CMH Dhaka Research Articles

Inflammatory Breast Cancer: Challenges and Opportunities in the Management

Background: Inflammatory Breast Cancer (IBC) is a rare and highly aggressive form of breast cancer characterized by rapid onset, inflammatory changes in the breast, and a poor prognosis. Its management requires a multidisciplinary approach due to its aggressive nature and diagnostic challenges. Objective: The objective of this study is to comprehensively evaluate the management of Inflammatory Breast Cancer at the Cancer Centre, CMH Dhaka, and Border Guard Bangladesh (BGB) Hospital in Dhaka, focusing on clinical presentation, diagnostic methods, treatment strategies, and patient outcomes. Methods: This prospective study included patients who presented with Inflammatory Breast Cancer at CMH, Dhaka and BGB Hospital Dhaka Cancer Centre over a specified period from June 2021 to June 2023. Results: The study revealed that IBC continues to pose significant diagnostic challenges, often leading to delayed treatment initiation. Among the studies, a total of N=13 patients were managed within the past two years, and the prognosis remained unfavorable. Even after receiving neoadjuvant chemotherapy, a patient passed away from the illness within half a year of being diagnosed. Physical examinations consistently identified signs of inflammation, with skin changes in 54% of cases and palpable masses in 85%. Hormone receptor status revealed 23% of patients with triple- negative breast cancer (TNBC), while 31% were HER2 positive. Molecular classification showed that 31% belonged to the Luminal type-A category, and 31% were HER2 positive. Conclusion: Inflammatory Breast Cancer management at CMH, Dhaka and BGB Hospital, Dhaka, underscores the critical need for early detection and a multidisciplinary approach. The aggressive nature of IBC, coupled with diagnostic uncertainties, highlights the importance of a high clinical suspicion. To improve patient outcomes, timely and comprehensive management by a multidisciplinary team is imperative. This study highlights the complexity of IBC and underscores the importance of early intervention and holistic patient care despite the challenges faced.

Evaluation of Keratoconus Patients Refractive Status Before and after Corneal Collagen Cross-linking

Background: Corneal Collagen Cross Linking (CXL) incorporated with riboflavin solution activated by UV (Ultraviolet) irradiation is a modern promising treatment protocol for keratoconus. Evaluation of the clinical effect of CXL treatment on keratoconus patients was the aim of this study. Methods: This Quasi Experimental (before-and-after) study was comprised with 50 patients, having progressive keratoconus (progression was documented by Corneal Topography), reported to Cornea Clinic, CMH Dhaka, from February 2022 to January 2023. Before and after the CXL procedure; un-corrected and best-corrected visual acuity of study population was documented using Snellen visual acuity chart. Auto-refractometry readings were also noted. Results: Among the 50 study subjects; 26 (52%) were men and 24 (48%) were female, age was 24.14 ± 5.07 (mean+SD) years and age range was 18-35 years. Mean preoperative spherical power was −1.84 ± 0.82 Diopter (D) and mean cylindrical power was −3.66 ± 0.97 D. Postoperatively, mean spherical power was found −1.15 ± 0.55 D and mean cylindrical power was −2.87 ± 0.99 D. After CXL treatment; significant vision improvement found in 15 (30%) patients (p<0.05). Conclusion: Despite strengthening the corneal stromal collagen bond and halting the keratoconus progression, CXL treatment stabilize the refractive status of keratoconus patient and also in some extent, it improves vision. Bangladesh Armed Forces Med J Vol 56 No (2) December 2023, pp 45-50

Clinical Features and Treatment Outcome of Pediatric Acute Promyelocytic Leukemia in Combined Military Hospital, Dhaka

Background: Acute promyelocytic leukemia (APML) is a relatively rare blood disease in children that is highly curable with current treatment strategies. It is a distinct type of AML characterized by chromosomal translocations involving the retinoid acid receptor (RAR-A) gene on chromosome 17. It accounts for 20-25% of all AML cases. The aim of this study was to describe the diagnostic features of pediatric APL and the result with ATRA and ATO based protocol. Methods: It was a descriptive type of cross-sectional study with purposively selected 10 newly diagnosed APML patients treated in the Pediatric Oncology unit of the Department of Pediatrics in CMH Dhaka during the period of 2018 to 2022. Diagnosis of all patients were done by aspirating bone marrow morphology and cytogenetic t(15:17) or t(11:17) transcript. Informed written consent was taken from parents. Data were collected by semi-structured questionnaire and analyzed by Statistical Package for Social Sciences (SPSS version 25). Results: Among 10 respondents median age was 4.2 years with female predominant (60%). Most common clinical presentations at diagnosis were fever (100%), bleeding manifestations (100%), Hepatomegaly (90%) bony tenderness (90%), splenomegaly (70%), and lymphadenopathy (70%). Almost all the patients had low Hb & low platelet count & WBC were variable. Cytogenetic analysis revealed 90% had PML/RARA positive & 30% had FLT3/ITD positive. All of these patients were treated with trans-retinoic acid (ATRA) based treatment, which led to 80% cases ATRA syndrome. Other common toxicities noticed febrile neutropenia (50%), severe headache (30%), hyperpigmented skin (10%), pseudotumor cerebri (10%) and others. There were 10% relapse cases, which later proceeded to relapse protocol and were in remission. The remaining 90% of patients were alive and in remission until the last day of follow-up. Conclusion: With ATRA-based treatment overall survival is good achieved remission and only 10% of patients developed relapse. Bangladesh Armed Forces Med J Vol 56 No (2) December 2023, pp 1-9

Breast Conserving Surgery (BCS) is Superior to Mastectomy in Early Stage Triple Negative Breast Cancer (TNBC) a Comparative Study

Background: Breast cancer is the most prevalent form of cancer in women worldwide and the second-leading cause of death from cancer in women. Because the estrogen receptor, progesterone receptor, and HER2 are not expressed, triple-negative breast cancer (TNBC) has an aggressive clinical history. The highest rates of recurrence and survival, higher average grades, and larger tumor sizes at diagnosis are all characteristics of TNBC. Objective: To compare between breast conserving surgery (BCS) and mastectomy patients with early stage Triple negative breast cancer (TNBC). Materials and Methods: We conducted a comparative retrospective monocentric study that evaluated TNBC patients treated with upfront surgery at CMH Dhaka, CMH Bogura and Kurmitola General Hospital, Dhaka. The observation period was from 1 January 2021 to 31 December 2022. All patients received biopsy to obtain the pathological tissue before treatment, and their immunohistochemical results met the diagnostic criteria for TNBC. Study patients divide din to two group 40 surgeries with primary site were categorized as receiving BCS and other hand 40 surgeries with categorized as receiving mastectomy. BCSS and OS were the primary outcomes of our study. Results: Tumor grade II, tumor size >20.0 mm and lymph node 2 were significantly associated with breast cancer-specific survival. Tumor size >20.0 mm and lymph node 2 were significantly associated with TNBC survival. Conclusion: TNBC is a breast cancer type that is aggressive and has a bad prognosis. With regard to breast cancer-specific survival, advanced age, being single, left side of laterality, tumor grades II and III, large tumor size, and lymph node 2 were all substantially related.

Risk Factors for Acute Ischaemic Stroke in Young Adults in Armed Forces Medical Institute of Dhaka

Background: Stroke is a leading cause of death and disability in developing countries, afflicting individuals at a young age. The affection of economically productive group adds further to the overall disease burden. The contribution of established vascular risk factors to ischaemic stroke in young adults has not been evaluated systematically in CMH, Dhaka Cantonment. The purpose of the study is to detect the risk factors for acute Ischaemic stroke in adults. Materials and methods: The case-control study was carried out in the department of Neurology and Medicine, CMH Dhaka during October 2019 to August 2020. Consecutive ischemic stroke patients who met the inclusion criteria and were hospitalized in the Department of Neurology and Medicine at CMH Dhaka were included in the study. Results: The mean age of young patients with ischaemic stroke was 40.1 (SD± 6.6) years (Range 17-45 years). There were 40 (59.7%) male and 27 (40.3%) female with ratio of male to female was 1.5:1. Risk of acute ischaemic stroke was 2.7 times higher in smoker [36 (53.7%) vs 20 (29.9%) OR=2.7, 95% of 01=1.34-5.55, p<0.01] 2.4 times higher in diabetic [23 (34.3%) vs 12 (17.9%), OR=2.4, 95% of 01=1.07-5.35, p<0.05], 2.6 times higher in hypertensive patients [27 (40.3%) vs 14 (20.9%), OR=2.6, 95% of 01=1.19-5.49; p<0.05], 4.2 times higher in patients with atrial fibrillation [11 (16.4%) vs 3 (4.5%)]. The mean BMI of the respondents was 21.8 (SD± 3.3) Kg/M2 in stroke patients of young and was 22.3 (SD 2.9) Kg/M2 in control group (p>0.05). Conclusion: Ischemic stroke in young patients has wider risk factors. Hypertension, diabetes mellitus, smoking and atrial fibrillation are the most common risk factors of acute ischemic stroke in young adults. Early identification of risk factors and proper prevention, treatment and life style modification may reduce the morbidity and mortality in young stroke patients. IAHS Medical Journal Vol 5(2), Dec 2022; 52-57

Bone Marrow Transplantation: Pre and after care

Worldwide, Hematopoietic stem cell transplantation is one of the curative options of treatment for hematological malignancies and other hematological diseases. In few recent years, in Bangladesh, Hematopoietic stem cell transplantation (HSCT) has started and improved significantly, especially in patients with hematological malignancies & nonmalignant hematological diseases. As one of the leading BMT Center, CMH Dhaka has started BMT 8 years ago with the successful case of Allogeneic Bone Marrow Transplantation (Allo-HSCT) which was first time in Bangladesh. It was a historic event and landmark achievements in the history of Medical Science of Bangladesh as Allo-HSCT Bone Marrow Transplantation comparatively have a higher risk of life-threatening complications than Auto-HSCT. Till date, Dhaka CMH BMT Center has successfully completed 65 Bone Marrow Transplantation (48 Auto- HSCT & 17 Allo-HSCT). It is an amazing milestone and advancement in medicine of Bangladesh. A series of tests (Like-Hematological profile, Extensive infection screening, Heart function test, Lung function test, Bone Marrow Study, Bone density scan, PET-scan, CT-scan, Chest X-ray, HLA Typing etc.) and procedures can assess general health and the status of patient‘s condition. The tests and procedures also ensure that patient is physically prepared for the transplant. The evaluation may take several days or more. In the days and weeks after bone marrow transplant, BMT specialists do blood tests and other tests to monitor patient‘s condition. They may need medicine to manage complications, such as nausea and diarrhea. After bone marrow transplant, the patient remains under close medical care. If a patient experiencing infections or other complications, he/ she may need to stay in the hospital for several days or longer for close monitoring. Patients may need periodic transfusions of red blood cells and platelets until bone marrow begins producing enough of those cells on its own. Patient needs follow up and Transplant Physician supervision till death. Bangladesh J Medicine 2023; Vol. 34, No. 2(1) Supplement: 191

Hearing and Visual Impairment in Children with Cerebral Palsy, A Study in Tertiary Level Hospital in Bangladesh

Background: Cerebral palsy (CP) is a diagnostic term used to describe a group of motor syndromes resulting from disorders of early brain development. CP remains unexplained in most cases and is typically diagnosed outside the neonatal period. Visual impairment decreases the quality of life and hearing impairment hampers linguistic development. This study aimed to observe the visual and hearing impairment of children with cerebral palsy associated with developmental disabilities. Material Methods: This is a cross-sectional observational descriptive study carried out in the department of Paediatric Neurology CMH Dhaka from March 2018 to February 2022. The participants (N=120) were from birth to 12 years of age. Detailed information was obtained in each case according to protocol. The pediatric neurologist based on the study definition crosschecked the diagnosis. The hearing assessment was done with the help of an Otolaryngologist in the department of Otolaryngology and the ophthalmological evaluation was done with the help of an ophthalmologist of the department of ophthalmology of CMH Dhaka. Hearing impairment, Ophthalmological motor disturbance, and developmental disabilities were correlated. A convenience sampling technique was used in this study. Relevant data were collected from hospital records. All the information was recorded in the fixed protocol. Collected data were classified, edited, coded, and entered into the computer for statistical analysis by using SPSS 2021. Results: In this study, among the 120 children with CP, the mean age of the study was 5.57(SD±3.89) age range of 2-12 years Males were 82(68%) and females were 38(32%), male-female ratio (sex M: F 2.15: 1). Spastic quadriplegia constitutes the predominant group 59(49%), followed by Spastic diplegia 21(18%), Spastic hemiplegia 20(17.5%), dyskinetic CP 09(8%), 7(6%) were mixed CP and 4(3%) were hypotonic CP. Hearing impairment was found in 87 (72%) cases and visual impairment was detected in 92(76%). Among them, the child with Spastic Quadriplegic (83%) and diplegic CP (62%) children had a hearing impairment. Regarding vision, no fix and follow were observed in 69(57%) cases. Among the studied CP child (n=120) 16 children (13.33%) had normal eye finding and 104 (86%) had abnormal eye findings. Refractive error (32.5%) and Squint (19%) were the most common ocular defect among studied patients. Other ocular defect were nystagmus(10%), optic atrophy(12.5%), microphthalmia(10%), corneal opacity(3%), optic hypoplasia(4.1%), cataract(2.5%), pigmentary retinopathy(5%), retro-lental fibroplasias(3.3%) and ptosis(2.5%). In children with hypotonic (athetoid) and mixed CP, almost all (11 of 11) children had visual impairment. Spastic quadriplegic CP children (80%) and Spastic diplegic CP children (90%) had one or more domains of visual impairment. Conclusion: Cerebral Palsy is a non-progressive various form of neurological disorder in children. Early visual screening and hearing assessment can help CP children to minimize mental retardation, learning difficulties, and speech delay.

Laparoscopic Intra Peritoneal Onlay Mesh Plus (IPOM Plus) repair of Ventral Hernias – Experience in a Tertiary Hospital

Introduction: Laparoscopic Ventral Hernia Repair (LVHR) was first described by Karl Leblanc in 1992 and has increasingly been gaining popularity in this present era of minimal access surgery. Laparoscopic Intraperitoneal Onlay Mesh (IPOM) repair with its modification intraoperative Onlay Mesh Plus (IPOM Plus) repair is now being well-accepted option for the treatment of ventral hernias. Objective: To assess the safety and efficacy of the laparoscopic IPOM plus modality in the management of ventral hernias. Methods: This is a descriptive observational study, carried out on 22 patients who underwent Laparoscopic ventral hernia repair by IPOM Plus technique between January 2017 to December 2018 at CMH Dhaka. Patients who had ventral hernia with a defect size> 2 cm but < 10 cm were included in this study. Primary subcutaneous transfascial suture closure of all ventral hernias with defect size >2 cm were done using prolene 1-0.Optimized composite mesh (ParietexTM) and Polymesh composite partially absorbable mesh were used as prosthesis anchored with four corner sutures and fixed with non absorbable tacking device. Follow up period was one year. Results: A total of 22 patients underwent Laparoscopic IPOM Plus repair of ventral hernias. Intraoperative and postoperative complications were negligible. No seroma, bulging of mesh, intestinal obstruction, mesh infection and recurrence observed in one year follow up time. But one patient developed de novo spigelian hernia on the right side outside the mesh system after one year. One patient (4.5%) developed post operative persisting pain requiring analgesic at 2 months. Conclusion:: Laparoscopic IPOM plus repair of ventral hernia is a safe, effective and well accepted modality. J Bangladesh Coll Phys Surg 2023; 41: 150-155

Complications in Laparoscopic Cholecystectomy: Experiences from A Study of 1425 Cases

Objective: To evaluate the complications of laparoscopic cholecystectomy in the symptomatic cholelithiasis and other benign gall bladder diseases. Methods: This descriptive observational study was carried out at CMH Dhaka and CMH Jashore from March 2016 to Jun 2022, to evaluate the frequency and outcome of management of all the complications in laparoscopic cholecystectomy. A total of 1425 patients of laparoscopic cholecystectomy were included in this study. Patients were followed up for a period of three months after operation. The complications in laparoscopic cholecystectomy observed in this study were divided into (i) Access related (ii) Intraoperative (biliary and extrabiliary) and (iii) Postoperative. Results: The incidence of access-related, intraoperative or procedure-related biliary, extrabiliary and postoperative complications were 3.64%, 2.95%, 4.98% and 1.96% respectively. Access related complications were extraperitoneal insufflations 1.40%, port site bleeding 1.19%, small bowel laceration 0.21% and transverse colon injury 0.07%.Procedural biliary complications included common bile duct (CBD) injury 0.14%, common hepatic duct (CHD) injury 0.07% and iatrogenic gall bladder perforation with bile leakage 2.74%. Procedural extrabiliary complications were Liver injury 0.56%, duodenal perforation 0.07%, colon perforation 0.07%, bleeding through cystic artery 0.49% and bleeding from gall bladder fossa 1.12%. Two colonic perforations and one duodenal perforation were the major complications encountered in this series. Two colonic perforations required conversion to open procedure but duodenal perforation was managed laparoscopically by intracorporeal suturing. Total nine (0.63%) patients required conversion to open procedure. Postoperative complications included port site infection (PSI) 1.05%, port site hernia 0.56%, major sepsis 0.14% and ischemic stroke 0.07%. There was no retained stone, biliary stricture and mortality reported in this series. Conclusion: Complications in laparoscopic cholecystectomy are mainly due to access related and intraoperative and have their own characteristics.. CBD transaction, CHD injury, Colonic perforations and duodenal perforations were the major complications requiring conversion to open procedure except duodenal perforation which was dealt laparoscopically. Conversion to open procedure should not be considered as a complication. J Bangladesh Coll Phys Surg 2023; 41: 75-81

Clinical Presentation and Outcome of Management of Congenital Heart Diseases Associated with Down Syndrome in a Tertiary Care Hospital

Introduction: Treatment of children with Down syndrome having congenital heart defects has not been reported well in Bangladesh. This study has been carried out to inform practitioners about findings from cases in Combined Military Hospital, Dhaka. Methods: Three years retrospective observational study (clinical data, hospital course and follow-up) was carried out on 114 patients (49 males and 65 females, age range 1 month to 12 years) who underwent diagnostic and therapeutic work up in the pediatric cardiology department CMH Dhaka between January 2018 and December 2020. Results: Among 114 patients ,64 were (57%) were infants and 50 were older children (43%) , twenty-five had congestive cardiac failure and eighteen had hypothyroidism. The study showed that 33.3% were atrioventricular septal defect (AVSD), 28.1% were patent ductus arteriosus (PDA),8.75% were tetralogy of Fallot (TOF) ,5.25% were coartation of aorta (COA) ,3.5% were patent ductus arteriosus with coarctation of aorta 3.5%, double outlet right ventricle with pulmonary stenosis were 3.5%, ventricular septal defect were 7% whereas atrial septal defect along with ventricular septal defect were 5.3% ,atrial septal defect were 3.5%, transposition of great arteries with multiple ventricular septal defect were 1.8%.Forty (35%) patients using per cutaneous intervention,had 100% procedural success and no mortality .45 patients underwent surgery,few of them were not operated due to severe pulmonary hypertension. Conclusion: Congenital heart disease was more frequent in DS children,having worse prognosis.Children with DS required special attention due to increased risk of pulmonary hypertension. Delayed treatment was an important risk factor for poor prognosis.So early diagnosis is needed in order to provide optimal intervention and surgery ,before occurrence of irreversible PAH. J Bangladesh Coll Phys Surg 2023; 41: 7-14

Hematopoietic Stem Cell Transplantation in Bangladesh : Activity and Outcome Update

Background : Hematopoietic stem cell transplantation(HSCT) is a potentially life saving curative modality of treatment procedure for many hematological malignancies, bone marrow failure syndromes and thalassemia. Bangladesh started first bone marrow transplant program with autologous transplant for myeloma in 2014 with the international collaboration between Massachusetts general hospital ( MGH) and Dhaka Medical College Hospital (DMCH). Since then it is growing in both public and private sector hospitals. Method : This is a multicenter retrospective study describing the demographics, activities and outcome of HSCT in Bangladesh. HSCT related Data were collected from three eminent HSCT centres of Bangladesh ( DMCH, Evercare hospitals and Combined Military Hospital Dhaka) and were analyzed. Result : As of June 2022, total 163 HSCT have been done in Bangladesh in major three centres as DMCH(52), Evercare hospital (62)and CMH Dhaka(49). Mean age of all patients is 39.4 years( range 15-69 Y) and sex distribution is M:F 3:1. Total autologous transplants were 125(77%) for myeloma(52), Hodgkins lymphoma(27) ,non-Hodgkins lymphoma(39) and others(7). Total allogeneic transplants were 38(23%) for AML(23), ALL(6), other hematological malignancy(03), Severe aplastic anemia (04) and thalassemia (02). Donor type wise majority were from matched sibling transplant (30/78%) from mostly male donor. Eight (08) haplo transplant were also successfully done. Each center follows specific infection control protocols, conditioning chemo protocols and growth factor protocols for the best patient care. Conditioning chemo protocols that usually used are high dose melphalan for MM, BEAM( Carmustine, Etoposide, Ara-C and Melphalan) for lymphoma and Bu-Cy( Busulphan-Cyclophosphamide) based for acute leukemia. Some leukemia patients received total body irradiation( TBI), thiotepa and Fludarabine based conditioning chemotherapy. All centres use irradiated blood components as transfusion products to avoid transfusion associated GVHD. As all centre used almost similar conditioning for particular disease, mean engraftment time in all centres were almost similar. Average time for neutrophil and platelet engraftment was 10-12 and 12-16 days post transplant respectively. Major early complications following transplant were neutropenic fever (>80%) and bacteraemia (25-30%) commonly with coagulase negative Staphylococcus, Pseudomonas sp, E. Coli and Klebsiella sp. Severe sepsis, pneumonia, typhlitis, hemorrhagic cystitis and CMV reactivation were observed in few cases. Acute GVHD ( G I to GII) was observed in almost all allogeneic transplanted patients. Mucositis, vomiting and diarrhoea were mild to moderate in most patients. Almost all patients required at least 1-3 red cell and platelet transfusion during the time waiting for engraftment. Progression free survival for all patients was variable in different centres (62% to 83%) since 2014 . Relapse of primary disease is more observed in autologous than allogeneic. Transplant related mortality( TRM) was 2% for autologous transplants and 5% for allogeneic transplant. Three early deaths were due to sepsis with COVID-19 infection in autologous transplant in pandemic period. Overall cost of transplantation is much lower in Bangladesh than that of developed countries. Approximate cost of autologous stem cell transplant is about $7000 and that for allogeneic transplant is $12000 to $15,000. Conclusion : Considering total population and burden of hematological malignancy in Bangladesh, the number of transplant is very low and it needs to be grown more rapidly to provide maximum benefit to save the lives as HSCT offers a curative approach to many hematological malignancies. Financial constrain, lack of health insurance and shortage of trained human resource are the main challenges for doing transplant in Bangladesh. National transplant registry and national donor registry both are yet to be developed. Comparing the cost difference with developed countries the overall outcome of stem cell transplantation is not inferior in Bangladesh.

Dissection of Tubercular Neck Node for Diagnosis as well as Therapy- A Study of 150 Cases in CMH Dhaka

Introduction: Tubercular lymphadenitis nowadays is the commonest extra pulmonary manifestation of tuberculosis in Bangladesh. Sometimes it causes diagnostic and therapeutic challenge for the clinicians. Occasionally Clinical, laboratory findings and fine needle aspiration cytology (FNAC) is not optimum that creates diagnostic and therapeutic dilemma. FNAC is often inconclusive. Sometimes therapy failed cases and atypical tuberculosis require open biopsy and neck dissection. Objective: To see the effectiveness of lymph node dissection & biopsy for diagnostic purpose and efficacy of the operation in suspected Multi-drug resistant tuberculosis (MDR-TB) for treatment failure due to any reason. Material and Methods: This cross sectional observational study was conducted during the time period of 01st Jan 2014 to 1st Jan 2020 in ENT & Head-Neck Surgery & Pulmonology department, Combined Military Hospital Dhaka on 150 patients who have undergone surgical neck dissection. Results: In this study total number of patients were 216. FNAC was done for all of them and found nonspecific lymphadenitis for 41 cases, lymphoma for 12 cases, sarcoidosis for 08 cases and kikuchi disease for 05 cases. 150 patients were found inconconclusive in FNAC. Inclusion criteria are followings, 1. FNAC is inconclusive & negative 2. Surgery was not done before. Among 150 patients different types of surgery was done like enblock resection, selective neck dissection and modified neck dissection. Histopathologically 06 cases found nonspecific lymphadenitis, 03 cases found lymphoma and 01 case found sarcoid granuloma. 150 cases were found histopathologically tubercular lymphadenitis. They show positive findings in biopsy, caseation necrosis- (100%), C/S +, among the Gene Xpert tests- Gene X-pert (Rif sensitive 83.33%, Rif resistant 16.66%). After completion of anti-tubercular therapy (ATT) (CAT-I HRZE) for total 150 patients, 125 patients were cured and 25 patients were not cured (treatment failure). Out of 25 patients 10 developed multiple cold abscess, 08 developed discharging sinus and 07 had relapse during follow up. 2nd Surgical interventions were done in total 25 patients, 10 TB abscess during ATT (CAT-1 HRZE), 8 discharging sinus and 7 relapse patients along with ATT (CAT-2 SHRZE) and all these patients had no relapse or treatment failure during further follow up. Conclusion: Tuberculous lymphadenitis is best treated with antitubercular medication and in addition surgical neck dissection is more useful in selected cases. So role of surgery is most useful for diagnostic accuracy as well as adjunct to the treatment avoiding prolongation of ATT and noxious side effects of drugs and also to prevent the formation of abscess and sinus. JAFMC Bangladesh. Vol 18, No 1 (June) 2022: 86-89

Immediate Outcome of Mechanically Ventilated Neonate : One Year Experience in Neonatal Intensive Care Unit of Combined Military Hospital Dhaka

Background: A large number of neonates in intensive care unit require mechanical ventilation due to various disease conditions. There has been a dramatic fall in neonatal mortality in developed countries with the advent of mechanical ventilation. This study was carried out to see the immediate outcome of neonates who required mechanical ventilation.
 Materials and methods: This prospective observational study was carried out in Neonatal Intensive Care Unit, CMH Dhaka from January 2016 to December 2016. Neonates who required mechanical ventilation during the study period were enrolled in this study. During the time of mechanical ventilation neonates were followed up for any complication till discharge or death.
 Results: Total 30 neonates were enrolled in the study. Among them 22(73.3%) of the neonates were preterm and 8(26.7%) were term, 25(83.3%) having birth weight <2500 gm. Respiratory Distress Syndrome was the most common reason for mechanical ventilation accounting for 11(36.7%),other indications were Perinatal Asphyxia 7(23.3%), Septicemia 6(20.0%), Congenital Pneumonia 5(16.7%) and Meconium Aspiration Syndrome 1(3.3%). Common complications during the period of ventilation were Septicemia (40.0%), Acute Renal Failure (16.7%), Pneumonia (16.7%), Pulmonary Hemorrhage (10.0%), Intraventricular Hemorrhage (6.7%), Pneumothorax(10.0%) and Heart Failure (6.7%). 17(56.7%) neonates survived and 13(43.3%) were died. Most of the neonate died of Perinatal Asphyxia 4(57.1%), Septicemia 3(50.0%), RDS 5(45.5%) and Congenital Pneumonia 1(20.0%).
 Conclusion: The survival rate of ventilated neonates was 56.7%. The higher gestational age and birth weight was significantly associated with better outcome. Septicemia and Pneumonia (PNA) was the leading cause of death in this study. Effective measures for prevention and management of sepsis could improve the outcome of neonates in NICU.
 IAHS Medical Journal Vol 4(2), June 2021; 27-32

Evaluation of Pressure Ulcer Among the Critically Ill Patients Admitted in a Tertiary Hospital

Background: All over the world pressure ulcer is a significant health care problem due to high morbidity and mortality rates and also high health care cost. This study was carried out with the objectives to identify the characteristics and associated factors of pressure ulcer among the critically ill patients admitted in a tertiary military hospital. Few studies have been conducted on pressure ulcer in Bangladesh and very few in military hospitals. Methodology: This was a cross sectional study conducted among purposively selected 53 critically ill admitted pressure ulcer patients in CMH Dhaka from 01 July 2018 to 31 December 2018 and data were collected by face to face interview and checklist. Results: Among the study population half (50.9%) were aged between 61-80 years with the mean age 69.13 years. The most common anatomical site of pressure ulcer were buttock (51.9%) followed by sacrum (38.5%) and 30.2% had multiple pressure ulcer. Among the critically ill patients, 81.1% had developed pressure ulcer after admission into hospital. The most common place of pressure ulcer was geriatric HDU (30.2%) and officers ward (18.9%). Among the pressure ulcer patients 79.2% were male. Most common stage of pressure ulcer were stage II (66.0%) followed by stage I (18.9%), stage III (13.2%) and stage IV (1.9%). All of them were bedridden and half (50.9%) were completely immobile. According to Braden Scale, about half (50.9%) had high risk for development of pressure ulcer followed by moderate risk (26.4%) and there were none beyond risk. About three fourth (73.6%) of pressure ulcer patients had hypertension & cerebrovascular diseases. Age group of 60-90 years, SSC & above educational group, male sex, immobility, low Braden score group patients are statistically significant (p < 0.05), and hypertensive and cerebrovascular diseased patients are not statically significant (p > 0.05) but having clear trends to be associate factors of pressure ulcer. Conclusion: The number of pressure ulcer were increasing with the increase of age. The higher age, male sex, immobilization, low Braden score, hypertension, and cerebrovascular diseased patients were more prone for development of pressure ulcer among the critically ill patients. J Bangladesh Coll Phys Surg 2022; 40: 23-30

Pattern of Childhood Cholelithiasis- Experience in a Tertiary Level Hospital

Introduction: Cholelithiasis is being frequently diagnosed in children, although not as often as in adult. The real aetiology of gallstone formation is poorly understood, but some inciting factors are assumed to be involved in gallstone formation in children. Traditionally cholelithiasis in children is classified as haemolytic or nonhaemolytic in origin. Nonhaemolytic cholelithiasis seems to be more frequent than haemolytic cholelithiasis at present. Aim: To find out the pattern of childhood cholelithiasis presenting in a tertiary level military hospital. Methods: This retrospective observational study was carried out in the Department of Paediatric Surgery, CMH Dhaka from January 2015 to December 2018. A total of 35 children with cholelithiasis were admitted in this hospital. Results: During the study period 35 children with cholelithiasis were admitted. Among them maximum children 31(88.6%) were in the age group of 6-12 years. Out of them 23(65.7%) were female and 12(34.3%) were male making a female to male ratio of 1.92:1. Twelve children (34.3%) were asymptomatic and 23(65.71%) were symptomatic. Among symptomatic group 10(28.6%) had biliary colic, 10(28.6%) had nonspecific abdominal pain and 3(13.0%) had acute abdominal pain. Out of these 35 children, only 4(11.4%) had link with haemolytic anaemia. Conclusion: Cholelithiasis in children is being recognized with increased frequency in recent years. The ratio of cholecystitis and cholelithiasis varies considerably in different countries and centres. Childhood cholelithiasis has less chance of complication and high rate of resolution. JAFMC Bangladesh. Vol 15, No 1 (June) 2020: 8-11

Clinical Profile of Cerebral Palsy: A Study in Tertiary Level Hospitals of Bangladesh

Introduction: Cerebral palsy (CP) is the most common motor neurodevelopmental disorder among children which incurs a huge economic burden in respect of treatment and rehabilitation. Aim: To assess the clinical profile of CP in the outdoors of tertiary level hospitals in Bangladesh. Methods: This cross-sectional study was carried out in two hospitals, namely Child Development Center, CMH Dhaka and Institute of Pediatric Neurodisorder and Autism, BSMMU, Dhaka from October 2019 to January 2020. A total of 134 cases were included by convenient sampling. Data were collected from the parents of the children by face to face interviews through a pretested semi-structured questionnaire. Results: CP was found more prevalent in male children (76.1%) than female children (23.9%). Most of the families (83.6%) belonging to CP children have monthly income ≤ Taka 24000.00. The majority of the parents were HSC qualified or less which accounted for 76.9% for father and 91.8% for mother respectively. Among the etiologies; perinatal asphyxia ranked highest (78.4%). The spastic variety was the most common (78.4%) presentation of which 41.0% suffered from quadriplegia. The majority of the CP cases (83.6%) were associated with intellectual disability. Conclusion: CP has a wide range of presentation, association and co-morbidities. Physicians should be aware of these diversified presentations and co-morbidities of CP and deal accordingly for better outcome of the patients. JAFMC Bangladesh. Vol 15, No 1 (June) 2020: 19-21

Fetomaternal Outcome of Pregnancy with COVID-19: An Observational Study in A Tertiary Care Hospital of Bangladesh

Introduction: Corona virus is a new pathogen of high contagious abilities. Pregnant women are at an increased risk due to physiologic changes in their immune, cardiopulmonary and coagulation systems. This study was designed to evaluate the fetomaternal outcome of the pregnant patients with COVID-19.
 Methods: This retrospective observational study was conducted in CMH Dhaka from May 2020 to July 2020. Total 81 hospitalized pregnant patients with confirmed COVID-19 were enrolled. Relevant data were recorded in a preformed data collection sheet and analyzed by SPSS version 20.
 Results: Total patients were 81 with a mean age of 27 years; 49.1% were in third trimester, 83% were in 35-40 weeks of gestation and 48% were asymptomatic. Common symptom severe cough (26%) and fever(14%); 7.4% patients had multiorgan failure, 81% hadlymphopenia, 7.4% patients under went chest CT and had in filtrates in both lungs. Mild to moderate disease was common and 7.4 % had severe disease, 3.7% needed mechanical ventilation. There was a single maternal death. Most (92.6%) patients were treated in Corona ward and 7.4% in Corona HDU and ICU. There were 3 spontaneous abortions; 64.2% delivered during the study period, 80.8% underwent a Caesarean section, 2.4% had hysterotomy, 15.1% underwent normal vaginal delivery (NVD), 15.4% patients underwent premature termination of pregnancy. Ongoing pregnancy was 26 (32.1%).Four neonates were found COVID-positive. There was 47 livebirths, 3 intrauterine deaths (IUD) and 2 neonatal deaths. Their hospital stay was 13.1 days (SD±6.37).Mean interval of breastfeeding was 13.3 days (SD±6.44).
 Conclusion: From the study findings, it can be concluded that, COVID-19 had adverse fetomaternal outcomes. COVID-19 pandemic has exerted immense stress on health care system. With this study we can further modify our treatment strategy and reduce the load on our health system.
 J Bangladesh Coll Phys Surg 2021; 39(2): 100-105

Socio-demographic Characteristics of Women with Reproductive Tract Infection Attending a Military Hospital

Introduction: Reproductive tract infections (RTIs) are being increasingly recognized as a serious global health problem with impact on individual women and men, their families and communities. RTIs are a group of disease that cause infection of the genital tract and include both those that are sexually transmitted and those that are not. RTIs are a significant cause of morbidity and mortality in both men and women, especially in women of reproductive age.
 Objectives: To determine the socio-demographic characteristics among women with RTIs attending at gynecology outpatient department, CMH, Dhaka.
 Materials and Methods: This descriptive cross-sectional study was carried out with a view to find out the socio-demographic characteristics of women with RTIs and their common clinical presentations. The study was conducted among women of reproductive age group of Bangladesh Armed Forces attending at Gynecology OPD, CMH Dhaka, for the period of 1st march to 30th June 2011. A total of 128 women (114 married and 14 were unmarried) were interviewed with the help of structured question and checklist. Data was collected through clinical diagnostic approach made by gynecologists.
 Results: It was found that highest percentage of respondents (32.8%) were in the age group of 30-34 years, mean age at marriage was 17.79 years. The highest percentage of respondents (46.5%) was married at the age range of 16-18 years. Among the respondents, 89.1% were married and 10.9% were unmarried. The women with higher education level had lower occurrence of RTIs than women with lower education. In relation to status of spouse of married women, RTIs were significantly more among the wife of other ranks. Practice of personal hygiene during menstruation showed safe positive impact on RTIs. It was found that 50% respondents were presenting with vaginal discharge (Leucorrhoea). Most of the causes were vaginitis (38.3%).
 Conclusion: Study findings indicate that high prevalence of RTIs among women is due to the influence of less educational status, low income and also husband's educational background and employment status.
 JAFMC Bangladesh. Vol 15, No 2 (December) 2019: 218-220

Socio-demographic Characteristics of Depressive Illness Patients Attending a Selected Military Hospital

Introduction:Depressive illness is generally not perceived as an important public health problem and is not priority in health care delivery system in Bangladesh. It is the leading cause of disease-related disability in the country today. Gender differences in depression are likely to be result of certain risk factors.
 Objectives: To find out gender difference in epidemiological and socio-demographic features associated with depressive illness.
 Materials and Methods: This descriptive cross sectional study was carried out among 91 diagnosed depressive patients attending in the psychiatry department of CMH Dhaka from January to December 2014. The patients were interviewed through an interviewer-administered questionnaire. Data were analyzed by using SPSS version 20. Chi-square test was used to see the level of significance.
 Results: In this study the mean age of the patients was 34.47±9.577 years. The study revealed that depressive illness appears to be more in female during child bearing and child rearing period of 16-39 years and male of 40-63 years were more sufferer than female which was significantly different (p<0.05). In this study 63.74% of patients were female and 36.26% were male with ratio of 1.757:1. It was observed that the association of depression with residence in urban area in female (72.1%) was significantly (p<0.05) higher than male (27.9%) in the same area. This study revealed that the association of depression with history of financial hardship in female was statistically significant (p<0.05) over their male counter-part.The study also revealed that strenuous job was significantly (p<0.05) associated with depression in female than male.
 Conclusion: The overall finding of the study indicates that possibility of gender difference in certain epidemiological and sociodemographic features of depressive illness is significantly present. As depressive illness has significant impact on burden of disease and quality of life, this issue needs to be addressed.
 JAFMC Bangladesh. Vol 15, No 2 (December) 2019: 178-180

Experience of Mini PCNL in Horseshoe Kidneys

Objective: The objective of this article is to share our experience of Mini PCNL in horseshoe kidneys. Methods: We performed Mini PCNL in 05 patients with Horse shoe kidneys in theurology centre of CMH Dhaka. Per cutaneous puncture was made with patient in proneposition. Their ages ranged between 35-52 years with a mean age of 42.3 years. PCNLaccess tract was made in upper pole of the kidney in 03(60%) while 01(20%) throughmiddle calyx, and 01(20%) had direct pelvic access. The stone size was 2.3-2.75cm withmultiple calculi in two kidneys. Results: Complete Stone clearance was achieved in all 05 cases .Mean hospital stay was3.8 days (range 3-5 days).All cases were followed up at 4 weeks and after 3 months. Nosignificant Complications were seen except one patient who developed transient postoperativepyrexia which subsided with antipyretics. None of our patients developedpost PCNL bleeding or wound infection. Conclusion: Mini PCNL in horse shoe kidneys are not too difficult than normal kidneysand does not carry significant risk than reported for normal kidneys. This effectivemodality resulted in almost100% stone clearance with minimal morbidity. Bangladesh Journal of Urology, Vol. 23, No. 1, January 2020 p.82-86