Vol. 28, No. 3, September 2010 Official Journal of the Bangladesh College of Physicians and Surgeons BCPS Bhaban, 67 Shaheed Tajuddin Ahmed Sarani Mohakhali, Dhaka-1212, Bangladesh

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EDITORIAL Autism Spectrum Disorders 143 Md Mizanur Rahman ORIGINAL ARTICLES Presentation and Immediate Outcome of Surgical Treatment of Patients with Carcinoma 145 of the Stomach – A Comparative Study between Young and Elderly patients SA Chowdhury, MM Hussain, J Ahmed Student’s Opinion Towards the Assessment System of Revised Undergraduate 151 Medical Curriculum - An Experience in A Private Medical College R Nazneen, HK Talukder, MZ Hossain Estrogen Receptor, Progesterone Receptor, and Her-2/neu Oncogene Expression 157 in Breast Cancers Among Bangladeshi Women MG Mostafa, MT Larsen, RR Love Gestational Age Predicted by Femur Length in Bangladesh 163 SQ Rashid REVIEW ARTICLES The Role of Mirena (Intra-uterine progestogens), Other than Contraceptive 167 benefits: Current Concepts and Practices I Bina Evaluation & Management of Obscure Gastrointestinal Bleeding (OGIB) 174 S Perveen, MR Hossain, SMB Hussain, MA Ahmed, H Aftab CASE REPORTS Non-Coronary Aortic Sinus Dilatation with Aortic Regurgitation in a 183 Marfan’s Syndrome Patient – A Case Report M Siraj, MH Rahman Adrenoleukodystrophy: A Rare Case Report 189 MBA Mondol, MMR Siddiqui, L Wahab, MA Hoque, SU Khan, KM Rahman, QD Mohammad Goldenhar Syndrome-A Case Report 193 MAR Siddique, J Hossain, MJ Abedin, M Parvez Pregnancy with Idiopathic Thrombocytopenic Purpura - A Case Report 196 R Akther, T Hossain, MA Khan, Maliha Rashid SHORT COMMUNICATION Bezoar, A Rare Cause of Gastrointestinal Obstruction 199 MM Hussain, CA Kawser IMAGES IN MEDICAL PRACTICE 202 MMR Siddiqui, QT Islam, A Hossain, MS Mahbub LETTER TO THE EDITOR 203 COLLEGE NEWS 206

FROM THE DESK OF THE EDITOR IN CHIEF 212 NAME OF THE REVIEWER OF ARTICLES IN THIS ISSUE 213 OBITUARY 214 EDITORIAL

Autism Spectrum Disorders

Autism Spectrum Disorders (ASD) are cognitive and abnormalities seen in autism are caused by genetic neurobehavioural disorders, having three core features: defects in brain growth factors5. The previous deficits in socialization, deficits in verbal & nonverbal observation that MMR vaccine may be associated with communication and restricted and repetitive patterns of autism has been proved untrue4. Lack of breast feeding behaviours1. These disorders manifest in early childhood have been found to be a risk factor in autism 6. There is and are likely to last the life time of the person. In 1943, no effect of family income, life style and education on Dr.Leo Kanner of the Jhon Hopkins Hospital, was the prevalence of autism. ASD is also not related to first to describe the syndrome of autistic disturbances.1 parenting style. However, over the period it is recognized as a spectrum Investigations are not always indicated. of disorder that includes: Childhood autism, Asperger’s Electroencephalography and a neurology referral are syndrome, childhood disintegrative disorder, Rett’s indicated in children with suspected seizures or those syndrome and pervasive developmental disorders - not who have symptoms of regression. Lead screening, DNA 1 otherwise specified . analysis, high-resolution chromosome analysis, and Until recently, autism was thought to be rare. Earlier, referral to a geneticist may be considered in specific 1,4 prevalence was considered to be 2 to 4 cases per 10,000 situation. children1. Currently, it is estimated that the prevalence Though there is a myth that there is no cure for autism, is as high as 1 in 150 individnals in USA2. Extrapolated one can improve the quality of life of autistic children on the basis of above figure, in Bangladesh nearly 10.5 by various methods like sensory integration therapy , lakhs individuals may have autism. However, there is applied behaviour analysis and auditory integration no national epidemiological study on autism in therapy1,4. Approximately 10% of the autistic Bangladesh. In the centre for Child Development and individuals have savant abilities. People with ASD have Autism at Bangabandhu Sheikh Mujib Medical emotional feelings and are able to love & feel loved. University only 12 children attended with autism in the They care deeply but lack the ability to spontaneously year 2001, which increased to 105 children in 2009 develop empathic behavior. They do not prefer self suggesting probable prevalence, awareness amongst isolate rather they want to interact socially; but lack the parents and probably increased capability of the ability to spontaneously develop effective social paediatricians to diagnose the problem. interaction skills. They can learn social skills if they receive specialized training. With appropriate treatment, It is felt that there may be a definite increase in the almost 50% of individuals with autism will become incidence of Autism spectrum disorders all over the indistinguishable from the mainstream population. Many world. It has no racial, ethnic or social boundaries. Better others will develop independent living skills and can diagnostic facilities and greater awareness increase the live successfully and can contribute and small numbers yield of diagnosis of ASD. Environmental and perinatal will require support throughout their lives. factors along with genetic predispositions are the main etiologic determinants3. However, there is a clear They may need medical management for associated agreement that the disorder may be associated with conditions like epilepsy, hyperactivity, gastrointestinal structural and functional abnormalities in several areas problems, sleep disturbances, anxiety and depression, 1 of the brain, suggesting that a disruption in fetal brain when indicated . Management of ASD also depends on development contributes to the disorder4. The “growth educating and empowering clinicians to recognize the dysregulation hypothesis” holds that the anatomical wide spectrum of symptoms that ASD now comprises Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 and use standardized developmental and ASD- specific References: screening and diagnostic tools. Well-child visit during 1. Hirtz DG, Wagner A, Filipek PA. Autistic Spectrum Disorders. toddler and preschool years is needed to exclude ASD1. In: Swiman KF, Asnwal S, Ferriero DM. Editor, Pediatric Neurology: Principles and Practice, Vol-1, Philadelphia; The earlier ASD is diagnosed & treated, the better is Elsevier; 2006.P.905-935. outcome. It is neither to be hidden and nor to “wait and 2. Mayers SM, Johnson CP. Management of Children with see” and neglect. Autism Spectrum Disorders. Pediatrics 2007; 120: 1162-82. But for this one need to educate and empower parents, 3. Glasson EJ, Bower C, Petterson B, Klerk ND, Chaney G, develop facilities for early diagnosis and management/ Hallmayr JF. Perinatal factors and the development of Autism. Archives of general Psychiatry 2004; 61:618-627. training of patient and parents, and lastly motivate the 4. Nair MKC. Autism Spectrum Disorders. Indian Pediatrics. society to become caring and attentive to the need of 2004; 41: 541-542. these children. 5. Carper RA, Courchesne E. Inverse correlation between frontal (J Bangladesh Coll Phys Surg 2010; 28: 143-144) lobe and cerebellum sizes in Children with autism. Brain 2000; 123: 836-844. 6. Schultz ST, Klonoff-Coheu HS, Wingard DL, Akshoomoff Professor Md Mizanur Rahman NA, Macera CA, Jim, Bacher C. Breastfceding, infant formula Professor Paediatric Neurology, Bangabandhu Sheikh supplementation, and Autistic disorder: the results of a Parent Mujib Medical University, Shahbag, Dhaka-1000. Survey. Int Breastfeed J 2006; 1:16-29

144 ORIGINAL ARTICLES

Presentation and Immediate Outcome of Surgical Treatment of Patients with Carcinoma of the Stomach – A Comparative Study between Young and Elderly patients SA CHOWDHURYa, MM HUSSAINb, J AHMEDc

Summary: The operability in carcinoma of the stomach was more in Carcinoma of the stomach is a common malignancy and young group probably due to physical fitness of patient. In have a high mortality. Incidence under the age of 45 is both the groups antrum was the commonest site of malignancy. The incidence of malignancy in body was more comparatively low but appear more aggressive then elderly in young patients. In young group tumor status was T in group. This study was designed to describe the presentation 4 54.5% and in elderly group 56% was in T stage. 80% had and operative findings in the two groups of patients and to 4 lymph node involvement in both the groups. Resection was record the outcome of surgical management in these possible in young group in about 90% and gastrojejunostomy patients. in 9.09% cases. Conversely, in the elderly group resection A total of 86 cases were included in this study. 14 were was possible in 58% and gastrojejunostomy was done in 42% from below 40 years (young group) and 72 were above 40 cases. Total gastrectomy was done in 18.18% in young group years (elderly group). Young patients had less definitive and 4% in elderly group. Another important finding was symptoms than elderly group. Pain (85.71%) and vomiting partial gastrectomy was done in 72.73% in young but 46% in elderly only. The mortality was more (18.2%) in young group (78%) were the most prominent symptoms in both the in comparison to (10%) in elderly. groups. But in elderly a significant number 54(75%) of cases had anorexia. Lump and visible peristalsis were present in Gastric carcinoma was found more aggressive in young with both groups in approximately similar proportion. high mortality and morbidity. Efforts should be taken for Histopathologically younger patients had more aggressive early diagnosis and prompt surgical treatment. disease than the elderly group.. (J Bangladesh Coll Phys Surg 2010; 28: 145-150)

Introduction: women3. Gastric cancer rarely disseminates widely Carcinoma of the stomach is the second most common before it involves the lymph nodes and therefore some cancer worldwide. Higher incidence have been reported believe this is an opportunity to cure the disease prior from Japan, China and South Korea and a lower to dissemination2. It occurs in the younger individuals incidence have been reported from India, Pakistan and with a much higher rate of mortality and morbidity4. Thiland1. Some series have reported overall 5 year Early diagnosis is therefore the key to success in survival rate of about 5%2. Carcinoma of the stomach management of patients presenting with this disease. is rare under age 40 years, from which point the risk The only treatment modality to cure the disease is gradually increases with age. The mean age at diagnosis resectional surgery and chemotherapy2 . In a study in is 63 years 3 . It is about twice as common in men as in Chittagong Medical College the incidence of carcinoma 5 a. Dr. Shafiul Azam Chowdhury FCPS, Resident Surgeon, of the stomach in hospitalized patients was 6.96% . The Comilla Medical College risk factors of gastric carcinoma in Chittagong and its b. Professor Md Margub Hussain, Professor of Surgery, Dhaka sea belt area was alcohol, dried and salted fish intake. Medical College Although the etiological factors and pathogenesis of c. Dr. Jasimuddin Ahmed, Associate Professor of Surgery gastric carcinoma are not yet fully understood 6, the Chittagong Medical College most important pathological determinant to evaluate Address of Correspondance: Dr. Shafiul Azam Chowdhury FCPS, Resident Surgeon , Comilla Medical College clinical and prognostic significance is the depth of penetration of stomach wall by the lesion. The others Received: 12 June, 2008 Accepted: 24 June, 2010 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 are histological types, location of primary site and Operability was judged on the basis of clinical and metastasis. investigation findings. All had palliative surgery . The operative procedures included total gastrectomy, A study was conducted to compare the clinical proximal or distal partial gastrectomy, subtotal presentation, operative findings and outcome of surgery gastrectomy and gastrojejunostomy along with removal between two age groups of patients presenting as of lymph nodes based on findings at laparotomy. carcinoma stomach. Post-operatively all patients were monitored carefully Materials and Method: and complications were recorded. All the patients got This was a prospective quasi experimental study. The 1st cycle chemotherapy as per advice of Oncologist. study was carried out in the Department of Surgery, Statistical analysis Chittagong Medical College & Hospital. The study was Statistical analysis was done manually and by using undertaken during the period of May 2002 to December computer statistical software package SPSS-10.0 for 2003. Cases were selected consecutively following the windows 2000 (SPSS-Statistical Programme for inclusion and exclusion criteria. Evaluation of patients Scientific Study). ‘Unpaired t’ tests were done where was based on history, physical examinations and applicable. P values less than 0.05 was considered as investigations. For analysis of results patients were significant, by setting the minimal level of statistical divided into two groups as Group A, below 40 years significance at 5%. and Group B above 40 years of age . Ethical issues a) Inclusion Criteria: Patient of either sex admitted Permission for the study was duly obtained from Ethical with presentations suggestive of carcinoma of the Committee of Chittagong Medical College. On ethical stomach and histopathologically confirmed from tissue consideration the patients were first explained about the obtained by endoscopy. treatment procedures with their possible outcome. b) Exclusion Criteria: Histopathologically negative Informed written consent was taken from them. cases were excluded. Results: Patients were admitted from surgical out-patient A total of 86 patients were included in the study. Only departments after clinical diagnosis of Carcinoma of 14 (16.3%) cases were below 40 years (Group A) and the stomach. Some of these patients had tissue 72 (83.7%) cases were above 40 years (Group B). The confirmation before being admitted. Referred patients male: female ratio was 2.58:1 from medical units after diagnosis of Carcinoma of the Table-I stomach were also included. Comparison of Clinical Presentation of two groups Preoperative clinical assessment included detailed of patients of Carcinoma of the stomach history regarding presenting illness, dietary pattern and personal habits. Meticulous systematic physical Symptoms Group A* Group B* examination was performed in each case . n=14 n=72 Ultrasonography was done to detect secondary deposits Dyspepsia 02(14.28) 34 (47.22) in liver , involvement of lymph nodes and presence of ascitis. Radioisotope scan of liver and bone was obtained Pain in the abdomen 12(85.71%) 52(72.22) in relevant cases. All relevant information were recorded Vomiting 11 (78%) 54 (75) methodically and carefully as far as possible in pre- Hemetemesis and Melena 00 05(6.94) designed data sheet for each individual case. Lump in the abdomen 06(42.85%) 18(25) During laparotomy tumor size, serosal involvement, Anorexia 07 (50%) 54 (75) hepatic metastasis, lymph node involvement including Gen. weakness 07(50%) 43 (59.72) group, size and number, peritoneal metastasis and ascitis Personal habits were observed and recorded in detail . Specimen was Smoking 6 (43 %) 41 (57% ) obtained in every operated case for histopathological Smoked and Salted fish 7 ( 50% ) 26 ( 36% ) reconfirmation. · Figures in parentheses represent percentages

146 Presentation and Immediate Outcome of Surgical Treatment of Patients with Carcinoma SA Chowdhury et al.

In Group A, 12 (85.7%) patients and in Group B, 52 Ba-meal study was done in all the 86 cases. 06(57.14%) (72.2%) patients had pain in abdomen. Vomiting was group A and 34 (66.67%) group B cases were positive present in 78% and 75% cases of group A and B for carcinoma of stomach by Ba-meal examination. respectively. Endoscopic Examination 07 (50%) patients of group A and 26 (36.11%) patients On endoscopy 92.86% of group A and 95.83% of group B of group B consumed smoked and salted fish. Similarly patients had lesions suggestive of gastric carcinoma. Tissue 06 (42.86%) group A and 41 (56.94%) group B cases biopsy was taken from all the cases. Poorly differentiated were smoker. carcinoma stomach was found in 35.71% of group A and Table-II 41.14% of group B patients. The histopathological findings were inconclusive only in 1 patient of group A and 16 Clinical Examination findings of two groups (22.86) cases of group B patients. of patients ( n=86) Surgical management Group A* Group B * Exploration was done in 61 out of 86 patients of (n=14 ) ( n=72 ) carcinoma of the stomach. Palliative procedure was General Examination Findings possible on 78.57% of group A patients 69.44% in group Anemia 09(64.28) 67(93.06) B patients. Jaundice 01(7.14) 02(02.78) In both the groups’ maximum number of tumour was in Dehydration 05(45.71) 08(11.11) Supraclavicular LN 01(7.14) 02(02.78) the antrum. The growth was present in the antrum in 63.6% of cases in group A and 78% in group B. 36.4% Loco-regional Examination Findigns patients of Group A and 14% patrients of Group B patients Lump 07(50) 43(59.72) had growth in body of the stomach. Growth in cardia Ascites 02(14.28) 13(18.06) (8%) was found only in elderly (group B) patients. Liver 00 04(5.56) Tumor status as observed during exploration , was · Figures in parentheses represent percentages recorded according to TNM classification . T3 stage Table no III shows that 67 (93.06) cases of group B was present in 05 of 11 in group A (45.45%) and 13 of was anaemic. Lump was present in 07(50%) of group A 50 ( 26 %) of cases present in elderly ( group B ) patients. patients and 43(59.71%) group B patients, and visible T4 status was present in 06 of group A (54.55%) and 28 peristalsis 05(35.71%) and 23 (31.94%) cases (56%) of 50 cases of group B. Findings were significant respectively. ( p value <0.05 ) . This comparison is shown in Table IV.

Table-III

Endoscopic Biopsy Results of two groups of patients

Group A (%)N=14 Group B (%)N=70 EndoscopicBiopsy Report Well differentiated 04(28.57) 06 (08.57) Moderately differentiated 02(14.29) 14(20) Poorly differentiated 05(35.71) 33(41.14) Diffuse 02(14.29) 01(01.430) Inconclusive 01(07.14) 16(22.86) USG Liver metastasis 0 4 Ascitis 4 15 Lymphadenopathy 6 37 Ba meal Suggestive 6 (33% ) 34 (66.6% ) · Figures in parentheses represent percentages

147 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010

Table- IV Table-VI

Tumor Status in TNM classification in two groups Extent of Resection in Patients with Ca-stomach of patients with carcinoma of the stomach ( according to laparotomy Finding n=61) Procedure Group A (%) Group B (%) Total gastrectomy 02(18.18) 02(4) Tumor status * Group A (%) Group B (%) Proximal partial gastrectomy 00 03(6)

T2 00 09(18) Distal partial gastrectomy 08(72.73) 23(46)

T3 05(45.45) 13(26) Distal subtotal gastrectomy 00 01(2) Gastrojejunostomy 01(9.09) 21(42) T4 06(54.55) 28(56) 11 50 Total 11 50 *Note - there was no patients with T1 tumor · Figures in parentheses represent percentages The mortality was 02 (18.18%) among group A and in Lymph node involvement was present in 09(81.82%) 05 (10%) in group B. Postoperative complications of Group A and 46(92%) of Group B cases. Peritoneal developed in 16% patients of group B. involvement was present in 01 (09.09%) and 09 (18%) Discussion: cases of Group A and Group B respectively. Hepatic A total of 86 histopathologically confirmed cases were involvement was found in 02(18.18%) and 09(18%) of included in the present study. Among them 14 cases were cases of Group A and Group B respectively. Nodal included in young group of which 11 cases were involvement of these patients with carcinoma of the operated. In elderly group 72 cases were included and stomach has been presented and compared in table V. 50 cases were operated .In 22 cases of elderly patients Table-V operation could not be done either for refusal of operation or extensive disease involvement . Showing difference in Nodal Involvement In the present study the incidence of gastric carcinoma ( as per TNM classification ) in two groups in young group was 16% ( 14 of 86 patients). ,. In one of gastric cancer patients review Milne et al 7, about 10% patients were found below 45 years and in another study it was 13.% 4 in a Lymph node status Group A (%) Group B (%) series of 130 cases. The patients below 45 yeas has been 7 N 0 02(18.18) 03(8) grouped as early onset gastric carcinoma ( EOGC ). Though the diagnosis of gastric neoplasm is sometimes N 03(27.27) 18(30) 1 reserved in young patients, symptoms observed in this (8-11) N 2 06(45.45) 28(26) age group did not differ from those in adults . N 00 01(06) Similar observations was also noted in this study. A X recent study reported observations that early onset Total 11 50 gastric carcinoma (EOGC) has molecular genetic profile different from elderly group of patients where As the patients presented with incurable tumor mass environmental factors are held responsible for exploration was done with palliative intent. Resection carcinogenesis. 7 In another study, a statistically was possible in 10 (90.91%) young patients ( group A ) significant increase in number of patients below the age and 29 (58%) elderly patients ( group B )..Procedures of forty years was seen in cancers involving oesopageo performed has been tabulated in table VI. 72.7% group gastric junction in Indian subcontinent.12 A patients were treated by distal partial gastrectomy. In the present study the main presenting symptoms were Whereas group B patients were treated by distal partial abdominal pain and anorexia in both the groups. Another gastrectomy in 46% and gastrojejunostomy in 42% study from Iran revealed abdominal pain and anorexia cases. p value >0.05. to be present in 95% of cases 13. Comparable pattern of

148 Presentation and Immediate Outcome of Surgical Treatment of Patients with Carcinoma SA Chowdhury et al. clinical features were reported from India, Pakistan and involvement was 0% for tumors less than 1cm , it Nigeria 14-17 reached to 46% for peri gastric and 15% for extra gastric ( 22) Tobacco smoking has a positive association while nodes for a 4 cm lesion, This also indicates early increasing consumption of vegetables and dietary lymph node metastasis in carcinoma of the stomach. products has a protective effect 18. Smoking was the On the other hand a German study found no relationship ( prominent risk factors in both the groups but smoked with the size of lymph node and metastatic infiltration 23 ). and salted fish intake was more in younger group.. In a Data from several large series indicate that 60% to cohort study , Poulsen (19) and his co workers found 90% of patients had primary tumor presenting with association of proton pump inhibitors (PPI ) and H2 involvement of the serosa or invading adjacent organs ( 24-25) receptor blockers with increased incidence of gastric . In a study in India cancers were diagnosed in an 1 carcinoma. PPI and H2 receptor blockers are available advanced stage and 70% had serosal infiltration . as over the counter drugs and are used randomly and Early reporting and early diagnosis no doubt will indiscriminately . Effect of these drugs in our population improve results of treatment in any type of cancer. In could not be assessed in this study. Japan where gastric cancers are diagnosed at an early Half of the young patients and 43 (59.77 % ) elderly stage the results are admirable . Kitano has reported cases had visible or palpable lump. Other studies showed 100% resectability with T1A and T1B tumours with 5 similar observations in different countries(4,14-16 ). year disease free survival of 99.8 for T1a and 98.7% Ascites was present in 14.28% and 18.06% cases and for T1B gastric cancers following laparoscopic ( 26 ) hepatomegaly present in 05.56% cases only.. Similar intervention. The reason for late presentation are observation were reported from neighboring countries. many. One important issue in our patients may be due ( 14-16 ) to vague symptoms and casual use of PPI and H2 receptor blockers as self medication. In an attempt to Endoscopy is investigation of choice for diagnosis of promote early presentation of cancers specially in gastric carcinoma. Numerous reports had demonstrated disadvantaged communities Lyon and workers had an that its accuracy of diagnosis was greater than 95% (20). innovative approach of involving people in the Negative results were more common in younger age community . This could improve reporting of breast group in this series. Spiral CT scan has limited ability cancer and bowel cancer. ( 27 ) Similar strategy may to identify lymph node metastases but can detect improve early presentation in gastric cancers as well. adjacent organ invasion. Whenever possible these modalities may be used for preoperative assessment. Lymph node involvement was greater in elderly group Endoscopic ultrasound has been found 80% and 68.8% than young group of patients. The overall lymph node accurate respectively for Tumor and Nodal status in a involvement was over 90%. Sunderlands described an study in Korea. ( 21 ) Pre operative assessment of nodal 88% incidence of involvement of nodes with the status therefore remains difficult and has low specificity proximal lesions ( 28 ). This was also observed in this but a combined approach might give better series that lymph node involement in younger patients understanding and outcome. were more rapid. Histopathologically in young patient’s malignancy were Resection was done in more than 90% young patients more aggressive than older group. The percentage of and 58% in older group. Resection was possible in diffuse variety was more in young group and poorly significantly higher proportion of young patients. This differentiated were more in elderly group. may be due to involvement of body and involvement of TNM staging was done in all the operated cases. In both fewer lymph nodes or due to more operative fitness in the groups malignancy was in advanced state. T stage young group. Another factor might be less number of 3 patients in this group. tumor was more in young group whereas, T4 was more common in the elderly group and was statistically The maximum palliative surgery was distal partial significant. Involvement of peri gastric and extra gastric gastrectomy. Gastrojejunostomy done in older group lymph nodes are found directly related to tumor size was 21 (42%) cases. In other series by pass operation and depth of invasion. In a Japanese study lymph node was done in 7.23% and 5% cases ( 29 ). In the present

149 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 study the mortality rate was 02(18%) in young patients Khujestan, Southwest of Iran. World J gastroenrol 2006; 12 and 05 (10%) in older patients. However, none of the (4): 189-90 14. Sambasivaiah K, Ibraullah M, Reddy M K , Reddy P V , operative procedure was statistically significant. Wagholiker JS . Clinical profile of carcinoma stomach at a tertiary care hospital in south india . Trop Gastroenterol 2004; Recommendation: 25: 21-26. More focused studies with more cases are required to 15. Phukan R K, Narain , Zomawia E , Hazarika N C, Mahanta identify risk factors and surgical outcome in both groups. J, Dietary habits and stomach cancer in Mizoram, India . India J Gastorenterol 2006; 41 : 418-24 Acknowledgement: 16. Durrani A A , Yaqoob N, Abbasi S, Siddiq M, Moin S. Pattern This study was done in as a part of dissertation in partial of gastro Intestinal malignancies in northern Punjab. Pak J fulfillment of FCPS part II examination in Surgery in Med Sc 2009; 25 (2 ) 302-307. 17. Bakari AA , Ibrahim A G, Gali BM, Dogo D, Nggada HA. Chittagong Medical College Hospital. Pattern of Gastric Canaer in Nort –eastern Nigeria : A clinic We are indebted to Professor K.Z. Mamun who has pathological study. Journal of Chinese Clinical Medicine ; 2010 : 5 (4) given his valuable time in statistical analysis and over 18. Trendaniel J, Boffetta P, Buiatti E, Saracci R, Hirsch A. all review of the paper . Tobacco smoking and Gastric Cancer: Review and Meta analysis . Int J Cancer 1997 ; 72 ( 4 ) 565-73. References: 19. Poulsen A H, Christensen S, McLaughin J K, Thomsen R.W, 1. Pavithran K, Doval DC, Pandey KK. Gastric cancer in India, Sorensen H T, Olsen JH and Friis S. Proton pump inhibitors Epidemiology note, International and Japanese Gastric cancer and risk of gastric cancer: A population based cohort study. association. Gastric Cancer. 2002:5; 240-243. Br J Cancer 2009 ;100 (9) : 1503-07 2. Primrose JN. Stomach and Duodenum; Russell RCG, Williams 20. Dekher W, Tygat GN. Diagnostic accuracy of Fibre endoscopy NS, Bulstrode JK. Editors; Bailey and Loves Short Practice in the detection of upper intestional malignancy; a follow up of Surgery; Arnold, International Student Edition; 23rd ed. analysis. Gastroenterology. 1997;73:710. 2000:918-926. 21. Xi W D, Zhao C, Ren G S , Endoscopic Ultrasonography in 3. Dohery GM, Way LW, Stomach and Duodenum Way LW. pre operative staging of gastric cancer : determination of tumor Dohery GM. Editors. Current Surgical Diagnosis and invasion depth, nodal involvement and surgical resectability. Treatment; International edition; Gastric Carcinoma: 11th ed. World J Gastroenterol 2003; 9(2 ) : 254-257. 2003:556-559. 22 Yasuda K, Shirishi N, Sumatsu T, Yamaguchi K, Adachi Y , 4. Deodhar SD, Mohite JD, Joshi AS, Vora IM. Gastric Kitano S. Rate of detection of lymph node metastasis is carcinoma in the young (review of 14 cases). J Postgrad Med. correlated with the depth of submucosal invasion in early stage 1990;6:27-30. gastric carcinoma ; Cancer 1999; 85 : 10; 2119 -23 5. Alam AMMS, Chowdhury T, Anwar S, Jagirder MSU, Hosen 23. Moing S P, Zirbes T K, Schroder W , Baldus S E, Lindermann MM. Cancer in Chittagong: A cancer based survey. JCMCTA. DG, Dienes H P, Holscher A H. Staging of gastric cancer : 1994;5 (S2): 6-25. correlation of lymph node size and metastatic infiltration. American Journal of Roentgenology. 1999 ;173 ( 2): 365-367. 6. Khan FA, Shukla AN. Pathogenesis and treatment of gastric carcinoma. Res Ther. 2006;2:196-199. 24. Serlin O, Keehn R, Higgins G, Harrower HP, Mendeloff G. Factors related to survival follow resection for gastric 7. Milne AN, Sitraz R, Carvalho R, Carnerio F , Offerhaus A, carcinoma analysis of 903 cases. Cancer. 1977,40:1318. Johan G. Early Onset Gastric cancer: On the road to unraveling 25. Papaachriston D, Shui M. Management by enbloc multiple gastric carcinogenesis . Current Molecular Medicine 2007 ; organ resection of carcinoma of the stomach invading adjacent 7 ( 1 ) ; 15-28. organs. Surg Gynaecol Obstret. 1981:46. 8. Bellegie NJ, Dahlin DC. Malignant disease of the stomach in 26 Kitano S, Shiraishi N, uyama I, Sugihara K, Tanigawa N. A young adults; Ann Surg. 1953;138:7-12. multicenter study on oncologic outcome of laparoscopic 9. Mc Neer G, Pack GT. In “Neoplasms of the Stomach” London: gastrectomy for early gastric cancer in Japan. Ann Surg. 2007; Pitman Medical Publishing Co. 1967; pp 126. 245 ( 1 ): 68-72. 10. Sharma GC, Vickers P. Gastric carcinoma in the young. Ind J 27. Lyon D, Knowels J, Slater B and Kennedy R. Improving the Surg. 1976;38:207-210. early presentation of cancer symptom in disadvantaged communities : putting local people in control. Br J cancer ; 11. Tamura PY, Curtiss C. Carcinoma of the stomach in the young 2009; 101 (52 ): s49-s54. adult. Cancer 1960;13:379-385. 28. Barr H, Greeall MJ. Carcinoma of the stomach; Morris PJ 12. Cherian JV, Sivaraman R , Muthusamy AK, Venkataraman J. and Mac RA editor; Oxford Textbook of Surgery; vol.1; Stomach carcinoma in the Indian sub-continent : A 16 year Oxford Medical Publication; 931-943. trend; Saudi J Gastroenterol 2007; 13 : 114-117. 29. Sayeed A. Management of carcinoma of stomach: problems 13. Eskander H, Shostari S, Hossein M, Rahim M, Jalaj H, and Strategies. J Bangladesh College of Physicians and Meherdad A et al. Clinical profile of gastric cancer in Surgeons. 1999;17 (2) :54-57.

150 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 Student’s Opinion Towards the Assessment System of Revised Undergraduate Medical Curriculum - An Experience in A Private Medical College R NAZNEENa, HK TALUKDERb, MZ HOSSAINc

Summary: the student was not compulsory to maintain secrecy. 5 point Objectives: The aim of the study was to assess the attitude Likert scales was used to measure the responses of the of the undergraduate medical students towards the participants. Statistical analysis was done using the SPSS assessment system of revised medical curriculum. system version 11. Materials and Methods: Study design: It was a -descriptive Results: Out of 82 students, 70 participated. Among them, cross sectional study. Study period: From February 2008 to 37.1% were male, and 48.6% were female students. 44.2 % April 2008. said that the curriculum and 35.7 % said that the exam Setting: Department of Obstetrics and Gynaecology in Holy system is easy to follow, 47.1 % wanted to have single subject Family Red Crescent Medical College and Hospital. and 65.7% wanted to have all the major subjects Sample size: Total 82 students were selected for the study simultaneously in block posting. 74.1 % said that the 6 hours out of which 70 participated. learning period is tiring. 42.9 % were in favour of 3-6 pm break, 64.3% were in favour of giving MOCK test weekly, Inclusion criteria: students who were selected for the final 55.7 % liked formative assessment test, 64.3 % did not adopt MBBS examination. any unfair means in the examination, 78.6% students are Exclusion Criteria: Students not qualified for final comfortable with MCQ,81.4 % with SAQ, about 41.5% with professional examination. SEQ, 74.2% with OSPE, 71.5% with SOE and 77.2% liked Procedure: During the placement of the students in the Clinical examination. department of Obstetrics and Gynaecology, the basic idea Key Words: Under graduate medical Curriculum, Students of the old and the new curriculum was explained to them. opinion. The objective of the study was explained and a pretested questionnaire was given to each student. Identification of (J Bangladesh Coll Phys Surg 2010; 28: 151-156)

Introduction: the medical graduates are far from expectations of the Many leading medical schools in the world have stake holders 2. A number of cross-cultural studies have extensively revised their respective course curriculum to looked closely at the study approaches using Biggs’ prepare ‘Today’s Medical Students’ to become Study Process Questionnaire (SPQ) in various countries ‘Tomorrow’s Doctors’1. Medical curricula need to be worldwide including Asia. defined in accordance to the needs of specific Study has been done using revised version of the communities. Skills and attitude components have questionnaire (R-SPQ-2F) among the Pakistani students recently started receiving such attention in curricula. in tertiary institutions3. But the scenario is a little The concern is growing that the teaching and assessment different in our settings. After the adoption of the new of clinical skills lacks uniformity and that the skills of curriculum in the medical colleges all over the country, students have become frustrated and worried4. In the a. Dr. Rumana Nazneen, Associate Professor, Obs. & Gyn Deptt. new system, every professional examination will be held Holy Family Red Crescent Medical College & Hospital. b. Dr. Humayun Kabir Talukder, Associate Professor, Teaching two times in a year after six months. In this system, Methodology, Centre for Medical Education (CME), BMRC. pass marks has been fixed at sixty per cent. Since the c. Dr. Md. Zakir Hossain. Dental Surgeon and Research Faculty of medicine has gone through a successful Assistant, CME. revolution in launching the new MBBS curriculum in Address of Correspondence: Dr. Rumana Nazneen . MBBS, FCPS. 2002, now on the verge of final professional ( Gynae/Obs.), House no. 29. Road no. 12 A New. Dhanmondi R/A. Dhaka 1205, Cell no. 01713032794 examination, few opinions has arisen from the final year Received: 31 August, 2008 Accepted: 2 September, 2010 students regarding their adaptation with the curriculum. Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010

With that point in mind this study has been done to assess informed of the role that their feedback plays an their opinion about it. important role in changing the curriculum. The objective of the study was explained and a pretested questionnaire Objectives of the study: was given to each of them. Identification of the student • The aim of the study was to know the opinion of the was not compulsory for privacy issue. At the end of the undergraduate medical students towards the placement, students filled up the questionnaire to give assessment system of revised medical curriculum. their opinion regarding the curriculum and also their • To analyze the student’s evaluation and attitude towards it. The questionnaire consisted of 14 implementation of the idea to overcome the statements. The respondents had to indicate their degree shortcomings of teaching curriculum. of agreement with the individual statements using a 5 point Likert scale. Statistical analysis was done using Materials and Methods: the SPSS system version 11. Study design: It was a descriptive cross sectional study. Study period: From February 2008 to May 2008. Result: Setting: Department of Obstetrics and Gynaecology in Table-I Holy Family Red Crescent Medical College and Distribution of the respondents as per their Gender. Hospital. Sample size: Total 82 students of were selected for the study out of which 70 participated. Inclusion Gender Frequency % criteria: Students who were selected for the final MBBS exam. Exclusion Criteria: Students ineligible for the final Male 26 37.1 professional examination. Procedure: A total of 70 Female 34 48.6 students participated in the study. During the placement Total 60 85.7 of the students in the department of Obstetrics and Missing System 10 14.3 Gynaecology, the basic idea of the old and the new Grand total 70 100.0 curriculum was explained to them. Students were Table-II

Distribution of the respondents according to different aspects of revised curriculum. (n= 70)

Different events Level of opinions of revised curriculum Strongly Disagree Neither Agree Strongly Total Missing Grand disagree agree nor agree System Total disagree Simplicity of F 2 9 18 26 5 60 10 70 Present curriculum % 2.9 12.9 25.7 37.1 7.1 85.7 14.3 100 Simplicity of F 3 15 17 22 3 60 10 70 Examination system % 4.3 21.4 24.3 31.4 4.3 85.7 14.3 100 Block posting in 1 F 8 13 6 28 5 60 10 70 subject per rotation % 11.4 18.6 8.6 40 7.1 85.7 14.3 100 is help full for learning Bl. posting should F 5 5 3 36 10 59 11 70 contain all the major % 7.1 7.1 4.3 51.4 14.3 84.3 15.7 100 subjects in single rotation Learning hours F 4 1 3 8 44 60 10 70 % 5.7 1.4 4.3 11.4 62.9 85.7 14.3 100 3-6 pm break will be F 10 13 7 16 14 60 10 70 better for learning % 14.3 18.6 10 22.9 20 85.7 14.3 100 * F- Frequency, % = Percentage.

152 Student’s Opinion Towards the Assessment System of Revised Undergraduate R Nazneen et al.

Table-III

Distribution of the respondents according to different aspects of examination system. (n=70).

Weekly Twice a Once a Total Missing month month system Frequency of taking mock tests F 45 12 3 60 10 % 64.3 17.1 4.3 85.7 14.3 yes no Liking of formative assessment examination F 39 16 55 15 % 55.7 22.9 78.6 21.4 Adoption of any unfair means in the exam F 3 45 48 22 % 4.3 64.3 68.6 31.4 Saw others to do the same F 21 34 55 15 % 30.0 48.6 78.6 21.4 Having sufficient time for study F 8 51 59 11 % 11.4 72.9 84.3 15.7 * F- Frequency, % = Percentage Table-IV

Distribution of the respondents as per comfortableness in different type of assessment examination . (n=70).

Type of examination Degree of comfortableness Highly Comfortable Mildly Not Don’t Total Missing comfortable Comfortable Comfortable know System MCQ. F 30 18 7 5 0 60 10 % 42.9 25.7 10.0 7.1 85.7 14.3 SAQ. F 16 33 8 3 60 10 % 22.9 47.1 11.4 4.3 85.7 14.3 SEQ F 13 16 29 1 59 11 % 18.6 22.9 41.4 1.4 84.3 15.7 OSPE. F 11 26 15 6 1 59 11 % 15.7 37.1 21.4 8.6 1.4 84.3 15.7 SOE F 4 23 23 3 5 58 12 % 5.7 32.9 32.9 4.3 7.1 82.9 17.1 Clinical examination F 13 25 16 4 2 60 10 % 18.6 35.7 22.9 5.7 2.9 85.7 14.3 * F- Frequency, % = Percentage MCQ-Multiple Choice Question, SAQ-Short Answer Question, SEQ- Structured Essay Question, OSPE-Objective Structured Practical Examination, SOE-Structured Oral Examination.

Table I shows the gender distribution among the Table-II shows the distribution of the respondents students. Out of 82 students, 70 participated. Among according to different aspects of revised curriculum. Regarding simplicity of the curriculum, 37.1 % (26) them, 37.1% (26) were male student, and 48.6% (34) agreed that the curriculum is easy to follow, 25.7% (18) were female student. 10 respondents did not mention neither agreed nor disagreed to the question. 7.1 % (5) their gender and mentioned as missing system. agreed strongly and 12.9 % (9) disagreed.

153 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010

Out of 70 students, 31.4 % (22) agreed that the with MCQ, 25.6 % (18) are comfortable, mildly examination system is easy to follow. 24.3 % (17) comfortable 10% (7) & not comfortable are 7.1% (5). respondents neither agreed nor disagreed to the question. About SAQ, 22.9 % (16) are highly comfortable, 47.1% 21.4 % (15) Disagreed, Strongly disagreed 4.3 % (3) & (33) are comfortable, 11.4% (8) are mildly comfortable the same percentage strongly agreed. and 4.3% (3) are not comfortable. Again, 40 % (28) respondents agreed that the block As with SEQ, 18.6% (13) are comfortable, 22.9% (16) posting in one subject at a time per rotation is effective mildly comfortable, 41.4% (29) not comfortable. 1.4 for learning.8.6 % (6) respondents neither agreed nor % (1) did not comment on this. disagreed. 11.4 % (8) strongly disagreed, 7.1% (5) strongly agreed & disagreed 18.6 % (13). Regarding OSPE, 37.1 % (26) are comfortable, highly comfortable & mildly comfortable are 15.7% (11) & Among the same respondents, 51.4 % (36) agreed that 21.4% (15) respectively, 8.6 % (6) not comfortable 1.4 block posting should contain all the major subjects % (1) did not give any opinion. simultaneously per rotation. Strongly agreed 14.3 % (10), strongly disagreed 7.1 % (5), same proportion About SOE, 32.9 % (23) are comfortable with it, same disagreed & 4.3 % (3) neither agreed nor disagreed. percentage is mildly comfortable, 5.7 % (4) are highly comfortable, and 7.1% (5) do not know about this. Out of 70 students, 62.9 % (44) respondents strongly 17.1% (12) did not give any opinion. agreed that the 6 hours learning period is tiring. 4.3% (3) respondents neither agreed nor disagreed to the As with Clinical examinations, 35.7 % (25) are question. 11.4 % (8) agreed, 1.4% (1) disagreed and comfortable with it, 18.6 % (13) are highly comfortable, 5.7 % (4) strongly disagreed to the question. 22.9% (16) are mildly comfortable, not comfortable Regarding the break time, 20 % (14) respondents 5.7% (4) & did not know about it are 2.9% (2). strongly agreed that the 3-6 pm break will be better for All parameters were statistically analyzed by T test by learning eventually. 14.3 % (10) disagreed strongly. SPSS package system version 11. 18.6% (13) disagreed, 22.9 % (16) agreed & 10 % (7) respondents neither agreed nor disagreed to the question. Discussion: Student’s evaluation of any teaching curriculum is a Table III shows the opinion of the students about firmly recommended part of the teaching-learning various aspects of the examination system. 64.3 % (45) process and is aimed at achieving the desired objectives. students were in favour of giving MOCK test weekly, The concept of “adult learner” in the teaching–learning 17.1% (12) were in favour of twice a month and 4.3 % process further authenticates the utility of a feedback (3) , once a month. from students to evaluate teaching curriculum. However, Again, 55.7 % (39) respondents were in favour of giving it also has to be remembered that such an exercise is formative assessment test, 22.9 % (16) in favour of useful only if the student’s evaluation is analyzed and summative test. 15 students did not make any comment implemented to further overcome the shortcomings of on this . teaching curriculum5. The students overall, had a Regarding adoption of unfair means in the examination, positive opinion regarding the newly implemented 64.3 % (45) students did not do so, 4.3 % (3) adopted, curriculum in MBBS. The recent change of the 30 % (21) saw others to do and 48.6 % (34) did not see curriculum was done to make the knowledge more any one to do so. 22 students did not give any comment practically applicable for the benefit of the patient. Since on the former part & 15 in the following part of this the curriculum is new for both the teachers and the question. students, implementation of it was a little bit difficult. But the result of the study revealed the positive reception Out of 70 students, 72.9 % (51) expressed that they did of most medical students to it. Likert scale grading was not get sufficient time for study themselves during block more than 3 in majority of the questions (Q.1 to 6). But posting. 11.4% (8) student got time for study for their own. there are some issues regarding the flaws of the system. Table IV revealed the comfortableness with the According to the new syllabus, first professional examination, 42.9 % (30) students are highly comfortable examination will be held after eighteen months, second

154 Student’s Opinion Towards the Assessment System of Revised Undergraduate R Nazneen et al. professional after two years from the earlier professional 11. Students must be informed of the role that their examination and third professional will be held after feedback plays in changing the curriculum. It will be fair eighteen months from the second professional to say that many issues remain unresolved, but students’ examination. In the new system, every professional opinion must not be ignored and the information that has examination will be held two times in a year after six been gathered here should contribute to the GMC’s months. In this system, pass marks has been fixed at consultations before any policy changes are implemented sixty per cent4. So the failed student will fall behind for 12. Problem-based learning (PBL) has been six months from his batch mates and he will be treated acknowledged as a method that enhances integration of as an irregular candidate in the next examination. In learning, self-directed learning and provides relevance this process, this is not clear where the unsuccessful and context to the subject. It is also used to prepare student would be placed? The authorities have not yet students for professional life as physicians 13. The use of decided which batch they would belong to. So this PBL has been reported from several medical colleges 13- problem should be properly addressed, evaluated and 15. To overcome some of the shortcomings of a purely solved. As the new curriculum is implicated from 1st PBL curriculum some schools in New Zealand, have used year, the new batches do a hybrid system in their preclinical curriculum 15. The not face much problem to follow this. There are pros programme used newer educational methods within a 16 and cons of each system. In the field of medical conventional curriculum . So there should always be an option for a versatile method of assessment system in education, new trends are emerging in teaching and curriculum of medical education. Groups of faculty learning as well as in assessment of students 6. More experts identified specific desired outcomes, referred to emphasis is now being placed on the learning outcomes as “standards,” for each competency 17. A modified and its integration with the curriculum. Students are now Delphi approach was used to engage these groups of required to possess a breadth of skills - abilities, experts to define the developmentally appropriate adaptabilities, problem solving talents, creativity and standards for each competency at the ends of year one communication skills - all the necessary competencies and year two and at graduation (year five) 18. Medical to be a professional7. education has revolutionized through the years to reach perfectness in curriculum making and assessment system. Conclusion: And student opinion plays a very important role in it. The overall impact of the system is effective, practical and student friendly which have the potentiality of Recommendations: fulfilling the criteria to create a professional medical The overall system is very student friendly and practical. person. The findings have important implications for But there are some pitfalls which could be overcome curriculum development and review regarding the very easily. Since the system is implimented for the best implementation and conduct of strategies for reflection, benefit of the students, learning hours and the break time can be rearranged specially during the block and the impact on student learning. The development placements. Students should have some time of there and delivery of an undergraduate medical curriculum is own for preparing themselves for examinations. Another a far- point can also be mentioned that they should cover the reaching and complex system with many stakeholders. major subjects concurrently in the rotation during their Of these stakeholders, no group better understands the block placements. Usually they are placed rotation wise intricacies or is better equipped to comment on the in a single subject at a time in their block placement. strengths and weaknesses of a program than its students Mostly the problem of such arrangement was that, by 8. A study from the United Kingdom 9 observed that when the time they complete their present placement they medical students were instructed on methods of providing forget the learning from the previous one. At least 4 feedback (through exercises of reflection and discussion), classes (3 recapitulation classes and 1 review class) of other subjects beside the main subject they were more confident in the feedback they were able to provide and could attribute it to this newly learned will help them to remember their learning. More skill set. An important first step in soliciting meaningful assessments of the system will reveal the competency and constructive feedback is “student empowerment” 10- of it for the fulfilment of the criteria.

155 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010

Acknowledgement: 8. David C, Dorothy T, Elizabeth A, Undergraduate Medical My deepest gratitude and thankfulness are extended to Education Curriculum Renewal. Student Responsibility for the Curriculum. November, 2009; Dalhousi University, all my students of HF-4, Holy Family Red Crescent Faculty of medicine. Medical College for their help and cooperation. Also I 9. Hammond, A., Collins, S., Booth, J., & Kalia, S. (2009). thank Miss Rojina Akter Khanom, research manager, Learning from evaluation: A descriptive, student-informed Insights and Ideas, Bangladesh, for her technical support approach. The Clinical Teacher, 6, 73 – 78. in data processing and analysis. 10. Abrahams, M.B., & Friedman, C.P. (1996). Preclinical course- evaluation methods at U.S. and Canadian medical schools. References: Academic Medicine, 71, 371 – 374. 1. Boud D. and. Feletti G, London/Stirling (USA): Kogan Page 11. Griffin, A., & Cook, V. (2009). Acting on evaluation: Twelve Ltd, Taking Medical Education into the New Millennium: tips from a national conference on student evaluations. Implementing Problem-based Learning (PBL) in the Faculty Medical Teacher, 31, 101 – 104. of Medicine by the Dean & Members of PBL Committee 12. Kamran Z Khan, John W Sear, Downloaded from Faculty of Medicine Jul 1999 Vol. 3 No. 2. pmj.bmj.com on September 2, 2010 - Published by 2. Rashida A, Naqvi1 Z & Wolfhagen I; Psychomotor Skills for group.bmj.com. the Undergraduate Medical Curriculum in a Developing 13. Antepohl W, Domeij E, Forsberg P, Ludvigsson J. A follow- Country—Pakistan 1 Aga Khan University, Karachi, Pakistan, up of medical graduates of a problem-based learning and 2 Maastricht University, Maastricht, The Netherlands. curriculum. Med Educ 2003;37:155–62. 3. Siddiqui, Zarrin S; Study Approaches of Students in Pakistan: 14. Ghosh S, Dawka V. Combination of didactic lecture with The Revised Two-factor Study Process Questionnaire problem-based learning sessions in physiology teaching in a Experience. developing medical college in Nepal. Adv Physiol Educ 2000; 24:8–12. 4. Arif Bulbon S; Medical students worried over curriculum change: Mon, 31 Oct 2005, 11:16:00 New Nation Online 15. Bhattacharya N, Shankar N, Khaliq F, Rajesh CS, Tandon Edition. Copyright 2003 by ittefaq.com. OP. Introducing problem-based learning in physiology in the conventional Indian medical curriculum. Natl Med J India 5. Tyagi A. Ahuja, S, Bhattacharya A, Undergraduate medical 2005;18:92–5. students assessment of teaching curriculum – A cross sectional 16. VYAS r., et al. An effective integrated learning programme study. 186 Indian Journal of Anaesthesia, June 2002. in the first year of the medical course the national medical 6. Newble D.I. ASME, Medical Education Booklet No.25. journal of india 2008; 21:.21-26 . Assessing clinical competency at the undergraduate level. 17. Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin Association for the study of Medical Education. Dundee, C. Shifting paradigms: Educational Strategies 500 Academic Scotland, 1992. Medicine, Vol. 82, No. 5 / May 2007 from Flexner to 7. ROUF S, MAJID A :Performance of Postgraduate students in competencies. Acad Med. 2002;77:361–367. Objective Structured Practical Examination (OSPE) in the 18. Elaine F. Dannefer, and Lindsey C. Henson, The Portfolio Speciality of Obstetrics and Gynaecology .Journal of Approach to Competency-Based Assessment at the Cleveland Bangladesh College of Physicians and Surgeons. Vol. 25, No. Clinic Lerner College of Medicine. Educational Strategies 1, January 2007. 498 Academic Medicine, Vol. 82, No. 5 / May 2007.

156 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 Estrogen Receptor, Progesterone Receptor, and Her-2/neu Oncogene Expression in Breast Cancers Among Bangladeshi Women MG MOSTAFAa, MT LARSENb, RR LOVEb

Summary: Results: Estrogen Receptor expression was positive in Two-thirds of all women who develop breast cancer each 69.0%, PR expression was positive in 72.3%, and Her-2/ year live in Asia. In many countries, including Bangladesh, neu was over-expressed (IHC score 3+) in 28.4% of the there are few data on the pathological characteristics of cases. Her-2/neu over-expression did not consistently breast tumours. The objectives of this study were a) to correlate with ER and PR expression. ER and PR describe the estrogen receptor (ER), progesterone receptor expression were inversely associated with tumour (PR), and the expression of Her-2/neu oncogene expression histological grade. Cases with axillary lymph node metastases had higher rates of ER and PR expression. No status in a large series of breast cancers occurring in significant association was observed with patient’s age. Bangladeshi women and b) to correlate these findings with the patients’ age at diagnosis, tumour histological grade, Conclusion: Estrogen Receptor, PR, and Her-2/neu and presence of axillary lymph node metastatic disease. expression frequencies and prognostic factor associations in Bangladeshi women with breast cancer referred for Method: One thousand forty two cases were evaluated in a tumour marker testing are very similar to those reported in referral practice. Tumour sections were stained Western countries. These findings have important immunohistochemically using Dako 1D5 (ER) and Dako implications for ensuring optimal testing capacity for all 636 (PR) and semiquantitatively scored for ER and PR patients with these tumours, to allow for appropriate choices expression. Three hundred thirty five of these cases were of treatment. also stained using Dako c-erb2 oncoprotein and scored for Her-2/neu over-expression. (J Bangladesh Coll Phys Surg 2010; 28: 157-162)

Introduction: countries, including Bangladesh, there has been a The causes of cancer and time of its appearance varying widespread impression that the frequencies of expression among populations and thus it may be expected that the of hormonal receptor proteins in breast tumours are biological characteristics of tumours among populations significantly lower than those seen in western women. would differ. However, for breast cancer, with the Such impressions have led to reluctance to even assess exception of greater frequencies of inherited cancer patients’ tumours for these proteins because “the tumours susceptibility genes such as BRCA 1 and 2, there has are always negative”. In these circumstances, women been little evidence of different causes among populations are not offered the possibility of hormonal treatment, from and generally when population comparisons have been which benefits are only expected in the face of expression carefully made. The most commonly described biological of hormonal receptor proteins in the tumours 2. Her-2/ characteristics of tumours—the histological types and neu over-expression in tumours has been associated with grades, and hormonal receptor expression have been resistance to one form of hormonal therapy that is with 1 similar across populations . Nevertheless, in some tamoxifen 3. a. Mohammad Golam Mostafa, M.B.B.S., M. Phil (pathology), In these contexts the objectives of the current study were, The National Institute for Cancer Research Hospital Dhaka in a large series of cases of breast cancer among and Consultant Anwara Diagnostic Center, Dhaka (MGM) Bangladeshi women: a) to ascertain the estrogen b. Michael T. Larsen, The College of Medicine, The Ohio State receptor (ER) status, the progesterone receptor (PR) University, Columbus, Ohio, U.S.A. (MTL and RRL), Richard status, and the over-expression of Her-2/neu oncogene; R. Love, M.D, The College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A. (MTL and RRL). and b) to evaluate correlations of these results with Address of Correspondence: Mohammad Golam Mostafa, email: each other and with patients’ ages at diagnosis, tumour [email protected] histological grading, and evidence of axillary metastatic Received: 20 June, 2009 Accepted: 26 May, 2010 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 lymph node involvement in those patients with clinical mounted for analysis. For each run of staining, a positive stages I-III breast-operated disease. and negative control slide was also prepared. The positive control slides were prepared from breast Materials and Methods: carcinoma known to be positive for the antigen under A retrospective study of one thousand forty two breast study. The negative control slides were prepared from cancer specimens was done from patients of different the same tissue block, but incubated with PBS instead districts of Bangladesh during the period of January of the primary antibody. 2003 to April 2008. These specimens were received originally as surgical specimens fixed in 10% formalin A semi-quantitative histochemical score was used to at Anwara Diagnostic Center (ADC) in Dhaka. The record results of ER and PR staining according to the 4 specimens received were mastectomies, lumpectomies, system established by Allred et al. . This system Trucut biopsies, wide local excisions or chest wall skin considers both the pro-portion and intensity of stained biopsies. These surgical specimens were then fixed in cells. The intensity score (IS) ranges from 0 to 3, with 0 10% neutral buffered formalin for 24 hours and then being no staining, 1 weak staining, 2 intermediate the tissue was processed for routine hematoxylin and staining, and 3 intense staining. The proportion eosin staining through the steps of dehydration, clearing, score (PS) estimates the proportion of positive tumour paraffin impregnation and finally sectioning and cells and ranges from 0 to 5, with 0 being non-reacting, staining. 1 for 1% reacting tumour cells, 2 for 10%, 3 for one- third, 4 for two-thirds , and 5 if 100% of tumour cells Sections were cut at 4 µm thickness, mounted onto show reactivity. The PS and IS are added to obtain a salinized slides, and left to dry overnight at 37°C. total score (TS) that ranges from 0 to 8. Tumour cells Sections were then deparaffinized and rehydrated. with a total score of 3 to 8 were considered positive, Antigen retrieval was achieved by heat retrieval using a whereas those with TS less than 3 were considered bench autoclave. Briefly, slides were placed in Coplin negative cases. jars containing enough TrisEDTA (pH 9.0) to cover the sections, then autoclaved at 121°C for 15 minutes for Her-2/neu was scored on a 0 to 3 scale according to the both ER and PR. For Her-2/neu, the slides were placed criteria set by Dako. The staining was scored as: in Coplin jars containing enough Citrate buffer (pH 6, negative (0) when no membrane staining was observed, Dako, Denmark) to cover the sections, and autoclaved or when membranous staining was observed in less than at 121° C for 10 minutes. After washing, the sections 10% of the tumour cells; weak positive (1+) if weak were covered by applying Endogenous Enzyme Block focal membrane staining was seen in more than 10% of for 10 minutes (3% hydrogen peroxide from Dako the tumour cells; intermediate (2+) if weak to moderate, Denmark), the slides were then rinsed with Phosphate complete membrane staining was seen in more than 10% of the tumour cells; and strongly positive (3+) if intense Buffer Solution (PBS). Slides were incubated with100– membrane staining with weak to moderate cytoplasmic 200 µl of primary antibodies for 30 minutes at room reactivity was seen in more than 10% of the tumour temperature in a moisture chamber, then rinsed in PBS. cells. The procedure was standardized in comparison The dilution of the primary antibodies against ER (Dako with Dako Hercep kit. clone 1D5, Denmark) and PR (Dako, clone PgR636, Denmark) was 1:130, and for Her-2/neu (c- Results: erb2oncoprotein, Dako, Denmark) was 1:50. Then the The study population consisted of One thousand forty slides are incubated with Horse Redish Peroxidase two female patients with invasive breast cancer with (HRP) labelled polymer which is conjugated with tumour tissues. Patients‘ mean age at diagnosis was secondary antibodies (Dako Label polymer). Finally, 45.6 years. Infiltrating ductal carcinoma (IDC), not the sections were washed for four times in four minutes otherwise specified (NOS), accounted for 986 (94.6%) with changes of PBS, followed by adding 3,3 of cases. Tweenty five patients were diagnosed with diaminobenzidine tetra hydrochloride (Dako) as a metastatic ductal carcinoma, 12 with infiltrating lobular chromogen to produce the characteristic brown stain. carcinoma, nine with mucinous carcinoma, six with The sections were then counterstained, dehydrated, and medullary carcinoma, two with metaplastic carcinoma,

158 Estrogen Receptor, Progesterone Receptor, and Her-2/neu Oncogene Expression MG Mostafa et al. one with tubular carcinoma, and another one with status (Table II). As the ER IHC scores increased from Paget’s disease 5. Nine hundred eighty seven of the two to seven, Her-2/neu over-expression continually cases were graded histologically, 11 (1.1%) were well- decreased from 63.6% to 0%. In addition, when the differentiated (Grade I); 351 (35.6%) were moderately data was divided into three groups based on low (0-2), differentiated (Grade II), and 625 (63.3%) were poorly medium (3-5) and high (6-8) ER IHC staining, statistical differentiated (Grade III) 6. power was gained and a strong correlation was seen. Table-I Forty (40.3%) percent of those specimens that had an ER, PR, Her-2 Status of the histological specimens IHC score of 0 to2 over-expressed Her-2/neu, 26.1% of those with a score between 3 to 5 were her-2/neu Histological Patients positive, and only 22.0% of those with a score between marker No. (%) 6 to 8 were Her-2/neu positive (correlation r= -0.95). HR (n=1042) This inverse correlation can also be seen by looking at ER+ 719 (69.0) the ER IHC score distribution of Her-2/neu + and Her- PR+ 753 (72.3) 2/neu - cases. A greater percentage of the Her-2+ cases ER+,PR+ 698 (67.0) are distributed amongst the lower ER IHC scores ER+,PR- 21 (2.0) compared to the Her-2- cases, where a greater ER-,PR+ 55 (5.3) percentage of the Her-2- cases is distributed amongst ER-,PR- 268 (25.7) Her-2 (n=335) the higher ER IHC scores. For example, 32.6% of Her- Her-2 + 95 (28.4) 2/neu + cases had an ER IHC score of 0 to 2, and only HR, hormone receptor; ER, estrogen receptor; PR, progesterone 18.9% of the Her-2+ cases had a score between 6-8. receptor; Her-2, Human epidermal growth factor receptor 2; +, Conversely, only 5.0% of Her-2/neu - cases had an IHC positive; -, negative score of two, while 26.7% of the Her-2- cases had an The estrogen and progesterone receptors and Her-2/neu IHC score in the range of 6-8. expression status of the tumours is summarized in Table Biological tumour marker expression was not correlated I. Of note, 69.0% (719/1042) of the specimens were with patient age at diagnosis (Table-III). Similarly, age ER positive, 72.3% (753/1042) were PR positive, and was not significantly correlated with tumour grade or 28.4% (95/335) of the specimens tested for Her-2/neu axillary lymph node status. were positive. A tumour was considered to be “positive” or to over-express Her-2/neu if it had an IHC score of No significant associations were seen among tumour 3+. There was a strong correlation seen between ER histological grade and dichotomous hormonal receptor and PR status: when tumours were ER positive, 97.1% or Her-2/neu expression status (Table-IV). Significant (698/719) were also PR positive; similarly, when differences were seen however when the IHC scores of tumours were ER negative, 83.0% (268/323) were the histological grades were investigated. Table-V simultaneously PR negative. Also, thirty tumours (9.0%) shows these trends. With greater histological were “triple negative” for ER, PR and Her-2 over- differentiation, tumours had higher ER IHC scores. For expression. example, a much higher percentage of Grade I tumours A consistent relationship was not seen between Her-2/ had ER IHC scores in the 5-8 range (72.7%), meaning neu over-expression and HR status, likely because of a strongly positive, than did the Grade II (47.9%) or Grade lack of statistical power. Overall, 22.7% (10/44) of ER III tumours (40.8%) (p=0.015, chi-square). The same negative cases showed Her-2/neu over-expression could be seen with PR expression: 72.7% of Grade I, compared to 29.2% (85/291) of the ER positive cases; 52.7% of Grade II, and 45.9% of Grade III had IHC however, this positive relationship was not statistically scores of 5-8 (p=0.035, chi-square). significant (p=0.37, chi-square). On the other hand, statistical power was gained when ER status was Cases with axillary lymph node metastases had a slightly stratified by IHC score, and an inverse relationship was higher Her-2/neu over-expression (29.5%) (31/105) than then seen between Her-2/neu over-expression and HR those without (27.8%) (64/230) (p=0.75, chi-square).

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Table-II

ER IHC scores in 335 Her-2-assessed cases

Her-2+ [n=95] Her-2- [n=240] IHC Score No. (%) No. (%) Her-2 Overexpression 0 10 (10.5) 34 (14.2) 10/44 22.7%

2 21 (22.1) 12 (5.0) 21/33 63.6%

3 3 (3.2) 7 (2.9) 3/10 30.0%

4 20 (21.1) 54 (22.5) 20/74 27.0%

5 23 (24.2) 69 (28.8) 23/92 25.0%

6 8 (8.4) 38 (15.8) 8/46 17.4%

7 0 (0.0) 2 (0.8) 0/2 0%

8 10 (10.5) 24 (10.0) 10/34 29.4%

0 (ER-) 10 (10.5) 34 (14.2) 10/44 22.7%

2-8 (ER+) 85 (89.5) 206 (85.8) 85/291 29.2%

2 21 (22.1) 12 (5.0) 21/33 63.6%

3-5 46 (48.4) 130 (54.2) 46/176 26.1%

6-8 18 (18.9) 64 (26.7) 18/82 22.0%

Table-III Table-IV

Biological tumour marker expression by Age ER, PR, and Her-2/neu expression by Histological Grade <50 yrs old ³50 yrs old p-value Grade I (%) Grade II (%) Grade III (%) ER+ 68.9% 69.1% 0.96 ER PR+ 71.2% 74.1% 0.32 Cases 11 351 625 Her-2+ 29.8% 26.0% 0.45 ER+ 9(81.8) 241(68.7) 429(68.6)

There was a statistically significant difference in ER PR expression between the cases that had lymph node Cases 11 351 625 involvement (85.4%) (205/240) and those that did not (64.1%) (514/802) (p<0.001, chi-square). A similar PR+ 9(81.8) 255(72.6) 449(71.8) association was seen with PR expression: 86.7% (208/ Her-2 240) of the cases with lymph node involvement were Cases 5 106 210 positive, while 68.0% (545/802) of the cases without lymph Her+ 0 34(32.1) 58(27.6) node involvement were PR+ (p<0.001, chi-square).

160 Estrogen Receptor, Progesterone Receptor, and Her-2/neu Oncogene Expression MG Mostafa et al.

Table-V

Histological grade by HR IHC scores

ER PR Total Grade 1 (%) Grade 2 (%) Grade 3 (%) Total Grade 1(%) Grade 2 (%) Grade 3 (%) 0 323 2 (18.2) 110 (31.3) 196 v(31.4) 289 2 (18.2) 96 (27.4) 176 (28.2) 2 64 0 (0) 17 (4.8) 42 (6.7) 63 0 (0) 17 (4.8) 41 (6.6) 3 17 0 (0) 4 (1.1) 13 (2.1) 13 0 (0) 3 (0.9) 10 (1.6) 4 181 1 (9.1) 52 (14.8) 119 (19.0) 170 1 (9.1) 50 (14.2) 111 (17.8) 5 206 2 (18.2) 74 (21.1) 121 (19.4) 217 2 (18.2) 72 (20.5) 132 (21.1) 6 128 2 (18.2) 52 (14.8) 68 (10.9) 132 1 (9.1) 56 (16.0) 71 (11.4) 7 9 0 (0) 4 (1.1) 5 (0.8) 12 0 (0) 6 (1.7) 6 (1.0) 8 114 4 (36.4) 38 (10.8) 61 (9.8) 146 5 (45.5) 51 (14.5) 78 (12.5) 2-4 1 (9.1) 73 (20.8) 174 (27.8) 1 (9.1) 70 (19.9) 162 (25.9) 5-8 8 (72.7) 168 (47.9) 255 (40.8) 8 (72.7) 185 (52.7) 287 (45.9)

Discussion: The patients in this series are younger than those The case series reported here is not population-based, reported in most series from high income countries; it but rather composed of referred cases for which most likely reflects the sizes of the different age hormonal receptors and Her-2/neu marker tests were populations in Bangladesh from which these cases come. requested by the physicians obtaining the tissues, and Younger patients are more likely to have higher grade for which the patients were able to pay. Thus this is a tumours, as is observed in this series 8. Younger age selected case series. The degrees of difference in also appears to be an independent adverse prognostic results from those obtainable from a population-based risk factor 8. The observation that cases with axillary series are unknown. Most reports on hormonal receptor nodal metastases were more frequently hormonal and Her-2/neu oncogene expression are similarly of receptor positive, more likely reflects case selection than selected case series, and on few occasions when expression of biological natural history. Patients with population based series have been reported, hormonal receptor negative tumours have biologically interestingly, the frequencies of these markers have and temporally more aggressive disease and, in the been remarkably similar to those found in the same difficult economic and health system circumstances of geographic populations7. most patients in Bangladesh, may be less likely to have In these contexts the most important results of the current tissue samples studied. Finally, in this study the study are those suggesting that the frequencies of ER, previously noted inverse relationship between positive PR and Her-2/neu expression in tumours from Her-2/neu over-expression and positive hormonal Bangladeshi women with invasive breast cancer are very receptor status were also observed. similar to those found in high income country population Diaz, Uy and other authors have emphasized the and most importantly, for ER and PR status, more than importance of tissue management prior to laboratory two third of all patients had tumours that were positive testing, which issues will be explored from this series in for ER, PR or both markers. While higher histological a future communication 9, 10. Here it is emphasized that tumour grade was associated with lower hormonal efforts to place specimens in buffered fixatives within 30 receptor Allred scores, approximately 40% of grade III minutes of surgical removal, and fixation for at least eight tumours were ER or PR moderately or strongly positive. hours are critical factors in assuring likelihood of Thus higher histological grade is a poor predictor of discovery of present hormonal receptor proteins, and hormone receptor status. preventing their destruction and non-detection.

161 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010

Because the presence of hormonal receptor proteins in 2. Early Breast Cancer Trialists’ Collaborative Group. Effects tumours strongly predicts for response to hormonal of chemotherapy and hormonal therapy for early breast cancer therapies, which are less costly and toxic than systemic on recurrence and 15 year survival: an overview of the chemotherapies, the general observation that these randomized trials. Lancet 2005; 365: 1687-1717. proteins are present in more than 2/3rd of cases in 3. Pritchard KI. Endocrine therapy of advanced disease: analysis Bangladeshi women, and that specific testing in and implications of existing data. Clin Ca Res 2003; 9: 460S- individual cases can be successfully accomplished in 467S. Bangladesh are important issues for patients and their 4. Allred DC, Harvey JM, Berardo M, Clark GM. Prognostic physicians 2. The possibility of offering hormonal and predictive factors in breast cancer by treatment to all patients with breast cancer in Bangladesh immunohistochemical analysis. Mod Pathol 1998; 11: 155- must now strongly be considered. Similarly, with 168. respect to Her-2/neu testing, available data strongly 5. Tavassoli FA, Devilee P, Editors: World Health Organization suggest that only Her-2/neu positive tumour-bearing Classification of Tumours. Pathology and Genetics of patients benefit from anthracycline chemotherapies, and Tumours of the Breast and Female Genital Organs. Lyon: thus this testing can potentially save two third of patients, IARC Press 2004. for whom chemotherapy is under consideration, from 6. Todd JH, Williams MR. Confirmation of a prognostic index the expense, gastro-intestinal, haematopoetic and in primary breast cancer. Br J Cancer 1987; 56:489-496. cardiac toxicities of anthracycline treatments 11, 12,13. 7. Carey LA, Perou CM, Livasy CA et al. Race, breast cancer subtypes, and survival in the Carolina Breast Cancer Study. In summary, frequency of hormonal receptor positive JAMA 2006; 295: 2492 - 2502. and Her-2/neu over-expressing tumours in Bangladeshi women with invasive breast cancer to be similar to those 8. Love RR, Duc NB, Dinh NV, Quy TT, Xin Y, Havighurst TC. Young age as an adverse prognostic factor in premenopausal found in patients from high income countries. women with operable breast cancer. Clinical Breast Cancer Limitation: 2002; 2: 294-298. Each breast specimen had taken different times to reach 9. Diaz LK, Sneige N. Estrogen receptor analysis for breast our laboratory as they had come from different parts of cancer: current issues and keys to increasing testing accuracy. Adv Anat pathol 2005; 12: 10-19. the country by different means. They were immersed in 10. Uy GB, Meis PM, Laudico AV et al. Immunohistochemistry 10% formalin immediately after operation and kept in it assay of hormonal receptors in breast cancer: Philippines while transportation. Then they were immediately re-fixed General Hospital Protocol and recommendations for improved in 10% buffered neutral formalin (BNF) solution on testing. Philippine J Surgical Specialties 2007; 62: 128-134. receipt at our laboratory. So, in some cases, (where the 11. Paik S, Bryant J, Park C et al. C erb-2 and response to specimens had travelled long ways from remote areas) doxorubicin in patients with axillary lymph node-positive, complete tissue fixation may have occurred already when hormone receptor-negative breast cancer. J Natl Cancer Inst we received them, causing uneven fixation of the 1998; 90: 1361-1370. specimens, although the number is negligible. However, 12. Paik S. Bryant J, Tan-Chiu E et al. Her-2 and choice of it may have minor influence on our testing accuracy. adjuvant chemotherapy for invasive breast cancer: National Surgical Adjuvant Breast and Bowel Project Protocol B-15. J References: Natl Cancer Inst 2000; 92: 1991-1998. 1. Olopade OI, Grushlo TA, Nanda R, Huo D. Advances in 13. Pritchard KI, Shepherd LE, O’Malley FP et al. Her-2 and breast cancer: pathways to personalized medicine. Clin Cancer responsiveness of breast cancer to adjuvant chemotherapy. Res 2008; 14: 7988-7999. New Engl J Med 2006; 354: 2103-211.

162 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 Gestational Age Predicted by Femur Length in Bangladesh SQ RASHID

Summary: presented here in a tabulated form. Percentiles, mean and Objective: Fetal femur length is an important parameter standard deviations were also derived. The quadratic model for determining gestational age. If we use tables based on showed a good fit to the data. There was a gradual increase Bangladeshi population, gestational age estimation will be of the femur length measurements. From 13 to 27 weeks more accurate. This study was therefore designed to gestation, there was no clinically important difference determine the gestational age by fetal femur length between this and western nomograms for predicting measurement in our country. gestational age but after 32 weeks the difference with western nomograms became significant. Methods: Healthy gravid patients with optimal dates were Conclusion: This nomogram is special for Bangladeshi included in a prospective study. Fetal femur length along population. It will give more accurate gestational age with other parameters was measured. A table and a graph assessment than the western tables that are still followed in were prepared by Polynomial regression model. Previously our country, especially in the 3rd trimester. established nomograms were compared with it. Key Words: Gestational age, femur length, Bangladesh. Results: The gestational age predicted from the femur length measurements of 1223 subjects from 13 to 40 weeks are (J Bangladesh Coll Phys Surg 2010; 28: 163-166)

Introduction: Subjects and Methods: Literature is fraught with studies and tables to determine This was a prospective, cross sectional study. It was gestational age from various fetal parameters. Still we carried out from December 2004 to November 2007. do not have tables by fitting models, for gestational age Structured questionnaires were filled up. Consecutive determination of Bangladeshi population. For this healthy gravid women were studied who met the reason our gestational age assessment is not so accurate, following criteria: especially in the third trimester when the growth trend of our fetuses is less than that of the western fetuses. Regular periods, well-defined last menstrual period Therefore if we use western charts for age determination (LMP), an ultrasound scan before 20 weeks which of fetus there is significant error in gestational age confirmed the LMP age within 10 days, no history of estimation and the fetus may appear small for date even maternal medical, surgical or obstetric complications when it is not. For this purpose this study was conducted, or malnutrition, no uterine anomaly or large fibroids to prepare nomogram of Bangladeshi population, so that and no congenital anomaly of the fetus. we can determine the gestational age more accurately The ultrasonic scans were performed by a single by using our own table. This is of much importance sonologist on one ultrasound machine, by a 3.5 MHz here as gestational age assessment is the most common reason for fetal ultrsonography in our country since curvilinear transducer. This excluded inter-observer routine scanning is not the practice here in most cases. variations. The measurements were made by electronic This is probably due to socio-economic reason. calipers in mm and the gestational age was expressed in weeks (w) with 2 standard deviations (2SD), also The accuracy of femoral measurement in the prediction expressed similarly, in weeks. of fetal age has been shown by various studies. 1,2 That is why this parameter has been selected in this study to The technique of measuring the femur length (FL) assess the fetal age accurately. involves an initial determination of the lie of the fetus and locating the femur. Once the femur has been located, Address of Correspondence: Dr. Sabrina Quddus Rashid, an attempt is made to define both ends of the calcified Sonologist, MBBS (DMC), PMS (USA), DMUD, PhD, SONOLAB, portion. The image is then frozen and with Centre for Diagnostic Ultrasound, 38, Green Super Market. 1st floor. Green Road, Dhaka 1205, Tel: 9116940 (C), 8811711 (R). multidirectional electronic calipers, the calcified portion Received: 12 July, 2009 Accepted: 20 December, 2009 is measured. The aim is a femur which is finely outlined Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 and has clear-cut ends.1 After 32 menstrual weeks the Table-I distal femoral epiphysis is visible but not included in 2 the measurement.2 Weeks of gestation for FL R =0.975 Body mass index (BMI) was used to determine the G. Age (w) nutritional status. 18.5 was taken as the cutoff value.3 FL (mm) Mean (w) 2 SD (w) SPSS was used for data entry and analysis in the 10 13.2 0.75 computer. Polynomial regression model was fitted to 11 13.5 0.79 the data. 12 13.7 0.83 13 14.0 0.87 Results: 14 14.3 0.91 The demographic characteristics of the study population 15 14.5 0.94 of 1223 subjects were as follows. Mean maternal age 16 14.8 0.98 was 26.95 ± 4.49 (1SD) with a range of 17 to 40 years. 17 15.1 1.02 It was predominantly a middle class population. 96.9% 18 15.4 1.06 were from middle class, 0.8% belonged to lower class 19 15.6 1.09 and 2.3% were from upper class. 20 15.9 1.13 21 16.2 1.17 93.6% were from urban and 6.4% from rural areas. 22 16.5 1.21 54.7% were primipara and 45.3% were multipara. Mean 23 16.8 1.25 parity was 0.6 (±0.78). Mean BMI was found to be 23.67 24 17.2 1.28 (±3.4). 25 17.5 1.32 The coefficient of multiple correlation, R2 = 0.975. The 26 17.8 1.36 quadratic model gave a good fit to the data. Graph 1 27 18.1 1.40 shows raw data of fetal femur length with fitted 3rd, 28 18.5 1.43 10th, 50th, 90th and 97th percentiles. 29 18.8 1.47 30 19.2 1.51 In Table 1, 10mm predicts 13.2 (±0.75) (2SD) weeks, 31 19.5 1.55 45mm predicts 25(±2.08)weeks, 68mm predicts 36.1 32 19.9 1.59 (±2.95)weeks and 74mm predicts 40(±3.14) weeks. 33 20.2 1.62 34 20.6 1.66 35 21.0 1.70 36 21.3 1.74 37 21.7 1.78 38 22.1 1.81 39 22.5 1.85 40 22.9 1.89 41 23.3 1.93 42 23.7 1.96 43 24.1 2.00 44 24.5 2.04 45 25.0 2.08 46 25.4 2.12 47 25.8 2.15 48 26.3 2.19 Fig.-1: Raw data of fetal Femur length with fitted 3rd, 49 26.7 2.23 th th th th 10 , 50 , 90 and 97 centiles. Table Continue

164 Gestational Age Predicted by Femur Length in Bangladesh SQ Rashid

G. Age (w) value of coefficient of multiple correlations shows a FL (mm) Mean (w) 2 SD (w) good relation between the two variables. The polynomial regression quadratic model showed a good fit to the 50 27.2 2.27 data. The graph shows that there was increased 51 27.6 2.30 dispersion of data and the fitted curves as the gestational 52 28.1 2.34 age increased. 53 28.5 2.38 54 29.0 2.42 Previous studies on Bangladeshi population had 55 29.5 2.46 determined that our fetal measurements were smaller 56 30.0 2.49 than the western ones.5-11 In this study 10 mm predicted 57 30.4 2.53 13 week (2SD, ±1w) and 74 mm predicted 40 weeks 58 30.9 2.57 (±3w). Whereas in another Bangladeshi study at 16w, 59 31.4 2.61 femur length was 19mm (±2.6mm) (1SD) and at 40 week 60 31.9 2.64 it was 72mm (±3.2mm).10 61 32.4 2.68 In an Indian study, at 13 week gestational age femur 62 32.9 2.72 length was 11mm and at 40 week it was 76mm.12 63 33.5 2.76 In Western studies, 10mm predicted 13 week (±7d) 64 34.0 2.80 (2SD) and 75mm predicted 40 week (±23d), 13 10mm 65 34.5 2.83 predicted 13 week (±10d) (2SD) and 78mm predicted 66 35.0 2.87 40 week (±22d) 14 and in an early study 18mm indicated 67 35.6 2.91 15w (±6d) (2SD) and 75mm indicated 40 week (±22d). 68 36.1 2.95 15 69 36.7 2.98 70 37.2 3.02 All studies showed that in the early 2nd trimester 71 37.8 3.06 Bangladeshi, Indian and Western measurements were 72 38.4 3.10 similar but as pregnancy progressed there was 73 38.9 3.14 discrepancy between different races. The observed 74 39.5 3.17 values of femur length measurement of other Bangladeshi studies were similar to this one. Indian and western were little bigger than Bangladeshi values. Discussion: Estimation of gestational age accurately is one of the most LIMITATION: The study population was predominantly important functions of diagnostic ultrasound. Of all the of middle class as poor patients mostly deliver at home. parameters used to determine gestational age, femur Even when they go to doctors most of them are unable length has been proved to be one of the most accurate, to recall their LMP accurately, which was necessary for by different studies.1,2 Determination of gestational age this study. by ultrasound has now become an integral part of maternal Conclusion: antenatal care. Since up to 50% of mothers who claim to In 1223 subjects, from 13 to 27 weeks gestation, there know with certainty are in fact more than two weeks in was no clinically important difference between this and error when gestational age is calculated with ultrasound. western nomograms but after 32 weeks the difference A discrepancy of 2 weeks can be critical for the survival with western nomograms became significant. This of an infant who has to be delivered early because of nomogram is therefore special for Bangladeshi 4 some antenatal complication. population and can be useful for accurate dating of In this study femur length was measured from 13 to 40 pregnancies specially in the third trimester, as there was weeks gestational age. It was found to increase gradually a difference of 2-3 weeks at term between this and with gestational age. After regression analysis of the different western charts. raw data the table to predict the gestational age from Recommendation: More such studies can be done on femur length measurement, was prepared. The high other fetal parameters to prepare Bangladeshi charts.

165 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010

References: 8. Rashid SQ. Ultrasonic measurement of fetal abdominal 1. O’Brien GD, Queenan JT, Campbell S. Assessment of circumference in context to Bangladeshi population. gestational age in the second trimester by real-time ultrasound Bangladesh Med J 2000; 29: 36- 8. measurement of the femur length. Am J Obstet Gynecol 1981; 9. Rashid SQ, Khatun S. A study of estimated fetal weights by 139(5): 540- 5. ultrasound in Bangladesh and its correlation with Birth weights. J Bangladesh Coll Phys and Surg 2001; 19: 47- 51. 2. Queenan JT, O’Brien GD, Campbell S. Ultrasound measurement of fetal limb bones. Am J Obstet Gynecol 1980; 10. Quddus S. Fetal Biometry and Fetal weight in Bangladeshi 138: 297- 302. population. Dissertation DMUD (USTC) 2002; 53- 69. 3. WHO Technical Report Series. Diet, Nutrition and the 11. Rashid SQ. Gestational age estimation from fetal Head circumference in Bangladesh. 11th Congress of the World prevention of chronic diseases. Report of a Joint WHO/FAO Federation for Ultrasound in Medicine and Biology Expert consultation 2003; Vol. 916. (WFUMB), Paper presented. Ultrasound in Medicine and 4. Palmer PES. Estimation of fetal size and age (Fetal biometry). Biology. Clinical Obstetrics 2006; 32 (5S) 2361: 163. Manual of diagnostic ultrasound. Geneva. WHO 1995; p 236- 12. Rajan R, Girija B, Vasantha R. Ultrasound determination of fetal 44. growth parameters and gestational age. In: Malhotra N, Kumar 5. Moslem F, Latifa S, Iffatara B, Shamsuddin AK, Nasreen M, P, Dasgupta S, Rajan R (eds.) Ultrasound in Obstetrics and Momen A, et al. Relation of BPD with gestational age in Gynecology, 3rd Ed. New Delhi, Jaypee Brothers 2001; 394-98. Bangladeshi fetus. Bangladesh J Ultrasonogr 1996; 3: 3- 8. 13. Hansmann M, Hackeloer BJ, Staudach A. Ultrasound diagnosis 6. Bala KG. Ultrasound assessment of fetal BPD during normal in Obstetrics and Gynecology. Berlin. 1985; 62-70. pregnancy in Bangladeshi women and review of literatures. 14. Hadlock FP, Harrist RB, Deter RL, Park SK. Fetal femur Bangladesh J Ultrasonogr 1991; 1: 3. length as a predictor of menstrual age: Sonographically measured. Am J Radiology 1982; 138: 875- 8. 7. Rashid SQ. A study correlating the menstrual age and fetal age by ultrasonography in Bangladeshi population. 15. Campbell S and group. At Harris Birthright Center, King’s Bangladesh J Ultrasonogr 1999; 6: 3- 8. College Hospital. 1977.

166 REVIEW ARTICLES The Role of Mirena (Intra-uterine progestogens), Other than Contraceptive benefits: Current Concepts and Practices I BINA

Summary: Mirena is now licensed for the treatment of menorrhagia in Mirena is a long acting intrauterine hormone-releasing UK because it reduces 97% of blood loss in 12 months uses. It (LNG-IUS) contraceptive system with a flexible plastic is also an effective progestogenic endometrial protection in T-shaped frame bearing a levonorgestrel(LNG)- women with Hormone replacement therapy. There are containing cylinder which releases small doses conflicting evidence of LNG-IUS in the management of levonorgestrel into the uterine cavity after insertion with Fibroids uterus but it reduces fibroid related menstrual blood maximum effect on the endometrium and minimum losses. It has also some beneficial effect in endometriosis and progestogenic side-effect. LNG causes thinning of the adenomyosis by reducing pain and blood loss. The LNG-IUS endometrium, atrophy of the endometrial glands and also reduces endometrial hyperplasia and may take place in decidualisation of the endometrial stroma. The most the treatment of eartly endometrial cancer in some cases. The common side-effect of LNG-IUS is unscheduled vaginal rate of ectopic pregnancy and pelvic inflammatory diseases bleeding in the first 3 months, so proper counseling is are reduced in Mirena users compared with IUCD users. needed. In some cases functional ovarian cysts may occur Keywords: Mirena /Intrauterine progestogens/ which are relatively small, symptomless and resolved Noncontraceptive/ LNG-IUS spontaneously within a short time. (J Bangladesh Coll Phys Surg 2010; 28: 167-173)

Introduction: secondary to the effect of the local action of the Mirena is a long acting intrauterine hormone-releasing progestogen on the endometrium have been observed contraceptive system. It comprises a small flexible plastic and researched which has supported the granting of a T-shaped frame (length: 3 mm) bearing a license for the use of the levonorgestrel-releasing system levonorgestrel(LNG)- containing cylinder. After insertion for the non-contraceptive indication of menorrhagia, into the uterus, levonorgestrel-Intrauterine system (LNG specially idiopathic menorrhagia2 and the treatment of IUS) released from the cylinder in small doses (initial other endometrial pathology. release rate, 20 mg/day) into the uterine cavity. Here, we explore the evidence obtained from the use of First of all, the concept of intra-uterine administration these intra-uterine hormone delivery systems to provide of progesterone for contraception was introduced in the a review of their current and proposed wider clinical US in the 1970s. Then, the levonorgestrel-releasing applications, advantages and disadvantages of such intra-uterine system was devised in Finland gaining a devices. license there for contraception in 1990 and is currently Types of Intrauterine Progesterone marketed in most European countries, in the UK, since There are four types of Intra-uterine systems: May 19951 and in the US since 2000. It is now widely Progestasert, Mirena, Mirena ML and Fibroplant. The used for its excellent contraceptive benefits. Then the latter two are still undergoing clinical trials3. non-contraceptive health benefits of these systems The Mirena Intrauterine System (LNG-IUS) has a T- Address of Correspondence: Dr. Ismatara Bina*, MD, DGO, shaped frame (based on the Nova T IUCD) 32 mm by MCPS, FCPS (O&G), MRCOG(UK), Consultant Obstetrician and 32mm made of polyethylene surrounded by an Gynaecologist, Khalishpur Clinic, Plot#41, Rd.#101, Khalishpur H/ E, Khulna-9000, Bangladesh elastomer sleeve in its vertical part. This sleeve is a Received: 11 November, 2009 Accepted: 25 May, 2010 1:1 mixture of 52 mg of levonorgestrel and Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 polymethylsiloxane. The membrane (also made of of gyanecology referrals and is the commonest cause of polymethylsiloxane) allows a controlled release of 20 iron-deficiency anaemia affecting 20-25% of healthy mcg of levonorgestrel daily at a constant rate over 5 fertile women in the UK. years3. The rate slowly decreases to 15 mcg a day after One in 20 women aged 30-49 years consult their general 5 years and then to 12 mcg at 7 years. Both the serum practitioner each year with menorrhagia.5 Of women and intra-uterine levels remain constant over the life- referred secondary care, 60% are likely to have a time of the device in one individual. The serum levels hysterecomy within 5 years of referral as shown by 6 vary from 0.3 to 0.6mmol/l . Coulter et al. and in most of these women have a normal uterus removed. Effects on Endometrium. In 1993-1994, 73,517 hysterectomies were carried out The high levonorgestrel (LNG) concentration in the in England, there was a decline in 1997-1998 when endometrium down regulate endometrial oestrogen and 63,345 operations were carried out. Endometrial progesterone receptors, making the endometrium ablations had risen markedly from 9945 to 36,440 in insensitive to circulating E2 (thereby suppressing the same period. endometrial growth). After only a couple of months of To date, the management of menorrhagia has relied on Mirena use, the glands of endometrium atrophy, the pharmacological or surgical therapy. Current stroma becomes swollen and decidual, the mucosa thins pharmaceutical options include non-steroidal anti- and the epithelium becomes inactive. Vascular changes inflammatory drugs (NSAIDs), antifibrinolytics, are thickening of arterial walls, suppression of spiral danazol, Progestogens and combined oral arterioles and capillary thrombosis. The endometrial contraceptives. The surgical treatments include changes are uniform within 3 cycles after insertion of hysterectomy and endometrial ablation or resection. the system and no further histological changes take over the long term. Biochemical modulators shows a A. Medical therapies for Menorrhagia reduction of cell proliferation and an increase in The LNG-IUS is more effective than oral treatment in 7,8 9 programmed cell death. These result in a reduction in the management of menorrhagia. Milsom et al. the endometrial thickness. These changes are reversible studied that Mirena is superior to tranexamic acid and and after long-term use; normal menstruation is restored flurbiprofen in reducing blood loss (see Figure-1) on 1month after the removal of the system. menorrhagia with a lesser side-effects. 10 The main principle of non-contraceptive health benefits Several studies by various types of drugs showed the reduction of menstrual blood loss by mefenamic acid of the LNG-IUS is based on this endometrial suppression 25%, Combined oral contraceptive pill 40%, tranexamic and these include beneficial effects on menorrhagia, as acid 50%, GnRh analogues 75% and danazol 80%. the progestogenic component of combined HRT, in the treatment of hyperplastic and endometrotic endometrium and fibroids and their symptoms. Other health benefits include a reduction in pelvic inflammatory disease and ectopic pregnancy and a possible application in the treatment of premenstrual syndromes. 3

Effects on ovarian function. Over 85% of women have ovulatory cycles using the LNG-IUS.4 and thereafter most cycles are ovulatory. For complete suppression of ovulation, a daily intrauterine release of more than 50mcg of LNG is required.3

Benefits Fig.-1: Reduction in menstrual blood loss as a Role in the management of menorrhagia. percentage of mean of two control cycles for Mirena*, Menorrhagia is experienced by up to 30% women of Tranexamic acid (TA) and flurbiprofen (FLURB); 3 reproductive age, it accounts for 60% of general *p<0.05 (between TA and FLURB); **P<0.001 practice consultations for menstrual dysfunction, 12% (between Mirena* and TA/FLURB).9

168 The Role of Mirena (Intra-uterine progestogens), Other than Contraceptive benefits I Bina

The study of 20 women with menorrhagia by Andersson with Mirena was 96% compared with mefenamic acid and Rubo11 used the LNG-IUS and demonstrated a was only 17%. significant reduction in menstrual loss of 85% at 3 Tang GE,13 et al. involved 10 Chinese women with months‘ and 97% at 12 months of LNG-I US usage with anaemia and who had objectively measured blood significant increase in mean serum ferritin by 47% in loss of > 80ml, used the LNG IUS and demonstrated a the first year of use.( See Table-I, Fig-2 & Fig-3). reduction of MBL 54% at one month, 87% at 3 month and 95% at 6 month of treatment and an Irvine et al. 7 showed that Mirena reduced MBL by 94% increase in mean haemoglobin by 19.2% at 6 months after 3 months of treatment (see Table-I), compared compared with pre-treatment cycles. In addition, Xio with 87% with oral norethisterone (15 mg daily for et al14 showed that Mirena significantly reduced MBL 21days in each cycle). More recently, Reid and Virtanen- and increased hemoglobin and ferritin levels over 3 Kari 12 showed that reduction of MBL after 6 months years’ follow up.

Table-I

Summary of comparative and non-comparative studies evaluating the effectiveness of Mirena* in the treatment of menorrhagia.

Mean menstrual blood loss (ml) Study Duration Pre-treatment After treatment Reduction in Significance (months) menstrual blood loss (%) Scholten4 12-Jul 119 17 -86 *** Anderssin & Rybo11 3 176 24 -86 **** 6 176 15 -91 **** 12 176 5 -97 ****

Milsaon et al. 9 3 203 34 -82 **** 6 25 -88 **** 12 9 -96 ****

Tang & Lo13 1 183 84 -54 *** 3 183 24 -87 * 6 183 10 -95 ***

Xiao et al. 14 6 124 23 -81 **** 12 124 26 -79 **** 24 124 3 -98 **** 54 124 14 -89 ****

Reid & Virtanen-Kari12 3 122 12 -90 *** 6 122 5 -96 ***

Irvine et al. 7 1 105 16 -85 **** 3 105 6 -94 **** * Median values. * p<0.05; **p<0.01; ***p<0.005; ****p<0.001.

169 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010

Stewart et al.8 and Scholten15 has also showed the same biopsy where appropriate. FFPRHC Guidance1 (April result in their study: MBL reduced by 86% (see Table 2004) in The LNG-IUS in contraception and I) with increase of Hb% and serum ferritin level (see reproductive health stated “The LNG-IUS is effective Figure-2 & Figure-3). The results of the meta-analysis option to treat menorrhagia (Grade A).” showed the use of the LNG IUS could significantly reduce menstrual blood loss (range, 74-97%) in women with confirmed menorrhagia. However, to establish the effectiveness and cost effectiveness relative to other

treatments and effect on surgical waiting lists, larger, more powerful, randomised, controlled trails with longer follow-up are required.

The Royal College of Obstetricians and

Gynaecologists (RCOG) guideline on the management of menorrhagia in primary care does not identify the LNG-IUS as a treatment option.5 However, the RCOG guideline on the management of menorrhagia in secondary care16 suggests the Fig.-2: Reduction in menstrual blood loss (MBL) in LNG-IUS may be used to treat menorrhagia after an women with menorrhagia after 3, 6 and 12 months of 11 assessment of the uterine cavity and endometrial Mirena* use; *p<0.001 vs baseline.

Fig.-3: Mean concentrations (+SD) of a) hemoglobin and b) serum ferritin in women with menorrhagia before Mirena* insertion and after 3, 6 and 12 months of use (hemoglobin) and 6 and 12 months of use (ferritin); **p<0.01, ***p<0.001.11

170 The Role of Mirena (Intra-uterine progestogens), Other than Contraceptive benefits I Bina

B. Surgical management for menorrhagia 2. ”The LNG-IUS is as effective as conservative A Cochrane review17, which included five studies, surgery (resection and ablation) in the management compared to the LNG-IUS with surgery (hysterectomy, of menorrhagia after the first year (Grade A).” endometrial resection and ablation) and concluded that 3. ”Patient satisfaction and quality of life appear conservative surgery appeared to be significantly more similar following LNG-IUS or surgical treatment effective in controlling bleeding at 12 months [odds ratio of menorrhagia (Grade A).” (OR) 3.99; 95% CI 1.53–10.38] with beneficial effect in improving quality of life as conservative surgery, in So the LNG-IUS provides an effective, efficient, well- the long term. Reports suggest that the treatment was so tolerated, cost-effective alternative to other medical and effective that 64-82% of women need not to do surgical management of menorrhagia. hysterectomy and around 14% of women continue Progestogenic component of HRT & Effects on Lipid existing medical therapies. metabolism Nagrani and Bowen-Simpkins18 showed recently in one Hormone replacement therapy (HRT), oestrogen (ERT), study of 4-5-year long-term follow-up of the patients is an acceptable option for women who require relief of 62 continuation rate of 50% after a mean 54 months vasomotor symptoms. Exposure to unopposed follow-up and only 26.4% eventually had surgical oestrogens increases the risk of endometrial hyperplasia treatment and an overall 67.4% avoided surgery. and malignancy. Progestogens reduce this risk. Randomized trials suggest that the LNG-IUS is effective When MBL is measured using a pictorial assessment chart in providing endometrial protection from the stimulatory (PBAC) by Higham et al,19 treatment success, defined effects of oestrogen, oral21 or transdermal. Cohort as a PBAC score of d” 75 at 12 months, has been shown studies provide evidence of endometrial protection with in similar comparisons. In the Visual Analogue Scale the LNG-IUS and percutaneous oestradiol22 gel use. (VAS) assessment of the subjective symptoms, sleeping The majority of postmenopausal women (98.2%) using problems were slightly increased in the TCRE group, an LNG-IUS as the progestogenic component of HRT general feeling of genital health was increased and were amenorrhoeic after 12 months of use.21 menstrual pain decreased over time in both the groups. Mirena causes favourable effects on ERT on the plasma 20 In a randomized trial by Hurskainen et al. on quality of lipid and lipoprotein profiles. A recent study by life and cost effectiveness of the LNG-IUS (n=119) Raudaskoski et al.23 using 2 mg oestradiol valerate and versus hysterectomy(n=117), for treatment of the Mirena intra-uterine system showed HDL- menorrhagia total cost were 3 folds lower with Mirena cholesterol remaining at baseline level after 12 months than hysterectomy.31 Health-related quality of of treatment. The LDL-cholesterol levels were reduced life(HRQoL) and indices of psychosocial well-being by all the LNG-IUS.23 These changes might be favorable improved significantly in both group. Overall Mirena in cardioprotection. provides effective option for the treatment of menorrhagia LNG IUS and endometrosis with avoidance of the risk associated with a surgical A prospective, non-comparative study showed that of procedure, and without permanent loss of fertility. women with the LNG-IUS reported 80% reduction in The RCOG guideline on management in secondary primary dysmenorrhoea and MBL.24 According to the care16 outlines “A progestogen releasing IUD is an visual chart devised by Higham et al.19, women with effective treatment for reducing heavy menstrual blood endometriosis have a higher baseline mean menstrual loss and should be considered as an alternative to score than normal. A pilot study25 demonstrated a greatly surgical treatment (A).” reduced visual analogue scale for menstrual pain which FFPRHC Guidance1 (April 2004) in the LNG-IUS in was associated with a 76% mean reduction in PBLA contraception and reproductive health stated: chart score. 1. ”Surgery (hysterectomy, endometrial resection or Fibroids ablation) is more effective than the LNG-IUS in The intra-uterine Levonorgestrel systems provide an treating menorrhagia at 1 year (Grade A).” improvement in fibroid-related menorrhagia with a

171 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 reduction in dymenorrhoea. Five observational studies spontaneously. Occurrence was not related to bleeding were identified that investigated the effect of LNG-IUS pattern, age or FSH levels. 24,25 on uterine fibroids which showed a reduction in Progestogenic side effects & Unscheduled vaginal 26 MBL and fibroid volume with LNG-IUS use. bleeding 1 FFPRHC Guidance (April 2004) in The LNG-IUS in Some women do complain of hormonal side effects like contraception and reproductive health stated “The LNG- oedema, weight gain, headache, breast tenderness, acne IUS is effective in the management of menorrhagia, even and hirsutism and decrease in LDL level. The multicentre in the presence of fibroids (Grade C).” “It is not contraceptive study in Europe noticed no difference in generally recommended that the LNG-IUS be used if the weight gain between LNG IUS users and copper IUD fibroids are distorting the uterine cavity (Grade C).” users. Irregular vaginal bleeding and spotting in the first 27 WHOMEC recommends that if the uterine cavity is few months after insertion is a great problem with LNG- distorted with fibroids, the risks of LNG-IUS use IUS. This usually settles within 3-6 months, in which time outweigh the benefits (WHO 4) because this may not the full endometrial transformation occurs. 35% of be compatible with insertion. premenopausal women develop amenorrhoea at the end Endometrial hyperplasia & Treatment of early of the first year of use, and normal menstruation will return endometrial cancer once the device is removed.

The LNG-IUS is effective in the treatment of Conclusions: endometrial hyperplasia due to the antiproliferative and The LNG IUS shows a wider spectrum of benefit other suppressive effects on the endometrium.The largest case than contraception. Careful pre-insertion counseling; 28 report found that all 12 women with simple and insertion by a trained fitter can minimize the side hyperplasia or atypical hyperplasia had normal effects and bothersome symptoms. endometrium 12 months after LNG-IUS insertion. Montz et al. 29 showed that intra-uterine progesterone The Mirena is a useful tool in the treatment of appears to eradicate some cases of presumed stage la menorrhagia and progestogenic compomnent of the grade 1 endometrial cancer in women with a high risk hormone replacement armory mainly due to the local of peri-operative morbidity. effect of Levonorgestrel in the endometrium which may lead to the development of the treatment of other Pelvic inflammatory disease endometrial diseases. A large randomised study30 in 5 European countries concluded that women using the LNG IUS had a References: significantly lower rate of PID than IUCD users. There 1. Faculty of Family Planning and Reproductive Health Care is also a protective effect in the long term, preventing (FFPRHC) The levonorgestrel-releasing intrauterine system (LNG-IUS) in contraception and reproductive health FFPRHC sexually transmitted infection developing into PID with Guidance (April 2004) Journal of Family Planning and no protection against sexually transmitted infection. Reproductive Health Care 2004; 30(2): 99–109 Prevention of ectopic pregnancy 2. Schering Health Care Ltd. Mirena. 0053/0265,1-8.2002. http/ /www.schering.co.uk. The LNG-IUS have a very low failure rates in prevention of pregnancy which makes the ectopic pregnancy rate 3. Hockey J, Verma V, Panay N, The Wider role of intrauterine progestogens. Progress in Obstetrics and Gynaecology. 1st 27 very low. WHOMEC recommends that women with Edition, London, Elsevier,2005. a previous ectopic pregnancy may use the LNG-IUS 4. Scholten PC. The levonorgestrel IUD. Clinical performace (WHO Category 1: unrestricted use). and impact on menstruation. Thesis, University of Utrecht, 1989, 94 Risks 5. Royal College of Obstetricians and Gynaecologists (RCOG). Ovarian cyst formation The Initial Management of Menorrhagia. National Evidence- The incidence of functional ovarian cysts was higher in Based Clinical Guidelines. London, UK: RCOG, 1998.54 the LNG-IUS group compared to IUCD users 1.2 versus 6. Coulter A et al. Outcomes of referralsto gynaecology outpatient 0.4 per 100 women-years.9 The majority of cysts (94%) clinics for menstrual problems: an audit of general practice were asymptomatic, relatively small and resolved records. Br J Obstet Gynaecdol 1991; 98: 789-796

172 The Role of Mirena (Intra-uterine progestogens), Other than Contraceptive benefits I Bina

7. Irvine GA et al. Randomised comparative trail of the 19. Higham JM, O‘Brien PM, Shaw RW. Assessment of menstrual levonorgestrel intra-uterine system and norethisteronefor blood loss using a pictorial chart. Br J Obstet Gynaecol 1990; treatment of idiopathic menorrhagia. Br J Obstet Gynaecol 97: 734-739 1998; 105: 592-598 20. Hurskainen R et al. Quality of life and cost-effectiveness of 8. Stewart A et al. The effectiveness of the levonorgestrel- levonorgestrel-releasing intra-uterine system releasing intra-uterine system in menorrhagia: a systematic vesushysterectomy for treatment of menorrhagia: a review. Br J Obstet Gynaecol 2001; 108: 74-86 randomised trail Lancet 2001: 357: 273-277 9. Milsom I, Andersson K, Andersch B, et al. A comparison of 21. Raudaskoski T, Tapanainen J, Tomás E, et al. Intrauterine 10 flurbiprofen,tranexamic acid, and a levonorgestrel-releasing mg and 20 mg levonorgestrel systems in postmenopausal intrauterine contraceptive device in the treatment of idiopathic women receiving oral oestrogen replacement therapy: clinical, menorrhagia. Am J Obstet Gynecol 1991; 164: 879–83. endometrial and metabolic response. Br J Obstet Gynaecol 10. Bonnar J, Sheppard BL. Treatmentof menorrhagia during 2002; 109: 136–144. menstruation: randomised controlled trail of ethamsylate, 22. Varila E, Wahlström T, Rauramo I. A 5-year follow-up study mefenamic acid, and tranexamic acid. BMJ 1996; 313: 579- on the use of a levonorgestrel intrauterine system in women 582 receiving hormone replacement therapy. Fertil Steril 2001; 11. Andersson JK, Rybo G. Levonorgestrel-releasing intra-uterine 76: 969–973. device in the treatment of menorrhagia Br J Obstet Gynaecol 23. Raudaskoski T, Tapanainen E, Tomas E et al. Intrauterine 10 1990; 97: 690-694 mcg and 20 mcg Levonorgestrel systemsin postmenopausal 12. Reid PC, Virtanen-Kari S. Randomesed comparative trial of women receiving oral oesterogen replacement therapy: the levonorgestrel-releasing intra-uterine system and clinical. endometrial and metabolic. Br J Obstet Gynaecol mefenamic acid for the treatment of idiopathic menorrhagia: 2002; 109:136-144 a multiple analysis using total menstrual fluid loss, menstrual blood loss and pictorial blood loss assessment charts. Br J 24. Barrington JW, Bowen-Simpkins P. The levonorgestrel Obstet Gynaecol 2005:112:1121-5 intrauterine system in the management of menorrhagia. Br J Obstet Gynaecol 1997; 104: 614–616. 13. Tang GE, Lo SS. Levonorgestrel intra-uterine device in the treatment of menorrhagia in Chinese women effecacy versus 25. Vercellini P, Aimi G, Panazza S, De Giorgi O, Pesole A, acceptability. Contraception 1995; 51: 231-235 Crosignani PG. A levonorgestrel – releasing intra-uterine 14. Xiao B, Wu S-C, Chong J, et al. Therapeutic use of the system for the treatment of dysmennorrhea associated with levonorgestrel-releasing intra-uterine system in the treatment endometriosis. A pilot study. Fertil Steril 1999; 72; 505-508 of idiopathic menorrhagia. Fertil Steril 2003;79:963-9 26. Grigorieva V, Chen-Mok M, Tarasova M, et al. Use of a 15. Scholten PC, Christiaens GCML, Haspels AA,Treatment of levonorgestrel- releasing intrauterine system to treat bleeding menorrhagia by intra-uterine administration of Levonorgestrel. related to uterine leiomyomas. Fertil Steril 2003; 79: 1194– In: Scholten PC. (ed) The levonorgestrel IUD: clinical 1198. performance and impact on menstruation (thesis). Utrecht; 27. World Health Organization (WHO). Medical Eligibility The Netherlands: Utrecht University Hospital. 1989; 47-55 Criteria for Contraceptive Use. Geneva, Switzerland: WHO, 16. Royal College of Obstetricians and Gynaecologists (RCOG). 2000. The Management of Menorrhagia in Secondary Care. 28. Wildemeersch D, Dhont M. Treatment of non atypical National Evidence-Based Clinical Guidelines. London, UK: endometrial hyperplasia with a levonorgestrel-releasing RCOG, 1999. intrauterine system. Am J Obstet Gynecol 2003; 188: 1297– 17. Majoribanks J, Lethaby A, Farquhar C. Surgery versus medical 1298. therapy for heavy 29. Montz F, Bristow R, Bovicelli A, Tomacruz R, Kuiman R. menstrual bleeding (Cochrane Review). In: The Cochrane Intrauterine progesterone treatment of early endometrial Library, Issue 4, 2003. Chichester, UK: John Wiley & cancer. Am J Obstet Gynecol 2002; 186: 651-657 Sons,Ltd. 30. Luukainen T, Allonen H, Haukkamma M et al. Effective 18. Nagrani R, Bowen-Simpkins P, Barringto JW. Can the4 contraception with levonorgestrel-releasing untra-uterine levonorgestrel intra-uterine system replace surgical treatment device. 12 months report of a European multicentre study. for the management of menorrhagia ? Br J Obstet Gynaecol Contraception 1987; 36: 169-179 2002; 109: 345-347

173 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 Evaluation & Management of Obscure Gastrointestinal Bleeding (OGIB) S PERVEENa, MR HOSSAINb, SMB HUSSAINc, MA AHMEDd, H AFTABe

Summary: endoscopic evaluation including colonoscopy and/or upper Gastrointestinal bleeding is a common entity. Incidence of endoscopy. OGIB can be either Occult (no visible blood) or bleeding has comparatively increased though case fatality Overt (Passage of visible blood). is static. Despite improved treatments and better Less common aetiologies of GI bleeding e.g. Cameron understanding of the underlying pathophysiology of peptic erosions, Dieulafoy’s lesion, Watermelon stomach that are ulcer disease the rising figures of GI bleeding reflect an sometimes difficult to identify at endoscopy often present increasing proportion of elderly population and non- as OGIB. They need special techniques even thrombolytic steroidal anti-inflammatory use. Overall, 5% of all cases of therapy to precipitate bleeding for diagnostic angiography. gastrointestinal bleeding fall under the category of Obscure Increased awareness of the existence of such conditions help gastrointestinal bleeding (OGIB) in the USA. Obscure in rapid and accurate identification of the lesion. Review of gastrointestinal bleeding is defined as bleeding of unknown such cases will be the focus of this publication. origin that persists or recurs after an initial negative (J Bangladesh Coll Phys Surg 2010; 28: 174-182)

Introduction: colonoscopy and/or upper endoscopy (esophagogas- Bleeding from the upper gastrointestinal (GI) tract troduodenoscopy [EGD]).3 OGIB can be classified as remains common, with a reported annual incidence of either: up to 172 per 1000001, which has increased. Case (1) Occult OGIB- which is manifested by recurrent iron fatality was recently reported as 14%2 which is static, deficiency anemia and/or recurrent positive fecal occult despite improved treatments and better understanding of the underlying pathophysiology of peptic ulcer blood test (FOBT) results disease. The rising figures may reflect an increasing (2) Overt OGIB- which is manifested as melena or proportion of elderly patients and non-steroidal anti- hematochezia. inflammatory use. Of patients in whom a diagnosis is Overall, OGIB accounts for 5% of all cases of confirmed, more than 90% suffer from peptic ulcers, gastrointestinal bleeding in the USA4. Angiectasias of oesophageal or gastric malignancy, varices, Mallory- the small bowel are the most common source of OGIB Weiss syndrome, erosive disease and oesophagitis1,2. Less common aetiologies of upper GI bleeding which and account for 30% to 40% of gastrointestinal bleeding are sometimes difficult to identify at endoscopy and in the elderly population, whereas tumors such as manage will be the focus of this study. leiomyomas, carcinoids, lymphomas and adenocarcinomas are the predominant cause in patients Definition aged 30 to 50 years5. Meckel’s diverticulum, erosions Obscure gastrointestinal bleeding (OGIB) is defined as and ulcers from nonsteroidal anti-inflammatory drug bleeding of unknown origin that persists or recurs after (NSAID) use6 and Crohn’s disease of small bowel are an initial negative endoscopic evaluation including also potential causes of OGIB. The term ‘mid- gastrointestinal bleeding’ rather than obscure bleeding a. Lt Col Shaila Perveen, MBBS, MCPS, FCPS. is now applied if the origin is thought to be between b. Maj Gen Muhammad Rabiul Hossain, MBBS, MCPS, FCPS, papilla and ileocaecal valve7. FRCP c. Brig Gen Sk. Md. Bahar Hussain, MBBS, FCPS, FRCP Causes of Obscure GI Blood Loss: d. Lt Col Mir Azimuddin Ahmed, MBBS, DCP, MCPS, FCPS Common causes (any site): e. Dr. Hafeza Aftab, MBBS, MD Peptic ulcer, Reflux esophagitis, Erosive gastritis, Address of Correspondence: Dr. Shaila Perveen, Classified Medical Specialist, CMH Patenga, Chittagong, Phone: 01819294922 Carcinoma(Specially colon),Vascular ecstasia / Received: 10 December, 2009 Accepted: 28 June, 2010 angiodysplasia, Chron’s disease Evaluation & Management of Obscure Gastrointestinal Bleeding (OGIB) S Perveen et al.

Uncommon Causes (Upper GIT) tract (Figure 1). Their endoscopic appearance is 1. Esophagus / Stomach indistinguishable from other angiodysplastic lesions Dieulafoy’s lesion, Cameron’s erosions with hiatal (Figure 2) but more widespread. hernia, Prolapse erosions, Gastric antral vascular ecstasia (Water melon stomach), Portal gastropathy, Varices 2. Small Intestine Meckel’s diverticulum, Celiac sprue, Chron’s disease, Duodenitis

Uncommon Causes (Lower GIT) 3. Colon Diverticula (obscure overt bleeding), Colitis Fig.-1: Cutaneous manifest of O-W-R (ulcerative/ ischaemic/ radiation injury), Endometriosis, Infection (hookworm, ascariasis, whipworm, strongiloidosis, amoebiasis, cytomegalovirus, tubercular entero colitis) 4. Rectum Fissure, Haemorrhoid 5. Any site Vasculitis, Telengiectasia, Aorto enteric fistula, Other cancers (lymphoma-gastric NHL, Kaposi’s, leiomyoma, sarcoma, melanoma, carcinoids), Large Fig.-2: Mucosal lesion of OWR polyps, Blue rubber bleb nevus syndrome, Haemangioma, Radiation damage, Amyloidosis Dieulafoy’s Lesion Dieulafoy’s lesion is a cause of diagnostic difficulty in 6. Extra intestinal patients with repeated haematemesis. The exposed, Haemobilia, Wirsungorrhoea, Haemoptysis, eroded vessel in a very small mucosal defect is difficult Epistaxis, bleeding gums to spot at endoscopy (Figure 3) and accounts for perhaps 12 7. No source identified. 2% of upper GI bleeds . It was described in detail by Dieulafoy13 in 1896 who termed ‘Exulceratio Simplex’ Angiodysplasia as bleeding from a simple tortuous abberant submucosal Gastrointestinal angiodysplasias are the most common artery of small size. The typical endoscopic appearance cause of obscure chronic blood loss from the digestive is that of a dark red ‘nipple’. tract with small bowel angiodysplasia accounting for up to 40% of obscure GI bleeding8. The pathophysiology is unknown, but has been suggested to result from low grade venous obstruction of submucosal veins as they cross muscle layers [9]. It is said to be more prevalent in chronic renal failure patients [10] and in patients with aortic stenosis, although, recent reports have failed to confirm this link11. Osler-Weber- Rendu Syndrome is an autosomal dominant condition characterized by angiodysplastic lesions involving the skin, mucosal membranes and organs other than the GI Fig.-3: Dieulafoy’s lesion

175 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010

Gastric Antral Vascular Ectasia (Watermelon Unusual Upper GI Malignancies Stomach) Adenocarcinoma accounts for 90% of gastric tumours This was first described in 1952 by Rider et al and used with lymphoma accounting for 5%, stromal tumours 2% to be called gastric antral vascular ectasia. Jabbari et al and the rest include carcinoids, metastases and others. [14] coined the phrase “watermelon stomach” to describe GI involvement occurs in 50% of non Hodgkins the endoscopic features (Figure 4). Recognition of this lymphoma, with the stomach being the most common characteristic lesion is important since it is commonly extranodal site. 95% of gastric lymphomas are non- dismissed by less experienced endoscopists as antral Hodgkins lymphoma. gastritis. Other Vascular Disorders The Blue Rubber Bleb Naevus Syndrome (Figure 6) is an example of intestinal haemangioma which is an autosomal dominant condition causing GI bleeding in infants and children.

Fig.-4: Watermelon stomach

Cameron Erosions Erosive disease is an uncommon cause of severe upper GI bleeding. However, some lesions warrant mentioning as they are often overlooked or missed at endoscopy. Cameron erosions are chronic linear erosions (Figure 5) positioned on the crests of folds at the diaphragmatic impression with a large hiatus hernia15.

Fig.-6: Jejunal phlebectasia

Haemobilia Bleeding from either the biliary tree (haemobilia) or from the pancreatic duct (Wirsungorrhagia) into the duodenum can be difficult to identify. Recent series indicate iatrogenic trauma accounting for 40% and Fig.-5: Cameron lesion accidental trauma 20%16. Classically, patients present with the triad of pain, jaundice and melaena. A history Prolapse Erosions of chronic pancreatitis or pseudocyst may be a pointer Prolapsing gastropathy is a focal area with subepithelial to a bleed from the pancreatic duct. haemorrhage and occasionally, erosions within a few centimeters of the cardioesophageal junction. This Evaluation mucosal area prolapses into the distal oesophagus Evaluation starts from elaborate history and careful commonly from 10 o’clock position during retching, bedside examination to provide clue to the cause of often prior to haematemesis. bleeding.

176 Evaluation & Management of Obscure Gastrointestinal Bleeding (OGIB) S Perveen et al.

History Investigations A history can reveal ingestion of medications known to In OGIB, repeat EGD and colonoscopy with cause bleeding (e.g., aspirin, nonsteroidal anti- ileoscopy should be considered before performing inflammatory drugs, alendronate, potassium chloride, a small bowel evaluation. A repeat EGD may yield anticoagulants). A family history might suggest a a source even when the initial exam was negative. hereditary vascular problem. Zaman and colleagues reported that 64% of lesions Physical Exam identified with push enteroscopy were within reach The bedside examination may be helpful in providing of a standard endoscope19. Commonly missed clues to the cause of bleeding (Table I). Rare causes lesions in the upper gastrointestinal tract include of bleeding may be detected on physical examination peptic ulcers, Cameron ulcers associated with large like Plummer-Vinson syndrome, acquired immuno- hiatal hernia, and angiectasias. Lesions often deficiency syndrome (AIDS), neurofibromatosis, missed in the colon include angiectasias and Osler-Weber-Rendu syndrome, pseudoxanthoma neoplasms. The diagnostic yield of repeat EGD is elasticum, amyloidosis (Figure 7) and other diseases sufficient to recommend a second-look with typical cutaneous manifestations17-18. Symptoms endoscopy20,21,22. Adequate inflation to distend the specific to the upper or lower intestinal tract may direct folds in the upper stomach, a retroflexed endoscope the initial endoscopic procedure, but data do not support and close examination of the mucosa posteriorly limiting the evaluation to the symptomatic region. on the lesser curve may help to identify Dieulafoy’s. Multiple examinations are commonly required and the abnormality is sometimes diagnosed when pulsatile arterial bleeding is seen coming from apparently normal mucosa. In the absence of clear evidence of gastrointestinal bleeding, small-bowel biopsies should be taken to rule out celiac sprue in the evaluation of patients with iron deficiency anemia23,24,25. Gastrointestinal investigative techniques for occult and obscure bleeding are summarized in table II. Fig.-7: Intestinal amyloid

Table-I

Clinical Clues for Specific Causes of Gastrointestinal Bleeding

Age greater than 50 Carcinoma

Chronic renal failure Vascular ectasia/angiodysplasia

Cutaneous hemangiomas Blue rubber bleb nevus syndrome

Chronic diarrhea/abdominal pain Celiac sprue

Acquired-immunodeficiency syndrome (AIDS) Acquired-immunodeficiency syndrome (AIDS)

177 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010

Table-II

Comparison of Gastrointestinal Investigative Techniques for Occult and Obscure Bleeding

The British Society of Gastroenterology’s guidelines episode26,27. On the basis of the findings, the clinician propose small-bowel evaluation with capsule endoscopy may proceed with push enteroscopy or double-balloon as first test for patients with bleeding if no bleeding enteroscopy. Intraoperative enteroscopy should be source is identified on upper and lower endoscopy, as reserved for patients with recurrent bleeding and diagnostic yield is highest during or soon after a bleeding transfusion dependency.

178 Evaluation & Management of Obscure Gastrointestinal Bleeding (OGIB) S Perveen et al.

So in Patients with OGIB if endoscopic evaluation of undertaken prior to endoscopy in theatre since upper and lower tracts is negative or equivocal, 2nd look endoscopy can precipitate torrential bleeding. examination by repeat upper and lower endoscopy is Management preferred before small bowel imaging [consensus/expert Importance of resuscitation can not be overemphasized. guidelines]. Cameron’s erosions (within a hiatal hernia), With adequate resuscitation as defined by hemodynamic peptic ulcer disease and vascular ectasias are the most stability there is significant reduction of post procedure common upper tract lesions found on repeat endoscopy, complications. Antibiotic prophylaxis is another key and cancer and angiodysplasias (Figure 8) are the most component in the preparation prior to endoscopic commonly overlooked lower tract abnormalities1. intervention as there is likely development of transient bacteremia. Coagulation factor and platelet factor abnormalaties should be assesed and corrected prior to endoscopy. Appropriate level of sedation can be reached through use of a benzodiazepine combined with a narcotic. Endoscopy plays a major role in the evaluation of OGIB and the management approach is summarized in the flowchart (Table III).

Treatment and Outcome Treatment varies according to the etiology of bleeding, its severity and patient comorbidities. Treatment options include endoscopic, angiographic, pharmacotherapy, surgical therapies and non-specific measures. Endoscopic therapies include thermal contact probes, Fig.-8: Bleeding jejunal ulcer laser coagulation, injection sclerotherapy and banding. Thermal ablation of bleeding is the treatment most Endoscopically lymphomas may present as enlarged commonly used for accessible lesions. Endoscopic gastric folds, mucosal nodularities, multiple polypoid therapy is successful in more than 90% of cases of masses with or without ulceration or with a diffuse Dieulafoy’s bleeding. Adrenaline is frequently injected infiltrative process. One unusual feature is that peristalsis into the base prior to definitive treatment with is often preserved. Diagnosis can be difficult, sometimes electrocoagulation or more recently, band ligation. requiring full thickness biopsy but when combined with During angiography, interventional radiologists inject endoscopic ultrasound (EUS) diagnostic accuracy vasopressin or embolization material into bleeding approaches 100%. vessels. Medical therapies are one of the few options Haemobilia or Wirsungorrhagia into the duodenum may available for diffuse vascular lesions, but they have 28 require the use of a side viewing endoscope to make limited success rates . Various thermal coagulation the diagnosis. It has been suggested that the endoscopic devices, including heater probes, bipolar probes, the appearance at the ampulla of a filiform clot suggests Nd:YAG laser and the argon plasma coagulator appear biliary bleeding and of fresh bleeding a pancreatic to be successful in treating these lesions. Coagulation origin. Angiographic or CT findings may be needed to should begin at the central feeding arteriole and work make the diagnosis of an aneurysm, pseudoaneurysm peripherally. Primary treatment modality is the bipolar or arterio portal venous fistula. probe because it causes more superficial injury than other thermal methods. Laser treatment can cause deep A history of abdominal aortic graft surgery should injury relatively easily and must be used carefully. prompt a careful endoscopic examination of the second and third parts of the duodenum. If aorto-oesophageal Complication rates are low for gastric lesions and in fistula is suspected, CT investigation should be the small bowel. Colonic complications are reported in

179 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010

Table-III Flowchart - Management plan of Obscure Bleeding

180 Evaluation & Management of Obscure Gastrointestinal Bleeding (OGIB) S Perveen et al. up to 10% cases and include partially treated lesions Non specific measures are beneficial when rate of blood and perforation. Treatment is not required for incidental loss is slow and in the elderly. There have indeed been lesions. Treatment of isolated gastric lesions will often a number of improvements in the management of OGIB terminate bleeding, whereas many small bowel lesions but morbidity is still high. Adopting new technologies are not reached and new lesions develop with time. (endoscopic ultrasound, confocal laser endomicroscopy, Some patients will maintain a stable hemoglobin on iron narrow band imaging and endoscopic suturing devices) therapy alone. may be helpful in conquering this challenging problem.

Gastrointestinal bleeding from arterial venous Acknowledgement: malformations has been successfully treated with The authors thank Sabrina Mehnaz for her help in combined hormone (ethinyl estradiol 0.035-0.05 mg; designing and editing the manuscript. norethisterone 1 mg) therapy. However, continuous use of hormones for months has considerable side effects. References: The risk of thromboembolic events increases although 1. Rockall TA, Logan RF, Devlin HB, Northfield TC. Incidence observational studies have not confirmed a risk of and mortality from acute upper gastrointestinal increase29. With hereditary telangiectasias, von haemorrhage in the United Kingdom. Steering Committee and members of the National Audit of Acute Upper Willebrand’s disease, or angiodysplasias in the setting Gastrointestinal Haemorrhage BMJ, 1995;311:222-226 of end-stage renal disease Octreotide (Sandostatin), 2. Blatchford O, Davidson LA, Murray WR, Blatchford M, Pell given at a dosage of 0.05 to 0.1 mg subcutaneously two J. Acute upper gastrointestinal haemorrhage in west of to three times per day, has been successful in case Scotland: case ascertainment study. BMJ, 1997;315:510-514 studies. 3. Zuckerman GR, Prakash C, Askin MP, et al. AGA technical Treatment of lymphoma is according to histology and review on the evaluation and management of occult and includes helicobacter eradication for MALT obscure gastrointestinal bleeding. Gastroenterology lymphomas. 1999;118:201-221. 4. Foutch PG. Angiodysplasia of gastrointestinal tract. Am J Unless a single causative lesion is identified, surgical Gastroenterol 1993;88:807-818. therapy should be a last resort. Currently, exploratory 5. Lewis BS, Kornbluth A, Waye JD. Small bowel tumours: yield laparatomy is seldom preferred without concomitant of enteroscopy . Gut 1991;32:763-765. intraoperative enteroscopy in cases of transfusion 30 6. Kwo PY, Tremaine WJ. Nonsteroidal anti-inflammatory drug- dependant bleeding . Patients with obscure bleeding induced enteropathy: case discussion and review of the often have multiple bleeding sites and bleeding may literature. Mayo Clin Proc. 1995;70:55-61. persist after surgery. 7. Palmer K, Nairn M. Management Of Acute Gastrointestinal Non-specific therapy represents the primary approach Blood Loss: Summary of SIGN Guidelines. BMJ, to treatment in selected patients and should not be 2008;337:928-931. considered as failure of diagnostic approach. Non- 8. Morris AJ, Mokhashi M, Straiton M, Murray L, Mackenzie JF. specific measures include iron replacement, correction Push enteroscopy and heater probe therapy for small bowel of coagulation or platelet disorders, intermittent blood bleeding. transfusions if anemia cannot be corrected with iron Gastrointest Endosc 1996;44:394-397. supplement alone. These measures are beneficial when 9. Jensen DM, Machicado GA. Bleeding Colonic Angioma: rate of blood loss is slow and in elderly patients in whom Endoscopic the risk of further diagnostic evaluation is greater. coagulation and follow up. Gastroenterology 1985;88:1433

Conclusion: 10. Chalasani N, Cotsonis G, Wilcox CM. Upper gastrointestinal bleeding in patients with chronic renal failure: role of vascular There is no single efficient diagnostic test or therapeutic ectasia. Am J Gastroenterol 1996;91:2329-2332 approach in the management of obscure GI bleeding. 11. Gostout CJ. Angiodysplasia and aortic valve disease: lets close Most patients will benefit from a meticulous the book on this association editorial; comment. Gastrointest investigative routine that attempts to visualize as much Endosc 1995;42:491-493 of the bowel as necessary. Definitive therapy may not 12. Reilly HF, Al-Kawas FH. Dieulafoy’s lesion. Diagnosis and be possible in all the cases. management. Dig Dis Sci 1991;36:1702-170713

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13. Dieulafoy G. Exulceratio simplex. Bull Acad Med 1898:39- 22. Descamps C, Schmit A, Van Gossum A. Missed upper 40,49-82 gastrointestinal tract lesions may explain occult bleeding. 14. Jabbari M, Cherry R, Lough JO, Daly DS, Kinnear DG, Endoscopy 1999;31:452-455. Goresky CA. Gastric antral vascular ectasia: the watermelon 23 American Gastroenterological Association medical position stomach. Gastroenterology 1984;87:1165-1170 statement: evaluation and management of occult and obscure 15. Cameron AJ, Higgins JA. Linear gastric erosion. A lesion gastrointestinal bleeding. Gastroenterology 2000;118:197- associated with large diaphragmatic hernia and chronic blood 201. loss anemia. Gastroenterology 1986;91:338-342 24. Bampton PA, Holloway RH. A prospective study of the 16. Czerniak A, Thompson JN, Hemingway AP, Soreide O, gastroenterological causes of iron deficiency anaemia in Benjamin IS, Allison DJ. Hemobilia. A disease in evolution. general hospital. Aust NZ J Med 1996;26:793-799. Arch Surg 1988;123:718-721 25. Kepczyk T, Kadakia SC. Prospective evaluation of 17. Oksuzoglu BC, Oksuzoglu G, Cakir U, Bayir T, Esen M. Blue gastrointestinal tract in patients with iron-deficiency anemia. rubber bleb nevus syndrome. Am J Gastroenterol Dig Dis Sci 1995;40:1283-1289. 1996;91:780-2. 26. Sidhu R, Saunders DS, Morris AJ, MC Alindon ME. Guidelines 18. Bennett ML, Sherertz EF, Jorizzo JL. Skin lesions associated on small bowel enteroscopy and capsule endoscopy in adults. with gastrointestinal diseases. In: Yamada T, Alpers DH. Atlas Gut 2008; 57:125-36. of gastroenterology. 3d ed. Philadelphia: Lippincott Williams 27. Lewis BS, Swain P. Capsule endoscopy in the evaluation of & Wilkins 2003:127-45. patients with suspected small intestinal bleeding: results of a 19. Zaman A, Katon RM. Push enteroscopy for obscure pilot study. Gastrointest Endosc 2002;56:349-53. gastrointestinal bleeding yields a high incidence of proximal 28. Van Cutsem E, Rutgeerts P, Vantrappen G. Treatment of lesions with in reach of a standard endoscope. Gastrointest bleeding gastrointestinal vascular malformations with Endosc 1998;47:372-376. oestrogen progesterone. Lancet 1990;335:953-955] 20. Chak A, Koehler MK, Sundaram SN, et al. Diagnostic and 29. Lewis BS, Salomon P, Rivera-MacMurray S, Kornbluth AA, therapeutic impact of push enteroscopy: analysis of factors Wenger J, Waye JD. Does hormonal therapy have any benefit associated with positive findings. Gastrointest Endosc for bleeding angiodysplasia? J Clin Gastroenterol 1998;47:18-22. 1992;15:99-103. 21. Hayat M, Axon AT, O’Mahony S. Diagnostic yield and effect 30. Zukerman GR, Prakash C.Acute lower Intestinal bleeding:part on clinical outcomes of push enteroscopy in suspected small II:etiology, therapy and outcomes. Gastrointest Endosc bowel bleeding. Endoscopy 2000;32:369-372. 1999;49:227-238.

182 CASE REPORTS Non-Coronary Aortic Sinus Dilatation with Aortic Regurgitation in a Marfan’s Syndrome Patient – A Case Report M SIRAJa, MH RAHMANb

Summary: carried out a modified Bentall’s procedure on an elective Aneurysm of the coronary sinus is an uncommon clinical basis for this patient. It may be noted this is the first time condition. It is rare to come across an uncomplicated such a surgical procedure has been carried out successfully aneurysm as it remains silent and most of the available in Bangladesh. Here we describe the rationale in deciding literature describe treatment plan after a rupture has taken our treatment plan. place. Our case a 41 year old female also had aortic regurgitation and was a Marfan Syndrome patient. We (J Bangladesh Coll Phys Surg 2010; 28: 183-188)

Introduction: but not everyone experiences the same symptoms to the Marfan’s syndrome is a disease of the connective tissue. same degree. In the human body connective tissue holds and provides Marfan’s syndrome is present at birth. However, it may support to many structures throughout the body. In not be diagnosed until adolescence or young adulthood. Marfan’s syndrome as the connective tissue is abnormal Marfan’s syndrome is fairly common, the estimated , many systems are affected particularly the heart, blood incidence ranges from 1 in 5,000 to 1 in 10,000 vessels, bones, tendons, cartilage, eyes, nervous system, persons2. It has been found in people of all races and skin and lungs. Marfan’s syndrome is caused by a defect ethnic backgrounds, but is more common in China. in the gene that encodes the structure of fibrillin and the elastic fibers. These are the major components of Sometimes Marfan’s syndrome is so mild, few if any, connective tissue. symptoms occur. In most cases, the disease progresses with age and symptoms of Marfan’s syndrome become In most cases, Marfan’s syndrome is inherited. The noticeable as the changes in connective tissue occur. pattern is called “autosomal dominant,” meaning it Marfan’s syndrome patients are usually tall and thin. occurs equally in men and women and can be inherited Their arms, legs, fingers and toes may seem out of from just one parent with Marfan’s syndrome. People proportion , too long for the rest of their body. Their with Marfan’s syndrome, have a 50 % chance of passing spine may have scoliosis and the sternum may either along the disorder to their children. In 27% of cases a protrude or be indented inward. Their joints may be new genetic mutation defect occurs due to an unknown weak and easily become dislocated. Often, people with 1 cause . Marfan’s syndrome is also referred to as a Marfan’s syndrome have a long, narrow face and the “variable expression” genetic disorder, in that everyone roof of the mouth may be higher than normal, causing with Marfan’s syndrome has the same defective gene, the teeth to be crowded. More than half of all people a. Dr. Masoom Siraj, FRCS (Ed), Department of Cardiac Surgery, with Marfan syndrome have eye problems. Ibrahim Cardiac Hospital and Research Institute, Dhaka. Marfan’s syndrome cannot be diagnosed by a single b. Lt. Col. (Retd.) Dr. Md. Hamidur Rahman, FCPS, Department of Cardiac Anaesthesia, Ibrahim Cardiac Hospital and Research molecular test but requires a scoring system that Institute, Dhaka. combines various diagnostic items. The so-called Ghent Address of Correspondence: Dr. Masoom Siraj, FRCS (Ed), nosology subdivides diagnostic features into “major Department of Cardiac Surgery, Ibrahim Cardiac Hospital and Research Institute, Dhaka. criteria”, “minor criteria”, “organ involvement” and Received: 20 February, 2008 Accepted: 30 July, 2009 manifestations that only in combination with other Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 manifestations constitute a “major” or “minor” criterion. severe aortic regurgitation. CT Angio very beautifully Individuals without a family history of Marfan’s demonstrated the anatomy. The details are given below. syndrome require major criteria in at least two different Her daughter now 14 years old has also grown much organ systems and involvement of a third organ system. taller than her brother and has a thin skeletal frame. All Individuals carrying an FBN1 mutation known to cause these findings warranted a surgical intervention. Marfan’s syndrome or cases with a positive family Rationale and logic behind choosing a particular type history require one major criterion and involvement of of surgical procedure is given in the discussion part. an additional organ to establish Marfan syndrome3 . The patient was electively admitted on the 3rd of January A thorough physical examination of the eyes, heart and 2008. blood vessels, and muscle and skeletal system; a history Physical examination revealed she was normotensive of symptoms; and information about family members with a blood pressure of 130/60 mmHg, heart rate was that may have had the disorder usually leads to a 60 per minute and regular, heart murmur of aortic diagnosis. Other tests, such as Chest X-Ray, ECG, regurgitation and a clear chest on auscultation. She was Echocardiography, Trans Esophageal Echocardio- 168cm in height ( much taller then her siblings and graphy, CT scan, MRI and CT Angiography are useful parents) and weighed 65Kg. All blood investigations tools in the diagnosis. Nowadays CT Angio is proving were within normal limits, ECG and Chest X-ray were itself to be a very valuable tool in showing the vascular normal. Echocardiography report stated hugely dilated system changes. aortic root with aneurismal non-coronary sinus, normal chamber dimensions and wall thickness, intact IAS and Case Report: IVS, no thrombus or vegetation, severe aortic and mild th Ours was a 41 year old female patient born on the 6 of tricuspid regurgitation, mild pulmonary hypertension. January 1968. She is the youngest among four brothers CT Angiogram clearly showed the abnormal anatomy. and three sisters. She grew much taller in comparison Root of the aorta measured 55.0X46.6 mm ,non- to her siblings . The physical height of her parents were coronary sinus 34.7X36.7 mm in size, ascending, arch in proportion to her siblings. Her first symptom was and descending aorta appeared normal about the age of 14 years in 1982. She describes her After due explanation consent was taken and the patient symptoms as “palpitation” for which she consulted a was taken to the operating room on the 6th of January village doctor. The symptoms however continued 08. General anaesthesia was induced taking into account intermittently and were not severe enough to be a cause problems specific to the underlying pathology of of undue concern to her or to the family. She got married Marfan’s Syndrome. Systolic blood pressure was in 1991 at the age of 23 years. She gave birth to a maintained between 85 – 110 mmHg throughout the daughter in 1993 and a son in 1997. Both the peri-operative period. This is necessary to avoid suture pregnancies had a normal course resulting in normal line dehiscence, aortic dissection distal to the prosthesis. vaginal deliveries. Around the beginning of 2005 her Furthermore the patient was unduly sensitive to narcotics “palpitation” as she described it increased. She consulted and muscle relaxants. This was managed using short/ an herbal practitioner who prescribed her a “Hamdard” intermediate acting drugs namely Fentanyl and Propofol. preparation. This did give her a good response and she The procedure was carried out via median sternotomy. was alright till the end of 2005. Now the “palpitation” The patient was connected to the heart lung machine reoccurred. This time she consulted a cardiologist in using an aortic and two stage venous cannulation. The early 2007 who arranged for an Echo Doppler study of patient was cooled down to 26 degree Celsius. Heart the heart and a coronary angiogram. The reports showed was arrested after aortic cross clamp using antegrade a normal coronary tree , dilated non-coronary sinus and cold blood cardioplegia directly into the coronary ostia. a grade III aortic regurgitation. With this report she Operative findings confirmed the preoperative contacted the surgeon at our hospital in December 2007. investigations. The wall of the aneurysmal non-coronary A repeat Trans thoracic echo study of the heart and a sinus was extremely stretched and thinned out suggesting CT Angio was done. The Echo showed a hugely dilated a possible rupture in the near future. A modified Bentall’s aortic root with aneurismal non-coronary sinus, also procedure was carried out with reimplantation of the

184 Non-Coronary Aortic Sinus Dilatation with Aortic Regurgitation in a Marfan’s Syndrome M Siraj & MH Rahman coronary buttons. An ATS size 27 composite graft discharged on the 8th post operative day after the INR prosthesis was used. After removal of the cross-clamp had come up to the desired level. there was significant bleeding from the left coronary On discharge the patient was prescribed Warfarin to button. We were unable to control it satisfactorily. Also keep the INR between 3.00 and 3.5, Metprolol to reduce remembering that bleeding and arrhythmias are a the heart rate and blood pressure, Digoxin partly to common cause of post Bentall mortality. We decided to reduce the heart rate and also to act as an ionotopic redo the left coronary button. The heart was again cooled agent and NSAIDs for pain relief. down, cross clamp applied and arrested with antegrade root cardioplegia . The graft to aorta suture line was Discussion: taken down. The left coronary button was oversewn and The treatment approach depends on the structures the procedure was completed as before. There was good affected and the severity. Medications are not used to haemostasis this time. The patient came off bypass with treat Marfan’s syndrome, however they may be used to moderate ionotropic support. The patient was closed prevent or control complications. Beta-blockers and and was shifted to the ICU in a stable condition. The calcium channel blockers are used to prevent or to slow Bypass time was 322 minutes and the total cross clamp down the enlargement of the aorta4. Surgery for time was 148 minutes. External pacing was started at Marfan’s syndrome is aimed at preventing aortic 120 per minute as the desired heart rate was not present. dissection or rupture and treating valve problems. It is also the only way to deal with the same complications In the ICU patient started getting isolated ventricular when they actually happen. Composite valve graft ectopics which steadily got worse despite correction of replacement or valve sparing procedures can be done. all possible causes and doing the recommended medical With valve-sparing operations, there is risk of possible management. Arrhythmia following Bentall’s procedure re-operation in future, because the long-term durability is a common complication and sometimes is due to of this type of repair is not yet established5. kinking of the coronaries just distal to the buttons. In order to improve coronary perfusion an Intra Aoortic Advances in the use of medication and surgery have Balloon Pump (IABP) was inserted electively. Though dramatically increased the lifespan of people with this improved the haemodynamics but the arrhythmia Marfan’s syndrome. An average life expectancy in 1972 did not improve. Soon after , the patient started getting was about 45 years. The average life expectancy now is 6 runs of ventricular tachycardia and ventricular approaching that of the general population . Providing fibrillation needing DC shocks. As the situation got great hope and optimism to people with Marfan’s worse the patient was reopened in the ICU. There was syndrome and their families. This change has occurred very little collection, heart behaved normally as long as primarily because of the quality of surgical intervention, the sinus rhythm was maintained. But the bouts of VT although drug therapy may also have played a role. But, and VF continued needing defibrillation by internal only through increased awareness about the disorder, pedals. Just when we had nearly given up hope we earlier diagnosis and proper treatment can a person with decided to stop the external pacing to carry out a certain Marfan’s syndrome have realistic hope to live a normal maneuver. But this had a completely unexpected life span. response. The heart momentarily went into asystole then Immediate surgical intervention is the single, life-saving reverted back into sinus rhythm with a heart rate of 80 measure to rescue patients with acute dissection or – 82 per minute. There were no further episodes of intramural haemorrhage of the ascending aorta (Stanford arrhythmias of any type and haemodynamics improved type A). However, it may only be 20% of individuals to the extent that we had to reduce ionotropic support with acute aortic syndromes who make it into the rapidly. It seems all this time the arrhythmia was due to operating room, and of those who get operated upon “R on T” phenomenon resulting from the external more than 10% do not survive acute intervention. pacing. This was a lucky find in a desperate situation. Moreover, survivors of emergency surgery frequently From this point of time onwards the patient made a experience complications from the dissected aortic flap smooth and steady recovery. The patient was moved to that persists downstream from the ascending aorta. the surgical ward on the 3rd post operative day. She was Conversely, when the aortic root is replaced before

185 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 complications occur, both early and late survival improves The decision to operate in these cases is frequently not dramatically. A classical study with retrospective review simple: there is a substantial gray area that changes with of outcomes from 10 centers has set the standard for time. elective prophylacticaortic root replacement in Marfan’s Recommending surgery at a diameter of 6 cm may have syndrome. The vast majority of patients were treated with been appropriate in an era when the surgical mortality a composite-graft replacement according to Bentall and for elective replacement of the ascending aorta was De Bono or a modification of that technique. The study relatively high. Today, in light of a markedly reduced documented an early mortality of 1.5% and an actuarial risk of elective surgery, it seems excessively survival rate of 84% at 5 years, 75% at 10 years and 59% conservative. Strict adherence to this guideline from at 20 years7 . another era undoubtedly leads to missing the opportunity Sinuses of Valsalva are three localized bulgings in the to prevent lethal complications in a substantial number aortic root opposite the cusps of the aortic root. of patients with a dilated ascending aorta17 . There are Aneurysm of the sinus is a rare condition which may be no large follow-up studies to give a guideline for such a a congenital or acquired cardiac anomaly, having an situation17 -20. To make matters worse there are hardly incidence of 1.09% in the oriental population and 0.2% any recommendations available for an unruptured in the western population8. Aneurysms of the sinus of coronary aneurysm with aortic regurgitation in a valsalva are not usually clinically apparent unless Marfan’s Syndrome patient. perforation occurs which simulates aortic regurgitation9.

The two anterior sinuses are named after their respective Currently, elective root replacement with an coronary ostia. That is right coronary sinus and left appropriately chosen technique should not carry an coronary sinus and posterior coronary sinus is called operative risk much higher than that of routine aortic the non- coronary sinus. valve replacement. Composite replacement of the aortic valve and the ascending aorta, as originally described The unruptured aneurysm is usually silent and it often by Bentall, DeBono and Edwards (classic Bentall), or remains undiagnosed but may cause symptoms by right modified by Kouchoukos (button Bentall), remains the ventricular outflow obstruction10. The rupture may occur most versatile and widely applied method. into any cardiac chamber, predominantly the right ventricle11, the intraventricular septum12, and the In our case we were faced with a clinical situation which pericardial space13 . by it self is a rare occurrence21. Furthermore this clinical entity is usually silent prior to rupture. There Surgery of the aortic root removes the weakest spot in are publications in relation to sinus aneurysm but most the cardiovascular system of Marfan patients. However, of them deal with the measures taken after rupture. with increasing life expectancy weaknesses of the heart Publications dealing with an unruptured sinus aneurysm valves, the myocardium and distal aorta get time to are very difficult to come by. One such paper describes evolve. Currently, about one quarter of Marfan patients a non-coronary sinus aneurysm21 accidentally requiring surgery undergo mitral valve surgery, another discovered after a road traffic accident in a 38 year old quarter undergo reintervention at distal sites of the aorta, male. As we already know such aneurysms can be caused 6% have tricuspid valve surgery, and 3% require heart by clinical conditions other than Marfan’s syndrome22- transplantation for dilated cardiomyopathy14. Moreover, 24. Investigations also showed a moderate to severe 21% of adult Marfan patients develop ventricular aortic regurgitation. The patient underwent elective arrhythmia with lethal outcome in 3% of cases15. We surgery when a metallic prosthetic valve was used to believe that future strategies need to consider these replace the aortic valve and the non-coronary sinus was potential complications16 . repaired by direct suturing. The clinical scenario was Patients with aneurysm of sinus of valsalva remain very much similar to ours except the fact the patient asymptomatic clinically unless the aneurysm ruptures. was a Non- Marfan. This was a prime consideration in The onset may be sudden or insidious. In our case patient deciding our direction of treatment. Marfan syndrome presented with palpitation the investigation of which is a progressive disease where the problems usually resulted in the diagnosis. starts as a sinus dilatation and slowly progresses to full

186 Non-Coronary Aortic Sinus Dilatation with Aortic Regurgitation in a Marfan’s Syndrome M Siraj & MH Rahman blown aortic dilatation. Replacing the aortic valve and There are no guidelines how to deal with an aneurysmal repairing the aneurysm would have been a simpler coronary sinus. We sifted through existing surgical approach. But literature exists stating such case have experience as available. We decided on what we thought returned years later with aneurysm of the remaining was best for the patient taking into consideration the sinuses with or without aortic dilatation. A redo surgery underlying Marfan’s Syndrome and aortic regurgitation. in such situations carries a very high risk. We decided to surgically address not only the How do deal with an uncomplicated coronary sinus aneurysmal coronary sinus and the aortic regurgitation aneurysm generates much controversy with some , but also the potential problem of aortic root dilatation advocating a conservative approach whilst others in the future. Till the write up of this paper the patient favoring aggressive surgery. We took the following was keeping a very good health. strategy in deciding our surgical treatment. The purpose of writing this paper is to contribute some We established the diagnosis of Marfan’s Syndrome ideas about a clinical situation, on which very little has based on the following : been published. We hope our opinion will be shared by others so that a guideline may be established in the Cardio-vascular – regurgitant aortic valve, aneurysmal future. non-coronary sinus References: Skeletal - Increased arm span–to–height ratio , reduced 1. Dean. Marfan’s syndrome: clinical diagnosis and upper-to-lower segment ratio ,positive wrist sign , management. Eur J Human Genetics; 2007; 15:724-733. positive thumb (Steinberg) sign , joint hypermobility, high arched palate with dental crowding 2. Khalid. Marfan Syndrome; channel-e-medicine; Oct 2004. 3. De Paepe A, Devereux RB, Dietz HC, et al. Revised diagnostic Skin and integument - Striae atrophicae not associated criteria for the Marfan syndrome; Am J Med Genet with pregnancy or repetitive stress 1996;62:417–26. Family history – Both her daughter and son exhibited 4. Shores J, Berger KR, Murphy EA, et al. Progression of aortic the same skeletal and skin criteria of Marfan’s dilatation and benefit of long-term ß-adrenergic blockade in syndrome. But for social reasons the family declined Marfan’s syndrome; N Engl J Med 1994;330:1335–41. the daughter to be examined. She was approaching 5. Kodolitsch,Robinson. Marfan syndrome-update of genetics marriageable age. ,medical and surgical management;Heart; 2007:93:755-760. Next we took note of the fact that emergency or urgent 6. Silverman DI, Burton KJ, Gray J et al. Life expectancy in the surgery after a complication has occurred carries a very Marfan syndrome; Am J Cardiol ; 1995;75:157-60. high mortality. Even post operative mortality and 7. Gott VL, Greene PS, Alejo DE, et al. Replacement of the aortic morbidity is high. Therefore we decided on an elective root in patients with Marfan syndrome; N Engl J Med surgical intervention. We also have to remember all the 1999;340:1307–13. studies published are in the western countries where the 8. Shuttsun Chu, Chei-Ren Hung, Sou-sien How, Hang Chang home to hospital time is very short. The complete et al. Ruptured aneurysm of the sinus of valsalva in oriental opposite is true for our country. population ; J Thoracic Cardiovas Surgery ;1990;99:288-98. 9. Bulkely HB,Hutchins MG and Ross SR.Aortic sinus of Next on deciding upon the type of surgical intervention valsalva simulating primary right sided valvular heart disease; the underlying Marfan’s condition had a very important Circulation; 1975; 52:696-99. bearing.. Changes in the vessel walls are the commonest 10. Malcolm I.Unruptured aneurysm of the sinus of valsalva; Can complication of Marfan’s Syndrome and these changes J Cardiol 1996; 12 (9):783-5. manifest themselves with time. An aortic valve 11. Kucukcoglu S,Ural E,Mutlu H, et al.Ruptured aneurysm of replacement with aneurysm repair ran the risk of the the sinus of valsalva into the left ventricule : report and review patient returning with additional changes in the future. of the literature; J Am Soc Echocardiography ;1997; 10 (8): So we went ahead and did a Modified Buttonhole 862-5. Bentall’s Procedure. This procedure also took care of 12. Abad C. Congenital aneurysm of the sinus of valsalva the aneurysmal non-coronary sinus thereby eliminating dissecting into the intraventricular septum; Cardiovas Surg ; the possibility of any future rupture. 1995;3 (5): 563-4.

187 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010

13. Barbram KR,Roberts WC.Fatal intrapericardial rupture of 19. Jebara VA et al. Isolated extracardiac unruptured sinus of sinus of valsalva aneurysm; Am Heart J 1990;120(6 Pt 1) : valsalva aneurysm ; Ann Thorc Surg ;1992:54:323-6. 1455-6. 20. WilliamsTG et al. Isolated unruptured aneurysm of the left 14. Hetzer R, Pregla R, Barthel F. Surgery for cardiovascular coronary sinus of valsalva ; Ann of Thorc Surg ; 1983: 35: disorders in Marfan syndrome. Eurekah.com and Kluwer 556-9. Academic/Plenum Publishers; 2004:81–92. 21. Ribero et al:Heart . Non coronary sinus of valsalva aneurysm 15. Yetman AT, Bornemeier RA, McCrindle BW. Long-term diagnosed after road traffic accident ; 1999:82 outcome in patients with Marfan syndrome: is aortic dissection the only cause of sudden death? ; J Am Coll Cardiol ; 22. Holman WL. Aneurysms of the sinuses of Valsalva. In: 2003;41:329–32. Sabiston DC, Spencer FC, eds. Surgery of the chest. Philadelphia: WB Saunders & Co ; 1995:1316-1326. 16. von Kodolitsch Y, Rybczynski M. Cardiovascular aspects of the Marfan syndrome – a systematic review ; Eurekah.com 23. Friedman WF. Aortic sinus aneurysm and fistula. In: and Kluwer Academic/Plenum Publishers ; 2004:45–69. Braunwald E, ed. Heart disease. A text book of cardiovascular 17. Ergin et al . Surgical treatment of the dilated ascending aorta: medicine. Philadelphia: WB Saunders & Co ; 1997;910-911. when and how? ; Ann Thorac Surg 1999; 67:1834-1839. 24. Gharzudine WS, Sawaya JI, Kazma HK, et al. Traumatic 18. Hiyamuta et al ; Aneurysm of the left aortic sinus causing pseudoaneurysm of the left sinus of Valsalva: a case report ; J acute MI ; Circulation;1983 ;67:1151-4. Am Soc Echocardiography ; 1997;10:377-380.

188 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 Adrenoleukodystrophy: A Rare Case Report MBA MONDOLa, MMR SIDDIQUIb, L WAHABc, MA HOQUEd, SU KHANe, KM RAHMANf, QD MOHAMMADg

Summary: white matter abnormalities in parieto-occipital regions. The A young boy of 18 years was admitted at department of diagnosis of Adreno-leukodystrophy (ALD) was strongly Neurology, Dhaka Medical College Hospital with the suggested from the medical history, biochemical and complaints of progressive generalized hyper-pigmentation, radiological (MRI) findings of brain. The purpose of our gradual loss of vision, hearing impairment, abnormal report is to highlight this very rare nontreatable disease to behaviors and one episode of seizure. Examination finding all. A patient of neuropsychiatric symptoms with Addison’s revealed, abnormal behaviors, generalized hyper disease we must think about ALD, because it’s progression pigmentation of skin, oral mucosa, gum, tongue and palmer creases. He has diffuse hair loss, bilateral primary optic can be delayed with early diagnosis and supportive treatments, atrophy, bilateral sensoryneural deafness. All routine it’s incidence can be reduced by genetic counseling. investigations revealed normal findings except, CSF protein Key words: Adrenoleukodystrophy (ALD), Addison’s were elevated, biochemical features (very high ACTH, low disease, Very long chain fatty acid (VLCFA). basal cortisol) of primary adrenal failure, Magnetic resonance imaging (MRI) of the head showed bilateral symmetrical (J Bangladesh Coll Phys Surg 2010; 28: 189-192)

Introduction: been described: childhood cerebral ALD (more severe Adrenoleukodystrophy (ALD) is a group of genetically form), adolescent cerebral ALD, adult cerebral ALD, determined peroxisomal disorders associated with adrenomyeloneuropathy (AMN), Addison’s disease progressive central demye-lination of brain, primary only, presymptomatic (asymptomatic) and heterozygous adrenal cortical insufficiency (Addison’s disease) and women4. Most patients are diagnosed in childhood or hypo-gonadism1. The more common form of ALD is adolescence when they have such neurologic X-linked with abnormal gene location in Xq28 region2 manifestations as cognitive dysfunction, behavioral and occurs in childhood or adolescence; however, a problems, visual loss, seizures or features of adrenal neonatal form occurs from autosomal recessive insufficiency5. Progression is usually rapid, with the inheritance. ALD affecting 1/20,000 males whose patient reaching a vegetative state within 10 years after having impaired ß-oxidation of very long chain fatty the neurologic symptom onset. In patients with acids (VLCFA) in peroxisomes, particularly Addison’s disease, diagnosis of ALD is suggested by hexacosanoic acid (C26:0), pentacosanoic acid (C25:0) the abrupt development of neuropsychiatric symptoms, and tetracosanoic acid (C24:0), which accumulate in associated with MRI confirmation of extensive, usually tissues and body fluids2,3. This accumulation probably symmetric, white matter disease. Here we report a case incorporated into myelin which leads to instability and of ALD. dysmyelination with possible direct cytotoxic effect on Case report: oligodendrocytes. At least seven clinical subtypes have A 18 years old young boy from Feni was admitted at a. Dr. Md. Badrul Alam Mondol, Associate Professor department of Neurology, Dhaka Medical College b. Dr. Md. Mahmudur Rahman Siddiqui, Postgraduate Resident, c. Dr. Luna Wahab, Postgraduate Resident Hospital with the complaints of progressive blackening d. Dr. Md. Azharul Hoque, Associate Professor of the whole body for the last 15 years, gradual e. Dr. Sharif Uddin Khan, Assistant Professor impairment of vision for last 7 years, hearing impairment f. Dr. Kazi Mohibur Rahman, Assistant Professor g. Professor Dr. Quazi Deen Mohammad, Professor & Head of and abnormal behaviors noticed for last 3 months. He the Department started his schooling at the age of five, but failed to Department of Neurology, Dhaka Medical College Hospital, Dhaka. continue due to lack of attention, and subsequent visual Address of Correspondence: Dr. Md. Badrul Alam Mondol, impairment. Gradually he also started having hearing Associate Professor, Department of Neurology, Dhaka Medical College Hospital, Dhaka. impairment. He had a single episode of seizure 3 months Received: 14 July, 2008 Accepted: 10 April, 2010 back. During his hospital stay he also had features of Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 psychosis and complained of vertigo. His past medical history was unremarkable. Prior to his admission to the hospital he was not on any medications except for some herbal products. His family history was also unremarkable. Examination finding revealed, generalized hyper-pigmentation (Fig-1,2) of skin including pigmentation of the oral mucosa, gum, tongue and palmer creases. He has diffuse hair loss, his blood pressure was within normal limits without any postural drop. His genital examination revealed testicular atrophy. Neurological examination revealed, bilateral primary optic atrophy (confirmed by ophthalmologist), sensory-neural hearing loss in both ears (confirmed by Audiometry). All routine investigations revealed normal findings, but CSF examination revealed high protein: 208 mg/dl (normal level 15-45 mg/dl) without any change of cell count, glucose and microbiological findings. Serum electrolytes were within normal limits. On imaging abdominal USG was normal but MRI of the brain showed bilateral symmetrical hypointence Fig-2: Generalized hyper pigmentation. signal change in T1 weighted images and bilateral symmetrical hyperintance signal changes in T2 and Flair parieto-occipital regions, which were compatible with weighted images in the sub cortical white matter of both Leukodystrophy (Fig-3,4,5). His basal cortical level was

Fig-3: Axial T1 weighted MRI of brain showing bilateral, symmetrical hypointence signal change in the sub cortical white matter of both occipito-parietal Fig-1: Generalized hyper pigmentation. regions.

190 Adrenoleukodystrophy: A Rare Case Report MBA Mondol et al.

1.95 micg/dl at 9.00 AM (normal level 5-25 micg/dl at morning), serum ACTH level was >1250 pg/ml (normal level 5-46 pg/ml). The diagnosis of adrenoleuko- dystrophy was strongly suggested from the medical history, biochemical and radiological (MRI of head) findings. Then treatment was started with antipsychotic and prednisolone with good control of symptoms. Now he is in regular follow up.

Discussion: The clinical course in adrenoleukodystrophy is characterized by behavioral disorders, ataxia, visual loss, decreased hearing, and epileptic seizures, followed by mental deterioration, psychosis and death. Adrenal insufficiency is a usual finding, but does not always precede neurologic disease 5,6. Abnormal skin pigmentation and other features of adrenal insufficiency may become apparent before neurological symptoms. In some cases adrenal symptoms will never appear 7. Most common cause of primary adrenal insufficiency are either autoimmune adrenal failure (about 75% to Fig-4: Axial T2 weighted MRI of brain showing 80%) or tuberculosis (about 20%) 1, other etiologies symmetrical, bilateral hyperintence signal changes in such as ALD are thought to be distinctly uncommon 1. sub cortical white matter of both occipito-parietal We should think of ALD when adrenal insufficiency regions. associated with neuropsychiatric manifestations, like our patient. Typically demyelination begins bilaterally in the occipital region, extending across the splenium of the corpus callosum. Gradually the process spreads outward and forward as a confluent lesion, affecting the parietal, temporal, and finally, the frontal white matter, cerebellar white matter, cerebellar peduncles, and corticospinal and corticobulbar tracts. Calcium deposition can also be found. MR is more sensitive than computed tomography to detect these demyelinating plaques. Plain MRI show hypointense signal on T1 and hyperintense signal on T2 and flair images. Post contrast study shows contrast enhancement at the outer margins due to active demyelination and disruption of blood brain barrier 7. VLCFA can be measured in plasma, which will be raised. Features of primary adrenal insufficiency (Serum ACTH, ACTH stimulation test, Serum. Cortisol, Serum. testosteron & gonadotropin level) should be measured 8. The prognosis of ALD can be estimated on the basis of Fig-5: Axial Flair MRI image of brain showing age and the severity of the brain MRI abnormality, but hyperintense signal change in the same regions. there are exceptions to these rules, and some patients

191 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 may remain stable with no further progression for up to References: 12 years after the initial neurological symptoms 9. 1. Sydney AW. Adrenomyeloneuropathy presenting in adulthood. Although childhood cerebral form, causing a severe WJM 1998; 168(1): 45-47. disability that leads to death early. On the other hand 2. Sagarika M, Elizabeth N, John NH. Adrenomyelo-neuropathy the adrenomyeloneuropathy is a milder adult form with in patients with ‘Addison’s disease’: genetic case analysis. J R Soc Med 2006; 99: 245–49. involvement of mainly the spinal cord and peripheral nerves, having a slow progression with better prognosis. 3. Antonio A, Simonetta P, Glorgio C, Leopoldo S, Aldo I et al. Rapid decline of fertility in a case of Adrenoleukodystrophy. Treatment is symptomatic, for example, steroid use for Human reproduction 1998; 13(9): 2474-79. adrenal insufficiency and psychotropics for psychiatric 4. Moser HW, Bergin A, Naidu S, Ladenson PW. symptoms. No clear effective treatments are available, Adrenoleukodystrophy. Endocrinol Metab Clin North Am although Lorenzo’s oil (4:1 glyceryl trioleate and glycery 1991; 20:296-318. trierucate) can be used before the age of 6 may reduce 5. Castellote A, Vera J, Vazquez E, Roig M, Belmonte JA et al. the probability of develop neurological deficit in late MR in Adrenoleukodystrophy: Atypical Presentation as Bilateral Frontal Demyelination. AJNR 1995; 16: 814–15. life2,8. Statins can reduce VLCFA level, but no influence in neuronal and endocrine functions 2,8. Fatty diet should 6. Lee AG, Olson RJ, Bonthius DJ, Phillips PH. Increasing exotropia and decreasing vision in a school aged boy. Surv be restricted. Bone marrow transplantation is an option Ophthalmol 2007; 52(6):672-79. in patient with early neurological features, abnormal 7. Shuang W, Ji-Min W, Yuan-Shen C. Asymmetric Cerebral magnetic resonance imaging scans and Lesion Pattern in X-linked Adrenoleuko-dystrophy. J Chin neuropsychological dysfunction but is not recommended Med Assoc 2006; 69(8):383-86. in the severely affected group (i.e. performance IQ580) 8. Monika S, Regina TG, Stan VU, Hasnain MK. and has a significant morbidity and mortality 2,8. As ALD Adrenomyeloneuropaty as a cause of primary adrenal is an X-linked recessive disorder, genetic counseling of insufficiency and spastic paraparesis. CMAJ 2004; 171 (9): family members may be advisable. Early diagnosis also 1073-77. brings the possibility of genetic counseling; carrier 9. Doris EB, Rosalyn D, Steve J, Frank ME, Peter R et al. An Unusual Case of X-Linked Adrenoleukodystrophy with detection and antenatal diagnosis and thus we can reduce Auditory Processing Difficulties as The First And Sole Clinical the incidence of this devastating disease. Manifestation. J Am Acad Audiol 2004, 15:152–60.

192 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 Goldenhar Syndrome-A Case Report MAR SIDDIQUEa, J HOSSAINb, MJ ABEDINc, M PARVEZd

Summary: small chin since birth. His vertebral anomalies also detected A 7 years old boy was diagnosed a case of Goldenhar by skiagram of the vertebral column as spina bifida. His Syndrome. He presented with swelling in the upper and outer ocular and auricular problems were solved by surgery part of the left eye as limbal dermoid associated with without any complicatons. Patient is leading a normal life. preauricular tags, hemifacial asymmetry, microtia and (J Bangladesh Coll Phys Surg 2010; 28: 193-195)

Introduction: and lipodermoid are the most common. Coloboma of the Goldenhar syndrome is a birth defect resulting from the upper eyelid may be present. Limbal dermoid or maldevelopment of the first two branchial arches with lipodermoid are mainly located in the inferotemporal incomplete development of the ear, nose, soft palate, lip region of the eye. Ocular defects are reported in 65% of and mandible. The phenotype is highly variable 1. the cases and include pre-auricular tags, microtia, anotia Goldenhar Syndrome is one of the Varriants of & conductive hearing loss. Vertebral anomalies are craniofacial anomalies. It is unilateral in 70-80% of the combination of hemivertebra, fused ribs, kyphosis and 7,8 cases 2. It is known as oculoauriculo vertebral (OAV) scoliosis. Additional features - cardiac, genito-urinary dysplasia. The syndrome complex includes limbal and pulmonary systems can also be affected. Cardio dermoid or lipodermoid, pre-auricular tags, hemifacial pulmonary distress within the few months of life is asymmetry and vertebral anomalies. These are the relatively common life threatening complication. The commmon anomalies of the condition. It is a rare purpose of this article is to report a rare case of condition characterized by the triad (usually unilateral) craniofacial anomalies and manage satisfactorily. of craninofacial microsomia, ocular dermal cyst and spine Case Report: anomalis. Age of onset during neonatal & infancy. A 7 years old boy reported to BNS Patenga a Naval Hospital Prevalence rate is in 1-9/100000 3,4, incidence rate is 1 of Bangladesh Navy at Chittagong on 07 july 2008 with in 25000-45000 births 5. Male is more commonly complains of swelling of the upper and outer part of the affected than the female ( ratio 2:1). Most of the cases of left eye associated with preauricular tags, hemifacial OAV are sporadic, autosomal dominant transmission is asymmetry, microtia, small chin and abnormalities in the 5 reported for 1% - 2% of the cases . A few person spine. The swelling in the inferotemporal region of the left manifested with autosomal recessive inheritance has been eye was gradually increasing and causing obstruction of reported. Aetiology of the syndrome remains unclear. the visual axis by the drooping of the eye lid. The patient Currently a deficiency in mesodermal formation or was examined thoroughly. Ocular examination revealed a defective interaction between neural crest or mesoderm small soft mass of the left eye locating in the is suggested as possible aetiology5. Different factors also ineferotemporal region obscuring the visual axis. But his contributed to the development of the disease such as: visual acuity was 6/6 in both eyes. Fundoscopic ingestion of some drugs (Cocaine, Thalidomide, Retinoic examination was found normal. ENT examination revealed acid and temoxifen), environmental factors (Insecticides, preauricular tags present in the left ear and small ear present Herbicides) and maternal diabetes 6. Ocular anomalies on the left side. No other abnormalities are detected. occur about 50% of the case of OAV 6. Epibulbar dermoid Systemic examination like cardiovascular, pulmonary and genito-urinary systems are done but no abnormalities are a. DR MAR Siddique detected. CNS examination showed slow mental uptake. b. Dr. Colonel Jakaria Hossain, MBBS, DO (DU), FCPS (Oph), CMH Chittagong Cantonment, Chittagong The laboratory investigations are within normal limit. ECG c. Dr. Mohd Jainal Abedin, MBBS, DO, FCPS (Oph), Chittagong - normal, X-ray chest (postero anterior view) showed Medical College Hospital, Chittagong nothing abnormality detected, X-ray of the vertebral d. Dr. Masud Parvez, MBBS, MS (Oph), FCPS (Oph), Chittagong column showed spina bifida. The patient operated under Medical College Hospital, Chittagong GA for his visual and auricular anomalies. The result was Address of Correspondence: Dr. Lt. Col. Md. Abdur Rouf Siddique, Eye Spl and Surgeon, Dept. of Ophthalmology, BNS Patenga, satisfactory without any complications or no uneventful Chittagong. occurrence happened. Now the patient is cured and leading Received: 14 December, 2008 Accepted: 5 May, 2009 a normal life. Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010

Photograph of the Patient

Photograph(Before operation): 1 Showed Limbar Skiagram of the vertebral coulmn (Cervical Spine) dermoid (Left eye & Preauricular tags (Left ear) (Lateral view)- 4 showed spina bifida involving C6- T1 Vertebrae.

Discussion: Goldenhar syndrome is known as oculoauriculo vertebral dysplasia. It is proposed to represent a variant of hemifacial microsomia group. It includes hemifacial hypoplasia, oculoauriculo vertebral dysplasia and first and second arch syndrome. The involvement is unilateral in 70%-80% of cases 2, 9. Ocular manifestation are limbal dermoid or lipodermoid and occasional coloboma of the upper eye lid. Limbal dermoid is more common than lipodermoid. It is usually present in the Photograph (After operation): 2- Showed exsion of inferotemporal quadrant and can be bilateral in 25% Limbar dermoid (left eye) with lamellar keratoplasty cases 7. There are 2 types of limbal dermoid - large & and exsion of Preauricular tags (left ear). small. The larger one interferes with the visual axis causing astigmatism and predisposing to secondary strabismus from anisometropic amblyopia. Other associations are Duane Retraction syndrome and lower incidence of decreased corneal sensation, cataract and iris abnormalities 10, 12 Ear tags are common. Inner ear anomalies are occur in some cases. The central nervous system are occasionally affected. Vertebral anomalies are common which includes kyphosis, scoliosis and lumber lordosis. Hemifacial asymmetry is also common. Other findings include microtia, macrosomia and mandibular anomalies. The clinical diagnosis is based on the obvious clinical findings and other laboratory and radiological findings. The most common complaints of swelling in the left eye lid, preauricular tags, difficulty Skiagram of the vertebral coulmn (Cervical Spine) (AP in opening of the mouth and difficulty in walking view)- 3 showed spina bifida involving C6- T1 occasionally. The most common findings are limbal Vertebrae. dermoid or epibulbar dermoid in the upper and outer

194 Goldenhar Syndrome-A Case Report MAR Siddique et al. part of the left eye. Other includes preauricular tags, 3. Bayraktar S, Bayraktar ST, Ataoglu E, Ayaz A, Elveli M. microtia and hemifacial asymmetry. Vertebral anomalies Goldenhar’s syndrome associated with multiple congenital are not obvious in this particular case. X-ray of the abnormalites. J Trop Pediatr. 2005;51(6):377-9. vertebral column is done to exclude vertebral anomalies. 4. Beck AE, hudgins L, Hoyme HE. Autosomal dominant microtia and ocular coloboma: new syndrome or an extension Only spina bifida is detected by skiagram which is not of the oculo-auriculo-vertebral spectrum? Am J Med Genet significantly affects the child. Treatment of the disease A. 2005;1;134(4):359-62. 13 varies according to the severity of the manifestation . 5. Cohen J, Schanen NC. Branchial cleft anomaly, congenital With regard to the rule of ophthalmology is aimed first heart disease, and biliary atresia: Goldenhar complex or at strong amblyogenic risk causing obstruction of the Lambert syndrome? Genet Couns. 2000;11(2):153-6. visual axis, severe astigmatism or strabismus, second 6. Gorlin RJ, et al. Oculo-auriculovertebral dysplasia. J Pediatr. at ocular exposure (due to large coloboma or large limbal 1963;63:991-999. dermoid preventing lid closure), third at working with 7. Goldenhar M. Associations malformatives de l’oeil et l’oreille, craniofacial surgeon in case of severe muscular en particulier le syndrome dermoide epibulbaire-appendices auriculaires-fistula auris congenital et ses relations avec la weakness that requires reconstruction of the upper face. dysostose mandibulo-fistula auris congenita et ses relations Systemic treatment may be related for cardio-renal or avec la dysostose mandibulo-faciale. J Genet Hum CNS malformation 11. Surgical treatment of the 1952;1:243-282. condition related to large coloboma requires surgical 8. “Oculoauriculovertebral Dysplasis.” Online Mendelian repair and spectacle correction, large limbal dermoid inheritance in Man. WWW. ncbi.nlm.nih.gov/entrez/entrez/ needs excision of the dermoid with lamellar keratoplasty. dispomim.cgi?id=164210. Severe anomalies of the mandible requires 9. Schaefer, Bradley G, Olney A, Kolodziej P. Oculoauriculo- reconstruction with bone graft. In case of microtia or vertebral Spectrum. ENT-Ear, Nose & throat Joumal. 1998;77:17-18. other ear defects needs extensive ear reconstruction to be done within 6-8 years of age 12. If the facial or 10. Singer SL, Haan E, Slee J, Goldblatt J. Familial hemifacial microsomia due to autosomal dominant inheritance. Case congenital malformation are severe speech therapy is reports. Aust Dent J. 1994;39(5):287-91. required 13. In this particular case there is anomalies of 11. Stoll C, Viville B, Treisser A, Gasser B. A family with eye and ear that was corrected by surgical intervention dominant oculoauriculovertebral spectrum. Am J Med Genert. without any comlications. Patient is now cured and 1998;78(4):345-9. leading a normal life. 12. Tasse C, hohringer S, Fisher S, Ludecke HJ, Albrecht B, et al. Oculo-auriculo-vertebral spectrum (OAVS): clinical References: evaluation and severity scoring of 53 patients and proposal 1. Jack J Kanaski, Clinical Ophthalmology, 5th edition, for a new classification. Eur J Med Genet. 2005;48(4):397- Butterworths London, 2005: Page 92, 607. 411. 2. Basic AAO and clinical science course, 2003-2004, Section- 13. Tewfik TL, Alnoury Kl;Manifestations of Craniofacial 6, Page 391-92 Syndromes; eMedicine, October 2008.

195 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 Pregnancy with Idiopathic Thrombocytopenic Purpura - A Case Report R AKTHERa, T HOSSAINb, MA KHANc, MALIHA RASHIDd

Summary: the last 8 months. She treated with Prednisolone during Thrombocytopenia in pregnancy has many common causes, pregnancy period, platelet transfusion before and after including gestational thrombocytopenia, viral and bacterial delivery and Danazol in puerperium. Her baby was delivered infections, and preeclampsia complicated by hemolysis, by caesarean section .Her intra-operative and post operative elevated liver enzymes, and low platelet (HELLP) syndrome. period was uneventful. She delivered a healthy male baby The great concern for ITP during pregnancy is the risk of weighted 2.5 kg and breast feeding established successfully. thrombocytopenia in the newborn infant. A 30yrs old 3rd She was discharged on seventh post operative day. The aim gravid women was admitted in maternity unit 3, Dhaka of this case report to reveal pregnancy with ITP and its Medical College Hospital with the complaints of 36weeks clinical presentation, investigation and management with pregnancy, lower abdominal pain and less fetal movement. review of relevant literatures. She had been suffering from severe thrombocytopenia for (J Bangladesh Coll Phys Surg 2010; 28: 196-198)

Introduction: (NAIT) and its management during pregnancy, labor and Thrombocytopenia is a common diagnostic & puerperium. These relatively rare causes of management issue during pregnancy1.Asymptomatic thrombocytopenia are important, as neonatal outcomes thrombocytopenia occurs near term or peripartum period can be significantly impaired and subsequent in about 5% normal pregnancies .The reference range pregnancies can be affected.1 of a normal platelet count in non pregnant women and Case Report: newborns is 150,000-400,000/ µL .However, platelet counts during pregnancy are normal in most 2 women. A 30yrs old lady became pregnant for 3 times and given st Thrombocytopenia in pregnancy has many common birth thrice (G3 P3). Her 1 two pregnancies were rd causes, including gestational thrombocytopenia, viral uncomplicated but 3 pregnancy complicated by severe and bacterial infections, and pre-eclampsia complicated thrombocytopenia. She was admitted to DMCH with by hemolysis, elevated liver enzymes, and low platelet the complaints of 36weeks pregnancy, lower abdominal (HELLP syndrome) count. This article focuses on the pain and less fetal movement for three days. She has gestational thrombocytopenia, immune thrombocytopenic been suffering from ITP for the last 8 months. She was purpura (ITP) and neonatal alloimmune thrombocytopenia on regular antenatal care and jointly monitored by obstetrician and Hematologist at DMCH. Her total a. Dr. Rabeya Akther, FCPS, Bangladesh Bank Medical Center, platelet count was within the range of 20,000-30,000 / Dhaka, Bangladesh. µL of blood throughout the pregnancy. She was treated b. Dr. Taufiqua Hossain, FCPS, MS, Consultant, Dhaka Medical with Prednisone 20gm bid and Folic acid. It was her Collage& Hospital, Dhaka. adjusted dose below this level she developed purpuric c. Prof. Mohiuddin Ahmed Khan, FCPS, Professor, Department of Hematology, Dhaka Medical Collage& Hospital, Dhaka, spot. She had no history of thrombocytopenia in Bangladesh. previous pregnancy, menorrhagia, bleeding after d. Prof. Maliha Rashid, FCPS, Professor, Department of circumcision or simple cut injury of her children. Obstetrics and Gynecology, Dhaka Collage& Hospital, Dhaka, Bangladesh. Regarding her past history, she suddenly developed Address of Correspondence: Dr. Rabeya Akther Fellow no: mild gum bleeding eight months back and her 1996(Obstetric & Gynaecology), Senior Medical Officer, Bangladesh hematological examination revealed that bleeding time Bank Medical Center Motijheel, Dhaka, Bangladesh, Telephone: 8313533, 01817517100 (mobile), Email: [email protected] was 8.4 min and clotting time was 4.30 min and total Received: 13 May, 2008 Accepted: 20 September, 2010 platelet count was 30,000/ µL of blood, her ANA Pregnancy with Idiopathic Thrombocytopenic Purpura - A Case Report R Akther et al. antibody and Anti-ds DNA were negative. Bone the mucous membranes (epistaxis or gingival bleeding), marrow study showed that normal M: E ratio and or purpura 3,4,5 ITP occurs in all races 1and is diagnosed Dysmegakaryopoises. She became pregnant during her more commonly in females than males (ratio 3:1) 1,2,4- lactational amenorrhoea period .Positive pregnancy 6, specially in women of child bearing age (2nd and 3rd test and sonography (11 wks 4 days) confirmed her decade of life )1,4,5 with an incidence of one to two in pregnancy. Because of risk of severe bleeding and 1000 pregnancies 7,8 They may have a history of complexity of the disease, they (Couple) decided to menorrhagia or menometrorrhagia prior to pregnancy, continue the pregnancy. She developed severe per history of delivering a term newborn with vaginal bleeding at her 12 weeks of gestation and thrombocytopenia, visceral or intracranial hemorrhage, admitted at DMCH for splenectomy operation .She was or spontaneous or prolonged bleeding after venipuncture duly immunized against pneumococcus, meningococcus. 4. Most women with ITP have normal findings on Her active bleeding was stopped after fresh frozen physical examination (splenomegaly is absent) and plasma transfusion and sonography revealed that single purpura may be present especially in the lower limb 4,7. viable pregnancy of 13weeks size, moderate amount Newborns have normal findings on physical of retro placental collection and no splenomegaly. Her examinations, no cephalohematoma, ecchymoses over splenectomy operation was postponed and pregnancy the presenting part, and no purpura 4. was continued uneventfully till term. Her anomaly scan ITP is a diagnosis of exclusion with peripheral was done at 24 weeks of gestation & revealed no fetal thrombocytopenia and normal or increased anomaly. megakaryocytes in the bone marrow , red and white cell After admission in the hospital, she was followed up count is normal 1, 2,4 .There is no history of drug intake for one week. Clinically she was well. There were few (e g, heparin, sulfonamides), Gestational thrombocytopenia, purpuric spots, especially in the legs. Her all test Preeclampsia in current pregnancy, and other medical reports and USG of pregnancy profile was normal conditions that can cause thrombocytopenia (e g, 4 except total platelet count (TPC) ,which was less than leukemia, viral infection) . Platelet counts less than 1 10000/ µL of blood. Her TPC rose to 50,000/ µL by 70,000/ µL are suspicious for the disorder . Bone allowing complete bed rest and reducing physical marrow aspiration demonstrates normal or increased numbers of megakaryocyte4.Anti platelet antibodies can activity in addition to Prednisolone. After consultation be detected in the serum of women with ITP. A negative with hematologist her pregnancy was terminated by test does not exclude the diagnosis 1,4,5,7. Additionally, elective caesarean section. She was transfused four many women with gestational thrombocytopenia have units of platelet before caesarean section and caesarean high levels of circulating platelet-associated delivery was performed within one hour after immunoglobulin.1 transfusion. Her platelet transfusion continued for three consecutive days 3 in the same way and start Danazol References: (100mg) orally from the first post operative day. Her 1. Jamaes N George, Muzahid A. Rizvi: Thrombocytopenia: intra-operative and post operative period was Ernest Beutler Marshall A Lichtman, Barry S Coller Thonmas J Kipps,Uri Seligsohn: Williams Hematology: McGraw-Hill, uneventful. She delivered a male baby weighted 2.5 New York, 6th edition:2001. Pp 1514-1520. kg, APGAR score 8/10 and 10/10 .Immediately after 2. Giles C, Inglis TCM: Thrombocytopenia and delivery baby was seen by Pediatrician and found macrothrombocytosis in gestational hypertension.Br J Obstet healthy. Breast feeding established successfully. She Gynaecol: 1981; 88:1115. was discharged on seventh post operative day with 3. Carr JM, Kruskall MS, Kaye JA, Robinson SH: Efficacy of platelet count was 20000/ µL and platelet count rises platelet transfusions in immune thrombocytopenia. Am J Med 400000 /µL after seven days. 80:1051, 1986. 4. Frank Firkin, Colin Chesterman, David Penington& Bryan Discussion: Rush: de Gruchy’s Clinical Haematology in Medical Practice. Pregnant women with ITP can be asymptomatic or may The Hemorrhagic Disorder: Capillary and Platelet defects; present with a history of easy bruisability, bleeding into ch14, 5thedition, Blackwell Science, pp 377-385.

197 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010

5. Robert N Handin, Clotting disorders; Harrison Principle of 10. kitchens CS, Pendergast JF: Human thrombocytopenia is Medicine ; McGraw-Hill, New York, 13th edition 1994, vol - associated withstructural abnormalities of the endothelium 2, pp1800. that are ameliorated by glucocorticosteroid administration. Blood 67:203, 1986. 6. George JN, EI-Harake MA, Raskob GE: Chronic idiopathic thrombocytopenic purpura. N Eng J Med 1994;331:1207. 11. Gernsheimer T,Stratton J,Ballem PJ,Slicher SJ: Mechanism of response to treatment in autoimmune thrombocytopenic 7. Lynnae millar, MD; Immune Thrombocytopenia and purpura. N Eng J Med ; 1989;320:974. Pregnancy, Last Updated: June 29, 2006. 12. Bussel JB: Immune thrombocytopenia in pregnancy: 8. Keith, Edmonds: Disorders of platelets in pregnancy: autoimmune and alloimmune. J Reprod Immunol 1997 Dec Dewhurst’s Textbook of Obstetric and Gynaecology for post 15; 37(1): 35-61[Medline]. graduates; 6th edi: Blackwell Science Page 229-233. 13. Jobaida Sultana, Kohinoor Begum,Masuma Jalil,Md.Monir 9. George JN, Woolf SH,Raskob GE, et al: Idiopathic Hossain Khan; Immune thrombocytopenic purpura and thrombocytopenic purpura:A practical guideline developed pregnancy: a case report: Bangladesh J Obstet Gynecol,2006, by explicit methods for the American society of hematology, 21(2):90-92. Blood 88:3,1996.

198 SHORT COMMUNICATION Bezoar, A Rare Cause of Gastrointestinal Obstruction MM HUSSAINa, CA KAWSERb (J Bangladesh Coll Phys Surg 2010; 28: 199-201)

Bezoars are rare but bizzare and well known entity . On examination , she was anaemic . Upper abdomen We recently treated three cases of bezoar in the stomach was slightly bulged . A hard smooth lump with rounded and intestine presenting with obstructive symptoms . lower boarder was palpable in the epigastrium .It could The presentation and findings were suggestive. These not be moved . there was no other organomegaly. were removed surgically with relief of symptoms. Respiratory and other systemic examination was essentially normal. Plain radiology of abdomen and Case 1: Chest and routine blood or urine tests were normal . Miss M , a 12 year old female child was brought with CT scan showed a large mass extending into the complaints of abdominal pain and vomiting for two duodenum. A diagnosis of Tricobezoar was made . An weeks. She was suffering from recurrent abdominal pain upper midline incision was made. Stomach was found for about a year. Pain was mostly in the epigastrium, larger than usual , compactly filled with a hard mass in aggravated after meals and frequently followed by the stomach. A gastrotomy was done and the concretion vomiting. There were episodes of severe pain but she was delivered intact . Post operative period was had no hematemesis or malaena and her bowel habit uneventful. was normal. She was reluctant to eat as she did not feel Case 2: hungry. She has recently lost weight for two - three Mr S.A a 26 year young man presented with complaints months and for last two weeks was taking liquids only. of repeated acute abdominal pain along with vomiting On enquiry mother agreed that the child has the habit of and abdominal distension for about two years. Pain was taking her own hairs for quite long time . central abdominal , sudden , colicky and relieved after a few hours. He was hospitalized twice for this. On examination everything was normal except an abdominal lump that was firm, slightly elongated, non- tender and freely mobile. In a repeat physical examination the lump could not be palpated. A barium

Photograph of the Bezoar conforming the shape of stomach and also extension into duodenum. a. Prof. Md. Margub Hussain, Professor of Surgery , Dhaka Medical College, Dhaka b. Prof. CA Kawser , Professor of Paediatrics, BSMMU, Dhaka. Address of Correspondence: Md. Margub Hussain, Professor of CT scan coronal plane showing extension of Bezoar Surgery , Dhaka Medical College, Dhaka into duodenum Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 follow through was normal. Exploration revealed a firm Bezoars are found mostly in the stomach. But there solid mass in the ileum at the terminal part. Attempt for are reports of cases with bezoars in the intestine, fragmentation failed. The bezoar was pushed proximally esophagus, colon and even in Meckel’s diverticulum and taken out through enterotomy. It consisted of .2,3 Sometimes the tail of the bezoar may extend to vegetable seeds and fibers. There was no other mass in jejunum ( Rapunzel syndrome). They occur mainly in stomach or jejunum. the young women who chew and swallow their hair Case-3: (trichobezoar) or phytobezoar (vegetable fibres) or One of the author was called in to see a girl of 6 years pharmacobezoar (tablets/semi solid masses of drugs) with features of acute abdomen. She was complaining .Cotton threads swallowed by a tailor was reported to of abdominal pain and vomiting after each feed. She form a bezoar4. Initially these do not cause problem was treated in the clinic as acute abdomen with suction, and continue to grow and become enmeshed, creating a saline and antibiotic. On examination a firm, nontender, mass in the shape of the stomach where they are usually elongated mass without any mobility could be felt in found. Causes of bezoar include the presence of the epigastrium. Bowel sound was normal. There was indigestible material in the lumen, gastric dysmotility no other significant abnormal physical finding except (including previous surgery like vagotomy and partial thin built. Extensive laboratory work-up was already gastrectomy etc.) and certain other substances that completed including abdominal CT Scan. Scan showed encourage stickiness and concretion formation.5 irregular density mass in the stomach. On further enquiry, mother informed that child used chew mother Trichobezoars usually presents with pain in the hair in infancy followed by chewing and swallowing of abdomen , nausea, vomiting, anorexia, dyspepsia, fur from stuffed toys which she is continuing to do now. malaise, weakness, loss of weight, and a sense of Diagnosis of tricobezoar was made. Surgical extraction heaviness in the epigastrium. Pain is mainly in the of the mass was done with uneventful recovery. epigastrium, mimicking peptic ulcer pain , having recurrent acute exacerbations. The most characteristic physical finding is a large, readily, palpable and freely movable abdominal mass, usually located in the epigastrium but sometimes occupying lower positions, with a well-defined, smooth outer surface and uniform firmness. Phytobezoars in the intestine usually presents with acute intestinal obstruction. A lump is sometimes palpable that may disappear and reappear. The incidence of associated peptic ulceration with the more abrasive phytobezoars (24%) is greater than with trichobezoars (10%). Bezoar may cause ulceration, hemorrhage, perforation and peritonitis. Presence of CT scan showing mass involving the Stomach and typical mass in the epigastrium with typical history is Duodenum quite diagnostic and do not need much investigations. Discussion: Treatment of bezoars is relief of obstruction by removal Bezoars are compact masses formed of various of bezoars Rarely resection of intestinal loop may be indigestible foreign or intrinsic substances found in the required for gangrenous or other pathological changes. gastrointestinal tract of human and animals. The term Multiple enterotomies is recommended for bezoars bezoar, is believed to be derived from the Arabic extraction in Rapunzel syndrome. In cases of intestinal ‘Badzehr‘, Persian ‘Padzahr‘ or Turkish word ‘Panzehir‘, bezoars stomach and proximal gut must be checked for all meaning counter poison or an antidote. In fact bezoars concomitant bezoars . Surgical treatment of gastric were used in India from 1200 B.C. for many reason bezoars may be avoided when small. Following the including rejuvenating to neutralizing snake venom1. introduction of minimally invasive surgery and endoscopy

200 Bezoar, A Rare Cause of Gastrointestinal Obstruction MM Hussain & CA Kawser with mechanical and laser fragmentation techniques, 3. Kim K H, Choi S C, Seo GS, Kim Y S, Choi CS, Im C J. successful management of bezoars has been recorded.6 Esophageal bezoar in a patient with achalasia: case report and literature review. Gut Liver. 2010 ;4(1):106-9. Procedures involve fragmentation of the mass by scissors, 4. Chintamani , Durkhure R, Singh JP and Singhal V. Cotton or by ultrasound, Dissolutionof phytobezoar by Coca Bezoar- a rare cause of intestinal obstruction: case report. cola lavage was reported recently 7 BMC Surgery 2003, 3:5 5. Gaia E, Gallo M, Caronna S, Angeli A. Endoscopic diagnosis References: and treatment of gastric bezoars. Gastrointest Endosc. 1. Gorter R R , Kneepkens C M F , Mattens E C J L, Aronson 1998;48:113–114. D C and Heij H A . Management of trichobezoar: case report 6. Nirasawa Y, Mori T, Ito Y, Tanak H, Seki N, Atomi Y. and literature review. Pediatr Surg Int. 2010; 26(5): 457– Laparoscopic removal of a large gastric trichobezoar. J Pediatr 463. Surg. 1998;33:663–665. 2. Debakey M, Oschner A. Bezoars and concretions, 7. Ladas S D; Triantafyllou K; Tzathas C; Tassios P; Rokkas comprehensive review of literature with analysis of 303 T and Raptis S A. Gastric phytobezoars may be treated by collected cases and presentation of 8 additional cases. Surgery. nasogastric Coca-Cola lavage. European Journal of 1939;5:132–160. Gastroenterology & Hepatology: 2002 ; 14 : 7 : 801-803.

201 IMAGES IN MEDICAL PRACTICE

MMR SIDDIQUIa, QT ISLAMb, A HOSSAINc, MS MAHBUBd

(J Bangladesh Coll Phys Surg 2010; 28: 202)

A 40-year-old previously healthy house wife presented In both cases investigations revealed they had acute with fever for 1 months and swelling of the lower lip myeloid leukemia (AML) with possible deposition of for 15 days. Initially her lower lip became swollen and leukemic cells (blast) in lip and retro-bulbar tissue after 7 days it became ulcerated without any pain (fig- respectively. In AML, malignant clones of immature 1). Clinical examination revealed she was febrile with myeloid cells (primarily blasts) proliferate, replace bone swollen, ulcerated, crusted lower lip. Her upper lip and marrow, circulate in blood and invade other tissues.1,2 mouth cavity were absolutely normal. Other clinical Leukemic cells may infiltrate any extra-medullary site examinations were unremarkable. occurring in approximately 3% of patients with AML.1,2 A 14-year-old previously healthy school boy presented References: with fever for 6 weeks and gradual protrusion of the 1. Rajput D, Naval R, Yadav K, Tungaria A, Behari S. Bilateral both eyes for 20 days. Clinical examination revealed he proptosis and bitemporal swelling: A rare manifestation of had fever, bony tenderness, purpura and bilateral acute myeloid leukemia. J Pediatr Neurosci 2010;5:68-71. proptosis (fig-2). He had no eye pain, chemosis or 2. Paydas S, Zorludemir S, Ergin M. Granulocytic sarcoma: congestion. Thyroid gland was normal. 32 cases and review of the literature. Leuk Lymphoma. 2006;47:2527-2541.

a. Dr. Md. Mahmudur Rahman Siddiqui, FCPS (Med) Part-II Course student, Dept. of Medicine, DMCH, Dhaka. b. Prof. Quazi Tarikul Islam, Professor, Dept of Medicine, DMCH, Dhaka. c. Dr. Ahmed Hossain, Assistant Professor, Dept. of Medicine, DMCH, Dhaka. d. Dr. Md. Shahriar Mahbub, FCPS (Med) Part-II Course student, Dept. of Medicine, DMCH, Dhaka. LETTER TO THE EDITOR

(J Bangladesh Coll Phys Surg 2010; 28: 203-205)

Cost Effective Preoperative Evaluation: The editorial References: of the Journal of Bangladesh College of Physicians and 1. Vicanti CJ, ‘Jar~Houten RJ, Hill-RC. A statistical analysis of Surgeons, May 2010, Vol. 28, No. 2 the relationship of physical status to postoperative mortality in 68,388 cases. Anesth Analg 1970; 49: 564-6. 1. To the Editor-in-Chief: We have gone through the 2. Rabiul MA, Zahurul MI, Mahbubul MA, Moinul HC. time-demanding editorial on ‘Cost Effective Incidental detection of systemic diseases during Preoperative Evaluation’ with keen interest. We would pre-anaesthetic assessment. Journal ofArmed Forces Medical like to supplement few relevant data of study performed College 2005; 1:27-29. 3. Delahunt B, Turnbull PRG. How in our centre. Assessing and optimising a patient before cost effective are routine preoperative investigations? N Z Med J 1980; 92: 431-2. surgery is an essential for planning and administering a successful peri-operative management with the best Dr. (Lt Col) Md Rabiul Alam possible outcome. Peri-operative morbidity, mortality Classified Anaesthesiologist and thereby cost increase with the severity of pre- CMH, Chittagong Cantonment, Chittagong. Email: existing diseases.’ We studied a total of 2,086 patients rabiuldr gmaiLcom in CMH Dhaka, who were scheduled for routine surgery. During pre-anaesthetic assessment we tried to detect 2. Sir the pre-existing systemic diseases which were not Thank You for publishing a well informed journal. I diagnosed earlier. The incidental findings of diseases throughly gone through May 2010 Vo. 28, No. 2. About were: conduction heart block 18.75%, COPD 15%, Editorial of this issue I want to mention that its a time anaemia 11.62%, IHD 5.55%, bronchial asthma 1.61%, honoured publication and it may be a guideline in all hypertension 1.3% and some other conditions like drug the institute where Anaesthesia is being practiced as an 2 allergy, CRF, and peptic ulcer disease. speciality. Its nice to see Anesthesia grade has been This report depicts that the patients with incidental matched with Surgery grades and rewrite the importance findings were fortunate enough to come across a of ASA score. I demand well circulation of this editorial functioning anaesthesia OPD setup and they got the among those who use anesthesia as an speciality. scopes to be optimised for the planned procedures With thanks before hand. But this is the scenario of quite a thin DR. Abul Bashar Md. Jamal section of in vogue anaesthesia practice in our country. FCPS ( Surgery), FRCS (Edin), MMEd Asst. Prof. of Surgery The author has very correctly mentioned that ‘the Shaheed Suhrawardy Medical College, Dhaka. practice of seeing patients preoperatively by an anaesthesiologist just before surgery still exists in this part of the world and yet a fair number make their way Author’s Reply for both letters to OR without being seeing at all’. This custom is mainly We do not have enough study backup in this country to prevailing in private practice and requires improvement say with some assurance about the incidence of particularly for the patients with co-morbidity to have incidental co-morbidity during preoperative assessment. desired safety and cost effectiveness. The advised Dr. Alam’s series is quite a pioneer in this area. He is investigations should also be rational and logical ones right that a great but unknown number of surgical following the guidelines to reduce the procedural patients do not meet the anesthesiologist before the day expenditures.3 This can be achieved by integrated and of surgery albeit this responsibility lies with both the concerted efforts of the health care continuum of family Surgeons and Anesthesiologists. practitioners, internists, residents, surgeons, pathologists Regarding the correrelation of comorbidity and increase and anaesthesiologists. in expenses as Dr. Alam mentioned, I think the guideline Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010 laid down by various work groups can act as optimizer. information or molecular imaging techniques such as Dr. Jamal also mentions about an integral approach the MR diffusion –weighted imaging or MR consisting of relevant disciplines. This, I believe ought spectroscopy. MR imaging with diffusion and to be a product of team work and the job to be done in perfusion imaging provides information regarding phases. The first person to start the ball to roll is the brain lesions induced by the toxic agents (vasogenic surgeon and then with collaboration of the edema, cytotoxic edema, infarction, hemorrhage, anesthesiologists other clinicians and investigative 5 departments could get involved. demyelination). Treatment is mainly for the symptoms that toxic encephalopathy brings upon victims, varying depending on how severe the case Kazi Mesbahuddin Iqbal is. To reduce or halt seizures, anticonvulsants may be prescribed. Dialysis or organ replacement surgery may be needed in some severe cases.5 Toxic Images in medical practice: Short communication encephalopathy is often irreversible. If the source of of Journal of Bangladesh College of Physician and the problem is treated, by removing the toxic chemical Surgeons, May 2010; 28(2): 128. from the system, further damage can be prevented, To the editor in chief: At first I thank to the editor for but prolonged exposure to toxic chemicals can starting some new section like ‘letter to the editor’ quickly destroy the brain. Research is being done by and short communication. I have gone through the organizations such as NINDS (National Institute of report and I would like to give some comments about Neurological Disorders and Stroke) on what Toxic encephalopathy. Toxic encephalopathy, also substances can cause encephalopathy, why they do known as toxic-metabolic encephalopathy, is a this, and eventually how to protect, treat, and cure degenerative neurologic disorder caused by exposure the brain from this condition.6 It is increasing day by to toxic substances.1 It can be an acute or chronic day in our country due to ignorance, illiteracy, poverty disorder.Toxic encephalopathy has a wide variety of & illegal practice of different substances by local symptoms, which can include memory loss, small traditional healer. I thank to author to highlight the personality changes, lack of concentration, case and image which will make awarness among involuntary movements, nausea, fatigue, seizures and medical practioner about toxic encephalopathy. depression.2,3 Toxic encephalopathy may be caused References: by prolonged exposure to toxic elements including 1. “Neurotoxicity Syndromes”. Medical Subject Headings. solvents, drugs, radiation, paints, industrial United States National Library of Medicine. 1999-11-03. chemicals, and certain metals. In addition, chemicals, http://www.nlm.nih.gov/cgi/mesh/2009/ such as lead, that could instigate toxic encephalopathy MB_cgi?mode=&index=18803. Retrieved 2009-03-30. are sometimes found in everyday products such as 2. “What is Encephalopathy?”. Disorders A-Z. National Institute cleaning products, building materials, pesticides, air of Neurological Disorders and Stroke. 2007-02-12. http:// 3,4 fresheners, and even perfumes. Different kinds of www.ninds.nih.gov/disorders/encephalopathy/ lesions, which lack specificity for toxic injury, can encephalopathy.htm#What_is. Retrieved 2009-03-30. be observe on radiological images, but deep grey 3. Fidler AT, Baker EL, Letz RE. “Neurobehavioural effects of matter lesions with symmetrical distribution through occupational exposure to organic solvents among construction out basal ganglia are most often seen. However, such painters”. Occupational and Environmental Medicine May findings have also been reported after anoxic- 1987;44 (5): 292–308. doi:10.1136/oem.44.5.292. http:// ischemic insults or during severe metabolic oem.bmj.com/cgi/reprint/44/5/292. Retrieved 2009-04-26. disturbances. Lesions in the white matter may also 4. “National Toxic Encephalopathy Foundation”. http://national- be present in the case of acute exposure to toxic toxic-encephalopathy-foundation.org/. Retrieved 2009-03-30. agents. The true prognostic value of toxic-induced 5. Hantson P, Duprez. The value of morphological neuroimaging brain changes in the acute phase in CT or MR studies after acute exposure to toxic substances. Toxicol Rev. is unclear, although serial MRI may add new 2006;25(2):87-98.

204 Letter to the Editor

6. “What research is being done?”. Disorders A-Z. National encephalopathy patient. In the short communication, Institute of Neurological Disorders and Stroke. 2007-02-12. there were little scope of detailed discussion on various http://www.ninds.nih.gov/disorders/encephalopathy/ expects of toxic encephalopathy but I must appreciate encephalopathy.htm#What_research_is_being_done. and thank you for your letter highlighting the etiology, Retrieved 2009-04-12. clinical presentation, diagnostic approach and treatment of toxic encephalopathy.2 I gladly accept the additional Dr. Aparna Das information you have provided. It was gratifying to read Assistant Professor, the response from the reader. Department of Medicine References: Dhaka Medical College, Dhaka. 1. Siddiqui MMR, Hossain A, Rahman MU, Islam QT. Images in Medical Practice: short communication. J Bangladesh Coll Phys Surg 2010;28(2):128. Author’s Reply: 2. Das A. Letter to the editor: Images in Medical Practice: short communication. J Bangladesh Coll Phys Surg 2010. We pleased to see the keen interest of Dr. Aparna Das regarding the article “Images in Medical Practice: Short Dr. Md. Mahmudur Rahman Siddiqui Communication of JBCPS, May 2010;28(2):128”.1 We FCPS Med Part-II course student, appreciate the opportunity to respond. In my short Department of Medicine, Dhaka Medical College, communication I wanted to highlight the changes that Dhaka. occur in the CT scan and MRI of brain of a toxic

205 COLLEGE NEWS

(J Bangladesh Coll Phys Surg 2010; 28: 206-211) Examination news: Result of FCPS Part-I, FCPS Part-II and MCPS examinations held in July 2010 are given bellow: 3686 candidates appeared in FCPS Part-I examination held in July 2010 of which 675 candidates come out successful, subject wise result are as follows:

Sl. No. Subject Appeared Pass % of Pass 1. Medicine 1124 275 24.47 2. Surgery 539 61 11.32 3. Paediatrics 405 56 13.83 4. Obst. & Gynae 880 160 18.18 5. Otolaryngology 98 14 14.29 6. Ophthalmology 91 24 26.37 7. Psychiatry 9 1 11.11 8. Anaesthesiology 74 7 9.46 9. Radiology 52 4 7.69 10. Radiotherapy 20 4 20.00 11. Dermatology and Venereology 67 6 8.96 12. Physical Medicine & Rehabilitation 26 5 19.23 13. Dentistry 251 52 20.72 14. Family Medicine 3 0 0.00 15. Haematology 22 2 9.09 16. Microbiology 7 0 0.00 17. Histopathology 18 4 22.22 Grand Total 3686 675 18.31

The following candidates satisfied the Board of Examiners and are declared to have passed the FCPS Examinations held in July 2010 subject to confirmation by the council of Bangladesh College of Physicians and Surgeons

Roll No. Name From where Graduated Subject 016-8501 Lima Asrin Sayami Jahurul Islam Medical College, Bajitpur Cardiology 016-8502 Sabina Hashem Chittagong Medical College, Chittagong Cardiology 077-7003 Dr. Md. Manowarul Islam MAG Osmani Medical College, Sylhet Anaesthesiology 077-7006 Md Rafiqul Islam Mymensing Medical College, Mymensing Anaesthesiology 077-7009 Md. Abdul Mannan Miah Rajshahi Medical College, Rajshahi Anaesthesiology 077-7010 A K M Bashar Dhaka Dental College, Dhaka Conservative Dentistry and Endodontics 077-7011 Mohammad Naser Dhaka Dental College, Dhaka Conservative Dentistry and Endodontics 077-7016 Anzirun Nahar Asma Chittagong Medical College, Chittagong Dermatology and Venereology 077-7027 Mohammad Asifuzzaman Dhaka Medical College, Dhaka Dermatology and Venereology 077-7031 Lubna Khondker Rangpur Medical College, Rangpur Dermatology and Venereology 077-7038 Tawhida Nawazesh Rosie MAG Osmani Medical College, Sylhet Dermatology and Venereology 077-7042 Mujahida Rahman Bangladesh Medical College, Dhaka Haematology 077-7048 Md Nurun Nabi Odessa Medical University, Ukraine Haematology 077-7057 Anita Marium Islam Chittagong Medical College, Chittagong Medicine 077-7060 Ahmad Monjurul Aziz Chittagong Medical College, Chittagong Medicine 077-7066 Binoy Krishna Tarafder Mymensing Medical College, Mymensing Medicine College News

Roll No. Name From where Graduated Subject

077-7072 Ashiqur Rahman Khan Dhaka Medical College, Dhaka Medicine 077-7074 Ariful Basher Chittagong Medical College, Chittagong Medicine 077-7075 Dr. Abul Mansur Mohammad Rezaul Karim Comilla Medical College, Comilla Medicine 077-7091 Dr. Hafez Mohammad Nazmul Ahsan Rajshahi Medical College, Rajshahi Medicine 077-7100 Dr. Md Mokarram Hossain Dhaka Medical College, Dhaka Medicine 077-7111 Dr. Md. Shahidullah Sher-E-Bangla Medical College, Barisal Medicine 077-7142 Iqbal Ahmed Chowdhury Sir Salimullah Medical College, Dhaka Medicine 077-7161 Dr. Shaikh Md. Eunus Ali Sher-E-Bangla Medical College, Barisal Medicine 077-7188 Dr. Mohammad Ashaduzzaman Sir Salimullah Medical College, Dhaka Medicine 077-7195 Mohammed Shahjahan Kabir MAG Osmani Medical College, Sylhet Medicine 077-7223 Mohammad Akter Hossain Mymensing Medical College, Mymensing Medicine 077-7229 Md. Zakirul Islam Rajshahi Medical College, Rajshahi Medicine 077-7239 Md. Naushad Ali Dhaka Medical College, Dhaka Medicine 077-7263 Md Shafiul Alam Sir Salimullah Medical College, Dhaka Medicine 077-7288 Nusrat Sultana Dhaka Medical College, Dhaka Medicine 077-7289 Noor Mohammed Institute of Applied Health Science, under USTC, Chittagong Medicine 077-7300 Muhammad Kamruzzaman Khokan Chittagong Medical College, Chittagong Medicine 077-7304 Mst Irin Pervin Sir Salimullah Medical College, Dhaka Medicine 077-7307 Dr. Md.Moyeen Uddin Dhaka Medical College, Dhaka Medicine 077-7312 Dr. Md.Abdur Rouf Dhaka Medical College, Dhaka Medicine 077-7338 Dr. Joyabrata Das Chittagong Medical College, Chittagong Medicine 077-7349 Sudip Ranjan Deb Dhaka Medical College, Dhaka Medicine 077-7357 Zeenat Sultana Bangladesh Medical College, Dhaka Medicine 077-7362 Shikha Paul Dhaka Medical College, Dhaka Microbiology 077-7368 Ayesha Siddika Purabi Rangpur Medical College, Rangpur Obst and Gynae 077-7389 Alifa Nasrin Jalalabad Ragib-Rabeya Medical College, Sylhet Obst and Gynae 077-7403 Dr. Zebun Nessa Sher-E-Bangla Medical College, Barisal Obst and Gynae 077-7406 Dr. Umme Kulsum Sher-E-Bangla Medical College, Barisal Obst and Gynae 077-7414 Dr. Sushmita Paul Rajshahi Medical College, Rajshahi Obst and Gynae 077-7415 Dr. Shamsunnahar Rangpur Medical College, Rangpur Obst and Gynae 077-7421 Dr. Shahela Nazneen MAG Osmani Medical College, Sylhet Obst and Gynae 077-7422 Dr. Shahanaj Sharmin Chittagong Medical College, Chittagong Obst and Gynae 077-7423 Dr. Seema Bhattacharjee Chittagong Medical College, Chittagong Obst and Gynae 077-7431 Dr. Sabina Sharmeen Mymensing Medical College, Mymensing Obst and Gynae 077-7434 Dr. Rina Haider Mymensing Medical College, Mymensing Obst and Gynae 077-7441 Dr. Parveen Sultana Mymensing Medical College, Mymensing Obst and Gynae 077-7449 Dr. Najnin Munni Moulana Bhasani Medical College, Dhaka Obst and Gynae 077-7455 Dr. Most.Sabina Yeasmin Rajshahi Medical College, Rajshahi Obst and Gynae 077-7466 Dr. Lailo Nahar Dhaka Medical College, Dhaka Obst and Gynae 077-7471 Dr. Kamrun-Nesa-Begum. Chittagong Medical College, Chittagong Obst and Gynae 077-7473 Quazi Mah-Zebeen Akter Faridpur Medical College, Faridpur Obst and Gynae 077-7485 Naznin Akter Zahan Dhaka Medical College, Dhaka Obst and Gynae 077-7495 Nazia Ahmed Dhaka Medical College, Dhaka Obst and Gynae 077-7497 Nasrin Hossain MAG Osmani Medical College, Sylhet Obst and Gynae 077-7506 Nargis Akther Shiddique Rangpur Medical College, Rangpur Obst and Gynae 077-7542 Khirunneassa Chittagong Medical College, Chittagong Obst and Gynae

207 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010

Roll No. Name From where Graduated Subject

077-7556 Shahnaz Neelanjana Rahman Bangladesh Medical College, Dhaka Obst and Gynae 077-7564 Shah Mohammad Hassanur Rahman Dhaka Medical College, Dhaka Obst and Gynae 077-7578 Sadia Jabeen Khan Sir Salimullah Medical College, Dhaka Obst and Gynae 077-7618 Shraboni Chakrabarty Dhaka Medical College, Dhaka Obst and Gynae 077-7624 Kazi Nazma Begum MAG Osmani Medical College, Sylhet Obst and Gynae 077-7629 Kaniz Fatema Rangpur Medical College, Rangpur Obst and Gynae 077-7634 Jinnat Ara Islam Rajshahi Medical College, Rajshahi Obst and Gynae 077-7674 Farhana Rahman Sher-E-Bangla Medical College, Barisal Obst and Gynae 077-7675 Farhana Rahman Mymensing Medical College, Mymensing Obst and Gynae 077-7678 Dr. Jebunnessa Begum Mymensing Medical College, Mymensing Obst and Gynae 077-7694 Monowara Begum Comilla Medical College, Comilla Obst and Gynae 077-7699 Mohshina Abedin Chittagong Medical College, Chittagong Obst and Gynae 077-7721 Sohely Akter Sir Salimullah Medical College, Dhaka Obst and Gynae 077-7728 Suraiya Parvin Sher-E-Bangla Medical College, Barisal Obst and Gynae 077-7735 Toufiqua Ahmed Sir Salimullah Medical College, Dhaka Obst and Gynae 077-7736 Threshika Islam Chowdhury Z.H. Shikder Women’s Medical College, Dhaka Obst and Gynae 077-7742 Tania Afroz Sher-E-Bangla Medical College, Barisal Obst and Gynae 077-7746 Yeasmin Samad Lipe Sir Salimullah Medical College, Dhaka Obst and Gynae 077-7747 Ummul Nusrat Zahan Sher-E-Bangla Medical College, Barisal Obst and Gynae 077-7759 Tahmina Akhter Rangpur Medical College, Rangpur Obst and Gynae 077-7760 Tahmina Ahmed Sir Salimullah Medical College, Dhaka Obst and Gynae 077-7768 Zahida Jabbar Mymensing Medical College, Mymensing Ophthalmology 077-7771 Shahnaz Begum Sir Salimullah Medical College, Dhaka Ophthalmology 077-7773 Rajashree Das MAG Osmani Medical College, Sylhet Ophthalmology 077-7775 Muhammad Moniruzzaman Khulna Medical College, Khulna Ophthalmology 077-7787 Md. Azizur Rahman Rangpur Medical College, Rangpur Ophthalmology 077-7789 Md Kamrul Hasan Khan Sher-E-Bangla Medical College, Barisal Ophthalmology 077-7793 Maliha Sharmin Mymensing Medical College, Mymensing Ophthalmology 077-7802 Mahmuda Akhter Dhaka Dental College, Dhaka Oral and Maxillofacial Surgery 077-7803 Shoma Banik Pioneer Dental College, Dhaka Oral and Maxillofacial Surgery 077-7804 Nitish Krishna Das Dhaka Dental College, Dhaka Oral and Maxillofacial Surgery 077-7805 Manjur-E-Mahmud Dhaka Dental College, Dhaka Oral and Maxillofacial Surgery 077-7807 Ahmed Tariq Sher-E-Bangla Medical College, Barisal Otolaryngology 077-7811 Salah Uddin Ahmmed Sir Salimullah Medical College, Dhaka Otolaryngology 077-7812 S. M. Nazmul Huque Khulna Medical College, Khulna Otolaryngology 077-7814 Nripendra Nath Biswas Sir Salimullah Medical College, Dhaka Otolaryngology 077-7819 Mohammad Kamal Hossain Jahurul Islam Medical College, Bajitpur Otolaryngology 077-7820 Mohammad Arif Murshed Khan Dhaka Medical College, Dhaka Otolaryngology 077-7821 Mohammad Abdul Quayum Comilla Medical College, Comilla Otolaryngology 077-7825 Kazi Atikuzzaman Mymensing Medical College, Mymensing Otolaryngology 077-7832 Dr. Md.Golam Mustafa MAG Osmani Medical College, Sylhet Otolaryngology 077-7841 Subrata Ghosh Mymensing Medical College, Mymensing Otolaryngology 077-7851 Somayra Nasreen MAG Osmani Medical College, Sylhet Paediatrics 077-7886 Samiha Amin Chittagong Medical College, Chittagong Paediatrics 077-7898 Naharuma Aive Hyder Chowdhury Sir Salimullah Medical College, Dhaka Paediatrics 077-7928 Mamun Reza Khan Sher-E-Bangla Medical College, Barisal Paediatrics

208 College News

Roll No. Name From where Graduated Subject

077-7932 Jesmin Hossain Rajshahi Medical College, Rajshahi Paediatrics 077-7936 Habiba Jesmin Mymensing Medical College, Mymensing Paediatrics 077-7943 Farhana Rahat Dhaka Medical College, Dhaka Paediatrics 077-7944 Farhana Naznin Dhaka Medical College, Dhaka Paediatrics 077-7958 Shahnaz Akter Dhaka Medical College, Dhaka Paediatrics 077-7970 Dr. Nandita Nazma MAG Osmani Medical College, Sylhet Paediatrics 077-7972 Dr. Mrinal Kanti Das Dhaka Medical College, Dhaka Paediatrics 077-7991 Badrunnesa Ahmed Mymensing Medical College, Mymensing Physical Medicine & Rehabilitation 077-7992 Mohammad Abul Kalam Azad Comilla Medical College, Comilla Physical Medicine & Rehabilitation 077-7993 Muhammed Abdullah Al Mamun Mymensing Medical College, Mymensing Physical Medicine & Rehabilitation 077-7994 Nadia Rahman MAG Osmani Medical College, Sylhet Physical Medicine & Rehabilitation 077-7995 Shafiul Karim Md Elias MAG Osmani Medical College, Sylhet Physical Medicine & Rehabilitation 077-7997 Farzana Khan Shoma Dhaka Medical College, Dhaka Physical Medicine & Rehabilitation 077-8001 Rubaba Ahmed Dhaka Dental College, Dhaka Prosthodontics 077-8003 Muhammad Zillur Rahman Khan Sir Salimullah Medical College, Dhaka Psychiatry 077-8004 Muhammad Abdul Kayum Shaikh Mymensing Medical College, Mymensing Psychiatry 077-8005 Mekhala Sarkar Sir Salimullah Medical College, Dhaka Psychiatry 077-8029 Dr. Hashim Rabbi Bangladesh Medical College, Dhaka Surgery 077-8031 Dr. Hamudur Rahman Jahurul Islam Medical College, Bajitpur Surgery 077-8037 Dr. Abu Bakar Siddique Dhaka Medical College, Dhaka Surgery 077-8038 Dr. Abdur Rabban Talukder Sir Salimullah Medical College, Dhaka Surgery 077-8040 Debasish Das Khulna Medical College, Khulna Surgery 077-8046 Dr. Md Abdul Mobin Choudhury MAG Osmani Medical College, Sylhet Surgery 077-8051 S M Nuruddin Abu Al Baki Chittagong Medical College, Chittagong Surgery 077-8057 Prabir Chowdhury Institute of Applied Health Science, under USTC, Chittagong Surgery 077-8077 Mohammad Zillur Rahman Mymensing Medical College, Mymensing Surgery 077-8141 Md Abdul Baset Mymensing Medical College, Mymensing Surgery 077-8146 Md Nazmul Hoque Masum Dhaka Medical College, Dhaka Surgery 077-8161 Khandaker A B M Abdullah Al Hasan Sir Salimullah Medical College, Dhaka Surgery 077-8164 Kazi Taslima Ahmed Dhaka Medical College, Dhaka Surgery 077-8166 Jahir Ahmed MAG Osmani Medical College, Sylhet Surgery 077-8178 Shantanu Biswas Shahid Ziaur Rahman Medical College, Bogra Surgery 077-8180 Farhad Uddin Ahmed Chittagong Medical College, Chittagong Surgery 077-8184 Dr. Tamanna Narmeen Chittagong Medical College, Chittagong Surgery 077-8186 Dr. Syed Khalid Hasan Institute of Applied Health Science, under USTC, Chittagong Surgery 077-8189 Dr. Mehtab Uddin Ahmed Mymensing Medical College, Mymensing Surgery 077-8195 Dr. Md. Shariful Alam Khan Mymensing Medical College, Mymensing Surgery 077-8209 Dr. Md. Shahiduzzaman Mymensing Medical College, Mymensing Surgery 077-8227 Be-Nazir Barna Dhaka Medical College, Dhaka Surgery 077-8232 Angel Shubhagata Baidya Jalalabad Ragib-Rabeya Medical College, Sylhet Surgery 077-8233 Dizen Chandra Barman Rajshahi Medical College, Rajshahi Surgery 077-8253 Tariq Akhtar Khan Mymensing Medical College, Mymensing Surgery

209 Journal of Bangladesh College of Physicians and Surgeons Vol. 28, No. 3, September 2010

The following candidates satisfied the Board of Examiners and are declared to have passed the Preli - FCPS - II Examinations held in July 2010 subject to confirmation by the council of Bangladesh College of Physicians and Surgeons

Roll No. Name From where Graduated Subject 011-8606 Dr. Mohammad Abul Khair Dhaka Medical College, Dhaka Preli - Medicine 011-8608 Dr. Muhammad Abdullahel Kafi Chittagong Medical College, Chittagong Preli - Medicine 011-8609 Md Golam Rabbani Dhaka Medical College, Dhaka Preli - Medicine 011-8617 Mamunur Rashid Shikder Sir Salimullah Medical College, Dhaka Preli - Medicine 011-8618 Marufa Mustari Rangpur Medical College, Rangpur Preli - Medicine 011-8621 Eshita Das Chittagong Medical College, Chittagong Preli - Medicine 011-8640 Muhammed Shahidul Islam Jahurul Islam Medical College, Bajitpur Preli - Paediatrics 011-8651 Mohammed Abdullah As Sajjad Rahimi Comilla Medical College, Comilla Preli - Surgery 011-8663 Md Saifullah Kabir Dhaka Medical College, Dhaka Preli - Surgery 011-8675 Dr. Khaled Mahmud Mymensing Medical College, Mymensing Preli - Surgery

The following candidates satisfied the Board of Examiners and are declared to have passed the MCPS Examinations held in July 2010 subject to confirmation by the council of Bangladesh College of Physicians and Surgeons

Roll No. Name From where Graduated Subject

077-9005 Md. Ghulam Haider Rangpur Medical College, Rangpur Anaesthesiology 077-9006 Mohammad Jahangir Alam MAG Osmani Medical College, Sylhet Anaesthesiology 077-9008 Lipika Sanjowal Rangpur Medical College, Rangpur Anaesthesiology 077-9009 Muhammad Abdur Rahman Mymensing Medical College, Mymensing Anaesthesiology 077-9011 Md Zahedul Islam Sir Salimullah Medical College, Dhaka Anaesthesiology 077-9012 Muhammad Saiful Islam Rangpur Medical College, Rangpur Anaesthesiology 077-9014 Mohd Iqbal Kabir Sir Salimullah Medical College, Dhaka Anaesthesiology 077-9017 Rahat Anjum Jalalabad Ragib-Rabeya Medical College, Sylhet Clinical Pathology 077-9019 Mohammad Shameem Montasir Hossen Chittagong Medical College, Chittagong Clinical Pathology 077-9020 Towhid Tofail Sappro Dental College, Dhaka Dental Surgery 077-9021 Mohammad Deedarul Alam Dhaka Dental College, Dhaka Dental Surgery 077-9023 Ranjit Ghosh Chittagong Medical College, Chittagong Dental Surgery 077-9026 Ashis Kumar Biswas Chittagong Medical College, Chittagong Dental Surgery 077-9030 Aminul Islam Dhaka Dental College, Dhaka Dental Surgery 077-9033 Shantaj Khondoker Dhaka Medical College, Dhaka Dermatology and Venereology 077-9034 Farhana Wahab Sir Salimullah Medical College, Dhaka Dermatology and Venereology 077-9035 Pragwa Permita Jahurul Islam Medical College, Bajitpur Dermatology and Venereology 077-9036 Noor Jahan Begum MAG Osmani Medical College, Sylhet Dermatology and Venereology 077-9040 Md Khasroo Bhuiyann Sher-E-Bangla Medical College, Barisal Family Medicine 077-9041 Syed Akm Nurul Amin Mymensing Medical College, Mymensing Family Medicine 077-9045 Sumon Mutsuddy Rangpur Medical College, Rangpur Forensic Medicine 077-9078 Jinnat Fatema Saira Safa Chittagong Medical College, Chittagong Medicine 077-9079 Tufayel Ahmed Chowdhury Faridpur Medical College, Faridpur Medicine 077-9116 Poly Sengupta Chittagong Medical College, Chittagong Medicine 077-9119 Muhammed Muhiuddin Mazumder MAG Osmani Medical College, Sylhet Medicine 077-9130 Mohammad Ashif Rahman Chittagong Medical College, Chittagong Medicine 077-9144 Dr. Abu Saif Mohammad Lutful Kabir Chittagong Medical College, Chittagong Medicine 077-9149 Dr. Md. Abul Kashem Sir Salimullah Medical College, Dhaka Medicine 077-9160 Dr. Most. Arifa Sharmin Dinajpur Medical College, Dinajpur Obst and Gynae 077-9162 Dr. Hosney Naznin Dhaka Medical College, Dhaka Obst and Gynae

210 College News

Roll No. Name From where Graduated Subject

077-9172 Dr. Delu.Ara.Parveen Mymensing Medical College, Mymensing Obst and Gynae 077-9178 Rehana Ferdoesh Sher-E-Bangla Medical College, Barisal Obst and Gynae 077-9183 Sarbin Boby Sultana Faridpur Medical College, Faridpur Obst and Gynae 077-9188 Shahin Afrose Rajshahi Medical College, Rajshahi Obst and Gynae 077-9197 Jannatul Hosna Medical College for Women and Hospital, Dhaka Obst and Gynae 077-9210 Nasrin Hasan Jahurul Islam Medical College, Bajitpur Obst and Gynae 077-9216 Md Shahidul Islam Sher-E-Bangla Medical College, Barisal Obst and Gynae 077-9242 Samira Chowdhury University of Science & Technology Chittagong Obst and Gynae 077-9243 Anuradha Chakravartty Jahurul Islam Medical College, Bajitpur Obst and Gynae 077-9244 Mosammath Nazma Begum Dinajpur Medical College, Dinajpur Obst and Gynae 077-9245 Mst Umma Salma Chowdhury Sir Salimullah Medical College, Dhaka Obst and Gynae 077-9261 Sampa Rani Kundu Sir Salimullah Medical College, Dhaka Obst and Gynae 077-9263 Shamima Haque Mymensing Medical College, Mymensing Obst and Gynae 077-9272 Most Salma Akhtar Zahan Rangpur Medical College, Rangpur Obst and Gynae 077-9286 Nihar Ranjan Roy Rangpur Medical College, Rangpur Ophthalmology 077-9296 Dr. Mohammad Altaf Hossain MAG Osmani Medical College, Sylhet Ophthalmology 077-9302 Farhana Rahman Dhaka Medical College, Dhaka Paediatrics 077-9335 Md Zahidul Hasan Khulna Medical College, Khulna Paediatrics 077-9347 Dr. Sarbari Saha Dhaka Medical College, Dhaka Paediatrics 077-9349 Md Shahedul Islam Shahid Ziaur Rahman Medical College, Bogra Psychiatry 077-9351 A K M Sharifur Rahman Sir Salimullah Medical College, Dhaka Radiology & Imaging 077-9387 Muhammed Alam Mymensing Medical College, Mymensing Surgery 077-9389 S M Eqbal Hossain Dhaka Medical College, Dhaka Surgery

211 FROM THE DESK OF THE EDITOR in CHIEF

(J Bangladesh Coll Phys Surg 2010; 28: 212)

The editorial board meeting was held on 30th countries around the world. We are trying to disseminate August,2010 and chaired by Professor AKM Mahbubur the journal to many different web sites and data bases. Rahman. Decision taken by the Reference Committee Already the journal is indexed in the following data of BCPS has been endorsed that from January, 2011 bases (HINARI, DOAJ, Google Scholar, Index instead of 3 issues of journal , 4 issues will be published Copernicus, ProQuest, CrossRef, Ulrichsweb, EBSCO, (Jan/ April/ July/ Oct) in each year. BanglaJOL, AsiaJOL) and waiting for many others. This peer-reviewed journal is a valuable collection of We are eagerly waiting for your valuable advice and different articles in all disciplines so that healthcare new articles. Hope to give more new information and professionals, researchers can find important medical further development in the coming days. Best wishes information. Our all new section started from the last for all the fellows. two issues are already much appreciated by the fellows. We have got tremendous support from home and abroad. Prof. Quazi Tarikul Islam We are receiving many articles in our new editorial Editor-in-Chief mail address ([email protected]) from many JBCPS. NAME OF THE REVIEWER OF ARTICLES IN THIS ISSUE

(J Bangladesh Coll Phys Surg 2010; 28: 213)

Professor Md. Sanawar Hossain & Dr. A.B.M. Golam Rabbani Professor Farhana Dewan & Professor Tahmina Begum Professor Faruq Ahmed & Professor Parveen Shahida Akhter

Professor Faisal Kabir & Professor (Brig. Gen.) Zuberul Islam Chowdhury Professor Sultana Razia Begum & Professor A.K.M. Anowarul Azim Professor A S M A Raihan & Professor Faruqe Ahmed

Professor Aftab Uddin, Dr. Abdul Wadud Chowdhury & Dr. Fazilatunnesa Malik Professor Fatema Begum & Dr. Nazneen Akhter Banu Professor Md. Abdul Hayee & Dr. Narayan Chandra Kundu

Dr. Md. Shafiqul Islam & Dr. Md. Musharaf Hossain Obituary

(J Bangladesh Coll Phys Surg 2010; 28: 214) The following Fellows who died between January to May 2010.

Professor Chowdhury Humayun Kabir Professor Chowdhury Humayun Kabir died on 8 June, 2010.He was awarded honorary fellowship in surgery in 2004 from Bangladesh College of Physicians and Surgeons (BCPS). He was the worked as Professor Head, Department of Surgery, Bangladesh Medical College and Honourary Secretary of BMSRI and also Chairman, Uttara Adhunik Medical College

Dr. Md. Taibur Rahman Dr. Md. Taibur Rahman (fellow no.523) died on 19 June,2010.He passed fellowship examination in Surgery in July 1991 from Bangladesh College of Physicians and Surgeons (BCPS). He died in a road traffic accident. Before his death, he was in service as Associate Professor at Dinajpur Medical College, Dinajpur.

Dr. Md. Yusuf Ali Dr. Md. Yusuf Ali (fellow no.692) died on 19 June,2010. He passed fellowship examination in Surgery in January, 1994 from Bangladesh College of Physicians and Surgeons (BCPS).He died in road traffic accident. Before his death, he was in service as Associate Professor at Dinajpur Medical College, Dinajpur.

Professor Sofia Khatun Professor Sofia khatun died on 21 September, 2010.She was awarded fellowship without examination in Obst.& Gynae in 1974 from Bangladesh College of Physicians and Surgeons (BCPS).

Dr. Uttam Kumar Singha Baul Dr.Uttam Kumar Singha Baul (fellow no.2016) died on 24 September,2010. He passed fellowship examination in Otolaryngology in July, 2006 from Bangladesh College of Physicians and Surgeons (BCPS). He died in road traffic accident. Before his death, he was working as RS (ENT) at Rajshahi Medical College Hospital,Rajshahi.