403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 editorial-1 [converted].eps the term suicide originated from latin word “sui” (of oneself) and “caedere” (to kill).1 it was first used by british physician sir thomas browne in 1642. in united kingdom it is the third contributor to death after coronary heart disease and cancer.2 it is alarming that the rate of suicide is gradually increasing day by day among the teenage and young men and women. world health organization put attention for suicide prevention in national and international level. higher rates of suicide are found in eastern and northern europe and lower rates in mediterranean countries; the rate is very low in islamic countries2 due to religious constraint. in bangladesh the suicide rates are increasing among teenage and young group. it is also reported that in bangladesh the rates have been highest in jhenaidah. the epidemiology of suicide indicates that two-thirds of the depressive patients have suicidal ideation, but 11–17% (average 15%) of depressive patients die by suicide.2-4 researchers found that suicide rate is 3 times more in male than female (m:f=3:1); but the rate of parasuicide (deliberate self-harm) is 2 times more in female than male (m:f=1:2).2 it has been mentioned that there is a four-fold increase in death rates of patients over age 55 years having depressive disorders in western world.3 in one study in united states it was found that more than two-thirds of those who die by suicide have expressed previously about the idea of suicide.2 it was also found that risk of suicide is more in those persons who write suicide note or tear up the note after writing.2 researchers found that people who have intentionally harmed themselves (deliberate self-harm) have a much increased risk of suicide later on.2 patients may commit suicide during the treatment of depressive disorder when they begin to improve and regain energy needed for plan to carry out suicide. this is called paradoxical suicide. the questions may arise why people commit suicide. the answers remain in the main two domains: a. psychological causes and b. social causes. among the psychological causes the following conditions are included: 1. personality disorder (30–50%): this is predisposed to depressive illness and/or alcoholism. 2. depressive disorder (15%) 3. alcohol misuse (7%) (more in old group) 4. drug misuse 5. schizophrenia (7%) 6. epilepsy (7%) 7. chronic painful illness, eg, cancer 8. widow, widower, separated, older and unmarried male among the social causes the following factors may be responsible: 1. eve teasing 2. sexual abuse 3. problems in relationship with partner/breaking of affairs 4. stressful life events 5. social isolation 6. unemployment 7. poverty 8. poor physical ill health 9. students 10. doctors 11. immigrants 12. farmers 13. media coverage of suicide: showing of fictional television program and films depicting suicide.2 sometimes people copy methods of suicide that have received wide media attention. 14. mass suicide among the members of special religious community, eg, 913 followers of temple cult died in guyana in 1978 and 39 members of heaven gate cult in california in 1997.2 recently in mymensingh (bangladesh) a group of people of same family committed mass suicide by jumping under the train. 15. pack suicide: in this case dominant partner of love affair initiates the suicide. suicide pacts have to be editorial fight against suicide doi: 10.3329/jemc.v5i1.21490 4 journal of enam medical college vol 5 no 1 january 2015 distinguished from cases where homicide is followed by suicide or where one person aids another person’s suicide without intending to kill himself. 16. previous suicide attempts: 40–60% of those who die by suicide have made previous attempts.5 for prevention of suicide we need multiple approaches. among the suicide cases 65% suffered from depressive disorder and 15% were chronic alcoholics.5 following measures will help to fight against suicide. 1. family education about morality and sound religious knowledge and practice which help the children to make up their development of good adjustable personality. 2. teaching the general practitioners about diagnosis and treatment of depressive disorders and other psychiatric disorders related to suicide. 3. better and more available psychiatric services should be disseminated in the community. 4. public awareness by campaigning to educate the people regarding suicide. 5. restricting the means of suicide by reducing availability of methods of suicide. 6. counseling services by crisis centers and ‘hotlines’: here people in despair are encouraged to contact a widely published telephone numbers. the help offered (befriending) is provided by nonprofessional volunteers who are trained to listen sympathetically and empathetically also. 7. long term medication for psychiatric patients: less toxic antidepressant drugs for treatment of depressive disorders reduce the risk of suicidal behaviors. lithium prophylaxis (mood stabilizer) reduces the suicide rates of patient having bipolar mood disorder (both depression and mania/hypomania). clozapine (antipsychotic) may reduce suicidal attempts by patients with schizophrenia and schizoaffective disorders.2 dewan akm abdur rahim professor, department of psychiatry enam medical college, savar, dhaka email: emc_savar@yahoo.com references 1. dk illustrated oxford dictionary. new delhi: penguin books india, 2006: 832 2. suicide and deliberate self-harm. in: gelder m, harrison p, crowen p (eds). oxford textbook of psychiatry. 5th edn. new delhi: oxford university press, 2006: 407–428. 3. mood disorders. kaplan hl, sadock bj, grebb ja (eds). kaplan and sadock’s synopsis of psychiatry. 7th edn. new delhi: bl waverly pvt ltd., 1994: 332–333. 4. black d, winokur g, hasrallah a. suicide in subtypes of major affective disorders. archives of gen psych 1987; 44: 878–880. 5. roy a. self-destructive behavior. in: hill p, murray r, thorley a (eds). essentials of postgraduate psychiatry. 2nd edn. g&s london 1986: 445–460. 5 j enam med col vol 5 no 1 january 2015 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 microsoft word desk of editor-in-chief.doc 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 college news [converted].eps college news compiled by md. aminul haque khan and rukhsana parvin cpd programme continuing professional development is the process of life-long learning in practice. it helps the medical professionals to keep them up-to-date to meet the needs of the patient and health care services and to improve their knowledge, skill and attitude. in enam medical college total 15 seminars were held during the period of september to december 2014. around 300 students, doctors and teachers attended each of these seminars. cme programme to enhance communication skill in teaching and learning and efficiency of judgment of teachers, especially the freshly appointed teachers in the assessment in examinations and to improve medical teaching standard of teachers by refreshing knowledge, skill and attitude, continued medical education (cme) programmes are very much needed. it is also essential to make them oriented with the updating of education system, teaching and research methodology and to share experience and views of senior faculties. in these perspectives, medical education unit of enam medical college is arranging monthly teaching and learning sessions for all teachers of the college. all the teachers of the college actively participate in these sessions. special seminars four special seminars were held during the period september to december 2014. date : september 16, 2014 topic : management of congenital anomalies speaker : prof. bijoy krishna das, pediatric plastic surgeon, operation cleft australia foundation chairperson : prof. md. khalilur rahman, head, department of surgery, enam medical college & hospital, savar, dhaka date : september 17, 2014 topic : acute flaccid paralysis (afp) and expanded programme on immunisation (epi) disease surveillance speaker : dr. md. aminul islam, surveillance medical officer, world health organisation chief guest : prof. abdul mannan sikder, principal, enam medical college, savar, dhaka chairperson : dr. md. moniruzzaman, director, enam medical college hospital, savar, dhaka date : september 23, 2014 topic : distribution of the holy quran with bengali translation among students, teachers and doctors by al quran academy london speaker : lt col (retd) md. shahidullah psc, mds regional director, south asia, al quran academy london chairperson : prof. abdul mannan sikder, principal, enam medical college, savar, dhaka 62 journal of enam medical college vol 5 no 1 january 2015 date : october 21, 2014 topic : battle against depression and suicide speaker : prof. dewan a. k. m. abdur rahim, head, department of psychiatry, enam medical college & hospital, savar, dhaka chairperson : prof. abdul mannan sikder, principal, enam medical college, savar, dhaka the seminar was held to coincide with observance of world mental health day. scientific presentations dr. md. aminul haque khan, professor & head, department of biochemistry, enam medical college, savar, dhaka and editor-in-chief, journal of enam medical college presented a paper titled ‘recent techniques in the monitoring of glycemic status’ in the bio-trade international symposium of the 20th diabetes & endocrine conference organised jointly by bangladesh endocrine society and diabetic association of bangladesh held in bangladesh university of health sciences (buhs), dhaka on december 18–20, 2014. prof. gulshan ara, head, department of obstetrics & gynaecology, enam medical college & hospital, savar, dhaka presented a paper titled ‘urogenital problems at postmenopause’ in the safom session of the 23rd international scientific conference of obstetrical & gynaecological society of bangladesh held in bangabandhu international conference centre, dhaka on september 26–27, 2014. dr. sumia bari, assistant professor, department of obstetrics & gynaecology, enam medical college & hospital, savar, dhaka presented a paper titled ‘morbidly adherent placenta: can we limit the aftermath?’ in the scientific session of the 23rd international scientific conference of obstetrical & gynaecological society of bangladesh held in bangabandhu international conference centre, dhaka on september 26–27, 2014. she also acted as a trainer in life saving skills on essential obstetrics care & newborn care (lss-eoc-nc) drill session. participation and presentation in scientific conference abroad dr. md. aminul haque khan, professor & head, department of biochemistry, enam medical college, savar, dhaka and editor-in-chief, journal of enam medical college attended the second international congress on publication ethics held in shiraz, iran on 4th–5th december, 2014. he presented a paper titled ‘authorship in scientific papers’ in the plenary session of the congress. he also chaired one plenary session of the congress. 63 j enam med col vol 5 no 1 january 2015 editor-in-chief from the desk of editor-in-chief alhamdulillah! the journal of enam medical college is being published regularly and timely in both print and electronic versions. the credit should go to teachers of enam medical college, contributors, reviewers, members of editorial board, office staff and chairman and principal of enam medical college for their multifarious co-operation, support and encouragement. improvement of the quality of a scientific journal is a continuous process. the editorial board is always working hard for this. we are committed to lift the esteem of the journal to further heights. the journal is already indexed in many indexing databases. our next target is to get it indexed in the databases of medline index medicus, pubmed and pubmed central. the flow of paper submission for publication in the journal of enam medical college is very good. papers are flowing in also from outside the country. this has been because of the quality of the journal and regular and timely publication. participation in the national and international conferences regarding publication of scientific journals would promote exchange of ideas among editors, authors, researchers, librarians and publishers of medical journals and would also expand collaboration among different countries. editor-in-chief of journal of enam medical college participated in the second international congress on medical writing held in ajman, united arab emirates on 5–7 march, 2015. editors/representatives from different journals of the world participated in the congress. his participation in that congress has greatly acquainted the journal of enam medical college and also the institution among the journal editors and research scientists attending the congress. an earthquake of 7.8 magnitude struck central nepal including its capital kathmandu on april 25, 2015 causing fatalities, injuries and massive damage. we mourn the sad demise of thousands of people and express our heart-felt sympathy for the members of the bereaved families. with all the best wishes. prof. md. aminul haque khan editor-in-chief article05 [converted].eps abstract background: diabetic retinopathy is a vascular disorder affecting the microvasculature of retina. it is caused by changes in the blood vessels of retina. if untreated, it may lead to blindness which is usually preventable if retinopathy is diagnosed early and treated promptly. in ophthalmology, color doppler imaging is a new method that enables us to assess the orbital vasculature. it allows for simultaneous two dimensional anatomical and doppler evaluations of hemodynamic characteristics of retinal artery. objective: to observe the difference between doppler flow velocity indices (peak systolic velocity, end diastolic velocity and resistive index) of retinal artery in type 2 diabetic subjects without retinopathy and those of normal controls. materials and methods: this case-control study was carried out in the department of radiology and imaging, bangladesh institute of research and rehabilitation in diabetes, endocrine and metabolic disorders (birdem) in collaboration with ophthalmology outpatient department, birdem, dhaka from july 2011 to june 2013. eighty diabetic patients without retinopathy aged 27–68 years were enrolled as cases and age and sex matched 80 healthy subjects were selected as controls. type 1 diabetic patients, type 2 diabetics with retinopathy, hypertensive and dyslipidemic subjects were excluded from the study. all the selected subjects underwent duplex doppler ultrasonography of both eyes using 5 to 7.5 mhz linear phase transducer. duplex color doppler findings including spectral analysis (psv, edv and ri) were recorded. unpaired t test was done to compare blood flow velocity indices of retinal artery in type 2 diabetic patients without retinopathy and that of healthy control subjects. p value <0.05 was considered as significant. results: majority (42.5% and 47.5%) of subjects were in 4th decade of life in both groups with predominance of males. the mean duration of diabetes was 4.56 ± 2.1 years. mean peak systolic velocity (psv) in 80 diabetic patients without retinopathy was 10.70 ± 1.50 cm/sec ranging 5.30 –16.10 cm/sec and that of 80 healthy subjects was 11.27 ± 0.98 cm/sec ranging 9.0 –13.10 cm/sec. mean end diastolic velocity (edv) in 80 diabetic patients without retinopathy was 2.58 ± 0.67 cm/sec ranging 1.00 –5.10 cm/sec and that of 80 healthy subjects was 4.11 ± 2.7 cm/sec ranging 3.00–4.60 cm/sec. mean resistive index (ri) in 80 diabetic patients without retinopathy was 0.75 ± 0.04 ranging 0.66 –0.81 and that of 80 healthy subjects was 0.64 ± 0.02 ranging 0.60 –0.70. mean difference of retinal arterial ri of diabetic subjects without retinopathy and healthy control eyes was statistically significant (p<0.001). conclusion: from the present study it can be concluded that, there is statistically significant difference between retinal arterial ri of type 2 diabetic patients without retinopathy and that of healthy control adult subjects. key words: retinopathy; ultrasonography; type 2 dm; duplex color doppler j enam med col 2014; 4(3): 168--173 168 duplex color doppler evaluation of retinal arterial blood flow in type 2 diabetic subjects without retinopathy 1. assistant professor, department of radiology and imaging, enam medical college & hospital, savar, dhaka 2. junior consultant, department of radiology and imaging, bangladesh institute of research and rehabilitation in diabetes, endocrine and metabolic disorders (birdem), dhaka 3. medical officer, department of radiology and imaging, birdem, dhaka 4. assistant professor, department of radiology and imaging, enam medical college & hospital, savar, dhaka 5. assistant professor, department of radiology and imaging, north east medical college & hospital, sylhet 6. senior consultant, department of radiology and imaging, birdem, dhaka correspondence mashah binte amin, email: mashah.amin@gmail.com original article mashah binte amin1, farzana shegufta2, md. towhidur rahman3, tarana yasmin4, khaleda parvin rekha5, a. s. mohiuddin6 received: may 24, 2014 accepted: june 20, 2014 journal of enam medical college vol 4 no 3 september 2014 diabetes mellitus is one of the most common noncommunicable diseases globally. the prevalence of diabetes for all age groups worldwide has been estimated to be 6.4%, affecting 285 million adults in 2010.1 bangladesh is a developing country that has been facing a high prevalence of diabetes mellitus. in 2011, 8.4 million of people with diabetes have been estimated in our country with prevalence of 8.1% in urban and 2.3% in rural areas.2-3 as the prevalence of diabetes is rising, the systemic complications that include retinopathy, nephropathy and neuropathy and involvement of cardiovascular system are also increasing.4 diabetic retinopathy is a vascular disorder affecting the microvasculature of retina. it is caused by changes in the blood vessels of retina. if untreated, it may lead to blindness. therefore, if diagnosed and treated promptly, blindness is usually preventable.5-7 in ophthalmology, color doppler imaging is a new method that enables us to assess the orbital vasculature. it allows for simultaneous two dimensional anatomical and doppler evaluations of hemodynamic characteristics of retinal artery.8-13 standard ophthalmoscopy can detect retinal abnormalities, but after the development of retinopathy and it is very much observer dependent.14-16 on the other hand, slit-lamp biomicroscopy can assess retinal changes, but it is very much time consuming and needs pupillary dilatation which causes discomfort to patient.17-18 retinal arterial hemodynamic changes can also be assessed by the gold standard fluorescein dye-dilution technique, but accurate measurement of staining after intravenous injection of fluorescein is difficult at retinal arterial level. therefore, duplex color doppler ultrasonography is the investigation of choice for qualitative and quantitative assessment of retinal arterial blood flow velocities very quickly without any invasive procedure.19-21 diabetic retinopathy is the leading cause of blindness. as the prevalence of diabetes is rising, the incidence of retinopathy is increasing day by day. for diagnosis of early changes in retinal blood flow in dm without retinopathy duplex color doppler ultrasonography is the investigation of choice to assess the problem very quickly without any invasive procedures. thus, this would be a beneficial tool for the ophthalmologist to assess and make quick decision about patient with impaired blood flow and to take necessary actions. therefore, we designed this study in our population to assess the different doppler flow velocity indices of retinal arteries. materials and methods this case-control study was conducted on both eyes of 160 subjects aged 27–68 years in the department of radiology and imaging, bangladesh institute of research and rehabilitation in diabetes, endocrine and metabolic disorders (birdem) from july 2011 to june 2013. patients with type 2 diabetes without retinopathy (normal findings in slit lamp biomicroscopy) were referred from ophthalmology opd, birdem to the department of radiology and imaging for duplex color doppler study of eyes. among them 80 diabetic patients without retinopathy were enrolled as cases and age and sex matched 80 healthy subjects with normal ophthalmology examination findings were taken as controls. patients with hypertension and dyslipidemia were excluded. the objective of the study was discussed in details with the patients before enrollment. demographic information was recorded and substantiated by means of inspection of medical record. information included the subject’s age, sex, medical and surgical history, clinical history of diabetes, followed by duplex color doppler study with spectral analysis. the color doppler study was performed first by the investigator herself and subsequently confirmed by a radiologist of the department of radiology and imaging, birdem who was not informed of the subject’s condition to eliminate bias. peak systolic velocity (psv), end diastolic velocity (edv) and resistive index (ri) of retinal arteries were recorded from both right and left eyes. duplex color doppler sonography of retinal arteries was also carried out in control group after informing them about the purpose of the study. psv, edv and ri were also measured in both eyes in control group. psv, edv and ri values of retinal artery of both groups were compared. all the relevant collected data were compiled on a master chart first, then organized by using scientific calculator and standard statistical formulas. percentage was calculated to find out the proportion of the findings. introduction 169 j enam med col vol 4 no 3 september 2014 further statistical analysis of the results was done by spss version 17.0. comparison between the velocity indices in diabetic patients without retinopathy and normal control individuals was done by the unpaired student t test. p value <0.05 was considered significant. results mean age of the diabetic patients was 46.05 ± 9.78 years with range from 27–68 years. among them 58.7% were male and 41.3% were female. most of the patients (42.5%) were found in 4th decade. on the other hand, the mean age of healthy control subjects was 42.78 ± 7.31 years with range from 30–59 years. among them 53.7% were male and 46.3% were female. majority (47.5%) were found in 4th decade. the mean duration of diabetes was 4.56 ± 2.1 years. the study also reveals that there was no significant difference (p>0.05) in retinal arterial mean psv, mean edv and mean ri between right and left eyes of diabetic patients without retinopathy and also in control subjects. in the current study, it was found that the mean psv in diabetic patients without retinopathy was 10.70 ± 1.50 cm/sec ranging 5.30 –16.10 cm/sec and the mean psv measured in healthy subjects was 11.27 ± 0.98 cm/sec ranging 9.00–13.10 cm/sec (table i). in the present study, it was also found that the mean edv in diabetic patients without retinopathy was 2.58 ± 0.67 cm/sec ranging 1.00–5.10 cm/sec and the mean edv measured in healthy subjects was 4.11 ± 2.7 cm/sec ranging 3.00–4.60 cm/sec (table ii). in this study the mean differences of retinal arterial psv and edv in diabetic eyes without retinopathy and healthy control eyes was statistically significant (p<0.01). in the current study, it was found that the mean ri in 80 diabetic patients without retinopathy was 0.75 ± 0.04 ranging 0.66 –0.81. and the mean ri value measured in 80 healthy subjects was 0.64 ± 0.02 ranging 0.60 – 0.70. the mean difference was statistically significant (p<0.001) between two groups (table iii). spectral doppler flow patterns of retinal arteries of both eyes in a normal control subject and a type 2 diabetic subject are shown in figures 1, 2, 3 and 4. table i: comparison between mean peak systolic velocity of retinal artery of 160 control eyes and 160 diabetic patients’ eyes without retinopathy (n=320) groups mean (cm/sec) range (cm/sec) t value p value control group 11.27 ± 0.98 9.00–13.10 (n=160) 78.45 <0.01 diabetic group 10.70 ± 1.50 5.30–16.10 (n=160) p value was achieved from unpaired t test table ii: comparison between mean end diastolic velocity of retinal arteries of 160 control eyes and 160 diabetic patients’ eyes without retinopathy (n=320) groups mean (cm/sec) range (cm/sec) t value p value control group 4.11 ± 2.7 3.00–4.60 (n=160) 71.76 <0.01 diabetic group 2.58 ± 0.67 1.00–5.10 (n=160) p value was achieved from unpaired t test table iii: comparison of retinal arterial mean resistive index (ri) between 160 control eyes and 160 diabetic patients’ eyes without retinopathy (n=320) groups mean ± sd range t value p value control group 0.64 ± 0.02 0.60–0.70 (n=160) 13.41 <0.001 diabetic group 0.75 ± 0.04 0.66–0.81 (n=160) p value was achieved from unpaired t test 170 j enam med col vol 4 no 3 september 2014 discussion as the prevalence of diabetes is rising, the systemic complications that include retinopathy, nephropathy, neuropathy and involvement of cardiovascular system are also increasing. diabetic retinopathy is the leading cause of blindness in the world. prevention of retinopathy needs early diagnosis.22 despite the improvement in ophthalmoscopic examination in outpatient department (opd) in ophthalmology, in order to diagnose early changes in retinal arterial flow velocity, a newer imaging modality may be used for diagnosis of early changes in retinal artery before clinical manifestation of retinopathy. color doppler imaging is the most promising modality that produces conventional gray-scale ultrasound images along with information regarding the direction and velocity of blood flow.23 the present study was attempted to evaluate clinically diagnosed diabetic patients without retinopathy by measuring the retinal arterial ri and compare the result with normal healthy controls by duplex color doppler study. in this study the age of the patients ranged from 27 to 68 years with the maximum number of cases found in the 40 – 49 years age group. observation reveals no statistically significant difference regarding mean age between cases and controls (p>0.05). a similar study done by kawagishi et al24 showed no significant difference between the two groups with respect of age. in this study the mean difference of retinal arterial psv in diabetic eyes without retinopathy and control eyes fig 1. spectral doppler flow patterns of retinal artery of right eye in a normal control subject fig 2. spectral doppler flow patterns of retinal artery of right eye in a type 2 diabetic subject fig 3. spectral doppler flow patterns of retinal artery of left eye in a normal control subject fig 4. spectral doppler flow patterns of retinal artery of left eye in a type 2 diabetic subject 171 j enam med col vol 4 no 3 september 2014 was statistically significant (p<0.01). one investigator guthoff et al25 who compared the mean psv of retinal artery in diabetic patients without retinopathy and healthy subjects also found significant difference in retinal arterial psv between cases and controls. the mean edv of 160 diabetic eyes without retinopathy and 160 control eyes was statistically significant (p<0.01). this observation is supported by the study done by jack et al15 who has compared the mean edv of diabetic patients and control group and discovered that there was statistically significant difference of mean retinal arterial edv between cases and control groups. in this study mean ri in 160 eyes of 80 diabetic patients without retinopathy was found 0.75 ± 0.04 (0.66 – 0.81). kawagishi et al24 found the mean ri value 0.70 ± 0.005. mean ri value measured in 160 eyes of 80 healthy subjects was 0.64 ± 0.02 (0.60 – 0.70) in this study and kawagishi et al24 found the mean ri value 0.65 ± 0.05 in healthy subjects. so, the result of present study is consistent with the study done by kawagishi et al.24 from the results of the present study it can be concluded that there is statistically significant difference between retinal arterial ri of type 2 diabetic patients without retinopathy and that of healthy control adult subjects included in this study. higher ri in type 2 diabetics may predict the early hemodynamic changes in the retinal artery of these patients before the clinical onset of retinopathy. however, further studies including large number of study subjects are recommended. references 1. ahmed kr, karim mn, bhowmik b, habib sh, ali l. incidence of diabetic retinopathy. j diabetes 2012; 4: 386–391. 2. shaw je, sieree ra, zimmet pz. global estimates of the prevalence of diabetes. diabetes res clin prac 2010; 87(1): 4–14. 3. idf diabetes atlas. available at: http//www. idf.org/diabetesatlas/5e/the global burden. accessed november 2012. 4. yau jw, rogers sl, kawasaki r, lamourese el, bek t. global prevalence and major risk factors of diabetic retinopathy. diabetes care 2012; 35(3): 556–564. 5. sandeman dd, shore ac, tooke je. relation of skin capillary pressure in patients with insulin-dependent diabetes to complications and metabolic control. n engl j med 1992; 327: 760–764. 6. dandona r, dandona l. socioeconomic status and blindness. br j ophthalmol 2001; 85: 1484–1488. 7. dandona r, dandona l. review findings from the andhra pradesh eye disease study. indian j ophthalmol 2001; 49: 215–234. 8. mackinnon jr, mckillop g, brien o, butt z, nelson p. colour doppler imaging of the ocular circulation in diabetic retinopathy. acta ophthalmol 2000; 78: 386–389. 9. mendivil a, cuartero v, mendivil mp. ocular flow velocities in patients with proliferative diabetic retinopathy and healthy volunteers. b j of ophthalmology 1995; 79: 413–416. 10. dimitrova g. colour doppler imaging of ocular and orbital blood vessels in retinal diseases. european ophthalmic review 2011; 5: 16–19. 11. fielding ja. ultrasound imaging of the eye through the closed lid using a non dedicated scanner. clin radiol 1987; 38: 131–135. 12. guthoff rf, berger rw, winkler p, helmke k, chumbley lc. doppler ultrasonography of the ophthalmic and central retinal vessels. arch ophthalmol 1991; 109: 532–536. 13. goebal w, leib h, sergott rc, farhoumand r, grehn f. colour doppler imaging: a new technique to assess orbital blood flow in patients with diabetic retinopathy. invest ophthalmol vis c 1995; 36: 864–870. 14. tamaki y, nagahara m, yamashita h, kikuchi m. blood velocity in the ophthalmic artery determined by colour doppler imaging in normal subjects and diabetics. jpn j ophthalmol 1993; 37: 385–392. 15. jack ph. colour doppler ultrasonographic imaging of central retinal artery. available at: http://www.resmedical.com/endocrine-glands/58571. accessed april 2012. 16. little hl. the role of abnormal hemodynamic in the pathogenesis of diabetic retinopathy. trans am ophthalmol soc 1976; 74: 573–636. 17. eliash zb, nelsol da, barak a, bartal o. reduced retinal blood flow velocity in diabetes retinopathy. retina 2010; 10: 1–11. 18. nagaoka a, sato e, takahashi a,yokota h, sogawa k, yoshida a. impaired retinal circulation in patients with type 2 diabetes mellitus: retinal laser doppler velocimetry study. invest ophthalmol vis sci 2010; 51: 6729–6734. 19. zawinka c, dornar gt, polska e, frank b. calculation of the diameter of the central retinal artery from non invasive measurements in human. current eye research 2002; 25: 341–345. 172 j enam med col vol 4 no 3 september 2014 20. polska e, kircher k, ehrlich p, vecsei pv, schmetterer l. ri in central retinal artery as assessed by cdi does not correspond to retinal vascular resistance. am j physiol heart circ physiol 2001; 280(4): 1442–1447. 21. dimitrova g. colour doppler imaging of ocular and orbital blood vessels in retinal diseases. european ophthalmic review 2011; 5: 16–19. 22. prahs p, helbig h. diabetic eye disease. ther umsch 2009; 66: 183–188. 23. benden cj, abbitt pl, beadless ka. colour doppler us of the orbit. radio graphic 1995; 15: 589–608. 24. kawagishi t, nishizawa y, emoto m, konishi t, maekawa k, hagiwara s et al. impaired retinal artery blood flow in iddm patients before clinical manifestations of diabetic retinopathy. diabetes care 1995; 18: 1544–1549. 25. guthoff rf, berger rw, winkler p, helmke k, chumbley lc. doppler ultrasonography of the ophthalmic and central retinal vessels. arch ophthalmol 1991; 109: 532–536. 173 j enam med col vol 4 no 3 september 2014 article07 [converted].eps abstract ebola virus is a filamentous, enveloped, non-segmented, single-stranded, negative-sense rna virus. it belongs to the filoviridae and was first recognized near the ebola river valley in zaire in 1976. since then most of the outbreaks have occurred to both human and nonhuman primates in sub-saharan africa. ebola virus causes highly fatal hemorrhagic fever in human and nonhuman primates. in addition to hemorrhagic fever, it could be used as a bioterrorism agent. although its natural reservoir is yet to be proven, current data suggest that fruit bats are the possibility. infection has also been documented through the handling of infected chimpanzees, gorillas, monkeys, forest antelope and porcupines. human infection is caused through close contact with the blood, secretion, organ or other body fluids of infected animal. human-to-human transmission is also possible. ebola virus infections are characterized by immune suppression and a systemic inflammatory response that causes impairment of the vascular, coagulation, and immune systems, leading to multiorgan failure and shock. the virus constitutes an important public health threat in africa and also worldwide as no effective treatment or vaccine is available till now. key words: ebola virus; hemorrhagic fever; fruit bats j enam med col 2015; 5(1): 44–51 ebola virus (ev) is the causative agent of the ongoing deadly epidemic in west africa. it is one of the world's most dreadful pathogens, causing catastrophic clinical disease1 and remains one of the most lethal transmissible infections with high fatality rates up to 90% and substantial morbidity during sporadic outbreaks.2,3 high case-fatality rates, as well as known aerosol infectivity, make the virus a potential global health threat and possible biological warfare agent and is classified as category a bioterrorism threats.4-6 ebov together with marburg virus comprise the family filoviridae in the order mononegavirales.7 the genus ebolavirus is comprised of five genetically distinct species: bundibugyo ebolavirus (bdbv), zaire ebolavirus (zebov), sudan ebolavirus (sudv), tai forest ebolavirus (tafv) and reston ebolavirus (restv).8-10 among the five species zaire, sudan and bundibugyo ebolaviruses are responsible for most of the ebola hemorrhagic fever (ehf) outbreaks.11 reston ebolavirus has caused disease in nonhuman primates but not in humans in the philippines.12 the recent ongoing epidemic is caused by the zebov and has been the most severe outbreak since ebola virus was first identified in 1976.13 no previous outbreak has been as large or persistent as the current epidemic. to date, the number of cases now exceeds the number from all previous outbreaks combined. in addition to mortality, indirect effects include disruption of standard medical care, substantial economic losses, insecurity and social disruption in countries that were already struggling to recover from decades of war.14 on august 8, 2014 the world health organization (who) declared the current epidemic as a public health emergency of international concern (pheic).15 though ebola infections are generally confined to central africa, there is always a risk of spreading to the rest of the world. furthermore, the virus causes highly fatal disease in human, could be used as a bioterrorism agent introduction 44 ebola virus --a global threat 1. associate professor, department of microbiology, enam medical college, savar, dhaka 2. assistant professor, department of microbiology, enam medical college, savar, dhaka correspondence mejbah uddin ahmed, email: mejbahua@gmail.com review article mejbah uddin ahmed1, sushmita roy2 received: september 6, 2014 accepted: october 25, 2014 doi: 10.3329/jemc.v5i1.21497 journal of enam medical college vol 5 no 1 january 2015 and at present no effective treatment or vaccine is available. therefore, people should be aware of the threats from the ebola virus in order to avoid infection and scientists should try their best to formulate a treatment and vaccine. history and geographic distribution sporadic outbreaks of marburg virus and ebola virus infection have presumably occurred in central africa for millennia, but the agents were not recognized by the scientific community until the late 20th century.16 the cases of filovirus hemorrhagic fever were reported first in 1967 among workers in german and yugoslavian vaccine plants who were processing tissues from monkeys imported from uganda. the causative agent was identified as marburg virus.17,18 similar cases of hemorrhagic fever were described in 1976 from outbreaks in two neighboring locations: first in southern sudan and subsequently in northern zaire, now democratic republic of the congo (drc). an unknown causative agent was isolated from patients in both outbreaks and was named ebolavirus after a small river in northwestern drc.19 these two epidemics were caused by two distinct species of ebolavirus, sudan ebolavirus and zaire ebolavirus. the third african ebola virus species, tai forest ebolavirus (côte d'ivoire ebolavirus) was discovered in 1994 from an infected ethnologist who had worked in the tai forest reserve in côte d'ivoire and had done a necropsy on a chimpanzee. bundibugyo ebolavirus is the fourth species of ebola virus found in equatorial africa.7,20 an additional species, the reston ebolavirus, was first described in 1989 and isolated from cynomolgus monkeys (macaca fascicularis) housed at a quarantine facility in reston, va, usa. subsequently, reston ebolavirus has been found in the philippines on several occasions in pigs.20,21 since the time of first recovery, with the exception of a few accidental laboratory infections, ebola outbreaks have been mostly concentrated in remote areas of sub-saharan africa, but evidence of ebola infection of swine in the philippines, the presence of antibodies among orangutans in indonesia and bats in china indicates that ebola virus may be more widespread than previously thought.22-24 the frequency of recognized outbreaks has been increasing since 1990.25 after smaller outbreaks in zaire and sudan, some 15 years passed before ebola virus reappeared in 1994 in gabon. a large hospital-based epidemic in the democratic republic of congo in 1995 brought the virus to worldwide attention and re-emergence of sudan ebolavirus in uganda in late 2000 resulted in 425 cases and 225 deaths. epidemics of zaire ebolavirus have increased in frequency in recent years.16 the virus has caused more than 20 outbreaks since its identification. in most instances, the virus emerged in geographically restricted rural regions.26 outbreak of ebola virus disease in west africa is so large and severe; there are many factors behind it, but poverty is considered as the main reason. the hardest-hit countries guinea, liberia and sierra leone are among the poorest nations and have recently emerged from years of conflict and civil war. their health systems are destroyed or severely disabled and in some areas war left a generation of children without education. health care infrastructure is inadequate and health workers and essential supplies including personal protective equipments are scarce. population movements across the porous borders are constant, so transmission is intense and people continue to reinfect each other.27 traditional practices, such as bathing of corpses before burial, are also an important factor for disease transmission.26 current situation the recent ongoing epidemic caused by the zaire ebolavirus started in guinea in december 2013 and then spread to liberia, sierra leone and nigeria; it is the largest ebola virus epidemic in history. it has been the most severe outbreak in terms of the number of human cases and fatalities since the discovery of the virus in 1976.13 the situation is changing rapidly and other countries might experience imported cases or outbreaks. instances of civil unrest and violence against aid workers have been reported in west africa as a result of the outbreak. the public health systems in the affected countries are being severely strained as the outbreak grows.28 on 10 december 2014, who reported a total of 17,942 suspected cases and 6,388 deaths.29 ebola virus and bangladesh situation olival et al19 conducted a study in bangladesh during april 2010 to march 2011. they tested 276 bats of several species from faridpur, rajbari, lalmonirhat, and comilla districts. among them five bats were positive for antibodies against ebola zaire and reston viruses, but no virus was detected by pcr. there are reasons to speculate that bats might be a reservoir for ebola or ebola-like viruses and extend the range of 45 j enam med col vol 5 no 1 january 2015 filoviruses to mainland asia. failure to detect filovirus nucleic acid might reflect the relatively small sample size, low virus prevalence, or use of a pcr that has low sensitivity for filoviruses circulating in bangladesh.19 the national disease monitoring arm institute of epidemiology, disease control and research (iedcr) is keeping a close watch on the current situation. due to travel restrictions on ebola patients and the absence of direct air links with the affected west african countries made the deadly virus making its way to bangladesh “a remote possibility”. director of iedcr considers bangladesh a low-risk country and urged everyone not to spread panic. bangladesh has also issued an alert against ebola virus for three months, after the who declared the epidemic an international health emergency.30 viral structure ebola virus is filamentous, enveloped, non-segmented, single-stranded, negative-sense rna virus.31,32 the ebov genome is about 19000 nucleotides long that encodes seven structural proteins, nucleoprotein (np), polymerase cofactor (vp35), matrix protein (vp40), glycoprotein (gp), replication-transcription protein (vp30), minor matrix protein (vp24) and rna-dependent rna polymerase (l).33,34 the structural proteins vp40 and vp24 represent viral matrix proteins connecting the nucleocapsid with the viral envelope. vp40 plays an essential role in assembly and budding of the virus.35 ebola virus is susceptible to 3% acetic acid, 1% glutaraldehyde, alcohol-based products and dilutions of 5.25% sodium hypochlorite and calcium hypochlorite. the who recommendation for cleaning up spills of blood or body fluids is flooding the area with a 1:10 dilution of 5.25% sodium hypochlorite for 10 minutes. the virus is moderately thermolabile and can be inactivated by heating for 30 to 60 minutes at 60°c, boiling for 5 minutes or gamma irradiation combined with 1% glutaraldehyde. it has been reported that the virus is capable to survive for weeks in blood particularly at low temperatures (4°c). when dried in tissue culture media and stored at 4°c, zaire ebolavirus survived for over 50 days. this information is based on experimental findings and intended to be used to support local risk assessments in a laboratory setting.36 cell tropism and replication ebola virus is known to be pantropic in infection of human and can infect a wide variety of cell types. though ebola shows broad tissue tropism, hepatocytes, endothelial cells, dendritic cells, monocytes, and macrophages are thought to be their preferred target cells.31 infection begins with the attachment of the virion to a receptor or lectin on the cell surface. binding is followed by endocytosis, fusion of the viral envelope with the cellular endosomal membrane and release of the rna genome and viral proteins into the cytoplasm. a replication complex made up of vp30, nucleoprotein, vp35 and large protein then generates mrna transcripts. the new genomes associate with nucleoprotein and vp30 to form nucleocapsids which accumulate in inclusion bodies. meanwhile, newly synthesized viral glycoprotein becomes glycosylated during its transit through the host-cell golgi apparatus and is cleaved by a furinlike enzyme before transfer to the cell surface, producing extracellular gp1 and transmembrane gp2 segments that remain linked by a disulphide bond. the assembly of new virions takes place on the inner surface of the plasma membrane, when nucleocapsids associate with matrix proteins linked to the cytoplasmic tail of membrane-bound gp. the nascent virions leave the cell through budding.16 natural reservoir the first recorded human outbreak of ebola virus was in 1976, but the wild reservoir of this virus is still unknown.37 since the discovery of filoviruses more than 40 years ago, ostensibly random, sporadic and fatal outbreaks of disease in primates have evoked interest in delineation of host tropisms, potential reservoirs for disease transmission and persistence in nature.8 however, researchers have hypothesized that it is an animal origin virus.38 current data suggest that in africa fruit bats are the possible natural reservoir hosts. as a result, the geographic distribution of ebola viruses may overlap with the range of the fruit bats.9 infection has also been documented through the handling of infected chimpanzees, gorillas, monkeys, forest antelope and porcupines.13 transmission the exact mode of transmission of the virus from the natural reservoir to a human is not known. evidence suggests that human infection is caused through close contact with the blood, secretion, organ or other body fluids of infected animal. human-to-human transmission is also possible.9 ebov is shed in a wide variety of body fluids 46 j enam med col vol 5 no 1 january 2015 (saliva, stool, semen, breast milk, tears, nasal blood and skin swab of infected person) during the acute period of illness. however, the risk of transmission from fomite of a patient and during the convalescent period is low.39 it was found that men who have recovered from the disease can still transmit the virus through their semen for up to 7 weeks after recovery from illness. healthcare workers may get infection through close contact with patients, when infection control precautions are not practiced properly.9 although ebola virus has been detected in breast milk, it is not known clearly whether ebola virus can be transmitted through breastfeeding. infected mothers may be critically ill and unable to breastfeed; but when they are able to breastfeed, decisions about whether or not to breastfeed may depend on the age of the infant, the availability and feasibility of safe nutrition and infant care and overall sanitary conditions. the recommendation of cdc is when safe alternatives to breastfeeding and infant care exist, mothers with probable or confirmed ebola virus disease should not have close contact with their infants including breastfeeding.40 pathogenesis ebov is an aggressive pathogen that causes highly fatal hemorrhagic fever in human and nonhuman primates.41 the virus has the specialized mechanisms to evade the immune system and the course of illness results from a complex pathogenic mechanism.16 in a study it is shown that fatal outcome is associated with aberrant innate immune responses and suppression of the adaptive immunity. the innate immune responses are characterized by the hypersecretion of numerous proinflammatory cytokines (il-1β, il-1ra, il-6, il-8, il-15 and il-16), chemokines, growth factors (mip-1α, mip-1β, mcp-1, m-csf, mif, ip-10, gro-α and eotaxin) and by the noteworthy absence of antiviral ifnα2. suppression of adaptive immunity is characterized by very low levels of circulating cytokines produced by t lymphocytes and by massive loss of peripheral cd4 and cd8 lymphocytes.37,42 viral replication, in conjunction with immune and vascular dysregulation, is thought to play the vital role in the disease process. specific organ involvement includes extensive disruption of the parafollicular regions in the spleen and lymph nodes and proliferation of the virus in mononuclear phagocytic cells has been demonstrated.43 studies in nonhuman primate models depicted monocytes, macrophages and dendritic cells are the major sites of initial viral replication. virus is then distributed by the circulating phagocytic cells to a wide variety of organs and cells. infected dendritic cell cultures supported exponential viral growth without releasing interferon (ifn-α).44 two viral proteins (ebov vp35 and ebov vp24) are responsible for suppression of interferon responses. it seems that ebov infection blocks the cellular production of ifnα/β and the ability to respond to ifn-α/β or ifn-γ. the vp24 is likely to be an important virulence factor that allows the virus to evade the antiviral effects of ifns.45,46 in most instances, patients fail to produce antibodies against the virus and die with persistent high viremia. for initiation of an adaptive immune response presentation of viral antigens to lymphocytes is required. phagocytic cells are the major sites of viral replication, which block their maturation and cause their death through necrosis. the system-wide release of proinflammatory cytokines and chemokines by these infected cells causes fever, disseminated intravascular coagulation, vascular instability, hypotension, shock and multi-organ failure. although lymphocytes remain free of infection, they are destroyed in massive numbers over the course of illness through apoptosis.47 massive apoptosis of natural killer and t cells further impairs immunity.48 although some studies have shown that survival of the patient is associated with the ability of production of antigen-specific antibodies, a recent report from sudan suggests that cell-mediated responses could also play an important role in protection.49,50 blood samples obtained during several outbreaks in gabon also suggested that survival is associated with the earlier appearance of proinflammatory cytokines in the blood.51 clinical features clinical findings are variable in ebola infection. after an incubation period of around 2–21 days,4 disease starts nonspecifically with the abrupt onset of fever, chills, headache, malaise, anorexia, sore throat, myalgia and joint pains.20,46 the initial features of the disease may mimic other tropical diseases and it is difficult to distinguish these features from other febrile illnesses. conjunctival infection is seen in up to half of the patients.46 respiratory symptoms include chest pain, shortness of breath, dry cough and nasal discharge.20 gastrointestinal manifestations including nausea, vomiting, abdominal pain and diarrhea develop within the first few days of illness. in severe cases, vascular 47 j enam med col vol 5 no 1 january 2015 instability develops, usually 4–5 days after the onset of symptoms and may be evidenced by facial flushing, edema, proteinuria, bleeding, hypotension and shock.46 maculopapular rash associated with varying severity of erythema appears which desquamates by day 5–7 of the illness; this symptom is a valuable differential diagnostic feature and is usually followed by desquamation in survivors.20 hemorrhage is most often gastrointestinal but vaginal bleeding, petechie, purpura, epistaxis and bleeding from the gums may be seen. central nervous system manifestations including disorientation, gait anomalies, convulsions and hiccups may also be noted in end-stage disease.46 laboratory diagnosis in the absence of effective intervention strategies, diagnosis becomes a key element in response to ebola virus infection. diagnosis of ehf must be sensitive, specific and reliable because misdiagnosis may bring huge turmoil to society. therefore, the diagnosis of ehf must not rely on any single method. during outbreak, patients with ehf must be isolated and a false-positive result will put an individual at unnecessary risk of cross infection by placing the person in an isolation ward. a false-negative result will allow infected persons to be released into the community and may cause person-to-person transmission of the virus in the community.52 laboratory diagnosis of ebola virus is achieved in two ways: measurement of host-specific immune responses to infection and detection of viral particles or particle components in infected individuals.20 therefore, the diagnosis rests largely on molecular techniques utilizing multiple reverse-transcriptase–polymerase-chainreaction assays that can be used at remote outbreak sites. antigen detection may be performed in parallel or serve as a confirmatory test for immediate diagnosis whereas assays for detection of antibodies (igm and igg) using unique virus antigens are secondary tests that are primarily important in surveillance.53,54 definitive diagnosis is usually made by pcr and virus isolation on vero cells. as a class-4 pathogen, ebola virus culture requires a maximum containment facility. additional immunological tests include elisas for the detection of ebola iggand igm-specific antibodies and virus antigens; more specialized molecular testing is also available but is not readily available in the usual clinical setting.11 now-a-days, rt-pcr and antigen detection elisa are the primary assays to diagnose an acute infection. viral antigen and nucleic acid can be detected in blood from day 3 up to 7–16 days after onset of symptoms. for antibody detection the most generally used assays are direct igg and igm elisas and igm capture elisa. igm antibodies can appear as early as 2 days postonset of symptoms and disappear between 30 and 168 days after infection. igg-specific antibodies develop between day 6 and 18 after onset and persist for many years. an igm or rising igg titer constitutes a strong presumptive diagnosis. decreasing igm or rising igg titers (four-fold), or both, in successive paired serum samples are highly suggestive of a recent infection.20 histopathological techniques and antigen detection by immunohistochemical analyses are sensitive methods, particularly for postmortem diagnosis. diagnosis by detection of virus antigens is suitable for patients in the early stage and detection of specific igm and igg antibodies is suitable for patients in a relatively late stage of illness.48 treatment ebov infections are a public health concern because of the high mortality rate and lack of prophylactic and therapeutic interventions as no specific antiviral treatment is available at present.55 severely ill patients require intensive supportive care which includes oxygen, blood pressure medication, blood transfusions, rehydration with intravenous fluids containing electrolytes and treatment for other infections.9 a study done by qiu et al in 2012 shows that a combination of three neutralizing monoclonal antibodies directed against the envelope glycoprotein resulted in complete survival of four of four cynomolgus macaques with no apparent side effects when three doses were administered 3 days apart beginning at 24 hours after a lethal challenge with ebov. the same treatment initiated 48 hours after resulted in two of four cynomolgus macaques fully recovering.56 prevention although safe and effective vaccines or other medicinal agents to block ebola infection are currently unavailable, a significant effort has been put forth to identify several promising candidates for the treatment and prevention.2,57 some vaccines under trial have been shown to protect nhps: a replication-incompetent adenovirus expressing the ebov glycoprotein (29–31), a replication-competent vesicular stomatitis virus (vsv) expressing gp (7, 15), a recombinant 48 j enam med col vol 5 no 1 january 2015 paramyxovirus expressing gp (4), and virus-like particles (38, 41).5 in the absence of effective treatment and vaccine, raising awareness regarding the risk factors and personal protective measures is the only way to reduce human infection and death.9 there are three key preventive interventions which have gained attention with encouraging outcome. the first is meticulous infection control in health care settings. second is educating and supporting the community to avoid contact with body fluids of people who died from evd, at least temporarily until the outbreak is controlled. and the third is avoiding handling of bush meat and contact with bats.14 conclusion the main goal currently being addressed with ebola virus is finding ways of treatment and effective vaccines that can be applied to humans. although ebola virus infection is not a problem right now for most populations outside africa, it has the potential to be alarming from the point of view in global health in the future. references 1. goodman jl. studying “secret serums” — toward safe, effective ebola treatments. n engl j med 2014; 371(12): 1086–1089. doi: 10.1056/nejmp1409817. 2. oestereich 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infectious diseases 2007; 196(2): 142–147. 40. ebola virus disease. centers for disease control and prevention. recommendations for breastfeeding/infant feeding in the context of ebola. available at: http://www.cdc. gov/vhf/ebola/hcp/recommendations-breastfeeding-infantfeeding-ebola.html. accessed september 2014. 41. casillas am, nyamathi am, sosa a, wilder cl, sands h. a current review of ebola virus: pathogenesis, clinical presentation, and diagnostic assessment. biological research for nursing 2003; 4(4): 268–275. 42. wauquier n, becquart p, padilla c, baize s, leroy em. human fatal zaire ebola virus infection is associated with an aberrant innate immunity and with massive lymphocyte apoptosis. plos negl trop dis 2010; 4(10): e837. 43. bente d, gren j, strong je, feldmann h. disease modeling for ebola and marburg viruses. dis model mech 2009; 2(1-2): 12–17. 44. bosio cm, aman mj, grogan c, hogan r, ruthel g, negley d et al. ebola and marburg viruses replicate in monocytederived dendritic cells without inducing the production of cytokines and full maturation. j infect dis 2003; 188(11): 1630–1638. 45. basler cf, mikulasova a, martinez-sobrido l, paragas j, mühlberger e, bray m et al. the ebola virus vp35 protein inhibits activation of interferon regulatory factor 3. j virol 2003; 77(14): 7945–7956. 46. reid sp, leung lw, hartman al, martinez o, shaw ml, carbonnelle c et al. ebola virus vp24 binds karyopherin j enam med col vol 5 no 1 january 2015 50 alpha1 and blocks stat1 nuclear accumulation. j virol 2006; 80(11): 156–167. 47. bausch dg, sprecher ag, jeffs b, boumandouki p. treatment of marburg and ebola hemorrhagic fevers: a strategy for testing new drugs and vaccines under outbreak conditions. antiviral research 2008; 78: 150–161. 48. bray m, geisbert tw. ebola virus: the role of macrophages and dendritic cells in the pathogenesis of ebola hemorrhagic fever. the international journal of biochemistry & cell biology 2005; 37(8): 1560–1566. 49. ksiazek tg, rollin pe, williams aj, bressler ds, martin ml, swanepoel r et al. clinical virology of ebola hemorrhagic fever (ehf): virus, virus antigen, and igg and igm antibody findings among ehf patients in kikwit, democratic republic of the congo, 1995. j infect dis 1999; 179(suppl 1): s177–s187. 50. towner js, rollin pe, bausch dg, sanchez a, crary sm, vincent m et al. rapid diagnosis of ebola hemorrhagic fever by reverse transcription-pcr in an outbreak setting and assessment of patient viral load as a predictor of outcome. j virol 2004; 78(8): 4330–4341. 51. baize s, leroy em, georges-courbot mc, capron m, lansoud-soukate j, debré p et al. defective humoral responses and extensive intravascular apoptosis are associated with fatal outcome in ebola virus-infected patients. nat med 1999; 5(4): 423–426. 52. saijo m, niikura m, ikegami t, kurane i, kurata t, morikawa s. laboratory diagnostic systems for ebola and marburg hemorrhagic fevers developed with recombinant proteins. clin vaccine immunol 2006; l3 (4): 444–451. 53. zaki sr, shieh wj, greer pw, goldsmith cs, ferebee t, katshitshi j et al. a novel immunohistochemical assay for the detection of ebola virus in skin: implications for diagnosis, spread, and surveillance of ebola hemorrhagic fever. the journal of infectious diseases 1999; 179(1): 36–47. 54. feldmann h. ebola — a growing threat? n engl j med 2014; 371(15): 1375–1378. doi: 10.1056/nejmp1405314. 55. nakayama e, takada a. ebola and marburg viruses. journal of disaster research 2011: 6(4): 381–382. 56. qiu x, audet j, wong g, pillet s, bello a, cabral t et al. successful treatment of ebola virus–infected cynomolgus macaques with monoclonal antibodies. sci transl med 2012: 4(138): 138ra81. 57. choi jh, croyle ma. emerging targets and novel approaches to ebola virus prophylaxis and treatment. bio drugs 2013; 27(6): 565–583. 51 j enam med col vol 5 no 1 january 2015 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 from the desk of editor-in-chief doi: https://doi.org/10.3329/jemc.v11i2.65186 alhamdulillah! we could publish this issue of journal of enam medical college in spite of prevailing of wide spread of corona virus in the country. we share this success with the contributors, reviewers and faculties and authority of the college without whose active and sincere cooperation it would not have been possible to publish the journal in this situation. we are very grateful to all of them. the flow of paper submission for publication in the journal of enam medical college continues to be very good. papers are flowing in also from outside the country. this has been because of the quality of the journal and regular and timely publication. we request all to take care of their personal health and health of the family members by following health guidelines and pray to the almighty for improvement of the covid situation. with all the best wishes. prof. md. aminul haque khan editor-in-chief from the desk of editor-in-chief doi: https://doi.org/10.3329/jemc.v11i1.63166 alhamdulillah! we have already completed ten years of publication of journal of enam medical college. this is the 10th anniversary issue of journal of enam medical college. this is a great success and landmark in the trajectory of the journal. we share this success with the contributors, reviewers, faculties and authority of the college without whose active support and cooperation it would not have been possible to publish the journal regularly and timely. we feel very grateful to all of them. journal of enam medical college is already indexed in many indexing databases. the flow of paper submission for publication in the journal of enam medical college continues to be very good. papers are flowing in also from outside the country. this has been because of the quality of the journal and regular and timely publication. participation in the national and international conferences and workshops promotes exchange of ideas among professionals. during the last four months period faculties of enam medical college could not participate in scientific conferences at home and abroad because of pandemic covid situation and present papers, but many faculties did it online. their participation in these conferences and workshops greatly acquainted enam medical college among the professionals participating these online conferences. we congratulate all of them. with all the best wishes. prof. md. aminul haque khan editor-in-chief journal of enam medical college vol 11 no 2 may 2021 135 college news compiled by halima begum doi: https://doi.org/10.3329/jemc.v11i2.65197 cpd programme continuing professional development (cpd) is a process by which individuals take control of their own learning and development by engaging themselves in an ongoing process of reflection and action. it assists the medical professionals to keep them up-to-date to converge the necessity of the patient and health care services and to upgrade their knowledge, skill and attitude. the coronavirus disease 2019 (covid-19) pandemic has caused an unprecedented disruption in medical education. seminars were not organized in enam medical college during the period of january 2021 to april 2021 due to safety issues. cme programme to enhance communication skill in teaching and learning and efficiency of judgment of teachers, especially the freshly appointed teachers in the assessment in examinations and to improve medical teaching standard of teachers by refreshing knowledge, skill and attitude, continued medical education (cme) programmes are very much needed. it is also essential to make them oriented with the updating of education system, teaching and research methodology and to share experience and views of senior faculties. in these perspectives, medical education unit of enam medical college is arranging teaching and learning session for all teachers of the college every two months. the covid-19 pandemic has affected healthcare systems worldwide. the disruption to hospital routines has affected continuing medical education also. programmes were switched to videoconferencing to maintain teaching. some programmes also utilized small group teachings with precautions and e-learning modules. teachers actively participated in these sessions. attending scientific conferences in home and abroad prof. shaheen akter, professor and head, department of paediatrics & neonatology, enam medical college & hospital, savar, dhaka attended in 42nd meeting of adverse event following immunization(aefi) expert review committee held at epi bhaban, mohakhali, dhaka on 24 february 2021. dr. sumia bari, associate professor, department of gynaecology& obstetrics, enam medical college & hospital, savar, dhaka attended in 29th international scientific conference at dhaka on 27 march 2021. the covid pandemic commuted many international conferences to acquire an online format, where many of our teachers from different departments participated. a dedicated medical oxygen generation plant at enam medical college hospital has been installed enam medical college hospital has further consolidated its position as one of the best hospitals in the country by installation of a dedicated three-tier supply line for continuous medical oxygen generation to fulfill the increasing requirements for life-saving oxygen among corona surge across the upazila on 3 may 2021. both covid and non-covid patients are receiving continuous oxygen supply from that plant. the project was implemented by spectra oxygen limited. insha allah enam medical college will go far in the service of people with the love of all. journal of enam medical college vol 11 no 1 january 2021 4 editorial cancer phobia received: 16 february 2020 accepted: 18 november 2020 doi: https://doi.org/10.3329/jemc.v11i1.63167 in one morning session of my private practice at rajshahi, i found a group 10−12 females and accompanying two males waiting in the patients’ waiting room. their ages ranged from 35 to 50 years, all were looking very tired an anxious. they came from long distance by overnight train journey. seeing a group of same aged village women i became little bit astonished. i asked my chamber assistant about them. he told me that all were patients and they wanted to consult with you. at first one female and a male person entered into my room and took their seats. the male person said they were husband and wife and the wife had been suffering from breast problems. rest other patients were his relatives and neighbours. i asked the patient to state her problems. she stated her breast problems nicely and briefly. then rest others met me one by one and stated their breast problems. the gists of the ten female patients’ clinical histories were almost similar. all were married and multiparous suffering from breast pain, lump, occasional fever and general weakness. their problems aggravated following death of a breast cancer patient of their locality. they said that the deceased was my patient and i operated her about six months back. at the time of discharge from hospital i told her husband that his wife would not survive for a long time. and she died within six months. so they came to me to get their breasts examined and to know whether they were suffering from breast cancer or not. i could guess why they came en-mass with their breast problems. i listened to them with patience and examined each patient very carefully. physical examination revealed none of them was breast cancer patient. two of them had fibroadenosis, one fibroadenoma and one chronic mastitis. these four females were advised some essential laboratory investigations and asked to attend in the evening time of practice. they came accordingly with investigation reports. investigation found no evidence of malignancy in any case. i met them all at a time and discussed freely and affectionately about breast cancer. i told them that it was good that they were conscious about carcinoma breast and so they came in a group for examination of their breasts. they were very happy to know that none of them was suffering from carcinoma breast. i thanked them for their consciousness not to become frightened unnecessarily. i told them, “breast cancer is not an infectious or contagious disease. so it does not spread from person to person and it will not attack close neighbour and relatives. fear, being frightened and scared on false believe of cancer is very harmful for mental and physical health.you have come here en-mass due to panicky attack of cancer as one of your relative died from breast cancer. so, my advice is that please examine your breasts with your hands at least at the time of taking bath. if you feel any lump in your breast then please attend an experienced and senior doctor for further consultation.” role of doctors in cancer phobia after taking clinical history and necessary physical examination of a patient, if it seems clinically that the patient has been suffering from cancer (malignancy), it should not be disclosed to the relative or to the patient instantly by the doctor. • which is unethical and may create anxiety, worries and panic. • if requisite cancer proving investigations such as a fnac, biopsy-histopathology, x-ray, ct-scan, blood test etc. find evidence of cancer, then fact should be disclosed to the patient’s party and patient after proper counseling. january 2021j enam med col vol 11 no 1 5 • sometimes clinical diagnosis does not correlate with confirmatory tests. prior false information of cancer is very much disgusting and disgraceful to that doctor. it is also responsible for producing unnecessary panic to close relatives and patient. • this type of wrong information sometimes produces misunderstanding between the doctor and patient’s party. so a doctor should maintain delicacy and etiquette before giving breaking bad news of cancer. md. khalilur rahman former professor, department of surgery rajshahi medical college & hospital, rajshahi and enam medical college & hospital, savar, dhaka journal of enam medical college vol 11 no 1 january 2021 55 case report caroli’s syndrome in a 5½-year-old bangladeshi girl: a case report nazmul ahamed1, dipanwita saha2, azm raihanur rahman3, mukesh khadga4, sharmin akter5, md rukunuzzaman6 received: 2 march 2020 accepted: 7 august 2020 doi: https://doi.org/10.3329/jemc.v11i1.63175 abstract caroli’s syndrome is a rare inherited disorder characterized by multiple segmental cystic or saccular dilatation of the intrahepatic bile duct associated with congenital hepatic fibrosis. symptoms of caroli’s syndrome may appear early or late during life and its presentation is highly variable. portal hypertension followed by development of oesophageal varices is the main consequence of congenital hepatic fibrosis. up to 60% of caroli’s syndrome patients are associated with renal involvement. the diagnosis of caroli’s syndrome mainly depends on histology and imaging method that can show the communication between bile ducts and saccule. important complication is cholangitis and later may progress to cholangiocarcinoma. for symptomatic caroli’s syndrome, liver transplantation is the only curative treatment. here, we report a case of caroli’s syndrome in a 5½ year old girl admitted in the department of pediatric gastroenterology and nutrition, bsmmu with the complaints of abdominal distension since birth. her ct scan report showed type v choledochal cyst with large cyst in right lobe of liver and polycystic kidney disease. endoscopy of upper git revealed grade ii oesophageal varices and mrcp also suggested caroli’s disease (type v choledochal cyst). finally, she was diagnosed as a rare case of caroli’s syndrome (type v choledochal cyst with grade ii oesophageal varices with polycystic kidney disease). key words: caroli’s syndrome; congenital hepatic fibrosis; cholangitis j enam med col 2021; 11(1): 55−58 1. resident, department of pediatric gastroenterology and nutrition, bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh 2. resident, department of pediatric gastroenterology and nutrition, bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh 3. resident, department of pediatric gastroenterology and nutrition, bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh 4. resident, department of pediatric gastroenterology and nutrition, bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh 5. resident, department of pediatric gastroenterology and nutrition, bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh 6. professor and head, department of pediatric gastroenterology and nutrition, bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh. correspondence nazmul ahamed dr.nazmulahamed1985@gmail.com introduction a rare congenital condition caroli’s disease was first described by jacques caroli in 1958 characterized by multiple segmental saccular or cystic dilatation of the intrahepatic bile ducts. it is also classified january 2021j enam med col vol 11 no 1 56 as type v choledochal cysts according to todani’s classification.1,2 caroli’s disease when associated with congenital hepatic fibrosis, it is referred as caroli’s syndrome.3,4 caroli’s syndrome is generally autosomal recessive. the prevalence of cs is approximately one in 6,000– 40,000 newborns.4 case report a 5½-year-old girl, 2nd issue of non-consanguineous parents, got admitted in the department of pediatric gastroenterology and nutrition, bsmmu with the complaints of gradual abdominal distension since birth and low-grade intermittent fever, occasionally associated with chill and rigor, highest recorded temperature 101℉ for last five days. she was suffering from similar type of illness for one year of her age and admitted in several private hospitals, but her condition did not improve. there was no remarkable past history. on examination she was ill-looking, mildly pale, anicteric, afebrile, bcg mark present, all vitals were in normal limit, anthropometrically well-thrived. her liver edge was 6 cm from right costal margin in mid clavicular line, consistency was firm and nontender. spleen was 7 cm enlarged along its long axis, ascites was present evidenced by shifting dullness. other physical sign was unremarkable. laboratory investigations showed reduced haemoglobin (hb 9.4 g/dl), platelet count 1,00,000/cmm, esr slightly high (30 mm in 1st hr.), liver function test was normal. usg of whole abdomen showed hepatic cyst in both lobes and bigger both kidneys with high cortical echogenicity and loss of renal architecture, renal function test was also normal and ct scan report showed hepatosplenomegaly, type v choledochal cyst with large cyst in right lobe of liver and polycystic kidney disease. endoscopy of upper git showed grade ii oesophageal varices which were a result of portal hypertension due to development of hepatic fibrosis. diagnosis was confirmed by mrcp that suggested caroli’s disease (type v choledochal cyst) with large hepatic cyst in right lobe of liver. both cholangiography and liver biopsy are helpful to establish the final diagnosis, but not possible due to financial problem. the child was treated conservatively with broad spectrum antibiotics. oral supplementations with vitamin a, d, e, k and hematinics were given. fever resolved within two days of admission. by this time, consultation was taken from pediatric surgery department, bsmmu and advice for definitive treatment liver transplantation was given. the parents were counseled regarding the disease progression with prognosis and advised to come for regular follow-up. endoscopy of upper git (grade ii oesophageal varices) ct scan of the abdomen showing hepatosplenomegaly, areas of focal intrahepatic biliary radicals dilatation type v choledochal cyst with large cyst in right lobe of liver and polycystic kidney disease mrcp report suggested caroli’s disease (type v choledochal cyst) with large hepatic cyst in right lobe of liver january 2021j enam med col vol 11 no 1 57 discussion caroli’s syndrome is a rare form of congenital disease that represents ectasia of intrahepatic bile duct and congenital hepatic fibrosis. in 1958, jacques caroli first reported a case with a distinct clinical entity known as caroli’s disease. caroli described two forms of this disease: the so called “pure form” of caroli’s disease which occurs in a focal or diffuse manner, characterized by saccular, communicating intrahepatic bile duct dilatation and the second form, termed as caroli’s syndrome having relatively less bile duct dilatation, but associated with hepatic fibrosis that results in portal hypertension and terminal liver failure.3 the ductal plate malformation (dpm), a developmental abnormality of the portobiliary system, is the basis of the liver disease in cs. the severity of dpm and the level of the affected portobiliary tree results in a spectrum of abnormalities including congenital hepatic fibrosis (chf) (microscopic bile ducts), cs (microscopic and medium size bile ducts) and cd (medium and large bile).3,4,5 many authors believe that cd and cs are actually different stages of the same disease characterized by peri-portal fibrosis and ductal dilatation.6 depending on whether duct dilatation or portal hypertension is the predominant pathology, patients present with recurrent cholangitis or hematemesis respectively. associated cystic dilatation of kidneys is seen in 60−80% of the cases (renal tubular ectasia, medullary sponge kidney, cortical cyst, recessive polycystic kidney disease or rarely autosomal dominant polycystic kidney disease). these patients are usually asymptomatic (as far as renal disease is concerned) but may develop renal stone disease and infections.3 caroli’s syndrome is a combination of caroli’s disease (bouts of cholangitis, gall bladder stones and hepatolithiasis) and congenital hepatic fibrosis (portal hypertension). our patient presented with abdominal distension since birth with recurrent history of fever suggesting as cholangitis. on examination, patient had hepatomegaly and splenomegaly that also indicate developing hepatic fibrosis followed by portal hypertension. the main consequence of congenital hepatic fibrosis are portal hypertension and the development of oesophageal varices.6 in the majority of patients, portal hypertension will not be present or will appear only later in the disease evolution.7 the late appearance of these symptoms in patients with caroli’s disease suggests that congenital hepatic fibrosis is dynamic and progressive.8 as hepatic fibrosis in cs is dynamic and progressive, portal hypertension is usually a late feature. also, hepatocellular function of the liver is relatively well preserved in the early stages, with liver enzymes being either normal or mildly elevated.5,6 thrombocytopenia and leukopenia are present with portal hypertension and hypersplenism. the elevated erythrocyte sedimentation rate and leukocytosis may indicate cholangitis. renal function tests can be deranged in cs having associated renal involvement, as in our patient.6 laboratory findings of our patient showed anaemia, platelet count 1,00,000/cmm, slightly high esr, and normal liver function tests. definitive diagnosis of cs is confirmed with imaging studies such as ultrasonography, endoscopic/ magnetic retrograde cholangiopancreatography, computed tomography (central dot sign), radionuclide hepatobiliary imaging, intraoperative cholangiography and percutaneous transhepatic cholangiography.1,5,6,9 ultrasonographyis the initial investigation of choice. ct scan is an invaluable adjunct that complements ultrasound. it can identify cholangiocarcinoma and hepatic masses not identified by ultrasound. the diagnosis is more difficult to establish in the case of fusiform dilatations of the biliary tracts and endoscopic retrograde cholangiopancreatography (ercp) is the gold standard in this situation. ercp shows communication between the sacculi and bile ducts and diverticulum-like sacculi of the intra-hepatic biliary tree. in our case, ercp was not required. us of our patient showed hepatic cyst in both lobes and bigger both kidneys with high cortical echogenicity and loss of renal architecture but renal function test was also normal. ct scan revealed hepatosplenomegaly, type v choledochal cyst with large cyst in right lobe of liver and polycystic kidney disease. endoscopy of upper git showed grade ii oesophageal varices and diagnosis was confirmed by mrcp that suggested caroli’s disease (type v choledochal cyst) january 2021j enam med col vol 11 no 1 58 with large hepatic cyst in right lobe of liver. though cholangiography and liver biopsy are helpful to establish the diagnosis, it was not done in our case due to financial crisis. the treatment is primarily aimed at managing the associated complications of recurrent cholangitis, hepatic abscesses, biliary calculi and carcinoma. recurrent cholangitis requires drainage which can be done by open surgery, positioning of an open stent or by percutaneous drainage. however, this treatment is just palliative. if the disease is confined to one lobe, partial lobectomy is the surgical treatment of choice.10 in case of diffuse involvement of liver, treatment options include conservative management, endoscopic therapy (sphincterotomy for clearance of intra-hepatic stone), internal biliary bypass procedures and liver transplantation.11 our patient got supportive treatment along with antibiotics for suspected cholangitis and advice was given for definitive treatment (liver transplantation). because of silent and slow progression with bouts of cholangitis of this rare disease, caroli’s syndrome should be considered as one of the important differential diagnoses. references 1. todani t, watanabe y, narusue m, tabuchi k, okajima k. congenital bile duct cysts: classification, operative procedures, and review of thirty-seven cases including cancer arising from choledochal cyst. the american journal of surgery 1977; 134(2): 263–269. 2. biliary cysts. available at: http://www.uptodate.com. accessed december 2018. 3. bavikar r, kulkarni r. caroli’s syndrome: a case report. curr pediatr res 2011; 5(1): 59–60. 4. kim jt, hur yj, park jm, kim mj, park yn, lee js. caroli’s syndrome with autosomal recessive polycystic kidney disease in a two month old infant. yonsei med j 2006; 47(1): 131–134. 5. gunay-aygun m. liver and kidney disease in ciliopathies. am j med genet c semin med genet 2009; 151(4): 296–306. 6. yonem o, bayraktar y. clinical characteristics of caroli’s syndrome. world j gastroenterol 2007; 13(13): 1934–1937. 7. de kerckhove l, de meyer m, verbaandert c, mourad m, sokal e, goffette p et al. the place of liver transplantation in caroli’s disease and syndrome. transpl int 2006; 19(5): 381–388. 8. gorka w, lewall db. value of doppler sonography in the assessment of patients with caroli’s disease. j clin ultrasound 1998; 26(6): 283–287. 9. mrowka c, adam g, sieberth hg, matern s. caroli’s syndrome associated with medullary sponge kidney and nephrocalcinosis. nephrol dial transplant 1996; 11(6): 1142–1145. 10. waechter fl, sampaio ja, pinto rd, alvares-da-silva mr, cardoso fg, francisconi c et al. the role of liver transplantation in patients with caroli’s disease. hepatogastro-enterology 2001; 48(39): 672–674. 11. karim as. caroli’s disease. indian pediatr 2004; 41(8): 848–850. 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 microsoft word article.02.doc journal of enam medical college vol 11 no 2 may 2021 64 editorial sars-cov-2 variants and vaccines: what we learn and what we can forecast? received: 18 february 2021 accepted: 28 march 2021 doi: https://doi.org/10.3329/jemc.v11i2.65187 the covid-19 pandemic has had devastating health, social and economic consequences around the world. in the absence of effective medical countermeasures, preventing disease and minimizing the spread of infection has required exceptional public health measures. we are still dealing with covid-19 and surprisingly not finished yet, despite the efforts of public health officials to curtail infections and the work done by scientists to provide vaccinations in record time. the increase in new cases around the world after a period of sharp decreases makes that much abundantly obvious. the emergence of sars-cov-2 in late 2019 was followed by a period of relative evolutionary stasis lasting about 11 months. since late 2020, however, sars-cov-2 evolution has been characterized by the emergence of sets of mutations, in the context of variants of concern (voc), that impact virus characteristics, including transmissibility and immunogenicity, probably in response to the changing immune profile of the human population.1 there is emerging evidence of reduced neutralization of some sars-cov-2 variants by post vaccination serum; however, a greater understanding of correlates of protection is required to evaluate how this may impact vaccine effectiveness. coronaviruses have a novel exoribonuclease (exon) encoded in their genomes, which is correcting many of the errors that occur during replication.2 genetic inactivation of the exonuclease in sars-cov increases mutation rates by 15 to 20-folds. the molecular basis of this cov proofreading complex is being investigated as a possible therapeutic target for sars-cov-2. importantly, nucleotide deletions, unlike substitutions, cannot be corrected by this proofreading mechanism, which is a factor that may accelerate adaptive evolution to some extent. the tremendous progress has been made with the authorization and deployment of vaccines and antibody therapies. these strategies are directed at the viral spike protein, but the emergence of viral variants, particularly in the s gene, threatens their continued efficacy.3 the mutations in the s gene, particularly those that affect portions of the protein that are critical for pathogenesis and normal function such as the receptor binding domain (rbd) or furin cleavage site or those that cause conformational changes to the s protein, are of the utmost interest. if these changes are not recognized by first-wave antibodies, these mutations may provide an avenue for the virus to escape from immunity to the original sars-cov-2 strain. initial reports that a mutation had been identified in the sars-cov-2 genome began circulating in march 2020, and by the end of june, d614g, which constitutes replacement of aspartate (d) with glycine (g) at the 614th amino acid of s protein, was found in nearly all sars-cov-2 samples worldwide. d614g has been found to enhance viral replication in human lung epithelial cells and primary human airway tissues by increasing infectivity and stability of virions.2 additional research has suggested that the increased infectivity may be the result of enhanced functional s protein assembly on the surface of the virion. in addition, several other studies have reported that d614g may be associated with higher viral loads. according to the centers for disease control and prevention (cdc), deletion of amino acids 69 and 70 in b.1.1.7 is likely to cause a conformational change in the spike protein. the creation of a δ69δ70 deletion mutant via site-directed mutagenesis and lentiviral pseudotyping resulted in 2-fold higher may 2021j enam med col vol 11 no 2 65 infectivity than the wt (d614g background), indicating that this linked pair of amino acid deletions may improve sars-cov-2 fitness. deletion of amino acid 144 in b.1.1.7 and amino acids 242-244 in b.1.351 have also been associated with reduced binding capacity of certain neutralizing antibodies. the first reported sars-cov-2 mutation, d614g, which has now become common to nearly all sequenced sars-cov-2 genomes worldwide, followed by analysis of key s protein mutations associated with sarscov-2 variants of interest (voi) and voc, including b.1.1.7, b.1.351, p.1., b.1.427/b.1.429, b.1.526 and multiple lineages of variants that contain mutations at amino acid position 677.4 the receptor binding domain (rbd) of s protein is comprised of amino acids 319-541. it binds directly to ace2 receptors on human cells. therefore, mutations in this portion of the genome are particularly significant to sars-cov-2 fitness and antigenicity. currently, there are four main types of covid-19 vaccine: nucleic acid (mrna and dna), viral vector, protein subunit, and inactivated virus. two covid-19 mrna vaccines (bnt162b2 developed by pfizerbiontech and mrna-1273 by moderna) have been authorized by the u.s. food and drug administration (fda) and european medicines agency (ema). in addition, ad26.cov2.s (johnson & johnson) was approved by the fda and ema and chadox1 ncov19 (astrazeneca) was authorized by the ema, both of which are viral vector vaccines. vaccination with various vaccine platforms, including mrna and viral vectors, has been shown to elicit sars-cov-2-specific cd4+ and cd8+ t-cell responses. in principle, it is more difficult to evade t-cell responses than a neutralizing antibody response because multiple t-cell epitopes are scattered across viral proteins, whereas neutralizing antibody targets a narrow region in the viral protein. although sarscov-2 mutations that abrogate binding to major histocompatibility complex have been reported, researchers reported an insignificant impact of sars-cov-2 variants on both cd4+ and cd8+ t-cell responses in covid-19 convalescents and recipients of covid-19 mrna vaccines.5 t-cell responses to the variants b.1.1.7, b.1.351, p.1, and cal.20c were not different from those to the ancestral strain of sars-cov-2. b.1.1.7, b.1.351 and p.1 all have a mutation that replaces asparagine (n) with tyrosine (y) at position 501 of the rbd. n501y has been shown to increase binding capacity of sars-cov-2 to human ace2 receptors, disrupt antibody binding to rbd and has been implicated in reduced antibody production via impaired t and b cell cooperation. together, these findings suggest that sars-cov-2 variants possessing the n501y mutation may have an increased potential for immunological escape. the sars-cov-2 b.1.617 lineage was identified in october 2020 in india. it has since then become dominant in some indian regions and uk and further spread to many countries including bangladesh.6 the lineage includes three main subtypes (b1.617.1, b.1.617.2 and b.1.617.3), harboring diverse spike mutations in the n-terminal domain (ntd) and the receptor binding domain (rbd) which may increase their immune evasion potential. b.1.617.2, also termed variant delta, is believed to spread faster than other variants. the delta variant spread is associated with an escape to antibodies targeting non-rbd and rbd spike epitopes. according to current estimates, the delta variant could be more than twice as transmissible as the original strain of sars-cov-2 and also replicates much faster.7 individuals infected with delta also had viral loads up to 1,260 times higher than those in people infected with the original strain. but evidence is mounting that the delta variant, first identified in india, is capable of infecting fully vaccinated people at a greater rate than previous versions, and concerns have been raised that they may even enhance the spread of the virus. a study in china found that people infected with the delta variant carry 1,000 times more virus in their noses compared with the original version first identified in wuhan in 2019. preliminary reports show that the 501y.v2 variant has complete immune-escape in south african convalescent serum samples and reductions in neutralizing activity in vaccinee serum samples for all may 2021j enam med col vol 11 no 2 66 four vaccines tested.8 extrapolating vaccine efficacy against pre-existing variants to new variants could be seriously misleading. adequate genomic surveillance standardized variant nomenclature, and a repository of variants and vaccinee serum samples are needed to deal with the challenges of repeatedly emerging new sars-cov-2 variants.9 virus genomic sequences are being generated and shared at an erratic rate, with more than one million sars-cov-2 sequences available via the global initiative on sharing all influenza data (gisaid), permitting near real-time surveillance of the unfolding pandemic.10 the use of pathogen genomes on this scale to track the spread of the virus internationally, study local outbreaks and inform public health policy signify a new age in virus genomic investigations. as highly deleterious mutations are rapidly purged, most mutations observed in genomes sampled from circulating sars-cov-2 are expected to be either neutral or mildly deleterious. such mutations may alter various aspects of virus biology, such as pathogenicity, infectivity, transmissibility and antigenicity. the extent to which mutations affecting the antigenic phenotype of sars-cov-2 will enable variants to circumvent immunity conferred by natural infection or vaccination remains to be determined. however, there is growing evidence that mutations that change the antigenic phenotype of sars-cov-2 are circulating and affect immune recognition to a degree that requires immediate attention. the spike protein mediates attachment of the virus to host cell-surface receptors and fusion between virus and cell membranes.11 it is also the principal target of neutralizing antibodies generated following infection by sars-cov-2, and is the sars-cov-2 component of both mrna and adenovirus-based vaccines licensed for use and others awaiting regulatory approval.12 the people of bangladesh are highly vulnerable to covid-19 as evident by a number of circulating variants in different regions of this country.13 in a global response, many countries, including bangladesh, acted decisively and rapidly to restrict population movement and introduce additional social and behavioral interventions, all designed to slow the spread of the virus. sars-cov-2 genomic diversity and mutation rate in bangladesh is comparable to strains circulating globally. notably, the data on the genomic changes of sars-cov-2 in bangladesh is reassuring, suggesting that immunotherapeutic and vaccines being developed globally should also be suitable for this population.14 it is worth noting that research works evaluating neutralization potency against the p.1, b.1.427/b.1.429 and b.1.526 lineages are still needed, and new information about sars-cov-2 variants is being produced daily. this ongoing mutation threat emphasizes the necessity of genomic surveillance programs that will track sars-cov-2 evolution, help contain the spread of disease and inform public health practices, including diagnostics and vaccine development with distribution.3 together, these observations provide support for current strategies to monitor multiple variables proactively. these strategies include viral testing of symptomatic and asymptomatic persons, sequencing of viral rna, and monitoring of neutralizing antibody titers, particularly in vaccinated persons who subsequently become infected. given the short time since the covid-19 vaccines have become available, it is not surprising that many scientific uncertainties persist and are the subject of intense ongoing research. they include i) the ability of vaccines to reduce/eliminate sars-cov-2 transmission, ii) duration of immunity, iii) correlates (indicators) of protection, iv) vaccine efficacy/ effectiveness in specific populations and in individuals with prior infection, and v) protection against infection/reinfection by different virus variants. iftikhar ahmed professor, department of microbiology enam medical college, savar, dhaka email: ia65831@gmail.com references 1. harvey wt, carabelli am, jackson b, gupta rk, thomson ec, harrison em et al. sars-cov-2 may 2021j enam med col vol 11 no 2 67 variants, spike mutations and immune escape. nat rev microbiol 2021; 19(7): 409–424. 2. hagen a. sars-cov-2 variants vs vaccines. american society for microbiology 2021. 3. hacisuleyman e, hale c, saito y, blachere ne, bergh m, conlon eg et al. vaccine breakthrough infections with sars-cov-2 variants. n engl j med 2021; 384(23): 2212−2218. 4. bhattacharya m, chatterjee s, sharma ar, agoramoorthy g, chakraborty c. d614g mutation and sars-cov-2: impact on s-protein structure, function, infectivity, and immunity. appl microbiol biotechnol 2021; 105(24): 9035−9045. 5. tarke a, sidney j, methot n, jhang y, dan jm, goodwin b et al. negligible impact of sars-cov-2 variants on cd4+ and cd8+ t cell reactivity in covid-19 exposed donors and vaccinees. biorxiv 2021. 6. planas d, veyer d, baidaliuk a, staroploli i, guivelbenhassine f, rajah mm et al. reduced sensitivity of sars-cov-2 variant delta to antibody neutralization. nature 2021; 596(7871): 276−280. 7. hummel s, burpo fj, hershfield j, kick a, o’donovan kj, barnhil j. a new age of bioterror: anticipating exploitation of tunable viral agents. ctc sentinel 2022; 15: 4. 8. wibmer ck, ayres f, hermanus t, madzivhandila m, kgagudi p, oosthuysen b et al. sars-cov-2 501y.v2 escapes neutralization by south african covid-19 donor plasma. nature medicine 2021; 27(4): 622−625. 9. fontanet a, autran b, lina b, kieny mp, abdool karim ss, sridhar d. sars-cov-2 variants and ending the covid-19 pandemic. the lancet 2021; 397(10278): 952−954. 10. meredith, lw, hamilton wl, warne b, houldcroft cj, hosmillo m, jahun as et al. rapid implementation of sars-cov-2 sequencing to investigate cases of health-care associated covid-19: a prospective genomic surveillance study. lancet infect dis 2020; 20(11): 1263–1271. 11. maclean oa, orton rj, singer jb, robertson dl. no evidence for distinct types in the evolution of sarscov-2. virus evol 2020; 6(1): veaa034. 12. liu l, wang p, nair ms, yu j, rapp m, wang q et al. potent neutralizing antibodies against multiple epitopes on sars-cov-2 spike. nature 2020; 584(7821): 450–456. 13. hasan mm, das r, rasheduzzaman m, hussain mh, muzahid nh, salauddin a et al. global and local mutations in bangladeshi sars-cov-2 genomes. virus res 2021; 297: 198390. 14. cowley la, afrad mh, rahman si, mahfuzalmamun m, chin t, mahmud a et al. genomic and mobility data reveal mass population movement as a driver of sarscov-2 dissemination and diversity in bangladesh. medrxiv 2021; 01−17. journal of enam medical college vol 11 no 1 january 2021 18 original article computed tomographic findings in children with cerebral palsy in a developing country roushan jahan1, md. mizanur rahman2, kanij fatema3, md. enayet karim4, subrata roy5 received: 13 january 2020 accepted: 25 august 2020 doi: https://doi.org/10.3329/jemc.v11i1.63169 abstract background: cerebral palsy (cp) is one of the most common causes of chronic childhood disability. to know the aetiopathogenesis, severity and prognosis of cp, neuroimaging is an important modality of investigation. objective: this study was done to observe the findings in ct scan of brain in children with cp. materials and methods: this is a cross-sectional descriptive study. one hundred and ten patients who were clinically diagnosed as cerebral palsy were enrolled in the study. after selection of the subjects, demographic and clinical characteristics were recorded. all other comorbidities including visual and hearing impairments were identified. ct scan of brain was done in all children and reporting had been done by a single qualified radiologist. results: the mean age of the studied children was 2.6±2.2 years (1 to 14 years). seven types of cp were found in the study group. among them quadriplegic cp were the most common (39.1%). history of perinatal asphyxia was found in 81.8% children. cognitive delay was found in 90% children, speech delay was found in 88.2% children, visual impairment was found in 35.5% children and hearing impairment in 31.8% cases. epilepsy was found in 44.4% among studied subjects. most common finding on ct scan of brain was cerebral atrophy (62.7%), followed by encephalomalacia (15.5%), calcification (13.6%), and brain malformations (11.8%). abnormal ct scan findings were found in 88.2% of study population. conclusion: this study showed that most common type of cp was quadriplegic cp. maximum children had abnormal ct scan findings. most common ct scan finding was cerebral atrophy. key words: cerebral palsy; computed tomography; encephalomalacia j enam med col 2021; 11(1): 18−23 1. consultant, general hospital, narayanganj 2. professor, department of pediatric neurology, bsmmu 3. associate professor, department of pediatric neurology, bsmmu 4. professor, department of radiology and imaging, bsmmu, dhaka 5. senior consultant (pediatrics), national institute of kidney diseases and urology, dhaka correspondence kanij fatema, email: mailmonami@gmail.com introduction cerebral palsy (cp) describes a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain.1 the motor disorders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, communication and behavior by epilepsy and by secondary musculoskeletal problems.2-4 it is one of the most common causes of chronic childhood disability.5 the january 2021j enam med col vol 11 no 1 19 prevalence of cp in the world is about 2−2.5/1000 live births.6-8 in the developed world the prevalence of cp remains very stable for many years at this percentage.3 in bangladesh the prevalence is about 6.1/1000 live births.9,10 cp is known to be associated with a host of proven etiologic factors. prenatal causes are maternal hyperthyroidism, intrauterine infections, malnutrition etc. perinatal causes are prematurity, vlbw, birth asphyxia, brain malformation, intrauterine growth retardation, hypoglycemia, dyselectrolytemias, sepsis, being a twin, torch infections, kernicterus etc. postnatal risk factors are meningitis, encephalitis, head injury, seizures etc.11-13 different etiologies occurring at different developmental stages can result in the same clinical pattern of cerebral palsy.14 alternatively, a similar etiology may produce variable outcomes.15 the american academy of neurology, in 2004, published a practice parameter that advocated for the first time the routine neuroimaging of children with suspected cerebral palsy.15,16 a practice parameter regarding the value and indications for obtaining neuroimaging in preterm and term infants has recently been published.6 the current parameter addresses the role of neuroimaging in the infant or child who has been diagnosed with or is suspected of having cp based upon a motor deficit.6,17 materials and methods this cross sectional descriptive study has been carried out in the department of paediatric neurology and institute of paediatric neurodisorder and autism (ipna), bangabandhu sheikh mujib medical university (bsmmu), dhaka over a period of 1 year and 6 months from march 2016 to august 2017. purposive sampling was done and sample size was calculated. total 200 cp patients had done ct scan of brain, among them 90 patients were excluded, because 30 patients had neurometabolic disease, 20 patients had neurodegenerative disease, 25 cases did not give consent, 15 patients were < 1 year old. patients were eligible if they had chronological age 1to18 years. child clinically diagnosed as a case of cerebral palsy and ct scan of brain was done following standard method as practiced in different centers but was reported by a single expert radiologist from the department of radiology and imaging at bsmmu. informed written consent was taken from the parents. demographic and clinical characteristics were recorded, physical examination (mainly detailed neurological examination) was done to identify the type of cp and associated co-morbid conditions. the psychologists of pediatric neurology unit did the psychological tests by using appropriate tools. cognitive level was designated as normal or impaired with cut-off iq of 70. all the children had a formal visual and hearing assessment. brainstem auditoryevoked responses/auditory brainstem responses (baer/abr) or otoacoustic emissions (oaes) test were done to assess hearing. ct scan was done by 64 slice spiral ct machine. results out of 110 patients with cp 69 (62.7%) were male and 41 (37.3%) were female. most of them (77, 70.0%) were socioeconomically poor. most of the patients (67, 60.9%) lived in rural areas. table i shows the demographic and socioeconomic characteristics of children with cerebral palsy table i: demographic and socioeconomic characteristics of children with cerebral palsy (n=110) demographic variables frequency percentage age 1−5 years 5−12 years 12−18 years 99 10 1 90.0 9.1 0.9 sex male female 69 41 62.7 37.3 place of birth rural urban 67 43 60.9 39.1 socioeconomic condition poor middle class rich 77 33 0 70.0 30.0 0.0 birth order of the child first born second child third or later born twin 75 28 7 8 68.1 25.5 6.4 7.3 january 2021j enam med col vol 11 no 1 20 seven types of cp were found in the study group (fig 1). among them, quadriplegic cp were the most common (39.1%), followed by cases of hemiplegic cp (28.2%) and mixed type was 16.4%. most of the patients (77.27%) were born at term. table ii shows the distribution of the findings of ct scan of brain (n=110). some patients had multiple findings. fig 1. bar diagram showing the types of cerebral palsy (n=110) fig 2. bar diagram showing the gestational age at birth (n=110) fig 4. bar diagram showing the frequency of associated co-morbidities (n= 110) fig 3. bar diagram showing the extent of perinatal problems (n=110) this study found most of the patients had perinatal asphyxia (81.8%). most of the patients had cognitive delay (90.9%), 2nd most common finding was speech delay (88.2%), seizure was present among 49 patients (44.4%). table ii: distribution of patients accroding to the findings of ct scan of brain (n=110) ct scan findings number percentage brain atrophy (fig 5) 69 62.7 encephalomalacia (fig 6) 17 15.5 brian malformation (fig 7, 8, 9) 13 11.8 periventricular leukomalacia (pvl) 2 1.8 calcification due to torch infection 15 13.6 delayed myelination 1 0.9 focal arterial infarction 1 0.9 normal 13 11.8 january 2021j enam med col vol 11 no 1 21 discussion computerized tomography is a useful tool for demonstrating the anatomical lesions responsible for cp patient’s clinical findings, useful in predicting prognosis and functional outcomes and to diagnose lesions which are correctable by neurosurgery.18−20 in bangladesh perspective, mostly ct scan of brain is done as mri of brain is costly and needs general anesthesia. according to several literatures ct scan is considered to be a proven useful method of correlating morphology with clinical features in cp.21−23 kolawole et al21 reported that 72.5% of children with cerebral palsy had positive ct scan findings while taudorf et al23 found that 67% of children with cp had pathological ct scan findings. in this study it was fig 9. ct scan of brain showing porencephalic cyst in left fronto-parietal region fig 5. ct scan of brain showing moderate generalized cerebral atrophy fig 6. ct scan of brain showing diffuse cerebral atrophy with encephalomalatic change and mild subdural collection fig 7. ct scan of brain showing dandy walker malformation with hydrocephalus fig 8. ct scan of brain showing arachnoid cyst january 2021j enam med col vol 11 no 1 22 found that 88.18% of children with cp had abnormal ct scan findings, most frequent (62.7%) pathological ct finding was cerebral atrophy which was similar to moifo et al24, taudorf et al23 and kolawole et al21 studies. moifo et al24 found atrophy in 52.7% cases, kolawole et al21 found atrophy in 30.8% cases and taudorf et al23 found presence of brain atrophy in 44 children among 56 pathological ct scan findings. again in this study it was found that 2nd most common finding was encephalomalacia which was present in 15.5% cases followed by calcification due to infections (13.6%) and brain malformations were in 11.8% of children with cp. brain malformations found in this study were hydrocephalus with dandy walker malformation (1 children with cp), corpus callosal agenesis (3 children with cp), cortical dysplasia and arachnoid cyst in left temporo-paraetal regions (1 children with cp), poor myelination (1 children with cp), giant cisterna magna (2 children with cp), open lip schizencephaly with corpus callosal agenesis (1 children with cp), porencephaly (2 children with cp), holoporencephaly with hypoplastic cerebellar vernis and posterior fossa cyst (1children with cp), cortical dysplasia (1children with cp). korzeniewski15 also found about 10% of children with cerebral palsy was attributable to brain malformations. martin , clare & olof found in their study there was 9.1% of children with cp had brain malformation.17 moifo et al24 was also found brain malformations in 7.4% of children with cp. multiple findings in ct scan of brain is common in children with cp. in this study it was found that significant number of studied population (26) had two/more findings at a time which included-atrophy with calcification (3), atrophy with encephalomalacia (7), atrophy with infarct (4), atrophy with encephalomalacia with calcification (2), hydrocephalus with encephalomalacia (2), atrophy with calcification with subdural hematoma (1), atrophy with calcification with infarct (2), atrophy with encephalomalacia with subdural hematoma (1), atrophy with malformation (1), atrophy with encephalopathy (1), atrophy with calcification with malformation (1) and infective encephalopathy (1). encephalomalacia was found in 15.5% of children with cp, calcification was found in 13.6% of children with cp and periventricular leukomalacia was found in 1.8% of children with cp. taudorf et al23 found the frequency of pathological ct findings increased with increasing severity of the motor handicap. there were significantly more children with pathological ct findings among cp children suffering from epilepsy than among cp children without epilepsy. this study had also same results. most of the children who had pathological ct findings suffered from epilepsy and had other co-morbid conditions like cognitive disorder, visual, hearing impairment, and feeding difficulty. this study showed that most common types of cp were quadriplegic cp and hemiplegic cp. a significant number of patients had mixed type cp. in this study 88.2% children with cp showed abnormality in ct scan. most common findings of this study were cerebral atrophy followed by encephalomalacia, calcifications and brain malformation. epilepsy and other co-morbid conditions were found in many children with abnormal ct scan findings, but no relation was investigated. references 1. wikipedia. a report: the definition and classification of cerebral palsy. united cerebral palsy research and education foundation (us). 2006. 2. rosenbaum p, paneth n, leviton a, goldstein m, bax m. a report: the definition and classification of cerebral palsy. correspondence to murray goldstein, ucp research and educational foundation; suite 700, 1660 l street nw, washington, dc, usa 20036; 2006. 3. kliegman rm, stanton bf, schor nf, geme jw, behrman re. cerebral palsy. in: nelson textbook of paediatrics, 20th edn, philadelphia: saunders, 2016: 2896–2899. 4. kakooza-mwesige a, forssberg h, eliasson ac, tumwine jk. cerebral palsy in children in kampala, uganda: clinical subtypes, motor function and comorbidities. biomed central 2015; 8(1): 1−10. 5. aneja s. evaluation of a child with cerebral palsy. indian j pediatric 2004; 71(7): 627−634. 6. ashwal s, russman bs, blasco pa, miller g, sandler january 2021j enam med col vol 11 no 1 23 a, shevell m. et al. practice parameter: diagnostic assessment of the child with cerebral palsy. neurology 2004; 62: 851– 863. 7. rosenbaum pl, walter sd, hanna se, palisano rj, russell dj, raina p et al. prognosis for gross motor function in cerebral palsy. jama 2002; 288(11): 1357−1363. 8. piovesana amsg, moura-ribeiro mv, zanardi vda, goncalves vm. hemiparetic cerebral palsy: etiological risk factors and neuroimaging. arq neuropsiquiatr 2001; 59(1): 29−34. 9. khan nz, ferdous s, munir s, huq s, mcconachie h. mortality of urban and rural young children with cerebral palsy in bangladesh. developmental medicine and child neurology 1998; 40(11): 749−753. 10. tabib smsb. prevalence of childhood disabilities and cerebral palsy in the community. 19th asian federation on intellectual disabilities conference, singapore, concurrent session 6, 16.30-18.00, 226 november. 2009. 11. kalra v. practical paediatric neurology. 2nd edn. arya publications, industrial area, trilokpur road, 2008: 127−141. 12. najar ba, kachroo a, gattoo ia, hussain sq. cerebral palsy: risk factors, comorbidities and associated mri findings, a hospital based observational study. int j contemppediatr 2015; 2(2): 90−95. 13. grether jk, nelson kb. maternal infection and cerebral palsy in infants of normal birth weight. jama 1997; 278(3): 207−211. 14. humphreys p, whiting s and pham b. hemiparetic cerebral palsy: clinical pattern and imaging in prediction of outcome. can j neurol.sci 2000; 27: 210−219. 15. korzeniewski sj, gretchen b, mark c, michael jp, and nigel p. a systematic review of neuroimaging for cerebral palsy. journal of child neurology 2008; 23: 216−227. 16. schouman-claeys e, picard a, lalande g, kalifa g, lacert p, brentanos e et al. contribution of computed tomography in the aetiology and prognosis of cerebral palsy in children. british journal of radiology 1989; 62: 248−252. 17. martin b, clare t, olof f. clinical and mri correlates of cerebral palsy: the european cerebral palsy study free. jama 2006; 296(13): 1602−1608. 18. koch b, bralljier d, eng g, binder m. computerized tomography in cerebral palsied children. developmental medicine and child neurology 1980; 22(5): 595−607. 19. himmelmann k, uvebrant p. function and neuroimaging in cerebral palsy: apopulation-based study. developmental medicine and child neurology 2011; 53: 516-521. 20. pederssen h, taudorf k, and melchior jc. computed tomography in spastic cerebral palsy. neuroradiology 1982; 23: 275−278. 21. kolawole tm, patel pj, mahdi ah. computed tomographic (ct) scans in cerebral palsy. pediatr radiol 1989; 20: 23−27. 22. schouman-claeys e, picard a, lalande g, kalifa g, lacert p, brentanos e et al. contribution of computed tomography in the aetiology and prognosis of cerebral palsy in children. british journal of radiology 1989; 62: 248−252. 23. taudorf k, melchior jc and pedersen h. ct findings in spastic cerebral palsy-clinical, etiological and prognostic aspects. neuropediatric 1984; 15(3): 120−124. 24. moifo b, nguefack s, zeh of, obi fa, tambe j and mah e. computed tomography findings in cerebral palsy in yaounde-cameroon. j afr imag med 2013; 3(5): 134−142. microsoft word article.06.doc journal of enam medical college vol 11 no 2 may 2021 72 original article antihyperglycemic and glucose homeostasis effect of ethanol and dcm extract of gymnema sylvestre on type 1 diabetic model rat nasreen chowdhury1, rokeya begum2, liaquat ali3, md. mahbubur rahman4 received: 26 january 2021 accepted: 30 march 2021 doi: https://doi.org/10.3329/jemc.v11i2.65188 1. professor, department of biochemistry, university of science and technology chittagong (ustc) medical college, chittagong 2. professor, department of pharmacology, bangladesh institute of research and rehabilitation in diabetes, endocrine and metabolic disorders (birdem), shahbagh, dhaka 3. professor, department of biochemistry and cell biology, bangladesh institute of research and rehabilitation in diabetes, endocrine and metabolic disorders (birdem), shahbagh, dhaka 4. department of biochemistry, jahurul islam medical college, bajitpur, kishoreganj correspondence nasreen chowdhury, email: drnasreenchy@yahoo.com abstract bacground: plants have formed the basis for the treatment of diseases in traditional medicine systems for thousands of years and continue to play a major role in the primary health care of about 80% of the world inhabitants. gymnema sylvestre is one of the most studied herbs which has been claimed to be active against both type of diabetes mellitus. objective: the dried powder leaves of gymnema extracted with ethanol and dichloromethane (dcm) and then its effect were studied in streptozotocin induced type 1 diabetic model rat at different prandial state. materials and methods: in the present study both of the extracts (gs ethoh and gs dcm) of gymnema sylvestre produced a significant antihyperglycemic effect in type 1 diabetic model rats when the extract was given 30 minutes before glucose load. the effectiveness of the extracts in type 1 diabetic rats with residual insulin secretion indicates that the hypoglycemic effect of active plant compound(s) is probably mediated either by improving insulin secretion from the existing β cells or by increasing its sensitivity. results: the baseline value of fasting serum glucose reflects that the degree of damage of β cells by the toxic effect of streptozotocin was gradual. the findings at one week show some spontaneous recovery in water control group and better recovery in all the treated groups. after two weeks, fasting serum glucose level was improved in all the extract treated groups. conclusion: the data suggest that gymnema sylvestre leaf extracts improve the glycemic status in type 1 diabetic model rat. key words: gymnema sylvestre; type 1 diabetes; streptozotocin; antihyperglycemic j enam med col 2021; 11(2): 72−77 introduction plants have formed the basis for the treatment of diseases in traditional medicinal systems for thousands of years, and continue to play a major role in the primary health care of about 80% of the world’s inhabitants.1 traditional antidiabetic plants might provide a useful source of new oral hypoglycemic compounds for development as pharmaceutical entities or as simple dietary adjuncts to existing therapies.2 many of the currently available drugs have been derived directly or indirectly from plants. however, only a few have, till now, been subjected to scientific and systematic medicinal studies to assess their efficiency. various may 2021j enam med col vol 11 no 2 73 plant extracts have been found to be active both in type 1 and type 2 which may potentially be the pharmacological target of modern antidiabetic drug research. gymnema sylvestre a plant used in the ayurvedic medicine of india for the treatment of diabetes mellitus for over 2000 years by ayurvedic and unani practitioners.3 it is one of the most studied herbs which has been claimed to be active against both type of diabetes mellitus.4 the plant belongs to the family asclepiadaceae and grows in open woods in india, china, indonesia, japan, malaysia, sri lanka, vietnam and south africa. gymnema sylvestre possesses tremendous importance as a medicinal plant. the hot water extract of gymnema sylvestre leaves is usually taken orally for the treatment of diabetes.5,6 hypoglycemic effects of water and methanol extracts of gymnema sylvestre leaves have been reported in diabetic rats and humans.7,8 a pure compound conduritol also isolated from methanol extract.9 it has been claimed that, oral administration of water soluble acidic fraction of ethanol extract normalized blood sugar level in streptozotocin treated rat by secretion of endogenous insulin, possibly due to regeneration of beta cell.10 the present work was undertaken to study the glucoselowering effects of the ethanol extract and dcm extracts in streptozotocin-induced types 1 diabetic rat at different prandial states. materials and methods collection & identification of gymnema sylvestre leaves dried gymnema sylvestre leaves (5 kg) were purchased from a local herbal medicinal shop of old dhaka town. botanical identification was performed and the accession no is 30381 by national herbarium, bangladesh. the leaves were cleaned, separated from petiole and stems and dried in an oven at 40 0c. finally they were grounded to powder and stored in a well-stopper plastic container. extraction and fractionation procedure gymnema sylvestre leaves powders were extracted with 80% ethanol in the extraction tank for about 4 days at room temperature by changing ethanol every alternate day. the extracts were filtered and evaporated by rotary evaporator and finally freezedried to obtain a 210 g extract. the dry samples were stored in reagent bottles at 4oc in a freezer. the ethanol extract (100 g) was partitioned between dichloromethane and water. dcm part was separated and evaporated to dryness to get dcm soluble material, which was kept, separately for chemical analysis. the residual aqueous part was condensed by rotary evaporator and finally freeze-dried (60 g). animal preparation adult male long-evans rats weighing 180−220 gm were used throughout the study. the animals were bred at birdem (bangladesh) and maintained on 12 hour light-dark cycle, fed on a standard laboratory pellet diet and with water supplied ad libitum. animal described as fasted were deprived of food for at least 12 hr but allowed free access to drinking water. induction of type 1 diabetes in rats type 1 diabetes was induced by intraperitoneal injection of streptozotocin (stz, 65 mg/kg body weight) dissolved in citrate buffer (ph 4.5) immediately before use to 3 month old, healthy adult rats fasted for 18 hours. the blood glucose level was checked on the 5th day after injection of stz. animals having high blood glucose levels (>20 mm) were considered as type 1 diabetic. administration of extracts and glucose loading rats were kept fasted for 12 h before use. solutions or suspensions of plant extracts (1.25 g/kg body weight in 10 ml of water) were administered orally by gastric intubations. for postprandial condition the extracts were fed 30 minutes before glucose (2.5 g/kg body weight in 10 ml of water) load following the standard procedure developed in birdem laboratory. the corresponding negative control rats were fed orally with deionized water (10 ml) and positive control rats were given injection insulin (actrapid hm-40 u: 1ml). experiment on glucose homeostasis for chronic study, type 1 diabetic rats were fed plant may 2021j enam med col vol 11 no 2 74 extracts (1.25 g/kg bw) by a metallic tube once daily for 14 days. control rats were administered water (10 ml/kg bw). the extract treated rats were divided into 3 subgroups depending on the administration of the extracts. gs-0 group received extracts immediately after injection of streptozotocin. the gs-3 group and gs-5 group were fed with the extracts after 3 days and 5 days of giving streptozotocin injection. all the groups remained under similar environmental conditions, and were provided with enough food and water throughout the experiment. body weight of each rat was recorded every 7th day. blood samples were collected at the beginning of the experiment from the tail tips under mild ether anaesthesia and at the end directly from heart/abdominal aorta under pentobarbital anaesthesia. serum was separated by centrifugation for the analysis of glucose and insulin. serum was preserved immediately at –70 0c and stored until analyzed. blood collection from the experimental rats and biochemical analysis blood samples were collected by cutting tail tip under mild ether anesthesia at 0 min, 60 min and 105 min. after collecting blood at 0 min, extracts, water and insulin were given to rats; the experiment was followed by glucose load 30 min after feeding extracts. the glucose level was measured immediately by the glucose-oxidase method using accutrend gc blood glucose analyzer from boehringer mannheim gmbh (germany). statistical analysis results are expressed as mean ± sd or median (range) as appropriate. between groups, comparison of data was done by using one-way anova with post hoc bonferroni test. the level of significance was set at 0.05. data were managed using the computer software statistical package for social sciences (spss) for windows, version 10.0. results acute effect of g sylvestre on serum glucose level ethanol extract of g sylvestrae (gs-ethoh) was fed 30 min before oral glucose load. statistical analysis indicated that oral administration of the ethanol extract of g sylvestrae (gs-ethoh) significantly opposed the rise of serum glucose at 60 min (p=0.033) compared to water control (wc) but it did not bring significant effect on the group, which was fed dcm extract (gsdcm) in compared to wc at 60 min (p=0.06). at 105 min, serum glucose level of the wc and gs-ethoh groups was comparable. compared to wc, gs-dcm extract significantly opposed the rise of serum glucose at 105 min (p=0.01) (table i). table i: effect of 80% ethanol extract and aqueous part of dcm extract of on serum glucose level of type 1 diabetic model rats when the extract was fed 30 minutes before glucose load groups min 0 (mmol/l) min 60 (mmol/l) min 105 (mmol/l) wc (n=10) 22.2 ± 4.2 31.3 ± 3.0 28.4 ± 4.3 ic (n = 12) 16.2 ± 3.9 3.9 ± 0.37 7.5 ± 1.7 gseth (n=11) 18.8 ± 5.1 23.1 ± 3.2 24.4 ± 3.3 gsdcm (n=9) 20.3 ± 2.7 26.0 ± 3.4 21.7 ± 4.8 bonferroni p values wc vs ic 0.198 <0.001 <0.001 wc vs gseth 0.375 0.033 0.684 wc vs gsdcm 2.871 0.06 0.010 ic vs gseth 1.809 <0.001 <0.001 ic vs gsdcm 0.045 <0.001 <0.001 gseth vs gsdcm 0.168 0.726 1.206 results are expressed as mean ± sd; wc, water control; ic, insulin control; gs, gymnema sylvestre; eth, ethanol; dcm dichloromethane. one way anova with post hoc bonferroni test was performed as the test of significance. may 2021j enam med col vol 11 no 2 75 0 5 10 15 20 25 30 35 0 60 105 time (min) s g lu c o se ( m m o l/ l ) wc ic gs dcm gs ethoh fig 1. effect of gymnema sylvestre (gs) ethanol (ethoh) and dcm extracts on serum glucose level when fed 30 min after glucose load. dcm, dichlormethane; wc, water control; ic, insulin control table ii: effect on fasting serum glucose of the study rats after 14 days groups s glucose baseline (mmol/l) s glucose 1 wk (mmol/l) s glucose 2 wk (mmol/l) t/p value baseline vs 1 wk baseline vs 2 wks 1 wk vs 2 wks wc (n = 17) 22.2 ± 4.1 15.5 ± 4.9 17.6 ± 5.1 3.36/0.02 0.33/0.75 1.58/0.13 gs-0 (n=9) 8.5 ± 3.1 14.1 ± 4.7 11.0 ± 4.3 1.35/0.35 1.02/0.25 0.25/0.80 gs-3 (n=7) 16.7 ± 6.4 6.4 ± 1.4 8.4 ± 4.1 2.10/0.17 2.81/0.04 1.95/0.10 gs-5 (n=10) 20.9 ± 3.5 11.4 ± 6.7 10.4 ± 5.6 1.77/0.15 1.33/0.27 0.04/0.96 bonferroni p values wc vs gs-0 0.003 1.506 0.012 wc vs gs-3 0.055 0.003 0.006 wc vs gs-5 0.483 0.348 0.033 gs-0 vs gs-3 0.032 0.003 0.567 gs-0 vs gs-5 0.012 0.972 2.364 gs-3 vs gs-5 0.124 0.144 1.212 results are expressed as mean + sd; wc, water control; gs, gymnema sylvestre; gs-0, extract feeding started on 0 day of stz injection; gs-3, extract feeding started on 3 day of stz injection; gs-5, extract feeding started on 5 day of stz injection; between group comparison was done using one way anova with post hoc bonferroni test. within group comparison was done using paired t test. may 2021j enam med col vol 11 no 2 76 chronic effect of g sylvestre on glucose homeostasis results of fasting serum glucose (fsg) level of the study rats at baseline (before onset of feeding), at 1 week and at 2 week after feeding is shown in table ii. at baseline, the mean fasting serum glucose (fsg) (mmol/l) of the gs-o group was significantly lower than the wc group (p=0.003). the level of fsg (mmol/l) at baseline of the gs-3 & gs-5 group was lower than the wc group but was not statistically significant. at 1 week, the value of fsg (mmol/l) level of the gs-3 group was significantly lower than the wc group (p=0.003). the mean fsg (mmol/l) at 1 week of the group gs-3 was significantly lower than the gs-0 group (p=0.003). compared to wc, the level of fsg at 1 week of the gs-0 and gs-5 groups were not significantly different. at 2 week, the level of fasting serum glucose level of the group gs-0, gs-3 and gs-5 were significantly lower (p=0.012, p=0.006 and p=0.033 respectively) compared to wc. discussion diabetes is a serious disorder that has a significant impact on health and life expectancy of the patient. the cost of treating this disease already put a heavy burden on the health care system. among the noncommunicable diseases diabetes now considered as an emerging epidemic in bangladesh.11 people living with diabetes are especially facing an increasing demand for long term continuous care of health service and burden of health care cost. currently available drug regimens for management of diabetes have certain drawback. there is need for safer and more effective antidiabetic drugs. the present study was undertaken to assess hypoglycemic properties and to investigate the underlying mechanism of action of g sylvetre leaf extracts in type 1 diabetic model rats. in the present study both of the extracts (gs ethoh and gs dcm) of g sylvetre produced a significant antihyperglycemic effect in type 1 diabetic model rats when the extract was given 30 minutes before glucose load. the effectiveness of the extracts in type 1 diabetic rats with residual insulin secretion indicates that the hypoglycemic effect of active plant compound(s) is probably mediated either by improving insulin secretion from the existing β cells or by increasing its sensitivity. the antihyperglycemic properties of g sylvetre was supported by the results of others.7,8,12,13 in the chronic study, the baseline values of fasting serum glucose (at 0, 3 and 5 days of giving streptozotocin) reflects that the degree of damage of β cells by the toxic effect of streptozotocin was gradual. the findings at one week show some spontaneous recovery in water control group and better recovery in all the treated groups. after 2 weeks, fasting serum glucose in the water control group deteriorated whereas it was improved in all the extract treated groups. the data suggest that gymnema sylvestre leaf extracts improve the glycemic status in type 1 diabetic model rat. acknowledgement financial support from the asian network of research on antidiabetic plants (anrap), bangladesh is gratefully acknowledged. we thank dr. mahbuba akhter for the identification of plant materials. references 1. farnsworth nro, akerele as, bingel dd, guo z. medicinal plants in therapy. bul world health org 1985; 63: 965−981. 2. bailey cj, day c. traditional plant medicines as treatment for diabetes. diabetes care 1989; 12(8): 553−564. 3. warren rp, warren rm, weninger mg, inhibition of the sweet taste by gymnema sylvestre. nature 1969; 223: 94−95. 4. kirtikar kr and basu bd (reprinted 1987) indian medicinal plant 3, international book distributors, india : 1625−1627. 5. jain sr, sharma sn. gymnema sylvestre leaves for treatment of diabetes mellitus. plant med 1967; 15: 439−442. 6. gupta ss. effect of hot water extract of gymnema may 2021j enam med col vol 11 no 2 77 shanmugasundaram kr, rajendran vm. possible regeneration of islets of langerhans in streptozotocin diabetic rats given gymnema sylvestre leaf extracts. j ethnopharmacol 1990; 30: 265−279. 11. icddrb documents, annual report: 2008, discovery: diabetes the emerging epidemic in bangladesh. available at: http://centre.icddrb.org/pub/ publication.jsp?classificationid=46&pubid=10327 12. baskaran k, ahmath bk, shanmugasundaram kr, shanmugasundaram er. antidiabetic effect of a leaf extract from gymnema sylvestre in non insulin dependent diabetes mellitus. j ethnopharmacol 1990; 30: 295−300. 13. persaud sj, al-majed h, rahman a, jones pm. gymnema sylvestre stimulates insulin release in vitro by increased membrane permeability. j ethnopharmacol 1999; 163: 207−212. sylvestre leaves on diabetic subjects. indian j med sci 1963; 17: 501−505. 7. rokeya b, nahar n, ali l, hassan z, nur-e-alam m, chowdhury ns et al. effects of five medicinal plants on blood glucose levels of nondiabetic and diabetic model rats. diabetes res 1999; 34: 219−228. 8. shanmugasundaram erb, rajeshwari g, baskaran k, rajeshkumar br, shanmugasundaram kr, ahmath bk. use of gymnema sylvestre leaf extract in the control of blood glucose in insulin dependent diabetes mellitus. j ethnopharmacol 1990; 30: 281−294. 9. nahar n, rokeya b, ali l, hassan z, nur-e-alam m, chowdhury ns et al. effects of three medicinal plants on blood glucose levels of nondiabetic and diabetic model rats. diabetes res 2000; 35: 41−49. 10. shanmugasundaram erb, gopinath kl, microsoft word article.07.doc article-9 97 a 38-year-old lady presented to the ibn sina breast care centre, dhaka with the complaints of bloody discharge through the left breast nipple. on examination, there was spontaneous bloody discharge from left breast nipple through a single duct. there was no mass on palpation. she was then referred for ultrasonography and ductography of the left breast. usg showed multiple cysts, however no intracystic solid portion could be noted. ductography revealed dilated duct with contrast agent filling defects approximately 2.9 cm from the nipple and sudden cut-off of the contrast column about 3.7 cm from the nipple. findings are consistent with intraductal papilloma with duct ectasia. fig 1. galactography of left breast abnormal nipple discharge is associated with an underlying malignancy in 1.2% to 15% of patients.1 abnormal discharge is defined as nonlactational, persistent, spontaneous, and unilateral.2 bloody or hemoccult-positive discharge is more likely to be associated with cancer (5% to 28%) and should prompt further evaluation.3 however, clear or watery discharge has been associated with breast cancer in up to 7% of cases.1 mammography is advocated as part of the routine evaluation of women with breast complaints. mammography is associated with a 9.5% false-negative rate and a 1.6% false-positive rate in detecting breast cancer in patients with nipple discharge.4 ductography is an increasingly available method of examination and is relatively easy to perform with few complications. ductography has been shown to be accurate in providing the location and depth of ductal abnormalities when a single duct is identified as the source.1 data regarding the location of the lesion greatly facilitate biopsy, especially with deep lesions. ductography has also been shown to improve the diagnostic yield of surgical biopsy from 67% in nonstudied patients to 100% in patients receiving a ductogram.5 sharmin akhtar rupa associate professor department of radiology & imaging enam medical college & hospital, savar, dhaka email: dr.sharminakhtarrupa@yahoo.com mahbooba ishrat medical officer ibn sina breast care centre, dhaka sonia shahid medical officer ibn sina breast care centre, dhaka references 1. tabar l, dean pb, pentek z. galactography: the diagnostic procedure of choice for nipple discharge. radiology 1983; 149: 31–38. 2. fiorica jv. breast disease. curr opin obstet gynecol 1992; 4: 897–903. 3. chaudary ma, millis rr, davies gc, hayward jl. the diagnostic value of testing for occult blood. ann surg 1982; 196: 651–655. 4. fiorica jv. nipple discharge. obstet gynecol clin north am 1994; 21: 453–460. 5. van zee kj, ortega perez g, minnard e, cohen ma. preoperative galactography increases the diagnostic yield of major duct excision for nipple discharge. cancer 1998; 82: 1874–1880. 97 ductography: the diagnostic procedure of choice in patients with abnormal nipple discharge images in clinical medicine 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.banglajol.info port 443 college news 98 cpd programme continuing professional development is the process of life-long learning in practice. it helps the medical professionals to keep them up-to-date to meet the needs of the patient and health care services and to improve their knowledge, skill and attitude. enam medical college arranges cpd programmes regularly. during the period of january to july 2012, total 10 seminars were held. around 300 students, doctors and teachers attended each of these seminars. special seminar one special seminar was held on june 11, 2012. 1. sound, noise and noise pollution speaker : prof. pran gopal datta, vice chancellor, bsmmu, dhaka chairperson : prof. abdul mannan sikder, principal, enam medical college, savar, dhaka scientific presentations dr. md. aminul haque khan, professor & head, department of biochemistry, enam medical college, savar, dhaka and editor, journal of enam medical college presented a paper titled ‘laboratory errors: types and frequency in a tertiary hospital in bangladesh' in the scientific session of the 7th national convention of bangladesh society of medical biochemists held in dhaka on 07– 08 january 2012. dr. rukhsana parvin, assistant professor, department of medicine, enam medical college & hospital, savar, dhaka presented a paper titled ‘measurement of temperature in a tertiary care hospital – an observational study’ in a conference organised by bangladesh society of medicine held on march 1-2, 2012. dr. md. aminul haque khan delivered a lecture in a seminar on ‘quality control in clinical laboratories’ as main speaker on 1st april 2012. the seminar was organised by bangladesh institute of health sciences (bihs), dhaka in giasuddin milki auditorium, khamarbari, farmgate, dhaka on the occasion of welcome ceremony of students of bsc in health technology (laboratory), msc in laboratory technology, postgraduate diploma in laboratory technology and masters in health informatics. participation and presentation in scientific conference abroad dr. md. aminul haque khan, professor & head, department of biochemistry, enam medical college, savar, dhaka and dr. irin perveen, associate professor & head, department of gastroenterology, enam medical college, savar, dhaka participated in the joint conference of bangladesh college of physicians and surgeons (bcps) and college of physicians and surgeons pakistan (cpsp) in hotel pearl continental, lahore, pakistan on 13th -14th april, 2012. the joint conference was held on the occasion of golden jubilee anniversary of cpsp. dr. md. aminul haque khan presented a paper titled ‘modification of friedewald’s formula to calculate low-density lipoprotein cholesterol up to serum triglyceride concentration of 1000 mg/dl’ in the plenary scientific session of the conference. college news article01 8 abstract background: following menopause there are changes in values of lipid profile parameters. abdominal obesity has also been linked to significant metabolic abnormalities including changes in lipid parameter values. so, we designed this study to observe the pattern of lipid profile parameters in postmenopausal central obese women. objective: to assess the lipid profile status of postmenopausal women with central obesity. materials and methods: this cross sectional study was carried out in the department of biochemistry, bangabandhu sheikh mujib medical university, dhaka, bangladesh during the period of january 2005 to december 2005. seventy four postmenopausal women with central obesity and age matched 56 nonobese postmenopausal women were included in the study. central obesity was defined having waist hip ratio more than 0.8. all statistical analyses were done by spss 12.0. p values <0.05 were considered significant. results: statistically no significant difference was observed between the central obese women and nonobese women in total cholesterol and ldl-cholesterol levels. but hdl-cholesterol was found lower and triacylglycerol was found higher in postmenopausal central obese women. conclusion: dyslipidaemia is a feature of postmenopausal women with central obesity. key words: central obesity, postmenopausal, nonobese j enam med col 2013; 3(1): 8-12 postmenopausal women have an increased tendency for gaining weight. the decline of endogenous oestrogen, together with physical inactivity is probably the major cause of this phenomenon. postmenopausal overweight and obesity lead to increased rates of hypertension, diabetes mellitus, coronary heart disease (chd) and all-cause mortality.1 following menopause, adverse changes in lipid profile occur and the levels of several coagulation factors increase.2 the lipid profile is a group of tests that are often done together to determine risk of chd. it includes total cholesterol (tc), hdl-cholesterol, ldlcholesterol and triacylglycerol (tag). it is used to guide health care providers in decision making as to how a person at risk should be treated. the scenario of the lipid profile is considered along with other known risk factors of chd to develop a plan of treatment and follow-up.3 it is well known that in pre-menopausal women the incidence of cardiovascular events is lower than in men of the same age and after menopause cardiovascular morbidity and mortality in women become similar to that of man indicating that female sex hormones play a relevant protective role upon the vasculature. the prevalence of obesity and overweight is also higher in postmenopausal women than that in men of comparable age.4 introduction 8 lipid profile of postmenopausal women with central obesity 1. assistant professor, department of biochemistry, national institute of kidney diseases and urology, dhaka 2. professor, department of biochemistry, enam medical college, savar, dhaka 3. associate professor, department of biochemistry, delta medical college, dhaka 4. associate professor, department of biochemistry, national institute of kidney diseases and urology, dhaka 5. professor, department of biochemistry, bangabandhu sheikh mujib medical university, dhaka correspondence monowara khanam, email:monowara59@gmail.com original article monowara khanam1, md. aminul haque khan2, md. rezwanur rahman3, selima akhter4, md. mozammel hoque5 obesity is a term commonly used to describe individual with increased body fat. it is associated with an increased risk of atherosclerosis, diabetes mellitus and gall bladder disease. normal fat content of body is considered to be 12–18% of body weight in men and 18–25% of body weight in women. obesity is commonly said to be present when body fat content is more than 20% and 25% of body weight in men and women respectively. a value that correlates better with body fat is the body mass index (bmi).5 individuals with bmi between 25 and 29.9 are overweight, and bmi > 30 are defined as obese.6 there are two major types of fat distribution in adult obese.7 1. some adults store their fat mainly around the hips and thigh, which gives them a pear shape known as gynoid distribution; this is a characteristic of women. 2. the second type found in both sexes is the storage of fat primarily in the abdomen, producing an ‘apple’ shape known as android distribution. excess fat located in the central abdominal area of the body is called android, ‘apple-shaped’ or upper body obesity and is associated with a greater risk for hypertension, insulin resistance, diabetes, dyslipidaemia and coronary heart disease. android fat distribution is defined by waist to hip ratio (whr) more than 0.8 for women and more than 1 for men.6 through the effect of menopausal transition, the morbidity and mortality of cardiovascular diseases in women are increased. lack of the oestrogen protection is presumed to be the major reason. however, several other physiological changes (such as aging effect, increased body weight or android pattern of body fat distribution, decreasing resting metabolic rate and physical activity etc.) which develop during menopause may also influence the risk of cardiovascular disease. among these factors the android pattern of body fat distribution seems to be the major issue. the android body fat distribution, glucose intolerance, hyperlipidaemia and hypertension appear to be clustered together in the same subject.8 the metabolic phenotype of postmenopausal women, which includes an increased tendency for body fat deposition in the abdominal region, suggests that insulin resistance may underlie the characteristic features of postmenopausal dyslipidaemia. adverse effects of insulin resistance on lipid metabolism, with consequent effects on circulating tag concentrations, may be the primary metabolic defects that lead to low hdl-cholesterol and increased prevalence of small dense ldl which are the key features of the atherogenic lipoprotein phenotype. greater tendency for central fat deposition after the menopause may be particularly relevant to the higher incidence of chd in postmenopausal women. although central obesity has been shown to be a strong risk factor of chd for both men and women, studies in women generally produce values for relative risk that are higher than those found in men.9 the possibility that raised tag is a key feature of the lipid disturbance that leading to increased risk of chd after the menopause is supported by the fact that raised tag is more strongly associated with chd risk in women than men. the framingham study10 showed that in women the strongest predictor of chd risk was a tag level greater than 1.7 mmol/l and hdl-cholesterol values less than 1.3 mmol/l. in a prospective follow-up study (over a 20 years period) on 1462 women a strong association between serum tag concentrations and chd mortality was reported. the dominance of tag as a risk factor in postmenopausal women and its link with central obesity and insulin resistance is also supported by the observation that women with non-insulin-dependent diabetes mellitus have a 4-5 fold increase in risk of chd, compared with a 2-3 fold increase in men.9 obesity is commonly regarded as an important contributor to the development of hyperlipidaemia on the basis that cross-sectional studies have documented statistically significant, although modest, associations between lipid levels and various estimates of obesity. vague et al11 introduced the ‘masculine differentiation index’ to distinguish between ‘android’ and ‘gynoid’ obesity. he found that a predominance of fat in the upper body (android obesity) was associated with metabolic disturbances, while a predominance of fat in the lower body (gynoid obesity) was associated only with problems such as abdominal pressure and locomotor difficulty. following menopause fat is increasingly deposited in the upper body region which is associated with low hdl-cholesterol, high apolipoprotein-b and high triglycerides.12 9 j enam med col vol 3 no 1 january 2013 lipid parameters cases (n=74) controls (n=56) t values p values (mg/dl) mean ± sd mean ± sd total cholesterol 197.1 ± 50.6 184.9 ± 41.2 1.47 > 0.05 triacylglycerol 149.4 ± 65.6 120.7 ± 46.3 2.91 < 0.01 hdl-cholesterol 29.6 ± 6.3 33.5 ± 7.2 3.32 < 0.01 ldl-cholesterol 137.1 ± 50.1 128.0 ± 41.5 1.10 > 0.05 10 j enam med col vol 3 no 1 january 2013 abdominal obesity has been linked to significant metabolic abnormalities including insulin resistance, hyperinsulinaemia, and elevated tag levels as well as increased incidence of hypertension, glucose intolerance and diabetes mellitus. abdominal adiposity as measured by waist-hip ratio (whr), is an independent risk factor for chd in men and perhaps also in women.13 waist circumference and whr are important indicators of cardiovascular risk even after adjustment for bmi. the increased visceral fat mass associated with increased waist circumference is largely the result of overall obesity, whereas in case of an increased whr, the increase in visceral fat is due to other factors as well.14 the prevalence of obesity is increasing worldwide. cardiovascular disease (cvd) remains the major cause of death in postmenopausal women. before menopause, women are relatively protected from ischaemic heart disease and thromboembolism by their circulating oestrogen, but this protection is lost after menopause.2 therefore it is important to study lipid profile in postmenopausal women with central (abdominal) obesity. so this study was designed to observe the pattern of lipid profile parameters in the postmenopausal central obese women. materials and methods this cross sectional study was done in the department of biochemistry, bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh during the period of january 2005 to december 2005. seventy four postmenopausal women with central obesity and age matched 56 nonobese postmenopausal women were included in the study. the subjects were selected by nonrandom purposive sampling from outpatient departments of bsmmu, dhaka, dhaka medical college hospital, dhaka, bashail and shakhipur upazilla health complexes, tangail and different places of dhaka city. permission for the study was taken from the concerned authorities. all the subjects included in the study were informed of the purpose of the study. written consent was taken after detailed explanation about the study. central obesity was defined having whr >0.8. postmenopausal women with diabetes mellitus, alcoholism, chronic renal failure, nephritis, nephrotic syndrome, myocardial infarction, hypertension, and hypothyroidism were excluded from the study. after selection of the subjects, 4 ml of blood specimen was collected from each of them in fasting condition with all aseptic precautions for estimation of serum tc, tag and hdl-cholesterol levels. ldl-cholesterol level was calculated by applying friedewald’s formula. all statistical analyses were done by spss 12.0. unpaired student’s t test was done to compare the values between groups. p values <0.05 were considered significant. results the mean age of the postmenopausal women with central obesity was 55.80 (40–80) years and that of nonobese controls was 57.70 (40–76). table i shows the comparison of serum lipid parameters between postmenopausal centrally obese cases and nonobese controls. statistically there was no difference between the two groups in total cholesterol and ldl-cholesterol levels. but hdl-cholesterol was significantly lower in centrally obese postmenopausal women compared to postmenopausal nonobese controls and tag levels were found significantly higher in the centrally obese cases compared to controls. table i: comparison of serum lipid parameters between postmenopausal centrally obese cases and nonobese controls discussion obesity is a well documented separate risk factor for metabolic and vascular disease, which may reduce life expectancy for overweight people.15 menopause tends to be associated with an increased risk of obesity and a shift to an abdominal fat distribution with associated increase in health risk.16 in this study we have measured serum lipid profile in 74 cases of postmenopausal central obese women and 56 nonobese control postmenopausal women. the mean serum hdl-cholesterol level was found to be significantly low and mean serum tag level was found to be significantly high in central obese cases compared to that of controls. with respect to tc and ldl-cholesterol two groups did not differ. this finding supports other similar studies.17-19 serum tc and ldl-cholesterol of two groups did not differ significantly, but the values of tc and ldl-cholesterol had trend to increase in central obese cases. it may be due to small sample size in our study. carr20 observed that elevated ldlcholesterol is not a feature of dyslipidaemia in case of postmenopausal women with abdominal obesity. our study is similar with this observation. many longitudinal studies have shown that tag level increases with transition through the menopause and the increase in tag also appears early in the postmenopausal period. poehlman et al21 found that prospective transition to postmenopause was associated with a 16% increase in tag. it was observed in most studies that total hdl-cholesterol level falls slightly with menopause, whereas other blood lipids had no change.22 increasing tag with menopause may be related to the fact that tag levels are highly correlated with increasing abdominal fat content and insulin resistance.22 in this study whr was used as indicator of central obesity. in a small study of swedish men, it was observed that a high waist-to-hip ratio after adjustment for age and bmi was associated with an increased visceral fat area and a decreased thigh muscle area.23 the study done by seidell et al24 observed that larger waist and smaller hip circumferences than what was predicted on the basis of bmi and age are both independently related (but in opposite direction) to risk factors such as low hdl-cholesterol, high triacylglycerol and high insulin concentration. in this study of central obese cases we have found increased tag, decreased hdl-cholesterol without significant differences in tc and ldl-cholesterol. central obesity is associated with a threatening combination of metabolic abnormalities that includes dyslipidaemia (low hdl-cholesterol and high tag), insulin resistance, glucose intolerance and hypertension which have been referred to metabolic syndrome. individuals with this syndrome have a significantly increased risk for developing diabetes mellitus and cardiovascular disorders. so increased tag and low hdl-cholesterol are risk factors for central obese postmenopausal women. from the findings of the present study, it can be concluded that dyslipidaemia is a feature of postmenopausal women with central obesity. however, further prospective studies with large sample size should be carried out to evaluate the degree of dyslipidaemia of centrally obese postmenopausal women. extensive studies should be done on central obesity in men, women and children as obesity is a global problem now-a-days. we recommend creating awareness regarding metabolic complications of central obesity in postmenopausal women as well as in general population. references 1. berry em, brejezinski a, dubnov g. weight control and the management of obesity after menopause: the role of physical activity. maturitas 2003; 44(2): 89-101. 2. basurto l, hermandez m, zarate a. the metabolic syndrome in postmenopausal women: clinical implication. gac med mex 2003; 139(6): 625-628. 3. libby p. prevention and treatment of atherosclerosis. in: dl kasper, fauci as, longo dl, braunwald e, hauser sl, jameson jl (eds). harrison’s principles of internal medicine. 16 th edn. new york: mcgraw-hill, 2005: 1430-1433. 4. r u p p e l l i a . h y p e r t e n s i o n a n d o b e s i t y a f t e r t h e menopause. j hypertens 2002; 20(2): s26-28. 5. gannong wf. energy balance, metabolism and nutrition. in: review of medical physiology. 20 th edn. new york: mcgraw-hill companies, 2001: 271-306. 11 j enam med col vol 3 no 1 january 2013 6. obesity. in: champe pc, harvey ra, ferrier dr (eds). lippincott’s illustrated reviews: biochemistry. 3 rd edn. philadelphia: lippincott williams & wilkins, 2005: 347-354. 7. frier bm, truswell as, shepherd j, de looy a, jung r. diabetes mellitus, and nutritional and metabolic disorders. in: haslett c, chilver er, hunter jaa, boon na (eds). davidson’s principles and practice of medicine. 18 th edn. london: churchill livingstone, 1999: 471-542. 8. chang cj, wu ch, yao wj, yang yc, wu js, lu fh. relationship of age, menopause and central obesity on cardiovascular disease risk factor in chinese women. international journal of obesity 2000; 24: 1699-1704. 9. loverove ja, sliva r, wright jw, williams cm. adiposity, insulin and lipid metabolism in postmenopausal women. international journal of obesity 2002; 26: 475-486. 10. castelli wp. the triglyceride issue: a view from framingham. am heart j 1988; 112: 432-437. 11. vague j. the degree of masculine differentiation of obesities: a factor determining predisposition to diabetes, atherosclerosis, gout, and uric calculous disease. am j clin nutr january 1956; 4(1): 20-34. 12. gower ba, nagy tr, goran mi, toth mj, poehlman et. fat distribution and plasma lipid-lipoprotein concentrations in preand postmenopausal women. international journal of obesity 1998; 22: 605-611. 13. rexrode km, carey vj, hennekens ch, walters ee, colditz ga, stampfer mj et al. abdominal adiposity and coronary heart disease in women. jama 1998; 280(21): 1843-1848. 14. rexrode km, carey vj, hennekens ch, walters ee, colditz ga, stampfer mj et al. abdominal adiposity and coronary heart disease in women. jama 1999; 281: 2284-2285. 15. silberbauer k. cardiovascular sequele and risk of obesity. acta med austriaca 1998; 25(4-5): 133-135. 16. lovejoy pc. the menopause and obesity. prim care 2003; 30(2): 317-325. 17. bruzell jd, hokanson je. low-density and high-density lipoprotein subspecies and risk for premature coronary artery disease. am j med 1999; 107: 165. 18. bikkina m, larson mg, levy d. prognostic implications of asymptomatic ventricular arrhythmias: the framingham heart study. ann intern med 1992; 117: 990-996. 19. lee et, cowan ld, welty tk, sievers m, howard wj, oopik a et al. all-cause morality and cardiovascular disease mortality in three american indian populations, aged 45–74 years, 1984–1988: the strong heart study. am. j. epidemiol. 1998; 147(11): 995-1008. 20. carr mc, brunzell jd. abdominal obesity and dyslipidemia in the metabolic syndrome. the journal of clinical endocrinology & metabolism 2004; 89(6): 2601-2607. 21. poehlman et, toth mj, gardner aw. changes in energy balance and body composition at menopause: a controlled longitudinal study. ann intern medicine 1995; 123: 673-675. 22. carr mc. the emergence of the metabolic syndrome with menopause. j clin endocrinol metab 2003; 88(6): 24042411. 23. seidell jc, bjorntorp p, sjostrom l, sannerstdt r, krotkiewski m, kvist h. regional distribution of muscle and fat mass in men – new insight into the risk of abdominal obesity using computed tomography. int j obes 1989; 13: 289-303. 24. seidell jc, perusse l, despres jp, bouchard c. waist and hip circumferences have independent and opposite effects on cardiovascular disease risk factors: the quebec family study. american journal of clinical nutrition 2001; 74(3): 315-321. 12 j enam med col vol 3 no 1 january 2013 article07 47 abstract a 43-year-old woman presented with bilateral ectopic breasts in both the axillae in chittagong medical college hospital in july 1996. she was diagnosed having carcinoma in the left ectopic breast. she was successfully treated with local surgical excision and regional lymph node dissection, adjuvant chemotherapy, loco-regional radiotherapy and hormone therapy. the patient continued tamoxifen for 5 years. till last follow-up in december 2011, the patient was asymptomatic without any evidence of residual disease or local recurrence and evidence of metastases. key words: ectopic accessory breasts, adjuvant chemotherapy, radiotherapy j enam med col 2013; 3(1): 47-49 the incidence of ectopic accessory breast is uncertain, but it is generally found in 1-2% of humans.1 an alternative classification of ectopic breast tissue has been offered by copeland and geschickter2, in which accessory nipple formation, areola formation or both, with or without glandular breast, is termed supernumerary breast, as opposed to aberrant breast, referring to ectopic breast tissue without a nipple or areola complex. aberrant breast tissue can develop with any disease that affects the normal breast, including breast carcinoma.3 carcinoma of aberrant breast tissue is rare.4 ectopic mammary gland includes both accessory and aberrant mammary glands. ectopic breast tissue can occur anywhere along the primitive embryonic milk line, extending from axilla to groin bilaterally. it has also been reported within axillary lymph nodes5 and along the ‘milk line’ that runs from the axilla to the inguinal region, the most common sites being the chest wall and the vulva.6 ectopic breast parenchyma is subject to changes similar to those of the orthotopic organ, including lactational changes, benign tumors and carcinoma.6 the incidence of ectopic mammary gland is not low, but the development of malignancy within these anomalies has been scarcely reported. in view of the relative rarity, to remind the surgeons and oncologists regarding its good prognosis provided diagnosed early and properly treated, it was thought worthwhile in publishing the following case. case report mrs. rowshan ara, aged 43 years and mother of a son and two daughters, was admitted in chittagong medical college & hospital (cmch) on july 28, 1996 with the complaints of a painless lump on the upper part of the medial wall of the left axilla for 8 months which was gradually increasing in size. fig 1. bilateral accessory breasts with carcinoma of the left (excised) introduction 47 carcinoma of the ectopic breast 1. professor, department of oncology, enam medical college & hospital, savar, dhaka 2. former assistant professor, department of radiotherapy, chittagong medical college & hospital, chittagong correspondence a. m. m. shariful alam, email: nicrh2002@gmail.com case report a. m. m. shariful alam1, shamima anwar2 she had been on homeopathic treatment since development of the lump without any improvement. on admission, physical examination revealed a nontender, slightly mobile, palpable lump of about 5 cm × 5 cm in size, partly fixed to the underlying structures and free from overlying structures. there was no palpable lump in any breast and no palpable lymph gland could be detected either in the axillae or elsewhere in the body. on careful examination of the lump, there was small rudimentary nipple-like structure over the lump. the nipple-like structure of the same size was also found on the same site of the right axilla but without any lump or swelling. she was menopausal for the last two years and was hypertensive. she also observed coming out of milk from both these nipple-like structures of the axillae simultaneously during breastfeeding from original breasts following her every child birth. no abnormality was detected in her haematological profile, chest radiography, ultrasonogram of the abdomen and pelvis. she underwent local surgical excision and regional lymph node resection on 16.09.1996. histopathology revealed an invasive ductal carcinoma in the breast tissue, with foci of necrosis and moderate lymphocytic infiltration. axillary lymph nodes showed reactive change. estrogen and progesterone receptor positivity tests were performed and revealed estrogen and progesterone positivity. hence the diagnosis was confirmed as infiltrating duct cell carcinoma of the left accessory breast. then she attended the radiotherapy outpatient department (ropd), cmch on 10.10.96. adjuvant combination chemotherapy including cyclophosphamide, adriamycin and 5-flurouracil was prescribed after satisfactory wound healing. this protocol was repeated on every 3 weeks with proper hematological care up to total of 6 cycles. the hematological parameters before each cycle of chemotherapy was normal and toxicity of the above cytotoxic drugs was on tolerable limit. the chemotherapy schedule was continued regularly up to 22.04.97. after completion of 6 cycles of chemotherapy, the patient was asymptomatic except some sorts of weakness and mild loss of appetite and on physical examination, no abnormality could be detected. considering her age and menopausal status, tamoxifen (20 mg daily) was advised to continue it for 5 years. three weeks after completion of chemotherapy, she was planned for radiotherapy by a direct field to the operated axilla with a field size of 12 × 12 cm and total dose given was 4000cgy in 20 fractions up to 29.06.97. the total period of radiotherapy was uneventful. six weeks after completion of radiotherapy, she was asymptomatic and there were no sign and symptom of recurrence or residual disease especially in the operated accessory breast. opposite accessory breast and both normal breasts were also normal. no features of organomegaly and lymphadenopathy (locally or distant) were observed. complete blood profile, chest radiography, ultrasonogram of the abdomen and pelvis were normal. ct scan of the chest and abdomen were also normal. so all sorts of antimitotic treatment were stopped, except tamoxifen which was advised to continue for 5 years. the patient was also advised to come for follow-up at 6 weeks interval. after completion of 5-year courses of tamoxifen, the patient was asymptomatic. physical examination and relevant investigations were normal. the patient underwent last follow-up examination in december 2011. she was asymptomatic without any sign and symptom of recurrence or residual disease locally or elsewhere in the body. relevant investigation reports were also normal. discussion in most cases, the accessory breast tissue was either bilateral or confined to the right side.5 in the present case, the accessory axillary breast tissue was bilateral and carcinoma was found only in the left ectopic breast. a frequency of 14% seen in one series appears so high that the occurrence of malignant changes in the accessory breast is not actually rare.7 although the incidence of ectopic breast tissue is about 1-2%8, it is more prone to develop malignant change than normal breast parenchyma.9 malignant tumors occur more frequently than benign tumors in ectopic mammary glands.10 in this article, we used the term ‘ectopic breast cancer’ for neoplasm developed in the left accessory gland. review of nakao et al11 showed that out of 37 cases 33 (89%) occurred in the axilla, 2 in the parasternum and 2 in the inframammary region. marshal7 reported that 58% of ectopic breast cancers were found in close proximity to the axilla. in japan, ectopic breast cancer occurred more frequently in the 48 j enam med col vol 3 no 1 january 2013 49 j enam med col vol 3 no 1 january 2013 axilla.11 in this case, cancer also occurred in the ectopic breast of the left axilla. accessory breasts and nipples have been known to function during lactation.12 in this case, lactation of both the ectopic breasts was observed during every pregnancy. accessory breast tissue responds to the hormonal influences of the menstrual cycle, pregnancy and lactation as normally situated breasts. in this case, response to hormonal influence and carcinoma of the axillary accessory breast tissue was observed. if ductal carcinoma is confirmed to the ectopic breast, the differential diagnoses of primary mammary carcinoma of the axilla, metastatic breast carcinoma, primary skin appendage carcinoma, lymphoma, metastatic carcinoma from other sites, eg, lung should be considered. a thorough metastatic workup should be performed, with attention directed toward detecting a primary site in breast by history, physical examination and radiological examination. suspicious lesions of the breast should be evaluated by biopsy. if axillary mammary duct carcinoma is confirmed, current treatment strategy of breast cancer to establish a sensible management approach should be followed. although the prognosis of this case seems to be very good, prognostic conclusions could not be made by studying a case only. conclusion if accessory breast carcinoma is diagnosed earlier and optimal treatment can be offered, a very good outcome can be achieved. the patient must be cooperative and should be regular in follow-up examination to have a disease free survival. acknowledgement we are indebted to mrs. rowshan ara for allowing us to publish this case report. references 1. cogswell hd, czerny ew. carcinoma of aberrant breast of the axilla. am j surg 1961; 27: 388-390. 2. copeland mm, geschickter cf. diagnosis and treatment of premalignant lesions of the breast. surg clin north am 1950; 30: 1717-1741. 3. yerra l, karunad ab, votaw ml. primary breast cancer in aberrant breast tissue in the axilla. south med j 1997; 90: 661-662. 4. cheong jh, lee bc, lee ks. carcinoma of the axillary breast.yonsei med j 1999; 40: 290-293. 5. turner dr, millis rr. breast tissue inclusions in axillary lymph nodes. histopathology 1980; 4: 631-663. 6. o’hara mf, page dl. adenomas of the breast and ectopic breast under lactational influences. human pathol1985; 16: 707-712. 7. s p e e r t h . s u p e r n u m e r a r y m a m m a c w i t h s p e c i a l reference to the rhesus monkey. quar j 1942; 17: 59-68. 8. adler dd, renber m, pennes dr. accessory breast tissue in the axilla: mammographic appearance. radiology 1987; 163(3): 709-711. 9. badejo oa. fungating accessory breast carcinoma in nigerian women. trop geogr med 1984; 36(1): 45-49. 10. kanazawa k, ishikawa k, kusama s et al. carcinoma of the axillary accessory mammary gland. tokyo j med sci 1970; 78: 99-103. 11. nakao a, saito s, inoue f, notohara k, tanaka n. ectopic breast cancer : a case report and review of the japanese literature. anticancer research 1998; 18: 3737-3740. 12. marshall mb, moynihan jj, frost a, evans srt. ectopic breast cancer: case report and literature review. surg oncol 1994; 3: 295-304. journal of enam medical college vol 11 no 2 may 2021 92 original article hemodynamic effects of oxytocin when given as bolus or slow intravenous infusion during cesarean section nasima begum1, tahamina khanum2, rahima khatun3, nelufa tahera rahman4 received: 5 january 2021 accepted: 14 april 2021 doi: https://doi.org/10.3329/jemc.v11i2.65191 abstract background: oxytocin is a uterotonic drug with profound haemodynamic effects. the effects of oxytocin on women undergoing cesarean section include tachycardia, hypotension and decreased cardiac output. these can be sufficient to cause significant compromise in high risk patients. objective: this study aims to find out a simple way to decrease these risks without compromising the therapeutic benefits such as decreasing bleeding after delivery and uterine contraction. materials and methods: we recruited 60 women undergoing cesarean section. the subjects were randomly divided into two groups, 30 subjects per group, randomly selected by blind envelope method. group a: parturient received 5 iu bolus (approximately over 2 seconds). group b: parturient received 5 iu oxytocin iv slow infusion (diluted with 10 ml distilled water) over 2 minutes. results: a significant increase in heart rate and fall in blood pressure in the group where oxytocin was given iv bolus compared to the slow iv infusion group. there were no differences in the estimated blood loss and uterine contraction between the two groups. conclusion: the haemodynamic changes are more marked in the iv bolus than the slow iv infusion of oxytocin. slower injection of oxytocin can effectively minimize the cardiovascular side effects without compromising the therapeutic benefits. key words: obstetric anaesthesia; anaesthetic techniques; regional; spinal; complications; haemodynamic; oxytocin j enam med col 2021; 11(2): 92−98 1. assistant professor, department of gynaecology and obstetrics, enam medical college & hospital, savar, dhaka 2. associate professor, department of gynaecology and obstetrics, enam medical college & hospital, savar, dhaka 3. assistant professor, department of gynaecology and obstetrics, ad-din women’s medical college & hospital, dhaka 4. medical officer, department of anesthesiology & icu, enam medical college & hospital, savar, dhaka correspondence nasima begum, email: nasimadr1975@gmail.com introduction the hemodynamic changes in parturient women after cesarean delivery may be caused by the elimination of the aorta-caval compression, autotransfusion of blood immediately after delivery, haemorrhage, and vasoconstriction and excitation, but some studies have reported that uterotonic drug is the main factor.1,2 uterotonic drug, which is most frequently used for cesarean section, is oxytocin which induces uterine contraction during cesarean section and peripheral vasodilation along with a decrease in arterial pressure after delivery and thus reduces hemorrhage.3,4 however, intravenous injection of oxytocin during cesarean section may cause cardiovascular side effects such as tachycardia or hypotension1,2 and is reported to cause even cardiovascular collapse and death in the most severe cases.5,6 moreover, various may 2021j enam med col vol 11 no 2 93 other side effects have been reported including fluid pooling or pulmonary edema by the antidiuretic effect of oxytocin.7−9 hence, determining the oxytocin concentration for cesarean section is important. however, since the activity of oxytocin varies from individual to individual10 and an appropriate dose has not been established, 5−20 iu is intravenously injected based on experience.11,12 there is recent assertion that bolus intravenous injection or bolus-continuous parallel intravenous injection of oxytocin is more effective than continuous intravenous injection in cesarean section.13,14 there is also report that a great quantity of bolus intravenous injection requires caution because it causes hemodynamic changes related to hypotension.1,2 therefore, research is necessary on the method of oxytocin injection and the effective minimum concentration for cesarean section to induce uterine contraction without side effects. in this study, we tried to find out the effects of hemodynamic changes such as changes in heart rate, blood pressure and uterine contraction of the recommended dose (i.e., 5 iu) of oxytocin when given as iv bolus or slow iv infusion (diluted in 10 ml of distilled water) over 2 minutes during cesarean section under spinal anesthesia. materials and methods this study was approved by the hospital ethics committee. we recruited women undergoing cesarean section under spinal anesthesia who were 38 weeks or more into their pregnancy, and were classified as class 1 or 2 according to the american society of anesthesiologist (asa) physical status classification. the study was conducted in obstetrics and gynecology department in dhaka medical college hospital (dmch), dhaka from 1 january 2009 to 30 august 2009. pregnant women who had contraindication for spinal anesthesia, those whose weight was 100 kg or higher, those who had fetal abnormalities, diabetes, gestational hypertension, cardiovascular disease, or cerebral hemorrhage, and those whose labor pain had already started, were excluded from the study. the subjects were visited before the operation and written consent was given by the subjects. the age, height and weight of the patients were recorded. about 500 ml of hartmann solution was rapidly dripped into all the parturient women before inducing anesthesia. an electrocardiograph, automated noninvasive blood pressure device, and a pulse oximeter were attached to the subjects, and oxygen was administered at 5 l/min through a face mask. for the spinal anesthesia, the l3−4 or l4−5 lumbar region was punctured with a 25 g quincke needle when the parturient women were in the left lateral recumbent position, and a 0.5% hyperbaric bupivacaine solution (10−12 mg) was injected after verifying the cerebrospinal fluid leakage. immediately after the anesthesia, the parturient women were asked to take the supine position and the maximum sensory block level was set to t4−6. the blood pressure and heart rate (hr) were measured in five-minute intervals from the time just after the anesthesia started to the end of the operation. however, during the 10 minutes after the oxytocin was injected, the blood pressure and hr were recorded in one-minute intervals, and delivery of the newborn was set as the baseline. the parturient women were asked if they felt or experienced nausea or vomiting after oxytocin injection and the results were recorded. when some of the parturient women had severe vomiting or continual nausea, the antiemetic drug, ondansetron 8 mg, was intravenously injected. in the cases where the systolic pressure decreased by more than 20% compared to the blood pressure before coming to the operating room, 10 mg of ephedrine was intravenously injected until the blood pressure was normalized, and these cases were excluded from the study. the subjects were randomly divided into two groups, 30 subjects per group, randomly selected by blind envelope method. group a: parturient received 5 iu bolus (approximately over 2 seconds). group b: parturient received 5 iu oxytocin iv slow infusion (diluted with 10 ml distilled water) over 2 minutes. after delivery of the fetus, group a was given 5 iu oxytocin bolus (approximately over 2 seconds) and group b was given 5 iu oxytocin iv infusion slowly (diluted with 10 ml distilled water) over 2 minutes. baseline data were taken before oxytocin was given. may 2021j enam med col vol 11 no 2 94 after delivery of the fetus, patient was monitored by measuring systolic and diastolic bp, mean arterial pressure (map), heart rate, oxygen saturation (spo2), uterine contraction, uterine bleeding and any adverse effects was recorded every one minute. the study period was started just before oxytocin was given and it was continued for a further 10 minutes. the study period of 10 minutes was set after a small pilot study. patient was observed by the surgeon and the state of the uterine contraction was expressed as mild, moderate or satisfactorily contracted. uterine bleeding was calculated clinically after suctioning amniotic fluid and blood in separate bottles. visual estimation of the blood loss was done by surgical sponges and laparotomy pads (laps). a fully-soaked sponge (4″ × 4″) on each side holds 10 ml of blood whereas a soaked “lap” holds 100−150 ml. in case of cesarean section 800−1000 ml of blood loss is considerable. patient can tolerate this amount of blood loss. so, more than 1000 ml blood loss is considered as excessive blood loss. at the end of surgery 200 microgram misoprostol was given per-rectally for each patient. postoperatively patients’ state of uterine contraction, p/v bleeding and cardiovascular status were also monitored. the results were compiled and analyzed statistically by unpaired ‘t’ test and ‘chi-square’ test with level of significance at p value <0.05. results a total of 60 subjects were included in the study. table i shows age, gestational age and weight distribution of the subjects. table ⅱ shows comparison of hemodynamic mean parameters between group a and group b at 0 minute. table ⅲ shows comparison of hemodynamic mean parameters between group a and group b at 3 minutes. table ⅳ shows comparison of hemodynamic mean parameters between group a and group b at 5 minutes. table i: age, gestational age and weight distribution of the subjects group a n=30 group b n=30 t values p values mean±sd mean±sd age in years 24.1±6.0 25.1±4.7 0.70 0.489ns gestational age (wks) 39.4±0.7 39.6±0.8 0.921 0.360ns weight of the patients (kg) 59.3±3.0 59.9±2.3 0.99 0.327ns group a: 5 iu oxytocin bolus, group b: 5 iu oxytocin iv infusion. p value for age and weight of the patients was reached by unpaired t test and p value for gestational age was reached by chi squire test. no significant difference was found between group a and group b. table ⅱ: comparison of haemodynamic mean parameters between group a and group b at 0 minute (n=60) 0 min group a(n=30) group b (n=30) t values p values mean±sd mean±sd heart rate (beats/min) 89.5±8.4 86.9±9.5 0.73 0.471 systolic bp (mm hg) 116.7±7.5 119.7±6.7 1.63 0.109 diastolic bp (mm hg) 75.7±6.8 77.8±4.9 1.42 0.160 spo2 (%) 97.7±0.6 98.0±0.6 1.71 0.093 map (mm hg) 88.9±7.0 86.8±4.4 1.93 0.059 group a: 5 iu oxytocin bolus, group b: 5 iu oxytocin iv infusion. p value reached from unpaired t-test. the mean difference of all haemodynamic parameters at 0 minute were not statistically significant (p>0.05) in unpaired t-test. may 2021j enam med col vol 11 no 2 95 table ⅲ: comparison of haemodynamic mean parameters between group a and group b at 3 minutes (n=60) 3 minutes group a (n=30) group b (n=30) t values p values mean±sd mean±sd heart rate (beats/min) 101.8±5.1 90.4±4.4 2.23 0.026s systolic bp (mm hg) 95.5±5.4 108.7±4.3 2.16 0.006s diastolic bp (mm hg) 60.0±9.9 73.7±8.1 2.39 0.022s spo2 (%) 98.7±0.5 98.8±0.5 0.25 0.802 ns map (mm hg) 64.2±6.2 74.7±7.3 2.07 0.034s group a: 5 iu oxytocin bolus, group b: 5 iu oxytocin iv infusion. p value reached from unpaired t-test. the mean difference of all hemodynamic parameters at 3 minute were statistically significant (p<0.05) in unpaired t-test except spo2, which was not statistically significant (p>0.05). table ⅳ: comparison of hemodynamic mean parameters between group a and group b at 5 minutes (n=60) 5 minutes group a (n=30) group b (n=30) t values p values mean±sd mean±sd heart rate (beats/min) 105.8±5.2 90.1±2.1 2.27 0.029s systolic bp (mmhg) 97.3±4.5 106.9±3.6 2.21 0.032s diastolic bp (mmhg) 61.3±3.6 72.6±4.9 2.21 0.032s spo2 (%) 98.9±0.3 98.8±0.4 1.20 0.235 ns map (mmhg) 64.7±4.2 74.3±5.3 2.55 0.016s group a: 5 iu oxytocin bolus, group b: 5 iu oxytocin iv infusion. p value reached from unpaired t-test. the mean difference of all hemodynamic parameters at 5 minute were statistically significant (p<0.05) in unpaired t-test except spo2, which was not statistically significant (p>0.05). table ⅴ shows amount of blood loss and occurance of postpartum haemorrhage in two groups. in case of cesarean section 800−1000 ml of blood loss is considerable. patient can tolerate this amount of blood loss. so, more than 1000 ml blood loss is considered as excessive blood loss. uterus was found mildly contracted in 27 (90%) cases in group a and in 26 (86.7%) cases in group b at 1 minute. however, at 2 minutes uterus was found moderately contracted in 29 (96.7%) in group a, and 28 (93.3%) in group b. uterus was found fully contracted at 3 minutes and onwards in all patients in both groups. regarding uterine contraction, no statistical significant (p>0.05) difference was found between two groups in chi square test (table vi). table ⅴ: amount of blood loss and occurance of postpartum haemorrhage in two groups complications group a group b number percentage number percentage ignored bleeding up to 1000 ml 30 100.0 30 100.0 postpartum hemorrhage 0 0 0 0 group a: 5 iu oxytocin bolus, group b: 5 iu oxytocin iv infusion. p value reached from chi square test. may 2021j enam med col vol 11 no 2 96 discussion oxytocin, a hormone that is secreted from the pituitary posterior lobe, decreases blood pressure by causing peripheral vasodilation and increasing the hr and induces uterine contraction.3,4 uterine contraction by oxytocin is enhanced since there are more intrauterine oxytocin receptors.15 the oxytocin sensitivity of pregnant women reaches the maximum in the full term of the pregnancy because of the increase of intrauterine oxytocin receptors by gestational estrogen.10 hence, during normal delivery, the oxytocin discharged from the pituitary posterior lobe by the obstetric canal stimulus of the fetus can induce labor pain and sufficient uterine contraction with an extreme low-dose of 10 miu/min.16 in the case of a planned cesarean section, however, a relatively highdose of oxytocin (5−20 iu) is intravenously injected since the action of the oxytocin is not normal.11,12 since hemodynamic changes are proportional to the intravenously injected dose of oxytocin, studies have been done on effective concentrations and intravenous injection methods. sarna et al11 reported that oxytocin infusion at a rate of 1 iu/min did not show any difference in uterine contraction and blood loss with that of 5 iu/min by intravenous injection even though the total dose may have been more than 5 iu. kim et al12 published the same assertion. on the contrary, zarzur17 recommended an infusion at a rate lower than 1 iu/ min because infusion at a rate higher than 0.25 iu/ min may cause such symptoms as hemangiectatic hypotension, tachycardia, increased cardiac output, and myocardial ischemia. according to many recent studies, oxytocin bolus injection was reported to be more effective than infusion by intravenous injection to reduce blood loss by inducing the appropriate uterine contraction13, and thus, the minimum bolus dose has been discussed.18−20 a suggested method to reduce hemodynamic changes is the repeated intravenous injections of a small quantity of a bolus dose and bolus-continuous parallel intravenous injection.14,21 svanstrom et al6 stated that attention is required because a bolus injection of 10 iu oxytocin may cause temporary hypotension and tachycardia as well as myocardial ischemia, apart from the operation, pregnancy, and autonomic blocking by spinal anesthesia. pinder et al2 recommended 5 iu as the bolus dose since 10 iu of bolus intravenous dose might not be considered as safe, either. on the contrary, butwick et al19 asserted that a dose of more than 5 iu might not be necessary because the appropriate uterine contraction occurred even with a bolus dose of 0.5−3 iu. their results were similar to our results and the hemodynamic changes were always temporary. this study shows that slower infusion of 5 iu oxytocin can effectively minimize the cardiovascular side-effects but rapid bolus oxytocin causes marked cardiovascular instability. the current study demonstrated that there was an average decrease in map of 24 mm hg ranging from table ⅵ: states of uterine contraction in both groups uterine contraction group a (n=30) group b (n=30) p values number percentage number percentage 1 minute mildly contracted moderately contracted 27 90.0 26 86.7 3 10.0 4 13.3 0.500 2 minute mildly contracted 1 3.3 2 6.7 moderately contracted 29 96.7 28 93.3 0.500 3 minute fully contracted 30 100.0 30 100.0 group a: 5 iu oxytocin bolus, group b: 5 iu oxytocin iv infusion. p value reached from chi square test. may 2021j enam med col vol 11 no 2 97 19 to 32 mm hg in group a during 2 to 5 minutes who received 5 iu of oxytocin as a rapid bolus. but in group b average decrease in map was 12 mm hg ranging from 8 to 18 mm hg during 2 to 5 minutes. it was observed that the changes in heart rate were significantly higher in group a compared to group b during 2 to 5 minutes. thus, it was found that the hemodynamic changes varied by the bolus injected oxytocin dose and changes were recovered from in about 4−5 minutes after oxytocin injection. it is shown in this study that delivery of the newborn and the following excitement may affect the hr because parturient women are conscious during cesarean section under spinal anesthesia. however, the main factor of the changes may be the effect of oxytocin itself. the half-life of oxytocin is about 2−5 minutes and a blood steady state is reached in about 30−60 minutes after intravenous injection.21 thus, the oxytocin dose and injection method play an important role in the hemodynamic changes before a steady state is reached. these hemodynamic changes by oxytocin are always temporary and the effect on healthy parturient women is small. however, it may be dangerous to parturient women who have hypovolemia or cardiovascular diseases. hence, continuous intravenous injection of oxytocin at a low concentration is primarily recommended as a safe injection method for parturient women in a high-risk group.1,2 nevertheless, repeated bolus intravenous injection with a small quantity of bolus or parallel intravenous injection of a small quantity of bolus plus continuous injection is also used because of rapid desensitization by which the hemodynamic changes are significantly decreased in the repeated oxytocin than in the initial injection.14,22 while the cardiovascular results of this study are unequivocal, it was acceptable that <1000 ml bleeding during cesarean section was ignored in this study. uterine contraction and uterine bleeding were in satisfactory level in both groups. this study supports the need for caution in using oxytocin as a bolus in cardiovascular unstable patients and offers relatively less adverse effects when given as an infusion over two minutes. the hemodynamic changes are more marked in the iv bolus than the slow iv infusion of oxytocin. slower injection of oxytocin can effectively minimize the cardiovascular side effects without compromising the therapeutic benefits. references 1. thomas js, koh sh, cooper gm. haemodynamic effects of oxytocin or infusion on women undergoing cesarean section. br j anaesth 2007; 98(1): 116–119. 2. pinder aj, dresner m, calow c, shorten gd, o’riordan j, johnson r. haemodynamic changes caused by oxytocin during cesarean section under spinal anaesthesia. int j obstet anesth 2002; 11(3): 156–159. 3. shyken jm, petrie rh. the use of oxytocin. clin perinatology 1995; 22(4): 907–931. 4. petersson m. cardiovascular effects of oxytocin. prog brain res 2002; 139: 281–288. 5. wildsmith ja, thomas ta, cooper g. confidential enquiries into maternal deaths, 1997–1999. british journal of anaesthesia 2003; 90(2): 257–258. 6. svanström mc, biber b, hanes m, johansson g, näslund u, bålfors em. signs of myocardial ischemia after injection of oxytocin: a randomized double-blind comparison of oxytocin and methylerogometrine during cesarean section. br j anaesth 2008; 100(5): 683–689. 7. edwards br, larochelle jr ft. antidiuretic effect of endogenous oxytocin in dehydrated brattleboro homozygous rats. am j physiology 1984; 247(3): 453–465. 8. heytens l, camu f. pulmonary edema during cesarean section related to the use of oxytocic drugs. acta anaesthesiol belg 1984; 35(2): 155–164. 9. shahin j, guharoy sr. pulmonary edema possibly developing secondary to the intravenous administration of oxytocin. vet hum toxicol 1991; 33(6): 587–588. 10. kimura t, tanizawa o, mori k, brownstein mj, okayama h. structure and expression of a human oxytocin receptor. nature 1992; 356(6369): 526–529. 11. sarna mc, soni ak, gomez m, oriol ne. intravenous may 2021j enam med col vol 11 no 2 98 oxytocin in patients undergoing elective cesarean section. anesth &analgesia1997; 84(4): 753–756. 12. kim dy, han ji, chung ry, lee ch. the effect of three different doses of intravenous oxytocin on patients undergoing elective caesarian section. korean j anesthesiology 2000; 38(3): 476–480. 13. davies ga, tessier jl, woodman mc, lipson a, hahn ph. maternal hemodynamics after oxytocin bolus compared with infusion in the third stage of labour: a randomized controlled trial. obstetrics & gynecology 2005; 105(2): 294–299. 14. sartain jb, barry jj, howat pw, mccormack di, bryant m. intravenous oxytocin bolus of 2 units is superior to 5 units during elective cesarean section. br j anaesth 2008; 101(6): 822–826. 15. wray s. uterine contraction and physiological mechanisms of modulation. am j physiology 1993; 264(1): 1–8. 16. xenakis em, langer o, piper jm, conway d, berkus md. low-dose versus high-dose oxytocin augmentation of labora randomized trial. am j obstetrics & gynecology 1995; 173(6): 1874–1878. 17. zarzur e. intravenous oxytocin in patients undergoing elective cesarean section. anesthesia & analgesia 1998; 86(6): 1334. 18. balki m, ronayne m, davies s, fallah s, kingdom j, windrim r el al. minimum oxytocin dose requirement after cesarean delivery for labor arrest. obstetric & gynecology 2006; 107(1): 45–50. 19. butwick aj, coleman l, cohen se, riley et, carvalho b. minimum effective bolus dose of oxytocin during elective cesarean delivery. br j anaesth 2010; 104(3): 338–343. 20. carvalho jc, balki m, kingdom j, windrim r. oxytocin requirements at elective cesarean delivery: a dose-finding study. obstet gynecol 2004; 104(5): 1005–1010. 21. langesaeter e, rosseland la, stubhaug a. haemodynamic effects of repeated doses of oxytocin during cesarean delivery in healthy parturients. br j anaesthesia 2009; 103(2): 260–262. 22. crall hd, mattison dr. oxytocin pharmacodynamics: effect of long infusions of uterine activity. gynecol obstet invest 1991; 31(1): 17–22. 88 abstract background: among the several human species of malarial parasites, plasmodium falciparum can cause severe infection and if left untreated, there may be fatal complications. early diagnosis and prompt treatment have been proposed to reduce the morbidity and mortality from malaria. objective: to assess the diagnostic efficacy of antigen detection by immunochromatographic test (ict) at different levels of parasitemia for diagnosis of malaria. materials and methods: this study was carried out in the department of microbiology, mymensingh medical college for a period of one year from july 2005 to june 2006. a total of 98 clinically suspected malaria patients were included in this study. peripheral blood films (pbf) were examined under microscope and parasite count/µl of blood was performed. subsequently ict for malaria antigen was done for each case. results: out of 59 cases positive by microscopic examination of blood films, 54 cases had parasitemia >600 parasites/µl of blood and all these cases were positive by ict for malaria antigen. rest 5 cases showed parasitemia < 600 parasites/µl of blood and one case was found positive by ict for malaria antigen. conclusion: immunochromatographic test can be used for early diagnosis of malaria with hyperparasitemia, especially for cerebral malaria. keywords: immunodiagnosis, severe malaria, hyperparasitemia j enam med col 2013; 3(2): 88--90 malaria is a febrile illness caused by four human species of the genus plasmodium, which causes more deaths worldwide than any other parasitic disease. among the four human species plasmodium falciparum is the most dangerous and is responsible for severe malaria.1 malaria is a major public health problem in bangladesh. thirteen, out of 64 districts are seriously affected by malaria and among the malaria cases, more than 70% are falciparum malaria. the emergence and spread of antimalarial drug resistant falciparum malaria is worsening the malaria problem in bangladesh.2,3 malaria may result in a wide variety of symptoms; ranging from no symptoms or very mild symptoms to severe disease and even death.4 if falciparum malaria is not treated properly, complicated ‘severe malaria’ may occur. according to who ‘severe malaria’ may be defined by at least one of the following criteria: absence of detectable, nonmalarious causes of severe anemia, prostration, respiratory distress, convulsion, impaired consciousness, hypoglycemia, hemoglobinuria, circulatory collapse, renal failure, pulmonary edema and combined with the presence of p. falciparum ‘hyperparasitemia’. the term ‘hyperparasitemia’ is introduction 88 efficacy of immunodiagnosis of falciparum malaria at different levels of parasitemia 1. associate professor, department of microbiology, enam medical college, savar, dhaka 2. professor, department of microbiology, mymensingh medical college, mymensingh 3. department of microbiology, khwaja younus ali medical college, enayetpur, sirajgonj 4. graded specialist, department of ent, combined military hospital, dhaka cantonment, dhaka correspondence mejbah uddin ahmed, email: mejbahua@gmail.com original article mejbah uddin ahmed1, mohammad akram hossain2, abul hossain khan3, salah uddin ahmed4 journal of enam medical college vol 3 no 2 july 2013 defined as a parasite density >5% parasitemia or >250,000 parasites/µl of blood. among the complications of severe malaria, cerebral malaria is the most common. the case fatality rate with severe malaria may exceed 20% or more.1,3,5 a prompt and accurate diagnosis is the key to reduce the sufferings and complications. malaria is usually diagnosed clinically and by microscopic examination of peripheral blood film. clinical diagnosis may overlap with other febrile illnesses. therefore, diagnosis based on clinical grounds should be confirmed by laboratory investigations. in addition to traditional blood film microscopy, fluorescence microscopy, detection of antigen and antibody by ict, enzyme-linked immunosorbent assay (elisa) and molecular techniques are also available. among all the methods, microscopic examination of blood film is regarded as the ‘gold standard’.6,7 this method is relatively simple and cost-effective. but it is time consuming, needs expert microscopist and sensitivity is questionable at low level of parasitemia.8 moreover, in infection with p. falciparum, parasites are sequestered in the deep capillaries of spleen, liver and bone marrow and parasite detection may be missed in the blood films due to insufficient number of parasites.9 for these reasons, in case of severe malaria, especially ‘cerebral malaria’ where parasitemia remains high (>2,500 parasites/µl), antigen detection by ict may be an alternative choice. because, this is a rapid test and is able to detect low level of parasitemia (60--100 parasites/µl of blood).6 in addition to conventional microscopy for diagnosis of malaria, a rapid and reliable test like ict for antigen can contribute to reduce the mortality and morbidity. therefore, this study was designed to see the efficacy of ict for detection of antigen at different levels of parasitemia. materials and methods this study was carried out in the department of microbiology, mymensingh medical college during the period of july 2005 to june 2006. a total of 98 clinically suspected malaria cases were selected from haluaghat thana health complex, mymensingh, mymensingh medical college hospital and community based medical college hospital, mymensingh. cases were selected clinically on the basis of fever with chill and rigor, sweating, splenomegaly, hepatomegaly, headache, vomiting, fatigue and abdominal discomfort. relevant history, clinical findings and results of laboratory investigations of every case was systematically recorded in a predesigned data sheet and subsequently analyzed by computer program spss version 12.0. capillary blood from the tip of the finger for thick and thin films and intravenous blood for ict were collected aseptically. the slides of thick and thin films were labeled and stained with giemsa stain.5 parasites were detected and counted and subsequently antigen was detected by ict method for each case. results out of 98 clinically suspected cases 59 (60.20%) were positive by microscopic examination of peripheral blood film and among them 55 (56.12%) were positive by ict for antigen (table i). table i: rate of detection of malaria by microscopy and ict methods tests positive negative peripheral blood film (n = 98) 59 (60.20%) 39 (39.80%) ict for antigen (n = 98) 55 (56.12%) 43 (43.88%) table ii shows the distribution of parasitemia and their relation with ict for antigen. parasitemia between 10,00049,999 parasites/µl of blood was found in 20 cases. seventeen cases showed parasitemia µl of blood. the cases with parasitemia >600 parasites/µl of blood were positive by ict for antigen. parasitemia parasites/µl of blood were found in 5 (8.7%) cases of which 1 (20%) was positive by ict for antigen. table ii: distribution of parasitemia among the 59 microscopy positive cases and their relation with ict for antigen parasite count/ number (%) positive by ict for antigen (%) µl of blood >50000 17 (28.81) 17 (100) 10000–49999 20 (33) 20 (100) 1000–9999 13 (22) 13 (100) 601–999 04 (6.77) 04 (100) < 600 05 (8.47) 01 (20) total 59 55 89 j enam med col vol 3 no 2 july 2013 discussion in the present study, out of 98 clinically suspected malaria cases, 59 (60.20%) were positive for malarial parasite by microscopic examination of peripheral blood film and 57 (58.16%) were positive by ict for antigen. khan et al in pakistan found 45.5% cases positive by microscopic examination of peripheral blood film and 43.2% positive by ict for antigen.10 in our study, parasitemia between 10,000-49,999/µl of blood was found in highest number of cases (20, 33%) and 17(28.81%) cases with 50,000 parasites/µl of blood. in a study in thailand, pattanasin et al reported highest number of patients (37, 26.24%) had parasitemia between 5,000--50,000/µl of blood and 20 (14.18%) patients had parasitemia >50,000/µl of blood.11 we found all 54 (100%) cases with parasitemia > 600/µl of blood positive by ict for antigen. cooke et al from gambia in 1999 found 100% cases positive by ict for antigen with parasitemia >500/µl of blood.12 we found one case positive by ict for antigen when parasite count was <600 parasites/µl of blood. in a study in kuwait, iqbal et al found 96% sensitivity when parasitemia was >500 parasites/µl and 44% sensitivity when parasitemia was <500 parasites/µl.7 kakkilaya in 2003 observed that many studies showed >95% sensitivity when parasitemia was 500 parasites/µl.13 from the above discussion it is observed that some results are consistent with our findings and some remarkably differ from the present study. these variations of results may be because of different places and use of different diagnostic kits. in conclusion, diagnosis of malaria by ict is simple, easy to perform, can be done as bedside test and diagnostic efficacy of ict is satisfactory. so, this method can be used in case of malaria, especially for cerebral malaria where urgent diagnosis is needed. references 1. trampuz a, jereb m, muzlovic i, rajesh m. clinical review: severe malaria. critical care 2003; 7(4): 315–323. 2. international center for diarrheal diseases and research, bangladesh. new strategies for treating falciparum malaria in bangladesh. health and science bulletin 2006; 4: 1--6. 3. alam ms, khan mgm, chaudhury n, deloer s, nazib f, bangali am et al. prevalence of anopheline species and their plasmodium infection status in epidemic-prone border areas of bangladesh. malaria journal 2010; 9: 2--8. 4. stauffer w, fischer pr. . diagnosis and treatment of malaria in children. clinical infectious diseases 2003; 37: 1340--1348. 5. mockenhaupt fp, ehrhardt s, burkhardt j, bosomtwe sy, laryeas s, anemana sd. manifestation and outcome of severe malaria in children in northern ghana. the american journal of tropical medicine and hygiene 2004; l(2): 167--172. 6. moody a. rapid diagnostic tests for malaria parasites. clinical microbiology reviews 2002; 15: 66--78. 7. iqbal j, khalid n, hira pr. comparison of two commercial assays with expert microscopy for confirmation of symptomatically diagnosed malaria. journal of clinical microbiology 2002; 40(12): 4675--4678. 8. mankhambo l, kanjala m, rudman s, lema vm, rogerson sj. evaluation of the optimal rapid antigen test and species-specific pcr to detect placental plasmodium falciparum infection at delivery. journal of clinical microbiology 2002; 40: 155--158. 9. joshi hh. monoclonal antibody based elisa: an effective diagnostic tool for the diagnosis of falciparum malaria. journal of nepal medical association 2005; 44: 79--83. 10. khan sa, anwar m, hussain s, qureshi ah, ahmad m, afzal s. comparison of optimal malarial test with light microscopy for the diagnosis of malaria. journal of pakistan medical association 2004; 54: 404--408. 11. pattanasin s, proux s, chompasuk d, luwiradaj k, jacquier p, looareesuwan s. evaluation of a new plasmodium lactate dehydrogenase assay for the detection of malaria. transaction of the royal society of tropical medicine and hygiene 2003; 97: 672--674. 12. cooke ah, doherty t, chiodini pl, moody ah, ries j, pinder m. comparison of a parasite lactate dehydrogenase based immunochromatographic antigen detection assay with microscopy for the detection of malaria parasite in human blood samples. am. j. trop. med. 1999; 60 (2): 173--176. 13. kakkilaya bs. rapid diagnosis of malaria. laboratory medicine 2003; 34(8): 602--608. 90 j enam med col vol 3 no 2 july 2013 94 abstract background: dyslipidemia is one of the important causes of cardiovascular disease related mortality and morbidity. recently it has become a significant issue in public health problem of developing countries. the purpose of the study was to find a suitable solution for reducing blood lipid in dyslipidemic patients by conducting a research on the effect of cinnamon in hypercholesterolemic rats. objective: to study the lipid lowering effect of cinnamomum cassia on experimentally induced hypercholesterolemic rats. materials and methods: this study was done on 30 male long evans rats weighing about 200--210 gram. for convenience, the study was divided into two experiments --experiment i and experiment ii. in experiment i, 12 animals were divided into two groups. one was group a (n = 6, control group) fed on laboratory diet and the other was group b (n = 6) fed on laboratory diet and cinnamon for 35 days. in experiment ii, the remaining 18 rats were fed fatty mixture diet containing 1% cholesterol and 0.25% cholic acid. the hypercholesterolemic rats were then divided into 3 groups, group c, d, and e (n=6 in each group). group d and group e were additionally fed on cinnamon powder and tablet atorvastatin for 35 days respectively. serum tc, tg, ldl-c and hdl-c were measured after 35 days. results: fatty mixture diet increased tg, tc and ldl-c significantly. cinnamon treated fatty mixture diet group showed that cinnamomum cassia decreased plasma tc, tg and ldl-c. atorvastatin therapy decreased tc, tg and ldl-c levels significantly compared with the lowering effect of cinnamon. conclusion: the results of this experimental study indicate that cinnamomum cassia can act as a hypocholesterolemic agent and thereby can improve cardiovascular functions. key words: cinnamomum cassia, dyslipidemia, hypercholesterolemic rats j enam med col 2013; 3(2): 94--98 hypercholesterolemia is a condition characterized by very high levels of cholesterol in the blood. cholesterol is a waxy, fat-like substance that is produced in the body and obtained from foods that come from animals (particularly egg yolks, meat, poultry, fish, and dairy products). the body needs this substance to build cell membranes, make certain hormones, and produce compounds that aid in fat digestion. introduction 94 effect of cinnamon (cinnamomum cassia) as a lipid lowering agent on hypercholesterolemic rats 1. former m phil student, department of pharmacology and therapeutics, sir salimullah medical college, dhaka 2. assistant professor, department of pharmacology and therapeutics, enam medical college, savar, dhaka 3. associate professor, department of pharmacology and therapeutics, enam medical college, savar, dhaka 4. professor, department of pharmacology and therapeutics, sir salimullah medical college, dhaka 5. assistant professor, department of pharmacology and therapeutics, sir salimullah medical college, dhaka 6. assistant professor, department of pharmacology and therapeutics, northern international medical college, dhanmondi, dhaka correspondence sonia rahman, email: mrtsr2003@yahoo.com original article sonia rahman1, halima begum2, zaida rahman3, ferdous ara4, md. jalaluddin iqbal5, abul kalam mohammad yousuf 6 journal of enam medical college vol 3 no 2 july 2013 recently, hypercholesterolemia has been associated with enhanced oxidative stress related to increased lipid peroxidation. increased generation of oxidized ldl is a major factor in the vascular damage associated with high cholesterol levels. hence, the inhibition of oxidative stress under hypercholesterolemic conditions is considered to be an important therapeutic approach and efforts have been made to identify the antioxidative functions of various medicinal plants.1 the use of plant extracts in managing various disorders is currently a common practice. many plant materials are also in current use as supplements. sometimes the aim is to lower the levels of some markers of disease states in order to improve health conditions. an example may be found in the use of substances that lower the cholesterol level in the system. many studies indicate that lowering the serum cholesterol may prevent, control and even reverse artherosclerosis and coronary heart disease. low triacylglycerol and low-density lipoprotein cholesterol (ldl-c) levels or high density lipoprotein cholesterol (hdl-c) levels are desirable health outcomes known to have resulted from the use of some plant materials.2 cinnamon is a plant that has a variety of uses among many different cultures, from spicing up foods to deterring germs from growing. there are actually two main forms of cinnamon that are commonly found in foods. the first, cinnamomum verum, also known as “true” cinnamon or ceylon cinnamon, is commonly used in sweet pastries. on the other hand, cinnamomum cassia, also known as cassia, chinese cinnamon or “bastard” cinnamon, is used as a stronger spice in a variety of foods. in fact, it is cassia-based cinnamon that is often seen on the grocery shelves and is most often cheaper than true cinnamon.3 cinnamate, a phenolic compound found in the inner bark of cinnamon lowers cholesterol level in high fat fed rats by inhibiting hepatic hmg co-a reductase activity.4 polyphenolic polymers found in cinnamon have antioxidant activity and have been shown to reduce oxidative stress in dose dependent manner through inhibition of 5-lipoxygenase enzyme.5 cinnamon has a long history of use as spice and flavoring agent. indeed, there are reports of cinnamon being imported to egypt from china as early as 2000 bc. cinnamon is mentioned in chinese text written 400 years ago as well as in the bible.6 the aim of this study was to find a suitable solution for the hypercholesterolemic patients by conducting a research of cinnamon’s effect on rats. materials and methods this experimental study was carried out in the department of pharmacology and therapeutics in sir salimullah medical college and bangladesh centre for scientific and industrial research (bcsir) from july 2011 to june 2012. preparation of the cinnamon powder cinnamon powder was obtained from cinnamon bark which contained cinnamonaldehyde. the cinnamon powder was produced by crushing sun-dried cinnamon bark in a grinder machine. chemicals cholesterol and cholic acid (manufactured by loba chemic) and atorvastatin (manufactured by beximco pharmaceuticals) were purchased from the local market in dhaka. a mixture of cholesterol, cholic acid and standard laboratory diet for rats had been administered to each rat per day for 35 days.4 animals the study was performed on total number of 30 healthy adult long evans ( rattus rattus) rats weighing between 200 to 210 gm collected from the bcsir laboratory. the chosen animals were housed in cages separately at normal atmospheric temperature between 26 to 290c under good ventilation and were given water and standard balanced diet. animals were randomly distributed into five groups of six animals in each. each cage was labeled for identification of different groups. experiment i experiment i was conducted to demonstrate the effect of cinnamomum cassia on normal adult male rats. for this purpose a total number of 12 rats were taken and was divided into two groups containing six animals in each group. group a: each animal received laboratory diet 20 gm/day and distilled water for 35 days. 95 j enam med col vol 3 no 2 july 2013 group b: each animal received 15% powder of cinnamomum cassia mixed with laboratory diet 20 gm/day for 35 days. experiment ii experiment ii was conducted to demonstrate the effect of cinnamomum cassia on hypercholesterolemic rats. for this purpose a total number of 18 rats were taken and divided into three groups containing six animals in each group. group c: hypercholesterolemic group that received fatty mixture diet (normal laboratory diet plus 1% cholesterol with 0.25% cholic acid) for 35 days. group d: this group received fatty mixture diet with 15% powder of cinnamomum cassia for 35 days. group e: this group received fatty mixture diet and tablet atorvastatin at the dosage of 0.2 mg/kg body weight administered orally by gastric intubation daily for 35 days. collection of blood specimens the rats were kept fasted overnight before taking the blood samples. all the animals were anesthetized with diethyl ether and sacrificed. blood samples were collected in test tubes and allowed to coagulate at room temperature. it was then centrifuged at 3000 rpm for 30 minutes in a centrifuge machine. the clear nonhemolysed supernatant sera was quickly removed and stored at --20ºc for biochemical analysis of serum lipid profile at the biochemistry department of sir salimullah medical college. biochemical analysis after collection of all blood specimens, serum total cholesterol (tc), serum high density lipoprotein cholesterol (hdl-c) and serum triglycerides (tg) were measured by enzymatic colorimetric (chod-pap) method. low density lipoprotein cholesterol (ldl-c) was calculated by friedewald’s formula. statistical analysis the data were analyzed using unpaired t test. results were expressed as mean ± se and p values <0.05 and <0.01 were considered statistically significant and highly significant respectively. results experiment i: table i shows the effect of cinnamon on serum lipid profile of adult male rats. serum total cholesterol, serum ldl cholesterol, hdl cholesterol and serum triglyceride levels did not show any significant difference between the cinnamomum cassia treated group (group b) and the control group (group a). table i: effect of cinnamon on serum lipid profile of adult male rats (a vs b) parameters group a (n=6) group b (n=6) p values mean ± se mean ± se serum total 71.17±1.59 69.83 ± 3.04 > 0.05 cholesterol (mg/dl) serum tg (mg/dl) 78.10 ± 2.45 76.33 ± 1.93 > 0.05 serum hdl cholesterol (mg/dl) 31.50 ± 0.93 30.67 ± 4.87 > 0.05 serum ldl cholesterol (mg/dl) 26.61 ± 2.23 23.90 ± 6.00 > 0.05 experiment ii: table ii shows the effect of fatty mixture feeding on serum lipid profile of adult male rats. serum total cholesterol, serum ldl cholesterol, and serum triglyceride levels showed significant difference between the fatty mixture diet group (group c) and the control group (group a). but there was no change in serum hdl-c level. table iii shows the effect of cinnamon on serum lipid profile of adult male rats fed with fatty mixture diet. serum total cholesterol, serum ldl cholesterol, and serum triglyceride levels decreased significantly in group d compared to group c. but there was no change in serum hdl level. table iv shows the comparison of serum lipid profile parameters between ‘fatty mixture diet + cinnamon fed’ and ‘fatty mixture diet + atorvastatin fed’ adult male rats. it was found that atorvastatin significantly lowered serum total cholesterol, serum triglyceride and serum ldl cholesterol levels compared with the lowering effect of cinnamon. but there was no change of hdl level. 96 j enam med col vol 3 no 2 july 2013 table ii: effect of fatty mixture feeding on serum lipid profile of adult male rats (a vs c) parameters group a (n=6) group c (n=6) p values mean ± se mean ± se serum total cholesterol (mg/dl) 71.17 ± 1.59 136 ± 3.74 < 0.01 serum tg (mg/dl) 78.10 ± 2.45 106.5 ± 2.85 < 0.01 serum hdl cholesterol (mg/dl) 31.50 ± 0.93 30.81± 2.78 > 0.05 serum ldl cholesterol (mg/dl) 26.61 ± 2.23 83.81 ± 5.6 < 0.01 table iii: effect of cinnamon on serum lipid profile of adult male rats fed with fatty mixture feed (c vs d) parameters group c (n=6) group d (n=6) p values mean ± se mean ± se serum total cholesterol (mg/dl) 136 ± 3.74 119.5 ± 2.68 < 0.01 serum tg (mg/dl) 106.5 ± 2.85 92.13 ± 3.02 < 0.01 serum hdl cholesterol (mg/dl) 30.81 ± 2.78 29.17 ± 1.73 > 0.05 serum ldl cholesterol (mg/dl) 83.81 ± 5.61 71.91 ± 1.88 < 0.05 table iv: comparison of effects of cinnamon and atorvastatin on serum lipid profile of fatty mixture diet fed adult male rats (d vs e) parameters group d (n=6) group e (n=6) p values mean ± se mean ± se serum total cholesterol (mg/dl) 119.5 ± 2.68 83.83 ± 3.51 < 0.01 serum tg (mg/dl) 92.13 ± 3.02 75.67 ± 2.18 < 0.01 serum hdl cholesterol (mg/dl) 29.17 ± 1.73 30.50 ± 2.09 > 0.05 serum ldl cholesterol (mg/dl) 71.91 ± 1.88 38.20 ± 3.73 < 0.01 discussion a growing body of research has demonstrated that the commonly used herbs and spices such as garlic, black cumin, cloves, cinnamon, thyme, five spices, bay leaves, mustard and rosemary possess antimicrobial properties and can be used therapeutically in some cases.7 medicinal plants play a vital role for the development of new drugs. the bioactive extract should be standardized on the basis of active compound and should undergo safety studies. almost 70% of modern medicines in india are derived from natural products. medicinal plants play a central role not only as traditional medicines but also as trade commodities, meeting the demand of distant markets.8 in experiment i, all conventionally measured indicators (serum cholesterol, tg, ldl, and hdl levels) of lipid profiles were slightly changed in group b as compared to those in the control group a. but changes were not statistically significant. these findings support the findings of another similar study.9 in experiment ii, the effect of cinnamomum cassia was observed on serum lipid profile of hyperlipidemic long evans rats. on administrating the fatty diet, group c showed significant (p<0.01) increase of serum lipid profile parameters (tc, tg, ldl-c) compared to those of control group (group a). this finding indicates that fatty mixture diet that is used to elevate the serum lipid profile parameters was able to elevate all parameters except hdl-c measured in this experiment. similar study done by javed et al10 supports the present study. it was found in this study that 15% cinnamon powder significantly decreased the serum tc, tg, ldl-c approximately by 12%, 11% and 14% respectively (p<0.01, p<0.01 and p<0.05) of fatty mixture diet fed rats; but hdl-c level was not significantly changed. soheir et al11 administered 15% cinnamon powder in hypercholesterolemic diabetic rats and found decreased plasma cholesterol from 268 to 121 mg/dl (54%), tg levels from 228 mg/dl to 100 mg/dl (56%) and ldl-c from 211 mg/dl to 61 mg/dl (71%) and hdl-c increased from 36 mg/dl to 63 mg/dl (75%). as soheir et al performed their study on diabetic rats fed on basal diet (corn starch 70%, casein 10%, corn seed oil 10%, cellulose 5%, salt mixture 4% and vitamins mixture 1%), this might be the 97 j enam med col vol 3 no 2 july 2013 possible cause of difference in lipid-lowering effects of cinnamon between these studies. in this study administration of atorvastatin at 0.2 mg/kg body weight for 35 days decreased serum cholesterol, tg, ldl-c approximately by 38%, 28% and 54% respectively of fatty mixture diet fed rats. hdl-c level was not changed significantly. these findings support study of amin et al.4 cinnamon might have a direct role in lipid metabolism and prevent hypercholesterolemia and hypertriglyceridemia and lower free fatty acids by its strong lipolytic activity. dietary cinnamate inhibits the hepatic hmg co-a reductase activity resulting in lower hepatic cholesterol content and suppresses lipid peroxidation via enhancement of hepatic antioxidant enzyme activity.12 cinnamomum cassia may have an effect on treating hyperlipidemia and thereby may be responsible for the prevention of consequences of the aging process, from hypertension to heart failure, cardiovascular diseases and myocardial infarction. therefore, further studies could establish the effect of cinnamomum cassia on hyperlipidemic human beings. from the findings of the present study, it can be concluded that cinnamomum cassia has hypolipidemic effect on hypercholesterolemic rats under different experimental conditions. before establishing cinnamomum cassia as a therapeutically effective hypolipidemic agent, further studies should be carried out to determine the active principle responsible for hypolipidemic effect and its cellular mechanism of action. references 1. adaramoye oa, akintayo o, achem j, fafunso ma. lipid-lowering effects of methanolic extract of vernonia amygdalina leaves in rats fed on high cholesterol diet. vascular health & risk management 2008; 4(1): 235--241. 2. owen oj, amakiri ao, karibi-botoye ta. lipid lowering effect of bitter leaf (vernonia amygdalina) in broiler chickens fed finishers mash. agric biol j n am 2011; 2(6): 1038--1041. 3. moll j, foster. cinamon: does it lower cholesterol levels? available at: http://cholesterol.about.com/od/ naturalalternatives /a/cinnamon.htm. accessed january 2013. 4. amin ka, abdel-twab tm. oxidative markers, nitric oxide and homocysteine alteration in hypercholesterolemic rats: role of atorvastatin and cinnamon. int j clin exp med 2009; 2(3): 254--265. 5. anderson ra, broadhurst cl, polansky mm, schmidt wf, khan a, flanagan vp et al. isolation and characterization of polyphenol type-a polymers from cinnamon with insulin like biological activity. j agri food chem 2004; 52(1): 65--70. 6. leung ay, foster. encyclopedia of common natural ingredients used in food, drugs and cosmetics. 2nd edn. new york: john wiley & sons, 1996. 7. lai pk, roy j. antimicrobial and chemopreventive properties of herbs and spices. curr med chem 2004; 11(11): 1451--1460. 8. verma s, singh sp. current and future status of herbal medicines. veterinary world 2008; 1(11): 347--350. 9. amin r. anti-obesity effect of mushroom (ganoderma lucidum) on experimentally induced obese rats, akmmc j 2012; 3(2): 11--14. 10. javed i, faisal i, khan mz, rahman z, muhammad f, aslam b et al. lipid lowering effect of cinnamomum zeylanicum in hyperlipidemic albino rabbit. pakistan j pharm sci 2012; 25(1): 141--147. 11. soheir n, abd el. rahman, amal m.h. abdel-haleem, hessa m. al mudhaffar. anti-diabetic effect of cinnamon powder and cinnamon aqueous extract on serum glucose of rats. international journal of food, nutrition and public health 2010; 3(2): 183--197. 12. lee js, jeon sm, park em, huh tl, kwon os, lee mk et al. cinnamate supplementation enhances hepatic lipid metabolism and anti oxidant defense systems in high cholesterol fed rat. j. medicinal food 2003; 6(3): 183--191. 98 j enam med col vol 3 no 2 july 2013 journal of enam medical college vol 11 no 2 may 2021 120 review article chronic diarrhea in children fahmida begum1, khan lamia nahid2, md. wahiduzzaman mazumder3, md. rukunuzzaman4, asm bazlul karim5 received: 4 april 2020 accepted: 18 march 2021 doi: https://doi.org/10.3329/jemc.v11i2.65194 1. professor, department of pediatric gastroenterology and nutrition, bangabandhu sheikh mujib medical university, shahbag, dhaka 2. assistant professor, department of pediatric gastroenterology and nutrition, bangabandhu sheikh mujib medical university, shahbag, dhaka 3. associate professor, department of pediatric gastroenterology and nutrition, bangabandhu sheikh mujib medical university, shahbag, dhaka 4. professor, department of pediatric gastroenterology and nutrition, bangabandhu sheikh mujib medical university, shahbag, dhaka 5. fellow, pediatric gastroenterology, liver diseases (australia) correspondence fahmida begum, email: fahmidalily@gmail.com abstract chronic diarrhea (cd) is a common but challenging clinical scenario in pediatric medicine. it has several hundred disorders in the differential diagnosis and can create a complex situation for practitioners and families. some of the disorders cause failure to thrive but some are not. this article focuses on important aetiologies of cd, their clinical features, diagnostic approach as well as treatment approaches. key words: chronic diarrhea; osmotic diarrhea; secretory diarrhea j enam med col 2021; 11(2): 120−127 introduction diarrhea is defined as stool volume >10 g/kg per day in infants and toddlers, and >200 g/day in older children.1 chronic diarrhea (cd) is one which lasts for more than 14 days, is usually noninfectious and associated with malabsorptive features. some experts also refer cd for episodes lasting more than 4 weeks.2 on the other hand persistent diarrhea (pd) is an episode of diarrhea of presumed infectious etiology, which starts acutely but lasts for more than 14 days and excludes recurrent diarrheal disorders such as tropical sprue, gluten sensitive enteropathy or other hereditary disorders.3 epidemiology according to the world health organization, diarrheal illness is the second leading cause of death in developing countries in children younger than 5 years of age and is responsible for 1.7 million child morbidities and 760,000 child mortalities.4 in 2002, the world health organization estimated that 13.2% of all childhood deaths worldwide were caused by diarrheal diseases, 50% of which were chronic diarrheal illnesses.5 among children aged 1 to 4 years, persistent diarrhea accounted for more than 25% of diarrheal deaths in bangladesh, ethiopia and uganda.6 large-scale studies indicate that the prevalence of chronic diarrheal illnesses worldwide ranges from 3% to 20%, and the incidence is ≈ 3.2 episodes per child year.7 may 2021j enam med col vol 11 no 2 121 pathophysiology the basic pathophysiology of cd is incomplete absorption of water from the intestinal lumen. this occurs either because of a reduced rate of net water absorption (related to impaired electrolyte absorption or excessive electrolyte secretion) or because of osmotic retention of water in the lumen. reduction of net water absorption as little as one percent is sufficient to cause diarrhea.8 the four principal pathophysiologic mechanisms of cd are osmotic, secretory, dysmotility associated, and inflammatory. often, a single disorder may involve multiple overlapping mechanisms. osmotic diarrhea is caused by a failure to absorb a luminal solute. as a result, there are secretion of fluids and net water retention across an osmotic gradient. this may occur from either congenital or acquired diseases such as lactose malabsorption.9 secretory diarrhea occurs when there is a net secretion of electrolyte and fluid from the intestine without compensatory absorption. endogenous substances, often called “secretagogues,” induce fluid and electrolyte secretion into the lumen even in the absence of an osmotic gradient. typically, secretagogues affect ion transport in the large and small bowel both by inhibiting sodium and chloride absorption and by stimulating chloride secretion via cystic fibrosis (cf) transmembrane regulator activation. multiple congenital diarrheal disorders associated with identified genetic mutations that affect gut epithelial ion transport are the example of secretory diarrhea.10 congenital chloride diarrhea (ccd) is one such disorder. children with a pure secretory diarrhea will therefore continue to experience diarrhea even while fasting. cd associated with intestinal dysmotility typically occurs in the setting of intact absorptive abilities. intestinal transit time is decreased, the time allowed for absorption is minimized, and fluid is retained within the lumen. high-amplitude propagated contractions cause diarrhea predominant irritable bowel syndrome (ibs) in older adolescents and changes in small intestinal motility results chronic nonspecific diarrhea (cnsd) in toddlers.11 inflammatory diarrhea may include all of the pathophysiologic mechanisms. inflammation that results injury to the intestine may lead to malabsorption of dietary macronutrients which, in turn, creates a luminal osmotic gradient. moreover, particular infectious agents may induce secretion of fluid into the lumen, and blood in the gut may alter intestinal motility. diseases such as inflammatory bowel disease (ibd) and celiac disease are the example of this inflammatory mechanism.9 common causes of chronic diarrhea in children causes of chronic diarrhea can also be divided into following subgroups (table ii). table ii: causes of chronic diarrhea infective due to exogenous substances abnormal digestive processes nutrient malabsorption immune and inflammatory structural defects defects of electrolytes and metabolite transport motility disorders neoplastic chronic non-specific diarrhea table i: differences between osmotic and secretory diarrhea variables secretory diarrhea osmotic diarrhea volume of stool >200 ml/24 hours <200 ml/24 hours response to fasting diarrhea continues diarrhea stops stool na >70 meq/l <70 meq/l reducing substances negative positive stool ph >6 <5 stool osmotic gap {stool osmolarity – 2 (stool na+ k )} < 100 >100 may 2021j enam med col vol 11 no 2 122 infective causes: infective causes of chronic diarrhea can be seen in any age and common organisms implicated includes salmonella, yersinia, e.coli, campylobacter, aeromonas, plesiomonas, giardia, cryptosporidium, viral causes (rota, entero, norwalk). they have associated fever, abdominal pain, exposure history, blood/mucus in stool. giardia causes both osmotic and secretory diarrhea. microscopic examination of a freshly passed stool on three consecutive days is recommended for detection of giardia trophozoites. antimicrobial therapy for giardiasis is metronidazole, tinidazole, or nitazoxanide. non typhoidal salmonella organisms typically cause gastroenteritis with diarrhea, abdominal cramping, and fever. salmonella organisms typically are detected in routine stool culture for up to 5 weeks but may be excreted in stool for >1 year in 5% of patients.12 antibiotic therapy for uncomplicated nontyphoidal serotypes is not indicated as it does not shorten the disease duration but may prolong the duration of excretion of bacteria in the stool.13 antibiotic is indicated only for children younger than 3 months of age or those with immunosuppressive diseases.14 small bowel bacterial overgrowth: there are overgrowths of aerobic and anaerobic bacteria in the small bowel such as in short bowel syndrome, bowel strictures, pseudo-obstruction, malnutrition. osmotic diarrhea occurs due to enhanced bile acid deconjugation and fatty acid hydroxylation by bacteria. the patients present with abdominal pain and diarrhea. the diagnosis can be made by breath hydrogen with lactulose testing. metronidazole or non absorbable rifaximin is the treatment of choice.15 whipple’s disease: whipple’s disease is caused by gram +ve bacteria: tropheryma whipplei. the patients have malabsorption, central nervous system, joints and cardiovascular involvement. it is a rare condition and carries a poor prognosis. tropical sprue: it is a rare condition in children and coliform organisms are implicated in its etiopathogenesis. abnormal digestive processes cystic fibrosis pancreatic insufficiency is common in approximately 90% of patients with cf and this causes diarrhea in this disorder.16 loss of exocrine pancreatic function leads to malabsorption of carbohydrates, fat, and protein because of dysfunctional amylases, lipases, and proteases, respectively. pancreatic exocrine function can be assessed by fecal elastase, and low levels indicating possible pancreatic insufficiency. pancreatic enzyme replacement therapy may improve malabsorptive diarrhea in patients with cf. nutrient malabsorption carbohydrate malabsorption: intestinal lactase deficiency causes carbohydrate malabsorption that can be congenital, adult-onset and secondary lactase deficiency. congenital lactase deficiency is a rare entity. adult onset is relatively common and ‘normal’ for most humans. secondary lactase deficiency is seen after infectious gastroenteritis or injury to small intestinal mucosa caused by gluten or other sensitizing substances, crohn’s disease, and other enteropathies. symptoms of lactose intolerance are independent of the cause. incompletely digested lactose reaches the dense colonic microbial population, which ferments the sugar to hydrogen and other gases, thereby causing gassy discomfort and flatulence. the no absorbed lactose serves as an osmotic agent, resulting in an osmotic diarrhea. diagnosis can be made by a successful lactose-free diet trial of 2 weeks or by hydrogen breath-testing. minimizing lactose intake is the treatment of choice, as the symptoms are dose dependent and so complete removal of dietary lactose is not necessary.17 lipid malabsorption: lipid malabsorption is seen in diseases like cystic fibrosis, shwachmandiamond syndrome, pearson syndrome, johanson-blizzard syndrome, celiac disease, cholestatic liver disease, beta lipoproteinemia, lymphangectasia and short bowel syndrome. protein malabsorption: protein malabsorption is seen in condition like pancreatitis, cystic fibrosis, trypsinogen deficiency, enterokinase deficiency, hartnup disease, lymphangectasia, lowes syndrome and lysinuric protein intolerance. may 2021j enam med col vol 11 no 2 123 cow’s milk protein allergy (cmpa): cow’s milk protein allergy presents in first year of life, but may present up to two years of age. the child present with streaks of blood and mucus in stool, in otherwise healthy infant. it typically occurs in child on top milk, however 0.5% may present in exclusive breast-fed infants. withdrawal of cow’s milk from diet is the treatment of choice. inflammatory bowel disease21 inflammatory bowel diseases (ibd) can present in children and adolescents with chronic diarrhea along with passage of blood or mucus in stools. the child can have weight loss, anemia, tenesmus, joint pains, and redness of eyes. in crohn’s disease, stool may contain microscopic blood but may not be grossly bloody. in ulcerative colitis, diarrhea is a more consistent presenting feature. immune and inflammatory celiac disease: celiac disease is an immunemediated systemic disease that occurs due to gluten ingestion in a genetically susceptible individual. with its prevalence in adults and children approaching 1% worldwide.18 it is most common cause of chronic diarrhea and malabsorption in more than 2 years age group patients.19 the typical presentation of celiac disease in children is failure to thrive, diarrhea and abdominal distension. the presence of raised anti-tissue transglutaminase antibody/anti endomysial antibody make the suspicion of celiac disease and is confirmed by histologic findings in the duodenum which is graded according to marsh criteria.20 the management of celiac disease is lifelong restriction of food containing gluten in diet which includes wheat, rye, and barley. multivitamin and mineral deficiency should also be managed appropriately. patient with suspected ibd screen with fecal calprotectin level negative positive urgent endoscopy negative positive plan other investigation start treatment for ibd fig 1. workup for suspected inflammatory bowel disease (ibd) in adults20 treatment includes anti-inflammatory agents like steroids, 5asa, azathioprine etc. nocturnal diarrhea with urgency may be a sign of left-sided colonic inflammation in either crohn disease or ulcerative colitis. diarrhea associated with ibd typically improves with therapy as mucosal inflammation resolves. autoimmune enteropathies: autoimmune enteropathies are rare disorders that may present as severe diarrhea during infancy or toddlerhood. the diarrhea may be isolated, or may occur in association with diabetes mellitus as part of the ipex (immunodysregulation polyendocrinopathy enteropathy x-linked) syndrome. diagnosis is made by documenting antienterocyte, anticolonocyte, or antigoblet cell antibodies in the blood. treatment may 2021j enam med col vol 11 no 2 124 is difficult but may be accomplished with immunosuppressive agents such as corticosteroids, 6-mercaptopurine, tacrolimus, and infliximab. immunodeficiency: patient with chronic diarrhea should be evaluated for primary or secondary immunodeficiency such as hiv disease. in this case, the evaluation should focus on potential infectious causes of the diarrhea, particularly parasites and opportunistic infections such as cryptosporidium, isospora, and cyclospora.20 structural defects: these include disease like tufting enteropathy, microvillous inclusion disease, phenotypic diarrhea, lymphangiectasia, intergrin deficiency, heparan sulphate deficiency. these are rare diseases and cause neonatal diarrhea and carries a poor prognosis. defects with effects of electrolytes and metabolite transport: it includes congenital chloride diarrhea (ccd) and congenital sodium diarrhea (csd), these disorders cause secretory diarrhea and present in 1−2 week of life and carry a poor prognosis. chronic nonspecific diarrhea of childhood or infancy (cnsd) cnsd is the most common form of chronic diarrhea in the first 3 years after birth.21 the typical time of onset may range from 1 to 3 years of age and can last from infancy until age 5 years. it presents with varied stool frequency and consistency without blood or mucus and stool contain undigested food particles. there is no failure to thrive. potential pathophysiologic mechanisms for cnsd include increased intestinal motility and osmotic effects of intraluminal solutes (e.g. carbohydrates).12 reassurance is the cornerstone of therapy for cnsd. treatment includes decreased fruit juices (fructose) and reassurance along with liberalization of fat to encourage normal caloric intake and to slow intestinal transit time is also important.22 motility disorders irritable bowel syndrome (ibs) according to rome iv diagnostic criteria irritable bowel syndrome must include all of the followings: 1. abdominal pain at least 4 days per month associated with one or more of the followings: a. related to defecation; b. a change in frequency of stool; c. a change in form (appearance) of stool; 2. in children with constipation, the pain does not resolve with resolution of the constipation (children in whom the pain resolves have functional constipation, not irritable bowel syndrome). 3. after appropriate evaluation, the symptoms cannot be fully explained by another medical condition.23 criteria fulfilled for at least 2 months before diagnosis treatment is often challenging. antispasmodic agents, tricyclic antidepressants, and selective serotoninreuptake inhibitors may improve symptoms. some probiotics have been useful in adult and pediatric ibs, but results are not consistent.24 among the causes of cd some are associated with failure to thrive and some are not (table iii). table iii: causes of chronic diarrhea without failure to thrive with failure to thrive cnsd idi (intractable diarrhea of infancy) infectious colitis allergic enteropathy lactose malabsorption ibd small bowel bacterial overgrowth celiac disease ibs immunodeficiency state (various diseases) congenital secretory diarrhea (chronic chloride and chronic sodium diarrhea) tufting enteropathy microvillous inclusion disease autoimmune enteropathy cf may 2021j enam med col vol 11 no 2 125 evaluation of cd history and physical examination for diagnosis of different causes of cd detailed history and examination is a must. characteristics of the stool as well as feeding history are very important in assessing the cause and severity of the illness. there are differences in pattern of stool in small and large bowel diarrhea. so, it is important to differentiate small bowel diarrhea from large bowel type of diarrhea. small bowel diarrhea differs from large bowel diarrhea with its large volume, foulsmelling stools with undigested food particles and often it is associated with features of lactose intolerance like explosive diarrhea and bloating. on the other hand, large bowel type of diarrhea has blood, mucus, tenesmus, urgency and high frequency. in toddler’s diarrhea children often have loose stools with undigested food particles. frequent loose watery stools may indicate carbohydrate intolerance and pasty or loose foul-smelling stools indicate fat malabsorption. it is also necessary to take history of extraintestinal symptoms like presence or absence of weight loss, rash, fatigue, vomiting, joint aches, or oral ulcers. a detailed history of source of drinking water, family history, complementary feeding and whether onset of diarrhea after introduction of specific foods like seen in celiac disease and cow’s milk protein allergy should be evaluated. there may be history of repeated infections in cystic fibrosis or immune deficiency syndromes. in physical examination one should have to look for anthropometry assessment and status of dehydration. clubbing may be seen in celiac disease and ibd. extraintestinal manifestations of ibd like joint pain, swelling and erythema may also be found. there also may be signs of various nutrient and vitamin deficiencies like zinc, vitamin d,vitamin a, vitamin k and b complex. distended abdomen may be seen in malabsorption syndromes or small bowel bacterial overgrowth. rectal examination is also important as it may reveal perianal disease in ibd and perianal excoriation in carbohydrate malabsorption. laboratory evaluation: a detailed history and examination is needed so that unnecessary investigations are better avoided. initial investigations include a complete hemogram to evaluate anemia, total counts and platelets. stool routine and culture with urine routine should be done in all cases of chronic diarrhea. stool may contain rbc, wbc and mucus indicating a mucosal inflammation in large bowel and analysis of the stool for electrolyte content and osmolarity may be helpful in distinguishing an osmotic from a secretory diarrhea. serum electrolytes with renal function test should also be done. serology for celiac disease, ttg with total iga should be done in cases of small bowel diarrhea. upper gi endoscopy and when required colonoscopy with mucosal biopsy are required in many diseases like celiac disease, ibd, eosinophilic enteropathy, microvillous inclusion disease, tufting enteropathy, giardiasis, intestinal lymphangiectasia. in special cases, fecal fat estimation, fecal elastase, h2 breath test, hormonal assays may be required. treatment it depends on primary cause of chronic diarrhea; it may vary from just reassurance in cases of chronic nonspecific diarrhea to bowel transplant in structural enteropathies. in addition to specific disease-oriented therapy the patients should be given vitamin and mineral supplement. disease like cow’s milk protein allergy, celiac disease, and giardiasis are easily treatable. celiac disease management includes a lifelong strict adherence to gluten free diet and nutritional counseling. for cmpa, the ideal management it extensively hydrolyzed formula, unfortunately they are not still available in india and are to be imported thereby increasing their cost. conclusion chronic diarrhea is important cause of morbidity in developing countries. timely evaluation and management are of paramount importance to prevent complications. the patient should be referred to a tertiary care center in time for appropriate diagnosis and treatment. may 2021j enam med col vol 11 no 2 126 references 1. diarrhea, who. available at: https://www.who.int/ health-topics/diarrhoea#tab=tab_1. accessed january 2023. 2. fine kd, schiller lr. aga technical review on the evaluation and management of chronic diarrhea. gastroenterology 1999; 116(6): 1464–1486. 3. memorandum from a who meeting. persistent diarrhea in children in developing countries. bull who 1988; 66(6): 709−717. 4. world health organization. diarrhoeal disease. available at: http://www.who.int/mediacentre/ factsheets/fs330/en/. accessed september 2022. 5. abba k, sinfield r, hart ca, garner p. pathogens associated with persistent diarrhoea in children in lowand middle-income countries: systematic review. bmc infectious diseases 2009; 9(1): 1–5. 6. rahman ae, moinuddin m, molla m, worku a, hurt l, kirkwood b et al. childhood diarrhoeal deaths in seven lowand middle-income countries. bulletin of world health organization 2014; 92(9): 664–671. 7. kosek m, bern c, guerrant rl. the global burden of diarrhoeal disease, as estimated from studies published between 1992 and 2000. bulletin of world health organization 2003; 81(3): 197–204. 8. gibson pr, newnham e, barrett js, shepherd sj, muir jg. review article: fructose malabsorption and the bigger picture. aliment pharmacology & therapeutics 2007; 25(4): 349–363. 9. israel e. chronic diarrheal disease. in: kleinman re (ed). pediatric nutrition handbook. 6th edn. elk grove village, il: american academy of pediatrics 2009: 637–649. 10. binder hj. causes of chronic diarrhea. n england j med 2006; 355(3): 236–239. 11. fenton tr, harries jt, milla pj. disordered small intestinal motility: a rational basis for toddlers’ diarrhoea. gut 1983; 24(10): 897–903. 12. buchwald ds, blaser mj. a review of human salmonellosis: ii duration of excretion following infection with nontyphi salmonella. rev infect dis 1984; 6(3): 345–356. 13. barber da, miller gy, mcnamara pe. models of antimicrobial resistance and foodborne illness: examining assumptions and practical applications. j food prot 2003; 66(4): 700–709. 14. american academy of pediatrics. salmonella infections. in: pickering lk, baker cj, kimberlin dw, long ss, (eds). red book 2009 report of the committee on infectious diseases. 28th edn. elk grove village, il: american academy of pediatrics 2009: 584–589. 15. lauritano ec, gabrielli m, lupascu a, santoliquido a, nucera g, scarpellini e et al. rifaximin dose‐ finding study for the treatment of small intestinal bacterial overgrowth. alimentary pharmacology & therapeutics 2005; 22(1): 31–35. 16. borowitz d, baker ss, duffy l, baker rd, fitzpatrick l, gyamfi j et al. use of fecal elastase-1 to classify pancreatic status in patients with cystic fibrosis. the journal of pediatrics 2004; 145(3): 322–326. 17. heyman mb; committee on nutrition. lactose intolerance in infants, children, and adolescents. pediatrics 2006; 118(3): 1279–1286. 18. green ph, cellier c. celiac disease. n engl j med 2007; 357(17): 1731–1743. 19. yachha sk, misra s, malik ak, nagi b, mehta s. spectrum of malabsorption syndrome in north indian children. indian j gastroenterol 1993; 12(4): 120–125. 20. van rheenen pf, van de vijver e, fidler v. faecal calprotectin for screening of patients with suspected inflammatory bowel disease: diagnostic meta-analysis. bmj 2010; 15: 341. 21. cohen sa, hendricks km, eastham ej, mathis rk, walker wa. chronic nonspecific diarrhea: a complication of dietary fat restriction. am j dis child 1979; 133(5): 490–492. may 2021j enam med col vol 11 no 2 127 22. hoekstra jh, van den aker jh, hartemink r, kneepkens cm. fruit juice malabsorption: not only fructose. acta paediatrica 1995; 84(11): 1241–1244. 23. hyams s, di lorenzo c, saps m, shulman rj, staiano a, vantilburg m. childhood functional gastrointestinal disorders: child/adolescent. gastroenterology 2016; 150: 1456–1468. 24. kligler b, hanaway p, cohrssen a. probiotics in children. pediatric clinics of north america 2007; 54(6): 949–967. journal of enam medical college vol 11 no 2 may 2021 78 original article association of carpal tunnel syndrome with diabetic polyneuropathy sayeda shabnam malik1, mohammad rezaul karim khan2, ma hannan3, sk mahbub alam 4 received: 17 february 2021 accepted: 30 march 2021 doi: https://doi.org/10.3329/jemc.v11i2.65189 abstract background: common thought is that diabetic neuropathy is a predisposing factor to entrapment syndromes. carpal tunnel syndrome (cts) is the most frequent entrapment neuropathy. objectives: to find out association of carpal tunnel syndrome with diabetic polyneuropathy. materials and methods: during the period of march 2013 to september 2015, this cross-sectional study was carried out in the department of neurology, bangabandhu sheikh mujib medical university, dhaka. a total of 100 adult patients having symptoms and signs of polyneuropathy were recruited as study population. of them 50 patients grouped into diabetic polyneuropathy (dpn) and the rest 50 patients in non-diabetic neuropathy due to other causes. results: out of all patients, the mean age was found 49.60 (13.53) years with 42% female in diabetic neuropathy patients and mean age was 44.64 (15.72) years with 46% female in non-diabetic neuropathy patients. the duration of diabetes was found 8.44 (7.79) years. according to development of carpal tunnel syndrome (cts), in diabetic neuropathy patients, about 58% patients developed cts while in non-diabetic neuropathy patients, that of 14% (p=0.0001). we found diabetic neuropathy patients have 8.48 times higher possibility of development of cts than non-diabetic neuropathy patients. on adjusted model, age as confounding variable, diabetic neuropathy and female sex were found significantly associated with development of cts with adjusted odd ratio 10.92 and 3.78 respectfully (p<0.0001). conclusion: in conclusion, we revealed the higher frequency of cts in diabetics with dpn. as well we also found dpn and female sex were strongly associated with development of cts. as dpn is a risk factor for cts, priority should also be given to the treatment of dpn. key words: diabetic neuropathy; carpal tunnel syndrome j enam med col 2021; 11(2): 78−85 1. assistant professor, department of neurology, enam medical college, savar, dhaka 2. professor, department of neurology, bangabandhu sheikh mujib medical university, shahbag, dhaka 3. department of neurology bangabandhu sheikh mujib medical university, shahbag, dhaka 4. associate professor, department of neurology, bangabandhu sheikh mujib medical university, shahbag, dhaka correspondence sayeda shabnam malik, email: sayedashabnam.malik@gmail.com introduction diabetes mellitus is the most common chronic non communicable disease now-a-days. peripheral neuropathy has been considered as the most troublesome complication of dm. diabetes affects 382 million people worldwide and its prevalence is expected to increase to 592 million by the year 2035.1 diabetes mellitus is a clinical syndrome characterized by hyperglycemia caused by absolute or relative deficiency of insulin.2 diabetic neuropathy, a wellknown long term complication of diabetes, can affect almost half of the diabetic population3 and is associated with higher mortality and morbidity.4 the may 2021j enam med col vol 11 no 2 79 overall prevalence of neuropathy is 66% for type 1 and 59% for type 2 diabetes.5 prevalence of neuropathic symptoms increases at the time of diagnosis, the incidence increases to about 50% after 20−25 years of diabetic life.6 painful diabetic neuropathy (pdn) is a common type of diabetic neuropathy and the most common cause of neuropathic pain.7 neuropathic pain can be a prominent presenting symptom in a great number of peripheral neuropathy.8 dpn is insidious in onset and patient complains of tingling, pricking, burning sensation and numbness of mild to moderate severity.9 pdn is caused by the involvement of small nerve fibers, which may affect without objective clinical findings. the diagnosis of dpnp does not require evidence of a large-fiber abnormality.10 other common causes of neuropathy, e.g., guillaine barre syndrome, cidp, toxins and metabolic and nutritional diseases.5 carpal tunnel syndrome (cts) is a compressive neuropathy which is defined as a mononeuropathy or radiculopathy caused by mechanical distortion produced by a compressive force11 and a symptomatic compression neuropathy of the median nerve at the level of the wrist.12 cts is the most well-known and frequent form of median nerve entrapment, and accounts for 90% of all entrapment neuropathies13 and the second most important cause of diabetic neuropathy after distal symmetric sensory motor polyneuropathy.9 cts is caused by entrapment of the median nerve at the level of the carpal tunnel, and delimitated by the carpal bones and by the transverse carpal ligament.12 physiological evidence indicates increased pressure within the carpal tunnel, and therefore decreased function of the median nerve at that level.12 the prevalence of cts is 15−25% in patients with dpn.14 the most typical symptoms are pain and paresthesia in the thumb, index, middle finger and the radial side of ring finger, occurring especially at night.14 the main conditions associated with carpal tunnel syndrome are diabetes, hypothyroidism, rheumatoid arthritis, osteoarthritis, obesity and pregnancy.15 carpal tunnel syndrome and diabetic polyneuropathy are common conditions in patients with diabetes and therefore frequently occur concomitantly. carpal tunnel syndrome has been reported in up to 20% of people with diabetes. the diabetic link is possibly due to the fact that when blood glucose levels are high the proteins in the tendons of the carpal tunnel become glycosylated, inflaming them and forming a sort of biological superglue that makes the tendon less able to slide freely.15 the two provocative tests most commonly used in the clinical settings are phalen’s and tinel’s tests. the sensitivity of phalen’s test is 67−83% and specificity is 40−98%. tinnel’s test has sensitivity of 48−73% and specificity is 30−94%.16 nerve conduction study is considered to be gold standard in the diagnosis of cts. this is the most sensitive and accurate technique, with a sensitivity of 80−92% and specificity of 80−99%.17 ncs criteria is used to diagnose cts in diabetic subjects without distal peripheral neuropathy in the same manner as in the non-diabetic population. the standard method of diagnosis is comparing the latency and amplitude of a median nerve segment across the carpal tunnel to another nerve segment that does not go through the carpal tunnel, such as the radial or ulnar nerve.17 prolonged motor and sensory latencies of the median nerve and reduced sensory and motor conduction velocities are accepted as diagnostic criteria for carpal tunnel syndrome.14 when cts occurs due to entrapment then only distal latency is increased in both motor and sensory parts. if two stimuli are given in both proximal and distal to the wrist, entrapment can be identified. in diabetic mononeuropathy usually homogenous involvement of nerve (axonal and demyelinating) may occur both proximal and distal to wrist joint. it is important to determine whether median neuropathy is due to entrapment or it results from diabetic polyneuropathy. for future treatment planning it is important to determine whether cts is an entrapment of the median nerve under the transverse carpal ligament or it results from diabetic polyneuropathy. materials and methods this cross-sectional analytical study was carried out in the inpatient and outpatient departments of neurology may 2021j enam med col vol 11 no 2 80 including neuropathy clinic of bangabandhu sheikh mujib medical university (bsmmu), dhaka from march 2013 to september 2015. study population was adult patients having symptoms and signs of polyneuropathy. then these patients were grouped into diabetic polyneuropathy and non-diabetic polyneuropathy due to other causes. patients having symptoms of cts were included in both groups by random sampling method 107 adult patients who were having symptoms and signs of polyneuropathy undergo meticulous history and physical examination. then these patients were divided into diabetic polyneuropathy and non-diabetic polyneuropathy (due to other cause). 50 patients were in diabetic polyneuropathy group and 50 were in nondiabetic polyneuropathy group (due to other cause). rest 7 patients did not give consent to take part in the study and had other diseases like hypothyroidism. • the diagnosis of cts was done by the presence of nocturnal and activity related pain or dyseshesia limited to hand. patients having symptoms of cts were included in both groups. • height and weight were measured and bmi was calculated as weight (kg)/height (m)2. • 2015 american diabetes association (ada) diabetes guidelines criteria used for diabetes diagnosis, the values were hba1c ≥6.5%, fpg ≥126 mg/dl (7.0 mmol/l), two-hr pg ≥200 mg/dl (11.1 mmol/l) during ogtt (75g). • the diabetic and non-diabetic patients with a history and signs of polyneuropathy were evaluated by some routine investigations (cbc, esr, fbs, ppbs, hba1c, serum creatinine, ra test, tsh) for exclusion of other diseases. • for evaluation for presence of cts distal latency, conduction velocity of sensory and motor component of medial nerve was measured. • if the median motor latency exceed 4.4 ms or the difference between distal motor latency of median and ulnar nerve exceed 1.1 ms or the difference between distal sensory latency of median and ulnar nerve exceed 0.2ms used as a parameter for diagnosis of cts. data were collected by face to face interview or history taking of the patient. clinical examination, laboratory investigations were collected by using structured data information sheet. data were analyzed by computer with the help of spss version 21.0 software package. all data were recorded systematically in a preformed data collection sheet. quantative variables are expressed as mean ± sd. analysis of the variables was done by using chi square test and independent t-test. for all statistical tests, we considered p value <0.05 as statistically significant. binary logistic regression was seen to reveal the association of cts with diabetic polyneuropathy and nondiabetic polyneuropathy. results this cross-sectional analytical study was carried out in the department of neurology, bangabandhu sheikh mujib medical university, dhaka from march 2013 to september 2015. by random sampling method 107 adult patients who were having symptoms and signs of polyneuropathy were enrolled in this study. seven patients who did not give consent to take part in the study and had other diseases like hypothyroidism were excluded. finally, a total of 100 adult patients having symptoms and signs of polyneuropathy were recruited as study population. out of these patients, 58% were male and 42% female. fifty patients had diabetic polyneuropathy and 50 patients non-diabetic neuropathy due to other causes. all diabetics had type 2 dm and mean (sd) duration was 8.44 years. table i shows the distribution of the patients by gender. table ii shows comparison of patients according to nerve conduction velocity. in context of median nerve and ulnar nerve, all the parameters showed statistically significant difference between diabetic and non-diabetic neuropathy patients except the distal latency of ulnar nerve which was found statistically nonsignificant. other nerve shows non-significant difference. may 2021j enam med col vol 11 no 2 81 table i: distribution of the patients by gender (n=100) gender type of patients chi-square value (df) p value*diabetic neuropathy (n=50) non-diabetic neuropathy (n=50) male 29 (58.0%) 27 (54.0%) 0.041 (1) 0.840ns female 21 (42.0%) 23 (46.0%) ns=non significant; *chi square test was done to measure level of significance #figure within parenthesis denoted corresponding column percentage table ii: comparison of patients according to nerve conduction velocity (n=100) diabetic neuropathy (n=50) mean (sd) non-diabetic neuropathy (n=50) mean (sd) p values* median nerve distal motor latency (ms) 5.02 (1.50) 3.84 (1.21) <0.0001s motor amplitude (mv) 8.29 (4.12) 5.13 (4.61) <0.0001s sensory amplitude (µv) 11.40 (8.86) 29.22 (25.69) <0.0001s ncv (m/s) 32.96 (13.41) 40.22 (10.17) 0.003s ulnar nerve distal latency (ms) 2.84 (0.64) 3.21 (1.20) 0.067ns motor amplitude (mv) 9.80 (6.10) 7.61 (5.24) 0.060s sensory amplitude (µv) 12.85 (9.30) 30.63 (25.48) <0.0001s ncv (m/s) 36.72 (12.82) 31.04 (12.27) 0.027s ncv (m/s) tibial nerve 31.79 (9.36) 32.88 (8.88) >0.05ns ncv (m/s) peroneal nerve 33.33 (5.14) 33.75 (7.40) >0.05ns ncv (m/s) sural nerve 39.09 (7.20) 42.03 (9.03) >0.05ns ns=non significant; s=significant; *independent sample t test was done to measure the level of significance table iii shows distribution of patients according to development of carpal tunnel syndrome (cts). in diabetic neuropathy patients, about 58% patients developed cts while in non-diabetic neuropathy patients cts was 14%. there was statistically highly significant difference between these groups in terms of cts development. table iii: distribution of patients according to development of carpal tunnel syndrome (cts) (n=100) cts diabeteic neuropathy (n=50) non-diabetic neuropathy (n=50) p value* present 29 (58.0) 7 (14.0) <0.0001s absent 21 (42.0) 43 (86.0) *chi square test was done to measure the level of significance. figure within parenthesis indicates percentage. s= significant may 2021j enam med col vol 11 no 2 82 binary logistic regression was seen in enter method to reveal the association of carpal tunnel syndrome with diabetic neuropathy (table iv). here we found diabetic neuropathy patients have 8.48 times higher possibility of development of cts than non-diabetic neuropathy patients which is statistically highly significant (p <0.0001). table v shows multiple logistic regression model done in forward conditional method. here age was act as confounding variable. diabetic neuropathy and female sex were found significantly associated with development of cts with adjusted odd ratio 10.92 and 3.78 respectfully. table iv: binary logistic regression model to see the association of carpal tunnel syndrome with diabetic neuropathy patients (enter method) unadjor p value 95% ci lower value upper value non-diabetic neuropathy (ref) 1 diabetic neuropathy 8.48 <0.0001 3.195 22.523 unadjor= unadjusted odd ratio table v: multiple logistic regression model to see the association of carpal tunnel syndrome with age, sex and diabetic neuropathy (forward conditional method) adjor p value 95% ci lower value upper value group non-diabetic neuropathy (ref) 1 diabetic neuropathy 10.92 < 0.0001 3.76 31.74 sex male (ref) 1 female 3.78 0.010 1.370 10.417 adjor= adjusted odd ratio discussion carpal tunnel syndrome (cts) which is the most wellknown and frequent form of median nerve entrapment accounting for 90% of all entrapment neuropathies, remains a puzzling and disabling condition.13,18 one in every five subjects who complain of symptoms such as pain, numbness and a tingling sensation in the hands is expected to have cts based on clinical examination and electrophysiological testing.18 an epidemiological study in uk reported that median number of days away from work due to cts is amongst the highest in the uk at 27 days.19 therefore, the underlying cause of cts is necessary to detect for its better management. the prevalence of diabetic polyneuropathy (dpn) has been reported as 5 to 60%.20 it occurs thrice as frequently in a diabetic population compared with a normal healthy population.21,22 the increased prevalence in diabetes may be related to repeated undetected trauma, metabolic changes, accumulation of fluid or edema within the confined space of the carpal tunnel, and diabetic cheiroarthropathy.23 cts is found in up to one-third of patients with diabetes, when demonstrated electrophysiologically, but may only be symptomatic in 5.8%.24 this cross-sectional study was carried out in the department of neurology, bangabandhu sheikh mujib medical university, dhaka from march 2013 to september 2015. a total of 100 adult patients having symptoms and signs of polyneuropathy were recruited as study population. of them 50 patients were diabetic polyneuropathy and 50 patients nondiabetic neuropathy due to other causes. there are substantial numbers of publications may 2021j enam med col vol 11 no 2 83 demonstrating the prevalence and association of cts with diabetic neuropathy patients. we compared our study findings with result of some other published articles elsewhere in the world to verify our results.25−27 analysis of gender distribution showed that out of all patients, 58% were male and 42% female in diabetic neuropathy diagnosed patients and in non-diabetic neuropathy patients, 54% were male and 46% female. but in unadjusted odd ratio model, we found female were 2.5 times more prone to develop cts than male and that was statistically significant (p<0.05). our study findings are consistent to some other studies done in the world. aybin et al28 studied on 100 patients, 16 patients developed cts and among them 11 were female and 5 were male. according to development of carpal tunnel syndrome (cts), in diabetic neuropathy patients, about 58% patients developed cts while in non-diabetic neuropathy patients it was 14% which is statistically highly significant (p<0.0001). cts was present in 16% of all diabetic patients and of these 93% were found to have dpn (p<0.001). a review was done comi et al29 on carpal tunnel syndrome (cts) in patients with diabetes mellitus. the prevalence of cts is higher in diabetic patients with peripheral polyneuropathy compared to patients with diabetes, who do not have diabetes-related late complications (30% vs. 14%). one of the study observed the prevalence of carpal tunnel syndrome (cts) in diabetic polyneuropathy (dpn) patients in a cross-sectional design in a total of 478 subjects.25 on the basis of nerve conduction study, the prevalence of clinical cts was 2% in the reference population, 14% in diabetic subjects without dpn, and 30% in those with dpn. moreover reported the prevalence of symptomatic cts in those with diabetes as 11 and 6% in type 1 and type 2 diabetic patients, respectively.25 on the measuring of distal motor latency of median nerve, the mean (sd) of non-diabetic neuropathic patients with cts was found 6.29 (1.54) m/sec which was statistically significant than ndpn without cts, 3.45 (0.47). meanwhile, statistical significant difference was also found in distal motor latency of median nerve between diabetic neuropathy with cts and without cts [6.03 (1.21) vs. 3.64 (0.11), p<0.0001]. binary logistic regression was seen in enter method to reveal the association of carpal tunnel syndrome with diabetic neuropathy patients. here we found diabetic neuropathy patients have 8.48 times higher possibility of development of cts than non-diabetic neuropathy patients which was statistically highly significant (p<0.0001). we also found age is not associated with development of cts. but in case of female gender, we found female were 2.5 times more prone to develop cts than male and that was statistically significant (p<0.05). diabetic neuropathy and female sex were found significantly associated with development of cts with adjusted odd ratio 10.92 and 3.78 respectfully (p<0.0001). a similar study done by galer et al30 evaluated the prevalence of carpal tunnel syndrome (cts) in diabetics and associated risk factors. the strongest risk factors for cts, in order of importance, were: female sex, older age and presence of neuropathy which is in accordance of our study findings, found that there were more cts patients than control subjects who had diabetes (p=0.03; odds ratio, 3.02) which is in agreement of our study findings.27 in other studies, dpn is found to be a major risk factor for developing cts.21,22,31,32 in our study, we recorded 58% patients developed carpal tunnel syndrome (cts) in diabetic neuropathy patients while in non-diabetic neuropathy patients, that of 14% which was statistically highly significant. we also found diabetic neuropathy patients have 8.48 times higher possibility of development of cts than non-diabetic neuropathy patients (p<0.0001). diabetic neuropathy and female sex were found significantly associated with development of cts with adjusted odd ratio 10.92 and 3.78 respectfully (p<0.05). therefore, on our study findings cts development is common in diabetic neuropathy patients in our country context. examination of the hands and shoulders should be included in the evaluation of patients with diabetes. so, proper monitoring and advice may reduce the frequency of development of cts in dpn patients. references 1. international diabetes federation. idf diabetes may 2021j enam med col vol 11 no 2 84 atlas. international diabetes federation, 6th edition, brussels, belgium, 2013. 2. brian rw, nicki rc, stuart hr, ian d, robert b. davidson’s principles and practice of medicine. 21st edition. london: elsevier saunders, 2010. 3. tapp r, shaw j. epidemiology of diabetic neuropathy. oxford university press, oxford, 2009. 4. vinikn ai, mithcell bd, leichter sb. “epidemiology of the complications of diabetes,” in diabetes: clinical science in practice. cambridge university press, cambridge 1994; 221–287. 5. fauci a, braunwald e, kasper d, hauser s, longo d, jameson j et al. peripheral neuropathy. harrison’s principles of internal medicine. 17th edn. london: elsevier, 2013: 577−579, 593. 6. barrett am, lucero ma, le t, robinson rl, dworkin rh, chappell as. epidemiology, public health burden, and treatment of diabetic peripheral neuropathic pain: a review. pain med 2007; 8(2): s50–62. 7. chong ms, hester j. diabetic painful neuropathy. drugs 2007; 67(4): 569–585. 8. mendell jr, sahenk z. ‘painful sensory neuropathy.’ n engl j med 2003; 349: 306−307. 9. dyck pj, kratz km, karnes jl, litchy wj, klein r, pach jm et al. the prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: the rochester diabetic neuropathy study. neurology 1993; 43(4): 817–824. 10. simmons z, feldman el. update on diabetic neuropathy. curropin neurol 2002; 15: 595−603. 11. alfonso c, jann s, massa r, torreggiani a. diagnosis treatment and follow-up of the carpal tunnel syndrome: a review. neurolog sci 2010; 31(3): 243–252. 12. american academy of orthopaedic surgeons work group panel. clinical guidelines on diagnosis of carpal tunnel syndrome 2007. journal of bone and joint surgery; 91 (10): 2478−2479. 13. somaiah a, roy aj. carpal tunnel syndrome. ulster medical j 2008; 77(1): 6−17. 14. oge a, demir s, gemalmaz a, fikri ak. relationship between carpal tunnel syndrome and polyneuropathy in diabetics: is the polyneuropathy a risk factor or not? turkish journal of endocrinology and metabolism 2004; 1: 43−47. 15. chan l, turner ja, comstock ba, levenson lm, hollingworth w, heagerty pj et al. the relationship between electrodiagnostic findings and patient symptoms and function in carpal tunnel syndrome. archives of physical medicine and rehabilitation, 2007; 88(1): 19−24. 16. uchiyama s, itsubo t, nakamura k, kat h, yasutomi t, momose t. current concepts of carpal tunnel syndrome pathophysiology treatment, and evaluation. j orthop sci 2010; 15: 1–13. 17. ibrahim i, khan ws, goddard n, smitham p. carpal tunnel syndrome: a review of the recent literature. j open orthop 2012; 6: 69−76. 18. amirlak b, upadhyaya k, ahmed o, wolff t, tsai t, scheker l. median nerve entrapment. internet communication 2010; 1(11): 179−185. 19. prime ms, palmer j, khan ws, goddard nj. is there light at the end of the tunnel? controversies in the diagnosis and management of carpal tunnel syndrome. hand 2010; 5(4): 354−360. 20. thomas pk, tomlinson dr. diabetic and hypoglycemic neuropathy. peripheral neuropathy 1993; 1219−1250. 21. chammas m, bousquet p, renard e, poirier j, jaffiol c, allieu y. dupuytren’s disease, carpal tunnel syndrome, trigger finger, and diabetes mellitus. am j hand surg 1995; 20: 109–114. 22. gamstedt a, holm-glad j, ohlson c, sundstrom m. hand abnormalities are strongly associated with the duration of diabetes mellitus. j intern med 1993; 234: 189–193. 23. chaudhuri kr, davidson ar, morris im . limited joint mobility and carpal tunnel syndrome in insulin dependent diabetes. br j rheumatol 1989; 28: 191– 194. 24. wilbourn a. diabetic entrapment and compression may 2021j enam med col vol 11 no 2 85 neuropathies. diabetic neuropathy 1999; 481–508. 25. perkins b, olaleye d, zinman b, bril v. simple screening tests for peripheral neuropathy in the diabetes clinic. diabetes care 2001; 24(2): 250–256. 26. cagliero e, apruzzese w, perlmutter gs, nathan dm. musculoskeletal disorders of the hand and shoulder in patients with diabetes mellitus. the american journal of medicine 2002; 112(6): 487−490. 27. kouyoumdjian ja, zanetta dm, morita mp . evalution of age, body mass index and wrist index as risk factor for carpal tunnel syndrome severity. muscle & nerve 2002; 25(1): 93−97. 28. aybin a, mondelli m, giannini e, giachi m. carpal tunnel syndrome incidence in a general population. neurology 2002; 58 (2): 289−294. 29. comi g, lozza l, galardi g, ghilardi mf, medaglini s, canal n. presence of carpal tunnel syndrome in diabetics: effect of age, sex, diabetes duration and polyneuropathy. acta diabetol la 1985; 22(3): 259−262. 30. galer bs, gianas a, jensen mp. painful diabetic polyneuropathy: epidemiology, pain description and quality of life. diabetes res clinpract 2000; 47 : 123−138. 31. bahrmann a, zieschang t, neumann t, hein g, oster p. carpal tunnel syndrome in diabetes mellitus. med klin 2010; 105(3): 150−154. 32. ozaki i, baba m, matsunaga m, takebe k. deleterious effect of the carpal tunnel on nerve conduction in diabetic polyneuropathy. electromyogr clin neurophysiol.1988; 28: 301–306. journal of enam medical college vol 11 no 1 january 2021 39 original article comparative study of topical terbinafine 1% cream versus butenafine 1% cream in the treatment of tinea cruris meher afsun1, iftekhar ahmed 2 received: 30 december 2019 accepted: 30 december 2020 doi: https://doi.org/10.3329/jemc.v11i1.63172 abstract background: tinea cruris constitutes a major health problem worldwide. although not lifethreatening, it can cause significant discomfort in daily activities. so, search for better therapeutic options in terms of clinical efficacy and safety profile is ongoing. objective: to compare the efficacy and safety of topical terbinafine 1% and butenafine 1% cream in the treatment of tinea cruris. materials and methods: this comparative interventional study was carried out in the dermatology & venereology department of bangabandhu sheikh mujib medical university between october 2014 and march 2015. a total of 50 patients of tinea cruris who met the inclusion criteria and provided consent were enrolled in the study. they were then divided into two groups as group a (terbinafine group) and group b (butenafine group) in a 1:1 ratio following a simple randomization method. patients were advised to apply the medication once daily for 2 weeks and evaluated on the basis of clinical assessment score at the end of 1 and 2 weeks. results: the baseline socio-demographic characteristics of the two groups were not statistically significantly different. higher clinical cure was observed in butenafine recipients as compared with terbinafine recipients on the basis of mean clinical assessment score at the end of 7 days (5.72±0.7 vs 4.12±0.7) and 14 days (3.04±0.5 vs 1.44±0.9). the difference was statistically significant at both the time points. both the drugs were well-tolerated except one patient of terbinafine group complained of transient burning. conclusion: treatment with butenafine 1% cream can be considered superior to terbinafine 1% cream in case of tinea cruris. key words: tinea cruris; dermatophytosis; terbinafine cream; butenafine cream j enam med col 2021; 11(1): 39−46 1. assistant professor, department of dermatology and venereology, enam medical college & hospital, savar, dhaka 2. assistant professor, department of dermatology and venereology, sir salimullah medical college & mitford hospital, dhaka correspondence meher afsun,email: drmafsun@gmail.com introduction tinea cruris, a pruritic superficial fungal infection of the groin and adjacent skin, is the second most common clinical presentation for dermatophytosis. it is an important clinical problem that may, at times, be a diagnosticas well as therapeutic challenge.1 tinea cruris has a worldwide distribution but is found more commonly in hot, humid climates and affects individual of all age and sex.2,3 it is a contagious infection transmitted by fomites or by autoinoculation from a reservoir on the hands or feet (tinea manuum, tinea pedis and tinea unguium). the most common etiologic agents for tinea cruris include trichophyton rubrum and epidermophyton floccosum; less commonly trichophyton mentagrophytes and trichophyton verrucosum are involved.1 topical preparations with good local bioavailability january 2021j enam med col vol 11 no 1 40 are the commonly used and preferred first line agents in the treatment of localized dermatophytosis. their improved efficacy aims to shorten the treatment period with fewer side effects. ease of application, enhanced patient compliance, and minimal recurrences also add to the therapeutic response.4 quest for more potent and more compliant medication is going on. finding a medication with more potency and capability to treat this disorder at less inconvenience will empower the dermatologist and the general physicians to fight the disorder with better efficacy. clinical cure of an uncomplicated tinea cruris infection usually can be achieved using topical antifungal agents.5 many topical antifungals of different groups are available for the treatment of dermatophytosis such as azole derivatives, allylamines, benzylamines, morpholine, etc.6 terbinafine hydrochloride is one of the fungicidal allylamine group of drugs with broad spectrum of antifungal activity. it interferes with fungal sterol biosynthesis at an early stage.7 butenafine hydrochloride is a novel, benzylamine derivative with a chemical structure and mode of action is similar to allylamine antifungals.8 it likes the allylamines, butenafine also inhibits squalene epoxidation, blocking the biosynthesis of ergosterol, an essential lipid component of fungal cell membrane. the antifungal activity of both allylamine and benzylamine results from ergosterol deficiency and intracellular accumulation of squalene, which interferes with fungal cell membrane function and synthesis.7,8 the dermatophytes responsible for tinea cruris have been shown to be susceptible to both terbinafine and butenafine.9,10 however, comparative study between topical terbinafine 1% and butenafine 1% cream in the treatment of tinea cruris is lacking. under these circumstances, the current study was undertaken to compare the efficacy and safety of topical terbinafine 1% and butenafine 1% cream in the treatment of tinea cruris. materials and methods this prospective, randomized, open-labeled comparative interventional study was conducted on 50 patients over the age of 14 years who visited dermatology and venereology outpatient department of bangabandhu sheikh mujib medical university (bsmmu) duringthe period of october 2014 to march 2015, a duration of 6 months. the inclusion criteria comprised of untreated patients of tinea cruris whose diagnosis was confirmed by potassium hydroxide (koh) examination for fungal elements and who had at least three signs and symptoms of tinea cruris namely pruritus (symptom); polycyclic lesions, erythema, scaling, macerations, papules and vesiculation (signs). patients were excluded from the study, if they had received topical or oral antifungals either one to four weeks prior to the initiation of the study respectively, history of hypersensitivity to allylamine or benzylamine anti-fungal agents, any known severe systemic disease, immunocompromised status, pregnant or lactating women. all potential patients were screened following the inclusion and exclusion criteria, then the first 50 patients who met those criteria and provided consent were enrolled in the study. informed written consent was at first obtained from all the patients, then a structured questionnaire was administered to gather valuable information about socio-demographic characteristics and disease-related informations. the patients were then randomized into two groups as group a (n=25) and group b (n=25) in a 1:1 ratio following a simple randomization method by allocatinga code for each patient. at the initial visit, all the study patients underwent detailed physical and cutaneous examination. all clinical details were recorded on a predesigned proforma. the symptoms and signs like erythema, scaling and pruritus were designated on a scale of 0 to 3 as follows: 0=none, 1=mild, 2=moderate and 3=severe. the individual symptom scores were added and a total score (clinical assessment score) was recorded. group a patients were treated with terbinafine 1% cream and group b patients were treated with january 2021j enam med col vol 11 no 1 41 butenafine 1% cream. patients were advised to apply the medication after bath to the affected sites and also to the surrounding areas, once daily for 2 weeks. the patients were then clinically evaluated at the end of one and two weeks (i.e., at the end of treatment period). at each visit, thorough clinical examination was carried out and clinical assessment score was calculated to determine clinical efficacy. adverse effects, if any, were also recorded at each visit. clinical efficacy was defined in this study as reduction in the severity of symptoms and signs of tinea cruris (pruritus, erythema, scaling, etc.) as evident by decreased clinical assessment score from baseline during follow-up visit. all data were collected at first using a structured paper-based questionnaire containing all the variables of interest. data were then initially extracted in microsoft excel, coded, cleaned and then entered into statistical package for social sciences version 16.0 for windows (spss inc., chicago, illinois, usa) for further statistical analyses. the mean values were calculated for continuous variables. the quantitative observations were indicated by frequencies and percentages. chi-square test with yates correction was used to analyze the categorical variables, shown with cross tabulation. student t-test/unpaired t-test was used for continuous variables. p values <0.05 were considered as statistically significant. results there was a total of 50 patients, 25 patients in the terbinafine group (group a) and 25 patients in the butenafine group (group b). in group a (terbinafine group), majority of the patients were in the age group of 21−30 years. in group b (butenafine group), majority of the patients were in the age group of >30 years. the mean age with sd in group a (terbinafine group) and group b (butenafine group) were 31.88±11.08 years and 30.40±9.51 years respectively. the difference between the age of two group was not statistically significant (p=0.614). proportion of male was higher than female in group a (terbinafine group), which was 76.0% and 24.0% cases respectively. same is also true for group b (butenafine group), where proportion of male versus female was 84.0% vs16.0% cases respectively. the difference between these two groups was not statistically significant (p=0.479). distribution of study participants on the basis of marital status showed that in group b (butenafine group), married persons were more than unmarried persons which was 16 (64.0%) cases and 9 (36.0%) cases respectively. similar distribution was observed in group a (terbinafine group), where proportion of married and unmarried persons was 56.0% cases and 44.0% cases respectively. the difference between these two groups was not statistically significant (p=0.563). majority of the patients of group a (terbinafine group) were graduate and above level which was 9 (36.0%) cases followed by ssc, hsc, primary school and illiterate which were 6 (24.0%) cases, 6 (24.0%) cases, 3 (12.0%) cases and 1 (4.0%) case respectively. somewhat similar pattern was observed among the patients of group b (butenafine group) where majority were graduate and above level which is 11 (44.0%) cases followed by primary school, ssc, hsc, and illiterate which were 6 (24.0%) cases, 4 (16.0%) cases, 3 (12.0%) cases and 1 (4.0%) case respectively. the difference between these two groups was not statistically significant (p=0.628). service was the main occupation of the patients of group a (terbinafine group). we found 15 (60.0%) cases in this category followed by student, housewife, business and laborers which were 5 (20.0%) cases, 2 (8.0%) cases, 2 (8.0%) cases and 1 (4.0%) case respectively. in contrast, among the patients of group b (butenafine group) majority (9, 36.0%) were students followed by service, housewife, laborers and business which were 8 (32.0%) cases, 3 (12.0%) cases, 3 (12.0%) cases and 2 (8.0%) cases respectively. the difference between these two groups was not statistically significant (p=0.345) (table i). january 2021j enam med col vol 11 no 1 42 table i: characteristics of the study participants characteristics group a (n=25)number (%) group b (n=25) number (%) p values age in years <21 03 (12.0) 06 (24.0) 0.614ns 21−30 13 (52.0) 07 (28.0) >30 09 (36.0) 12 (48.0) mean ± sd 31.88 ±11.08 30.40 ±9.51 sex male 19 (76.0) 21 (84.0) 0.479ns female 06 (24.0) 04 (16.0) marital status married 14 (56.0) 16 (64.0) 0.563ns single 11 (44.0) 09 (36.0) educational level illiterate 01 (4.0) 01 (4.0) 0.628 ns primary school 03 (12.0) 06 (24.0) ssc 06 (24.0) 04 (16.0) hsc 06 (24.0) 03 (12.0) graduate & above 09 (36.0) 11 (44.0) occupation service 15 (60.0) 08 (32.0) 0.345ns house wife 02 (8.0) 03 (12.0) student 05 (20.0) 09 (36.0) business 02 (8.0) 02 (8.0) laborers 01 (4.0) 03 (12.0) ns = not significant baseline clinical presentation of the study participants most of the study participants (88%) had presented with multiple lesions in both group a (terbinafine group) and group b (butenafine group). the difference between these two groups was not statistically significant (p=1.000). in group a (terbinafine group), erythema was present in 25 (100.0%) cases, scaling was present in 25 (100.0%) cases, central clearing was present in 22 (88.0%) cases, papule was present in 23 (92.0%) cases, vesicles was present in 9 (36.0%) cases, maceration was present in 5 (20.0%) cases and pruritus was present in 25 (100.0%) cases. in group b (butenafine group), erythema was present in 24 (96.0%) cases, scaling was present in 23 (92.0%) cases, central clearing was present in 19 (76.0%) cases, papule was present in 21 (84.0%) cases, vesicles was present in 10 (40.0%) cases, maceration was present in 6 (24.0%) cases and pruritus was present in 24 (96.0%) cases, the difference was not statistically significant (p>0.05) between two groups (table ii). january 2021j enam med col vol 11 no 1 43 table ii: presentation of tinea cruris among the study participants characteristics group a (n=25) number (%) group b (n=25) number (%) p values number of lesions multiple 22 (88.0) 22 (88.0) 1.000nssingle 03 (12.0) 03 (12.0) clinical findings erythema 25 (100.0) 24 (96.0) 0.312ns scaling 25 (100.0) 23 (92.0) 0.148ns central clearing 22 (88.0) 19 (76.0) 0.269ns papule 23 (92.0) 21 (84.0) 0.333ns vesicles 09 (36.0) 10 (40.0) 0.770ns maceration 05 (20.0) 06 (24.0) 0.732ns pruritus 25 (100.0) 24 (96.0) 0.500ns ns= not significant comparison of clinical assessment score between the groups before and after treatment the mean and standard deviation (sd) of clinical assessment score in group a (terbinafine group) and group b (butenafine group) were 8.92 ± 0.6 and 8.84±0.8 respectively before initiation of treatment. the difference between the mean score of two group was not significant (p=0.690). after one week of treatment the mean clinical assessment score with sd of group a (terbinafine group) and group b (butenafine group) participants were 5.72±0.7 and 4.12±0.7 respectively. the difference between the mean score of the two groups was significant (p=0.001). the mean clinical assessment score with sd in group a (terbinafine group) and group b (butenafine group) were 3.04±0.5 and 1.44±0.9 respectively after 2 weeks of treatment. the difference between the mean score of the two groups was significant (p=0.001) (table iii and fig 1). table iii: comparative clinical assessment score between the groups before and after treatment follow up & observation group a (mean ± sd) group b (mean ± sd) p value base line 8.92±0.6 8.84±0.8 0.690ns after 1st week 5.72±0.7 4.12±0.7 0.001s after 2nd week 3.04±0.5 1.44±0.9 0.001s ns=not significant; s= significant fig 1. line graph showing the improvements of the study patients according to clinical assessment scoring january 2021j enam med col vol 11 no 1 44 comparison of adverse effects between the groups after treatment transient burning sensation at the application site was found in one of 25 (4.0%) cases of group a (terbinafine group); but it resolved spontaneously and did not require discontinuation of therapy. in contrast, no side effects were reported by group b (butenafine group) participants. the difference was not statistically significant (p>0.05). discussion newer classes of antifungals like the allylamines and benzylamines were developed to combat the increasing incidence of resistant fungal infections as well as to produce quicker response with lesser side effects. terbinafine and butenafine are the antifungals that represent the groups respectively and both were tested individually for their efficacy. however, there is still paucity of published evidence where their efficacy has been compared together. under this circumstance, our current study which to the best of our knowledge was the first study in bangladesh that compared the efficacy and safety of topical terbinafine 1% and butenafine 1% cream in the treatment of tinea cruris. in the present study, it was observed that in group a (terbinafine group), majority of the patients (52.0%) were in their 3rd decade of life followed by more than 30 years (36.0%) and under 21 years (12.0%). in group b (butenafine group), majority of the patients were in the age group of more than 30 years (48.0%) followed by 3rd decade and under 21 years which were 28.0% cases and 24.0% cases respectively. the mean age with sd in group a (terbinafine group) and group b (butenafine group) were 31.88±11.08 years and 30.40±9.51 years respectively, which were similar in two groups. the mean difference between the age of two groups was not statistically significant (p>0.05), which indicates that tinea cruris is predominant in 3rd decade and above. similarly, choudhary et al11 showed in their study that all the patients had similar demographic features with age ranged in between 16 and 35 years in both the groups. das et al12 also found most of the patients’ age belonged to 30−45 years accounting for 67.0% of the study group. the youngest patient was 18 years and the oldest patient was 61 years, which are consistent with the findings of our current study. on the other hand, jerajani et al13 and rotta et al14 observed higher mean age in their respective studies, which were 36.49±14.70 years and 38.4±13.4 years respectively. the higher mean age might be due to geographical variations, racial, ethnic differences, genetic causes, different lifestyle and increased life expectancy. tinea cruris is a dermatophyte infection of the groin and is more common in men than in women probably because males perspire more than females, greater areas of occlusive skin where the scrotum is in contact with the thigh and clothing difference.15 similarly, in this current study it was observed that in group a (terbinafine group) male was predominant than female which was 76.0% cases and 24.0% cases respectively. in group b (butenafine group) males were predominant compared with females (84.0% cases and 16.0% cases respectively). the difference between these two groups was not statistically significant (p>0.05). male to female ratio was 3.2:1 and 5.3:1 in group a (terbinafine group) and group b (butenafine group) respectively and 4:1 in the whole study patients. as regards to the incidence of tinea cruris, a number of other studies found male predominance (11−14), which closely resembles with the findings of the present study. table iv: comparison of adverse effects among the treatment groups side effect group a (n=25) number (%) group b (n=25) number (%) p value burning yes 01 (4.0) 0 (0.0) 0.500ns no 24 (96.0) 25 (100.0) ns= not significant january 2021j enam med col vol 11 no 1 45 it was observed in this study that, the mean clinical assessment scoring with sd in group a (terbinafine group) and group b (butenafine group) were 8.92 ± 0.6 and 8.84±0.8 respectively at baseline before initiation of treatment. the difference between the mean score of two groups is not significant (p=0.690). the mean clinical assessment scoring with sd in group a (terbinafine group) and group b (butenafine group) were 5.72±0.7 and 4.12±0.7 respectively after 1 week of treatment. the difference between the mean score of the two groups was significant (p=0.001). the mean clinical assessment scoring with sd in group a (terbinafine group) and group b (butenafine group) were 3.04±0.5 and 1.44±0.9 respectively after 2 weeks of treatment. the difference between the mean score of the two groups was significant (p=0.001). ramam et al9 observed in the butenafine group, the clinical score declined from a mean of 7.36 at baseline to 1.5±1.43 at week 2, 1.04±1.55 at week 4, 1.45±2.3 at week 6 and 1.5±2.3 at week 8. the reduction in the sign and symptom score from baseline at 4 weeks post-treatment follow-up in the butenafine treated group was 81.5%.9 similar findings were also reported by singal et al16 where they showed that mean clinical assessment score declined from 6.65±1.29 at baseline to 1.00±0.62 at 2nd week, 0.56±0.51 at 4th week and 0.65±0.49 at the end of 8th week in the group treated with butenafine. one single study by das et al12 that compared these two drugs butenafine and terbinafine in the treatment of tinea cruris showed that at the end of 42 days, the overall cure rates were 79.49% in the regimen ii (butenafine) group and 62.16% in the regimen i (terbinafine) group. the effective treatment rates after 2 weeks of post-treatment follow-up was 92.31% in regimen ii (butenafine) and 81.08% in regimen i (terbinafine) study group which were all statistically significant (p<0.05). the study concluded that treatment with butenafine 1% cream was considered superior to treatment with terbinafine 1% cream in case of tinea cruris.12 in this study, it was observed that burning was found in 1(4.0%) case in group a (terbinafine group) and not found in group b (butenafine group). the difference was not statistically significant (p>0.05) between two groups. similar findings were also reported by a study of jerajani et al13, where only one patient using terbinafine 1% cream had complained of burning sensation on application. this could be attributed to the pharmacological property of any topical antifungal drug or hypersensitivity to the study drug, that could not be assessed as the patient was lost to follow-up.17 in conclusion, results of our present study revealed that there were significant difference between the mean clinical assessment score of the two groups at the end of 2 weeks treatment period. butenafine produced the quickest result and clinical efficacy was much higher with butenafine cream than that of terbinafine cream and this difference was statistically significant. therefore, treatment with butenafine 1% cream was reported superior to treatment with terbinafine 1% cream in case of tinea cruris. strength and limitations of the study although this study was important due to its unique nature of being the first study done in low-resource setting exploring the efficacy of butenafine 1% cream and terbinafine 1% cream in treatment of tinea cruris, its findings should be interpreted in light of some limitations. the first limitation was that the study population which was selected from one selected hospital of dhaka city, so that the results of the study might not reflect the exact picture of the whole country. moreover, the present study was conducted over a very short period of time on a small sample size which was also a limitation of the present study. therefore, in future further study may be under taken with large sample size and robust methodology. references 1. foster kw, ghannoum ma, elewski be. epidemiologic surveillance of cutaneous fungal infection in the united states from 1999 to 2002. journal of the american academy of dermatology 2004; 50(5): 748–752. 2. sadri mf, farnaghi f, danesh-pazhooh m, shokoohi a. the frequency of tinea pedis in patients with tinea cruris in tehran, iran. mycoses 2000; 43(1-2): 41–44. 3. yehia ma, el-ammawi ts, al-mazidi km, abu el-ela ma, al-ajmi hs. the spectrum of fungal january 2021j enam med col vol 11 no 1 46 infections with a special reference to dermatophytosis in the capital area of kuwait during 2000-2005: a retrospective analysis. mycopathologia 2010; 169(4): 241–246. 4. moodahadu-bangera ls, martis j, mittal r, krishnankutty b, kumar n, bellary s, et al. eberconazole--pharmacological and clinical review. indian j dermatol venereol leprol 2012; 78(2): 217– 222. 5. chang c-h, young-xu y, kurth t, orav je, chan ak. the safety of oral antifungal treatments for superficial dermatophytosis and onychomycosis: a meta-analysis. am j med 2007; 120(9): 791–798. 6. niewerth m, korting hc. the use of systemic antimycotics in dermatotherapy. eur j dermatol 2000; 10(2): 155–160. 7. ryder ns. terbinafine: mode of action and properties of the squalene epoxidase inhibition. br j dermatol 1992; 126 suppl 39: 2–7. 8. mcneely w, spencer cm. butenafine. drugs 1998; 55(3): 405–413. 9. ramam m, prasad hr, manchanda y, khaitan bk, banerjee u, mukhopadhyaya a et al. randomised controlled trial of topical butenafine in tinea cruris and tinea corporis. indian j dermatol venereol leprol 2003; 69(2): 154–158. 10. budimulja u, bramono k, urip ks, basuki s, widodo g, rapatz g et al. once daily treatment with terbinafine 1% cream (lamisil) for one week is effective in the treatment of tinea corporis and cruris. a placebo-controlled study. mycoses 2001; 44(7-8): 300–306. 11. choudhary s, bisati s, singh a, koley s. efficacy and safety of terbinafine hydrochloride 1% cream vs. sertaconazole nitrate 2% cream in tinea corporis and tinea cruris: a comparative therapeutic trial. indian j dermatol 2013; 58(6): 457–460. 12. das s, barbhuniya jn, biswas i, bhattacharya s, kundu pk. studies on comparison of the efficacy of terbinafine 1% cream and butenafine 1% cream for the treatment of tinea cruris. indian dermatol online j 2010; 1(1): 8–9. 13. jerajani hr, janaki c, kumar s, phiske m. comparative assessment of the efficacy and safety of sertaconazole (2%) cream versus terbinafine cream (1%) versus luliconazole (1%) cream in patients with dermatophytosis: a pilot study. indian j dermatol 2013; 58(1): 34–38. 14. rotta i, otuki mf, sanches ac, correr cj. efficacy of topical antifungal drugs in different dermatomycoses: a systematic review with meta-analysis. rev assoc med bras (1992). 2012; 58(3): 308–318. 15. kanwar a, mamta cj. superficial fungal infections in: valia rg valia ar (eds). iadvl textbook and atlas of dermatology. 2ndedn. mumbai: bhalani publishing house, 2001: 211–258. 16. singal a, pandhi d, agrawal s, das s. comparative efficacy of topical 1% butenafine and 1% clotrimazole in tinea cruris and tinea corporis: a randomized, double-blind trial. j dermatolog treat 2005; 16(5-6): 331–335. 17. torres j, márquez m, camps f. sertaconazole in the treatment of mycoses: from dermatology to gynecology. int j gynaecol obstet 2000; 71(1): 3–20. journal of enam medical college vol 11 no 1 january 2021 10 original article comparison of blood homocysteine levels between women with recurrent pregnancy loss and women with normal fertility mossammat nigar sultana1, shamima rahman2, julia akhtar nira3, parveen fatima4 received: 11 january 2020 accepted: 19 june 2020 doi: https://doi.org/10.3329/jemc.v11i1.63168 1. assistant professor, department of gynaecology and obstetrics, mugda medical college & hospital, dhaka 2. assistant professor, department of gynaecology and obstetrics, col. malek medical college, manikganj 3. graded specialist, reproductive endocrinology & infertility, combined military hospital, dhaka cantonment, dhaka 4. professor of infertility, bangabandhu sheikh mujib medical university, shahbag, dhaka correspondence mossammat nigar sultana, email: m.nigar.sultana@hotmail.com abstract background: recurrent early pregnancy loss is a common but frequently unexplained obstetric problem. as it happens in early weeks of pregnancy, abnormal vasculogenesis and disordered cell multiplication are possible causes. hyperhomocysteinemia is associated with both these pathological processes. objective: to assess the association between hyperhomocysteinemia and recurrent pregnancy loss. materials and methods: this case-control observational study was conducted in the department of gynaecology and obstetrics of bangabandhu sheikh mujib medical university, dhaka during january to december 2015. sixty patients were divided into two groups: 30 with recurrent pregnancy loss (rpl) as cases and 30 normal healthy mothers as controls. results: all the subjects were matched in terms of age (p = 0.504). all were within normal bmi range (19.5 to 25 kg/square meter). subjects in both groups were comparable in height, weight and bmi. 33.3% women of control group were in the low income stratum (monthly income 20000 taka or less) compared to50% of the rpl group. control group had an equal mix of educational level from below secondary school to post-graduates whereas there were fewer post graduate patients (3.3%) in the rpl group compared to control group (23.3%). the frequency of hyperhomocysteinemia (>15 micromoles/l) was significantly higher in cases compared to controls (46.7 vs.16.7%, p= 0.012). mean homocysteine level was also significantly higher in cases compared to controls (13.67+/-4.80 vs. 9.87+/-4.84 micromole/l; p= 0.003). conclusion: this study shows that blood homocysteine level in recurrent pregnancy loss patients is significantly higher compared to normal fertile mothers. there is a strong association between hyperhomocysteinemia and rpl. key words: recurrent early pregnancy loss; hyperhomocysteinemia; fertility j enam med col 2021; 11(1): 10−17 introduction hyperhomocysteinemia has been identified as an emerging risk factor for several diseases of diverse systems such as vascular thrombosis, adverse pregnancy outcome, congenital malformations, vascular dementia; its role in unexplained infertility and recurrent early pregnancy loss is currently a focal point of research, owing to its association with ivf failures. homocysteine (hcy) is a sulfhydryl containing amino acid which does not occur in natural proteins, but january 2021j enam med col vol 11 no 1 11 rather is a de-methylated derivative of methionine and also occurs as an intermediary product in the metabolism of other amino acids such as glycine, cysteine, cystathionine, serine, glutathione etc. however, normally the homocysteine thus formed is only a transient product, going to produce cysteine (an important amino acid required for protein synthesis) or glutathione (an important anti-oxidant in cells) or being re-methylated into methionine, effectively recycling the homocysteine. impaired function of these metabolic pathways leads to accumulation of homocysteine, either by insufficient trans-sulfuration or by an impairment of re-methylation.1 elevation in intracellular homocysteine concentration with a corresponding increase in blood levels can result from either genetic defects in the enzymes involved in its metabolism or nutritional deficiency of vitamin cofactors.2 in atherosclerotic vascular disease models, homocysteine has been shown to a) induce vascular inflammation by enhanced expression of proinflammatory cytokines;3 b) reduce endotheliumdependent vasodilatation by accelerated inactivation of no (nitric oxide)/eno (endothelial no) or by increased serum di-methyl-arginine formation;4 c) increase endothelial oxidative stress by auto-oxidation by the highly reactive thiol group, formation of intracellular superoxides and peroxyl radicals, and reduced cellular anti-oxidants (superoxide dismutase and glutathione peroxidase)3 and d) alter cellular redox potential and interfere with disulfide bond formation in endoplasmic reticulum (er), causing unfolded or misfolded proteins to accumulate in er, which then activate the so called unfolded protein reaction (upr) leading to subsequent growth arrest and apoptosis.5 no is involved in almost every step of female reproduction, i.e., ovulation, early embryonic cleavage, implantation, regulation of circulatory dynamics, uterine quiescence, etc. physiological no concentration has a very narrow range and either an excess or a lack of no adversely affects reproductive outcomes. similarly, oxidative stress and apoptosis play a role in events such as follicular development and cyclical endometrial change.6 traditionally recurrent early pregnancy loss (rpl) has been defined as three or more spontaneous pregnancy losses before 20 weeks of gestation (age of viability). the practice committee of the american society of reproductive medicine (asrm) defines rpl as “ a disease distinct from infertility, defined by two or more failed pregnancies.” in young women, 15 to 20% of clinically recognized and more than 50% of all pregnancies undergoes spontaneous loss. these figures increase substantially with maternal age to as high as 40% and 85% respectively in women 40 years and older. the chance of having two consecutive losses is 5% with 1% of couples experiencing three consecutive miscarriages.7 in efforts to minimize otherwise preventable pregnancy loss, most clinicians favor diagnosing rpl after two consecutive losses, but it is important to note that many of the potential etiologies of rpl are not absolute, so occurrence of interval live births does not preclude a diagnosis of rpl.8 a large amount of scientific work has been done to investigate the role of hyperhomocysteinemia in malformations and pathogenesis of ongoing pregnancy, while data and observations are only emerging now regarding a possible involvement of this biochemical phenomenon in the early stages of reproduction and related diseases. there is a significant negative correlation between follicular fluid homocysteine concentration and the degree of maturity of retrieved oocytes as well as embryo quality on day 3 in patients undergoing ivf.9 ivf outcomes in terms of pregnancy rate (defined as usg detected fetus at 7 weeks of ivf), implantation rate (number of gestational sacs per 100 embryo-transfers) were reduced and abortion rate (between usg detected pregnancy and 20 completed weeks of gestational age) were significantly increased in women with hyperhomocysteinemia compared to those in whom interventions were instituted to reduce blood homocysteine levels.10 studies also found that folate, cobalamin and thcy levels in monofollicular fluid are related to embryo quality in women undergoing ivf/icsi.11 review of the evidence on the effects of hyperhomocysteinemia on reproductive outcome show that while there are evidence that maternal hyperhomocysteinemia is a risk factor for recurrent january 2021j enam med col vol 11 no 1 12 embryo loss and even a first early pregnancy loss, evidence also indicate that genetic polymorphism due to mutation in mthfr enzyme causing high homocysteine concentration from abnormal folate metabolism increased risk of repl.12 possible mechanisms of the deleterious effects of hyperhomocysteinemia on female reproduction include reduced cell division (e.g., of oogonia or of granulose cells), increased oxidative stress, apoptosis, reduced extra-embryonic vasculogenesis, etc.13 there has been a growing awareness about reproductive failure with the advent of reproductive techniques and services in bangladesh recently. the investigation of recurrent pregnancy loss includes laboratory, imaging, invasive and genetic analysis. despite all these work-up, the cause of a significant portion of cases of reproductive failures such as recurrent early pregnancy loss remains unknown. such unexplained cases merit exploration for other uncommon causes. there are reports of 2 to 3-fold higher concentration of homocysteine among such patients, both in western as well as sub continental countries.14,15 hyperhomocysteinemia merits consideration in such cases. because hyperhomocysteinemia is easily detected and is amenable to easy intervention by vitamin supplementation in a majority (i.e., two-thirds) of cases, exploring its relation to and contribution towards recurrent early pregnancy loss are important. the present study explores the blood levels of homocysteine in women with recurrent early pregnancy loss without an obvious cause compared to women with normal fertility. materials and methods this was a case-control observational study, conducted from january 2015 to december 2015. the study population consisted of women of reproductive age attending the outdoor and indoor department of obstetrics and gynecology at bangabandhu sheikh mujib medical university with women having normal fertility (as controls), unexplained recurrent pregnancy loss (as cases). the approval of the local ethical committee was taken. the aims, objectives, procedures of collecting samples, risks (if any) and benefits were explained to study subjects in very easily understandable local language. participation of subjects was strictly on voluntary basis, on the basis of informed consent. subjects were assured that all records would be kept confidential. it was explained to them that the study would help both physicians and patients by finding out scientific facts that will help in making rational treatment choices regarding the management of patients. a purposive sampling method was used. all subjects were selected by history, examination as well as appropriate diagnostic workup. inclusion criteria: a. married women aged 20 to 40 years, and bmi between 19 and 25. b. control group: healthy women with one or more successful pregnancy without any obstetrical complications (e.g., intrauterine growth restriction, preeclampsia, abortion and mr) and never required assisted reproduction, c. cases: women who, despite conception, have had two or more pregnancy losses before 20 weeks of gestation and diagnosed as unexplained after i) anatomic evaluation of by tas, tvs and hsg and/ or hysteroscopy with laparoscopy reveal normal uterine cavity and absence of polycystic ovaries, ii) endocrine assessment by basal fsh, lh, estradiol, tsh, prolactin and fasting blood glucose were normal, iii) evaluation of immunological factors antinuclear antibody (ana), anti-dna antibody, antiphospholipid antibody, anticardiolipin antibody, iv) karyotyping of both partners were normal and v) normal semen analysis of husband. exclusion criteria: a. women aged <20 or >40 years, bmi <19 or >25 kg/m2 b. women with recurrent pregnancy loss due to identifiable causes c. women having other significant medical disorder (chronic cardiac, renal, hepatic or pulmonary disorders requiring chronic medications). d. women who have received folate, vitamin b6 and b12 supplementation within last three months. january 2021j enam med col vol 11 no 1 13 operational definitions for the purpose of this study: 1. recurrent early pregnancy loss: two consecutive or more involuntary termination of pregnancy before twenty weeks of gestation (dated from the last menstrual period). 2. hyperhomocysteinemia: defined as a fasting serum homocysteine concentration of more than 15 micromole/l. 3. reproductive age group: 15−49 years samples were identified and data were collected on a structured data collection sheet and divided into controls and cases according to the inclusion and exclusion criteria. all data were collected by interview, physical and laboratory examination of blood samples and recorded in the data collection sheet. after editing and coding, coded data was entered into computer database of the statistical package for the social sciences (spss) software (spss inc., chicago, illinois, usa) version 22 and data organizing and final analysis were performed on the above software. categorical data was presented as frequency and percentage, and continuous variables were expressed as mean and standard deviation. the chi-squared test was used to analyze and compare discrete variable and students t test where appropriate. the statistical significance (p) threshold was set to ≤0.05 (twotailed). results results of comparison of sixty women, 30 in control group (women with normal fertility) and 30 in the unexplained recurrent early pregnancy loss group are presented in the following tables. all the subjects matched in terms of age group categories. the mean ages of all the groups were comparable, with no statistically significant difference. the subjects in the groups were well-matched in terms of height, weight and bmi. the women included in the study were within the normal bmi range (from 19.5 to 25.0 kg/m2) with no statistical difference between group means among the pre-specified groups. this excluded any role of height or low body weight contributing to the incidence of cases among these subjects. analysis of the socio-economic status in terms of monthly income showed that there were more patients in the lowest stratum of monthly income among those with recurrent early pregnancy loss; however, overall there was no statistically significant difference between the groups in terms of monthly income level. since the study was conducted in a hospital setting accessible to patients of even low income status, subjects included in the study represented mostly low and middle income family background. the subjects in the control group had an equal mix of educational levels from below secondary school certificate to post-graduate levels whereas there were very low post-graduate patients in the recurrent early pregnancy loss group commensurate with their socioeconomic status in terms of monthly income (table ii); however, difference in the frequency of various educational achievements between the groups did not reach statistical significance. the distribution of various occupations between the study groups did not show any significant difference table i: comparison of biological variables between controls (women with normal fertility) and cases (women with recurrent early pregnancy loss) (n=60) variables controls (n=30) cases (n=30) p values age (years) 28.90±5.09 28.0±5.27 0.504ns height (cm) 156.17±6.92 153.20±7.14 0.108ns weight (kg) 56.73±6.78 56.37±5.77 0.822 ns bmi (kg/m2) 23.26±1.55 23.75±1.38 0.204 ns data are presented as mean ± sd. student’s t test was used to compare the variables between the groups. n=number of study population; n=number in each group; s= significant; ns=not significant; sd=standard deviation january 2021j enam med col vol 11 no 1 14 table ii: comparison of socioeconomic status by monthly income of the subjects between two groups (n=60) variables controls (n=30) cases (n=30) p values monthly income taka < 1000 1 (3.3%) 7 (23.3%) 0.072ns taka 10000−20000 9 (30.0%) 8 (26.7%) taka >20000 20 (66.7%) 15 (50.0%) educational status below ssc ssc hsc graduates postgraduates 7 (23.3%) 6 (20.0%) 4 (13.3%) 6 (20.0%) 7 (23.3%) 9 (30.0%) 4 (13.3%) 3 (10.0%) 13 43.3%) 1 (3.3%) 0.096ns occupations housewives students services doctors nurses day labors 14 (46.7%) 0 (0.0%) 12 (40.0%) 1 (3.3%) 2 (6.7%) 1 (3.3%) 14 (46.7%) 4 (13.3%) 10 (33.3%) 1 (3.3%) 1 (3.3%) 0 (0.0%) 0.356ns chi-square test was used to compare between two groups. n=number of study population; n=number in each group; s= significant; ns=not significant table iii: comparison of marital and obstetric history between two groups (n=60) variables controls (n=30) cases (n=30) p values marital history marital period (years) 7.88±3.54 7.94±4.40 0.960ns coital frequency per week 3.63±0.76 3.40±0.81 0.257ns obstetric history abortion 0 (0%) 30 (100.0%) <0.001s ectopic pregnancy 0 (0%) 1 (3.3%) 0.313ns mr 0 (0%) 3 (10.0%) 0.076ns parity (mean±sd) 1.50±0.63 0.47±0.73 <0.001s continuous variables are presented as mean±sd and categorical variables are presented as number and percentage. student’s t test was used to compare continuous variables and chi-square test for frequency data. n=number of study population; n=number in each group; s= significant; ns=not significant; sd=standard deviation table iv: comparison of the frequency of hyperhomocysteinemia between two groups (n=60) homocysteine level controls (n=30) cases (n=30) p values < 15 μmol/l > 15 μmol/l 25 (83.3%) 5 (16.7%) 16 (53.3%) 14 (46.7%) 0.012s mean, sd μmol/l 9.87±4.84 13.67±4.80 0.003s frequency data are presented as number and percentage while continuous variables were presented as mean and standard deviation. statistical analysis was done by chi-square test. n=number of study population; n=number in each group; s= significant; ns=not significant; sd=standard deviation january 2021j enam med col vol 11 no 1 15 based on the institutional cut-off value of 15 micromoles/l for serum fasting homocysteine level, the frequency of hyperhomocysteinemia was found in significantly higher number of patients in the recurrent early pregnancy loss group compared to the control group. comparison of serum fasting homocysteine levels among the two study groups showed that patients and the recurrent early pregnancy loss group had significantly higher levels compared to the control group of women. discussion the results of the present study showed that the frequency of hyperhomocysteinemia defined as fasting serum homocysteine levels >15micromole/l (table iv) are significantly higher in the repl group (46.7% p = 0.012 for difference from controls) compared to control group (16.7%). furthermore, the fasting serum homocysteine levels (table iv) in study women with unexplained recurrent early pregnancy loss (mean 13.67 ± sd 4.80 micromoles/l) were significantly higher compared to those in study control women with normal fertility (mean 9.87 ± sd 4.84 micromoles/l). the findings of this study are consistent with results from previous studies in europe as well as the subcontinent. the association of hyperhomocysteinemia with adverse pregnancy outcomes, including recurrent pregnancy loss has been in evidence in several previous studies. furthermore, while considerable bodies of evidence are available from studies in the assisted reproductive background, epidemiological evidence is rare. the findings of comparable levels of serum homocysteine in the recurrent (early) pregnancy loss groups in all these studies – upheld by the findings of the present study – also strengthens the association of hyperhomocysteinemia with unexplained adverse pregnancy outcomes. as has been already mentioned, a link between hyperhomocysteinemia and adverse pregnancy outcomes have been demonstrated in various previous studies, most notably the large epidemiological hordaland homocysteine study.16 data available from 5883 women with hyperhomocysteinemia in the age group 40−42 years with over 14,000 pregnancies showed increased incidence of stillbirths and placental abruptions among other adverse pregnancy outcomes. in china, a pilot study exploring the nutritional background of 30 women with an embryonic gestations with absent fetal poles showed higher homocysteine levels compared to 30 controls with a normal healthy delivery.17 a retrospective casecontrol study of 200 women in each group found that while mthf 677 t/t (homozygous genotype) was associated with increased chances of recurrent early and late pregnancy losses as well as similar elevations of serum homocysteine among cases and controls, regression analysis did not reveal any association between hyperhomocysteinemia (defined as serum homocysteine level >15micr-moles/l) and recurrent pregnancy loses.18 it may be argued that in both studies the presence of other stronger adverse modulators of fertility and pregnancy outcomes have predominated and confounded the effects of hyperhomocysteinemia. for example, it is postulated that the association of mthfr 677 t/t homozygous genotype and vitamin b6 status with recurrent early pregnancy loss, independently of hyperhomocysteinemia, was due to interference with red blood cell folate metabolism. in the present study confounding variables were avoided by matching the cases for age and bmi. however, the study included far smaller sample size than the number suggested by the sample size calculation. furthermore, since all women with history of recent intake of vitamin folic acid, b6 and b12 supplementation were excluded and no attempts were made to assess their vitamin status, the effects of statistically. subjects from all social strata were included in the study, owing to the fact that the place of study is an institution accessible to a wide section of the population of the country. all the subjects included in both the study groups, had similar duration of marriage and had a healthy marital life in terms of their coital frequencies. this pattern reflects regular marital habits. history of previous menstrual regulation procedures were seen in 10% of the subjects with recurrent early pregnancy loss and none in the control group, giving rise to a statistically significant difference among the groups in terms of obstetric history. january 2021j enam med col vol 11 no 1 16 serum homocysteine on pre-eclampsia and eclampsia, the healthy control population of 136 women at late middle to late pregnancy (gestational age of mean 30.80 ±sd 4.03 weeks) had a fasting homocysteine level of 6.86±2.47 micromoles/l, which is considerably low compared to the control group in the present study (9.87±4.84 micromoles/l). likewise, the 84 pre-eclampsia patients (with homocysteine level of mean 9.54±sd 3.21 micromole/l) and 120 eclampsia patients (homocysteine level 10.57±3.39 micromole/l) had considerably lower levels of homocysteine compared to the cases in the current study (table iv). however, their difference can be explained by the fact that serum homocysteine level decreases during pregnancy, especially in the later parts.19 das et al20 found a serum homocysteine level in a control group without coronary artery disease was mean 9.66±sd 3.54 micromole/l, which was comparable to finding in the present study (9.87±4.84 micro-mole/l). in a large population based cohort, gamble et al21 on prevalence of folate and cobalamin deficiency and incidence of hyperhomocysteinemia in bangladesh, in 973 women, the plasma homocysteine was found to be mean 9.5±4.7 micromole/l, also comparable to the level found in controls in the current study, showing that the subjects were representatives of the women in bangladesh. in a limited sample of women with recurrent early pregnancy loss mean serum fasting homocysteine levels and hyperhomocysteinemia were increased compared 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���@������6� #,a@36$� � � �� ��� ���� ,a@������ 6@���������� ����� ������� ����2���>�� ���<����%((0/�1#0$���9)9*�991� )( !�"����2���>����:���9��,��� !�������%(�9 article05 [converted].eps abstract background: retained placenta is one of the causes of post-partum hemorrhage in bangladesh as it is worldwide. if a retained placenta is left untreated, there is a high risk of maternal morbidity and mortality and it has inherent risks of infection and hemorrhage. manual removal of placenta which is the recommended treatment of retained placenta usually requires regional or general anesthesia. intraumbilical injection of saline solution with oxytocin might represent an important option for management of retained placenta. objectives: the aim of this study was to assess the effect of intraumbilical vein oxytocin in the management of retained placenta and to compare it to the risk of manual removal of placenta. materials and methods: this experimental study was conducted in the department of obstetrics and gynecology in dhaka medical college & hospital during july to december 2004. total 50 patients with retained placenta were included in this study. the patients were divided purposively randomly into two groups ---groups a and b. twenty patients in group a were managed by intraumbilical vein injection of 10 units of oxytocin in 20 ml of normal saline slowly and 30 patients in group b were managed by manual removal of placenta. results: among the patients of group a, 16 (80%) delivered placenta spontaneously with expulsion time of 7--12 minutes. remaining 4 patients (20%) required manual removal of placenta even after intraumbilical vein injection of oxytocin. group a patients had less complications, required less blood transfusion, less antibiotics and less hospital stay compared to group b patients. conclusion: intraumbilical vein administration of oxytocin is superior to manual removal in the management of retained placenta. key words: oxytocin; intraumbilical vein; retained placenta j enam med col 2014; 4(2): 102--105 placenta is said to be retained when it is not expelled out even 30 minutes after birth of the baby.1 retained placental tissue and membrane causes 5--10% of post-partum hemorrhage (pph).2 worldwide, pph remains one of the most common causes of maternal mortality. if a retained placenta is left untreated, there is a high risk of maternal death. manual removal of placenta which is the recommended treatment also carries other risks such as immediate trauma to uterus, hemorrhage and an increased incidence of puerperal infection.3,4 retained placenta is potentially life-threatening not only because of retention but also because of associated hemorrhage and infection as well as complications related to its removal.4 there are now introduction 102 effect of oxytocin injection into umbilical vein for management of retained placenta 1. assistant professor, department of obstetrics and gynecology, enam medical college & hospital, savar, dhaka 2. professor, department of obstetrics and gynecology, ad-din medical college & hospital, dhaka 3. professor, department of obstetrics and gynecology, enam medical college & hospital, savar, dhaka 4. professor, department of obstetrics and gynecology, enam medical college & hospital, savar, dhaka correspondence lima shompa, email: lshompa@gmail.com original article lima shompa1, sayeba akhter2, khadija nazneen3, monnujan begum4 received: december 11, 2013 accepted: april 12, 2014 journal of enam medical college vol 4 no 2 may 2014 evidences that manual removal of placenta may be a risk factor for infection3, post-partum endometritis and risk of increased bleeding by interfering with normal mechanism of placental separation.2 routine administration of oxytocin during the third stage hastens placental separation, reduces blood loss of delivery and decreases the chance of pph by 40%.2 oxytocin is the first line agent because of the paucity of side effects compared with all other available agents.5 umbilical vein injection of saline solution with oxytocin might represent an important option for management of retained placenta. this relatively simple and affordable technique could be used either for first response before proceeding to manual removal if necessary or as the only response where manual removal is not feasible.6 this procedure facilitates high concentration of oxytocin to the placental bed and uterine wall, resulting in uterine contraction and placental separation.7 intraumbilical vein injection (iuv) is inexpensive, non-surgical, non-aggressive, cheap and pharmacological method which may be included in the treatment of retained placenta before going to manual lysis of placenta.8 regarding retained placenta, findings from international studies and clinical researches showed that appropriate and adequate management during emergency can reduce the mortality and long term complications. as there are very few numbers of studies done on retained placenta in bangladesh, we designed this experimental study to assess the effect of intraumbilical vein oxytocin in the management of retained placenta and to compare it to the risk of manual removal of placenta. materials and methods this experimental study was conducted in labor ward in the department of obstetrics and gynecology in dhaka medical college hospital (dmch), dhaka during the period july to december, 2004. patients who had undergone vaginal delivery and failed to deliver placenta within 30 minutes of delivery of the baby and admitted with retained placenta irrespective of whether active management policy was followed or not were included. patients having comorbidities along with retained placenta, having partial separation, morbid adhesion and retention of placenta for more than 24 hours, who presented with chorioamnionitis, complicated 1st and 2nd stage of labor and with abruption placenta were excluded. study subjects were purposively randomly divided into two groups. group a included 20 patients who were given intraumbilical vein oxytocin and group b included 30 patients who were managed with planned manual removal of placenta. a solution of 10 ml oxytocin diluted in 20 ml normal saline (0.9% sodium chloride) was injected into the umbilical vein in all patients of group a after the umbilical cord was clamped distally. the umbilical vein injection was given over a period of 30 minutes and traction was avoided until there was evidence of placental separation.9 suprapubic pressure was applied while observing for evidence of placental separation. no other intervention was performed to cause placental separation until at least 15 minutes after administration of oxytocin. after expulsion of the placenta oxytocin was administered as indicated. comparison between the groups was done by chisquare test using the spss version 16.0. p values <0.05 were considered significant. results total 8501 obstetric patients were admitted during the study period. among them, number of patients having retained placenta was 175 (2.05%). out of 50 study subjects 32 (64%) patients presented at 38 weeks of pregnancy and 15 (30%) patients at 39 weeks. majority of the patients (38, 76%) delivered babies at home. only 8 (16%) patients delivered in dmch. delivery was conducted by dai or relatives in majority patients (38, 76%). about 62% patients were admitted with features of shock and 12 (24%) had pph without shock. after administration of intraumbilical vein injection (iuv) of oxytocin in patients of group a, placenta was delivered in 16 (80%) cases. four (20%) cases required manual removal of placenta. group b patients (30, 100%) were managed with planned manual removal of placenta. table i shows that in group a, 5 (25%) patients required one unit of blood transfusion, 4 (20%) required two units, 4 (20%) three units and 7 (35%) 103 j enam med col vol 4 no 2 may 2014 patients did not require blood transfusion. in group b, 6 (20%) patients needed 4 units of blood transfusion, 8 (26.66%) needed 3 units, 10 (33.3%) required two units, 4 (13.33%) required one unit and 2 (6.6%) required no blood transfusion. table i: units of blood transfusion per patient units group a group b χ2 value p value (n=20) (n=30) number (%) number (%) 0 7 (35) 2 (6.6) 1 5 (25) 4 (13.3) 2 4 (20) 10 (33.3) 11.24 0.024 3 4 (20) 8 (26.66) 4 0 (0) 6 (20) table ii shows that in group a, duration of staying in hospital was <1 day in 16 (80%) patients and 2-4 days in 4 (20%) cases. in group b, 8 (26.66%) patients stayed in the hospital <1 day, 20 (66.66%) for 2-4 days and 2 (6.66%) patients for 5--7 days. the duration of hospital stay was significantly less (p=0.001) in oxytocin group. table ii: length of hospital stay duration group a group b χ2 value p value (n=20) (n=30) number (%) number (%) <1day 16 (80) 8 (26.66) 2--4 days 4 (20) 20 (66.66) 13.9 0.001 5--7 days 0 (0) 2 (6.66) table iii shows that in group a, 16 (80%) cases required no anesthesia or analgesia, 2 (10%) required general anesthesia and 2 (10%) needed sedative with analgesia. in group b, 20 (66.66%) patients required general anesthesia and 10 (33.33%) cases required sedative with analgesia. table iii: types of anesthesia and/or analgesia used during removal of retained placenta group a group b χ2 value p value (n=20) (n=30) types number (%) number (%) sedative with 2 (10) 10 (33.33) analgesia general anesthesia 2 (10) 20 (66.66) 35.5 0.000 no anesthesia or 16 (80) 0 (0) analgesia table iv shows the frequency and types of complications at or after removal of placenta. in group a, 2 (10%) cases developed pph and 18 (90%) cases had no complications. in group b, 6 (20%) cases developed pph, and 4 (13.33%) cases developed sepsis or endometritis. table iv: frequency of complications at or after removal of retained placenta group a group b χ2 value p value (n=20) (n=30) complications number (%) number (%) pph 2 (10) 6 (20) sepsis or 0 (0) 4 (13.33) 4.28 0.118 endometritis no complications 18 (90) 20 (66.66) table v shows the use of antibiotics in study subjects. in group a, 16 (80%) patients required double antibiotics and 4 (20%) cases required triple antibiotics. in group b, 3 (10%) cases needed double antibiotics and 27 (90%) cases required triple antibiotics. table v: frequency of use of antibiotics antibiotics group a group b χ2 value p value (n=20) (n=30) number (%) number (%) double 16 (80) 3 (10) antibiotics 24.95 0.000 triple 4 (20) 27 (90) antibiotics discussion this study showed that during the period from january to december 2004 the incidence of retained placenta was 2.05% of total obstetric admission in dmch. in a study by chhabra et al10 in kasturba hospital, delhi, it was found that incidence of retained placenta was 0.23% of all births over 15 years. in their study, out of four deaths two women delivered at nearby district hospital and were referred moribund and died. the policy option was that the properly conducted delivery can reduce the incidence of retained placenta and if removal occurs timely, appropriate care can save life. regarding management of retained placenta the present study can be compared with a number of 104 j enam med col vol 4 no 2 may 2014 studies. in this study, 16 (80%) patients of group a, who were managed by intraumbilical vein injection of 10 units oxytocin in 20 ml normal saline, delivered placenta spontaneously with an expulsion time of 7 to 12 minutes after injection and 4 (20%) patients required manual removal. study done by golan et al3 using the same methodology showed that expulsion of placenta occurred in all of their 10 cases a few minutes after intraumbilical injection. the average injection-expulsion time was 2--5 minutes. using the proposed method of oxytocin injection into the umbilical cord of retained placenta they were able to spare 80% of the patients. a study done in department of obstetrics and gynecology, liverpool women’s hospital, united kingdom revealed that women given an intraumbilical oxytocin injection had a significant increase in spontaneous expulsion of placenta within 45 minutes of delivery and fewer manual removal of placenta was needed. the result of their study suggested clinically important beneficial effect of intraumbilical oxytocin injection in the management of retained placenta.11 these findings are consistent with the present study. in this study, requirement of blood transfusion was less in oxytocin group. this finding correlates with study done by gajvani et al.11 a study done by das sr12 shows that 23.31% cases needed general anesthesia while removing the placenta manually. in the present study, only 2 (10%) patients in group a required general anesthesia whereas in group b, 20 (66.66%) patients required general anesthesia. patients of group b required exploration of uterus and had to stay longer in hospital than patients of group a. in this study complications at or after management of retained placenta with intraumbilical vein injection of oxytocin was less than the non-oxytocin group. among oxytocin group 18 (90%) cases had no complications and 2 (10%) cases developed pph. in non-oxytocin group eight patients developed fever and sepsis after manual removal of placenta. the complications were very less in oxytocin group which correlates with the findings of study done by golan et al.3 the present study reveals that intraumbilical oxytocin solution is superior to manual removal of placenta. as this study was done in a small number of patients, we recommend that community based study having adequate sample size should be carried out to find out further evidence of efficacy and feasibility of the method in low resource setting. references 1. dutta dc. complications of the third stage of labour. in: hiralal konar (ed). textbook of obstetrics. 6th edn. calcutta: new central book agency, 2004: 450–454. 2. poggi sbh, kapernick ps. postpartum hemorrhage and the abnormal puerperium. in: decherney ah, nathan l (eds). current obstetrics and gynecologic diagnosis & treatment. 9th edn. new york: mcgraw-hill, 2003: 531–552. 3. golan a, lidor al, wexlers david mp. a new method for the management of retained placenta. am j obstet gynecol 1983; 146: 708–709. 4. carroli g, bergel e. umbilical vein injection for management of retained placenta. cochrane database of systematic reviews 2001, issue 4. art. no. cd001337. doi: 10.1002/14651858.cd001337. 5. van dongen pw, van roosmalen j, de boer cn, van rooy j. oxytocics for the prevention of post-partum haemorrhages, a review. pharm weekbl sci 1991; 13: 238–243 6. purwar m. injection umbilical vein for management of retained placenta commentary (17 nov 2000) who reproductive health library no. 4, oxford update software. 7. neri a, goldman j, ganj b. intraumbilical vein injection of pitocin. a new method in the management of third stage of labour. harefuah 1966; 70: 351–353. 8. habeks d, hrgovic z, ivanisevic m, delmis j. treatment of retained placenta with intraumbilical injection. zentralbi-gynakol 2001; 123(7): 415–417. 9. david h, chestnut md. influence of umbilical vein administration of oxytocin on 3rd stage of labour: a randomized, double blind, placebo-controlled study. am j obstet gynecol 1987; 157(1):160–162. 10. chhabra s, dhorey m. retained placenta continues to be fatal but frequency can be reduced. journal of obstetrics and gynecology 2002; 22(6): 630–633. 11. gajvani mr, luckus mjm, drakeley aj, emery sj, alfirevic z, walkinshaw sa. intraumbilical vein injection for the management of retained placenta; a randomized controlled trial. obstet gynecol 1998; 203–207. 12. das sr. incidence and causes of retained placenta of admitted cases in ipd of dhaka medical college hospital. 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