Solid Pseudopapillary Neoplasm (SPN) of the Pancreas: A 7-year Study in A Tertiary Level Teaching Hospital in Bangladesh

Solid pseudopapillary neoplasm (SPN) of the pancreas, also referred to as Frantz's tumour, is a rare tumour and represents 1-3% of all pancreatic tumours, which typically affects young women without significant clinical symptoms. This cross-sectional study was done in the Department of Pathology, Bangabandhu Sheikh Mujib Medical Un iversity (BSMMU) between January 2009 and December 2015. A total of nineteen cases of solid pseudopapillary neoplasm (SPN) of pancreas were detected in patients and included in this study. In all the patients the diagnosis was confirmed by histopathology after the surgery. Tumours were nodular, cystic or solid-cystic, often encapsulated. Some of them were received as irregular fragmented pieces, as intact removal was not possible. Cut surfaces were partly grey-white and partly tan-brown with cystic degeneration. Areas of necrosis and hemorrhage were present in all the specimens.The age range was of 14-45 years (mean age 26.9±3.7 years) (Table-I). Among the tumours, 18 were found in female patients, while only 1 was from male patient. In all the cases, preoperative imaging contributed to diagnosis of an abdominal mass in the patients. 11 of these were reported as pancreatic mass, while 3 as pancreatic cystic mass, 2 as retroperitoneal mass, 2 as mesenteric mass and only 1 as adrenal mass. Tumour-size ranged from 6 to 19 cm (mean size 9.3±1.5 cm). 7 tumours were solid and cystic in nature, while 8 were solid and 4 were only cystic. Complete capsule was found in 17 specimens. Calcifications were found in only 5 specimens. Surgical resection was found generally curative. In our study, absence of metastasis suggests that these tumours hardly show aggressive clinical behaviour. However, follow-up is important to observe potential local recurrence and metastasis. CBMJ 2020 July: Vol. 09 No. 02 P: 34-38

Usage of telecommunication technology in perpetration of sexual assault- A study conducted on reported victims in a Tertiary Medical College Hospital OCC

The sexual assaults and its consequences are increasing along with socioeconomic development of the country. Rise of modern communication technology add fuel to the flame. This descriptive cross-sectional study aimed to evaluate the role of communication technology in sexual assaults in Bangladesh. There were 87 victims included in this study. All were female of 6 years to 40 years of age, mean age was 15.67 (± 6.69) year. Most of the victims were below 20 years of age and came from low income families. About 76% mobile used were smart phone. Among them 46% were owned by the victims herself, 26% gifted by the assailants to the victims. Talking through mobile (37%) was the main communication route between the assailants and the victims; followed by direct verbal (31%), mixed verbal and mobile talking (26%) and others (6%). Regarding methods of communication, they only talk in 42% cases and 36% cases used mixed method (talking, SMS and video chatting). The assailant paid all the costs in 62% cases. Mobile phone came as a blessing in communication, but inchoate use makes it a curse to our society. Parents should be cautious about their children's mobile usage (especially smart phone) daily. Government also should make some policy on using mobile technology by the younger citizens. CBMJ 2020 July: Vol. 09 No. 02 P: 03-07

Conversion of laparoscopic cholecystectomy to open cholecystectomy in a single center

Laparoscopic cholecystectomy (LC) has become the gold standard for the surgical treatment of gallbladder disease, but conversions to open cholecystectomy are still inevitable in certain cases. Knowledge about the rate and underlying reasons for conversion could help surgeons during preoperative assessment and improve the informed consent of patients. We decide to review the rate and causes of conversion of our LC series. This study included 320 consecutive laparoscopic cholecystectomies from January 2017 to December 2019 at Community Based Medical College Hospital Bangladesh, Mymensingh. All patients had surgery performed by same surgeon. Conversion to open cholecystectomy required in 15 (4.6%) patients. Out of 15 cases, the highest number of patients 10(66.6%) were in age group 50 to 59 years with a mean age of 60.1 years and standard deviation (SD) of 9.8 years. Of them 9 (60%) were male. The most common reasons for conversion of them were severe adhesions at calot's triangle 6 (40%) and acutely inflamed gallbladder 5 (33.3%), bleeding 2 (13%). No surgical procedures are complication free. The most common complication was superficial wound infection 8(2.5%). Delayed complications seen in our series is port site incisional hernia 2 (0.62%). Male gender, age older than 60 years, previous upper abdominal surgery, diabetes, and severity of inflammation were all significantly correlated with an increased conversion rate to laparotomy. LC is the preferred method even in difficult cases. This study emphasizes that although the rate of conversion to open surgery and complication rate are low in experienced hands, the surgeons should keep a low threshold for conversion to open surgery. CBMJ 2020 July: Vol. 09 No. 02 P: 14-18

Coinfection of Mycobacterial diseases

Although both mycobacterial infections are endemic in developing countries, the coinfection has hardly been reported in the last decade. The combined National TB & Leprosy Control Programme of Bangladesh came into effect in 1994. Though the Elimination of Leprosy (<1 case / 10,000 population) was achieved nationally in 1998, Bangladesh is still endemic for Tuberculosis. A 10 years cohort study was conducted in six districts of the Northern part of Bangladesh, covered by the Damien Foundation. This cohort consisted of a total of 4,788 leprosy cases registered from 2007 to 2016. Reviewing the records of all these cases, 25 (0.52%) patients were identified as having coinfection with Tuberculosis & Leprosy. All cases were coinfected with smear positive pulmonary TB. This study concludes that duel infection with mycobacteria is uncommon. Early diagnosis is very important for better outcomes of both diseases. CBMJ 2020 July: Vol. 09 No. 02 P: 39-41

Ethical Considerations in Conducting Paediatric Research

Health research is a moral duty because it is the foundation for evidence-based care by all health care practitioners. Hence, paediatric research is essential for improving health outcomes of children. Waiting for adult studies before conducting paediatric studies may prolong the denial of effective treatment for children. The CIOMS and other guidelines clearly allow research procedures that involve a low degree of risk. However, the critical need for pediatric research on drugs and biological products underscores the responsibility to ensure that children are enrolled in clinical research that is both scientifically necessary and ethically sound. Even in a resource poor setting of a developing country like Bangladesh, the things that should be taken under considerations are the status of children as a vulnerable population; the appropriate balance of risk and potential benefit in research; ethical considerations underlying study design, including clinical equipoise, placebo controls, and non-inferiority designs; the use of data; compensation; and parental permission and child assent where applicable to participate in research. Such ethical dilemmas are more evident in paediatric research especially when a collaborative research is done by a developed country in a developing country setting. It is the role of the health policy makers, and community of paediatric physicians, nurses, and caregivers to advocate not only for more research for children but also to ensure that the research conducted is of the highest quality from ethical viewpoint. CBMJ 2020 July: Vol. 09 No. 02 P: 54-58

Approach to the Diagnosis of Bleeding Disorders in Children

Hemostasis is the cessation of bleeding in the intravascular compartment. This occurs by the formation of clot formation at the site of injury. The intricately related system also regulates the size of the clots by the activation of fibrinolysis. The disorders that lead to the bleeding outside the intravascular space is bleeding disorder. Bleeding occurs as a result of defective quality or quantitative deficiencies of platelets, coagulation problems in the extrinsic or intrinsic or the common pathways and abnormalities in the vascular walls to contain hemorrhage. Although the values of different coagulation and fibrinlytic factors are pretty much like that of the adults yet, neonates have considerable differences in these values than their senior counterparts even in pediatric age groups. Considering all these facts the history, physical examination and laboratory investigations always provide the clinicians some important clues to reach the diagnosis. Because of the complicated relationship among the different pathways of coagulations and fibrinolytic systems the whole procedure might look complex yet methodical approach paves the way of an intelligent clinician to arrive at the diagnosis with precision and clinical perfection. CBMJ 2020 July: Vol. 09 No. 02 P: 45-53

The RAGE Trial (Radial Arterial Graft in the Elderly)- A Pilot Study

Use of radial artery (RA) as a second arterial conduit in Coronary Artery Bypass Grafting (CABG) is well established and appreciated for its higher long-term patency rate compared to vein grafts. This study tends to investigate if there are any detrimental consequences when it is used in elderly (aged 60 and above) population of Bangladesh. A total of 71 patients who received RA grafts at elective, isolated CABG operation were consecutively enrolled in this study from May 2018 to September 2019. 31 patients were in the Elderly group and 40 patients were in the Non-elderly group. The groups were compared for baseline characteristics and co-morbidities; preoperative techniques, findings, events and procedures; and postoperative outcomes or end-point variables inclusive of local complications related to RA harvesting wound. Elderly and Non-elderly groups had statistically different age (p=0.000) and Society of Thoracic Surgery (STS) Score predicted mortality (p=0.000). Operative techniques, events, findings and procedures were similar. Clinical outcomes were found to be similar with no statistical difference between the groups. Number of deaths also was not statistically different. There were no local complications related to RA harvesting wound in either of the two groups. Harvesting and grafting of radial artery in suitable patients, using meticulous "no-touch" technique and for ideal target coronary artery stenosis is as safe in the elderly patients as in the younger ones. CBMJ 2020 July: Vol. 09 No. 02 P: 08-13

A comparative study of oral Ketoconazole versus Itraconazole in the treatment of Tinea versicolor

Tinea (pityriasis) versicolor is a superficial fungal infection and one of the most commonly found pigmentary disorders of the skin caused by the yeast Malassezia. Multiple topical as well as systemic therapies are available for treatment. Systemic therapies are used for extensive disease, frequent relapse or where topical agents have failed. The aim that translates the rationale of the study was to compare the efficacy, safety, tolerability and cost effectiveness of oral ketoconazole dose 200mg daily for 7 days versus a single dose of 400 mg of itraconazole in the treatment of tinea versicolor. A total of 64 patients (aged 18-50 years) were selected for the study from the period of June 2019 to November 2019 in the Department of Dermatology and Venereology, Bangabandhu Sheikh Mujib Medical University, Bangladesh. Cases having extensive involvement were diagnosed clinically and confirmed by wood's lamp and KOH microscopy was taken. Patients were randomly allocated into equal groups. Group A was given oral ketoconazole dose 200mg daily for 7 days and Group B has given a single dose of 400 mg of itraconazole. 47 (73.4%) male and 17(26.6%) female were included in the study. The mean age of group A was 29.2(SD±8.6) and in group B 28.2(SD±8.5) years. The mean duration of the disease in group A was 3.9(±2.7) months and 3.5(±2.2) months in group B. In group A clinical responders was found cure 25(78.1%), improvement 5(15.6%) and failure in 2(6.2%) and in group B it was found cure 22(68.8%), improvement 7(21.87%) and failure 3(9.4%) at one month. At two months in the group A clinical responder was found to cure 22(68.8%), improvement 5(15.6%), failure in 3(9.4%) and relapse 2(6.2%). In group B it was found cure 18(56.2%), improvement 6(18.75%), failure 4(12.5%) and relapse 4(12.5%). Both oral ketoconazole dose 200mg daily for 7 days versus single dose 400 mg of itraconazole can be effective in the treatment of tinea versicolor with extensive involvement. CBMJ 2020 July: Vol. 09 No. 02 P: 26-33

"Micronutrient Deficiency", A public health problem

not available CBMJ 2020 July: Vol. 09 No. 02 P: 01-02

Frosted Branch Angiitis (FBA): A case report

The purpose of the study is to describe a rare case report for raising the awareness of existence of this rare ocular disease and also review the characteristics of this disease. A 35-year-old man presented with acute vision loss in both eye after high grade fever. On fundoscopic examination flower petal pattern blood vessel sheathing in temporal quadrant of both eyes was seen. A provisional diagnosis of frosted branch angiitis was considered. The patient responds promptly with Intravenous and oral corticosteroid. A total of 58 cases have been reported in worldwide literature. The disease is likely to represent a common immune pathway in response to multiple infective agents. CBMJ 2020 July: Vol. 09 No. 02 P: 42-44