z h sikder women’s medical college journal vol. 2 no. 1 ... · 3/2/2020 · prof. dr. afzal...

Journal of ZHSWMC

Volume 1, Number 2, July 2019

1

CHIEF PATRONMr. Zainul Haque SikderChairman, Governing BodyZ H Sikder Women’s Medical College

EDITORIAL BOARD

ChairmanProf. Dr. Md. Saizuddin

Editor in chiefProf. Dr. Shaikh Zinnat Ara Nasreen

Executive EditorProf. Dr. Monowar Ahmad Tarafdar

Associate EditorDr. Shila Rani Das

Assistant EditorsDr. Afrina Sharmin Dr. Nusrat Mahjabeen Dr. Sadika Kadir

MembersDr. Shirin AkhterDr. Md. Abul Kalam AzadDr. Nashid Tabassum KhanDr. Samina Shafiullah Dr. Md. Johurul Hoque

ETHICAL COMMITTEEProf. Dr. Layla Afroza BanuProf. Dr. Rasel KabirDr. Golam Nabi

ADVISORSProf. Dr. Mujibur RahmanProf. Dr. Paritosh Kumar BaralProf. Dr. Mohammad Ataur Rahman Prof. Dr. Tamanna BegumProf. Dr. Moinuddin ChistyProf. Dr. A.K.M. Khayerul IslamProf. Dr. Afzal Hossain Prof. Dr. Shirin Mohol Prof. Dr. Md. Abdullah-Hel-KafiProf Dr. Md. Fakhrul IslamProf Dr. M. M. Mafizur Rahman

ANNUAL SUBSCRIPTIONTk. 100/- for local subscriptions US $ 10 for overseas subscriptions

PUBLISHED BY Prof. Dr. Monowar Ahmad Tarafdar, Professor and Head, Department of Community Medicine, Z H Sikder Women’s Medical College on behalf of Z H Sikder Women’s Medical College Journal committee.

PRINTED BY Maruf [email protected]

The Z H Sikder Women’s Medical College Journal is a peer reviewed journal. It accepts original articles, review articles and case reports. While every effort is always made by the Editorial Board to avoid any inaccurate or misleading information from appearing in the Sikder Women’s Medical College Journal, information within the individual article is the responsibility of its author (s). Z H Sikder Women’s Medical College Journal and /or its Editorial Board accept no liability whatsoever for the consequences of any such inaccurate and misleading information, opinion or statement.

ADDRESS OF CORRESPONDENCE

Dr. Shila Rani Das, Associate Editor, Z H Sikder Women’s Medical College Journal and Associate Professor, Department of Community Medicine, Z H Sikder Women’s Medical College, Monica Estate, West Dhanmondi,

Dhaka 1209, Bangladesh.

email: [email protected], [email protected], Cell – 01911183906, 01711887646

Z H Sikder Women’s Medical college JournalVol. 2 No. 1. July 2019

An Official Organ of Z H Sikder Women’s Medical College

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EditorialSafe water: a far cry for the Dhaka city dwellers

Dr. Mohammad Iqbal

Fecal contamination of water is the main cause of communicable diseases in the capital city of Dhaka. Actual population of Dhaka city is unknown. But, it is assumed that total population of Dhaka city is about 20 million.1 Total amount of human excreta produced in the Dhaka city is unknown. But it is known that capacity of waste management of Dhaka Water Supply and Sewerage Authority or WASA is very poor, specially the capacity of management of human excreta. Pagla sewage treatment plant has the capacity to treat only 20% of human excreta of Dhaka city.2 But, due to broken sewerage lines Pagla sewage treatment plant is receiving only 2% of the sewage. In 2014 World Bank had drawn a diagram of sewage treatment plants and septic tanks of Dhaka city. It had shown that outcome of pagla sewage treatment plant was only 2%.3 Referring to this information, Professor of Civil engineering department of BUET and planner of Hatirjheel project, Prof. Md. Mujibur Rahman told, according to the diagram of World Bank only 2% of human excreta are safely refined and decontaminated.4 Rest 98% of human excreta is going to the four rivers surrounding the Dhaka city. In last six years after the publication of the report, this situation has further deteriorated. In Dhaka city water and sewerage are running side by side under the roads. Old lines are damaged and sewerage mixes with suppllied water. Sometimes colour and smell of supplied water is obnoxious. WASA also supply water from surrounding rivers, which is unpurtable due to presence of heavy wastages.Water born communicable diseases are very common in Dhaka city. Every day ICDDR,B receives 500 to 1500 diarrhoea cases.5 Diarrhoea is the main cause of malnutrition of Children under 5 years. Other than diarrhea, typhoid, hepatitis due to A and E viruse are also very common. Hepatitis E causes many maternal deaths every year in Dhaka city. Skin diseases due to contaminated water are also very common in Dhaka. We want safe and wholesome water to drink, to cook food, to wash our hands, to bathe and for so many purposes. It seems that, it is a far cry for the Dhaka city dwellers.

Dr. Mohammad Iqbal, Project Coordinator, Health system and Population Science Division, ICDDR,B – DhakaReferences:

1. http://worldpopulationreview.com/world-cities/dhaka-popula-tion/

2. Dhaka Sanitation Improvement Project (DSIP). Dhaka Water Supply and Sewerage Authority December 2018.

3. Hossain A, Mahtab SB, Morshed A. Performance evaluation of the pagla sewage treatment plant. International Journal of Current Research; 10(11): 75048-75060

4. Kumar U. Detention and Retention Function of Hatirjheel Integrated Project and Its Management Aspect, Field Study Report. Institute of Water and Flood Management Bangladesh University of Engineering and Technology

5. icddrb. Cholera and other diarrhoeal diseases. Available from: URL: https://www.icddrb.org/news-and-events/press-corner/media-resources/cholera-and-other-diarrhoeal-diseases

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Abstract: This was a cross sectional descriptive study conducted to assess Health Status of Waste pickers collecting waste from private waste bins or dumpsters along streets & some landfill sites of Dhaka City Corporation using a semi-structured questionnaire employing purposive sampling technique with a sample size of 200 by face to face interview from January to December 2018. Most of the respondents (45%) belonged to age group within 20 to 30 years of age and 55% were male. About 45% of respondents completed primary education and half of the respondents got married and three fourth of respondents absolutely depended on waste pickings and only 28% have other sources of income where 20% had monthly income less than 3000 taka. Three fourth of respondents lived in hut in a slum area and used kacha latrine. Almost all were used supply water for consumption and More than half of the respondents (119, 59.4%) suffered from injury. There is therefore a need to facilitate improvement in their working conditions and raise awareness on their health status.

Key note: Waste pickers, Health status, Dhaka.

Original article

Study on factors determining health status of waste pickers at Dhaka city-corporation

Saizuddin Kabir,1 Shila Rani Das,2 Shaidul Hasan,3 Nadia Begum4, Sultana Begum,5 Meheruba Afrin6

Address of correspondence:Prof Dr. Md Saizuddin Kabir, Principal, ZH Sikder Women’s Medical College & Hospital, West Dhanmondi, Dhaka. Mobile No: 01712031610; E Mail: [email protected]

1. Professor and Principal, ZH Sikder Women’s Medical College & Hospital, Dhaka, Bangladesh.2. Associate Professor, Department of Community Medicine, Z H Sikder Women’s Medical College, Dhaka,

Bangladesh.3. MPH student in course, National institute of Preventive and Social Medicine, Mohakhali, Bangladesh.4. Associate Professor, Department of Community Medicine, Z H Sikder Woman’s Medical College, Dhaka,

Bangladesh.5. Associate Professor, Department of Community Medicine, Z H Sikder Woman’s Medical College, Dhaka,

Bangladesh.6. Assistant Professor Department of Community Medicine, Z H Sikder Woman’s Medical College, Dhaka,

Bangladesh.

Introduction:

A waste picker is a person who salvages reusable or recyclable materials thrown away by others to sell or for personal consumption. Millions of people worldwide make a living collecting, sorting, recycling, and selling materials that someone else has thrown away. In some countries, waste pickers provide the only form of solid waste collection, providing widespread public benefits and achieving high recycling rates. Waste pickers contribute to local economies, to public health and safety, and to environmental sustainability. While recognition for their contributions is growing in some places, they often face low social status, deplorable living and working conditions, and get little support from local governments. Waste pickers collect household or commercial/industrial waste. They may collect from private waste bins or dumpsters, along streets and waterways or on dumps and landfills. Work situations differ greatly across countries, but there are basic categories of waste pickers.1

They are adversely affected by exposure to health hazards due to unsafe handling of municipal waste.2 Waste pickers in Dhaka make their living by selling recyclable

items collected from dumped waste. Most are children living on the streets or in slums where they have little access to infrastructure, a low status in society and an uncertain future.3

The working environment of waste pickers is very critical because it combines unhygienic context and risks of accidents. Sometimes children and adults even look for food among the wastes because they cannot afford to buy it. Street children sometimes warte-picking for survival than to work in the households.4

By gathering waste from public spaces, waste pickers contribute to cleanliness and help to beautify the city. Recycling is one of the cheapest, fastest ways to reduce greenhouse gas emissions. Recycling reduces emissions 25 times more than incineration does5.

Reuse and recycling of materials decreases the amount of virgin materials needed for production, conserving natural resources and energy while reducing air and water pollution6.

There is growing recognition that waste pickers contribute to the local economy, to public health and

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safety and to environmental sustainability. But they often face low social status, deplorable living and working conditions, and get little support from local governments. Reuse and recycling of materials decreases the amount of virgin materials needed for production, conserving natural resources and energy while reducing air and water pollution7.

Thus waste pickers are extremely vulnerable owing to intense risks and impending dangers for their overlapping living and working environments and are, therefore, deserve to be a crucial target for health programs and policies. With these aforesaid considerations, the present study was undertaken to explore the health status of this particular vulnerable population.

Method & Materials: A cross-sectional study was conducted to explore Health Status of Waste pickers in four areas of Dhaka City Corporation namely Mirpur area, Bansree area, Dhanmondi area & Sadarghat area. Data were collected by using pre-designed, pre–tested, semi-structured interviewer administered questionnaire & check list. with observations by some trained volunteers from January to December, 2018. The sample size was 200 & selected by non-probability purposive sampling method. After collection, data were checked to exclude any error or inconsistency.

Result: Out of 200 respondents (110,55%) were male & 90,( 45%) were female. (figure I). About 90,( 45%) re-spondents age were within 20 to 30 years of age followed by 48,( 24%) within 10 to 20 years, 34,( 17%) within 30 to 40 years, 15,( 8%) more than 40 years and 13, (7%) less than 10 years respectively. Among the respondents 90,(45%) respondents were illiterate and 40,( 20%) with-in primary level, 70,( 35%) never attended any formal or non-formal school. Half of the respondents were mar-ried and three fourth of respondents absolutely depend-ed on waste pickings and only 28% have other sources of income where 20% had monthly income less than 3000 taka & only 6% have more than 12,000 Taka. Almost 172,( 86%) of respondents lived in hut in a slum area (Ta-ble 1). Majority of them used Kacca Latrine (80%) (Figure II). Almost all 188(94%) used supply water for consump-tion. (Figure III) More than half of the respondents 119, ( 59.4%) suffered from injury followed by 85,(42.30%) itching 55, (19.1%) diarrhea, 63, (21.9%) cough and cold, 40, (20.10%) warm infestation, 6, (3.10%) suffered from jaundice. (Figure IV)

110,55%

90, 45%

Male Female

Figure 1: Distribution f respondents according to sex

Table 1: Demographic characteristics of respondents (n = 200)

Age in years Frequency (n) Percentages (%)

Less than 10 13 710 - 20 48 2420 – 30 90 4530 - 40 34 17More than 40 15 8Status of EducationInformal education 70 35Illiterate 40 20Primary 90 45Marital statusUnmarried 82 41Married 100 50Divorced 04 2Widow 14 7Monthly Income in TakaLess than 3000 Tk 40 203000 – 6000 Tk 100 50 6000 – 12.000 Tk 48 24More than 12,000 Tk

12 6

Type of houseSlum & shanty 172 86Tin shed 26 13Half building 02 1Total 200 100

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160(80%)

16(8%)24(12%)

Open latrine Kachha latrine Sanitary latrine

Figure 2: Sanitary system of respondents?

188(94...

12(6%)

Deep tubewell water Supply water

Figure 3: Consumption of water

* Multiple responses

119, 59.40%85, 42.30%

55, 19.10% 63, 21.90% 40, 20.10%

6, 3.10%

Injury SkinDisease

Diarrhoea Cough and cold

Warminfestation

Jaundice

Figure 4: Health problems of the respondents (n = 200)

Discussion: The present study was aimed to assess health status of waste pickers. Total 200 waste pickers were selected. It was found that 90(45%) respondents age were within 20 to 30 years of age followed by 48(24%) were within 10 to 20 years, 34(17%) were within 30 to 40 years, 15(8%) more than 40 years and 13(7%) less than 10 years respectively. In another study it was indicated that nearly 50% of these waste pickers are children under the age of 15, and about half of them are girls.4 On the other hand, a study in Dharan Municipality, Nepal showed that sixty-eight percent of the street children were between 11-15 years of age and among them ninety-five percent were males8. Among the respondents 90,(45%) respondents were illiterate and 40, (20%) were within primary level, 70, (35%) never attended any formal or non-formal school. Half of the respondents were married. About 110,(55%) were male & 90, (45%) were female. Majority of waste pickers absolutely depends on waste pickings and only few percentages have other sources of income from where only 6% had monthly income more than 12,000 Taka. They were more likely to live in overcrowded, poorly ventilated slum. In the 2006 Bangladesh Urban Health Survey the mean household size varied little across all three domains: slums (4.5 members), non-slums (4.6 members), and district

municipalities (4.9 members).9 A study in Cambodia found that most waste pickers come from large households of greater than 5 members, the average waste picker households having 5.42 persons. Majority of them used Kacca Latrine. Almost all respondents used supply water for consumption. More than half of the respondents suffered from injury and rest got itching, skin diseases, diarrhea, cough and cold. It was reported that the most prevalent types of occupational risks include: bites from insects and rats, cuts and bruises, skin disease, respiratory and gastro-intestinal tract problems, eye irritation, body aches, general weakness, and frequent fever.4 Headache problems appear to be a prevalent condition among waste pickers, and have shown to be one of the recurring complaints in other studies as noted by Nguyen et.al.11

Conclusion: Health problems among waste-pickers showed a wide range. Major health problems were injury, skin disease, common cough and cold, and diarrhoea and jaundice. In this study found that more than half of the respondents had injury on the basis of spot observation. Waste pickers, need to have better employment opportunity, basic literacy program and regular health checkup facilities. Better academic and research policy should be conducted among waste pickers in order to formulate a way out from such predicament. Reference:

1. WIEGO. 2014, The Urban Informal Workforce: Waste Pick-ers/Recyclers (IEMS Sector Summary).

2. Advocacy Site for youth health http://www.cdc.gov/HealthyYouth/az/

3. Waste pickers in Dhaka: Using the sustainable livelihoods ap-proach - Key findings and field notes. Retrieved from http://store.lboro.ac.uk/browse/extra_info.asp?modid on September 15,2011.

4. Parveen S, Faisal IM. Occupational health impacts on the child waste-pickers of Dhaka City. Environmental Health Risk 2005; 3: 295-304

5. Tellus Institute 2008, WIEGO Policy Brief (Urban Policies). 6. The Urban Informal Workforce: Waste Pickers / Recy-

clers (español) 7. Urban Informal Workers & the Green Economy, Achtell, Er-

nest. 2013. Waste Pickers and Carbon Finance: Issues to Con-sider. WIEGO Technical Brief No 7.

8. Thapa K, Ghatane S, Rimal SP. Health problems among the street children of Dharan municipality University Medical Journal 2009; 7: 272-7.

9. Bangladesh Urban Health Survey 200610. Parveen S, Faisal IM. Occupational health impacts on the

child waste-pickers of Dhaka City. Environmental Health Risk 2005; 3: 295-304.

11. Nguyen H, Chalin C, Lam T, Maclaren V. Health and social needs of waste pickers in Vietnam. Research paper WASTE-ECON program in Southeast Asia, 2003.

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Original articleStudy on factors affecting fertility of Bangladeshi women

Monowar Ahmad Tarafdar,1 Nadia Begum,2 Shila Rani Das,3 Sultana Begum,4 Mehruba Afrin,5 Syed Shawkat Ahmed6

Abstract:This is a cross sectional study conducted among Currently Married Women of Reproductive Age (CMWRA) with a sample size of 476 selected purposively using a semi-structured questionnaire in 2018 at Moulvibazar Sadar to explore the factors affecting fertility. The result shows that 55.26% respondents were within 35 years age whereas only 4.28% from age group 46-49 years age group, 33% of the respondents got married at <16 years of age and 18.70% were illiterate, 47.90% had primary education. It is evident that 76% of the respondents were from rural area; 88% were Muslims, 29.41% from lower middle class followed by upper middle class (25.42%) and poorest comprised only 7.56%. The result explored that 73.91% of the respondents were from age group 41-45 got married before 16 years of age followed by 36-40 years (68.24%), 46-49 years (66%), 20-25 and 26-30 years age groups 52.38% and 52.75% respectively; 73.33% of respondents from rural area got married at <16 years of age, 68.42% of the Muslim at <16 years. The study explored that 96.39% from poorer section and 83.33% from poorest section got married at <16 years of age. Current study revealed that 82.91% of the respondents having secondary education got married before 16 years of age followed by illiterate (82.02%). It is explored that the age at marriage is statistically associated with residence, education, wealth index and religion (p= 0.001, 0.03, 0.001, 0.001 respectively). We conclude that the socio-demographic condition contributes mostly to fertility differentials in Bangladesh.

Key words: Factors affecting fertility, religion, residence, wealth index, education.

Address of correspondence Dr. Monowar Ahmad Tarafdar, Professor, Department of Community Medicine, ZH Sikder Women’s Medical College, Dhaka. Email: [email protected]

1. Professor, Department of Community Medicine, ZH Sikder Women’s Medical College, Dhaka2. Associate Professor, Department of Community Medicine, ZH Sikder Women’s Medical College, Dhaka3. Associate Professor, Department of Community Medicine, ZH Sikder Women’s Medical College, Dhaka4. Associate Professor, Department of Community Medicine, ZH Sikder Women’s Medical College, Dhaka5. Assistant Professor, Department of Community Medicine, ZH Sikder Women’s Medical College, Dhaka6. Professor, Department of Dermatology, Jahurul Islam Medical College, Bajidpur

Introduction: Bangladesh is one of the most cited countries which achieved remarkable progress in fertility decline in the last three and a half decades. Despite pervasive poverty and underdevelopment, Bangladesh has achieved a considerable decline in fertility. Indeed, Bangladesh represents an apparent anomaly for its decline in fertility, despite the absence of the conditions believed to be necessary for such reproductive changes.1 As a social institution, marriage is identified by some studies as near universal. Generally, any variation relates to the age at which marriage takes place, rather than whether it happens at all.2 Women also tend to marry younger than men. For exam-ple, about 90% of women aged 15–49 years were mar-ried by ages 25–29 years in Bangladesh, India, and Nepal compared with 80% of men; marriage is nearly universal among women aged 30 and above and men aged 45 and above.3

Two out of three girls in Bangladesh are married before the legal age of 18. Most become mothers while they themselves are still children. Child marriage forces girls

into sexual relationships for which they are not physical-ly or emotionally prepared.4 It can cause them to drop out of school and it limits their opportunities for community participation, including employment. A delayed marriage greatly improves a girl’s chances for a healthy, happy, productive life. And the benefits of a later marriage go beyond the girl: her children, family, community, and country experience better health, economic, and social outcomes.5

Cultural and economic factors do not affect fertility directly; they influence another set of variables that determine the rate and the level of childbearing. These are exposure to sexual intercourse, marriage, postpartum infecundity, breast feeding, contraception, and induced abortion. One of the major demographic advances of the last 15 years has been the development of a crude but simple method to express the fertility reducing impact of the major direct determinants of fertility.6

Material and methods:This is a cross sectional study conducted among Currently Married Women of Reproductive Age (CMWRA) with a sample size of 476 using a semi-structured interviewer

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administered questionnaire from July-December 2018 in Moulvibazar Sadar Upazilla to explore the factors affecting fertility employing purposive sampling technique. The sample data collection method was face to face interview at the household level. The respondents were informed verbally the nature, aim and purpose of the study. After collection, the data were cleaned and edited for any inconsistencies and were analyzed with the help of HPSS version 16.

Result: This cross sectional study conducted to reveal the factors affecting fertility of Bangladeshi women shows the following characteristics.Table No. 1: Distribution of the respondents according to age group (n=476)

Current age group (in years) Frequency Percentage

(%)20-25 95 19.9626-30 88 18.4931-35 80 16.8136-40 75 15.7641-45 70 15.7146-49 68 4.28

Mean ± SD = 34.30 ± 8.5

Table No. 1 shows that more than half of the respondents (55.26%) were within 35 years age whereas only 4.28% from age group 46-49 years age group.Table No. 2: Distribution respondents according to age at first marriage (n=476)

Age at first marriage (in years) Frequency Percentage

(%)<14 133 27.94

14-16 157 33.016-18 96 20.16≥ 18 90 18.90

Mean ± SD = 16.4 ± 2.8

Table No. 2 shows that one third (33%) of the respondents got married below the age of 16 years whereas only 18.90% got married after 18 years of marriage which is the legitimate age of marriage in Bangladesh. Table No. 3: Distribution respondents according to Education (n=476)

Level of education Frequency Percentage (%)

Illiterate 89 18.70Primary 228 47.90

Secondary 117 24.58Higher secondary and above 42 8.82

Table No. 3 shows that almost one fifth of the respondents (18.70%) were illiterate; about half of the respondents (47.90%) had primary level of education and only 8.82% of the respondents had education higher secondary or above.

Urban, 11624%

Rural, 36076%

Residence

Fig. No. 1: Distribution respondents according to Residence (n=476)Figure No. 1 shows that 76% of the respondents were from rural area.

Muslim, 418,88%

Others, 4, 1%Religion

Hindu, 54,11%

Fig. No. 2: Distribution respondents according to Religion (n=476)

Figure No. 2 shows that 88% of the respondents were Muslim, 11% Hindu and only 1% had other religious belief.

Wealth index160

140, 29.41%

36, 7.56%

83, 17.44%

121, 25.42%

96, 20.17%

140

120

100

80

60

40

20

0Poorest Poorer Lower middle Upper middle Rich

Fig. No. 3: Distribution respondents according to Wealth index (n=476)

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Figure No. 3 shows that about one third of the respondents were from lower middle class followed by upper middle class (25.42%). One fifth (20.17%) of the respondents were rich and only 7.56% of the respondents were belonging to the poorest section of the society. Table No. 4: Distribution respondents according to prevalence of marriage at age < 16 years and age > 16 years by age group (n=476)

Current age group (in

years)

Age at marriage <

16 years (%)

Age at marriage >

16 years (%)Total

20-25 55 (52.38) 50 (47.62) 10526-30 48 (52.75) 43 (47.25) 9131-35 45 (59.21) 31 (40.79) 7636-40 58 (68.24) 27 (21.76) 8541-45 51 (73.91) 18 (26.09) 6946-49 33 (66.0) 17 (34.0) 50Total 290 186 476

Table No. 4 shows that 73.91% of the respondents from age group 41-45 got married before they reached 16 years of age followed by 36-40 years (68.24%), 46-49 years (66%). 20-25 and 26-30 years age groups 52.38% and 52.75% respectivelyTable No. 5: Distribution respondents according to prevalence of marriage at age < 16 years and age > 16 years by residence (n=476)

ResidenceAge at

marriage < 16 years (%)

Age at marriage > 16

years (%)Total

Urban 26 (22..41) 90 (77.59) 116Rural 264 (73.33) 96 (26.67) 360Total 290 186 476

Table No. 5 reveals that 73.33% of respondents from rural area got married before they reach 16 years of age, while only 22.41% of the respondents from urban area got married before the age of 16 years. Table No. 6: Distribution respondents according to prevalence marriage at age < 16 years and age > 16 years by religion (n=476)

ReligionAge at



years (%)Total

Muslim 286 (68.42) 132 (31.58) 418Hindu 4 (7.41) 50 (92.59) 54Others 0 04 (100) 04Total 290 186 476

Table No. 6 shows that 68.42% of the Muslim respondents got married before their 16th birthday while 92.59%

Hindu respondents got married after 16 years of age. Table No. 7: Distribution respondents according to prevalence marriage at age < 16 years and age > 16 years by wealth index (n=476)

Wealth indexAge at marriage < 16 years (%)

Age at marriage > 16 years (%)

Total

Poorest 30 (83.33) 6 (16.67) 36Poorer 80 (96.39) 3 (3.61) 83Lower Middle 92 (65.71) 48 (34.29) 140Upper Middle 51 (42.15) 70 (57.85) 121Rich 37 (38.54) 59 (61.46) 96Total 290 186 476

Table No. 7 explored that 96.39% of the respondents from poorer section and 83.33% from poorest section of the community got married before they reach 16 years of their life. Table No. 8: Distribution respondents according to prevalence marriage at age < 16 years and age > 16 years by wealth index (n=476)

EducationAge at



years (%)Total

Illiterate 73 (82.02) 16 (17.98) 89Primary 109 (47.81) 119 (52.19) 228Secondary 97 (82.91) 20 (17.09) 117H i g h e r secondary and above

11 (26.19) 31 (73.81) 42

Total 290 186 476

Table No. 8 revealed that 82.91% of the respondents having secondary level education got married before 16 years of age followed by illiterate (82.02%).Table No. 9: Association between prevalence marriage at age < 16 years and age > 16 years with socio-demographic characteristics (n=476)

Characteristics

Age at first marriage

P value< 16 years

> 16 years

Residence: Urban 26 900.001

Residence: Rural 264 96Education:

0.03Illiterate 73 16Primary 109 119

Secondary 97 20Higher secondary and above 11 31

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Wealth index

0.001Poorest 30 6Poorer 80 3

Lower Middle 92 48Upper Middle 51 70

Religion

0.001Muslim 286 132Hindu 4 50Others 0 04

Discussion and Conclusion:The religion in Bangladesh has a significant association with age at first marriage of women in the rural area. The current study shows that non-Muslim respondents married at a later age than Muslim respondents. 92.59 percent Hindu respondents married after 16 years while 68.42 percent Muslim respondents married before they completed their 16th years of life. Women in the rural part of the study were married early (73.33%), i.e., before or at the age of 16 years. The finding is consistent with the finding of study conducted by Roy S and Hossain S M I in 2014.7

The socio-economic status of the respondents in rural Bangladesh has a significant effect on age at first marriage, i.e., the poorest 83.33%, poorer 96.39%, lower middle 65.71%, whereas richer respondents married after 16 years (upper middle 57.85%, and rich 61.46%). Women from 15 to 49 years who had higher education had the lowest fertility compared with women with only secondary, primary and no education, which means that fertility was delayed as educational level increased in Bangladesh; respondents who had education higher secondary and above, of whom 73.81% had their first child after the age of 16 years. These data is supported by the findings of Mosharaf Hossain and Md. Rafiqul Islam, where they found that age at first marriage is an important factor in demographic transition as it affects fertility tremendously and mortality and migration to a lesser extent. Marriage is nearly universal everywhere in Bangladesh. Age at first marriage has a strong influence on a variety of demographic, social and economic factors. Early marriage is more common among the poorest women in Bangladesh than women from wealthy families is borne out in this study.8

Present study shows that there is significant association between age at first marriage and residence (p< 0001), Education (p< 0.03), wealth index (p< 0.001) and religion< 0.001). This finding is supported by the findings of the study conducted by Chowdhury AHMY, Rumana AS, Arif M and Faisal AM in Bangladesh in 2017.9 Fertility is affected by factors like educational attainment,

religion and residence as per data of this study. The median age at marriage is higher in case of women with higher education and is lower for women with less education. The finding is supported by findings where it was evident that Education may affect the timing of marriage in various ways. The highly educated spend many years in school and college receiving instruction and knowledge.10 Also, fertility rates are higher in rural women than urban women with no education. Overall, women in rural areas and those with less advanced levels of education had more children, and women with higher education had less children per women. Similar finding was observed in a study in China in 2018.11 It is explored that age at marriage is statistically associated with residence, education, wealth index and religion (p= 0.001, 0.03, 0.001, 0.001 respectively). Similar observations were published in a report from USA in 2016.12 We conclude from this study that the education level contributes mostly to fertility differentials in Bangladesh. References:

1. Fertility decline in Bangladesh: understanding demographic components and socioeconomic correlates. Available from: URL: https://paa2012.princeton.edu/papers/120509

2. Bell, Duran (1997). “Defining Marriage and Legitimacy”. Cur-rent Anthropology. 38 (2): 237–54.

3. Marphatia A A, Ambale G S, and Reid A M. Women’s Mar-riage Age Matters for Public Health: A Review of the Broader Health and Social Implications in South Asia. Front Public Health. 2017; 5: 269. Published online 2017 Oct18.

4. United Nations Convention on the Elimination of all Forms of Discrimination against Women. Available from: URL: http://www.un.org/womenwatch/daw/cedaw/text/econvention.htm#article16

5. Amin S, Ahmed J, Saha J Hossain M I, E F Haque. Delaying child marriage through community-based skills-development programs for girls; Population Council–Bangladesh. Available from: URL: https://www.popcouncil.org/uploads/pdfs/2016P-GY_BALIKA_EndlineReport.pdf

6. Bongaarts J and Watkins S C. Social Interactions and Con-temporary Fertility Transitions. Population and Development Review; 22(4): 639-682

7. Roy S and Hossain S M I. Fertility differential of women in Bangladesh demographic and health survey 2014; Fertil Res Pract. 2017; 3: 16.

8. Mosharaf Hossain and Md. Rafiqul Islam. Effects of So-cio-Economic and Demographic Variables on Age at First Marriage in Bangladesh. Current Research Journal of Biologi-cal Sciences 5(4): 149-152

9. Factors Affecting Age for First Birth: An Exploratory Analy-sis on Bangladeshi Women; International Journal of Research

10 Journal of ZHSWMC


Studies in Medical and Health Sciences 2017, 2(7): 31-37

10. Sraboni E. Education and the Transition to Marriage in Ru-ral Bangladesh. Report at PAA (Population Association of America) 2017 Annual Meeting. Available from: URL: https://paa.confex.com/paa/2017/meetingapp.cgi/Paper/16376

11. Wei J, Xue J, and Wang D. Socioeconomic determinants of ru-ral women’s desired fertility: A survey in rural Shaanxi, China, PLoS One. 2018; 13(9): e0202968.Published online 2018 Sep 13. doi: 10.1371/journal.pone.0202968

12. MacQuarrie, Kerry L.D. 2016. Marriage and Fertility Dynam-ics: The Influence of Marriage Age on the Timing of First Birth and Birth Spacing. DHS Analytical Studies No. 56. Rockville, Maryland, USA: ICF International.

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Original articlePlatelet rich plasma is better than corticosteroid in longterm outcome in

planter fasciitis: A study in a tertiary level teaching hospital at Dhaka, Bangladesh

Md. Johurul Hoque ,1 Muhammad Emam Zaman,2 Ripon Kumar Das,3 Mohammad Sayeed AL Mahmud,4 Mahbuba Khatun5

AbstractThis is a prospective comparative study to compare the efficacy of PRP injection versus corticosteroid injection for planter fasciitis. 35 male and 25 female (Mean Age 35.5 yrs.) presenting with planter fasciitis were randomized to receive there Platelet-rich plasma (PRP) injection (2ml PRP with 2ml of 2% xylocaine) given by a single surgeon. Patients were assessed before (Days0) and after (Days 30, 60, 90) treatment for chronic heel pain more than 6 months. Patients where followed up 1 year to assess heel pain over the calcaneal tuberocity. In the present study of 60 patients there were 35 male and 25 female. In the present study of 60 patients the mean age was 35.5 years (Range between 35 to 65 years). Infection, rupture of plantar fascia, heel pad atrophy and neurovascular damage where not found. Five pa-tient reported pain for unto 9 days after PRP injection. In both groups heel pain improved dramatically after treatment, but the mode of improvement different. Compared with PRP injection. Corticosteroid injection improve at a faster rate over the first 30 days and then started to decline slightly until 90 days. After PRP injection heel pain, function improve steadily and where eventually better. PRP injection and Corticosteroid injection 30 days and faster rate 60 days of both group P-Value 0.0001. Almost high grater rate 60 days, group comparison with heel pain and function of the patients. PRP was more effective over the long term follow up period then corticosteroid injection in improving heel pain and function. That’s way we recommend PRP in a first line injection treatment because it is very simple, cheap and more effective.Keywords: PRP Injection, heel pain, planter fasciitis, corticosteroid injection

Address of Correspondence:Md. Johurul Hoque, Associate Professor, Department of Orthopedic, Zainul Haque Sikder Womens Medical College & Hospital, Dhaka.

1. Associate Professor, Department of Orthopedic, Zainul Haque Sikder Womens Medical College & Hospital, Dhaka 2. Registrar, Orthopedics, Zainul Haque Sikder Women’s Medical College & Hospital, Dhaka3. Assistant Professor, Department of Orthopedic, Zainul Haque Sikder Womens Medical College & Hospital, Dhaka4. Medical Officer, Norsingdi Sadar Hospital, Dhaka5. OSD, Department of Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka.

Introduction

Platelet-rich plasma (PRP) uses injections of a degree of a patient’s own platelets to accelerate the healing of de-generated tendons, ligaments, muscles and joints. During this approach, PRP injections use every individual pa-tient’s own healing system to boost contractor issues. PRP injections are prepared by taking anyplace from one to a number of tubes of your own blood and running it through a centrifuge to concentrate the platelets. These activated platelets are then injected directly into your de-generated or unhealthy body tissue. Chronic heel pain is one of the most common disorders of the foot, the exact cause of which is still not known.[1] Degenerative chang-es of the Plantar fasciitis due to repetitive microtrauma at the origin of plantar fascia are the common findings in heel pain.[2,3] Stiell in 1922 stated, that heel pain is a condition which is yet to be treated efficiently as the causation is not known exactly.[4] Lapidus and Guidotti, stated that the name painful heel is used deliberately since

the cause of this definitive clinical entity still remains un-known.[5] This entity of painful heel still remains a dilem-ma for the treating doctor. Woolnough called the entity “tennis heel”, and postulated that repeated traction with aging and repeated trauma produces microscopic tears and cystic degeneration in the origin of the plantar fas-cia and the flexor digitorum brevis immediately beneath the plantar fascia.[6] Schon and Baxter concluded that in a few patients a neurogenic cause, involving entrapment of first branch of the lateral plantar nerve to the abductor digiti minimi, is associated with painful heel syndrome.[7] The diagnosis of plantar fasciitis is mainly clinical as the etiology is often not clear. Most often the patients are between 35-65 years of age.[8] Patients usually complain of pain beneath the heel that is more on rising in the morning or after sitting for a while. As the patient starts walking the pain diminishes, and the patient is comfort-able during the day. The most common clinical finding is a localised tenderness at the inferomedial aspect of the



calcaneal tuberosity.[1,9] Various treatment modalities are available for this condition like rest, rigid or non-rigid orthosis, plantar fasciitis stretching exercises, ultrasound, extra-corporeal shock wave therapy, anti- inflammatory medications, local steroids, local autologous blood or platelet rich plasma injections and surgery in selected patients.[10-12]

Use of local steroid injections are superior in onset of action; however, rupture of plantar fascia and atrophy of heel found 15 women received PRP injection. Whereas 15 men and 20 women received corticosteroid injection. All patients completed the 1 year follow up.

Table 1: Distribution patients of age groups (n=60).

Age Group Frequen-cy

percent-age

35-45 25 41.646-55 13 21.656-65 22 36.8

Mean age 35.5 years

42%

WomenMen

58%

Fig 1: Sex distribution study of patients.Table 2: characteristics of both groups (n=60)

Category PRP(N=25) Triamcinolone Acetonide

corticosteroid injection (N=35)

P value

Age (years) 35±2.1 42±7.3 0.095

No of male: Fe-male

3:2 4:3 0.400

No of left: right side

18:7 12:23 0.160

Table 3: Physical Demands of patient’s comparison (n=60)

Sedentary Light Medium Heavy Very heavy

1 1 10 1 2

2 0 11 1 4

No complication was noted. In both groups heel pain, function improved dramatically after treatment but the mode of improvement differed compared with PRP in-jection, corticosteroid injection improved two scores at a faster rate after the first 30 days and then started to decline slightly until 60 day. After PRP injection two score (Pain and function) improved steadily and were much better (table 4).

Table 4: Group comparison with heel pain, function (n=60)

Category Day 0 Day 30 Day 60 Day 90 P valueHeel pain:

PRP 5.9 ± 1.2 4.3 ± 1.2 3.5 ± 1.1 1.1 ± 1.0 0.0001

Corticosteroid injection 5.8 ± 1.1 1.6 ± 0.8 1.5 ± 1.0 2.7 ± 1.0 0.0001

p value 0.578 0.0001 0.0001 0.0001

FunctionPRP 65.6 ± 11.7 50.2 ± 15.2 30.3 ± 10.2 18.2 ± 8.1 0.0001

Corticosteroid injection 60.1 ± 12.4 15.5 ± 8.6 20.0 ± 10.2 30.5 ± 16.5 0.0001

p value 0.155 0.0001 0.0001 0.0001

Table 4: VAS (visual analog scale) at 30 days and

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90 days for comparison to pain reduction to PRP and Ste-roid.

VASPRP (n= 25) Steroid (n = 35)

30 days 90 days 30 days 90 days

0-3 (mild/pain free) 8 (32%) 20 (80%)

12 (34%)

25 (71%)

4-7 (moderate) 15 (20%) 5 (20%) 20

(57%)10

(28%)

8-10 (severe) 2 (.8%) 3 (8.5%)

Total 25 35Discussion

Injection of PRP was more effective then corticosteroid injection in case of pain control, function. Decrease heel pain at 2 months was 90% after PRP injection and 55% af-ter corticosteroid injection. Corticosteroid injection gives rapid recovery but temporary improvement in the first month. PRP injection stimulate the inflammatory cascade within the generated fascia, tendon sheath by providing cellular and humoral mediators for regeneration. Histo-logical studies shows non inflammatory angiofibroblas-tic tendinosis,fibrosis, neurovascularization and mucoid degeneration in planter region. Alisara Arirachakaran et al. (2015)[22] did a systematic review and network meta- analysis of randomized controlled trials, conducted with the aim of comparing relevant clinical outcomes between the use of PRP, autologous blood and corticosteroid in-jection. They concluded that the network meta-analysis provided additional information that PRP injection can improve pain and lower the risk of complications, where-as autologous blood injection can improve pain, disabil-ities scores and pressure pain threshold but has a higher risk of complications. The level of evidence of the study was Level I evidence. The result of the pres-ent study was that PRP injection significantly improves score. In this study after 6 months of PRP injection, when asked about overall subjective satisfaction among the pa-tients of planter fasciitis. The PRP treatment should be adapted as a best of therapy for relief symptoms. Though this must be advised merely next other type of nonsurgi-cal treatment failed because lower involvement of tools/technologies & fewer contact to blood products in other type of therapies [23-26]. The main findings of this study are that PRP injection resulted in better pain control and the improvement in functional outcome was stable and maintained up to a midterm follow-up. It is current opin-ion that the therapeutic activity of PRP is mainly due to the release of many growth factors (GFs), which can act on many aspects of fascia, tendon repair including angio-genesis, chemotaxis, and cell proliferation by activating intracellular signal-transduction pathways [25, 26]. In the short term (1–33 months) effect, GFs can directly stimu-

late fibro cyt e, tenocytes to produce extracellular ma-trix, and promote neofibrils formation and remodeling. Insulinlike GF-12 stimulates production of collagen [31]. in long-term (62– 122 months), depend on a direct stimu-lation, probably relies on the activation of resident tendon stem/progenitor cells (TSPCs), which have been recently identified in tendons tissue from different animal species. Like stem cells found in adult tissues, TSPCs are be-lieved to be the source of recent differentiated fibro c yt e, tenocytes, responsible for maintaining adequate fibro-cyte,tenocyte numbers in the tissue throughout life and replenishing them after injury[27]. Regarding the amount of injection, Although smaller volume 3ml of PRP was injected in present study or even 1.52 ml such as in pre-vious study, the proportion of spread beyond fascia was little.so the amount of PRP is even 1.52 ml is adequate to achieve good result on the other hand the greater volume of PRP could be an option. However, large volume can lead to further diffusion and require much more blood collection, which is undesirable. In our study, we not used ultrasonographic injection technique and the accuracy of injection was not to be guaranteed. There-fore, we increase the volume of injection up to 3ml so we can get maximum distribution of PRP in the area of max-imal tenderness, in comprising with ultrasound injection which use 1.52 ml. Other therapies modalities want few expertise in contrast to injection PRP therapy. All staff should be good trained to make PRP from blood while this is not required in steroid injections or others. Corti-costeroid injections have also been used for this problem, but studies showed that there is controversy about their efficacy [28]. Local corticosteroid injections in plantar fasciitis decreases both the pain and the inflammation. Rupture of plantar fascia and heel pad atrophy and other complications have been associated with corticosteroid use[13,14 ] but our study shows no such effects.

complication.

There is essential of long-time trials to found PRP as a best of treatment for long term permanent heal from fas-ciitis due to mechanical causes. The study was limited by a minor sample size and absence of a control group. Larger-scale randomized controlled studies are required to assistance elucidate PRP as a good management for this musculoskeletal injury.

Other modalities of treatment like extracorporeal shock wave therapy (ESWT) have been tried recently, however there is no conclusive data regarding its use. According to Saber et al, both local steroid injection and ESWT are proved to be effective in treatment of PF, but as steroid injection is more cost effective and has more reproduc-ible results regardless of machine or operator, it is pre-ferred.[18]



Conclusion

PRP injection is more effective then corticosteroid injec-tion in improving pain, function. So that is why if recom-mend is as a first line treatment because it easy to push very effective for long term treatment. We believe that PRP injection should be offered to all patients suffering from planter fasciitis after failure of other conservative treatment. Further comparative studies with other type of injection or surgery are required to evaluate the long-term outcomes.

Reference1. Goff JD, Crawford R. Diagnosis and treatment of plantar

fasciitis. Am Fam Physician. 2011;84(6):676- 82.

2. Canale TS, Beaty HJ, Murphy AG. Disorder of tendons and fascia. Campbell’s Orthopaedics. 11th ed. Philadelphia USA; 2008:4815-4818.

3. Lemont H, Ammirati K, Usen N. Plantar fasciitis: a degen-erative process (fasciosis) without inflammation. JAPMA. 2003;93:234-7.

4. Stiell WF. Painful heel. Practitioner. 1922;108:345.\

5. Lapidus PW, Guidotti FP. Painful heel: report of 323 patients with 364 painful heels. Clin Orthop. 1965;39:178-86.

6. Woolnough J. Tennis heel. Med J Aus. 1954;2:857-61.

7. Schon LC. Plantar fascia and Baxter’s nerve release. In My-erson M, ed: Current therapy in foot and ankle surgery, St Louis, 1993:177-182.

8. Schepsis A, Leach R, Gorzyca J. Plantar fasciitis: etiology, treatment, surgical results, and review of the literature. Clin Orthop. 1991;266:185-96.

9. Ryan MB, Wong AD, Gillies JH, Wong J, Taunton JE. Sono-graphically guided intra-tendinous injections of hyperosmolar dextrose/lidocaine: a pilot study for the treatment of chronic plantar fasciitis. Br J Sports Med. 2009;43;303-6.

10. Kim E, Lee JH. Autologous platelet-rich plasma versus dex-trose prolotherapy for the treatment of chronic recalcitrant plantar fasciitis. PM&R. 2014 Feb 28;6(2):152-8.

11. Crawford F, Thomson C. Interventions for treat-ing plantar heel pain. Cochrane Database Syst Rev. 2003;3(3):CD000416.

12. Landorf K, Menz H. Plantar heel pain and fasciitis. Clin Evid. 2008;2:1111.

13. Sellman JR. Plantar fascia rupture associated with corticoste-roid injection. Foot Ankle Int. 1994;15:376- 81.

14. Acevedo JI, Beskin JL. Complications of plantar fascia rup-ture associated with corticosteroid injection. Foot Ankle Int. 1998;19:91-7.

15. Lee TG, Ahmad TS. Intralesional autologous blood injection compared to corticosteroid injection for treatment of chronic plantar fasciitis. A prospective, randomized, controlled trial. Foot Ankle Int. 2007;28:984-90.

16. Prichasuk S. The heel pad in plantar heel pain. J Bone Joint Surg Br. 1994;76:140-2.

17. Kauffman J. Plantar Fasciitis Medline Plus Medical Encyclo-paedia. National Institutes Health. 2006;09-21.

18. Saber N, Diab H, Nassar W, Razaak HA. Ultrasound guided local steroid injection versus extracorporeal shockwave ther-apy in the treatment of plantar fasciitis. Alexandria J Med. 2011;48:35- 42.

19. Yesiltas F, Aydogan U, Parlak A. The comparison of in-tralesionary steroid injection and autologous venous blood

injection in patients with plantar fasciitis. Acta Medica Medi-terranea. 2015;3:711.

20. Vahdatpour B, Kianimehr L, Ahrar MH. Autologous plate-let-rich plasma compared with whole blood for the treatment of chronic plantar fasciitis; a comparative clinical trial. Adv Biomed Res. 2016;5:84.

21. Ahmed Baba M, Mir BA, Halwai MA, Bbashir A, Rashid S, Khursheed O. E valuation of the results of autologous blood injection in the treatment of refractory heel pain. The Foot and Ankle Online Journal. 2013;6(10).

22. K. The biology of platelet-rich plasma and its application in trauma and orthopaedic surgery: a review of the literature. J Bone Joint Surg Br. 2009; 91:987e996.

23. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009; 42:409-16.

24. Wilson JJ, Best TM. Common overuse tendon problems: a review and recommendations for treatment. Am Fam Physi-cian. 2005; 72:811-8.

25. Sun Y, Feng Y, Zhang CQ, Chen SB, Cheng XG. the regener-ative effect of platelet-rich plasma on healing in large osteo-chondral defects. Int Orthop. 2010; 34(4):589-97.

26. Fardale PD, Wiggens ME. Corticosteroid injections: their use and abuse. J Am Acad Orthop Surg. 1994; 2:133e140.

27. Bonnici AV, Spenser JD. Survey of “Trigger finger”?

28. Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Classifi-cation of platelet concentrates from pure platelet-rich plasma (P-PRP) to leucocyte- and platelet- rich fibrin (L-PRF). Trends Biotechnol. 2009; 27:158e167.

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Abstract

The current descriptive type of cross sectional study was conducted during 16th May to 31st May 2018 to assess awareness regarding personal hygiene and sanitation practices in Dhamrai, Dhaka with a sample size of 120 using interviewer administered semi-structured questionnaire employing convenience sampling technique. More than one third (35.9%) of the respondents were in age group 25-35 years and about 65% were female, 32.5% were housewives and 35.8% were found illiterate. source of drinking water was from71.67% tube well and 78.3% used sanitary latrine. More than half of the respondents (61.67%) were taking daily bath with soap and water, 61.66% cut their nails at leisure time and 51.67% wash hair with shampoo and water; while 59.67% washed their hands before meal and 76.67% after defecation with soap and water. It is revealed that 43.3% were aware about the transmission of diarrheoa through dirty nail and 73.3% were aware not to defecate on barefoot. Health education and comprehensive knowledge of proper personal hygiene and sanitation is essential in daily life and should be used to prevent the spread of infectious diseases.

Keywords: Awareness, Personal hygiene, Sanitation, Transmissible Diseases.

Original ArticleAwareness regarding personal hygiene and sanitation practices among adult

population in Dhamrai, DhakaSultana Begum1, Monowar Ahmad Tarafdar2, Md Saizuddin3, Nadia Begum4, Shila Rani Das5, Meheruba Afrin6

Address of correspondence:Sultana Begum, Associate Professor, Department ofCommunity Medicine, Z H Sikder Women’s Medical College, Dhaka. Email: [email protected]

1. Associate Professor, Department of Community Medicine, Z H Sikder Women’s Medical College, Dhaka2. Professor, Department of Community Medicine, Z H Sikder Women’s Medical College, Dhaka3. Professor, Department of Community Medicine, Z H Sikder Women’s Medical College, Dhaka4. Associate Professor, Department ofCommunity Medicine, Z H Sikder Women’s Medical College, Dhaka5. Associate Professor, Department ofCommunity Medicine, Z H Sikder Women’s Medical College, Dhaka6. Assistant Professor, Departmentof Community Medicine, Z H Sikder Women’s Medical College, Dhaka

Introduction

Health awareness and practices is an essential part of human life in the process of active learning process. Inadequate hygiene and sanitation has direct effect on health of an individual, family, communities and nation as a whole. Toilet is considered as an essential and basic indicator of health and sanitation worldwide.1 Proper sanitation is a necessary prerequisite for improvement in general health standards, productivity of labor force and good quality of life.2 It is just alarming that in every 20 seconds, a child around the world dies as a result of poor sanitation.3 About 80% of all diseases of the developing world is related to drinking unsafe water and inadequate sanitation.4 Worldwide, 5.3% of all deaths and 6.8% of all disability are caused by poor sanitation, poor hygiene and unsafe water. Nearly two-thirds (67%) of the total population go for open-air defecation and only one-third (33%) having access to a latrine.5

In a developing country like Bangladesh, almost one-third of the population lives below the poverty line. Various diseases are rampant due to lack of safe drinking water and sanitation.6 Among the poorest, nearly one-third defecate in the open, making the everyday environment unsafe.7 According to a World Health Organization

(WHO) estimate, 1.5 million children die from diarrheoal diseases each year worldwide, with 88% of these deaths occurring due to inadequate sanitation, hygiene, and safe drinking water.8 So, hygiene practice becomes difficult in many parts of the world, including Bangladesh, due to lack of awareness about using safe water, soap and disinfectants.9 Only 26.7% people wash their hands with soap or ashes after defecation.10 The main barrier to success of sanitation coverage is lack of awareness about the benefits of a safe latrine, poverty, lack of adequate space, and attitude for open defecation.11 In this regard, Government of Bangladesh initiated a program to achieve 100% sanitation by 2013.

Materials and Methods

This descriptive type of cross sectional study conducted to assess awareness regarding personal hygiene and sanitation practices in Dhamrai, Dhaka during 16th May to 31st May 2018 with a sample size of 120 using interviewer administered semi-structured questionnaire employing convenience sampling technique. After collection, the data were checked, verified and edited. Compilation and tabulation of data according to key variables was done by using calculator and computer. Data were presented by tables and diagrams based on nature of data.



Results

This descriptive type of cross sectional study conducted to assess awareness regarding personal hygiene and sanitation practices in Dhamrai, Dhaka. While examining the socio-demographics characteristics, it was found that 35.9% were from 25 to 35 years age group, 65% were female and 35% male; 35.8% was found illiterate. House wives were 32.5%, 45% of the respondents had monthly income of 5000 to 10,000 taka. The current study revealed that 71.67% respondents used tube well as a source of drinking water and 78.33% of the respondents used sanitary latrine.

Table No. 1: Distribution of respondents regarding socio-demographic characteristics (n = 120)

Variables Frequency Percentage (%)

Age Group (year)15-25 41 34.125-35 43 35.935-45 14 11.745-55 16 13.3> 55 6 5SexMale 42 35Female 78 65ReligionIslam 112 93.3Hindu 8 6.7Educational LevelIlliterate 43 35.8Class I-IV 18 15Class V – X 19 15.8SSC 16 13.4HSC 10 8.3Graduation 8 6.7Masters 6 5OccupationHousewife 39 32.5Service holder 14 11.67Day labourers 6 5Domestic helper 13 10.83Business 8 6.67Agriculture 7 5.83Driver 5 4.17

Rickshaw puller 13 10.83Carpenter 1 0.83Masonry 1 0.83Student 14 10.84Monthly Family Income(Tk)<5000 7 5.845000 – 10,000 54 45.010,000 – 15,000 43 35.83>15,000 16 13.13

Source of drinking water80.00% 86, 71.67%

7, 5.83%

27, 22.50%

70.00%60.00%50.00%40.00%30.00%20.00%10.00%0.00%

Tube-well Tap water Pond

Figure 1: Bar-diagram showing distribution of respondents according to sources of drinking water.

Table No. 2: Distribution of respondents regarding personal hygiene (n = 120)

Habit of bathing Frequency Percentage (%)

Daily 89 74.17At interval 31 25.83Method of taking bathWith water only 34 28.33With soap & water daily 74 61.67With soap & water at interval 12 10Habit of brushing teethDaily 87 72.5At interval 33 27.5Habit of Cutting nailsWeekly 37 30.34Fortnight 16 13.33At only leisure time 62 61.66Not at all 5 4.17Method of washing hairWith soap & water 34 28.33With shampoo & water 62 51.67With shampoo, soap &water 18 15

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Others 6 5Method of Washing hands after mealOnly water 41 34.67Soap & water 71 59.67Ash & water 2 1.67Nothing 4 3.33Other 2 1.67Method of Washing hands after defecationOnly water 19 15.83Soap & water 90 75Mud & water 7 5.83Ash & water 4 33.33

SanitaryLatrine,78.30%

Kacchalatrine,21.70%

Type of latrine used

Figure 2: Pie diagram showing distribution of respondents according to type of latrine used.

Diseases transmitted by dirty nail50.00%

40.00%

30.00%

20.00%

10.00%

0.00%

43.33%

31.67%

5% 2.50%

Diarrhoealdiseases

Worminfestation

Dysetery Hepatitis

Figure 3: Bar-diagram showing distribution of respondents by knowledge on Transmission of worm infestation through dirty nail.

Yes, 26.70%

No 2, 73.30%

Defecation barefoot

Figure 4: Pie diagram showing distribution of respondents who defecates barefoot.Discussion

In this study, 60% respondents had good personal hygiene practice and 40% did not practice adequate hygiene and 78.33% of the houses showed good sanitary condition. Slightly different picture was observed in Nepal by Rajiv Ranjan Karn, Buna Bhandari, and Nilambar Jha where they found the sanitary knowledge had 90% respondents and hand washing with soap water of 65% of the community people was high.12

In this study, 78.3% of the houses had sanitary latrine and the respondents had toilet facilities and they do not use open air defecation. Almost similar data was presented in a study conducted in Dhaka in 2014.13 Overall, the majority 59.67% reported washing hands with soap and water; 34.67% washing hands with only water before taking meals. These findings are almost similar in the studies carried out in Jahangirnagar University in 2012 by Mashura Shammi and Mahedi Morshed.14

In this study, 75% of the respondents reported washing hands with soap and water after defecation, and 34.67% washing hands with water after defecation. Slightly different findings were observed in Bangladesh National Hygiene Baseline Survey 2014.15 Approximately 74% of the respondents reported daily bathing practices and 72% reported tooth brushing practices. These findings are dissimilar with the findings of a study conducted in Quatar which showed that 35% of respondent reported poor bathing.16

This current study shows that 72% of the respondents used tube well as a source of drinking water,17 43.3% of the respondents were aware about the transmission of diarrheoa through dirty nails and majority 73.3% of the respondents do not defecate barefoot.16

Conclusion and Recommendations:

Hygienic practice is important when people get adequate education and information. Mass media can play an important role in dissemination of hygienic education to the rural people. There should be extensive health



education program for the people about the personal hygiene and sanitation.

References1. Environmental sanitation guidelines, Rural Village Water

Resources Management Project, 2009.

2. Dwivedi P, Sharma A. N. A Study on Environmental Sanitation, Sanitary Habits and Personal Hygiene among the Baigas of Samnapur Block of Dindori District, MadhyaPradesh, J. Hum. Ecol 2007;1:7-1.0

3. World Health Organization and United Nations Children’s Fund Joint Monitoring Programme on Water Supply and Sanitation and Water Supply and Sanitation Collaborative Council, 2012.

4. Thapa M, Sharma AP. Study of Bacteriological Treatment of Water for Rural Communities. Nepal Journal of Science and Technology. Royal Nepal; Academy of Science and Technology, Kathmandu 1999; 1:27-33.

5. Ahmed MF. South Asian Conference on Sanitation, BCHIMES, Between Census Household Information, Monitoring and Evaluation System; 2001.

6. Akter T, Ali A Mehrab. Factors influencing knowledge and practice of hygiene in Water, Sanitation and Hygiene (WASH) programme areas of Bangladesh Rural Advancement Committee. Rural and Remote Health (Internet) 2014; 14: 2628.

7. UNICEF. Rural sanitation, hygiene and water supply. (Online) 2008. Available: http://www.unicef.org/bangladesh/ RURAL_Water_Sanitation_and JHygiene.pdf (Accessed 7 September 2011).

8. Lipson J. The public health benefits of sanitation interventions. EPAR Brief No. 104. University of Washington: Evans School of Public Affairs, 2010.

9. Nath KJ, Chowdhury B, Sengupta A. Study on perception and practice of hygiene and impact on health in India. In: Proceedings of South Asia Hygiene Practitioners’ Workshop, 1-4 February, Dhaka, Bangladesh. (Online) 2010.

10. Centers for Disease Control. Global WASH-related diseases and contaminants.(Online). 2010.

11. Kabir B, Barua MK, Karim R, Bodiuzzaman M, Rahman M, Mia HA. Contributions of village WASH committee in breaking the cycle of unhygienic behaviours in rural Bangladesh. In: Proceedings of South Asia Hygiene Practitioners’ Workshop, 1-44 February, Dhaka, Bangladesh. (Online) 2010.

12. Rajiv Ranjan Karn, Buna Bhandari, and Nilambar Jha a study on personal hygiene and sanitary practices in a rural village of mornag district of Nepal; Journal of Nobel Medical College (2011), 1(2): 39-44.

13. Farah S, Karim M, Akther N, Begum M, & Begum N. (2015). Knowledge and Practice of Personal Hygiene and Sanitation: A Study in Selected Slums of Dhaka City. Delta Medical Col-lege Journal, 3(2), 68-73.

14. Shammi M and Morshed M. Assessment of Practices of Sani-tation and Hygiene Comparison of a Declared Sanitation Area to a Non Area of Sirajganj District, Bangladesh; Jahangirnagar Univrsity Environmental Bulletin 2013, 2: 50-60.

15. Bangladesh National Hygiene Baseline Survey 2014. Inter-national Centre for Diarrheal Diseases Research, Bangladesh (icddr,b) and WaterAid Bangladesh.

16. Shammi M and Morshed M. Assessment of Practices of Sani-tation and Hygiene Comparison of a Declared Sanitation Area to a Non Area of Sirajganj District, Bangladesh; Jahangirnagar Univrsity Environmental Bulletin 2013, 2: 50-60.

17. Begum S, Ahmed M, Sen B. Do Water and Sanitation Inter-ventions Reduce Childhood Diarrhoea? New Evidence from Bangladesh Bangladesh; Development Studies September 2011, XXXIV(3): 6-8.

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Original article

Comparison of 550 cases of surgical and natural menopause in respect to Genito-urinary Syndrome of Menopause (GSM)

Nusrat Mahjabeen, Sk. Zinnat Ara Nasreen.

Address of correspondence:

Nusrat Mahjabeen, Assistant Professor, Department of Obs. & Gynae, Z H Sikder Women’s Medical College & Hospital, Dhaka.Cell: 01626771927; Email: [email protected]

Abstract:

Natural menopause and surgical menopause are used interchangeably when conditions of patients are discussed. But they are different entirely. One is a natural stage of life that all women experience, the other is the result of surgery. This prospective observational study was conducted in the Department of Obstetrics and Gynaecology, Z.H. Sikder Women’s Medical College & Hospital, Dhaka from January 2016 to December 2018 over a period of three years to compare the GSM effects in natural and surgical menopause cases. During the study period a total of 275 patients with surgical menopause and 275 patients with natural menopause were enrolled employing purposive sampling method using a predesigned data collection sheet. Age of the most of the patients in surgical menopause group was within 41 to 50 years and most of the patients were >50 years old in natural menopause group. Most of the patients were illiterate in both groups and maximum patients were poor in both groups. Hot flush (48.0% vs 28.0%), dryness of vagina (12.0% vs 0.0%) and dyspareunia (72.0% vs 28.0%) were found significantly higher in surgical menopause than natural menopause. Dysuria (92.0% vs 40.0%) and increased frequency of urination (68.0% vs 36.0%) were significantly higher in surgical menopause than natural menopause group. Urgency, hesitancy and incontinence of urination were significantly lower (p=<0.001) in surgical menopause than natural menopause group. In most of the surgical menopause cases, ovaries were also sacrificed. And this may be the reason of more deleterious effects in surgical menopause than natural menopause. So, it is highly recommended to preserve ovaries in hysterectomies due to benign indications.

Keywords: GSM, surgical menopause and natural menopause.

Introduction:

Menopause is the permanent cessation of menstruation resulting from reduced ovarian hormone secretion that occurs either naturally or is induced by surgery, chemo-therapy, or radiation. Natural menopause can be recog-nized after 12 months of amenorrhea that is not associ-ated with a pathologic cause.1 Surgical menopause is the cessation of menses resulting from surgical removal of the uterus, leaving one or both ovaries, or the removal of both ovaries.2

The genitourinary syndrome of menopause (GSM) is a new term that describes various menopausal symptoms and signs associated with physical changes of the vulva, vagina, and lower urinary tract. The GSM includes not only genital symptoms (dryness, burning, and irritation) and sexual symptoms (lack of lubrication, discomfort or pain, and impaired function), but also urinary symptoms (urgency, dysuria and recurrent urinary tract infections).3

The syndrome or its features manifest in some manner in approximately 15% of premenopausal women4 and 40-54% of postmenopausal women.5 Because women have a higher life expectancy than men, and >17% of the population will be age >65 years by 2030, the

consequences of declined endogenous estrogen levels in menopausal women should be of great interest to clinicians.6

In Western women, 45% to 63% of postmenopausal women reported that they had experienced vulvovaginal symptoms,7 most commonly vaginal dryness; other symptoms included dyspareunia, vaginal irritation, itching sensation, vaginal tenderness, and vaginal bleeding or spotting during intercourse.7-9 Similarly, in a Korean study, 49% of postmenopausal women had experienced vulvovaginal symptoms including vaginal dryness and dyspareunia.10

As a result of estrogen deficiency after menopause, anatomic and histologic changes occur in female genital tissues, including reduction in the content of collagen and hyaluronic acid and in the levels of elastin, thinning of the epithelium, alterations in the function of smooth muscle cells, increase in the density of connective tissue, and fewer blood vessels. These changes reduce elasticity of the vagina, increase vaginal pH, lead to changes in vaginal flora, diminish lubrication, and increase vulnerability to physical irritation and trauma.11,12

The female genital tract and lower urinary tract share



a common embryonic origin, both arising from the urogenital sinus. As estrogen plays an important role in the function of the lower urinary tract throughout the premenopausal period, estrogen deficiency after menopause causes lower urinary tract symptoms, such as dysuria, urgency, frequency, nocturia, urinary incontinence (UI), and recurrent UTI.13

In a study by Robinson and Cardozo13 about 20% of postmenopausal women had severe urgency and almost 50% had stress incontinence. In particular, urge incontinence is more prevalent after menopause than before menopause, and its prevalence increases with time in women with estrogen deficiency. The study by Hyun et al.14 suggested that the major cause of UI in postmenopausal women was the intrinsic sphincteric dysfunction related to altered connective tissue following estrogen deficiency, while the anatomical change was the most responsible factor of UI in premenopausal women. The incidence of UTI rises dramatically in elderly women. Studies have shown that 15% to 20% of women aged 65 to 70 years and 20% to 50% of women aged > 80 years have bacteriuria.15,16

Methods:

This prospective observational study was conducted in the Department of Obstetrics and Gynaecology, Z.H. Sikder Women’s Medical College & Hospital, Dhaka from January 2016 to December 2018 over a period of three years to compare the GSM effects in natural and surgical menopause cases. During the study period a total of 275 patients with surgical menopause and 275 patients with natural menopause were enrolled employing purposive sampling method using a predesigned data collection sheet. After collection, data was cleaned, edited and analyzed with the help of SPSS version 21 and presented in tables and graphs.

Results:

Table 1: Demographic profile of the study subjects in surgical and normal menopause groups (n=550)

Surgical menopause

(n=275)

Natural menopause

(n=275)

p-value

Age (years)

41 – 50 209 (76.0) 88 (32.0) <0.001

51 – 60 44 (16.0) 99 (36.0)

61 – 70 22 (8.0) 77 (28.0)

>70 0 (0.0) 11 (4.0)

Mean±SD 48.32±7.15 56.96±8.91

Education

Illiterate 187 (68.0) 176 (64.0) <0.001

Primary 66 (24.0) 66 (24.0)

HSC 11 (4.0) 0 (0.0)

Higher 11 (4.0) 33 (12.0)

Socio-economic status

Poor 165 (60.0) 154 (56.0) <0.001

Lower middle 99 (36.0) 77 (28.0)

upper middle 11 (4.0) 11 (4.0)

Upper 0 (0.0) 33 (12.0)

Table 2: Genital complaints of the study subjects in surgical and normal menopause groups (n=550)

Surgical menopause

(n=275)

Natural meno-pause

(n=275)p-value

Hot flush 132 (48.0) 77 (28.0) <0.001

Dryness of vagina 33 (12.0) 0 (0.0) <0.001

Irritation 11 (4.0) 22 (8.0) 0.048

Dyspareunia 198 (72.0) 77 (28.0) <0.001

*Multiple responses

Table 3: Urinary complaints of the study subjects in surgical and normal menopause groups (n=550)

Surgical menopause

(n=275)

Natural menopause

(n=275)

p-value

Dysuria 253 (92.0) 110 (40.0) <0.001

Increased frequency 187 (68.0) 99 (36.0) <0.001

Incomplete evacuation 110 (40.0) 110 (40.0) 1.000

Urgency 0 (0.0) 33 (12.0) <0.001

Hesitancy 11 (4.0) 33 (12.0) 0.001

Incontinence 0 (0.0) 44 (16.0) <0.001

*Multiple responses

Discussion:

In this study mean age was 48.32±7.15 years in surgical menopause and 56.96±8.91 years in natural menopause patients. Age of the natural menopause patients was sig-nificantly higher than surgical menopause patients. In the study of Mahajan et al.17 and Ozdemir et al. 18, there were no significant difference in age between surgical meno-pause and natural menopause patients.

During menopause women experience numerous bothersome symptoms like hot flushes, sweating, poor memory and decreased libido as well as decrease BMD and some metabolic changes. In this study, hot

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flush (48.0% vs 28.0%), dryness of vagina (12.0% vs 0.0%) and dyspareunia (72.0% vs 28.0%) were found significantly higher in surgical menopause than natural menopause. But irritation (4.0% vs 8.0%) was found lower in surgical menopause than natural menopause. Nasreen et al.19 found significantly higher incidence of hot flush in surgical menopause. Similarly, Ozdemir et al.18 found significantly higher incidence of hot flushes and change in sexual desire in surgical menopause. Duffy et al.20 also stated that higher proportion of surgically menopause women experience the extremely bothersome symptoms than naturally menopause women. Incidence of dyspareunia was significantly higher in surgically menopause women than naturally menopause women. Similarly, incidence of urinary complains (Dysuria and Increased frequency) were found significantly higher in surgically menopause women than naturally menopause women. Similar to this study, urinary complaints were found more in surgical menopause than natural menopause even though not statistically significant. Hesitancy was found significantly less in surgical menopause than natural menopause in this study. Almost similar finding was seen in the study of Ozdemir et al.18.

Conclusion:

In most of the surgical menopause cases, ovaries were sacrificed, which may cause the deleterious effects in surgical menopause than natural menopause. So, it is highly recommended to preserve ovaries in hysterectomies due to benign indications.

References:1. Rahman SA, Zainudin SR, Mun VL. Assessment of meno-

pausal symptoms using modified menopause rating scale (MRS) among middle age women in Kuching, Sarawak, Ma-laysia. Asia Pac Fam Med 2010;9:5.

2. Brett KM. Can hysterectomy be considered a risk factor for cardiovascular disease? Circulation 2005;111:1456-8.

3. Portman DJ, Gass ML, Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Climac-teric. 2014 Oct 1;17(5):557-63.

4. Palacios S. Managing urogenital atrophy. Maturitas. 2009 Aug 20;63(4): 315-8

5. DiBonaventura M, Luo X, Moffatt M, Bushmakin AG, Kumar M, Bobula J. The association between vulvovaginal atrophy symptoms and quality of life among postmenopausal women in the United States and Western Europe. J Womens Health (Larchmt) 2015;24: 713-22.

6. Keil K. Urogenital atrophy: diagnosis, sequelae, and manage-ment. Curr Womens Health Rep 2002;2:305-11.

7. Nappi RE, Kokot-Kierepa M. Women’s voices in the meno-

pause: results from an international survey on vaginal atrophy. Maturitas 2010; 67: 233-8.

8. Nappi RE, Kokot-Kierepa M. Vaginal Health: Insights, Views & Attitudes (VIVA) - results from an international survey. Cli-macteric 2012; 15: 36-44.

9. Kingsberg SA, Wysocki S, Magnus L, Krychman ML. Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. J Sex Med 2013; 10: 1790-9.

10. Chae HD, Choi SY, Cho EJ, Cho YM, Lee SR, Lee ES, et al. Awareness and experience of menopausal symptom and hor-mone therapy in korean postmenopausal women. J Menopaus-al Med 2014; 20: 7-13.

11. Nappi RE, Palacios S. Impact of vulvovaginal atrophy on sex-ual health and quality of life at postmenopause. Climacteric 2014; 17: 3-9.

12. Tan O, Bradshaw K, Carr BR. Management of vulvovaginal atrophy-related sexual dysfunction in postmenopausal women: an up-to-date review. Menopause 2012; 19: 109- 17.

13. Robinson D, Cardozo LD. The role of estrogens in female low-er urinary tract dysfunction. Urology 2003; 62: 45-51.

14. Hyun HS, Park BR, Kim YS, Mun ST, Bae DH. Urodynamic characterization of postmenopausal women with stress uri-nary incontinence: retrospective study in incontinent pre- and post-menopausal women. J Korean Soc Menopause 2010; 16: 148-52.

15. Brown JS, Vittinghoff E, Kanaya AM, Agarwal SK, Hulley S, Foxman B. Urinary tract infections in postmenopausal wom-en: effect of hormone therapy and risk factors. Obstet Gynecol 2001; 98: 1045-52.

16. Raz R. Urinary tract infection in postmenopausal women. Ko-rean J Urol 2011; 52: 801-8. Palacios S. Managing urogenital atrophy. Maturitas 2009;63:315-8.

17. Mahajan N, Kumar D, Fareed P. Comparison of Menopaus-al Symptoms and Quality of Life after Natural and Surgical Menopause. International Journal of Scientific Study. 2016 Feb 1;3(11):74-7.

18. Özdemir S, Çelik Ç, Görkemli H, Kıyıcı A, Kaya B. Compared effects of surgical and natural menopause on climacteric symptoms, osteoporosis, and metabolic syndrome. International Journal of Gynecology & Obstetrics. 2009 Jul 1;106(1):57-61.

19. Nasreen SZA, Shahreen S, Rahman S. Comparison between surgical and normal menopause in genitourinary syndrome of menopause (GSM)? J South Asian Feder Menopause Coc 2013; 1(2): 63-65.

20. Duffy OK, Iversen L, Hannaford PC. The impact and manage-ment of symptoms experienced at midlife: a community‐based study of women in northeast Scotland. BJOG: An International Journal of Obstetrics & Gynaecology. 2012 Apr;119(5):554-64.



Review articleWork ability of health care professional: Enhancing Productivity

Shila Rani Das Introduction:

The work ability can be conceptualized as the physical and mental well-being of workers, which enables them to develop their work according to the demands of the occupation and their state of health 1. Work ability comprises physical, psychological, and social capacities. It is influenced by demographic, socio-economic, environmental and life style factors.2 work ability should be seen from a framework that takes into account the interaction between work, lifestyle, health conditions and biological aging 3. Work ability can be considered as an important component of the broader concept of employability. It also can be a sign of person’s ability to cope with working life. The concept of work ability is defined as the ability of a worker to perform his/her job, taking into account the specific work demands, individual health condition, mental resources and work life 4.

The correct appraisal of the employees’ work ability is important for employers in economic viewpoint and improving it is one of the ways for increasing the human resources productivity in industries and organization. The concept of work ability is the base for designing work stations and proper choose of staffs for various jobs in the other hand, if employee’s physical and psychological abilities is not according to their job’s requirements, it would led to detect safety and health issues, decreasing production and increasing costs related to dismissal of employees. Quality of healthcare depends on many factors, including health, quality of life and work ability of healthcare workers. Globally, nurses are the largest category of health care workers in the world and provide up to 80% of direct patient care 5. Work places with high physical demands, psychological and physical work-related factors are the most important determinants of work ability. Among physical factors repetitive movements, static work postures, awkward back postures were the most important factors and among psychological factors, lack of support at work, high work demands and low job control and prominent effects on work ability 6. There is a need for employees to remain productive until retirement age. This need is particularly apparent in health care, due to a shortage of nurses and a high turnover of nursing personnel 7. Decreased work ability is associated with diminished productivity at work, increased risk of long-

term sickness absence and early retirement. Particularly in healthcare jobs, work ability is a precondition to cope with demanding tasks in different work conditions (eg, high patient loads, working under pressure) 8.

In the 1980s, with the aging of the Finnish working population, the Finnish Institute of Occupational Health (FIOH) began the first studies on work ability and functional aging, based on the stress-wear model of Rutenfraz and Colquhoun. This model assumes that the wear experienced by the worker is dependent on stressors resulting from the physical and mental loads of the work, the labor environment and equipment, and the characteristics and resources of the worker. This wear can lead to the triggering of physiological, psychological and behavioral responses, with an impact on the health of the individual and on his or her work ability 9.

More specifically, it is the worker’s perception of own work ability. Thus, work ability should be measured using multiple criteria. The Finnish Institute of Occupational Health developed one of the most appropriate instruments for measuring work ability during 1980: Work Ability Index (WAI) an instrument translated for 26 languages. “reveals how well a worker is able to perform his or her work”. It “is primarily a question of a balance between work and personal resources. In practice people search for an optimal balance throughout their entire work life” and it “may be very different in different phases of work life” The WAI has seven items: (1) current work ability compared with the life time best, (2) work ability in relation to the demands of the job, (3) number of current diseases diagnosed by a physician, (4) estimated work impairment due to diseases, (5) sick leave during the past year, (6) own prognosis of work ability two years from now, (7) mental resources and vary from 7 to 49 points 10, 11. In the context of the world of work, the nursing team corresponds to a portion of the contingent of health workers which routinely perform functions that require physical and psychosocial efforts in unhealthy environments, shift schedules, continuous and direct assistance to patients and relatives, and direct experience of pain, suffering and death. These factors, associated with the complexity of the tasks and, often, with other jobs, can generate, over time, wear of the worker’s vital capacities, with consequences for the development of

Address of correspondence:

Shila Rani Das, Associate Professor, Department of Community Medicine, Z H Sikder Woman’s Medical College, Dhaka, Bangladesh. Email:[email protected]

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occupational tasks 12, 13.

Investigating the nursing team’s work capacity can contribute to the early identification of the loss of work ability and associated factors and, consequently, to provide for the planning of strategies for health promotion and prevention of injuries, the health maintenance of workers, and possible improvements in the organization and work environment14. Nurses are among the many healthcare professionals affected by the requirement to work outside of normal daytime hours, as in working alternate shifts 15. Nurses are among the many healthcare professionals affected by the requirement to work outside of normal daytime hours, as in working alternate shifts. This may lead to long working hours (12 vs. 8 hours) and non-ergonomic planning of work schedules (e.g. lack of rest time between shifts and working consecutive night shifts or weekends.). Hence, difficulties in shift-work-related problems, both for the nurses and for those supervising them, may increase the current global nursing shortage16.

It has been agreed that, in the caring profession, nurses form the largest group, of which the principal mission is the nurturing of, and caring for people in the human health experience. They provide around-the-clock services to patients in hospitals, nursing homes, long-term care facilities, as well as to clients using supportive and preventative programs and related community services. The nursing profession follows a holistic approach, taking into account the person in totality in his or her environment. Nurses provide presence, comfort, help and support for people confronted with loneliness, pain, incapacity, disease and even death17.

Shift work is a known cause of disturbances in the health and well-being of nurses18. However, nursing services must be available on a 24-hour basis, making shift work a necessity. The effect of shift work on nurses’ lifestyle, their occupational health issues, and the demands of staffing are documented19. Also, adverse effects have been noted on workers’ physiological, psychological, and health related problems due to an impairment of biorhythms, although adverse effects vary according to type of shift worked, as in rotational versus fixed shifts 20.

Factors related to the management, ergonomics, and lifestyles explained both a decline and an improvement in work ability during ageing. In some studies, poor work ability has been associated with older age, obesity, high mental work demands, lack of autonomy, poor physical work environment, and high physical work load. Individuals with poor work ability have an increased risk of early retirement, long-term sickness absence and work disability as well as decreased functional ability and higher mortality in old age 21.

Large-scale epidemiological studies which aim to describe nurses’ quality of life and its main determinants and to assess its associations with work ability and different health outcomes are needed to translate the research findings into evidence based strategies effectively with the final goal being to maintain work ability among nurses 22. Nowadays, one of the most important personnel management challenges is to explore factors that stimulate or hinder the development of individual work ability and quality of life throughout a career. Maintaining clinical nurses’ quality of life and work ability is an important issue, because it is the foundation for the well-being of the workforce 23. Furthermore, knowledge on the role of basis modifiable lifestyle related and work-related factors is essential for designing effective interventions to improve the workability of workers with health problems and to prevent long-term sickness absence.

References:

1. Hilleshein EF, Lautert L.Work capacity of nurses in a univer-sity hospital. Rev. Latino-Am. Enfermagem. 2012;20(3):[8 telas]. Available at: http://www.scielo.br/pdf/rlae/v20n3/pt_a13v20n3.pdf

2. Kordi, M. Mohamadirizi, S. Shakeri, M.T. Gharavi, M.M. & Fadardi, JS. Relationsehip between Occupational Stress and Work Ability of Midwives in Mashhad. Journal of Midwifery and Reproductive Health. 2011; vol2(3):188-94.

3. Martinez MC, Latorre MRDO, Fischer FM. Capacidade para o trabalho: revisão de literatura. Cienc.saúde coletiva. 2010;15 (supl 1): 1553-61.Available at:http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232010000700067

4. Ilmarinen J & Rantanen J (1999) Promotion of work abili-ty during ageing. American Journal of Industrial Medicine 1(Suppl), 21–23

5. World Health Organization. ‘Occupational stress in the care of the critically ill, the dying and the bereaved’, Hemisphere Publishing Coporation, 2014. Available at: http://whqlibdoc.who.int/publications/2002/924156 217X.pdf

6. Alavinia SM, Duivenbooden C, and Burdorf A. Influence of work-related factors and individual characteristics on work ability among Duch construction workers. Scand J Work Environ Health. 2007; vol 33(5):351-7.

7. Hayes L,j, O’Brien-paalas L, Duffield C, Shamian J, Buchan J, Hughes F et al, Nurse turnover: a literature review. Int J Nurs Stud. 2006;43(2):237-263

8. van den Berg TI, Elders LA, de Zwart BC, et al. The effects of work-related and individual factors on the Work Ability In-dex: a systematic review. Occup Environ Med 2009;66:211–20. doi:10.1136/oem.2008.039883

9. Camerino D, Conway PM, Sartori S, et al. Fac-



tors affecting work ability in day and shift-work-ing nurses. Chronobiol Int.2008;25(2): 425-42. Available at: [http://dx.doi.org/10.1080/07420520802118236] [PMID: 18484372]

10. West S, Boughton M, Byrnes M. Juggling mul-tiple temporalities: the shift work story of mid-life nurses. J Nurs Manag. 2009; 17(1): 110-9. Available at: [http://dx.doi.org/10.1111/j.1365-2834.2008.00920.x] [PMID: 19166529]

11. Saberi HR, Moravveji AR. Gastrointestinal com-plaints in shift-working and day-working nurs-es in Iran. J Circadian Rhythms. 2010; 8: 9-12. Available at: [http://dx.doi.org/10.1186/1740-3391-8-9] [PMID: 20929565

12. Queiroz DL, Souza JC. Qualidade de vida e capacidade para o trabalho de profissionais de enfermagem. Psicólogo Infor-mação ;16(16):103-26. Available at:https://www.metodista.br/revistas/revistas-ims/index.php/PINFOR/article/view-File/3999/3478

13. Oliveira JDS, Pessoa Júnior JM, Miranda FAN, Cavalcante ES, Almeida MG. Stress of nurses in emergency care: a social representations study. Online braz j nurs . 2014 Jun;13(2):150-7. Available at: http://www. objnursing.uff.br/index.php/nurs-ing/article/view/4342 doi: http://dx.doi.org/10.5935/1676-4285.20144342

14. Cossi MS, Costa RRO, Medeiros SM, Menezes RMP. A ca-pacidade para o trabalho da equipe de enfermagem inserida no ambiente hospitalar. Rev. de Atenção à Saúde, 2015(43):5-9. Available at: http://seer.uscs.edu.br/index.php/revista_cien-cias_saude/article/view/2676/pdf_1 doi: 10.13037/rbcs.vol13n43.2374

15. Blachowicz E, Letizia M. The challenges of shift work. Med-surg Nurs 2006; 15(5): 274-80.[PMID: 17128897]

16. Camerino D, Conway PM, Sartori S, et al. Factors affect-ing work ability in day and shift-working nurses. Chrono-biol Int. 2008; 25(2): 425-42. Available at:[http://dx.doi.org/10.1080/07420520802118236] [PMID: 18484372]

17. A, H Shivaprasad, RN, and PGCDE. Work related stress of nursing. Journal of Psychiatry Nursing. 2013; 2 (2): 53-59.

18. Martinez MC, Latorre MRDO, Fischer FM. Capacidade para o trabalho: revisão de literatura. Cienc.saúde coletiva . 2010;15 (supl 1): 1553-61.Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232010000700067

19. Tuomi K, Toikkanen J, Eskelinen L, Backman AL, Ilmarinen J, Jarvinen E & Klockars M (1991) Mortality, disability and changes in occupation among aging municipal employees. Scandinavian Journal of Work and Environmental Health 17(Suppl 1), 58–66.

20. J. Ilmarinen, Work ability – a comprehensive concept for oc-cupational health research and prevention, Scand. J. Work En-vironn. Health, 2009, 35, 1–5. [7] K.

21. von Bonsdorff MB, Seitsamo J, Ilmarinen J, Nygård CH, von Bonsdorff ME, Rantanen T. Work ability in midlife as a pre-dictor of mortality and disability in later life: a 28-year pro-spective follow-up study. CMAJ. 2011 Mar;183(4):E235–42. http://dx.doi.org/10.1503/ cmaj.100713.

22. Peterson, M. & Wilson, J. F. The culture-work-health model and work stress. American Journal of Health Behavior. 2002. Vol 26(1): 16-24.

23. Milutinovic, D. Golubovic, B. Brkic, N. and Prokes, B. Pro-fessional stress and health among critical care nurses in Serbia. Arh hig Rada Toksikol. 2012; vol 63(1)

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Review articleCollection, preservation and forwarding of biological samples for toxicological

analysis in medico legal autopsy cases Utpal Kumar Biswas,1 Nashid Tabassum Khan,2 Mohammad Ahad Hossain, Abdul Kader4

Abstract

Collection of proper autopsy specimen is an essential step in the process of toxicology case work. Improper collection of these specimens can greatly alter or negate chemical and toxicological analysis. This article is an update about the standard methods of biological specimen collection procedures for toxicological analysis which will be helpful for the forensic pathologist and forensicscientists.1

Keywords: Sampling, preservation, body fluids, poison, tissues.

1. Assistant Professor, Department of Forensic Medicine, Monowara Sikder Medical College,2. Associate Professor Department of Forensic Medicine, Z H Sikder Women’s Medical college, 3. Assistant Professor, Department of Forensic Medicine, Dhaka Central International Medical college,

4. Lecturer, Department of Forensic Medicine, Z H Sikder Women’s Medical collegeAddress of correspondence:

Dr. Utpal Kumar Biswas. Assistant Professor, Department of Forensic medicine, Monowara Sikder Medical College. e-mail: [email protected]

Introduction

In handling the Medico legal autopsy cases, certain standard guidelines are necessary to be laid down to assist in the selection of appropriate specimens of the body fluids and tissue for postmortem biochemical and toxicological analysis. After death there is a rapid change in the cellular level biochemistry due to autolysis. The drugs and other poisons may be released from the binding sites in tissues and major organs. The unabsorbed drug may diffuse fromstomach; care should be taken in selection of blood and tissue sampling sites. Many a times the autopsy is conducted before all the circumstantial evidences are collected and investigated. Hence, it is vital to preserve all the necessary samples at the time of autopsy. Ideally the samples for toxicological or biochemical analysis should be collected before the postmortem. However, it may not be possible for all the samples and there maybe difficulty in sampling without opening the body.

Biological fluids

1. Blood

In all medico legal investigation cases blood specimen should be obtained when blood is available. It is used as a reference sample for identification in unidentified cases and also for toxicological analysis. Peripheral blood concentration has been shown to be more reliable for toxicological analysis than the conventional heart blood. Therefore, in all suspected poisoning deaths or in all cases of unknown causes of death a femoral blood specimen should be collected. Before autopsy it can be collected by inserting the needle at about two finger breadths below

the inguinal ligament at middle point marked between the anterior superior iliac spine and the symphysis. But it is best obtained by puncturing the femoral vein using a 30 ml syringe with wide bore needle after exposing the vein by dissection and clamping or ligating it proximal to the collection site.

Usually 20 ml of blood4is sufficient and it has to be preserved in sodium fluoride of 10mg/ml and potassium oxalate, 30 mg/10 ml of blood concentration in a fresh wide mouthed glass container of 30 ml with screw cap 1 (universal container). The glass container should be made of amber glass to inhibit photo degeneration. The rubber or cork caps should be avoided. Sodium fluoride should be avoided. Sodium fluoride protects blood from postmortem changes such as bacterial production of ethanol or other alcohols. It also helps to protect other labile drugs such as cocaine, nitrazepam and clonazepam from degradation4. The most satisfactory way of obtaining a venous blood sample is venipuncture of the femoral vein by direct puncture in the groin before the autopsy begins.

2. Urine

Urine specimen is of great value even in small amount especially in screening of unknown drug or poison, particularly substance of abuse since the concentrations are generally higher than in blood and a number of metabolites may also be present. Urine specimen is also valuable in the quantitative analysis of alcohol, where there is uncertainty over the validity of a blood specimen. Before conducting the autopsy, urine can be collected



by catheter or suprapubic puncture with 5-10 ml syringe and needle (22 gauge 3 inch). With the body in supine position, palpate the bladder and identify the insertion site at midline and 2 cm cephalad to the pubic bone. At the insertion site, introduce the 22 gauge 3 inch needle attached to the 10 ml syringe. Direct the needle caudad (the bladder is a peritoneal organ in adults) at a 10o to 20o

angle from the perpendicular at midline. Gently aspirate while introducing the needle. If no urine is aspirated, withdraw the needle to the subcutaneous space and readvance in a slightly different direction, 10o caudad or cephalad and aspirate again. But it can be best obtained during autopsy after exposing the abdomen by puncturing the fundus of the bladder with syringe and needle. It has to be preserved in sodium fluoride (10 mg/ml) in a 30ml glass container with a screw cap. A sample of 20 ml is sufficient for toxicological analysis.

3. Bile

Bile is helpful in estimating the drugs, which are concentrated by liver and excreted into the gall bladder like opiates and acetaminophen (paracetamol). It is not routinely preserved, but only in selected cases. It is preserved in 30 ml glass screw capped container. A 20 ml of bile is adequate for toxicological analysis. It can be collected directly by incising the gall bladder into a glass bottle. It is a viscous fluid, which makes it difficult to be sucked by needle and syringe.

4. Vitreous Humor

The vitreous humor specimen is particularly useful for alcohols or in diabetes and insulin related deaths. It is also very useful where the body has decomposed. The fluid in the eye resists putrefaction longer than other body fluids as it is sterile and remains well protected in eye. It is useful for certain biochemical tests such as urea, creatinine, glucose, lactose and alcohol. Vitreous humor must be collected from both eyes in separate vials of 10 ml. It is preserved with sodium fluoride (10 mg/ml). A puncture should be made through the sclera at the outer canthus with a fine 19 gauge needle in 5 ml syringe. It should be placed laterally as far as possible, pulling the lid out, so that when released, it returns to cover of the puncture mark for cosmetic reasons. The sclera should be punctured at latitude of about 60o taking the pupil as the North Pole. The needle should be directed towards the center of the eyeball. The fluid comes out slowly because of its viscosity. Gentle aspiration will usually yield 2-3 ml of vitreous humor. Once the sample has been collected the syringe should be detached from the needle, leaving the needle in place. A volume of water or physiological saline equal to the amount of vitreous humor removed should be slowly injected into the eye to achieve cosmetic

restoration. The preservative used is sodium fluoride.

5. Cerebrospinal fluid

The cerebrospinal fluid sample is rarely required for toxicological analysis. If needed it should be collected by cisternal puncture. It is difficult to collect CSF at medico legal autopsy by conventional lumbar puncture. It is relatively easier to obtain by cisternal puncture. With the neck flexed, palpate the atlanto- occipital membrane in the midline and, using a needle and syringe, gently introduce a disposable spinal needle through the skin at that point, directing the needle towards the bridge of the nose. As the atlanto occipital membrane is punctured at a depth of approximately 2 cm, loss of resistance will be felt following which CSF can be aspirated. It should be collected in a 30 ml screw capped plastic or glass container. The CSF sample has to be preserved in sodium fluoride.

6. Other body fluids

In cases where blood and urine are not available other available body fluids like pericardial14andsynovial fluids15 can be used for toxicological analysis like alcohol.

BIOLOGICAL TISSUES

1. Liver

Body tissues are often used for toxicological analysis. Liver is the most important tissue because it concentrates many substances. It can contain large number of drugs and metabolites and may in some difficult cases help establish whether acute or chronic toxicity has occurred. Ideally the part of the liver retained should be fresh unfixed, taken from the periphery of right lobe, away from the stomach, major vessels and gall bladder. A minimum of 100 gm. is sufficient for toxicological analysis.

2. Stomach contents

The other routinely preserved viscera are stomach and small intestine with its contents and kidney. The sample is useful when drugs have been taken orally as the concentrations will be many times higher than in other fluids. It can also be helpful to determine the amount of drug present in stomach if blood concentration is difficult to interpret. The stomach should be ligated on both ends (esophagus and pylorus) and dissected out. Then the greater curvature should be opened up, so that, the contents directly pour onto the wide mouthed jar. About 30 cm of small intestine are preserved with the contents. One half of each kidney is preserved. The stomach and intestine with its contents are preserved in one bottle.

3. Other tissues

Other tissue samples may be useful for investigating

Journal of ZHSWMC


27

deaths where volatile substances e.g. solvents or gases, are implicated. Brain, fat tissue, lung and kidney are the most useful. Ideally a wet unfixed tissue should be collected into separate glass containers. In case of lung, the sample has to be collected from the apex ofthe lung. The whole lung may have to be preserved in case of solvent abuse or volatile substance poisoning. After opening the thorax, the lung is mobilized and the main bronchus tied off tightly with a string ligature. The hilum is then divided and the lung placed immediately into a nylon bag (prevents the volatile in the sample from escaping) which is sealed and sent as soon as possible to the laboratory.

4. Bone and Muscle tissue

In case of decomposed, exhumed, burnt or skeletonized body it becomes difficult and challenging due to absence of blood or scarcity of solid tissues. But whatever remains are available we have to collect all the relevant samples though it may not be the routine sample. If bones10are available the whole long bone should to becollected and preserved. It has to be dried in normal temperature and sealed in plastic bag. Bone marrow samples may be useful in drug identification (qualitative and also quantitative) in cases where all soft tissue has degenerated. The skeletal muscle is also useful for toxicological analysis. A 100 gm. muscle tissue (preferably quadriceps muscle ) has to be preserved in saturated solution of common salt in a plastic or glass container.

5. Hair and Nail

Hair and nails are useful samples for analyzing chronic poison (heavy metals) or drug of abuse (opioids). These should be sent if chronic poisoning is suspected, particularly to distinguish between episodic or continuous exposure or for those poisons which may have already been eliminated from the body by the time of death. Hair should be plucked from the scalp with the entire root, shaft and tip. About 500 g (20 – 30hairs) of hair should be collected and laid aligned by rolling into a clean plastic or foil sheet with an indication of the scalp ends on the attached label. The whole nail from one toe or fingers can be lifted and collected in a plastic packet.

6. Maggots

In decomposed body, if maggots9,16 are present 20 gms of maggots can be collected in a plastic or glass container with saturated common salt as the preservative. If drugs or intoxicants are detected they could only have originated from tissues upon which the larvae were feeding. However, the correlations between the level in the larvae and the human have not been established. It only provides qualitative information about drug use.

7. Injection sites or snake bite

In case of death due to injection of drugs or suspected snake bite the sample from the injection site has to be preserved. The skin sample with the underneath muscle tissue around the injection site area must be preserved along with a control sample of similar composition from the opposite normal site in saturated solution of common salt

8. Tablets, powders and syringes

These samples should be packed with care and any needle protected by a suitable Shield to avoid injury. These items may be particularly useful in deaths in medical personal or drug addicts who may use agents which are difficult to detect once they have entered the body. The use of disposable, hard plastic or glass containers are recommended for preservation. The plastic containers (especially of polypropylene) are increasingly used and have the advantage of not smashing when dropped and also much lighter. The ideal samples are best sent in their original state without adding any preservative in a refrigerated storage (40C) within few hours. But generally, it is not possible to send in this ideal state due to lack of good autopsy facilities, cold storage facilities, quick transport arrangements, legal formalities and quick forensic laboratory services. It usually gets delayed. Therefore, sample has to be put in ideal preservatives to provide optimal conditions till they reach the laboratory. The specimens are generally preserved at 4oC during the time until they are analyzed. For long term storage it has to be kept in freezer (- 10oC) until analyzed and disposed of. The most commonly used preservative for viscera tissues are saturated solution of common salt. It is the most easily available, cheap and effective preservative. It is important that the solution should be prepare using pure sodium chloride in distilled water to avoid any contaminants. The other option is rectified spirit (90% ethanol) except in cases of poisoning due to alcohol, chloral hydrate, chloroform, phenol, formaldehyde, ether, and phosphorus. In acid or alkali poisoning rectified spirit is the prescribed preservative. The blood for toxicological analysis has to be preserved in Na Fat the concentration of 10 mg/ml of blood and potassium oxalate, 30 mg/10 ml of blood. Fluoride should be added to urine, vitreous humor if alcohol estimations are required.

Forwarding Samples

All samples should be properly sealed and labeled with the deceased’s name, postmortem number, nature of sample, collection site, preservative used, date and time of collection. Particular attention should be paid to the packaging of samples to avoid loss during transport, and to comply with health and safety regulations. It should



be protected by the use of tamper-evident seals around the lids, and accompanied by an intact chain of custody record. It should be handed over to the Investigating officer after obtaining proper receipt.

The following documents should be enclosed along with the samples4:

I. Name, address and phone number of forensic pathologist and investigating Officer.

II. Circumstances of death and details of drugs thought to be implicated.

III. Past medical history including current or recent prescription medication.

IV. Details of emergency hospital treatment and medication given.

V. Copy of forensic pathologist report if available.

Conclusion

The samples collected during the postmortem may not yield the expected normal results. However much useful information can be obtained by the thoughtful analysis of samples obtained at postmortem examination and the interpretation of results obtained. Most drugs and poisons including alcohol shows variation in concentration5-8in blood according to the time of specimen collected after death, choice of specimen site, methods of sampling and the volume of blood collected. The blood specimens taken from central sites e.g. heart tends to give particularly high value for most of the analysts. It is particularly important that blood should not be milked from the limbs as this process can engender significant changes in the concentration of critical analysis in the expressed blood. The most consistent quantitative findings are obtained from blood taken from the femoral vein, which is the recommended site for specimen collection. Because of the very great variations12 in the concentration of drugs in blood samples taken from different sites, it is important that sample collection is standardized, so that the results obtained can be meaningfully interpreted by comparison with the databases that are being developed incorporating the results of the analysis of samples of blood collected by a uniform technique at postmortem examinations.

References

1. Walter C. McCurdy. Postmortem specimen col-lection. Forensic Sci Int.1987; 35: 61-65.

2. Guidline for poison control, WHO, Geneva,1997: 64-65.

3. Peter White. Crime scene to court: The essen-tials of forensic sciences. 1 Edn. Royal society of chemistry, Cambridge,U.K, 1998: 232-253.

4. Laboratory guideline, The Medical toxicology

unit, Guys and St. Thomas hospital, NHS Trust, London, England.

5. Plueckhahn VD. The evaluation of autopsy blood alcohol levels. Med Sci Law.1968; 8: 168-176.

6. Prouty RW and Anderson WH. The forensic im-plications of site and temporal influences on post-mortem blood-drug concentrations. J Forensic Sci. 1990; 35:243.

7. Jones Gr, Puuder DJ. Site dependence of drug concentrations in postmortem blood-a case study. J Anal Toxicol. 1987; 11: 184-190.

8. O Neal CL and Poklis A. Postmortem production of ethanol and factors which influence interpreta-tion: a critical review. Am J Forensic Med Pathol. 1996; 17: 8-20.

9. Pouuder JD. Forensic entomotoxicology. J Foren-sic Sci. 1991; 31: 469-472.

10. Noguchi TT, Nakamma GR and Griesemer EC. Drug analysis of skeletonizing remains. J Fornsic Sci. 1978;23: 490-492.

11. Baker RC. In Cravey, R.H and Baselt RC. Intro-duction to forensic toxicology,1st Edn, Biomedi-cal publication, Davis: CA, 1981: 142-150.

12. Julian Burton and Guy Rutty. The hospital autop-sy. 2nd Ed, Arnold, NewDelhi, 2001: 126-133.

13. Bryan Ballantyne, Timothy Marrs and Tore Syversen. General and Applied Toxicology. 2nd Ed, Macmillan, London,1999: 1495-1496.

14. Moriya F and Hashimoto Y. Pericardial fluid as an alternative specimen to blood for postmortem tox-icological analysis. LegMed. 1999; 1 (2): 86-94.

15. Oshima T, Kondo T, Sato Y and Takayasu T. Post-mortem alcohol analysisof the synovial fluid and its availability inMedicolegal practices. Forensic Sci Int.1997; 10 (90): 131-8.

16. M. Lee Geoff and Wayne D Ford. Entomotoxicol-ogy – A new area for forensic investigation. Am J ForMedPathol. 1994; 15(1): 51-57.

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Case reportHypokalemic periodic paralysis: a case report.

Golam Nabi,1 Fahmida Ferdou,2 Sadika Kadir,3 Sarah Ambarin Chowdhury,4 Mohammad Babul Miah,5 Mahmudul Hasan,6 NMW Rahman.7

Abstract:

Hypokalemic periodic paralysis (HKPP) is a rare genetic disorder with autosomal dominant inheritance and characterized by recurrent attacks of skeletal muscle weakness with associated hypokalemia which is precipitated by stress, cold, carbohydrate load, infection, glucose infusion, hypothermia, metabolic alkalosis, anesthesia and steroids. Hypokalemic Periodic Paralysis is one form of Periodic Paralysis, a rare group of disorders that can cause of sudden onset weakness. A case of a 29 year old male is presented here. The patient presented with sudden onset paralysis of his extremities. Laboratory evaluation revealed a markedly low potassium level. The patient’s paralysis resolved upon repletion of his low potassium and he was discharged with no neurologic deficits. Although rare, Periodic Paralysis must differentiated

1. Associate Professor of Medicine, Z.H.Sikder Women’s Medical College & Hospital.2. Assistant Professor of Psychiatry,.Z.H.Sikder Women’s Medical College & Hospital.3. Assistant Professor of Paediatric.Z.H.Sikder Women’s Medical College & Hospital.4. Assistant Professor Obs.& Gynae. International Medical College, Tongi. 5. Assistant Professor of Medicine, Enam Medical College & Hospital6. Junior Consultant (Medicine), UHC Shibpur, Madaripur.7. Associate Professor in Microbiology,ZH.Sikder Women’s Medical College & Hospital.

Address of correspondence:Golam Nabi, Associate Professor of Medicine, Z. H. Sikder Women’s Medical College & Hospital. Email: [email protected]. Mob. 01819229570

from other causes of weakness and paralysis so that the proper treatment can be initiated quickly.

Case presentation:

A 29 year-old male Mr. Akbar Ali from Ati Bazar, with no significant past medical history presented to the emergency department of ZHSWMC&H with sudden onset paralysis in the mid night. The patient had gone to bed at 10 pm with no weakness and awoke at midnight unable to move his upper or lower extremities. The weakness was bilateral and involved both the proximal muscles of the shoulders and hips as well as the distal extremities. He had no respiratory or swallowing difficulty and was able to move his neck and facial muscles. He denied any pain or paresthesia. Prior to this episode, the patient had been healthy and denied any recent diarrhea, chest pain, shortness of breath, or weight change. He did report several episodes of waking from sleep with a “racing heart.” He did not take any medications and denied use of alcohol or drugs, or significant changes in diet or activity levels. His mother had been diagnosed with hyperthyroidism but his parents and brother had no history of similar episodes and no other significant illnesses.

On physical exam, the patient’s heart rate was 124 and blood pressure was 125/81. He was average built, but otherwise normal in overall appearance. His skin was cool and dry, and the oral mucosa was moist. No

jugular venous distension, goiter or lymphadenopathy were appreciated. Cardiac exam revealed tachycardia with a regular rhythm and no murmurs. Examination of the lungs and abdomen were unremarkable. There were no deformities or edema of the extremities and distal pulses were present and equal bilaterally. Neurologic exam revealed flaccid paralysis of all extremities which involved the proximal and distal muscles and included the hips and shoulders. Sensation was intact but deep tendon reflexes were slightly diminished to 3 out of 4 throughout. Cranial nerve function was grossly intact.Plantar reflexes were equivocal bilaterally.

Blood routine biochemistry, liver enzymes and complete blood count were normal except for a potassium level of 1.6 (3.5–5 mmol/L). Electrocardiogram revealed sinus tachycardia with ‘U’ wave in chest leads.After treatment, the ECG revealed a return to a sinus rhythm.

Two hours after initiation of intravenous potassium replacement, the patient’s neurologic symptoms had completely resolved. His blood pressure remained elevated at 125/80, however repeat electrocardiogram revealed a normal sinus rhythm and rate. Follow up studies were performed to determine the etiology of the patient’s hypokalemia. Urine sodium and potassium, and serum aldosterone and renin levels were measured to rule out adrenal involvement and were found to be normal. Thyroid stimulating hormone (TSH), triiodothyronine (T3) and thyroxine (T4) levels were obtained and



revealed a normal reading, thyroid scan subsequently demonstrated a normal uniform thyroid with no other abnormality detected.

The patient was diagnosed with Hypokalemic Periodic Paralysis with no absolute cause. He was discharged home with advice to follow up in Medicine OPD.

Discussion:

Weakness is a common, non-specific, presentation in both the emergency and outpatient setting. Although the differential diagnosis for the complaint of weakness is extensive, the focus is considerably narrowed when a patient presents with a demonstrable decrease in muscle strength on physical exam. Strokes and tumors causing nerve compression are potentially life-threatening and must be ruled out first. Other relatively common neurologic concerns include post-ictal paralysis or one of the various motor neuron diseases. Diagnosis of these disorders requires obtaining a complete history with special consideration of timing, duration, and distribution of symptoms. Periodic Paralysis is often overlooked in the initial work-up.

Causes of acute weakness:

Neurologic: Stroke, Post-seizure paralysis, Myasthenia gravis, Cataplexy, Multiple sclerosis, Inflammatory: Polymyositis, Dermatomyositis; Infectious: Polio, Diphtheria, Botulism; Metabolic, Porphyria, Alcohol/Opiates, Electrolyte disorders.

There are several types of Periodic Paralysis associated with metabolic and electrolyte abnormalities. Of these, Hypokalemic Periodic Paralysis (HPP) is the most common with a prevalence of 1 in 100,000.1 The clinical features of the syndrome vary somewhat depending on the underlying etiology but the most striking feature is the sudden onset of weakness ranging in severity from mild, transient weakness to severe disability resulting in life-threatening respiratory failure. Attacks may be provoked by stress such as a viral illness or fatigue, or certain medications such as beta-agonists, insulin or steroids. A perturbation of sodium and calcium ion channels results in low potassium levels and muscle dysfunction.2 As this is primarily a problem with muscle contraction rather than nerve conduction, tendon reflexes may be decreased or absent but sensation is generally intact. Although the serum potassium level is often alarmingly low, other electrolytes are usually normal. Indeed, total body potassium is actually normal with the change in the serum level reflecting a shift of potassium into cells.3 Electrocardiographic changes are common, but unlike patients who are truly potassium depleted the changes do not correlate well with the measured serum

level.4 Diagnosis between paralytic episodes is difficult as the patient may have normal strength and potassium levels. Electromyography reveals abnormalities in some patients but is often normal, especially between episodes when no clinically detectable weakness is present.

Causes of Hypokalemia:

Potassium Depletion – Renal, Increased aldosterone, diuretics, hypomagnesemia, renal Tubular Acidosis (Type I and II), Metabolic alkalosis, Liddle’s syndrome, Potassium Depletion – Extra-renal, Decreased intake, vomiting/Diarrhea, zollinger-ellison syndrome, fistulas, potassium Shift into Cells, Increased insulin, Alkalosis, Thyrotoxic Periodic Paralysis, Familial Hypokalemic Paralysis.

HPP occurs in several settings and the diagnosis may require an extensive search for the underlying etiology since the treatment varies according to the cause. HPP may occur sporadically in the form of Familial Hypokalmic Paralysis (FHP), a poorly understood disorder which may occur spontaneously or as the result of autosomal dominant inheritance [1]. This form of Periodic Paralysis is felt to be the result of disordered cellular potassium regulation perhaps due to sodium or calcium channel abnormalities.5 Mutations of the CACNA1S and SCN4A genes have been identified that cause abnormalities in sodium channels resulting in abnormal potassium ion flux.6 Acute paralytic episodes are treated with potassium replacement and close monitoring of the cardiac rhythm and serum potassium levels. Spironolactone and acetazolamide have been used for prophylaxis with some success although long-term potassium supplementation may be necessary.2

Paralytic episodes often occur at night, as was the case with this patient.9 Any cause of hyperthyroidism can be associated with TPP but Grave’s disease is the most common.7 The major feature distinguishing TPP from other Periodic Paralyses is the association of paralytic episodes with the hyperthyroid state. Paralytic episodes can be induced in these patients by administering insulin and glucose, but only when they are hyperthyroid.3 Euthyroid patients are typically free from spontaneous and induced attacks. The underlying mechanism is not known but is thought to be different from that of FHP since, in that disorder, thyroid hormone levels are normal and the administration of exogenous thyroid hormone does not result in paralytic episodes. Furthermore, the genetic abnormalities felt to be responsible for FHP have not been identified in patients with TPP.5 Although acute paralytic episodes are treated with potassium replacement, prophylactic potassium or acetazolamide administration is not felt to benefit these patients since

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potassium levels are normal between episodes and may result in dangerous hyperkalemia.10 Beta-blocking agents may prevent attacks but the definitive treatment is correction of the underlying thyrotoxicosis.3

Endocrine abnormalities such as hyperinsulinemia and primary hyperaldosteronism have been associated with HPP.11 Surgical removal of the aldosterone producing tumor is the preferred treatment although symptoms can often be managed with spironolactone.8

Hyperkalemic Periodic Paralysis and Paramyotonia Congenita are rare forms of Periodic Paralysis that are also associated SCN4A mutations that cause gain-of-function abnormalities in the sodium channel resulting in prolonged muscle cell excitation.12

Conclusion:

This patient presented with sudden onset paralysis and markedly abnormal potassium. The paralysis resolved completely following potassium replacement. At the time of discharge, he had no neurologic findings and a normal blood pressure of 125/80 and pulse of 74. He has not suffered any further episodes of paralysis and his potassium is now in the normal range.

Periodic Paralysis is important to consider when seeing a patient with sudden onset weakness or paralysis, especially those with no history or evidence of other diseases and no significant risk factors for stroke. Failure to properly diagnose and treat Periodic Paralysis can be fatal, but rapid correction of potassium abnormalities can resolve the symptoms quickly and completely. When possible, the underlying cause must be adequately addressed to prevent the persistence or recurrence of paralysis.

Abbreviations

TSH: Thyroid Stimulating Hormone; T3: Triiodothyronine; T4: Thyroxine; HPP: Hypokalemic Periodic Paralysis; FHP: Familial Hyperkalemic Paralysis; TPP: Thyrotoxic Periodic Paralysis

References:1. Fontaine B, Vale-Santos J, Jurkat-Rott K, Reboul J, Plassart E,

Rime CS, Elbaz A, Heine R, Guimaraes J, Weissenbach J, et al. Mapping of the hypokalaemic periodic paralysis (HypoPP) locus to chromosome 1q31-32 in three European families. Nat Genet. 1994;6:267–272. doi: 10.1038/ng0394-267. [PubMed] [CrossRef] [Google Scholar]

2. Jurkat-Rott K, Lerche H, Lehmann-Horn F. Skeletal mus-cle channelopathies. J Neurol. 2002;249:1493–1502. doi: 10.1007/s00415-002-0871-5. [PubMed] [CrossRef] [Google Scholar]

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archinte.164.14.1561. [PubMed] [CrossRef] [Google Scholar]

4. Kelley DE, Gharib H, Kennedy FP, Duda RJ, Jr, McManis PG. Thyrotoxic periodic paralysis. Report of 10 cases and review of electromyographic findings. Arch Intern Med. 1989;149:2597–2600. doi: 10.1001/archinte.149.11.2597. [PubMed] [CrossRef] [Google Scholar]

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6. Okinaka S, Shizume K, Iino S, Watanabe A, Irie M, Noguchi A, Kuma S, Kuma K, Ito T. The association of periodic paral-ysis and hyperthyroidism in Japan. J Clin Endocrinol Metab. 1957;17:1454–1459. [PubMed] [Google Scholar]

7. Shizume K, Shishiba Y, Kuma K, Noguchi S, Tajiri J, Ito K, Noh JY. Comparison of the incidence of association of periodic paralysis and hyperthyroidism in Japan in 1957 and 1991. En-docrinol Jpn. 1992;39:315–318. [PubMed] [Google Scholar]

8. Saeian K, Heckerling PS. Thyrotoxic periodic paralysis in a hispanic man. Arch Intern Med. 1988;148:708. doi: 10.1001/archinte.148.3.708. [PubMed] [CrossRef] [Google Scholar]

9. Kung AW. Clinical review: Thyrotoxic periodic paralysis: a di-agnostic challenge. J Clin Endocrinol Metab. 2006;91:2490–2495. doi: 10.1210/jc.2006-0356. [PubMed] [CrossRef] [Goo-gle Scholar]

10. Tassone H, Moulin A, Henderson SO. The pitfalls of potassi-um replacement in thyrotoxic periodic paralysis: a case report and review of the literature. J Emerg Med. 2004;26:157–161. doi: 10.1016/j.jemermed.2003.05.004. [PubMed] [CrossRef] [Google Scholar]

11. Ogawa T, Kamikubo K. Hypokalemic periodic paralysis asso-ciated with hypophosphatemia in a patient with hyperinsulin-emia. Am J Med Sci. 1999;318:69–72. doi: 10.1097/00000441-199907000-00012. [PubMed] [CrossRef] [Google Scholar]

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Case reportEwing’s sarcoma of the distal part of ulna treated by wide excision and

reconstruction by non-vascularized autogenous fibular graft: A case report.Arefin KN1, Mahmud SA2, Khatun M3, Hoque MJ4 Zaman ME5,Rahman A6

Abstruct:

Ewing’s sarcoma of the bone is the second most frequently occurring malignant bone tumor in children and adolescents. Ewing’s sarcoma in the distal ulna is extremely rare. Thus, the surgical options for reconstruction of the ulna are limited and technically challenging. It can be treated with different methods of reconstruction. Wide local excision following neoadjuvant chemotherapy followed by reconstructive procedure is the usual method of limb salvage surgery. Patient needs post operative adjuvant chemotherapy and local radiotherapy to reduce the chance of local recurrence and systemic metastasis. We present a case of Ewing sarcoma of distal end of ulna in a 9 years girls treated with limb salvage surgery as neoadjuvant chemotherapy followed by wide excision and reconstruction with non vascularised fibular graft and post operative chemotherapy and local radiotherapy. Graft was uniting well and without any local recurrence or systemic metastasis at subsequent follow up to 6 months. There was no neurovascular and functional deficit occurred.

Key words: Ewing’s sarcoma, stabilization, resections, non-vascularized fibular graft, ulna, Bone tumor.

1. Khondokar Nurul Arefin, Associate Professor, Department of Orthopaedic surgery, BSMMU.2. Sayeed al mahmud, MO, Narsingdi Sadar Hospital.3. Mahbuba Khatun, OSD surgery, BSMMU.4. Md. Johurul Hoque, Associate Professor, Department of Orthopaedic surgery, ZH Sikder Womens Medical College,

Dhaka. 5. Muhammad Emam-Uz-Zaman, D-Ortho, Registrar, Department of Orthopaedic surgery, ZH Sikder Womens

Medical College, Dhaka.6. Azizur Rahman, MO, Faridpur Medical college Hospital.

Address of Correspondence:

Muhammad Emam-Uz-Zaman, D-Ortho, Registrar of Department of Orthopaedic surgery, ZH Sikder Womens Medical College, Dhaka. Email: [email protected]

Introduction:

Ewing’s sarcoma of the bone is the second most frequently occurring malignant bone tumor in children and adolescents. It is a member of the Ewing’s sarcoma family of tumors, which also includes primitive neuroectodermal tumors, Ewing’s soft tissue sarcomas and Askin’s tumors. The Ewing’s sarcoma family of tumors is high-grade aggressive lesions that most commonly originate in the bone and are associated with large soft tissue masses and frequent metastases. The majority of Ewing’s sarcomas of the bone are located in the lower extremities and pelvic girdle, but occasionally arise in the ulna1. Previous treatments for Ewing’s sarcomas, such as surgery (alone), radiotherapy or monochemotherapy, have failed to achieve ideal results. The majority of patients succumbed within two years and the fiveyear survival rate was <20 %2. However, with progress in chemotherapy, the prognosis for patients with Ewing’s sarcoma has improved considerably during the past three decades3. Currently, chemotherapy and surgery are the standard treatment for Ewing’s sarcomas4. The ulna is an uncommon site for these malignant and aggressive

tumors. Thus, the surgical options for reconstruction are limited and technically challenging4-8. The current study presents the case of a successful wide excision and reconstruction using a non-vascularized, autogenous fibular graft in a 9-year-old girl with Ewing’s sarcoma of the ulna. Written informed consent was taken from the patient’s gurdian.

Case report:

A 9-year-old, healthy appearing, right-hand dominant girl, presented with an one and half –month history of painless, increasing swelling along the ulnar aspect of his left distal forearm. On examination the swelling was diffusely tender and its consistency was firm. The overlying skin colour was normal, free from under lying structure. Temperature over the swelling was raised. Tenderness was preset. Nerurovascular status was intact. Range of movement of left wrist, elbow and shoulder within normal and painless. The grasping power was equal in both hands. There was no evidence of lymphadenopathy and no known systemic disease. Systemic examinations did not reveal any abnormality.

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Figure 1: x-ray left forearm lateral and AP view showing fusiform shaped mixed lesion with cortical

breech in lower end of ulna.

Haematological and biochemical investigations were normal. A plain radiograph demonstrated a mixed osteolytic lesion with cortical destruction involving the middle and distal ulna (Fig. 1). Magnetic resonance imaging demonstrated an intramedullary mass lesion (6.7x2.6x2.4 cm) that involved the lower diaphyseal and metaphyseal region of the ulna, with cortical breech and large soft tissue component with irregular interrupted periosteal reaction (Fig-2)

Figure 2: MRI showing an intramedullary mass lesion ( 6.7x 2.6x 2.4 cms ) that involved the lower diaphyseal and metaphyseal region of the ulna.

The surrounding neurovascular structure was not

involved. On 27th april FNAC was done and reveals malignant tumor cells are round to oval even spindle shaped and have attempted at rosette formation in other areas. Then the patient underwent a core biopsy, and histopathology examination demonstrated malignant tumor made of small round cells arranged in sheets separated by fibrous septa with finely dispersed nuclear chromatin and inconspicuous nucleoli. Subsequently, immunohistochemistry revealed that the cell membrane was strongly positive for cluster of differentiation 99 and negative for Desmin. Thus, the analysis of the tumor biopsy supported diagnosis of Ewing’s sarcoma. Bone scan revealed uptake only in the left ulna and chest x-ray showed no evidence of metastatic disease. Therefore, the patient was classified as having stage IIB according to the Enneking surgical staging system. Then the patient received 6 cycle chemo twice weekly interval including Ifosfamide, Etoposide, Vincristin, Cycloposphamide and doxorubicin. As the tumor involved distal half of the ulna, patient underwent a wide excision of the ulna except proximal 3rd of the ulna (fig-3).

Figure 3: per operative picture showing tumor mass in distal ulna.

Reconstruction of the bony defect was performed by using a non-vascularized, autologous fibular graft harvested from the ipsilateral leg (fig-4).

Figure 4: Graft harvesting from fibula

Then the fibular graft was fixed with ulna by a Kirschner wire (fig-6). Post-operatively chemotherapy was given as



schedule. Post operative rehabilitation included 4 weeks of full immobilization by above elbow POP cast at 90˚ flexion. Then followed by passive and active assisted flexion and extension of the left elbow was done.

Figure 5: Excised Fibular graft (a) and tumor mass from ulna (b)

Figure 6: Figure 6: Reconstruction of ulna by nonvascularized fibular graft.

Graft was uniting well (fig 7), without any local recurrence or systemic metastasis in the subsequent follow up. There was no neurovascular and functional deficit. No morbidity in the donor site was observed and the functional capability of the leg was good.

Figure 7: x-ray showing uniting fibular graft in ulna with K wire in situ.

5 months later, patient was found well, active and able to

perform to her daily activities freely.

Figure 8: After 5 month, ROM of elbow and wrist normal.

Discussion

Ewing sarcoma involving long bone is common and most common primary malignancy in less than 10 years of age4. The most unfavorable prognostic factor in Ewing’s sarcoma is the presence of distant metastasis at the time of diagnosis7. Even with aggressive treatment, patients with metastases have only an approximately 20% chance of long-term survival8. Involvement of the ulnar diaphysis with this tumor posses challenge to surgeon for limb salvage surgery. If expertise and resources are limited excision through normal plane after neo-adjuvant chemotherapy and reconstruction with nonvascularised diaphysis of the fibula is viable option. Other options for reconstructions are vascularized fibular graft which demands much more operative time, microsurgery expertise and vascular instrument sets.

Chemotherapy most commonly used to treat Ewing sarcoma regardless of their identification at initial staging includes doxorubicin (DXR), cyclophsophamide (CPA), vincristine (VCR), actinomycin-D (ACT), ifosfamide (IFM), and etoposide (VP16)3 . As Ewing’s sarcomas are sensitive to both chemotherapy and irradiation, even questionable candidates for limb salvage may be eligible after neoadjuvant chemotherapy with or without irradiation. If the surgical margins are found to be inadequate after surgery, postoperative radiotherapy is added. When surgical margins are certain to be inadequate at preoperative imaging, amputation is the only surgical option available.

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Conclusion:

In this case, early diagnosis of Ewing, sarcoma of ulnar diaphysis and metaphysis which was initially treated with neoadjuvant chemotherapy and followed by limb salvage surgery as wide excision and reconstruction with non vascularised fibular graft and postoperative chemotherapy showed satisfactory results in well being and functional state of limbs.

References

1. Moore DD and Haydon RC: Ewing’s sarcoma of bone. Cancer Treat Res 162: 93-115, 2014.

2. Widhe B and Widhe T: Initial symptoms and clinical features in osteosarcoma and Ewing sarcoma. 2000 J Bone Joint Surg Am 82: 667674, Cotterill SJ, Ahrens S, Paulussen M, Jürgens HF, Voûte PA, Gadner H and Craft AW: Prognostic factors in Ewing’s tumor of bone: Analysis of 975 patients from the European intergroup cooperative Ewing’s Sarcoma study group. 2000 J Clin Oncol 18: 31083114.

3. Wunder JS, Paulian G, Huvos AG, Heller G, Meyers PA and Healey JH: The histological response to chemotherapy as a predictor of the oncological outcome of operative treatment of Ewing sarcoma. 1998 J Bone Joint Surg Am 80: 10201033,

4. Enneking WF: A system of staging musculoskeletal neoplasms. 1986 Clin Orthop Relat Res 204: 924.

5. Sułko J: Elbow reconstruction following an extensive resection of the proximal part of the ulna in a patient with Ewing Sarcoma. A case report. 2013 JBJS Case Connect 3: e111.

6. S Pandey and S Pokharel: ewing sarcoma of ulna treated with resection and reconstruction with fibula: a case report. Journal of Chitwan Medical College; 2012, 1(2); 63-64 .

7. KAYIAS et al :Resection of the distal ulna for tumours and stabilisation of the stump. A case report and literature review. Acta Orthop. Belg., 2006, 72, 484-491



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access and utilization [dissertation]. St. Louis (MO): Washington Univ.; 1995.Patent: Larsen CE, Trip R, Johnson CR, inventors; No-voste Corporation, assignee. Methods for procedures related to the electrophysiology of the heart. US patent 5,529,067. 1995 Jun 25.Other Published MaterialNewspaper article:Lee G. Hospitalizations tied to ozone pollution: study estimates 50,000 admissions annually. The Washington Post 1996 Jun 21; Sect. A: 3 (col. 5).Audiovisual material:HIV+/AIDS: the facts and the future [videocassette]. St. Louis (MO): Mosby-Year Book; 1995.Legal material:Public law:Preventive Health Amendments of 1993, Pub. L. No. 103-183, 107 Stat. 2226 (Dec. 14, 1993).Un enacted bill:Medical Records Confidentiality Act of 1995, S. 1360, 104th Cong., 1st Sess. (1995).Code of Federal Regulations:Informed Consent, 42 C.F.R. Sect. 441.257 (1995).Hearing:Increased Drug Abuse: the Impact on the Nation’s Emer-gency Rooms: Hearings Before the Subcomm. On Hu-man Resources and Intergovernmental Relations of the House Comm. on Government Operations, 103rd Cong., 1st Sess. (May 26, 1993).Map:North Carolina. Tuberculosis rates per 100,000 popula-tion, 1990 [demographic map]. Raleigh: North Carolina Dept. of Environment, Health, and Natural Resources, Div. of Epidemiology; 1991.Book of the Bible:The Holy Bible. King James Version. Grand Rapids (MI): Zondervan Publishing House; 1995. Ruth 3:1-18.Dictionary and similar references:Stedman’s medical dictionary. 26th ed. Baltimore: Wil-liams & Wilkins; 1995. Apraxia; p. 119-20.Classical material:The Winter’s Tale: act 5, scene 1, lines 13-16. The com-plete works of William Shakespeare. London: Rex; 1973.UNPUBLISHED MATERIALIn press:(Note: NLM prefers “forthcoming” because not all items will be printed.) Leshner AI. Molecular mechanisms of

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