used, differences between the research populations, and women with inflammatory conditions included in some but not all of the studies14,18,20-22 . in our study, when the via and papanicolaou test results were compared, ppv (47.83%) was low and npv (75.79%) was high, which means that when a test is negative, the women can go home reassured that she is not likely to have shaheen, sharma r, rashi 456 no. % via negative 666 70.7 positive 276 29.3 total 942 100.0 papanicolaou test negative 764 81.1 positive 178 18.9 total 942 100.0 bethesda system normal 404 42.89 inflammatory lesions 360 58.04 agus 4 0.42 ascus 20 2.12 lsil 86 9.13 hsil 68 7.22 total 942 100.0 abbreviation: via, visual inspection with acetic acid. table 1: distribution of via and papanicolaue test results via positive negative total positive 132 144 276 negative 46 144 190 total 178 288 464 table 2: sensitivity and specificity of via versus papanicolaou test outcome abbreviation: npv, negative predictive value; ppv, positive predictive value, via, visual inspection with acetic acid. sensitivity: 74.16%; ppv, 47.83%; specificity, 50.00%; npv, 75.79%. papanicolaou test table 3: results of via for other countries author(s) (year) via positive (%) country no. of women londhe et at (1997) 52.96 india 372 ardahan et al (2011) 9.7 turkey 350 belinson et al (2001) 27.3 china 1977 denny et al (2002) 18.1 africa 2754 tayyeb et al (2003) 28.9 pakistan 501 goel et al (2005) 12.5 new delhi 400 doh et al (2005) 21.7 cameroon 4813 present study (2011) 29.3 aligarh(india) 942 a neoplastic cervical lesion; eliminating the need for follow-up visits. however, the low ppv of via does present the problem of many false positives, discouraging the see-and-treat method. however, ppv is dependent on incidence and if a see-and-treat method were implemented in a high-risk population with a high incidence of cervical cancer, the qualities of the via test may improve. therefore, the “seeand-treat” method with via could be accepted by patients in developing countries like india. conclusion: via is an adequate and acceptable screening method for cervical cancer. furthermore, in low-resource areas like india, via can be better than cytology for its ease of use and low cost. cytology based screening programmes are difficult to organize owing to limited infrastructure, trained personnel, and funds. our results outline the potential benefits of using via based screening at all levels of health care systems in developing countries. there is therefore, the time has come, to integrate via based screening programs at the primary care level of health services, and to downstage cancer cervix in our country. visual inspection with acetic acid (via) in cervical cancer screening 457 author(s) country no. of women sensitivity specificity megevand et al (1996) south africa 2426 65 98 londhe et al (1997) india 372 72 54 zimbabwe university jhpiego (1999) zimbabwe 2203 77 64 denny et al (2000) africa 2944 67 83 belinson et al (2001) china 1977 71 74 tayyeb et al (2003) pakistan 501 93.9 30.4 wu et al (2003) china 1997 70.9 74.3 bhatla et al (2004) india 100 87.5 63 el – shalakany et al (2004) egypt 2049 85.5 96.8 ghaemmahani et al (2004) iran 1200 74.3 94 sankaranarayanan et al (2004) india 18675 60.3 86.8 goel et al (2005) new delhi 400 96.7 36.4 vuyst et al (2005) nairobi (kenya) 853 73.3 80.0 shastri et al (2005) mumbai (india) 4039 59.7 88.4 doh et al (2005) cameroon 4813 70.4 77.6 eftekhar et al (2006) iran 200 95.7 44.0 sodhani et al (2006) india 472 86.7 90.7 chumwonathayi et al (2008) thailand 648 60.0 93.9 cagle et al (2009) china 1839 69.5 89.0 ardhahan et al (2011) turkey 350 82.4 50 present study india 942 74.16 50.0 table 4: comparison of sensitivity and specificity of via with other studies shaheen, sharma r, rashi 458 references: 1. sankaranarayanan r, budukh am, rajkumar r. effective screening programmes for cervical cancer in low-and middle-income developing countries. bull world health organ. 2001;79(10):954-962. 2. ferlay j et al., globocan 2002: cancer incidence, mortality and prevalence world wide, version 2.0, lyon, france: international agency for research on cancer, 2004, <http://www.dep.iarc.fr/globocan/database.htm>, accessed may 16, 2008. 3. haydaroglu a. epidemiology in gynaecologic cancers. izmir, turkey: gynaecologic oncology symposium; 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1 7 ( 6 ) : 3 4 8 3 5 2 . http://dx.doi.org/10.1111/j.1365-2303.2006.00351.x 31. ardahan, malek, temel, ayla. visual inspection of acetic acid in cervical cancer screening. canc. nursing. 2 0 1 1 , 3 4 ; ( 2 ) : 1 5 8 1 5 3 . http://dx.doi.org/10.1097/ncc.0b013e3181efe69f visual inspection with acetic acid (via) in cervical cancer screening 459 page mackup july-14.qxd bangladesh journal of medical science vol. 13 no. 04 october’14 421 original article an educational intervention program on knowledge about oral hygiene measures karim f1, begum j2 introduction: oral health knowledge is considered to be an essential prerequisite for health-related practices1, there is an association between increased knowledge and better oral health2,3. those who have assimilated the knowledge and feel a sense of personal control over their oral health are more likely to adopt selfcare practices4. now-a-days oral disease can be considered as a public health problem due to its high prevalence and significant social impact. chronic oral disease typically leads to tooth loss, and in some cases have physical, emotional and economical impacts5. physical appearance and diet are often worsened and the pattern of daily life and social relations are also often negatively affected. these impacts lead in turn to reduce welfare and quality of life. to minimize these negative impacts of chronic oral diseases, there is a clear need to reduce harmful oral health habits. such a reduction can be achieved through appropriate health education program5,6 . bangladesh is a developing country with a vast population. many people of this country live below poverty line. they possess a harmful life style for health, especially oral health. dental problem is still a significant public health problem in both developed and developing countries. good oral health is a key for ensuring overall well being. our teeth play corresponds to: dr. farzana karim, assistant professor, department of paediatric dentistry, marks dental college, mirpur-14, dhaka, bangladesh. e-mail: bluebird4445@yahoo.com abstract: background: health education is a process of transmission of knowledge and skills necessary for improvement in quality of life. objectives: the purpose of this quasi-experimental study was to evaluate the oral hygiene related knowledge among the population in a selected community before and after health education. materials and methods: a total of 106 respondents were taken purposively at south pirerbag of dhaka city. baseline data were collected by pre-tested structured questionnaire. an educational intervention program was conducted by dividing the respondents into seven groups, 15 in each group; method was group discussion and lecture; poster, model of teeth and brush were the aids. post intervention data were collected by the same questionnaire. results: among the respondents, 61.32% were male and 38.68% were female, mean age was 46.25 years, 35.85% had primary level education, monthly family income was tk 5000-10000 in 66.98%. before intervention 64.15% told that teeth should be cleaned twice daily, 62.26% told teeth should be cleaned by brush and paste and 2.83% told teeth should be cleaned after breakfast and night; whereas after intervention the result was 91.51%, 85.85% and 67.93% respectively. before intervention 66.98% stated that tobacco is hazardous to health but 32.4% have no idea about the type of diseases that occur due to tobacco; whereas after intervention 89.62% told that tobacco is hazardous to health and most of them had idea about harmful effect of tobacco. conclusion: educational intervention program is effective to improve the knowledge of the respondents about oral hygiene. keywords: knowledge; oral hygiene; health education 1. dr. farzana karim, assistant professor, department of paediatric dentistry, marks dental college, mirpur, dhaka, bangladesh. 2. dr. jahanara begum, assistant professor and head, department of health promotion and health education, national institute of preventive & social medicine, mohakhali, dhaka, bangladesh. doi: http://dx.doi.org/10.3329/bjms.v13i4.20589 bangladesh journal of medical science vol. 13 no. 04 october '14. page: 421-426 an important role in our daily lives. it increases the beauty of the face, helps in digestion of food by chewing and grinding and enables to articulate and pronounce words correctly while talking. in order to establish oral hygiene as an important prophylactic measure influencing successful protection of oral health of the whole population, it is necessary to inform as many people as possible about oral hygiene effectiveness and its necessity in preventing oral and dental diseases; to develop the habits of regular oral hygiene maintenance in the people. regarding high prevalence of dental problem in population, the issue of prophylaxis is of great significance. in that respect, health education should point out to the significance of proper and regular oral hygiene, all aimed at preventing dental diseases. the purpose of the study is to assess the knowledge about oral hygiene among the population in a selected community before and after health education. the information from this study will help policy makers to identify the information gaps and formulate guidelines and act as a baseline for further study. methodology: study design: this was a quasi-experimental type of study. in this study the outcome of educational intervention is obtained by comparing pre and post intervention on knowledge of the same group of people. the study was carried out at south pirerbag, dhaka. the study population was selected randomly irrespective of age, sex and religion. participation was voluntary. the sample size was 106. the sample was collected by non probability purposive sampling. data collection procedure: a structured questionnaire was developed based on the objectives and variables of the study. it was finalized after modification and correction based on the findings of questionnaire pretesting. before collection of data permission was taken from the respondents. the purpose of the study was explained to the respondents prior to administering the interview. with the consent of the respondents data was collected by face to face interview by using bengali version questionnaire. the study population was interviewed twice with the same sets of structured questionnaire. at first baseline data were collected. after collection of baseline data, health education program was conducted by preparing a lesson plan according to the objectives. second phase of data was collected after intervention. the privacy of the respondents was maintained strictly. this study was not involved any physical, mental and social risk of the respondents. data processing and analysis: after collection of information through questionnaire, the data were coded, entered and analyzed in a computer. the findings of the study were presented by frequency, percentage and table and data analysis was done using statistical package for social sciences or spss version 14 (chicago, il, usa). educational intervention program according to the baseline information an educational curriculum was prepared with necessary educational materials for health education intervention program. a total 106 respondents were selected purposively. they were divided into seven groups, each groups consist of 15 respondents. the allocated time was thirty minutes for each group. the respondents were informed previously according to scheduled date and time. health education intervention session was conducted using various methods (lecture, group discussion) and media (poster, model of teeth, tooth brush) for dissemination of knowledge. the program was evaluated on the basis of change in knowledge about oral hygiene before and after intervention by applying structured questionnaire.post intervention data collection was started after 15 days of educational intervention program. results: in this study 106 respondents were participated with mean age 46.25 ± 11.27 years. majority of them had only school level education and others were illiterate. mean monthly family income was 7520.94 ± 320.40 taka. among the respondents 61.32% were male and 38.68% were female. among 106 respondents, before intervention 64.15% respondents told that teeth should be cleaned twice daily and 25.47% respondents told once daily; whereas after intervention it was changed into 91.51% and 4.72% respectively. (table-1). knowledge about oral hygiene measures 422 frequency of tooth cleaning before intervention after intervention frequency percent frequency percent once daily 27 25.47 5 4.72 twice daily 68 64.15 97 91.51 thrice daily 11 10.38 4 3.77 total 106 100.00 106 100.00 table 1: distribution of the respondents by knowledge on frequency of tooth cleaning before and after intervention (n=106) before intervention 62.26% respondents told that teeth should be cleaned by tooth brush and tooth paste, 20.76% respondents told tooth powder, rest of them told coal, miswak and ash were ideal tooth cleaning materials; whereas after intervention 85.85% respondents told that teeth should be cleaned by tooth brush and tooth paste, 10.38% respondents told tooth powder (table-2). before intervention 72.64% respondents told that people should visit to dentist when dental problem occur and 10.38% respondents told taking drug from pharmacy; whereas after intervention percentage towards dental visit was increased into 95.28%. (table-3) table -4 shows the distribution of the respondents by knowledge on time of tooth cleaning before and after intervention. among 106 respondents 26 (24.53%) told teeth should be cleaned before breakfast, 2 (1.89%) told after breakfast, 9( 8.49%) told every after meal, 66 (62.26%) told before breakfast and before going to bed, 3 (2.83%) told after breakfast and before going to bed ; where after intervention 10 (9.43%) told teeth should be cleaned before breakfast, 1 (0.94%) told after breakfast, 6 (5.66%) told every after meal, 17 (16.04%) told before breakfast and before going to bed, 72 (67.93%) told after breakfast and before going to bed. table – 5 shows that before intervention 42 ( 39.62%) respondents told that after every meal teeth should be cleaned by gargling with water, 11 (10.38%) respondents told tooth brushing, 39 (36.79%) respondents told nothing and 14 (13.21%) karim f, begum j 423 materials used for tooth cleaning before intervention after intervention frequency percent frequency percent tooth brush & tooth paste 66 62.26 91 85.85 tooth powder 22 20.76 11 10.38 coal 6 5.66 1 0.94 miswak 7 6.60 3 2.83 ash 5 4.72 0 0 total 106 100.00 106 100.00 table -2: distribution of the respondents by knowledge on materials used for tooth cleaning before and after intervention (n=106) duration of tooth cleaning before intervention after intervention frequency percent frequency percent less than 1 minute 19 17.92 9 8.50 1-2 minutes 26 24.53 78 73.58 3-5 minutes 38 35.85 19 17.92 don’t know 23 21.70 0 0 total 106 100.00 106 100.00 table – 3: distribution of the respondents by knowledge on duration of tooth cleaning before and after intervention (n=106) time of tooth cleaning before intervention after intervention frequency percent frequency percent before breakfast 26 24.53 10 9.43 after breakfast 2 1.89 1 0.94 every after meal 9 8.49 6 5.66 before breakfast and night 66 62.26 17 16.04 after breakfast and before going to bed 3 2.83 72 67.93 total 106 100.00 106 100.00 table -4: distribution of the respondents by knowledge on time of tooth cleaning before and after intervention (n=106) cleaning teeth after every meal before intervention after intervention frequency percent frequency percent gargling with water 42 39.62 98 92.45 tooth brushing 11 10.38 5 4.72 nothing 39 36.79 3 2.83 don’t know 14 13.21 0 0 total 106 100.00 106 100.00 table -5: distribution of the respondents by knowledge on cleaning teeth after every meal before and after intervention (n=106) respondents did not know the answer where after intervention 98 (92.45%) respondents told that after every meal teeth should be cleaned by gargling with water, 5 (4.72%) respondents told tooth brushing. table – 6 shows that before intervention 77 (72.64%) respondents told that measures taken during dental problem should be go to dentist, 18 (16.98%) respondents told gargling with warm salt water and 11 (10.38%) respondents told taking drug from pharmacy; where after intervention 101 (95.28%) respondents told that go to dentist in a dental problem is correct decision, 5 (4.72%) told gargling with warm salt water and no respondent was positive for taking drug from pharmacy in a dental problem. table – 7 shows that before intervention 71 ( 66.98%) respondents told that tobacco is hazardous to health, 35 (33.02%) respondents told tobacco is not hazardous to health; where after intervention 95 (89.62%) respondents told that tobacco is hazardous to health and 11 (10.38%) respondents told that tobacco is non hazardous to health. table – 8 shows that before intervention 23 (32.40%) respondents did not know what kind of disease occur due to smokeless tobacco consumption. 12 (16.90%) respondents told that smokeless tobacco cause both bad breath and stain in tooth, 7 (9.86%) told cancer, 9 (12.68%) told bad breath only; where after intervention 63 ( 66.32%) respondents told that smokeless tobacco cause ulcer, stain, bad breath, loss of taste and cancer all, 9 (9.47%) told both bad breath and stain of tooth and 6 ( 6.32%) told cancer only. discussion: this educational intervention study was carried out among the general population in a selected community with a view to assess the effect of health education about oral hygiene measures. a total 106 respondents were interviewed with structured questionnaire and an educational intervention program was conducted which was evaluated after intervention. among 106 respondents maximum 35 (33.02%) belongs to 4150 years age groups, 28(26.42%) belonged to 31-40 years, 22 (20.75%) were 51-60 years, 14(13.21%) were 61-70 years and 7 (6.60%) belonged to 21-30 years. the mean age was 46.25± 11.27 years. about 38 (35.85%) of respondents were primary level education, 28 (26.41%) were secondary level, 27 (25.47%) were illiterate, 11 (10.38%) were s.s.c. passed and 2 (1.89%) were h.s.c. passed. among the respondents 37 (34.90%) were day laborer, 19 (17.92%) were service holder, 17 (16.04%) were housewives, 11 (10.38%) were rickshaw puller, 9 (8.49%) were driver, 8(7.55%) were businessman and 5 (4.72%) were self employed. majority 71 (66.98%) of the respondents monthly family income within taka 5000 – 10000, 25 knowledge about oral hygiene measures 424 measures taken during dental problem before intervention after intervention frequency percent frequency percent taking drug from pharmacy 11 10.38 0 0 go to dentist 77 72.64 101 95.28 gargling with warm salt water 18 16.98 5 4.72 tables 6: distribution of the respondents according to knowledge on measures taken during dental problem before and after intervention (n=106) tobacco is hazardous to oral health before intervention after intervention frequency percent frequency percent yes 71 66.98 95 89.62 no 35 33.02 11 10.38 total 106 100.00 106 100.00 table -7: distribution of respondents by opinion on effect of tobacco on oral health before and after intervention (n=106) type of disease before intervention after intervention frequency percent frequency percent cancer 7 9.86 6 6.32 bad breath 9 12.68 3 3.16 stain in tooth 6 8.45 5 5.26 loss of taste, ulcer in the mouth 5 7.04 4 4.21 bad breath, cancer 5 7.04 5 5.26 bad breath, stain in tooth 12 16.90 9 9.47 ulcer, stain, bad breath, cancer, loss of taste 4 5.63 63 66.32 don’t know 23 32.40 0 0 total 71 100.00 95 100.00 table – 8: distribution of the respondents by knowledge on type of disease occur in the mouth due to smokeless tobacco use before and after intervention (23.59%) respondents family income below 5000, 7 (6.60%) respondents family income between 1100015000 and 3 (2.83%) respondents family income more than taka 15000. oral health includes preservation of dentition and maintenance of good oral hygiene. dental diseases—such as dental caries (tooth decay) and periodontal disease (gum diseases)—cause pain, discomfort on chewing, hypersensitivity, and bad breath. tooth loss may restrict choices of food, and be associated with loss of pleasure in eating,4 decline in self-confidence7, poor articulation and malnutrition. chewing difficulties are associated with a personal perception of poor health and depression8. oral health affects the quality of life. thus, good oral hygiene benefits both oral and general health. this educational intervention study showed that the knowledge of the respondents regarding oral hygiene measures was improved after health educational intervention. this was similar to a study done by hebbal et al. in belgaum, india9. similar result was found in the study done by shenoy in india, thomas in kerala and tewari in ambala10-12. though after intervention the percentage of the respondents on oral hygiene knowledge slightly improved, but the increase percentage is not satisfactory. the concerned authority can play a vital role to improve the knowledge on everyday science and personal hygiene including oral hygiene among the mass population in bangladesh. hence we may get a generation free of oral diseases and a good oral health. conclusion: the change to healthy attitude and knowledge can be occurred by giving adequate information and motivation to the respondents. therefore dental health education is needed focusing on the special needs of the population to improve their quality of life. recommendation: on the basis of the findings of the present study following recommendations were drawn: community oriented intervention program for community people should be arranged. provide effective and appropriate messages on oral health through mass media such as radio, television, newspaper, folk song, billboard etc. educational intervention program should be arranged at school, work place and hospital. include a chapter on oral hygiene and practices in the health education curriculum at school so that the school going children improve their knowledge and practice and dissemination of information among their family members. regular training among the community health workers to educate the community people about oral health. train up the community leaders about proper oral hygiene so that they can build awareness to the community people through disseminating information. karim f, begum j 425 references: 1. ashley fp. role of dental health education in preventive dentistry, in prevention of dental disease. murray jj. ed. oxford university press, oxford, uk. 1996:406–414. 2. woodgroove j, cumberbatch g, gylbier s. understanding dental attendance behavior. community dent health 1987;4:215–221. 3. hamilton me and coulby wm. oral health knowledge and habits of senior elementary school students. j public health dent. 1991;51(4):212–219, http://dx.doi.org/10.1111/j.1752-7325.1991.tb02217.x 4. freeman r, maizels j, wyllie m, sheiham a. the relationship between health related knowledge, attitudes and dental health behaviours in 14–16-year-old adolescents. community dent health. 1993;10(4):397-404. 5. kwan sy, petersen pe, pine cm, borutta a. healthpromoting schools: an opportunity for oral health promotion. bull world health organ. 2005;83(9):677-85. 6. petersen pe, kwan s. evaluation of community-based oral health promotion and oral disease prevention-who recommendations for improved evidence in public health practice. community dent health. 2004;21(4):319-29. 7. scott bj, leung kc, mcmillan as, davis dm, fiske j. a transcultural perspective on the emotional effect of tooth loss in complete denture wearers. int j prosthodont 2001;14:461-5. 8. woo j, ho s, lau j, yuen yk. chewing difficulties and nutritional status in the elderly. nutr res 1 9 9 4 ; 1 4 : 1 6 4 9 5 4 . http://dx.doi.org/10.1016/s0271-5317(05)80319-7 9. hebbal m, vadavi d, patel k. evaluation of knowledge and plaque scores in school children befote and alter health education. dent res j (isfahan). 2011;8(4):1899 6 . http://dx.doi.org/10.4103/1735-3327.86036 10. shenoy rp,sequeira ps. effectiveness of a school dental education program in improving oral health knowledge and oral hygiene practices and status of 12to 13-year-old school children. indian j dent res. 2 0 1 0 ; 2 1 ( 2 ) : 2 5 3 9 . http://dx.doi.org/10.4103/0970-9290.66652 11. thomas s, tandon s, nairs, manipal. effect of dental health education on the oral health status of rural child population by involving target groups. j indian soc pedo prev dent. 2000:18(3):115-25. 12. tewari a,gauba k, goyal a. evaluation of kap of oral hygiene measures following oral health education through existing health and educational infrastructure. j indian soc pedod prev dent.1992;10(1):7-17. knowledge about oral hygiene measures 426 page mackup-final.qxd original article lead exposure and intellectual function: findings from primary school children in bangladesh haque m1, faruquee mh2, lahiry s3, tasnim s4, yasmin r5, yasmin n6, chaklader ma7 abstract backgrounds: about 120 million people around the world are overexposed to lead which is neurotoxic and 99 percent of the most severely affected children are in the developing world including bangladesh. methods and materials: the present cross-sectional ecological study was carried out to explore the impact of lead poisoning on the intelligence level among 84 primary school children of a school of bangladesh, aged between 8 and 14 years from september 2010 through january 2011. the research instrument was an interviewer questionnaire, questionnaire for iq test and assessment of blood lead level (inductively-coupled plasma mass spectrometry with collision/reaction cells) of the study subjects after obtaining permission from their parents and the school authority. results: data were cross-checked and frequency distribution and association using chi-square test was accomplished. background information depicted majority (69.1%) of the children aged10-11 years (mean = 10.25 ±1.177 yrs), female (51.2%), parents having primary level of education or below (73.8% in case of father and 77.4% in mother) and from lower socioeconomics (78.6% earned bdt 10,000 or below per month). among all, majority (56%) were found to be moron, 27.4% in borderline, while 8.3% were imbecile with the same proportion with normal level. by their blood lead level. majority (70.2%) had blood lead level up to 10 microgram/dl and the rest (29.8%) had more than 10 microgram/dl. though no statistically significant association was found between iq level of the children and their blood lead level (p>0.05), the health problems found among the respondents as abdominal pain (53.57%), impatience (14.29%), nausea (10.71%) and all other problems (loss of concentration to study, ear problem, anorexia and loss of weight) amounting for 21.43% are suggestive of chronic lead poisoning. conclusion: further studies in large scale with larger samples including comparative studies of inter-industrial areas have been strongly recommended. key words: blood lead level; iq level; children 1. mahbuba haque, lecturer, delta medical college, dhaka 2. m.h.faruquee, assistant professor, department of public health, state university of bangladesh 3. suman lahiry, assistant professor, institute of health economics, university of dhaka 4. saira tasmin, doctoral student, department of human ecology,the university of tokyo 5. rabeya yasmin, senior lecturer, department of occupational & environmental health, bangladesh institute of health sciences, 6. nawzia yasmin, associate professor, department of public health, state university of bangladesh 7. mainul alam chaklader, assistant professor, community medicine, bangladesh medical college corresponds to: mahbuba haque, lecturer, delta medical college, dhaka introduction lead is neurotoxic, and young children are at particular risk for exposure i . numerous studies indicate that blood lead concentrations above 10?g per deciliter (0.483 ?mol per liter) are associated with adverse outcomes on measures of intellectual functioning as well as with social and behavioral conduct 1,2,3 . lead may impair brain development and have harmful health effects even at lower levels, and there is no known safe exposure level 4 . the world health organization estimates that 15-18 million children in developing countries are suffering from permanent brain damage due to lead poisoning. hundreds of millions of children and pregnant women in practically all the developing countries including bangladesh are exposed to elevated levels of lead 5 . lead poisoning may be acute (from intense exposure of short duration) or chronic (from repeated low-level exposure over a prolonged period), but the latter is much more common. children with developing physique are especially vulnerable to chronic lead poisoning because of their rapidly developing nervous systems that are particularly bangladesh journal of medical science vol. 11 no. 04 oct’12 292 sensitive to the effects of lead 6 . there is no safety level of lead for children 7 . high quantity of lead is found in the environment as paints on the walls and doors, the playground equipments and batteries 8,9 . intelligence testing as iq (intelligence quotient) is the score of an intelligence test 10 and it is expected that average iq among children in third world countries will increase if toxicity and malnutrition of various kinds get eradicated 11 . with the aforesaid public health concern, the present cross-sectional study was planned and conducted to explore the impact of lead poisoning on the intelligence of the environmentally lead-exposed primary school children of bangladesh. methodology the present cross-sectional ecological study was conducted among children in a purposively selected school (panpara govt. primary school) in an industrial area (rajfulbaria thana in savar district) from september 2010 through january 2011. the school was selected owing to its close proximity to the industries. study population was children of class iii, iv and v. all the children of these classes who met the selection criteria and who were present at school during the data collection time (n = 84) were taken for iq test, blood collection and face to face interview after obtaining permission from their parents and the school authority. after aseptic precaution blood was collected for lead level. lead level in whole blood was measured using inductively-coupled plasma mass spectrometry with collision/reaction cells (icp-ms, agilent 7500ce-agilent technologies, waldbronn, germany).whole blood was digested with 60% nitric acid (hno3) in an oven for 4 hours at 140 0 c. before analysis samples were diluted with milliq and filtered. two commercial certified reference materials (crms) for blood were used for quality control (seronorm™ trace elements whole blood l-1, ref 201505; lot mr4206 and seronorm™ trace elements whole blood l-2, ref 210205; lot 1003192). a structured questionnaire was developed; its first part was designed to know the socio-economic condition from their parents. the second portion was for participants iq test. data was collected through face to face interview by using a pre tested questionnaire. the children who refused to participate in the study and who were unable to provide information owing to physical or mental illness were excluded. data were cross-checked and frequency distribution and association using chi-square test was accomplished. before study ethical clearance was taken from panpara govt. primary school committee. about instrument: findings the socio-demographic background of the respondents, the iq score, the blood lead level and the analyses are shown as follows. table i: distribution of the children by age (n=84) mean = 10.25 ±1.177 years majority 40.5% (n=34) of the children were ?10 years old, followed by 28.6% (n=24) who were 11 years old, while the lowest 2.4% (n=2) was of 14 years or older. the mean age was found to be 10.25 ±1.177 years. figure i: distribution of the children by sex (n=84) among all the study subjects, female were slightly higher (51.2%) than the male children (48.8%). lead exposure and intellectual function 293 age of the respondents (in years) frequency (n) percentage (%) 8 -10 52 61.0 11-13 30 35.8 ≥14 2 2.4 total 84 100.0 figure ii: distribution of the children by their father’s educational level (n=84) figure ii shows the distribution of the children by their fathers’ education. in majority of the cases (41.7%), fathers of the subject were found to have primary level of education. this was followed by 32.1% who were illiterate, 11.9% who had h.s.c level of education, 10.7% who had s.s.c level, while in case of only 3.6%, fathers were found to be graduate. figure iii: distribution of the children by their mother’s education (n=84) figure iii shows the distribution of the children by their mothers’ education. in majority of the cases (39.3 %), mothers of the subject were found to have primary level of education. this was followed by 38.1% who were found to be illiterate, 10.7% got s.s.c level of education, 9.5% with h.s.c level, while the lowest, i.e. 2.4% were graduate. table ii: distribution of respondents by monthly family income (n =84) table ii shows that out of all respondents’ parents, 53.6% had monthly income less than bdt 5000, 25% with monthly income bdt 5000-10000, 11.9% with monthly income bdt 10000-20000, while only 9.5% had monthly income more than bdt 20000. figure iv: distribution of the children by their level of iq (n=84) the pie chart shows the distribution of the respondents by their level of iq. among the total, majority of the children (56%) were found to be moron, 27.4% in borderline, while 8.3% were imbecile with the same proportion with normal level. figure v: distribution of the children by their blood lead level (n=84) figure v shows the distribution of the respondents by their blood lead level. majority of the children, i.e. 70.2% had blood lead level up to 10 microgram/dl and the rest (29.8%) had more than 10 microgram/dl. table ii: distribution of the children by iq level and level of blood lead (n=84) haque m, faruquee mh, lahiry s, tasnim s, yasmin r, yasmin n, chaklader ma 294 32.1 41.7 10.7 11.9 3.6 0 5 10 15 20 25 30 35 40 45 illiterate primary s.s.c h.s.c graduate illiterate primary s.s.c h.s.c graduate 38.1 39.3 10.7 9.5 2.4 0 5 10 15 20 25 30 35 40 45 illiterate primary s.s.c h.s.c graduate lmbecile(2 5-49), 8.3 moron(5069), 56 borderline (7079), 27.4 normal(70 -79), 8.3 up to 10 microgram/d l, 70.2% more than 10 microgram/d l, 29.8% income range (bdt) frequency (n) percentage (%) <5000 45 53.6 5000-10000 21 25 10000-20000 10 11.9 >20000 08 9.5 total 84 100.00% table ii shows that there is no statistically significant association between iq level of the children and their blood lead level (p>0.05). table iii shows that out of all children, 56 suffered from different ailments. among them, majority (53.57%) was found to suffer from abdominal pain; this was followed by impatience (14.29%) and nausea (10.71%) while all other problems (loss of concentration to study, ear problem, anorexia and loss of weight) amounted for 21.43% of the respondents. table iv shows that 22(39.29%) of the respondents were found to suffer from health problem(s) of any kind for 2-3 months, 16(28.57%) for 6 months, followed by 8(14. 29%) for 1 year, while only 10(17.86%) for more than 1 year. table v: breast feeding of the respondents (n = 84) table v shows that all of the respondents were provided colostrums,12(14.3%)of the respondents did not take milk after colostrums, exclusive breast feeding was completed by 72(85.71%) and up to 2 years by 25(29.76%) of the respondents. discussion most industrialized countries may have adequate information about the environmental hazards as lead poisoning status of the adults as well as children, whereas such data are rare in developing countries like bangladesh. it is difficult to ascertain the severity of the problem, because there are very few studies which may reflect the actual situation of lead poisoning among the children of bangladesh. it may be mentioned here that childhood lead poisoning continues to be a major public health problem for certain at-risk groups of children, and concerns remain over the effects of lead on intellectual development in infants and children 12 . the present cross-sectional study was conducted to explore the impact of lead poisoning on the intelligence among primary school children. among 84 respondents, 43 were female and 41 were male. the age ranged between 8 and 14 years. more than forty percent of the children were 10 years old. regarding age of respondents, the current study was found to be very similar with the study done by kaiser et al 13 where they evaluated children at five primary schools in dhaka to determine blood lead (bpb) levels, sources of environmental exposure, and potential risk factors for lead poisoning. selected schools represented a range of geographic and socioeconomic strata. in a total of 779 students, 4-12 years of age participated. it may be mentioned here that childhood lead poisoning continues to be a major public health problem for certain at-risk groups of children, and concerns remain over the effects of lead on intellectual development in infants and children 14 . the centre for disease control has set the standard elevated blood lead level for adults to be 25 µg/dl of lead exposure and intellectual function 295 χ2=0.262 p=0.967 iq level blood lead level total up to 10 microgram/dl more than 10 microgram/dl imbecile (25-49) 5 2 7 moron (50-69) 32 15 47 borderline (70-79) 17 6 23 normal (90-109) 5 2 7 total 59 25 84 table v: breast feeding of the respondents (n = 84) breast feeding frequency (n) percentage (%) non-exclusive breast feeding 12 14.3 exclusive breast feeding 72 85.7 table iii: distribution of health problems among respondents health problems frequency (n) percentage (%) anorexia 5 8.93 abdominal pain 30 53.57 nausea 6 10.71 weight loss 1 1.79 loss of patience 8 14.29 loss of concentration to study 5 8.93 ear problem 1 1.79 total 56 100.0 duration of health problem frequenc y (n) percentage (%) 2-3 months 22 39.29 6 months 16 28.57 1 year 8 14.29 more than 1 years 10 17.86 total 56 100 table iv: distribution of the respondents on durationof their health problems (n = 56) the whole blood. for children however, the number is set much lower at 10 µg/dl of blood and in 2012 there were recommendations to reduce this to 5 (µg/dl) 15 children are especially prone to the health effects of lead and as a result, blood lead levels must be set lower and closely monitored if contamination is possible 16 . in the present study we found blood level lead more than 5(µg/dl). in the present study the socio-economic status were not so high, which were reflected by the respondents monthly family income, father’s and mother’s education and occupation, home material etc. more than 60 percent respondents, fathers and mother had primary level of education, ssc, hsc and graduate and thirty-two percent were illiterate. parent’s education level is a factor to iq level of the children 12,13 . in the current study, majority (about 85.71%) of the respondents had taken their mothers’ breast milk for 6 months. numerous studies report that breastfeeding is associated with higher scores on tests of neurodevelopment and cognition in later life 17 , suggesting that breast milk may impact early brain development, with potentially important biological, medical and social implications. regarding the iq score, it was found that majority of the children (about fifty-six percent) were moron and about twenty-seven percent of the children were in borderline. the rest, i.e. eight percent were imbecile with the same proportion of normal level children. in case of blood lead level seventy percent of the children had blood lead level up to ten microgram/ dl and thirty percent of children had blood lead level more than ten microgram/ dl (highest 65 mg/dl and lowest 4 mg/dl). in a similar type of study which was conducted on 1,333 children who participated in seven international population-based longitudinal cohort studies, followed from birth or infancy until 5–10 years of age. the full-scale iq score was the primary outcome measure. in that study it was concluded that environmental lead exposure in children who have maximal blood lead levels < 7.5 ?g/dl is associated with intellectual deficits 18 . in the present study, no significant association was found in between iq level and blood lead concentration of the respondents. limitations of the study include small sample size (only 84 children), limited time and resources; each of which was a major constraint. the study was carried out only in one primary school in bangladesh. therefore, it may not reveal the true picture of the country. conclusion and recommendations the present cross-sectional ecological study revealed that 56% of the children under study were found to be moron, 27.4% to be in borderline and 8.3% found as imbecile. regarding lead level in blood, 70.2% children had blood lead level up to 10 microgram/dl, while 29.8% had it more than 10 microgram/dl. though no statistically significant association was found between iq level of the children and their blood lead level, respondents were found to suffer from health problems suggestive of chronic lead poisoning. therefore, further studies in large scale with larger samples are strongly recommended among children residing in industrial areas. haque m, faruquee mh, lahiry s, tasnim s, yasmin r, yasmin n, chaklader ma 296 references: 1. preventing lead poisoning in young children: a statement by the centers for disease control. atlanta: centers for disease control, october, 1991. 2. baghurst pa, mcmichael aj, wigg nr, et al. environmental exposure to lead and children's intelligence at the age of seven years: the port pirie cohort study. n engl j med 1992;327:1279-1284 3. bellinger d, sloman j, leviton a, rabinowitz m, needleman hl, waternaux c. low-level lead exposure and children's cognitive function in the preschool years. pediatrics 1991;87:219227[erratum, pediatrics 1994;93:a28.] 4. international programme on chemical safety. inorganic lead. environmental health criteria 165. geneva: world health organization, 1995. 5. lead poisoning-wikipedia. available from:url: http://en.wikipedia.org/wiki/lead_poisoning 6. problem of lead poisoning. national referral centre for lead poisoning in india, [cited 2011 aug 22] available from url: http://www.tgfworld.org/lead.html 7. lead exposure in children affects brain and behaviour [serial online]2004[cited 2004 november].available from:url: http://www.aacap.org/cs/root/facts_for_families/le ad_exposure_in_children_affects_brain_and_beha vior 8. lead poisoning in children. available from:url: http://www.medindia.net/patients/patientinfo/leadpoisoning-in-children.htm 9. preventing and screening for childhood lead poisoning, available from url: http://www.idph.state.il.us/healthwellness/lead_r ef_guide.htm. 10. lead exposure in children affects brain and behaviour [serial online]2004[cited2004 november].availablefrom:url: http://www. aacap.org/cs/root/facts_for_families/lead_exposure_in_children_affects_brain_and_behavior 11. wechsler adult intelligence scale(wais,iq test, intelligence quotient)available from:url: http://www.cartage.org.lb/en/themes/reference/di ctionary/biologie/w/52.html 12. intelligence quotient-wikipedia, the free encyclopedia.available from:url: http://en.wiki pedia.org/wiki/intelligence_quotient 13. karin koller, terry brown, anne spurgeon, and len levy , recent developments in low-level lead exposure and intellectual impairment in children. environ health prospect 2005; 113: a16-a19.downloaded from url: http://www. ncbi.nlm.nih.gov/pmc/articles/pmc1247191/ on 22th august 2011. 14. kaiser r, henderson a k, daley w r, naughton m, khan m h, rahman m, kieszak s, rubin c h. blood lead levels of primary school children in dhaka, bangladesh. environ health prospect 2001; 109(6): 563-6. downloaded from url; http://www.ncbi.nlm.nih.gov/pmc/articles/pmc12 40336/ 15. karin koller, terry brown, anne spurgeon, and len levy , recent developments in low-level lead exposure and intellectual impairment in children. environ health prospect 2005; 113: a16-a19. downloaded from url: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc12 47191/ on 22th august 2011. 16. blood lead level testing, department of ecology state of washington. 2011 17. "low level lead exposure harms children: a renewed call for primary prevention". center for disease control and prevention. http://www. cdc.gov/nceh/lead/acclpp/final_document_01 0412.pdf. retrieved 5 january 2012. 18. angelsen nk, vik t, jacobsen g, bakketeig ls. breast feeding and cognitive development at age 1 and 5 years. arch dis child 2001;85:183–8. lead exposure and intellectual function 297 page mackup-final.qxd original article: the outcome of the severity of diarrhoea in adult hospitalized patients with the assessment of nutritional and socioeconomic status islam a 1 , daula au 2 abstract background: diarrhoea is a leading cause of morbidity and mortality in developing countries. this study observed the influences of nutritional status and age on the outcome of severe diarrhoea in adult male patients. methods and materials: data were obtained through interview by arranged questionnaire. it is a prospective longitudinal study, where one group of patient was well nourished and other group was malnourished. results: significant differences were found in all study factors between malnourished and well nourished diarrhoea patients. patients with poor nutritional status had low body weight and muscle mass index than well nourished patients. the stool volume was higher in malnourished patients than well nourished patient. in addition mean duration of diarrhoea for malnourished patients was higher than well nourished patients until discharge from hospital. conclusion: therefore, the diarrhoea of malnourished and low socioeconomic status of adult patients is more severe, and the incidence of this disease can be reduced by growing awareness as well as improve nutritional and socioeconomic status of those patient groups. key words: diarrhoea, nutritional status, bmi, malnourished and wellnourished patients introduction diarrhoea is an alteration in normal bowel movement, characterized by increased frequency, volume, and water content of stools. the incidence of diarrhoea was associated with 2.2 million deaths worldwide 1 . deaths due to diarrhoeal illness occur predominantly in children, with an estimated 1.5 million deaths in under 5-year-olds each year, making diarrhoeal illness the second leading cause of death in this age group 2 . however, in developed countries diarrhoea is a major public health problem and estimated to 21-37 million episodes of diarrhea occurs annually 3, 4 . but, in low income country about 6.9% death occurs due to diarrhoea 1 . all estimates derive from population-based studies, including both adults and children. generally the cause of diarrhoea depends on geographical location, standards of food hygiene, sanitation, water supply, and season. commonly identified causes of sporadic diarrhoea in adults in low income countries include campylobacter, salmonella, shigella, escherichia coli, yersinia, protozoa, and viruses 5, 6 . in addition, the duration and severity of acute diarrhoea increases in undernourished children 7 . malnutrition contributes to diarrhoea which is more severe, prolonged, and possibly more frequent 8 . low body mass index (bmi), indicative of chronic energy deficiency (ced) and malnutrition are associated with compromised immune function, increased susceptibility to infectious illnesses, and reduced survival of people 9 . although the incidence of diarrhoea is more discussed for children but the severity of acute diarrhoea of adults in low income countries is largely unknown owing to the lack of large-scale surveillance studies in these countries. in the year 2007, around 11,000 diarrhoeal patients attended to the dhaka hospital, and 44% of them were adults, of whom 58.7% had severe 1. alimul islam, department of applied nutrition and food technology, islamic university, kushtiajhenidah, bangladesh. 2. asad ud-daula, department of applied nutrition and food technology, islamic university, kushtia-jhenidah, bangladesh. corresponds to: asad – uddaula, assistant professor, department of applied nutrition and food technology, islamic university, kushtia-jhenidah, bangladesh e-mail: asad.uddaula@googlemail.com; ud-daula_bd@hotmail.de bangladesh journal of medical science vol. 12 no. 03 july’13 250 diarrhoea 10 . in recent years, the frequency and hospitalization period of adult patients who suffering from severe diarrhoea is increases significantly. therefore, the management of diarrhoea is becoming increasingly difficult. in addition, less attention has been given to adult with acute severe diarrhoea compared to children; thereby deaths among adults may increases during epidemic of acute severe diarrhoea. all of these may significantly contribute to economic loss (through daily weight loss) with reduced disability adjusted life years (daly). there were many studies conducted on adult diarrhea based on used of antibiotic, ors , zinc, other medicines and micro nutrients 11-14 but not based on nutritional status of adult diarrhoeal patients. the previous study done on the basis of nutritional status that related with severe diarrhoea in children. therefore, the purpose of this study is the determination of outcome of the severity of adult diarrhoeal patients based on nutritional status, age and socioeconomic condition. this can help to determine the relationship between nutritional status and outcome of diarrhoea in future. materials and methods study design it is a hospital based prospective longitudinal study and conducted in dhaka hospital of international center for diarrhoeal diseases research, bangladesh (icddr,b). the duration of the study was conducted from september 2010 to january 2011. there are two criteria: inclusion & exclusion criteria were selected for this study. inclusion criteria includes adult male patients with age of 2050 years, two group of patient (wellnourished and malnourished), basal metabolic index (bmi), dehydration (severe or some according to dhaka method) and stool characteristics/volume. stool characteristics/volume (volume/frequency/consistency) was observed for 4 hours prior to study. written informed consent was taken from every patient. exclusion criteria include patients with bacillary dysentery (presence of visible blood in stool) and unconscious or patients with medical emergencies. this study was also counted major indicators of patients such as malnourishment (bmi less than 18.5), well nourishment (bmi greater than 18.5), income, weight, height, mean bmi, housing condition, leaving own or rent house, educational status, duration of diarrhoea, stool volume and iv fluid requirement. total sample size was 130 in which 65 malnourished and 65 well nourished. this research was approved by ethics committee of icddr,b. method of data collection to reduce observer variation, a standardized form was used at the dhaka hospital for assessment of dehydration. this is a minor modification of the who guidelines, known as the dhaka method, as presented in the table 1. patients who fulfill the selection criteria of “dhaka method” was admitted to the ward of dhaka hospital of icddr,b and bmi was calculated after measuring the height and weight of patients. duty nurses were measured and recorded vital signs (pulse and respiratory rates, temperature and blood pressures). physicians took their detailed medical history and performed thoroughly physical examination, including assessment of dehydration using the “dhaka method”. according to the dehydration status, patients was either initially re-hydrated by introduce intravenous fluid (patients with severe dehydration and frequent vomiting) or drinking ors solution (those with some dehydration and able to drink), and then observed for next 4 hours. patients stool and urine was separately collected by attendant and patients were allowed to drink water and food as their ability. at the end of the 4 hour observation period, stool volume was measured and the patients who fulfill the selection criteria i.e. having watery stool volume of 5 ml/kg/hour or more (20 ml/kg/4-hour observation period) were selected for this experiments and cordially asked for their consent to participation questionnaire of “dhaka method” in this study. the selected patients were received a single 1.0 gm dose of azithromycin antibiotic orally. stool and urine was collected separately, measured and recorded for each 6 hour-period of the study until resolution of diarrhoea. the intake of intravenous and ors solutions, water and other fluids (e.g. milk) was similarly measured. patients who developed any complication during study was considered as failures and withdrawn from the study. outcome of the severity of diarrhoea in adult 251 statistical analysis data were coded, scrutinized and put on to entry using statistical package for social science (spss). nutritional status was calculated by who anthro software. data were expressed as mean±sd and number (percent). unpaired student’s-‘t’ ‘chisquared and mann whitney rank sum tests were performed as applicable. a p value <0.05 was taken as level of significance. results a total number of 130 adult male patients with severe diarrhoea were included in the study of them 65 were malnourished (bmi <18) and 65 wellnourished (bmi>18). the major indicator of patient’s were age, monthly income, housing condition, leaving own or rent house, weight, height, mean bmi, educational status, duration of diarrhoea, stool volume and iv fluid requirement. age, monthly, housing and leaving condition of the patients mean age of malnourished and well nourished group was 28 years and 33 years respectively which demonstrated that malnourished group was significantly younger (p<0.001). the monthly mean income of malnourished and wellnourished patients was tk 4953/and tk 6938/respectively and the difference was statistically significant (p<0.02) (table 2). well nourished patients (29.2%) had their own house compared to the malnourished (12.3%) and the distribution did not show statistical significant difference (p=ns). housing condition of the patients divided into three types such as khaca, sami pacca and pacca. among these patients 38.46% malnourished and 23% wellnourished were lived in khaca house, 33.85% malnourished and 43% wellnourished were lived in samipacca house, and 27.7% malnourished and 33.86% wellnourished were lived in pacca house respectively (table 2). table 2: age, monthly income, housing and leaving condition of the study subjects data were expressed as mean±sd and number (percent) as applicable. unpaired student’s-‘t’ test and chi-squared tests were performed as applicable to calculate statistical difference and/ or association between groups. height, weight and bmi of the patient mean height (cm) of the malnourished group (162.68 cm) and well nourished group (162.38 cm) was almost similar (p=0.781). mean weight (kg) of the malnourished and well nourished groups was 45.00 and 56.26 respectively which islam a, daula au 252 table 1: dhaka method for the assessment severity of dehydration/diarrhoea assessment of dehydration condition* normal irritable/less active* lethargic/ comatose* eyes normal sunken mucosa normal dry thirst* normal thirsty* unable to drink* skin turgor* normal reduced* assess radial pulse* normal uncountable or absent* diagnose no sign of dehydration if at least 2 signs including one (*) sign present, diagnose "some dehydration" if "some dehydration" plus one of these (*) signs are present, diagnose "severe dehydration" showed significant statistical difference (p<0.001) as depicted in table 3. table 3: weigh, height and bmi of the study subjects data were expressed as mean±sd. unpaired student’s ‘t’ test was performed to calculate statistical difference between two groups. educational status of the patients educational status of the study subjects evaluated in the form of illiterate, attended primary school but did not complete (<class 5), high school attended (<ssc), ssc passed and, hsc and above. education attainment of the respondent’s showed that 23.07% malnourished and 15.38% wellnourished patients were illiterate. the distribution in the two groups for <class 5 was 30% and 20%, <ssc 35.38% and 38.46%, ssc 5 (7.69%) and 7 (10.76%) and, hsc and above 3.07% and 7.69% respectively (table 3). over all distribution showed statistical significant association (p<0.001) (table 4). table 4: educational status of adult diarrhoea patients admitted in the hospital data were expressed number (percent). chi-squared test was performed to calculate statistical association. stool volume during 4 hour observation before get admission stool volume determines the severity of diarrhoea. the mean stool volume of malnourished and wellnourished patient was 38.95 ml and 32.4 ml respectively. the value was showed that in malnourished group the volume was 20% higher than the well nourished counterpart during the 4 hours observation period. the value was significantly different between two groups (<0.001). duration of diarrhoea, stool volume and iv fluid volume required for the study subjects duration of diarrhoea of the malnourished group was 48.85 hrs and wellnourished 36.13 hrs that is malnourished group had 33.5% time hour longer diarrhea [duration in the two groups was significantly different, p<0.004]. the total stool volume [(median (range); ml/kg body weight) was 310 and 230 for malnourished and well nourished group respectively which showed that it was 34.7% higher in malnourished group compared to well nourished counterpart (p<0.002). intravenous (iv) fluid is requires to re-hydration the diarrhoea patients. median (range) iv fluid (ml/kg bw) required for the malnourished and well nourished group was 222 and 213 respectively (p<0.001) (table 5). table 5: duration of diarrhoea, stool volume and iv fluid requirement of the study subjects data were expressed as mean±sd and median (range) as appropriate. statistical difference between two groups was calculated using unpaired student’s-t test and mann whitney rank sum tests as applicable. discussion the previous study, islam et. al. reported that households having a higher socioeconomic status showed the low incidence of diarrhoea in adult 15 . but they did not assessed nutritional status with severity of adult diarrhoea. however, this study assess the outcome of severity of adult diarrhoea patients according to their nutritional status considering some indicators who come to the dhaka hospital of icddr,b seeking treatment of diarrhoea. outcome of the severity of diarrhoea in adult 253 variables malnourished group (n=65) well nourished group (n=65) p value height (cm) 162.68±5.78 162.38±6.34 0.781 weight (kg) 45.00±4.48 56.26±8.36 <0.001 variables malnourished group (n=65) well nourished group (n=65) p value illiterate 15 (23.07%) 10 (15.38%) <class 5 20 (30%) 13 (20%) under ssc 23 (35.38%) 25 (38.46%) ssc pass 5 (7.69%) 7 (10.76%) over hsc 2 (3.07%) 5 (7.69%) <0.001 indicators malnourished group (n=65) well nourished group (n=65) p value duration in hours 48.85 ±24.25 36.13±23.66 <0.004 stool volume (ml/kg bw) 310 (301250) 230 (831260) <0.002 intravenous fluid (ml/kg bw) 222 (0-1055) 213 (0-1350) <0.001 the measured factors age and incomes of the patients were essential due to maintaining hygiene and ensuring proper balanced diet. in addition, the factors weight and height determines nutritional status of the patients, bmi determines malnourishment and well nourishment of patients, house condition determines the hygienic condition of leaving place of patients, education determines the social status of the patients, and stool volume, duration and iv fluid requirement determines the severity of diarrhoea of the patients. the above factors together indicate the socioeconomic condition and severity of diarrhoeal adult patients. this study exhibits that the malnourished patient was significantly younger as compared to wellnourished patients. the monthly income of wellnourished patients was more compared to the malnourished one. the malnourished diarrhoeal patients weighed 25% less compared to the well nourished subjects. the mean height of the malnourished patients was almost similar to well nourished patients (162.68 cm vs. 162.38cm). this study also showed that the mean bmi of malnourished patient was lower than the wellnourished patient. education pattern of wellnourished patients was better that malnourished patient. the malnourished patient’s stool volume (ml) per kg body weight within 4 hours was more compared to the well nourished patients. the stool volume of malnourished study subjects was 20% more than the wellnourished patients because malnourished patients had been found to have extensive mucosal injury and more intestinal infection thus causes severity of diarrhoea and excess stool volume 7 . therefore, the diarrheal duration of malnourished patients was high then the wellnourished patients malnourished patient may be due to the extensive mucosal injury which changes in intestinal functions in malnourished patients may be one of the factor contributing to the intestinal infection and causes of diarrhoea as a result prolonging diarrhoea of the malnourished patients, 33.5% higher than the wellnourished patients. literature study also showed that the duration of diarrhoea of underweight children was found to 33% higher than wellnourished children. 16 malnourished children suffer zinc deficiency, and its supplementation led to significant decrease in diarrhoea duration (6.2 vs. 4.7 days) 7, 17 as well as, the supplementation of zinc to the adults diarrhoea patients led to significant reduction (30%) in stool volume. in addition, this study indicates that wellnourished patients group requires less iv fluid than malnourished patient require more iv fluid. therefore the malnourished patients require more iv fluid to get rehydrated. conclusions in conclusion (i) severity of diarrhea and requirement of intravenous fluid to rehydrate these patients are increased by the nutritional status of the patients; (ii) area of their residence, in a way the household hygiene, also associated in contacting the disease and influenced by educational status; and (iii) to reduce the burden of the diarrhoeal disease in the community residence of the people at risk needs to be addressed further and also the improvement of the awareness. acknowledgement the authors would like to express deep gratitude and thanks to the hospital authority of icddr,b, dhaka. authors also wants to thanks to duty doctors, nurses and other attendance who were responsible for managements of the patients in the hospital of icddr,b. islam a, daula au 254 references 1. who. the global burden of disease. 2004, update, 2008. 2. who, unicef. diarrhoea: why children are still dying and what can be done? 2009. 3. snyder j and merson mh. the magnitude of the global problem of acute diarrhoeal disease: a review of active surveillance data. bull who 1982; 60:605-13. 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[london (uk)]: university of london; for the degree of doctor of philosophy in the faculty of science 1990: 30-48. 8. who. the rational use of drugs in the management of acute diarrhoea in children. geneva 1990. 9. faruque asg, khan al, roy cn, malek ma, salam ma, and khaled ma. anthropometric characteristics of elderly people: observations at a large diarrhoeal hospital in dhaka, bangladesh. southeast asian j tropical med pub health 2006; 37:784-792. pmid:17121307 10. dhaka hospital of icddr,b. diarrheal disease surveillance system 2007. 11. bhutta za, bird sm, black re, brown kh, gardner jm, hidayat a et al. therapeutic effects of oral zinc in acute and persistent diarrhea in children in devel¬oping countries: pooled analysis of randomized con¬trolled trials. am j clin nutr 2000; 72: 1516-22. pmid:11101480 12. robberstad b, strand t, black r and sommerfelt h. cost-effectiveness of zinc as adjunct therapy for acute childhood diarrhoea in developing countries. bull. who 2004; 82(7): 523-531. pmid:15500284 pmcid:2622915 13. osendarp s, santosham m, black r, wahed m, van raaij j and fuchs g. effect of zinc supplementation between 1 and 6 mo of life on growth and morbidity of bangladeshi infants in urban slums. am. j. clin. nutr 2002; 76(6):1401–1408.pmid:12450909 14. strand ta, chandyo rk, bahl r, sharma pr, adhikari rk, bhandari n, ulvik rj et al. effectiveness and efficacy of zinc for the treatment of acute diarrhea in young children. pediatrics 2002; 109:898-903. http://dx.doi.org/10.1542/peds.109.5.898 pmid:11986453 15. islam ms, bhuiya a, yunus m. socioeconomic differentials of diarrhoea morbidity and mortality in selected villages of bangladesh. j diarrhoeal dis res 1984; 2(4):232-7.pmid:6530532 16. tomkins a. nutritional status and severity of diarrhea among pre-school children in rural nigeria. the lancet 1981; 317:860-862. h t t p : / / d x . d o i . o r g / 1 0 . 1 0 1 6 / s 0 1 4 0 6736(81)92139-5 17. roy sk, tomkins am, ara g, jolly sp, khatun w, chowdhury r and chakrabarty b. impact of zinc deficiency on vibrio cholerae enterotoxin-stimulated water and electrolyte transport in animal model. j health popull nutr 2006; 24(1):42-47. pmid:16796149 outcome of the severity of diarrhoea in adult 255 page mackup-final.qxd original article: cardio-protective properties of momordica charantia in albino rats sheriff ol1, yusuf fa2 abstract: momordica charantia, commonly known as bitter gourd, is used as a vegetable by the asian community in africa. it is frequently used as an anti-diabetic herb for the management of disease in the ayurvedic system of medicine. this present study was aimed at evaluating possible cardio-protective properties of m. charantia by determining its effect on blood cholesterol levels in albino rats. the study involved 25 rats and they were divided into 5 groups each comprising of 5 rats. the aqueous extract of m. charantia was administered orally with syringes and cannula to 4 groups at different doses (80mg/kg, 100mg/kg, 120mg/kg and 140mg/kg body weights per day, respectively) and the last group served as the control and were given drug vehicle (normal saline) only. after two weeks of administration, the 25 rats were sacrificed and blood samples were collected and assayed for total blood cholesterol, triglyceride, highdensity lipoprotein and low-density lipoprotein levels. results indicated that m. charantia plant extract increased significantly (p<0.05) the low density lipoprotein levels in the experimental group b (100mg/kg), and significantly reduced low density lipoprotein levels (p<0.05) in the experimental group a (80mg/kg), when compared to the control group. this study showed that m. charantia plant extract has cardio-protective properties by its dose-dependent effects on blood cholesterol. key words: momordica charantia, cardio-protective, orally, dose-dependent, cholesterol introduction finding healing powers in plants is an ancient idea. people on all continents have long applied poultices and imbibed infusions of hundreds, if not thousands, of indigenous plants, dating back to prehistory 1 . it is estimated that there are 250,000 to 500,000 species of plants on earth 2 . relatively small percentages (1 to 10%) of these are used as foods by both humans and other animal species. it is possible that even more are used for medicinal purposes3. momordica charantia (mc), a member of the cucurbitaceae family, is known as bitter melon, bitter gourd, balsam pear, karela, and pare. it grows in tropical areas of the amazon, east africa, asia, india, south america, and the caribbean and is used traditionally as both food and medicine. several studies revealed that this plant has antiulcer, anti-diabetic, antifungal, anti-leukemic, antiprotozoan, antibacterial, anti-fertility, antiviral, and hypoglycemic effects 3, 4, 5 . cholesterol is a waxy steroid metabolite found in the cell membrane and transported in the blood plasma of animals 6 . it is an essential structural component of mammalian cell membranes and also an important component for the manufacture of bile acids, steroid hormones and fat soluble vitamins 7 . cholesterol, being amphipathic, is transported in the surface monolayer of the lipoprotein particle. there are several lipoproteins within the blood; these include chylomicrons, very-low density lipoproteins (vldl), intermediate-density lipoproteins (idl), low-density lipoproteins (ldl), and high-density lipoproteins (hdl). the lipoprotein particles are molecular addresses that determine the startand endpoint for cholesterol transport. the more cholesterol and less protein a lipoprotein has, the less dense it is. the ldl molecules are the major carriers of cholesterol in the blood8. studies have shown that having large numbers of hdl particles correlates with better health outcomes; in contrast to having small numbers which has been associated with atheromatous disease progression within the arteries 2 . low hdl cholesterol is an independent cardiovascular risk factor. 1. ojulari lekan sheriff, department of physiology, university of ilorin. 2. yusuf fa, department of physiology, university of ilorin. corresponds to: ojulari lekan sheriff, department of physiology, university of ilorin, nigeria. email: ojulari@unilorin.edu.ng bangladesh journal of medical science vol. 12 no. 03 july’13 291 clinical evidence also indicates that a low level of hdl is a major risk factor of atherosclerosis. raising hdl significantly reduces this risk, making hdl levels an important target of treatment, particularly in patients with pre-existing atherosclerosis. both ldl and hdl cholesterol levels are important factors to determining the risk for coronary artery disease. an increase in coronary artery disease is associated with increased ldl and decreased hdl cholesterol levels 10 . as high ldl and low hdl are both independent risk factors for heart disease, the ratio of the two numbers is a useful tool to evaluate cardiovascular risk. numerous natural substances have been shown to positively affect the hdl/ldl ratio. triglycerides are esters composed of a glycerol bound to three fatty acids. they are major components of vldl and chylomicrons and play an important role in metabolism as energy sources and transporters of dietary fat. high levels in the bloodstream have been linked to some cardiovascular diseases 11 . despite the widespread usage of this plant in folk medicine in the management of many health conditions, only a few, nonrandomized clinical studies have investigated the effects of mc in humans 12, 13, 16, 15 . it is therefore crucial to conduct more studies which will shed more light on its other physiological effects. this study therefore seeks to assess possible cardio-protective properties of mc by determining its effect on the blood cholesterol level in rats. materials and methods: experimental protocol: twenty-five albino rats (mean weight 150-180g) were maintained under standard laboratory conditions and were allowed free access to food and water ad libitum. animals were divided randomly into five groups. control (distilled water): group a, mc (80mg/kg for 14 days); group b, mc (100mg/kg for 14 days), group c, mc (120mg/kg for 14 days); and group d, mc (140mg/kg for 14 days). extract, route and blood collection: the leaves of mc were aired and dried and milled into powder. 1.5 kg of the sample was percolated in 13 liters of water for about 48 hours, after which it was filtered and evaporated using water bath to give about 220g of a dark solid extract which was stored at 40c temperature before physiological studies were made before oral administration. after two weeks of administration, the 25 rats were sacrificed by cervical dislocation after being anaesthetized with chloroform. blood samples were obtained through cardiac puncture. statistical analysis: all results were expressed as mean±sem. data was analysed by one-way analysis of variance (anova) and duncan new multiple range test (dmrt). differences in means were considered significant at p<0.05. all analysis was performed using spss version 17. results effect of momordica charantia (mc) on total cholesterol: administration of mc caused insignificant changes in the total cholesterol levels in experimental groups after 14 days of treatment when compared to the control group (fig1). effect of momordica charantia on triglyceride: the effect of mc on triglyceride is shown in fig 2. triglyceride levels for the treated groups a, b, c and d (1.4, 1.6, 1.2,1.6 mmol/l) were not significantly different from the compared controls after 14 days of treatment. effect of momordica charantia on hdl-c: the effect of mc on hdl-c was depicted in fig 3. administration of mc had no significant impact on hdl as evidenced by measured values of 0.5, 1.0, 0.5, 1.0 mmol/l for groups a, b, c, and d respectively. effect of momordica charantia on ldl-c: the measured levels of ldl-c showed significant changes in the groups a (80mg/kg) and b (100mg/kg). it was significantly lowered in group a (1.1 mmol/l) and signicantly raised in group b, when compared with the control. the other experimental groups showed no significant changes when compared to the control (fig 4). discussion the study revealed insignificant changes in total cholesterol level in mc administered rats as comcardio-protective properties of momordica charantia in albino rats 292 pared with controls. the blood triglyceride levels and hdl-c levels exhibited insignificant increases and decreases while the ldl-c levels showed significant changes at different doses of administration. these results suggest that mc, when administered orally and at doses employed, has a significant dose/duration modulating effect on blood cholesterol levels. the normal total cholesterol levels seen in our study indicates that mc possibly has no effect on total cholesterol levels. this is contrary to findings of chaturvedi et al; 2004 16 , who reported that rats exposed to mc for 30 days had significantly lowered total blood cholesterol levels. this differing result is probably due to the difference in duration and dose of administration. it therefore appears that the effect of mc on total cholesterol levels in rats is both dose and duration dependent, with the duration factor being more pronounced. the triglyceride level usually provides a useful index for cardiovascular risk assessment in experimental studies. the observed levels in control and experimental rats suggest that the administration of mc at doses and duration used had no effect on blood levels. this is contrary to results by chatuvedi and ahmed et al in which triglyceride levels showed a dose-dependent response to the mc extract 16,17 . it may therefore be plausible to note that the levels of blood triglyceride may be associated with the insensitivity of triglyceride to mc in-vivo, which is likely due to the short duration of treatment. the ldl-c level in this study showed significant increase and decrease at differing doses. experimental rats in group b showed significantly lowered ldl-c levels. this corresponds to results observed in studies carried out by chaturvedi (2005) in which ldl-c levels where found to be low, even in the groups on 80mg/kg dose 18 . this is probably due to the lowering effect of mc on apolipoprotein b (apo b) secretion by the liver, with a consequent reduction in ldl-c levels 19 . experimental rats in group b showed significantly increased ldl-c blood levels. this also corresponds to results in studies by chaturvedi in which ldl-c levels increased significantly after administration of higher doses of mc 18 . serum lipids are important markers for overall cardiovascular risk. according to the centres for disease control and prevention (cdc), an estimated 106.9 million american adults have elevated total blood cholesterol levels; approximately 47.9 percent of men and 49.7 percent of women 20 . the world health organization states that 18 percent of stroke events and about 56 percent of heart disease is attributable to total cholesterol levels above 3.2 mmol/l, which amounts to about 4.4 million deaths 21 . according to the lipid hypothesis, abnormal chosheriff ol, yusuf fa 293 groups mean (mg/ml) s.e.m. p-value control 2.4 2.4 ± 0.2 a (80mg/kg) 3.2 3.2 ± 0.3 p > 0.05 b (100mg/kg) 2.5 2.5 ± 0.3 p > 0.05 c (120mg/kg) 2.6 2.6 ± 0.2 p > 0.05 d (140mg/kg) 2.1 2.1 ± 0.2 p > 0.05 table 1: total cholesterol level in control and experimental rats table 2: triglyceride level in control and experimental rats groups mean (mg/ml) s.e.m. p-value control 1.4 1.4 ± 0.1 a (80mg/kg) 1.4 1.4 ± 0.2 p > 0.05 b (100mg/kg) 1.6 1.6 ± 0.1 p > 0.05 c (120mg/kg) 1.2 1.2 ± 0.2 p > 0.05 d (140mg/kg) 1.6 1.6 ± 0.2 p > 0.05 groups mean (mg/ml) s.e.m. p-value control 0.8 0.8 ± 0.1 a (80mg/kg) 0.5 0.5 ± 0.2 p > 0.05 b (100mg/kg) 1.0 1.0 ± 0.1 p > 0.05 c (120mg/kg) 0.5 0.5 ± 0.1 p > 0.05 d (140mg/kg) 1.0 1.0 ± 0.2 p > 0.05 table 3: high-density lipoprotein cholesterol (hdl-c) in control and experimental rats groups mean (mg/ml) s.e.m. p-value control 1.3 1.3 ± 0.1 a (80mg/kg) 1.1 1.1 ± 0.4 p ? 0.05 b (100mg/kg) 1.4 1.4 ± 0.2 p ? 0.05 c (120mg/kg) 1.0 1.0 ± 0.2 p > 0.05 d (140mg/kg) 1.2 1.2 ± 0.1 p > 0.05 table 4: low-density lipoprotein cholesterol (ldl-c) in control and experimental rats cardio-protective properties of momordica charantia in albino rats 294 lesterol levels (hypercholesterolemia)—that is, higher concentrations of ldl and lower concentrations of functional hdl, are strongly associated with cardiovascular disease 22 . high levels of cholesterol in blood, depending on how it is transported within lipoproteins, are strongly associated with progression of atherosclerosis. ldl molecules are the major carriers of cholesterol in blood. when there is high level of cholesterol, the molecules are oxidized and taken up by macrophages, which become engorged and form foam cells. these cells often become entrapped in the walls of blood vessels and contribute to atherosclerotic plaque formation. these plaques are the main causes of heart attacks, strokes and other serious medical problems 19 . as high ldl and low hdl are both independent risk factors for heart disease, the ratio of the two numbers is a useful tool to evaluate cardiovascular risk 11 . in fact, one study showed that a 1 percent greater ldl value is associated with slightly more than a 2 percent increase in coronary artery disease over 6 years, and a 1 percent lower hdl value is associated with a 3 to 4 percent increase in coronary artery disease, even at total cholesterol levels less than 200 mg/dl. additionally, low hdl levels are associated with increased heart attacks and death from coronary artery disease 10 . numerous natural substances have also been shown to positively affect the hdl/ldl ratio 23-24 . the hdl/ldl ratio which is a biomarker for cardiovascular disease was increased in rats given mc at longer duration of treatment. this was evidenced by the significant decrease in ldl levels at lower doses of administration of the extract. this development was shown to be mostly duration dependent and it appears that longer duration of treatment may play an important role in the development of higher hdl/ldl ratios. in conclusion, administration of mc, at doses and duration employed in this study, had dose-dependent cardio-protective properties via its effect on the blood cholesterol levels. however, there is an indication that higher doses should be discouraged. sheriff ol, yusuf fa 295 references: 1) stockwell, c: nature's pharmacy. century hutchinson ltd., london, united kingdom. 1988 2) borris rp. natural products research: perspectives from a major pharmaceutical company. j ethnopharmacol. 1996; 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128(2): 43954435. 8) tymoczko jl, stryer b and berg jm. biochemistry. san francisco: w.h. freeman. 2002; 726–727. 9) gordon dj, probsfield jl, garrison rj, neaton jd, castelli wp, knoke jd, jacobs dr, bangdiwala s, and tyroler ha. highdensity lipoprotein cholesterol and cardiovascular disease. four prospective american studies. circulation 1989; 79 (1): 8-15. http://dx.doi.org/10.1161/01.cir.79.1.8 pmid:2642759 10) wilson pw. high-density lipoprotein, lowdensity lipoprotein and coronary artery disease. am j cardiol 1990; 66(6):7a-10a. h t t p : / / d x . d o i . o r g / 1 0 . 1 0 1 6 / 0 0 0 2 9149(90)90562-f 11) american heart association. cholesterol statistics from national health and nutrition examination survey (nhanes), 1999-2004, national center for health statistics and the nhlbi. available at: http://www.americanheart.org/presenter. 12) basch e, gabardi s and ulbricht c. bitter melon (momordica charantia): a review of efficacy and safety. am j health syst pharm 2003; 60: 356-359.pmid:12625217 13) leatherdale ba, panesar rk, singh g, atkins tw, bailey cj and bignell ah. improvement in glucose tolerance due to momordica charantia (karela). br med j (clin res ed) 1981; 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51(3):155-61.http://dx.doi.org/ 10.1016/s0168-8227(00)00224-2 18) chaturvedi p. role of momordica charantia in maintaining the normal levels of lipids and glucose in diabetic rats fed a high-fat and low-carbohydrate diet. british journal of biomedical science. 2005pmid:16196458 19) umesh cs, yadav k and najma z. combined treatment of sodium orthovanadate and momordica charantia fruit extract prevents alterations in lipid profile and lipogenic enzymes in alloxan diabetic rats. baquer molecular and cellular biochemistry 2005; 268(1-2): 111-120. http://dx.doi.org/10.1007/s11010-005-3703-y 20) center for disease control and prevention. division for heart disease and stroke prevention cholesterol fact sheet. available at:http://www.cdc.gov/dhdsp/library/fs_cho lesterol.htm. 21) world health organization. chronic disease risk factors. available at: http://www.who.int/dietphysicalactivity/publications/facts/riskfactors/en/index.html. 22) brunzell jd, davidson m, furberg cd, goldberg rb, howard bv, stein jh and witztum jl. lipoprotein management in patients with cardiometabolic risk: consensus statement from the american diabetes association and the american college of cardiology foundation. diabetes care 2008; 31 (4): 811–22. http://dx.doi.org/ 10.2337/dc08-9018pmid:18375431 23. k matira, zf dewan, tc rehnuma, a farhana, un zeba, s shahin. pre treatment by the crude and the n-hexane extract of nigella sativa linn. (kalajira) alleviates diabetes mellitus. bangladesh journal of medical science 2009; 8 (1-2): 5-9. doi: 10.3329/bjms. v8i1.3182 24. dc nanjunda. ethno-medico-botanical investigation of jenu kuruba ethnic group of karnataka state, india. bangladesh journal of medical science 2010: 09 (3): 161-169. doi: 10.3329/bjms.v9i3.6479 sheriff ol, yusuf fa 297 page mackup-final.qxd original article clinicopathological analysis of ovarian tumors in perimenopausal women: a study in a rural teaching hospital of eastern india phukan jp 1 , sinha a 2 , sardar r 3 , guha p 4 abstract introduction: ovarian tumors are important in perimenopausal women as they are more likely to be malignant. aim: the aim was to study the various histological pattern of ovarian tumors and their clinical presentation in perimenopausal age group. materials and methods: the study was carried out in the departments of gynaecology and obstetrics and pathology in a teaching hospital for two years from june 2007 to may 2009. all patients presented with ovarian tumors of perimenopausal age group (4050 years) were included. detailed clinical information, radiological findings and histopathological reports were recorded. results: a total 52 ovarian tumors were included in this study. most common histological types were surface epithelial tumors (92.3%), out of which 54.2% were benign, 41.7% were malignant and 4.2% were borderline. serous cystadenoma was the most common benign tumor and serous cystadenocarcinoma was the commonest malignant tumor. abdominal discomfort was the commonest presenting symptom both in benign and malignant tumors (85.7% and 45.4% respectively). most of the malignant tumors were presented in stage iii (50%), followed by stage ii (27.3%). conclusion: in this: study, we found a relatively higher proportion of ovarian malignancies. so, any ovarian tumor in perimenopausal age group is more likely to be malignant and that require a thorough evaluation and management. further research should be advocated in this field. key words: ovarian tumor, perimenopausal age group, histological type introduction ovarian cancer is the second most common gynaecological malignancy after cervical cancer in india 1 . asian countries have rate of 2-6 new cases per 1,00,000 women per year 2 . approximately 25% of all gynaecologic malignant tumors are of ovarian origin, but ovarian cancer is the most common fatal gynaecologic malignancy 3 . ovarian carcinoma accounts for the greatest number of deaths from malignancies of the female genital tract and is the fifth leading cause of cancer fatalities in women 4 . although ovarian cancers affect all age groups, primarily it is seen in postmenopausal women 3,5 . perimenopausal women are also at higher risk of developing ovarian malignancies as postmenopausal women. the term perimenopause should include the period immediately before the menopause (when the endocrinological, biological and clinical features of approaching menopause commence) and the first year after menopause 6 . variability is the hallmark of the menopausal transition and no operational definition was given of those features by the who 6 . however a better practical definition is the phase preceding the onset of menopause, generally occurring around 40-50 years of age during which the regular cycle of a woman transitions to a pattern of irregular cycles 7 . in india, the mean age of menopause is 45 years 8 . 1. jyoti prakash phukan, department of pathology, bankura sammilani medical college, bankura, west bengal, india. 2. anuradha sinha, department of pathology, bankura sammilani medical college, bankura, west bengal, india. 3. rakhi sardar, department of gynaecology & obstetrics, chittaranjan seva sadan, kolkata, west bengal, india. 4. paulami guha, department of gynaecology and obstetrics, riverside regional medical center, virginia, usa. corresponds to: dr jyoti prakash phukan, department of pathology, bankura sammilani medical college, p.o. kenduadihi, bankura722102, west bengal, india email: drjyotiphukan@yahoo.co.in bangladesh journal of medical science vol. 12 no. 03 july’13 263 during this time, in addition to the various perimenopausal symptoms including menstrual disorders as a result of anovulation, women also become at increased risk of developing various ovarian pathologies. various studies revealed that malignant ovarian tumor is common after 40 years 9-12 . surface epithelial tumors account for majority of malignancies 3,13 . ovarian cancers are usually fatal when diagnosed because of delay in diagnosis. symptoms are usually absent in early stages and nonspecific in advanced cases. common presenting symptoms are abdominal lump or distension of abdomen, pain in abdomen, pressure effects and menstrual disturbances 8,10,14 . in this background, this study was undertaken to determine clinical presentation and histological pattern of ovarian tumor in perimenopausal age group in a rural teaching hospital of eastern india. materials and methods the study is a prospective study of two years duration undertaken in a teaching hospital of eastern india, in the departments of gynaecology and obstetrics and department of pathology from june 2007 to may 2009. before starting the study, clearance from ethical committee was obtained. a total 52 ovarian tumors of perimenopausal age group, diagnosed histopathologically were included. all oophorectomy specimens as well as hysterectomy with bilateral or unilateral salpingoophorectomy specimens in perimenopausal age group were included in this study. ovarian tumors in which histological typing could not be done due to torsion were excluded from this study. detailed clinical history was reviewed with regard to age, clinical features, mode of presentation and radiological findings. information regarding signs and symptoms, fine needle aspiration (fnac) findings of available cases, complete blood count, ultrasonography (usg)/ computed tomography (ct) findings and biochemical investigation findings including serum tumor markers like ca125, fetoprotein and human chorionic gonadrotrophin (hcg) levels were recorded in available cases. histopathological typing of ovarian tumors were done according to world health organization classification 15 . we took 40-50 years age group as perimenopausal age group. womens, who were diagnosed with ovarian tumors after their menopause even if she falls in this age group, were excluded from the study. results a total number of 52 cases were studied. among them 28 (53.8%) were benign, 2 (3.8%) were borderline and 22 (42.3%) were malignant tumors. surface epithelial tumors were the commonest ovarian tumor (92.3%), out of which 54.2% were benign, 41.7% were malignant and 4.2% were borderline [table 1]. among surface epithelial tumors serous tumors were the commonest (57.7%), followed by mucinous tumors (23.1%). the most common benign tumor was serous cystadenoma (53.6% of all benign tumors), which was also the commonest of all ovarian tumors (28.8%). majority of malignant tumors were of surface epithelial origin, serous cystadenocarcinoma being the commonest (63.6% of all malignant tumors) followed by mucinous cystadenocarcinoma [table 1]. endometrioid tumors comprises 7.7% and brenner tumor (figure 1) comprises only 3.8% of all ovarian tumors. only 2 cases of sex-cord stromal tumors were found, figure 1: photomicrograph showing brenner tumor with solid nests of epithelial cells (arrows) embedded within fibrous tissue (h&e, 10x). inset shows epithelial nest in high power (h&e, 40x) one was benign fibroma and the other was malignant granulosa cell tumor (figure 2). clinicopathological analysis of ovarian tumors in perimenopausal women 264 figure 2: photomicrograph showing malignant granulosa cell tumor with trabecular and microfollicular (with call-exner bodies) growth pattern (h&e, 20x). other varieties includes only 1 case of germ cell tumor (mature cystic teratoma) and 1 krukenberg tumor. abdominal discomfort was the commonest presenting symptom both in benign and malignant tumors (85.7% and 45.4% respectively) [table 2]. abdominal swelling was present in 12 (42.8%) and 9 (40.9%) of benign and malignant cases respectively. menstrual abnormalities like dysmenorrhoea, menometrorrhagia and metrorrhagia were also found both in benign and malignant tumors. metrorrhagia was the commonest menstrual abnormality which was present in 35.7% and 27.3% of benign and malignant categories. cachexia was present only in few malignant cases (13.6%). cystic tumors were most commonly benign 23(82.1%) while most hard lumps were malignant 14(63.6%) [table 3]. most benign tumors had smooth surface (92.8%) while most malignant tumors had irregular surface (81.8%). most benign tumors were mobile (85.7%) while most malignant tumors had restricted mobility (77.3%). most of the malignant tumors were presented in stage iii (50%), followed by stage ii (27.3%) disease. only 3 cases (13.6%) presented in stage i and 2 cases (9.1%) presented in stage iv disease. discussion the incidence, clinical appearances and the behaviour of different types of ovarian tumors are extremely variable 14 . ovarian tumors also displays histological heterogeneity 16,17 . in our study, benign tumors accounted for 28 (53.8%), malignant ovarian tumors 22 (43.2%) and 2 (3.8%) of borderline. this result is similar to the findings of other studies 12,14,18 . similar studies by mondal et al found 63.1% benign, 29.6% malignant and 7.3% borderline tumors 9 . again phukan jp, sinha a, sardar r, guha p 265 table 1: showing distribution of ovarian tumors according to histological types (n=52) histogenesis histological types total number percentage surface epithelial tumors serous tumors 30 57.7 (n=48) 92.3% benign 15 28.8 9.1 1 enilredrob 9.62 41 tnangilam 1.32 21 sromut suonicum 6.9 5 ngineb 9.1 1 enilredrob 5.11 6 tnangilam 7.7 4 sromut dioirtemodne 7.7 4 ngineb 8.3 2 sromut llec lanoitisnart brenner 2 3.8 sex cord-stromal tumors fibroma 1 1.9 (n=2) 3.8% granulosa cell tumor 9.1 1 )tnangilam( germ cell tumors teratoma (benign) 1 1.9 (n=1) 1.9% 9.1 1 romut grebnekurk srehto (n=1) 1.9% gupta et al reported 72.9% benign, 22.9% malignant and 4.1% borderline ovarian tumors 19 . the slight increased proportion of malignant tumors in our study is because our study population comprised of perimenopausal age group (40-50 years). previous studies also showed that malignant tumors are common in 41 to 50 years age group which was our study population 9 . ovarian cancer incidence rises as the age of the patient increases. ovarian cancer rises sharply between ages 45 and 54 years and remains elevated for the remainder of a women’s life, paralleling gonadotropin levels over this period 20 . histologically, surface ovarian tumors are the commonest. in our study also surface epithelial tumors were the commonest ovarian tumors (92.3%) which is higher than previous studies 5,9,10,11,21,22 . this is because these tumors are more common in older age group. among the surface epithelial tumors, serous cystadenoma is the commonest of all tumors (28.8%) and also the commonest in benign category (53.6%). in the study by saeed et al and ahmad et al found 38.09% and 31.42% of serous cystadenoma which is close to our study 23,24 . in other studies, benign germ cell tumors constitutes a major proportion of benign group, which is common in younger age group. this younger age group was excluded from our study. majority of malignant tumors were of surface epithelial origin. serous cystadenocarcinoma being the commonest (63.6% ) of all malignant tumors. this finding is similar to previous studies 9,14 . endometrioid carcinoma ranges from 1025% of all primary ovarian cancers 25 . however in india, its proportion is found to be low ranging from 4.2% to 5% 9,26 . but we have not found any malignant endometrioid tumors. it may be due to small sample size of our study. sex-cord stromal tumors were the second largest group of tumors in this study comprising 3.8% of tumors which is similar with previous study from eastern india 9,26 . germ cell tumors in our study comprises only 1.9% of all tumors. this finding is contrary to the previous studies 9-11,25 . this is because germ cell tumors are mostly seen in children and young adults 27 . this age group is excluded from our study. the majority of women with epithelial ovarian cancer have vague and non-specific symptoms 28-30 . in early stage, irregular menses (especially in premenopausal women), urinary frequency, constipation, lower abdominal distension, pressure or pain such as dyspareunia are usually seen 28-30 . in advanced stage, patients have symptoms related to the presence of ascites, omental metastasis or bowel metastasis. the symptoms include abdominal distension, bloating, constipation, nausea, anorexia and early satiety. again menstrual abnormalities like menorrhagia, metrorrhagia are also seen. in our study, abdominal discomfort was the commonest presenting symptom both in benign and malignant tumors (85.7% and 45.4%) respectively. abdominal swelling was also present in significant number of cases. in few studies, abdominal pain is the commonest presenting complaint, while in some other studies distension of the abdomen was commonest 10,14,21,31,32 . menstrual abnormalities constitute the second commonest symptoms in our study. they are present in 46.3% benign cases and 59.1% malignant cases respectively. metrorrhagia was the commonest menstrual abnormality seen in clinicopathological analysis of ovarian tumors in perimenopausal women 266 table 2: table showing clinical presentations of ovarian tumors symptoms benign tumors malignant (%) (n=28)(n=22) tumors (%) abdominal swelling 12(42.8%) 9(40.9%) abdominal discomfort/pain 24(85.7%) 10(45.4%) alimentary symptoms 5(17.8%) 6(27.3%) cachexia --3(13.6%) menstrual abnormalities dysmennorhoea 2(7.1%) 5(22.7%) menometrorrhagia 1(3.5%) 2(9.1%) metrorrhagia 10(35.7%) 6(27.3%) urinary symptoms 4(14.2%) 6(27.3%) nonspecific symptoms 4(14.2%) 8(36.4%) table 3: showing clinical findings of different ovarian tumors clinical findings benign tumors malignant tumors n=28 (%) n=22(%) consistency of lump cystic 23(82.1%) 2(9.1%) hard 14(63.6%) variable 5(17.8%) 6(27.3%) surface of lump smooth 26(92.8%) 4(18.2%) irregular 2(7.1%) 18(81.8%) tenderness of lump present 2(7.1%) 12(54.5%) absent 26(92.8%) 10(45.5%) mobility of lump mobile 24(85.7%) 5(22.7%) restricted 4(14.3%) 17(77.3%) 35.7% and 27.3% of benign and malignant cases respectively. other menstrual abnormalities like dysmenorrhoea and menometrorrhagia were also seen. this finding is in contrast with other studies. it may due be to our study is restricted to perimenopausal women in whom menstrual abnormalities are quite common. in our study, majority of benign tumors were cystic (82.1%), while a minor proportion of malignant tumors were cystic (9.1%) on palpation. in a previous study by amatya s et al found that 93.7% of cystic tumors were benign while only 2.5% of malignant tumors were cystic which is consistent with our study 14 . we found that most benign tumors were mobile (85.7%) while most malignant tumors had restricted mobility (77.3%). local spread of malignant tumor was cause of restricted mobility as the diagnosis was in late stage. ovarian cancers are considered as “silent killer” as they do not produce symptoms until in advanced stage 20 . so there is delay in diagnosis. most of the malignant tumors in our study were presented in stage iii (50%), followed by stage ii (27.3%) disease. this findings are consistent with previous studies 14,26 . conclusion in this study, we found that surface epithelial tumors were the commonest ovarian tumor in perimenopausal age group with a higher incidence of malignancy. this is an alarming finding. however our sample size is very small to make any definite opinion. amongst malignant ovarian tumors delayed diagnosis is common and patients usually present in late stage of the disease. so awareness among public and doctors for early detection of ovarian cancer in this vulnerable perimenopausal age group and further research in this field with larger samples are advocated. references 1. devi ku. current status of gynaecological cancer care in india. j gynecol oncol. 2009;2:77-80. http://dx.doi.org/10.3802/jgo.2009.20.2.77 pmcid:2705002 2. murad a. ovulation induction and ovarian tumor: the debate continues. j pak med assoc 1998;48:353-6.pmid:10323063 3. yancik r. ovarian cancer age contrasts in incidence, histology, disease stage at diagnosis, and mortality. cancer 1993;71:517-23.http://dx.doi.org/10. 1002/cncr.2820710205pmid:8420671 4. piver ms, baker tr, piedmonte m, sandecki am. epidemiology and etiology of ovarian cancer. semin oncol 1991;18:177-85.pmid:2042059 5. saeed s, akram m. epithelial ovarian cancer; epidemiology and clinicopathological features. professional med j 2012;19:040-5. 6. who 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tumors in perimenopausal women 268 146 bangladesh journal of medical science vol. 14 no. 02 april’15 original article patient’s satisfaction with orthodontic treatment at king khalid university, college of dentistry, saudi arabia shahrani i1, tikare s2, togoo ra3, qahtani f4, assiri k5, meshari a6 abstract: introduction: patient satisfaction is important for ensuring patient’s adherence in orthodontic treatment. as teaching institutions, dental college clinics must constantly strive to find a balance between satisfyingthe needs of the patients and ensuring proper training of the students. the objective of the present studywas to assess dental patient’s satisfaction with orthodontic treatment and related services at king khalid university,college of dentistry (kku cod), saudi arabia. materials and methods: a 19 item closed end questionnaire was developed and pretested to assess patient’s satisfaction with orthodontic care. the questionnaire items were designed under three domains: 1) reception and work environment, 2) doctor-patient relationship, and 3) treatment expectations and satisfaction. the study sample consisted of all patients consulting the orthodontic clinics during the time frame of the survey and those who were willing to participate. results: a total of 72 patients completed the survey within the time framework. the mean age of the patients was 21.2 ± 8.06 of which males were 69.5% and females 30.5%. the highest subscale score was found to be with patient’s treatment expectations and satisfaction (92.6%) followed by reception and work environment (89.3%) and dentist-patient relationship (82.7%). the overall patient’s satisfaction for orthodontic services among the patients was found to be 87.1%. conclusion: there was a high dental patient’s satisfaction with orthodontic services at cod kku, saudi arabia as a teaching institution.the dentist-relationship wasfound to be key factor in determining dental patient’s satisfaction. keywords: orthodontic treatment; patient satisfaction; saudi arabia corresponds to: dr. ibrahim al shahrani, assistant professor, division of orthodontics, department of preventive dental sciences, king khalid university college of dentistry, kingdom of saudi arabia. email: ishahrani@gmail.com 1. dr. ibrahim alshahrani, assistant professor, division of orthodontics, department of preventive dental sciences, king khalid university college of dentistry, kingdom of saudi arabia 2. dr. shreyas tikare, lecturer, division of dental public health, department preventive dental sciences, king khalid university college of dentistry, kingdom of saudi arabia 3. dr. rafi a. togoo, associate professor, division of pedodontics, department of preventive dental sciences, king khalid university college of dentistry, kingdom of saudi arabia 4. fahad al qahtani, intern student, king khalid university college of dentistry, kingdom of saudi arabia 5. khalid assiri, intern student, king khalid university college of dentistry, kingdom of saudi arabia 6. ahmad al meshari, intern student, king khalid university college of dentistry, kingdom of saudi arabia introduction satisfaction is the contentment one feels when on fulfilment of a desire, need, or expectation1. over the past decade, consumer satisfaction has gained widespread recognition as a measure of quality in many public sector services. the service relationships of doctors with patients are now commodities2,3. as the health care industry shifts towards a consumer-oriented approach in the delivery of care dentists are now considered as service providers and dental patients as customers4. patient satisfaction is an important and widely accepted measure of health care efficiency5. it provides crucial information on what the patient’s expectations are and how they perceive the quality of care, which may be different from that of all staff providing that care. giving the patient an opportunity to voice their opinions about the care they receive can influence the whole quality improvement agenda and provide an opportunity for organizational learning doi: http://dx.doi.org/10.3329/bjms.v14i2.17837 bangladesh journal of medical science vol.14(2) 2015 p.146-150 147 patient’s satisfaction with orthodontic treatment at king khalid university, college of dentistry, saudi arabia and development6. with the advent of information era, information dissemination has assumed unimaginable proportions. scientific information has now reached the public domain and public is now-a-days well informed about dental care. the dental patient visiting a dentist might harbour certain expectations regarding the provision of oral health services. satisfaction of dental patients is the ultimate motive of oral health care professionals. patient satisfaction is important for ensuring patient’s adherence in orthodontic treatment7,8. provision of oral health services by dental institutions constitutes an important component of the oral health care delivery system in saudi arabia. as teaching institutions, dental college clinics must constantly strive to find a balance between meeting the needs of the patients and those of the students. the recent past has witnessed a sudden increase in the number of dental institutions in the kingdom of saudi arabia9. although the universities aim at providing good dental services for its patients and spends a considerable amount of money and human resources, little information on patient satisfaction is available. theprivate dental practice set-ups collect fees for services offered and are usually more concerned about their patient’s satisfaction. the objective of the present study was to assess dental patient’s satisfaction with orthodontic services at king khalid university,college of dentistry(kku cod), saudi arabia as part of the continuous quality improvement programme. materials and methods the present study was conducted at the orthodontic specialtyclinic, college of dentistry, kku. a 19 item closed end questionnaire was developed to assess patient’s satisfaction with orthodontic care. the questionnaire items were designed under3 domains: reception and work environment, doctor-patient relationship, treatment expectations and satisfaction. the responses for 10questions had four point likert scale, 4 questions had dichotomous response and rest had simple multiple choice options. all items were reviewed many times and checked for face validity before subjecting for reliability analysis.the ethical approval was obtained from the ethical review board, kkucod (kkucod/erc24/2013). the study sample consisted of all patients consulting the orthodontic clinics during the time frame of the survey and those who were willing to participate. the questionnaires were distributed at the opd registration by the clinic receptionist. the patients filled out the questionnaire in the waiting rooms of orthodontics clinics. each patient was allowed to complete the questionnaire once and was asked to submit the same only at the end of their treatment (final visit in case of multiple appointments). the patient’s feedback response was collected for two months from the start date of the survey. given that there were no independent interviewers and dental staff allowed assisting in the completion of the questionnaire. the collected data was entered into the computer (microsoft excel)and further analysed using smith’s statistical package version 2.80. results a total of 72 patients completed the survey within the time framework. the mean age of the patients was 21.2 ± 8.06 of which males were 69.5% and females 30.5%. graph 1 shows patient responses as to who suggested orthodontic treatment for them. it can be seen that majority of the patients were either directed by a dentist/dental specialist (n=30) or they were self-motivated with parental suggestion (n=38). only few patients (n=4) were seeking orthodontic 148 shahrani i, tikare s, togoo ra, qahtani f, assiri k, meshari a treatment as suggested by their friends/relatives. graph 2 shows patient responses for reason to choose university orthodontic clinic for their treatment. the graph clearly indicates that majority of the patients (n=53) had confidence in academic facilities. a very few (n=14) patients chose the university dental clinic as their choice for orthodontic treatmentsincethe same treatment is expensive in private dental clinics. the remaining patients (n=5) were referred from the local dentists. the internal consistency of the total scale satisfaction questionnaire was satisfactory. cronbach’s alpha was found to be 0.77. table 1 shows the mean and the standard deviation sub scale scores for patient’s satisfaction with orthodontic services. the highest sub scale score was found to be with patient’s treatment expectations and satisfaction (92.6%) followed by reception and work environment (89.3%) and dentist-patient relationship (82.7%). the overall patient’s satisfaction for orthodontic services among the patients was found to be 87.1%. discussion our findings show that majority of the patients chose to get treated here at kku because they had high confidence in academic facilities. many factors go into choosing whether private dental clinics or the academic dental clinics are the right one for seeking the treatment. there are some pros and cons to being treated at academic dental clinics. on the other hand there are some undeniable potential benefits: the residents and fellows are well supervised which means that patients could be consulted and examined by several different people. academic dental clinics also place a strong emphasis on research, and tend to provide new ways of treating patients with cutting edge facilities which highly subsidized or free. previous investigations have indicated that the quality of treatment outcomes and overall patient satisfaction are of great importance in influencing a general dentist to refer a patient to an orthodontist10-13. in our study significant numbers (n=30, 41.6%) of patients were referred by the general dentists, which can be attributed to high quality treatment outcomes at kku. almost equal to the number of referred patients (n=38, 52.7%) were those who directly reported to kku since high confidence they have with academic facilities. patient satisfaction after orthodontic treatment is influenced by a number of factors7,8,14,15. the investigations of patient satisfaction after orthodontic treatment have shown a wide range of satisfaction levels16-18. the use of different questionnaires to assess satisfaction makes comparison with other studies difficult. our questionnaire tries to measure the level of satisfaction as well as performance of quality attributes related to orthodontic treatment. it was observed in our survey that the highest satisfaction rank is with the patient’s expectations of treatment results followed by work environment and reception and dentist-patient relationship. however, the patient’ssatisfaction isrelatively ranked according to total subscale percentage values. although, the least ranked sub-scale, dentist-patient relationship indicates high degree of satisfaction. this fact is evident with undoubtedly high sum satisfaction score of the survey investigation. the inclination of all doctors towards patients is usuallyto meet the desired treatment expectations. the technical competence of the dentist is often cited as a key determinant factor contributing to patient’s satisfaction19,20. our patients were highly satisfied with technical aspects of the treatment. this fact can be attributed to patient–centred treatment procedures done with due consideration to the current principles of ethics and good clinical practice thereby ensuring reliable and best quality services to the public. this also reflects the dedication and enthusiasm of the dental faculty and technical staff towards the same questionnaire domains mean score sd maximum score satisfaction per cent ranking reception and work environment (4) 14.2917 1.5873 16 89.3 2 dentist-patient relationship (7) 22.3333 3.2501 27 82.7 3 treatment expectations and satisfaction (6) 14.8194 1.5136 16 92.6 1 sum satisfaction sore (17) 51.4 5.0738 59 87.1 table 1: total and sub-scale mean patient’s satisfaction scores 149 patient’s satisfaction with orthodontic treatment at king khalid university, college of dentistry, saudi arabia end. however, very few patients demonstrated certain levels of dissatisfaction with the dentition after orthodontic treatment which might be because of patient compliance or unrealistic expectations. the patient’s first ever experience of health care facility is at the hospital reception. a dental receptionist has responsibilities of courteous communication with patients and effective office administration. our survey results with orthodontic patients revealed average sense of satisfaction as compared to the other two dimensions. majority of them not very satisfied with the waiting period and duration for completion of treatment. the dental care delivery system in kku is based on scheduled appointments, and dental faculty carry out dental treatment only during the specialty practice sessions. these factors probably lengthen the treatment period compared to the patient’s expectations. a doctor–patient relationship is important in the practice of dentistry and is essential for the delivery of high-quality care in the diagnosis and treatment. the patients are likely to be more positive when effort is made to build good relationships with patients and not where effort is focused on technical excellence alone. the importance of interpersonal factors (personality and communication) for dental patient satisfaction is most frequently cited in the literature21-23. our results suggest that the patients were relatively less satisfied regarding interaction with the orthodontist. most of the patients who participated in this study were dissatisfied with the explanation of the procedure during treatment. this may be explained because the procedures are so common and clear, the orthodontists do not see the importance of talking about them and explaining them to their patients. providing the patient with further explanation of their treatment options should be highlighted to achieve high level of satisfaction with service provided. in conclusion, there was a high dental patient’s satisfaction with orthodontic services at cod kku, saudi arabia as a teaching institution. the importance of establishing social relationship and verbal communication should be strongly emphasized. to obtain adequate patient feedback in a reasonable time, regular surveys monitoring patient satisfaction are needed to determine the main weakness in various other services provided in king khalid university. continuous evaluations of data from such surveys are essential in monitoring the changes in patient satisfaction levels. acknowledgements the authors thank all the 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assessment of nutritional status among adolescent garo in sherpur district, bangladesh tamanna s1, rana mm2, ferdoushi a3, ishtiyaq ahmad sa4, rahman m5, rahman a6 abstract: background: garo is one of the largest indigenous communities of bangladesh. adolescence is a golden period of time for nutritional promotion. adolescent nutrition did not receive adequate attention in bangladesh. tribal people like the garo are even more unaware about the importance of adolescent nutrition. objectives: to find out physical growth as well as nutritional status among adolescent garo children in sherpur district on the basis of anthropometric indices. methods and materials: this cross sectional descriptive study was conducted among 384 adolescent garo children (boys and girls) aged 1018 years. a structured pre-tested questionnaire and a checklist were used to collect data through interview. anthropometric survey of randomly selected adolescent was carried out and compared against the nchs/who reference indicators such as bmi-for-age, height-for-age and weight-for-age. standard methods were applied to measure the height and weight of the adolescent and bmi was calculated. associations of nutritional status with socio-economic status, maternal working status, family type and family size were determined. results: in most of the age groups it is notable that the mean height and weight of both boys and girls were lower than the who/nchs standards. the prevalence of thinness, stunting and underweighting was 49.74%, 15.1% and 7.29% respectively. conclusions: significant association between malnutrition and socio-economic parameters was observed. so socio-economic status, maternal working status, family type and family size are important determinants of nutritional status of adolescent. therefore, comprehensive programmes are required to be undertaken for the overall nutritional development of the garo population with special focus on the adolescents. kew words: nutritional status, adolescence, anthropometry, garo, bangladesh. introduction: adolescents constitute a core resource of a nation for national rejuvenation and augmentation. they are a large and growing segment of the global population. adolescence is a period in life when transition from childhood to adulthood takes place and behaviours and life styles are shaped 1 . according to the world health organization people aged between 10-19 years are considered as adolescence 2 . they form a distinct group in the society, which is clearly different from children and the adults. they need a special support, care and require special health services 3 . proper nutrition during adolescence period can be an important link in nutrition throughout lifespan. to invest in the health and development of the adolescents is to invest in the greater well-being of the country. united nations estimated that about 1/5th of the total population of the world are adolescents 4 . again, among the total adolescents of the world, about one-fifth (19%) live in asia 5 . bangladesh is one of the world's most densely populated councorresponds to: aysha ferdoushi, lecturer, department of biotechnology and genetic engineering, mawlana bhashani science and technology university, bangladesh. e-mail: nupur_bmb@yahoo.com 1. sonia tamanna, department of biochemistry and molecular biology, university of dhaka, bangladesh. 2. md. masud rana, department of biotechnology and genetic engineering, mawlana bhashani science and technology university, bangladesh. 3. aysha ferdoushi, department of biotechnology and genetic engineering, mawlana bhashani science and technology university, bangladesh. 4. shah adil ishtiyaq ahmad, department of biotechnology and genetic engineering, mawlana bhashani science and technology university, bangladesh. 5. mustafizur rahman , department of biochemistry and molecular biology, university of dhaka, bangladesh. 6. atiqur rahman, department of biochemistry and molecular biology, university of dhaka, bangladesh. bangladesh journal of medical science vol. 12 no. 03 july’13 269 tries facing major health and economic challenges. rates of malnutrition in bangladesh are among the highest in the world 6 . malnourished children are more probable to grow into malnourished adults who face heightened risks of diseases and death 7 . dr sohail ally reported that the adolescent population in bangladesh is 29.5 million 8 . adolescent growth spurt is delayed, extended, and less intense in the bangladeshi females than in their western counterparts 8. chronic energy deficiency, protein energy malnutrition, low birth weight, micronutrient deficiency are all serious problems in bangladesh. although it affects people of all ages, the children, women and the female adolescents are mostly affected 9 . again chronic under-nutrition is considered to be the primary cause of ill health and premature mortality among children in developing countries 10 . in bangladesh there are indigenous groups, approximately 1.2 million and 1.13% of the total population 9, 11 . among them the garo is one of the largest indigenous communities. according to the historians of this continent, the garo tribe colonized bangladesh in the first century. they were refugees from mongolia and came to this region through tibet. recent estimates suggest that in total there are 97,695 garo people. they live in the north-eastern parts of the country especially in gajipur, mymensingh, netrakona, tangail, sherpur, jamalpur and some in syllet districts close to the indian border 12 . the garo tribe, like every other indigenous community has its own culture. their dresses, food habits and celebration styles can be easily distinguished from the native people and other tribes. compared to the other tribal groups, the garo tribe is little advanced in education and social activities. the problem of food security is common in all the ethnic groups. being part of a developing country, the garo community also suffers from poverty. children belonging to socially rearward groups like scheduled castes 13 and tribes 14 are very much prone to malnutrition. in general, the tribal population is at a higher risk of malnutrition, because of the sociocultural, socio-economic and environmental factors influencing the food intake and health seeking behaviour 15 . however, nutrition-related data of adolescents in the region is very scarce 16 . this area obviously needs more focus. to protect garo adolescents from health risks and make healthy choices, complete and disaggregated data (by age and sex) must be collected. the objective of the present study is to evaluate the nutritional status of the garo children aged 10-18 years using anthropometric indices. the subjects for the present cross-sectional study were selected from jhenaigati upazila in sherpur district, a hilly district of bangladesh that has a significant number (about 16232) of tribal people. methods and materials: this cross sectional study was conducted among 384 adolescent garo children in sherpur district, dhaka, bangladesh. among the 384 adolescent children 209 (54.43%) were males and 175 (45.57%) were females. the study subject was chosen following simple random sampling method. samples were collected from the place of residence and schools. the sample size (n) was calculated by the following formula17:n=z 2 pq/d 2 =384 where, n= desired sample size z=normal standard deviation confidence level of set will be 95%, which corresponds to 1.96 p=the estimated prevalence (assume 0.5 or 0.05) q= 1-p=1-0.5=0.5 d=degree of accuracy desired usually set at 5 % (0.05) a well structured questionnaire was developed to obtain relevant information on anthropometric and socioeconomic condition of the garo adolescents. all questions were customized and resettled to obtain and record information easily. nutritional status was assessed by anthropometric measurements such as height, weight, bmi using standardized methodology 18 . age of the subjects under study was determined by interrogation and confirmed through probing if the birth certificate were unavailable. the weight was measured by using digital scale to the nearest 0.1 kg and height was measured using anthropometer to the nearest of 0.1cm. bmi was computed using the standard equation: bmi = weight (kg) / height (m2). two nutritional indices such as “weight for age z score” (waz), “height forage z score” (haz) were calculated using world health organization (who) standard (who, 2000). zscores <-2 sd of the above indices were assessment of nutritional status among adolescent garo in sherpur district, bangladesh 270 considered as underweight (waz) and stunting (haz). data were analyzed by using spss version 14.0. p-values of less than 0.05 were considered to local ethical approval was taken before study. results and discussions: malnutrition continues to be a serious public health problem in bangladesh. consecutive national nutrition surveys reported high prevalence of malnutrition in our country 19, 20. the nutritional status of adolescent contributes significantly to the nutritional status of the community. as adolescent is a critical period of growth and development, any programme for a long-term effect on health should have a focus on this period of life. the present study was carried out among the garo children aged 10-18 years in sherpur district to find out their physical growth as well as nutritional status on the basis of anthropometric indices. anthropometry is widely recognized as one of the useful techniques for nutritional assessment because it is highly sensitive to detect under-nutrition 21 . it can be used to verify the existence of nutritional problem in a population and to assess its magnitude. these types of measurements are nonexpensive, need minimal training and readings are reproducible. table i: detail age and sex wise distribution of the study sample the age and sex distribution of the studied children are given in table i. a total of 384 adolescent were studied. among them 209 (54.43%) were male and 175 (45.57%) were female. of them 11.19%, 8.07%, 25%, 11.46%, 14.58%, 16.14%, 7.55%, 2.86% and 3.12% children were in age group 10, 11, 12, 13, 14, 15, 16, 17 and 18 years respectively. tamanna s, rana mm, ferdoushi a, ishtiyaq ahmad sa, rahman m, rahman a 271 frequency age in years male female total 10 21(48.8) 22(51.2) 43(100) 11 17(54.83) 14(45.17) 31(100) 12 48(50) 48(50) 96(100) 13 23(52.27) 21(47.73) 44(100) 14 29(51.79) 27(48.21) 56(100) 15 39(62.9) 23(37.1) 62(100) 16 21(72.41) 8(27.59) 29(100) 17 5(45.46) 6(54.54) 11(100) 18 6(50) 6(50) 12(100) total 209(54.43) 175(45.57) 384(100) boys girls number examined mean weight (kg) sd who/nchs standard weight (kg) number examined mean weight (kg) sd who/nchs standard weight (kg) pvalue 21 27.36 3.37 31.4 22 28.18 4.21 32.5 0.481 17 29.70 6.07 32.2 14 30.71 6.37 33.7 0.658 48 36.12 6.78 37.0 48 37.06 6.69 38.7 0.519 23 46.0 7.05 40.9 21 42.81 5.06 44.0 0.091 29 46.24 5.53 47.0 27 43.26 5.53 48.0 0.049 39 50.74 6.34 52.6 23 47.43 3.75 51.5 0.027 21 53.19 7.18 58.0 8 45.13 5.35 53.0 0.008 5 57.4 6.06 62.7 6 45.00 3.16 54.0 0.002 6 57.84 4.66 65.0 6 45.5 2.66 54.4 0.000 table ii: comparison of mean weight of boys and girls sd= standard deviation table ii focused the mean weights of boys and girls of the study group. the mean weight of girls was more than the boys till twelve years of age, there after the boys weighed more. in age group 16 to 18 there was statistically significant difference in the mean weight of the boys and girls. on comparison with the who/nchs standard the mean weight of boys and girls was found to be lower in most of the age groups. only thirteen years old boys weighted more than the standard value. it is noticeable that the mean weight of girls was found to be much lower compared to who/nchs standard. table iii: comparison of mean height of the study population height may be considered most representative characteristic of overall growth and development. table iii represents the mean height of boys and girls. no significant mean height difference was found in 10, 11 and 12 aged adolescents but thereafter the boys were taller than the girls. in most of the age groups it was notable that the mean height of both boys and girls was lower than the who/nchs standards. only the boys aged thirteen years were taller than the standard height. table iv: nutritional status of study population according to who international classification of underweight, overweight and obesity based on bmi in the current study (presented in table iv) according to who reference standard 49.47% adolescents were normal (bmi 18.5-24.99), 49.74% adolescents were undernourished (bmi<18.5) and rest 0.79% were overweight and none of the adolescent was found to be obese. boys suffering from chronic energy deficiency grade i, ii and iii were 25.36%, 17.22% and 7.65 % respectively and for girls it was 71%, 16% and 7.03 % respectively. so girls were more undernourished than boys. table v: prevalence of stunting and underweight in study group according to who/nchs standards according to who/nchs standards, 58 (15.1%) out of 384 adolescent were stunted, with 9 (2.34%) adolescent showing severe grade of stunting (table v). among them girls (17.71%) were more stunted compared to boys (12.91 %). however 28 (7.29%) adolescent were underweight with 1.56% showing severe grade of underweight. among them girls (10.86%) were more underweight than boys (4.3%). assessment of nutritional status among adolescent garo in sherpur district, bangladesh 272 boys girls number examined mean height (cm) sd who/nchs standard height (cm) number examined mean height (cm) sd who/nchs standard height (cm) pvalue 21 132.14 7.82 137.5 22 132.32 6.05 138.3 0.79 17 135.24 9.56 140.0 14 137.29 6.71 142.0 0.49 48 143.94 8.87 147.0 48 140.16 6.68 148.0 0.64 23 155.57 8.08 153.0 21 148.61 5.74 150.0 0.002 29 154.62 5.77 160.0 27 149.19 5.91 155.0 0.001 39 158.05 6.36 166.0 23 152.17 4.83 161.0 0.000 21 161.76 5.88 171.0 8 149.13 4.73 162.0 0.000 5 164.20 2.58 175.0 6 151.5 4.13 163.0 0.000 6 163.67 1.96 177.0 6 149.67 3.07 164.0 0.000 age 10 11 12 13 14 15 16 17 18 grade of under nutrition bmi cut off value kg/m2 no. of adolescent boys (%) no. of adolescent girls (%) no. of total adolescent (%) grade 3 thinness < 16 16(7.65) 27(7.03) 43(11.20) grade 2 thinness 16.0-16.99 36(17.22) 28(16) 64(16.67) grade 1 thinness 17-18.49 53(25.36) 31(17.71) 84(21.87) normal 18.5-24.99 103(49.28) 87(49.71) 190(49.47) overweight 25-29.99 1(0.47) 2(1.14) 3(0.79) obese >30 0 0 0 stunted underweight severe (%) moderate (%) total (%) severe (%) moderate (%) total (%) boys (n=209) 3(1.43) 24(11.48) 27(12.91) 1(0.47) 8(3.83) 9(4.3) girls (n=175) 6(3.42) 25(14.28) 31(17.71) 5(2.85) 14(8) 19(10.86) total (n=384) 9(2.34) 49(12.76) 58(15.1) 6(1.56) 22(5.73) 28(7.29) table vi: prevalence of stunting and underweight in study group according to mothers’ working status table vi executed that the prevalence of stunting and underweight was higher among adolescent whose mothers were housewives than those who are involved in different types of working. similar study carried out by mukherjee et. al also found the parallel result. table vii: prevalence of stunting and underweight with respect to socioeconomic status table vii represents that out of 384 study population 244 (63.54%) belongs to the family of farmer, 61 (15.89%) belong to day labourer, 47 (12.24%) belong to employee, 7 (1.82%) belong to small businessman and rest 25 (6.51%) from other category. majority of the mothers 331(86.2%) were housewives and most of them were illiterate. from this table it is revealed that of the 384 adolescent whose father are day labour were more stunted (24.59%) and underweighted (21.31%) than those whose father are employee, while the lowest prevalence of stunning(4.25%) and underweight (2.13%) were observed in the adolescents whose father are employee. so, these figures suggest that socioeconomic conditions are closely associated with nutritional status of the adolescents. table viii: prevalence of stunting and underweight in study group according to family type significant association was also observed between stunting, underweight and socio economic indicators such as type of family (table viii). prevalance of stunning and underweight was observed to be much higher in the joint families compared to the nuclear families. table ix: prevalence of stunting and underweight with respect to family size table ix represents that 114 (29.68%) adolescent children came from families consisting three-four members, 199 (51.82%) were from families of five-six members and 71 (18.49%) were from families consisting more than six members. higher prevalence of stunning and underweight was observed in the families having more than six members whereas lowest prevalence of stunning and underweight was seen in those families having three-four members. thus the present study implies that family size is significantly associated with nutritional status. similar results have been reported by gopaldas et al and mukherjee et al. 22,23 tamanna s, rana mm, ferdoushi a, ishtiyaq ahmad sa, rahman m, rahman a 273 thgiewrednu detnutsmaternal working status n (%) stunted (%) normal (%) underweight (%) normal (%) working 53(100) 6(11.32) 47(88.68) 3(5.67) 50(94.33) housewives 331(100) 52(15.71) 279(84.29) 25(7.55) 306(92.45) total 384 58(15.10) 326 (84.9) 28(7.29) 356(92.71) thgiewrednu detnutssocioeconomic status n stunted (%) normal (%) underweight (%) normal (%) farmer 244 36(14.75) 208(85.25) 10(4.09) 234(95.91) day labour 61 15(24.59) 46(75.41) 13(21.31) 48(78.69) employee 47 2(4.25) 45(95.75) 1(2.13) 46(97.87) business 7 1(14.28) (85.72) 1(14.28) 6(85.72) other 25 4(16) 21(84) 3(12) 22(88) total 384 58(15.10) 326(84.9) 28(7.29) 356(92.71) thgiewrednu detnuts type of family n (%) stunted (%) normal (%) underweight (%) normal (%) nuclear family 347(100) 39(11.24) 308(88.76) 17(5.67) 330(94.33) joint family 37(100) 14(51.35) 23(48.65) 11(29.72) 26(70.28) total 384 58(15.10) 326 (84.9) 28(7.29) 356(92.71) stunted underweight family size (members) n stunted (%) normal (%) underweight (%) normal (%) 3-4 members 114 13(11.4) 101(88.6) 5(4.38) 109(95.62) 5-6 members 199 21(10.55) 178(89.45) 12(6.03) 187(93.97) aove-6 members 71 24(33.81) 47(66.19) 11(15.49) 60(84.51) total 384 58(15.1) 326(84.9) 28(7.29) 356(92.71) figure i: prevalence of stunted (a) and underweight (b) children with respect to different socioeconomic parameters. a. b. in figure i, we have tried to summarize the findings of the study with respect to the association of different socioeconomic parameters with adolescent nutrition of the subjected garo tribe. from the figure, we can see that the joint families, families with more than 6 members and families of day labourers are the worst in maintaining adolescent nutrition. so, in order to improve the adolescent health status we must give emphasis on these three types of families. conclusion: adolescence is a golden period of time for nutritional promotion as it is a vital phase of physical growth and development in the lifespan. another proposition of adolescence in human life cycle lies in its immediacy to later life. thus, health and nutritional status of adolescent children may have great impact on the quality of the next generations. according to unicef report there are 27.7 million adolescents aged 10-19 years in bangladesh – 13.7 million girls and 14 million boys – making up about one fifth of the total population. regardless of all these important considerations, adolescent nutrition did not receive adequate attention in bangladesh. tribal people like the garo are even more unaware about the importance of adolescent nutrition. the aim of this study was to prepare an adolescent health profile for the adolescent garo of jhenaigati upazila. the results of the present study indicate that nutritional status of these children is not satisfactory as more than half of the adolescents are malnourished. this study also focuses on some other contributing factors which may affect adolescent nutrition like socio-economic status, maternal working status, family type and family size etc. there is much scope for the improvement of their nutritional status. the economic status of the parents must first be improved. besides, the parents must be cautious about the child health and development. children must be supplied with the balanced diet. therefore valuable health and nutritional endorsement programs can be started based on the findings of this study with the eventual objective of decreasing under nutrition and to recover the health status of the adolescent. assessment of nutritional status among adolescent garo in sherpur district, bangladesh 274 references: 1. health profile of adolescents and youth in bangladesh based on the bangladesh demographic health surveys 1993/94-2007. 2. young people's healtha challenge for society. who technical report series 731, geneva 86: 11-23, 69. 3. nahar q, amin s, sultan r, nazrul h, islam m, kane tt. strategies to meet the health needs of adolescents: a review. operation research project icddr,b: sp. publication no. 1999;91: 2,13. 29-30. 4. hossain smi, bhuiya i, rob aku, anam r. directory of organizations working with adolescents/youth in bangladesh. first edition. dhaka: population council;1998; 2-16. 5. khabir r. adolescent girls in bangladesh. dhaka: unicef bangladesh country office;1999; 9: 49. 6. nutrition country profile bangladesh 1999, fao, rome. 7. sommerfelt, a.e. 1991.comparative analysis of the determinants of children's nutritional status. paper presented at the demographic and health surveys world conference, washington, d.c.1991; 12 (9): 981-998. 8. improvement of nutritional status of adolescents report of the regional meeting chandigarh, india 17-19 september 2002. 9. bbs (bangladesh bureau of statistics) statistical year book of bangladesh, dhaka, 2001. 10. nandy s, irving m, gordon d, subramanian sv, smith gd, poverty, child under nutrition and morbidity: new evidence from india. bull world organ 2005; 83: 210-216. 11. bpc. bangladesh population census: district tables, bangladesh bureau of statistics, dhaka division, dhaka. demographic and health surveys world conference, washington, d.c., august 5-7 1991; 12 (9): 981-998. 12. rahman s. m. b., uddin m. b., i. hussain. anthropometric study on children of garo and non-garo families in netrakona district of bangladesh. j. bangladesh agril. univ. 2011; 9(2), 267–272. 13. uppal m, kumari k, sidhu s. clinical assessment of health and nutritional status of scheduled caste preschool children of amritsar. anthropologist 2005; 7: 169-171. 14. national nutrition monitoring bureau 2000. diet and nutritional status of tribal population repeat survey. national institute of nutrition, hyderabad. 15. basu sk, jindal a, kshatriya gk. the determinants of health seeking behaviour among tribal population of bastar district, madhya pradesh. south asian anthropologist 1990;1: 1 – 6. 16. khan mr and ahmed f. physical status, nutrient intake and dietary pattern of adolescent female factory workers in urban bangladesh. asia pac j clin nutr. 2005;14 (1):19-26 pmid:15734704 17. huq a.k.o., alam m.a. and islam m.j. patterns of delinquency, dietary behavior and nutritional status of the adolescent waste pickers in dhaka city. journal of science and technology 2012; 2(2):85-94. 18. lohman t., roche a. f., martorell r. anthropometric standardization reference manual. chicago: human kinetics publication 1988pmcid:279682 19. bbs/unicef. progatir pathey (on the road to progress). dhaka, bangladesh: bangladesh bureau of staistics/united nations children's fund, 2000. 20. jahan k, hossain m 1995 nature and extent of malnutrition in bangladesh. bangladesh national nutrition survey, dhaka, bangladesh: institute of nutrition and food science university of dhaka, 1998. 21. pre-conference workshop on epidemiological tools in assessment of nutritional status, national institute of nutrition, hyderabad 2005. 22. mukherjee r, chaturvedi s and bhalwar r. determinants of nutritional status of school children mjafi 2008; 64: 227-231. 23. gopaldas t, patel p, bakshi m. selected socioeconomic,environmental, maternal, and child factors associated with the nutritional status of infants and toddlers. food and nutrition bulletin 1998:10. tamanna s, rana mm, ferdoushi a, ishtiyaq ahmad sa, rahman m, rahman a 275 page mackup january-15.qxd bangladesh journal of medical science vol. 14 no. 01 january’15 59 original article fabrication of provisional restoration on freshly prepared tooth: indirect and direct technique choudhury m 1 , nahar n 2 , yazdi s 3 , choudhury f 4 , sultana a 5 introduction: in fixed partial denture, provisional restorations are inserted on freshly prepared teeth, for the time being, until a final prostheses is inserted. provisional restorations have evolved through significant changes during the past several decades. probably the most stimulators of change is provisional restoration have been major amount of fixed prosthodontics therapy1. provisional restorations are fabricated to protect the prepared tooth structure during the period between the preparation and the final restoration2. after tooth preparation, a temporary protective or functional restoration is fabricated over the prepared tooth to be used until the fabrication of the final prostheses. temporary restorations are usually fabricated and provided on the same day of tooth preparation3. provisional restorations can also be used for extended treatment intervals by providing long term tooth protection and stabilization during adjunctive pericorresponds to: dr. nurunnahar, asstt. professor & head, dept. of conservative dentistry, bangladesh medical college, dhaka. abstract: background: provisional restorations are fabricated to protect the prepared tooth structure during period between the preparation and the final restoration, and the techniques applied are direct, indirect and indirect direct. various materials are used to fabricate provisional restoration, such as, preformed crown, acrylic, metal shell, composite, etc. objectives: the study was designed to evaluate the advantages of fabrication of provisional restorations by indirect technique over direct technique. methods: this prospective comparative study carried out in the department of prosthodontics, faculty of dentistry, bangabandhu sheikh mujib medical university, dhaka, from january 2006 to december 2007, included 20 patients each for insertion of provisional restorations fabricated by indirect (group a) and direct (group b) technique. outcome was evaluated on the basis of marginal adaptation, biocompatibility and aesthetic status. results: on day 7 of provisional restoration, grade i marginal adaptation were observed in 75% and 40% of group a and group b patients, respectively, and on day 15 were 75% and 20%, respectively. grade i biocompatibility on day 7 of group a patients were 100% and group b 30%, and on day 15 was 95% and 35%, respectively. grade i aesthetic status on day 7 were in 100% of both group a and group b patients, and on day 15 was 95% and 85%, respectively. none of the patients was in grade iii, either in marginal adaptation, biocompatibility or aesthetic status. conclusion: indirect provisional restoration is better and safer in relation to marginal adaptation, biocompatibility and aesthetic status. key words: fabrication; provisional restoration doi: http://dx.doi.org/10.3329/bjms.v14i1.21560 bangladesh journal of medical science vol. 14 no. 01 january'15. page: 59-64 1. dr. marium choudhury, asstt. professor & head, dept. of oral pathology & periodontology, bangladesh medical college, dhaka 2. dr. nurun nahar, asstt. professor & head, dept. of conservative dentistry, bangladesh medical college, dhaka 3. dr. shegufa yazdi, asstt. professor & head, dept. of paediatric dentistry, bangladesh medical college, dhaka 4. dr. farhana choudhury, associate professor & head, dept. of conservative dentistry, bangladesh medical college, dhaka 5. prof. alia sultana, ex-chairman, dept. of prothodontics, bsmmu, dhaka odontal and endodontic treatment procedures4-5. mechanically the provisional restorations, during function, must resist functional loads that occur during chewing as well as resist removal forces without fracturing6. there are several methods, such as, direct, indirect and indirect direct technique to fabricate provisional restorations. various materials are used to fabricate provisional restoration, such as, preformed crown, acrylic, metal shell, composite, etc. in the direct technique, the prostheses are fabricated in the patient's mouth by inserting an impression which is previously taken before tooth preparation and loaded with acrylic resin material. in the indirect technique, it is fabricated outside the patient's mouth, on a mode which is prepared from an impression taken before tooth preparation. in practice, direct technique is commonly used; but it has some disadvantages, like it caused more polymerization shrinkage of the prostheses that results in poor marginal adaptation, adverse reaction to oral tissue because of its residual monomer, proper curing of the material is not possible in presence of oral fluid, and also exothermic heat produced during polymerization causes discomfort to the patient. on the other hand, as in the indirect technique, the prostheses is prepared outside the mouth in the laboratory, therefore, it is free from these disadvantages, though it takes more time and extra cost. many dentists will not go for indirect provisional restoration because of high laboratory cost. however, indirect provisional restorations have certain advantages: (a) stronger and durable material like acrylic resin can be used; (b) any aesthetic or occlusal change can be made on an articulator, (c) there is also no contact of free monomer with the prepared tooth or gingival than cause tissue damage, and (d) it avoids subjecting a prepared tooth to the heat created from the polymerizing resin. provisional restorations fabricated by direct technique are though cheaper and easier to fabricate but have certain disadvantages, like it shows poor marginal adaptation because of polymerization shrinkage, its residual monomer causes tissue inflammation and exothermic heat of polymerization causes pulpal damage and patient discomfort. in our study, we tried to find out the outcome of both indirect and direct technique of fabrication of provisional restorations on freshly prepared tooth in our hospital. materials and methods: this prospective comparative study was carried out in the department of prosthodontics, faculty of dentistry, bangabandhu sheikh mujib medical university, from january 2006 to december 2007. forty patients who fulfilled inclusion criteria were divided into two groups: group a (n=20) for insertion of provisional restorations fabricated by indirect technique, and group b (n=20) for insertion of provisional restorations fabricated by direct technique. inclusion criteria were (a) one or more missing tooth/teeth for restoration by fixed partial denture, (b) endodontically treated teeth for restoration with fixed prostheses, (c) fractured drown, and (d) healthy periodontal tissue. exclusion criteria were (a) periodontally compromised patients, (b) parafunctional habit, like bruxism, (c) vertical fracture, and (d) developmentally defective teeth. provisional restoration by indirect technique before tooth preparation, an impression is made with silicone rubber and allowed to set (external surface form [esf]). after tooth preparation by maintaining standard technique, another impression is made and a cast poured (tissue surface form [tsf]). separating medium is applied uniformly with a camel hairbrush, over the tissue surface form and allowed to dry. when the cast is thoroughly dry, the finished line of the preparation is marked with a sharp and soft lead pencil to serve later as a guide for trimming. autopolymerizing resin (opaque variety) is mixed. the mixing is then poured into the tissue surface form (mould should not be overfilled and the resin should reach the level of the gingiva). the tsf is sealed into the external surface form, and lightly held together by rubber bands. the assembly is then placed in warm water. after five minutes it is removed and the external surface form is separated from the cured resin restoration, which usually remains in contact with the tissue surface form. resin flush is eliminated with an acrylic trimming bur and a fine grit garnet paper disk. care is taken for any resin blebs or remnants of stone on the internal surface of the restoration. finishing touch is given with carborundum bar and polishing is done with wet pumice powder. the final restoration is cemented with zinc oxide eugenol cement on the prepared tooth surface. provisional restoration by direct technique first, an impression is made with silicone rubber and sectional impression tray, and then tooth preparation is carried out by maintaining standard technique. after tooth preparation and bleeding control, the prepared tooth and the surrounding tissue is coated with petroleum jelly. the autopolymerizing resin is mixed and loaded into the impression taken earlier. the fabrication of provisional restoration on tooth 60 resin is allowed start polymerization, when the rubbery stage of polymerization (about 2 min in the mouth), it is removed from the mouth and excess material is removed with a scissors and again inserted into the same place. during this procedure, sufficient aircooling is provided with a air syringe over the area. after the polymerization is complete, the tray along the restoration is removed from the mouth and the restoration is departed from the impression and soaked in warm water for 3 5 min. margins are marked with a pencil. voids in the restoration is checked and corrected by additional material. excess material is trimmed up to the finish line. the restoration is completed by carborundum bur and polished with polishing material (stone bur, sandpaper no. 0, pumice powder). the final restoration is cemented with zinc oxide eugenol cement on the prepared tooth surface. evaluation: the prepared provisional restoration was evaluated in patient's mouth for marginal adaptation of the prostheses to the prepared tooth, biocompatibility of the restoration and aesthetic status on day 7 and day 157-8. any defect was corrected by adding resin. marginal adaptation: the index was based on the adaptation of the restoration to the margin of the prepared tooth. grade i: no visible evidence of crevice along the margin into which explorer will penetrated. grade ii: visible evidence of slight marginal discrepancy with no evidence of decay; repair can be made or is unnecessary. grade iii: discoloration on the margin between the restoration and the tooth surface. biocompatibility: the index was based on the criteria of gingival redness and bleeding on probing. grade i: no bleeding on probing and no plaque accumulation. grade ii: mild to moderate bleeding. grade iii: severe bleeding. aesthetic status: the index was based on colour, surface, morphology of tooth. grade i: exactly similar to adjacent/contralateral natural teeth. grade ii: slight mismatched to adjacent/contralateral natural teeth. grade iii: not similar to adjacent/contralateral teeth. data analysis: collected data were compiled and analyzed using computerbased software (spss, version 13). results: table 1 shows marginal adaptation of provisional restoration of grade i and grade ii (none in grade iii) of group a and group b patients on day 7 and day 15. on day 7, marginal adaptation of grade i was seen in 15 (75%) and 8 (40%) patients, and marginal adaptation of grade ii was seen in 5 (25%) and 12 (60%) patients of group a and group b, respectively. statistically, no significant variation was observed. on day 15, marginal adaptation of grade i was seen in 15 (75%) and 4 (20%) patients, and marginal adaptation of grade ii was seen in 5 (25%) and 16 (80%) patients of group a and b, respectively. variation was significant (p<0.01). marginal adaptation of grade i and grade ii of group a patients on day 7 was 15 (75%) and 5 (25%), and on day 15 was 15 (75%) and 5 (25%), respectively. no significant variation was observed. marginal adaptation of grade i and grade ii of group b patients on 7 was 8 (40%) and 12 (60%), and on day 15 was 4 (20%) and 16 (80%), respectively. the variation was not statistically significant. table 2 shows biocompatibility of provisional restoration of grade i and grade ii (none in grade iii) of group a and group b patients on day 7 and day 15. on day 7, biocompatibility of grade i was seen in 20 (100%) and 6 (30%) patients, and biocompatibility of grade ii was seen in 0 (0%) and 14 (70%) patients of group a and group b, respectively. statistically, choudhury m, nahar n, yazdi s, choudhury f, sultana a 61 group/ grade i grade ii p value follow up no. (%) no. (%) marginal adaptation day 7 0.054ns group a 15 (75.0) 5 (25.0) group b 8 (40.0) 12 (60.0) day 15 0.001** group a 15 (75.0) 5 (25.0) group b 4 (20.0) 16 (80.0) group a 1.000ns day 7 15 (75.0) 5 (25.0) day 15 15 (75.0) 5 (25.0) group b 0.301ns day 7 8 (40.0) 12 (60.0) day 15 4 (20.0) 16 (80.0) group a : indirect technique (n=20) group b : direct technique (n=20) fisher's exact test, ns = not significant ** = significant at p<0.01 table 1: marginal adaptation of provisional restoration the distribution was highly significant (p<0.001). on day 15, biocompatibility of grade i was seen in 19 (95%) and 7 (35%) patients, and biocompatibility of grade ii was seen in 1 (5%) and 13 (65%) patients of group a and b, respectively. variation was highly significant (p<0.001). biocompatibility of grade i and grade ii of group a patients on day 7 was 20 (100%) and 0 (0%), and on day 15 was 19 (95%) and 1 (5%), respectively. no significant variation was observed. biocompatibility of grade i and grade ii of group b patients on 7 was 6 (30%) and 14 (70%), and on day 15 was 7 (35%) and 13 (65%), respectively. the variation was statistically not significant. table 3 shows aesthetic status of provisional restoration of grade i and grade ii (none in grade iii) of group a and group b patients on day 7 and day 15. on day 7, marginal adaptation of grade i was seen in all 20 (100%) patients of both group a and group b. on day 15, aesthetic status of grade i was seen in 19 (95%) and 17 (85%) patients, and aesthetic status of grade ii was seen in 1 (5%) and 3 (15%) patients of group a and b, respectively. statistically, no significant variation was observed. aesthetic status of grade i and grade ii of group a patients on day 7 was 20 (100%) and 0 (0%), and on day 15 was 19 (95%) and 1 (5%), respectively. no significant variation was observed. aesthetic status of grade i and grade ii of group b patients on 7 was 20 (100%) and 0 (0%), and on day 15 was 17 (85%) and 3 (15%), respectively. the variation was statistically not significant. discussion: provisional restorations are fabricated to protect the freshly prepared tooth structure during the period between tooth preparation and insertion of the definitive restoration. these restorations are also referred to in the literature as interim, temporary or provisional restorations (prostheses). such restorations should be uncomplicated and inexpensive to fabricate in a short period of time. several laboratory and clinical techniques for the fabrication of provisional restorations have been described in the literature, such as the indirect technique, direct technique and indirect direct techniques for both single and multiple unit restorations2. crispin et al. evaluated marginal accuracy with direct fabrication of provisional restoration on tooth 62 group/ grade i grade ii p value follow up no. (%) no. (%) biocompatibility day 7 0.0001*** group a 20 (100.0) 0 group b 6 (30.0) 14 (70.0) day 15 0.0001*** group a 19 (95.0) 1 (5.0) group b 7 (35.0) 13 (65.0) group a 1.000ns day 7 20 (100.0) 0 day 15 19 (95.0) 1 (5.0) group b 1.000ns day 7 6 (30.0) 14 (70.0) day 15 7 (35.0) 13 (65.0 group a : indirect technique (n=20) group b : direct technique (n=20) fisher's exact test, ns = not significant, *** = significant at p<0.001 table 2: biocompatibility of provisional restoration group/ grade i grade ii p value follow up no. (%) no. (%) aesthetic status day 7 group a 20 (100.0) 0 group b 20 (100.0) 0 day 15 0.605ns group a 19 (95.0) 1 (5.0) group b 17 (85.0) 3 (15.0) group a 1.000ns day 7 20 (100.0) 0 day 15 19 (95.0) 1 (5.0) group b 0.231ns day 7 20 (100.0) 0 day 15 17 (85.0) 3 (15.0) group a : indirect technique (n=20) group b : direct technique (n=20) fisher's exact test, ns = not significant table 3: aesthetic status of provisional restoration and indirect techniques. they reported that indirect fabrication provided significant improvements in marginal fit relative to direct method when methylmeth acrylate resin was used. they demonstrated that marginal fit of polymethyl methyacrylate restoration could be improved by up to 70% with an indirect technique9. monday and blais observed that the marginal fit of provisional restorations that have been polymerized undistributed on stone cast was significantly better than provisional that have been removed from mouth before becoming rigid10. rosentiel and gegauff reported that cementation of provisional restoration with zinc oxide eugenol cement reduced surface hardness that might result in margin discrepancy11. lepe et al. reported that volumetric polymerization shrinkage of polymethylmeth acrylate was 6% which would play an important role in fit of a provisional restoration12. yannikakis et al. immersed provisional materials into various staining solutions for up to one month. they reported that all the materials showed perceptible colour changes after one week. after one month, the methyl methacrylate materials exhibited the best colour stability13. waerhaug and zander found that there were presence of plaque material in areas with poor marginal adaptation and roughness of interim restoration which was a constant source of gingival inflammation14. garvin et al. concluded that periodontal inflammation associated with provisional treatment could be expected to be a reversible process provided that the amount of gingival irritation is minimal and provisional treatment occurs over a short time span15. hensten pettersen and helgeland reported that there was no contact of free monomer with the prepared tooth or gingiva which might cause tissue damage in indirect technique16. yannikasis et al. immersed provisional materials in various stating solution for up to one month and reported that all materials showed perceptible colour changes after one week, and after one month the methylmethacrylate materials exhibited the best colour stability13. in our study, we selected two group of patients for insertion of provisional restorations fabricated by indirect technique (group a, n=20) and another group of patients for insertion of provisional restorations fabricated by direct technique (group b, n=20). we evaluated marginal accuracy according to the california dental association quality evaluation system7. marginal adaptation on day 7 showed that 75% patients of group a and 40% patients of group b were in grade i. on day 15, 20% group b patients were in grade i. the cause of marginal discrepancy was volumetric shrinkage of the resin restoration and dissolution of luting agent. though zinc oxide eugenol cement reduces surface hardness, it was used for easy removal of the restoration and its easy availability. marginal adaptation of provisional restorations fabricated by indirect technique showed similar results as above studies. in our study, analysis of biocompatibility showed that after 7, 100% patients of group a and 30% patients of group b were in grade i, i.e. no bleeding on probing and no plaque accumulation; and 70% patients of group b were in grade ii, i.e. mild to moderate bleeding on probing. on day 15, 95% patients of group a and 35% in group b were in grade i, and 65% patients of group b were in grade ii. the percentage of bleeding on probing in direct provisional restorations were higher than indirect provisional restoration. the cause of gingival tissue inflammation was due to irritation from the irregular margin of the restoration where place accumulated. our result is similar to the above studies as because provisional restorations prepared with direct technique shows more marginal discrepancy. in our study, on day 7, aesthetic status of all the patients of both the groups were grade i, i.e. exactly similar to adjacent/contralateral lateral teeth. on day 15, aesthetic status of 95% group a and 85% of group b patients was grade i. the difference was marginal, which indicates that aesthetic statu of provisional restorations prepared by any technique with the same material, like polymethylmethacrylate show minor difference. it has been reported that provisional restorations fabricated indirectly have superior margins to those from direct techniques because the acrylic resin polymerizes in an undisturbed mater17-18. polymerizing autopolymerizing acrylic resin under heat and pressure improves the physical properties of the material. reinforming the vacuum or pressure formed matrix allows it to be secured to the cast on which the provisional shell is polymerized19-21. moreover, fabricating a provisional restoration wholly or in part using an indirect method reduces exposure of oral tissues to monomer, heat, shrinkage and reduces the volume of volatile hydrocarbons inhaled by a patient18,22. choudhury m, nahar n, yazdi s, choudhury f, sultana a 63 most patients, however, require a more conventional approach. fabricating provisional restorations directly on teeth using the 'direct method' is suitable for single units and up to 4 unit partial denture provisional restorations23. conclusion: provisional restorations fabricated by direct technique though cheaper and easier to fabricate but have certain disadvantages, like it shows poort marginal adaptation because of polymerization shrinkage, its residual monomer causes tissue inflammation and exothermic heat of polymerization causes pulpal damage and discomfort to the patient. on the other hand, indirect provisionals have certain advanges, such as, stronger and durable material like acrylic resin can be used, any aesthetic or occlusal change can be made on an articulator, no contact of free monomer with the prepared tooth or gingival that can cause tissue damage, and marginal fit is better. although longer time is required to fabricate an indirect provisional restoration, it reduces the clinical time. we may conclude that marginal adaptation, aesthetic and biocompatibility, fabrication of provisional restorations by indirect technique on a freshly prepared tooth is better than restorations fabricated by direct technique. fabrication of provisional restoration on tooth 64 references: 1. christensen gj. the fastest and best provisional restorations. j am dent assoc 2003; 134:397. http://dx.doi.org/10.14219/jada.archive.2003.0233 2. schwedhelm er. direct technique for the fabrication of acrylic provisional restorations. j contemp dental pract 2006; 7:10 25. 3. nallaswamy d. textbook of prosthodontics. 1st ed. calcutta: jaypee brothers, 2003: p.639. 4. moore bk, wang rl. a comparison of resins for fabricating provisional fixed restorations. int j prosthodon 1989; 2:173 84. 5. amel em, phinney tl. fixed provisional restorations for extended preprothodontic treatment. j oral implant 1995; 21:201 6. 6. powel db, nicholls ji, youdelis ra. a comparison of wire and kevlar reinforced provisional restorations. int j prosthodon 1994; 7:81 9. 7. california dental association. quality evaluation system. 2004. 8. carranza. the textbook of periodontology, 10th ed. philadelphia: wb saunders company, 2007: p.80. 9. crispin bj, caputo aa. color stability of temporary restorative materials. j prosthet dent 1979; 42:27 33. http://dx.doi.org/10.1016/0022-3913(79)90326-3 10. monday jj, blais d. marginal adaptation of provisional acrylic resin crowns. j prosthet dent 1985; 54:194 7. http://dx.doi.org/10.1016/0022-3913(85)90285-9 11. rosenstiel sf, gegauff ag. effect of provisional cementing agents on provisional resin. j prosthet dent 1988; 59:29. http://dx.doi.org/10.1016/0022-3913(88)90102-3 12. lepe x, bales dj, johnson gh. retention of provisional crowns fabricated from two materials with the use of four temporary cements. j prosthet dent 1999; 81:469 75. http://dx.doi.org/10.1016/s0022-3913(99)80016-x 13. yannikasis sa. zissis aj, polyzoois gl, caroni c. color stability of provisional resin restorative materials. j prosthet dent 1998; 80:539 53. 14. waerhaug j, zander ha. reaction of the gingival tissue to self curing acrylic restorations. j am dent assoc 1957; 54:760 8. 15. garvin ph, malone wp, toto pd, mazur b. effect of self curing acrylic resin treatment restorations on the crevicular fluid volume. j prosthet dent 1973; 47:284 9. http://dx.doi.org/10.1016/0022-3913(82)90158-5 16. hensten pettersen a, helgeland k. sensitivity of different human cell lines in the biologic evaluation of dental resin based restorative materials. scand j dent 1981; 89:102. 17. moulding mb, loney rw, ritsco rg. marginal accuracy of indirect provisional restorations fabricated on poly(vinyl siloxane) models. int j prosthodont 1994; 7:554 6. 18. fisher dw, shillingburg ht jr, dewhirst rb. indirect temporary restorations. j am dent assoc 1971; 82:160 3. 19. fox cw, abrams bl, doukoudakis a. provisional restoration for altered occlusions. j prosthet dent 1984; 52:567 72. http://dx.doi.org/10.1016/0022-3913(84)90350-0 20. cho gc, chee ww. custom characterization of the provisional restoration. j prosthet dent 1993; 69:529 32. http://dx.doi.org/10.1016/0022-3913(93)90165-k 21. rudick gs. fabrication and duplication of a temporary acrylic resin splint. j prosthet dent 1972; 28:318 24. http://dx.doi.org/10.1016/0022-3913(72)90226-0 22. kucey bk, matrices in metal ceramics. j prosthet dent 1990; 63:32 7. http://dx.doi.org/10.1016/0022-3913(90)90261-a 23. kopp fr. esthetic principles for full crown restorations. part ii: provisionalization. j esthet dent 1993; 5:258 64. 215 bangladesh journal of medical science vol. 14 no. 02 april’15 letter to editor opiate dependence and withdrawal: role of oxidative stress in opiate regulations hashim snb 1, bakar nha2, mohamad n3 corresponds to: dr nasir mohamad, professor and deputy dean, (innovation and research) faculty of medicine and health sciences,university sultan zainal abidin, 20400, kuala terengganu, terengganu, malaysia.email: drnasirmohamadkb@yahoo.com 1. siti norhajah bt hashim phd student, faculty of medicine and health sciences. 2. nor hidayah abu bakar, lecturer. 3. nasir mohamad, professor and deputy dean, (innovation and research), fpsk, university sultan zainal abidin (unisza), 20400, kuala terengganu, terengganu, malaysia. opiate dependence is defined as the need to take opiate at regular interval to avoid withdrawal syndrome. it occurs because of changes in the brain system especially at the base of the brain in the locus ceruleus. absence of exogenous opioids will stimulate locus ceruleus brain cells to release excessive amounts of noradrenaline triggering jitter, anxiety, muscle cramps and diarrhea, increased heart rate, increased blood pressure, widening of pupils and widening of air passages in the lungs and narrowing of blood vessels in non-essential organs. on the other hand, when opiate molecule binds to mµ receptors on brain cells in midbrain dopaminergic regions , they suppress the release of noradrenaline resulting in drowsiness, slow respiratory rate and low blood pressure 1. one of the proposed mechanisms that regulate the opiate dependency and withdrawal is oxidative stress. there are two mechanisms involved in the development of oxidative stress; formation of free radicals and reduce activity of antioxidant2. the neurotransmitter and gasotransmitters involved are predominantly glutamate and nitric oxide. this proposed mechanism was further supported by pretreatment with free radicals scavengers attenuated the expression of morphine induced withdrawal syndrome3. in our study, we are trying to explore the ability of honey as a supplementary therapy to methadone to reduce opiate addiction. this is because honey contains phenolic compound which have higher antioxidant properties. antioxidants reduce free radicals in oxidative stress pathway. hence, it blocks of oxidative stress in opiate dependence and tolerance4. phenolic compound has an ability to increase radical scavenging activity by cutting off the formation of free radicals. when the free radicals concentration in the cell is reduced, the oxidative stress was noted to be reduced5. this study is further supported by the fact that the property of honey is healing for human6. it corresponded with the result of studies that phenolic compound in honey that actively involved in reducing oxidative stress which occurs due to the presence free radicals presence in the cells. better understanding on the effect of honey on oxidative stress produced by honey to opiate dependency and withdrawal need to be further explored. doi: http://dx.doi.org/10.3329/bjms.v14i2.22784 bangladesh journal of medical science vol.14(2) 2015 p.215 references: 1. abdel-zaher ao, abdel-rahman ms, elwasei fm. blockade of nitric oxide overproduction and oxidative stress by nigella sativa oil attenuates morphine-induced tolerance and dependence in mice. neurochem res. 2010; 35(10):1557-1565. 2. jitka s, zdenka d, jiri n. morphine as a potential oxidative stress-causing agent. mini -reviews in organic chemistry.2013; 10:367-372. 3. kishore rk, ahmad sh, syazana n, sirajudeen kns. tualang honey has higher phenolic content and greater radical scavenging activity compared with other honey sources. nutrition research. 2011; 31 (4); 322-325. 4. kosten tr and george tp. the neurobiology if opioid dependence: implications for treatment. sci pract perspect. 2002; 1: 12-20. 5. mori t, ito s, matsubayashi k, sawaguchi t. comparison of nitric oxide synthase inhibitors, phospholipase a2 inhibitor and free radical scavengers as attenuators of opioid withdrawal syndrome. behav pharmacol. 2007; 18:725–729. 6. tahereh eo and moslem n.traditional and modern uses of natural honey in human diseases: a review. iranian journal of basic medical sciences. 2013; 16 (6); 731-742. 196 bangladesh journal of medical science vol. 14 no. 02 april’15 case report ameloblastic carcinoma of the mandible purmal k1, alam mk2, pohchi a3, rahman sa4 abstract: ameloblastic carcinoma is a highly malignant tumour and requires aggressive treatment. this case report describes an aggressive ameloblastic carcinoma that infiltrated the mandible. mandibulectomy with right functional radical neck dissection and left supra omohyoid dissection was followed by primary reconstruction with a single free vascularised fibula flap. the postoperative course was uneventful. the 2 year regular follow up revealed no signs of recurrent tumour or metastasis. future reporting of this rare condition is encouraged in lieu of limited information in its clinical course and prognosis. keywords: ameloblastic carcinoma; mandibulectomy; radical neck dissection; malignant tumour; metastasis corresponds to: dr. mohammad khursheed alam, orthodontic unit, school of dental science, universiti sains malaysia. kubang kerian 16150, kota bharu, kelantan, malaysia. email: dralam@gmail.com, dralam@usm.my. 1. kathiravan purmal, resident, oral and maxillofacial surgery department, 2. mohammad khursheed alam, senior lecturer, orthodontic unit. 3. abdullah pohchi, senior lecturer, oral and maxillofacial surgery department. 4. shaifulizan abdul rahman, senior lecturer, oral and maxillofacial surgery department. school of dental science, universiti sains malaysia, kota bharu, kelantan, malaysia. introduction ameloblastoma is the most common epithelial odontogenic tumour, representing 1% of all oral neoplasia with incidence of 80% in the mandible and 20% in the maxilla.1this benign neoplasma is locally invasive and shows considerable tendency to recur, but rarely behaves aggressively or shows metastatic dissemination.2 malignant ameloblastoma on the other hand has a typical benign histological appearance but gives rise to nodal or pulmonary metastasis. both the primary and metastatic lesions retain their benign histologic appearances. therefore the ability of ameloblastoma to metastasize cannot be predicted by the histology alone.3, 4 ameloblastic carcinoma which is different entity form malignant ameloblastoma is a rare malignant odontogenic tumour.5 in fact in 2005, the world health organization have reclassified odontogenictumours and defined it as anodontogenic malignancy that combines the histological features of ameloblastoma with cyctologicatypia, even in the absence of metastases. it may develop de no vo (primary type) or by malignant transformation of an ameloblastoma (secondary type) with a distinction between intraosseous and periphery ameloblastoma.6 ameloblastic carcinoma shows many histologic doi: http://dx.doi.org/10.3329/bjms.v14i2.20931 bangladesh journal of medical science vol.14(2) 2015 p.196-202 figure 1. extra oral presentation of the swelling. 197 ameloblastic carcinoma features of malignancy like dysplasia, increased mitosis, and infiltration of surrounding tissues. however the common features of ameloblastoma like having epithelium in which the basal cells contains columnar or palisaded cells that have a tendency for the nucleus to move from the basement membrane to the opposing end of the cell (reverse polarization) is still present. the epithelium is also known to in the form of islands, strands and medullary arrangements against a background stroma of fibrous connective tissue (follicular pattern) or the epithelium proliferates in a mesh arrangement (plexiform pattern). clinical presentation of this lesion is the rapid growth, causing pain and may even perforate the cortex. although rare, these lesions have been known to metastasize mostly to the lung or regional lymph nodes.7 case report a 53 year old malay fisherman came to the school of dental sciences university sains malaysia with complaints of swelling in the lower jaw. he had first noticed the swelling about 6 months ago. the swelling has been increasing in size with bilateral lower lip parathesia. it was also associated with pain and trismus. his significant medical history includes pulmonary tuberculosis diagnosed one year ago. he has since completed the regime of anti-tuberculosis drugs and currently on regular follow-up with the respiratory team. clinical examination revealed a fit man with no signs and symptoms elsewhere. there was a bony hard swelling from the right ramus to the left ramus. the size of the swelling was 6cm by 5 cm. the overlying skin was normal and not fixed to the lesion (figure 1). there was reduced mouth opening about 3cm. on the neck the right submandibular lymph nodes (level i) and right upper cervical lymph nodes (level ii) were palpable. the size of both the lymph nodes was 1cm by 1cm. the lymph nodes were not tender or fixed to the overlying skin. the bony lesion had perforated the oral mucosa of the right side which is highly suggestive of malignancy (figure 2 and 3). intraoral examination showed a partial edentulous arch with mobile (grade 3) teeth. bony expansion was evident bilaterally. orthopanthomogram radiograph showed a multilocularosteolytic lesion with distinct margin extending from right to the left angle of mandible (figure 4). there is resorption of root of lower first left molar in the mandible. no lesion detected in the maxilla. there is multiple retain roots and vertical bone loss around the teeth present. the posterior anterior chest radiograph shows left upper lobe fibrotic changes (figure 5). ct scans of from the base of skull to the abdomen figure 2. right side of the lesion. figure 3. left side of the lesion. figure 4. orthopantomogram radiograph showing extension of the lesion. 198 purmal k, alam mk, pohchi a, rahman sa showed the lesion is confined to the mandible. ct guidedpercutaneous lung biopsy was done. it showed no ameloblastic carcinoma cells on the left upper lobe. fine needle aspiration cytology of the palpable lymph nodes was done. that showed ameloblastic cells infiltration. tnm staging t4n2bm0 based on these findings, the diagnosis was ameloblastic carcinoma and the differential diagnosis was intraosseous carcinoma, squamous odontogenictumour, calcifying epithelial odontogenic tumour, salivary gland neoplasia or other metastatic carcinoma to the jaws from other primary locations. histopathology incisional biopsy revealed the tumour was composed of islands and sheets of odontogenic epithelium exhibiting basal cell palisading and hypercellular stellate reticulum like cells having vacuolated nuclei with prominent nucleoli. the periphery of cells nests exhibited a columnar morphology. these cells contained pleomorphic nuclei with mitotic figures. squamous metaplasma together with infiltrating well-differented squamous cell carcinoma islands were present in these areas (figure 6 a-d) treatment surgical excision (2cm clear margin) with primary reconstruction of the defect was the mode of treatment chosen for this patient (figure 7).tracheostomy and reconstruction with osteomyocutanous free fibula flap was planned. the mandible was resected from the right body to the left body preserving both condyles. all the upper teeth which had poor prognosis and retain roots were also extracted. right functional neck dissection and left supraomohyoid dissection was done. figure 4. orthopantomogram radiograph showing extension of the lesion. figure 6. histopathology: a. sheets of odontogenic epithelium with palisading basal cell and hypercellular stellate reticulum like cells with vacuolated nuclei. b. higher magnification showing cells containing pleomorphic nuclei with mitotic figures. c. squamous cell metaplasia with infiltrating squamous cell carcinoma. d. higher magnification showing tumour infiltrating the muscle tissues. 199 ameloblastic carcinoma a 23 cm length fibula graft with overlying skin was harvested from the right leg. the fibula graft was fixed with the mandible with reconstruction plates and titanium screws. the vessels were anastomosed to the facial artery and veins while the skin from the dorsum of the thigh was used to provide the intraoral cover. nasogastric tube was inserted to facilitate feeding (figure 8).the graft and donor site healed without any complications (figure 9). postoperativeorthopanthomogram radiograph shows two reconstruction plate with the fibula graft (figure 10). the resected mandible and lymph nodes were sent for histopathological study. the results confirmed our diagnosis of ameloblastic carcinoma with 2 cm clear margin of the lesion and the remaining lymph nodes free from any lesions. the patient was sent for radiotherapy after 4 weeks to eliminate any residual cancer cells. the dose given was 60 gy over a 6 weeks period with radiation 5 days a week. post radiation shows area of fibrosis on the right and left neck area (figure 11 and 12). noted wound breakdown on left side of the neck (figure 12). the breakdown was managed by daily dressing and cleaning with chlorhexidine solution weekly. the wound healed uneventfully. he also complained about the hair growth intraorally which was trimmed regularly. retrospectively a skin graft from nonhair bearing area might have avoided this problem. after six months, the patient was fitted with upper and lower full dentures. he is able to lead a reasonable normal life after the rehabilitation. after 2 years our patient continues to remain free of local, regional or distant metastasis as he remains on active follow-up with periodic radiographic follow up (figure 13). discussion our patient was diagnosed as having pulmonary tuberculosis one year before seeing us. as a consequence, the lesion seen in the chest radiograph (figure 5) and the palpable lymph node could be also due to the metastasis or pulmonary tuberculosis. datta et al8 have mentioned that ameloblastic carcinoma is figure 7. mandible resected and recon plate being contoured. figure 9. intra oral view of the reconstructed flap and skin cover. figure 8. immediate post op view with tracheostomy and nasogastric tube. 200 purmal k, alam mk, pohchi a, rahman sa an aggressive neoplasm that is locally invasive and can spread to regional lymph nodes or distant sites such as lungs and bones. fine needle aspiration cytology confirmed the palpable lymph nodes were infiltrated with ameloblastic cells and biopsy of the lungs showed no ameloblastic cells in the lungs. even though this case demonstrated unusual spread within short period time (6 months), we had to delay the treatment because of the patient’s pulmonary tubercolosis. we waited until his sputum tests were negative for 3 consecutive weeks before doing the operation to reduce the chances of cross infection. the diagnosis criteria of ameloblastic carcinoma from ameloblastoma or malignant ameloblastoma are based on cytologicatypia and increased mitotic activity.9 most ameloblastic carcinoma arise de novo and less than 1% of ameloblastoma undergo malignant transformation.10 some studies have recorded widespread metastatsis to the lung, bones through lymphatics and bloodstream.11, 12these lesions should be distinguished from metastatic ameloblastoma which is defined as a histoloigical benign appearing ameloblastoma with metastasis. from the differential diagnosis, intraosseous carcinoma is difficult to differentiate radiographically, histologically or clinically from ameloblastic carcinoma. in fact the intra osseous carcinoma may represent a less differentiated non keratinizing form of ameloblastic carcinoma both being deprieved from odontogenic epithelial remants.3, 13 nonethess, typical features of ameloblasticdfferentiation which would justify a diagnosis of ameloblastomic carcinoma are usually lacking in intraosseous carcinoma.14 squamous odontogenic tumour is composed of islands of squamous cells and epithelial odontogenic tumour contains sheets of epithelial and amyloid like material with concentric ring calcification which can differentiate it from ameloblastic carcinoma. salivary gland neoplasm or secondary from other sites may invade the jaws and can be differentiate from the history and clinical symptoms.15, 16 marsuzaki et al17 have reported that immunohistochemistry study of ameloblastic carcinoma will reveal high positive rates of p53 and ki67 to aid in the diagnosis of this lesion. chromosal imbalances in ameloblastomawhith losses in choromsoam 22 and 10 have been reported. figure 10. post surgery opg with two reconstruction plate and the fibula graft. figure 11. post radiation right side of the neck. figure 12. left side of the neck post radiation. wound breakdown noted at angle of the mandible. 201 ameloblastic carcinoma in additional to that aneuploidy is more common in ameloblastic carcinoma and may predict its malignant potential.18 in our patient, the histology showed features of malignancy like higher mitotic activity, ell atyplia, hyperchromatic nuclear, invasion of bone and muscles. clinically ameloblastoma have a slow growth with 27 months as the mean duration before any symptoms.19 this case shows growth in only 6 months. moreover there is perforation of the cortex of mandible intraorally. ameloblastoma hardly perforates the cortex unless left undetected for a very long time. pain and parathesia is also not a common finding in ameloblastoma.19 from the demographics, the mean age for ameloblastic carcinoma is 52, male to female ratio is 2: 1 and 66% of the times the lesion is located in the mandible.7 this information is consistent with our patient presented here. most of the cases of ameloblastic carcinoma in the literature was treated with extensive surgery with margins of 2-3 cm. radiotherapy was used after the surgery for cases with close resection margin, extracapsular or perineural invasion.6, 20, 21 chemotherapy did not show any promising results.6, 22 radiotherapy alone is also not recommended given its intraosseous location.23 recently perera et al. have reported on the use of gamma knife stereotatic radiosurgery in the management of recurrent ameloblastic carcinoma lesion. the authors showed promising results for recurrent lesions after 2 years of post-resection. based on the above information, we decided surgical option with concomitant radiotherapy. we managed to preserve the condyle in this patient. keeping the mandibular condyle allows the patient to preserve the temporomandibular joint which gives better mobility to the rest of the jaws and also diminishes post-op pain. the task of restoring the mandibular defect is a challenging problem for surgeons after ablation of the tumour. microvascular techniques to transfer vascularized bone to the head and neck region have been successfully applied to solve the problem of various segmental mandibular defects.24, 25 in our case, almost the entire mandible was successfully reconstructed with a vascularised fibula flap. local recurrence have been reported between 5 to 151 months.20, 26 distant metastasis has also been reported as early as 4 months and as late as 47 months after surgery.20, 27 therefore long term follow-up is mandatory to detect the late recurrence or metastasis. the 5 and 10 year survival rates were 72.9% and 56.8% respectively.21 it is important that people should be fortified to immediately report to a surgeon whenever they see any unusual swelling any discomfort. management should also include the awareness of the people of their responsibilities regarding their own health, and not wait for the swelling to grow and cause great discomfort and difficulty to themselves in future.28 nonetheless, it is generally known that there were significant association between histological subtype and recurrence outcome and between treatment and recurrence of ameloblastoma.29 conclusion ameloblastoma shows a spectrum of histology and biologic behaviour ranging from benignity at one end to malignancy at the other end. cases of ameloblastoma should thus be carefully analysed to detect subtle changes in the histology that may predict its aggressive behaviour. we have reported a rare case of primary ameloblastic carcinoma of the mandible in a 53 year old man. aggressive wide excision and radiotherapy with primary reconstruction has given a successful outcome. however long term follow up is necessary to detect the late recurrence or metastasis. conflict of interest: none declared. figure 13. after 2 years follow up review. 202 purmal k, alam mk, pohchi a, rahman sa references 1. shafer wg, hine mk, levy bm. a textbook of oral pathology. philadelphia: pa saunders; 1983. 2. neville bw, damm dd, allen cm, bouquot je. oral and maxillofacial pathology. 2 ed. philadelphia: wb saunders co.; 2002. 3. corio rl, goldblatt li, edwards pa, hartman ks. ameloblastic carcinoma: a clinicopathologic study and assessment of eight cases. oral surg oral med oral pathol 1987;64(5):570-6. 4. dorner l, sear aj, smith gt. a case of ameloblastic carcinoma with pulmonary metastases. br j oral maxillofac surg 1988;26:503. 5. karakida k, takahashi m, sekido y. ameloblastic carcinoma, secondary type: a case report. med oral pathol oral radiol endod 2010;110:e33-e37. 6. benlyazid a, lacroix-triki m, aziza r, gomez-brouchet a, guichard m, sarini j. ameloblastic carcinoma of the maxilla: case report and review of the literature. oral surg oral med oral pathol oral radiol endod 2007;104(6):e17-24. 7. akrish s, shoshani y, dayan d. ameloblastic carcinoma: report of a new case, literature review and comparison to ameloblastoma. j oral maxillofac surg 2007;65:77783. 8. datta r, winston js, diaz-reyes g, loree tr, myers l, kuriakose ma, et al. ameloblastic carcinoma: report of an aggressive case with multiple bony metastases. am j otolaryngol 2003;24(1):64-9. 9. slater lj. odontogenic malignancies. oral maxillofacial surg clin n am 2004;16:409. 10. yoshioka y, ogawa i. ameloblastoma carcinoma, secondary type, of the mandible: a case report. j oral maxillofac surg 2013;71:e58-e62. 11. dhir k, sciubba j, tufano rp. ameloblastic carcinoma of the maxilla; report of an aggressive case with multiple bony metastases. oral oncol 2003;39:735. 12. data r, winstron js, diaz-reyes g. ameloblastic carcinoma: report of an aggressive case with multiple bony metastases. am j otolaryngol 2003;24:64. 13. avon sl, mc comb j, clokie c. ameloblastic carcinoma: case report and literature review. j can dent assoc 2003;69:573-76. 14. elzay rp. primary intraosseous carcinoma of the jaws. review and update of odontogenic carcinomas. oral surg oral med oral pathol 1982;54(3):299-303. 15. simko ej, brannon rb, eibling de. ameloblastic carcinoma of the mandible. head neck 1998;20:654-59. 16. matear dw, crewe tc. malignant ameloblastoma? a case report and review of literature outlining problem in diagnosis and treatment. j r nav med serv 1991;77:5-10. 17. matsuzaki h, asaumi j, hisatomi m, nagatsuka h. ameloblastic carcinoma: a case report with radiological features of computed tomography and magnetic resonance imaging and positron emission tomography. oral surg oral med oral pathol oral radiol endod 2011;112:e40-e47. 18. nodit l, barnes l, childers e, finkelstein s, swalsky p, hunt j. allelic loss of tumour suppressor genes in ameloblastic tumours. mod pathol 2004;17:1062-7. 19. reichart pa, philipsen hp, sonner s. ameloblastoma: biological profile of 3677 cases. oral oncol eur j cancer 1995;31b:86. 20. hall jm, weathers dr, unni kk. ameloblastic carcinoma: an analysis of 14 cases. oral surg oral med oral pathol oral radiol endod 2007;103:799-807. 21. yoon hj, hong sp, lee ss, hong sd. ameloblastic carcinoma: an analysis of 6 cases with review of the literature. oral surg oral med oral pathol oral radiol endod 2009;108:904-13. 22. philip m, morris cg, werning jw, mendenhall mw. radiotherapy in the treatment of ameloblastoma and ameloblastic carcinoma. j hk coll radiol 2005;8:15761. 23. small ia, waldron ca. ameloblastoma of the jaws. oral surg 1955;8:281. 24. urken ml, buchbinder d, costantino pd, sinha u, okay d, lawson w, et al. oromandibular reconstruction using microvascular composite flaps. arch otolaryngol head neck surg 1998;124(1):46-55. 25. cordeiro pg, disa jj, hidalgo da, hu qy. reconstruction of the mandible with osseous free flaps: 10 year experience with 150 consecutive patients. plastic reconstr surg 1999;104(5):1314-20. 26. lee l, maxymiw wg, wood re. ameloblastic carcinoma of the maxilla metastatic to the mandible. case report. j craniomaxillofac surg 1990;18:247-50. 27. bruce ra, jackson it. ameloblastic carcinoma. report of an aggressive case and review of the literature. j craniomaxillofac surg 1991;19(6):267-71. 28. malik sn, alam mk, shahina m, siddique s, prabhu vd. calcifying epithelial odontogenic tumor (ceot) – a review. bangladesh j med sci. 2014;13(1):14-19. 29. ismail r, pohchi a, rajion za, rahman ra, alam mk. ameloblastoma at hospital universiti sains malaysia (husm): a fifteen year retrospective study. int med j. 2014;21(1):113-116. page mackup-final.qxd original article a comparative study of surgical management of subtrochanteric fractures in children sahu rl1, gupta p2 abstract: introduction: subtrochateric femoral fracture is a major cause of morbidity and mortality in patients with lower extremity injuries. there have been no studies that have specifically looked at the management of subtrochanteric femoral fractures in skeletally immature adolescents. it was the purpose of this study to investigate the treatment of this injury in this unique patient population. methods: this study was conducted in the department of orthopaedic surgery in m. m. medical college from july 2006 to november 2008. thirty-four patients were recruited from emergency and out patient department having closed subtrochanteric femoral fracture. all patients were operated under general or spinal anesthesia. all patients were followed for twelve months. results: all children achieved union in a mean time of 10 weeks (range from 6 16 weeks) depending on the type of long bone. full weight bearing was possible in a mean time of 8.8 weeks. mean duration of hospital stay was 9.8 days. the mean follow-up period was 28 months (17-48 months). complications were recorded in 4 (11.77%) patients and included: two entry site skin irritations, one protrusion of the wires through the skin and one delayed union. the results were excellent in 97.06% and good in 2.97% patients. conclusions: we conclude that rigid and close interlocking nailing between the age of 9-16 years offered excellent fracture stability allowing early mobilization (early weight bearing) and joint motion in comparisons to the other groups and between the age of 6-8 years titanium elastic nail and bridging plate offered excellent result. key wards: subtrochanter, fracture, pediatric, intramedullary. introduction femoral shaft fractures, including subtochanteric and supracondylar fractures, represent approximately 1.6% of all bony injuries in children 1 . paediatric subtrochanteric femoral fractures are rare and have received limited attention in the literature 2; 3 . the subtrochanteric femoral fracture in children is a special type which occurs 1 to 2 cm below the lesser trochanter. the proximal fragment tends to flex (iliopsoas), abduct (abductor group) and rotate externally (short external rotators) 4 . the treatment of subtrochanteric femoral fractures in children is controversial. different treatment options have been used: skin traction, 90/90 skeletal traction, immediate spica casting, cast bracing, internal fixation and external fixation. treatment choices are influenced by the child’s age and size and whether the femoral fracture is an isolated injury or part of a polytrauma. economic concerns, the family’s ability to care for a child with a spica cast or external fixator, and the advantages and disadvantages of any operative procedure are also important factors 1 . indications for operative treatment include multiple trauma, head injury, open fracture, floating knee, vascular or neurological injuries, failure of conservative treatment, older child or adolescent and social indications 5 ,6, 7, 8 . methods of internal fixation include; intramedullary nails, compression plating and external fixator 5, 7, 9, 10 . methods: this prospective study was carried out at orthopaedics department of m.m. medical college from july 2006 to november 2008. it was approved by institutional medical ethics committee. a total of 34 patients with subtrochanteric femur fracture bangladesh journal of medical science vol. 11 no. 03 july’12 178 1. dr ramji lal sahu ms, associate professor, department of orthopedics, sms and ri, sharda university., greater noida, u. p.,india 2. dr pratiksha gupta md, associate professor, pgimsr,esic, basaidarapur, new-delhi, india corresponds to: dr ramji lal sahu, house number 11284 laj building,no 1, doriwalan new rohtak road,karol bagh new, email drrlsahu@gmail.com admitted to our institute were included in present study. a written informed consent was obtained from all the patients; they were explained about treatment plan, cost of operation, and hospital stay after surgery, and complications of anaesthesia. they were followed up after surgery, were clinically and radiologically assessed for fracture healing, joint movements and implant failure. according to the criteria the results are graded as excellent when the fractures unites within 16 weeks without any complication, good when union occur within 24 weeks with treatable complications like superfi cial infection and knee stiffness and poor when union occur before or after 24 weeks with one or more permanent complications like infection (osteomyelitis), implant failure, non-union, limb shortening and permanent knee stiffness. delayed union was recorded when the fracture united between three to six months while nonunion was noted when union had not occurred after eight months of treatment follow-up was done. patients with closed subtrochanteric femoral fracture with age between 6-16 years and presented within a week of the injury and did not have any previous surgical treatment for the fracture was included in the study. malnourished patients and those with open fractures, pathological fractures and fracture nonunion were excluded from the study. examination of patients was done thoroughly at the time of admission to exclude other injuries. patients were included when part of the fracture was within the inferior aspect of the lesser trochanter and 5 cm below it, patients underwent skin traction till their operation. anteroposterior and lateral radiographs were obtained from the hip to the knee. fractures were classified according to seinsheimer classification ( in type i there were 6 patients, in type ii a-10 patients, in type ii b8 patients, in type ii c4 patients, in type iii a-3 patients, in type iii b-2 patients, in type iv-1 patient and in type v0 patient) (table ii). in all the patients surgical management of subtrochater of the femur was performed on seventh to fourteenth day after the injury. in patients who were not fit for surgery due to associated injuries to vital organs, were haemodynamically unstable or due to active infection at injury site, or were pyrexial delayed surgical management was performed when their over-all condition improved. all patients were operated under general or spinal anesthesia. first generation cephalosporin was administered at the time of induction of anesthesia as prophylaxis. patients were laid supine on the fracture table with traction pin in condyles of fractured femur. the fracture was reduced by traction and manipulation under image intensifi cation. after preparing the femur in standard manner, internal fixation with implants were done. rehabilitation such as touch down weight bearing was started on 2nd post-operative day and sutures were removed on 14th post-operative day. these patients were assessed clinically and radio logically for union timing at nine months following surgery. patients were assessed for delayed union (more than 4-6 weeks postoperative) and non union (nine months following surgery). stastical analysis was limited to calculation of percentage of patients who had unions, malunions, delayed unions, a comparative study of surgical management of subtrochanteric fractures in children 179 table i. age and sex variations in study group (n=34) age (years) male r l female r l total 6-8 9-12 13-16 4 6 12 3 3 7 1 3 5 2 4 6 1 2 4 1 2 2 6 10 18 total 22 13 9 12 7 5 34 table i. age and sex variations in study group (n=34) age (years) male r l female r l total 6-8 9-12 13-16 4 6 12 3 3 7 1 3 5 2 4 6 1 2 4 1 2 2 6 10 18 total 22 13 9 12 7 5 34 implant group a group b group c group d group e group f group g age (years) esin pfn iln enders dhs dcs lcdcp 6-8 9-12 13-16 1 2 2 0 2 3 0 2 3 1 2 2 1 2 3 1 1 3 1 2 3 total 5 5 5 4 5 5 5 table iii: implant used in subtrochanteric fractures (n=34), elastic stable intra-medullary nailing (esin),proximal femoral nail (pfn), interlocking nail (iln), dynamic hip screw (dhs), dinamic condylar screw (dcs),low contact dynamic compression screw (lcdcp). or non unions and excellent, good, and poor outcomes (table iv). ethical and legal procedure the protocol was approved by an ethics committee and thus meets the standards of the declaration of helsinki in its revised version of 1975 and amendments made to it in 1983, 1989 and 1996 (jama 1997; 277:925–6). results: there were 22 (64.70%) male and 12 (35.29%) female patients (table i). the mechanism of injury was road traffic accident in 80% of patients, fall from height 10% and industrial accident was 10%. injury to left lower limb was seen in 41.18% and right lower limb in 58.82% of patients. the average hospital stay was 18 days. in group a, patients were having fracture according to seinsheimer classification, type i (6 fractures), type ii a (10 fractures), type iib (8 fractures), type iic (4 fractures), type iiia (3 fractures), type iiib (2 fractures), type iv (1 fracture) and type v (0 fracture). these patients were divided into seven groups. patients in a group were fixed with elastic stable intramedullary nailing, group b with proximal femoral nailing, group c with interlocking nailing, group d with enders nailing, group e with dynamic hip screws, group f with dynamic condylar screws and group g with lowcontact dynamic compression plates (table iii) (figurei-iv). in group a, complication of titaneum elastic nails was skin irritation at the nail entry site and in group d there was protrusions of the wires through the skin and malunion. in group b,c, e,f and g found no significant complication. flexible nails are not suitable for proximal fractures and can withstand only 40% of the body weight and recommend starting of weight bearing to be delayed until the appearance of early callus formation at three to four weeks time following the fixation. in group b and c, between the age of 9-16 years, rigid and close interlocking nailing on the other hand offered excellent fracture stability even in heavier adolescents especially those with a comminuted fracture pattern allowing early mobilization and joint motion in comparisons to the other groups. we placed the nails through the lateral aspect of the trochanter between the apophysis and the tip of the trochanter and avoid the piriformis fossa and the tip of the trochanter. no patient developed any significant complications such as alterations in the proximal femoral anatomy or a vascular necrosis. physical therapy was started immediately if it was possible because of related injuries. post-operatively, mean follow-up was 28 months (17 -48 months). no major complications were observed in relation to surgery. complications as a result of the procedure were recorded in 4(11.77%) patients and included one patient (2.97%) were labeled as delayed union because of obvious gap at the fracture site in subsequent radiographs (table v). this was due to over distraction of fracture during operation, and was treated by bone graft, two entry site skin irritations; one protrusion of the wires through the skin although they had been buried during the procedure. this nail required removal 2–3 weeks prior to the planned date of removal. there was no instance of loss of reduction, or nail migration during the post-operative period. no clinically significant deformities were ob-served. there were no cases of nonunion or mal-union. all patients achieved complete radiographic healing at a mean of 10 weeks (range from 6 -16 weeks).in a subjective measure of outcome at follow-up, 33(97.06%) of the patients were excellent and 1 (2.97%) good; no patients or parents reported their out-come as not satisfied (table iv). at followup all patients went on to osseous union and regained a full range of movement after rehabilitation. discussion paediatric subtrochanteric femoral fractures present a special unstable type which receives no special attention in the literature 2, 3 . patient’s age may be the most important single variable regarding pediatric femoral fracture treatment. the treatment for children between the ages 6-12 years is the most controversial. treatment options include traction followed by hip spica cast, immediate spica casting, cast bracing, internal fixation and external fixation 11 . traction sahu rl, gupta p 180 out comes no percentage excellent good poor 33 1 0 97.06% 2.97% 0% table iv: out come of results of subtrochanteric fractures (n=34) complications no 1 entry site skin irritations 2 protrusions of the wires through the ski n 3 delayed union 2 1 1 table v: complications (n=34) followed by hip spica cast is the method preferred by many surgeons for the treatment of children aged 610 years 8 . aronson et al 12 studied 54 children who had been treated in distal femoral 90/90 traction for an average of 24 days before being placed in a 1 1/2 hip spica cast. at an average follow-up of 4.3 years, all children were functionally normal and showed a symmetric range of motion of hip and knee. however, this method requires a relatively long hospitalization and accurate control of fracture alignment with frequent radiographs and adjustment in traction as needed. 90/90 skeletal traction with post traction spica is not suitable in children weighing more than 45 kg or in children older than 10 years of age as it will be associated with an unacceptable high incidence of femoral shortening and malrotation 13, 14 . immediate spica casting, popularized by staheli and sheridan 15 is indicated for isolated femoral shaft fractures in children under 6 years of age. infante et al 16 expanded the indications for spica casts to children up to age 10 and up to 50 kg. its primary advantages are simplicity, low cost, and generally good results. ferguson and nicol 17 conducted a prospective study of early spica casting in children less than 10 years of age. they found that age greater than 7 years was a variable predictive of a higher risk of failure of this technique to achieve satisfactory alignment. martinez et al 18 reported excessive shortening and angular deformity in 26 of 51 patients after immediate spica casting. several studies have documented superior results with internal fixation compared to non operative treatment 19, 20, 21 . according to kregor et al 5 the indications for operative fixation of paediatric femoral fractures were presence of associated closed head injury and/or multiple injuries, open fractures and failure of conservative treatment. we applied the indications to include isolated paediatric subtrochanteric femoral fractures as we believe that it is difficult to maintain such fractures in an accepted position by non operative means. methods of internal fixation of paediatric subtrochanteric fractures include intramedullary nails, compression plating and external fixators 5, 7, 9, 10 . awareness of the advantages and disadvantages of intramedullary nails, compression plates and external fixator and the skill to apply each method safely are requisites to the ideal management of such fractures 4 . good results were reported with external fixators, but the rates of pin tract infection, refracture and loss of reduction are high 7, 11, 22, and 23. we preferred not to use the external fixator in the treatment of paediatric subtrochanteric femoral fractures as there is no sufficient room for application of the pins into the proximal femoral fragment. flexible intramedullary nailing is nowadays the treatment of choice in paediatric femoral fractures. a comparative study of surgical management of subtrochanteric fractures in children 181 figure 1: pre and post operative radiograph of subtrochanter fracture of 5 years old child treated with titanium elastic nail. figure 2: pre and post operative radiograph of subtrochanter fracture of 15 years old child treated with proximal femoral nail. figure 3: pre and post operative radiograph of subtrochanter fracture of 16 years old child treated with 95 0 dynamic condyler plate figure 4: pre and post operative radiograph of subtrochanter fracture of 9 years old child treated with low contact dynamic compression plate. patients are able to partially weight bear early because a rod is a load-sharing device, there is rapid fracture healing and a low incidence of malunion and non union 6, 9, 19, 20, 24 . disadvantages of intramedullary nailing are lack of rotational control, exposure to irradiation and backing out of implants 5. fixation of subtrochanteric fractures in children using intramedullary nails need special experience and may be difficult to achieve. plate fixation, despite the negative report of ziv and rang 25 , has been shown to work well in the paediatric age group 5, 10, 14, 26, 27 . the disadvantage of plating are the need for plate removal, poor cosmetic appearance of the scar, blood loss associated with exposure and reduction of the fracture and reported higher degree of overgrowth induced by the plates compared with intramedullary fixation 25, 28 . on the other hand, patients treated with a plate require less assistance, can walk with crutches within ten days postoperatively and return to school sooner than children treated in 90/90 skeletal traction 21 . ward et al 27 reported the use of a 4.5 mm ao dynamic compression plate for the treatment of femoral shaft fractures in 25 children, 6 to 16 years of age, 22 of whom had associated fractures or multisystem injury. the primary indication for this technique was simplification of nursing care and rehabilitation of children with an associated head injury or polytrauma. the average time to fracture union was 11 weeks. there were no infections and no angular deformities. kregor et al 5 reported on 12 patients who had 15 femoral fractures treated with compression plating. all fractures healed at an average of 8 weeks. the mean healing time in our study was the same as that reported by kregor et al 5 . ziv and rang 25 reported three deep infections among five children with head injuries and with femoral shaft fractures. they believed that infec-tions were related to the large number of tubes attached to these patients and their decreased resistance. eren et al 26 reported one case of osteomyelitis (2.1%) which occurred in a child with polytrauma. in our study, we encountered no deep infections. many other reports documented no deep infection with plate fixation 5, 10, and 27 . flynn et al reported two deep infections (3%) with titanium elastic nails 9 . extensive dissection and periosteal stripping during plate application may lead to overgrowth. overgrowth was not a significant problem in the series of kregor et al 5 , with an average increase in length of 0.9 cm (ranging between 0.3 and 1.4 cm), but ward et al 27 reported several patients with considerable overgrowth (approximately 2.5 cm), and hansen 29 reported overgrowth of 2.5 cm in a 12-year-old boy, suggesting that overgrowth is possible in children over 10 years of age. eren et al 26 reported a series of 40 children aged 4 to 10 years with significant lengthening on the operated side in 40% of patients, averaging 1.2 cm (range, 0.4-1.8 cm). in agreement with kregor et al 5 , overgrowth was not a significant problem in our study. scanograms revealed overgrowth of the injured femur with an average of 0.9 cm (range, 0.5 to 1.2 cm) in twelve patients (72.2%). hardware failure is a possible complication with any implant. in the series of ward et al 27 , there was one broken plate postoperatively in a boy who began full weight bearing a few days postoperatively. fyodorov et al 10 reported hardware failure in 2 of 23 femoral fractures treated with dynamic compression plating. hardware failure occurred at 6 weeks. one was treated with revision plating and the other with spica casting; both fractures healed uneventfully. no other complications were noted in their patients. in this study, implant failure did not occur in any patient. the need for hardware removal is controversial 26, 27 and30 . refracture is rare distal to the plate or through screw holes and whether bone atrophy under the plate is caused by stress shielding or by avascularity of the cortex is unknown 1 and 31 . in the series of ward et al 27 , there was a refracture through a screw hole in one of 15 patients who had the plate removed. they do not recommend plate removal in asymptomatic children. eren et al 26 also reported one patient (out of 40 patients) who sustained a refracture 9 years after plate removal. this occurred with a minor trauma while he was playing basketball. on the other hand, bransbyzachary 30 recommended plate removal because they had five late fractures 20 to 60 months after internal fixation. in this study, we encountered no refracture or problems leaving the implants in place during the follow-up period. conclusion: subtrochanteric femoral fractures in children can be managed successfully in a variety of ways. ultimately, many factors play a role in the choice of management, including the age and size of the child, fracture pattern, associated injuries and surgeon and family preferences. operative management whether intramedullary or extramedullary devices both give better results because when operative treatment is undertaken, it should be by experienced surgeons using the technique with which they are most familiar. children between the ages of 6 and 8 years are typically managed with tens, but submuscular bridge plating is also an option, particularly for comsahu rl, gupta p 182 minuted fractures. for children older than 8 years, rigid antegrade nails using a lateral trochanteric entry site have been successful and without reported major complications, although more studies are needed. in length-unstable fractures and in older, heavier patients, trochanteric entry nailing or plating is recommended. traditional plating has excellent results reported in the literature, but involves a larger surgical approach and scar. references: 1. kasser jr, beaty jh. femoral shaft fractures. in : rockwood and wilkins, fractures in children, 6th ed, acta orthopædica belgica, vol. 73 4 – 2007 490 m. el-sayed, m. abulsaad, m. elhadidi, w. el-adl, m. el-batouty beaty jh, kasser jr (eds). 2006; vol 3, pp 894-936, lippincott williams and wilkins. 2. delee jc, clanton to, rockwood ca jr. closed treatment of subtrochanteric fractures of the femur in a modified cast brace. j bone joint surg 1981; 63-a: 773-779. 3. ireland dc, fisher rl. subtrochanteric fractures of the femur in children. clin orthop 1975; 110: 157-166. 4. staheli, lt. fractures of the shaft of the femur. in : rockwood ca jr., wilkins ke, and king re (eds). fractures in children, 3rd ed., 1991, vol 3b, pp 1121-1163, lippincott. 5. kregor pj, song km, routt mlc et al. plate fixation of femoral shaft fractures in multiply injured children. j bone joint surg 1993; 75-a: 17741780. 6. ligier, jn, metaizeau, jp, prevot, j, lascombes, p. elastic stable intramedullary nailing of femoral shaft fractures in children. j bone joint surg 1988; 70-b: 7477. 7. miner t, carrol kl. outcomes of external fixation of pediatric femoral shaft fractures. j pediat orthop 2000; 20: 405-410. 8. tolo vt. treatment of fractures of the long bones and pelvis in children who have sustained multiples injuries. j bone joint surg 2000; 82-a: 272280. 9. flynn jm, hresko t, reynolds ra et al. titanium elastic nails for pediatric femur fractures : a multicenter study of early results with analysis of complications. j pediat orthop 2001; 21: 4-8. 10. fyodorov i, sturm pf, robertson ww jr. compressionplate fixation of femoral shaft fractures in children aged 8 to12 years. j pediat orthop 1999; 19: 578-581. 11. gregory p, pevny t, teague d. early complications with external fixation of pediatric femoral shaft fractures. j orthop trauma 1996 ; 10 : 191. 12. aronson dd, singer rm, higgins rf. skeletal traction for fractures of the femoral shaft in children. a long term study. j bone joint surg 1987; 69-a: 1435-1439. 13. humberger fw, eyring ej. proximal tibial 90-90 traction in treatment of children with femoral-shaft fractures. j bone joint surg 1969; 51-a: 499-504. 14. reeves rb, ballard ri, hughes jl. internal fixation versus traction and casting of adolescent femoral shaft fractures. j pediat orthop 1990: 10: 592-595. 15. staheli, lt, sheridan gw. early spica cast management of femoral shaft fractures in young children : a technique utilizing bilateral fixed skin traction. clin orthop 1977; 126: 162-166. 16. infante af jr, albert mc, jenning wb et al. immediate hip spica casting for femur fractures in pediatric patients : a review of 175 patients. clin orthop 2000; 376: 106-112. 17. ferguson j, nicol ro. early spica treatment of pediatric femoral shaft fractures. j pediat orthop 2000; 20: 189192. 18. martinez ag, carrol nc, sarwark jf et al. femoral shaft fractures in children treated with early spica cast. j pediat orthop 1991; 11: 712716. 19. buechsenschuetz ke, mehlman ct, shaw ah et al. femoral shaft fractures in children : traction and casting versus elastic stable intramedulary nailing. j trauma 2002; 53: 914-921. 20. kissel eu, miller me. closed ender nailing of femur fractures in older children. j trauma 1989; 29: 15851588. 21. reeves rb, ballard ri, hughes jl. internal fixation versus traction and casting of adolescent femoral shaft fractures. j pediat orthop 1990: 10: 592-595. 22. blaiser rd, aronson j, tursky ea. external fixation of femur fractures in children. j pediat orthop 1997; 17: 342-346. 23. skaggs dl, leet a, money md et al. secondary fractures associated with external fixation in pedia comparative study of surgical management of subtrochanteric fractures in children 183 atric femur fractures. j pediat orthop 1999; 19: 582-586. 24. oh cw, park bc, klim pt et al. retrograde flexible intramedullary nailing in children’s femoral fractures. int orthop 2002; 26: 52-55. 25. ziv i, rang m. treatment of femoral fractures in the child with head injury. j bone joint surg 1983; 65-b: 276-278. 26. eren ot, kucukkaya m, kockesen c et al. open reduction and plate fixation of femoral shaft fractures in children aged 4 to 10. j pediat orthop 2003; 23: 190-193. 27. ward wt, levy j, kaye a. compression plating for child and adolescent femur fractures. j pediat orthop 1992; 12: 626-632. 28. ziv i, blackburn n, rang m. femoral intramedullary nailing in the growing child. j trauma 1984; 24: 432-434. 29. hansen tb. fractures of the femoral shaft in children treated with an oa-compression plate ; report of 12 cases followed until adulthood. acta orthop scand 1992; 63: 50-52. 30. bransby-zachary map, macdonald da, singh i et al. late fracture associated with internal fixation. j bone joint surg 1989; 71a: 539. 31. buckley sl. current trends in the treatment of femoral shaft fractures in children and adolescents. clin orthop 1997; 338: 60-73. sahu rl, gupta p 184 page mackup-final.qxd original article gender differentials in nutritional status of elderly people in selected rural areas of bangladesh ali mh1, karim m2, lahiry s3, faruquee mh4, yasmin n5, chaklader ma6 abstract background: the present cross sectional study was undertaken to assess the food habits and nutritional status among elderly people in rural bangladesh and to compare the same between male and female. a simple random sampling and geographical re-conciliation method was used to select the study population. all the patients in a pre-publicized medical camp were approached and a total of 186 male and 237 female participated in the study. data were collected through face to face interview with a semi-structured questionnaire and anthropometric measures were collected using instruments. associations between dietary intake and world health organization (who) referred body mass index (bmi) range was done using cross tabulation. results: the mean age of male was 67.69 years and that of female was 65.46 years. the female subjects were higher than males in number in this study. the rate of male literacy was found to be 39.8% where literacy among the female was 13.9%. among all, 79.6% males were found to be living with their spouse where the rate of living with spouse among the female amounted 53.2%. about half of elderly people were found to be living under poor and 32% in low middle class socio-economic condition. study revealed that 80.6% male and 78.9% female got no opportunity to take protein-rich food more than three days per week. again 95.7% male and 97.5% female had no opportunity take more than two servings of protein rich food per week. the similar case occurred in case of taking fatty food, vegetable and fruits per week. similarly 100 % male and 99.6% female reported that they were taking more than two servings of fatty food per week. no significant association was found between bmi and food intake. the significance was tested by pearson chi-square. in this test the p –value for protein rich food was 0.234 (p?0.05), while fatty food (0.712), vegetable (0.502) and fruits (0.274) which was more than referred significance p-value ?0.05. hence, the study confirmed that malnutrition remains a common problem among older people living in rural bangladesh though there is no significant association was found between food intake and nutrition. conclusion: management of malnutrition in case of elderly population requires a multidisciplinary approach that treats pathology and uses both social and dietary forms of intervention. key words: nutritional status; elderly people; gender differentials; bangladesh introduction aging of population is gradually emerging as an issue not separate from social integration, gender advancement, economic stability or poverty. demographically, population ageing is a global experience and bangladesh is also not left untouched by this demographic reality 1 . bangladesh, has started to experience another emerging issue of population ageing in its highly vulnerable population and development context 2 . in 2007, the number of the elderly people aged 60 and over in this country was 9.41 million and it has increased from 1.94 million in 1951 which is quite phenomenal 3, 4 . more than half of the world’s 1. mh ali, transparency international of bangladesh 2. n karim, who regional office, new delhi 3. s lahiry, institute of health economics, university of dhaka 4. mh. faruquee, department of public health, state university of bangladesh 5. n yasmin department of public health, state university of bangladesh 6. ma chaklader department of public health, state university of bangladesh corresponds to: dr. s lahiry, institute of health economics, university of dhaka, bangladesh, email: lahiry@univdhaka.ebu bangladesh journal of medical science vol. 12 no. 02 april’13 150 older population lives in developing countries 4-5 . medical scientists are expecting that a person can live up to 200 years, even up to 300 years. to increase life expectancy every person has to practice physical work regularly, walk regularly and has to take meals on time with sufficient nutrition 6 . bangladesh is one of the twenty countries in the world with the largest elderly populations, and by 2025, along with four other asian countries, will account for 44% of world's total elderly population. this rapidly increasing population is a new and important group in terms of social and health policy in the country 7 . people are living longer; the average life expectancy at birth in bangladesh has increased to over 60 years 8 . it is found that in poor families, both in rural and urban areas, older people are often unable to meet the demand due to extreme poverty where food is the top priority 9,10 . it has traditionally been the responsibility of the family to provide food and shelter to its elderly members in bangladesh 11 . most of the elderly people of bangladesh are not in a good socio-economic condition due to various problems such as poverty, wage discrimination, want of essential goods and commodities, shelter and compulsory retirement from job when age limit is attained 12 . a small proportion (around 6%) of the total population of bangladesh constitutes the elderly population, but the absolute number of them is quite significant (about 7.2 million) and the rate of their increase is fairly high 13 . the majority are male in the urban area while most are women in the rural area. about 90% of the urban elderly males live alone and are married, whereas 89% of the rural elderly women living alone are widowed 14 . an extensive study on the importance of health education for improving the health quality of the rural elderly of bangladesh was conducted b. they concluded that provision of communitybased health education intervention might be a potential public health initiative to enhance the health status of the elderly 15 . the work revealed that marital status, work status, monthly income, habit of intoxication significantly affects the health status of female elderly of rural in bangladesh 16 . the government of bangladesh has initiated some programs like pension, gratuity, welfare fund, aged persons fund, group insurance and provident fund for the retired government officials and employees. health care issue of the elderly people in bangladesh has not yet received any importance, though it is increasing alarmingly. the present study was undertaken to gather overall information on factors effecting the food habit and nutritional status of old age people in bangladesh motivated by the recognition that the best approach to enhance the aged people’s dietary habit on the basis of nutritional intake in their daily food in taking condition and lifestyle in bangladesh. specifically, the attempt in this study was to investigate the knowledge and habit of elderly people in terms of nutrition intake and prohibiting malnutrition that influence the successful/positive aging of the old age people of the country. methodology the present cross-sectional study was carried out in some rural areas of boidderbazar union of sonargaon upazilla under narayanganj district of bangladesh from january through june 2012. study population were all men and women aged 60 years who resided in the study area permanently at least for last one year. a simple random sampling method was used to draw the adequate respondents and a total of 423 subjects were selected to interview. a house hold list was collected from the boidderbazar union parishad. then elderly population were identified from the listed house hold based on house to house visit and government grn data. eligible elderly was approached those who consented were recruited. all live old age people whose ages were over 60 years during the study period were included in the study, the respondents who refused to participate in the study and would not willing to provide information was excluded. a bengali semi-structured questionnaire was prepared based on the stated research question and objectives of the study. who’s step manual and framework followed to design the dietary habit related questionnaire. after explaining the purpose of the study data were collected through face to face interview using questionnaire. measurement tape and weight machine was used for recording the anthropometric data. the data from the complete questionnaires were entered and analyzed by means of spss (statistical package for ethical approval: this protocol was approved by local ethics committee. results data was collected in this cross sectional study through face to face interview and organizing health camp for getting anthropometric data. a total of 423 respondents including 186 male and 237 female respondents participated in this study whose mean age from male group were 67.69± 10.918 and from female group it was 65.46± 10.918 years . in this study number of female respondents is higher than number of male respondents. the rate of literacy among the respondents gender differentials in nutritional status of elderly people in selected rural areas of bangladesh 151 were 39.8 %male and 13.9 %(n-33) female . here we found that the literacy of male is almost three times higher than female respondents. female respondents reported that their spouse are absent from their life for some certain causes like; died, divorced widowed or separated. the rates of spouse live in male group were higher than female group. it was found that 80.6 % (n=150) males among the male respondents and 78.9 % ( n=187) females among the female respondents reported they took protein rich food more than three days in a week. more over 66.3 % (n=124) male and 77.2 % (n=183) female told they took same amount of fatty food in a week. from the male respondents 26.3 % (n=49) male and from the female respondents 16.0% (n=38) female expressed that they took vegetable where 97.8% (n=182) males and 90.3 % ( n=214) females reported that they took fruits three days in a week. from this table we instigate that protein rich food intakes in three to five days in a week among the male respondents are 9.1 % (n=17) and in female respondents it is 7.6 %( n=18). besides 9.7%(n=18) male and 7.2% (n=17) females reported that they took fatty food where 14.3%(n=34) female and 8.1% (n=15) males took vegetable and 2.2% (n=4) male and 4.6%(n=11) took fruits in three to five days in a week. considerably it is noticed that protein rich food, fatty food, vegetable and fruits intake pattern for more than five days in week among the female respondents are 13.5 % (n=32), 15.6% (n=37), 69.6% (n=165) in that order . in this regard it was also found that among the male respondents more than five days in a week protein rich food , fatty food and vegetable intake pattern is 10.2%(n=19), 23.7% (n=44), 65.6% (n=122) consequently. no male respondents found who too fruits more than five days in a week. among the respondents, 95.7% (n=178) male mh ali, m karim, s lahiry, mh faruquee, n yasmin, ma chaklader 152 respondents reported that they are taking more than two servings of protein rich food in a week where 100 % (n=186) male reported that they are taking more than two servings of fatty food, 84.4 % (n=157) told that they are taking more than two servings of vegetable and 100 % (n=186) said that they also taking more than two servings of fruits in a week. at the same time, 97.5% (n=231) female respondents reported that they are taking more than two servings of protein rich food. where 99.6% (n=236) are taking fatty food, 57% (n=135) taking vegetable and 99.6% (n=236) are gender differentials in nutritional status of elderly people in selected rural areas of bangladesh 153 taking more than two servings of fruits in a week. among the respondents, less than two servings of protein rich food, fatty food, vegetable and fruits intake is considerably very poor. in male respondents only 4.3 %( n=8) and 15.6 %( n=29) respectively are taking protein rich food and vegetable in a week which is less than or equal to two servings. in female respondents 2.5 % (n=6) are taking protein rich food, 0.4 % (n=1) fatty food, 43% (n=102) vegetable and 0.4 % (n=1) are taking fruits in a week which is quantify as less than two serving. a cross tabulation was done to find out the association between servings of food intake in a week and world health organization (who) referred body mass index (bmi) range. no significant association was found when the cross tabulation was tested by pearson chi-square. in this test the p –value of protein rich food is 0.234, fatty food 0.712, vegetable 0.502 and fruits 0.274 which is more than referred significance p-value ?0.05. so from this tabulation and statistical test we can say that there is no significant association between food habit and bmi. the above table shows that the mean height and weight of male is 161.84 cm and 54.82kg where the mean height and weights of females are 150.83 cm and 48.39 kg respectively. among the males the maximum height was 177 cm and minimum were 145 cm and the maximum weights of the males were 91 kg where minimum weight was 35 kg during the survey. besides the maximum heights of the females were 165 cm where the minimum were 95 cm. and maximum weight among them were 76 kg where minimum was 29 kg. among the respondents the mean bmi of males 20.82 and females are 21.23 and maximum bmi of male is 34.67 where the minimum is 13.01. on the other hand the maximum bmi among females are 42.11 and minimum is 15.01. the mean hip ratio of male is 88.61cm and female is 87.88cm and the mean waist ratio of male and females are 73.30 cm and 72.56 cm respectively. the mean waist-hip ratios (whr) among the male respondents are 0.82 cm, the same mean of whr found in the female respondents (0.82cm). the maximum whr among male and female are not far difference from each other respondents. in male respondents the maximum whr is found 0.89 and minimum is 0.67 cm where female respondent’s maximum whr are 0.90 and minimum is 0.71cm. the minimum whr among the female respondents are little bit higher than male respondents. no significant relation was found both male and female except height and weight. discussion the present cross sectional study has confirmed that malnutrition remains a common problem among older people living in rural areas of bangladesh. during the last 15 years a considerable number of studies have examined the nutritional status of institutionalized elderly people and reported prevalence figures for malnutrition and nutritional problems, this study was conducted among the 423 male and female senior citizen of boidderbazar union of sonargaon upazilla of narayanganj district. the male female ratio in this study was 186 male and 237 female. the mean age of the interviewed male participants of this study were 67.69 years where the mean ages of female were 65.46 years. ideally the respondents were selected age over sixty years as the elderly people defined as the age not less than 60 years. so the selection of sample by age category for this study was very correct. based on the availability the respondents were interviewed and in this regards the number of female were higher than number of male respondents. female respondents were more available during the field work. its actually bangladeshi social context that female is more home seeker than male. during the old age female are become dependent on other family member that’s why during household listing more female were found in the house than female. the literacy of the respondents were categorize into two broad category one is literate and another is illiterate. persons those who had no formal or informal education they are in illiterate category and those who had at least one or more years of education are in literate category. the literacy rate among the male is higher than the female. the rate of male literacy is 39.8% where among the female is 13.9% almost three times lower than male elderly people. in some studies, the level of education was directly associated with nutritional status. in a study at iran found, nutritional status was also associated with education. a higher level of education was possibly associated with higher income and better lifestyle, depression is also extremely prevalent in older adults, but is a problem that is often overlooked. it contributes to illness, alcohol and prescription drug abuse, mortality and suicide. despite these obstacles, seniors, especially in rural areas, often exhibit a strong sense of independence and coping, determination, and a sense of community 17 . the habits and lifestyles that have led to resiliency (i.e. a greater ability to cope with stress and adversity) in these elderly people is the focus mh ali, m karim, s lahiry, mh faruquee, n yasmin, ma chaklader 154 of the current study. in the following sections, studies examining resiliency, the importance of gender and a rural setting, along with the uniqueness of using a narrative approach are reviewed. the average life expectancy in bangladesh is ± 60 years. generally it is found that after the age of 60, the old age people become alone as because of dead of husbands or wife. in some cases before age of 60 separations or divorce lead old age people to become couple less. during this study it was found that 79.6% males are living with their spouse where the rate of living with spouse among the female were 53.2%. on the other hand 20.4% males and 46.8% females spouse is absent from their life due to some certain causes like, died, widow, divorce etc. it is found that the spouses present among the males are higher than female respondents. psychological and socio-economic problems such as depression, life events and loneliness may reduce appetite. loneliness and reluctance to eat may complicate an already marginal situation for nutritional risk in the elderly. elderly people are especially vulnerable to loneliness. as an interesting and surprising subject, loneliness is also an important problem for many elderly people in iran. a bigger number of old age people have no any occupation. they are doing nothing in this retirement period. the proportion of this group of senior citizen found in this study is 35.9%.as this proportion citizens are doing nothing they said they have no self income. in this regard 60.8 % older people found who have no any income. interestingly it is found in this study that 23.6% elderly are involved in home work , some 18.7% are in agriculture sector and 10.2% are in day labour and/or rickshaw puller. so we can say that our senior citizen are not our burden, they are our resource. we just need to ensure their good health. older people’s health may also be compromised by poor diet and nutrition. a study in central ethiopia found that 67% of older people were malnourished; a third of these were severely malnourished 18 . malnutrition’s causes may include poverty, responsibility for supporting grandchildren, living alone or age-related disabilities such as immobility, blindness and/or loss of teeth 19 . most of the elderly people of bangladesh aren’t in a good socio-economic condition due to various problems such as poverty, wage discrimination, want of essential goods and commodities, shelter and compulsory retirement from job when age limit is attained. as the socio-economic impact of ageing population on the society is evident, it is important to consider not only the degree but also the pace of the changes in the age structure. in this study it is found that almost 50% of elderly people are living under poor and 32% are in low middle class socio-economic condition. the nutritional status found in this study was associated with some of socio-economic conditions such as education, marital status, gender, number of child, type of living and taking medicine social and economic conditions can adversely affect dietary choices and eating patterns. elderly people become vulnerable to malnutrition owing to inappropriate dietary intake, poor economic status and social deprivation, in this study it is found that 0nly 10.2% male and 13.5% female elderly can have protein rich food more than five days in a week. major portion that is 80.6% male and 78.9% female have no opportunity to take protein rich food more than three days in a week. again 95.7% male and 97.5% female had no opportunity take more than two servings of protein rich food in a week. the similar case is occurred in taking fatty food, vegetable and fruits in a week. in this study it is found that the percentage of more than three days in a week fatty food, vegetable and fruits intake among the male elderly is 66.7%, 26.7% and 97.8%. in female the rate is 78.9% fatty food, 77.2% vegetable and 90.3% fruits. according to the one review of 79 published studies conducted on elderly people 20 , the proportion of elderly people suffering from malnutrition varies between 1 %and 74%and the risk of malnutrition were between 8 % and 87. % in the study performed in all nursing homes in helsinki, malnutrition was common among elderly residents living in nursing homes and according to the mini nutritional assessment, 11 %to 57 %of the elderly people studied actually suffered from malnutrition, and 40 %to 89 %were at risk of malnutrition, whereas only 0 %to 16 %was in good nutritional status 21, 22 . among the respondents, 95.7% male and 97.5% female respondents reported that they are taking more than two servings of protein rich food in a week where 100 % male and 99.6% female reported that they are taking more than two servings of fatty food in a week. 84.4 % male and 57% female told that they are taking more than two servings of vegetable and 100 % male and 99.6% female said that they also taking more than two servings of fruits in a week. gender differentials in nutritional status of elderly people in selected rural areas of bangladesh 155 the lower scores of mini nutritional assessment were associated in our study with female gender .findings of other studies were similar. nutritional status, eating patterns and energy intake in those institutionalized elderly individuals who respond positively to interventions. a cross tabulation was done to find out the association between servings of food intake in a week and world health organization(who) referred body mass index ( bmi) range. no significant association was found when the cross tabulation was tested by pearson chi-square. in this test the p –value of protein rich food is 0.234, fatty food 0.712, vegetable 0.502 and fruits 0.274 which is more than referred significance p-value ?0.05. so from this tabulation and statistical test we can say that there is no significant association between food habit and bmi. inadequate micronutrient intake among older people is common due to diminished amount of food intake. in this study it was found that a major portion (81.6%) of the respondents reported that they are not taking any kind of vitamin. only 18.4 % respondents said that “yes” they are taking some kind of vitamin currently. in this study it was found that, 30.6% male are in low physical activities, 17.2 % are in medium physical activities and 52.2 % are involved in high physical activities. on the other hand 38.8% female are in low physical activities, 25.3% are in medium physical activities and 35.9% females are involved in high physical activities. associations between dietary intake and nutritional status were examined in 423 elderly people aged ?60 years and found no significant association between food intake and nutrition among the study population. the dietary patterns of the elderly are in general "healthier" than that of younger adults except for higher salt intake among the elderly. conclusion and recommendations the present study revealed that malnutrition remains a common problem among older people living in rural bangladesh though there is no significant association was found in food intake and bmi. malnutrition in this group is an increasing hazard especially for women, for people having a disease, low level of education, number of child, and psychological problems. the elderly population is affected by many causes of malnutrition, which can be reversed if it is addressed earlier than the development of malnutrition. management of malnutrition in the elderly population requires a multidisciplinary approach that treats pathology and uses both social and dietary forms of intervention. without intervention, it presents as a downward trajectory leading to poor health and decreased quality of life. it is important to assess elderly individuals’ nutrition, pay attention to nutritional problems, use more nutritional supplements, and provide energy and protein-dense food which might delay malnutrition or even improve the nutritional status of elderly residents. simple methods for assessing nutritional status as well as food and nutrient intake of elderly residents are needed. based on the key study findings, some very specific recommendations for further betterment of improving nutritional status of elderly people of bangladesh considering gender sensitivity are suggested: (a) ensuring equal access for all elderly irrespective of gender, class or education to take adequate nutritional food, shelter, medical care and other services that promote self-support and personal health.(b) before any elderly peoples oriented nutritional intervention, this kind of study in large scale is needed for getting authentic information and large scale project planning and implementation. (c) there is a need for the package programmes to improve nutritional status as well as health care of the elderly people. (d) a national policy for the elderly people is needed for the safeguard of the elderly peoples particularly for female elderly from malnutrition. 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(2006). the mini nutritional assessment (mna®) review of the literature – what does it tell us? j nutr health aging, 10:466–485.pmid:17183419 21. wojszel, z.b• (2006). determinants of nutritional status of older people in long-term care settings on the example of the nursing home in bia?ystok. advances in medical sciences, 51. 23 22. suominen m, muurinen s, routasalo p, soini h, suur-uski i, peiponen a. malnutrion and associated factors among aged residents in all nursing homes in helsinki. eur j clin nutr 2005 59:578–83. gender differentials in nutritional status of elderly people in selected rural areas of bangladesh 157 page mackup april-14.qxd bangladesh journal of medical science vol. 13 no. 02 april’14 128 original article association of attention deficit hyperactivity disorder with heroin addiction salman s1, idrees m2, anees m3, idrees j4, idrees f5, badshah s6 introduction: the attention deficit hyperactivity disorder (adhd) is one of the most common neuropsychiatric childhood onset disorders that affect 3% to 6%1 and almost 5% of adults2 and personality characteristics and diseases, such as novelty-seeking personality, substance abuse, and heroin addiction, whose features are similar to adhd or are associated with adhd3. its prevalence in school children is approximately 6% to 9% and etiology of this disorder is unknown4. there was a myth for many years that the disorder remits during adolescence, but it is now well established that it can be experienced by a patient in adulthood as well. there is a bidirectional overlap between adhd and drug abuse and dependence5 and affect 27% of adult population6. corresponds to: saad salman, department of pharmacy, university of peshawar, pakistan. email: saadirph@gmail.com abstract: objectives: to study the association of attention-deficit hyperactivity disorder (adhd) with heroin addiction. study design: a cross-sectional, hospital based study. place and duration of study: the study was carried out at lady reading hospital and khyber teaching hospital, peshawar, pakistan from 4th april 2012 to 13th september 2012. subjects and methods: a sample of 137 adult heroin addicts were analyzed that whether they were adhd and that childhood problem continues to manifest symptoms in adults. for retrospective assessment of childhood adhd, the wender utah rating scale (wurs) as well as the diagnostic and statistical manual of mental disorders (dsm-iv) symptom checklist for adhd was used. the conners’ adult adhd rating scales (caars) was used to assess the persisting symptoms of adhd in adults. inclusion criteria: patient diagnosed with heroin addiction according to icd-9 and dsm-iv. exclusion criteria: patient has co-morbid with any other mental illnesses. results: the difference between the mean score of wurs and caars of adhd patients were significantly greater than the normal patients. heroin addicts showed 41.6% (wurs) and 38.6% (dsm-iv diagnostic criteria) that indicated evidence of retrospective adhd affliction in childhood. 22.6% were iv users. caars was presented in 37.9% heroin addicts who exhibited a substantiation of adhd persistent in adulthood. the difference between the mean score of wurs and caars of adhd patients were significantly greater (p = 0.003), than the normal patients. conclusions: these results revealed that addiction is associated with co-morbidity with adhd, expressed in the form of heroin addiction. key words: attention-deficit hyperactivity disorder, heroin addiction, wender utah rating scale, conners’ adult adhd rating scale. 1. saad salman, department of pharmacy, university of peshawar, pakistan 2. muhammad idrees, department of chemistry, islamia college university peshawar, pakistan 3. muhammad anees, khyber medical college, peshawar, pakistan 4. jawaria idrees, department of zoology, islamia college university peshawar, pakistan 5. fariha idrees, department of chemistry, islamia college university peshawar, pakistan 6. sareer badshah, department of statistics, islamia college university peshawar, pakistan doi: http://dx.doi.org/10.3329/bjms.v13i2.18294 bangladesh journal of medical science vol.13(2) 2014 p.128-134 the co-occurrence of adhd and addiction is very common. previous studies have shown that adults with adhd are a risk for substance use disorder (sud) and almost 52% of adult had a lifetime history of sud2, 4. the co-morbidity between adhd and su shows relativity and relevant to research and clinical development in psychiatry, pediatrics and psychology6. the diagnosing and specific risk factor associated with su within adhd may lead to a better targeted pharmacotherapy and psychotherapeutic treatments for both the disorders upon expression at early stage of their lives8, 9. higher rates of adhd have been reported in patients having sud relative to controls10, 11. 15% to 25% adults with sud history have been estimated to have adhd12. studies have conducted in juvenile adolescents for assessing adhd and other disorders in substance abusing groups had overrepresentation of adhd11,12. adhd predominates from 15% to 25% in individuals with sud13,14. two studies showed that the 24% of 201 inpatients15 and 10% cocaine abusers for drug detoxification treatment had adhd16. the treatment of adhd is usually done with stimulants like methylphenidate, amphetamine etc., with the behavioral therapy of the patient and family counseling. biederman and colleagues demonstrated that untreated adhd is a risk factor for the development of an sud5. wilens14 drew the conclusion that a pharmacological treatment had no negative influence on suds in adhd patients. various studies have shown that a treatment of addicted adhd patients with stimulants reduces drug consumption16,17. adolescents medicated with stimulants showed a lower risk of developing an addiction (cocaine, alcohol and other drugs). in our previous study, we demonstrated that many substance-dependent patients like thc (tetra-hydrocannabinol), poly drug, alcohol and opium abuse were suffered because of adhd or were adult adhd17. material and methods: one hundred and thirty seven consecutive patients admitted in psychiatry ward of lrh for drug detoxification were included in the study. all the patients were analyzed through an extended clinical semistructured interview to collect socio-demographic, drug use related, clinical data and also the nonadhd psychiatric diagnoses were assessed in both the hospitals by the use of a semi structured diagnostic interview previously validated against the structured clinical interview for dsm-iv-tr13-15. patients evaluated in the hospitals were also assessed for adhd, using dsm-iv criteria and a structured interview provided by j. biederman, m.d.2,5. adult patients with various drug and alcohol dependence gave their consent to participate in this study as in-patients at the department for addiction lady reading hospital. at a clinical interview, all 137patients (all males) met the diagnostic criteria required for heroine according to diagnostic and statistical manual of mental disorders (dsm-iv), and were permitted to participate in this investigation. the examination was performed only after a 10-day detoxification therapy as it was imperative that the patients were no longer suffering from any withdrawal symptoms. exclusion criteria included other illnesses. approval for this study was given by the ethics committee of lady reading hospital. the wender utah rating scale (wurs) and the dsm-iv symptom checklist for adhd served as investigating instruments for the retrospective assessment of the presence of adhd in childhood. furthermore, the dsm-iv criteria were used to divide the patients into diagnostic sub-groups (inattentive type, impulsive type, combined type). the conners’ adult adhd rating scales (caars, short version) (conners et al., 1999) were used to assess persisting adhd symptoms in adulthood as a part of a comprehensive intake valuation battery. statistical analyses: we analyzed demographic differences between groups, using chi-square tests for categorical variables and comparisons of proportion and for the comparison of proportions. the unpaired t-test was used to compare means between two groups. the unpaired t-test was used to compare means between two groups; 61.3%, patients with adhd showed a marked tendency towards substance abuse when compared to those patients without adhd (38.7%) (p = 0.003).a principal components analysis using varimax rotation was performed on the 25 test items of wurs and 25 items of caars-s. the number of factors retained was determined by examination of the screen plot and use of the kaiser-guttman rule (i.e., eigenvalues greater than 1.0). cronbach's alpha was calculated as a measure of internal consistency on all the items of wurs and caars-s resulting from the factor analysis in wender utah and conners rating scales. attention deficit hyperactivity disorder and heroin addiction 129 results: the total sample comprised of 137 male patients with an average age groups of 37.5 ± 9.8 years. the socio-demographic data have been presented (table 1).the mean score of 61-items of wurs and 26items of caars-s were calculated but we arbitrarily chose 25-items of wurs and 25-items of caars-s showing the greatest mean difference between the patients of adhd and normal. table 1: socio-demographic data of the patients. total iv-users in the sample were 31 and affected were 21 (67.7): hbv 5 (23.8%), hcv 13 (61.9%), and hiv 3 (14.2%) respectively. their distribution in different addiction is shown. (table 2) table 2: total iv users in the sample (n=31, affected n=21). heroin addicts showed 41.6% (wurs) and 38.6% (dsm-iv diagnostic criteria) indicated evidence of retrospective adhd affliction in childhood. caars was presented in 37.9% heroin addicts. scree-test and eigenvalues greater than one, exclusion of factor loadings less than 0.30, factors loading greater than 0.30 not on more than one factor. a varimax rotation yielded the four factors:(1) inattention/memory problems, (2) hyperactivity/restlessness, (3) impulsivity/emotional liability, and (4) problems with self-concept29 additionally, an adhd index and indices for dsm-iv subscales (dsm-iv: predominantly inattentive, predominantly hyperactive-impulsive, combined sub-type) can be obtained11. test-retest correlations range between 0.81 (impulsivity/emotional lability) and 0.88 (problems with self-concept). construct-validity with wurs reached moderate to satisfying correlations of 0.31 (inattention problems) to 0.68 (impulsivity/emotional lability). criterion validity with a semi-structured interview for adult adhd yielded a sensitivity of 81% and a specificity of 83% 33.52 (47.2%) of the patients achieved the cutoff 50 in the wurs-k and, therefore, fulfilled the criteria for adhd symptoms in childhood. the correlation matrix was subjected to principal axis factoring, yielding 11 factors with eigenvalues greater than 1.0. conners et al. decided on an orthogonal rotation to obtain independent factors of inattention, hyperactivity, and impulsivity. since it is unlikely that these three dimensions are totally unrelated, we did not limited our analyses to varimax rotation, but also used oblique rotations. items were eliminated from further analyses if they failed to load above 0.30 on any one factor, or if they loaded greater than 0.30 on more than one factor. the first factor accounted for 12.91% of the total variance. the eight items that loaded on this factor were related to inattention/distractability ( =0.82). the second factor explained 8.12% of the total variance. the five items loading on that factor tapped on problems with self-concept ( =0.75). the third factor accounted for 4.82% of the variance and the four items loading on it are related to emotional instability ( =0.77). the fourth factor explained 4.27% of the total variance with six items related to impulsivity ( =0.71). five items loaded on the fifth factor that explained 2.25% of the total variance, tapping on hyperactivity ( =0.87). the sixth factor accounted for 2.36% of the total variance and the six items loading on it are related to sensation seeking ( =0.67). salman s, idrees m, anees m, idrees j, idrees f, badshah s 130 socio-demographics adhd number of patients, n 137 males/females, n 137/nil age (mean ± sd) 37.5 ± 9.8 employed n (%) 61 (44.5) married n (%) 37 (27) divorced n (%) 11 (8.02) types of indications no. %age heroin users hbv 5 23.8% present n=3 hcv 13 61.9% present n=7 hiv 3 14.2% present n=1 total n (%) 21 100% approx. 11(52.3) table 3: attention deficit hyperactivity disorder diagnosed with wender utah rating scale (wurs), dsm-iv symptom check-list for adhd and conners’ adult adhd rating scales (caars). *wurs = the wender utah rating scale (wurs) indicates adhd with a score of more than 30. **caars = conners adult adhd rating scales (the analysis is conducted to indicate subject’s current state). ***dsm-iv = diagnostic and statistical manual of mental disorders (a score higher than six in the first nine items indicates attention problems: a score higher than six in the last nine items indicates hyperactivity). discussion: this study comprised of sample of adults admitted in psychiatry ward seeking detoxification treatment for heroin addiction were studied that whether they were adhd in childhood and this disorder is persisting in adulthood or not. results of this study suggest that the four factors: inattention/memory problems, hyperactivity/restlessness, impulsivity/emotional liability, and problems with self-concept characterize the wurs and caars-s. these four factors are found in both the retrospective childhood and the adult assessment in the corresponding instruments. these factors helped: in distinguishing adhd from non-adhd, associate patients with a clinical diagnosis of drug and alcohol addiction comorbid with adhd, and do better to identify adults who do not have adhd. in addition to poor specificity of wurs, 31 the underlying factor structure suggests that wurs can measures depression and conduct problems, which are not specific to the dsm-iv adhd classification. another possible reason for the low specificity of the wurs may be a response bias on the part of patients evaluated in an adhd specialty clinic; this is more probable in adult patients, who are unlikely to have parents available as informants regarding childhood behavior. other studies of symptom clusters in children with adhd support two factors: inattention and hyperactivity-impulsivity32,33. the finding that these four factors are the best discriminator in adults is consistent with the evolution of adhd over the lifespan from mixed to more predominantly inattentive and hyperactive. this finding also highlights that the cognitive symptom domain is perhaps the most important to consider when evaluating a general psychiatric population for presence of adhd. our investigations showed significantly high values for the hyperactive and the combined types. the isolated inattentive type was under-represented. the over-representation of the hyperactive type in this group reflects those individuals willing to take on a higher risk. patients categorized under the inattentive type most likely use the substance primarily for recreational purposes and later on became dependent. the results of this study confirm that a high percentage of the drug and alcohol-dependent patients admitted in psychiatry fulfilled the diagnostic criteria of dsm-iv for the presence of adhd. the highest rate of adhd was in children born to mothers with heroin dependency raised at home, being twice that observed in the other groups. mothers of these groups of children also had a high rate of adhd34. one study suggests that cyclothymic, and to a lesser extent irritable traits could represent the temperamental profile of heroin addicts, largely irrespective of co-morbidity, and tend to cohere with previous conceptualizations hypothesizing sensation-seeking as the main personality characteristics of addiction35. kessler et al. (2006) found quite a high prevalence of adhd in alcohol addicts of 4.4%. our study found a rather moderate rate of persisting adhd in the entire examined group of alcohol-dependent patients. however, according to our data concerning the prevalence in childhood, adhd can represent a considerable risk factor for the onset and developattention deficit hyperactivity disorder and heroin addiction 131 heroin addicts n=137 frequency percent dsm-iv-tr* 53 38.6 inattentive type 6 11.3 hyperactive-impulsive type 27 50.9 combined type 20 37.7 wurs** 57 41.6 caars*** 52 37.9 inattentive type, 5 9.6 hyperactive-impulsive type 25 48.07 combined type 19 36.5 indistinct type 3 5.7 ment of heroin and other drug dependence as well. furthermore, those patients with adhd were much more likely to commence with drugs at an early age, so adhd can be considered to be a risk factor for ‘early introduction’ to drug addiction. pre-clinical investigators (fung and lau, 1989) hypothesized that early exposure to nicotine may result in neuronal sensitization and initiation, pre-disposing to later behaviors linked to sud. from a preventive standpoint, reducing the manifest psychiatric symptoms, such as in adhd, may result in a decrease in cigarette consumption as well. findings also indicate that adhd accelerates the transition from substance abuse to substance dependence (biederman et al., 1998). there is also evidence that adhd increases the risk of drug use disorders in those individuals with alcohol abuse or dependence (biederman et al., 1998). adhd is also known to affect remission from sud. a study was carried out with 130 adults with adhd and sud and 71 non-adhd adults with sud, and the results showed that the average time to sud remission was more than twice as long in adhd patients than in the control subjects (144 vs. 60 months, respectively) (wilens et al., 1998). studies performed on adhd patients suggest that persisting adhd can lead to continued misuse and abuse of substances following dependence, a longer duration of sud and a lower rate of remission (biederman et al., 1998; wilens et al., 1998). in summary, these findings indicate that adhd influences the initiation, transition and recovery from sud. the high coincidence of adhd and addiction illnesses may also be due to a number of other causes. in particular, adhd patients suffering from hyperactivity and disturbed control impulses and patients of the combined type are known to derive a higher level of pleasure from experimentation and risk-taking concerning drugs and alcohol. it was found that hyperactive adhd patients with drug dependence were more likely to have an additional other addictions compared to those patients with just attention disorders (saules et al., 2003). conclusion: it was confirmed that adhd forms an association with heroin addiction and that many patients suffering from an addiction may also have co-morbid adhd. with the help of caars, it could be demonstrated that a significant number of patients who fulfilled the diagnostic criteria of adhd, according to dsm-iv, had persisting adhd in adulthood. an adhd patient poses a marked risk for the development of different types of addictions. limitations: some limitations have to be taken into account that when doing psychometrics on a scale, generally the sample of subjects chosen to complete the scale should be similar to the population; 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january-march 2009 editorial medical services without medical ethics: sailing the ship without compass brig. gen. (rtd) prof. m nuruzzaman1, dr. abu kholdun al-mahmood2 our lives, both present and future, are shaped by the ever-growing knowledge and power of the life sciences and of healthcare. medicine is the universal science intended everywhere to sustain or better human health but ethical inquiry is an immense need to us when we are not sure about the direction where we are heading. it is to be noted that on his presidential speech to the american college of surgeons in oct 2001 prof r scott jones said, “to function effectively in the health care system…….to navigate in a trillion dollar industry, we need compass: medical ethics”1. unfortunately in our country we are navigating our ship without this compass in the ever expanding ocean of medical industry. that’s why every time we are facing a situation where there is a gap between the caregivers and expectations of the clients. very often we found news on patient’s dissatisfaction towards our caregivers in newspapers. medical education curriculum without any component of morality is producing caregivers without conscience like robots. in this situation our patients are not banking on us and our healthcare market is being taken out by foreign hospitals and healthcare personnel of all categories. it is not only affecting our healthcare industry but also jeopardizing quality of medical education. the overall scenario is not a happy experience for us. to bring a major change in this bleak reality we have to incorporate moral and ethical input in every level of our undergraduate and post-graduate medical education curriculum. moreover we have to prepare proper legislation and strictly impose them to guide our physicians. _____________________________________________________________________________ reference 1. dent md. licensed to heal. bulletin of the american college of surgeons, 2002; 87 (8): 812. ________________________________________________________________________________________________________ 1. principal, ibn sina medical college 2. prof. & head of the department of biochemistry, ibn sina medical college corresponds to: brig. gen. (rtd) prof. m nuruzzaman, mcps, ms, fics principal ibn sina medical college, 1/1b kalyanpur, mirpur road, dhaka-1216, bangladesh “every illness has a cure, and when the proper cure is applied to the disease, it ends it, allāh willing.” [sahih muslim] 4 bangladesh journal of medical science case report orthodontic treatment of mandibular anterior crowding mk alam abstract this paper concerns orthodontic treatment of a 17 years old bangladeshi female with a class i malocclusion along with anterior crowding in the mandibular arch. orthodontic treatment carried out with preadjusted roth type (018 slot) fixed brackets with labial flaring of the mandibular incisors to accomplish the treatment. the esthetics and occlusion were maintained after retention. key words: crowding, malocclusion, labial flaring. _________________________________________________________________________ introduction crowding is a quantitative discrepancy between the clinical length of the dental arch and the sum of the mesiodistal widths of the teeth1. while crowding may occur in the anterior or posterior areas of either arch, adults are most likely to have crowding in the mandibular anterior area2. crowding is the lack of space for all the teeth to fit normally within the jaws. the teeth may be twisted or displaced3. crowding occurs when there is disharmony in the tooth to jaw size relationship or when the teeth are larger than the available space1-2. crowding can be caused by improper eruption of teeth and early or late loss of primary teeth. crowding should be corrected because it can: a. prevent proper cleaning of all the surfaces of your teeth b. cause dental decay increase c. the chances of gum disease prevent proper functioning of teeth d. prevent proper functioning of teeth e. make your smile less attractive treatment object braces are a simple yet effective form of orthodontic treatment and can generally be used to remedy crowding of the teeth. while many people are hesitant to get braces because of their cosmetic nature and effect on social life, the results generally outweigh the temporary effect. _____________________________________________________________________________________ corresponds to: dr. mohammad khursheed alam, assistant professor and head, department of orthodontics, bangladesh dental college. road 14 a (new) dhanmondi residential area, dhaka, bangladesh email: dralam@gmail.com bangladesh journal of medical science volume-8 no. 1-2; january-march 2009 33 alam mk treatment objectives were to: 1. level and align the arches. 2. correct mandibular arch length discrepancies. 3. maintain class i canine and molar relationships. 4. maintain dental and facial midline. 5. normalize the overbite and overjet. 6. improve the gingival condition. 7. maintain the profile. 8. achieve long-term stability. treatment progress the mandibular arch needed to be leveled to correct misalignments, considering that the patient had completed growth. the mandibular arch had 3.5 mm arch length discrepancy (fig-1) and overjet was 4 mm. to normalize the overjet and misalignments, the best treatment option is 1.75 mm labial flaring of mandibular incisors. treatment was started in the mandibular arch with preadjusted roth type (018 slot) brackets. a 0.014 and 0.016 inch nitinol arch was used for leveling and labial flaring of the mandibular incisors. after labial flaring and leveling of the mandibular incisors, a 0.016 × 0.022 inch nitinol arch was inserted for the final alignment and detailing. lastly a 0.016 × 0.022 inch stainless steel arch wire was used for the alignment stabilization. an ideal occlusion was obtained after 5 months active fixed orthodontic treatment, and all the appliances were removed. fixed lingual type retainer was set on the lingual surface of the mandibular anteriors prepared by coaxial wire and set by light cure composite (fig-1). discussion tooth crowding is a common orthodontic problem1-2. it is basically what it sounds like, the teeth are too crowded together, and become crooked. peck and peck4 reported a clear relationship between the shape of mandibular incisors and their irregularity, smith5 found little correlation between the shape of mandibular incisors and the degree of the teeth. there is some disagreement regarding the role of incisor crowding in periodontal disease, but there is no dispute about the improvement in oral esthetics that can be achieved by alignment of the teeth. although treatment of mandibular anterior crowding must be individualized, clinicians should always keep in mind the high potential for relapse as they consider esthetics, treatment mechanics, periodontal conditions, and ultimate retention. crooked teeth are generally not considered attractive and it is not an optimal occlusion so orthodontic treatment is required to fix this orthodontic problem1-2. 34 orthodontic treatment of mandibular anterior crowding treatment will not only help create a beautiful smile but will help oral health as well. there are a number of different possibilities for dental treatment of tooth crowding depending on the severity of the case; different situations should be treated differently. extra space can be created by expansion of the arches or extraction of teeth or stripping or labial flaring. every treatment option has its own merits and demerits. on orthodontist’s point of view, present case was treated best by labial flaring. once space is created, braces will eliminate crowding and align the teeth. correction of crowding can help to prevent dental decay and periodontal disease by improving the ability to remove plaque from the teeth1-2. figure 1. pre and post treatment (photographs published with permission). 35 conclusion the treatment goals set in the pretreatment planning were all attained and were successful. solid intercuspation of the teeth was maintained with class i molar relationship. the mandibular teeth were found to be esthetically satisfactory in the line of occlusion. the over jet become near ideal and normal overbite was found. _________________________________________________________________________ references 1. bishara se. an approach to the diagnosis of different malocclusion. textbook of orthodontics. philadelphia, wb saunders 2001:146-184. 2. proffit wr and fields, jr. hw. orthodontic treatment planning: from problem list to specific plan. in proffit wr. ed. contemporary orthodontics. 2nd ed. north carolina, mosbi 1992: 186-224. 3. bhuiyan mm and islam kr. orthodontic treatment of severe crowding of male preadolescent by fixed braces. city dental college j 2007; 4 (1):19-22. 4. peck h and peck s. an index for assessing tooth shape deviations as applied to the mandibular incissors. am j orthod 1972; 61 (4):384-401. 5. smith rj, davidson wm, gipe dp. incisor shape and incisor crowding: a reevaluation of the peck and peck ratio. am j orthod 1982; 82 (3):231-235. ___________________________________________________________________________ the prophet (s) said, “whoever is offered some perfume should not refuse it because it is light to wear and has a good scent” [abu dawud, an-nasai] 36 microsoft word bjms-june09-fina-pressl width of attached gingiva in an indian population: a descriptive study shaju jacob p1, zade rm2 abstract objectives: attached gingiva is important for maintaining periodontium in a healthy state. the present study tries to find the normal values of width of attached gingiva in a periodontally healthy indian population. material and methods: the width of attached gingiva was measured with a periodontal probe in periodontally healthy patients attending the periodontics department. descriptive statistical analysis was done to get the mean, which will represent the normal values of width of attached gingiva for the population. results: female patients had a greater width than males and the 20 to 30 year old group had the greatest width of attached gingiva. the mean values of attached gingiva varied in different areas of the mouth with greatest width in maxillary central incisors and least in mandibular molars. conclusion: width of attached gingiva varies with age, gender and in different areas of the mouth. key words: periodontium, gingiva, health, introduction: attached gingiva is one of the most important anatomic and functional landmarks in the periodontium. though there is not enough evidence on the role of attached gingiva in maintaining psence of the attached gingiva can lead to inflammation in individuals with less than optimal plaque control1. creation of an increasing the width of attached gingiva forms a major portion of periodontal plastic surgery. there are very few studies done to evaluate the width of attached gingiva and no studies on the indian population. assessing the width of the attached gingiva will help in assessing the risk for a periodontium to be affected by disease for which normal values need be known for that population. the study was aimed to assess the width of attached gingiva in the population attending the dental college in chhattisgarh. 1. dr. shaju jacob p, department of periodontics and oral implantology 2.prof. zade rm ,dean, chhattisgarh dental college and research institute corresponds to: dr. shaju jacob p, reader, department of periodontics and oral implantology chhattisgarh dental college and research institute, rajnandgaon, chhattisgarh. india. email: shajujacob@yahoo.com bangladesh journal of medical science volume-8 no. 3; june 2009 materials and methods: patients attending the periodontal outpatient department in the age group of 20 to 50 years were invited to participate in the study. patients with more than 4 mm of clinical attachment level in any of the assessed teeth were excluded. as there was no probing of gingiva involved, no medical contraindication for inclusion criteria was kept. institutional ethics committee gave approval for the study. after getting informed consent, patients’ data were collected through an administered questionnaire and clinical examination. attached gingiva was measured by the following way with a unc 15 periodontal probe. the distance from the crest of marginal gingiva to mucogingival junction is measured and is subtracted with the probing depth in the mid buccal region to get the width of attached gingiva on the buccal side of all the central incisors, first premolars and first molars, a total of 12 teeth. results: a total of 73 patients participated in the study of which 43 (59%) were females. female patients had a higher width of 3.04 mm than males with an average of 2.67 mm (table 1). maxillary central incisors had the greatest width with an average of 3.77 mm and mandibular molars had the least width of 2.48 mm (table 2). mandibular incisors had a width of 2.52 mm, maxillary premolars 3.04 mm, mandibular premolars 2.75 mm and maxillary molars 2.58 mm. width of a gingiva was the looked in to in different age groups. in the age group of 20-30 year the width was found to be greatest, 2.97 mm while 30-40 year olds patients had the lowest of 2.721 mm. the greatest width was seen in a left maxillary premolar and the lowest value was 0 mm (0mm indicates absence of attached gingiva) found in all categories of teeth. table 1: width of attached gingiva in males and females n mean ± sd (mm) female 43 3.035±1.269 male 30 2.674±1.536 table 2: width of attached gingiva among different types of tooth tooth type mean ± sd (mm) maxillary central incisors 3.771±1.761 maxillary first premolars 3.044±1.929 maxillary first molars 2.578±1.581 mandibular central incisors 2.516±1.370 mandibular first premolars 2.752±1.730 mandibular first molars 2.480±1.273 width of attached gingiva in health table 3: width of attached gingiva in different age groups discussion: there are very studies done on the width of attached gingiva. one of the most often study quoted on width is by bowers2 gm in 1963 and ainamo3 in 1976. the present study measured attached gingiva with the help of a periodontal probe similar to tenenbaum4 while talari5, ainamo6 and saario7,8 used schiller’s iodine solution and orthopantomograms to measure. bowers2 found the facial attached gingiva varied in different areas of the mouth as seen in the present study. ainamo3 found greatest in maxillary incisors similar to our study. the least width in our study was in mandibular molars while ainamo3 found it to be mandibular premolars. ainamo3 and vincent9 found the width of attached gingiva increases with age where as our study found width was greatest in the 20 30 age group while the middle age group of 30-40 years was the least (table3). conclusion: width of attached gingiva varies in different areas of the mouth with the maxillary incisors having the greatest width. there was no relationship with age while females had a greater width of attached gingiva. further studies should be done on periodontally healthy individuals in different population in india to get a reference value for width of attached gingiva. acknowledgements: i like to thank the students and management of chhattisgarh dental college and research institute for the support and help rendered towards conduct of the above study. ___________________________________________________________________________ reference: 1. h.h.takei, r.r.azzi, t.j.han. periodontal plastic and esthetic surgery. in newman mg, takei hh, klokkevold pr, carranza fa eds carranza's clinical periodontology, 10th ed.. 2006: 1005-1029. 2. bowers gm. a study of the width of the attached gingiva. j periodontology, 1963; 34:210-13. 3. ainamo j, talari a. the increase with age of the width of attached gingiva. j periodontal res 1976; 11:182-88. age group in years n mean± sd (mm) 20-30 39 2.97±1.34 30-40 14 2.72±1.63 40-50 20 2.85±1.35 p shaju jacob and rm zade 4. tenenbaum h, tenenbaum m. a clinical study of the width of the attached gingiva in the deciduous, transitional and permanent dentitions. j clin periodontol 1986; 13(4):270-75. 5. talari a, ainamo j. orthopantomographic assessment of the width of attached gingiva. j periodontal res 1976; 11(4):177-81. 6. ainamo a, ainamo j. the width of attached gingiva on supraerupted teeth. j periodontal res 1978; 13(3):194-98. 7. saario m, ainamo a, mattila k, suomalainen k, ainamo j. the width of radiologically-defined attached gingiva over deciduous teeth. j clin periodontology 1995; 22(12):895-98. 8. saario m, ainamo a, mattila k, ainamo j. the width of radiologicallydefined attached gingiva over permanent teeth in children. j clin periodontology 1994; 21(10):666-69. 9. vincent jw, machen jb, levin mp. assessment of attached gingiva using the tension test and clinical measurements j periodontology 1976; 47(7): 412-14. ___________________________________________________________________________ bangladesh journal of medical science bangladesh journal of medical science vol.09 no.2 apr’10 case report a rare case of laryngeal kaposi’s sarcoma j mohd tahir1, kn gopalan2, mb marina3, sha primuharsa putra4 abstract kaposi’s sarcoma (ks) is the most common malignancy observed in patient with acquired immune deficiency syndrome (aids). it rarely causes upper airway obstruction. we report a 39-year-old gentleman, a former intravenous drug user with aids and hepatitis c positive who developed progressive hoarseness with stidor. he underwent an emergency tracheostomy and direct laryngoscopy revealed a whitish globular laryngeal mass obscuring the glottic region. a biopsy of the mass was taken and the histopathological report showed evidence of spindle cell connective tissue, consistent with kaposi’s sarcoma. it is important for clinicians or surgeons to maintain a high index of suspicion for the diagnosis of laryngeal ks in immunodeficiency patient even without cutaneous manifestation. keywords: airway obstruction, laryngeal, kaposi’s sarcoma, hiv. introduction kaposi’s sarcoma (ks) is a rare subcutaneous lesion linked mainly with patients suffering from aids. in hiv infection, kaposi sarcoma is an aidsdefining disease. it is usually an indolent vascular tumour with some variance depending on the epidemiologic subtype, of which there are four: classical type, african-endemic ks, iatrogenic ks and epidemic aids-related ks.1,2,3 the presentation of aids patient with ks as laryngeal emergency is rare and only a few cases being reported in the literature.1,4 it was first described in 1872 by the hungarian physician moritz kaposi. the characteristic feature of this lesion is multifocal violaceous nodules with the predilection for the skin of the lower extremities. ks may involve every tissue in the human body. incidence of ks has been reported as high as 20% in homosexual men who have hiv, 3% in heterosexual intravenous drug users, 3% in women and children, 3% in transfusion recipients and 1% in hemophiliacs.5 mochloulis g et al in his 10 years retrospective study showed the commonest site of laryngeal involvement was the supraglottis (65%).6 case report a 39-year-old gentleman with aids and hepatitis c presented with 4 month history of progressive hoarseness and stridor. he was a former intravenous drug user with a history of sexual promiscuity. fibreoptic laryngoscopy revealed a large, whitish globular mass occupying about two-thirds of the laryngeal inlet, obscuring the glottic region (fig 1). there were no cutaneous manifestations of the disease. the emergency tracheostomy was performed under local anesthesia as patient had 1. j mohd tahir, md, msurg orl-hns, department of otorhinolaryngology-head & neck surgery, hospital sultanah aminah, johor bahru, malaysia. 2. kn gopalan, md, msurg orl-hns, ear, nose & throat-head & neck consultant clinic, lam wah ee hospital, penang, malaysia. 3. mb marina, md, msurg orl-hns, department of otorhinolaryngology-head & neck surgery, universiti kebangsaan, malaysia medical centre, kuala lumpur, malaysia. 4. *sha primuharsa putra, md, msurg orl-hns, ear, nose & throat-head & neck consultant clinic, kpj seremban specialist hospital, seremban, negeri sembilan, malaysia. *corresponds to: dr primuharsa putra bin sabir husin athar, ear, nose & throat-head & neck consultant clinic, kpj seremban specialist hospital, jalan toman 1, kemayan square, 70200 seremban, negeri sembilan, malaysia. tel: 07-767 7800. direct/fax: 06-765 3406. email: putrani@yahoo.co.uk. primuharsa putra sha et al. impending upper airway obstruction. direct laryngoscopy revealed the above mass, as well as oesophageal candidiasis. a biopsy of the mass was taken and the histopathological report showed evidence of spindle cell connective tissue, consistent with kaposi’s sarcoma (fig 2). subsequent staining and cultures for tuberculosis and fungal organisms were negative. he has not encountered any significant complications and was evaluated for radiation therapy. he was discharged home with the tracheostomy and plans for outpatient follow-up visits. figure 1: laryngeal view showing mass obstructing the airway figure 2: slide showing presence of spindle cell discussion kaposi’s sarcoma (ks) of the head and neck has been well described in the literature. ks of the upper aerodigestive tract is not unusual; the palate and gingiva are the most frequently involved sites.7 however, ks resulting in upper airway obstruction in aids patients is extremely rare. the epiglottis appears to be the most common laryngeal site. 6,8 as with any laryngeal disorder, the presenting symptoms can range from hoarseness and dysphagia to stridor or complete airway obstruction. other symptoms commonly seen with laryngeal involvement are pain, bleeding and speech abnormalities. the diagnosis can usually be easily established by fiberoptic laryngeal examination. after establishing the diagnosis, therapy is usually aimed at symptomatic relief. urgent intervention is indicated for lesions producing acute or impending airway obstruction. in this case, endotracheal tube intubation was impossible to be done because the mass was located at the supraglottic region and obstructing a direct view of the glottis. tracheostomy should be immediately offered and should always be considered prior to any treatment protocol, since local therapy can often exacerbate airway compromise as mucositis and soft tissue edema develop. mochloulis g et al had experienced of significant hemorrhage and developed acute airway obstruction after performing biopsy of the ks lesion of the larynx.6 therefore, he didn’t recommend biopsy of suspected laryngeal ks. in our case, we were able to do direct laryngoscopy and took biopsy from the lesion using cold instrument without any complication. schiff et al in his report of 2 cases had performed a biopsy using a carbon dioxide laser without major complication.8 histologically, the distinctive features of ks are spindle-shaped cells with a random orientation, many extravasated erythrocytes, and thin vascular slits occurring in a reticular network of collagen fibers. treatment of laryngeal ks was in general, conservative. it consists of systemic and 108 a rare case of laryngeal kaposi’s sarcoma local therapies. systemic therapy is usually reserved for patients with rapidly progressing and/or widespread disease while local therapy is usually used to palliate pain and to improve function.8 low dose radiotherapy to the larynx and systemic chemotherapy had been advocated.9 apart from that, treatment of the hiv itself is important as ks often responds to the improvement in immunological status. in the late 1990s, the introduction of 2 new classes of antiretroviral drugs, the non-nucleoside analog reverse transcriptase inhibitors and protease inhibitors, resulted in improved antiretroviral efficacy in patients with aids.10 combinations of three or more antiretroviral agents from at least two different classes became known as haart (highly active antiretroviral treatment). lukawska et al reported that more than 50% of patients with cutaneous ks responded to haart.9 the cutaneous response is not as immediate as the virological and immunological responses, taking 3-6 months to improve. he had evaluated that mucosal presentation of ks has an equivalent response rate to cutaneous ks. palliative radiotherapy was planned to this patient as he presented with life-threatening clinical disease progression. during the pre-haart era, radiotherapy had an important role in the management of low-volume cutaneous ks. however, this method is now less common as a first-line treatment, and is becoming a second-line or third-line treatment after chemotherapy. ______________ references 1. levy fe, tansek km. aids – associated kaposi’s sarcoma of the larynx. ear nose throat j 1990; 69: 177-84. 2. ares c, allal as. long-term complete remission of laryngeal kaposi’s sarcoma after palliative radiotherapy. nat clin pract oncol 2005; 2: 473-7. 3. angouridakis n, constantinidis j, karkavelas g et al. classic (mediterranean) kaposi’s sarcoma of the true vocal cord: a case report and review of the literature. eur arch otorhinolaryngol 2006; 263: 537-40. 4. alkhuja s, menkel r, patel b, ibrahimbacha a. stridor and difficult airway in an aids patient. aids patient care and stds 2001:15:293-5. 5. dezube bj. aids-related kaposi’s sarcoma. the role of local therapy for a systemic disease. arch dermatol 2000; 136: 1554-6. 6. mochloulis g, irving rm, grant hr, miller rf. laryngeal kaposi’s sarcoma in patients with aids. j laryngol otol 1996; 110: 1034-7. 7. lozadaf, silverman s jr, migliorati ca, conant ma, volberding pa. oral manifestations of tumor and opportunistic infections in the acquired immunodeficiency syndrome (aids): findings in 53 homosexual men with kaposi’s sarcoma. oral surg oral med oral pathol 1983; 56:491-4. 8. schiff nf, annino dj, woo p, shapshay sm. kaposi’s sarcoma of the larynx. ann otol rhinol laryngol 1997; 106: 563-7. 9. lukawska j, cottrill c, bower m. the changing role of radiotherapy in aids-related malignancies. clin oncol 2003; 15: 2-6. 10. palella fj jr, delaney km, moorman ac et al. declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. hiv outpatient study investigators. n engl j med 1998; 338:853-60. ______________ 109 microsoft word _bjms jul 2010 online bangladesh journal of medical science vol.09 no.3 jul’10 1. *dr. rakesh kumar manne., m.d.s, assistant professor, department of oral medicine & radiology, ** 2. dr. ramesh amirisetty, m.d.s, assistant professor, department of oral medicine & radiology, chhattisghar dental college, rajnandagaon, chhattisghar, india. 3. dr. sravani tippireddy., m.b.b.s, lecturer, department of biochemistry,** 4. dr. suneel yadav, m.b.b.s, medical officer, regional antiretroviral centre, government general hospital, nellore, andhra pradesh, india. 5. dr.prachi nayak., m.d.s, assistant professor, oral and maxillofacial pathology & microbiology,** 6. dr. sushruth nayak., m.d.s, assistant professor, department of oral and maxillofacial pathology & microbiology,** **vyas dental college & hospital, jodhpur, rajasthan, india. *corresponds to: dr. rakesh kumar manne., m.d.s, teesra prahar bhawan, 1 st a road, sardarpura, jodhpur-342005, rajasthan, india. phone: +91-9680974277. email: rmannae@rediffmail.com. original article oral manifestations associated with human immunodeficiency virus infection in 200 indian patients. manne rk 1 , amirisetty r 2 , tippireddy s 3 , yadav s 4 , nayak p 5 , nayak s 6 abstract objective: to determine the pattern and prevalence of oral lesions in hiv infected 200 costal andhra pradesh patients. patients and methods: the study population comprised 200 consecutive hiv seropositive patients presented to regional art center at andhra pradesh, india. the oral lesions were diagnosed based on clinical appearance and were entered in to the database for analysis. results: 30-39 yrs age group was most commonly affected and 87% of the patients had acquired infection via heterosexual contact. oral lesions were seen in 66% of the patients. gingivitis (36.7% males & 33.9% females) was the most common lesion followed by candidiasis (21% males & 26.4% females), periodontitis (6.8% males & 7.5% females), pigmentation (36.7% males & 33.9% females), ulcers (2.7% males & 0% females) and leukoplakia (1.3% males & 0% females). conclusion: the pattern of oral lesions associated with hiv infection was not markedly different form those reported in the literature, the prevalence of each type of lesion differ slightly. key words: cd4 lymphocyte count, female, hiv infections, male, humans. introduction human immunodeficiency virus (hiv) infection is a major global health problem. it is estimated that number of people living with hiv infection in india, by the end of 2007 is 2.31million. the prevalence rate of hiv infection in the country has stabilized over the last few years with estimated adult prevalence of 0.34%. andhra pradesh showed the higher prevalence rate (>1%) when compared with all other states (<1%) in india. 1 systemic and oral lesions in hiv infection reflect the immune status of the patients. these lesions are not only important for the morbidity they cause but also for their diagnostic value in monitoring the immune status of the patient. some oral lesions have been observed to be more rampant in hiv infected patients than healthy individuals and sometimes may be the first indication of the disease 2 . furthermore, the appearance of some of these lesions in an hiv infected patient may signal the deterioration of the disease 3 . the aim of this study, therefore, is to determine the pattern and frequency of oral lesions associated with hiv infection in our environment in order to contribute to the existing data on oral hiv lesions in india. patients and methods two hundred consecutive patients attending the art centre (government rk manne, r amirisetty, s tippireddy, s yadav, p nayak, s nayak 151 regional centre for counseling and treatment of hiv/aids infection, andhra pradesh, india.) over a period of four months (from october 2009 to january 2010) were the subjects of this study. a trained counselor confirmed sources of infection. confirmation of hiv seropositive positive status for all the patients was by elisa and western immunoblot. examination of the orofacial tissues for each patient was performed by a trained medical doctor in oral manifestations of hiv/aids. data was captured on an adopted who record form for oral hiv/aids and subjected to statistical analysis. results table 1: demographics of 200 hiv seropositive patients age group (y) male (n=147) no. ( %) female (n=53) no. ( %) <9 4(2.7) 3(5.6) 10-19 13(8.8) 5(9.4) 20-29 27(18.3) 9(16.9) 30-39 56(38.0) 23(43.3) 40-49 31(21.0) 8(15.0) >50 16(10.8) 5(9.4) occupation farmer 17(11.5) 0(0.0) business 7(4.7) 0(0.0) driver 14(9.5) 0(0.0) employed 17(11.5) 2(3.7) housewife 0(0.0) 22(41.5) labourer 49(33.3) 21(39.6) others 43(29.2) 8(15.0) table 1 shows the demographics of 200 hiv seropositive patients. 147 (73.5%) were males and 53(26.5%) were females, giving male to female ratio of 2.8:1. the age of the youngest patient was 2 years and the age of the oldest patient was 58yrs.the maximum number of cases was in the 3039yrs age group for either genders (38.0% males and 43.3% females, respectively). labourer (33.3%) in male and housewife (39.6%) in female were more infected than other occupations. table 2 shows the source of infection. the main source of infection for both male and female (88% and 83%, respectively) was through the heterosexual route. table 3 shows the distribution of patients by cd4+ counts. the maximum number of male patients showed cd4+ count <200 (37.9%) and the maximum number of female patients showed cd4+ count 200-500 (35.8%). table 2: distribution of hiv-positive patients by source of infection source of infection male (n=147) no. ( %) female (n=53) no. ( %) heterosexual 130(88.0) 44(83.0) mother to child 16(10.8) 9(16.9) blood transfusion 1(0.6) 0(0.0) table 3: distribution of hiv-positive patients by cd4+ counts cd4 count male(n=145) no. ( %) female(n=53) no. ( %) <200 55(37.9) 16(30.1) 200-500 52(35.8) 19(35.8) >500 38(26.2) 18(33.9) table 4 shows prevalence of hivrelated oral lesions by gender. of the 200 patients, 112 patients (84 males and 28 females) showed 157 (117 in males and 40 in females) oral lesions. the most common lesion seen in both male and female patients is gingivitis (54 males and 18 females) followed by candidiasis (pseudomembranous, erythematous and angular cheilitis) (31males and 14 oral manifestations associated with human immunodeficiency virus infection 152 females). oral pigmentation was seen in 12 male patients and 2 female patients and all the pigmentations were seen on buccal mucosa. male patients showed four oral ulcers and two leukoplakias and was not seen in female patients. number of lesions seen in each patient was varying from 0 to 3. 63 male patients and 25 female patients showed no lesions, 52 males and 17 females showed one lesion, 31 males and 10 females showed two lesions and 1 patient of either genders showed three lesions. table 4: prevalence of hiv-related oral lesions by gender oral lesions male (n=147) no. ( %) female (n=53) no. ( %) candidiasis 31(21.0) 14(26.4) gingivitis 54(36.7) 18(33.9) periodontitis 10(6.8) 4(7.5) ulcers 4(2.7) 0(0.0) pigmentation 12(8.1) 2(3.7) leukoplakia 2(1.3) 0(0.0) others 4(2.7) 2(3.7) number of lesions 0 63(42.8) 25(47.1) 1 52(35.3) 17(32.0) 2 31(21.0) 10(18.8) 3 1(0.6) 1(1.8) discussion oral lesions of the hiv infected patients have been widely studied and were found to have diagnostic and prognostic value 4 . this study determined the prevalence of oral lesions in hiv infection in the costal part of andhra pradesh. it has been consistently shown that hiv infection affects young and active age groups (3 rd and 4 th decades). the age of patients in this study agrees with the previous indian study 5 . regarding the occupation, labourers and housewives were most commonly affected in the present study agrees with the study done by singh h et al. 6 . the source of infection in the present study showed heterosexual transmission and is in agreement with previous studies 5,6 . the maximum number of male patients showed cd4+ count <200 (37.9%) and the maximum number of female patients showed cd4+ count 200-500 (35.8%) and is in agreement with the previous studies 6,7 . hiv infection is associated with gingival disease which accounted for 36.7% in males and 33.9% in females in the present study. this is comparable to the previous study 8 . candidiasis has been consistently found to be the first recognized oral manifestation and sometimes the only initial clinical sign of the hiv infection 9 . the prevalence rate of candidiasis in the present study in males is 21% and in females is 26.4% and is in agreement with the previous study 10 . intraoral pigmentation was seen in 8.1% male and 3.7% female patients. the presence of intra oral pigmentation in the hiv patients has been reported in the previous study 5 . we had two patients with leukoplakia and both patients had tobacco chewing habit. conclusion the pattern of oral lesions associated with hiv infection was not markedly different form those reported in the literature, the prevalence of each type of lesion differ slightly. the present study again emphasizes the usefulness of orofacial examination of the patients by dental surgeon and increases their index of suspicion of the infection with the appearance of these hiv associated oral lesions. ______________ rk manne, r amirisetty, s tippireddy, s yadav, p nayak, s nayak 153 references 1. annual report 2008-2009, national aids control organization (naco), india. available at: http://www.nacoonline.org. accessed on 28 jan 2010. 2. pindborg j j. classification of oral lesions associated with hiv infection. oral surg. oral med. oral pathol. 1989;67:292-295. 3. greenspan d, greenspan js. hiv related oral diseases. lancet. 1996; 384:729 -733. 4. moniaci d, greco d, flecchia g, raitieri r, sinicco a. epidemiology, clinical features and prognostic value of hiv-1 related oral lesions. j oral pathol med 1990;19:477-81 5. 5..ranganathan k, umadevi m, saraswathi tr, kumarasamy n, solomon s, johnson n. oral lesions and conditions associated with human immu-nodeficiency virus infection in 1000 south indian patients. ann acad med singapore 2004;33:37-42. 6. 6.singh h, singh p, tiwari p, dey v, dulhani n, singh a. dermatological manifestations in hiv-infected patients at a tertiary care hospital in a tribal (bastar) region of chhattisgarh, india. indian j dermatol 2009;54:338-41 7. 7. goldstein b, berman b, sukeni ke, frankel sj. correlation of skin disorders with cd4 lymphocyte counts in patients with hiv/aids. j am acad dermatol 1997;36:262-4 8. 8.jt aarotiba, ra adebola, z lliyasu, m babashani et al oral manifestations of hiv/aids infection in nigerian patients. nigerian journal of surgical research 2005:7:176-81 9. 9. schulten eamj, t en kate, van der waal. oral manifestation of hiv infection in 75 dutch patients. j.oral pathol.med 1989:18:42-46 10. 10. ferreira s, cardoso as, silva junior a, oliveria am, reixoto ca. oral manifestations in hiv/aids patients under combined antiretroviral therapy. int conf aids. 1998; 12: 511. ______________ bangladesh journal of medical science bangladesh journal of medical science volume-8 no. 1-2; january-march 2009 original article pattern of psychiatric morbidity among the patients admitted in a private psychiatric clinic a fahmida1, wahab ma2, rahman mm3 abstract: background: mental health problem is a major public health issue in the world across the developed and developing countries. however, data in most of the developing countries including bangladesh are scarce. in bangladesh, socio-political situation is insecure and unstable with poverty and vulnerable to natural disaster which causes psychiatric morbidity. the pattern of psychiatric morbidity in private clinic is quite different from that in government hospital. objective: this study was aimed to assess the diagnostic pattern of psychiatric morbidity among the admitted patients in a private psychiatric clinic. methodology: the study was carried out in a 20 bedded private psychiatric clinic in the heart of dhaka city. all the information including longitudinal histories of patients was recorded in files and the diagnosis was confirmed by psychiatrist. admission and discharge notes were recorded in register. socio-demographic parameters and family history of mental illness were collected from the record file of individual patient. results: among 304 patients 184 (60.53%) were males and 120 (36.47%) were females. more than 50% of patients were in the age group of 18 to 37 years. most common psychiatric disorders were schizophrenia and other psychotic disorders (39.4%), mood disorder (18.75%), borderline personality disorder (3.6%), conduct disorder (2.3), somatoform disorder (1.6%), anxiety disorder (0.7%), organic psychiatric disorder (2%), impulse control disorder (1.3%) and adjustment disorder (0.7%). conclusion: major forms of psychiatric disorders are common both in urban and rural areas of bangladesh. keywords: psychiatric morbidity ___________________________________________________________________________ introduction psychiatric morbidity is a major public health problem in the world across developed and the developing countries. today mental health and mental illnesses are key public health issues. a large number of people worldwide suffer from mental disorders. according to world health organization at least 40 million people in the world suffer from mental disorders such as schizophrenia and dementia1-4. bangladesh is a densely populated area where prevalence of psychiatric illness is not less than that of any other country in the world. a study showed that 29% of patients attending general practice were suffering from functional disorder and 6% from both functional and organic disorder. the same study demonstrated that 47% patients were suffering from neurotic disorder, 37% from psychosomatic disorder, 10% from affective disorder, 1.44% from schizophrenia, 2.88% from substance use disorder and 2% organic psychiatric syndrome5. ________________________________________________________________________ 1. assistant professor, ibn sina medical college, kallyanpur, dhaka. 2. assistant professor, national institute of mental health, dhaka. 3. trainee clinical psychologist, university of dhaka. corresponding author: dr. fahmida ahmed, assistant professor, dept. of psychiatry, ibn sina medical college, 1/1b kalyanpur, mirpur road, dhaka-1216, bangladesh. email: wahabminar@yahoo.com 23 fahmida a. et al. another study in dasherkandi, a village nearby dhaka city indicated that 6.52% people had been suffering from psychiatric illnesses6. still now maximum people are out of modern treatment facilities due to poor economic condition, prevailing superstition, stigma on mental patients and lack of education and knowledge about scientific method of treatment of mental illness. study conducted in outpatient department of national institute of mental health (nimh), dhaka revealed that 37.4% of patients were suffering from schizophrenia and schizophrenia like psychotic disorders, 16.14% from anxiety disorders, 11.19% from major depressive disorder, 8.95% from bipolar mood disorder, 7.66 % from substance related disorder, 6.60% from somatoform disorder, 4.12% from mental retardation and 7.88% from other disorders7. the main objective of the present study was to observe the types of the psychiatric diagnoses among the admitted patients in a private hospital in dhaka city, to see the relationship of psychiatric disorders with some socio-demographic parameters and also to observe the relationship between the family history of psychiatric illness and different types of psychiatric disorders. subjects and methods the study was carried out in a private clinic in dhaka city. it is a 20 bedded clinic. most of the patients came from dhaka city. all the information about the patients including their thorough histories was recorded in files. admission and discharge notes were recorded in register. patients were diagnosed by the consultant psychiatrist three hundred and four patients were admitted here throughout the year of 2007 from january to december. they were diagnosed according to diagnostic and statistical manual for mental disorder criteria by the psychiatrist8. necessary informations regarding patients were collected from record files. data were processed and analyzed manually following the simple descriptive statistical procedure. results total three hundred and four patients admitted in a private psychiatric clinic in dhaka city during the period of january to december in the year 2007 were included in the study within the age group of 10 to 55 years. out of 304 patients, 184 (60.53%) were male and 120 (36.47%) were female. 135 patients (44.4%) were married, 158 patients (50.66%) were unmarried and 15 (4.93%) were divorcee. 92.76% were muslins, 4.60% were hindu and 2.63% were christians (table i). regarding occupational status most of the patients (30.2%) were unemployed, followed by students (23.7%). eighteen to twenty eight years of age group had more psychiatric disorder (42%), which was nearer to the finding of other study9. as the study was carried out in a private clinic almost all the patients belonged to medium to high social class (monthly income >10,000 taka). results showed that most of the patients were educated, 19% completed graduation, and 56.6% completed higher secondary certificate examinations (table iii). out of three hundred and four patients 39.4% were suffering from schizophrenia and other psychotic disorders, 29.6% substance related disorder, 12.17% from bipolar mood disorder, 6.58% from major depressive disorder, 3.6% from borderline personality disorder, conduct disorder 2.3%, organic psychiatric disorder 2%, somatoform disorder 1.6%, impulse control disorder 1.3% and others 1.4% . 24 pattern of psychiatric morbidity among the patients admitted in a private psychiatric clinic table i distribution of patients by sex, age group, religion and marital status table ii distribution of patients by occupational status sex number percentage (%) male 184 60.53% female 120 39.47% age group < 18 years 23 7.6% 18-27 years 128 42% 28-37 years 107 35% 32 11% 38-47 years 48 years and above 14 4.6% residence rural 90 29.6% urban 214 70.4% marital status married 135 44.4% unmarried 154 50.66% divorcee 15 4.93% religion islam 282 92.76% hinduism 14 4.60% christians 8 2.63% occupational status number percentage (%) business 65 21.4% student 72 23.7% service 29 9.6% house wife 43 14.1% unemployed 92 30.2% farmer 3 1.0% table iii distribution of patients by their educational status educational status number percentage (%) primary 25 8.22% secondary 49 16.11% ssc/hsc 172 56.6% graduate 58 19% 25 table iv types of psychiatric disorder among the admitted patients fahmida a. et al. types total number percentage (%) schizophrenia and other psychotic disorders 120 39.4% substance related disorders 90 29.6% bipolar mood disorder 37 12.17% major depressive disorder 20 6.58% borderline personality disorder 11 3.6% conduct disorder 7 2.3% somatoform disorder 5 1.6% organic psychiatric disorder 6 2% anxiety disorder 2 0.7% impulse control disorder 4 1.3% adjustment disorder 2 0.7% table v distribution of different psychiatric disorders by sex type of disorder male % female % schizophrenia and other psychotic disorders 77 25.3 43 14.1% substance related disorders 87 28.6 3 1% bipolar mood disorder 26 9.0 11 3.6% major depressive disorder 7 2.3 13 4.3% borderline personality disorder 3 1 8 2.6% conduct disorder 5 1.6 2 0.7% somatoform disorder 0 0 5 1.6% alzheimer’s disease 2 0.7 0 0% postpartum psychosis 0 0 4 1.3% anxiety disorder 0 0 2 0.7% impulse control disorder 3 1 1 0.3% adjustment disorder 0 0 2 0.7% 26 table vi distribution of patients by family history of mental illness. pattern of psychiatric morbidity among the patients admitted in a private psychiatric clinic family history of mental illness number psychiatric disorders number percentage (%) total schizophrenia and other psychotic disorders 52 17.1% bipolar mood disorder 21 7% present 80 substance related disorders 7 2.3% 26.3 absent 224 73.7 discussion schizophrenia and psychotic disorders were the commonest psychiatric disorders requiring admission (39.4%) in the hospital5. the study showed that next to schizophrenia was substance related disorder (29.6%). substance use disorder is a rising problem of present day and a serious threat to our social integrity and cohesion. a significant number of our young generation has been abusing illicit drugs and substances. present study revealed that drugs use was high among the age group of 18 to 37 years, similar to other study. among ninety cases of substance related disorder three were female and rests were males. less access to narcotics to female abusers may justify less prevalence of substance use disorder among females. this finding was consistent to other study6. next to substance related disorder 12.17% patients of bipolar mood disorder were admitted and more among males. present study also showed patients of anxiety disorders (0.7%) were admitted less frequently as majority of them were treated in the out patient department6. study revealed that major depressive disorder (6.58%), somatoform disorder (1.6%), anxiety disorder (0.7%) were more among females probably because of stressful life events, the effects of child birth and behavioral model of learned helplessness 5,7. borderline personality disorder was present in 3.6% of patients and also more among females9. conduct disorder was common among boys (1.6%) than in girls (0.7%)10. as the study place was in the dhaka city, most of the patients (70.4%) were from urban background and from rural area 29.6% patients. psychiatric morbidity was higher among urban people. because these people are facing the daily life stresses and thereby more vulnerable to psychiatric illness. in this study a substantial number of patients (30.2%) were unemployed. this could be due to presence of psychiatric disorders11. next to unemployment psychiatric morbidity appeared to be higher among students (23.7%), who were mostly of adolescents and of early adulthood and thereby were most vulnerable for most of the psychiatric disorders. findings were consistent to other study6. there are enough evidences that psychiatric disorders particularly major psychiatric disorders have substantial contribution 27 fahmida a. et al. of genetic hereditability in their causation. one of our aim was also to estimate the relationship between positive family history of mental illness and major psychiatric disorders. study showed positive family history for mental disorder was in 26.3% cases and it was highest (17.1%) among schizophrenia and schizophrenia like disorder. next to schizophrenia for bipolar mood disorder it was about 7% followed by 2.3% in substance related disorder. finding was consistent to other study12. our observation suggests that psychiatric disorders are common in both rural and urban areas, which create hazards in personal, occupational or social level. countrywide advertisement to increase people’s awareness, co-operation of the government and efficiency and commitment of service providers will be needed. awareness about psychiatric illness is gradually increasing day by day among the people of bangladesh. so, the number of patients seeking treatment is also increasing. to meet the need of the people the number of mental health professionals and facilities for mental health services are needed to be increased in government level as well as private sector. ___________________________________________________________________________ references 1. firoz ahm, karim me, alam mf, rahman ahm, zaman mn, chandra v. community based multicentric service oriented research on mental illness with focus on prevalence, medical care, awareness and attitude towards mental illness in bangladesh. who published data, 2003-2005. bang j psychiatry 2006; 20 (1):9-32. 2. hamid ma, chowdhury s, mohit ma. comparative study of patients in different out patient department(opd) and the pattern of psychiatric disorder in a district hospital. bang j psychiatry 2003; 17 (2):5-12. 3. alam mn. psychiatric morbidity in general practices. bang med res coun bull 1981; 4 (1):22-39. 4. chowdhury akmn, alam mn, ali smk. dasherkandi project studies: demography, morbidity and mortality in a rural community of bangladesh. bang med res coun bull 1981; 4 (1):22-39. 5. mohit ma. diagnosis of patients attending out patient department (opd) of nimh. bang j psychiatry, june 2001; 15 (1):5-12. 6. rahman f, sabeka mm, karim me. psychiatric co-morbidity and sexual dysfunction in substance use disorder. bang j psychiatry 2003; 17 (2):14-21. 7. gelder m, gath d, mayou r, cowen p. mood disorder in gelder m, gath d, mayou r, cowen p (eds). oxford text book of psychiatry, 5th ed. oxford. 2005: 290-294. 8. diagnostic and statistical manual for menbtal disorders. american psychiatric association. 4th ed. newyork, usa. 1994. 9. kaplan hi, sadock bj. synopsis of psychiatry. williams and wilkins, pa, 2003; 809 10. goodman r, scoll s. child and adolescent psychiatry. blackwell publishing ltd. 2nd edn. uk, 2005; 64 11. meyer r. in psychopathology and addictive disorders, ny: the guildford press, 1986; 3-6. 12. islam tm, ahmed hu, uddin jmm, rahman f and firoz ahm. relationship between positive family history of mental illness and major psychiatric disorder-a study in teaching hospital. bang j psychiatry 2006; 20 (2): 50-56. __________________________________________________________________________ “in their hearts is a disease (of doubt and hypocrisy) and allah has increased their disease” [al-quran 2:10] 28 bangladesh journal of medical science vol.09 no.4 jul’10 *corresponds to: dr. md. nurul islam, assistant professor, islami bank medical college, rajshahi. email: dr.nuruleye.bd@gmail.com. review article management of glaucoma with neuroprotective drug islam n* abstract glaucoma is an optic neuropathy characterized by progressive loss of retinal ganglion cells (rgcs). death of ganglion cells is not always only pressure dependent mechanism but also have several pressure independent mechanism that establish a cascade of changes that ultimately leads to cell death. neuroprotection is a process that attempt to preserve the cells that were spared during initial insult, but are still vulnerable to damage. although not yet available, a neuroprotective agent would be great use that rescue neurons already compromised or that promote regrowth of axonal or dendritic connection to restore function. this review based on literature, giving the idea of varies mechanism of rgc death delineated by research and discussed some pharmacological agent believed to have a neuroprotective role in glaucoma. introduction glaucoma is a neurodegenerative disease in which intraocular pressure (iop) is a leading risk factor1,2. despite iop lowering, glaucoma continues to worsen in a subset of patients2-5. the final stage in glaucoma involves retinal ganglion cell (rgc) damage and death2. this damage can occur at statistically high, average, or low levels of iop. while the biomechanics of optic disc cupping specifically, loss of neuroretinal rim and posterior bowing of the lamina cribrosa have been extensively studied6,7. they do not adequately explain why certain patients continue to demonstrate worsening of the disease in spite of apparently low iop. in addition to iop, several other triggers are hypothesized to contribute to rgc axonal injury and death8. these triggers include loss of neurotrophic factors, localized ischemia, excitotoxicity, alterations in immunity, and oxidative stress. there is increasing evidence that these factors, triggered by high iop or occurring independently of iop, may contribute to affecting the optic nerve. basis of neuroprotection glaucoma is an axonal disease in which retinal ganglion cell (rgc) axons are the initial site of damage. according to the biomechanical model of damage, structural failure of laminar beams and strain along the retinal nerve fiber layer lead to axonal damage. damaged axons then degenerate via apoptosis (an energy-requiring form of cell death) either in a retrograde fashion or by wallerian degeneration. axonal transport is disrupted primarily at the level of the lamina cribrosa9,10. a decrease in the axonal blood flow follows mechanical injury and death of rgcs9,10. the exact pathophysiology of axonal injury and death remains unclear; however, a variety of inter and intra-cellular events are triggered during the process of cell death, and these events may be potential targets of neuroprotective strategies. in many neurologic diseases, injury can spread to connected neurons by a mechanism called transsynaptic degeneration. the surrounding axons may undergo apoptosis because of the loss of certain neurotrophic factors, such as brain-derived neurotrophic factor and nerve growth factor11,12. on the other hand, surrounding axons may be exposed to upregulated factors that lead to cytotoxicity, such as tumor necrosis factorn islam 200 a (tnf-a) 13,14. it is unclear whether the process of transsynaptic degeneration affects only surrounding rgc axons or whether afferent neurons within the inner retina may also be affected. inhibition of intracellular calcium ion (ca2+) uptake has been a major focus of glaucoma neuroprotection because an increase in intracellular ca2+ is associated with rgcs degeneration. calcium enters cells through voltage-gated channels and n-methyl-d-aspartate (nmda) glutamate receptor associated channels. an increase in intracellular ca2+ activates calcineurin, which causes the release and activation of apoptotic mediators, such as caspases from mitochondria into the cytoplasmic space15.cytoplasmic ca2+ also stimulates nitric oxide production. the upstream trigger for this cascade of events may be glutamate dependent. neuroprotection in glaucoma is the targeted treatment of neurons of the visual pathway (particularly rgcs) that are damaged in the glaucomatous process. in neuroprotection, the goal is to directly stimulate or inhibit specific biochemical pathways that either prevent injury or stimulate recovery of these neurons. indirect treatments, such as iop lowering, by definition are not neuroprotection. retinal ganglion cell njury may occur by a variety of pathophysiologic mechanisms including increased intraocular pressure, ischemia, genetic factors, and failure of trophic support. conventional treatment to prevent optic neuropathy has focused on preventing or mitigating the effect of the inciting factor. neuroprotection in glaucoma involves targeted modification of nmda receptor and promotes ca2+ uptake16. an increase in intravitreal glutamate causes rgc death in vitro; however, an increase in intravitreal glutamate has not been observed in experimental models of glaucoma17. glutamate toxicity has also been shown to lead to degeneration of postsynaptic neurons in the lateral geniculate nucleus18. neuroprotective medications there are several theoretically effective neuroprotective therapies that unfortunately remain somewhat limited in practice. while cell culture results with brain-derived neurotrophic factor have been promising, its effect is only transient, which may possibly be due to receptor turnover19. altering the expression of apoptosis proteins is possible in transgenic animals, but it cannot be easily achieved or controlled in humans20. finally, experimental models of rgcs axonal injury (cell cultures and murine or primate models) do not entirely reproduce the multifactorial pathophysiologic events of glaucoma in humans. nevertheless, strong experimental evidence for certain medications may lead to clinical use in the near future. memantine memantine is an nmda receptor antagonist that blocks the excite toxic effects of glutamate21. the drug has been used to treat parkinson’s and alzheimer’s disease22. glutamate-mediated synaptic transmission is critical for normal functioning of the nervous system; however, if neurons are injured and unable to properly control the regulation or clearance of glutamate, secondary excite toxic damage can result. under pathologic conditions, the nmda receptor is over activated and excessive ca2+ influx occurs23. therefore, oral memantine theoretically may benefit patients with progressive glaucoma. memantine has been shown to protect rgcs and brainstem neurons in a monkey model of glaucoma24. however, a recent report from a phase iii clinical trial indicates that memantine failed to show efficacy compared with placebo when used in patients with glaucoma25.given the results of this trial, the exact role of memantine in glaucoma patients remains unclear. we currently management of glaucoma with neuroprotective drug 201 counsel patients who show stereophotographic or perimetric progression of glaucoma despite maximally tolerable iop lowering therapy about the absence of additional clinically proven therapies for glaucoma. because of the safety profile of memantine and its theoretical benefit in preventing axonal injury, patients in whom standard medical or surgical therapy is ineffective or not possible are offered treatment with memantine. brimonidine in addition to lowering iop, alpha-2 adrenergic receptor agonists also increase release of neurotrophic factors, inhibit glutamate toxicity, and reduce ca2+ uptake by neurons in both in vitro and in vivo animal models26,27. this class of medication may also inhibit activation of proteins involved in apoptosis28. alpha-2 receptors are found in a variety of retinal locations and are expressed in rgcs29. topically administered alpha-2 agonists, such as brimonidine, have been found to achieve neuroprotective intravitreal concentrations30. the efficacy of brimonidine in normal-tension glaucoma patients is currently being evaluated prospectively. however, the neuroprotective effect of brimonidine remains controversial given the medication’s accompanying ioplowering effect. a clinician also cannot a priori determine whether glaucomatous damage is due to a pressure-dependent or pressure-independent process. as such, we do not use brimonidine as a first-line treatment for glaucoma when other medications are tolerated, nor do we use brimonidine for a neuroprotective effect. further studies are needed to determine the utility of brimonidine in glaucoma neuroprotection. betaxolol selective beta-1 adrenergic antagonists (betaxolol) have a similar neuroprotective effect in vitro as the alpha-2 agonists. betaxolol increases neurotrophin levels, decreases intracellular ca2+, and blocks glutamate excitoxicity31.however, the concentrations required to achieve this effect are nonpharmacologic32. topical administration does not appear to achieve necessary intravitreal neuroprotective concentrations. as such, currently available topical beta-1 adrenergic antagonists should not be used for glaucoma neuroprotection. calcium channel blockers systemic calcium channel blockers (ccb) cause vasodilation by preventing the intracellular uptake of ca2+. ccb may improve optic nerve head perfusion, particularly in patients with normal-tension glaucoma33. while ccbs have been shown to improve psychophysical testing in a small group of patients, these results have not been confirmed in a large study34. side effects associated with systemic ccbs may limit their practical use. in a small group of patients placed on systemic nifedipine, a significant number were intolerant of the medication and had to discontinue it35. a recent prospective population-based study has also shown a positive correlation between systemic ccb use and the development of incident glaucoma. further prospective studies are needed to determine the safety and efficacy of ccbs. we presently do not make recommendations to glaucoma patients regarding the use of ccbs. conclusion the concept of direct optic nerve protection is in its infancy. nonetheless research in to inventive delivery –systems improved safety and discovery of additional neuroprotective agents will undoubtedly lead us further in to this promising era in glaucoma therapy. ______________ n islam 202 references 1. glaucoma panel. primary open angle glaucoma preferred practice pattern guideline. american academy of ophthalmology, san francisco, 2005. 2. weinreb rn, khaw pt. primary open-angle glaucoma. lancet 2004; 363(9422):1711–20. 3. kass ma, heuer dk, higginbotham ej, et al. the ocular hypertension treatment study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma.arch ophthalmol 2002; 120(6):701–13; discussion 829 30. 4. collaborative normal-tension glaucoma study group. comparison of glaucomatous progression between untreated patients with normal-tension glaucoma and patients with therapeutically reduced intraocular pressures. am j ophthalmol 1998; 126(4):487–97. 5. the agis investigators. the advanced glaucoma intervention study (agis): 7. the relationship between control of intraocular pressure and visual field deterioration. am ophthalmol 2000; 130(4):429–40. 6. quigley ha, addicks em. chronic experimental glaucoma in primates. ii. effect of extended intraocular pressure elevation on optic nerve head and axonal transport. invest ophthalmol vis sci 1980; 19(2):137–52. 7. bellezza aj, rintalan cj, thompson hw, et al. deformation of the lamina cribrosa and anterior scleral canal wall in early experimental glaucoma. invest ophthalmol vis sci 2003; 44(2):623–37. 8. weinreb rn. glaucoma neuroprotection: what is it? why is it needed? can j ophthalmol 2007; 42(3):396–8. 9. quigley ha, anderson dr. distribution of axonal transport blockade by acute intraocular pressure elevation in the primate optic nerve head. invest ophthalmol vis sci 1977; 16(7):640–4. 10. quigley h, anderson dr. the dynamics and location of axonal transport blockade by acute intraocular pressure elevation in primate optic nerve. invest ophthalmol 1976; 15(8): 606–16. 11. quigley ha, mckinnon sj, zack dj, et al. retrograde axonal transport of bdnf in retinal ganglion cells is blocked by acute iop elevation in rats. invest ophthalmol vis sci 2000; 41(11):3460–6. 12. pease me, mckinnon sj, quigley ha, et al. obstructed axonal transport of bdnf and its receptor trkb in experimental glaucoma. invest ophthalmol vis sci 2000; 41(3): 764– 74. 13. yuan l, neufeld ah. tumor necrosis factoralpha: a potentially neurodestructive cytokine produced by glia in the human glaucomatous optic nerve head. glia 2000; 32(1): 42–50. 14. tezel g, wax mb. increased production of tumor necrosis factor-alpha by glial cells exposed to simulated ischemia or elevated hydrostatic pressure induces apoptosis in cocultured retinal ganglion cells. j neurosci 2000; 20(23): 8693–700. 15. wang hg, pathan n, ethell im, et al. ca2+induced apoptosis through calcineurin dephosphorylation of bad. science 1999; 284(5412):339–43. 16. lipton sa. paradigm shift in neuroprotection by nmda receptor blockade: memantine and beyond. nat rev drug discov 2006; 5(2):160– 70. 17. wamsley s, gabelt bt, dahl db, et al. vitreous glutamate concentration and axon loss in monkeys with experimental glaucoma. arch ophthalmol 2005; 123(1):64–70. 18. gupta n, yucel yh. glaucoma as a neurodegenerative disease. curr opin ophthalmol 2007; 18(2):110–4. 19. di polo a, aigner lj, dunn rj, et al. prolonged delivery of brain-derived neurotrophic factor by adenovirus-infected muller cells temporarily rescues injured retinal ganglion cells. proc natl acad sci u s a 1998; 95(7):3978–83. 20. bilsland j, harper s. caspases and neuroprotection. curr opin investig drugs 2002; 3(12):1745–52. 21. seif el nasr m, peruche b, rossberg c, et al. neuroprotective seffect of memantine demonstrated in vivo and in vitro. eur management of glaucoma with neuroprotective drug 203 22. reisberg b, doody r, stoffler a, et al. memantine in moderateto-severe alzheimer’s disease. n engl j med 2003; 348(14):1333–41. 23. lipton sa. the role of glutamate in neurodegenerative diseases including glaucoma. in weinreb rn (ed) glaucomaneuroprotection. wolters kluwer health, netherlands, 2006,pp. 9–22. 24. yucel yh, gupta n, zhang q, et al. memantine protects neurons from shrinkage in the lateral geniculate nucleus in experimental glaucoma. arch ophthalmol 2006; 124(2): 217–25. 25. memantine update. www.glaucoma.org/treating/memantine_updat _1.php. accessed at 21 march 2008. 26. gao h, qiao x, cantor lb, wudunn d. upregulation of brain-derived neurotrophic factor expression by brimonidine in rat retinal ganglion cells. arch ophthalmol 2002; 120(6): 797–803. 27. wheeler la, gil dw, woldemussie e. role of alpha-2 adrenergic receptors in neuroprotection and glaucoma. surv ophthalmol 2001; 45(suppl 3):s290–4; discussion s5–6. 28. tatton wg, chalmers-redman rm, tatton na. apoptosis and anti-apoptosis signalling in glaucomatous retinopathy. eur j ophthalmol 2001;11(suppl 2):s12–22. 29. wheeler la, woldemussie e, lai rk. alpha-2 agonists and neuronal survival in glaucoma. in weinreb rn (ed) glaucoma neuroprotection. wolters kluwer health, netherlands, 2005, pp. 53–63. 30. kent ar, nussdorf jd, david r, et al. vitreous concentration of topically applied brimonidine tartrate 0.2%. ophthalmology 2001; 108(4):784–7. 31. zhang j, wu sm, gross rl. effects of betaadrenergic blockers on glutamate-induced calcium signals in adult mouse retinal ganglion cells. brain res 2003; 959(1):111–9. 32. hollo g, whitson jt, faulkner r, et al. concentrations of betaxolol in ocular tissues of patients with glaucoma and normal monkeys after 1 month of topical ocular administration. invest ophthalmol vis sci 2006; 47(1):235–40. 33. netland pa, chaturvedi n, dreyer eb. calcium channel blockers in the management of low-tension and open-angle glaucoma. am j ophthalmol 1993; 115(5):608–13. 34. boehm ag, breidenbach ka, pillunat le, et al. visual function and perfusion of the optic nerve head after application of centrally acting calcium-channel blockers. graefes arch clin exp ophthalmol 2003; 241(1):34–8. 35. rainer g, kiss b, dallinger s, et al. a double masked placebo controlled study on the effect of nifedipine on optic nerve blood flow and visual field function in patients with open angle glaucoma. br j clin pharmacol 2001; 52(2): 210–2. ______________ y . conaftbiiitoii of.aizbert'm tit b'o[ogr prci m.s. khd abu-rl rarhan muhannad ibr ahnad al-berunt v6 bom ar khwatum rdow j h q?3 atrhoush h. r< ku radh ro ai ae;3t3 and indologtsls as a nattdmdc, . strchm€r, phlslctsrs. gogmpher, mru.altst. and?ncyclopaedct. hls mme ts scldom tound rn dy of the rrea *s d€atrng sdrh thc 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iii,llii.*-..0 r"o r.r') ar'b.*s b6k on phma(v md rokna m"drca p, i {r9?3) hddard nauonal fo 40 bajreladesh jomai of medtcai s.id'e bangladesh journal of medical science bangladesh journal of medical science volume-8 no. 1-2; january-march 2009 original article evaluation of the antibody response against hepatitis b virus infection in patients on maintenance hemodialysis: a pilot study s shahin1, khoybar a2, a farhana3, k matira4 abstract objective: this study was undertaken to evaluate the antibody response of hepatitis b virus infection in patients on maintenance hemodialysis (mhd) by detecting different viral markers. method: study subjects comprised a total of 88 chronic kidney disease (ckd) patients from bangladesh institute of research and rehabilitation in diabetes, endocrine and metabolic disorders (birdem) and bangabandhu sheikh mujib medical university (bsmmu). of them 63 patients on mhd and 25 predialysis patients served as cases and controls respectively. clinical history was taken and serological markers for hbv (hbsag, anti-hbs, and anti-hbc) were determined by using elisa. results: hepatitis b virus was positive in 1.6% of maintenance hemodialysis (mhd) patients and in 16% of controls (p<0.02). anti-hbc antibody was positive in 62% of dialysis patients and 72% of controls (p=ns) and the positivity was significantly associated in dialysis subjects with longer duration of dialysis (18 ± 22 vs. 10 ± 7, months, p<0.04), multiple units of blood transfusions (22 ± 29 vs. 10 ± 12, units, p<0.04) and more reuse of dialyzer (3 ± 1 vs. 2 ± 1, times, p<0.03) than the negative ones. among mhd patients 84% were vaccinated against hbv with a schedule of 3 (79%) and 4 (21%) doses and protective antibody titer (>10 iu/l) was found in 57%. none of the controls were vaccinated but 66% had protective titer indicating post exposure natural immunity. conclusions: hepatitis b virus positivity was significantly higher among the predialysis subjects compared to dialysis group. key words: hepatitis b virus, antibody response, hemodialysis ______________________________________________________________________________ introduction end-stage renal disease (esrd) subjects on maintenance hemodialysis are at high risk for hepatitis b virus infection1. parenteral route is the major route for hbv transmission2. the process of hemodialysis requires vascular access for prolonged period3. furthermore, hemodialysis patients are immunosuppressed4 that increases their susceptibility to infection requiring frequent hospitalization and surgery, which again increases their risk for exposure to nosocomial infections3. although vaccination is routinely recommended in esrd patients, antibody response to vaccination is suppressed and its level rapidly declines among patients on chronic dialysis due to the decreased immunological responses5. the prevalence of chronic hepatitis b virus (hbv) infection is high (>8%) in sub-saharan africa, most of asia and the pacific islands, intermediate prevalence (2 to 7%) regions include the ________________________________________________________________________ ______ 1. assistant professor, department of microbiology, shahabuddin medical college, dhaka 2. assistant professor, department of paediatrics, ibn sina medical college, dhaka 3. assistant professor, department of biochemistry, uttara adhunic medical college, dhaka 4. assistant professor, department of pharmacology & therapeutics, shahabuddin medical college, dhaka corresponds to: 15 dr md khoybar ali fcps. assistant professor, department of paediatrics, ibn sina medical college, 1/1b kalyanpur, mirpur road, dhaka-1216, bangladesh. 16 shahin s. et al. amazon, southern parts of eastern and central europe, the middle east and the indian sub-continent, low prevalence (<2%) regions include most of western europe and north america6. in india, hbv prevalence was 8.8% and 14.2% in predialysis and hemodialysis group respectively7,8. in turkey, prevalence of hbv was 10.5% and 13.3% in predialysis and hemodialysis patient’s respectively9,10. in bangladesh, around 12% of all patients on mhd were serologically positive for hepatitis b virus infection, has been shown in a recent study11. so far no study has been conducted to see the seroprevalence of hbv in ckd (predialysis) patients in bangladesh. therefore, this study was undertaken to evaluate the antibody status of hbv in predialysis and dialysis patients followupped in two selected tertiary renal care center subjects and methods study design this cross sectional study was carried out in the department of immunology, birdem, dhaka and nephrology department of bsmmu during the period of june 2006 to june 2007. study subjects eighty-eight patients were finally included in this study. of them 63 end stage renal disease (esrd) patients who were on maintenance hemodialysis for at least 3 months and getting dialysis through arteriovenous (av) fistula considered as cases and 25 chronic renal failure (crf) patients attending nephrology out-patients departments of birdem and bsmmu and ‘crf patients follow-up project’ who were not on dialysis (predialysis) considered as control group. sample collection and preservation five milliliter blood was taken from the arterial channel immediately after pricking the fistula during dialysis session in mhd patients and labeled with a known serial number for each patient. in controls fasting samples were taken. serum sample were preserved at -20°c and assayed within fifteen days of collection. laboratory analysis serological markers for hepatitis b (hbsag, anti-hbc, anti-hbs) were assessed using commercial third generation enzyme-linked immunosorbent assay kit (diasorin, italy). serum creatinine and alanine aminotransferase were assessed by standard laboratory method (kinetic method). statistical analysis of data all the relevant data were entered and then analyzed using the statistical package for social science (spss) version 13. results were expressed as mean ± sd or percentage as appropriate. level of significance was expressed as ‘p’ value and p<0.05 was considered as significant. 17 antibody response against hbv infection in patients on maintenance hemodialysis results table ibaseline parameters of study subjects parameters cases (n=63) controls (n=25) p value age (yrs) 54±11 57±10 0.28 m/f 36/27 15/10 0.80 dm duration(yrs) 12±6 5±2 0.92 ckd duration(yrs) 6±4 4±3 0.53 s cr (mg %) 9±2.5 4±2 0.001 alt (u/l) 25±17 20±16 0.30 dm = diabetes mellitus, results are expressed in mean ± sd on percentage where suitable, m/f = male/female, ckd = chronic kidney disease, s cr = serum creatinine, alt = alanine aminotransferase table ii distribution of patients by hepatitis b virus infection hbsag cases n (%) controls n (%) p value positive 1 (1.6%) 4 (16%) negative 62 (98.4%) 21 (84%) 0.022 hbsag – hepatitis b surface antigen p value reached from chi square test; p<0.05 considered significant figure 1distribution of patients by anti-hbc total 61.9 38.1 72.0 28.0 0 10 20 30 40 50 60 70 80 % case control study patients positive negative note: figure 2 above indicated that among cases and controls, anti-hbc positive was 61.9% (n=39) vs. 72% (n=18) (p=ns) and this was not significantly different between the two groups 18 shahin s. et al. table iiidistribution of cases (mhd patients) by anti-hbc total parameters positive (n=39) negative (n=24) p value age (yrs) 52±10 58±11 0.03 ckd duration(yrs) 6±4 5±2 0.41 dm duration(yrs) 14±7 13±7 0.28 dialysis duration (m) 18± 22 10±7 0.03 bt (total units) 22± 29 10±12 0.03 bt (units/month) 1.4± 1.2 1.1±1.3 0.07 dialyzer reuse 3±1 2±1 0.02 ckdchronic kidney disease, dm – diabetes mellitus, btblood transfusion, m months results are shown in mean ± sd table iv level of immunity against hepatitis b virus in cases (mhd) vaccinated n=53, (84%) non-vaccinated n=10, (16%) p value protective (>100iu/l) 11 (19%) 4 (57%) low protective (10-100iu/l) 20 (39%) non protective (<10iu/l) 22 (42%) 3 (43%) 0.74 p value reached from chi square test; p<0.05 considered significant different laboratory parameters were similar between cases (mhd patients) and controls (predialysis patients). the only difference was in serum creatinine (s. cr) level and this was higher in mhd patients (p<0.001) (table i). the proportion of positive hepatitis b virus infection was found to be higher among the control (16%) compared to case (1.6%) and the difference was statistically significant (p<0.02) (table ii). results showed no significant association between positivity of anti-hbc with duration of chronic renal failure and duration of diabetes mellitus (table iii). however, data shows higher preponderance of positive anti-hbc among the patients with prolonged duration of maintenance haemodialysis (p<0.03) and number of total units of blood transfusion (p<0.03). a statistically significant association was also found between anti-hbc status and number of reuse of dialyser (p<0.02) indicating the positivity of anti-hbc was high among the patients with more reuse of dialyser. data analysis also indicated that the mean age of the positive anti-hbc total was found to be low (52.21±10.2 years) compared to negative anti-hbc total (57.96±10.8 years) and the difference was significant (p<0.05). result showed that 84% of the cases (dialysis patients) were vaccinated and 16% of them non-vaccinated (p<0.001). no significant difference was seen in proportion 19 antibody response against hbv infection in patients on maintenance hemodialysis of the patients with protective and nonprotective titers among the vaccinated and non-vaccinated subjects. vaccination schedule was 3 doses in 79% and 4 doses in 21% of cases (table iv). discussion bangladesh has an intermediate prevalence of hepatitis b virus infection with a 4% hbsag positive population12. in a previous study 3.5% prevalence rate of hepatitis b virus infection in pregnant woman of bangladesh was seen13. it was observed in the present study that hbsag was positive in hemodialysis patients in lower frequency (1.6%). lower prevalence of hbsag in mhd patients probably due to routine screening for hbsag before selection of patients for mhd. furthermore, we selected patients from two hemodialysis units where hbsag positive patients were not accepted for hemodialysis to minimize the risk of spreading of hbv infection. this notion was similar to14. moreover, 84% of our dialysis patients were vaccinated which might also contribute to low number of hbsag positive cases in mhd group. on the other hand, hbsag was found in higher frequencies in our predialysis diabetic ckd patients (16%). in diabetic patients hbv infection has been shown about 14% in a study15 and in predialysis patients it ranged from 8-10% in studies from india and turkey7,9. higher prevalence of hbsag in our predialysis patients may be attributed to the fact that these patients had not been undergone routine screening for hbsag and vaccination. although, other factors like, frequent hospitalization, history of injections (including insulin), poor nutritional status (metabolic derangement) leading to suppressed immune response etc. remain common for both groups. therefore, hbv vaccination alone seems to make the difference of hbsag status observed in both groups. we found 62% of the dialysis patients and 72% controls are anti-hbc positive, which is higher than some other reports showing around 40%16 but similar to one showing 76%17. positive anti-hbc total always indicate a remote hbv infection and is the most valuable single serologic marker in diagnosis of hbv infection even when hbsag remains negative. we found positivity of anti-hbc total higher among the patients with more reuse of dialyzer18, qadi et al. reported reuse of dialyzer is one of the risk factors for viral transmissions. similarly increased duration of dialysis and higher number of blood transfusion has been shown to be associated with increased frequency of hcv infection19, which was seen in our patients too. it is possible that our patients became more anti-hbc positive due to higher blood transfusion and longer duration of dialysis. majority of our mhd patients had vaccination (84%) but analysis found that only 19% have protective immunity, 39% low protective immunity and 42% have non protective immunity indicating that approximately half of the dialysis patients had no protection despite vaccination which is probably due to immunosuppression. in present study in all immunity groups, majority of the patients were more than 50 years ages. it has been suggested that advanced age reduces the response against hbv vaccine in hemodialysis patients20. in our study response against hepatitis b vaccine to attain a protective titer was in 58% subjects. this relatively low response may be due to higher age, presence of diabetes and lower doses of vaccination schedule as majority (79%) took three-dose regimen. some studies showed that vaccine response is 64% with 3 doses whereas 86% with 4 doses21. 20 shahin s. et al. we can conclude that hepatitis b virus positivity was significantly higher among the predialysis subjects compared to dialysis group. anti-hbc antibody was positive in two-third of the study subjects. with a threedose vaccine schedule only half of the dialysis patients could attain protective antibody titer. according to standard statistical formula, a large sample size should have been taken to reflect the picture of whole population. however, as this is a pilot study sample size was confined at 88 subjects. acknowledgement the authors sincerely acknowledge the help and cooperation of the immunology department and chronic renal failure (crf) project of birdem. ________________________________________________________________________ ______ references 1. otedo ae, mc ligeyo so, okoth fa, kayima jk. seroprevalence of hepatitis b and hepatitis c in maintenance dialysis in a public hospital in a developing country. south african medical journal 2003; 93:380-4. 2. teles sa, martins rmb, lopes clr, carneiro ma, souza kp, yoshida cft. immunogenicity of a recombinant hepatitis b vaccine (euvax-b) in a hemodialysis patients and staff. europian journal of epidemiology 2001; 17: 145-49. 3. busek su, baba eh, tavares filho ha, pimenta l, salomao a, correa-oliveira r, oliveira gc. hepatitis c and hepatitis b virus infection in different hemodialysis units in belo horizonte, minas gerais, brazil. mem inst oswaldo cruz 2002; 97: 775-778. 4. devesa m, khudyakov ye, capriles f, blitz l, fields ha, liprandi f, pujol fh. reduced antibody reactivity to hepatitis c virus antigens hemodialysis patients coinfected with hepatitis b virus. clinical and diagnostic laboratory immunology 1997; 4: 639-642. 5. tong nkc, beran j, kee sa, miguel jl, sanchez c, bayas jm, vilella a, de juanes jr, arrazola p, torrecillas fc, de novales el, hamtiaux v, lievens m, stoffel m. immunogenicity and safety of an adjuvanted 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hemodialysis patients. ren fail 2006; 28: 729-35. 11. islam mn, hossain rm, rahman mh, mansur ma, hassan ms, islam ms, sultana r, iqbal mm. hepatitis b (hbv) and c (hcv) among maintenance hemodialysis patients, family members and dialysis staffs. intern society hemodial 2007; 11: 108. 12. kane m, 1994. global plan of action for hepatitis b immunization: global program for vaccine and immunization. expanded program on immunization. geneva: world health organization. 13. rumi mak, begum k, hassan ms, hasan smm, azam mg, hasan kn, shirin m, khan aka. detection of hepatitis b surface antigen in pregnant woman attending a public hospital for delivery: implication for vaccination strategy in bangladesh. am j trop med hyg 1998; 59: 318-322. 14. qadi aa, tamim h, ameen g, bu-ali a, al-arrayed s, fawaz na, almawi wy. hepatitis b and hepatitis c virus prevalence among dialysis patients in bahrain and saudi arabia: a survey by serologic and molecular methods. am j infect control 2004; 32: 493-5. 15. chen hf, li cy, chen p, see tt, lee hy. seroprevalence of hepatitis b and c in type 2 diabetic patients. j chin med assoc 2006; 69: 146-152. 16. souza kp, luj a, teles sa, carneiro mas, oliveira la, gomes as, dias ma, gomes sa, yoshida cft. hepatitis b and c in the hemodialysis unit of tocantins, brazil: serological and molecular profiles. mem inst oswaldo cruz, rio de janeiro 2003; 98: 599-603. 17. ambuhl pm, binswanger u, renner el. epidemiology of chronic hepatitis b and c among dialysis patients in switzerland. schweiz med wochenschr 2000; 103: 341348. 18. saxena anil k, panhotra br. impact of dedicated space, dialysis equipment, and nursing staff on the transmission of hepatitis c virus in a hemodialysis unit of the middle east. am j infect control 2003; 31:26-33. 19.albuquerque accd, coelho mrcd, lopes epa, lemos mf, moreira rc prevalence and risk factors of hepatitis c virus infection in hemodialysis patients from one center in recife, brazil. mem inst oswaldo cruz rio de janeiro 2005; 100: 467-70. 20. taheri sh, shahidi sh, moghtaderi j, seirafian sh, emami a, eftekhari sm. response rate to hepatitis b vaccination in patients with chronic renal failure and end-stage-disease: influence of diabetes mellitus. j res med sci 2005; 10: 384-390. 21.centers for diseases control and prevention. recommendation for preventing transmission of infections among chronic hemodialysis patients. mmwr 2001; 50: 1-43. __________________________________________________________________________ “allah has not sent down a disease except that he also sent down its cure: whoever knows it (the cure), knows it, and whoever is unaware of it (the cure), he is unaware of it.” (the medicine) while those who are ignorant of it are unaware of it.” [an-nasai’, ibn mãjah, al-hakim and ibn hibban] antibody response against hbv infection in patients on maintenance hemodialysis 22 microsoft word _bjms jul 2010 online bangladesh journal of medical science vol.09 no.3 jul’10 *corresponds to: dr. shaju jacob p, department of periodontics and oral implantology, chhattisgarh dental college and research institute, sundara, rajnandgaon, chhattisgarh 491441, india. fax no: 00917744-281930. email: shajujacob@yahoo.com. review article periodontitis in india and bangladesh. need for a population based approach in epidemiological surveys. a literature review. p shaju jacob* abstract background: early surveys showed people of india and its neighbors to be highly susceptible to periodontitis. this was based on the early surveys which estimated a higher prevalence. aim: this paper reviews the prevalence of periodontitis in india and bangladesh and attempts to find out why the populations of the indian subcontinent were considered more susceptible to periodontitis. settings and design: review of periodontitis prevalence studies on the indian and bangladeshi population. methods and material: after identifying articles from pub med, daoj and hand searching, the epidemiology of periodontitis is reviewed. results and conclusion: this review identifies that very few studies have been done on representative population. yet it can be certainly concluded that there is a high prevalence of periodontitis in the adults and the economically weak population which can be reduced by adopting preventive public health strategies. conclusions: standardized population based studies in a representative population with a robust design to identify the true prevalence of periodontitis is needed. keywords: periodontitis, india, bangladesh, epidemiology, prevalence. introduction india and bangladesh share more in common than being two of the most populous nations in terms of population density. culture, trade, security are some of the areas where the two countries meet. the two countries are also considered to be affected by periodontitis, the major reason for tooth loss in adults, which is higher than the western nations. oral health has been neglected for long in india. with the formulation of the oral health policy india has started recognizing the benefits of having a healthy population including in oral health. in india, dental care scenario is unique 1 . at present there are more than 267 dental schools, producing approximately 19,000 dental graduates/year and almost 3000 specialists. bangladesh has 14 dental schools (bangladesh medical and dental council). the dental schools are major players for inexpensive oral care and also offer excellent tertiary care. on the other hand, even the most basic oral health education, simple interventions like pain relief, emergency care for acute infection and trauma are not available to the vast majority of population, especially in rural area. there is variation in the periodontitis prevalence as reflected in the two major surveys conducted 1, 2 . lack of epidemiological data on representative rural population compounds the problem further. albandar 3 in an overview concluded that subjects of asian ethnicity had the third highest prevalence of periodontitis. the aim of this review is to find the prevalence of periodontitis in india and bangladesh. method using keywords “periodontitis” and “india”, “periodontal” and “india” and “periodontitis” and “bangladesh”, “periodontal” and “bangladesh” various index were searched including pubmed and medind. search for india gave 163 articles while bangladesh had 12 articles. studies which gave prevalence data on shaju jacob p 125 periodontitis were selected and thus 13 articles were selected for the review. in this review moderate periodontitis is considered if a person has at least one site 4mm and severe periodontitis at least one site 6mm of probing depth. greene 4 conducted one of the very earliest prevalence studies in india. the periodontal index (russell, 1956) was used. the survey was on the school population in a low socio economic area. ninety-seven per cent of the 11-17 year old persons examined had overt evidence of periodontal disease, while fewer than 2 per cent of the total had obvious periodontal pockets. all the 63 persons over 17 years of age had overt gingival inflammation, and 19persons (30.2%) per cent, had obvious periodontal pockets. persons with obvious periodontal pocket (periodontitis) were 0.2% in 11 yrs, 0.4 in 13 years, 1%in 15 and 6% in 17 years group. ramfjord 5 observed that there is 100% prevalence of periodontal disease (including gingivitis) in india. at 17 years 10% of indian boys had periodontitis. this periodontitis was due to accumulation of calculus, plaque and debris rather than due to age, sex, geography, economic status or nutrition. sanjana et. al 6 did a study on bombay residents in 1956. 83.2% had signs of periodontal disease. national oral health survey and flouride mapping, 2002-2003, dental council of india, new delhi, 2004: this is the first ever national level epidemiological survey done in india. the survey was to collect information covering various dimensions of oral health including prevalence of oral health problems. community periodontal index (cpi) was used for disease assessment. the prevalence of periodontal disease increased with age. moderate periodontitis was seen in 17.5% of 35-44yr old, and 21.4% in 6574 yr old, whereas severe disease defined as at least one tooth with >6mm probing depth was 7.8% in 35-44yr old, and 18.1% in 65-74 yr old. no marked gender differentials were observed and marginally higher prevalence seen in rural subjects. this survey gave a reliable baseline data at a national and state level. oral health in india: a report of the multicentric study 1 , directorate general of health services, ministry of health and family welfare, government of india & world health organisation collaborative program. under the government of india and world health organization collaborative program on oral health, a multicentric oral health survey was envisaged in the year 2004, in order to have a baseline data of the oral diseases burden and associated risk profile of the population for four index age group i.e 12, 15, 35-44 and 65-74 years. this survey was conducted in seven different geographical locations in india i.e. arunachal pradesh, delhi, maharashtra, puducherry, rajasthan, orissa and uttar pradesh. the loss of attachment (3 mm or more) was 77% in 35-44 year age group and 96% in 65-74 years olds in maharashtra in the present study. attachment loss of >3mm in 35 -44 years was highest in maharashtra (78%) followed by orissa 68% and delhi 46%. the rest of the centers had the prevalence ranging between 15-33%. the prevalence of loss of attachment was significantly higher in 65-74 years age group compared to 35-44 yrs. group. the highest prevalence in 65-74 years group was recorded from maharashtra (96%), followed by orissa (90%), delhi (85.5%), rajasthan (75%), uttar pradesh (68%) and puducherry (55%). arunachal pradesh recorded the lowest prevalence of 20%. the general trend for loss of attachment observed was that it was higher in rural than in urban periodontitis in india and bangladesh 126 population and was higher in males compared to females. naseem shah 7 in her report for the national commission on macroeconomics observed more advanced periodontal disease affecting 40%–45% of the population of india. m sood 8 in a field survey in punjab found 29.1% having shallow pockets (moderate periodontitis) and 12.5% deep pockets ( 6mm severe periodontitis), assessed by who recommended methods. gpi singh 9 did a prevalence study in the rural and urban subjects of ludhiana, punjab. he found that the urban subjects had more prevalence of moderate and severe periodontitis than rural subjects. jagadeesan 10 did a systematic random sampling of rural women in pondichery. the prevalence of moderate periodontitis increased with age; there was a risk of 2.3 times for persons above 35 years to get periodontitis. doifode 11 in a field survey of two randomly selected nagars of nagpur, maharashtra found 34.8% periodontal disease. vandana k.l 12 found 27% periodontitis in flourosis affected patients attending periodontics opd. prevalence increased with age and was significantly more in females. helderman 13 in a review observed the prevalence of subjects with deep periodontal pockets in bangladesh was 26 per cent and it can tentatively be concluded that bangladesh belongs to the 20 per cent of countries in the world where periodontal conditions of the population are among the worst. akhter 14 found that of the 582 patients attending dhaka dental college hospital who underwent extractions of their teeth, 18.5% was due to periodontal reasons. arvidson-bufano 15 found shallow pockets in 34% of the urban slum group and in 42% of the rural group, in a survey of 826 individuals residing in central and western bangladesh. table 1: prevalence data of periodontitis year author country sample size population age range prevalence 1956 m.k. sanjana 6 india 1445 urban 16-50 n.a 1957 ramfjord 5 india 1677 urban + rural 11-17, 19-30. 10% at age 17 1960 greene 4 india 802 urban males 11-17 <2% 1960 greene 4 india 748 rural males 11-17 <2% 1960 greene 4 india 63 rural males 18-30 30.2% 2000 doifode 11 india 5061 urban, representative population 0-60+ 34.8% (31.7m, 32.5f ) 2000 m jagadeesan 10 india 912 field survey, rural women >15 years 20.63% moderate, 25.6% (severe periodontitis.) shaju jacob p 127 year author country sample size population age range prevalence 2004 bali et al 2 india 310 per region urban and rural 5,12,3544,65-74 groups 17.5% moderate &7.8% severe periodontitis (3544years) 21.4%moderate and 18.1 severe periodontitis (6574years) 2005 m. sood 8 india 1000 field survey n.a 29.1%moderate, 12.5%severe periodontitis. 2005 gpi singh 9 india 1000 field survey >15years 39.4%moderate, 16.9%severe periodontitis. 2005 gpi singh 9 india 500 urban field survey >15years 43.2%moderate, 22.9%severe periodontitis 2005 gpi singh 9 india 500 rural field survey >15years 31.7%moderate, 11.0%severe periodontitis. 2007 vandana kl 12 india 1029 periodontics opd 1574years. 27% (24.2m, 32.8f) 2007 who 1 arunachal pradesh india 3200 field survey 12, 15, 35-44, 65-74 age group. 15% moderate and 2.6 severe periodontitis (35-44 years), 18% moderate and 0.6% severe periodontitis (65-74 years) 2007 who 1 delhi india 3200 field survey 12, 15, 35-44, 65-74 age group. 34% mod and 1.0% severe in 35-44, 1.7% mod and 1.7% sev in 65-74 age groups. 2007 who 1 maharashtra india 3200 field survey 12, 15, 35-44, 65-74 age group. 48% moderate and 2.9% severe periodontitis (35-44 years), 55.2% moderate and 4.5% severe periodontitis (65-74 years) 2007 who 1 orissa india 3200 field survey 12, 15, 35-44, 65-74 age group. 35.7% moderate and 9.7% severe periodontitis (35-44 years), 42% moderate and 15.6% severe periodontitis (65-74 years) 2007 who 1 puduchery india 3200 field survey 12, 15, 35-44, 65-74 age group. 26.3% moderate and 4.7% severe periodontitis ( 35-44 years) periodontitis in india and bangladesh 128 year author country sample size population age range prevalence 2007 who 1 rajasthan india 3200 field survey 12, 15, 35-44, 65-74 age group. 48% moderate and 2% severe periodontitis (35-44 years) 2007 who 1 uttar pradesh india 3200 field survey 12, 15, 35-44, 65-74 age group. 23.5% moderate periodontitis (35-44 years), 34.5% moderate and 14% severe (65-74 years). 1990 arvidsonbufano 15 bangladesh hospital, urban slums 34% 1990 arvidsonbufano 15 bangladesh hospital, rural 42% 1996 helderman 13 bangladesh review 26% (severe periodontitis) 2008 akhter 14 bangladesh 582 hospital 18.5% discussion school and hospital population are easy to access and study. but they are convenient samples which cannot be generalized to the target population. there is an increase of about 10% between the prevalence in general population and hospital based population. the early studies 4,5 were done on school population. the school population will be a young population and only persons affordable to attend the schools will be represented. and the school population is least representative of the periodontitis susceptible population. but if young persons show levels of periodontitis as seen in ramfjord 5 surveys, it is a cause for alarm as it reflects a poor hygiene status and dental service utilization by the population. another limitation observed was the use of cpitn as a case definition for periodontitis. cpitn is a treatment need index to find the prevalence of persons requiring treatment. it does not give true prevalence in terms of severity and extent. further the prevalence data should correlate with tooth loss to find if the increased prevalence of periodontitis is reflected in increased tooth mortality. this will also help us to find at what level of severity of periodontitis is tooth loss a consequence. abnormal probing depth is a cause for concern if it leads to increased risk for tooth loss and its threshold should be identified based on its consequence. yet very little data are available on tooth loss. 7 the who global oral health programme 16 formulated the policies and the necessary actions for the improvement of oral health. the strategy is that oral disease prevention and the promotion of oral health needs to be integrated with chronic disease prevention and general health promotion as the risks to health are linked (like tobacco consumption and the standard of hygiene). yet for effective integration of oral disease management with other chronic diseases, prevalence data along with risk due to various factors should be available. oral disease including periodontal disease and tooth loss is a serious public-health problem. its impact on individuals and communities in terms of pain and suffering, impairment of function shaju jacob p 129 and reduced quality of life, is considerable. with the growing consumption of tobacco in many low and middle income countries, the risk of periodontal disease, tooth loss and oral-cavity cancer is likely to increase. naseem shah 7 in her report for the national commission on macroeconomics and health (ncmh) observed that for periodontal diseases the projection is alarming with prevalence at present being 45% for 15+ years, and the actual prevalence in lakhs will be 2957.6 (year 2000), 3190.2(year 2005), 3413.8(year 2010) and 3624.8(year 2015). due to the rampant use of paan masala and gutka by persons of all age groups and both the sexes’ periodontal disease prevalence will increase than projected. if minor periodontal diseases are included, the proportion of population above the age of 15 years with this disease could be 80%– 90%. concerned 11 with the urgent need for action in promoting sound oral health, prevention of dental caries and periodontal diseases and to give impetus to activities to promote oral health, who had dedicated world health day 1994 to oral health. conclusion there is a lack of prevalence data of the indian and bangladesh population. case definitions have to be formed with the local population in mind. as bangladesh and india share more in common, a common approach can be developed to study periodontal diseases with the subcontinent’s uniqueness in mind. this will help us utilizing the scarce resources available to combat and prevent periodontitis and its related tooth loss. ______________ periodontitis in india and bangladesh 130 reference 1. naseem shah, pandey r.m. et al,., oral health in india: a report of the multi centric study, directorate general of health services, ministry of health and family welfare, government of india & world health organisation collaborative program, december 2007. 2. bali, mathur, talwar, chanana. national oral health survey and flouride mapping 20022003. india. dental council of india, new delhi, 2004. 3. albandar & rams. global epidemiology of periodontal diseases: an overview. periodontology 2000 2002; 29:7-10. 4. greene. j.c. periodontal disease in india: report of an epidemiological study. journal of dental research 1960; 39:302-312. 5. ramfjord.s.p, emslie, greene j.c, held and waerhaug.j. epidemiological studies of periodontal diseases. american journal of public health 1968; 58(9):17-22. 6. sanjana m.k., mehta f.s., doctor r.h. and baretto m.a. mouth hygiene habits and their relation to periodontal disease journal of dental research 1956; 35:645-47. 7. naseem shah. oral and dental diseases: causes, prevention and treatment strategies in ncmh background papers—burden of disease in india (new delhi, india), september 2005, national commission on macroeconomics and health, ministry of health & family welfare, government of india, new delhi september 2005, 275-298 8. sood m. a study of epidemiological factors influencing periodontal diseases in selected areas of district ludhiana, punjab. indian journal of community medicine 2005; 30(2):70-71. 9. singh gpi, bindra j, soni. prevalence of periodontal diseases in urban and rural areas of ludhiana, punjab. indian journal of community medicine 2005; 30(4):128-9 10. jagadeesan m, rotti sb, dananbalan m. oral health status and risk factors for dental and periodontal diseases among rural women in pondicherry. indian journal of community medicine 2000; xxv(1):31-38 11. doifode vv, ambadekar nn, lanewar ag. assessment of oral health status and its association with some epidemiological factors in population of nagpur, india. indian j med sci. 2000; 54(7):261-9 12. vandana kl, reddy sm, assessment of periodontal status in dental fluorosis subjects using community periodontal index of treatment needs. indian journal of dental research 2007; 18:67-71 13. van palenstein helderman wh, joarder ma, begum a. prevalence and severity of periodontal diseases and dental caries in bangladesh. int dent j. 1996 apr;46(2):76-81. 14. akhter r, hassan nm, aida j, zaman ku, morita m. risk indicators for tooth loss due to caries and periodontal disease in recipients of free dental treatment in an adult population in bangladesh. oral health prev dent. 2008;6(3):199-207. 15. arvidson-bufano ub, holm ak. dental health in urban and rural areas of central and western bangladesh. odontostomatol trop. 1990 sep;13(3):81-6. 16. poul erik petersen, world health organization,geneva, switzerland. world health organization global policy for improvement of oral health – world health assembly 2007. international dental journal 2008; 58:115-121. ______________ 262 bangladesh journal of medical science vol. 15 no. 02 april’16 original article type of psychosocial stressor as risk factor of depressive symptom in metabolic syndrome fauziyati a1, siswanto a2, purnomo lb3, sinorita h3 abstract: metabolic syndrome and depression are two major diseases over the world, which are increasing in prevalence over time. depression is a major mental health burden over the world. in long time, depression can lead to metabolic syndrome, while metabolic syndrome is a risk factor for developing depression. metabolic syndrome is a major risk factor for developing cardiovascular disease. chronic stress induced by psychosocial stressor leads to the development of both metabolic syndrome and depression. further research is important to identify which type of psychosocial stressor is the risk factor for depressive symptom in patients with metabolic syndrome. the objective of this study is to identify the type of psychosocial stressor which could be the risk factor for depressive symptom. the study design was case control. the case group consisted of metabolic syndrome patients with depressive symptom, while the control group consisted of metabolic syndrome patients without depressive symptom. metabolic syndrome was diagnosed based on international diabetes federation (idf) criteria. depressive symptom was measured by beck depression inventory (bdi). psychosocial stressors were measured by stressful life events (sle) questionnaire. dependent variable was depressive symptom, while independent variables were type of psychosocial stressors (finance, work, social relationship, health and housing). analysis methods that used in this study were independent t test, pearson/ spearman correlation analysis, chi square and logistic regression. there were 54 patients in this study, consisted of 24 in case group and 30 in control group. there was no significant difference in most basic characteristics between two groups. there was significant difference of sle score between two groups. chi square analysis showed that housing, finance, health, social relationship, and work stressors were risk factors for developing depressive symptom in metabolic syndrome (or 24.5 (p 0.001); 9.7 (p 0.039); 8.4 (p 0.016); 5.4 (p 0.004); 3.9 (p 0.001), respectively). demographic factor which also influenced depressive symptom was salary less than 1 million per month (or 45, p 0.004). according to logistic regression analysis, psychosocial stressors which most influenced the depressive symptom were finance and housing. in conclusion, this study showed that housing, finance, health, social relationship and work stressors were risk factors for developing depressive symptom in metabolic syndrome. keywords: psychosocial stressor; metabolic syndrome; depression corresponds to: ana fauziyati, internal medicine department, faculty of medicine, universitas islam indonesia, jalan kaliurang km 14,5, yogyakarta, indonesia. e-mail: afauziyati@yahoo.com 1. internal medicine department, faculty of medicine, universitas islam indonesia 2. sub division of psychosomatic, internal medicine department, faculty of medicine, gadjah mada university 3. sub division of endocrine, metabolic and diabetes, internal medicine department, faculty of medicine, gadjah mada university bangladesh journal of medical science vol. 15 no. 02 april’16. page : 262-268 introduction metabolic syndrome and depression are two major diseases which are increasing over time because of sedentary lifestyle, including high calory intake and poor physical activity1. about 15% population ever had major depression episode in their life and 263 type of psychosocial stressor as risk factor of depressive symptom in metabolic syndrome note: *significant; education 1: no education andelementary school, 2: junior and senior high school, bachelor, 3: graduate and post graduate; occupation 1: unemployed,house wife, 2: private, labor, farmer 3: government employment, retired, army, policeman,income 1:<1 million/month, 2:1-5 million/month, 3:>5 million/month, marital status 1: never married, 2: married, 3: divorce/death spouse table 1. baseline characteristic between case group and control group characteristic (mean) case group (n=24) control group (n=30) significance (p) age (year) 51,29 52,05 0,771 duration of dm (month) 52,67 40,83 0,356 body mass index (kg/m2) 25,87 27,10 0,37 waist circumference (cm) 90,42 94,95 0,124 systolic blood pressure (mm hg) 134,3 135,5 0,821 diastolic blood pressure (mm hg) 78,38 78,6 0,52 fasting glucose (mg/dl) 187 154 0,196 post prandial glucose (mg/dl) 304 208 0,02* hba1c (%) 9,8 8,2 0,095 trygliserid (mg/dl) 160 188 0,3 hdl cholesterol (mg/dl) 40,5 46 0,15 ldl cholesterol(mg/dl) 132 131 0,978 total cholesterol (mg/dl) 199 196 0,882 bun (mg/dl) 17,4 16,9 0,679 creatinin (mg/dl) 1,30 1,16 0,799 uric acid (mg/dl) 6,5 6,0 0,552 sgot (u/l) 33 22 0,319 sgpt (u/l) 85 22 0,35 demographic factor n (proportion %) or (95% ci) p education 1 4 (0,17) 3 (0,1) 4,0 (0,55-29,17) p 0,171 2 17 (0,78) 18 (0,6) 2,83 (0,6-1,2) p 0,164 3 3 (0,12) 9 (0,3) referee occupation1 5 (0,21) 9 (0,3) 0,9 (0,2-4,0) p 0,947 2 12 (0,5) 9 (0,3) 2,28 (0,64-8,15) p 0,202 3 7 (0,29) 12 (0,4) referee income 1 9 (0,38) 2 (0,07) 45,0 (3,4-584) p 0,004* 2 14 (0,59) 18 (0.6) 7,78 (0,88-68) p 0.064 3 1 (0,42) 10 (0,33) referee sex female 13 (54,2) 16 (53,3) 0,97 (0,33-2,84) p 0,951 male 11 (45,8) 14 (46,7) marital status1 1 (0,042) 2 (0,07) 0,66 (0,05-7,0) p 0,74 2 4 (0,17) 3 (0,1) 1,75 (0,35-8,79) p 0,494 19 (0,79) 25 (0,83) referee complication retinopathy yes 5 (20,8) 7 (23,3) 0,86 (0,24-3,17) p 0,826 no 19 (79,2) 23 (76,7) nephropathy yes 5 (20,8) 5 (16,7) 1,32 (0,33-5,21) p 0,695 no 19 (79,72) 25 (83,3) neuropathy yes 10 (41,7) 8 (26,7) 1,96 (0,62-6,17) p 0,245 no 14 (58,3) 22 (73,3) peripheral artery diseaseyes 0 (0) 4 (13,3) 0,52 (0,39-0,68) p 0,063 no 24 (100) 26 (86,7) coronary artery disease yes 3 (12,5) 5 (16,7) 0,71 (0,15-3,35) p 0,688 no 21 (87,5) 25 (83,3) stroke yes 0 (0) 1(3,3) 0,55(0,43-0,70) p 0,367 no 24 (100) 29 (96,7) 264 fauziyati a, siswanto a, purnomo lb, sinorita h table 2. correlation between metabolic syndrome component and depressive symptom table 3. comparison of stressful life events (sle) score between case and control group note: *significant metabolic syndrome component classi fication control group case group significance (p) waist circumference 0 4 6 0,273 1 26 18 systolic blood pressure 0 14 13 0,584 1 16 11 diastolic blood pressure 0 21 18 0,684 1 9 6 fasting glucose 0 5 2 0,318 1 22 21 trygliserid 0 15 11 0,49 1 11 12 hdl cholesterol 0 15 9 0,149 1 10 14 total of metabolic syndrome component ≤3 22 14 0,245 >3 8 10 sle score (mean) case group control group significance(p) sle total score 12,2 4,63 0,001* finance 3,88 1,00 0,001* work 1,21 0,7 0,165 social relationship 1,04 0,33 0,023* health 4,92 2,2 0,001* housing 1,67 0,33 0,004* note: * significant table 4. correlation between sle score and bdi score dependent variable independent variable pearson/spearman correlation (r) significance (p) bdi score sle total score 0,688 0,001* finance 0,308 0,076 work 0,171 0,423 social relationship 0,643 0,007* health 0,384 0,01* housing 0,480 0,032* about 6-8% out patients in primary health care met the criteria of depression. depression was often undiagnosed2. depression makes the treatment of metabolic syndrome complicated. some studies showed depression made the glucose control difficult in patient with metabolic syndrome and diabetes mellitus3,4,5. depression decreased quality of life 6,7. depression increased the risk of metabolic syndrome and cardiovascular disease8. in the other hand, metabolic syndrome also increased the risk of depression9,10. the relationship between metabolic syndrome and depression is bidirectional 10,11,12,13,14,15. there are some studies which could not find the relationship between depression and metabolic syndrome16,17,18. psychosocial stressor in long time lead to depression. type of psychosocial stressor include marital status, family problems, interpersonal relationship, work problem, environtment, law, finance and health19. study showed subject with chronic life stressor especially work and finance had higher risk for developing metabolic syndrome20. psychosocial stressor and chronic stress increased the activity of hypothalamuspituitary-adrenal which increased cortisol level in blood, which in long time caused the insulin resistance or metabolic syndrome through central obesity21,22. hypercortisolism induced the neurobiology imbalance in amigdala and frontal cortex that manifested in emotional disorder, mood and depression23. psychosocial stressors which are not adapted well will induce the depressive symptomp19. problem in this study is what kind of psychosocial stressor which can be risk factor for developing depressive symptomp in metabolic syndrome. method design of the study is case control. case group consist of patients with metabolic syndrome who have depressive symptom, while control group consist of patients without 265 type of psychosocial stressor as risk factor of depressive symptom in metabolic syndrome type of psychosocial stressor depressive symptom (+) no depressive symptom odds ratio (or) ci 95% significance p finance no 24 7 9,714* 2,7-34,07 0,001* yes 6 17 work no 26 15 3,9* 1,0214,86 0,039* yes 4 9 social relationship no 27 15 5,4* 1,2623,04 0,016* yes 3 9 health no 13 2 8,4* 1,6742,41 0,004* yes 17 22 housing no 29 13 24,5* 2,8-210 0,001* yes 1 11 table 5. chi squareanalysis of type of psychosocial stressors as risk factor for developing depressive symptom in metabolic syndrome table 6. logistic regression of type of psychosocial stressor as risk factor for developing depressive symptom in metabolic syndrome step variable coefficient p or (ci 95%) step 1 finance 3,277 0,138 0,689-15,732 work 1,800 0,500 0,326-9,915 social relationship 3,196 0,235 0,47-21,755 health 3,241 0,247 0,443-23,712 housing 13,304 0,037* 1,17-151,296 constant 0,088 0,050 step 2 finance 3,474 0,160 0,735-16,42 social relationship 3,400 0,196 0,525-23,148 health 3,579 0,206 0,495-25,870 housing 13,602 0,034* 1,223-152,394 constant 0,089 0,050 step 3 finance 3,535 0,105 0,769-16,238 health 3,498 0,214 0,485-25,209 housing 14,952 0,022* 1,468-152,267 constant 0,109 0,009* step 4 finance 5,876 0,011* 1,500-23,017 housing 13,420 0,023* 1,423-126,578 constant 0,233 0,020* depressive symptom. the study was conducted at dr sardjito central hospital, from july 2014 until the minimum sample of subject achieved. subjects of the study are achieved from the population who meet the inclusion criteria and do not have exclusion criteria. inclusion criteria for case group are: age ≥18 and ≤60 years old, signed informed consent and have depressive symptom with beck depression inventory (bdi) score ≥ 14. inclusion criteria for control group are: age ≥18 and ≤ 60 years old, signed informed consent and do not have depressive symptom (score of bdi <14). exclusion criteria are: psychotic mental disorder, end stage of renal disease, congestive heart failure class functional iv, acute myocardial infarct, stroke or post stroke, diabetic ulcer, diabetes mellitus more than 10 years, using psychotropic agent, active smoker, alcoholic, and pregnant woman. the measurement of sample size is based on case control design24. characteristic of study subject is presented in mean. distribution of data was detected by normality test. to analyze the difference of mean between two groups we used t test. to determine the relationship between psychosocial stressor and depressive symptom we used chi square. to determine which psychosocial stressor to be the risk of depressive symptom in metabolic syndrome 266 fauziyati a, siswanto a, purnomo lb, sinorita h patient, we used multivariate analysis using logistic regression. during the study, patients who meet the inclusion and exclusion criteria are asked about their history and psychosocial stressor, fulfill the beck depression inventory and the stressful life event inventory. physical examination is conducted to all patients, especially to measure height, weight, blood pressure, and waist circumference. all the study subjects signed their informed consent to joint this study. this study was approved by ethics committee of faculty of medicine, gadjah mada university and had license from director of dr. sardjito central hospital. result there were 54 patients, consisted of 24 in case group, and 30 in control group. table 1 showed no differences of age, duration of diabetes mellitus, body mass index, waist circumference, systolic and diastolic blood pressure, fasting glucose, hba1c, trygliserid, high density lipoprotein cholesterol, low density lipoprotein cholesterol, total cholesterol, blood urea nitrogen, creatinin, sgot, sgpt, and uric acid between two groups. there was significant difference in post prandial glucose between two groups (304 vs. 208, p = 0.02). there was no difference between proportions of demographic factors between two groups, except income. patient with income less than 1 million per month had higher risk for developing depression than patient with income more than 5 million per month (or 45, ci 95% 3.4-584). proportion of complication such as retinopathy, nephropathy, neuropathy, peripheral artery disease, coronary heart disease, and were not different between two groups. chi square analysis showed no correlation between metabolic syndrome component and total of metabolic syndrome component with depressive symptom (table 2). there was significant difference of sle total score, score of finance, social relationship, health and housing between two groups (table 3). pearson and spearman correlation test showed that there were positive correlations between beck depression inventory score with sle total score (r = 0,688, p < 0,001), social relationship (r = 0,643, p = 0,007), health (r = 0,384, p = 0,01) and housing (r = 0,480, p = 0,032) (table 4). table 5 showed the high and significant odds ratio (or) of all stressors, with the highest was housing (or 24.5), followed by finance (or 9.714), health (or 8.4), social relationship (or 5.4), and work (or 3.9). logistic regression showed that the most influencing factors for developing depressive symptom were housing and finance (table 6). discussion this study compared 24 patients in case group and 30 patients in control group. there was difference of post prandial glucose between two groups, that was significant higher in case groups (304 vs. 208, p=0.02). this is relevant with previous study which stated depression complicate blood glucose control in metabolic syndrome or diabetes patient3,4,5,25,26. there was no correlation between metabolic syndrome component and depression. this result was different with previous study27,28. there was no difference of complication propotion between two groups, that is good to minimalize bias. income was correlated with depreesive symptom. this was relevant with previous study that stated low social economic level correlated with mental disorder in obese women29. there was significant difference of type of psychosocial stressor between two groups. this evidence supported that psychosocial stressor influenced the developing of depression in metabolic syndrome23. correlation test also showed the moderate and high correlation between sle total score, social relationship, health and housing with bdi score. chi square analysis showed that housing, finance, health, social relationship and work stressors were the risk factors for developing depressive symptom in metabolic syndrome. this result was relevant with previous study that stated people with finance and work stressors had higher risk for developing metabolic syndrome20. this result was different with previous study that stated there was no correlation between psychological distress and metabolic syndrome30. logistic regression showed that housing and finance stressors were the highest risk factors for developing depressive symptom in metabolic syndrome. this was relevant with previous study20. conclusion type of psychosocial stressors which defined as the risk factors for developing depressive symptom in metabolic syndrome were housing, finance, health, social relationship and work. 267 type of psychosocial stressor as risk factor of depressive symptom in metabolic syndrome 1. eckel, r.h., 2008. the metabolic syndrome. chapter 236:1509-1513, in: fauci, a.s., braunwald, e., kasper, d.l., 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(eds.), 2008. harrison’s principles of internal medicine, 17th ed., mcgraw hill medical, new york. 3. zuberi, s.i., syed, e.u., bhatti, j.a., 2011. association of depression with treatment outcomes in type 2 diabetes mellitus: a cross sectional study from karachi, pakistan. bmc psychiatry, 11(27):1-6. 4. pouwer, f. & snoek, f.j., 2001. association between symptoms of depression and the glycaemic control may be unstable across gender. diabetic medicine, 18:595598. 5. zihl, j., schaaf, l., ziler, e.a., 2010. the relationship between adult neurophysiological profiles and diabetic patient’s glycemic control. applied neurophysiology, 17:44-51. 6. eren, i., erdi, o., sahin, m., 2008. the effect of depression on quality of life of patients with type ii diabetes mellitus. depression and anxiety, 25; 98-106. 7. hyvarinen, m.p., wahlbeck, k., erickson, j.g., 2007. quality of life and metabolic status in mildly depressed patients with type 2 diabetes treated with paroxetine: a double-blind randomized controlled 6-month trial. bmc family practice, 8(34):1-7. 8. vanhala, m, jokelainen, j., kiukaanniemi, k., s., kumpuasalo, e., koponen, h., 2009. depressive symptoms predispose females to metabolic syndrome: a 7 year follow up study. acta psychiatrica scandinavica, 119:137-142. 9. dortland, r.a.k.b., giltay, e.j., veen, t., zitman, f.g., penninx, b.w.j.h., 2010. metabolic syndrome abnormalities are associated with severity of anxiety and depression and with tricyclic antidepressant use. acta psychiatrica scandinavica, 122:30-39. 10. akbaraly, t.n., ancelin, m.l., jaussent, i., ritchie, c., gateau, p.b., et al., 2011. metabolic syndrome and onset of depressive symptoms in the elderly findings from the three city study. diabetes care, 34:904-909. 11. toker, s., shirom, a., melamed, s., 2008. depression and the metabolic syndrome: gender dependent associations. depression and anxiety, 25:661-669. 12. heiskanen t., viinamaki, h., lehto, s.m., niskanen, l., honkanen, k., et al., 2009. association of depressive symptoms and the metabolic syndrome in men. acta psychiatrica scandinavica, 120:23-29. 13. akbaraly, t.n., kivimaki, m., brunner, e.j., chandola, t., marmot, m.g., et al., 2009. association between metabolic syndrome and depressive symptoms in middle-aged adults results from the whitehall ii study. diabetes care, 32(3):499-504. 14. hartley, t.a., knox, s.s., fekedulegn, d., leiker, c.b., violanti, j.m., et al., 2012. association between depressive symptoms and metabolic syndrome in police officers: results from two cross sectional studies. journal of environmental and public health, 1-9. 15. meittola, j., niskanen, l.k., vinamaki, h., kumpusalo, e., 2008. metabolic syndrome is associated with self perceived depression. scandinavian journal of primary health care, 26:203-210. 16. demirci, h., cinar, y., bilgel, n., 2011. metabolic syndrome and depressive symptoms in a primary health care setting in turkey. bulletin of clinical psychopharmacology, 21(1):49-57. 17. hildrum, b., mykletun, a., midthjell, k., ismail, k., dahl, a.a., 2009. no association of depression and anxiety with the metabolic syndrome: the norwegian hunt study. acta psychiatrica scandinavica, 120:1422. 18. foley, d.l., morley, k.i., madden, p.a.f., heath, a.c., whitfield, j.b., martin, n.g., 2010. major depression and the metabolic syndrome. twin research and human genetics, 13(4):347-358. 19. mudjaddid, e. & shatri, h., 2009. gangguan psikosomatik: gambaran umum dan patofisiologinya, in: sudoyo, a.w., setiyohadi, b., alwi, i., simadibrata, m.k., setisti, s. (editor). buku ajar ilmu penyakit dalam. jilid iii, edisi v., page: 2093-2097. interna publishing, jakarta. 20. pyykkonen, a.j., raikkonen, k., tuomi, t., erickson, j.g., groop, l., isomaa, b., 2010. stressful life events and the metabolic syndrome. diabetes care, 33(2): 378-384. 21. bjontorp, p., 2001. do stress reaction cause abdominal obesity and comorbidities?. obesity reviews, 2:73-86. 22. vogelzangs, n., 2010. depression & metabolic syndrome. dissertation. universiteit amsterdam. 23. sharpley, c.f., 2009. neurobiological pathway between chronic stress and depression: dysregulated reference: 268 fauziyati a, siswanto a, purnomo lb, sinorita h adaptive mechanisms?. clinical medicine: psychiatry 2:39-45. 24. dahlan, m.s., 2010. besar sampel dan cara pengambilan sampel dalam penelitian kedokteran dan kesehatan, ed. 3:46-60. salemba medika publisher, jakarta. 25. toker, s., shirom, a., melamed, s., 2008. depression and the metabolic syndrome: gender dependent associations. depression 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cohort study. psychosom med 68:213–216. 368 bangladesh journal of medical science vol. 15 no. 03 july’16 original article cost analysis of combination diuretic therapy with ace-inhibitors to diuretic therapy without ace-inhibitors in heart failure patients pribadi fw1 , dwiprahasto i2, thobari ja2 abstract: background: heart failure is the final stage of the entire heart disease and become a major health problem because of the high morbidity and mortality. diuretic combination therapy with ace inhibitors compared to diuretic therapy without ace inhibitors will affect the costs and hospitalization for heart failure patients; so it can be used to study pharmacoeconomics. method and design: this study is an analytic observational retrospective cohort study design. researchers compared the cost analysis between groups having diuretic combination therapy with an ace inhibitor and diuretic therapy without ace inhibitors. data taken with a total sampling of heart failure databases claimed prescribing health insurance between january 1, 2010 until december 31, 2011. results: out of the 377 patients of the study population, 64 patients received combination therapy with ace inhibitors and diuretics, and 60 patients received diuretic therapy without ace inhibitors. the analysis showed that the total cost was rp. 4.96 million and rp. 5.14 million; the average total inpatient days a year was 10.67 days and 7.00 days. conclusion: this study showed that the diuretic combination therapy with an ace inhibitor is more cost-effective. further research is needed to assess the total costs and effectiveness of therapy with more number of subjects and longer periods. key words: diuretics; ace-inhibitors; heart failure; cost analysis corresponds to: fajar wahyu pribadi, department of pharmacology, the faculty of medicine, jenderal soedirman university, indonesia. e-mail: tarique@iium.edu.my | m.tariqur.rahman@gmail.com. 1. fajar wahyu pribadi, department of pharmacology, the faculty of medicine, jenderal soedirman university. 2. iwan dwiprahasto, 3. jarir at thobari, department of pharmacology and toxicology, the faculty of medicine, gadjah mada university introduction: heart failure is the final stage of the entire heart disease and to this day remains a major health problem because of the high morbidity and mortality1. figures prevalence, incidence or new cases a year which is the highest frequency cause of hospitalization in patients aged 65 years or more. figures hospital discharge increased2.3. unfavorable prognosis with survival rates of 50% and 10% in a period of 5 and 10 years and also occupy about 3035% of the total hospitalisation4. in addition, case fatality rates after hospitalization within 30 days was 10.4%; whereas in 1 year was 22% and in 5 years was 42.3%5. in indonesia, there was 13.396 hospitalized cases, outpatient 16,431 cases with a case fatality rate 13.42%6. lodging in central java province categorized in groups of heart and blood vessel disease or cardiovascular diseases such as heart disease, stroke, hypertension is the number of 833 094 cases (54.33%) with a prevalence of 0.14%, which means there are 10,000 people 14 people who suffer from heart failure6,7. costs incurred for the management of heart failure was 5.9% of the total health budget in amerika8. while the national heart, lung, and blood institute estimates that the total cost of heart failure in 2010 of 39.2 million dollars to the direct cost of 35.1 million dollar9. in developing countries, consume between 1-2% of the total health budget and twothirds is the cost of hospitalization10. given standard therapy for severe heart failure is a loop diuretic, an ace inhibitor, digoxin, β-blocker or a combination thereof. in two rcts bangladesh journal of medical science vol. 15 no. 03 july’16. page : 368-375 369 cost analysis of combination diuretic therapy (consensus and solvd-treatment) conducted in 2,800 patients with a diagnosis of mild to severe heart failure who were given enalapril and placebo showed the results of therapy with ace inhibitors reduce the risk of death (rrr = relative risk reduction) by 27% in consensus and 16 % in solvd-treatment. in addition to the solvdtreatment also showed rrr of 26% in hospital admission for worsening heart failure. this advantage arises when combined with conventional therapy11. in a meta-analysis of diuretic therapy showed a decrease in mortality of 75% (or = 0:25, 95% ci 0.84% to 0:07%; p = 0:03; arr 8.2%; nnt = 12) and an increase in exercise capacity 63% (or = 0:37, 95% ci 0.1% to 0.64%) 12. incremental cost-effectiveness to ace inhibitors in the aire and hope shows an estimate of $ 2.800 / yols (year of life saved) and $ 15,000 / yols, while the estimated lifetime treatment for $ 5,000 / yols and 8.500 / yols. research on rales get that diuretics decrease heart failure hospitalization figure 1. the selection process of the study sum (%) total characteristics diuretic & ace diuretik tanpa p-value n=124 inhibitor ace inhibitor (n=64) n (%) (n=60) n (%) sex female 48 (38,7) 28 (43,8) 30 (33,2) 0,234 male 76 (61,3) 36 (56,2) 40 (46,8) age < 45 year 4 (3,2) 2 (3,1) 2 (66,1) 0,668 45-64 year 63 (50,8) 35 (54,7) 28 (46,7) > 64 year 57 (46,0) 27 (42,2) 30 (50,0) room class i 75 (60,5) 40 (62,5) 35 (58,3) 0,092 ii 45 (36,3) 20 (31,3) 25 (71,7) icu 4 (3,2) 4 (6,3) 0 (0) comorbid no 97 (78,2) 51 (79,7) 46 (76,7) 0,684 yes 27 (21,8) 13 (20,3) 14 (23,3) table 1: characteristics of subjects research source: processed secondary data 2012 370 pribadi fw , dwiprahasto i, thobari ja of 250 (663 versus 413, placebo versus diuretic)13. then research the total cost of torasemide and furosemide was 1,502 dem and dem 1.863. while the cost effectiveness (annual cost per patient with improved nyha class) is 3.954 dem and dem 7.60514 . all of these studies was to compare between each drug with placebo. while the study was to compare between diuretic spannheimer. therefore, this study sought to obtain information on cost analysis diuretic combination therapy with ace inhibitors to diuretic therapy without ace inhibitors in heart failure patients askes participants so that the results of this study will be used as a basis for the study of other pharmacoeconomics. research methods: this study was an observational study with retrospective cohort study design study using a database of participants claimed prescribing health insurance from pt. askes persero. the data used is the patient data for one year, ie between no. variabel shapiro-wilk statistic df sig 1 hospitalization cost 0,794 124 0,000 2 services and laboratories cost 0,690 124 0,000 3 drug costs 0,643 124 0,000 4 total costs 0,850 124 0,000 5 cer/day 0,763 124 0,000 table 2. normality test source: processed secondary data 2012 mean (±sd) long hospitalization diuretik & ace diuretik without ace p inhibitor inhibitor (n=64) (n=60) day/ year 7,00 10,67 0,000 (4,42) (4,34) source: processed secondary data 2012 table 3. long hospitalization between diuretics and ace inhibitor group with diuretics without ace inhibitors rupiah, in thousand (mean ± sd) cost diuretic& diuretic without p ace inhibitor ace inhibitor (n=64) (n=60) hospitalization cost 2782,81 3473,33 0,001 (2620,41) (2262,51) services and laboratories cost 754,44 635,75 0,836 (873,22) (661,10) drug costs 1572,13 859,95 0,000 (1765,38) (1241,72) total costs 4960,72 5143,06 0,620 (3677,66) (2920,60) table 4. bivariate analysis regarding the cost of diuretics and ace inhibitor group with diuretics without ace inhibitors source: processed secondary data 2012 371 cost analysis of combination diuretic therapy january 2010 until december 2011, which were then followed for 1 year. the perspective adopted in this study is the perspective of payers in this case is the pt. askes persero. inclusion criteria for this study is the case group participants askes patients with a diagnosis of heart failure and age over 18 years (has entered the adult criteria), a patient undergoing diuretic combination therapy with an ace inhibitor and diuretic therapy without ace inhibitors, have the data about the patient in the form of : patient data (askes id number, date of birth, and gender), data about the prescription (prescription date, trade name drugs, drug dosage, frequency of administration, the amount of drug administered and the cost of drugs), the data and the length of hospital diagnosis in hospital . the exclusion criteria in this study include the pregnant condition, there is a diagnosis of malignancy. the results of this study were analyzed using the data processing software and presented in tabular form and narrative. ethical approval was taken prior study. research result: subjects characteristics based on the data claimed prescribing heart failure, there were 377 patients with heart failure. the subjects of the study after the selection is based on inclusion and exclusion criteria, were allocated into two groups, the first group of cases (n = 64) who received diuretic combination therapy with an ace inhibitor. the second was the control group (n = 60) who received diuretic therapy without ace inhibitors the selection process of the study are shown on figure 1 characteristics of subjects in each group are shown in table 1. based on results of the normality test using the cer rupiah, in thousand (mean ± sd) n day/ year therapy diuretic & ace 64 824,77 inhibitor (487,61) diuretic without ace 60 468,61 inhibitor (202,40) p value 0,000 age <45 year 4 886,30 (445,79) diuretic & ace 2 927,29 inhibitor (206,89) diuretic without 2 845,32 ace inhibitor (739,37) 45-64 year 63 636,03 (387,17) diuretic & ace 35 748,62 inhibitor (465,82) diuretic without 28 495,30 ace inhibitor (184,38) > 64 year 57 654,15 (447,63) diuretic & ace 27 915,90 inhibitor (523,76) diuretic without 30 418,58 table 5. bivariate analysis cer between diuretics and ace inhibitor group with diuretics without ace inhibitors 372 pribadi fw , dwiprahasto i, thobari ja shapiro-wilk test the dependent variable in this study, namely the cost of hospitalization, cost of services and laboratories, drug costs, and the total cost, and cer / day unknown that all the data were not normally distributed because all p values (sig) <0.05, so that the results of this study can not be generalized and can only be inferred for research subjects. then the analysis followed by mann-whitney test, while for analysis seen from age followed by the kruskal-wallis test. normality test results can be seen in table 2 below: effectiveness hospitalization based on table 3 it can be seen that the time of hospitalization was there are different views on the number of days in heart failure patients who use drugs diuretics and ace inhibitors with diuretics without ace inhibitors (p = 0.000) in which the number of days of hospitalization mean that using diuretics and ace inhibitors as much as 7 days things this is less than the number of days of hospitalization average with diuretics without ace inhibitors as many as 10.067 days. this shows that the treatment of heart failure patients using diuretics and ace inhibitor drugs turned out to have a higher cer compared to treatment with diuretics without ace inhibitors, but the results of table 3 indicate that the treatment of heart failure patients using diuretics and ace inhibitor drugs ace inhibitor (140,62) p value 0,313 sex female 48 724,14 (510,27) diuretic & ace 28 944,98 inhibitor (564,10) diuretic without 20 414,96 ace inhibitor (139,30) male 76 607 (340,71) diuretic & ace 36 731,28 inhibitor (403,21) diuretic without 40 495,43 ace inhibitor (224,29) p value 0,307 comorbid non comorbid 97 672,74 (458,15) diuretic & ace 51 861,58 inhibitor (536,26) diuretic without 46 463,38 ace inhibitor (207,50) comorbid 27 579,49 (197,59) diuretic & ace 13 680,40 inhibitor (153,47) diuretic without 14 485,79 ace inhibitor (190,95) p value 0,710 source: processed secondary data 2012 373 cost analysis of combination diuretic therapy turned out to be the number of days average for each hospitalization is smaller than treatment with diuretics without ace inhibitors. both of these results it can be concluded that the use of diuretics and ace inhibitor drugs able to reduce the number of days of hospitalization in heart failure patient by 1 day for each hospitalization. charge based on table 4 it can be seen that the cost of hospitalization and medication costs incurred in the year between the heart failure patients using diuretics and ace inhibitor drugs with diuretics without ace inhibitors showed a difference (p = 0.001) at the cost of hospitalization and (p = 0.000) at the cost of drugs. while the cost of services and laboratories (p = 0.836) and total cost (p = 0.620) were issued in the year between the heart failure patients using diuretics and ace inhibitor drugs with diuretics without ace inhibitors showed no difference (p>0.005) relationship therapy, hospitalization and costs based on table 5 it can be seen that the cer difference from the number of days of hospitalization for one year in patients with heart failure between the use of drugs diuretics and ace inhibitors with diuretics without ace inhibitors showed a significant difference (p = 0.000). at cer analysis based on age, it can be seen that there is no difference cer seen from inpatient day for a year for each hospitalization in patients with heart failure between the ages <45 years, 4564 years , and more than 64 years, because all p values> 0.05. on gender, based on table 5 it can be seen that there is no difference cer inpatient day for a year for each hospitalization in patients with heart failure between female and male, because p values> 0.05. in comorbidities, it is known that there is no difference cer views of inpatient day for a year in patients with heart failure between the noncomorbid and comorbid, because all p values> 0.05. discussion: the results showed that the subjects in this study mostly over the age of 45 years the majority of men (61.3%). these results have the same results with the nhanes study and the nhlbi who reported that the age 45 years and older have a higher prevalence of heart failure more than under the age of 45 year9. in addition, the prevalence occurs in men more than women15. for the results obtained that the hospitalization costs incurred for hospitalization diuretic group without ace inhibitors during the year is greater than the costs incurred for hospitalization group diuretics and ace inhibitors during the year. this happens because of the length of stay (in days) diuretic and ace inhibitor groups fewer than longer hospitalization diuretic group without ace inhibitors. these results have similarities with the results of research conducted by tilson l et al. where the standard therapy group diuretic and lowers the cost of hospitalization. however, in these studies there was a drop of only 5%. this is probably caused by the studies conducted using specific diuretic that spironolactone16. at the cost of services and laboratory results, it was found that the group of diuretics and ace inhibitors to pay more than the diuretic group without ace inhibitors, but was not statistically mean (±sd) cost diuretik & diuretik without � ace inhibitor ace inhibitor (n=64) (n=60) total cost* 4960,72 5143,06 182,34 (3677,66) (2920,6) outcome day 7,00 10,67 3,67 (4,42) (4,34) cer incremental cer (day)* 824,77 468,61 356,16 (487,97) (202,40) *in thousand rupiah tabel 6. summary 374 pribadi fw , dwiprahasto i, thobari ja significant (p> 0.005). this occurs because the amount of the diuretic and ace inhibitor group more than the amount of the diuretic group without ace inhibitors. in addition, the group of diuretics and ace inhibitors are a class rooms comparison in between class i (62.5%), class ii (31.3%) and icu (6.3%). while in the diuretic group without ace inhibitors are a class room on the comparison between class i by 58.3%, amounting to 71.7% class ii and icu at 0%. while the results of the cost of the drug, also found that subjects in the group of diuretics and ace inhibitors to pay more than the diuretic group without ace inhibitors, although it was not statistically significant (p> 0.005). this happens because there are additional costs ace inhibitor drugs in the group of diuretics and ace inhibitors. on the total costs incurred, it was found that the two groups nearing cost almost the same (difference of only 182.34). diuretics without ace inhibitor group issued a total cost of greater but not statistically significant (p> 0.005). this happens because the total cost is the sum of the cost of hospitalization, cost of services and laboratory and drug costs. although the cost of hospitalization in the diuretic group without ace inhibitors greater, but the cost of services and laboratory and drug costs less than the group issued a diuretic and ace inhibitors in the cer results consisting of cer (days / year) is divided into several outcomes, namely between the diuretic and ace inhibitors with diuretics without ace inhibitors, the patient’s age, gender, co-morbidities. it was found that the cer (days / year) diuretic and ace inhibitor group is greater than the diuretic group without ace inhibitors. this happens because the average days diuretic and ace inhibitor group is smaller than the diuretic group without ace inhibitors. results of cer (days/ year) found that the largest is at age <45 years, and the smallest is at the age of 45-64 years. this happens because the average number of patients smallest at age <45 years, and the largest is at the age of 45-64 years. in the cer results obtained views of gender cer (days/ year) is greater in women than men. this happens because the average average days of women less than men even though statistically not significant (p> 0.005). while the results of co-morbidities seen cer (day) in the group without comorbidities greater than the group with comorbidities. this happens because the average days /year group without comorbidities smaller than the group with comorbidities. another result of this study is the combination therapy showed diuretic and ace inhibitors lower the results of inpatient day average compared to diuretic therapy without ace inhibitors. in connection with the above results, similar studies have been done on the atlas study which found that ace inhibitors decrease hospitalization for heart failure by 24% (p = 0.002). this research was carried out for 36 months in 3164 heart failure patients. while the pep-chf trial conducted in 850 patients with heart failure found that ace inhibitors decrease the rate of heart failure hospitalization for 1 year by 35% (rr = 0.65, 95% ci 0.98 to 0:43)18. conclusion: the total cost diuretic combination therapy with ace inhibitors in patients with heart failure askes participant in a year is rp. 4.96072 million, -. the total cost diuretic therapy without ace inhibitors in heart failure patients askes participant in a year is rp. 5.14306 million, -. effectiveness diuretic combination therapy with ace inhibitors in heart failure patients askes participants judging from the total number of days hospitalized in a year is 7 days. effectiveness diuretic therapy without ace inhibitors in heart failure patients askes participants judging from the total number of days hospitalized in a year is 10.67 days. icer therapy diuretic therapy without ace inhibitors in heart failure patients seen in total number of days hospitalized in a year is rp. 356 160, research limitations: this study has several limitations, especially in a short period of study and number of samples are minimal. further research is needed to assess the total costs and effectiveness of therapy with more number of subjects and a period of over one year. acknowledgments: the author would like to acknowledge the support of the head of pt. askes persero branch of kudus, director of mardi rahayu hospital, chairman of the program of basic medical sciences and biomedical program, chair of pharmacology and toxicology faculty of medicine, gadjah mada university and dean of the faculty of medicine and health sciences university of general sudirman purwokerto. conflict of interest: none 375 cost analysis of combination diuretic therapy 1. maggioni ap. review of the new esc guidelines for the pharmacological management of chronic heart failure. european heart journal 2005; 7 suppl j:j15-j20. 2. göhler, a, geisler, bp, manne, jm, kosiborod, m, zhang, z, weintraub, ws, spertus, ja, gazelle, s, siebert, u, cohen dj. utility estimates for decision– analytic modeling in chronic heart failure—health states based on new york heart association classes and number of rehospitalizations. ispor 2008; 12: 185-7. 3. nchs, national hospital discharge survey 2006 annual summary. nchs, maryland, 2006. 4. roger, v.l., 2010. the heart failure epidemic. int. j. environ. res. public health 7: 1807-1830. 5. loehr, lr, rosamond, wd, chang, pp, folsom, ar, chambless, le. heart failure incidence and survival (from the atherosclerosis risk in communities study). am j cardiol 2008; 101:1016–1022. 6. badan penelitian dan pengembangan kesehatan.. laporan hasil riset kesehatan dasar (riskesdas) nasional. departemen kesehatan ri, jakarta, 2007. 7. dinkes provinsi jawa tengah. profil kesehatan provinsi jawa tengah. dinkes provinsi jawa tengah, semarang, 2009. 8. riley, gf. long-term trends in the concentration of medicare spending. health aff (millwood) 2007; 26:808–816. 9. nhlbi. incidence and prevalence: 2006 chart book on cardiovascular and lung diseases. nhlbi, bethesda, 2007. 10. mcmurray, j, davie, a. the pharmacoeconomics of ace inhibitors in chronic heart failure. pharmacoeconomics 1996; 9(3):188-97. 11. national institute for health and clinical excellence. chronic heart failure: management of chronic heart failure in adults in primary and secondary care (nice clinical guideline 108). london, 2010. 12. faris, r, flather, m, purcell, h, henein, m, coats, wp. current evidence supporting the role of diuretics in heart failure: a meta analysis of randomised controlled trials. int j cardiol, 2002; 82(2):149-58. 13. pitt, b, zannad, f, remme, wj. the effect of spironolactone on morbidity and mortality in patients with severe heart failure (rales). n engl j med, 1999; 341 (10):709-717. 14. spannheimer, a, goertz, a, dreckmann, bb. comparison of therapies with torasemide or furosemide in patients with congestive heart failure from a pharmacoeconomic viewpoint. int j clin pract, 1998; 52:467–71 15. lloyd-jones, d, adams, rj, brown, tm, carnethon, m, ai, s, & imone, gd. heart disease and stroke statistics—2010 update. american heart association. circulation, 2010; 121: e129-e133. 16. tilson l, mcgowan b, ryan m, barry m. costeffectiveness of spironolactone in patients with severe heart failure. ijms 2003;172(2):70-72. 17. packer, m, wilson, pap, armstrong, pw, cleland, jgf, horowitz, jd, massie, bm, et al. comparative effects of low and high doses of the angiotensinconverting enzyme inhibitor, lisinopril, on morbidity and mortality in chronic heart failure. circulation; 1999; 100:2312-2318. 18. cleland, jg, tendera, m, adamus, j. the perindopril in elderly people with chronic heart failure (pep-chf) study. eur heart j, 2006; 27(19):2338-2345. reference: 505 bangladesh journal of medical science vol. 15 no. 04 october’16 review article healthcare financing in bangladesh: challenges and recommendations hassan mz1, fahim sm2, zafr aha3, islam ms 4, alam s5 abstract: bangladesh has achieved remarkable success in improving most of the health indicators over the last couple of decades despite pervasive economic poverty. however, for a sustainable growth health sector should be among the top lists at government’s policy table. unfortunately, the recent trend in budget allocation portrayed just the opposite and is concerning as expressed by health experts. over the last seven fiscal years, budgetary allocation for health dropped from 6.2% to 4.3% of total government expenditure. due to insufficient public spending, out of pocket payment (opp) is much higher which is about two-third (64.7%) of total health care spending in bangladesh. inadequate and inefficient public healthcare and profiteering tendency of the private healthcare sector are two major factors behind such high private spending. suffering from a massive shortage of health workforce and with such low public funding it would be very difficult for bangladesh to fight against upcoming challenges like increasing burden of non communicable diseases (ncds) and emerging threats due to climate change. keywords: healthcare financing; health budget; mdgs; universal health coverage; bangladesh corresponds to: md. zakiul hassan, crescent gastroliver and general hospital, 25/i, green road, dhaka-1205, bangladesh. email: drzakiulbd@gmail.com 1. md. zakiul hassan, crescent gastroliver and general hospital, dhaka, bangladesh 2. shah mohammad fahim, lecturer, ibn sina medical college, dhaka, bangladesh 3. abu hena abid zafr crescent gastroliver and general hospital, dhaka, bangladesh 4. md. shoriful islam, assistant professor of finance, department of business administration, northern university bangladesh 5. shahinul alam, associate professor, department of hepatology, bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh bangladesh journal of medical science vol. 15 no. 04 october’16 505 introduction: bangladesh has made substantial progress in most health indicators over the last two decades1. under-5 child mortality decreased significantly from 144 to 41 per 1,000 live births 2, 3 maternal mortality rates have dropped markedly by 66 per cent (194/100,000 live births) and life expectancy jumped to nearly 70 years at birth4. two years back, one of the most prestigious medical journals, the lancet, published a case-series on bangladesh’s massive success in health and termed it a great mystery in global health5. lancet stated that, despite spending less on health care than other neighboring countries, bangladesh now has the longest life expectancy, the lowest total fertility rate, and the lowest infant and under-5 mortality rates in south-asia5, 6. bangladesh is among the only six countries that are on track to achieve mdgs 7. but much still remains to be done. still nearly 40% of children whose ages are under five in bangladesh are stunted and 35% are under weight8. one out of every 24 children dies before their fifth birthday, 60 percent of those within the first 28 days of life, many from conditions which would have been easily treatable if they had access to a skilled health workers9. therefore, to sustain the development that bangladesh has achieved and to get to a middle income status by 2021, health should be given high priority. but unfortunately, in recent years, the health budget reflects just the opposite picture. the sector remains extremely neglected in the budget allocation 506 healthcare financing in bangladesh: challenges and recommendations of the government. it is unanimously recognized that public spending on health must be increased for achieving the mdgs in developing countries like bangladesh10. however, budgetary share of health sector is going down every year threatening the future of post-mdg goals. the aim of this review is to highlight the healthcare financing features of bangladesh, identify the potential challenges to achieve sustainable development goals for the country. healthcare financing features: in practice, the government of any country has a prime responsibility about the development of health facilities as well as medical system which should be applied through allocating a significant percentage of total expenditures in health sector. unfortunately, the yearly allocation in bangladesh is far short of required level set by world health organization (who) which is at least 15% of total budget of a country11 . figure 1 shows the scenario of health allocation in percentage of total expenditure in last seven fiscal years in bangladesh. figure 2: health expenditure in bangladesh in total % of gdp14 health spending can be compared with the total gdp and it is remarkably noted that bangladesh is clearly behind among some other asian countries in this aspect. from the presented figure, it is observed that maldives hold the top position and their health expenditure is 10.8% of total gdp. in this case bangladesh is in lowest position and india use slightly higher percentage than us which is 4%. the total amount of budget allocated for health in this fiscal year is bdt 12,726 crore15. though the amount is a bdt 1,157 crore hike from the outgoing fiscal year’s allocation16, the sector’s share in the total budget has declined 0.51 percent15. we can also compare the per capita expenditures for health purpose. table 1 shows the per capita health spending in neighboring countries. table 1: per capita health spending (in usd) 17 figure 1: health expenditure in bangladesh as a % of total government expenditure during 2009-201612, 13 according to the above mentioned diagram, it can be said that during last seven years, government health care spending in proportion of total public spending has decreased gradually. moreover, the fund allocation was decreased with time whereas population as well as different type of new diseases increased within the same time period. in fiscal year (fy) 2009-10, the allocation for health was 6.2% of total budget which dropped to 4.3% in 2015-16 fy12, 13. the total health spending in bangladesh is 3.7 percent of gdp whereas in developed countries, the health sector constitutes nine percent of the total gdp14. figure 2 shows health expenditure in total % of gdp in neighboring countries. bangladesh’s per capita health expenditure is $32, which is the lowest in the region compared to india, afghanistan, nepal, bhutan, pakistan and sri lanka17. however, the spending is more than three times higher for sri lanka and nearest to double in india. who recommends a per capita spending of $54 11. the government allocation is 700 taka per person per year or 1.92 taka per person per day18. with ever increasing health care cost, one can easily realize to what extent the allocated money could help. 507 hassan mz, fahim sm, zafr aha, islam ms , alam s the public spending on health is currently only 35.3%, almost one third of total health care spending19. in developed countries the picture is just opposite. table 2 shows the government spending in health in some developed and neighboring countries. table 2: public health expenditure (% of total health expenditure) 19 with more effective drugs and interventions etc. on the other hand non-development sector indicates employees’ salaries, wages and other operating costs. last three year’s scenario of development and non-development budget in health sector can be presented with the following tabletable 3: allocation of budget (in % of total) 12, 15 because public spending is much lower, people have to pay for health from their own pocket (opp) which is about two-third (64.7%) in bangladesh. the global standard for out of pocket payment (opp) is less than 32 percent20. due to the high opp, thousands of poor households are being pushed into poverty every year which is called catastrophic expenditure. studies have shown that 6.4 million (4%) people in bangladesh get poorer every year due to excessive health cost21, 22. people have to borrow money or sell assets to pay for health care. it has also been found that 20 percent of the poorest spend 16.5 percent of their household consumption for health reasons, while 20 percent of the richest spend 9.2 percent 21. inadequate and inefficient public healthcare and profiteering in the private healthcare sector are two major factors behind such private spending. as a result the gap between those who can access needed health services without fear of financial hardship and those who cannot is widening23. so, despite the rising health care costs in the country, the declining trend of health care allocation is against gob target to plummet the opp down from 64% to 32% by 203224. in fact, the opp will increase further if the allocation is not increased in the budget. another important issue can be considered as the budgetary allocation between development and non-development sectors of medical and health care division. for healthcare sector, development budget meant allocation for construction and infrastructural development of hospitals and medical care units, enrichment of modern medical equipments and diagnostic tools, improvement of treatment systems from the table 3, it can be said that the allocation for the development sector is lower in comparison to the allocation for non-development sector. although the table shows an increasing trend of development budget from fy 2013-14 to the running period of time, still it is much lower than 50 percent. even then a significant portion of development budget remains unspent every year. over the past seven years it has been observed that the health ministry can utilize only 76% percent of its annual development budget 25. despite suffering from acute shortage of resources, government hospitals only utilize a little more than half of their annual budget, forcing patients to seek treatment in the private sector. government hospitals in rural areas receive their budget near the end of the fiscal year due to bureaucratic tangles and thus do not have much time to spend the money. in addition, there is a core system weakness and knowledge gap. typically at the ground level, government has made big investment for buying an ambulance but does not have the system for small investment to repair puncture. a 2012 world bank survey identified, about 10% of installed medical equipments in public health facilities had been unused and another 20 percent had never been installed 26. this is clearly inefficient use of resources and reflects lack of transparency and good governance. tib repeatedly reported that the sector has been plagued with corruption and corruption has been institutionalized in all bodies within the sector which is, one of the prime reasons, for under utilization of allocated fund27. another problem is unequal distribution of funds and resources. figure 3 shows the unequal distribution of budget allocation in seven different divisions, where dhaka got almost half. but sylhet and barisal division jointly received fund less than one-fourth of dhaka 28 and second largest amount received by chittagong division which is 18%. 508 healthcare financing in bangladesh: challenges and recommendations figure 3: distribution of division-wise total health expenditure (the) challenges and recommendations: bangladesh has a massive shortage of skilled health work force. the country has only 0·5 doctors and 0·2 nurses per 1000 people, far less than the minimum standard of 2·28 per 1000 recommended by who29. trained and skilled workforce is a key to ensure quality health care for people. bangladesh has an extensive health infrastructure, but due to shortage of health care workers and logistics, most public health facilities cannot perform optimally30. a workforce plan for the short, medium and long term is necessary with a clear strategy to achieve targets within a specified time, addressing both the public and the private sectors. the plan should also address the needs and motivations of the workers, as well as their responsibilities and accountability towards patients. in bangladesh, rates of antenatal care use, skilled birth attendance, and facility-based deliveries are lower than those are for neighboring countries. still home delivery is 63% and delivery with no skill birth attendant is 58%. delivery at facility among the poorest quintal is only 15% and delivery with skill birth attendant is only 18%. we need to reach this quintal of the population and special fund for mother would help to improve maternal health indicators 9. in this year budget, gob took an initiative for the mothers named ‘maternal health voucher scheme’ 15. it is a good initiative and effective plan to expand this program would bring positive changes in case of maternal health and achieving mdg 5. we are having an epidemiological shift in disease burden where infectious diseases are taking a back seat and non communicable diseases (ncds) are coming up31. our health system is not ready for this transition and healthcare is likely to be more costly. ncds like heart diseases, hypertension, diabetes and cancer are emerging as major health threats and are responsible for 52 percent of the total deaths in bangladesh32. it is high time to plan ahead and allocate enough funds to fight the upcoming ncd epidemic. moreover, with the increase in life expectancy, aged people would constitute a major part of our population in near future and consequently geriatric diseases would go up. we should have a plan to improve the medical care for senior citizen. government of bangladesh plan to provide 13,861 mini laptops to community clinics 15, but a recent study by world vision identified several potential barriers to delivering expected healthcare services from community health clinics including infrastructural weakness, irregular medicine supply, a lack of monitoring and negligence in duties of caregivers. none of the community clinics surveyed has electricity connections and in most of those, tube wells do not work and the toilet facility is not available. about 34 percent of the clinics did not receive medicines on a regular basis. besides, inadequate training for service providers and their limited capacity to deal with things during emergency situation and critical diseases are hindering the optimal services33. therefore, what is needed first is to remove the barriers to improve their performance and strengthen their functional capacity. due to their proximity to people, we also propose that in addition to the primary health care, the community clinics can serve as a potential platform for preventive service package. also, we recommend reinforcing the upazilla health complexes and district hospitals to enable them to function as the principal service hospitals for general population. the provision for free health care services should be expanded. we strongly recommend for free health services for the vulnerable population including ultra poor, pregnant women, under-five children, urban slum dwellers, garments workers, labors and people in hard to reach areas. under an initiative launched by the united nations called coia (commission on information and accountability) for maternal and child health, the mis started to electronically register and track every pregnant woman and under-five child, using 11 core indicators and this registry can be used for providing free service to these groups. for others, free health cards can be issued. we also advocate to provide free primary and emergency health services to the migrant workers to acknowledge their substantial contribution to national economy with remittance and because most of them cannot afford health care overseas. recent ebola outbreak in africa highlighted how 509 hassan mz, fahim sm, zafr aha, islam ms , alam s vulnerable our health care system is in terms of a pandemic or epidemic threat and it reminds us of the desperate need to strengthen health systems for everyone, everywhere. we recommend investing for strong, equitable health systems to be prepared to fight against emerging threats and increasingly severe natural disasters. conclusion: bangladesh has achieved many of the millennium development goals (mdgs), but a stronger commitment is needed to achieve the universal health coverage (uhc) 34. uhc is right to health that means every person everywhere should have access to quality healthcare without suffering financial hardship 35, 36. it says about reducing the out of pocket expenditure through the cost sharing or pre-payment mechanism. inadequate funding, inequity in financing and its inefficient use are some of the crucial challenges that should be resolved to ensure quality health for all and establish universal health coverage 37. healthcare is not a charity, but a basic human right enshrined in article 15a, 16 and 18 of bangladesh’s constitution38. it is recognized by the un declaration. bangladesh is also committed to ensure health for all as a signee of alma ata declaration39. therefore to uphold people’s right to health gob should put health as a national priority, allocate sufficient budget for the sector and ensure the utilization of the allocated fund rationally, and these initiatives will help bangladesh to step forward towards post-mdg goals and achieving universal health coverage. conflict of interest: none of the authors declared any 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republic of bangladesh, 2015. 34. kieny m-p, evans db. universal health coverage. who emro. 2013;19(4). 35. garrett l, chowdhury amr, pablos-méndez a. all for universal health coverage. the lancet. 2009;374(9697):1294-9. http://dx.doi.org/10.1016/ s0140-6736(09)61503-8 36. adams am, ahmed t, el arifeen s, evans tg, huda t, reichenbach l. innovation for universal health coverage in bangladesh: a call to action. the lancet. 2014;382(9910):2104-11. http://dx.doi.org/10.1016/ s0140-6736(13)62150-9 37. habibullah m. the constitution of the people’s republic of bangladesh. government printing press, tejgaon, dhaka; 1996. 38. stanton b, clemens j. user fees for health care in developing countries: a case study of bangladesh. social science & medicine. 1989;29(10):1199-205. http:// dx.doi.org/10.1016/0277-9536(89)90363-8 microsoft word final_bjms_jan_2011 bangladesh journal of medical science vol.10 no.1 jan’11 *corresponds to: dr. musa mohd. nordin, mbbch (wales), frcp (edin); famm consultant paediatrician & neonatologist, damansara specialist hospital, kualalumpur, malaysia. email: musamn@gmail.com. editorial human genetic and reproductive technologies – an international medico-legal-religious impasse? musa mohd. nordin* introduction heralded by the revelation of the double helical structure of the dna molecule in 1953, the 21st century is aptly designated the biotechnology century. the 20th century of physics, which saw the transformation of silicon into computing magic, was embraced with enthusiasm by virtually every household. however, unlike her predecessor, the same cannot be said about the advancements in biomedicine. these revolutionary procedures in biotechnology have probed the outermost boundaries of what is scientifically possible and acceptable. micro manipulation at the very earliest stages of human development, at the level of the embryo, single cell and genetic structure is undoubtedly a very delicate and sensitive issue with potentially explosive ethical, social, medico-legal and religious ramifications. hence, the turbulent and not uncommonly hostile controversies that has since evolved. some of the issues in biotechnology which are debated contentiously and extensively across all segments of human society include assisted reproductive technologies, human reproductive cloning, therapeutic cloning, embryo research, genetic engineering, euthanasia, organ transplantation, abortion and contraception. the jurisprudence of biotechnology as a complete and comprehensive way of life, the teachings of islam encompasses all fields of human endeavours, spiritual and material, individual and societal, economics and politics, national and international. this is well understood from the revelation during the occasion of the prophet’s farewell pilgrimage. “this day, i have perfected your religion for you, completed my favour upon you, and have chosen for you islam as your religion” (5:3) and the instructions which regulate our everyday activity of life is called shariah (islamic law). the shariah is the epitome of the islamic spirit, the most typical manifestation of the islamic way of life, the kernel of islam itself1. bioethical deliberations is inseparable from the religion itself, hence islamic bioethics must remain and flourish within the confines of the shariah. all muslim scholars and jurists are agreed that four sources of islamic law remain in the forefront of all deliberations in islamic jurisprudence (fiqh), known as the masadir al shariah2. they are: 1. quran 2. sunnah (authentic traditions of the prophet) 3. ijma’ (consensus) 4. qiyas (analogy) others which are not founded on a material source (nass) from the quran or sunnah but capturing the spirit of the shariah and taking into consideration the welfare of the community include: 1. istihsan – the choice of one of several lawful options 2. istishab – continuation of an existing ruling until the contrary is proved 3. urf – customs or precedent which does not contradict nass musa mn 2 4. maslahah or istislah – consideration of public interest or welfare 5. shar’u man qabluna – the laws of our predecessors, either confirmed or abrogated by the primary sources 6. qawl as-sahabi – the narrative of the companion of the prophet the purposes of the law (maqasid al shariah) arranged in their order of importance are directed towards the preservation of3: 1. deen (religion) 2. nafs (life) 3. aql (mind) 4. nasl (progeny) 5. maal (property) this classification which is permanent and immutable defines succinctly and clearly the objectives of the community and gives it balance and a sense of purpose. three of these priorities are directly related to the preservation of health, namely life, mind and progeny. and from the outset it must be emphasized that the shariah is guided by five cardinal principles (qawaid al shariah). these are4: 1. the principle of intention – intent is all important in actions 2. the principle of certainty – certainty cannot be changed by doubt and all acts are permissible unless there are clear prohibitions 3. the principle of injury – do no harm, injury must be removed or compensated 4. the principle of hardship – hardship calls forth ease and facilitation, need or necessity makes for allowing what is prohibited 5. the principle of custom – custom or precedent is the rule unless contradicted by nass these cardinal rules lead the scholars and jurists to think of islamic fiqh as the subject of five vital conceptions5: 1. there are few absolute obligations (takalif) 2. gradualism in the promulgation of laws 3. making the burden lighter when making and executing laws 4. hardship is avoided and necessity is taken into account 5. justice and equity must always prevail the shariah is therefore a living, dynamic and relevant entity. it is for everyone, everywhere and for all times. it also describes itself as a guide, a light and a mercy6. it is this philosophy of the law which is alive to the contemporary challenges of advancing biotechnologies. i have chosen to illustrate this harmony and the relevance of the law to three areas of cutting edge biotechnology, namely: 1. reproductive human cloning 2. therapeutic cloning 3. genetic technology and human embryo research human reproductive cloning when man was experimenting with cloning in plants, frogs and small marine animals, the islamic organisation of medical sciences (ioms) based in kuwait, convened a seminar in 1983 in which 2 papers were presented which dealt with the potential of human cloning and the shariah perspective on this possibility. when the cloning of dolly the sheep by the technique of somatic cell nuclear transfer was announced in february 1997, the ioms in their 9th fiqh medical seminar updated their juristic opinion on this most contentious issue7. like the ioms, virtually every islamic seminar, jurisprudence council or individual scholars have concluded that cloning procedures aimed at producing human clones is not permissible. the majority considered it haram (not permissible) in all its details8. whilst a minority opinion considered in haram as a way to prevent a cause of harm (the human genetic and reproductive technologies 3 necessity to refrain from causing harm to oneself and others). this latter juristic opinion keeps open the option of readdressing the issue should new information become available and approved by shariah. the use of somatic cell nuclear transfer technology even between husband and wife was also not approved. the rationales for prohibition were as follows: a. the basic concept in reproduction is to abide by the shariah approved system of legally binding marriage, through the union of the sperm and ovum. b. human cloning is against the natural process (fitrah) of human relationship of marriage and reproduction c. the major harms far exceed the benefits. these include the disruption of lineage, family relationships and social fabric of humanity. d. the anticipated social, moral, psychological and legal implications of human copies. e. the possibility of interfering with the male-female population dynamics the ethics aside, the science of human reproductive cloning is not evidence based: 1. it is an inexact science – there were 277 attempts before dolly was possible. "even with mammals the risks are monumental let alone humans, it is criminally irresponsible" says ian wilmut, the "creator of dolly". failure rates are in excess of 98% 2. it is an inefficient technology abortion rates are 10x higher, stillbirth rates are 3x higher. natural reproduction is more efficient and … more fun. musa mn 4 3. unproven safety – dolly suffered from premature rheumatism and early death (she was “a sheep in lamb's clothings"). other abnormalities include large offspring syndrome, underdeveloped lungs, reduced immunity, and increased congenital anomalies. the list of misadventures increase by the day and which infertility expert or cloner is going to publish their failures! 4. besides it compromises the gene pool it reduces genetic variability and diversity. one virulent pathogen may be sufficient to wipe out the whole clone population. the national and international responses to the new technologies of human reproductive cloning have suffered a policy lull. eight years post-dolly, only a few countries have either drafted or enacted laws to bring human genetic and reproductive technology under responsible societal governance. as of november 2003, 77% of countries have not taken action to ban reproductive human cloning. malaysia is in the final stages of drafting laws to ban the reproductive cloning of human beings. apart from a small minority of “rogue cloners” there is an international consensus against the reproductive cloning of human beings. however the opportunity to elaborate an international convention to ban reproductive human cloning was lost when member countries disagreed on the extent of the ban. the usa and costa rica in the policy on un cloning treaty 2003, proposed a full ban on both reproductive and therapeutic cloning; whilst other member countries supported the belgium proposal for a partial ban that is to ban reproductive cloning and allow national discretion on therapeutic cloning. therapeutic cloning unfortunately, the confusion and disgust at the prospect of cloning and creating babies has been transferred to therapeutic cloning. in therapeutic cloning unlike human reproductive cloning the end point is not cloning a human being. this technology involves the production of human clonal embryos for the purpose of harvesting stem-cells, tissues and organs. this would open the potential of curing a whole host of chronic and debilitating diseases including diabetes mellitus, parkinsonism, myocardial infarction and spinal injuries. the source of the totipotent stem cells has however been a source of intense controversy. stem cells found in umbilical cord blood, bone marrow and aborted fetuses are generally acceptable from the ethical and moral point of view. though less plastic, scarce and sometimes quite inaccessible, there have been some success stories with the use of these non-embryonic stem cells. the use of embryonic stem cells (esc) is however fraught with highly charged religio-bio-ethical debate. the source of controversy revolves around the various questions about when life becomes a human life; namely: 1. is an ovum and sperm a person? 2. when do the products of conception become a person? 3. does a zygote have a full set of human rights? 4. does the foetus have a soul? this concept of personhood is neither logical nor empirical. it is based on one’s fundamental assumptions about the nature of the world. it is primarily a religious or quasi-religious concept. the roman catholics believe that the soul enters the body at conception and the fertilized ovum is a human person will full human rights. pope john paul ii, on 29 august 2000 said, “methods that fail to respect the dignity and value of the person human genetic and reproductive technologies 5 must always be avoided. i am thinking in particular of attempts at human cloning with a view to obtaining organs for transplants: these techniques, in so far as they involve the manipulation and destruction of human embryos, are not morally acceptable, even when their proposed goal is good in itself” the scientific paradigm defines the preembryonic stage as the period from fertilization up to the determinant of the primitive streak at the age of 14 days. the pre-embryo is unable to feel pain or pleasure and therefore has no moral status. they may be cryopreserved, discarded or used for research purposes. lord may of oxford, the president of the royal society said, “to cut off this research (without clear understanding of the science of therapeutic cloning and its potential to contribute to mankind) would be an act of intellectual vandalism comparable to papal censorship of galileo and copernicus.” the first verse revealed to prophet muhammad in the cave of hira’ translates as follows: “read! in the name of your lord, who has created. has created man from alaqa.” (96:1-2) this verse embodies two very significant messages. from the outset, the quran emphasizes the primacy of knowledge and follows this with the first lesson in embryology, the very creation of man himself. the quran is a book of guidance to invite mankind to the truth and salvation. but nonetheless it contains many “signs” which invites mankind to reflect upon his creation and the world that surrounds him. in various verses, it illustrates lucidly both the physical and spiritual dimensions of man’s creation. in chapter 23, verses 12-14, the quran says: “and indeed we created man from a quintessence of clay. then we placed him as a small quantity of liquid (nutfa) in a safe lodging firmly established. then we have fashioned the nutfa into something which hangs (alaqa). then we made alaqa into a chewed lump of flesh (mudgha). and we made the mudgha into bones, and clothed the bones with flesh. and then we brought it forth as another creation. so blessed be god, the best to create” the nutfa represents the blastocyst which embeds within the endometrium. the alaqa, much intrigued the distinguished embryologist, prof. moore who was puzzled at how 1400 years ago anyone could accurately describe it as something which clings to the inner uterine wall like a leech. the scholars of quran were similarly unable to explain the concept of mudgha until microsopy revealed that the chewed lump of flesh resembled accurately the appearances of the somites. and note how explicit the verses have been in illustrating that the ossification centres preceded the formation of the myotomes. in another verse the quran very clearly revealed another phase of man’s being, the process of ensoulment. “and breathe into him of his spirit” (32:9) the soul is a metaphysical concept which is fundamental in islam and it defines a human individual. the majority opinion in islam accepts the 120th day of pregnancy as the time of ensoulment. eventhough ensoulment occurs later; the embryo is respected from the onset of fertilization and acquires consideration as a human foetus after implantation. and based on these fundamental premises, at least three islamic fiqh (jurisprudence) councils have given permission for the use of surplus embryos from ivf laboratories for esc research9,10,11. however, it is not permissible at this juncture, to consciously musa mn 6 generate pre-embryos either by conventional ivf techniques or somatic cell nuclear transfer (scnt) for esc research. as at november 2003, 6 (3%) countries have allowed therapeutic cloning whilst 30 (16%) have prohibited it. the 6 countries in favour of allowing therapeutic cloning to proceed within stipulated policy guidelines are china, singapore, belgium, uk, cuba and usa. the federal embryo protection law (1990) of germany prohibits both reproductive and therapeutic cloning. this represents the spectrum of countries with “relatively restrictive” laws related to reproductive technologies. others include austria, the scandinavian countries, ireland, italy, netherlands, spain and switzerland. the other end of the spectrum is represented by the united kingdom’s human fertilisation and embryology act (1990) and human reproductive cloning act (2001) and singapore’s bioethics advisory committee (bac) report on “ethical, legal and social issues in human stem cell research, reproductive and therapeutic cloning” which was approved by the government on 18 july 2002. the uk and singapore “more permissive” regulations allows the generation of embryos by both ivf and scnt technologies if there is a demonstrable and exceptional need which cannot be met by the use of surplus embryos. the “in-between” policies are demonstrated by the canadian’s new assisted human reproduction act (2004) and australia’s research involving embryos act (2003). they both allow the utilization of surplus ivf embryos for research but prohibit the creation of human embryos for research and scnt for research and reproduction. the current thinking in our malaysian national committee on human cloning seems to favour this line of thought and legal framework; which is also resonates well with the fatwa issued by the three jurisprudence councils in jeddah, usa and jordan. region countries reproductive cloning research cloning igm prohibited prohibited allowed prohibited # # % # % # % # % africa 53 1 2% 1 2% 0 0% 1 2% middle east 23 1 4% 0 0% 0 0% 1 4% south asia / east asia / pacific 33 6 18% 3 9% 2 6% 5 15% europe eastern 24 14 58% 8 33% 0 0% 9 38% europe western 24 16 67% 13 54% 2 8% 8 33% americas & caribbean 35 8 23% 5 14% 2 6% 3 9% world 192 46 23% 30 16% 6 3% 27 14% except for israel, none of the nations in the middle east have taken legal action to regulate either reproductive or therapeutic cloning. as at 6 november 2003, bahrain, iran, jordan, kuwait, lebanon, oman, pakistan, qatar, saudi arabia, syria, uae and yemen voted in favour of iran’s motion on the un cloning treaty process, to postpone further discussions for another 2 years. this is illustrated in the table above. human genetic and reproductive technologies 7 previously it was thought that it would be extremely difficult to develop comprehensive policies to govern human genetic and reproductive technologies. despite the earlier skepticism, various countries have now shown that it is possible to break the policy deadlock and draft legislation to regulate these new technologies of human genetic modification. despite their different political and social experiences, some of the national policies thus available have exhibited a remarkable sharing of core principles; namely: a. they affirm technologies with a real chance of preventing or curing disease b. they ban technologies which could harm children or open the door to free market eugenics c. they ensure research involving embryos is tightly regulated d. they establish publicly accountable means to review policies & make new ones e. they pose no risk for reproductive rights probably one of the most far reaching thoughts on this highly controversial issue of esc research has been that propounded by sheikh dr. yusuf al-qardawi, a highly respected and contemporary muslim scholar who related in his concluding remarks after a lengthy juristic deliberation the following position12: “if it becomes possible through research to clone organs such as the heart, liver, kidneys or others which may benefit those who are in dire need of them; then this is permitted by religion and the researcher or scientist will receive the reward from allah. this is because the research will confer benefit on humanity without loss to others or infringing upon them. therapeutic cloning with this noble research pursuit is permissible and it is encouraged. in fact, in some circumstances, it may become mandatory to enhance this research in accordance with the need and man’s research capability and accountability.” the following diagram illustrates the extreme potential for therapeutic cloning, with virtually zero risk of graft versus host disease (gvhd), with the option of either de-differentiation of the patients’ indigenous stem cells or utilizing somatic cell nuclear transfer technology to generate embryonic stem cells. genetic technology and human embryo research two hadiths (authentic traditions) related from the prophet has helped us to have a better insight into the science of genetics. “select your spouses carefully in the interest of your offspring because lineage is a crucial issue” “do not marry your close relatives because you will beget weak offsrpings” the second caliph of islam, omar ibn elkhattab, upon noting that a particular tribe intermarried with increased frequency, remarked to them: “you have weakened your descendants. you should marry strangers (people outside your tribe)”. the spirit of the exhortations of the prophet saw and his companion was to secure normal and healthy babies, protection of their early well being, endowed with the benefits of good genes from both parents and the prevention of congenital malformations and its consequent disabilities. a variety of inherited diseases may now be diagnosed in the pre-embryo stage prior to implantation into the uterus. highly sensitive polymerase chain reaction (pcr) techniques have enabled the rapid amplification of minute amounts of dna material from the embryonic cells. musa mn 8 fluorescent in situ hybridization (fish) technologies with combination chromosomal probes have made possible the genetic analysis of embryonal sex and various aneuploidies13. some of the potentially debilitating diseases which may be screened include trisomy 13, 17 and 21, cystic fibrosis, haemophilia, marfan’s syndrome, incontinentia pigmentosa, x-linked immune deficiency, retinitis pigmentosa, fragile x syndrome, muscular dystrophy and leschnyhan disease. the first preimplantation genetic diagnosis (pgd) was achieved in 1989. since then, well over 200 diseases or conditions has been further isolated with ongoing pgd research14. the first international conference on bioethics in the muslim world held in cairo from 10-13 dec 1991 examined very human genetic and reproductive technologies 9 carefully this area of pre-embryo research15. collaborating this with the decisions of other scientific cum islamic jurisprudence seminars, the following practice guidelines may be summarized: 1. cryopreserved pre-embryos may be used for research purposes with the free and informed consent of the couple. 2. research conducted on pre-embryos is limited only to therapeutic research. genetic analysis of pre-embryos to detect specific genetic disorders is permissible. hence diagnostic aids should be provided for couples at high risk for selected inherited diseases. the treated embryo may only be implanted into the uterus of the wife who is the owner of the ova and only during the span of the marriage contract. 3. any pre-embryos found to be genetically defective maybe rejected from transfer into the uterus after proper counselling by the physician. 4. research aimed at changing the inherited characteristics of pre-embryos (e.g. hair and eye colour, intelligence, height) including sex selection is forbidden. 5. sex selection is however permitted if a particular sex predisposes to a serious genetic condition. one of the first couple to use the technique of sex selection was hoping to escape a neurologically debilitating disease known as x-linked hydrocephalus, which almost always affected boys. embryonal sex selection would make possible the weeding out of other serious x-linked disorders including haemophilia, duchenne muscular dystrophy and fragile x syndrome. 6. the free informed consent of the couple should be obtained prior to conducting any non-therapeutic research on the preembryos. these pre-embryos should not be implanted into the uterus of the wife or that of any other woman. 7. research of a commercial nature or not related to the health of the mother or child is not allowed. 8. the research should be undertaken in accredited and reputable research facilities. the medical justification for the research proposal must be sound and scientific and conducted by a skilled and responsible researcher. the designer baby technology or inheritable genetic modification (igm) has further accentuated the ethical debate often referred to as “slippery slope” issues. the world’s first true designer baby, nash brown, was born on 29 august 2000. he was conceived specifically for the sake of his six year old sister, molly who suffered from fanconi’s anaemia. his umbilical cord blood was transfused into molly, with the hope of curing her condition. another landmark case was in the uk in 2001, where a british couple was given the go ahead by the courts to select an ivf baby who is thalassaemia free and has a tissue make-up which precisely match their son zain who suffers from thalassaemia and does not have a compatible donor. umbilical cord blood from the ivf baby would be transplanted into zain to cure his thalassaemia. the table shows that only 27 (14%) countries have taken action to ban the creation of designer babies. conclusion islamic medical bioethics is firmly grounded on the fundamental tenets of the islamic shariah. the close collaboration between the scholars of jurisprudence and the scientific and medical fraternity has enabled her to keep abreast of the plethora of advancing biotechnologies. despite the wide ranging bio-religioethical problems and dilemmas posed by these emerging biotechnologies, islamic medical bioethics, has provided a “middle of the road” approach moderating between the extremes of conservatism and liberalism. this it does without impeding musa mn 10 the genuine and responsible quest for new knowledge and breakthroughs in new research frontiers. it has provided a legal framework for responsible societal governance of human genetic and reproductive technologies and banned all forms of free market eugenics. allah says in chapter 2, verse 143: “thus we have appointed you a middle nation, that you may be witness against mankind, and that the messenger maybe witness against you …” ______________ references 1. schacht, joseph. an introduction to islamic law. reprinted 1966, 1971:1. 2. ash-shafi’i; al-umm, 1993, vol. 7:492-494; ramadan, islamic law, 1970:33; madkour, almadkhal, 1966:90,196. 3. ash-shatibi, al-muwafaqat, 1975, vol. 2:10. 4. borno, al-wajiz, 1998, pp8,63. 5. madkour, al-madkhal, 1966:12-20. 6. al-quran 5:44-46. 7. recommendations of the 9th fiqh-medical seminar; islamic organisation of medical sciences. 8. aly a. mishal. cloning and advances in molecular biotechnology. fima year book 2002, pp 38. 9. the council of islamic fiqh academy of the muslim world league. 2003; 17th session in makkah, 13-17 december. 10. fiqh council of north america, international institute of islamic thought, graduate school of islamic and social sciences, islamic institute news release august 27, 2001. 11. aly a. mishal. stem cells: controversies and ethical issues. jordan medical journal. may 2001; 35(1) pp 80-82. 12. yusuf al-qardawi. hadyul islam fatawi mu’athirah. darul qalam kuwait 2001. translated gema insani press, october 2002. 13. grifo ja,et al. update in preimplantation diagnosis. advances and problems. current opinions obstet gynae 8:135-138. 14. fact sheet: preimplantation genetic diagnosis. american society for reproductive medicine. dec 1996. 15. serour gi. proceeding to the 1st international congress on bioethics in human reproduction research in the muslim world. iicpsr 1992 vol ii. ______________ microsoft word final_bjms_jan_2011 bangladesh journal of medical science vol.10 no.1 jan’11 1. *mm rahman, phd (india), postdoc. virology (taiwan); 2. wk ken, msc medical microbiology (ukm); 3. mr norzuriza, bsc technology biomedical (um); 4. i isahak, md, msc medical microbiology (uk); 5. ss azura, md, mpath (microbiology) (ukm); 6. mn tzar, md, mpath (microbiology) (ukm); department of medical microbiology and immunology, medical centre, faculty of medicine, university kebangsaan malaysia, cheras-56000, kuala lumpur, malaysia. *corresponds to: dr. mm rahman, department of medical microbiology and immunology, university kebangsaan malaysia, medical centre, cheras-56000, kuala lumpur, malaysia. email: mmr@ppukm.ukm.my, mostabau@yahoo.com. original article scenerio of hiv patients reported to university kebangsaan medical centre during 2006-2009 rahman mm1, ken wk2, norzuriza mr3, isahak i4, azura ss5, tzar mn6 abstract objective: a study was undertaken to identify the hiv-positive cases from suspected patients reported to university kebangsaan malaysia medical centre (ukmmc) from january, 2006 to december; 2009. methods: cases were identified and confirmed by three established sero-diagnostic tests: micro particulate enzyme immunoassay, passive particle agglutination test and line immunoassay. results: a total of 256 hiv positive patients were identified and highlighted about their age, sex, ethnic origin and year wise distribution of cases. frequency distribution of hiv-positive cases among different age groups indicated that, 144 (%) were aged between 21 to 40 years, 81 (%) were aged 41 to 60, 19 (%) were aged above 60 and 12 (%) were in the age group of 0-20 years. it revealed that the highest number of hiv-positive patients was in the age group of 21-40 years. among the 4 groups of people living in malaysia, hiv infection was found more in chinese community (101), followed by malaya community (97), other community (sikhs, tribes, foreigners) living in malaysia (30) and indian community (28). a total of 179 male and 77 female were positive for hiv infection. monthly records of case detection indicate more or less similar prevalence pattern throughout the study period. conclusions: it reveals from the report that the malysian patients are mostly infected at the adulthood unlike other countries where majority of infections occur in young age .a high percent of hiv infection in males in the country indicates that they might played a vital role in carrying and disseminating infectiions to their female parterners. keywords: hiv/aids, sero-diagnosis, socio-demographic profile, malaysia. introduction human immunodeficiency virus (hiv) is a member of the retroviridae family causes acquired immunodeficiency syndrome (aids). the virus produces a condition in humans in which the immune system begins to fail, leading to life-threatening opportunistic infections. infection with hiv occurs by the transfer of blood, semen, vaginal fluid, pre-ejaculate, or breast milk. within these bodily fluids, hiv is present as both free virus particles and virus within infected immune cells. the four major routes of transmission are unsafe sex, contaminated needles, breast milk, and transmission from an infected mother to her baby at birth (perinatal transmission). screening of blood products for hiv has largely eliminated transmission through blood transfusions or infected blood products in the developed world.1 hiv infection in humans is considered pandemic by the world health scenario of hiv patients 22 organization . from its discovery in 1981 to 2006, aids killed more than 30 million people.2 each minute, five new persons get infected with hiv, and the virus kills young people, found in their productive period. about 3.3 million people with hiv die annually. sixty eight million people could die from 2000 to 2020. in developed world, 58% of the new cases are drug addicts who share syringes, and 33% are infected through unprotected sexual contacts, but in undeveloped countries, it is mainly transmitted through unprotected sex and blood transfusions.28 million of the hiv infected people are found in africa and 0.5 million in western europe; 300,000 in eastern europe, 600,000 in eastern asia and oceania; 2.6 million in america.3 world health organization (who) released their annual figures for world aids day in 2009. they said that at the end of 2008 there were 33.4 million people living with hiv. in 2008 there were 2.7 million new infections and 2 million hivrelated deaths. the vast majorities of hiv infected people, more than 30 million, live in low and middle-income countries; according to the world health organization.4 most untreated people infected with hiv eventually develop aids. these individuals mostly die from opportunistic infections or malignancies associated with the progressive failure of the immune system. hiv progresses to aids at a variable rate affected by viral, host, and environmental factors; most will progress to aids within 10 years of hiv infection: some will have progressed much sooner, and some will take much longer.therefore ,it is prerequisite to identify the virus at the early stage of infection so that proper antiretroviral therapy can be given to the patients5 the present research article is aimed at to identify the samples collected from suspected hiv patients and highlighted the scenario of the patients: age, sex, and community and year wise distribution. materials & methods specimen collection: blood samples collected from the suspected patients during january 2006 to december, 2009 reported to ukm medical centre were immediately sent to the laboratory of the department of medical microbiology & immunology, faculty of medicine, national university malaysia, cheras56000, kuala lumpur, malaysia. ethics approval: it has been approved by the ethics committee of the medical faculty and hospital. samples processing: all the samples were kept for sometime for clotting and sera were collected in vials after centrifugation and then used in the following test proper: test 1: micro particulate enzyme immunoassay (meia) the test was performed with the kits of abbott axsym system hiv ½ go ref3d41-22, b3d4a0, 36-63881/r3. the kits were provided with :antibiotin(rabbit) alkaline phosphatase, conjugate in tris buffer, hiv-1 and hiv-2 antigen coated microplates in tris buffer, biotinylated hiv-1 and hiv-2 antigens in tris buffer, specimen diluent in tris buffer and positive and negative control of hiv-1 and hiv-2 antigens. the test was performed as per the method described by the manufacturer.6 the presence or absence of antibodies tohiv-1 and or hiv-2 in the samples is determined by comparing the rate of formation of fluorescent product to the cut off rate which is calculated by axsym hiv-1/2 index calibration. the rate of formation of fluorescent product in the sample is grater than or equal to the cutoff rate, the sample is considered reactive for anti-hiv. mm rahman, wk ken, mr norzuriza, i isahak, ss azura, mn tzar 23 test 2: passive particle –agglutination test for detection of antibodies to hiv-1 and or hiv-2 the test was performed as per the procedure described by serodiahiv1/2. the kits contain sample diluent, hiv sensitized particle, hiv-1 sensitized particles, hiv-2 sensitized particles, unsensitized particles and positive control. agglutinated particles spread out covering the bottom of the well uniformly considered positive. specimens showed inconclusive results were retested. test 3: inno-lia hiv 1/2 score: line immunoassay (lia) the test was performed as per the procedure described in the kits of innogenetics (biotechnology for healthcare): the test confirmed the presence of hiv1/2 in the specimens if found discrepancy of the above two tests. figure-1: month and year wise scenario of hiv positive cases during january 2006-december 2009 figure-2: scenario of hiv positive cases in different age groups during january 2006-december 2009 12 144 81 19 0 20 40 60 80 100 120 140 160 0‐20 21‐40 41‐60 >60 14 8 4 4 5 7 3 6 5 4 12 4 3 4 3 7 3 5 5 4 3 4 2 8 10 2 3 4 3 12 11 5 5 3 2 5 8 5 4 5 3 5 3 5 7 3 11 5 0 2 4 6 8 10 12 14 16 ja n‐ 06 a pr ‐0 6 ju l‐0 6 o ct ‐0 6 ja n‐ 07 a pr ‐0 7 ju l‐0 7 o ct ‐0 7 ja n‐ 08 a pr ‐0 8 ju l‐0 8 o ct ‐0 8 ja n‐ 09 a pr ‐0 9 ju l‐0 9 o ct ‐0 9 mm rahman, wk ken, mr norzuriza, i isahak, ss azura, mn tzar 24 results and discussion during the period of january 2006 to december 2009 a total number of 256 specimens were confirmed for hiv infection from the samples those were suspected to analyze for the purpose. it was observed from the scenario of hiv infections from monthly data of the laboratory that the prevalence of hiv infection starting from january 2006 to december 2009(fig-1) going on in a same patterns with a little variation in different months. therefore, hiv infection due to seasonal variation has little or no impact. it is observed from the figure that the prevalence of the infection tended to declined at the end of december, 2009.it might be due to creation of awareness among the people due to mass media propaganda for the fatal effect of hiv and aids. due to paucity of published reports of seasonal effect on hiv infection our data generated in the present study could not be compared. malaysian aids council and aids foundation7 reported from the surveillance data on hiv and aids and mentioned that a total 86,127 hiv infections were reported to the ministry of health, malaysia up to june 2009. the council reported that in malaysia, the first hiv case was reported in 1986. since then, the number of cases continued to increase with the highest number recorded in 2002 at 6,978 a notification rate of 28.5 cases per 100,000 populations. there was a decrease in the number of hiv cases in the year 2003 where 6,756 cases were reported and that were less than the record of 2002. the number and rate of notification continued to decrease to 13.3 cases per 100,000 populations (3,692 cases) in 2008. the period between january and june 2009, a total of 1,497 hiv cases were reported. the ministry of health forecasts that until the end of 2009, the estimated rate of hiv notification would be 10.0 cases per 100,000 populations in malaysia. 7 the present study correlates with the above report, it reveals from the fig-1 that at the end of december 2009 a declining trend of hiiv prevalence was observed. figure-3: scenario of hiv positive cases in different community during 2006-2009 97 101 28 30 0 20 40 60 80 100 120 malay c hinese indian others scenario of hiv patients 25 hiv positive samples were classified according to different age groups (fig-2). it was observed from our results that out of 256 patients’ samples those were proved to be positive for hiv infections 144 were aged between 21 to 40 years, 81 were aged 41 to 60, 19 were aged above 60 and 12 were in the age group of 0-20. it reveals (fig-2) that the highest number of patients(144/256) showing hiv infection in the age group of 21-40.this scenario gives an idea about the vulnerable ages for the picking up of hiv infections in malaysia. the present report agrees with the recently published report of global fact book.8 in the report it was observed that during 2009 and 2010 among the hiv and aids affected patients 50% were adult (aged 15-49).the adult prevalence rates of hiv and aids were 23.9% in botswana, 23.2% in lesotho, 18.1% in south africa, 15.3% in zimbabwe and 15.3% namibia. comparing the above reports high rate of hiv infections are recorded in adult population in malaysia. figure-4: scenario of hiv positive cases in male and female during 2006-2009 a report from international aids conference held at vienna july, 2010 pointed out that in thailand 22% of men were hiv-positive at baseline but were generally unaware of their infection. after three years of study, another 135 men had acquired hiv. in a 12-month period, the annual rate of hiv acquisition (incidence) was 5.9 per 100 person years. this did not vary between years 1, 2 or 3 of the study. the mean age at sero-conversion was 26.4, and the median was 26. “this means that 50% of the men who became infected during follow-up were younger than 26 years, and they observed a quite large number of cases where men got infected when they were 18 or 19 years of age. in the report men were found to be the most vulnerable to infection when they were younger – men who did not acquire hiv at a young age were less likely to acquire it when they are older. in the study they pointed out that prevalence relates to an infection acquired at any time in the past, so older men were more likely to have prevalent hiv. a man aged 30 or over was three times more likely to have prevalent hiv than a man aged 18 to 21.on the other hand, incidence refers only to newly acquired infections. a man aged 18 to 21 was also almost three times more likely to have incident hiv than a man aged over 309. hiv infections scenario in terns of community during 2006 to 2009 has been presented in fig-3.it reveals from the results that among the 4 groups of people living in malaysia hiv infection was found more in chinese community (101), scenario of hiv patients 26 next is malaya community (97) next other community (foreigners) living in malaysia and lowest the indian community (28).the highest prevalence hiv infections in the chinese community might me due to their adaptation with western life style. on the other hand, the malay community is muslims and most of them are practicing which prevents them to pick up hiv infections. however, the present report varied from the statistical data of malaysia from 1986 to 2008 where malaya community was the highest recorded hiv and aids sufferers.7 henry bauer10 described hiv infection relating to community and race discrimination of hiv is unique, not only as an infection that discriminates by race; it’s unique as a sexually transmitted infection that discriminates by race. he mentioned that no other sexually transmitted infection has managed to be quarantined geographically and racially in this way. the evidence is simply overwhelming: from every tested social group, high-risk as well as low-risk; from every part of the world; for both sexes and at all ages—wherever “hiv” tests are reported separately by race in any given sample, the tendency to test “hiv”positive is paralleled by racial ancestry. in another report from usa on adults and adolescents those were diagnosed of hiv/aids in the 34 states with confidential name-based hiv infection reporting, 50% were black/african american, 29% were white, 18% were hispanic/latino, 1% each were asian and american indian/alaska native, and less than 1% were native hawaiian/other pacific islander.11 reports on the racial affiliation of hiv infections are described above are inclusive; it depends on the sexual habit and awareness. it is observed from fig 4, out of 256 samples found positive during 2006 to 2009, hiv positive infections were 179 male and 77 female in different age groups. it is observed from the fig 4 that male might have played a vital role for carrying hiv infection and disseminating it to the female partner. more than half of women who have hiv got the infection from sexual partners. a woman can be infected by contact with a man or contact with another woman. when a woman has sex with an infected man, she has a high risk of getting hiv if a condom is not used properly.12 in malaysia hiv infections occur mostly in intravenous drug users 7 and almost all drug users are male, this might be the reason of being higher prevalence of hiv infection in male than female. in our report though female are less infected by hiv, however, report of michel sidibé, executive director of unaids11 mentioned that aids ‘this epidemic unfortunately remains an epidemic of women.” he also mentioned that at the end of 2008 it was estimated that out of the 31.3 million adults worldwide living with hiv and aids, around half are women. it was mentioned that 98 percent of these women live in developing countries the aids epidemic has had a unique impact on women, which has been exacerbated by their role within society and their biological vulnerability to hiv infection. in his report it was also pointed that generally women are at a greater risk of heterosexual transmission of hiv. biologically women are twice more likely to become infected with hiv through unprotected heterosexual intercourse than men. in many countries women are less likely to be able to negotiate condom use and are more likely to be subjected to nonconsensual sex. in malaysia hiv transmission occurred by intravenous drug users during 1986 to 2008 were 58, 1358.7 it is the highest transmission source next to heterosexual mm rahman, wk ken, mr norzuriza, i isahak, ss azura, mn tzar 27 transmission. in a report from the government agency pointed out that malaysia is poised to achieve the “millennium goal” set by the united nations of stopping the spread of hiv/aids and reducing infant and mother mortality by the end of the decade. in a recent report malaysia has recorded a significant drop in the number of hiv cases due to the government's implementation of various initiatives and awareness programmes14. in a report14 it is mentioned that malaysia recorded a significant drop last year as 3,080 cases per 100,000 population were recorded (10.8%) compared with 21.7% in 2000 based on the millennium development goals (mdg) report. the report added that though the target of mdg was to reduce the number of new hiv cases to 11% per 100,000 population by 2015, malaysia has been able to achieve that target six years ahead.the government, through government agencies and non governmental organisations had carried out 55 medium and long term hiv and aids awareness programmes over the past five years, she mentioned that of 2009, 87,710 hiv cases reported, in which, 74,316 were still alive, 15,317 or (17.5%) are aids cases while 13,394 (15.3%) have died. total number of infected cases were malays topped the list with 62,953 cases, chinese (12,887), indians (6,929), bumiputra sarawak (2,200), bumiputra sabah (630), others (478), foreigners (1,298) and the of 535 cases has yet to be determined.14 the present paper highlighted the scenario of hiv positive patients reported to ukmmc based on laboratory detection of hiv. the detection was confirmed by three tests, if any discrepancies occurred in 1st and 2nd tests then 3rd test was performed to be reconfirmed. it reveals from the report that the malaysian patients are mostly infected at the adulthood unlike other countries where majority of infections occur in young age that are carried to adulthood period. it is expected that recent awareness created by malaysian government may help reduce the number of hiv and aids cases in the forthcoming years. authors contribution all the authors worked in a team to formulate, execute and finalized the research works. ethical approval the laboratory of the department of medical microbiology & immunology is an accredited laboratory for the diagnosis of diseases from the samples received from the university kebangsaan malaysia medical centre, ukm, malaysia. therefore it does not need separate approval from ethical committee. ______________ scenario of hiv patients 28 references 1. http://en.wikipedia.org/wiki/hiv:human immunodeficiency virus. accessed on december, 22, 2010. 2. hiv and aids sharing knowledge, changing lives.2010. (http://aidsmap.com/en/email-afriend/tpl/1412195/page/1494731/hiv. accessed on october, 12, 2010. 3. softpedia.2010. http://news.softpedia.com/news/top-10-viralinfections-83189.shtml. accessed on october, 8, 2010. 4. afp: 2010. researchers develop treatment for hiv that kills infected cells. http://www.jamaicaobserver.com/news/researc hers-develop-treatment-for-hiv-that-killsinfected-cells_7932372. accessed on october 10, 2010. 5. medicinenet.com. http://www.medicinenet.com/human_immunode ficiency_virus_hiv_aids/article.htm. accessed on december22, 2010. 6. abbot.2010.microplate enzyme immunoassay for the detection of antibodies to hiv-1/hiv-2. http://www.abbottdiagnostics.com. accessed on september, 20, 2010. 7. malaysian aids council and aids foundation.2009. http://www.mac.org.my/statistics.htm. accessed on october 9, 2010. 8. cia-world fact book cia. 2010. hiv/aids adult prevalence rate. https://www.cia.gov/library/publications/theworld-factbook/fields/2155.html-world fact book. accessed on october 10, 2010. 9. namaidsmap.2010.three years of follow-up in the bangkok msm cohort: evidence of an explosive epidemic of hiv infection. eighteenth international aids conference, vienna, abstract tuac0301, 2010. 10. henry bauer. 2008. hiv: a racediscriminating sexually transmitted virus! http://hivskeptic.wordpress.com/2008/04/16/hiv. accessed on october, 9, 2010. 11. cdc hiv and aids facts. 2009. http://img.thebody.com/cdc/pdfs/raceethnicity_12.pdf. accessed on october 10, 2010. 12. family doctor. 2010. http://familydoctor.org/online/famdocen/home.h tml 13. michel sidibé, executive director of unaids (http://www.avert.org/women-hiv-aids.htm). accessed on october 8, 2010. 14. the dewan rakyat, thursday october, 2010, http://thestar.com.my/news/story. accessed on october, 9, 2010. ______________ bangladesh journal of medical science vol.09 no.4 oct’10 1. *shafiqur rahman, phd candidate, macquarie university, sydney. 2. sadia jahan, financial analyst, sydney. 3. nicholas mcdonald, management consultant, sydney. *corresponds to: shafiqur rahman, phd candidate, macquarie university, sydney. email: rahmanbangladesh@yahoo.com. original article csr by islami bank in healthcare – stakeholders’ perception r shafiqur1, j sadia2, m nicholas3 abstract background: in the bangladesh society, a few organizations are contributing through their activities on corporate social responsibility (csr). it is a general belief that the contribution of islami bank bangladeshi limited in csr is highest among the financial institutions. it is an observation that ibbl’s csr contribution in the healthcare sector is very significant. objective: this paper explores the stockholders’ perception of csr contribution in the healthcare sector by islami bank bangladesh limited (ibbl). method: authors used qualitative approach in doing the research. data were collected through a survey. likert scale was used to explore the significance of stakeholders’ perception. results: this paper reports the findings of a qualitative study on perceptions of csr by ibbl in the healthcare sector of a heterogeneous group of stakeholders. the findings reveal the perception of stakeholders towards the social contribution of islami bank central hospital (ibch), an institution for csr in healthcare by ibbl. the stakeholders believe that this hospital is significantly contributing to the society through its support in the healthcare sector. it is also found that the hospital is proactive in providing healthcare support to the community through its highly standard human resources, world class medical equipment, outstanding management team and superb customer care support. conclusion: this exploratory study makes a contribution to the relatively new body of work on csr in bangladesh, especially in the healthcare sector by ibbl and hopefully will encourage further research on the topic. this study will also contribute to improve the governance, social, ethical, and environmental conditions of the healthcare sector. key words: corporate social responsibility (csr), healthcare sector, stakeholders’ perception. csr by islami bank in healthcare – stakeholders’ perception while a huge work has emerged during the past three decades on corporate social responsibility (csr), the focus has been generally given on csr in developed countries.1 literature on csr is bangladesh is limited. in this paper, the authors explore the perception of the stakeholders of csr by the islami bank bangladeshi limited (ibbl) during 2009 through a pilot study. for the purpose of this paper, “csr in developing countries” has been defined, borrowing from visser at el2 as follows: “the formal and informal ways in which business makes a contribution to improving the governance, social, ethical, labour and environmental conditions of the developing countries in which they operate, while remaining sensitive to prevailing religious, historical and cultural contexts”. a number of businesses in bangladesh are contributing in healthcare csr, but the csr activities performed by ibbl in the healthcare sector seem to be the most significant. ibbl is addressing the social concerns in the healthcare sector targeting the poor and middle income people of bangladesh. shafiqur r, sadia j, nicholas m 209 the first part of the paper provides the research context through a brief profile of bangladesh; the second part provides a brief literature review to determine what is known about csr in bangladesh, and the third part discusses the main findings of the study carried out in 2009 to explore the perceptions of a divers group of stakeholders of bangladeshi citizens in relation to csr activities of ibbl. research context: bangladesh bangladesh, with an area of 147,570 sq km, is a small south asian country which borders the bay of bengal, burma and india. 83% of bangladeshis are muslims, 16% are hindus, and 1% from other religions and ethnic groups.3 described as one of the most densely populated country in the world,4 bangladesh has a population of 160 million.5 according to bangladesh bureau of statistics6, 12,797,394 people live in the capital, dhaka. bangladesh has an average gdp of approximately 5.7%7 mainly generated through its sizeable service sector. improved economic performance bangladesh has been gradually shifting towards parliamentary democracy since 1990s, which prompted an increasing adoption of market economy principles and the rise of a private sector. “a private sector-led industrial development policy is being aggressively pursued with the aim of attracting as much foreign investment as possible”.8 this has led to amazing improvements in the economic performance of bangladesh over the past two decades. investments have grown from an average of us$ 5 million during 1985-1995 to us$ 460 million in 2004, can be a good example. also bangladesh’s export earnings rose from us$ 1994 million during 1991/1992 to us$ 8655 during 2004/2005.9 social, environmental and ethical issues in bangladesh having all the successes described above, child labour, equal opportunity and occupational health and safety are key issues of concern in the garment and textile sector.10 the majority of its employees are female and they are mostly forced to work 12 hours a day with one day’s holiday a month and have mandatory overtime requirements. they are also subject to pregnancy tests and subject to undignifying body search at the entry and exit point of the factory. they further points out that, due to neglect of health and safety rules in workplaces, hundreds of workers have been killed in the last few years as a result of fire incidents. the economic growths in bangladesh in recent times have also generated severe environmental problems, particularly in urban and industrialized areas. for example, industrial pollution is a serious environmental issue in the capital city of the country, and the buriganga river “has been declared ‘clinically dead’ because of the unscrupulous discharge of industrial wastes and effluents.”11 it is pointed out in a report12 that environmental degradation negatively impacts on poor households, as they are heavily dependent on natural resources and thus particularly exposed to environmental risks. the report concludes that bangladesh is: …highly vulnerable to the projected impacts of climate change, which will increase the already high risk of disasters, exacerbating existing vulnerabilities both to flooding and drought, and threatening agricultural productivity in coastal areas that face increasing salinity. the bangladeshi government has not been successful to provide an effective regulatory mechanism to address this country’s social and environmental problems, which has led to the emergence of an increasing number of pressure groups csr by islami bank in healthcare – stakeholders’ perception 210 demanding greater accountability and transparency by local industries.13 there has also been pressure at an international level on domestic export-oriented companies who are operating as suppliers of large multinationals to adopt international labour standards and conduct their business in a responsible manner both socially and environmentally. as a result, the ground has been paved in bangladesh for a stronger commitment to csr which will hopefully lead to a widespread adoption of csr principles in coming years. the banking sector in bangladesh is comparatively doing better in terms of csr than any other sectors due to its financial ability and strong regulatory control. especially ibbl has gone far than any other the financial institutions in bangladesh and this study has explored the perception of the healthcare stakeholders of ibbl, which we explained below. however, before we go for the study, we present here what is known about csr in bangladesh. what we know about csr in bangladesh most csr studies conducted on bangladesh focus on csr reporting practices, where belal has played the role of a prolific author on this topic.14 his work can be traced back to 1999 when he published the findings of a study which examined csr reporting patterns in bangladesh, where he found that 90% of the companies studied made environmental disclosures; 97 % made employee disclosures and 77 % made ethical disclosures. however, sobhani15 expressed this study as “superficial and incomplete” because it provides only brief commentary on csr practices in bangladesh. in a later study focusing on annual reports published by large companies, belal16 found that from a sample of 30 reports produced by companies listed on the dhaka stock exchange and in the directory of dhaka’s metropolitan chamber of commerce, majority of them made social disclosures, but only a small amount of information was provided, and this information was of a descriptive nature. he summarises that the reasons for this were: lack of statutory requirements for social disclosures; the existence of very few organized social groups; very little social awareness; underdeveloped corporate culture, and the existence of a relatively new stock market in bangladesh. sobhani et al17 carried out a content analysis of 100 companies listed on the dhaka stock exchange and chittagong stock exchange, based on the work of belal18. sobhani et al looked into csr in relation to human resource; consumer and product; community; environmental and “general” and found that the “status of disclosure has improved over the last ten years”. the findings of belal and owen19 echo with those of islam and deegan’s,20 which also examined social and environmental reporting practices in bangladesh in the context of a major garment export company. they conclude that stakeholders play a significant role in driving the industry's social policies and related disclosure practices in that country. in a more detailed manner, quazi and o’brien21 carried out a comparative study to develop a “two-dimensional model of corporate social responsibility” and test its validity in the context of a developed nation (australia) and a developing nation (bangladesh). the two dimensions of the model were the span of corporate responsibility and the range of outcomes of social commitments of businesses. naeem and welford22 investigated levels of awareness in relation to csr within the context of sustainable development in bangladesh and pakistan, in another comparative study. shafiqur r, sadia j, nicholas m 211 we can finally draw a conclusion from this literature review that, albeit in its early stages, csr is already present in the collective consciousness of the bangladeshi’s business community. though csr is done by the multinationals due to the practice by its parent companies, local companies including the local financial institutions are also participating csr in an increased manner nowadays. the next section will contribute to a better understanding of how csr is perceived in bangladesh by presenting the findings of a qualitative study on the perception of the stakeholders of csr by islami bank in the healthcare sector carried out in dhaka in 2009 exploring the views of a diverse group of stakeholders in relation to csr. csr by ibbl in healthcare: stakeholders’ perception: the study methodology this pilot study was carried out in dhaka, bangladesh during 2009 on the stakeholders’ perceptions of csr by ibbl in healthcare sector. the study had a qualitative design, which enabled the researchers to obtain richer data, and a deeper understanding of the stakeholders’ perception through an investigation. in this study, non-random sampling method was used, which means that the researchers deliberately sought out a given population (in this case, the authors identified the stakeholders through convenience sampling). the professional networks of one of the researchers were used to recruit the participants from a csr workshop held at a local private university in dhaka, bangladesh. the survey was participated by 37 (21 male and 16 female) stakeholders (associated with ibbl’s csr in the healthcare sector); 20 of them were direct beneficiaries; 3 social scientists; 4 journalists; 4 employees (of islami bank hospital); 2 environmentalists and 4 community members. it should be taken into account that there could be a significant level of self-selection in these samples, as it is likely that the respondents attended the said workshop because of their interest in csr. the survey was divided in two parts: the first contained three questions designed to explore the participants’ understanding of the notion of csr by ibbl in healthcare sector. it contained the following questions: 1. what is your overall perception of corporate social responsibility (csr) by ibbl in the healthcare sector? 2. what are the areas, ibbl can improve its csr in healthcare? 3. what are the strengths of csr activities by ibbl you noticed so far? the second part of the survey used a likert scale, ranging from “strongly agree” to “strongly disagree”, to identify numerical patterns in the respondents’ reactions to the following statements: 1. ibbl is playing a very significant role in csr through its contribution in the healthcare. 2. it is just a public relations exercise to make ibbl look good. 3. csr by ibbl goes against the bank’s business interests because it reduces the company’s profit margins. 4. csr by ibbl in the healthcare is really addressing the social concerns. the purpose of the second part of the survey was to obtain further information on the respondents’ perceptions of csr by ibbl in the healthcare sector and associated principles and concepts, to supplement the information provided in the first part. the section below explores the stakeholders’ perception of csr on ibbl’s contribution and its impact in the society. csr by islami bank in healthcare – stakeholders’ perception 212 perception of csr by ibbl in the healthcare sector there were a variety of views regarding the csr activities by ibbl in the healthcare sector and most of them are very positive, which indicate ibbl’s commitment to the society. a few examples are given below: a) i am personally benefited by the low cost [and good quality] treatment at islami bank central hospital (ibch), which otherwise, i would not be able to afford. i broke my leg last year and i am fully cured now. i appreciate this kind of csr activities by ibbl (r1, male, beneficiary). b) my daughter got operated at the islamic bank central hospital; she is in good health now. they got a caring team of healthcare professionals. i am grateful for having the opportunity for good medical treatment provided by ibbl (r5, female, beneficiary). c) csr activities of ibbl are noticeable in the bangladesh media. however, the bank can concentrate on more media presence as it is doing enormous csr activities in the healthcare sector (this would encourage other organisations to do csr). (r12, male, journalist). the above views against the 1st question reveal that the stakeholders found ibch services are low cost (very suitable for poor and middleclass families) and they also care their patients a lot. this is a real example of csr activities that significantly contributing to the society by ibch. what are the areas, ibbl can improve its csr in healthcare? a) i had my daughter born at the islami bank central hospital. in addition to their great customer support, they provided my daughter a ‘new born baby kit’. i think they are already doing (csr) excellent in the healthcare sector (r10, female, beneficiary). b) i had a surgery at islami bank central hospital and found the doctors and other staffs are really supportive. but i had an attendant with me to communicate with the hospital staff to update me about the progress of the treatment. i would expect, they develop a system so that every patient may stay in the hospital with out the support of an attendant, which became a culture in bangladesh (r17, male, beneficiary). c) i am fully aware about the waste management system of islami bank hospital. they are effectively disposing the clinical wastes (like, body fluid, drainage bags, vials, culture dishes, gauze, bandages, organs, tissues) as well as laboratory waste (like, slides, needles, blades, syringes; radioactive waste such as iodine-125, iodine -131). this accountability by islami bank central hospital clearly shows that they are in compliance with international norms and practices which conforms the pattern of csr (r15, male, environmentalist). the stakeholders, in response to the 2nd question, express that the csr activities by ibch is of very high quality and there is little to improve in their services at this point. what are the strengths of csr activities by ibbl you noticed so far? a) i got medical check-ups at different hospitals in last two decades. i found that the doctors and nurses of islami bank central hospital are of very high quality, pieces equipment are of international standard; the infrastructure is adequate. this is a real example of healthcare and real example of csr (r19, male, beneficiary). b) islami bank central hospital is situated in my locality. it is a great support and shafiqur r, sadia j, nicholas m 213 blessings for the community and the first place, where we rush for the emergency medical assistance. we always found the emergency medical team very supportive and they really exhibit socially responsible behaviour (r25, male, community representative). c) as a patient of diabetics, i take my regular treatments and check-ups from the islami bank central hospital. they response at the quickest possible time, whenever i arrive their. the cleanliness is superb; security is very strong; monitoring is timely (r27, female, beneficiary). the above views responding the 3rd question exhibit that the islami bank central hospital (ibch) is exhibiting socially responsible behaviour, contributing the community and always ready to provide world class service to the community. the csr by ibbl is supported by garriga and meleé23 conceptual framework which has four major theories. the csr by the ibch conform the ethical and the integrative perspectives of garriga and melee’s theory. likert scale responses the likert scale responses also revealed very positive attitudes to ibbl’s role in csr through its contribution in the healthcare. all respondents agreed (100%) that ibbl’s contribution to csr is very effective in healthcare support to the poor and middleclass families (29 strongly agreed and 8 agreed). an overwhelming majority of respondents (35/37; 95%) do not believe that ibbl is doing csr as a public relation tool. consistent with the findings discussed in the previous section, most respondents (31/37; 84%) disagreed with the instrumentally based statement that csr goes against ibbl’s business’ interests because it reduces profit margins. only 4 participants agreed with this assertion, and 2 ticked the “indifferent” option. with regard to the statement that csr by ibbl in the healthcare is really addressing the social concerns, almost all the respondents (36/37; 97%) agreed with it, and only one of them ticked “indifferent.” this appears to reveal a good faith by the respondents towards ibbl’s social concerns in healthcare. in conclusion, the above responses exhibit generally variable attitudes and receptiveness of the stakeholders towards the csr by ibbl in the healthcare sector. however, the participants who attended the survey, all of them attended the csr workshop at a private university in bangladesh; therefore, they would be more likely to have positive attitudes towards csr (and of the central hospital of islami bank, as it earned a reputation for its csr in last few years). summary and conclusions ibbl has established ibch initially with philanthropic intention in mind. however, very recently, ibbl has adopted the modern csr concept. through ibch, ibbl has not only giving opportunity for the low income people to get access to healthcare, it also generated substantial number of employment in the society. one can debate that the low cost of service at ibch might result in compromising in quality, but the patient satisfaction clearly shows that the service quality is comparable with other modern hospitals in bangladesh. it can also be argued that the low cost of ibch may compel other hospitals to reduce their costs. in fact, in an open market economy like bangladesh, it is the freedom of the service providers to choose their own product/service costs. moreover, the ibch is serving only a small fraction of total patient population, due to which other hospitals will not get affected in price competition. csr by islami bank in healthcare – stakeholders’ perception 214 ibch is fully aware of its social responsibility and contributing to the society accordingly. it provides ‘full free’ services to a certain number of needy patients. it maintains modern clinical waste disposal system which is very essential for environment. it makes a minimum profit as it does not have a target to distribute dividend rather it strives to provide high quality services to the patience. ibbl’s experience from ibch has encouraged ibbl to extend its healthcare csr program to a number of districts outside the capital city and these initiatives are also equally successful and are making a great contribution in the bangladesh healthcare sector. this paper reports the findings of a qualitative study on perceptions of csr by islami bank bangladesh limited (ibbl) in the healthcare sector through heterogeneous stakeholders recruited at a csr workshop held in a private university in dhaka, bangladesh. the findings reveal the perception of stakeholders towards the social contribution of islami bank central hospital, an institution for csr in healthcare by ibbl. the stakeholders believe that this hospital is proactive in providing healthcare support to the community through its highly standard human resources, world class medical equipment, outstanding management team and superb customer care support. these stakeholders (beneficiaries, islami bank employees, social scientists, environmentalists, community members and journalists) express their extreme satisfaction and positive attitude regarding ibbl’s csr activities in healthcare. while the current study brings out the perceptions of the stakeholders of csr by ibbl, the authors recognize that it has a number of limitations including the small sample size. it is strongly recommended that future studies supplement surveys with in-depth face-to-face interviews for a richer perspective on the topic. this exploratory study makes significant contribution to the relatively new body of knowledge on csr in bangladesh, especially in the healthcare sector. this study will also contribute to improve the governance, social, ethical and environmental condition of the healthcare sector as well as will help the future researchers in this field. ______________ references 1. de bakker, f. g. a., groenewegen, p., den hond, f. a bibliometric analysis of 30 years of research and theory on corporate social responsibility and corporate social performance. business and society. 2005; 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(2007) 3. bangladesh bureau of statistics. [internet]. 2008 (cited 2010 march 21). available from: http://www.bbs.gov.bd/dataindex/pby/pk_book _08.pdf 4. belal, a. r. a study of corporate social disclosures in bangladesh. managerial auditing journal. 2001; 16(5):274-289 5. poverty assessment for bangladesh: creating opportunities and bridging the east-west divide. dhaka: world bank;2008. 6. bangladesh bureau of statistics. [internet]. 2008 (cited 2010 march 21). available from: http://www.bbs.gov.bd/dataindex/pby/pk_book _08.pdf 7. world bank [internet]. 2009 [cited 2010 april 11]. available from http://devdata.worldbank.org/aag/bgd_aag.pd f http://devdata.worldbank.org/aag/bgd_aag.pdf http://devdata.worldbank.org/aag/bgd_aag.pdf shafiqur r, sadia j, nicholas m 215 8. belal, a. r., owen, d. l. the views of corporate managers on the current state of, and future prospects for, social reporting in bangladesh. accounting, auditing & accountability journal. 2007; 20(3a):472-494. 9. belal, a. r., owen, d. l. the views of corporate managers on the current state of, and future prospects for, social reporting in bangladesh. accounting, auditing & accountability journal. 2007; 20(3b):472-494 10. belal, a. r., owen, d. l. the views of corporate managers on the current state of, and future prospects for, social reporting in bangladesh. accounting, auditing & accountability journal. 2007; 20(3c):472-494 11. belal, a. r. a study of corporate social disclosures in bangladesh. managerial auditing journal. 2001; 16(5a):274-289. 12. world bank [internet]. 2006 [cited 2010 june 10]. available from: http://siteresources.worldbank.org/banglad eshextn/resources/2957591173922647418/complete.pdf 13. belal, a. r., owen, d. l. the views of corporate managers on the current state of, and future prospects for, social reporting in bangladesh. accounting, auditing & accountability journal. 2007; 20(3c):472-494 14. belal, a. r. corporate social reporting in bangladesh. social and environmental accounting. 1999; 19(1):8-12. 15. sobhani, f. a., amran, a., zainuddin. revisiting the practices of corporate social and environmental disclosure in bangladesh. corporate social responsibility and environmental management. 2009; 16(3a):167-183. 16. belal, a. r. a study of corporate social disclosures in bangladesh. managerial auditing journal. 2001; 16(5b):274-289. 17. sobhani, f. a., amran, a., zainuddin. revisiting the practices of corporate social and environmental disclosure in bangladesh. corporate social responsibility and environmental management. 2009; 16(3b):167-183 18. belal, a. r. a study of corporate social disclosures in bangladesh. managerial auditing journal. 2001; 16(5c):274-289. 19. belal, a. r., owen, d. l. the views of corporate managers on the current state of, and future prospects for, social reporting in bangladesh. accounting, auditing & accountability journal. 2007; 20(3c):472-494 20. islam, m. a., deegan, c. motivations for an organisation within a developing country to report social responsibility information. accounting, auditing & accountability journal. 2008; 21(6):850-874. 21. quazi, a. m., o'brien, d. an empirical test of a cross-national model of corporate social responsibility. journal of business ethics. 2000; 25(1):33-51. 22. naeem, m. a., welford, r. a comparative study of corporate social responsibility in bangladesh and pakistan. corporate social responsibility and environmental management. 2009; 16(2):108-122 23. garriga, e., & melé, d. corporate social responsibility theories: mapping the territory. journal of business ethics. 2004; 53(1-2), 51. ______________ bangladesh journal of medical science bangladesh journal of medical science vol.10 no.3 jul’11 1. *akanda fazle rabbi, lecturer, dhaka medical college, dhaka, bangladesh. 2. robindra nath sarker, assistant professor, 3. ahmed hossain, professor and head, department of radiology and imaging, dhaka medical college and hospital, dhaka, bangladesh. *corresponds to: dr. akanda fazle rabbi, department of anatomy, dhaka medical college, dhaka, bangladesh. email: rabbi.dmc44@yahoo.com. original aricle diagnostic value of transabdominal hydrosonography in gastric carcinoma rabbi af1, sarker rn2, hossain a3 abstract aim: to evaluate the efficacy of transabdominal hydrosonography in the diagnosis of gastric carcinoma. materials and methods: transabdominal hydrosonography of the stomach was carried out on fifty patients with clinical suspicion of gastric carcinoma. endoscopic or peroperative biopsy was taken from pathological sites in all cases. the validity of transabdominal hydrosonography of the stomach was evaluated as compared to histopathological diagnoses. results: the sensitivity, specificity, accuracy, positive predictive value and negative predictive value of transabdominal hydrosonography in the diagnosis of gastric carcinoma were 81.82%, 96.43%, 90.00%, 94.74% & 87.10% respectively. conclusion: transabdominal hydrosonography is a useful diagnostic modality for the diagnosis of gastric carcinoma. key words: gastric carcinoma, transabdominal hydrosonography. introduction gastric carcinoma is the fourth most common cancer worldwide with 930,000 cases diagnosed in 2002.1 it is more common in men and in developing countries.2 many asian countries, including korea, china, taiwan, and japan have very high rates of gastric carcinoma. although it is a common malignant tumour in bangladesh, no epidemiological study has yet been carried out to find out its prevalence. incidence of gastric carcinoma is increasing day by day with high prevalence of helicobacter pylori being an important contributing factor. 3 it is a disease with a high death rate (about 800,000 per year worldwide) making it the second most common cause of cancer-related deaths in the world. 4 the high mortality is mainly due to early metastasis before the diagnosis is made and recurrence of the disease after surgical resection. so, an accurate and early preoperative diagnosis as well as follow-up of the patients under treatment is necessary for proper management. numerous imaging modalities have been used to diagnose gastric carcinoma. computed tomography, magnetic resonance imaging, and positron emission tomography have all been used with varying degrees of success 5 .but these modalities are expensive and not widely available in bangladesh and other developing countries. endoscopy and upper gastrointestinal series with double-contrast study have significantly improved the diagnostic accuracy in gastric carcinoma but they cannot assess of the exogastric extension and distant metastases and therefore are unable to assess the surgical resectability preoperatively. another useful modality is endoscopic ultrasonography which can detect tumour infiltration and metastasis 6 but is an invasive, relatively complex and expensive procedure and can not be performed successfully in some patients due to obstruction of gastric lumen caused by the tumour or intolerable discomfort of the patient during the examination. moreover, follow-up of gastric carcinoma requires repeated examinations of the tumour. so a less invasive and cheaper method would be welcome. transabdominal ultrasound performed after injection of a hypotonic agent and ingestion of water provides detailed evaluation of the stomach because water provides an acoustic window of transmission to the tissue defining the stomach and adjacent tissues or organs. this technique is referred to as transabdominal hydrosonography. in transabdominal hydrosonography, the normal wall of the water-filled stomach is seen as a 5-layer structure. 7 the wall thickness, echotexture and wall layering can suggest the diagnosis. localized or circumferential wall thickening more than 5mm in the fundus and body or more than 8 mm in the antrum, hypoechoic mural mass or heterogeneous intraluminal mass with loss of wall layering, luminal narrowing, reduced peristalsis and breached serosa with features of exogastric extension or distant metastasis suggest a malignant lesion while af rabbi, rn sarker, a hossain 171  increased wall thickness with maintained wall stratification suggests a benign lesion. 8-14 the efficacy transabdominal hydrosonography in the evaluation of the gastric carcinoma have been studied extensively. different studies concluded that it is a reliable and accurate diagnostic and staging method of gastric carcinoma 8,12,15-18 having higher specificity than computed tomography19-21 and is comparable to endoscopic ultrasonography in assessing depth of invasion of early gastric carcinoma.22 as ultrasound is often used as the first imaging modality in a large variety of abdominal complaints, clinically unsuspected gastric carcinoma may also be imaged first by it.23 moreover this method is also found to be ideal for follow-up of patients under treatment. so, authors recommended it as an initial technique for the diagnosis and follow-up of gastric carcinoma taking into accounts its non-invasiveness, wideavailability, low-cost, easiness-to-use, and lack of radiation load.24 some investigators, however, recommended further studies.25 as no similar study was carried out before in bangladesh and it was yet to be known whether this method can be equally useful in bangladesh with our present knowledge, skill and available instruments, the aim of this study was to assess and validate the diagnostic value of transabdominal hydrosonography in gastric carcinoma. materials and methods this cross-sectional study was carried on 50 patients clinically suspected as gastric carcinoma (32 males 18 females, aged 31-80 years) admitted in the department of surgery of dhaka medical college hospital, dhaka during the period of july 2005 to december 2006. 50 of the 62 patients approached for this study agreed and cooperated fully yielding a response rate of 80.65%. the patients were subjected to transabdominal hydrosonography at the department of radiology and imaging, dhaka medical college hospital, dhaka. sonography was performed first by one investigator which was then confirmed by another investigator. the sonographic findings were noted. the extent of tumour infiltration and metastasis was assessed in all patients with suspected gastric malignancy. 41 patients subsequently underwent endoscopic examination and biopsy was taken from pathological or suspicious sites. in nine patients who underwent surgery without endoscopic examination operative findings were noted and excision biopsy was carried out from the pathological sites. tissues of the biopsies were sent to a pathologist for histopathological diagnosis. transabdominal hydrosonographic diagnoses and histopathological diagnoses were then compared. the diagnosis of gastric carcinoma was based on the following four criteria: i) localized or circumscribed wall thickening (> 5 mm in the fundus and body or > 8 mm in the antrum) or hypoechoic mural mass or heterogeneous intraluminal mass with /without breached serosa, exogastric extension and distant metastasis. ii) loss of normal wall stratification iii) luminal narrowing. iv) absent or reduced peristalsis. ultrasound examinations were performed using real time image units (toshiba400, siemens-g20, logic-α200) with transducer frequency varied between 3.57.5 mhz as required for proper visualization. patients were examined in empty stomach after overnight fasting or after ryle's tube aspiration in cases of gastric outlet obstruction. first 20mg hyoscine n butyl bromide (butapan) was injected intravenously to achieve optimal distension and to suppress gastric peristalsis. then patients were given 250 ml to a maximum of 1000 ml of water orally or through ryle’s tube. transabdominal ultrasonography was performed 3 min after ingestion of water. patients were examined usually in the supine position. for optimum visualization of lesions at different locations sitting position and left or right lateral decubitus position were also chosen if required. scanning was done in longitudinal, transverse and left subcostal oblique planes. the appearance of each disorder on us scans was analyzed in terms of wall thickness, wall stratification and the echogenicity of the lesion. wall thickness was measured by electronic caliper on the transverse view of the most thickened lesion. liver, pancreas, gallbladder, aorta, spleen, diaphragm, duodenum were also examined for features of metastasis. ascites and metastatic paraaortic lymph nodes were also looked for. large (length 2cm or more), irregular, fusiform and inhomogenously hypoechic lymph nodes were considered as metastatic lymph nodes. sonographic findings of metastasis were compared with the peroperative findings. diagnostic value of transabdominal hydrosonography in gastric carcinoma 172  data was analyzed with the spss (statistical package for the social sciences) version 11.5. diagnostic value of transabdominal hydrosonography in gastric carcinoma was determined by its sensitivity, specificity, accuracy, positive and negative predictive values. prior to commencement of this study, the research protocol was approved by the local ethical committee. observations and results of the total 50 patients, transabdominal hydrosonography diagnosed 19 as gastric carcinoma and 31 as normal or benign conditions. histopathology of the biopsied tissues confirmed 22 as gastric carcinoma and the rest 28 as normal or benign conditions. among the 22 cases of gastric carcinoma, 19 cases (86.36%) were adenocarcinoma. lymphoma, squamous cell carcinoma and leiomyosarcoma comprised one case each. 18 cases diagnosed as gastric carcinoma by transabdominal hydrosonography were proved to be correct by histopathological findings but four cases of gastric carcinoma which escaped diagnosis by transabdominal hydrosonography or considered benign were subsequently diagnosed correctly by histopathology. one case suspected as gastric carcinoma by transabdominal hydrosonography was finally diagnosed as a benign condition by histopathology. among the 18 cases of gastric carcinoma diagnosed correctly by transabdominal hydrosonography, the commonest site of involvement was the antrum – 10 out of 18 cases (55.56%). involvement was seen in the fundus in 3 (16.67%) cases, the body in 3 cases and diffuse involvement of the stomach was seen in 2 cases. in one case, two sites of involvement was notedone in the fundus and the other in the antrum .in all 18 cases (100%) wall layering was completely lost and wall thickness was increased ranging from 10mm to 34 mm with an average of 23.5 mm. luminal narrowing and reduced peristalsis was also seen in all cases. heterogeneous intraluminal masses were seen in 15 out of 18 (83.33%) and serosal breach was seen in 13 out of 18 (72.22%) cases. gastric carcinoma presented as hypoechoic mural mass in only 5 (27.78%) cases. (table i). table i: ultrasonographic findings of gastric carcinoma (n=18) characteristics no. percentage wall layering preserved lost 0 18 0% 100% wall thickness normal increased 0 18 0% 100% lumen normal narrow 0 18 0% 100% peristalsis normal reduced/absent 0 18 0% 100% hypoechoic mural mass present absent 5 13 27.78% 72.22% intraluminal mass present absent 15 3 83.33% 16.67% serosa intact breached 5 13 27.78% 72.22% in this study, the sensitivity, specificity, accuracy, positive predictive value and negative predictive value of transabdominal hydrosonography for the diagnosis of gastric carcinoma were 81.82%, 96.43%, 90.00%, 94.74% & 87.10% respectively. the validity parameters are shown in table ii. transabdominal hydrosonography demonstrated exogastric extension and distant metastasis in 13 patients (table iii). among them metastatic paraaortic lymph nodes were seen in 5 patients and hepatic metastases was detected in 4 patients ascites was seen in 8t patients. sonography detected involvement of duodenum in 2 patients. table ii: validity of transabdominal hydrosonography as diagnostic modality for gastric carcinoma 95% confidence interval test parameter estimated value lower limit upper limit sensitivity 81.82 % 58.99% 94.01% specificity 96.43% 79.76% 99.81% accuracy 90.00% 77.41% 96.26% positive predictive value 94.74% 71.89% 99.72% negative predictive value 87.10% 69.23% 95.78% af rabbi, rn sarker, a hossain 173  involvement of the gallbladder and hilum of the spleen seen at operation in 1 patient each was not seen preoperatively on sonography. table iii: exogastric extent and distant spread of gastric carcinoma as detected by ultrasound (n=13) exogastric extent and metastasis no. of patients liver 04 para aortic lymph nodes 05 ascites 08 pancreas 04 duodenum 02 discussion transabdominal hydrosonography is a simple and rapid technique in which water is introduced to substantially fill the stomach of a fasting patient by ingestion or intubation, preferably the former. to prevent rapid gastric emptying and allow examination while water is present in the stomach of an antispasmodic agent is injected which inhibits peristalsis. the upper abdomen is then scanned with conventional ultrasound diagnostic equipment to produce an image of the stomach and of the upper abdominal organs if required. because of its sonolucency, water appears dark and makes possible the ultrasonographic visualization of the five distinct layers of the stomach wall: superficial mucosa, deep mucosa, submucosa, muscularis propria, and serosa as alternating hypoechoic and hyperechoic layers. the ultrasonic images may be used to detect extension of gastric carcinoma in the tissues or organs being visualized. previous studies indicate that transabdominal ultrasonography can be used effectively in the diagnosis and staging gastric carcinoma. some researchers consider this method as a supportive and supplementary diagnostic procedure to endoscopy 8, but others as a reliable screening method for the diagnosis of gastric carcinoma 20 which can be a routine diagnostic approach 17 and should rank with the initial methods used for diagnosing gastric carcinoma. 21 yet some researchers think that it can be a diagnostic alternatives in selected patients who cannot be stressed by other methods 10 and it is possible to diagnose gastric carcinoma by it despite silent clinical symptoms.23 according to some, its use in initial evaluation of patients may allow earlier detection of gastric carcinoma.18 and it can be an alternative method in the follow-up of patients already diagnosed.16 in this study, the sensitivity, specificity, accuracy, positive predictive value and negative predictive value of transabdominal hydrosonography for the diagnosis of gastric carcinoma were 81.82%, 96.43%, 90.00%, 94.74% & 87.10% respectively. these findings are compared with those of one past study in table iv. table iv: validity parameters of present study compared with a previous study validity parameters present study tous & busto sensitivity 81.82% 77.8% specificity 96.43% 99.1% accuracy 90.00% positive predictive value 94.74% 94.9% negative predictive value 87.10% 95.5% in both of the studies it is obvious that transabdominal hydrosonography has high validity parameters that make it useful as a diagnostic method of gastric carcinoma. in the present study increase in wall thickness, complete loss of wall stratification, luminal narrowing and reduced peristalsis was observed in all cases of gastric carcinoma. heterogeneous intraluminal masses were seen in 15 out of 18 cases (83.33%). gastric carcinoma presented as hypoechoic mural mass in only 5 (27.78%) cases. in rest of the cases, gastric wall showed hypoechoic intramural infiltration and thickening. breach of serosa was seen in 13 out of 18 (72.22%) cases. in two cases of gastric carcinoma, diffuse circumferential wall thickening was seenone was a case of scirrhous carcinoma, another gastric lymphoma. the sonographic features of gastric carcinoma found in this study are similar to that of the previous studies.8-10 transabdominal hydrosonography demonstrated exogastric extension and distant metastasis of gastric carcinoma in 13 patients. in this study, 4 cases of gastric carcinoma could not be diagnosed by transabdominal hydrosonography which were subsequently diagnosed correctly by histopathology. in one case the tumour was too small to be detected by sonography and in three cases small tumours located at the fundus and gastro-esophageal junction could not be visualized by sonography. in our study, most of the cases of gastric carcinoma diagnosed correctly by hydrosonography were in advanced stage of the diagnostic value of transabdominal hydrosonography in gastric carcinoma 174  disease with a relatively large tumour. it is obvious that transabdominal hydrosonography can miss detection of very small lesions and lesions at certain locations e.g. fundus and gastro-esophageal junction. pancreas is a common organ invaded by gastric carcinoma. in this study, metastasis of the pancreas was identified in four patients by transabdominal hydrosonography. the above four cases of metastasis was confirmed at surgery. in addition 2 patients having pancreatic metastasis undetected by transabdominal hydrosonography were detected at surgery. in one patient pancreas was invaded slightly. in the remaining one, the tail of pancreas was invaded which was not detected by sonography due to interference of bowel gas and ribs. transabdominal hydrosonography failed to detect involvement of duodenum seen at operation in two patients. correct diagnosis was made preoperatively in 2 of 4 patients with duodenum invasion by transabdominal hydrosonography. it is necessary to fill duodenum by water for the assessment of duodenum. because tumour caused gastric lumen obstruction, duodenum was not filled adequately and not visualized clearly leading to misdiagnosis. involvement of the gallbladder and hilum of the spleen seen at operation in one patient each was not seen preoperatively on sonography. splenic hilum could not be observed completely with hydrosonography leading to the detection failure. in this study liver metastases were seen in four patients. tumours invading liver located in anterior wall of stomach or lesser curvature and were close to the liver. the relationship between tumour and liver could be visualized clearly by using ultrasonographic beam through liver without interference of bowel gases. ascites was seen in eight patients, only five of these patients had presented clinically. para-aortic lymphadenopathy was identified at sonography in five patients. very small lymph nodes were undetectable with transabdominal hydrosonography. in addition, bowel gas was unfavorable for detection of lymph nodes. thus, though sonography misdiagnosed or underdiagnosed the presence and exogastric extent of gastric carcinoma in a few cases, it did provide accurate diagnosis and a rough estimate of its extent in the majority of the cases. the possible reasons for misdiagnosis or underdiagnosis were as follows: (1) the procedure did not practice adequately, because the investigators had limited experience of this procedure. (2)the transducers that were available and used in this study had frequencies up to 7.5mhz. so resolution more than this limit was not technically possible. higher resolution is needed for optimal visualization of small lesions. (3) location of gastric carcinoma also affected the diagnosis. transabdominal hydrosonography may fail to correctly diagnose carcinoma located in gastric fundus or cardia. three cases of gastric carcinoma not diagnosed correctly by hydrosonography in this study were located in the above locations. (4) location of the involved organs and size of the metastases also affects the diagnosis of exogastric extension. for example, it is difficult to clearly visualize the hilum of the spleen and the tail of the pancreas by transabdominal hydrosonography. invasions of the tail of pancreas in one patient and hilum of the spleen in anther were not detected with transabdominal hydrosonography in this study. very small metastases were also undetected by hydrosonography. moreover, this study involved only a limited number of patients. a larger study population could have given more precise results regarding diagnostic validity of this method. conclusion this study concluded that transabdominal hydrosonography is a useful diagnostic modality for the diagnosis of gastric carcinoma and to asses its exogastric invasion and validates the related previous study findings regarding its efficacy. sonograph 1: us image of scirrhous carcinoma showing diffuse hypoechoic wall thickening with loss of stratification af rabbi, rn sarker, a hossain 175  sonograph 2: ultrasound showing gross hypoechoic wall thickening with luminal narrowing in the region of the antrum. serosa appears intactcarcinoma antrum sonograph 3: transverse scans of the fluid filled stomach showing hypoechoic circumferential wall thickening and loss of wall layers-gastric lymphoma sonograph 4: sonogram of the fluid filled stomach showing two heterogeneous intraluminal masses, one in the fundus and the other in the antrum with complete disruption of wall layering in the region of the masses with breach of serosa – carcinoma stomach sonograph 5: sonogram of the fluid filled stomach showing a heterogeneous intraluminal mass in the body with complete disruption of wall layering in the region of the mass– carcinoma stomach. huge ascites is also seen ______________ diagnostic value of transabdominal hydrosonography in gastric carcinoma 176  references 1. parkin dm, bray f, ferlay j, pisani p. global cancer statistics 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endosonography: can surveillance be simplified? endoscopy 2002; 34(12):979-83. http://dx.doi.org/10.1055/s-2002-35839. pmid:12471542. ______________ microsoft word bjms-apr-11.doc bangladesh journal of medical science vol.10 no.2 apr’11 1. *oe yama, 2. fio duru, 3. aa oremosu, 4. cc noronha department of anatomy, college of medicine, university of lagos, idi-araba, lagos, nigeria. *corresponds to: dr. yama oshiozokhai eboetse, department of anatomy, college of medicine of the university of lagos, p.m.b. 12003, lagos, nigeria, email: dro_yama@yahoo.com. original article: testicular oxidative stress in sprague-dawley rats treated with bitter melon (momordica charantia): the effect of antioxidant supplementation oe yama1, fio duru2, aa oremosu3, cc noronha4 abstract objective: an important mediator of testicular injury is oxidative stress; the implicating pathway has been pointed at a free radical mechanism by researchers. this article, investigates the effect of bitter melon (momordica charantia) (mc) seed extract and antioxidant supplementation in the testes of sprague-dawley (s-d) rat. methodology: ninety male s-d rats, weighing between 110214 g, were assigned randomly into six main groups a to f. group a was administered 50 mg/100 g of mc extract orally, between 6 to 16 weeks. group b were pre-treated with ascorbic acid (aa) 0.01mg/kg, three days/week, α-tocopherol (at) 20 mg/kg, five days/week and both test solutions (ts) i.e. aa and at; 0.01 and 20 mg/kg, three and five days/week for 8 weeks. this was followed by administration of the extract at dose and duration as in a. group c received the extract for 8 weeks and afterwards post-treated for another 8 weeks with aa, at and both ts (as above). group d in addition to the extract administration were treated with aa, at and both ts in dose and duration similar to b above. group e had aa, at and both ts alone for 8 weeks. group f served as the control subjects. the animals testicular tissues were processed for malondialdehyde (mda) and aa concentrations. serum testosterone (tt) assay was done from left ventricular blood. results: the extract administered for 6, 8 and 16 weeks produced significantly (p < 0.05) increased testicular mda (1.74 ± 1.15, 1.84 ± 0.38 and 2.38 ± 0.40) compared to control (0.38 ± 0.02, 0.38 ± 0.03 and 0.35 ± 0.02) and decreased aa (0.01± 0.02, 0.01± 0.01 and 0.00± 0.01) compared to control (0.15 ± 0.02, 0.12 ± 0.02 and 0.13 ± 0.02). there was also an associated significant decrease (p < 0.05) in peripheral tt levels compared to control. the extract produced responses that showed no prophylactic rather modulatory effect with ts. conclusion: these findings suggest that the extract resulted in changes in the testicular oxidative status. this may play a role in testicular dysfunction that may compromise fertility. key words: momordica charantia, malondialdehyde, ascorbic acid, testosterone. introduction over seven decades ago, α-tocopherol (at) was recognized as a powerful lipophilic antioxidant that is absolutely vital for the maintenance of mammalian spermatogenesis [1]. ascorbic acid (aa) contributes to the support of spermatogenesis at least in part through its capacity to reduce at and maintain this antioxidant in an active state [2]. free oxygen radicals are known to possess ability to react with cellular macromolecules such as nucleic acids, lipids, proteins and carbohydrates to produce a destructive effect [3]. for example oxygen radicals have a destructive effect on lipids (lipid peroxidation) of all membranes. the end product of this phenomenon is called malondialdehyde (mda). it is a reliable and generally accepted indicator of lipid peroxidation [3]. the levels can increase to the extent that it cumulates into a situation known as oxidative stress [3, 4, 5]. free oxygen radicals or reactive oxygen species (ros) such as superoxide anions, hydrogen peroxide, and the hydroxyl ion are molecules that contain an oxygen atom. a free radical is any chemical yama oe, duru fio, oremosu aa, noronha cc 105 species capable of independent existence and contains one or more unpaired electrons. they are highly reactive due to the presence of unpaired valence shell electrons. the cellular structures of membranes are prevented from the damaging effect of ros by systems that scavenge the free radicals from the cellular environment [4]. there is normally an intricate balance between these amount of free radicals generated and scavenged by a cell with damage occurring when the equilibrium is disturbed [6]. thus when there is increased production of ros, cellular structures are vulnerable to the effects of oxidative stress [4]. spermatozoa are rich in polyunsaturated fatty acids and this makes them susceptible to attack by ros or membrane lipid peroxide ions. the equilibrium between the amount of ros produced and scavenged is related to the stability and damage of the gamete cell[4]. free radicals are implicated to have detrimental effects on sperm functions, which depend on its nature and concentration [7]. antioxidants are substances that inhibit the destructive effects of oxidation by the ros in the body [8]. numerous antioxidants include ascorbic acid, alpha tocopherol, beta carotene and melatonin. other known antioxidants include enzymes such as superoxide dismutase catalase and gluthatione peroxidase are credited to ros detoxification [9]. the antioxidant properties of momordica charantia has been pointed out previously by researchers [10] but its prooxidant effect on the testes is yet to be described. research has proven that at a high dose antioxidant could act as pro-oxidant releasing free radicals [11]. this present study was thus designed to determine the possible role of oxidative stress of momordica charantia on the testes as a mode of contraception in male s-d rats previously described. materials and methods test solutions the test solutions (ts) used were the antioxidants α-tocopherol (at) and ascorbic acid (aa) at doses 20 mg/kg [12] and 0.01 mg/kg [13] respectively.the doses were calculated based on the animal’s individual weekly body weights and aliquots approximated to the nearest numeral administered. it was done using insulin syringe (100 iu equivalent to 1ml) via intramuscular (i.m.) route. collection and identification the ripe fruits of mc harvested in june were purchased from the local market in lagos. it was authenticated by professor j. olowokudejo, a taxonomist in the department of botany, university of lagos, where the voucher specimen was deposited (ascension number fhi 108422). preparation of seed extract the seeds were dried in an oven (temperature of between 30-40oc) for a week. the dried seeds were weighed and soxhlet extraction done using alcohol and water as solvents at the pharmacognosy department of college of medicine, university of lagos. the percentage yield was 23.0% w/w, from which a dose of 50 mg/100 g of body weight was calculated and administered orally. sources and maintenance of rats ninety male s-d rats 6-8 weeks old were used in this study. the rats were procured from the laboratory animal centre of the college of medicine of the university of lagos and were authenticated by a taxonomist [14] in the department of zoology of the university of lagos. they were kept in plastic cages in the animal room of the department of anatomy and allowed to acclimatize for two weeks under standard laboratory conditions of temperature 27-30oc. lighting was by natural daylight such that the rats were exposed to approximately 12:12 light–dark cycle. they were fed with commercially available rat chow (livestock feeds plc, ikeja, lagos, nigeria) and had unrestricted access to water. experimental protocol the animals were randomly allocated into 6 main groups a to f. which were further subdivided into 3 sub-groups (a1 to a3; b1 to b3; c1 to c3; d1 to d3; e1 to e3 and f1 to f3) of 5 rats. subgroups a1 to a3 indicate different testicular oxidative stress in sprague-dawley rats administered momordica charantia 106 treatment durations of 6, 8 and 16 weeks administered a single oral dose of 50 mg/100 g of mc extract. group b pre-treated with ts (bi: 0.01 mg/kg of aa, three times a week mondays, wednesdays and fridays; b2: 20 mg/kg of at, five days a week mondays, tuesdays, wednesdays, thursdays and fridays while b3: both ts) for 8 weeks and then fed the extract at dose and duration as in a. subgroups c1 to c3 received the extract for 8 weeks (as in group a) and afterwards posttreated for another 8 weeks with aa, at and both ts (as in group b). group d comprise rats receiving the extract and ts simultaneously for a duration of 8 weeks. therefore in addition to the extract d1 to d3 were treated with aa, at and both ts in dose and duration similar to b above. subgroups e1 to e3 had aa, at and both ts. finally, group f animals were used to compare events in the other groups was administered distilled water throughout the experiment. at the end of the different experimental durations, the animals were sacrificed. the testes were assessed for malondialdehyde and ascorbic acid concentration, cauda epididymal fluids were processed for sperm count and motility. testicular morphometry (weight and volume) was also assessed. the protocol was approved by ethical committee of the institute. testicular malondialdehyde concentration testicular tissue samples weighing 0.25 g were homogenized in 2.5 ml of 0.15 m potassium chloride. the supernatant from the homogenate was collected and stored at 200c. the mda levels were determined as described by buege and aust (1978) [15]. a 2ml aliquot of 0.375% trichloroacetic acidthiobarbituric acid hydrochloric acid (tca-tba-hcl) was added to 1.0ml of the supernatant of testicular tissue homogenate. this was mixed vigorously and heated for 15minutes in a water bath at 80900c. the sample was cooled in ice cold water again for 15 minutes at 1500 g and the tubes were placed in the photometer and absorbance taken at 535nm against the reagent blank. concenration was calculated using the molar absorptivity of malondialdehyde which is 1.56 x 105 m-1cm-1. testicular ascorbic acid concentration testicular aa concentrations were determined as by the association of official analytical chemist (1990) [16]. this method is based on the oxidation of ascorbic acid to dehydro ascorbic acid, which when heated with dinitrophenylhydrazine forms a coloured complex with absorption maxima at 520 nm. briefly, 0.5 g testicular tissue sample was homogenized in 12.5 ml of 0.5% oxalic acid for 10 minutes. the homogenate was centrifuged at 1000 g and the supernatant collected. 1.5 ml of 4% trichloroacetate and 1.0 ml of 2, 4-dinitrophenylhydrazine were added to 0.5 ml of supernatant in test tubes. the tubes were then incubated at 50oc for 1 hour. with the tubes in ice-bath, 1.25 ml of 85% sulphuric acid was added drop-wise with mixing after each drop. the tubes were removed from the ice-bath and left at room temperature for 30 minutes. the absorbance was then read at 520 nm after setting the spectrophotometer to zero with the blank. the concentration of ascorbic acid was calculated using the formula: concentration of ascorbic acid = abs(test) x con(std)/abs(std) where, abs(test) is the absorbance for the sample, con(std), concentration of standard ascorbic acid and abs(std), absorbance of standard ascorbic acid (0.086), derived from beer-lambert law (absorbance proportion to concentration) (association of official analytical chemists, 1990). testosterone assay serum tt was assayed from blood obtained from a left ventricular puncture. the samples were spun at 3000 g for 10 min in an angle head centrifuge at 25 oc. the samples were assayed in batches from a standardized curve using the enzyme linked immunosorbent assay (elisa) method [17]. the microwell kits used were from syntro bioresearch inc., california usa. using 10 µl of the standard, the samples and control were dispensed into coated wells. 100 µl tt conjugate reagent was added and then 50 µl of anti-tt reagent. the contents of the microwell were thoroughly mixed and then incubated for 90 minutes at room temperature. the mixture was washed in distilled water and further incubated for 20 minutes. the reaction was stopped with 100 µl yama oe, duru fio, oremosu aa, noronha cc 107 of 1n hydrochloric acid. absorbance was measured with an automatic spectrophotometer at 450 nm. a standard curve was obtained by plotting the concentration of the standard versus the absorbance and tt concentration was determined from the standard curve. table i: malondialdehyde and ascorbic acid concentration in experimental and control sprague-dawley rats groups (n = 90) testicular mda (nmol/g of testis x 10-7) testicular aa (mg/100 m3 of testis) a1 a2 a3 wk 6 wk 8 wk 16 1.74 ± 1.15b 1.84 ± 0.38b 2.38 ± 0.40b 0.01± 0.02b 0.01± 0.01b 0.00± 0.01b b1 b2 b3 aa8wks – mc8wks at8wks – mc8wks aa8wks,at8wks – mc8wks 2.12 ± 0.08b 2.35 ± 0.80b 1.73 ± 0.34b 0.02 ± 0.02b 0.04 ± 0.06b 0.02 ± 0.02b c1 c2 c3 mc8wks – aa8wks mc8wks – at8wks mc8wks – aa8wks,at8wks 0.31 ± 0.08 0.69 ± 0.45 0.45 ± 0.20 0.10 ± 0.02 0.08 ± 0.04 0.12 ± 0.02 d1 d2 d3 mc8wks + aa8wks mc8wks + at8wks mc8wks+ aa8wks,at8wks 0.37 ± 0.05 0.59 ± 0.22 0.30 ± 0.009 0.19 ± 0.02 0.16 ± 0.02 0.21 ± 0.09 e1 e2 e3 aa8wks at8wks aa8wks,at8wks 0.34 ± 0.08 0.39 ± 0.18 0.36 ± 0.12 0.14 ± 0.05 0.12 ± 0.05 0.11 ± 0.06 f1 f2 f3 distilled water6wks distilled water8wks distilled water16wks 0.38 ± 0.02 0.32 ± 0.03 0.35 ± 0.02 0.15 ± 0.02 0.12 ± 0.02 0.13 ± 0.02 values expressed as mean ± standard deviation; bp < 0.05; distilled water given for 6 to 8 weeks; mda: malondialdehyde; mc8wks: 50 mg/100 g of momordica charantia extract fed for 8wks; aa8wks: 0.01 of ascorbic acid treated for 8wk; at8wks: 20 mg/kg of α-tocopherol treated for 8wk; aa8wks, at8wks: α-tocopherol & ascorbic acid at doses 0.01 and 20 mg/kg administered simultaneously for 8wk; wk: weeks statistical analysis results were expressed as mean±sd. analysis was carried out using analysis of variance (anova) with scheffe’s post hoc test. the level of significance was considered at p < 0.05. results testicular malondialdehyde levels there was a marked duration dependent statistically significantly (p < 0.05) increase in testicular mda concentration compared to control (table-i). the mean values for animals fed distilled water and mc extract for 6, 8 and 16 weeks were 0.38 ± 0.02, 0.32 ± 0.03, 0.35 ± 0.02 vs1.74 ± 1.15, 1.84 ± 0.38, 2.38 ± 0.40 respectively. this increase is also same for those pre-treated with aa, at, ts for 8 weeks and later post-treated with the extract for another 8 weeks, mean values were 2.12 ± 0.08, 2.35 ± 0.80, 1.73 ± 0.34. animals fed the extract for 8 weeks followed by treatment with aa, at and both ts for 8 week were 0.31 ± 0.08, 0.69 ± 0.45, 0.45 ± 0.20 respectively, when compared to control (0.38 ± 0.02, 0.32± 0.03, 0.35 ± 0.02) showed no significant difference (p < 0.05; table-i). the mean mda for animals post treated with at was observed to be slightly higher values were not statistically significant. also showing no significant difference from control (0.38 ± 0.02) were the groups in which the extract was administered concurrently with aa, at, ts for 8 weeks viz 0.37 ± 0.05, 0.59 ± 0.22, 0.30 ± 0.01 (table-i). finally mda values for rats treated with aa, at, and ts for 8 weeks alone were similar to control. testicular oxidative stress in sprague-dawley rats administered momordica charantia 108 testicular ascorbic acid concentration levels the mean aa values followed an inverse relationship to mda concentration. it showed a significant (p < 0.05) duration dependent decrease in testicular aa form a control of 0.15 ± 0.02, 0.12 ± 0.02, 0.13 ± 0.02 to 0.01± 0.02, 0.01± 0.01 and 0.00 ± 0.01 for animals fed the extract for 6, 8 and 16 weeks. also those pretreated with aa, at, ts for 8 weeks and later post-treated with the extract for another 8 weeks (0.02±0.02, 0.04±0.06, 0.02±0.02) compared to control. the testicular aa showed substantial recovery to base line control value in rats fed the extract for 8 weeks thereafter treated with aa, at and both ts for 8 weeks (0.10 ± 0.02, 0.08 ± 0.04, 0.12 ± 0.02; p < 0.05; table-i). the group in which the extract was administered concurrently with aa, at and ts for 8 weeks, showed an appreciable modulation (table-i). these showed no significant difference. lastly, aa values for rats treated with aa, at, and ts for 8 weeks alone were similar to control. table ii: serum testosterone levels in experimental and control sprague-dawley rats groups (n =75) testosterone (ng/ml) b1 b2 b3 aa8wks – mc 8wks at8wks–mc8wks aa8wks,at8wks –mc8wks 0.13 ± 0.02b 0.12 ± 0.07b 0.17 ± 0.09b c1 c2 c3 mc8wks–aa8wks mc 8wks –at8wks mc 8wks –aa8wks,at8wks 0.32 ± 0.35 0.35 ± 0.24 0.34 ± 0.21 d1 d2 d3 mc8wks+aa8wks mc8wks +at8wks mc8wks+aa8wks,at8wks 0.31 ± 0.08 0.34 ± 0.20 0.37 ± 0.24 e1 e2 e3 aa8wks at8wks aa8wks,at8wks 0.38 ± 0.06 0.33 ± 0.15 0.37 ± 010 f1 f2 f3 distilled water6wks distilled water8wks distilled water16wks 0.36 ± 0.02 0.31 ± 0.09 0.29 ± 0.01 values expressed as mean ± standard deviation; bp < 0.05; distilled water given for 6 to 8 weeks; mc8wks: 50 mg/100 g of momordica charantia seed extract fed for 8wks; aa8wks: 0.01 of ascorbic acid treated for 8wk; at8wks: 20 mg/kg of α-tocopherol treated for 8wk; aa8wks, at8wks: αtocopherol & ascorbic acid at doses 0.01 and 20 mg/kg administered simultaneously for 8wk; wk: weeks. testosterone concentration the serum tt level following administration of the extract for 6, 8 and 16 weeks were observed to diminish markedly. it decreased from 0.36 ± 0.02 (control) to 0.15 ± 0.09 (after 8 weeks) and 0.05 ± 0.02 ng/ml (after 16 weeks; figure 1). these values only become significant (p < 0.05) after the 8 weeks. a similar reduction in serum tt levels was also observed in rats pre-treated prophylactically with aa, at and both ts for 8 weeks followed by the extract for another 8 weeks (table-ii). there was no significant (p < 0.05) difference observed in serum tt in rats administered the extract and antioxidant concurrent and with ts treatment alone compared to control (table-ii). discussion it has been shown previously from research that administration of aa to normal animals stimulates both sperm production and tt secretion [18]. it is also known that aa counteracts the testicular oxidative stress induced by exposure to pro-oxidant substances such as arsenic, cadmium, endosulfan and alcohol [19, 20]. in this present study, animals fed yama oe, duru fio, oremosu aa, noronha cc 109 the extract alone (group a) and those pre-treated with ts before administering the extract (group b) had both showed a high level of testicular lipid peroxidation. this means the extract triggered oxidative stress via the release of free radicals in the testes, as evidenced by the elevation of testicular mda and also a decrease in testicular aa in these groups. the treatment with at has also been shown to suppress lipid peroxidation in testes [21] and reverse detrimental effects of oxidative stress on testicular function [22, 23]. this finding is in concert with our results, where the extract resulted in a decreased in testicular aa level. there is a high possibility that the extract may have acted via production of oxidative stress, in view of the fact that co-administration of aa, at or both ts with mc (group d) were found to protect against the elevation of mda levels as values were identical to control. it was also observed that both ts and aa offered a better protection against the oxidative stress from mc than at when concurrently administered with the extract compared to their control counterpart. the reason for these differential actions of these two vitamins cannot be fully explained. however, it is possible for aa to be acting in somewhat unexplained mechanism(s) in addition to its action as an antioxidant. it is known that aa is necessary for steroidogenesis [24] and has a coenzymatic function in the biosynthesis of steroid hormones, such as testosterone [21]. our finding of a decreased serum tt level in group a rats fed the extract may not be unconnected with the effect of mc. studies have shown that the serum tt level correlates positively with sperm concentration and motility [25, 26]. it is also known that sperm production cannot proceed to an optimal completion without a continuous tt supply 27]. our result demonstrated that mc produced a significant reduction in serum tt level and therefore, could be linked to a cessation of spermatogenesis. a resulting decreased spermatogenesis and increased sperm damage secondary to the oxidative stress induced by mc at the level of testicular microenvironment could therefore be correctly extrapolated. also the mda resulting from the membrane damage can also induced further sperm damage have shown in previous studies [28]. thus animals in these groups were expected to show a diminished fertility. in conclusion, the present study showed that mc exerted its effect via generation of free radicals with accompanying decrease in serum tt, when administered at an oral dose of 50mg/100 g body weight of rat. this effect was also observed to be dose dependent. serum testosterone level in sprague-dawley rats treated with momordica charantia extract compared to control 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 controlwk 6 wk 8 wk 16 s er u m t es to st er o n e (n g /m l) figure 1: serum testosterone level in sprague-dawley rats treated with momordica charantia extract compared to control testicular oxidative stress in sprague-dawley rats administered momordica charantia 110 acknowledgement we wish to acknowledge mr. adeleke of the department of pharmacognosy, faculty of pharmacy, university of lagos, nigeria for his help in preparation of the herbal decoction and encouragement to do this 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