Exposure to domestic violence and the risk of developing depression within 6 months postpartum in Bangladesh

Purpose

Domestic violence (DV) by husbands or in-laws is a recognized problem in many countries and is associated with a wide range of adverse mental health outcomes. However, detailed knowledge on the relationship between DV experience and postpartum depression (PPD) is essential to design appropriate interventions. Therefore, this study assesses the relationship between maternal experience of DV perpetrated by husbands or in-laws and PPD in Bangladesh.

Methods

A cross-sectional survey was conducted from October to December 2019 among 497 mothers within the first 6 months postpartum who attended a health center in Rajshahi City Corporation, Bangladesh. Multivariable logistic regressions were performed to identify the associations after controlling for potential confounders.

Results

The prevalence of PPD in this sample was 34% within the first 6 months after birth; 58.6% of mothers reported having experienced any form of DV in their lifetime. Maternal experience of any form of DV (Adjusted Odds Ratio [AOR] = 1.87; 95% confidence interval [CI] = 1.19–2.93) was associated with PPD, as were experiences of any physical DV (AOR = 2.25; 95% CI = 1.40–3.59), emotional DV (AOR = 2.07; 95% CI = 1.34–3.19), and controlling behavior (AOR = 1.69; 95% CI = 1.08–2.66). Additionally, the likelihood of PPD significantly increased among women who experienced more forms of DV.

Conclusion

DV perpetrated by husband and/or in-laws is highly prevalent and significantly associated with PPD in Bangladesh. Strategies in developing interventions for improving maternal mental health should consider DV perpetrated by either husband or in-laws.

     

Cryptococcosis masquerading as a tuboovarian abscess.

This report describes a 25-year-old human immunodeficiency virus- seropositive patient who initially presented with clinical features of a tuboovarian abscess. After a poor response to antibiotic therapy, laparotomy and excision of a right-sided, unilocular, pseudocystic ovarian mass measuring 140 x 80 x 60 mm were undertaken. Mucoid gelatinous material, with a glistening appearance and slimy consistency, coated the inner surface of the thick wall. The cyst contained clear, viscid fluid with a similar slimy consistency. Although the macroscopic diagnosis was that of an ovarian mucinous cystadenocarcinoma, histopathologic assessment confirmed a well-circumscribed pseudocystic cryptococcoma with a wall of granulation and fibrous tissue and compressed ovarian stroma. The inner surface was covered by large, paucireactive, extracellular "yeast lakes" of carminophilous Cryptococcus neoformans yeasts of varying shape and size. To the best of our knowledge, this is the first documentation of ovarian cryptococcosis in the English language literature. Despite their rarity in the female genital tract, fungal infections must be considered in the differential diagnosis of patients presenting with pelvic pain of obscure origin and a pelvic mass that is refractory to antibiotic therapy.     

DNR directives are established early in mechanically ventilated intensive care unit patients

Purpose

Setting treatment goals in the intensive care unit (ICU) often involves resuscitation decisions. Our objective was to study the rate of establishing do-not-resuscitate (DNR) directives, determinants, and outcomes of those directives for mechanically ventilated patients.

Methods

In a multicentre observational study, we included consecutive adults with no DNR directives within 24 hr of ICU admission who were mechanically ventilated for at least 48 hr. We identified the rate with which DNR directives were established, and factors associated with these directives.

Results

Among 765 patients, DNR directives were established for 231 (30.2%) patients; 143 (62.1%) of these were established within the first week. Factors independently associated with a DNR directive were: patient age [> 75 yr (hazard ratio [HR] 2.3, 95% confidence interval 1.5–3.4], 65 to 74yr(HR 1.8, 1.2–2.7), 50 to 64 yr (HR 1.4, 1.0–2.2) relative to < 50 yr); medical rather than surgical diagnosis (HR 1.8, 1.3–2.5); multiple organ dysfunction score (HR 1.7 for each five-point increment, 1.4–2.0); physician prediction of ICU survival [< 10% (HR 15.0, 6.7–33.6)], 10 to 40% [(HR 5.0, 2.3–11.2), 41 to 60% (HR 4.0, 1.8–9.0) relative to > 90%]; and physician perception of patient preference to limit life support (no advanced life support [(HR 5.8, 3.6–9.4) or partial advanced life support (HR 3.2, 2.2–4.6) compared to full measures].

Conclusion

One third of mechanically ventilated patients had DNR directives established early during their ICU stay after the first 24 hr of admission. The strongest predictors of DNR directives were physician prediction of low probability of survival, physician perception of patient preference to limit life support, organ dysfunction, medical diagnosis and age.     

Modification of the peritoneoscopic technique of peritoneal dialysis catheter insertion: experience of an interventional nephrology program

Bowel perforation is a well-recognized complication of peritoneal dialysis catheter insertion and is associated with increased morbidity and cost of medical care. In this article we describe our 2-year experience (August 2001-October 2003) with a modified peritoneoscopic technique of peritoneal dialysis catheter insertion to minimize the incidence of bowel perforation. Seventy patients underwent 82 consecutive peritoneal dialysis catheter insertions using the innovative technique. The modified technique is very similar to the traditional peritoneoscopic procedure except for the following differences. To gain access to the peritoneal cavity, a Veress insufflation needle (Ethicon Endo-Surgery Inc., Cincinnati, OH) is utilized instead of the trocar. In contrast to the sharp tip of the trocar, the Veress needle has a blunt, self-retracting end. In addition, the Veress needle is only 14 gauge as opposed to the 2.2 mm diameter of the trocar. Upon introduction of the Veress needle into the abdominal cavity, two "pops" are discerned similar to the trocar. After introduction, 400-500 cc of air are infused and the needle is removed. The infusion of air creates a space between the peritoneal surface of the anterior abdominal wall and the bowel loops. At this point, the cannula with trocar is inserted into the space created. The rest of the steps of the procedure are the same as the traditional peritoneoscopic technique. Utilizing the innovative technique, all 82 catheter insertions were performed successfully without a single bowel perforation. No other complications except for catheter migration (n = 2) were noted. The extra cost of the needle (35 USD) should be viewed in the context of the costs associated with management of a bowel perforation. Large-scale studies are needed to confirm the superiority of this innovative technique over the traditional peritoneoscopic insertion found in our case series. In the interim, however, the increased morbidity and cost associated with bowel perforation calls for logical measures to be taken to avoid this dreaded complication.     

P53 gene mutations in pleuropulmonary blastomas

Pleuropulmonary blastoma (PPB) is rarechildhoodtumororiginating fromeitherlung orpleura. Although several cytogenetic changes, such as trisomy 2, trisomy 8, and loss of 17p material, have been reported, evidence of gene mutations is still lacking. Pathologically, PPB shares similarities with rhabdomyosarcoma in which p53 mutations are frequently detected. Possible implication of p53 mutations in PPB was investigated. PPBs of 3 patients were analyzed for occurrence of p53 mutations by using polymerase chain reaction-single-strand conformation polymorphism (PCR-SSCP) method, and the nature of mutations was confirmed by direct sequencing. Two PPBs were confirmed to harbor p53 mutations. One was a Val to Leu substitution at codon 173, and another was a ArgArg to TrpCys substitution at codons 282 and 283. In each tumor, only the mutated allele was detected, suggesting inactivation of p53. Both patients with mutations had fatal outcome, while the remaining patient in whom no mutation was detected is disease free for 3 years after completion of treatment. The results raise the possibility that p53 inactivation can occur as a nonrandom genetic change involving the pathogenesis and outcome of PPB. Further studies in a larger series are necessary to clarify these matters.     

The cost‐effectiveness of consistent and early intervention of harm reduction for injecting drug users in Bangladesh

Aims To assess the cost‐effectiveness of the CARE‐SHAKTI harm reduction intervention for injecting drug users (IDUs) over a 3‐year period, the impact on the cost‐effectiveness of stopping after 3 years and how the cost‐effectiveness might vary with baseline human immunodeficiency virus (HIV) prevalence. Design Economic cost data were collected from the study site and combined with impact estimates derived from a dynamic mathematical model. Setting Dhaka, Bangladesh, where the HIV prevalence has remained low despite high‐risk sexual and injecting behaviours, and growing HIV epidemics in neighbouring countries. Findings The cost per HIV infection prevented over the first 3 years was US$110.4 (33.1–182.3). The incremental cost‐effectiveness of continuing the intervention for a further year, relative to stopping at the end of year 3, is US$97 if behaviour returns to pre‐intervention patterns. When baseline IDU HIV prevalence is increased to 40%, the number of HIV infections averted is halved for the 3‐year period and the cost per HIV infection prevented doubles to US$228. Conclusions The analysis confirms that harm reduction activities are cost‐effective. Early intervention is more cost‐effective than delaying activities, although this should not preclude later intervention. Starting harm reduction activities when IDU HIV prevalence reaches as high as 40% is still cost‐effective. Continuing harm reduction activities once a project has matured is vital to sustaining its impact and cost‐effectiveness.