The Insight is the official journal of Gopalganj Medical College, Gopalganj, Bangladesh and accepts articles for publication from home and abroad. This is a quarterly peer-reviewed journal and aims to publish work of the highest quality from all branches of medical science. The aim of the publication is to promote research and serves as a media for the dissemination of scientific information and recent knowledge among the readers. e-ISSN: 2789-6897 ISSN: 2663-9491
Prevalence of Methicillin-Resistant Staphylococcus aureus in Diabetic Foot Ulcers at Dhaka Medical College Hospital
Background: Diabetic foot ulcer is a significant global health burden. These ulcers are more common in patients with long-standing or poorly controlled diabetes. A major concern in the management of these ulcers is the emergence of antibiotic-resistant pathogens, notably Methicillin-Resistant Staphylococcus aureus (MRSA). MRSA colonization in these ulcers has been linked to delayed healing, increased healthcare costs, and other complications. This study aimed to determine the prevalence of Methicillin-Resistant Staphylococcus aureus (MRSA) among patients with diabetic foot ulcers. Methods & Materials: This cross-sectional study was conducted in the Microbiology Department of Dhaka Medical College, Bangladesh, from January 2024 to December 2024. Staphylococcus aureus was isolated by culture, microscopy and different biochemical tests. MRSA was isolated by cefoxitin disc diffusion method using Kirby-Bauer technique and MIC of oxacillin by agar dilution method. PCR for mecA gene was done. Results: Out of 35 Staphylococcus aureus, 34.29% were identified as Methicillin-Resistant Staphylococcus aureus by cefoxitin disc diffusion method and oxacillin agar dilution method. All MRSA isolates were confirmed by detection of mecA gene. Conclusion: The study shows a high prevalence of MRSA in diabetic foot ulcers; therefore, early diagnostic facilities should be made available in both government and non-government hospitals, and appropriate treatment protocols must be followed.
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Patterns of Spirometric Abnormalities Among Dyspnoeic Patients with Obstructive and Restrictive Lung Disease
Background: Chronic respiratory diseases are a significant public health hazard worldwide, and yet there is scanty evidence related to spirometric patterns in Bangladesh. The objective of this study was to identify the patterns and grades of severity of lung function abnormalities in patients with dyspnoea attending a tertiary care hospital in Bangladesh. Methods & Materials: This cross-sectional study based on 200 patients with dyspnoea of pulmonary origin was done over a period of six months in Dhaka Medical College Hospital. All participants had a comprehensive clinical assessment and spirometry. Descriptive patterns of diagnosis, degree of impairment, and demographic associations with diagnosis were calculated from the data. Results: Forty-one (20.5%) of the 200 patients had COPD, 70 (35.0) asthmatic, and 49 (24.5%) restrictive disease in this study. COPD patients were considerably older (mean age 57.1 years) and ex-smokers predominated, while a positive family history was positively associated with asthma. Most patients (54.0%) had severe airflow limitation. The most severe impairment was observed in the COPD group, with 82.9% of patients having severe disease, and a broader distribution of severity was seen for the asthma cohort, with mild cases also present. Conclusion: We found a high proportion of advanced respiratory disease at diagnosis in Bangladesh. These results highlight the importance of increased use of spirometry in primary care to facilitate the early diagnosis and management of respiratory disease.
Management of Tardy Ulnar Nerve Palsy in A Tertiary Level Hospital
Background: Tardy ulnar nerve palsy is a delayed ulnar neuropathy that usually develops years after elbow trauma or cubitus valgus deformity due to neglected lateral condyle fracture nonunion, leading to sensory and motor dysfunction of the hand. Aim of the study: This study aimed to evaluate the management of tardy ulnar nerve palsy at a tertiary-level hospital. Methods & Materials: This hospital-based retrospective study was conducted in the Department of Orthopedics, Monno Medical College Hospital, Manikgonj, Bangladesh, from January to December 2025 and included 28 selected patients with tardy ulnar nerve palsy. Clinical, radiological, and electrophysiological data were collected using a structured form, and patients underwent appropriate surgical management with postoperative assessment of complications and final outcome. Results: Among 28 patients, the mean age was 32.8 ± 11.6 years, and 71.4% were male. The most common etiology was neglected or non-united lateral condyle fracture, 64.3%, while 82.1% had elbow deformity. Sensory symptoms predominated, particularly numbness in the ring and little fingers (96.4% and 89.3%, respectively); nerve conduction study was abnormal in 92.9%. Subcutaneous anterior transposition (53.6%) was the most common procedure, and 75.0% of patients achieved an excellent or good final outcome. Conclusion: Tardy ulnar nerve palsy was mainly related to post-traumatic elbow deformity, especially neglected lateral condyle fracture nonunion. Most patients had longstanding neurological deficits, and surgical treatment resulted in favorable outcomes in most cases, with better sensory than motor recovery.
Concurrent Chemotherapy and Radiotherapy Improves Sphincter Preservation without Significant Toxicity in Low Rectal Disease
Background: Rectal cancer is an important cause of cancer-related morbidity and mortality. Low rectal tumors often create major challenges in achieving sphincter preservation. Preoperative concurrent chemoradiotherapy may downstage Stage II rectal adenocarcinoma, improve respectability, and reduce the need for permanent colostomy, but local evidence from Bangladesh remains limited. Aim of the study: This study compared preoperative concurrent chemoradiotherapy followed by surgery with immediate surgery alone in patients with Stage II low rectal adenocarcinoma, focusing on sphincter preservation and treatment-related toxicity. Methods & Materials: This comparative interventional study was conducted from July 2011 to January 2017 at BSMMU, NICRH, and DMCH, Dhaka. A total of 60 patients with Stage II low rectal adenocarcinoma were enrolled purposively and divided into two groups: Group I received preoperative concurrent chemoradiotherapy followed by surgery, while Group II underwent immediate surgery. Treatment response, sphincter preservation, Karnofsky performance status, and treatment-related toxicities were assessed. Data were analyzed using SPSS version 26.0, and p<0.05 was considered statistically significant. Results: Among 60 patients, the mean age was 42.3 ± 10.17 years in Group I and 44.0 ± 10.47 years in Group II, with male predominance in both groups. Per rectal bleeding, complete response was observed in Group I, while alteration of bowel habit improved more in Group I than in Group II, 60.0% versus 52.0%, p<0.05. Karnofsky performance score also improved more in Group I. Sphincter-sparing surgery was significantly higher in Group I than Group II, 22 (73.3%) versus 14 (46.7%), p=0.032. Non-hematological toxicities were comparable between groups, and grade I neutropenia in Group I did not interrupt treatment. Conclusion: Preoperative concurrent chemoradiotherapy followed by surgery significantly improved sphincter preservation and functional outcome in selected patients with Stage II low rectal adenocarcinoma. It was well tolerated, with no significant increase in major non-hematological toxicity.
Occurrence of gyrA Gene Mutations and their Association with Ciprofloxacin MIC Levels among Uropathogenic Escherichia coli Isolates
Introduction: Uropathogenic Escherichia coli is the leading cause of urinary tract infection, while increasing ciprofloxacin resistance has reduced the effectiveness of empirical therapy. Mutations in the gyrA gene, especially at Ser83 and Asp87, are important mechanisms of fluoroquinolone resistance and may increase ciprofloxacin minimum inhibitory concentration (MIC). Methods & Materials & Materials: This cross-sectional analytical study aimed to determine the prevalence of gyrA mutations among uropathogenic E. coli isolates and assess their association with ciprofloxacin MICs. The study was conducted at the Department of Microbiology, Sir Salimullah Medical College, Dhaka, from January to December 2020. A total of 229 urine samples from clinically suspected UTI patients were cultured, and 113 uropathogenic E. coli isolates were analyzed. Antimicrobial susceptibility was tested by Kirby-Bauer disc diffusion, ciprofloxacin MIC was determined by agar dilution following CLSI 2019 breakpoints, and gyrA mutations at Ser83 and Asp87 were detected by PCR-RFLP. Result: Among culture-positive isolates, E. coli was predominant (113, 81.88%). Ciprofloxacin MICs ranged from 0.007 to 16 µg/mL; 52 (46.02%) isolates were sensitive, 4 (3.54%) intermediate, and 57 (50.44%) resistant. The gyrA gene was detected in all isolates, with mutations in 63 (55.75%). A single Ser83 mutation was found in 21 (18.58%), while double Ser83 and Asp87 mutations were found in 42 (37.17%). Conclusion: The gyrA gene mutations were common among uropathogenic E. coli and were significantly associated with ciprofloxacin resistance and elevated MIC levels. Double mutations at Ser83 and Asp87 were strongly associated with high MIC values, indicating the need for culture-guided, cautious use of ciprofloxacin in UTI treatment.
Ciprofloxacin resistance and Urinary tract infection
Assessment of Periodontal Health and Oral Hygiene Practice in Low-Socioeconomic School-Going Children
Background: Oral diseases disproportionately affect disadvantaged children in low- and middle-income countries. In Bangladesh, school-going children from low socioeconomic backgrounds face a high burden of periodontal conditions, yet data on their oral hygiene practices and periodontal status remain limited. Objective: To assess periodontal health status and oral hygiene practices among low-socioeconomic school-going children in Bangladesh. Methods & Materials: This prospective cohort study was conducted in the Gonopathshala of Gonoshasthaya Kendra, Savar, Bangladesh, from January to June 2025 among 123 school children selected through purposive sampling. Periodontal health was assessed using the Community Periodontal Index (CPI), Gingival Index (GI), and Plaque Index (PI). Oral hygiene practices were recorded using a structured questionnaire. Data were analyzed using SPSS version 23.0. Results: Mean age was 9.2±1.9 years. Gingival bleeding and calculus were present in 72.4% and 58.5%, respectively. Mean GI and PI scores were 1.2±0.6 and 1.1±0.5. Daily brushing was reported by 67.5%, while 84.6% used toothpaste. Irregular brushing and no prior dental visits were noted in 82.1% and 91.9%, respectively. Older children (10-12 years) had significantly higher GI (p=0.021) and PI (p=0.008) scores compared to younger children. Conclusion: Periodontal disease is highly prevalent among low-socioeconomic schoolchildren in Savar, strongly associated with poor oral hygiene and negligible dental care. School-based oral health education with supervised brushing and regular screening is urgently needed to address this preventable burden.
Evaluation Of Coriandrum Sativum Seed Extracts As Potential Antimicrobial Agents Against Certain Common Pathogens
Background: Antimicrobial resistance (AMR) poses a major global health threat, necessitating alternative therapeutic agents. Plant-derived compounds offer promising solutions, and Coriandrum sativum (coriander) has traditional medicinal uses against infections. Objective: To evaluate the antibacterial activity of aqueous and methanolic extracts of Coriandrum sativum seeds against Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa. Methods & Materials: This experimental study was conducted at Mymensingh Medical College, Bangladesh, from January to December 2025. Disc diffusion and broth dilution methods were used to evaluate aqueous (ACSE) and methanolic (MCSE) seed extracts against standard bacterial strains (ATCC 25923, 25922, 27853). Zone of inhibition (ZOI) and minimum inhibitory concentration (MIC) were determined. Ciprofloxacin served as the reference antibiotic. Results: ACSE at 1000 mg/ml produced ZOI of 17 mm, 15 mm, and 23 mm against S. aureus, E. coli, and P. aeruginosa, respectively. MCSE showed corresponding ZOI of 17 mm, 16 mm, and 23 mm. MIC values for ACSE were 800, 800, and 700 mg/ml; for MCSE were 700, 750, and 700 mg/ml against the three organisms, respectively. Ciprofloxacin MIC ranged from 0.5 to 1 µg/ml. Conclusion: Coriandrum sativum seed extracts demonstrate significant, broad-spectrum antibacterial activity. Methanolic extracts showed slightly superior efficacy. These findings support traditional medicinal use and warrant further investigation for developing plant-based antimicrobial therapies.
Evaluation of Management of Prolapsed Lumbar Intervertebral Disc by Fenestration and Discectomy
Background: Prolapsed lumbar intervertebral disc (PLID) is a common cause of low back pain and sciatica that may require surgical intervention when conservative treatment fails. Fenestration and discectomy remain established surgical procedures for relieving nerve root compression and improving functional outcomes. This study aimed to evaluate the outcome of management of PLID by fenestration and discectomy. Methods: & Materials This prospective interventional study was conducted in the Department of Orthopedic Surgery, Dhaka Medical College & Hospital, Dhaka, from January 2017 to December 2018. A total of 28 patients with clinically and radiologically confirmed PLID underwent fenestration and discectomy and were followed up regularly. Clinical outcomes were assessed using pain status, neurological improvement, postoperative complications and functional outcome based on the Visual Analogue Scale (VAS) and Modified MacNab criteria. Results: The mean age of the patients was 38.25±9.34 years, with the highest proportion (39.3%) in the 31-40 years age group. Males constituted 67.9% of the study population. L4/L5 was the most commonly affected disc level (57.1%), followed by L5/S1 (35.7%). Preoperatively, all patients had moderate pain. At the third follow-up visit, 92.9% of patients were pain-free, with a significant reduction in pain scores throughout follow-up (p<0.001). Only one patient (3.6%) developed superficial wound infection. Functional assessment showed excellent outcome in 82.1% of patients, good outcome in 14.3%, fair outcome in 3.6% and no poor outcome. Conclusion: Fenestration and discectomy is a safe and effective surgical procedure for PLID, providing significant pain relief, excellent functional recovery and a low postoperative complication rate.
Outcome of Posterior Lumbar Interbody Fusion in Spondylolisthesis with Cage and Bone Graft
Background: Spondylolisthesis is a common cause of low back pain and neurological symptoms, with approximately 10-15% of patients requiring surgical intervention after failure of conservative treatment. Posterior lumbar interbody fusion (PLIF) with cage and bone graft is a well-established technique that provides spinal stability, high fusion rates, and satisfactory clinical outcomes in appropriately selected patients. Objective: The aim of the study was to evaluate the clinical, radiological, and functional outcomes of posterior lumbar interbody fusion with cage and bone graft in patients with spondylolisthesis. Methods & Materials: This prospective interventional study was conducted in the Department of Orthopaedic Surgery, Dhaka Medical College Hospital (DMCH), Dhaka, Bangladesh, from January 2019 to December 2020. Twenty patients with clinical and radiological spondylolisthesis were included based on predefined criteria. Outcomes assessed included VAS, ODI, MRC grading, Modified Macnab criteria, Hackenberg fusion status, and complications. Patients underwent standard surgical management and were followed for at least 6 months. Data were analyzed using SPSS version 26, with paired t-test applied (p < 0.05). Results: Among the 20 patients, the mean age was 42.80 ± 12.10 years, and 12 (60.0%) were female. Significant postoperative improvements were observed in VAS scores, ODI, and motor function, with motor deficits decreasing from 9 (45.0%) to 2 (10.0%). Solid fusion was achieved in 18 (90.0%) patients, superficial surgical site infection occurred in 3 (15.0%), and no cases of pseudarthrosis or implant failure were observed. According to the Modified Macnab criteria, 16 (80.0%) patients had excellent and 4 (20.0%) had good functional outcomes. Conclusion: Posterior lumbar interbody fusion with cage and bone graft is a safe and effective surgical technique that provides significant pain relief, neurological and functional improvement, a high fusion rate, and satisfactory clinical outcomes in patients with spondylolisthesis.
Prevalence of Alpha-1 Antitrypsin Deficiency Among Patients with Early-Onset Chronic Obstructive Pulmonary Disease
Background: Chronic Obstructive Pulmonary Disease (COPD) is a heterogeneous respiratory disorder in which genetic factors contribute significantly to disease susceptibility, particularly in early-onset cases. Alpha-1 antitrypsin deficiency (AATD), caused by mutations in the SERPINA1 gene, is an important but underdiagnosed cause of COPD. Limited data exist regarding its prevalence and clinical association in South Asian populations, especially in Bangladesh. Objective: This study aimed to determine the prevalence of AATD among patients with early-onset COPD and evaluate its association with disease severity. Methods & Materials: A descriptive cross-sectional study was conducted at the Department of Respiratory Medicine, NIDCH, Dhaka, from July to December 2025. A total of 80 early-onset COPD patients were enrolled. Data were collected using structured questionnaires and spirometric records. Serum alpha-1 antitrypsin levels were measured quantitatively using nephelometry. Participants with low serum AAT levels underwent confirmatory targeted genotyping for the PiS and PiZ alleles via real-time PCR. COPD severity was classified using GOLD criteria. Statistical analysis was performed using SPSS version 25.0. Results: AATD was identified in 12.5% of patients. PiMZ was the most common variant (6.25%), followed by PiSZ (3.75%) and PiZZ (2.5%). A significant association was observed between AATD status and COPD severity (p = 0.02), with 80% of AATD cases presenting in GOLD III and IV stages. Non-AATD cases were predominantly in milder stages. Conclusion: AATD is a notable contributor to early-onset COPD and is significantly associated with increased disease severity. Routine screening for SERPINA1 mutations may facilitate early diagnosis and improved clinical management in COPD patients.
Pain and Functional Recovery in Lateral Epicondylitis: An Evaluation of ESWT and Ultrasound Therapy
Background: Lateral epicondylitis is a common degenerative tendinopathy of the elbow that causes pain and functional impairment, particularly in individuals involved in repetitive upper-limb activities. Extracorporeal shock wave therapy (ESWT) and therapeutic ultrasound therapy (UST) are widely used conservative treatment modalities; however, comparative evidence regarding their effectiveness remains limited. Aim of the study: To compare the effectiveness of extracorporeal shock wave therapy and therapeutic ultrasound therapy on pain reduction and functional recovery in patients with lateral epicondylitis. Methods & Materials: This prospective comparative interventional study was conducted at the Department of Physical Medicine and Rehabilitation, Dhaka Medical College Hospital, from June 2019 to May 2020. Sixty patients with clinically diagnosed lateral epicondylitis were allocated into two groups: ESWT (n = 30) and UST (n = 30). Both groups received their respective modalities along with NSAIDs, activity-of-daily-living advice, and therapeutic exercises for three weeks. Pain intensity was assessed using the Visual Analog Scale (VAS) at rest and during resisted wrist extension (RWE). Functional recovery was evaluated using hand grip strength and the Patient-Rated Tennis Elbow Evaluation (PRTEE) score. Outcomes were assessed at baseline and at the fourth follow-up. Result: Both ESWT and UST groups demonstrated statistically significant improvements in pain and functional outcomes. VAS scores at rest and during RWE significantly decreased in both groups by the fourth follow-up (p ≤ 0.001). Grip strength significantly improved, and PRTEE scores markedly decreased in both groups (p < 0.001). Although improvements were observed in both modalities, the UST group showed slightly greater reductions in pain during resisted wrist extension and marginally better functional outcomes; however, these differences were not consistently statistically significant. Treatment adherence, patient satisfaction, and recurrence rates were comparable between groups. Conclusion: Both extracorporeal shock wave therapy and therapeutic ultrasound therapy are effective, safe, and well-tolerated treatment options for reducing pain and improving functional outcomes in patients with lateral epicondylitis. Therapeutic ultrasound demonstrated slightly better short-term pain relief and functional recovery, though both modalities can be recommended as part of conservative management.
Prevalence and Awareness of Urinary Incontinence among Postmenopausal Women
Background: Urinary incontinence (UI) is a prevalent yet often underreported health issue among postmenopausal women, significantly affecting quality of life. In Bangladesh, limited data exist regarding the prevalence and awareness of this issue in rural healthcare settings, creating a gap in targeted interventions. Objective: To determine the prevalence of and awareness regarding urinary incontinence among postmenopausal women in rural Bangladesh. Methods & Materials: A prospective cohort study was conducted at the Upazila Health Complex, Pirgonj, Thakurgaon, Bangladesh, from January 2023 to December 2024. A total of 147 postmenopausal women were selected using a purposive sampling technique. Data were collected through face-to-face interviews using a structured questionnaire and were analyzed using SPSS version 23.0. Results: The study revealed a high prevalence of urinary incontinence, affecting 78 participants (53.1%) out of 147. Among those experiencing UI, stress incontinence was the most common type (44.9%), followed by mixed incontinence (30.8%) and urgency incontinence (24.3%). Despite the high prevalence, awareness regarding UI was significantly low. Only 32 (21.8%) of all participants considered it a medical condition, and merely 18 (12.2%) were aware of available treatment options. Furthermore, a substantial majority (73.5%) had never discussed their symptoms with a healthcare provider. Conclusion: Urinary incontinence is highly prevalent among postmenopausal women in rural Bangladesh, yet awareness of the condition as a treatable medical issue remains critically low. This highlights an urgent need for community-based health education programs to improve awareness, reduce stigma, and encourage affected women to seek timely medical care.
Resurgence of Measles in Bangladesh: The Cost of Immunization Gaps - an editorial
Socio-demographic and Reproductive Factors Influencing Contraceptive Use among Women with Rheumatoid Arthritis and Systemic Lupus Erythematosus
Introduction: Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are chronic autoimmune diseases predominantly affecting women of reproductive age, presenting significant reproductive health challenges including infertility, reduced family size, and teratogenic medication exposure. Despite recommendations for effective contraception, evidence suggests low and inequitable contraceptive uptake among these patients. Aim of the Study: To examine the socio-demographic and reproductive factors influencing contraceptive use among women with RA and SLE attending rheumatology clinics in Bangladesh. Methods & Materials: This cross-sectional study was conducted from July 2022 to April 2023 at Bangladesh Medical University (formerly BSMMU), enrolling 83 married women aged 18-49 years with confirmed RA (n=42) or SLE (n=41). Data were collected on socio-demographic variables, reproductive factors, contraceptive practices, and contraceptive counselling receipt. Multivariable logistic regression was used to identify factors associated with contraceptive use. Results: The mean age was 30.75±5.32 years. Contraceptive prevalence was 74.7% (71.4% in RA, 78.0% in SLE). Condoms (31.3%) and oral contraceptive pills (25.3%) were the most common methods, with 54.2% receiving contraceptive counselling. High rates of unwanted pregnancy (43.4%) and abortion (30.1%) were documented. Multivariable analysis identified age ≥30 years as the sole significant predictor of contraceptive use (AOR=2.38, 95% CI: 1.03-5.50; p=0.042). No significant associations were found for BMI, education, residence, reproductive history, or disease type. Conclusion: Contraceptive use among women with RA and SLE in Bangladesh is comparable to the general population, with age ≥30 years as the key determinant. However, high rates of unwanted pregnancy and abortion, and predominant reliance on barrier methods, indicate critical gaps in reproductive healthcare. Targeted contraceptive counselling within rheumatology clinics is essential to improve outcomes in this vulnerable population.
Effectiveness of Quadriceps Strengthening Exercise in Patients with Knee Osteoarthritis
Background: Knee osteoarthritis is a common degenerative joint disease and a major cause of pain and disability, particularly in older adults, with the knee being the most frequently affected joint. Quadriceps weakness is a key contributor to pain, instability, and functional limitation in knee OA, making quadriceps strengthening an essential part of its conservative management. Objective: The aim of the study was to evaluate the effectiveness of quadriceps strengthening exercise in improving pain, physical function, knee range of motion, and quadriceps muscle strength in patients with knee osteoarthritis. Methods & Materials: This quasi-experimental study was conducted at the Department of Physical Medicine and Rehabilitation, Bangladesh Medical University (BMU), Dhaka, Bangladesh, from January to December 2025 among 70 patients with knee osteoarthritis. Pain, functional status, knee range of motion, and quadriceps muscle strength were assessed before and after a quadriceps strengthening exercise program. Data were analyzed using SPSS version 26.0, with p < 0.05 considered statistically significant. Results: Among 70 patients with knee osteoarthritis (mean age 57.4 ± 8.7 years), most were female (62.9%) and had Kellgren-Lawrence grade II disease (51.4%). Following quadriceps strengthening exercise, significant improvements were observed in pain, WOMAC scores, knee range of motion, and quadriceps muscle strength (all p < 0.001). Overall, 57.1% of patients showed moderate improvement, 28.6% marked improvement, and 14.3% mild improvement, with no patient showing no improvement. Conclusion: Quadriceps strengthening exercise significantly improved pain, physical function, knee range of motion, and quadriceps muscle strength in patients with knee osteoarthritis, supporting its role as an effective non-pharmacological treatment modality.
Per-operative Evaluation of Patient Related Difficulties of Laparoscopic Cholecystectomy
Background: Gallstone disease is a common cause of morbidity, with an estimated prevalence of 5-22% in the general population. In settings where delayed presentation is frequent due to limited healthcare access and low patient awareness, laparoscopic cholecystectomy can be technically challenging because of difficulties with abdominal access, pneumoperitoneum creation, dissection of the gallbladder, and specimen retrieval. Methods & Materials: This descriptive study was performed in the Chittagong Medical College Hospital General Surgery wards from August 2016 to January 2017. In this study, 100 patients who underwent laparoscopic cholecystectomy during the study period were included by purposive consecutive sampling meeting the inclusion criteria. Data were analyzed using chi-square and Student t-tests as appropriate. Results: Among the 100 patients who underwent laparoscopic cholecystectomy, 12 cases were categorized as difficult, primarily due to prolonged operative time exceeding 50 minutes, although all were completed laparoscopically. The average operative duration was 36.53 minutes. Difficulties were more frequent among females (66.7%) and patients aged 40-60 years. Significant predictors of operative difficulty included intra-abdominal adhesion of the gallbladder to the gut (p<0.001, OR=29.40), short and wide cystic duct (p=0.008, OR=5.79), and adhesion at Calot's triangle (p=0.041, OR=3.90). Two cases required conversion to open surgery due to unclear anatomy and risk of common bile duct injury. Conclusion: Laparoscopic cholecystectomy is a common operation, but sometimes it becomes difficult due to several factors. Adhesion of GB with gut, short, wide cystic duct, and adhesion at Calot's triangle are challenging to operate upon and increase the operating time.
Influence of Antiretroviral Therapy on Lipid Profile in HIV Patients
Background: As dyslipidemia is associated with an elevated risk of cardiovascular disease, it represents significant health issues for HIV-positive patients receiving antiretroviral therapy (ART). There is limited information regarding ART treatment and its influence on lipid profiles manifest in HIV infected persons in Bangladesh. To determine the pattern and characteristic of lipid profile among HIV patients on WHO recommended firstline antiretroviral therapy, the study was performed. Methods & Materials: A total 51 HIV patients receiving ART for >1 year (group A) and 51 treatment naïve patients (group B) were enrolled in this study. Written informed consent was obtained from all subjects. Each patient was subjected to a full clinical examination, history-taking and lipid profile determination. After collection of the required data, analysis was performed in SPSS 27.0. Results: The mean age was 35.52±11.55 (SD) years among total study population and more than two third (77.5%) patients were male altogether. Majority of HIV infected patients had history of unprotected sex (89.2%) and 17.7% had history of transmission of HIV from partner. Mean values of serum lipid profile was found significantly higher among treatment receiver groups (TC=176.7±37.1, HDL=36.7±6.7, LDL=104.46±32.9, TG=196.86±88.91) compared to treatment naive patients (TC=151.9±35.6, HDL=31.9±10.6, LDL=87.8±25, TG=158.7±67.4). Being on ART for three or more years was associated with higher levels of TC and LDL-c (p<0.05). Conclusion: The present study findings have suggested an association between antiretroviral therapy (ART) and lipid abnormalities. However, further large multi-centre study is recommended.
Demographic Characteristics and Injury Patterns in Patients with Flail Chest Trauma
Background: Flail chest is a serious form of blunt thoracic trauma associated with significant respiratory compromise and frequently accompanied by other thoracic injuries. Understanding the demographic characteristics and injury patterns of affected patients is important for timely diagnosis and management. Methods & Materials: This cross-sectional study was conducted in the Department of Thoracic Surgery, National Institute of Diseases of the Chest and Hospital (NIDCH), Dhaka, Bangladesh, from January 2010 to December 2010. A total of 60 patients with flail chest were included. Patients were divided into Group I (Central Flail Chest, n=22) and Group II (Other Flail Chest, n=38). Results: The mean age was 38.3 ± 14.4 years in Group I and 41.4 ± 18.2 years in Group II (p=0.471). Male patients predominated in both groups, accounting for 81.8% and 65.8% of Group I and Group II, respectively (p=0.184). Chest pain was present in all patients. Respiratory distress occurred in 72.7% of Group I and 57.9% of Group II patients, while cyanosis was observed in 40.9% and 15.8%, respectively. The mean number of fractured ribs was significantly higher in Group I than in Group II (9 ± 2 vs. 5 ± 1; p<0.001). Road traffic accidents were the leading cause of injury in both groups. Haemopneumothorax was the most common associated condition, followed by lung contusion and surgical emphysema. Conclusion: Flail chest trauma predominantly affected males and was most commonly caused by road traffic accidents. Central flail chest was associated with a higher number of rib fractures and more severe clinical manifestations.
Clinical Presentation and Biochemical Parameters of Childhood Lupus Nephritis and Its Correlation with Underlying Renal Histopathology: A Cross-sectional Study
Background: Lupus nephritis is a major concern in patients with systemic lupus erythematosus. Clinical presentation and biochemical parameters are usually correlated with histopathological classes of lupus nephritis; however, patients with mild clinical features may have moderate to severe glomerular injury, while severe presentations may sometimes show less severe damage. The aim of this study was to assess clinical presentation and biochemical parameters of childhood lupus nephritis and their correlation with renal histopathology. Methods & Materials: This cross-sectional observational study was conducted in the Department of Pediatric Nephrology, Bangladesh Shishu Hospital & Institute (BSH&I), from October 2022 to March 2024. A total of 44 children aged 4-18 years who fulfilled the 2019 ACR/EULAR criteria. Results: Among 44 participants, mean age was 10.6 years with a female-to-male ratio of 3.4:1. About 81.81% had nephritis with systemic features and 18.19% had isolated lupus nephritis. Class IV was the most common histopathological class (32%). Proteinuria was present in 97.3%, of whom 56.8% had nephrotic-range proteinuria. Other findings included hematuria, anasarca, hypertension, and acute kidney failure. Anasarca, nephrotic-range proteinuria, acute kidney failure, reduced eGFR, increased spot uPCR, hypoalbuminemia, SLEDAI, and renal SLEDAI were significantly higher in Class IV LN. However, 18.18% of Class II LN also had nephrotic-range proteinuria. Non-nephrotic proteinuria was significantly higher in Class II LN (p=0.005), but was also seen in 22.22% of Class III, 14.28% of Class IV, and 33.33% of Class V LN. Conclusion: Clinical and biochemical severity is greater in advanced lupus nephritis, especially Class IV LN.
Serum β-hCG as an Indicator for Persistence in Gestational Trophoblastic Neoplasia
Background: Gestational trophoblastic neoplasia (GTN) is a potentially aggressive trophoblastic disorder in which persistent elevation or abnormal regression of serum beta-human chorionic gonadotropin (β-hCG) after molar evacuation may indicate persistent disease. Early identification of persistent GTN is essential to reduce morbidity and improve treatment outcomes. Aim of the study: To evaluate the role of serial serum β-hCG levels as an indicator for predicting persistence in gestational trophoblastic neoplasia during post-evacuation follow-up. Methods & Materials: This prospective observational study was conducted in the Department of Gynecological Oncology at Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh, from January 2021 to December 2021. Fifty patients with histopathologically confirmed hydatidiform mole who underwent suction evacuation were enrolled consecutively. Serial serum β-hCG levels were measured 48 hours after evacuation and monitored weekly for at least 8 weeks. Patients were categorized into persistent GTN (Group A, n=7) and spontaneous remission (Group B, n=43). Statistical analyses included chi-square test, unpaired t-test, ROC curve analysis, and multivariate logistic regression. Result: Persistent GTN developed in 14.0% of patients. Younger age, low socioeconomic status, low BMI, previous molar pregnancy, thyrotoxic features, uterine enlargement, expulsion of grape-like vesicles, large theca lutein cysts, and vesicular uterine appearance on ultrasonography were significantly associated with persistent GTN. All patients with persistent GTN had 48-hour post-evacuation β-hCG levels >100,000 mIU/mL (p=0.011). Mean log β-hCG values became significantly higher in persistent GTN cases from the 5th week onward (p=0.001). Diagnostic performance improved progressively over time, with the highest predictive accuracy observed at the 8th week (cutoff 1.59; sensitivity 97.7%, specificity 100%, AUC 0.997). Multivariate logistic regression identified younger age and elevated 48-hour β-hCG levels as independent predictors of persistent GTN. Conclusion: Serial serum β-hCG monitoring is a highly effective tool for early detection of persistent GTN following molar evacuation. Elevated 48-hour β-hCG levels and delayed decline of β-hCG after the 5th post-evacuation week are strong predictors of persistence. Regular β-hCG surveillance may facilitate timely intervention and improve clinical outcomes in patients with gestational trophoblastic disease.
Clinicopathological and Radiological Features of Unilateral Nasal Mass in Adults - A Tertiary Care Hospital Experience
Abu Zafar Saleh1*, Mostafa Kamal2 Introduction: Aim and objectives of the study were to analyze and study the diverse presentations of unilateral nasal mass and to identify the suggestive features of neoplastic pathology in adult's population at a tertiary referral hospital. Aim of the study: Aim and objectives of the study were to analyze and study the diverse presentations of unilateral nasal mass and to identify the suggestive features of neoplastic pathology in adult's population at a tertiary referral hospital. Methods: This prospective observational study was conducted in the Department of ENT, Khulna Medical College and Hospital, Khulna, Bangladesh. The study period was between January 2021 and December 2021. The parameters include patient history, clinical assessments and histopathological examinations, which were supplemented with radiological investigations. In addition, demographic information and histopathological examinations for patients, who underwent surgical excision was analyzed for correlation with clinical diagnosis. Result: The reported cases are 55 males and 35 females with a median follow-up period of 12 months, ranging from 2-72 months. Nasal obstruction is the major symptom 34 (38%), 25 (27.8%) cases were reported with nasal mass and clinical diagnosis indicates 18 (20%) cases of malignancy. Type of disease and gender demonstrates low significance (p=0.023), whereas the diagnosis with age is highly significant (p=0.005). Conclusion: Carcinoma, inflammatory polyposis, inverted papilloma and allergic fungal sinusitis were the highest histological diagnosis. The clinical diagnosis and the suggestive features of radiological findings mostly resembled the histological findings. In contrary to the resemblance, the histological finding reveals the general diagnosis of nasal mass to the precise diagnosis, especially the fatal conditions like carcinoma. The high rate of malignancy and its suggestive radiological findings indicates that the specialists should consider the cases with caution to carryout histological analysis to rule out the probability of neoplasm.
Prediction of the consistency of intracranial meningioma by MRI: Correlation with peroperative finding
Background: Meningiomas constitute 13-26% of primary intracranial tumors and commonly occur in the fourth to sixth decades of life, with a female-to-male ratio of approximately 1.8:1. Preoperative prediction of tumor consistency aids neurosurgeons in planning the surgical approach and anticipating technical challenges. The aim of this study was to evaluate the correlation between T2-weighted MRI signal intensity and the peroperative consistency of intracranial meningiomas. Methods & Materials: This study involved 31 patients with MRI-confirmed intracranial meningiomas. T2-weighted MRI signal intensity was categorized as isointense, hypointense, or hyperintense compared to cortical gray matter, with hyperintense tumors predicted as soft and iso-/hypointense tumors as firm. Intraoperative tumor consistency was classified as soft or firm based on surgical handling. The study assessed correlation, agreement, and diagnostic performance of MRI in predicting tumor consistency. Results: T2-weighted MRI showed 18 isointense, 1 hypointense, and 12 hyperintense tumors. Peroperatively, 19 tumors were firm and 12 softs. Iso/hypointense tumors predicted as firm were confirmed in 17/19 cases, while 10/12 hyperintense tumors predicted as soft were confirmed. Correlation between MRI signal intensity and tumor consistency was significant (p < 0.001). Agreement analysis showed a Kappa value of 0.6 (fair agreement). For predicting firm tumors, MRI sensitivity was 90%, specificity 83.3%, positive predictive value 89.5%, negative predictive value 83.3%, and accuracy 87%. For soft tumors, sensitivity was 83.3%, specificity 89.5%, PPV 83.3%, NPV 89.5%, and accuracy 87%. Conclusion: T2-weighted MRI can reliably predict meningioma consistency, with hyperintense tumors likely soft and iso- or hypointense tumors likely firm, aiding preoperative surgical planning.
An Analysis of Medical Undergraduates' Performance on Problem-based Objective Written Questions Compared to Traditional Objective Written Questions on Circulatory System and Lymphoid Organs in Histology
Background: Histology is a fundamental component of undergraduate medical education, with assessment methods significantly influencing student learning and skill development. Problem-based objective written questions (PBQ) aim to assess higher-order cognitive skills, while traditional objective written questions (TQ) primarily evaluate recall and understanding. Objective: To compare medical undergraduates' performance in problem-based objective written questions and traditional objective written questions in histology, focusing on the circulatory system and lymphoid organs. Methods & Materials: This cross-sectional analytical study was conducted in the Department of Anatomy, Bangladesh Medical University (BMU), Dhaka, from September 2024 to August 2025. A total of 220 medical undergraduate students were included, with 110 students in the problem-based question (PBQ) group and 110 students in the traditional question (TQ) group. A structured test comprising 100 objective written questions was administered under standardized conditions. Only responses related to the circulatory system and lymphoid organs were analyzed. Data were analyzed using SPSS version 27.0, and statistical significance was set at p ≤ 0.05. Results: The mean score of the PBQ group was 31.59 ± 19.29, while the TQ group achieved a higher mean score of 38.48 ± 18.68. The difference between the two groups was statistically significant (p = 0.00). The 95% confidence interval (-7.29 to -7.06) confirmed significantly poorer performance in the PBQ group compared to the TQ group. Conclusion: Medical undergraduate students performed significantly poorer in PBQ than in TQ in Histology, particularly on the circulatory system and lymphoid organs. These findings suggest that students may require greater exposure and training in problem-based assessment formats to improve their application-level cognitive skills.
Perinatal Risk Factors of Seizures in Pediatric Patients: A Hospital Based Study
Background: Seizures in neonates and young children are emergencies, primarily caused by hypoxic-ischaemic encephalopathy, infections, metabolic issues, and intracranial bleeding. Key risks involve premature birth and asphyxia at birth, particularly in low-resource areas such as Bangladesh. They are associated with higher mortality rates and long-term neurodevelopmental issues, yet comprehensive data on perinatal risk factors are still scarce. Methods & Materials: This study took place in the Department of Emergency, Observation & Referral of Bangladesh Shishu Hospital & Institute, Dhaka (March 2025-February 2026) involving 110 children (0-14 years) experiencing seizures. Information regarding perinatal factors and seizure characteristics was gathered through interviews and examination of records. Analysis was conducted utilizing SPSS-26 (p<0.05 significant), with ethical approval and informed consent maintaining confidentiality. Results: A total of 110 children experiencing seizures were examined (average age 4.9 ± 3.1 years; 56.4% male). Perinatal risk factors were observed in 50.9%, primarily low birth weight (23.6%) and preterm delivery (18.2%). Generalized seizures were the most prevalent, while focal seizures were comparatively more frequent among exposed cases. Strong correlations were identified between perinatal risk factors and extended seizures (42.9% vs 18.5%, p=0.04) and their recurrence (50.0% vs 25.9%, p=0.05). Low birth weight and premature birth were strongly associated with more severe seizure results. Conclusion: Perinatal risk elements, particularly low birth weight and preterm delivery, are prevalent in pediatric seizures and correlate with more severe consequences, including extended and recurring seizures. These results emphasize the significance of perinatal health in the intensity of seizures and the necessity for enhanced maternal and neonatal care to decrease morbidity.
Clinical and Demographic Characteristics of Patients with Intracranial Meningiomas: A Descriptive Analysis
Background: Intracranial meningiomas are common primary central nervous system tumors with variable clinical presentation and demographic distribution. Understanding their clinical and demographic profile is essential for early recognition and appropriate management. Methods & Materials: A cross-sectional study was conducted in the Department of Neurosurgery, National Institute of Neurosciences & Hospital (NINS&H), Agargaon, Dhaka, from April 2021 to September 2022 among 67 consecutive patients with radiologically and clinically diagnosed intracranial meningioma who underwent surgical treatment. Results: The majority of patients were in the 41-50 years age group (31.3%), followed by 31-40 years (23.9%) and 51-60 years (19.4%), with a mean age of 43.55±11.76 years (range 19-65 years). Females comprised 67% of cases, with a female-to-male ratio of 2:1. Headache was the most common presenting symptom (81.1%), followed by weakness (40.3%), visual disturbance (35.8%) and vomiting (11.9%). Neurological findings included motor signs in 40.3%, cranial nerve involvement in 38.8%, altered consciousness in 6%, aphasia/dysphasia in 9%, sensory signs in 9%, cerebellar signs in 4.5%, autonomic dysfunction in 7.5% and other signs in 7.5%. Convexity meningiomas were most frequent (34.3%), followed by falcine/parasagittal (31.3%) and skull base lesions (25.4%), with sphenoid wing being the most common skull base subtype. Conclusion: Intracranial meningiomas predominantly affect middle-aged females and most commonly present with headache and focal neurological deficits. Convexity and parasagittal regions are the most frequent tumor locations. These findings highlight characteristic clinical and demographic patterns that may aid early diagnosis and management.
Characterization of Bacterial Isolates from Bronchoalveolar Lavage and Their Antimicrobial Resistance Patterns in a Tertiary Care Hospital in Bangladesh: A VITEK 2-Based Cross-Sectional Study
Background: Lower respiratory tract infections (LRTIs) cause significant morbidity and mortality. Bronchoalveolar lavage (BAL) helps identify pathogens and guide therapy. This study determined the bacteriological profile and antimicrobial resistance patterns of BAL isolates in a Bangladeshi tertiary care hospital. Methods & Materials: This retrospective laboratory-based study was conducted at Bangabandhu Sheikh Mujib Medical University, Dhaka, from January 2024 to December 2024. A total of 245 BAL specimens from patients with suspected pulmonary infections were processed. Bacterial identification and antimicrobial susceptibility testing were performed using the VITEK 2 automated system and interpreted per CLSI guidelines. Results: Of 245 BAL specimens, 161 (65.7%) showed significant bacterial growth. Culture positivity was higher in males (55.9%) and in the 51-60 years age group (29.2%). Gram-negative bacteria comprised 98.1% of isolates. Pseudomonas aeruginosa (49.1%) was most common, followed by Klebsiella pneumoniae (26.7%), Escherichia coli (13.0%), Acinetobacter baumannii (6.8%), Enterobacter cloacae (2.5%), and Staphylococcus aureus (1.9%). Colistin showed 100% susceptibility among Gram-negatives. Amikacin and imipenem were the most active non-polymyxin agents. High resistance was seen to cephalosporins and ciprofloxacin. All S. aureus isolates were methicillin-sensitive and fully susceptible to vancomycin and linezolid. Conclusions: Gram-negative bacteria, especially P. aeruginosa, predominate in BAL isolates from pulmonary infection patients. High antimicrobial resistance highlights the need for routine surveillance, local antibiograms, and antimicrobial stewardship. BAL remains valuable for targeted therapy.
Impact of Hemodialysis Duration and Clinical Factors on Health-Related Quality of Life in Chronic Kidney Disease Patients
Background: Chronic kidney disease (CKD) progressing to end stage renal disease (ESRD) is an increasing global health burden with high prevalence and significant mortality, including in Bangladesh. In ESRD patients, maintenance hemodialysis is the main life-sustaining therapy that improves survival but imposes a substantial physical and psychosocial burden, thereby reducing health-related quality of life. Objective: The aim of the study was to assess the impact of hemodialysis duration and clinical factors on health-related quality of life in chronic kidney disease patients. Methods & Materials: This observational cross-sectional study was conducted in the Department of Nephrology, Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladesh, over six months after ethical approval. A total of 100 CKD patients on maintenance hemodialysis were selected by purposive sampling to assess the impact of dialysis duration and clinical factors on health-related quality of life. Data were collected through face-to-face interviews using a structured questionnaire and the validated Bangla SF-36 tool, and analyzed using SPSS version 20.0, with p < 0.05 considered significant. Results: The study included 100 maintenance hemodialysis patients, mainly aged 61-70 years (33.0%) and male (76.0%). Diabetic nephropathy was the leading cause of CKD (32.0%), and most had serum creatinine 5-7 mg/dl (42.0%). Most patients were on dialysis for 1-5 years (56.0%). SF-36 scores were lowest for general health perception and highest for pain. Longer dialysis duration (>5 years) was significantly associated with lower scores in multiple SF-36 domains (p < 0.05). Conclusion: Maintenance hemodialysis is associated with significantly impaired quality of life, which progressively worsens with longer treatment duration.
Hemodynamic Profile and Postoperative Pain Following Propofol-Remifentanil and Isoflurane-Remifentanil Anaesthesia in Laparoscopic Cholecystectomy
Background: Laparoscopic cholecystectomy is the standard approach for cholelithiasis, offering reduced postoperative pain and faster recovery compared to open surgery. General anaesthesia is routinely used, and the choice of technique plays a key role in ensuring haemodynamic stability and optimal perioperative outcomes. Objective: The aim of the study was to compare the hemodynamic profile and postoperative pain outcomes between propofol-remifentanil and isoflurane-remifentanil anesthesia in patients undergoing laparoscopic cholecystectomy. Methods & Materials: This quasi-experimental study was conducted in the operation theatre of the Department of General Surgery, Bangladesh Medical University, Dhaka, Bangladesh (October 2024-September 2025). Seventy-two patients undergoing elective laparoscopic cholecystectomy were purposively sampled and equally allocated to Group PR (propofol-remifentanil) and Group IR (isoflurane-remifentanil) to compare perioperative haemodynamic parameters and postoperative pain outcomes. Standardized anaesthetic protocols were applied, and data were analysed using SPSS version 29.0. Results: A total of 72 patients (36 per group) were included, with comparable baseline demographic and clinical characteristics between the PR and IR groups (p > 0.05). Heart rate remained similar throughout the perioperative period, while systolic and diastolic blood pressures were significantly lower in the PR group (p < 0.01). Postoperative pain was significantly reduced in the PR group at early time points, and opioid requirement was markedly lower (27.8% vs. 77.8%; 28.6 ± 12.3 vs. 46.9 ± 15.8 mg; p < 0.001), with differences resolving by 24 hours. Conclusion: Propofol-remifentanil anesthesia offers better hemodynamic stability and postoperative pain control than isoflurane-remifentanil anesthesia in laparoscopic cholecystectomy.
Comparative study of sonology-guided nerve root block versus conservative treatment of radiculopathy
Background: Radiculopathy is a common disabling condition characterized by pain and functional impairment due to nerve root compression. Ultrasound-guided nerve root block has emerged as a minimally invasive treatment option for symptomatic relief. This study aimed to compare the effectiveness of sonoguided nerve root block with conservative treatment in patients with radiculopathy. Methods & Materials: This comparative interventional study was conducted in the Department of Physical Medicine & Rehabilitation of Bangladesh Medical University from January 2025 to December 2025 among 41 patients with cervical radiculopathy. Participants were divided into sonoguided nerve root block group (n=21) and conservative treatment group (n=20). Pain intensity was assessed using Visual Analogue Scale (VAS) and functional disability using Oswestry Disability Index (ODI). Data were analyzed using SPSS version 25. Results: The majority of patients belonged to the 41-50 years age group (36.6%) and males constituted 61.0% of participants. After 12 weeks, the mean VAS score was significantly lower in the sonoguided group compared to the conservative group (2.6 ± 1.1 vs 4.8 ± 1.4; p=0.001). ODI score also improved significantly in the intervention group (18.4 ± 5.6 vs 29.7 ± 6.3; p=0.002). Patient satisfaction was higher in the sonoguided group (85.7%) than the conservative group (50.0%). Conclusion: Sonoguided nerve root block was more effective than conservative treatment in reducing pain and improving functional outcome among patients with radiculopathy.
Clinical Spectrum, Comorbidities, and Quality of Life among Patients with Psoriasis: A Hospital-Based Outpatient Study in Bangladesh
Background: Psoriasis is a chronic immune-mediated inflammatory skin disease with systemic, metabolic, psychological, and quality-of-life impacts. In Bangladesh, hospital-based evidence on its clinical spectrum and associated comorbidities remains limited. Objective: To assess the clinical spectrum, comorbidities, disease severity, and quality of life among psoriasis patients in Bangladesh. Methods & Materials: This hospital-based retrospective study included 160 adult psoriasis patients attending Bangladesh Multicare Hospital, Rampura, Dhaka, from June to November 2025. Data were collected from medical records using a structured form. Disease severity was assessed by PASI, and quality of life by DLQI. Results: Plaque psoriasis was the most common clinical type (65.0%). Most patients had mild (41.3%) or moderate (36.3%) disease, while 22.5% had severe psoriasis. Hypertension (32.5%), diabetes mellitus (27.5%), depression/anxiety (25.0%), obesity (23.8%), and dyslipidemia (21.3%) were common comorbidities. Severe psoriasis was significantly associated with these conditions. Obesity was the strongest independent predictor of severe disease, and PASI scores showed a strong positive correlation with DLQI impairment. Conclusion: Psoriasis substantially affects physical and psychosocial well-being, requiring integrated care, routine comorbidity screening, and quality-of-life assessment.